| Psychoses | MS-DRG 885 | $17,341 |
| Psychiatric diagnostic evaluation | CPT 90791 | — |
| Psychiatric eval with medical services | CPT 90792 | — |
| Psychotherapy 30 minutes | CPT 90832 | — |
| Psychotherapy 45 minutes | CPT 90834 | — |
| Psychotherapy 60 minutes | CPT 90837 | — |
| Crisis psychotherapy 60 minutes | CPT 90839 | — |
| ED visit level 1 | CPT 99281 | — |
| ED visit level 2 | CPT 99282 | — |
| ED visit level 3 | CPT 99283 | — |
| ED visit level 4 | CPT 99284 | — |
| ED visit level 5 | CPT 99285 | — |
| Critical care, first hour | CPT 99291 | — |
| CT head without contrast | CPT 70450 | — |
| CT head with contrast | CPT 70460 | — |
| CT head with and without contrast | CPT 70470 | — |
| CT neck with contrast | CPT 70491 | — |
| MRI brain without contrast | CPT 70551 | — |
| MRI brain with contrast | CPT 70552 | — |
| MRI brain with and without contrast | CPT 70553 | — |
| Chest X-ray single view | CPT 71045 | — |
| Chest X-ray 2 views | CPT 71046 | — |
| Chest X-ray 3 views | CPT 71047 | — |
| CT chest without contrast | CPT 71250 | — |
| CT chest with contrast | CPT 71260 | — |
| CT chest with and without contrast | CPT 71270 | — |
| MRI chest without contrast | CPT 71550 | — |
| MRI chest with contrast | CPT 71551 | — |
| MRI chest with and without contrast | CPT 71552 | — |
| Lumbosacral spine X-ray | CPT 72100 | — |
| CT cervical spine without contrast | CPT 72125 | — |
| CT thoracic spine without contrast | CPT 72128 | — |
| CT lumbar spine without contrast | CPT 72131 | — |
| MRI cervical spine without contrast | CPT 72141 | — |
| MRI thoracic spine without contrast | CPT 72146 | — |
| MRI lumbar spine without contrast | CPT 72148 | — |
| MRI lumbar spine with and without contrast | CPT 72149 | — |
| MRI cervical spine with and without contrast | CPT 72156 | — |
| MRI lumbar spine with contrast | CPT 72158 | — |
| CT pelvis without contrast | CPT 72192 | — |
| CT pelvis with contrast | CPT 72193 | — |
| Shoulder X-ray | CPT 73030 | — |
| Humerus X-ray | CPT 73060 | — |
| Hand X-ray 3 views | CPT 73130 | — |
| MRI upper extremity joint without contrast | CPT 73221 | — |
| MRI upper extremity joint with and without contrast | CPT 73223 | — |
| Knee X-ray 1-2 views | CPT 73560 | — |
| Ankle X-ray 3 views | CPT 73610 | — |
| MRI lower extremity joint without contrast | CPT 73721 | — |
| MRI lower extremity joint with and without contrast | CPT 73723 | — |
| CT abdomen without contrast | CPT 74150 | — |
| CT abdomen with contrast | CPT 74160 | — |
| CT abdomen with and without contrast | CPT 74170 | — |
| CT abdomen and pelvis without contrast | CPT 74176 | — |
| CT abdomen and pelvis with contrast | CPT 74177 | — |
| CT abdomen and pelvis with and without contrast | CPT 74178 | — |
| MRI abdomen without contrast | CPT 74181 | — |
| MRI abdomen with and without contrast | CPT 74183 | — |
| Abdominal ultrasound complete | CPT 76700 | — |
| Abdominal ultrasound limited | CPT 76705 | — |
| Retroperitoneal ultrasound complete | CPT 76770 | — |
| Obstetric ultrasound first trimester | CPT 76801 | — |
| Obstetric ultrasound after first trimester | CPT 76805 | — |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | — |
| Transvaginal ultrasound | CPT 76830 | — |
| Pelvic ultrasound complete | CPT 76856 | — |
| Scrotal ultrasound | CPT 76870 | — |
| Diagnostic mammography unilateral | CPT 77065 | — |
| Diagnostic mammography bilateral | CPT 77066 | — |
| Screening mammography bilateral | CPT 77067 | — |
| EKG tracing only | CPT 93005 | — |
| Transthoracic echocardiogram complete | CPT 93306 | — |
| Transthoracic echocardiogram | CPT 93307 | — |
| Stress echocardiogram | CPT 93350 | — |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $24,464 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $12,545 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $8,498.54 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $19,265 |
| COPD w MCC | MS-DRG 190 | $13,755 |
| COPD w CC | MS-DRG 191 | $10,468 |
| COPD w/o CC/MCC | MS-DRG 192 | $7,972.04 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $10,007 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $7,804.40 |
| AMI discharged alive w MCC | MS-DRG 280 | $19,745 |
| AMI discharged alive w CC | MS-DRG 281 | $11,413 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $8,979.10 |
| Heart failure & shock w MCC | MS-DRG 291 | $15,942 |
| Heart failure & shock w CC | MS-DRG 292 | $10,542 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $7,028.31 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $14,951 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $9,135.56 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $7,029.55 |
| GI hemorrhage w CC | MS-DRG 378 | $12,178 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $7,827.99 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $9,680.69 |
| Fractures of femur w/o MCC | MS-DRG 533 | $19,323 |
| Kidney/UTI w MCC | MS-DRG 689 | $14,408 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $10,052 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $23,670 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $12,707 |
| Basic metabolic panel (BMP) | CPT 80048 | — |
| Electrolyte panel | CPT 80051 | — |
| Comprehensive metabolic panel | CPT 80053 | — |
| Lipid panel | CPT 80061 | — |
| Renal function panel | CPT 80069 | — |
| Hepatic function panel | CPT 80076 | — |
| Urinalysis non-automated | CPT 81002 | — |
| Urinalysis automated | CPT 81003 | — |
| Glucose quantitative | CPT 82947 | — |
| Hemoglobin A1c | CPT 83036 | — |
| Thyroid stimulating hormone (TSH) | CPT 84443 | — |
| Complete blood count with automated differential | CPT 85025 | — |
| Complete blood count without differential | CPT 85027 | — |
| Urine culture bacterial | CPT 87086 | — |
| Urine culture identification | CPT 87088 | — |
| Tissue exam by pathologist level IV | CPT 88305 | — |
| Fetal non-stress test | CPT 59025 | — |
| Upper GI endoscopy diagnostic | CPT 43235 | — |
| Upper GI endoscopy with biopsy | CPT 43239 | — |
| Sigmoidoscopy diagnostic | CPT 45330 | — |
| Sigmoidoscopy with biopsy | CPT 45331 | — |
| Colonoscopy diagnostic | CPT 45378 | — |
| Colonoscopy with biopsy | CPT 45380 | — |
| Colonoscopy with polyp removal | CPT 45385 | — |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $54,449 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $28,943 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $20,659 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $20,760 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $16,960 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $40,655 |
| Major joint replacement w MCC | MS-DRG 469 | $36,319 |
| Major joint replacement w/o MCC | MS-DRG 470 | $24,293 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $34,917 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $25,432 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $20,057 |
| OR procedure for obesity w MCC | MS-DRG 619 | $34,628 |
| OR procedure for obesity w CC | MS-DRG 620 | $19,701 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $18,635 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $15,406 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $24,906 |
| PCI single major coronary artery | CPT 92920 | — |
| PCI with drug-eluting stent | CPT 92928 | — |
| PCI bypass graft | CPT 92937 | — |
| Left heart catheterization | CPT 93452 | — |
| Coronary angiography with cath | CPT 93455 | — |
| Coronary angiography with bypass cath | CPT 93458 | — |
