Saint Camillus Medical Center

Case Rates inlcude facility, surgeon, assistant surgeon, pathology and anesthesiologist fees. Bundled General Procedure Name CPT Codes MS-DRG Codes Rate SPINE Laminotomy – Cervical One Level 63020 $12,500 490 Two Level 63035-50 – Add On $13,600 Three Level 63035-50 – Add On $14,600 Laminotomy – Lumbar One Level 63030 $13,000 491 Two Level 63035-50 – Add On $14,500 Three Level – Bilateral 63035-50 – Add On $15,600 Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, 21556 $4,000 intramuscular); less than 5 cm Anterior Lumbar Interbody Fusion (ALIF) One Lvl 22558 $47,135 Two Levels 22585-50 – Add On 460 $55,655 Three Levels 22585-50 – Add On $68,500 Posterior Lumbar Interbody Fusion (PLIF) One Lvl 22630 $25,000 456, 457, 458, Two Levels 22632-50 – Add On $27,000 459, 460 Three Levels 22632-50– Add On $29,000 Anterior, Posterior or Posterolateral Lumbar 360 (Anterior -Posterior Lumbar Fusion) One Level 22612 459, 460 $55,000 (453,454, 455) Two Level 22614-50 – Add On $59,000

Three Level 22614-50 – Add On $65,000 Anterior Cervical Fusion – ACF One Level 63081 $19,000 Two Levels 63082-50 – Add On 471, 472, 473 $21,000 Three Levels 63082-50 – Add On $23,000 Posterior Cervical Fusion – PCF One Level 22600 $19,000 Two Levels 22614-50 - Add On 471, 472, 473 $21,000 Two Levels 22614 – Add On $21,000 Three Levels 22614-50 – Add On $22,000 Artificial Disc Replacement- Lumbar One Level 22857 $20,700 Two Levels 0163T – Add On 028, 029, 030 $22,500 Three Levels 0163T – Add On $25,950 Spinal Cord Stimulator Trial 1 Lead 63650/63661, L8680, C1778 $7,400 028, 029, 030 Trial 2 Leads 63650/63661, L8680, C1778 $8,400 Implant - 1 Lead $8,000 Implant Pulse Generator- 028, 029, 030 8 Lead 63685, L8687, C1820 $27,000 PAIN MANAGEMENT Lumbar Epidural Steroid Injection (Transforaminal) 62311, 64483 400 $850 Cervical Epidural Steroid Injection 62310, 64479 400 $850 Lumbar Sympathetic Block 64520 400 $850 Stellate Ganglion Block 64510 500 $850 Epidural Blood Patch 62273 600 $850 Injection, anesthetic agent; femoral nerve, single 64447 $850 Injection, anesthetic agent; femoral nerve, continuous infusion by catheter 64448 $850 Injection(s), paravertebral facet joint, lumbar; single level 64493 $850 Injection(s), paravertebral facet joint, lumbar; second level 64494 $850 Injection(s), paravertebral facet joint, lumbar; third and add'l levels 64495 $850

*This list of procedures are for review purposes only and is not a guarantee of benefits. Please refer to your Summary Plan Description. ORTHO 27445 469 $22,000 Knee Replacement, Partial or Total, Unilateral 27446 470 $22,000 461 $32,000 Knee Replacement - Bilateral 27447 462 $32,000 466 $25,000 Knee Replacement Revision 27487 467 $25,000 468 $25,000

29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, Knee Arthroscopy $3,840 29880, 29881, 29882, 29883, 29884, 29886, 29887

ACL Repair 29888, 29889 $6,820

469 $22,000 Hip Replacement - Partial or Total, Unilateral 27125

470 $22,000 461 $35,000 Hip Replacement - Bilateral 27130 462 $35,000 466 $23,500 Hip Replacement Revision 27134 467 $23,500 468 $23,500 Hip Arthroscopy 29860-29863, 29914-29916 $5,300 UPPER EXTREMITY

29806, 29807, 29819, 29820, Shoulder Arthroscopy 29821, 29822, 29823, 29824, $6,000 29825, 29826, 29827, 29828 Rotator Cuff Repair 23410, 23412, 23415, 23420 $6,200

23430, 23455, 23460, 23465, Shoulder Repair $6,550 23485, 23490, 23491

Shoulder Repair - total 23470, 23472, 23473 484 $17,000

Shoulder Repair Revision - total 23472 483, 484 $19,000

Elbow - debridement 24358 $2,800 Wrist Endoscopy 29848, 29840 $4,150 Carpal Tunnel Release 64721 $2,620 Trigger Finger Release 26055 $2,630 GYN AND GENERAL Hysterectomy, Open (Abdominal) 58150 742, 743 $10,500 Hysterectomy, Open with removal of tubes and/or ovaries 58542 $10,000 Lithotripsy 50590 $5,200 Cholecystectomy - open 47562, 47563, 47564, 47570 358 $5,500 Gastric Sleeve 43775 $10,900 Gastric Bypass 43846-53848, 43644 $18,500 Hernia Repair - open 49505, 49585,49560 $5,000 Hernia Repair - laparoscopic 49652-49657, 49659 $6,000 Hiatal Hernia Repair 43281, 43282 $9,200 Cholecystectomy - laparoscopic 47560, 47561 $5,000 Mastectomy 19301, 19302 $5,500

*This list of procedures are for review purposes only and is not a guarantee of benefits. Please refer to your Summary Plan Description. Plantar Fasciotomy 28060 $2,980 Bunionectomy 28292 $4,255 Hammertoe 28285 $2,930 MRI Abdomen without contrast 74181 $720 Abdomen with contrast 74182 $770 Abdomen with and without contrast 74183 $820 Brain without contrast 70551 $770 Brain with contrast 70552 $820 Brain with and without contrast 70553 $870 Extremity without contrast 73218, 73718 $720 Extremity with contrast 73219, 73719 $770 Extremity with and without contrast 73220, 73720 $820 Joint without contrast 73221, 73721 $720 Joint with contrast 73222, 73722 $770 Joint with and without contrast 73223, 73723 $820 Pelvis without contrast 72195 $720 Pelvis with contrast 72196 $770 Spine Cervical without contrast 72141 $770 Spine Cervical with contrast 72142 $820 Spine Cervical with and without contrast 72156 $870 Spine Lumbar without contrast 72148 $770 Spine Lumbar with contrast 72149 $820 Spine Lumbar with and without contrast 72158 $870 Spine Thoracic without contrast 72146 $770 Spine Thoracic with contrast 72147 $820 Spine Thoracic with and without contrast 72157 $870 CT Abdomen without contrast 74150 $400 Abdomen with contrast 74160 $450 Abdomen & Pelvis without contrast 74176 $450 Abdomen & Pelvis with contrast 74177 $550 Abdomen & Pelvis with and without contrast 74178 $650 Head without contrast 70450 $400 Head with contrast 70460 $450 Head with and without contrast 70470 $500 Hip without contrast 72192 $400 Hip with contrast 72193 $450 Facial without contrast 70486 $400 Facial with contrast 70487 $450 Facial with and without contrast 70488 $600 Spine Cervical without contrast 72125 $400 Spine Lumbar without contrast 72128 $400 Spine Thoracic without contrast 72131 $400

Implants included in all case rates

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