| Psychoses | MS-DRG 885 | $18,976 |
| Psychiatric diagnostic evaluation | CPT 90791 | $155.53 |
| Psychiatric eval with medical services | CPT 90792 | $155.53 |
| Psychotherapy 30 minutes | CPT 90832 | $42.35 |
| Psychotherapy 45 minutes | CPT 90834 | $55.32 |
| Psychotherapy 60 minutes | CPT 90837 | $82.41 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $82.03 |
| ED visit level 1 | CPT 99281 | $195.84 |
| ED visit level 2 | CPT 99282 | $327.73 |
| ED visit level 3 | CPT 99283 | $605.88 |
| ED visit level 4 | CPT 99284 | $1,013.17 |
| ED visit level 5 | CPT 99285 | $1,438.2 |
| Critical care, first hour | CPT 99291 | $932.08 |
| CT head without contrast | CPT 70450 | $703.18 |
| CT head with contrast | CPT 70460 | $991.69 |
| CT head with and without contrast | CPT 70470 | $1,101.51 |
| CT neck with contrast | CPT 70491 | $948.33 |
| MRI brain without contrast | CPT 70551 | $726.33 |
| MRI brain with contrast | CPT 70552 | $1,686 |
| MRI brain with and without contrast | CPT 70553 | $1,482 |
| Chest X-ray single view | CPT 71045 | $106.25 |
| Chest X-ray 2 views | CPT 71046 | $131.61 |
| Chest X-ray 3 views | CPT 71047 | $159.54 |
| CT chest without contrast | CPT 71250 | $400.65 |
| CT chest with contrast | CPT 71260 | $890.31 |
| CT chest with and without contrast | CPT 71270 | $738.72 |
| MRI chest without contrast | CPT 71550 | $782.73 |
| MRI chest with contrast | CPT 71551 | $764.79 |
| MRI chest with and without contrast | CPT 71552 | $1,448.09 |
| Lumbosacral spine X-ray | CPT 72100 | $131.29 |
| CT cervical spine without contrast | CPT 72125 | $851.51 |
| CT thoracic spine without contrast | CPT 72128 | $706.12 |
| CT lumbar spine without contrast | CPT 72131 | $402.28 |
| MRI cervical spine without contrast | CPT 72141 | $819.24 |
| MRI thoracic spine without contrast | CPT 72146 | $868.46 |
| MRI lumbar spine without contrast | CPT 72148 | $882.16 |
| MRI lumbar spine with and without contrast | CPT 72149 | $1,633.59 |
| MRI cervical spine with and without contrast | CPT 72156 | $1,517.2 |
| MRI lumbar spine with contrast | CPT 72158 | $1,633.59 |
| CT pelvis without contrast | CPT 72192 | $425.43 |
| CT pelvis with contrast | CPT 72193 | $904.32 |
| Shoulder X-ray | CPT 73030 | $138.35 |
| Humerus X-ray | CPT 73060 | $100.15 |
| Hand X-ray 3 views | CPT 73130 | $121.66 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,084.28 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $1,855.8 |
| Knee X-ray 1-2 views | CPT 73560 | $104.97 |
| Ankle X-ray 3 views | CPT 73610 | $109.46 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,079.71 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $1,848.3 |
| CT abdomen without contrast | CPT 74150 | $859.34 |
| CT abdomen with contrast | CPT 74160 | $1,218.6 |
| CT abdomen with and without contrast | CPT 74170 | $1,383.3 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,087.27 |
| CT abdomen and pelvis with contrast | CPT 74177 | $1,647 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $1,861.2 |
| MRI abdomen without contrast | CPT 74181 | $837.17 |
| MRI abdomen with and without contrast | CPT 74183 | $1,549.8 |
| Abdominal ultrasound complete | CPT 76700 | $305.03 |
| Abdominal ultrasound limited | CPT 76705 | $227.72 |
| Retroperitoneal ultrasound complete | CPT 76770 | $284.09 |
| Obstetric ultrasound first trimester | CPT 76801 | $185.53 |
| Obstetric ultrasound after first trimester | CPT 76805 | $213.23 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $298.91 |
| Transvaginal ultrasound | CPT 76830 | $269.6 |
| Pelvic ultrasound complete | CPT 76856 | $328.54 |
| Scrotal ultrasound | CPT 76870 | $257.68 |
| Diagnostic mammography unilateral | CPT 77065 | $287.03 |
| Diagnostic mammography bilateral | CPT 77066 | $435.13 |
| Screening mammography bilateral | CPT 77067 | $112.47 |
| EKG tracing only | CPT 93005 | $119.03 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,290.1 |
| Transthoracic echocardiogram | CPT 93307 | $233.99 |
| Stress echocardiogram | CPT 93350 | $804.47 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $24,169 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $15,216 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $10,299 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $20,830 |
| COPD w MCC | MS-DRG 190 | $16,408 |
| COPD w CC | MS-DRG 191 | $12,855 |
| COPD w/o CC/MCC | MS-DRG 192 | $9,684.38 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $12,270 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $9,317.78 |
| AMI discharged alive w MCC | MS-DRG 280 | $21,053 |
| AMI discharged alive w CC | MS-DRG 281 | $13,793 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $10,850 |
| Heart failure & shock w MCC | MS-DRG 291 | $18,037 |
| Heart failure & shock w CC | MS-DRG 292 | $12,887 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $8,210.48 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $17,151 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $11,063 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $8,372.08 |
| GI hemorrhage w CC | MS-DRG 378 | $14,753 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $9,527.27 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $11,676 |
| Fractures of femur w/o MCC | MS-DRG 533 | $20,009 |
| Kidney/UTI w MCC | MS-DRG 689 | $16,832 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $12,010 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $23,926 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $15,396 |
| Basic metabolic panel (BMP) | CPT 80048 | $59.06 |
| General health panel | CPT 80050 | $16.62 |
| Electrolyte panel | CPT 80051 | $33.05 |
| Comprehensive metabolic panel | CPT 80053 | $131.89 |
| Lipid panel | CPT 80061 | $84.46 |
| Renal function panel | CPT 80069 | $51.71 |
| Hepatic function panel | CPT 80076 | $49.27 |
| Urinalysis non-automated | CPT 81002 | $11.63 |
| Urinalysis automated | CPT 81003 | $10.4 |
| Glucose quantitative | CPT 82947 | $7.21 |
| Hemoglobin A1c | CPT 83036 | $33.05 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $58.45 |
| Complete blood count with automated differential | CPT 85025 | $51.1 |
| Complete blood count without differential | CPT 85027 | $30.6 |
| Urine culture bacterial | CPT 87086 | $14.67 |
| Urine culture identification | CPT 87088 | $20.81 |
| Tissue exam by pathologist level IV | CPT 88305 | $117.36 |
| Fetal non-stress test | CPT 59025 | $151.68 |
| Vaginal delivery only | CPT 59409 | $4,925 |
| Upper GI endoscopy diagnostic | CPT 43235 | $907.58 |
| Upper GI endoscopy with biopsy | CPT 43239 | $907.58 |
| Sigmoidoscopy diagnostic | CPT 45330 | $640.38 |
| Sigmoidoscopy with biopsy | CPT 45331 | $882.55 |
| Colonoscopy diagnostic | CPT 45378 | $882.55 |
| Colonoscopy with biopsy | CPT 45380 | $1,141.37 |
| Colonoscopy with polyp removal | CPT 45385 | $1,141.37 |
| Total shoulder arthroplasty | CPT 23472 | $17,802 |
| Hip hemiarthroplasty | CPT 27125 | $10,385 |
| Total hip replacement | CPT 27130 | $12,455 |
| Total knee replacement | CPT 27447 | $12,455 |
| Knee revision arthroplasty single component | CPT 27486 | $10,829 |
| Knee revision arthroplasty all components | CPT 27487 | $10,829 |
| Shoulder arthroscopy with decompression | CPT 29826 | $1,741 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $6,915.27 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $3,140.85 |
| ACL reconstruction | CPT 29888 | $6,915.27 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $47,487 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $27,524 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $21,139 |
| CABG single arterial graft | CPT 33533 | $4,086 |
| CABG 2 arterial grafts | CPT 33534 | $4,086 |
| CABG 3 arterial grafts | CPT 33535 | $4,086 |
| CABG 4+ arterial grafts | CPT 33536 | $4,086 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $21,205 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $18,152 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $37,968 |
| Open appendectomy | CPT 44950 | $6,040.2 |
| Laparoscopic appendectomy | CPT 44970 | $5,647.78 |
| Major joint replacement w MCC | MS-DRG 469 | $35,632 |
| Major joint replacement w/o MCC | MS-DRG 470 | $23,240 |
| Laparoscopic cholecystectomy | CPT 47562 | $5,647.78 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $5,647.78 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $32,696 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $24,937 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $20,560 |
| Lap inguinal hernia repair | CPT 49650 | $5,647.78 |
| Total abdominal hysterectomy | CPT 58150 | $6,505 |
| Vaginal hysterectomy | CPT 58260 | $4,778.58 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $5,647.78 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $10,078 |
| Lap salpingo-oophorectomy | CPT 58661 | $5,647.78 |
| OR procedure for obesity w MCC | MS-DRG 619 | $30,774 |
| OR procedure for obesity w CC | MS-DRG 620 | $20,655 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $19,444 |
| Complex cataract surgery | CPT 66982 | $2,207.79 |
| Cataract surgery with lens implant | CPT 66984 | $2,207.79 |
| Intravitreal injection | CPT 67028 | $375.57 |
| Vitrectomy mechanical | CPT 67042 | $3,894.21 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $17,087 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $23,853 |
| PCI single major coronary artery | CPT 92920 | $10,385 |
| PCI with drug-eluting stent | CPT 92928 | $10,978 |
| PCI bypass graft | CPT 92937 | $10,385 |
| Left heart catheterization | CPT 93452 | $4,374.27 |
| Coronary angiography with cath | CPT 93455 | $3,113.55 |
| Coronary angiography with bypass cath | CPT 93458 | $5,660.39 |
