| Psychoses | MS-DRG 885 | $80.00 |
| Psychiatric diagnostic evaluation | CPT 90791 | $265.92 |
| Psychiatric eval with medical services | CPT 90792 | $71.00 |
| Psychotherapy 30 minutes | CPT 90832 | $122.83 |
| Psychotherapy 45 minutes | CPT 90834 | $185.22 |
| Psychotherapy 60 minutes | CPT 90837 | $199.11 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $71.00 |
| ED visit level 1 | CPT 99281 | $71.00 |
| ED visit level 2 | CPT 99282 | $71.00 |
| ED visit level 3 | CPT 99283 | $71.00 |
| ED visit level 4 | CPT 99284 | $71.00 |
| ED visit level 5 | CPT 99285 | $71.00 |
| Critical care, first hour | CPT 99291 | $71.00 |
| CT head without contrast | CPT 70450 | $59.40 |
| CT head with contrast | CPT 70460 | $59.40 |
| CT head with and without contrast | CPT 70470 | $59.40 |
| CT neck with contrast | CPT 70491 | $59.40 |
| MRI brain without contrast | CPT 70551 | $1,529.96 |
| MRI brain with contrast | CPT 70552 | $1,260.64 |
| MRI brain with and without contrast | CPT 70553 | $2,018.46 |
| Chest X-ray single view | CPT 71045 | $59.40 |
| Chest X-ray 2 views | CPT 71046 | $59.40 |
| Chest X-ray 3 views | CPT 71047 | $59.40 |
| CT chest without contrast | CPT 71250 | $59.40 |
| CT chest with contrast | CPT 71260 | $59.40 |
| CT chest with and without contrast | CPT 71270 | $59.40 |
| MRI chest without contrast | CPT 71550 | $1,066.91 |
| MRI chest with contrast | CPT 71551 | $59.40 |
| MRI chest with and without contrast | CPT 71552 | $1,819.06 |
| Lumbosacral spine X-ray | CPT 72100 | $59.40 |
| CT cervical spine without contrast | CPT 72125 | $59.40 |
| CT thoracic spine without contrast | CPT 72128 | $360.80 |
| CT lumbar spine without contrast | CPT 72131 | $374.25 |
| MRI cervical spine without contrast | CPT 72141 | $59.40 |
| MRI thoracic spine without contrast | CPT 72146 | $1,936.35 |
| MRI lumbar spine without contrast | CPT 72148 | $1,936.35 |
| MRI lumbar spine with and without contrast | CPT 72149 | $59.40 |
| MRI cervical spine with and without contrast | CPT 72156 | $59.40 |
| MRI lumbar spine with contrast | CPT 72158 | $2,552.26 |
| CT pelvis without contrast | CPT 72192 | $1,103.64 |
| CT pelvis with contrast | CPT 72193 | $59.40 |
| Shoulder X-ray | CPT 73030 | $59.40 |
| Humerus X-ray | CPT 73060 | $59.40 |
| Hand X-ray 3 views | CPT 73130 | $59.40 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,673.02 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $1,957.56 |
| Knee X-ray 1-2 views | CPT 73560 | $59.40 |
| Ankle X-ray 3 views | CPT 73610 | $59.40 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,535.66 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $2,033.88 |
| CT abdomen without contrast | CPT 74150 | $336.37 |
| CT abdomen with contrast | CPT 74160 | $59.40 |
| CT abdomen with and without contrast | CPT 74170 | $1,791.12 |
| CT abdomen and pelvis without contrast | CPT 74176 | $619.90 |
| CT abdomen and pelvis with contrast | CPT 74177 | $762.14 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $878.24 |
| MRI abdomen without contrast | CPT 74181 | $1,134.97 |
| MRI abdomen with and without contrast | CPT 74183 | $2,153.38 |
| Abdominal ultrasound complete | CPT 76700 | $180.87 |
| Abdominal ultrasound limited | CPT 76705 | $652.12 |
| Retroperitoneal ultrasound complete | CPT 76770 | $154.55 |
| Obstetric ultrasound first trimester | CPT 76801 | $126.14 |
| Obstetric ultrasound after first trimester | CPT 76805 | $141.36 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $240.67 |
| Transvaginal ultrasound | CPT 76830 | $140.53 |
| Pelvic ultrasound complete | CPT 76856 | $177.27 |
| Scrotal ultrasound | CPT 76870 | $141.86 |
| Diagnostic mammography unilateral | CPT 77065 | $247.32 |
| Diagnostic mammography bilateral | CPT 77066 | $313.95 |
| Screening mammography bilateral | CPT 77067 | $223.27 |
| EKG complete | CPT 93000 | $50.00 |
| EKG tracing only | CPT 93005 | $133.28 |
| EKG interpretation only | CPT 93010 | $30.22 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,772.08 |
| Transthoracic echocardiogram | CPT 93307 | $1,007.76 |
| Stress echocardiogram | CPT 93350 | $1,757.36 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $90.00 |
| COPD w MCC | MS-DRG 190 | $90.00 |
| COPD w CC | MS-DRG 191 | $90.00 |
| COPD w/o CC/MCC | MS-DRG 192 | $90.00 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $90.00 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $90.00 |
| AMI discharged alive w MCC | MS-DRG 280 | $90.00 |
| AMI discharged alive w CC | MS-DRG 281 | $90.00 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $90.00 |
| Heart failure & shock w MCC | MS-DRG 291 | $90.00 |
| Heart failure & shock w CC | MS-DRG 292 | $90.00 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $90.00 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $90.00 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $90.00 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $90.00 |
| GI hemorrhage w CC | MS-DRG 378 | $90.00 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $90.00 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $90.00 |
| Fractures of femur w/o MCC | MS-DRG 533 | $90.00 |
| Kidney/UTI w MCC | MS-DRG 689 | $90.00 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $90.00 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $90.00 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $90.00 |
| Initial hospital care, low complexity | CPT 99221 | $68.70 |
| Initial hospital care, moderate complexity | CPT 99222 | $68.70 |
| Initial hospital care, high complexity | CPT 99223 | $68.70 |
| Hospital discharge, <30 min | CPT 99238 | $68.70 |
| Hospital discharge, >30 min | CPT 99239 | $68.70 |
| Basic metabolic panel (BMP) | CPT 80048 | $59.40 |
| General health panel | CPT 80050 | $205.80 |
| Electrolyte panel | CPT 80051 | $64.48 |
| Comprehensive metabolic panel | CPT 80053 | $156.80 |
| Lipid panel | CPT 80061 | $76.38 |
| Renal function panel | CPT 80069 | $79.98 |
| Hepatic function panel | CPT 80076 | $71.87 |
| Urinalysis non-automated | CPT 81002 | $33.02 |
| Urinalysis automated | CPT 81003 | $59.40 |
| Glucose quantitative | CPT 82947 | $25.66 |
| Hemoglobin A1c | CPT 83036 | $59.40 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $103.88 |
| Complete blood count with automated differential | CPT 85025 | $2,261.00 |
| Complete blood count without differential | CPT 85027 | $59.40 |
| Urine culture bacterial | CPT 87086 | $59.40 |
| Urine culture identification | CPT 87088 | $59.40 |
| Tissue exam by pathologist level IV | CPT 88305 | $59.40 |
| Fetal non-stress test | CPT 59025 | $432.05 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $68.70 |
| Vaginal delivery only | CPT 59409 | $71.00 |
| Vaginal delivery with postpartum | CPT 59410 | $68.70 |
| Routine obstetric care with C-section | CPT 59510 | $68.70 |
| C-section delivery only | CPT 59514 | $68.70 |
| C-section with postpartum | CPT 59515 | $68.70 |
| Office visit, new patient, 15-29 min | CPT 99202 | $196.48 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $217.77 |
| Office visit, new patient, 45-59 min | CPT 99204 | $68.70 |
| Office visit, new patient, 60-74 min | CPT 99205 | $441.05 |
| Office visit, established patient, 5 min | CPT 99211 | $164.88 |
| Office visit, established patient, 10-19 min | CPT 99212 | $154.57 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $193.73 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $243.19 |
| Office visit, established patient, 40-54 min | CPT 99215 | $272.73 |
| Upper GI endoscopy diagnostic | CPT 43235 | $71.00 |
| Upper GI endoscopy with biopsy | CPT 43239 | $71.00 |
| Sigmoidoscopy diagnostic | CPT 45330 | $71.00 |
| Sigmoidoscopy with biopsy | CPT 45331 | $71.00 |
| Colonoscopy diagnostic | CPT 45378 | $71.00 |
| Colonoscopy with biopsy | CPT 45380 | $71.00 |
| Colonoscopy with polyp removal | CPT 45385 | $71.00 |
| Total shoulder arthroplasty | CPT 23472 | $71.00 |
| Hip hemiarthroplasty | CPT 27125 | $71.00 |
| Total hip replacement | CPT 27130 | $71.00 |
| Total knee replacement | CPT 27447 | $71.00 |
| Knee revision arthroplasty single component | CPT 27486 | $71.00 |
| Knee revision arthroplasty all components | CPT 27487 | $71.00 |
| Shoulder arthroscopy with decompression | CPT 29826 | $68.70 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $71.00 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $71.00 |
| ACL reconstruction | CPT 29888 | $71.00 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $90.00 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $90.00 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $90.00 |
| CABG single arterial graft | CPT 33533 | $68.70 |
| CABG 2 arterial grafts | CPT 33534 | $68.70 |
| CABG 3 arterial grafts | CPT 33535 | $68.70 |
| CABG 4+ arterial grafts | CPT 33536 | $68.70 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $90.00 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $90.00 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $90.00 |
| Open appendectomy | CPT 44950 | $71.00 |
| Laparoscopic appendectomy | CPT 44970 | $71.00 |
| Major joint replacement w MCC | MS-DRG 469 | $90.00 |
| Major joint replacement w/o MCC | MS-DRG 470 | $89.00 |
| Laparoscopic cholecystectomy | CPT 47562 | $71.00 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $71.00 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $90.00 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $90.00 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $90.00 |
| Lap inguinal hernia repair | CPT 49650 | $71.00 |
| Total abdominal hysterectomy | CPT 58150 | $68.70 |
| Vaginal hysterectomy | CPT 58260 | $71.00 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $71.00 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $71.00 |
| Lap salpingo-oophorectomy | CPT 58661 | $71.00 |
| OR procedure for obesity w MCC | MS-DRG 619 | $90.00 |
| OR procedure for obesity w CC | MS-DRG 620 | $90.00 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $90.00 |
| Complex cataract surgery | CPT 66982 | $71.00 |
| Cataract surgery with lens implant | CPT 66984 | $71.00 |
| Intravitreal injection | CPT 67028 | $169.92 |
| Vitrectomy mechanical | CPT 67042 | $71.00 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $90.00 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $90.00 |
| PCI single major coronary artery | CPT 92920 | $71.00 |
| PCI with drug-eluting stent | CPT 92928 | $71.00 |
| PCI bypass graft | CPT 92937 | $71.00 |
| Left heart catheterization | CPT 93452 | $71.00 |
| Coronary angiography with cath | CPT 93455 | $71.00 |
| Coronary angiography with bypass cath | CPT 93458 | $71.00 |
