| Psychoses | MS-DRG 885 | $8,276.54 |
| Psychiatric diagnostic evaluation | CPT 90791 | $147.89 |
| Psychotherapy 30 minutes | CPT 90832 | $147.89 |
| Psychotherapy 45 minutes | CPT 90834 | $147.89 |
| ED visit level 1 | CPT 99281 | $107.1 |
| ED visit level 2 | CPT 99282 | $145.76 |
| ED visit level 3 | CPT 99283 | $254.86 |
| ED visit level 4 | CPT 99284 | $391.94 |
| ED visit level 5 | CPT 99285 | $564.32 |
| Critical care, first hour | CPT 99291 | $775.57 |
| CT head without contrast | CPT 70450 | $97.88 |
| CT head with contrast | CPT 70460 | $157.89 |
| CT head with and without contrast | CPT 70470 | $157.89 |
| CT neck with contrast | CPT 70491 | $157.89 |
| MRI brain without contrast | CPT 70551 | $222.49 |
| MRI brain with contrast | CPT 70552 | $322.57 |
| MRI brain with and without contrast | CPT 70553 | $328.72 |
| Chest X-ray single view | CPT 71045 | — |
| Chest X-ray 2 views | CPT 71046 | $75.33 |
| Chest X-ray 3 views | CPT 71047 | $34.68 |
| CT chest without contrast | CPT 71250 | $97.88 |
| CT chest with contrast | CPT 71260 | $163.86 |
| CT chest with and without contrast | CPT 71270 | $157.89 |
| MRI chest without contrast | CPT 71550 | $204.44 |
| MRI chest with and without contrast | CPT 71552 | $322.57 |
| Lumbosacral spine X-ray | CPT 72100 | $93.58 |
| CT cervical spine without contrast | CPT 72125 | $97.88 |
| CT thoracic spine without contrast | CPT 72128 | $93.58 |
| CT lumbar spine without contrast | CPT 72131 | $93.58 |
| MRI cervical spine without contrast | CPT 72141 | $222.49 |
| MRI thoracic spine without contrast | CPT 72146 | $204.44 |
| MRI lumbar spine without contrast | CPT 72148 | $222.49 |
| MRI lumbar spine with and without contrast | CPT 72149 | $322.57 |
| MRI cervical spine with and without contrast | CPT 72156 | $322.57 |
| MRI lumbar spine with contrast | CPT 72158 | $322.57 |
| CT pelvis without contrast | CPT 72192 | $93.58 |
| CT pelvis with contrast | CPT 72193 | $157.89 |
| Shoulder X-ray | CPT 73030 | $76.07 |
| Humerus X-ray | CPT 73060 | $76.07 |
| Hand X-ray 3 views | CPT 73130 | $76.07 |
| MRI upper extremity joint without contrast | CPT 73221 | $204.44 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $322.57 |
| Hip X-ray 2 views | CPT 73510 | — |
| Knee X-ray 1-2 views | CPT 73560 | $76.07 |
| Ankle X-ray 3 views | CPT 73610 | $76.07 |
| MRI lower extremity joint without contrast | CPT 73721 | $222.49 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $322.57 |
| CT abdomen without contrast | CPT 74150 | $93.58 |
| CT abdomen with contrast | CPT 74160 | $157.89 |
| CT abdomen with and without contrast | CPT 74170 | $157.89 |
| CT abdomen and pelvis without contrast | CPT 74176 | $154.67 |
| CT abdomen and pelvis with contrast | CPT 74177 | $257.22 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $288.12 |
| MRI abdomen without contrast | CPT 74181 | $204.44 |
| MRI abdomen with and without contrast | CPT 74183 | $322.57 |
| Abdominal ultrasound complete | CPT 76700 | — |
| Abdominal ultrasound limited | CPT 76705 | $93.58 |
| Retroperitoneal ultrasound complete | CPT 76770 | $93.58 |
| Obstetric ultrasound first trimester | CPT 76801 | $93.58 |
| Obstetric ultrasound after first trimester | CPT 76805 | $93.58 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $204.44 |
| Transvaginal ultrasound | CPT 76830 | $93.58 |
| Pelvic ultrasound complete | CPT 76856 | — |
| Scrotal ultrasound | CPT 76870 | $93.58 |
| EKG tracing only | CPT 93005 | $54.67 |
| Transthoracic echocardiogram complete | CPT 93306 | $181.84 |
| Stress echocardiogram | CPT 93350 | $217.08 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $44,093 |
| COPD w MCC | MS-DRG 190 | $26,822 |
| COPD w CC | MS-DRG 191 | $21,594 |
| COPD w/o CC/MCC | MS-DRG 192 | $16,942 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $7,806.71 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $6,470.99 |
| AMI discharged alive w MCC | MS-DRG 280 | $39,316 |
| AMI discharged alive w CC | MS-DRG 281 | $23,704 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $8,584.24 |
| Heart failure & shock w MCC | MS-DRG 291 | $11,221 |
| Heart failure & shock w CC | MS-DRG 292 | $22,488 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $5,280.88 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $28,147 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $18,188 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $12,992 |
| GI hemorrhage w CC | MS-DRG 378 | $10,568 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $6,422.31 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $7,679.7 |
| Fractures of femur w/o MCC | MS-DRG 533 | $33,429 |
| Kidney/UTI w MCC | MS-DRG 689 | $25,069 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $7,624.21 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $15,854 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $9,115.49 |
| Initial hospital care, low complexity | CPT 99221 | — |
| Basic metabolic panel (BMP) | CPT 80048 | $8.71 |
| General health panel | CPT 80050 | $60.88 |
| Electrolyte panel | CPT 80051 | $6.18 |
| Comprehensive metabolic panel | CPT 80053 | $10.88 |
| Lipid panel | CPT 80061 | $13.79 |
| Renal function panel | CPT 80069 | $8.94 |
| Hepatic function panel | CPT 80076 | $8.42 |
| Urinalysis non-automated | CPT 81002 | — |
| Urinalysis automated | CPT 81003 | $1.97 |
| Glucose quantitative | CPT 82947 | $4.05 |
| Hemoglobin A1c | CPT 83036 | $10 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $16.22 |
| Complete blood count with automated differential | CPT 85025 | $6.8 |
| Complete blood count without differential | CPT 85027 | $6.66 |
| Urine culture bacterial | CPT 87086 | $8.31 |
| Urine culture identification | CPT 87088 | $8.33 |
| Tissue exam by pathologist level IV | CPT 88305 | — |
| Vaginal delivery only | CPT 59409 | $2,926.57 |
| Office visit, new patient, 15-29 min | CPT 99202 | — |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $151.72 |
| Office visit, new patient, 45-59 min | CPT 99204 | $151.72 |
| Office visit, new patient, 60-74 min | CPT 99205 | $253.36 |
| Office visit, established patient, 5 min | CPT 99211 | — |
| Office visit, established patient, 10-19 min | CPT 99212 | — |
| Office visit, established patient, 20-29 minutes | CPT 99213 | — |
| Office visit, established patient, 30-39 minutes | CPT 99214 | — |
| Office visit, established patient, 40-54 min | CPT 99215 | $151.72 |
| Upper GI endoscopy diagnostic | CPT 43235 | $862.97 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $117,475 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $59,100 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $12,654 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $12,789 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $12,180 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $24,270 |
| Major joint replacement w MCC | MS-DRG 469 | $23,515 |
| Major joint replacement w/o MCC | MS-DRG 470 | $18,534 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $31,372 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $18,501 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $12,032 |
| OR procedure for obesity w MCC | MS-DRG 619 | $21,710 |
| OR procedure for obesity w CC | MS-DRG 620 | $42,643 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $11,270 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $9,303.61 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $39,038 |
| PCI single major coronary artery | CPT 92920 | $3,146.56 |
| PCI with drug-eluting stent | CPT 92928 | $10,438 |
| PCI bypass graft | CPT 92937 | $10,438 |
| Left heart catheterization | CPT 93452 | $2,960.51 |
| Coronary angiography with cath | CPT 93455 | $2,348.36 |
| Coronary angiography with bypass cath | CPT 93458 | $2,348.36 |
