Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price I & D ABSCESS SIMPLE/SINGLE $ 530.00 I&D ABSC; SMPL OR SGL $ 530.00 I&D ABSC; SMPL OR SGL $ 530.00 INC/REM FOR BODY SUBCUT SIMPLE $ 940.00 INC & REM FB SQ; SMPL $ 940.00 INC/REM FOR BODY SUBCUT COMPLE $ 4,415.00 INC & REM FB SQ; COMPL $ 4,415.00 DEB SUBQ TISSUE ADD-ON =<20 SQ CM $ 90.00 DEB SUBQ TISSUE ADD-ON =<20 SQ CM $ 90.00 EXC BEN LES T/A/L; 2.1-3.0CM $ 1,738.00 EXC BEN LES T/A/L; 2.1-3.0CM $ 1,738.00 DEBRIDEMENT OF NAIL $ 168.00 DEBRIDE NAIL 1-5 $ 168.00 DEBRIDE NAIL 6 OR MORE $ 168.00 DEBRIDE NAIL 6 OR MORE $ 168.00 SINGLE NAIL AVULSION $ 530.00 AVULSION OF NAIL PLATE,SIMPLE, SINGLE $ 530.00 NAIL AVULSION EACH ADDITIONAL $ 60.00 SPL AVULSE NP; EA ADDTL $ 60.00 EVACUATION SUBUNGUAL HEMATOMA $ 320.00 EVAC SU HEMATOMA $ 320.00 REMOVAL OF NAIL BED $ 940.00 REMOVAL OF NAIL BED RIGHT $ 940.00 REMOVAL OF NAIL BED LEFT $ 940.00 REPAIR NAIL BED $ 1,449.00 REPAIR NAIL BED $ 1,449.00 ER SIMPLE <2.5 CM LACERATION $ 529.00 SREP S/N/A/G/TR/E; 2.5CM/< $ 529.00 TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING $ 942.00 TX OF SUPERFICIAL WOUND DEHISCENC W PACK $ 942.00 FACIAL INTERMEDIATE REP <2.5CM $ 942.00 FACIAL INTERMEDIATE 0-2.5 CM $ 942.00 DRESS/DEBRIDE INIT W/O ANES SM $ 529.00 DRESS/DEBRID P-THICK BURN S $ 529.00 DRESS/DEBRID P-THICK BURN S $ 529.00 SIMPLE FOR BODY REMOVAL MUS/TE $ 4,127.00 REMOVAL OF FOREIGN BODY IN MUSCLE/TENDON $ 4,127.00 INJ SGL TENDON SHTH OR LIGAMENT $ 742.00 TENDON SHETH/LIGAMENT/CYST INJECTION $ 742.00 INJ SGL TENDON SHTH OR LIGAMENT $ 742.00 INJ TRIGGER POINT 1/2 MUSCL $ 742.00 INJ TRIGGER POINT 1/2 MUSCL $ 742.00 TRIGGER POINTS INJECTION $ 742.00 INJECT TRIGGER POINTS 3/> $ 742.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price INJECT TRIGGER POINTS =/> 3 $ 742.00 INJECT TRIGGER POINTS =/> 3 $ 742.00 SMALL JOINT INJECTION/ASPIRATION $ 742.00 SMALL JOINT/BURSA INJ OR ASPIR $ 742.00 MEDIUM JOINT/BURSA INJ OR ASPIR $ 742.00 MEDIUM JOINT/BURSA INJ OR ASPIR $ 742.00 DRAIN/INJ INTERM JNT/BURSA $ 742.00 LARGE JOINT/BURSA INJ OR ASPIR $ 742.00 DRAIN/INJ MAJOR JNT/BURSA $ 742.00 GANGLION CYST INJECTION $ 742.00 GANGLION CYST INJ OR ASPIR $ 742.00 ASPIRATE/INJ GANGLION CYST $ 742.00 CLOSED TX SHOULDER DISLOCATION $ 700.00 CL TX SHLDR DISL W MANIP; W/O ANESTH $ 700.00 CLOSED TX RADIAL HEAD W/MANIP $ 675.00 CL TX RADIAL HD/NECK FX; WO MANIP- ER $ 675.00 CL TX RAD & ULN SHFT FX W/O MANI $ 675.00 CL TX OF RADIAL SHAFT FX; WO MANIP $ 675.00 CL TX RADIAL & ULNAR SHFT FX; WO MANIP $ 675.00 CLOSED TX RAD/ULN SHAF W/MANI $ 3,940.00 CL TX ULNAR SHFT FX W MANIP $ 3,940.00 CLTX DSTL RDL FX/EPIPHYSL SEP W MNP $ 3,940.00 CLTX DSTL RDL FX/EPIPHYSL SEP W MNP $ 3,940.00 CL TX MC FX SGL; W MANIP $ 675.00 CL TX MC FX SGL; W MANIP $ 675.00 CL TX MC FX SGL; W MANIP $ 675.00 CLOSED TX INTERPHAL JT DISLOCATION $ 675.00 CL TX IP JT D W MANIP W/O ANESTH $ 675.00 CL TX TIB SHFT FX W MANIP $ 3,940.00 CL TX TIB SHFT FX W MANIP $ 3,940.00 PARTIAL REMOVAL PHALANX OF TOE $ 7,870.00 PARTIAL EXC PHALANX TOE BONE $ 7,870.00 JT EXCISION PROX END PHALA $ 7,870.00 INTERPHALANG TOE JNT EXC EA SGL $ 7,870.00 REMOVAL OF FOREIGN BODY, FOOT; SUBCUTANE $ 1,738.00 REM FB FOOT; SQ $ 1,738.00 CORRECTION OF HALLUX VALGUS $ 7,870.00 KELLER/MCBRIDE/MAYO BUNION CORRECT $ 7,870.00 CL TX FX PHALANX/PHALANG; W MANIP $ 675.00 CL TX FX PHALANX/PHALANG; W MANIP $ 675.00 APPLICATION SPLINT- LONG ARM $ 404.00 APPLICATION-LONG ARM SPLINT $ 404.00 LONG ARM SPLINTS APPLICATION $ 404.00 OT APPLY LONG ARM SPLINT $ 404.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price APPLICATION LONG ARM SPLINT $ 404.00 SHORT ARM SPLINTS OR ONLY $ 319.00 SHORT ARM SPLINTS APPL STATIC $ 319.00 APPLICATION STATIC SPLINT- SHORT ARM $ 319.00 APPLIC-SHORT ARM SPLINT DYNAM $ 319.00 OT APPLY SHORT ARM SPLINT; DYNAMIC $ 319.00 APPLY SHORT ARM SPLINT; DYNAMIC $ 319.00 FINGER SPLINT APPLICATION $ 168.00 FINGER SPLINT APPLICATION $ 168.00 STRAPPING; SHOULDER $ 319.00 STRAPPING; SHOULDER $ 319.00 STRAPPING; ELBOW OR WRIST $ 96.00 STRAPPING ELBOW $ 96.00 APPLICATION LONG LEG SPLINT $ 404.00 LONG LEG SPLINT APPLICATION $ 404.00 APPLICATION SPLINT- SHORT LEG $ 404.00 APPLICATION SHORT LEG SPLINT $ 404.00 SHORT LEG SPLINT $ 404.00 APPLY SHORT LEG SPLINT $ 404.00 STRAPPING ANKLE $ 404.00 STRAP ANKLE OR FOOT $ 404.00 STRAPPING OF THE TOES $ 168.00 STRAPPING OF TOES $ 168.00 STRAPPING UNNA BOOT $ 404.00 UNNA BOOT STRAPPING $ 404.00 UNNA BOOT STRAPPING $ 404.00 STRAPPING UNNA BOOT CLINIC $ 404.00 APPLY MULTILAYER COMPRESS - LOWER LEG $ 404.00 APPLY MULTLAY COMPRS LWR LEG $ 404.00 RMVE CAST REMOVE FULL ARM OR LEG CAST $ 707.00 REMOVE FULL ARM OR LEG CAST $ 707.00 INTUBATION ET EMERGENT $ 618.00 INTUBATION MED SURG $ 618.00 MET PATH DRAW FEE $ 9.00 SPECIMEN COLLECTION $ 9.00 VENIPUNCT-HOMEBOUND $ 9.00 VENIPUNCTURE $ 9.00 ER VENIPUNCTURE FEE $ 9.00 TRANSFUSION-BLOOD OVER 4 HRS $ 1,149.00 BLOOD TRANSFUSION $ 1,149.00 TRANSFUSION BLOOD UP TO 2 HOURS $ 1,149.00 TRANSFUSION BLOOD UP TO 4 HOURS $ 1,149.00 TRANSFUSION BLOOD UP TO 6 HOURS $ 1,149.00 TRANSFUSION BLOODUP TO 8 HOURS $ 1,149.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price BLOOD DRAW FROM PORT $ 319.00 DRAW BLOOD OFF VENOUS DEVICE $ 319.00 TOUNGUE LACERATION 2.5CM/LESS $ 618.00 TONGUE LACERATION 2.6 CM $ 618.00 GASTRIC LAVAGE INTUB $ 757.00 TX GASTRO INTUB W/ASP $ 757.00 INS TEMP BLADDER CATH (STRAIGHT CATH) $ 319.00 INSERT BLADDER CATHETER $ 319.00 INJ ANESTH ; GREATER OCCIPITAL NERVE $ 742.00 INJ ANESTH ; GREATER OCCIPITAL NERVE $ 742.00 INJ ANESTH AGENT PERIPH NERVE $ 1,796.00 INJ ANESTH; OTHR PERIPHERAL NRV/BRANCH $ 1,796.00 INJ PARAVERT F JNT L/S 3 LEV $ 171.00 INJ PARAVERT F JNT L/S 3 LEV $ 171.00 X-RAY EXAM OF FACIAL BONES <3 VIEWS $ 187.00 X-RAY EXAM OF FACIAL BONES <3 VIEWS $ 187.00 CT ORBIT/EAR/FOSSA W/O DYE $ 340.00 CT ORBIT/EAR/FOSSA W/O DYE $ 340.00 CT ORBIT/EAR/FOSSA W/DYE $ 605.00 CT ORBIT/EAR/FOSSA W/DYE $ 605.00 X-RAY EXAM OF BREASTBONE 3+ VIEWS $ 187.00 X-RAY EXAM OF BREASTBONE 3+ VIEWS $ 187.00 X-RAY EXAM OF LOWER SPINE $ 338.00 X-RAY EXAM OF LOWER SPINE $ 338.00 X-RAY EXAM OF SHOULDER 1 VIEW, RIGHT $ 186.00 X-RAY EXAM OF SHOULDER 1 VIEW, BILAT $ 342.00 X-RAY EXAM OF SHOULDER 2+ VIEWS, LEFT SIDE $ 187.00 X-RAY EXAM OF SHOULDER 2+ VIEWS, RIGHT SIDE $ 187.00 X-RAY EXAM OF SHOULDER 2+ VIEWS $ 187.00 X-RAY EXAM OF HUMERUS 2+ VIEWS, RIGHT $ 187.00 X-RAY EXAM OF HUMERUS 2+ VIEWS, LEFT $ 187.00 X-RAY EXAM OF HUMERUS 2+ VIEWS $ 187.00 X-RAY EXAM OF FOREARM 2 VIEWS, RIGHT $ 187.00 X-RAY EXAM OF FOREARM 2 VIEWS, LEFT $ 187.00 X-RAY EXAM OF FOREARM 2 VIEWS $ 187.00 X-RAY EXAM OF FOREARM 2 VIEWS, BILATERAL $ 187.00 X-RAY EXAM OF WRIST 2 VIEWS, LEFT $ 187.00 X-RAY EXAM OF WRIST 2 VIEWS, RIGHT $ 187.00 X-RAY EXAM OF WRIST 2 VIEWS, BILAT $ 187.00 X-RAY EXAM OF WRIST 3+ VIEWS, LEFT $ 187.00 X-RAY EXAM OF WRIST 3+ VIEWS, RIGHT $ 187.00 X-RAY EXAM OF WRIST 3+ VIEWS, BILAT $ 187.00 X-RAY EXAM OF ANKLE 2 VIEWS, RIGHT $ 187.00 X-RAY EXAM OF ANKLE 2 VIEWS, LEFT $ 187.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price X-RAY EXAM OF ANKLE 2 VIEWS, BILAT $ 187.00 X-RAY EXAM OF ANKLE 2 VIEWS, BILAT $ 187.00 X-RAY EXAM OF ANKLE 3+ VIEWS, RIGHT $ 187.00 X-RAY EXAM OF ANKLE 3+ VIEWS, LEFT $ 187.00 X-RAY EXAM OF ANKLE 3+ VIEWS, BILAT $ 187.00 X-RAY EXAM OF FOOT; 3+ VIEWS, RIGHT $ 187.00 X-RAY EXAM OF FOOT; 3+ VIEWS, LEFT $ 187.00 X-RAY EXAM OF FOOT; 3+ VIEWS, BILAT $ 187.00 MRI LOWER EXT; ANY JOINT W/DYE $ 2,075.00 MRI LOWER EXT; ANY JOINT W/DYE $ 2,075.00 FLUID AND ABCESS DRAINAGE $ 391.00 ABSCESS DRAINAGE UNDER X-RAY $ 391.00 US EXAM ABDOM COMPLETE $ 600.00 US EXAM ABDOM COMPLETE $ 600.00 US ABDOMEN LIMITED $ 600.00 US OF GALLBLADDER $ 600.00 US ABDOMEN LIMITED $ 600.00 US EXAM ABDO BACK WALL LIM $ 500.00 US EXAM ABDO BACK WALL LIM $ 500.00 US XTR NON-VASC LMTD $ 338.00 US XTR NON-VASC LMTD $ 338.00 US GUIDED NEEDLE PLACEMENT $ 183.00 US GUIDED NEEDLE PLACEMENT $ 183.00 US GUIDED NEEDLE PLACEMENT $ 183.00 US GUIDED NEEDLE PLACEMENT $ 183.00 US GUIDED NEEDLE PLACEMENT $ 183.00 CARDIAC BLD POOL MUGA SCAN $ 1,060.00 MUGA; SGL W WM & EF $ 1,060.00 LUNG VENT AEROSOL ; MULTIPLE $ 1,367.00 LUNG VENTILATION/PERFUSION STUDY $ 1,367.00 LUNG PERF W VENTIL; RB W WO $ 1,367.00 LUNG PERF W VENTIL; SGL BRTH $ 1,367.00 DEPAKENE VALPROIC ACID $ 50.00 DEPAKOTE LEVEL/VALPORIC ACID (VALPORATE) $ 50.00 VANCOMUCIN PEAK $ 50.00 VANCOMUCIN THROUGH $ 50.00 VANCOMYCIN TROUGH $ 50.00 DRUG SCREEN $ 215.00 DRUG TEST PRSMV CHEM ANLYZR $ 215.00 ACETONE SEMI QUANT $ 30.00 SERUME KETONE $ 30.00 ALBUMIN URINE $ 23.00 ALBUMIN FLUID $ 23.00 OSMOLALITY FLUID $ 23.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price MICROALBUMIN URINE $ 21.00 MICROALBUMIN 24 HR URINE $ 21.00 ALPHA 1 ANTITRYPSIN $ 50.00 ALPHA I ANTITRYPSIN TOTAL $ 50.00 A-1 ANTITRYPSON $ 50.00 ALPHA FETO PROTEIN $ 62.00 LH-SERUM $ 62.00 LEUKEMIA/LYMPHOCYTE EVALUATION $ 62.00 AFP TUMOR MARKER SERUM $ 62.00 HEMO CARDS $ 13.00 OCCULT BLOOD-STOOL $ 13.00 CARBON DIOXIDE (CO2) $ 18.00 CARBOXY HGB $ 18.00 LAMOTRIGINE $ 72.00 MEXILETINE $ 72.00 NEURONTIN (GABAPENTIN) $ 72.00 COL CHROMOTOGRAPHY QUAL/QUAN $ 72.00 CC/MS; QUAN SS & MP $ 72.00 KEPPRA (LEVETIRACETAM) $ 72.00 ERYTHROPOIETIN-SERUM $ 70.00 ERYTHROPOIETIN -EPOGEN $ 70.00 FOLIC ACID; SERUM $ 54.00 FOLIC ACID (FOLATES) $ 54.00 IGA QUANT CSF $ 34.00 IMMUNOGLOB G CSF (IGG) $ 34.00 GLUCOSE BODY FLUID $ 15.00 GLUCOSE CSF $ 15.00 INSULIN TOLERANCE (3) $ 42.00 INSULIN $ 42.00 DIRECT LDL $ 35.00 LOW DENSITY LIPO PROTEIN $ 35.00 METANEPHRINES 24 HR URIN $ 63.00 METANEPHRINES PLASMA $ 63.00 PROTEIN; EP FRACT & QUAN $ 40.00 SERUM ELECTROPHORESIS $ 40.00 ZINC 24HR URIN $ 42.00 ZINC $ 42.00 FACTOR V $ 65.00 FACTOR V LEIDEN $ 65.00 CLOTTING INHIBITOR PROTEIN S FREE $ 57.00 PROTEIN S FUNCTIONAL $ 57.00 THYROID ANTIMICROSOMAL AB $ 54.00 ANTI-PEROXIDASE ANTIBODY $ 54.00 INFLUENZA A ANTIBODY $ 50.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price INFLUENZA B ANTIBODY $ 50.00 V ZOSTER IGM TITER $ 48.00 VARICELLA SCREEN (IGG-EIA) $ 48.00 ABO AND RH TYPE $ 319.00 ABO GROUP $ 319.00 CULTURE BLOOD $ 74.00 AEROBIC/ANAEROBIC CULTURE $ 74.00 BACTERIAL CULTURE $ 32.00 CULTURE CATHETER TIPS $ 32.00 CULTURE CSF $ 32.00 CULTURE FLUID $ 32.00 CULTURE SPUTUM $ 32.00 CULTURE THROAT (CULTURE AND SENSITIVITY) $ 32.00 CULTURE UROGENITAL $ 32.00 CULTURE WOUND $ 32.00 EYE CULTURE $ 32.00 QUICK STREP $ 32.00 BORDETELLA PERTUSSIS NASOPHARYNGEAL CULT $ 32.00 BACTERIAL ID $ 30.00 BACTERIAL ID $ 30.00 BETA STREP CULTURE $ 25.00 CULTURE G C $ 25.00 URINE CULTURE $ 30.00 BIOCHEMICAL ID $ 30.00 URINE CULTURE ID $ 30.00 M I C $ 32.00 ANTIBIOTIC SENSITIVITY $ 32.00 ANTIBIOTIC SENSITIVITY $ 32.00 ANTIBIOTIC SENSITIVITY $ 32.00 EOSINOPHIL $ 16.00 STOOL FOR WBC $ 16.00 ACID FAST SMEAR $ 20.00 FUNGUS STAIN $ 20.00 PERTUSSIS SMEAR $ 20.00 GENET VIRUS ISOLATE HSV $ 125.00 GENET VIRUS ISOLATE HSV $ 125.00 TISSUE PATHOLOGY $ 153.00 GROSS & MICRO LAB ONLY(TISSUE PATHOLOGY) $ 153.00 FLUARIX QUADRIVALENT FLU VACCINE 17-18 $ 49.00 FLUARIX QUADRIVALENT FLU VACCINE 2014-15 $ 47.00 FLUARIX QUADRIVALENT FLU VACCINE $ 63.00 FLUARIX QUAD 2018-2019 SYRINGE 0.5 mL, 0.5 mL $ 61.00 CPR $ 757.00 HEART/LUNG RESUSCITATION CPR $ 757.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price ER CARDIOVERSION ELECTIVE EXT $ 1,579.00 CARDIOVERSION ELECTRIC EXT $ 1,579.00 CARDIOVERSION ELECTRIC EXT $ 1,579.00 CARDIOVASCULAR STRESS TEST; TRACING $ 757.00 CARDIOVASCULAR STRESS TEST; TRACING $ 757.00 US ARTERY EXTREMITY UPPER LT $ 338.00 DUPLEX UE ART/BPG; UNIL/LIMIT RT $ 338.00 DUPLEX UE ART/BPG; UNIL/LIMIT $ 338.00 US ARTERY EXTREMITY UPPER RIGHT $ 338.00 DUPLEX EXT VEINS; BILAT $ 700.00 US VEIN EXTREMITY LOWER BILAT $ 700.00 US VEIN EXTREMITY UPPER BILATERAL $ 700.00 US VEIN EXTREMITY UPPER LEFT $ 600.00 US VEIN EXTREMITY UPPER RIGHT $ 600.00 US VEIN EXTREMITY UPPER UNILAT $ 338.00 US VEIN EXTREMITY LOWER UNI $ 338.00 DUPLEX EXT VEINS; UNIL/LIMIT $ 338.00 US VEIN ETREMITY LOWER LEFT $ 338.00 US VEIN EXTREMITY LOWER RIGHT $ 338.00 DUPLEX EXT VEINS; UNIL/LIMIT $ 338.00 VASCULAR DUPLEX STUDY OTHER VISCERAL COM $ 692.00 DUPLEX ARTERIAL FLOW; COMPL $ 692.00 DUPLEX ARTERIAL FLOW; COMPL $ 692.00 DUPLEX SCAN ARTERIAL IN&OUTFLOW ABD,PELV $ 338.00 DUPLEX ARTERIAL FLOW; LIMITED $ 338.00 VAS DUPLEX STUDY AORTA/ILIAC/BYPASS COMP $ 692.00 US ABDOMEN DUPLEX $ 692.00 AEROSOL TREATMENT $ 400.00 NEBULIZER TERATMENT 1 $ 400.00 NEBULIZER TREATMENT 2 $ 400.00 NEBULIZER TREATMENT 3 $ 400.00 NEBULIZER TREATMENT 4 $ 400.00 NONINVASIVE EAR OR PULSE OXIMETRY FOR OX $ 14.00 PULSE OX MULTIPLE RESPIRATORY $ 14.00 IM OR SUBCUTANEOUS $ 170.00 THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC $ 170.00 TX/PRO/DX INJ NEW DRUG ADDON $ 155.00 IV PUSH SEQ INJ SAME DRUG ADDITIONAL $ 155.00 IV PUSH SUBSEQUENT $ 155.00 PORT FLUSH ER $ 168.00 IRRIG IMPLANT VENOUS ACCESS DEVICE $ 168.00 IV PORT FLUSH (OMP ONLY) $ 168.00 PT COLD PACKS ONLY $ 42.00 HOT PACKS $ 42.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price OT HOT OR COLD PACKS THERAPY 1+ AREAS $ 42.00 ELECTRIC STIMULATION THERAPY 1+ AREAS $ 98.00 OT ELECTRIC STIMULATION THERAPY 1+ AREAS $ 98.00 PARAFFIN BATH $ 23.00 OT PARAFFIN BATH THERAPY 1+ AREAS $ 23.00 OT PARAFFIN BATH THERAPY 1+ AREAS $ 23.00 WHIRLPOOL THERAPY $ 58.00 OT WHIRLPOOL THERAPY 1+ AREAS $ 58.00 PT ELECTRIC STIM/UNATTEND OTHER THAN WND $ 47.00 ELECTRICAL STIMULATION EA 15 MINS $ 47.00 OT ELECTRICAL STIMULATION EA 15 MINS $ 47.00 PT IONTOPHORESIS $ 67.00 OT ELECTRIC CURRENT THERAPY EA 15 MINS $ 67.00 ULTRASOUND THERAPY EA 15 MINS $ 60.00 OT ULTRASOUND THERAPY EA 15 MINS $ 60.00 THERAPEUTIC EXERCISES 15 MIN $ 80.00 OT THERAPEUTIC EXERCISES EA 15 MINS $ 80.00 OT THERAPEUTIC EXERCISES EA 15 MINS $ 80.00 NEUROMUSC REEDUCATION 15 MIN $ 130.00 OT NEUROMUSCULAR REEDUCATION EA 15 MINS $ 130.00 OT NEUROMUSCULAR REEDUCATION EA 15 MINS $ 130.00 PT GAIT TRAINING THERAPY EA 15 MINS $ 118.00 OT GAIT TRAINING THERAPY EA 15 MINS $ 118.00 MASSAGE 15 MINUTES THERAPEUTIC $ 92.00 OT MASSAGE THERAPY EA 15 MINS $ 92.00 OT MASSAGE THERAPY EA 15 MINS $ 92.00 MANUAL THERAPY EA 15 MINS $ 130.00 OT MANUAL THERAPY EA 15 MINS $ 130.00 OT MANUAL THERAPY EA 15 MINS $ 130.00 THERAPEUTIC DIRECT ACTIVITY 15 MIN $ 129.00 P T ONE HALF HOUR $ 129.00 P T ONE HOUR UP TO TWO HOURS $ 129.00 OT THERAPEUTIC ACTIVITY DIR EA 15M $ 129.00 THERAPEUTIC ACTIVITY 15 MIN $ 129.00 OT THERAPEUTIC ACTIVITIES EA 15 MINS $ 129.00 OT ADL/SELF CARE TR EA 15 M $ 110.00 OT SELF CARE MNGMENT TRAINING EA 15 MINS $ 110.00 WORK TASK ANALYSIS $ 105.00 OT COMMUNITY/WORK REINTEGRATION EA 15 MINS $ 105.00 WHEELCHAIR MNGMENT TRAINING EA 15 MINS $ 106.00 OT WHEELCHAIR MNGMENT TRAINING EA 15 MIN $ 106.00 OT WHEELCHAIR MNGMENT TRAINING EA 15 MINS $ 106.00 WORK HARDENING INIT 2 HRS $ 127.00 OT WORK HARDENING INIT 2 HRS $ 127.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price SELECTIVE WOUND DEBRIDEMENT ADDTL 20CM< $ 529.00 OT SLCTV WND DEBRIDEM 20 CM OR < $ 529.00 SLCTV WND DEBRIDEM 20 CM OR < $ 529.00 SLCTV WND DEBRIDEM 20 CM OR < $ 40.00 SLCTV WND DEBRIDEM ADDL 20 CM/< $ 40.00 NON-SELECTIVE DEBRIDEMENT $ 529.00 NON-SELECTIVE DEBRIDEMENT $ 529.00 OT WOUND(S) CARE NON-SELECTIVE,PER SESSION $ 529.00 PHYSICAL PERFORM TEST EA 15M $ 112.00 OT PHYSICAL PERFORM EA 15M $ 112.00 ORTHOTIC MGMT AND TRAINING EA 15 MINS $ 154.00 OT ORTHOTIC MGMT AND TRAINING EA 15 MINS $ 154.00 OT ORTHOTIC MGMT AND TRAINING EA 15 MINS $ 154.00 SELF CARE TRAINING 15 MIN HOME MGMT $ 88.00 SELF-MGMT EDUC & TRAIN 1 PT $ 88.00 TECHNETIUM TC99M AEROSOL =< 75 MCI $ 98.00 TECHNETIUM TC99M AEROSOL =< 75 MCI $ 98.00 GAD-BASE MR CONTRAST NOS PER 1 ML $ 277.00 GAD-BASE MR CONTRAST NOS PER 1 ML $ 277.00 GAD-BASE MR CONTRAST NOS PER 1 ML (OPTIMARK) $ 277.00 4.3 X 48MM COMPRSION SCREW $ 361.00 4.3 X 50MM COMPRSION SCREW $ 361.00 4.0MM CANCELLOUS SCREW, SMALL HEX RECESS $ 75.00 4.0MM CANNULATED SCREW $ 658.00 2.7 LOCKING SCREW $ 1,104.00 2.7 NON-LOCKING SCREW $ 560.00 6.0 ALLOPURE GRAFT $ 7,869.00 ANCHOR (ICONIX 2.3MM) $ 1,475.00 SUPER QUICK ANCHOR PLUS #212032 $ 1,633.00 3.5MM CORTICAL SCREW,SF-TAP SMALL HEX RE $ 93.00 3.5MM CORTICAL SHAFT SCREW, NON SF-TAP $ 82.00 2.5CM X 3.0CM GAMMA GRAFT $ 1,080.00 GASTROGRAFFIN 120ML $ 70.00 AVISTA MRI LEAD - 56CM/74CM $ 14,137.00 INFINION 50 CM 16 CONTACT LEAD KIT $ 15,458.00 LEAD KITS $ 8,532.00 MEDTRONIC LEAD KIT $ 8,532.00 MEDTRONIC IMPLANT LEAD KIT $ 8,532.00 LINEAR ST LEAD 50CM $ 9,826.00 LINEAR ST LEAD 50CM $ 9,826.00 LINEAR ST LEAD 70CM $ 9,826.00 VENTRALEX HERNIA PATCH SMALL $ 1,684.00 VENTRALEX HERNIA PATCH MEDIUM $ 2,376.00 VENTRALEX HERNIA PATCH LARGE $ 2,803.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price MICROPUNCTURE INTRODUCER SET $ 128.00 ONE STEP INTRODUCER $ 193.00 ADRENALIN EPINEPHRINE INJ 0.1 MG $ 22.15 ADRENALIN EPINEPHRINE INJ 0.1 MG $ 22.15 ADRENALIN EPINEPHRINE INJ 0.1 MG $ 22.15 AMIODARONE 450MG INJ 9ML $ 27.30 AMIODARON HCL INJ 30 MG $ 7.73 AMPICILLIN SODIUM INJ 500 MG $ 12.30 AMPICILLIN SODIUM INJ 500 MG $ 12.30 AMPICILLIN SODIUM PER 1.5 GM $ 59.23 AMPICILLIN SODIUM PER 1.5 GM $ 59.23 BUPRENORPHINE ORAL 1MG $ 3.00 BUPRENORPHINE ORAL 1MG $ 3.00 BUPRENORPHINE 2 MG TABLET SL 1 ea, 30 eaches $ 6.50 BUPRENORPHINE 8 MG TABLET SL 1 mg, 30 eaches $ 3.00 SUBOXONE 8 MG-2 MG SL FILM 1 ea, 30 eaches $ 30.00 SUBOXONE 2 MG-0.5 MG SL FILM 1 ea, 30 eaches $ 17.00 BUPRENORPHIN-NALOXON 8-2 MG SL 1 ea, 30 eaches $ 32.00 CEFAZOLIN SODIUM INJECTION 500 MG $ 8.00 CEFAZOLIN SODIUM INJECTION 500 MG $ 8.00 CEFEPIME HCL INJ 500 MG $ 36.00 CEFEPIME HCL INJ 500 MG $ 36.00 CEFTRIAXONE SODIUM, PER 250 MG $ 3.09 CEFTRIAXONE SODIUM, PER 250 MG $ 3.09 CEFTRIAXONE SODIUM, PER 250 MG $ 3.09 CEFTRIAXONE SODIUM, PER 250 MG $ 3.09 CILASTATIN SODIUM; IMIPENEM, PER 250 MG $ 75.00 CILASTATIN SODIUM; IMIPENEM, PER 250 MG $ 75.00 CIPROFLOXACIN IV INJ 200 MG $ 10.82 CIPROFLOXACIN LACTATE 10MG/ML SDV 10X40M $ 18.00 PROCRIT 40,000 UNITS/ML VIAL 40000 UNIT, 1 ML $ 39.00 PROCRIT 20,000 UNITS/ML VIAL 1000 unit, 1 mL $ 40.00 DOBUTAMINE HYDROCHLORIDE INJ, PER 250 MG $ 18.00 DOBUTAMINE HYDROCHLORIDE INJ, PER 250 MG $ 18.00 FLUCONAZOLE, 200 MG $ 1.80 FLUCONAZOLE INJ, 200 MG $ 3.71 HEPARIN SODIUM INJ PER 1000 UNITS $ 31.00 HEPARIN SODIUM INJ PER 1000 UNITS $ 31.00 ENOXAPARIN SODIUM INJ, 10 MG $ 3.00 LOVENOX INJ 10 MG $ 2.79 LOVENOX INJ 10 MG $ 2.79 ENOXAPARIN SODIUM INJ, 10 MG $ 3.00 LOVENOX INJ 10 MG $ 2.79 LOVENOX INJ 10 MG $ 2.79 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price ENOXAPARIN SODIUM INJ, 10 MG $ 3.00 FONDAPARINUX SODIUM 2.5MG/0.5ML SYRN 10X $ 206.26 ARIXTRA 0.5 MG INJECTION $ 30.00 HYDROCORTISONE SODIUM SUCCINATE, UP TO 100 MG $ 34.76 SOLU-CORTEF 250 MG $ 6.00 INSULIN INJ PER 5 UNITS $ 6.18 INSULIN INJ PER 5 UNITS $ 6.18 INSULIN INJ PER 5 UNITS $ 6.18 KETOROLAC TROMETHAMINE, PER 15 MG $ 9.00 KETOROLAC TROMETHAMINE, PER 15 MG $ 9.00 LEVOFLOXACIN INJ, 250 MG $ 27.00 LEVOFLOXACIN INJ, 250 MG $ 27.00 LEVOFLOXACIN INJ, 750 MG $ 16.22 LIDOCAINE HCL INJ FOR IV 10 MG $ 6.18 LIDOCAINE HCL INJ FOR IV 10 MG $ 6.18 LIDOCAINE HCL INJ FOR IV 10 MG $ 6.18 LIDOCAINE HCL INJ FOR IV 10 MG $ 6.18 LIDOCAINE HCL INJ FOR IV 10 MG $ 6.18 LIDOCAINE HCL INJ FOR IV 10 MG $ 6.18 LIDOCAINE HCL INJ FOR IV 10 MG $ 6.18 LIDOCAINE HCL INJ FOR IV 10 MG $ 6.18 MORPHINE SULFATE INJ TO 10 MG $ 28.00 MORPHINE SULFATE INJ TO 10 MG $ 28.00 MORPHINE SULFATE 5MG/ML SDV 25X1ML $ 9.00 NALOXONE HYDROCHLORIDE INJ, PER 1 MG $ 61.00 NALOXONE HYDROCHLORIDE, PER 1 MG $ 57.17 NALOXONE HYDROCHLORIDE INJ, PER 1 MG $ 61.00 ONDANSETRON HYDROCHLORIDE INJ, PER 1 MG $ 6.00 ONDANSETRON HCL 2MG/ML MDV 20 ML $ 0.27 NEULASTA 6MG INJECTION $ 18,560.25 PEGFILGRASTIM 6 MG INJ $ 8,203.00 PIPERACILLIN/TAZOBACTAM INJ, 1 GRAM/0.125 GRAMS (1.125 GRAMS) $ 40.69 PIPERACILLIN/TAZOBACTAM INJ, 1 GRAM/0.125 GRAMS (1.125 GRAMS) $ 26.01 ZOSYN INJ 1 GM/0.125 GM $ 50.47 PIPERACIL-TAZOBACT 2.25 GM VL 1.125 g, 1 each $ 2.50 PROPOFOL INJ, 10 MG $ 22.15 PROPOFOL INJ, 10 MG $ 115.88 REGADENOSON INJ 0.1 MG $ 165.00 LEXISCAN .1MG $ 179.00 ROPIVACAINE HCL INJ 1 MG $ 54.00 ROPIVACAINE HCL INJ 1 MG $ 54.00 ROPIVACAINE HCL INJ 1 MG $ 54.00 METHYLPREDNISOLONE INJ TO 125 MG $ 30.00 METHYLPREDNISOLONE INJ TO 125 MG $ 30.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price TRIAMCINOLONE ACET INJ NOS 10 MG $ 32.00 TRIAMCINOLONE ACET INJ NOS 10 MG $ 32.00 INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG $ 255.45 DIAZEPAM INJ TO 5 MG $ 84.98 DIAZEPAM 5MG/ML MDV 10X10ML $ 45.00 VANCOMYCIN HCL 500 MG INJ $ 30.00 VANCOMYCIN HCL 500 MG INJ $ 30.00 VITAMIN B-12 CYANOCOBALAMIN INJ, UP TO 1000 MCG $ 37.08 VITAMIN B-12 INJECTION TO 1000 MCG $ 6.18 POTASSIUM CHLORIDE INJ, PER 2 MEQ $ 12.00 POTASSIUM CHLORIDE INJ, PER 2 MEQ $ 12.00 POTASSIUM CHLORIDE INJ, PER 2 MEQ $ 12.00 POTASSIUM CHLORIDE INJ, PER 2 MEQ $ 12.00 GLYCOPYROLLATE INJ $ 85.23 VECURONIUM BR INJ 10 MG $ 32.70 ZYPREXA INJ $ 144.72 DOXAPRAM HCL 20MG/ML MDV 6X20ML $ 7.73 FLUMAZENIL 0.1MG/ML MDV 10X10ML $ 6.18 BUMETANIDE 0.25MG/ML SDV 10X2ML $ 7.73 BUPIVACAINE HCL 5MG/ML MDV 50 ML $ 6.18 BUPIVACAINE/DEXTROSE 7.5MG/ML AMPS 10X2M $ 14.68 FAMOTIDINE 10MG/ML SDPF 25X2ML $ 6.18 HEPATITIS B VACCINE 20MCG/ML SDPF 10X1ML $ 200.08 NAFCILLIN SODIUM 1GM PWVL 10X1EA $ 40.69 SUFENTANIL CITRATE 50MCG/ML AMPS 10X2ML $ 28.07 DEXTROSE 50%/WATER 0.5 LSSY 10X50ML $ 29.61 BACITRACIN 50000 U $ 41.20 CLEOCIN PHOSPHATE 150 MG/ML $ 9.01 SMZ-TMP CONCENTRATE (M.D.V.) 80 MG/ML-16 MG/ML $ 6.00 SULFAMETHOXAZOLE/TRIMETHOPRIM INJECTION 400/80, 5 ML INJECTION $ 20.00 CLINDAMYCIN PHOSPHATE 150MG/ML SDV 25X4M $ 10.82 BUPIVACAINE HCL 2.5MG/ML MDV 50 ML $ 6.18 5% DEXTROSE/WATER (500 ML = 1 UNIT) $ 19.57 5% DEXTROSE/WATER (500 ML = 1 UNIT) $ 19.57 5% DEXTROSE/WATER (500 ML = 1 UNIT) $ 19.57 5% DEXTROSE/WATER (500 ML = 1 UNIT) $ 19.57 ORTHOVISC INJ PER DOSE $ 1,350.00 ORTHOVISC INJ $ 497.00 ORTHOVISC INJ PER 15.MG DOSE $ 538.00 BUDESONIDE NEB SOL 0.25 $ 29.10 BUDESONIDE NEB SOL 0.5 $ 33.50 ANTIEMETIC RECTAL/SUPP NOS $ 54.59 ANTIEMETIC RECTAL/SUPP NOS $ 54.59 ANTIEMETIC RECTAL/SUPP NOS $ 54.59 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price PACKED RED BLOOD CELLS (BLOOD BANK) $ 530.00 FRESH FROZEN PLASMA $ 626.00 CT PERFUSION W/CONTRAST CBF $ 2,719.00 XTRNL PT ACT ECG IN-OFF CONN $ 116.00 COR FFR DATA PREP & TRANSMIS $ 510.00 COR FFR ALYS GNRJ FFR MDL $ 4,461.00 I & D ABSCESS COMPLEX/MULTIPLE $ 942.00 I&D ABSC; COMPL OR MULTI $ 942.00 I&D ABSC; COMPL OR MULTI $ 942.00 I & D CYST PILONIDAL SIMPLE $ 1,738.00 I&D OF PILONIDAL CYST; SIMPLE $ 1,738.00 I&D PILONID CYST; CPLX $ 1,738.00 I & D HEMATOMA SEROMA FLUID $ 4,127.00 I&D HEMATOMA/FLUID $ 4,127.00 PUNCTURE ASP ABCESS HEMA CYST $ 942.00 PUNCT ASP - ABSC HEMAT CYST $ 942.00 I & D POST OP WOUND INFECTION $ 7,135.00 DEB SUBQ TISSUE 20 SQ CM/< $ 942.00 DEB MUSC/FASCIA 20 SQ CM/< $ 1,449.00 DEB MUSC/FASCIA 20 SQ CM/< $ 1,449.00 DEB MUSC/FASCIA 20 SQ CM/< $ 1,449.00 DEB BONE 20 SQ CM/< $ 4,127.00 DEB MUSC/FASCIA ADD-ON =<20 SQ CM $ 624.00 PARE BENIGN LES; SINGLE $ 529.00 PARE BENIGN LES; SGL $ 529.00 TRIM SKIN LESIONS 2 TO 4 $ 529.00 TRIM SKIN LESIONS OVER 4 $ 529.00 REM SKIN TAGS; <=15 LESIONS $ 529.00 REMOVE SKIN TAGS ADD-ON =<10 LESIONS $ 55.00 SHAVE LES T/A/L; 0.5CM/< $ 529.00 SHAVE LES T/A/L; 0.6-1.0CM $ 529.00 SHAVE LES T/A/L; 1.1-2.0CM $ 529.00 SHAVE LES T/A/L; > 2.0CM $ 942.00 SHAVE LES S/N/H/F/G; 0.5CM/< $ 529.00 SHAVE LES S/N/H/F/G; 0.5CM/< $ 529.00 EXC BEN LES T/A/L; 0.6-1.0CM $ 942.00 EXC BENIGN LES TRUNK/ARM/LEG; 1.1-2.0CM $ 1,738.00 EXC BEN LES T/A/L; 1.1-2.0CM $ 1,738.00 EXC BEN LES T/A/L; > 4.0CM $ 4,127.00 EXC BLES S/N/EX G; 0.5CM/< $ 4,127.00 EXC BLES S/N/EX G; 0.6-1.0CMC $ 2,139.00 EXC BLES S/N/EX G; 1.1-2.0CM $ 4,127.00 EXC BLES S/N/EX G; 2.1-3.0CM $ 4,127.00 EXC BLES S/N/EX G; 3.1-4.0CM $ 4,127.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price EXC BLES S/N/EX G; > 4.0CM $ 7,135.00 EXC FACE-MM B9+MARG 1.1-2 CM $ 1,738.00 TRIM ND NAILS $ 168.00 BX NAIL UNIT $ 1,738.00 WEDGE EXC NAIL FOLD $ 942.00 WEDGE EXC NAIL FOLD $ 942.00 EXC PILONID CYST; SMPL $ 7,135.00 INJECTION INTO SKIN LESIONS =<7 $ 529.00 ER SIMPLE 2.6 TO 7.5 CM $ 529.00 SIMPLE REPAIR-2.6-7.5CM $ 529.00 SIMPLE REPAIR-7.6-12.5CM $ 529.00 ER SIMPLE REPAIR-12.6-20.0CM $ 942.00 ER SIMPLE REPAIR-20.1-30.0CM $ 942.00 SIMPLE REPAIR >30CM $ 529.00 SIMPLE REPAIR-2.5 OR LESS $ 529.00 SIMPLE REPAIR-2.6-5.0CM $ 529.00 SIMPLE REPAIR-5.1 TO 7.5CM $ 529.00 SMPL REPAIR 7.6-12.5CM $ 529.00 SIMPLE REPAIR-12.6 TO 20.0CM $ 942.00 SIMPLE REPAIR-20.1 TO 30.0CM $ 942.00 SREP SIMP REPAIR; > 30.0CM $ 705.00 SIMPLE REPAIR WOUND DEHISCENCE $ 1,449.00 LAYER CLOSURE-2.5 CM OR LESS $ 942.00 LAYER CLOSURE-2.6 TO 7.5CM $ 942.00 LAYER CLOSURE-7.6 TO 12.5CM $ 942.00 INTERMEDIATE 12.6 TO 20 CM $ 942.00 INTERMEDIATE 20.1 TO 30 CM $ 1,449.00 LAYER INTERMEDIATE >30 CM $ 5,209.00 LAYER CLOSURE-2.5CM OR LESS $ 942.00 LAYER INTERMEDIATE 2.6-7.5 CM $ 942.00 LAYER INTERMEDIATE 7.6-12.5 CM $ 1,449.00 LAYER CLOSURE-12.6 TO 20CM $ 1,449.00 LAYER CLOSURE-20.1 TO 30.0MC $ 942.00 LAYER INTERMEDIATE >30CM $ 4,647.00 LAYER CLOSURE-2.6 TO 5.0CM $ 942.00 LAYER CLOSURE-5.1 TO 7.5CM $ 942.00 FACIAL INTERMIDIATE CLOSURE 7.6-12.5CM $ 942.00 FACIAL INTERMIDIATE CLOSURE 12.6-20CM $ 942.00 FACIAL INTERMEDIATE CLOSURE >30CM $ 942.00 LAYER CLOSURE-20.1 TO 30.0CM $ 942.00 COMP REP TRUNK 1.1CM TO 2.5CM $ 4,298.00 COM REP TRUNK 2.6CM TO 7.5CM $ 1,449.00 COM REPAIR TRUNK EACH ADD 5CM $ 332.00 C R -SCA ARS &/OR LGS 1.1TO2.5 $ 1,449.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price C R-SCA AMS&/OR LGS 2.6TO7.5 $ 1,449.00 C R SCA AMS&/OR LGS EA AD 5CM $ 332.00 COMPLEX REPAIR-1.1 TO 2.5CM $ 1,305.00 COMPLEX REPAIR-2.6 TO 7.5CM $ 1,449.00 COMPLEX REPAIR-EACH ADD 5CM $ 432.00 CPLX REP E/N/E/L; 1.1-2.5CM $ 1,658.00 CPLX REP E/N/E/L; 2.6 CM $ 1,449.00 CREP E/N/E/L; EA ADDTL 5 CM/< $ 467.00 SKIN SUB GRAFT TRNK/ARM/LEG $ 4,647.00 SKIN SUB GRAFT FACE/NK/HF/G $ 4,647.00 DRESSNG CHG NOT FOR BURN $ 1,449.00 BURN INITIAL TREAT FIRST DEGRE $ 529.00 DRESS/DEBRIDE INIT W/O ANES ME $ 687.00 ESCHAROTOMY; INIT INC $ 1,708.00 ESCHAROTOMY; ADDL INCISION $ 1,398.00 DESTRUCT B9 LESION 1-14 $ 529.00 REM FB MUSCLE; DEEP $ 7,135.00 CARPAL TUNNEL INJECTION $ 742.00 TENDON ORIGIN INJECTION $ 742.00 DRAIN/INJ SMALL JOINT/BURSA W/US $ 742.00 DRAIN/INJ INTER JOINT/BURSA W/US $ 1,796.00 DRAIN/INJ MAJOR JOINT/BURSA W/US $ 742.00 CLOSED TREATMENT OF NASAL BONE FRACTURE $ 3,837.00 CL TX NASAL SEPTAL FX $ 6,694.00 CLOSED TX TEMPMAND DISLOCATION $ 675.00 I&D DEEP ABSC SFT TISS NK/THOR $ 7,135.00 SHOULDER ARTHROGRAM INJ $ 244.00 CLOSED TX CLAVICLE FRACTURE $ 675.00 CL TX CLAVICULAR FX; W MANIP $ 4,267.00 CLOSED TX PROX HUMERAL FRACTUR $ 675.00 CL TX SHLDR DISL W MANIP; W ANESTH $ 3,900.00 CL TX SHLDR DISLOC & FX GT; W MAN $ 3,940.00 CL TX SHDR DISLOC W NK FX W MANIP $ 3,940.00 DEEP I&D - UA/ELBOW $ 4,415.00 I&D BURSA UPPER ARM OR ELBOW $ 4,415.00 REM FB UP ARM OR ELBOW; SQ $ 4,127.00 MANIP ELBOW W ANESTH $ 3,940.00 CL TX SC/TX HUMERUS SHFT FX W MANIP $ 4,151.00 CLOSED TX ELBOW DISLOCATION $ 675.00 CL TX RADIAL HD/NECK FX; WO MANIP $ 675.00 INC FTS WRIST $ 7,870.00 DEEP I&D ABSC - FARM/WRIST $ 7,870.00 WRIST ARTHROGRAPHY INJ $ 581.00 DEEP FB REM - FOREARM/WRIST $ 4,948.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price MANIPULATE WRIST W ANESTH $ 4,449.00 CL TX RADIAL SHFT FX W MANIP $ 3,940.00 CL TX ULNAR SHAFT FX; WO MANIP $ 675.00 CLTX DSTL RADIAL FX/EPIPHYSL SEP WO MNP $ 675.00 CLTX CARPL BONE FX WO MNP EA BONE $ 675.00 CLTX CARPL BONE FX W MNP EA BONE $ 3,940.00 CLOSED TX OF ULNAR STYLOID FX $ 675.00 CLOSED TX OF ULNAR STYLOID FX $ 675.00 PIN ULNAR STYLOID FX $ 7,870.00 CL TX DSTL RADIOULNAR DISLOC W MANIP $ 675.00 I & D ABSCESS FINGER SIMPLE $ 529.00 I & D ABSCESS FINGER COMPLEX $ 4,127.00 DEEP INCISION OF HAND/FINGER $ 4,542.00 EXC HAND LES SC < 1.5 CM $ 4,127.00 PARTIAL REMOVAL FINGER BONE $ 3,940.00 MANIP FING JNT W AN EA $ 3,940.00 EXTENSOR TENDON REPAIR EACH $ 7,870.00 CL TX MC FX SGL; WO MANIP EA BONE $ 675.00 CLOSED TX THUMB DISLOCATION $ 675.00 CL TX CMC FX DISLOC THUMB W MANIP $ 3,940.00 CL TX CMC DISL W M EA $ 675.00 CL TX MCP DISLOC SGL W MANIP $ 675.00 CL TX PHAL SHAFT FX; WO MANIP $ 675.00 CL TX PHALANG SHFT FX; W MANIP $ 675.00 CL TX PHALANG SHFT FX; W MANIP $ 675.00 CL TX ART FX MCP/IP JNT; WO MAN $ 675.00 CL TX ARTFX MCP/IP JNT; W MANIP $ 3,940.00 CL TX D PHAL FX FGR/THMB; WO MANIP $ 675.00 CL TX D PHAL FX FGRR/THMB; W MANIP $ 675.00 CL TX IP JT D W MANIP; W ANESTH $ 707.00 INJECT SACROILIAC JOINT $ 648.00 CL TX TRAUMA HIP DICLOC WO ANESTH $ 675.00 TX SP HIP DISL ABD SPLNT/TRAC; WO $ 675.00 TX SPONTAN HIP DISLOC W ANESTH $ 3,940.00 DEEP I&D THIGH/KNEE $ 7,135.00 ARTHROPL KNEE C&P; MEDIAL LAT $ 32,142.00 CL TX PROX TIBIAL FX W SK TRACTION $ 7,870.00 CL TX KNEE DISL; WO ANESTH $ 675.00 CL TX KNEE DISL; W ANESTHESIA $ 3,940.00 CLOSED TX PATELLAR DISLOCATION $ 675.00 I&D LEG/ANKLE DEEP ABSC/HEMATOMA $ 7,135.00 CL TX PROX FIB/SHAFT FX W MANIP $ 3,940.00 CL TX DISTL FIB FX W MANIP $ 675.00 CLTX BIMALLEOLAR ANKLE FRACT WO MNP $ 675.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price CLTX BIMALLEOLAR ANKLE FRACT W MNP $ 3,940.00 CL TX WB DSTL TIB FX W MANIP $ 3,940.00 CLOSED TX ANKLE DISLOCATION $ 675.00 TENOTOMY SQ TOE; SINGLE $ 5,007.00 INC MULTI SQ TOE TENDONS $ 3,940.00 REMOVE SGLE TOE PHALNGE EA $ 7,870.00 RESECT HD OF TOE PHALANX $ 7,870.00 REM DEEP FB OF FOOT $ 4,127.00 COMPLIC REM FB FROM FOOT $ 4,127.00 COMPLIC REM FB FROM FOOT $ 4,127.00 HAMMERTOE OP ONE TOE $ 7,870.00 COCK-UP 5TH TOE W PLSTC CLOSE $ 7,870.00 PRTL REM FOOT BONE MTRSL HD 1-5 EA $ 7,870.00 REPAIR HALLUX RIGIDUS $ 7,870.00 CL TX CALCANEAL FX; W MANIP $ 1,846.00 CL TX TALUS FX; WO MANIP $ 675.00 TX TARSAL BONE FX ; WO MANIPU $ 675.00 TX TARSAL BONE FX; W MANIP $ 4,948.00 CL TX METATARSAL FX; WO MANIP $ 675.00 CL TX METATARSAL FX; W MANIP $ 675.00 CL TX METATARSAL FX; W MANIP $ 675.00 PERC SK FIX METATARSAL FX W MANIP $ 7,870.00 CL TX FX GT PHALANX(S); WO MANIP $ 675.00 CL TX FX GT PHALANX(S); W MANIP $ 675.00 CL TX FX PHALNX/PHALANG WO MANIP $ 675.00 CL TX SESAMOID FRACTURE $ 675.00 CL TX MTP JNT DISLOC; WO ANESTH $ 675.00 CL TX MTP JNT DISLOC; W ANESTH $ 4,650.00 LONG ARM CAST APPLICATION $ 707.00 APPLY SHORT ARM CAST $ 707.00 APPLICATION HAND & LOW FOREARM $ 404.00 APPLY FINGER CAST $ 404.00 APPLY FINGER SPLINT; STATIC $ 168.00 STRAPPING; THORAX $ 404.00 STRAPPING; HAND OR FINGER $ 98.00 LONG LEG CAST APPLICATION $ 707.00 SHORT LEG CAST APPLICATION $ 707.00 APPLY SH LEG CAST $ 707.00 SHORT LEG WALKING CAST APPLICATION $ 707.00 APPLY CLUBFOOT CAST LONG OR SHORT LEG $ 578.00 STRAPPING OF THE KNEE $ 319.00 APPL MULTLAY COMPRS ARM/HAND $ 404.00 REM GAUNTLET BOOT OR BODY CAST $ 707.00 WINDOWING OF CAST $ 404.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price WEDGING OF CAST NOT CLUBFOOT CAST $ 707.00 UNLISTED PROCEDURE CASTING OR STRAPPING $ 404.00 KNEE ARTHROSCOPY W LAT RLS $ 7,870.00 NASAL FOREIGN BODY REMOVAL $ 319.00 CONTROL NASAL HEMORRH ANT SIMPLE $ 319.00 NASAL HEMORRAGE ANTERIOR COMPL $ 319.00 NASAL HEMORRAGE POSTERIOR INIT $ 319.00 CTRL POST EPISTAX SQ $ 618.00 TRACH TUBE CHG BEFORE FISTULA TRACT $ 618.00 LARYNGOSCOPY IND; DIAGNOSTIC $ 492.00 TRACHEOSTOMY EMERG; TRANSTRACHL $ 3,837.00 TRACHEOSTOMY EMERG; CRICOTHYROID $ 3,837.00 CATHETER ASPIRATION $ 575.00 CHEST TUBE INSERTION $ 3,281.00 THORACENTESIS ASPIRATE PLEURA WO IMAGING $ 1,860.00 PERICARDIOCENTESIS INITIAL $ 3,281.00 INTRODUCTION OF NEEDLE OR INTRACATHETER, $ 39.00 BL DRAW < 3 YRS OTHER VEIN $ 306.00 VENIPUNCTURE AGE 3 YRS/> $ 306.00 CAPILLARY BLOOD DRAW $ 380.00 VEIN ACCESS CUTDOWN < 1 YR $ 306.00 BL PUSH TRANSFUSE 2 YR OR < $ 1,149.00 INSERT NON-TUNNEL CV CATH <5 YRS $ 3,281.00 INS NON-TUNNEL CV CATH 5 YRS/> $ 3,281.00 CENTRAL LINE (PERCUT) > 5 YRS AGE $ 7,925.00 INSERT PICC CATH <5 YRS $ 1,860.00 INSERTION OF PICC,W/O SUBCUTANEOUS PORT $ 3,281.00 REPLACE NON-TUNNELED CV CATH $ 3,281.00 REPLACEMENT PICC SAME VENOUS ACCESS $ 3,281.00 REMOVE TNL CV CATH $ 1,860.00 REMOVE TNL CV CATH $ 1,860.00 COLLECT BLOOD FROM PICC $ 319.00 COLLECT BLOOD FROM PICC $ 319.00 DECLOT VASCULAR DEVICE $ 1,708.00 ARTERIAL PUNCTURE $ 319.00 PLACE NEEDLE INTRAOSSEOUS INFUSION $ 1,044.00 OT THERAPY EXERCISE JOINT RX $ 131.00 REPAIR LIP FT; UP TO HALF VERTICAL HGHT $ 1,658.00 REPAIR LIP FT; > 1/2 V HGT OR COMPLEX $ 3,837.00 DR ABSC CYST HEMAT-MOUTH; SIMPLE $ 1,738.00 CL LACERATION MOUTH VESTIB; > 2.5 CM $ 865.00 R MO FL&ANT2/3TON 2.5CM/LESS $ 535.00 REM EMB FB FROM DENTOALV; SFT TISSUE $ 6,736.00 I&D ABSCESS; PERITONSILLAR $ 694.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price FOREIGN BODY REMOVE PHARYNS $ 1,044.00 FOREIGN BODY REMOVE PHARYNS $ 1,044.00 SIMPLE CNTRL NOSE BLEED $ 618.00 UGI W BX. SGL/MULTIPLE $ 2,285.00 NASO- OR ORO-GASTRIC TUBE PLACEMENT W FL $ 1,044.00 LAP PLACE GASTR ADJ DEVICE $ 23,370.00 COLONOSCOPY FLEX ; DX $ 2,291.00 COLONOSCOPY FLEX W REM LES BY HBF/BPC $ 2,939.00 COLONOSCOPY FLEX W REM LESION BY SNARE $ 2,939.00 I&D ABSCESS ISCHIO/PERIRECTA $ 2,939.00 I & D ABSCESS ISCHIO/PERIRECTA $ 2,939.00 I & D ABSCESS PERIANAL SUPERFICI $ 2,235.00 INCISION EXT THROMB HEMORRHOID $ 694.00 REMOVAL OF HEMORRHOID CLOT $ 5,528.00 ANOSCOPY; WITH REMOVAL OF FOREIGN BODY $ 2,235.00 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR TH $ 2,285.00 ABD PARACENTESIS W/IMAGING $ 2,285.00 REP INIT INCI/ VENTRAL HERNIA; REDUCIBLE $ 9,022.00 RENAL BIOPSY PERQ $ 4,415.00 CBI CONT BLADDER IRRIG $ 694.00 INS TEMP BLADDER CATH (FOLEY CATH) $ 319.00 INS TEMP BLADDER CATH SIMPLE $ 319.00 INS TEMP BLADDER CATH SIMPLE $ 319.00 INS BLADDER CATH COMPLEX $ 408.00 CHANGE OF CYSTOSTOMY TUBE; SIMPLE $ 694.00 US PV RESIDUAL URINE ER ONLY $ 168.00 I & D ABSCESS VULVA OR PERINEAL $ 819.00 I & D ABSCESS BARTHOLINS GLAND $ 502.00 REMOVE VAGINAL FOREIGN BODY $ 7,084.00 EPISIOTOMY OR VAGINAL REPAIR, BY OTHER T $ 7,084.00 VAGINAL DELIVERY ONLY $ 7,084.00 DELIVERY OF PLACENTA $ 7,084.00 SPINAL PUNCTURE LUMBAR DIAGNOSTIC $ 1,796.00 INJ EPIDURAL BLOOD OR CLOT PATCH $ 1,796.00 INJ INTERLAM CRV/THRC W/O IMG $ 1,796.00 INJ INTERLAM CRV/THRC W/ IMG $ 1,796.00 INJ INTERLAM LMBR/SAC W/O IMG $ 1,796.00 INJ INTERLAM LMBR/SAC W/ IMG $ 1,796.00 INJ INTLAM W/ CATH C/T W/O IMG $ 2,295.00 INJ INTLAM W/ CATH C/T W/ IMG $ 2,295.00 INJ INTLAM W/ CATH L/S W/O IMG $ 2,295.00 INJ INTLAM W/ CATH L/S W/ IMG $ 2,295.00 INJ ANESTH ; TRIGEMINAL NERVE $ 742.00 INJ ANESTH ; TRIGEMINAL NERVE $ 742.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price INJ ANESTH AGENT FACIAL NERVE $ 535.00 NERVE BLOCK ILIOING/ILIOHYPOGASTRIC $ 1,796.00 N BLOCK INJ PLANTAR DIGIT $ 742.00 INJ FORAMEN EPIDURAL C/T $ 2,295.00 INJ A/S TRANSF EPID; L/S EA ADTL LEV $ 883.00 INJ(S) FORAMEN EPIDURAL L/S $ 2,295.00 INJ FORAMEN EPIDURAL ADD-ON $ 943.00 INJ PARAVERT F JNT C/T 1 LEV $ 2,566.00 INJ PARAVERT F JNT C/T 2 LEV $ 591.00 INJ PARAVERT F JNT C/T 3 LEV $ 591.00 INJ PARAVERT F JNT L/S 1 LEV $ 2,295.00 INJ PARAVERT F JNT L/S 2 LEV $ 600.00 FB REMOVAL CONJUNCTIVA, EXTERNAL EYE, SI $ 319.00 FB REM EXT EYE CONJUCT EMBED $ 1,044.00 FB REM EXT EYE; CORNEAL WO SLIT LAMP $ 1,044.00 FB REMOVE EXT EYE CORNEAL $ 1,044.00 FB REM EXT EYE CORNEAL SL LAMP $ 391.00 BLEPHAROTOMY DRAIN ABSC EYELID $ 851.00 EXCISION CHALAZION SINGLE $ 851.00 FB REMOVE EMBEDDED EYELID $ 851.00 DR EXT EAR ABSCESS/HEMATOMA; SIMPLE $ 1,738.00 FB REM EXT AUDITORY CANAL; WO ANESTH $ 319.00 RMVL IMPACTED EARWAX USING IRRI/LAVAGE,U $ 180.00 REM IMP EAR WAX $ 175.00 REMOVE IMPACTED EAR WAX 1-2 EARS $ 175.00 X-RAY EYE FOR FOREIGN BODY $ 187.00 X-RAY EXAM OF JAW <4 VIEWS $ 316.00 X-RAY EXAM OF JAW 4+ VIEWS $ 338.00 X-RAY EXAM OF MASTOIDS <3 VIEWS $ 338.00 X-RAY EXAM OF MASTOIDS 3+ VIEWS $ 468.00 X-RAY EXAM OF FACIAL BONES 3+ VIEWS $ 461.00 X-RAY EXAM OF NASAL BONES 3+ VIEWS $ 190.00 X-RAY EXAM OF OPTIC FORAMINA $ 187.00 X-RAY EXAM OF EYE SOCKETS 4+ VIEWS $ 366.00 X-RAY EXAM OF SINUSES <3 VIEWS $ 187.00 X-RAY EXAM OF SKULL <4 VIEWS $ 343.00 X-RAY EXAM OF SKULL 4+ VIEWS $ 441.00 X-RAY EXAM OF TEMPOROMANDIBULAR JOINT, UNILAT $ 462.00 X-RAY EXAM OF TEMPOROMANDIBULAR JOINT, BILAT $ 558.00 MRI OF TMJ(S) $ 2,847.00 X-RAY EXAM OF NECK SOFT TISSUE $ 206.00 SPEECH EVALUATION COMPLEX $ 808.00 CT HEAD/BRAIN W/O DYE $ 1,151.00 CT HEAD/BRAIN W/DYE $ 1,239.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price CT HEAD/BRAIN W/O & W/DYE $ 1,332.00 CT ORBIT/EAR/FOSSA W/O&W/DYE $ 1,332.00 CT MAXILLOFACIAL W/O DYE $ 1,151.00 CT MAXILLOFACIAL W/DYE $ 1,239.00 CT MAXILLOFACIAL W/O & W/DYE $ 1,332.00 CT SOFT TISSUE NECK W/O DYE $ 1,263.00 CT SOFT TISSUE NECK W/DYE $ 1,505.00 CT SFT TSUE NCK W/O & W/DYE $ 1,595.00 CT ANGIOGRAPHY HEAD $ 2,588.00 CT ANGIOGRAPHY NECK $ 2,588.00 MRI ORBIT/FACE/NECK W/O DYE $ 2,588.00 MRI ORBIT/FACE/NECK W/DYE $ 3,779.00 MRI ORBT/FAC/NCK W/O &W/DYE $ 3,903.00 MRA HEAD W/O DYE $ 2,620.00 MRA HEAD W/DYE $ 2,226.00 MRA HEAD W/O&W/DYE $ 1,656.00 MRA NECK W/O DYE $ 2,692.00 MRA NECK W/DYE $ 2,588.00 MRA NECK W/O&W/DYE $ 3,313.00 MRI BRAIN STEM W/O DYE $ 2,433.00 MRI BRAIN STEM W/DYE $ 1,864.00 MRI BRAIN STEM W/O & W/DYE $ 3,779.00 X-RAY EXAM CHEST 1 VIEW $ 191.00 X-RAY EXAM CHEST 2 VIEWS $ 191.00 X-RAY EXAM CHEST 3 VIEWS $ 191.00 X-RAY EXAM CHEST 4+ VIEWS $ 365.00 X-RAY EXAM OF RIBS 2 VIEWS UNILAT, LEFT $ 248.00 X-RAY EXAM OF RIBS 2 VIEWS UNILAT, RIGHT $ 248.00 X-RAY EXAM OF RIBS/CHEST 3+ VIEWS UNILAT $ 338.00 X-RAY EXAM OF RIBS 3 VIEWS BILAT $ 338.00 X-RAY EXAM OF RIBS/CHEST 4+ VIEWS BILAT $ 338.00 X-RAY EXAM OF BREASTBONE 2+ VIEWS $ 190.00 CT THORAX W/O DYE $ 1,242.00 CT THORAX W/DYE $ 1,505.00 CT THORAX W/O & W/DYE $ 1,595.00 CT ANGIOGRAPHY CHEST $ 2,692.00 MRI CHEST W/O DYE $ 2,692.00 MRI CHEST W/DYE $ 3,106.00 MRI CHEST W/O & W/DYE $ 4,400.00 MRI ANGIO CHEST W OR W/O DYE $ 2,278.00 X-RAY EXAM OF SPINE 1 VIEW $ 187.00 X-RAY EXAM NECK SPINE 2-3 VW $ 276.00 X-RAY EXAM NECK SPINE 4/5VWS $ 388.00 X-RAY EXAM NECK SPINE 6/>VWS $ 388.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price X-RAY EXAM OF THORACIC SPINE 2 VIEWS $ 338.00 X-RAY EXAM OF THORACIC SPINE 3 VIEWS $ 502.00 X-RAY EXAM OF THORACIC SPINE 4+ VIEWS $ 502.00 X-RAY EXAM ENTIRE SPI 1 VW $ 205.00 X-RAY EXAM ENTIRE SPI 2/3 VW $ 338.00 X-RAY EXAM ENTIRE SPI 2/3 VW $ 338.00 X-RAY EXAM ENTIRE SPI 4/5 VW $ 690.00 X-RAY EXAM ENTIRE SPI 6/> VW $ 400.00 X-RAY EXAM OF LOWER SPINE 2-3 VIEWS $ 338.00 X-RAY EXAM OF LOWER SPINE 4+ VIEWS $ 410.00 CT NECK SPINE W/O DYE $ 1,506.00 CT NECK SPINE W/DYE $ 1,505.00 CT NECK SPINE W/O & W/DYE $ 2,615.00 CT CHEST SPINE W/O DYE $ 1,346.00 CT CHEST SPINE W/DYE $ 1,915.00 CT CHEST SPINE W/O & W/DYE $ 1,598.00 CT LUMBAR SPINE W/O DYE $ 1,413.00 CT LUMBAR SPINE W/DYE $ 1,505.00 CT LUMBAR SPINE W/O & W/DYE $ 1,598.00 MRI CERVICAL SPINE W/O DYE $ 2,588.00 MRI CERVICAL SPINE W/DYE $ 3,779.00 MRI THORACIC SPINE W/O DYE $ 2,278.00 MRI THORACIC SPINE W/DYE $ 4,348.00 MRI LUMBAR SPINE W/O DYE $ 2,381.00 MRI LUMBAR SPINE W/DYE $ 2,951.00 MRI CERVICAL SPINE W/O & W/DYE $ 3,779.00 MRI THORACIC SPINE W/O & W/DYE $ 3,986.00 MRI LUMBAR SPINE W/O & W/DYE $ 3,882.00 MRA SPINE W/O&W/DYE $ 3,882.00 X-RAY EXAM OF PELVIS 1-2 VIEWS $ 338.00 X-RAY EXAM OF PELVIS 3+ VIEWS $ 376.00 CT ANGIOGRAPH PELV W/O&W/DYE $ 3,313.00 CT PELVIS W/O DYE $ 1,413.00 CT PELVIS W/DYE $ 1,505.00 CT PELVIS W/O & W/DYE $ 2,381.00 MRI PELVIS W/O DYE $ 2,278.00 MRI PELVIS W/DYE $ 3,779.00 MRI PELVIS W/O & W/DYE $ 3,882.00 MR ANGIO PELVIS W/O & W/DYE $ 1,276.00 X-RAY EXAM SACROILIAC JOINTS <3 VIEWS $ 338.00 X-RAY EXAM SACROILIAC JOINTS 3+ VIEWS $ 336.00 X-RAY EXAM OF TAILBONE 2+ VIEWS $ 279.00 EPIDUROGRAPHY, RAD. SUPERVISION & INTERP $ 399.00 X-RAY OF LOWER SPINE DISK $ 4,894.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price X-RAY EXAM OF CLAVICLE, LEFT $ 248.00 X-RAY EXAM OF CLAVICLE COMPLETE $ 248.00 X-RAY EXAM OF CLAVICLE, RIGHT $ 248.00 X-RAY EXAM OF SCAPULA, LEFT $ 338.00 X-RAY EXAM OF SCAPULA, RIGHT $ 338.00 X-RAY EXAM OF SHOULDERS $ 279.00 X-RAY EXAM OF ELBOW 2 VIEWS, RIGHT $ 213.00 X-RAY EXAM OF ELBOW 2 VIEWS, LEFT $ 213.00 X-RAY EXAM OF ELBOW 3+ VIEWS, RIGHT $ 280.00 X-RAY EXAM OF ELBOW 3+ VIEWS, LEFT $ 280.00 X-RAY EXAM OF HAND 2 VIEWS, RIGHT $ 338.00 X-RAY EXAM OF HAND 2 VIEWS, LEFT $ 338.00 X-RAY EXAM OF HAND 3+ VIEWS, RIGHT $ 222.00 X-RAY EXAM OF HAND 3+ VIEWS, LEFT $ 222.00 X-RAY EXAM OF FINGER(S) 2+ VIEWS, LT SECOND DIGIT $ 211.00 X-RAY EXAM OF FINGER(S) 2+ VIEWS, LT THIRD DIGIT $ 211.00 X-RAY EXAM OF FINGER(S) 2+ VIEWS, LT FOURTH DIGIT $ 211.00 X-RAY EXAM OF FINGER(S) 2+ VIEWS, LT FIFTH DIGIT $ 211.00 X-RAY EXAM OF FINGER(S) 2+ VIEWS, RT THUMB $ 211.00 X-RAY EXAM OF FINGER(S) 2+ VIEWS, RT SECOND DIGIT $ 211.00 X-RAY EXAM OF FINGER(S) 2+ VIEWS, RT THIRD DIGIT $ 211.00 X-RAY EXAM OF FINGER(S) 2+ VIEWS, RT FOURTH DIGIT $ 211.00 X-RAY EXAM OF FINGER(S) 2+ VIEWS, RIGHT FIFTH DIGIT $ 211.00 X-RAY EXAM OF FINGER(S) 2+ VIEWS, LT THUMB $ 211.00 CT UPPER EXTREMITY W/O DYE $ 1,332.00 CT UPPER EXTREMITY W/DYE $ 1,413.00 CT UPPR EXTREMITY W/O&W/DYE $ 1,336.00 CT ANGIO UPR EXTRM W/O&W/DYE $ 2,588.00 MRI UPPER EXT; NON JOINT W/O DYE $ 3,427.00 MRI UPPER EXT; NON JOINT W/ DYE $ 3,209.00 MRI UPPER EXT; NON JOINT W/O & W/DYE $ 4,400.00 MRI UPPER EXT; ANY JOINT W/O DYE $ 2,240.00 MRI UPPER EXT; ANY JOINT W DYE $ 3,572.00 MRI UPPER EXT; ANY JOINT W/O & W/DYE $ 4,400.00 MRA UPPER EXT W/O&W/DYE $ 2,278.00 X-RAY EXAM HIP UNI 1 VIEW, LEFT $ 197.00 X-RAY EXAM HIP UNI 1 VIEW, RIGHT $ 197.00 X-RAY EXAM HIP UNI 2-3 VIEWS, LEFT $ 197.00 X-RAY EXAM HIP UNI 2-3 VIEWS, RIGHT $ 197.00 X-RAY EXAM HIPS BI 5/> VIEWS $ 596.00 X-RAY EXAM OF FEMUR 1, RIGHT $ 197.00 X-RAY EXAM OF FEMUR 1, LEFT $ 197.00 X-RAY EXAM OF FEMUR 2/> $ 190.00 X-RAY EXAM OF KNEE 1 OR 2, LEFT $ 248.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price X-RAY EXAM OF KNEE 1 OR 2, RIGHT $ 248.00 X-RAY EXAM OF KNEE 3, RIGHT $ 271.00 X-RAY EXAM OF KNEE 3, LEFT $ 271.00 X-RAY EXAM KNEE 4 OR MORE, RIGHT $ 338.00 X-RAY EXAM KNEE 4 OR MORE, LEFT $ 338.00 X-RAY EXAM KNEE; BOTH KNEES STANDING AP $ 211.00 X-RAY EXAM OF LOWER LEG 2 VIEWS, LEFT $ 206.00 X-RAY EXAM OF LOWER LEG 2 VIEWS, RIGHT $ 206.00 X-RAY EXAM OF FOOT; 2 VIEWS, RIGHT $ 190.00 X-RAY EXAM OF FOOT; 2 VIEWS, LEFT $ 190.00 X-RAY EXAM OF HEEL 2+ VIEWS, RIGHT $ 211.00 X-RAY EXAM OF HEEL 2+ VIEWS, LEFT $ 211.00 X-RAY EXAM OF TOE(S) 2+ VIEWS, LEFT, SECOND DIGIT $ 206.00 X-RAY EXAM OF TOE(S) 2+ VIEWS, LEFT, THIRD DIGIT $ 206.00 X-RAY EXAM OF TOE(S) 2+ VIEWS, LEFT, FOURTH DIGIT $ 206.00 X-RAY EXAM OF TOE(S) 2+ VIEWS, LEFT, FIFTH DIGIT $ 206.00 X-RAY EXAM OF TOE(S) 2+ VIEWS, RIGHT, GREAT TOE $ 206.00 X-RAY EXAM OF TOE(S) 2+ VIEWS, RIGHT, SECOND DIGIT $ 206.00 X-RAY EXAM OF TOE(S) 2+ VIEWS, RIGHT, THIRD DIGIT $ 206.00 X-RAY EXAM OF TOE(S) 2+ VIEWS, RIGHT, FOURTH DIGIT $ 206.00 X-RAY EXAM OF TOE(S) 2+ VIEWS, RIGHT, FIFTH DIGIT $ 206.00 X-RAY EXAM OF TOE(S) 2+ VIEWS, LEFT, GREAT TOE $ 206.00 CT LOWER EXTREMITY W/O DYE $ 1,449.00 CT LOWER EXTREMITY W/DYE $ 1,413.00 CT LWR EXTREMITY W/O&W/DYE $ 1,505.00 CT ANGIO LWR EXTR W/O&W/DYE $ 760.00 MRI LOWER EXT; NON JOINT W/O DYE $ 2,588.00 MRI LOWER EXT; NON JOINT W DYE $ 2,847.00 MRI LOWER EXT; NON JOINT W/O&W/DYE $ 4,005.00 MRI LOWER EXT; ANY JOINT W/O DYE $ 2,278.00 MRI LOWER EXT; ANY JOINT W/O&W/DYE $ 3,882.00 MRA LWR EXT W OR W/O DYE $ 1,812.00 X-RAY EXAM ABDOMEN 1 VIEW $ 191.00 X-RAY EXAM ABDOMEN 2 VIEWS $ 365.00 X-RAY EXAM ABDOMEN 3+ VIEWS $ 365.00 CT ABDOMEN W/O DYE $ 1,398.00 CT ABDOMEN W/DYE $ 1,505.00 CT ABDOMEN W/O & W/DYE $ 2,448.00 CT ANGIO ABD&PELV W/O&W/DYE $ 1,158.00 CT ANGIO ABDOM W/O & W/DYE $ 2,692.00 CT ABD & PELVIS W/O DYE $ 1,413.00 CT ABD & PELV W/ DYE $ 1,505.00 CT ABD & PELV 1/> REGNS $ 1,595.00 MRI ABDOMEN W/O DYE $ 2,692.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price MRI ABDOMEN W/DYE $ 2,071.00 MRI ABDOMEN W/O & W/DYE $ 4,096.00 MRA ABDOMEN W/ W/O DYE $ 2,278.00 SWALLOWING FCN W CINE/VIDEO $ 338.00 CT COLONOGRAPHY DX $ 2,692.00 CT COLONOGRAPHY DX W/DYE $ 2,588.00 X-RAY EXAM OF COLON, CONTRAST $ 608.00 X-RAY EXAM RETROGRADE PYELOGRAM $ 1,158.00 X-RAY EXAM OF BLADDER 3+ VIEWS, CONTRAST $ 1,158.00 X-RAY PELVIMETRY W/WO PLACENTAL LOCALIZATION $ 233.00 US HYSTEROSALPINGOGRAM $ 692.00 CT ANGIO ABDOMINAL ARTERIES $ 3,168.00 FLUOROSCOPE EXAMINATION =< 1 HR $ 692.00 FLUOROSCOPE EXAMINATION =< 1 HR $ 692.00 X-RAY EXAM NOSE TO RECTUM FOR FB CHILD $ 220.00 X-RAY EXAM OF SURGICAL SPECIMEN $ 1,492.00 3D RENDER W/INTRP W/POSTPROCES $ 75.00 3D RENDER W/INTRP W/POSTPROCES $ 230.00 MAGNETIC RESONANCE SPECTROSCOPY $ 2,393.00 US EXAM OF HEAD AND NECK $ 368.00 US EXAM CHEST $ 338.00 US EXAM BREAST(S) COMPLETE $ 340.00 US BREAST UNILATERAL LIMITED $ 332.00 US ABDL AORTA SCREEN AAA $ 338.00 US EXAM ABDO BACK WALL COMP $ 631.00 US EXAM K TRANSPL W/DOPPLER $ 631.00 US EXAM SPINAL CANAL $ 338.00 OB US < 14 WKS SINGLE FETUS $ 621.00 OB US < 14 WKS ADDL FETUS $ 673.00 OB US >/= 14 WKS SNGL FETUS $ 601.00 OB US >/= 14 WKS ADDL FETUS $ 357.00 OB US DETAILED SNGL FETUS $ 1,004.00 OB US DETAILED ADDL FETUS $ 770.00 OB US LIMITED FETUS(S) $ 403.00 OB US FOLLOW-UP PER FETUS $ 338.00 US TRANSVAGINAL OBSTETRIC $ 338.00 FETAL BIOPHYS PROFILE W/NST $ 451.00 FETAL BIOPHYS PROFIL W/O NST $ 340.00 US TRANSVAGINAL NON-OB $ 338.00 HYSTEROSONOGRAPHY $ 692.00 US EXAM PELVIC COMPLETE $ 494.00 US EXAM PELVIC LIMITED $ 461.00 US EXAM SCROTUM $ 653.00 US TRANSRECTAL $ 466.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price US PROSTATE VOLUME FOR BT $ 429.00 US XTR NON-VASC COMPLETE $ 468.00 US GUIDE VASCULAR ACCESS $ 110.00 US GUIDE VASCULAR ACCESS $ 110.00 US FOLLOW-UP STUDY $ 338.00 US GUIDE INTRAOP $ 2,665.00 US UNLISTED $ 244.00 CT SCAN FOR LOCALIZATION $ 2,588.00 BREAST TOMOSYNTHESIS BI $ 177.00 MAMMOGRAM DX CAD UNILAT $ 433.00 MAMMOGRAM DX CAD BILAT $ 548.00 MAMMOGRAM SCR CAD BILAT $ 400.00 X-RAY FOR BONE AGE $ 338.00 X-RAY BONE LENGTH STUDIES $ 338.00 X-RAY BONE SURVEY LIMITED $ 742.00 X-RAY BONE SURVEY COMPLETE $ 742.00 CT BONE DENSITY AXIAL $ 187.00 DXA BONE DENSITY AXIAL 1+ SITES $ 354.00 DXA BONE DENSITY/PERIPHERAL 1+ SITES $ 345.00 DEXA-VERTEBRAL FRACTURE ASSES $ 355.00 THYROID UPTAKE MULTIPLE $ 1,060.00 NM RAI UPTAKE SINGLE DET $ 1,060.00 THYROID METS UPTAKE $ 596.00 PARATHYROID IMAGING $ 1,242.00 LIVER SPECT IMAGING $ 3,688.00 LIVER/SPLEEN AND ONLY IMAGING STATIC $ 1,060.00 GB SCAN W/O DRUG $ 1,060.00 GB SCAN W DRUG $ 1,367.00 GASTROESOPHAGEAL REFLUX STUDY $ 1,060.00 GASTRIC EMPTYING STUDY $ 1,221.00 GI BLEEDING $ 1,180.00 MECKELS SCAN $ 1,398.00 BONE AND/OR JOINT IMAGING LIMITED $ 1,060.00 MULTIPLE AREA STATIC BONE $ 1,060.00 BONE SCAN-WHOLE BODY $ 1,114.00 THREE PHASE BONE SCAN $ 1,180.00 BONE SPECT $ 2,071.00 NON-CARDIAC VASC FLOW $ 1,398.00 CARDIAC SPECT SINGLE $ 3,688.00 CARDIAC SPECT MULTI $ 2,400.00 ACUTE VENOUS THROMBOSIS IMAGE $ 3,688.00 MUGA; MULTI W WM & EF $ 2,516.00 CARD PET PERFUS; SINGLE $ 4,127.00 CARD PET PERFUS; MULTIPLE $ 4,127.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price MUGA SPECT W WM & EF $ 1,060.00 MUGA SGL W RV EF BY 1ST PASS $ 362.00 NM BRAIN W/FLOW <4 VIEWS $ 1,424.00 BRAIN IMAGE W/FLOW 4 + VIEWS $ 1,433.00 BRAIN SPECT $ 3,688.00 BRAIN VASCULAR FLOW ONLY $ 1,460.00 CISTERNOGRAPHY $ 1,367.00 SHUNT EVALUATION $ 1,367.00 KIDNEY IMAGING MORPHOL $ 1,060.00 KIDNEY IMAGING WITH FLOW $ 1,060.00 RENAL SCAN W/O DRUG $ 1,780.00 CAPTOPRIL RENAL $ 1,367.00 RENAL SCAN W AND W/O $ 1,462.00 KIDNEY IMAGING (3D) $ 1,641.00 TESTICULAR SCAN W/ FLOW $ 1,060.00 TUMOR LOCALIZED SPECT $ 1,367.00 NM ABCESS LIMITED $ 3,688.00 ABSC LOCALIZ; WB $ 3,688.00 NM ABCESS WHOLE BODY $ 3,688.00 WBC/GALLIUM WHOLE BODY W/ SPECT $ 1,668.00 INTRA-ARTERIAL PHARM RX PARTICULATE $ 780.00 BASIC METABOLIC PANEL $ 46.00 GENERAL HEALTH PANEL $ 123.00 ELECTROLYTE PANEL $ 29.00 ELECTROLYTES (URINE) $ 29.00 COMPREHENSIVE METABOLIC PANEL $ 52.00 LIPID PROFILE $ 50.00 RENAL FUNCTION PANEL $ 41.00 ACUTE HEPATITIS PANEL $ 230.00 HEPATIC FUNCTION PANEL $ 38.00 AMIKACIN $ 104.00 TEGRETOL (CARBAMAZEPINE) $ 54.00 CYCLOSPORIN WHOLE BLOOD $ 120.00 DIGOXIN SERUM $ 69.00 ETHOSUXIMIDE $ 80.00 ETHOSUXIMIDE $ 80.00 GENTAMICIN TROUGH $ 61.00 GENTAMICIN PEAK $ 61.00 GENTAMICIN RANDON $ 61.00 LIDOCAINE LAB $ 79.00 LITHIUM SERUM $ 24.00 DRUG SCRN QUANT OXCARBAZEPIN $ 57.00 PHENOBARBITAL $ 46.00 DILANTIN SERUM $ 49.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price FREE PHENYTOIN-DILANTIN $ 64.00 MYSOLINE $ 85.00 N-ACETYL PROCAINAMIDE $ 82.00 QUINIDINE SERUM $ 54.00 TACROLIMUS-BLOOD $ 177.00 THEOPHYLLINE $ 74.00 TOBRAMYCIN $ 60.00 TOPAMAX (TOPIRAMATE) $ 161.00 AUTOM URINE DIP W MICRO $ 17.00 N-AUTOM URINALYS WO MICRO $ 20.00 URINALYSIS (NO MICROSCOPE) $ 18.00 HOMOGENTISIC ACID $ 27.00 URINALYSIS $ 31.00 ACTH $ 257.00 AMP CYLIC-URINE $ 213.00 ALBUMIN SERUM $ 24.00 ALDOLASE $ 53.00 ALDOSTERONE & RENIN $ 151.00 ALPHA-1-ANTITRYPSIN; PHENOTYPE $ 67.00 AFP-AMNIOTIC FLUID $ 62.00 ALUMINUM SERUM/URINE $ 124.00 DELTA AMINOLEV ACID ALA $ 61.00 AMMONIA PLASMA $ 94.00 AMYLASE SERUM $ 36.00 ANDROSTANEDIOL GLUCURONIDE $ 107.00 ANDROSTENEDIONE-SERUM $ 193.00 ANGIOTENSION CONV ENZ (AC) $ 92.00 APOLIPOPROTEIN A-1 $ 76.00 ARSENIC BLOOD $ 100.00 VIT C $ 114.00 BETA-2-MICROGLOBULINS S $ 111.00 URINE BILE ACID $ 72.00 BILIRUBIN TOTAL $ 31.00 BILIRUBIN DIRECT $ 24.00 CADMIUM $ 86.00 VITAMIN D 25 HYDROXY $ 305.00 CALCITONIN $ 254.00 CALCIUM SERUM $ 27.00 IONIZED CALCIUM $ 94.00 CALCIUM URINE 24HR $ 100.00 STONE; QUAN CHEMICAL $ 130.00 CEA $ 94.00 CARNITINE QUAN EA $ 148.00 CAROTENE SERUM $ 65.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price CATECHOL FRACT PLASMA $ 233.00 CERULOPLASMIN $ 323.00 CHLORIDE SERUM $ 23.00 CHLORIDE URINE $ 46.00 CHOLESTEROL TOTAL $ 21.00 CHROMIUM $ 100.00 CITRATE URINE $ 136.00 COPPER SERUM $ 65.00 CORTISOL FREE URINE $ 105.00 CORTISOL SERUM-PLASMA $ 60.00 CREATINE SERUM $ 44.00 CPK TOTAL $ 36.00 CPK ISOENZYMES-INC CPK $ 68.00 CPK-MB SCREEN $ 43.00 CREATININE SERUM $ 27.00 CREATININE URINE RANDOM $ 28.00 CREATININE; NOT BLOOD $ 28.00 CREATININE CLEARANCE $ 52.00 CRYOGLOBULINS QUAL $ 35.00 VITAMIN B-12 LEVEL $ 74.00 VIT B12 UNSATUR BIND CA $ 105.00 DHEA SERUM $ 205.00 DHEA SULFATE $ 156.00 ESTRADIOL SERUM $ 154.00 ESTROGENS TTL SERUM $ 146.00 ESTRIOL SERUM $ 119.00 ETHYLENE GLYCOL $ 55.00 FATTY ACID STOOL QUAL $ 36.00 FAT FECAL 24 HR STOOL $ 144.00 FERRITIN $ 50.00 FOLATES RBS $ 130.00 IMMUNOGLOBULIN E (IGE) $ 102.00 BLOOD GAS ANALYSIS $ 95.00 BLOOD GAS MIXED WO O2 SAT $ 95.00 VENOUS BLOOD GAS (VBG) $ 95.00 GASTRIN SERUM $ 92.00 GLUCOSE RANDOM $ 21.00 GLUCOSE; BLOOD REAGENT STRIP $ 33.00 POST GLUCOSE DOSE $ 23.00 LACTOSE TOL (3 SEPC) $ 64.00 GLUTOL EACH ADD SPEC $ 16.00 LACTOSE TOL EACH ADDITION $ 16.00 GLUC-6 PD QUAN $ 74.00 GLUC-6-PD SCREEN $ 87.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price GLUCOSE BLOOD BY MONITOR $ 32.00 GLUCOSE; BLD BY MONITOR DEVICE (POC) $ 32.00 GAMMA GLUT TRANS (GGT) $ 37.00 FRUCTOSAMINE $ 74.00 FSH-SERUM $ 69.00 LUTEINIZING HORMONE-SERU $ 69.00 GROWTH HORMONE $ 62.00 HAPTOGLOBIN $ 82.00 BARIUM $ 112.00 HGB CHROMATOGRAPHY $ 93.00 GLYCOSYLATED HEMOGLOBIN $ 53.00 HEMOGLOBIN FREE PLASMA $ 56.00 HEMOSIDERINE URINE $ 40.00 HISTAMINE BLOOD $ 328.00 HOMOCYSTEINE $ 83.00 HOMOVANILLIC ACID HVA $ 174.00 17 HYDROXYCORTICOSTERCID $ 65.00 5-HIAA URINE QUANTITATIVE $ 90.00 HYDROXYPROGESTERONE 17-D $ 133.00 IMMUNOASSAY QUANT NOS NONAB $ 228.00 IRON $ 35.00 IRON BINDING CAP/TIBC $ 44.00 17 KETOSTEROIDS TOTAL $ 47.00 LACTIC ACID $ 78.00 LDH $ 32.00 LDH-ISOENZYMES $ 94.00 LEAD SERUM BLOOD TEST $ 46.00 L/S RATIO AMNIOTIC FLUID $ 185.00 LIPASE SERUM $ 90.00 LIPOPROTEIN ELECTROPHORE $ 42.00 HIGH DENSITY LIPO PROTEIN $ 76.00 MAGNESIUM $ 36.00 MANGANESE $ 120.00 MERCURY QUANTITIVE-SERUM $ 60.00 MYELIN BASIC PROTEIN CSF $ 139.00 MYOGLOBIN-URINE QUALITA $ 93.00 NATRIURETIC PEPTIDE $ 423.00 5-NUCLEOTIDASE $ 69.00 OLIGOCLONAL PROTEINS $ 82.00 ORGANIC ACIDS; QUALITATIVE, EACH SPECIMEN $ 67.00 METHYLMALONIC ACID, SERUM $ 73.00 OSMOLALITY-SERUM $ 43.00 OSMOLARITY URINE $ 36.00 OXALATE $ 91.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price PARATHYROID HORMONE $ 153.00 PROST ACID PHOS SER MON $ 60.00 ALKALINE PHOSPHATASE $ 27.00 ALKALINE PHOSPHATASE ISO $ 82.00 PHOSPHORUS $ 24.00 URINE PHOSPHATE $ 19.00 PORPHOBILINOGEN URQN $ 31.00 PORPHYRINS $ 106.00 POTASSIUM $ 23.00 POTASSIUM URINE 24 HR $ 23.00 PREALBUMIN $ 96.00 PREGNENOLONE $ 147.00 PROGESTERONE SERUM $ 108.00 PROLACTIN $ 127.00 PROSTATE-SPECIFIC AG $ 68.00 PSA; FREE $ 176.00 PROTEIN TOTAL $ 20.00 URINE TOTAL PROTEIN $ 37.00 TOTAL PROTEIN OTHER SPECIMEN $ 47.00 PEP URINE OR CSF $ 126.00 PROINSULIN $ 104.00 VITAMIN B6 $ 208.00 PYRUVATE $ 130.00 RENIN $ 136.00 VITAMIN B2 $ 165.00 SELENIUM $ 125.00 SEROTONIN $ 115.00 SODIUM SERUM $ 24.00 SODIUM URINE 24 HR $ 24.00 SOMATOMEDIN-C $ 271.00 SPECTROPHOTOMETRY ANALYTE NES $ 31.00 TESTOSTERONE FREE SERUM $ 253.00 TESTOSTERONE; TOTAL $ 96.00 VITAMIN B1 $ 104.00 THYROGLOBULIN $ 171.00 T4 (THYROXINE) $ 36.00 FREE THROXINE INDEX $ 46.00 THYROXIN BIND GOLD (TBG) $ 124.00 THYROID STIM HORM (TSH) $ 85.00 TSI $ 248.00 VITAMIN E $ 144.00 AST (SGOT) $ 27.00 ALT (SGPT) $ 27.00 TRANSFERRIN $ 69.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price TRIGLYCERIDE $ 31.00 T3 UPTAKE $ 35.00 T3 TRIIODOTHYRONINE $ 95.00 T3 FREE $ 219.00 REVERSE T3 $ 208.00 TROPONIN QUAN $ 116.00 UREA NITROGEN $ 19.00 UREA NITROGEN (URINE) $ 23.00 URIC ACID; BLOOD $ 52.00 URIC ACID $ 24.00 VMA URINE 24HR $ 57.00 VASOACTIVE INTEST POLPEP $ 260.00 ADH $ 260.00 VITAMIN A $ 94.00 C-PEPTIDE SERUM $ 77.00 HCG; QUAN $ 74.00 PREG TEST SERUM QUAL $ 38.00 PREG TEST/URINE QUAL $ 38.00 BLEEDING TIME $ 44.00 DIFFERENTIAL (MANUAL) $ 13.00 RBC MORPHOLOGY $ 18.00 HEMATOCRIT $ 17.00 HEMOGLOBIN $ 35.00 CBC WITH DIFF (AUTO) $ 41.00 COMPL AUTOM CBC W PLT $ 31.00 RETICULOCYTE COUNT $ 23.00 LEUKOCYTE(WBC) COUNT $ 18.00 AUTOMATED PLATELET COUNT $ 47.00 CLOTTING FACTOR II PT SPEC $ 65.00 FACTOR VII $ 184.00 ANTIHEMOPHILIC FACTOR $ 204.00 CLOTTING: FACTOR VIII VW FACTOR AG $ 242.00 FACTOR 8 VWF MULTIMRIC $ 114.00 ANTIHEMOPHILIC FACTOR B $ 190.00 FACTOR X $ 198.00 ANTIHEMOPHILIC FACTOR C $ 198.00 FACTOR XII $ 198.00 CLOTTING; FACTOR XIII - FS $ 217.00 FACTOR XIII $ 127.00 ANTI-THROMBIN III ACTIVITY $ 160.00 ANTITHROMBIN III $ 198.00 CLOTTING INHIBITOR; PROTEIN C AG $ 187.00 PROTEIN C (PRO C-ACTIVITY) $ 51.00 PROTEIN S ANTIGEN $ 111.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price ACTIVATED PROTEIN C RESISTANCE $ 100.00 FACTOR INHIBITOR TEST $ 252.00 FIBRIN SPLIT PRODUCTS-FD $ 61.00 D-DIMER $ 74.00 FIBRINOGEN $ 31.00 LEUKOCYTE ALKALINE PHOSP $ 54.00 PROTHROMBIN TIME $ 19.00 ESR-SEDIMENTATION RATE $ 19.00 HEMOGLOBIN SOLUBILITY (S) $ 35.00 THROMBIN TIME $ 46.00 PTT $ 32.00 GRANULOCYTE ANTIBODIES $ 163.00 ANTIPLATELET ANTIBODY $ 196.00 ANTI-NUCLEAR ANTIBODY SC $ 60.00 ANTINUCLEAR AB (ANA); TITER $ 98.00 ANTISTREPTOLYSIN O TITER $ 27.00 ASO; SCREEN $ 119.00 C-REACTIVE PROTEIN CRP $ 33.00 CARDIO CRP $ 82.00 BETA 2 GLYCOPROTEIN I AB EA $ 182.00 ANTICARDIOLIPIN AB IGM QN $ 136.00 C1 ESTERASE INHIBITOR $ 60.00 COMPLEMENT C3 $ 44.00 CH50 $ 140.00 CHLAM TRACH ANTI PSITACO $ 99.00 ANTI-DNA ANTIBODY DBLE S $ 75.00 DNA ANTIBODIES $ 99.00 ANTI JO 1 $ 118.00 SJOGREN AB $ 118.00 ANTIMITOCHONDRIAL AB $ 83.00 TITER EACH ANTIBODY $ 178.00 IA QUANT; CA 15-3 (27.29) $ 155.00 CA 19-9 $ 102.00 CA-125 $ 102.00 HETEROPHILE ABS QUAL $ 27.00 HETEROPHILE ABS QUAN $ 49.00 CA-27-29 $ 208.00 ANTIGLIADIN ABS AIGG/A $ 74.00 IMMUNFIX E-PHORSIS/URINE/CSF $ 142.00 INHIBIN SERUM $ 246.00 INSULIN ABS-BOVINE $ 105.00 ANTIPANCREATIC ISLET CELL $ 137.00 B CELLS TOTAL COUNT $ 140.00 T CELLS; TOTAL COUNT $ 171.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price LYMPH SUBSET CD4-CD8 $ 415.00 T CELLS; ABSOL CD4 COUNT $ 176.00 RHEUMATOID FACTOR R A $ 21.00 TB TEST CELL IMMUN MEASURE $ 309.00 SYPHLIS (RPR-STS) SCREEN $ 28.00 VDRL CSF $ 40.00 ADENOVIRUS GROUP ANTIBODY $ 103.00 ASPERGILLUS FLAVUS AB $ 58.00 AB; BARTONELLA $ 55.00 BLASTOMYCES (YEAST ID) $ 120.00 QUANT BORDITELLA PERTUSSIS IGA IGM IGG $ 257.00 LYME DIS TOT ABS REF BLOT $ 146.00 LYME SCREEN $ 83.00 CHLAM TRACH GROUP ABS $ 116.00 CHLAMYDIA IGM ANTIBODY $ 116.00 AB; CRYPTOCOCCUS $ 53.00 CMV ANTIBODIES IGG $ 100.00 CMV ABS IGM QUAN $ 111.00 COXSACKIE VIRUS GROUP A $ 190.00 EBV PROFILE $ 72.00 ERLICHIOSIS SEROLOGY $ 111.00 GIARDIA LAMBLIA ABS EIA $ 154.00 TOXOCARA AB S $ 139.00 AB; HTLV OR HIV WB $ 163.00 HEP D AGENT AB $ 87.00 HERPES CULTURE $ 135.00 AB; HSV 1 $ 163.00 88-BLOOD $ 142.00 AB; HIV-1 & HIV-2 SGL ASSAY $ 100.00 HEP B CORE AB TOTAL $ 75.00 HEP B CORE AB IGM $ 84.00 HEP B SURF ANTIBODY $ 74.00 HEPATITIS BE AB $ 163.00 HEP A AB TOTAL $ 46.00 HEP A AB IGM $ 75.00 L LONGBEACHEA AB $ 75.00 LEPTOSPIRAL ABS $ 94.00 MUMPS SCREEN IGG $ 53.00 MYCOPLASMA PNEUMONIA AB $ 83.00 AB; PARVOVIRUS $ 73.00 RUBELLA ABS IGM $ 127.00 MEASLES (RUBEOLA SCREEN) $ 64.00 TOXOPLASMA GONDI IGG $ 53.00 TOXOPLASMA GONDI IGM $ 133.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price TREPONEMA PALLIDUM $ 104.00 WEST NILE VIRUS AB IGM $ 260.00 WEST NILE VIRUS ANTIBODY $ 363.00 WEST NILE VIRUS $ 230.00 ANTI-THYROGLUBULIN ANTIB $ 78.00 HEP C VIRUS AB $ 53.00 HEPATITIS C AB/RIBA $ 139.00 HLA TYPING $ 357.00 ANTIBODY SCREEN $ 153.00 ANTIBODY IDENTIFICATION $ 823.00 COOMBS DIRECT $ 171.00 RH TYPE $ 105.00 COMPATIBILITY TEST EACH UNIT $ 434.00 THAW (BILL ONLY) $ 637.00 FROZEN BLOOD FREEZE & THAW $ 96.00 IRRADIATE BLD PRODUCT EA UNIT $ 100.00 CULTURE STOOL $ 78.00 CULTURE ANAEROBIC $ 85.00 CULTURE URINE ROUTINE $ 52.00 CULT FUNGUS W P ID; SKIN HR NL $ 67.00 CANDIDA SCREEN $ 43.00 FUNGUS CULTURE BLOOD $ 130.00 ORGANISM ID MOLD $ 112.00 FUNGUS CULTURE DEF ID MOLD $ 38.00 MYCOPLASMA PNEUMON CULTU $ 128.00 CHLAMYDIA CULTURE $ 124.00 MYCOBACTERIA CULTURE & STAIN $ 99.00 CULTURE AFB URINE $ 99.00 STREP SERO GROUP $ 33.00 MACROSCOPIC EXAM PARASITE $ 52.00 PINWORM EXAM $ 104.00 OVA AND PARASITES & GIARDIA AG $ 84.00 MALARIA SMEAR $ 53.00 INDIA INK PREP $ 35.00 CULTURE FUNGUS KOH SMR $ 69.00 TOXIN ASSAY TISSUE CULTURE $ 98.00 CULTURE VIRAL $ 265.00 VIRUS ISOL SHELL VIAL TECHN $ 265.00 ENTEROVIRUS AB BY DFA $ 171.00 LEGIONELLA P AG BY DFA $ 117.00 RSV AG BY IF $ 98.00 ADENOVIRUS AG EIA $ 100.00 H PYLORI FOR STOOL $ 201.00 HEP B PREVACCINATION $ 53.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price HEPATITIS BE ANTIGEN $ 196.00 HIV-1 AG W/HIV-1 & HIV-2 AB $ 119.00 INFLUENZA A/B AG EIA $ 114.00 ROTAVIRUS AG EIA $ 98.00 STREP A AG EIA $ 50.00 C-DIFFICILE TOXIN $ 123.00 LYMES AMPLIFIED NA PROBE $ 175.00 CHLAMYDIA P AMPLIF NA PROBE $ 130.00 CHLAMYDIA T DIR NA PROBE $ 96.00 CHLAMYDIA T AMPLIF NA PROBE $ 130.00 CYTOMEGALOV AMPLIF NA PROBE $ 180.00 ENTEROVIRUS PROBE&REVRS TRNS $ 174.00 HEP-B NA QUAN $ 342.00 HEP C RNA (PCR) $ 236.00 HVS 1/2 PCR $ 550.00 HIV1 RNA QUANT BY PCR $ 315.00 LEGIONELLA DIR NA PROBE $ 74.00 NEISSERIA DIR NA PROBE $ 112.00 NEISSERIA AMPLIF NA PROBE $ 1,942.00 HCV QUANT $ 301.00 CHLAM & GONOCO DNA PROBE $ 195.00 RSV IA W DIR OBSERV-CULTURE $ 95.00 STREP A ASSAY W/OPTIC $ 60.00 HEP C GENOTYPE $ 1,238.00 CYTOLOGY EFFUSIONS $ 96.00 CYTOLOGY RESPIRATORY $ 96.00 CP CONCENTR TECH SMEAR $ 109.00 CSF CELL COUNT $ 93.00 FLUID CRYSTAL EXAM (SYNOVIAL) $ 158.00 CIRCULATING EOS-NASAL $ 44.00 SEMEN ANALYSIS $ 126.00 IMMUNIZATION ADMIN 1 VACCINE $ 179.00 HEPATITIS A VACCINE 1440ELU/ML SYRN 5X1M $ 237.00 FLUARIX (FLU VACCINE) $ 41.00 TETANUS/DIPTHERIA TOX < 7 YRS AGE $ 30.00 TENIVAC 5-2 LFU INJ(TETANUS, DIPTHERIA) $ 118.71 DIPHTH PERTUSSIS(ADACEL)TET VAC SYRN 10X $ 141.88 TREATMENT SPEECH LANGUAGE VOICE AUD IND $ 303.00 EVALUATION SPEECH FLUENCY STUTTERING $ 423.00 EVAL SPEECH SOUND PRODUCT ARTICULATION $ 353.00 EVAL SPEECH SOUND PROD W/EVAL LANG COMP $ 736.00 BEHAVRAL QUALIT ANALYS VOICE $ 283.00 TREAT OF SWALLOWING DYSFUCTION DYSPHAGIA $ 328.00 EVAL-PRESCRIPT VOICE PROSTHETI $ 545.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price EVALUATE ORAL AND PHARYNGEAL SWALLOW FCN $ 323.00 MOTION FLUORO SWALLOW FCN $ 426.00 TRANSCUTANEOUS PACING TEMPORAR $ 1,579.00 CARDIOVERSION ELECTIVE; INT $ 1,579.00 EKG 12 LEAD; TRACING ONLY $ 203.00 EKG 12 LEAD; TRACING ONLY $ 203.00 CARDIOVASCULAR STRESS TEST $ 603.00 CARDIAC RHYTHM MONITORING 1-3 LEADS $ 168.00 HOLTER MONITOR - ECG MONIT/REPRT UP TO 48 HRS $ 319.00 REMOTE 30 DAY ECG REV/REPORT $ 253.00 ECG/MONITORING AND ANALYSIS $ 353.00 TTE W/DOPPLER COMPLETE $ 1,300.00 ECHOCARDIOGRAPHY, TRANSTHORACIC FOLLOW-UP OR LIMITED STUDY $ 718.00 ECHO TRANSESOPHAGEAL $ 1,676.00 DOPPLER ECHO; COMPLETE $ 550.00 DOPPLER ECHO; LIMITED/ F-UP $ 350.00 DOPPLER COLOR FLOW ADD-ON $ 281.00 STRESS TTE ONLY $ 2,062.00 US STRESS ECHOGARDIOGRAM $ 1,594.00 ABP MONITORING 24+ HRS; RECORDING $ 319.00 ABP MONITORING 24+ HRS; SCANNING ANALYSIS $ 319.00 CARDIAC REHAB W/O MONITOR $ 384.00 CARDIAC REHAB W/ MONITOR $ 424.00 CARDOTID DUPLEX DOPPLER $ 1,171.00 UPR/L XTREMITY ART 2 LEVELS $ 328.00 UPR/LXTR ART STDY 3+ LVLS $ 425.00 LWR XTR VASC STDY BILAT $ 425.00 US ARTERY EXTREMITY LOWER BI $ 881.00 US ARTERY EXTREMITY LOWER BILATERAL $ 881.00 US ARTERY EXTREMITY LOWER LEFT $ 442.00 US ARTERY LOWER RIGHT $ 442.00 US ARTERY EXTREMITY LOWER LEFT $ 442.00 DUPLEX UE ART/BPG; COMP BILAT $ 881.00 US ARTERY EXTREMITY UPPER BILAT $ 881.00 DUPLEX A IVC IL/BPG; UNIL/LIM $ 395.00 US ABDOMEN DUPLEX LIMITED $ 395.00 VENTILATION INITIAL DAY $ 1,530.00 VENTILATION ASSIST AND MANAGEMENT INITIT $ 1,530.00 VENTILATION ASSIST AND MANAGEMENT SUBS D $ 1,530.00 SPIROMETRY $ 408.00 RESP FLOW VOLUME LOOP $ 757.00 EXERCISE TST BRNCSPSM $ 323.00 PULMONARY STRESS TESTING $ 323.00 PULMONARY STRESS TEST $ 1,266.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price CPAP $ 575.00 EVALUATE PT USE OF INHALER IPPB $ 575.00 RIBAVIRIN THERA (*3 DAYS) IPPB DEMO EVAL $ 575.00 CHEST PHYSICAL THERAPY-INITIAL $ 319.00 AIRWAY RESISTANCE $ 757.00 CO DIFFUSING CAPACITY $ 198.00 PULMONARY COMPLIANCE $ 405.00 ER PROCEDURE PULSE OXIMETRY ONLY $ 64.00 PULSE OXIMETRY SINGLE DETERMINATION $ 64.00 PULSE OXIMETRY $ 64.00 PULSE OX SINGLE RESPIRATORY $ 64.00 PULSE OXIMETRY CONT $ 405.00 CARBOGEN PER RX UNLSTD PULM PROCEDURE $ 405.00 MMT EXT/TRUNK EXCLUDING HAND MUSCL TEST $ 56.00 MMT HAND MUSCLE TESTING $ 54.00 MUSCLE TEST; TOT BODY WO HANDS $ 85.00 MUSCLE TEST; TOT BODY W HANDS MANUAL $ 101.00 ROM HAND MEASUREMENTS REPORT $ 27.00 CANALITH REPOSITIONING PROC $ 120.00 APHASIA ASSESSMENT PER HOUR $ 398.00 HYDRATION IV INFUSION INIT 31-60 MINS $ 562.00 HYDRATION EACH ADDITIONAL HOUR $ 117.00 THER/PROPH/DIAG IV INF INIT =<1 HR $ 370.00 IV THERAPY INITIAL $ 370.00 IV THERAPY EACH HOUR OVER 1.5 HOURS $ 114.00 TX/PROPH/DG ADDL $ 179.00 THER/DIAG CONCURRENT INF $ 140.00 INTRA-ARTERIAL $ 562.00 IVP SINGLE DRUG OR SUBSTANCE $ 370.00 THER PROPH DX INJ INTRAVENOUS $ 370.00 ADDITIONAL IVP SAME DRUG INJ SEQ $ 180.00 CHEMO IV INFUSION 1 HR $ 865.00 CHEMO IV INFUSION ADDL HR $ 179.00 MECHANICAL TRACTION THERAPY 1+ AREAS $ 47.00 VASOPNEUMATIC DEVICE THERAPY 1+ AREAS $ 114.00 CONTRAST BATH APPLICATION PER 15 MINUTES $ 54.00 OT CONTRAST BATH THERAPY EA 15 MINS $ 54.00 OT AQUATIC THERAPY/EXERCISES EA 15 MINS $ 125.00 THER IVNTJ W/FOCUS COG FUNCJ $ 86.00 GROUP TREATMENT THERA PROCED $ 59.00 OT THERAPEUTIC REHAB GROUP (2 OR MORE) $ 59.00 PT EVAL LOW COMPLEX 20 MIN $ 272.00 PT EVAL MOD COMPLEX 30 MIN $ 272.00 PT EVAL HIGH COMPLEX 45 MIN $ 272.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price PT RE-EVAL EST PLAN CARE $ 185.00 OT EVAL LOW COMPLEX 30 MIN $ 293.00 OT EVAL MOD COMPLEX 45 MIN $ 293.00 OT EVAL HIGH COMPLEX 60 MIN $ 293.00 OT RE-EVAL EST PLAN CARE $ 201.00 OT SENSORY INTEGRATION EA 15 MINS $ 138.00 WORK HARDENING EA ADDTL 1.00 HR $ 67.00 ORTHC/PROSTC MGMT SBSQ ENC $ 164.00 MEDICAL NUTRITION THERAPY, INITIAL, EA 15 MINS $ 108.00 MEDICAL NUTRITION THERAPY, RE-ASSESS, EA 15 MINS $ 92.00 MEDICAL NUTRITION THERAPY, GROUP (2 OR MORE), EA 30 MINS $ 51.00 HANDLING FEE $ 38.00 MOD SEDATION SAME PHYS/QHP <5 YRS $ 254.00 MOD SEDATION SAME PHYS/QHP 5/>YRS $ 168.00 MOD SEDATION SAME PHYS/QHP EA $ 38.00 MOD SEDATION OTH PHYS/QHP <5 YRS $ 309.00 MOD SEDATION OTH PHYS/QHP 5/>YRS $ 253.00 MOD SEDATION OTHER PHYS/QHP EA $ 206.00 PHLEBOTOMY THERAPEUTIC $ 319.00 OFFICE/OUTPATIENT VISIT NEW LVL 1 $ 93.00 OFFICE/OUTPATIENT VISIT NEW LVL 2 $ 174.00 OFFICE/OUTPATIENT VISIT NEW LVL 3 $ 265.00 OFFICE/OUTPATIENT VISIT NEW LVL 4 $ 448.00 OFFICE/OUTPATIENT VISIT NEW LVL 5 $ 583.00 OFFICE/OUTPATIENT VISIT EST LVL 1 $ 33.00 OFFICE/OUTPATIENT VISIT EST LVL 2 $ 88.00 OFFICE/OUTPATIENT VISIT EST LVL 3 $ 175.00 OFFICE/OUTPATIENT VISIT EST LVL 4 $ 271.00 OFFICE/OUTPATIENT VISIT EST LVL 5 $ 382.00 EMERGENCY DEPT VISIT LVL 1 $ 170.00 EMERGENCY DEPT VISIT LVL 2 $ 310.00 EMERGENCY DEPT VISIT LVL 3 $ 540.00 EMERGENCY DEPT VISIT LVL 4 $ 900.00 EMERGENCY DEPT VISIT LVL 5 $ 1,325.00 CRITICAL CARE 1ST HOUR $ 2,220.00 TEAM CONF W/PAT BY HC PRO >=30 MINS $ 88.00 SODIUM CHLORIDE 7% INHALAT 0.07 AMIH 60X $ 6.00 CATH INDW FOLEY 3 WAY $ 54.00 MED SPECIALTY ARM SLING $ 14.00 LARGE SPECIALTY ARM SLING $ 14.00 HOT/COLD H2OBOT/CAP/COL/WRAP $ 54.00 CARDIOLITE UNIT DOSE $ 209.00 TECHNETIUM TC99M TEBOROXIME PER DOSE $ 480.00 TC99M MDP =< 30 MCI $ 411.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price TL201 THALLIUM PER 1 MCI $ 149.00 IODINE I-123 SOD IODIDE MIL PER 1 MCI $ 32.00 TC99M HEPATOLITE $ 129.00 TC99M PERTECHNETATE $ 129.00 IODINE I-123 SOD IODIDE 100-999 UCI $ 358.00 I131 IODIDE CAP RX PER 1 MCI THERA $ 124.00 TC99M EXAMETAZIME =< 25 MCI $ 2,446.00 IODINE I-125 SERUM ALBUMIN DX PER 5 UCI $ 59.00 TC99M CHOLETEC =< 15 MCI MEBROFENIN $ 464.00 TC99M PENTETATE =< 25 MCI $ 523.00 TC99M MAA =< 10 MCI $ 294.00 TC99M SULFUR COLLOID =< 20 MCI $ 373.00 GALLIUM 67 (PER MCI) $ 63.00 TC99M LABELED RBC =< 30 MCI $ 373.00 PYROPHOSPHATE $ 373.00 TC99M MAG 3 =< 15 MCI MERTIATIDE $ 480.00 TECHNETIUM TC99M AUTO WBC EXAME PER DOSE $ 347.00 INDIUM IN-111 AUTO PLATELET PER DOSE $ 2,941.00 INDIUM IN-111 PENTETREOTIDE =< 6 MCI $ 693.00 IODINE I-123 IOBENGUANE =< 15 MCI $ 98.00 SM 153 LEXIDRONAM =< 150 MCI THERA $ 43,975.00 DBM BONE GRAFT $ 4,825.00 NITINOL WIRE GUIDE $ 82.00 BENTSON PLUS WIRE GUIDE $ 82.00 SYNCHROMED II PUMP $ 39,925.00 METATARSAL DECOMPRESSION IMPLANT (MDI) $ 15,963.00 SENSIA DR PACEMAKER $ 15,533.00 IMPL SGL CHAMBR RR PACEMAKER $ 16,370.00 PRECISION IMPLANTABLE PULSE GE $ 96,532.00 BS 30CM SPLITTER 2X8 KIT $ 6,169.00 SUPRAPUBIC CATH SET 14 FR $ 346.00 MRA ABD W CONTRAST $ 2,329.00 MRA ABD WO CONTRAST $ 1,708.00 MRA ABD W/WO CONTRAST $ 2,847.00 MRA CHEST W CONTRAST $ 1,708.00 MRA CHEST WO CONTR $ 1,915.00 MRA CHEST W/WO CONTR $ 1,708.00 MRA LEXTREM W CONT $ 2,847.00 MRA LEXTREM WO CONTR $ 1,449.00 MRA LEXTREM W/WO CONTR $ 3,986.00 PELVIS MRA W CONTR $ 2,847.00 PELVIS MRA WO CONTR $ 1,915.00 PELVIS MRA W & WO CONTR $ 2,847.00 TTE W OR W/O FOL W/CONT COM $ 2,101.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price 2D TTE W OR W/O FOL W/CON CO $ 2,101.00 2D TTE W OR W/O FOL W/CON FU $ 1,370.00 TTE W OR WO FOL WCON DOPPLER $ 2,101.00 MRA W/DYE SPINAL CANAL $ 1,158.00 MRA W/O DYE SPINAL CANAL $ 1,864.00 MRA W/O&W/DYE SPINAL CANAL $ 2,071.00 MRA W/DYE UPPER EXTREMITY $ 1,158.00 MRA W/O DYE UPPER EXTR $ 1,812.00 MRA W/O&W/DYE UPPER EXTR $ 2,174.00 PANTOPRAZOLE SODIUM, PER VIAL $ 18.54 KCENTRA, PER I.U. OF FACTOR IX ACTIVITY $ 7.50 BRIDION INJECTION (Sugammadex) 200 mg/ 2 ml $ 171.00 ADMINIST-PNEUMOCOCCAL VACCINE $ 114.00 ADMINIST-HEPATITIS B VACCINE $ 132.00 PSA SCREENING $ 155.00 OT AS PART OF P HOSP/DAY PER SESS 45+ MI $ 183.00 SIJ INJ - ARTHROGR/ANESTHETIC $ 13.00 SIJ ANESTH/STEROID INJ $ 1,796.00 TOMOSYNTHESIS, MAMMO $ 177.00 OT WND CARE ELEC STIM UA, STAGE 3-4 ULCERS $ 47.00 PT NON WND ELECT STIM $ 47.00 OT NON WND ELECT STIM $ 47.00 KNEE ARTHRO DIFF COMPARTMENT SK $ 715.00 LOW DOSE CT SCAN (LDCT) FOR LUNG CANCER SCREENING $ 609.00 OBSERVATION ROOM 1 HR-OPER RM $ 133.00 OBSERVATION ROOM 1 HR-EMER RM $ 133.00 OBSERVATION ROOM 1 HR-MED SURG $ 133.00 HOSPITAL OUTPT CLINIC VISIT $ 344.00 ACETAMINOPHEN $ 343.00 ETHANOL QUANT BLOOD $ 343.00 SALICYLATE $ 343.00 DEV COGNITIVE SKILLS / 15 MIN $ 103.00 DEV COGNITIVE SKILLS / 15 MIN $ 103.00 MOBILITY CURRENT STATUS 0% $ 0.01 MOBILITY CURRENT STATUS 1-19% $ 0.01 MONILITY CURRENT STATUS 20-39% $ 0.01 MOBILITY CURRENT STATUS 40-59% $ 0.01 MOBILITY CURRENT STATUS 60-79% $ 0.01 MOBILITY CURRENT STATUS 80-99% $ 0.01 MOBILITY CURRENT STATUS 0% $ 0.01 MOBILITY CURRENT STATUS 1-19% $ 0.01 MOBILITY CURRENT STATUS 20-39% $ 0.01 MOBILITY CURRENT STATUS 40-59% $ 0.01 MOBILITY CURRENT STATUS 60-79% $ 0.01 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price MOBILITY CURRENT STATUS 80-99% $ 0.01 MOBILITY CURRENT STATUS 100% $ 0.01 MOBILITY CURRENT STATUS 100% $ 0.01 MOBILITY GOAL STATUS 0% $ 0.01 MOBILITY GOAL STATUS 1-19% $ 0.01 MOBILITY GOAL STATUS 20-39% $ 0.01 MOBILITY GOAL STATUS 40-59% $ 0.01 MOBILITY GOAL STATUS 60-79% $ 0.01 MOBILITY GOAL STATUS 80-99% $ 0.01 MOBILITY GOAL STATUS 100% $ 0.01 MOBILITY GOAL STATUS 0% $ 0.01 MOBILITY GOAL STATUS 1-19% $ 0.01 MOBILITY GOAL STATUS 20-39% $ 0.01 MOBILITY GOAL STATUS 40-59% $ 0.01 MOBILITY GOAL STATUS 60-79% $ 0.01 MOBILITY GOAL STATUS 80-99% $ 0.01 MOBILITY GOAL STATUS 100% $ 0.01 MOBILITY D/C STATUS 0% $ 0.01 MOBILITY D/C STATUS 1-19% $ 0.01 MOBILITY D/C STATUS 20-39% $ 0.01 MOBILITY D/C STATUS 40-59% $ 0.01 MOBILITY D/C STATUS 60-79% $ 0.01 MOBILITY D/C STATUS 80-99% $ 0.01 MOBILITY DISCHARGE STATUS 0% $ 0.01 MOBILITY DISCHARGE STATUS 1-19% $ 0.01 MOBILITY DISCHARGE STATUS 20-39% $ 0.01 MOBILITY DISCHARGE STATUS 40-59% $ 0.01 MOBILITY DISCHARGE STATUS 60-79% $ 0.01 MOBILITY DISCHARGE STATUS 80-99% $ 0.01 MOBILITY DISCHARGE STATUS 100% $ 0.01 MOBILITY D/C STATUS 100% $ 0.01 CHNG&MNT CURRENT STATUS 0% $ 0.01 CHNG&MNT CURRENT STATUS 1-19% $ 0.01 CHNG&MNT CURRENT STATUS 20-39% $ 0.01 CHNG&MNT CURRENT STATUS 40-59% $ 0.01 CHNG&MNT CURRENT STATUS 60-79% $ 0.01 CHNG&MNT CURRENT STATUS 80-99% $ 0.01 CHNG&MNT CURRENT STATUS 100% $ 0.01 BODY POSITION CURRENT STATUS 0% $ 0.01 BODY POSITION CURRENT STATUS 1-19% $ 0.01 BODY POSITION CURRENT STATUS 20-39% $ 0.01 BODY POSITION CURRENT STATUS 40-59% $ 0.01 BODY POSITION CURRENT STATUS 60-79% $ 0.01 BODY POSITION CURRENT STATUS 80-99% $ 0.01 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price BODY POSITION CURRENT STATUS 100% $ 0.01 CHNG&MNT GOAL STATUS 0% $ 0.01 CHNG&MNT GOAL STATUS 1-19% $ 0.01 CHNG&MNT GOAL STATUS 20-39% $ 0.01 CHNG&MNT GOAL STATUS 40-59% $ 0.01 CHNG&MNT GOAL STATUS 60-79% $ 0.01 CHNG&MNT GOAL STATUS 80-99% $ 0.01 CHNG&MNT GOAL STATUS 100% $ 0.01 BODY POSITION GOAL STATUS 0% $ 0.01 BODY POSITION GOAL STATUS 1-19% $ 0.01 BODY POSITION GOAL STATUS 20-39% $ 0.01 BODY POSITION GOAL STATUS 40-59% $ 0.01 BODY POSITION GOAL STATUS 60-79% $ 0.01 BODY POSITION GOAL STATUS 80-99% $ 0.01 BODY POSITION GOAL STATUS 100% $ 0.01 CHNG&MNT D/C STATUS 0% $ 0.01 CHNG&MNT D/C STATUS 1-19% $ 0.01 CHNG&MNT D/C STATUS 20-39% $ 0.01 CHNG&MNT D/C STATUS 40-59% $ 0.01 CHNG&MNT D/C STATUS 60-79% $ 0.01 CHNG&MNT D/C STATUS 80-99% $ 0.01 CHNG&MNT D/C STATUS 100% $ 0.01 BODY POSITION DISCHARGE STATUS 0% $ 0.01 BODY POSITION DISCHARGE STATUS 1-19% $ 0.01 BODY POSITION DISCHARGE STATUS 20-39% $ 0.01 BODY POSITION DISCHARGE STATUS 40-59% $ 0.01 BODY POSITION DISCHARGE STATUS 60-79% $ 0.01 BODY POSITION DISCHARGE STATUS 80-99% $ 0.01 BODY POSITION DISCHARGE STATUS 100% $ 0.01 CARRY&MOB CURRENT STATUS 0% $ 0.01 CARRY&MOB CURRENT STATUS 1-19% $ 0.01 CARRY&MOB CURRENT STATUS 20-39% $ 0.01 CARRY&MOB CURRENT STATUS 40-59% $ 0.01 CARRY&MOB CURRENT STATUS 60-79% $ 0.01 CARRY&MOB CURRENT STATUS 80-99% $ 0.01 CARRY&MOB CURRENT STATUS 100% $ 0.01 CARRY CURRENT STATUS 0% $ 0.01 CARRY CURRENT STATUS 1-19% $ 0.01 CARRY CURRENT STATUS 20-39% $ 0.01 CARRY CURRENT STATUS 40-59% $ 0.01 CARRY CURRENT STATUS 60-79% $ 0.01 CARRY CURRENT STATUS 80-99% $ 0.01 CARRY CURRENT STATUS 100% $ 0.01 CARRY&MOB GOAL STATUS 40-59% $ 0.01 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price CARRY&MOB GOAL STATUS 60-79% $ 0.01 CARRY&MOB GOAL STATUS 80-99% $ 0.01 CARRY&MOB GOAL STATUS 100% $ 0.01 CARRY&MOB GOAL STATUS 0% $ 0.01 CARRY&MOB GOAL STATUS 1-19% $ 0.01 CARRY&MOB GOAL STATUS 20-39% $ 0.01 CARRY GOAL STATUS 0% $ 0.01 CARRY GOAL STATUS 1-19% $ 0.01 CARRY GOAL STATUS 20-39% $ 0.01 CARRY GOAL STATUS 40-59% $ 0.01 CARRY GOAL STATUS 60-79% $ 0.01 CARRY GOAL STATUS 80-99% $ 0.01 CARRY GOAL STATUS 100% $ 0.01 CARRY&MOB DC STATUS 0% $ 0.01 CARRY&MOB DC STATUS 1-19% $ 0.01 CARRY&MOB DC STATUS 20-39% $ 0.01 CARRY&MOB DC STATUS 40-59% $ 0.01 CARRY&MOB DC STATUS 60-79% $ 0.01 CARRY&MOB DC STATUS 80-99% $ 0.01 CARRY&MOB DC STATUS 100% $ 0.01 CARRY DISCHARGE STATUS 0% $ 0.01 CARRY DISCHARGE STATUS 1-19% $ 0.01 CARRY DISCHARGE STATUS 20-39% $ 0.01 CARRY DISCHARGE STATUS 40-59% $ 0.01 CARRY DISCHARGE STATUS 60-79% $ 0.01 CARRY DISCHARGE STATUS 80-99% $ 0.01 CARRY DISCHARGE STATUS 100% $ 0.01 SELF CARE CURRENT STATUS 0% $ 0.01 SELF CARE CURRENT STATUS 1-19% $ 0.01 SELF CARE CURRENT STATUS 20-39% $ 0.01 SELF CARE CURRENT STATUS 40-59% $ 0.01 SELF CARE CURRENT STATUS 60-79% $ 0.01 SELF CARE CURRENT STATUS 80-99% $ 0.01 SELF CARE CURRENT STATUS 100% $ 0.01 SELF CARE CURRENT STATUS 0% $ 0.01 SELF CARE CURRENT STATUS 1-19% $ 0.01 SELF CARE CURRENT STATUS 20-39% $ 0.01 SELF CARE CURRENT STATUS 40-59% $ 0.01 SELF CARE CURRENT STATUS 60-79% $ 0.01 SELF CARE CURRENT STATUS 80-99% $ 0.01 SELF CARE CURRENT STATUS 100% $ 0.01 SELF CARE GOAL STATUS 0% $ 0.01 SELF CARE GOAL STATUS 1-19% $ 0.01 SELF CARE GOAL STATUS 20-39% $ 0.01 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price SELF CARE GOAL STATUS 40-59% $ 0.01 SELF CARE GOAL STATUS 60-79% $ 0.01 SELF CARE GOAL STATUS 80-99% $ 0.01 SELF CARE GOAL STATUS 100% $ 0.01 SELF CARE GOAL STATUS 0% $ 0.01 SELF CARE GOAL STATUS 1-19% $ 0.01 SELF CARE GOAL STATUS 20-39% $ 0.01 SELF CARE GOAL STATUS 40-59% $ 0.01 SELF CARE GOAL STATUS 60-79% $ 0.01 SELF CARE GOAL STATUS 80-99% $ 0.01 SELF CARE GOAL STATUS 100% $ 0.01 SELF CARE DC STATUS 0% $ 0.01 SELF CARE DC STATUS 1-19% $ 0.01 SELF CARE DC STATUS 20-39% $ 0.01 SELF CARE DC STATUS 40-59% $ 0.01 SELF CARE DC STATUS 60-79% $ 0.01 SELF CARE DC STATUS 80-99% $ 0.01 SELF CARE DC STATUS 100% $ 0.01 SELF CARE DISCHARGE STATUS 0% $ 0.01 SELF CARE DISCHARGE STATUS 1-19% $ 0.01 SELF CARE DISCHARGE STATUS 20-39% $ 0.01 SELF CARE DISCHARGE STATUS 40-59% $ 0.01 SELF CARE DISCHARGE STATUS 60-79% $ 0.01 SELF CARE DISCHARGE STATUS 80-99% $ 0.01 SELF CARE DISCHARGE STATUS 100% $ 0.01 OTHER PRIM CURR STATUS 0% $ 0.01 OTHER PRIM CURR STATUS 1-19% $ 0.01 OTHER PRIM CURR STATUS 20-39% $ 0.01 OTHER PRIM CURR STATUS 40-59% $ 0.01 OTHER PRIM CURR STATUS 60-79% $ 0.01 OTHER PRIM CURR STATUS 80-99% $ 0.01 OTHER PRIM CURR STATUS 100% $ 0.01 OTHER PT/OT CURRENT STATUS 0% $ 0.01 OTHER PT/OT CURRENT STATUS 1-19% $ 0.01 OTHER PT/OT CURRENT STATUS 20-39% $ 0.01 OTHER PT/OT CURRENT STATUS 40-59% $ 0.01 OTHER PT/OT CURRENT STATUS 60-79% $ 0.01 OTHER PT/OT CURRENT STATUS 80-99% $ 0.01 OTHER PT/OT CURRENT STATUS 100% $ 0.01 OTHER PRIM GOAL STATUS 0% $ 0.01 OTHER PRIM GOAL STATUS 1-19% $ 0.01 OTHER PRIM GOAL STATUS 20-39% $ 0.01 OTHER PRIM GOAL STATUS 40-59% $ 0.01 OTHER PRIM GOAL STATUS 60-79% $ 0.01 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price OTHER PRIM GOAL STATUS 80-99% $ 0.01 OTHER PRIM GOAL STATUS 100% $ 0.01 OTHER PT/OT GOAL STATUS 0% $ 0.01 OTHER PT/OT GOAL STATUS 1-19% $ 0.01 OTHER PT/OT GOAL STATUS 20-39% $ 0.01 OTHER PT/OT GOAL STATUS 40-59% $ 0.01 OTHER PT/OT GOAL STATUS 60-79% $ 0.01 OTHER PT/OT GOAL STATUS 80-99% $ 0.01 OTHER PT/OT GOAL STATUS 100% $ 0.01 OTHER PRIM DC STATUS 0% $ 0.01 OTHER PRIM DC STATUS 1-19% $ 0.01 OTHER PRIM DC STATUS 20-39% $ 0.01 OTHER PRIM DC STATUS 40-59% $ 0.01 OTHER PRIM DC STATUS 60-79% $ 0.01 OTHER PRIM DC STATUS 80-99% $ 0.01 OTHER PRIM DC STATUS 100% $ 0.01 OTHER PT/OT DISCHARGE STATUS 0% $ 0.01 OTHER PT/OT DISCHARGE STATUS 1-19% $ 0.01 OTHER PT/OT DISCHARGE STATUS 20-39% $ 0.01 OTHER PT/OT DISCHARGE STATUS 40-59% $ 0.01 OTHER PT/OT DISCHARGE STATUS 60-79% $ 0.01 OTHER PT/OT DISCHARGE STATUS 80-99% $ 0.01 OTHER PT/OT DISCHARGE STATUS 100% $ 0.01 OTHER PRIM SUBQ STATUS 0% $ 0.01 OTHER PRIM SUBQ STATUS 1-19% $ 0.01 OTHER PRIM SUBQ STATUS 20-39% $ 0.01 OTHER PRIM SUBQ STATUS 40-59% $ 0.01 OTHER PRIM SUBQ STATUS 60-79% $ 0.01 OTHER PRIM SUBQ STATUS 80-99% $ 0.01 OTHER PRIM SUBQ STATUS 100% $ 0.01 SUB PT/OT CURRENT STATUS 0% $ 0.01 SUB PT/OT CURRENT STATUS 1-19% $ 0.01 SUB PT/OT CURRENT STATUS 20-39% $ 0.01 SUB PT/OT CURRENT STATUS 40-59% $ 0.01 SUB PT/OT CURRENT STATUS 60-79% $ 0.01 SUB PT/OT CURRENT STATUS 80-99% $ 0.01 SUB PT/OT CURRENT STATUS 100% $ 0.01 OTHER SUBQ GOAL STATUS 0% $ 0.01 OTHER SUBQ GOAL STATUS 1-19% $ 0.01 OTHER SUBQ GOAL STATUS 20-39% $ 0.01 OTHER SUBQ GOAL STATUS 40-59% $ 0.01 OTHER SUBQ GOAL STATUS 60-79 $ 0.01 OTHER SUBQ GOAL STATUS 80-99% $ 0.01 OTHER SUBQ GOAL STATUS 100% $ 0.01 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price SUB PT/OT GOAL STATUS 20-39% $ 0.01 SUB PT/OT GOAL STATUS 40-59% $ 0.01 SUB PT/OT GOAL STATUS 60-79% $ 0.01 SUB PT/OT GOAL STATUS 80-99% $ 0.01 SUB PT/OT GOAL STATUS 100% $ 0.01 SUB PT/OT GOAL STATUS 0% $ 0.01 SUB PT/OT GOAL STATUS 1-19% $ 0.01 OTHER SUBQ DC STATUS 0% $ 0.01 OTHER SUBQ DC STATUS 1-19% $ 0.01 OTHER SUBQ DC STATUS 20-39% $ 0.01 OTHER SUBQ DC STATUS 40-59% $ 0.01 OTHER SUBQ DC STATUS 60-79% $ 0.01 OTHER SUBQ DC STATUS 80-99% $ 0.01 OTHER SUBQ DC STATUS 100% $ 0.01 SUB PT/OT DISCHARGE STATUS 0% $ 0.01 SUB PT/OT DISCHARGE STATUS 1-19% $ 0.01 SUB PT/OT DISCHARGE STATUS 20-39% $ 0.01 SUB PT/OT DISCHARGE STATUS 40-59% $ 0.01 SUB PT/OT DISCHARGE STATUS 60-79% $ 0.01 SUB PT/OT DISCHARGE STATUS $ 0.01 SUB PT/OT DISCHARGE STATUS $ 0.01 SWALLOW FUNC LIMIT, CURR STATUS, 0% $ 0.01 SWALLOW FUNC LIMIT, CURR STATUS, 1-20% $ 0.01 SWALLOW FUNC LIMIT, CURR STATUS, 21-40% $ 0.01 SWALLOW FUNC LIMIT, CURR STATUS, 41-60% $ 0.01 SWALLOW FUNC LIMIT, CURR STATUS, 61-80% $ 0.01 SWALLOW FUNC LIMIT, CURR STATUS, 81-100% $ 0.01 SWALLOW FUNC LIMIT, CURR STATUS, 100% $ 0.01 SWALLOW FUNC LIMIT, PROJ STATUS, 100% $ 0.01 SWALLOW FUNC LIMIT, PROJ STATUS, 0% $ 0.01 SWALLOW FUNC LIMIT, PROJ STATUS, 1-20% $ 0.01 SWALLOW FUNC LIMIT, PROJ STATUS, 21-40% $ 0.01 SWALLOW FUNC LIMIT, PROJ STATUS, 41-60% $ 0.01 SWALLOW FUNC LIMIT, PROJ STATUS, 61-80% $ 0.01 SWALLOW FUNC LIMIT, PROJ STATUS, 81-100% $ 0.01 SWALLOW FUNC LIMIT, D/C STATUS, 0% $ 0.01 SWALLOW FUNC LIMIT, D/C STATUS, 1-20% $ 0.01 SWALLOW FUNC LIMIT, D/C STATUS, 21-40% $ 0.01 SWALLOW FUNC LIMIT, D/C STATUS, 41-60% $ 0.01 SWALLOW FUNC LIMIT, D/C STATUS, 61-80% $ 0.01 SWALLOW FUNC LIMIT, D/C STATUS, 81-100% $ 0.01 SWALLOW FUNC LIMIT, D/C STATUS, 100% $ 0.01 MOTOR SPEECH FUNC, CURR STATUS, 0% $ 0.01 MOTOR SPEECH FUNC, CURR STATUS, 1-20% $ 0.01 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price MOTOR SPEECH FUNC, CURR STATUS, 21-40% $ 0.01 MOTOR SPEECH FUNC, CURR STATUS, 41-60% $ 0.01 MOTOR SPEECH FUNC, CURR STATUS, 61-80% $ 0.01 MOTOR SPEECH FUNC, CURR STATUS, 81-100% $ 0.01 MOTOR SPEECH FUNC, CURR STATUS, 100% $ 0.01 MOTOR SPEECH FUNC, D/C STATUS, 0% $ 0.01 MOTOR SPEECH FUNC, D/C STATUS, 1-20% $ 0.01 MOTOR SPEECH FUNC, D/C STATUS, 21-40% $ 0.01 MOTOR SPEECH FUNC, D/C STATUS, 41-60% $ 0.01 MOTOR SPEECH FUNC, D/C STATUS, 61-80% $ 0.01 MOTOR SPEECH FUNC, D/C STATUS, 81-100% $ 0.01 MOTOR SPEECH FUNC, D/C STATUS, 100% $ 0.01 SPOKEN LNGUGE COMP, CURR STATUS, 0% $ 0.01 SPOKEN LNGUGE COMP, CURR STATUS, 1-20% $ 0.01 SPOKEN LNGUGE COMP, CURR STATUS, 21-40% $ 0.01 SPOKEN LNGUGE COMP, CURR STATUS, 41-60% $ 0.01 SPOKEN LNGUGE COMP, CURR STATUS, 61-80% $ 0.01 SPOKEN LNGUGE COMP, CURR STATUS, 81-100% $ 0.01 SPOKEN LNGUGE COMP, CURR STATUS, 100% $ 0.01 SPOKEN LNGUGE COMP, PROJ STATUS, 0% $ 0.01 SPOKEN LNGUGE COMP, PROJ STATUS, 1-20% $ 0.01 SPOKEN LNGUGE COMP, PROJ STATUS, 21-40% $ 0.01 SPOKEN LNGUGE COMP, PROJ STATUS, 41-60% $ 0.01 SPOKEN LNGUGE COMP, PROJ STATUS, 61-80% $ 0.01 SPOKEN LNGUGE COMP, PROJ STATUS, 81-100% $ 0.01 SPOKEN LNGUGE COMP, PROJ STATUS, 100% $ 0.01 SPOKEN LNGUGE COMP, D/C STATUS, 0% $ 0.01 SPOKEN LNGUGE COMP, D/C STATUS, 1-20% $ 0.01 SPOKEN LNGUGE COMP, D/C STATUS, 21-40% $ 0.01 SPOKEN LNGUGE COMP, D/C STATUS, 41-60% $ 0.01 SPOKEN LNGUGE COMP, D/C STATUS, 61-80% $ 0.01 SPOKEN LNGUGE COMP, D/C STATUS, 81-100% $ 0.01 SPOKEN LNGUGE COMP, D/C STATUS, 100% $ 0.01 SPOKEN LNGUGE EXPR, CURR STATUS, 0% $ 0.01 SPOKEN LNGUGE EXPR, CURR STATUS, 1-20% $ 0.01 SPOKEN LNGUGE EXPR, CURR STATUS, 21-40% $ 0.01 SPOKEN LNGUGE EXPR, CURR STATUS, 41-60% $ 0.01 SPOKEN LNGUGE EXPR, CURR STATUS, 61-80% $ 0.01 SPOKEN LNGUGE EXPR, CURR STATUS, 81-100% $ 0.01 SPOKEN LNGUGE EXPR, CURR STATUS, 100% $ 0.01 SPOKEN LNGUGE EXPR, PROJ STATUS, 0% $ 0.01 SPOKEN LNGUGE EXPR, PROJ STATUS, 1-20% $ 0.01 SPOKEN LNGUGE EXPR, PROJ STATUS, 21-40% $ 0.01 SPOKEN LNGUGE EXPR, PROJ STATUS, 41-60% $ 0.01 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price SPOKEN LNGUGE EXPR, PROJ STATUS, 61-80% $ 0.01 SPOKEN LNGUGE EXPR, PROJ STATUS, 81-100% $ 0.01 SPOKEN LNGUGE EXPR, PROJ STATUS, 100% $ 0.01 SPOKEN LNGUGE EXPR, D/C STATUS, 0% $ 0.01 SPOKEN LNGUGE EXPR, D/C STATUS, 1-20% $ 0.01 SPOKEN LNGUGE EXPR, D/C STATUS, 21-40% $ 0.01 SPOKEN LNGUGE EXPR, D/C STATUS, 41-60% $ 0.01 SPOKEN LNGUGE EXPR, D/C STATUS, 61-80% $ 0.01 SPOKEN LNGUGE EXPR, D/C STATUS, 81-100% $ 0.01 SPOKEN LNGUGE EXPR, D/C STATUS, 100% $ 0.01 ATTENTION FUNC, CURR STATUS, 0% $ 0.01 ATTENTION FUNC, CURR STATUS, 1-20% $ 0.01 ATTENTION FUNC, CURR STATUS, 21-40% $ 0.01 ATTENTION FUNC, CURR STATUS, 41-60% $ 0.01 ATTENTION FUNC, CURR STATUS, 61-80% $ 0.01 ATTENTION FUNC, CURR STATUS, 81-100% $ 0.01 ATTENTION FUNC, CURR STATUS, 100% $ 0.01 ATTENTION FUNC, PROJ STATUS, 0% $ 0.01 ATTENTION FUNC, PROJ STATUS, 1-20% $ 0.01 ATTENTION FUNC, PROJ STATUS, 21-40% $ 0.01 ATTENTION FUNC, PROJ STATUS, 41-60% $ 0.01 ATTENTION FUNC, PROJ STATUS, 61-80% $ 0.01 ATTENTION FUNC, PROJ STATUS, 81-100% $ 0.01 ATTENTION FUNC, PROJ STATUS, 100% $ 0.01 ATTENTION FUNC, D/C STATUS, 0% $ 0.01 ATTENTION FUNC, D/C STATUS, 1-20% $ 0.01 ATTENTION FUNC, D/C STATUS, 21-40% $ 0.01 ATTENTION FUNC, D/C STATUS, 41-60% $ 0.01 ATTENTION FUNC, D/C STATUS, 61-80% $ 0.01 ATTENTION FUNC, D/C STATUS, 81-100% $ 0.01 ATTENTION FUNC, D/C STATUS, 100% $ 0.01 MEMORY FUNC LIMIT, CURR STATUS, 0% $ 0.01 MEMORY FUNC LIMIT, CURR STATUS, 1-20% $ 0.01 MEMORY FUNC LIMIT, CURR STATUS, 21-40% $ 0.01 MEMORY FUNC LIMIT, CURR STATUS, 41-60% $ 0.01 MEMORY FUNC LIMIT, CURR STATUS, 61-80% $ 0.01 MEMORY FUNC LIMIT, CURR STATUS, 81-100% $ 0.01 MEMORY FUNC LIMIT, CURR STATUS, 100% $ 0.01 MEMORY FUNC LIMIT, PROJ STATUS, 1-20% $ 0.01 MEMORY FUNC LIMIT, PROJ STATUS, 21-40% $ 0.01 MEMORY FUNC LIMIT, PROJ STATUS, 41-60% $ 0.01 MEMORY FUNC LIMIT, PROJ STATUS, 61-80% $ 0.01 MEMORY FUNC LIMIT, PROJ STATUS, 81-100% $ 0.01 MEMORY FUNC LIMIT, PROJ STATUS, 100% $ 0.01 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price MEMORY FUNC LIMIT, PROJ STATUS, 0% $ 0.01 MEMORY FUNC LIMIT, D/C STATUS, 0% $ 0.01 MEMORY FUNC LIMIT, D/C STATUS, 1-20% $ 0.01 MEMORY FUNC LIMIT, D/C STATUS, 21-40% $ 0.01 MEMORY FUNC LIMIT, D/C STATUS, 41-60% $ 0.01 MEMORY FUNC LIMIT, D/C STATUS, 61-80% $ 0.01 MEMORY FUNC LIMIT, D/C STATUS, 81-100% $ 0.01 MEMORY FUNC LIMIT, D/C STATUS, 100% $ 0.01 VOICE FUNC LIMIT, CURR STATUS, 0% $ 0.01 VOICE FUNC LIMIT, CURR STATUS, 1-20% $ 0.01 VOICE FUNC LIMIT, CURR STATUS, 21-40% $ 0.01 VOICE FUNC LIMIT, CURR STATUS, 41-60% $ 0.01 VOICE FUNC LIMIT, CURR STATUS, 61-80% $ 0.01 VOICE FUNC LIMIT, CURR STATUS, 81-100% $ 0.01 VOICE FUNC LIMIT, CURR STATUS, 100% $ 0.01 VOICE FUNC LIMIT, PROJ STATUS, 0% $ 0.01 VOICE FUNC LIMIT, PROJ STATUS, 1-20% $ 0.01 VOICE FUNC LIMIT, PROJ STATUS, 21-40% $ 0.01 VOICE FUNC LIMIT, PROJ STATUS, 41-60% $ 0.01 VOICE FUNC LIMIT, PROJ STATUS, 61-80% $ 0.01 VOICE FUNC LIMIT, PROJ STATUS, 81-100% $ 0.01 VOICE FUNC LIMIT, PROJ STATUS, 100% $ 0.01 VOICE FUNC LIMIT, D/C STATUS, 0% $ 0.01 VOICE FUNC LIMIT, D/C STATUS, 1-20% $ 0.01 VOICE FUNC LIMIT, D/C STATUS, 21-40% $ 0.01 VOICE FUNC LIMIT, D/C STATUS, 41-60% $ 0.01 VOICE FUNC LIMIT, D/C STATUS, 61-80% $ 0.01 VOICE FUNC LIMIT, D/C STATUS, 81-100% $ 0.01 VOICE FUNC LIMIT, D/C STATUS, 100% $ 0.01 OTH SLP FUNC LIMIT, CURR STATUS, 0% $ 0.01 OTH SLP FUNC LIMIT, CURR STATUS, 1-20% $ 0.01 OTH SLP FUNC LIMIT, CURR STATUS, 21-40% $ 0.01 OTH SLP FUNC LIMIT, CURR STATUS, 41-60% $ 0.01 OTH SLP FUNC LIMIT, CURR STATUS, 61-80% $ 0.01 OTH SLP FUNC LIMIT, CURR STATUS, 81-100% $ 0.01 OTH SLP FUNC LIMIT, CURR STATUS, 100% $ 0.01 OTH SLP FUNC LIMIT, PROJ STATUS, 0% $ 0.01 OTH SLP FUNC LIMIT, PROJ STATUS, 1-20% $ 0.01 OTH SLP FUNC LIMIT, PROJ STATUS, 21-40% $ 0.01 OTH SLP FUNC LIMIT, PROJ STATUS, 41-60% $ 0.01 OTH SLP FUNC LIMIT, PROJ STATUS, 61-80% $ 0.01 OTH SLP FUNC LIMIT, PROJ STATUS, 81-100% $ 0.01 OTH SLP FUNC LIMIT, PROJ STATUS, 100% $ 0.01 OTH SLP FUNC LIMIT, D/C STATUS, 0% $ 0.01 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price OTH SLP FUNC LIMIT, D/C STATUS, 1-20% $ 0.01 OTH SLP FUNC LIMIT, D/C STATUS, 21-40% $ 0.01 OTH SLP FUNC LIMIT, D/C STATUS, 41-60% $ 0.01 OTH SLP FUNC LIMIT, D/C STATUS, 61-80% $ 0.01 OTH SLP FUNC LIMIT, D/C STATUS, 81-100% $ 0.01 OTH SLP FUNC LIMIT, D/C STATUS, 100% $ 0.01 MOTOR SPEECH FUNC, PROJ STATUS, 0% $ 0.01 MOTOR SPEECH FUNC, PROJ STATUS, 1-20% $ 0.01 MOTOR SPEECH FUNC, PROJ STATUS, 21-40% $ 0.01 MOTOR SPEECH FUNC, PROJ STATUS, 41-60% $ 0.01 MOTOR SPEECH FUNC, PROJ STATUS, 61-80% $ 0.01 MOTOR SPEECH FUNC, PROJ STATUS, 81-100% $ 0.01 MOTOR SPEECH FUNC, PROJ STATUS, 100% $ 0.01 ACETAMINOPHEN INJECTION 10 MG $ 1.61 ACETYLCYSTEINE INJECTION 100 MG $ 697.05 ACYCLOVIR INJECTION 5 MG $ 69.78 ADENOSINE INJ 1MG $ 40.69 AMINOPHYLLINE 250MG INJ $ 38.63 SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG $ 0.98 HYDRALAZINE HCL TO 20 MG $ 164.03 AZITHROMYCIN 500 MG INJ $ 22.15 ATROPINE SULFATE INJECTION 0.01 MG $ 6.44 DICYCLOMINE INJ TO 20 MG $ 124.37 BUPRENORPHN-NALOXN 2-0.5 MG SL 1 ea, 50 eaches $ 15.00 SUBOXONE 4 MG-1 MG SL FILM 1 ea, 30 eaches $ 30.00 SUBOXONE 12 MG-3 MG SL FILM 1 ea, 30 eaches $ 60.00 CALCIUM GLUCONATE, PER 10 ML $ 20.09 CEFOXITIN SODIUM INJECTION 1 GM $ 22.15 STERILE CEFUROXIME SODIUM INJ, PER 750 MG $ 20.73 BETAMETHASONE ACET&SOD PHOSP 3MG $ 130.81 CEFTAROLINE FOSAMIL INJ 10 MG $ 549.25 INJECTION CEFTAZIDIME PER 500 MG $ 19.31 INJ CLONIDINE HCL 1 MG $ 162.23 PROCHLORPERAZINE INJ, UP TO 10 MG $ 68.50 DAPTOMYCIN INJ 1 MG $ 3.21 ARANESP 200 MG $ 8.00 INJECTION, DEFEROXAMINE MESYLATE, 500 MG $ 29.10 METHYLPREDNISOLONE ACETATE INJ, 40 MG $ 30.64 METHYLPREDNISOLONE ACETATE INJ, 80 MG $ 53.30 DEXAMETHASONE SODIUM PHOSPHATE, 1 MG $ 0.36 DEXAMETHASONE SODIUM PHOSPHATE, 1 MG $ 0.36 DEXAMETHASONE SODIUM PHOSPHATE, 1 MG $ 0.36 ACETAZOLAMIDE SODIUM, UP TO 500 MG $ 153.99 DIGOXIN INJ, UP TO 0.5 MG $ 20.34 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price DIGOXIN IMMUNE FAB (OVINE) PER VIAL $ 10,849.51 PHENYTOIN SODIUM, PER 50 MG $ 6.18 HYDROMORPHONE INJ, UP TO 4 MG $ 6.18 INJECTION, HYDROMORPHONE, UP TO 4 MG $ 6.18 DIPHENHYDRAMINE HCL, UP TO 50 MG $ 6.18 DOPAMINE INJECTION 40 MG $ 33.22 ERTAPENEM SODIUM 500 MG INJ $ 186.43 ERYTHROMYCIN LACTOBIONATE, PER 500 MG $ 225.00 INJECTAFER 750 MG/15 ML VIAL 1 mg, 15 mL $ 5.00 INJECTAFER 750 MG/15 ML VIAL 1 MG, 15 ML $ 5.00 FOMEPIZOLE INJ, 15 MG $ 4,094.50 GARAMYCIN GENTAMICIN INJ, UP TO 80 MG $ 11.85 GLUCAGON HCL INJ, PER 1 MG $ 852.50 HALOPERIDOL INJ, UP TO 5 MG $ 110.98 HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 UNITS $ 9.01 HUMAN TETANUS IG INJ TO 250 UNITS $ 866.12 INFLIXIMAB, EXCLUDES BIOSIMILAR, 10 MG $ 385.73 PROPRANOLOL HCL INJ TO 1 MG $ 30.90 FUROSEMIDE INJ, UP TO 20 MG $ 18.80 LEVETIRACETAM INJECTION 10 MG $ 0.48 LINEZOLID INJ 200 MG $ 296.64 LORAZEPAM INJ 2 MG $ 6.18 MANNITOL INJ 25% IN 50 ML $ 6.70 MEPERIDINE HYDROCHLORIDE INJ, PER 100 MG $ 6.18 MEROPENEM 100 MG INJ $ 217.33 MIDAZOLAM HYDROCHLORIDE INJ, PER 1 MG $ 6.18 MIDAZOLAM HYDROCHLORIDE INJ, PER 1 MG $ 6.18 MOXIFLOXACIN 100 MG INJ $ 6.18 NALBUPHINE HYDROCHLORIDE INJ, PER 10 MG $ 10.82 OCTREOTIDE NOT DEPOT 25 MCG INJ $ 36.82 PHENYLEPHRINE HCL, UP TO 1 ML $ 44.55 PROMETHAZINE HCL, UP TO 50 MG $ 6.18 OXYTOCIN INJECTION TO 10 UNITS $ 6.18 INJ DESMOPRESSIN ACETATE PER 1 MCG $ 211.75 NEOSTIGMINE METHYLSULFATE 0.736111111111 $ 52.79 PROTAMINE SULFATE INJ PER 10 MG $ 43.26 METOCLOPRAMIDE HCL TO 10 MG $ 19.10 KINEVAC (CCK) $ 194.00 FERRLECIT INJ 12.5 MG $ 23.59 METHYLPREDNISOLONE INJ TO 40 MG $ 18.28 ALTEPLASE RECOMBINANT, 1 MG $ 235.50 FENTANYL CITRATE INJ 0.1 MG $ 6.18 SUMATRIPTAN SUCCINATE INJ, 6 MG $ 96.31 TENECTEPLASE INJECTION 1 MG $ 355.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price TERBUTALINE SULFATE INJ TO 1 MG $ 66.69 INJECTION, TRIAMCINOLONE ACETONIDE, PRESERVATIVE FREE, 1 MG $ 452.00 HYDROXYZINE HCL INJ TO 25 MG $ 16.48 THIAMINE HCL 100 MG INJ $ 38.37 PYRIDOXINE HCL 100 MG INJ $ 56.39 PHYTONADIONE (VITAMIN K) INJ, PER 1 MG $ 140.08 MAGNESIUM SULFATE INJ, 500 MG $ 6.18 INJ MAGNESIUM SULFATE/500 MG $ 6.18 ZOLEDRONIC ACID INJ, 1MG $ 3,071.72 METERED DOSE INHALER DRUG $ 196.47 NORMAL SALINE INFUSION 1000 CC $ 19.57 NORMAL SALINE INFUSION 1000 CC $ 19.57 NORMAL SALINE INFUSION 1000 CC $ 19.57 5% DEXTROSE/NORMAL SALINE 500 ML=1 UNIT $ 19.57 LACTATED RINGER'S 1000 ML $ 19.57 LACTATED RINGER'S + 5 % DEXTROSE 1000 ML $ 19.57 HYALGAN/SUPARTZ INJ PER DOSE $ 829.00 HYALURONAN,SYNVISC 1MG $ 186.59 PREDNISOLONE ORAL PER 5 MG $ 7.47 PREDNISONE IR OR DR ORAL 1MG $ 0.03 PREDNISONE IR OR DR ORAL 1MG $ 0.03 PREDNISONE IR OR DR ORAL 1MG $ 0.03 PREDNISONE IR OR DR ORAL 1MG $ 0.03 IPRATROPIUM BROMIDE 0.2MG/ML AMIH 60X2.5 $ 6.18 METHOTREXATE ORAL 2.5 MG $ 19.31 VINCRISTINE SULFATE 1MG/ML SDPF 1 ML $ 18.00 ELBOW ORTHOTIC (EO), WITHOUT JOINTS, CUSTOM FABRICATED $ 765.00 WRIST-HAND-FINGER ORTHOTIC (WHFO), RIGID WITHOUT JOINTS $ 1,087.00 WRIST-HAND ORTHOTIC (WHO), WITHOUT JOINTS $ 1,112.00 FINGER ORTHOTIC, WITHOUT JOINTS, CUSTOM FABRICATED $ 566.00 LEUKOREDUCED RBC $ 554.00 PLATELET RICH PLASMA - ONE UNIT $ 376.00 LEUKO REDUCED PLATELETS EA UNIT $ 410.00 PLATELET PHERESIS LEUKOREDUCED $ 1,552.00 PLATE, PHERESIS, PATHOGEN-REDUCED, EA $ 1,921.00 THERASKIN PER 1 SQ CM $ 419.00 INJ SULF HEXA LIPID MICROSPH, PER ML (LUMASON) $ 88.00 ORAL MR CONTRAST, 100 ML $ 1,600.00 LOCM 300-399MG/ML IODINE,1ML $ 1.00 METRONIDAZOLE 500 MG INJ $ 8.00 REM SUTURES BY MD, DIFF THAN ORIG MD $ 52.00 LOW-LEVEL LASER TRMT 15 MIN $ 69.00 POSITION SEAT SPEC ORTH NEED $ 32.00 ACETAMINOPHEN 325MG SUPP 12 EA $ 6.18 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price ACETAMIN/BUTALB/CAFF 325-50-40MG TABS 10 $ 6.18 ACETAMINOPHEN 120MG SUPP 12 EA $ 6.18 CODEINE/ACETAMIN 12-120MG/5ML ELIX 100X5 $ 6.18 CODEINE/ACETAMIN 30-300MG TABS 100 EA $ 6.18 ACETAZOLAMIDE 250MG TABS 100 EA $ 9.01 CHARCOAL/SORBITOL SOLUTION 50GM LIQD 240 $ 73.13 ACTIVATED CHARCOAL 50GM LIQD 240 ML $ 73.13 ACYCLOVIR 400MG TABS 100 EA $ 11.59 FLUTICASONE PROP/SALMETEROL 100-50MCG AR $ 477.92 FLUTICASONE PROP/SALMETEROL 250-50MCG AR $ 477.92 FLUTICASONE PROP/SALMETEROL 500-50MCG AR $ 778.94 OXYMETAZOLINE HCL 0.0005 SPIN 15 ML $ 16.00 DIPYRIDAMOLE/ASPIRIN 200-25MG CAPS 60 EA $ 28.58 BACITRACIN/POLYMYXIN B 500-10000U/GM OIN $ 79.31 ALBUTEROL SULFATE 0.83MG/ML AMIH 60X3ML $ 6.18 ALBUTEROL/IPRATROPIUM 2.5-0.5MG/3ML AMIH $ 6.70 ALLOPURINOL 100MG TABS 100 EA $ 6.18 ALPRAZOLAM 0.25MG TABS 10X10EA $ 6.18 ETOMIDATE 2MG/ML SDV 10X10ML $ 36.31 AMITRIPTYLINE HCL 10MG TABS 100 EA $ 6.18 AMITRIPTYLINE HCL 25MG TABS 100 EA $ 6.18 AMLODIPINE BESYLATE 10MG TABS 10X10EA $ 7.21 AMLODIPINE BESYLATE 2.5MG TABS 10X10EA $ 6.18 AMLODIPINE BESYLATE 5MG TABS 10X10EA $ 6.18 AMMONIUM LACTATE 0.12 CRM 140 GM $ 43.00 AMMONIUM LACTATE 0.12 LOTN 225 GM $ 56.39 AMOXICILLIN TRIHYDRATE 250MG/5ML POSR 80 $ 6.18 AMOXICILLIN TRIHYDRATE 400MG/5ML POSR 50 $ 6.18 AMOXICILLIN TRIHYDRATE 500MG CAPS 100 EA $ 6.18 AMOXICILLIN TRIHYDRATE 875MG TABS 100 EA $ 6.18 AMOXICILLIN/POT CLAVULANATE 500-125MG TA $ 11.33 AMOXICILLIN/POT CLAVULANATE 875-125MG TA $ 15.19 ANASTROZOLE 1MG TABS 3X10EA $ 6.44 HYDROCORTISONE ACETATE 25MG SUPP 12 EA $ 70.04 TUBERCULIN PURIF PROT DERIV 5TU/0.1ML MD $ 22.92 DONEPEZIL HCL 5MG TABS 10X10EA $ 6.18 ARTIFICIAL TEARS 0.014 DROP 15 ML $ 6.18 ASPIRIN 325MG TABS 100 EA $ 6.18 ASPIRIN 81MG CHEW 25X30EA $ 6.18 ASPIRIN 81MG TABS 10X10EA $ 6.18 ATROPINE SULFATE 0.1MG/ML ANSY 10X10ML $ 6.18 IPRATROPIUM BROMIDE 17MCG ARIN 12.9 GM $ 1,059.10 DUTASTERIDE 0.5MG GCAP 30 EA $ 20.86 AZITHROMYCIN 100MG/5ML POSR 15 ML $ 35.79 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price BRINZOLAMIDE 0.01 DROP 10 ML $ 927.00 BACLOFEN 20MG TABS 10X10EA $ 6.18 BENZONATATE 100MG CAPS 10X10EA $ 6.18 BISACODYL 10MG SUPP 12 EA $ 6.18 BISACODYL 5MG TABS 100 EA $ 6.18 ESMOLOL HCL 10MG/ML SDV 25X10ML $ 27.04 BUMETANIDE 1MG TABS 10X10EA $ 6.18 BUPROPION HCL 75MG TABS 10X10EA $ 6.18 BUPROPION HCL 150MG TABS 30 EA $ 14.42 CALAMINE LOTN 120 ML $ 6.18 CALCIUM CARBONATE 500MG CHEW 150 EA $ 6.18 CALCIUM CHLORIDE 100MG/ML ANSY 10X10ML $ 33.48 CALAMINE/ZINC OXIDE OINT 113 GM $ 13.65 CAPTOPRIL 12.5MG TABS 10X10EA $ 6.18 CARBAMAZEPINE 200MG TABS 10X10EA $ 6.18 CARBIDOPA/LEVODOPA 25-100MG TABS 10X10EA $ 6.18 CARISOPRODOL 350MG TABS 10X10EA $ 6.18 CARVEDILOL 12.5MG TABS 10X10EA $ 6.70 CARVEDILOL 25MG TABS 10X10EA $ 6.18 CARVEDILOL 3.125MG TABS 10X10EA $ 6.18 CARVEDILOL 6.25MG TABS 10X10EA $ 6.44 CEFACLOR 250MG CAPS 30 EA $ 6.18 CEFPROZIL 125MG/5ML POSR 50 ML $ 6.44 CEFUROXIME AXETIL 500MG TABS 60 EA $ 24.72 CELECOXIB 100MG CAPS 100 EA $ 22.66 BENZOCAINE/MENTHOL 15-3.6MG LOZG 16 EA $ 6.18 CEPHALEXIN MONOHYDRATE 250MG CAPS 100 EA $ 6.18 CEPHALEXIN MONOHYDRATE 250MG/5ML POSR 10 $ 6.18 CEPHALEXIN MONOHYDRATE 500MG CAPS 100 EA $ 6.18 CHLORDIAZEPOXIDE HCL 25MG CAPS 100 EA $ 6.18 CHLORDIAZEPOXIDE HCL 5MG CAPS 100 EA $ 6.18 CHOLESTYRAMINE/SUCROSE 4GM PCKT 60 EA $ 10.30 CIPROFLOXACIN HCL 500MG TABS 10X10EA $ 15.71 CIPROFLOXACIN HCL 250MG TABS 10X10EA $ 16.74 CITALOPRAM HYDROBROMIDE 10MG TABS 10X10E $ 7.47 MAGNESIUM CITRATE SOLN 10 OZ $ 6.18 CLINDAMYCIN HCL 150MG CAPS 10X10EA $ 6.18 CLONAZEPAM 0.5MG TABS 10X10EA $ 6.18 CLONIDINE HCL 0.1MG TABS 10X10EA $ 6.18 CLOTRIMAZOLE 0.01 CRM 15 GM $ 17.25 CLOTRIMAZOLE 10MG LOZG 70 EA $ 6.18 CLOTRIMAZOLE/BETAMETH DIP 1-0.05% CRM 15 $ 105.58 COLCHICINE 0.6MG TABS 30 EA $ 24.46 CORTISONE ACETATE 25MG TABS 100 EA $ 9.53 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price WARFARIN SODIUM 1MG TABS 100 EA $ 6.95 WARFARIN SODIUM 2.5MG TABS 100 EA $ 7.47 WARFARIN SODIUM 2MG TABS 100 EA $ 7.21 WARFARIN SODIUM 3MG TABS 100 EA $ 7.47 WARFARIN SODIUM 4MG TABS 100 EA $ 7.47 WARFARIN SODIUM 5MG TABS 100 EA $ 7.73 WARFARIN SODIUM 6MG TABS 100 EA $ 10.04 WARFARIN SODIUM 7.5MG TABS 100 EA $ 10.30 ROSUVASTATIN CALCIUM 10MG TABS 100 EA $ 30.64 CYCLOBENZAPRINE HCL 10MG TABS 10X10EA $ 6.18 DULOXETINE HCL 30MG CAPS 100 EA $ 27.04 MICONAZOLE NITRATE 0.02 POWD 85 GM $ 17.25 DICLOXACILLIN SODIUM 500MG CAPS 100 EA $ 6.95 DICYCLOMINE HCL 10MG CAPS 100 EA $ 6.18 PHENYTOIN SOD EXTENDED 100MG CAPS 10X10E $ 6.18 DILTIAZEM HCL 30MG TABS 100 EA $ 6.18 DILTIAZEM HCL 5MG/ML SDV 10X5ML $ 6.70 DILTIAZEM HCL 5MG/ML SDV 10X25ML $ 6.18 DILTIAZEM HCL 120MG CAPS 100 EA $ 6.18 DILTIAZEM HCL 180MG CAPS 100 EA $ 6.18 DIPHENOXYLATE/ATROPINE 2.5-0.025MG TABS $ 6.18 DIVALPROEX SODIUM 250MG TABS 10X10EA $ 7.47 DIVALPROEX SODIUM 500MG TABS 10X10EA $ 10.30 BELLADONNA ALK/PB 16.2MG/5ML ELIX 120 ML $ 33.22 DORZOLAMIDE/TIMOLOL 2-0.5% DROP 10 ML $ 208.58 DOXAZOSIN MESYLATE 2MG TABS 100 EA $ 11.59 DOXYCYCLINE HYCLATE 100MG PWVL 10X1EA $ 56.14 CARBAMIDE PEROXIDE 0.065 DROP 15 ML $ 7.73 DARIFENACIN 7.5MG TABS 30 EA $ 41.72 ENALAPRIL MALEATE 10MG TABS 10X10EA $ 6.18 ENALAPRIL MALEATE 5MG TABS 10X10EA $ 6.18 ENALAPRILAT DIHYDRATE 1.25MG/ML SDV 10X1 $ 11.07 ERYTHROMYCIN BASE 250MG TABS 100 EA $ 22.66 ERYTHROMYCIN BASE 5MG/GM OINT 3.5 GM $ 58.71 ETHYL CHLORIDE AREX 103.5 ML $ 10.56 RALOXIFENE HCL 60MG TABS 30 EA $ 24.46 FAMOTIDINE 20MG TABS 100 EA $ 6.18 FENTANYL 100MCG/HR PTCH 5 EA $ 190.55 FENTANYL 25MCG/HR PTCH 5 EA $ 51.50 FENTANYL 50MCG/HR PTCH 5 EA $ 81.37 FERROUS SULFATE 325MG TABS 100 EA $ 6.18 FINASTERIDE 5MG TABS 10X10EA $ 10.30 DICLOFENAC EPOLAMINE 0.013 PTCH 6X5EA $ 38.37 SODIUM PHOS MB/SODIUM PHOS DB ENMA 133 $ 6.18 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price FLUTICASONE PROPIONATE 110MCG ARIN 12 GM $ 787.95 FLUCONAZOLE 150MG TABS 12X1EA $ 43.26 FLUDROCORTISONE ACETATE 0.1MG TABS 100 E $ 6.18 FLURBIPROFEN SODIUM 0.0003 DROP 2.5 ML $ 27.04 FLUTICASONE PROPIONATE 50MCG SPIN 16 GM $ 232.52 FOLIC ACID 1MG TABS 10X10EA $ 6.18 FOLIC ACID 5MG/ML MDV 10 ML $ 6.18 FUROSEMIDE 20MG TABS 10X10EA $ 6.18 FUROSEMIDE 40MG TABS 100 EA $ 6.18 GABAPENTIN 400MG CAPS 10X10EA $ 6.18 GABAPENTIN 300MG CAPS 10X10EA $ 6.18 GEMFIBROZIL 600MG TABS 25 EA $ 13.65 GENTAMICIN SULFATE 0.003 OINT 3.5 GM $ 60.77 GENTAMICIN SULFATE 0.001 OINT 15 GM $ 152.70 GENTAMICIN SULFATE 0.003 DROP 5 ML $ 132.36 GLIPIZIDE 5MG TABS 10X10EA $ 6.18 GLIPIZIDE 2.5MG TABS 30 EA $ 6.18 DEXTROSE 0.4 GEL 3X37.5GM $ 12.10 GLYBURIDE 5MG TABS 100 EA $ 6.18 GUAIFENESIN 100MG/5ML SYRP 100X10ML $ 6.18 GUAIFEN/DM 100-10MG/5ML SYRP 100X10ML $ 6.18 GUAIFEN/COD 100-10MG/5ML SYRP 100X5ML $ 6.18 HALOPERIDOL 1MG TABS 100 EA $ 6.18 HYDRALAZINE HCL 25MG TABS 10X10EA $ 6.18 EMOLLIENT/SKIN CLEANSER CRM 4 OZ $ 14.94 HYDROCHLOROTHIAZIDE 12.5MG CAPS 10X10EA $ 6.18 HYDROCHLOROTHIAZIDE 25MG TABS 100 EA $ 6.18 HYDROCORTISONE 0.025 CRM 30 GM $ 31.67 HYDROCORTISONE 10MG TABS 100 EA $ 6.18 HYDROCORTISONE ACETATE 0.01 PCKT 144X.9G $ 6.18 HYDROMORPHONE HCL 2MG TABS 4X25EA $ 6.18 HYOSCYAMINE SULFATE 0.125MG TABS 100 EA $ 6.18 IBUPROFEN 200MG TABS 10X10EA $ 6.18 IBUPROFEN 400MG TABS 100 EA $ 6.18 IBUPROFEN 600MG TABS 10X10EA $ 6.18 IBUPROFEN 800MG TABS 10X10EA $ 6.18 INDOMETHACIN 25MG CAPS 100 EA $ 6.18 MULTIVITAMIN SDV 5X10ML $ 32.70 ISOSORBIDE MONONITRATE 30MG TABS 10X10EA $ 6.18 KETOCONAZOLE 0.02 CRM 15 GM $ 405.82 POTASSIUM CHLORIDE 20MEQ TABS 100 EA $ 6.18 POTASSIUM CHLORIDE 20MEQ/15ML LIQD 100X1 $ 16.74 TAMSULOSIN HCL 0.4MG CAPS 10X10EA $ 6.18 TEMAZEPAM 15MG CAPS 100 EA $ 6.18 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price POTASSIUM PHOS MONO-DIBASIC 3MMOL/ML SDV $ 10.56 TETRACAINE HCL 0.005 DROP 15 ML $ 33.99 DABIGATRAN ETEXILATE 75MG CAPS 10X6EA $ 21.63 REPAGLINIDE 1MG TABS 100 EA $ 23.18 MULTIVIT/MINERALS TABS 10X10EA $ 6.18 PRAVASTATIN SODIUM 20MG TABS 10X10EA $ 10.04 PREDNISOLONE ACETATE 0.01 DROP 5 ML $ 170.98 TIMOLOL MALEATE 0.005 DROP 5 ML $ 55.62 TOBRAMYCIN/DEXAMETHASONE 0.3-0.1% DROP 5 $ 80.86 TOPIRAMATE 25MG TABS 10X10EA $ 6.44 PRIMIDONE 50MG TABS 10X10EA $ 6.18 TOPIRAMATE 50MG TABS 10X10EA $ 15.71 METOPROLOL SUCCINATE 25MG TABS 10X10EA $ 6.18 METOPROLOL SUCCINATE 50MG TABS 10X10EA $ 6.18 TRAMADOL HCL 50MG TABS 100 EA $ 6.18 SCOPOLAMINE 1.5MG/72HR PTCH 10X1EA $ 79.05 PROMETHAZINE HCL 6.25MG/5ML SYRP 118 ML $ 6.18 TRAZODONE HCL 50MG TABS 100 EA $ 6.18 PROMETHAZINE HCL 25MG TABS 10X10EA $ 6.18 TRIAMCINOLONE ACETONIDE 0.005 OINT 15 GM $ 31.16 TRIAMTERENE/HCTZ 37.5-25MG CAPS 100 EA $ 6.18 TRIHEXYPHENIDYL HCL 2MG TABS 10X10EA $ 6.18 PROPRANOLOL HCL 10MG TABS 100 EA $ 6.18 TERAZOSIN 5 MG CAPSULE $ 6.18 TIGECYCLINE 50MG PWVL 10X1EA $ 580.41 ACETAMINOPHEN 325MG TABS 20X150EA $ 6.18 FEBUXOSTAT 40MG TABS 30 EA $ 33.48 VALACYCLOVIR HCL 500MG TABS 30 EA $ 22.40 VALPROATE SODIUM INJECTABLE 100MG/ML SDV $ 13.39 BYSTOLIC 5 MG TAB $ 13.91 PROCHLORPERAZINE 5 MG TABLET $ 6.18 VANCOMYCIN HCL 250MG CAPS 20 EA $ 178.45 ACETAMINOPHEN 160MG/5ML SUSP 120 ML $ 6.18 ELIQUIS TAB 5 MG $ 22.15 LEFLUNOMIDE 20 MG (GENERIC ARAVA ) TABL $ 50.73 XYLOCAINE 2% 10ML INJ $ 11.07 KETAMINE 100 MG/ML INJECTION $ 6.18 RANOLAZINE 500MG TABS 60 EA $ 20.60 BRIMONIDINE 0.2 % EYE DROPS $ 56.14 BYSTOLICE 10 MG TABLET $ 10.82 VASOPRESSIN 20U/ML MDV 25X1ML $ 137.25 HYDROXYIREA 500 MG CAPSULE $ 6.18 VENLAFAXINE HCL 37.5MG TABS 10X10EA $ 6.18 ELIQUIS 2.5 MG TABLET $ 22.15 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price CLARITHROMYCIN 500 MG TABLET $ 19.06 ALBUTEROL SULFATE ARIN 8 GM $ 74.93 LAMOTRIGINE 100 MG TABLET $ 14.68 OXYBUTYNIN 5 MG $ 10.04 TRANEXAMIC ACID 100 MG / ML INJECTION, 1 $ 113.82 VERAPAMIL HCL 120MG TABS 100 EA $ 6.18 VERAPAMIL HCL 2.5MG/ML SDV 25X2ML $ 117.94 RISPERIDONE 0.25MG TABS 100 EA $ 10.82 LYRICA CAPSULES 100 MG $ 23.43 VERAPAMIL HCL 40MG TABS 100 EA $ 6.18 METOCLOPRAMIDE ORAL SOLUTION, 10 MG $ 6.18 ROCURONIUM BROMIDE 10MG/ML MDV 10X10ML $ 26.01 SOLIFENACIN SUCCINATE 5MG TABS 30 EA $ 35.79 ROPINIROLE HCL 0.25MG TABS 10X10EA $ 6.18 RACEPINEPHRINE 0.0225 AMIH 30X.5ML $ 6.18 VITA B COMPLEX CAPS 100 EA $ 6.18 VANCOMYCIN 125 MG CAPSULE $ 96.82 SODIUM CHLORIDE 0.65% 0.0065 SPIN 45 ML $ 7.21 AZACTAM (AZTREONAM) INJECTION 2 GRAMS $ 215.01 BIOGLO FLUORESCEIN OPHTH DIAGNOSTIC STRI $ 6.18 COLLAGENASE 250U/GM OINT 30 GM $ 759.37 ASCORBIC ACID (VITA C) 500MG TABS 100 EA $ 6.18 70 MG TABLET (ALENDRONATE $ 63.35 VITAMIN D 1000U TABS 100 EA $ 6.18 SENNOSIDES 8.6MG TABS 10X10EA $ 6.18 SUPRANE $ 6.18 PANTOPRAZOLE TAB20MG $ 12.36 HYDROCODONE/APAP 5/325 TABLET $ 6.18 VITAMIN D 400U TABS 100 EA $ 6.18 QUETIAPINE FUMARATE 100MG TABS 10X10EA $ 21.12 TERRELL SOLUTION $ 6.18 BISOPROLOL 5 MG TABLET $ 6.18 VITAMIN E 400U CAPS 100 EA $ 6.18 QUETIAPINE FUMARATE 25MG TABS 10X10EA $ 14.42 HYDROCODONE/APAP 10/325 TABLETS $ 6.18 LOSARTAN 25 MG TAB NDC 68084-0346-01 $ 6.18 SERTRALINE HCL 50MG TABS 10X10EA $ 6.18 MIDODRINE 5 MG TAB, NDC 50268-0565-15 $ 12.10 SEVOFLURANE LIQD 250 ML $ 6.18 LOSARTAN 50 MG TABLET, NDC 00904-6390-61 $ 6.95 LATANOPROST 0.00005 DROP 3X2.5ML $ 293.55 SILVER NITRATE STCK 100 EA $ 6.18 SIMETHICONE 80MG CHEW 10X10EA $ 6.18 SIMVASTATIN 10MG TABS 10X10EA $ 8.50 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price LEVALBUTEROL HCL 0.63MG/3ML AMIH 24X3ML $ 20.60 LYRICA CAP 75 MG $ 23.43 SIMVASTATIN 40MG TABS 10X10EA $ 15.19 LEVALBUTEROL HCL 1.25MG/3ML AMIH 24X3ML $ 20.60 CALCITRATE ORAL $ 6.18 MONTELUKAST SODIUM 10MG TABS 100 EA $ 17.51 XARELTO 15 MG TAB $ 44.55 SODIUM BICARBONATE 0.5MEQ/ML SDV 25X5ML $ 6.18 XARELTO 20 MG TABLET $ 44.55 SODIUM BICARBONATE 1MEQ/ML LSSY 10X50ML $ 39.14 SODIUM BICARBONATE 325MG TABS 100 EA $ 6.18 SODIUM CHLORIDE 0.9% INHALAT 0.009 AMIH $ 6.18 EZETIMIBE 10MG TABS 10X10EA $ 35.28 SODIUM CHLORIDE 0.9% 0.009 SDV 25X10ML $ 6.18 ZINC SULFATE 220MG CAPS 100 EA $ 6.18 DELZICOL 400 MG CAPSULE $ 11.07 ZOLPIDEM TARTRATE 5MG TABS 10X10EA $ 14.16 COMBIVENT RESPIMAT INHALER (MD $ 1,184.24 COMBIGAN EYE DROPS 5 ML $ 498.01 SOTALOL HCL 80MG TABS 100 EA $ 6.18 TIOTROPIUM BROMIDE 18MCG ARIN 5 EA $ 58.45 OLANZAPINE 2.5MG TABS 30 EA $ 38.37 CALCITRIOL CAPSULE 0.25 MCG $ 6.18 SPIRONOLACTONE 25MG TABS 10X10EA $ 6.18 OLANZAPINE 5MG TABS 30 EA $ 40.94 LIDOCAINE JELLY 2%, 5 ML SIZE $ 24.21 HUMALOG INSULIN KWIKPEN 100 UNITS/ML, $ 339.39 CYANOCOBALAMIN (VITAMIN B-12) 1000 MCG T $ 6.18 SODIUM POLYSTYRENE SULFONATE 15GM/60ML S $ 34.76 SILVER SULFADIAZINE 0.01 CRM 50 GM $ 46.61 METFORMIN TABLET 850 MG $ 6.18 SUCRALFATE 1GM TABS 10X10EA $ 6.18 MELOXICAM TAB 7.5 MG $ 9.79 PSEUDOEPHEDRINE HCL 30MG TABS 24 EA $ 6.18 NYSTATIN POWDER 30 GRAMS $ 226.60 MEXILETINE 150 MG CAPSULE $ 7.73 NYSTATIN OINTMENT 30 GRAMS $ 77.77 SULFACETAMIDE SODIUM 0.1 DROP 15 ML $ 188.49 SULFAMETHOXAZOLE/TMP 800-160MG TABS 10X1 $ 6.18 BUDESONIDE/FORMOTEROL FUM DIHY 160-4.5MC $ 733.88 MISC PHARMACY $ 0.01 TORSEMIDE TABLET 5 MG $ 6.18 20 MEQ KCL IN DEXTROSE 5% 1000 ML $ 10.00 0.45 % SODIUM CHLORIDE 1000 ML $ 20.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price BYSTOLIC 2.5 MG TABLET $ 13.91 GLIMEPERIDE 1 MG TABLET $ 6.18 0.9 % SODIUM CHLORIDE 100 ML $ 6.00 0.9 % SODIUM CHLORIDE 50 ML $ 6.00 10MEQ KCL IN5% DEXTROS+.45%SODCHL 1000ML $ 9.00 FENOFIBRIC ACID 45 MG CAPSULES $ 6.18 20MEQ KCL IN5% DEXTROSE+.9%SODCHL 1000ML $ 11.00 MORPHINE SULFATE ORAL LIQUID SOLUTION CO $ 6.18 20MEQ KCL INDEXTRO 5%+.45%SOD CHL 1000ML $ 8.00 CLOBETASOL CREAM 0.05% 15 GRAMS $ 396.29 40MEQ KCL IN5% DEXTROS+.45%SODCHL 1000ML $ 9.00 40MEQ KCL IN5% DEXTROSE+.9%SODCHL 1000ML $ 12.00 NITROFURANTOIN MONOHYDRATE MACROCRYSTALS $ 7.21 KETAMINE INJECTION 10 MG/ML $ 54.85 5 % DEXTROSE + 0.45 % SODCHL 1000 ML $ 20.00 5 % DEXTROSE + 0.45 % SODCHL 500 ML $ 20.00 CHILDREN'S APAP SUSPENSION 160 MG/ 5 ML $ 6.18 MAG AL PLUS XS 30 ML UNIT DOSE CONTAIN $ 6.70 NYSATIN ORAL SUP 5ML $ 6.18 STERILE WATER 1000 ML $ 20.00 CALCIUM ACETATE 667 MG TABLET $ 6.18 ONDANSETRON 4 MG TABLET $ 76.48 IBUPROFEN SUSP 100MG 5MG $ 6.18 NAMENDA 10 MG TABLET $ 22.92 SENSORCAINE MPF .0025 INJ 10 ML $ 6.18 XYLOCAINE MPF .01 INJ 5ML $ 12.62 POTASSIUM CHLORIDE 10MEQ TABS 100 EA $ 6.18 LABETALOL HCL 100MG TABS 10X10EA $ 6.18 JANUVIA 25 MG $ 44.81 CYMBALTA 20 MG $ 23.95 LIDOCAINE ORAL SOLUTION 2% VISCOUS 15ML $ 6.18 BENZTROPINE 1 MG $ 6.18 LABETALOL HCL 5MG/ML CARP 10X4ML $ 23.18 LACTULOSE 10GM/15ML SOLN 40X30ML $ 6.18 DIGOXIN 0.125MG TABS 100 EA $ 26.78 INSULIN GLARGINE 100U/ML SYRN 5X3ML $ 276.56 SERTALINE 25 MG $ 6.18 ASPIRIN 325 MG $ 6.18 MAGNESIUM HYDROX/AL HYDROX/SIM 400-400-4 $ 6.18 DOCUSATE 100 MG CAP $ 6.18 CYCLOBENZAPRINE 5 MG TAB $ 6.18 VENLAFAXINE XR 37.5 MG CAP $ 11.59 GLIPIZIDE ER 5 MG $ 6.18 PREVACID SOLUTAB 15 MG $ 49.70 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price ROPINEROLE 1 MG TAB $ 6.18 TRIPLE ANTIBIOTIC OINTMENT $ 6.18 DOCUSATE LIQUID 50 MG $ 6.18 TYLENOL EXTRA STRENGTH 500MG $ 6.18 LEVOFLOXACIN 250MG TABS 10X10EA $ 26.78 LEVOFLOXACIN 500MG TABS 50 EA $ 58.45 LEVETIRACETAM 100MG/ML SOLN 500 ML $ 6.18 LEVETIRACETAM 250MG TABS 10X10EA $ 8.76 LEVETIRACETAM 500MG TABS 10X10EA $ 10.82 NOREPINEPHRINE BITARTRATE 1MG/ML AMPS 10 $ 27.04 ESCITALOPRAM OXALATE 10MG TABS 10X10EA $ 13.65 HYDRALAZINE 10 MG TABLET $ 6.18 OXCARBAZEPINE 150 MG $ 6.18 LIDOCAINE 0.05 OINT 35.44 GM $ 927.00 SIMVASTATIN 20 MG $ 15.19 M-M-R II $ 231.49 GLYCERIN SUPPOS (PED) $ 6.18 ASPIRIN SUPPOS 300MG $ 6.18 ASPIRIN SUPPOS 600MG $ 6.18 ACEPHEN SUPPOS 650 MG $ 6.18 DIAZEPAM TAB 2 MG $ 6.18 LIDOCAINE HCL/D7.5W 5-7.5% AMPS 25X2ML $ 30.90 DIAZEPAM 5 MG TAB $ 6.18 LIDOCAINE HCL 0.02 SOLN 100 ML $ 43.78 LIDOCAINE/EPINEPHRINE 1-0.001% MDV 25X20 $ 7.98 LIDOCAINE/EPINEPHRINE 2-0.001% MDV 25X30 $ 6.18 LIDOCAINE/PRILOCAINE 2.5-2.5% CRM 5X5GM $ 24.72 LIDOCAINE 0.05 PTCH 30 EA $ 44.03 FENTANYL PATCH 75 MCG/HR $ 143.69 ATORVASTATIN CALCIUM 10MG TABS 10X10EA $ 6.18 ATORVASTATIN CALCIUM 40MG TABS 10X10EA $ 6.18 LISINOPRIL 10MG TABS 10X10EA $ 6.18 LISINOPRIL 20MG TABS 100 EA $ 6.18 ZYVOX 600 MG TAB $ 567.53 LISINOPRIL 40MG TABS 100 EA $ 6.18 LISINOPRIL 5MG TABS 10X10EA $ 6.18 LIDOCAINE 0.04 CRM 5X5GM $ 30.64 LOPERAMIDE HCL 2MG CAPS 100 EA $ 6.18 LORATADINE 10MG TABS 10X10EA $ 6.18 LORAZEPAM 0.5MG TABS 100 EA $ 6.18 PERMETHRIN CREAM $ 573.45 TERBINAFINE CR 1% $ 24.72 LOVASTATIN 20MG TABS 10X10EA $ 6.18 TRIAMCINOLONE CR 0.1% 30 G $ 36.05 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price OMEGA-3-ACID ETHYL ESTERS 1GM GCAP 120 E $ 6.44 TRIAMCINOLONE DENTAL PASTE $ 249.00 LDR STOMACH RELIEF $ 6.18 CHLORHEXIDINE .12 % ORAL RINSE $ 6.18 BIMATOPROST 0.0001 DROP 2.5 ML $ 556.20 SUCRALFATE SUSP $ 24.21 PEDIATRIC ELECTROLYTE SOLN ORAL $ 13.13 PREGABALIN 25MG CAPS 90 EA $ 21.37 SMZ-TMP SUSP $ 6.95 PREGABALIN 50MG CAPS 10X10EA $ 23.43 ORACIT $ 7.21 PEDIA LAX 4 OZ LIQ $ 6.18 MAGNESIUM OXIDE 400MG TABS 10X10EA $ 6.18 FLUCONAZPLE ORAL SUSP $ 15.19 EPHEDRINE SULFATE $ 127.46 ETOMIDATE INJ $ 28.84 MECLIZINE HCL 12.5MG TABS 100 EA $ 6.18 MECLIZINE HCL 25MG TABS 100 EA $ 6.18 METFORMIN HCL 500MG TABS 100 EA $ 6.18 METFORMIN HCL 1000MG TABS 10X10EA $ 6.18 METFORMIN HCL 750MG TABS 100 EA $ 6.18 METHADONE HCL 10MG TABS 10X10EA $ 6.18 METHIMAZOLE 5MG TABS 10X10EA $ 6.18 METHYLENE BLUE 0.01 SDV 10X10ML $ 506.50 METOCLOPRAMIDE HCL 10MG TABS 100 EA $ 6.18 METOLAZONE 2.5MG TABS 10X10EA $ 10.04 METOLAZONE 5MG TABS 10X10EA $ 11.59 METOPROLOL TARTRATE 100MG TABS 100 EA $ 6.18 METOPROLOL TARTRATE 25MG TABS 10X10EA $ 6.18 METOPROLOL TARTRATE 50MG TABS 100 EA $ 6.18 METRONIDAZOLE 250MG TABS 100 EA $ 6.18 METRONIDAZOLE 500MG TABS 100 EA $ 6.18 MIDODRINE HCL 2.5MG TABS 10X10EA $ 6.18 MAGNESIUM HYDROXIDE 400MG/5ML SUSP 100X3 $ 6.18 CETACAINE SPRAY $ 244.11 MORPHINE SULFATE 15MG TABS 10X10EA $ 6.18 TOBRADEX OO $ 726.15 TOBREX OO $ 714.05 TOBRAMYCIN OS $ 45.06 TIMOLOL 0.5% GFS $ 422.56 EYE DROPS (GENERIC VISINE) $ 6.44 GUAIFENESIN 600MG TABS 100 EA $ 6.18 DRONEDARONE 400MG TABS 10X10EA $ 35.02 ALPHAGANP 0.15 OS $ 402.73 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price MUPIROCIN 0.02 OINT 22 GM $ 34.76 OFLOXACIN OS $ 229.43 NABUMETONE 500MG TABS 100 EA $ 6.18 DICLOFENAC OS 0.1% $ 138.28 FML OO $ 450.37 NAFCILLIN SODIUM 2GM PWVL 10X1EA $ 107.12 FLUOROMETHALONE OS $ 229.18 DETROL LA 2 MG $ 38.11 MEPHYTON 5 MG $ 217.85 AMOXICILLIN 250 MG CAP $ 6.18 MEMANTINE HCL 5MG TABS 10X10EA $ 22.92 AMPICILLIN 250 MG CAP $ 6.18 NAPROXEN 500MG TABS 10X10EA $ 6.18 HYDRALAZINE 50 MG TAB $ 6.18 METFORMIN 500 MG TAB $ 6.18 METAXALONE 800 MG $ 18.54 RISPERIDONE 1 MG TAB $ 7.21 OXYMETAZOLINE HCL 0.0005 SPIN 15 ML $ 16.00 NEOMYCIN/POLYMYXIN/DEXAMETH 0.001 DROP 5 $ 135.96 VITAMIN B 1 (THIAMINE) 100 MG TAB $ 6.18 VITAMIN B 6 (PYRIDOXINE) 100 MG TAB $ 6.18 NEOMYCIN/POLYMYXIN/GRAMIC DROP 10 ML $ 191.32 NEOMYCIN/POLYMYXIN/HC 0.01 DROP 10 ML $ 311.06 PLAN B $ 125.40 HYDROXYCHLOROQUINE 100 MG TAB $ 13.65 PHENYLEPHRINE HCL 0.01 SPIN 15 ML $ 13.13 MELATONIN 5 MG $ 6.18 MEGESTROL 40 MG TAB $ 6.18 NIACIN (VITA B3) 500MG TABS 90 EA $ 19.06 NICOTINE 21MG/24HR PTCH 14 EA $ 6.70 NICOTINE 14MG/24HR PTCH 14 EA $ 7.73 NICOTINE 7MG/24HR PTCH 14 EA $ 6.70 SODIUM CHLORIDE 1 G TAB $ 6.18 NIFEDIPINE 30MG TABS 10X10EA $ 6.18 VITAMIN D3 50,000 UNITS CAP $ 6.18 NITROGLYCERIN 0.02 OINT 48X1GM $ 7.73 ATENOLOL 25 MG $ 6.18 NITROFURANTOIN MACROCRYSTALS 100MG CAPS $ 10.56 NITROGLYCERIN 0.4MG/HR PTCH 30 EA $ 6.18 NITROGLYCERIN 5MG/ML SDV 25X10ML $ 38.63 NITROGLYCERIN/D5W 0.1MG/ML BTTL 12X250ML $ 59.23 TRICOR 145 MG $ 15.97 NITROPRUSSIDE SODIUM 25MG/ML SDV 2 ML $ 3,266.39 FLUOXETINE 10 MG $ 7.47 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price NITROGLYCERIN 0.4MG TABS 4X25EA $ 6.18 ISONIAZID 100 MG $ 6.18 KETOROLAC TAB 10 MG $ 6.70 COMBIVIR TAB $ 55.62 METHYLPREDNISOLONE 4 MG TAB $ 6.18 MIRTAZAPINE 15 MG TAB $ 10.56 NYSTATIN 100MU/GM CRM 30 GM $ 81.11 NYSTATIN/TRIAMCINOLONE 100MU-0.1%/GM CRM $ 345.82 TERAZOSIN 1 MG CAP $ 6.18 CIPROFLOXACIN OS $ 76.99 OFLOXACIN 0.003 DROP 5 ML $ 69.53 CYCLOPENTOLATE 1 % OS $ 57.17 TORSEMIDE 20 MG PO $ 6.18 URSODIOL 300 MG $ 23.69 ONDANSETRON 4MG TDIS 30 EA $ 68.75 XARELTO 10MG $ 44.55 BUPROPION SR 150MG $ 6.18 LAMOTRIGINE 25 MG $ 12.88 METHENAMINE 1G $ 6.44 VERAPAMIL 120 MG $ 7.21 OXYBUTYNIN CHLORIDE 5MG TABS 100 EA $ 6.18 OXYCODONE HCL 5MG TABS 10X10EA $ 6.18 OXYCODONE/ACETAMIN 5-325MG TABS 10X10EA $ 6.18 OXYCODONE HCL 10MG TABS 2X10EA $ 11.59 ALLOPURINOL 300 MG $ 6.18 OXYCODONE HCL 20MG TABS 2X10EA $ 21.63 PHOS-LO (CA ACETATE) 667 MG $ 6.18 BUSPIRONE 15 MG $ 6.18 METHYLDOPA 250 MG TAB $ 6.18 PANTOPRAZOLE SODIUM 40MG TABS 10X10EA $ 12.62 PAROXETINE HCL 10MG TABS 10X10EA $ 8.24 PRAMIPEXOLE 0.125 MG TABLETS $ 9.01 ALFUZOSIN 10 MG TAB $ 13.00 OLOPATADINE HCL 0.001 DROP 5 ML $ 880.65 DOXEPIN 50 MG CAPSULES $ 6.00 PENICILLIN V POTASSIUM 250MG/5ML POSR 10 $ 6.18 AZACTAM 1 GRAM INJECTION $ 110.00 PENICILLIN V POTASSIUM 500MG TABS 100 EA $ 6.18 FLUCONAZOLE 100 MG $ 28.00 PHENAZOPYRIDINE HCL 100MG TABS 10X10EA $ 6.18 PHENYLEPHRINE HCL 0.025 DROP 3 ML $ 72.10 NORTRIPTYLINE 25 MG CAPSULE $ 6.18 SODIUM PHOS/POT PHOS PCKT 100 EA $ 6.18 PILOCARPINE HCL 0.01 DROP 15 ML $ 304.62 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price BUPROPION SR 100 MG TAB $ 6.18 CLOPIDOGREL BISULFATE 75MG TABS 100 EA $ 6.18 PNEUMOCOCCAL 23 VAL PSAC VACC 25MCG/0.5M $ 292.52 POLYETHYLENE GLYCOL PCKT 14 EA $ 6.18 POLYMYXIN B SULF/TMP 10MU-0.1% DROP 10 M $ 41.46 DIPHENHYDRAMINE HCL 12.5MG/5ML LIQD 4 OZ $ 6.18 DIPHENHYDRAMINE HCL 25MG CAPS 10X10EA $ 6.18 OSELTAMIVIR PHOSPHATE 75MG CAPS 10 EA $ 50.00 DEXTROSE 25%/WATER 0.25 ANSY 10X10ML $ 27.04 CEFAZOLIN SODIUM INJECTION 500 MG $ 8.00 ACETYLCYSTEINE 20% 4 ML $ 47.38 WATER STERILE - INJECTION SDV 25X10ML $ 6.18 WATER STERILE - INJECTION SDV 25X50ML $ 7.21 SODIUM CHLORIDE 0.9% 0.009 IVSL 80X100ML $ 18.54 ISOPROTERENOL HCL 0.2MG/ML AMPS 10X5ML $ 179.99 SODIUM CHLORIDE 3% 0.03 IVSL 24X500ML $ 18.28 HYDROXYZINE PAMOATE 25MG CAPS 100 EA $ 6.18 DEXAMETHASONE 0.75MG TABS 10X10EA $ 6.18 CEFDINIR 300MG CAPSULE $ 2.40 AMANTADINE (GENERIC SYMMETREL) 100 MG CAPSULE $ 4.50 COLCHICINE 0.6 MG CAPSULES $ 10.00 FENTANYL PATCH $ 25.00 ORAL DEXAMETHASONE 0.25 MG $ 0.27 ORAL DEXAMETHASONE 0.25 MG $ 0.27 LEVOTHYROXINE 88 MCG TABLET $ 1.50 LEVOTHYROXINE 75 MCG TABLET $ 1.50 TOLTERODINE 2 MG TABLET $ 4.00 DIVALPROEX DR 250 MG TABLET $ 1.00 levothyroxine 50 MCG TABLET 50 mcg, 100 eaches $ 1.50 levothyroxine 125 MCG TABLET 125 mcg, 100 eaches $ 2.00 SILVER SULFADIAZINE 1% CREAM 1 ea, 25 g $ 16.00 CULTURELLE HEALTH-WELLNESS CAP 1 ea, 30 eaches $ 1.50 MARINOL CAPSULES 2.5 MG $ 27.00 DOXYCYCLINE 100 MG $ 14.00 LEVOTHYROXINE SODIUM $ 1.50 4" STRAIGHT INSERTION NEEDLE (10CM) $ 661.00 CLIK X MRI ANCHOR $ 1,215.00 28CM TUNNELING TOOL $ 923.00 7.6CM HEX WRENCH $ 231.00 GABAPENTIN 100MG CAPS 10X10EA $ 6.18 CLONIDINE HCL 0.1MG/24HR PTCH 4 EA $ 45.00 ARANESP 60 MCG/ML (J0881 ƒ?? NON ESRD USE, J0882 ƒ?? ESRD USE) $ 12.00 ARIPiprazole 2 MG TABLET 2 mg, 30 eaches $ 28.00 ARIPiprazole 5 MG TABLET 5 mg, 50 eaches $ 20.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price cefTRIAXone 2 GM-D5W BAG 250 mg, 1 each $ 7.50 levothyroxine 112 MCG TABLET 112 mcg, 90 eaches $ 6.00 DOXEPIN 25 MG CAPSULE 25 mg, 100 eaches $ 6.00 BUPIVACAINE-DEXTR 0.75% AMP 1 ea, 2 mL $ 6.00 AZITHROMYCIN 250MG TABS $ 16.50 METOPROLOL TARTRATE 1MG/ML AMPS 12X5ML $ 9.50 RIFAXIMIN 200MG TABS 30 EA $ 59.48 RIFAMPIN 300 MG PO $ 7.50 OSELTAMIVIR PHOS 45 MG CAPSULE 45 mg, 10 eaches $ 43.00 TAMIFLU 30 MG CAPSULE 30 mg, 10 eaches $ 51.00 TAMIFLU 45 MG CAPSULE 45 mg, 10 eaches $ 51.00 CARDENE IV SOLUTION 20 MG / 200 ML $ 352.26 CEFUROXIME 250 MG TABLET $ 6.00 RM & BED-SEMI PRIVATE $ 974.00 RM & BED-TELEMETRY $ 974.00 RM & BED-ISOLATION $ 974.00 BORDER STATUS ROOM AND BED SEMI PRIVATE $ 452.00 RM & BED-SWING $ 965.00 OPERATING RM 1/4 HOUR $ 1,197.00 OPERATING RM 1/2 HOUR $ 1,738.00 OR 3/4 HOUR OPERATION $ 2,280.00 OR 1 HOUR OPERATION $ 2,821.00 OR 1 1/4 HOUR OPERATION $ 3,362.00 OR 1 1/2 HOUR OPERATION $ 3,901.00 OR 1 3/4 HOUR OPERATION $ 4,442.00 OR 2 HOUR OPERATION $ 4,984.00 OR 2 1/4 HOUR OPERATION $ 5,525.00 OR 2 1/2 HOUR OPERATION $ 6,066.00 OR 2 3/4 HOUR OPERATION $ 6,607.00 OR 3 HOUR OPERATION $ 7,148.00 OR 3 1/4 HOUR OPERATION $ 7,690.00 OR 3 1/2 HOUR OPERATION $ 8,231.00 OR 3 3/4 HOUR OPERATION $ 8,772.00 OR 4 HOURS OPERATION $ 9,312.00 OR 4 1/4 HOURS OPERATION $ 9,853.00 OR 4 1/2HOURS OPERATION $ 10,395.00 OR 4 3/4 HOURS OPERATION $ 10,936.00 OR 5 HOURS OPERATION $ 11,477.00 OR 5 1/4 HOURS OPERATION $ 12,018.00 OR 5 1/2 HOURS OPERATION $ 12,559.00 OR 5 3/4 HOURS OPERATION $ 13,101.00 OR 6 HOURS OPERATION $ 13,642.00 RECOVERY ROOM LEVEL 1( 0-3 HRS) $ 790.00 RECOVRY ROOM LEVEL2 4-9 HOURS $ 1,581.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price RECOVER ROOM LEVEL3 10+ HOURS $ 2,371.00 GROSS&MICRO PATHOLOGY $ 369.00 SPECIMEN COLLECNTION OR ONLY $ 21.00 OR LEVEL 1 ADD ON $ 0.01 OR LEVEL 2 ADD ON $ 0.01 OR LEVEL 3 ADD ON $ 0.01 OR LEVEL 4 ADD ON $ 0.01 OR LEVEL 5 ADD ON $ 0.01 JMAX EQUIPMENT LOANER FEE $ 1,071.00 OR FLUOROSCOPY $ 328.00 OR LEVEL 6 ADD ON $ 0.01 OR LEVEL 7 ADD ON $ 0.01 OR LEVEL 8 ADD ON $ 0.01 OR LEVEL 9 ADD ON $ 0.01 OR LEVEL 10 ADD ON $ 0.01 OR LEVEL 11 ADD ON $ 0.01 OR LEVEL 12 ADD ON $ 0.01 RECOVERY ROOM - FIRST 30 MINS $ 283.00 RECOVERY ROOM - 31-60 MINS $ 449.00 RECOVERY ROOM - 61-90 MINS $ 615.00 RECOVERY ROOM - 91-120 MINS $ 781.00 RECOVERY ROOM - 121-150 MINS $ 948.00 RECOVERY ROOM - 151-180 MINS $ 1,114.00 RECOVERY ROOM - OVER 180 MINS (3+ HRS) $ 1,280.00 ANESTHESIA 15 MINS $ 76.00 ANESTHESIA 30 MINUTES $ 98.00 ANESTHESIA 60 MINUTES $ 199.00 ANESTHESIA 90 MIN $ 297.00 ANESTHESIA 120 MIN $ 356.00 ANESTHESIA 150 MIN $ 416.00 ANESTHESIA 180 MIN $ 475.00 ANESTHESIA 210 MIN $ 534.00 GUIDANCE FOR NEEDLE BREAST MAMMOGRAPHIC $ 438.00 THORACENTESIS RAD $ 853.00 ENTIRE SPINE AP & LAT $ 879.00 INJECTION OF STEROID $ 2,232.00 THYROID-UPTAKE AND SCAN $ 913.00 LUNG VENT; GAS W RB & WO MULTI $ 1,996.00 NM THYROID $ 1,039.00 INDIUM 111 OXINE $ 1,583.00 NON IONIC CONTRAST $ 187.00 ACETYLMORPHINE CONF $ 138.00 CLONAZEPAM (KLONOPIN) SE $ 109.00 CYTOLOGY FLUIDS $ 312.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price CYTOPATH FLUID WASH BRUS $ 87.00 DESIPRAMINE NORPRAMIN $ 110.00 DRUG 8 BLOOD $ 274.00 ELAVIL $ 110.00 TOFRANIL SERUM $ 110.00 OCCULT BLOOD OTHER SOURCES $ 76.00 URINE COLLECTION FEE $ 17.00 ECUP TEST $ 54.00 CETIRIZINE HCL 10MG TABS 100 EA $ 7.00 LOPERAMIDE HCL 1MG/5ML LIQD 4 OZ $ 6.00 ANTIPYRINE/BCAINE/GLYCERIN 5.4-1.4% DROP $ 27.00 HERBAL/HOMEOPATHIC PRODUCTS GEL 45 GM $ 6.00 MESALAMINE 400MG TABS 180 EA $ 7.00 ASPIRIN 325MG TABS 500 EA $ 6.00 VITAMIN B12/INTRINSIC FACTOR 1000MCG TAB $ 6.00 BENZOIN SPEX 4 OZ $ 6.00 CALCIUM CIT/VITA D 315MG-250U TABS 400 E $ 6.00 CALCIUM/VITA D/PHOSPHORUS 1000MG-1000U-2 $ 6.00 EMOLLIENT/SKIN CLEANSER PCKT 144X3.5 $ 15.00 CAPTOPRIL 50MG TABS 10X10EA $ 6.00 CAPSAICIN 0.001 CRM 1.5 OZ $ 33.00 BENZOIN COMPOUND SWAB 100 EA $ 16.00 NORGESTREL/ETH ESTRADIOL 0.3-0.03MG TABS $ 8.00 SOD THIOSULF/SOD NITRATE/AMYL KIT 1 EA $ 1,442.00 TETANUS DIPHTHER TOXOID ADULT 5-2LFU SYR $ 79.00 ZINC OXIDE 0.4 OINT 28 GM $ 6.00 DIAZEPAM 5MG/ML SYRN 10X2ML $ 9.00 DILTIAZEM HCL 5MG/ML SDV 10X10ML $ 6.00 DOXYCYCLINE HYCLATE 100MG TABS 10X10EA $ 6.00 HYDROCOLLOID DRESSING BNDG 20 EA $ 24.00 DIFLUPREDNATE 0.0005 DROP 5 ML $ 404.00 PRASUGREL 10MG TABS 30 EA $ 24.00 LACTOSE FREE FOOD LIQD 24X8OZ $ 6.00 SODIUM BORATE/SOD CL/BORIC AC SOLN 120 $ 11.00 HYDROCORTISONE 0.1 GEL 60 GM $ 331.00 AMMONIUM LACTATE 0.12 LOTN 8 OZ $ 24.00 HUMIDIFIER EQIP 1 EA $ 168.00 IBUTILIDE FUMARATE 0.1MG/ML SDV 10 ML $ 1,054.00 KETOROLAC TROMETHAMINE 0.004 DROP 5 ML $ 331.00 LEVOCARNITINE 500MG TABS 30 EA $ 6.00 MENTHOL 7MG LOZG 30 EA $ 6.00 LEFLUNOMIDE 10MG TABS 30 EA $ 51.00 BIMATOPROST 0.0003 DROP 2.5 ML $ 365.00 MAGNESIUM HYDROX/AL HYDROX/SIM SUSP 360 $ 17.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price METHYL SALIC/MENTHOL CRM 50 GM $ 6.00 PSYLLIUM PCKT 30 EA $ 6.00 METOCLOPRAMIDE HCL 5MG TABS 10X10EA $ 6.00 IBUPROFEN 200MG CAPS 500 EA $ 6.00 NAPROXEN 250MG TABS 10X10EA $ 6.00 FISH OIL 1000MG GCAP 160+20EA $ 6.00 FOAM BANDAGE BNDG 10 EA $ 10.00 PRAMIPEXOLE DI-HCL 0.25MG TABS 10X10EA $ 9.00 ADHESIVE BANDAGE BNDG 20 EA $ 6.00 RESPIRATORY EQUIPMENT EQIP 1 EA $ 103.00 TETRACYC HCL/BIS SC/METRONID 125-140-125 $ 17.00 PHARMACY SUPPLIES EACH 6 EA $ 6.00 SILVER DRESSING GEL 45 GM $ 96.00 GEL DRESSING GEL 3 OZ $ 6.00 MISC MEDICAL SUPPLY SDV 1 EA $ 6.00 PHENOBARB SOLN 20 MG / 5 ML $ 6.00 ENOXAPARIN 30 MG INJ $ 6.00 ENOXAPARIN 40 MG INJ $ 6.00 FLUARIX QUADRAVALENT FLU VACCINE $ 47.00 FLUARIX QUADRAVALENT FLU VACCINE $ 47.00 GLYCERIN USP LIQ $ 6.00 DUODERM GEL $ 27.00 TUCKS PADS $ 6.00 STANDARD GRAFT JACKET $ 7,985.00 REPAIR KIT 8590-9 AND ANCHOR MEDTRONIC $ 325.00 TAMIFLU 30 MG CAPSULE $ 0.01 GENTIAN VIOLET $ 6.00 CLOVE LEAF OIL $ 6.00 6" 17G PERCUTANEOUS DISCECTOMY $ 6,163.00 SUTURE LOOP GUIDE RODS $ 656.00 REGENERATIVE TISSUE SKIN GRAFT $ 4,919.00 CATH 8709SC 1PC SUTHERLESS US TRAY MED $ 2,373.00 SUTURELESS CATH $ 2,280.00 CEPACOL 3 MG $ 6.00 HEPARIN FLUSH 100 UNITS/ML 300UNITS 3ML $ 11.00 COLD PACK SUPPLY $ 42.00 LNLRATHECAL CATH $ 3,758.00 NITROFURANTOIN 50 MG CAP $ 7.00 COMPOUND BENZOIN SWAB 100 EA $ 6.00 HEP LOCK FLUSH $ 9.00 BLADE SURGICAL SZ 10 $ 31.00 EXTREMITY DRAPE $ 35.00 STRIP IODOFORM PAC 1/4X5YD $ 11.00 ATORVASTATIN CALCIUM 10 MG TABS $ 6.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price BARRIER SKIN 11/4 FLEX $ 21.00 NITROMIST 400 MCG SPRAY $ 378.00 STRIP IODOFORM PAC 1/2X5YD $ 13.00 BARRIER SKIN 1 1/2 FLEX COST BOX $ 21.00 STRIP IODOFORM PAC 1"X5YD $ 14.00 CO-Q-10 100MG $ 6.00 BARRIER SKIN 2 1/4 FLEX COST BOX $ 25.00 STRIP IODOFORM PAC 2"X5YD $ 18.00 BARRIER SKIN 2 3/4 FLEX COST BOX 10 $ 25.00 TUBING FLOWTRON $ 42.00 5-10 MM STYLET SATIN SLIP $ 23.00 PERSONAL THERAPY MANAGER $ 2,608.00 SIZE 4 SHILEY $ 320.00 CATH FOLEY LATEX 5CC 22FR $ 19.00 6" 15G PERCUTANEOUS DISCECTOMY $ 6,163.00 CHARCOCAPS $ 6.00 SIZE 6 SHILEY $ 320.00 VENTRICULAR LEAD $ 2,066.00 6.5 ET TUBE CUFFED $ 22.00 CAPSUREFIX NOVUS III $ 2,272.00 OLIVE STABILIZER $ 1,265.00 CAPSUREFIX NOVUS II $ 2,272.00 7.0 ET TUBE CUFFED $ 15.00 RAD. REDUCING GLOVES SIZE 7.5 $ 141.00 CAPSUREFIX NOVUS $ 2,272.00 7.5 ET TUBE CUFFED $ 15.00 NERVER BLOCK TRAY W/O DRUGS-SUPPLY ONLY $ 63.00 STRYKER BATTERY PACK 9.6V $ 1,420.00 EPIDURAL CATHETER SET $ 215.00 TENSOGRIP STOCKINETTE 3 1/2" E $ 125.00 CATH FOLEY 16FR BARDEX SI $ 51.00 TENSOGRIP STOCKINETTE 3 1/2" F $ 137.00 MISC PHARMACY $ 0.01 BITE BLOCKS $ 46.00 CRESTOR 10 MG $ 6.00 TENSOGRIP STOCKINETTE 4.5" G $ 159.00 CALAMINE LOTION 120 ML $ 6.00 GUHL ANKLE DISTRAKTER $ 909.00 TENSOGRIP STOCKINETTE 3" D $ 99.00 ENDOSCOPIC CYTOLOGY BRUSH $ 50.00 ADAPTA DR $ 18,856.00 BISOPROLOL 10 MG $ 6.00 DRILL FOR 4.3MM SCREW $ 159.00 PROPRANOLOL 10 MG TAB $ 6.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price STRYKER CUTTING BLADE $ 103.00 2 FIBERWIRE SUTURE $ 64.00 HEAD DRILL4.3MM COMPRS SCREW $ 262.00 PEDIATRIC DRAPE $ 23.00 APPLICATOR SEPP CHLORAPREP 0. $ 1.00 MINERAL OIL $ 6.00 18G 3-1/2 IN SPINAL NEEDLE $ 31.00 O2 SENSOR ADULT $ 29.00 BIPOLAR PROBE 10FR. $ 492.00 WET SKIN PREP TRAY $ 13.00 EASY CAP CO2 DETECTOR $ 34.00 BIPOLAR PROBE 7FR. $ 546.00 PRADAXA 150 MG $ 6.00 LPT REG GREAT TOE $ 5,884.00 CATH URETHRAL TRAY $ 10.00 LISINOPRIL 5 MG TAB $ 6.00 12" PANEL BINDER 30-45" $ 30.00 BONE CEMENT PLUS MIXER $ 1,145.00 ATORVASTATIN 10 MG TAB $ 6.00 12" PANEL BINDER 45-62" $ 30.00 SPINAL TRAY 25GA WHITACRE $ 53.00 PHENOBARBITAL 30MG $ 6.00 TROCAR ENDO BLUNT 12MM THREA $ 724.00 12" PERSONAL BINDER $ 30.00 HEEL FLOAT MEDIUM $ 113.00 MISC PHARM $ 6.00 OPTICAL ACCESS KII THREADED $ 96.00 BASIC PACKS $ 37.00 ALLIANCE_ II INFLATION SYSTEM $ 1,541.00 ER NASAL PACKING $ 26.00 2" STRETCH BANDAGE $ 2.00 RADIATION REDUCTION GLOVES 8.5 $ 159.00 NEEDLE SPINAL 20GX6 YELLOW $ 19.00 PHARMACY GI COCKTAIL $ 31.00 14FR FOLEY CATHETER 8760514 $ 16.00 4" STRETCH BANDAGE $ 5.00 4"X0.045" K-WIRES $ 21.00 COENZYME Q 10 CAPSULE $ 6.00 16FR FOLEY CATHETER 8760516 $ 16.00 6"X0.045" K-WIRES $ 21.00 4"X36" NYLATEX WRAPS $ 33.00 18FR FOLEY CATHETER 8760518 $ 16.00 4"X48" NYLATEX WRAPS $ 42.00 ECONOMY COTTON STOCKINETTE 5" $ 13.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price LAP CHOLE PACK $ 851.00 BONE CEMENT W/MIXER KYPHX HV-R $ 724.00 2" COBAN STERILE LF $ 13.00 LAPAROSCOPY PACK $ 150.00 COTTON STOCKINET 3"" $ 35.00 4" COBAN STERILE LF $ 11.00 CLIP APPLIER 10MM $ 583.00 COTTON STOCKINET 4"" $ 13.00 14FR COUDE CATH $ 57.00 UPPER EXTREMITY PACK $ 106.00 SUBOXONE SUBLINGUAL FILM $ 23.00 2" SMOOTH CAST PADDING STERILE $ 26.00 18FR COUDE CATH $ 133.00 TROCAR BALLOON KIT $ 327.00 4" SMOOTH CAST PADDING STERILE $ 46.00 DISP HIGH FLOW INSULFLATOR $ 50.00 XXL GOWN $ 15.00 6" SMOOTH CAST PADDING $ 13.00 CATH FOLEY LATEX 5CC 14FR $ 50.00 CAUTERY PENCIL $ 19.00 RETRIEVAL SYSTEM 10MM ENDSCP $ 188.00 LEUKOTAPE 1.5" X 15 YDS $ 38.00 HOT BIOPSY $ 158.00 3.5MM COMPRESSION PLATE, 2-8 HOLES $ 453.00 CAUTERY PAD $ 11.00 DORSAL PF NIGHT SPLINT MED $ 125.00 SINGLE LUMEN CENTRAL VENOUS CA $ 129.00 3.5MM COMPRESSION PLATE, 9-12 HOLES $ 514.00 GRAPE SEED OIL 100MG $ 6.00 DORSAL PF NIGHT SPLINT LARGE $ 125.00 COTTON STOCKINET 6"" $ 13.00 3.5MM COMPRESSION PLATE, 12> HOLES $ 1,327.00 SHAVE PREP TRAY 2 COMPARTMEN $ 10.00 CERVICOLL KIT CEK-17-75-2 $ 2,870.00 TRAECHEOSTOMY SET 6MM $ 550.00 TENEX (GUANFACINE) $ 6.00 1/3TH TUBULAR PLATE W/ COLLAR $ 240.00 LUMBAR KIT (CERVICOOL)GENIC LUK-17-100-4 $ 2,870.00 10CC SALINE FLUSH $ 6.00 MELATONON 5MG TABLET $ 6.00 ACCESS SYS KII OPTCL THRD 5MMX $ 62.00 3.5MM T-PLATE, 3-5 HOLE SHAFT $ 438.00 SINGERY KIT (CERVICOOL) SIK-17-75-4 $ 2,008.00 VIBRYD 10MG $ 38.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price 7.0 ET TUBE $ 10.00 3.5MM T-PLATE, 5> HOLE SHAFT $ 622.00 TRIPLE LUMEN TRAY $ 354.00 COOLED LUMBAR PROBE LUP-17-100-4 $ 2,008.00 SAPHRIS 5MG $ 91.00 2-0 ETHIBOND CT-2 SUTURE $ 18.00 3.5MM T-PLATE OBLIQUE $ 656.00 7.5 ET TUBE $ 8.00 SILVER ALGINATE DRESSING $ 58.00 VITAMIN D 50000 $ 6.00 6" ESMARK $ 17.00 3.5MM CLOVERLEAF PLATE, 3-5 HOLES $ 924.00 SKIN BARRIER (COLOSTOMY SUPPLY) $ 32.00 8.0 ET TUBE $ 10.00 4" SCOTCHCAST PLUS CAST TAPE $ 21.00 3.5MM CLOVERLEAF PLATE, 5> HOLES $ 1,340.00 SEAL COHESIVE WAFFER (COLOSTOMY SUPPLY) $ 16.00 5" SCOTCHCAST PLUS CAST TAPE $ 25.00 UNNA BOOT WITH CALAMINE 4" $ 18.00 3.5MM CALCANEAL PLATE $ 1,486.00 DRAIN POUCH (COLOSTOMY SUPPLY $ 9.00 SULFAMETHOXAZOLE AND TRIMETHOPRIM $ 6.00 DISP BIOPSY FORCEPS - SPIKED $ 33.00 MEDTRONIC POCKET ADAPTOR $ 1,624.00 PEDIATRIC PULSE OX $ 67.00 3.5MM RECON PLATE, STRAIGHT, 3-7 HOLES $ 1,022.00 SHEET FLAT BARD MESH 1X4IN STE $ 360.00 PEDIATRIC CAPNOLINE (CANNULA) $ 39.00 HYDROCOLLOID 6X6IN $ 21.00 2.7X14MM LOCK SCREW $ 668.00 3.5MM RECON PLATE, STRAIGHT 7> HOLES $ 1,327.00 SILVER ALGINATE DRESSING $ 58.00 DRESSING DUODERM 4INX4IN $ 52.00 LOVASTATIN 20 MG $ 6.00 2.7X16MM LOCK SCREW $ 668.00 CATH FOLEY 14FR DOVER $ 51.00 THERACOOL PROBE KIT, SINGLE-USE $ 965.00 SMALL WASHER $ 82.00 2.7X22MM LOCK SCREW $ 668.00 DISPOSABLE GAIT BELTS $ 15.00 OR IV TUBING 3 CLAVE $ 16.00 MISCELLANEOUS INSTRUMENTS $ 294.00 ISOVUE 300 50 ML $ 27.00 4MM ROW II LOCK PLATE $ 5,611.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price CVC/PICC DRESSING CHANGE KIT $ 64.00 AMYL NITRATE $ 6.00 ISOVUE 300 100ML $ 100.00 2.0MM DRILL $ 587.00 DRILL BIT, JACOBS CHUCK $ 585.00 AMINOSYN 3.5% $ 175.00 OSTOMY BAG $ 13.00 PLEUR EVAC $ 126.00 DILATION SYRINGE 60CC $ 119.00 THORACIC RF KIT:THK-17-75 $ 2,870.00 XL UNIVER KNEE WRAP W/CLOSED P $ 31.00 LUMBAR PUNCTURE TRAY 20GX3 1 $ 53.00 KNEE KIT:CRK-17-100-4 $ 2,870.00 XXL UNIVER KNEE WRAP CLOSED P $ 48.00 HOT DISP BIOPSY FORCEPS $ 67.00 SUTURE VICRYL 0 18IN VIOLET $ 459.00 KOBYGARD SINGLE USE BLADES $ 633.00 DISPERSIVE ELECTRODE: PMA-GP-BAY 4479209 $ 328.00 CATH FOLEY 16FR DOVER $ 51.00 SIZE 3 BIOPSY $ 21.00 ISOVUE 200M 10ML $ 27.00 ECHOBRIGHT 22GX50MM NEEDLE $ 55.00 XS SPECIALTY ARM SLING $ 14.00 4MM BOW PLATE $ 6,854.00 CHLORASEPTIC PUMP SPRAY $ 6.00 SIZE 2 BONE BIOPSY DEVICE $ 499.00 ISOVUE 200M 20ML $ 84.00 ECHOBRIGHT 20GX100MM NEEDLE $ 55.00 SMALL SPECIALTY ARM SLING $ 14.00 LEVOTHYROXINE SODIUM 200MCG TABS 100 EA $ 6.00 BIOPSY FORCEPS 3.7MM CHANNEL $ 1,186.00 4" ACE BANDAGE $ 3.00 ECHOBRIGHT 20GX1501MM NEEDLE $ 55.00 HOT BIOPSY FORCEPS $ 1,186.00 STOCKINETTE,IMPERVIOUS,LARGE $ 10.00 ECHOLONG 18GX50MM NEEDLE $ 128.00 4" ECONOMY COTTON STOCKINETTE $ 13.00 UNIVERSAL ANKLE BRACE $ 41.00 ECHOLONG 18GX100MM NEEDLE $ 128.00 SUTURE ETHILON 6/0 18IN BLAC $ 33.00 TEMP STABILIOZE PIN $ 396.00 ECHOLONG 18GX150MM NEEDLE $ 150.00 XLARGE SPECIALTY ARM SLING $ 14.00 4-0 ETHILON 18" PS-4 CUTTING $ 33.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price CANNULA 20GX100MMX10MM $ 745.00 PICC LINE TURBO-JET PICK SET $ 529.00 10/2 FIRST FRACTURE KIT $ 13,514.00 3-0 ETHILON 18" PS-2 CUTTING $ 18.00 XS RIGHT COMFORTFORM WRIST $ 25.00 GROUNDING PADS $ 39.00 MAGIC MOUTHWASH $ 19.00 JUGULAR VENA CAVA FILTER $ 5,231.00 DEVICE 5MM ENDO PEANUT LAPAR $ 265.00 PHILLIPS MASK AF531 $ 147.00 AUTOCLAVE CASES $ 957.00 FEMORAL VENA CAVA FILTER $ 5,231.00 SMALL RIGHT COMFORTFORM WRIST $ 25.00 SMALL STOCKING ANTI-EMB THIGH $ 38.00 SINERGY STERILE PROBE TIP SIP-17-75-4 $ 2,008.00 MED RIGHT COMFORTFORM WRIST $ 25.00 TETRACYCLINE HCL 250MG CAPS 10X10EA $ 6.00 MED STOCKING ANTI-EMB THIGH $ 38.00 COOLED INTRODUCER (GENERIC) BOX OF 2 $ 190.00 3" X 22" CERVICAL COLLAR $ 10.00 CULTURELLE CAPSULES $ 6.00 SUTURE SURGILON 1 5X18IN BLAC $ 33.00 LARGE RIGHT COMFORTFORM WRIST $ 25.00 PROBE KIT GENICULAR SYSTEM $ 2,870.00 4" X 23" CERVICAL COLLAR $ 10.00 LVAD DRIVELINE KIT $ 57.00 3.5" X 22" CERVICAL COLLAR $ 10.00 THERACOOL KIT-8451775 KIMBERLY CLARK $ 2,870.00 XLARGE RIGHT COMFORTFORM WRIST $ 25.00 4.5" X 24" CERVICAL COLLAR $ 10.00 MULTIVITAMIN LIQD 120 ML $ 6.00 PORT-A-CATH $ 915.00 STERILE DRAPE-61050 $ 22.00 LARGE STOCKING ANTI-EMB THIGH $ 18.00 HERCULES 3-STAGE DIALATOR 8CM $ 665.00 XS LEFT COMFORTFORM WRIST $ 39.00 STIRRUPS-52710 $ 15.00 HERCULES 3-STAGE DIALATOR 8CM $ 665.00 SHOULDER IMMOB W/FOAM M $ 30.00 SMALL LEFT COMFORTFORM WRIST $ 25.00 STARCH POWD 30 OZ $ 6.00 DUODERM CGF BORDER $ 31.00 HERCULES 3-STAGE DIALATOR 8CM $ 665.00 XL STOCKING ANTI-EMB THIGH $ 18.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price PATRIOT COLLAR $ 24.00 MEDIUM LEFT COMFORTFORM WRIST $ 25.00 DUDERM 4X4 CGF DRESSING $ 25.00 3 STAGE BALLOON DILA 18-19-20 $ 67.00 STERILE 3IN STOCKINETTE $ 13.00 1 POLYSORB GS-24 $ 16.00 LARGE LEFT COMFORTFORM WRIST $ 25.00 4X5 AQUACEL AG DRESSING $ 64.00 HERCULES 3-STAGE DIALATOR 8CM $ 665.00 STERILE 10IN STOCKINETTE $ 13.00 0 POLYSORB 3.5 12X18 $ 74.00 XLARGE LEFT COMFORTFORM WRIST $ 25.00 4X4 AQUACEL DRESSING $ 30.00 STERILE 8IN STOCKINETTE $ 24.00 PRIMARY IV TUBING $ 37.00 4-0 MONOSOF P-12 $ 28.00 SUTURE POLYSORB 0 6X18IN VIO $ 22.00 4.5MM ANGLED AGGRESSIVE PLUS $ 192.00 R XS WRIST W/ABDUCTED THUMB $ 54.00 PORT-A-CATH II IMPLANTABLE VE $ 914.00 0 3.5 METRIC POLYSORB BRAIDED $ 40.00 COLD BIOPSY FORCEPS $ 15.00 CROSSFLOW INTEGRATED CASSETTE TUBING $ 497.00 R SMALL WRIST W/ABDUCTED THUMB $ 53.00 4-0 MONOSOF P-13 $ 29.00 TEGADERM DRESSING $ 183.00 HEELBO SMALL YELLOW $ 34.00 RESOLUTION CLIP 235CM $ 813.00 R MED WRIST W/ABDUCTED THUMB $ 53.00 VICRYL P-3 $ 31.00 .9% SODCH 1000ML IRRIGATION BAG $ 4.00 18FR PEG FEEDING TUBE W/ BALLO $ 86.00 15X7MM OSCILLATING BLADES $ 31.00 R LARGE WRIST W/ABDUCTED THUMB $ 53.00 LUMBAR RF KIT_LUK-17-150-4 $ 2,870.00 3-0 MONOSOF P-12 $ 30.00 ENDOVIVE SAFETY PEG PUSH METH $ 622.00 R XL WRIST W/ABDUCTED THUMB $ 53.00 DOBUTAMINE 5%DEXTROSE 250MG $ 7.00 LUMBAR COOLED INTRODUCER LUI-17-100 $ 382.00 3-0 2.0 METRIC SILK $ 30.00 ER EYE TRAY $ 29.00 EZ-IO AD 15G INTRAOSSEOUS NEE $ 410.00 L XS WRIST W/ABDUCTED THUMB $ 54.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price NASOPHARYNGE AIRWAY 6.0 $ 10.00 THERA-COOL INTRODUCER THI-17-75-5.5 $ 191.00 0 TR CRON GS-22 $ 72.00 EZ-IO AD 15G INTRAOSSEOUS NEE $ 410.00 L SMALL WRIST W/ABDUCTED THUMB $ 53.00 NASOPHARYNGE AIRWAY 7.0 $ 11.00 KYPHON EXPRESS CURETTE T-TIP 7.0MM SZ 2 $ 328.00 3-0PROLENE FS-1 $ 21.00 L MED WRIST W/ABDUCTED THUMB $ 53.00 EZ-IO LD 15G 45MM IO NEE $ 410.00 NASOPHARYNGE AIRWAY 8.0 $ 10.00 SINERGY SYSTEM 17GX150 SIK-17-150-4 $ 2,870.00 ETHILON CT-1 GRN BRAIDED $ 17.00 L LARGE WRIST W/ABDUCTED THUMB $ 53.00 3M COBAN 3"X5YD $ 17.00 SINERGY INTRODUCER 17GX150 SII-17-1750 $ 381.00 FOLEY INSERTION TRAY 10CC $ 16.00 SUTURE TRAY ER $ 35.00 PRAMOXINE/MO/ZN OX 1-46.6-12.5% OINT 28. $ 6.00 3-0 POLYSORB GL-126 $ 13.00 L XL WRIST W/ABDUCTED THUMB $ 53.00 3M COBAN 4"X5YD $ 8.00 SINERGY PROBE 17GX75MMX4MM SIK-17-75-4 $ 2,870.00 LUMBAR PUNCTURE TRAY ADULT 2 $ 33.00 WITCH HAZEL PADA 40 EA $ 6.00 ANTISEPTIC SCRUB ER $ 13.00 POST-OP SHOE MALE SMALL $ 18.00 3-0 SURGIPRO II P-14 $ 15.00 SINERGY INTRODUCER 17X75MM SII-75-5 $ 191.00 3M COBAN 6"X5YD $ 17.00 WITCH HAZEL PADA 12 EA $ 6.00 _LUMBAR PUNCTURE TRAY PEDIATR $ 43.00 I&D TRAY ER $ 33.00 POST-OP SHOE MALE MEDIUM $ 18.00 5-0 ETHILON FS-2 $ 10.00 SINERGY EPSILON RULER SIA-E10 $ 67.00 FOLEY KIT W/TOWER BAG,16FR $ 26.00 THORACENTESIS TRAY 16GAX3 $ 55.00 POST-OP SHOE MALE LARGE $ 18.00 TRANSDISCAL PROBE KIT TDK2-17-150-6 $ 4,783.00 5-0 ETHILON PS-2 $ 46.00 1.4 K-WIRE $ 99.00 SOLUTION SURGICAL DURAPREP 26M $ 21.00 TRANSDISCAL PROBETIP TDP-17-150-6 $ 2,008.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price POST-OP SHOE MALE XLARGE $ 42.00 5-0 MONOSOF P-13 $ 28.00 SOLUTION SURGICAL DURAPREP 6M $ 10.00 STRYKEFLOW II W/ TIP SUC/IRR $ 309.00 TRANSDISCAL + SINERGYCABLE TDX-Y-TSW-TDP $ 1,626.00 POST-OP SHOE FEMALE SMALL $ 18.00 6-0 MONOSOF P-13 $ 38.00 FLUORESCEIN STRIP ER $ 13.00 STAPLER SKIN PRECISE SYSTEM $ 14.00 BIOPSY FORCEPS $ 2,214.00 TRANSDISCAL INTRODUCER TDIB-17-150 $ 381.00 POST-OP SHOE FEMALE MEDIUM $ 18.00 2-0 ETHILON PS-2 $ 13.00 ER COLD PACK $ 16.00 CHLORAPREP 10.5ML $ 14.00 TRANSDISCAL TUBING+BURETTE KIT TDA-TBK-1 $ 458.00 MEROCEL NASAL PACKING 4.5CM $ 128.00 DRESSING ADHESIVE ISLAND NON-ADH PAD STE $ 10.00 POST-OP SHOE FEMALE LARGE $ 18.00 26ML CHLORAPREP $ 25.00 ER HOT PACK $ 16.00 CERVICOLL KIT CEK-17-50-2 $ 2,870.00 MEROCEL NASAL PACKING 8.0CM $ 128.00 VENTILATOR CIRCUIT $ 11.00 .9 % SOD CHLOR. 3000ML IRRIGA $ 26.00 CUTTERS/BURRS ULTIMATE SERIES $ 159.00 EZY SPLINT ROLL 5" $ 35.00 GEN COOLED RF KIT CRK-17-100-4 $ 2,870.00 100FT CORRUGATED TUBING $ 40.00 4.0 MM TOMCAT ARTHROSCOPY BLAD $ 159.00 16" QUICK-FIT BASIC KNEE SPLIN $ 40.00 GEN COOLED RF PROBE TIP CRP 17-100-4 $ 2,008.00 25GA 6" SPINAL NEEDLE $ 10.00 ANEST. BREATHING CIRCUIT $ 8.00 ALBUTEROL SULFATE 90MCG ARIN 8 GM $ 43.00 5.5 MM ROUND BUR ARTHROSCOPY B $ 170.00 18" QUICK-FIT BASIC KNEE SPLIN $ 48.00 EZY SPLINT ROLL 2" $ 19.00 GEN COOLED PROBE NO TIP CRI-17-100 $ 382.00 ADULT BREATHING CIRCUIT $ 13.00 SERFAS PROBE NON-SUCTION $ 99.00 GEN COOLED RF KIT 75MM CRK-17-75-4 $ 2,870.00 EZY SPLINT ROLL 3" $ 24.00 22" QUICK-FIT BASIC KNEE SPLIN $ 52.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price SERFAS PROBE 90 ASD (SUCTION) $ 402.00 10FR 3CC FOLEY $ 17.00 EZY SPLINT ROLL 4" $ 28.00 26" QUICK-FIT BASIC KNEE SPLIN $ 65.00 HEEL FLOAT SMALL $ 22.00 8FR 3CC FOLEY $ 23.00 INSULIN SYRINGE LO-DOSE $ 21.00 ORTHOWEDGE SMALL $ 48.00 7.5 NEOPRENE SURG GLOVE $ 5.00 14FR 23CM LOOP SUPRAPUBIC CATH $ 178.00 18GA 1 1/2" NEEDLE PORTEX $ 1.00 ORTHOWEDGE MEDIUM $ 47.00 7.0 NEOPRENE SURG GLOVE $ 3.00 26FR 5CC FOLEY $ 14.00 GEN II INTRODUCER NEEDLE 17X6" $ 0.01 ORTHOWEDGE LARGE $ 47.00 HEEL FLOAT LARGE $ 128.00 CPLX REP E/N/E/L; 1.0CM/< $ 879.00 ORTHOWEDGE XL $ 48.00 VITAMIN D 400U GCAP 100 EA $ 6.00 5X5CM SKIN GRAFT MATRISTEM $ 2,459.00 2"X10YDS HYPAFIX $ 19.00 PROSTEP CAM WALKER SMALL $ 71.00 3" ECONOMY COTTON STOCKINETTE $ 13.00 AMBU SPUR II ADULT, CLOSED R $ 32.00 PROSTEP CAM WALKER MEDIUM $ 71.00 PRECISION IMPLANTABLE PULSE GE SN115645 $ 105,050.00 LACERATION TRAY SS INSTRU $ 19.00 PROSTEP CAM WALKER LARGE $ 71.00 CAUTERY LOW TEMP FINE TIP $ 23.00 DUAL SPRAY FOR GPS III $ 147.00 OCTRODE PERM LEAD $ 9,673.00 4" CANNULA FOR GPS III $ 159.00 GPS III APPLICATOR KIT $ 120.00 SHOULDER IMMOB W/FOAM L $ 30.00 GPS III SYSTEM $ 1,971.00 CAUTERY HIGH TEMP FINE TIP $ 29.00 LIDOCAINE/EPINEPHRINE 1-0.001% MDV 5X10M $ 6.00 HEELBO MEDIUM BLUE $ 22.00 UNIVERSAL STRYKER SAW BLADE $ 135.00 LIDOCAINE/EPINEPHRINE 2-0.001% MDV 20 ML $ 6.00 HEELBO LARGE WHITE $ 22.00 OIL EMULSION 3IN X 3IN $ 5.00 10% DEX 500ML IN 1K PLASTIC $ 19.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price ZINC GLUCONATE 50MG TABS 100 EA $ 6.00 XL HEELBO $ 23.00 TRAY,IRRIGATION W/60 CC BULB $ 4.00 0.4% LIDOCAINE HCI 5% DEX $ 19.00 CRUTCH ALUM PUSH BTN ADULT $ 30.00 SPONGE GAUZE CURITY 4X4IN 12-P $ 2.00 24FR 5CC FOLEY $ 14.00 .45 SOD CHLORIDE 500ML $ 17.00 ARTHROSCOPY PUMP TUBING $ 164.00 PROXIMAL REVISION KIT $ 1,075.00 5%DEX .33 SOD CHLORIDE $ 17.00 MEDTRONIC IMPLANT ACCESSORY KI $ 1,013.00 IRRIGATION/ TUR SET "Y" TYPE $ 16.00 ACYCLOVIR 0.05 OINT 15 GM $ 630.00 5CC ALLOMATRIX PUTTY $ 3,106.00 5% DEXTROSE &RINGERS INJ 500 $ 4.00 MEDTRONIC IMPLANT ACCESSORY KI $ 1,013.00 10FRX45" ENTERAL FEEDING TUBE $ 52.00 MEDTRONIC IMPLANT ACCESSORY KI $ 1,013.00 MEDTRONIC IMPLANT ACCESSORY KI $ 1,013.00 5.5 ET TUBE $ 22.00 IV PUMP USAGE $ 19.00 MEDTRONIC IMPLANT ACCESSORY KI $ 1,013.00 8.5 ET TUBE $ 97.00 IV START $ 39.00 MEDTRONIC IMPLANT ANTENNA $ 306.00 PERCUTANEOUS DECOMPRESSION DEVICE KIT #M $ 7,685.00 EON MINI CHARGING SYSTEM $ 5,165.00 SLING QUICK RELEASE ARM ENVELOPE MEDIUM $ 13.00 4.0MM RESECTOR CUTTER $ 164.00 SLING QUICK RELEASE ARM ENVELOPE LARGE $ 11.00 HOT BIOPSY FORCEPS (COOK) $ 21.00 4.0MM AGRESSIVE PLUS CUTTER $ 164.00 TEMP THERAPY PAD $ 16.00 1.2 MICRON FILTER EXTENTION SE $ 34.00 4.0MM TOMCAT CUTTER $ 164.00 BLANKET $ 26.00 OR IV TUBING $ 13.00 4.0MM END CUTTER $ 164.00 FIRST FRACTURE KIT 10/2 $ 14,027.00 3-0 VICRYL MHV-26 SUTURE $ 15.00 4.0MM 12 FLUTE ROUND BUR-HOLLO $ 164.00 BONE CEMENT AND MIXER PACK $ 1,088.00 5-0 VICRYL 18" FS-2 CUTTING $ 14.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price 4.0MM 12 FLUTEBARREL BUR-HOLLO $ 164.00 IV INFUSION KIT $ 98.00 EXPRESS CURETTE $ 1,607.00 4-0 VICRYL 18" FS-2 CUTTING $ 21.00 MEDTRONIC PAIN IMPLANT $ 61,483.00 IV PORT FLUSH KIT $ 60.00 BONE FILLER DEVICE - SIZE 2 $ 423.00 6-0 VICRYL UNDYED 18" PC-3 CON $ 31.00 MEDTRONIC PATIENT PROGRAMMER $ 4,552.00 POLYPECTOMY SNARE $ 180.00 IV BLOOD TRANSFUSION KIT $ 76.00 6-0 VICRYL UNDYED 18" PC-3 CON $ 31.00 MEDTRONIC CHARGING SYSTEM $ 9,143.00 BOXER SPLINT LRG LT $ 48.00 BIOCLUSIVE DRESS 2" X 3 $ 37.00 CANE $ 35.00 3X3YD SPECIALIST EXTRA-FAST PL $ 31.00 6X5YD SPECIALIST EXTRA-FAST PL $ 86.00 SPOT INDIAN INK $ 71.00 SECONDARY IV TUBING $ 3.00 COLLAR PHILADELPHIA 5 1/4 IN SM $ 51.00 EON MINI IPG $ 59,007.00 COLLAR PHILADELPHIA 5 1/4 IN MED $ 51.00 EON PROGRAMMER $ 4,064.00 PCA TUBING $ 38.00 COLLAR PHILADELPHIA 5 1/4 IN LRG $ 51.00 MEDTRONIC TRIAL LEAD $ 1,148.00 LACTATED RINGER'S INJ 1000ML $ 17.00 EPIDURAL CATHETER HMS# 2000 $ 340.00 FOLY SILICON 5CC 16FR $ 23.00 DVT BOOT FOR FLOWTRON 17" $ 47.00 THERACATH EPIDURAL CATHETER EC-05000 $ 93.00 SALEM SUMP 10FR $ 1,472.00 DVT BOOT FOR FLOWTRON 23" $ 69.00 DISP DUAL-INCI FALOPE-RING BAND 8MM W T $ 871.00 EPISTAT NASAL CATH II $ 155.00 3" CAST PADDING $ 23.00 DISP DUAL-INCI FALOPE-RING BAND W/O TRO $ 615.00 SALEM SUMP 12FR $ 1,472.00 SIZE 15/2 BALLOONS $ 1,766.00 FALOPE RING BANDS,30 PROCEDURE $ 51.00 SALEM SUMP 14FR $ 6.00 16 FR SILICONE FOLEY CATH $ 51.00 NEUTRON NEEDLEFREE CATHETER LIFESHIELD $ 11.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price SALEM SUMP 16FR $ 5.00 MEDTRONIC SCS IMPLANT $ 71,558.00 SALEM SUMP 18FR $ 6.00 PATIENT PROGRAMMER KIT $ 4,557.00 SONNET SHORT THROW SNARE STAND $ 93.00 VALVE F/SALEM SUMP ANTI-REFLU $ 22.00 MEDTRONIC ACESSORY KIT 377860 $ 9,602.00 PATIENT PROGRAMMER KIT $ 4,557.00 BOXER SPLINT SMALL RT $ 48.00 CATH TROCAR 20FR 16"L $ 1,270.00 PATIENT PROGRAMMER KIT $ 4,557.00 IPG GENERATOR SC-1110-02 $ 71,472.00 BOXER SPLINT SMALL LT $ 48.00 TETANUS/DIPTHERIA TOX > 7 YRS AGE $ 290.00 SHOULDER IMMOB W/FOAM ST XL $ 31.00 PRECISION CHARGING KIT 2.0 SN128768 $ 6,656.00 BOSTON SCIENTIFIC CHARGING KIT SC64123 $ 8,163.00 BOXER SPLINT MED RT $ 48.00 CATH TROCAR 24FR 16"L $ 1,270.00 PROGRAMER KIT SC5500-04 BOS SCIENTIFIC $ 4,748.00 PRECISION CHARGING SYSTEM KIT SN128768 $ 11,115.00 GEN COOLED RF GUAGE CRP-17-75-4 $ 2,008.00 BOXER SPLINT MED LT $ 48.00 CATH TROCAR 28FR 16"L $ 1,270.00 SHORT THROW SNARE STAND $ 19.00 BOXER SPLINT LRG RT $ 48.00 PRECISION CHARGING SYSTEM KIT $ 13,619.00 RADIO-OPAQUE EPIDURAL CATHETER $ 169.00 DISPOSIBLE SCLEROTHERAPY NEEDL $ 100.00 WAYNE PNEUMOTHORAX $ 552.00 RAPID FIRE LIGATOR $ 249.00 MONOSOF 6/0 18IN BLACK P-24 $ 33.00 INNER CANNULA DISPOSABLE $ 25.00 ELIM PYLORIC/COLONIC $ 362.00 SURGIPRO 4/0 18IN BLUE FS-2 C- $ 31.00 SENSOR BATTERY IMPLANT $ 71,558.00 3-0 SURGIPRO 18" C-14 CUTTING $ 15.00 ADULT PACER PADS $ 60.00 20GA 3/4" GRIPPER HUBER NEEDLE $ 15.00 PEDIATRIC PACER PAD $ 60.00 20GA 1" GRIPPER HUBER NEEDLE $ 15.00 ENT(WOODS LAMP)TRAY $ 49.00 20GA 1 1/4" GRIP HUBER NEEDLE $ 15.00 JACKSON-PRATT WOUND DRAIN 10MM $ 39.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price SPIROMETER COACH-2 $ 31.00 GEN COOLED RF PROBE CRI 17-75 $ 382.00 25GA 3CC SYRINGE & NEEDLE $ 21.00 LUMBAR PROBE LUP-17-150-4 $ 2,008.00 22GA 6" SPINAL NEEDLE $ 9.00 3.5MM CORTICAL SCREW, SLF TAPPING SM HEX $ 98.00 22GA 8" SPINAL NEEDLE $ 10.00 4.0MM CANCELLOUS SCREW SM HEX FULL RECES $ 98.00 FLUOR-GUIDE STEERABLE CATH KIT $ 427.00 4.0MM 1/3 THREAD CANULATED SCREW 00-1147 $ 246.00 TARGET CATH ACCESSORIES KI $ 86.00 ONE-THIRD TUBULAR PLATE WITH COLLAR $ 60.00 NEEDLE EPIDURAL 18GX6IN DETAC $ 14.00 K WIRE $ 53.00 17G X 3.5" WAVE POINT INTRODUC $ 34.00 TENSION BAND WIRE $ 28.00 TUBING OXYGEN 7FT CRSH RESIS $ 13.00 CANNULA CURVED SHARP 10MMX100MM 20GA $ 74.00 CONNECTOR OXYGEN TUBING CONN $ 13.00 PNEUMOTHORAX TRAY $ 668.00 AIR MATTRESS $ 175.00 COUDE BLUNT NERVE BLOCK NEEDLE 20 GA $ 62.00 EYE TRAY $ 49.00 IV SALINE LOC $ 26.00 STIRRUP WITH SLIP RING#52712 $ 16.00 3" SCOTCH PLUS CAST TAPE $ 11.00 PROGRAMMER 8835 PERSONAL THERAPY $ 2,716.00 SHOULDER ARTHROSCOPY PACK#7779972 $ 338.00 4" SCOTCH PLUS CST TP $ 15.00 PUMP 8637-20 BATTERY PACEMAKER $ 38,256.00 5.0FR TURBOJECT PICC SET#403806 $ 631.00 ER IODOFORM PAC /= 1X5YD $ 18.00 3.5MM SURFAS SUCT#1246 $ 159.00 ER ARM SLING CHILD $ 15.00 26ML CHLORAPREP WITH TINT#1238 $ 30.00 ER ARM SLING ADULT $ 15.00 ER SMOOTH PADING 4-6+" $ 16.00 CANE $ 35.00 ER LEG SPLINT $ 49.00 ER SOFT CAST JONES $ 19.00 COLLES(COCK UP) SPLINT $ 19.00 CLAVICLE STRAP ANY SIZE $ 24.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price ER CERVICAL COLLAR $ 24.00 ER CATH TROCAR ANY SIZE $ 47.00 ER CATH FOLEY(DOVER) ANY SIZE $ 55.00 ER CATH FOLEY(BARD) ANY SIZE $ 30.00 ER WRIST IMMOB/SPLINT $ 33.00 ER RAPID RHINO/EPITAXIS ANY CM $ 87.00 ER STERI STRIPS $ 26.00 SPIROMTR,VOL INCENT4000ML W $ 10.00 ER PELVIC EXAM SUPPLIES $ 26.00 IV SUPPLIES SOLUTIONING $ 44.00 FLOWMTR PEAK ASTHMA $ 38.00 SUTURES POLYSORB $ 11.00 ROTH NET 2.5MM DISPOSIBLE $ 322.00 ER PLAIN PACKING STRIP $ 10.00 FLUORO-GUIDED STEERABLE CATH $ 116.00 ER IODOFORM PACKING STRIP $ 17.00 PERFIX PLUG MEDIUM, 1.3" X 1. $ 1,749.00 ER SPINAL NEEDLE ANY SIZE $ 17.00 PERFIX PLUG LARGE, 1.6" $ 1,348.00 CRUTCHES ANY SIZE $ 48.00 CATH 16FR 2WAY COUDE $ 63.00 ER ABSORBABLE HEMOSTATE 4 X 8 INCHES $ 100.00 GLUCOMETER $ 17.00 METER PEAK FLOW $ 68.00 GLUCOMETER X2 $ 35.00 6" STOCKINETTE DBLE PLY STRL $ 14.00 GLUCOMETER X3 $ 35.00 GLUCOMETER X4 $ 44.00 AIR-STIRRUP ANKLE BRACE UNIVE $ 56.00 AUTOSUTURE ROYAL 35W SKIN STAPLER $ 67.00 2.5MM SMALL-JOINT FULL RADIUS $ 170.00 ETHIBOND GREEN 30" CT-1 TAPER $ 13.00 TICRON BLUE 5 X 18" GS-22 TAPER $ 34.00 CATHETHER SECUREMENT KIT $ 17.00 4.5CM SMALL ANATOMY/PEDIATRICS $ 110.00 5.5CM FOR ADULT EPISTAXIS $ 91.00 8CMX5M COMPRILAN $ 18.00 10CMX5M COMPRILAN $ 22.00 TRAECHEOSTOMY SET 3.5MM $ 545.00 TRAECHEOSTOMY SET 4.0MM $ 545.00 17G TUOHY NDL WINGED#491117 $ 10.00 17G TUOHY NEEDLE#4908 $ 23.00 5.0 BARRELL BURR#3759511 $ 192.00 MEDIHONEY TOPICAL APPLICATION GEL/JELLY $ 154.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price 8FR CATHETER KIT 10820 $ 13.00 5FR CATH KIT 10815 $ 13.00 JMAX TRIGGER FLEX LOT 13070112A $ 1,224.00 JMAX VERTICAL ISOLATION DRAPE D122822 $ 153.00 JMAX TUBING SET JIFP2000 IRRIGATION PUMP $ 153.00 JMAX DISP ACCESS KIT W/3 REAMERS FINE 98 $ 4,208.00 CRUTCHES-S $ 29.00 JMAX NEEDLE GUIDE WIRE SET $ 210.00 AVAMAX BONE CEMENT DELIVERY SYS VMX00CT $ 2,569.00 AFLEX VERTEBRAL BALLOON TRAY10X20AFB1020 $ 8,799.00 PREC SPEC IMPLANT PULSE GEN KIT SN115645 $ 51,874.00 PREC SPEC REMOTE CONTROL KIT SN201138 $ 5,434.00 AQUACEL DRESSING $ 23.00 ANGLED TOMCAT 4.5MM 3805451 $ 192.00 SOFSILK 4-0 $ 15.00 CHROMIC GUT 4-0 $ 19.00 BIOSYN 5-0 $ 13.00 CHROMIC GUT 5-0 $ 31.00 BIOSYN 6-0 $ 15.00 6"X.035 TROCAR 2 END K-WIRE $ 28.00 6"X.035 TROCAR 1 END K-WIRE $ 28.00 6"X.045 TROCAR 2 END K-WIRE $ 28.00 6"X.045 TROCAR 1 END K-WIRE $ 28.00 6"X.062 TROCAR 2 END K-WIRE $ 28.00 6"X.062 TROCAR 1 END K-WIRE $ 28.00 18GAUGE ORTHO WIRE $ 44.00 HERCULES 3 STAGE #431928 $ 323.00 PRISM DRESSING 5562028 $ 44.00 PLEURX VACUUM BOTTLE 5072102 $ 180.00 WOUND ULTRASOUND $ 76.00 THERAPY PUTTY $ 39.00 SPEECH DEVELOP EX 60 $ 721.00 SPEECH LANGUAGE GRP 60 MIN $ 161.00 DEBRIDEMENT TRAY $ 82.00 DEBRIDEMENT TRAY $ 82.00 levothyroxine 100 MCG TABLET 100 mcg, 100 eaches $ 17.00 Brilinta 90 MG TABLET 90 mg, 60 eaches $ 21.00 THEOPHYLLINE ER 300 MG TAB 300 mg, 100 eaches $ 13.00 EZETIMIBE 10 MG TABLET 10 mg, 1 each $ 37.50 OSELTAMIVIR PHOS 75 MG CAPSULE 75 mg, 10 eaches $ 46.38 MEGESTEROL UNIT DOSE 400 MG / 10 ML $ 7.50 LABETALOL HCL 5MG/ML MDV 20 ML $ 45.00 ACTOS 15 MG $ 21.05 2X8 OR CABLE (60 CM) & EXTENSION $ 1,845.00 Ellenville Regional Hospital - List of Standard Charges 02.01.20

Description Price DUTASTERIDE 0.5 MG CAPSULE 0.5 mg, 30 eaches $ 18.00 DONNATAL ELIXIR 5 mL, 5 mL $ 126.00 PRAMIPEXOLE 1 MG TABLET 1 mg, 30 eaches $ 6.00 Narcan 4 MG NASAL SPRAY 4 mg, 2 eaches $ 225.00 cefoTAXime SODIUM 1 GM VIAL 1 g, 1 each $ 8.00 BALANCE B-50 TABLET 1 ea, 1 each $ 6.00 morphine SULFATE 10 MG/ML VIAL 10 mg, 1 mL $ 7.00 MISOPROSTOL 100 MCG TABLET $ 6.18 TPN, UP TO ONE LITER PER DAY, ALL SUPPLIES/EQUIPMENT $ 390.00 TPN, > 1 LITER, <= 2 LITER PER DAY, ALL SUPPLIES/EQUIPMENT $ 420.00 TPN, > 2, <=3 LITERS PER DAY, ALL SUPPLIES/EQUIPMENT $ 450.00 TPN, > 3 LITERS PER DAY, ALL SUPPLIES/EQUIPMENT $ 480.00 PUMP RENTAL FEE $ 15.00 TRAVATAN Z OS $ 555.94 VIREAD 300 MG TABLET $ 105.00 KETAMINE HCL 50MG/ML SDV 10X10ML $ 22.15 DORZOLAMIDE HCL 2% EYE DROPS 10 mL, 10 mL $ 200.00 ISENTRESS 400 MG TABLET $ 90.00 TRUVADA 200/300 TABLET $ 201.00 AMIODARONE HCL 200MG TABS 100 EA $ 7.50 AMOXICILLIN/POT CLAVULANATE 400-57MG/5ML $ 6.18 XIFAXAN 550 MG TABLET 550 mg, 60 eaches $ 132.00 FNA BX, W/ US GUIDE; 1ST LES $ 1,738.00 FNA BX, W/ US GUIDE; EA ADDL LES $ 180.00 FNA BX W/FLUOR GDN 1ST LES $ 1,738.00 FNA BX W/FLUOR GDN EA ADDL $ 222.00 FNA BX, W/ CT GUIDE; 1ST LES $ 1,738.00 FNA BX, W/ CT GUIDE; EA ADDL LES $ 300.00 FNA BX, W/ MR GUIDE; 1ST LES $ 1,738.00 FNA BX, W/ MR GUIDE; EA ADDL LES $ 300.00 TANGNTL BX SKIN SINGLE LES $ 529.00 TANGNTL BX SKIN EA SEP/ADDL $ 90.00 PUNCH BX SKIN SINGLE LESION $ 529.00 PUNCH BX SKIN EA SEP/ADDL $ 100.00 INCAL BX SKN SINGLE LES $ 942.00 INCAL BX SKN EA SEP/ADDL $ 120.00 RPLC GTUBE NO REVJ TRC $ 694.00 RPLC GTUBE REVJ GSTRST TRC $ 694.00 DILAT XST TRC NDURLGC PX $ 5,219.00 DILAT XST TRC NEW ACCESS RCS $ 8,781.00 MRI, BREAST, W/O CONTRAST; UNI $ 692.00 MRI, BREAST, W/O CONTRAST; BILAT $ 692.00 CAD BREAST MRI $ 100.00