| Psychoses | MS-DRG 885 | $42,774 |
| Psychiatric diagnostic evaluation | CPT 90791 | $117.38 |
| Psychiatric eval with medical services | CPT 90792 | $117.38 |
| Psychotherapy 30 minutes | CPT 90832 | $58.59 |
| Psychotherapy 45 minutes | CPT 90834 | $87.98 |
| Psychotherapy 60 minutes | CPT 90837 | $117.38 |
| Crisis psychotherapy 60 minutes | CPT 90839 | $117.38 |
| ED visit level 1 | CPT 99281 | $231.84 |
| ED visit level 2 | CPT 99282 | $410.98 |
| ED visit level 3 | CPT 99283 | $708.9 |
| ED visit level 4 | CPT 99284 | $1,185.33 |
| ED visit level 5 | CPT 99285 | $1,557.41 |
| Critical care, first hour | CPT 99291 | $2,384.25 |
| CT head without contrast | CPT 70450 | $1,858.87 |
| CT head with contrast | CPT 70460 | $2,072.07 |
| CT head with and without contrast | CPT 70470 | $2,811.89 |
| CT neck with contrast | CPT 70491 | $1,746.57 |
| MRI brain without contrast | CPT 70551 | $4,214.35 |
| MRI brain with contrast | CPT 70552 | $4,017.44 |
| MRI brain with and without contrast | CPT 70553 | $5,516.98 |
| Chest X-ray single view | CPT 71045 | $199.66 |
| Chest X-ray 2 views | CPT 71046 | $366.95 |
| Chest X-ray 3 views | CPT 71047 | $423 |
| CT chest without contrast | CPT 71250 | $2,245.71 |
| CT chest with contrast | CPT 71260 | $2,279.12 |
| CT chest with and without contrast | CPT 71270 | $2,554.5 |
| MRI chest without contrast | CPT 71550 | $4,017.44 |
| MRI chest with contrast | CPT 71551 | $3,366.66 |
| MRI chest with and without contrast | CPT 71552 | $3,901.33 |
| Lumbosacral spine X-ray | CPT 72100 | $362.09 |
| CT cervical spine without contrast | CPT 72125 | $1,952.78 |
| CT thoracic spine without contrast | CPT 72128 | $2,343.42 |
| CT lumbar spine without contrast | CPT 72131 | $1,952.78 |
| MRI cervical spine without contrast | CPT 72141 | $4,282.24 |
| MRI thoracic spine without contrast | CPT 72146 | $4,166.97 |
| MRI lumbar spine without contrast | CPT 72148 | $4,282.24 |
| MRI lumbar spine with and without contrast | CPT 72149 | $4,282.24 |
| MRI cervical spine with and without contrast | CPT 72156 | $5,932.15 |
| MRI lumbar spine with contrast | CPT 72158 | $5,444.22 |
| CT pelvis without contrast | CPT 72192 | $2,147.99 |
| CT pelvis with contrast | CPT 72193 | $2,542.02 |
| Shoulder X-ray | CPT 73030 | $362.09 |
| Humerus X-ray | CPT 73060 | $312.17 |
| Hand X-ray 3 views | CPT 73130 | $362.09 |
| MRI upper extremity joint without contrast | CPT 73221 | $1,145.48 |
| MRI upper extremity joint with and without contrast | CPT 73223 | $5,266.77 |
| Knee X-ray 1-2 views | CPT 73560 | $244.92 |
| Ankle X-ray 3 views | CPT 73610 | $362.09 |
| MRI lower extremity joint without contrast | CPT 73721 | $3,871.51 |
| MRI lower extremity joint with and without contrast | CPT 73723 | $5,266.77 |
| CT abdomen without contrast | CPT 74150 | $2,014.96 |
| CT abdomen with contrast | CPT 74160 | $2,166.18 |
| CT abdomen with and without contrast | CPT 74170 | $2,469.05 |
| CT abdomen and pelvis without contrast | CPT 74176 | $2,844.68 |
| CT abdomen and pelvis with contrast | CPT 74177 | $3,045.6 |
| CT abdomen and pelvis with and without contrast | CPT 74178 | $3,918.25 |
| MRI abdomen without contrast | CPT 74181 | $3,871.51 |
| MRI abdomen with and without contrast | CPT 74183 | $4,898.34 |
| Abdominal ultrasound complete | CPT 76700 | $1,329.28 |
| Abdominal ultrasound limited | CPT 76705 | $646.13 |
| Retroperitoneal ultrasound complete | CPT 76770 | $1,383.42 |
| Obstetric ultrasound first trimester | CPT 76801 | $1,032.33 |
| Obstetric ultrasound after first trimester | CPT 76805 | $930.18 |
| Obstetric ultrasound with fetal anatomy | CPT 76811 | $1,247.85 |
| Transvaginal ultrasound | CPT 76830 | $761.61 |
| Pelvic ultrasound complete | CPT 76856 | $757.38 |
| Scrotal ultrasound | CPT 76870 | $654.8 |
| EKG tracing only | CPT 93005 | $249.15 |
| Transthoracic echocardiogram complete | CPT 93306 | $3,971.12 |
| Intracranial hemorrhage/CVA w MCC | MS-DRG 064 | $60,362 |
| Intracranial hemorrhage/CVA w CC | MS-DRG 065 | $30,858 |
| Intracranial hemorrhage/CVA w/o CC/MCC | MS-DRG 066 | $20,886 |
| Respiratory infections & inflammations w MCC | MS-DRG 177 | $49,053 |
| COPD w MCC | MS-DRG 190 | $34,077 |
| COPD w CC | MS-DRG 191 | $26,069 |
| COPD w/o CC/MCC | MS-DRG 192 | $19,639 |
| Simple pneumonia & pleurisy w CC | MS-DRG 194 | $24,883 |
| Simple pneumonia & pleurisy w/o CC/MCC | MS-DRG 195 | $18,896 |
| AMI discharged alive w MCC | MS-DRG 280 | $49,808 |
| AMI discharged alive w CC | MS-DRG 281 | $27,972 |
| AMI discharged alive w/o CC/MCC | MS-DRG 282 | $22,003 |
| Heart failure & shock w MCC | MS-DRG 291 | $39,594 |
| Heart failure & shock w CC | MS-DRG 292 | $26,133 |
| Heart failure & shock w/o CC/MCC | MS-DRG 293 | $16,650 |
| Cardiac arrhythmia w MCC | MS-DRG 308 | $36,593 |
| Cardiac arrhythmia w CC | MS-DRG 309 | $22,434 |
| Cardiac arrhythmia w/o CC/MCC | MS-DRG 310 | $16,978 |
| GI hemorrhage w CC | MS-DRG 378 | $29,917 |
| GI hemorrhage w/o CC/MCC | MS-DRG 379 | $19,321 |
| Esophagitis/gastroenteritis w/o MCC | MS-DRG 392 | $23,678 |
| Fractures of femur w/o MCC | MS-DRG 533 | $46,273 |
| Kidney/UTI w MCC | MS-DRG 689 | $35,513 |
| Kidney/UTI w/o MCC | MS-DRG 690 | $24,355 |
| Septicemia or severe sepsis w MV 96+ hrs | MS-DRG 871 | $59,540 |
| Septicemia or severe sepsis w/o MV 96+ hrs | MS-DRG 872 | $31,286 |
| Basic metabolic panel (BMP) | CPT 80048 | $8.46 |
| General health panel | CPT 80050 | $40.66 |
| Electrolyte panel | CPT 80051 | $168.35 |
| Comprehensive metabolic panel | CPT 80053 | $249.15 |
| Lipid panel | CPT 80061 | $14.6 |
| Renal function panel | CPT 80069 | $8.68 |
| Hepatic function panel | CPT 80076 | $8.17 |
| Urinalysis non-automated | CPT 81002 | $3.85 |
| Urinalysis automated | CPT 81003 | $2.49 |
| Glucose quantitative | CPT 82947 | $75.08 |
| Hemoglobin A1c | CPT 83036 | $10.73 |
| Thyroid stimulating hormone (TSH) | CPT 84443 | $40.61 |
| Complete blood count with automated differential | CPT 85025 | $133.46 |
| Complete blood count without differential | CPT 85027 | $27.07 |
| Urine culture bacterial | CPT 87086 | $8.07 |
| Urine culture identification | CPT 87088 | $8.09 |
| Tissue exam by pathologist level IV | CPT 88305 | $50.14 |
| Fetal non-stress test | CPT 59025 | $230.75 |
| Routine obstetric care including vaginal delivery | CPT 59400 | $8,450 |
| Vaginal delivery only | CPT 59409 | $7,870 |
| Vaginal delivery with postpartum | CPT 59410 | $8,450 |
| Routine obstetric care with C-section | CPT 59510 | $8,450 |
| C-section delivery only | CPT 59514 | $7,870 |
| C-section with postpartum | CPT 59515 | $8,085 |
| Office visit, new patient, 15-29 min | CPT 99202 | $272.8 |
| Office visit, new patient, 30-44 minutes | CPT 99203 | $334.18 |
| Office visit, new patient, 45-59 min | CPT 99204 | $500.59 |
| Office visit, new patient, 60-74 min | CPT 99205 | $661.54 |
| Office visit, established patient, 5 min | CPT 99211 | $147.31 |
| Office visit, established patient, 10-19 min | CPT 99212 | $209.37 |
| Office visit, established patient, 20-29 minutes | CPT 99213 | $263.93 |
| Office visit, established patient, 30-39 minutes | CPT 99214 | $354.64 |
| Office visit, established patient, 40-54 min | CPT 99215 | $512.18 |
| Upper GI endoscopy diagnostic | CPT 43235 | $6,159 |
| Upper GI endoscopy with biopsy | CPT 43239 | $6,159 |
| Sigmoidoscopy diagnostic | CPT 45330 | $6,159 |
| Sigmoidoscopy with biopsy | CPT 45331 | $6,159 |
| Colonoscopy diagnostic | CPT 45378 | $6,159 |
| Colonoscopy with biopsy | CPT 45380 | $7,870 |
| Colonoscopy with polyp removal | CPT 45385 | $7,870 |
| Total shoulder arthroplasty | CPT 23472 | $13,958 |
| Hip hemiarthroplasty | CPT 27125 | $8,894 |
| Total hip replacement | CPT 27130 | $13,958 |
| Total knee replacement | CPT 27447 | $15,055 |
| Knee revision arthroplasty single component | CPT 27486 | $13,958 |
| Knee revision arthroplasty all components | CPT 27487 | $13,958 |
| Shoulder arthroscopy with decompression | CPT 29826 | $5,749 |
| Shoulder arthroscopy with rotator cuff repair | CPT 29827 | $13,958 |
| Knee arthroscopy with meniscectomy | CPT 29881 | $8,894 |
| ACL reconstruction | CPT 29888 | $13,958 |
| Major small/large bowel procedures w MCC | MS-DRG 329 | $139,341 |
| Major small/large bowel procedures w CC | MS-DRG 330 | $71,726 |
| Major small/large bowel procedures w/o CC/MCC | MS-DRG 331 | $50,100 |
| CABG single arterial graft | CPT 33533 | $14,056 |
| CABG 2 arterial grafts | CPT 33534 | $14,056 |
| CABG 3 arterial grafts | CPT 33535 | $14,056 |
| CABG 4+ arterial grafts | CPT 33536 | $14,056 |
| Laparoscopic cholecystectomy w/o CDE w MCC | MS-DRG 418 | $50,324 |
| Laparoscopic cholecystectomy w/o CDE w CC | MS-DRG 419 | $39,983 |
| Laparoscopic cholecystectomy w/o CDE w/o CC/MCC | MS-DRG 420 | $107,103 |
| Open appendectomy | CPT 44950 | $8,894 |
| Laparoscopic appendectomy | CPT 44970 | $11,838 |
| Major joint replacement w MCC | MS-DRG 469 | $99,189 |
| Major joint replacement w/o MCC | MS-DRG 470 | $57,216 |
| Laparoscopic cholecystectomy | CPT 47562 | $11,838 |
| Lap cholecystectomy with cholangiography | CPT 47563 | $11,838 |
| Hip & femur procedures except major joint w MCC | MS-DRG 480 | $89,245 |
| Hip & femur procedures except major joint w CC | MS-DRG 481 | $62,963 |
| Hip & femur procedures except major joint w/o CC/MCC | MS-DRG 482 | $48,139 |
| Lap inguinal hernia repair | CPT 49650 | $11,838 |
| Total abdominal hysterectomy | CPT 58150 | $11,655 |
| Vaginal hysterectomy | CPT 58260 | $10,948 |
| Lap-assisted vaginal hysterectomy | CPT 58550 | $11,838 |
| Lap-assisted vaginal hysterectomy >250g | CPT 58552 | $15,055 |
| Lap salpingo-oophorectomy | CPT 58661 | $11,838 |
| OR procedure for obesity w MCC | MS-DRG 619 | $82,736 |
| OR procedure for obesity w CC | MS-DRG 620 | $48,461 |
| OR procedure for obesity w/o CC/MCC | MS-DRG 621 | $44,358 |
| Complex cataract surgery | CPT 66982 | $7,870 |
| Cataract surgery with lens implant | CPT 66984 | $7,870 |
| Intravitreal injection | CPT 67028 | $5,749 |
| Vitrectomy mechanical | CPT 67042 | $10,948 |
| Uterine & adnexa procedures w CC/MCC | MS-DRG 743 | $36,375 |
| Uterine & adnexa procedures w/o CC/MCC | MS-DRG 744 | $59,294 |
| PCI single major coronary artery | CPT 92920 | $18,060 |
| PCI with drug-eluting stent | CPT 92928 | $18,060 |
| PCI bypass graft | CPT 92937 | $18,060 |
| Left heart catheterization | CPT 93452 | $13,913 |
| Coronary angiography with cath | CPT 93455 | $13,913 |
| Coronary angiography with bypass cath | CPT 93458 | $13,913 |
