| Psychoses | MS-DRG 885 | $11,925 |
| Psychiatric diagnostic evaluation | CPT 90791 | $149.5 |
| Psychiatric eval with medical services | CPT 90792 | $169.63 |
| Psychotherapy 30 minutes | CPT 90832 | $72.24 |
| Psychotherapy 45 minutes | CPT 90834 | $207.03 |
| Psychotherapy 60 minutes | CPT 90837 | $141.03 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $136.15 |
| ED visit level 1 | CPT 99281 | $310.2 |
| ED visit level 2 | CPT 99282 | $123.24 |
| ED visit level 3 | CPT 99283 | $166.19 |
| ED visit level 4 | CPT 99284 | $318.73 |
| ED visit level 5 | CPT 99285 | $1,135.38 |
| Critical care, first hour | CPT 99291 | $798.44 |
| CT head without contrast | CPT 70450 | $761.03 |
| CT head with contrast | CPT 70460 | $80.6 |
| CT head with and without contrast | CPT 70470 | $608.37 |
| CT neck with contrast | CPT 70491 | $98.17 |
| MRI brain without contrast | CPT 70551 | $185.17 |
| MRI brain with contrast | CPT 70552 | $227.62 |
| MRI brain with and without contrast | CPT 70553 | $162.74 |
| Chest X-ray single view | CPT 71045 | $26.37 |
| Chest X-ray 2 views | CPT 71046 | $34.52 |
| Chest X-ray 3 views | CPT 71047 | $35.11 |
| CT chest without contrast | CPT 71250 | $702.21 |
| CT chest with contrast | CPT 71260 | $83.18 |
| CT chest with and without contrast | CPT 71270 | $575.45 |
| MRI chest without contrast | CPT 71550 | $182.5 |
| MRI chest with contrast | CPT 71551 | $304 |
| MRI chest with and without contrast | CPT 71552 | $160.67 |
| Lumbosacral spine X-ray | CPT 72100 | $31.02 |
| CT cervical spine without contrast | CPT 72125 | $693.84 |
| CT thoracic spine without contrast | CPT 72128 | $261.33 |
| CT lumbar spine without contrast | CPT 72131 | $691.44 |
| MRI cervical spine without contrast | CPT 72141 | $183.89 |
| MRI thoracic spine without contrast | CPT 72146 | $184.05 |
| MRI lumbar spine without contrast | CPT 72148 | $184.22 |
| MRI lumbar spine with and without contrast | CPT 72149 | $227.89 |
| MRI cervical spine with and without contrast | CPT 72156 | $302.92 |
| MRI lumbar spine with contrast | CPT 72158 | $163.26 |
| CT pelvis without contrast | CPT 72192 | $739.97 |
| CT pelvis with contrast | CPT 72193 | $642.01 |
| Shoulder X-ray | CPT 73030 | $27.1 |
| Humerus X-ray | CPT 73060 | $24.77 |
| Hand X-ray 3 views | CPT 73130 | $28.34 |
| MRI upper extremity joint without contrast | CPT 73221 | $137.16 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $153.44 |
| Hip X-ray 2 views | CPT 73510 | $37.06 |
| Knee X-ray 1-2 views | CPT 73560 | $26.48 |
| Ankle X-ray 3 views | CPT 73610 | $28.1 |
| MRI lower extremity joint without contrast | CPT 73721 | $169.21 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $152.92 |
| CT abdomen without contrast | CPT 74150 | $261.33 |
| CT abdomen with contrast | CPT 74160 | $642.01 |
| CT abdomen with and without contrast | CPT 74170 | $642.01 |
| CT abdomen and pelvis without contrast | CPT 74176 | $123.99 |
| CT abdomen and pelvis with contrast | CPT 74177 | $197.69 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $1,114.62 |
| MRI abdomen without contrast | CPT 74181 | $103.33 |
| MRI abdomen with and without contrast | CPT 74183 | $156.03 |
| Abdominal ultrasound complete | CPT 76700 | $118.4 |
| Abdominal ultrasound limited | CPT 76705 | $41.85 |
| Retroperitoneal ultrasound complete | CPT 76770 | $110.45 |
| Obstetric ultrasound first trimester | CPT 76801 | $70.78 |
| Obstetric ultrasound after first trimester | CPT 76805 | $71.3 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $159.23 |
| Transvaginal ultrasound | CPT 76830 | $121.21 |
| Pelvic ultrasound complete | CPT 76856 | $107.61 |
| Scrotal ultrasound | CPT 76870 | $102.42 |
| Diagnostic mammography unilateral | CPT 77065 | $57.86 |
| Diagnostic mammography bilateral | CPT 77066 | $71.3 |
| Screening mammography bilateral | CPT 77067 | $132.3 |
| EKG complete | CPT 93000 | $35.44 |
| EKG tracing only | CPT 93005 | $20.06 |
| EKG interpretation only | CPT 93010 | $24.88 |
| Transthoracic echocardiogram complete | CPT 93306 | $199.49 |
| Transthoracic echocardiogram | CPT 93307 | $145.22 |
| Stress echocardiogram | CPT 93350 | $187.88 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $16,719 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $8,908.24 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $6,365.3 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $13,220 |
| COPD w MCC | MS-DRG 190 | $9,669.32 |
| COPD w CC | MS-DRG 191 | $7,602.32 |
| COPD w/o CC/MCC | MS-DRG 192 | $6,033.52 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $7,312.94 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $5,928.58 |
| AMI discharged alive w MCC | MS-DRG 280 | $13,544 |
| AMI discharged alive w CC | MS-DRG 281 | $8,196.98 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $6,667.4 |
| Heart failure & shock w MCC | MS-DRG 291 | $11,043 |
| Heart failure & shock w CC | MS-DRG 292 | $7,650.02 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $5,440.98 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $10,421 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $6,764.92 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $5,440.98 |
| GI hemorrhage w CC | MS-DRG 378 | $8,677.16 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $5,943.42 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $7,108.36 |
| Fractures of femur w/o MCC | MS-DRG 533 | $13,260 |
| Kidney/UTI w MCC | MS-DRG 689 | $10,080 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $7,341.56 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $16,185 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $9,010 |
| Initial hospital care, low complexity | CPT 99221 | $269.8 |
| Initial hospital care, moderate complexity | CPT 99222 | $405.01 |
| Initial hospital care, high complexity | CPT 99223 | $566.63 |
| Hospital discharge, <30 min | CPT 99238 | $246.75 |
| Hospital discharge, >30 min | CPT 99239 | $349.45 |
| Basic metabolic panel (BMP) | CPT 80048 | $110.88 |
| General health panel | CPT 80050 | $53.49 |
| Electrolyte panel | CPT 80051 | $50.41 |
| Comprehensive metabolic panel | CPT 80053 | $150.47 |
| Lipid panel | CPT 80061 | $17.23 |
| Renal function panel | CPT 80069 | $11.35 |
| Hepatic function panel | CPT 80076 | $10.52 |
| Urinalysis non-automated | CPT 81002 | $4.62 |
| Urinalysis automated | CPT 81003 | $2.94 |
| Glucose quantitative | CPT 82947 | $44.25 |
| Hemoglobin A1c | CPT 83036 | $12.61 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $27.09 |
| Complete blood count with automated differential | CPT 85025 | $76.41 |
| Complete blood count without differential | CPT 85027 | $87.5 |
| Urine culture bacterial | CPT 87086 | $10.52 |
| Urine culture identification | CPT 87088 | $10.52 |
| Tissue exam by pathologist level IV | CPT 88305 | $38.85 |
| Fetal non-stress test | CPT 59025 | $86.25 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $6,977.76 |
| Vaginal delivery only | CPT 59409 | $1,800.22 |
| Vaginal delivery with postpartum | CPT 59410 | $2,916.2 |
| Routine obstetric care with C-section | CPT 59510 | $7,645.29 |
| C-section delivery only | CPT 59514 | $826.49 |
| C-section with postpartum | CPT 59515 | $3,575.45 |
| Office visit, new patient, 15-29 min | CPT 99202 | $167.85 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $331.87 |
| Office visit, new patient, 45-59 min | CPT 99204 | $506.91 |
| Office visit, new patient, 60-74 min | CPT 99205 | $562.49 |
| Office visit, established patient, 5 min | CPT 99211 | $22.55 |
| Office visit, established patient, 10-19 min | CPT 99212 | $137.83 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $279.72 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $392.39 |
| Office visit, established patient, 40-54 min | CPT 99215 | $528.64 |
| Upper GI endoscopy diagnostic | CPT 43235 | $385.78 |
| Upper GI endoscopy with biopsy | CPT 43239 | $787.82 |
| Sigmoidoscopy diagnostic | CPT 45330 | $180.06 |
| Sigmoidoscopy with biopsy | CPT 45331 | $184.01 |
| Colonoscopy diagnostic | CPT 45378 | $518.75 |
| Colonoscopy with biopsy | CPT 45380 | $1,315.92 |
| Colonoscopy with polyp removal | CPT 45385 | $851.62 |
| Total shoulder arthroplasty | CPT 23472 | $5,337.4 |
| Hip hemiarthroplasty | CPT 27125 | $3,054.96 |
| Total hip replacement | CPT 27130 | $12,808 |
| Total knee replacement | CPT 27447 | $12,808 |
| Knee revision arthroplasty single component | CPT 27486 | $3,470.06 |
| Knee revision arthroplasty all components | CPT 27487 | $4,281.44 |
| Shoulder arthroscopy with decompression | CPT 29826 | $1,002.5 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $7,222.85 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $2,162.27 |
| ACL reconstruction | CPT 29888 | $3,813.38 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $36,900 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $19,734 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $14,158 |
| CABG single arterial graft | CPT 33533 | $2,179.5 |
| CABG 2 arterial grafts | CPT 33534 | $2,179.5 |
| CABG 3 arterial grafts | CPT 33535 | $2,274.23 |
| CABG 4+ arterial grafts | CPT 33536 | $2,447.53 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $14,226 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $11,683 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $27,616 |
| Open appendectomy | CPT 44950 | $2,308.77 |
| Laparoscopic appendectomy | CPT 44970 | $1,370.6 |
| Major joint replacement w MCC | MS-DRG 469 | $24,698 |
| Major joint replacement w/o MCC | MS-DRG 470 | $16,078 |
| Laparoscopic cholecystectomy | CPT 47562 | $1,491.69 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $721.49 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $23,755 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $17,371 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $13,754 |
| Open umbilical hernia repair | CPT 49560 | $2,742.1 |
| Umbilical hernia repair age 5+ | CPT 49585 | $1,887.52 |
| Lap inguinal hernia repair | CPT 49650 | $991.22 |
| Lap incisional hernia repair | CPT 49652 | $3,102.33 |
| Total abdominal hysterectomy | CPT 58150 | $4,474.5 |
| Vaginal hysterectomy | CPT 58260 | $4,913.72 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $859.82 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $955.19 |
| Lap salpingo-oophorectomy | CPT 58661 | $1,955.48 |
| OR procedure for obesity w MCC | MS-DRG 619 | $23,560 |
| OR procedure for obesity w CC | MS-DRG 620 | $13,514 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $12,796 |
| Complex cataract surgery | CPT 66982 | $2,270.23 |
| Cataract surgery with lens implant | CPT 66984 | $1,963 |
| Intravitreal injection | CPT 67028 | $92.1 |
| Vitrectomy mechanical | CPT 67042 | $3,751.55 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $10,707 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $17,017 |
| PCI single major coronary artery | CPT 92920 | $480.7 |
| PCI with drug-eluting stent | CPT 92928 | $534.47 |
| PCI bypass graft | CPT 92937 | $534.13 |
| Left heart catheterization | CPT 93452 | $711 |
| Coronary angiography with cath | CPT 93455 | $5,252.12 |
| Coronary angiography with bypass cath | CPT 93458 | $874.55 |
