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 |