| Psychoses | MS-DRG 885 | $1,594 |
| Psychiatric diagnostic evaluation | CPT 90791 | $529.48 |
| Psychiatric eval with medical services | CPT 90792 | $424.53 |
| Psychotherapy 30 minutes | CPT 90832 | $279.34 |
| Psychotherapy 45 minutes | CPT 90834 | $327.6 |
| Psychotherapy 60 minutes | CPT 90837 | $415.58 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $285.68 |
| ED visit level 1 | CPT 99281 | $246.23 |
| ED visit level 2 | CPT 99282 | $326.55 |
| ED visit level 3 | CPT 99283 | $412.34 |
| ED visit level 4 | CPT 99284 | $600.86 |
| ED visit level 5 | CPT 99285 | $749.4 |
| Critical care, first hour | CPT 99291 | $1,002.21 |
| CT head without contrast | CPT 70450 | $131.56 |
| CT head with contrast | CPT 70460 | $287.2 |
| CT head with and without contrast | CPT 70470 | $320.24 |
| CT neck with contrast | CPT 70491 | $223.45 |
| MRI brain without contrast | CPT 70551 | $401.1 |
| MRI brain with and without contrast | CPT 70553 | $586.46 |
| Chest X-ray single view | CPT 71045 | $4,344.04 |
| Chest X-ray 2 views | CPT 71046 | $106.03 |
| Chest X-ray 3 views | CPT 71047 | $135.79 |
| CT chest without contrast | CPT 71250 | $134.46 |
| CT chest with contrast | CPT 71260 | — |
| CT chest with and without contrast | CPT 71270 | $361.99 |
| MRI chest without contrast | CPT 71550 | $401.1 |
| Lumbosacral spine X-ray | CPT 72100 | $191.68 |
| CT cervical spine without contrast | CPT 72125 | $249.03 |
| CT thoracic spine without contrast | CPT 72128 | $249.03 |
| CT lumbar spine without contrast | CPT 72131 | $249.03 |
| MRI cervical spine without contrast | CPT 72141 | $319.43 |
| MRI thoracic spine without contrast | CPT 72146 | $319.43 |
| MRI lumbar spine without contrast | CPT 72148 | $319.43 |
| MRI cervical spine with and without contrast | CPT 72156 | $534.22 |
| MRI lumbar spine with contrast | CPT 72158 | $534.42 |
| CT pelvis without contrast | CPT 72192 | $245.55 |
| CT pelvis with contrast | CPT 72193 | $313.42 |
| Shoulder X-ray | CPT 73030 | $168.25 |
| Humerus X-ray | CPT 73060 | $104.29 |
| Hand X-ray 3 views | CPT 73130 | $140.85 |
| MRI upper extremity joint without contrast | CPT 73221 | $401.1 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $586.46 |
| Knee X-ray 1-2 views | CPT 73560 | $106.9 |
| Ankle X-ray 3 views | CPT 73610 | $110.87 |
| MRI lower extremity joint without contrast | CPT 73721 | $401.1 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $586.46 |
| CT abdomen without contrast | CPT 74150 | $242.64 |
| CT abdomen with contrast | CPT 74160 | $327.68 |
| CT abdomen with and without contrast | CPT 74170 | $328.15 |
| CT abdomen and pelvis without contrast | CPT 74176 | $303.97 |
| CT abdomen and pelvis with contrast | CPT 74177 | $439.01 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $586.46 |
| MRI abdomen without contrast | CPT 74181 | $401.1 |
| MRI abdomen with and without contrast | CPT 74183 | $586.46 |
| Abdominal ultrasound complete | CPT 76700 | $128.43 |
| Abdominal ultrasound limited | CPT 76705 | $131.56 |
| Retroperitoneal ultrasound complete | CPT 76770 | $131.56 |
| Obstetric ultrasound first trimester | CPT 76801 | $202.88 |
| Obstetric ultrasound after first trimester | CPT 76805 | $202.88 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $309.76 |
| Transvaginal ultrasound | CPT 76830 | $128.43 |
| Pelvic ultrasound complete | CPT 76856 | $131.56 |
| Scrotal ultrasound | CPT 76870 | $167.04 |
| Diagnostic mammography unilateral | CPT 77065 | $95.19 |
| Diagnostic mammography bilateral | CPT 77066 | $208.59 |
| Screening mammography bilateral | CPT 77067 | $137.6 |
| EKG complete | CPT 93000 | $124 |
| EKG tracing only | CPT 93005 | $91.52 |
| Transthoracic echocardiogram complete | CPT 93306 | $824.28 |
| Transthoracic echocardiogram | CPT 93307 | $426.34 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $18,560 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $9,493.7 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $6,540.99 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $14,499 |
| COPD w MCC | MS-DRG 190 | $10,376 |
| COPD w CC | MS-DRG 191 | $7,977.92 |
| COPD w/o CC/MCC | MS-DRG 192 | $6,156.83 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $7,641.81 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $6,034.51 |
| AMI discharged alive w MCC | MS-DRG 280 | $17,441 |
| AMI discharged alive w CC | MS-DRG 281 | $24,013 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $17,842 |
| Heart failure & shock w MCC | MS-DRG 291 | $11,972 |
| Heart failure & shock w CC | MS-DRG 292 | $8,032.28 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $39,257 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $7,005.76 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $5,469.16 |
| GI hemorrhage w CC | MS-DRG 378 | $9,225.51 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $6,051.74 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $7,403.51 |
| Kidney/UTI w MCC | MS-DRG 689 | $10,853 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $7,674.41 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $17,940 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $9,611.46 |
| Basic metabolic panel (BMP) | CPT 80048 | $24.95 |
| General health panel | CPT 80050 | $156.8 |
| Electrolyte panel | CPT 80051 | $31.17 |
| Comprehensive metabolic panel | CPT 80053 | $31.89 |
| Lipid panel | CPT 80061 | $34.77 |
| Renal function panel | CPT 80069 | $61.89 |
| Hepatic function panel | CPT 80076 | $20.7 |
| Urinalysis non-automated | CPT 81002 | $4 |
| Urinalysis automated | CPT 81003 | $7.31 |
| Glucose quantitative | CPT 82947 | $22.26 |
| Hemoglobin A1c | CPT 83036 | $12.01 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $23.63 |
| Complete blood count with automated differential | CPT 85025 | $8.56 |
| Complete blood count without differential | CPT 85027 | $15.26 |
| Urine culture bacterial | CPT 87086 | $9.99 |
| Urine culture identification | CPT 87088 | $18.7 |
| Tissue exam by pathologist level IV | CPT 88305 | $93.98 |
| Fetal non-stress test | CPT 59025 | $278.38 |
| Vaginal delivery only | CPT 59409 | $4,095.35 |
| C-section delivery only | CPT 59514 | $2,770.05 |
| Vaginal delivery w complicating dx | MS-DRG 774 | $18,181 |
| Vaginal delivery w/o complicating dx | MS-DRG 775 | $13,560 |
| Office visit, new patient, 15-29 min | CPT 99202 | $161.53 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $166.19 |
| Office visit, new patient, 45-59 min | CPT 99204 | $164.85 |
| Office visit, new patient, 60-74 min | CPT 99205 | $286.19 |
| Office visit, established patient, 5 min | CPT 99211 | $168.85 |
| Office visit, established patient, 10-19 min | CPT 99212 | $169.61 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $210.65 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $164.85 |
| Office visit, established patient, 40-54 min | CPT 99215 | $162.21 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,141.32 |
| Upper GI endoscopy with biopsy | CPT 43239 | $2,366.83 |
| Sigmoidoscopy diagnostic | CPT 45330 | $1,175.24 |
| Sigmoidoscopy with biopsy | CPT 45331 | $1,170.23 |
| Colonoscopy diagnostic | CPT 45378 | $1,139.91 |
| Colonoscopy with biopsy | CPT 45380 | $1,493.77 |
| Colonoscopy with polyp removal | CPT 45385 | $1,493.77 |
| Total shoulder arthroplasty | CPT 23472 | $21,273 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $15,653 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $16,647 |
| Total hip replacement | CPT 27130 | — |
| Total knee replacement | CPT 27447 | $15,577 |
| Knee revision arthroplasty single component | CPT 27486 | $15,577 |
| Knee revision arthroplasty all components | CPT 27487 | $20,138 |
| Shoulder arthroscopy with decompression | CPT 29826 | $3,969.86 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | — |
| Knee arthroscopy with meniscectomy | CPT 29881 | $2,999.94 |
| ACL reconstruction | CPT 29888 | $9,244.03 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $41,985 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $22,059 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $15,588 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $15,666 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $12,715 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $14,468 |
| Laparoscopic appendectomy | CPT 44970 | $7,334.93 |
| Major joint replacement w MCC | MS-DRG 469 | $27,821 |
| Major joint replacement w/o MCC | MS-DRG 470 | $18,139 |
| Laparoscopic cholecystectomy | CPT 47562 | $7,334.93 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $7,334.93 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $26,726 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $19,317 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $15,117 |
| Lap inguinal hernia repair | CPT 49650 | — |
| Lap salpingo-oophorectomy | CPT 58661 | $6,235.79 |
| Complex cataract surgery | CPT 66982 | $2,870.04 |
| Cataract surgery with lens implant | CPT 66984 | $2,708.5 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $11,581 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $18,905 |
