| Psychoses | MS-DRG 885 | $24,291 |
| Psychiatric diagnostic evaluation | CPT 90791 | $500.69 |
| Psychiatric eval with medical services | CPT 90792 | $560.91 |
| Psychotherapy 30 minutes | CPT 90832 | $168.51 |
| Psychotherapy 45 minutes | CPT 90834 | $222.23 |
| Psychotherapy 60 minutes | CPT 90837 | $329.19 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $403.18 |
| ED visit level 1 | CPT 99281 | $91.84 |
| ED visit level 2 | CPT 99282 | $173.79 |
| ED visit level 3 | CPT 99283 | $272.33 |
| ED visit level 4 | CPT 99284 | $477.75 |
| ED visit level 5 | CPT 99285 | $701.30 |
| Critical care, first hour | CPT 99291 | $1,148.82 |
| CT head without contrast | CPT 70450 | $127.28 |
| CT head with contrast | CPT 70460 | $165.82 |
| CT head with and without contrast | CPT 70470 | $200.75 |
| CT neck with contrast | CPT 70491 | $200.39 |
| MRI brain without contrast | CPT 70551 | $293.60 |
| MRI brain with contrast | CPT 70552 | $352.50 |
| MRI brain with and without contrast | CPT 70553 | $452.82 |
| Chest X-ray single view | CPT 71045 | $147.95 |
| Chest X-ray 2 views | CPT 71046 | $198.69 |
| Chest X-ray 3 views | CPT 71047 | $249.43 |
| CT chest without contrast | CPT 71250 | $199.30 |
| CT chest with contrast | CPT 71260 | $201.45 |
| CT chest with and without contrast | CPT 71270 | $247.49 |
| MRI chest without contrast | CPT 71550 | $289.41 |
| MRI chest with contrast | CPT 71551 | $342.79 |
| MRI chest with and without contrast | CPT 71552 | $445.08 |
| Lumbosacral spine X-ray | CPT 72100 | $249.51 |
| CT cervical spine without contrast | CPT 72125 | $199.30 |
| CT thoracic spine without contrast | CPT 72128 | $199.30 |
| CT lumbar spine without contrast | CPT 72131 | $199.30 |
| MRI cervical spine without contrast | CPT 72141 | $158.88 |
| MRI thoracic spine without contrast | CPT 72146 | $297.28 |
| MRI lumbar spine without contrast | CPT 72148 | $297.28 |
| MRI lumbar spine with and without contrast | CPT 72149 | $355.89 |
| MRI cervical spine with and without contrast | CPT 72156 | $242.88 |
| MRI lumbar spine with contrast | CPT 72158 | $456.67 |
| CT pelvis without contrast | CPT 72192 | $157.24 |
| CT pelvis with contrast | CPT 72193 | $190.71 |
| Shoulder X-ray | CPT 73030 | $221.30 |
| Humerus X-ray | CPT 73060 | $207.20 |
| Hand X-ray 3 views | CPT 73130 | $246.67 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,814.00 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $2,431.60 |
| Knee X-ray 1-2 views | CPT 73560 | $224.14 |
| Ankle X-ray 3 views | CPT 73610 | $241.00 |
| MRI lower extremity joint without contrast | CPT 73721 | $269.44 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $453.14 |
| CT abdomen without contrast | CPT 74150 | $159.72 |
| CT abdomen with contrast | CPT 74160 | $216.45 |
| CT abdomen with and without contrast | CPT 74170 | $276.26 |
| CT abdomen and pelvis without contrast | CPT 74176 | $158.06 |
| CT abdomen and pelvis with contrast | CPT 74177 | $206.04 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $261.39 |
| MRI abdomen without contrast | CPT 74181 | $289.41 |
| MRI abdomen with and without contrast | CPT 74183 | $434.11 |
| Abdominal ultrasound complete | CPT 76700 | $168.31 |
| Abdominal ultrasound limited | CPT 76705 | $121.49 |
| Retroperitoneal ultrasound complete | CPT 76770 | $152.38 |
| Transvaginal ultrasound | CPT 76830 | $143.18 |
| Pelvic ultrasound complete | CPT 76856 | $141.68 |
| Scrotal ultrasound | CPT 76870 | $131.58 |
| Diagnostic mammography unilateral | CPT 77065 | $104.04 |
| Diagnostic mammography bilateral | CPT 77066 | $127.22 |
| Screening mammography bilateral | CPT 77067 | $250.24 |
| EKG tracing only | CPT 93005 | $162.11 |
| EKG interpretation only | CPT 93010 | $27.07 |
| Transthoracic echocardiogram complete | CPT 93306 | $438.45 |
| Transthoracic echocardiogram | CPT 93307 | $359.45 |
| Stress echocardiogram | CPT 93350 | $532.48 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $38,471 |
| COPD w MCC | MS-DRG 190 | $28,320 |
| COPD w CC | MS-DRG 191 | $22,461 |
| COPD w/o CC/MCC | MS-DRG 192 | $24,291 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $21,472 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $24,291 |
| AMI discharged alive w MCC | MS-DRG 280 | $39,490 |
| AMI discharged alive w CC | MS-DRG 281 | $24,489 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $24,291 |
| Heart failure & shock w MCC | MS-DRG 291 | $31,605 |
| Heart failure & shock w CC | MS-DRG 292 | $22,621 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $24,291 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $29,640 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $20,460 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $15,909 |
| GI hemorrhage w CC | MS-DRG 378 | $26,130 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $24,291 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $21,053 |
| Fractures of femur w/o MCC | MS-DRG 533 | $24,291 |
| Kidney/UTI w MCC | MS-DRG 689 | $29,011 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $21,568 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $47,820 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $27,211 |
| Initial hospital care, low complexity | CPT 99221 | $412.97 |
| Initial hospital care, moderate complexity | CPT 99222 | $555.94 |
| Initial hospital care, high complexity | CPT 99223 | $814.03 |
| Hospital discharge, <30 min | CPT 99238 | $301.77 |
| Hospital discharge, >30 min | CPT 99239 | $441.04 |
| Basic metabolic panel (BMP) | CPT 80048 | $76.78 |
| Electrolyte panel | CPT 80051 | $76.78 |
| Comprehensive metabolic panel | CPT 80053 | $81.45 |
| Lipid panel | CPT 80061 | $72.24 |
| Hepatic function panel | CPT 80076 | $60.04 |
| Urinalysis automated | CPT 81003 | $35.40 |
| Glucose quantitative | CPT 82947 | $23.48 |
| Hemoglobin A1c | CPT 83036 | $52.73 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $74.65 |
| Complete blood count with automated differential | CPT 85025 | $51.60 |
| Complete blood count without differential | CPT 85027 | $38.77 |
| Urine culture identification | CPT 87088 | $32.36 |
| Tissue exam by pathologist level IV | CPT 88305 | $375.25 |
| Fetal non-stress test | CPT 59025 | $8,530.00 |
| Vaginal delivery only | CPT 59409 | $8,337.00 |
| Vaginal delivery with postpartum | CPT 59410 | $5,815.69 |
| C-section delivery only | CPT 59514 | $9,290.00 |
| C-section with postpartum | CPT 59515 | $8,735.99 |
| Office visit, new patient, 15-29 min | CPT 99202 | $310.07 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $440.19 |
| Office visit, new patient, 45-59 min | CPT 99204 | $671.03 |
| Office visit, new patient, 60-74 min | CPT 99205 | $840.53 |
| Office visit, established patient, 5 min | CPT 99211 | $1,373.88 |
| Office visit, established patient, 10-19 min | CPT 99212 | $185.86 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $303.07 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $438.94 |
| Office visit, established patient, 40-54 min | CPT 99215 | $588.01 |
| Upper GI endoscopy diagnostic | CPT 43235 | $6,080.25 |
| Upper GI endoscopy with biopsy | CPT 43239 | $6,683.50 |
| Sigmoidoscopy diagnostic | CPT 45330 | $1,875.59 |
| Sigmoidoscopy with biopsy | CPT 45331 | $252.47 |
| Colonoscopy diagnostic | CPT 45378 | $1,121.25 |
| Colonoscopy with biopsy | CPT 45380 | $2,211.33 |
| Colonoscopy with polyp removal | CPT 45385 | $6,775.50 |
| Total shoulder arthroplasty | CPT 23472 | $2,944.73 |
| Hip hemiarthroplasty | CPT 27125 | $9,772.75 |
| Total hip replacement | CPT 27130 | $14,552 |
| Total knee replacement | CPT 27447 | $14,857 |
| Knee revision arthroplasty single component | CPT 27486 | $5,026.34 |
| Knee revision arthroplasty all components | CPT 27487 | $6,253.33 |
| Shoulder arthroscopy with decompression | CPT 29826 | $7,576.75 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $14,115 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $7,969.94 |
| ACL reconstruction | CPT 29888 | $14,115 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $113,157 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $59,014 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $41,430 |
| CABG single arterial graft | CPT 33533 | $16,079 |
| CABG 2 arterial grafts | CPT 33534 | $16,079 |
| CABG 3 arterial grafts | CPT 33535 | $16,079 |
| CABG 4+ arterial grafts | CPT 33536 | $16,079 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $41,644 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $33,623 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $24,291 |
| Open appendectomy | CPT 44950 | $1,324.42 |
| Laparoscopic appendectomy | CPT 44970 | $11,086 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $24,291 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $24,291 |
| Major joint replacement w MCC | MS-DRG 469 | $74,671 |
| Major joint replacement w/o MCC | MS-DRG 470 | $47,486 |
| Laparoscopic cholecystectomy | CPT 47562 | $729.60 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $11,643 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $71,695 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $51,562 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $40,152 |
| Open umbilical hernia repair | CPT 49560 | $7,743.50 |
| Umbilical hernia repair age 5+ | CPT 49585 | $7,743.50 |
| Lap inguinal hernia repair | CPT 49650 | $406.40 |
| Lap incisional hernia repair | CPT 49652 | $10,455 |
| Total abdominal hysterectomy | CPT 58150 | $9,914.00 |
| Vaginal hysterectomy | CPT 58260 | $9,198.25 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $11,643 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $14,261 |
| Lap salpingo-oophorectomy | CPT 58661 | $2,908.65 |
| OR procedure for obesity w MCC | MS-DRG 619 | $24,291 |
| OR procedure for obesity w CC | MS-DRG 620 | $24,291 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $24,291 |
| Complex cataract surgery | CPT 66982 | $8,306.74 |
| Cataract surgery with lens implant | CPT 66984 | $8,306.74 |
| Intravitreal injection | CPT 67028 | $202.00 |
| Vitrectomy mechanical | CPT 67042 | $9,363.50 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $30,544 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $50,445 |
| PCI single major coronary artery | CPT 92920 | $13,574 |
| PCI with drug-eluting stent | CPT 92928 | $15,485 |
| PCI bypass graft | CPT 92937 | $15,485 |
| Left heart catheterization | CPT 93452 | $9,526.00 |
| Coronary angiography with cath | CPT 93455 | $9,526.00 |
| Coronary angiography with bypass cath | CPT 93458 | $9,526.00 |
