| Psychoses | MS-DRG 885 | $23,174 |
| Psychiatric diagnostic evaluation | CPT 90791 | $182.35 |
| Psychiatric eval with medical services | CPT 90792 | $148.21 |
| Psychotherapy 30 minutes | CPT 90832 | $406.70 |
| Psychotherapy 45 minutes | CPT 90834 | $144.90 |
| Psychotherapy 60 minutes | CPT 90837 | $405.31 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $247.69 |
| CT head without contrast | CPT 70450 | $246.03 |
| CT head with contrast | CPT 70460 | $286.84 |
| CT head with and without contrast | CPT 70470 | $335.17 |
| CT neck with contrast | CPT 70491 | $289.75 |
| MRI brain without contrast | CPT 70551 | $711.45 |
| MRI brain with contrast | CPT 70552 | $714.37 |
| MRI brain with and without contrast | CPT 70553 | $714.37 |
| Chest X-ray single view | CPT 71045 | $99.46 |
| Chest X-ray 2 views | CPT 71046 | $99.46 |
| Chest X-ray 3 views | CPT 71047 | $108.19 |
| CT chest without contrast | CPT 71250 | $281.51 |
| CT chest with contrast | CPT 71260 | $305.87 |
| CT chest with and without contrast | CPT 71270 | $352.70 |
| MRI chest without contrast | CPT 71550 | $708.50 |
| MRI chest with contrast | CPT 71551 | $999.02 |
| MRI chest with and without contrast | CPT 71552 | $1,216.97 |
| Lumbosacral spine X-ray | CPT 72100 | $118.15 |
| CT cervical spine without contrast | CPT 72125 | $281.51 |
| CT thoracic spine without contrast | CPT 72128 | $297.32 |
| CT lumbar spine without contrast | CPT 72131 | $292.05 |
| MRI cervical spine without contrast | CPT 72141 | $714.37 |
| MRI thoracic spine without contrast | CPT 72146 | $550.74 |
| MRI lumbar spine without contrast | CPT 72148 | $539.78 |
| MRI lumbar spine with and without contrast | CPT 72149 | $714.37 |
| MRI cervical spine with and without contrast | CPT 72156 | $714.37 |
| MRI lumbar spine with contrast | CPT 72158 | $714.37 |
| CT pelvis without contrast | CPT 72192 | $237.07 |
| CT pelvis with contrast | CPT 72193 | $295.21 |
| Shoulder X-ray | CPT 73030 | $109.08 |
| Humerus X-ray | CPT 73060 | $107.29 |
| Hand X-ray 3 views | CPT 73130 | $109.08 |
| MRI upper extremity joint without contrast | CPT 73221 | $862.79 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $1,020.64 |
| Knee X-ray 1-2 views | CPT 73560 | $107.29 |
| Ankle X-ray 3 views | CPT 73610 | $109.08 |
| MRI lower extremity joint without contrast | CPT 73721 | $862.79 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $902.36 |
| CT abdomen without contrast | CPT 74150 | $271.84 |
| CT abdomen with contrast | CPT 74160 | $314.09 |
| CT abdomen with and without contrast | CPT 74170 | $371.88 |
| CT abdomen and pelvis without contrast | CPT 74176 | $371.92 |
| CT abdomen and pelvis with contrast | CPT 74177 | $570.53 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $697.50 |
| MRI abdomen without contrast | CPT 74181 | $708.50 |
| MRI abdomen with and without contrast | CPT 74183 | $1,215.64 |
| Abdominal ultrasound complete | CPT 76700 | $200.76 |
| Abdominal ultrasound limited | CPT 76705 | $483.35 |
| Retroperitoneal ultrasound complete | CPT 76770 | $171.74 |
| Obstetric ultrasound first trimester | CPT 76801 | $177.20 |
| Obstetric ultrasound after first trimester | CPT 76805 | $170.98 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $367.69 |
| Transvaginal ultrasound | CPT 76830 | $168.93 |
| Pelvic ultrasound complete | CPT 76856 | $168.93 |
| Scrotal ultrasound | CPT 76870 | $135.34 |
| Diagnostic mammography unilateral | CPT 77065 | $181.37 |
| Diagnostic mammography bilateral | CPT 77066 | $231.10 |
| Screening mammography bilateral | CPT 77067 | $191.52 |
| EKG tracing only | CPT 93005 | $56.51 |
| Transthoracic echocardiogram complete | CPT 93306 | $265.37 |
| Transthoracic echocardiogram | CPT 93307 | $326.83 |
| Stress echocardiogram | CPT 93350 | $748.47 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $34,600 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $18,152 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $12,286 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $27,073 |
| COPD w MCC | MS-DRG 190 | $19,190 |
| COPD w CC | MS-DRG 191 | $14,605 |
| COPD w/o CC/MCC | MS-DRG 192 | $11,553 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $14,637 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $11,115 |
| AMI discharged alive w MCC | MS-DRG 280 | $29,299 |
| AMI discharged alive w CC | MS-DRG 281 | $16,454 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $12,943 |
| Heart failure & shock w MCC | MS-DRG 291 | $22,241 |
| Heart failure & shock w CC | MS-DRG 292 | $15,372 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $9,794.30 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $20,918 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $13,197 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $9,987.08 |
| GI hemorrhage w CC | MS-DRG 378 | $17,598 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $11,365 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $13,596 |
| Fractures of femur w/o MCC | MS-DRG 533 | $27,219 |
| Kidney/UTI w MCC | MS-DRG 689 | $20,028 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $13,991 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $33,593 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $18,403 |
| Basic metabolic panel (BMP) | CPT 80048 | $19.72 |
| General health panel | CPT 80050 | $155.58 |
| Electrolyte panel | CPT 80051 | $14.75 |
| Comprehensive metabolic panel | CPT 80053 | $24.63 |
| Lipid panel | CPT 80061 | $29.50 |
| Renal function panel | CPT 80069 | $16.68 |
| Hepatic function panel | CPT 80076 | $19.03 |
| Urinalysis non-automated | CPT 81002 | $4.28 |
| Urinalysis automated | CPT 81003 | $5.08 |
| Glucose quantitative | CPT 82947 | $5.24 |
| Hemoglobin A1c | CPT 83036 | $15.47 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $26.74 |
| Complete blood count with automated differential | CPT 85025 | $156.18 |
| Complete blood count without differential | CPT 85027 | $11.18 |
| Urine culture bacterial | CPT 87086 | $16.86 |
| Urine culture identification | CPT 87088 | $365.76 |
| Tissue exam by pathologist level IV | CPT 88305 | $76.60 |
| Fetal non-stress test | CPT 59025 | $213.94 |
| Office visit, new patient, 15-29 min | CPT 99202 | $78.87 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $92.84 |
| Office visit, new patient, 45-59 min | CPT 99204 | $117.60 |
| Office visit, new patient, 60-74 min | CPT 99205 | $188.00 |
| Office visit, established patient, 5 min | CPT 99211 | $46.04 |
| Office visit, established patient, 10-19 min | CPT 99212 | $79.20 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $108.99 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $151.08 |
| Office visit, established patient, 40-54 min | CPT 99215 | $151.08 |
| Upper GI endoscopy diagnostic | CPT 43235 | $629.92 |
| Upper GI endoscopy with biopsy | CPT 43239 | $994.76 |
| Sigmoidoscopy diagnostic | CPT 45330 | $1,165.59 |
| Sigmoidoscopy with biopsy | CPT 45331 | $1,165.59 |
| Colonoscopy diagnostic | CPT 45378 | $671.52 |
| Colonoscopy with biopsy | CPT 45380 | $1,119.36 |
| Colonoscopy with polyp removal | CPT 45385 | $1,070.56 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $57,438 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $36,276 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $79,632 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $42,192 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $29,470 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $29,602 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $23,279 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $63,002 |
| Laparoscopic appendectomy | CPT 44970 | $6,583.59 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $123,790 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $72,263 |
| Major joint replacement w MCC | MS-DRG 469 | $52,549 |
| Major joint replacement w/o MCC | MS-DRG 470 | $33,656 |
| Laparoscopic cholecystectomy | CPT 47562 | $7,453.12 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $7,453.12 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $52,497 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $37,037 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $28,317 |
| Lap inguinal hernia repair | CPT 49650 | $7,453.12 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $11,576 |
| Lap salpingo-oophorectomy | CPT 58661 | $7,453.12 |
| OR procedure for obesity w MCC | MS-DRG 619 | $48,668 |
| OR procedure for obesity w CC | MS-DRG 620 | $28,506 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $26,093 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $14,516 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $33,787 |
| PCI single major coronary artery | CPT 92920 | $5,964.24 |
| PCI with drug-eluting stent | CPT 92928 | $11,860 |
| PCI bypass graft | CPT 92937 | $11,860 |
| Left heart catheterization | CPT 93452 | $3,604.28 |
| Coronary angiography with cath | CPT 93455 | $4,296.88 |
| Coronary angiography with bypass cath | CPT 93458 | $4,046.72 |
