Common Consumer Shoppable Services for HMO Pricing for More Common Health Plans
WellStar AMC, Cobb, Douglas, Kennestone, North Fulton, Paulding, Spaulding, Sylvan Grove and Windy Hill Hospitals
Code Code Description Aetna HMO Cigna HMO
United
Health Care
HMO
Humana
HMO
Anthem HMO
(Blue Cross Blue
Shield Georgia)
10005 Fine needle aspiration of first lesion using ultrasound guidance $2,764.00 $1,908.00 $3,235.00 $3,260.00
$3,299.03
10060 Drainage of abscess $2,764.00 $1,908.00 $2,120.00 $1,859.00
$3,299.03
10160 Aspiration of abscess, blood accumulation, blister, or cyst $2,764.00 $1,908.00 $2,120.00 $1,859.00
$3,299.03
12013
Repair of wound (2.6 to 5.0 centimeters) of the face, ears, eyelids, nose, lips, and/or mucous membranes $4,126.00 $1,908.00 $2,120.00 $1,859.00
$3,299.03
19120 Removal of 1 or more breast growth, open procedure $4,734.00 $3,131.00 $4,916.00 $3,051.00
$5,754.40
20610 Aspiration and/or injection of large joint or joint capsule $2,764.00 $1,908.00 $2,120.00 $1,859.00
$3,299.03
23350 Injection of dye for X-ray imaging of shoulder joint $2,764.00 $1,908.00 $2,120.00 $1,859.00
$3,299.03
29826 Shaving of shoulder bone using an endoscope $4,734.00 $3,131.00 $2,120.00 $3,051.00
$5,754.40
29881 Removal of one knee cartilage using an endoscope $5,207.00 $3,653.00 $6,722.00 $3,622.00
$6,073.96
38222 Diagnostic aspirations and biopsies of bone marrow $2,764.00 $1,908.00 $4,194.00 $3,260.00
$3,299.03
42820 Removal of tonsils and adenoid glands patient younger than age 12 $4,734.00 $3,131.00 $4,916.00 $3,051.00
$5,754.40
43235 Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope $2,764.00 $1,908.00 $4,194.00 $1,859.00
$3,299.03
43239 Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope $3,841.00 $2,550.00 $4,194.00 $2,484.00
$4,758.54
45378 Diagnostic examination of large bowel using an endoscope $3,841.00 $2,550.00 $4,194.00 $2,484.00
$4,758.54
45380 Biopsy of large bowel using an endoscope $3,841.00 $2,550.00 $4,194.00 $2,484.00
$4,758.54
45385 Removal of polyps or growths of large bowel using an endoscope $3,841.00 $2,550.00 $4,194.00 $2,484.00
$4,758.54
45391 Ultrasound examination of lower large bowel using an endoscope $3,841.00 $2,550.00 $4,194.00 $2,484.00
$4,758.54
49505 Repair of groin hernia patient age 5 years or older $5,207.00 $3,653.00 $6,722.00 $3,622.00
$6,073.96
55700 Biopsy of prostate gland $3,841.00 $2,550.00 $4,194.00 $2,484.00
$4,758.54
59400 Obstetrical pre- and postpartum care and vaginal delivery $4,234.00 $3,956.90 $3,817.50 $3,622.00
$3,731.56
59510 Cesarian delivery with pre- and post-delivery care $4,414.00 $4,392.60 $4,312.46 $3,622.00
$4,018.61
59610 Vaginal delivery after prior cesarean delivery $4,315.00 $4,165.57 $3,994.78 $3,622.00
$3,731.56
62270 Spinal tap for diagnosis $2,764.00 $1,908.00 $3,235.00 $1,859.00
$3,299.03
62322 Injection of substance into spinal canal of lower back or sacrum $2,764.00 $1,908.00 $3,235.00 $3,260.00
$3,299.03
62323 Injection of substance into spinal canal of lower back or sacrum using imaging guidance $2,764.00 $1,908.00 $3,235.00 $3,260.00
$3,299.03
64483
Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance,
single level
$2,764.00 $1,908.00 $3,235.00 $1,859.00
$3,299.03
64490 Injections of upper or middle spine facet joint using imaging guidance, single level $2,764.00 $1,908.00 $3,235.00 $3,260.00
$3,299.03
64493 Injections of lower or sacral spine facet joint using imaging guidance, single level $2,764.00 $1,908.00 $3,235.00 $3,260.00
$3,299.03
64635 Destruction of lower or sacral spinal facet joint nerves using imaging guidance $2,764.00 $4,228.00 $4,916.00 $3,260.00
$4,361.52
66821 Removal of recurring cataract in lens capsule using laser $3,841.00 $2,550.00 $3,235.00 $2,484.00
$4,758.54
Effective: June 1, 2021 The information contained in this file is intended for informational purposes only and does not represent any obligation or agreement. 1 of 11
Common Consumer Shoppable Services for HMO Pricing for More Common Health Plans
WellStar AMC, Cobb, Douglas, Kennestone, North Fulton, Paulding, Spaulding, Sylvan Grove and Windy Hill Hospitals
Code Code Description Aetna HMO Cigna HMO
United
Health Care
HMO
Humana
HMO
Anthem HMO
(Blue Cross Blue
Shield Georgia)
66984 Removal of cataract with insertion of lens $8,022.00 $5,977.00 $4,916.00 $5,821.00
$9,080.15
70150 X-ray of bones of face, minimum of 3 views $116.13 $58.67 $111.13 $111.13
$111.13
70160 X-ray of bones of nose, minimum of 3 views $97.19 $49.64 $93.00 $92.96
$93.00
70220 X-ray of paranasal sinus, complete, minimum of 3 views $103.48 $45.77 $99.02 $99.02
$99.02
70250 X-ray of skull, less than 4 views $97.19 $45.77 $93.00 $93.00
$93.00
70355 Orthopantogram (e.g., panoramic x-ray) $39.06 $15.47 $37.38 $37.38
$37.38
70360 X-ray of soft tissue of neck $75.71 $38.68 $72.45 $72.45
$72.45
70450 CT scan head or brain $451.00 $131.52 $446.00 $425.00
$400.00
70460 CT scan head or brain with contrast $451.00 $192.77 $446.00 $425.00
$400.00
70470 CT scan head or brain before and after contrast $451.00 $230.81 $446.00 $425.00
$400.00
70480 CT scan of cranial cavity $451.00 $246.92 $446.00 $425.00
$400.00
70481 CT scan of cranial cavity with contrast $451.00 $302.37 $446.00 $425.00
$400.00
70486 CT scan of face $451.00 $174.07 $446.00 $425.00
$400.00
70487 CT scan of face with contrast $451.00 $199.86 $446.00 $425.00
$400.00
70490 CT scan of neck $451.00 $181.16 $446.00 $425.00
$400.00
70491 CT scan of neck with contrast $451.00 $241.12 $446.00 $425.00
$400.00
70496 CT scan of blood vessel of head with contrast $451.00 $378.44 $446.00 $425.00
$400.00
70498 CT scan of neck blood vessels with contrast $451.00 $377.80 $446.00 $425.00
$400.00
70543 MRI scan bones of the eye, face, and/or neck before and after contrast $678.00 $511.25 $670.00 $650.00
$600.00
70544 MRA scan of head blood vessels $678.00 $335.25 $670.00 $650.00
$600.00
70547 MRA scan of neck blood vessels $678.00 $336.54 $670.00 $650.00
$600.00
70549 MRA scan of neck blood vessels before and after contrast $678.00 $542.20 $670.00 $650.00
$600.00
70551 MRI scan brain $678.00 $268.84 $670.00 $650.00
$600.00
70552 MRI scan of brain with contrast $678.00 $397.14 $670.00 $650.00
$600.00
70553 MRI scan of brain before and after contrast $678.00 $452.59 $670.00 $650.00
$600.00
71045 X-ray of chest, 1 view $39.50 $29.66 $37.80 $53.10
$37.80
71046 X-ray of chest, 2 views $72.31 $39.33 $69.20 $72.42
$69.20
71047 X-ray of chest, 3 views $92.02 $49.64 $88.06 $89.36
$88.06
71048 X-ray of chest, minimum of 4 views $94.62 $51.58 $90.55 $114.73
$90.55
71100 X-ray of ribs of one side of body, 2 views $83.29 $43.84 $79.70 $79.70
$79.70
Effective: June 1, 2021 The information contained in this file is intended for informational purposes only and does not represent any obligation or agreement. 2 of 11
Common Consumer Shoppable Services for HMO Pricing for More Common Health Plans
WellStar AMC, Cobb, Douglas, Kennestone, North Fulton, Paulding, Spaulding, Sylvan Grove and Windy Hill Hospitals
Code Code Description Aetna HMO Cigna HMO
United
Health Care
HMO
Humana
HMO
Anthem HMO
(Blue Cross Blue
Shield Georgia)
71101 X-ray of ribs on one side of body including the chest, minimum of 3 views $102.23 $49.64 $97.83 $97.83
$97.83
71111 X-ray of both sides of the ribs including the chest, minimum of 4 views $145.17 $63.18 $138.92 $138.92
$138.92
71250 CT scan chest $451.00 $181.16 $446.00 $425.00
$400.00
71260 CT scan chest with contrast $451.00 $241.77 $446.00 $425.00
$400.00
71270 CT scan chest before and after contrast $451.00 $295.28 $446.00 $425.00
$400.00
71275 CT scan of blood vessels in chest with contrast $451.00 $383.60 $446.00 $425.00
$400.00
72020 X-ray of spine, 1 view $61.81 $29.01 $59.15 $59.15
$59.15
72040 X-ray of spine of neck, 2 or 3 views $93.38 $48.35 $89.36 $89.36
$89.36
72050 X-ray of upper spine, 4 or 5 views $126.23 $66.40 $120.79 $120.79
$120.79
72070 X-ray of middle spine, 2 views $88.33 $38.68 $84.53 $84.53
$84.53
72072 X-ray of middle spine, 3 views $102.23 $48.35 $97.83 $97.83
$97.83
72080 X-ray of middle and lower spine, 2 views $97.19 $41.90 $93.00 $92.96
$93.00
72081 X-ray of spine, entire middle and lower spine, 1 view $93.41 $50.93 $89.39 $100.24
$89.39
72082 X-ray of spine, entire middle and lower spine, 2 or 3 views $169.82 $92.84 $162.51 $137.73
$162.51
72100 X-ray of lower and sacral spine, 2 or 3 views $40.57 $48.35 $38.82 $38.81
$38.82
72110 X-ray of lower and sacral spine, minimum of 4 views $55.18 $63.83 $52.80 $52.80
$52.80
72120 X-ray lower and sacral spine including bending views 2 or 3 views $50.85 $50.93 $48.66 $48.66
$48.66
72125 CT scan of upper spine $451.00 $190.83 $446.00 $425.00
$400.00
72128 CT scan of middle spine $451.00 $190.83 $446.00 $425.00
$400.00
72131 CT scan of lower spine $451.00 $189.54 $446.00 $425.00
$400.00
72132 CT scan of lower spine with contrast $451.00 $243.70 $446.00 $425.00
$400.00
72141 MRI scan of upper spinal canal $678.00 $257.88 $670.00 $650.00
$600.00
72146 MRI scan of middle spinal canal $678.00 $257.88 $670.00 $650.00
$600.00
72148 MRI scan of lower spinal canal $678.00 $258.53 $670.00 $650.00
$600.00
72156 MRI scan of upper spinal canal before and after contrast $678.00 $457.74 $670.00 $650.00
$600.00
72157 MRI scan of middle spinal canal before and after contrast $678.00 $459.03 $670.00 $650.00
$600.00
72158 MRI scan of lower spinal canal before and after contrast $678.00 $456.45 $670.00 $650.00
$600.00
72170 X-ray of pelvis, 1 or 2 views $76.95 $35.46 $73.64 $73.64
$73.64
72190 X-ray of pelvis, minimum of 3 views $124.98 $50.29 $119.60 $119.56
$119.60
72192 CT scan pelvis $451.00 $164.40 $446.00 $425.00
$400.00
Effective: June 1, 2021 The information contained in this file is intended for informational purposes only and does not represent any obligation or agreement. 3 of 11
Common Consumer Shoppable Services for HMO Pricing for More Common Health Plans
WellStar AMC, Cobb, Douglas, Kennestone, North Fulton, Paulding, Spaulding, Sylvan Grove and Windy Hill Hospitals
Code Code Description Aetna HMO Cigna HMO
United
Health Care
HMO
Humana
HMO
Anthem HMO
(Blue Cross Blue
Shield Georgia)
72193 CT scan pelvis with contrast $451.00 $333.31 $446.00 $425.00
$400.00
72195 MRI scan of pelvis $678.00 $348.79 $670.00 $650.00
$600.00
72197 MRI scan of pelvis before and after contrast $678.00 $508.68 $670.00 $650.00
$600.00
72202 X-ray of sacroiliac joints, 3 or more views $98.43 $47.71 $94.19 $94.19
$94.19
72220 X-ray of pelvis, minimum of 2 views $79.48 $40.62 $76.06 $76.06
$76.06
73000 X-ray of collar bone $80.76 $41.26 $77.28 $77.28
$77.28
73020 X-ray of shoulder, 1 view $63.06 $24.50 $60.34 $60.34
$60.34
73030 X-ray of shoulder, minimum of 2 views $82.00 $42.55 $78.47 $78.47
$78.47
73060 X-ray of upper arm, minimum of 2 views $79.48 $41.26 $76.06 $76.06
$76.06
73070 X-ray of elbow, 2 views $80.76 $36.10 $77.28 $77.28
$77.28
73080 X-ray of elbow, minimum of 3 views $97.19 $39.97 $93.00 $92.96
$93.00
73090 X-ray of forearm, 2 views $76.95 $36.75 $73.64 $73.68
$73.64
73100 X-ray of wrist, 2 views $89.61 $43.84 $85.75 $85.72
$85.75
73110 X-ray of wrist, minimum of 3 views $113.60 $54.15 $108.71 $108.68
$108.71
73120 X-ray of hand, 2 views $75.71 $39.33 $72.45 $72.45
$72.45
73130 X-ray of hand, minimum of 3 views $93.38 $47.06 $89.36 $89.36
$89.36
73140 X-ray of fingers, minimum of 2 views $104.75 $51.58 $100.24 $100.24
$100.24
73200 CT scan of arm $451.00 $232.74 $446.00 $425.00
$400.00
73201 Computed tomography, upper extremity; with contrast material(s) $346.41 $297.86 $446.00 $580.10
$400.00
73218 MRI scan of arm $678.00 $516.41 $670.00 $547.49
$600.00
73221 MRI scan of arm joint $678.00 $291.41 $670.00 $437.16
$600.00
73222 MRI scan of arm joint with contrast $678.00 $513.83 $670.00 $738.98
$600.00
73501 X-ray of hip with pelvis, 1 view $74.98 $39.97 $71.75 $67.59
$71.75
73502 X-ray of hip with pelvis, 2-3 views $110.53 $61.25 $105.77 $105.07
$105.77
73521 Radiologic examination, hips, bilateral, with pelvis when performed; 2 views $103.95 $51.58 $99.47 $102.66
$99.47
73552 X-ray of femur, minimum 2 views $84.20 $45.77 $80.57 $72.45
$80.57
73560 X-ray of knee, 1 or 2 views $84.53 $45.13 $80.89 $80.89
$80.89
73562 X-ray of knee, 3 views $108.55 $53.51 $103.88 $103.85
$103.88
73564 X-ray of knee, 4 or more views $124.98 $58.67 $119.60 $119.60
$119.60
73590 X-ray of lower leg, 2 views $74.44 $40.62 $71.23 $71.23
$71.23
Effective: June 1, 2021 The information contained in this file is intended for informational purposes only and does not represent any obligation or agreement. 4 of 11
Common Consumer Shoppable Services for HMO Pricing for More Common Health Plans
WellStar AMC, Cobb, Douglas, Kennestone, North Fulton, Paulding, Spaulding, Sylvan Grove and Windy Hill Hospitals
Code Code Description Aetna HMO Cigna HMO
United
Health Care
HMO
Humana
HMO
Anthem HMO
(Blue Cross Blue
Shield Georgia)
73600 X-ray of ankle, 2 views $80.76 $41.90 $77.28 $77.28
$77.28
73610 X-ray of ankle, minimum of 3 views $97.19 $47.06 $93.00 $92.97
$93.00
73620 X-ray of foot, 2 views $33.53 $36.10 $32.09 $32.09
$32.09
73630 X-ray of foot, minimum of 3 views $38.94 $43.84 $37.26 $37.26
$37.26
73650 X-ray of heel, minimum of 2 views $80.76 $36.10 $77.28 $77.28
$77.28
73660 X-ray of toes, minimum of 2 views $93.38 $38.68 $89.36 $89.36
$89.36
73700 CT scan leg $451.00 $189.54 $446.00 $425.00
$400.00
73701 CT scan leg with contrast injection $451.00 $245.63 $446.00 $425.00
$400.00
73706 CT scan of lower leg blood vessels with contrast $451.00 $473.21 $446.00 $425.00
$400.00
73718 MRI scan of leg $678.00 $344.27 $670.00 $724.46
$600.00
73721 MRI scan of leg joint $678.00 $291.41 $670.00 $437.16
$600.00
74018 X-ray of abdomen, 1 view $67.08 $36.10 $64.19 $56.70
$64.19
74019 X-ray of abdomen, 2 views $80.21 $43.84 $76.76 $99.02
$76.76
74021 X-ray of abdomen, minimum of 3 views $93.34 $50.93 $89.32 $99.02
$89.32
74150 CT scan abdomen $451.00 $161.82 $446.00 $425.00
$400.00
74160 CT scan abdomen with contrast $451.00 $332.03 $446.00 $425.00
$400.00
74170 CT scan abdomen before and after contrast $451.00 $377.80 $446.00 $425.00
$400.00
74174 CT scan of abdominal and pelvic blood vessels with contrast $451.00 $535.11 $446.00 $425.00
$400.00
74176 CT scan of abdomen and pelvis $451.00 $203.73 $446.00 $425.00
$400.00
74177 CT scan of abdomen and pelvis with contrast $451.00 $426.80 $446.00 $425.00
$400.00
74178 CT scan of abdomen and pelvis before and after contrast $451.00 $484.18 $446.00 $425.00
$400.00
74181 MRI scan of abdomen $678.00 $274.65 $670.00 $634.00
$600.00
74183 MRI scan of abdomen before and after contrast $678.00 $509.96 $670.00 $973.10
$600.00
74230 Imaging for evaluation of swallowing function $451.00 $183.29 $240.45 $240.45
$240.45
74240 X-ray of upper digestive tract with single contrast $451.00 $140.84 $296.03 $296.07
$296.03
74246 X-ray of upper digestive tract with double contrast $451.00 $166.57 $350.42 $350.07
$350.42
74250 X-ray of upper digestive tract with single contrast and multiple serial films $451.00 $144.70 $315.39 $315.39
$315.39
74300 Radiological supervision and interpretation X-ray of bile and/or pancreatic ducts during surgery $122.13 $962.14 $116.87 $82.01
$116.87
75561 MRI of heart before and after contrast $678.00 $529.31 $670.00 $741.74
$600.00
75571 CT scan of heart with evaluation of blood vessel calcium $147.77 $137.32 $446.00 $425.00
$400.00
Effective: June 1, 2021 The information contained in this file is intended for informational purposes only and does not represent any obligation or agreement. 5 of 11
Common Consumer Shoppable Services for HMO Pricing for More Common Health Plans
WellStar AMC, Cobb, Douglas, Kennestone, North Fulton, Paulding, Spaulding, Sylvan Grove and Windy Hill Hospitals
Code Code Description Aetna HMO Cigna HMO
United
Health Care
HMO
Humana
HMO
Anthem HMO
(Blue Cross Blue
Shield Georgia)
75572 CT scan of heart structure with contrast $451.00 $293.34 $446.00 $425.00
$400.00
75574 CT scan of heart blood vessels and grafts with contrast dye $451.00 $437.11 $446.00 $425.00
$400.00
75710 Radiological supervision and interpretation of imaging of artery of one arm or leg $478.62 $191.66 $458.01 $458.01
$458.01
76010 Imaging from nose to rectum, single view, child $69.39 $35.46 $66.40 $66.40
$66.40
76506 Ultrasound of brain $361.14 $150.86 $345.59 $345.59
$345.59
76536 Ultrasound of head and neck $362.43 $159.24 $346.82 $346.82
$346.82
76604 Ultrasound of chest $234.85 $90.90 $224.74 $224.74
$224.74
76641 Ultrasound of one breast, complete $264.07 $128.30 $252.70 $369.74
$252.70
76642 Ultrasound of one breast, limited $202.33 $97.35 $193.62 $369.74
$193.62
76700 Ultrasound of abdomen $165.61 $148.93 $158.48 $158.46
$158.48
76705 Ultrasound of abdomen, limited $130.42 $112.18 $124.80 $124.82
$124.80
76770 Ultrasound behind abdominal cavity $368.72 $138.61 $352.84 $352.87
$352.84
76775 Ultrasound behind abdominal cavity, limited $308.11 $54.15 $294.84 $294.84
$294.84
76801 Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus $128.81 $131.52 $123.26 $123.24
$123.26
76805 Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or $162.89 $163.76 $155.88 $155.90
$155.88
76815 Ultrasound of pregnant uterus, 1 or more fetus(es) $96.86 $93.48 $92.69 $92.69
$92.69
76817 Vaginal ultrasound of pregnant uterus $107.14 $105.73 $102.53 $102.53
$102.53
76818 Fetal biophysical profile; with non-stress testing $275.26 $119.27 $263.41 $263.41
$263.41
76830 Ultrasound pelvis through vagina $67.62 $160.53 $64.71 $64.71
$64.71
76856 Ultrasound of pelvis, complete, not pregnancy related $149.37 $136.68 $142.94 $142.94
$142.94
76857 Ultrasound of pelvis, limited, not pregnancy related $125.01 $43.19 $119.63 $119.63
$119.63
76870 Ultrasound of scrotum $356.09 $132.81 $340.76 $340.76
$340.76
76882 Partial ultrasound of joint or other non-blood vessel structure of arm or leg $42.87 $59.31 $41.02 $41.02
$41.02
76885 Ultrasound of hips with manipulation, infant $431.88 $193.41 $413.28 $413.28
$413.28
77065 Diagnostic mammography of one breast $99.49 $168.91 $95.21 $196.95
$95.21
77066 Diagnostic mammography of both breasts $127.27 $215.33 $121.79 $259.37
$121.79
77072 Imaging for bone age assessment $54.25 $28.37 $51.91 $51.87
$51.91
77075 X-ray survey of forearm or wrist bone density $304.30 $108.69 $291.20 $291.24
$291.20
77077 Imaging of 2 or more joints, single view $92.14 $51.58 $88.17 $88.17
$88.17
77081 Bone density measurement of the core or extremities (e.g., radius, wrist, heel) $65.58 $39.97 $62.76 $62.79
$62.76
Effective: June 1, 2021 The information contained in this file is intended for informational purposes only and does not represent any obligation or agreement. 6 of 11
Common Consumer Shoppable Services for HMO Pricing for More Common Health Plans
WellStar AMC, Cobb, Douglas, Kennestone, North Fulton, Paulding, Spaulding, Sylvan Grove and Windy Hill Hospitals
Code Code Description Aetna HMO Cigna HMO
United
Health Care
HMO
Humana
HMO
Anthem HMO
(Blue Cross Blue
Shield Georgia)
78452 Nuclear medicine study of vessels of heart using drugs or exercise multiple studies $1,579.75 $721.42 $1,452.00 $1,511.72
$1,511.72
80048 Blood test, basic group of blood chemicals (Calcium, total) $12.27 $16.76 $14.83 $11.63 CO
80053 Blood test, comprehensive group of blood chemicals $15.52 $21.28 $18.53 $14.53 CO
80061 Blood test, lipids (cholesterol and triglycerides) $25.26 $26.43 $23.48 $18.42 CO
80069 Kidney function blood test panel $12.63 $17.41 $15.22 $11.94 CO
80076 Liver function blood test panel $11.91 $16.12 $14.32 $11.23 CO
80170 Gentamycin $23.82 $32.24 $28.72 $22.53 CO
80178 Lithium $9.74 $12.89 $11.58 $9.09 CO
80185 Dilantin $19.49 $26.43 $23.23 $18.22 CO
81000 Manual urinalysis test with examination using microscope, non-automated $4.69 $7.09 $5.56 $4.35 CO
81001 Urinalysis auto w/microscope $4.69 $6.45 $5.56 $4.35 CO
81002 Urinalysis, manual test $3.61 $6.45 $4.49 $3.52 CO
81003 Automated urinalysis test $3.25 $4.51 $3.94 $3.09 CO
81025 Urine pregnancy test, by visual color comparison methods $9.38 $15.47 $11.09 $8.70 CO
82043 Albumin; urine (e.g., microalbumin), quantitative $8.30 $11.60 $10.14 $7.95 CO
82105 Alpha-fetoprotein (AFP); serum $24.54 $33.53 $29.39 $23.06 CO
82232 Beta-2 microglobulin $23.46 $32.24 $28.34 $22.24 CO
82306 Vitamin D $43.30 $58.67 $51.86 $40.70 CO
82310 Calcium $7.58 $10.32 $9.04 $7.09
$7.25
82436 Cloride urine $7.22 $10.32 $8.81 $6.91 CO
82570 Creatinine urine $7.58 $10.32 $9.07 $7.11 CO
82607 B12 $22.02 $29.66 $26.41 $20.72 CO
82652 Vitamin D; 1, 25 dihydroxy, includes fraction(s), if performed $56.29 $76.72 $67.44 $52.92 CO
82668 Erythopoietin $27.43 $37.39 $32.94 $25.84 CO
82677 Estriol $35.36 $47.71 $42.37 $33.25 CO
82728 Ferritin $19.84 $27.08 $23.87 $18.73 CO
82731 Fetal fibronectin, cervicovaginal secretions, semi-quantitative $93.83 $127.65 $112.85 $88.54
$89.79
82977 Glutamyltransferase, gamma (GGT) $10.46 $14.18 $12.61 $9.90 CO
83036 Hemoglobin; glycosylated (A1C) $14.08 $19.34 $17.00 $13.34 CO
83051 Hemoglobin; plasma $10.83 $14.18 $12.80 $10.05 CO
Effective: June 1, 2021 The information contained in this file is intended for informational purposes only and does not represent any obligation or agreement. 7 of 11
Common Consumer Shoppable Services for HMO Pricing for More Common Health Plans
WellStar AMC, Cobb, Douglas, Kennestone, North Fulton, Paulding, Spaulding, Sylvan Grove and Windy Hill Hospitals
Code Code Description Aetna HMO Cigna HMO
United
Health Care
HMO
Humana
HMO
Anthem HMO
(Blue Cross Blue
Shield Georgia)
83540 Iron $9.38 $12.89 $11.35 $8.90 CO
83550 Iron binding capacity $12.63 $17.41 $15.32 $12.02 CO
83630 Lactoferrin, fecal; qualitative $28.51 $38.68 $34.39 $26.98 CO
83735 Magnesium $9.74 $13.54 $11.74 $9.21 CO
84133 Potassium; urine $6.13 $8.38 $7.54 $5.91 CO
84153 PSA (prostate specific antigen) measurement, total $26.70 $36.75 $32.22 $25.29 CO
84154 PSA (prostate specific antigen) measurement, free $26.70 $36.75 $32.22 $25.29 CO
84425 Thiamine (Vitamin B-1) $31.04 $41.91 $37.21 $29.19 CO
84439 Thyroxine; free $12.99 $18.05 $15.80 $12.40 CO
84443 Blood test, thyroid stimulating hormone (TSH) $24.54 $33.53 $29.44 $23.10 CO
84481 Triiodothyronine T3; free $24.54 $33.53 $29.69 $23.29 CO
84540 Urea nitrogen, urine $6.86 $9.67 $8.32 $6.53 CO
84702 Gonadotropin, chorionic (hCG); quantitative $22.02 $29.66 $26.38 $8.82 CO
85025
Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential
white blood cell count
$10.02 $15.47 $13.62 $10.69
$10.71
85027 Complete blood cell count (red cells, white blood cell, platelets), automated test $9.38 $12.89 $11.34 $8.89
$8.98
85300 Clotting inhibitors or anticoagulants; antithrombin III, activity $17.33 $23.21 $20.76 $16.29 CO
85610 Blood test, clotting time $5.78 $7.74 $6.89 $5.40
$5.53
85652 Sedimentation rate, erythrocyte; automated $3.97 $5.16 $4.73 $3.71 CO
85730 Coagulation assessment blood test, plasma or whole blood $8.66 $11.60 $10.51 $8.25
$8.29
86003 Allergen specific IgE; quantitative or semiquantitative, crude allergen extract, each $7.58 $10.32 $9.14 $7.10 CO
86140 C-reactive protein $7.58 $10.32 $9.07 $7.11
$7.25
86146 Beta 2 Glycoprotein I antibody, each $37.17 $50.29 $44.57 $34.97 CO
86148 Anti-phosphatidylserine (phospholipid) antibody $23.46 $31.59 $28.14 $22.08 CO
86304 Immunoassay for tumor antigen, quantitative; CA 125 $30.32 $41.26 $36.46 $28.61 CO
86308 Heterophile antibodies; screening $7.58 $10.32 $9.07 $7.11 CO
86735 Antibody; mumps $19.12 $25.79 $22.87 $17.94 CO
86765 Antibody; rubeola $18.77 $25.79 $22.57 $17.71 CO
86780 Antibody; Treponema pallidum $19.12 $26.43 $22.76 $18.20 CO
86787 Antibody; varicella-zoster $18.17 $25.79 $22.57 $17.71 CO
86803 Hepatitis C antibody $20.93 $28.37 $25.01 $19.62 CO
Effective: June 1, 2021 The information contained in this file is intended for informational purposes only and does not represent any obligation or agreement. 8 of 11
Common Consumer Shoppable Services for HMO Pricing for More Common Health Plans
WellStar AMC, Cobb, Douglas, Kennestone, North Fulton, Paulding, Spaulding, Sylvan Grove and Windy Hill Hospitals
Code Code Description Aetna HMO Cigna HMO
United
Health Care
HMO
Humana
HMO
Anthem HMO
(Blue Cross Blue
Shield Georgia)
87046 Culture, bacterial; stool, aerobic, additional pathogens $13.71 $18.70 $16.52 $12.97 CO
87086 Culture, bacterial; quantitative colony count, urine $11.91 $16.12 $14.15 $11.10 CO
87324 Infectious agent antigen detection qualitative or semiquantitative; Clostridium difficile toxin(s) $17.33 $23.85 $21.02 $16.49 CO
87389 Infectious agent antigen detection HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies, single result $35.01 $47.71 $40.94 $33.11 CO
87400 Infectious agent antigen detection by immunoassay technique Influenza, A or B, each $17.33 $25.14 $21.02 $16.49 CO
87491
Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique $51.25 $69.63 $61.50 $26.97 CO
87591 Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique $51.25 $69.63 $61.50 $26.97 CO
88175
Cytopathology, cervical or vaginal, collected in preservative fluid, automated thin layer preparation; with
screening by automated system and manual rescreening or review, under physician supervision
$38.61 $52.87 $46.42 $36.38 CO
90832 Psychotherapy, 30 minutes $354.58 $335.07 $325.89 $275.40
$327.86
90834 Psychotherapy, 45 minutes $448.82 $424.13 $412.51 $348.60
$415.01
90837 Psychotherapy, 60 minutes $874.47 $826.36 $803.72 $679.20
$808.59
90846 Family psychotherapy, 50 minutes $231.73 $179.79 $195.79 $174.00
$136.08
90847 Family psychotherapy including patient, 50 minutes $339.13 $320.47 $311.69 $263.40
$313.58
90853 Group psychotherapy $367.71 $347.48 $337.96 $285.00
$340.01
92507 Treatment of speech, language, voice, communication, and/or hearing processing disorder $393.00 $282.00 $364.00 $192.00
$366.02
92521 Evaluation of speech fluency $393.00 $282.00 $364.00 $192.00
$366.02
92523 Evaluation of speech sound production with evaluation of language comprehension and expression $393.00 $282.00 $364.00 $192.00
$366.02
92526 Treatment of swallowing and/or oral feeding function $393.00 $282.00 $364.00 $192.00
$366.02
92605
Evaluation for prescription of non-speech-generating augmentative and alternative communication device,
face-to-face with the patient; first hour
$393.00 $282.00 $364.00 $192.00
$366.02
92610
Evaluation of swallowing function $393.00 $282.00 $364.00 $192.00
$366.02
92611
Fluoroscopic and video recorded motion evaluation of swallowing function $393.00 $282.00 $364.00 $537.00
$366.02
93005
Routine electrocardiogram (EKG) with tracing using at least 12 leads $23.20 $427.78 $416.06 $351.60
$418.58
93015
Cardiac stress test with supervision and report $216.38 $178.05 $243.77 $200.73
$215.67
93270
Heart rhythm symptom-related tracing of 24-hour EKG monitoring up to 30 days $25.12 $88.33 $68.16 $72.60
$86.43
93452
Insertion of catheter into left heart including imaging interpretation and supervision and injection $10,546.00 $9,395.00 $9,459.00 $12,033.00
$11,314.74
93458
Insertion of catheter in left heart for imaging of blood vessels and left lower heart including imaging
interpretation and supervision and injection
$10,546.00 $9,395.00 $9,459.00 $12,033.00
$11,314.74
93798
Physician services for outpatient heart rehabilitation with continuous EKG monitoring per session $221.00 $205.86 $200.22 $169.00
$201.43
93923
Ultrasound study of arteries of both arms and legs, complete $380.88 $200.50 $447.30 $378.00
$442.30
Effective: June 1, 2021 The information contained in this file is intended for informational purposes only and does not represent any obligation or agreement. 9 of 11
Common Consumer Shoppable Services for HMO Pricing for More Common Health Plans
WellStar AMC, Cobb, Douglas, Kennestone, North Fulton, Paulding, Spaulding, Sylvan Grove and Windy Hill Hospitals
Code Code Description Aetna HMO Cigna HMO
United
Health Care
HMO
Humana
HMO
Anthem HMO
(Blue Cross Blue
Shield Georgia)
94640
Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen $395.00 $282.00 $364.00 $302.40
$360.01
95708
Measurement of brain wave activity (EEG), 12-26 hours, unmonitored $5,306.77 $4,942.83 $4,807.41 $4,062.60
$4,836.53
95800
Study of sleep patterns, including sleep time $1,130.00 $801.54 $779.58 $658.80
$784.30
95816
Measurement and recording of brain wave (EEG) activity, awake and drowsy $1,294.75 $1,205.96 $1,172.92 $991.20
$1,180.02
95992
Canalith repositioning procedure(s) (e.g., Epley maneuver, Semont maneuver), per day $393.00 $282.00 $364.00 $192.00
$366.02
97033
Application of medication through skin using electrical current, each 15 minutes $393.00 $282.00 $364.00 $192.00
$366.02
97035
Application of ultrasound to 1 or more areas, each 15 minutes $393.00 $282.00 $364.00 $192.00
$366.02
97110
Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes $393.00 $282.00 $364.00 $192.00
$366.02
97112
Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes $393.00 $282.00 $364.00 $192.00
$366.02
97113
Water pool therapy with therapeutic exercises to 1 or more areas, each 15 minutes $393.00 $282.00 $364.00 $192.00
$366.02
97116
Walking training to 1 or more areas, each 15 minutes $393.00 $282.00 $364.00 $192.00
$366.02
97129
Therapeutic interventions that focus on cognitive function (e.g., attention, memory, reasoning, executive
function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the
performance of an activity (e.g., managing time or schedules, initiating, organizing, and sequencing tasks),
direct (one-on-one) patient contact; initial 15 minutes
$393.00 $282.00 $364.00 $192.00
$366.02
97130
Therapeutic interventions that focus on cognitive function (e.g., attention, memory, reasoning, executive
function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the
performance of an activity (e.g., managing time or schedules, initiating, organizing, and sequencing tasks),
direct (one-on-one) patient contact; each additional 15 minutes
$393.00 $282.00 $364.00 $192.00
$366.02
97140
Manual (physical) therapy techniques to 1 or more regions, each 15 minutes $393.00 $282.00 $364.00 $192.00
$366.02
97161
Evaluation of physical therapy, typically 20 minutes $393.00 $282.00 $364.00 $192.00
$366.02
97162
Evaluation of physical therapy, typically 30 minutes $393.00 $282.00 $364.00 $192.00
$366.02
97163
Evaluation of physical therapy, typically 45 minutes $393.00 $282.00 $364.00 $192.00
$366.02
97164
Re-evaluation of physical therapy, typically 20 minutes $393.00 $282.00 $364.00 $192.00
$366.02
97165
Evaluation of occupational therapy, typically 30 minutes $393.00 $282.00 $364.00 $192.00
$366.02
97166
Evaluation of occupational therapy, typically 45 minutes $393.00 $282.00 $364.00 $192.00
$366.02
97167
Evaluation of occupational therapy established plan of care, typically 60 minutes $393.00 $282.00 $364.00 $192.00
$366.02
97168
Re-evaluation of occupational therapy established plan of care, typically 30 minutes $393.00 $282.00 $364.00 $192.00
$366.02
97530
Therapeutic activities to improve function, with one-on-one contact between patient and provider, per each
15 minutes
$393.00 $282.00 $364.00 $192.00
$366.02
97535
Self-care or home management training, each 15 minutes $393.00 $282.00 $364.00 $192.00
$366.02
97606
Negative pressure wound therapy, surface area greater than 50 square centimeters, per session $393.00 $282.00 $182.00 $281.40
$335.01
97760
Training in use of orthotics (supports, braces, or splints) for arms, legs and/or trunk, per 15 minutes $393.00 $282.00 $364.00 $192.00
$366.02
Effective: June 1, 2021 The information contained in this file is intended for informational purposes only and does not represent any obligation or agreement. 10 of 11
Common Consumer Shoppable Services for HMO Pricing for More Common Health Plans
WellStar AMC, Cobb, Douglas, Kennestone, North Fulton, Paulding, Spaulding, Sylvan Grove and Windy Hill Hospitals
Code Code Description Aetna HMO Cigna HMO
United
Health Care
HMO
Humana
HMO
Anthem HMO
(Blue Cross Blue
Shield Georgia)
C8908
Magnetic resonance imaging without contrast followed by with contrast, breast; bilateral $678.00 $652.88 $670.00 $650.00
$600.00
C8924
Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with
image documentation (2D), includes M-mode recording, when performed, follow-up or limited study
$1,069.81 $996.45 $969.15 $819.00
$975.02
C8929
Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with
image documentation (2D), includes M-mode recording, when performed, complete, with spectral doppler
echocardiography, and with color flow doppler echocardiography
$3,597.41 $1,436.64 $1,397.28 $2,754.00
$1,405.74
C8930
Transthoracic echocardiography, with contrast, or without contrast followed by with contrast, real-time with
image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular
stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and
report; including performance of continuous electrocardiographic monitoring, with physician supervision
$2,078.50 $2,014.80 $1,959.60 $1,591.20
$1,971.47
G0283
Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of
a therapy plan of care
$392.92 $282.00 $364.00 $192.00
$366.02
G0424
Pulmonary rehabilitation, including exercise (includes monitoring), one hour, per session, up to two sessions
per day
$97.96 $91.25 $88.75 $75.00
$99.47
Abbreviation Key
Acronym
Meaning
CO
Carve-Out. These services are carved out by Anthem and only covered through their national lab contracts
CT
Computed Tomography
DNA
Deoxyribonucleic Acid
EEG
Electroencephalogram
EKG or ECG
Electrocardiogram
HCG
Human Chorionic Gonadotropin
MRA
Magnetic Resonance Angiogram
MRI
Magnetic Resonance Imaging
RNA
Ribonucleic Acid
TTE
Transthoracic echocardiography
Effective: June 1, 2021 The information contained in this file is intended for informational purposes only and does not represent any obligation or agreement. 11 of 11
