| Psychoses | MS-DRG 885 | $13,747 |
| Psychiatric diagnostic evaluation | CPT 90791 | $227.16 |
| Psychotherapy 30 minutes | CPT 90832 | $227.16 |
| Psychotherapy 45 minutes | CPT 90834 | — |
| Psychotherapy 60 minutes | CPT 90837 | $227.16 |
| ED visit level 1 | CPT 99281 | $161.88 |
| ED visit level 2 | CPT 99282 | $286.90 |
| ED visit level 3 | CPT 99283 | $349.37 |
| ED visit level 4 | CPT 99284 | — |
| ED visit level 5 | CPT 99285 | — |
| Critical care, first hour | CPT 99291 | $1,057.20 |
| CT head without contrast | CPT 70450 | $133.80 |
| CT head with contrast | CPT 70460 | $224.48 |
| CT head with and without contrast | CPT 70470 | $224.48 |
| CT neck with contrast | CPT 70491 | $224.48 |
| MRI brain without contrast | CPT 70551 | — |
| MRI brain with contrast | CPT 70552 | $446.50 |
| MRI brain with and without contrast | CPT 70553 | — |
| Chest X-ray single view | CPT 71045 | $33.00 |
| Chest X-ray 2 views | CPT 71046 | — |
| Chest X-ray 3 views | CPT 71047 | — |
| CT chest without contrast | CPT 71250 | — |
| CT chest with contrast | CPT 71260 | $224.48 |
| CT chest with and without contrast | CPT 71270 | $224.48 |
| MRI chest without contrast | CPT 71550 | $355.46 |
| MRI chest with and without contrast | CPT 71552 | $446.50 |
| Lumbosacral spine X-ray | CPT 72100 | $133.80 |
| CT cervical spine without contrast | CPT 72125 | $133.80 |
| CT thoracic spine without contrast | CPT 72128 | $133.80 |
| CT lumbar spine without contrast | CPT 72131 | $133.80 |
| MRI cervical spine without contrast | CPT 72141 | — |
| MRI thoracic spine without contrast | CPT 72146 | $305.38 |
| MRI lumbar spine without contrast | CPT 72148 | $305.38 |
| MRI lumbar spine with and without contrast | CPT 72149 | $446.50 |
| MRI cervical spine with and without contrast | CPT 72156 | $446.50 |
| MRI lumbar spine with contrast | CPT 72158 | $446.50 |
| CT pelvis without contrast | CPT 72192 | — |
| CT pelvis with contrast | CPT 72193 | $224.48 |
| Shoulder X-ray | CPT 73030 | — |
| Humerus X-ray | CPT 73060 | $111.37 |
| Hand X-ray 3 views | CPT 73130 | $145.00 |
| MRI upper extremity joint without contrast | CPT 73221 | — |
| MRI upper extremity joint with and without contrast | CPT 73223 | — |
| Knee X-ray 1-2 views | CPT 73560 | $162.00 |
| Ankle X-ray 3 views | CPT 73610 | — |
| MRI lower extremity joint without contrast | CPT 73721 | — |
| MRI lower extremity joint with and without contrast | CPT 73723 | $446.50 |
| CT abdomen without contrast | CPT 74150 | $133.80 |
| CT abdomen with contrast | CPT 74160 | $224.48 |
| CT abdomen with and without contrast | CPT 74170 | $255.65 |
| CT abdomen and pelvis without contrast | CPT 74176 | $305.38 |
| CT abdomen and pelvis with contrast | CPT 74177 | — |
| CT abdomen and pelvis with and without contrast | CPT 74178 | — |
| MRI abdomen without contrast | CPT 74181 | $305.38 |
| MRI abdomen with and without contrast | CPT 74183 | $446.50 |
| Abdominal ultrasound complete | CPT 76700 | $133.80 |
| Abdominal ultrasound limited | CPT 76705 | — |
| Retroperitoneal ultrasound complete | CPT 76770 | — |
| Obstetric ultrasound after first trimester | CPT 76805 | $133.80 |
| Transvaginal ultrasound | CPT 76830 | $133.80 |
| Pelvic ultrasound complete | CPT 76856 | $133.80 |
| Scrotal ultrasound | CPT 76870 | $133.80 |
| EKG tracing only | CPT 93005 | — |
| Transthoracic echocardiogram | CPT 93307 | $82.00 |
| Stress echocardiogram | CPT 93350 | $82.00 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $22,016 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $11,178 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $7,648.52 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $15,355 |
| COPD w MCC | MS-DRG 190 | $10,945 |
| COPD w CC | MS-DRG 191 | $9,366.24 |
| COPD w/o CC/MCC | MS-DRG 192 | $6,432.54 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $8,432.97 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $6,717.54 |
| AMI discharged alive w MCC | MS-DRG 280 | $17,609 |
| AMI discharged alive w CC | MS-DRG 281 | $10,190 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $8,067.67 |
| Heart failure & shock w MCC | MS-DRG 291 | $12,962 |
| Heart failure & shock w CC | MS-DRG 292 | $9,431.22 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $6,288.68 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $11,879 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $7,340.53 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $5,697.04 |
| GI hemorrhage w CC | MS-DRG 378 | $10,506 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $7,063.68 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $7,765.94 |
| Fractures of femur w/o MCC | MS-DRG 533 | $17,215 |
| Kidney/UTI w MCC | MS-DRG 689 | $12,803 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $8,055.69 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $19,671 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $10,128 |
| Basic metabolic panel (BMP) | CPT 80048 | — |
| Electrolyte panel | CPT 80051 | $7.15 |
| Comprehensive metabolic panel | CPT 80053 | — |
| Lipid panel | CPT 80061 | $13.39 |
| Hepatic function panel | CPT 80076 | — |
| Urinalysis non-automated | CPT 81002 | $3.48 |
| Urinalysis automated | CPT 81003 | $51.00 |
| Glucose quantitative | CPT 82947 | — |
| Hemoglobin A1c | CPT 83036 | — |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $16.94 |
| Complete blood count with automated differential | CPT 85025 | $7.77 |
| Complete blood count without differential | CPT 85027 | $4.53 |
| Urine culture bacterial | CPT 87086 | $6.77 |
| Tissue exam by pathologist level IV | CPT 88305 | $71.00 |
| Office visit, new patient, 15-29 min | CPT 99202 | — |
| Office visit, new patient, 30-44 minutes | CPT 99203 | — |
| Office visit, new patient, 45-59 min | CPT 99204 | — |
| Office visit, new patient, 60-74 min | CPT 99205 | — |
| Office visit, established patient, 5 min | CPT 99211 | — |
| Office visit, established patient, 10-19 min | CPT 99212 | — |
| Office visit, established patient, 20-29 minutes | CPT 99213 | — |
| Office visit, established patient, 30-39 minutes | CPT 99214 | — |
| Office visit, established patient, 40-54 min | CPT 99215 | — |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,160.81 |
| Sigmoidoscopy diagnostic | CPT 45330 | $1,190.22 |
| Total shoulder arthroplasty | CPT 23472 | $22,665 |
| Total knee replacement | CPT 27447 | $16,432 |
| Shoulder arthroscopy with decompression | CPT 29826 | $605.06 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $9,286.97 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $4,187.71 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $46,888 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $26,199 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $18,463 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $18,557 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $15,028 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $37,137 |
| Major joint replacement w MCC | MS-DRG 469 | $33,087 |
| Major joint replacement w/o MCC | MS-DRG 470 | $21,127 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $7,737.45 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $31,778 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $22,921 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $17,901 |
| Lap inguinal hernia repair | CPT 49650 | $7,737.45 |
| Lap salpingo-oophorectomy | CPT 58661 | $7,737.45 |
| OR procedure for obesity w MCC | MS-DRG 619 | $31,508 |
| OR procedure for obesity w CC | MS-DRG 620 | $17,568 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $16,573 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $13,674 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $20,068 |
| PCI single major coronary artery | CPT 92920 | — |
| PCI with drug-eluting stent | CPT 92928 | $20,074 |
| Left heart catheterization | CPT 93452 | — |
| Coronary angiography with cath | CPT 93455 | $4,149.23 |
| Coronary angiography with bypass cath | CPT 93458 | $4,149.23 |
