| Psychoses | MS-DRG 885 | $9,871.00 |
| Psychiatric diagnostic evaluation | CPT 90791 | $486.60 |
| Psychiatric eval with medical services | CPT 90792 | $538.90 |
| Psychotherapy 30 minutes | CPT 90832 | $207.08 |
| Psychotherapy 45 minutes | CPT 90834 | $265.61 |
| Psychotherapy 60 minutes | CPT 90837 | $470.57 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $491.47 |
| Critical care, first hour | CPT 99291 | $765.10 |
| CT head without contrast | CPT 70450 | $6,101.03 |
| CT head with contrast | CPT 70460 | $6,310.94 |
| CT head with and without contrast | CPT 70470 | $6,416.38 |
| CT neck with contrast | CPT 70491 | $7,081.09 |
| MRI brain without contrast | CPT 70551 | $6,986.83 |
| MRI brain with contrast | CPT 70552 | $7,435.07 |
| MRI brain with and without contrast | CPT 70553 | $7,798.53 |
| Chest X-ray single view | CPT 71045 | $4,503.64 |
| Chest X-ray 2 views | CPT 71046 | $976.38 |
| Chest X-ray 3 views | CPT 71047 | $4,618.55 |
| CT chest without contrast | CPT 71250 | $6,801.22 |
| CT chest with contrast | CPT 71260 | $7,081.09 |
| CT chest with and without contrast | CPT 71270 | $7,221.28 |
| MRI chest without contrast | CPT 71550 | $6,986.83 |
| MRI chest with contrast | CPT 71551 | $7,435.07 |
| MRI chest with and without contrast | CPT 71552 | $7,733.17 |
| Lumbosacral spine X-ray | CPT 72100 | $4,414.48 |
| CT cervical spine without contrast | CPT 72125 | $6,100.55 |
| CT thoracic spine without contrast | CPT 72128 | $6,100.55 |
| CT lumbar spine without contrast | CPT 72131 | $6,100.55 |
| MRI cervical spine without contrast | CPT 72141 | $3,880.10 |
| MRI thoracic spine without contrast | CPT 72146 | $6,986.83 |
| MRI lumbar spine without contrast | CPT 72148 | $3,880.10 |
| MRI lumbar spine with and without contrast | CPT 72149 | $7,435.07 |
| MRI cervical spine with and without contrast | CPT 72156 | $7,733.17 |
| MRI lumbar spine with contrast | CPT 72158 | $7,733.17 |
| CT pelvis without contrast | CPT 72192 | $6,801.22 |
| CT pelvis with contrast | CPT 72193 | $7,081.09 |
| Shoulder X-ray | CPT 73030 | $4,497.32 |
| Humerus X-ray | CPT 73060 | $4,379.73 |
| Hand X-ray 3 views | CPT 73130 | $4,397.23 |
| MRI upper extremity joint without contrast | CPT 73221 | $6,986.83 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $7,733.17 |
| Knee X-ray 1-2 views | CPT 73560 | $4,432.70 |
| Ankle X-ray 3 views | CPT 73610 | $4,397.23 |
| MRI lower extremity joint without contrast | CPT 73721 | $2,925.85 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $7,466.34 |
| CT abdomen without contrast | CPT 74150 | $6,801.22 |
| CT abdomen with contrast | CPT 74160 | $7,081.09 |
| CT abdomen with and without contrast | CPT 74170 | $7,010.64 |
| CT abdomen and pelvis without contrast | CPT 74176 | $7,735.12 |
| CT abdomen and pelvis with contrast | CPT 74177 | $8,108.77 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $8,460.43 |
| MRI abdomen without contrast | CPT 74181 | $7,334.49 |
| MRI abdomen with and without contrast | CPT 74183 | $7,733.17 |
| Abdominal ultrasound complete | CPT 76700 | $5,038.13 |
| Abdominal ultrasound limited | CPT 76705 | $4,775.50 |
| Retroperitoneal ultrasound complete | CPT 76770 | $4,774.04 |
| Obstetric ultrasound first trimester | CPT 76801 | $4,623.66 |
| Obstetric ultrasound after first trimester | CPT 76805 | $4,647.46 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $1,581.12 |
| Transvaginal ultrasound | CPT 76830 | $4,664.71 |
| Pelvic ultrasound complete | CPT 76856 | $4,775.50 |
| Scrotal ultrasound | CPT 76870 | $4,775.50 |
| EKG tracing only | CPT 93005 | $1,039.60 |
| Transthoracic echocardiogram complete | CPT 93306 | $6,587.04 |
| Transthoracic echocardiogram | CPT 93307 | $2,141.88 |
| Stress echocardiogram | CPT 93350 | $6,332.00 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $19,312 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $19,312 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $24,970 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $24,970 |
| COPD w MCC | MS-DRG 190 | $24,970 |
| COPD w CC | MS-DRG 191 | $9,871.00 |
| COPD w/o CC/MCC | MS-DRG 192 | $9,871.00 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $9,871.00 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $9,871.00 |
| Heart failure & shock w MCC | MS-DRG 291 | $38,730 |
| Heart failure & shock w CC | MS-DRG 292 | $9,871.00 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $9,871.00 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $9,871.00 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $9,871.00 |
| GI hemorrhage w CC | MS-DRG 378 | $9,871.00 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $9,871.00 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $9,871.00 |
| Fractures of femur w/o MCC | MS-DRG 533 | $9,871.00 |
| Kidney/UTI w MCC | MS-DRG 689 | $9,871.00 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $9,871.00 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $38,730 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $9,871.00 |
| Initial hospital care, low complexity | CPT 99221 | $342.94 |
| Initial hospital care, moderate complexity | CPT 99222 | $534.00 |
| Initial hospital care, high complexity | CPT 99223 | $786.00 |
| Hospital discharge, <30 min | CPT 99238 | $252.81 |
| Hospital discharge, >30 min | CPT 99239 | $418.00 |
| Basic metabolic panel (BMP) | CPT 80048 | $451.21 |
| Electrolyte panel | CPT 80051 | $551.21 |
| Comprehensive metabolic panel | CPT 80053 | $541.89 |
| Lipid panel | CPT 80061 | $288.60 |
| Renal function panel | CPT 80069 | $438.57 |
| Hepatic function panel | CPT 80076 | $375.36 |
| Urinalysis non-automated | CPT 81002 | $71.80 |
| Urinalysis automated | CPT 81003 | $159.56 |
| Glucose quantitative | CPT 82947 | $169.59 |
| Hemoglobin A1c | CPT 83036 | $26.16 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $35.42 |
| Complete blood count with automated differential | CPT 85025 | $194.00 |
| Complete blood count without differential | CPT 85027 | $193.56 |
| Urine culture bacterial | CPT 87086 | $413.72 |
| Urine culture identification | CPT 87088 | $241.95 |
| Tissue exam by pathologist level IV | CPT 88305 | $844.87 |
| Fetal non-stress test | CPT 59025 | $703.04 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $7,171.43 |
| Routine obstetric care with C-section | CPT 59510 | $7,879.75 |
| Office visit, new patient, 15-29 min | CPT 99202 | $274.91 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $350.95 |
| Office visit, new patient, 45-59 min | CPT 99204 | $438.33 |
| Office visit, new patient, 60-74 min | CPT 99205 | $685.16 |
| Office visit, established patient, 5 min | CPT 99211 | $88.34 |
| Office visit, established patient, 10-19 min | CPT 99212 | $167.10 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $270.37 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $389.21 |
| Office visit, established patient, 40-54 min | CPT 99215 | $459.04 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $12,858 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $9,871.00 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $9,871.00 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $9,871.00 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $9,871.00 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $38,730 |
| Major joint replacement w MCC | MS-DRG 469 | $12,858 |
| Major joint replacement w/o MCC | MS-DRG 470 | $12,858 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $9,871.00 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $9,871.00 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $9,871.00 |
| OR procedure for obesity w MCC | MS-DRG 619 | $12,858 |
| OR procedure for obesity w CC | MS-DRG 620 | $12,858 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $12,858 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $9,871.00 |
| PCI single major coronary artery | CPT 92920 | $6,843.45 |
| PCI with drug-eluting stent | CPT 92928 | $17,804 |
| Left heart catheterization | CPT 93452 | $20,494 |
| Coronary angiography with cath | CPT 93455 | $63,035 |
| Coronary angiography with bypass cath | CPT 93458 | $13,910 |
