CMS Shoppable Services
#
Code
Description
Available
1
90832
Psychotherapy, 30 minutes with patient
YES
2
90834
Psychotherapy, 45 minutes with patient
YES
3
90837
Psychotherapy, 60 minutes with patient
YES
4
90846
Family psychotherapy
N/A
5
90847
Family psychotherapy including patient
YES
6
90853
Group psychotherapy
N/A
7
99203
New patient ofice visit, complex
YES
8
99204
New patient office or other outpatient visit, typically 45 min
YES
9
99205
New patient ofice visit, comprehensive visit
N/A
10
99243
Office visit consultation, complex
YES
11
99244
Office consultation - new or established patient - 60 min
YES
12
99385
Initial new patient preventative medicine evaluation (18-39 years)
YES
13
99386
Initial new patient preventative medicine evaluation (40-64 years)
YES
14
80048
Blood test, basic group of blood chemicals
YES
15
80053
Blood test, comprehensive group of blood chemicals
YES
16
80055
Obstetric panel (includes HIV testing)
N/A
17
80061
Blood test, lipids (cholesterol and triglycerides)
YES
18
80069
Kidney Function Blood Test Panel
YES
19
80076
Liver function blood test panel
YES
20
81000
Manual urinalysis test with examination using microscope
N/A
21
81001
Urinalysis with Examination, using Microscope
YES
22
81002
Urinalysis, Manual Test
YES
23
81003
Urinalysis, Automated Test
YES
24
84153
PSA (prostate specific antigen) measurement
YES
25
84154
PSA Measurement; Free
YES
26
84443
Blood test, thyroid stimulating hormone (TSH)
YES
27
85025
Complete blood cell count - automated differential WBC count
YES
28
85027
Complete blood cell count - automated test with out Differential
YES
29
85610
Blood test, clotting time
YES
30
85730
Coagulation assessment blood test
YES
31
70450
CT Head Brain without Contrast
YES
32
70553
MRI Brain with and without Conrast
YES
33
72110
X-Ray Lower Sacral Spine, 4 or More Views
YES
34
72148
MRI Spine Lumbar without Contrast
YES
35
72193
CT Pelvis with Contrast
YES
36
73721
MRI Leg Joint without Contrast
YES
37
74177
CT Abdomen & Pelvis with Contrast
YES
38
76700
Ultrasound Abdomen - Complete
YES
39
76805
Ultrasound Pregnant Uterus > 14 Weeks Pregnant
YES
40
76830
Ultrasound Pelvis through Vagina
YES
41
77065
Diagnostic mammography, unilateral
YES
42
77066
Diagnostic mammography, bilateral
YES
43
77067
Screening Mammography, Bilateral, with CAD
YES
44
216
Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with major complications
N/A
45
460
Spinal fusion other than the neck without major complications
N/A
46
470
Total Knee or Hip Replacement
YES
47
473
Cervical spinal fusion without complications
N/A
48
743
Uterus or Ovary Surgery Not Related to Cancer without complications
YES
49
19120
Removal of 1 or more breast growth, open procedure
YES
50
29826
Shaving of shoulder bone using an endoscope
YES
51
29881
Removal of one knee cartilage using an endoscope
YES
52
42820
Removal of tonsils and adenoid glands patient younger than age 12
YES
53
43235
Diagnostic Examination of Esophagus, Stomach, and/or Upper Small Bowel with Endoscope
YES
54
43239
Biopsy of the Esophagus, Stomach, Using an Endoscope
YES
55
45378
Colonscopy
YES
56
45380
Biopsy of Large Bowel, Using an Endoscope
YES
57
45385
Removal of Polyps in Large Bowel, Using an Endoscope
YES
58
45391
Ultrasound examination of lower large bowel using an endoscope
N/A
59
47562
Gallbladder Removal Using an Endoscope
YES
60
49505
Repair of groin hernia patient age 5 years or older
YES
61
55700
Biopsy of prostate gland
N/A
62
55866
Surgical removal of prostate and surrounding lymph nodes using an endoscope
N/A
63
59400
Routine obstetric care for vaginal delivery, including pre and post
YES
64
59510
Routine obstetric care for cesarean delivery, including pre and post
YES
65
59610
Routine obstetric care for vaginal delivery after prior cesarean delivery, including pre and post
N/A
66
62322
Injection of substance into spinal canal or lower back using imaging
YES
67
62323
Epidural Injection Thoracic
YES
68
64483
Injection of anesthetic and/or steroid into lower spine nerve root using imaging
YES
69
66821
Removal of recurring cataract in lens capsule using laser
N/A
70
66984
Removal of cataract with insertion of lens
YES
71
93000
Routine electrocardiogram
N/A
72
93452
Insertion of catheter into left heart for diagnosis
N/A
73
95810
Sleep monitoring of patient (6 years or older) in sleep lab
YES
74
97110
Physical Therapy Exercise, 15 Minutes
YES

This link leads to the downloadable machine-readable file of all items and services provided by this facility as required by CMS. Please be advised the file size may exceed 1.5 gigabytes and therefore may take an extended amount of time to download depending on each individual user’s internet speed, bandwidth, connectivity, available hard drive space, etc.

Disclaimer

This good faith ESTIMATE should not be relied on as the final out-of-pocket cost for services as your final cost will vary based upon your specific needs at the time of the service, including additional treatments or services deemed necessary by the physician and/or additional information provided by your insurer.

This good faith ESTIMATE does not include bills from medical specialists, including by not limited to: physician charges, anesthesiology charges, radiologist reading fees and pathologist fees. Charges from these medical specialists will be billed separately to you.

If you are requesting a good faith ESTIMATE for a surgical procedure, the good faith ESTIMATE will not include:

  • Pre-Procedure Office Visits
  • Post-Procedure Office Visits
  • Diagnostic Testing

If you have met all or part of your deductible or maximum out-of-pocket expenses, the actual amount you owe may be different.

The estimated cost is not a guarantee of insurance coverage. Please check with your insurance company if you need help understanding your benefits for the service chosen.

Final determination of eligibility and services covered are determined at the time the claim is processed by the insurance company. Any services determined non-covered by your plan are your responsibility to pay.

This good faith ESTIMATE is intended only for the use of the intended recipient. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action taken in reliance on the contents of these documents is strictly forbidden.

If you are requesting a good faith ESTIMATE for any of the services below, please use the contact information provided in order to obtain a complete good faith ESTIMATE.

Fort Wayne Radiology (Physician Review and Resulting of Imaging) 888-929-7811

Hospitalist Care Group (Inpatient Stays) 260-344-4035

Professional Emergency Physicians (Emergency Room Physician Visits) 260-482-4440

Associated Anesthesiologists of Fort Wayne (Anesthesia Administration) 260-435-6732

South Bend Medical Foundation (Pathology) 1-800-950-7263

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I HAVE READ AND UNDERSTAND THE ABOVE LIMITATIONS AND I FULLY UNDERSTAND THIS IS ONLY A GOOD FAITH ESTIMATE.

IMPORTANT INFORMATION REGARDING USE AND LIMITATIONS OF THIS ESTIMATE

  1. To obtain the most accurate estimate of patient out of pocket costs, it strongly recommended that patients contact their insurer to request an estimate or Cameron Memorial Community Hospital at 260-667-5128. To obtain the most accurate estimate possible, the patient's insurance information, if any, as well as a specific description of the service requested, preferably a physician's order, are necessary.
  2. Actual cost to the insurer and/or patient, as well as the out-of-pocket (OOP) amount for which a patient will be directly responsible, are determined by several factors and are not in the exclusive control of Cameron Memorial Community Hospital, including, but not limited to:
    1. The payment methodology applied by the patient's insurance, which may include commercial health insurance, automobile insurance, workers compensation insurance, or government health insurance coverage, e.g. such as Medicare, Medicaid, or Veterans Administration, etc.
    2. These insurance payment methodologies, including the prospective payment methodologies applied by Medicare and Medicaid, frequently are not directly related to fee schedules charges or a percentage of charges,
    3. The patient's level of coverage, particular insurance plan (e.g. HMO, PPO, etc.), network participation status of each provider, and the patient's currently outstanding benefits within the patient's plan benefit package, including co-pays, co-insurance, remaining deductible, and OOP maximum,
    4. The most appropriate services, as determined by the patient's treating and/or referring physician(s) at the time they receive the services, and acknowledging that the patient's actual medical need, as determined be the treating physician at the time of service, may be substantially different than the anticipated medical need prior to provision of the medical treatment or services.
    5. Although estimates are available through Cameron Memorial Community Hospital for most scheduled service, the nature of healthcare, including the factors described above, dictates that the appropriate level of care, and thus patient OOP cost of that care, frequently cannot be accurately determined until the care has actually been provided.
    6. The actual cost for which the insurance and/or patient may be responsible are often, although not always, significantly less than the total charges posted to a patient's account, and thus, estimating payer cost or patient OOP responsibility using a fee schedule alone will not produce an accurate estimate.
    7. Patients with no insurance coverage are eligible for a minimum of a 38% discount off of standard charges at Cameron Memorial Community Hospital; however, depending on the type of services received, timing of payment, and patient's financial need, pre-payment discounts, prompt-payment discounts, packaged pricing, as well as financial assistance may be available to further lower an uninsured patient's actual OOP expenses.

BY DOWNLOADING AND ACCESSING THIS GOOD FAITH ESTIMATE, YOU ARE ACKNOWLEDGING THE FOLLOWING:

  • I have read and am aware of the above information, the contextual limitations of the Cameron Memorial Community Hospital Out-of-Pocket Cost Estimator, and recognize that the Cameron Memorial Community Hospital Out-of-Pocket Cost Estimator cannot be used as a single source for determining actual cost to any payer, including insurers, employers, or patient out-of-pocket responsibility, and if such single service determination is attempted, the information will be out-of-context and therefore, incomplete and inaccurate.
  • If I am a non-patient, third-party, I acknowledge that I have read and am aware of the above information, the contextual limitations of the Cameron Memorial Community Hospital Out-of-Pocket Cost Estimator, and recognize that the Cameron Memorial Community Hospital Out-of-Pocket Cost Estimator cannot be used as a single source for determining actual cost to any payer, including insurers, employers, or patient out-of-pocket responsibility, and if such single service determination is attempted, the information will be out-of-context and therefore, incomplete and inaccurate. I further acknowledge that if I or my organization republish, post online, or otherwise re-communicate this information to another party and hold-out these fee schedules to the sole determining factor in establishing payer cost or patient out-of-pocket responsibility, without providing the contextual limitations described above, I risk misleading the consumers of such information due to the limitations detailed in this disclaimer. If my or my organization's intent is to aid a payer or patient in determining actual payer cost or patient out-of-pocket responsibility, I acknowledge that this intent is most accurately and effectively achieved by recommending that such individuals contact their insurer or Cameron Memorial Community Hospital at 260-667-5128.