| Psychoses | MS-DRG 885 | $1,356.44 |
| Psychiatric diagnostic evaluation | CPT 90791 | $451.12 |
| Psychiatric eval with medical services | CPT 90792 | $410.25 |
| Psychotherapy 30 minutes | CPT 90832 | $343.5 |
| Psychotherapy 45 minutes | CPT 90834 | $411.75 |
| Psychotherapy 60 minutes | CPT 90837 | $455.25 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $414 |
| ED visit level 1 | CPT 99281 | $411.4 |
| ED visit level 2 | CPT 99282 | $686.08 |
| ED visit level 3 | CPT 99283 | $593.29 |
| ED visit level 4 | CPT 99284 | $1,187.18 |
| ED visit level 5 | CPT 99285 | $1,432.61 |
| Critical care, first hour | CPT 99291 | $3,596.96 |
| CT head without contrast | CPT 70450 | $133.19 |
| CT head with contrast | CPT 70460 | $653.31 |
| CT head with and without contrast | CPT 70470 | $678.67 |
| CT neck with contrast | CPT 70491 | $221.67 |
| MRI brain without contrast | CPT 70551 | $305.97 |
| MRI brain with contrast | CPT 70552 | $3,309 |
| MRI brain with and without contrast | CPT 70553 | $1,237.2 |
| Chest X-ray single view | CPT 71045 | $12,734 |
| Chest X-ray 2 views | CPT 71046 | $5.6 |
| Chest X-ray 3 views | CPT 71047 | $319.12 |
| CT chest without contrast | CPT 71250 | $128.95 |
| CT chest with contrast | CPT 71260 | $220.72 |
| CT chest with and without contrast | CPT 71270 | $1,819.48 |
| MRI chest without contrast | CPT 71550 | $796.38 |
| MRI chest with and without contrast | CPT 71552 | $1,296.15 |
| Lumbosacral spine X-ray | CPT 72100 | $342.47 |
| CT cervical spine without contrast | CPT 72125 | $542.71 |
| CT thoracic spine without contrast | CPT 72128 | $542.71 |
| CT lumbar spine without contrast | CPT 72131 | $542.71 |
| MRI cervical spine without contrast | CPT 72141 | $352.73 |
| MRI thoracic spine without contrast | CPT 72146 | $352.73 |
| MRI lumbar spine without contrast | CPT 72148 | $331.29 |
| MRI lumbar spine with and without contrast | CPT 72149 | $1,178.24 |
| MRI cervical spine with and without contrast | CPT 72156 | $571.8 |
| MRI lumbar spine with contrast | CPT 72158 | $554.47 |
| CT pelvis without contrast | CPT 72192 | $542.71 |
| CT pelvis with contrast | CPT 72193 | $653.31 |
| Shoulder X-ray | CPT 73030 | $109.51 |
| Humerus X-ray | CPT 73060 | $109.51 |
| Hand X-ray 3 views | CPT 73130 | $109.51 |
| MRI upper extremity joint without contrast | CPT 73221 | $796.38 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $1,237.2 |
| Knee X-ray 1-2 views | CPT 73560 | $305.43 |
| Ankle X-ray 3 views | CPT 73610 | $110.87 |
| MRI lower extremity joint without contrast | CPT 73721 | $796.38 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $1,237.2 |
| CT abdomen without contrast | CPT 74150 | $542.71 |
| CT abdomen with contrast | CPT 74160 | $212.81 |
| CT abdomen with and without contrast | CPT 74170 | $678.67 |
| CT abdomen and pelvis without contrast | CPT 74176 | $303.97 |
| CT abdomen and pelvis with contrast | CPT 74177 | $250.82 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $1,488.92 |
| MRI abdomen without contrast | CPT 74181 | $796.38 |
| MRI abdomen with and without contrast | CPT 74183 | $1,237.2 |
| Abdominal ultrasound complete | CPT 76700 | $513.01 |
| Abdominal ultrasound limited | CPT 76705 | $129.45 |
| Retroperitoneal ultrasound complete | CPT 76770 | $462.93 |
| Obstetric ultrasound first trimester | CPT 76801 | $498.74 |
| Obstetric ultrasound after first trimester | CPT 76805 | $504.09 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $812.39 |
| Transvaginal ultrasound | CPT 76830 | $128.43 |
| Pelvic ultrasound complete | CPT 76856 | $132.81 |
| Scrotal ultrasound | CPT 76870 | $133.19 |
| Diagnostic mammography unilateral | CPT 77065 | $92.93 |
| Diagnostic mammography bilateral | CPT 77066 | $760 |
| Screening mammography bilateral | CPT 77067 | $200.93 |
| EKG tracing only | CPT 93005 | $150.54 |
| Transthoracic echocardiogram complete | CPT 93306 | $684.97 |
| Transthoracic echocardiogram | CPT 93307 | $831.47 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $20,104 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $10,653 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $7,450.88 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $15,781 |
| COPD w MCC | MS-DRG 190 | $11,393 |
| COPD w CC | MS-DRG 191 | $8,840.99 |
| COPD w/o CC/MCC | MS-DRG 192 | $6,958 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $8,483.22 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $6,901.54 |
| AMI discharged alive w MCC | MS-DRG 280 | $20,387 |
| AMI discharged alive w CC | MS-DRG 281 | $28,070 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $20,855 |
| Heart failure & shock w MCC | MS-DRG 291 | $13,092 |
| Heart failure & shock w CC | MS-DRG 292 | $8,898.83 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $6,287.39 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $45,889 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $56,201 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $43,670 |
| GI hemorrhage w CC | MS-DRG 378 | $10,169 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $6,920.23 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $8,229.62 |
| Fractures of femur w/o MCC | MS-DRG 533 | $15,829 |
| Kidney/UTI w MCC | MS-DRG 689 | $11,901 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $8,517.94 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $19,444 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $10,580 |
| Basic metabolic panel (BMP) | CPT 80048 | $26.21 |
| Electrolyte panel | CPT 80051 | $29.88 |
| Comprehensive metabolic panel | CPT 80053 | $81.63 |
| Lipid panel | CPT 80061 | $62.73 |
| Renal function panel | CPT 80069 | $46.25 |
| Hepatic function panel | CPT 80076 | $85.4 |
| Urinalysis non-automated | CPT 81002 | $6.36 |
| Urinalysis automated | CPT 81003 | $37.43 |
| Glucose quantitative | CPT 82947 | $51.64 |
| Hemoglobin A1c | CPT 83036 | $23.06 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $351.71 |
| Complete blood count with automated differential | CPT 85025 | $64.17 |
| Complete blood count without differential | CPT 85027 | $38.03 |
| Urine culture bacterial | CPT 87086 | $19.19 |
| Urine culture identification | CPT 87088 | $33.34 |
| Tissue exam by pathologist level IV | CPT 88305 | $117.95 |
| Fetal non-stress test | CPT 59025 | $528.36 |
| Vaginal delivery only | CPT 59409 | $5,259.72 |
| C-section delivery only | CPT 59514 | $4,620.9 |
| Vaginal delivery w complicating dx | MS-DRG 774 | $11,900 |
| Vaginal delivery w/o complicating dx | MS-DRG 775 | $15,851 |
| Office visit, new patient, 15-29 min | CPT 99202 | $135 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $166.19 |
| Office visit, new patient, 45-59 min | CPT 99204 | $167.53 |
| Office visit, new patient, 60-74 min | CPT 99205 | $172.74 |
| Office visit, established patient, 5 min | CPT 99211 | $39.51 |
| Office visit, established patient, 10-19 min | CPT 99212 | $75.53 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $118.02 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $151.72 |
| Office visit, established patient, 40-54 min | CPT 99215 | $224.36 |
| Upper GI endoscopy diagnostic | CPT 43235 | $435.44 |
| Upper GI endoscopy with biopsy | CPT 43239 | $503.05 |
| Sigmoidoscopy diagnostic | CPT 45330 | $872.35 |
| Sigmoidoscopy with biopsy | CPT 45331 | $41.9 |
| Colonoscopy diagnostic | CPT 45378 | $505.52 |
| Colonoscopy with biopsy | CPT 45380 | $1.98 |
| Colonoscopy with polyp removal | CPT 45385 | $752.91 |
| Total shoulder arthroplasty | CPT 23472 | $10,845 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $18,298 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $19,459 |
| Total hip replacement | CPT 27130 | — |
| Total knee replacement | CPT 27447 | $8.4 |
| Knee revision arthroplasty single component | CPT 27486 | — |
| Shoulder arthroscopy with decompression | CPT 29826 | $6,517.81 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | — |
| Knee arthroscopy with meniscectomy | CPT 29881 | $4,117.39 |
| ACL reconstruction | CPT 29888 | $5,823.72 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $45,036 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $23,828 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $16,940 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $17,024 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $13,882 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $33,567 |
| Open appendectomy | CPT 44950 | $7,758.53 |
| Laparoscopic appendectomy | CPT 44970 | $7.59 |
| Major joint replacement w MCC | MS-DRG 469 | $29,961 |
| Major joint replacement w/o MCC | MS-DRG 470 | $19,496 |
| Laparoscopic cholecystectomy | CPT 47562 | $1,906.54 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $7,245.25 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $36,976 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $20,909 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $28,037 |
| Lap inguinal hernia repair | CPT 49650 | $7,245.25 |
| Lap salpingo-oophorectomy | CPT 58661 | $124.11 |
| OR procedure for obesity w MCC | MS-DRG 619 | $28,555 |
| OR procedure for obesity w CC | MS-DRG 620 | $16,451 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $15,403 |
| Complex cataract surgery | CPT 66982 | — |
| Cataract surgery with lens implant | CPT 66984 | $7.23 |
| Intravitreal injection | CPT 67028 | $1,130.89 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $12,676 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $20,471 |
| PCI single major coronary artery | CPT 92920 | $6,821.04 |
| PCI with drug-eluting stent | CPT 92928 | $14,790 |
| PCI bypass graft | CPT 92937 | $14,928 |
| Left heart catheterization | CPT 93452 | $6,608.87 |
| Coronary angiography with cath | CPT 93455 | $6,629.18 |
| Coronary angiography with bypass cath | CPT 93458 | $6,629.18 |
