| Psychoses | MS-DRG 885 | $16,674 |
| Psychiatric diagnostic evaluation | CPT 90791 | $164.03 |
| Psychiatric eval with medical services | CPT 90792 | $184.09 |
| Psychotherapy 30 minutes | CPT 90832 | $77.69 |
| Psychotherapy 45 minutes | CPT 90834 | $102.53 |
| Psychotherapy 60 minutes | CPT 90837 | $151.85 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $145.85 |
| ED visit level 1 | CPT 99281 | $12.32 |
| ED visit level 2 | CPT 99282 | $43.12 |
| ED visit level 3 | CPT 99283 | $72.92 |
| ED visit level 4 | CPT 99284 | $124.29 |
| ED visit level 5 | CPT 99285 | $163.82 |
| Critical care, first hour | CPT 99291 | $256.36 |
| CT head without contrast | CPT 70450 | $842.40 |
| CT head with contrast | CPT 70460 | $950.40 |
| CT head with and without contrast | CPT 70470 | $1,228.40 |
| CT neck with contrast | CPT 70491 | $1,360.80 |
| MRI brain without contrast | CPT 70551 | $2,033.20 |
| MRI brain with contrast | CPT 70552 | $2,340.00 |
| MRI brain with and without contrast | CPT 70553 | $2,808.80 |
| Chest X-ray single view | CPT 71045 | $146.00 |
| Chest X-ray 2 views | CPT 71046 | $262.80 |
| Chest X-ray 3 views | CPT 71047 | $362.80 |
| CT chest without contrast | CPT 71250 | $816.80 |
| CT chest with contrast | CPT 71260 | $1,028.40 |
| CT chest with and without contrast | CPT 71270 | $1,130.40 |
| MRI chest without contrast | CPT 71550 | $2,819.60 |
| MRI chest with contrast | CPT 71551 | $2,963.60 |
| MRI chest with and without contrast | CPT 71552 | $3,060.00 |
| Lumbosacral spine X-ray | CPT 72100 | $228.80 |
| CT cervical spine without contrast | CPT 72125 | $904.00 |
| CT thoracic spine without contrast | CPT 72128 | $904.00 |
| CT lumbar spine without contrast | CPT 72131 | $904.00 |
| MRI cervical spine without contrast | CPT 72141 | $1,478.80 |
| MRI thoracic spine without contrast | CPT 72146 | $1,613.60 |
| MRI lumbar spine without contrast | CPT 72148 | $1,532.00 |
| MRI lumbar spine with and without contrast | CPT 72149 | $2,614.00 |
| MRI cervical spine with and without contrast | CPT 72156 | $3,032.00 |
| MRI lumbar spine with contrast | CPT 72158 | $3,138.80 |
| CT pelvis without contrast | CPT 72192 | $904.00 |
| CT pelvis with contrast | CPT 72193 | $1,526.40 |
| Shoulder X-ray | CPT 73030 | $268.40 |
| Humerus X-ray | CPT 73060 | $222.40 |
| Hand X-ray 3 views | CPT 73130 | $243.20 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,675.60 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $2,316.80 |
| Knee X-ray 1-2 views | CPT 73560 | $222.40 |
| Ankle X-ray 3 views | CPT 73610 | $243.20 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,682.80 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $2,320.80 |
| CT abdomen without contrast | CPT 74150 | $900.00 |
| CT abdomen with contrast | CPT 74160 | $1,526.40 |
| CT abdomen with and without contrast | CPT 74170 | $1,447.60 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,335.60 |
| CT abdomen and pelvis with contrast | CPT 74177 | $1,526.40 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $2,148.40 |
| MRI abdomen without contrast | CPT 74181 | $1,464.40 |
| MRI abdomen with and without contrast | CPT 74183 | $2,913.20 |
| Abdominal ultrasound complete | CPT 76700 | $558.00 |
| Abdominal ultrasound limited | CPT 76705 | $292.40 |
| Retroperitoneal ultrasound complete | CPT 76770 | $492.40 |
| Obstetric ultrasound first trimester | CPT 76801 | $228.00 |
| Obstetric ultrasound after first trimester | CPT 76805 | $124.61 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $173.29 |
| Transvaginal ultrasound | CPT 76830 | $490.00 |
| Pelvic ultrasound complete | CPT 76856 | $490.00 |
| Scrotal ultrasound | CPT 76870 | $366.00 |
| Diagnostic mammography unilateral | CPT 77065 | $260.45 |
| Diagnostic mammography bilateral | CPT 77066 | $317.19 |
| Screening mammography bilateral | CPT 77067 | $301.19 |
| EKG complete | CPT 93000 | $15.00 |
| EKG tracing only | CPT 93005 | $6.44 |
| EKG interpretation only | CPT 93010 | $8.34 |
| Transthoracic echocardiogram complete | CPT 93306 | $180.27 |
| Transthoracic echocardiogram | CPT 93307 | $904.80 |
| Stress echocardiogram | CPT 93350 | $181.17 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $22,528 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $12,707 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $9,388.68 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $18,764 |
| COPD w MCC | MS-DRG 190 | $13,779 |
| COPD w CC | MS-DRG 191 | $11,114 |
| COPD w/o CC/MCC | MS-DRG 192 | $8,973.63 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $10,719 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $8,726.23 |
| AMI discharged alive w MCC | MS-DRG 280 | $19,015 |
| AMI discharged alive w CC | MS-DRG 281 | $11,747 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $9,760.30 |
| Heart failure & shock w MCC | MS-DRG 291 | $15,615 |
| Heart failure & shock w CC | MS-DRG 292 | $11,135 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $7,978.93 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $14,616 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $9,903.70 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $8,087.99 |
| GI hemorrhage w CC | MS-DRG 378 | $12,394 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $8,867.59 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $10,318 |
| Fractures of femur w/o MCC | MS-DRG 533 | $17,838 |
| Kidney/UTI w MCC | MS-DRG 689 | $14,257 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $10,543 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $22,254 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $12,850 |
| Initial hospital care, low complexity | CPT 99221 | $84.71 |
| Initial hospital care, moderate complexity | CPT 99222 | $131.59 |
| Initial hospital care, high complexity | CPT 99223 | $174.76 |
| Hospital discharge, <30 min | CPT 99238 | $81.78 |
| Hospital discharge, >30 min | CPT 99239 | $115.47 |
| Basic metabolic panel (BMP) | CPT 80048 | $131.08 |
| General health panel | CPT 80050 | $410.64 |
| Electrolyte panel | CPT 80051 | $134.56 |
| Comprehensive metabolic panel | CPT 80053 | $167.04 |
| Lipid panel | CPT 80061 | $143.26 |
| Renal function panel | CPT 80069 | $168.78 |
| Hepatic function panel | CPT 80076 | $213.44 |
| Urinalysis non-automated | CPT 81002 | $49.88 |
| Urinalysis automated | CPT 81003 | $40.02 |
| Glucose quantitative | CPT 82947 | $23.78 |
| Hemoglobin A1c | CPT 83036 | $156.02 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $169.36 |
| Complete blood count with automated differential | CPT 85025 | $67.86 |
| Complete blood count without differential | CPT 85027 | $58.00 |
| Urine culture bacterial | CPT 87086 | $114.84 |
| Urine culture identification | CPT 87088 | $90.48 |
| Tissue exam by pathologist level IV | CPT 88305 | $234.90 |
| Vaginal delivery only | CPT 59409 | $819.99 |
| Office visit, new patient, 15-29 min | CPT 99202 | $65.00 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $104.96 |
| Office visit, new patient, 45-59 min | CPT 99204 | $157.62 |
| Office visit, new patient, 60-74 min | CPT 99205 | $208.14 |
| Office visit, established patient, 5 min | CPT 99211 | $15.85 |
| Office visit, established patient, 10-19 min | CPT 99212 | $46.26 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $85.86 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $120.91 |
| Office visit, established patient, 40-54 min | CPT 99215 | $169.83 |
| Upper GI endoscopy diagnostic | CPT 43235 | $181.76 |
| Upper GI endoscopy with biopsy | CPT 43239 | $231.74 |
| Sigmoidoscopy diagnostic | CPT 45330 | $109.18 |
| Sigmoidoscopy with biopsy | CPT 45331 | $1,187.28 |
| Colonoscopy diagnostic | CPT 45378 | $262.87 |
| Colonoscopy with biopsy | CPT 45380 | $285.77 |
| Colonoscopy with polyp removal | CPT 45385 | $361.69 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $48,817 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $26,311 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $19,112 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $19,187 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $15,745 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $38,086 |
| Major joint replacement w MCC | MS-DRG 469 | $35,452 |
| Major joint replacement w/o MCC | MS-DRG 470 | $21,481 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $32,142 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $23,394 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $18,460 |
| OR procedure for obesity w MCC | MS-DRG 619 | $29,975 |
| OR procedure for obesity w CC | MS-DRG 620 | $18,567 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $17,201 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $14,544 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $22,173 |
