| Specified Shoppable Services | Primary HCPCS Code | Charge | |
|---|---|---|---|
| Laboratory & Pathology Service | |||
| Basic metabolic panel | 80048 | $ | 37.60 |
| Blood test, comprehensive group of blood chemicals | 80053 | $ | 42.24 |
| Blood test, lipids (cholesterol and triglycerides) | 80061 | $ | 59.52 |
| Kidney function panel test | 80069 | $ | 34.72 |
| Liver function blood test panel | 80076 | $ | 32.68 |
| Manual urinalysis test with examination using microscope | 81000 | $ | 16.08 |
| PSA (prostate specific antigen) | 84153 | $ | 73.56 |
| Blood test, thyroid stimulating hormone (TSH) | 84443 | $ | 67.20 |
| Complete blood cell count, with differential white blood cells automated | 85025 | $ | 34.52 |
| Complete blood count, automated | 85027 | $ | 28.72 |
| Coagulation assessment blood test | 85730 | $ | 30.16 |
| Radiology Services | |||
| CT scan, head or brain, without contrast | 70450 | $ | 1,769.30 |
| X-Ray, lower back, minimum four views | 72110 | $ | 383.76 |
| CT scan, pelvis, with contrast | 72193 | $ | 2,801.50 |
| CT scan of abdomen and pelvis with contrast | 74177 | $ | 3,250.00 |
| Ultrasound of abdomen | 76700 | $ | 994.40 |
| Medicine and Surgery Service | |||
| Biopsy of the esophagus, stomach, and/or small bowel using an endoscope | 43239 | $ | 567.68 |
| Diagnostic examination of large bowel using an endoscope | 45378 | $ | 760.12 |
| Biopsy of large bowel using an endoscope | 45380 | $ | 824.36 |
| Removal of polyps or growths of large bowel using an endoscope | 45385 | $ | 2,558.40 |
| Sleep study | 95810 | $ | 3,016.50 |
| Physical therapy, therapeutic exercise | 97110 | $ | 178.54 |