SELF-PAY RATES

Thank you for choosing Atlanta Gastroenterology Associates (AGA, LLC) and it’s affiliated endoscopy centers. Our discounted rates for self-pay patients are listed below. If more than one service is rendered on the same day, the payment due equals the sum of the fees for each service. OFFICE SERVICES INFUSION SERVICES J Office visit J New patient $ 225 J Administration J First hour $ 225 J Established patient $ 125 J Each additional hour $ 55 J J Anoscop y ...... $ 125 Injection $ 200 J J CIMZIA ® medication B12 injection ...... $ 25 J Flexible sigmoidoscopy ...... $ 250 Number of 200 mg vials $ 4,000/vial J ® J G-tube replacement ...... $ 600 ENTYVIO medication Number of 300 mg vials $ 6,100/vial J Guaiac ...... $ 10 J Injectafer ® medication J H. Pylori breath test ...... $ 175 Number of 750 mg vials $ 1,500/vial J Hemorrhoid banding ...... $ 450 J REMICADE ® medication J ® Hemosure ...... $ 75 Number of 100 mg vials $ 880/vial J ® Hepatitis A vaccine ( HAVRIX ) ...... S 120 J STELARA ® medication ® J Hepatitis B vaccine ( ENGERIX -B ) ...... $ 130 Number of 120 mg vials $ 2,500/vial J Hepatitis A & B vaccine (Twinrix ®) ...... $ 160 Number of 45 mg vials $12,635/vial J Hydrogen breath test (HBT) ...... $ 100 J TYSABRI ® medication J PillCam ® patency capsule ...... $ 100 Number of 300 mg vials $ 6,000/vial J PillCam ® or PillCam ® Colon ...... $ 1,400 J Venofer ® medication J Ultrasound ...... $ 200 Number of 200 mg vials $ 120/vial J Ultrasound, doppler (complete) ...... $ 450 HOSPITAL SERVICES J Ultrasound, doppler (limited) ...... $ 250 The fees below represent physician charges only. Other charges may apply. J Vitamin D injection ...... $ 35 J Colonoscopy ...... $ 500 ENDOSCOPY CENTER PROCEDURES J EGD ...... $ 400 The fees below are all-inclusive and represent charges from the physician, J EGD and colonoscopy ...... $ 800 facility, pathology and anesthesia, unless otherwise noted. J EGD with Bravo pH testing ...... $ 1,000 J Colonoscopy ...... $ 1,500 J Endoscopic ultrasound (EUS) ...... $ 1,200 J Colonoscopy with hemorrhoid banding . . . . . $ 1,900 J ERCP ...... $ 1,250 J EGD ...... $ 1,300 J Esophagoscopy ...... $ 400 J EGD and colonoscopy ...... $ 2,000 J Liver biopsy ...... $ 500 J EGD with Bravo pH testing ...... $ 2,000 J Paracentesis ...... $ 125 J Flexible sigmoidoscopy ...... $ 900 J PillCam ® ...... $ 300 J Hemorrhoid banding ...... $ 500 J InterStim ® SNS ...... $ 8,145 MOTILITY SERVICES J Liver biopsy ...... $ 1,375 The fees below represent physician charges only. Other charges may apply. J Paracentesis ...... $ 625 J Anorectal manometry ...... $ 275 (Pathology charged separately. Anesthesia not required for procedure.) J Catheter based pH monitoring ...... $ 225 J Esophageal impedance ...... $ 200 IMAGING SERVICES J Esophageal manometry ...... $ 225 J CT abdomen/pelvis with contrast ...... $ 675 J Esophageal manometry + pH ...... $ 450 J CT abdomen/pelvis without contrast ...... $ 675 J Esophageal manometry with impedance . . . . $ 425 J CT abdomen with contrast ...... $ 400 J CT angiography abdomen/pelvis with contrast .$1,400 NUTRITION SERVICES J CT angiography abdomen with contrast . . . . $ 750 J Nutrition new consult ...... $ 110 J CT bone density ...... $ 300 J Nutrition established/follow-up visit ...... $ 75 J CT enterography with contrast ...... $ 675 If you pay in full at the time of service, we will offer a 10% discount on the above published rates. For balances not paid in full at the time of service, a monthly payment plan with automatic credit card draft will be required. The 10% discount cannot be applied to previous services rendered. Please refer to the Payment Agreement form for additional information.

06-11Rev. 03-19