| Psychoses | MS-DRG 885 | $10,015 |
| Psychiatric diagnostic evaluation | CPT 90791 | $148.95 |
| Psychiatric eval with medical services | CPT 90792 | $148.95 |
| Psychotherapy 30 minutes | CPT 90832 | $148.95 |
| Psychotherapy 45 minutes | CPT 90834 | $148.95 |
| Psychotherapy 60 minutes | CPT 90837 | $148.95 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $363.50 |
| ED visit level 1 | CPT 99281 | $200.00 |
| ED visit level 2 | CPT 99282 | $327.00 |
| ED visit level 3 | CPT 99283 | $545.00 |
| ED visit level 4 | CPT 99284 | $855.50 |
| ED visit level 5 | CPT 99285 | $2,974.40 |
| Critical care, first hour | CPT 99291 | $1,883.00 |
| CT head without contrast | CPT 70450 | $806.00 |
| CT head with contrast | CPT 70460 | $959.00 |
| CT head with and without contrast | CPT 70470 | $1,044.00 |
| CT neck with contrast | CPT 70491 | $1,109.00 |
| MRI brain without contrast | CPT 70551 | $1,334.00 |
| MRI brain with contrast | CPT 70552 | $1,418.50 |
| MRI brain with and without contrast | CPT 70553 | $1,503.50 |
| Chest X-ray single view | CPT 71045 | $187.50 |
| Chest X-ray 2 views | CPT 71046 | $234.50 |
| Chest X-ray 3 views | CPT 71047 | $320.50 |
| CT chest without contrast | CPT 71250 | $974.00 |
| CT chest with contrast | CPT 71260 | $1,120.00 |
| CT chest with and without contrast | CPT 71270 | $1,172.50 |
| MRI chest without contrast | CPT 71550 | $1,165.50 |
| MRI chest with contrast | CPT 71551 | $1,349.50 |
| MRI chest with and without contrast | CPT 71552 | $1,844.50 |
| Lumbosacral spine X-ray | CPT 72100 | $281.50 |
| CT cervical spine without contrast | CPT 72125 | $1,005.50 |
| CT thoracic spine without contrast | CPT 72128 | $938.50 |
| CT lumbar spine without contrast | CPT 72131 | $1,112.00 |
| MRI cervical spine without contrast | CPT 72141 | $1,406.50 |
| MRI thoracic spine without contrast | CPT 72146 | $1,452.50 |
| MRI lumbar spine without contrast | CPT 72148 | $1,452.50 |
| MRI lumbar spine with and without contrast | CPT 72149 | $1,565.00 |
| MRI cervical spine with and without contrast | CPT 72156 | $1,660.50 |
| MRI lumbar spine with contrast | CPT 72158 | $1,660.50 |
| CT pelvis without contrast | CPT 72192 | $893.00 |
| CT pelvis with contrast | CPT 72193 | $1,096.50 |
| Shoulder X-ray | CPT 73030 | $295.50 |
| Humerus X-ray | CPT 73060 | $233.00 |
| Hand X-ray 3 views | CPT 73130 | $276.50 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,363.50 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $1,685.00 |
| Knee X-ray 1-2 views | CPT 73560 | $181.50 |
| Ankle X-ray 3 views | CPT 73610 | $254.50 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,685.00 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $1,685.00 |
| CT abdomen without contrast | CPT 74150 | $1,104.00 |
| CT abdomen with contrast | CPT 74160 | $1,258.00 |
| CT abdomen with and without contrast | CPT 74170 | $1,313.50 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,550.50 |
| CT abdomen and pelvis with contrast | CPT 74177 | $1,595.00 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $1,603.20 |
| MRI abdomen without contrast | CPT 74181 | $1,465.00 |
| MRI abdomen with and without contrast | CPT 74183 | $1,685.50 |
| Abdominal ultrasound complete | CPT 76700 | $718.00 |
| Abdominal ultrasound limited | CPT 76705 | $482.50 |
| Retroperitoneal ultrasound complete | CPT 76770 | $623.50 |
| Obstetric ultrasound first trimester | CPT 76801 | $514.00 |
| Obstetric ultrasound after first trimester | CPT 76805 | $556.00 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $587.00 |
| Transvaginal ultrasound | CPT 76830 | $562.50 |
| Pelvic ultrasound complete | CPT 76856 | $589.50 |
| Scrotal ultrasound | CPT 76870 | $471.50 |
| Diagnostic mammography unilateral | CPT 77065 | $322.00 |
| Diagnostic mammography bilateral | CPT 77066 | $403.20 |
| Screening mammography bilateral | CPT 77067 | $326.50 |
| EKG tracing only | CPT 93005 | $187.50 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,363.00 |
| Transthoracic echocardiogram | CPT 93307 | $819.50 |
| Stress echocardiogram | CPT 93350 | $1,249.50 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $14,715 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $7,670.90 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $5,290.37 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $12,015 |
| COPD w MCC | MS-DRG 190 | $8,439.53 |
| COPD w CC | MS-DRG 191 | $6,527.71 |
| COPD w/o CC/MCC | MS-DRG 192 | $4,992.62 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $6,244.47 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $4,815.13 |
| AMI discharged alive w MCC | MS-DRG 280 | $12,195 |
| AMI discharged alive w CC | MS-DRG 281 | $6,981.95 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $5,556.98 |
| Heart failure & shock w MCC | MS-DRG 291 | $9,756.58 |
| Heart failure & shock w CC | MS-DRG 292 | $6,542.94 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $4,279.04 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $9,040.09 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $5,659.84 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $4,357.29 |
| GI hemorrhage w CC | MS-DRG 378 | $7,446.32 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $4,916.56 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $5,956.86 |
| Fractures of femur w/o MCC | MS-DRG 533 | $11,351 |
| Kidney/UTI w MCC | MS-DRG 689 | $8,782.21 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $6,118.39 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $14,518 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $7,773.05 |
| Basic metabolic panel (BMP) | CPT 80048 | $79.00 |
| General health panel | CPT 80050 | $58.25 |
| Electrolyte panel | CPT 80051 | $77.00 |
| Comprehensive metabolic panel | CPT 80053 | $127.00 |
| Lipid panel | CPT 80061 | $38.35 |
| Renal function panel | CPT 80069 | $120.50 |
| Hepatic function panel | CPT 80076 | $91.00 |
| Urinalysis non-automated | CPT 81002 | $22.00 |
| Urinalysis automated | CPT 81003 | $41.50 |
| Glucose quantitative | CPT 82947 | $37.70 |
| Hemoglobin A1c | CPT 83036 | $65.00 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $87.50 |
| Complete blood count with automated differential | CPT 85025 | $67.00 |
| Complete blood count without differential | CPT 85027 | $58.00 |
| Urine culture bacterial | CPT 87086 | $81.00 |
| Urine culture identification | CPT 87088 | $8.09 |
| Tissue exam by pathologist level IV | CPT 88305 | $275.60 |
| Fetal non-stress test | CPT 59025 | $308.34 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $2,336.00 |
| Vaginal delivery only | CPT 59409 | $2,716.80 |
| Vaginal delivery with postpartum | CPT 59410 | $2,441.60 |
| Routine obstetric care with C-section | CPT 59510 | $2,336.00 |
| C-section delivery only | CPT 59514 | $2,839.18 |
| C-section with postpartum | CPT 59515 | $4,060.24 |
| Office visit, established patient, 5 min | CPT 99211 | $112.00 |
| Office visit, established patient, 10-19 min | CPT 99212 | $94.90 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $119.47 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $119.47 |
| Office visit, established patient, 40-54 min | CPT 99215 | $119.47 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,612.00 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,580.00 |
| Sigmoidoscopy diagnostic | CPT 45330 | $1,130.50 |
| Sigmoidoscopy with biopsy | CPT 45331 | $1,245.00 |
| Colonoscopy diagnostic | CPT 45378 | $1,668.50 |
| Colonoscopy with biopsy | CPT 45380 | $1,627.00 |
| Colonoscopy with polyp removal | CPT 45385 | $1,585.00 |
| Total shoulder arthroplasty | CPT 23472 | $17,048 |
| Hip hemiarthroplasty | CPT 27125 | $7,832.67 |
| Total hip replacement | CPT 27130 | $11,928 |
| Total knee replacement | CPT 27447 | $12,107 |
| Knee revision arthroplasty single component | CPT 27486 | $11,234 |
| Knee revision arthroplasty all components | CPT 27487 | $11,234 |
| Shoulder arthroscopy with decompression | CPT 29826 | $1,438.97 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $6,622.52 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $3,007.88 |
| ACL reconstruction | CPT 29888 | $6,622.52 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $33,570 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $17,428 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $12,265 |
| CABG single arterial graft | CPT 33533 | $2,706.94 |
| CABG 2 arterial grafts | CPT 33534 | $2,706.94 |
| CABG 3 arterial grafts | CPT 33535 | $2,706.94 |
| CABG 4+ arterial grafts | CPT 33536 | $2,706.94 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $12,318 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $9,849.29 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $25,873 |
| Open appendectomy | CPT 44950 | $5,784.50 |
| Laparoscopic appendectomy | CPT 44970 | $5,408.69 |
| Major joint replacement w MCC | MS-DRG 469 | $23,984 |
| Major joint replacement w/o MCC | MS-DRG 470 | $13,963 |
| Laparoscopic cholecystectomy | CPT 47562 | $5,408.69 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $5,408.69 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $21,610 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $15,336 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $11,797 |
| Open umbilical hernia repair | CPT 49560 | $2,339.20 |
| Umbilical hernia repair age 5+ | CPT 49585 | $2,339.20 |
| Lap inguinal hernia repair | CPT 49650 | $5,408.69 |
| Lap incisional hernia repair | CPT 49652 | $4,025.26 |
| Total abdominal hysterectomy | CPT 58150 | $3,985.12 |
| Vaginal hysterectomy | CPT 58260 | $4,576.29 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $5,408.69 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $9,651.62 |
| Lap salpingo-oophorectomy | CPT 58661 | $5,408.69 |
| OR procedure for obesity w MCC | MS-DRG 619 | $20,056 |
| OR procedure for obesity w CC | MS-DRG 620 | $11,873 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $10,894 |
| Complex cataract surgery | CPT 66982 | $2,114.33 |
| Cataract surgery with lens implant | CPT 66984 | $2,114.33 |
| Intravitreal injection | CPT 67028 | $307.49 |
| Vitrectomy mechanical | CPT 67042 | $3,729.35 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $8,987.94 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $14,460 |
| PCI single major coronary artery | CPT 92920 | $19,416 |
| PCI with drug-eluting stent | CPT 92928 | $14,467 |
| PCI bypass graft | CPT 92937 | $14,467 |
| Left heart catheterization | CPT 93452 | $7,604.51 |
| Coronary angiography with cath | CPT 93455 | $8,624.50 |
| Coronary angiography with bypass cath | CPT 93458 | $7,604.51 |
