| Psychoses | MS-DRG 885 | $12,391 |
| Psychiatric diagnostic evaluation | CPT 90791 | $130.57 |
| Psychiatric eval with medical services | CPT 90792 | $157.99 |
| Psychotherapy 30 minutes | CPT 90832 | $130.57 |
| Psychotherapy 45 minutes | CPT 90834 | $130.57 |
| ED visit level 1 | CPT 99281 | $71.56 |
| ED visit level 2 | CPT 99282 | $128.7 |
| ED visit level 3 | CPT 99283 | $225.02 |
| ED visit level 4 | CPT 99284 | $716.96 |
| ED visit level 5 | CPT 99285 | $2,482.2 |
| Critical care, first hour | CPT 99291 | $195.02 |
| CT head without contrast | CPT 70450 | $86.42 |
| CT head with contrast | CPT 70460 | $639.54 |
| CT head with and without contrast | CPT 70470 | $144.67 |
| CT neck with contrast | CPT 70491 | $144.67 |
| MRI brain without contrast | CPT 70551 | $196.44 |
| MRI brain with contrast | CPT 70552 | $1,365.03 |
| MRI brain with and without contrast | CPT 70553 | $290.23 |
| Chest X-ray single view | CPT 71045 | $71.56 |
| Chest X-ray 2 views | CPT 71046 | $71.56 |
| Chest X-ray 3 views | CPT 71047 | $127.46 |
| CT chest without contrast | CPT 71250 | $86.42 |
| CT chest with contrast | CPT 71260 | $144.67 |
| CT chest with and without contrast | CPT 71270 | $144.67 |
| MRI chest without contrast | CPT 71550 | $1,213.11 |
| MRI chest with and without contrast | CPT 71552 | $1,213.11 |
| Lumbosacral spine X-ray | CPT 72100 | $86.42 |
| CT cervical spine without contrast | CPT 72125 | $86.42 |
| CT thoracic spine without contrast | CPT 72128 | $86.42 |
| CT lumbar spine without contrast | CPT 72131 | $86.42 |
| MRI cervical spine without contrast | CPT 72141 | $196.44 |
| MRI thoracic spine without contrast | CPT 72146 | $196.44 |
| MRI lumbar spine without contrast | CPT 72148 | $196.44 |
| MRI lumbar spine with and without contrast | CPT 72149 | $1,265.84 |
| MRI cervical spine with and without contrast | CPT 72156 | $290.23 |
| MRI lumbar spine with contrast | CPT 72158 | $290.23 |
| CT pelvis without contrast | CPT 72192 | $86.42 |
| CT pelvis with contrast | CPT 72193 | $955.27 |
| Shoulder X-ray | CPT 73030 | $90.88 |
| Humerus X-ray | CPT 73060 | $90.88 |
| Hand X-ray 3 views | CPT 73130 | $91.11 |
| MRI upper extremity joint without contrast | CPT 73221 | $196.44 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $290.23 |
| Knee X-ray 1-2 views | CPT 73560 | $229.2 |
| Ankle X-ray 3 views | CPT 73610 | $265.8 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,144.66 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $1,213.11 |
| CT abdomen without contrast | CPT 74150 | $86.48 |
| CT abdomen with contrast | CPT 74160 | $144.67 |
| CT abdomen with and without contrast | CPT 74170 | $144.67 |
| CT abdomen and pelvis without contrast | CPT 74176 | $196.44 |
| CT abdomen and pelvis with contrast | CPT 74177 | $290.23 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $290.23 |
| MRI abdomen without contrast | CPT 74181 | $196.44 |
| MRI abdomen with and without contrast | CPT 74183 | $1,011.6 |
| Abdominal ultrasound complete | CPT 76700 | $86.42 |
| Abdominal ultrasound limited | CPT 76705 | $211.38 |
| Retroperitoneal ultrasound complete | CPT 76770 | $185.13 |
| Obstetric ultrasound first trimester | CPT 76801 | $330.54 |
| Obstetric ultrasound after first trimester | CPT 76805 | $45.73 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $196.44 |
| Transvaginal ultrasound | CPT 76830 | $330.54 |
| Pelvic ultrasound complete | CPT 76856 | $86.42 |
| Scrotal ultrasound | CPT 76870 | $86.42 |
| Diagnostic mammography unilateral | CPT 77065 | $36.71 |
| Diagnostic mammography bilateral | CPT 77066 | $45.18 |
| Screening mammography bilateral | CPT 77067 | $34.13 |
| EKG complete | CPT 93000 | $143.4 |
| EKG tracing only | CPT 93005 | — |
| EKG interpretation only | CPT 93010 | $19.52 |
| Transthoracic echocardiogram complete | CPT 93306 | $987.36 |
| Stress echocardiogram | CPT 93350 | $445.6 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $13,863 |
| COPD w MCC | MS-DRG 190 | $9,826.66 |
| COPD w CC | MS-DRG 191 | $7,478.45 |
| COPD w/o CC/MCC | MS-DRG 192 | $5,695.33 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $7,149.32 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $5,575.57 |
| AMI discharged alive w MCC | MS-DRG 280 | $14,230 |
| AMI discharged alive w CC | MS-DRG 281 | $8,153.55 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $6,414.79 |
| Heart failure & shock w MCC | MS-DRG 291 | $11,389 |
| Heart failure & shock w CC | MS-DRG 292 | $7,531.67 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $5,021.12 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $10,681 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $6,526.56 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $5,022 |
| GI hemorrhage w CC | MS-DRG 378 | $8,700.02 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $5,592.42 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $6,916.01 |
| Fractures of femur w/o MCC | MS-DRG 533 | $13,907 |
| Kidney/UTI w MCC | MS-DRG 689 | $10,293 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $7,181.26 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $17,232 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $9,077.93 |
| Initial hospital care, low complexity | CPT 99221 | $72.79 |
| Initial hospital care, moderate complexity | CPT 99222 | $114.33 |
| Initial hospital care, high complexity | CPT 99223 | $152.94 |
| Hospital discharge, <30 min | CPT 99238 | $72.54 |
| Hospital discharge, >30 min | CPT 99239 | $103.34 |
| Basic metabolic panel (BMP) | CPT 80048 | $153.92 |
| General health panel | CPT 80050 | $274.2 |
| Electrolyte panel | CPT 80051 | $7.01 |
| Comprehensive metabolic panel | CPT 80053 | $210.9 |
| Lipid panel | CPT 80061 | $254.56 |
| Renal function panel | CPT 80069 | $8.68 |
| Hepatic function panel | CPT 80076 | $198.32 |
| Urinalysis non-automated | CPT 81002 | $3.48 |
| Urinalysis automated | CPT 81003 | $37.74 |
| Glucose quantitative | CPT 82947 | $130.24 |
| Hemoglobin A1c | CPT 83036 | $78.82 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $193.14 |
| Complete blood count with automated differential | CPT 85025 | $115.44 |
| Complete blood count without differential | CPT 85027 | $6.47 |
| Urine culture bacterial | CPT 87086 | $8.07 |
| Tissue exam by pathologist level IV | CPT 88305 | $43.42 |
| Fetal non-stress test | CPT 59025 | $163.49 |
| Vaginal delivery only | CPT 59409 | $2,583.96 |
| Office visit, new patient, 15-29 min | CPT 99202 | $54.76 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | — |
| Office visit, new patient, 45-59 min | CPT 99204 | — |
| Office visit, new patient, 60-74 min | CPT 99205 | $161.55 |
| Office visit, established patient, 5 min | CPT 99211 | $87.74 |
| Office visit, established patient, 10-19 min | CPT 99212 | $335.4 |
| 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 | — |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $40,777 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $21,266 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $14,929 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $15,007 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $12,116 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $30,225 |
| Major joint replacement w MCC | MS-DRG 469 | $26,908 |
| Major joint replacement w/o MCC | MS-DRG 470 | $17,112 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $25,836 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $18,581 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $14,469 |
| OR procedure for obesity w MCC | MS-DRG 619 | $25,615 |
| OR procedure for obesity w CC | MS-DRG 620 | $14,197 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $13,381 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $11,007 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $18,178 |
| PCI single major coronary artery | CPT 92920 | $4,633.55 |
| Left heart catheterization | CPT 93452 | $2,613.94 |
| Coronary angiography with cath | CPT 93455 | $4,321.72 |
| Coronary angiography with bypass cath | CPT 93458 | $6,254.7 |
