Shoppable Services

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