STAR MEDICAL CENTER

Below pricing includes surgeon, anesthesia, facility, implants, and pathology fees: DRG CPT PROCEDURE FEE Spine 455 Comined Anterior/Posterior Spinal Fusion- 1 level $60,150 455 Comined Anterior/Posterior Spinal Fusion- 2 level $60,650 460 Spinal Fusion except Cervical / Lumbar - 1 level $41,450 460 Spinal Fusion except Cervical / Lumbar - 2 level $41,950 473 Cervical Spine Fusion- 1 level $25,925 473 Cervical Spine Fusion- 2 level $26,425 520 63030 Lumbar Laminotomy- 1 level $11,500 520 63030, 63035 Lumbar Laminotomy- 2 level $11,825 520 63047 Lumbar Laminectomy- 1 level $11,500 520 63047, 63048 Lumbar Laminectomy- 2 level $11,825 520 63020 Cervical Laminotomy- 1 level $11,500 520 63020, 63035 Cervical Laminotomy- 2 level $11,825 520 63045 Cervical Laminectomy- 1 level $11,500 520 63045, 63048 Cervical Laminectomy- 2 level $11,825 Orthopedics 470 27130 Total Hip Arthroplasty $25,000 468 Revision of Hip Arthroplasty $28,525 470 27447 Total Knee Arthroplasty $23,250 470 27446 Knee Arthroplasty - unicompartmental (medial or lateral) $20,475 468 Revision of Knee Arthroplasty $24,000 29888, 29889 ACL Repair/Reconstruction $7,300 29888, 29889 ACL Repair/Reconstruction with Allograft $10,200 508 23472 Total Shoulder Arthroplasty $17,350 508 23473, 23474 Reverse Total Shoulder Arthroplasty $17,950 483 23470 Shoulder Hemiarthroplasty $19,000 29805 Shoulder Arthroscopy without repair $6,060 29806 Arthroscopy, shoulder, surgical; capsulorrhaphy $6,060 29807 Arthroscopy, shoulder, surgical; repair of SLAP lesion $6,060 Arthroscopy, shoulder, surgical; with removal of loose body or 29819 foreign body $6,060 29820 Arthroscopy, shoulder, surgical; synovectomy, partial $6,060 29821 Arthroscopy, shoulder, surgical; synovectomy, complete $6,060 29822 Arthroscopy, shoulder, surgical; debridement, limited $6,060 29823 Arthroscopy, shoulder, surgical; debridement, extensive $6,060 Arthroscopy, shoulder, surgical; distal claviculectomy including 29824 distal articular surface $6,060 Arthroscopy, shoulder, surgical; with lysis and resection of 29825 adhesions, with or without manipulation $6,060 29827 Shoulder Arthroscopy with repair $6,330 483 23470, 23472 Shoulder Reconstruction $18,500 29822, 29824, 29826, 23827 Rotator Cuff Repair (Arthroscopic) $6,550

*This list of procedures are for review purposes only and is not a guarantee of benefits. Please refer to your Summary Plan Description. STAR MEDICAL CENTER

Below pricing includes surgeon, anesthesia, facility, implants, and pathology fees: 29822, 29824, 29826, 23412 Rotator Cuff Repair (Open) $6,260 General Surgery Open repair of Umbilical, incisional, ventral, Spigelian or epigastric 49560 hernia (With or Without Mesh) $4,700 Repair initial incisional or ventral hernia; incarcerated or 49561 strangulated $4,700 49565 Repair recurrent incisional or ventral hernia; reducible $4,700 Repair recurrent incisional or ventral hernia; incarcerated or 49566 Implantationstrangulated of mesh or other prosthesis for open incisional or $4,700 ventral hernia repair or mesh for closure of debridement for 49568 necrotizing soft tissue infection $4,700 49570 Repair epigastric hernia; reducible $4,700 49572 Repair epigastric hernia $4,700 49580 Repair umbilical hernia, younger than age 5 years; reducible $4,700 49582 Repair umbilical hernia, younger than age 5 years $4,700 49585 Repair umbilical hernia, age 5 years or older; reducible $4,700 49587 Repair umbilical hernia, age 5 years or older $4,700 49590 Repair spigelian hernia $4,700 49650, 49651 Laparoscopic Inguinal hernia repair (With or Without Mesh) $5,500 49505 Open repair of Inguinal Hernia (With or W/O Mesh) $4,700 49507 Repair initial inguinal hernia, age 5 years or older $4,700 49520 Repair recurrent inguinal hernia, any age; reducible $4,700 49521 Repair recurrent inguinal hernia $4,700 49525 Repair inguinal hernia, sliding, any age $4,700 Bariatric Surgery 620 43644 Laparoscopic Gastric Bypass (Roux-en-Y) $17,200 620 43775 Laparoscopic Sleeve Gastrectomy $12,200

*This list of procedures are for review purposes only and is not a guarantee of benefits. Please refer to your Summary Plan Description.