| Psychoses | MS-DRG 885 | $12,937 |
| Psychiatric diagnostic evaluation | CPT 90791 | $192.12 |
| Psychotherapy 30 minutes | CPT 90832 | $155.4 |
| Psychotherapy 45 minutes | CPT 90834 | $158.91 |
| Psychotherapy 60 minutes | CPT 90837 | $176.79 |
| ED visit level 1 | CPT 99281 | $417.88 |
| ED visit level 2 | CPT 99282 | $790.74 |
| ED visit level 3 | CPT 99283 | $1,182.1 |
| ED visit level 4 | CPT 99284 | $1,358.49 |
| ED visit level 5 | CPT 99285 | $2,211.25 |
| Critical care, first hour | CPT 99291 | $3,467.01 |
| CT head without contrast | CPT 70450 | $223.68 |
| CT head with contrast | CPT 70460 | $313.35 |
| CT head with and without contrast | CPT 70470 | $370.96 |
| CT neck with contrast | CPT 70491 | $405.93 |
| MRI brain without contrast | CPT 70551 | $435.16 |
| MRI brain with contrast | CPT 70552 | $605.38 |
| MRI brain with and without contrast | CPT 70553 | $643.09 |
| Chest X-ray single view | CPT 71045 | $96.07 |
| Chest X-ray 2 views | CPT 71046 | $96.07 |
| Chest X-ray 3 views | CPT 71047 | $96.07 |
| CT chest without contrast | CPT 71250 | $248.66 |
| CT chest with contrast | CPT 71260 | $386.53 |
| CT chest with and without contrast | CPT 71270 | $407.72 |
| MRI chest without contrast | CPT 71550 | $610.4 |
| MRI chest with contrast | CPT 71551 | $849.7 |
| MRI chest with and without contrast | CPT 71552 | $693.55 |
| Lumbosacral spine X-ray | CPT 72100 | $496.98 |
| CT cervical spine without contrast | CPT 72125 | $248.66 |
| CT thoracic spine without contrast | CPT 72128 | $248.66 |
| CT lumbar spine without contrast | CPT 72131 | $248.66 |
| MRI cervical spine without contrast | CPT 72141 | $423.83 |
| MRI thoracic spine without contrast | CPT 72146 | $423.83 |
| MRI lumbar spine without contrast | CPT 72148 | $423.14 |
| MRI lumbar spine with and without contrast | CPT 72149 | $605.14 |
| MRI cervical spine with and without contrast | CPT 72156 | $643.09 |
| MRI lumbar spine with contrast | CPT 72158 | $643.09 |
| CT pelvis without contrast | CPT 72192 | $248.66 |
| CT pelvis with contrast | CPT 72193 | $407.72 |
| Shoulder X-ray | CPT 73030 | $564.3 |
| Humerus X-ray | CPT 73060 | $403.92 |
| Hand X-ray 3 views | CPT 73130 | $361.68 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,229.58 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $2,053.26 |
| Knee X-ray 1-2 views | CPT 73560 | $279.18 |
| Ankle X-ray 3 views | CPT 73610 | $376.2 |
| MRI lower extremity joint without contrast | CPT 73721 | $3,037.32 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $2,278.32 |
| CT abdomen without contrast | CPT 74150 | $248.66 |
| CT abdomen with contrast | CPT 74160 | $407.72 |
| CT abdomen with and without contrast | CPT 74170 | $413.07 |
| CT abdomen and pelvis without contrast | CPT 74176 | $276.09 |
| CT abdomen and pelvis with contrast | CPT 74177 | $446.92 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $489.56 |
| MRI abdomen without contrast | CPT 74181 | $1,839.42 |
| MRI abdomen with and without contrast | CPT 74183 | $5,462.82 |
| Abdominal ultrasound complete | CPT 76700 | $176.6 |
| Abdominal ultrasound limited | CPT 76705 | $164.68 |
| Retroperitoneal ultrasound complete | CPT 76770 | $173.67 |
| Obstetric ultrasound first trimester | CPT 76801 | $129.58 |
| Obstetric ultrasound after first trimester | CPT 76805 | $181.38 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $273.28 |
| Transvaginal ultrasound | CPT 76830 | $145.56 |
| Pelvic ultrasound complete | CPT 76856 | $145.56 |
| Scrotal ultrasound | CPT 76870 | $141.17 |
| Diagnostic mammography unilateral | CPT 77065 | $208.8 |
| Diagnostic mammography bilateral | CPT 77066 | $254.4 |
| Screening mammography bilateral | CPT 77067 | $181.93 |
| EKG tracing only | CPT 93005 | $92.74 |
| Transthoracic echocardiogram complete | CPT 93306 | $573.87 |
| Transthoracic echocardiogram | CPT 93307 | $383.23 |
| Stress echocardiogram | CPT 93350 | $573.87 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $18,330 |
| COPD w MCC | MS-DRG 190 | $11,926 |
| COPD w CC | MS-DRG 191 | $9,796.29 |
| COPD w/o CC/MCC | MS-DRG 192 | $8,127.2 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $9,615.85 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $7,863.61 |
| AMI discharged alive w MCC | MS-DRG 280 | $16,188 |
| AMI discharged alive w CC | MS-DRG 281 | $10,206 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $8,396.98 |
| Heart failure & shock w MCC | MS-DRG 291 | $13,193 |
| Heart failure & shock w CC | MS-DRG 292 | $9,612.31 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $7,192.26 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $12,597 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $8,612.8 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $6,920.71 |
| GI hemorrhage w CC | MS-DRG 378 | $10,762 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $7,610.64 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $8,748.13 |
| Fractures of femur w/o MCC | MS-DRG 533 | $14,501 |
| Kidney/UTI w MCC | MS-DRG 689 | $11,830 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $8,997.57 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $18,534 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $11,052 |
| Basic metabolic panel (BMP) | CPT 80048 | $16.5 |
| General health panel | CPT 80050 | $309.39 |
| Electrolyte panel | CPT 80051 | $13.59 |
| Comprehensive metabolic panel | CPT 80053 | $20.59 |
| Lipid panel | CPT 80061 | $23.96 |
| Renal function panel | CPT 80069 | $15.52 |
| Hepatic function panel | CPT 80076 | $15.93 |
| Urinalysis non-automated | CPT 81002 | $1.11 |
| Urinalysis automated | CPT 81003 | $35.38 |
| Glucose quantitative | CPT 82947 | $19.8 |
| Hemoglobin A1c | CPT 83036 | $18.93 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $32.76 |
| Complete blood count with automated differential | CPT 85025 | $15.15 |
| Complete blood count without differential | CPT 85027 | $11.58 |
| Urine culture bacterial | CPT 87086 | $14.43 |
| Urine culture identification | CPT 87088 | $11.73 |
| Tissue exam by pathologist level IV | CPT 88305 | $51.23 |
| Fetal non-stress test | CPT 59025 | $336 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $2,989.04 |
| Vaginal delivery only | CPT 59409 | $3,116.06 |
| Vaginal delivery with postpartum | CPT 59410 | $2,962.67 |
| Routine obstetric care with C-section | CPT 59510 | $2,990.83 |
| C-section delivery only | CPT 59514 | $1,304.86 |
| C-section with postpartum | CPT 59515 | $4,498 |
| Office visit, new patient, 15-29 min | CPT 99202 | $312.84 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $1.11 |
| Office visit, new patient, 45-59 min | CPT 99204 | $186.79 |
| Office visit, established patient, 5 min | CPT 99211 | $189.89 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $1.11 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $101.67 |
| Upper GI endoscopy diagnostic | CPT 43235 | $961.95 |
| Upper GI endoscopy with biopsy | CPT 43239 | $961.95 |
| Sigmoidoscopy diagnostic | CPT 45330 | $943.44 |
| Sigmoidoscopy with biopsy | CPT 45331 | $943.44 |
| Colonoscopy diagnostic | CPT 45378 | $993.68 |
| Colonoscopy with biopsy | CPT 45380 | $1,232.79 |
| Colonoscopy with polyp removal | CPT 45385 | $1,321.7 |
| Total shoulder arthroplasty | CPT 23472 | $14,645 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $29,610 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $19,428 |
| Hip hemiarthroplasty | CPT 27125 | $3,467.73 |
| Total hip replacement | CPT 27130 | $7,206.5 |
| Total knee replacement | CPT 27447 | $10,954 |
| Knee revision arthroplasty single component | CPT 27486 | $5,877 |
| Knee revision arthroplasty all components | CPT 27487 | $4,828.69 |
| Shoulder arthroscopy with decompression | CPT 29826 | $2,681.54 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $7,439.13 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $3,363.43 |
| ACL reconstruction | CPT 29888 | $7,439.13 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $45,194 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $24,524 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $17,104 |
| CABG single arterial graft | CPT 33533 | $6,399.77 |
| CABG 2 arterial grafts | CPT 33534 | $6,793.85 |
| CABG 3 arterial grafts | CPT 33535 | $7,168.46 |
| CABG 4+ arterial grafts | CPT 33536 | $7,699.17 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $16,914 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $13,609 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $33,079 |
| Open appendectomy | CPT 44950 | $3,778.67 |
| Laparoscopic appendectomy | CPT 44970 | $6,009.51 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $61,534 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $36,742 |
| Major joint replacement w MCC | MS-DRG 469 | $29,270 |
| Major joint replacement w/o MCC | MS-DRG 470 | $18,783 |
| Laparoscopic cholecystectomy | CPT 47562 | $6,009.51 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $6,009.51 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $28,738 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $20,515 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $16,532 |
| Open umbilical hernia repair | CPT 49560 | $3,778.67 |
| Umbilical hernia repair age 5+ | CPT 49585 | $3,778.67 |
| Lap inguinal hernia repair | CPT 49650 | $6,009.51 |
| Lap incisional hernia repair | CPT 49652 | $6,009.51 |
| Total abdominal hysterectomy | CPT 58150 | $2,197.88 |
| Vaginal hysterectomy | CPT 58260 | $5,237.11 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $6,009.51 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $9,319 |
| Lap salpingo-oophorectomy | CPT 58661 | $6,009.51 |
| OR procedure for obesity w MCC | MS-DRG 619 | $29,056 |
| OR procedure for obesity w CC | MS-DRG 620 | $17,566 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $16,101 |
| Complex cataract surgery | CPT 66982 | $2,544.7 |
| Cataract surgery with lens implant | CPT 66984 | $3,236.61 |
| Intravitreal injection | CPT 67028 | $790.18 |
| Vitrectomy mechanical | CPT 67042 | $4,651.12 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $11,994 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $17,855 |
| PCI single major coronary artery | CPT 92920 | $5,892.24 |
| PCI with drug-eluting stent | CPT 92928 | $11,848 |
| PCI bypass graft | CPT 92937 | $11,848 |
| Left heart catheterization | CPT 93452 | $4,309.66 |
| Coronary angiography with cath | CPT 93455 | $4,309.66 |
| Coronary angiography with bypass cath | CPT 93458 | $4,309.66 |
