| Psychoses | MS-DRG 885 | $13,464 |
| Psychiatric diagnostic evaluation | CPT 90791 | $191.47 |
| Psychiatric eval with medical services | CPT 90792 | $455.92 |
| Psychotherapy 30 minutes | CPT 90832 | $115.5 |
| Psychotherapy 45 minutes | CPT 90834 | $445.73 |
| Psychotherapy 60 minutes | CPT 90837 | $1,246.76 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $209.71 |
| ED visit level 1 | CPT 99281 | $116.95 |
| ED visit level 2 | CPT 99282 | $1,991.12 |
| ED visit level 3 | CPT 99283 | $305.7 |
| ED visit level 4 | CPT 99284 | $1,991.12 |
| ED visit level 5 | CPT 99285 | $639.36 |
| Critical care, first hour | CPT 99291 | $869.85 |
| CT head without contrast | CPT 70450 | $134.5 |
| CT head with contrast | CPT 70460 | $189.21 |
| CT head with and without contrast | CPT 70470 | $198.52 |
| CT neck with contrast | CPT 70491 | $190.86 |
| MRI brain without contrast | CPT 70551 | $385.6 |
| MRI brain with contrast | CPT 70552 | $415.28 |
| MRI brain with and without contrast | CPT 70553 | $415.28 |
| Chest X-ray single view | CPT 71045 | $92.99 |
| Chest X-ray 2 views | CPT 71046 | $92.99 |
| Chest X-ray 3 views | CPT 71047 | $92.99 |
| CT chest without contrast | CPT 71250 | $144.6 |
| CT chest with contrast | CPT 71260 | $191.92 |
| CT chest with and without contrast | CPT 71270 | $205.83 |
| MRI chest without contrast | CPT 71550 | $399.43 |
| MRI chest with contrast | CPT 71551 | $845.64 |
| MRI chest with and without contrast | CPT 71552 | $617.26 |
| Lumbosacral spine X-ray | CPT 72100 | $111.17 |
| CT cervical spine without contrast | CPT 72125 | $144.6 |
| CT thoracic spine without contrast | CPT 72128 | $148.51 |
| CT lumbar spine without contrast | CPT 72131 | $146.64 |
| MRI cervical spine without contrast | CPT 72141 | $385.6 |
| MRI thoracic spine without contrast | CPT 72146 | $303.89 |
| MRI lumbar spine without contrast | CPT 72148 | $300.77 |
| MRI lumbar spine with and without contrast | CPT 72149 | $415.28 |
| MRI cervical spine with and without contrast | CPT 72156 | $415.28 |
| MRI lumbar spine with contrast | CPT 72158 | $415.28 |
| CT pelvis without contrast | CPT 72192 | $131.95 |
| CT pelvis with contrast | CPT 72193 | $195.38 |
| Shoulder X-ray | CPT 73030 | $93.88 |
| Humerus X-ray | CPT 73060 | $93.88 |
| Hand X-ray 3 views | CPT 73130 | $93.88 |
| MRI upper extremity joint without contrast | CPT 73221 | $366.77 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $564.51 |
| Knee X-ray 1-2 views | CPT 73560 | $93.88 |
| Ankle X-ray 3 views | CPT 73610 | $93.88 |
| MRI lower extremity joint without contrast | CPT 73721 | $366.77 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $564.51 |
| CT abdomen without contrast | CPT 74150 | $141.85 |
| CT abdomen with contrast | CPT 74160 | $196.42 |
| CT abdomen with and without contrast | CPT 74170 | $218.42 |
| CT abdomen and pelvis without contrast | CPT 74176 | $257.39 |
| CT abdomen and pelvis with contrast | CPT 74177 | $376.34 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $407.58 |
| MRI abdomen without contrast | CPT 74181 | $385.57 |
| MRI abdomen with and without contrast | CPT 74183 | $616.83 |
| Abdominal ultrasound complete | CPT 76700 | $118.62 |
| Abdominal ultrasound limited | CPT 76705 | $1,828.31 |
| Retroperitoneal ultrasound complete | CPT 76770 | $113.44 |
| Obstetric ultrasound first trimester | CPT 76801 | $114.39 |
| Obstetric ultrasound after first trimester | CPT 76805 | $114.39 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $257.57 |
| Transvaginal ultrasound | CPT 76830 | $114.39 |
| Pelvic ultrasound complete | CPT 76856 | $112.78 |
| Scrotal ultrasound | CPT 76870 | $112.78 |
| Diagnostic mammography unilateral | CPT 77065 | $270.25 |
| Diagnostic mammography bilateral | CPT 77066 | $336.5 |
| Screening mammography bilateral | CPT 77067 | $299.25 |
| EKG tracing only | CPT 93005 | $45.05 |
| Transthoracic echocardiogram complete | CPT 93306 | $211.53 |
| Transthoracic echocardiogram | CPT 93307 | $267.19 |
| Stress echocardiogram | CPT 93350 | $597.86 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $19,266 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $9,813.55 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $6,735.12 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $15,031 |
| COPD w MCC | MS-DRG 190 | $10,734 |
| COPD w CC | MS-DRG 191 | $8,233.26 |
| COPD w/o CC/MCC | MS-DRG 192 | $6,334.62 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $7,882.81 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $6,207.12 |
| AMI discharged alive w MCC | MS-DRG 280 | $15,423 |
| AMI discharged alive w CC | MS-DRG 281 | $8,952.1 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $7,100.69 |
| Heart failure & shock w MCC | MS-DRG 291 | $12,397 |
| Heart failure & shock w CC | MS-DRG 292 | $8,289.92 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $5,616.75 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $11,643 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $7,219.71 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $5,617.69 |
| GI hemorrhage w CC | MS-DRG 378 | $9,533.96 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $6,225.04 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $7,634.39 |
| Fractures of femur w/o MCC | MS-DRG 533 | $15,079 |
| Kidney/UTI w MCC | MS-DRG 689 | $11,230 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $7,916.82 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $18,619 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $9,936.35 |
| Basic metabolic panel (BMP) | CPT 80048 | $11.7 |
| General health panel | CPT 80050 | $197.42 |
| Electrolyte panel | CPT 80051 | $8.75 |
| Comprehensive metabolic panel | CPT 80053 | $14.61 |
| Lipid panel | CPT 80061 | $17.5 |
| Renal function panel | CPT 80069 | $12 |
| Hepatic function panel | CPT 80076 | $11.29 |
| Urinalysis non-automated | CPT 81002 | $3.71 |
| Urinalysis automated | CPT 81003 | $3.55 |
| Glucose quantitative | CPT 82947 | $390.39 |
| Hemoglobin A1c | CPT 83036 | $10.35 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $26.53 |
| Complete blood count with automated differential | CPT 85025 | $9.32 |
| Complete blood count without differential | CPT 85027 | $9.4 |
| Urine culture bacterial | CPT 87086 | $10 |
| Urine culture identification | CPT 87088 | $1,321.32 |
| Tissue exam by pathologist level IV | CPT 88305 | $56.22 |
| Fetal non-stress test | CPT 59025 | $226.4 |
| Office visit, new patient, 15-29 min | CPT 99202 | $79.73 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $113.17 |
| Office visit, new patient, 45-59 min | CPT 99204 | $147.15 |
| Office visit, new patient, 60-74 min | CPT 99205 | $176 |
| Office visit, established patient, 5 min | CPT 99211 | $10 |
| Office visit, established patient, 10-19 min | CPT 99212 | $21.6 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $207.6 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $303.58 |
| Office visit, established patient, 40-54 min | CPT 99215 | $303.58 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,003.17 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,003.17 |
| Sigmoidoscopy diagnostic | CPT 45330 | $1,017.5 |
| Sigmoidoscopy with biopsy | CPT 45331 | $1,017.5 |
| Colonoscopy diagnostic | CPT 45378 | $1,017.5 |
| Colonoscopy with biopsy | CPT 45380 | $1,290.85 |
| Colonoscopy with polyp removal | CPT 45385 | $1,290.85 |
| Total shoulder arthroplasty | CPT 23472 | $18,374 |
| Total hip replacement | CPT 27130 | $13,520 |
| Total knee replacement | CPT 27447 | $13,520 |
| Knee revision arthroplasty single component | CPT 27486 | $13,520 |
| Shoulder arthroscopy with decompression | CPT 29826 | $2,466 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $7,603.85 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $3,445.56 |
| ACL reconstruction | CPT 29888 | $7,603.85 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $43,689 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $22,914 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $16,167 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $16,249 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $13,172 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $32,454 |
| Laparoscopic appendectomy | CPT 44970 | $6,335.15 |
| Major joint replacement w MCC | MS-DRG 469 | $28,922 |
| Major joint replacement w/o MCC | MS-DRG 470 | $18,491 |
| Laparoscopic cholecystectomy | CPT 47562 | $6,366.21 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $6,366.21 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $27,780 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $20,055 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $15,677 |
| Lap inguinal hernia repair | CPT 49650 | $6,335.15 |
| Total abdominal hysterectomy | CPT 58150 | $2,354 |
| Lap salpingo-oophorectomy | CPT 58661 | $6,335.15 |
| OR procedure for obesity w MCC | MS-DRG 619 | $27,544 |
| OR procedure for obesity w CC | MS-DRG 620 | $15,387 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $14,519 |
| Complex cataract surgery | CPT 66982 | $2,477.67 |
| Cataract surgery with lens implant | CPT 66984 | $2,465.81 |
| Vitrectomy mechanical | CPT 67042 | $4,416.37 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $11,990 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $19,626 |
| PCI single major coronary artery | CPT 92920 | $6,051.95 |
| PCI with drug-eluting stent | CPT 92928 | $12,097 |
| PCI bypass graft | CPT 92937 | $12,097 |
| Left heart catheterization | CPT 93452 | $6,613.58 |
| Coronary angiography with cath | CPT 93455 | $3,597.08 |
| Coronary angiography with bypass cath | CPT 93458 | $3,497.16 |
