| Psychoses | MS-DRG 885 | $10,323 |
| Psychiatric diagnostic evaluation | CPT 90791 | $157.81 |
| Psychiatric eval with medical services | CPT 90792 | $164.01 |
| Psychotherapy 30 minutes | CPT 90832 | $75.69 |
| Psychotherapy 45 minutes | CPT 90834 | $99.91 |
| Psychotherapy 60 minutes | CPT 90837 | $144.72 |
| ED visit level 1 | CPT 99281 | $91.95 |
| ED visit level 2 | CPT 99282 | $165.33 |
| ED visit level 3 | CPT 99283 | $275.00 |
| ED visit level 4 | CPT 99284 | $402.02 |
| ED visit level 5 | CPT 99285 | $583.02 |
| Critical care, first hour | CPT 99291 | $805.46 |
| CT head without contrast | CPT 70450 | $43.54 |
| CT head with contrast | CPT 70460 | $72.76 |
| CT head with and without contrast | CPT 70470 | $72.76 |
| CT neck with contrast | CPT 70491 | $72.76 |
| MRI brain without contrast | CPT 70551 | $97.04 |
| MRI brain with contrast | CPT 70552 | $152.29 |
| MRI brain with and without contrast | CPT 70553 | $152.29 |
| Chest X-ray single view | CPT 71045 | $35.98 |
| Chest X-ray 2 views | CPT 71046 | $90.31 |
| Chest X-ray 3 views | CPT 71047 | $88.02 |
| CT chest without contrast | CPT 71250 | $43.54 |
| CT chest with contrast | CPT 71260 | $72.76 |
| CT chest with and without contrast | CPT 71270 | $72.76 |
| MRI chest without contrast | CPT 71550 | $97.04 |
| MRI chest with contrast | CPT 71551 | $317.06 |
| MRI chest with and without contrast | CPT 71552 | $152.29 |
| Lumbosacral spine X-ray | CPT 72100 | $99.79 |
| CT cervical spine without contrast | CPT 72125 | $43.54 |
| CT thoracic spine without contrast | CPT 72128 | $90.60 |
| CT lumbar spine without contrast | CPT 72131 | $43.54 |
| MRI cervical spine without contrast | CPT 72141 | $97.04 |
| MRI thoracic spine without contrast | CPT 72146 | $97.04 |
| MRI lumbar spine without contrast | CPT 72148 | $97.04 |
| MRI lumbar spine with and without contrast | CPT 72149 | $152.29 |
| MRI cervical spine with and without contrast | CPT 72156 | $152.29 |
| MRI lumbar spine with contrast | CPT 72158 | $152.29 |
| CT pelvis without contrast | CPT 72192 | $43.54 |
| CT pelvis with contrast | CPT 72193 | $72.76 |
| Shoulder X-ray | CPT 73030 | $87.35 |
| Humerus X-ray | CPT 73060 | $82.48 |
| Hand X-ray 3 views | CPT 73130 | $85.23 |
| MRI upper extremity joint without contrast | CPT 73221 | $97.04 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $152.29 |
| Knee X-ray 1-2 views | CPT 73560 | $82.48 |
| Ankle X-ray 3 views | CPT 73610 | $85.23 |
| MRI lower extremity joint without contrast | CPT 73721 | $97.04 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $152.29 |
| CT abdomen without contrast | CPT 74150 | $43.54 |
| CT abdomen with contrast | CPT 74160 | $72.76 |
| CT abdomen with and without contrast | CPT 74170 | $72.76 |
| CT abdomen and pelvis without contrast | CPT 74176 | $97.04 |
| CT abdomen and pelvis with contrast | CPT 74177 | $152.29 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $280.74 |
| MRI abdomen without contrast | CPT 74181 | $97.04 |
| MRI abdomen with and without contrast | CPT 74183 | $152.29 |
| Abdominal ultrasound complete | CPT 76700 | $99.65 |
| Abdominal ultrasound limited | CPT 76705 | $43.54 |
| Retroperitoneal ultrasound complete | CPT 76770 | $108.82 |
| Obstetric ultrasound first trimester | CPT 76801 | $99.79 |
| Obstetric ultrasound after first trimester | CPT 76805 | $99.21 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $242.53 |
| Transvaginal ultrasound | CPT 76830 | $99.21 |
| Pelvic ultrasound complete | CPT 76856 | $111.13 |
| Scrotal ultrasound | CPT 76870 | $99.51 |
| Diagnostic mammography unilateral | CPT 77065 | $100.28 |
| Diagnostic mammography bilateral | CPT 77066 | $118.08 |
| Screening mammography bilateral | CPT 77067 | $106.00 |
| EKG complete | CPT 93000 | $47.89 |
| EKG tracing only | CPT 93005 | $44.65 |
| Transthoracic echocardiogram complete | CPT 93306 | $500.75 |
| Stress echocardiogram | CPT 93350 | $517.58 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $17,712 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $10,028 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $6,273.00 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $14,450 |
| COPD w MCC | MS-DRG 190 | $9,955.37 |
| COPD w CC | MS-DRG 191 | $7,724.72 |
| COPD w/o CC/MCC | MS-DRG 192 | $6,382.04 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $7,693.65 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $6,094.26 |
| AMI discharged alive w MCC | MS-DRG 280 | $13,951 |
| AMI discharged alive w CC | MS-DRG 281 | $8,066.06 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $9,529.07 |
| Heart failure & shock w MCC | MS-DRG 291 | $11,618 |
| Heart failure & shock w CC | MS-DRG 292 | $7,915.84 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $5,410.73 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $10,737 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $6,667.43 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $5,250.44 |
| GI hemorrhage w CC | MS-DRG 378 | $9,721.96 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $5,876.77 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $6,979.49 |
| Kidney/UTI w MCC | MS-DRG 689 | $9,974.31 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $6,981.91 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $18,200 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $9,523.12 |
| Initial hospital care, low complexity | CPT 99221 | $105.39 |
| Initial hospital care, moderate complexity | CPT 99222 | $153.08 |
| Initial hospital care, high complexity | CPT 99223 | $202.46 |
| Hospital discharge, <30 min | CPT 99238 | $81.75 |
| Hospital discharge, >30 min | CPT 99239 | $110.13 |
| Basic metabolic panel (BMP) | CPT 80048 | $11.23 |
| General health panel | CPT 80050 | $52.67 |
| Electrolyte panel | CPT 80051 | $9.10 |
| Comprehensive metabolic panel | CPT 80053 | $14.03 |
| Lipid panel | CPT 80061 | $17.40 |
| Renal function panel | CPT 80069 | $11.52 |
| Hepatic function panel | CPT 80076 | $10.84 |
| Urinalysis non-automated | CPT 81002 | $4.28 |
| Urinalysis automated | CPT 81003 | $3.28 |
| Glucose quantitative | CPT 82947 | $5.10 |
| Hemoglobin A1c | CPT 83036 | $10.81 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $24.53 |
| Complete blood count with automated differential | CPT 85025 | $8.65 |
| Complete blood count without differential | CPT 85027 | $9.02 |
| Urine culture bacterial | CPT 87086 | $10.40 |
| Tissue exam by pathologist level IV | CPT 88305 | $49.19 |
| Fetal non-stress test | CPT 59025 | $180.87 |
| Vaginal delivery only | CPT 59409 | $2,837.76 |
| Vaginal delivery with postpartum | CPT 59410 | $2,460.00 |
| C-section delivery only | CPT 59514 | $4,658.22 |
| Vaginal delivery w/o complicating dx | MS-DRG 775 | $7,368.50 |
| Office visit, new patient, 15-29 min | CPT 99202 | $89.04 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $108.03 |
| Office visit, new patient, 45-59 min | CPT 99204 | — |
| Office visit, new patient, 60-74 min | CPT 99205 | — |
| Office visit, established patient, 5 min | CPT 99211 | $48.00 |
| Office visit, established patient, 10-19 min | CPT 99212 | $53.48 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $75.00 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $102.69 |
| Office visit, established patient, 40-54 min | CPT 99215 | $170.43 |
| Upper GI endoscopy diagnostic | CPT 43235 | $798.57 |
| Upper GI endoscopy with biopsy | CPT 43239 | $878.10 |
| Sigmoidoscopy diagnostic | CPT 45330 | $829.59 |
| Sigmoidoscopy with biopsy | CPT 45331 | $829.59 |
| Colonoscopy diagnostic | CPT 45378 | $805.16 |
| Colonoscopy with biopsy | CPT 45380 | $1,039.59 |
| Colonoscopy with polyp removal | CPT 45385 | $1,039.59 |
| Total shoulder arthroplasty | CPT 23472 | $7,010.13 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $6,743.64 |
| Total knee replacement | CPT 27447 | $5,906.78 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $36,249 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $21,046 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $14,701 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $14,766 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $11,732 |
| Open appendectomy | CPT 44950 | $6,032.00 |
| Laparoscopic appendectomy | CPT 44970 | $5,237.33 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $49,292 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $32,276 |
| Major joint replacement w MCC | MS-DRG 469 | $24,193 |
| Major joint replacement w/o MCC | MS-DRG 470 | $15,749 |
| Laparoscopic cholecystectomy | CPT 47562 | $5,237.33 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $5,237.33 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $26,051 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $18,475 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $14,125 |
| Lap inguinal hernia repair | CPT 49650 | $5,230.02 |
| OR procedure for obesity w CC | MS-DRG 620 | $14,220 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $13,016 |
| PCI single major coronary artery | CPT 92920 | $5,188.03 |
| PCI with drug-eluting stent | CPT 92928 | $9,985.60 |
| PCI bypass graft | CPT 92937 | $9,985.60 |
| Coronary angiography with cath | CPT 93455 | $2,998.00 |
| Coronary angiography with bypass cath | CPT 93458 | $3,156.51 |
