| Psychoses | MS-DRG 885 | $14,545 |
| Psychiatric diagnostic evaluation | CPT 90791 | $332.25 |
| Psychiatric eval with medical services | CPT 90792 | $749 |
| Psychotherapy 30 minutes | CPT 90832 | $211.7 |
| Psychotherapy 45 minutes | CPT 90834 | $284.2 |
| Psychotherapy 60 minutes | CPT 90837 | $307.4 |
| ED visit level 1 | CPT 99281 | $359.8 |
| ED visit level 2 | CPT 99282 | $672.1 |
| ED visit level 3 | CPT 99283 | $946.03 |
| ED visit level 4 | CPT 99284 | $1,202.3 |
| ED visit level 5 | CPT 99285 | $1,475.25 |
| Critical care, first hour | CPT 99291 | $1,613.77 |
| CT head without contrast | CPT 70450 | $2,295.27 |
| CT head with contrast | CPT 70460 | $3,594.59 |
| CT head with and without contrast | CPT 70470 | $3,995.03 |
| CT neck with contrast | CPT 70491 | $3,594.59 |
| MRI brain without contrast | CPT 70551 | $4,329.2 |
| MRI brain with contrast | CPT 70552 | $5,410.72 |
| MRI brain with and without contrast | CPT 70553 | $7,862.79 |
| Chest X-ray single view | CPT 71045 | $536.42 |
| Chest X-ray 2 views | CPT 71046 | $536.42 |
| Chest X-ray 3 views | CPT 71047 | $536.42 |
| CT chest without contrast | CPT 71250 | $2,295.27 |
| CT chest with contrast | CPT 71260 | $3,594.59 |
| CT chest with and without contrast | CPT 71270 | $3,995.03 |
| MRI chest without contrast | CPT 71550 | $4,355.67 |
| MRI chest with contrast | CPT 71551 | $4,940.73 |
| MRI chest with and without contrast | CPT 71552 | $7,164.63 |
| Lumbosacral spine X-ray | CPT 72100 | $536.42 |
| CT cervical spine without contrast | CPT 72125 | $2,295.27 |
| CT thoracic spine without contrast | CPT 72128 | $2,295.27 |
| CT lumbar spine without contrast | CPT 72131 | $2,295.27 |
| MRI cervical spine without contrast | CPT 72141 | $4,355.67 |
| MRI thoracic spine without contrast | CPT 72146 | $4,530.59 |
| MRI lumbar spine without contrast | CPT 72148 | $4,504.17 |
| MRI lumbar spine with and without contrast | CPT 72149 | $5,410.72 |
| MRI cervical spine with and without contrast | CPT 72156 | $7,911.97 |
| MRI lumbar spine with contrast | CPT 72158 | $7,862.79 |
| CT pelvis without contrast | CPT 72192 | $2,295.27 |
| CT pelvis with contrast | CPT 72193 | $3,594.59 |
| Shoulder X-ray | CPT 73030 | $743.6 |
| Humerus X-ray | CPT 73060 | $743.6 |
| Hand X-ray 3 views | CPT 73130 | $743.6 |
| MRI upper extremity joint without contrast | CPT 73221 | $6,732.05 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $10,626 |
| Knee X-ray 1-2 views | CPT 73560 | $743.6 |
| Ankle X-ray 3 views | CPT 73610 | $743.6 |
| MRI lower extremity joint without contrast | CPT 73721 | $6,732.05 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $10,626 |
| CT abdomen without contrast | CPT 74150 | $2,295.27 |
| CT abdomen with contrast | CPT 74160 | $3,594.59 |
| CT abdomen with and without contrast | CPT 74170 | $3,995.03 |
| CT abdomen and pelvis without contrast | CPT 74176 | $4,845.61 |
| CT abdomen and pelvis with contrast | CPT 74177 | $6,943.47 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $6,943.47 |
| MRI abdomen without contrast | CPT 74181 | $4,355.67 |
| MRI abdomen with and without contrast | CPT 74183 | $7,186.62 |
| Abdominal ultrasound complete | CPT 76700 | $995.94 |
| Abdominal ultrasound limited | CPT 76705 | $1,054.09 |
| Retroperitoneal ultrasound complete | CPT 76770 | $987.03 |
| Obstetric ultrasound first trimester | CPT 76801 | $1,422.17 |
| Obstetric ultrasound after first trimester | CPT 76805 | $1,422.17 |
| Transvaginal ultrasound | CPT 76830 | $1,807.61 |
| Pelvic ultrasound complete | CPT 76856 | $987.03 |
| Scrotal ultrasound | CPT 76870 | $949.05 |
| Diagnostic mammography unilateral | CPT 77065 | $633.5 |
| EKG tracing only | CPT 93005 | $181.75 |
| Transthoracic echocardiogram complete | CPT 93306 | $2,279.98 |
| Transthoracic echocardiogram | CPT 93307 | $1,236.48 |
| Stress echocardiogram | CPT 93350 | $1,119.29 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $22,645 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $11,513 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $7,887.22 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $17,658 |
| COPD w MCC | MS-DRG 190 | $9,159.77 |
| COPD w CC | MS-DRG 191 | $31,581 |
| COPD w/o CC/MCC | MS-DRG 192 | $15,684 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $9,238.9 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $7,265.35 |
| AMI discharged alive w MCC | MS-DRG 280 | $9,172.94 |
| AMI discharged alive w CC | MS-DRG 281 | $7,745.74 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $7,280.19 |
| Heart failure & shock w MCC | MS-DRG 291 | $14,555 |
| Heart failure & shock w CC | MS-DRG 292 | $9,718.37 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $6,570.06 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $13,802 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $9,916.16 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $10,627 |
| GI hemorrhage w CC | MS-DRG 378 | $11,183 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $7,286.49 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $8,946.3 |
| Fractures of femur w/o MCC | MS-DRG 533 | $17,714 |
| Kidney/UTI w MCC | MS-DRG 689 | $13,182 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $9,278.94 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $21,883 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $11,657 |
| Basic metabolic panel (BMP) | CPT 80048 | $101 |
| Electrolyte panel | CPT 80051 | $80.95 |
| Comprehensive metabolic panel | CPT 80053 | $126.14 |
| Lipid panel | CPT 80061 | $122.38 |
| Renal function panel | CPT 80069 | $103.59 |
| Hepatic function panel | CPT 80076 | $97.49 |
| Urinalysis non-automated | CPT 81002 | $23.4 |
| Urinalysis automated | CPT 81003 | $30.75 |
| Glucose quantitative | CPT 82947 | $34.17 |
| Hemoglobin A1c | CPT 83036 | $92.56 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $291.2 |
| Complete blood count with automated differential | CPT 85025 | $67.5 |
| Complete blood count without differential | CPT 85027 | $56.22 |
| Urine culture bacterial | CPT 87086 | $581.6 |
| Urine culture identification | CPT 87088 | $70.26 |
| Tissue exam by pathologist level IV | CPT 88305 | $198.94 |
| Fetal non-stress test | CPT 59025 | $872.07 |
| Vaginal delivery only | CPT 59409 | $12,691 |
| Office visit, new patient, 15-29 min | CPT 99202 | $233.8 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $298.2 |
| Office visit, new patient, 45-59 min | CPT 99204 | $350 |
| Office visit, new patient, 60-74 min | CPT 99205 | $422.8 |
| Office visit, established patient, 5 min | CPT 99211 | $112.7 |
| Office visit, established patient, 10-19 min | CPT 99212 | $130.2 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $172.2 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $196 |
| Office visit, established patient, 40-54 min | CPT 99215 | $233.8 |
| Upper GI endoscopy diagnostic | CPT 43235 | — |
| Upper GI endoscopy with biopsy | CPT 43239 | — |
| Sigmoidoscopy diagnostic | CPT 45330 | $938.75 |
| Sigmoidoscopy with biopsy | CPT 45331 | — |
| Colonoscopy diagnostic | CPT 45378 | $1,750 |
| Colonoscopy with biopsy | CPT 45380 | $4,691.7 |
| Colonoscopy with polyp removal | CPT 45385 | $4,691.7 |
| Total shoulder arthroplasty | CPT 23472 | $15,500 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $8,454.85 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $8,456.65 |
| Total hip replacement | CPT 27130 | $13,248 |
| Total knee replacement | CPT 27447 | $13,248 |
| Shoulder arthroscopy with decompression | CPT 29826 | $2,644.32 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $6,921.14 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $2,415.33 |
| ACL reconstruction | CPT 29888 | $4,955.54 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $51,409 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $26,942 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $18,995 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $19,092 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $15,468 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $38,177 |
| Open appendectomy | CPT 44950 | $6,424.76 |
| Laparoscopic appendectomy | CPT 44970 | $6,007.35 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $15,644 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $11,144 |
| Major joint replacement w MCC | MS-DRG 469 | $34,017 |
| Major joint replacement w/o MCC | MS-DRG 470 | $21,732 |
| Laparoscopic cholecystectomy | CPT 47562 | $6,007.35 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $6,007.35 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $32,672 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $23,574 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $18,418 |
| Lap inguinal hernia repair | CPT 49650 | $5,652.97 |
| Lap salpingo-oophorectomy | CPT 58661 | $11,587 |
| OR procedure for obesity w MCC | MS-DRG 619 | $32,395 |
| OR procedure for obesity w CC | MS-DRG 620 | $18,076 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $17,054 |
| Complex cataract surgery | CPT 66982 | $2,348.35 |
| Cataract surgery with lens implant | CPT 66984 | $2,348.35 |
| Intravitreal injection | CPT 67028 | $2,467.92 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $14,076 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $21,282 |
| PCI single major coronary artery | CPT 92920 | $25,893 |
| PCI with drug-eluting stent | CPT 92928 | $39,332 |
| PCI bypass graft | CPT 92937 | $39,332 |
| Left heart catheterization | CPT 93452 | $12,890 |
| Coronary angiography with cath | CPT 93455 | $9,218.48 |
| Coronary angiography with bypass cath | CPT 93458 | $12,782 |
