| Psychoses | MS-DRG 885 | $15,808 |
| Psychiatric diagnostic evaluation | CPT 90791 | $326.11 |
| Psychiatric eval with medical services | CPT 90792 | $179.32 |
| Psychotherapy 30 minutes | CPT 90832 | $154.12 |
| Psychotherapy 45 minutes | CPT 90834 | $154.12 |
| Psychotherapy 60 minutes | CPT 90837 | $154.12 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $154.12 |
| ED visit level 1 | CPT 99281 | $59.75 |
| ED visit level 2 | CPT 99282 | $116.89 |
| ED visit level 3 | CPT 99283 | $78.56 |
| ED visit level 4 | CPT 99284 | $133.66 |
| ED visit level 5 | CPT 99285 | $193.60 |
| Critical care, first hour | CPT 99291 | $491.79 |
| CT head without contrast | CPT 70450 | $92.28 |
| CT head with contrast | CPT 70460 | $128.37 |
| CT head with and without contrast | CPT 70470 | $150.00 |
| CT neck with contrast | CPT 70491 | $159.14 |
| MRI brain without contrast | CPT 70551 | $2,940.11 |
| MRI brain with contrast | CPT 70552 | $4,921.74 |
| MRI brain with and without contrast | CPT 70553 | $4,921.74 |
| Chest X-ray single view | CPT 71045 | $473.67 |
| Chest X-ray 2 views | CPT 71046 | $458.17 |
| Chest X-ray 3 views | CPT 71047 | $473.67 |
| CT chest without contrast | CPT 71250 | $112.88 |
| CT chest with contrast | CPT 71260 | $144.45 |
| CT chest with and without contrast | CPT 71270 | $163.09 |
| MRI chest without contrast | CPT 71550 | $253.43 |
| MRI chest with contrast | CPT 71551 | $314.98 |
| MRI chest with and without contrast | CPT 71552 | $374.27 |
| Lumbosacral spine X-ray | CPT 72100 | $825.89 |
| CT cervical spine without contrast | CPT 72125 | $1,497.52 |
| CT thoracic spine without contrast | CPT 72128 | $1,497.52 |
| CT lumbar spine without contrast | CPT 72131 | $1,497.52 |
| MRI cervical spine without contrast | CPT 72141 | $2,940.11 |
| MRI thoracic spine without contrast | CPT 72146 | $1,187.90 |
| MRI lumbar spine without contrast | CPT 72148 | $3,039.57 |
| MRI lumbar spine with and without contrast | CPT 72149 | $4,921.74 |
| MRI cervical spine with and without contrast | CPT 72156 | $4,921.74 |
| MRI lumbar spine with contrast | CPT 72158 | $4,921.74 |
| CT pelvis without contrast | CPT 72192 | $112.66 |
| CT pelvis with contrast | CPT 72193 | $179.11 |
| Shoulder X-ray | CPT 73030 | $244.19 |
| Humerus X-ray | CPT 73060 | $458.17 |
| Hand X-ray 3 views | CPT 73130 | $473.67 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,363.54 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $4,921.74 |
| Knee X-ray 1-2 views | CPT 73560 | $458.17 |
| Ankle X-ray 3 views | CPT 73610 | $458.17 |
| MRI lower extremity joint without contrast | CPT 73721 | $3,039.57 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $4,921.74 |
| CT abdomen without contrast | CPT 74150 | $1,548.18 |
| CT abdomen with contrast | CPT 74160 | $1,677.21 |
| CT abdomen with and without contrast | CPT 74170 | $2,685.74 |
| CT abdomen and pelvis without contrast | CPT 74176 | $3,173.31 |
| CT abdomen and pelvis with contrast | CPT 74177 | $5,137.38 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $5,311.17 |
| MRI abdomen without contrast | CPT 74181 | $169.02 |
| MRI abdomen with and without contrast | CPT 74183 | $4,921.74 |
| Abdominal ultrasound complete | CPT 76700 | $95.65 |
| Abdominal ultrasound limited | CPT 76705 | $543.47 |
| Retroperitoneal ultrasound complete | CPT 76770 | $812.92 |
| Obstetric ultrasound first trimester | CPT 76801 | $66.41 |
| Obstetric ultrasound after first trimester | CPT 76805 | $816.14 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $170.23 |
| Transvaginal ultrasound | CPT 76830 | $543.47 |
| Pelvic ultrasound complete | CPT 76856 | $251.33 |
| Scrotal ultrasound | CPT 76870 | $812.92 |
| Diagnostic mammography unilateral | CPT 77065 | $482.67 |
| Diagnostic mammography bilateral | CPT 77066 | $593.19 |
| Screening mammography bilateral | CPT 77067 | $97.70 |
| EKG complete | CPT 93000 | $11.99 |
| EKG tracing only | CPT 93005 | $204.84 |
| EKG interpretation only | CPT 93010 | $6.67 |
| Transthoracic echocardiogram complete | CPT 93306 | $649.57 |
| Transthoracic echocardiogram | CPT 93307 | $129.53 |
| Stress echocardiogram | CPT 93350 | $133.80 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $22,225 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $11,461 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $7,822.39 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $18,099 |
| COPD w MCC | MS-DRG 190 | $12,635 |
| COPD w CC | MS-DRG 191 | $9,713.41 |
| COPD w/o CC/MCC | MS-DRG 192 | $7,367.35 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $9,280.53 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $7,096.09 |
| AMI discharged alive w MCC | MS-DRG 280 | $18,375 |
| AMI discharged alive w CC | MS-DRG 281 | $10,408 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $8,229.82 |
| Heart failure & shock w MCC | MS-DRG 291 | $14,648 |
| Heart failure & shock w CC | MS-DRG 292 | $9,736.67 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $6,276.79 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $13,553 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $8,387.04 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $6,396.38 |
| GI hemorrhage w CC | MS-DRG 378 | $11,117 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $7,251.09 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $8,840.99 |
| Fractures of femur w/o MCC | MS-DRG 533 | $17,085 |
| Kidney/UTI w MCC | MS-DRG 689 | $13,159 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $9,087.87 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $21,925 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $11,617 |
| Initial hospital care, low complexity | CPT 99221 | $91.59 |
| Initial hospital care, moderate complexity | CPT 99222 | $144.45 |
| Initial hospital care, high complexity | CPT 99223 | $191.36 |
| Hospital discharge, <30 min | CPT 99238 | $173.15 |
| Hospital discharge, >30 min | CPT 99239 | $126.58 |
| Basic metabolic panel (BMP) | CPT 80048 | $9.31 |
| General health panel | CPT 80050 | $61.35 |
| Electrolyte panel | CPT 80051 | $78.70 |
| Comprehensive metabolic panel | CPT 80053 | $11.62 |
| Lipid panel | CPT 80061 | $171.63 |
| Renal function panel | CPT 80069 | $8.90 |
| Hepatic function panel | CPT 80076 | $54.72 |
| Urinalysis non-automated | CPT 81002 | $7.61 |
| Urinalysis automated | CPT 81003 | $17.86 |
| Glucose quantitative | CPT 82947 | $46.31 |
| Hemoglobin A1c | CPT 83036 | $14.08 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $193.95 |
| Complete blood count with automated differential | CPT 85025 | $8.55 |
| Complete blood count without differential | CPT 85027 | $9.38 |
| Urine culture bacterial | CPT 87086 | $9.42 |
| Urine culture identification | CPT 87088 | $8.58 |
| Tissue exam by pathologist level IV | CPT 88305 | $49.40 |
| Fetal non-stress test | CPT 59025 | $110.75 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $2,544.17 |
| Vaginal delivery only | CPT 59409 | $1,187.96 |
| Vaginal delivery with postpartum | CPT 59410 | $1,037.00 |
| Routine obstetric care with C-section | CPT 59510 | $2,587.80 |
| C-section delivery only | CPT 59514 | $1,126.52 |
| C-section with postpartum | CPT 59515 | $1,454.65 |
| Office visit, new patient, 15-29 min | CPT 99202 | $171.84 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $90.84 |
| Office visit, new patient, 45-59 min | CPT 99204 | $147.80 |
| Office visit, new patient, 60-74 min | CPT 99205 | $201.04 |
| Office visit, established patient, 5 min | CPT 99211 | $10.61 |
| Office visit, established patient, 10-19 min | CPT 99212 | $149.64 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $155.39 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $342.04 |
| Office visit, established patient, 40-54 min | CPT 99215 | $123.62 |
| Upper GI endoscopy diagnostic | CPT 43235 | $219.85 |
| Upper GI endoscopy with biopsy | CPT 43239 | $899.36 |
| Sigmoidoscopy diagnostic | CPT 45330 | $105.78 |
| Sigmoidoscopy with biopsy | CPT 45331 | $874.57 |
| Colonoscopy diagnostic | CPT 45378 | $822.23 |
| Colonoscopy with biopsy | CPT 45380 | $431.27 |
| Colonoscopy with polyp removal | CPT 45385 | $545.65 |
| Total shoulder arthroplasty | CPT 23472 | $17,641 |
| Hip hemiarthroplasty | CPT 27125 | $1,479.93 |
| Total hip replacement | CPT 27130 | $12,343 |
| Total knee replacement | CPT 27447 | $12,343 |
| Knee revision arthroplasty single component | CPT 27486 | $1,668.75 |
| Knee revision arthroplasty all components | CPT 27487 | $2,273.17 |
| Shoulder arthroscopy with decompression | CPT 29826 | $219.84 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $6,852.69 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $923.53 |
| ACL reconstruction | CPT 29888 | $6,852.69 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $51,041 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $26,372 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $18,481 |
| CABG single arterial graft | CPT 33533 | $1,744.03 |
| CABG 2 arterial grafts | CPT 33534 | $2,047.89 |
| CABG 3 arterial grafts | CPT 33535 | $2,274.93 |
| CABG 4+ arterial grafts | CPT 33536 | $2,449.30 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $18,563 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $14,790 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $39,279 |
| Open appendectomy | CPT 44950 | $847.78 |
| Laparoscopic appendectomy | CPT 44970 | $764.17 |
| Major joint replacement w MCC | MS-DRG 469 | $36,392 |
| Major joint replacement w/o MCC | MS-DRG 470 | $21,077 |
| Laparoscopic cholecystectomy | CPT 47562 | $951.76 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $1,020.50 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $32,763 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $23,174 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $17,766 |
| Open umbilical hernia repair | CPT 49560 | $1,535.85 |
| Umbilical hernia repair age 5+ | CPT 49585 | $936.49 |
| Lap inguinal hernia repair | CPT 49650 | $5,596.67 |
| Total abdominal hysterectomy | CPT 58150 | $1,323.63 |
| Vaginal hysterectomy | CPT 58260 | $1,175.17 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $1,429.31 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $1,356.83 |
| Lap salpingo-oophorectomy | CPT 58661 | $920.97 |
| OR procedure for obesity w MCC | MS-DRG 619 | $30,388 |
| OR procedure for obesity w CC | MS-DRG 620 | $17,883 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $16,386 |
| Complex cataract surgery | CPT 66982 | $1,763.00 |
| Cataract surgery with lens implant | CPT 66984 | $1,478.78 |
| Intravitreal injection | CPT 67028 | $256.40 |
| Vitrectomy mechanical | CPT 67042 | $2,652.27 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $13,473 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $21,836 |
| PCI single major coronary artery | CPT 92920 | $1,085.02 |
| PCI with drug-eluting stent | CPT 92928 | $1,205.84 |
| PCI bypass graft | CPT 92937 | $1,204.19 |
| Left heart catheterization | CPT 93452 | $811.85 |
| Coronary angiography with cath | CPT 93455 | $911.88 |
| Coronary angiography with bypass cath | CPT 93458 | $940.74 |
