| Psychiatric diagnostic evaluation | CPT 90791 | $289 |
| Psychotherapy 30 minutes | CPT 90832 | $102 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $174.25 |
| CT head without contrast | CPT 70450 | $494.7 |
| CT head with contrast | CPT 70460 | $755.16 |
| CT head with and without contrast | CPT 70470 | $842.52 |
| CT neck with contrast | CPT 70491 | $755.16 |
| MRI brain without contrast | CPT 70551 | $932.45 |
| MRI brain with contrast | CPT 70552 | $1,174.32 |
| MRI brain with and without contrast | CPT 70553 | $1,434.72 |
| Chest X-ray single view | CPT 71045 | $114.75 |
| Chest X-ray 2 views | CPT 71046 | $114.75 |
| CT chest without contrast | CPT 71250 | $494.7 |
| CT chest with contrast | CPT 71260 | $755.16 |
| CT chest with and without contrast | CPT 71270 | $842.52 |
| MRI chest without contrast | CPT 71550 | $932.45 |
| MRI chest with and without contrast | CPT 71552 | $1,451.8 |
| Lumbosacral spine X-ray | CPT 72100 | $115.43 |
| CT cervical spine without contrast | CPT 72125 | $494.7 |
| CT thoracic spine without contrast | CPT 72128 | $604.8 |
| CT lumbar spine without contrast | CPT 72131 | $494.7 |
| MRI cervical spine without contrast | CPT 72141 | $932.45 |
| MRI thoracic spine without contrast | CPT 72146 | $932.45 |
| MRI lumbar spine without contrast | CPT 72148 | $932.45 |
| MRI lumbar spine with and without contrast | CPT 72149 | $1,174.32 |
| MRI cervical spine with and without contrast | CPT 72156 | $1,434.72 |
| MRI lumbar spine with contrast | CPT 72158 | $1,434.72 |
| CT pelvis without contrast | CPT 72192 | $488.88 |
| CT pelvis with contrast | CPT 72193 | $755.16 |
| Shoulder X-ray | CPT 73030 | $115.43 |
| Humerus X-ray | CPT 73060 | $115.43 |
| Hand X-ray 3 views | CPT 73130 | $115.43 |
| MRI upper extremity joint without contrast | CPT 73221 | $932.45 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $1,434.72 |
| Knee X-ray 1-2 views | CPT 73560 | $105.17 |
| Ankle X-ray 3 views | CPT 73610 | $103.46 |
| MRI lower extremity joint without contrast | CPT 73721 | $815.15 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $1,434.72 |
| CT abdomen without contrast | CPT 74150 | $488.88 |
| CT abdomen with contrast | CPT 74160 | $755.16 |
| CT abdomen with and without contrast | CPT 74170 | $842.52 |
| CT abdomen and pelvis without contrast | CPT 74176 | $835.8 |
| CT abdomen and pelvis with contrast | CPT 74177 | $1,147.5 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $1,331.4 |
| MRI abdomen without contrast | CPT 74181 | $932.45 |
| MRI abdomen with and without contrast | CPT 74183 | $1,434.72 |
| Abdominal ultrasound complete | CPT 76700 | $296.69 |
| Abdominal ultrasound limited | CPT 76705 | $191.25 |
| Retroperitoneal ultrasound complete | CPT 76770 | $296.69 |
| Obstetric ultrasound first trimester | CPT 76801 | $186.15 |
| Obstetric ultrasound after first trimester | CPT 76805 | $256.5 |
| Transvaginal ultrasound | CPT 76830 | $247.1 |
| Pelvic ultrasound complete | CPT 76856 | $287.3 |
| Scrotal ultrasound | CPT 76870 | $257.55 |
| Diagnostic mammography unilateral | CPT 77065 | $55.25 |
| Diagnostic mammography bilateral | CPT 77066 | $250.75 |
| Screening mammography bilateral | CPT 77067 | $55.25 |
| EKG tracing only | CPT 93005 | $85 |
| Transthoracic echocardiogram complete | CPT 93306 | $595 |
| Transthoracic echocardiogram | CPT 93307 | $1,122 |
| Stress echocardiogram | CPT 93350 | $1,542.24 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $21,355 |
| COPD w MCC | MS-DRG 190 | $12,991 |
| COPD w CC | MS-DRG 191 | $10,458 |
| COPD w/o CC/MCC | MS-DRG 192 | $8,205.19 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $10,757 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $7,978.54 |
| AMI discharged alive w MCC | MS-DRG 280 | $19,041 |
| AMI discharged alive w CC | MS-DRG 281 | $11,480 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $8,478.95 |
| Heart failure & shock w MCC | MS-DRG 291 | $16,616 |
| Heart failure & shock w CC | MS-DRG 292 | $10,891 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $7,558.91 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $13,632 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $8,808.82 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $6,292.18 |
| GI hemorrhage w CC | MS-DRG 378 | $11,163 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $7,530.86 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $8,302.8 |
| Fractures of femur w/o MCC | MS-DRG 533 | $16,190 |
| Kidney/UTI w MCC | MS-DRG 689 | $12,141 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $8,783.02 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $20,113 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $11,699 |
| Basic metabolic panel (BMP) | CPT 80048 | $27.2 |
| General health panel | CPT 80050 | $161.71 |
| Electrolyte panel | CPT 80051 | $27.2 |
| Comprehensive metabolic panel | CPT 80053 | $29.75 |
| Lipid panel | CPT 80061 | $38.25 |
| Renal function panel | CPT 80069 | $26.88 |
| Hepatic function panel | CPT 80076 | $130.63 |
| Urinalysis non-automated | CPT 81002 | $8.4 |
| Urinalysis automated | CPT 81003 | $6.8 |
| Glucose quantitative | CPT 82947 | $10.08 |
| Hemoglobin A1c | CPT 83036 | $21.25 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $52.7 |
| Complete blood count with automated differential | CPT 85025 | $25.5 |
| Complete blood count without differential | CPT 85027 | $17 |
| Urine culture bacterial | CPT 87086 | $27.2 |
| Urine culture identification | CPT 87088 | $11.12 |
| Tissue exam by pathologist level IV | CPT 88305 | $85 |
| Fetal non-stress test | CPT 59025 | $323 |
| C-section delivery only | CPT 59514 | $3,603.15 |
| Cesarean section w CC/MCC | MS-DRG 765 | $10,459 |
| Cesarean section w/o CC/MCC | MS-DRG 766 | $7,409.73 |
| Vaginal delivery w complicating dx | MS-DRG 774 | $6,485.05 |
| Vaginal delivery w/o complicating dx | MS-DRG 775 | $5,133.77 |
| Office visit, new patient, 15-29 min | CPT 99202 | $127.5 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $191.25 |
| Office visit, new patient, 45-59 min | CPT 99204 | $259.25 |
| Office visit, new patient, 60-74 min | CPT 99205 | $340 |
| Office visit, established patient, 5 min | CPT 99211 | $47.6 |
| Office visit, established patient, 10-19 min | CPT 99212 | $102 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $127.5 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $191.25 |
| Office visit, established patient, 40-54 min | CPT 99215 | $297.5 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,277.37 |
| Upper GI endoscopy with biopsy | CPT 43239 | $940.5 |
| Sigmoidoscopy diagnostic | CPT 45330 | $919.7 |
| Sigmoidoscopy with biopsy | CPT 45331 | $682.55 |
| Colonoscopy diagnostic | CPT 45378 | $1,047.38 |
| Colonoscopy with biopsy | CPT 45380 | $1,320.98 |
| Colonoscopy with polyp removal | CPT 45385 | $1,409.04 |
| Total shoulder arthroplasty | CPT 23472 | $6,128.5 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $36,458 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $23,906 |
| Total hip replacement | CPT 27130 | $8,194.85 |
| Total knee replacement | CPT 27447 | $7,441.75 |
| Knee revision arthroplasty single component | CPT 27486 | $4,920.65 |
| Knee revision arthroplasty all components | CPT 27487 | $8,755 |
| Shoulder arthroscopy with decompression | CPT 29826 | $3,076.15 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $5,283.9 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $4,377.5 |
| ACL reconstruction | CPT 29888 | $6,164.55 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $57,251 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $28,623 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $18,503 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $18,607 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $14,070 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $42,035 |
| Open appendectomy | CPT 44950 | $2,145.4 |
| Laparoscopic appendectomy | CPT 44970 | $4,403.25 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $73,441 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $45,450 |
| Major joint replacement w MCC | MS-DRG 469 | $36,983 |
| Major joint replacement w/o MCC | MS-DRG 470 | $23,356 |
| Laparoscopic cholecystectomy | CPT 47562 | $5,636.16 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $4,579.38 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $33,649 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $22,265 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $18,208 |
| Open umbilical hernia repair | CPT 49560 | $3,413.67 |
| Umbilical hernia repair age 5+ | CPT 49585 | $3,677.1 |
| Lap inguinal hernia repair | CPT 49650 | $5,778.3 |
| Lap incisional hernia repair | CPT 49652 | $10,430 |
| Total abdominal hysterectomy | CPT 58150 | $11,382 |
| Vaginal hysterectomy | CPT 58260 | $4,681.8 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $8,062 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $8,096.98 |
| Lap salpingo-oophorectomy | CPT 58661 | $5,724.23 |
| OR procedure for obesity w MCC | MS-DRG 619 | $34,902 |
| OR procedure for obesity w CC | MS-DRG 620 | $21,105 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $18,861 |
| Complex cataract surgery | CPT 66982 | $1,892.1 |
| Cataract surgery with lens implant | CPT 66984 | $617.31 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $12,585 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $18,907 |
