| Psychoses | MS-DRG 885 | $13,624 |
| Psychiatric diagnostic evaluation | CPT 90791 | $170.94 |
| Psychiatric eval with medical services | CPT 90792 | $187.96 |
| Psychotherapy 30 minutes | CPT 90832 | $100.8 |
| Psychotherapy 45 minutes | CPT 90834 | $134.1 |
| Psychotherapy 60 minutes | CPT 90837 | $176.96 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $198.05 |
| ED visit level 1 | CPT 99281 | $294.38 |
| ED visit level 2 | CPT 99282 | $412.46 |
| ED visit level 3 | CPT 99283 | $792.94 |
| ED visit level 4 | CPT 99284 | $1,193.69 |
| ED visit level 5 | CPT 99285 | $2,059 |
| Critical care, first hour | CPT 99291 | $3,126.5 |
| CT head without contrast | CPT 70450 | $1,064.2 |
| CT head with contrast | CPT 70460 | $1,527.45 |
| CT head with and without contrast | CPT 70470 | $1,870.85 |
| CT neck with contrast | CPT 70491 | $2,434.4 |
| MRI brain without contrast | CPT 70551 | $948.1 |
| MRI brain with contrast | CPT 70552 | $3,316.08 |
| MRI brain with and without contrast | CPT 70553 | $3,741.96 |
| Chest X-ray single view | CPT 71045 | $166.16 |
| Chest X-ray 2 views | CPT 71046 | $310.62 |
| Chest X-ray 3 views | CPT 71047 | $392.45 |
| CT chest without contrast | CPT 71250 | $2,070.6 |
| CT chest with contrast | CPT 71260 | $3,075.3 |
| CT chest with and without contrast | CPT 71270 | $3,757.55 |
| MRI chest without contrast | CPT 71550 | $4,871.5 |
| MRI chest with contrast | CPT 71551 | $6,715.99 |
| MRI chest with and without contrast | CPT 71552 | $8,076.4 |
| Lumbosacral spine X-ray | CPT 72100 | $365.73 |
| CT cervical spine without contrast | CPT 72125 | $1,641.35 |
| CT thoracic spine without contrast | CPT 72128 | $2,059.55 |
| CT lumbar spine without contrast | CPT 72131 | $2,059.55 |
| MRI cervical spine without contrast | CPT 72141 | $2,180.25 |
| MRI thoracic spine without contrast | CPT 72146 | $2,729.7 |
| MRI lumbar spine without contrast | CPT 72148 | $2,716.22 |
| MRI lumbar spine with and without contrast | CPT 72149 | $4,132.54 |
| MRI cervical spine with and without contrast | CPT 72156 | $3,760.16 |
| MRI lumbar spine with contrast | CPT 72158 | $4,739.92 |
| CT pelvis without contrast | CPT 72192 | $1,691.5 |
| CT pelvis with contrast | CPT 72193 | $169.69 |
| Shoulder X-ray | CPT 73030 | $296.43 |
| Humerus X-ray | CPT 73060 | $314.8 |
| Hand X-ray 3 views | CPT 73130 | $83.93 |
| MRI upper extremity joint without contrast | CPT 73221 | $3,048.17 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $6,453.67 |
| Knee X-ray 1-2 views | CPT 73560 | $347.36 |
| Ankle X-ray 3 views | CPT 73610 | $346.52 |
| MRI lower extremity joint without contrast | CPT 73721 | $3,053.22 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $6,477.67 |
| CT abdomen without contrast | CPT 74150 | $1,648.15 |
| CT abdomen with contrast | CPT 74160 | $3,094.85 |
| CT abdomen with and without contrast | CPT 74170 | $3,536.82 |
| CT abdomen and pelvis without contrast | CPT 74176 | $2,060.4 |
| CT abdomen and pelvis with contrast | CPT 74177 | $4,022.94 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $4,628.7 |
| MRI abdomen without contrast | CPT 74181 | $4,645.59 |
| MRI abdomen with and without contrast | CPT 74183 | $340.42 |
| Abdominal ultrasound complete | CPT 76700 | $1,234.63 |
| Abdominal ultrasound limited | CPT 76705 | $948.86 |
| Retroperitoneal ultrasound complete | CPT 76770 | $1,159.33 |
| Obstetric ultrasound first trimester | CPT 76801 | $1,110.51 |
| Obstetric ultrasound after first trimester | CPT 76805 | $1,386.89 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $1,287.22 |
| Transvaginal ultrasound | CPT 76830 | $679.15 |
| Pelvic ultrasound complete | CPT 76856 | $1,139.47 |
| Scrotal ultrasound | CPT 76870 | $550.8 |
| Diagnostic mammography unilateral | CPT 77065 | $840.74 |
| Diagnostic mammography bilateral | CPT 77066 | $1,074.1 |
| Screening mammography bilateral | CPT 77067 | $873.84 |
| EKG tracing only | CPT 93005 | $142.82 |
| Transthoracic echocardiogram complete | CPT 93306 | $2,628.14 |
| Transthoracic echocardiogram | CPT 93307 | $1,359.58 |
| Stress echocardiogram | CPT 93350 | $3,861.12 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $18,616 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $10,241 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $7,410.26 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $15,406 |
| COPD w MCC | MS-DRG 190 | $11,155 |
| COPD w CC | MS-DRG 191 | $8,881.57 |
| COPD w/o CC/MCC | MS-DRG 192 | $7,056.22 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $8,544.75 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $6,845.15 |
| AMI discharged alive w MCC | MS-DRG 280 | $15,620 |
| AMI discharged alive w CC | MS-DRG 281 | $9,421.68 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $7,727.27 |
| Heart failure & shock w MCC | MS-DRG 291 | $12,721 |
| Heart failure & shock w CC | MS-DRG 292 | $8,899.65 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $6,207.72 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $11,869 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $7,849.58 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $6,300.77 |
| GI hemorrhage w CC | MS-DRG 378 | $9,973.86 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $6,965.79 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $8,202.78 |
| Fractures of femur w/o MCC | MS-DRG 533 | $14,617 |
| Kidney/UTI w MCC | MS-DRG 689 | $11,562 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $8,394.86 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $18,383 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $10,362 |
| Basic metabolic panel (BMP) | CPT 80048 | $91.84 |
| General health panel | CPT 80050 | $511.4 |
| Electrolyte panel | CPT 80051 | $79.13 |
| Comprehensive metabolic panel | CPT 80053 | $114.36 |
| Lipid panel | CPT 80061 | $144.98 |
| Renal function panel | CPT 80069 | $98.19 |
| Hepatic function panel | CPT 80076 | $92.42 |
| Urinalysis non-automated | CPT 81002 | $32.35 |
| Urinalysis automated | CPT 81003 | $27.15 |
| Glucose quantitative | CPT 82947 | $35.81 |
| Hemoglobin A1c | CPT 83036 | $92.42 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $153.64 |
| Complete blood count with automated differential | CPT 85025 | $79.13 |
| Complete blood count without differential | CPT 85027 | $65.85 |
| Urine culture bacterial | CPT 87086 | $85.48 |
| Urine culture identification | CPT 87088 | $85.48 |
| Tissue exam by pathologist level IV | CPT 88305 | $350.03 |
| Fetal non-stress test | CPT 59025 | $149.78 |
| Office visit, new patient, 15-29 min | CPT 99202 | $64.88 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $89.31 |
| Office visit, new patient, 45-59 min | CPT 99204 | $518.5 |
| Office visit, new patient, 60-74 min | CPT 99205 | $171.87 |
| Office visit, established patient, 5 min | CPT 99211 | $21.07 |
| Office visit, established patient, 10-19 min | CPT 99212 | $38.76 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $55.61 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $84.25 |
| Office visit, established patient, 40-54 min | CPT 99215 | $128.9 |
| Upper GI endoscopy diagnostic | CPT 43235 | $893.68 |
| Upper GI endoscopy with biopsy | CPT 43239 | $893.68 |
| Sigmoidoscopy with biopsy | CPT 45331 | $869.04 |
| Colonoscopy diagnostic | CPT 45378 | $869.04 |
| Colonoscopy with biopsy | CPT 45380 | $1,123.9 |
| Colonoscopy with polyp removal | CPT 45385 | $1,123.9 |
| Total shoulder arthroplasty | CPT 23472 | $17,529 |
| Total hip replacement | CPT 27130 | $12,265 |
| Total knee replacement | CPT 27447 | $12,265 |
| Knee revision arthroplasty all components | CPT 27487 | $20,428 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $6,809.4 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $3,092.76 |
| ACL reconstruction | CPT 29888 | $6,809.4 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $41,037 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $21,843 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $15,703 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $15,767 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $12,831 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $31,885 |
| Laparoscopic appendectomy | CPT 44970 | $5,561.31 |
| Major joint replacement w MCC | MS-DRG 469 | $29,638 |
| Major joint replacement w/o MCC | MS-DRG 470 | $17,723 |
| Laparoscopic cholecystectomy | CPT 47562 | $5,561.31 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $5,561.31 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $26,815 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $19,355 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $15,147 |
| Lap inguinal hernia repair | CPT 49650 | $5,561.31 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $5,561.31 |
| Lap salpingo-oophorectomy | CPT 58661 | $5,561.31 |
| OR procedure for obesity w MCC | MS-DRG 619 | $24,968 |
| OR procedure for obesity w CC | MS-DRG 620 | $15,238 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $14,073 |
| Complex cataract surgery | CPT 66982 | $2,173.99 |
| Cataract surgery with lens implant | CPT 66984 | $2,173.99 |
| Intravitreal injection | CPT 67028 | $262.55 |
| Vitrectomy mechanical | CPT 67042 | $3,834.59 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $11,807 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $18,313 |
| Coronary angiography with bypass cath | CPT 93458 | $14,682 |
