| Psychoses | MS-DRG 885 | $9,371.76 |
| Psychiatric diagnostic evaluation | CPT 90791 | $162.18 |
| Psychiatric eval with medical services | CPT 90792 | $162.18 |
| Psychotherapy 30 minutes | CPT 90832 | $162.18 |
| Psychotherapy 45 minutes | CPT 90834 | $162.18 |
| Psychotherapy 60 minutes | CPT 90837 | $162.18 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $162.18 |
| ED visit level 1 | CPT 99281 | $48.97 |
| ED visit level 2 | CPT 99282 | $94.47 |
| ED visit level 3 | CPT 99283 | $141.68 |
| ED visit level 4 | CPT 99284 | $125.71 |
| ED visit level 5 | CPT 99285 | $375.41 |
| Critical care, first hour | CPT 99291 | $222.55 |
| CT head without contrast | CPT 70450 | $103.84 |
| CT head with contrast | CPT 70460 | $138.26 |
| CT head with and without contrast | CPT 70470 | $155.32 |
| CT neck with contrast | CPT 70491 | $169.41 |
| MRI brain without contrast | CPT 70551 | $244 |
| MRI brain with contrast | CPT 70552 | $360.5 |
| MRI brain with and without contrast | CPT 70553 | $360.5 |
| Chest X-ray single view | CPT 71045 | $88.88 |
| Chest X-ray 2 views | CPT 71046 | $88.88 |
| Chest X-ray 3 views | CPT 71047 | $88.88 |
| CT chest without contrast | CPT 71250 | $141.78 |
| CT chest with contrast | CPT 71260 | $152.64 |
| CT chest with and without contrast | CPT 71270 | $168.57 |
| MRI chest without contrast | CPT 71550 | $244 |
| MRI chest with contrast | CPT 71551 | $797.51 |
| MRI chest with and without contrast | CPT 71552 | $360.5 |
| Lumbosacral spine X-ray | CPT 72100 | $107.34 |
| CT cervical spine without contrast | CPT 72125 | $122.37 |
| CT thoracic spine without contrast | CPT 72128 | $122.37 |
| CT lumbar spine without contrast | CPT 72131 | $122.36 |
| MRI cervical spine without contrast | CPT 72141 | $244 |
| MRI thoracic spine without contrast | CPT 72146 | $244 |
| MRI lumbar spine without contrast | CPT 72148 | $244 |
| MRI lumbar spine with and without contrast | CPT 72149 | $360.5 |
| MRI cervical spine with and without contrast | CPT 72156 | $360.5 |
| MRI lumbar spine with contrast | CPT 72158 | $360.5 |
| CT pelvis without contrast | CPT 72192 | $132.98 |
| CT pelvis with contrast | CPT 72193 | $141.78 |
| Shoulder X-ray | CPT 73030 | $88.88 |
| Humerus X-ray | CPT 73060 | $88.88 |
| Hand X-ray 3 views | CPT 73130 | $88.88 |
| MRI upper extremity joint without contrast | CPT 73221 | $244 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $360.5 |
| Hip X-ray 2 views | CPT 73510 | $68.72 |
| Knee X-ray 1-2 views | CPT 73560 | $88.88 |
| Ankle X-ray 3 views | CPT 73610 | $88.88 |
| MRI lower extremity joint without contrast | CPT 73721 | $244 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $360.5 |
| CT abdomen without contrast | CPT 74150 | $145.6 |
| CT abdomen with contrast | CPT 74160 | $156.17 |
| CT abdomen with and without contrast | CPT 74170 | $170.92 |
| CT abdomen and pelvis without contrast | CPT 74176 | $212.68 |
| CT abdomen and pelvis with contrast | CPT 74177 | $223.25 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $245.35 |
| MRI abdomen without contrast | CPT 74181 | $244 |
| MRI abdomen with and without contrast | CPT 74183 | $360.5 |
| Abdominal ultrasound complete | CPT 76700 | $107.34 |
| Abdominal ultrasound limited | CPT 76705 | $71.5 |
| Retroperitoneal ultrasound complete | CPT 76770 | $107.34 |
| Obstetric ultrasound first trimester | CPT 76801 | $143.12 |
| Obstetric ultrasound after first trimester | CPT 76805 | $143.12 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $232.38 |
| Transvaginal ultrasound | CPT 76830 | $143.12 |
| Pelvic ultrasound complete | CPT 76856 | $107.34 |
| Scrotal ultrasound | CPT 76870 | $107.34 |
| Diagnostic mammography unilateral | CPT 77065 | $99.42 |
| Diagnostic mammography bilateral | CPT 77066 | $122.36 |
| Screening mammography bilateral | CPT 77067 | $89.82 |
| EKG complete | CPT 93000 | $15.15 |
| EKG tracing only | CPT 93005 | $6.55 |
| EKG interpretation only | CPT 93010 | $8.6 |
| Transthoracic echocardiogram complete | CPT 93306 | $553.47 |
| Transthoracic echocardiogram | CPT 93307 | $244 |
| Stress echocardiogram | CPT 93350 | $553.47 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $14,293 |
| COPD w MCC | MS-DRG 190 | $10,131 |
| COPD w CC | MS-DRG 191 | $7,710.21 |
| COPD w/o CC/MCC | MS-DRG 192 | $5,871.84 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $7,370.89 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $5,748.36 |
| AMI discharged alive w MCC | MS-DRG 280 | $14,671 |
| AMI discharged alive w CC | MS-DRG 281 | $8,406.23 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $6,613.59 |
| Heart failure & shock w MCC | MS-DRG 291 | $11,742 |
| Heart failure & shock w CC | MS-DRG 292 | $7,765.09 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $5,176.72 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $11,012 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $6,728.83 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $5,177.63 |
| GI hemorrhage w CC | MS-DRG 378 | $8,969.63 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $5,765.73 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $7,130.34 |
| Fractures of femur w/o MCC | MS-DRG 533 | $14,338 |
| Kidney/UTI w MCC | MS-DRG 689 | $10,612 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $7,403.82 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $17,766 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $9,359.27 |
| Initial hospital care, low complexity | CPT 99221 | $86.18 |
| Initial hospital care, moderate complexity | CPT 99222 | $137.23 |
| Initial hospital care, high complexity | CPT 99223 | $182.93 |
| Hospital discharge, <30 min | CPT 99238 | $85.82 |
| Hospital discharge, >30 min | CPT 99239 | $121.25 |
| Basic metabolic panel (BMP) | CPT 80048 | $8.88 |
| General health panel | CPT 80050 | $61.92 |
| Electrolyte panel | CPT 80051 | $9.85 |
| Comprehensive metabolic panel | CPT 80053 | $14.84 |
| Lipid panel | CPT 80061 | $18.75 |
| Renal function panel | CPT 80069 | $9.11 |
| Hepatic function panel | CPT 80076 | $10.01 |
| Urinalysis non-automated | CPT 81002 | $4.26 |
| Urinalysis automated | CPT 81003 | $2.36 |
| Glucose quantitative | CPT 82947 | $5.46 |
| Hemoglobin A1c | CPT 83036 | $13.59 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $23.35 |
| Complete blood count with automated differential | CPT 85025 | $10.72 |
| Complete blood count without differential | CPT 85027 | $8.93 |
| Urine culture bacterial | CPT 87086 | $9.89 |
| Urine culture identification | CPT 87088 | $9.91 |
| Tissue exam by pathologist level IV | CPT 88305 | $53.94 |
| Fetal non-stress test | CPT 59025 | $169.43 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $2,425.82 |
| Vaginal delivery only | CPT 59409 | $788.43 |
| Vaginal delivery with postpartum | CPT 59410 | $1,069.8 |
| Routine obstetric care with C-section | CPT 59510 | $2,670.36 |
| C-section delivery only | CPT 59514 | $885.84 |
| C-section with postpartum | CPT 59515 | $1,316.09 |
| Office visit, new patient, 15-29 min | CPT 99202 | $139.05 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $201.06 |
| Office visit, new patient, 45-59 min | CPT 99204 | $306.26 |
| Office visit, new patient, 60-74 min | CPT 99205 | $379.86 |
| Office visit, established patient, 5 min | CPT 99211 | $38.15 |
| Office visit, established patient, 10-19 min | CPT 99212 | $81.77 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $135.99 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $199.84 |
| Office visit, established patient, 40-54 min | CPT 99215 | $267.4 |
| Upper GI endoscopy diagnostic | CPT 43235 | $126.8 |
| Upper GI endoscopy with biopsy | CPT 43239 | $901.33 |
| Sigmoidoscopy diagnostic | CPT 45330 | $876.48 |
| Sigmoidoscopy with biopsy | CPT 45331 | $876.48 |
| Colonoscopy diagnostic | CPT 45378 | $876.48 |
| Colonoscopy with biopsy | CPT 45380 | $206.66 |
| Colonoscopy with polyp removal | CPT 45385 | $261.49 |
| Total shoulder arthroplasty | CPT 23472 | $1,482.79 |
| Hip hemiarthroplasty | CPT 27125 | $3,237.89 |
| Total hip replacement | CPT 27130 | $23,745 |
| Total knee replacement | CPT 27447 | $23,745 |
| Knee revision arthroplasty single component | CPT 27486 | $23,745 |
| Knee revision arthroplasty all components | CPT 27487 | $23,745 |
| Shoulder arthroscopy with decompression | CPT 29826 | $173.24 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $1,104.34 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $567.3 |
| ACL reconstruction | CPT 29888 | $1,007.95 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $42,040 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $21,925 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $15,392 |
| CABG single arterial graft | CPT 33533 | $1,830.61 |
| CABG 2 arterial grafts | CPT 33534 | $2,148.65 |
| CABG 3 arterial grafts | CPT 33535 | $2,387.66 |
| CABG 4+ arterial grafts | CPT 33536 | $2,572.45 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $15,472 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $12,492 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $31,162 |
| Open appendectomy | CPT 44950 | $645.4 |
| Laparoscopic appendectomy | CPT 44970 | $609.18 |
| Major joint replacement w MCC | MS-DRG 469 | $27,742 |
| Major joint replacement w/o MCC | MS-DRG 470 | $17,642 |
| Laparoscopic cholecystectomy | CPT 47562 | $665.89 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $723.39 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $26,636 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $19,157 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $14,917 |
| Open umbilical hernia repair | CPT 49560 | $3,304.47 |
| Umbilical hernia repair age 5+ | CPT 49585 | $1,999.87 |
| Lap inguinal hernia repair | CPT 49650 | $440.73 |
| Lap incisional hernia repair | CPT 49652 | $3,330.25 |
| Total abdominal hysterectomy | CPT 58150 | $1,052.32 |
| Vaginal hysterectomy | CPT 58260 | $870.4 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $913.99 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $1,015.01 |
| Lap salpingo-oophorectomy | CPT 58661 | $674.48 |
| OR procedure for obesity w MCC | MS-DRG 619 | $26,409 |
| OR procedure for obesity w CC | MS-DRG 620 | $14,637 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $13,796 |
| Complex cataract surgery | CPT 66982 | $786.85 |
| Cataract surgery with lens implant | CPT 66984 | $574.8 |
| Intravitreal injection | CPT 67028 | $318.87 |
| Vitrectomy mechanical | CPT 67042 | $1,202.61 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $11,348 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $14,056 |
| PCI single major coronary artery | CPT 92920 | $11,216 |
| PCI with drug-eluting stent | CPT 92928 | $1,184.36 |
| PCI bypass graft | CPT 92937 | $1,182.95 |
| Left heart catheterization | CPT 93452 | $1,818.57 |
| Coronary angiography with cath | CPT 93455 | $893.68 |
| Coronary angiography with bypass cath | CPT 93458 | $2,230.46 |
