| Psychoses | MS-DRG 885 | $12,836 |
| Psychiatric diagnostic evaluation | CPT 90791 | $109.8 |
| Psychotherapy 45 minutes | CPT 90834 | $70.54 |
| Psychotherapy 60 minutes | CPT 90837 | $78.84 |
| ED visit level 1 | CPT 99281 | $108 |
| ED visit level 2 | CPT 99282 | $203.36 |
| ED visit level 3 | CPT 99283 | $465.24 |
| ED visit level 4 | CPT 99284 | $550.71 |
| ED visit level 5 | CPT 99285 | $985.32 |
| Critical care, first hour | CPT 99291 | $932.03 |
| CT head without contrast | CPT 70450 | $244.79 |
| CT head with contrast | CPT 70460 | $355.58 |
| CT head with and without contrast | CPT 70470 | $397.51 |
| CT neck with contrast | CPT 70491 | $355.58 |
| MRI brain without contrast | CPT 70551 | $354.1 |
| MRI brain with contrast | CPT 70552 | $472.57 |
| MRI brain with and without contrast | CPT 70553 | $539.44 |
| Chest X-ray single view | CPT 71045 | $89.39 |
| Chest X-ray 2 views | CPT 71046 | $89.39 |
| Chest X-ray 3 views | CPT 71047 | $89.39 |
| CT chest without contrast | CPT 71250 | $244.79 |
| CT chest with contrast | CPT 71260 | $355.58 |
| CT chest with and without contrast | CPT 71270 | $397.51 |
| MRI chest without contrast | CPT 71550 | $371.99 |
| MRI chest with contrast | CPT 71551 | $722.13 |
| MRI chest with and without contrast | CPT 71552 | $539.44 |
| Lumbosacral spine X-ray | CPT 72100 | $89.39 |
| CT cervical spine without contrast | CPT 72125 | $244.79 |
| CT thoracic spine without contrast | CPT 72128 | $244.79 |
| CT lumbar spine without contrast | CPT 72131 | $244.79 |
| MRI cervical spine without contrast | CPT 72141 | $354.1 |
| MRI thoracic spine without contrast | CPT 72146 | $354.1 |
| MRI lumbar spine without contrast | CPT 72148 | $354.1 |
| MRI lumbar spine with and without contrast | CPT 72149 | $472.57 |
| MRI cervical spine with and without contrast | CPT 72156 | $539.44 |
| MRI lumbar spine with contrast | CPT 72158 | $539.44 |
| CT pelvis without contrast | CPT 72192 | $244.79 |
| CT pelvis with contrast | CPT 72193 | $355.58 |
| Shoulder X-ray | CPT 73030 | $178.47 |
| Humerus X-ray | CPT 73060 | $89.39 |
| Hand X-ray 3 views | CPT 73130 | $178.47 |
| MRI upper extremity joint without contrast | CPT 73221 | $354.1 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $539.44 |
| Knee X-ray 1-2 views | CPT 73560 | $178.47 |
| Ankle X-ray 3 views | CPT 73610 | $178.47 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,006.56 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $397.82 |
| CT abdomen without contrast | CPT 74150 | $244.79 |
| CT abdomen with contrast | CPT 74160 | $355.58 |
| CT abdomen with and without contrast | CPT 74170 | $402.36 |
| CT abdomen and pelvis without contrast | CPT 74176 | $497.77 |
| CT abdomen and pelvis with contrast | CPT 74177 | $601.8 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $601.8 |
| MRI abdomen without contrast | CPT 74181 | $354.1 |
| MRI abdomen with and without contrast | CPT 74183 | $539.44 |
| Abdominal ultrasound complete | CPT 76700 | $139.72 |
| Abdominal ultrasound limited | CPT 76705 | $139.72 |
| Retroperitoneal ultrasound complete | CPT 76770 | $139.72 |
| Obstetric ultrasound first trimester | CPT 76801 | $139.72 |
| Obstetric ultrasound after first trimester | CPT 76805 | $143.01 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $265.63 |
| Transvaginal ultrasound | CPT 76830 | $141.65 |
| Pelvic ultrasound complete | CPT 76856 | $139.72 |
| Scrotal ultrasound | CPT 76870 | $139.72 |
| Diagnostic mammography unilateral | CPT 77065 | $95.52 |
| Diagnostic mammography bilateral | CPT 77066 | $107.51 |
| Screening mammography bilateral | CPT 77067 | $106 |
| EKG tracing only | CPT 93005 | $52.4 |
| Transthoracic echocardiogram complete | CPT 93306 | $767.33 |
| Transthoracic echocardiogram | CPT 93307 | $406.81 |
| Stress echocardiogram | CPT 93350 | $367.4 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $15,882 |
| COPD w MCC | MS-DRG 190 | $10,537 |
| COPD w CC | MS-DRG 191 | $8,337.64 |
| COPD w/o CC/MCC | MS-DRG 192 | $6,536.09 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $8,104.62 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $6,395.23 |
| AMI discharged alive w MCC | MS-DRG 280 | $14,853 |
| AMI discharged alive w CC | MS-DRG 281 | $8,894.1 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $7,199.5 |
| Heart failure & shock w MCC | MS-DRG 291 | $12,119 |
| Heart failure & shock w CC | MS-DRG 292 | $8,402.85 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $5,837.9 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $11,409 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $7,430.77 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $5,764 |
| GI hemorrhage w CC | MS-DRG 378 | $9,509.69 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $6,461.31 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $7,786.39 |
| Kidney/UTI w MCC | MS-DRG 689 | $11,167 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $7,971.59 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $18,561 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $9,910.51 |
| Basic metabolic panel (BMP) | CPT 80048 | $15.08 |
| General health panel | CPT 80050 | $95.25 |
| Electrolyte panel | CPT 80051 | $12.43 |
| Comprehensive metabolic panel | CPT 80053 | $18.77 |
| Lipid panel | CPT 80061 | $18.22 |
| Renal function panel | CPT 80069 | $15.4 |
| Hepatic function panel | CPT 80076 | $14.53 |
| Urinalysis non-automated | CPT 81002 | $3.48 |
| Urinalysis automated | CPT 81003 | $4 |
| Glucose quantitative | CPT 82947 | $7.56 |
| Hemoglobin A1c | CPT 83036 | $17.22 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $29.85 |
| Complete blood count with automated differential | CPT 85025 | $13.82 |
| Complete blood count without differential | CPT 85027 | $11.5 |
| Urine culture bacterial | CPT 87086 | $14.38 |
| Urine culture identification | CPT 87088 | $14.43 |
| Tissue exam by pathologist level IV | CPT 88305 | $64.76 |
| Fetal non-stress test | CPT 59025 | $168.2 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $42,286 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $22,208 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $15,653 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $15,304 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $12,374 |
| Major joint replacement w MCC | MS-DRG 469 | $31,174 |
| Major joint replacement w/o MCC | MS-DRG 470 | $17,616 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $27,608 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $19,425 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $14,871 |
| PCI single major coronary artery | CPT 92920 | $5,936.53 |
| PCI with drug-eluting stent | CPT 92928 | $10,263 |
| PCI bypass graft | CPT 92937 | $8,814.64 |
| Left heart catheterization | CPT 93452 | $3,965.23 |
| Coronary angiography with cath | CPT 93455 | $3,077.72 |
| Coronary angiography with bypass cath | CPT 93458 | $4,386.79 |
