| Psychoses | MS-DRG 885 | $11,676 |
| Psychiatric diagnostic evaluation | CPT 90791 | $120.56 |
| Psychotherapy 45 minutes | CPT 90834 | $117.92 |
| ED visit level 1 | CPT 99281 | $227.13 |
| ED visit level 2 | CPT 99282 | $323.41 |
| ED visit level 3 | CPT 99283 | $591.48 |
| ED visit level 4 | CPT 99284 | $988.82 |
| ED visit level 5 | CPT 99285 | $1,023.64 |
| Critical care, first hour | CPT 99291 | $1,428.14 |
| CT head without contrast | CPT 70450 | $1,274.07 |
| CT head with contrast | CPT 70460 | $1,885.1 |
| CT head with and without contrast | CPT 70470 | $2,149.84 |
| CT neck with contrast | CPT 70491 | $1,996.24 |
| MRI brain without contrast | CPT 70551 | $1,906.57 |
| MRI brain with contrast | CPT 70552 | $2,313.93 |
| MRI brain with and without contrast | CPT 70553 | $3,024.18 |
| Chest X-ray single view | CPT 71045 | $139.28 |
| Chest X-ray 2 views | CPT 71046 | $461.26 |
| Chest X-ray 3 views | CPT 71047 | $396.86 |
| CT chest without contrast | CPT 71250 | $1,784.46 |
| CT chest with contrast | CPT 71260 | $2,117.88 |
| CT chest with and without contrast | CPT 71270 | $2,506.16 |
| MRI chest without contrast | CPT 71550 | $1,998.63 |
| MRI chest with contrast | CPT 71551 | $2,486.57 |
| MRI chest with and without contrast | CPT 71552 | $3,168.71 |
| Lumbosacral spine X-ray | CPT 72100 | $331.51 |
| CT cervical spine without contrast | CPT 72125 | $1,676.18 |
| CT thoracic spine without contrast | CPT 72128 | $1,648.99 |
| CT lumbar spine without contrast | CPT 72131 | $1,630.86 |
| MRI cervical spine without contrast | CPT 72141 | $1,927.08 |
| MRI thoracic spine without contrast | CPT 72146 | $1,998.63 |
| MRI lumbar spine without contrast | CPT 72148 | $1,998.63 |
| MRI lumbar spine with and without contrast | CPT 72149 | $2,486.57 |
| MRI cervical spine with and without contrast | CPT 72156 | $3,074.74 |
| MRI lumbar spine with contrast | CPT 72158 | $3,188.27 |
| CT pelvis without contrast | CPT 72192 | $1,044.15 |
| CT pelvis with contrast | CPT 72193 | $1,512.09 |
| Shoulder X-ray | CPT 73030 | $276.23 |
| Humerus X-ray | CPT 73060 | $509.83 |
| Hand X-ray 3 views | CPT 73130 | $264.9 |
| MRI upper extremity joint without contrast | CPT 73221 | $2,260.51 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $3,606.02 |
| Knee X-ray 1-2 views | CPT 73560 | $547.06 |
| Ankle X-ray 3 views | CPT 73610 | $276.23 |
| MRI lower extremity joint without contrast | CPT 73721 | $2,260.51 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $3,606.02 |
| CT abdomen without contrast | CPT 74150 | $1,729.12 |
| CT abdomen with contrast | CPT 74160 | $2,204.22 |
| CT abdomen with and without contrast | CPT 74170 | $2,763.74 |
| CT abdomen and pelvis without contrast | CPT 74176 | $2,639.72 |
| CT abdomen and pelvis with contrast | CPT 74177 | $3,540.29 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $4,550.1 |
| MRI abdomen without contrast | CPT 74181 | $1,998.63 |
| MRI abdomen with and without contrast | CPT 74183 | $3,188.27 |
| Abdominal ultrasound complete | CPT 76700 | $728.86 |
| Abdominal ultrasound limited | CPT 76705 | $549.03 |
| Retroperitoneal ultrasound complete | CPT 76770 | $582.42 |
| Obstetric ultrasound first trimester | CPT 76801 | $549.03 |
| Obstetric ultrasound after first trimester | CPT 76805 | $549.03 |
| Transvaginal ultrasound | CPT 76830 | $539.49 |
| Pelvic ultrasound complete | CPT 76856 | $581.94 |
| Scrotal ultrasound | CPT 76870 | $513.73 |
| Diagnostic mammography unilateral | CPT 77065 | $321.03 |
| Diagnostic mammography bilateral | CPT 77066 | $489.44 |
| Screening mammography bilateral | CPT 77067 | $207.94 |
| EKG tracing only | CPT 93005 | $58.4 |
| Transthoracic echocardiogram complete | CPT 93306 | $1,800.67 |
| Stress echocardiogram | CPT 93350 | $737.8 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $16,599 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $8,577.22 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $5,964.58 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $13,006 |
| COPD w MCC | MS-DRG 190 | $6,425.68 |
| COPD w CC | MS-DRG 191 | $42,323 |
| COPD w/o CC/MCC | MS-DRG 192 | $16,870 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $6,938.62 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $5,516.45 |
| AMI discharged alive w MCC | MS-DRG 280 | $6,446.76 |
| AMI discharged alive w CC | MS-DRG 281 | $4,161.79 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $3,416.43 |
| Heart failure & shock w MCC | MS-DRG 291 | $10,770 |
| Heart failure & shock w CC | MS-DRG 292 | $7,284.15 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $5,015.42 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $13,858 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $7,636.66 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $8,774.83 |
| GI hemorrhage w CC | MS-DRG 378 | $8,339.92 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $5,531.7 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $6,727.78 |
| Fractures of femur w/o MCC | MS-DRG 533 | $13,046 |
| Kidney/UTI w MCC | MS-DRG 689 | $9,779.71 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $6,967.48 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $16,050 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $8,681.44 |
| Basic metabolic panel (BMP) | CPT 80048 | $134.42 |
| Electrolyte panel | CPT 80051 | $94.22 |
| Comprehensive metabolic panel | CPT 80053 | $155.16 |
| Lipid panel | CPT 80061 | $164.24 |
| Renal function panel | CPT 80069 | $112.37 |
| Hepatic function panel | CPT 80076 | $167.26 |
| Urinalysis non-automated | CPT 81002 | $37.06 |
| Urinalysis automated | CPT 81003 | $27.23 |
| Glucose quantitative | CPT 82947 | $37.93 |
| Hemoglobin A1c | CPT 83036 | $119.29 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $163.38 |
| Complete blood count with automated differential | CPT 85025 | $68.72 |
| Complete blood count without differential | CPT 85027 | $57.92 |
| Urine culture bacterial | CPT 87086 | $157.32 |
| Tissue exam by pathologist level IV | CPT 88305 | $195.41 |
| Fetal non-stress test | CPT 59025 | $304.16 |
| Vaginal delivery only | CPT 59409 | $8,149.69 |
| Vaginal delivery with postpartum | CPT 59410 | $1,145.31 |
| C-section with postpartum | CPT 59515 | $1,145.31 |
| Office visit, new patient, 15-29 min | CPT 99202 | $226.77 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $124 |
| Office visit, new patient, 45-59 min | CPT 99204 | $133.24 |
| Office visit, new patient, 60-74 min | CPT 99205 | $157.8 |
| Office visit, established patient, 5 min | CPT 99211 | $120.9 |
| Office visit, established patient, 10-19 min | CPT 99212 | $120.9 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $120.9 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $295.67 |
| Office visit, established patient, 40-54 min | CPT 99215 | $380.84 |
| Upper GI endoscopy diagnostic | CPT 43235 | $2,803.33 |
| Upper GI endoscopy with biopsy | CPT 43239 | $2,803.33 |
| Sigmoidoscopy diagnostic | CPT 45330 | $658.02 |
| Sigmoidoscopy with biopsy | CPT 45331 | $2,509.5 |
| Colonoscopy diagnostic | CPT 45378 | $1,192.5 |
| Colonoscopy with biopsy | CPT 45380 | $2,585.82 |
| Colonoscopy with polyp removal | CPT 45385 | $2,585.82 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $5,297.09 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $5,299.96 |
| Total knee replacement | CPT 27447 | $12,512 |
| Shoulder arthroscopy with decompression | CPT 29826 | $2,548.05 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $6,946.9 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $2,184.48 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $37,327 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $19,696 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $13,969 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $14,039 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $11,427 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $27,792 |
| Laparoscopic appendectomy | CPT 44970 | $5,673.61 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $16,807 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $9,602.59 |
| Major joint replacement w MCC | MS-DRG 469 | $24,794 |
| Major joint replacement w/o MCC | MS-DRG 470 | $15,941 |
| Laparoscopic cholecystectomy | CPT 47562 | $5,673.61 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $5,673.61 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $23,825 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $17,269 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $13,553 |
| Lap inguinal hernia repair | CPT 49650 | $5,673.61 |
| Lap salpingo-oophorectomy | CPT 58661 | — |
| OR procedure for obesity w MCC | MS-DRG 619 | $23,625 |
| OR procedure for obesity w CC | MS-DRG 620 | $13,307 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $12,570 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $10,424 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $16,905 |
| PCI single major coronary artery | CPT 92920 | $4,349.4 |
| PCI with drug-eluting stent | CPT 92928 | $8,695.5 |
| PCI bypass graft | CPT 92937 | $5,500.98 |
| Left heart catheterization | CPT 93452 | $3,626.15 |
| Coronary angiography with cath | CPT 93455 | $4,366.45 |
| Coronary angiography with bypass cath | CPT 93458 | $4,491.3 |
