| Psychoses | MS-DRG 885 | $14,210 |
| Psychiatric diagnostic evaluation | CPT 90791 | $104.18 |
| Psychiatric eval with medical services | CPT 90792 | $210.03 |
| Psychotherapy 30 minutes | CPT 90832 | $39.07 |
| Psychotherapy 45 minutes | CPT 90834 | $51.09 |
| Psychotherapy 60 minutes | CPT 90837 | $76.13 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $75.8 |
| ED visit level 1 | CPT 99281 | $223.76 |
| ED visit level 2 | CPT 99282 | $374.03 |
| ED visit level 3 | CPT 99283 | $691.46 |
| ED visit level 4 | CPT 99284 | $1,156.51 |
| ED visit level 5 | CPT 99285 | $1,641.43 |
| Critical care, first hour | CPT 99291 | $1,063.83 |
| CT head without contrast | CPT 70450 | $821.64 |
| CT head with contrast | CPT 70460 | $1,088.76 |
| CT head with and without contrast | CPT 70470 | $1,233.52 |
| CT neck with contrast | CPT 70491 | $1,060.73 |
| MRI brain without contrast | CPT 70551 | $908.31 |
| MRI brain with contrast | CPT 70552 | $1,905.9 |
| MRI brain with and without contrast | CPT 70553 | $1,706.46 |
| Chest X-ray single view | CPT 71045 | $117.04 |
| Chest X-ray 2 views | CPT 71046 | $144.8 |
| Chest X-ray 3 views | CPT 71047 | $175.57 |
| CT chest without contrast | CPT 71250 | $468.22 |
| CT chest with contrast | CPT 71260 | $1,040.4 |
| CT chest with and without contrast | CPT 71270 | $863.15 |
| MRI chest without contrast | CPT 71550 | $979.01 |
| MRI chest with and without contrast | CPT 71552 | $1,686.66 |
| Lumbosacral spine X-ray | CPT 72100 | $144.46 |
| CT cervical spine without contrast | CPT 72125 | $994.92 |
| CT thoracic spine without contrast | CPT 72128 | $825.25 |
| CT lumbar spine without contrast | CPT 72131 | $470.02 |
| MRI cervical spine without contrast | CPT 72141 | $1,024.6 |
| MRI thoracic spine without contrast | CPT 72146 | $1,086.03 |
| MRI lumbar spine without contrast | CPT 72148 | $1,103.03 |
| MRI lumbar spine with and without contrast | CPT 72149 | $1,765.5 |
| MRI cervical spine with and without contrast | CPT 72156 | $1,726.8 |
| MRI lumbar spine with contrast | CPT 72158 | $1,765.5 |
| CT pelvis without contrast | CPT 72192 | $497.1 |
| CT pelvis with contrast | CPT 72193 | $1,047.3 |
| Shoulder X-ray | CPT 73030 | $152.16 |
| Humerus X-ray | CPT 73060 | $110.35 |
| Hand X-ray 3 views | CPT 73130 | $133.76 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,355.71 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $2,160.44 |
| Knee X-ray 1-2 views | CPT 73560 | $115.37 |
| Ankle X-ray 3 views | CPT 73610 | $120.39 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,350.3 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $2,151.5 |
| CT abdomen without contrast | CPT 74150 | $1,003.94 |
| CT abdomen with contrast | CPT 74160 | $1,407.96 |
| CT abdomen with and without contrast | CPT 74170 | $1,598.16 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,217.75 |
| CT abdomen and pelvis with contrast | CPT 74177 | $1,902.67 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $2,150.37 |
| MRI abdomen without contrast | CPT 74181 | $1,047.01 |
| MRI abdomen with and without contrast | CPT 74183 | $1,733.5 |
| Abdominal ultrasound complete | CPT 76700 | $341.5 |
| Abdominal ultrasound limited | CPT 76705 | $254.76 |
| Retroperitoneal ultrasound complete | CPT 76770 | $317.94 |
| Obstetric ultrasound first trimester | CPT 76801 | $207.63 |
| Obstetric ultrasound after first trimester | CPT 76805 | $238.71 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $334.67 |
| Transvaginal ultrasound | CPT 76830 | — |
| Pelvic ultrasound complete | CPT 76856 | $367.8 |
| Scrotal ultrasound | CPT 76870 | $288.23 |
| Diagnostic mammography unilateral | CPT 77065 | $327.69 |
| Diagnostic mammography bilateral | CPT 77066 | $496.83 |
| Screening mammography bilateral | CPT 77067 | $126.49 |
| EKG tracing only | CPT 93005 | $136.04 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,472.29 |
| Stress echocardiogram | CPT 93350 | $918.19 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $20,052 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $10,251 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $6,938.48 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $16,295 |
| COPD w MCC | MS-DRG 190 | $11,321 |
| COPD w CC | MS-DRG 191 | $8,660.25 |
| COPD w/o CC/MCC | MS-DRG 192 | $6,524.17 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $8,266.1 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $6,277.2 |
| AMI discharged alive w MCC | MS-DRG 280 | $16,546 |
| AMI discharged alive w CC | MS-DRG 281 | $9,292.31 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $7,309.45 |
| Heart failure & shock w MCC | MS-DRG 291 | $13,153 |
| Heart failure & shock w CC | MS-DRG 292 | $8,681.42 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $5,531.23 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $12,156 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $7,452.59 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $5,640.1 |
| GI hemorrhage w CC | MS-DRG 378 | $9,938.47 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $6,418.32 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $7,865.9 |
| Fractures of femur w/o MCC | MS-DRG 533 | $15,372 |
| Kidney/UTI w MCC | MS-DRG 689 | $11,797 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $8,090.7 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $19,779 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $10,393 |
| Basic metabolic panel (BMP) | CPT 80048 | $68.24 |
| General health panel | CPT 80050 | $16.62 |
| Electrolyte panel | CPT 80051 | $38.93 |
| Comprehensive metabolic panel | CPT 80053 | $152.2 |
| Lipid panel | CPT 80061 | $97.68 |
| Renal function panel | CPT 80069 | $59.88 |
| Hepatic function panel | CPT 80076 | $56.87 |
| Urinalysis non-automated | CPT 81002 | $14.01 |
| Urinalysis automated | CPT 81003 | $12.05 |
| Glucose quantitative | CPT 82947 | $8.37 |
| Hemoglobin A1c | CPT 83036 | $38.13 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $67.57 |
| Complete blood count with automated differential | CPT 85025 | $59.21 |
| Complete blood count without differential | CPT 85027 | $35.46 |
| Urine culture bacterial | CPT 87086 | $15.37 |
| Urine culture identification | CPT 87088 | $24.09 |
| Tissue exam by pathologist level IV | CPT 88305 | $121.69 |
| Fetal non-stress test | CPT 59025 | $147.96 |
| Vaginal delivery only | CPT 59409 | $4,113.67 |
| Office visit, established patient, 5 min | CPT 99211 | — |
| Sigmoidoscopy diagnostic | CPT 45330 | $613.31 |
| Sigmoidoscopy with biopsy | CPT 45331 | $988.37 |
| ACL reconstruction | CPT 29888 | $14,154 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $46,289 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $23,828 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $16,643 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $16,718 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $13,282 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $35,580 |
| Major joint replacement w MCC | MS-DRG 469 | $32,950 |
| Major joint replacement w/o MCC | MS-DRG 470 | $19,007 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $29,647 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $20,916 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $15,992 |
| OR procedure for obesity w MCC | MS-DRG 619 | $27,485 |
| OR procedure for obesity w CC | MS-DRG 620 | $16,099 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $14,736 |
| Intravitreal injection | CPT 67028 | $341.05 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $12,084 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $19,698 |
| PCI single major coronary artery | CPT 92920 | $5,614.87 |
| PCI with drug-eluting stent | CPT 92928 | $8,077.38 |
| PCI bypass graft | CPT 92937 | $8,077.38 |
| Left heart catheterization | CPT 93452 | $4,916.73 |
| Coronary angiography with cath | CPT 93455 | $2,693.68 |
| Coronary angiography with bypass cath | CPT 93458 | $6,362.22 |
