| Psychoses | MS-DRG 885 | $15,603 |
| Psychiatric diagnostic evaluation | CPT 90791 | $328.9 |
| Psychiatric eval with medical services | CPT 90792 | $283.36 |
| Psychotherapy 30 minutes | CPT 90832 | $148.95 |
| Psychotherapy 45 minutes | CPT 90834 | $194.94 |
| Psychotherapy 60 minutes | CPT 90837 | $273.65 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $407.12 |
| ED visit level 1 | CPT 99281 | $184.24 |
| ED visit level 2 | CPT 99282 | $301.84 |
| ED visit level 3 | CPT 99283 | $576.24 |
| ED visit level 4 | CPT 99284 | $787.36 |
| ED visit level 5 | CPT 99285 | $4,051.18 |
| Critical care, first hour | CPT 99291 | $2,172.24 |
| CT head without contrast | CPT 70450 | $907.49 |
| CT head with contrast | CPT 70460 | $1,053.92 |
| CT head with and without contrast | CPT 70470 | $1,148 |
| CT neck with contrast | CPT 70491 | $1,218.56 |
| MRI brain without contrast | CPT 70551 | $1,610.56 |
| MRI brain with contrast | CPT 70552 | $1,770.72 |
| MRI brain with and without contrast | CPT 70553 | $1,877.12 |
| Chest X-ray single view | CPT 71045 | $180.32 |
| Chest X-ray 2 views | CPT 71046 | $210.56 |
| Chest X-ray 3 views | CPT 71047 | $283.36 |
| CT chest without contrast | CPT 71250 | $1,215.2 |
| CT chest with contrast | CPT 71260 | $1,230.88 |
| CT chest with and without contrast | CPT 71270 | $1,288 |
| MRI chest without contrast | CPT 71550 | $1,454.88 |
| MRI chest with contrast | CPT 71551 | $1,852.48 |
| MRI chest with and without contrast | CPT 71552 | $2,159.92 |
| Lumbosacral spine X-ray | CPT 72100 | $248.64 |
| CT cervical spine without contrast | CPT 72125 | $1,105.44 |
| CT thoracic spine without contrast | CPT 72128 | $1,032.08 |
| CT lumbar spine without contrast | CPT 72131 | $1,221.92 |
| MRI cervical spine without contrast | CPT 72141 | $1,545.6 |
| MRI thoracic spine without contrast | CPT 72146 | $1,626.24 |
| MRI lumbar spine without contrast | CPT 72148 | $1,611.12 |
| MRI lumbar spine with and without contrast | CPT 72149 | $1,953.84 |
| MRI cervical spine with and without contrast | CPT 72156 | $2,072.56 |
| MRI lumbar spine with contrast | CPT 72158 | $2,072.56 |
| CT pelvis without contrast | CPT 72192 | $981.12 |
| CT pelvis with contrast | CPT 72193 | $1,205.12 |
| Shoulder X-ray | CPT 73030 | $283.36 |
| Humerus X-ray | CPT 73060 | $286.72 |
| Hand X-ray 3 views | CPT 73130 | $239.68 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,701.84 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $2,102.8 |
| Knee X-ray 1-2 views | CPT 73560 | $230.72 |
| Ankle X-ray 3 views | CPT 73610 | $282.24 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,850.8 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $2,102.8 |
| CT abdomen without contrast | CPT 74150 | $1,212.96 |
| CT abdomen with contrast | CPT 74160 | $1,382.08 |
| CT abdomen with and without contrast | CPT 74170 | $1,443.12 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,732.08 |
| CT abdomen and pelvis with contrast | CPT 74177 | $1,753 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $1,753 |
| MRI abdomen without contrast | CPT 74181 | $1,829.52 |
| MRI abdomen with and without contrast | CPT 74183 | $2,103.36 |
| Abdominal ultrasound complete | CPT 76700 | $800.24 |
| Abdominal ultrasound limited | CPT 76705 | $539.84 |
| Retroperitoneal ultrasound complete | CPT 76770 | $792.4 |
| Obstetric ultrasound first trimester | CPT 76801 | $603.12 |
| Obstetric ultrasound after first trimester | CPT 76805 | $614.32 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $832.72 |
| Transvaginal ultrasound | CPT 76830 | $661.36 |
| Pelvic ultrasound complete | CPT 76856 | $557.76 |
| Scrotal ultrasound | CPT 76870 | $528.08 |
| Diagnostic mammography unilateral | CPT 77065 | $239.99 |
| Diagnostic mammography bilateral | CPT 77066 | $333.5 |
| Screening mammography bilateral | CPT 77067 | $242 |
| EKG tracing only | CPT 93005 | $218.96 |
| EKG interpretation only | CPT 93010 | $13.4 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,363.6 |
| Transthoracic echocardiogram | CPT 93307 | $936.88 |
| Stress echocardiogram | CPT 93350 | $1,399.44 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $28,068 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $14,348 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $9,711.91 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $22,809 |
| COPD w MCC | MS-DRG 190 | $15,846 |
| COPD w CC | MS-DRG 191 | $12,122 |
| COPD w/o CC/MCC | MS-DRG 192 | $9,131.99 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $11,570 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $8,786.3 |
| AMI discharged alive w MCC | MS-DRG 280 | $23,160 |
| AMI discharged alive w CC | MS-DRG 281 | $13,007 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $10,231 |
| Heart failure & shock w MCC | MS-DRG 291 | $18,411 |
| Heart failure & shock w CC | MS-DRG 292 | $12,152 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $7,968.09 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $17,015 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $10,432 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $8,073.64 |
| GI hemorrhage w CC | MS-DRG 378 | $13,911 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $8,983.84 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $11,010 |
| Fractures of femur w/o MCC | MS-DRG 533 | $21,516 |
| Kidney/UTI w MCC | MS-DRG 689 | $16,513 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $11,325 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $27,685 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $14,547 |
| Basic metabolic panel (BMP) | CPT 80048 | $87.92 |
| General health panel | CPT 80050 | $17.1 |
| Electrolyte panel | CPT 80051 | $87.36 |
| Comprehensive metabolic panel | CPT 80053 | $142.24 |
| Lipid panel | CPT 80061 | $36.93 |
| Renal function panel | CPT 80069 | $134.96 |
| Hepatic function panel | CPT 80076 | $101.92 |
| Urinalysis non-automated | CPT 81002 | $24.64 |
| Urinalysis automated | CPT 81003 | $38.08 |
| Glucose quantitative | CPT 82947 | $20.72 |
| Hemoglobin A1c | CPT 83036 | $79.5 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $118.5 |
| Complete blood count with automated differential | CPT 85025 | $70.56 |
| Complete blood count without differential | CPT 85027 | $64.96 |
| Urine culture bacterial | CPT 87086 | $90.72 |
| Urine culture identification | CPT 87088 | $8.09 |
| Tissue exam by pathologist level IV | CPT 88305 | $318.91 |
| Fetal non-stress test | CPT 59025 | $289.42 |
| Vaginal delivery only | CPT 59409 | $2,092.35 |
| C-section delivery only | CPT 59514 | $3,642.09 |
| Office visit, established patient, 5 min | CPT 99211 | $69.64 |
| Office visit, established patient, 10-19 min | CPT 99212 | $93.64 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $100.98 |
| 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 | $1,883.84 |
| Upper GI endoscopy with biopsy | CPT 43239 | $2,043.44 |
| Sigmoidoscopy diagnostic | CPT 45330 | $1,191.62 |
| Sigmoidoscopy with biopsy | CPT 45331 | $1,491.25 |
| Colonoscopy diagnostic | CPT 45378 | $1,868.72 |
| Colonoscopy with biopsy | CPT 45380 | $1,942.99 |
| Colonoscopy with polyp removal | CPT 45385 | $1,892.48 |
| Total shoulder arthroplasty | CPT 23472 | $17,048 |
| Hip hemiarthroplasty | CPT 27125 | $34,405 |
| Total hip replacement | CPT 27130 | $11,928 |
| Total knee replacement | CPT 27447 | $12,107 |
| Knee revision arthroplasty single component | CPT 27486 | $34,405 |
| Knee revision arthroplasty all components | CPT 27487 | $34,405 |
| Shoulder arthroscopy with decompression | CPT 29826 | $2,453.36 |
| 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 | $64,792 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $33,352 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $23,296 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $23,400 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $18,591 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $49,801 |
| Open appendectomy | CPT 44950 | $5,784.5 |
| Laparoscopic appendectomy | CPT 44970 | $5,408.69 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $57,369 |
| Major joint replacement w MCC | MS-DRG 469 | $36,514 |
| Major joint replacement w/o MCC | MS-DRG 470 | $26,604 |
| 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 | $41,498 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $29,277 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $22,384 |
| Open umbilical hernia repair | CPT 49560 | $2,693.6 |
| Umbilical hernia repair age 5+ | CPT 49585 | $2,693.6 |
| Lap inguinal hernia repair | CPT 49650 | $5,408.69 |
| 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 | $38,471 |
| OR procedure for obesity w CC | MS-DRG 620 | $22,534 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $20,626 |
| 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 | $16,482 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $27,571 |
| PCI single major coronary artery | CPT 92920 | $6,999.44 |
| PCI with drug-eluting stent | CPT 92928 | $11,186 |
| PCI bypass graft | CPT 92937 | $21,892 |
| Left heart catheterization | CPT 93452 | $11,282 |
| Coronary angiography with cath | CPT 93455 | $6,577.76 |
| Coronary angiography with bypass cath | CPT 93458 | $12,668 |
