| Psychoses | MS-DRG 885 | $6,772.07 |
| Psychiatric diagnostic evaluation | CPT 90791 | $499.36 |
| Psychiatric eval with medical services | CPT 90792 | $561.63 |
| Psychotherapy 30 minutes | CPT 90832 | $74.5 |
| Psychotherapy 45 minutes | CPT 90834 | $74.5 |
| Psychotherapy 60 minutes | CPT 90837 | $74.5 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $74.5 |
| ED visit level 1 | CPT 99281 | $143 |
| ED visit level 2 | CPT 99282 | $193.78 |
| ED visit level 3 | CPT 99283 | $473 |
| ED visit level 4 | CPT 99284 | $780 |
| ED visit level 5 | CPT 99285 | $780 |
| Critical care, first hour | CPT 99291 | $1,156 |
| CT head without contrast | CPT 70450 | $258.74 |
| CT head with contrast | CPT 70460 | $313.01 |
| CT head with and without contrast | CPT 70470 | $370.85 |
| CT neck with contrast | CPT 70491 | $379.83 |
| MRI brain without contrast | CPT 70551 | $57 |
| MRI brain with contrast | CPT 70552 | $57 |
| MRI brain with and without contrast | CPT 70553 | $57 |
| Chest X-ray single view | CPT 71045 | $57 |
| Chest X-ray 2 views | CPT 71046 | $57 |
| Chest X-ray 3 views | CPT 71047 | $57 |
| CT chest without contrast | CPT 71250 | $272.39 |
| CT chest with contrast | CPT 71260 | $377.05 |
| CT chest with and without contrast | CPT 71270 | $453.21 |
| MRI chest without contrast | CPT 71550 | $57 |
| MRI chest with contrast | CPT 71551 | $57 |
| MRI chest with and without contrast | CPT 71552 | $57 |
| Lumbosacral spine X-ray | CPT 72100 | $57 |
| CT cervical spine without contrast | CPT 72125 | $274.13 |
| CT thoracic spine without contrast | CPT 72128 | $249.19 |
| CT lumbar spine without contrast | CPT 72131 | $259.74 |
| MRI cervical spine without contrast | CPT 72141 | $57 |
| MRI thoracic spine without contrast | CPT 72146 | $57 |
| MRI lumbar spine without contrast | CPT 72148 | $57 |
| MRI lumbar spine with and without contrast | CPT 72149 | $57 |
| MRI cervical spine with and without contrast | CPT 72156 | $57 |
| MRI lumbar spine with contrast | CPT 72158 | $57 |
| CT pelvis without contrast | CPT 72192 | $250.68 |
| CT pelvis with contrast | CPT 72193 | $387.15 |
| Shoulder X-ray | CPT 73030 | $85 |
| Humerus X-ray | CPT 73060 | $85 |
| Hand X-ray 3 views | CPT 73130 | $85 |
| MRI upper extremity joint without contrast | CPT 73221 | $326 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $436 |
| Knee X-ray 1-2 views | CPT 73560 | $85 |
| Ankle X-ray 3 views | CPT 73610 | $85 |
| MRI lower extremity joint without contrast | CPT 73721 | $326 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $436 |
| CT abdomen without contrast | CPT 74150 | $248.32 |
| CT abdomen with contrast | CPT 74160 | $406.04 |
| CT abdomen with and without contrast | CPT 74170 | $470.21 |
| CT abdomen and pelvis without contrast | CPT 74176 | $377.26 |
| CT abdomen and pelvis with contrast | CPT 74177 | $489.55 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $617.75 |
| MRI abdomen without contrast | CPT 74181 | $57 |
| MRI abdomen with and without contrast | CPT 74183 | $57 |
| Abdominal ultrasound complete | CPT 76700 | $57 |
| Abdominal ultrasound limited | CPT 76705 | $137.05 |
| Retroperitoneal ultrasound complete | CPT 76770 | $57 |
| Obstetric ultrasound first trimester | CPT 76801 | $57 |
| Obstetric ultrasound after first trimester | CPT 76805 | $57 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $226.5 |
| Transvaginal ultrasound | CPT 76830 | $57 |
| Pelvic ultrasound complete | CPT 76856 | $57 |
| Scrotal ultrasound | CPT 76870 | $57 |
| Diagnostic mammography unilateral | CPT 77065 | — |
| Diagnostic mammography bilateral | CPT 77066 | $286.37 |
| Screening mammography bilateral | CPT 77067 | $57 |
| EKG complete | CPT 93000 | $74.5 |
| EKG tracing only | CPT 93005 | $201.04 |
| EKG interpretation only | CPT 93010 | $59.7 |
| Transthoracic echocardiogram complete | CPT 93306 | $2,608.75 |
| Transthoracic echocardiogram | CPT 93307 | $1,287.91 |
| Stress echocardiogram | CPT 93350 | $1,613.52 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $27,461 |
| COPD w MCC | MS-DRG 190 | $17,839 |
| COPD w CC | MS-DRG 191 | $13,744 |
| COPD w/o CC/MCC | MS-DRG 192 | $11,251 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $13,310 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $10,825 |
| AMI discharged alive w MCC | MS-DRG 280 | $25,682 |
| AMI discharged alive w CC | MS-DRG 281 | $14,780 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $12,606 |
| Heart failure & shock w MCC | MS-DRG 291 | $20,784 |
| Heart failure & shock w CC | MS-DRG 292 | $14,049 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $9,538.87 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $19,461 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $12,852 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $9,726.62 |
| GI hemorrhage w CC | MS-DRG 378 | $15,926 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $11,069 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $12,717 |
| Fractures of femur w/o MCC | MS-DRG 533 | $26,409 |
| Kidney/UTI w MCC | MS-DRG 689 | $19,011 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $13,062 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $32,094 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $16,672 |
| Initial hospital care, low complexity | CPT 99221 | $88.25 |
| Initial hospital care, moderate complexity | CPT 99222 | $3,047 |
| Initial hospital care, high complexity | CPT 99223 | $3,047 |
| Hospital discharge, <30 min | CPT 99238 | $3,047 |
| Hospital discharge, >30 min | CPT 99239 | $3,047 |
| Basic metabolic panel (BMP) | CPT 80048 | $57 |
| General health panel | CPT 80050 | $161.56 |
| Electrolyte panel | CPT 80051 | $11.48 |
| Comprehensive metabolic panel | CPT 80053 | $18.48 |
| Lipid panel | CPT 80061 | $57 |
| Renal function panel | CPT 80069 | $57 |
| Hepatic function panel | CPT 80076 | $57 |
| Urinalysis non-automated | CPT 81002 | $57 |
| Urinalysis automated | CPT 81003 | $57 |
| Glucose quantitative | CPT 82947 | $4.72 |
| Hemoglobin A1c | CPT 83036 | $57 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $29.4 |
| Complete blood count with automated differential | CPT 85025 | $9.32 |
| Complete blood count without differential | CPT 85027 | $7.87 |
| Urine culture bacterial | CPT 87086 | $57 |
| Urine culture identification | CPT 87088 | $57 |
| Tissue exam by pathologist level IV | CPT 88305 | $57 |
| Fetal non-stress test | CPT 59025 | $439.75 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $64.95 |
| Vaginal delivery only | CPT 59409 | $401.02 |
| Vaginal delivery with postpartum | CPT 59410 | $64.95 |
| Routine obstetric care with C-section | CPT 59510 | $64.95 |
| C-section delivery only | CPT 59514 | $73.26 |
| C-section with postpartum | CPT 59515 | $64.95 |
| Office visit, new patient, 15-29 min | CPT 99202 | $234.6 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $346.8 |
| Office visit, new patient, 45-59 min | CPT 99204 | $418.2 |
| Office visit, new patient, 60-74 min | CPT 99205 | $485.4 |
| Office visit, established patient, 5 min | CPT 99211 | $183 |
| Office visit, established patient, 10-19 min | CPT 99212 | $279 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $307.8 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $338.4 |
| Office visit, established patient, 40-54 min | CPT 99215 | $399 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,024.64 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,024.64 |
| Sigmoidoscopy diagnostic | CPT 45330 | $996.39 |
| Sigmoidoscopy with biopsy | CPT 45331 | $996.39 |
| Colonoscopy diagnostic | CPT 45378 | $996.39 |
| Colonoscopy with biopsy | CPT 45380 | $1,288.59 |
| Colonoscopy with polyp removal | CPT 45385 | $1,288.59 |
| Total shoulder arthroplasty | CPT 23472 | $20,098 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $49,781 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $44,213 |
| Hip hemiarthroplasty | CPT 27125 | $3,266 |
| Total hip replacement | CPT 27130 | $14,062 |
| Total knee replacement | CPT 27447 | $14,062 |
| Knee revision arthroplasty single component | CPT 27486 | $3,266 |
| Knee revision arthroplasty all components | CPT 27487 | $3,266 |
| Shoulder arthroscopy with decompression | CPT 29826 | $91.49 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $7,306.5 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $3,545.97 |
| ACL reconstruction | CPT 29888 | $5,845 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $79,828 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $41,092 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $28,702 |
| CABG single arterial graft | CPT 33533 | $78.74 |
| CABG 2 arterial grafts | CPT 33534 | $78.74 |
| CABG 3 arterial grafts | CPT 33535 | $78.74 |
| CABG 4+ arterial grafts | CPT 33536 | $78.74 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $28,830 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $22,906 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $60,818 |
| Open appendectomy | CPT 44950 | $1,566.24 |
| Laparoscopic appendectomy | CPT 44970 | $5,168 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $149,699 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $84,062 |
| Major joint replacement w MCC | MS-DRG 469 | $56,825 |
| Major joint replacement w/o MCC | MS-DRG 470 | $25,986 |
| Laparoscopic cholecystectomy | CPT 47562 | $6,376.26 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $6,376.26 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $51,128 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $36,071 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $27,579 |
| Lap inguinal hernia repair | CPT 49650 | $5,168 |
| Total abdominal hysterectomy | CPT 58150 | $79 |
| Vaginal hysterectomy | CPT 58260 | $5,392.48 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $6,376.26 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $6,949.5 |
| Lap salpingo-oophorectomy | CPT 58661 | $6,376.26 |
| OR procedure for obesity w MCC | MS-DRG 619 | $24,295 |
| OR procedure for obesity w CC | MS-DRG 620 | $22,762 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $22,762 |
| Complex cataract surgery | CPT 66982 | $2,492.56 |
| Cataract surgery with lens implant | CPT 66984 | $2,492.56 |
| Intravitreal injection | CPT 67028 | $362.5 |
| Vitrectomy mechanical | CPT 67042 | $4,396.5 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $20,839 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $33,969 |
| PCI single major coronary artery | CPT 92920 | $10,904 |
| PCI with drug-eluting stent | CPT 92928 | $13,375 |
| PCI bypass graft | CPT 92937 | $13,375 |
| Left heart catheterization | CPT 93452 | $15,268 |
| Coronary angiography with cath | CPT 93455 | $9,370.08 |
| Coronary angiography with bypass cath | CPT 93458 | $15,268 |
