| Psychoses | MS-DRG 885 | $16,240 |
| Psychiatric diagnostic evaluation | CPT 90791 | $171.88 |
| Psychiatric eval with medical services | CPT 90792 | $207.15 |
| Psychotherapy 30 minutes | CPT 90832 | $78.18 |
| Psychotherapy 45 minutes | CPT 90834 | $103.22 |
| Psychotherapy 60 minutes | CPT 90837 | $152.81 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $205.89 |
| ED visit level 1 | CPT 99281 | $17.86 |
| ED visit level 2 | CPT 99282 | $53.11 |
| ED visit level 3 | CPT 99283 | $91.22 |
| ED visit level 4 | CPT 99284 | $152.32 |
| ED visit level 5 | CPT 99285 | $233.98 |
| Critical care, first hour | CPT 99291 | $362.98 |
| CT head without contrast | CPT 70450 | $1,637.35 |
| CT head with contrast | CPT 70460 | $1,909.57 |
| CT head with and without contrast | CPT 70470 | $2,396.14 |
| CT neck with contrast | CPT 70491 | $2,465.81 |
| MRI brain without contrast | CPT 70551 | $2,757.72 |
| MRI brain with contrast | CPT 70552 | $3,148 |
| MRI brain with and without contrast | CPT 70553 | $4,094.82 |
| Chest X-ray single view | CPT 71045 | $243.02 |
| Chest X-ray 2 views | CPT 71046 | $338.52 |
| Chest X-ray 3 views | CPT 71047 | $380.52 |
| CT chest without contrast | CPT 71250 | $1,770.5 |
| CT chest with contrast | CPT 71260 | $2,171.32 |
| CT chest with and without contrast | CPT 71270 | $2,272.02 |
| MRI chest without contrast | CPT 71550 | $2,731.25 |
| MRI chest with and without contrast | CPT 71552 | $5,053.36 |
| Lumbosacral spine X-ray | CPT 72100 | $543.38 |
| CT cervical spine without contrast | CPT 72125 | $1,708.65 |
| CT thoracic spine without contrast | CPT 72128 | $1,422.05 |
| CT lumbar spine without contrast | CPT 72131 | $1,747.61 |
| MRI cervical spine without contrast | CPT 72141 | $2,774.59 |
| MRI thoracic spine without contrast | CPT 72146 | $2,774.59 |
| MRI lumbar spine without contrast | CPT 72148 | $2,816.64 |
| MRI lumbar spine with and without contrast | CPT 72149 | $3,148 |
| MRI cervical spine with and without contrast | CPT 72156 | $4,512.87 |
| MRI lumbar spine with contrast | CPT 72158 | $4,536.34 |
| CT pelvis without contrast | CPT 72192 | $1,728.01 |
| CT pelvis with contrast | CPT 72193 | $2,066.71 |
| Shoulder X-ray | CPT 73030 | $474.41 |
| Humerus X-ray | CPT 73060 | $431.26 |
| Hand X-ray 3 views | CPT 73130 | $474.41 |
| MRI upper extremity joint without contrast | CPT 73221 | $2,816.64 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $5,053.36 |
| Knee X-ray 1-2 views | CPT 73560 | $442.65 |
| Ankle X-ray 3 views | CPT 73610 | $442.15 |
| MRI lower extremity joint without contrast | CPT 73721 | $2,816.64 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $5,329.5 |
| CT abdomen without contrast | CPT 74150 | $1,961.69 |
| CT abdomen with contrast | CPT 74160 | $2,237.9 |
| CT abdomen with and without contrast | CPT 74170 | $3,130.22 |
| CT abdomen and pelvis without contrast | CPT 74176 | $3,179.87 |
| CT abdomen and pelvis with contrast | CPT 74177 | $4,104.45 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $4,698.48 |
| MRI abdomen without contrast | CPT 74181 | $2,816.64 |
| MRI abdomen with and without contrast | CPT 74183 | $4,319.53 |
| Abdominal ultrasound complete | CPT 76700 | $728.89 |
| Abdominal ultrasound limited | CPT 76705 | $401.84 |
| Retroperitoneal ultrasound complete | CPT 76770 | $578.33 |
| Obstetric ultrasound first trimester | CPT 76801 | $638.16 |
| Obstetric ultrasound after first trimester | CPT 76805 | $732.36 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $263.7 |
| Transvaginal ultrasound | CPT 76830 | $905.34 |
| Pelvic ultrasound complete | CPT 76856 | $772.21 |
| Scrotal ultrasound | CPT 76870 | $876.27 |
| Diagnostic mammography unilateral | CPT 77065 | $687.37 |
| Diagnostic mammography bilateral | CPT 77066 | $730.06 |
| Screening mammography bilateral | CPT 77067 | $628.9 |
| EKG complete | CPT 93000 | $22.73 |
| EKG tracing only | CPT 93005 | $9.92 |
| EKG interpretation only | CPT 93010 | $12.81 |
| Transthoracic echocardiogram complete | CPT 93306 | $96.35 |
| Transthoracic echocardiogram | CPT 93307 | $66.92 |
| Stress echocardiogram | CPT 93350 | $105.68 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $23,146 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $11,833 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $8,009.04 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $18,810 |
| COPD w MCC | MS-DRG 190 | $13,067 |
| COPD w CC | MS-DRG 191 | $9,996.49 |
| COPD w/o CC/MCC | MS-DRG 192 | $7,530.79 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $9,541.48 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $7,245.73 |
| AMI discharged alive w MCC | MS-DRG 280 | $19,099 |
| AMI discharged alive w CC | MS-DRG 281 | $10,726 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $8,437.25 |
| Heart failure & shock w MCC | MS-DRG 291 | $15,183 |
| Heart failure & shock w CC | MS-DRG 292 | $10,021 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $6,384.66 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $14,032 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $8,602.48 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $6,510.32 |
| GI hemorrhage w CC | MS-DRG 378 | $11,472 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $7,408.64 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $9,079.55 |
| Fractures of femur w/o MCC | MS-DRG 533 | $17,744 |
| Kidney/UTI w MCC | MS-DRG 689 | $13,618 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $9,339.04 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $22,831 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $11,997 |
| Initial hospital care, low complexity | CPT 99221 | $121.25 |
| Initial hospital care, moderate complexity | CPT 99222 | $169.87 |
| Initial hospital care, high complexity | CPT 99223 | $240.89 |
| Hospital discharge, <30 min | CPT 99238 | $102.97 |
| Hospital discharge, >30 min | CPT 99239 | $141.97 |
| Basic metabolic panel (BMP) | CPT 80048 | $73.54 |
| General health panel | CPT 80050 | $210.35 |
| Electrolyte panel | CPT 80051 | $70.69 |
| Comprehensive metabolic panel | CPT 80053 | $112.02 |
| Lipid panel | CPT 80061 | $96.58 |
| Renal function panel | CPT 80069 | $102.06 |
| Hepatic function panel | CPT 80076 | $108.82 |
| Urinalysis non-automated | CPT 81002 | $30.46 |
| Urinalysis automated | CPT 81003 | $51.96 |
| Glucose quantitative | CPT 82947 | $48.39 |
| Hemoglobin A1c | CPT 83036 | $117.59 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $176.15 |
| Complete blood count with automated differential | CPT 85025 | $53.52 |
| Complete blood count without differential | CPT 85027 | $48.35 |
| Urine culture bacterial | CPT 87086 | $67.36 |
| Urine culture identification | CPT 87088 | $72.96 |
| Tissue exam by pathologist level IV | CPT 88305 | $211.86 |
| Fetal non-stress test | CPT 59025 | $46.42 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $2,721.3 |
| Vaginal delivery only | CPT 59409 | $1,136.05 |
| Vaginal delivery with postpartum | CPT 59410 | $1,402.91 |
| Routine obstetric care with C-section | CPT 59510 | $2,998.48 |
| C-section delivery only | CPT 59514 | $1,267.71 |
| C-section with postpartum | CPT 59515 | $1,598.27 |
| Office visit, new patient, 15-29 min | CPT 99202 | $74.49 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $127.73 |
| Office visit, new patient, 45-59 min | CPT 99204 | $192.79 |
| Office visit, new patient, 60-74 min | CPT 99205 | $244.38 |
| Office visit, established patient, 5 min | CPT 99211 | $22.37 |
| Office visit, established patient, 10-19 min | CPT 99212 | $55.06 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $95.56 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $135.61 |
| Office visit, established patient, 40-54 min | CPT 99215 | $189.12 |
| Upper GI endoscopy diagnostic | CPT 43235 | $270.63 |
| Upper GI endoscopy with biopsy | CPT 43239 | $350.7 |
| Sigmoidoscopy diagnostic | CPT 45330 | — |
| Sigmoidoscopy with biopsy | CPT 45331 | — |
| Colonoscopy diagnostic | CPT 45378 | $342.68 |
| Colonoscopy with biopsy | CPT 45380 | $405.36 |
| Colonoscopy with polyp removal | CPT 45385 | $465.98 |
| Total shoulder arthroplasty | CPT 23472 | $2,114.88 |
| Hip hemiarthroplasty | CPT 27125 | $1,762.16 |
| Total hip replacement | CPT 27130 | $2,047.31 |
| Total knee replacement | CPT 27447 | $2,045.09 |
| Knee revision arthroplasty single component | CPT 27486 | $1,817.91 |
| Knee revision arthroplasty all components | CPT 27487 | $2,557.82 |
| Shoulder arthroscopy with decompression | CPT 29826 | $271.21 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $1,417.7 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $876.97 |
| ACL reconstruction | CPT 29888 | $1,562.81 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $53,431 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $27,504 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $19,211 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $19,297 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $15,332 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $41,069 |
| Open appendectomy | CPT 44950 | $888 |
| Laparoscopic appendectomy | CPT 44970 | $799.35 |
| Major joint replacement w MCC | MS-DRG 469 | $38,035 |
| Major joint replacement w/o MCC | MS-DRG 470 | $21,940 |
| Laparoscopic cholecystectomy | CPT 47562 | $976.15 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $1,054.05 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $34,221 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $24,143 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $18,459 |
| Lap inguinal hernia repair | CPT 49650 | $596.35 |
| Total abdominal hysterectomy | CPT 58150 | $1,432.98 |
| Vaginal hysterectomy | CPT 58260 | $4,891.43 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $1,338.48 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $1,443.73 |
| Lap salpingo-oophorectomy | CPT 58661 | $977.99 |
| OR procedure for obesity w MCC | MS-DRG 619 | $31,725 |
| OR procedure for obesity w CC | MS-DRG 620 | $18,583 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $17,009 |
| Complex cataract surgery | CPT 66982 | $2,259.93 |
| Cataract surgery with lens implant | CPT 66984 | $2,259.93 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $13,948 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $22,737 |
