| Psychoses | MS-DRG 885 | $8,986.36 |
| Psychiatric diagnostic evaluation | CPT 90791 | $138.31 |
| Psychotherapy 45 minutes | CPT 90834 | $138.31 |
| Psychotherapy 60 minutes | CPT 90837 | $138.31 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $138.31 |
| ED visit level 1 | CPT 99281 | $450.00 |
| ED visit level 2 | CPT 99282 | $495.00 |
| ED visit level 3 | CPT 99283 | $585.00 |
| ED visit level 4 | CPT 99284 | $276.30 |
| ED visit level 5 | CPT 99285 | $2,340.00 |
| Critical care, first hour | CPT 99291 | $1,800.00 |
| CT head without contrast | CPT 70450 | $107.60 |
| CT head with contrast | CPT 70460 | $174.94 |
| CT head with and without contrast | CPT 70470 | $174.94 |
| CT neck with contrast | CPT 70491 | $174.94 |
| MRI brain without contrast | CPT 70551 | $1,933.20 |
| MRI brain with contrast | CPT 70552 | $2,066.04 |
| MRI brain with and without contrast | CPT 70553 | $4,159.08 |
| Chest X-ray single view | CPT 71045 | $76.62 |
| Chest X-ray 2 views | CPT 71046 | $76.62 |
| Chest X-ray 3 views | CPT 71047 | $171.00 |
| CT chest without contrast | CPT 71250 | $107.60 |
| CT chest with contrast | CPT 71260 | $174.94 |
| CT chest with and without contrast | CPT 71270 | $174.94 |
| MRI chest with and without contrast | CPT 71552 | $4,770.00 |
| Lumbosacral spine X-ray | CPT 72100 | $107.60 |
| CT cervical spine without contrast | CPT 72125 | $107.60 |
| CT thoracic spine without contrast | CPT 72128 | $2,113.56 |
| CT lumbar spine without contrast | CPT 72131 | $107.60 |
| MRI cervical spine without contrast | CPT 72141 | $223.73 |
| MRI thoracic spine without contrast | CPT 72146 | $1,410.48 |
| MRI lumbar spine without contrast | CPT 72148 | $2,499.12 |
| MRI lumbar spine with and without contrast | CPT 72149 | $366.59 |
| MRI cervical spine with and without contrast | CPT 72156 | $366.59 |
| MRI lumbar spine with contrast | CPT 72158 | $3,635.28 |
| CT pelvis without contrast | CPT 72192 | $107.60 |
| CT pelvis with contrast | CPT 72193 | $174.94 |
| Shoulder X-ray | CPT 73030 | $76.62 |
| Humerus X-ray | CPT 73060 | $76.62 |
| Hand X-ray 3 views | CPT 73130 | $76.62 |
| MRI upper extremity joint without contrast | CPT 73221 | $2,273.40 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $3,150.36 |
| Knee X-ray 1-2 views | CPT 73560 | $76.62 |
| Ankle X-ray 3 views | CPT 73610 | $270.00 |
| MRI lower extremity joint without contrast | CPT 73721 | $2,128.68 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $3,207.60 |
| CT abdomen without contrast | CPT 74150 | $107.60 |
| CT abdomen with contrast | CPT 74160 | $174.94 |
| CT abdomen with and without contrast | CPT 74170 | $174.94 |
| CT abdomen and pelvis without contrast | CPT 74176 | $3,894.48 |
| CT abdomen and pelvis with contrast | CPT 74177 | $4,284.36 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $366.59 |
| MRI abdomen without contrast | CPT 74181 | $223.73 |
| MRI abdomen with and without contrast | CPT 74183 | $4,718.52 |
| Abdominal ultrasound complete | CPT 76700 | $107.60 |
| Abdominal ultrasound limited | CPT 76705 | $630.00 |
| Retroperitoneal ultrasound complete | CPT 76770 | $107.60 |
| Obstetric ultrasound first trimester | CPT 76801 | $1,260.00 |
| Obstetric ultrasound after first trimester | CPT 76805 | $1,260.00 |
| Transvaginal ultrasound | CPT 76830 | $1,260.00 |
| Pelvic ultrasound complete | CPT 76856 | $107.60 |
| Scrotal ultrasound | CPT 76870 | $107.60 |
| Diagnostic mammography unilateral | CPT 77065 | $74.28 |
| Diagnostic mammography bilateral | CPT 77066 | $95.21 |
| Screening mammography bilateral | CPT 77067 | $78.60 |
| EKG tracing only | CPT 93005 | $54.56 |
| EKG interpretation only | CPT 93010 | $13.00 |
| Transthoracic echocardiogram complete | CPT 93306 | $477.58 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $10,054 |
| COPD w MCC | MS-DRG 190 | $7,126.43 |
| COPD w CC | MS-DRG 191 | $5,423.47 |
| COPD w/o CC/MCC | MS-DRG 192 | $4,130.32 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $5,184.78 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $4,043.47 |
| AMI discharged alive w MCC | MS-DRG 280 | $10,320 |
| AMI discharged alive w CC | MS-DRG 281 | $5,913.06 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $4,652.08 |
| Heart failure & shock w MCC | MS-DRG 291 | $8,259.38 |
| Heart failure & shock w CC | MS-DRG 292 | $5,462.07 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $3,641.37 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $7,745.98 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $4,733.15 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $3,642.02 |
| GI hemorrhage w CC | MS-DRG 378 | $6,309.36 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $4,055.70 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $5,015.58 |
| Fractures of femur w/o MCC | MS-DRG 533 | $10,086 |
| Kidney/UTI w MCC | MS-DRG 689 | $7,464.83 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $5,207.95 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $12,497 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $6,583.44 |
| Initial hospital care, low complexity | CPT 99221 | $260.10 |
| Initial hospital care, moderate complexity | CPT 99222 | $351.00 |
| Initial hospital care, high complexity | CPT 99223 | $521.10 |
| Hospital discharge, <30 min | CPT 99238 | $186.30 |
| Hospital discharge, >30 min | CPT 99239 | $276.30 |
| Basic metabolic panel (BMP) | CPT 80048 | $8.46 |
| Electrolyte panel | CPT 80051 | $7.99 |
| Comprehensive metabolic panel | CPT 80053 | $10.56 |
| Lipid panel | CPT 80061 | $100.80 |
| Renal function panel | CPT 80069 | $261.00 |
| Hepatic function panel | CPT 80076 | $26.10 |
| Glucose quantitative | CPT 82947 | $68.40 |
| Hemoglobin A1c | CPT 83036 | $9.71 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $131.40 |
| Complete blood count with automated differential | CPT 85025 | $7.77 |
| Urine culture bacterial | CPT 87086 | $8.07 |
| Urine culture identification | CPT 87088 | $8.09 |
| Tissue exam by pathologist level IV | CPT 88305 | $51.66 |
| Fetal non-stress test | CPT 59025 | $181.44 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $3,600.00 |
| Vaginal delivery only | CPT 59409 | $9,000.00 |
| Vaginal delivery with postpartum | CPT 59410 | $2,475.00 |
| Routine obstetric care with C-section | CPT 59510 | $5,400.00 |
| C-section with postpartum | CPT 59515 | $3,150.00 |
| Cesarean section w CC/MCC | MS-DRG 765 | $7,572.27 |
| Cesarean section w/o CC/MCC | MS-DRG 766 | $5,385.51 |
| Vaginal delivery w complicating dx | MS-DRG 774 | $5,342.40 |
| Vaginal delivery w/o complicating dx | MS-DRG 775 | $4,152.20 |
| Office visit, new patient, 15-29 min | CPT 99202 | $100.08 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $154.06 |
| Office visit, new patient, 45-59 min | CPT 99204 | $260.55 |
| Office visit, new patient, 60-74 min | CPT 99205 | $338.63 |
| Office visit, established patient, 5 min | CPT 99211 | $31.50 |
| Office visit, established patient, 10-19 min | CPT 99212 | $32.11 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $101.52 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $180.00 |
| Office visit, established patient, 40-54 min | CPT 99215 | $225.00 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $19,271 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $12,285 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $29,572 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $15,422 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $10,827 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $10,883 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $8,786.93 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $21,920 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $42,669 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $23,533 |
| Major joint replacement w MCC | MS-DRG 469 | $19,514 |
| Major joint replacement w/o MCC | MS-DRG 470 | $12,410 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $18,736 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $13,475 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $10,493 |
| OR procedure for obesity w MCC | MS-DRG 619 | $18,576 |
| OR procedure for obesity w CC | MS-DRG 620 | $10,296 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $9,704.35 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $7,982.09 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $13,183 |
| PCI single major coronary artery | CPT 92920 | $5,304.24 |
| PCI with drug-eluting stent | CPT 92928 | $10,796 |
| Coronary angiography with cath | CPT 93455 | $3,008.86 |
| Coronary angiography with bypass cath | CPT 93458 | $5,940.63 |
