| Psychoses | MS-DRG 885 | $1,920 |
| Psychiatric diagnostic evaluation | CPT 90791 | $523.71 |
| Psychiatric eval with medical services | CPT 90792 | $523.71 |
| Psychotherapy 30 minutes | CPT 90832 | $220.11 |
| Psychotherapy 45 minutes | CPT 90834 | $318.78 |
| Psychotherapy 60 minutes | CPT 90837 | $468.05 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $212.16 |
| ED visit level 1 | CPT 99281 | $576.84 |
| ED visit level 2 | CPT 99282 | $538.89 |
| ED visit level 3 | CPT 99283 | $794.42 |
| ED visit level 4 | CPT 99284 | $359.26 |
| ED visit level 5 | CPT 99285 | $285.89 |
| Critical care, first hour | CPT 99291 | $141.68 |
| CT head without contrast | CPT 70450 | $796.95 |
| CT head with contrast | CPT 70460 | $984.17 |
| CT head with and without contrast | CPT 70470 | $1,191.63 |
| CT neck with contrast | CPT 70491 | $1,156.21 |
| MRI brain without contrast | CPT 70551 | $1,983.52 |
| MRI brain with contrast | CPT 70552 | $2,221.34 |
| MRI brain with and without contrast | CPT 70553 | $3,147.32 |
| Chest X-ray single view | CPT 71045 | $101.2 |
| Chest X-ray 2 views | CPT 71046 | $111.32 |
| Chest X-ray 3 views | CPT 71047 | $159.39 |
| CT chest without contrast | CPT 71250 | $1,037.3 |
| CT chest with contrast | CPT 71260 | $1,244.76 |
| CT chest with and without contrast | CPT 71270 | $1,472.46 |
| MRI chest without contrast | CPT 71550 | $2,117.61 |
| MRI chest with contrast | CPT 71551 | $2,380.73 |
| MRI chest with and without contrast | CPT 71552 | $3,258.64 |
| Lumbosacral spine X-ray | CPT 72100 | $134.09 |
| CT cervical spine without contrast | CPT 72125 | $994.29 |
| CT thoracic spine without contrast | CPT 72128 | $991.76 |
| CT lumbar spine without contrast | CPT 72131 | $991.76 |
| MRI cervical spine without contrast | CPT 72141 | $1,819.07 |
| MRI thoracic spine without contrast | CPT 72146 | $1,872.2 |
| MRI lumbar spine without contrast | CPT 72148 | $1,935.45 |
| MRI lumbar spine with and without contrast | CPT 72149 | $2,218.81 |
| MRI cervical spine with and without contrast | CPT 72156 | $3,010.7 |
| MRI lumbar spine with contrast | CPT 72158 | $2,972.75 |
| CT pelvis without contrast | CPT 72192 | $989.23 |
| CT pelvis with contrast | CPT 72193 | $1,184.04 |
| Shoulder X-ray | CPT 73030 | $108.79 |
| Humerus X-ray | CPT 73060 | $101.2 |
| Hand X-ray 3 views | CPT 73130 | $103.73 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,836.78 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $2,838.66 |
| Hip X-ray 2 views | CPT 73510 | $131.56 |
| Knee X-ray 1-2 views | CPT 73560 | $96.14 |
| Ankle X-ray 3 views | CPT 73610 | $103.73 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,953.16 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $2,831.07 |
| CT abdomen without contrast | CPT 74150 | $996.82 |
| CT abdomen with contrast | CPT 74160 | $1,323.19 |
| CT abdomen with and without contrast | CPT 74170 | $1,725.46 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,986.05 |
| CT abdomen and pelvis with contrast | CPT 74177 | $2,507.23 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $3,165.03 |
| MRI abdomen without contrast | CPT 74181 | $1,768.47 |
| MRI abdomen with and without contrast | CPT 74183 | $2,990.46 |
| Abdominal ultrasound complete | CPT 76700 | $490.82 |
| Abdominal ultrasound limited | CPT 76705 | $356.73 |
| Retroperitoneal ultrasound complete | CPT 76770 | $450.34 |
| Obstetric ultrasound first trimester | CPT 76801 | $473.11 |
| Obstetric ultrasound after first trimester | CPT 76805 | $523.71 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $799.48 |
| Transvaginal ultrasound | CPT 76830 | $432.63 |
| Pelvic ultrasound complete | CPT 76856 | $435.16 |
| Scrotal ultrasound | CPT 76870 | $412.39 |
| Diagnostic mammography unilateral | CPT 77065 | $475.64 |
| Diagnostic mammography bilateral | CPT 77066 | $589.49 |
| Screening mammography bilateral | CPT 77067 | $508.53 |
| EKG complete | CPT 93000 | $106.26 |
| EKG tracing only | CPT 93005 | $394.68 |
| EKG interpretation only | CPT 93010 | $93.61 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,103.08 |
| Transthoracic echocardiogram | CPT 93307 | $1,153.68 |
| Stress echocardiogram | CPT 93350 | $2,884.2 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $8,963.5 |
| COPD w MCC | MS-DRG 190 | $3,284.49 |
| COPD w CC | MS-DRG 191 | $3,595.16 |
| COPD w/o CC/MCC | MS-DRG 192 | $4,798.97 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $3,641.98 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $1,920 |
| AMI discharged alive w MCC | MS-DRG 280 | $2,278.67 |
| AMI discharged alive w CC | MS-DRG 281 | $3,292.62 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $2,039.81 |
| Heart failure & shock w MCC | MS-DRG 291 | $1,920 |
| Heart failure & shock w CC | MS-DRG 292 | $1,920 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $1,920 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $5,448.49 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $7,029.63 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $4,302.61 |
| GI hemorrhage w CC | MS-DRG 378 | $1,920 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $1,920 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $1,920 |
| Fractures of femur w/o MCC | MS-DRG 533 | $1,920 |
| Kidney/UTI w MCC | MS-DRG 689 | $1,920 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $20,610 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $1,920 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $1,920 |
| Initial hospital care, low complexity | CPT 99221 | $278.42 |
| Initial hospital care, moderate complexity | CPT 99222 | $379.33 |
| Initial hospital care, high complexity | CPT 99223 | $500.94 |
| Hospital discharge, <30 min | CPT 99238 | $296.72 |
| Hospital discharge, >30 min | CPT 99239 | $431.69 |
| Basic metabolic panel (BMP) | CPT 80048 | $14.2 |
| General health panel | CPT 80050 | $49.49 |
| Electrolyte panel | CPT 80051 | $11.76 |
| Comprehensive metabolic panel | CPT 80053 | $17.72 |
| Lipid panel | CPT 80061 | $22.46 |
| Renal function panel | CPT 80069 | $14.56 |
| Hepatic function panel | CPT 80076 | $13.7 |
| Urinalysis non-automated | CPT 81002 | $4.28 |
| Urinalysis automated | CPT 81003 | $3.77 |
| Glucose quantitative | CPT 82947 | $6.58 |
| Hemoglobin A1c | CPT 83036 | $16.27 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $28.16 |
| Complete blood count with automated differential | CPT 85025 | $13.03 |
| Complete blood count without differential | CPT 85027 | $10.85 |
| Urine culture bacterial | CPT 87086 | $13.54 |
| Urine culture identification | CPT 87088 | $13.57 |
| Tissue exam by pathologist level IV | CPT 88305 | $105.03 |
| Office visit, new patient, 15-29 min | CPT 99202 | $63.25 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $121.44 |
| Office visit, new patient, 45-59 min | CPT 99204 | $179.63 |
| Office visit, new patient, 60-74 min | CPT 99205 | $270.71 |
| Office visit, established patient, 5 min | CPT 99211 | $389.62 |
| Office visit, established patient, 10-19 min | CPT 99212 | $173.24 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $196.59 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $311.34 |
| Office visit, established patient, 40-54 min | CPT 99215 | $442.81 |
| Knee revision arthroplasty single component | CPT 27486 | $9,156.6 |
| Knee revision arthroplasty all components | CPT 27487 | $11,495 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $1,920 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $1,920 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $1,920 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $1,920 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $1,920 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $1,920 |
| Major joint replacement w MCC | MS-DRG 469 | $3,636.42 |
| Major joint replacement w/o MCC | MS-DRG 470 | $5,921.04 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $5,059.25 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $1,920 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $3,406.3 |
| OR procedure for obesity w MCC | MS-DRG 619 | $29,607 |
| OR procedure for obesity w CC | MS-DRG 620 | $29,607 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $16,632 |
| Complex cataract surgery | CPT 66982 | $3,941 |
| Cataract surgery with lens implant | CPT 66984 | $3,941 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $1,920 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $1,920 |
| PCI single major coronary artery | CPT 92920 | $16,990 |
| PCI with drug-eluting stent | CPT 92928 | $16,990 |
| PCI bypass graft | CPT 92937 | $16,990 |
| Left heart catheterization | CPT 93452 | $5,678 |
| Coronary angiography with cath | CPT 93455 | $5,678 |
| Coronary angiography with bypass cath | CPT 93458 | $5,678 |
