| Psychoses | MS-DRG 885 | $16,002 |
| Psychiatric diagnostic evaluation | CPT 90791 | $195.70 |
| Psychiatric eval with medical services | CPT 90792 | $225.41 |
| Psychotherapy 30 minutes | CPT 90832 | $85.02 |
| Psychotherapy 45 minutes | CPT 90834 | $126.33 |
| Psychotherapy 60 minutes | CPT 90837 | $186.45 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $202.47 |
| ED visit level 1 | CPT 99281 | $16.72 |
| ED visit level 2 | CPT 99282 | $44.64 |
| ED visit level 3 | CPT 99283 | $75.53 |
| ED visit level 4 | CPT 99284 | $128.57 |
| ED visit level 5 | CPT 99285 | $186.27 |
| Critical care, first hour | CPT 99291 | $277.96 |
| CT head without contrast | CPT 70450 | $2,061.95 |
| CT head with contrast | CPT 70460 | $1,923.90 |
| CT head with and without contrast | CPT 70470 | $2,377.10 |
| CT neck with contrast | CPT 70491 | $2,031.15 |
| MRI brain without contrast | CPT 70551 | $2,085.60 |
| MRI brain with contrast | CPT 70552 | $3,585.45 |
| MRI brain with and without contrast | CPT 70553 | $4,271.85 |
| Chest X-ray single view | CPT 71045 | $316.80 |
| Chest X-ray 2 views | CPT 71046 | $328.35 |
| Chest X-ray 3 views | CPT 71047 | $328.35 |
| CT chest without contrast | CPT 71250 | $1,752.30 |
| CT chest with contrast | CPT 71260 | $2,689.50 |
| CT chest with and without contrast | CPT 71270 | $1,705.00 |
| MRI chest without contrast | CPT 71550 | $2,935.35 |
| MRI chest with contrast | CPT 71551 | $5,272.85 |
| MRI chest with and without contrast | CPT 71552 | $3,315.40 |
| Lumbosacral spine X-ray | CPT 72100 | $475.20 |
| CT cervical spine without contrast | CPT 72125 | $2,004.20 |
| CT thoracic spine without contrast | CPT 72128 | $1,850.20 |
| CT lumbar spine without contrast | CPT 72131 | $1,893.10 |
| MRI cervical spine without contrast | CPT 72141 | $3,062.95 |
| MRI thoracic spine without contrast | CPT 72146 | $3,017.30 |
| MRI lumbar spine without contrast | CPT 72148 | $2,951.85 |
| MRI lumbar spine with and without contrast | CPT 72149 | $2,109.25 |
| MRI cervical spine with and without contrast | CPT 72156 | $4,346.10 |
| MRI lumbar spine with contrast | CPT 72158 | $4,326.85 |
| CT pelvis without contrast | CPT 72192 | $1,833.70 |
| CT pelvis with contrast | CPT 72193 | $2,480.50 |
| Shoulder X-ray | CPT 73030 | $433.95 |
| Humerus X-ray | CPT 73060 | $370.70 |
| Hand X-ray 3 views | CPT 73130 | $394.90 |
| MRI upper extremity joint without contrast | CPT 73221 | $2,822.05 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $4,219.05 |
| Knee X-ray 1-2 views | CPT 73560 | $356.95 |
| Ankle X-ray 3 views | CPT 73610 | $407.55 |
| MRI lower extremity joint without contrast | CPT 73721 | $2,765.40 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $4,045.80 |
| CT abdomen without contrast | CPT 74150 | $1,851.85 |
| CT abdomen with contrast | CPT 74160 | $2,363.90 |
| CT abdomen with and without contrast | CPT 74170 | $2,816.00 |
| CT abdomen and pelvis without contrast | CPT 74176 | $3,421.00 |
| CT abdomen and pelvis with contrast | CPT 74177 | $3,604.15 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $5,389.45 |
| MRI abdomen without contrast | CPT 74181 | $2,955.70 |
| MRI abdomen with and without contrast | CPT 74183 | $3,525.50 |
| Abdominal ultrasound complete | CPT 76700 | $1,035.65 |
| Abdominal ultrasound limited | CPT 76705 | $630.85 |
| Retroperitoneal ultrasound complete | CPT 76770 | $684.75 |
| Obstetric ultrasound first trimester | CPT 76801 | $550.00 |
| Obstetric ultrasound after first trimester | CPT 76805 | $674.30 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $727.10 |
| Transvaginal ultrasound | CPT 76830 | $733.15 |
| Pelvic ultrasound complete | CPT 76856 | $686.40 |
| Scrotal ultrasound | CPT 76870 | $583.55 |
| Diagnostic mammography unilateral | CPT 77065 | $448.70 |
| Diagnostic mammography bilateral | CPT 77066 | $571.84 |
| Screening mammography bilateral | CPT 77067 | $621.60 |
| EKG complete | CPT 93000 | $15.57 |
| EKG tracing only | CPT 93005 | $7.59 |
| EKG interpretation only | CPT 93010 | $8.73 |
| Transthoracic echocardiogram complete | CPT 93306 | $188.28 |
| Transthoracic echocardiogram | CPT 93307 | $130.83 |
| Stress echocardiogram | CPT 93350 | $178.32 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $22,582 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $11,544 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $7,813.79 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $18,351 |
| COPD w MCC | MS-DRG 190 | $12,749 |
| COPD w CC | MS-DRG 191 | $9,752.78 |
| COPD w/o CC/MCC | MS-DRG 192 | $7,347.23 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $9,308.92 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $7,069.09 |
| AMI discharged alive w MCC | MS-DRG 280 | $18,634 |
| AMI discharged alive w CC | MS-DRG 281 | $10,465 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $8,231.55 |
| Heart failure & shock w MCC | MS-DRG 291 | $14,812 |
| Heart failure & shock w CC | MS-DRG 292 | $9,776.60 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $6,229.01 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $13,690 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $8,392.76 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $6,351.61 |
| GI hemorrhage w CC | MS-DRG 378 | $11,192 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $7,228.02 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $8,858.22 |
| Fractures of femur w/o MCC | MS-DRG 533 | $17,311 |
| Kidney/UTI w MCC | MS-DRG 689 | $13,286 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $9,111.38 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $22,274 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $11,704 |
| Initial hospital care, low complexity | CPT 99221 | $102.54 |
| Initial hospital care, moderate complexity | CPT 99222 | $155.33 |
| Initial hospital care, high complexity | CPT 99223 | $210.80 |
| Hospital discharge, <30 min | CPT 99238 | $97.19 |
| Hospital discharge, >30 min | CPT 99239 | $137.55 |
| Basic metabolic panel (BMP) | CPT 80048 | $68.12 |
| General health panel | CPT 80050 | $249.60 |
| Electrolyte panel | CPT 80051 | $31.14 |
| Comprehensive metabolic panel | CPT 80053 | $79.80 |
| Lipid panel | CPT 80061 | $66.82 |
| Renal function panel | CPT 80069 | $121.32 |
| Hepatic function panel | CPT 80076 | $75.91 |
| Urinalysis non-automated | CPT 81002 | $4.00 |
| Urinalysis automated | CPT 81003 | $24.66 |
| Glucose quantitative | CPT 82947 | $19.47 |
| Hemoglobin A1c | CPT 83036 | $8.35 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $84.34 |
| Complete blood count with automated differential | CPT 85025 | $34.39 |
| Complete blood count without differential | CPT 85027 | $32.44 |
| Urine culture bacterial | CPT 87086 | $59.69 |
| Urine culture identification | CPT 87088 | $48.01 |
| Tissue exam by pathologist level IV | CPT 88305 | $72.54 |
| Fetal non-stress test | CPT 59025 | $47.37 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $2,521.71 |
| Vaginal delivery only | CPT 59409 | — |
| Vaginal delivery with postpartum | CPT 59410 | $1,114.53 |
| Routine obstetric care with C-section | CPT 59510 | $2,781.28 |
| C-section delivery only | CPT 59514 | $1,055.43 |
| C-section with postpartum | CPT 59515 | $1,373.69 |
| Office visit, new patient, 15-29 min | CPT 99202 | $68.52 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $106.70 |
| Office visit, new patient, 45-59 min | CPT 99204 | $167.10 |
| Office visit, new patient, 60-74 min | CPT 99205 | $223.89 |
| Office visit, established patient, 5 min | CPT 99211 | $22.37 |
| Office visit, established patient, 10-19 min | CPT 99212 | $54.00 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $87.09 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $125.11 |
| Office visit, established patient, 40-54 min | CPT 99215 | $180.55 |
| Upper GI endoscopy diagnostic | CPT 43235 | $270.63 |
| Upper GI endoscopy with biopsy | CPT 43239 | $350.69 |
| Sigmoidoscopy diagnostic | CPT 45330 | — |
| Sigmoidoscopy with biopsy | CPT 45331 | — |
| Colonoscopy diagnostic | CPT 45378 | $319.51 |
| Colonoscopy with biopsy | CPT 45380 | $405.36 |
| Colonoscopy with polyp removal | CPT 45385 | $424.77 |
| Total shoulder arthroplasty | CPT 23472 | $1,544.75 |
| Hip hemiarthroplasty | CPT 27125 | $1,215.65 |
| Total hip replacement | CPT 27130 | $1,372.61 |
| Total knee replacement | CPT 27447 | $1,370.94 |
| Knee revision arthroplasty single component | CPT 27486 | $1,503.08 |
| Knee revision arthroplasty all components | CPT 27487 | $1,867.24 |
| Shoulder arthroscopy with decompression | CPT 29826 | $219.84 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $1,149.90 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $591.92 |
| ACL reconstruction | CPT 29888 | $1,048.86 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $52,129 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $26,833 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $18,743 |
| CABG single arterial graft | CPT 33533 | $1,910.13 |
| CABG 2 arterial grafts | CPT 33534 | $2,242.93 |
| CABG 3 arterial grafts | CPT 33535 | $2,491.59 |
| CABG 4+ arterial grafts | CPT 33536 | $2,682.57 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $18,827 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $14,958 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $40,068 |
| Open appendectomy | CPT 44950 | $674.68 |
| Laparoscopic appendectomy | CPT 44970 | $637.24 |
| Major joint replacement w MCC | MS-DRG 469 | $37,107 |
| Major joint replacement w/o MCC | MS-DRG 470 | $21,405 |
| Laparoscopic cholecystectomy | CPT 47562 | $697.41 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $757.54 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $33,387 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $23,555 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $18,009 |
| Lap inguinal hernia repair | CPT 49650 | $461.89 |
| Total abdominal hysterectomy | CPT 58150 | $1,087.27 |
| Vaginal hysterectomy | CPT 58260 | $4,974.95 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $942.31 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $1,047.19 |
| Lap salpingo-oophorectomy | CPT 58661 | $695.04 |
| OR procedure for obesity w MCC | MS-DRG 619 | $27,823 |
| OR procedure for obesity w CC | MS-DRG 620 | $17,643 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $16,595 |
| Complex cataract surgery | CPT 66982 | $804.68 |
| Cataract surgery with lens implant | CPT 66984 | $588.01 |
| Intravitreal injection | CPT 67028 | $121.09 |
| Vitrectomy mechanical | CPT 67042 | $4,054.24 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $13,608 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $22,182 |
| PCI single major coronary artery | CPT 92920 | $535.51 |
| PCI with drug-eluting stent | CPT 92928 | $595.26 |
| PCI bypass graft | CPT 92937 | $594.89 |
| Left heart catheterization | CPT 93452 | $806.30 |
| Coronary angiography with cath | CPT 93455 | $911.88 |
| Coronary angiography with bypass cath | CPT 93458 | $940.74 |
