| Psychoses | MS-DRG 885 | $16,853 |
| Psychiatric diagnostic evaluation | CPT 90791 | $402.52 |
| Psychiatric eval with medical services | CPT 90792 | $321.57 |
| Psychotherapy 30 minutes | CPT 90832 | $242.85 |
| Psychotherapy 45 minutes | CPT 90834 | $251.23 |
| Psychotherapy 60 minutes | CPT 90837 | $321.57 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $252.48 |
| ED visit level 1 | CPT 99281 | $65.00 |
| ED visit level 2 | CPT 99282 | $239.36 |
| ED visit level 3 | CPT 99283 | $432.95 |
| ED visit level 4 | CPT 99284 | $749.17 |
| ED visit level 5 | CPT 99285 | $1,397.20 |
| Critical care, first hour | CPT 99291 | $3,248.49 |
| CT head without contrast | CPT 70450 | $1,011.46 |
| CT head with contrast | CPT 70460 | $1,314.94 |
| CT head with and without contrast | CPT 70470 | $1,416.04 |
| CT neck with contrast | CPT 70491 | $1,314.94 |
| MRI brain without contrast | CPT 70551 | $1,511.76 |
| MRI brain with contrast | CPT 70552 | $1,632.43 |
| MRI brain with and without contrast | CPT 70553 | $2,231.63 |
| Chest X-ray single view | CPT 71045 | $175.12 |
| Chest X-ray 2 views | CPT 71046 | $184.26 |
| Chest X-ray 3 views | CPT 71047 | $194.00 |
| CT chest without contrast | CPT 71250 | $1,011.46 |
| CT chest with contrast | CPT 71260 | $1,314.94 |
| CT chest with and without contrast | CPT 71270 | $1,416.04 |
| MRI chest without contrast | CPT 71550 | $1,588.73 |
| MRI chest with contrast | CPT 71551 | $1,678.92 |
| MRI chest with and without contrast | CPT 71552 | $2,231.63 |
| Lumbosacral spine X-ray | CPT 72100 | $194.00 |
| CT cervical spine without contrast | CPT 72125 | $1,011.46 |
| CT thoracic spine without contrast | CPT 72128 | $1,011.46 |
| CT lumbar spine without contrast | CPT 72131 | $1,011.46 |
| MRI cervical spine without contrast | CPT 72141 | $1,588.73 |
| MRI thoracic spine without contrast | CPT 72146 | $1,588.73 |
| MRI lumbar spine without contrast | CPT 72148 | $1,588.73 |
| MRI lumbar spine with and without contrast | CPT 72149 | $1,632.43 |
| MRI cervical spine with and without contrast | CPT 72156 | $2,231.63 |
| MRI lumbar spine with contrast | CPT 72158 | $2,231.63 |
| CT pelvis without contrast | CPT 72192 | $1,011.46 |
| CT pelvis with contrast | CPT 72193 | $1,314.94 |
| Shoulder X-ray | CPT 73030 | $184.62 |
| Humerus X-ray | CPT 73060 | $474.64 |
| Hand X-ray 3 views | CPT 73130 | $176.77 |
| MRI upper extremity joint without contrast | CPT 73221 | $2,087.14 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $2,231.63 |
| Hip X-ray 2 views | CPT 73510 | $109.26 |
| Knee X-ray 1-2 views | CPT 73560 | $174.40 |
| Ankle X-ray 3 views | CPT 73610 | $209.88 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,588.73 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $2,231.63 |
| CT abdomen without contrast | CPT 74150 | $1,011.46 |
| CT abdomen with contrast | CPT 74160 | $1,314.94 |
| CT abdomen with and without contrast | CPT 74170 | $1,416.04 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,011.46 |
| CT abdomen and pelvis with contrast | CPT 74177 | $1,416.04 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $1,011.46 |
| MRI abdomen without contrast | CPT 74181 | $1,588.73 |
| MRI abdomen with and without contrast | CPT 74183 | $2,231.63 |
| Abdominal ultrasound complete | CPT 76700 | $390.72 |
| Abdominal ultrasound limited | CPT 76705 | $285.24 |
| Retroperitoneal ultrasound complete | CPT 76770 | $360.08 |
| Obstetric ultrasound first trimester | CPT 76801 | $366.01 |
| Obstetric ultrasound after first trimester | CPT 76805 | $412.05 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $639.25 |
| Transvaginal ultrasound | CPT 76830 | $310.27 |
| Pelvic ultrasound complete | CPT 76856 | $347.94 |
| Scrotal ultrasound | CPT 76870 | $326.77 |
| Diagnostic mammography unilateral | CPT 77065 | $246.91 |
| Diagnostic mammography bilateral | CPT 77066 | $377.71 |
| Screening mammography bilateral | CPT 77067 | $317.54 |
| EKG complete | CPT 93000 | $69.34 |
| EKG tracing only | CPT 93005 | $334.25 |
| EKG interpretation only | CPT 93010 | $29.41 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,347.50 |
| Transthoracic echocardiogram | CPT 93307 | $1,014.30 |
| Stress echocardiogram | CPT 93350 | $1,357.80 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $23,783 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $12,158 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $8,229.32 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $19,327 |
| COPD w MCC | MS-DRG 190 | $13,427 |
| COPD w CC | MS-DRG 191 | $10,271 |
| COPD w/o CC/MCC | MS-DRG 192 | $7,737.93 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $9,803.92 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $7,445.00 |
| AMI discharged alive w MCC | MS-DRG 280 | $19,625 |
| AMI discharged alive w CC | MS-DRG 281 | $11,021 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $8,669.30 |
| Heart failure & shock w MCC | MS-DRG 291 | $15,600 |
| Heart failure & shock w CC | MS-DRG 292 | $10,297 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $6,560.26 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $14,418 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $8,839.07 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $6,689.39 |
| GI hemorrhage w CC | MS-DRG 378 | $11,787 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $7,612.39 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $9,329.27 |
| Fractures of femur w/o MCC | MS-DRG 533 | $18,232 |
| Kidney/UTI w MCC | MS-DRG 689 | $13,992 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $9,595.89 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $23,459 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $12,327 |
| Initial hospital care, low complexity | CPT 99221 | $222.74 |
| Initial hospital care, moderate complexity | CPT 99222 | $304.68 |
| Initial hospital care, high complexity | CPT 99223 | $447.57 |
| Hospital discharge, <30 min | CPT 99238 | $165.99 |
| Hospital discharge, >30 min | CPT 99239 | $239.54 |
| Basic metabolic panel (BMP) | CPT 80048 | $49.86 |
| General health panel | CPT 80050 | $202.36 |
| Electrolyte panel | CPT 80051 | $25.58 |
| Comprehensive metabolic panel | CPT 80053 | $89.34 |
| Lipid panel | CPT 80061 | $50.42 |
| Renal function panel | CPT 80069 | $31.15 |
| Hepatic function panel | CPT 80076 | $66.03 |
| Urinalysis non-automated | CPT 81002 | $5.84 |
| Urinalysis automated | CPT 81003 | $8.53 |
| Glucose quantitative | CPT 82947 | $14.46 |
| Hemoglobin A1c | CPT 83036 | $61.22 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $128.26 |
| Complete blood count with automated differential | CPT 85025 | $38.26 |
| Complete blood count without differential | CPT 85027 | $24.83 |
| Urine culture bacterial | CPT 87086 | $30.77 |
| Urine culture identification | CPT 87088 | $63.51 |
| Tissue exam by pathologist level IV | CPT 88305 | $317.54 |
| Fetal non-stress test | CPT 59025 | $601.65 |
| Vaginal delivery only | CPT 59409 | $1,681.01 |
| Office visit, new patient, 15-29 min | CPT 99202 | $124.68 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $155.17 |
| Office visit, new patient, 45-59 min | CPT 99204 | $186.73 |
| Office visit, new patient, 60-74 min | CPT 99205 | $218.29 |
| Office visit, established patient, 5 min | CPT 99211 | $102.96 |
| Office visit, established patient, 10-19 min | CPT 99212 | $129.60 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $155.17 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $186.73 |
| Office visit, established patient, 40-54 min | CPT 99215 | $218.29 |
| Upper GI endoscopy diagnostic | CPT 43235 | $2,623.74 |
| Upper GI endoscopy with biopsy | CPT 43239 | $2,623.74 |
| Sigmoidoscopy diagnostic | CPT 45330 | $2,597.87 |
| Sigmoidoscopy with biopsy | CPT 45331 | $2,597.87 |
| Colonoscopy diagnostic | CPT 45378 | $1,954.00 |
| Colonoscopy with biopsy | CPT 45380 | $2,865.44 |
| Colonoscopy with polyp removal | CPT 45385 | $2,865.44 |
| Total shoulder arthroplasty | CPT 23472 | $23,667 |
| Hip hemiarthroplasty | CPT 27125 | $12,497 |
| Total hip replacement | CPT 27130 | $19,448 |
| Total knee replacement | CPT 27447 | $19,448 |
| Knee revision arthroplasty single component | CPT 27486 | $17,349 |
| Knee revision arthroplasty all components | CPT 27487 | $17,349 |
| Shoulder arthroscopy with decompression | CPT 29826 | $3,655.50 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $11,749 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $6,481.46 |
| ACL reconstruction | CPT 29888 | $11,749 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $54,901 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $28,260 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $19,739 |
| CABG single arterial graft | CPT 33533 | $3,779.00 |
| CABG 2 arterial grafts | CPT 33534 | $3,779.00 |
| CABG 3 arterial grafts | CPT 33535 | $3,779.00 |
| CABG 4+ arterial grafts | CPT 33536 | $3,779.00 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $19,828 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $15,753 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $42,199 |
| Open appendectomy | CPT 44950 | $8,799.72 |
| Laparoscopic appendectomy | CPT 44970 | $11,412 |
| Major joint replacement w MCC | MS-DRG 469 | $39,081 |
| Major joint replacement w/o MCC | MS-DRG 470 | $22,543 |
| Laparoscopic cholecystectomy | CPT 47562 | $11,412 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $11,412 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $35,163 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $24,808 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $18,967 |
| Lap inguinal hernia repair | CPT 49650 | $11,412 |
| Total abdominal hysterectomy | CPT 58150 | $7,252.50 |
| Vaginal hysterectomy | CPT 58260 | $7,461.49 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $11,412 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $14,905 |
| Lap salpingo-oophorectomy | CPT 58661 | $11,412 |
| OR procedure for obesity w MCC | MS-DRG 619 | $32,598 |
| OR procedure for obesity w CC | MS-DRG 620 | $19,094 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $17,477 |
| Complex cataract surgery | CPT 66982 | $4,849.88 |
| Cataract surgery with lens implant | CPT 66984 | $4,849.88 |
| Intravitreal injection | CPT 67028 | $1,961.93 |
| Vitrectomy mechanical | CPT 67042 | $7,955.77 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $14,332 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $23,362 |
| PCI single major coronary artery | CPT 92920 | $8,617.90 |
| PCI with drug-eluting stent | CPT 92928 | $7,190.59 |
| PCI bypass graft | CPT 92937 | $11,953 |
| Left heart catheterization | CPT 93452 | $5,626.40 |
| Coronary angiography with cath | CPT 93455 | $7,480.01 |
| Coronary angiography with bypass cath | CPT 93458 | $8,388.80 |
