Code|Code Description|Aetna HMO|Cigna 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 |$3,260.00 |$3,299.03 10060|Drainage of abscess|$2,764.00 |$1,908.00 |$1,859.00 |$3,299.03 10160|Aspiration of abscess, blood accumulation, blister, or cyst|$2,764.00 |$1,908.00 |$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 |$1,859.00 |$3,299.03 19120|Removal of 1 or more breast growth, open procedure|$4,734.00 |$3,131.00 |$3,051.00 |$5,754.40 20610|Aspiration and/or injection of large joint or joint capsule|$2,764.00 |$1,908.00 |$1,859.00 |$3,299.03 23350|Injection of dye for X-ray imaging of shoulder joint|$2,764.00 |$1,908.00 |$1,859.00 |$3,299.03 29826|Shaving of shoulder bone using an endoscope|$4,734.00 |$3,131.00 |$3,051.00 |$5,754.40 29881|Removal of one knee cartilage using an endoscope|$5,207.00 |$3,653.00 |$3,622.00 |$6,073.96 38222|Diagnostic aspirations and biopsies of bone marrow|$2,764.00 |$1,908.00 |$3,260.00 |$3,299.03 42820|Removal of tonsils and adenoid glands patient younger than age 12|$4,734.00 |$3,131.00 |$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 |$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 |$2,484.00 |$4,758.54 45378|Diagnostic examination of large bowel using an endoscope|$3,841.00 |$2,550.00 |$2,484.00 |$4,758.54 45380|Biopsy of large bowel using an endoscope|$3,841.00 |$2,550.00 |$2,484.00 |$4,758.54 45385|Removal of polyps or growths of large bowel using an endoscope|$3,841.00 |$2,550.00 |$2,484.00 |$4,758.54 45391|Ultrasound examination of lower large bowel using an endoscope|$3,841.00 |$2,550.00 |$2,484.00 |$4,758.54 49505|Repair of groin hernia patient age 5 years or older|$5,207.00 |$3,653.00 |$3,622.00 |$6,073.96 55700|Biopsy of prostate gland|$3,841.00 |$2,550.00 |$2,484.00 |$4,758.54 59400|Obstetrical pre? and postpartum care and vaginal delivery|$4,234.00 |$3,956.90 |$3,622.00 |$3,731.56 59510|Cesarian delivery with pre- and post?delivery care|$4,414.00 |$4,392.60 |$3,622.00 |$4,018.61 59610|Vaginal delivery after prior cesarean delivery|$4,315.00 |$4,165.57 |$3,622.00 |$3,731.56 62270|Spinal tap for diagnosis|$2,764.00 |$1,908.00 |$1,859.00 |$3,299.03 62322|Injection of substance into spinal canal of lower back or sacrum|$2,764.00 |$1,908.00 |$3,260.00 |$3,299.03 62323|Injection of substance into spinal canal of lower back or sacrum using imaging guidance|$2,764.00 |$1,908.00 |$3,260.00 |$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 |$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 |$3,260.00 |$3,299.03 64493|Injections of lower or sacral spine facet joint using imaging guidance, single level|$2,764.00 |$1,908.00 |$3,260.00 |$3,299.03 64635|Destruction of lower or sacral spinal facet joint nerves using imaging guidance|$2,764.00 |$4,228.00 |$3,260.00 |$4,361.52 66821|Removal of recurring cataract in lens capsule using laser|$3,841.00 |$2,550.00 |$2,484.00 |$4,758.54 66984|Removal of cataract with insertion of lens|$8,022.00 |$5,977.00 |$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 70160|X-ray of bones of nose, minimum of 3 views|$97.19 |$49.64 |$92.96 |$93.00 70220|X-ray of paranasal sinus, complete, minimum of 3 views|$103.48 |$45.77 |$99.02 |$99.02 70250|X-ray of skull, less than 4 views|$97.19 |$45.77 |$93.00 |$93.00 70355|Orthopantogram (e.g., panoramic x-ray)|$39.06 |$15.47 |$37.38 |$37.38 70360|X-ray of soft tissue of neck|$75.71 |$38.68 |$72.45 |$72.45 70450|CT scan head or brain|$451.00 |$131.52 |$425.00 |$400.00 70460|CT scan head or brain with contrast|$451.00 |$192.77 |$425.00 |$400.00 70470|CT scan head or brain before and after contrast|$451.00 |$230.81 |$425.00 |$400.00 70480|CT scan of cranial cavity|$451.00 |$246.92 |$425.00 |$400.00 70481|CT scan of cranial cavity with contrast|$451.00 |$302.37 |$425.00 |$400.00 70486|CT scan of face|$451.00 |$174.07 |$425.00 |$400.00 70487|CT scan of face with contrast|$451.00 |$199.86 |$425.00 |$400.00 70490|CT scan of neck|$451.00 |$181.16 |$425.00 |$400.00 70491|CT scan of neck with contrast|$451.00 |$241.12 |$425.00 |$400.00 70496|CT scan of blood vessel of head with contrast|$451.00 |$378.44 |$425.00 |$400.00 70498|CT scan of neck blood vessels with contrast|$451.00 |$377.80 |$425.00 |$400.00 70543|MRI scan bones of the eye, face, and/or neck before and after contrast|$678.00 |$511.25 |$650.00 |$600.00 70544|MRA scan of head blood vessels|$678.00 |$335.25 |$650.00 |$600.00 70547|MRA scan of neck blood vessels|$678.00 |$336.54 |$650.00 |$600.00 70549|MRA scan of neck blood vessels before and after contrast|$678.00 |$542.20 |$650.00 |$600.00 70551|MRI scan brain|$678.00 |$268.84 |$650.00 |$600.00 70552|MRI scan of brain with contrast|$678.00 |$397.14 |$650.00 |$600.00 70553|MRI scan of brain before and after contrast|$678.00 |$452.59 |$650.00 |$600.00 71045|X-ray of chest, 1 view|$39.50 |$29.66 |$53.10 |$37.80 71046|X-ray of chest, 2 views|$72.31 |$39.33 |$72.42 |$69.20 71047|X-ray of chest, 3 views|$92.02 |$49.64 |$89.36 |$88.06 71048|X-ray of chest, minimum of 4 views|$94.62 |$51.58 |$114.73 |$90.55 71100|X-ray of ribs of one side of body, 2 views|$83.29 |$43.84 |$79.70 |$79.70 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 71111|X-ray of both sides of the ribs including the chest, minimum of 4 views|$145.17 |$63.18 |$138.92 |$138.92 71250|CT scan chest|$451.00 |$181.16 |$425.00 |$400.00 71260|CT scan chest with contrast|$451.00 |$241.77 |$425.00 |$400.00 71270|CT scan chest before and after contrast|$451.00 |$295.28 |$425.00 |$400.00 71275|CT scan of blood vessels in chest with contrast|$451.00 |$383.60 |$425.00 |$400.00 72020|X-ray of spine, 1 view|$61.81 |$29.01 |$59.15 |$59.15 72040|X-ray of spine of neck, 2 or 3 views|$93.38 |$48.35 |$89.36 |$89.36 72050|X-ray of upper spine, 4 or 5 views|$126.23 |$66.40 |$120.79 |$120.79 72070|X-ray of middle spine, 2 views|$88.33 |$38.68 |$84.53 |$84.53 72072|X-ray of middle spine, 3 views|$102.23 |$48.35 |$97.83 |$97.83 72080|X-ray of middle and lower spine, 2 views|$97.19 |$41.90 |$92.96 |$93.00 72081|X-ray of spine, entire middle and lower spine, 1 view|$93.41 |$50.93 |$100.24 |$89.39 72082|X-ray of spine, entire middle and lower spine, 2 or 3 views|$169.82 |$92.84 |$137.73 |$162.51 72100|X-ray of lower and sacral spine, 2 or 3 views|$40.57 |$48.35 |$38.81 |$38.82 72110|X?ray of lower and sacral spine, minimum of 4 views|$55.18 |$63.83 |$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 72125|CT scan of upper spine|$451.00 |$190.83 |$425.00 |$400.00 72128|CT scan of middle spine|$451.00 |$190.83 |$425.00 |$400.00 72131|CT scan of lower spine|$451.00 |$189.54 |$425.00 |$400.00 72132|CT scan of lower spine with contrast|$451.00 |$243.70 |$425.00 |$400.00 72141|MRI scan of upper spinal canal|$678.00 |$257.88 |$650.00 |$600.00 72146|MRI scan of middle spinal canal|$678.00 |$257.88 |$650.00 |$600.00 72148|MRI scan of lower spinal canal|$678.00 |$258.53 |$650.00 |$600.00 72156|MRI scan of upper spinal canal before and after contrast|$678.00 |$457.74 |$650.00 |$600.00 72157|MRI scan of middle spinal canal before and after contrast|$678.00 |$459.03 |$650.00 |$600.00 72158|MRI scan of lower spinal canal before and after contrast|$678.00 |$456.45 |$650.00 |$600.00 72170|X-ray of pelvis, 1 or 2 views|$76.95 |$35.46 |$73.64 |$73.64 72190|X-ray of pelvis, minimum of 3 views|$124.98 |$50.29 |$119.56 |$119.60 72192|CT scan pelvis|$451.00 |$164.40 |$425.00 |$400.00 72193|CT scan pelvis with contrast|$451.00 |$333.31 |$425.00 |$400.00 72195|MRI scan of pelvis|$678.00 |$348.79 |$650.00 |$600.00 72197|MRI scan of pelvis before and after contrast|$678.00 |$508.68 |$650.00 |$600.00 72202|X-ray of sacroiliac joints, 3 or more views|$98.43 |$47.71 |$94.19 |$94.19 72220|X-ray of pelvis, minimum of 2 views|$79.48 |$40.62 |$76.06 |$76.06 73000|X-ray of collar bone|$80.76 |$41.26 |$77.28 |$77.28 73020|X-ray of shoulder, 1 view|$63.06 |$24.50 |$60.34 |$60.34 73030|X-ray of shoulder, minimum of 2 views|$82.00 |$42.55 |$78.47 |$78.47 73060|X-ray of upper arm, minimum of 2 views|$79.48 |$41.26 |$76.06 |$76.06 73070|X-ray of elbow, 2 views|$80.76 |$36.10 |$77.28 |$77.28 73080|X-ray of elbow, minimum of 3 views|$97.19 |$39.97 |$92.96 |$93.00 73090|X-ray of forearm, 2 views|$76.95 |$36.75 |$73.68 |$73.64 73100|X-ray of wrist, 2 views|$89.61 |$43.84 |$85.72 |$85.75 73110|X-ray of wrist, minimum of 3 views|$113.60 |$54.15 |$108.68 |$108.71 73120|X-ray of hand, 2 views|$75.71 |$39.33 |$72.45 |$72.45 73130|X-ray of hand, minimum of 3 views|$93.38 |$47.06 |$89.36 |$89.36 73140|X-ray of fingers, minimum of 2 views|$104.75 |$51.58 |$100.24 |$100.24 73200|CT scan of arm|$451.00 |$232.74 |$425.00 |$400.00 73201|Computed tomography, upper extremity; with contrast material(s)|$346.41 |$297.86 |$580.10 |$400.00 73218|MRI scan of arm|$678.00 |$516.41 |$547.49 |$600.00 73221|MRI scan of arm joint|$678.00 |$291.41 |$437.16 |$600.00 73222|MRI scan of arm joint with contrast|$678.00 |$513.83 |$738.98 |$600.00 73501|X-ray of hip with pelvis, 1 view|$74.98 |$39.97 |$67.59 |$71.75 73502|X-ray of hip with pelvis, 2-3 views|$110.53 |$61.25 |$105.07 |$105.77 73521|Radiologic examination, hips, bilateral, with pelvis when performed; 2 views|$103.95 |$51.58 |$102.66 |$99.47 73552|X-ray of femur, minimum 2 views|$84.20 |$45.77 |$72.45 |$80.57 73560|X-ray of knee, 1 or 2 views|$84.53 |$45.13 |$80.89 |$80.89 73562|X-ray of knee, 3 views|$108.55 |$53.51 |$103.85 |$103.88 73564|X-ray of knee, 4 or more views|$124.98 |$58.67 |$119.60 |$119.60 73590|X-ray of lower leg, 2 views|$74.44 |$40.62 |$71.23 |$71.23 73600|X-ray of ankle, 2 views|$80.76 |$41.90 |$77.28 |$77.28 73610|X-ray of ankle, minimum of 3 views|$97.19 |$47.06 |$92.97 |$93.00 73620|X-ray of foot, 2 views|$33.53 |$36.10 |$32.09 |$32.09 73630|X-ray of foot, minimum of 3 views|$38.94 |$43.84 |$37.26 |$37.26 73650|X-ray of heel, minimum of 2 views|$80.76 |$36.10 |$77.28 |$77.28 73660|X-ray of toes, minimum of 2 views|$93.38 |$38.68 |$89.36 |$89.36 73700|CT scan leg|$451.00 |$189.54 |$425.00 |$400.00 73701|CT scan leg with contrast injection|$451.00 |$245.63 |$425.00 |$400.00 73706|CT scan of lower leg blood vessels with contrast|$451.00 |$473.21 |$425.00 |$400.00 73718|MRI scan of leg|$678.00 |$344.27 |$724.46 |$600.00 73721|MRI scan of leg joint|$678.00 |$291.41 |$437.16 |$600.00 74018|X-ray of abdomen, 1 view|$67.08 |$36.10 |$56.70 |$64.19 74019|X-ray of abdomen, 2 views|$80.21 |$43.84 |$99.02 |$76.76 74021|X-ray of abdomen, minimum of 3 views|$93.34 |$50.93 |$99.02 |$89.32 74150|CT scan abdomen|$451.00 |$161.82 |$425.00 |$400.00 74160|CT scan abdomen with contrast|$451.00 |$332.03 |$425.00 |$400.00 74170|CT scan abdomen before and after contrast|$451.00 |$377.80 |$425.00 |$400.00 74174|CT scan of abdominal and pelvic blood vessels with contrast|$451.00 |$535.11 |$425.00 |$400.00 74176|CT scan of abdomen and pelvis|$451.00 |$203.73 |$425.00 |$400.00 74177|CT scan of abdomen and pelvis with contrast|$451.00 |$426.80 |$425.00 |$400.00 74178|CT scan of abdomen and pelvis before and after contrast|$451.00 |$484.18 |$425.00 |$400.00 74181|MRI scan of abdomen|$678.00 |$274.65 |$634.00 |$600.00 74183|MRI scan of abdomen before and after contrast|$678.00 |$509.96 |$973.10 |$600.00 74230|Imaging for evaluation of swallowing function|$451.00 |$183.29 |$240.45 |$240.45 74240|X-ray of upper digestive tract with single contrast|$451.00 |$140.84 |$296.07 |$296.03 74246|X-ray of upper digestive tract with double contrast|$451.00 |$166.57 |$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 74300|Radiological supervision and interpretation X-ray of bile and/or pancreatic ducts during surgery|$122.13 |$962.14 |$82.01 |$116.87 75561|MRI of heart before and after contrast|$678.00 |$529.31 |$741.74 |$600.00 75571|CT scan of heart with evaluation of blood vessel calcium|$147.77 |$137.32 |$425.00 |$400.00 75572|CT scan of heart structure with contrast|$451.00 |$293.34 |$425.00 |$400.00 75574|CT scan of heart blood vessels and grafts with contrast dye|$451.00 |$437.11 |$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 76010|Imaging from nose to rectum, single view, child|$69.39 |$35.46 |$66.40 |$66.40 76506|Ultrasound of brain|$361.14 |$150.86 |$345.59 |$345.59 76536|Ultrasound of head and neck|$362.43 |$159.24 |$346.82 |$346.82 76604|Ultrasound of chest|$234.85 |$90.90 |$224.74 |$224.74 76641|Ultrasound of one breast, complete|$264.07 |$128.30 |$369.74 |$252.70 76642|Ultrasound of one breast, limited|$202.33 |$97.35 |$369.74 |$193.62 76700|Ultrasound of abdomen|$165.61 |$148.93 |$158.46 |$158.48 76705|Ultrasound of abdomen, limited|$130.42 |$112.18 |$124.82 |$124.80 76770|Ultrasound behind abdominal cavity|$368.72 |$138.61 |$352.87 |$352.84 76775|Ultrasound behind abdominal cavity, limited|$308.11 |$54.15 |$294.84 |$294.84 76801|Abdominal ultrasound of pregnant uterus (less than 14 weeks 0 days) single or first fetus|$128.81 |$131.52 |$123.24 |$123.26 76805|Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or|$162.89 |$163.76 |$155.90 |$155.88 76815|Ultrasound of pregnant uterus, 1 or more fetus(es)|$96.86 |$93.48 |$92.69 |$92.69 76817|Vaginal ultrasound of pregnant uterus|$107.14 |$105.73 |$102.53 |$102.53 76818|Fetal biophysical profile; with non-stress testing|$275.26 |$119.27 |$263.41 |$263.41 76830|Ultrasound pelvis through vagina|$67.62 |$160.53 |$64.71 |$64.71 76856|Ultrasound of pelvis, complete, not pregnancy related|$149.37 |$136.68 |$142.94 |$142.94 76857|Ultrasound of pelvis, limited, not pregnancy related|$125.01 |$43.19 |$119.63 |$119.63 76870|Ultrasound of scrotum|$356.09 |$132.81 |$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 76885|Ultrasound of hips with manipulation, infant|$431.88 |$193.41 |$413.28 |$413.28 77065|Diagnostic mammography of one breast|$99.49 |$168.91 |$196.95 |$95.21 77066|Diagnostic mammography of both breasts|$127.27 |$215.33 |$259.37 |$121.79 77072|Imaging for bone age assessment|$54.25 |$28.37 |$51.87 |$51.91 77075|X-ray survey of forearm or wrist bone density|$304.30 |$108.69 |$291.24 |$291.20 77077|Imaging of 2 or more joints, single view|$92.14 |$51.58 |$88.17 |$88.17 77081|Bone density measurement of the core or extremities (e.g., radius, wrist, heel)|$65.58 |$39.97 |$62.79 |$62.76 78452|Nuclear medicine study of vessels of heart using drugs or exercise multiple studies|$1,579.75 |$721.42 |$1,511.72 |$1,511.72 80048|Blood test, basic group of blood chemicals (Calcium, total)|$12.27 |$16.76 |$11.63 |CO 80053|Blood test, comprehensive group of blood chemicals|$15.52 |$21.28 |$14.53 |CO 80061|Blood test, lipids (cholesterol and triglycerides)|$25.26 |$26.43 |$18.42 |CO 80069|Kidney function blood test panel|$12.63 |$17.41 |$11.94 |CO 80076|Liver function blood test panel|$11.91 |$16.12 |$11.23 |CO 80170|Gentamycin|$23.82 |$32.24 |$22.53 |CO 80178|Lithium|$9.74 |$12.89 |$9.09 |CO 80185|Dilantin|$19.49 |$26.43 |$18.22 |CO 81000|Manual urinalysis test with examination using microscope, non-automated|$4.69 |$7.09 |$4.35 |CO 81001|Urinalysis auto w/microscope|$4.69 |$6.45 |$4.35 |CO 81002|Urinalysis, manual test|$3.61 |$6.45 |$3.52 |CO 81003|Automated urinalysis test|$3.25 |$4.51 |$3.09 |CO 81025|Urine pregnancy test, by visual color comparison methods|$9.38 |$15.47 |$8.70 |CO 82043|Albumin; urine (e.g., microalbumin), quantitative|$8.30 |$11.60 |$7.95 |CO 82105|Alpha-fetoprotein (AFP); serum|$24.54 |$33.53 |$23.06 |CO 82232|Beta-2 microglobulin|$23.46 |$32.24 |$22.24 |CO 82306|Vitamin D|$43.30 |$58.67 |$40.70 |CO 82310|Calcium|$7.58 |$10.32 |$7.09 |$7.25 82436|Cloride urine|$7.22 |$10.32 |$6.91 |CO 82570|Creatinine urine|$7.58 |$10.32 |$7.11 |CO 82607|B12|$22.02 |$29.66 |$20.72 |CO 82652|Vitamin D; 1, 25 dihydroxy, includes fraction(s), if performed|$56.29 |$76.72 |$52.92 |CO 82668|Erythopoietin|$27.43 |$37.39 |$25.84 |CO 82677|Estriol|$35.36 |$47.71 |$33.25 |CO 82728|Ferritin|$19.84 |$27.08 |$18.73 |CO 82731|Fetal fibronectin, cervicovaginal secretions, semi-quantitative|$93.83 |$127.65 |$88.54 |$89.79 82977|Glutamyltransferase, gamma (GGT)|$10.46 |$14.18 |$9.90 |CO 83036|Hemoglobin; glycosylated (A1C)|$14.08 |$19.34 |$13.34 |CO 83051|Hemoglobin; plasma|$10.83 |$14.18 |$10.05 |CO 83540|Iron|$9.38 |$12.89 |$8.90 |CO 83550|Iron binding capacity|$12.63 |$17.41 |$12.02 |CO 83630|Lactoferrin, fecal; qualitative|$28.51 |$38.68 |$26.98 |CO 83735|Magnesium|$9.74 |$13.54 |$9.21 |CO 84133|Potassium; urine|$6.13 |$8.38 |$5.91 |CO 84153|PSA (prostate specific antigen) measurement, total|$26.70 |$36.75 |$25.29 |CO 84154|PSA (prostate specific antigen) measurement, free|$26.70 |$36.75 |$25.29 |CO 84425|Thiamine (Vitamin B-1)|$31.04 |$41.91 |$29.19 |CO 84439|Thyroxine; free|$12.99 |$18.05 |$12.40 |CO 84443|Blood test, thyroid stimulating hormone (TSH)|$24.54 |$33.53 |$23.10 |CO 84481|Triiodothyronine T3; free|$24.54 |$33.53 |$23.29 |CO 84540|Urea nitrogen, urine|$6.86 |$9.67 |$6.53 |CO 84702|Gonadotropin, chorionic (hCG); quantitative|$22.02 |$29.66 |$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 |$10.69 |$10.71 85027|Complete blood cell count (red cells, white blood cell, platelets), automated test|$9.38 |$12.89 |$8.89 |$8.98 85300|Clotting inhibitors or anticoagulants; antithrombin III, activity|$17.33 |$23.21 |$16.29 |CO 85610|Blood test, clotting time|$5.78 |$7.74 |$5.40 |$5.53 85652|Sedimentation rate, erythrocyte; automated|$3.97 |$5.16 |$3.71 |CO 85730|Coagulation assessment blood test, plasma or whole blood|$8.66 |$11.60 |$8.25 |$8.29 86003|Allergen specific IgE; quantitative or semiquantitative, crude allergen extract, each|$7.58 |$10.32 |$7.10 |CO 86140|C-reactive protein|$7.58 |$10.32 |$7.11 |$7.25 86146|Beta 2 Glycoprotein I antibody, each|$37.17 |$50.29 |$34.97 |CO 86148|Anti-phosphatidylserine (phospholipid) antibody|$23.46 |$31.59 |$22.08 |CO 86304|Immunoassay for tumor antigen, quantitative; CA 125|$30.32 |$41.26 |$28.61 |CO 86308|Heterophile antibodies; screening|$7.58 |$10.32 |$7.11 |CO 86735|Antibody; mumps|$19.12 |$25.79 |$17.94 |CO 86765|Antibody; rubeola|$18.77 |$25.79 |$17.71 |CO 86780|Antibody; Treponema pallidum|$19.12 |$26.43 |$18.20 |CO 86787|Antibody; varicella-zoster|$18.17 |$25.79 |$17.71 |CO 86803|Hepatitis C antibody|$20.93 |$28.37 |$19.62 |CO 87046|Culture, bacterial; stool, aerobic, additional pathogens|$13.71 |$18.70 |$12.97 |CO 87086|Culture, bacterial; quantitative colony count, urine|$11.91 |$16.12 |$11.10 |CO 87324|Infectious agent antigen detection qualitative or semiquantitative; Clostridium difficile toxin(s)|$17.33 |$23.85 |$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 |$33.11 |CO 87400|Infectious agent antigen detection by immunoassay technique Influenza, A or B, each|$17.33 |$25.14 |$16.49 |CO 87491|Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique|$51.25 |$69.63 |$26.97 |CO 87591|Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique|$51.25 |$69.63 |$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 |$36.38 |CO 90832|Psychotherapy, 30 minutes|$354.58 |$335.07 |$275.40 |$327.86 90834|Psychotherapy, 45 minutes|$448.82 |$424.13 |$348.60 |$415.01 90837|Psychotherapy, 60 minutes|$874.47 |$826.36 |$679.20 |$808.59 90846|Family psychotherapy, 50 minutes|$231.73 |$179.79 |$174.00 |$136.08 90847|Family psychotherapy including patient, 50 minutes|$339.13 |$320.47 |$263.40 |$313.58 90853|Group psychotherapy|$367.71 |$347.48 |$285.00 |$340.01 92507|Treatment of speech, language, voice, communication, and/or hearing processing disorder|$393.00 |$282.00 |$192.00 |$366.02 92521|Evaluation of speech fluency|$393.00 |$282.00 |$192.00 |$366.02 92523|Evaluation of speech sound production with evaluation of language comprehension and expression|$393.00 |$282.00 |$192.00 |$366.02 92526|Treatment of swallowing and/or oral feeding function|$393.00 |$282.00 |$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 |$192.00 |$366.02 92610|Evaluation of swallowing function|$393.00 |$282.00 |$192.00 |$366.02 92611|Fluoroscopic and video recorded motion evaluation of swallowing function|$393.00 |$282.00 |$537.00 |$366.02 93005|Routine electrocardiogram (EKG) with tracing using at least 12 leads|$23.20 |$427.78 |$351.60 |$418.58 93015|Cardiac stress test with supervision and report|$216.38 |$178.05 |$200.73 |$215.67 93270|Heart rhythm symptom-related tracing of 24-hour EKG monitoring up to 30 days|$25.12 |$88.33 |$72.60 |$86.43 93452|Insertion of catheter into left heart including imaging interpretation and supervision and injection|$10,546.00 |$9,395.00 |$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 |$12,033.00 |$11,314.74 93798|Physician services for outpatient heart rehabilitation with continuous EKG monitoring per session|$221.00 |$205.86 |$169.00 |$201.43 93923|Ultrasound study of arteries of both arms and legs, complete|$380.88 |$200.50 |$378.00 |$442.30 94640|Respiratory inhaled pressure or nonpressure treatment to relieve airway obstruction or for sputum specimen|$395.00 |$282.00 |$302.40 |$360.01 95708|Measurement of brain wave activity (EEG), 12-26 hours, unmonitored|$5,306.77 |$4,942.83 |$4,062.60 |$4,836.53 95800|Study of sleep patterns, including sleep time|$1,130.00 |$801.54 |$658.80 |$784.30 95816|Measurement and recording of brain wave (EEG) activity, awake and drowsy|$1,294.75 |$1,205.96 |$991.20 |$1,180.02 95992|Canalith repositioning procedure(s) (e.g., Epley maneuver, Semont maneuver), per day|$393.00 |$282.00 |$192.00 |$366.02 97033|Application of medication through skin using electrical current, each 15 minutes|$393.00 |$282.00 |$192.00 |$366.02 97035|Application of ultrasound to 1 or more areas, each 15 minutes|$393.00 |$282.00 |$192.00 |$366.02 97110|Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes|$393.00 |$282.00 |$192.00 |$366.02 97112|Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes|$393.00 |$282.00 |$192.00 |$366.02 97113|Water pool therapy with therapeutic exercises to 1 or more areas, each 15 minutes|$393.00 |$282.00 |$192.00 |$366.02 97116|Walking training to 1 or more areas, each 15 minutes|$393.00 |$282.00 |$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 |$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 |$192.00 |$366.02 97140|Manual (physical) therapy techniques to 1 or more regions, each 15 minutes|$393.00 |$282.00 |$192.00 |$366.02 97161|Evaluation of physical therapy, typically 20 minutes|$393.00 |$282.00 |$192.00 |$366.02 97162|Evaluation of physical therapy, typically 30 minutes|$393.00 |$282.00 |$192.00 |$366.02 97163|Evaluation of physical therapy, typically 45 minutes|$393.00 |$282.00 |$192.00 |$366.02 97164|Re-evaluation of physical therapy, typically 20 minutes|$393.00 |$282.00 |$192.00 |$366.02 97165|Evaluation of occupational therapy, typically 30 minutes|$393.00 |$282.00 |$192.00 |$366.02 97166|Evaluation of occupational therapy, typically 45 minutes|$393.00 |$282.00 |$192.00 |$366.02 97167|Evaluation of occupational therapy established plan of care, typically 60 minutes|$393.00 |$282.00 |$192.00 |$366.02 97168|Re-evaluation of occupational therapy established plan of care, typically 30 minutes|$393.00 |$282.00 |$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 |$192.00 |$366.02 97535|Self-care or home management training, each 15 minutes|$393.00 |$282.00 |$192.00 |$366.02 97606|Negative pressure wound therapy, surface area greater than 50 square centimeters, per session|$393.00 |$282.00 |$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 |$192.00 |$366.02 C8908|Magnetic resonance imaging without contrast followed by with contrast, breast; bilateral |$678.00 |$652.88 |$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 |$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 |$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 |$1,591.20 |$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 |$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 |$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||||