| Psychoses | MS-DRG 885 | $11,126 |
| Psychiatric diagnostic evaluation | CPT 90791 | $359.57 |
| Psychiatric eval with medical services | CPT 90792 | $163.18 |
| Psychotherapy 30 minutes | CPT 90832 | $166.94 |
| Psychotherapy 45 minutes | CPT 90834 | $219.82 |
| Psychotherapy 60 minutes | CPT 90837 | $324.82 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $163.18 |
| ED visit level 1 | CPT 99281 | $121.02 |
| ED visit level 2 | CPT 99282 | $156.44 |
| ED visit level 3 | CPT 99283 | $274.42 |
| ED visit level 4 | CPT 99284 | $427.38 |
| ED visit level 5 | CPT 99285 | $613.85 |
| Critical care, first hour | CPT 99291 | $859.8 |
| CT head without contrast | CPT 70450 | $139.1 |
| CT head with contrast | CPT 70460 | $201.97 |
| CT head with and without contrast | CPT 70470 | $201.97 |
| CT neck with contrast | CPT 70491 | $202.22 |
| MRI brain without contrast | CPT 70551 | $261.53 |
| MRI brain with contrast | CPT 70552 | $412.62 |
| MRI brain with and without contrast | CPT 70553 | $412.62 |
| Chest X-ray single view | CPT 71045 | $97.3 |
| Chest X-ray 2 views | CPT 71046 | $97.3 |
| Chest X-ray 3 views | CPT 71047 | $47.54 |
| CT chest without contrast | CPT 71250 | $160.72 |
| CT chest with contrast | CPT 71260 | $204.62 |
| CT chest with and without contrast | CPT 71270 | $201.97 |
| MRI chest without contrast | CPT 71550 | $261.53 |
| MRI chest with contrast | CPT 71551 | $829.6 |
| MRI chest with and without contrast | CPT 71552 | $412.62 |
| Lumbosacral spine X-ray | CPT 72100 | $119.7 |
| CT cervical spine without contrast | CPT 72125 | $194.84 |
| CT thoracic spine without contrast | CPT 72128 | $157.5 |
| CT lumbar spine without contrast | CPT 72131 | $157.1 |
| MRI cervical spine without contrast | CPT 72141 | $261.53 |
| MRI thoracic spine without contrast | CPT 72146 | $261.53 |
| MRI lumbar spine without contrast | CPT 72148 | $261.53 |
| MRI lumbar spine with and without contrast | CPT 72149 | $412.62 |
| MRI cervical spine with and without contrast | CPT 72156 | $412.62 |
| MRI lumbar spine with contrast | CPT 72158 | $412.62 |
| CT pelvis without contrast | CPT 72192 | $161.07 |
| CT pelvis with contrast | CPT 72193 | $213.73 |
| Shoulder X-ray | CPT 73030 | $47.56 |
| Humerus X-ray | CPT 73060 | $45.3 |
| Hand X-ray 3 views | CPT 73130 | $45.57 |
| MRI upper extremity joint without contrast | CPT 73221 | $261.53 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $412.62 |
| Hip X-ray 2 views | CPT 73510 | $50.2 |
| Knee X-ray 1-2 views | CPT 73560 | $43.93 |
| Ankle X-ray 3 views | CPT 73610 | $271.8 |
| MRI lower extremity joint without contrast | CPT 73721 | $261.53 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $412.62 |
| CT abdomen without contrast | CPT 74150 | $164.99 |
| CT abdomen with contrast | CPT 74160 | $225.48 |
| CT abdomen with and without contrast | CPT 74170 | $240.67 |
| CT abdomen and pelvis without contrast | CPT 74176 | $261.53 |
| CT abdomen and pelvis with contrast | CPT 74177 | $412.62 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $423.6 |
| MRI abdomen without contrast | CPT 74181 | $261.53 |
| MRI abdomen with and without contrast | CPT 74183 | $412.62 |
| Abdominal ultrasound complete | CPT 76700 | $119.7 |
| Abdominal ultrasound limited | CPT 76705 | $111.32 |
| Retroperitoneal ultrasound complete | CPT 76770 | $119.7 |
| Obstetric ultrasound first trimester | CPT 76801 | $119.7 |
| Obstetric ultrasound after first trimester | CPT 76805 | $119.7 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $241.95 |
| Transvaginal ultrasound | CPT 76830 | $119.7 |
| Pelvic ultrasound complete | CPT 76856 | $114.83 |
| Scrotal ultrasound | CPT 76870 | $119.05 |
| Diagnostic mammography unilateral | CPT 77065 | $90.59 |
| Diagnostic mammography bilateral | CPT 77066 | $113.15 |
| Screening mammography bilateral | CPT 77067 | $164.64 |
| EKG complete | CPT 93000 | $23.63 |
| EKG tracing only | CPT 93005 | $15.16 |
| EKG interpretation only | CPT 93010 | $8.47 |
| Transthoracic echocardiogram complete | CPT 93306 | $563.48 |
| Transthoracic echocardiogram | CPT 93307 | $261.53 |
| Stress echocardiogram | CPT 93350 | $563.48 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $16,673 |
| COPD w MCC | MS-DRG 190 | $8,325.07 |
| COPD w CC | MS-DRG 191 | $8,325.07 |
| COPD w/o CC/MCC | MS-DRG 192 | $8,325.07 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $10,197 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $8,483.93 |
| AMI discharged alive w MCC | MS-DRG 280 | $13,610 |
| AMI discharged alive w CC | MS-DRG 281 | $12,011 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $10,742 |
| Heart failure & shock w MCC | MS-DRG 291 | $11,865 |
| Heart failure & shock w CC | MS-DRG 292 | $11,865 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $11,865 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $9,252.56 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $8,794.24 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $7,160.96 |
| GI hemorrhage w CC | MS-DRG 378 | $9,338.07 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $7,580.73 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $6,938.31 |
| Fractures of femur w/o MCC | MS-DRG 533 | $6,104.62 |
| Kidney/UTI w MCC | MS-DRG 689 | $7,991.45 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $7,086.29 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $16,208 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $16,200 |
| Initial hospital care, low complexity | CPT 99221 | $53.33 |
| Initial hospital care, moderate complexity | CPT 99222 | $87.63 |
| Initial hospital care, high complexity | CPT 99223 | $116.67 |
| Hospital discharge, <30 min | CPT 99238 | $50.28 |
| Hospital discharge, >30 min | CPT 99239 | $65.64 |
| Basic metabolic panel (BMP) | CPT 80048 | $11.7 |
| General health panel | CPT 80050 | $106.58 |
| Electrolyte panel | CPT 80051 | $8.35 |
| Comprehensive metabolic panel | CPT 80053 | $12.59 |
| Lipid panel | CPT 80061 | $18.51 |
| Renal function panel | CPT 80069 | $10.34 |
| Hepatic function panel | CPT 80076 | $9.73 |
| Urinalysis non-automated | CPT 81002 | $4.06 |
| Urinalysis automated | CPT 81003 | $2.68 |
| Glucose quantitative | CPT 82947 | $27.9 |
| Hemoglobin A1c | CPT 83036 | $11.57 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $109.8 |
| Complete blood count with automated differential | CPT 85025 | $9.26 |
| Complete blood count without differential | CPT 85027 | $8.95 |
| Urine culture bacterial | CPT 87086 | $9.62 |
| Urine culture identification | CPT 87088 | $8.09 |
| Tissue exam by pathologist level IV | CPT 88305 | $56.15 |
| Fetal non-stress test | CPT 59025 | $199.49 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $1,113.88 |
| Vaginal delivery only | CPT 59409 | $3,166.56 |
| Vaginal delivery with postpartum | CPT 59410 | $684.96 |
| Routine obstetric care with C-section | CPT 59510 | $1,500 |
| C-section delivery only | CPT 59514 | $930.03 |
| C-section with postpartum | CPT 59515 | $1,000 |
| Cesarean section w CC/MCC | MS-DRG 765 | $3,681 |
| Cesarean section w/o CC/MCC | MS-DRG 766 | $3,681 |
| Vaginal delivery w complicating dx | MS-DRG 774 | $3,681 |
| Vaginal delivery w/o complicating dx | MS-DRG 775 | $3,681 |
| Office visit, new patient, 15-29 min | CPT 99202 | $48.03 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $68.82 |
| Office visit, new patient, 45-59 min | CPT 99204 | $99.17 |
| Office visit, new patient, 60-74 min | CPT 99205 | $122.28 |
| Office visit, established patient, 5 min | CPT 99211 | $9.17 |
| Office visit, established patient, 10-19 min | CPT 99212 | $24.13 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $36.31 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $56.46 |
| Office visit, established patient, 40-54 min | CPT 99215 | $83.57 |
| Upper GI endoscopy diagnostic | CPT 43235 | $924.52 |
| Upper GI endoscopy with biopsy | CPT 43239 | $924.52 |
| Sigmoidoscopy diagnostic | CPT 45330 | $930.71 |
| Sigmoidoscopy with biopsy | CPT 45331 | $930.71 |
| Colonoscopy diagnostic | CPT 45378 | $930.71 |
| Colonoscopy with biopsy | CPT 45380 | $1,212.79 |
| Colonoscopy with polyp removal | CPT 45385 | $1,212.79 |
| Total shoulder arthroplasty | CPT 23472 | $14,613 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $22,444 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $16,596 |
| Hip hemiarthroplasty | CPT 27125 | $891.37 |
| Total hip replacement | CPT 27130 | $14,613 |
| Total knee replacement | CPT 27447 | $14,613 |
| Knee revision arthroplasty single component | CPT 27486 | $1,149.06 |
| Knee revision arthroplasty all components | CPT 27487 | $1,483.24 |
| Shoulder arthroscopy with decompression | CPT 29826 | $575.82 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $7,407.99 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $3,333.68 |
| ACL reconstruction | CPT 29888 | $7,407.99 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $30,743 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $25,327 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $15,202 |
| CABG single arterial graft | CPT 33533 | $1,847.57 |
| CABG 2 arterial grafts | CPT 33534 | $1,718.37 |
| CABG 3 arterial grafts | CPT 33535 | $1,875.81 |
| CABG 4+ arterial grafts | CPT 33536 | $2,031.76 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $11,833 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $8,470.49 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $25,414 |
| Open appendectomy | CPT 44950 | $3,966.75 |
| Laparoscopic appendectomy | CPT 44970 | $5,837.3 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $32,044 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $30,289 |
| Major joint replacement w MCC | MS-DRG 469 | $16,765 |
| Major joint replacement w/o MCC | MS-DRG 470 | $12,124 |
| Laparoscopic cholecystectomy | CPT 47562 | $5,837.3 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $5,837.3 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $19,870 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $19,435 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $14,651 |
| Open umbilical hernia repair | CPT 49560 | $1,829.01 |
| Umbilical hernia repair age 5+ | CPT 49585 | $1,738.61 |
| Lap inguinal hernia repair | CPT 49650 | $5,837.3 |
| Lap incisional hernia repair | CPT 49652 | $1,814.51 |
| Total abdominal hysterectomy | CPT 58150 | $837.47 |
| Vaginal hysterectomy | CPT 58260 | $5,191.05 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $5,837.3 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $10,177 |
| Lap salpingo-oophorectomy | CPT 58661 | $5,837.3 |
| OR procedure for obesity w MCC | MS-DRG 619 | $20,563 |
| OR procedure for obesity w CC | MS-DRG 620 | $20,563 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $20,484 |
| Complex cataract surgery | CPT 66982 | $2,418.44 |
| Cataract surgery with lens implant | CPT 66984 | $2,418.44 |
| Intravitreal injection | CPT 67028 | $372.51 |
| Vitrectomy mechanical | CPT 67042 | $4,474.81 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $9,377.49 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $7,832.49 |
| PCI single major coronary artery | CPT 92920 | $5,840.94 |
| PCI with drug-eluting stent | CPT 92928 | $11,889 |
| PCI bypass graft | CPT 92937 | $11,889 |
| Left heart catheterization | CPT 93452 | $3,313.3 |
| Coronary angiography with cath | CPT 93455 | $3,313.3 |
| Coronary angiography with bypass cath | CPT 93458 | $3,313.3 |
