| Psychoses | MS-DRG 885 | $17,623 |
| Psychiatric diagnostic evaluation | CPT 90791 | — |
| Psychiatric eval with medical services | CPT 90792 | — |
| Psychotherapy 30 minutes | CPT 90832 | — |
| Psychotherapy 45 minutes | CPT 90834 | — |
| Psychotherapy 60 minutes | CPT 90837 | — |
| Crisis psychotherapy 60 minutes | CPT 90839 | — |
| ED visit level 1 | CPT 99281 | $12.59 |
| 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 | $257.96 |
| CT head without contrast | CPT 70450 | $1,030.15 |
| CT head with contrast | CPT 70460 | $1,256.75 |
| CT head with and without contrast | CPT 70470 | $1,538.35 |
| CT neck with contrast | CPT 70491 | $1,203.4 |
| MRI brain without contrast | CPT 70551 | $2,033.35 |
| MRI brain with contrast | CPT 70552 | $1,466.3 |
| MRI brain with and without contrast | CPT 70553 | $2,753.85 |
| Chest X-ray single view | CPT 71045 | $215.05 |
| Chest X-ray 2 views | CPT 71046 | $276.65 |
| Chest X-ray 3 views | CPT 71047 | $239.25 |
| CT chest without contrast | CPT 71250 | $1,309.55 |
| CT chest with contrast | CPT 71260 | $1,527.9 |
| CT chest with and without contrast | CPT 71270 | $1,082.95 |
| MRI chest without contrast | CPT 71550 | $1,305.15 |
| MRI chest with and without contrast | CPT 71552 | $3,070.65 |
| Lumbosacral spine X-ray | CPT 72100 | $346.5 |
| CT cervical spine without contrast | CPT 72125 | $1,311.75 |
| CT thoracic spine without contrast | CPT 72128 | $760.1 |
| CT lumbar spine without contrast | CPT 72131 | $1,308.45 |
| MRI cervical spine without contrast | CPT 72141 | $1,826.55 |
| MRI thoracic spine without contrast | CPT 72146 | $2,000.9 |
| MRI lumbar spine without contrast | CPT 72148 | $1,998.15 |
| MRI lumbar spine with and without contrast | CPT 72149 | $1,375.55 |
| MRI cervical spine with and without contrast | CPT 72156 | $2,660.9 |
| MRI lumbar spine with contrast | CPT 72158 | $2,583.35 |
| CT pelvis without contrast | CPT 72192 | $1,283.15 |
| CT pelvis with contrast | CPT 72193 | $1,461.9 |
| Shoulder X-ray | CPT 73030 | $259.05 |
| Humerus X-ray | CPT 73060 | $249.7 |
| Hand X-ray 3 views | CPT 73130 | $235.95 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,760.55 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $2,434.3 |
| Knee X-ray 1-2 views | CPT 73560 | $249.7 |
| Ankle X-ray 3 views | CPT 73610 | $254.1 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,908.5 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $2,563 |
| CT abdomen without contrast | CPT 74150 | $1,272.7 |
| CT abdomen with contrast | CPT 74160 | $1,496 |
| CT abdomen with and without contrast | CPT 74170 | $1,730.85 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,712.15 |
| CT abdomen and pelvis with contrast | CPT 74177 | $1,935.45 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $2,051.5 |
| MRI abdomen without contrast | CPT 74181 | $1,491.6 |
| MRI abdomen with and without contrast | CPT 74183 | $2,014.1 |
| Abdominal ultrasound complete | CPT 76700 | $370.7 |
| Abdominal ultrasound limited | CPT 76705 | $272.8 |
| Retroperitoneal ultrasound complete | CPT 76770 | $371.25 |
| Obstetric ultrasound first trimester | CPT 76801 | $277.75 |
| Obstetric ultrasound after first trimester | CPT 76805 | $286 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $644.05 |
| Transvaginal ultrasound | CPT 76830 | $370.7 |
| Pelvic ultrasound complete | CPT 76856 | $371.8 |
| Scrotal ultrasound | CPT 76870 | $372.35 |
| Diagnostic mammography unilateral | CPT 77065 | $416.29 |
| Diagnostic mammography bilateral | CPT 77066 | $502.08 |
| Screening mammography bilateral | CPT 77067 | $433.58 |
| EKG complete | CPT 93000 | — |
| EKG tracing only | CPT 93005 | — |
| EKG interpretation only | CPT 93010 | $8.81 |
| Transthoracic echocardiogram complete | CPT 93306 | $74.55 |
| Stress echocardiogram | CPT 93350 | $74.55 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $24,869 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $12,713 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $8,605.13 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $20,209 |
| COPD w MCC | MS-DRG 190 | $14,040 |
| COPD w CC | MS-DRG 191 | $10,740 |
| COPD w/o CC/MCC | MS-DRG 192 | $8,091.29 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $10,252 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $7,785 |
| AMI discharged alive w MCC | MS-DRG 280 | $20,521 |
| AMI discharged alive w CC | MS-DRG 281 | $11,524 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $9,065.2 |
| Heart failure & shock w MCC | MS-DRG 291 | $16,313 |
| Heart failure & shock w CC | MS-DRG 292 | $10,767 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $6,859.85 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $15,076 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $9,242.73 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $6,994.87 |
| GI hemorrhage w CC | MS-DRG 378 | $12,326 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $7,960.02 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $9,755.31 |
| Fractures of femur w/o MCC | MS-DRG 533 | $19,064 |
| Kidney/UTI w MCC | MS-DRG 689 | $14,631 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $10,034 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $24,530 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $12,890 |
| Initial hospital care, low complexity | CPT 99221 | $91.09 |
| Initial hospital care, moderate complexity | CPT 99222 | $143.68 |
| Initial hospital care, high complexity | CPT 99223 | $191.45 |
| Hospital discharge, <30 min | CPT 99238 | $87.66 |
| Hospital discharge, >30 min | CPT 99239 | $124.06 |
| Basic metabolic panel (BMP) | CPT 80048 | $66 |
| General health panel | CPT 80050 | $311.22 |
| Electrolyte panel | CPT 80051 | $63.8 |
| Comprehensive metabolic panel | CPT 80053 | $100.1 |
| Lipid panel | CPT 80061 | $75.35 |
| Renal function panel | CPT 80069 | $86.35 |
| Hepatic function panel | CPT 80076 | $55.55 |
| Urinalysis non-automated | CPT 81002 | — |
| Urinalysis automated | CPT 81003 | $19.8 |
| Glucose quantitative | CPT 82947 | $22.55 |
| Hemoglobin A1c | CPT 83036 | $70.4 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $104.5 |
| Complete blood count with automated differential | CPT 85025 | $53.35 |
| Complete blood count without differential | CPT 85027 | $37.4 |
| Urine culture bacterial | CPT 87086 | $35.75 |
| Urine culture identification | CPT 87088 | $41.25 |
| Tissue exam by pathologist level IV | CPT 88305 | $134.75 |
| Fetal non-stress test | CPT 59025 | $30.66 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $2,236.65 |
| Vaginal delivery only | CPT 59409 | $833.97 |
| Vaginal delivery with postpartum | CPT 59410 | $1,065.98 |
| Routine obstetric care with C-section | CPT 59510 | $2,464.45 |
| C-section delivery only | CPT 59514 | $828.53 |
| C-section with postpartum | CPT 59515 | $1,292.16 |
| Office visit, new patient, 15-29 min | CPT 99202 | $67.35 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $104.96 |
| Office visit, new patient, 45-59 min | CPT 99204 | $159.11 |
| Office visit, new patient, 60-74 min | CPT 99205 | $209.81 |
| Office visit, established patient, 5 min | CPT 99211 | $29.7 |
| Office visit, established patient, 10-19 min | CPT 99212 | $52.99 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $85.86 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $120.91 |
| Office visit, established patient, 40-54 min | CPT 99215 | $171.82 |
| Upper GI endoscopy diagnostic | CPT 43235 | $243.58 |
| Upper GI endoscopy with biopsy | CPT 43239 | $199.85 |
| Sigmoidoscopy diagnostic | CPT 45330 | $116.05 |
| Sigmoidoscopy with biopsy | CPT 45331 | $105.01 |
| Colonoscopy diagnostic | CPT 45378 | $313.32 |
| Colonoscopy with biopsy | CPT 45380 | $375.65 |
| Colonoscopy with polyp removal | CPT 45385 | $416.79 |
| Total shoulder arthroplasty | CPT 23472 | $1,348.72 |
| Hip hemiarthroplasty | CPT 27125 | $1,060 |
| Total hip replacement | CPT 27130 | $1,199.35 |
| Total knee replacement | CPT 27447 | $1,197.89 |
| Knee revision arthroplasty single component | CPT 27486 | $1,312.34 |
| Knee revision arthroplasty all components | CPT 27487 | $1,632.91 |
| Shoulder arthroscopy with decompression | CPT 29826 | $158.9 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $1,001.18 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $514.72 |
| ACL reconstruction | CPT 29888 | $913.05 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $57,408 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $29,551 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $20,641 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $20,733 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $16,473 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $44,126 |
| Open appendectomy | CPT 44950 | $674.68 |
| Laparoscopic appendectomy | CPT 44970 | $637.24 |
| Major joint replacement w MCC | MS-DRG 469 | $40,865 |
| Major joint replacement w/o MCC | MS-DRG 470 | $23,573 |
| Laparoscopic cholecystectomy | CPT 47562 | $614.66 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $757.54 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $36,768 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $25,940 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $19,833 |
| Lap inguinal hernia repair | CPT 49650 | $461.89 |
| Total abdominal hysterectomy | CPT 58150 | $950.59 |
| Vaginal hysterectomy | CPT 58260 | $4,689.63 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $823.9 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $915.95 |
| Lap salpingo-oophorectomy | CPT 58661 | $608.51 |
| OR procedure for obesity w MCC | MS-DRG 619 | $34,087 |
| OR procedure for obesity w CC | MS-DRG 620 | $19,966 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $18,275 |
| Complex cataract surgery | CPT 66982 | $2,349.6 |
| Cataract surgery with lens implant | CPT 66984 | $2,166.69 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $14,986 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $24,429 |
| Coronary angiography with bypass cath | CPT 93458 | — |
