| Psychoses | MS-DRG 885 | $12,738 |
| Psychiatric diagnostic evaluation | CPT 90791 | $995.53 |
| Psychiatric eval with medical services | CPT 90792 | $995.53 |
| Psychotherapy 30 minutes | CPT 90832 | $200.62 |
| Psychotherapy 45 minutes | CPT 90834 | $200.62 |
| Psychotherapy 60 minutes | CPT 90837 | $219.83 |
| ED visit level 1 | CPT 99281 | $304.59 |
| ED visit level 2 | CPT 99282 | $845.14 |
| ED visit level 3 | CPT 99283 | $1,183.09 |
| ED visit level 4 | CPT 99284 | $14,686 |
| ED visit level 5 | CPT 99285 | $27,266 |
| Critical care, first hour | CPT 99291 | $38,207 |
| CT head without contrast | CPT 70450 | $269.74 |
| CT head with contrast | CPT 70460 | $378.36 |
| CT head with and without contrast | CPT 70470 | $447.49 |
| CT neck with contrast | CPT 70491 | $475.85 |
| MRI brain without contrast | CPT 70551 | $499.09 |
| MRI brain with contrast | CPT 70552 | $746.51 |
| MRI brain with and without contrast | CPT 70553 | $810.58 |
| Chest X-ray single view | CPT 71045 | $121.28 |
| Chest X-ray 2 views | CPT 71046 | $121.28 |
| Chest X-ray 3 views | CPT 71047 | $121.28 |
| CT chest without contrast | CPT 71250 | $338.69 |
| CT chest with contrast | CPT 71260 | $430.82 |
| CT chest with and without contrast | CPT 71270 | $511.96 |
| MRI chest without contrast | CPT 71550 | $749.59 |
| MRI chest with contrast | CPT 71551 | $1,062.81 |
| MRI chest with and without contrast | CPT 71552 | $841.24 |
| Lumbosacral spine X-ray | CPT 72100 | $163.23 |
| CT cervical spine without contrast | CPT 72125 | $332.64 |
| CT thoracic spine without contrast | CPT 72128 | $331.75 |
| CT lumbar spine without contrast | CPT 72131 | $330.94 |
| MRI cervical spine without contrast | CPT 72141 | $493.44 |
| MRI thoracic spine without contrast | CPT 72146 | $493.44 |
| MRI lumbar spine without contrast | CPT 72148 | $493.84 |
| MRI lumbar spine with and without contrast | CPT 72149 | $749.43 |
| MRI cervical spine with and without contrast | CPT 72156 | $814.74 |
| MRI lumbar spine with contrast | CPT 72158 | $813.9 |
| CT pelvis without contrast | CPT 72192 | $339.38 |
| CT pelvis with contrast | CPT 72193 | $530.8 |
| Shoulder X-ray | CPT 73030 | $121.28 |
| Humerus X-ray | CPT 73060 | $121.28 |
| Hand X-ray 3 views | CPT 73130 | $121.28 |
| MRI upper extremity joint without contrast | CPT 73221 | $509.65 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $757.3 |
| Knee X-ray 1-2 views | CPT 73560 | $121.28 |
| Ankle X-ray 3 views | CPT 73610 | $121.28 |
| MRI lower extremity joint without contrast | CPT 73721 | $3,788.93 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $756.12 |
| CT abdomen without contrast | CPT 74150 | $347.83 |
| CT abdomen with contrast | CPT 74160 | $542 |
| CT abdomen with and without contrast | CPT 74170 | $616.97 |
| CT abdomen and pelvis without contrast | CPT 74176 | $355.33 |
| CT abdomen and pelvis with contrast | CPT 74177 | $566.42 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $606.55 |
| MRI abdomen without contrast | CPT 74181 | $502.26 |
| MRI abdomen with and without contrast | CPT 74183 | $670.89 |
| Abdominal ultrasound complete | CPT 76700 | $234.57 |
| Abdominal ultrasound limited | CPT 76705 | $202.2 |
| Retroperitoneal ultrasound complete | CPT 76770 | $230.99 |
| Obstetric ultrasound first trimester | CPT 76801 | $198.69 |
| Obstetric ultrasound after first trimester | CPT 76805 | $264.49 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $345 |
| Transvaginal ultrasound | CPT 76830 | $212.16 |
| Pelvic ultrasound complete | CPT 76856 | $212.16 |
| Scrotal ultrasound | CPT 76870 | $203.81 |
| Diagnostic mammography unilateral | CPT 77065 | $441.19 |
| Diagnostic mammography bilateral | CPT 77066 | $589.34 |
| EKG complete | CPT 93000 | $361.58 |
| EKG tracing only | CPT 93005 | $131.94 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,640.32 |
| Transthoracic echocardiogram | CPT 93307 | $409.08 |
| Stress echocardiogram | CPT 93350 | $682.3 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $18,802 |
| COPD w MCC | MS-DRG 190 | $11,602 |
| COPD w CC | MS-DRG 191 | $9,206.61 |
| COPD w/o CC/MCC | MS-DRG 192 | $7,329.85 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $9,003.71 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $7,033.47 |
| AMI discharged alive w MCC | MS-DRG 280 | $15,926 |
| AMI discharged alive w CC | MS-DRG 281 | $9,532.55 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $7,633.19 |
| Heart failure & shock w MCC | MS-DRG 291 | $13,026 |
| Heart failure & shock w CC | MS-DRG 292 | $8,999.74 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $6,278.59 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $12,355 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $7,875.87 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $5,973.26 |
| GI hemorrhage w CC | MS-DRG 378 | $10,293 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $6,749.02 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $8,028.04 |
| Fractures of femur w/o MCC | MS-DRG 533 | $14,497 |
| Kidney/UTI w MCC | MS-DRG 689 | $11,493 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $8,308.51 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $19,032 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $10,619 |
| Basic metabolic panel (BMP) | CPT 80048 | $22.55 |
| General health panel | CPT 80050 | $331.89 |
| Electrolyte panel | CPT 80051 | $18.7 |
| Comprehensive metabolic panel | CPT 80053 | $28.13 |
| Lipid panel | CPT 80061 | $7.54 |
| Renal function panel | CPT 80069 | $23.12 |
| Hepatic function panel | CPT 80076 | $21.77 |
| Urinalysis non-automated | CPT 81002 | $8.07 |
| Urinalysis automated | CPT 81003 | $62.42 |
| Glucose quantitative | CPT 82947 | $19.05 |
| Hemoglobin A1c | CPT 83036 | $25.87 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $44.77 |
| Complete blood count with automated differential | CPT 85025 | $20.71 |
| Complete blood count without differential | CPT 85027 | $17.26 |
| Urine culture bacterial | CPT 87086 | $21.53 |
| Urine culture identification | CPT 87088 | $39.38 |
| Tissue exam by pathologist level IV | CPT 88305 | $29.71 |
| Fetal non-stress test | CPT 59025 | $276 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $6,717.17 |
| Vaginal delivery only | CPT 59409 | $4,051.6 |
| Vaginal delivery with postpartum | CPT 59410 | $7,073 |
| Routine obstetric care with C-section | CPT 59510 | $7,666.96 |
| C-section delivery only | CPT 59514 | $6,459.55 |
| C-section with postpartum | CPT 59515 | $8,704 |
| Office visit, new patient, 15-29 min | CPT 99202 | $249.6 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $284.26 |
| Office visit, new patient, 45-59 min | CPT 99204 | $347.08 |
| Office visit, new patient, 60-74 min | CPT 99205 | $404.79 |
| Office visit, established patient, 5 min | CPT 99211 | $215.62 |
| Office visit, established patient, 10-19 min | CPT 99212 | $203 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $203 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $300 |
| Office visit, established patient, 40-54 min | CPT 99215 | $343.5 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,703.91 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,703.91 |
| Sigmoidoscopy diagnostic | CPT 45330 | $1,671.1 |
| Sigmoidoscopy with biopsy | CPT 45331 | $1,671.1 |
| Colonoscopy diagnostic | CPT 45378 | $1,693.91 |
| Colonoscopy with biopsy | CPT 45380 | $2,183.64 |
| Colonoscopy with polyp removal | CPT 45385 | $2,296.3 |
| Total shoulder arthroplasty | CPT 23472 | $17,310 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $30,588 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $19,465 |
| Hip hemiarthroplasty | CPT 27125 | $7,000.38 |
| Total hip replacement | CPT 27130 | $13,809 |
| Total knee replacement | CPT 27447 | $16,419 |
| Knee revision arthroplasty single component | CPT 27486 | $9,962.5 |
| Knee revision arthroplasty all components | CPT 27487 | $9,717 |
| Shoulder arthroscopy with decompression | CPT 29826 | $5,813 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $9,110.03 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $5,363.75 |
| ACL reconstruction | CPT 29888 | $8,083.42 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $49,008 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $25,766 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $17,424 |
| CABG single arterial graft | CPT 33533 | $14,698 |
| CABG 2 arterial grafts | CPT 33534 | $14,698 |
| CABG 3 arterial grafts | CPT 33535 | $14,698 |
| CABG 4+ arterial grafts | CPT 33536 | $14,752 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $17,210 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $13,493 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $35,386 |
| Open appendectomy | CPT 44950 | $4,492.62 |
| Laparoscopic appendectomy | CPT 44970 | $7,346 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $67,381 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $39,505 |
| Major joint replacement w MCC | MS-DRG 469 | $31,103 |
| Major joint replacement w/o MCC | MS-DRG 470 | $19,311 |
| Laparoscopic cholecystectomy | CPT 47562 | $9,424 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $9,424 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $30,505 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $21,259 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $16,780 |
| Open umbilical hernia repair | CPT 49560 | $5,363.75 |
| Umbilical hernia repair age 5+ | CPT 49585 | $5,363.75 |
| Lap inguinal hernia repair | CPT 49650 | $7,144.95 |
| Lap incisional hernia repair | CPT 49652 | $8,338.79 |
| Total abdominal hysterectomy | CPT 58150 | $5,231.05 |
| Vaginal hysterectomy | CPT 58260 | $6,190.41 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $9,424 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $12,577 |
| Lap salpingo-oophorectomy | CPT 58661 | $7,813.74 |
| OR procedure for obesity w MCC | MS-DRG 619 | $30,862 |
| OR procedure for obesity w CC | MS-DRG 620 | $17,943 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $16,296 |
| Complex cataract surgery | CPT 66982 | $4,372.93 |
| Cataract surgery with lens implant | CPT 66984 | $5,767.49 |
| Intravitreal injection | CPT 67028 | $2,089.12 |
| Vitrectomy mechanical | CPT 67042 | $5,566 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $11,678 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $18,268 |
| PCI single major coronary artery | CPT 92920 | $7,653.77 |
| PCI with drug-eluting stent | CPT 92928 | $14,101 |
| PCI bypass graft | CPT 92937 | $14,101 |
| Left heart catheterization | CPT 93452 | $8,638 |
| Coronary angiography with cath | CPT 93455 | $8,638 |
| Coronary angiography with bypass cath | CPT 93458 | $8,638 |
