| Psychoses | MS-DRG 885 | $20,783 |
| Psychiatric diagnostic evaluation | CPT 90791 | $158.06 |
| Psychiatric eval with medical services | CPT 90792 | $335.91 |
| Psychotherapy 30 minutes | CPT 90832 | $158.06 |
| Psychotherapy 45 minutes | CPT 90834 | $158.06 |
| Psychotherapy 60 minutes | CPT 90837 | $158.06 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $158.06 |
| ED visit level 1 | CPT 99281 | $173.06 |
| ED visit level 2 | CPT 99282 | $313.45 |
| ED visit level 3 | CPT 99283 | $517.14 |
| ED visit level 4 | CPT 99284 | $782.09 |
| ED visit level 5 | CPT 99285 | $1,014.88 |
| Critical care, first hour | CPT 99291 | $834.72 |
| CT head without contrast | CPT 70450 | $921.46 |
| CT head with contrast | CPT 70460 | $1,234.9 |
| CT head with and without contrast | CPT 70470 | $1,594.81 |
| CT neck with contrast | CPT 70491 | $1,569.79 |
| MRI brain without contrast | CPT 70551 | $1,831.68 |
| MRI brain with contrast | CPT 70552 | $2,308.48 |
| MRI brain with and without contrast | CPT 70553 | $2,454.49 |
| Chest X-ray single view | CPT 71045 | $178.17 |
| Chest X-ray 2 views | CPT 71046 | $225.13 |
| Chest X-ray 3 views | CPT 71047 | $225.13 |
| CT chest without contrast | CPT 71250 | $990.37 |
| CT chest with contrast | CPT 71260 | $1,301.27 |
| CT chest with and without contrast | CPT 71270 | $1,536.1 |
| MRI chest without contrast | CPT 71550 | $1,366.61 |
| MRI chest with contrast | CPT 71551 | $777.24 |
| MRI chest with and without contrast | CPT 71552 | $351.34 |
| Lumbosacral spine X-ray | CPT 72100 | $260.87 |
| CT cervical spine without contrast | CPT 72125 | $1,112.89 |
| CT thoracic spine without contrast | CPT 72128 | $746.86 |
| CT lumbar spine without contrast | CPT 72131 | $768.31 |
| MRI cervical spine without contrast | CPT 72141 | $1,900.08 |
| MRI thoracic spine without contrast | CPT 72146 | $1,400.82 |
| MRI lumbar spine without contrast | CPT 72148 | $1,870.48 |
| MRI lumbar spine with and without contrast | CPT 72149 | $1,907.74 |
| MRI cervical spine with and without contrast | CPT 72156 | $2,280.41 |
| MRI lumbar spine with contrast | CPT 72158 | $2,356.98 |
| CT pelvis without contrast | CPT 72192 | $1,064.4 |
| CT pelvis with contrast | CPT 72193 | $1,497.81 |
| Shoulder X-ray | CPT 73030 | $233.3 |
| Humerus X-ray | CPT 73060 | $184.8 |
| Hand X-ray 3 views | CPT 73130 | $233.3 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,795.43 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $2,136.95 |
| Knee X-ray 1-2 views | CPT 73560 | $208.29 |
| Ankle X-ray 3 views | CPT 73610 | $214.41 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,788.8 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $2,861.36 |
| CT abdomen without contrast | CPT 74150 | $1,067.97 |
| CT abdomen with contrast | CPT 74160 | $1,482.5 |
| CT abdomen with and without contrast | CPT 74170 | $1,660.66 |
| CT abdomen and pelvis without contrast | CPT 74176 | $2,134.91 |
| CT abdomen and pelvis with contrast | CPT 74177 | $2,963.96 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $3,438.22 |
| MRI abdomen without contrast | CPT 74181 | $1,617.27 |
| MRI abdomen with and without contrast | CPT 74183 | $2,566.8 |
| Abdominal ultrasound complete | CPT 76700 | $578.91 |
| Abdominal ultrasound limited | CPT 76705 | $578.91 |
| Retroperitoneal ultrasound complete | CPT 76770 | $475.79 |
| Obstetric ultrasound first trimester | CPT 76801 | $180.21 |
| Obstetric ultrasound after first trimester | CPT 76805 | $180.21 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $237.8 |
| Transvaginal ultrasound | CPT 76830 | $457.92 |
| Pelvic ultrasound complete | CPT 76856 | $550.83 |
| Scrotal ultrasound | CPT 76870 | $431.88 |
| Diagnostic mammography unilateral | CPT 77065 | $460.98 |
| Diagnostic mammography bilateral | CPT 77066 | $695.81 |
| Screening mammography bilateral | CPT 77067 | $259.85 |
| EKG tracing only | CPT 93005 | $156.03 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,250.73 |
| Transthoracic echocardiogram | CPT 93307 | $237.8 |
| Stress echocardiogram | CPT 93350 | $954.64 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $29,329 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $14,993 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $10,148 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $23,834 |
| COPD w MCC | MS-DRG 190 | $16,557 |
| COPD w CC | MS-DRG 191 | $12,666 |
| COPD w/o CC/MCC | MS-DRG 192 | $9,542.25 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $12,090 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $9,181.03 |
| AMI discharged alive w MCC | MS-DRG 280 | $24,201 |
| AMI discharged alive w CC | MS-DRG 281 | $13,591 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $10,691 |
| Heart failure & shock w MCC | MS-DRG 291 | $19,238 |
| Heart failure & shock w CC | MS-DRG 292 | $12,697 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $8,089.98 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $17,780 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $10,900 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $8,249.21 |
| GI hemorrhage w CC | MS-DRG 378 | $14,536 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $9,387.44 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $11,505 |
| Fractures of femur w/o MCC | MS-DRG 533 | $22,483 |
| Kidney/UTI w MCC | MS-DRG 689 | $17,255 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $11,833 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $28,929 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $15,201 |
| Basic metabolic panel (BMP) | CPT 80048 | $27.57 |
| General health panel | CPT 80050 | $16.62 |
| Electrolyte panel | CPT 80051 | $33.69 |
| Comprehensive metabolic panel | CPT 80053 | $55.14 |
| Lipid panel | CPT 80061 | $68.92 |
| Renal function panel | CPT 80069 | $27.57 |
| Hepatic function panel | CPT 80076 | $51.05 |
| Urinalysis non-automated | CPT 81002 | $4.68 |
| Urinalysis automated | CPT 81003 | $19.91 |
| Glucose quantitative | CPT 82947 | $15.32 |
| Hemoglobin A1c | CPT 83036 | $38.8 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $65.86 |
| Complete blood count with automated differential | CPT 85025 | $71.98 |
| Complete blood count without differential | CPT 85027 | $31.14 |
| Urine culture bacterial | CPT 87086 | $22.98 |
| Urine culture identification | CPT 87088 | $25.02 |
| Tissue exam by pathologist level IV | CPT 88305 | $174.59 |
| Fetal non-stress test | CPT 59025 | $378.28 |
| Vaginal delivery only | CPT 59409 | $6,338.88 |
| Upper GI endoscopy diagnostic | CPT 43235 | $922.35 |
| Upper GI endoscopy with biopsy | CPT 43239 | $922.35 |
| Sigmoidoscopy diagnostic | CPT 45330 | $952.09 |
| Sigmoidoscopy with biopsy | CPT 45331 | $896.92 |
| Colonoscopy diagnostic | CPT 45378 | $896.92 |
| Colonoscopy with biopsy | CPT 45380 | $1,159.95 |
| Colonoscopy with polyp removal | CPT 45385 | $1,159.95 |
| Total shoulder arthroplasty | CPT 23472 | $18,092 |
| Total hip replacement | CPT 27130 | $12,658 |
| Total knee replacement | CPT 27447 | $12,658 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $7,027.81 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $3,191.96 |
| ACL reconstruction | CPT 29888 | $7,027.81 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $67,702 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $34,850 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $24,342 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $24,451 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $19,427 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $52,039 |
| Open appendectomy | CPT 44950 | $6,138.5 |
| Laparoscopic appendectomy | CPT 44970 | $5,739.69 |
| Major joint replacement w MCC | MS-DRG 469 | $48,193 |
| Major joint replacement w/o MCC | MS-DRG 470 | $27,800 |
| Laparoscopic cholecystectomy | CPT 47562 | $5,739.69 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $5,739.69 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $43,362 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $30,592 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $23,390 |
| Lap inguinal hernia repair | CPT 49650 | $5,739.69 |
| Vaginal hysterectomy | CPT 58260 | $4,856.35 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $5,739.69 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $10,242 |
| Lap salpingo-oophorectomy | CPT 58661 | $5,739.69 |
| OR procedure for obesity w MCC | MS-DRG 619 | $40,199 |
| OR procedure for obesity w CC | MS-DRG 620 | $23,546 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $21,553 |
| Complex cataract surgery | CPT 66982 | $2,243.72 |
| Cataract surgery with lens implant | CPT 66984 | $2,243.72 |
| Intravitreal injection | CPT 67028 | $326.31 |
| Vitrectomy mechanical | CPT 67042 | $3,957.58 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $17,674 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $28,810 |
| PCI single major coronary artery | CPT 92920 | $5,609 |
| PCI with drug-eluting stent | CPT 92928 | $11,157 |
| PCI bypass graft | CPT 92937 | $11,157 |
| Left heart catheterization | CPT 93452 | $3,164.22 |
| Coronary angiography with cath | CPT 93455 | $3,164.22 |
| Coronary angiography with bypass cath | CPT 93458 | $3,164.22 |
