| Psychoses | MS-DRG 885 | $97.00 |
| Psychotherapy 30 minutes | CPT 90832 | $333.12 |
| Psychotherapy 45 minutes | CPT 90834 | $333.12 |
| Psychotherapy 60 minutes | CPT 90837 | $333.12 |
| ED visit level 1 | CPT 99281 | $58.56 |
| ED visit level 2 | CPT 99282 | $114.24 |
| ED visit level 3 | CPT 99283 | $193.92 |
| ED visit level 4 | CPT 99284 | $328.32 |
| ED visit level 5 | CPT 99285 | $476.16 |
| Critical care, first hour | CPT 99291 | $521.28 |
| CT head without contrast | CPT 70450 | $2,457.60 |
| CT head with contrast | CPT 70460 | $2,998.08 |
| CT head with and without contrast | CPT 70470 | $3,661.44 |
| CT neck with contrast | CPT 70491 | $3,193.92 |
| MRI brain without contrast | CPT 70551 | $5,496.00 |
| MRI brain with contrast | CPT 70552 | $5,751.36 |
| MRI brain with and without contrast | CPT 70553 | $5,088.96 |
| Chest X-ray single view | CPT 71045 | $45.12 |
| Chest X-ray 2 views | CPT 71046 | $56.64 |
| Chest X-ray 3 views | CPT 71047 | $355.20 |
| CT chest without contrast | CPT 71250 | $3,051.84 |
| CT chest with contrast | CPT 71260 | $3,429.12 |
| CT chest with and without contrast | CPT 71270 | $4,046.40 |
| MRI chest without contrast | CPT 71550 | $2,674.56 |
| MRI chest with contrast | CPT 71551 | $3,580.80 |
| MRI chest with and without contrast | CPT 71552 | $4,104.96 |
| Lumbosacral spine X-ray | CPT 72100 | $72.00 |
| CT cervical spine without contrast | CPT 72125 | $2,968.32 |
| CT thoracic spine without contrast | CPT 72128 | $2,930.88 |
| CT lumbar spine without contrast | CPT 72131 | $3,016.32 |
| MRI cervical spine without contrast | CPT 72141 | $4,547.52 |
| MRI thoracic spine without contrast | CPT 72146 | $4,398.72 |
| MRI lumbar spine without contrast | CPT 72148 | $4,478.40 |
| MRI lumbar spine with and without contrast | CPT 72149 | $4,478.40 |
| MRI cervical spine with and without contrast | CPT 72156 | $5,047.68 |
| MRI lumbar spine with contrast | CPT 72158 | $4,970.88 |
| CT pelvis without contrast | CPT 72192 | $3,085.44 |
| CT pelvis with contrast | CPT 72193 | $2,838.72 |
| Shoulder X-ray | CPT 73030 | $378.24 |
| Humerus X-ray | CPT 73060 | $58.56 |
| Hand X-ray 3 views | CPT 73130 | $59.52 |
| MRI upper extremity joint without contrast | CPT 73221 | $3,334.08 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $4,134.72 |
| Hip X-ray 2 views | CPT 73510 | $79.68 |
| Knee X-ray 1-2 views | CPT 73560 | $60.48 |
| Ankle X-ray 3 views | CPT 73610 | $63.36 |
| MRI lower extremity joint without contrast | CPT 73721 | $3,350.40 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $4,153.92 |
| CT abdomen without contrast | CPT 74150 | $3,127.68 |
| CT abdomen with contrast | CPT 74160 | $3,380.16 |
| CT abdomen with and without contrast | CPT 74170 | $4,193.28 |
| CT abdomen and pelvis without contrast | CPT 74176 | $6,314.88 |
| CT abdomen and pelvis with contrast | CPT 74177 | $6,718.08 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $8,733.12 |
| MRI abdomen without contrast | CPT 74181 | $3,335.04 |
| MRI abdomen with and without contrast | CPT 74183 | $4,833.60 |
| Abdominal ultrasound complete | CPT 76700 | $1,103.04 |
| Abdominal ultrasound limited | CPT 76705 | $584.64 |
| Retroperitoneal ultrasound complete | CPT 76770 | $945.60 |
| Obstetric ultrasound first trimester | CPT 76801 | $1,249.92 |
| Obstetric ultrasound after first trimester | CPT 76805 | $962.88 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $1,418.88 |
| Transvaginal ultrasound | CPT 76830 | $823.68 |
| Pelvic ultrasound complete | CPT 76856 | $945.60 |
| Scrotal ultrasound | CPT 76870 | $591.36 |
| Diagnostic mammography unilateral | CPT 77065 | $216.00 |
| Diagnostic mammography bilateral | CPT 77066 | $295.68 |
| Screening mammography bilateral | CPT 77067 | $378.24 |
| EKG tracing only | CPT 93005 | $17.28 |
| EKG interpretation only | CPT 93010 | $23.04 |
| Transthoracic echocardiogram complete | CPT 93306 | $220.89 |
| Transthoracic echocardiogram | CPT 93307 | $1,612.80 |
| Stress echocardiogram | CPT 93350 | $1,605.12 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $97.00 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $97.00 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $97.00 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $97.00 |
| COPD w MCC | MS-DRG 190 | $97.00 |
| COPD w CC | MS-DRG 191 | $97.00 |
| COPD w/o CC/MCC | MS-DRG 192 | $97.00 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $97.00 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $97.00 |
| AMI discharged alive w MCC | MS-DRG 280 | $97.00 |
| AMI discharged alive w CC | MS-DRG 281 | $97.00 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $97.00 |
| Heart failure & shock w MCC | MS-DRG 291 | $97.00 |
| Heart failure & shock w CC | MS-DRG 292 | $97.00 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $97.00 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $97.00 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $97.00 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $97.00 |
| GI hemorrhage w CC | MS-DRG 378 | $97.00 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $97.00 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $97.00 |
| Fractures of femur w/o MCC | MS-DRG 533 | $97.00 |
| Kidney/UTI w MCC | MS-DRG 689 | $97.00 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $97.00 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $97.00 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $97.00 |
| Initial hospital care, low complexity | CPT 99221 | $119.54 |
| Initial hospital care, moderate complexity | CPT 99222 | $362.88 |
| Initial hospital care, high complexity | CPT 99223 | $534.72 |
| Hospital discharge, <30 min | CPT 99238 | $176.40 |
| Hospital discharge, >30 min | CPT 99239 | $284.16 |
| Basic metabolic panel (BMP) | CPT 80048 | $24.96 |
| General health panel | CPT 80050 | $88.32 |
| Electrolyte panel | CPT 80051 | $21.12 |
| Comprehensive metabolic panel | CPT 80053 | $30.72 |
| Lipid panel | CPT 80061 | $39.36 |
| Renal function panel | CPT 80069 | $25.92 |
| Hepatic function panel | CPT 80076 | $24.00 |
| Urinalysis non-automated | CPT 81002 | $86.40 |
| Urinalysis automated | CPT 81003 | $61.44 |
| Glucose quantitative | CPT 82947 | $2.88 |
| Hemoglobin A1c | CPT 83036 | $28.80 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $168.96 |
| Complete blood count with automated differential | CPT 85025 | $14.40 |
| Complete blood count without differential | CPT 85027 | $19.20 |
| Urine culture bacterial | CPT 87086 | $24.00 |
| Urine culture identification | CPT 87088 | $24.00 |
| Tissue exam by pathologist level IV | CPT 88305 | $385.92 |
| Fetal non-stress test | CPT 59025 | $125.76 |
| Vaginal delivery only | CPT 59409 | $2,029.44 |
| Office visit, new patient, 15-29 min | CPT 99202 | $195.84 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $301.44 |
| Office visit, new patient, 45-59 min | CPT 99204 | $451.20 |
| Office visit, new patient, 60-74 min | CPT 99205 | $597.12 |
| Office visit, established patient, 5 min | CPT 99211 | $62.40 |
| Office visit, established patient, 10-19 min | CPT 99212 | $151.68 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $245.76 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $348.48 |
| Office visit, established patient, 40-54 min | CPT 99215 | $279.36 |
| Upper GI endoscopy diagnostic | CPT 43235 | $824.64 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,056.00 |
| Sigmoidoscopy diagnostic | CPT 45330 | $513.60 |
| Sigmoidoscopy with biopsy | CPT 45331 | $802.56 |
| Colonoscopy diagnostic | CPT 45378 | $720.00 |
| Colonoscopy with biopsy | CPT 45380 | $1,208.64 |
| Colonoscopy with polyp removal | CPT 45385 | $1,257.60 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $97.00 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $97.00 |
| Total knee replacement | CPT 27447 | $3,348.48 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $97.00 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $97.00 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $97.00 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $97.00 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $97.00 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $97.00 |
| Open appendectomy | CPT 44950 | $1,660.80 |
| Laparoscopic appendectomy | CPT 44970 | $1,561.92 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $97.00 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $97.00 |
| Major joint replacement w MCC | MS-DRG 469 | $97.00 |
| Major joint replacement w/o MCC | MS-DRG 470 | $97.00 |
| Laparoscopic cholecystectomy | CPT 47562 | $1,708.80 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $1,859.52 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $97.00 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $97.00 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $97.00 |
| Open umbilical hernia repair | CPT 49560 | $1,910.40 |
| Umbilical hernia repair age 5+ | CPT 49585 | $1,165.44 |
| Lap inguinal hernia repair | CPT 49650 | $1,125.12 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $2,606.40 |
| OR procedure for obesity w MCC | MS-DRG 619 | $97.00 |
| OR procedure for obesity w CC | MS-DRG 620 | $97.00 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $97.00 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $97.00 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $97.00 |
