| Psychoses | MS-DRG 885 | $17,028 |
| Psychiatric diagnostic evaluation | CPT 90791 | $196.18 |
| Psychiatric eval with medical services | CPT 90792 | $198.15 |
| Psychotherapy 30 minutes | CPT 90832 | $149.8 |
| Psychotherapy 45 minutes | CPT 90834 | $188.3 |
| Psychotherapy 60 minutes | CPT 90837 | $526.7 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $272.97 |
| ED visit level 1 | CPT 99281 | $132.94 |
| ED visit level 2 | CPT 99282 | $637.37 |
| ED visit level 3 | CPT 99283 | $430.38 |
| ED visit level 4 | CPT 99284 | $637.37 |
| ED visit level 5 | CPT 99285 | $782.44 |
| Critical care, first hour | CPT 99291 | $937 |
| CT head without contrast | CPT 70450 | $164.84 |
| CT head with contrast | CPT 70460 | $276.54 |
| CT head with and without contrast | CPT 70470 | $276.54 |
| CT neck with contrast | CPT 70491 | $276.54 |
| MRI brain without contrast | CPT 70551 | $399.21 |
| MRI brain with contrast | CPT 70552 | $550.05 |
| MRI brain with and without contrast | CPT 70553 | $550.05 |
| Chest X-ray single view | CPT 71045 | $100.62 |
| Chest X-ray 2 views | CPT 71046 | $100.62 |
| Chest X-ray 3 views | CPT 71047 | $100.62 |
| CT chest without contrast | CPT 71250 | $164.84 |
| CT chest with contrast | CPT 71260 | $276.54 |
| CT chest with and without contrast | CPT 71270 | $276.54 |
| MRI chest without contrast | CPT 71550 | $399.21 |
| MRI chest with contrast | CPT 71551 | $1,029.96 |
| MRI chest with and without contrast | CPT 71552 | $583.71 |
| Lumbosacral spine X-ray | CPT 72100 | $120.88 |
| CT cervical spine without contrast | CPT 72125 | $164.84 |
| CT thoracic spine without contrast | CPT 72128 | $169.31 |
| CT lumbar spine without contrast | CPT 72131 | $166.31 |
| MRI cervical spine without contrast | CPT 72141 | $399.21 |
| MRI thoracic spine without contrast | CPT 72146 | $376.19 |
| MRI lumbar spine without contrast | CPT 72148 | $376.19 |
| MRI lumbar spine with and without contrast | CPT 72149 | $550.05 |
| MRI cervical spine with and without contrast | CPT 72156 | $550.05 |
| MRI lumbar spine with contrast | CPT 72158 | $550.05 |
| CT pelvis without contrast | CPT 72192 | $164.84 |
| CT pelvis with contrast | CPT 72193 | $276.54 |
| Shoulder X-ray | CPT 73030 | $117.5 |
| Humerus X-ray | CPT 73060 | $114.34 |
| Hand X-ray 3 views | CPT 73130 | $117.5 |
| MRI upper extremity joint without contrast | CPT 73221 | $387.7 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $566.88 |
| Knee X-ray 1-2 views | CPT 73560 | $107.99 |
| Ankle X-ray 3 views | CPT 73610 | $117.5 |
| MRI lower extremity joint without contrast | CPT 73721 | $387.7 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $566.88 |
| CT abdomen without contrast | CPT 74150 | $164.84 |
| CT abdomen with contrast | CPT 74160 | $276.54 |
| CT abdomen with and without contrast | CPT 74170 | $276.54 |
| CT abdomen and pelvis without contrast | CPT 74176 | $375.71 |
| CT abdomen and pelvis with contrast | CPT 74177 | $550.05 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $550.05 |
| MRI abdomen without contrast | CPT 74181 | $399.21 |
| MRI abdomen with and without contrast | CPT 74183 | $583.71 |
| Abdominal ultrasound complete | CPT 76700 | $164.84 |
| Abdominal ultrasound limited | CPT 76705 | $139.53 |
| Retroperitoneal ultrasound complete | CPT 76770 | $164.84 |
| Obstetric ultrasound first trimester | CPT 76801 | $164.84 |
| Obstetric ultrasound after first trimester | CPT 76805 | $164.84 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $376.19 |
| Transvaginal ultrasound | CPT 76830 | $164.84 |
| Pelvic ultrasound complete | CPT 76856 | $164.84 |
| Scrotal ultrasound | CPT 76870 | $164.84 |
| Diagnostic mammography unilateral | CPT 77065 | $227.48 |
| Diagnostic mammography bilateral | CPT 77066 | $288.43 |
| Screening mammography bilateral | CPT 77067 | $232.57 |
| EKG tracing only | CPT 93005 | $73.44 |
| Transthoracic echocardiogram complete | CPT 93306 | $344.86 |
| Transthoracic echocardiogram | CPT 93307 | $330.82 |
| Stress echocardiogram | CPT 93350 | $717.91 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $25,316 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $13,252 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $9,322.46 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $19,911 |
| COPD w MCC | MS-DRG 190 | $14,426 |
| COPD w CC | MS-DRG 191 | $11,978 |
| COPD w/o CC/MCC | MS-DRG 192 | $9,394.56 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $10,787 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $8,648.57 |
| AMI discharged alive w MCC | MS-DRG 280 | $20,410 |
| AMI discharged alive w CC | MS-DRG 281 | $12,152 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $9,789.04 |
| Heart failure & shock w MCC | MS-DRG 291 | $16,549 |
| Heart failure & shock w CC | MS-DRG 292 | $12,055 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $8,417.64 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $15,587 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $9,940.93 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $7,896.26 |
| GI hemorrhage w CC | MS-DRG 378 | $12,895 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $8,671.45 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $10,470 |
| Fractures of femur w/o MCC | MS-DRG 533 | $19,971 |
| Kidney/UTI w MCC | MS-DRG 689 | $15,060 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $10,831 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $61,382 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $48,389 |
| Basic metabolic panel (BMP) | CPT 80048 | $12.69 |
| General health panel | CPT 80050 | $204.07 |
| Electrolyte panel | CPT 80051 | $10.52 |
| Comprehensive metabolic panel | CPT 80053 | $15.84 |
| Lipid panel | CPT 80061 | $20.09 |
| Renal function panel | CPT 80069 | $13.02 |
| Hepatic function panel | CPT 80076 | $12.26 |
| Urinalysis non-automated | CPT 81002 | $3.58 |
| Urinalysis automated | CPT 81003 | $3.38 |
| Glucose quantitative | CPT 82947 | $115.4 |
| Hemoglobin A1c | CPT 83036 | $14.56 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $25.2 |
| Complete blood count with automated differential | CPT 85025 | $15.81 |
| Complete blood count without differential | CPT 85027 | $9.71 |
| Urine culture bacterial | CPT 87086 | $12.11 |
| Urine culture identification | CPT 87088 | $390.59 |
| Tissue exam by pathologist level IV | CPT 88305 | $82.16 |
| Fetal non-stress test | CPT 59025 | $255 |
| Cesarean section w CC/MCC | MS-DRG 765 | $34,908 |
| Cesarean section w/o CC/MCC | MS-DRG 766 | $26,907 |
| Vaginal delivery w complicating dx | MS-DRG 774 | $20,763 |
| Vaginal delivery w/o complicating dx | MS-DRG 775 | $15,662 |
| Office visit, new patient, 15-29 min | CPT 99202 | $77.5 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $110 |
| Office visit, new patient, 45-59 min | CPT 99204 | $136.69 |
| Office visit, new patient, 60-74 min | CPT 99205 | $111.59 |
| Office visit, established patient, 5 min | CPT 99211 | $6.34 |
| Office visit, established patient, 10-19 min | CPT 99212 | $13.7 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $131.62 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $194.14 |
| Office visit, established patient, 40-54 min | CPT 99215 | $194.14 |
| Upper GI endoscopy diagnostic | CPT 43235 | $907.48 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,183.34 |
| Sigmoidoscopy diagnostic | CPT 45330 | $1,124.08 |
| Sigmoidoscopy with biopsy | CPT 45331 | $1,221.83 |
| Colonoscopy diagnostic | CPT 45378 | $967.41 |
| Colonoscopy with biopsy | CPT 45380 | $1,612.58 |
| Colonoscopy with polyp removal | CPT 45385 | $1,542.28 |
| Total shoulder arthroplasty | CPT 23472 | $19,167 |
| PCI w drug-eluting stent w MCC | MS-DRG 246 | $62,246 |
| PCI w drug-eluting stent w/o MCC | MS-DRG 247 | $39,313 |
| Total hip replacement | CPT 27130 | $14,034 |
| Total knee replacement | CPT 27447 | $14,034 |
| Knee revision arthroplasty single component | CPT 27486 | $14,034 |
| Knee revision arthroplasty all components | CPT 27487 | $19,167 |
| Shoulder arthroscopy with decompression | CPT 29826 | $3,748 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $7,919.84 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $3,714.27 |
| ACL reconstruction | CPT 29888 | $7,931.97 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $58,356 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $30,964 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $21,360 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $22,176 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $18,118 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $42,147 |
| Open appendectomy | CPT 44950 | $7,144.75 |
| Laparoscopic appendectomy | CPT 44970 | $6,672.07 |
| Spinal fusion (non-cervical) w MCC | MS-DRG 459 | $134,153 |
| Spinal fusion (non-cervical) w/o MCC | MS-DRG 460 | $78,312 |
| Major joint replacement w MCC | MS-DRG 469 | $93,611 |
| Major joint replacement w/o MCC | MS-DRG 470 | $69,762 |
| Laparoscopic cholecystectomy | CPT 47562 | $6,672.07 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $6,672.07 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $37,379 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $27,194 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $21,421 |
| Lap inguinal hernia repair | CPT 49650 | $6,672.07 |
| Total abdominal hysterectomy | CPT 58150 | $6,368 |
| Vaginal hysterectomy | CPT 58260 | $5,731.21 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $6,830.93 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $11,396 |
| Lap salpingo-oophorectomy | CPT 58661 | $6,672.07 |
| OR procedure for obesity w MCC | MS-DRG 619 | $37,069 |
| OR procedure for obesity w CC | MS-DRG 620 | $21,038 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $19,894 |
| Complex cataract surgery | CPT 66982 | $2,668.28 |
| Cataract surgery with lens implant | CPT 66984 | $2,634.16 |
| Vitrectomy mechanical | CPT 67042 | $4,779.03 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $16,029 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $25,775 |
| PCI single major coronary artery | CPT 92920 | $6,460.89 |
| PCI with drug-eluting stent | CPT 92928 | $12,377 |
| PCI bypass graft | CPT 92937 | $12,377 |
| Left heart catheterization | CPT 93452 | $4,287.54 |
| Coronary angiography with cath | CPT 93455 | $4,271.85 |
| Coronary angiography with bypass cath | CPT 93458 | $3,985.03 |
