| Psychoses | MS-DRG 885 | $11,264 |
| Psychiatric diagnostic evaluation | CPT 90791 | $233.2 |
| Psychotherapy 30 minutes | CPT 90832 | $89.59 |
| Psychotherapy 45 minutes | CPT 90834 | $125.05 |
| Psychotherapy 60 minutes | CPT 90837 | $172.56 |
| ED visit level 1 | CPT 99281 | $84.48 |
| ED visit level 2 | CPT 99282 | $160.3 |
| ED visit level 3 | CPT 99283 | $275.39 |
| ED visit level 4 | CPT 99284 | $423.51 |
| ED visit level 5 | CPT 99285 | $604.6 |
| Critical care, first hour | CPT 99291 | $820.28 |
| CT head without contrast | CPT 70450 | $157.03 |
| CT head with contrast | CPT 70460 | $199.2 |
| CT head with and without contrast | CPT 70470 | $216.61 |
| CT neck with contrast | CPT 70491 | $201.63 |
| MRI brain without contrast | CPT 70551 | $454.09 |
| MRI brain with contrast | CPT 70552 | $455.96 |
| MRI brain with and without contrast | CPT 70553 | $455.96 |
| Chest X-ray single view | CPT 71045 | $89.16 |
| Chest X-ray 2 views | CPT 71046 | $89.16 |
| Chest X-ray 3 views | CPT 71047 | $90.67 |
| CT chest without contrast | CPT 71250 | $179.68 |
| CT chest with contrast | CPT 71260 | $206.95 |
| CT chest with and without contrast | CPT 71270 | $225.12 |
| MRI chest without contrast | CPT 71550 | $452.21 |
| MRI chest with and without contrast | CPT 71552 | $776.74 |
| Lumbosacral spine X-ray | CPT 72100 | $107.67 |
| CT cervical spine without contrast | CPT 72125 | $179.68 |
| CT thoracic spine without contrast | CPT 72128 | $189.77 |
| CT lumbar spine without contrast | CPT 72131 | $186.41 |
| MRI cervical spine without contrast | CPT 72141 | $455.96 |
| MRI thoracic spine without contrast | CPT 72146 | $351.52 |
| MRI lumbar spine without contrast | CPT 72148 | $344.52 |
| MRI lumbar spine with and without contrast | CPT 72149 | $455.96 |
| MRI cervical spine with and without contrast | CPT 72156 | $455.96 |
| MRI lumbar spine with contrast | CPT 72158 | $455.96 |
| CT pelvis without contrast | CPT 72192 | $151.31 |
| CT pelvis with contrast | CPT 72193 | $213.69 |
| Shoulder X-ray | CPT 73030 | $90.67 |
| Humerus X-ray | CPT 73060 | $90.67 |
| Hand X-ray 3 views | CPT 73130 | $90.67 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,046.56 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $1,122.38 |
| Knee X-ray 1-2 views | CPT 73560 | $90.67 |
| Ankle X-ray 3 views | CPT 73610 | $90.67 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,035.75 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $1,122.38 |
| CT abdomen without contrast | CPT 74150 | $173.51 |
| CT abdomen with contrast | CPT 74160 | $216.41 |
| CT abdomen with and without contrast | CPT 74170 | $237.36 |
| CT abdomen and pelvis without contrast | CPT 74176 | $267.85 |
| CT abdomen and pelvis with contrast | CPT 74177 | $396.66 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $447.51 |
| MRI abdomen without contrast | CPT 74181 | $452.21 |
| MRI abdomen with and without contrast | CPT 74183 | $775.89 |
| Abdominal ultrasound complete | CPT 76700 | $129.57 |
| Abdominal ultrasound limited | CPT 76705 | $109.49 |
| Retroperitoneal ultrasound complete | CPT 76770 | $120 |
| Obstetric ultrasound first trimester | CPT 76801 | $121.8 |
| Obstetric ultrasound after first trimester | CPT 76805 | $122.82 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $436.06 |
| Transvaginal ultrasound | CPT 76830 | $110.13 |
| Pelvic ultrasound complete | CPT 76856 | $110.13 |
| Scrotal ultrasound | CPT 76870 | $109.49 |
| Diagnostic mammography unilateral | CPT 77065 | $178 |
| Diagnostic mammography bilateral | CPT 77066 | $255 |
| Screening mammography bilateral | CPT 77067 | $178.43 |
| EKG tracing only | CPT 93005 | $60.65 |
| Transthoracic echocardiogram complete | CPT 93306 | $555.18 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $15,968 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $8,303.52 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $5,807.29 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $12,535 |
| COPD w MCC | MS-DRG 190 | $6,353.5 |
| COPD w CC | MS-DRG 191 | $41,848 |
| COPD w/o CC/MCC | MS-DRG 192 | $16,681 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $6,737.9 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $5,379.1 |
| AMI discharged alive w MCC | MS-DRG 280 | $6,374.35 |
| AMI discharged alive w CC | MS-DRG 281 | $4,115.05 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $3,378.05 |
| Heart failure & shock w MCC | MS-DRG 291 | $10,398 |
| Heart failure & shock w CC | MS-DRG 292 | $7,068.03 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $4,900.41 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $13,703 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $7,550.88 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $8,676.27 |
| GI hemorrhage w CC | MS-DRG 378 | $8,076.78 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $5,393.67 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $6,536.46 |
| Fractures of femur w/o MCC | MS-DRG 533 | $12,573 |
| Kidney/UTI w MCC | MS-DRG 689 | $9,452.43 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $6,765.48 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $15,444 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $8,403.08 |
| Basic metabolic panel (BMP) | CPT 80048 | $10.58 |
| Electrolyte panel | CPT 80051 | $7.91 |
| Comprehensive metabolic panel | CPT 80053 | $13.21 |
| Lipid panel | CPT 80061 | $15.82 |
| Renal function panel | CPT 80069 | $10.85 |
| Hepatic function panel | CPT 80076 | $10.21 |
| Urinalysis non-automated | CPT 81002 | $4.03 |
| Urinalysis automated | CPT 81003 | $13.6 |
| Glucose quantitative | CPT 82947 | $4.52 |
| Hemoglobin A1c | CPT 83036 | $10.49 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $26.23 |
| Complete blood count with automated differential | CPT 85025 | $8.39 |
| Complete blood count without differential | CPT 85027 | $8.5 |
| Urine culture bacterial | CPT 87086 | $9.04 |
| Urine culture identification | CPT 87088 | $9.04 |
| Tissue exam by pathologist level IV | CPT 88305 | $55.01 |
| Vaginal delivery only | CPT 59409 | $3,159.22 |
| Office visit, new patient, 15-29 min | CPT 99202 | $100.71 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $130.44 |
| Office visit, new patient, 45-59 min | CPT 99204 | $174.02 |
| Office visit, new patient, 60-74 min | CPT 99205 | $158.56 |
| Office visit, established patient, 5 min | CPT 99211 | $136.8 |
| Office visit, established patient, 10-19 min | CPT 99212 | $65.67 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $110.88 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $105.69 |
| Office visit, established patient, 40-54 min | CPT 99215 | $137.98 |
| Upper GI endoscopy diagnostic | CPT 43235 | $949.32 |
| Upper GI endoscopy with biopsy | CPT 43239 | $959.26 |
| Sigmoidoscopy diagnostic | CPT 45330 | $833.41 |
| Sigmoidoscopy with biopsy | CPT 45331 | $906.76 |
| Colonoscopy diagnostic | CPT 45378 | $938.71 |
| Colonoscopy with biopsy | CPT 45380 | $1,193.87 |
| Colonoscopy with polyp removal | CPT 45385 | $1,193.87 |
| Total shoulder arthroplasty | CPT 23472 | $17,533 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $5,237.59 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $5,240.43 |
| ACL reconstruction | CPT 29888 | $6,810.69 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $35,901 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $18,991 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $13,455 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $13,522 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $11,026 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $26,758 |
| Laparoscopic appendectomy | CPT 44970 | $5,562.36 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $16,618 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $9,494.73 |
| Major joint replacement w MCC | MS-DRG 469 | $23,884 |
| Major joint replacement w/o MCC | MS-DRG 470 | $15,340 |
| Laparoscopic cholecystectomy | CPT 47562 | $5,797.09 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $5,797.09 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $22,954 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $16,628 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $13,058 |
| Lap inguinal hernia repair | CPT 49650 | $5,562.36 |
| OR procedure for obesity w MCC | MS-DRG 619 | $22,763 |
| OR procedure for obesity w CC | MS-DRG 620 | $12,823 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $12,119 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $10,068 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $16,274 |
| PCI single major coronary artery | CPT 92920 | $6,677.5 |
| PCI with drug-eluting stent | CPT 92928 | $9,506 |
| Left heart catheterization | CPT 93452 | $3,311.78 |
| Coronary angiography with cath | CPT 93455 | $3,311.78 |
| Coronary angiography with bypass cath | CPT 93458 | $3,311.78 |
