| Psychoses | MS-DRG 885 | $10,470 |
| Psychiatric diagnostic evaluation | CPT 90791 | $164.51 |
| Psychiatric eval with medical services | CPT 90792 | $164.51 |
| Psychotherapy 30 minutes | CPT 90832 | $164.51 |
| Psychotherapy 45 minutes | CPT 90834 | $164.51 |
| Psychotherapy 60 minutes | CPT 90837 | $164.51 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $166.12 |
| ED visit level 1 | CPT 99281 | $91.03 |
| ED visit level 2 | CPT 99282 | $163.73 |
| ED visit level 3 | CPT 99283 | $286.28 |
| ED visit level 4 | CPT 99284 | $440.25 |
| ED visit level 5 | CPT 99285 | $4,977 |
| Critical care, first hour | CPT 99291 | $6,826.5 |
| CT head without contrast | CPT 70450 | $109.94 |
| CT head with contrast | CPT 70460 | $184.05 |
| CT head with and without contrast | CPT 70470 | $393.89 |
| CT neck with contrast | CPT 70491 | $184.05 |
| MRI brain without contrast | CPT 70551 | — |
| MRI brain with contrast | CPT 70552 | $369.23 |
| MRI brain with and without contrast | CPT 70553 | $369.23 |
| Chest X-ray single view | CPT 71045 | $91.03 |
| Chest X-ray 2 views | CPT 71046 | $91.03 |
| Chest X-ray 3 views | CPT 71047 | $91.03 |
| CT chest without contrast | CPT 71250 | $109.94 |
| CT chest with contrast | CPT 71260 | $184.05 |
| CT chest with and without contrast | CPT 71270 | $393.89 |
| MRI chest without contrast | CPT 71550 | $249.91 |
| MRI chest with contrast | CPT 71551 | $1,716.48 |
| MRI chest with and without contrast | CPT 71552 | $369.23 |
| Lumbosacral spine X-ray | CPT 72100 | — |
| CT cervical spine without contrast | CPT 72125 | $235.69 |
| CT thoracic spine without contrast | CPT 72128 | $235.69 |
| CT lumbar spine without contrast | CPT 72131 | $235.69 |
| MRI cervical spine without contrast | CPT 72141 | — |
| MRI thoracic spine without contrast | CPT 72146 | — |
| MRI lumbar spine without contrast | CPT 72148 | — |
| MRI lumbar spine with and without contrast | CPT 72149 | $369.23 |
| MRI cervical spine with and without contrast | CPT 72156 | $369.23 |
| MRI lumbar spine with contrast | CPT 72158 | $369.23 |
| CT pelvis without contrast | CPT 72192 | $109.94 |
| CT pelvis with contrast | CPT 72193 | $184.05 |
| Shoulder X-ray | CPT 73030 | $194.81 |
| Humerus X-ray | CPT 73060 | $194.81 |
| Hand X-ray 3 views | CPT 73130 | $1,027.65 |
| MRI upper extremity joint without contrast | CPT 73221 | — |
| MRI upper extremity joint with and without contrast | CPT 73223 | $367.44 |
| Knee X-ray 1-2 views | CPT 73560 | $194.81 |
| Ankle X-ray 3 views | CPT 73610 | $1,076.1 |
| MRI lower extremity joint without contrast | CPT 73721 | — |
| MRI lower extremity joint with and without contrast | CPT 73723 | $367.44 |
| CT abdomen without contrast | CPT 74150 | $109.94 |
| CT abdomen with contrast | CPT 74160 | $184.05 |
| CT abdomen with and without contrast | CPT 74170 | $393.89 |
| CT abdomen and pelvis without contrast | CPT 74176 | $249.91 |
| CT abdomen and pelvis with contrast | CPT 74177 | $369.23 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $369.23 |
| MRI abdomen without contrast | CPT 74181 | $249.91 |
| MRI abdomen with and without contrast | CPT 74183 | $824.45 |
| Abdominal ultrasound complete | CPT 76700 | $109.94 |
| Abdominal ultrasound limited | CPT 76705 | $235.69 |
| Retroperitoneal ultrasound complete | CPT 76770 | $235.69 |
| Obstetric ultrasound first trimester | CPT 76801 | $235.69 |
| Obstetric ultrasound after first trimester | CPT 76805 | $235.69 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $525.31 |
| Transvaginal ultrasound | CPT 76830 | — |
| Pelvic ultrasound complete | CPT 76856 | $1,707.48 |
| Scrotal ultrasound | CPT 76870 | $235.69 |
| Diagnostic mammography unilateral | CPT 77065 | $241.24 |
| Diagnostic mammography bilateral | CPT 77066 | $247.55 |
| Screening mammography bilateral | CPT 77067 | $630.36 |
| EKG complete | CPT 93000 | $1,617 |
| EKG tracing only | CPT 93005 | $61.41 |
| EKG interpretation only | CPT 93010 | $1,617 |
| Transthoracic echocardiogram complete | CPT 93306 | $564.13 |
| Transthoracic echocardiogram | CPT 93307 | $248.7 |
| Stress echocardiogram | CPT 93350 | $566.88 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $11,701 |
| COPD w MCC | MS-DRG 190 | $10,172 |
| COPD w CC | MS-DRG 191 | $8,723.6 |
| COPD w/o CC/MCC | MS-DRG 192 | $7,300 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $8,339.68 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $7,300 |
| AMI discharged alive w MCC | MS-DRG 280 | $10,747 |
| AMI discharged alive w CC | MS-DRG 281 | $9,511.11 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $7,482.85 |
| Heart failure & shock w MCC | MS-DRG 291 | $10,470 |
| Heart failure & shock w CC | MS-DRG 292 | $8,785.69 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $7,300 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $10,470 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $7,613.23 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $7,300 |
| GI hemorrhage w CC | MS-DRG 378 | $10,149 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $7,300 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $8,067.53 |
| Fractures of femur w/o MCC | MS-DRG 533 | $10,470 |
| Kidney/UTI w MCC | MS-DRG 689 | $10,188 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $8,376.93 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $12,305 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $10,172 |
| Initial hospital care, low complexity | CPT 99221 | $67.81 |
| Initial hospital care, moderate complexity | CPT 99222 | $112.11 |
| Initial hospital care, high complexity | CPT 99223 | $156.04 |
| Hospital discharge, <30 min | CPT 99238 | $70.03 |
| Hospital discharge, >30 min | CPT 99239 | $100 |
| Basic metabolic panel (BMP) | CPT 80048 | — |
| General health panel | CPT 80050 | $47.28 |
| Electrolyte panel | CPT 80051 | $13.01 |
| Comprehensive metabolic panel | CPT 80053 | — |
| Lipid panel | CPT 80061 | — |
| Renal function panel | CPT 80069 | $8.9 |
| Hepatic function panel | CPT 80076 | — |
| Urinalysis non-automated | CPT 81002 | — |
| Urinalysis automated | CPT 81003 | $4.18 |
| Glucose quantitative | CPT 82947 | — |
| Hemoglobin A1c | CPT 83036 | — |
| Thyroid stimulating hormone (TSH) | CPT 84443 | — |
| Complete blood count with automated differential | CPT 85025 | — |
| Complete blood count without differential | CPT 85027 | — |
| Urine culture bacterial | CPT 87086 | $8.27 |
| Urine culture identification | CPT 87088 | $8.29 |
| Tissue exam by pathologist level IV | CPT 88305 | $66.13 |
| Fetal non-stress test | CPT 59025 | $206.98 |
| Office visit, new patient, 15-29 min | CPT 99202 | $63.72 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $95.12 |
| Office visit, new patient, 45-59 min | CPT 99204 | $134.67 |
| Office visit, new patient, 60-74 min | CPT 99205 | $171.42 |
| Office visit, established patient, 5 min | CPT 99211 | $20.73 |
| Office visit, established patient, 10-19 min | CPT 99212 | $37.61 |
| 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 | $117.66 |
| Upper GI endoscopy diagnostic | CPT 43235 | $969.33 |
| Upper GI endoscopy with biopsy | CPT 43239 | $969.33 |
| Sigmoidoscopy diagnostic | CPT 45330 | $942.61 |
| Sigmoidoscopy with biopsy | CPT 45331 | $942.61 |
| Colonoscopy diagnostic | CPT 45378 | $942.61 |
| Colonoscopy with biopsy | CPT 45380 | $8,688 |
| Colonoscopy with polyp removal | CPT 45385 | $8,688 |
| Total hip replacement | CPT 27130 | $20,977 |
| Total knee replacement | CPT 27447 | $20,714 |
| Shoulder arthroscopy with decompression | CPT 29826 | $19,776 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $19,776 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $19,776 |
| ACL reconstruction | CPT 29888 | $19,776 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $28,828 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $15,035 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $11,153 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $10,927 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $10,470 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $21,368 |
| Open appendectomy | CPT 44950 | $8,688 |
| Major joint replacement w MCC | MS-DRG 469 | $19,023 |
| Major joint replacement w/o MCC | MS-DRG 470 | $12,429 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $18,265 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $13,530 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $10,536 |
| Lap inguinal hernia repair | CPT 49650 | $9,500 |
| OR procedure for obesity w MCC | MS-DRG 619 | $18,180 |
| OR procedure for obesity w CC | MS-DRG 620 | $12,024 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $11,133 |
| Intravitreal injection | CPT 67028 | $341.27 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $10,470 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $12,980 |
| PCI single major coronary artery | CPT 92920 | $11,390 |
| PCI with drug-eluting stent | CPT 92928 | $22,049 |
| PCI bypass graft | CPT 92937 | $22,049 |
| Left heart catheterization | CPT 93452 | $16,775 |
| Coronary angiography with cath | CPT 93455 | $16,775 |
| Coronary angiography with bypass cath | CPT 93458 | $16,775 |
