| Psychoses | MS-DRG 885 | $3,791.85 |
| Psychiatric diagnostic evaluation | CPT 90791 | $167.54 |
| Psychiatric eval with medical services | CPT 90792 | $171.75 |
| Psychotherapy 30 minutes | CPT 90832 | $82.83 |
| Psychotherapy 45 minutes | CPT 90834 | $106.88 |
| Psychotherapy 60 minutes | CPT 90837 | $163.73 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $221.88 |
| ED visit level 1 | CPT 99281 | $129.79 |
| ED visit level 2 | CPT 99282 | $200.72 |
| ED visit level 3 | CPT 99283 | $315.12 |
| ED visit level 4 | CPT 99284 | $518.70 |
| ED visit level 5 | CPT 99285 | $810.26 |
| Critical care, first hour | CPT 99291 | $1,024.74 |
| CT head without contrast | CPT 70450 | $661.50 |
| CT head with contrast | CPT 70460 | $695.94 |
| CT head with and without contrast | CPT 70470 | $924.84 |
| CT neck with contrast | CPT 70491 | $924.42 |
| MRI brain without contrast | CPT 70551 | $1,449.42 |
| MRI brain with contrast | CPT 70552 | $1,434.30 |
| MRI brain with and without contrast | CPT 70553 | $1,562.40 |
| Chest X-ray single view | CPT 71045 | $174.74 |
| Chest X-ray 2 views | CPT 71046 | $183.94 |
| Chest X-ray 3 views | CPT 71047 | $123.68 |
| CT chest without contrast | CPT 71250 | $890.40 |
| CT chest with contrast | CPT 71260 | $628.74 |
| CT chest with and without contrast | CPT 71270 | $1,193.22 |
| MRI chest without contrast | CPT 71550 | $1,252.44 |
| MRI chest with and without contrast | CPT 71552 | $1,561.56 |
| Lumbosacral spine X-ray | CPT 72100 | $230.18 |
| CT cervical spine without contrast | CPT 72125 | $1,211.70 |
| CT thoracic spine without contrast | CPT 72128 | $890.40 |
| CT lumbar spine without contrast | CPT 72131 | $890.40 |
| MRI cervical spine without contrast | CPT 72141 | $1,214.22 |
| MRI thoracic spine without contrast | CPT 72146 | $1,103.76 |
| MRI lumbar spine without contrast | CPT 72148 | $1,345.26 |
| MRI lumbar spine with and without contrast | CPT 72149 | $1,416.66 |
| MRI cervical spine with and without contrast | CPT 72156 | $1,640.52 |
| MRI lumbar spine with contrast | CPT 72158 | $1,420.44 |
| CT pelvis without contrast | CPT 72192 | $682.08 |
| CT pelvis with contrast | CPT 72193 | $924.84 |
| Shoulder X-ray | CPT 73030 | $230.75 |
| Humerus X-ray | CPT 73060 | $174.95 |
| Hand X-ray 3 views | CPT 73130 | $147.92 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,254.12 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $1,524.18 |
| Knee X-ray 1-2 views | CPT 73560 | $151.03 |
| Ankle X-ray 3 views | CPT 73610 | $214.54 |
| MRI lower extremity joint without contrast | CPT 73721 | $1,620.36 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $1,631.28 |
| CT abdomen without contrast | CPT 74150 | $781.62 |
| CT abdomen with contrast | CPT 74160 | $1,192.38 |
| CT abdomen with and without contrast | CPT 74170 | $1,157.52 |
| CT abdomen and pelvis without contrast | CPT 74176 | $1,425.48 |
| CT abdomen and pelvis with contrast | CPT 74177 | $1,636.74 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $1,357.86 |
| MRI abdomen without contrast | CPT 74181 | $1,628.76 |
| MRI abdomen with and without contrast | CPT 74183 | $1,523.34 |
| Abdominal ultrasound complete | CPT 76700 | $294.92 |
| Abdominal ultrasound limited | CPT 76705 | $233.23 |
| Retroperitoneal ultrasound complete | CPT 76770 | $287.27 |
| Obstetric ultrasound first trimester | CPT 76801 | $90.24 |
| Obstetric ultrasound after first trimester | CPT 76805 | $310.80 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $145.59 |
| Transvaginal ultrasound | CPT 76830 | $217.54 |
| Pelvic ultrasound complete | CPT 76856 | $160.97 |
| Scrotal ultrasound | CPT 76870 | $247.30 |
| Diagnostic mammography unilateral | CPT 77065 | $246.12 |
| Screening mammography bilateral | CPT 77067 | $328.95 |
| EKG tracing only | CPT 93005 | $122.92 |
| EKG interpretation only | CPT 93010 | $9.63 |
| Transthoracic echocardiogram complete | CPT 93306 | $968.48 |
| Transthoracic echocardiogram | CPT 93307 | $538.98 |
| Stress echocardiogram | CPT 93350 | $719.70 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $3,791.85 |
| COPD w MCC | MS-DRG 190 | $3,791.85 |
| COPD w CC | MS-DRG 191 | $3,791.85 |
| COPD w/o CC/MCC | MS-DRG 192 | $3,791.85 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $3,791.85 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $3,791.85 |
| AMI discharged alive w MCC | MS-DRG 280 | $3,791.85 |
| AMI discharged alive w CC | MS-DRG 281 | $3,791.85 |
| Heart failure & shock w MCC | MS-DRG 291 | $3,791.85 |
| Heart failure & shock w CC | MS-DRG 292 | $3,791.85 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $3,791.85 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $3,791.85 |
| GI hemorrhage w CC | MS-DRG 378 | $3,791.85 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $3,791.85 |
| Kidney/UTI w MCC | MS-DRG 689 | $3,791.85 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $3,791.85 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $3,791.85 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $3,791.85 |
| Initial hospital care, low complexity | CPT 99221 | $85.76 |
| Initial hospital care, moderate complexity | CPT 99222 | $290.15 |
| Initial hospital care, high complexity | CPT 99223 | $401.78 |
| Hospital discharge, <30 min | CPT 99238 | $165.04 |
| Hospital discharge, >30 min | CPT 99239 | $242.60 |
| Basic metabolic panel (BMP) | CPT 80048 | $87.36 |
| General health panel | CPT 80050 | $185.74 |
| Electrolyte panel | CPT 80051 | $66.11 |
| Comprehensive metabolic panel | CPT 80053 | $144.48 |
| Lipid panel | CPT 80061 | $75.18 |
| Renal function panel | CPT 80069 | $60.36 |
| Hepatic function panel | CPT 80076 | $82.87 |
| Urinalysis non-automated | CPT 81002 | $15.77 |
| Urinalysis automated | CPT 81003 | $15.73 |
| Glucose quantitative | CPT 82947 | $20.16 |
| Hemoglobin A1c | CPT 83036 | $35.36 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $68.64 |
| Complete blood count with automated differential | CPT 85025 | $40.05 |
| Complete blood count without differential | CPT 85027 | $50.51 |
| Urine culture bacterial | CPT 87086 | $31.50 |
| Urine culture identification | CPT 87088 | $36.97 |
| Tissue exam by pathologist level IV | CPT 88305 | $110.17 |
| Fetal non-stress test | CPT 59025 | $418.90 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $5,020.48 |
| Vaginal delivery only | CPT 59409 | $2,224.32 |
| Vaginal delivery with postpartum | CPT 59410 | $2,283.33 |
| Routine obstetric care with C-section | CPT 59510 | $2,994.72 |
| C-section delivery only | CPT 59514 | $986.76 |
| C-section with postpartum | CPT 59515 | $1,468.41 |
| Office visit, new patient, 15-29 min | CPT 99202 | $102.47 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $131.50 |
| Office visit, new patient, 45-59 min | CPT 99204 | $178.05 |
| Office visit, new patient, 60-74 min | CPT 99205 | $230.26 |
| Office visit, established patient, 5 min | CPT 99211 | $32.02 |
| Office visit, established patient, 10-19 min | CPT 99212 | $150.14 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $221.68 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $182.31 |
| Office visit, established patient, 40-54 min | CPT 99215 | $228.55 |
| Upper GI endoscopy diagnostic | CPT 43235 | $143.36 |
| Upper GI endoscopy with biopsy | CPT 43239 | $1,090.60 |
| Sigmoidoscopy diagnostic | CPT 45330 | $160.95 |
| Sigmoidoscopy with biopsy | CPT 45331 | $1,278.43 |
| Colonoscopy diagnostic | CPT 45378 | $1,354.53 |
| Colonoscopy with biopsy | CPT 45380 | $1,628.52 |
| Colonoscopy with polyp removal | CPT 45385 | $1,463.33 |
| Total shoulder arthroplasty | CPT 23472 | $4,106.14 |
| Hip hemiarthroplasty | CPT 27125 | $2,768.87 |
| Total hip replacement | CPT 27130 | $3,828.18 |
| Total knee replacement | CPT 27447 | $3,826.32 |
| Knee revision arthroplasty single component | CPT 27486 | $3,969.64 |
| Knee revision arthroplasty all components | CPT 27487 | $4,967.33 |
| Shoulder arthroscopy with decompression | CPT 29826 | $268.37 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $2,582.22 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $1,524.45 |
| ACL reconstruction | CPT 29888 | $2,775.28 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $3,791.85 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $3,791.85 |
| Open appendectomy | CPT 44950 | $1,675.22 |
| Laparoscopic appendectomy | CPT 44970 | $1,573.46 |
| Major joint replacement w MCC | MS-DRG 469 | $3,791.85 |
| Major joint replacement w/o MCC | MS-DRG 470 | $3,791.85 |
| Laparoscopic cholecystectomy | CPT 47562 | $1,866.94 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $1,801.17 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $3,791.85 |
| Lap inguinal hernia repair | CPT 49650 | $1,216.08 |
| Total abdominal hysterectomy | CPT 58150 | $1,169.50 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $2,746.74 |
| Lap salpingo-oophorectomy | CPT 58661 | $1,816.06 |
| Cataract surgery with lens implant | CPT 66984 | $644.76 |
