| Psychoses | MS-DRG 885 | $9,635.77 |
| Psychiatric diagnostic evaluation | CPT 90791 | $326.50 |
| Psychiatric eval with medical services | CPT 90792 | $153.42 |
| Psychotherapy 30 minutes | CPT 90832 | $161.20 |
| Psychotherapy 45 minutes | CPT 90834 | $153.42 |
| Psychotherapy 60 minutes | CPT 90837 | $231.55 |
| 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 | $3,317.60 |
| Critical care, first hour | CPT 99291 | $1,883.00 |
| CT head without contrast | CPT 70450 | $773.76 |
| CT head with contrast | CPT 70460 | $900.00 |
| CT head with and without contrast | CPT 70470 | $960.48 |
| CT neck with contrast | CPT 70491 | $1,020.28 |
| MRI brain without contrast | CPT 70551 | $1,280.64 |
| MRI brain with contrast | CPT 70552 | $1,351.00 |
| MRI brain with and without contrast | CPT 70553 | $1,383.22 |
| Chest X-ray single view | CPT 71045 | $187.50 |
| Chest X-ray 2 views | CPT 71046 | $227.87 |
| Chest X-ray 3 views | CPT 71047 | $307.68 |
| CT chest without contrast | CPT 71250 | $900.00 |
| CT chest with contrast | CPT 71260 | $1,030.40 |
| CT chest with and without contrast | CPT 71270 | $1,078.70 |
| MRI chest without contrast | CPT 71550 | $1,118.88 |
| MRI chest with contrast | CPT 71551 | $1,349.50 |
| MRI chest with and without contrast | CPT 71552 | $1,696.94 |
| Lumbosacral spine X-ray | CPT 72100 | $275.23 |
| CT cervical spine without contrast | CPT 72125 | $925.06 |
| CT thoracic spine without contrast | CPT 72128 | $900.00 |
| CT lumbar spine without contrast | CPT 72131 | $1,023.04 |
| MRI cervical spine without contrast | CPT 72141 | $1,350.24 |
| MRI thoracic spine without contrast | CPT 72146 | $1,351.00 |
| MRI lumbar spine without contrast | CPT 72148 | $1,351.00 |
| MRI lumbar spine with and without contrast | CPT 72149 | $1,439.80 |
| MRI cervical spine with and without contrast | CPT 72156 | $1,527.66 |
| MRI lumbar spine with contrast | CPT 72158 | $1,527.66 |
| CT pelvis without contrast | CPT 72192 | $857.28 |
| CT pelvis with contrast | CPT 72193 | $1,008.78 |
| Shoulder X-ray | CPT 73030 | $283.68 |
| Humerus X-ray | CPT 73060 | $227.87 |
| Hand X-ray 3 views | CPT 73130 | $265.44 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,308.96 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $1,550.20 |
| Knee X-ray 1-2 views | CPT 73560 | $181.50 |
| Ankle X-ray 3 views | CPT 73610 | $244.32 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,550.20 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $1,550.20 |
| CT abdomen without contrast | CPT 74150 | $1,015.68 |
| CT abdomen with contrast | CPT 74160 | $1,157.36 |
| CT abdomen with and without contrast | CPT 74170 | $1,208.42 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,426.46 |
| CT abdomen and pelvis with contrast | CPT 74177 | $1,470.62 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $1,536.40 |
| MRI abdomen without contrast | CPT 74181 | $1,351.00 |
| MRI abdomen with and without contrast | CPT 74183 | $1,550.66 |
| Abdominal ultrasound complete | CPT 76700 | $689.28 |
| Abdominal ultrasound limited | CPT 76705 | $463.20 |
| Retroperitoneal ultrasound complete | CPT 76770 | $598.56 |
| Obstetric ultrasound first trimester | CPT 76801 | $493.44 |
| Obstetric ultrasound after first trimester | CPT 76805 | $533.76 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $587.00 |
| Transvaginal ultrasound | CPT 76830 | $540.00 |
| Pelvic ultrasound complete | CPT 76856 | $565.92 |
| Scrotal ultrasound | CPT 76870 | $452.64 |
| Diagnostic mammography unilateral | CPT 77065 | $296.24 |
| Diagnostic mammography bilateral | CPT 77066 | $386.40 |
| Screening mammography bilateral | CPT 77067 | $300.38 |
| EKG tracing only | CPT 93005 | $180.00 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,363.00 |
| Transthoracic echocardiogram | CPT 93307 | $786.72 |
| Stress echocardiogram | CPT 93350 | $1,249.50 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $14,074 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $7,436.61 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $5,193.27 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $11,530 |
| COPD w MCC | MS-DRG 190 | $8,160.95 |
| COPD w CC | MS-DRG 191 | $6,359.31 |
| COPD w/o CC/MCC | MS-DRG 192 | $4,912.67 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $6,092.37 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $4,745.42 |
| AMI discharged alive w MCC | MS-DRG 280 | $11,700 |
| AMI discharged alive w CC | MS-DRG 281 | $6,787.36 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $5,444.49 |
| Heart failure & shock w MCC | MS-DRG 291 | $9,402.08 |
| Heart failure & shock w CC | MS-DRG 292 | $6,373.64 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $4,240.23 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $8,726.91 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $5,541.43 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $4,313.94 |
| GI hemorrhage w CC | MS-DRG 378 | $7,224.98 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $4,840.99 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $5,821.33 |
| Fractures of femur w/o MCC | MS-DRG 533 | $10,905 |
| Kidney/UTI w MCC | MS-DRG 689 | $8,483.86 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $5,973.58 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $13,889 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $7,532.86 |
| Basic metabolic panel (BMP) | CPT 80048 | $72.68 |
| General health panel | CPT 80050 | $41.41 |
| Electrolyte panel | CPT 80051 | $70.84 |
| Comprehensive metabolic panel | CPT 80053 | $116.84 |
| Lipid panel | CPT 80061 | $38.35 |
| Renal function panel | CPT 80069 | $110.86 |
| Hepatic function panel | CPT 80076 | $83.72 |
| Urinalysis non-automated | CPT 81002 | $20.24 |
| Urinalysis automated | CPT 81003 | $38.18 |
| Glucose quantitative | CPT 82947 | $26.68 |
| Hemoglobin A1c | CPT 83036 | $59.80 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $80.50 |
| Complete blood count with automated differential | CPT 85025 | $61.64 |
| Complete blood count without differential | CPT 85027 | $53.36 |
| Urine culture bacterial | CPT 87086 | $74.52 |
| Urine culture identification | CPT 87088 | $8.09 |
| Tissue exam by pathologist level IV | CPT 88305 | $275.60 |
| Fetal non-stress test | CPT 59025 | $331.96 |
| Vaginal delivery only | CPT 59409 | $1,910.00 |
| Vaginal delivery with postpartum | CPT 59410 | $1,910.00 |
| C-section with postpartum | CPT 59515 | $3,679.00 |
| Office visit, established patient, 5 min | CPT 99211 | $113.40 |
| Office visit, established patient, 10-19 min | CPT 99212 | $119.47 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $361.30 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $86.94 |
| Office visit, established patient, 40-54 min | CPT 99215 | $135.91 |
| Upper GI endoscopy diagnostic | CPT 43235 | $1,612.00 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,580.00 |
| Sigmoidoscopy diagnostic | CPT 45330 | $1,243.55 |
| Sigmoidoscopy with biopsy | CPT 45331 | $1,441.44 |
| Colonoscopy diagnostic | CPT 45378 | $1,668.50 |
| Colonoscopy with biopsy | CPT 45380 | $1,857.44 |
| Colonoscopy with polyp removal | CPT 45385 | $1,857.44 |
| Total shoulder arthroplasty | CPT 23472 | $17,304 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $28,946 |
| Hip hemiarthroplasty | CPT 27125 | $4,776.00 |
| Total hip replacement | CPT 27130 | $12,107 |
| Total knee replacement | CPT 27447 | $12,107 |
| Knee revision arthroplasty single component | CPT 27486 | $4,776.00 |
| Knee revision arthroplasty all components | CPT 27487 | $4,776.00 |
| Shoulder arthroscopy with decompression | CPT 29826 | $2,712.18 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $6,622.52 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $3,098.12 |
| ACL reconstruction | CPT 29888 | $6,622.52 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $31,843 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $16,631 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $11,766 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $11,816 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $9,489.46 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $24,590 |
| Open appendectomy | CPT 44950 | $5,871.27 |
| Laparoscopic appendectomy | CPT 44970 | $5,489.82 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $83,618 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $61,319 |
| Major joint replacement w MCC | MS-DRG 469 | $22,810 |
| Major joint replacement w/o MCC | MS-DRG 470 | $13,367 |
| Laparoscopic cholecystectomy | CPT 47562 | $5,489.82 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $5,489.82 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $20,572 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $14,660 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $11,325 |
| Open umbilical hernia repair | CPT 49560 | $2,693.60 |
| Umbilical hernia repair age 5+ | CPT 49585 | $2,693.60 |
| Lap inguinal hernia repair | CPT 49650 | $5,408.69 |
| Total abdominal hysterectomy | CPT 58150 | $7,667.00 |
| Vaginal hysterectomy | CPT 58260 | $4,644.94 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $5,570.95 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $9,796.40 |
| Lap salpingo-oophorectomy | CPT 58661 | $5,408.69 |
| OR procedure for obesity w MCC | MS-DRG 619 | $19,108 |
| OR procedure for obesity w CC | MS-DRG 620 | $11,397 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $10,474 |
| Complex cataract surgery | CPT 66982 | $2,220.04 |
| Cataract surgery with lens implant | CPT 66984 | $2,220.04 |
| Intravitreal injection | CPT 67028 | $319.79 |
| Vitrectomy mechanical | CPT 67042 | $3,785.29 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $8,677.75 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $13,834 |
| PCI single major coronary artery | CPT 92920 | $7,844.20 |
| PCI with drug-eluting stent | CPT 92928 | $11,039 |
| PCI bypass graft | CPT 92937 | $19,546 |
| Left heart catheterization | CPT 93452 | $7,801.50 |
| Coronary angiography with cath | CPT 93455 | $8,324.47 |
| Coronary angiography with bypass cath | CPT 93458 | $10,258 |
