| Psychoses | MS-DRG 885 | $11,646 |
| Psychiatric diagnostic evaluation | CPT 90791 | $204.77 |
| Psychotherapy 30 minutes | CPT 90832 | $210.94 |
| Psychotherapy 45 minutes | CPT 90834 | $210.94 |
| Psychotherapy 60 minutes | CPT 90837 | $210.94 |
| ED visit level 1 | CPT 99281 | $91.3 |
| ED visit level 2 | CPT 99282 | $164.2 |
| ED visit level 3 | CPT 99283 | $287.1 |
| ED visit level 4 | CPT 99284 | $441.52 |
| ED visit level 5 | CPT 99285 | $663.61 |
| Critical care, first hour | CPT 99291 | $957.52 |
| CT head without contrast | CPT 70450 | $110.26 |
| CT head with contrast | CPT 70460 | $184.58 |
| CT head with and without contrast | CPT 70470 | $185.86 |
| CT neck with contrast | CPT 70491 | $192.69 |
| MRI brain without contrast | CPT 70551 | $250.63 |
| MRI brain with contrast | CPT 70552 | $378.43 |
| MRI brain with and without contrast | CPT 70553 | $370.3 |
| Chest X-ray single view | CPT 71045 | $89.07 |
| Chest X-ray 2 views | CPT 71046 | $89.07 |
| Chest X-ray 3 views | CPT 71047 | $89.07 |
| CT chest without contrast | CPT 71250 | $115.1 |
| CT chest with contrast | CPT 71260 | $192.69 |
| CT chest with and without contrast | CPT 71270 | $192.69 |
| MRI chest without contrast | CPT 71550 | $261.64 |
| MRI chest with contrast | CPT 71551 | $799.21 |
| MRI chest with and without contrast | CPT 71552 | $386.55 |
| Lumbosacral spine X-ray | CPT 72100 | $107.57 |
| CT cervical spine without contrast | CPT 72125 | $115.1 |
| CT thoracic spine without contrast | CPT 72128 | $115.1 |
| CT lumbar spine without contrast | CPT 72131 | $115.1 |
| MRI cervical spine without contrast | CPT 72141 | $250.63 |
| MRI thoracic spine without contrast | CPT 72146 | $250.63 |
| MRI lumbar spine without contrast | CPT 72148 | $250.63 |
| MRI lumbar spine with and without contrast | CPT 72149 | $378.43 |
| MRI cervical spine with and without contrast | CPT 72156 | $370.3 |
| MRI lumbar spine with contrast | CPT 72158 | $370.3 |
| CT pelvis without contrast | CPT 72192 | $115.1 |
| CT pelvis with contrast | CPT 72193 | $192.69 |
| Shoulder X-ray | CPT 73030 | $89.07 |
| Humerus X-ray | CPT 73060 | $89.07 |
| Hand X-ray 3 views | CPT 73130 | $89.07 |
| MRI upper extremity joint without contrast | CPT 73221 | $250.63 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $386.55 |
| Knee X-ray 1-2 views | CPT 73560 | $89.07 |
| Ankle X-ray 3 views | CPT 73610 | $89.07 |
| MRI lower extremity joint without contrast | CPT 73721 | $250.63 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $386.55 |
| CT abdomen without contrast | CPT 74150 | $115.1 |
| CT abdomen with contrast | CPT 74160 | $192.69 |
| CT abdomen with and without contrast | CPT 74170 | $192.69 |
| CT abdomen and pelvis without contrast | CPT 74176 | $250.63 |
| CT abdomen and pelvis with contrast | CPT 74177 | $361.27 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $370.3 |
| MRI abdomen without contrast | CPT 74181 | $250.63 |
| MRI abdomen with and without contrast | CPT 74183 | $386.55 |
| Abdominal ultrasound complete | CPT 76700 | $115.1 |
| Abdominal ultrasound limited | CPT 76705 | $110.26 |
| Retroperitoneal ultrasound complete | CPT 76770 | $111.56 |
| Obstetric ultrasound first trimester | CPT 76801 | $110.26 |
| Obstetric ultrasound after first trimester | CPT 76805 | $115.1 |
| Transvaginal ultrasound | CPT 76830 | $115.1 |
| Pelvic ultrasound complete | CPT 76856 | $110.26 |
| Scrotal ultrasound | CPT 76870 | $110.26 |
| Screening mammography bilateral | CPT 77067 | $139.31 |
| EKG tracing only | CPT 93005 | $60.09 |
| Transthoracic echocardiogram complete | CPT 93306 | $557.08 |
| Stress echocardiogram | CPT 93350 | $554.65 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $12,981 |
| COPD w MCC | MS-DRG 190 | $9,319.43 |
| COPD w CC | MS-DRG 191 | $7,189.34 |
| COPD w/o CC/MCC | MS-DRG 192 | $5,302.8 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $6,890.8 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $5,463.22 |
| AMI discharged alive w MCC | MS-DRG 280 | $13,314 |
| AMI discharged alive w CC | MS-DRG 281 | $7,801.73 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $6,224.48 |
| Heart failure & shock w MCC | MS-DRG 291 | $10,737 |
| Heart failure & shock w CC | MS-DRG 292 | $7,237.63 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $4,960.26 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $10,094 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $6,325.88 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $4,961.07 |
| GI hemorrhage w CC | MS-DRG 378 | $8,297.45 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $5,478.5 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $6,679.15 |
| Fractures of femur w/o MCC | MS-DRG 533 | $13,021 |
| Kidney/UTI w MCC | MS-DRG 689 | $9,742.72 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $6,919.76 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $16,037 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $8,640.25 |
| Basic metabolic panel (BMP) | CPT 80048 | $8.97 |
| General health panel | CPT 80050 | $61.28 |
| Electrolyte panel | CPT 80051 | $7.43 |
| Comprehensive metabolic panel | CPT 80053 | $11.19 |
| Lipid panel | CPT 80061 | $14.19 |
| Renal function panel | CPT 80069 | $9.2 |
| Hepatic function panel | CPT 80076 | $8.66 |
| Urinalysis non-automated | CPT 81002 | $3.69 |
| Urinalysis automated | CPT 81003 | $2.39 |
| Glucose quantitative | CPT 82947 | $4.17 |
| Hemoglobin A1c | CPT 83036 | $10.29 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $17.81 |
| Complete blood count with automated differential | CPT 85025 | $8.24 |
| Complete blood count without differential | CPT 85027 | $6.63 |
| Urine culture bacterial | CPT 87086 | $8.55 |
| Urine culture identification | CPT 87088 | $8.58 |
| Tissue exam by pathologist level IV | CPT 88305 | $71.69 |
| Fetal non-stress test | CPT 59025 | $203.5 |
| Office visit, established patient, 40-54 min | CPT 99215 | $261.16 |
| Upper GI endoscopy diagnostic | CPT 43235 | $948.42 |
| Upper GI endoscopy with biopsy | CPT 43239 | $948.42 |
| Sigmoidoscopy diagnostic | CPT 45330 | $922.27 |
| Sigmoidoscopy with biopsy | CPT 45331 | $922.27 |
| Colonoscopy diagnostic | CPT 45378 | $945.32 |
| Colonoscopy with biopsy | CPT 45380 | $1,192.73 |
| Colonoscopy with polyp removal | CPT 45385 | $1,192.73 |
| Total hip replacement | CPT 27130 | $12,139 |
| Total knee replacement | CPT 27447 | $12,139 |
| Shoulder arthroscopy with decompression | CPT 29826 | $1,213.91 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $6,739.39 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $3,190 |
| ACL reconstruction | CPT 29888 | $6,758.34 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $37,395 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $19,696 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $13,948 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $14,018 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $11,396 |
| Laparoscopic appendectomy | CPT 44970 | $5,901.92 |
| Major joint replacement w MCC | MS-DRG 469 | $24,814 |
| Major joint replacement w/o MCC | MS-DRG 470 | $15,928 |
| Laparoscopic cholecystectomy | CPT 47562 | $5,703.03 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $5,901.92 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $23,368 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $16,918 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $13,531 |
| Lap inguinal hernia repair | CPT 49650 | $5,703.03 |
| Lap salpingo-oophorectomy | CPT 58661 | $5,901.92 |
| OR procedure for obesity w MCC | MS-DRG 619 | $23,641 |
| OR procedure for obesity w CC | MS-DRG 620 | $13,284 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $12,544 |
| Complex cataract surgery | CPT 66982 | $2,307.14 |
| Cataract surgery with lens implant | CPT 66984 | $2,307.14 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $10,390 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $16,895 |
| PCI single major coronary artery | CPT 92920 | $5,804.37 |
| PCI with drug-eluting stent | CPT 92928 | $11,361 |
| Left heart catheterization | CPT 93452 | $3,253.66 |
| Coronary angiography with cath | CPT 93455 | $3,335 |
| Coronary angiography with bypass cath | CPT 93458 | $3,253.66 |
