CMS Shoppable Services
#
Code
Description
Available
1
74177
Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]
YES
2
76700
Abdominal ultrasound (complete) [HCPCS 76700]
YES
3
76805
Abdominal ultrasound of pregnant uterus after first trimester, greater than or equal to 14 weeks 0 days (single or first fetus) [HCPCS 76805]
NO
4
64483
Anesthetic agent and/or steroid injection into lower or sacral spine nerve root with imaging guidance (single level) [HCPCS 64483]
NO
5
19120
Breast cyst removal, male or female (1 or more cysts) [HCPCS 19120]
NO
6
216
Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with major complications
NO
7
66984
Cataract removal involving removal of the front part of the capsule and the central part of the lens with lens prosthesis insertion [HCPCS 66984]
NO
8
93452
Catheter insertion into left heart with injection, imaging interpretation, and supervision [HCPCS 93452]
NO
9
473
Cervical spinal fusion without complications
NO
10
45380
Colon (large bowel) examination and biopsy with endoscope [HCPCS 45380]
YES
11
45385
Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385]
YES
12
45391
Colon (large bowel) examination and ultrasound of large bowel with flexible endoscope [HCPCS 45391]
NO
13
45378
Colon (large bowel) examination with endoscope for diagnosis (high risk) [HCPCS 45378]
NO
14
59510
Delivery of infant through incision in abdomen and uterus (cesarean delivery) with obstetric care before and after delivery [HCPCS 59510]
NO
15
59610
Delivery of infant through uterus and vagina after previous delivery of infant through incision in abdomen and uterus (cesarean delivery) with obstetric care before and after delivery [HCPCS 59610]
NO
16
59400
Delivery of infant through uterus and vagina with obstetric care before and after delivery [HCPCS 59400]
NO
17
43239
Esophagus, stomach, and/or upper small bowel examination and biopsy with endoscope [HCPCS 43239]
YES
18
43235
Esophagus, stomach, and/or upper small bowel examination with endoscope for diagnosis [HCPCS 43235]
NO
19
90847
Family psychotherapy treatment with patient (50 minutes) [HCPCS 90847]
NO
20
90846
Family psychotherapy treatment without patient (50 minutes) [HCPCS 90846]
NO
21
47562
Gallbladder removal with an endoscope [HCPCS 47562]
NO
22
49505
Groin hernia repair for patient 5 years of age or older (herniated tissue that is not trapped) [HCPCS 49505]
NO
23
70450
Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]
YES
24
70553
Imaging of brain by MRI without contrast, followed by contrast [HCPCS 70553]
NO
25
73721
Imaging of leg joint by MRI without contrast [HCPCS 73721]
NO
26
72148
Imaging of lower spinal canal by MRI without contrast [HCPCS 72148]
NO
27
76830
Imaging of pelvis by ultrasound through vagina [HCPCS 76830]
YES
28
99385
Initial new patient well visit (preventive medicine evaluation) to assess overall health and identify potential health problems before they occur (18-39 years of age) [HCPCS 99385]
YES
29
99386
Initial new patient well visit (preventive medicine evaluation) to assess overall health and identify potential health problems before they occur (40-64 years of age) [HCPCS 99386]
YES
30
29881
Knee cartilage removal with endoscope (one knee) [HCPCS 29881]
NO
31
80055
Lab analysis for pregnant woment identify the hepatitis B antigen, rubella anitbody, test for syphilis, and perform ABO and Rh(D) blood typing from blood specimen [HCPCS 80055]
NO
32
81001
Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001]
YES
33
81000
Lab analysis of urine specimen by dipstick with microscope (non-automated) [HCPCS 81000]
NO
34
81003
Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003]
YES
35
81002
Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002]
NO
36
80069
Lab analysis to evaluate kidney function via a blood test panel [HCPCS 80069]
YES
37
85610
Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610]
YES
38
84443
Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443]
YES
39
85730
Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730]
YES
40
85027
Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test [HCPCS 85027]
YES
41
85025
Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]
YES
42
80076
Lab analysis to measure the amount of albumin, total and direct bilirubin, alkaline phosphatase, total protein, alanine amino transferase, and asparate amino transferase in blood specimen to evaluate liver function [HCPCS 80076]
YES
43
84154
Lab analysis to measure the amount of free PSA (prostate specific antigen) in serum specimen [HCPCS 84154]
NO
44
80061
Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061]
YES
45
84153
Lab analysis to measure the amount of total PSA (prostate specific antigen) in serum specimen [HCPCS 84153]
YES
46
80048
Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]
YES
47
80053
Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053]
YES
48
77067
Mammography of both breasts (screening exam) [HCPCS 77067]
NO
49
77066
Mammography of both breasts for diagnosis [HCPCS 77066]
NO
50
77065
Mammography of one breast for diagnosis [HCPCS 77065]
NO
51
99203
New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 30-44 minutes) [HCPCS 99203]
YES
52
99204
New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 45-59 minutes) [HCPCS 99204]
YES
53
99205
New patient office or outpatient visit with physician to diagnose and treat illness or injury (total time 60-74 minutes) [HCPCS 99205]
NO
54
99243
Patient office consultation visit with consulting physician or other qualified health care professional (typically 40 minutes) [HCPCS 99243]
NO
55
99244
Patient office consultation visit with consulting physician or other qualified health care professional (typically 60 minutes) [HCPCS 99244]
NO
56
72193
Pelvis CT scan with contrast to examine injury, foreign bodies, or tumors [HCPCS 72193]
NO
57
97110
Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]
YES
58
55700
Prostate gland biopsy [HCPCS 55700]
NO
59
90832
Psychotherapy treatment by physician face-to-face with patient (30 minutes) [HCPCS 90832]
YES
60
90834
Psychotherapy treatment by physician face-to-face with patient (45 minutes) [HCPCS 90834]
YES
61
90837
Psychotherapy treatment by physician face-to-face with patient (60 minutes) [HCPCS 90837]
YES
62
90853
Psychotherapy treatment for multiple patients in one group session [HCPCS 90853]
NO
63
66821
Recurring cataract removal in lens capsule by laser [HCPCS 66821]
NO
64
93000
Routine EKG (electrocardiogram) tracing using at least 12 wires with interpretation and report (complete) [HCPCS 93000]
NO
65
29826
Shoulder examination and shoulder bone shaving with endoscope [HCPCS 29826]
NO
66
95810
Sleep pattern monitoring of patient in sleep lab, sleep staging with 4 or more parameters of sleep (6 years of age or older) [HCPCS 95810]
YES
67
62322
Spinal canal injection of substance into lower back or sacrum [HCPCS 62322]
NO
68
62323
Spinal canal injection of substance into lower back or sacrum with imaging guidance [HCPCS 62323]
NO
69
460
Spinal fusion other than the neck without major complications
NO
70
72110
Spinal x-ray of lower and sacral spine (minimum of 4 views) [HCPCS 72110]
YES
71
55866
Surgical prostate removal and surrounding lymph nodes with endoscope [HCPCS 55866]
NO
72
42820
Tonsils and adenoid glands removal (younger than 12 years of age) [HCPCS 42820]
NO
73
470
Total Knee or Hip Replacement
NO
74
743
Uterus or Ovary Surgery Not Related to Cancer without complications
NO

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Disclaimer

This out-of-pocket 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 out-of-pocket 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.

  • 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 out-of-pocket 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.

To obtain a fully personalized out-of-pocket ESTIMATE contact Customer Service at 806-323-6422.

The final price may be higher or lower based on actual services rendered at time of appointment. It is advised that you contact your health insurer for most accurate individual payment responsibilities and to confirm any applicable remaining deductible balances.

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