| Psychoses | MS-DRG 885 | $9,381.25 |
| Psychiatric diagnostic evaluation | CPT 90791 | $209.36 |
| Psychiatric eval with medical services | CPT 90792 | $209.36 |
| Psychotherapy 30 minutes | CPT 90832 | $209.36 |
| Psychotherapy 45 minutes | CPT 90834 | $209.36 |
| Psychotherapy 60 minutes | CPT 90837 | $209.36 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $172.51 |
| ED visit level 1 | CPT 99281 | $91.79 |
| ED visit level 2 | CPT 99282 | $165.08 |
| ED visit level 3 | CPT 99283 | $288.64 |
| ED visit level 4 | CPT 99284 | $443.88 |
| ED visit level 5 | CPT 99285 | $639.11 |
| Critical care, first hour | CPT 99291 | $878.35 |
| CT head without contrast | CPT 70450 | $139.06 |
| CT head with contrast | CPT 70460 | $237.53 |
| CT head with and without contrast | CPT 70470 | $237.53 |
| CT neck with contrast | CPT 70491 | $237.53 |
| MRI brain without contrast | CPT 70551 | $322.44 |
| MRI brain with contrast | CPT 70552 | $476.52 |
| MRI brain with and without contrast | CPT 70553 | $476.52 |
| Chest X-ray single view | CPT 71045 | $96.38 |
| Chest X-ray 2 views | CPT 71046 | $107.89 |
| Chest X-ray 3 views | CPT 71047 | $114.74 |
| CT chest without contrast | CPT 71250 | $139.06 |
| CT chest with contrast | CPT 71260 | $237.53 |
| CT chest with and without contrast | CPT 71270 | $237.53 |
| MRI chest without contrast | CPT 71550 | $322.52 |
| MRI chest with contrast | CPT 71551 | $947.11 |
| MRI chest with and without contrast | CPT 71552 | $476.52 |
| Lumbosacral spine X-ray | CPT 72100 | $128.45 |
| CT cervical spine without contrast | CPT 72125 | $139.06 |
| CT thoracic spine without contrast | CPT 72128 | $139.06 |
| CT lumbar spine without contrast | CPT 72131 | $139.06 |
| MRI cervical spine without contrast | CPT 72141 | $315.48 |
| MRI thoracic spine without contrast | CPT 72146 | $315.48 |
| MRI lumbar spine without contrast | CPT 72148 | $316.30 |
| MRI lumbar spine with and without contrast | CPT 72149 | $476.27 |
| MRI cervical spine with and without contrast | CPT 72156 | $476.52 |
| MRI lumbar spine with contrast | CPT 72158 | $476.52 |
| CT pelvis without contrast | CPT 72192 | $139.06 |
| CT pelvis with contrast | CPT 72193 | $237.53 |
| Shoulder X-ray | CPT 73030 | $101.73 |
| Humerus X-ray | CPT 73060 | $97.99 |
| Hand X-ray 3 views | CPT 73130 | $99.24 |
| MRI upper extremity joint without contrast | CPT 73221 | $322.52 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $476.52 |
| Hip X-ray 2 views | CPT 73510 | $134.16 |
| Knee X-ray 1-2 views | CPT 73560 | $96.14 |
| Ankle X-ray 3 views | CPT 73610 | $99.24 |
| MRI lower extremity joint without contrast | CPT 73721 | $322.52 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $476.52 |
| CT abdomen without contrast | CPT 74150 | $139.06 |
| CT abdomen with contrast | CPT 74160 | $237.53 |
| CT abdomen with and without contrast | CPT 74170 | $237.53 |
| CT abdomen and pelvis without contrast | CPT 74176 | $289.77 |
| CT abdomen and pelvis with contrast | CPT 74177 | $465.35 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $465.35 |
| MRI abdomen without contrast | CPT 74181 | $322.52 |
| MRI abdomen with and without contrast | CPT 74183 | $476.52 |
| Abdominal ultrasound complete | CPT 76700 | $141.89 |
| Abdominal ultrasound limited | CPT 76705 | $141.89 |
| Retroperitoneal ultrasound complete | CPT 76770 | $141.89 |
| Obstetric ultrasound first trimester | CPT 76801 | $141.89 |
| Obstetric ultrasound after first trimester | CPT 76805 | $141.89 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $289.77 |
| Transvaginal ultrasound | CPT 76830 | $141.89 |
| Pelvic ultrasound complete | CPT 76856 | $141.89 |
| Scrotal ultrasound | CPT 76870 | $141.89 |
| Diagnostic mammography unilateral | CPT 77065 | $109.59 |
| Diagnostic mammography bilateral | CPT 77066 | $139.38 |
| Screening mammography bilateral | CPT 77067 | $114.98 |
| EKG complete | CPT 93000 | $85.14 |
| EKG tracing only | CPT 93005 | $61.92 |
| EKG interpretation only | CPT 93010 | $36.12 |
| Transthoracic echocardiogram complete | CPT 93306 | $714.45 |
| Transthoracic echocardiogram | CPT 93307 | $314.96 |
| Stress echocardiogram | CPT 93350 | $714.45 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $10,444 |
| COPD w MCC | MS-DRG 190 | $7,365.93 |
| COPD w CC | MS-DRG 191 | $5,605.74 |
| COPD w/o CC/MCC | MS-DRG 192 | $4,354.52 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $5,359.03 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $4,221.16 |
| AMI discharged alive w MCC | MS-DRG 280 | $10,667 |
| AMI discharged alive w CC | MS-DRG 281 | $6,111.79 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $4,856.51 |
| Heart failure & shock w MCC | MS-DRG 291 | $8,622.32 |
| Heart failure & shock w CC | MS-DRG 292 | $5,702.10 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $3,801.40 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $8,166.43 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $5,211.12 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $4,127.63 |
| GI hemorrhage w CC | MS-DRG 378 | $6,586.62 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $4,233.92 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $5,235.99 |
| Fractures of femur w/o MCC | MS-DRG 533 | $10,529 |
| Kidney/UTI w MCC | MS-DRG 689 | $7,792.86 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $5,544.46 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $13,046 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $6,872.74 |
| Initial hospital care, low complexity | CPT 99221 | $273.48 |
| Initial hospital care, moderate complexity | CPT 99222 | $374.10 |
| Initial hospital care, high complexity | CPT 99223 | $549.54 |
| Hospital discharge, <30 min | CPT 99238 | $203.82 |
| Hospital discharge, >30 min | CPT 99239 | $294.12 |
| Basic metabolic panel (BMP) | CPT 80048 | $9.86 |
| General health panel | CPT 80050 | $177.10 |
| Electrolyte panel | CPT 80051 | $8.17 |
| Comprehensive metabolic panel | CPT 80053 | $13.20 |
| Lipid panel | CPT 80061 | $15.40 |
| Renal function panel | CPT 80069 | $10.85 |
| Hepatic function panel | CPT 80076 | $9.52 |
| Urinalysis non-automated | CPT 81002 | $3.97 |
| Urinalysis automated | CPT 81003 | $2.62 |
| Glucose quantitative | CPT 82947 | $4.58 |
| Hemoglobin A1c | CPT 83036 | $11.31 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $19.58 |
| Complete blood count with automated differential | CPT 85025 | $9.06 |
| Complete blood count without differential | CPT 85027 | $7.54 |
| Urine culture bacterial | CPT 87086 | $9.41 |
| Urine culture identification | CPT 87088 | $9.43 |
| Tissue exam by pathologist level IV | CPT 88305 | $69.63 |
| Fetal non-stress test | CPT 59025 | $215.99 |
| Office visit, new patient, 15-29 min | CPT 99202 | $203.82 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $299.28 |
| Office visit, new patient, 45-59 min | CPT 99204 | $454.08 |
| Office visit, new patient, 60-74 min | CPT 99205 | $572.76 |
| Office visit, established patient, 5 min | CPT 99211 | $64.50 |
| Office visit, established patient, 10-19 min | CPT 99212 | $123.84 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $183.18 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $276.06 |
| Office visit, established patient, 40-54 min | CPT 99215 | $397.32 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,006.65 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,006.65 |
| Sigmoidoscopy diagnostic | CPT 45330 | $978.89 |
| Sigmoidoscopy with biopsy | CPT 45331 | $978.89 |
| Colonoscopy diagnostic | CPT 45378 | $978.89 |
| Knee revision arthroplasty single component | CPT 27486 | $9,156.60 |
| Knee revision arthroplasty all components | CPT 27487 | $11,495 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $9,654.00 |
| ACL reconstruction | CPT 29888 | $9,654.00 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $30,871 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $16,100 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $11,303 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $11,361 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $9,173.05 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $22,656 |
| Major joint replacement w MCC | MS-DRG 469 | $20,170 |
| Major joint replacement w/o MCC | MS-DRG 470 | $12,827 |
| Laparoscopic cholecystectomy | CPT 47562 | $9,654.00 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $9,654.00 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $19,366 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $14,067 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $10,846 |
| Open umbilical hernia repair | CPT 49560 | $9,654.00 |
| Lap inguinal hernia repair | CPT 49650 | $9,654.00 |
| Total abdominal hysterectomy | CPT 58150 | $9,654.00 |
| OR procedure for obesity w MCC | MS-DRG 619 | $19,777 |
| OR procedure for obesity w CC | MS-DRG 620 | $10,961 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $10,432 |
| Complex cataract surgery | CPT 66982 | $3,941.00 |
| Cataract surgery with lens implant | CPT 66984 | $3,941.00 |
| Intravitreal injection | CPT 67028 | $356.13 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $8,332.84 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $13,762 |
| PCI single major coronary artery | CPT 92920 | $13,322 |
| PCI with drug-eluting stent | CPT 92928 | $16,990 |
| PCI bypass graft | CPT 92937 | $16,990 |
| Left heart catheterization | CPT 93452 | $7,517.50 |
| Coronary angiography with cath | CPT 93455 | $6,855.00 |
| Coronary angiography with bypass cath | CPT 93458 | $7,517.50 |
