Medicine Lodge Memorial Hospital CDM Report December 13, 2018 This Charge Information Provides a General Idea of the Prices for Services Provided at Our Hospital

Medicine Lodge Memorial Hospital CDM Report December 13, 2018 This charge information provides a general idea of the prices for services provided at our hospital. There may be additional charges (for example, pre-procedure office visits, surgeon, anesthesiologist, radiologist, pathologist, consulting physicians, emergency room physicians, supplies and drugs.). Charges are applied based on the practitioner orders and services provided. The estimated cost is not a guarantee of insurance coverage. Consumers are encouraged to check with their insurance company to best understand benefits and out of pocket responsibility for the service chosen. Please contact the business office at 620-886-3771 if you have questions or need assistance.

Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price Echocardiogram Tracing Only Cardiovascular $64.70 ALS MILEAGE NONCOVERED .10 MILES Emergency Room $0.85 ALS MILEAGE PER .10 MILES Emergency Room $0.65 AMBU BLS EMERG TRANS AI Emergency Room $390.00 APPLICATION LOWER LEG SPLINT Emergency Room $274.00 APPLICATION OF FINGER SPLINT Emergency Room $274.00 APPLICATION OF LONG ARM CAST Emergency Room $175.00 APPLY FOREARM SPLINT Emergency Room $274.00 ARTERIAL PUNCTURE DRAW FEE Emergency Room $97.75 ARTHROCENT/ASP/INJ INT JNT WO US Emergency Room $190.00 BLOOD ADMIN 0-12HRS (PER DAY) ER Charge Emergency Room $648.00 BLOOD ADMIN 0-16HRS (PER DAY) ER Charge Emergency Room $648.00 BLOOD ADMIN 0-4HRS (PER DAY) Emergency Room $648.00 BLOOD COLLECT- IMPLANT VENOUS Emergency Room $70.00 BLOOD COLLECT- IMPLANT VENOUS ER Charge Emergency Room $70.00 BLS MILEAGE NONCOVERED .10 MILES Emergency Room $0.85 BLS MILEAGE PER .10 MILES Emergency Room $0.85 BLS MILEAGE PER MILE Emergency Room $8.50 BURN CARE INITIAL 1ST DEGREE Emergency Room $170.00 CARDIOPULMONARY RESUSCITATION ER Charge Emergency Room $385.92 CARDIOVERSION ELECTIVE Emergency Room $502.50 CHEST TUBE INSERT ER Charge Emergency Room $900.00 CLSD TRMT DISTAL RADIAL W MAN Emergency Room $1,107.00 CLSD TRMT ELBOW DISLOC WO ANES Emergency Room $815.00 CLSD TRMT RADIAL HD SBLUX CHILD Emergency Room $600.00 CLSD TRMT SHLDR DIS W/ANEST Emergency Room $815.00 CLSD TRMT SHOULDER DISCLOC W/MNP Emergency Room $1,092.10 CLSD TX INTERPHALANGE WO ANE Emergency Room $743.00 CLSD TX PATELLAR DSLC WO ANS Emergency Room $801.00 CNTRL NASAL HEMORRHAGE ANT SIM Emergency Room $300.00 Critical Care Emergency Room $1,267.00 Critical Care, each 30 min Emergency Room $482.40 DEBRIDEMENT SKIN TISS/MSCL/BONE Emergency Room $331.00 DECLOT VASCULAR DEVICE Emergency Room $95.00 DRAINAGE OF FINGER ABSCESS SIMP Emergency Room $315.00 DRESS/DEBRID BURN SM < 5% Emergency Room $442.00 DRESS/DEBRID BURN LG >10% Emergency Room $441.60 DRESS/DEBRIDE BURN MED 5-10% Emergency Room $423.20 DRN/INJ MAJOR JOINT/BURSA WO US Emergency Room $250.00 ER BLOOD COLLECT - IMPLANT VENOUS Emergency Room $70.00 ER BLOOD COLLECT CENTRAL/PERIPH DEV ER Charge Emergency Room $75.00

1/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price ER CARDIOVERSION ELECTIVE Emergency Room $502.50 ER IMMUNIZATION ADMIN ONE VACCINE Emergency Room $69.01 ER INTRO NEEDLE OR INTRACATH- VEIN Emergency Room $117.92 EVACUATION SUBUNGUAL HEMATOMA Emergency Room $90.00 Evaluation Level 1 Emergency Room $300.00 Evaluation Level 2 Emergency Room $330.00 Evaluation Level 3 Emergency Room $425.00 Evaluation Level 4 Emergency Room $442.20 Evaluation Level 5 Emergency Room $509.20 EXPL PENETRATING WOUND EXTRM Emergency Room $305.00 Hydration, each additional hour Emergency Room $201.00 Hydration, first hour Emergency Room $306.86 I&D ABSCESS SIMPLE/SINGLE Emergency Room $275.00 I&R FRGN BODY SUBCU TISS SIMPLE Emergency Room $291.00 IMMUNIZATION ADMIN ONE VACCINE Emergency Room $69.01 Influenza Vac for ER Emergency Room $34.00 INJ ANES AGENT OTHR PERIPH NRV Emergency Room $150.00 INJ TENDON SHEATH/LIGAMENT Emergency Room $170.00 INJ TRIGGER POINT 1 OR 2 MUSCL Emergency Room $177.00 INSERT FOLEY CATHETER SIMPLE Emergency Room $167.00 INSERT STRAIGHT CATHETER ER Emergency Room $107.20 INTMD RPR FACE/MM 2.5 CM/< Emergency Room $295.00 INTMD RPR FACE/MM 2.6-5.0 CM Emergency Room $315.00 INTMD RPR N-HF/GENIT 2.5CM/< Emergency Room $200.00 INTMD RPR N-HF/GENIT2.6-7.5 Emergency Room $225.00 INTMD RPR S/A/T/EXT 12.6-20 Emergency Room $620.00 INTMD RPR S/TR/EXT 7.6-12.5 Emergency Room $620.00 INTRMD RPR SATE 2.5CM OR LESS Emergency Room $295.00 INTRO NEEDLE OR INTRACATH- VEIN Emergency Room $117.92 INTUBATION Emergency Room $500.00 IRRIGATE IMPLANT VEN ACC DEVICE Emergency Room $67.00 IRRIGATION OF BLADDER Emergency Room $70.00 IV Injection, Add new drug Emergency Room $69.68 IV Injection, Add same drug Emergency Room $69.68 IV Injection, single/initial Emergency Room $69.68 IV START ATTEMPTED Emergency Room $117.92 IV tx, concurrent infusion Emergency Room $14.74 IV tx, each additional hour Emergency Room $201.00 IV tx, first hour Emergency Room $306.86 IV tx, sequential infusion Emergency Room $306.86 LAYER CLOSURE NHF 12.6 TO 20CM Emergency Room $1,370.00 MASTOTOMY DEEP ABSCESS Emergency Room $1,797.00 NASAL HEMOR POS W/NASAL PK SUB Emergency Room $57.00 NASAL HEMOR POSTER W/NASAL PK Emergency Room $191.00 NASAL/OROGASTRIC W/TUBE PLCMNT Emergency Room $507.00 NERVE BLK INJ PLANTAR DIGIT Emergency Room $150.00 PLACE NEEDLE INTRAOSSEOUS INFUS Emergency Room $129.00 POS AIRWAY PRESSURE CPAP Emergency Room $308.00 PRESSURIZED/NOPRESS INHAL TRMT Emergency Room $80.40 REM FRGN BODY CORNEAL WO LAMP Emergency Room $525.00 REM FRGN BODY EXT ADTRY Emergency Room $86.00 REM FRGN BODY EXT EYE SUPRF Emergency Room $275.00

2/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price REM FRGN BODY INTRANASAL Emergency Room $80.00 REM FRGN BODY MUSC/TENDON Emergency Room $305.00 REMOVE IMPACT EAR WAX W INSTRMT Emergency Room $140.00 REMOVE IMPACTED EAR WAX UNI Emergency Room $140.00 REPAIR CMPLX FNH 2.6-7.5CM Emergency Room $495.00 REPAIR COMP FNH 1.1CM-2.5CM Emergency Room $295.00 REPAIR INTER SATE 2.6-7.5CM Emergency Room $325.00 REPAIR SIMP FEL 2.6CM-5.0CM Emergency Room $295.00 RPR SIMP S/N/A/G/TRNK >30.0 CM Emergency Room $1,400.00 RPR SIMP F/E/E/N/L/M 5.1-7.5 CM Emergency Room $325.00 RPR SIMP F/E/E/N/L/M 7.6-12.5 CM Emergency Room $600.00 RPR SIMP S/N/A/GN/TRK20.1-30.0CM Emergency Room $1,200.00 SIMPLE RPR FACE 2.5CM OR LESS Emergency Room $275.00 SIMPLE RPR STHF 12.6-20CM Emergency Room $590.00 SIMPLE RPR STHF 2.5CM OR LESS Emergency Room $265.00 SIMPLE RPR STHF 2.6CM-7.5CM Emergency Room $285.00 SIMPLE RPR STHF 7.6CM-12.5CM Emergency Room $315.00 Subq/IM Injection Emergency Room $69.68 TRMT KNEE DISLOC WO ANES Emergency Room $570.00 TUBE THORACOSTOMY W/WO WATER S Emergency Room $900.00 VAG DELIVERY ONLY Emergency Room $200.00 .Gluc 3 Hr General Lab $18.40 .Gluc Fasting General Lab $57.50 81001 UA AUTOMATED W/ MICRO General Lab $16.40 ABORh GL General Lab $20.70 Acetaminophen AMS General Lab $59.00 Aerobic Body Fluid Culture AMS General Lab $54.74 Aerobic Wound Culture AMS General Lab $54.74 Aerobic/Anaerobic Wound Culture - AMS General Lab $54.74 Alanine Aminotransferase General Lab $16.68 Albumin Level General Lab $17.25 Albumin Random Urine (Microalbumin) - AMS General Lab $24.85 Albumin/Creatinine Ratio, Urine - AMS General Lab $24.85 Alcohol, Blood AMS General Lab $72.00 Alkaline Phosphatase General Lab $20.20 Alpha Fetal Protein AMS General Lab $61.87 Ammonia AMS General Lab $73.20 Amylase Level General Lab $29.90 ANA Panel, Quantitative AMS General Lab $95.22 ANA Screen AMS General Lab $83.30 ANCA AMS General Lab $53.59 Antibody ID AMS General Lab $111.55 Antibody Screen AMS General Lab $25.35 Aspartate Aminotransferase General Lab $17.25 AT3 AMS General Lab $58.31 Barbiturates Confirmation, Urine - AMS General Lab $58.00 Basic Metabolic Panel General Lab $45.83 Benzodiazepine Confirmation AMS General Lab $58.00 Beta-2 Microglobulin, S AMS General Lab $47.60 Bilirubin Direct General Lab $24.15 Bilirubin Direct General Lab $24.15 Bilirubin Total General Lab $25.30

3/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price Bilirubin Total General Lab $27.60 Bleeding Time General Lab $15.00 Blood Culture #2 AMS General Lab $48.82 Blood Culture AMS General Lab $48.82 Blood Gas Arterial General Lab $79.35 Blood Glucose Monitoring POC (GPHA) General Lab $10.35 Blood Glucose POC General Lab $17.25 Blood Urea Nitrogen General Lab $17.25 Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simu General Lab $34.00 Body Fluid Culture (Aerobic and Anaerobic) AMS General Lab $54.74 Body Fluid Culture (Aerobic and Anaerobic) with Gram Stain AMS General Lab $54.74 B-Type Natriuretic Peptide General Lab $85.00 C. difficile Antigen Test - AMS General Lab $63.65 C. difficile toxin B gene by PCR - AMS General Lab $91.66 C3 Complement AMS General Lab $74.75 C4 Complement AMS General Lab $74.75 CA 19-9 AMS General Lab $60.55 CA-125 AMS General Lab $69.63 Calcium Ionized AMS General Lab $51.75 Calcium Level Total General Lab $17.25 Carbamazepine AMS General Lab $111.25 Carbon Dioxide Level General Lab $22.75 CEA AMS General Lab $110.69 Chlam/ GC Nucleic Acid Screen AMS General Lab $86.25 Chlamydia trachomatis and N gonorrhoeae Swab - AMS General Lab $86.25 Chloride Level General Lab $21.20 Cholesterol General Lab $17.25 Cholesterol High Density Lipid General Lab $21.85 CK-MB General Lab $63.25 CMV DNA QT, Plasma - AMS General Lab $147.00 Cocaine Confirmation, Urine - AMS General Lab $58.00 Cold Agglutinin Titer AMS General Lab $40.90 COLLECTION: Arterial Draw General Lab $97.75 COLLECTION: Capillary General Lab $13.69 COLLECTION: Fingerstick General Lab $13.69 COLLECTION: Venous Draw General Lab $20.82 Complete Blood Count w/o Diff General Lab $33.93 Complete Blood Count with Automated Differential General Lab $36.92 Complete Blood Count with Manual Differential General Lab $33.93 Comprehensive Metabolic Panel General Lab $55.95 Cortisol AM AMS General Lab $88.09 Cortisol PM AMS General Lab $88.09 C-Peptide AMS General Lab $85.68 C-Reactive Protein General Lab $31.05 C-Reactive Protein AMS General Lab $29.00 Creatine Kinase General Lab $27.60 Creatine Kinase General Lab $27.60 Creatine Kinase MB General Lab $63.25 Creatinine General Lab $17.25 Creatinine 24 Hour Urine General Lab $29.79

4/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price Creatinine Clearance - AMS General Lab $33.65 Creatinine Urine General Lab $29.79 Creatinine with eGFR General Lab $17.25 CRP High Sensitivity AMS General Lab $71.95 Crystal Exam, Synovial Fluid AMS General Lab $97.58 Cyc. Citrullinated Peptide - AMS General Lab $166.64 DAT GL General Lab $28.58 D-Dimer AMS General Lab $84.85 Digoxin Level General Lab $63.25 DS DNA Autoantibody AMS General Lab $95.22 Electrolyte Panel General Lab $27.95 Epstein-Bar Virus Serology - AMS General Lab $79.79 Estradiol - AMS General Lab $170.78 Eye Culture AMS General Lab $54.74 Fecal Leukocyte Stain - AMS General Lab $24.38 Fecal Occult Blood Diagnostic - IA General Lab $39.10 Fecal Occult Blood Screen - IA General Lab $39.10 Ferritin - AMS General Lab $73.20 Folate - AMS General Lab $91.66 Francisella Tularensis Ab - AMS General Lab $25.35 Free Thyroxine Index General Lab $35.65 FSH - AMS General Lab $102.35 Fungal Culture AMS General Lab $41.40 Genital Culture AMS General Lab $54.74 Gentamicin Random AMS General Lab $65.70 GGT - AMS General Lab $22.20 Giardia / Cryptosporidium Antigen Screen AMS General Lab $65.70 Glucose 1 Hr Post Glucola General Lab $24.15 Glucose 2 Hour Postprandial General Lab $57.50 Glucose Level General Lab $17.25 Gonorrhoeae Culture AMS General Lab $25.59 Gram Stain - AMS General Lab $15.47 Group A Strep Culture - AMS General Lab $25.59 HCG Quantitative AMS General Lab $94.10 Helicobacter IgG - AMS General Lab $87.28 Hematocrit General Lab $14.26 Hematocrit Neonatal General Lab $14.26 Hematocrit POC General Lab $14.26 Hemoccult POC General Lab $17.10 Hemoglobin General Lab $14.26 Hemoglobin A1c General Lab $42.55 Hemoglobin A1c POC General Lab $42.55 Hemoglobin Neonatal General Lab $14.26 Hemoglobin POC General Lab $17.10 Hep B Surface Antibody AMS General Lab $61.00 Hepatic Function Panel General Lab $36.92 Hepatitis B Surface Antigen AMS General Lab $37.49 Hepatitis C RNA AMS General Lab $235.69 Hepatitis C Total Ab - AMS General Lab $67.28 Hepatitis Panel - AMS General Lab $67.28 HIV Antigen/Antibody Combo - AMS General Lab $92.00 Homocysteine - AMS General Lab $172.00

5/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price Immunoelectrophoresis, Serum AMS General Lab $55.37 Immunoelectrophoresis, Urine AMS General Lab $201.14 Immunoglobulin Free Light Chains, Serum AMS General Lab $177.33 Immunoglobulin Light Chains, Urine AMS General Lab $177.33 Insulin - AMS General Lab $63.65 Iron - AMS General Lab $39.85 Iron Profile - AMS General Lab $39.85 JO1 Autoantibody AMS General Lab $73.20 KOH General Lab $21.85 KOH POC General Lab $21.85 KOH Prep General Lab $21.85 Lactate Dehydrogenase General Lab $20.70 Lactate Dehydrogenase General Lab $20.70 Lactic Acid General Lab $48.00 Lamotrigine - AMS General Lab $99.90 LDH - AMS General Lab $23.23 LDL Direct AMS General Lab $51.75 Lead, Blood AMS General Lab $21.75 Levetiracetam - AMS General Lab $99.90 Lipase Level General Lab $33.35 Lipid Panel Screen General Lab $50.60 Lithium - AMS General Lab $33.93 Luteinizing Hormone AMS General Lab $108.91 Lyme Disease EIA - AMS General Lab $103.56 Magnesium Level - AMS General Lab $42.84 Manual Differential (05) General Lab $10.70 Metanephrines Fractionated, 24 hr Urine - AMS General Lab $97.58 Methadone Confirmation - AMS General Lab $58.00 Microalbumin Level 24 Hour Urine General Lab $29.00 Microalbumin Level Urine General Lab $29.00 Mono Spot POC General Lab $24.15 MRSA Screen AMS General Lab $25.59 Mumps, Measles, Rubella, Varicella Zoster Ig - AMS General Lab $74.50 Neonatal Screen General Lab $58.00 NT-Pro BNP - AMS General Lab $83.30 Opiate Confirmation, Ur - AMS General Lab $58.00 Osmolality, Urine - AMS General Lab $33.93 Ova and Parasite Exam AMS General Lab $39.70 Oxalate, 24 hr Urine - AMS General Lab $67.28 Partial Thromboplastin Time General Lab $27.60 Phenobarbital - AMS General Lab $73.20 Phenytoin AMS General Lab $51.25 Phenytoin Level General Lab $64.40 Phosphorus Level General Lab $22.60 Phosphorus Level - AMS General Lab $18.46 Platelet Count General Lab $16.04 Potassium Level General Lab $18.46 Prealbumin AMS General Lab $71.99 Pro-BNP General Lab $85.00 Procalcitonin - AMS General Lab $204.00 Progesterone - AMS General Lab $106.55 Prolactin - AMS General Lab $112.47

6/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price Prostate Specific Antigen Diagnostic General Lab $79.35 Prostate Specific Antigen Screen General Lab $79.35 Protein electrophoresis, Urine AMS General Lab $55.95 Protein Total General Lab $21.20 Protein/Creatinine Ratio, Urine AMS General Lab $23.81 PSA Reflex - AMS General Lab $200.10 PSA Total - AMS General Lab $200.10 PT General Lab $17.88 PT/ INR POC General Lab $17.88 PTH - AMS General Lab $213.67 Quantiferon TB Test - AMS General Lab $125.00 Rapid Influenza A and B General Lab $63.25 Rapid Influenza A and B with QC General Lab $63.25 Rapid Mono Screen General Lab $24.15 Rapid Mono Screen with QC General Lab $24.15 Rapid Occult Blood Screen Stool General Lab $12.40 Rapid Pregnancy Test General Lab $38.07 Rapid Pregnancy Test Urine General Lab $32.20 Rapid Pregnancy Test Urine with QC General Lab $32.20 Rapid Pregnancy Test with QC General Lab $38.70 Rapid Strep A Screen General Lab $60.09 Renal Function Panel General Lab $62.50 Respiratory Virus Panel-PCR - AMS General Lab $230.00 Reticulocyte Count Automated - AMS General Lab $90.85 Rheumatoid Factor - AMS General Lab $40.48 Rhogam Workup GL General Lab $20.70 Rotaviris, Rapid Ag - AMS General Lab $65.70 RPR - AMS General Lab $17.88 RPR - Physical (AMS) General Lab $17.88 RSV - Rapid Molecular - AMS General Lab $187.00 Rubella IgG - AMS General Lab $33.35 SCL Autoantibody AMS General Lab $73.20 Sedimentation Rate General Lab $17.88 Semen Post Vasectomy 1 General Lab $55.20 Semen Post Vasectomy 2 General Lab $55.20 Semen Post Vasectomy 3 General Lab $55.20 Serum Protein Electrophoresis(SPEP) - AMS General Lab $30.36 SM Autoantibody AMS General Lab $41.40 Sodium Level General Lab $24.38 Sputum Culture with Gram Stain AMS General Lab $15.47 SSA Autoantibody AMS General Lab $73.20 SSB Autoantibody AMS General Lab $73.20 Stool Culture with Shiga toxin AMS General Lab $30.36 Streptolysin O Ab AMS General Lab $41.90 Syphilis Ab Screen w/ Reflex - AMS General Lab $17.88 T3 Free - AMS General Lab $129.72 T3 Total - AMS General Lab $54.05 Tacrolimus (Prograf) - AMS General Lab $82.80 Testosterone Free and Total - AMS General Lab $152.95 Testosterone Total - AMS General Lab $152.95 THC GC/MS Confirmation - AMS General Lab $58.00 Theophylline Level General Lab $62.00

7/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price Thryoid Stimulating Hormone General Lab $51.75 Thyroglobulin Ab screen AMS General Lab $108.15 Thyroglobulin, Tumor Marker - AMS General Lab $138.69 Thyroid Stimulating Hormone General Lab $51.75 Thyroperoxidase Ab (TPO) - AMS General Lab $59.00 Thyroxine General Lab $20.70 Thyroxine General Lab $20.70 Thyroxine (T4) AMS General Lab $20.82 Thyroxine Free General Lab $35.65 Triglycerides General Lab $17.25 Troponin-I General Lab $80.50 Troponin-I General Lab $80.50 Type and Cross GL General Lab $20.70 Type and Screen GL General Lab $20.70 U Drug Scrn General Lab $102.00 UA automated, without microscopy General Lab $13.80 UA Dipstick POC (Glucose and Protein) General Lab $10.85 UA Microscopic General Lab $17.00 UA non-automated without microscopy General Lab $11.00 Upper Respiratory Culture AMS General Lab $54.74 Uric Acid General Lab $24.38 Urinalysis General Lab $13.80 Urinalysis with Microscopic, if indicated General Lab $13.80 Urine Creatinine General Lab $29.79 Urine Culture AMS General Lab $45.25 Urine Dipstick Amb POC General Lab $13.80 Urine Dipstick POC General Lab $13.80 Urine Microalbumin General Lab $29.00 Urine Microalbumin POC General Lab $29.90 Urine Pregnancy POC General Lab $28.00 Valproic Acid General Lab $75.90 Vancomycin Level Peak General Lab $70.84 Vancomycin Level Trough General Lab $70.84 Vancomycin Trough - AMS General Lab $66.75 Vitamin B12 AMS General Lab $80.93 Vitamin B12 and Folate - AMS General Lab $80.96 Vitamin D, 1,25-Dihydroxy AMS General Lab $95.75 Vitamin D, 25-Hydroxy AMS General Lab $298.77 West Nile virus Antibody IgG, IgM, Serum - AMS General Lab $110.11 Wet Mount POC General Lab $20.70 Wet Prep 1 General Lab $20.70 White Blood Cell Count General Lab $17.10 Wound Culture Aerobic w/ Gram Stain - AMS General Lab $54.74 Yes - Manual Differential? General Lab $33.93 Yes - Manual Differential? General Lab $33.93 Zinc, Serum - AMS General Lab $55.90

Anaerobic Culture RL General Lab Add-On $46.40

ANTIBODY SCREENING RBC General Lab Add-On $36.92

AST/SGOT AMS General Lab Add-On $26.00

8/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price

BCR/ABL1 Gene Other BP AMS General Lab Add-On $114.00

Beta Lactamase RL General Lab Add-On $45.00

BLOOD TYPE RH(D) General Lab Add-On $20.70

C Diff Toxin B Ag Detection AMS General Lab Add-On $18.00

CHLAMYDIA TRACH DNA AMP PROBE General Lab Add-On $86.25

Cholesterol AMS General Lab Add-On $27.00

CMV-DNA Quant AMS General Lab Add-On $147.00

Crossmatch Antiglobulin Technique General Lab Add-On $54.17

Crossmatch IS Technique/Unit General Lab Add-On $64.29

Cult Type Amp Probe Cult/Isol Ea AMS General Lab Add-On $140.00

Culture Bacterial Def Other Source General Lab Add-On $54.74

Culture Typing GLC/HPLC RL General Lab Add-On $52.00

Culture/ID Anaerobic Bacteria RL General Lab Add-On $33.35

Culture/Typing/Serologic Method AMS General Lab Add-On $20.70

Cyto-Path-Conc Tech Smear/Interp General Lab Add-On $92.00

DNA Detect Agent Mult Amplified General Lab Add-On $187.00

Drug Buprenorphine General Lab Add-On $107.00

Empty Vaccutainer General Lab Add-On $7.75

FNA Interp/Report General Lab Add-On $225.00

Folic Acid/Folates-Serum AMS General Lab Add-On $91.66

Glucose AMS General Lab Add-On $18.00

Gram Stain RL General Lab Add-On $15.47

Immunohisto Antibody Slide Ea Add'l General Lab Add-On $327.75

Immunohisto Antibody Slide Multx General Lab Add-On $283.00

Influenza B Virus AG Detect General Lab Add-On $67.90

Leuko Reduced Red Blood Cells Ea Unit General Lab Add-On $341.03

9/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price

Lipoprotein LDL Dir Measurement AMS General Lab Add-On $51.75

Liquid Base Prep w/Interp General Lab Add-On $82.00

M Tuberculo DNA Amp Probe General Lab Add-On $248.00

Manual Diff General Lab Add-On $10.70

Molecular ID Quantification AMS General Lab Add-On $307.00

Opiods & Opiate Analogs 3/4 RL General Lab Add-On $58.00

OVA and Parasite Exam AMS General Lab Add-On $48.70

Partial Thromboplastin Time RL General Lab Add-On $47.00

Preg Test HCG Quant AMS General Lab Add-On $94.01

Protein/Creatinine Ration, Urine AMS General Lab Add-On $24.85

Protein-Urine 24 Hour AMS General Lab Add-On $34.50

Protime-Substitution/Plasma Frac AMS General Lab Add-On $97.00

RL Aerobic Add'l Meth ID Ea Isolate General Lab Add-On $47.61

RL Culture Stool Addn'l Pathogens General Lab Add-On $33.35

RL Iron Binding Capacity General Lab Add-On $64.86

RL RSV Immunoassay General Lab Add-On $77.00

RL Shiga-like Toxin Ag ELA General Lab Add-On $73.20

RL Smear w/interp AFB General Lab Add-On $40.35

RL Testosterone Free General Lab Add-On $157.72

RL Vitamin B12 General Lab Add-On $80.96

Rubella - AMS General Lab Add-On $33.35

Rubeola - AMS General Lab Add-On $81.75

Russell Viper Venom Time Diluted AMS General Lab Add-On $43.40

Sensitivity General Lab Add-On $48.82

Smear - Any Other Source General Lab Add-On $82.00

Smear w/ Interp Gram Stain General Lab Add-On $15.47

10/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price

STAPH AUREUS AMP PROBE TECH General Lab Add-On $67.00

Stool Culture With Shiga Toxin AMS General Lab Add-On $73.20

Surgical Path Decal General Lab Add-On $55.20

Surgical Path Level I General Lab Add-On $40.90

Surgical Path Level II General Lab Add-On $92.00

Surgical Path Level III General Lab Add-On $133.40

Surgical Path Level IV General Lab Add-On $223.10

Surgical Path Level V General Lab Add-On $270.00

Surgical Path Level VI General Lab Add-On $418.60

Surgical Path Stains - Group I General Lab Add-On $88.55

Surgical Path Stains - Group II General Lab Add-On $76.19

Tissue Immunoperoxidase General Lab Add-On $327.75

Urine Culture ID General Lab Add-On $38.70

Varicella Zoster - AMS General Lab Add-On $79.70

Venipuncture General Lab Add-On $20.82

West Nile Virus IGM AMS General Lab Add-On $110.11 Nutrition Services DIETARY COUNSELING Charges $51.75 Nutrition Services MED NUTRITION REASSESSMENT 15 MIN Charges $16.55 Nutrition Services MED NUTRTN THER INITIAL ASSESS 15MN Charges $16.55 OBSRV 1ST HOUR Observation $496.00 OBSRV 1ST HR W/IV INFUSION Observation $274.80 OBSRV ADD'L HR 1ST DAY Observation $23.00 OBSRV ADD'L HR SUBSEQUENT DAY Observation $32.00 OBSRV ADD'L HR W/IV INF 1ST DAY Observation $11.00 OBSRV ADD'L HR W/IV INF SUBSEQ DAY Charge Observation $16.00 OBS Admin Influenza Vaccine G0008 Observation $34.00 OBS ADMIN PNEUMOCOCCAL VACCINE Charge Observation $51.50 OBS CARDIOPULMONARY RESUSCITATION Charge Observation $288.00 OBS CARDIOVERSION ELECTIVE Charge Observation $375.00 OBS IM OR SQ INJECTION PER STICK Charge Observation $63.60 OBS INHALATION TRMT (AEROSOL/NEB) Charge Observation $55.20 OBS INTRO NEEDLE OR INTRACATH VEIN Charge Observation $91.80 OBS IV INFU HYDRAT EA ADD'L HR 2ND Observation $274.80

11/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price OBS IV INFU HYDRAT EA ADD'L HRCharge Observation $13.20 OBS IV INFU THER INITIAL 16-90 MIN Charge Observation $274.80 OBS IV INFU THERAP CONCURRENT Charge Observation $13.20 OBS IV INFU THERAP EA ADD'L HR Charge Observation $13.20 OBS IV INFU THERAP EA ADD'L SEQ NEW Charge Observation $274.80 OBS IV INFUS HYDRAT INIT 31 MIN-1HR Charge Observation $274.80 OBS IV PUSH EA ADD'L SAME DRUG Charge Observation $63.60 OBS IV PUSH EA ADD'L SEQ NEW DRUG Charge Observation $63.60 OBS IV PUSH SINGLE OR INITIAL Charge Observation $63.60 OBSRV BLOOD ADMIN 1ST HR Charge Observation $386.40 OBSRV BLOOD ADMIN EA ADDL HR Observation $92.00 Occupational Attended E-Stim Charges Therapy $47.50 Occupational Cognitive Retraining Units Therapy $77.00 Occupational Iontophoresis Charges Therapy $45.50 Occupational OT Contrast Bath Units Therapy $47.50 Occupational OT Manual Therapy Charge Units Therapy $47.50 Occupational OT Massage Charge Units Therapy $47.50 Occupational OT Neuromuscular Reeducation Charges Therapy $47.50 Occupational OT Paraffin Bath Charge Therapy $47.50 Occupational OT Self Care, Home Management Units Therapy $54.50 Occupational OT Therapeutic Activities Charges Therapy $54.50 Occupational OT Therapeutic Exercise Charges Therapy $47.50 Occupational Ultrasound Charges Therapy $47.50 E-STIM Manual/15min Units Physical Therapy $55.90 Gait Training Units Physical Therapy $55.90 Manual Therapy Charge Units Physical Therapy $67.30 Mechanical Traction Provided Units Physical Therapy $80.20 NEG Wound PRSR THPY <50CM W/SUPP Units Physical Therapy $111.00 NEG Wound PRSR THPY <50CM WO/SUPP RF Units Physical Therapy $111.00 NEG Wound PRSR THPY <50CM WO/SUPP Units Physical Therapy $111.00 NEG Wound PRSR THPY >50CM W/SUPP RF Units Physical Therapy $221.00 NEG Wound PRSR THPY >50CM W/SUPP Units Physical Therapy $221.00 NEG Wound PRSR THPY >50CM WO/SUPP Units Physical Therapy $221.00 Neuromuscular Reeducation Units Physical Therapy $55.90 Orthotic Training Units Physical Therapy $70.00 Phonophoresis Units Physical Therapy $65.70 PT App Multi Layer Compress Lower Leg Units Physical Therapy $330.00 PT Apply Multi Layer Compress UPR Leg Units Physical Therapy $330.00 PT Diathermy Charge Physical Therapy $67.30 PT Electrical Stimulation Unattended Charge Physical Therapy $54.50

12/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price PT High Complex Units Physical Therapy $285.70 PT Iontophoresis Charges Physical Therapy $55.90 PT IP Neg Wound Prsr Thpy <50cm-Supp. Units Physical Therapy $650.00 PT IP Neg Wound Prsr Thpy >50cm - Supp. Units Physical Therapy $774.00 PT Low Complex Units Physical Therapy $142.85 PT Massage Charge Units Physical Therapy $32.60 PT Moderate Complex Units Physical Therapy $214.28 PT Neg Wound PRSR Thpy <50CM Units Physical Therapy $111.00 PT Neg Wound PRSR Thpy >50CM Units Physical Therapy $221.00 PT Parafin Bath Charge Physical Therapy $55.90 PT Physical Performance Test Physical Therapy $96.25 PT ReEval Units Physical Therapy $83.85 PT Self Care, Home Management Charges Physical Therapy $67.30 PT Strapping of Ankle and/or Foot Units Physical Therapy $330.00 PT Strapping Shoulder Units Physical Therapy $330.00 PT Tens APP W/O Charge Physical Therapy $368.00 PT TENS Use Charge Physical Therapy $368.00 PT Ultrasound Charges Physical Therapy $65.70 PT Ultrasound Units Physical Therapy $65.70 PT Unna Boot Units Physical Therapy $330.00 STATIC AFO Physical Therapy $66.36 Therapeutic Activities Charge Physical Therapy $67.30 Therapeutic Exercise Charges Physical Therapy $55.35 Therapeutic Exercise Units Physical Therapy $55.35 Vasopneumatic Pump Units Physical Therapy $50.20 WhirlpoolFluidotherapy Units Physical Therapy $134.05 Wound Care Debride Add'L 20sq CM Units Physical Therapy $181.00 Wound Care Selective Debridement Charge Physical Therapy $155.00 BD Bone Density DEXA Axial Skeleton Radiology $235.00 CT 3D Reconstruction Radiology $477.65 CT Abdomen + Pelvis w/ + w/o Contrast Radiology $716.64 CT Abdomen + Pelvis w/ Contrast Radiology $779.16 CT Abdomen + Pelvis w/o Contrast Radiology $686.00 CT Abdomen w/ + w/o Contrast Radiology $1,006.00 CT Abdomen w/ Contrast Radiology $806.25 CT Abdomen w/o Contrast Radiology $798.50 CT Angiography Abd Aorta + Iliofemoral Radiology $1,485.00 CT Angiography Abdomen + Pelvis Radiology $2,025.00 CT Angiography Chest for PE Radiology $1,359.00 CT Angiography Chest w/ + w/o Contrast Radiology $1,359.00 CT Angiography Head w/ + w/o Contrast Radiology $1,377.00 CT Angiography Lower Extremity Left Radiology $1,265.30 CT Angiography Lower Extremity Right Radiology $1,265.30 CT Angiography Neck w/ + w/o Contrast Radiology $1,378.00 CT Angiography Upper Extremity Bilat Radiology $1,265.30 CT Angiography Upper Extremity Left Radiology $1,265.30 CT Angiography Upper Extremity Right Radiology $1,265.30 CT Head or Brain w/ + w/o Contrast Radiology $837.92 CT Head or Brain w/ Contrast Radiology $577.00 CT Head or Brain w/o Contrast Radiology $611.88 CT IAC w/o Contrast Radiology $1,060.90 CT Limited or Localized F/U Study Radiology $559.95

13/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price CT Lower Extremity w/+w/o Contrast Bilat Radiology $1,043.30 CT Lower Extremity w/+w/o Contrast Left Radiology $1,043.30 CT Lower Extremity w/+w/o Contrast Right Radiology $1,043.30 CT Lower Extremity w/o Contrast Bilat Radiology $550.00 CT Lower Extremity w/o Contrast Left Radiology $550.00 CT Lower Extremity w/o Contrast Right Radiology $550.00 CT Maxillofacial w/ + w/o Contrast Radiology $758.65 CT Maxillofacial w/ Contrast Radiology $1,060.90 CT Maxillofacial w/o Contrast Radiology $614.36 CT Pelvis w/ + w/o Contrast Radiology $709.20 CT Pelvis w/ Contrast Radiology $778.85 CT Pelvis w/o Contrast Radiology $579.60 CT Sinus w/o Contrast Radiology $614.36 CT Soft Tissue Neck w/ + w/o Contrast Radiology $605.28 CT Soft Tissue Neck w/ Contrast Radiology $548.12 CT Soft Tissue Neck w/o Contrast Radiology $548.00 CT Spine Cervical w/o Contrast Radiology $838.76 CT Spine Lumbar w/ + w/o Contrast Radiology $624.00 CT Spine Lumbar w/o Contrast Radiology $633.00 CT Spine Thoracic w/ + w/o Contrast Radiology $624.00 CT Spine Thoracic w/o Contrast Radiology $851.60 CT Thorax w/ + w/o Contrast Radiology $731.12 CT Thorax w/ Contrast Radiology $647.92 CT Thorax w/o Contrast Radiology $650.40 CT Upper Extremity w/o Contrast Bilat Radiology $623.60 CT Upper Extremity w/o Contrast Left Radiology $623.60 CT Upper Extremity w/o Contrast Right Radiology $623.60 ECHO (Rad) Radiology $1,800.00 EKG (Radiology) Radiology $64.70 Holter Monitor Recording (RAD) Radiology $346.00 MRA Abdomen w/ + w/o Contrast Radiology $752.00 MRA Head w/o Contrast Radiology $753.00 MRA Lower Extremity w/ + w/o Bilat Radiology $680.00 MRA Lower Extremity w/ + w/o Left Radiology $680.00 MRA Lower Extremity w/ + w/o Right Radiology $680.00 MRA Neck w/ + w/o Contrast Radiology $813.00 MRA Neck w/ Contrast Radiology $783.00 MRA Neck w/o Contrast Radiology $753.00 MRI Abdomen w/ + w/o Contrast Radiology $680.00 MRI Abdomen w/ Contrast Radiology $660.00 MRI Abdomen w/o Contrast Radiology $646.90 MRI Brain w/ + w/o Contrast Radiology $680.00 MRI Brain w/ Contrast Radiology $660.00 MRI Brain w/o Contrast Radiology $646.90 MRI Face Neck Orbit w/ + w/o Contrast Radiology $680.00 MRI Face Neck Orbit w/o Contrast Radiology $646.90 MRI LE Joint w/ + w/o Contrast Bilateral Radiology $680.00 MRI LE Joint w/ + w/o Contrast Left Radiology $680.00 MRI LE Joint w/ + w/o Contrast Right Radiology $680.00 MRI LE Joint w/o Contrast Bilateral Radiology $646.90 MRI LE Joint w/o Contrast Left Radiology $646.90 MRI LE Joint w/o Contrast Right Radiology $646.90

14/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price MRI LE Non Joint w/ + w/o Contrast Bilat Radiology $680.00 MRI LE Non Joint w/ + w/o Contrast Left Radiology $680.00 MRI LE Non Joint w/ + w/o Contrast Right Radiology $680.00 MRI LE Non Joint w/o Contrast Bilat Radiology $646.90 MRI LE Non Joint w/o Contrast Left Radiology $646.90 MRI LE Non Joint w/o Contrast Right Radiology $646.90 MRI Pelvis w/ + w/o Contrast Radiology $680.00 MRI Pelvis w/ Contrast Radiology $660.00 MRI Pelvis w/o Contrast Radiology $646.90 MRI Spine Cervical w/ + w/o Contrast Radiology $680.00 MRI Spine Cervical w/o Contrast Radiology $646.90 MRI Spine Lumbar w/ + w/o Contrast Radiology $680.00 MRI Spine Lumbar w/ Contrast Radiology $660.00 MRI Spine Lumbar w/o Contrast Radiology $646.90 MRI Spine Thoracic w/ + w/o Contrast Radiology $680.00 MRI Spine Thoracic w/o Contrast Radiology $646.90 MRI UE Joint w/ + w/o Contrast Left Radiology $680.00 MRI UE Joint w/ + w/o Contrast Right Radiology $680.00 MRI UE Joint w/ Contrast Left Radiology $660.00 MRI UE Joint w/ Contrast Right Radiology $660.00 MRI UE Joint w/o Contrast Left Radiology $646.90 MRI UE Joint w/o Contrast Right Radiology $646.90 MRI UE Non Joint w/ + w/o Contrast Left Radiology $680.00 MRI UE Non Joint w/ + w/o Contrast Right Radiology $680.00 MRI UE Non Joint w/o Contrast Bilateral Radiology $646.90 MRI UE Non Joint w/o Contrast Left Radiology $646.90 MRI UE Non Joint w/o Contrast Right Radiology $646.90 NM Bone Three Phase Study Radiology $527.00 NM Kidney Imaging w/ Function Radiology $842.00 NM Kidney Imaging w/ Vascular Flow Radiology $957.00 US Abdomen Complete Radiology $415.00 US Abdomen Limited Radiology $260.00 US Abdomen/Pelvic/Scrotal Art/Vein Comp Radiology $575.00 US Ankle Brachial Index Radiology $575.00 US Aorta Duplex Limited Radiology $271.50 US Aorta IVC Iliac Duplex Complete Radiology $597.00 US Aorta Screening Radiology $187.00 US Carotid Doppler Bilateral Radiology $575.00 US Chest Radiology $573.00 US Echo 2D Comp w/ Color Flow Doppler Radiology $1,800.00 US Echo 2D Comp w/o Color Flow Doppler Radiology $684.00 US Echo Doppler Complete Radiology $571.00 US Echocardiogram Radiology $1,800.00 US Extremity Non Vascular Left Radiology $182.50 US Extremity Non Vascular Limited Radiology $238.00 US Extremity Non Vascular Right Radiology $182.50 US Guided Needle Placement Radiology $469.00 US Head/Neck Soft Tissue Radiology $643.50 US LE Arterial Duplex Bilateral Radiology $575.00 US LE Arterial Duplex Left Radiology $575.00 US LE Arterial Duplex Right Radiology $575.00 US LE Venous Doppler Bilateral Radiology $575.00

15/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price US LE Venous Duplex Bilateral Radiology $575.00 US LE Venous Duplex Left Radiology $575.00 US LE Venous Duplex Right Radiology $575.00 US Pelvis Non OB Complete Radiology $263.50 US Pelvis Non OB Limited Radiology $127.00 US Pregnancy 1st Trimester Radiology $237.50 US Pregnancy After 1st Trim Ea Addl Gest Radiology $336.50 US Pregnancy After 1st Trimester Radiology $324.00 US Pregnancy Limited Radiology $607.00 US Pregnancy Transvaginal Radiology $336.50 US Renal Artery Doppler Radiology $575.00 US Retroperitoneal Complete Radiology $257.50 US Retroperitoneal Limited Radiology $271.50 US Scrotum (Contents) Radiology $244.00 US Thyroid Radiology $643.50 US Transvaginal Non OB Radiology $224.00 US UE Arterial Duplex Bilateral Radiology $626.50 US UE Arterial Duplex Left Radiology $571.00 US UE Arterial Duplex Right Radiology $571.00 US UE Venous Duplex Bilateral Radiology $575.00 US UE Venous Duplex Left Radiology $575.00 US UE Venous Duplex Right Radiology $575.00 XR Abdomen 1 View Radiology $199.00 XR Abdomen 2 View Radiology $249.00 XR Abdomen 2 Views Radiology $249.00 XR AC Joints Bilateral w/ + w/o wts Radiology $163.00 XR Ankle 2 Views Bilateral Radiology $198.86 XR Ankle 2 Views Left Radiology $198.86 XR Ankle 2 Views Right Radiology $198.86 XR Ankle Complete Bilateral Radiology $229.79 XR Ankle Complete Left Radiology $229.79 XR Ankle Complete Right Radiology $229.79 XR Bone Survey Complete (Mets) Radiology $929.45 XR Calcaneus Bilateral Radiology $229.79 XR Calcaneus Left Radiology $229.79 XR Calcaneus Right Radiology $229.79 XR Chest 1 View Radiology $199.00 XR Chest 2 Views Radiology $249.00 XR Cholangiogram in OR Radiology $399.00 XR Clavicle Bilateral Radiology $179.28 XR Clavicle Left Radiology $179.28 XR Clavicle Right Radiology $179.28 XR Elbow 2 Views Bilateral Radiology $229.79 XR Elbow 2 Views Left Radiology $229.79 XR Elbow 2 Views Right Radiology $229.79 XR Facial Bones < 3 Views Radiology $238.02 XR Femur 1 View Lt Radiology $207.00 XR Femur 1 View Rt Radiology $207.00 XR Femur Min 2 Views Lt Radiology $284.76 XR Femur Min 2 Views Rt Radiology $284.76 XR Finger 2nd Digit Left Radiology $179.28 XR Finger 2nd Digit Right Radiology $179.28

16/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price XR Finger 3rd Digit Left Radiology $179.28 XR Finger 3rd Digit Right Radiology $179.28 XR Finger 4th Digit Left Radiology $179.28 XR Finger 4th Digit Right Radiology $179.28 XR Finger 5th Digit Left Radiology $179.28 XR Finger 5th Digit Right Radiology $179.28 XR Finger Thumb Left Radiology $179.28 XR Finger Thumb Right Radiology $179.28 XR Fluoro Vascular Placement Radiology $221.50 XR Fluoroscopy > 1 Hour Non Rad Radiology $333.25 XR Fluoroscopy Up to 1 Hour Radiology $270.23 XR Foot 2 Views Bilateral Radiology $198.86 XR Foot 2 Views Left Radiology $198.86 XR Foot 2 Views Right Radiology $198.86 XR Foot Complete Bilateral Radiology $229.79 XR Foot Complete Left Radiology $229.79 XR Foot Complete Right Radiology $229.79 XR Forearm 2 Views Bilateral Radiology $229.79 XR Forearm 2 Views Left Radiology $229.79 XR Forearm 2 Views Right Radiology $229.79 XR Foreign Body Loc Nose/Rectum Child Radiology $163.00 XR Hand 2 Views Bilateral Radiology $198.86 XR Hand 2 Views Left Radiology $198.86 XR Hand 2 Views Right Radiology $198.86 XR Hand Complete Bilateral Radiology $229.79 XR Hand Complete Left Radiology $229.79 XR Hand Complete Right Radiology $229.79 XR Hip 1 View Left Radiology $124.99 XR Hip 1 View Lt w/ Pelvis Radiology $124.99 XR Hip 1 View Right Radiology $124.99 XR Hip 1 View Rt w/ Pelvis Radiology $124.99 XR Hip 2-3 Views Lt w/ Pelvis Radiology $248.76 XR Hip 2-3 Views Rt w/ Pelvis Radiology $248.76 XR Hips Bil w/ Pelvis 2 Views Radiology $299.27 XR Humerus Bilateral Radiology $229.79 XR Humerus Left Radiology $229.79 XR Humerus Right Radiology $229.79 XR IVP Radiology $572.00 XR Knee 1 or 2 Views Bilateral Radiology $229.79 XR Knee 1 or 2 Views Left Radiology $229.79 XR Knee 1 or 2 Views Right Radiology $229.79 XR Knee 3 Views Bilateral Radiology $229.79 XR Knee 3 Views Left Radiology $229.79 XR Knee 3 Views Right Radiology $229.79 XR Knee Complete 4 or More Views Radiology $275.00 XR Knee Complete Left Radiology $275.00 XR Knee Complete Right Radiology $275.00 XR Knee Standing AP Bilateral Radiology $167.65 XR Mandible Partial Less Than 4 Views Radiology $245.30 XR Mastoids < 3 Views Left Radiology $245.30 XR Mastoids < 3 Views Right Radiology $245.30 XR Nasal Bones Minimum 3 Views Radiology $238.02

17/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price XR Neck Soft Tissue Radiology $154.00 XR Pelvis 1 or 2 Views Radiology $198.86 XR Ribs 2 Views Left Radiology $299.27 XR Ribs 2 Views Right Radiology $299.27 XR Sacroiliac Joints 1 or 2 Views Radiology $245.30 XR Sacrum/Coccyx Minimum 2 Views Radiology $299.27 XR Scapula Left Radiology $188.35 XR Scapula Right Radiology $188.35 XR Shoulder 1 View Bilateral Radiology $196.97 XR Shoulder 1 View Left Radiology $196.97 XR Shoulder 1 View Right Radiology $196.97 XR Shoulder Complete Bilateral Radiology $230.46 XR Shoulder Complete Left Radiology $230.46 XR Shoulder Complete Right Radiology $230.46 XR Sinuses Paranasal Complete Radiology $279.08 XR Skull < 4 Views Radiology $163.00 XR Skull Complete Radiology $245.30 XR Spine Cervical 2 or 3 Views Radiology $198.86 XR Spine Cervical Complete Radiology $363.30 XR Spine Cervical Minimum 4 Views Radiology $352.95 XR Spine Lumbosacral 2 or 3 Views Radiology $248.76 XR Spine Lumbosacral 3v - Physical Radiology $248.76 XR Spine Lumbosacral Minimum 4 Views Radiology $399.00 XR Spine Single View Specify Level Radiology $203.00 XR Spine Thoracic 2 Views Radiology $248.15 XR Sternoclavicular Joint(s) Radiology $203.90 XR Sternum Minimum 2 Views Radiology $203.90 XR Tibia/Fibula Bilateral Radiology $229.79 XR Tibia/Fibula Left Radiology $229.79 XR Tibia/Fibula Right Radiology $229.79 XR TMJ Open and Closed Bilateral Radiology $285.65 XR TMJ Open and Closed Left Radiology $147.50 XR TMJ Open and Closed Right Radiology $147.50 XR Toes 2nd Digit Left Radiology $179.28 XR Toes 2nd Digit Right Radiology $179.28 XR Toes 3rd Digit Left Radiology $179.28 XR Toes 3rd Digit Right Radiology $179.28 XR Toes 4th Digit Left Radiology $179.28 XR Toes 4th Digit Right Radiology $179.28 XR Toes 5th Digit Left Radiology $179.28 XR Toes 5th Digit Right Radiology $179.28 XR Toes Great Left Radiology $179.28 XR Toes Great Right Radiology $179.28 XR Wrist 2 Views Bilateral Radiology $198.86 XR Wrist 2 Views Left Radiology $198.86 XR Wrist 2 Views Right Radiology $198.86 XR Wrist Complete Bilateral Radiology $229.79 XR Wrist Complete Left Radiology $229.79 XR Wrist Complete Right Radiology $229.79 CT Angiography Upper Extremity Bilat Radiology Add-On $1,265.30 CT Lower Extremity w/+w/o Contrast Bilat Radiology Add-On $1,043.30 CT Lower Extremity w/o Contrast Bilat Radiology Add-On $550.00

18/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price CT Upper Extremity w/o Contrast Bilat Radiology Add-On $623.60 MRA Lower Extremity w/ + w/o Bilat Radiology Add-On $680.00 MRI LE Joint w/ + w/o Contrast Bilateral Radiology Add-On $680.00 MRI LE Joint w/o Contrast Bilateral Radiology Add-On $646.90 MRI LE Non Joint w/ + w/o Contrast Bilat Radiology Add-On $680.00 MRI LE Non Joint w/o Contrast Bilat Radiology Add-On $646.90 MRI UE Non Joint w/o Contrast Bilateral Radiology Add-On $646.90 XR Ankle 2 Views Bilateral Radiology Add-On $198.86 XR Ankle Complete Bilateral Radiology Add-On $229.79 XR Calcaneus Bilateral Radiology Add-On $229.79 XR Clavicle Bilateral Radiology Add-On $179.28 XR Elbow 2 Views Bilateral Radiology Add-On $229.79 XR Foot 2 Views Bilateral Radiology Add-On $198.86 XR Foot Complete Bilateral Radiology Add-On $229.79 XR Forearm 2 Views Bilateral Radiology Add-On $229.79 XR Hand 2 Views Bilateral Radiology Add-On $198.86 XR Hand Complete Bilateral Radiology Add-On $229.79 XR Humerus Bilateral Radiology Add-On $229.79 XR Knee 1 or 2 Views Bilateral Radiology Add-On $229.79 XR Knee 3 Views Bilateral Radiology Add-On $229.79 XR Knee Complete Bilateral Radiology Add-On $275.00 XR Shoulder 1 View Bilateral Radiology Add-On $196.97 XR Shoulder Complete Bilateral Radiology Add-On $230.46 XR Tibia/Fibula Bilateral Radiology Add-On $229.79 XR Wrist 2 Views Bilateral Radiology Add-On $198.86 XR Wrist Complete Bilateral Radiology Add-On $229.79

ARTERIAL PUNCTURE DRAWING FEE Respiratory Therapy $97.75

CARDIAC COLOR FLOW MAP Respiratory Therapy $571.00

CARDIAC EVENT MONITOR RECORDING Charge Respiratory Therapy $142.00

CPAP INITIATION AND MANAGEMENT Respiratory Therapy $1,232.00

ECHO 2D M-MODE DOPPLER Respiratory Therapy $684.00

ECHO 2D W/SPEC/CLR FLOW M-MODE COMP Respiratory Therapy $1,800.00

ECHOCARDIOGRAPHY DOPPLER Respiratory Therapy $571.00

HOLTER MONITOR ANALYSIS W/REPORT Respiratory Therapy $346.20

HOLTER MONITOR RECORDING Respiratory Therapy $346.00

O2 PER HOUR CHARGE Respiratory Therapy $2.05

PF BRONCHOSPASM EVALUATION Respiratory Therapy $227.00

PF DIFFUSING CAPACITY CO/MEMBRANE Respiratory Therapy $156.00

PF GAS DILUTION OR WASHOUT Respiratory Therapy $186.00

19/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price

PF PULSE OXIMETRY MULT DETERMINATNS Respiratory Therapy $148.00

PF PULSE OXIMETRY SINGLE DETERMINAT Respiratory Therapy $37.50

PF SPIROMETRY EVALUATION Respiratory Therapy $358.00

PRESSURIZED/NOPRESS INHALATION TRMT Respiratory Therapy $46.00 ROOM/BED: Private Room & Board $1,025.00 ROOM/BED: SB Intermediate Private Room & Board $175.00 ROOM/BED: SB Skilled Private Room & Board $925.00 ROOM/BED: SB Skilled Semi Private Room & Board $875.00 ROOM/BED: Semi Private Room & Board $975.00 POLYSOMNOGRAPHY =>4 ADDL PARAM 6>YR Sleep Lab Charges $1,764.00 POLYSOMNOGRAPHY W/CPAP 4+ADD PAR 6+ Sleep Lab Charges $2,352.50 CL OP VISIT Specialty Clinic $87.00 Development of Cognitive Skills/15M Units Speech Therapy $77.00 Swallow Evaluation Units Speech Therapy $153.00 Treatment of Speech,Lang,Voice Units Speech Therapy $115.00 Treatment of Swallowing Dysfunction Unit Speech Therapy $78.00 AIRWAY Supplies $2.05 AIRWAY DEVICE SUPRAGLOTTIC Supplies $27.00 AIRWAY NASOPHARYNGEAL Supplies $27.95 ANTI REFLUX VALVE Supplies $36.75 ASPIRATOR MICONIUM Supplies $25.35 BAG BILE Supplies $44.50 BIOPSY FORCEP DISP Supplies $202.85 BIPAP MACHINE PER DAY Supplies $520.00 BREATHING CIRCUIT Supplies $207.00 CANNULA VAPOTHERM Supplies $10.00 CAST BOOT Supplies $115.40 CAST FIBER Supplies $35.20 CAST PADDING Supplies $16.55 CAST PLASTER Supplies $11.90 CAST PLASTER SPLINT Supplies $98.85 CAST SHOE Supplies $31.05 CATH ADAPTER Supplies $3.60 CATH CHOLANGIOCATH Supplies $241.65 CATH CHOLANGIOGRAM Supplies $207.00 CATH EPIDURAL BREVI XL Supplies $129.00 CATH EXTERNAL MALE Supplies $8.80 CATH FOLEY 3 WAY Supplies $61.60 CATH FOLEY 30CC Supplies $37.25 CATH FOLEY 5CC Supplies $37.25 CATH KIT Supplies $22.75 CATH LEG STRAP Supplies $13.45 CATH SECURE Supplies $13.45 CATH STRAIGHT Supplies $3.10 CATH SUPRAPUBIC Supplies $189.90 CATH THORACIC Supplies $37.25 CATH UMBILICAL Supplies $63.65 CATH WHISTLE TIP Supplies $48.15

20/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price CAUTERY CLEANER Supplies $5.70 CAUTERY GROUNDING PAD ADULT Supplies $24.30 CAUTERY NEEDLE Supplies $3.10 CAUTERY PENCIL Supplies $24.30 CO2 ORAL/NASAL CANNULA Supplies $21.97 CO2 TUBING SET W/O FILTER Supplies $56.95 COLLECTION SET DISP Supplies $3.10 COLOSTOMY BRIDGE Supplies $17.10 COLOSTOMY CLAMP Supplies $11.40 COLOSTOMY PASTE Supplies $53.80 COLOSTOMY POUCH Supplies $10.85 COLOSTOMY WAFER Supplies $33.10 COMBITUBE Supplies $72.00 COMPRESSION SLEEVE Supplies $118.50 COMPRESSION SLEEVE THIGH Supplies $166.65 CONNECTOR Supplies $46.05 CYSTO TUBING Supplies $19.15 DERMABOND Supplies $61.60 DERMATONE BLADE Supplies $68.30 DILATOR ESOPHAGEAL Supplies $658.80 DRAIN PENROSE Supplies $10.85 DRSG ABD Supplies $2.05 DRSG ADAPTIC Supplies $3.10 DRSG AQUACEL AG Supplies $27.30 DRSG AVITENE ENDO Supplies $403.00 DRSG COBAN COFLEX Supplies $6.75 DRSG CUTIMED SORBACT Supplies $13.17 DRSG DRAIN SPONGE Supplies $2.05 DRSG ELASTIC Supplies $5.20 DRSG ELASTOGEL Supplies $33.10 DRSG ESMARK Supplies $20.70 DRSG EYE Supplies $0.50 DRSG GAUZE 4X4 Supplies $0.50 DRSG GAUZE SPLIT Supplies $0.50 DRSG HYDROCOL Supplies $16.00 DRSG KERLIX GAUZE Supplies $7.75 DRSG KLING Supplies $3.60 DRSG MEPILEX Supplies $29.70 DRSG MEPILEX AG Supplies $27.45 DRSG MESALT Supplies $15.55 DRSG NU-GAUZE IODOFORM Supplies $32.10 DRSG NU-GAUZE PLAIN Supplies $25.35 DRSG OP SITE Supplies $7.25 DRSG PRIMAPORE Supplies $7.75 DRSG RETAINER Supplies $25.35 DRSG STRAPS Supplies $6.75 DRSG TELFA Supplies $0.50 DRSG TUBE GAUZE Supplies $11.90 DRSG VASELINE GAUZE Supplies $5.20 DRSG XEROFORM Supplies $3.60 ELASTIC GARMENT/COVERING Supplies $52.00 ELECTRODE BUGBEE Supplies $71.50

21/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price ELECTRODE CUTTING LOOP Supplies $28.45 ELECTRODE DEFIB Supplies $102.45 ELECTRODE MONITOR 3/PK Supplies $4.15 ENEMA CLEANSING Supplies $11.40 EVACUATOR Supplies $21.20 EVACUATOR BOTTLE Supplies $7.75 EYE LENS IRRIGATION Supplies $40.35 FASCIA LATA TISSUE 7X12CM Supplies $4,662.70 FEEDING BAG Supplies $42.95 FEEDING PUMP/DAY Supplies $42.45 FEEDING TUBE Supplies $6.75 FILTER LINE SET ET Supplies $21.37 FISH Supplies $48.65 FIXATION SYSTEM ABSORBABLE Supplies $1,656.00 GUIDE WIRE Supplies $116.95 HEEL/ELBOW PROTECTORS Supplies $47.60 HEMOCLIP Supplies $42.45 HOSE KNEE Supplies $40.35 HOSE THIGH & WAIST Supplies $57.95 HUMIDIVENT PORTAVENT Supplies $12.95 INTRODUCER CATH KIT Supplies $185.25 INTUBATION SET RETROGRADE Supplies $279.00 IPPB CIRCUIT Supplies $70.40 IRRIGATION H2O/NS 1000CC Supplies $40.90 IRRIGATION H2O/NS 100CC Supplies $11.40 IRRIGATION H2O/NS 3000CC Supplies $59.50 IRRIGATION H2O/NS 500CC Supplies $41.40 IV ADAPTER Supplies $3.60 IV ARMBOARD Supplies $5.20 IV BLOOD SET Supplies $16.55 IV CATH KIT CENTRAL VEIN COMPLETE Supplies $65.70 IV CATH KIT TRIPLE LUMEN Supplies $76.05 IV CATH PLUG Supplies $4.15 IV EXTENSION TUBING SET 2-INJ SITES Supplies $20.70 IV NEEDLE BUTTERFLY Supplies $3.60 IV NEEDLE IVC Supplies $14.50 IV NEEDLE PORT-A-CATH Supplies $25.35 IV PICC INTRODUCER Supplies $129.40 IV PICC LINE DUAL LUMEN Supplies $210.10 IV PICC LINE SINGLE LUMEN Supplies $140.75 IV PUMP MINI Supplies $36.75 IV PUMP PER DAY Supplies $104.00 IV PUMP PER HOUR Supplies $4.15 IV START KIT (IP ONLY) Supplies $6.75 IV STOPCOCK Supplies $12.95 IV TUBING BLOOD W/FILTER Supplies $180.60 IV TUBING BURETROL Supplies $48.15 IV TUBING EXTENSION Supplies $19.15 IV TUBING EXTENSION MACRO Supplies $16.05 IV TUBING EXTENSION W/T Supplies $16.05 IV TUBING FILTER Supplies $40.90 IV TUBING PRIMARY NONVENTED Supplies $23.80

22/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price IV TUBING PRIMARY VENTED Supplies $7.25 IV TUBING PUMP Supplies $48.65 IV TUBING SECONDARY NONVENTED Supplies $23.80 IV TUBING SOLUSET Supplies $12.95 IV TUBING SURGICAL Supplies $21.75 JACKSON PRATT DRAIN Supplies $50.20 JACKSON PRATT DRAIN W/TROCAR Supplies $68.85 JACKSON PRATT RESERVOIR Supplies $49.15 LAP ANTI FOG KIT Supplies $25.35 LAP BABCOCK Supplies $461.10 LAP CATCH Supplies $406.75 LAP CHOLE RETRACT Supplies $488.00 LAP CLIP APPLIER Supplies $306.35 LAP CLOSE Supplies $89.00 LAP CUTTER LINEAR Supplies $464.70 LAP CUTTER LINEAR RELOAD Supplies $235.45 LAP ENDO STAPLER Supplies $385.55 LAP HARM SCAL SHEARS CURV PISTOL 23 Supplies $1,229.05 LAP LIGA CLIP Supplies $214.75 LAP MULTI SEAL CAP Supplies $508.70 LAP POUCH Supplies $215.80 LAP REDUCER Supplies $31.05 LAP SHEARS Supplies $465.75 LAP SURGIWAND Supplies $215.80 LAP/LAVH PACK Supplies $3,366.35 LOPEZ VALVE Supplies $11.40 MESH 11CM X 15CM TWIN POCKET OVAL Supplies $567.34 MESH 3D MAX Supplies $627.00 MESH ABDOMINAL PATCH LARGE Supplies $4,319.05 MESH ABDOMINAL PATCH MEDIUM Supplies $3,273.70 MESH HERNIA PATCH LARGE Supplies $1,246.15 MESH HERNIA PATCH MEDIUM Supplies $958.40 MESH HERNIA PATCH SMALL Supplies $1,038.10 MESH MARLEX Supplies $319.80 MESH ONFLEX Supplies $805.00 MESH PROLENE Supplies $319.30 MESH SURGIMESH 10CM CIRCLE Supplies $1,185.10 MESH SURGIMESH 11.4CM CIRCLE VENTRA Supplies $2,063.00 MESH SURGIMESH 11CM X 15CM TEAR DRP Supplies $597.20 MESH SURGIMESH 12.5CM CIRCLE Supplies $1,933.06 MESH SURGIMESH 15CM CIRCLE Supplies $2,167.30 MESH SURGIMESH 15CM X 22CM ELLIPSE Supplies $3,358.60 MESH SURGIMESH 4.5 X 6 Supplies $1,406.52 MESH VENTRALIGHT ST/ECHO PS SYSTEM Supplies $3,022.00 MESH VENTRIO 8CM X 12CM Supplies $1,575.00 MESH VENTRIO OVAL 11.0CM X 14.0CM Supplies $2,327.00 NASAL CATH Supplies $51.25 NASAL NOZ-STOP Supplies $37.80 NEEDLE BIOPSY TRU CUT Supplies $76.05 NEEDLE COUDE 16G EPIDURAL Supplies $34.00 NEEDLE COUDE 18G X 3.5 Supplies $34.00 NEEDLE COUDE 20G Supplies $27.00

23/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price NEEDLE COUDE 20G X 4.5 Supplies $27.00 NEEDLE EPIDURAL CATH Supplies $2.05 NEEDLE INTRAOSSEOUS Supplies $187.00 NEEDLE SCLEROTHERAPY Supplies $45.55 NEEDLE SPINAL Supplies $12.40 NEEDLE VERSES Supplies $95.75 NOVASURE ABLATION CO2 Supplies $56.95 NOVASURE ENDOMETRIAL ABLATION KIT Supplies $2,212.30 NUKNIT Supplies $29.00 O2 AEROSOL T-PIECE Supplies $8.80 O2 CANNULA Supplies $8.80 O2 CANOPY Supplies $67.30 O2 CHRISTMAS TREE Supplies $3.10 O2 CONNECTIVE TUBING Supplies $2.05 O2 DAILY Supplies $49.20 O2 HUMIDIFIER PREFILL Supplies $2.05 O2 INCENTIVE SPIROMETER Supplies $39.35 O2 MASK AEROSOL Supplies $4.15 O2 MASK ALL SIZES Supplies $15.00 O2 MASK FACE Supplies $9.30 O2 MASK LARYNGEAL Supplies $36.75 O2 MASK MULTI-VENT Supplies $10.85 O2 MASK NON-REBREATHER Supplies $10.85 O2 MASK TRACH Supplies $5.70 O2 NEBULIZER HEATED Supplies $23.30 O2 NEBULIZER HUMIDIFIER Supplies $7.75 O2 NEBULIZER SMALL VOLUME Supplies $17.10 O2 OXISENSOR Supplies $58.50 O2 PEAK FLOW Supplies $63.65 O2 PER HOUR Supplies $2.05 O2 SPACER MDI Supplies $68.85 OB VACUUM DELIVERY Supplies $62.10 PACK LAPAROTOMY Supplies $174.90 PADS DEFIBRILLATOR Supplies $81.75 PCA (PAIN) PUMP PER DAY Supplies $15.00 PCA MICROBORE EXT SET Supplies $29.00 PNEUMOTHORAX SET Supplies $322.40 PO LO FLEX L1-BELOW L5 PRE OTS Supplies $35.70 PO SHLDR ACRO/CLAV CAN WEB PRE OTS Supplies $52.00 PO SPLINT ANKLE Supplies $66.36 PO SPLINT CLAVICLE Supplies $42.28 PO SPLINT COLLAR PHILADELPHIA Supplies $94.91 PO SPLINT COLLAR SMALL Supplies $23.80 PO SPLINT COLLAR UNIVERSAL Supplies $13.45 PO SPLINT KNEE HINGED BRACE Supplies $175.95 PO SPLINT KNEE IMMOBILIZER Supplies $56.05 PO SPLINT KNEE SUPPORT Supplies $41.40 PO SPLINT LUMBOSACRAL Supplies $48.15 PO SPLINT TENNIS ELBOW Supplies $18.10 PO SPLINT WALKER BOOT Supplies $206.01 PO URINE LEG BAG Supplies $14.25 PO WHO COCK-UP NONMOLD PRE OTS Supplies $53.11

24/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price POLYP SNARE Supplies $57.45 POLYP TRAP Supplies $63.65 PORT INDWELLING IMP Supplies $437.00 PRESSURE RELIEF BOOT Supplies $85.00 PULSE SENSOR CONT USE Supplies $42.45 SCALPEL HARMONIC Supplies $1,535.20 SHAVER HEAD Supplies $26.40 SITZ BATH Supplies $20.20 SNARE DISP Supplies $40.35 SPLINT BURNHAM Supplies $81.75 SPLINT COLLAR LARGE Supplies $54.85 SPLINT FINGER Supplies $10.85 SPLINT FINGER 4 PRONG Supplies $7.75 SPLINT FINGER ALUMNI Supplies $10.85 SPLINT FINGER FREDDIE FROG Supplies $31.05 SPLINT METACARPAL Supplies $66.25 SPLINT OCL Supplies $18.10 SPLINT SLING ARM Supplies $14.50 SPLINT THUMB SPICA Supplies $50.20 SPLINT WRIST Supplies $61.60 STAPLE REMOVER Supplies $25.35 STAPLER ENDO LAP RELOAD Supplies $385.55 STAPLER ENDO PATH Supplies $802.65 STAPLER OPEN SURGERY Supplies $252.55 STAPLER OPEN SURGERY REFILL Supplies $449.20 STAPLER SKIN Supplies $27.45 STERI STRIP Supplies $9.30 STERILE H2O FOR INHALATION 100 Supplies $5.00 STOCKINETTE Supplies $2.05 STOCKINETTE IMPERVIOUS Supplies $42.95 STYLET INTUBATION Supplies $25.35 SUCTION CATHETER Supplies $29.50 SUCTION CATHETER DELEE Supplies $20.70 SUCTION W CAUTERY Supplies $45.00 SUPPORTER MALE Supplies $45.00 SUTURE 0 BONDEK Supplies $52.25 SUTURE 0 CHROMIC 812 Supplies $11.90 SUTURE 0 CHROMIC 884 Supplies $11.90 SUTURE 0 DEXON 9337-61 Supplies $34.65 SUTURE 0 MAXON 6267-61 Supplies $15.55 SUTURE 0 PDS Z358 Supplies $18.10 SUTURE 0 PROLENE 8690 Supplies $12.40 SUTURE 0 SILK 678 Supplies $10.85 SUTURE 0 SILK CO27 Supplies $30.00 SUTURE 0 SURGILON 1971-61 Supplies $17.10 SUTURE 0 VICRYL Supplies $65.00 SUTURE 0 VICRYL J207 Supplies $16.55 SUTURE 0 VICRYL J352 Supplies $15.00 SUTURE 0 VICRYL J376 Supplies $15.00 SUTURE 1 VICRYL J208 Supplies $16.55 SUTURE 1 VICRYL J353 Supplies $15.00 SUTURE 2 ETHILON BLACK 460T Supplies $11.90

25/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price SUTURE 2-0 CHROMIC 883 Supplies $11.90 SUTURE 2-0 CHROMIC G123 Supplies $13.45 SUTURE 2-0 ETHILON 3460 Supplies $11.90 SUTURE 2-0 ETHILON 628 Supplies $9.30 SUTURE 2-0 ETHILON 664 Supplies $10.85 SUTURE 2-0 NOVALON 445951 Supplies $19.65 SUTURE 2-0 PROLENE 8833 Supplies $16.55 SUTURE 2-0 SILK CO12 Supplies $12.00 SUTURE 2-0 SILK K833 Supplies $11.40 SUTURE 2-0 TI-CRON 3129-51 Supplies $26.40 SUTURE 2-0 VICRYL J206 Supplies $18.10 SUTURE 2-0 VICRYL J317 Supplies $13.95 SUTURE 2-0 VICRYL J602 Supplies $7.75 SUTURE 3-0 CHROMIC 636 Supplies $27.45 SUTURE 3-0 CHROMIC 882 Supplies $11.90 SUTURE 3-0 CHROMIC 892 Supplies $11.90 SUTURE 3-0 CHROMIC 912 Supplies $13.45 SUTURE 3-0 CHROMIC 982 Supplies $27.45 SUTURE 3-0 CHROMIC G112 Supplies $11.90 SUTURE 3-0 ETHILON 18936 Supplies $33.65 SUTURE 3-0 ETHILON 663 Supplies $9.30 SUTURE 3-0 PLAIN H822 Supplies $11.90 SUTURE 3-0 PROLENE 8665 Supplies $35.20 SUTURE 3-0 PROLENE 8675 Supplies $15.00 SUTURE 3-0 SILK C003 Supplies $63.15 SUTURE 3-0 SILK K832 Supplies $11.40 SUTURE 3-0 VICRYL J205 Supplies $16.55 SUTURE 3-0 VICRYL J316 Supplies $15.00 SUTURE 3-0 VICRYL J338 Supplies $13.45 SUTURE 3-0 VICRYL J864 Supplies $43.45 SUTURE 4-0 CHROMIC 635 Supplies $11.90 SUTURE 4-0 CHROMIC G121 Supplies $8.30 SUTURE 4-0 CHROMIC G181 Supplies $12.95 SUTURE 4-0 CHROMIC U203 Supplies $11.40 SUTURE 4-0 ETHILON 662 Supplies $8.30 SUTURE 4-0 PROLENE 8634 Supplies $35.70 SUTURE 4-0 PROLENE 8683 Supplies $15.55 SUTURE 4-0 PROLENE 8699 Supplies $35.20 SUTURE 4-0 PROLENE 8757 Supplies $35.20 SUTURE 4-0 SILK 683 Supplies $10.85 SUTURE 4-0 VICRYL J845 Supplies $11.90 SUTURE 5-0 CHROMIC 1652 Supplies $28.45 SUTURE 5-0 CHROMIC 634 Supplies $11.90 SUTURE 5-0 ETHILON 1865 Supplies $35.70 SUTURE 5-0 PLAIN H820 Supplies $3.60 SUTURE 5-0 PROLENE 8655 Supplies $34.65 SUTURE 5-0 PROLENE 8681 Supplies $32.10 SUTURE 5-0 SILK 682 Supplies $10.85 SUTURE 5-0 VICRYL J303 Supplies $13.45 SUTURE 6-0 PLAIN 1625 Supplies $27.45 SUTURE 6-0 PROLENE 8660 Supplies $15.00 SUTURE 6-0 PROLENE 8697 Supplies $33.10

26/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price SUTURE 6-0 PROLENE 8711 Supplies $35.20 SUTURE CAPTURE DEVICE Supplies $692.95 SUTURE PDS Supplies $41.00 SUTURE RETENTION TUBING Supplies $15.00 SYRINGE ASEPTO Supplies $3.60 SYRINGE BULB Supplies $20.20 TENS ELECTRODES Supplies $5.70 TRACH SUCTION Supplies $3.60 TRAY IRRIGATION Supplies $8.84 TRAY NERVE BLOCK PAIN9013S Supplies $270.00 TRAY TRACHEOSTOMY Supplies $106.10 TRIPOLAR CUTTING FORCEPS Supplies $818.70 TROCAR (ALL SIZES) Supplies $317.75 TROCAR SLEEVE Supplies $85.40 TUBE AEROSOL Supplies $4.15 TUBE ASPIRATING Supplies $22.75 TUBE CO2 W/ANTI-FOG Supplies $46.60 TUBE ET HOLDER Supplies $27.95 TUBE GASTROSTOMY Supplies $380.35 TUBE LEVINE Supplies $130.40 TUBE N/G ATTACH Supplies $14.50 TUBE PEG Supplies $89.00 TUBE SALEM SUMP Supplies $13.45 TUBE TRACH ALL SIZES Supplies $28.45 TUBING ANESTHESIA Supplies $35.00 TURP IRRIGATION SET Supplies $48.15 UNNA BOOT Supplies $21.75 URINE METER Supplies $78.65 UROSTOMY BAG Supplies $11.70 VAGINAL IRRIGATION Supplies $9.30 VAS TIES MAXI BLUE Supplies $17.60 VENTILATOR CIRCUIT ADULT Supplies $23.80 VENTILATOR H20 SET Supplies $48.65 VENTILATOR T Supplies $22.25 WARMING UNIT Supplies $19.15 ABD PARACENTESIS W/O IMAGING Surgery $353.00 ADD'L PUSH NEW DRUG Charge Surgery $71.02 ADD'L PUSH SAME DRUG Charge Surgery $71.02 ADMIN IMMUNIZATION ONE VACCINE Charge Surgery $71.02 APPENDECTOMY Surgery $1,200.00 ASPIRATE PLEURA W/O IMAGING Surgery $845.00 ASPIRATE PLEURA WITH IMAGING Surgery $982.00 BLOOD ADMIN 0-12HRS (PER DAY) Charge Surgery $650.00 BLOOD ADMIN 0-16 HRS (PER DAY) Charge Surgery $800.00 BLOOD ADMIN 0-24HRS (PER DAY) Charge Surgery $900.00 BLOOD ADMIN 0-4HRS (PER DAY) Charge Surgery $613.72 BLOOD ADMIN 0-8HRS (PER DAY) Charge Surgery $737.00 BLOOD COLLECT CENTRAL/PERIPH DEV Charge Surgery $70.00 BLOOD COLLECT- IMPLANT VENOUS Charge Surgery $70.00 CARDIOVERSION ELECTIVE Charge Surgery $274.50 CARPAL TUNNEL SURGERY Surgery $1,200.00 CLOSURE WOUND W/PACKING Charge Surgery $361.80

27/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price CLSD TRMT ELBOW DISLOC WO ANES Charge Surgery $815.00 CLSD TRMT SHLDR DIS W/ANESTHESIA Charge Surgery $815.00 CLSD TRMT SHOULDER DISCLC W/MNP Charge Surgery $1,092.00 CNTRL NASAL HEMORRHAGE ANT SIMP Charge Surgery $575.00 COLECTOMY W/END COLOST DSTL PART Surgery $2,900.00 COLONOSCOPY DX W/WO SPECIMEN Surgery $1,300.00 COLONOSCOPY DX W/WO SPECIMEN Charge Surgery $1,300.00 COLONOSCOPY W/ REM FORCEPS CAUT Charge Surgery $1,517.00 COLONOSCOPY W/ REM FORCEPS CAUT Charge Surgery $1,517.00 COLONOSCOPY W/BIOPSY SINGLE/MULT Charge Surgery $1,300.00 COLONOSCOPY W/BIOPSY SINGLE/MULT Charge Surgery $1,300.00 COLONOSCOPY W/REM SNARE Charge Surgery $1,517.00 COLONOSCOPY W/REM SNARE Charge Surgery $1,517.00 CONIZATION CERVIX W/WO D&C RPR KNIFE/LASER Surgery $4,757.00 CYSTO W/ DILATION Surgery $1,120.00 CYSTOSCOPY W/BIOPSY(S) Surgery $1,000.00 CYSTOURETHROSCOPY Charge Surgery $1,283.00 DECLOT VENOUS DEVICE W/THROM AGT Charge Surgery $190.00 DESTROY INTERNAL HEMORRHOIDS Surgery $1,400.00 DILATE & CURETTAGE DIAG NON OB Surgery $1,050.00 DRAIN/INJ JNT/BURSA MAJ W/US Charge Surgery $417.00 EGD BX SINGLE/MULTI Charge Surgery $870.00 EGD BX SINGLE/MULTI Charge Surgery $870.00 EGD DX BRUSH WASH Surgery $850.00 EGD DX BRUSH WASH Charge Surgery $850.00 EGD ESOPH DILATE <30MM Surgery $870.00 EGD ESOPH DILATE <30MM Surgery $870.00 EGD PLACE GASTRO TUBE Surgery $1,041.00 EGD PLACE GASTRO TUBE Charge Surgery $1,041.00 EGD WITH REMOVAL OF FOREIGN BODY Charge Surgery $870.00 EGD WITH REMOVAL OF FOREIGN BODY Charge Surgery $870.00 ENDOMETRIAL ABLATION THERMAL Surgery $1,750.00 ENDOMETRIAL SAMPLING WO DILAT Surgery $1,827.00 ESOPHAGOSCOPY FLEX REMOVE FB Surgery $800.00 ESOPHAGOSCOPY FLEX REMOVE FB Charge Surgery $800.00 EVAL LEVEL 1 Charge Surgery $261.30 EVAL LEVEL 2 Charge Surgery $290.00 EVAL LEVEL 3 Charge Surgery $446.00 EXC ARM/ELBOW LES SC 3 CM/> Charge Surgery $800.00 EXC FEENL MAL LESION 1.1-2.0 CM Surgery $507.00 EXC NECK LES SC 3 CM/> Charge Surgery $1,097.00 EXCIS BEN LES TAL OVER 4.0CM Charge Surgery $1,570.00 EXCISE GANGLION WRIST PRIMARY Surgery $2,937.00 EXCISE PILONIDAL CYST/SINUS COMP Surgery $2,740.00 EXCISION ELBOW BURSA Charge Surgery $3,297.00 GASTROINTESTINAL TRACT IMAGING Charge Surgery $43.50 HEMORRHOIDOPEXY BY STAPLING Surgery $1,715.00 I&D ABSCESS SIMPLE SINGLE Surgery $495.80 I&D COMPLICATED/MULTIPLE Charge Surgery $1,764.00 IM OR SQ INJECTION PER STICK Charge Surgery $71.02 INHALATION TRMT (AEROSOL/NEB) Charge Surgery $61.64 INJ FORAMEN EPIDURAL ADD-ON Surgery $1,195.00

28/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price INJ PARAVERT F JNT C/T 2 LEV Surgery $972.00 INJ PARAVERT F JNT C/T 3 LEV Surgery $1,157.00 INJ PARAVERT F JNT L/S 1 LEV Surgery $734.00 INJ PRVT FACET JNT C/T SINGLE Surgery $568.81 INJ PVRT FACET JNT L/S 2ND LEV Charge Surgery $1,052.00 INJ PVRT FACET JNT L/S 3+ LEV Charge Surgery $1,500.00 INJ TRANSFORAMINAL EPI L/S SNGL Surgery $730.42 INJECT SPINE CRV/THRC W/IMG Surgery $1,211.42 INJECT SPINE LMBR/SAC W/IMAGE Surgery $1,211.42 INJECT SPINE LUMBAR/SACRAL Charge Surgery $850.00 INSERT FOLEY CATHETER SIMPLE Charge Surgery $167.00 INSERT PICC WO PRT/PMP 5+ Charge Surgery $500.00 INSERT STRAIGHT CATHETER Surgery $70.00 INSERT TUNNELED CV CATH 5> YRS Charge Surgery $1,200.00 INSRT/REDO SPINE N GENERATOR Surgery $1,046.00 IRRIGATION OF BLADDER Charge Surgery $95.00 IV HRDRA ADD'L > 90 MIN Charge Surgery $306.86 IV HYDRA. INITIAL 31-90 MIN Charge Surgery $306.86 IV PUSH SINGLE OR INITIAL Surgery $71.02 IV THER. ADD'L HRS > 91 MINS Charge Surgery $160.00 IV THER. INITIAL 16-90 MIN Charge Surgery $306.86 LAP CHOLE W/CHOLANGIO Surgery $1,200.00 LAP ENTEROLYSIS Surgery $1,200.00 LAP ING HERNIA REPAIR INIT Surgery $9,137.00 LAPARO PARTIAL COLECTOMY Surgery $2,100.00 LAPAROSCOPIC APPENDECTOMY Surgery $1,770.00 LAPAROSCOPY CHOLECYSTECTOMY Surgery $1,200.00 LAPAROSCOPY TUBAL CAUTERY Surgery $1,700.00 LAPARO-VAG HYST INCL T/O Surgery $4,000.00 MASTOTOMY DEEP ABSCESS Surgery $2,270.00 NEEDLE BIOPSY OF LIVER Charge Surgery $800.00 NON SELECTIVE DEBRIDEMENT Charge Surgery $90.00 RECOVERY ROOM 1ST HOUR Surgery $220.00 RECOVERY ROOM EACH ADD HOUR Surgery $155.00 RECOVERY ROOM STEP DOWN 1ST HOUR Surgery $198.00 RECOVERY ROOM STEP DOWN EA Add'L HR Surgery $136.40 REMOVE CENTRAL VEN DEV W/PMP-PRT Charge Surgery $2,266.00 REMOVE CENTRAL VENOUS CATHETER Charge Surgery $1,139.00 REMOVE ELBOW LESION Charge Surgery $4,337.00 REMOVE TENDON SHEATH LESION Surgery $2,114.00 REP HERNIA INCIS/VENT INIT REDU Surgery $1,725.00 REP INGUINAL HERNIA OVER 5YR Surgery $1,170.00 REP UMBILICAL HERNIA INCAR/STNG Surgery $2,703.00 REPAIR RECTUM-VAGINA FISTULA Charge Surgery $907.00 RPR VENTRAL HERN INIT BLOCK Surgery $1,577.00 RPR VENTRAL HERN INIT REDUC Surgery $1,725.00 SCREEN COLONOSCOPY HIGH RISK Surgery $1,151.00 SCREEN COLONOSCOPY HIGH RISK Charge Surgery $1,326.00 SCREEN COLONOSCOPY NOT HIGH RISK Surgery $1,147.00 SCREEN COLONOSCOPY NOT HIGH RISK Charge Surgery $1,326.00 SHAVE LESION TAL 0.5CM OR LESS Charge Surgery $94.91 SIGMOIDOSCOPY FLEXIBLE DIAG Surgery $920.00

29/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price SIGMOIDOSCOPY FLEXIBLE DIAG Charge Surgery $920.00 SKIN FULL GRFT EEN & LIPS 20CM/< Surgery $970.00 SPINAL PUNCTURE DIAGNOSTIC Charge Surgery $515.00 THERAPEUTIC PHLEBOTOMY Charge Surgery $78.50 TISSUE TRANS FGHF 10SQ.CM OR < Surgery $1,097.00 TOTAL ABDOMINAL HYSTERECTOMY Surgery $7,000.00 TREAT INCOMPLETE ABORTION SURG Surgery $1,907.00 VASECTOMY Surgery $800.00 VASECTOMY Surgery $800.00 WOUND CARE 11-25 SQ CM Charge Surgery $147.40 WOUND CARE UP TO 10 SQ CM Charge Surgery $140.70 OR EXCIS GANGLION CYSTECTOMY LT Charge Surgery Add-On $2,937.00 Blood Administration Transfusion Treatment Room $92.00 TR ADMIN INFLUENZA VACCINE Charge Treatment Room $45.56 TR ADMIN PNEUMONIA VAC Charge Treatment Room $69.01 TR IM/SQ WITH IV Charge Treatment Room $50.00 TR IRRIGATE IMPLANT VEN ACC DEVICE Charge Treatment Room $88.00 TR IV CONCURRENT - 1x ONLY Charge Treatment Room $11.00 TR IV INF THERP 1ST HR REPEAT VISIT Charge Treatment Room $201.00 TR IV INF THERP ADD HR REPEAT VISIT Charge Treatment Room $150.00 TR IV INFU HYDRAT EA ADD'L HR Charge Treatment Room $160.00 TR IV INFU THER EA ADD'L HR SEQ NEW Charge Treatment Room $229.00

TR WOUND CARE 76 SQ CM > Charge Wound Care Charges $170.00

CLINIC / PROFESSIONAL FEES 15 Or More Lesions Clinic / Rounding $106.00 Abdominal paracentesis; without imaging guidance Clinic / Rounding $580.00 Adj Trans Forehd 10 Sq Cm Or L Clinic / Rounding $750.00 Administration of influenza virus vaccine when no physician fee schedule service on the same d Clinic / Rounding $10.00 Administration of pneumococcal vaccine when no physician fee schedule service on the same day Clinic / Rounding $10.00 Air Walker Clinic / Rounding $300.00 Allergy Injection Clinic / Rounding $19.00 Allergy Injection Clinic / Rounding $14.00 Allergy Injection 2 or more Clinic / Rounding $28.00 AMPUTATION W/ LOCAL ADV FLAPS Clinic / Rounding $520.00 Amputation, thigh, through femur, any level Clinic / Rounding $950.00 Ankle control orthosis, stirrup Clinic / Rounding $70.00 Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit Clinic / Rounding $100.00 Apendectomy Clinic / Rounding $900.00 App Of Long Leg Cast Thigh To Clinic / Rounding $295.00 App Short Leg Splint Calf To F Clinic / Rounding $91.00 App Short Leg Walking Or Ambul Clinic / Rounding $154.00 APPENDECTOMY ADD-ON Clinic / Rounding $700.00 $700.00 Appendectomy, Laparoscopy Clinic / Rounding $1,725.00 Application of finger splint; static Clinic / Rounding $75.00 Application of long arm splint Clinic / Rounding $118.00 Application of long leg splint Clinic / Rounding $101.00 Application of short arm splint; static Clinic / Rounding $78.00

30/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price Application of short leg cast Clinic / Rounding $127.00 Application, cast; elbow to finger (short arm) Clinic / Rounding $119.00 Application, cast; finger (eg, contracture) Clinic / Rounding $53.00 Application, cast; shoulder to hand (long arm) Clinic / Rounding $132.00 Arthrocentesis, aspiration and or injection with ultrasound guidance with permanent recording Clinic / Rounding $110.00 Arthrocentesis, aspiration and/or injection, intermediate joint or bursa; without ultrasound g Clinic / Rounding $97.00 Arthrocentesis, aspiration and/or injection, major joint or bursa; without ultrasound guidance Clinic / Rounding $110.00 Arthrocentesis, aspiration and/or injection, small joint or bursa; without ultrasound guidance Clinic / Rounding $94.00 Aspiration Fine Needle Clinic / Rounding $190.00

Aspiration of bladder; with insertion of suprapubic catheter Clinic / Rounding $375.00 Aspiration/Injection Ganglion Clinic / Rounding $161.00 AVUL PAR/COMP NAIL Clinic / Rounding $47.00

Avulsion of nail plate, partial or complete, simple; single Clinic / Rounding $87.00 B Arthrocentesis, Aspiration and/or Injection X 2 Clinic / Rounding $220.00 Biopsy E/O Lymph node open deep axillary Clinic / Rounding $905.00 Biopsy of lip Clinic / Rounding $104.00 Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless Clinic / Rounding $137.00 Biopsy or excision of lymph node(s); by needle, superficial (eg, cervical, inguinal, axillary) Clinic / Rounding $175.00 Biopsy or excision of lymph nodes; open, superficial Clinic / Rounding $695.00 Biopsy Skin Subcut Each Separa Clinic / Rounding $62.00 BLEPHAROTOMY, DRAINAGE Clinic / Rounding $250.00 Bone Marrow; biopsy, needle or trocar Clinic / Rounding $194.00 BPCHK Blood Pressure Check Clinic / Rounding STAT Canalith repositioning procedure(s) (eg, Epley maneuver, Semont maneuver), per day Clinic / Rounding $94.00 Cardiopulmonary Resuscitation Clinic / Rounding $583.00 Cardioversion Of Arrhythmia, Clinic / Rounding $396.00 Carpal Tunnel Clinic / Rounding $893.00 Change of Gastrostomy Tube Clinic / Rounding $465.00 Chest tube insertion Clinic / Rounding $185.00 Circumcision, except newborn Clinic / Rounding $500.00 Circumcision, using clamp or other device with regional dorsal penile or ring block Clinic / Rounding $275.00 Clos Tx Articular Fx W/O Manip Clinic / Rounding $821.00 Clos Tx Carpal Bone W/O Man E Clinic / Rounding $260.00 Clos Tx Dislocate Thumb W/Man Clinic / Rounding $350.00 Clos Tx Interphal W Man W Anes Clinic / Rounding $260.00 Clos Tx Interphal W Man W/O An Clinic / Rounding $222.00 Clos Tx Metacarpal Sing W Mani Clinic / Rounding $375.00 Clos Tx Patellar Without Anest Clinic / Rounding $289.00 Clos Tx Phal Other Gt Toe W Ma Clinic / Rounding $300.00 Clos Tx Prox Humeral W/O Mani Clinic / Rounding $318.00 Clos Tx Radial Shaft W/O Manip Clinic / Rounding $255.00 Clos Tx Radial/Ulnar W/O Manip Clinic / Rounding $370.00

31/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price Clos Tx Shoulder W Man W/Anes Clinic / Rounding $425.00 Clos Tx Ulnar Proximal W/O ManClos Clinic / Rounding $260.00 Closed Nasal Bone W/O Manipula Clinic / Rounding $126.00 Closed treatment of distal radial fracture or epiphyseal separation, includes closed treatment Clinic / Rounding $350.00 Closed treatment of distal radial fracture or epiphyseal separation, includes closed treatment Clinic / Rounding $485.00

Closed treatment of knee dislocation; without anesthesia Clinic / Rounding $150.00 Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation Clinic / Rounding $243.00 Closed treatment of shoulder dislocation, with manipulation; without anesthesia Clinic / Rounding $402.00 Closed treatment of trimalleolar ankle fracture; with manipulation Clinic / Rounding $550.00 Closted treatment of interphalangeal w/o an Clinic / Rounding $116.00

Colectomy, partial; with skin level cecostomy or colostomy Clinic / Rounding $2,700.00 Colonoscopy high risk Medicare Only Clinic / Rounding $788.00 COLONOSCOPY W/ABLATION Clinic / Rounding $950.00 Colonoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, Clinic / Rounding $637.00 Colonoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, Clinic / Rounding $823.00 Colonoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, Clinic / Rounding $998.00 Colonoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, Clinic / Rounding $922.00 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk Clinic / Rounding $788.00 Colorectal cancer screening; flexible sigmoidoscopy Clinic / Rounding $788.00 $788.00 Colpocleisis (Le Fort type) Clinic / Rounding $980.00 Colposcopy of the cervix including upper/adjacent vagina; with biopsy[s] of the cervix and end Clinic / Rounding $368.00 Complex Forehead 2.6 To 7.5 Cm Clinic / Rounding $525.00 Complex Scalp/Arms 2.6 To 7.5 Clinic / Rounding $404.00 Conization of cervix, with or without fulguration, with or without dilation and curettage, wit Clinic / Rounding $625.00 Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method Clinic / Rounding $99.00 Critical care, evaluation and management of the critically ill or critically injured patient; Clinic / Rounding $358.00 Critical care, evaluation and management of the critically ill or critically injured patient; Clinic / Rounding $205.00 Cystocele repair Clinic / Rounding $1,260.00 CYSTOSCOPY & URETER CATHETER Clinic / Rounding $375.00 $375.00 Cystourethroscopy (separate procedure) Clinic / Rounding $315.00 Debridement (eg, high pressure waterjet with/without [suction], sharp selective debridement wi Clinic / Rounding $280.00

Debridement subcutaneous tissue; first 20 sq cm or less Clinic / Rounding $110.00

32/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if p Clinic / Rounding $296.00 Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, m Clinic / Rounding $35.00 Dest Mal Les Face <0.6cm Clinic / Rounding $134.00 Destr Mal Les Face 0.6-1.0 Cm Clinic / Rounding $215.00 Destr Mal Les Scalp <=.5cm Clinic / Rounding $155.00 Destr Malg Les Trnk/Ext .6-1cm Clinic / Rounding $233.00 Destr Malg Les Trnk/Ext =<.5cm Clinic / Rounding $155.00 Destruction of internal hemorrhoid(s) by thermal energy (eg, infrared coagulation, cautery, ra Clinic / Rounding $340.00 Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesi Clinic / Rounding $435.00 Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic ves Clinic / Rounding $200.00 Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic ves Clinic / Rounding $350.00 DESTRUCTION OF LESION, PE Clinic / Rounding $145.00

Destruction of lesion[s], penis, simple; chemical; cryosurgery Clinic / Rounding $145.00 Destruction of vaginal lesion, simple Clinic / Rounding $95.00 Destruction premalignant lesions (eg, actinic keratoses); 15 or more lesions Clinic / Rounding $578.00 Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, s Clinic / Rounding $220.00 Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, s Clinic / Rounding $520.00 Destruction, malignant lesion, scalp, neck, hands, feet, genitalia 0.6-1.0cm Clinic / Rounding $155.00 Destruction, of benign lesions other than skin tags or cutaneous vascular proliferative lesio Clinic / Rounding $102.00 $102.00 Destruction, premalignant lesions; first lesion Clinic / Rounding $107.00 Destruction, premalignant lesions; second through 14 lesions, each Clinic / Rounding $29.00 DILATION AND CURETTAGE Clinic / Rounding $735.00 dilation of fem urethra including suppository Clinic / Rounding $101.00 Dilation of urethral stricture by passage of sound or urethral dilator, male; initial Clinic / Rounding $58.00 Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to indi Clinic / Rounding $18.00 DOTPX DOT Physical Clinic / Rounding $75.00 Drainage of abscess, cyst, hematoma from dentoalveolar structures Clinic / Rounding $200.00 Drainage of abscess, cyst, hematoma, vestibule of mouth; simple Clinic / Rounding $225.00 Drainage of finger abscess; complicated (eg, felon) Clinic / Rounding $173.00 Drainage of finger abscess; simple Clinic / Rounding $94.00 Dress/Debrid Intial W/O Anes Clinic / Rounding $58.00 DRSG PRISMA MATRIX 4.34",2776789" Clinic / Rounding $21.70 E.G.D. Clinic / Rounding $588.00 E.G.D. With Balloon Dilitation Clinic / Rounding $950.00 E.G.D. With Biopsy Clinic / Rounding $630.00

33/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price E.G.D.With Foreign Body Remov Clinic / Rounding $840.00 E/O Breast Tumor Clinic / Rounding $550.00 E/O OLECRANON BURSA Clinic / Rounding $5,500.00 E/O Skin Sub Tissue Hidradenitis, Perianal Clinic / Rounding $420.00 E/O Subc Tissue for Hidradenitis Clinic / Rounding $415.00 Ednometrial sampling with or w/o endocervical sampling without endocervical sampling Clinic / Rounding $165.00 EGD diagnostic w/ removal of polyp or lesion by snare technique Clinic / Rounding $750.00 $750.00 Elbow orthosis, without joints, may include soft interface, straps, custom fabricated, include Clinic / Rounding $35.00 Electrical Stimulation Clinic / Rounding $43.00 Electrical stimulation (unattended), to one or more areas for indication(s) other than wound c Clinic / Rounding $43.00 Emergency department visit for the evaluation and management of a patient - Level 1 Clinic / Rounding $117.00 Emergency department visit for the evaluation and management of a patient - Level 2 Clinic / Rounding $141.00 Emergency department visit for the evaluation and management of a patient - Level 3 Clinic / Rounding $176.00 Emergency department visit for the evaluation and management of a patient - Level 4 Clinic / Rounding $231.00 Emergency department visit for the evaluation and management of a patient - Level 5 Clinic / Rounding $301.00 Endometrial ablation, thermal, without hysteroscopic guidance Clinic / Rounding $434.00 Endoscopy procedures of the rectum Clinic / Rounding $800.00 Esophagogastroduodenoscopy, flexible, transoral; with dilation of gastric/duodenal stricture(s Clinic / Rounding $683.00 ESOPHAGOSCOPY BALLOON <30MM Clinic / Rounding $900.00 Esophagoscopy w/Biopsy Clinic / Rounding $130.00 Evac Of Subungual Hematoma Clinic / Rounding $58.00 Ex Ben Lesion Face >4.0cm Clinic / Rounding $318.00 Ex Ben Lesion Face 0.6-1.0cm Clinic / Rounding $143.00 Ex Ben Lesion Face 2.1-3.0cm Clinic / Rounding $359.00 Ex Ben Lesion Face 3.1-4.0cm Clinic / Rounding $388.00 Ex Ben Lesion Scalp >4.0cm Clinic / Rounding $355.00 Ex Ben Lesion Scalp 2.1-3.0cm Clinic / Rounding $219.00 Ex Ben Lesion Scalp 3.1-4.0cm Clinic / Rounding $260.00 Ex Ben Lesion Trunk >4.0cm Clinic / Rounding $525.00 Ex Benign Lesion Trnk 2.1-3cm Clinic / Rounding $208.00 Ex Benign Lesion Trnk 3.1-4cm Clinic / Rounding $237.00 Ex Mal Les Face 3.1 To 4.0 Cm Clinic / Rounding $458.00 Ex Mal Lesion Face >4cm Medicare Clinic / Rounding $586.00 Ex Mal Lesion Face 2.1 To 3.0 Clinic / Rounding $385.00 Ex Mal Lesion Scalp 2.1 To 3.0 Clinic / Rounding $312.00 Ex Mal Lesion Scalp 3.1 To 4.0 Clinic / Rounding $378.00 Ex Mal Lesion Scalp Over 4.0 C Clinic / Rounding $446.00 Ex Mal Lesion Trunk 3.1-4.0cm Clinic / Rounding $327.00 Ex Mal Lesion Trunk Over 4.0 C Clinic / Rounding $382.00 Ex Nail W Amput Of Tuft Dis Ph Clinic / Rounding $300.00

34/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price Excision of frenum, labial or buccal (frenumectomy, frenulectomy, frenectomy) Clinic / Rounding $191.00 $191.00 Excision of hydrocele Clinic / Rounding $800.00 Excision of Mouth Lesion Clinic / Rounding $250.00 Excision of nail and nail matrix, partial or complete or permanent removal Clinic / Rounding $318.00 Excision of Neck 3cm or greater Clinic / Rounding $950.00 Excision of pilonidal cyst or sinus; complicated Clinic / Rounding $630.00 Excision of rectal tumor, transanal approach; not including muscularis propria (ie, partial th Clinic / Rounding $950.00 Excision, benign lesion including margins, except skin tag, scalp, neck, hands, feet, genitali Clinic / Rounding $197.00 Excision, benign lesion including margins, except skin tag, scalp, neck, hands, feet, genitali Clinic / Rounding $148.00 Excision, benign lesion including margins, except skin tag, scalp, neck, hands, feet, genitali Clinic / Rounding $161.00 Excision, benign lesion including margins, except skin tag, trunk, arms or legs; excised diame Clinic / Rounding $150.00 $150.00 Excision, benign lesion including margins, except skin tag, trunk, arms or legs; excised diame Clinic / Rounding $131.00 Excision, benign lesion including margins, except skin tag, trunk, arms or legs; excised diame Clinic / Rounding $148.00 Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diamete Clinic / Rounding $208.00 Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diamete Clinic / Rounding $267.00 Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diamete Clinic / Rounding $327.00 Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised dia Clinic / Rounding $278.00 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.6 to 1. Clinic / Rounding $196.00 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2. Clinic / Rounding $255.00 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 2.1 to 3. Clinic / Rounding $291.00 Excision, other benign lesion including margins, except skin tag, face, ears, eyelids, nose, l Clinic / Rounding $110.00 Excision, other benign lesion including margins, except skin tag, face, ears, eyelids, nose, l Clinic / Rounding $177.00 Excision, tumor, soft tissue of abdominal wall, subcutaneous; 3 cm or greater Clinic / Rounding $600.00 $600.00 Excision, tumor, soft tissue of foot or toe, subcutaneous; less than 1.5 cm Clinic / Rounding $435.00 Fine needle aspiration w/ imaging guidance Clinic / Rounding $250.00 Fluzone, IM for ages 6-35 months Clinic / Rounding $17.00

Foreskin manipulation including lysis of preputial adhesions Clinic / Rounding $106.00 Ganglion Cyst Clinic / Rounding $1,050.00 GANGLION CYST REMOVAL Clinic / Rounding $525.00 Hand & Lower Forearm (Gauntlet Clinic / Rounding $76.00 Handling/Conveyance of specimen for transfer Clinic / Rounding $25.00

35/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price Hemorrhage, Anterior Nasal Clinic / Rounding $166.00 Hemorrhoidectomy, Int/Ext Complex Extens Clinic / Rounding $945.00 Hemorrhoidopexy (eg, for prolapsing internal hemorrhoids) by stapling Clinic / Rounding $700.00 Hepatitis B Adult Vaccine Clinic / Rounding $56.00 High Dose Fluzone Vaccine Clinic / Rounding $52.00 Home visit for the evaluation and management of an established patient, 25 minutes are spent f Clinic / Rounding $88.00 Home visit for the evaluation and management of an established patient, 40 minutes are spent f Clinic / Rounding $96.00 Hospital Care Admit Discharge Patient Level 1 Clinic / Rounding $180.00 Hospital Care Admit Discharge Patient Level 2 Clinic / Rounding $246.00 Hospital Care Admit Discharge Patient Level 3 Clinic / Rounding $295.00 Hospital discharge day management; Patient Level 1 Clinic / Rounding $115.00 Hospital discharge day management; Patient Level 2 Clinic / Rounding $125.00 Hyaluronan or derivative, Hyalgan or Supartz, for intra- articular injection, per dose Clinic / Rounding $245.00 Hyaluronan or derivative, synvisc or synvisc-one, for intra- articular injection, 1mg Clinic / Rounding $797.00 Hysterectomy, Total Abdominal Clinic / Rounding $2,625.00 Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or with Clinic / Rounding $175.00 I&D Bursa Deep Abscess Hemato Clinic / Rounding $225.00 I&D Complex p op wound Clinic / Rounding $327.00 I&D Pilonidal Cyst, Simple Clinic / Rounding $105.00 I&Removal FB SQ, Complicated Clinic / Rounding $204.00 Immunization administration; each additional vaccine Clinic / Rounding $20.00 Immunization administration; one vaccine Clinic / Rounding $20.00 Incision and drainage of abscess; complicated/multiple Clinic / Rounding $245.00 Incision and drainage of abscess; simple or single Clinic / Rounding $137.00 Incision and drainage of hematoma, seroma or fluid collection Clinic / Rounding $143.00 $143.00 Incision and drainage of submucosal abscess, rectum Clinic / Rounding $151.00 Incision and removal of foreign body, subcutaneous tissues; simple Clinic / Rounding $95.00 Incision Thrombosed Ext Hemorr Clinic / Rounding $229.00 Indirect Laryscopy Clinic / Rounding $102.00 Influenza virus vaccine, quadrivalent IM use Clinic / Rounding $20.00 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and olde Clinic / Rounding $20.00 Influenza virus vaccine, trivalent (IIV3), when administered to children 6-35 months Clinic / Rounding $12.00 Influenza virus vaccine, trivalent, 3yrs or older Clinic / Rounding $20.00 Initial comprehensive preventive medicine evaluation and management; new pt; age 12-17 Clinic / Rounding $150.00 Initial comprehensive preventive medicine evaluation and management; new pt; age 1-4 Clinic / Rounding $150.00 Initial comprehensive preventive medicine evaluation and management; new pt; age 40-64 Clinic / Rounding $150.00 Initial comprehensive preventive medicine evaluation and management; new pt; age 5-11 Clinic / Rounding $150.00

36/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price Initial comprehensive preventive medicine evaluation and management; new pt; age younger than Clinic / Rounding $150.00 Initial hospital care, Level 1 Clinic / Rounding $147.00 Initial hospital care, Level 2 Clinic / Rounding $205.00 Initial hospital care, Level 3 Clinic / Rounding $227.00 Initial nursing facility care, Patient Level 1 Clinic / Rounding $102.00 Initial nursing facility care, Patient Level 2 Clinic / Rounding $129.00 Initial nursing facility care, Patient Level 3 Clinic / Rounding $176.00 Initial observation care, Level 1 Clinic / Rounding $125.00 Initial observation care, Level 2 Clinic / Rounding $192.00 Initial observation care, Level 3 Clinic / Rounding $297.00 $297.00 Initial preventive physical examination; face-to-face visit, services limited to new beneficia Clinic / Rounding $100.00 Initial Tx 1st Deg Local Tx Re Clinic / Rounding $64.00 Inj Ten Sheath Lig/Gang Cyst Clinic / Rounding $102.00 Injection Intralesional Clinic / Rounding $35.00 Injection of trigger points 1 or 2 muscles Clinic / Rounding $95.00 Injection therapeutic carpal tunnel Clinic / Rounding $156.00 Injection(single tendon origin/insertion) Clinic / Rounding $156.00 Injection, anesthetic agent, intercostal nerve, single Clinic / Rounding $327.00

Injection, anesthetic agent; other peripheral nerve or branch Clinic / Rounding $75.00 Injection, anesthetic agent; sciatic nerve, single Clinic / Rounding $327.00 Injection, butrophanol tartrate, 1mg Clinic / Rounding $10.00 Injection, ceftriaxone sodium 250mg Clinic / Rounding $17.00 Injection, chlorpromazine HCl, up to 50mg Clinic / Rounding $10.00 Injection, depo-estradiol cypionate, up to 5mg Clinic / Rounding $28.00 Injection, dexamethasone sodium phosphate, 1 mg Clinic / Rounding $11.00 Injection, diphenhydramine HCL, up to 50 mg Clinic / Rounding $11.00 Injection, enoxaparin sodium, 10mg Clinic / Rounding $22.50 Injection, epoetin alfa, (for non-ESRD use), 1000 units Clinic / Rounding $22.00 Injection, ertapenem sodium, 500 mg Clinic / Rounding $50.00 Injection, Hydroxyzine hydrochloride Clinic / Rounding $11.00 Injection, intralesional; more than 7 lesions Clinic / Rounding $75.00 Injection, ketorolac tromethamine, per 15 mg Clinic / Rounding $11.00 Injection, medroxyprogesterone acetate, 1 mL Clinic / Rounding $0.80 Injection, mehtylprednisolone sodium succinate, up to 125mg Clinic / Rounding $29.00 Injection, Meperidine Hydrochloride Clinic / Rounding $17.00 Injection, Methylprenisolone 40mg Clinic / Rounding $13.00 Injection, metoclopramide HCl, up to 10mg Clinic / Rounding $1.50 Injection, Neupogen per 1mcg Clinic / Rounding $0.71 Injection, onabotulinumtoxina, 1 unit Clinic / Rounding $10.00 Injection, ondansetron HCl, per 1mg Clinic / Rounding $3.00 Injection, orphenadrine citrate, up to 60mg Clinic / Rounding $15.00 Injection, orphenadrine citrate, up to 60mg Clinic / Rounding $15.00 Injection, phytonadione (Vitamin K), per 1mg Clinic / Rounding $15.00 Injection, prochlorperazine, up to 10mg Clinic / Rounding $13.00 Injection, promethazine HCL, up to 50 mg Clinic / Rounding $15.00 Injection, sumatriptan succinate, 6 mg Clinic / Rounding $63.00 Injection, testosterone cypionate, 1mg Clinic / Rounding $0.16

37/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price Injection, triamcinolone acetonide, not otherwise, specified, per 10 mg Clinic / Rounding $3.00 Injection, triamcinolone acetonide, not otherwise, specified, per 10 mg Clinic / Rounding $3.00 Injection, vitamin B-12 cyanocobalamin, up to 1000 mcg Clinic / Rounding $11.00 Injection[s], anesthetic agent and/or steroid, plantar common digital nerve[s] Clinic / Rounding $75.00 Inpatient Consult for New or Established Patient Clinic / Rounding $210.00 Inpatient Consultation for a new or established, with 3 key requirements Clinic / Rounding $253.00 Inquinal Hernia Repair Clinic / Rounding $997.00 Insertion of bladder catheter Clinic / Rounding $65.00 Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast in Clinic / Rounding $1,750.00 Insertion of intrauterine device (IUD) Clinic / Rounding $200.00 Insertion of non-tunneled centrally inserted central venous catheter, age 5 yrs or older Clinic / Rounding $420.00 Insertion Of Port-A-Cath Clinic / Rounding $1,000.00 Insertion Of Port-A-Cath, Over 5 Years Clinic / Rounding $420.00

Insertion of temporary indwelling bladder catheter; simple Clinic / Rounding $85.00 INTUBATION, ENDOTRACHE Clinic / Rounding $208.00 Irrigation of implanted venous access device for drug delivery systems Clinic / Rounding $35.00 Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid Clinic / Rounding $55.00 Knee orthosis, elastic with joints, prefabricated item that has been trimmed, bent, molded, as Clinic / Rounding $85.00 Knee orthosis, immobilizer, canvas longitudinal, prefabricated, off-the-shelf Clinic / Rounding $70.00 Lap Cholecystectomy Clinic / Rounding $1,890.00 LAP INC HERN RECUR COMP Clinic / Rounding $3,200.00 Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes me Clinic / Rounding $2,500.00 Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes me Clinic / Rounding $2,800.00 Laparoscopy, surgical; cholecystectomy with cholangiography Clinic / Rounding $1,467.00

Laparoscopy, surgical; colectomy, partial, with anastomosis Clinic / Rounding $2,750.00 Laparoscopy, surgical; repair initial inguinal hernia Clinic / Rounding $1,070.00 Laryngoscopy, flexible; diagnostic Clinic / Rounding $404.00 Lay Clos Face/Ears 12.6 - 20.0 Clinic / Rounding $750.00 Lay Clos Face/Ears 5.1 To 7.5 Clinic / Rounding $635.00 Lay Clos Face/Ears 7.6 To 12.5 Clinic / Rounding $681.00 Lay Clos Neck/Hand 12.6-20.0 Clinic / Rounding $555.22 Lay Clos Neck/Hand 2.6-7.5 Cm Clinic / Rounding $288.00 Lay Clos Neck/Hand 7.6-12.5 Cm Clinic / Rounding $427.00 Layer Clos Neck/Hand 2.5 Or Le Clinic / Rounding $205.00 Layer Clos Sclp/Truk 20.1-30.0 Clinic / Rounding $450.00 Layer Clos Sclp/Truk Over 30.0 Clinic / Rounding $450.00 Ligation of Biopsy Temporal Artery Clinic / Rounding $263.00

38/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price Mastectomy, subcutaneous Clinic / Rounding $2,000.00 $2,000.00 Methylprednisolone Acetate, 80mg Clinic / Rounding $14.00 Mill Physical and drug screen Clinic / Rounding $100.00 $100.00 Mirena 52mg 5 yr Duration Clinic / Rounding $900.00 Naso- or oro-gastric tube placement, requiring physician's skill and fluoroscopic guidance (in Clinic / Rounding $158.00 NOCHG No Charge Clinic / Rounding STAT

Nursing facility discharge day management; Patient Level 1 Clinic / Rounding $105.00 $105.00

Nursing facility discharge day management; Patient Level 2 Clinic / Rounding $123.00 Observation care discharge day management Clinic / Rounding $110.00 Office or other outpatient visit for the evaluation and management of a new patient - Level 1 Clinic / Rounding $73.00 Office or other outpatient visit for the evaluation and management of a new patient - Level 2 Clinic / Rounding $102.00 Office or other outpatient visit for the evaluation and management of a new patient - Level 3 Clinic / Rounding $145.00 Office or other outpatient visit for the evaluation and management of a new patient - Level 4 Clinic / Rounding $215.00 Office visit for the evaluation and management of an established pt - Level 1 Clinic / Rounding $52.00 Office visit for the evaluation and management of an established pt - Level 2 Clinic / Rounding $67.00 Office visit for the evaluation and management of an established pt - Level 3 Clinic / Rounding $88.00 Office visit for the evaluation and management of an established pt - Level 4 Clinic / Rounding $163.00 Office visit for the evaluation and management of an established pt - Level 5 Clinic / Rounding $160.00 OOPHORECTOMY, PARTIAL Clinic / Rounding $840.00 Orchiectomy Clinic / Rounding $765.00 Osteopathic (OMT), 1-2 Regions Clinic / Rounding $55.00 Osteopathic (OMT), 3-4 Regions Clinic / Rounding $65.00 Paring Or Cut Benign Hyper 2-4 Clinic / Rounding $81.00 Paring Or Cut Benign Hyperkera Clinic / Rounding $45.00 PEG Insertion Clinic / Rounding $985.00 Pelvic and Clinical Breast Examination Clinic / Rounding $107.00 Pneumococcal 13-Valent Vaccine Clinic / Rounding $177.00 Pneumococcal 23-Valent Vaccine Clinic / Rounding $115.00 Porta-A-Cath peripherally inserted Clinic / Rounding $945.00 Preventive medicine reevaluation and management; established pt; age 12-17 Clinic / Rounding $150.00 Preventive medicine reevaluation and management; established pt; age 1-4 Clinic / Rounding $150.00 Preventive medicine reevaluation and management; established pt; age 18-39 Clinic / Rounding $150.00 Preventive medicine reevaluation and management; established pt; age 40-64 Clinic / Rounding $195.00 Preventive medicine reevaluation and management; established pt; age 5-11 Clinic / Rounding $150.00

39/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price Preventive medicine reevaluation and management; established pt; age 65 and older Clinic / Rounding $150.00 Preventive medicine reevaluation and management; established pt; age younger than 1 Clinic / Rounding $150.00 PROCTOSIGMOID W/REM TUMOR SNARE Clinic / Rounding $1,000.00 $1,000.00 Professional services for allergen immunotherapy not including [provision of allergenic extr Clinic / Rounding $14.00 Professional services for allergen immunotherapy not including [provision of allergenic extrac Clinic / Rounding $19.00 Punc Aspir Breast Cyst Clinic / Rounding $110.00

Puncture aspiration of abscess, hematoma, bulla, or cyst Clinic / Rounding $87.00 Radiologic examination, chest; single view, frontal Clinic / Rounding $24.00 Rem Fb Mus/Ten Simple Clinic / Rounding $177.00 Rem Fb Upper Arm Elbow Subcut Clinic / Rounding $220.00 Removal Embedded FB Eyelid Clinic / Rounding $225.00 Removal FB Conjunctival Embed Clinic / Rounding $87.00 Removal FB Corneal W/Slit Lamp Clinic / Rounding $150.00 Removal Fb Foot Subcutaneous Clinic / Rounding $122.00 Removal foreign body from external auditory canal; without anesthesia Clinic / Rounding $101.00 Removal Foreign Body, Nasal Clinic / Rounding $87.00 Removal impacted cerumen requiring instrumentation, unilateral Clinic / Rounding $59.00 Removal of foreign body, external eye; conjunctival superficial Clinic / Rounding $141.00 Removal of foreign body, external eye; conjunctival superficial; corneal, without [slit lamp] Clinic / Rounding $179.00 Removal of intrauterine device (IUD) Clinic / Rounding $125.00 Removal of pilonidal lesion Clinic / Rounding $400.00 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions Clinic / Rounding $107.00 Removal Port-A-Cath w/o Port or pump Clinic / Rounding $420.00 Removal Skin Tags Addtl 10 Clinic / Rounding $30.00 Removal, non-biodegradable drug delivery implant Clinic / Rounding $125.00 Remove elbow Lesion Clinic / Rounding $750.00 $750.00 Remove Indwelling Tunneled Pleural Catheter w/Cufff Clinic / Rounding $250.00 $250.00 Reopening Recent Laparotomy Clinic / Rounding $900.00 Rep Incarc/Strang Ventral Hernia Clinic / Rounding $2,520.00 Repair Inguinal Hernia,Any Age Reducible Clinic / Rounding $760.00 Repair of incarcerated Clinic / Rounding $1,260.00 Repair Recurrent Incis/Vent Hernia Clinic / Rounding $1,575.00 Repair umbilical hernia, i Clinic / Rounding $2,100.00 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1 Clinic / Rounding $327.00 Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 c Clinic / Rounding $355.00 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities excluding hands and f Clinic / Rounding $321.00 Shaving Epiderm 0.6 To 1.0 Cm Clinic / Rounding $206.00 Shaving Epiderm Face 0.6-1.0cm Clinic / Rounding $125.00 Shaving Epiderm Face 1.1-2.0cm Clinic / Rounding $145.00

40/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price Shaving Epidermal 0.6-1.0cm Clinic / Rounding $90.00 Shaving Lesion >2.0 Cm Clinic / Rounding $125.00 Shaving Lesion 1.1 To 2.0 Cm Clinic / Rounding $115.00 Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous Clinic / Rounding $80.00 Shaving of epidermal or dermal lesion, single lesion, trunk, arm or legs; lesion diameter 0.5 Clinic / Rounding $80.00 Shoulder orthosis, acromio/clavicular (canvas and webbing type), prefabricated, off-the-shelf Clinic / Rounding $12.00 Shoulder orthosis, figure of eight design abduction restrainer, prefabricated, off-the-shelf Clinic / Rounding $52.00 Sigmoidoscopy, diagnostic Clinic / Rounding $170.00 Sigmoidoscopy, with biopsy Clinic / Rounding $170.00 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes Clinic / Rounding $161.00 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes Clinic / Rounding $219.00 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or Clinic / Rounding $128.00 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or Clinic / Rounding $151.00 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or Clinic / Rounding $188.00 Sling Clinic / Rounding $25.00 Special reports such as insurance forms, more than the information conveyed in the usual medic Clinic / Rounding $16.29 Sphincterotomy, Anal Clinic / Rounding $450.00 Spinal puncture, lumbar, diagnostic Clinic / Rounding $180.00 SPORT Sport Physical Clinic / Rounding $25.00 Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, Clinic / Rounding $175.00 Subsequent hospital care, Level 1 Clinic / Rounding $74.00 Subsequent hospital care, Level 2 Clinic / Rounding $108.00 $108.00 Subsequent hospital care, Level 3 Clinic / Rounding $119.00 Subsequent nursing facility care, Patient Level 1 Clinic / Rounding $67.00 Subsequent nursing facility care, Patient Level 2 Clinic / Rounding $92.00 Subsequent nursing facility care, Patient Level 3 Clinic / Rounding $128.00 Subsequent nursing facility care, Patient Level 4 Clinic / Rounding $168.00 Surgical treatment of anal fistula (fistulectomy/fistulotomy); subcutaneous Clinic / Rounding $550.00 Suture Face/Ears 5.1 To 7.5 Cm Clinic / Rounding $296.00 Suture Face/Ears 7.6 To 12.5 C Clinic / Rounding $387.00 Suture Trunk/Extrem 12.6-20.0 Clinic / Rounding $296.00 TB Skin Test POC Clinic / Rounding $16.00 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to indiv Clinic / Rounding $49.00 Therapeutic, prophylactic, or diagnostic injection; each additional sequential IV push of new Clinic / Rounding $75.00 Therapeutic, prophylactic, or diagnostic injection; IV push, single or initial substance Clinic / Rounding $75.00 Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular Clinic / Rounding $40.00

41/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance Clinic / Rounding $910.00 Thoracentesis, puncture Clinic / Rounding $177.00 Tonsillectomy/Adenoidectomy Clinic / Rounding $578.00 Tracheostomy, emergency procedure; cricothyroid membrane Clinic / Rounding $250.00

Treatment of closed elbow dislocation; without anesthesia Clinic / Rounding $600.00 Tumor Soft Tiss Hand/Finger Su Clinic / Rounding $420.00 Unna Boot Clinic / Rounding $50.00 Upper extremity fracture orthosis, wrist, prefabricated, includes fitting And Adjustment Clinic / Rounding $74.00 Vasectomy, unilateral or bilateral, including postoperative semen examination[s] Clinic / Rounding $735.00 Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface mater Clinic / Rounding $52.00 WHFO W/O Joint Prefab Clinic / Rounding $75.00 Wrist hand orthosis, without joints, may include soft interface, straps, custom-fabricated Clinic / Rounding $70.00 Wrist-Hand-Finger Orthoses - Custom Fitted Clinic / Rounding $45.00 #NAME? Clinic / Rounding $275.00 #NAME? Clinic / Rounding $1,950.00 #NAME? Clinic / Rounding $2,520.00 ANES CRNA ANESTHESIA ADMIN I (1500) CRNA Fees $60.00 ANES CRNA ANESTHESIA ADMIN I (UB) CRNA Fees $60.00 Pain Management PF HOSP M1 DRAIN/INJ JNT/BURSA MAJ W/US Prof Fees $170.00 Pain Management PF Hosp M1 Established Patient Level 4 Prof Fees $163.00 Pain Management PF HOSP M1 IMPLANT NEUROELECTRODES Prof Fees $5,200.00 Pain Management PF HOSP M1 INJ FORAMEN EIPIDURAL ADD-ON Prof Fees $67.00 Pain Management PF HOSP M1 INJ PARAVERT F JNT L/S 1 LEV Prof Fees $177.00 Pain Management PF HOSP M1 INJ PRVT FACET JNT C/T SINGLE Prof Fees $152.00 Pain Management PF HOSP M1 INJ PVRT FACET JNT C/T 2ND LEV Prof Fees $77.00 Pain Management PF HOSP M1 INJ PVRT FACET JNT C/T 3+ LEV Prof Fees $77.00 Pain Management PF HOSP M1 INJ PVRT FACET JNT L/S 2ND LEV Prof Fees $67.00 Pain Management PF HOSP M1 INJ PVRT FACET JNT L/S 3+ LEV Prof Fees $67.00 Pain Management PF HOSP M1 INJECT SPINE CRV/THRC W/IMG Prof Fees $292.00 Pain Management PF HOSP M1 INJECT SPINE LMBR/SAC W/IMG Prof Fees $292.00 Pain Management PF HOSP M1 INSRT/REDO SPINE N GENERATOR Prof Fees $243.00

42/43 Pricing CDM Description Activity Type Clinic Price Hospital Price Rounding Price Pain Management PF Hosp M1 New Patient Level 3 Prof Fees $145.00 Pain Management PF Hosp M1 New Patient Level 4 Prof Fees $215.00 Pain Management PF HOSP M1 NJ TRANSFORAMINAL EPI L/S SNGL Prof Fees $177.00 Pain Management PF Hosp M1 Office Visit Estab Pt Expanded Level 3 Prof Fees $88.00 Pain Management PF Hosp M2 Established Patient Level 4 Prof Fees $163.00 Pain Management PF HOSP M2 IMPLANT NEUROELECTRODES Prof Fees $5,200.00 Pain Management PF HOSP M2 INJ FORAMEN EIPIDURAL ADD-ON Prof Fees $67.00 Pain Management PF HOSP M2 INJ PARAVERT F JNT C/T 2 LEV Prof Fees $77.00 Pain Management PF HOSP M2 INJ PARAVERT F JNT L/S 1 LEV Prof Fees $177.00 Pain Management PF HOSP M2 INJ PARAVERT FACET JNT L/S 2ND LEV Prof Fees $67.00 Pain Management PF HOSP M2 INJ PRVT FACET JNT C/T SINGLE Prof Fees $152.00 Pain Management PF HOSP M2 INJ PVRT FACET JNT C/T 3+ LEV Prof Fees $77.00 Pain Management PF HOSP M2 INJ PVRT FACET JNT L/S 3+ LEV Prof Fees $67.00 Pain Management PF HOSP M2 INJECT SPINE CRV/THRC W/IMG Prof Fees $292.00 Pain Management PF HOSP M2 INJECT SPINE LMBR/SAC W/IMG Prof Fees $292.00 Pain Management PF HOSP M2 INSRT/REDO SPINE N GENERATOR Prof Fees $243.00 Pain Management PF Hosp M2 New Patient Level 3 Prof Fees $145.00 Pain Management PF Hosp M2 New Patient Level 4 Prof Fees $215.00 Pain Management PF HOSP M2 NJ TRANSFORAMINAL EPI L/S SNGL Prof Fees $177.00 Pain Management PF HOSP M2 Office Visit Estab Pt Expanded Level 3 Prof Fees $88.00

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