NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price No Show/Cancellation 00000 $25 $25 $15 CPM-No Show/Cancellation $50 00002 $50 $50 $30 Injection(s), platelet rich plasma, any site, incl 0232T 0361 $954 $288 $1,242 $745 Fine Needle Aspiration without Imaging 10021 0361 $182 $111 $293 $176 ACNE SURGERY MILIA CYSTS (10040) 10040 0361 $338 $248 $586 $352 Incision and Drainage of Abscess, single or simple 10060 0361 $580 $380 $960 $576 Incision and Drainage of Abscess, complicated or m 10061 0361 $585 $680 $1,265 $759 I&D PILONID CYS; SMPL (10080) 10080 0361 $572 $291 $863 $518 I&D PILONID CYST; CPLX (10081) 10081 0361 $3,306 $493 $3,799 $2,279 FB removal in sub q-simple 10120 0361 $955 $376 $1,331 $799 FB removal in sub q-complex 10121 0361 $5,114 $780 $5,894 $3,536 Incision and Drainage of Hematoma, Seroma or Fluid 10140 0361 $4,755 $497 $5,252 $3,151 Incision and drainage complex, post-op infection 10180 0361 $6,011 $753 $6,764 $4,058 DEBR EXZ/INF SKIN; 10% BS (11000) 11000 0361 $992 $76 $1,068 $641 DEBRIDE INFECTED SKIN ADD-ON =<10% BS (11001) 11001 0361 $338 $38 $376 $226 DEBR NECROTIZ ST - GENITALS & PERINEUM (11004) 11004 $1,654 $1,654 $992 DEBR NECROTIZ STISS - ABD WALL (11005) 11005 $2,277 $2,277 $1,366 DEBR W OPEN FX; SKIN & SQ Charge (11010) 11010 0361 $1,812 $1,164 $2,976 $1,786 Debride Skin to Muscle, Open FX 11011 0361 $1,532 $1,318 $2,850 $1,710 Deb skin bone at FX site 11012 0360 $1,796 $1,794 $3,590 $2,154 Debridement-skin, 20 Sq cm/< (11042) 11042 0361 $1,109 $208 $1,317 $790 Debridement-skin , sub q, muscle/fascia 20 Sq cm/< 11043 0361 $1,184 $977 $2,161 $1,297 DEB BONE 20 SQ CM/< (11044) 11044 0361 $2,938 $1,344 $4,282 $2,569 Deb Subq Tissue ADD-on=<20 Sq cm 11045 0361 $963 $74 $1,037 $622 DEB MUSC/FASCIA ADD-ON =<20 SQ CM 11046 0361 $963 $161 $1,124 $674 Deb Bone ADD-on =<20 Sq cm 11047 0361 $3,000 $280 $3,280 $1,968 Paring or cutting of benign hyperkeratotic lesion 11055 0361 $99 $99 $59 Paring or cutting of benign hyperkeratotic lesion, 11056 0361 $140 $140 $84 Paring or cutting of benign hyperkeratotic lesion, 11057 0361 $184 $184 $110 Removal Skin Tags 11200 0361 $326 $282 $608 $365 Removal Skin Tags 11200 0361 $326 $282 $608 $365 REMOVE SKIN TAGS ADD-ON =<10 LESIONS (11201) 11201 0361 $338 $44 $382 $229 SHAVE LES S/N/H/F/G; 0.6-1.0CM (11306) 11306 0361 $382 $191 $573 $344 SHAVE LES S/N/H/F/G; 1.1-2.0CM (11307) 11307 0361 $382 $245 $627 $376 EXC TR-EXT B9+MARG 0.5CM/< (11400) 11400 0361 $296 $296 $178 EXC BEN LES T/A/L; 0.6-1.0CM (11401) 11401 0361 $393 $393 $236 Exc. Benign Les T/A/L; 1-1-2.0 CM 11402 0361 $1,796 $455 $2,251 $1,351 EXC BEN LES T/A/L; 2.1-3.0CM (11403) 11403 0361 $558 $558 $335 EXC BEN LES T/A/L; 3.1-4.0CM (11404) 11404 0361 $247 $247 $148 EXC BEN LES T/A/L; > 4.0CM (11406) 11406 0361 $953 $953 $572 EXC BLES S/N/EX G; 0.5CM/< (11420) 11420 0361 $2,660 $218 $2,878 $1,727 EXC BLES S/N/EX G; 0.6-1.0CM (11421) 11421 0361 $2,767 $312 $3,079 $1,847 EXC BLES S/N/EX G; 1.1-2.0CM (11422) 11422 0361 $2,767 $381 $3,148 $1,889 EXC BLES S/N/EX G; 2.1-3.0CM (11423) 11423 0361 $5,319 $445 $5,764 $3,458 EXC BLES S/N/EX G; 3.1-4.0CM (11424) 11424 0361 $5,018 $632 $5,650 $3,390 EXC FACE-MM B9+MARG 0.5CM/< (11440) 11440 $372 $372 $223 EXC FACE-MM B9+MARG 0.6-1 CM (11441) 11441 $476 $476 $286 EXC FACE-MM B9+MARG 1.1-2 CM (11442) 11442 $531 $531 $319 EXC FACE-MM B9+MARG 2.1-3 CM (11443) 11443 $652 $652 $391 EXC FACE-MM B9+MARG 3.1-4 CM (11444) 11444 0361 $2,922 $839 $3,761 $2,257 EXC FACE-MM B9+MARG > 4 CM (11446) 11446 $1,210 $1,210 $726 EXC HIDRAD AXIL; CPLX REP (11451) 11451 $1,209 $1,209 $725 EXC HIDRAD AXIL; CPLX REP; Bilateral (11451-50) 1145150 $1,814 $1,814 $1,088 EXC H-F-NK-SP MAL+MARG 0.5 < (11620) 11620 0361 $2,922 $446 $3,368 $2,021 EXC S/N/H/F/G MAL+MRG 1.1-2 (11622) 11622 0361 $2,922 $627 $3,549 $2,129 Debride Nail 1-5 (11720) 11720 0361 $267 $54 $321 $193 Avulsion of nail plate, partial or complete, simpl 11730 0361 $617 $168 $785 $471 Excision nail matrix-ingrown nail 11750 0361 $720 $720 $432 Repair Nail Bed (11760) 11760 0361 $872 $470 $1,342 $805 Wedge Exc Nail Fold 11765 0361 $321 $266 $587 $352 Injection intralesional; up to and incl. 7 lesions 11900 $115 $115 $69 Injection, intralesional; more than 7 lesions (119 11901 $180 $180 $108 Simple Repair S/N/A/G/TR/E; 2.5CM/< (12001) 12001 0361 $367 $164 $531 $319 Simple Repair PS/N/A/G/TR/E; 2.6-7.5 CM 12002 0361 $469 $293 $762 $457 Simple repair S/N/G/TR/E; 7.6-12.5 CM 12004 0361 $451 $233 $684 $410 Repair, Intermediate S/T/Ext/2.5 cm/< 12031 0361 $560 $653 $1,213 $728 INTMD WND REPAIR S/A/T/EXT, 2.6-7.5 cm (12032) 12032 $709 $709 $425 INTMD WND REPAIR S/TR/EXT 7.6-12.5 CM (12034) 12034 0361 $872 $734 $1,606 $964 INTMD WND REPAIR S/A/T/EXT (12035) 12035 0361 $1,192 $693 $1,885 $1,131 INTMD WND REPAIR S/A/T/EXT (12036) 12036 0361 $1,146 $776 $1,922 $1,153 INTMD WND REPAIR S/TR/EXT 30.0+ CM (12037) 12037 $1,239 $1,239 $743 Repair, intermediate, wounds of neck, hands, feet 12042 0361 $1,146 $541 $1,687 $1,012 Repair, Complex, Trunk; 2.6 cm to 7.5 cm 13101 0361 $555 $439 $994 $596 Repair, complex, scalp, arms, and/or legs; 2.6 cm 13121 0361 $1,866 $985 $2,851 $1,711 Secondary closure of surgical wound or dehiscence, 13160 0361 $7,674 $3,360 $11,034 $6,620 ATT TRUNK; D 10 SQ CM/< (14000) 14000 0361 $5,270 $1,435 $6,705 $4,023 ATT TRUNK; D 10.1-30 SQ (14001) 14001 0361 $5,270 $1,863 $7,133 $4,280 ATT S/A/L; D 10 SQ CM/< (14020) 14020 0361 $5,270 $1,618 $6,888 $4,133 ATT S/A/L; D 10.1-30 SQ CM (14021) 14021 0361 $5,270 $2,037 $7,307 $4,384

Page 1 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price ATT F/C/M/N/A/G/H/F; 10 SQ CM (14040) 14040 0361 $5,270 $1,791 $7,061 $4,237 ATT F/C/M/N/A/G/H/F; 10.1-30SQCM (14041) 14041 0361 $5,270 $2,193 $7,463 $4,478 ATT E/N/E/L; D 10 SQ CM (14060) 14060 0361 $5,270 $1,906 $7,176 $4,306 ATT E/N/E/L; D 10.1-30 (14061) 14061 0361 $5,270 $2,342 $7,612 $4,567 SKIN TISSUE REARRANGEMENT 30.1-60.0 SQ CM (14301) 14301 0361 $7,158 $2,514 $9,672 $5,803 SKIN TISSUE REARRANGE ADDL 30.0 SQ CM (14302) 14302 0361 $7,158 $625 $7,783 $4,670 WOUND PREP TRK/ARM/LEG 100 SQ CM/1% BA (15002) 15002 $628 $628 $377 WOUND PREP ADDL 100 CM (15003) 15003 $133 $133 $80 WOUND PREP F/N/HF/G 100 SQ CM/1% BA (15004) 15004 $770 $770 $462 WND PREP F/N/HF/G ADDL 100 SQ CM/1% BA (15005) 15005 $263 $263 $158 SKIN SPLT GRFT TRNK/ARM/LEG 100 SQ CM/1% BA (15100 15100 $2,062 $2,062 $1,237 SKIN SPLT GRFT T/A/L ADDL 100 SQ CM/1% BA (15101) 15101 $319 $319 $191 SKN SPLT A-GRFT FAC/NCK/HF/G 100 SQ CM/1% BA (1512 15120 $1,988 $1,988 $1,193 SKN SPLT A-GRFT F/N/HF/G ADDL 100 SQ CM/1% BA (151 15121 $379 $379 $227 SKIN FULL GRAFT SCLP/ARM/LEG =< 20 SQ CM (15220) 15220 $1,754 $1,754 $1,052 SKIN FULL GRAFT S/A/L ADDL =<20 SQ CM (15221) 15221 $206 $206 $124 SKIN FULL GRFT FACE/GENIT/HF =< 20 SQ CM (15240) 15240 $2,275 $2,275 $1,365 SKIN FULL GRAFT F/C/C/M/N/AX/G/H/F ADDL =<20 SQ CM 15241 $319 $319 $191 SKIN SUB GRAFT TRNK/ARM/LEG (15271) 15271 0361 $5,747 $339 $6,086 $3,652 SKIN SUB GRAFT T/A/L ADD-ON (15272) 15272 0361 $398 $66 $464 $278 SKIN SUB GRAFT FACE/NK/HF/G (15275) 15275 0361 $1,080 $396 $1,476 $886 SKIN SUB GRAFT F/N/HF/G ADDL (15276) 15276 0361 $398 $95 $493 $296 MUSCLE FLAP; TRUNK (15734) 15734 $3,821 $3,821 $2,293 MUSCLE FLAP; UPPER EXTREMITY (15736) 15736 $3,315 $3,315 $1,989 MUSCLE FLAP; LOWER EXTREMITY (15738) 15738 0361 $7,158 $3,593 $10,751 $6,451 EXC C P ULCER; W 1' SUTURE (15920) 15920 $1,756 $1,756 $1,054 EXC C P ULCER; W FLAP (15922) 15922 $2,250 $2,250 $1,350 EXC S P ULCER W SKIN FLAP (15934) 15934 $2,667 $2,667 $1,600 EXC S P ULCER PREP FOR FLAP (15936) 15936 $2,582 $2,582 $1,549 ESC I P ULCER W OSTECT & FLAP (15946) 15946 0361 $7,158 $4,724 $11,882 $7,129 EXC T P ULCER; W FLAP (15956) 15956 $3,207 $3,207 $1,924 DESTRUCT B9 LESION 1-14 (17110) 17110 0361 $382 $245 $627 $376 Mammaplasty, augmentation; with prosthetic implant 19325 0361 $2,431 $2,431 $1,459 Removal of mammary implant material (19330) 19330 0361 $2,382 $2,382 $1,429 Open periprosthetic capsulotomy, breast (19370) 19370 0361 $2,582 $2,582 $1,549 EXPL P WND; EXTREM (20103) 20103 0361 $3,851 $1,313 $5,164 $3,098 Excision epiphyeal bar 20150 0361 $3,942 $3,942 $2,365 MUSCLE BX; SUPERF (20200) 20200 0361 $5,319 $276 $5,595 $3,357 Biopsy, muscle deep 20205 0361 $628 $628 $377 MUSCLE BX; PERC NDL (20206) 20206 $162 $162 $97 BONE BX TR/NDL; SUPERF (20220) 20220 0361 $2,767 $198 $2,965 $1,779 Aspiration (biopsy) deep (femur, vertebral body) 20225 0361 $518 $518 $311 OPEN SUPERF BONE BX (20240) 20240 0361 $7,874 $626 $8,500 $5,100 Exc Bone BX;DEEP 20245 0361 $2,675 $2,675 $1,605 Removal of foreign body in muscle or tendon sheath 20520 0361 $1,726 $416 $2,142 $1,285 Injection Therapeutic Carpal Tunnel Charge (20526) 20526 0361 $955 $251 $1,206 $724 Injection Therapeutic Carpal Tunnel-Bilateral Char 2052650 0361 $1,447 $378 $1,825 $1,095 Injection Tendon Sheath, Ligament Charge (20550) 20550 0361 $955 $182 $1,137 $682 Injection Tendon Origin/Insertion Charge (20551) 20551 0361 $955 $182 $1,137 $682 Injection Trigger Point(s): 1 or 2 Muscle(s) Charg 20552 0361 $955 $176 $1,131 $679 Injection Trigger Point(s): 3 or more Muscle(s) Ch 20553 0361 $955 $176 $1,131 $679 NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES (205 20560 0361 $47 $47 $28 NEEDLE INSERTION W/O INJECTION 3 OR MORE MUSCLES ( 20561 0361 $71 $71 $43 Arthrocentesis Small Joint Charge (20600) 20600 0361 $889 $118 $1,007 $604 Arthrocentesis Small Joint - Bilateral Charge (206 2060050 0361 $1,336 $179 $1,515 $909 DRAIN/INJ SMALL JOINT/BURSA W/US (20604) 20604 0361 $889 $155 $1,044 $626 DRAIN_INJ SMALL JOINT_BURSA W_US, Bilateral (20604 2060450 0361 $1,336 $235 $1,571 $943 Arthrocentesis Intermediate Joint Charge (20605) 20605 0361 $889 $125 $1,014 $608 CA-Arthrocentesis Intermediate Joint/Bursa 20605 0361 $917 $193 $1,110 $666 Arthrocentesis Intermediate Joint - Bilateral Char 2060550 0361 $1,336 $185 $1,521 $913 DRAIN/INJ INTER JOINT/BURSA W/US (20606) 20606 0361 $889 $179 $1,068 $641 DRAIN/INJ INTER JOINT/BURSA W/US,Bilateral (20606- 2060650 0361 $1,336 $269 $1,605 $963 Arthrocentesis Major Joint Charge (20610) 20610 0361 $889 $156 $1,045 $627 Arthrocentesis Major Joint Bilateral Charge (20610 2061050 0361 $1,336 $237 $1,573 $944 DRAIN/INJ MAJOR JOINT/BURSA W/US (20611) 20611 0361 $889 $214 $1,103 $662 DRAIN/INJ MAJOR JOINT/BURSA W/US, Bilateral (20611 2061150 0361 $1,336 $321 $1,657 $994 Aspiration/Injection Ganglion Cyst Charge (20612) 20612 0361 $889 $142 $1,031 $619 Aspiration/injection bone cyst 20615 0361 $666 $666 $400 Plate Removal 20680 0361 $7,573 $2,058 $9,631 $5,779 Application ex-fix 20690 0361 $2,044 $2,044 $1,226 Removal, under anesthesia, of external fixation sy 20694 0361 $1,457 $1,457 $874 BONE GRFT; MINOR/SM (20900) 20900 $663 $663 $398 Bone Graft Ileum 20902 0361 $1,565 $1,565 $939 Division of SCM for torticollis 21720 0361 $1,651 $1,651 $991 EXC ABD LES SC 3 CM/> (22903) 22903 0361 $7,915 $1,619 $9,534 $5,720 Incision bone cortex (osteomyelitis) shoulder area 23035 0361 $2,989 $2,989 $1,793 Arthrotomy, glenohumeral joint 23040 0361 $3,102 $3,102 $1,861 EXC SHOULDER LES SC 3 CM/> (23071) 23071 0361 $7,915 $1,569 $9,484 $5,690 EXC BC/B Tumor Clav/Scapula 23140 0361 $8,113 $2,131 $10,244 $6,146

Page 2 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price EXC BC/B Tumor Clav/Scapula, Bilateral 2314050 0361 $12,170 $3,197 $15,367 $9,220 Excision or curettage of bone cyst of proximal hum 23150 0361 $2,777 $2,777 $1,666 Removal of Humerus Lesion;with allograft 23156 0361 $2,878 $2,878 $1,727 Removal of Humerus Lesion;with allograft, Bilatera 2315650 0361 $4,125 $4,125 $2,475 Scapulopexy 23400 0361 $3,457 $3,457 $2,074 Closed Red. Clavicle w/Man 23500 0361 $671 $671 $403 Closed Red. Clavicle w/o Man 23505 0361 $1,153 $1,153 $692 Open treatment of clavicular fracture 23515 0361 $2,902 $2,902 $1,741 OP TX SCLAV DISL ACUTE/CHR (23530) 23530 0361 $16,551 $2,163 $18,714 $11,228 Closed Red. Prox Humerus w.o Man 23600 0361 $955 $955 $573 Closed treatment of proximal humerus fracture with 23605 0361 $1,788 $1,788 $1,073 Open treatment of proximal humerus fracture 23615 0361 $3,657 $3,657 $2,194 Deep I&D - UA/ELBOW (23930) 23930 0361 $6,878 $777 $7,655 $4,593 Arthrotomy, elbow 24000 0361 $2,014 $2,014 $1,208 Excision Osteochondroma Humerus 24110 0361 $2,502 $2,502 $1,501 Remove/Graft bone lesion; with allograft 24116 0361 $3,737 $3,737 $2,242 Remove/Graft bone lesion; with allograft, Bilatera 2411650 0361 $5,318 $5,318 $3,191 Elbow Arthrogram inj 24220 0361 $304 $304 $182 Elbow Arthrogram inj, Bilateral 2422050 0361 $606 $606 $364 Manipulation Elbow G/A 24300 0361 $1,316 $1,316 $790 Muscle/Tendon Transfer Upper Arm/Elbow, Single 24301 0361 $2,637 $2,637 $1,582 Tendon Lengthening, upper arm/elbow, each tendon 24305 0361 $4,696 $4,696 $2,818 Tenotomy Elbow/Shoulder (ea) 24310 0361 $2,030 $2,030 $1,218 Flexor-Plasty Elbow 24330 0361 $2,389 $2,389 $1,433 Osteotomy humerus 24400 0361 $3,568 $3,568 $2,141 Closed TX Humerus Shaft FX w/o Man 24500 0361 $1,263 $1,263 $758 Treatment of humeral shaft fracture with intramedu 24516 0361 $3,761 $3,761 $2,257 Closed TX Supracondylar Humeral FX w/o Man 24530 0361 $1,369 $1,369 $821 Closed TX Supracondylar Humeral FX w/ Man 24535 0361 $2,413 $2,413 $1,448 Percutaneous skeletal fixation of supracondylar fr 24538 0361 $3,225 $3,225 $1,935 Open treament of humeral supracondylar fracture 24545 0361 $3,829 $3,829 $2,297 Open treatment of humeral supacondylar fracture wi 24546 0361 $4,665 $4,665 $2,799 Open treatment of humeral epicondylar fracture 24575 0361 $3,231 $3,231 $1,939 Closed TX Humeral Condyle Med/Lat w/o Man 24576 0361 $1,195 $1,195 $717 Open treatment of humeral condylar fracture 24579 0361 $3,631 $3,631 $2,179 Treat Humerus Fracture 24582 0361 $3,282 $3,282 $1,969 Treat Humerus Fracture, Bilateral 2458250 0361 $5,761 $5,761 $3,457 OP TX ELBOW PA FX/DISLOC (24586) 24586 0361 $24,537 $4,077 $28,614 $17,168 TX CL ELBOW DISLOC W ANESTH (24605) 24605 $1,466 $1,466 $880 Closed treatment of Monteggia fracture 24620 0361 $2,336 $2,336 $1,402 Open treatment of Monteggia fracture 24635 0361 $3,687 $3,687 $2,212 Closed TX Radial Head/Neck FX w/o Man 24650 0361 $915 $915 $549 Closed treatment of radial neck fracture, with man 24655 0361 $1,639 $1,639 $983 Open treatment of radial neck fracture 24665 0361 $2,793 $2,793 $1,676 Closed TX Ulnar FX Prox w/o Man 24670 0361 $1,027 $1,027 $616 Open treatment of olecranon fracture 24685 0361 $2,827 $2,827 $1,696 Decompression fasciotomy forearm 25020 0361 $2,549 $2,549 $1,529 With Debridement Muscle 25023 0361 $4,816 $4,816 $2,890 Incision bone cortex, forearm/wrist 25035 0361 $3,098 $3,098 $1,859 Arhtrotomy wrist, I&D 25040 0361 $2,492 $2,492 $1,495 Excision ganglion 25111 0361 $1,364 $1,364 $818 Excision/Curretage Bone Cyst Radius/Ulna 25120 0361 $2,470 $2,470 $1,482 Removal of Wrist Bone 25215 $2,533 $2,533 $1,520 Forearm Flexor Lenghtening each tendon 25280 0361 $4,859 $4,859 $2,915 Pronator Teres Release Each Tendon 25290 0361 $2,389 $2,389 $1,433 Flexor Carpo Ulnaris Transfer 25310 0361 $3,874 $3,874 $2,324 Flexor Origin Slide Forearm/Wrist 25315 0361 $3,425 $3,425 $2,055 Osteotomy Radius (Distal) 25350 0361 $3,465 $3,465 $2,079 Osteotomy Ulna 25360 0361 $3,381 $3,381 $2,029 Osteotomy Radius & Ulna 25365 0361 $4,510 $4,510 $2,706 Epiphyseal Arrest Distal Radius or Ulna 25450 0361 $2,470 $2,470 $1,482 Epiphyseal Arrest Radius and Ulna 25455 0361 $2,637 $2,637 $1,582 Closed TX Radial Shaft w/o Man 25500 0361 $943 $943 $566 Closed TX Radial Shaft w/ Man 25505 0361 $1,917 $1,917 $1,150 Open treatment of radial shaft fracture 25515 0361 $2,899 $2,899 $1,739 Closed treatment of Galeazzi fracture 25520 0361 $2,189 $2,189 $1,313 Open treatment of Galeazzi fracture 25525 0361 $3,607 $3,607 $2,164 Closed TX Ulnar Shaft w/ Man 25535 0361 $1,879 $1,879 $1,127 Open treatment of ulna shaft fracture 25545 0361 $2,757 $2,757 $1,654 Closed TX Radial & Ulnar Shaft w/o Man 25560 0361 $930 $930 $558 Closed TX Radial & Ulnar Shaft w/ Man 25565 0361 $1,980 $1,980 $1,188 Open treatment of radial AND ulna shaft fracture 25574 0361 $2,774 $2,774 $1,664 With Internal Fixation of Radial AND Ulna 25575 0361 $3,800 $3,800 $2,280 Closed TX Distal Radius w/o Man 25600 0361 $1,037 $1,037 $622 Closed TX Distal Radius w/Man 25605 0361 $2,359 $2,359 $1,415 Percutaneous fixation of distal radial fracture 25606 0361 $2,873 $2,873 $1,724 Open treatment of distal radial fracture 25607 0361 $2,973 $2,973 $1,784 Closed TX Carpal Bone w/o Man (ea) 25630 0361 $1,089 $1,089 $653 Arthrodesis Wrist Complete 25800 0361 $3,251 $3,251 $1,951

Page 3 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price Arthrodesis Wrist w/Sliding Graft 25805 0361 $3,729 $3,729 $2,237 Arthrodesis with Bone Graft 25810 0361 $3,715 $3,715 $2,229 INTERCARPAL FUSION, WO BONE GRAFT (25820) 25820 0361 $15,488 $2,018 $17,506 $10,504 Drainage of finger abscess 26010 0361 $544 $544 $326 Complicated (felon) 26011 0361 $782 $782 $469 Drainage of Tendon Sheath 26020 0361 $1,796 $1,796 $1,078 Drainage of palmar bursa; single, bursa (26025) 26025 0361 $5,929 $1,654 $7,583 $4,550 Drain Palmar Bursa; Complicated 26030 0361 $7,068 $1,975 $9,043 $5,426 Incision, bone cortex, hand or finger (eg. osteomy 26034 0361 $2,220 $2,220 $1,332 Trigger Finger 26055 0361 $1,225 $1,225 $735 EXPL/REM FB IPH Joint EA (26080) 26080 0361 $5,481 $1,366 $6,847 $4,108 EXC TNDN SHTH LES HND/FING (26160) 26160 0361 $936 $936 $562 Excision Osteochondroma Metacarpal 26200 0361 $1,908 $1,908 $1,145 Excision Osteochondroma Phalanx 26210 0361 $1,853 $1,853 $1,112 Repair flexor tendon not in zone 2 26350 0361 $3,226 $3,226 $1,936 Repair Flexor Tendon, Zone 2 26356 0361 $4,584 $4,584 $2,750 Repair extensor tendon hand 26410 0361 $2,572 $2,572 $1,543 Repair extensor tendon finger 26418 0361 $2,581 $2,581 $1,549 Lengthen, Extensor, Hand/Finger (ea) Tendon 26476 0361 $2,561 $2,561 $1,537 Lengthen Flexor Tendon (ea) 26478 0361 $2,389 $2,389 $1,433 Tendon Transfer Hand (ea) 26480 0361 $2,800 $2,800 $1,680 Adductor Release Thumb 26508 0361 $2,225 $2,225 $1,335 Reconstruction Polydactyly 26587 0361 $3,980 $3,980 $2,388 Closed TX Metacarpal FX w/o Man (ea) 26600 0361 $967 $967 $580 Closed TX Metarpal FX w/Man (ea) 26605 0361 $1,178 $1,178 $707 Percutaneous skeletal fixation of metacarpal fract 26608 0361 $2,022 $2,022 $1,213 TREAT KNUCKLE DISLOCATION (26715) 26715 0361 $9,026 $2,027 $11,053 $6,632 Closed TX Phalanx Shaft FX w/o Man 26720 0361 $691 $691 $415 Closed TX Phalanx Shaft FX w/Man 26725 0361 $1,239 $1,239 $743 Percutaneous skeletal fixation of phalangeal fract 26727 0361 $1,987 $1,987 $1,192 Open treatment of phalangeal fracture 26735 0361 $2,318 $2,318 $1,391 Closed TX Phalanx Distal FX w/o man 26750 0361 $683 $683 $410 Closed TX Phalanx Distal FX w/Man 26755 0361 $1,085 $1,085 $651 Open Tx distal Phalang FX ,each 26765 0361 $9,375 $1,968 $11,343 $6,806 TREAT FINGER DISLOCATION (26785) 26785 0361 $9,026 $1,539 $10,565 $6,339 Amputation, finger or thumb , primary or secondary 26951 0361 $2,644 $2,644 $1,586 I&D PELV/HIP JNT; INF BURSA (26991) 26991 $1,497 $1,497 $898 INC DEEP W OP BONE CORTEX PELV (26992) 26992 $3,291 $3,291 $1,975 Tenotomy, Adductor or Hip, Open 27001 0361 $2,141 $2,141 $1,285 Tenotomy, adductor of hip, open; Bilateral 2700150 0361 $4,696 $4,696 $2,818 Tenotomy, Hip Flexor(s), Open (separate procedure) 27005 0361 $4,365 $4,365 $2,619 Tenotomy, Hip Flexor(s), open (separate procedure) 2700550 0361 $6,318 $6,318 $3,791 Tenotomy Abductors 27006 0361 $3,047 $3,047 $1,828 Arthrotomy, hip 27030 0361 $4,118 $4,118 $2,471 Arthrotomy Hip 27033 0361 $4,256 $4,256 $2,554 Capsulotomy Hip w/Release Hip Flexor 27036 0361 $4,321 $4,321 $2,593 EXCISION; ISCHIAL BURSA (27060) 27060 $1,323 $1,323 $794 EXC TROCHANTERIC BURSA/CALCIFICAT (27062) 27062 $1,297 $1,297 $778 Removal of Hip Bone Lesion 27066 $3,467 $3,467 $2,080 REMOVAL OF TAIL BONE (27080) 27080 0361 $10,934 $1,473 $12,407 $7,444 Arthrogram, hip 27095 0361 $341 $341 $205 Sacroiliac Joint Injection (27096) 27096 0361 $976 $279 $1,255 $753 Sacroiliac Joint Injection-Bilateral (27096) 2709650 0361 $1,459 $418 $1,877 $1,126 Release or recession, hamstring, proximal (27097) 27097 $2,473 $2,473 $1,484 Acetabuloplasty (27120) 27120 $4,767 $4,767 $2,860 Reconstruction of Hip Socket 27122 $4,572 $4,572 $2,743 Reconstruction of Hip Socket, Bilateral 2712250 $6,858 $6,858 $4,115 TRANSPL FEMUR RIDGE (27140) 27140 0360 $2,562 $2,562 $1,537 Pelvic Osteotomy 27146 0360 $6,752 $6,752 $4,051 Iliac Osteotomy with Open Reduction 27147 0361 $6,119 $6,119 $3,671 Iliac Osteotomy with Femoral Shortening 27151 0361 $6,447 $6,447 $3,868 Iliac Osteotomy with Femoral Shortening and Open R 27156 0361 $7,148 $7,148 $4,289 Osteotomy Intertrochanteric 27165 0361 $7,080 $7,080 $4,248 Incision/fixation of femur bilateral 2716550 0361 $11,391 $11,391 $6,835 Treatment of slipped femoral epiphysis; by single 27176 0360 $3,957 $3,957 $2,374 Treatment of Slipped Femoral Epiphysis; by Single 2717650 $5,934 $5,934 $3,560 OP TX SF EPIPHYSIS; OSTEOTOMY (27181) 27181 0360 $3,213 $3,213 $1,928 Prophylactic treatment femoral neck, proximal femu 27187 0361 $4,346 $4,346 $2,608 CL TX OF ACETABULUM X(S); WO MAN 27220 0361 $557 $2,130 $2,687 $1,612 Treat Hip Wall Fracture 27226 0360 $4,328 $4,328 $2,597 Treat Hip Wall Fracture Bilateral 2722650 $6,493 $6,493 $3,896 Closed TX Femoral FX Prox/Neck w/o Man 27230 0361 $1,947 $1,947 $1,168 Closed TX Femoral FX Prox/Neck w/Man 27232 0361 $3,352 $3,352 $2,011 Perc Fix Fem Prox NK Fx 27235 $3,770 $3,770 $2,262 Open treatment of femoral neck fracture 27236 0361 $5,107 $5,107 $3,064 Closed TX Intertrochanteric FX w/o Man 27238 0361 $1,910 $1,910 $1,146 Closed TX Intertrochanteric FX w/Man 27240 0361 $4,106 $4,106 $2,464 Treatment of intertroch/subtroch fracture with pla 27244 0361 $5,050 $5,050 $3,030 Treatment of intertroch/subtroch fracture with int 27245 0361 $5,174 $5,174 $3,104

Page 4 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price Closed TX Trochanteric RX w/o Man 27246 0361 $1,634 $1,634 $980 Treat Hip Dislocation with Manipulation & Anesthes 27257 $1,387 $1,387 $832 Treat Hip Dislocation with Manipulation & Anesthes 2725750 $2,082 $2,082 $1,249 Open Reduction Hip 27258 0361 $5,764 $5,764 $3,458 Open Reduction Hip, Bilateral 2725850 $6,882 $6,882 $4,129 Open Reduction with Femoral Shortening 27259 0361 $6,456 $6,456 $3,874 Manipulation of Hip Joint 27275 $716 $716 $430 Incision and Drainage, deep abscess, bursa, or hem 27301 0361 $6,956 $2,097 $9,053 $5,432 Incision and Drainage, deep abscess, bursa or hema 2730150 0361 $12,069 $3,054 $15,123 $9,074 Incision deep femur (osteomyelitis) 27303 0361 $2,752 $2,752 $1,651 Incise Thigh Tendon and Fascia 27305 0361 $9,131 $1,914 $11,045 $6,627 Incise Thigh Tendon and Fascia, Bilateral 2730550 0361 $13,694 $2,871 $16,565 $9,939 Arthrotomy Knee 27310 0361 $3,047 $3,047 $1,828 EXC THIGH/KNEE LES SC < 3 CM (27327) 27327 0361 $4,409 $1,050 $5,459 $3,275 EXC THIGH/KNEE TUM DEEP <5CM (27328) 27328 0361 $5,866 $2,450 $8,316 $4,990 EXC THIGH/KNEE TUM DEEP <5CM, Bilateral (27328-50) 2732850 0361 $8,797 $3,677 $12,474 $7,484 Patellectomy or hemipatellectomy (27350) 27350 $2,333 $2,333 $1,400 Excision/Curettage Bone Cyst Femur 27355 0361 $2,600 $2,600 $1,560 Excision or curettage of bone cyst femur with allo 27356 0361 $3,168 $3,168 $1,901 With Internal Fixation 27358 0361 $1,292 $1,292 $775 Removal of foreign body, deep, thigh region or kne 27372 0361 $8,114 $1,165 $9,279 $5,567 Suture of Infrapatellar Tendon; Primary 27380 0361 $8,080 $2,495 $10,575 $6,345 Suture of Infrapatellar Tendon; Primary, Bilateral 2738050 0361 $13,694 $3,596 $17,290 $10,374 Hamstring Lengthening-Unilateral 27394 0361 $2,800 $2,800 $1,680 Hamstring Lengthening-Bilateral 27395 0361 $4,365 $4,365 $2,619 Revise thigh muscles/tendons (Rectus Transfer) 27400 0361 $4,036 $4,036 $2,422 Revise thigh muscle/tendons, Bilateral(Rectus Tran 2740050 0361 $25,065 $4,256 $29,321 $17,593 Arthrotomy W/ OP Meniscus Repair (27403) 27403 $2,315 $2,315 $1,389 Insall 27422 0361 $3,231 $3,231 $1,939 Open lateral release 27425 0361 $1,901 $1,901 $1,141 Quadricepsplasty 27430 0361 $3,034 $3,034 $1,820 Quadricepsplasty, Bilateral 2743050 $4,550 $4,550 $2,730 Capsulotomy, Posterior Capsular Release, Knee 27435 0361 $4,859 $4,859 $2,915 Capsulotomy, posterior capsular release, knee; Bil 2743550 0361 $4,923 $4,923 $2,954 Patella Dislocation Reconstruction Misc. 27442 0361 $3,457 $3,457 $2,074 Osteotomy Femur Shaft/Supracondylar w/o Fix 27448 0361 $3,582 $3,582 $2,149 Supracondylar Osteo Femur 27450 0361 $4,212 $4,212 $2,527 Osteotomy proximal tibia 27455 0361 $4,115 $4,115 $2,469 Femoral Shortening 27465 0361 $5,148 $5,148 $3,089 Repair Non-Union Femur w/o Graft 27470 0361 $5,131 $5,131 $3,079 Repair Non-Union Femur w/Graft 27472 0361 $5,562 $5,562 $3,337 Epiphysiodesis Distal Femur 27475 0361 $2,699 $2,699 $1,619 Arrest, epiphyseal, any method (eg, epiphysiodesis 2747550 0361 $16,422 $2,865 $19,287 $11,572 Epiphysiodesis Prox Tib/Fib 27477 0361 $4,036 $4,036 $2,422 Combined Epiphy. Dis Femur Prox Tib 27479 0361 $3,378 $3,378 $2,027 Hemiepiphysiodesis Distal Femur or Prox Tibia 27485 0361 $2,963 $2,963 $1,778 Hemiepiphysiodesis Distal Femur or Prox Tibia Bila 2748550 0361 $4,135 $4,135 $2,481 Prophylactic treatment femur 27495 0361 $4,946 $4,946 $2,968 Closed TX Femoral Shaft Fx w/o Man 27500 0361 $2,011 $2,011 $1,207 Closed TX Supracondylar FX w/o Man 27501 0361 $2,092 $2,092 $1,255 Closed TX Femoral Shaft FX w/Man 27502 0361 $3,418 $3,418 $2,051 Closed TX Supracondylar FX w/Man 27503 0361 $3,466 $3,466 $2,080 Open treatment of femoral shaft fracture with intr 27506 0361 $5,739 $5,739 $3,443 Open treatment of femoral shaft fracure with plate 27507 0361 $4,312 $4,312 $2,587 Percutaneous skeletal fixation of distal femoral f 27509 0361 $2,787 $2,787 $1,672 CL TX FEMUR FX OR EPIPHYS SEP (27510) 27510 0361 $1,826 $2,091 $3,917 $2,350 CL TX FEMUR FX OR EPIPHYS SEP;Bilateral (27510-50) 2751050 0361 $2,633 $3,017 $5,650 $3,390 Open treatment of femoral supracondylar fracture 27511 0361 $4,498 $4,498 $2,699 OPEN TX FEMORAL SUPRACONDYLAR FRACT W XTN (27513) 27513 $4,200 $4,200 $2,520 Closed TX Dist. Femur Epiphyseal Sep. w/o Man 27516 0361 $1,931 $1,931 $1,159 Closed TX Dist. Femur Epiphyseal Sep. w/Man 27517 0361 $2,833 $2,833 $1,700 Open treatment of distal femoreal epiphyseal separ 27519 0361 $4,256 $4,256 $2,554 Closed TX Patellar FX w/o Man 27520 0361 $1,158 $1,158 $695 OP TX PATEL FX W IF &/REP (27524) 27524 $2,611 $2,611 $1,567 Closed TX Tibial Fx Prox. w/o Man 27530 0361 $1,507 $1,507 $904 Closed treatment proximal tib fracture with manipu 27532 0361 $2,470 $2,470 $1,482 Open treatment intercondylar spine fracture 27540 0361 $3,718 $3,718 $2,231 Closed TX Patellar Disl w/o Anesthesia 27560 0361 $1,264 $1,264 $758 Manipulation Knee Under G/A 27570 0361 $631 $631 $379 AMPUTATE THIGH-FEMUR ANY LEVEL (27590) 27590 $3,138 $3,138 $1,883 Amputation Secondary Closure or Scar Revision 27594 $2,153 $2,153 $1,292 Amputation Secondary Closure or Scar Revision Bila 2759450 $3,227 $3,227 $1,936 Fasciotomy leg 27600 0361 $1,817 $1,817 $1,090 All 4 compartments 27602 0361 $2,233 $2,233 $1,340 Incision and Drainage; Leg, Ankle, Deep Abscess, o 27603 0361 $7,539 $1,641 $9,180 $5,508 Incision and Drainage, leg or ankle; Infected burs 27604 0361 $1,446 $1,446 $868 Incision and Drainage, leg or ankle; Infected burs 2760450 0361 $2,065 $2,065 $1,239 Percutaneous TAL general anesthesia 27606 0361 $1,309 $1,309 $785 Percutaneous TAL gen anesthesia - bilateral 2760650 0361 $11,384 $1,722 $13,106 $7,864

Page 5 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price Incision (eg, osteomyelitis or bone abscess), leg 27607 0361 $2,632 $2,632 $1,579 Incision (eg, osteomyelitis or bone abscess), leg 2760750 0361 $3,779 $3,779 $2,267 Arthrotomy ankle 27610 0361 $2,825 $2,825 $1,695 Arthrotomy, posterior capsular release, ankle, wit 27612 0361 $2,435 $2,435 $1,461 Arthrotomy, posterior capsular release, ankle, wit 2761250 0361 $4,869 $4,869 $2,921 EXC LEG/ANKLE TUM < 3 CM (27618) 27618 0361 $5,640 $1,183 $6,823 $4,094 Excision Osteochondroma Tib 27635 0361 $2,578 $2,578 $1,547 EXC TIB/FIB CYST/TUMOR W ALLOGRFT (27638) 27638 0361 $2,223 $2,223 $1,334 Flexor/Extensor Tendons 27681 0361 $2,637 $2,637 $1,582 Lengthening or Shortening of Tendon, leg or ankle; 27685 0361 $1,977 $1,977 $1,186 Lengthening or Shortening of Tendon, leg or ankle; 2768550 0361 $2,868 $2,868 $1,721 Peroneus Lengthening 27686 0361 $1,977 $1,977 $1,186 LNGTHN.SHORTN MULTI LEG/ANKLE TENDONS EA BILATERAL 2768650 0361 $16,763 $3,311 $20,074 $12,044 Gastrocnemius Recession 27687 0361 $1,977 $1,977 $1,186 Gastrocnemius Recession, Bilateral 2768750 $2,808 $2,808 $1,685 SUPERF TRANF/TRASPL SGL TENDON (27690) 27690 0361 $2,236 $2,236 $1,342 SUPERF TRANF/TRASPL SGL TENDON Bilateral (27690-50 2769050 0361 $23,609 $3,358 $26,967 $16,180 Transfer of tendon deep 27691 0361 $3,188 $3,188 $1,913 each additional leg tendon (leg) 27692 0361 $502 $502 $301 Osteotomy, tibia 27705 0361 $3,365 $3,365 $2,019 Osteotomy; Tibia and Fibula 27709 0361 $5,519 $5,519 $3,311 Osteotomy; Tibia and Fibula; Bilateral 2770950 0361 $9,066 $9,066 $5,440 Hemiepiphysiodesis Distal Tibia 27730 0361 $2,717 $2,717 $1,630 Arrest, epiphysiodesis, open; distal fibula (27732 27732 0361 $11,179 $1,539 $12,718 $7,631 OP EPIPHYSEAL ARREST- DISTL TIB & FIB (27734) 27734 $1,671 $1,671 $1,003 Closed TX Tib Shaft FX w/o Man 27750 0361 $1,278 $1,278 $767 Closed TX Tib Shaft FX w/Man 27752 0361 $2,103 $2,103 $1,262 Percutaneous fixation of tibial fracture 27756 0361 $2,441 $2,441 $1,465 Open treatment of tibia fracture with plate/screws 27758 0361 $3,851 $3,851 $2,311 Treatment of tibia fracture with intramedullary im 27759 0361 $4,375 $4,375 $2,625 Open treatment of medial mall fracture 27766 0361 $2,676 $2,676 $1,606 Closed TX Prox Fib or Shaft FX w/o Man 27780 0361 $1,072 $1,072 $643 Closed TX Prox Fib or Shaft FX w/Man 27781 0361 $1,621 $1,621 $973 Open treatment of distal fibula fracture 27792 0361 $2,934 $2,934 $1,760 CLTX BIMALLEOLAR ANKLE FRACT W MNP (27810) 27810 $1,217 $1,217 $730 Open treatment of bimall fracture 27814 0361 $3,398 $3,398 $2,039 Open Treatment Bimalleolar Ankle Fracture, Include 2781450 0361 $4,768 $4,768 $2,861 Open treatment of distal tibia articular fracture 27827 0361 $4,770 $4,770 $2,862 Open treatment of tib fib synostosis 27829 0361 $2,698 $2,698 $1,619 Fixation of ankle joint (Ankle/Foot Manipulation G 27860 0361 $771 $771 $463 AMPUTATELEG THRU TIBIA AND FIBULA (27880) 27880 $3,437 $3,437 $2,062 Amputation, leg, through tibia and fibula; re-ampu 27886 $2,436 $2,436 $1,462 AMPUT ANKLE TO TIB-FIB M W PL REP (27888) 27888 $2,402 $2,402 $1,441 DEEP DISSECT FOOT INF; SGL BURSA SP (28002) 28002 0361 $7,918 $966 $8,884 $5,330 DEEP DISSECT FOOT INF; MULTI AREAS (28003) 28003 0361 $4,536 $1,833 $6,369 $3,821 Deep Inc Foot w Op Bone Cortex 28005 0361 $7,979 $2,392 $10,371 $6,223 INCISE FOOT/TOE FASCIA (28008) 28008 $1,059 $1,059 $635 Tenotomy, Percutaneous, Toe Single Tendon 28010 0361 $922 $922 $553 Tenotomy Toe, Percutaneous, Multiple Tendons 28011 0361 $1,315 $1,315 $789 Arthrotomy Intertarsal or Tarsometatarsal Joint 28020 $1,462 $1,462 $877 Exploration of Foot Joint 28022 $1,328 $1,328 $797 Excision of Foot Lesion 28043 $1,079 $1,079 $647 EXC FOOT CYST/GANGLION (28090) 28090 0361 $7,622 $1,191 $8,813 $5,288 Excision or curettage of calcaneus cyst 28100 0361 $1,805 $1,805 $1,083 Excision/Curettage Bone Cyst Metatarsal 28104 0361 $1,577 $1,577 $946 Excision/Curettage Bone Cyst Phalanges Foot 28108 0361 $1,294 $1,294 $776 Excision Tarsal Coalition 28116 0361 $2,333 $2,333 $1,400 PARTL EXC ANKLE OR HEEL BONE (28120) 28120 0361 $7,622 $1,922 $9,544 $5,726 Talectomy (astraglectomy) 28130 0361 $3,787 $3,787 $2,272 Talectomy (astragalectomy); Bilateral 2813050 0361 $4,077 $4,077 $2,446 Phalangetomy Toe (ea) 28150 0361 $1,284 $1,284 $770 RESECT PHALANX OF TOE TUMOR (28175) 28175 $1,778 $1,778 $1,067 Removal of FB, foot; subcutaneous (28190) 28190 0361 $2,853 $516 $3,369 $2,021 Removal of FB, foot, Bilateral; subcut. (28190-50) 2819050 0361 $4,280 $776 $5,056 $3,034 REPR FOOT EXTENSOR TENDON EA (28208) 28208 $1,089 $1,089 $653 Tenotomy Flexor Tendon Foot 28230 0361 $1,480 $1,480 $888 Tenotomy Toe, Single Tendon 28232 $1,012 $1,012 $607 Tenotomy, open, extensor, foot or toe, each tendon 28234 $914 $914 $548 ADV POST TIBIAL TENDON W EXC NAVICLR BONE (28238) 28238 0361 $20,126 $1,917 $22,043 $13,226 ADV POST TIBIAL TENDON W EXC NAVICLR BONE,Bilatera 2823850 0361 $30,184 $2,875 $33,059 $19,835 Tenotomy Lengthening Abductor Hallucis 28240 0361 $1,402 $1,402 $841 Division of Plantar Release 28250 0361 $1,811 $1,811 $1,087 DIVIDE PLANTAR FASCIA & MSCL,BILATERAL (28250-50) 2825050 0361 $11,435 $2,341 $13,776 $8,266 Midfoot/Post Talotibial Capsulotomy with Tendon Le 28262 0361 $5,353 $5,353 $3,212 EXTENSIVE MIDFOOT CAPSULOTOMY;Bilateral (28262-50) 2826250 0361 $11,435 $5,037 $16,472 $9,883 Capsulotomy MP Joint 5th Toe Extensor Tendon (ea) 28270 0361 $1,486 $1,486 $892 Correction hammertoe 28285 0361 $1,419 $1,419 $851 Correction cock-up toe 28286 0361 $1,368 $1,368 $821 Akin 28298 0361 $2,271 $2,271 $1,363

Page 6 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price Osteotomy Oscalcis 28300 0361 $2,620 $2,620 $1,572 Osteotomy Oscalcis, Bilateral 2830050 0361 $19,514 $3,935 $23,449 $14,069 Osteotomy Oscalcis, Bilateral 2830050 0361 $19,514 $3,935 $23,449 $14,069 Osteotomy Cuneiform 28304 0361 $2,886 $2,886 $1,732 OSTEOTOMY MIDT BONE;Bilateral (28304-50) 2830450 0361 $30,187 $3,500 $33,687 $20,212 Cuboid Osteotomy with Autograft 28305 0361 $3,214 $3,214 $1,928 Cuboid Osteotomy with Autograft, Bilateral 2830550 0361 $4,196 $27,198 $31,394 $18,836 Osteotomy 1st Metatarsal 28306 0361 $1,784 $1,784 $1,070 Other Than 1st Metatarsal (ea) 28308 0361 $1,618 $1,618 $971 Osteotomy, metatarsals multiple for cavus foot 28309 0361 $3,938 $3,938 $2,363 Osteotomy Prox. Phalanx, First Toe (Separate) 28310 0361 $1,588 $1,588 $953 Open Treatment of Osteotomy, Shortening, Angular 28312 0361 $1,416 $1,416 $850 Reconstruction toe polydactyly 28344 0361 $1,329 $1,329 $797 Closed TX Calcaneal FX w/o Man 28400 0361 $936 $936 $562 Closed TX Metatarsal FX w/o Man (ea) 28470 0361 $784 $784 $470 Closed TX Metatarsal FX w/ Man (ea) 28475 0361 $1,048 $1,048 $629 Percutaneous skeletal fixation of metatarsal fract 28476 0361 $1,454 $1,454 $872 Percutaneus skeletal fixation of fracture great to 28496 0361 $982 $982 $589 Treat Big Toe Fracture (28505) 28505 $1,779 $1,779 $1,067 Closed TX FX Phalanx (Not Gerat Toe) w/o Man (ea) 28510 0361 $471 $471 $283 Closed TX FX Phalanx (Not Great Toe) w/Man (ea) 28515 0361 $588 $588 $353 PERC SK FIX IP JNT DISL; W MANIP (28666) 28666 0361 $7,467 $613 $8,080 $4,848 Triple Arthrodesis 28715 0361 $4,258 $4,258 $2,555 Subtalar Arthrodesis 28725 0361 $3,278 $3,278 $1,967 Arthrodesis w/Tendon Lengthen and Advancement, Mid 28737 0361 $3,083 $3,083 $1,850 Fusion of Foot Bones 28740 $2,717 $2,717 $1,630 Arthrodesis Great Toe, MP Joint 28750 0361 $2,605 $2,605 $1,563 Arthrodesis Great Toe, MP Joint,Bilateral (28750-5 2875050 0361 $30,187 $3,550 $33,737 $20,242 Arthrodesis Interphalangeal Joint Great Toe 28755 0361 $1,485 $1,485 $891 Jones Procedure 28760 0361 $1,590 $1,590 $954 ARTHROD GT IP JNT W EHL TRANSFER,Bilateral (28760- 2876050 0361 $2,383 $2,383 $1,430 Amputation Metatarsal (Single) 28810 0361 $1,917 $1,917 $1,150 Amputation, Toe; Metatarsal Phalangeal Joint 28820 0361 $1,896 $1,896 $1,138 Amputation Toe, Interphalangeal Joint 28825 0361 $1,674 $1,674 $1,004 OT Long Arm Cast Units 29065 0430 $189 $189 $113 Long Arm Cast (29065) 29065 0361 $943 $294 $1,237 $742 Long Arm Cast (29065) 29065 0361 $943 $294 $1,237 $742 OT Short Arm Cast Units 29075 0430 $189 $189 $113 Short Arm Cast (29075) 29075 0361 $943 $263 $1,206 $724 Short Arm Cast (29075) 29075 0361 $943 $263 $1,206 $724 OT Hand and Lower Forearm Cast Units 29085 0430 $189 $189 $113 OT Finger Cast Units 29086 0430 $189 $189 $113 OT Long Arm Splint Application Units 29105 0430 $364 $364 $218 PT Long Arm Splint Application Units 29105 0420 $364 $364 $218 OT Static Short Arm Splint App Units 29125 0430 $189 $189 $113 OT Dynamic Short Arm Splint App Units 29126 0430 $468 $468 $281 PT Dynamic Short Arm Splint App Units 29126 0420 $468 $468 $281 PT Static Short Arm Splint App Units 29126 0420 $468 $468 $281 Apply Short Arm Splint; Dynamic (29126) 29126 $164 $164 $98 OT Static Finger Splint App Units 29130 0430 $168 $168 $101 PT Static Finger Splint App Units 29130 0420 $168 $168 $101 OT Dynamic Finger Splint App Units 29131 0430 $378 $378 $227 PT Dynamic Finger Splint App Units 29131 0420 $378 $378 $227 PT Taping/Thorax Units 29200 0420 $225 $225 $135 OT Strapping Shoulder Units 29240 0430 $189 $189 $113 PT Strapping Shoulder Units 29240 0420 $189 $189 $113 OT Strapping Elbow/Wrist Units 29260 0430 $189 $189 $113 PT Strapping Elbow/Wrist Units 29260 0420 $189 $189 $113 OT Strapping Hand/Finger Units 29280 0430 $189 $189 $113 PT Strapping Hand/Finger Units 29280 0420 $189 $189 $113 Spica 29325 0361 $577 $577 $346 Long Leg Cast 29345 0361 $943 $443 $1,386 $832 Long Leg Cast Bilateral 2934550 0361 $1,413 $663 $2,076 $1,246 PT Long Leg Cast Application Units 29358 0420 $189 $189 $113 PT Cylindrical Cast Application Units 29365 0420 $189 $189 $113 Cylinder Cast (29365) 29365 0361 $943 $382 $1,325 $795 PT Short Leg Cast Application Units 29405 0420 $189 $189 $113 Short Leg Cast 29405 0361 $943 $343 $1,286 $772 Short Leg Cast, Bilateral 2940550 0361 $1,945 $518 $2,463 $1,478 PT Patellar Tendon Bearing Cast App Unit 29435 0420 $273 $273 $164 PT Rigid Total Contact Leg Cast App Unit 29445 0420 $273 $273 $164 Appl. of Rigid Total Contact Leg Cast/TCC (2944) 29445 $263 $263 $158 PT Club Foot w/Molding/Manip App Units 29450 0420 $122 $122 $73 Clubfoot Cast (29450) 29450 0361 $448 $544 $992 $595 Clubfoot Cast Bilateral 2945050 0361 $654 $730 $1,384 $830 PT Long Leg Splint App Units 29505 0420 $344 $344 $206 Long Leg Splint 29505 0361 $199 $199 $119 PT Short Leg Splint App Units 29515 0420 $273 $273 $164 Short Leg Splint 29515 0361 $199 $199 $119

Page 7 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price PT Strapping Hip Units 29520 0420 $189 $189 $113 PT Strapping Knee Units 29530 0420 $189 $189 $113 PT Strapping Ankle/Foot Units 29540 0420 $189 $189 $113 PT Strapping Toes Units 29550 0420 $189 $189 $113 PT Unna Boot Units 29580 0420 $208 $208 $125 Venous Stasis Four Layer Wrap 29580 0361 $374 $146 $520 $312 Apply Multlay Comprs LWR Leg (29581) 29581 0361 $436 $138 $574 $344 Apply Multlay Comprs LWR Leg, Bilateral (29581) 2958150 0361 $873 $276 $1,149 $689 REM Shoulder Or Hip Spica 29710 0361 $974 $358 $1,332 $799 REM Shoulder Or Hip Spica, Bilateral 2971050 0361 $1,940 $718 $2,658 $1,595 Rep Spica Body Cast or Jacket (29720) 29720 $157 $157 $94 Casting/Strapping Procedure 29799 0361 $442 $442 $265 Arthroscopy shoulder with debridement 29822 0361 $2,503 $2,503 $1,502 Arhtroscopically aided treatment on intercondylar 29851 0361 $4,107 $4,107 $2,464 Arthroscopy knee, diagnostic 29870 0361 $1,758 $1,758 $1,055 Arthroscopy knee, infection and drainage 29871 0361 $2,220 $2,220 $1,332 Arthroscopy knee, lateral release 29873 0361 $2,225 $2,225 $1,335 Arthroscopy knee, removal loose body 29874 0361 $2,299 $2,299 $1,379 Arthroscopy knee, plica 29875 0361 $2,153 $2,153 $1,292 Arthroscopy knee, chondroplasty 29877 0361 $2,634 $2,634 $1,580 Arthroscopy knee, chondroplasty microfracture 29879 0361 $2,820 $2,820 $1,692 Arthroscopy knee, medial AND lateral meniscectomy 29880 0361 $2,945 $2,945 $1,767 Arthroscopy knee, medial OR lateral meniscectomy 29881 0361 $2,743 $2,743 $1,646 Arthroscopy knee, meniscus repair 29882 0361 $2,967 $2,967 $1,780 Arthroscopy knee, OCD drilling 29886 0361 $2,681 $2,681 $1,609 Arthroscopy knee, OCD internal fixation 29887 0361 $3,164 $3,164 $1,898 Arthroscopically aided ACL 29888 0361 $4,318 $4,318 $2,591 Arthroscopy ankle, OCD drilling 29891 0361 $2,977 $2,977 $1,786 Arthroscopy ankle, debridement 29897 0361 $2,295 $2,295 $1,377 RHINOPL 1'; COMPLETE EXT PARTS (30410) 30410 $4,115 $4,115 $2,469 SEPTAL OR OTHER IN DERMATOPLASTY (30620) 30620 0361 $2,256 $2,256 $1,354 Change of Windpipe Airway (31502) 31502 0361 $603 $151 $754 $452 Laryngoscopy Indirect Diagnostic (31505) 31505 0920 $331 $201 $532 $319 COLLECTION: Venous Draw 36415 0300 $28 $28 $17 Collection: Venous Draw 36415 0300 $27 $24 $51 $31 Insert Non-Tunnel CV Cath age 5 Yr/> 36556 0361 $4,630 $524 $5,154 $3,092 INS PIC Age 5 yrs/> 36569 0361 $3,431 $3,431 $2,059 Declot Vascular Device 36593 0361 $708 $708 $425 Withdrawl of Arterial Blood 36600 0361 $95 $67 $162 $97 Arterial Blood Gas Collection 36600 0361 $141 $141 $85 Salivary Gland Procedure, unlisted 42699 0361 $1,029 $361 $1,390 $834 Reposition Gastric Feeding Tube, through the duode 43761 0361 $3,502 $466 $3,968 $2,381 RPLC GTUBE NO REVJ TRC (43762) 43762 0750 $858 $115 $973 $584 Diagnostic Anoscopy Charge-46600 46600 0361 $262 $150 $412 $247 Bladder Irrigation/Lavage/Instill Charge (51700) 51700 0361 $200 $200 $120 Straight Cath Charge (51701) 51701 0361 $119 $119 $71 Cath-Simple Urethral Charge (51702) 51702 0361 $133 $133 $80 Cath-Complex Urethral Charge (51703) 51703 0361 $493 $493 $296 Simple Cystometrogram (51725) 51725 0361 $1,253 $334 $1,587 $952 Complex Cystometrogram (51726) 51726 0361 $1,253 $376 $1,629 $977 Cystometrogram w/ UP 51727 0361 $1,253 $462 $1,715 $1,029 Complex Cystometrogram w/ VP (51728) 51728 0361 $1,253 $452 $1,705 $1,023 Complex Cystometrogram w/ VP & UP (51729) 51729 0361 $1,253 $535 $1,788 $1,073 Simple Uroflowmetry (51736) 51736 0361 $454 $134 $588 $353 Complex Uroflowmetry 51741 0361 $454 $249 $703 $422 EMG Anal/Urethr Sphinct, Not Needle (51784) 51784 0361 $454 $334 $788 $473 Needle EMG, Anal/Urethral Sphincter (51785) 51785 0361 $837 $338 $1,175 $705 Urinary Reflex Study (51792) 51792 0361 $454 $243 $697 $418 Intra-abdominal Pressure Test (51797) 51797 0361 $837 $182 $1,019 $611 BVI 51798 0920 $139 $139 $83 Electroejaculation Charge 55870 0361 $1,135 $763 $1,898 $1,139 EXCISE VAGINAL CYST OR TUMOR (57135) 57135 $624 $624 $374 Fit or Insert Pessary 57160 0510 $634 $205 $839 $503 Drain Cerebrospinal Fluid 62272 0361 $1,559 $364 $1,923 $1,154 Inj Epidural Blood or Clot Patch 62273 0361 $1,285 $438 $1,723 $1,034 INJ NEUROLYTIC; EPIDURAL LUMB/CAUDAL (62282) 62282 0361 $7,042 $1,239 $8,281 $4,969 Percutaneous Disc Decompression (62287) 62287 0361 $15,461 $2,224 $17,685 $10,611 Lumbar Discography (62290) 62290 0929 $821 $821 $493 CA-Lumbar Disography 62290 0929 $887 $887 $532 C-sp Disc. Add'l level x___ 62291 0929 $1,860 $1,860 $1,116 T-sp Disc. Add'l level x___ 62291 0929 $1,860 $1,860 $1,116 Cervical-Thoracic Discography (62291) 62291 0361 $670 $670 $402 CA-Cervical or Thoracic Discography 62291 0361 $1,649 $1,649 $989 NJX INTERLAMINAR CRV/THR, C without imaging guidan 62320 0361 $2,055 $334 $2,389 $1,433 NJX INTERLAMINAR CRV/THRC, with imaging guidance ( 62321 0361 $2,055 $358 $2,413 $1,448 NJX INTERLAMINAR LMBR/SAC, without imaging guidanc 62322 0361 $2,055 $286 $2,341 $1,405 NJX INTERLAMINAR LMBR/SAC, with imaging guidance ( 62323 0361 $2,055 $327 $2,382 $1,429 NJX INTERLAMINAR CRV/THRC, incl indw cath/cont fus 62324 0361 $2,589 $308 $2,897 $1,738 NJX INTERLAMINAR CRV/THRC, incl indw cath, cont in 62325 0361 $2,589 $353 $2,942 $1,765

Page 8 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price NJX INTERLAMINAR LMBR/SAC,incl ind cath, cont infu 62326 0361 $2,589 $298 $2,887 $1,732 NJX INTERLAMINAR LMBR/SAC,incl indw cath, cont inf 62327 0361 $2,589 $319 $2,908 $1,745 IMPL OR REVISE EPID CATH FOR PAIN (62350) 62350 $1,508 $1,508 $905 REM PREV IMPL EPID CATH (62355) 62355 0361 $7,042 $986 $8,028 $4,817 IMPL/REPL PR PUMP FOR INFUSION (62362) 62362 $1,464 $1,464 $878 REM Sq RSVR/Pump For Prev Epid DR Inf 62365 0361 $15,461 $1,335 $16,796 $10,078 Pump Analysis without Reprogramming Charge (62367) 62367 0361 $956 $96 $1,052 $631 Pump Analysis Without Reprogramming (62367) 62367 0361 $884 $884 $530 Pump Analysis with Reprogramming Charge (62368) 62368 0361 $956 $153 $1,109 $665 Pump Analysis with Reprogramming (62368) 62368 0361 $884 $884 $530 Anal SP inf pmp wt reprog/refill (62369) 62369 0361 $828 $828 $497 Anal SP inf pmp wt reprog/refill RN(62369) 62369 0361 $735 $735 $441 ANL SP infusion pmp wt/MD reprogram and refill (62 62370 0361 $828 $130 $958 $575 Implant Neuroelectrodes 63650 0361 $26,246 $1,693 $27,939 $16,763 REMOVE SPINE ELTRD PERQ ARAY (63661) 63661 $1,188 $1,188 $713 INC/REPL SPINE NSTIM PG/RCVR (63685) 63685 $1,361 $1,361 $817 Revise/Remove Neuroreceiver 63688 0361 $14,159 $1,544 $15,703 $9,422 Injection, anesthetic agent; trigeminal nerve, any 64400 0361 $834 $190 $1,024 $614 Greater Occipital Nerve Injection Charge 64405 0361 $1,684 $293 $1,977 $1,186 INJ ANESTH; SUPRASCAPULAR NERVE (64418) 64418 0361 $1,613 $272 $1,885 $1,131 Injection, anesthetic agent; intercostal nerve, si 64420 0361 $1,540 $279 $1,819 $1,091 Inj Anesth; Intercost Nrv, Multi/Region 64421 0361 $2,655 $386 $3,041 $1,825 Inj Anesth; Intercost Nrv, Multi/Region, Bilateral 6442150 0361 $3,983 $1,451 $5,434 $3,260 Nerve Block Ilioning/Iliohypogastric 64425 0361 $1,287 $373 $1,660 $996 Nerve Block Ilioing/Iliohypogastric Bilateral 6442550 0361 $2,056 $574 $2,630 $1,578 INJ ANESTH; PUDENDAL NERVE (64430) 64430 0361 $3,053 $298 $3,351 $2,011 INJECTION ANESTHETIC AGENT SCIATIC NRV SINGLE(6444 64445 $209 $209 $125 Other Nerve Block Peripheral or Branch Charge (644 64450 0361 $1,684 $427 $2,111 $1,267 Other Nerve Block Peripheral or Branch BiL Charge 6445050 0361 $2,317 $427 $2,744 $1,646 INJECTION AA&/STRD NERVES NRVTG SI JOINT W/IMG (64 64451 0361 $2,171 $229 $2,400 $1,440 INJECTION AA&/STRD NERVES NRVTG SI JOINT W/IMG Bil 6445150 0361 $3,257 $343 $3,600 $2,160 INJECTION AA&/STRD GENICULAR NRV BRANCHES W/IMG (6 64454 0361 $2,171 $236 $2,407 $1,444 INJECTION AA&/STRD GENICULAR NRV BRANCHES W/IMG Bi 6445450 0361 $3,257 $353 $3,610 $2,166 Injection(s) Plantar digital nerve(s) (Morton's Ne 64455 0361 $880 $155 $1,035 $621 Cervical-Thoracic Transforaminal (64479) 64479 0361 $2,904 $622 $3,526 $2,116 Cervical-Thoracic Transforaminal-Bilateral (64479) 6447950 0361 $4,480 $777 $5,257 $3,154 T-spine TFESI add'l level x___ 64480 0361 $1,226 $1,226 $736 Cervical-Thoracic Transforaminal-additional level 64480 0361 $1,739 $410 $2,149 $1,289 Cervical-Thoracic Transforaminal-additional level 6448050 0361 $2,317 $519 $2,836 $1,702 Lumbar Epidural (64483) 64483 0361 $2,904 $572 $3,476 $2,086 CA-Transforaminal Injection/Lumbar or Sacral 64483 0361 $2,793 $615 $3,408 $2,045 Lumbosacral Transforaminal-Bilateral (64483) 6448350 0361 $4,354 $1,141 $5,495 $3,297 Lumbar TFESI add'l level x___ 64484 0361 $1,226 $1,226 $736 Lumbar Transforaminal Epidural Injection-Additiona 64484 0361 $1,739 $410 $2,149 $1,289 CA-Additional Transforaminal Lum/Sac Inject Paravert 64484 0361 $1,672 $443 $2,115 $1,269 Lumbar Transforaminal Epidural Inj-Add'l Level BiL 6448450 0361 $2,317 $418 $2,735 $1,641 Transversus abdominis plane (TAP) Block, by inject 64486 0361 $365 $222 $587 $352 Transversus abdominis plane (TAP) block, injection 64488 0361 $365 $277 $642 $385 Inj Paravert F Jnt C/T One Level (64490) 64490 0361 $2,987 $361 $3,348 $2,009 Inj Paravert F Jnt C/T One Level-Bilateral (64490- 6449050 0361 $5,971 $720 $6,691 $4,015 Inj Paravert F Jnt C/T Two Levels (64491) 64491 0361 $1,059 $207 $1,266 $760 CA-Cervical/Thoracic Second Level Inj Paravert 64491 0361 $1,020 $222 $1,242 $745 Inj Paravert F Jnt C/T Two Levels-Bilateral (64491 6449150 0361 $2,119 $414 $2,533 $1,520 Inj Paravert F Jnt C/T Three Levels (64492) 64492 0361 $1,059 $269 $1,328 $797 CA-Cervical/Thoracic Third Level Inj Para and Addtional Levels 64492 0361 $1,020 $289 $1,309 $785 Inj Paravert F Jnt C/T Three Levels-Bilateral (644 6449250 0361 $2,119 $422 $2,541 $1,525 Inj Paravert F Jnt L/S One Level (64493) 64493 0361 $2,987 $307 $3,294 $1,976 CA-Lumbar/Sacral Single Level Inj Paravert 64493 0361 $2,871 $330 $3,201 $1,921 Inj Paravert F Jnt L/S One Level-Bilateral (64493- 6449350 0361 $5,971 $609 $6,580 $3,948 Inj Paravert F Jnt L/S Two Levels (64494) 64494 0361 $1,059 $176 $1,235 $741 CA-Lumbar/Sacral Second Level Inj Para 64494 0361 $1,020 $190 $1,210 $726 Inj Paravert F Jnt L/S Two Levels-Bilateral (64494 6449450 0361 $2,119 $353 $2,472 $1,483 Inj Paravert F Jnt L/S Three Levels (64495) 64495 0361 $1,059 $180 $1,239 $743 CA-Lumbar/Sacral Third and Addtl Level Inj Para 64495 0361 $1,020 $196 $1,216 $730 CA-Lumbar/Sacral Third and Addtl Level Inj Para 64495 0361 $1,020 $196 $1,216 $730 Inj Paravert F Jnt L/S Three Levels-Bilateral (644 6449550 0361 $2,119 $358 $2,477 $1,486 INJ ANESTH; SPHENOPALATINE GANGLION (64505) 64505 0361 $920 $308 $1,228 $737 Injection, Anesthetic Agent; Stellate Ganglion 64510 0361 $2,987 $279 $3,266 $1,960 CA-Stellate Ganglion Injection Block 64510 0361 $2,871 $298 $3,169 $1,901 NB INJ HYPOGAS PLXS (64517) 64517 0361 $3,053 $435 $3,488 $2,093 Injection, Anesthetic Agent; Lumbar or Thoracic (p 64520 0361 $2,686 $318 $3,004 $1,802 CA-Lumbar Sympathetic Injection Block 64520 0361 $2,584 $344 $2,928 $1,757 Chemodenerv Saliv Glands (64611) 64611 0361 $942 $382 $1,324 $794 Chemodenervation-Face (64612) 64612 0361 $955 $774 $1,729 $1,037 DESTROY NERVE FACE MUSCLE, BILATERAL (64612-50) 6461250 0361 $1,431 $1,160 $2,591 $1,555 CHEMODENERV MUSC MIGRAINE (64615) 64615 0361 $867 $386 $1,253 $752 CHEMODENERV MUSC NECK DYSTON (64616) 64616 0361 $920 $421 $1,341 $805 CHEMODENERV MUSC NECK DYSTON,Bilateral (64616-50) 6461650 0361 $1,382 $631 $2,013 $1,208 CHEMODENER MUSCLE LARYNX EMG (64617) 64617 0361 $1,613 $419 $2,032 $1,219

Page 9 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price CHEMODENER MUSCLE LARYNX EMG,Bilateral (64617-50) 6461750 0361 $1,852 $433 $2,285 $1,371 DESTR W NEUROLYTIC; INTERCOSTAL NRV (64620) 64620 0361 $7,042 $630 $7,672 $4,603 DESTRUCTION NEUROLYTIC AGT GENICULAR NERVE W/IMG ( 64624 0361 $5,974 $420 $6,394 $3,836 DESTRUCTION NEUROLYTIC AGT GENICULAR NERVE W/IMG B 6462450 0361 $8,960 $631 $9,591 $5,755 RADIOFREQUENCY ABLTJ NRV NRVTG SI JT W/IMG GDN (64 64625 0361 $5,974 $556 $6,530 $3,918 RADIOFREQUENCY ABLTJ NRV NRVTG SI JT W/IMG GDN Bil 6462550 0361 $8,960 $833 $9,793 $5,876 Destroy Cer/Thor Facet Joint (64633) 64633 0361 $2,580 $655 $3,235 $1,941 DESTROY CERV/THOR FACET JNT, Bilateral (64633-50) 6463350 0361 $3,866 $1,354 $5,220 $3,132 DESTROY C/TH FACET JNT ADDL (64634) 64634 0361 $903 $271 $1,174 $704 Destroy lumb/sac Facet Joint (64635) 64635 0361 $4,449 $641 $5,090 $3,054 Destroy L/S facet joint, bilateral (64635-50) 6463550 0361 $6,673 $962 $7,635 $4,581 Destroy L/S Facet joint each add'l (64636) 64636 0361 $2,580 $171 $2,751 $1,651 Destroy L/S Facet Joint B, ea add'l (64636-50) 6463650 0361 $3,866 $258 $4,124 $2,474 DESTROY C/TH FACET JNT ADDL, Bilateral (64634-50) 6463650 0361 $1,352 $405 $1,757 $1,054 Nerve Destruction Other Peripheral or Branch Charg 64640 0361 $2,904 $762 $3,666 $2,200 Nerve Destruction Other Peripheral or Branch Charg 6464050 0361 $2,987 $1,090 $4,077 $2,446 CHEMODENERV 1 EXTREMITY 1-4 (64642) 64642 0361 $1,613 $404 $2,017 $1,210 CHEMODENERV EACH ADD'L EXTRM 1-4 MUSCLES (64643) 64643 0361 $272 $272 $163 CHEMODENERV 1 EXTREM 5/> MUS (64644) 64644 0361 $1,613 $443 $2,056 $1,234 CHEMODENERV EACH ADD'L EXTREM 5/> MUSCLES (64645) 64645 0361 $313 $313 $188 CHEMODENERV TRUNK MUSC 1-5 (64646) 64646 0361 $1,613 $438 $2,051 $1,231 CHEMODENERV TRUNK MUSC 6/> (64647) 64647 0361 $1,613 $504 $2,117 $1,270 CHEMODENERV ECCRINE GLANDS OTHER AREAS (64653) 64653 0361 $867 $158 $1,025 $615 Neuroplasty; ulnar nerve 64718 0361 $6,755 $2,391 $9,146 $5,488 Unlisted Procedure, Nervous System 64999 0361 $2,938 $313 $3,251 $1,951 UNLISTED CODE, PELVIC FLOOR INJ (64999) 64999 0361 $2,938 $313 $3,251 $1,951 Removal Impacted Ceruman 69210 0361 $262 $143 $405 $243 XR Mandible Partial Less Than 4 Views 70100 0320 $743 $743 $446 XR Mandible Complete Minimum 4 Views 70110 0320 $100 $100 $60 XR Mastoids Complete Left 70130 0320 $372 $372 $223 XR Mastoids Complete Right 70130 0320 $372 $372 $223 XR Zygomas 70140 0320 $676 $676 $406 XR Facial Bones Minimum 3 Views 70150 0320 $676 $676 $406 XR Nasal Bones Minimum 3 Views 70160 0320 $238 $238 $143 XR Optic Foramina Left 70190 0320 $88 $88 $53 XR Optic Foramina Right 70190 0320 $88 $88 $53 XR Orbits Complete Bilateral 70200 0320 $877 $877 $526 XR Orbits Complete Left 70200 0320 $877 $877 $526 XR Orbits Complete Right 70200 0320 $877 $877 $526 XR Sinuses Paranasal < 3 Views 70210 0320 $145 $145 $87 XR Sinuses Paranasal Complete 70220 0320 $790 $790 $474 XR Skull < 4 Views 70250 0320 $436 $436 $262 XR Skull Complete 70260 0320 $676 $676 $406 XR TMJ Open and Closed Bilateral 70330 0320 $88 $88 $53 MRI TMJ W/O Contrast 70336 0610 $3,097 $3,097 $1,858 MRI TMJ W&W/O Contrast 70336 0610 $3,097 $3,097 $1,858 XR Neck Soft Tissue 70360 0320 $137 $137 $82 CT Head/Brain W/O Contrast 70450 0350 $3,110 $3,110 $1,866 CT Head/Brain W/ Contrast 70460 0350 $3,332 $3,332 $1,999 CT Head/Brain W/&W/O Contrast 70470 0350 $4,784 $4,784 $2,870 CT Orbit/Ear/Fossa W/O Contrast 70480 0350 $3,394 $3,394 $2,036 CT Orbit/Ear/Fossa W/ Contrast 70481 0350 $3,636 $3,636 $2,182 CT Orbit/Ear/Fossa W/&W/O Contrast 70482 0350 $3,636 $3,636 $2,182 CT Maxillofacial W/O Contrast 70486 0350 $3,365 $3,365 $2,019 CT Maxillofacial W/ Contrast 70487 0350 $3,636 $3,636 $2,182 CT Maxillofacial W/&W/O Contrast 70488 0350 $3,636 $3,636 $2,182 CT Soft Tissue Neck W/O Contrast 70490 0350 $3,219 $3,219 $1,931 CT Soft Tissue Neck W/ Contrast 70491 0350 $4,037 $4,037 $2,422 CT Soft Tissue Neck W/&W/O Contrast 70492 0350 $3,636 $3,636 $2,182 CT Angiography Head 70496 0350 $4,037 $4,037 $2,422 CT Angiography Neck 70498 0350 $4,469 $4,469 $2,681 MRI Face/Neck W/O Contrast 70540 0610 $3,097 $3,097 $1,858 MRI Orbits W/O Contrast 70540 0610 $3,097 $3,097 $1,858 MRI Face/Neck W/Contrast 70542 0610 $5,850 $5,850 $3,510 MRI Orbits W/ Contrast 70542 0610 $5,850 $5,850 $3,510 MRI Face/Neck W&W/O Contrast 70543 0610 $6,559 $6,559 $3,935 MRI Orbits W&W/O Contrast 70543 0610 $6,559 $6,559 $3,935 MRA Head W/O Contrast 70544 0610 $5,340 $5,340 $3,204 MRV Head W/O Contrast 70544 0610 $5,340 $5,340 $3,204 MRA Head W/ Contrast 70545 0610 $3,636 $3,636 $2,182 MRA Head W&W/O Contrast 70546 0610 $7,217 $7,217 $4,330 MRV Head W&W/O Contrast 70546 0610 $7,217 $7,217 $4,330 MRA Neck W/O Contrast 70547 0610 $4,271 $4,271 $2,563 MRA Neck W/ Contrast 70548 0610 $4,832 $4,832 $2,899 MRA Neck W&W/O Contrast 70549 0610 $6,041 $6,041 $3,625 MRI Brain W/O Contrast 70551 0610 $3,097 $3,097 $1,858 MRI Brain IAC/Cranial Nerve W/O Contrast 70551 0610 $3,097 $3,097 $1,858 MRI Brain CSF Study W/O Contrast 70551 0610 $3,097 $3,097 $1,858 MRI Brain W&W/O Contrast-70553 70553 0610 $5,920 $5,920 $3,552

Page 10 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price MRI Pituitary W&W/O Contrast 70553 0610 $5,920 $5,920 $3,552 MRI Brain FMRI 70554 0610 $3,097 $3,097 $1,858 MRI Brain IAC/Cranial Nerve W/Contrast 70558 0610 $5,850 $5,850 $3,510 MRI Brain W/Contrast 70558 0610 $5,850 $5,850 $3,510 MRI Brain W&W/O Contrast 70559 0610 $3,636 $3,636 $2,182 MRI Brain IAC/Cranial Nerve W&W/O Cont 70559 0610 $3,636 $3,636 $2,182 MRI Brain CSF Study W&W/O Contrast 70559 0610 $3,636 $3,636 $2,182 MRI Brain W&W/O Contrast w/ Perfusion 70559 0610 $3,636 $3,636 $2,182 XR Chest 1 View 71045 0320 $431 $431 $259 XR Chest 2 View 71046 0320 $559 $559 $335 XR Chest 3 View 71047 0320 $645 $645 $387 XR Chest 4 View 71048 0320 $645 $645 $387 XR Ribs 2 Views Left 71100 0320 $490 $490 $294 XR Ribs 2 Views Right 71100 0320 $490 $490 $294 XR Ribs w/ PA Chest Left 71101 0320 $850 $850 $510 XR Ribs w/ PA Chest Right 71101 0320 $850 $850 $510 XR Ribs 3 Views Bilateral 71110 0320 $641 $641 $385 XR Ribs w/ PA Chest Bilateral 71111 0320 $1,128 $1,128 $677 XR Sternum Minimum 2 Views 71120 0320 $307 $307 $184 XR Sternoclavicular Joint(s) 71130 0320 $297 $297 $178 CT Thorax W/O Con Lung CA Screen 71250 0350 $3,515 $3,515 $2,109 CT Thorax W/O Con Lung CA Screen:Ep 71250 0350 $3,515 $3,515 $2,109 CT Thorax W/O Contrast-71250 71250 0350 $3,515 $3,515 $2,109 CT Thorax W/ Contrast 71260 0350 $4,167 $4,167 $2,500 CT Thorax W/&W/O Contrast 71270 0350 $4,381 $4,381 $2,629 CT Angiography Chest 71275 0350 $4,651 $4,651 $2,791 CT Angiography Chest PE-71275 71275 0350 $1,155 $1,155 $693 MRI Brachial Plexus W/O Contrast Rt 71550 0610 $4,062 $4,062 $2,437 MRI Brachial Plexus W/O Contrast Lt 71550 0610 $4,062 $4,062 $2,437 MRI Chest W/O Contrast 71550 0610 $4,062 $4,062 $2,437 MRI Chest Wall W/O Contrast 71550 0610 $4,062 $4,062 $2,437 MRI Chest W/Contrast 71551 0610 $9,010 $9,010 $5,406 MRI Brachial Plexus W/W&O Contrast Rt 71552 0610 $5,964 $5,964 $3,578 MRI Brachial Plexus W&W/O Contrast Lt 71552 0610 $5,964 $5,964 $3,578 MRI Chest W&W/O Contrast 71552 0610 $5,964 $5,964 $3,578 MRI Chest Wall W&W/O Contrast 71552 0610 $5,964 $5,964 $3,578 MRA Chest W/O Contrast 71555 0610 $4,438 $4,438 $2,663 MRA Chest W/ Contrast 71555 0610 $4,438 $4,438 $2,663 XR Spine 1 View Cervical 72020 0320 $955 $955 $573 XR Spine 1 View Lumbar 72020 0320 $955 $955 $573 XR Spine 1 View Thoracic 72020 0320 $955 $955 $573 XR Spine Single View Specify Level 72020 0320 $955 $955 $573 XR Spine Thoracolumbar AP Only 72020 0320 $955 $955 $573 XR Spine Cervical 2 or 3 Views 72040 0320 $449 $449 $269 XR Spine Cervical Flexion/Extension Only 72040 0320 $619 $619 $371 XR Spine Cervical 4 Views 72050 0320 $725 $725 $435 XR Spine Cervical w/ Obliques 72050 0320 $725 $725 $435 XR Spine Cervical 5 Views 72050 0320 $374 $374 $224 XR Cervical Spine with Flexion/Extension 72052 0320 $725 $725 $435 XR Spine Thoracic 3 Views 72072 0320 $1,085 $1,085 $651 XR Spine Thoracic Flex/Ext 72072 0320 $726 $726 $436 XR Spine Thoracolumbar 2 Views 72080 0320 $561 $561 $337 XR Spine Thoracolumbar In/Out of Brace 72080 0320 $1,047 $1,047 $628 XR Exam Scoliosis 1 View Only 72081 0320 $250 $250 $150 XR Scoliosis Series 2/3 Views 72082 0320 $802 $802 $481 XR Spine T-L Spine Upright + Supine 72082 0320 $805 $805 $483 XR Exam Scoliosis 4 Views 72083 0320 $514 $514 $308 XR Spine Lumbosacral 2 or 3 Views 72100 0320 $531 $531 $319 XR Spine Lumbosacral Flex/Ext 72100 0320 $531 $531 $319 XR Spine Lumbosacral w/ Obliques 72110 0320 $941 $941 $565 XR Spine Lumbosacral Complete w/ Bending 72114 0320 $816 $816 $490 CT C-Spine W/O Contrast 72125 0350 $3,628 $3,628 $2,177 CT C-Spine W/ Contrast 72126 0350 $4,195 $4,195 $2,517 CT C-Spine W/&W/O Contrast 72127 0350 $3,636 $3,636 $2,182 CT T-Spine W/O Contrast 72128 0350 $4,568 $4,568 $2,741 CT T-Spine W/ Contrast 72129 0350 $4,568 $4,568 $2,741 CT T-Spine W/&W/O Contrast 72130 0350 $3,636 $3,636 $2,182 CT L-Spine W/O Contrast 72131 0350 $4,126 $4,126 $2,476 CT L-Spine W/ Contrast 72132 0350 $4,651 $4,651 $2,791 CT L-Spine W/&W/O Contrast 72133 0350 $3,636 $3,636 $2,182 MRI Spine Cervical W/O Contrast 72141 0610 $4,977 $4,977 $2,986 MRI Spine Cervical W/Contrast 72142 0610 $5,850 $5,850 $3,510 MRI Spine Thoracic W/O Contrast 72146 0610 $4,970 $4,970 $2,982 MRI Spine Thoracic W/ Contrast 72147 0610 $5,850 $5,850 $3,510 MRI Spine Lumbar W/O Contrast 72148 0610 $4,970 $4,970 $2,982 MRI Spine Lumbar W/Contrast 72149 0610 $5,850 $5,850 $3,510 MRI Spine Cervical W&W/O Contrast 72156 0610 $6,415 $6,415 $3,849 MRI Spine Thoracic W&W/O Contrast 72157 0610 $6,415 $6,415 $3,849 MRI Spine Lumbar W&W/O Contrast 72158 0610 $6,415 $6,415 $3,849

Page 11 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price MRA Spinal Canal W/O Contrast 72159 0610 $4,684 $4,684 $2,810 MRA Spinal Canal W&W/O Contrast 72159 0610 $4,684 $4,684 $2,810 MRA Spinal Canal W/ Contrast 72159 0610 $4,684 $4,684 $2,810 XR Pelvis 1 or 2 Views 72170 0320 $448 $448 $269 XR Ischium 72170 0320 $448 $448 $269 XR Pelvis Inlet/Outlet Views 72170 0320 $448 $448 $269 XR Symphysis Pubis 72170 0320 $448 $448 $269 XR Pelvis AP/Lat 2 Views 72170 0320 $448 $448 $269 XR Pelvis Judet Series 72190 0320 $514 $514 $308 CT Pelvis W/O Contrast 72192 0350 $2,927 $2,927 $1,756 CT Pelvis W/ Contrast 72193 0350 $4,167 $4,167 $2,500 CT Pelvis W/&W/O Contrast 72194 0350 $4,445 $4,445 $2,667 MRI Pelvis MSK W/O Contrast 72195 0610 $4,506 $4,506 $2,704 MRI Pelvis Viscera W/O Contrast 72195 0610 $4,506 $4,506 $2,704 MRI Prostate W/O Contrast 72195 0610 $4,506 $4,506 $2,704 MRI Sacrum Coccyx W/O Contrast 72195 0610 $4,506 $4,506 $2,704 MRI Sacrum Coccyx W/ Contrast 72196 0610 $5,850 $5,850 $3,510 MRI Pelvis MSK W&WO Contrast 72197 0610 $6,659 $6,659 $3,995 MRI Pelvis Viscera W&W/O Contrast 72197 0610 $6,659 $6,659 $3,995 MRI Prostate W&W/O Contrast 72197 0610 $6,659 $6,659 $3,995 MRI Sacrum Coccyx W&W/O Contrast 72197 0610 $6,659 $6,659 $3,995 MRA Pelvis W/O Contrast 72198 0610 $4,486 $4,486 $2,692 MRA Pelvis W/ Contrast 72198 0610 $4,486 $4,486 $2,692 MRV Pelvis W&W/O Contrast 72198 0610 $4,486 $4,486 $2,692 XR Sacroiliac Joints Minimum 3 Views 72202 0320 $646 $646 $388 XR Coccyx 72220 0320 $501 $501 $301 XR Sacrum 72220 0320 $501 $501 $301 XR Sacrum/Coccyx Minimum 2 Views 72220 0320 $501 $501 $301 XR Epidurography 72275 0320 $348 $348 $209 XR Diskography Cervical 72285 0320 $2,809 $2,809 $1,685 XR Diskography Thoracic 72285 0320 $2,809 $2,809 $1,685 XR Diskography Lumbar 72295 $1,920 $777 $2,697 $1,618 XR Diskography Lumbar 72295 0320 $2,891 $2,891 $1,735 Radiological Interpretation for Lumbar Discography 72295 0361 $8,304 $1,086 $9,390 $5,634 CA-Radiological interp/Discography/Lumbar 72295 0361 $7,985 $1,170 $9,155 $5,493 XR Clavicle Left 73000 0320 $402 $402 $241 XR Clavicle Right 73000 0320 $402 $402 $241 XR Scapula Left 73010 0320 $370 $370 $222 XR Scapula Right 73010 0320 $370 $370 $222 XR Shoulder 1 View Left 73020 0320 $278 $278 $167 XR Shoulder 1 View Right 73020 0320 $278 $278 $167 XR Transthoracic Shoulder Left 73020 0320 $278 $278 $167 XR Transthoracic Shoulder Right 73020 0320 $278 $278 $167 XR Shoulder AP True + Outlet + AX. Left 73030 0320 $499 $499 $299 XR Shoulder AP True + Outlet + Axillary View Right 73030 0320 $499 $499 $299 XR Shoulder + Grashey + Y View Left 73030 0320 $499 $499 $299 XR Shoulder + Grashey + Y View Right 73030 0320 $499 $499 $299 XR Shoulder + Grashey Left 73030 0320 $499 $499 $299 XR Shoulder + Grashey Right 73030 0320 $499 $499 $299 XR Shoulder + Grashey + Axillary View Left 73030 0320 $499 $499 $299 XR Shoulder + Grashey + Y View + Axillary View Rig 73030 0320 $499 $499 $299 XR Shoulder + Grashey + Axillary View Right 73030 0320 $499 $499 $299 XR Shoulder + Grashey + Y View + Axillary ViewLeft 73030 0320 $499 $499 $299 XR AC Joints Bilateral w/ + w/o wts 73050 0320 $350 $350 $210 XR Humerus Left 73060 0320 $712 $712 $427 XR Humerus Right 73060 0320 $712 $712 $427 XR Elbow 2 Views Left 73070 0320 $429 $429 $257 XR Elbow 2 Views Right 73070 0320 $429 $429 $257 XR Elbow Complete Left 73080 0320 $398 $398 $239 XR Elbow Complete Right 73080 0320 $398 $398 $239 XR Forearm 2 Views Left 73090 0320 $429 $429 $257 XR Forearm 2 Views Right 73090 0320 $429 $429 $257 XR Upper Extremity Infant Left 73092 0320 $88 $88 $53 XR Upper Extremity Infant Right 73092 0320 $88 $88 $53 XR Wrist 2 Views Left 73100 0320 $448 $448 $269 XR Wrist 2 Views Right 73100 0320 $448 $448 $269 XR Wrist Carpal Tunnel Left 73100 0320 $448 $448 $269 XR Wrist Carpal Tunnel Right 73100 0320 $448 $448 $269 XR Wrist Navicular View Left 73100 0320 $448 $448 $269 XR Wrist Navicular View Right 73100 0320 $448 $448 $269 XR Wrist Complete Left 73110 0320 $408 $408 $245 XR Wrist Complete Right 73110 0320 $408 $408 $245 XR Hand 2 Views Left 73120 0320 $392 $392 $235 XR Hand 2 Views Right 73120 0320 $392 $392 $235 XR Hand Complete Left 73130 0320 $448 $448 $269 XR Hand Complete Right 73130 0320 $448 $448 $269 XR Finger 2nd Digit Left 73140 0320 $357 $357 $214 XR Finger 2nd Digit Right 73140 0320 $357 $357 $214 XR Finger 3rd Digit Left 73140 0320 $357 $357 $214

Page 12 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price XR Finger 3rd Digit Right 73140 0320 $357 $357 $214 XR Finger 4th Digit Left 73140 0320 $357 $357 $214 XR Finger 4th Digit Right 73140 0320 $357 $357 $214 XR Finger 5th Digit Left 73140 0320 $357 $357 $214 XR Finger 5th Digit Right 73140 0320 $357 $357 $214 XR Finger Thumb Left 73140 0320 $357 $357 $214 XR Finger Thumb Right 73140 0320 $357 $357 $214 CT Upper Extremity W/O Contrast Bil 73200 0350 $3,311 $3,311 $1,987 CT Upper Extremity W/O Contrast Lt 73200 0350 $3,311 $3,311 $1,987 CT Upper Extremity W/O Contrast Rt 73200 0350 $3,311 $3,311 $1,987 CT Upper Extremity W/ Contrast Bil 73201 0350 $3,636 $3,636 $2,182 CT Upper Extremity W/ Contrast Lt 73201 0350 $3,636 $3,636 $2,182 CT Upper Extremity W/ Contrast Rt 73201 0350 $3,636 $3,636 $2,182 CT Upper Extremity W/&W/O Contrast Bil 73202 0350 $3,636 $3,636 $2,182 CT Upper Extremity W/&W/O Contrast Lt 73202 0350 $3,636 $3,636 $2,182 CT Upper Extremity W/&W/O Contrast Rt 73202 0350 $3,636 $3,636 $2,182 MRI Finger W/O Contrast Right 73218 0610 $3,097 $3,097 $1,858 MRI Finger W/O Contrast Left 73218 0610 $3,097 $3,097 $1,858 MRI Forearm W/O Contrast Right 73218 0610 $3,097 $3,097 $1,858 MRI Forearm W/O Contrast Left 73218 0610 $3,097 $3,097 $1,858 MRI Hand W/O Contrast Right 73218 0610 $3,097 $3,097 $1,858 MRI Hand W/O Contrast Left 73218 0610 $3,097 $3,097 $1,858 MRI Humerus W/O Contrast Rt 73218 0610 $3,097 $3,097 $1,858 MRI Humerus W/O Contrast Lt 73218 0610 $3,097 $3,097 $1,858 MRI Upper Ext W/ Contrast Right 73219 0610 $5,850 $5,850 $3,510 MRI Upper Ext W/ Contrast Left 73219 0610 $5,850 $5,850 $3,510 MRI Forearm W&W/O Contrast Right 73220 0610 $5,850 $5,850 $3,510 MRI Hand W&W/O Contrast Left 73220 0610 $5,850 $5,850 $3,510 MRI Humerus W&W/O Contrast Rt 73220 0610 $5,850 $5,850 $3,510 MRI Finger W&W/O Contrast Right 73220 0610 $5,850 $5,850 $3,510 MRI Finger W&W/O Contrast Left 73220 0610 $5,850 $5,850 $3,510 MRI Forearm W&W/O Contrast Left 73220 0610 $5,850 $5,850 $3,510 MRI Hand W&W/O Contrast Right 73220 0610 $5,850 $5,850 $3,510 MRI Humerus W&W/O Contrast Lt 73220 0610 $5,850 $5,850 $3,510 MRI Elbow W/O Contrast Right 73221 0610 $4,708 $4,708 $2,825 MRI Elbow W/O Contrast Left 73221 0610 $4,708 $4,708 $2,825 MRI Shoulder W/O Contrast Rt 73221 0610 $4,708 $4,708 $2,825 MRI Shoulder W/O Contrast Lt 73221 0610 $4,708 $4,708 $2,825 MRI Wrist W/O Contrast Rt 73221 0610 $4,708 $4,708 $2,825 MRI Wrist W/O Contrast Lt 73221 0610 $4,708 $4,708 $2,825 MRI Upper Ext Joint W/Contrast Rt 73222 0610 $9,010 $9,010 $5,406 MRI Upper Ext Joint W/Contrast Lt 73222 0610 $9,010 $9,010 $5,406 MRI Elbow W&W/O Contrast Right 73223 0610 $5,850 $5,850 $3,510 MRI Elbow W&W/O Contrast Left 73223 0610 $5,850 $5,850 $3,510 MRI Shoulder W&W/O Contrast Rt 73223 0610 $5,850 $5,850 $3,510 MRI Shoulder W&W/O Contrast Lt 73223 0610 $5,850 $5,850 $3,510 MRI Wrist W&W/O Contrast Rt 73223 0610 $5,850 $5,850 $3,510 MRI Wrist W&W/O Contrast Lt 73223 0610 $5,850 $5,850 $3,510 MRA Upper Ext W/O Contrast 73225 0610 $4,645 $4,645 $2,787 MRA Upper Ext W&W/O Contrast 73225 0610 $4,645 $4,645 $2,787 MRA Upper Ext W/ Contrast 73225 0610 $4,645 $4,645 $2,787 XR Hip Complete Left 73502 0320 $448 $448 $269 XR Hip Complete Right 73502 0320 $448 $448 $269 XR Pelvis + Hips Infant/Child 73521 0320 $297 $297 $178 XR Hip Bilateral w/Pelvis 73522 0320 $571 $571 $343 Hip Arthrogram (73525) 73525 $95 $95 $57 XR Femur Left 73552 0320 $431 $431 $259 XR Femur Right 73552 0320 $431 $431 $259 XR Knee 1 or 2 Views Left 73560 0320 $448 $448 $269 XR Knee 1 or 2 Views Right 73560 0320 $448 $448 $269 XR Knee + Tunnel Left 73562 0320 $499 $499 $299 XR Knee + Tunnel Right 73562 0320 $499 $499 $299 XR Knee 3 Views Left 73562 0320 $241 $241 $145 XR Knee 3 Views Right 73562 0320 $241 $241 $145 XR Knee + Sunrise Left 73562 0320 $499 $499 $299 XR Knee + Sunrise Right 73562 0320 $499 $499 $299 XR Knee + Obliques Left 73564 0320 $555 $555 $333 XR Knee + Obliques Right 73564 0320 $555 $555 $333 XR Knee + Tunnel + Sunrise Left 73564 0320 $555 $555 $333 XR Knee + Tunnel + Sunrise Right 73564 0320 $555 $555 $333 XR Knee Standing AP Bilateral 73565 0320 $463 $463 $278 XR Tibia/Fibula Left 73590 0320 $762 $762 $457 XR Tibia/Fibula Right 73590 0320 $762 $762 $457 XR Lower Extremity Infant Left 73592 0320 $88 $88 $53 XR Lower Extremity Infant Right 73592 0320 $88 $88 $53 XR Ankle 2 Views Left 73600 0320 $392 $392 $235 XR Ankle 2 Views Right 73600 0320 $392 $392 $235 XR Ankle Complete Left 73610 0320 $531 $531 $319 XR Ankle Complete Right 73610 0320 $531 $531 $319

Page 13 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price XR Foot 2 Views Left 73620 0320 $392 $392 $235 XR Foot 2 Views Right 73620 0320 $392 $392 $235 XR Foot Complete Left 73630 0320 $407 $407 $244 XR Foot Complete Right 73630 0320 $407 $407 $244 XR Calcaneous Left 73650 0320 $392 $392 $235 XR Calcaneous Right 73650 0320 $392 $392 $235 XR Toes 2nd Digit Left 73660 0320 $357 $357 $214 XR Toes 2nd Digit Right 73660 0320 $357 $357 $214 XR Toes 3rd Digit Left 73660 0320 $357 $357 $214 XR Toes 3rd Digit Right 73660 0320 $357 $357 $214 XR Toes 4th Digit Left 73660 0320 $357 $357 $214 XR Toes 4th Digit Right 73660 0320 $357 $357 $214 XR Toes 5th Digit Left 73660 0320 $357 $357 $214 XR Toes 5th Digit Right 73660 0320 $357 $357 $214 XR Toes Great Left 73660 0320 $357 $357 $214 XR Toes Great Right 73660 0320 $357 $357 $214 CT Lower Extremity W/O Contrast Bil 73700 0350 $3,430 $3,430 $2,058 CT Lower Extremity W/O Contrast Lt 73700 0350 $3,430 $3,430 $2,058 CT Lower Extremity W/O Contrast Rt 73700 0350 $3,430 $3,430 $2,058 CT Lower Extremity W/ Contrast Bil 73701 0350 $3,775 $3,775 $2,265 CT Lower Extremity W/ Contrast Lt 73701 0350 $3,775 $3,775 $2,265 CT Lower Extremity W/ Contrast Rt 73701 0350 $3,775 $3,775 $2,265 CT Lower Extremity W/&W/O Contrast Bil 73702 0350 $4,461 $4,461 $2,677 CT Lower Extremity W/&W/O Contrast Lt 73702 0350 $4,461 $4,461 $2,677 CT Lower Extremity W/&W/O Contrast Rt 73702 0350 $4,461 $4,461 $2,677 MRI Femur W/O Contrast Right 73718 0610 $4,708 $4,708 $2,825 MRI Femur W/O Contrast Left 73718 0610 $4,708 $4,708 $2,825 MRI Foot W/O Contrast Rt 73718 0610 $4,708 $4,708 $2,825 MRI Foot W/O Contrast Lt 73718 0610 $4,708 $4,708 $2,825 MRI Tibia W/O Contrast Rt 73718 0610 $4,708 $4,708 $2,825 MRI Tibia W/O Contrast Lt 73718 0610 $4,708 $4,708 $2,825 MRI Lower Ext W/O Contrast Lt-73718 73718 0610 $4,708 $4,708 $2,825 MRI Lower Ext W/O Contrast Rt-73718 73718 0610 $4,708 $4,708 $2,825 MRI Femur W&W/O Contrast Right 73720 0610 $5,697 $5,697 $3,418 MRI Femur W&W/O Contrast Left 73720 0610 $5,697 $5,697 $3,418 MRI Foot W&W/O Contrast Rt 73720 0610 $5,697 $5,697 $3,418 MRI Foot W&W/O Contrast Lt 73720 0610 $5,697 $5,697 $3,418 MRI Tibia W&W/O Contrast Rt 73720 0610 $5,697 $5,697 $3,418 MRI Tibia W&W/O Contrast Lt 73720 0610 $5,697 $5,697 $3,418 MRI Ankle/Hindfoot W/O Contrast Right 73721 0610 $5,090 $5,090 $3,054 MRI Ankle/Hindfoot W/O Contrast Left 73721 0610 $5,090 $5,090 $3,054 MRI Hip W/O Contrast Rt 73721 0610 $5,090 $5,090 $3,054 MRI Hip W/O Contrast Lt 73721 0610 $5,090 $5,090 $3,054 MRI Knee W/O Contrast Rt 73721 0610 $5,090 $5,090 $3,054 MRI Knee W/O Contrast Lt 73721 0610 $5,090 $5,090 $3,054 MRI Lower Ext Joint W/O Contrast Lt-73721 73721 0610 $5,090 $5,090 $3,054 MRI Lower Ext Joint W/O Contrast Rt-73721 73721 0610 $5,090 $5,090 $3,054 MRI Lower Ext W/Contrast Right 73722 0610 $6,154 $6,154 $3,692 MRI Lower Ext W/Contrast Left 73722 0610 $6,154 $6,154 $3,692 MRI Lower Ext Joint W/Contrast Rt 73722 0610 $5,090 $5,090 $3,054 MRI Lower Ext Joint W/Contrast Lt 73722 0610 $5,090 $5,090 $3,054 MRI Ankle/Hindfoot W&W/O Contrast Right 73723 0610 $6,154 $6,154 $3,692 MRI Ankle/Hindfoot W&W/O Contrast Left 73723 0610 $6,154 $6,154 $3,692 MRI Hip W&W/O Contrast Rt 73723 0610 $6,154 $6,154 $3,692 MRI Hip W&W/O Contrast Lt 73723 0610 $6,154 $6,154 $3,692 MRI Knee W&W/O Contrast Rt 73723 0610 $6,154 $6,154 $3,692 MRI Knee W&W/O Contrast Lt 73723 0610 $6,154 $6,154 $3,692 MRA Lower Ext W/O Contrast 73725 0610 $4,477 $4,477 $2,686 MRA Lower Ext W&W/O Contrast 73725 0610 $4,477 $4,477 $2,686 MRA Lower Ext W/Contrast 73725 0610 $4,477 $4,477 $2,686 XR Abdomen 1 View 74018 0320 $652 $652 $391 XR Abdomen 2 View 74019 0320 $567 $567 $340 CT Abdomen W/O Contrast 74150 0350 $3,438 $3,438 $2,063 CT Abdomen W/ Contrast 74160 0350 $3,891 $3,891 $2,335 CT Abdomen W/&W/O Contrast 74170 0350 $4,488 $4,488 $2,693 CT Angiography Abd/Pel W/&W/O Contrast 74174 0350 $5,978 $5,978 $3,587 CT Angiogram Abdomen W/&W/O Contrast 74175 0350 $5,387 $5,387 $3,232 CT Abdomen/Pelvis W/O Contrast 74176 0350 $6,545 $6,545 $3,927 CT Abdomen/Pelvis W/ Contrast 74177 0350 $8,063 $8,063 $4,838 CT Abdomen/Pelvis W/&W/O Contrast 74178 0350 $9,283 $9,283 $5,570 MRI Abdomen W/O Contrast 74181 0610 $4,677 $4,677 $2,806 MRI Abdomen MRCP W/O Contrast 74181 0610 $4,677 $4,677 $2,806 MRI Abdominal Wall W/O Contrast 74181 0610 $4,677 $4,677 $2,806 MRI Abdomen W/ Contrast 74182 0610 $5,850 $5,850 $3,510 MRI Abdominal Wall W/ Contrast 74182 0610 $5,850 $5,850 $3,510 MRI Pelvis Enterography W&W/O Contrast 74183 0610 $5,977 $5,977 $3,586 MRI Pelvis Urography W&W/O Contrast 74183 0610 $5,977 $5,977 $3,586 MRI Abdomen W&W/O Contrast 74183 0610 $5,977 $5,977 $3,586 MRI Abdomen MRCP W&W/O Contrast 74183 0610 $5,977 $5,977 $3,586

Page 14 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price MRI Abdomen Enterography W&W/O Contrast 74183 0610 $5,977 $5,977 $3,586 MRI Abdomen Urography W&W/O Contrast 74183 0610 $5,977 $5,977 $3,586 MRA Abdomen W/O Contrast 74185 0610 $4,512 $4,512 $2,707 MRA Abdomen W&W/O Contrast 74185 0610 $4,512 $4,512 $2,707 MRA Abdomen W/ Contrast 74185 0610 $4,512 $4,512 $2,707 XR Swallowing Function w/ Video 74230 0320 $365 $365 $219 Video Fluroscopy Physician Charge 74230 0320 $240 $240 $144 XR Shuntogram Non-Vascular 75809 0320 $960 $960 $576 XR Fluoroscopy Up to 1 Hour 76000 0320 $671 $671 $403 Fluoroscopy (separate procedure), up to 1 hour phy 76000 $31 $31 $19 XR Foreign Body Loc Nose/Rectum Child 76010 0320 $88 $88 $53 XR Abdomen AP + Lateral 76499 0320 $427 $427 $256 US XTR NON-VASC COMPLETE (76881) 76881 0402 $453 $80 $533 $320 US XTR NON-VASC LMTD (76882) 76882 0402 $293 $63 $356 $214 US Guide Vascular Access Charge 76937 0402 $1,295 $1,295 $777 Ultrasonic Guidance for Injection Charge (76942) 76942 0402 $150 $261 $411 $247 XR Fluoro Guidance Needle Placement 77002 0320 $2,009 $465 $2,474 $1,484 XR Fluoro Guidance Needle Placement 77002 0320 $1,895 $465 $2,360 $1,416 Fluoro Guide Non-spine 77002 0320 $1,895 $1,895 $1,137 Fluoroscopic Guidance- Needle Localization (77002) 77002 0320 $2,987 $431 $3,418 $2,051 XR Fluoro Guidance Needle Loc Spine 77003 0320 $2,009 $465 $2,474 $1,484 XR Fluoro Guidance Needle Loc Spine 77003 0320 $2,110 $465 $2,575 $1,545 Fluoro Guide Spinal Injection 77003 0320 $2,110 $2,110 $1,266 Fluoroscopic Guidance- Spine (77003) 77003 0320 $2,987 $431 $3,418 $2,051 XR Manual Stress Application to Joint 77071 0320 $88 $88 $53 XR Bone Age Studies 77072 0320 $137 $137 $82 Bonth Length Studies 77073 0320 $241 $241 $145 XR Bone Survey Limited (Mets) 77074 0320 $1 $1 $1 XR Bone Survey Complete (Mets) 77075 0320 $1,002 $1,002 $601 XR Bone Survey Infant 77076 0320 $149 $149 $89 XR Joint Survey Single View 77077 0320 $88 $88 $53 XR Multiple Joints 1 View Bilateral Hands 77077 0320 $221 $221 $133 XR Multiple Joints 1 View Infant Lower Extremity 77077 0320 $221 $221 $133 Dexa Exam 77080 0320 $561 $561 $337 Bone Density DEXA Axial Skeleton Charge 77080 0320 $380 $380 $228 Dexa Exam 77081 0320 $174 $174 $104 Bone Density DEXA App Skeleton Charge 77081 0320 $164 $164 $98 DXA BONE DENSITY STUDY (77085) 77085 $63 $63 $38 Vertebral fracture assessment via dual-energy X-ra 77086 $63 $63 $38 Basic Chemistry Panel, Calcium, total 80048 0301 $433 $390 $823 $494 Basic Chemistry Panel 80048 0301 $433 $390 $823 $494 Electrolyte Panel 80051 0301 $262 $236 $498 $299 Fecal Lytes/pH/Osmo Timed Collection 80051 0301 $262 $236 $498 $299 Comprehensive Metabolic Panel 80053 0301 $413 $372 $785 $471 Coronary Risk/Lipid Panel 80061 0301 $376 $340 $716 $430 Kidney Chemistry Panel 80069 0301 $386 $348 $734 $440 Acute Hepatitis Panel 80074 0302 $398 $358 $756 $454 Liver Chemistry Panel 80076 0301 $304 $274 $578 $347 Amikacin-Trough 80150 0301 $446 $402 $848 $509 Amikacin-Random 80150 0301 $446 $402 $848 $509 Amikacin-Peak 80150 0301 $446 $402 $848 $509 Tegretol/Carbamezapine 80156 0301 $151 $136 $287 $172 Cyclosporine Level 80158 0301 $295 $266 $561 $337 Digoxin/Ditgitalis Level 80162 0301 $255 $231 $486 $292 Valproic Acid Level 80164 0301 $190 $172 $362 $217 Valproic Acid, Free 80164 0301 $122 $110 $232 $139 Everolimus Level 80169 0301 $89 $80 $169 $101 Gentamcin-Trough 80170 0301 $196 $176 $372 $223 Gentamicin-Random 80170 0301 $196 $176 $372 $223 Gentamicin-Peak 80170 0301 $255 $231 $486 $292 Lamotrigine Level 80175 0301 $439 $397 $836 $502 Lithium Level 80178 0301 $139 $126 $265 $159 Mycophenolic acid Level 80180 0301 $120 $108 $228 $137 Oxcarbazepine Level 80183 0301 $439 $397 $836 $502 Phenobarbital Level 80184 0301 $167 $150 $317 $190 Dilantin/Phenytoin, Free 80186 0301 $324 $293 $617 $370 Primidone Level 80188 0301 $367 $331 $698 $419 Mysoline Level 80188 0301 $367 $331 $698 $419 Pronestyl Level 80190 0301 $307 $277 $584 $350 Procainamide and NAPA 80192 0301 $156 $141 $297 $178 Quinidine Level 80194 0301 $447 $403 $850 $510 Tacrolimus Level 80197 0301 $343 $310 $653 $392 Theophylline/Aminophylline 80198 0301 $172 $156 $328 $197 Tobramycin-Peak 80200 0301 $461 $416 $877 $526 Tobramycin-Trough 80200 0301 $461 $416 $877 $526 Tobramycin-Random 80200 0301 $461 $416 $877 $526 Topiramate Level 80201 0301 $406 $367 $773 $464 Vancomycin-Trough 80202 0301 $248 $224 $472 $283 Vancomycin-Random 80202 0301 $248 $224 $472 $283

Page 15 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price Methotrexate Level 80299 0301 $439 $397 $836 $502 Fluoxetine & Norfluoxetine 80299 0301 $439 $397 $836 $502 Norpace (Disopyramide) Level 80299 0301 $439 $397 $836 $502 Propanolol Level 80299 0301 $439 $397 $836 $502 Levetiracetam Level 80299 0301 $439 $397 $836 $502 Trazodone Level 80299 0301 $439 $397 $836 $502 Klonopin Level 80299 0301 $439 $397 $836 $502 Mirtazapine Level 80299 0301 $439 $397 $836 $502 Propanolol Level 80299 0301 $120 $120 $72 Voriconazole Level 80299 0301 $300 $271 $571 $343 Itraconazole Level 80299 0301 $439 $397 $836 $502 Urinalysis with Microscopic 81001 0301 $105 $95 $200 $120 Urinalysis 81003 0301 $69 $63 $132 $79 Urinalysis 81003 0301 $69 $63 $132 $79 URINALYSIS; QUAL NOT IA 81005 0301 $14 $14 $8 Pregnancy, Urine 81025 0301 $125 $113 $238 $143 Urine Pregnancy POC 81025 0307 $117 $105 $222 $133 F5 Gene Analysis 81241 0301 $324 $293 $617 $370 Acetone, Serum 82009 0301 $31 $28 $59 $35 Adrenocorticotropic Hormone (ACTH) 82024 0301 $449 $405 $854 $512 Albumin Level 82040 0301 $79 $71 $150 $90 Albumin-Fluid 82042 0301 $41 $37 $78 $47 Microalbumin with Creatinine, Urine Timed 82043 0301 $40 $36 $76 $46 Microalbumin with Creatinine, Urine, Random 82043 0301 $84 $76 $160 $96 Aldolase 82085 0301 $117 $105 $222 $133 Aldosterone 82088 0301 $1,261 $1,138 $2,399 $1,439 Aldosterone, Urine timed 82088 0301 $661 $596 $1,257 $754 Aldosterone, random Urine 82088 0301 $381 $343 $724 $434 Alpha 1 Antitrypsin Total 82103 0301 $342 $309 $651 $391 Alpha 1 Antitrypsin Phenotype 82104 0301 $104 $94 $198 $119 Panel-Alpha Fetoprotein (Maternal) 82105 0301 $304 $274 $578 $347 Alpha Fetoprotein, Tumor Marker 82105 0301 $250 $226 $476 $286 Alpha Fetoprotein 82105 0301 $304 $274 $578 $347 Aluminum Level, Serum 82108 0301 $185 $167 $352 $211 Aluminum Level, Urine timed 82108 0301 $259 $234 $493 $296 Aluminum Level, Urine Random 82108 0301 $259 $234 $493 $296 Aminolevulinic Acid, Urine 82135 0301 $385 $347 $732 $439 Amino Acid Profile, Quantitative 82139 0301 $505 $455 $960 $576 Ammonia 82140 0301 $61 $55 $116 $70 Amylase Level, Serum 82150 0301 $156 $141 $297 $178 Amylase, Fluid 82150 0301 $102 $92 $194 $116 Amylase Level, Random Urine 82150 0301 $122 $110 $232 $139 Amylase, Timed Urine 82150 0301 $118 $106 $224 $134 Androstenedione 82157 0301 $408 $369 $777 $466 Angiotensin Converting Enzyme 82164 0301 $168 $151 $319 $191 Angiotensin Converting Enzyme-CSF 82164 0301 $168 $151 $319 $191 Apolipoprotein B 82172 0301 $113 $102 $215 $129 Apolipoprotein E 82172 0301 $113 $102 $215 $129 Apolipoprotein (a) 82172 0301 $113 $102 $215 $129 Arsenic 82175 0301 $522 $471 $993 $596 Arsenic Level, Urine timed 82175 0301 $154 $139 $293 $176 Arsenic, random Urine 82175 0301 $154 $139 $293 $176 Vitamin C Level 82180 0301 $80 $72 $152 $91 Beta 2 Mircroglobulin, Serum 82232 0301 $113 $102 $215 $129 Bilirubin, Total 82247 0301 $97 $88 $185 $111 Bilirubin, Fluid 82247 0301 $97 $88 $185 $111 Bilirubin, Direct 82248 0301 $97 $88 $185 $111 Occult Blood, Feces-POCT 82270 0300 $80 $72 $152 $91 Occult Blood Screen 82270 0300 $80 $72 $152 $91 Occult Blood Exam 82271 0300 $80 $72 $152 $91 Cadmium,random Urine with Creatinine Ratio 82300 0300 $231 $208 $439 $263 Vitamin D, 25-Hydroxy 82306 0301 $569 $513 $1,082 $649 Vitamin D, 25-Hydroxy 82306 0301 $471 $471 $283 Vitamin D, 125-Dihydroxy 82306 0301 $471 $471 $283 Calcitonin Level 82308 0301 $195 $175 $370 $222 Calcium/CA++ Level 82310 0301 $133 $119 $252 $151 Calcium Ionized 82330 0301 $254 $230 $484 $290 Calcium, Urine Random 82340 0301 $84 $76 $160 $96 Calcium, Urine Timed 82340 0301 $104 $94 $198 $119 Calculus Analysis 82365 0301 $115 $104 $219 $131 Stone Analysis, Kidney 82365 0301 $115 $104 $219 $131 Stone Analysis, Non-Kidney 82365 0301 $115 $104 $219 $131 CO2/Bicarb 82374 0301 $71 $64 $135 $81 Carbon Dioxide, Urine 82374 0301 $117 $105 $222 $133 Carbon Monoxide, quant. 82375 0301 $82 $82 $49 Carcinoembryonic Antigen 82378 0301 $415 $374 $789 $473 Fluid CEA 82378 0300 $167 $150 $317 $190 Carotene Level 82380 0301 $259 $234 $493 $296 Catecholamines, Plasma, Fractionated 82383 0301 $295 $266 $561 $337

Page 16 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price VMA/CAT/MET Profile 82384 0301 $416 $375 $791 $475 Catecholamines, Fractionated, Urine, Random 82384 0301 $262 $236 $498 $299 Catecholamines-Fractionated, Urine timed 82384 0301 $280 $252 $532 $319 Ceruloplasmin 82390 0301 $181 $163 $344 $206 Interleukin-6 82397 0301 $248 $224 $472 $283 Chloride 82435 0301 $40 $36 $76 $46 Chloride, Urine Random 82436 0301 $102 $92 $194 $116 Chloride, Timed Urine 82436 0301 $117 $105 $222 $133 Lipoprotein Fractionation 82465 0301 $66 $60 $126 $76 Cholesterol 82465 0301 $71 $64 $135 $81 Citrate, Urine Timed 82507 0301 $149 $134 $283 $170 Deoxypyridin 82523 0301 $248 $224 $472 $283 N-Telopeptides (NTX) with Creatinine, Urine Random 82523 0301 $269 $243 $512 $307 N-Telopeptides (NTX), Urine Timed 82523 0301 $268 $242 $510 $306 N-Telopeptide Serum 82523 0301 $161 $145 $306 $184 N-Telopeptide Serum 82523 0301 $161 $145 $306 $184 Copper Level 82525 0301 $250 $226 $476 $286 Copper Level, Urine Timed 82525 0301 $250 $226 $476 $286 Copper Level, Urine random 82525 0301 $238 $215 $453 $272 Cortisol, Free & Creatinine, Urine Timed 82530 0301 $616 $555 $1,171 $703 Cortisol-Total 82533 0301 $513 $462 $975 $585 Creatine with Creatinine, Urine Timed 82540 0301 $144 $130 $274 $164 Lamictal Level 82542 0301 $236 $213 $449 $269 Sirolimus 82542 0301 $183 $165 $348 $209 CK/CPK 82550 0301 $331 $299 $630 $378 CKMB Fraction 82553 0301 $62 $56 $118 $71 CKMB Fraction 82553 0300 $62 $62 $37 Creatinine 82565 0301 $74 $67 $141 $85 Creatinine, Fluid 82570 0301 $91 $82 $173 $104 Creatinine, Urine Random 82570 0301 $91 $82 $173 $104 Timed Urine Creatinine 82570 0301 $91 $82 $173 $104 Creatinine Clearance 82570 0301 $91 $82 $173 $104 Metanephrines, Fractionated -24 Hr Urine 82570 0301 $75 $68 $143 $86 Urine Creatinine 82570 0300 $75 $75 $45 CREATININE; NOT BLOOD 82570 0301 $32 $32 $19 Cryoglobulin Identification 82595 0301 $139 $126 $265 $159 Cryoglobulin Screen 82595 0301 $139 $126 $265 $159 Cyanide 82600 0301 $206 $186 $392 $235 Vitamin B12 and Folate 82607 0301 $283 $255 $538 $323 Vitamin B-12 Level 82607 0301 $283 $255 $538 $323 Cystatin C 82610 0301 $162 $146 $308 $185 Homocysteine-Urine 82615 0301 $196 $176 $372 $223 DHEA Sulfate 82626 0301 $355 $320 $675 $405 Dehydroepiandrosterone 82626 0301 $355 $320 $675 $405 11-Deoxycortisol, Urine Random 82634 0301 $606 $547 $1,153 $692 Vitamin D, 125-Dihydroxy 82652 0301 $537 $484 $1,021 $613 Erythropoietin Level 82668 0301 $398 $358 $756 $454 Estradiol 82670 0301 $912 $823 $1,735 $1,041 Estrogen-Total Serum 82672 0301 $254 $230 $484 $290 Estriol 82677 0300 $79 $79 $47 Estrone Level 82679 0301 $79 $71 $150 $90 Fecal Fat Timed Collection 82710 0301 $482 $435 $917 $550 Ferritin 82728 0301 $215 $194 $409 $245 Hemochromatosis Panel 82728 0301 $548 $494 $1,042 $625 Folate-Folic Acid Level 82746 0301 $156 $141 $297 $178 Folate-Folic Acid Level 82746 0310 $156 $156 $94 Folate-RBC 82747 0301 $130 $117 $247 $148 Kappa/Lambda Ratio 82784 0301 $136 $123 $259 $155 Quantitative IgA 82784 0301 $90 $81 $171 $103 Quantitative IgG 82784 0301 $90 $81 $171 $103 Quantitative IgM 82784 0301 $90 $81 $171 $103 Low Level IgM 82784 0301 $90 $81 $171 $103 IgG/Albumin Index, CSF 82784 0301 $154 $139 $293 $176 Immunoglobulins 82784 0300 $903 $903 $542 Assay IgA/IgD/IgG/IgM Each 82784 0301 $61 $61 $37 IgE Level 82785 0302 $34 $31 $65 $39 Arterial Blood Gas Lab Charge 82803 0300 $188 $188 $113 Blood Gas, Adult VBG w Measured Sat 82805 0301 $199 $179 $378 $227 Blood Gas, Adult ABG w Measured Sat 82805 0301 $199 $179 $378 $227 Gastrin Level 82941 0301 $336 $303 $639 $383 Glucagon Level 82943 0301 $57 $52 $109 $65 Glucose, Fluid 82945 0301 $75 $68 $143 $86 Glucose-CSF 82945 0301 $30 $27 $57 $34 Glucose, Urine, Random 82945 0301 $30 $27 $57 $34 Glucose, Timed Urine 82945 0301 $30 $27 $57 $34 Glucose Level 82947 0301 $71 $64 $135 $81 Glucose, post glucose dose, Including baseline 82950 0301 $108 $98 $206 $124 Glucose 6 PD 82960 0301 $231 $208 $439 $263 Bld Glucose, Capillary 82962 0300 $64 $58 $122 $73

Page 17 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price GGTP/GGT 82977 0301 $120 $108 $228 $137 Follicle Stimulating Hormone 83001 0301 $513 $462 $975 $585 Luteinizing Hormone 83002 0301 $321 $289 $610 $366 Growth Hormone Level 83003 0301 $356 $321 $677 $406 Haptoglobin 83010 0301 $482 $435 $917 $550 Heavy Metals Screen, Whole Blood 83015 0301 $1,038 $936 $1,974 $1,184 Heavy Metal Screen, Urine, Random 83015 0301 $1,038 $936 $1,974 $1,184 Heavy Metals Screen, Urine timed 83015 0301 $1,038 $936 $1,974 $1,184 Hemoglobin Electrophoresis 83020 0301 $533 $481 $1,014 $608 Hemoglobin A2 Quantitation 83021 0301 $321 $289 $610 $366 Hemoglobin Glycosated 83036 0301 $145 $131 $276 $166 Hemoglobin, Urine 83069 0301 $10 $8 $18 $11 Homocysteine-Serum 83090 0301 $122 $110 $232 $139 17 Hydroxycorticosteroids, Urine Timed 83491 0301 $415 $374 $789 $473 5-HIAA-24 Hr Urine 83497 0301 $113 $102 $215 $129 17 Hydroxyprogesterone, Serum 83498 0301 $197 $177 $374 $224 Anodal Trypsin Assay- HAT 83516 0301 $82 $74 $156 $94 Antibodies * 83516 0301 $118 $118 $71 Immunoassay Nonantibody (Histone) 83516 0301 $84 $84 $50 Glutamic Decarboxylast Abs 83519 0301 $189 $171 $360 $216 Immunoassay,other analytes 83519 0301 $241 $241 $145 Procollagen Type 1-N Terminal Propeptide 83519 0302 $423 $382 $805 $483 MUSK Antibody 83519 0302 $958 $864 $1,822 $1,093 PTH-Related Protein 83519 0301 $181 $163 $344 $206 Gliadin AB's IgG, IgA 83520 0301 $141 $128 $269 $161 GM 1 Autoantibodies 83520 0301 $141 $128 $269 $161 Human Anti-Mouse IgG Antibodies 83520 0301 $141 $128 $269 $161 Basement Membrane IgG Abs 83520 0301 $177 $160 $337 $202 Transglutaminase IgG and IgA Autoantibodies 83520 0301 $319 $287 $606 $364 Antibodies 83520 0301 $118 $118 $71 Immunoassay, RIA, not elsewhere specified 83520 0301 $223 $223 $134 GM 1 Autoantibodies 83520 0301 $141 $141 $85 Immunoassay Quant NOS NONAB 83520 0301 $79 $79 $47 Insulin Level 83525 0301 $232 $209 $441 $265 Iron and Iron Binding Capacity 83540 0301 $167 $150 $317 $190 Iron and Iron Binding Capacity with Transferrin 83540 0301 $211 $190 $401 $241 Iron Level 83540 0301 $167 $150 $317 $190 Iron 83540 0300 $139 $139 $83 Iron Binding Capacity 83550 0301 $177 $177 $106 17 Ketosteroids, Urine Timed 83586 0301 $312 $281 $593 $356 17-Ketosteroids with Creatinine, Urine Random 83586 0301 $312 $281 $593 $356 Lactic Acid, Venous Specimen 83605 0301 $74 $67 $141 $85 Lactate Dehydrogenase/LDH 83615 0301 $105 $95 $200 $120 Lactate Dehydrogenase Isoenzymes (contains LDH) 83615 0301 $87 $78 $165 $99 Lactate Dehydrogenase, Fluid 83615 0301 $87 $78 $165 $99 LDH Isoenzymes 83625 0306 $82 $82 $49 Lead Level 83655 0301 $365 $329 $694 $416 Lipase 83690 0301 $206 $186 $392 $235 Lipase, Fluid 83690 0301 $206 $186 $392 $235 Lipoprotein (a) 83695 0301 $141 $128 $269 $161 Lipoprotein Electrophoresis 83700 0301 $269 $243 $512 $307 Lipoprotein, blood 83700 0301 $88 $88 $53 High Density Lipoprotein 83718 0301 $220 $199 $419 $251 Magnesium Level 83735 0301 $135 $122 $257 $154 Magnesium, Random Urine 83735 0301 $50 $45 $95 $57 Magnesium, Timed Urine 83735 0301 $46 $41 $87 $52 Manganese, RBC 83785 0301 $181 $163 $344 $206 Amiodarone & Metabolites (Desethylamiodarone) 83789 0301 $43 $38 $81 $49 Mercury Level, Serum 83825 0301 $341 $308 $649 $389 Metanephrines 83835 0301 $69 $69 $41 Metanephrines, Plasma Free 83835 0301 $266 $240 $506 $304 Myelin Basic Protein, CSF 83873 0301 $115 $104 $219 $131 Myoglobin Serum 83874 0301 $204 $184 $388 $233 Myoglobin, Urine Random 83874 0301 $204 $184 $388 $233 B-Natiuretic Peptide 83880 0301 $350 $315 $665 $399 Retinol Binding Protein 83883 0301 $99 $90 $189 $113 Free Light Chains 83883 0301 $99 $90 $189 $113 Nephelometry 83883 0301 $100 $100 $60 Heavy and Light Chain, IgG 83883 0301 $93 $83 $176 $106 Heavy and Light Chain, IgA 83883 0301 $93 $83 $176 $106 Heavy and Light Chain, IgM 83883 0301 $93 $93 $56 Heavy and Light Chain, IgA 83883 0301 $93 $93 $56 Heavy and Light Chain, IgG 83883 0301 $93 $93 $56 5' Nucleotidase, Serum 83915 0301 $307 $277 $584 $350 Oligoclonal Bands 83916 0301 $233 $210 $443 $266 Methylmalonic Acid 83918 0301 $117 $105 $222 $133 Osmolality 83930 0301 $145 $131 $276 $166 Osmolality, Urine Random 83935 0301 $145 $131 $276 $166 Urine Osmolality 83935 0301 $145 $145 $87

Page 18 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price Osmolality, Urine Timed 83935 0301 $161 $145 $306 $184 Osteocalcin 83937 0301 $268 $242 $510 $306 Osteocalcin 83937 0301 $268 $242 $510 $306 Osteocalcin 83937 0301 $211 $211 $127 Oxalate, Urine timed 83945 0301 $150 $135 $285 $171 Parathyroid Hormone , C-Terminal 83970 0301 $362 $327 $689 $413 PTH Intact 83970 0301 $362 $327 $689 $413 PTH Intact 83970 0301 $362 $327 $689 $413 Intact Parathyroid Hormone 83970 0301 $362 $327 $689 $413 Parathyroid Hormone , C-Terminal 83970 0301 $1,031 $1,031 $619 Body Fluid pH 83986 0301 $98 $89 $187 $112 pH, Urine Timed 83986 0301 $98 $89 $187 $112 pH, Timed Urine 83986 0301 $98 $98 $59 Gastric Fluid pH 83986 0301 $145 $131 $276 $166 ASSAY PH BODY FLUID NOS 83986 0301 $29 $29 $17 Acid Phosphatase 84066 0301 $75 $68 $143 $86 Acid Phosphatase, Prostatic fraction 84066 0301 $75 $68 $143 $86 Alkaline Phosphatase 84075 0302 $97 $88 $185 $111 Alkaline Phosphatase-Bone Specific 84078 0300 $121 $109 $230 $138 Alkaline Phosphatase-Bone Specific 84078 0300 $121 $109 $230 $138 Alkaline Phosphatase-Isoenzymes 84080 0301 $269 $243 $512 $307 Alkaline Phosphatase-Iso 84080 0301 $269 $269 $161 Phosphorous Level 84100 0301 $79 $71 $150 $90 Phosphorous, Urine timed 84105 0301 $157 $142 $299 $179 Phosphorus, Random Urine 84105 0301 $43 $38 $81 $49 Porphobilinogen, Random Urine Quant. 84110 0301 $221 $200 $421 $253 Porphyrins, Fractionated, Urine, Random 84120 0301 $332 $300 $632 $379 Porphyrins-Fractionated, Urine timed 84120 0301 $332 $300 $632 $379 Potassium/K+ Level 84132 0301 $84 $76 $160 $96 Potassium, Urine Random 84133 0301 $102 $92 $194 $116 Potassium, Urine Timed 84133 0301 $34 $31 $65 $39 Prealbumin 84134 0301 $309 $279 $588 $353 Pregnanetriol, Urine timed 84138 0301 $468 $422 $890 $534 Pregnenolone Level 84140 0301 $258 $233 $491 $295 Progesterone Level 84144 0301 $242 $218 $460 $276 Procalcitonin 84145 0301 $197 $177 $374 $224 Prolactin 84146 0301 $533 $481 $1,014 $608 Prostate Specific Antigen, Diagnostic 84153 0301 $64 $64 $38 Prostate Specific Antigen, Diagnostic 84153 0301 $31 $31 $19 Prostate Specific Antigen, Diagnostic 84153 0301 $31 $31 $19 Assay of PSA, free 84154 0301 $135 $135 $81 Protein, Total 84155 0301 $97 $88 $185 $111 Total Protein, Fluid 84155 0301 $37 $34 $71 $43 Protein, Urine 84156 0301 $115 $104 $219 $131 Protein, Urine Timed 84156 0301 $63 $57 $120 $72 Protein, Total, Spinal Fluid 84157 0301 $73 $66 $139 $83 Protein Electrophoresis, Serum 84165 0301 $204 $184 $388 $233 Protein Electrophoresis, Random Urine 84166 0301 $182 $164 $346 $208 Protein Electrophoresis, Timed Urine 84166 0301 $196 $176 $372 $223 Purkinje Cell (Yo) Autoantibodies 84182 0301 $130 $117 $247 $148 Protein Probe ID band 84182 0301 $461 $461 $277 Zinc Protoporphyrins 84202 0301 $104 $94 $198 $119 Vitamin B6 Level 84207 0301 $544 $491 $1,035 $621 Pyruvic Acid Level 84210 0301 $168 $151 $319 $191 Acetylcholine Receptor Binding Antibody 84238 0301 $463 $417 $880 $528 Renin Activity, Plasma 84244 0301 $619 $558 $1,177 $706 Selenium Level 84255 0301 $185 $167 $352 $211 Serotonin 84260 0301 $482 $435 $917 $550 Sex Hormone Binding Globulin 84270 0301 $185 $167 $352 $211 Sodium Level 84295 0301 $141 $128 $269 $161 Sodium, Urine Random 84300 0301 $102 $92 $194 $116 Sodium, Urine Timed 84300 0301 $102 $92 $194 $116 Somatomedin C 84305 0301 $248 $224 $472 $283 Somatostatin 84307 0301 $84 $76 $160 $96 Specific Gravity, Fluid 84315 0301 $15 $13 $28 $17 Testosterone, Free 84402 0301 $374 $338 $712 $427 Testosterone, Total 84403 0301 $297 $268 $565 $339 Testosterone, total 84403 0301 $264 $264 $158 Vitamin B1 Level 84425 0301 $561 $507 $1,068 $641 Thyroglobulin 84432 0301 $117 $105 $222 $133 Thyroglobulin Evaluation 84432 0301 $117 $105 $222 $133 Thyroxine 4 RIA 84436 0301 $145 $131 $276 $166 T4, Total 84436 0301 $145 $131 $276 $166 Thyroxine Free 84439 0301 $88 $79 $167 $100 Thyroid Stimulating Immunogloblins w/TSH 84443 0301 $220 $199 $419 $251 TSH, 3rd Generation 84443 0301 $220 $199 $419 $251 TSH w/Reflex to FT4 84443 0301 $204 $184 $388 $233 Vitamin E Level 84446 0301 $48 $43 $91 $55 AST/SGOT 84450 0301 $98 $89 $187 $112

Page 19 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price ALT/SGPT 84460 0301 $103 $93 $196 $118 Transferrin 84466 0301 $281 $253 $534 $320 Transferrin 84466 0300 $62 $62 $37 Triglycerides 84478 0301 $105 $95 $200 $120 Triglycerides 84478 0300 $104 $104 $62 T3 Uptake 84479 0301 $145 $131 $276 $166 T3, Total 84480 0301 $173 $157 $330 $198 T3 Total 84480 0301 $173 $173 $104 T3, Free 84481 0301 $113 $102 $215 $129 T3 Free 84481 0301 $113 $113 $68 Reverse T3 84482 0301 $115 $104 $219 $131 Troponin I with CKMB Reflex 84484 0301 $257 $232 $489 $293 Troponin I 84484 0301 $257 $232 $489 $293 BUN, Serum 84520 0301 $69 $63 $132 $79 BUN, Fluid 84520 0301 $69 $63 $132 $79 Urea Nitrogen, Timed Urine 84540 0301 $74 $67 $141 $85 Urea Nitrogen, Random Urine 84540 0301 $74 $67 $141 $85 Uric Acid 84550 0301 $65 $59 $124 $74 Uric Acid, Urine Random 84560 0301 $87 $78 $165 $99 Uric Acid, Urine Timed 84560 0301 $113 $102 $215 $129 VMA (vanilylmandelic Acid), Urine Timed 84585 0301 $448 $404 $852 $511 VMA 84585 0301 $113 $113 $68 Antidiuretic Hormone 84588 0301 $205 $185 $390 $234 Vitamin A Level 84590 0301 $259 $234 $493 $296 Vitamin K Level 84597 0301 $80 $72 $152 $91 D-Xylose, 1Hr Blood 84620 0301 $91 $82 $173 $104 D-Xylose, 2Hr Blood 84620 0301 $91 $82 $173 $104 D-Xylose, 5 Hr Urine 84620 0301 $314 $283 $597 $358 Zinc Level 84630 0301 $269 $243 $512 $307 C-Peptide 84681 0301 $151 $136 $287 $172 HCG/Serum Pregnancy Test 84702 0301 $213 $192 $405 $243 Gonadotropin, chorionic 84702 0300 $104 $104 $62 CBC-Hemoglobin and Hematocrit Only 85014 0305 $50 $45 $95 $57 Hematocrit, Fluid 85014 0305 $32 $29 $61 $37 Hemoglobin 85018 0305 $32 $32 $19 CBC-Compete Blood Count with Differential and Plat 85025 0305 $173 $157 $330 $198 CBC with Platelets 85027 0305 $149 $134 $283 $170 CBC with Platelets 85027 0305 $104 $104 $62 CBC with Platelets 85027 0305 $149 $134 $283 $170 CBC with Manual Differential 85027 0305 $198 $178 $376 $226 Reticulocyte Count Manual 85045 0301 $69 $63 $132 $79 Platelet Count 85049 0301 $99 $90 $189 $113 Blood Smear Path Consult without Review of Chart 85060 0306 $82 $74 $156 $94 Hematopathology Review 85060 0305 $79 $71 $150 $90 Factor II Assay 85210 0305 $153 $138 $291 $175 Factor V Assay 85220 0305 $205 $185 $390 $234 Factor VII Assay 85230 0305 $205 $185 $390 $234 Factor VIII Assay 85240 0305 $205 $185 $390 $234 Ristocetin Cofactor 85245 0305 $367 $331 $698 $419 Von Willebrand Antigen 85246 0305 $166 $149 $315 $189 Factor IX Assay 85250 0305 $161 $145 $306 $184 Factor X Assay 85260 0305 $205 $185 $390 $234 Factor XI Assay 85270 0305 $205 $185 $390 $234 Factor XII Assay 85280 0305 $205 $185 $390 $234 Factor XIII Assay 85291 0305 $103 $93 $196 $118 Antithrombin III 85300 0305 $220 $199 $419 $251 Protein C Antigen 85302 0305 $139 $126 $265 $159 Protein C Activity 85303 0305 $191 $173 $364 $218 Protein S Activity 85306 0305 $214 $193 $407 $244 Protein S Antigen, Free 85306 0305 $214 $193 $407 $244 APC Resistance 85307 0305 $150 $135 $285 $171 Factor VIII Inhibitor 85335 0305 $297 $268 $565 $339 Fibrin Degradation Product 85362 0305 $74 $67 $141 $85 D-Dimer 85378 0300 $80 $80 $48 D-Dimer 85379 0305 $187 $169 $356 $214 Firbrin degradation products, quant. 85379 0305 $64 $64 $38 Fibrinogen 85384 0305 $149 $134 $283 $170 Fibrinogen 85384 0300 $100 $100 $60 Fibrinogen Antigen 85385 0305 $100 $91 $191 $115 Plasminogen Activity, Tissue 85420 0305 $75 $68 $143 $86 Heinz Body Prep, Direct 85441 0305 $50 $45 $95 $57 Anti Xa Assay - Fragmin 85520 0305 $93 $83 $176 $106 Anti Xa Assay - Lovenox 85520 0305 $93 $83 $176 $106 Anti Xa Assay - Rivaroxaban 85520 0305 $93 $83 $176 $106 Anti Xa Assay - Unfractionated Heparin 85520 0305 $93 $83 $176 $106 Anti Xa Assay - Atrixtra 85520 0305 $93 $83 $176 $106 Platelet Function Analysis 85576 0305 $69 $63 $132 $79 Platelet Function Analysis II 85576 0305 $69 $63 $132 $79 Platelet Aggregation 85576 0305 $69 $63 $132 $79

Page 20 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price Platelet Aggregation, Plavix 85576 0305 $241 $217 $458 $275 Prothrombin Time/INR 85610 0305 $103 $103 $62 Prothrombin Time/INR 85610 0305 $103 $93 $196 $118 Prothrombin Time/INR 85610 0305 $103 $93 $196 $118 DIC Panel 85610 0305 $259 $234 $493 $296 Prothrombin Time/PT 85610 0305 $103 $103 $62 Prothrombin Time/PT 85610 0300 $84 $84 $50 PT Mixing Studies 85610 0305 $313 $313 $188 PT Mixing Study 85610 0305 $313 $313 $188 PT/INR POC 85610 0300 $96 $96 $58 Russell viper venom time, diluted 85613 0305 $162 $162 $97 Sedimentation Rate Non-automated 85651 0305 $73 $66 $139 $83 Sickle Cell Screen 85660 0305 $63 $57 $120 $72 APTT-Activated PTT/Partial Thromboplastin Time 85730 0305 $205 $185 $390 $234 Activated PTT/Partial Thromboplastin Time 85730 0300 $124 $124 $74 PTT Mixing Studies 85730 0305 $617 $556 $1,173 $704 PTT Mixing Studies 85730 0305 $617 $617 $370 Viscosity 85810 0305 $164 $147 $311 $187 Viscosity 85810 0305 $133 $133 $80 Allergen-Latex Enhanced IgE 86003 0302 $63 $57 $120 $72 Anti Neutrophil Cytoplasmic AB by IF 86021 0302 $282 $254 $536 $322 Myeloperoxidase 86021 0302 $174 $158 $332 $199 Heparin Induced Antibody 86022 0302 $289 $261 $550 $330 Platelet Antibody Screen 86022 0302 $289 $261 $550 $330 Serotonin Release Assay, 1 Drug 86022 0302 $536 $483 $1,019 $611 Platelet Antibody Screen/Identification Referred 86022 0302 $1,379 $1,244 $2,623 $1,574 Antinuclear Antibody 86038 0302 $254 $230 $484 $290 ANTINUCLEAR AB (ANA) 86038 0302 $80 $80 $48 Anti Streptolysin O AB 86060 0302 $31 $28 $59 $35 C-Reactive Protein-Hi Sensitivity 86140 0302 $124 $112 $236 $142 C Reactive Protein 86140 0302 $124 $112 $236 $142 Beta-2 GPI Antoantibodies 86146 0302 $246 $246 $148 Anticardiolipin Antibody 86147 0302 $645 $582 $1,227 $736 Anticardiolipin Antibody 86147 0300 $297 $297 $178 Cardiolipin antibody 86147 0300 $297 $297 $178 CADIOLIPIN AB EA IG CLASS 86147 0302 $128 $128 $77 CD3,4 Peripheral Blood 86160 0302 $272 $245 $517 $310 Complement C3,C4 86160 0302 $100 $91 $191 $115 C1 Esterase Inhibitor 86160 0302 $121 $109 $230 $138 C3 86160 0302 $14 $12 $26 $16 C4 86160 0302 $14 $12 $26 $16 Complement, Antigen 86160 0302 $100 $100 $60 C3 86160 0302 $100 $100 $60 C4 86160 0302 $100 $100 $60 COMPLEMENT; AG EA 86160 0302 $73 $73 $44 Complement Functional Activity 86161 0302 $97 $88 $185 $111 C3 * 86161 0302 $100 $100 $60 C4 * 86161 0302 $100 $100 $60 CH50 86162 0302 $416 $375 $791 $475 Complement, Total (CH50, C3 & C4) 86162 0302 $416 $375 $791 $475 Cyclic Citrulinated Peptide 86200 0301 $91 $82 $173 $104 Anti-Dnase B Antibodies, Streptococcal 86215 0302 $98 $89 $187 $112 Anti-DNA Antibody 86225 0302 $313 $282 $595 $357 Lupus Activity Reporter 86225 0302 $516 $466 $982 $589 Anti-DNA Antibody 86225 0300 $313 $313 $188 DNA 86225 0302 $106 $106 $64 DNA * 86225 0302 $106 $106 $64 DNA ** 86225 0302 $106 $106 $64 Histone Semi-Quantitative 86235 0302 $135 $122 $257 $154 Jo-1 Quantitative 86235 0302 $135 $122 $257 $154 RNP/Sm Quantitative 86235 0302 $135 $122 $257 $154 Sjogren's Antibodies 86235 0302 $135 $122 $257 $154 SSA (Ro) Quantitative 86235 0302 $182 $164 $346 $208 SSB (La) Quantitative 86235 0302 $182 $164 $346 $208 Scl-70 Quantitative 86235 0302 $135 $122 $257 $154 Sm Quantitative 86235 0302 $135 $122 $257 $154 Extractable nuclear antigen 86235 0300 $14 $14 $8 Extractable nuclear antigen * 86235 0330 $14 $14 $8 Extractable nuclear antigen ** 86235 0300 $14 $14 $8 Anti-Parietal Cell AB 86255 0302 $161 $145 $306 $184 Anti-Smooth Muscle AB 86255 0302 $156 $141 $297 $178 Anticentromere Antibodies 86255 0302 $34 $31 $65 $39 Neuromyelitis Optica IgG 86255 0302 $522 $471 $993 $596 Anti-Mitochondrial AB 86256 0302 $149 $134 $283 $170 Endomysial Autoantibodies, IgG 86256 0302 $139 $126 $265 $159 Anti OKT3 Ab Titers 86256 0302 $420 $379 $799 $479 Rabies Antibodies Titer 86256 0302 $139 $126 $265 $159 Fluorescent AB; Titer Ea AB 86256 0302 $73 $73 $44 CA27.29 86300 0302 $74 $67 $141 $85

Page 21 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price CA19-9 86301 0302 $151 $136 $287 $172 Cancer Antigen 125 86304 0302 $257 $232 $489 $293 Heterophile Screen 86308 0302 $104 $94 $198 $119 Hepatitis B Surface Antibody, Quant, End 86317 0302 $196 $176 $372 $223 Immunofixation Profile 86334 0302 $204 $184 $388 $233 Immunofixation Electrophoresis, Urine 86334 0302 $300 $271 $571 $343 Immunofixation Electrophoresis, Timed Urine 86335 0302 $378 $341 $719 $431 immunofixation electrophoresis, other fluid requir 86335 0302 $378 $378 $227 Beta-2-Transferrin 86335 0302 $598 $539 $1,137 $682 Alpha Fetoprotein Quad 4 86336 0302 $575 $519 $1,094 $656 Natural Killer Cells(NK cells) 86357 0302 $324 $324 $194 Flow Cytometry, CSF 86359 0302 $688 $621 $1,309 $785 CD3 86359 0302 $688 $688 $413 T Cell Monitoring 86360 0302 $688 $621 $1,309 $785 T Cell Monitoring 86360 0302 $688 $688 $413 CD34 86367 0302 $272 $245 $517 $310 Thyroid Peroxidase Antibodies 86376 0302 $233 $210 $443 $266 Liver-Kidney Microsome Autoantibodies 86376 0301 $233 $210 $443 $266 Thyroid Peroxidase Antibodies 86376 0300 $11 $11 $7 Thyroid Peroxidase Antibodies * 86376 0300 $11 $11 $7 Cryptococcal Screen-CSF 86403 0302 $68 $68 $41 Cryptococcal Screen-Blood 86403 0302 $68 $68 $41 Cryptococcal Screen-Stool 86403 0302 $68 $68 $41 Rheumatoid Factor Quant. 86431 0302 $138 $125 $263 $158 Rheumatoid Factor Quntitative 86431 0302 $44 $44 $26 Rheumatoid Factor Quntitative * 86431 0302 $44 $44 $26 Tuberculosis Immunity Test 86480 0302 $486 $439 $925 $555 Syphilis Antibody, Treponemal w/ Reflex 86592 0302 $100 $91 $191 $115 VDRL, CSF 86592 0302 $67 $61 $128 $77 Adenovirus Antibody 86603 0302 $98 $89 $187 $112 Streptococcus Pneumoniae IgG Antibodies 86609 0302 $100 $91 $191 $115 Streptococcus Pneumoniae IgG Antibodies 86609 0302 $100 $100 $60 Lyme Disease, Serum (Confirmatory IgG & IgM) 86617 0302 $124 $112 $236 $142 Lymes Disease, Serum Confirmatory IgM 86617 0302 $124 $124 $74 Lyme's Disease Antibodies (Total IgG/IgM) Serum 86618 0302 $255 $231 $486 $292 Lyme Disease by PCR 86618 0300 $198 $198 $119 Brucella Abortus IgG Ab 86622 0302 $65 $59 $124 $74 Brucella Abortus IgG,IgM,IgA Ab 86622 0302 $191 $173 $364 $218 Serology, Fungus 86635 0302 $82 $74 $156 $94 Cytomegalovirus Antibody(IgG & IgM), Serum 86644 0302 $199 $179 $378 $227 Coxsackie B Antibodies, Serum 86658 0302 $97 $88 $185 $111 Coxsackievirus Antibodies, CSF 86658 0302 $97 $88 $185 $111 Coxsackie B Antibodies, Serum 86658 0302 $97 $97 $58 Epstein-Barr Viral Antibody-IgG 86665 0302 $67 $61 $128 $77 Epstein-Barr Virus by PCR 86665 0302 $153 $138 $291 $175 Epstein Barr Viral Antibody-IgM 86665 0302 $67 $67 $40 Epstein-Barr Virus IgG 86665 0302 $74 $74 $44 Epstein-Barr Virus IGM 86665 0302 $74 $74 $44 Saccharomyces Cerevisae IgG, IgA 86671 0302 $266 $240 $506 $304 Helicobacter Pylori- IgG Elisa 86677 0302 $201 $181 $382 $229 HTLV, IgG 86687 0302 $63 $57 $120 $72 HIV-2 IgG with Confirmation 86689 0302 $293 $265 $558 $335 Hepatitis D Virus Antibody Panel (IgG) 86692 0302 $141 $128 $269 $161 Hepatitis D Virus IgM 86692 0302 $141 $141 $85 Herpes Simplex AB IgG 86694 0302 $168 $151 $319 $191 Herpes Simplex AB IgM 86694 0302 $168 $151 $319 $191 HIV Antigen/Antibody Combo 86703 0302 $130 $117 $247 $148 Hepatitis B Core Antibody IgG + IgM 86704 0302 $288 $260 $548 $329 Hepatitis B Core Antibody IgM Acute Titer 86705 0302 $283 $255 $538 $323 Hepatitis B Core IgM 86705 0302 $204 $184 $388 $233 Hepatitis B Surface Antibody 86706 0302 $148 $133 $281 $169 Hepatitis BE Antigen/Antibody 86707 0302 $136 $123 $259 $155 Hepatitis A Antibody, Total 86708 0302 $187 $169 $356 $214 Hepatitis A IgM 86709 0302 $187 $169 $356 $214 Influenza A+B IgG, IgA & IgM Antibodies 86710 0302 $99 $90 $189 $113 Influenza A + B IgG, IgA, & IgM Antibodies 86710 0302 $99 $99 $59 Legionella Pneumophila IgG & IgM Antibodies, Sero 86713 0302 $181 $163 $344 $206 Leishmania Antibodies 86717 0302 $88 $79 $167 $100 Mumps Antibody IgM 86735 0302 $98 $89 $187 $112 Mumps Antibody IgG (Immunity) 86735 0302 $136 $123 $259 $155 Mycoplasma Antibody 86738 0302 $98 $89 $187 $112 Parvovirus B19 IgG, IgM Antibodies 86747 0302 $218 $197 $415 $249 E. Histolytica Antibodies 86753 0302 $90 $81 $171 $103 Rubella 86762 0302 $82 $74 $156 $94 Rubeola (measles) Antibody IgM 86765 0302 $182 $164 $346 $208 Rubeola (Immunity) Antibody IgG 86765 0302 $182 $164 $346 $208 Toxoplasma Antibody 86777 0302 $342 $309 $651 $391 Toxoplasma Antibody IgM 86778 0302 $168 $151 $319 $191 Treponema Pallidum Antibody Assay 86780 0302 $254 $230 $484 $290

Page 22 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price Varicella Zoster Antibody IgG 86787 0306 $150 $135 $285 $171 Varicella Zoster Antibody IgM 86787 0302 $150 $135 $285 $171 Anti-Thyroglobulin AB 86800 0302 $217 $196 $413 $248 Thyroid Antibodies 86800 0302 $217 $196 $413 $248 Anti-Thyroglobulin AB 86800 0300 $217 $217 $130 Hepatitis C Antibody IgM + IgG 86803 0302 $255 $231 $486 $292 HCV PCR Qualtitative 86803 0302 $161 $145 $306 $184 Hepatitis C Virus Antibodies (RIBA) & Bands 86804 0302 $207 $187 $394 $236 HLA B27 86812 0302 $205 $185 $390 $234 Antibody Screen (Blood Bank) 86850 0390 $188 $170 $358 $215 Antibody Screen 86850 0390 $173 $173 $104 Antibody Elution 86860 0300 $290 $262 $552 $331 Antibody Elution, referred 86860 0300 $191 $173 $364 $218 Antibody Identification Interpretation 86870 0390 $141 $128 $269 $161 Antibody Identification (blood bank) 86870 0390 $257 $232 $489 $293 Direct and Indirect Antiglobulin Test 86880 0390 $113 $113 $68 Coombs, Direct 86880 0300 $137 $124 $261 $157 Coombs, Direct (only C3 or IgG) 86880 0300 $50 $45 $95 $57 Coombs test, indirect, qual 86885 0390 $40 $40 $24 Coombs, Indirect 86885 0300 $141 $128 $269 $161 Antibody Titration, indirect, each 86886 0390 $111 $100 $211 $127 Prenatal Screen 86900 0390 $121 $109 $230 $138 ABO Rh Type 86900 0390 $121 $121 $73 Blood typing; ABO 86901 0390 $28 $28 $17 Rh Typing, includes DU, each unit 86901 0300 $71 $64 $135 $81 Type & Screen, PAT 86902 0390 $120 $108 $228 $137 Type & Screen, PAT 86902 0300 $120 $120 $72 P1 Typing (unit or patient) 86902 0300 $88 $79 $167 $100 Rh Typing, each unit 86902 0300 $71 $64 $135 $81 Antigen Screen on Blood, Reagent Method 86902 0300 $88 $79 $167 $100 Lewis Phenotyping, blood 86905 0300 $63 $57 $120 $72 MN Phenotyping, blood 86905 0300 $63 $57 $120 $72 K-Typing, Unit 86905 0300 $63 $57 $120 $72 K-Typing, Patient 86905 0300 $63 $57 $120 $72 Rh Phenotyping 86906 0300 $87 $78 $165 $99 Crossmatch for Transfusion (electronic, IS or IgG) 86923 0300 $105 $95 $200 $120 Platelet/Cryoprecipitate Pooling 86965 0300 $561 $507 $1,068 $641 RBC Pre-treatment 86970 0300 $121 $109 $230 $138 Routine Blood Culture 87040 0306 $272 $245 $517 $310 Culture-Stool 87045 0306 $233 $210 $443 $266 Culture-Surveillance 87045 0306 $233 $210 $443 $266 Culture-Eye 87070 0306 $233 $233 $140 Culture-Sputum Respiratory w/ Gm Stain 87070 0306 $233 $210 $443 $266 Culture-Fluid with Gram Stain 87070 0306 $151 $136 $287 $172 Routine Respiratory Culture and Gram Stain 87070 0306 $145 $145 $87 Culture-Tissue with Gram Stain 87070 0306 $233 $233 $140 Culture-IV Cath Tip 87070 0306 $215 $194 $409 $245 Culture-Wound Aerobic with Gram Stain 87070 0306 $196 $176 $372 $223 Culture-CSF with Gram Stain 87070 0306 $233 $233 $140 Culture-Eye with Gram Stain 87070 0306 $261 $261 $157 Culture-CSF Aerobic/Anaerobic Culture w/Gm Stain 87070 0306 $719 $719 $431 Culture-Wound Aerobic/Anaerobic w/Gm Stain 87070 0306 $359 $324 $683 $410 Culture-Fluid & Anaerobic w/Gram Stain 87070 0306 $233 $210 $443 $266 Culture-Genital with Gram Stain 87070 0306 $151 $151 $91 Culture-GC 87071 0306 $55 $49 $104 $62 Culture-Other Aerobic/Anaerobic w/Gm Stain 87075 0306 $196 $176 $372 $223 Tissue/Biopsy & Anaerobic Culture with Gram Stain 87075 0306 $343 $310 $653 $392 Culture-Fluid & Anaerobic Culture with Gram Stain 87075 0306 $343 $343 $206 Culture-C. Difficile 87075 0306 $295 $295 $177 Culture-C. Difficile Surveillance 87075 0306 $319 $319 $191 C Difficile Culture & Toxin 87075 0306 $280 $280 $168 Culture-Legionella 87081 0306 $74 $74 $44 Throat Strept Screen 87081 0306 $133 $133 $80 Culture-Throat 87081 0306 $133 $133 $80 Culture-Nose 87081 0306 $67 $61 $128 $77 VRE Screen 87081 0306 $74 $67 $141 $85 Culture-Urine 87086 0306 $196 $196 $118 Culture-Urine 87086 0306 $196 $196 $118 Routine Urine Culture 87086 0306 $196 $176 $372 $223 Culture-Other Fungal w/Smear 87102 0306 $188 $170 $358 $215 Culture-Fungus Blood 87102 0306 $188 $188 $113 Culture-Fungus CSF 87102 0306 $188 $188 $113 Culture-Fungus with Smear 87103 0306 $129 $116 $245 $147 Culture-Chlamydia 87110 0306 $153 $153 $92 Culture-Mycobacteria no Smear 87116 0306 $188 $188 $113 Culture-AFB Culture (non-blood) 87116 0306 $188 $188 $113 Culture-Mycobacteria Blood 87116 0306 $139 $139 $83 Worm Identification 87169 0306 $117 $117 $70 Parasite Identification 87169 0306 $124 $112 $236 $142

Page 23 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price Ova and Parasites-Stool 87177 0306 $226 $226 $136 Susceptibility studies 87181 0306 $34 $34 $20 Susceptibility studies 87181 0306 $34 $34 $20 Susceptibility Studies x1 87181 0306 $34 $31 $65 $39 Susceptibility Studies x2 87181 0306 $34 $31 $65 $39 Susceptibility Studies x3 87181 0306 $34 $31 $65 $39 Susceptibility Studies x4 87181 0306 $34 $31 $65 $39 Susceptibility Studies x5 87181 0306 $34 $31 $65 $39 Vaginitis Screen 87205 0306 $137 $124 $261 $157 Smear, primary source, with interpretation 87205 0306 $46 $46 $28 Culture-Mycobacteria with AFB Smear 87206 0306 $113 $113 $68 Cyclospora 87206 0306 $113 $113 $68 Mycobacteria Smear 87206 0306 $113 $113 $68 Microsporidium 87206 0306 $113 $102 $215 $129 Isospora Exam 87206 0306 $113 $102 $215 $129 Cryptosporidium Exam - Other 87206 0306 $113 $102 $215 $129 Malarial Prep 87207 0306 $68 $68 $41 Wet mount 87210 0300 $32 $32 $19 KOH Prep 87220 0306 $201 $201 $121 KOH Prep 87220 0306 $65 $65 $39 Viral Titre CSF 87252 0306 $272 $245 $517 $310 CMV Culture Non-Blood 87252 0306 $268 $242 $510 $306 Culture-Virus 87252 0306 $268 $242 $510 $306 Mumps Virus Culture 87252 0306 $168 $168 $101 Herpes Culture 87252 0306 $272 $272 $163 Virus isolation, tissue culture inoculation 87252 0306 $168 $168 $101 Virus Shell Isolation 87254 0306 $161 $145 $306 $184 Legionella DFA Stain 87278 0306 $191 $191 $115 Respiratory Synctial Virus DFA 87280 0306 $139 $139 $83 Varicella Zoster DFA 87290 0306 $102 $102 $61 Herpes Simplex DFA 87299 0306 $139 $139 $83 Infectious agent antigen detection 87300 0306 $88 $88 $53 C Difficile by PCR 87324 0306 $220 $199 $419 $251 C Difficile Toxin 87324 0306 $160 $160 $96 Cryptospordium Exam - Stool 87328 0306 $138 $125 $263 $158 Giardia Antigen, Stool (Infectious Agent antigen D 87329 0302 $141 $128 $269 $161 Entamoeba Histolytica Antigen 87337 0306 $125 $113 $238 $143 H. Pylori Antigen, Stool 87338 0306 $217 $196 $413 $248 Hepatitis B Surface Antigen 87340 0306 $151 $136 $287 $172 Hepatitis B Surface Antigen 87340 0302 $151 $136 $287 $172 Hepatitis BE Antigen 87350 0306 $37 $37 $22 Histoplasma Antigen, Urine 87385 0306 $137 $124 $261 $157 HIV P24 Antigen Test 87390 0306 $279 $251 $530 $318 Rotavirus Antigen, Stool 87425 0306 $139 $126 $265 $159 Legionella Antigen, Urine 87449 0306 $55 $49 $104 $62 Blastomyces Antigen, Urine 87449 0306 $252 $252 $151 Norovirus 87449 0306 $198 $178 $376 $226 Lyme Disease by PCR 87476 0302 $376 $340 $716 $430 Lyme Disease DNA, Real-Time PCR, Blood 87476 0306 $583 $525 $1,108 $665 Chlamydia by PCR 87491 0306 $168 $168 $101 CMV DNA Qualitative, Blood 87495 0306 $145 $131 $276 $166 Cytomegalovirus Viral Load PCR, blood 87496 0306 $417 $376 $793 $476 Cytomegalovirus by PCR, CSF Qualitative 87496 0306 $254 $230 $484 $290 Cytomegalovirus by PCR, Urine, Qualitative 87496 0306 $544 $491 $1,035 $621 Hepatitis B Viral DNA, Qualitative 87516 0306 $329 $297 $626 $376 Hepatitis B Virus Viral Load PCR 87517 0302 $499 $450 $949 $569 Hepatitis C Virus Qualitative RT-PCR 87521 0301 $353 $318 $671 $403 HCV PCR Quantitation Regular 87522 0306 $500 $451 $951 $571 Hepatitis C Virus-Quantitative 87522 0306 $500 $451 $951 $571 Herpes Simplex Virus 1&2 PCR 87529 0306 $507 $457 $964 $578 Herpes Simplex Virus PCR 87530 0302 $507 $457 $964 $578 HIV-1 Viral Load (Regular) 87536 0306 $618 $557 $1,175 $705 HIV-1 Viral Load (Ultra) 87536 0306 $618 $557 $1,175 $705 Mycobacterium Tuberculosis PCR 87556 0306 $430 $387 $817 $490 GC Culture 87591 0306 $254 $230 $484 $290 Gonorrhoeae by PCR 87591 0306 $254 $230 $484 $290 Respiratory Pathogen Panel by Muliplex PCR 87633 0306 $2,467 $2,226 $4,693 $2,816 COVID-19 POC 87635 0306 $219 $219 $131 MRSA Screen, PCR 87641 0306 $295 $266 $561 $337 Toxoplasma DNA by PCR 87798 0306 $433 $390 $823 $494 Varicella Zoster PCR 87798 0306 $424 $383 $807 $484 Infectious Agent Detection by Nucleic Acid,Amplifi 87798 0306 $98 $98 $59 EBV Qualitative by PCR, Blood 87798 0306 $248 $224 $472 $283 Coronavirus nCOV-19 by PCR (2019) 87798 0306 $150 $150 $90 Covid-19 (m2000) 87798 0306 $150 $150 $90 BK Virus Quant, Bld 87799 0306 $682 $615 $1,297 $778 BK Virus Quant, Urine 87799 0306 $682 $615 $1,297 $778 Viracore Quant Adenovirus PCR 87799 0306 $634 $572 $1,206 $724 Epstein-Barr Quantitative, Serum 87799 0306 $695 $627 $1,322 $793

Page 24 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price Epstein-Barr Quantitative, CSF 87799 0306 $695 $627 $1,322 $793 Culture-Group B Streptococcus 87802 0306 $98 $98 $59 Strep Pneumoniae Antigen Test, Urine 87899 0300 $206 $206 $124 Hepatitis C Genotype 87902 0306 $1,863 $1,681 $3,544 $2,126 Cytology-CSF 88104 0301 $307 $277 $584 $350 Cytology Fluid Specimen 88104 0311 $307 $307 $184 Cytology-CSF 88104 0301 $307 $307 $184 Cytopath, concentrate technique 88108 0311 $385 $385 $231 Pap Smear-Liquid and Thin Prep 88142 0306 $160 $160 $96 Pap Smear-Diagnostic 88150 0306 $79 $79 $47 Pap Smear-Screening 88150 0306 $79 $79 $47 Fetal Hemoglobin 88184 0310 $492 $444 $936 $562 Fetal Hemoglobin 88184 0310 $492 $492 $295 Flow cytometry each cell surface, cytoplasmic or n 88185 0310 $148 $148 $89 Flow cytometry Interpretation 16 or more markers 88189 0310 $604 $604 $362 Surgical Pathology, Skin, Tag, Cyst, Debridement 88304 0310 $345 $311 $656 $394 Surgical Pathology, Abscess 88304 0312 $430 $430 $258 Surgical Pathology, Bone Fragments Non-Pathologica 88304 0312 $430 $430 $258 Surgical Pathology, Endocervix Biopsy 88305 0300 $584 $584 $350 Surgical Pathology, Endocervix Curettings 88305 0300 $584 $584 $350 Surgical Pathology, Endometrium Biopsy 88305 0300 $584 $584 $350 Surgical Pathology, Endometrium Curettings 88305 0300 $584 $584 $350 Surgical Pathology, Endometrium Polyp 88305 0300 $584 $584 $350 Surgical Pathology, Cervical Polyp 88305 0300 $584 $584 $350 Surgical Pathology, Vaginal Biopsy 88305 0300 $584 $584 $350 Surgical Pathology, Vulva Biopsy 88305 0310 $585 $527 $1,112 $667 Surgical Pathology, Skin, other 88305 0312 $672 $672 $403 Surgical Pathology, Soft Tissue Biopsy 88307 0312 $1,300 $1,300 $780 Surgical Pathology, Soft Tissue Simple Excision 88307 0312 $1,300 $1,300 $780 Fungus Stain/PAS 88312 0306 $46 $46 $28 Fluid Cell Count and Diff 89050 0306 $104 $94 $198 $119 Cell Count and Differential, CSF 89051 0306 $69 $63 $132 $79 Body Fluid Cell Count and Differential 89051 0300 $166 $149 $315 $189 Fecal Leukocytes 89055 0300 $68 $68 $41 Crystals Analysis, Fluid 89060 0306 $124 $112 $236 $142 Crystal Identification, Fluid 89060 0306 $99 $90 $189 $113 Eosinophil Count, Urine & Body Fluid 89190 0306 $57 $52 $109 $65 Specimen Processing 89240 0319 $67 $61 $128 $77 Psychiatric Diagnostic Evalutation (90791) 90791 0900 $195 $221 $416 $250 Psychiatric Diagnostic Evaluation with Medical Ser 90792 0900 $195 $240 $435 $261 Psychotherapy, 30 minutes with Patient and/or Fami 90832 0914 $186 $186 $112 PSYTX PT&FA, W/E&M 30 MIN (90833) 90833 0914 $186 $186 $112 PSYTX PT&/FAMILY 45 MINUTES (90834) 90834 0914 $374 $374 $224 PSYTX PT&/FAM W/E&M 45 MINS (90836) 90836 0914 $374 $374 $224 PSYTX PT&/FAMILY 60 MINUTES (90837) 90837 0914 $561 $561 $337 PSYTX PT&/FAM W/E&M 60 MIN (90838) 90838 0914 $561 $561 $337 PSYTX CRISIS INITIAL 60 MIN (90839) 90839 0914 $561 $561 $337 PSYTX CRISIS EA ADDL 30 MIN (90840) 90840 0914 $186 $186 $112 Psychoanalysis 90845 0918 $195 $139 $334 $200 Family Psychotherapy Without Patient 90846 0916 $258 $146 $404 $242 Family Psychotherapy with Patient 90847 0916 $258 $176 $434 $260 Multiple Family Group Psychotherapy 90849 0916 $104 $50 $154 $92 Group Psychotherapy 90853 0915 $104 $50 $154 $92 PHARMACOLOGIC MGMT W/PSYTX (90863) 90863 0914 $561 $561 $337 Hypnotherapy 90880 0914 $195 $170 $365 $219 Unlisted Psychiatric Service or Procedure 90899 0918 $145 $145 $87 OT Biofeedback Units 90901 0430 $188 $188 $113 PT Biofeedback Units 90901 0420 $188 $188 $113 Biofeedback Training 90901 0917 $70 $70 $42 OT BioF/Peri/Urethral/Rectal Units 90912 0430 $126 $126 $76 PT BioF/Peri/Urethral/Rectal Units 90912 0420 $126 $126 $76 OT BioF/Peri/Ureth/Rect addl 15min Units 90913 0430 $70 $70 $42 PT BioF/Peri/Ureth/Rect addl 15min Units 90913 0420 $70 $70 $42 Rectal Sensation Test (91120) 91120 0750 $378 $140 $518 $311 Anorectal manometry (90911) 91122 0750 $1,117 $374 $1,491 $895 INTERMEDIATE NEW PATIENT, EYE EXAM PT (92002) 92002 0962 $245 $113 $358 $215 COMPREHENSIVE EYE EXAM. NEW PATIENT 1+ VISITS (920 92004 0962 $245 $237 $482 $289 INTERMEDIATE EYE EXAM EST PT (92012) 92012 0962 $245 $127 $372 $223 COMPREHENSIVE EYE EXAM & TREATMENT, ESTAB PT 1+ VI 92014 0962 $245 $190 $435 $261 CD Treatment Speech Language Voice Communication A 92507 0440 $128 $128 $77 SLP Auditory Processing Treatment Units 92507 0440 $128 $128 $77 SLP Class Units 92508 0443 $108 $108 $65 SLP Double Therapy Units 92508 0443 $108 $108 $65 SLP Group Therapy Units 92508 0443 $108 $108 $65 Evaluation of Speech Fluency Units 92521 0444 $232 $232 $139 Evaluation of Speech Sound Production Units 92522 0444 $232 $232 $139 Evaluation of Speech Sound Production w/ Evaluatio 92523 0444 $232 $232 $139 Evaluation of Language Comprehension and Expressio 92523 0444 $232 $232 $139 Behavioral and Qualitative Analysis of Voice and R 92524 0440 $181 $181 $109

Page 25 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price SLP Swallow Dysfnction Oral Feed Tx Unit 92526 0440 $181 $181 $109 SLP Screening Test, Pure Tone, Air Units 92551 0440 $170 $170 $102 SLP Use/Fit Speech Prosthetic Eval Units 92597 0444 $109 $109 $65 Eval Use/Fitting Voice Prosthetic Units 92597 0444 $109 $109 $65 Eval Use/Fitting Voice Prosthetic Units 92597 0444 $109 $109 $65 SLP Non-Speech AAC Device Tx Units 92606 0440 $146 $146 $88 SLP Speech AAC Eval First Hour Units 92607 0444 $630 $630 $378 SLP Speech AAC Eval Addl 1/2 Hour Units 92608 0444 $343 $343 $206 SLP Treatment-Speech Gen Device Units 92609 0440 $134 $134 $80 SLP Pharyngeal Swallow Fnctn Eval Units 92610 0444 $228 $228 $137 SLP Fluoroscopic Evaluation Units 92611 0444 $785 $785 $471 SLP Fiber Optic Endo Swallow Eval Units 92612 0444 $765 $765 $459 CPR Charge 92950 0410 $501 $501 $301 12 Lead Ekg, Tracing Only 93005 0730 $280 $252 $532 $319 US Exam 93880 0921 $725 $725 $435 US Exam 93925 0921 $908 $908 $545 US Exam 93926 0921 $580 $580 $348 US Exam 93970 0921 $908 $908 $545 US Exam 93970 0921 $908 $908 $545 US Exam 93971 0921 $580 $580 $348 US Exam 93971 0921 $580 $580 $348 US Exam 93978 0921 $908 $908 $545 US Exam 93979 0921 $580 $580 $348 Vent Mgmt Inpat Initial Day (94002) 94002 0410 $1,277 $378 $1,655 $993 Mechanical Ventilation Initiation Charge 94002 0410 $890 $890 $534 Vent Mgmt Inpat, subq Day (94003) 94003 0410 $1,021 $279 $1,300 $780 Mechanical Ventilation Subsequent Days Charge 94003 0410 $722 $722 $433 Spriometry without Bronchodilators 94010 0460 $411 $66 $477 $286 Spirometry without Bronchodilators Charge 94010 0460 $692 $692 $415 Review Patient Spirometry (94010) 94016 0460 $108 $108 $65 Spriometry with Bronchodilators 94060 0460 $145 $104 $249 $149 Bronchospasm- Pre & Post BD (94060) 94060 0460 $586 $63 $649 $389 Spirometry with Bronchodilators Charge 94060 0460 $245 $245 $147 Respiratory Parameter Assessment 94150 0460 $95 $95 $57 Pulmonary NIF 94150 0460 $319 $319 $191 Vital Capacity Test Charge-94150 94150 0460 $235 $235 $141 Total Vital Capacity Charge 94150 0460 $122 $122 $73 Peak Flow Meter Charge 94150 0410 $122 $122 $73 Negative Inspiratory Force Charge 94150 0460 $414 $414 $248 Maximum Breathing Capacity and Maximum Voluntary V 94200 0460 $139 $31 $170 $102 Acorn Nebulizer 94640 0410 $199 $199 $119 IPPB 94640 0410 $173 $173 $104 Small Volume Nebulizer Charge 94640 0410 $125 $125 $75 IPPB Charge 94640 0410 $224 $224 $134 Mechanical In-ExSufflator Charge 94640 0410 $224 $224 $134 Sm. Volume Neb. for Delivery of Pentamidine 94642 0410 $261 $261 $157 CPAP Initiation and Management Charge 94660 0410 $722 $722 $433 BiPAP Initial Charge 94660 0410 $890 $890 $534 BiPAP Subsequent Charge 94660 0410 $722 $722 $433 CPAP/BiPAP Initial Charge 94660 0410 $735 $735 $441 CPAP/BiPAP Subsequent Charge 94660 0409 $735 $735 $441 Meter Dose Inhaler 94664 0460 $75 $75 $45 Meter dose inhaler teaching = inhaler 94664 0410 $199 $199 $119 Bronchial Hygiene Evaluation Charge 94664 0410 $124 $124 $74 Meter Dose Inhaler Teaching Charge 94664 0460 $124 $124 $74 Chest Wall Oscillation Therapy 94667 0410 $177 $177 $106 Chest physical therapy-Initial 94667 0410 $177 $177 $106 Chest Physical Therapy Initial Charge 94667 0460 $231 $231 $139 Pulmonary Flutter Valve-Initial Charge 94667 0410 $231 $231 $139 Chest physical therapy-Subsequent 94668 0410 $148 $148 $89 Chest Physical Therapy Subsequent Charge 94668 0410 $190 $190 $114 Pulmonary Flutter Valve-Subsequent Charge 94668 0410 $190 $190 $114 Chest Wall Oscillation Therapy-Initial Charge 94669 0410 $231 $231 $139 Chest Wall Oscillation Therapy-Subsequent Charge 94669 0410 $190 $190 $114 Exhaled air analysisO2 Charge-94680 94680 0460 $325 $57 $382 $229 Exhaled air analysisO2/CO2 Charge-94681 94681 0410 $398 $39 $437 $262 Exhaled air analysis Charge-94690 94690 0460 $235 $13 $248 $149 Pulse Oximetry 94760 0460 $104 $104 $62 Pulse oximetry 94760 0410 $257 $257 $154 Measure Blood Oxygen Level 94760 $11 $11 $7 Pulse Oximetry-Spot Check Charge 94760 0410 $335 $335 $201 Exercise Oximetry 94761 0460 $308 $308 $185 Pulse oximetry-multiple determinations 94761 0410 $204 $204 $122 Pulse Oximetry-Multiple Determinations Charge 94761 0410 $266 $266 $160 Pulmonary Exercise Oximetry Charge 94761 0460 $518 $518 $311 Pulse oximetry-by continuous overnight monitoring 94762 0410 $204 $204 $122 Pulse Oximetry Overnight Monitoring Charge 94762 0410 $266 $266 $160 O2 Uptk Exp Gas Alys Rest Indir Spx Charge-95805 95805 0410 $2,373 $401 $2,774 $1,664 POLYSOMNOGRAPHY, 1-3 Charge-95808 95808 0740 $4,641 $565 $5,206 $3,124

Page 26 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price POLYSOMNOGRAPHY, 4 OR MORE Charge-95810 95810 0740 $4,641 $745 $5,386 $3,232 POLYSOMNOGRAPHY, W/CPAP Charge-95811 95811 0740 $4,641 $803 $5,444 $3,266 OT ROM/Extremity Units 95851 0430 $250 $250 $150 ROM Extr/Trunk Exclude Hands PT 95851 0420 $250 $250 $150 OT ROM/Hand Units 95852 0430 $64 $64 $38 ROM Measurement Hand Units PT 95852 0420 $64 $64 $38 EMG 1 Limb Charge (95860) 95860 0922 $739 $438 $1,177 $706 EMG 2 Limbs Charge (95861) 95861 0922 $924 $633 $1,557 $934 EMG 3 Limbs Charge (95863) 95863 0922 $1,060 $730 $1,790 $1,074 EMG 4 Limbs Charge (95864) 95864 0922 $1,158 $803 $1,961 $1,177 EMG Facial, Unilateral Charge (95867) 95867 0922 $476 $172 $648 $389 EMG Facial, Bilateral Charge (95868) 95868 0922 $476 $269 $745 $447 Needle Electromyography; Thoracic Paraspinal Muscl 95869 0922 $439 $83 $522 $313 EMG, Limited Charge (95870) 95870 0922 $238 $175 $413 $248 Electrical Stimulation Guidance for Chemodenervati 95873 0922 $330 $107 $437 $262 EMG Guidance with Chemodenervation Charge (95874) 95874 0922 $226 $107 $333 $200 Needle electromyography, each extremity; limited ( 95885 0922 $144 $46 $190 $114 Needle electromyography, each extremity; limited B 9588550 0922 $217 $70 $287 $172 Needle electromyography, each extremity, with rela 95886 0922 $151 $129 $280 $168 Needle electromyography, each extremity, with rela 9588650 0922 $226 $193 $419 $251 Needle Electromyography, non-extremity (95887) 95887 0922 $154 $99 $253 $152 Needle Electromyography, non-extremity Bilateral ( 9588750 0922 $232 $150 $382 $229 Motor/Sensory Nerve Conduct Test 95905 0983 $254 $9 $263 $158 MOTOR&/SENS 1-2 NRV CNDJ TST (95907) 95907 0922 $205 $135 $340 $204 MOTOR&/SENS 3-4 NRV CNDJ TST (95908) 95908 0922 $205 $171 $376 $226 MOTOR&/SENS 5-6 NRV CNDJ TST (95909) 95909 0922 $205 $203 $408 $245 MOTOR&SENS 7-8 NRV CNDJ TEST (95910) 95910 0922 $205 $273 $478 $287 MOTOR&SEN 9-10 NRV CNDJ TEST (95911) 95911 0922 $378 $340 $718 $431 MOTOR&SEN 11-12 NRV CND TEST (95912) 95912 0922 $378 $410 $788 $473 MOTOR&SENS 13/> NRV CND TEST (95913) 95913 0922 $378 $484 $862 $517 SSEP Single Upper Extremity Charge 95925 0922 $1,105 $416 $1,521 $913 SSEP (B) Upper Extremities Charge 95925 0922 $1,105 $691 $1,796 $1,078 SSEP Single Lower Extremity Charge 95926 0922 $1,105 $416 $1,521 $913 SSEP (B) Lower Extremities Charge 95926 0922 $1,105 $691 $1,796 $1,078 Visual Evoked Potentials 95930 0922 $1,105 $416 $1,521 $913 Orbicularis Oculi (Blink) Reflex, by electrodiagno 95933 0922 $238 $134 $372 $223 Repetitive Stimulation Charge (95937) 95937 0922 $476 $252 $728 $437 ONM IN OPERATNG ROOM 15 MIN (95940) 95940 0922 $126 $126 $76 IONM REMOTE/>1 PT OR PER HR (95941) 95941 $126 $126 $76 ANALYZE NEUROSTIM SIMPLE (95971) 95971 0361 $541 $134 $675 $405 Analyze Neurostim, Complex, 1st hour 95972 0361 $631 $343 $974 $584 Canalith Repositioning Units 95992 0420 $175 $175 $105 2D Gait Analysis Charge(95999) 95999 0920 $2,397 $2,397 $1,438 Comprehensive computer based motion analysis-4 Cha 96000 0920 $6,072 $6,072 $3,643 Comprehensive computer based motion analysis-5 Cha 96000 0920 $6,275 $6,275 $3,765 Comprehensive computer based motion analysis-1 Cha 96000 0920 $3,241 $3,241 $1,945 Comprehensive computer based motion analysis-3 Cha 96000 0920 $5,668 $5,668 $3,401 Comprehensive computer based motion analysis-2 Cha 96000 0920 $4,858 $4,858 $2,915 Dynamic plantar pressure meas during walk-3 Charge 96001 0920 $6,346 $6,346 $3,808 Dynamic plantar pressure meas during walk-1 Charge 96001 0920 $3,917 $3,917 $2,350 Dynamic plantar pressure meas during walk-2 Charge 96001 0920 $5,537 $5,537 $3,322 Dynamic plantar pressure meas during walk-5 Charge 96001 0920 $6,952 $6,952 $4,171 Dynamic plantar pressure meas during walk-4 Charge 96001 0920 $6,749 $6,749 $4,049 Dynamic surface electromyography, during walking o 96002 0920 $1,056 $1,056 $634 Dynamic fine wire electromyography Charge (96003) 96003 0920 $1,056 $1,056 $634 Physician Review and Interpretation of data (96004 96004 $443 $443 $266 Assessment of aphasia 96105 0444 $337 $337 $202 SLP Assessment of Aphasia Units 96105 0440 $366 $366 $220 Neurobehavioral Status Exam, per hour 96116 0918 $385 $186 $571 $343 Telehealth Neurobehavioral Status Exam, per hour ( 96116 0918 $385 $186 $571 $343 Neurobehavioral Status Exam Add On (96121) 96121 0918 $106 $106 $64 Telehealth Neurobehavioral Status Exam Add On (961 96121 0918 $106 $106 $64 Brief emotional/behavioral assessment (96127) 96127 0918 $54 $54 $32 Psych testing by physician or other qualified heal 96130 0918 $619 $285 $904 $542 Telehealth Psych testing by physician/qualified, 1 96130 0918 $619 $285 $904 $542 Psych testing by physician or other health profess 96131 0918 $556 $256 $812 $487 Telehealth Psych testing by physician/qualified, E 96131 0918 $556 $256 $812 $487 Neuropsych testing by physician or other qualified 96132 0918 $655 $302 $957 $574 Telehealth Neuropsych testing by physician/qualifi 96132 0918 $655 $302 $957 $574 Neuropsych testing by physician or other qualified 96133 0918 $589 $271 $860 $516 Telehealth Neuropsych testing by physician/qualifi 96133 0918 $589 $271 $860 $516 Psych or Neuropsych test admin or scoring by physi 96136 0918 $328 $150 $478 $287 Telehealth Psych or Neuropsych test admin & scorin 96136 0918 $328 $150 $478 $287 Psych or neuropsych test admin and scoring, each a 96137 0918 $295 $135 $430 $258 Telehealth Psych or Neuropsych test admin & scorin 96137 0918 $295 $135 $430 $258 Psych or neuropsych test admin and scoring by tech 96138 0918 $262 $119 $381 $229 Telehealth Psych or Neuropsych test admin & scorin 96138 0918 $262 $119 $381 $229 Psych or neuropsych test admin by technician, each 96139 0918 $235 $107 $342 $205 Telehealth Psych or Neuropsych test admin by techn 96139 0918 $235 $107 $342 $205

Page 27 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price Psych or neuropsych test admin with single automat 96146 0918 $262 $119 $381 $229 Health and Behavior Assessment/Re-Assessment (9615 96156 0914 $273 $244 $517 $310 Telehealth Health and Behavior Assessment/Re-Asses 96156 0914 $273 $244 $517 $310 Health and Behavior Intervention, Indiv, initial 3 96158 0914 $273 $165 $438 $263 Telehealth Health and Behavior Intervention, Indiv 96158 0914 $273 $165 $438 $263 Health and Behavior Intervention, Indiv, Ea Addtl 96159 0914 $137 $58 $195 $117 Telehealth Health and Behavior Intervention, Indiv 96159 0914 $137 $58 $195 $117 Health and Behavior Intervention Group, Initial 30 96164 0915 $95 $25 $120 $72 Telehealth Health and Behavior Intervention Grp, I 96164 0915 $95 $25 $120 $72 Health and Behavior Intervention Group, Ea Addtl 1 96165 0915 $47 $10 $57 $34 Telehealth Health and Behavior Intervention Grp, E 96165 0915 $47 $10 $57 $34 Health and Behavior Intervention Family, Initial 3 96167 0916 $95 $177 $272 $163 Telehealth Health and Behavior Intervention Family 96167 0916 $95 $177 $272 $163 Health and Behavior Intervention Family, Ea Addtl 96168 0916 $47 $63 $110 $66 Telehealth Health and Behavior Intervention Family 96168 0916 $47 $63 $110 $66 Health and Behavior Interv Fmly w/o Patient, Initi 96170 0916 $95 $216 $311 $187 Telehealth Health and Behavior Interv Fmly w/o Pat 96170 0916 $95 $216 $311 $187 Health and Behavior Interv Fmly w/o Patient, Ea Ad 96171 0916 $47 $79 $126 $76 Telehealth Health and Behavior Interv Fmly w/o Pat 96171 0916 $47 $79 $126 $76 Therapeutic,prophylactic or diagnostic injection 96372 0510 $130 $87 $217 $130 Chemotherapy, into CNS Charge-96450 96450 0335 $1,156 $373 $1,529 $917 PT Modality 1+ area/ Hot Cold Pack Application 97010 0420 $95 $95 $57 OT Hot/Cold Pack Units 97010 0430 $95 $95 $57 PT Hot/Cold Pack Units 97010 0420 $95 $95 $57 PT Mechanical Traction Units 97012 0420 $234 $234 $140 OT Mechanical Traction Units 97012 0430 $234 $234 $140 Chiro E-Stim Unattended Charge 97014 0420 $95 $95 $57 PT Unattended E-Stim Units 97014 0420 $146 $146 $88 OT Unattended E-Stim Units 97014 0430 $146 $146 $88 OT Vasopneumatic Devices Units 97016 0430 $234 $234 $140 PT Vasopeumatic Devices Units 97016 0420 $234 $234 $140 OT Paraffin Bath Units 97018 0430 $294 $294 $176 PT Paraffin Units 97018 0420 $294 $294 $176 OT Whirpool Units 97022 0430 $234 $234 $140 PT Whirlpool/Fluidotherapy Units 97022 0420 $234 $234 $140 PT Infrared Units 97026 0420 $146 $146 $88 OT Infrared Units 97026 0430 $146 $146 $88 INFRARED THERAPY 1+ AREAS OT (97026) 97026 0430 $18 $18 $11 INFRARED THERAPY 1+ AREAS PT (97026) 97026 0420 $18 $18 $11 Chiro E-Stim Attended Charge 97032 0420 $184 $184 $110 OT Attended E-Stim Units 97032 0430 $215 $215 $129 PT Attended E-Stim Units 97032 0420 $215 $215 $129 PT Modality 1+ area/ Iontophoresis 97033 0420 $177 $177 $106 OT Iontophoresis Units 97033 0430 $177 $177 $106 PT Iontophoresis Units 97033 0420 $177 $177 $106 OT Contrast Bath Units 97034 0430 $87 $87 $52 PT Contrast Bath Units 97034 0420 $87 $87 $52 Chiro Ultrasound Charge 97035 0420 $95 $95 $57 OT Ultrasound Units 97035 0430 $156 $156 $94 PT Ultrasound Units 97035 0420 $156 $156 $94 Chiro Therapeutic Exercise Charge 97110 0420 $119 $119 $71 PT Therapeutic Exercise Strength Endurance ROM Fle 97110 0420 $191 $191 $115 Outpatient Physical Therapy Treatment ABN 97110 0420 $191 $191 $115 OT Therapeutic Exercise Units 97110 0430 $191 $191 $115 PT Therapeutic Exercise Units 97110 0420 $191 $191 $115 Chiro Neuromuscular Re-education Charge 97112 0420 $127 $127 $76 PT Neuromuscular Re-Education 97112 0420 $189 $189 $113 OT Neuromuscular Reeducation Units 97112 0430 $189 $189 $113 PT NM Reed Units 97112 0420 $189 $189 $113 PT Neuromuscular Reeducation Units 97112 0420 $189 $189 $113 PT Aquatic Therapy Therapeutic Exercise 97113 0420 $194 $194 $116 PT Aquatic Units 97113 0420 $194 $194 $116 PT Gait Training Units 97116 0420 $161 $161 $97 Chiro Massage Charge 97124 0420 $96 $96 $58 PT Therapeutic procedure, massage 97124 0420 $91 $91 $55 OT Massage Units 97124 0430 $91 $91 $55 PT Massage Units 97124 0420 $91 $91 $55 OT Therapeutic Cognitive Function Units 97129 0430 $66 $66 $40 SLP Therapeutic Cognitive Function Units 97129 0440 $66 $66 $40 OT Ther Cognitive Func Addl 15min Units 97130 0430 $64 $64 $38 SLP Ther Cognitive Func Addl 15min Units 97130 0440 $64 $64 $38 Chiro Manual Therapy Techniques Charge 97140 0420 $138 $138 $83 PT Manual Therapy 1+ region 97140 0420 $194 $194 $116 OT Manual Therapy Units 97140 0430 $194 $194 $116 PT Manual Therapy Units 97140 0420 $194 $194 $116 PT Treatment Group 97150 0420 $93 $93 $56 PT Treatment Double 97150 0420 $93 $93 $56 OT Group Therapy Units 97150 0430 $93 $93 $56 OT Double Therapy Units 97150 0430 $93 $93 $56

Page 28 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price OT Class Units 97150 0430 $93 $93 $56 PT Double Therapy Units 97150 0420 $93 $93 $56 PT Group Therapy Units 97150 0420 $93 $93 $56 PT Evaluation Low Complexity Charge 97161 0424 $205 $205 $123 PT Evaluation Moderate Complexity Charge 97162 0424 $205 $205 $123 PT Evaluation High Complexity 97163 0424 $205 $205 $123 PT Re-Evaluation 97164 0424 $158 $158 $95 OT Evaluation Low Complexity 97165 0434 $205 $205 $123 OT Evaluation Moderate Complexity 97166 0434 $205 $205 $123 OT Evaluation High Complexity Charge 97167 0434 $205 $205 $123 OT Re-Evaluation 97168 0434 $170 $170 $102 Chiro Therapeutic Fuctional Act Charge 97530 0420 $138 $138 $83 PT Therapeutic Activity Functional Performance 97530 0420 $177 $177 $106 OT Therapeutic Activities Units 97530 0430 $177 $177 $106 PT Therapeutic Activity Units 97530 0420 $177 $177 $106 OT Sensory Integrative Techniques Units 97533 0430 $160 $160 $96 PT Sensory Integration Units 97533 0420 $160 $160 $96 SLP Sensory Integrative Techniques 97533 0440 $154 $154 $92 Chiro Patient Self/Home Care Charge 97535 0420 $130 $130 $78 PT Treatment Self Care Home Management 97535 0420 $134 $134 $80 OT Self Care/Home Management Units 97535 0430 $160 $160 $96 PT Self Care/Home Management Units 97535 0420 $160 $160 $96 Inpatient Vocational Rehab Evaluation 97537 0949 $185 $185 $111 Vocational Rehab Case Management 97537 0949 $118 $118 $71 Vocational Rehab Counseling - Group 97537 0949 $111 $111 $67 Job Placement - Individual 97537 0949 $82 $82 $49 Job Coaching Units 97537 0949 $125 $125 $75 Job Placement Group Units 97537 0949 $79 $79 $47 Job Placement Case Management Units 97537 0949 $148 $148 $89 Job Placement Individual Units 97537 0949 $82 $82 $49 Voc Rehab Group Units 97537 0949 $111 $111 $67 Voc Rehab Case Management Units 97537 0949 $157 $157 $94 Voc Rehab Inpatient Evaluations Units 97537 0949 $185 $185 $111 OT Community/Work Reintegration Units 97537 0430 $140 $140 $84 PT Community/Work Reintegration Units 97537 0420 $140 $140 $84 OT Wheelchair Management Units 97542 0430 $160 $160 $96 OT Wheelchair Management Units 97542 0430 $160 $160 $96 PT Wheelchair Management Units 97542 0420 $160 $160 $96 OT Wheelchair Management Units 97542 0430 $160 $160 $96 OT Wheelchair Management Units 97542 0430 $160 $160 $96 OT Wheelchair Management Units 97542 0430 $160 $160 $96 OT Wheelchair Management Units 97542 0430 $160 $160 $96 OT Wheelchair Management Units 97542 0430 $160 $160 $96 OT Wheelchair Management Units 97542 0430 $160 $160 $96 OT Wheelchair Management Units 97542 0430 $160 $160 $96 OT Wheelchair Management Units 97542 0430 $160 $160 $96 OT Wheelchair Management Units 97542 0430 $160 $160 $96 OT Wheelchair Management Units 97542 0430 $160 $160 $96 OT Wheelchair Management Units 97542 0430 $160 $160 $96 OT Wheelchair Management Units 97542 0430 $160 $160 $96 PT Work hardening/conditioning: initial 2 hours 97545 0420 $580 $580 $348 OT Work Hardening-Initial 2 Hours Units 97545 0430 $580 $580 $348 PT Work Hardening-Initial 2 Hours Units 97545 0420 $580 $580 $348 PT Work hardening/conditioning: each additional ho 97546 0420 $232 $232 $139 OT Work Hardening-Each Addl Hour Units 97546 0430 $232 $232 $139 PT Work Hardening-Each Addl Hour Units 97546 0420 $232 $232 $139 Selective Debridement Less than or Equal to 20 cm 97597 0361 $599 $215 $814 $488 Active Wound Care/20 cm or < Units 97597 0420 $189 $189 $113 Selective Debridement, Each Additional sq. 20 CM ( 97598 0361 $599 $270 $869 $521 Active Wound Care > 20 cm Units 97598 0420 $189 $189 $113 Non-Selective Debridement Including Topical Applic 97602 0361 $599 $171 $770 $462 Wound(s) Care Non-Selective Units 97602 0420 $189 $189 $113 Neg Pressure Wound Tx < 50 sq cm (97605) 97605 0510 $366 $117 $483 $290 Neg Pressure Wound Tx > 50 sq cm (97606) 97606 0510 $641 $134 $775 $465 PT Evaluation Physical Performance Functional Capa 97750 0420 $206 $206 $124 OT Physical Performance Test 97750 0430 $206 $206 $124 PT Physical Performance Test 97750 0420 $206 $206 $124 PT Evaluation Assistive Technology 97755 0420 $162 $162 $97 OT Assistive Technology Eval Units 97755 0430 $181 $181 $109 PT Assistive Technology Eval Units 97755 0420 $181 $181 $109 PT Orthotic Management and Training 97760 0420 $161 $161 $97 OT Orthotic Management/Train Units 97760 0430 $161 $161 $97 PT Orthotic Management/Train Units 97760 0420 $161 $161 $97 PT Prosthetic Management and Training 97761 0420 $176 $176 $106 OT Prosthetic Management/Train Units 97761 0430 $176 $176 $106 PT Prosthetic Management/Train Units 97761 0420 $176 $176 $106 PT Orthotic/Prosthetic Use Subsequent Unit(s) 97763 0420 $168 $168 $101 OT Orthotic/Prosthetic Use Subsequent Unit(s) 97763 0430 $168 $168 $101 Med Nutrition Assess and Intervention, Individual 97802 0942 $84 $84 $50

Page 29 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price Med Nutrition Re-Assessment and Intervention each 97803 0942 $84 $84 $50 Acupuncture without E-Stim. Initial 15 minutes Cha 97810 2101 $95 $95 $57 Acupuncture without E-Stim each additional 15 minu 97811 2101 $69 $69 $41 Acupuncture with E-Stim. Initial 15 minutes Charge 97813 2101 $116 $116 $70 Acupuncture with E-Stim. Each additional 15 minute 97814 2101 $69 $69 $41 OSTEOPATHIC MANIPULATION 1-2 BODY REGIONS (98925) 98925 0530 $120 $87 $207 $124 OSTEOPATHIC MANIPULATION 3-4 BODY REGIONS (98926) 98926 0530 $120 $127 $247 $148 OSTEOPATHIC MANIPULATION 5-6 BODY REGIONS (98927) 98927 0530 $120 $168 $288 $173 OSTEOPATHIC MANIPULATION 7-8 BODY REGIONS (98928) 98928 0530 $120 $210 $330 $198 OSTEOPATHIC MANIPULATION 9-10 BODY REGIONS (98929) 98929 0530 $120 $258 $378 $227 Chiro Manual Treatment Spinal 1-2 regions Charge 98940 0940 $187 $107 $294 $176 Chiro Manual Treatment Spinal 3-4 regions Charge 98941 0940 $187 $133 $320 $192 Chiro Manual Treatment Spinal 5 regions Charge 98942 0940 $187 $171 $358 $215 Chiro Manual Treatment Extra Spinal 1 or more Regi 98943 0940 $135 $107 $242 $145 Post Operative Follow-up 99024 0929 $0 $0 $0 SPECIAL REPORTS, MD/DO only (99080) 99080 $0 $0 $0 MOD SED SAME PHYS/QHP 5/>YRS, initial 15 minutes ( 99152 $39 $39 $23 Each Add'l 15 min. MOD SED SAME PHYS/QHP (99153) 99153 $35 $35 $21 NO SHOW / CANCELLATION PAIN PROGRAM CHARGE $1500 99199 0996 $1,500 $1,500 $900 Physician, special service or report (99199) 99199 $330 $330 $198 Office Visit Level 2 New Charge- 99202 99202 0510 $252 $153 $405 $243 Telehealth Visit Level 2 New Charge- 99202 99202 $123 $123 $74 Office Visit Level 3 New Charge- 99203 99203 0510 $332 $237 $569 $341 Telehealth Visit Level 3 New Charge- 99203 99203 $190 $190 $114 Office Visit Level 4 New Charge- 99204 99204 0510 $424 $386 $810 $486 Telehealth Visit Level 4 New Charge- 99204 99204 $309 $309 $185 Office Visit Level 5 New Charge- 99205 99205 0510 $552 $503 $1,055 $633 Telehealth Visit Level 5 New Charge- 99205 99205 $402 $402 $241 Office Visit Level 1 Est Charge- 99211 99211 0510 $213 $30 $243 $146 Telehealth Visit Level 1 Est Charge- 99211 99211 $24 $24 $14 Office Visit Level 2 Est Charge- 99212 99212 0510 $252 $78 $330 $198 Telehealth Visit Level 2 Est Charge- 99212 99212 $63 $63 $38 Office Visit Level 3 Est Charge- 99213 99213 0510 $252 $146 $398 $239 Telehealth Visit Level 3 Est Charge- 99213 99213 $117 $117 $70 Office Visit Level 4 Est Charge- 99214 99214 0510 $332 $231 $563 $338 Telehealth Visit Level 4 Est Charge- 99214 99214 $184 $184 $110 Office Visit Level 5 Est Charge- 99215 99215 0510 $424 $332 $756 $454 Telehealth Visit Level 5 Est Charge- 99215 99215 $266 $266 $160 Initial Hospital Care Level 1 Charge - 99221 99221 0929 $432 $432 $259 Telehealth New Inpatient Hospital Care Level 1 Cha 99221 0929 $432 $432 $259 Initial Hospital Care Level 2 Charge - 99222 99222 0929 $495 $495 $297 Telehealth New Inpatient Hospital Care Level 2 Cha 99222 0929 $495 $495 $297 Initial Hospital Care Level 3 Charge - 99223 99223 0929 $604 $604 $362 Telehealth New Inpatient Hospital Care Level 3 Cha 99223 0929 $604 $604 $362 Subsequent Hospital Care Level 1 Charge - 99231 99231 0929 $178 $178 $107 Telehealth Inpatient Subsequent Hospital Care Leve 99231 0929 $178 $178 $107 Subsequent Hospital Care Level 2 Charge - 99232 99232 0929 $249 $249 $149 Telehealth Inpatient Subsequent Hospital Care Leve 99232 0929 $249 $249 $149 Subsequent Hospital Care Level 3 Charge - 99233 99233 0929 $346 $346 $208 Telehealth Inpatient Subsequent Hospital Care Leve 99233 0929 $346 $346 $208 Hospital Discharge 30 min or less Charge - 99238 99238 0929 $296 $296 $178 Hospital Discharge > 30 min Charge - 99239 99239 0929 $374 $374 $224 Office Consult Level 1 Charge- 99241 99241 0510 $102 $112 $214 $128 Office Consult Level 1 Charge- 99241 99241 0510 $102 $112 $214 $128 Office Consult Level 2 Charge- 99242 99242 0510 $145 $241 $386 $232 Office Consult Level 2 Charge- 99242 99242 0510 $145 $241 $386 $232 Office Consult Level 3 Charge- 99243 99243 0510 $145 $334 $479 $287 Office Consult Level 3 Charge- 99243 99243 0510 $145 $334 $479 $287 Office Consult Level 4 Charge- 99244 99244 0510 $198 $519 $717 $430 Office Consult Level 4 Charge- 99244 99244 0510 $198 $519 $717 $430 Office Consult Level 5 Charge- 99245 99245 0510 $249 $653 $902 $541 Office Consult Level 5 Charge- 99245 99245 0510 $249 $653 $902 $541 Initial Inpatient Consultation Level 1Charge - 992 99251 0988 $432 $432 $259 Telehealth New Inpatient Consultation Level 1 Char 99251 0988 $432 $432 $259 Initial Inpatient Consultation Level 2 Charge- 992 99252 0988 $432 $432 $259 Telehealth New Inpatient Consultation Level 2 Char 99252 0988 $432 $432 $259 Initial Inpatient Consultation Level 3 Charge - 99 99253 0988 $495 $495 $297 Telehealth New Inpatient Consultation Level 3 Char 99253 0988 $495 $495 $297 Initial Inpatient Consultation Level 4 Charge - 99 99254 0988 $604 $604 $362 Telehealth New Inpatient Consultation Level 4 Char 99254 0988 $604 $604 $362 Initial Inpatient Consultation Level 5 Charge - 99 99255 0988 $604 $604 $362 Telehealth New Inpatient Consultation Level 5 Char 99255 0988 $604 $604 $362 Nursing fac care, subseq problem focused exam 99307 $107 $107 $64 Nursing fac care, subseq expanded problem focused 99308 $209 $209 $125 Nursing fac care, subseq detail exam 99309 $279 $279 $167 Nursing fac care, subseq comprehensive exam 99310 $411 $411 $247 Domicil/R-Home visit New Pat/problem focus 99324 $240 $240 $144 Domicil/R-Home visit New Pat / low complexity 99325 $346 $346 $208 Domicil/R-Home visit New Pat /moderate complexity 99326 $565 $565 $339

Page 30 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price Domicil/R-Home visit New Pat comprehensive/moderat 99327 $741 $741 $445 Domicil/R-Home visit New Pat comprehensive/high co 99328 $872 $872 $523 Domicil/R-Home visit est patient - problem focus/ 99334 $243 $243 $146 Domicil/R-Home visit est patient - expanded proble 99335 $376 $376 $226 Domicil/R-Home visit est patient - detailed modera 99336 $529 $529 $317 Domicil/R-Home Visit est Pat 99337 $722 $722 $433 Prolonged Face to Face (1-60 min) Charge-99354 99354 0929 $403 $403 $242 Prolonged Phys Srv Outpt Direct Pt Contact add 30 99355 0929 $291 $291 $175 Prolonged Physician Service Inpatient with Direct 99356 0929 $403 $403 $242 Prolonged Physician Service Inpatient with Direct 99357 0929 $291 $291 $175 Prolonged E/M (Non face to face); first hour-9935 99358 0988 $330 $330 $198 Prolonged E/M (non-face to face); each additional 99359 0988 $156 $156 $94 TEAM CONF W/O PAT BY PHYS 30+ MINS (99367) 99367 $270 $270 $162 Physician Supervision HH Patient; 15-29 min. 99374 $198 $198 $119 Physician Supervision HH Patient; 30 mins or more 99375 $105 $105 $63 Preventive Medicine 18-39 years New Charge- 99385 99385 0510 $357 $357 $214 Preventive Medicine 40-64 years New Charge- 99386 99386 0510 $390 $390 $234 Preventive Medicine 65+ years New Charge- 99387 99387 0510 $439 $439 $263 Preventive Medicine 18-39 years Est Charge- 99395 99395 0510 $245 $245 $147 Preventive Medicine 40-64 years Est Charge- 99396 99396 0510 $273 $273 $164 Preventive Medicine 65+ years Est Charge- 99397 99397 0510 $309 $309 $185 Smoking and tobacco use cessation counseling visit 99406 0510 $31 $31 $19 Audio Telephone E/M Services 5-10 min - 99441 99441 0960 $29 $29 $17 Audio Telephone E/M Services 11-20 min - 99442 99442 0960 $59 $59 $35 Audio Telephone E/M Services 21-30 min – 99443 99443 0960 $88 $88 $53 Work Related or Medical Disability Exam by Treatin 99455 0510 $1,235 $1,235 $741 Vocational Rehab Evaluation - Initial Assessment 99456 0949 $185 $185 $111 Vocational Rehab Evaluation/Counseling - Individua 99456 0949 $185 $185 $111 Work Related or Medical Disability Exam by Non-Tre 99456 0949 $2,470 $2,470 $1,482 Work Trial Assessment Units 99456 0949 $185 $185 $111 Voc Rehab Indiv Eval/Counseling Units 99456 0949 $185 $185 $111 Voc Rehab Initial Evaluation Units 99456 0949 $185 $185 $111 Advanced Care Planning 30 min (99497) 99497 0510 $175 $192 $367 $220 Advanced Care Planning 30 min (99497) 99497 0510 $175 $192 $367 $220 Evaluation and Management Unlisted Service (99499) 99499 $0 $0 $0 Research MRI 15 minute interval of time 99999 0610 $125 $125 $75 NEEDLE NEXIVA 22G X 1 IN A4215 0290 $28 $28 $17 NEEDLE NEXIVA 18G X 1 1/4 A4215 0290 $28 $28 $17 NEEDLE NEXIVA 20G X 1 IN A4215 0290 $28 $28 $17 NEEDLE NEXIVA 24G X 3/4 IN A4215 0290 $28 $28 $17 BREATHABLE UNDERPAD PROT PLUS 23 X 36" A4554 0270 $22 $22 $13 Pessary, non rubber, any type A4562 0278 $118 $118 $71 Legg Perthes Orthosis, Sling, Sam Brown Type A4565 0274 $0 $0 $0 A4566 Shoulder sling or vest design, abduction res A4566 0270 $240 $240 $144 A4595 FES Electrode, each A4595 0290 $40 $40 $24 Diabetics only, the off-the-shelf depth inlay to a A5500 0274 $354 $354 $212 Diabetic Only, Custom Molded Shoe A5501 0274 $1,056 $1,056 $634 Rock Bottom A5503 0274 $156 $156 $94 Wedge, Shoe A5504 0274 $98 $98 $59 Metatarsal Bar, Rocker A5505 0274 $156 $156 $94 Off-set Heel A5506 0274 $156 $156 $94 Diabetic Only, Not Otherwise Specified Shoe Modifi A5507 0274 $156 $156 $94 Multiple Density Insert, Prefabricated, Molded to A5512 0274 $143 $143 $86 Multi Density Insert A5513 0290 $143 $143 $86 Multiple Density Insert, Custom Fabricated, Molde A5513 0274 $214 $214 $128 HYDROFERA BLUE FOAM DRESSING 4" X 4" A6209 0272 $5 $5 $3 Tubular Elastic Dressing A6457 0274 $4 $4 $2 Compression Burn Mask, Custom Fabricated A6513 0272 $2,910 $2,910 $1,746 Thigh Gradient Comp Stocking 30-40mmHG by size eac A6534 0274 $241 $241 $145 A6545 Gradient Compression Wrap, Non-Elastic, Belo A6545 0274 $181 $181 $109 Helmet, Non-Molded A8000 0274 $690 $690 $414 Hard Protet Helmet Prefabricated A8001 0274 $849 $849 $509 Helmet, Molded to Model A8003 0274 $2,598 $2,598 $1,559 Equipment-Kangaroo 324 Enteral Feeding Pump LP B4035 0270 $169 $169 $101 Nontunnelled Catheter Charge C1752 0278 $648 $648 $389 Wheeled Walker Frame with Trunk Support E0140 0274 $1,341 $1,341 $805 Pad, Sheepskin, Synthetic E0188 0274 $12 $12 $7 Pad, Sheepskin, Lambs Wool, Any Size E0189 0274 $32 $32 $19 Positioning Cushion/Pillow/Wedge, Any Shape or Siz E0190 0274 $0 $0 $0 Protector, Heel or Elbow, Each E0191 0274 $29 $29 $17 Equipment-Cough Assist E0482 0291 $52 $52 $31 E0770 FES, Complete System, NOS E0770 0292 $7,038 $7,038 $4,223 FUNCTIONAL ELECTRIC STIM NOS (Bioness L300) E0770 0290 $11,270 $11,270 $6,762 OB Flat Headrest, Small E0955 0274 $172 $172 $103 OB Flat Headrest, Large E0955 0274 $207 $207 $124 OB Combination Headrest E0955 0274 $196 $196 $118 AEL Tri-pad Headrest E0955 0274 $802 $802 $481 AEL Lateral Trunk Support Pad E0956 0274 $188 $188 $113 MC Lateral Trunk Support Pad E0956 0274 $188 $188 $113

Page 31 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price AEL Abductor Hardware Lever Release E0956 0274 $524 $524 $314 AEL Abductor Hardware Push-Button Release E0956 0274 $524 $524 $314 MC Abductor Pad E0957 0274 $181 $181 $109 AEL Abductor Pad E0957 0274 $181 $181 $109 AEL H and X Straps E0960 0274 $239 $239 $143 AEL Dynaform Chest Harness, All Sizes E0960 0274 $205 $205 $123 TMS Chest Strap, 4 and 6 inch E0960 0274 $82 $82 $49 TMS Pelvic Positioning Belt, Lever Release E0978 0274 $82 $82 $49 TMS Pelvic Positioning Belt, Velcro E0978 0274 $82 $82 $49 TMS Pelvic Positioning Belt, Push-Button E0978 0274 $82 $82 $49 AEL Quick/Swing Away Trunk Support Hardware E1028 0274 $338 $338 $203 MC Abductor Hardware Swingaway E1028 0274 $145 $145 $87 MC Abductor Hardware Removable E1028 0274 $145 $145 $87 OB Single Axis Headrest Hardware E1028 0274 $252 $252 $151 E1399NU - Misc Durable Medical Equipment E1399NU 0290 $0 $0 $0 OB Forearm Trough E2209 0274 $125 $125 $75 AEL Contoured Arm Support, All Sizes, Each E2209 0274 $326 $326 $196 Labac Arm Support, All Sizes, Each E2209 0274 $417 $417 $250 Equipment-NPWT Wound Vac E2402 0291 $246 $246 $148 Solid Seat Cushion w/ Cover E2609 0274 $916 $916 $550 Solid Back Cushion w/ Cover, Non-Adjustable Hardwa E2617 0274 $1,343 $1,343 $806 Seat Cushion Cover E2619 0274 $520 $520 $312 Back Cover Only E2619 0274 $520 $520 $312 Shoulder-Elbow Orthosis, Mobile Arm Support Attach E2626 0290 $343 $343 $206 Shoulder-Elbow Orthosis, Mobile Arm Support Attach E2627 0290 $468 $468 $281 Shoulder-Elbow Orthosis, Mobile Arm Support Attach E2628 0290 $414 $414 $248 Shoulder-Elbow Orthosis, Mobile Arm Support Attach E2629 0290 $521 $521 $313 Shoulder-Elbow Orthosis, Mobile Arm Support, Monos E2630 0290 $366 $366 $220 Shoulder-Elbow Orthosis, Addition to Mobile Arm, E E2631 0290 $146 $146 $88 Shoulder-Elbow Orthosis, Addition to Mobile Arm, O E2632 0290 $95 $95 $57 Shoulder-Elbow Orthosis, Addition to Mobile Arm, S E2633 0290 $78 $78 $47 Prostate Specific Antigen, Screening G0103 0301 $154 $139 $293 $176 Home Health Re-certification Greater than 60 days G0179 0929 $200 $200 $120 Home Health Cert. Medicare Only Charge (G0180) G0180 0929 $262 $262 $157 CBC-Complete Blood Count without Platelets G0307 0305 $57 $52 $109 $65 Doctor service required to establish and document G0372 $26 $26 $16 Pulmonary Rehabilitation Program Code per hour, fo G0424 0948 $0 $0 $0 Telehealth Virtual Check-In Remote Eval G2010 $45 $45 $27 Telehealth PHY Virtual Check-In 5-10 min G2012 $37 $37 $22 Telehealth E-Visit 5-10 minutes G2061 $52 $52 $31 Telehealth E-Visit 11-20 minutes G2062 $62 $62 $37 Telehealth E-Visit 21 or more minutes G2063 $72 $72 $43 Affiliates 45945-0157-02 Baclofen 10mg J0475 0983 $2,230 $2,230 $1,338 Affiliates 00023-1145-01 Botox/unit J0585 0983 $14 $14 $8 Affiliates 00259-1610-01 Xeomin/unit J0588 0983 $12 $12 $7 Affiliates 00003-0293-20 Kenalog 40mg J3301 0983 $45 $45 $27 Affiliates 00409-1587-50 Marcaine .25% J3490 0983 $8 $8 $5 Affiliates 00409-1162-18- Bupivacaine 5mg/1ml- Sil J3490 0983 $3 $3 $2 Affiliates 58468-0090-03 Synvisc One 1mg J7325 0983 $168 $168 $101 One Piece Foot Board K0038 0274 $141 $141 $85 Calf Sling, Vinyl K0039 0274 $261 $261 $157 Calf Strap, 2 inch Webbing K0039 0274 $127 $127 $76 Seat Hardware - Drop/Flat Hooks K0108 0274 $406 $406 $244 Seat Hardware - Flat Hooks w/ Spacers K0108 0274 $482 $482 $289 Seat Hardware - Adjustable Growth K0108 0274 $775 $775 $465 Seat Cushion Cover Upgrade - Complex Upcharge K0108 0274 $254 $254 $152 Anti-Thrust Wedge Option K0108 0274 $129 $129 $77 Ethafoam Seat Wedge w/ Vinyl Cover K0108 0274 $261 $261 $157 Back Hardware - Adjustable/Growth Option K0108 0274 $775 $775 $465 Back Cushion Cover - Complex Upgrade Option K0108 0274 $254 $254 $152 Biangular Back Option K0108 0274 $154 $154 $92 Solid Backboard Only w/ Vinyl Cover K0108 0274 $408 $408 $245 Lateral Contour Option K0108 0274 $125 $125 $75 Lumbar/Sacral Contour Option K0108 0274 $127 $127 $76 Custom Contour (Foam In Place), Small K0108 0274 $313 $313 $188 Custom Contour (Foam In Place), Medium K0108 0274 $332 $332 $199 Custom Contour (Foam In Place), Large K0108 0274 $385 $385 $231 AEL Fixed Mounting Hardware K0108 0274 $137 $137 $82 Lateral Hip Block w/ Cover K0108 0274 $397 $397 $238 Nonadjustable Hip Block Hardware K0108 0274 $959 $959 $575 Adjustable Hip Block Hardware K0108 0274 $316 $316 $190 Hip Block Cover - Complex Upcharge K0108 0274 $64 $64 $38 Ankle Strap, Each K0108 0274 $129 $129 $77 Foot Plate Padding, Each K0108 0274 $133 $133 $80 Headrest Padding w/ Cover, All Sizes K0108 0274 $262 $262 $157 OB Headrest Hardware, Clamp Only K0108 0274 $77 $77 $46 AEL Bracket Adapter K0108 0274 $207 $207 $124 Laptray, Custom K0108 0274 $640 $640 $384 Laptray Edging K0108 0274 $500 $500 $300

Page 32 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price Elbow Block, Each K0108 0274 $204 $204 $122 Laptray Padding K0108 0274 $304 $304 $182 Laptray Velcro Straps, Pair K0108 0274 $127 $127 $76 Wrist Strap Padded, Each K0108 0274 $66 $66 $40 TFN Laptray, All Sizes K0108 0274 $313 $313 $188 OB Hand Pad, Flat K0108 0274 $102 $102 $61 OB Hand Pad, Molded K0108 0274 $102 $102 $61 OB Elevating/Swivel Arm Trough Hardware K0108 0274 $291 $291 $175 AEL POSAlinc Arm Support Hardware, Each K0108 0274 $507 $507 $304 AEL Wrist Strap Padded, Each K0108 0274 $67 $67 $40 Add Padding to Belt K0108 0274 $129 $129 $77

K0108NU - Misc Wheelchair DME Component K0108NU 0292 $0 $0 $0

Cranial Cervical Orthosis, Congenital Torticolous L0112 0274 $6,686 $6,686 $4,012 Foam Collar L0120 0274 $126 $126 $76 Cervical Collar, Flexible, Thermoplastic, Molded t L0130 0274 $346 $346 $208 Cervical Collar, Semi-Rigid, Adjustable Plastic L0140 0274 $138 $138 $83 Cervical Collar, Semi-Rigid, Adjustable Molded Chi L0150 0274 $512 $512 $307 Cervical Collar, Semi-Rigid, Wire-Frame L0160 0274 $747 $747 $448 Collar, Molded to Model L0170 0274 $3,844 $3,844 $2,306 Collar, Semi-Rigid 2-Piece L0172 0274 $675 $675 $405 Collar, Cervical, w/ Thoracic Extensions L0174 0274 $1,330 $1,330 $798 Cervical Collar, Muti-Post, Occip/Mand Supports, A L0180 0274 $2,156 $2,156 $1,294 Collar, Cervical, SOMI L0190 0274 $2,542 $2,542 $1,525 Collar, Cervical Multiple L0200 0274 $2,949 $2,949 $1,769 Rib Belt, Thoracic, Custom Fabricated L0220 0274 $295 $295 $177 L0450 Thoracic-Lumbar-Sacral Orthosis, Flexible, P L0450 0274 $777 $777 $466 L0452 Thoracic-Lumbar-Sacral Orthosis, Flexible, C L0452 0274 $1,621 $1,621 $973 Thoracic-Lumbar-Sacral Orthosis, Flexible, Prefabr L0454 0274 $1,656 $1,656 $994 TLSO FLEX TRNK SJ-T9 PRE OTS (L0455) L0455 0274 $1,534 $1,534 $920 Thoracic-Lumbar-Sacral Orthosis, Flexible, Dorsolu L0456 0274 $2,278 $2,278 $1,367 TLSO FLEX TRNK SJ-SS PRE OTS (L0457) L0457 0274 $4,398 $4,398 $2,639 Thoracic-Lumbar-Sacral Orthosis, 2 Rigid Plastic S L0458 0274 $2,045 $2,045 $1,227 Thoracic-Lumbar-Sacral Orthosis, 2 Rigid Plastic S L0460 0274 $2,990 $2,990 $1,794 Thoracic-Lumbar-Sacral Orthosis, 3 Rigid Shells, S L0462 0274 $2,859 $2,859 $1,715 Thoracic-Lumbar-Sacral Orthosis, 4 Rigid Shells, S L0464 0274 $3,407 $3,407 $2,044 Thoracic-Lumbar-Sacral Orthosis, Rigid Frame, Pref L0466 0274 $1,812 $1,812 $1,087 TLSO R FRAM SOFT PRE OTS (L0467) L0467 0274 $4,398 $4,398 $2,639 Thoracic-Lumbar-Sacral Orthosis, Rigid Frame, Pref L0468 0274 $2,271 $2,271 $1,363 TLSO RIG FRAM PELVIC PRE OTS (L0469) L0469 0274 $2,103 $2,103 $1,262 Thoracic-Lumbar-Sacral Orthosis, Triplaner Control L0470 0274 $1,507 $1,507 $904 Thoracic-Lumbar-Sacral Orthosis, Hyperextension Ri L0472 0274 $1,934 $1,934 $1,160 Thoracic-Lumbar-Sacral Orthosis, Triplaner Control L0480 0274 $7,218 $7,218 $4,331 Thoracic-Lumbar-Sacral Orthosis, Triplaner Control L0482 0274 $8,062 $8,062 $4,837 Thoracic-Lumbar-Sacral Orthosis, 2-Piece Rigid She L0484 0274 $8,708 $8,708 $5,225 Thoracic-Lumbar-Sacral Orthosis, 2-Piece Rigid She L0486 0274 $9,781 $9,781 $5,869 Thoracic-Lumbar-Sacral Orthosis, 1-Piece Rigid She L0488 0274 $4,797 $4,797 $2,878 L0490 Thoracic-Lumbar-Sacral Orthosis, 1-Piece Rig L0490 0274 $649 $649 $389 Thoracic-Lumbar-Sacral Orthosis 2-Piece Rigid Shel L0491 0274 $3,670 $3,670 $2,202 Thoracic-Lumbar-Sacral Orthosis 3-Piece Rigid Shel L0492 0274 $1,144 $1,144 $686 Sacoilac, Flexible, Prefabricated, Pelvic-Sacral S L0621 0274 $413 $413 $248 Sacoilac, Flexible, Custom Fabricated, Pelvic-Sacr L0622 0274 $613 $613 $368 Sacoilac, Rigid or Semi-Rigid Panels, Prefabricate L0623 0274 $0 $0 $0 Sacoilac, Rigid or Semi-Rigid Panels, Pelvic-Sagit L0624 0274 $119 $119 $71 Lumbar Orthosis, Flexible, Prefabricated, w/ Strap L0625 0274 $263 $263 $158 Lumbar Orthosis, Sagittal, Prefabricated, w/ Pads/ L0626 0274 $373 $373 $224 Lumbar Orthosis, Sagittal, Prefabricated, Rigid Pa L0627 0274 $940 $940 $564 Lumbar-Sacral Orthosis, Flexible, Prefabricated, S L0628 0274 $401 $401 $241 Lumbar-Sacral Orthosis, Flexible, Custom Fabricate L0629 0274 $222 $222 $133 Lumbar-Sacral Orthosis, Rigid Posterior, Prefabric L0630 0274 $776 $776 $466 Lumbar-Sacral Orthosis, Rigid Anterior, Sac - T9, L0631 0274 $2,350 $2,350 $1,410 Lumbar-Sacral Orthosis, Rigid Anterior-Posterior P L0632 0274 $2,958 $2,958 $1,775 L0633 Lumbar-Sacral Orthosis, Rigid Posterior Pane L0633 0274 $1,369 $1,369 $821 L0635 LSO Sag Rigid Panel, Pre L0635 0274 $2,290 $2,290 $1,374 L0636 LSO Sag Rigid Panel, Cust L0636 0274 $3,105 $3,105 $1,863 Lumbar-Sacral Orthosis, Rigid Anterior-Posterior F L0637 0274 $2,967 $2,967 $1,780 Lumbar-Sacral Orthosis, Rigid Posterior Frame/Pane L0638 0274 $3,021 $3,021 $1,813 L0639 Lumbar-Sacral Orthosis, Sac - T9, Prefabrica L0639 0274 $2,967 $2,967 $1,780 L0640 Lumbar-Sacral Orthosis, sac - T9, Custom Fab L0640 0274 $4,999 $4,999 $2,999 LO RIG POS PNL L1-L5 PRE OTS (L0641) L0641 0274 $344 $344 $206 LSO SAG CTR RIGI POS PRE OTS (L0643) L0643 0274 $717 $717 $430 LSO SAG R AN/POS PNL PRE OTS (L0648) L0648 0274 $4,541 $4,541 $2,725 LSO SC R POS/LAT PNL PRE OTS (L0649) L0649 0274 $1,268 $1,268 $761 LSO SC R ANT/POS PNL PRE OTS (L0650) L0650 0274 $5,731 $5,731 $3,439 LSO SAG-CO SHELL PNL PRE OTS (L0651) L0651 0274 $5,731 $5,731 $3,439 Cervical-Thoracic-Lumbar-Sacral Orthosis, Ant/Post L0700 0274 $4,531 $4,531 $2,719 Cervical-Thoracic-Lumbar-Sacral Orthosis, Ant/Post L0710 0274 $4,980 $4,980 $2,988 Cervical Halo Procedure, Incorporated Into Jacket L0810 0274 $6,084 $6,084 $3,650 Cervical Halo Procedure, Incorporated Into Plaster L0820 0274 $4,786 $4,786 $2,872

Page 33 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price Cervical Halo Procedure, Incorporated Into Milwauk L0830 0274 $7,322 $7,322 $4,393 Addition to Halo Procedure, MRI Compatible System L0859 0274 $2,683 $2,683 $1,610 Halo Replacement Liner/Interface L0861 0274 $1,030 $1,030 $618 Thoracic-Lumbar-Sacral Orthosis, Corset Front L0970 0274 $358 $358 $215 Lumbar-Sacral Orthosis, Corset Front L0972 0274 $358 $358 $215 Thoracic-Lumbar-Sacral Orthosis, Full Corset L0974 0274 $537 $537 $322 Lumbar-Sacral Orthosis, Full Corset L0976 0274 $714 $714 $428 Crutch, Axillary Extension L0978 0274 $465 $465 $279 Peroneal Straps, Pair L0980 0274 $40 $40 $24 Stocking, Supporter Grips, Set of 4, Replacement L0982 0274 $37 $37 $22 Lumbar-Sacral Orthosis, Protective Body Sock for S L0984 0274 $324 $324 $194 Cervical-Thoracic-Lumbar-Sacral Orthosis, Milwauke L1000 0274 $4,613 $4,613 $2,768 L1005 Tension Scoliosis Orthosis with Pads L1005 0274 $4,055 $4,055 $2,433 Cervical-Thoracic-Lumbar-Sacral Orthosis, Addition L1010 0274 $191 $191 $115 Cervical-Thoracic-Lumbar-Sacral Orthosis, Addition L1020 0274 $516 $516 $310 Cervical-Thoracic-Lumbar-Sacral Orthosis, Addition L1025 0274 $353 $353 $212 Cervical-Thoracic-Lumbar-Sacral Orthosis, Addition L1030 0274 $376 $376 $226 Cervical-Thoracic-Lumbar-Sacral Orthosis, Addition L1040 0274 $201 $201 $121 Cervical-Thoracic-Lumbar-Sacral Orthosis, Addition L1050 0274 $482 $482 $289 Cervical-Thoracic-Lumbar-Sacral Orthosis, Addition L1060 0274 $518 $518 $311 Cervical-Thoracic-Lumbar-Sacral Orthosis, Addition L1070 0274 $258 $258 $155 Cervical-Thoracic-Lumbar-Sacral Orthosis, Addition L1080 0274 $119 $119 $71 Cervical-Thoracic-Lumbar-Sacral Orthosis, Addition L1085 0274 $399 $399 $239 Cervical-Thoracic-Lumbar-Sacral Orthosis, Addition L1090 0274 $228 $228 $137 Cervical-Thoracic-Lumbar-Sacral Orthosis, Addition L1100 0274 $432 $432 $259 Cervical-Thoracic-Lumbar-Sacral Orthosis, Addition L1110 0274 $727 $727 $436 Cervical-Thoracic-Lumbar-Sacral Orthosis, Addition L1120 0274 $87 $87 $52 Thoracic-Lumbar-Sacral Orthosis, Inclusive of Init L1200 0274 $4,072 $4,072 $2,443 Thoracic-Lumbar-Sacral Orthosis, Addition, Lateral L1210 0274 $555 $555 $333 Thoracic-Lumbar-Sacral Orthosis, Addition, Anterio L1220 0274 $543 $543 $326 Thoracic-Lumbar-Sacral Orthosis, Addition, Milwauk L1230 0274 $1,517 $1,517 $910 Thoracic-Lumbar-Sacral Orthosis, Addition, Lumbar L1240 0274 $208 $208 $125 Thoracic-Lumbar-Sacral Orthosis, Addition, Anterio L1250 0274 $379 $379 $227 Thoracic-Lumbar-Sacral Orthosis, Addition, Anterio L1260 0274 $216 $216 $130 Thoracic-Lumbar-Sacral Orthosis, Addition, Abdomin L1270 0274 $186 $186 $112 Thoracic-Lumbar-Sacral Orthosis, Addition, Rib Gus L1280 0274 $200 $200 $120 Thoracic-Lumbar-Sacral Orthosis, Addition, Lateral L1290 0274 $372 $372 $223 Scoliosis Procedures, Body Jacket Molded to Patien L1300 0274 $3,921 $3,921 $2,353 Scoliosis Procedures, Post-Op Body Jacket L1310 0274 $4,087 $4,087 $2,452 L1499 - Spinal orthosis, not otherwise specified L1499 0274 $0 $0 $0 Hip Orthosis, Abduction Control, Flexible, Frejka L1600 0274 $615 $615 $369 Hip Orthosis, Adbuction Control, Flexible, Frejka L1610 0274 $262 $262 $157 Hip Orthosis, Abduction Control, Flexible, Pavlik L1620 0274 $358 $358 $215 Hip Orthosis, Abduction Control, Semi-Flexible (Vo L1630 0274 $483 $483 $290 Hip Orthosis, Abduction Control, Static, Pelvic Ba L1640 0274 $2,262 $2,262 $1,357 Hip Orthosis, Abduction Control, Static, Adjustabl L1650 0274 $561 $561 $337 Hip Orthosis Bilateral Thighcuffs w/ Spreader Bar L1652 0274 $1,701 $1,701 $1,021 Hip Orthosis, Abduction Control L1660 0274 $481 $481 $289 Hip Orthosis, Dynamic, Abduction/Pelvic/Adj Hip Co L1680 0274 $5,444 $5,444 $3,266 Hip Orthosis, Abduction Control, Custom Fabricated L1685 0274 $5,314 $5,314 $3,188 Hip Orthosis, Abduction Control, Post-op type L1686 0274 $4,477 $4,477 $2,686 Hip Orthosis, Adduction Control L1690 0274 $9,241 $9,241 $5,545 Legg Perthes Orthosis, Toronto Type L1700 0274 $3,543 $3,543 $2,126 Legg Perthes Orthosis, Newington Type L1710 0274 $4,509 $4,509 $2,705 Legg Perthes Orthosis, Trilateral, Tachdijan Type L1720 0274 $3,357 $3,357 $2,014 Scottish Rite Orthosis L1730 0274 $3,448 $3,448 $2,069 Legg Perthes Orthosis, Patten Bottom Type L1755 0274 $4,075 $4,075 $2,445 Knee Orthosis, Elastic w/ Joints L1810 0274 $490 $490 $294 KO ELASTIC W/JOINTS PRE OTS (L1812) L1812 0274 $455 $455 $273 Knee Orthosis, Elastic w/ Condylar Pads and Joints L1820 0274 $680 $680 $408 Knee Orthosis, Immobilizer, Canvas L1830 0274 $398 $398 $239 Knee Orthosis, Positional, Locking Knee Joint, Pre L1831 0274 $1,406 $1,406 $844 Knee Orthosis, Positional Adjustable Knee Joints, L1832 0274 $3,291 $3,291 $1,975 KO ADJ JNT POS R SUP PRE OTS (L1833) L1833 0274 $3,047 $3,047 $1,828 Knee Orthosis, Rigid, Molded to Patient, w/o Knee L1834 0274 $3,468 $3,468 $2,081 Knee Orthosis, Rigid, Prefabricated, w/o Knee Join L1836 0274 $306 $306 $184 Knee Orthosis, Derotation, Medial/Lateral, Custom L1840 0274 $2,005 $2,005 $1,203 Knee Orthosis, Single Upright w/ Adjustable Joint, L1843 0274 $2,312 $2,312 $1,387 Knee Orthosis, Single Upright, Thigh/Calf Adjustab L1844 0274 $7,278 $7,278 $4,367 Knee Orthosis, Double Upright, Medial/Lateral Rota L1845 0274 $4,003 $4,003 $2,402 Knee Orthosis, Double Upright, Medial/Lateral/Rota L1846 0274 $5,593 $5,593 $3,356 L1847 KO Adjustable with air Chambers L1847 0274 $2,747 $2,747 $1,648 KO DBL UPRIGHT W/AIR PRE OTS (L1848) L1848 0274 $2,543 $2,543 $1,526 Knee Orthosis, Swedish Style L1850 0274 $1,361 $1,361 $817 Knee Orthosis, Supracondylar Model, Molded to Pati L1860 0274 $5,958 $5,958 $3,575 Ankle-Foot Orthosis, Spring Wire, Dorsiflexion Cal L1900 0274 $697 $697 $418 Ankle-Foot Orthosis, Ankle Gauntlet L1902 0274 $357 $357 $214 Ankle-Foot Orthosis, Molded Ankle Gauntlet L1904 0274 $2,157 $2,157 $1,294 Ankle foot orthosis, multiligamentous ankle suppor L1906 0274 $539 $539 $323

Page 34 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price Ankle-Foot Orthosis, Supramalleolar w/ Straps L1907 0274 $2,689 $2,689 $1,613 Ankle-Foot Orthosis, Posterior, Single Bar, Clasp L1910 0274 $643 $643 $386 Ankle-Foot Orthosis, Single Upright w/ Static or A L1920 0274 $1,964 $1,964 $1,178 Ankle-Foot Orthosis, Prefabricated includes Fit an L1930 0274 $1,205 $1,205 $723 Ankle-Foot Orthosis, Rigid Anterior Tibial Section L1932 0274 $4,264 $4,264 $2,558 Ankle-Foot Orthosis, Plastic, Molded to Patient L1940 0274 $2,327 $2,327 $1,396 Ankle-Foot Orthosis, Plastic, Rigid Anterior Tibia L1945 0274 $5,363 $5,363 $3,218 Ankle-Foot Orthosis, Spiral, Plastic, Custom Fabri L1950 0274 $1,751 $1,751 $1,051 Ankle-Foot Orthosis, Spiral, Plastic or Other Mate L1951 0274 $4,013 $4,013 $2,408 Ankle-Foot Orthosis, Plastic, Posterior Solid Ankl L1960 0274 $2,962 $2,962 $1,777 Ankle-Foot Orthosis, Plastic, w/ Ankle Joint, Mold L1970 0274 $3,310 $3,310 $1,986 Ankle-Foot Orthosis, Plastic or Other Material, w/ L1971 0274 $2,241 $2,241 $1,345 Ankle-Foot Orthosis, Single Upright, Plantar/Dorsi L1980 0274 $917 $917 $550 Ankle-Foot Orthosis, Double Upright, Plantar Dorsi L1990 0274 $2,232 $2,232 $1,339 Knee-Ankle-Foot Orthosis, Single Upright, Free Kne L2000 0274 $5,348 $5,348 $3,209 Knee-Ankle-Foot Orthosis, Single or Double Upright L2005 0274 $19,580 $19,580 $11,748 L2006 KAFO, Microprocessor Swing and/or Stance L2006 0274 $92,700 $92,700 $55,620 Knee-Ankle-Foot Orthosis, Single Upright, Free Ank L2010 0274 $1,986 $1,986 $1,192 Knee-Ankle-Foot Orthosis, Double Upright, Free Kne L2020 0274 $5,266 $5,266 $3,160 Knee-Ankle-Foot Orthosis, Double Upright, Free Ank L2030 0274 $2,466 $2,466 $1,480 L2034 Knee-Ankle-Foot Orthosis, Full Plastic, Sing L2034 0274 $9,706 $9,706 $5,824 Knee-Ankle-Foot Orthosis, Full Plastic, Static, Pr L2035 0274 $396 $396 $238 Knee-Ankle-Foot Orthosis, Double Upright, Free Kne L2036 0274 $8,859 $8,859 $5,315 Knee-Ankle-Foot Orthosis, Single Upright, Full Pla L2037 0274 $7,925 $7,925 $4,755 Knee-Ankle-Foot Orthosis, Full Plastic, w/out Knee L2038 0274 $2,910 $2,910 $1,746 Hip-Knee-Ankle-Foot Orthosis, Torsion Control, Bil L2040 0274 $464 $464 $278 Hip-Knee-Ankle-Foot Orthosis, Torsion Control, Bil L2050 0274 $2,330 $2,330 $1,398 Hip-Knee-Ankle-Foot Orthosis, Torsion Control, Bil L2060 0274 $2,598 $2,598 $1,559 Hip-Knee-Ankle-Foot Orthosis, Torsion Control, Uni L2070 0274 $353 $353 $212 Hip-Knee-Ankle-Foot Orthosis, Torsion Control, Uni L2080 0274 $849 $849 $509 Hip-Knee-Ankle-Foot Orthosis, Torsion Control, Uni L2090 0274 $2,375 $2,375 $1,425 Ankle-Foot Orthosis, Tibial Fracture Orthosis, The L2106 0274 $1,795 $1,795 $1,077 Ankle-Foot Orthosis, Tibial Fracture Orthosis, Mol L2108 0274 $2,616 $2,616 $1,570 Ankle-Foot Orthosis, Soft, Tibial Fracture Orthosi L2112 0274 $2,409 $2,409 $1,445 Ankle-Foot Orthosis, Tibial Fracture Orthosis, Sem L2114 0274 $1,440 $1,440 $864 Ankle-Foot Orthosis, Rigid, Tibial Fracture Orthos L2116 0274 $1,789 $1,789 $1,073 Knee-Ankle-Foot Orthosis, Femoral Fx, Thermoplasti L2126 0274 $2,904 $2,904 $1,742 Knee-Ankle-Foot Orthosis, Molded to Patient, Femor L2128 0274 $3,414 $3,414 $2,048 Knee-Ankle-Foot Orthosis, Soft, Femoral Fx L2132 0274 $2,215 $2,215 $1,329 Knee-Ankle-Foot Orthosis, Semi-Rigid, Femoral Fx L2134 0274 $2,622 $2,622 $1,573 Knee-Ankle-Foot Orthosis, Rigid, Femoral Fx L2136 0274 $2,870 $2,870 $1,722 Lower Extremity Foot Orthosis Addition, Plastic, S L2180 0274 $325 $325 $195 Lower Extremity Foot Orthosis Addition, Drop Lock L2182 0274 $547 $547 $328 Lower Extremity Foot Orthosis Addition, Limited Mo L2184 0274 $284 $284 $170 Lower Extremity Foot Orthosis Addition, Adj Motion L2186 0274 $379 $379 $227 Lower Extremity Foot Orthosis Addition, Quadrilate L2188 0274 $690 $690 $414 Lower Extremity Foot Orthosis Addition, Waist belt L2190 0274 $209 $209 $125 Lower Extremity Foot Orthosis Addition, Hip Jt, Pe L2192 0274 $817 $817 $490 Lower Extremity Addition, Limited Ankle Motion Joi L2200 0274 $241 $241 $145 Lower Extremity Addition, Dorsiflexion/Plantarflex L2210 0274 $302 $302 $181 Lower Extremity Addition, Dorsiflexion/Plantarflex L2220 0274 $385 $385 $231 Lower Extremity Addition, Split Flat Caliper Stirr L2230 0274 $455 $455 $273 L2232 Rocker bottom, Cus Fab Only L2232 0274 $465 $465 $279 Lower Extremity Addition, Round caliper, Plate Att L2240 0274 $453 $453 $272 Lower Extremity Addition, Foot Plate, Stirrup Atta L2250 0274 $1,963 $1,963 $1,178 Lower Extremity Addition, Reinforced Solid Stirrup L2260 0274 $894 $894 $536 Addition to lower extremity, Long tongue stirrup L2265 0274 $674 $674 $404 Lower Extremity Addition, Valgus/Varus Correction L2270 0274 $293 $293 $176 Lower Extremity Addition, Valgus/Varus Correction L2275 0274 $624 $624 $374 Lower Extremity Addition, Molded Inner Boot L2280 0274 $2,699 $2,699 $1,619 Lower Extremity Addition, Abduction Bar, Jointed, L2300 0274 $543 $543 $326 Lower Extremity Addition, Abduction Bar, Straight L2310 0274 $552 $552 $331 Lower Extremity Addition, Non-Molded Lacer, Custom L2320 0274 $921 $921 $553 Lower Extremity Addition, Lacer, Molded to Patient L2330 0274 $1,757 $1,757 $1,054 Lower Extremity Addition, Anterior Swing Band L2335 0274 $637 $637 $382 Lower Extremity Addition, Pre-Tibial Shell, Molded L2340 0274 $1,996 $1,996 $1,198 Lower Extremity Addition, PTB Socket, Molded to Pa L2350 0274 $1,710 $1,710 $1,026 Lower Extremity Addition, Extended Steel Shank L2360 0274 $247 $247 $148 Lower Extremity Addition, Patten Bottom L2370 0274 $770 $770 $462 Lower Extremity Addition, Torsion Control, Ankle J L2375 0274 $303 $303 $182 Lower Extremity Addition, Torsion Control, Straigh L2380 0274 $318 $318 $191 Lower Extremity Addition, Straight Knee Joint, Hea L2385 0274 $702 $702 $421 L2387 Polycentric Knee JT L2387 0274 $914 $914 $548 Lower Extremity Addition, Offset Knee Joint L2390 0274 $489 $489 $293 Lower Extremity Addition, Offset Knee Joint, Heavy L2395 0274 $697 $697 $418 Lower Extremity Addition, Suspension Sleeve L2397 0274 $245 $245 $147 Addition, Knee Joint, Drop Lock, Stance or Swing L2405 0274 $416 $416 $250 Addition, Knee Joint, Cam Lock L2415 0274 $580 $580 $348 Addition, Knee Joint, Disc/Dial Lock L2425 0274 $686 $686 $412

Page 35 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price Addition, Knee Joint, Ratchet L2430 0274 $686 $686 $412 Addition, Knee Joint, Lift Loop for Drop Lock Ring L2492 0274 $560 $560 $336 Lower Extremity Addition, Thigh/Gluteal/Ischial We L2500 0274 $771 $771 $463 Lower Extremity Addition, Thigh/Weight Bearing Qua L2510 0274 $2,644 $2,644 $1,586 Lower Extremity Addition, Thigh Weight Bearing, Qu L2520 0274 $1,320 $1,320 $792 Lower Extremity Addition, Thigh/Weight Bearing Isc L2525 0274 $2,436 $2,436 $1,462 Lower Extremity Addition, Thigh Weight Bearing Isc L2526 0274 $1,572 $1,572 $943 Lower Extremity Addition, Thigh Weight Bearing Lac L2530 0274 $589 $589 $353 Lower Extremity Addition Thigh/Weight Bearing Lace L2540 0274 $2,169 $2,169 $1,301 Lower Extremity Addition, Thigh Weight Bearing, Hi L2550 0274 $838 $838 $503 Lower Extremity Addition, Pelvic Control, Hip Jt, L2570 0274 $1,096 $1,096 $658 Lower Extremity Addition, Pelvic Control Sling L2580 0274 $2,075 $2,075 $1,245 Lower Extremity Addition, Pelvic Control, Hip Jt, L2600 0274 $524 $524 $314 Lower Extremity Addition, Pelvic Control, Hip Jt, L2610 0274 $1,128 $1,128 $677 Lower Extremity Addition, Pelvic Control Hip Joint L2620 0274 $1,196 $1,196 $718 Lower Extremity Addition, Pelvic Control, Hip Jt, L2622 0274 $1,519 $1,519 $911 Lower Extremity Addition, Pelvic Control, Hip Jt, L2624 0274 $958 $958 $575 Lower Extremity Addition, Pelvic Control, Reciproc L2627 0274 $10,211 $10,211 $6,127 Lower Extremity Addition, Pelvic Control, Reciproc L2628 0274 $7,486 $7,486 $4,492 Lower Extremity Addition, Pelvic Control, Band/Bel L2630 0274 $570 $570 $342 Lower Extremity Addition, Pelvic Control Band/Belt L2640 0274 $1,502 $1,502 $901 Lower Extremity Addition, Pelvic/Thoracic Control L2650 0274 $662 $662 $397 Lower Extremity Addition, Thoracic Control Band L2660 0274 $853 $853 $512 Lower Extremity Addition, Thoracic Control, Parasp L2670 0274 $394 $394 $236 Lower Extremity Addition, Thoracic Control Lateral L2680 0274 $700 $700 $420 Lower Extremity Orthosis Addition, Plating Chrome/ L2750 0274 $193 $193 $116 Lower Extremity Orthosis Addition, Carbon Laminati L2755 0274 $625 $625 $375 Lower Extremity Orthosis Addition, Extension Per B L2760 0274 $520 $520 $312 Lower Extremity Orthosis Addition, Sidebar Disconn L2768 0274 $624 $624 $374 Lower Extremity Addition, Non-Corrosive Finish Bar L2780 0274 $303 $303 $182 Lower Extremity Orthosis Addition, Drop Lock Retai L2785 0274 $142 $142 $85 Lower Extremity Orthosis Addition, Full Knee Cap L2795 0274 $394 $394 $236 Lower Extremity Orthosis Addition, Knee Cap, Media L2800 0274 $483 $483 $290 Lower Extremity Orthosis Addition, Condylar Pad L2810 0274 $390 $390 $234 Lower Extremity Orthosis Addition, Soft Interface L2820 0274 $387 $387 $232 Lower Extremity Orthosis Addition, Soft Interface L2830 0274 $418 $418 $251 Lower Extremity Orthosis, Tibial Length Sock, Fx o L2840 0274 $208 $208 $125 Lower Extremity Orthosis Addition, Femoral Length L2850 0274 $289 $289 $173 TORSION MECHANISM KNEE/ANKLE L2861 0274 $276 $276 $166 L2999 - Lower extremity orthosis, not otherwise sp L2999 0274 $0 $0 $0 Foot Insert, Removable, UCB Type, Molded to Patien L3000 0274 $1,502 $1,502 $901 Foot Insert, Removable, Spenco, Molded to Patient L3001 0274 $631 $631 $379 Foot Insert, Removable, Plastizote Insert, Molded L3002 0274 $775 $775 $465 Foot Insert, Removable, Silicone Gel, Molded to Pa L3003 0274 $500 $500 $300 Foot Insert, Removable, Longitudinal Arch Support, L3010 0274 $837 $837 $502 Foot Insert, Removable, Longitudinal Support L3020 0274 $949 $949 $569 Foot Insert, Removable, Formed to Patient Foot L3030 0274 $364 $364 $218 HI STRNGTH LTWT FOOT INSERT EACH L3031 0274 $245 $245 $147 Foot Insert, Removable, Pre-Molded, Longitudinal A L3040 0274 $225 $225 $135 Foot Insert, Removable, Pre-Molded, Metatarsal Arc L3050 0274 $225 $225 $135 Foot Insert, Removable, Pre-Molded, Longitudinal/M L3060 0274 $319 $319 $191 Foot Orthosis, Non-Removable, Longitudinal Arch Su L3070 0274 $150 $150 $90 Foot Orthosis, Non-Removable, Metatarsal Support, L3080 0274 $150 $150 $90 Foot Orthosis, Arch Support, Longitudinal/Metatars L3090 0274 $96 $96 $58 Hallus-Valgus Night Dynamic Splint L3100 0274 $208 $208 $125 Foot Orthosis, Abduction Rotation Bar, Incl Shoes L3140 0274 $205 $205 $123 Foot Orthosis, Abduction Rotation Bar, w/out Shoes L3150 0274 $266 $266 $160 Plastic Heel Stabilizer, Cup L3170 0274 $245 $245 $147 Orthopedic Shoe, Ladies, Oxford L3215 0274 $495 $495 $297 Orthopedic Shoe, Ladies, Depth Inlay L3216 0274 $686 $686 $412 Orthopedic Shoe, Ladies, High Top Depth Inlay L3217 0274 $542 $542 $325 Orthopedic Shoe, Mens, Oxford L3219 0274 $770 $770 $462 Orthopedic Shoe, Mens, Depth Inlay L3221 0274 $882 $882 $529 Orthopedic Shoe, Mens, High Top Depth Inlay L3222 0274 $649 $649 $389 Orthopedic Shoe, Womens, Oxford, Used as Part of B L3224 0274 $324 $324 $194 Orthopedic Shoe, Mens, Oxford, Used as Part of Bra L3225 0274 $205 $205 $123 Orthopedic Shoe, Custom, Depth Inlay L3230 0274 $3,080 $3,080 $1,848 L3252 Custom Plastazote Ea L3252 0274 $184 $184 $110 Orthopedic Shoe, Custom Plastizote L3253 0274 $176 $176 $106 L3254 Non Standard Size/Width Pr L3254 0274 $227 $227 $136 L3255 Non Standard Size/Length Pr L3255 0274 $198 $198 $119 L3257 Split Size Additional charge L3257 0274 $263 $263 $158 Surgical Boot L3260 0274 $675 $675 $405 Lift, Heel, Tapered to Metatarsal, Per Inch L3300 0274 $249 $249 $149 Lift, Heel and Sole, Neoprene, Per Inch L3310 0274 $390 $390 $234 Lift, Heel and Sole, Cork, Per Inch L3320 0274 $184 $184 $110 Lift, Metal Extension (Skate) L3330 0274 $1,288 $1,288 $773 Lift, Inside Shoe, Tapered, Per Inch L3332 0274 $353 $353 $212 Lift, Heel, Per Inch L3334 0274 $182 $182 $109

Page 36 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price Wedge, Heel, Sach L3340 0274 $409 $409 $245 Wedge, Heel L3350 0274 $108 $108 $65 Wedge, Sole, Outside Sole L3360 0274 $171 $171 $103 Wedge, Sole, Between Sole L3370 0274 $237 $237 $142 Wedge, Clubfoot L3380 0274 $237 $237 $142 Wedge, Outflare L3390 0274 $237 $237 $142 Wedge, Metatarsal Bar, Rocker L3400 0274 $193 $193 $116 L3410 Metatarsal bar wedge, between sole L3410 0274 $436 $436 $262 Wedge, Heel/Full Sole, Between Sole L3420 0274 $261 $261 $157 Heel, Counter, Plastic Reinforced L3430 0274 $63 $63 $38 Wedge, Metatarsal Bar, Between Sole L3440 0274 $364 $364 $218 Heel, Sach Cushion Type L3450 0274 $112 $112 $67 Heel, New Rubber, Standard L3460 0274 $164 $164 $98 Heel, Thomas w/ Wedge L3465 0274 $71 $71 $43 Heel, New Leather, Standard L3470 0274 $142 $142 $85 L3480 Pad & Depression for Spur L3480 0274 $296 $296 $178 Heel, Pad, Removable for Spur L3485 0274 $65 $65 $39 Insole, Leather L3500 0274 $59 $59 $35 Insole, Rubber L3510 0274 $50 $50 $30 Orthopedic Shoe Addition, Insole, Felt Covered w/ L3520 0274 $71 $71 $43 Heel, Thomas Extended to Ball L3520 0274 $71 $71 $43 Orthopedic Shoe Addition, Sole, Half L3530 0274 $150 $150 $90 Orthopedic Shoe Addition, Sole, Full L3540 0274 $245 $245 $147 Orthopedic Shoe Addition, Toe Tap Standard L3550 0274 $40 $40 $24 Orthopedic Shoe Addition, Toe Tap Horseshoe L3560 0274 $61 $61 $37 Orthopedic Shoe Addition, Special Extension to Ins L3570 0274 $209 $209 $125 Orthopedic Shoe Addition, Convert to Velcro Closur L3580 0274 $309 $309 $185 Orthopedic Shoe Addition, Convert Firm Counter to L3590 0274 $134 $134 $80 Orthopedic Shoe Addition, March Bar L3595 0274 $104 $104 $62 Orthosis, Transfer, Caliper Plate L3600 0274 $127 $127 $76 Orthosis, Transfer, Existing Stirrup L3620 0274 $364 $364 $218 Orthosis, Transfer, New Stirrup L3630 0274 $482 $482 $289 L3649 Orthopedic Shoe Addition/Modification, Velcr L3649 0274 $140 $140 $84 Orthopedic Shoe Addition/Modification, Transfer Or L3649 0274 $271 $271 $163 Unlisted Orthopedic Shoe L3649 0274 $0 $0 $0 Unlisted Child Orthopedic Shoe L3649 0274 $78 $78 $47 L3649a Rockport L3649 0274 $282 $282 $169 Shoulder Orthosis, Figure 8 Abduction Restrainer L3650 0274 $315 $315 $189 Shoulder Orthosis, Figure of Eight, Canvas L3660 0274 $448 $448 $269 Shoulder Orthosis, Acro/Clavicular Canvas L3670 0274 $493 $493 $296 Shoulder Orthosis, Cap Design, Custom Fabricated L3671 0274 $1,789 $1,789 $1,073 SO AIRPLANE W/WO JOINT CF L3674 0274 $4,279 $4,279 $2,567 L3675 Shoulder orthosis (SO), vest type abduction L3675 0274 $751 $751 $451 Elbow Orthosis, Elastic, Custom Fabricated L3702 0274 $1,257 $1,257 $754 OT Elbow Orthosis Right Charge L3702 L3702 0274 $712 $712 $427 OT Elbow Orthosis Left Charge L3702 L3702 0274 $712 $712 $427 Elbow Orthosis, Elastic w/ Metal Jts L3710 0274 $622 $622 $373 Elbow Orthosis, Double Upright w/ Forearm/Arm Cuff L3720 0274 $2,972 $2,972 $1,783 Elbow Orthosis, Double Upright w/ Forearm/Arm Cuff L3730 0274 $3,942 $3,942 $2,365 Elbow Orthosis, Double Upright w/ Forearm/Arm Cuff L3740 0274 $4,673 $4,673 $2,804 EO with Joint, Prefabricated Custom Fit L3760 0274 $2,173 $2,173 $1,304 L3761 Elbow orthosis with adjustable position lock L3761 0274 $1,772 $1,772 $1,063 Elbow Orthosis, Rigid w/o Joints, Prefabricated L3762 0274 $468 $468 $281 Elbow-Wrist-Hand Orthosis, Rigid, Custom Fabricate L3763 0274 $3,254 $3,254 $1,952 Upper Extremity, Forearm Fx, Hand w/ Wrist Hinge L3764 0274 $1,328 $1,328 $797 Elbow-Wrist-Hand Orthosis, Nontorsion Joints, Cust L3764 0274 $3,407 $3,407 $2,044 Elbow-Wrist-Hand-Finger Orthosis, Rigid Custom Fab L3765 0274 $2,547 $2,547 $1,528 Elbow-Wrist-Hand-Finger Orthosis, Nontorsion Joint L3766 0274 $2,699 $2,699 $1,619 OT WHFO Orthosis Right Charge L3806 L3806 0274 $1,120 $1,120 $672 OT WHFO Orthosis Left Charge L3806 L3806 0274 $1,120 $1,120 $672 WHFO With Joint(s), Custom Fabricated L3806 0274 $3,566 $3,566 $2,140 Wrist-Hand-Finger Orthosis, w/o joints, Prefabrica L3807 0274 $1,089 $1,089 $653 OT WHFO Left Charge L3807 L3807 0274 $611 $611 $367 OT WHFO Right Charge L3807 L3807 0274 $611 $611 $367 OT Wrist Hand Finger Orthosis RT L3808 L3808 0274 $879 $879 $527 OT Wrist Hand Finger Orthosis LT L3808 L3808 0274 $879 $879 $527 WHFO, Rigid without joints, custom fabricated L3808 0274 $3,366 $3,366 $2,020 WHFO W/O JOINTS PRE OTS (L3809) L3809 0274 $1,006 $1,006 $604 TORSION MECHANISM WRIST/ELBO L3891 0274 $276 $276 $166 Wrist-Hand-Finger Orthosis, Dynamic Flexor Hinge, L3900 0274 $3,877 $3,877 $2,326 Wrist-Hand-Finger Orthosis, Dynamic Flexor Hinge, L3901 0274 $4,494 $4,494 $2,696 Wrist-Hand-Finger Orthosis, Electric, External Pow L3904 0274 $9,325 $9,325 $5,595 Wrist-Hand Orthosis, Nontorsion Joints, Custom Fab L3905 0274 $1,969 $1,969 $1,181 Wrist-Hand Orthosis, Gauntlet, Molded to Pt L3906 0274 $2,204 $2,204 $1,322 OT Wrist Hand Orthosis Left Charge L3906 L3906 0274 $1,252 $1,252 $751 OT Wrist Hand Orthosis RT Charge L3906 L3906 0274 $1,252 $1,252 $751 Wrist-Hand Orthosis, Wrist Extension Control Cock- L3908 0274 $319 $319 $191 Hand-Finger Orthosis, Flexion Glove w/ Elastic Fin L3912 0274 $218 $218 $131 L3913 HFO, w/o JTs, Custom Fab L3913 0274 $1,178 $1,178 $707

Page 37 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price OT Hand Finger Orthosis RT Charge L3913 L3913 0274 $669 $669 $401 OT Hand Finger Orthosis LT Charge L3913 L3913 0274 $669 $669 $401 WHO prefab, one or more nontorsion joints, elastic L3915 0274 $2,430 $2,430 $1,458 WHO NONTORSION JNTS PRE OTS (L3916) L3916 0274 $2,140 $2,140 $1,284 Hand Orthosis, Metacarpal Fx, Prefabricated L3917 0274 $219 $219 $131 METACARP FX ORTHOSIS PRE OTS (L3918) L3918 0274 $425 $425 $255 hand Orthosis, Custom Fabricated L3919 0274 $1,178 $1,178 $707 OT Hand Orthosis Right Charge L3919 L3919 0274 $669 $669 $401 OT Hand Orthosis Left Charge L3919 L3919 0274 $669 $669 $401 Hand-Finger Orthosis, Nontorsion Joints, Custom Fa L3921 0274 $1,398 $1,398 $839 OT HFO Right Charge L3921 L3921 0274 $793 $793 $476 OT HFO Left Charge L3921 L3921 0274 $793 $793 $476 Wrist-Hand Orthosis, Thumb Wrist Spica L3923 0274 $418 $418 $251 HFO WITHOUT JOINTS PRE OTS (L3924) L3924 0274 $387 $387 $232 Finger Orthosis, Safety Pin, Spring Wire L3925 0274 $142 $142 $85 FO PIP/DIP W/O JOINT/SPRING L3927 0274 $127 $127 $76 Hand-Finger Orthosis, Knuckle Bender L3929 0274 $209 $209 $125 Hand-Finger Orthosis, Knuckle Bender w/ Outrigger L3929 0274 $258 $258 $155 Hand-Finger Orthosis, Knuckle Bender, 2 Segment to L3929 0274 $247 $247 $148 Hand-Finger Orthosis, Finger Extension w/ Clock Sp L3929 0274 $143 $143 $86 Hand-Finger Orthosis, Reverse Knuckle Bender L3929 0274 $205 $205 $123 Hand-Finger Orthosis, Reverse Knuckle Bender, w/ O L3929 0274 $258 $258 $155 Hand-Finger Orthosis, Composite Elastic L3929 0274 $193 $193 $116 HFO Nontorsion Joint, Prefabricated L3929 0274 $398 $398 $239 HFO NONTORSION JNTS PRE OTS (L3930) L3930 0274 $368 $368 $221 Wrist-Hand-Finger Orthosis, Swanson Design L3931 0274 $827 $827 $496 Wrist-Hand-Finger Orthosis, Wrist Extension Cock-u L3931 0274 $324 $324 $194 Wrist-Hand-Finger Orthosis, Oppenheimer L3931 0274 $290 $290 $174 Wrist-Hand-Finger Orthosis, Thomas Suspension L3931 0274 $237 $237 $142 Wrist-Hand-Finger Orthosis, Finger Extension w/ Wr L3931 0274 $192 $192 $115 Wrist-Hand-Finger Orthosis, Palmer L3931 0274 $284 $284 $170 Wrist-Hand-Finger Orthosis, Dorsal Wrist L3931 0274 $281 $281 $169 Wrist-Hand-Finger Orthosis, Dorsal Wrist, w/ Outri L3931 0274 $271 $271 $163 Wrist-Hand-Finger Orthosis, Oppenheimer w/ Knuckle L3931 0274 $414 $414 $248 WHFO Nontorsion Joint, Prefabricated L3931 0274 $908 $908 $545 L3933 FO, w/o JTs, Custom Fab L3933 0274 $926 $926 $556 OT Finger Orthosis Left Charge L3933 L3933 0274 $528 $528 $317 OT Finger Orthosis Right Charge L3933 L3933 0274 $528 $528 $317 L3935 FO, Nontorsion JT, Custom Fab L3935 0274 $959 $959 $575 OT FO Right Charge L3935 L3935 0274 $543 $543 $326 OT FO Left Charge L3935 L3935 0274 $543 $543 $326 Shoulder-Elbow-Wrist-Hand Orthosis, Airplane Desig L3960 0274 $1,701 $1,701 $1,021 Shoulder-Elbow-Wrist-Hand-Finger Orthosis, Molded L3961 0274 $3,335 $3,335 $2,001 Shoulder-Elbow-Wrist-Hand Orthosis, Abduction Posi L3962 0274 $1,495 $1,495 $897 L3967 SEWHO, Airplane Design, w/o JTs, Custom Fab L3967 0274 $3,941 $3,941 $2,365 L3971 SEWHO, Shoulder cap design, Incl Nontorsion L3971 0274 $4,037 $4,037 $2,422 L3973 SEWHO, Airplane design, Incl Nontorsion JTs/ L3973 0274 $4,251 $4,251 $2,551 L3975 SEWHO, Shoulder cap design, w/o JTs L3975 0274 $3,603 $3,603 $2,162 L3976 SEWHFO, Airplane design, w/o JTs L3976 0274 $3,603 $3,603 $2,162 L3977 SEWHFO, Shoulder cap design, Incl nontorsion L3977 0274 $4,037 $4,037 $2,422 L3978 SEWHFO, Airplane design, Incl Nontorsion JTs L3978 0274 $4,251 $4,251 $2,551 Upper Extremity, Humeral Fx Cuff L3980 0274 $1,685 $1,685 $1,011 Upper Extremity, Radius/Ulner Fx Cuff L3982 0274 $812 $812 $487 Upper Extremity, Wrist Fx Cuff L3984 0274 $776 $776 $466 Upper Extremity Addition, Sock, Fx or Equal L3995 0274 $95 $95 $57 Utensil Slot L3999 0274 $176 $176 $106 Fork Holder L3999 0274 $29 $29 $17 Pencil Holder L3999 0274 $149 $149 $89 Spoon Holder L3999 0274 $29 $29 $17 Unlisted Upper Limb L3999 0274 $0 $0 $0 L3999 - Upper limb orthosis, not otherwise specifi L3999 0274 $0 $0 $0 Replace Girdle for Milwaukee Orthosis L4000 0274 $3,249 $3,249 $1,949 L4002 Replacement Strap, Any L4002 0274 $63 $63 $38 Replace Trilateral Socket Brim L4010 0274 $1,972 $1,972 $1,183 Replace Quadrilateral Socket Brim L4020 0274 $3,162 $3,162 $1,897 Replace Thigh Lacer, Molded, Custom Fabrication L4030 0274 $1,011 $1,011 $607 Replace Thigh Lacer, Non-Molded, Custom Fabricatio L4040 0274 $1,011 $1,011 $607 L4045 Replace non-molded thigh lacer, for custom f L4045 0274 $1,443 $1,443 $866 Replace Calf Lacer, Molded, Custom Fabrication L4050 0274 $1,349 $1,349 $809 Replace Calf Lacer, Non-Molded, Custom Fabrication L4055 0274 $614 $614 $368 Replace High Roll Cuff L4060 0274 $802 $802 $481 Replace Proximal and Distal Upright for KAFO L4070 0274 $1,258 $1,258 $755 Replace Metal bBands KAFO, Proximal Thigh L4080 0274 $474 $474 $284 Replace Metals Bands KAFO, Calf or Distal Thigh L4090 0274 $363 $363 $218 Replace Leather Cuff, Proximal Thigh L4100 0274 $485 $485 $291 Replace Leather Cuff, Calf or Distal Thigh L4110 0274 $379 $379 $227 Replace Pretibial Shell L4130 0274 $1,178 $1,178 $707 L4205 Repair Labor 15 minutes L4205 0274 $134 $134 $80 Repair/Replace Minor Part L4210 0274 $0 $0 $0

Page 38 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price Pneumatic Ankle Control Splint, Aircast, Prefabric L4350 0274 $464 $464 $278 Pneumatic Ankle-Foot Orthosis, w/ or w/out Jts, Pr L4360 0274 $1,240 $1,240 $744 PNEUMA/VAC WALK BOOT PRE OTS (L4361) L4361 0274 $1,145 $1,145 $687 Pneumatic Full Leg Splint, Prefabricated L4370 0274 $537 $537 $322 Non-Pneumatic Walking Splint L4386 0274 $757 $757 $454 NON-PNEUM WALK BOOT PRE OTS (L4387) L4387 0274 $700 $700 $420 Replace Interface, Ankle Contracture Splint L4392 0274 $62 $62 $37 Replace Foot, Drop Splint L4394 0274 $80 $80 $48 Ankle Contracture Splint L4396 0274 $804 $804 $482 STATIC OR DYNAMI AFO PRE OTS (L4397) L4397 0274 $744 $744 $446 Foot Drop Splint L4398 0274 $369 $369 $221 AFO WALK BOOT TYPE CUS FAB L4631 0274 $5,863 $5,863 $3,518 Partial foot, shoe insert with longitudinal arch, L5000 0274 $2,444 $2,444 $1,466 Partial foot, molded socket, ankle height, with to L5010 0274 $5,109 $5,109 $3,065 Partial foot, molded socket, tibial tubercle heigh L5020 0274 $8,083 $8,083 $4,850 Ankle, Symes, molded socket, SACH foot L5050 0274 $8,830 $8,830 $5,298 Ankle, Symes, metal frame, molded leather socket, L5060 0274 $8,312 $8,312 $4,987 Below knee, molded socket shin, SACH foot (EXO) L5100 0274 $8,787 $8,787 $5,272 Below knee, plastic socket, joints and thigh lacer L5105 0274 $12,288 $12,288 $7,373 Knee disartic (or through knee), molded socket, ex L5150 0274 $12,443 $12,443 $7,466 Knee disarticulation, molded socket, bent knee con L5160 0274 $11,566 $11,566 $6,940 Above knee, molded socket, single axis constant fr L5200 0274 $11,601 $11,601 $6,961 Above knee, short prosthesis, no knee joint (""stu L5210 0274 $9,210 $9,210 $5,526 Above knee, short prosthesis, no knee joint ("stub L5210 0274 $9,210 $9,210 $5,526 Above knee, short prosthesis, no knee joint (""stu L5220 0274 $7,882 $7,882 $4,729 Above knee, for proximal femoral focal deficiency, L5230 0274 $15,217 $15,217 $9,130 Hip disartic, Canadian type; molded socket, hip jt L5250 0274 $13,763 $13,763 $8,258 Hip disartic, tilt table type; molded socket, lock L5270 0274 $15,333 $15,333 $9,200 Hemipelvectomy, Canadian type; molded socket, hip L5280 0274 $14,908 $14,908 $8,945 Below knee, molded socket, shin, SACH foot, endosk L5301 0274 $8,551 $8,551 $5,131 KNEE DISART, SACH FT, ENDO (L5312) L5312 0274 $12,474 $12,474 $7,484 Above knee, molded socket, open end, SACH foot, en L5321 0274 $11,406 $11,406 $6,844 Hip disart, Canadian type; molded socket, endo sys L5331 0274 $16,701 $16,701 $10,021 Hemipel, Canadian type; molded socket, endo system L5341 0274 $13,783 $13,783 $8,270 Immediate postsurg/early fitting, app of initial r L5400 0274 $3,923 $3,923 $2,354 Immediate postsurg/early fitting, app of initial r L5410 0274 $1,085 $1,085 $651 Immediate postsurg/early fitting, app of initial r L5420 0274 $4,958 $4,958 $2,975 Immediate postsurg/early fitting, ""AK"" or knee d L5430 0274 $1,345 $1,345 $807 Immediate postsurg/early fitting, app of nonweight L5450 0274 $1,553 $1,553 $932 Immediate postsurg/early fitting, app of nonweight L5460 0274 $1,526 $1,526 $916 Initial, BK ""PTB"" type socket, non-alignable sys L5500 0274 $3,631 $3,631 $2,179 Initial, AK or knee disartic, ischial level socket L5505 0274 $5,104 $5,104 $3,062 Prep, BK ""PTB"" type socket, non-alignable sys, p L5510 0274 $4,334 $4,334 $2,600 Prep, BK ""PTB"" type socket, non-alignable sys, p L5520 0274 $3,884 $3,884 $2,330 Prep, BK ""PTB"" type socket, non-align sys, pylon L5530 0274 $6,622 $6,622 $3,973 Prep, BK ""PTB"" type socket, non-alignable sys, p L5535 0274 $4,760 $4,760 $2,856 Prep, BK ""PTB"" type socket, non-alignable sys, p L5540 0274 $6,602 $6,602 $3,961 Prep, AK or knee disartic, ischial level socket, n L5560 0274 $5,745 $5,745 $3,447 L5570 Prep, AK or knee disartic, ischial level soc L5570 0274 $0 $0 $0 L5580 Prep, AK or knee disartic, ischial level soc L5580 0274 $9,058 $9,058 $5,435 Prep, AK or knee disartic, ischial level socket, n L5585 0274 $8,106 $8,106 $4,864 Prep, AK or knee disartic, ischial level socket, n L5590 0274 $9,358 $9,358 $5,615 Prep, hip disartic - hemipel, pylon, no cover, SAC L5595 0274 $14,627 $14,627 $8,776 Prep, hip disartic or hemipel, pylon, no cover, SA L5600 0274 $16,644 $16,644 $9,986 Addition to LE, endo sys, AK, hydracadence system L5610 0274 $6,448 $6,448 $3,869 Addition to LE, endo sys, AK or knee disartic, 4-b L5611 0274 $5,379 $5,379 $3,227 Addition to LE, endo sys, AK or knee disartic, 4-b L5613 0274 $8,173 $8,173 $4,904 Addition to LE, endosys, AK or knee disartic, 4-ba L5614 0274 $4,357 $4,357 $2,614 Addition to LE, endo sys, AK, universal multiplex L5616 0274 $3,968 $3,968 $2,381 Addition to LE, quick change self aligning unit, A L5617 0274 $1,436 $1,436 $862 Addition to LE, test socket, Symes L5618 0274 $1,426 $1,426 $856 Addition to LE, test socket, BK L5620 0274 $1,266 $1,266 $760 Addition to LE, test socket, Knee disartic L5622 0274 $1,313 $1,313 $788 Addition to LE, test socket, AK L5624 0274 $1,312 $1,312 $787 Addition to LE, test socket, Hip disartic L5626 0274 $2,018 $2,018 $1,211 Addition to LE, test socket, Hemipel L5628 0274 $2,044 $2,044 $1,226 Addition to LE, BK, acrylic socket L5629 0274 $1,345 $1,345 $807 Addition to LE, Symes type, expandable wall socket L5630 0274 $1,448 $1,448 $869 Addition to LE, AK or knee disartic, acrylic socke L5631 0274 $1,436 $1,436 $862 Addition to LE, Symes type, ""PTB"" brim socket de L5632 0274 $1,152 $1,152 $691 Addition to LE, Symes type, posterior opening (Can L5634 0274 $1,073 $1,073 $644 Addition to LE, Symes type, medial opening socket L5636 0274 $819 $819 $491 Addition to LE, BK, total contact L5637 0274 $1,628 $1,628 $977 Addition to LE, BK, leather socket L5638 0274 $1,654 $1,654 $992 Addition to LE, BK, wood socket L5639 0274 $2,858 $2,858 $1,715 Addition to LE, knee disartic, leather socket L5640 0274 $1,879 $1,879 $1,127 Addition to LE, AK, leather socket L5642 0274 $1,741 $1,741 $1,045 Addition to LE, hip disartic, flexible inner socke L5643 0274 $6,393 $6,393 $3,836 Addition to LE, AK, wood socket L5644 0274 $1,506 $1,506 $904

Page 39 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price Addition to LE, BK flexible inner socket, external L5645 0274 $3,270 $3,270 $1,962 Addition to LE, BK, air cushion socket L5646 0274 $1,585 $1,585 $951 Addition to LE, BK, suction socket L5647 0274 $2,654 $2,654 $1,592 Addition to LE, AK, air cushion socket L5648 0274 $1,872 $1,872 $1,123 Addition to LE, ischial containment/narrow M-L soc L5649 0274 $8,225 $8,225 $4,935 Addition to LE, total contact, AK or knee disartic L5650 0274 $1,591 $1,591 $955 Addition to LE, AK, flexible inner socket, externa L5651 0274 $4,771 $4,771 $2,863 Addition to LE, suction suspension, AK or knee dis L5652 0274 $1,422 $1,422 $853 Addition to LE, knee disartic, expandable wall soc L5653 0274 $2,159 $2,159 $1,295 Addition to LE, socket insert, Synes L5654 0274 $1,284 $1,284 $770 Addition to LE, socket insert, BK (Kemblo, Pelite, L5655 0274 $930 $930 $558 Addition to LE,socket insert, knee disartic (Kembl L5656 0274 $1,413 $1,413 $848 Addition to LE, socket insert, AK (Kemblo, Pelite, L5658 0274 $2,007 $2,007 $1,204 Addition to LE, socket insert, multidurometer, Sym L5661 0274 $1,669 $1,669 $1,001 Addition to LE, socket insert, BK, silicone gel or L5661 0274 $1,669 $1,669 $1,001 Addition to LE, socket insert, knee disartic, sili L5661 0274 $1,669 $1,669 $1,001 Addition to LE, socket insert, AK, silicone gel or L5665 0274 $1,902 $1,902 $1,141 Addition to LE, BK, cuff suspension L5666 0274 $327 $327 $196 Addition to LE, BK, molded distal cushion L5668 0274 $378 $378 $227 Addition to LE, BK, molded supracondylar suspensio L5670 0274 $886 $886 $532 Addition to LE, BK/AK suspension locking mechanism L5671 0274 $2,189 $2,189 $1,313 Addition to LE, BK, removable medial brim L5672 0274 $921 $921 $553 Addition to LE, BK/AK, custom fab or prefab, socke L5673 0274 $2,639 $2,639 $1,583 Addition to LE, BK, knee joints, single axis, pair L5676 0274 $1,181 $1,181 $709 Addition to LE, BK, knee joints, polycentric, pair L5677 0274 $1,761 $1,761 $1,057 Addition to LE, BK, joint covers, pair L5678 0274 $126 $126 $76 Addit to LE, BK/AK, custom fab or prefab, socket i L5679 0274 $2,198 $2,198 $1,319 Addition to LE, BK, thigh lacer, non-molded L5680 0274 $993 $993 $596 Addit to LE, BK/AK, custom fab socket insert for c L5681 0274 $4,418 $4,418 $2,651 Addition to LE, BK, thigh lacer, gluteal/ischial, L5682 0274 $1,985 $1,985 $1,191 Addit to LE, BK/AK, custom fab socket insert for o L5683 0274 $4,418 $4,418 $2,651 Addition to LE, BK, fork strap L5684 0274 $151 $151 $91 Addition to LE, BK, suspension/sealing sleeve, w/ L5685 0274 $409 $409 $245 Addition to LE, BK, back check (extension control) L5686 0274 $186 $186 $112 Addition to LE, BK, waist belt, webbing L5688 0274 $196 $196 $118 Addition to LE, BK, waist belt, padded and lined L5690 0274 $399 $399 $239 Addition to LE, AK, pelvic control belt, light L5692 0274 $419 $419 $251 Addition to LE, AK, pelvic control belt, padded an L5694 0274 $775 $775 $465 Addition to LE, AK, pelvic control, sleeve suspens L5695 0274 $695 $695 $417 Addition to LE, AK or knee disartic, pelvic joint L5696 0274 $625 $625 $375 Addition to LE, AK or knee disarticulation, pelvic L5697 0274 $296 $296 $178 Addition to LE, AK or knee disartic, Silesian band L5698 0274 $510 $510 $306 Addition to LE, shoulder harness L5699 0274 $521 $521 $313 Replacement, socket, BK, molded to patient model L5700 0274 $10,294 $10,294 $6,176 Replacement, socket, AK/knee disartic, incl attach L5701 0274 $12,145 $12,145 $7,287 Replacement, socket, hip disartic, incl hip joint, L5702 0274 $12,378 $12,378 $7,427 L5703 Ankle, symes, molded to patient model w/o so L5703 0274 $5,953 $5,953 $3,572 Custom shaped protective cover, BK L5704 0274 $2,668 $2,668 $1,601 L5705 Custom shaped protective cover, AK L5705 0274 $3,846 $3,846 $2,308 Custom shaped protective cover, knee disartic L5706 0274 $3,570 $3,570 $2,142 Custom shaped protective cover, hip disartic L5707 0274 $4,797 $4,797 $2,878 Addition, exo knee-shin sys, single axis, manual l L5710 0274 $916 $916 $550 Addition, exo knee-shin sys, single axis, manual l L5711 0274 $1,539 $1,539 $923 Addition, exo knee-shin sys, single axis, friction L5712 0274 $1,098 $1,098 $659 Addition, exo knee-shin sys, single axis, variable L5714 0274 $1,118 $1,118 $671 Addition, exo knee-shin sys, polycentric mechanica L5716 0274 $2,209 $2,209 $1,325 Addition, exo knee-shin sys, polycentric, friction L5718 0274 $2,363 $2,363 $1,418 Addition, exo knee-shin sys, single axis, pneumati L5722 0274 $2,873 $2,873 $1,724 Addition, exo knee-shin sys, single axis, fluid sw L5724 0274 $4,461 $4,461 $2,677 Addition, exo knee-shin sys, single axis, external L5726 0274 $5,276 $5,276 $3,166 Addition, exo knee-shin sys, single axis, fluid sw L5728 0274 $6,222 $6,222 $3,733 Addition, exo knee-shin sys, single axis, pneumati L5780 0274 $3,404 $3,404 $2,042 Addition, vacuum pump, residual limb volume manage L5781 0274 $13,426 $13,426 $8,056 Addition, vacuum pump, residual limb volume manage L5782 0274 $13,462 $13,462 $8,077 Addition, exo sys, BK, ultra-light material (tita L5785 0274 $1,759 $1,759 $1,055 Addition, exo sys, AK, ultra-light material (titan L5790 0274 $2,540 $2,540 $1,524 Addition, exo sys, hip disartic, ultra-light mater L5795 0274 $3,408 $3,408 $2,045 Addition, endo knee-shin sys, single axis, manual L5810 0274 $1,867 $1,867 $1,120 Addition, endo knee-shin sys, single axis, manual L5811 0274 $2,577 $2,577 $1,546 Addition, endo knee-shin sys, single axis, frictio L5812 0274 $1,936 $1,936 $1,162 Addition, endo knee-shin sys, polycentric, hydraul L5814 0274 $12,466 $12,466 $7,480 Addition, endo knee-shin sys, polycentric, mechani L5816 0274 $2,778 $2,778 $1,667 Addition, endo knee-shin sys, polycentric, frictio L5818 0274 $3,049 $3,049 $1,829 Addition, endo knee-shin sys, single axis, pneumat L5822 0274 $5,593 $5,593 $3,356 Addition, endo knee-shin sys, single axis, fluid s L5824 0274 $5,283 $5,283 $3,170 Addition, endo knee-shin sys, single axis, hydraul L5826 0274 $8,062 $8,062 $4,837 Addition, endo knee-shin sys, single axis, fluid s L5828 0274 $9,406 $9,406 $5,644 Addition, endo knee-shin sys, single axis, pneumat L5830 0274 $5,127 $5,127 $3,076 Addition, endo knee-shin sys, 4-bar linkage or mul L5840 0274 $12,447 $12,447 $7,468

Page 40 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price Addition, endo knee-shin sys, stance flexion featu L5845 0274 $5,722 $5,722 $3,433 Addition, endo knee-shin sys, hydraulic stance ext L5848 0274 $3,431 $3,431 $2,059 Addition, endo system, AK or hip disartic, knee ex L5850 0274 $544 $544 $326 Addition, endo system, hip disartic, mechanical hi L5855 0274 $983 $983 $590 Addition to LE pros, endo knee-shin sys, microproc L5856 0274 $76,619 $76,619 $45,971 Addition to LE pros, endo knee-shin sys, microproc L5857 0274 $21,986 $21,986 $13,192 Addition to LE pros, endo knee-shin sys, microproc L5858 0274 $46,053 $46,053 $27,632 Addition to LE pros, endo knee-shin sys, powered & L5859 0274 $38,534 $38,534 $23,120 Addition, endo sys, BK, alignable system L5910 0274 $1,539 $1,539 $923 Addition, endo sys, AK or hip disartic, alignable L5920 0274 $2,253 $2,253 $1,352 Addition, endo sys, AK or knee disartic or hip dis L5925 0274 $1,065 $1,065 $639 Addition, endo sys, high activity knee control fra L5930 0274 $10,745 $10,745 $6,447 Addition, endo system, BK, ultra-light material (t L5940 0274 $2,128 $2,128 $1,277 Addition, endo sys, AK, ultra-light material (tita L5950 0274 $3,300 $3,300 $1,980 Addition, endo sys, hip disartic, ultra-light mate L5960 0274 $3,694 $3,694 $2,216 ENDO POLY HIP PNEU/HYD/ROT L5961 0274 $21,810 $21,810 $13,086 Addition, endo sys, BK, flexible protective outer L5962 0274 $2,497 $2,497 $1,498 Addition, endo sys, AK, flexible protective outer L5964 0274 $3,762 $3,762 $2,257 Addition, endo sys, hip disartic, flexible protect L5966 0274 $3,727 $3,727 $2,236 All LE prosthesis, ankle, multiaxial shock absorbi L5968 0274 $9,380 $9,380 $5,628 AK/FT POWER ASST INCL MOTORS (L5969) L5969 0274 $42,876 $42,876 $25,726 AllLE prostheses, foot, external keel, SACH foot L5970 0274 $713 $713 $428 L5971 All lower extremity prosthesis,solid ankle c L5971 0274 $693 $693 $416 All LE prostheses, flexible keel foot, (SAFE, STEN L5972 0274 $1,298 $1,298 $779 ANK-FOOT SYS DORS-PLANT FLEX L5973 0274 $46,912 $46,912 $28,147 All lLE prostheses, foot, single axis ankle foot L5974 0274 $763 $763 $458 All LE prostheses, combination single axis and fle L5975 0274 $1,478 $1,478 $887 All LE prostheses, energy storing foot (Seattle, C L5976 0274 $1,930 $1,930 $1,158 All LE prostheses, foot, multi-axial ankle/foot L5978 0274 $1,022 $1,022 $613 All LE prostheses, multi-axial ankle/foot, dynamic L5979 0274 $8,368 $8,368 $5,021 All LE prostheses, Flex-Foot system L5980 0274 $12,745 $12,745 $7,647 All LE prostheses, Flex-Walk system or equal L5981 0274 $11,451 $11,451 $6,871 All exoskeletal lower extremity prostheses, axial L5982 0274 $1,648 $1,648 $989 All endoskeletal LE prostheses, axial rotation uni L5984 0274 $2,743 $2,743 $1,646 All endoskeletal LE prostheses, dynamic prosthetic L5985 0274 $724 $724 $434 All LE prostheses, multi-axial rotation unit (""MC L5986 0274 $3,319 $3,319 $1,991 All LE prosthesis, shank foot system with vertical L5987 0274 $24,137 $24,137 $14,482 All LE prosthesis, combination vertical shock and L5988 0274 $6,703 $6,703 $4,022 Addtion to LE prosthesis, user adj heel height L5990 0274 $5,791 $5,791 $3,475 L5999 - Lower extremity prosthesis, not otherwise L5999 0274 $0 $0 $0 Partial Hand, Robin-Aids, thumb remaining, (or equ L6000 0274 $5,787 $5,787 $3,472 Partial hand, Robin-Aids, little and/or ring finge L6010 0274 $4,828 $4,828 $2,897 Partial hand, Robin-Aids, no fingers remaining (or L6020 0274 $5,833 $5,833 $3,500 PART HAND MYO EXCLU TERM DEV (L6026) L6026 0274 $13,069 $13,069 $7,841 Wrist disartic, molded socket, flexible elbow hing L6050 0274 $8,004 $8,004 $4,802 Wrist disarticulation, molded socket, flexible elb L6055 0274 $10,120 $10,120 $6,072 BE, molded socket, flexible elbow hinges, triceps L6100 0274 $8,103 $8,103 $4,862 BE, molded socket (Muenster or Northwestern suspen L6110 0274 $8,574 $8,574 $5,144 BE, molded socket (Muenster or Northwestern suspen L6120 0274 $7,460 $7,460 $4,476 L6130 BE, molded socket (Muenster or Northwestern L6130 0274 $7,865 $7,865 $4,719 Elbow disartic, molded socket, outside locking hin L6200 0274 $8,106 $8,106 $4,864 Elbow disartic, molded socket with expandable inte L6205 0274 $11,110 $11,110 $6,666 AE, molded double wall socket, internal locking el L6250 0274 $10,367 $10,367 $6,220 Shoulder disartic, molded socket, shoulder bulkhea L6300 0274 $14,168 $14,168 $8,501 Shoulder disartic, passive restoration (complete p L6310 0274 $9,901 $9,901 $5,941 Shoulder disartic, passive restoration (shoulder c L6320 0274 $6,692 $6,692 $4,015 Interscapular thoracic, molded socket, shoulder bu L6350 0274 $12,148 $12,148 $7,289 Interscapular thoracic, passive restoration (compl L6360 0274 $10,395 $10,395 $6,237 Intrascapular thoracic, passive restoration (shoul L6370 0274 $6,027 $6,027 $3,616 Immediate postsurg/early fitting, app of initial r L6380 0274 $3,486 $3,486 $2,092 Immediate postsurg/early fitting, app of initial r L6382 0274 $4,148 $4,148 $2,489 Immediate postsurg/early fitting, app of initial r L6384 0274 $5,249 $5,249 $3,149 Immediate postsurg/early fitting, each, addit cast L6386 0274 $1,152 $1,152 $691 Immediate postsurg/early fitting, app of rigid drs L6388 0274 $1,276 $1,276 $766 BE, molded socket, endo sys, incl soft prosthetic L6400 0274 $8,768 $8,768 $5,261 Elbow disartic, molded socket, endo sys, incl soft L6450 0274 $8,815 $8,815 $5,289 AE, molded socket, endo sys, incl soft prosthetic L6500 0274 $11,146 $11,146 $6,688 Shoulder disartic, molded socket, endo sys, incl s L6550 0274 $11,196 $11,196 $6,718 L6570 Shoulder disartic, molded socket, endo sys, L6570 0274 $12,511 $12,511 $7,507 Prep, wrist disartic or BE, single wall plastic so L6580 0274 $6,445 $6,445 $3,867 Prep, wrist disartic or BE, single wall plastic so L6582 0274 $5,003 $5,003 $3,002 Prep, elbow disartic or AE, single wall plastic so L6584 0274 $6,222 $6,222 $3,733 Prep, elbow disartic or AE, single wall plastic so L6586 0274 $6,222 $6,222 $3,733 Prep, shoulder disartic or interscapular thoracic, L6588 0274 $8,831 $8,831 $5,299 Prep, shoulder disartic or interscapular thoracic, L6590 0274 $7,645 $7,645 $4,587 UE additions, polycentric hinge, pair L6600 0274 $582 $582 $349 UE additions, single pivot hinge, pair L6605 0274 $745 $745 $447 UE additions, flexible metal hinge, pair L6610 0274 $565 $565 $339 Addition to UE, External power, additional switch L6611 0274 $1,313 $1,313 $788

Page 41 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price UE additions, disconnect locking wrist unit L6615 0274 $916 $916 $550 UE additions, additional disconnect insert for loc L6616 0274 $273 $273 $164 UE additions, flexion-friction wrist unit L6620 0274 $1,599 $1,599 $959 L6621 Upper extremity additions,flexion/extension L6621 0274 $7,300 $7,300 $4,380 UE additions, spring assisted rotational wrist uni L6623 0274 $2,341 $2,341 $1,405 Upper Extremity addition, flexion/extension and ro L6624 0274 $9,915 $9,915 $5,949 UE additions, rotation wrist unit with cable lock L6625 0274 $1,689 $1,689 $1,013 UE additions, quick disconnect hook adapter, Otto L6628 0274 $1,819 $1,819 $1,091 UE additions, quick disconnect lam collar with cou L6629 0274 $653 $653 $392 UE additions, stainless steel, any wrist L6630 0274 $958 $958 $575 UE addition, latex suspension sleeve, each L6632 0274 $273 $273 $164 UE addition, lift assist for elbow L6635 0274 $881 $881 $529 UE addition, nudge control elbow lock L6637 0274 $1,328 $1,328 $797 UE addition, electric lock feature, w/ manually po L6638 0274 $7,981 $7,981 $4,789 UE addition, shoulder abduction joint, pair L6640 0274 $867 $867 $520 UE addition, excursion amplifier, pulley type L6641 0274 $644 $644 $386 UE addition, excursion amplifier, lever type L6642 0274 $741 $741 $445 UE addition, shoulder flexion-abduction joint, eac L6645 0274 $1,162 $1,162 $697 UE addition, shoulder jt, multipositional lock, fl L6646 0274 $10,068 $10,068 $6,041 UE addition, shoulder lock mechanism, body powered L6647 0274 $1,656 $1,656 $994 UE addition, shoulder lock mechanism, external pow L6648 0274 $10,381 $10,381 $6,229 UE addition, shoulder universal joint, each L6650 0274 $1,260 $1,260 $756 UE addition, standard control cable, extra L6655 0274 $327 $327 $196 UE addition, heavy duty control cable L6660 0274 $439 $439 $263 UE addition, Teflon or equal, cable lining L6665 0274 $196 $196 $118 UE addition, hook to hand, cable adapter L6670 0274 $205 $205 $123 UE addition, harness, chest or shoulder, saddle ty L6672 0274 $933 $933 $560 UE addition, harness, figure of 8 type, for single L6675 0274 $510 $510 $306 UE addition, harness, figure of 8 type, for dual c L6676 0274 $534 $534 $320 L6677 Upper extremity addition,harness,triple cont L6677 0274 $730 $730 $438 UE addition, test socket, wrist disartic or BE L6680 0274 $1,313 $1,313 $788 UE addition, test socket, elbow disartic or AE L6682 0274 $1,450 $1,450 $870 UE addition, test socket, shoulder disartic or int L6684 0274 $1,476 $1,476 $886 UE addition, suction socket L6686 0274 $2,925 $2,925 $1,755 UE addition, frame type socket, BE or wrist disart L6687 0274 $1,929 $1,929 $1,157 UE addition, frame type socket, AE or elbow disart L6688 0274 $2,130 $2,130 $1,278 UE addition, frame type socket, shoulder disartic L6689 0274 $2,480 $2,480 $1,488 UE addition, frame type socket, interscapular-thor L6690 0274 $2,298 $2,298 $1,379 UE addition, removable insert L6691 0274 $1,501 $1,501 $901 UE addition, silicone gel insert or equal, each L6692 0274 $2,041 $2,041 $1,225 UE addition, external locking elbow, forearm count L6693 0274 $9,525 $9,525 $5,715 UE Addition, BE/AE, custom fab from mold or prefab L6694 0274 $2,639 $2,639 $1,583 UE Addition, BE/AE, custom fab from mold or prefab L6695 0274 $1,690 $1,690 $1,014 UE Addition, BE/AE, custom fab socket insert for c L6696 0274 $3,395 $3,395 $2,037 UE Addition, BE/AE, custom fab socket insert for o L6697 0274 $3,395 $3,395 $2,037 UE Addition, BE/AE suspension locking mech, exclud L6698 0274 $2,189 $2,189 $1,313 Terminal device, hand, passive hand L6703 0274 $1,497 $1,497 $898 Terminal device, hook, Dorrance or equal, model #6 L6704 0274 $3,247 $3,247 $1,948 Terminal device, hook, Dorrance or equal, model #5 L6706 0274 $1,910 $1,910 $1,146 Terminal device, hook, TRS Grip, Grip III, VC or e L6707 0274 $4,730 $4,730 $2,838 Terminal device, hand, Bock, VO L6708 0274 $3,127 $3,127 $1,876 Terminal device, hand, Bock, VC L6709 0274 $4,437 $4,437 $2,662 PED TERM DEV HOOK VOL OPEN L6711 0274 $2,147 $2,147 $1,288 PED TERM DEV HOOK VOL CLOS L6712 L6712 0274 $3,433 $3,433 $2,060 Terminal Device, Hand, Mechanical, Voluntary Openi L6713 0274 $5,237 $5,237 $3,142 L6714 Terminal device, hand, VC, pediatric L6714 0274 $4,224 $4,224 $2,534 Term Device, Multi Art Digit L6715 0274 $9,105 $9,105 $5,463 HOOK/HAND HVY DTY VOL OPEN L6721 0274 $5,958 $5,958 $3,575 HOOK/HAND HVY DTY VOL CLOS L6722 0274 $6,477 $6,477 $3,886 Terminal device, modifier wrist flexion L6805 0274 $1,635 $1,635 $981 Terminal device, pincher tool, Otto Bock or equal L6810 0274 $650 $650 $390 L6880 ELEC HAND IND ART DIGITS L6880 0274 $75,009 $75,009 $45,005 Automatic grasp feature, addition to upper-limb pr L6881 0274 $13,718 $13,718 $8,231 Microproc control feature, addtion to upper-limb p L6882 0274 $9,898 $9,898 $5,939 L6883 Replacement socket,below elbow/wrist disarti L6883 0274 $9,510 $9,510 $5,706 L6884 Replacement socket,above elbow/elbow disarti L6884 0274 $6,414 $6,414 $3,848 L6885 Replacement socket,shoulder disarticulation/ L6885 0274 $9,966 $9,966 $5,980 UE Pros Addition, glove for terminal device, any m L6890 0274 $670 $670 $402 L6895 UE Pros Addition, glove for terminal device, L6895 0274 $2,131 $2,131 $1,279 Hand restoration (incl cast/shade/measure), partia L6900 0274 $5,006 $5,006 $3,004 Hand restoration (incl cast/shade/measure), partia L6905 0274 $4,952 $4,952 $2,971 Hand restoration (incl cast/shade/measure), partia L6910 0274 $4,873 $4,873 $2,924 Hand restoration (incl cast/sahde/measure), replac L6915 0274 $2,586 $2,586 $1,552 Wrist disartic, ext power, self-susp inner socket, L6920 0274 $21,623 $21,623 $12,974 Wrist disartic, ext power, self-susp inner socket, L6925 0274 $23,097 $23,097 $13,858 be, ext power, self-susp inner socket, remov shell L6930 0274 $20,826 $20,826 $12,496 BE, ext power, self-susp inner socket, remov shell L6935 0274 $28,431 $28,431 $17,059 Elbow disartic, ext power, molded inner socket, re L6940 0274 $26,892 $26,892 $16,135 Elbow disartic, ext power, molded inner socket, re L6945 0274 $30,002 $30,002 $18,001

Page 42 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price AE, ext power, molded inner socket, remov shell, i L6950 0274 $33,195 $33,195 $19,917 AE, ext power, molded inner socket, remov shell, i L6955 0274 $31,128 $31,128 $18,677 Shoulder disartic, ext power, molded inner socket, L6960 0274 $40,492 $40,492 $24,295 Shoulder disartic, ext power, molded inner socket, L6965 0274 $47,968 $47,968 $28,781 Intrerscapular-thoracic, ext power, molded inner s L6970 0274 $41,520 $41,520 $24,912 Interscapular-thoracic, ext power, molded inner so L6975 0274 $45,769 $45,769 $27,461 Electronic hand, Otto Bock, Steeper or equal switc L7007 0274 $12,189 $12,189 $7,313 Electronic hand, System Teknik, Variety Village or L7008 0274 $18,077 $18,077 $10,846 Electronic Greifer, Otto Bock or equal, myoelectro L7009 0274 $11,926 $11,926 $7,156 Prehensile actuator, Hosmer or equal, switch contr L7040 0274 $7,852 $7,852 $4,711 Electronic hook, child, Michigan or equal, switch L7045 0274 $4,145 $4,145 $2,487 Electronic elbow, Hosmer or equal, switch controll L7170 0274 $15,526 $15,526 $9,316 Electronic elbow, microproc sequential control of L7180 0274 $100,451 $100,451 $60,271 Electronic elbow, microproc simultaneous control o L7181 0274 $110,931 $110,931 $66,559 Electronic elbow, adolescent, Variety Village or e L7185 0274 $16,326 $16,326 $9,796 Electronic elbow, child, Variety Village or equal, L7186 0274 $33,935 $33,935 $20,361 Electronic elbow, adolescent, Variety Village or e L7190 0274 $21,659 $21,659 $12,995 Electronic elbow, child, Variety Village or equal, L7191 0274 $28,865 $28,865 $17,319 Electronic Wrist Rotator Any L7259 0274 $11,819 $11,819 $7,091 Six volt battery, Otto Bock or equal, each L7360 0274 $845 $845 $507 Battery Charger, six volt, Otto Bock or equal L7362 0274 $921 $921 $553 Twelve volt battery, Utah or equal, each L7364 0274 $1,320 $1,320 $792 Battery Charger, twelve volt, Utah or equal L7366 0274 $1,817 $1,817 $1,090 Lithium ion battery, replacement L7367 0274 $1,243 $1,243 $746 Lithium ion battery, charger L7368 0274 $1,611 $1,611 $967 L7400 Addition to upper extremity prosthesis,below L7400 0274 $981 $981 $589 L7401 Addition to upper extremity prosthesis,above L7401 0274 $1,096 $1,096 $658 L7402 Addition to upper extremity prosthesis,shoul L7402 0274 $1,181 $1,181 $709 L7403 Addition to upper extremity prosthesis,below L7403 0274 $1,176 $1,176 $706 L7404 Addition to upper extremity prosthesis,above L7404 0274 $1,774 $1,774 $1,064 L7405 Addition to upper extremity prosthesis,shoul L7405 0274 $2,320 $2,320 $1,392 Charger, Hosmer L7499 0274 $164 $164 $98 Fast Charger L7499 0274 $1,553 $1,553 $932 Rocker Switch L7499 0274 $887 $887 $532 Recondition VV Hand L7499 0274 $5,913 $5,913 $3,548 Band Applicator L7499 0274 $132 $132 $79 Reciprocator L7499 0274 $1,595 $1,595 $957 Infant Above Elbow L7499 0274 $6,749 $6,749 $4,049 SA Circuit L7499 0274 $1,302 $1,302 $781 NU Pro Control L7499 0274 $8,551 $8,551 $5,131 Repair of prosthetic device, repair or replace min L7510 0274 $0 $0 $0 Repair of prosthetic device, labor component, per L7520 0274 $134 $134 $80 L7600 Prosthetic donning sleeve, any material, ea L7600 0274 $171 $171 $103 L7700 Gasket or seal, for use with prosthetic sock L7700 0274 $388 $388 $233 Prosthetic sheath, below knee, each L8400 0274 $54 $54 $32 Prosthetic sheath, above knee, each L8410 0274 $68 $68 $41 Prosthetic sheath, upper limb, each L8415 0274 $68 $68 $41 Prosthetic sheath/sock, including a gel cushion la L8417 0274 $254 $254 $152 Prosthetic sock, multiple ply, below knee, each L8420 0274 $68 $68 $41 Prosthetic sock, multiple ply, above knee, each L8430 0274 $78 $78 $47 Prosthetic sock, multiple ply, upper limb, each L8435 0274 $71 $71 $43 Prosthetic shrinker, below knee, each L8440 0274 $149 $149 $89 Prosthetic shrinker, above knee, each L8460 0274 $213 $213 $128 Prosthetic shrinker, upper limb, each L8465 0274 $196 $196 $118 Prosthetic sock, single ply fitting, below knee, e L8470 0274 $24 $24 $14 Prosthetic sock, single ply fitting, above knee, e L8480 0274 $34 $34 $20 Prosthetic sock, single ply, upper limb, each L8485 0274 $40 $40 $24 Unlisted procedure for miscellaneous prosthetic se L8499 0274 $0 $0 $0 Below Knee Nylon Hose PR L8499 0274 $54 $54 $32 Above Knee Nylon Hose PR L8499 0274 $88 $88 $53 Above Knee Suction Sheath L8499 0274 $139 $139 $83 Hypobaric Sheath L8499 0274 $149 $149 $89 Hypobaric Wool L8499 0274 $198 $198 $119 Tube Sock L8499 0274 $7 $7 $4 Powered UE Orthosis, Elbow Wrist Hand, Custom L8701 0274 $48,064 $48,064 $28,838 Powered UE Orthosis, Elbow Wrist Hand Finger, Cust L8702 0274 $91,582 $91,582 $54,949 Miscellaneous Prosthetic or Orthotic Supply, Acces L9900 0274 $0 $0 $0 Blood, Split Unit, 175 cc P9011 0390 $414 $373 $787 $472 Blood, split unit, 175 mL P9011 0390 $381 $381 $229 Cryoprecipitate Charge P9012 0390 $96 $96 $58 Red Blood Cells, Leukoreduced P9016 0390 $618 $557 $1,175 $705 RBC, LR, each unit P9016 0390 $593 $536 $1,129 $677 Platelets for Transfusion, each unit P9019 0390 $338 $305 $643 $386 Platelets for transfusion, each unit P9019 0390 $311 $311 $187 RBC's for Transfusion, each unit P9021 0390 $531 $479 $1,010 $606 RBC's Autologous, each unit P9021 0390 $773 $697 $1,470 $882 RBC's for transfusion, each unit P9021 0390 $486 $486 $292 RBC's for Transfusion, Washed, each unit P9022 0390 $768 $692 $1,460 $876 RBC's for transfusion,washed,each unit P9022 0390 $703 $703 $422

Page 43 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price Platelets for Transfusion, Leukoreduced, each unit P9031 0390 $295 $266 $561 $337 Platelets for transfusion, leukoreduced,each unit P9031 0390 $270 $270 $162 RBC's Leukoreduced P9031 0390 $567 $567 $340 Platelets for Transfusion, Irradiated, each unit P9032 0390 $295 $266 $561 $337 Platelets for Transfusion, Leukoreduced, Irradiate P9033 0390 $382 $344 $726 $436 Platelets for transfusion,leukoreduced,irradiated P9033 0390 $351 $351 $211 Platelet Pheresis P9034 0390 $1,555 $1,403 $2,958 $1,775 Platelet Pheresis, Leukoreduced P9035 0390 $1,607 $1,449 $3,056 $1,834 Platelets, PRH, LR, each unit P9035 0390 $1,484 $1,484 $890 Platelet Pheresis, Irradiated P9036 0390 $1,339 $1,208 $2,547 $1,528 Platelet Pheresis, Leukoreduced each unit P9037 0390 $2,116 $1,909 $4,025 $2,415 Platelet Pheresis, Leukoreduced, Irradiated P9037 0390 $2,116 $1,909 $4,025 $2,415 Platelets, PHR, LR, IR, each unit P9037 0390 $1,984 $1,984 $1,190 RBC's Irradiated, each unit P9038 0390 $710 $641 $1,351 $811 RBC's, irradiated, each unit P9038 0390 $651 $651 $391 RBC's Irradiated, leukoreduced each unit P9040 0390 $818 $737 $1,555 $933 RBC's,irradiated,leukoreduced,each unit P9040 0390 $750 $750 $450 Fresh Frozen Plasma P9059 0390 $231 $208 $439 $263 Fresh Frozen Plasma Charge P9059 0390 $213 $213 $128 Telehealth Facility Fee Q3014 0780 $198 $198 $119 Oasis wound matrix skin sub per sq cm (Q4102) Q4102 0636 $40 $40 $24 THERASKIN BVR 2 x 3IN Q4121 0636 $5,175 $5,175 $3,105 THERASKIN 1.00 in X 1.00 in Q4121 0636 $2,473 $2,473 $1,484 THERASKIN 1.00 in x 2.00 in Q4121 0636 $2,245 $2,245 $1,347 Gastrografin 30ml Q9963 0320 $90 $90 $54 PFS Interpreter T1013 0990 $0 $0 $0 PFS Transportation T2003 0990 $0 $0 $0 Affiliates On Site Technical Charge tc99213 0510 $264 $264 $158 Pain Program Full Day 0270 $40 $40 $24 Pain Program Half Day 0270 $28 $28 $17 RIC Laboratory Bench 0301 $1 $1 $2 $1 Equipment-Bariatric Bed 0270 $693 $693 $416 Equipment-Clinitron Specialty Bed 0270 $618 $618 $371 Equipment-Leg CPM (OrthoRehab) 0270 $231 $231 $139 Equipment-Heat Therapy Pump 0270 $153 $153 $92 Equipment-KCI Wound Vac 0270 $628 $628 $377 Equipment Care-E-Vac II W Battery, Table Top,Porta 0270 $22 $22 $13 Equipment-Instavac II Aspirator Suction Machine (E 0270 $22 $22 $13 Equipment-Flowtron Excel Leg Pneumatic Compression 0270 $139 $139 $83 Private Duty Nursing 0989 $64 $64 $38 Immunoglobulins, Quantitative IgA, IgG, IgM 0301 $903 $815 $1,718 $1,031 Knee Orthosis, Elastic w/ Stays 0274 $302 $302 $181 Knee Orthosis, Elastic w/ Conylar Pads 0274 $216 $216 $130 Rib Belt, Thoracic 0274 $108 $108 $65 Goal Post Style Joystick 0274 $66 $66 $40 ROOM/BED: LOA 0183 $0 $0 $0 Equipment-Flexicare Specialty Bed (Hill Rom) 0270 $712 $712 $427 Diabetisource AC 0250 $7 $7 $4 Enfamil 20 kcal 0250 $15 $15 $9 Enfamil 24 kcal 0250 $15 $15 $9 Fibersource HN 0250 $7 $7 $4 Isocal HN 0250 $3 $3 $2 Kindercal with Fiber 0250 $4 $4 $2 Resource 2.0 0250 $7 $7 $4 Resource Pulmonary 0250 $7 $7 $4 Resource Renal 0250 $7 $7 $4 Pedialyte 0250 $4 $4 $2 Pediasure 0250 $6 $6 $4 Pediasure with fiber 0250 $6 $6 $4 Peptamen Jr. 0250 $7 $7 $4 Resource Fruit Beverage- Peach 0250 $4 $4 $2 Resource Fruit Beverage- Berry 0250 $4 $4 $2 Resource Fruit Beverage- Orange 0250 $4 $4 $2 Traumacal 0250 $5 $5 $3 Glucerna- Chocolate 0250 $7 $7 $4 Glucerna- Vanilla 0250 $7 $7 $4 Isosource 0250 $7 $7 $4 Isosource 1.5 0250 $7 $7 $4 Crucial 0250 $7 $7 $4 Thicken Up 0250 $7 $7 $4 Equipment-Infusion Pump-PCU 0261 $213 $213 $128 Equipment-Overlay Low Air Loss Mattress 0270 $106 $106 $64 Equipment-Bariatric Overylay Low Air Loss Mattress 0270 $380 $380 $228 Equipment-Enclosure Canopy Posey 8050 0270 $337 $337 $202 AEROCHAMBER MV (USE W/MANU VENT) 0270 $61 $61 $37 AEROCHAMBER PLUS (USE W/MOUTHPC) 0270 $46 $46 $28 AEROCHAMBER W/LARGE MASK 0270 $94 $94 $56 AEROCHAMBER W/MEDIUM MASK 0270 $91 $91 $55 AEROCHAMBER W/SMALL MASK 0270 $117 $117 $70

Page 44 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price AEROTRACH PLUS (USE W/TRACH) 0270 $74 $74 $44 APATER FEEDING DUAL PORT 0270 $73 $73 $44 AVOGEL 8IN X 8IN SINGLE 0270 $201 $201 $121 BAG FEED GASTRIC GRAVITY 1000ML 0270 $14 $14 $8 LEG BAG: WITH LOWER LEG LATEX STRAPS BARD 0270 $24 $24 $14 HIGH OUTPUT DEPENDENT DRAINAGE BAG 0270 $38 $38 $23 BANDAGE COMPRILAN 6 CM LYMPHEDEMA 0270 $44 $44 $26 BANDAGE COMPRILAN 10CM LYMPHEDEMA 0270 $73 $73 $44 BANDAGE COMPRILAN 12CM LYMPHEDEMA 0270 $88 $88 $53 BANDAGE ELASTINET SURGILAST SZ-1 0270 $43 $43 $26 BANDAGE ELASTINET SURGILAST SZ-10 0270 $175 $175 $105 BANDAGE ELASTINET SURGILAST SZ-2 0270 $45 $45 $27 BANDAGE ELASTINET SURGILAST SZ-3 0270 $55 $55 $33 BANDAGE ELASTINET SURGILAST SZ-4 0270 $66 $66 $40 BANDAGE ELASTINET SURGILAST SZ-5 0270 $72 $72 $43 BANDAGE ELASTINET SURGILAST SZ-6 0270 $79 $79 $47 BANDAGE ELASTINET SURGILAST SZ-8 0270 $136 $136 $82 BANDAGE ELASTINET SURGILAST SZ-9 0270 $157 $157 $94 BANDAGE GAUZE KERLIX 4.5IN X 4YDS 0270 $6 $6 $4 BELT OSTOMY 0270 $29 $29 $17 BINDER ABDOMINAL LF LG 10IN 0270 $106 $106 $64 BINDER ABDOMINAL LF LG 8IN 0270 $91 $91 $55 BINDER ABDOMINAL LF MED 10IN 0270 $106 $106 $64 BINDER ABDOMINAL LF MED 8IN 0270 $91 $91 $55 BINDER ABDOMINAL LF SM 8IN 0270 $91 $91 $55 BINDER ABDOMINAL LF XL 8IN 0270 $99 $99 $59 BOARD SLIDING AIDE ALL 24IN 0270 $321 $321 $193 BOARD SLIDING REG 1/2IN X 8IN X 24IN 0270 $191 $191 $115 BUTTON TRACH SZ-10CM X 27CM 0270 $1,180 $1,180 $708 BUTTON TRACH SZ-10CM X 40CM 0270 $1,102 $1,102 $661 BUTTON TRACH SZ-11CM X 27CM 0270 $555 $555 $333 BUTTON TRACH SZ-11CM X 40CM 0270 $1,310 $1,310 $786 BUTTON TRACH SZ-12CM X 27CM 0270 $1,310 $1,310 $786 BUTTON TRACH SZ-12CM X 40CM 0270 $1,310 $1,310 $786 BUTTON TRACH SZ-9CM X 27CM 0270 $795 $795 $477 BUTTON TRACH SZ-9CM X 40CM 0270 $1,310 $1,310 $786 CANISTER SUCTION 1200ML 0270 $10 $10 $6 CANISTER SUCTION 2000ML 0270 $10 $10 $6 CATHETER 100% SILICONE 24FR 5CC 0270 $63 $63 $38 CATHETER ALL PURPOSE URETHRAL STRAIGHT 14FR 0270 $7 $7 $4 CATHETER ALL PURPOSE URETHRAL STRAIGHT 16FR 0270 $5 $5 $3 CATHETER ALL PURPOSE URETHRAL STRAIGHT 18FR 0270 $5 $5 $3 CATHETER CLEAN ULTRA M/F 16IN 14FR 0270 $7 $7 $4 CATHETER COUDE TAPPERED TIP SELF 10FR 0270 $10 $10 $6 CATHETER COUDE TIP FUNNEL END SELF 14FR 0270 $7 $7 $4 CATHETER EXTERNAL INTERMEDIATE 0270 $7 $7 $4 CATHETER EXTERNAL LG 0270 $7 $7 $4 CATHETER EXTERNAL MED 0270 $7 $7 $4 CATHETER EXTERNAL SM 0270 $7 $7 $4 CATHETER FOLEY 100% SILICONE 14FR 5CC-10CC 0270 $44 $44 $26 CATHETER FOLEY 100% SILICONE 16FR 5CC-10CC 0270 $37 $37 $22 CATHETER FOLEY 100% SILICONE 20FR 30CC 0270 $52 $52 $31 CATHETER FOLEY 16FR 5CC 0270 $55 $55 $33 CATHETER FOLEY COUDE TIP 16FR 5CC-10CC 0270 $38 $38 $23 CATHETER FOLEY SILICONE 20FR 5CC 0270 $37 $37 $22 CATHETER FOLEY SILICONE COATED 16FR 5CC-10CC 0270 $6 $6 $4 CATHETER FOLEY SILICONE COATED 18FR 5CC-10CC 0270 $6 $6 $4 CATHETER FOLEY SILICONE ELASTOMER COATED 5CC-10CC 0270 $6 $6 $4 CATHETER SELF COUDE OLIVE TIP FUNNEL END 8FR 0270 $7 $7 $4 CATHETER SELF COUDE TAPERED TIP FUNNEL END 8FR 0270 $27 $27 $16 CATHETER SUCTION/VENT RED RUBBER 10-12FR 0270 $6 $6 $4 CATHETER SUCTION/VENT RED RUBBER 14-16FR 0270 $6 $6 $4 CLAMP OSTOMY 0270 $13 $13 $8 CLEANSER HIBICLENS ANTIMICROBIAL 4-OZ 0270 $14 $14 $8 COLLECTOR MID STREAM 0270 $6 $6 $4 CONNECTOR VAC DRAIN Y-TYPE 10-PK 0270 $13 $13 $8 CONNECTOR W/GLOW RING CLAVE 0270 $27 $27 $16 CREAM LANTISEPTIC THERAPEUTIC 0270 $31 $31 $19 CREAM TRIPLE CARE EPC 7.75-OZ TUBE 0270 $79 $79 $47 DEORDORANT BANISH OSTOMY BTL 1-1/4-OZ 0270 $71 $71 $43 DIAPER BRIEF ADULT XXL 0270 $149 $149 $89 DRESSING 15CM X 20 CM TEGADERM 0270 $14 $14 $8 DRESSING 8IN X 9IN DUODERM 0270 $100 $100 $60 DRESSING BURN 9IN X 15IN EXU-DRY 0270 $34 $34 $20 DRESSING STERI STRIP 1/2IN X 4IN 0270 $6 $6 $4 DRESSING TRACHEOSTOMY 3.5INX 3.5IN ALLEVYN 0270 $31 $31 $19 DRESSING XEROFORM 4IN X 3YDS 0270 $31 $31 $19 OSTOMY, SEAL COHESIVE EAKIN LARGE 0270 $33 $33 $20 OSTOMY, SEAL COHESIVE EAKIN SMALL 0270 $30 $30 $18

Page 45 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price ELECTRODE SILVER MACTROD 0270 $28 $28 $17 ENEMA MINERAL OIL 4.5-OZ 0270 $6 $6 $4 FILTER BACTERIAL 0270 $38 $38 $23 FLEXION MITT ROYLAN BEIGE MED 0270 $65 $65 $39 INCENTIVE SPIROMETER 0270 $31 $31 $19 KIT BLOOD GAS W/SAFETY CATH 3CC 0270 $7 $7 $4 KIT CATHETER SUCTION W/NACL 10FR 0270 $6 $6 $4 KIT CATHETER SUCTION W/NACL 12FR 0270 $6 $6 $4 KIT CATHETER SUCTION W/NACL 14FR 0270 $6 $6 $4 KIT CATHETER SUCTION W/NACL 8FR 0270 $7 $7 $4 KIT CATHETER TOUCHLESS FOR INTERMITTENT UNISEX 14F 0270 $22 $22 $13 KIT IRRIGATION 60CC 0270 $10 $10 $6 KIT STAPLE REMOVER 0270 $6 $6 $4 KIT SUTURE REMOVER 0270 $5 $5 $3 KIT TRACHEOSTOMY CARE 0270 $7 $7 $4 LUBRICATING JELLY SURGILUBE FLIP-TOP 4.25-OZ TUBE 0270 $7 $7 $4 MIRROR LONG HANDLE HAND HELD 0270 $127 $127 $76 PROTECTIVE OINTMENT BARRIER GEL PO 4.6oz 0270 $34 $34 $20 PAD DECUBIOUS 30IN X 60IN 0270 $73 $73 $44 PAD ELBOW HEEL PROTECTOR WHITE LG 0270 $50 $50 $30 PAD EYE CURVED BLACK W/ELASTIC STRAP 0270 $6 $6 $4 THERMAL PAD 0270 $43 $43 $26 OSTOMY, STOMAHESVE PASTE EACH 0270 $41 $41 $25 PLUG CLOSURE FLANGE 10MM 0270 $343 $343 $206 PLUG CLOSURE FLANGE 12MM 0270 $343 $343 $206 PLUG CLOSURE FLANGE 9MM 0270 $343 $343 $206 OSTOMY, STOMAHESIVE POWDER EACH 0270 $30 $30 $18 PULL UP BRIEF DIAPER ADULT PROTECTION PLUS LG 0270 $120 $120 $72 PULL UP BRIEF DIAPER ADULT PROTECTION PLUS MED 0270 $120 $120 $72 SALINE IRRIGATION 0.90% STERILE 1000ML 0270 $7 $7 $4 SCALPEL STERILE DISPOSABLE #10 0270 $10 $10 $6 SCALPEL STERILE DISPOSABLE #11 0270 $13 $13 $8 SCALPEL STERILE DISPOSABLE #15 0270 $13 $13 $8 SHOELACE ELASTIC BLACK 24IN 0270 $7 $7 $4 SLING GIVMOHR LG 0279 $319 $319 $191 SLING GIVMOHR M 0279 $330 $330 $198 SLING GIVMOHR SMALL 0270 $330 $330 $198 SLIPPER DBL TREAD LG BEIGE 0279 $27 $27 $16 SLIPPER DBL TREAD MD BLUE 0270 $30 $30 $18 SLIPPER DBL TREAD SM YELLOW 0279 $14 $14 $8 SLIPPER DBL TREAD XLG GREY 0279 $28 $28 $17 SLIPPER DBL TREAD XXL GREEN 0279 $14 $14 $8 SPRAY ADHESIVE MEDICAL 3.2-OZ 0270 $108 $108 $65 THIGH STRAP: VELCRO STRAP 0270 $34 $34 $20 SWIMSUIT WOMEN SZ-32 0270 $111 $111 $67 SWIMSUIT WOMEN SZ-34 0270 $111 $111 $67 SWIMSUIT WOMEN SZ-36 0270 $111 $111 $67 SWIMSUIT WOMEN SZ-38 0270 $111 $111 $67 SWIMSUIT WOMEN SZ-40 0270 $111 $111 $67 SWIMSUIT WOMEN SZ-42 0270 $111 $111 $67 SWIMSUIT WOMEN SZ-44 0270 $111 $111 $67 SWIMSUIT WOMEN SZ-46 0270 $111 $111 $67 SWIMSUIT WOMEN SZ-48 0270 $111 $111 $67 SWIMSUIT WOMEN SZ-50 0270 $111 $111 $67 SWIMSUIT WOMEN SZ-52 0270 $111 $111 $67 SWIMSUIT WOMEN SZ-54 0270 $111 $111 $67 SWIMTRUNK MENS LG 0270 $121 $121 $73 SWIMTRUNK MENS MED 0270 $121 $121 $73 SWIMTRUNK MENS SZ-SM 0270 $121 $121 $73 SWIMTRUNK MENS XLG 0270 $121 $121 $73 SWIMTRUNK MENS XXL 0270 $138 $138 $83 TAPE HYPAFIX 2IN X 10YDS 0270 $55 $55 $33 TIE TRACHEOSTOMY LARGE 0270 $14 $14 $8 TIE TRACHEOSTOMY MEDIUM 0270 $14 $14 $8 TIE TRACHEOSTOMY SMALL 0270 $14 $14 $8 TOPICAL GEL SHEETS 4IN X 6IN 5/BX 0270 $183 $183 $110 TRACH DCP #6 0270 $31 $31 $19 TRACH DCP #8 0270 $31 $31 $19 TRACH DIC #6 0270 $28 $28 $17 TRACH DIC #8 0270 $28 $28 $17 TRACH TUBE # 3.0 PED 0270 $213 $213 $128 TRACH TUBE # 5.0 PED 0270 $238 $238 $143 TRACH TUBE # 5.5 PED 0270 $218 $218 $131 TRACH TUBE # 8 SCT 0270 $214 $214 $128 TRACH TUBE # 9 SCT 0270 $214 $214 $128 TRACH TUBE CFN # 6 0270 $300 $300 $180 TRACH TUBE CFN # 8 0270 $280 $280 $168 TRACH TUBE CFS # 4 0270 $274 $274 $164 TRACH TUBE CFS # 6 78MM CUFFLESS ADULT 0270 $274 $274 $164

Page 46 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price TRACH TUBE CUFFLESS # 5 BIVONA 0270 $423 $423 $254 TRACH TUBE CUFFLESS # 6 BIVONA 0270 $357 $357 $214 TRACH TUBE CUFFLESS # 7 BIVONA 0270 $356 $356 $214 TRACH TUBE CUFFLESS # 8 BIVONA 0270 $356 $356 $214 TRACH TUBE CUFFLESS # 9 BIVONA 0270 $423 $423 $254 TRACH TUBE CUFFLESS PEDS # 4.0 0270 $416 $416 $250 TRACH TUBE CUFFLESS PEDS # 4.5 0279 $370 $370 $222 TRACH TUBE FLEXTEND CUFFLESS PEDS # 5.0 0270 $980 $980 $588 TRACH TUBE LPC # 4 0270 $319 $319 $191 TRACH TUBE LPC # 6 0270 $319 $319 $191 TRACH TUBE LPC # 8 0270 $319 $319 $191 TRACH TUBE SLEEP APNEA # 6.0MM BIVONA 0270 $429 $429 $257 TRACH TUBE TTS # 6 BIVONA 0270 $484 $484 $290 TRACH TUBE TTS # 7 BIVONA 0270 $484 $484 $290 TRACH TUBE TTS # 7.5 BIVONA 0270 $484 $484 $290 TRACH TUBE TTS # 8 BIVONA 0270 $366 $366 $220 TRACH TUBE TTS # 8.5 BIVONA 0270 $561 $561 $337 TRACH TUBE TTS # 9.0 BIVONA 0270 $458 $458 $275 TRAP MUCOUS SPECIMEN 80CC 0270 $14 $14 $8 TRAY CATHETER FOLEY SILIC-ELAST 16FR 5CC-10CC 0270 $31 $31 $19 TRAY CATHETER URETHAL 15FR 0270 $13 $13 $8 TRAY INCISION & DRAINAGE 0270 $79 $79 $47 TRAY KIT FOLEY INSERTION 0270 $22 $22 $13 TRAY LUMBAR PUNCTURE ADULT 20G 0270 $190 $190 $114 TRAY SHARP DEBRIDEMENT 0270 $29 $29 $17 TUBE ENTERIC DOBHOFF 8FR 43 0270 $77 $77 $46 TUBE FEEDING INDWELLING 8FR 42IN 0270 $34 $34 $20 TUBE GAST BALLOON MIC 12FR 5CC 0270 $216 $216 $130 TUBE GAST BALLOON MIC 14FR 20CC 0270 $216 $216 $130 TUBE GAST BALLOON MIC 16FR 20CC 0270 $262 $262 $157 TUBE GAST BALLOON MIC 18FR 20CC 0270 $309 $309 $185 TUBE GAST BALLOON MIC 24FR 20CC 0270 $216 $216 $130 TUBE MIC LOW PROFILE GASTROSTOMY FEEDING 14FR 1.5C 0270 $555 $555 $333 TUBE SUCTION NOSEATTACH DEVICE 5-18FR 0270 $33 $33 $20 LEG BAG: EXTENSION TUBING FOR BARD LEG BAG (LATEX 0270 $6 $6 $4 TUBE SUCTION HANDLE AND COVERED YANKAUER 0270 $27 $27 $16 TUBE TRACHEOSTOMY TUBE HOLDER ALL SIZE 0270 $29 $29 $17 URINAL FEMALE 0270 $31 $31 $19 WATER IRRIGATION STERILE 250ML 0270 $7 $7 $4 WIPE, BABY FLUSHABLE 0270 $10 $10 $6 WRAP ELASTIC BANDAGE LF W/VELCRO 4IN X 5YARD 0270 $33 $33 $20 INFUSION PUMP- PCU 0270 $213 $213 $128 KANGAROO E-PUMP ENTERNAL FEEDING PUMP 0270 $169 $169 $101 PNEUMATIC COMPRESSION PUMP 0270 $139 $139 $83 CARE-E-VAC II W BATTERY, TABLE TOP PORTABLE 0270 $22 $22 $13 MEDELA WOUND VAC 0270 $628 $628 $377 THERMAL MACHINE (HEATING /COOLING DEVICE) 0270 $153 $153 $92 LEG CPM MACHINE 0270 $231 $231 $139 DO NOT USE-2 0270 $366 $366 $220 ENVELLA BED (HILL ROM) 0270 $618 $618 $371 DO NOT USE-3 0270 $693 $693 $416 DO NOT USE -5 0270 $380 $380 $228 ENCLOSURE BED 0270 $337 $337 $202 Case Management 0560 $0 $0 $0 Nursing Care 0550 $0 $0 $0 Productive Activity 0420 $0 $0 $0 Clinical Staffing 0500 $0 $0 $0 Participant/Input Education Units 0942 $0 $0 $0 OSTOMY, POUCH HIGH OUTPUT DRAINABLE 1-3/4" 0270 $117 $117 $70 Arginaid 0250 $1 $1 $1 Vivonex Pediatric 0250 $7 $7 $4 MIC-KEY SECUR-LOK EXT SET 0270 $71 $71 $43 VAGINAL IRRIGATION KIT MDI 0270 $7 $7 $4 CATHETER, CATH ADAPTER STERILE 0270 $22 $22 $13 CATHETER, CATH FOLEY COUDE 5CC 14FR BARD 0270 $118 $118 $71 TRACH CFN #4 0270 $306 $306 $184 REPAIR KIT HICKMAN CATH 9.6FR 0270 $726 $726 $436 CLAMP HICKMAN SOFT JAW EDS 0270 $145 $145 $87 TRACH DIC #4 0270 $28 $28 $17 TRACH CFS #8 0270 $274 $274 $164 TRACH DCT #4 0270 $280 $280 $168 TRACH DCT #6 0270 $317 $317 $190 TRACH DCT #8 0270 $304 $304 $182 TRACH SIC #4 0270 $52 $52 $31 TRACH SIC #6 0270 $63 $63 $38 TRACH SIC #8 0270 $63 $63 $38 TRACH DCP #4 0270 $34 $34 $20 CATHETER, CATH SUCTION RED RUBBER 8FR 0270 $22 $22 $13 CATHETER, CATH FOLEY 6FR 3CC SIL ELAST 0270 $28 $28 $17

Page 47 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price CATHETER, CATH FOLEY 10FR 3CC SIL ELAST 0270 $34 $34 $20 BANDAGE COMPRILAN 8 CM LYMPHEDEMA 0270 $72 $72 $43 HOSE ANTIEMBOLISM THIGH SMALL SHORT 0270 $50 $50 $30 CATHETER, CATH FOLEY SIL-CTD LATEX 22FR 5CC-10CC 0270 $10 $10 $6 CAP DDCP 15MM W/DISP FEN CANULA 0270 $33 $33 $20 CATHETER, CATH FOLEY 8FR 3CC SIL ELASTIC 0270 $55 $55 $33 FEED TUBE 10FR 36" STYLETE ULTR 0270 $129 $129 $77 TRACH CARE - 72 CLOSED SUCTION SYSTEM 14FR 0270 $191 $191 $115 TRACH CARE 72 CLOSED SUCTION SYSTEM 12FR 0270 $191 $191 $115 PULL-UP ADULT PROTECT PLUS XL 48" - 68" 0270 $115 $115 $69 CATHETER FOLEY SIL-CTD LTX 20FR 5CC-10CC 0270 $13 $13 $8 IVAC PROBE RECTAL TEMP PLUS 2880A 0270 $29 $29 $17 PROBE OXISENSOR D-25 0270 $148 $148 $89 IRRIGATION SYSTEM VISI-FLOW 0270 $304 $304 $182 DRESSING EXU-DRY 3" X 4" 0270 $7 $7 $4 WOUND VEIL 12 X 12 0270 $22 $22 $13 TRACH SCT #7 0270 $197 $197 $118 TRACH 5.5 PDL 0270 $233 $233 $140 CATHETER EXTERNAL WIDE BAND L 0270 $7 $7 $4 TRACH CUFFED 5.0 TTS BIVONA 0270 $1,311 $1,311 $787 Intensive Aphasia Program Daily Charge 996 0932 $996 $996 $598 HOSE COMPRESSION STOCKING JOBST 30-40MMhG SMALL 0270 $136 $136 $82 HOSE COMPRESSION MED 30-40mmHg 0270 $136 $136 $82 HOSE COMPRESSION LRG 30-40mmHg 0270 $136 $136 $82 HOSE COMPRESSION XLG 30-40mmHg 0270 $136 $136 $82 HOSE COMPRESSION SML 20-30mmHg 0270 $136 $136 $82 HOSE COMPRESSION MED 20-30mmHg 0270 $136 $136 $82 HOSE COMPRESSION LRG 20-30mmHg 0270 $136 $136 $82 HOSE COMPRESSION XLG 20-30mmHg 0270 $136 $136 $82 HOSE COMPRESSION SML 15-20mmHg 0270 $117 $117 $70 HOSE COMPRESSION MED 15-20mmHg 0270 $117 $117 $70 HOSE COMPRESSION LRG 15-20mmHg 0270 $117 $117 $70 HOSE COMPRESSION XLG 15-20mmHg 0270 $117 $117 $70 Massage Therapy 30 minutes 0990 $84 $84 $50 Massage Therapy 60 minutes 0990 $132 $132 $79 Massage Therapy 90 minutes 0990 $200 $200 $120 Intensive Aphasia Program Half Day Charge 498 0931 $498 $498 $299 International Case Managment, per hour 0998 $84 $84 $50 DO NOT USE -9 0270 $71 $71 $43 No Show/Cancellation 0996 $25 $25 $15 No Show/Cancellation-P&O 0996 $25 $25 $15 No Show/Cancellation-Program 0996 $25 $25 $15 XTRASORB SUPER ABSORBENT DRESSING 4" X 5" 0270 $14 $14 $8 XTRASORB SUPER ABSORBENT DRESSING 6" X 9" 0270 $37 $37 $22 MEDIHONEY CALCIUM ALGINATE DRESSING 4"X5" 0270 $66 $66 $40 INFUSION PUMP MODULE -LVP 0291 $55 $55 $33 CA-Additional Transforaminal Injection/Cer or Thor 0361 $1,672 $443 $2,115 $1,269 CA-Cervical/Thoracic Single Level Inj Paravert 0361 $2,871 $387 $3,258 $1,955 Oxygen Therapy Charge 0270 $125 $125 $75 Tracheostomy Tube Management Charge 0410 $144 $144 $86 Oxygen Therapy Charge 0270 $125 $125 $75 High Humidity Trach Collar Charge-Equipment 0270 $144 $144 $86 ELASTIC WRIST BRACE LARGE RIGHT 0270 $74 $74 $44 ELASTIC WRIST BRACE LARGE LEFT 0270 $74 $74 $44 SOCK AID 0270 $41 $41 $25 Misc. Lab Charge 0300 $0 $0 $0 $0 SUSPENSORY SCROTUM SUPPORT XLG 0270 $30 $30 $18 SUSPENSORY SCROTUM SUPPORT MED 0270 $30 $30 $18 SUSPENSORY SCROTUM SUPPORTLG 0270 $30 $30 $18 FLEXI SEAL SIGNAL FMS 0270 $1,087 $1,087 $652 FLEXI SEAL SIGNAL FMS COLLECT W/FILTER 0270 $241 $241 $145 BLISTEX LIP BALM .15oz 0271 $4 $4 $2 LACRI-LUB S.O.P. OINTMENT 3.5gm 0271 $52 $52 $31 DANDRUFF SHAMPOO 7oz 0271 $24 $24 $14 ARTIFICIAL TEARS EYE DROPS 15ML 0271 $29 $29 $17 EUCERIN CREAM 4oz 0271 $40 $40 $24 OASIS SALINE MOUTH SPRAY 1oz 0271 $34 $34 $20 OCEAN SALINE NASAL SPRAY 45cc 0271 $30 $30 $18 BENGAY CREAM 4oz 0271 $34 $34 $20 VITAMIN A&D OINTMENT 4oz 0271 $13 $13 $8 SARNA LOTION 7.5oz 0271 $45 $45 $27 LUBRIDERM 3.3oz 0271 $13 $13 $8 CEPACOL SORE THROAT LOZENGE 0271 $26 $26 $16 AQUAPHOR COMPOUNDING OINTMENT 14oz 0271 $71 $71 $43 DENTURE CLEANSER TABLET 0271 $22 $22 $13 DENTURE ADHESIVE 2.4oz 0271 $7 $7 $4 PILL CRUSHER 0271 $13 $13 $8 PILL SPLITTER 0271 $14 $14 $8 Q4 PED's 24 HOUR ORAL SUCTION CLEANING KIT 0270 $122 $122 $73

Page 48 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price BORDERED FOAM 6X8 0270 $34 $34 $20 NON-BORDERED FOAM DRESSING 2.5 X 2.5 0270 $11 $11 $7 NON BORDERED FOAM DRESSING 6X6 0270 $7 $7 $4 BORDERED FOAM DRESSING 4X4 0270 $7 $7 $4 NON BORDERED FOAM, HEEL 0270 $40 $40 $24 NON BORDERED FOAM, DRESSING 4X4 0270 $11 $11 $7 SILVER CALCIUM AGINATE DRESSING 4X4.75 0270 $33 $33 $20 CALCIUM ALGINATE DRESSING 4X4 0270 $11 $11 $7 CALCIUM ALGINATE DRESSING 4X8 0270 $29 $29 $17 CALCIUM ALGINATE DRESSING ROPE 12" 0270 $40 $40 $24 SILVER CALCIUM ALGINATE, ROPE HYDROGEL GAUZE PAD 1 0270 $40 $40 $24 HYDROGEL IMPREGNATEED GAUZE PAD 4X4 0272 $28 $28 $17 NON ADHERENT CONTACT LAYER DRESSING 2X2 0270 $10 $10 $6 HYDROGEL TUBE 3 OZ 0270 $29 $29 $17 Equipment-Infusion Pump - LVP Module 0261 $55 $55 $33 COUDE CATH TAPERED TIP STRL 14FR 0270 $6 $6 $4 RESTRAINT, MITT PAD FINGER CONTROL DBL 0270 $99 $99 $59 Pediatric Pain Program Half Day ED Materials 0270 $22 $22 $13 Equipment-Crib 0270 $181 $181 $109 SLING, GIVMOHR; EXTRA LARGE 0270 $241 $241 $145 GROIN/THIGH ADHESIVE DEVICE: CATHETER ANCHOR 0270 $21 $21 $13 Equipment-Ventilator LTV 1150 0291 $153 $153 $92 AQUAGUARD "7 X 7" 0270 $55 $55 $33 AQUAGUARD 12" X 14" 0270 $98 $98 $59 AQUAGUARD 9" X 9" 0270 $69 $69 $41 AQUAGUARD BOOT 0270 $55 $55 $33 SHAMPOO CAP 0270 $11 $11 $7 NAIL CARE KIT 0270 $6 $6 $4 Equipment-CPAP 0291 $7 $7 $4 Equipment-Ventilator LTV 950 0291 $148 $148 $89 Equipment BIPAP AVAPS 0291 $122 $122 $73 Equipment-Ventilator Trilogy 0291 $127 $127 $76 WIPES, SHIELD BARRIER CLOTHS 0270 $44 $44 $26 MESH UNDERWEAR SZ SM/MD 2/PK 0270 $5 $5 $3 MESH UNDERWEAR SZ LG/ XL 2/PK 0270 $6 $6 $4 MESH UNDERWEAR SZ 2X/3X 2/PK 0270 $6 $6 $4 MESH UNDERWEAR SZ 4X 2/PK 0270 $10 $10 $6 Equipment-Pulse Oximeter 0291 $13 $13 $8 SALLY SLIDER SHEET 0270 $37 $37 $22 USA BOOT AVERAGE SIZE 0270 $169 $169 $101 USA (ANTI ROTATION ATTACHMENT) 0270 $66 $66 $40 USA BOOT X-LENGTH SIZE 0270 $169 $169 $101 TUBE GAST BALLOON MIC 20F 0270 $205 $205 $123 MEDIHONEY ADHESIVE DRESSING 4 1/2"X 4 1/2" 0270 $61 $61 $37 MEDIHONEY GEL 0.5 TUBE 0270 $26 $26 $16 MEDIHONEY GEL 1.5 TUBE 0270 $61 $61 $37 DRESSING PROMOGRAN MATRIX 4.34SQ IN 0270 $45 $45 $27 USA BOOT SMALL SIZE 0270 $169 $169 $101 USA BOOT BARIATRIC SIZE 0270 $169 $169 $101 AVOGEL 8" X 8" 0270 $157 $157 $94 Hemodialysis Procedure Charge 0801 $1,772 $1,772 $1,063 PAD PROTECTOR ELBOW HEEL X-LG 0270 $37 $37 $22 HHTC Charge-Subsequent 0460 $112 $112 $67 PEAK FLOW METER 0270 $68 $68 $41 CATH STRAIGHT COUDE 14F 16" 0270 $5 $5 $3 CATH STRAIGHT COUDE 12FR 16" 0270 $5 $5 $3 SELF-CATH COUDE TIP STRL 8 FR 16" 0270 $5 $5 $3 MIC-KEY FEED TUBE 12FR 1.5CM 0270 $450 $450 $270 ADHESIVE GEL PATCH 0270 $36 $36 $22 EMST150 0270 $189 $189 $113 ORAL TEMPERATURE PROBE 0270 $446 $446 $268 THERMOMETER PROBE 9 FOOT ORAL VITAL SIGNS MONITOR 0270 $339 $339 $203 SPO2 CABLE ASSEMBLY GE V100 VITAL SIGNS MONITOR 0270 $282 $282 $169 SENSOR MASIMO SET LNOP ADHESIVE DISPOSABLE 0270 $62 $62 $37 G TUBE HOLDER 30" - 45" 0270 $62 $62 $37 G TUBE HOLDER 45" - 60" 0270 $62 $62 $37 IV SAFETY START KIT W/GLOVE, MEDC 0270 $10 $10 $6 PEDIATRIC OXYGEN MASK 0270 $5 $5 $3 NEBULIZER CAP 1000MI 0270 $14 $14 $8 BAG BREATHING ANESTHESIA TEST LUNG 3 LITER 0270 $6 $6 $4 THERMOMETER WITH U/ADAPT- IT BOTH 22MM 0270 $5 $5 $3 VENTURI MASK ADULT 0270 $5 $5 $3 ADULT RESUSCITATION BAG/MASK 0270 $43 $43 $26 BATERIAL FILTER 0270 $4 $4 $2 HUMID TRACH VENT 0270 $5 $5 $3 LTV CIRCUIT WITH PEEP, ADULT W/MOUTHPICE DEVICE 0270 $65 $65 $39 PEDS RESUSCITATION BAG W/MASK SPUR II 0270 $37 $37 $22 OXY - VENT W/TUBE 0270 $11 $11 $7 HUMID - VENT MINI 0270 $10 $10 $6

Page 49 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price ACAPELLA DH GREEN VIBRATORY PEP W/MOUTHPIECE DEVIC 0270 $206 $206 $124 DRAINAGE SYSTEM AEROSOL BAG 0270 $4 $4 $2 FLEX SUPERSET W/MASK ELBOW 0270 $14 $14 $8 PARI LCD PARINEB NEBULIZER DISPOSABLE 0270 $26 $26 $16 BAG BREATHING TEST LUNG 1 LITER 0270 $4 $4 $2 CAP SHILEY TRACHEOSTOMY WHITE FOR DECANNULATION 15 0270 $33 $33 $20 LTV CIRCUIT W/O PEEP, ADULT 0270 $46 $46 $28 INFANT RESUSCITATION BAG 0270 $38 $38 $23 PARAMETER KIT ADAPTER TRACH T W/ONE WAY VALVE 0270 $6 $6 $4 TRIOLOGY PASSIVE CIRCUIT 0270 $13 $13 $8 HUMID - VENT 2 STRAIGHT 0270 $10 $10 $6 PASSY MUIR VALVE BLUE 0270 $366 $366 $220 PEDIATRIC TUBING CUSHION CANNULA 0270 $5 $5 $3 NASAL CANNULA 21FT 0270 $6 $6 $4 HUMIDIFIER CHAMBER 0270 $53 $53 $32 HUMID - VENT 1 0270 $5 $5 $3 WATER STERILE FOR INHALATION BOTTLE 1000ML 0270 $6 $6 $4 PASSY MUIR VALVE CLEAR SPEAKING 0270 $366 $366 $220 DRESSING TRAY, PEDIATRIC W SORBAVIEW SHIELD IV 0270 $43 $43 $26 WATER SOLUTION FOR INHALATION 1000M 0270 $13 $13 $8 IPV PULMONARY TUBING CIRCUIT, INDIVIDUAL 0270 $300 $300 $180 FEED_FLUSH SET 1000ML, E-PUMP 0270 $29 $29 $17 WHISPER VALVE, TEMP CONTROLLED 0270 $185 $185 $111 MASK TRACHEOSTOMOY PEDIATRIC 0270 $5 $5 $3 STERILE WATER 650ML, AQUAPAK 640 0270 $6 $6 $4 Equipment-IPV 1C PERCUSSIONATOR 0270 $1,808 $1,808 $1,085 PROVALE DRINKING CUP 5CC 0270 $175 $175 $105 PROVALE DRINKING CUP 10CC 0270 $175 $175 $105 CONTOUR DELUXE W/HEADGEAR/SMALL 0270 $63 $63 $38 AF531 ORO-NASAL/SMALL 0270 $122 $122 $73 AF531 ORO-NASAL/MEDIUM 0270 $122 $122 $73 AF531 ORO-NASAL/LARGE 0270 $122 $122 $73 Equipment-CPM Right Hand 0270 $165 $165 $99 Equipment-CPM Left Hand 0270 $165 $165 $99 CONTOUR DELUXE W/HEADGEAR M/L 0270 $63 $63 $38 ADULT 24 HOUR ORAL SUCTION CLEANING KIT 6308 0270 $48 $48 $29 ORAL SWAB SYSTEM KIT 6001 0270 $29 $29 $17 CATH KIT TOUCLS URET UNISX 12FR INTERMIT 0270 $30 $30 $18 CATH KIT TOUCLS URET UNISX 10 FR INTERMIT 0270 $31 $31 $19 CATH KIT TOUCLS URET UNISX 8 FR INTERMIT 0270 $28 $28 $17 OAT BETA GLUCAN OCCLUSIVE OINTMENT 0270 $195 $195 $117 DRESSING FOAM MEPILEX AG 4X4 0270 $57 $57 $34 DRESSING FOAM MEPILEX AG 8X8 0270 $205 $205 $123 PATIENT CIRCUIT W/OUT PEEP PEDIATRIC 0270 $45 $45 $27 MR290 AUTO FILL HUMIDIFICATION CHAMBER 0270 $55 $55 $33 INFANT RESPIRATORY CARE SYSTEM 0270 $222 $222 $133 TCC-EZ BOOT/LARGE 0270 $331 $331 $199 TCC-EZ BOOT/EXTRA LARGE 0270 $348 $348 $209 CUFF, SMALL CHILD DISPOSABLE SOFT 2-TUBE, LOCKING 0270 $11 $11 $7 CUFF, SMALL ADULT, DISPOSABLE, SOFT 2-TUBE 0270 $13 $13 $8 CUFF, CHILD, DISPOSABLE, 2-TUBE LOCKING 0270 $11 $11 $7 CUFF, ADULT DISPOSABLE 0270 $13 $13 $8 CUFF, ADULT LONG, DISPOSABLE 0270 $14 $14 $8 CUFF, LARGE, ADULT, LONG, DISPOSABLE 0270 $15 $15 $9 CUFF,THIGH,DISPOSABLE 0270 $21 $21 $13 Equipment-META NEB 0291 $27 $27 $16 TCC-EZ 3 INCH SINGLE APPLICATION 0270 $490 $490 $294 AERPGEN NEB AERO KIT 0270 $220 $220 $132 TRANSCUTANEOUS ADHESIVE 0270 $34 $34 $20 TRANSCUTANEOUS EAR CLIP 0270 $50 $50 $30 TRANSCUTANEOUS MEMBRANE KIT 0270 $298 $298 $179 METANEB CIRCUITS 0270 $331 $331 $199 TRACH CARE 8 FRENCH PED ELBOW TRACH 0270 $48 $48 $29 TUBE NG WITHOUT STYLET 6 FR 36 INCH 0270 $44 $44 $26 MEPILEX TRANSFER 6X8 0270 $53 $53 $32 MIC-KEY SKIN LEVEL 12 FR 1.2 KIT 0270 $430 $430 $258 TRILOGY PASSIVE CIRCUIT PEDIATRIC 0270 $279 $279 $167 PEDIATRIC VENTED SYRINGE ADAPTAR SET for ALARIS PU 0270 $26 $26 $16 NEEDLE, INOJECT 38 X 0.45 MM X 26G 0270 $148 $148 $89 NEEDLE, INOJECT 50 X 0.50 MM X 25G 0270 $148 $148 $89 DISPOSABLE GROUND AND DISK ELECTRODES NCV KIT 0270 $37 $37 $22 HOSE, ANTIEMB THIGH XL SHORT 0270 $438 $438 $263 VALUE GASTRIC FARELL SYSTEM 0270 $4 $4 $2 PEDIPRINTS TRACH TIES 0270 $4 $4 $2 LITTLE SWIMMERS LARGE 0270 $4 $4 $2 LITTLE SWIMMERS MEDIUM 0270 $4 $4 $2 INTERVAL TIMER 0270 $91 $91 $55 CREME SKIN CONDITIONING 4 OZ BTL 0270 $36 $36 $22 TORTOISE REPOSITIONING SYSTEM-BARIATRIC 0270 $876 $876 $526

Page 50 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price FLUIDIZED ANCILLARY PAD 0270 $175 $175 $105 TORTOISE REPOSITIONING SYSTEM-REGULAR 0270 $603 $603 $362 BOOT, Z-FLEX FLUIDIZED HEEL BOOTS 0270 $181 $181 $109 ROOM/BED: 25 Room 0118 $4,110 $4,110 $2,466 ROOM/BED: Medically Advanced Care Unit 0118 $3,260 $3,260 $1,956 ROOM/BED: Neuro 0118 $2,680 $2,680 $1,608 ROOM/BED: General 0118 $2,400 $2,400 $1,440 ROOM/BED: International 0118 $3,130 $3,130 $1,878 I.M.S.T. 0270 $94 $94 $56 Intensive Aphasia Program Full Charge 20916 0949 $20,916 $20,916 $12,550 PULL-UP,ADULT PROTECT PLUS XXL 0270 $65 $65 $39 UTILITY POSITIONER MEDIUM 0270 $542 $542 $325 LNCS TFA - ADH SENSOR DISPOSABLE 0270 $103 $103 $62 PAMPERS SENSITIVE BABY WIPES 0270 $11 $11 $7 ENFADJUST GTUBE 16FR 0270 $79 $79 $47 ENFADJUST GTUBE 18FR 0270 $77 $77 $46 UNIVERSAL KIT 0270 $64 $64 $38 CLOTH-BATHING MOIST 0270 $5 $5 $3 ENF ADJUST GTUBE 12FR 0270 $128 $128 $77 ENFMINIONE 12FR 1.5CM 0270 $518 $518 $311 ENFMINIONE 14FR 2.5CM 0270 $518 $518 $311 ENFMINIONE 14FR 2CM 0270 $518 $518 $311 RD SET PDT/PED 0270 $44 $44 $26 THRESHOLD PEP THERAPY 0270 $120 $120 $72 TRACH CARE 10FR PED ELBOW 0270 $77 $77 $46 ENF EX SET BIFURCATED 8IN 0270 $13 $13 $8 ENF NG TUBE 10FR FEEDING 0270 $68 $68 $41 ENF FARRELL BAG 500ML 0270 $50 $50 $30 ENF NG TUBE 8FR FEEDING 0270 $41 $41 $25 ENF NG TUBE 6.5FR FEEDING 0270 $41 $41 $25 ENF NG TUBE 5FR FEEDING 0270 $41 $41 $25 ENFMINIONE 16FR 3CM 0270 $554 $554 $332 ENFBRUSH 30 DAY 0270 $51 $51 $31 SCISSORS,DISPOSABLE 0270 $7 $7 $4 ONLI HYDRO CATHETER 14FR-16" MALE 0270 $4 $4 $2 SENSICARE STING FREE ADHESIVE REMOVER SPRAY 0270 $36 $36 $22 DERMABLUE & FOAM WOUND DRESSING 4X5 1/4" 0270 $27 $27 $16 TRACH,FLEX-END PED 4.0 TTS 0270 $686 $686 $412 TRACH,FLEX-END PED 4.5 TTS 0270 $686 $686 $412 TRACH,FLEX-END PED 5.0 TTS 0270 $686 $686 $412 TRACH,FLEX-END PED 5.5 TTS 0270 $686 $686 $412 BULBS, IOWA ORAL PRESSURE INSTRUMENT 0270 $34 $34 $20 SKIN PROTECTANT WAND 0270 $37 $37 $22 MEPILEX BORDER FLEX 6 X 6 0270 $47 $47 $28 MEPILEX SOFT FOAM NON BORDER 4 X 4 0270 $29 $29 $17 MEPILEX BORDER FLEX 3 X 3 0270 $22 $22 $13 MEPILEX BORDER FLEX 4 X 4 0270 $32 $32 $19 MEPILEX BORDER SACRUM SMALL 6.7 X 7.9 0270 $53 $53 $32 MEPILEX BORDER SACRUM DRESSINGS 0270 $84 $84 $50 MEPILEX BORDER-LITE SELF ADHESIVE FOAM DRESSING 0270 $26 $26 $16 DIAPER BRIEF TRANQUILITY LGrr 0270 $37 $37 $22 DIAPER BRIEF TRANQUILITY MD 0270 $39 $39 $23 DIAPER BRIEF TRANQUILITY XLG 0270 $37 $37 $22 DRESSING DUODERM XTHIN 4X4 0270 $5 $5 $3 OSTOMY WAFER FLAT TWO PIECE 2 3/4 IN BLUE 0270 $32 $32 $19 OSTOMY WAFER CONVEX TWO PIECE 2 1/4 GREEN 0270 $43 $43 $26 OSTOMY WAFER CONVEX TWO PIECE 2 3/4 BLUE 0270 $43 $43 $26 OSTOMY FLAT ONE PIECE POUCHING SYTEM 0270 $49 $49 $29 OSTOMY TWO PIECE HIGH OUTPUT POUCH 2 3/4 BLUE 0270 $75 $75 $45 OSTOMY TWO PIECE STANDARD POUCH 1 3/4 GREEN 0270 $32 $32 $19 OSTOMY TWO PIECE STANDARD POUCH 2 1/4 RED 0270 $32 $32 $19 OSTOMY TWO PIECE STANDARD POUCH 2 3/4 BLUE 0270 $32 $32 $19 UROSTOMY POUCH 1 3/4 GREEN 0270 $39 $39 $23 UROSTOMY POUCH 2 1/4 RED 0270 $39 $39 $23 OSTOMY BARRIER RING 0270 $79 $79 $47 OSTOMY BELT 0270 $11 $11 $7 OSTOMY HYDROCOLLOID BARRIER EXTENDERS 0270 $8 $8 $5 UROSTOMY DRAIN TUBE ADAPTOR 0270 $5 $5 $3 OSTOMY TWO PIECE HIGH OUPUT POUCH 1 3/4 GREEN 0270 $77 $77 $46 BARIATRIC THIGH STRAP: VELCRO STRAP 0270 $36 $36 $22 RESTORE WOUND CLEANSER 0270 $17 $17 $10 INTERDRY ROLL SKIN FOLD MANAGEMENT 0270 $269 $269 $161 NPWT WOUND VAC TRANSPARENT ADHESIVE FILM 0270 $53 $53 $32 MEPILEX NON BORDER 6X6 FOAM 0270 $28 $28 $17 MEPILEX NON BORDER 8X20 FOAM 0270 $158 $158 $95 enoxaparin 40 mg/0.4 mL Soln 00075-0620-40 0.4 mL $286 $0 $286 $172 ONAbotulinum toxin type A 100 units REC I 00023-1145-01 1 vial(s) $1,552 $0 $1,552 $931 hylan G-F 20 8 mg/mL Soln 58468-0090-03 6 mL $8,196 $0 $8,196 $4,917 heparin 5000 units/mL Soln 63323-0262-55 1 mL $44 $0 $44 $27

Page 51 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price baclofen 2 mg/mL Soln 66794-0157-02 20 mL $2,270 $0 $2,270 $1,362 lidocaine 5% Patch 00591-3525-30 1 patch(es) $73 $0 $73 $44 immune globulin intravenous and subcutaneous 10% Soln 00944-2700-07 300 mL $29,050 $0 $29,050 $17,430 DAPTOmycin 500 mg REC Injection 63323-0871-15 10 mL $3,596 $0 $3,596 $2,158 enoxaparin 100 mg/mL Soln 00075-0623-00 1 mL $704 $0 $704 $423 collagenase topical 250 units/g Ointm 00064-5010-30 1 app $1,570 $0 $1,570 $942 enoxaparin 80 mg/0.8 mL Soln 00781-3428-68 0.8 mL $464 $0 $464 $278 valganciclovir 450 mg Tab 55111-0762-60 1 tab(s) $435 $0 $435 $261 posaconazole 100 mg EC Ta 00085-4324-02 1 tab(s) $403 $0 $403 $242 enoxaparin 60 mg/0.6 mL Soln 00955-1006-10 0.6 mL $384 $0 $384 $230 enoxaparin 30 mg/0.3 mL Soln 00781-3133-63 0.3 mL $179 $0 $179 $107 pantoprazole 40 mg EC Ta 00904-6474-61 1 tab(s) $31 $0 $31 $18 amphotericin B liposomal 50 mg REC I 00469-3051-30 12.5 mL $1,439 $0 $1,439 $863 insulin aspart 100 units/mL Soln 00169-7501-11 1 mL $477 $0 $477 $286 tobramycin inhalation soln 300 mg / 5 mL Soln 65162-0914-46 5 mL $999 $0 $999 $599 apixaban 5 mg Tab 00003-0894-31 1 tab(s) $46 $0 $46 $27 atovaquone 750 mg/5 mL Susp 66993-0062-72 1 mL $51 $0 $51 $30 cefepime 2 g REC I 60505-0681-04 12.5 mL $291 $0 $291 $174 LVP solution Sodium Chloride 0.9% Soln 00409-7984-37 100 mL $51 $0 $51 $31 bromocriptine 2.5 mg Tab 60687-0286-21 1 tab(s) $43 $0 $43 $26 incobotulinumtoxinA 100 units REC I 00259-1610-01 1 vial(s) $1,262 $0 $1,262 $757 levETIRAcetam 500 mg Tab 51079-0821-20 1 tab(s) $27 $0 $27 $16 ondansetron 4 mg DIS T 68462-0157-13 1 tab(s) $158 $0 $158 $95 sodium hyaluronate 10 mg/mL Soln 55566-4100-01 2 mL $2,866 $0 $2,866 $1,719 ondansetron oral soln 4 mg / 5 mL Soln 99345-0002-02 5 mL $173 $0 $173 $104 baclofen 2 mg/mL Soln 70257-0563-02 40 mL $2,270 $0 $2,270 $1,362 gabapentin 300 mg Cap 60505-0113-00 1 cap(s) $12 $0 $12 $7 piperacillin-tazobactam 3 g-0.375 g REC I 60505-0687-04 0 $158 $0 $158 $95 tamsulosin 0.4 mg Cap 00904-6401-61 1 cap(s) $32 $0 $32 $19 micafungin 100 mg REC I 00469-3211-10 5 mL $1,636 $0 $1,636 $982 valganciclovir 50 mg/mL REC P 00004-0039-09 1 mL $74 $0 $74 $44 potassium chloride oral Liquid UD 20 mEq / 15 mL Soln 17856-1542-01 15 mL $195 $0 $195 $117 tiotropium 18 mcg Cap 00597-0075-41 1 cap(s) $402 $0 $402 $241 chlorhexidine gluconate 0.12% 15 mL Soln 17856-2002-03 15 mL $9 $0 $9 $6 enoxaparin 150 mg/mL Soln 00075-2915-01 1 mL $1,053 $0 $1,053 $632 lacosamide 100 mg Tab 00131-2478-60 1 tab(s) $94 $0 $94 $56 polyethylene glycol 3350 - REC P 00904-6422-81 1 EA $14 $0 $14 $8 levETIRAcetam 500 mg / 5 mL Soln 00121-4799-05 5 mL $35 $0 $35 $21 meropenem 1 g REC I 00409-3506-01 10 mL $163 $0 $163 $98 ertapenem 1 g REC I 00006-3843-71 10 mL $752 $0 $752 $451 oxacillin 2 g REC I 55150-0128-24 20 mL $206 $0 $206 $124 insulin GLARgine 100 unit(s) / 1 mL Soln 00088-5021-01 0.01 mL $92 $0 $92 $55 enoxaparin 100 mg/mL Soln 00075-0626-03 1 mL $703 $0 $703 $422 albuterol-ipratropium 2.5 mg-0.5 mg/3 mL Soln 00487-0201-03 3 mL $23 $0 $23 $14 gabapentin 600 mg Tab 68084-0797-01 1 tab(s) $20 $0 $20 $12 ceftolozane-tazobactam 1 g-0.5 g REC I 67919-0030-01 11.4 mL $747 $0 $747 $448 CeFAZolin 10 g REC I 00143-9983-03 10 mL $97 $0 $97 $58 famotidine oral pre-filled syringe* 20 mg / 2.5 mL Susp 99345-0001-99 2.5 mL $67 $0 $67 $40 voriconazole 40 mg/mL REC P 00378-6270-45 1 mL $103 $0 $103 $62 filgrastim 480 mcg/1.6 mL Soln 55513-0546-10 1.6 mL $3,927 $0 $3,927 $2,356 famotidine 20 mg Tab 51079-0966-20 1 tab(s) $15 $0 $15 $9 Dextrose 70% in Water 00409-7120-07 1 mL $1,032 $0 $1,032 $619 mycophenolate mofetil 200 mg/mL REC P 67877-0230-22 1 mL $63 $0 $63 $38 filgrastim 300 mcg/mL Soln 55513-0530-10 1 mL $2,469 $0 $2,469 $1,482 vancomycin 1 g REC I 63323-0284-20 10 mL $177 $0 $177 $106 ramelteon 8 mg Tab 64764-0805-10 1 tab(s) $65 $0 $65 $39 midodrine 10 mg Tab 00245-0213-11 1 tab(s) $68 $0 $68 $41 temozolomide 100 mg Cap 16729-0050-54 1 cap(s) $1,931 $0 $1,931 $1,159 LVP solution Sodium Chloride 0.9% Soln 00264-7800-20 250 mL $100 $0 $100 $60 tacrolimus 1 mg Cap 68084-0450-01 1 cap(s) $33 $0 $33 $20 denosumab 60 mg/mL Soln 55513-0710-01 1 mL $7,214 $0 $7,214 $4,329 hylan G-F 20 8 mg/mL Soln 58468-0090-01 2 mL $2,737 $0 $2,737 $1,642 acetaminophen 325 mg Tab 50580-0600-02 1 tab(s) $7 $0 $7 $4 Tacrolimus oral susp 0.5 mg/mL Susp 99345-0001-69 1 mL $47 $0 $47 $28 ondansetron 4 mg Tab 51079-0524-20 1 tab(s) $169 $0 $169 $102 erythromycin ethylsuccinate 200 mg/5 mL susp 200 mg Susp 24338-0134-02 1 mL $24 $0 $24 $14 mycophenolate mofetil 500 mg Tab 51079-0379-20 1 tab(s) $56 $0 $56 $34 omeprazole 2 mg/mL oral Susp 99345-0001-07 10 mL $341 $0 $341 $205 epoetin alfa 10000 units/mL Soln 55513-0144-10 1 mL $1,225 $0 $1,225 $735 sildenafil 20 mg Tab 65162-0351-09 1 tab(s) $137 $0 $137 $82 fluticasone nasal 0.05 mg/nasal Spray 50383-0700-16 1 spray(s) $599 $0 $599 $359 albuterol CFC free 90 mcg/inh Aeros 59310-0579-22 1 puff(s) $699 $0 $699 $419 voriconazole 200 mg Tab 68084-0538-25 1 tab(s) $318 $0 $318 $191 gabapentin 250 mg Soln 50383-0311-47 1 mL $7 $0 $7 $4 Rifaximin 550 mg Tab 65649-0303-03 1 tab(s) $193 $0 $193 $116 epoetin alfa 4000 units/mL Soln 55513-0148-10 1 mL $495 $0 $495 $297 DULoxetine 60 mg EC Capsule 68084-0692-01 1 cap(s) $55 $0 $55 $33 pregabalin 75 mg Cap 00071-1014-41 1 cap(s) $42 $0 $42 $25 sevelamer 800 mg Tab 58468-0021-01 1 tab(s) $43 $0 $43 $26

Page 52 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price amlodipine 10 mg Tab 51079-0452-20 1 tab(s) $19 $0 $19 $12 baclofen 1 mg/mL Soln 66794-0156-02 20 mL $1,135 $0 $1,135 $681 vancomycin 5 g REC I 25021-0157-99 50 mL $344 $0 $344 $206 sodium chloride 0.9% Soln 82903-0065-00 10 mL $10 $0 $10 $6 eszopiclone 1 mg Tab 68180-0322-01 1 tab(s) $86 $0 $86 $52 fluconazole 100 mg Tab 55111-0144-30 1 tab(s) $62 $0 $62 $37 tacrolimus 5 mg Cap 51079-0028-20 1 cap(s) $153 $0 $153 $92 rivaroxaban 20 mg Tab 50458-0579-10 1 tab(s) $88 $0 $88 $53 iopamidol 61% Soln 00270-1412-15 15 mL $730 $0 $730 $438 amantadine 100 mg/10 mL Syrup 00121-0646-10 10 mL $23 $0 $23 $14 dronabinol 2.5 mg Cap 68084-0174-01 1 cap(s) $44 $0 $44 $27 carvedilol 25 mg Tab 51079-0932-20 1 tab(s) $18 $0 $18 $11 nystatin 500,000 units/5 mL oral susp UD cup 68094-0599-61 5 mL $7 $0 $7 $4 levalbuterol 1.25 mg/3 mL Soln 66993-0023-27 3 mL $55 $0 $55 $33 amiodarone 200 mg Tab 68084-0371-01 1 tab(s) $25 $0 $25 $15 docusate-senna 50 mg-8.6 mg Tab 00904-5643-61 1 tab(s) $5 $0 $5 $3 escitalopram 10 mg Tab 68084-0617-01 1 tab(s) $32 $0 $32 $19 cefpodoxime 100 mg Tab 00781-5438-20 1 tab(s) $49 $0 $49 $29 pregabalin 100 mg Cap 00071-1015-41 1 cap(s) $45 $0 $45 $27 baclofen 2 mg/mL Soln 70257-0563-01 20 mL $2,270 $0 $2,270 $1,362 baclofen 2 mg/mL Soln 70257-0563-01 40 mL $2,270 $0 $2,270 $1,362 baclofen 10 mg Tab 68084-0855-01 1 tab(s) $7 $0 $7 $4 budesonide-formoterol 160 mcg-4.5 mcg/inh Aeros 00186-0370-28 1 puff(s) $1,462 $0 $1,462 $877 baclofen 20 mg Tab 63739-0480-10 1 tab(s) $12 $0 $12 $7 diclofenac topical 1% Gel 63481-0684-47 0 $260 $0 $260 $156 piperacillin-tazobactam 4 g-0.5 g REC I 60505-0688-04 0 $216 $0 $216 $129 potassium chloride 10 mEq ER Ta 68084-0524-01 1 tab(s) $7 $0 $7 $4 atorvastatin 80 mg Tab 68084-0590-25 1 tab(s) $16 $0 $16 $10 iopamidol 76% Soln 00270-1316-04 1 mL $16 $0 $16 $9 ondansetron 8 mg DIS T 65862-0391-10 1 tab(s) $252 $0 $252 $151 LVP solution Sodium Chloride 0.9% Soln 00264-7800-00 1000 mL $100 $0 $100 $60 gabapentin 400 mg Cap 60505-0114-00 1 cap(s) $14 $0 $14 $9 lacosamide 50 mg Tab 00131-2477-60 1 tab(s) $62 $0 $62 $37 DULoxetine 30 mg DRC 68084-0683-01 1 cap(s) $55 $0 $55 $33 posaconazole 40 mg/mL Susp 00085-1328-01 1 mL $77 $0 $77 $46 magnesium sulfate 2 g/50 mL-sterile water Soln 00409-6729-24 50 mL $172 $0 $172 $103 escitalopram 5 mg/5 mL Soln 54838-0551-70 1 mL $15 $0 $15 $9 losartan 50 mg Tab 00904-6390-61 1 tab(s) $19 $0 $19 $11 avibactam-ceftazidime 0.5 g-2 g REC I 00456-2700-10 12 mL $2,243 $0 $2,243 $1,346 fluconazole 40 mg/mL REC P 59762-5030-01 1 mL $30 $0 $30 $18 diclofenac epolamine 1.3% patch(es) Patch 60793-0411-30 1 patch(es) $76 $0 $76 $46 lidocaine 1% preservative-free Soln 63323-0492-57 5 mL $36 $0 $36 $22 immune globulin intravenous 6 g REC I 44206-0417-06 100 mL $4,278 $0 $4,278 $2,567 nystatin topical 100000 units/g Powde 39822-3015-01 1 app $180 $0 $180 $108 APAP-HYDROcodone 325 mg-10 mg Tab 51079-0779-20 1 tab(s) $6 $0 $6 $4 acetaminophen 160 mg/5 mL LIQ 00121-0657-21 20.3 mL $10 $0 $10 $6 pantoprazole 40 mg REC G 00008-0844-02 1 packet(s) $68 $0 $68 $41 ocular lubricant - Soln 00023-0506-50 1 drop(s) $10 $0 $10 $6 APAP-HYDROcodone 325 mg-5 mg Tab 68084-0895-09 1 tab(s) $9 $0 $9 $6 dantrolene oral suspension 5 MG / 1 ML Susp 99345-0001-06 1 mL $6 $0 $6 $4 amlodipine 5 mg Tab 51079-0451-20 1 tab(s) $15 $0 $15 $9 carvedilol 12.5 mg Tab 51079-0931-20 1 tab(s) $18 $0 $18 $11 zolpidem 5 mg Tab 51079-0724-20 1 tab(s) $37 $0 $37 $22 tramadol 50 mg Tab 51079-0991-20 1 tab(s) $9 $0 $9 $5 saccharomyces boulardii lyo cap 250 mg Cap 17856-0002-01 1 cap(s) $9 $0 $9 $6 FLUoxetine 20 mg Cap 00904-5785-61 1 cap(s) $20 $0 $20 $12 abobotulinumtoxinA 500 units REC I 15054-0500-01 1 vial(s) $2,117 $0 $2,117 $1,270 atorvastatin 40 mg Tab 68084-0099-01 1 tab(s) $9 $0 $9 $5 carbidopa-levodopa 25 mg-100 mg Tab 00904-6237-61 1 tab(s) $7 $0 $7 $4 modafinil 100 mg Tab 68084-0621-21 1 tab(s) $189 $0 $189 $114 rosuvastatin 20 mg Tab 57237-0170-90 1 tab(s) $63 $0 $63 $38 ondansetron 8 mg Tab 63304-0459-30 1 tab(s) $280 $0 $280 $168 latanoprost ophthalmic 0.005% Soln 61314-0547-03 1 drop(s) $674 $0 $674 $404 mirtazapine 15 mg Tab 51079-0086-20 1 tab(s) $22 $0 $22 $13 magnesium oxide 400 mg Tab 63739-0354-10 1 tab(s) $5 $0 $5 $3 temozolomide 100 mg Cap 00781-2693-75 1 cap(s) $1,696 $0 $1,696 $1,017 metFORMIN 500 mg Tab 62584-0259-01 1 tab(s) $8 $0 $8 $5 midodrine 5 mg Tab 51079-0453-20 1 tab(s) $22 $0 $22 $13 mycophenolate mofetil 250 mg Cap 51079-0721-20 1 cap(s) $30 $0 $30 $18 ampicillin 2 g REC I 63323-0399-23 0 $130 $0 $130 $78 sodium hyaluronate 10 mg/mL Soln 89122-0724-20 2 mL $1,606 $0 $1,606 $964 gabapentin 100 mg Cap 68084-0783-01 1 cap(s) $7 $0 $7 $4 apixaban 2.5 mg Tab 00003-0893-31 1 tab(s) $46 $0 $46 $27 rivaroxaban 15 mg Tab 50458-0578-10 1 tab(s) $88 $0 $88 $53 glycopyrrolate 1 mg/5 mL Soln 00259-0501-16 1 mL $13 $0 $13 $8 pregabalin 50 mg Cap 00071-1013-41 1 cap(s) $45 $0 $45 $27 cobicistat/elvitegravir/emtricitabine/tenofov 150 mg-150 mg-200 mg-10 mg Tab 61958-1901-01 1 tab(s) $742 $0 $742 $445 clobazam 10 mg Tab 67386-0314-01 1 tab(s) $56 $0 $56 $34

Page 53 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price cinacalcet 30 mg Tab 55513-0073-30 1 tab(s) $115 $0 $115 $69 isavuconazonium 186 mg Cap 00469-0520-14 1 cap(s) $164 $0 $164 $99 metoprolol 25 mg Tab 51079-0255-20 1 tab(s) $5 $0 $5 $3 triamcinolone acetonide 40 mg/mL Susp 00003-0293-05 1 mL $73 $0 $73 $44 ciprofloxacin 500 mg Tab 51079-0182-20 1 tab(s) $38 $0 $38 $23 levofloxacin 250 mg Tab 68084-0481-01 1 tab(s) $114 $0 $114 $68 foscarnet 24 mg/mL Soln 76310-0024-25 1 mL $57 $0 $57 $34 glatiramer 20 mg/mL Soln 68546-0317-30 1 mL $1,641 $0 $1,641 $985 oxycodone 5 mg Tab 00406-0552-62 1 tab(s) $8 $0 $8 $5 budesonide 80 mcg/fomoterol fumarate 4.5 mcg 80/4.5 Inhaler 00186-0372-20 1 puff(s) $19,289 $0 $19,289 $11,573 budesonide 0.5 mg/2 mL Susp 00093-6816-73 2 mL $86 $0 $86 $51 insulin lispro 100 units/mL Soln 00002-7510-17 1 mL $197 $0 $197 $118 sucralfate 1 g/10 mL Susp 00121-0747-10 10 mL $65 $0 $65 $39 carvedilol 6.25 mg Tab 51079-0930-20 1 tab(s) $18 $0 $18 $11 oxyCODONE 5 mg Tab 68084-0354-01 1 tab(s) $7 $0 $7 $4 caffeine citrate 20 mg/mL LIQ 47335-0290-44 1 mL $103 $0 $103 $62 donepezil 10 mg Tab 00904-6409-61 1 tab(s) $46 $0 $46 $28 docusate sodium 100 mg Cap 63739-0478-10 1 cap(s) $4 $0 $4 $2 gabapentin 800 mg Tab 68084-0802-01 1 tab(s) $23 $0 $23 $14 fondaparinux syringe 2.5 mg / 0.5 mL Soln 43598-0607-10 0.5 mL $214 $0 $214 $128 oxyCODONE 10 mg CR Tablet 59011-0410-20 1 tab(s) $28 $0 $28 $17 lidocaine Topical 5% Cream 00496-0883-30 1 app $422 $0 $422 $253 ARIPiprazole 5 mg Tab 60505-2673-03 1 tab(s) $218 $0 $218 $131 nitrofurantoin 25 mg / 5 mL Susp 65162-0689-88 1 mL $23 $0 $23 $14 melatonin 3 mg Tab 50268-0524-15 1 tab(s) $6 $0 $6 $4 pravastatin 40 mg Tab 00003-5194-10 1 tab(s) $39 $0 $39 $23 dexamethasone 10 mg/mL preservative-free Soln 63323-0506-01 1 mL $42 $0 $42 $25 ursodiol 300 mg Cap 52544-0930-01 1 cap(s) $34 $0 $34 $20 fluticasone-salmeterol 500 mcg-50 mcg Powder 00173-0697-04 1 INH $1,524 $0 $1,524 $914 vancomycin 750 mg REC I 00409-6531-01 7.5 mL $142 $0 $142 $85 levETIRAcetam 100 mg/mL Soln 54838-0548-80 1 mL $9 $0 $9 $5 senna 8.6 mg Tab 00904-6522-61 1 tab(s) $4 $0 $4 $2 albuterol 0.083% Soln 00487-9501-01 3 mL $14 $0 $14 $8 alteplase 2 mg REC I 50242-0041-64 2 mL $968 $0 $968 $581 LVP solution Sodium Chloride 0.9% Soln 00338-0049-03 500 mL $65 $0 $65 $39 heparin flush 100 units/mL Soln 08290-3064-24 5 mL $12 $0 $12 $7 ranitidine 15 mg/mL Syrup 68094-0204-62 10 mL $61 $0 $61 $37 levETIRAcetam 750 mg Tab 68084-0882-01 1 tab(s) $9 $0 $9 $5 baclofen 0.5 mg/mL Soln 66794-0155-02 20 mL $568 $0 $568 $341 cholecalciferol 1,000 unit(s) Tab 00904-5824-61 1 tab(s) $4 $0 $4 $2 multivitamin with minerals Therapeutic Multiple Vitamins with Minerals Tab 00904-5042-60 1 tab(s) $4 $0 $4 $2 fluticasone CFC free 220 mcg/inh Aeros 00173-0720-20 1 puff(s) $2,423 $0 $2,423 $1,454 levalbuterol 0.63 mg/3 mL Soln 00093-4146-64 3 mL $55 $0 $55 $33 ARIPiprazole 2 mg Tab 13811-0679-30 1 tab(s) $218 $0 $218 $131 fluticasone-salmeterol 250 mcg-50 mcg Diskus Inhaler 00173-0696-04 1 INH $938 $0 $938 $563 ipratropium CFC free 17 mcg/inh Aeros 00597-0087-17 1 puff(s) $2,211 $0 $2,211 $1,327 escitalopram 20 mg Tab 51079-0544-20 1 tab(s) $34 $0 $34 $20 epoetin alfa 20000 units/mL Soln 55513-0478-10 1 mL $2,444 $0 $2,444 $1,466 baclofen 99345-0001-63 1 mL $8 $0 $8 $5 LORazepam 2 mg Conc 99345-0001-54 1 mL $16 $0 $16 $9 oxybutynin 10 mg/24 hr ER Ta 00093-5207-01 1 tab(s) $25 $0 $25 $15 fidaxomicin 200 mg Tab 52015-0080-01 1 tab(s) $1,258 $0 $1,258 $755 trazodone 100 mg Tab 00904-3991-61 1 tab(s) $9 $0 $9 $5 sevelamer carbonate 2.4 g REC P 65862-0931-90 60 mL $126 $0 $126 $76 iron sucrose 20 mg/mL Soln 00517-2340-10 5 mL $428 $0 $428 $257 fentaNYL 75 mcg/hr ER Fi 60505-7008-02 1 patch(es) $420 $0 $420 $252 omeprazole 20 mg DRC 68084-0128-01 1 cap(s) $11 $0 $11 $6 amLODIPine Oral susp 1 mg/mL Susp 99345-0002-50 1 mL $14 $0 $14 $9 bromocriptine 5 mg Cap 00378-7096-01 1 cap(s) $37 $0 $37 $22 entecavir 0.5 mg Tab 00093-5786-56 1 tab(s) $301 $0 $301 $181 aspirin 81 mg Chew 63739-0434-01 1 tab(s) $4 $0 $4 $2 urea topical 20% Cream 58980-0610-30 1 app $90 $0 $90 $54 sertraline 20 mg/mL Conc 59762-4940-01 1 mL $12 $0 $12 $7 hydrocortisone topical 25 mg Supp 00713-0503-12 1 supp $155 $0 $155 $93 hydralazine 50 mg Tab 63739-0127-10 1 tab(s) $8 $0 $8 $5 isavuconazonium 372 mg REC I 00469-0420-99 5 mL $2,360 $0 $2,360 $1,416 epoetin alfa 3000 units/mL Soln 55513-0267-10 1 mL $373 $0 $373 $224 atorvastatin 20 mg Tab 68084-0098-01 1 tab(s) $9 $0 $9 $5 morphine 30 mg ER/8-12 hr Tab 00406-8330-62 1 tab(s) $28 $0 $28 $17 acyclovir 50 mg/mL Soln 63323-0325-20 1 mL $64 $0 $64 $38 leflunomide 10 mg Tab 62332-0061-30 1 tab(s) $113 $0 $113 $68 tizanidine 4 mg Tab 51079-0998-20 1 tab(s) $13 $0 $13 $8 dolutegravir 50 mg Tab 49702-0228-13 1 tab(s) $377 $0 $377 $226 miconazole Topical 2% Cream 11701-0045-14 1 app $70 $0 $70 $42 mometasone nasal 50 mcg/nasal Spray 00085-1288-01 1 spray(s) $1,573 $0 $1,573 $944 voriconazole 50 mg Tab 51079-0164-03 1 tab(s) $91 $0 $91 $54 oxandrolone 10 mg Tab 49884-0302-02 1 tab(s) $136 $0 $136 $82 budesonide 3 mg EC Capsule 51079-0020-03 1 cap(s) $124 $0 $124 $74 simvastatin 40 mg Tab 68084-0513-01 1 tab(s) $36 $0 $36 $22

Page 54 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price sevelamer carbonate 0.8 g REC P 58468-0132-02 30 mL $54 $0 $54 $33 pantoprazole (compound) 2 mg/mL Susp 99345-0002-40 1 mL $12 $0 $12 $7 lactobacillus acidophilus and bulgaricus - Chew 64980-0129-50 1 tab(s) $6 $0 $6 $4 bumetanide 2 mg Tab 42799-0121-01 1 tab(s) $23 $0 $23 $14 ergocalciferol 50,000 intl units Cap 68084-0463-01 1 cap(s) $14 $0 $14 $8 tizanidine 2 mg Tab 10144-0592-15 1 tab(s) $13 $0 $13 $8 tizanidine 2 mg Tab 10144-0592-15 1 tab(s) $13 $0 $13 $8 rosuvastatin 10 mg Tab 57237-0169-90 1 tab(s) $63 $0 $63 $38 doxycycline hyclate 100 mg Cap 00143-3142-50 1 cap(s) $40 $0 $40 $24 morphine 15 mg/8-12 hr ER Ta 00406-8315-62 1 tab(s) $18 $0 $18 $11 potassium chloride 20 mEq/15 mL LIQ 00603-1542-58 1 mL $10 $0 $10 $6 ticagrelor 90 mg Tab 00186-0777-39 1 tab(s) $35 $0 $35 $21 cetirizine 10 mg Tab 51079-0597-20 1 tab(s) $20 $0 $20 $12 melatonin 5 mg Tab 00536-1098-08 1 tab(s) $4 $0 $4 $2 oxyCODONE CR 20 mg Tab 59011-0420-20 1 tab(s) $48 $0 $48 $29 acyclovir 200 mg/5 mL Susp 00472-0082-16 1 mL $11 $0 $11 $7 oxybutynin 5 mg/24 hours ER Ta 68084-0480-01 1 tab(s) $24 $0 $24 $14 lactulose 10 g/15 mL Syrup 66689-0038-50 30 mL $13 $0 $13 $8 sodium thiosulfate 25% Soln 60267-0705-50 1 mL $62 $0 $62 $37 mupirocin Topical 2% Cream 00029-1527-25 1 app $1,017 $0 $1,017 $610 cloNIDine Patch 0.3 mg/24 hr Patch 51862-0455-04 1 patch(es) $551 $0 $551 $330 metoprolol 50 mg Tab 51079-0801-20 1 tab(s) $7 $0 $7 $4 thiamine 100 mg Tab 50268-0851-15 1 tab(s) $5 $0 $5 $3 linezolid 100 mg/5 mL REC Powder 00009-5136-01 1 mL $44 $0 $44 $26 venlafaxine 75 mg ER Ca 68084-0709-01 1 cap(s) $31 $0 $31 $19 colchicine 0.6 mg Tab 66993-0165-02 1 tab(s) $49 $0 $49 $29 FLUoxetine 10 mg Cap 00777-3104-02 1 cap(s) $36 $0 $36 $21 cycloSPORINE modified 100 mg Cap 00078-0248-15 1 cap(s) $44 $0 $44 $27 ceftriaxone 2 g REC I 00409-7335-03 20 mL $32 $0 $32 $19 meropenem 500 mg REC I 00409-3505-01 10 mL $113 $0 $113 $68 tacrolimus 0.5 mg Cap 00469-0607-67 1 cap(s) $16 $0 $16 $10 bacitracin topical 500 units/g Ointm 00713-0280-31 1 app $33 $0 $33 $20 ergocalciferol 8000 intl units/mL Soln 39328-0357-60 1 mL $16 $0 $16 $10 ferrous sulfate 324 mg EC Ta 00574-0608-01 1 tab(s) $4 $0 $4 $2 brimonidine ophthalmic 0.15% Soln 61314-0144-10 1 drop(s) $538 $0 $538 $323 folic acid 1 mg Tab 62584-0897-01 1 tab(s) $6 $0 $6 $3 bisacodyl 10 mg Supp 00713-0109-01 1 supp $5 $0 $5 $3 methylphenidate 5 mg Tab 00406-1142-01 1 tab(s) $10 $0 $10 $6 bisacodyl 10 mg Supp 57648-0002-01 1 supp $6 $0 $6 $4 clopidogrel 75 mg Tab 51079-0557-20 1 tab(s) $6 $0 $6 $4 clobazam oral susp PFS 2.5 mg/mL Soln 99345-0002-04 4 mL $175 $0 $175 $105 dexamethasone 4 mg Tab 00006-0097-50 1 tab(s) $19 $0 $19 $11 scopolamine 1 mg/72 hr ER Fi 66758-0208-54 1 patch(es) $158 $0 $158 $95 insulin detemir 100 units/mL Soln 00169-3687-12 1 mL $428 $0 $428 $257 iopamidol 61% Soln 00270-1315-47 1 mL $16 $0 $16 $10 clobetasol topical 0.05% Ointm 00168-0162-30 1 app $1,829 $0 $1,829 $1,097 micafungin 50 mg REC I 00469-3250-10 5 mL $869 $0 $869 $521 QUEtiapine 100 mg Tab 68084-0532-01 1 tab(s) $47 $0 $47 $28 temozolomide 20 mg Cap 00085-1519-01 1 cap(s) $320 $0 $320 $192 gadobutrol 604.72 mg/mL Soln 50419-0325-12 1 mL $78 $0 $78 $47 olopatadine ophthalmic 0.1% Soln 64980-0517-05 1 drop(s) $1,806 $0 $1,806 $1,084 oxyCODONE 15 mg ER Ta 59011-0415-20 1 tab(s) $39 $0 $39 $23 QUEtiapine 50 mg Tab 60687-0338-01 1 tab(s) $45 $0 $45 $27 propranolol 20 mg/5 mL Soln 00054-3727-63 1 mL $5 $0 $5 $3 ezetimibe 10 mg Tab 60687-0373-21 1 tab(s) $86 $0 $86 $51 niMODipine 30 mg Cap 62559-0210-31 1 cap(s) $114 $0 $114 $69 immune globulin intravenous and subcutaneous 10% Soln 00944-2700-06 200 mL $18,247 $0 $18,247 $10,948 midodrine 5 mg Tab 68084-0241-01 1 tab(s) $17 $0 $17 $10 finasteride 5 mg Tab 68084-0399-01 1 tab(s) $16 $0 $16 $9 metoprolol 25 mg ER Ta 68084-0659-01 1 tab(s) $11 $0 $11 $6 fluticasone-vilanterol 200 mcg-25 mcg/inh Powde 00173-0882-14 1 INH $1,013 $0 $1,013 $608 methylphenidate 2.5 mg Chew 43386-0570-01 1 tab(s) $25 $0 $25 $15 ciprofloxacin 750 mg Tab 68084-0071-01 1 tab(s) $55 $0 $55 $33 doxepin Topical 5% Cream 45 gm 5% Cream 40076-0511-45 1 app $5,181 $0 $5,181 $3,109 levOCARNitine 100 mg/mL Soln 64980-0503-12 1 mL $6 $0 $6 $4 ceftaroline 600 mg REC I 00456-0600-10 20 mL $1,126 $0 $1,126 $676 DULoxetine 20 mg DR Ca 68084-0675-21 1 cap(s) $58 $0 $58 $35 simvastatin 20 mg Tab 51079-0455-20 1 tab(s) $36 $0 $36 $22 aztreonam 2 gm Injection 63323-0402-20 20 mL $571 $0 $571 $343 lacosamide pre-filled syringe 100 mg / 10 mL Soln 99345-0002-03 10 mL $16 $0 $16 $10 fluticasone CFC free 110 mcg/inh Aeros 00173-0719-20 1 puff(s) $1,562 $0 $1,562 $937 fluticasone-vilanterol 100 mcg-25 mcg/inh Powde 00173-0859-14 1 INH $1,013 $0 $1,013 $608 hydrALAZINE 25 mg Tab 63739-0126-10 1 tab(s) $8 $0 $8 $5 vancomycin 50 mg/mL REC P 65628-0208-10 1 mL $10 $0 $10 $6 cefepime 1 g REC I 60505-6030-04 10.5 mL $150 $0 $150 $90 atomoxetine 18 mg Cap 64980-0374-03 1 cap(s) $99 $0 $99 $59 lisinopril 10 mg Tab 51079-0982-20 1 tab(s) $10 $0 $10 $6 testosterone 4 mg/24 hr Patch 00023-5992-30 1 EA $162 $0 $162 $97 fentaNYL 50 mcg/hr ER Fi 60505-7007-02 1 patch(es) $277 $0 $277 $166

Page 55 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price amoxicillin-clavulanate 875 mg-125 mg Tab 66685-1001-01 1 tab(s) $36 $0 $36 $22 ibuprofen 100 mg/5 mL Susp 00472-1270-94 1 mL $80 $0 $80 $48 losartan 25 mg Tab 00006-0951-28 1 tab(s) $16 $0 $16 $10 cyclobenzaprine 10 mg Tab 00904-7809-61 1 tab(s) $11 $0 $11 $7 betamethasone-clotrimazole topical 0.05%-1% Cream 00168-0258-46 1 app $456 $0 $456 $273 lamoTRIgine 25 mg Tab 51079-0498-20 1 tab(s) $31 $0 $31 $19 itraconazole 100 mg Cap 60687-0299-25 1 cap(s) $30 $0 $30 $18 fluticasone-salmeterol 100 mcg-50 mcg Powde 00173-0695-04 1 INH $938 $0 $938 $563 venlafaxine 150 mg ER Capsule 68084-0713-01 1 cap(s) $34 $0 $34 $20 aspirin 81 mg EC Ta 63739-0522-10 1 tab(s) $4 $0 $4 $2 divalproex sodium 500 mg EC Ta 68084-0782-01 1 tab(s) $25 $0 $25 $15 valacyclovir 1 g Tab 63304-0905-30 1 tab(s) $88 $0 $88 $53 oxyCODONE 40 mg ER Ta 59011-0440-10 1 tab(s) $56 $0 $56 $33 metoprolol 100 mg ER Tab 00186-1092-05 1 tab(s) $13 $0 $13 $8 bumetanide 1 mg Tab 00185-0129-01 1 tab(s) $9 $0 $9 $5 atorvastatin 10 mg tab 68084-0097-01 1 tab(s) $8 $0 $8 $5 sennosides 17.6 mg / 10 mL Syrup 17856-1000-01 10 mL $16 $0 $16 $9 acetylcysteine 20% Soln 63323-0690-30 30 mL $149 $0 $149 $89 demeclocycline 150 mg Tab 65162-0554-10 1 tab(s) $66 $0 $66 $40 propranolol 10 mg Tab 00904-6550-61 1 tab(s) $6 $0 $6 $3 sitagliptin 100 mg Tab 00006-0277-31 1 tab(s) $44 $0 $44 $26 ciprofloxacin-dexamethasone otic 0.3%-0.1% Susp 00065-8533-02 1 drop(s) $1,347 $0 $1,347 $808 ascorbic acid 500 mg Tab 00904-0523-61 1 tab(s) $4 $0 $4 $2 colistimethate (Colistin base) NEB 75 mg/mL Soln 99345-0002-15 1 mL $129 $0 $129 $78 triamcinolone acetonide 40 mg/mL Susp 00003-0293-28 10 mL $503 $0 $503 $302 dorzolamide-timolol ophthalmic 2%-0.5% Soln 50383-0233-10 1 drop(s) $867 $0 $867 $520 cefixime 200 mg / 5 mL REC Powder 68180-0407-03 1 mL $67 $0 $67 $40 spironolactone 25 mg/5 mL Susp 46287-0020-04 1 mL $24 $0 $24 $14 acyclovir 400 mg Tab 00904-5790-61 1 tab(s) $18 $0 $18 $11 lisinopril 5 mg Tab 68084-0196-01 1 tab(s) $9 $0 $9 $5 loperamide 2 mg Cap 50458-0400-01 1 cap(s) $9 $0 $9 $5 zinc sulfate 1 mg/mL Soln 00517-6110-25 1 mL $23 $0 $23 $14 amoxicillin-clavulanate 250 mg-62.5 mg/5 mL REC P 43598-0204-53 1 mL $15 $0 $15 $9 cycloSPORINE ophthalmic 0.05% Emuls 00023-9163-30 1 drop(s) $54 $0 $54 $32 metronidazole 500 mg/100 mL Soln 00409-7811-24 100 mL $70 $0 $70 $42 sulfamethoxazole-trimethoprim 800 mg-160 mg Tab 68084-0230-01 1 tab(s) $5 $0 $5 $3 epoetin alfa 2000 units/mL Soln 55513-0126-10 1 mL $251 $0 $251 $151 baclofen 5 mg/mL Susp 65628-0101-04 1 mL $8 $0 $8 $5 emtricitabine-tenofovir 200 mg-300 mg Tab 61958-0701-01 1 tab(s) $300 $0 $300 $180 levofloxacin 500 mg Tab 00904-6352-61 1 tab(s) $116 $0 $116 $70 buPROPion 150 mg/24 hours ER Ta 51079-0047-20 1 tab(s) $38 $0 $38 $23 doxazosin 1 mg Tab 68084-0836-25 1 tab(s) $10 $0 $10 $6 abobotulinumtoxinA 300 units REC I 15054-0530-06 1 vial(s) $1,271 $0 $1,271 $762 sirolimus 1 mg/mL Soln 00008-1030-06 1 mL $156 $0 $156 $94 pregabalin 25 mg Cap 00071-1012-68 1 cap(s) $42 $0 $42 $25 darunavir 800 mg Tab 59676-0566-30 1 tab(s) $310 $0 $310 $186 sevelamer carbonate 2.4 gm Packet 58468-0131-02 60 mL $63 $0 $63 $38 potassium chloride 20 mEq/100 mL Soln 00409-7075-26 100 mL $77 $0 $77 $46 psyllium 3.4 g/5.2 g REC P 37000-0024-04 1 packet(s) $8 $0 $8 $5 guaiFENesin 100 mg/5 mL LIQ 00121-1488-00 10 mL $9 $0 $9 $5 vancomycin 500 mg REC Inj 00409-4332-01 5 mL $95 $0 $95 $57 levofloxacin 25 mg/mL Soln 50383-0286-04 1 mL $13 $0 $13 $8 docusate 10 mg/mL LIQ 00121-0544-10 10 mL $9 $0 $9 $6 riluzole 50 mg Tab 68462-0381-60 1 tab(s) $222 $0 $222 $133 clonidine oral suspension 20 mcg/mL Susp 99345-0001-05 1 mL $12 $0 $12 $7 interferon beta-1b 0.3 mg Syringe 50419-0523-35 1.2 mL $2,580 $0 $2,580 $1,548 celecoxib 200 mg Cap 00904-6503-61 1 cap(s) $15 $0 $15 $9 erythromycin ophthalmic 0.5% Ointm 00574-4024-35 1 app $134 $0 $134 $80 cholecalciferol 400 intl units/mL LIQ 00536-8400-80 1 mL $5 $0 $5 $3 amantadine 100 mg Cap 51079-0481-20 1 cap(s) $7 $0 $7 $4 ferrous sulfate 300 mg/5 mL LIQ 00121-0530-05 5 mL $9 $0 $9 $5 dornase alfa 2.5 mg/2.5 mL Soln 50242-0100-40 2.5 mL $743 $0 $743 $446 levOCARNitine 330 mg Tab 50383-0172-90 1 tab(s) $9 $0 $9 $5 furosemide 40 mg Tab 51079-0073-20 1 tab(s) $4 $0 $4 $3 aspirin-dipyridamole 25 mg-200 mg ER Ca 60687-0305-32 1 cap(s) $88 $0 $88 $53 baclofen 2 mg/mL Soln 70257-0561-02 20 mL $1,248 $0 $1,248 $749 sitagliptin 25 mg Tab 00006-0221-31 1 tab(s) $44 $0 $44 $26 sodium phosphate 3 mmol/mL Soln 63323-0170-05 1 mL $22 $0 $22 $13 busPIRone 10 mg Tab 68084-0029-01 1 tab(s) $12 $0 $12 $7 sodium chloride 3% Soln 00487-9003-60 4 mL $11 $0 $11 $6 albuterol-ipratropium CFC free 100 mcg-20 mcg/inh Aeros 00597-0024-02 1 puff(s) $2,141 $0 $2,141 $1,285 simethicone 80 mg Chew 63739-0225-10 1 tab(s) $4 $0 $4 $2 OLANZapine 10 mg Tab 60505-3113-00 1 tab(s) $137 $0 $137 $82 OLANZapine 5 mg Tab 00002-4115-33 1 tab(s) $58 $0 $58 $35 metroNIDAZOLE 500 mg Tab 68084-0966-01 1 tab(s) $10 $0 $10 $6 pravastatin 20 mg Tab 51079-0458-20 1 tab(s) $25 $0 $25 $15 lidocaine topical 4% Cream 00496-0882-06 1 app $370 $0 $370 $222 magnesium hydroxide 8% Susp 00121-0431-30 30 mL $11 $0 $11 $7 tigecycline 50 mg REC Inj 00008-5360-02 5 mL $460 $0 $460 $276

Page 56 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price metoprolol 100 mg Tab 00904-6342-61 1 tab(s) $11 $0 $11 $6 valacyclovir 500 mg Tab 63304-0904-30 1 tab(s) $18 $0 $18 $11 NIFEdipine 60 mg ER Ta 51079-0896-20 1 tab(s) $19 $0 $19 $11 azathioprine 50 mg Tab 65483-0590-10 1 tab(s) $24 $0 $24 $14 clonazePAM 0.5 mg Tab 63739-0263-10 1 tab(s) $10 $0 $10 $6 HYPROMELLOSE ophthalmic 0.5% Soln 00998-0408-15 1 drop(s) $191 $0 $191 $114 carvedilol 3.125 mg Tab 51079-0771-20 1 tab(s) $18 $0 $18 $11 rosuvastatin 5 mg Tab 31722-0882-90 1 tab(s) $63 $0 $63 $38 cycloSPORINE microemulsion 25 mg Cap 00591-2222-15 1 cap(s) $13 $0 $13 $8 incobotulinumtoxinA 50 units REC I 00259-1605-01 1 vial(s) $631 $0 $631 $379 heparin 1000 units/mL Soln 25021-0400-10 10 mL $38 $0 $38 $23 acetaminophen/butalbital/caffeine 325 mg-50 mg-40 mg Tab 68084-0396-65 1 tab(s) $15 $0 $15 $9 ascorbic acid 500 mg / 5 mL Soln 17856-0842-01 5 mL $12 $0 $12 $7 azelastine nasal 137 mcg/inh Spray 60505-0833-05 1 spray(s) $746 $0 $746 $448 anastrozole 1 mg Tab 00310-0201-30 1 tab(s) $64 $0 $64 $39 febuxostat 40 mg Tab 64764-0918-30 1 tab(s) $44 $0 $44 $26 clonidine 0.1 mg/24 hr ER Fi 00555-1009-16 1 patch(es) $240 $0 $240 $144 mirabegron 50 mg ER Ta 00469-2602-30 1 tab(s) $59 $0 $59 $36 mirtazapine 30 mg Tab 51079-0087-20 1 tab(s) $22 $0 $22 $13 fat emulsion, intravenous 20% Emuls 00338-0519-03 1 mL $31 $0 $31 $19 oxyCODONE 15 mg Tab 68084-0184-01 1 tab(s) $8 $0 $8 $5 lisinopril 40 mg Tab 68084-0199-01 1 tab(s) $7 $0 $7 $4 PARoxetine 25 mg ER Ta 60505-3674-03 1 tab(s) $42 $0 $42 $25 desonide topical 0.05% Lotio 00472-0803-02 1 app $2,119 $0 $2,119 $1,272 levOCARNitine 200 mg/mL Soln 54482-0147-01 1 mL $64 $0 $64 $38 nystatin-triamcinolone topical 100000 units/g-0.1% Cream 51672-1263-02 1 app $1,127 $0 $1,127 $676 cefTAZidime 2 g REC I 44567-0236-10 10 mL $92 $0 $92 $55 clobetasol topical 0.05% Cream 51672-1258-01 1 app $907 $0 $907 $544 fondaparinux 7.5 mg/0.6 mL Soln 43598-0609-10 0.6 mL $828 $0 $828 $497 valproic acid 250 mg/5 mL Syrup 00121-4675-55 5 mL $8 $0 $8 $5 atomoxetine 40 mg Cap 60687-0326-25 1 cap(s) $54 $0 $54 $33 multivitamin with minerals LIQ [Certa-Vite] UD 15 mL Soln 17856-4344-01 15 mL $13 $0 $13 $8 cycloSPORINE modified 100 mg/mL LIQ 00172-7313-20 1 mL $46 $0 $46 $28 silver sulfADIAZINE topical 1% Cream 00591-0810-46 1 app $456 $0 $456 $274 nitrofurantoin macrocrystals-monohydrate 100 mg Cap 68084-0446-01 1 cap(s) $21 $0 $21 $12 tacrolimus topical 0.1% Ointm 45802-0700-01 1 app $3,511 $0 $3,511 $2,107 arformoterol 15 mcg/2 mL Soln 63402-0911-30 2 mL $92 $0 $92 $55 fluticasone CFC free 44 mcg/inh Aeros 00173-0718-20 1 puff(s) $698 $0 $698 $419 fentaNYL 12 mcg/hr ER Fi 00781-7240-55 1 patch(es) $147 $0 $147 $88 spironolactone 25 mg Tab 51079-0103-20 1 tab(s) $6 $0 $6 $4 dexamethasone-tobramycin ophthalmic 0.1%-0.3% Susp 61314-0647-05 1 drop(s) $581 $0 $581 $349 dabigatran etexilate mesylate 150 mg Cap 00597-0135-60 1 cap(s) $30 $0 $30 $18 metoprolol 50 mg ER Ta 60687-0402-01 1 tab(s) $11 $0 $11 $6 mometasone 220 mcg/inh Aeros 00085-1341-06 1 INH $630 $0 $630 $378 midodrine 10 mg Tab 60687-0409-25 1 tab(s) $15 $0 $15 $9 potassium phosphate 3 mmol/mL Soln 63323-0086-15 1 mL $19 $0 $19 $12 ipratropium 0.02% Soln 00487-9801-01 2.5 mL $17 $0 $17 $10 oxybutynin 5 mg Tab 00904-2821-61 1 tab(s) $8 $0 $8 $5 fish oil 500 mg Cap 00904-5604-13 1 cap(s) $40 $0 $40 $24 LVP solution Sodium Chloride 0.9% Soln 00409-7984-36 50 mL $44 $0 $44 $26 labetalol 200 mg Tab 65483-0392-22 1 tab(s) $10 $0 $10 $6 furosemide 20 mg Tab 51079-0072-20 1 tab(s) $4 $0 $4 $3 lidocaine topical 2% Gel 76329-3012-05 5 mL $56 $0 $56 $34 nicotine 14 mg/24 hr ER Fi 43598-0447-74 1 patch(es) $23 $0 $23 $14 diazepam 2.5 mg Kit 00093-6137-32 1 EA $1,978 $0 $1,978 $1,187 loteprednol ophthalmic 0.5% Susp 24208-0299-10 1 drop(s) $2,654 $0 $2,654 $1,592 topiramate 100 mg Tab 00045-0641-65 1 tab(s) $40 $0 $40 $24 calcium carbonate 500 mg Chew 66553-0004-01 1 tab(s) $4 $0 $4 $2 cepHALexin 500 mg Cap 60687-0163-01 1 cap(s) $5 $0 $5 $3 ezetimbe 10 mg Tab 00591-3713-30 1 tab(s) $79 $0 $79 $47 ciprofloxacin 250 mg Susp 50419-0777-01 1 mL $14 $0 $14 $8 sertraline 100 mg Tab 60687-0253-01 1 tab(s) $6 $0 $6 $4 lisinopril 20 mg Tab 68084-0198-01 1 tab(s) $6 $0 $6 $4 clonazePAM 1 mg Tab 63739-0264-10 1 tab(s) $11 $0 $11 $7 cloNIDine Patch 0.2 mg/24 hr Patch 51862-0454-04 1 patch(es) $399 $0 $399 $239 nicotine 7 mg/24 hr ER Fi 43598-0446-74 1 patch(es) $20 $0 $20 $12 cefadroxil 500 mg Cap 00093-3196-01 1 cap(s) $27 $0 $27 $16 metFORMIN 500 mg ER Ta 00904-5794-61 1 tab(s) $8 $0 $8 $5 fat emulsion, intravenous with fish, medium chain, olive, and soy oil 20% Emuls 63323-0820-00 1 mL $51 $0 $51 $31 oxyCODONE 5 mg/5 mL oral Soln 99345-0001-59 5 mL $8 $0 $8 $5 bethanechol 25 mg Tab 00832-0512-01 1 tab(s) $21 $0 $21 $13 loratadine 10 mg Tab 51079-0538-20 1 tab(s) $9 $0 $9 $5 tbo-filgrastim 300 mcg/0.5 mL Soln 63459-0910-15 0.5 mL $2,039 $0 $2,039 $1,224 cyanocobalamin 1000 mcg Tab 50268-0855-15 1 tab(s) $6 $0 $6 $3 clobazam oral susp PFS 2.5 mg/mL Soln 99345-0002-05 1 mL $47 $0 $47 $28 FLUoxetine 20 mg/5 mL Soln 00121-0721-04 1 mL $5 $0 $5 $3 dorzolamide ophthalmic 2% Soln 50383-0232-10 1 drop(s) $476 $0 $476 $286 cloNIDine 0.1 mg Tab 00597-0006-61 1 tab(s) $8 $0 $8 $5 amphotericin B [Conventional] NEB 5 mg/mL Soln 99345-0002-10 1 mL $44 $0 $44 $26

Page 57 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price venlafaxine 75 mg Tab 51079-0482-20 1 tab(s) $18 $0 $18 $11 guaiFENesin ER 600 mg Tab 63824-0008-15 1 tab(s) $6 $0 $6 $4 HYDROmorphone 2 mg Tab 68084-0423-01 1 tab(s) $6 $0 $6 $4 risperidone 1 mg Tab 51079-0462-20 1 tab(s) $34 $0 $34 $20 phenazopyridine 100 mg Tab 51293-0810-01 1 tab(s) $21 $0 $21 $13 testosterone 2 mg/24 hr ER Fi 52544-0076-60 1 EA $55 $0 $55 $33 eszopiclone 3 mg Tab 51079-0414-03 1 tab(s) $86 $0 $86 $52 morphine sulfate 15 mg Tab 00054-0235-24 1 tab(s) $7 $0 $7 $4 baclofen 0.5 mg/mL Soln 70257-0560-02 40 mL $624 $0 $624 $374 cefdinir 300 mg Cap 00093-3160-06 1 cap(s) $38 $0 $38 $23 budesonide 0.25 mg / 2 mL Soln 69097-0318-87 2 mL $48 $0 $48 $29 clonazePAM 0.5 mg / 5 mL Susp 99345-0001-70 5 mL $10 $0 $10 $6 diazepam 2 mg Tab 51079-0284-20 1 tab(s) $6 $0 $6 $4 divalproex sodium 500 mg ER Ta 51079-0767-08 1 tab(s) $23 $0 $23 $14 brimonidine ophthalmic 0.1% Soln 00023-9321-10 1 drop(s) $1,584 $0 $1,584 $951 clindamycin topical 1% Lotio 59762-3744-01 1 app $849 $0 $849 $509 hydrocortisone-pramoxine topical 1%-1% Foam 00037-6822-10 1 app $785 $0 $785 $471 fludrocortisone 0.1 mg Tab 68084-0288-01 1 tab(s) $9 $0 $9 $5 risperidone 1 mg/mL Soln 00054-0063-44 1 mL $44 $0 $44 $26 metoclopramide 10 mg Tab 51079-0888-20 1 tab(s) $5 $0 $5 $3 topiramate 25 mg Tab 68084-0342-01 1 tab(s) $17 $0 $17 $10 brinzolamide ophthalmic 1% Susp 00065-0275-10 1 drop(s) $1,354 $0 $1,354 $812 divalproex sodium 125 mg DRC 68084-0313-01 1 cap(s) $9 $0 $9 $5 cloNIDine 0.3 mg Tab 00597-0011-01 1 tab(s) $17 $0 $17 $10 methadone Oral prefilled syringe 1 mg / 1 mL Soln 99345-0002-45 1 mL $15 $0 $15 $9 ketoconazole topical 2% Cream 00168-0099-30 1 app $374 $0 $374 $224 levothyroxine 100 mcg (0.1 mg) Tab 00074-6624-11 1 tab(s) $7 $0 $7 $4 predniSONE 5 mg Tab 00054-8724-25 1 tab(s) $4 $0 $4 $2 allopurinol 100 mg Tab 65483-0991-10 1 tab(s) $6 $0 $6 $4 enoxaparin (compound) 20 mg/mL Soln 99345-0002-01 1 mL $137 $0 $137 $82 dantrolene 50 mg Cap 00149-0031-05 1 cap(s) $16 $0 $16 $10 armodafinil 250 mg Tab 63459-0225-30 1 tab(s) $160 $0 $160 $96 risperidone 2 mg Tab 50458-0320-01 1 tab(s) $50 $0 $50 $30 ganciclovir 500 mg REC I 63323-0315-10 10 mL $745 $0 $745 $447 acyclovir 800 mg Tab 00173-0945-55 1 tab(s) $58 $0 $58 $35 zinc sulfate [compound] 44 mg/mL Soln 99345-0002-07 1 mL $15 $0 $15 $9 lamoTRIgine 200 mg Tab 69097-0152-03 1 tab(s) $41 $0 $41 $25 levothyroxine 75 mcg (0.075 mg) Tab 51079-0441-20 1 tab(s) $6 $0 $6 $3 iohexol 300 mg/mL Soln 00407-1413-10 10 mL $402 $0 $402 $241 divalproex sodium 250 mg EC Ta 00245-0181-01 1 tab(s) $16 $0 $16 $9 budesonide 180 mcg/inh Powde 00186-0916-12 1 INH $1,439 $0 $1,439 $864 nystatin topical 100000 units/g Cream 00603-7818-78 1 app $193 $0 $193 $116 cefpodoxime 200 mg Tab 63304-0521-20 1 tab(s) $49 $0 $49 $29 guar gum 100% REC P 43900-0976-47 1 packet(s) $7 $0 $7 $4 citalopram 10 mg Tab 00904-6084-61 1 tab(s) $20 $0 $20 $12 midodrine 2.5 mg Tab 00245-0211-11 1 tab(s) $11 $0 $11 $7 simethicone 40 mg/0.6 mL LIQ 00536-2220-75 0.6 mL $30 $0 $30 $18 linezolid 600 mg Tab 42292-0008-03 1 tab(s) $31 $0 $31 $19 traMADol 25 mg Tab 99345-0003-05 0.5 tab(s) $6 $0 $6 $4 warfarin 3 mg Tab 00832-1214-01 1 tab(s) $8 $0 $8 $5 warfarin 4 mg Tab 00832-1215-01 1 tab(s) $8 $0 $8 $5 aspirin 325 mg Tab 66553-0001-01 1 tab(s) $4 $0 $4 $2 dexamethasone 2 mg Tab 00054-8176-25 1 tab(s) $8 $0 $8 $5 diazepam 5 mg Tab 51079-0285-20 1 tab(s) $7 $0 $7 $4 sodium chloride 14.6% Soln 63323-0139-40 1 mL $9 $0 $9 $5 rivaroxaban 10 mg Tab 50458-0580-30 1 tab(s) $62 $0 $62 $37 propranolol 20 mg Tab 00603-5483-21 1 tab(s) $6 $0 $6 $3 silver sulfADIAZINE topical 1% Cream 67877-0124-05 1 app $113 $0 $113 $68 donepezil 5 mg Tab 60687-0292-01 1 tab(s) $9 $0 $9 $5 sodium polystyrene sulfonate 15 g/60 mL Susp 46287-0006-60 60 mL $84 $0 $84 $51 lidocaine topical 2% Gel 76329-3015-05 20 mL $72 $0 $72 $43 bacitracin/neomycin/poly B 400 units-3.5 mg-5000 uni Ointment 45802-0143-03 1 app $52 $0 $52 $31 calcitonin 200 intl units/inh Spray 60505-0823-06 1 spray(s) $839 $0 $839 $503 sulfamethoxazole-trimethoprim 200 mg-40 mg/5 mL Susp 50383-0823-16 1 mL $5 $0 $5 $3 torsemide 20 mg Tab 00004-0264-01 1 tab(s) $12 $0 $12 $7 formoterol 20 mcg/2 mL Soln 49502-0605-61 2 mL $49 $0 $49 $29 pramipexole 0.25 mg Tab 00597-0084-90 1 tab(s) $17 $0 $17 $10 methocarbamol 500 mg Tab 68084-0056-01 1 tab(s) $6 $0 $6 $4 predniSONE 10 mg Tab 63739-0519-10 1 tab(s) $4 $0 $4 $3 citalopram 20 mg Tab 00904-6085-61 1 tab(s) $21 $0 $21 $13 diazepam 10 mg Kit 00093-6138-32 1 EA $2,253 $0 $2,253 $1,352 thiamine 100 mg/mL Soln 63323-0013-02 2 mL $95 $0 $95 $57 iopamidol 76% Soln 00270-1316-52 1 mL $16 $0 $16 $10 diazepam 20 mg Kit 00093-6139-32 1 EA $2,253 $0 $2,253 $1,352 fenofibrate 145 mg Tab 00074-6123-90 1 tab(s) $44 $0 $44 $26 calcium gluconate 100 mg/mL Inj soln 63323-0311-19 1 mL $11 $0 $11 $6 multivitamin Multiple Vitamins Soln 61703-0423-83 1 mL $15 $0 $15 $9 potassium chloride 2 mEq/mL Soln 00409-6651-06 10 mL $18 $0 $18 $11 cefTRIAXone 1 g REC I 00409-7332-01 10 mL $76 $0 $76 $46

Page 58 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price PARoxetine 20 mg Tab 68084-0045-01 1 tab(s) $22 $0 $22 $13 eplerenone 25 mg Tab 59762-1710-01 1 tab(s) $31 $0 $31 $18 fentanyl 25 mcg/hr ER Fi 00406-9025-76 1 patch(es) $106 $0 $106 $63 omega-3 polyunsaturated fatty acids ethyl esters 1000 mg Cap 60687-0127-65 1 cap(s) $28 $0 $28 $17 flecainide 100 mg Tab 68084-0540-25 1 tab(s) $30 $0 $30 $18 calcipotriene topical 0.005% Cream 68462-0501-65 1 app $4,281 $0 $4,281 $2,569 zinc sulfate 220 mg Cap 00904-5332-60 1 cap(s) $4 $0 $4 $2 OLANZapine 2.5 mg Tab 00002-4112-33 1 tab(s) $50 $0 $50 $30 insulin isophane (NPH) human recombinant 100 units/mL Susp 00002-8315-17 1 mL $97 $0 $97 $58 efavirenz/emtricitabine/tenofovir 600 mg-200 mg-300 mg Tab 15584-0101-01 1 tab(s) $497 $0 $497 $298 mirabegron 25 mg ER Ta 00469-2601-30 1 tab(s) $59 $0 $59 $36 itraconazole 10 mg/mL Soln 50458-0295-15 1 mL $18 $0 $18 $11 aspirin 325 mg EC Ta 63739-0023-01 1 tab(s) $4 $0 $4 $2 nystatin topical 100000 units/g Ointm 45802-0048-11 1 app $193 $0 $193 $116 clindamycin 300 mg Cap 68084-0244-01 1 cap(s) $12 $0 $12 $7 methylphenidate 10 mg Tab 68084-0823-21 1 tab(s) $6 $0 $6 $4 predniSONE 20 mg Tab 00054-0018-20 1 tab(s) $4 $0 $4 $3 spironolactone 50 mg Tab 51079-0979-20 1 tab(s) $9 $0 $9 $6 oxyCODONE cr 60 mg ER Tablet 59011-0460-10 1 tab(s) $101 $0 $101 $60 fat emulsion, intravenous 20% Emuls 00338-0519-02 1 mL $50 $0 $50 $30 magnesium sulfate 50% Soln 63323-0064-02 1 mL $12 $0 $12 $7 PARoxetine 10 mg/5 mL Susp 60505-0402-05 1 mL $13 $0 $13 $8 dantrolene 25 mg Cap 00149-0030-77 1 cap(s) $10 $0 $10 $6 warfarin 5 mg Tab 00832-1216-01 1 tab(s) $8 $0 $8 $5 cholestyramine 4 g/9 g REC P 49884-0465-65 1 packet(s) $26 $0 $26 $16 bicalutamide 50 mg Tab 00904-6019-46 1 tab(s) $114 $0 $114 $68 clindamycin 150 mg Cap 00009-0225-03 1 cap(s) $24 $0 $24 $15 hydrALAZINE 10 mg Tab 68084-0447-01 1 tab(s) $7 $0 $7 $4 OXcarbazepine 300 mg/5 mL Susp 65162-0649-78 1 mL $10 $0 $10 $6 indomethacin 25 mg/5 mL Susp 42211-0101-11 1 mL $16 $0 $16 $10 levothyroxine 50 mcg (0.05 mg) Tab 51079-0440-20 1 tab(s) $6 $0 $6 $3 solifenacin 10 mg Tab 51248-0151-01 1 tab(s) $63 $0 $63 $38 hydrocortisone topical 2.5% Cream 10631-0407-01 1 app $656 $0 $656 $393 saliva substitutes - Soln 48582-0003-30 15 mL $41 $0 $41 $25 acetaminophen-oxycodone 325 mg-5 mg Tab 00406-0512-62 1 tab(s) $7 $0 $7 $4 levothyroxine 25 mcg (0.025 mg) Tab 51079-0444-20 1 tab(s) $5 $0 $5 $3 celecoxib 100 mg Cap 68084-0969-01 1 cap(s) $34 $0 $34 $21 megestrol 40 mg/mL Susp 68094-0250-62 10 mL $34 $0 $34 $20 hydrochlorothiazide 25 mg Tab 00172-2083-10 1 tab(s) $4 $0 $4 $3 simvastatin 10 mg Tab 00006-0735-31 1 tab(s) $24 $0 $24 $15 isosorbide mononitrate 30 mg ER Ta 68084-0591-01 1 tab(s) $15 $0 $15 $9 hydromorphone 4 mg Tab 68084-0472-01 1 tab(s) $6 $0 $6 $4 ocular lubricant - Soln 00023-4554-30 1 drop(s) $10 $0 $10 $6 sodium bicarbonate 650 mg Tab 00536-4544-10 1 tab(s) $3 $0 $3 $2 alendronate 70 mg Tab 69543-0131-20 1 tab(s) $141 $0 $141 $84 ibuprofen 600 mg Tab 59762-7379-01 1 tab(s) $5 $0 $5 $3 lidocaine topical 4% Cream 24357-0701-30 1 app $243 $0 $243 $146 desmopressin 0.1 mg Tab 50268-0220-15 1 tab(s) $23 $0 $23 $14 citalopram 10 mg/5 mL Soln 00054-0062-58 1 mL $11 $0 $11 $7 benzonatate 100 mg Cap 60687-0346-01 1 cap(s) $8 $0 $8 $5 zolpidem 6.25 mg ER Ta 00955-1702-10 1 tab(s) $47 $0 $47 $28 venlafaxine 25 mg Tab 00008-0701-01 1 tab(s) $17 $0 $17 $10 amphotericin B [conventional] Nasal Spray 5 mg/mL Spray 99345-0002-30 1 spray(s) $331 $0 $331 $199 cloNIDine 0.2 mg Tab 00597-0007-61 1 tab(s) $10 $0 $10 $6 amLODIPine 2.5 mg Tab 60687-0285-01 1 tab(s) $6 $0 $6 $4 ALPRAZolam 0.5 mg Tab 51079-0789-20 1 tab(s) $10 $0 $10 $6 temozolomide 10 mg/mL Susp 99345-0001-98 1 mL $189 $0 $189 $113 acetaminophen-HYDROcodone 325 mg-7.5 mg/15 mL Soln 00121-4772-15 15 mL $39 $0 $39 $24 OLANZapine 10 mg REC I 00781-3159-72 2 mL $299 $0 $299 $179 sulfamethoxazole-trimethoprim 400 mg-80 mg Tab 65862-0419-01 1 tab(s) $8 $0 $8 $5 LVP solution Dextrose 5% with 0.45% NaCl Soln 00264-7612-00 1000 mL $100 $0 $100 $60 sertraline 25 mg Tab 68084-0180-01 1 tab(s) $6 $0 $6 $4 carBAMazepine 100 mg ER Ca 60505-2805-07 1 cap(s) $16 $0 $16 $10 brimonidine-timolol ophthalmic 0.2%-0.5% Soln 00023-9211-05 1 drop(s) $877 $0 $877 $526 ropinirole 1 mg Tab 00007-4892-20 1 tab(s) $17 $0 $17 $10 digoxin 125 mcg (0.125 mg) Tab 42292-0003-20 1 tab(s) $10 $0 $10 $6 mycophenolic acid 360 mg EC Tablet 68084-0918-25 1 tab(s) $70 $0 $70 $42 sodium acetate 2 mEq/mL Soln 00409-7299-73 1 mL $9 $0 $9 $5 methadone 10 mg Tab 68084-0738-01 1 tab(s) $8 $0 $8 $5 tolterodine 4 mg ER Ca 00093-7164-56 1 cap(s) $57 $0 $57 $34 desonide topical 0.05% Cream 51672-1280-03 1 app $2,258 $0 $2,258 $1,355 lactobacillus acidophilus and bulgaricus - Granu 64980-0146-12 1 packet(s) $9 $0 $9 $5 warfarin 6 mg Tab 00832-1217-01 1 tab(s) $9 $0 $9 $6 sodium chloride 1 g Tab 00223-1760-01 1 tab(s) $4 $0 $4 $2 ofloxacin ophthalmic 0.3% Soln 17478-0713-10 1 drop(s) $291 $0 $291 $175 tramadol 100 mg ER Ta 00062-0653-30 1 tab(s) $27 $0 $27 $16 linagliptin 5 mg Tab 00597-0140-61 1 tab(s) $84 $0 $84 $50 hydrochlorothiazide 12.5 mg Cap 00603-3855-21 1 cap(s) $6 $0 $6 $4 calcitriol 1 mcg/mL LIQ 00054-3120-41 1 mL $88 $0 $88 $53

Page 59 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price budesonide 0.25 mg/2 mL Susp 00093-6815-73 2 mL $74 $0 $74 $44 tapentadol 50 mg Tab 50458-0820-02 1 tab(s) $19 $0 $19 $12 abacavir 300 mg Tab 00378-4105-91 1 tab(s) $71 $0 $71 $42 ampicillin-sulbactam 2 g-1 g REC I 63323-0369-20 0 $73 $0 $73 $44 linezolid 2 mg/mL Soln 00009-5140-04 300 mL $344 $0 $344 $207 Avosil ointment 120 gm 76170-0400-01 1 app $193 $0 $193 $116 magnesium lactate 84 mg ER Ta 59016-0420-17 1 tab(s) $5 $0 $5 $3 ascorbic acid 500 mg Chew 00904-0526-60 1 tab(s) $4 $0 $4 $2 QUEtiapine 25 mg Tab 00904-6638-61 1 tab(s) $6 $0 $6 $3 azithromycin 100 mg/5 mL REC P 00093-2027-23 1 mL $21 $0 $21 $13 senna 8.8 mg/5 mL Syrup 54162-0007-08 1 mL $5 $0 $5 $3 nicotine 21 mg/24 hr ER Fi 43598-0448-28 1 patch(es) $21 $0 $21 $13 predniSONE 5 mg/5 mL Soln 00054-3722-63 1 mL $6 $0 $6 $4 doxazosin 4 mg Tab 00049-2770-66 1 tab(s) $13 $0 $13 $8 iohexol 240 mg/mL Soln 00407-1412-30 1 mL $14 $0 $14 $9 amphetamine-dextroamphetamine 10 mg ER Ca 54092-0383-01 1 cap(s) $33 $0 $33 $20 memantine 5 mg Tab 00456-3205-60 1 tab(s) $21 $0 $21 $12 hydroxychloroquine 200 mg Tab 68084-0269-01 1 tab(s) $7 $0 $7 $4 bumetanide 0.25 mg/mL Soln 00641-6008-10 4 mL $27 $0 $27 $16 bumetanide 2 mg Tab 00185-0130-01 1 tab(s) $12 $0 $12 $7 furosemide 10 mg/mL LIQ 00054-3294-50 1 mL $6 $0 $6 $3 clotrimazole 10 mg Lozen 00574-0107-77 1 lozenge(s) $13 $0 $13 $8 OXcarbazepine 150 mg Tab 00078-0336-05 1 tab(s) $13 $0 $13 $8 Pravastatin 10 mg Tab 50268-0672-15 1 tab(s) $23 $0 $23 $14 rOPINIRole 0.25 mg Tab 68462-0253-01 1 tab(s) $20 $0 $20 $12 diazepam oral solution 2 mg Syringe 99345-0001-65 2 mL $11 $0 $11 $6 entacapone 200 mg Tab 51079-0273-03 1 tab(s) $31 $0 $31 $18 clonazePAM 0.25 mg DIS T 49884-0307-02 1 tab(s) $12 $0 $12 $7 atropine-diphenoxylate 0.025 mg-2.5 mg Tab 59762-1061-01 1 tab(s) $9 $0 $9 $6 LORazepam 1 mg Tab 51079-0386-20 1 tab(s) $11 $0 $11 $7 memantine 10 mg Tab 00456-3210-60 1 tab(s) $21 $0 $21 $12 cholecalciferol 5000 intl units Cap 00904-5986-60 1 cap(s) $4 $0 $4 $2 rasagiline 0.5 mg Tab 00378-1270-93 1 tab(s) $171 $0 $171 $102 isosorbide mononitrate 60 mg ER Tab 00085-4110-03 1 tab(s) $18 $0 $18 $11 dantrolene 100 mg Cap 00115-4433-01 1 cap(s) $18 $0 $18 $11 Benadryl-Maalox-Xylocaine 120 mL oral Susp 99345-0001-04 10 mL $96 $0 $96 $57 warfarin 2.5 mg Tab 68084-0027-01 1 tab(s) $8 $0 $8 $5 irbesartan 150 mg Tab 68180-0411-06 1 tab(s) $24 $0 $24 $14 multivitamin Vitamin B Complex with C and Folic Acid Tab 00536-7300-01 1 tab(s) $4 $0 $4 $3 phenytoin 100 mg ER Cap 51079-0905-20 1 cap(s) $6 $0 $6 $3 albumin human 25% Soln 68982-0643-02 100 mL $855 $0 $855 $513 venlafaxine 37.5 mg Tab 68084-0484-11 1 cap(s) $28 $0 $28 $17 beclomethasone [QVar 40] 40 mcg / 1 INH Aerosol 59310-0302-40 1 INH $1,432 $0 $1,432 $859 valproic acid 250 mg/5 mL Syrup 00121-0675-16 1 mL $6 $0 $6 $3 warfarin 2 mg Tab 62584-0984-01 1 tab(s) $8 $0 $8 $5 NIFEdipine 90 mg ER Ta 68084-0603-21 1 tab(s) $21 $0 $21 $12 methotrexate 2.5 mg/mL Soln 52652-2001-01 1 mL $137 $0 $137 $82 teriparatide 600 mcg/2.4 ml Syringe 00002-8400-01 0.08 mL $5,606 $0 $5,606 $3,363 acetaminophen 160 mg/5 mL Susp 46122-0211-26 5 mL $38 $0 $38 $23 busPIRone 5 mg Tab 00087-0818-41 1 tab(s) $10 $0 $10 $6 hydrocortisone 10 mg Tab 68084-0469-01 1 tab(s) $7 $0 $7 $4 cephalexin 250 mg/5 mL REC P 00093-4177-73 1 mL $6 $0 $6 $4 bupivacaine 0.25% preservative-free Soln 00409-1159-01 10 mL $24 $0 $24 $14 oseltamivir 75 mg Cap 00004-0800-85 1 cap(s) $60 $0 $60 $36 fondaparinux 10 mg/0.8 mL Soln 55111-0681-10 0.8 mL $909 $0 $909 $546 Mederma Oint 00259-0303-50 1 app $204 $0 $204 $122 traZODone 50 mg Tab 00904-6868-61 1 tab(s) $4 $0 $4 $3 mycophenolic acid 180 mg EC Ta 51079-0508-20 1 tab(s) $37 $0 $37 $22 calcium-vitamin D 500 mg-200 intl units Tab 63739-0291-01 1 tab(s) $4 $0 $4 $2 cefadroxil 250 mg/5 mL REC P 68180-0181-02 1 mL $9 $0 $9 $5 diltiazem 30 mg Tab 51079-0745-20 1 tab(s) $6 $0 $6 $4 potassium phosphate-sodium phosphate 250 mg-278 mg-164 mg REC P 60258-0006-01 1 packet(s) $6 $0 $6 $4 acyclovir 200 mg Cap 00904-5789-61 1 cap(s) $14 $0 $14 $8 triamcinolone topical 0.1% Cream 00168-0004-16 1 app $231 $0 $231 $138 ranolazine 500 mg ER Ta 61958-1003-01 1 tab(s) $32 $0 $32 $19 pilocarpine 5 mg Tab 68084-0928-25 1 tab(s) $23 $0 $23 $14 desmopressin 0.2 mg Tab 50268-0221-15 1 tab(s) $32 $0 $32 $19 rifampin 300 mg Cap 68084-0358-01 1 cap(s) $12 $0 $12 $7 bumetanide 0.5 mg Tab 00832-0540-11 1 tab(s) $20 $0 $20 $12 methadone 5 mg/5mL Soln PFS 99345-0001-53 5 mL $40 $0 $40 $24 fluocinonide topical 0.05% Cream 00093-0262-30 1 app $647 $0 $647 $388 prednisoLONE 15 mg/5 mL Syrup 50383-0042-48 1 mL $7 $0 $7 $4 methimazole 10 mg Tab 60793-0105-01 1 tab(s) $11 $0 $11 $7 pancrelipase 120,000 units-24,000 units-76,000 units DRC 00032-1224-01 1 cap(s) $29 $0 $29 $17 rifaximin 200 mg Tab 65649-0301-03 1 tab(s) $84 $0 $84 $50 mupirocin topical 2% Ointm 45802-0112-22 1 app $87 $0 $87 $52 cefpodoxime 100 mg/5 mL REC P 00781-6169-52 1 mL $12 $0 $12 $7 metroNIDAZOLE topical 0.75% Gel 51672-4116-06 1 app $506 $0 $506 $304 levothyroxine 125 mcg (0.125 mg) Tab 00074-7068-11 1 tab(s) $13 $0 $13 $8

Page 60 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price diltiazem 60 mg Tab 51079-0746-20 1 tab(s) $8 $0 $8 $5 doxercalciferol 2 mcg/mL Soln 58468-0122-01 1 mL $109 $0 $109 $65 omeprazole 10 mg DRC 62175-0114-37 1 cap(s) $28 $0 $28 $17 diphenhydrAMINE-zinc acetate topical 2%-0.1% Cream 51672-2066-02 1 app $37 $0 $37 $22 citric acid-potassium bicarbonate 20 mEq EFF T 51801-0012-30 1 tab(s) $7 $0 $7 $4 ipratropium nasal 42 mcg/inh Spray 24208-0399-15 1 spray(s) $328 $0 $328 $197 nebivolol 5 mg Tab 00456-1405-63 1 tab(s) $19 $0 $19 $11 mirtazapine 15 mg DIS T 65862-0021-06 1 tab(s) $19 $0 $19 $11 hydrocortisone 5 mg Tab 68084-0789-25 1 tab(s) $10 $0 $10 $6 citalopram 40 mg Tab 00456-4040-01 1 tab(s) $25 $0 $25 $15 armodafinil 50 mg Tab 00378-3431-93 1 tab(s) $55 $0 $55 $33 levalbuterol CFC free 45 mcg/inh Aeros 63402-0510-01 1 puff(s) $441 $0 $441 $265 sulfamethoxazole-trimethoprim 80 mg-16 mg/mL Soln 00703-9503-03 1 mL $14 $0 $14 $8 buPROPion 300 mg/24 hours ER Ta 68084-0252-21 1 tab(s) $35 $0 $35 $21 ciprofloxacin 400 mg/200 mL-5% Soln 00409-4777-02 200 mL $77 $0 $77 $46 amphetamine-dextroamphetamine 5 mg Tab 64720-0130-10 1 tab(s) $14 $0 $14 $8 levalbuterol 0.63 mg/3 mL Soln 66993-0022-27 3 mL $55 $0 $55 $33 nortriptyline 25 mg Cap 60687-0293-01 1 cap(s) $9 $0 $9 $6 triamcinolone topical 0.1% Ointm 45802-0055-05 1 app $294 $0 $294 $177 allopurinol 300 mg Tab 62584-0713-01 1 tab(s) $8 $0 $8 $5 phenytoin 125 mg/5 mL Susp 51672-4069-01 1 mL $6 $0 $6 $3 bisacodyl 10 mg Soln 00132-0703-36 37 mL $18 $0 $18 $11 ciprofloxacin ophthalmic 0.3% Soln 61314-0656-05 1 drop(s) $339 $0 $339 $204 rivastigmine 4.6 mg/24 hr ER Fi 00078-0501-15 1 patch(es) $60 $0 $60 $36 warfarin 1 mg Tab 00832-1211-01 1 tab(s) $7 $0 $7 $4 multivitamin Vitamin B Complex with Folic Acid Tab 51991-0384-90 1 tab(s) $8 $0 $8 $5 propranolol 40 mg Tab 00603-5484-21 1 tab(s) $8 $0 $8 $5 PARoxetine 10 mg Tab 00029-3210-13 1 tab(s) $25 $0 $25 $15 glipiZIDE 10 mg Tab 00049-4120-66 1 tab(s) $10 $0 $10 $6 ocular lubricant - Ointm 00023-0240-04 1 app $74 $0 $74 $45 calcium carbonate 1250 mg/5 mL Susp 00054-3117-63 1 mL $5 $0 $5 $3 oxycodone 2.5 mg Soln 99345-0001-60 2.5 mL $6 $0 $6 $4 econazole topical 1% Cream 51672-1303-02 1 app $1,533 $0 $1,533 $920 lamoTRIgine 100 mg Tab 68084-0319-01 1 tab(s) $5 $0 $5 $3 glipiZIDE 5 mg Tab 51079-0810-20 1 tab(s) $6 $0 $6 $3 cyanocobalamin 500 mcg Tab 50268-0854-15 1 tab(s) $5 $0 $5 $3 timolol ophthalmic 0.25% Soln 61314-0226-15 1 drop(s) $204 $0 $204 $122 oxandrolone 2.5 mg Tab 54396-0111-11 1 tab(s) $46 $0 $46 $27 LVP solution Dextrose 5% in Water Soln 00409-7922-25 250 mL $65 $0 $65 $39 conjugated estrogens topical 0.625 mg/g Cream 00046-0872-21 0 $1,133 $0 $1,133 $680 ibuprofen 400 mg Tab 63739-0442-10 1 tab(s) $5 $0 $5 $3 phenytoin 50 mg Chew 00071-0007-40 1 tab(s) $7 $0 $7 $4 pyridoxine 50 mg Tab 50268-0858-15 1 tab(s) $5 $0 $5 $3 phenylephrine topical 0.25%-3% Ointm 00573-2871-20 1 app $76 $0 $76 $45 dexamethasone 1 mg/mL Conc 00054-3176-44 1 mL $11 $0 $11 $6 lopinavir-ritonavir 200 mg-50 mg Tab 00074-6799-22 1 tab(s) $52 $0 $52 $31 LVP solution Dextrose 5% in Water Soln 00409-7923-37 100 mL $30 $0 $30 $18 bisoprolol 5 mg Tab 51285-0060-01 1 tab(s) $20 $0 $20 $12 azelastine ophthalmic 0.05% Soln 61314-0308-02 1 drop(s) $737 $0 $737 $442 sucralfate 1 g Tab 51079-0753-20 1 tab(s) $6 $0 $6 $4 cyanocobalamin 100 mcg Tab 50268-0852-15 1 tab(s) $5 $0 $5 $3 piperacillin-tazobactam 2 g-0.25 g REC I 60505-0686-04 0 $88 $0 $88 $53 beclomethasone 80 mcg/inh Aeros 59310-0204-12 1 INH $1,436 $0 $1,436 $862 oxybutynin 5 mg/5 mL Syrup 00603-1491-58 1 mL $5 $0 $5 $3 galantamine 4 mg Tab 68084-0729-21 1 tab(s) $22 $0 $22 $13 methylPREDNISolone 1 g REC Inj 00009-0698-01 16 mL $162 $0 $162 $97 prednisoLONE ophthalmic acetate 1% Susp 61314-0637-10 1 drop(s) $211 $0 $211 $127 calcitriol 0.25 mcg Cap 64380-0723-06 1 cap(s) $11 $0 $11 $7 mesalamine 500 mg ER Ca 54092-0191-12 1 cap(s) $19 $0 $19 $11 LORazepam 0.5 mg Tab 63739-0499-10 1 tab(s) $5 $0 $5 $3 NIFEdipine 30 mg ER Ta 68084-0597-01 1 tab(s) $12 $0 $12 $7 raltegravir 400 mg Tab 00006-0227-61 1 tab(s) $163 $0 $163 $98 trimethobenzamide 300 mg Cap 43386-0660-03 1 cap(s) $17 $0 $17 $10 risperiDONE 0.25 mg Tab 51079-0460-20 1 tab(s) $29 $0 $29 $18 diazepam 1 mg Soln 99345-0001-48 1 mL $7 $0 $7 $4 omega-3 polyunsaturated fatty acids 1600 mg/5 mL LIQ 88395-0015-40 1 mL $5 $0 $5 $3 isosorbide dinitrate 20 mg Tab 00143-1772-01 1 tab(s) $5 $0 $5 $3 tapentadol 50 mg ER Ta 50458-0860-01 1 tab(s) $24 $0 $24 $14 calcium-vitamin D 600 mg-400 intl units Tab 00005-5509-19 1 tab(s) $4 $0 $4 $2 atenolol 50 mg Tab 62584-0467-01 1 tab(s) $11 $0 $11 $7 prazosin 1 mg Cap 51079-0630-20 1 cap(s) $5 $0 $5 $3 ocular lubricant - Gel 00078-0429-47 1 app $59 $0 $59 $35 triamcinolone topical 0.1% Cream 00168-0004-15 1 app $47 $0 $47 $28 mineral oil 100% Enema 00132-0301-40 133 mL $12 $0 $12 $7 ketorolac ophthalmic 0.5% Soln 17478-0209-10 1 drop(s) $757 $0 $757 $454 primidone 50 mg Tab 68084-0202-01 1 tab(s) $9 $0 $9 $5 octreotide 100 mcg/mL Soln 25021-0452-01 1 mL $63 $0 $63 $38 diltiazem 90 mg Tab 51079-0747-20 1 tab(s) $11 $0 $11 $6 triamcinolone topical 0.1% Ointm 00168-0006-15 1 app $47 $0 $47 $28

Page 61 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price levothyroxine 88 mcg (0.088 mg) Tab 00527-1344-01 1 tab(s) $7 $0 $7 $4 hydrOXYzine pamoate 25 mg Cap 51079-0077-20 1 cap(s) $5 $0 $5 $3 mexiletine 150 mg Cap 00597-0066-01 1 cap(s) $12 $0 $12 $7 solifenacin 5 mg Tab 51248-0150-52 1 tab(s) $27 $0 $27 $16 levothyroxine 125 mcg (0.125 mg) Tab 00378-1813-77 1 tab(s) $8 $0 $8 $5 docusate 100 mg Tab 57896-0421-01 1 tab(s) $4 $0 $4 $2 mafenide topical 85 mg/g Cream 51079-0623-81 1 app $370 $0 $370 $222 atropine ophth 1% soln 17478-0215-05 1 drop(s) $329 $0 $329 $197 LORazepam 0.5 mg Conc 99345-0001-51 0.25 mL $7 $0 $7 $4 enalapril 10 mg Tab 68682-0712-01 1 tab(s) $8 $0 $8 $5 aztreonam 1 gm Injection 63323-0401-20 10 mL $285 $0 $285 $171 LVP solution Dextrose 5% in Water Soln 00338-0017-31 50 mL $96 $0 $96 $58 calcium-vitamin D 500 mg-200 intl units Tab 00904-5460-61 1 tab(s) $4 $0 $4 $2 cholecalciferol 400 intl units Tab 00904-5823-60 1 tab(s) $3 $0 $3 $2 clotrimazole topical 1% Cream 00904-7822-31 1 app $67 $0 $67 $40 docusate 283 mg Enema 17433-9876-03 1 EA $18 $0 $18 $11 fosfomycin 3 g REC P 00456-4300-08 1 packet(s) $313 $0 $313 $188 pramipexole 0.5 mg Tab 13668-0093-90 1 tab(s) $23 $0 $23 $14 calcium acetate 667 mg Cap 00054-0088-26 1 cap(s) $9 $0 $9 $5 carbidopa-levodopa 50 mg-200 mg ER Ta 51079-0923-20 1 tab(s) $15 $0 $15 $9 levothyroxine 112 mcg (0.112 mg) Tab 00527-1346-01 1 tab(s) $6 $0 $6 $3 dexamethasone-tobramycin ophthalmic 0.1%-0.3% Ointm 00065-0648-35 1 app $569 $0 $569 $342 metoclopramide 5 mg/5 mL Syrup 00121-1576-10 10 mL $9 $0 $9 $5 pioglitazone 45 mg Tab 16729-0022-15 1 tab(s) $81 $0 $81 $49 LVP solution Sodium Chloride 0.45% Soln 00264-7802-00 1000 mL $100 $0 $100 $60 ciprofloxacin ophthalmic 0.3% Ointm 00065-0654-35 1 app $1,120 $0 $1,120 $672 riboflavin 100 mg Tab 74312-0006-40 1 tab(s) $4 $0 $4 $2 LVP solution Dextrose 5% in Water Soln 00409-7922-03 500 mL $30 $0 $30 $18 dicyclomine 10 mg Cap 51079-0118-01 1 cap(s) $5 $0 $5 $3 PARoxetine 12.5 mg ER Ta 60505-3673-03 1 tab(s) $41 $0 $41 $24 bacitracin-polymyxin B topical 500 units-10000 units/g Ointm 00501-3798-01 1 app $69 $0 $69 $41 methotrexate 2.5 mg Tab 00054-8550-25 1 tab(s) $27 $0 $27 $16 fluticasone furoate 200 mcg Powde 00173-0876-14 1 INH $813 $0 $813 $488 PHENobarbital oral Elixir 20 mg / 5 mL Elixir 99345-0001-84 5 mL $9 $0 $9 $6 diltiazem (Once-a-Day) 120 mg/24 hours ER Cap 60687-0195-01 1 cap(s) $6 $0 $6 $4 trihexyphenidyl 2 mg/5 mL Elixi 00121-0658-16 1 mL $5 $0 $5 $3 docusate 10 mg/mL LIQ 54838-0116-80 1 mL $5 $0 $5 $3 isosorbide dinitrate 5 mg Tab 50268-0447-15 1 tab(s) $10 $0 $10 $6 carbidopa-levodopa 48.75 mg-195 mg ER Ca 64896-0663-01 1 cap(s) $25 $0 $25 $15 ARIPiprazole 10 mg Tab 60687-0179-01 1 tab(s) $205 $0 $205 $123 glatiramer 40 mg/mL Soln 68546-0325-12 1 mL $3,199 $0 $3,199 $1,920 atenolol 25 mg Tab 00781-1078-01 1 tab(s) $9 $0 $9 $5 acetaminophen 500 mg Tab 00904-6730-61 1 tab(s) $4 $0 $4 $2 umeclidinium 62.5 mcg (0.0625 mg)/inh Powde 00173-0873-06 1 INH $83 $0 $83 $50 digoxin 250 mcg (0.25 mg) Tab 42292-0002-20 1 tab(s) $21 $0 $21 $12 gadobutrol 604.72 mg/mL Soln 50419-0325-13 1 mL $78 $0 $78 $47 hydrocortisone topical 1% Cream 00603-0535-50 1 app $27 $0 $27 $16 capsaicin topical 0.025% Cream 00603-0648-88 1 app $126 $0 $126 $75 sodium hypochlorite topical 0.125% Soln 00436-0672-16 1 app $33 $0 $33 $20 tbo-filgrastim 480 mcg/0.8 mL Soln 63459-0912-11 0.8 mL $3,066 $0 $3,066 $1,840 ampicillin-sulbactam 1 g-0.5 g REC I 00641-6116-10 0 $93 $0 $93 $56 topiramate 50 mg Tab 50268-0751-15 1 tab(s) $33 $0 $33 $20 ascorbic acid 250 mg Tab 51079-0003-20 1 tab(s) $4 $0 $4 $2 fluconazole 150 mg Tab 00049-3500-79 1 tab(s) $108 $0 $108 $65 dexamethasone 1 mg Tab 00054-4181-25 1 tab(s) $5 $0 $5 $3 topiramate 25 mg Cap 00045-0645-65 1 cap(s) $18 $0 $18 $11 OLANZapine DIS Tab 10 mg Tab 66993-0687-38 1 tab(s) $144 $0 $144 $86 cetirizine 1 mg/mL Syrup 23155-0292-51 1 mL $7 $0 $7 $4 magnesium citrate 1.745 g/30 mL LIQ 00869-0693-38 296 mL $5 $0 $5 $3 amphetamine-dextroamphetamine 20 mg Tab 00555-0973-02 1 tab(s) $17 $0 $17 $10 mesalamine 400 mg DRC 00023-5853-18 1 cap(s) $29 $0 $29 $18 methadone 5 mg Tab 60687-0214-01 1 tab(s) $7 $0 $7 $4 labetalol 100 mg Tab 00904-5928-61 1 tab(s) $19 $0 $19 $11 ferrous sulfate (as elemental iron) 15 mg/mL LIQ 50383-0627-50 1 mL $6 $0 $6 $3 risperiDONE 0.5 mg Tab 00904-6358-61 1 tab(s) $5 $0 $5 $3 diltiazem 360 mg/24 hours ER Ca 47335-0679-81 1 cap(s) $69 $0 $69 $42 enalapril 20 mg Tab 68084-0392-01 1 tab(s) $4 $0 $4 $3 dronedarone 400 mg Tab 00024-4142-60 1 tab(s) $38 $0 $38 $23 hydrOXYzine hydrochloride 25 mg Tab 68084-0254-01 1 tab(s) $6 $0 $6 $4 cefdinir 125 mg/5 mL REC P 68180-0722-20 1 mL $11 $0 $11 $6 alendronate 70 mg/75 mL Soln 51224-0301-10 1 mL $7 $0 $7 $4 olmesartan 40 mg Tab 68462-0438-90 1 tab(s) $68 $0 $68 $41 morphine 10 mg/12-24 hr ER Ca 00832-0225-00 1 cap(s) $35 $0 $35 $21 pramoxine topical 1% Foam 51862-0180-15 1 app $355 $0 $355 $213 methylPREDNISolone 4 mg Tab 00781-5022-01 1 tab(s) $8 $0 $8 $5 methenamine hippurate 1 g Tab 43199-0020-01 1 tab(s) $17 $0 $17 $10 buPROPion 100 mg Tab 00173-0178-55 1 tab(s) $18 $0 $18 $11 clindamycin topical 1% Soln 59762-3728-02 1 app $559 $0 $559 $335 ciprofloxacin-hydrocortisone otic 0.2%-1% Susp 00065-8531-10 1 drop(s) $698 $0 $698 $419

Page 62 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price famotidine 20 mg Susp 68382-0444-05 2.5 mL $29 $0 $29 $18 melatonin 1 mg Tab 47469-0004-65 1 tab(s) $4 $0 $4 $2 azithromycin 250 mg Tab 60687-0282-01 1 tab(s) $32 $0 $32 $19 ammonium lactate topical 12% Lotio 00904-5984-26 1 app $276 $0 $276 $166 vitamin A 10000 units Cap 00904-2085-60 1 cap(s) $4 $0 $4 $2 lidocaine 2% preservative-free Soln 63323-0495-07 5 mL $32 $0 $32 $19 melatonin 0.25 mg/mL LIQ 47469-0004-57 1 mL $5 $0 $5 $3 divalproex sodium 250 mg ER Ta 51079-0766-08 1 tab(s) $15 $0 $15 $9 lamiVUDine 150 mg Tab 68084-0578-21 1 tab(s) $58 $0 $58 $35 diazepam 0.5 mg Soln 99345-0001-47 0.5 mL $6 $0 $6 $4 sodium hypochlorite topical 0.25% Soln 00436-0936-16 1 app $33 $0 $33 $20 gentamicin 40 mg/mL Soln 00409-1207-25 1 mL $69 $0 $69 $41 fexofenadine 60 mg Tab 45802-0425-78 1 tab(s) $8 $0 $8 $5 warfarin 7.5 mg Tab 00056-0173-75 1 tab(s) $12 $0 $12 $7 minocycline 100 mg Cap 13668-0484-50 1 cap(s) $15 $0 $15 $9 potassium phosphate-sodium phosphate 250 mg-45 mg-298 mg Tab 64980-0104-01 1 tab(s) $4 $0 $4 $3 citric acid-sodium citrate 334 mg-500 mg/5 mL Soln 00121-0595-30 1 mL $5 $0 $5 $3 citric acid-sodium citrate 334 mg-500 mg/5 mL Soln 00121-0595-30 30 mL $7 $0 $7 $4 clindamycin 75 mg/5 mL REC P 00574-0129-01 1 mL $9 $0 $9 $5 warfarin 10 mg Tab 00056-0174-75 1 tab(s) $16 $0 $16 $9 diphenhydrAMINE 25 mg Tab 00904-5551-59 1 tab(s) $4 $0 $4 $2 carbidopa-levodopa 25 mg-100 mg ER Tab 00056-0601-68 1 tab(s) $11 $0 $11 $6 meloxicam 15 mg Tab 68382-0051-01 1 tab(s) $36 $0 $36 $21 carbamide peroxide otic 6.5% Soln 00904-3220-35 5 drop(s) $26 $0 $26 $15 cefuroxime 250 mg Tab 52959-0029-20 1 tab(s) $35 $0 $35 $21 acetaZOLAMIDE 250 mg Tab 51672-4023-01 1 tab(s) $6 $0 $6 $4 methadone 2.5 mg Soln 99345-0001-58 2.5 mL $7 $0 $7 $4 morphine 10 mg/5 mL Soln 66689-0032-50 5 mL $9 $0 $9 $6 hydrocortisone topical 2.5% Cream 00168-0080-31 1 app $86 $0 $86 $51 clozapine 100 mg Tab 00093-7772-93 1 tab(s) $26 $0 $26 $16 labetalol 300 mg Tab 68084-0457-01 1 tab(s) $10 $0 $10 $6 levETIRAcetam 250 mg Tab 68084-0859-01 1 tab(s) $7 $0 $7 $4 enalapril 5 mg Tab 63304-0835-01 1 tab(s) $10 $0 $10 $6 enalapril 5 mg Tab 63304-0835-01 1 tab(s) $10 $0 $10 $6 baclofen 0.5 mg/mL Soln 70257-0560-01 20 mL $624 $0 $624 $374 calcium carbonate 1250 mg Tab 51645-0827-99 1 tab(s) $4 $0 $4 $2 alprostadil 20 mcg REC I 00009-3701-05 1 mL $490 $0 $490 $294 cyanocobalamin 1000 mcg/mL Soln 63323-0044-01 1 mL $41 $0 $41 $24 silver nitrate Topical - Stick 12870-0001-01 1 EA $11 $0 $11 $7 LORazepam 1 mg Conc 99345-0001-52 0.5 mL $10 $0 $10 $6 venlafaxine 37.5 mg Tab 00008-0781-01 1 tab(s) $17 $0 $17 $10 ALPRAZolam 0.25 mg Tab 68084-0647-01 1 tab(s) $9 $0 $9 $5 multivitamin Pediatric Multiple Vitamins LIQ 00536-8450-80 1 mL $5 $0 $5 $3 ramipril 5 mg Cap 61570-0112-56 1 cap(s) $15 $0 $15 $9 ferrous gluconate 324 mg Tab 00574-0508-11 1 tab(s) $4 $0 $4 $2 selenium 40 mcg/mL Soln 00517-6510-25 1 mL $11 $0 $11 $7 pancrelipase 10,440 units-39,150 units-39,150 units Tab 58914-0112-10 1 tab(s) $23 $0 $23 $14 candesartan 8 mg Tab 60687-0119-25 1 tab(s) $35 $0 $35 $21 dexmethylphenidate 2.5 mg Tab 00093-5275-01 1 tab(s) $9 $0 $9 $6 amoxicillin-clavulanate 500 mg-125 mg Tab 66685-1002-02 1 tab(s) $28 $0 $28 $17 prochlorperazine 10 mg Tab 51079-0542-20 1 tab(s) $10 $0 $10 $6 ubiquinone 50 mg Cap 35046-0004-31 1 cap(s) $5 $0 $5 $3 atomoxetine 25 mg Cap 00002-3228-30 1 cap(s) $31 $0 $31 $19 erythromycin 250 mg Tab 24338-0102-13 1 tab(s) $17 $0 $17 $10 triamcinolone topical 0.1% Paste 51672-1267-05 1 app $573 $0 $573 $344 mesalamine 1.2 g EC Ta 54092-0476-12 1 tab(s) $43 $0 $43 $26 levothyroxine 200 mcg (0.2 mg) Tab 00074-7148-11 1 tab(s) $9 $0 $9 $5 predniSONE 1 mg Tab 00054-8739-25 1 tab(s) $5 $0 $5 $3 carBAMazepine 100 mg/5 mL Susp 51672-4047-09 1 mL $6 $0 $6 $4 amikacin 250 mg/mL Soln 23155-0290-41 1 mL $42 $0 $42 $25 temozolomide 5 mg Cap 00085-3004-01 1 cap(s) $83 $0 $83 $50 trolamine salicylate 10% Cream 41167-0570-03 1 app $46 $0 $46 $27 multivitamin Vitamin B Complex with C and Folic Acid Cap 1 cap(s) Cap 58526-0005-41 1 cap(s) $10 $0 $10 $6 doxycycline 20 mg Tab 00527-1336-01 1 tab(s) $11 $0 $11 $7 varicella virus vaccine - REC I 00006-4827-00 0.5 mL $734 $0 $734 $441 fenofibrate 48 mg Tab 68084-0635-21 1 tab(s) $16 $0 $16 $10 potassium acid phosphate 500 mg Tab 00486-1111-01 1 tab(s) $4 $0 $4 $3 zaleplon 5 mg Cap 00093-5268-01 1 cap(s) $30 $0 $30 $18 tobramycin ophthalmic 0.3% Ointm 00065-0644-35 1 app $735 $0 $735 $441 copper chloride 0.4 mg/mL Soln 00409-4092-01 1 mL $13 $0 $13 $8 zonisamide 100 mg Cap 60687-0230-65 1 cap(s) $15 $0 $15 $9 polycarbophil 625 mg Tab 66553-0005-01 1 tab(s) $4 $0 $4 $2 bisacodyl 5 mg EC Ta 00904-6407-61 1 tab(s) $4 $0 $4 $2 multivitamin Multiple Vitamins Chew 00904-2621-60 1 tab(s) $4 $0 $4 $2 amantadine 100 mg/10 mL Syrup 00121-0646-16 10 mL $15 $0 $15 $9 amantadine 50 mg/5 mL Syrup 00121-0646-16 1 mL $6 $0 $6 $3 docosanol topical 10% Cream 00135-0200-01 1 app $132 $0 $132 $79 rifampin 150 mg Cap 00068-0510-30 1 cap(s) $16 $0 $16 $10 chlorthalidone 25 mg Tab 51079-0058-20 1 tab(s) $5 $0 $5 $3

Page 63 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price ciprofloxacin 250 mg Tab 68084-0069-11 1 tab(s) $40 $0 $40 $24 sotalol 80 mg Tab 68084-0654-01 1 tab(s) $6 $0 $6 $4 metroNIDAZOLE topical 0.75% Gel 00781-7077-87 1 app $1,026 $0 $1,026 $615 torsemide 10 mg Tab 00004-0263-01 1 tab(s) $10 $0 $10 $6 cyclosporine modified 100 mg Cap 00074-3109-32 1 cap(s) $60 $0 $60 $36 galantamine 8 mg Tab 51079-0853-03 1 tab(s) $32 $0 $32 $19 guanfacine 1 mg Tab 67286-8901-01 1 tab(s) $22 $0 $22 $13 insulin isophane (NPH)-insulin regular human recombinant 70 units-30 units/mL Susp 00002-8715-17 1 mL $165 $0 $165 $99 pyridostigmine 60 mg Tab 68084-0494-01 1 tab(s) $7 $0 $7 $4 aluminum hydroxide-magnesium hydroxide 225 mg-200 mg/5 mL Susp 00121-1760-30 30 mL $9 $0 $9 $5 acetaminophen-hydrocodone 325 mg-7.5 mg Tab 00904-6420-61 1 tab(s) $9 $0 $9 $5 diltiazem ER (Once-a-Day) 240 mg/24 hours ER Capsule 60687-0217-01 1 cap(s) $9 $0 $9 $5 triamcinolone topical 0.5% Cream 00168-0002-15 1 app $86 $0 $86 $51 indomethacin 75 mg ER Cap 00185-0720-01 1 cap(s) $18 $0 $18 $11 amoxicillin 500 mg Cap 00781-2613-01 1 cap(s) $6 $0 $6 $4 meclizine 12.5 mg Tab 50268-0522-15 1 tab(s) $8 $0 $8 $5 phenol topical 1.4% Spray 78112-0011-03 1 spray(s) $33 $0 $33 $20 cephalexin 250 mg Cap 60687-0152-01 1 cap(s) $8 $0 $8 $5 calcium citrate 950 mg (200 mg elemental) Tab 00904-5062-60 1 tab(s) $4 $0 $4 $2 montelukast 5 mg Chew 00093-7425-56 1 tab(s) $41 $0 $41 $25 warfarin sodium 0.5 mg Tab 99345-0001-41 0.5 tab(s) $4 $0 $4 $2 temazepam 15 mg Cap 00378-4010-01 1 cap(s) $10 $0 $10 $6 buPROPion 75 mg Tab 51079-0943-20 1 tab(s) $8 $0 $8 $5 OLANZapine 5 mg DIS T 59746-0306-32 1 tab(s) $99 $0 $99 $59 desvenlafaxine 50 mg ER Ta 00008-1211-30 1 tab(s) $40 $0 $40 $24 hydroCORTisone Oral suspension 2 mg/mL Susp 99345-0002-60 1 mL $13 $0 $13 $8 diltiazem 300 mg/24 hours ER Cap 64455-0798-49 1 cap(s) $27 $0 $27 $16 iohexol 350 mg/mL Soln 00407-1414-76 125 mL $919 $0 $919 $551 candesartan 32 mg Tab 49884-0661-09 1 tab(s) $32 $0 $32 $19 bethanechol 10 mg Tab 65473-0703-01 1 tab(s) $13 $0 $13 $8 ketoconazole topical 2% Shamp 45802-0465-64 1 app $201 $0 $201 $121 nitrofurantoin macrocrystals 50 mg Cap 68084-0077-01 1 cap(s) $33 $0 $33 $20 poliovirus vaccine, inactivated - Susp 49281-0860-52 0.5 mL $449 $0 $449 $270 umeclidinium-vilanterol 62.5 mcg-25 mcg/inh Powde 00173-0869-06 1 INH $112 $0 $112 $67 LVP solution Dextrose 5% with 0.45% NaCl Soln 00409-7926-03 500 mL $65 $0 $65 $39 naproxen 250 mg Tab 68462-0188-01 1 tab(s) $9 $0 $9 $5 trace elements with selenium 4 mcg-0.4 mg-0.1 mg-20 mcg-1 mg/mL Soln 00517-8201-25 1 mL $78 $0 $78 $47 benzoyl peroxide topical 5% Gel 45802-0216-96 1 app $151 $0 $151 $91 amoxicillin 250 mg/5 mL REC P 00143-9889-01 1 mL $5 $0 $5 $3 lidocaine-prilocaine topical 2.5%-2.5% Cream 00115-1468-60 1 app $64 $0 $64 $39 vitamin E 15 intl units/0.3 mL Soln 54838-0005-30 1 mL $14 $0 $14 $8 medium chain triglycerides 100% Oil 00087-0365-03 1 mL $5 $0 $5 $3 lithium 300 mg ER Ta 51079-0180-20 1 tab(s) $6 $0 $6 $4 levothyroxine 150 mcg (0.15 mg) Tab 51079-0445-20 1 tab(s) $3 $0 $3 $2 zinc oxide topical 20% Ointm 00168-0062-02 1 app $41 $0 $41 $25 OXcarbazepine 300 mg Tab 68084-0853-01 1 tab(s) $8 $0 $8 $5 desmopressin 10 mcg/inh Spray 66993-0025-01 1 spray(s) $1,739 $0 $1,739 $1,043 bupivacaine 0.25% preservative-free Soln 55150-0168-30 30 mL $23 $0 $23 $14 rasagiline 1 mg Tab 68546-0229-56 1 tab(s) $80 $0 $80 $48 penicillin V potassium 250 mg Tab 57237-0040-01 1 tab(s) $9 $0 $9 $5 LVP solution Dextrose 5% with 0.9% NaCl Soln 00264-7610-00 1000 mL $100 $0 $100 $60 dexamethasone 1.5 mg Tab 00054-4182-25 1 tab(s) $5 $0 $5 $3 phenobarbital 64.8mg Tab 00603-5167-21 1 tab(s) $5 $0 $5 $3 enalapril 2.5 mg Tab 00006-0014-94 1 tab(s) $10 $0 $10 $6 glimepiride 4 mg Tab 00039-0223-10 1 tab(s) $13 $0 $13 $8 morphine 100 mg/8-12 hours ER Ta 00406-8390-62 1 tab(s) $39 $0 $39 $23 amitriptyline 25 mg Tab 00603-2213-21 1 tab(s) $6 $0 $6 $3 carBAMazepine 100 mg Chew Tab 58887-0052-32 1 tab(s) $5 $0 $5 $3 polyethylene glycol 3350 with electrolytes - REC Powder 52268-0100-01 4000 mL $5 $0 $5 $3 nystatin-triamcinolone topical 100000 units/g-0.1% Cream 45802-0880-94 1 app $267 $0 $267 $160 hydrocortisone topical 1% Ointm 45802-0276-03 1 app $33 $0 $33 $20 triamcinolone Topical 0.025% Cream 00168-0003-80 1 app $86 $0 $86 $52 sodium chloride 7% Soln 83490-0107-60 4 mL $14 $0 $14 $8 carbidopa-levodopa 23.75 mg-95 mg ER Ca 64896-0661-01 1 cap(s) $25 $0 $25 $15 fexofenadine 180 mg Tab 00904-6214-89 1 tab(s) $8 $0 $8 $5 tolterodine 2 mg ER Ca 51079-0197-03 1 cap(s) $85 $0 $85 $51 valproic acid 250 mg Cap 63739-0251-10 1 cap(s) $10 $0 $10 $6 insulin regular human recombinant 100 units/mL Soln 00002-8215-17 1 mL $165 $0 $165 $99 lovastatin 20 mg Tab 68084-0559-01 1 tab(s) $12 $0 $12 $7 perampanel 8 mg Tab 62856-0278-30 1 tab(s) $150 $0 $150 $90 carBAMazepine 200 mg ER Ta 00781-5987-01 1 tab(s) $13 $0 $13 $8 liothyronine 5 mcg Tab 42794-0018-02 1 tab(s) $9 $0 $9 $5 metFORMIN 750 mg ER Ta 50268-0532-13 1 tab(s) $11 $0 $11 $7 desipramine 10 mg Tab 00781-5218-01 1 tab(s) $14 $0 $14 $8 metroNIDAZOLE Oral suspension 50 mg/mL Susp 99345-0002-65 1 mL $13 $0 $13 $8 tobramycin ophthalmic 0.3% Soln 61314-0643-05 1 drop(s) $246 $0 $246 $148 prasugrel 10 mg Tab 67877-0605-30 1 tab(s) $114 $0 $114 $68 carbamazepine 200 mg Tab 58887-0027-30 1 tab(s) $6 $0 $6 $4

Page 64 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price lidocaine-prilocaine topical 2.5%-2.5% Cream 00168-0357-30 1 app $365 $0 $365 $219 trospium 20 mg Tab 65473-0980-04 1 tab(s) $14 $0 $14 $9 oxymetazoline nasal 0.05% Spray 00904-5711-35 1 spray(s) $37 $0 $37 $22 betamethasone topical dipropionate 0.05% Ointm 00472-0381-15 1 app $60 $0 $60 $36 Dextromethorphan / Quinidine 20mg / 10mg Cap 64597-0301-60 1 cap(s) $92 $0 $92 $55 multivitamin with minerals Antioxidant Multiple Vitamins and Minerals Tab 24208-0432-62 1 tab(s) $4 $0 $4 $2 fexofenadine 30 mg/5 mL Susp 41167-4244-04 1 mL $5 $0 $5 $3 methocarbamol 750 mg Tab 70010-0770-01 1 tab(s) $8 $0 $8 $5 doxazosin 8 mg Tab 00093-8123-01 1 tab(s) $10 $0 $10 $6 morphine 10 mg/ 5 mL Soln 99345-0001-55 5 mL $22 $0 $22 $13 omega-3 polyunsaturated fatty acids - Cap 00904-4043-60 1 cap(s) $4 $0 $4 $2 furosemide 10 mg/mL Soln 00409-6102-04 4 mL $36 $0 $36 $22 alendronate 70 mg Tab 51079-0942-05 1 tab(s) $140 $0 $140 $84 pramipexole 1 mg Tab 13668-0094-90 1 tab(s) $23 $0 $23 $14 montelukast 4 mg Chew 00093-7424-98 1 tab(s) $41 $0 $41 $25 zoster vaccine live - REC I 00006-4963-00 0.65 mL $1,423 $0 $1,423 $854 exemestane 25 mg Tab 69097-0316-02 1 tab(s) $91 $0 $91 $54 timolol ophthalmic 0.5% Soln 17478-0288-10 1 drop(s) $50 $0 $50 $30 benzocaine topical 10% Gel 01031-0222-40 1 app $33 $0 $33 $20 haemophilus b conjugate (PRP-OMP) vaccine 7.5 mcg-125 mcg/0.5 mL Susp 00006-4897-00 0.5 mL $447 $0 $447 $268 cyproheptadine 4 mg Tab 50742-0190-01 1 tab(s) $11 $0 $11 $6 montelukast 10 mg Tab 00904-6808-61 1 tab(s) $6 $0 $6 $4 ramipril 2.5 mg Cap 61570-0111-56 1 cap(s) $14 $0 $14 $9 captopril 25 mg Tab 00904-5046-61 1 tab(s) $9 $0 $9 $5 naproxen 500 mg Tab 60687-0268-01 1 tab(s) $12 $0 $12 $7 PARoxetine 12.5 mg ER Ta 00378-2003-93 1 tab(s) $26 $0 $26 $16 alfuzosin 10 mg ER Ta 47335-0956-88 1 tab(s) $32 $0 $32 $19 dextromethorphan-guaiFENesin 10 mg-100 mg/5 mL LIQ 00603-0855-94 10 mL $21 $0 $21 $13 letrozole 2.5 mg Tab 00093-7620-56 1 tab(s) $125 $0 $125 $75 cycloSPORINE modified 25 mg Cap 00074-6463-32 1 cap(s) $13 $0 $13 $8 sumatriptan 6 mg/0.5 mL Soln 00173-0449-02 0.5 mL $654 $0 $654 $393 amitriptyline 75 mg Tab 00310-0042-10 1 tab(s) $12 $0 $12 $7 dextroamphetamine 5 mg Tab 00406-8958-01 1 tab(s) $7 $0 $7 $4 levofloxacin 750 mg/150 mL Soln 25021-0825-83 150 mL $144 $0 $144 $86 diclofenac ophthalmic 0.1% Soln 61314-0014-25 1 drop(s) $322 $0 $322 $193 lamivudine 100 mg Tab 00173-0662-00 1 tab(s) $64 $0 $64 $38 liraglutide 18 mg/3 mL Soln 00169-4060-12 3 mL $401 $0 $401 $241 irbesartan 75 mg Tab 50268-0440-15 1 tab(s) $12 $0 $12 $7 chlorothiazide 250 mg/5 mL Susp 65649-0311-12 1 mL $6 $0 $6 $4 clarithromycin 250 mg Tab 00781-1961-60 1 tab(s) $44 $0 $44 $26 phenobarbital 97.2 mg Tab 00603-5168-21 1 tab(s) $5 $0 $5 $3 metoclopramide 5 mg/5 mL Syrup 00121-0576-16 1 mL $5 $0 $5 $3 ampicillin 500 mg Cap 00003-0134-50 1 cap(s) $6 $0 $6 $4 digoxin 50 mcg/mL (0.05 mg/mL) Elixi 00054-0057-46 1 mL $10 $0 $10 $6 ciclopirox topical 8% Soln 00066-8008-02 1 app $1,226 $0 $1,226 $736 glucagon recombinant 1 mg REC Inj 00597-0260-10 1 mL $1,211 $0 $1,211 $726 ramipril 10 mg Cap 60687-0354-01 1 cap(s) $7 $0 $7 $4 carbidopa-levodopa 10 mg-100 mg Tab 00056-0647-68 1 tab(s) $9 $0 $9 $5 bupivacaine 0.5% preservative-free Soln 00409-1162-01 10 mL $27 $0 $27 $16 galantamine 24 mg ER Ca 00591-3498-30 1 cap(s) $46 $0 $46 $28 carbidopa-levodopa 25 mg-250 mg Tab 00056-0654-68 1 tab(s) $12 $0 $12 $7 dapsone 100 mg Tab 49938-0101-01 1 tab(s) $5 $0 $5 $3 folic acid 0.4 mg Tab 50268-0346-15 1 tab(s) $5 $0 $5 $3 cilostazol 100 mg Tab 51079-0213-20 1 tab(s) $16 $0 $16 $9 carBAMazepine 300 mg ER Cap 54092-0173-12 1 cap(s) $11 $0 $11 $7 hydrocortisone topical 2.5% Ointm 00168-0146-30 1 app $90 $0 $90 $54 mexiletine 200 mg Cap 00597-0067-61 1 cap(s) $12 $0 $12 $7 verapamil 180 mg/12 hours ER Ta 51079-0899-20 1 tab(s) $20 $0 $20 $12 perampanel 2 mg Tab 62856-0272-30 1 tab(s) $110 $0 $110 $66 fluconazole 400 mg/200 mL-5% Soln 00143-9666-06 200 mL $161 $0 $161 $97 cyproheptadine 2 mg / 5 mL Syrup 00472-1400-16 1 mL $5 $0 $5 $3 cloZAPine 25 mg Tab 51079-0921-20 1 tab(s) $12 $0 $12 $7 polymyxin B sulfate 500000 units REC I 55390-0139-01 0 $126 $0 $126 $76 phytonadione 10 mg/mL Soln 00409-9158-01 1 mL $56 $0 $56 $34 diltiazem 180 mg/24 hours ER Ca 60687-0206-01 1 cap(s) $7 $0 $7 $4 zinc oxide topical 40% Ointm 00501-3400-02 1 app $32 $0 $32 $19 meclizine 25 mg Tab 00781-1375-13 1 tab(s) $4 $0 $4 $2 amitriptyline 50 mg Tab 00310-0041-39 1 tab(s) $8 $0 $8 $5 hepatitis B pediatric vaccine 10 mcg/0.5 mL Susp 58160-0820-52 0.5 mL $349 $0 $349 $209 aluminum sulfate-calcium acetate topical - REC P 51224-0162-12 1 packet(s) $16 $0 $16 $9 cloBAZam 5 mg Tab 99345-0003-15 0.5 tab(s) $30 $0 $30 $18 indomethacin 25 mg Cap 00172-4029-60 1 cap(s) $6 $0 $6 $4 lansoprazole DIS 15 mg Tablet 64764-0543-11 1 tab(s) $52 $0 $52 $31 glycerin pediatric Supp 00132-0081-12 1 supp $4 $0 $4 $2 olmesartan 5 mg Tab 65597-0101-30 1 tab(s) $22 $0 $22 $13 chromic chloride hexahydrate 4 mcg/mL Soln 00409-4093-01 1 mL $8 $0 $8 $5 ritonavir 100 mg Tab 00074-3333-30 1 tab(s) $72 $0 $72 $43 LVP solution Dextrose 5% in Water Soln 00264-7510-00 1000 mL $30 $0 $30 $18 fluvastatin 20 mg Cap 00093-7442-01 1 cap(s) $29 $0 $29 $17

Page 65 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price fluconazole 200 mg/100 mL-0.9% Soln 25021-0113-82 100 mL $126 $0 $126 $76 rivastigmine 9.5 mg/24 hr ER Fi 00078-0502-15 1 patch(es) $22 $0 $22 $13 bismuth subsalicylate 262 mg Chew 37000-0477-09 1 tab(s) $4 $0 $4 $3 nitroglycerin 2% Ointm 00281-0326-08 1 packet(s) $25 $0 $25 $15 niacin 500 mg ER Ta 00093-7392-98 1 tab(s) $32 $0 $32 $19 barium sulfate 2.1% Susp 32909-0755-03 450 mL $36 $0 $36 $22 methylphenidate 36 mg/24 hr ER Ta 00406-0136-01 1 tab(s) $51 $0 $51 $30 miconazole topical 2% Cream 00713-0252-37 1 app $61 $0 $61 $36 triamterene 50 mg Cap 65197-0002-01 1 cap(s) $11 $0 $11 $7 pancrelipase 12,000 units-38,000 units-60,000 units DR Ca 00032-1212-01 1 cap(s) $21 $0 $21 $13 diphtheria/tetanus/pertussis (DTaP) ped 15 units-5 units-23 mcg/0.5 mL Susp 49281-0286-10 0.5 mL $480 $0 $480 $288 citric acid-potassium citrate 30 mEq REC P 60258-0005-01 1 packet(s) $9 $0 $9 $5 petrolatum Topical 100% Ointm 00168-0053-21 1 app $26 $0 $26 $15 cranberry - Tab 57896-0845-01 1 tab(s) $4 $0 $4 $2 dexamethasone 0.5 mg Tab 00006-0041-68 1 tab(s) $8 $0 $8 $5 dutasteride 0.5 mg Cap 00173-0712-04 1 cap(s) $34 $0 $34 $20 amitriptyline 100 mg Tab 00310-0043-10 1 tab(s) $15 $0 $15 $9 levothyroxine 300 mcg (0.3 mg) Tab 00527-1352-01 1 tab(s) $7 $0 $7 $4 bacitracin ophthalmic 500 units/g Ointm 00574-4022-35 1 app $158 $0 $158 $95 dexmethylphenidate 5 mg ER Ca 00093-5550-01 1 cap(s) $59 $0 $59 $36 hydrOXYzine hydrochloride 10 mg Tab 10702-0010-01 1 tab(s) $8 $0 $8 $5 predniSONE 50 mg Tab 00009-0388-01 1 tab(s) $5 $0 $5 $3 gentamicin topical 0.1% Cream 45802-0056-35 1 app $227 $0 $227 $136 pancrelipase 6000 units-19,000 units-30,000 units DR Ca 00032-1206-01 1 cap(s) $12 $0 $12 $7 trihexyphenidyl 2 mg Tab 00591-5335-01 1 tab(s) $5 $0 $5 $3 phenylephrine topical 0.25%-3% Supp 00573-2883-20 1 supp $7 $0 $7 $4 lidocaine hcl 2% mucous membrane oral Soln 00054-3500-49 15 mL $29 $0 $29 $17 HYDROmorphone 8 mg Tab 68094-0852-61 1 tab(s) $11 $0 $11 $6 ibuprofen 200 mg Tab 51079-0731-20 1 tab(s) $4 $0 $4 $2 gemfibrozil 600 mg Tab 60687-0224-01 1 tab(s) $19 $0 $19 $11 fluphenazine 2.5 mg Tab 51079-0486-20 1 tab(s) $9 $0 $9 $6 megestrol 40 mg Tab 49884-0290-04 1 tab(s) $11 $0 $11 $6 acetaZOLAMIDE 500 mg ER Ca 68084-0401-21 1 cap(s) $36 $0 $36 $22 cyanocobalamin 250 mcg Tab 50268-0853-15 1 tab(s) $5 $0 $5 $3 glycopyrrolate 1 mg Tab 13107-0014-01 1 tab(s) $12 $0 $12 $7 sodium hypochlorite topical 0.5% Soln 00436-0946-16 1 app $33 $0 $33 $20 Salt and Soda Mouthwash 1 mL Soln 99345-0001-01 1 mL $12 $0 $12 $7 sumatriptan 25 mg Tab 00173-0460-02 1 tab(s) $138 $0 $138 $83 calcium carbonate 1250 mg Tab 00054-8120-25 1 tab(s) $6 $0 $6 $3 OXcarbazepine 600 mg Tab 68084-0867-01 1 tab(s) $37 $0 $37 $22 cevimeline 30 mg Cap 00054-0334-25 1 cap(s) $24 $0 $24 $14 codeine-guaifenesin 10 mg-100 mg/5 mL Syrup 00121-1775-05 5 mL $9 $0 $9 $5 leucovorin 25 mg Tab 60687-0227-94 1 tab(s) $89 $0 $89 $54 sulfaSALAzine 500 mg Tab 00603-5801-21 1 tab(s) $5 $0 $5 $3 PHENobarbital 15 mg Tab 00143-1445-05 1 tab(s) $6 $0 $6 $3 leucovorin 5 mg Tab 51079-0581-06 1 tab(s) $25 $0 $25 $15 cetirizine 5 mg Tab 00378-3635-01 1 tab(s) $20 $0 $20 $12 tetanus/diphth/pertuss (Tdap) adult/adol 5 units-2 units-15.5 mcg/0.5 mL Susp 49281-0400-10 0.5 mL $774 $0 $774 $464 vitamin E 200 intl units Cap 00904-0272-60 1 cap(s) $4 $0 $4 $2 nitroglycerin 0.4 mg/hr ER Fi 00904-5496-46 1 patch(es) $21 $0 $21 $12 selenium sulfide topical 1% Shamp 00536-1995-53 10 mL $37 $0 $37 $22 selenium sulfide Topical 2.5% Lotio 45802-0040-64 1 app $151 $0 $151 $91 clomiPRAMINE 50 mg Cap 00406-9907-01 1 cap(s) $50 $0 $50 $30 selegiline 5 mg Cap 67253-0700-06 1 cap(s) $19 $0 $19 $11 phenytoin 30 mg ER Capsule 00071-3740-66 1 cap(s) $7 $0 $7 $4 glucose 40% Gel 00574-0069-30 1 EA $14 $0 $14 $9 permethrin topical 1% Lotio 46122-0108-46 1 app $82 $0 $82 $49 testosterone 1% gel 1% Gel 00051-8425-01 1 packet(s) $12 $0 $12 $7 glyBURIDE 2.5 mg Tab 00009-0141-01 1 tab(s) $8 $0 $8 $5 multivitamin with iron Pediatric Multiple Vitamins with Iron LIQ 00536-8530-80 1 mL $5 $0 $5 $3 diclofenac sodium 50 mg EC Ta 00228-2550-06 1 tab(s) $10 $0 $10 $6 AMIkacin NEB [compound] 250 mg/mL Soln 99345-0002-08 1 mL $46 $0 $46 $28 fluorometholone ophthalmic 0.25% Susp 11980-0228-05 1 drop(s) $235 $0 $235 $141 varenicline 1 mg Tab 00069-0469-56 1 tab(s) $16 $0 $16 $9 amitriptyline 10 mg Tab 00310-0040-10 1 tab(s) $5 $0 $5 $3 lactase 3000 units Tab 00045-0080-02 1 tab(s) $4 $0 $4 $2 verapamil 120 mg/12 hours ER Ta 00172-4285-10 1 tab(s) $11 $0 $11 $6 triamcinolone Topical 0.025% Ointm 00168-0005-80 1 app $86 $0 $86 $52 ethosuximide 250 mg/5 mL Syrup 00121-0670-16 1 mL $6 $0 $6 $4 levothyroxine 137 mcg (0.137 mg) Tab 00527-1638-01 1 tab(s) $6 $0 $6 $3 acetaminophen-codeine 300 mg-30 mg Tab 51079-0161-20 1 tab(s) $7 $0 $7 $4 penicillin V potassium 250 mg/5 mL REC P 00093-4127-74 1 mL $5 $0 $5 $3 verapamil 120 mg Tab 00591-0345-01 1 tab(s) $8 $0 $8 $5 sodium chloride 0.9% Soln 00487-9301-03 3 mL $9 $0 $9 $5 Multiple Vitamins with Iron Chew 00904-0536-60 1 tab(s) $4 $0 $4 $2 buPROPion 100 mg/12 hours ER Ta 68084-0697-01 1 tab(s) $14 $0 $14 $9 lidocaine 1% preservative-free Soln 63323-0492-27 2 mL $25 $0 $25 $15 glycopyrrolate 0.2 mg/mL Soln 00143-9679-10 1 mL $70 $0 $70 $42 hydrochlorothiazide-triamterene 25 mg-37.5 mg Tab 00591-0424-01 1 tab(s) $6 $0 $6 $3

Page 66 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price clonazePAM 0.125 mg DIS T 00555-0094-96 1 tab(s) $12 $0 $12 $7 pioglitazone 15 mg Tab 68084-0878-01 1 tab(s) $11 $0 $11 $6 hydrALAZINE 20 mg/mL Soln 63323-0614-01 1 mL $109 $0 $109 $65 folic acid 5 mg/mL Soln 63323-0184-10 1 mL $30 $0 $30 $18 Benadryl-Maalox-Cepacol 1 mL Susp 99345-0001-02 1 mL $47 $0 $47 $28 glucose 50% Soln 00409-4902-34 50 mL $106 $0 $106 $64 PHENobarbital 32.4 mg Tab 63739-0201-10 1 tab(s) $4 $0 $4 $2 acetylcysteine 10% Soln 00409-3307-03 30 mL $75 $0 $75 $45 sirolimus 0.5 mg Tab 00008-1040-05 1 tab(s) $48 $0 $48 $29 theophylline 80 mg/15 mL Elixi 00472-1444-16 1 mL $5 $0 $5 $3 metFORMIN 850 mg Tab 60687-0143-01 1 tab(s) $11 $0 $11 $7 ondansetron 2 mg/2.5 mL Soln 99345-0001-68 2.5 mL $89 $0 $89 $53 zonisamide 25 mg Cap 62856-0681-10 1 cap(s) $8 $0 $8 $5 hydrochlorothiazide 50 mg Tab 00182-0557-89 1 tab(s) $5 $0 $5 $3 benazepril 10 mg Tab 51079-0145-20 1 tab(s) $10 $0 $10 $6 glycerin-witch hazel Topical 10%-50% Pad 12547-0150-40 1 app $30 $0 $30 $18 famotidine 10 mg/mL Soln 00006-3539-04 1 mL $24 $0 $24 $15 ferrous sulfate [SlowFE] 140 mg Tab 86790-0019-30 1 tab(s) $5 $0 $5 $3 hyoscyamine 0.125 mg Tab 00574-0246-01 1 tab(s) $9 $0 $9 $5 isosorbide dinitrate 30 mg Tab 49884-0009-01 1 tab(s) $7 $0 $7 $4 calcitriol 0.5 mcg Cap 64380-0724-06 1 cap(s) $16 $0 $16 $10 bismuth subsalicylate 262 mg/15 mL Susp 37000-0032-01 15 mL $21 $0 $21 $13 sodium chloride 0.9% Soln 63323-0186-10 10 mL $14 $0 $14 $8 hydrOXYzine hydrochloride 10 mg/5 mL Syrup 60432-0150-16 1 mL $5 $0 $5 $3 niacin 1000 mg ER Ta 60598-0003-01 1 tab(s) $30 $0 $30 $18 pramipexole 1.5 mg Tab 00597-0091-61 1 tab(s) $18 $0 $18 $11 magnesium carbonate 54 mg/5 mL LIQ 00187-5267-01 1 mL $5 $0 $5 $3 mineral oil 100% LIQ 00574-0618-16 1 mL $5 $0 $5 $3 lidocaine 4% preservative-free Soln 00409-4283-01 5 mL $44 $0 $44 $26 doxepin 10 mg Cap 00662-5340-66 1 cap(s) $6 $0 $6 $3 PHENobarbital 16.2 mg Tab 63739-0200-10 1 tab(s) $5 $0 $5 $3 progesterone 200 mg Cap 00093-5354-01 1 cap(s) $30 $0 $30 $18 glimepiride 1 mg Tab 68084-0788-25 1 tab(s) $10 $0 $10 $6 pamidronate 3 mg/mL Soln 61703-0324-18 10 mL $171 $0 $171 $102 metOLazone 2.5 mg Tab 00185-5050-01 1 tab(s) $17 $0 $17 $10 lactobacillus rhamnosus GG - Cap 49100-0400-07 1 cap(s) $8 $0 $8 $5 torsemide 100 mg Tab 00004-0265-01 1 tab(s) $33 $0 $33 $20 testosterone cypionate 200 mg/mL Soln 62756-0015-40 1 mL $167 $0 $167 $100 glimepiride 2 mg Tab 00039-0222-10 1 tab(s) $9 $0 $9 $5 pentoxifylline 400 mg ER Ta 68682-0101-10 1 tab(s) $6 $0 $6 $4 methocarbamol 500 mg Tab 69543-0134-10 1 tab(s) $7 $0 $7 $4 benazepril 40 mg Tab 43547-0338-10 1 tab(s) $10 $0 $10 $6 lidocaine 1% Soln 63323-0201-10 10 mL $22 $0 $22 $13 glipiZIDE 2.5 mg ER Tab 00049-1620-30 1 tab(s) $7 $0 $7 $4 minoxidil 2.5 mg Tab 49884-0256-01 1 tab(s) $9 $0 $9 $5 terbinafine 1 app Cream 00067-3998-30 1 app $79 $0 $79 $47 ondansetron 2 mg/mL Soln 36000-0012-25 2 mL $12 $0 $12 $7 nortriptyline 10 mg Cap 00591-5786-01 1 cap(s) $6 $0 $6 $4 dexamethasone 0.5 mg/5 mL LIQ 00054-3177-63 1 mL $5 $0 $5 $3 diphenhydrAMINE 12.5 mg/5 mL LIQ 00121-0489-10 10 mL $11 $0 $11 $7 terbinafine 250 mg Tab 51991-0526-01 1 tab(s) $91 $0 $91 $55 verapamil 80 mg Tab 00591-0343-01 1 tab(s) $7 $0 $7 $4 mirtazapine 30 mg DIS T 65862-0022-06 1 tab(s) $20 $0 $20 $12 terbutaline 5 mg Tab 00527-1311-01 1 tab(s) $8 $0 $8 $5 furosemide 10 mg/mL Soln 00409-6102-02 2 mL $12 $0 $12 $7 olmesartan 20 mg Tab 65597-0103-30 1 tab(s) $15 $0 $15 $9 temazepam 7.5 mg Cap 68084-0549-21 1 cap(s) $63 $0 $63 $38 gentamicin ophthalmic 0.3% Soln 17478-0283-10 1 drop(s) $142 $0 $142 $85 glyBURIDE 5 mg Tab 00009-0171-05 1 tab(s) $12 $0 $12 $7 Dermaid Aloe Cream 80208-0000-04 1 app $84 $0 $84 $50 isoniazid 300 mg Tab 51079-0083-20 1 tab(s) $4 $0 $4 $3 hydroxyurea 500 mg Cap 00003-0830-50 1 cap(s) $13 $0 $13 $8 desipramine 25 mg Tab 00068-0011-01 1 tab(s) $9 $0 $9 $6 bupivacaine 0.5% preservative-free Soln 00409-1162-02 1 vial(s) $14 $0 $14 $8 bupivacaine 0.5% preservative-free Soln 00409-1162-02 30 mL $27 $0 $27 $16 ondansetron 4 mg/5 mL Soln 51672-4091-03 1 mL $38 $0 $38 $23 medroxyPROGESTERone 2.5 mg Tab 00009-0064-04 1 tab(s) $9 $0 $9 $5 rivastigmine 9.5 mg/24 hr ER Fi 00781-7309-31 1 patch(es) $17 $0 $17 $10 bacitracin-polymyxin B ophthalmic 500 units-10000 units/g Ointm 24208-0555-55 1 app $188 $0 $188 $113 naproxen 375 mg Tab 50268-0595-15 1 tab(s) $10 $0 $10 $6 ketotifen ophthalmic 0.025% Soln 17478-0717-10 1 drop(s) $93 $0 $93 $56 prochlorperazine 5 mg Tab 00555-0521-02 1 tab(s) $7 $0 $7 $4 glipiZIDE 5 mg ER Ta 59762-5032-01 1 tab(s) $6 $0 $6 $4 glipiZIDE 5 mg ER Ta 59762-5032-01 1 tab(s) $6 $0 $6 $4 diphtheria-tetanus toxoids pediatric Susp 49281-0275-10 0.5 mL $177 $0 $177 $106 loperamide 1 mg/7.5 mL Susp 00904-6256-20 7.5 mL $47 $0 $47 $28 pseudoephedrine 30 mg Tab 45802-0432-62 1 tab(s) $4 $0 $4 $2 benztropine 2 mg Tab 68084-0389-01 1 tab(s) $5 $0 $5 $3 LVP solution Sodium Chloride 0.45% Soln 00409-7985-03 500 mL $65 $0 $65 $39

Page 67 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price tuberculin purified protein derivative 5 tuberculin units/0.1 mL Soln 49281-0752-21 0.1 mL $49 $0 $49 $29 theophylline 300 mg ER Tab 00603-5946-21 1 tab(s) $6 $0 $6 $4 glucose 4 g Chew 00904-5896-15 1 tab(s) $19 $0 $19 $11 pramipexole 0.125 mg Tab 00597-0083-53 1 tab(s) $16 $0 $16 $9 megestrol 40 mg/mL Susp 00054-3542-58 1 mL $9 $0 $9 $5 dextrose 5% in water Syringe Pump Prime & Flush 10 mL soln 5% Syringe 99345-0001-97 10 mL $15 $0 $15 $9 thyroid desiccated 60 mg Tab 00456-0459-01 1 tab(s) $4 $0 $4 $3 sodium biphosphate-sodium phosphate 7 g-19 g Enema 00536-7415-51 133 mL $12 $0 $12 $7 cholecalciferol 50,000 intl units Cap 53191-0362-01 1 cap(s) $5 $0 $5 $3 insulin glargine 100 unit(s) /mL Soln 00088-2219-05 1 mL $151 $0 $151 $90 mupirocin topical 2% Ointm 00029-1526-11 1 EA $109 $0 $109 $65 tenofovir 300 mg Tab 60687-0366-25 1 tab(s) $14 $0 $14 $9 benzoyl peroxide topical 10% Gel 45802-0308-96 1 app $155 $0 $155 $93 felbamate 600 mg/5 mL Susp 65162-0686-88 1 mL $23 $0 $23 $14 lamiVUDine 10 mg Soln 49702-0205-48 1 mL $8 $0 $8 $5 dexamethasone/neomycin/polymyxin B ophthalmic 1 mg-3.5 mg-10000 units/g Ointm 00574-4160-35 1 app $148 $0 $148 $89 glucosamine/chondroitin 500mg/400mg Cap 00904-5481-18 1 cap(s) $5 $0 $5 $3 cromolyn nasal 5.2 mg/inh Spray 57782-0397-26 1 spray(s) $99 $0 $99 $59 benazepril 20 mg Tab 50268-0111-15 1 tab(s) $10 $0 $10 $6 clobetasol topical 0.05% Soln 60432-0133-50 1 app $285 $0 $285 $171 sodium bicarbonate 8.4% Soln 00409-6625-02 1 mL $9 $0 $9 $5 ofloxacin otic 0.3% Soln 24208-0410-05 1 drop(s) $137 $0 $137 $82 nystatin-triamcinolone topical 100000 units/g-0.1% Ointm 51672-1272-02 1 app $54 $0 $54 $32 conjugated estrogens 0.45 mg Tab 00046-1101-81 1 tab(s) $21 $0 $21 $12 vitamin E with mixed tocopherols 400 intl units Cap 00182-0082-01 1 cap(s) $4 $0 $4 $2 benzocaine 20% Gel 10310-0319-46 1 app $38 $0 $38 $23 insulin aspart 100 units/mL Soln 00169-6339-10 1 mL $257 $0 $257 $154 naloxone 0.4 mg/mL Soln 00409-1215-01 1 mL $135 $0 $135 $81 polymyxin B-trimethoprim ophthalmic 10000 units-1 mg/mL Soln 61314-0628-10 1 drop(s) $130 $0 $130 $78 trimethoprim 100 mg Tab 00591-5571-01 1 tab(s) $8 $0 $8 $5 lidocaine 1% Soln 00409-4276-01 20 mL $16 $0 $16 $10 pamidronate 9 mg/mL Soln 61703-0326-18 10 mL $372 $0 $372 $223 calcium carbonate-magnesium chloride 112 mg- 64 mg ER Ta 68585-0005-75 1 tab(s) $4 $0 $4 $2 cabergoline 0.5 mg Tab 00093-5420-88 1 tab(s) $249 $0 $249 $149 lithium 300 mg Cap 00054-8527-25 1 cap(s) $5 $0 $5 $3 indomethacin 50 mg Cap 51079-0191-20 1 cap(s) $8 $0 $8 $5 carbidopa-levodopa 25 mg-100 mg DIS T 62756-0187-88 1 tab(s) $13 $0 $13 $8 promethazine 25 mg Tab 00591-5307-01 1 tab(s) $7 $0 $7 $4 hyoscyamine 0.125 mg Tab 43199-0011-01 1 tab(s) $9 $0 $9 $5 captopril 12.5 mg Tab 49884-0793-01 1 tab(s) $14 $0 $14 $8 rivastigmine 1.5 mg Cap 68084-0550-01 1 cap(s) $31 $0 $31 $19 dipyridamole 25 mg Tab 00904-1086-61 1 tab(s) $6 $0 $6 $4 acetaminophen-traMADol 325 mg-37.5 mg Tab 68084-0825-01 1 tab(s) $10 $0 $10 $6 metroNIDAZOLE 250 mg Tab 51079-0216-20 1 tab(s) $7 $0 $7 $4 octreotide 50 mcg/mL Soln 67457-0239-01 1 mL $41 $0 $41 $25 tetrahydrozoline ophthalmic 0.05% Soln 00904-6334-35 1 drop(s) $20 $0 $20 $12 citric acid-sodium citrate 334 mg-500 mg/5 mL Soln 00121-0595-16 1 mL $5 $0 $5 $3 pantoprazole 40 mg REC I 00008-0923-55 10 mL $50 $0 $50 $30 pilocarpine 5 mg Tab 58063-0705-10 1 tab(s) $15 $0 $15 $9 glipiZIDE 10 mg ER Ta 68084-0112-01 1 tab(s) $8 $0 $8 $5 benazepril 5 mg Tab 65162-0751-10 1 tab(s) $10 $0 $10 $6 hydrocortisone 100 mg preservative-free REC I 00009-0011-03 2 mL $65 $0 $65 $39 codeine sulfate 30 mg Tab 00054-8156-24 1 tab(s) $8 $0 $8 $5 morphine oral conc PFS 20 mg/mL Conc 99345-0002-06 1 mL $10 $0 $10 $6 lidocaine topical 2% Gel 17478-0711-10 5 mL $63 $0 $63 $38 sirolimus 1 mg Tab 00008-1031-05 1 tab(s) $62 $0 $62 $37 doxepin 25 mg Cap 00662-5350-66 1 cap(s) $6 $0 $6 $4 prazosin 5 mg Cap 51079-0632-20 1 cap(s) $8 $0 $8 $5 potassium citrate 10 mEq ER Ta 00245-0071-11 1 tab(s) $7 $0 $7 $4 glycerin adult Supp 00713-0101-25 1 supp $4 $0 $4 $2 probenecid 500 mg Tab 00591-5347-01 1 tab(s) $10 $0 $10 $6 indapamide 2.5 mg Tab 00228-2571-11 1 tab(s) $9 $0 $9 $5 sevelamer 400 mg Tab 58468-0020-01 1 tab(s) $11 $0 $11 $6 miconazole topical 100 mg Supp 00472-1736-07 1 supp $81 $0 $81 $48 lamoTRIgine 200 mg ER Ta 00173-0757-00 1 tab(s) $85 $0 $85 $51 potassium acetate 2 mEq/mL Soln 00409-8183-01 1 mL $9 $0 $9 $5 pregabalin 20 mg/mL Soln 00071-1020-01 1 mL $15 $0 $15 $9 amoxicillin 250 mg Cap 00003-0101-50 1 cap(s) $5 $0 $5 $3 bethanechol 5 mg Tab 50111-0323-01 1 tab(s) $8 $0 $8 $5 multivitamin with minerals Antioxidant Multiple Vitamins (A,D,E,K-intensive) and 58914-0214-60 1 mL $7 $0 $7 $4 Minerals LIQ meloxicam 7.5 mg Tab 50268-0525-15 1 tab(s) $4 $0 $4 $3 carteolol ophthalmic 1% Soln 24208-0367-05 1 drop(s) $146 $0 $146 $87 hydrocortisone topical 0.5% Cream 24385-0190-03 1 app $16 $0 $16 $10 nitroglycerin 0.4 mg Tab 00071-0418-13 1 tab(s) $49 $0 $49 $29 niacin 500 mg Tab 00904-2272-60 1 tab(s) $4 $0 $4 $2 methadone 10 mg/mL Conc 64019-0553-67 1 mL $5 $0 $5 $3 haloperidol 5 mg Tab 60687-0161-01 1 tab(s) $9 $0 $9 $5

Page 68 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price ethacrynic acid 25 mg Tab 00006-0065-68 1 tab(s) $6 $0 $6 $3 ferrous sulfate (as elemental iron) 45 mg ER Ta 00536-3481-07 1 tab(s) $5 $0 $5 $3 mesalamine 0.375 g ER Ca 65649-0103-02 1 cap(s) $19 $0 $19 $11 haloperidol 0.5 mg Tab 00781-1391-01 1 tab(s) $5 $0 $5 $3 buffered lidocaine 1% [J-Tip] 1% buffered Injection 99345-0002-85 0.2 mL $16 $0 $16 $9 benztropine 0.5 mg Tab 00904-1055-61 1 tab(s) $5 $0 $5 $3 felbamate 600 mg Tab 65162-0735-03 1 tab(s) $43 $0 $43 $26 acetaminophen-HYDROcodone 325 mg-7.5 mg/15 mL Soln 00121-4772-05 5 mL $33 $0 $33 $20 diphenhydrAMINE 50 mg/mL Soln 00641-0376-25 1 mL $15 $0 $15 $9 nadolol 40 mg Tab 68001-0318-00 1 tab(s) $30 $0 $30 $18 barium sulfate 2.1% Susp 32909-0775-03 450 mL $36 $0 $36 $22 glycerin - LIQ 00574-0178-10 1 mL $5 $0 $5 $3 dexamethasone 4 mg/mL Soln 63323-0165-01 1 mL $22 $0 $22 $13 LORazepam 2 mg/mL Soln 00641-6044-25 1 mL $11 $0 $11 $7 primidone 250 mg Tab 68084-0203-01 1 tab(s) $10 $0 $10 $6 divalproex sodium 125 mg EC Ta 00245-0180-01 1 tab(s) $10 $0 $10 $6 tolterodine 2 mg Tab 00093-0018-06 1 tab(s) $26 $0 $26 $16 heparin flush 10 units/mL Soln 82903-0065-10 5 mL $31 $0 $31 $19 potassium chloride 8 mEq ER Tab 00078-0320-05 1 tab(s) $5 $0 $5 $3 labetalol 5 mg/mL Soln 00409-2267-25 1 mL $9 $0 $9 $5 clobazam 2.5 mg/mL Susp 67386-0313-21 1 mL $47 $0 $47 $28 gadopentetate dimeglumine 46.9% Soln 50419-0188-02 20 mL $706 $0 $706 $424 estradiol 1 mg Tab 00591-0487-01 1 tab(s) $6 $0 $6 $3 torsemide 5 mg Tab 31722-0529-01 1 tab(s) $8 $0 $8 $5 oxyCODONE 20 mg/mL Conc 66689-0025-30 1 mL $44 $0 $44 $26 triamcinolone topical 0.5% Ointm 45802-0049-35 1 app $79 $0 $79 $48 barium sulfate 2.1% Susp 32909-0725-03 450 mL $36 $0 $36 $22 nicotine 2 mg Gum 00536-3112-01 1 EA $6 $0 $6 $4 pilocarpine ophthalmic 1% Soln 61314-0203-15 1 drop(s) $72 $0 $72 $43 clarithromycin 250 mg/5 mL REC Powder 00074-3188-13 1 mL $11 $0 $11 $6 risperidone 0.5 mg DIS Tab 50458-0395-28 1 tab(s) $31 $0 $31 $19 chlordiazepoxide 5 mg Cap 51079-0374-20 1 cap(s) $6 $0 $6 $4 tobramycin 40 mg/mL Soln 63323-0306-02 1 mL $22 $0 $22 $13 caffeine 200 mg Tab 46017-0018-40 1 tab(s) $5 $0 $5 $3 Blistex 04138-8000-39 1 app $51 $0 $51 $30 acetaminophen 650 mg Supp 00713-0165-12 1 supp $8 $0 $8 $5 ropivacaine 0.5% Soln 00409-9301-30 30 mL $63 $0 $63 $38 citric acid-potassium citrate 334 mg-1100 mg/5 mL LIQ 60258-0003-16 1 mL $5 $0 $5 $3 verapamil 40 mg Tab 00591-0404-01 1 tab(s) $5 $0 $5 $3 pramoxine Topical - Lotio 00501-3251-06 1 app $46 $0 $46 $27 simvastatin 80 mg Tab 00006-0543-31 1 tab(s) $40 $0 $40 $24 risperidone 1 mg DIS Tab 50458-0315-28 1 tab(s) $36 $0 $36 $21 lidocaine 2% preservative-free Soln 00409-1323-05 1 mL $13 $0 $13 $8 lidocaine 2% preservative-free Soln 63323-0495-27 2 mL $29 $0 $29 $18 acetaminophen-codeine 120 mg-12 mg/5 mL LIQ 00121-0504-05 5 mL $9 $0 $9 $6 acetaminophen-codeine 120 mg-12 mg/5 mL LIQ 00121-0504-05 1 EA $9 $0 $9 $6 amoxicillin-clavulanate 250 mg-125 mg Tab 00029-6075-27 1 tab(s) $28 $0 $28 $17 dextromethorphan-guaifenesin 30 mg-600 mg ER Ta 63824-0056-32 1 tab(s) $7 $0 $7 $4 zonisamide 50 mg Cap 68462-0129-01 1 cap(s) $11 $0 $11 $6 conjugated estrogens 0.3 mg Tab 00046-1100-81 1 tab(s) $14 $0 $14 $9 lubiprostone 24 mcg Cap 64764-0240-10 1 cap(s) $25 $0 $25 $15 bumetanide 0.25 mg/mL Injection 00641-6162-10 1 mL $29 $0 $29 $17 doxycycline hyclate 50 mg Cap 00143-3141-50 1 cap(s) $8 $0 $8 $5 diphenhydrAMINE 12.5 mg/5 mL LIQ 00603-0823-81 1 mL $5 $0 $5 $3 lactulose 10 g/15 mL Syrup 00121-0577-08 1.5 mL $5 $0 $5 $3 midazolam 5 mg/mL preservative-free Soln 00409-2308-01 1 mL $17 $0 $17 $10 metoclopramide 5 mg/mL Soln 00409-3414-01 2 mL $15 $0 $15 $9 APAP/ASA/caffeine 250 mg-250 mg-65 mg Tab 00904-5135-59 1 tab(s) $4 $0 $4 $2 Al hydroxide/Mg hydroxide/simethicone 200 mg-200 mg-20 mg/5 mL Susp 00536-0025-83 30 mL $5 $0 $5 $3 chlordiazepoxide 25 mg Cap 51079-0141-20 1 cap(s) $6 $0 $6 $4 methadone 5 mg/5 mL Soln 00054-3555-63 1 mL $5 $0 $5 $3 amoxicillin 875 mg Tab 59762-1050-05 1 tab(s) $9 $0 $9 $5 Non-Form VOLUME med Soln 99999-9999-04 1 mL $0 $0 $0 $0 haloperidol 1 mg Tab 00781-1392-01 1 tab(s) $6 $0 $6 $3 theophylline 100 mg ER Ta 00904-5887-61 1 tab(s) $5 $0 $5 $3 PHENobarbital 20 mg/5 mL Elixi 00603-1508-58 5 mL $5 $0 $5 $3 magnesium gluconate 500 mg Tab 35046-0003-22 1 tab(s) $4 $0 $4 $2 21 Floor Pharmacy Delivery Storage - Test 99345-0003-20 1 EA $0 $0 $0 $0 abacavir 300 mg Tab 68084-0021-21 1 tab(s) $71 $0 $71 $42 abacavir 300 mg Tab 31722-0557-60 1 tab(s) $71 $0 $71 $42 ABObotulinumtoxinA 300 unit(s) REC Injection- Own Supply 99345-0004-30 1 vial(s) $0 $0 $0 $0 ABObotulinumtoxinA 500 unit(s) REC Injection- Own Supply 99345-0004-35 1 vial(s) $0 $0 $0 $0 acetaminophen 120 mg Supp 45802-0732-30 1 supp $7 $0 $7 $4 acetaminophen 120 mg Supp 51672-2115-02 1 supp $9 $0 $9 $5 acetaminophen 160 mg/5 mL LIQ 00904-6820-76 20.3 mL $19 $0 $19 $11 acetaminophen 160 mg/5 mL Susp 45802-0201-26 5 mL $30 $0 $30 $18 acetaminophen 160 mg/5 mL Susp 45802-0203-26 5 mL $30 $0 $30 $18 acetaminophen 160 mg/5 mL Susp 50580-0296-50 5 mL $47 $0 $47 $28 acetaminophen 160 mg/5 mL Susp 50580-0424-01 5 mL $55 $0 $55 $33

Page 69 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price acetaminophen 160 mg/5 mL Susp 50580-0614-01 5 mL $55 $0 $55 $33 acetaminophen 325 mg Supp 51672-2116-02 1 supp $9 $0 $9 $5 acetaminophen 325 mg Tab 51645-0703-01 1 tab(s) $3 $0 $3 $2 acetaminophen 325 mg Tab 50580-0496-60 1 tab(s) $4 $0 $4 $2 acetaminophen 325 mg Tab 00904-6719-80 1 tab(s) $3 $0 $3 $2 acetaminophen 325 mg Tab 00904-6773-61 1 tab(s) $4 $0 $4 $2 acetaminophen 500 mg Tab 00904-1988-60 1 tab(s) $4 $0 $4 $2 acetaminophen 500 mg Tab 50580-0412-02 1 tab(s) $4 $0 $4 $2 acetaminophen 650 mg / 20.3 mL Soln 00121-1971-00 20.3 mL $16 $0 $16 $9 acetaminophen 650 mg Supp 45802-0730-30 1 supp $8 $0 $8 $5 acetaminophen 80 mg Chew 00045-0485-32 1 tab(s) $4 $0 $4 $2 acetaminophen soln [UD] 160 mg / 5 mL Soln 66689-0056-99 20.3 mL $24 $0 $24 $14 acetaminophen-codeine 120 mg-12 mg/5 mL LIQ 50383-0079-06 5 mL $15 $0 $15 $9 acetaminophen-codeine 120 mg-12 mg/5 mL LIQ 50383-0079-16 1 mL $5 $0 $5 $3 acetaminophen-codeine 300 mg-30 mg Tab 00406-0484-62 1 tab(s) $30 $0 $30 $18 acetaminophen-HYDROcodone [Norco] 325 mg-5 mg Tab 68084-0895-01 1 tab(s) $9 $0 $9 $5 acetaminophen-hydrocodone 108 mg-2.5 mg/5 mL LIQ 00121-4772-40 5 mL $54 $0 $54 $33 acetaminophen-hydrocodone 325 mg-10 mg Tab 00406-0125-05 1 tab(s) $11 $0 $11 $7 acetaminophen-hydrocodone 325 mg-10 mg Tab 50268-0402-15 1 tab(s) $16 $0 $16 $9 acetaminophen-hydrocodone 325 mg-10 mg Tab 60687-0418-01 1 tab(s) $12 $0 $12 $7 acetaminophen-hydrocodone 325 mg-5 mg Tab 50268-0401-15 1 tab(s) $12 $0 $12 $7 acetaminophen-hydrocodone 325 mg-5 mg Tab 00406-0123-01 1 tab(s) $9 $0 $9 $6 acetaminophen-hydrocodone 325 mg-7.5 mg Tab 60687-0407-01 1 tab(s) $10 $0 $10 $6 acetaminophen-HYDROcodone 325 mg-7.5 mg/15 mL Soln 64376-0640-16 1 mL $7 $0 $7 $4 acetaminophen-HYDROcodone 325 mg-7.5 mg/15 mL Soln 66689-0023-50 15 mL $28 $0 $28 $17 acetaminophen-hydrocodone 500 mg-7.5 mg/15 mL Elixi 00121-4655-15 15 mL $32 $0 $32 $19 acetaminophen-oxycodone 325 mg-5 mg Tab 00406-0512-01 1 tab(s) $7 $0 $7 $4 acetaminophen-oxycodone 325 mg-5 mg Tab 00406-0512-23 1 tab(s) $7 $0 $7 $4 acetaminophen-oxyCODONE 325 mg-5 mg Tab 68084-0355-01 1 tab(s) $7 $0 $7 $4 acetaminophen-oxyCODONE 325 mg-5 mg Tab 68308-0405-47 1 tab(s) $14 $0 $14 $8 acetaminophen-tramadol 325 mg-37.5 mg Tab 50268-0774-15 1 tab(s) $10 $0 $10 $6 acetaminophen/butalbital/caffeine 325 mg-50 mg-40 mg Tab 00591-3369-01 1 tab(s) $15 $0 $15 $9 acetaminophen/butalbital/caffeine 325 mg-50 mg-40 mg Tab 00527-1695-01 1 tab(s) $15 $0 $15 $9 acetaZOLAMIDE 250 mg Tab 68084-0541-01 1 tab(s) $8 $0 $8 $5 acetaZOLAMIDE 250 mg Tab 00527-1050-01 1 tab(s) $6 $0 $6 $4 acetaZOLAMIDE 250 mg Tab 23155-0288-01 1 tab(s) $23 $0 $23 $14 acetaZOLAMIDE 500 mg ER Ca 50742-0233-01 1 cap(s) $32 $0 $32 $19 acetic acid Topical 0.25% Soln 00264-2304-00 1 app $78 $0 $78 $47 acetic acid topical 0.25% Soln 00338-0656-04 1 app $8 $0 $8 $5 acetylcysteine 20% Soln 00409-3308-03 30 mL $77 $0 $77 $46 acitretin 25 mg Cap 42794-0083-08 1 cap(s) $261 $0 $261 $157 acyclovir 200 mg Cap 68084-0107-01 1 cap(s) $12 $0 $12 $7 acyclovir 400 mg Tab 50268-0061-15 1 tab(s) $28 $0 $28 $17 acyclovir 400 mg Tab 68084-0108-01 1 tab(s) $17 $0 $17 $10 acyclovir 400 mg Tab 63304-0504-01 1 tab(s) $18 $0 $18 $11 acyclovir 50 mg/mL Soln 55150-0155-21 1 mL $60 $0 $60 $36 acyclovir 800 mg Tab 68084-0109-01 1 tab(s) $34 $0 $34 $20 acyclovir 800 mg Tab 00093-8947-01 1 tab(s) $28 $0 $28 $17 acyclovir 800 mg Tab 00093-8947-05 1 tab(s) $27 $0 $27 $16 adalimumab 40 mg/0.8 mL Soln 00074-3799-02 0.8 mL $8,608 $0 $8,608 $5,165 adenosine 3 mg/mL Soln 63323-0651-02 2 mL $100 $0 $100 $60 Al hydroxide/Mg hydroxide/simethicone 200 mg-200 mg-20 mg/5 mL Susp 00067-0330-71 30 mL $5 $0 $5 $3 albuterol 0.083% Soln 76204-0200-25 3 mL $17 $0 $17 $10 albuterol 2.5 mg/3 mL (0.083%) Soln 60687-0395-83 3 mL $10 $0 $10 $6 albuterol 90 mcg/inh Aeros 66993-0019-68 1 puff(s) $215 $0 $215 $129 albuterol CFC free 90 mcg/inh Aeros 00173-0682-21 1 puff(s) $145 $0 $145 $87 albuterol CFC free 90 mcg/inh Aeros 00173-0682-24 1 puff(s) $145 $0 $145 $87 albuterol-ipratropium 2.5 mg-0.5 mg/3 mL Soln 00487-0201-01 3 mL $23 $0 $23 $14 albuterol-ipratropium 2.5 mg-0.5 mg/3 mL Soln 60687-0405-83 3 mL $12 $0 $12 $7 alclometasone topical 0.05% Ointm 00168-0264-15 1 app $148 $0 $148 $89 alendronate 70 mg Tab 16252-0601-02 1 tab(s) $140 $0 $140 $84 alendronate 70 mg Tab 65862-0329-04 1 tab(s) $141 $0 $141 $84 allopurinol 100 mg Tab 29300-0349-01 1 tab(s) $7 $0 $7 $4 allopurinol 100 mg Tab 00904-7041-61 1 tab(s) $6 $0 $6 $4 allopurinol 100 mg Tab 51079-0205-01 1 tab(s) $5 $0 $5 $3 allopurinol 100 mg Tab 51079-0205-20 1 tab(s) $5 $0 $5 $3 allopurinol 100 mg Tab 62584-0988-01 1 tab(s) $5 $0 $5 $3 allopurinol 100 mg Tab 62584-0988-11 1 tab(s) $5 $0 $5 $3 allopurinol 100 mg Tab 63739-0410-10 1 tab(s) $5 $0 $5 $3 allopurinol 300 mg Tab 51079-0206-01 1 tab(s) $7 $0 $7 $4 allopurinol 300 mg Tab 51079-0206-20 1 tab(s) $7 $0 $7 $4 ALPRAZolam 0.25 mg Tab 67253-0900-10 1 tab(s) $9 $0 $9 $6 ALPRAZolam 0.25 mg Tab 00228-2027-10 1 tab(s) $9 $0 $9 $6 ALPRAZolam 0.5 mg Tab 00904-5859-61 1 tab(s) $10 $0 $10 $6 ALPRAZolam 0.5 mg Tab 59762-3720-01 1 tab(s) $5 $0 $5 $3 alprostadil 10 mcg REC I 00009-5181-01 1 mL $656 $0 $656 $394 alprostadil 20 mcg REC I 00009-5182-01 1 mL $466 $0 $466 $280 alprostadil 20 mcg REC I 00009-5182-01 1 mL $466 $0 $466 $280 alprostadil 20 mcg REC I 00091-1120-20 1 mL $307 $0 $307 $184

Page 70 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price aluminum acetate powder (Domeboro) 01650-0023-24 1 packet(s) $13 $0 $13 $8 amantadine 100 mg / 10 mL Soln UD 17856-0093-01 10 mL $96 $0 $96 $58 amantadine 100 mg Cap 50268-0069-15 1 cap(s) $29 $0 $29 $17 amantadine 100 mg Cap 60687-0422-01 1 cap(s) $18 $0 $18 $11 amantadine 100 mg Cap 68382-0512-01 1 cap(s) $17 $0 $17 $10 amantadine 100 mg/10 mL Syrup 63481-0205-16 10 mL $26 $0 $26 $15 amantadine 50 mg/5 mL Syrup 60687-0239-56 10 mL $23 $0 $23 $14 amantadine 50 mg/5 mL Syrup 60432-0093-16 1 mL $6 $0 $6 $3 amikacin 250 mg/mL Soln 00703-9032-03 1 mL $55 $0 $55 $33 aMILoride 5 mg Tab 00574-0292-01 1 tab(s) $5 $0 $5 $3 Amino Acids 15% (Clinisol Sulfite-Free) Soln 00338-0502-06 1 mL $0 $0 $0 $0 amiodarone 200 mg Tab 00185-0144-60 1 tab(s) $26 $0 $26 $16 amiodarone 200 mg Tab 00904-6556-61 1 tab(s) $7 $0 $7 $4 amiodarone 200 mg Tab 65862-0732-60 1 tab(s) $26 $0 $26 $16 amiodarone 200 mg Tab 60687-0437-01 1 tab(s) $7 $0 $7 $4 amiodarone 50 mg/mL Soln 00143-9875-10 1 mL $14 $0 $14 $8 amitriptyline 10 mg Tab 00781-1486-01 1 tab(s) $5 $0 $5 $3 amitriptyline 10 mg Tab 16729-0171-01 1 tab(s) $5 $0 $5 $3 amitriptyline 10 mg Tab 51079-0131-20 1 tab(s) $5 $0 $5 $3 amitriptyline 100 mg Tab 51079-0563-20 1 tab(s) $11 $0 $11 $6 amitriptyline 100 mg Tab 16729-0175-01 1 tab(s) $20 $0 $20 $12 amitriptyline 100 mg Tab 00378-2685-01 1 tab(s) $11 $0 $11 $6 amitriptyline 25 mg Tab 00904-0201-61 1 tab(s) $8 $0 $8 $5 amitriptyline 25 mg Tab 51079-0107-20 1 tab(s) $6 $0 $6 $3 amitriptyline 50 mg Tab 51079-0133-20 1 tab(s) $8 $0 $8 $5 amitriptyline 50 mg Tab 60687-0444-01 1 tab(s) $8 $0 $8 $5 amitriptyline 50 mg Tab 00904-0202-61 1 tab(s) $8 $0 $8 $5 amitriptyline 50 mg Tab 16729-0173-01 1 tab(s) $12 $0 $12 $7 amitriptyline 75 mg Tab 16729-0174-01 1 tab(s) $16 $0 $16 $10 amitriptyline 75 mg Tab 51079-0147-01 1 tab(s) $9 $0 $9 $6 amitriptyline 75 mg Tab 51079-0147-20 1 tab(s) $9 $0 $9 $6 amLODIPine 10 mg Tab 60687-0496-01 1 tab(s) $4 $0 $4 $2 amLODIPine 10 mg Tab 60687-0274-01 1 tab(s) $7 $0 $7 $4 amLODIPine 10 mg Tab 50268-0085-15 1 tab(s) $34 $0 $34 $20 amLODIPine 10 mg Tab 00904-6371-61 1 tab(s) $18 $0 $18 $11 amLODIPine 2.5 mg Tab 00904-6369-61 1 tab(s) $14 $0 $14 $8 amLODIPine 2.5 mg Tab 50268-0083-15 1 tab(s) $9 $0 $9 $5 amLODIPine 2.5 mg Tab 51079-0450-20 1 tab(s) $15 $0 $15 $9 amLODIPine 2.5 mg Tab 67877-0197-90 1 tab(s) $15 $0 $15 $9 amLODIPine 2.5 mg Tab 69097-0126-15 1 tab(s) $15 $0 $15 $9 amLODIPine 5 mg Tab 60687-0263-01 1 tab(s) $6 $0 $6 $4 amLODIPine 5 mg Tab 60687-0488-01 1 tab(s) $4 $0 $4 $2 amLODIPine 5 mg Tab 50268-0084-15 1 tab(s) $27 $0 $27 $16 amLODIPine 5 mg Tab 00904-6370-61 1 tab(s) $14 $0 $14 $9 amoxicillin 250 mg Cap 00781-2020-01 1 cap(s) $5 $0 $5 $3 amoxicillin 250 mg Cap 00093-3107-93 1 cap(s) $5 $0 $5 $3 amoxicillin 500 mg Cap 00093-3109-93 1 cap(s) $7 $0 $7 $4 amoxicillin 500 mg Cap 67253-0141-10 1 cap(s) $7 $0 $7 $4 amoxicillin 875 mg Tab 65862-0015-01 1 tab(s) $9 $0 $9 $5 amoxicillin-clavulanate 1000 mg-62.5 mg ER Ta 00781-1943-82 1 tab(s) $55 $0 $55 $33 amoxicillin-clavulanate 250 mg-125 mg Tab 00781-1874-31 1 tab(s) $31 $0 $31 $19 amoxicillin-clavulanate 250 mg-125 mg Tab 00029-6075-31 1 tab(s) $32 $0 $32 $19 amoxicillin-clavulanate 500 mg-125 mg Tab 00093-2274-34 1 tab(s) $29 $0 $29 $17 amoxicillin-clavulanate 500 mg-125 mg Tab 51079-0265-20 1 tab(s) $29 $0 $29 $17 amoxicillin-clavulanate 500 mg-125 mg Tab 65862-0502-20 1 tab(s) $29 $0 $29 $17 amoxicillin-clavulanate 600 mg-42.9 mg/5 mL REC P 00781-6139-54 5 mL $9 $0 $9 $5 amoxicillin-clavulanate 875 mg-125 mg Tab 00093-2275-34 1 tab(s) $17 $0 $17 $10 amoxicillin-clavulanate 875 mg-125 mg Tab 65862-0503-20 1 tab(s) $37 $0 $37 $22 amphetamine-dextroamphetamine 10 mg ER Ca 00228-3059-11 1 cap(s) $54 $0 $54 $32 amphetamine-dextroamphetamine 10 mg ER Ca 42858-0610-01 1 cap(s) $36 $0 $36 $22 amphetamine-dextroamphetamine 10 mg ER Capsule 60687-0276-25 1 cap(s) $58 $0 $58 $35 amphetamine-dextroamphetamine 20 mg Tab 57664-0646-08 1 tab(s) $17 $0 $17 $10 amphetamine-dextroamphetamine 5 mg Tab 00555-0971-02 1 tab(s) $14 $0 $14 $8 amphetamine-dextroamphetamine 5 mg Tab 00185-0831-01 1 tab(s) $17 $0 $17 $10 amphotericin B 50 mg REC I 00013-1405-44 10 mL $305 $0 $305 $183 amphotericin B 50 mg REC I 39822-1055-05 10 mL $328 $0 $328 $197 amphotericin B lipid complex 5 mg/mL Susp 57665-0101-41 20 mL $1,690 $0 $1,690 $1,014 ampicillin 1 g REC I 00781-9412-92 0 $124 $0 $124 $74 ampicillin 1 g REC I 55150-0113-10 0 $121 $0 $121 $73 ampicillin 1 g REC I 63323-0389-10 0 $113 $0 $113 $68 ampicillin 1 g REC I 70860-0114-15 0 $126 $0 $126 $76 ampicillin 2 g REC I 55150-0114-20 0 $175 $0 $175 $105 ampicillin 2 g REC I 00409-3720-01 0 $117 $0 $117 $70 ampicillin 250 mg Cap 00003-0122-50 1 cap(s) $5 $0 $5 $3 ampicillin 250 mg Cap 00781-2144-01 1 cap(s) $5 $0 $5 $3 ampicillin 250 mg Cap 67253-0180-10 1 cap(s) $5 $0 $5 $3 ampicillin 500 mg Cap 67253-0181-10 1 cap(s) $6 $0 $6 $4 ampicillin 500 mg Cap 00781-2145-01 1 cap(s) $6 $0 $6 $4 ampicillin 500 mg REC I 00781-3407-95 0 $94 $0 $94 $57

Page 71 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price ampicillin-SULbactam [Unasyn] 3 gm REC Injection 66794-0207-41 0 $79 $0 $79 $48 ampicillin-sulbactam 1 g-0.5 g REC I 66794-0206-41 0 $108 $0 $108 $65 ampicillin-sulbactam 1 g-0.5 g REC I 71288-0005-20 0 $97 $0 $97 $58 ampicillin-sulbactam 1 g-0.5 g REC I 55150-0116-20 0 $118 $0 $118 $71 ampicillin-sulbactam 2 g-1 g REC I 55150-0117-20 0 $110 $0 $110 $66 amprenavir 150 mg Cap 00173-0672-00 1 cap(s) $14 $0 $14 $8 anastrozole 1 mg Tab 16729-0035-15 1 tab(s) $92 $0 $92 $55 anastrozole 1 mg Tab 60687-0112-21 1 tab(s) $17 $0 $17 $10 APAP-HYDROcodone 325 mg-10 mg Tab 00406-0125-62 1 tab(s) $13 $0 $13 $8 APAP-HYDROcodone 325 mg-5 mg Tab 00406-0123-62 1 tab(s) $10 $0 $10 $6 APAP/butalbital/caffeine 325 mg-50 mg-40 mg Tab 00603-2544-21 1 tab(s) $8 $0 $8 $5 apixaban 2.5 mg Tab 00003-0893-21 1 tab(s) $46 $0 $46 $27 apixaban 5 mg Tab 00003-0894-21 1 tab(s) $59 $0 $59 $36 arformoterol tartrate 15 mcg Soln 63402-0911-01 2 mL $107 $0 $107 $64 arginine 500 mg Tab 00904-4215-51 1 tab(s) $4 $0 $4 $2 ARIPiprazole 1 mg/mL Soln 59148-0013-15 1 mL $60 $0 $60 $36 ARIPiprazole 10 mg Tab 62332-0099-30 1 tab(s) $218 $0 $218 $131 ARIPiprazole 10 mg Tab 62332-0099-31 1 tab(s) $218 $0 $218 $131 ARIPiprazole 2 mg Tab 62332-0097-30 1 tab(s) $218 $0 $218 $131 aripiprazole 2 mg Tab 60505-3075-03 1 tab(s) $218 $0 $218 $131 aripiprazole 5 mg Tab 13811-0680-30 1 tab(s) $218 $0 $218 $131 ARIPiprazole 5 mg Tab 62332-0098-31 1 tab(s) $218 $0 $218 $131 armodafinil 150 mg Tab 63459-0215-30 1 tab(s) $73 $0 $73 $44 armodafinil 150 mg Tab 63459-0215-60 1 tab(s) $80 $0 $80 $48 armodafinil 250 mg Tab 65862-0807-30 1 tab(s) $158 $0 $158 $95 armodafinil 250 mg Tab 00093-3094-56 1 tab(s) $157 $0 $157 $94 armodafinil 250 mg Tab 00378-3433-93 1 tab(s) $158 $0 $158 $95 armodafinil 50 mg Tab 00093-3090-56 1 tab(s) $55 $0 $55 $33 armodafinil 50 mg Tab 65862-0805-30 1 tab(s) $55 $0 $55 $33 armodafinil 50 mg Tab 63459-0205-30 1 tab(s) $55 $0 $55 $33 ascorbic acid 500 MG / 1 ML Soln 17856-0022-01 5 mL $12 $0 $12 $7 ascorbic acid 250 mg Tab 20555-0001-00 1 tab(s) $3 $0 $3 $2 ascorbic acid 250 mg Tab 50268-0860-15 1 tab(s) $5 $0 $5 $3 ascorbic acid 250 mg Tab 00904-0522-60 1 tab(s) $4 $0 $4 $2 ascorbic acid 500 mg Chew 87701-0407-43 1 tab(s) $4 $0 $4 $2 ascorbic acid 500 mg Tab 57896-0841-01 1 tab(s) $4 $0 $4 $2 ascorbic acid 500 mg Tab 00904-0523-60 1 tab(s) $4 $0 $4 $2 ascorbic acid 500 mg/mL Soln 67457-0118-50 1 mL $11 $0 $11 $6 ascorbic acid Chew Tab 500 mg Chew tab 58526-0005-37 1 tab(s) $12 $0 $12 $7 ascorbic acid Chew Tab 500 mg Tab 50268-0861-15 1 tab(s) $7 $0 $7 $4 ascorbic acid-iron polysaccharide 50 mg-150 mg Cap 51991-0703-90 1 cap(s) $12 $0 $12 $7 aspirin 325 mg EC Ta 63739-0523-01 1 tab(s) $4 $0 $4 $2 aspirin 325 mg EC Ta 00603-0168-21 1 tab(s) $4 $0 $4 $2 aspirin 325 mg EC Tablet 46122-0596-02 1 tab(s) $3 $0 $3 $2 aspirin 325 mg Tab 00536-1054-29 1 tab(s) $3 $0 $3 $2 aspirin 81 mg Chew 00904-6794-89 1 tab(s) $3 $0 $3 $2 aspirin 81 mg Chew tab 66553-0002-01 1 tab(s) $232 $0 $232 $139 aspirin 81 mg EC Ta 63739-0272-01 1 tab(s) $4 $0 $4 $2 aspirin 81 mg EC Ta 63739-0272-03 1 tab(s) $4 $0 $4 $2 aspirin 81 mg EC Ta 00904-6783-70 1 tab(s) $3 $0 $3 $2 aspirin 81 mg EC Ta 00904-6751-80 1 tab(s) $3 $0 $3 $2 aspirin 81 mg EC Ta 00904-6713-18 1 tab(s) $3 $0 $3 $2 aspirin-dipyridamole 25 mg-200 mg ER Ca 65162-0596-06 1 cap(s) $59 $0 $59 $36 atenolol 25 mg Tab 57664-0264-88 1 tab(s) $9 $0 $9 $5 atenolol 25 mg Tab 51079-0759-01 1 tab(s) $9 $0 $9 $5 atenolol 25 mg Tab 51079-0759-20 1 tab(s) $9 $0 $9 $5 atenolol 25 mg Tab 00904-5392-61 1 tab(s) $8 $0 $8 $5 atenolol 50 mg Tab 00310-0105-39 1 tab(s) $11 $0 $11 $6 atenolol 50 mg Tab 51079-0684-01 1 tab(s) $181 $0 $181 $109 atomoxetine 10 mg Cap 64980-0373-03 1 cap(s) $99 $0 $99 $59 atomoxetine 10 mg Cap 00093-3542-56 1 cap(s) $99 $0 $99 $59 atomoxetine 18 mg Cap 66993-0041-30 1 cap(s) $99 $0 $99 $59 atomoxetine 25 mg Cap 64980-0375-03 1 cap(s) $99 $0 $99 $59 atorvastatin 10 mg Tab 51079-0208-20 1 tab(s) $6 $0 $6 $3 atorvastatin 10 mg Tab 00904-6290-61 1 tab(s) $7 $0 $7 $4 atorvastatin 20 mg Tab 00904-6291-61 1 tab(s) $7 $0 $7 $4 atorvastatin 20 mg Tab 51079-0209-20 1 tab(s) $7 $0 $7 $4 atorvastatin 40 mg Tab 51079-0210-20 1 tab(s) $7 $0 $7 $4 atorvastatin 40 mg Tab 55111-0123-90 1 tab(s) $40 $0 $40 $24 atorvastatin 40 mg Tab 60505-2580-09 1 tab(s) $42 $0 $42 $25 atorvastatin 40 mg Tab 00904-6292-61 1 tab(s) $8 $0 $8 $5 atorvastatin 40 mg Tab 00093-5058-98 1 tab(s) $75 $0 $75 $45 atorvastatin 80 mg Tab 60505-2671-09 1 tab(s) $42 $0 $42 $25 atorvastatin 80 mg Tab 51079-0211-03 1 tab(s) $16 $0 $16 $10 atovaquone 750 mg/5 mL Susp 65162-0693-88 1 mL $51 $0 $51 $30 atropine 0.1 mg/mL Soln 76329-3339-01 10 mL $84 $0 $84 $50 atropine 0.1 mg/mL Soln 00409-4911-34 10 mL $35 $0 $35 $21 atropine 0.1 mg/mL Soln 00548-3339-00 10 mL $41 $0 $41 $25 atropine ophthalmic 1% Soln 00065-0303-55 1 drop(s) $401 $0 $401 $240

Page 72 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price atropine-diphenoxylate 0.025 mg-2.5 mg Tab 00378-0415-01 1 tab(s) $8 $0 $8 $5 atropine-diphenoxylate 0.025 mg-2.5 mg/5 mL LIQ 00054-3194-46 5 mL $11 $0 $11 $6 atropine-diphenoxylate Tab 0.025 mg-2.5 mg Tab 62559-0490-01 1 tab(s) $9 $0 $9 $6 azaTHIOprine 50 mg Tab 00054-8084-25 1 tab(s) $13 $0 $13 $8 azathioprine 50 mg Tab 68084-0229-01 1 tab(s) $9 $0 $9 $5 azathioprine 50 mg Tab 68084-0229-11 1 tab(s) $9 $0 $9 $5 azelastine nasal 137 mcg/inh Spray 65162-0676-84 1 spray(s) $1,028 $0 $1,028 $617 azelastine ophthalmic 0.05% Soln 47335-0938-90 1 drop(s) $729 $0 $729 $437 azithromycin 250 mg Tab 50268-0098-15 1 tab(s) $53 $0 $53 $32 azithromycin 250 mg Tab 50111-0787-66 1 tab(s) $15 $0 $15 $9 azithromycin 500 mg REC I 63323-0398-10 5 mL $70 $0 $70 $42 azithromycin 500 mg REC I 00409-0144-11 5 mL $66 $0 $66 $39 azithromycin 600 mg Tab 60687-0314-25 1 tab(s) $34 $0 $34 $20 aztreonam 1 g REC I 63323-0401-26 10 mL $285 $0 $285 $171 aztreonam 1 gm Injection 00003-2560-16 10 mL $252 $0 $252 $151 aztreonam 2 gm REC Injection 63323-0402-30 20 mL $467 $0 $467 $280 bacitracin topical 500 units/g Ointm 45802-0060-03 1 app $48 $0 $48 $29 bacitracin topical 500 units/g Ointm 45802-0060-70 1 packet(s) $9 $0 $9 $6 bacitracin-polymyxin B ophthalmic 500 units-10000 units/g Ointm 17478-0238-35 1 app $188 $0 $188 $113 bacitracin-polymyxin B ophthalmic 500 units-10000 units/g Ointm 00168-0273-38 1 app $196 $0 $196 $117 bacitracin-polymyxin B Topical 500 units-10000 units/g Ointm 00081-0798-87 1 app $54 $0 $54 $32 bacitracin-polymyxin B topical 500 units-10000 units/g Ointm 51672-2044-02 1 app $56 $0 $56 $34 bacitracin/HC/neomycin/polymyxin B ophthalmic 400 units-10 mg-3.5 mg-10000 00168-0029-38 1 app $122 $0 $122 $73 units/g Ointm bacitracin/HC/neomycin/polymyxin B ophthalmic 400 units-10 mg-3.5 mg-10000 48102-0005-35 1 app $428 $0 $428 $257 units/g Ointm bacitracin/HC/neomycin/polymyxin B Topical 400 units-10 mg-3.5 mg-10000 units/g 61570-0031-50 1 app $796 $0 $796 $478 Ointm bacitracin/neomycin/poly B [Triple Antibiotic] 400 units-3.5 mg-5000 uni Ointment 46122-0414-03 1 app $18 $0 $18 $11 bacitracin/neomycin/polymyxin B Topical 400 units-3.5 mg-5000 units/g Ointm 00472-0179-16 1 app $135 $0 $135 $81 bacitracin/neomycin/polymyxin B topical Ointm 0.9 gm 00168-0012-09 1 packet(s) $9 $0 $9 $6 baclofen 0.05 mg/mL Soln 58281-0562-01 1 mL $154 $0 $154 $92 baclofen 0.05 mg/mL Soln 45945-0151-01 1 mL $211 $0 $211 $127 baclofen 0.5 mg/mL Soln 45945-0155-02 20 mL $568 $0 $568 $341 baclofen 1 mg/mL Soln 45945-0156-02 20 mL $1,135 $0 $1,135 $681 baclofen 10 mg Tab 00904-6475-61 1 tab(s) $7 $0 $7 $4 baclofen 10 mg Tab 00172-4096-60 1 tab(s) $20 $0 $20 $12 baclofen 2 mg/mL Soln 45945-0157-02 20 mL $2,270 $0 $2,270 $1,362 baclofen 20 mg Tab 00832-1055-11 1 tab(s) $38 $0 $38 $23 baclofen 20 mg Tab 70710-1286-01 1 tab(s) $38 $0 $38 $23 baclofen 20 mg Tab 68084-0868-01 1 tab(s) $9 $0 $9 $5 baclofen Intrathecal Pump Device - Device 99345-0002-75 0 $0 $0 $0 $0 Baclofen-Clonidine (compound) Intrathecal Soln 2 mg-2.2 mg/ mL Soln 99345-0001-80 1 mL $0 $0 $0 $0 balsalazide 750 mg Cap 65649-0101-02 1 cap(s) $13 $0 $13 $8 balsalazide 750 mg Cap 00591-3570-35 1 cap(s) $14 $0 $14 $8 barium sulfate 0.1% Susp 32909-0945-03 450 mL $68 $0 $68 $41 barium sulfate 2.1% Susp 32909-0723-01 450 mL $36 $0 $36 $22 belatacept 250 mg REC I 00003-0371-13 10 mL $7,285 $0 $7,285 $4,371 belladonna-opium 16.2 mg-30 mg Supp 00574-7045-04 1 supp $294 $0 $294 $176 belladonna-opium 16.2 mg-30 mg Supp 00574-7045-12 1 supp $197 $0 $197 $118 benazepril 10 mg Tab 50268-0110-15 1 tab(s) $10 $0 $10 $6 benazepril 20 mg Tab 65162-0753-10 1 tab(s) $10 $0 $10 $6 benzocaine topical 10 mg Lozen 11509-0209-18 0 $9 $0 $9 $5 benzocaine-resorcinol topical 5%-2% Cream 11509-0003-67 1 app $29 $0 $29 $17 benzocaine-trimethobenzamide 2%-200 mg Supp 00713-0108-09 1 supp $13 $0 $13 $8 benzocaine-trimethobenzamide 2%-200 mg Supp 00713-0108-50 1 supp $13 $0 $13 $8 benzocaine-trimethobenzamide 2%-200 mg Supp 61570-0504-50 1 supp $26 $0 $26 $16 benzonatate 100 mg Cap 69452-0143-20 1 cap(s) $20 $0 $20 $12 benzoyl peroxide 10% Gel 00536-1056-56 1 app $75 $0 $75 $45 benzoyl peroxide topical 5% Gel 24470-0909-60 1 app $218 $0 $218 $131 benztropine 0.5 mg Tab 68084-0381-01 1 tab(s) $4 $0 $4 $2 benztropine 0.5 mg Tab 60687-0356-01 1 tab(s) $7 $0 $7 $4 benztropine 1 mg Tab 60687-0368-01 1 tab(s) $7 $0 $7 $4 benztropine 1 mg Tab 68084-0388-01 1 tab(s) $4 $0 $4 $3 benztropine 1 mg Tab 68084-0388-11 1 tab(s) $4 $0 $4 $3 benztropine 1 mg Tab 00904-1056-61 1 tab(s) $5 $0 $5 $3 benztropine 1 mg Tab 00603-2434-21 1 tab(s) $5 $0 $5 $3 benztropine 1 mg Tab 49884-0165-01 1 tab(s) $5 $0 $5 $3 benztropine 1 mg/mL Soln 00006-3275-16 2 mL $65 $0 $65 $39 benztropine 2 mg Tab 60687-0379-01 1 tab(s) $8 $0 $8 $5 betamethasone acetate- betamet NA PH 6 mg/mL Susp 00517-0720-01 1 mL $64 $0 $64 $38 bethanechol 10 mg Tab 00832-0511-01 1 tab(s) $14 $0 $14 $8 bethanechol 10 mg Tab 68084-0365-01 1 tab(s) $4 $0 $4 $3 bethanechol 10 mg Tab 68084-0166-01 1 tab(s) $13 $0 $13 $8 bethanechol 10 mg Tab 68084-0166-11 1 tab(s) $1,004 $0 $1,004 $602 bethanechol 25 mg Tab 68084-0704-01 1 tab(s) $5 $0 $5 $3 bethanechol 25 mg Tab 65162-0573-10 1 tab(s) $18 $0 $18 $11 bethanechol 5 mg Tab 00832-0510-00 1 tab(s) $9 $0 $9 $6

Page 73 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price bicalutamide 50 mg Tab 47335-0485-83 1 tab(s) $128 $0 $128 $77 bicalutamide 50 mg Tab 16729-0023-10 1 tab(s) $126 $0 $126 $76 bictegravir/emtricitabine/tenofovir 50 mg-200 mg-25 mg Tab 61958-2501-01 1 tab(s) $831 $0 $831 $499 bisacodyl 10 mg Supp 00574-7050-50 1 supp $4 $0 $4 $3 bisacodyl 10 mg Supp (Magic Bullet) 05764-8002-01 1 supp $8 $0 $8 $5 bisacodyl 5 mg EC Ta 00904-7927-60 1 tab(s) $4 $0 $4 $2 bisoprolol 5 mg Tab 29300-0126-01 1 tab(s) $12 $0 $12 $7 bisoprolol 5 mg Tab 00185-0771-01 1 tab(s) $12 $0 $12 $7 bisoprolol 5 mg Tab 59762-1258-02 1 tab(s) $12 $0 $12 $7 bisoprolol 5 mg Tab 68084-0487-21 1 tab(s) $12 $0 $12 $7 bisoprolol 5 mg Tab 65862-0086-01 1 tab(s) $12 $0 $12 $7 bosentan 125 mg Tab 66215-0102-06 1 tab(s) $335 $0 $335 $201 bosentan 62.5 mg Tab 66215-0101-06 1 tab(s) $335 $0 $335 $201 brimonidine ophthalmic 0.15% Soln 61314-0144-05 1 drop(s) $1,236 $0 $1,236 $742 brivaracetam 10 mg/mL LIQ 50474-0870-15 1 mL $37 $0 $37 $22 brivaracetam 100 mg Tab 50474-0770-09 1 tab(s) $157 $0 $157 $94 brivaracetam oral prefilled syringe 100 mg/ 10 mL Soln 99345-0004-20 10 mL $326 $0 $326 $195 bromocriptine 2.5 mg Tab 63304-0962-01 1 tab(s) $19 $0 $19 $11 bromocriptine 2.5 mg Tab 63304-0962-30 1 tab(s) $31 $0 $31 $19 bromocriptine 2.5 mg Tab 00574-0106-01 1 tab(s) $28 $0 $28 $17 bromocriptine 2.5 mg Tab 00378-2042-01 1 tab(s) $18 $0 $18 $11 bromocriptine 5 mg Cap 00378-7096-93 1 cap(s) $66 $0 $66 $39 bromocriptine 5 mg Cap 63304-0158-01 1 cap(s) $66 $0 $66 $39 bromocriptine 5 mg Cap 63304-0158-30 1 cap(s) $66 $0 $66 $39 budesonide 3 mg DR Ca 00093-7445-01 1 cap(s) $170 $0 $170 $102 budesonide 3 mg DR Ca 00574-9855-10 1 cap(s) $39 $0 $39 $23 budesonide 3 mg DR Ca 51862-0582-01 1 cap(s) $130 $0 $130 $78 budesonide 3 mg ER Ca 00378-7155-01 1 cap(s) $130 $0 $130 $78 budesonide-formoterol 80 mcg-4.5 mcg/inh Aeros 00310-7372-20 1 puff(s) $2,503 $0 $2,503 $1,502 bumetadine 1 mg Tab 60687-0384-25 1 tab(s) $16 $0 $16 $10 bumetanide 0.25 mg/mL Soln 00641-6161-10 4 mL $27 $0 $27 $16 bumetanide 0.25 mg/mL Soln 00641-6007-10 1 mL $29 $0 $29 $17 bumetanide 0.25 mg/mL Soln 10019-0506-10 1 mL $29 $0 $29 $17 bumetanide 0.25 mg/mL Soln 00409-1412-04 4 mL $29 $0 $29 $17 bumetanide 0.25 mg/mL Soln 00409-1412-10 1 mL $40 $0 $40 $24 bumetanide 0.25 mg/mL Soln 55390-0500-02 1 mL $67 $0 $67 $40 bumetanide 0.5 mg Tab 00185-0128-01 1 tab(s) $7 $0 $7 $4 bumetanide 0.5 mg Tab 42799-0119-01 1 tab(s) $19 $0 $19 $12 bumetanide 1 mg Tab 42799-0120-01 1 tab(s) $21 $0 $21 $13 Bumetanide 2 mg Tab 00093423401 1 tab(s) $577 $0 $577 $346 bumetanide 2 mg Tab 00832-0542-11 1 tab(s) $23 $0 $23 $14 bupivacaine 0.25% preservative-free Soln 00409-1159-02 30 mL $18 $0 $18 $11 bupivacaine 0.25% preservative-free Soln 55150-0167-10 10 mL $21 $0 $21 $13 bupivacaine 0.5% Soln 00409-1560-10 1 vial(s) $28 $0 $28 $17 buprenorphine-naloxone 4 mg-1 mg Film 43598-0580-30 1 EA $66 $0 $66 $40 buprenorphine-naloxone 8 mg-2 mg Film 43598-0582-30 1 EA $66 $0 $66 $40 buprenorphine-naloxone 8 mg-2 mg Film 47781-0357-03 1 EA $66 $0 $66 $40 buPROPion 75 mg Tab 60687-0340-01 1 tab(s) $12 $0 $12 $7 buPROPion 100 mg Tab 51079-0944-01 1 tab(s) $10 $0 $10 $6 buPROPion 100 mg Tab 51079-0944-20 1 tab(s) $10 $0 $10 $6 buPROPion 100 mg Tab 00781-1064-01 1 tab(s) $10 $0 $10 $6 buPROPion 100 mg Tab 00378-0435-01 1 tab(s) $10 $0 $10 $6 buPROPion 150 mg/12 hours ER Ta 51079-0392-01 1 tab(s) $6 $0 $6 $4 buPROPion 150 mg/12 hours ER Ta 00904-6585-61 1 tab(s) $8 $0 $8 $5 buPROPion 150 mg/24 hours ER Ta 16729-0443-15 1 tab(s) $38 $0 $38 $23 buPROPion 150 mg/24 hours ER Ta 60687-0312-01 1 tab(s) $35 $0 $35 $21 buPROPion 300 mg/24 hours ER Ta 51079-0109-03 1 tab(s) $46 $0 $46 $27 buPROPion 300 mg/24 hours ER Ta 68001-0321-04 1 tab(s) $46 $0 $46 $27 buPROPion 300 mg/24 hours ER Ta 16729-0444-10 1 tab(s) $46 $0 $46 $27 busPIRone 10 mg Tab 51079-0986-20 1 tab(s) $12 $0 $12 $7 busPIRone 10 mg Tab 64380-0742-06 1 tab(s) $12 $0 $12 $7 busPIRone 10 mg Tab 00093-0054-01 1 tab(s) $12 $0 $12 $7 busPIRone 5 mg Tab 00172-5663-10 1 tab(s) $9 $0 $9 $5 busPIRone 5 mg Tab 16729-0200-01 1 tab(s) $9 $0 $9 $5 busPIRone 5 mg Tab 68084-0028-01 1 tab(s) $9 $0 $9 $5 busPIRone 5 mg Tab 68382-0180-01 1 tab(s) $9 $0 $9 $5 busPIRone 5 mg Tab 51079-0985-01 1 tab(s) $9 $0 $9 $5 busPIRone 5 mg Tab 51079-0985-20 1 tab(s) $9 $0 $9 $5 cabergoline 0.5 mg Tab 49884-0673-14 1 tab(s) $235 $0 $235 $141 caffeine citrate 20 mg/mL LIQ 00574-0152-10 1 mL $111 $0 $111 $67 calcipotriene topical 0.005% Cream 66993-0877-61 1 app $2,977 $0 $2,977 $1,786 calcipotriene topical 0.005% Soln 00430-3030-15 1 app $1,000 $0 $1,000 $600 calcitonin 200 intl units/inh Spray 49884-0161-11 1 spray(s) $839 $0 $839 $503 calcitonin 200 intl units/mL Soln 67457-0675-02 1 mL $8,666 $0 $8,666 $5,200 calcitriol 0.25 mcg Cap 60687-0345-01 1 cap(s) $9 $0 $9 $5 calcitriol 0.25 mg Cap 23155-0662-03 1 cap(s) $5 $0 $5 $3 calcitriol 0.5 mcg Cap 69452-0208-20 1 cap(s) $16 $0 $16 $10 calcitriol 1 mcg/mL LIQ 63304-0241-59 1 mL $88 $0 $88 $53 calcitriol 1 mcg/mL Soln 17478-0931-01 1 mL $51 $0 $51 $31

Page 74 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price calcitriol 1 mcg/mL Soln 00703-7311-04 1 mL $100 $0 $100 $60 calcium acetate 667 mg Cap 62135-0191-22 1 cap(s) $10 $0 $10 $6 calcium acetate 667 mg Cap 69097-0862-83 1 cap(s) $8 $0 $8 $5 calcium acetate 667 mg Cap 68084-0479-01 1 cap(s) $13 $0 $13 $8 calcium acetate 667 mg Tab 59730-6401-01 1 tab(s) $5 $0 $5 $3 calcium carbonate 1250 mg Tab 00766-1651-60 1 tab(s) $4 $0 $4 $2 calcium carbonate 1250 mg Tab 00904-1883-61 1 tab(s) $4 $0 $4 $2 calcium carbonate 1250 mg/5 mL Susp 00121-0766-16 1 mL $5 $0 $5 $3 calcium chloride 100 mg/mL Soln 00409-1631-10 1 mL $10 $0 $10 $6 calcium gluconate 100 mg/mL Soln 63323-0360-19 1 mL $16 $0 $16 $9 calcium-vitamin D 250 mg-125 units Tab 00904-1882-61 1 tab(s) $4 $0 $4 $2 calcium-vitamin D 250 mg-125 units Tab 20555-0025-00 1 tab(s) $4 $0 $4 $2 calcium-vitamin D 500 mg-200 intl units Tab 00904-5460-72 1 tab(s) $4 $0 $4 $2 calcium-vitamin D 500 mg-200 intl units Tab 10006-0700-38 1 tab(s) $4 $0 $4 $2 calcium-vitamin D 500 mg-200 intl units Tab 00536-7817-08 1 tab(s) $4 $0 $4 $2 candesartan 32 mg Tab 00378-3232-93 1 tab(s) $31 $0 $31 $19 candesartan 8 mg Tab 49884-0659-09 1 tab(s) $25 $0 $25 $15 cannabidiol 100 mg/mL LIQ 70127-0100-10 1 mL $0 $0 $0 $0 capecitabine 150 mg Tab 00004-1100-20 1 tab(s) $39 $0 $39 $24 capecitabine 500 mg Tab 51079-0510-05 1 tab(s) $297 $0 $297 $178 captopril 25 mg Tab 00143-1172-01 1 tab(s) $8 $0 $8 $5 captopril 25 mg Tab 51079-0864-01 1 tab(s) $9 $0 $9 $5 captopril 25 mg Tab 51079-0864-20 1 tab(s) $9 $0 $9 $5 carBAMazepine 100 mg Chew 51079-0870-20 1 tab(s) $5 $0 $5 $3 carBAMazepine 100 mg Chew 00078-0492-35 1 tab(s) $6 $0 $6 $4 carBAMazepine 100 mg Chew 00904-3854-61 1 tab(s) $5 $0 $5 $3 carBAMazepine 100 mg ER Ca 66993-0407-32 1 cap(s) $15 $0 $15 $9 carBAMazepine 200 mg ER Ta 51672-4124-01 1 tab(s) $10 $0 $10 $6 carBAMazepine 200 mg ER Ta 68084-0561-21 1 tab(s) $18 $0 $18 $11 carbamazepine 200 mg Tab 68084-0444-01 1 tab(s) $14 $0 $14 $9 carBAMazepine 200 mg Tab 51672-4005-01 1 tab(s) $14 $0 $14 $8 carbamazepine 200 mg Tab 51079-0385-20 1 tab(s) $6 $0 $6 $3 carBAMazepine 300 mg ER Ca 60505-2807-07 1 cap(s) $16 $0 $16 $10 carBAMazepine 300 mg ER Ca 29033-0004-12 1 cap(s) $15 $0 $15 $9 carBAMazepine ER Tab 200 mg ER Tablet 00078-0511-05 1 tab(s) $11 $0 $11 $7 carbamazepine XR 100 mg ER Tablet 00078-0510-05 1 tab(s) $11 $0 $11 $7 carbidopa 25 mg Tab 43975-0220-10 1 tab(s) $77 $0 $77 $46 carbidopa 25 mg Tab 42799-0123-01 1 tab(s) $192 $0 $192 $115 carbidopa 25 mg Tab 00056-0511-68 1 tab(s) $8 $0 $8 $5 carbidopa-levodopa 10 mg-100 mg Tab 00228-2538-10 1 tab(s) $9 $0 $9 $5 carbidopa-levodopa 10 mg-100 mg Tab 51079-0755-20 1 tab(s) $8 $0 $8 $5 carbidopa-levodopa 10 mg-100 mg Tab 63739-0046-10 1 tab(s) $11 $0 $11 $7 carbidopa-levodopa 10 mg-100 mg Tab 63739-0107-10 1 tab(s) $6 $0 $6 $4 carbidopa-levodopa 25 mg-100 mg DIS T 47335-0187-88 1 tab(s) $13 $0 $13 $8 carbidopa-levodopa 25 mg-100 mg ER Ta 00378-0088-01 1 tab(s) $10 $0 $10 $6 carbidopa-levodopa 25 mg-100 mg ER Ta 51079-0978-20 1 tab(s) $10 $0 $10 $6 carbidopa-levodopa 25 mg-100 mg Tab 00378-0085-01 1 tab(s) $9 $0 $9 $5 carbidopa-levodopa 25 mg-100 mg Tab 63739-0047-10 1 tab(s) $12 $0 $12 $7 carbidopa-levodopa 25 mg-100 mg Tab 68084-0093-01 1 tab(s) $9 $0 $9 $5 carbidopa-levodopa 25 mg-250 mg Tab 68084-0094-01 1 tab(s) $10 $0 $10 $6 carbidopa-levodopa 25 mg-250 mg Tab 63739-0048-10 1 tab(s) $14 $0 $14 $8 carbidopa-levodopa 25 mg-250 mg Tab 00904-7720-61 1 tab(s) $11 $0 $11 $6 carbidopa-levodopa 36.25 mg-145 mg ER Ca 64896-0662-01 1 cap(s) $25 $0 $25 $15 carbidopa-levodopa 50 mg-200 mg ER Ta 62756-0457-88 1 tab(s) $15 $0 $15 $9 carbidopa-levodopa 50 mg-200 mg ER Ta 60505-0132-01 1 tab(s) $15 $0 $15 $9 carbidopa-levodopa 50 mg-200 mg ER Ta 68084-0282-01 1 tab(s) $14 $0 $14 $8 carbidopa-levodopa 50 mg-200 mg ER Ta 00378-0094-01 1 tab(s) $15 $0 $15 $9 carbidopa-levodopa 61.25 mg-245 mg ER Ca 64896-0664-01 1 cap(s) $30 $0 $30 $18 carbidopa/entacapone/levodopa 12.5 mg-200 mg-50 mg Tab 00078-0407-05 1 tab(s) $20 $0 $20 $12 carbidopa/entacapone/levodopa 18.75 mg-200 mg-75 mg Tab 00078-0544-05 1 tab(s) $31 $0 $31 $19 carbidopa/entacapone/levodopa 18.75 mg-200 mg-75 mg Tab 00781-5625-01 1 tab(s) $28 $0 $28 $17 carbidopa/entacapone/levodopa 18.75 mg-200 mg-75 mg Tab 47335-0002-88 1 tab(s) $28 $0 $28 $17 carbidopa/entacapone/levodopa 25 mg-200 mg-100 mg Tab 00078-0408-05 1 tab(s) $3 $0 $3 $2 carbidopa/entacapone/levodopa 37.5 mg-200 mg-150 mg Tab 00078-0409-05 1 tab(s) $20 $0 $20 $12 carbidopa/entacapone/levodopa 37.5 mg-200 mg-150 mg Tab 00781-5654-01 1 tab(s) $28 $0 $28 $17 carbidopa/entacapone/levodopa 50 mg-200 mg-200 mg Tab 00781-5669-01 1 tab(s) $28 $0 $28 $17 carbidopa/entacapone/levodopa 50 mg-200 mg-200 mg Tab 00078-0527-05 1 tab(s) $25 $0 $25 $15 carbidopa/levodopa 25 mg-100 mg CR Tablet 51079-0978-01 1 tab(s) $11 $0 $11 $7 carbidopa/levodopa 25 mg-100 mg CR Tablet 68084-0281-01 1 tab(s) $9 $0 $9 $5 carbidopa/levodopa 50 mg-200 mg tab(s) ER Tablet 51079-0923-01 1 tab(s) $21 $0 $21 $13 carisoprodol 350 mg Tab 68084-0380-01 1 tab(s) $5 $0 $5 $3 carisoprodol 350 mg Tab 00591-5513-01 1 tab(s) $7 $0 $7 $4 Cart Fill EAST Tray 1 [Rm 25-28] - Test 99345-0003-50 1 EA $0 $0 $0 $0 Cart Fill EAST Tray 2 [Rm 29-32] - Test 99345-0003-55 1 EA $0 $0 $0 $0 Cart Fill EAST Tray 3 [Rm 33-36] - Test 99345-0003-60 1 EA $0 $0 $0 $0 Cart Fill WEST Tray 1 [Rm 1-4] - Test 99345-0003-35 1 EA $0 $0 $0 $0 Cart Fill WEST Tray 2 [Rm 5-8] - Test 99345-0003-40 1 EA $0 $0 $0 $0 Cart Fill WEST Tray 3 [Rm 9-12] - Test 99345-0003-45 1 EA $0 $0 $0 $0 carvedilol 12.5 mg Tab 00904-6302-61 1 tab(s) $17 $0 $17 $10

Page 75 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price carvedilol 12.5 mg Tab 68001-0151-00 1 tab(s) $18 $0 $18 $11 carvedilol 25 mg Tab 68084-0876-01 1 tab(s) $16 $0 $16 $10 carvedilol 25 mg Tab 00904-6303-61 1 tab(s) $17 $0 $17 $10 carvedilol 3.125 mg Tab 00904-6300-61 1 tab(s) $17 $0 $17 $10 carvedilol 3.125 mg Tab 00093-0051-01 1 tab(s) $4 $0 $4 $2 carvedilol 6.25 mg Tab 68084-0854-01 1 tab(s) $4 $0 $4 $2 carvedilol 6.25 mg Tab 00904-6301-61 1 tab(s) $17 $0 $17 $10 cefadroxil 500 mg Cap 68180-0180-01 1 cap(s) $27 $0 $27 $16 cefadroxil 500 mg Cap 68180-0180-08 1 cap(s) $28 $0 $28 $17 cefadroxil 500 mg Cap 00093-3196-53 1 cap(s) $28 $0 $28 $17 cefadroxil 500 mg Cap 00172-4058-60 1 cap(s) $31 $0 $31 $19 ceFAZolin 1 g REC I 00143-9262-25 10 mL $39 $0 $39 $23 CeFAZolin 1 g REC I 10019-0611-03 10 mL $43 $0 $43 $26 ceFAZolin 10 g REC I 00781-3452-95 10 mL $115 $0 $115 $69 ceFAZolin 10 g REC I 60505-0769-00 10 mL $100 $0 $100 $60 ceFAZolin 500 mg REC I 00781-3450-95 5 mL $98 $0 $98 $59 cefdinir 125 mg/5 mL REC P 68180-0722-10 1 mL $10 $0 $10 $6 cefdinir 300 mg Cap 68180-0711-60 1 cap(s) $38 $0 $38 $23 cefdinir 300 mg Cap 68001-0362-06 1 cap(s) $38 $0 $38 $23 cefdinir 300 mg Cap 57237-0099-60 1 cap(s) $38 $0 $38 $23 cefepime 1 g REC I 00409-0217-01 10.5 mL $55 $0 $55 $33 cefepime 1 g REC I 60505-6144-00 10.5 mL $150 $0 $150 $90 cefepime 2 g REC I 60505-6145-00 12.5 mL $291 $0 $291 $174 cefepime 2 g REC I 63323-0340-20 12.5 mL $91 $0 $91 $55 cefepime 2 g REC I 00409-0218-01 12.5 mL $87 $0 $87 $52 cefepime 2 g REC I 00409-0220-01 12.5 mL $79 $0 $79 $48 cefePIME 2 gm REC Injection 60505-6147-00 12.5 mL $36 $0 $36 $22 cefixime 200 mg/5 mL REC P 65862-0752-50 1 mL $67 $0 $67 $40 cefOXitin 1 g REC I 44567-0245-25 10 mL $133 $0 $133 $80 cefOXitin 2 g REC I 44567-0246-25 20 mL $217 $0 $217 $130 cefpodoxime 100 mg Tab 65862-0095-20 1 tab(s) $36 $0 $36 $21 cefpodoxime 200 mg Tab 00781-5439-20 1 tab(s) $46 $0 $46 $28 cefpodoxime 200 mg Tab 65862-0096-20 1 tab(s) $46 $0 $46 $28 ceftaroline 400 mg REC I 00456-0400-10 20 mL $1,126 $0 $1,126 $676 ceftaroline 600 mg REC I 00456-0600-01 20 mL $1,478 $0 $1,478 $887 ceftazidime 1 g REC I 00409-5092-16 10 mL $69 $0 $69 $42 cefTAZidime 1 g REC I 44567-0235-25 10 mL $46 $0 $46 $27 cefTAZidime 1 g REC I 25021-0127-20 10 mL $48 $0 $48 $29 ceftazidime 2 g REC I 00409-5093-11 10 mL $163 $0 $163 $98 ceftazidime 2 g REC I 00409-5084-11 10 mL $85 $0 $85 $51 cefTRIAXone 1 g REC I 00409-7332-20 10 mL $76 $0 $76 $46 cefTRIAXone 1 g REC I 00409-7333-04 10 mL $165 $0 $165 $99 cefTRIAXone 1 g REC I 00409-7333-49 10 mL $97 $0 $97 $58 cefTRIAXone 2 g REC I 00409-7335-20 20 mL $32 $0 $32 $19 ceftriaxone 2 g REC I 00409-7336-04 20 mL $75 $0 $75 $45 cefTRIAXone 2 g/50 mL Soln 00338-5003-41 50 mL $631 $0 $631 $379 cefuroxime 250 mg Tab 67877-0215-60 1 tab(s) $41 $0 $41 $25 celecoxib 100 mg Cap 60687-0436-01 1 cap(s) $34 $0 $34 $21 celecoxib 100 mg Cap 00904-6502-61 1 cap(s) $10 $0 $10 $6 celecoxib 200 mg Cap 68084-0976-01 1 cap(s) $20 $0 $20 $12 celecoxib 200 mg Cap 60687-0447-01 1 cap(s) $20 $0 $20 $12 celecoxib 200 mg Cap 62332-0142-31 1 cap(s) $54 $0 $54 $32 cephalexin 250 mg Cap 00093-3145-01 1 cap(s) $8 $0 $8 $5 cephalexin 500 mg Cap 00093-3147-01 1 cap(s) $5 $0 $5 $3 cephalexin 500 mg Cap 50268-0152-15 1 cap(s) $12 $0 $12 $7 cetirizine 1 mg/mL Syrup 45802-0626-26 1 mL $7 $0 $7 $4 cetirizine 10 mg Tab 00904-6717-86 1 tab(s) $4 $0 $4 $2 cetirizine 10 mg Tab 00904-5852-61 1 tab(s) $20 $0 $20 $12 cetirizine 10 mg Tab 00378-3637-01 1 tab(s) $20 $0 $20 $12 cetirizine 10 mg Tab 60687-0165-01 1 tab(s) $20 $0 $20 $12 cetirizine 5 mg Tab 16571-0401-10 1 tab(s) $20 $0 $20 $12 charcoal 25 g Susp 00574-0121-04 120 mL $116 $0 $116 $70 charcoal 50 g Susp 00574-0121-08 240 mL $164 $0 $164 $98 children multivitamin chew tab 01650-0088-06 1 tab(s) $4 $0 $4 $3 chlorthalidone 25 mg Tab 60687-0317-25 1 tab(s) $19 $0 $19 $11 chlorthalidone 25 mg Tab 51079-0058-01 1 tab(s) $5 $0 $5 $3 cholecalciferol (D3) 1,000 unit(s) Tab 48433-0104-01 1 tab(s) $4 $0 $4 $3 cholecalciferol [D3] 1,000 International_Unit Tab 10006-0700-33 1 tab(s) $4 $0 $4 $2 cholecalciferol 1,000 International_Unit Tab 20555-0033-00 1 tab(s) $4 $0 $4 $2 cholecalciferol 400 intl units Tab 43292-0558-81 1 tab(s) $3 $0 $3 $2 cholecalciferol 400 intl units Tab 77333-0948-10 1 tab(s) $5 $0 $5 $3 cholecalciferol 400 intl units/mL LIQ 00087-0866-44 1 mL $6 $0 $6 $3 cholecalciferol 50,000 intl units Cap 75834-0020-01 1 cap(s) $5 $0 $5 $3 cholecalciferol 5000 intl units Cap 80681-0131-00 1 cap(s) $4 $0 $4 $2 cholecalciferol 5000 intl units Cap 10006-0701-27 1 cap(s) $4 $0 $4 $2 cholecalciferol 5000 intl units Cap 50268-0868-15 1 cap(s) $6 $0 $6 $4 cholestyramine 4 g/9 g REC P 00185-0940-98 1 packet(s) $26 $0 $26 $16 cholestyramine 4 g/9 g REC P 68382-0528-60 1 packet(s) $26 $0 $26 $16 ciclopirox topical 0.77% Cream 00168-0313-90 1 app $878 $0 $878 $527

Page 76 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price ciclopirox topical 0.77% Cream 45802-0138-18 1 app $967 $0 $967 $580 ciclopirox topical 1% Shamp 00591-2159-90 1 app $1,043 $0 $1,043 $626 ciclopirox Topical 1% Shamp 99207-0010-10 1 app $4,130 $0 $4,130 $2,478 ciclopirox topical 8% Soln 00713-0317-88 1 app $190 $0 $190 $114 cilostazol 100 mg Tab 00054-0044-21 1 tab(s) $16 $0 $16 $9 cimetidine 300 mg Tab 00108-5013-21 1 tab(s) $10 $0 $10 $6 cinacalcet $31.00 Tab 60687-0525-21 1 tab(s) $204 $0 $204 $123 cinacalcet 30 mg Tab 69097-0410-02 1 tab(s) $118 $0 $118 $71 ciprofloxacin 250 mg Tab 68084-0069-01 1 tab(s) $40 $0 $40 $24 ciprofloxacin 250 mg/5 mL REC P 68180-0392-01 1 mL $13 $0 $13 $8 ciprofloxacin 400 mg/200 mL-5% Soln 36000-0009-24 200 mL $91 $0 $91 $55 ciprofloxacin 400 mg/200 mL-5% Soln 00781-3240-09 200 mL $246 $0 $246 $147 ciprofloxacin 400 mg/200 mL-5% Soln 00409-4777-50 200 mL $63 $0 $63 $38 ciprofloxacin 500 mg Tab 68084-0070-01 1 tab(s) $25 $0 $25 $15 ciprofloxacin 500 mg Tab 65862-0077-01 1 tab(s) $41 $0 $41 $24 ciprofloxacin 500 mg Tab 61442-0223-01 1 tab(s) $39 $0 $39 $24 ciprofloxacin 500 mg Tab 63739-0559-10 1 tab(s) $5 $0 $5 $3 ciprofloxacin ophthalmic 0.3% Soln 00065-0656-05 1 drop(s) $408 $0 $408 $245 ciprofloxacin-dexamethasone otic 0.3%-0.1% Susp 43598-0326-75 1 drop(s) $1,894 $0 $1,894 $1,136 citalopram 10 mg Tab 00093-4740-01 1 tab(s) $19 $0 $19 $11 citalopram 10 mg Tab 00093-4740-93 1 tab(s) $19 $0 $19 $11 citalopram 20 mg Tab 68084-0744-01 1 tab(s) $20 $0 $20 $12 citalopram 40 mg Tab 60505-2520-03 1 tab(s) $20 $0 $20 $12 citalopram 40 mg Tab 00904-6086-61 1 tab(s) $27 $0 $27 $16 citalopram 40 mg Tab 00093-4742-19 1 tab(s) $20 $0 $20 $12 citalopram 40 mg Tab 00093-4742-93 1 tab(s) $20 $0 $20 $12 citric acid-potassium bicarbonate 20 mEq EFF T 51801-0011-30 1 tab(s) $7 $0 $7 $4 citric acid-potassium citrate 30 mEq REC Powder 76439-0261-10 1 packet(s) $15 $0 $15 $9 citric acid-sodium citrate 334 mg-500 mg/5 mL Soln 60258-0001-16 1 mL $5 $0 $5 $3 citric acid-sodium citrate 334 mg-500 mg/5 mL Soln 00121-1190-00 30 mL $17 $0 $17 $10 citric acid-sodium citrate 334 mg-500 mg/5 mL Soln 00121-0595-15 1 mL $5 $0 $5 $3 citric acid-sodium citrate 334 mg-500 mg/5 mL Soln 00575-0225-01 1 mL $5 $0 $5 $3 citric acid-sodium citrate 334 mg-500 mg/5 mL Soln 17314-9330-01 1 mL $5 $0 $5 $3 citric acid/K citrate/Na citrate 334 mg-550 mg-500 mg/5 mL LIQ 17314-9322-01 5 mL $5 $0 $5 $3 clarithromycin 125 mg/5 mL REC Powder 00074-3163-13 5 mL $320 $0 $320 $192 clarithromycin 250 mg Tab 65862-0225-60 1 tab(s) $11 $0 $11 $7 clarithromycin 250 mg/5 mL REC P 68774-0303-35 1 mL $10 $0 $10 $6 clarithromycin 500 mg Tab 00074-2586-11 1 tab(s) $40 $0 $40 $24 clarithromycin 500 mg Tab 00093-7158-06 1 tab(s) $34 $0 $34 $20 clarithromycin 500 mg Tab 00054-0037-21 1 tab(s) $34 $0 $34 $20 clarithromycin 500 mg Tab 68084-0437-11 1 tab(s) $43 $0 $43 $26 clarithromycin 500 mg Tab 68084-0437-65 1 tab(s) $43 $0 $43 $26 clindamycin 150 mg Cap 68084-0243-01 1 cap(s) $8 $0 $8 $5 clindamycin 150 mg Cap 63739-0059-10 1 cap(s) $8 $0 $8 $5 clindamycin 150 mg Cap 00904-5959-61 1 cap(s) $8 $0 $8 $5 clindamycin 150 mg/mL Soln 25021-0115-04 1 mL $15 $0 $15 $9 clindamycin 150 mg/mL Soln 00009-0775-26 1 mL $24 $0 $24 $14 clindamycin 300 mg Cap 63304-0693-01 1 cap(s) $28 $0 $28 $17 clindamycin 75 mg Cap 00009-0331-02 1 cap(s) $24 $0 $24 $14 clindamycin 75 mg/5 mL REC P 64980-0511-10 1 mL $9 $0 $9 $5 clindamycin topical 1% Lotio 00168-0203-60 1 app $849 $0 $849 $509 clindamycin topical 1% Soln 00168-0201-60 1 app $559 $0 $559 $335 clindamycin topical 1% Soln 45802-0562-02 1 app $412 $0 $412 $247 clobazam 10 mg Tab 67386-0311-01 1 tab(s) $56 $0 $56 $34 cloBAZam 10 mg Tab 42571-0315-01 1 tab(s) $131 $0 $131 $78 clobazam 10 mg Tab 00832-0580-11 1 tab(s) $16 $0 $16 $9 cloBAZam 2.5 mg/mL Susp 66689-0058-04 1 mL $10 $0 $10 $6 clobazam oral susp [Bottle] 2.5 mg/mL Susp 00832-0585-25 1 mL $61 $0 $61 $36 clobetasol 0.05% Cream 0.05% Cream 52565-0051-15 1 app $906 $0 $906 $543 clobetasol topical 0.05% Cream 00168-0163-15 1 app $181 $0 $181 $109 clobetasol topical 0.05% Ointm 00713-0656-31 1 app $1,829 $0 $1,829 $1,097 clobetasol topical 0.05% Ointm 51672-1259-02 1 app $1,829 $0 $1,829 $1,097 clobetasol Topical 0.05% Soln 51672-1293-03 1 app $369 $0 $369 $221 clomiPRAMINE 50 mg Cap 51672-4012-06 1 cap(s) $11 $0 $11 $7 clonazePAM 0.125 mg DIS T 49884-0306-02 1 tab(s) $12 $0 $12 $7 clonazePAM 0.125 mg DIS T 49884-0306-52 1 tab(s) $12 $0 $12 $7 clonazePAM 0.125 mg DIS T 57664-0783-86 1 tab(s) $12 $0 $12 $7 clonazePAM 0.25 mg DIS T 57664-0784-86 1 tab(s) $12 $0 $12 $7 clonazePAM 0.5 mg Tab 51079-0881-20 1 tab(s) $10 $0 $10 $6 clonazePAM 0.5 mg Tab 16729-0136-00 1 tab(s) $10 $0 $10 $6 clonazePAM 0.5 mg Tab 00904-6101-61 1 tab(s) $10 $0 $10 $6 clonazePAM 0.5 mg Tab 00185-0063-01 1 tab(s) $10 $0 $10 $6 clonazePAM 0.5 mg Tab 00378-1910-01 1 tab(s) $10 $0 $10 $6 clonazePAM 0.5 mg Tab 00228-3003-11 1 tab(s) $10 $0 $10 $6 clonazePAM 1 mg DIS T 00555-0097-96 1 tab(s) $13 $0 $13 $8 clonazePAM 1 mg DIS T 49884-0309-02 1 tab(s) $13 $0 $13 $8 clonazePAM 1 mg DIS T 57664-0786-86 1 tab(s) $13 $0 $13 $8 clonazePAM 1 mg Tab 51079-0882-20 1 tab(s) $11 $0 $11 $7 clonazePAM 1 mg Tab 00228-3004-11 1 tab(s) $11 $0 $11 $6

Page 77 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price clonazePAM 1 mg Tab 00093-3212-01 1 tab(s) $11 $0 $11 $6 cloNIDine 0.1 mg Tab 00228-2127-10 1 tab(s) $5 $0 $5 $3 cloNIDine 0.1 mg Tab 00904-5656-61 1 tab(s) $5 $0 $5 $3 cloNIDine 0.1 mg Tab 51079-0299-01 1 tab(s) $5 $0 $5 $3 cloNIDine 0.1 mg Tab 51079-0299-20 1 tab(s) $5 $0 $5 $3 cloNIDine 0.1 mg Tab 68001-0237-00 1 tab(s) $5 $0 $5 $3 cloNIDine 0.1 mg Tab 68001-0237-03 1 tab(s) $12 $0 $12 $7 cloNIDine 0.1 mg/24 hr ER Fi 00591-3508-04 1 patch(es) $240 $0 $240 $144 clonidine 0.1 mg/24 hr ER Patch 00378-0871-16 1 patch(es) $240 $0 $240 $144 cloNIDine 0.2 mg Tab 68001-0238-00 1 tab(s) $6 $0 $6 $4 cloNIDine 0.2 mg/24 hr ER Fi 00591-3509-04 1 patch(es) $399 $0 $399 $239 cloNIDine 0.3 mg Tab 00904-5658-61 1 tab(s) $6 $0 $6 $4 cloNIDine 0.3 mg Tab 68001-0239-00 1 tab(s) $7 $0 $7 $4 cloNIDine 0.3 mg Tab 51079-0301-01 1 tab(s) $7 $0 $7 $4 cloNIDine 0.3 mg Tab 51079-0301-20 1 tab(s) $7 $0 $7 $4 clonidine 0.3 mg/24 hr ER Fi 00555-1011-16 1 patch(es) $551 $0 $551 $330 cloNIDine Patch 0.1 mg/24 hr Patch 51862-0453-04 1 patch(es) $240 $0 $240 $144 clopidogrel 75 mg Tab 68084-0536-01 1 tab(s) $49 $0 $49 $29 clopidogrel 75 mg Tab 00904-6294-61 1 tab(s) $33 $0 $33 $20 clotrimazole 10 mg Lozen 00054-8146-22 1 lozenge(s) $26 $0 $26 $16 clotrimazole 10 mg Lozen 00054-4146-23 1 lozenge(s) $23 $0 $23 $14 clotrimazole topical 1% Cream 00472-0220-41 1 app $93 $0 $93 $56 clotrimazole topical 1% Cream 24385-0205-01 1 app $46 $0 $46 $27 clotrimazole topical 1% Cream 51672-2003-06 1 app $65 $0 $65 $39 clotrimazole topical 1% Cream 51672-1275-02 1 app $86 $0 $86 $51 clozapine 100 mg Tab 60687-0415-01 1 tab(s) $27 $0 $27 $16 cloZAPine 25 mg Tab 00378-0825-01 1 tab(s) $12 $0 $12 $7 codeine sulfate 30 mg Tab 00054-0244-25 1 tab(s) $8 $0 $8 $5 codeine-guaifenesin 10 mg-100 mg/5 mL Syrup 00121-1683-05 5 mL $8 $0 $8 $5 colchicine 0.6 mg Tab 00378-1086-93 1 tab(s) $34 $0 $34 $20 colchicine 0.6 mg Tab 00254-2008-01 1 tab(s) $37 $0 $37 $22 colchicine 0.6 mg Tab 60687-0389-21 1 tab(s) $78 $0 $78 $47 colestipol 1 g Tab 59762-0450-01 1 tab(s) $8 $0 $8 $5 colestipol 1 g Tab 00009-0450-03 1 tab(s) $8 $0 $8 $5 colistimethate 150 mg (colistin base) REC I 42023-0131-01 2 mL $243 $0 $243 $146 colistimethate 150 mg (colistin base) REC I 42023-0131-06 2 mL $243 $0 $243 $146 colistimethate 150 mg (colistin base) REC I 25021-0159-10 2 mL $221 $0 $221 $133 collagenase Topical Ointment 250 units/g Ointment 50484-0010-30 1 app $1,440 $0 $1,440 $864 conjugated estrogens 0.625 mg Tab 00046-1102-81 1 tab(s) $30 $0 $30 $18 conjugated estrogens 0.9 mg Tab 00046-1103-81 1 tab(s) $14 $0 $14 $9 conjugated estrogens 0.9 mg Tab 00046-0864-81 1 tab(s) $12 $0 $12 $7 conjugated estrogens 1.25 mg Tab 00046-1104-81 1 tab(s) $12 $0 $12 $7 cortisone 25 mg Tab 00143-1202-01 1 tab(s) $6 $0 $6 $4 cosyntropin 0.25 mg REC I 00781-3440-95 1 mL $682 $0 $682 $409 cosyntropin 0.25 mg REC Inj 00548-5900-00 1 mL $631 $0 $631 $378 cyanocobalamin 1,000 mcg Tab 07431-2013-80 1 tab(s) $4 $0 $4 $2 cyanocobalamin 100 mcg Tab 00904-1132-13 1 tab(s) $3 $0 $3 $2 cyanocobalamin 100 mcg Tab 00536-3542-01 1 tab(s) $3 $0 $3 $2 cyanocobalamin 100 mcg Tab 80681-0071-00 1 tab(s) $4 $0 $4 $2 cyanocobalamin 1000 mcg Tab 00536-3556-01 1 tab(s) $4 $0 $4 $2 cyanocobalamin 1000 mcg/mL Soln 00517-0031-25 1 mL $29 $0 $29 $18 cyanocobalamin 250 mcg Tab 00904-4218-13 1 tab(s) $4 $0 $4 $2 cyanocobalamin 500 mcg Tab 31604-0012-90 1 tab(s) $4 $0 $4 $2 cyanocobalamin 500 mcg Tab 00536-3551-01 1 tab(s) $4 $0 $4 $2 cyanocobalamin 500 mcg Tab 77333-0937-10 1 tab(s) $5 $0 $5 $3 cyclobenzaprine 10 mg Tab 69097-0846-07 1 tab(s) $11 $0 $11 $7 cyclobenzaprine 10 mg Tab 63739-0531-10 1 tab(s) $4 $0 $4 $2 cyclobenzaprine 10 mg Tab 51079-0644-20 1 tab(s) $10 $0 $10 $6 cyclobenzaprine 10 mg Tab 51079-0644-20 1 tab(s) $10 $0 $10 $6 cyclophosphamide 25 mg Cap 00054-0382-25 1 cap(s) $66 $0 $66 $40 cycloSPORINE 25 mg Cap 00078-0246-61 1 cap(s) $311 $0 $311 $186 cycloSPORINE microemulsion 100 mg/mL LIQ 00078-0274-22 1 mL $61 $0 $61 $37 cycloSPORINE microemulsion 25 mg Cap 00078-0246-15 1 cap(s) $14 $0 $14 $8 cycloSPORINE modified 100 mg Cap 00093-5742-65 1 cap(s) $40 $0 $40 $24 cycloSPORINE modified 100 mg Cap 00185-0933-30 1 cap(s) $40 $0 $40 $24 cycloSPORINE modified 100 mg Cap 51862-0460-47 1 cap(s) $40 $0 $40 $24 cycloSPORINE modified 100 mg Cap 60505-4632-03 1 cap(s) $40 $0 $40 $24 cycloSPORINE modified 25 mg Cap 00093-5740-65 1 cap(s) $13 $0 $13 $8 cycloSPORINE modified 25 mg Cap 00074-3108-32 1 cap(s) $17 $0 $17 $10 cyproheptadine 4 mg Tab 50742-0190-10 1 tab(s) $11 $0 $11 $6 cyproheptadine 4 mg Tab 51991-0838-01 1 tab(s) $11 $0 $11 $6 cysteine 50 mg/mL Soln 66758-0004-02 1 mL $18 $0 $18 $11 cytarabine 100 mg/mL Soln 67457-0452-20 1 mL $0 $0 $0 $0 cytarabine 100 mg/mL Soln 61703-0319-22 1 mL $0 $0 $0 $0 cytarabine 20 mg/mL Soln 67457-0455-52 1 mL $0 $0 $0 $0 cytomegalovirus immune globulin 50 mg/mL Soln 44206-0532-11 1 mL $206 $0 $206 $123 d-xylose 100% REC Powder 00281-8555-80 0 $411 $0 $411 $247 dabigatran 75 mg Cap 00597-0107-60 1 cap(s) $30 $0 $30 $18 dabigatran 75 mg Cap 00597-0355-09 1 cap(s) $52 $0 $52 $31

Page 78 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price dabigatran etexilate mesylate 150 mg Cap 00597-0360-82 1 cap(s) $57 $0 $57 $34 dalfampridine 10 mg ER Ta 10144-0427-60 1 tab(s) $134 $0 $134 $81 dalfampridine 10 mg ER Ta 16729-0292-12 1 tab(s) $328 $0 $328 $197 dantrolene 100 mg Cap 00527-3221-37 1 cap(s) $18 $0 $18 $11 dantrolene 25 mg Cap 00115-4411-01 1 cap(s) $11 $0 $11 $6 dantrolene 25 mg Cap 42023-0124-01 1 cap(s) $12 $0 $12 $7 dantrolene 25 mg Cap 68084-0300-21 1 cap(s) $11 $0 $11 $7 dantrolene 50 mg Cap 00115-4422-01 1 cap(s) $14 $0 $14 $8 dapsone 100 mg Tab 49938-0101-30 1 tab(s) $276 $0 $276 $165 dapsone 25 mg Tab 49938-0102-30 1 tab(s) $11 $0 $11 $6 dapsone 25 mg Tab 29033-0036-30 1 tab(s) $20 $0 $20 $12 dapsone 25 mg Tab 69543-0150-30 1 tab(s) $20 $0 $20 $12 DAPTOmycin 350 mg REC I 25021-0179-15 7 mL $2,393 $0 $2,393 $1,436 DAPTOmycin 500 mg REC I 63323-0371-19 10 mL $3,811 $0 $3,811 $2,286 DAPTOmycin 500 mg REC Inj 67919-0011-01 10 mL $2,850 $0 $2,850 $1,710 darbepoetin alfa 25 mcg/mL Soln 55513-0002-04 1 mL $1,225 $0 $1,225 $735 darunavir 600 mg Tab 59676-0562-01 1 tab(s) $126 $0 $126 $76 dasatinib 20 mg Tab 00003-0527-11 1 tab(s) $517 $0 $517 $310 dasatinib 50 mg Tab 00003-0528-11 1 tab(s) $1,030 $0 $1,030 $618 DEA 222 Form 0 Bag 99345-0001-81 1 EA $0 $0 $0 $0 deferoxamine 2 g REC Inj 00078-0347-51 20 mL $635 $0 $635 $381 demeclocycline 150 mg Tab 61748-0115-01 1 tab(s) $60 $0 $60 $36 demeclocycline 150 mg Tab 62584-0159-01 1 tab(s) $75 $0 $75 $45 desipramine 10 mg Tab 52152-0341-02 1 tab(s) $6 $0 $6 $4 desipramine 10 mg Tab 00068-0007-01 1 tab(s) $8 $0 $8 $5 desipramine 10 mg Tab 45963-0341-02 1 tab(s) $11 $0 $11 $7 desipramine 10 mg Tab 50742-0112-01 1 tab(s) $15 $0 $15 $9 desipramine 10 mg Tab 00781-1971-01 1 tab(s) $11 $0 $11 $7 desipramine 25 mg Tab 45963-0342-02 1 tab(s) $13 $0 $13 $8 desipramine 25 mg Tab 52152-0342-02 1 tab(s) $7 $0 $7 $4 desmopressin 0.1 mg Tab 68001-0325-00 1 tab(s) $39 $0 $39 $23 desmopressin 0.1 mg Tab 68084-0606-21 1 tab(s) $24 $0 $24 $14 desmopressin 10 mcg/inh Spray 47335-0788-91 1 spray(s) $1,734 $0 $1,734 $1,040 desmopressin 10 mcg/inh Spray 24208-0342-05 1 spray(s) $1,013 $0 $1,013 $608 desmopressin 10 mcg/inh Spray 69918-0501-05 1 spray(s) $1,665 $0 $1,665 $999 desmopressin 4 mcg/mL Soln 69918-0899-10 1 mL $502 $0 $502 $301 desmopressin 4 mcg/mL Soln 55566-5030-01 1 mL $168 $0 $168 $101 desmopressin 4 mcg/mL Soln 00703-5051-03 1 mL $110 $0 $110 $66 desmopressin 4 mcg/mL Soln 00075-2451-01 1 mL $234 $0 $234 $140 desmopressin 4 mcg/mL Soln 00409-2265-01 1 mL $63 $0 $63 $38 desonide topical 0.05% Cream 45802-0422-37 1 app $2,258 $0 $2,258 $1,355 desonide topical 0.05% Lotio 00168-0310-02 1 app $2,119 $0 $2,119 $1,272 desoximetasone topical 0.05% Cream 51672-1271-03 1 app $479 $0 $479 $287 desoximetasone topical 0.05% Cream 51672-5205-03 1 app $630 $0 $630 $378 desoximetasone topical 0.25% Cream 45802-0495-37 1 app $1,404 $0 $1,404 $843 desvenlafaxine 50 mg ER Ta 00054-0400-13 1 tab(s) $83 $0 $83 $50 deutetrabenazine 9 mg Tab 68546-0171-60 1 tab(s) $0 $0 $0 $0 dexamethasone 10 mg/mL Soln 70069-0021-25 1 mL $51 $0 $51 $30 dexamethasone 0.5 mg Tab 00054-4179-25 1 tab(s) $5 $0 $5 $3 dexamethasone 0.5 mg Tab 00054-8179-25 1 tab(s) $5 $0 $5 $3 dexamethasone 0.5 mg Tab 48102-0045-01 1 tab(s) $4 $0 $4 $3 dexamethasone 1 mg Tab 00054-8174-25 1 tab(s) $6 $0 $6 $3 dexamethasone 1.5 mg Tab 00054-8181-25 1 tab(s) $5 $0 $5 $3 dexamethasone 2 mg Tab 00054-4183-25 1 tab(s) $8 $0 $8 $5 dexamethasone 4 mg Tab 00054-8175-25 1 tab(s) $8 $0 $8 $5 dexamethasone 4 mg Tab 48102-0047-01 1 tab(s) $11 $0 $11 $7 dexamethasone 4 mg/mL Soln 63323-0165-30 1 mL $14 $0 $14 $8 dexamethasone 4 mg/mL Soln 67457-0421-30 1 mL $11 $0 $11 $6 dexamethasone ophthalmic 0.1% Soln 24208-0720-02 1 drop(s) $156 $0 $156 $94 dexamethasone ophthalmic 0.1% Susp 00998-0615-05 1 drop(s) $301 $0 $301 $180 dexamethasone-tobramycin ophthalmic 0.1%-0.3% Susp 24208-0295-05 1 drop(s) $925 $0 $925 $555 dexamethasone/neomycin/polymyxin B ophthalmic 1 mg-3.5 mg-10000 units/g Ointm 61314-0631-36 1 app $316 $0 $316 $190 dexmethylphenidate 5 mg ER Ca 00115-1682-01 1 cap(s) $59 $0 $59 $36 dexmethylphenidate 5 mg ER Ca 00527-8106-37 1 cap(s) $62 $0 $62 $37 dextroamphetamine 5 mg Tab 13107-0035-01 1 tab(s) $25 $0 $25 $15 dextromethorphan-guaifenesin 10 mg-100 mg/5 mL LIQ 54838-0209-40 10 mL $38 $0 $38 $23 dextromethorphan-guaifenesin 10 mg-100 mg/5 mL LIQ 24385-0578-26 10 mL $21 $0 $21 $13 Dextrose 5% in Water intravenous solution 1 mL Soln 00001-0001-01 1 mL $0 $0 $0 $0 diatrizoate 66%-10% Soln 00270-0445-35 30 mL $190 $0 $190 $114 diazePAM 10 mg Kit 68682-0652-20 1 EA $2,557 $0 $2,557 $1,534 diazepam 10 mg Kit 00187-0658-20 1 EA $2,370 $0 $2,370 $1,422 diazepam 2 mg Tab 00378-0271-01 1 tab(s) $5 $0 $5 $3 diazepam 2 mg Tab 00172-3925-60 1 tab(s) $5 $0 $5 $3 diazepam 2 mg Tab 51079-0284-21 1 tab(s) $6 $0 $6 $4 diazePAM 2.5 mg Kit 68682-0650-20 1 EA $2,156 $0 $2,156 $1,294 diazepam 2.5 mg Kit 66490-0650-20 1 EA $1,998 $0 $1,998 $1,199 diazepam 20 mg Kit 00187-0659-20 1 EA $2,856 $0 $2,856 $1,714 diazepam 5 mg gel syringe 66490-0651-20 0 $862 $0 $862 $517

Page 79 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price diazePAM 5 mg Tab 00378-0345-01 1 tab(s) $6 $0 $6 $3 diazePAM 5 mg Tab 00172-3926-60 1 tab(s) $6 $0 $6 $4 diazepam 5 mg Tab 00904-5880-61 1 tab(s) $7 $0 $7 $4 diazepam 5 mg/5 mL Soln 00054-3188-63 1 mL $5 $0 $5 $3 diazoxide 50 mg/mL Susp 00575-6200-30 1 mL $68 $0 $68 $41 dibucaine topical 1% Ointm 45802-0050-03 1 app $46 $0 $46 $27 diclofenac epolamine 1.3% Patch 00093-3225-55 1 patch(es) $51 $0 $51 $31 diclofenac sodium 100 mg ER Ta 00028-0205-01 1 tab(s) $40 $0 $40 $24 diclofenac sodium 100 mg ER Ta 00378-0355-01 1 tab(s) $22 $0 $22 $13 diclofenac sodium 100 mg ER Ta 00591-0676-01 1 tab(s) $22 $0 $22 $13 diclofenac sodium 25 mg EC Tab 00781-1785-01 1 tab(s) $7 $0 $7 $4 diclofenac sodium 50 mg EC Ta 51079-0466-20 1 tab(s) $13 $0 $13 $8 diclofenac sodium 50 mg EC Ta 68001-0280-00 1 tab(s) $13 $0 $13 $8 diclofenac sodium 50 mg EC Tablet 51079-0466-01 1 tab(s) $13 $0 $13 $8 diclofenac sodium 75 mg EC Ta 51079-0224-20 1 tab(s) $15 $0 $15 $9 diclofenac sodium 75 mg EC Ta 68084-0333-01 1 tab(s) $8 $0 $8 $5 diclofenac topical 1% Gel 69097-0524-44 0 $379 $0 $379 $228 diclofenac topical 1% Gel 49884-0935-47 0 $372 $0 $372 $223 dicloxacillin 250 mg Cap 00093-3123-01 1 cap(s) $8 $0 $8 $5 dicloxacillin 250 mg Cap 51079-0610-01 1 cap(s) $6 $0 $6 $4 dicloxacillin 250 mg Cap 51079-0610-20 1 cap(s) $6 $0 $6 $4 dicloxacillin 500 mg Cap 00093-3125-01 1 cap(s) $11 $0 $11 $7 dicloxacillin 500 mg Cap 00781-2258-01 1 cap(s) $11 $0 $11 $7 dicyclomine 10 mg Cap 00591-0794-01 1 cap(s) $4 $0 $4 $2 dicyclomine 10 mg Cap 00527-0586-01 1 cap(s) $5 $0 $5 $3 dicyclomine 10 mg Cap 51079-0118-20 1 cap(s) $5 $0 $5 $3 dicyclomine 10 mg Cap 60687-0369-01 1 cap(s) $7 $0 $7 $4 dicyclomine 10 mg/5 mL Syrup 58914-0015-16 1 mL $5 $0 $5 $3 digoxin 125 mcg (0.125 mg) Tab 68084-0366-01 1 tab(s) $21 $0 $21 $12 digoxin 250 mcg (0.25 mg) Tab 68084-0680-01 1 tab(s) $21 $0 $21 $12 digoxin 250 mcg/mL (0.25 mg/mL) Soln 00641-6184-25 2 mL $54 $0 $54 $32 digoxin 250 mcg/mL (0.25 mg/mL) Soln 00641-1410-35 2 mL $17 $0 $17 $10 digoxin prefilled syringe 50 mcg/mL Soln 99345-0004-25 1 mL $84 $0 $84 $51 diltiazem 120 mg/24 hours ER Cap 00378-5220-01 1 cap(s) $9 $0 $9 $6 diltiazem 180 mg/24 hours ER Ca 60687-0206-90 1 cap(s) $7 $0 $7 $4 diltiazem 30 mg Tab 63739-0079-10 1 tab(s) $6 $0 $6 $4 dilTIAZem 30 mg Tab 68682-0006-10 1 tab(s) $10 $0 $10 $6 diltiazem 30 mg Tab 00378-0023-01 1 tab(s) $6 $0 $6 $4 dilTIAZem 300 mg/24 hours ER Ca 60687-0228-01 1 cap(s) $21 $0 $21 $13 diltiazem 360 mg/24 hours ER Ca 00228-2918-09 1 cap(s) $72 $0 $72 $43 diltiazem 360 mg/24 hours ER Ca 00187-0799-42 1 cap(s) $84 $0 $84 $51 diltiazem 60 mg Tab 00378-0045-01 1 tab(s) $9 $0 $9 $5 diltiazem 60 mg Tab 63739-0080-10 1 tab(s) $8 $0 $8 $5 dilTIAZem 60 mg Tab 68682-0007-10 1 tab(s) $14 $0 $14 $8 dilTIAZem 90 mg Tab 68682-0008-10 1 tab(s) $20 $0 $20 $12 dimethyl fumarate 240 mg DR Ca 64406-0006-02 1 cap(s) $0 $0 $0 $0 diphenhydrAMINE 12.5 mg/5 mL LIQ 00121-0978-10 10 mL $24 $0 $24 $14 diphenhydrAMINE 12.5 mg/5 mL LIQ 24385-0379-26 1 mL $5 $0 $5 $3 diphenhydrAMINE-zinc acetate topical 2%-0.1% Cream 00904-5354-31 1 app $39 $0 $39 $24 diphenhydrAMINE-zinc acetate topical 2%-0.1% Cream 45802-0358-03 1 app $35 $0 $35 $21 diphth/haemophilus/pertussis/tetanus/polio - Kit 49281-0510-05 0.5 mL $610 $0 $610 $366 diphtheria-tetanus toxoids (DT) ped pediatric Susp 49281-0225-10 0.5 mL $1,054 $0 $1,054 $632 dipyridamole 25 mg Tab 64980-0133-01 1 tab(s) $10 $0 $10 $6 Discharge Prescription Binder Binder Device 99345-0002-80 1 EA $0 $0 $0 $0 disopyramide 100 mg Cap 00093-3127-01 1 cap(s) $8 $0 $8 $5 disopyramide 100 mg Cap 00182-1743-01 1 cap(s) $5 $0 $5 $3 disulfiram 250 mg Tab 51285-0523-02 1 tab(s) $24 $0 $24 $14 divalproex sodium 125 mg Cap 68084-0313-11 1 cap(s) $9 $0 $9 $5 divalproex sodium 125 mg DRC 55111-0532-01 1 cap(s) $11 $0 $11 $7 divalproex sodium 125 mg EC Ta 60687-0211-21 1 tab(s) $9 $0 $9 $6 divalproex sodium 125 mg EC Ta 00093-7439-01 1 tab(s) $9 $0 $9 $6 divalproex sodium 250 mg EC Ta 00093-7440-01 1 tab(s) $15 $0 $15 $9 divalproex sodium 250 mg EC Tablet 51079-0474-01 1 tab(s) $16 $0 $16 $10 divalproex sodium 250 mg EC Tablet 51079-0474-20 1 tab(s) $16 $0 $16 $10 divalproex sodium 250 mg EC Tablet 68084-0776-01 1 tab(s) $6 $0 $6 $4 divalproex sodium 250 mg EC Tablet 68084-0776-35 1 tab(s) $6 $0 $6 $4 divalproex sodium 250 mg ER Ta 68084-0310-01 1 tab(s) $20 $0 $20 $12 divalproex sodium 250 mg ER Ta 00904-5990-61 1 tab(s) $18 $0 $18 $11 divalproex sodium 250 mg ER Tablet 51079-0766-01 1 tab(s) $13 $0 $13 $8 divalproex sodium 500 mg EC Ta 68084-0782-61 1 tab(s) $6 $0 $6 $3 divalproex sodium 500 mg EC Ta 68382-0033-05 1 tab(s) $25 $0 $25 $15 divalproex sodium 500 mg EC Tablet 00832-7124-01 1 tab(s) $4 $0 $4 $3 divalproex sodium 500 mg ER Ta 68084-0415-01 1 tab(s) $29 $0 $29 $18 divalproex sodium 500 mg ER Tablet 51079-0767-01 1 tab(s) $21 $0 $21 $12 docusate 10 mg/mL LIQ 50383-0771-11 10 mL $9 $0 $9 $6 docusate 10 mg/mL LIQ 50383-0771-16 1 mL $5 $0 $5 $3 docusate sodium 100 mg Cap 00904-2244-61 1 cap(s) $4 $0 $4 $3 docusate sodium 100 mg Cap 00904-6455-61 1 cap(s) $4 $0 $4 $3 docusate sodium 100 mg Cap 60687-0129-01 1 cap(s) $4 $0 $4 $3

Page 80 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price docusate sodium 100 mg Cap 63739-0478-01 1 cap(s) $4 $0 $4 $2 docusate sodium 100 mg Tab 51645-0750-01 1 tab(s) $4 $0 $4 $2 docusate sodium 100 mg/10 mL LIQ 51079-0335-30 10 mL $7 $0 $7 $4 docusate UD cup 100 mg / 10 mL Soln 17856-0116-01 10 mL $7 $0 $7 $4 docusate UD cup 100 mg/10 mL Soln 17856-0398-02 10 mL $8 $0 $8 $5 docusate-senna 50 mg-8.6 mg Tab 00536-1248-01 1 tab(s) $4 $0 $4 $2 docusate-senna 50 mg-8.6 mg Tab 57896-0458-01 1 tab(s) $4 $0 $4 $2 docusate-senna 50 mg-8.6 mg Tab 63739-0432-10 1 tab(s) $5 $0 $5 $3 dofetilide 250 mcg Cap 00069-5810-43 1 cap(s) $19 $0 $19 $11 dofetilide 500 mcg Cap 00069-5820-43 1 cap(s) $19 $0 $19 $11 dofetilide 500 mcg Cap 00069-5820-60 1 cap(s) $25 $0 $25 $15 donepezil 10 mg Tab 00904-6478-61 1 tab(s) $4 $0 $4 $3 donepezil 10 mg Tab 60687-0182-01 1 tab(s) $9 $0 $9 $5 donepezil 10 mg Tab 60687-0303-01 1 tab(s) $9 $0 $9 $5 donepezil 10 mg Tab 59746-0330-90 1 tab(s) $61 $0 $61 $37 donepezil 10 mg Tab 68084-0734-01 1 tab(s) $9 $0 $9 $5 donepezil 5 mg Tab 60687-0171-01 1 tab(s) $9 $0 $9 $5 dorzolamide ophthalmic 2% Soln 24208-0485-10 1 drop(s) $330 $0 $330 $198 dorzolamide ophthalmic 2% Soln 61314-0019-10 1 drop(s) $476 $0 $476 $286 dorzolamide-timolol 2%-0.5% Soln 70069-0051-01 1 drop(s) $867 $0 $867 $520 dorzolamide-timolol ophthalmic 2.23%-0.68% Soln 24208-0486-10 1 drop(s) $481 $0 $481 $289 doxazosin 1 mg Tab 00904-5522-61 1 tab(s) $10 $0 $10 $6 doxazosin 4 mg Tab 51079-0959-20 1 tab(s) $10 $0 $10 $6 doxazosin 4 mg Tab 00904-5524-61 1 tab(s) $10 $0 $10 $6 doxazosin 8 mg Tab 59762-2380-06 1 tab(s) $13 $0 $13 $8 doxazosin 8 mg Tab 60505-0096-00 1 tab(s) $10 $0 $10 $6 doxazosin mesylate 4 mg Tab 51079-0959-01 1 tab(s) $6 $0 $6 $3 doxepin 10 mg Cap 51079-0436-01 1 cap(s) $6 $0 $6 $3 doxepin 10 mg Cap 51079-0436-20 1 cap(s) $5 $0 $5 $3 doxepin 10 mg/mL Conc 54838-0512-40 1 mL $6 $0 $6 $4 doxepin 25 mg Cap 51079-0437-01 1 cap(s) $6 $0 $6 $4 doxepin 25 mg Cap 51079-0437-20 1 cap(s) $6 $0 $6 $4 doxepin 50 mg Cap 00378-4250-01 1 cap(s) $7 $0 $7 $4 doxepin 50 mg Cap 51079-0438-01 1 cap(s) $7 $0 $7 $4 doxepin 50 mg Cap 51079-0438-20 1 cap(s) $7 $0 $7 $4 doxepin Topical 5% Cream 00064-3600-45 1 app $1,598 $0 $1,598 $959 doxepin topical 5% Cream 10337-0804-45 1 app $2,749 $0 $2,749 $1,649 doxepin Topical 5% Cream 45 gm 5% Cream 40076-0715-45 1 app $5,181 $0 $5,181 $3,109 doxercalciferol 2 mcg/mL Soln 58468-0123-01 1 mL $117 $0 $117 $70 doxyclycline 100 mg Cap 00182-1035-00 1 cap(s) $406 $0 $406 $244 doxycycline hyclate 100 mg Cap 00143-9803-50 1 cap(s) $15 $0 $15 $9 doxycycline hyclate 100 mg Cap 50268-0278-15 1 cap(s) $30 $0 $30 $18 doxycycline hyclate 100 mg Cap 60687-0118-21 1 cap(s) $19 $0 $19 $11 doxycycline hyclate 50 mg Cap 53489-0118-02 1 cap(s) $18 $0 $18 $11 dronabinol 2.5 mg Cap 00904-6745-61 1 cap(s) $44 $0 $44 $27 dronabinol 2.5 mg Cap 60687-0375-01 1 cap(s) $42 $0 $42 $25 dronedarone 400mg 400 mg Tab 00024-4142-10 1 tab(s) $38 $0 $38 $23 DULoxetine 20 mg DR Ca 47335-0381-86 1 cap(s) $50 $0 $50 $30 DULoxetine 30 mg DR Ca 47335-0382-81 1 cap(s) $56 $0 $56 $33 DULoxetine 60 mg DR Ca 00904-6368-61 1 cap(s) $43 $0 $43 $26 dutasteride 0.5 mg Cap 50268-0282-13 1 cap(s) $44 $0 $44 $26 econazole topical 1% Cream 45802-0466-11 1 app $252 $0 $252 $151 efavirenz 600 mg Tab 00378-2233-93 1 tab(s) $253 $0 $253 $152 efavirenz 600 mg Tab 00056-0510-30 1 tab(s) $119 $0 $119 $72 emtricitabine 200 mg Cap 61958-0601-01 1 cap(s) $116 $0 $116 $70 enalapril 1.25 mg/mL Soln 00143-9787-10 1 mL $33 $0 $33 $20 enalapril 10 mg Tab 00904-5610-61 1 tab(s) $11 $0 $11 $7 enalapril 2.5 mg Tab 64679-0923-02 1 tab(s) $9 $0 $9 $5 enalapril 2.5 mg Tab 51079-0950-01 1 tab(s) $541 $0 $541 $325 enalapril 2.5 mg Tab 51079-0950-20 1 tab(s) $4 $0 $4 $3 enalapril 2.5 mg Tab 00904-5609-61 1 tab(s) $9 $0 $9 $6 enalapril 20 mg Tab 00904-5611-61 1 tab(s) $15 $0 $15 $9 enalapril 20 mg Tab 51672-4040-01 1 tab(s) $22 $0 $22 $13 enalapril 5 mg Tab 68682-0711-01 1 tab(s) $8 $0 $8 $5 enalapril 5 mg Tab 68084-0390-01 1 tab(s) $4 $0 $4 $2 enalapril 5 mg Tab 68084-0390-11 1 tab(s) $4 $0 $4 $2 enalapril 5 mg Tab 51079-0951-01 1 tab(s) $687 $0 $687 $412 enalapril 5 mg Tab 51079-0951-20 1 tab(s) $4 $0 $4 $3 enalapril 5 mg Tab 00904-5502-61 1 tab(s) $10 $0 $10 $6 enalapril 5 mg Tab (Vasotec) 66304-0836-01 1 tab(s) $11 $0 $11 $7 eNOXaparin 100 mg/mL Injection 63323-0605-94 1 mL $852 $0 $852 $511 enoxaparin 150 mg/ mL Soln 00781-3655-69 1 mL $863 $0 $863 $518 eNOXaparin 30 MG / 0.3 ML Injection 63323-0533-83 0.3 mL $70 $0 $70 $42 eNOXaparin 80 MG / 0.8 ML Injection 63323-0531-98 0.8 mL $463 $0 $463 $278 eNOXaparin [Lovenox] 40 MG / 0.4 ML Injection 63323-0535-98 0.4 mL $345 $0 $345 $207 eNOXaparin 100 mg/mL Injection 63323-0605-84 1 mL $175 $0 $175 $105 enoxaparin 100 mg/mL Soln 00548-5605-00 1 mL $134 $0 $134 $80 eNOXaparin 120 mg Injection 63323-0609-90 0.8 mL $259 $0 $259 $155 enoxaparin 120 mg/0.8 mL Soln 63323-0569-90 0.8 mL $259 $0 $259 $155

Page 81 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price enoxaparin 120 mg/0.8 mL Soln 63323-0569-99 0.8 mL $1,021 $0 $1,021 $613 enoxaparin 120 mg/0.8 mL Soln 60505-0796-00 0.8 mL $197 $0 $197 $118 enoxaparin 120 mg/0.8 mL Soln 00548-5606-00 0.8 mL $197 $0 $197 $118 enoxaparin 120 mg/0.8 mL Soln 00703-8610-21 0.8 mL $235 $0 $235 $141 enoxaparin 150 mg/ mL Soln 63323-0569-95 1 mL $135 $0 $135 $81 enoxaparin 150 mg/mL Soln 63323-0537-84 1 mL $259 $0 $259 $155 eNOXaparin 30 MG / 0.3 ML Injection 63323-0533-93 0.3 mL $261 $0 $261 $157 enoxaparin 30 mg/0.3 mL Soln 63323-0568-83 0.3 mL $210 $0 $210 $126 enoxaparin 30 mg/0.3 mL Soln 00703-8530-23 0.3 mL $160 $0 $160 $96 enoxaparin 300 mg/3 mL Soln 63323-0565-93 1 mL $205 $0 $205 $123 enoxaparin 40 mg/0.4 mL Soln 63323-0568-87 0.4 mL $175 $0 $175 $105 enoxaparin 40 mg/0.4 mL Soln 63323-0568-96 0.4 mL $345 $0 $345 $207 enoxaparin 40 mg/0.4 mL Soln 63323-0535-87 0.4 mL $175 $0 $175 $105 enoxaparin 40 mg/0.4 mL Soln 00703-8540-23 0.4 mL $159 $0 $159 $96 enoxaparin 60 mg/0.6 mL Soln 00075-0621-60 0.6 mL $426 $0 $426 $255 enoxaparin 60 mg/0.6 mL Soln 00781-3356-66 0.6 mL $350 $0 $350 $210 enoxaparin 60 mg/0.6 mL Soln 00548-5603-00 0.6 mL $134 $0 $134 $80 enoxaparin 60 mg/0.6 mL Soln 63323-0568-98 0.6 mL $514 $0 $514 $308 enoxaparin 60 mg/0.6 mL Soln 63323-0607-88 0.6 mL $175 $0 $175 $105 enoxaparin 60 mg/0.6 mL Soln 63323-0607-98 0.6 mL $92 $0 $92 $55 enoxaparin 80 mg/0.8 mL Soln 63323-0568-99 0.8 mL $91 $0 $91 $54 enoxaparin 80 mg/0.8 mL Soln 63323-0531-90 0.8 mL $70 $0 $70 $42 enoxaparin 80 mg/0.8 mL Soln 00075-0622-80 0.8 mL $565 $0 $565 $339 enoxaparin Inj 100 mg Syringe 00781-3500-69 1 mL $578 $0 $578 $347 enoxaparin Inj 100 mg/mL Injection 63323-0568-95 1 mL $92 $0 $92 $55 entacapone 200 mg Tab 60687-0188-21 1 tab(s) $36 $0 $36 $22 entecavir 0.5 mg Tab 31722-0833-30 1 tab(s) $301 $0 $301 $181 entecavir 0.5 mg Tab 00003-1611-12 1 tab(s) $316 $0 $316 $189 enzalutamide 40 mg Cap 00469-0125-99 1 cap(s) $0 $0 $0 $0 EPINEPHrine 0.1 mg/mL Soln 00409-4921-34 1 mL $26 $0 $26 $16 EPINEPHrine 0.1 mg/mL Soln 00548-3316-00 1 mL $41 $0 $41 $25 EPINEPHrine 0.1 mg/mL Soln 76329-3316-01 1 mL $81 $0 $81 $49 EPINEPHrine 0.15 mg Kit 49502-0501-02 1 EA $582 $0 $582 $349 EPINEPHrine 0.15 mg Kit 49502-0101-02 1 EA $1,322 $0 $1,322 $793 EPINEPHrine 0.3 mg Kit 49502-0102-02 1 EA $1,322 $0 $1,322 $793 EPINEPHrine 0.3 mg Kit 00115-1694-49 1 EA $1,764 $0 $1,764 $1,058 EPINEPHrine 1 mg/mL Soln 00548-9061-00 1 mL $9 $0 $9 $5 eplerenone 25 mg Tab 68084-0948-25 1 tab(s) $28 $0 $28 $17 eplerenone 25 mg Tab 51991-0877-33 1 tab(s) $31 $0 $31 $19 eplerenone 25 mg Tab 60687-0451-21 1 tab(s) $37 $0 $37 $22 epoetin alfa 10,000 units/mL preservative-free Soln 55513-0144-01 1 mL $1,021 $0 $1,021 $613 epoetin alfa 2000 units/mL preservative-free Soln 55513-0126-01 1 mL $210 $0 $210 $126 epoetin alfa 3000 units/mL preservative-free Soln 55513-0267-01 1 mL $308 $0 $308 $185 epoetin alfa 40000 units/mL Soln 55513-0823-10 1 mL $4,358 $0 $4,358 $2,615 epoetin alfa epbx 10,000 units/mL preservative-free Soln 00069-1308-10 1 mL $936 $0 $936 $561 epoetin alfa epbx 2000 units/mL preservative-free Soln 00069-1305-10 1 mL $193 $0 $193 $116 epoetin alfa epbx 3000 units/mL preservative-free Soln 00069-1306-10 1 mL $286 $0 $286 $172 epoetin alfa epbx 4000 units/mL preservative-free Soln 00069-1307-10 1 mL $379 $0 $379 $227 ergocalciferol 50,000 unit(s) Cap 60687-0500-01 1 cap(s) $16 $0 $16 $10 ergocalciferol 50,000 intl units Cap 69452-0151-20 1 cap(s) $8 $0 $8 $5 ergocalciferol 8000 unit(s)/mL Soln 43199-0015-60 1 mL $16 $0 $16 $10 erlotinib 100 mg Tab 50242-0063-01 1 tab(s) $1,194 $0 $1,194 $716 erlotinib 150 mg Tab 50242-0064-01 1 tab(s) $1,350 $0 $1,350 $810 ertapenem 1 gm REC Injection 55150-0282-09 10 mL $1,115 $0 $1,115 $669 erythromycin ethylsuccinate 200 mg/5 mL REC G 24338-0132-13 1 mL $20 $0 $20 $12 erythromycin ophthalmic 0.5% Ointm 17478-0070-35 1 app $42 $0 $42 $25 escitalopram 10 mg Tab 00904-6426-61 1 tab(s) $33 $0 $33 $20 escitalopram 10 mg Tab 16729-0169-01 1 tab(s) $35 $0 $35 $21 escitalopram 10 mg Tab 69097-0848-05 1 tab(s) $38 $0 $38 $23 escitalopram 20 mg Tab 68084-0618-01 1 tab(s) $34 $0 $34 $20 escitalopram 20 mg Tab 51079-0544-01 1 tab(s) $34 $0 $34 $20 escitalopram 5 mg/5 mL Soln 31722-0569-24 1 mL $10 $0 $10 $6 estazolam 2 mg Tab 51862-0070-01 1 tab(s) $46 $0 $46 $28 estradiol 1 mg Tab 51862-0333-01 1 tab(s) $8 $0 $8 $5 estradiol 1 mg Tab 00555-0886-02 1 tab(s) $5 $0 $5 $3 eszopiclone 1 mg Tab 00093-5537-56 1 tab(s) $86 $0 $86 $52 eszopiclone 1 mg Tab 68462-0382-01 1 tab(s) $90 $0 $90 $54 eszopiclone 3 mg Tab 68180-0324-01 1 tab(s) $86 $0 $86 $52 etanercept 25 mg REC Inj 58406-0425-34 0 $1,386 $0 $1,386 $832 etanercept 50 mg/mL Soln 58406-0435-04 1 mL $4,076 $0 $4,076 $2,446 ethacrynic acid 25 mg Tab 25010-0205-15 1 tab(s) $16 $0 $16 $9 ethacrynic acid 25 mg Tab 25010-0215-15 1 tab(s) $173 $0 $173 $104 ethambutol 100 mg Tab 68180-0280-01 1 tab(s) $7 $0 $7 $4 ethambutol 100 mg Tab 68850-0010-01 1 tab(s) $7 $0 $7 $4 ethambutol 400 mg Tab 68850-0012-01 1 tab(s) $15 $0 $15 $9 ethambutol 400 mg Tab 68084-0280-01 1 tab(s) $14 $0 $14 $9 ethambutol 400 mg Tab 68084-0280-11 1 tab(s) $14 $0 $14 $9 ethambutol 400 mg Tab 00555-0923-02 1 tab(s) $15 $0 $15 $9 ethosuximide 250 mg Cap 61748-0025-01 1 cap(s) $12 $0 $12 $7

Page 82 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price ethyl chloride Topical 100% Spray Liquid 00386-0001-03 1 spray(s) $236 $0 $236 $142 everolimus 0.25 mg Tab 00078-0417-20 1 tab(s) $47 $0 $47 $28 everolimus 0.75 mg Tab 00078-0415-20 1 tab(s) $146 $0 $146 $88 everolimus 0.75 mg Tab 00054-0472-21 1 tab(s) $216 $0 $216 $129 everolimus 10 mg Tab 00078-0567-51 1 tab(s) $3,700 $0 $3,700 $2,220 excitalopram 10 mg Tab 51079-0543-20 1 tab(s) $33 $0 $33 $20 exemestane 25 mg Tab 59762-2858-01 1 tab(s) $91 $0 $91 $55 ezetimibe 10 mg Tab 00591-3713-19 1 tab(s) $79 $0 $79 $47 ezetimibe 10 mg Tab 67877-0490-90 1 tab(s) $72 $0 $72 $43 famotidine 10 mg/mL Soln 55390-0027-01 1 mL $13 $0 $13 $8 famotidine 20 mg Tab 00378-3020-01 1 tab(s) $15 $0 $15 $9 famotidine 20 mg Tab 24385-0385-71 1 tab(s) $6 $0 $6 $3 famotidine 20 mg Tab 50268-0303-15 1 tab(s) $14 $0 $14 $8 famotidine 20 mg Tab 62332-0001-31 1 tab(s) $15 $0 $15 $9 famotidine 20 mg Tab 61442-0121-01 1 tab(s) $15 $0 $15 $9 famotidine 20 mg Tab 63739-0645-10 1 tab(s) $4 $0 $4 $2 famotidine 20 mg Tab 68001-0240-00 1 tab(s) $20 $0 $20 $12 famotidine 20 mg Tab 65862-0859-01 1 tab(s) $20 $0 $20 $12 famotidine 20 mg Tab 68001-0397-00 1 tab(s) $20 $0 $20 $12 famotidine 40 mg/5 mL REC P 68180-0150-01 2.5 mL $29 $0 $29 $18 fat emulsion, intravenous 20% EMULS 00338-0519-09 1 mL $51 $0 $51 $30 fat emulsion, intravenous with fish, medium chain, olive, and soy oil 20% Emuls 63323-0820-50 1 mL $50 $0 $50 $30 fat emulsion, intravenous with fish, medium chain, olive, and soy oil 20% Emuls 63323-0820-74 1 mL $50 $0 $50 $30 fat emulsion, IV 20% (100 mL) 20% Emulsion 00338-0519-58 1 mL $30 $0 $30 $18 febuxostat 40 mg Tab 00378-3925-93 1 tab(s) $88 $0 $88 $53 febuxostat 40 mg Tab 72205-0028-30 1 tab(s) $75 $0 $75 $45 felbamate 400 mg Tab 65162-0734-09 1 tab(s) $38 $0 $38 $23 felbamate 400 mg Tab 51525-0430-01 1 tab(s) $38 $0 $38 $23 felbamate 400 mg Tab 00037-0430-01 1 tab(s) $41 $0 $41 $24 felbamate 600 mg Tab 51525-0431-01 1 tab(s) $43 $0 $43 $26 felbamate 600 mg/5 mL Susp 51525-0442-08 1 mL $23 $0 $23 $14 fenofibrate 145 mg Tab 68084-0636-25 1 tab(s) $38 $0 $38 $23 fenofibrate 145 mg Tab 00378-3066-77 1 tab(s) $42 $0 $42 $25 fenofibrate 48 mg Tab 00378-3065-77 1 tab(s) $16 $0 $16 $10 fentaNYL 100 mcg/hr ER Fi 00406-9000-76 1 patch(es) $379 $0 $379 $227 fentanyl 100 mcg/hr ER Fi 00378-9124-98 1 patch(es) $379 $0 $379 $227 fentaNYL 12 mcg/hr ER Fi 00378-9119-98 1 patch(es) $147 $0 $147 $88 fentaNYL 12 mcg/hr ER Fi 00406-9012-76 1 patch(es) $149 $0 $149 $89 fentanyl 25 mcg/hr ER Fi 00378-9121-98 1 patch(es) $105 $0 $105 $63 fentaNYL 25 mcg/hr ER Fi 60505-7006-02 1 patch(es) $154 $0 $154 $92 fentanyl 50 mcg/hr ER Fi 00378-9122-98 1 patch(es) $189 $0 $189 $114 fentanyl 50 mcg/hr ER Fi 00406-9050-76 1 patch(es) $182 $0 $182 $109 fentanyl 75 mcg/hr ER Fi 00406-9075-76 1 patch(es) $286 $0 $286 $172 fentanyl 75 mcg/hr ER Fi 00378-9123-98 1 patch(es) $285 $0 $285 $171 ferrous gluconate 300 mg Tab 00245-0061-01 1 tab(s) $4 $0 $4 $2 ferrous gluconate 300 mg Tab 00245-0061-11 1 tab(s) $3 $0 $3 $2 ferrous gluconate 300 mg Tab 00245-0061-89 1 tab(s) $68 $0 $68 $41 ferrous gluconate 324 mg Tab 00574-0508-10 1 tab(s) $4 $0 $4 $2 ferrous sulfate (as elemental iron) 15 mg/mL LIQ 39328-0057-50 1 mL $6 $0 $6 $3 ferrous sulfate (as elemental iron) 45 mg ER Ta 10006-0730-13 1 tab(s) $4 $0 $4 $3 ferrous sulfate 324 mg Tab 00574-0608-11 1 tab(s) $4 $0 $4 $2 ferrous sulfate 325 mg Tab 00677-0070-10 1 tab(s) $3 $0 $3 $2 ferrous sulfate 325 mg Tab 00603-0179-29 1 tab(s) $4 $0 $4 $3 ferrous sulfate 325 mg Tab 00904-7590-83 1 tab(s) $3 $0 $3 $2 ferrous sulfate 75 mg/0.6 mL LIQ 00087-0740-02 1 mL $6 $0 $6 $4 fexofenadine 180 mg Tab 00378-0782-93 1 tab(s) $20 $0 $20 $12 fexofenadine 180 mg Tab 45802-0571-78 1 tab(s) $6 $0 $6 $4 fexofenadine 180 mg Tab 51079-0548-20 1 tab(s) $20 $0 $20 $12 fexofenadine 60 mg Tab 51079-0547-20 1 tab(s) $13 $0 $13 $8 finasteride 1 mg Tab 31722-0526-30 1 tab(s) $22 $0 $22 $13 finasteride 1 mg Tab 31722-0526-90 1 tab(s) $20 $0 $20 $12 finasteride 1 mg Tab 00006-0071-31 1 tab(s) $24 $0 $24 $14 finasteride 5 mg Tab 31722-0525-90 1 tab(s) $24 $0 $24 $14 finasteride 5 mg Tab 16729-0090-01 1 tab(s) $24 $0 $24 $15 finasteride 5 mg Tab 50268-0314-15 1 tab(s) $24 $0 $24 $15 finasteride 5 mg Tab 60687-0428-01 1 tab(s) $11 $0 $11 $6 fingolimod 0.5 mg Cap 00078-0607-15 1 cap(s) $1,811 $0 $1,811 $1,086 fingolimod 0.5 mg Cap 00078-0607-51 1 cap(s) $1,157 $0 $1,157 $694 fish oil 1,000 mg Cap 87701-0408-18 1 cap(s) $4 $0 $4 $2 fish oil 1,000 mg Cap 77333-0308-10 1 cap(s) $5 $0 $5 $3 flecainide 100 mg Tab 50268-0321-15 1 tab(s) $43 $0 $43 $26 flecainide 100 mg Tab 00054-0011-25 1 tab(s) $22 $0 $22 $13 fluconazole 10 mg/mL REC P 00054-0002-85 1 mL $12 $0 $12 $7 fluconazole 100 mg Tab 00172-5411-46 1 tab(s) $62 $0 $62 $37 fluconazole 100 mg Tab 68084-0728-01 1 tab(s) $21 $0 $21 $13 fluconazole 100 mg Tab 68462-0102-30 1 tab(s) $62 $0 $62 $37 fluconazole 150 mg Tab 59762-5017-01 1 tab(s) $97 $0 $97 $58 fluconazole 150 mg Tab 00172-5412-11 1 tab(s) $97 $0 $97 $58 fluconazole 200 mg/100 mL-0.9% Soln 25021-0184-82 100 mL $126 $0 $126 $76

Page 83 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price flucytosine 500 mg Cap 00187-3555-10 1 cap(s) $81 $0 $81 $49 flucytosine 500 mg Cap 64980-0180-01 1 cap(s) $304 $0 $304 $182 fludrocortisone 0.1 mg Tab 50268-0330-15 1 tab(s) $14 $0 $14 $8 flumazenil 0.1 mg/mL Soln 63323-0424-05 1 mL $353 $0 $353 $212 fluocinolone topical 0.01% Oil 65162-0704-86 1 app $261 $0 $261 $157 fluocinolone topical 0.01% Soln 52565-0012-59 1 app $1,274 $0 $1,274 $764 fluocinolone topical 0.01% Soln 00168-0059-60 1 app $84 $0 $84 $50 fluocinonide topical 0.05% Soln 00168-0134-60 1 app $197 $0 $197 $118 fluocinonide topical 0.05% Soln 51672-1273-04 1 app $197 $0 $197 $118 FLUoxetine 10 mg Cap 00904-5784-61 1 cap(s) $20 $0 $20 $12 FLUoxetine 10 mg Cap 51079-0997-20 1 cap(s) $21 $0 $21 $12 FLUoxetine 20 mg Cap 65862-0193-01 1 cap(s) $21 $0 $21 $13 FLUoxetine 20 mg Cap 68084-0605-01 1 cap(s) $20 $0 $20 $12 FLUoxetine 20 mg/5 mL Soln 54838-0523-40 1 mL $11 $0 $11 $7 fluPHENAZine 1 mg Tab 51079-0485-20 1 tab(s) $7 $0 $7 $4 fluticasone 44 mcg/inh Aeros 00173-0491-00 1 INH $508 $0 $508 $305 fluticasone furoate 100 mcg Powde 00173-0874-14 1 INH $51 $0 $51 $30 fluticasone nasal 0.05 mg/nasal Spray 60505-0829-01 1 spray(s) $606 $0 $606 $363 fluticasone topical 0.005% Ointm 00168-0333-60 1 app $1 $0 $1 $1 fluticasone Topical 0.05% Cream 00173-0430-01 1 app $304 $0 $304 $183 fluticasone topical 0.05% Cream 45802-0222-11 1 app $248 $0 $248 $149 fluticasone topical 0.05% Cream 00713-0631-31 1 app $248 $0 $248 $149 fluticasone-salmeterol 100 mcg-50 mcg Powde 00378-9320-32 1 INH $599 $0 $599 $359 fluticasone-salmeterol CFC free 230 mcg-21 mcg/inh Aeros 00173-0717-20 1 INH $2,335 $0 $2,335 $1,401 fluvastatin 20 mg Cap 00378-8020-93 1 cap(s) $37 $0 $37 $22 folic acid 0.4 mg Tab 10006-0730-34 1 tab(s) $3 $0 $3 $2 folic acid 0.4 mg Tab 51645-0932-01 1 tab(s) $3 $0 $3 $2 folic acid 1 mg Tab 65162-0361-10 1 tab(s) $6 $0 $6 $3 folic acid 1 mg Tab 63739-0537-10 1 tab(s) $6 $0 $6 $3 fondaparinux 10 mg/0.8 mL Soln 55111-0681-02 0.8 mL $960 $0 $960 $576 fondaparinux 2.5 mg Injection 67457-0582-10 0.5 mL $774 $0 $774 $464 fondaparinux 2.5 mg/0.5 mL Soln 55111-0678-10 0.5 mL $774 $0 $774 $464 fondaparinux 5 mg/0.4 mL Soln 55111-0679-10 0.4 mL $909 $0 $909 $546 fondaparinux 5 mg/0.4 mL Soln 70710-1515-06 0.4 mL $909 $0 $909 $546 fondaparinux 7.5 mg/0.6 mL Soln 55111-0680-10 0.6 mL $1,510 $0 $1,510 $906 fondaparinux syringe 10 mg / 0.8 mL Soln 43598-0606-10 0.8 mL $500 $0 $500 $300 foscarnet 24 mg/mL Soln 76310-0024-01 1 mL $65 $0 $65 $39 fosfomycin 3 g REC P 00456-4300-01 1 packet(s) $533 $0 $533 $320 furosemide 10 mg/mL LIQ 60432-0613-60 1 mL $6 $0 $6 $3 furosemide 10 mg/mL Soln 00409-6102-25 2 mL $37 $0 $37 $22 furosemide 10 mg/mL Soln 00409-6102-26 4 mL $31 $0 $31 $19 furosemide 10 mg/mL Soln (10 mL vial) 00517-5710-25 2 mL $11 $0 $11 $7 furosemide 20 mg Tab 00378-0208-01 1 tab(s) $4 $0 $4 $3 furosemide 40 mg Tab 69315-0117-01 1 tab(s) $4 $0 $4 $3 furosemide 40 mg Tab 00054-8299-25 1 tab(s) $5 $0 $5 $3 gabapentin 250 mg / 5 mL Soln 59762-5025-01 1 mL $7 $0 $7 $4 gabapentin 100 mg Cap 60505-0112-00 1 cap(s) $7 $0 $7 $4 gabapentin 100 mg Cap 50228-0179-01 1 cap(s) $7 $0 $7 $4 gabapentin 100 mg Cap 00904-6665-61 1 cap(s) $4 $0 $4 $3 gabapentin 300 mg Cap 50268-0348-15 1 cap(s) $11 $0 $11 $7 gabapentin 300 mg Cap 45963-0556-11 1 cap(s) $12 $0 $12 $7 gabapentin 300 mg Cap 31722-0222-01 1 cap(s) $12 $0 $12 $7 gabapentin 300 mg Cap 00904-6666-61 1 cap(s) $5 $0 $5 $3 gabapentin 300 mg Cap 68084-0762-01 1 cap(s) $13 $0 $13 $8 gabapentin 300 mg Cap 67877-0223-01 1 cap(s) $12 $0 $12 $7 gabapentin 300 mg Cap 60505-0113-01 1 cap(s) $12 $0 $12 $7 gabapentin 400 mg Cap 63739-0984-10 1 cap(s) $5 $0 $5 $3 gabapentin 400 mg Cap 68084-0774-01 1 cap(s) $12 $0 $12 $7 gabapentin 400 mg Cap 00904-6667-61 1 cap(s) $5 $0 $5 $3 gabapentin 400 mg Cap 45963-0557-11 1 cap(s) $14 $0 $14 $8 gabapentin 400 mg Cap 50228-0181-01 1 cap(s) $4 $0 $4 $2 gabapentin 600 mg Tab 00904-6823-61 1 tab(s) $6 $0 $6 $4 gabapentin 600 mg Tab 68001-0006-00 1 tab(s) $20 $0 $20 $12 gabapentin 600 mg Tab 62756-0202-01 1 tab(s) $20 $0 $20 $12 gabapentin 600 mg Tab 60687-0507-01 1 tab(s) $20 $0 $20 $12 gabapentin 800 mg Tab 60687-0518-01 1 tab(s) $23 $0 $23 $14 gabapentin 800 mg Tab 68001-0007-00 1 tab(s) $24 $0 $24 $14 gabapentin 800 mg Tab 68462-0127-01 1 tab(s) $24 $0 $24 $14 gadobenate dimeglumine 529 mg/mL Soln 00270-5164-13 1 mL $57 $0 $57 $34 gadobenate dimeglumine 529 mg/mL Soln 00270-5164-14 1 mL $56 $0 $56 $33 gadobutrol 604.72 mg/mL Soln 50419-0325-15 1 mL $706 $0 $706 $424 galantamine 12 mg Tab 50458-0398-60 1 tab(s) $25 $0 $25 $15 galantamine 16 mg ER Ca 50458-0388-30 1 cap(s) $46 $0 $46 $28 galantamine 24 mg Cap 00555-1022-01 1 cap(s) $25 $0 $25 $15 galantamine 24 mg ER Ca 47335-0837-83 1 cap(s) $46 $0 $46 $28 galantamine 24 mg ER Ca 65862-0746-30 1 cap(s) $15 $0 $15 $9 galantamine 4 mg Tab 51079-0852-03 1 tab(s) $13 $0 $13 $8 galantamine 8 mg ER Ca 00555-1020-01 1 cap(s) $46 $0 $46 $28 galantamine 8 mg ER Cap 50458-0387-30 1 cap(s) $44 $0 $44 $26

Page 84 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price galantamine 8 mg Tab 57237-0050-60 1 tab(s) $25 $0 $25 $15 gentamicin 40 mg/mL Soln 63323-0010-02 1 mL $74 $0 $74 $45 gentamicin ophthalmic 0.3% Ointm 17478-0284-35 1 app $146 $0 $146 $87 gentamicin ophthalmic 0.3% Soln 60758-0188-05 1 drop(s) $69 $0 $69 $41 gentamicin topical 0.1% Ointm 45802-0046-11 1 EA $41 $0 $41 $25 glatiramer 40 mg/mL Soln 00781-3250-89 1 mL $3,683 $0 $3,683 $2,210 glatiramer Inj Soln 20 mg/mL Injection 00781-3234-34 1 mL $1,525 $0 $1,525 $915 glimepiride 4 mg Tab 51079-0426-01 1 tab(s) $12 $0 $12 $7 glimepiride 1 mg Tab 68001-0177-00 1 tab(s) $6 $0 $6 $4 glimepiride 1 mg Tab 00093-7254-01 1 tab(s) $6 $0 $6 $4 glimepiride 2 mg Tab 68084-0326-01 1 tab(s) $9 $0 $9 $6 glimepiride 2 mg Tab 51079-0425-01 1 tab(s) $8 $0 $8 $5 glimepiride 2 mg Tab 51079-0425-20 1 tab(s) $8 $0 $8 $5 glimepiride 4 mg Tab 51079-0426-20 1 tab(s) $12 $0 $12 $7 glimepiride 4 mg Tab 68084-0327-01 1 tab(s) $12 $0 $12 $7 glipiZIDE 10 mg ER Ta 59762-5033-01 1 tab(s) $9 $0 $9 $5 glipiZIDE 10 mg ER Ta 59762-5033-01 1 tab(s) $9 $0 $9 $5 gliPIZIDE 10 mg Tab 51079-0811-01 1 tab(s) $8 $0 $8 $5 glipiZIDE 10 mg Tab 51079-0811-20 1 tab(s) $8 $0 $8 $5 glipiZIDE 10 mg Tab 63739-0117-10 1 tab(s) $8 $0 $8 $5 glipiZIDE 10 mg Tab 00172-3650-10 1 tab(s) $8 $0 $8 $5 glipiZIDE 2.5 mg ER Ta 59762-5031-01 1 tab(s) $6 $0 $6 $4 glipiZIDE 2.5 mg ER Ta 68084-0295-11 1 tab(s) $8 $0 $8 $5 glipiZIDE 2.5 mg ER Ta 68084-0295-21 1 tab(s) $8 $0 $8 $5 glipiZIDE 5 mg ER Ta 00049-1550-66 1 tab(s) $7 $0 $7 $4 glipiZIDE 5 mg ER Ta 00591-0844-01 1 tab(s) $6 $0 $6 $4 glipiZIDE 5 mg ER Ta 68084-0111-01 1 tab(s) $7 $0 $7 $4 glipiZIDE 5 mg ER Ta 68084-0111-11 1 tab(s) $7 $0 $7 $4 glipiZIDE 5 mg Tab 60505-0141-00 1 tab(s) $6 $0 $6 $3 glucagon recombinant 1 mg REC I 00002-8031-01 1 mL $1,080 $0 $1,080 $648 glucosamine/chondroitin 500mg/400mg Cap 00904-5481-52 1 cap(s) $5 $0 $5 $3 glucose 4 g Chew 00904-6710-15 1 tab(s) $18 $0 $18 $11 glucose 40% Gel 00574-0070-30 1 EA $14 $0 $14 $9 glucose 50% Soln 00409-7517-16 50 mL $29 $0 $29 $17 glucose 50% Soln 76329-3301-01 50 mL $57 $0 $57 $34 glyBURIDE 2.5 mg Tab 51079-0872-01 1 tab(s) $6 $0 $6 $4 glyBURIDE 2.5 mg Tab 51079-0872-20 1 tab(s) $5 $0 $5 $3 glyBURIDE 2.5 mg Tab 00093-8343-01 1 tab(s) $6 $0 $6 $4 glyBURIDE 5 mg Tab 51079-0873-01 1 tab(s) $8 $0 $8 $5 glyBURIDE 5 mg Tab 51079-0873-20 1 tab(s) $7 $0 $7 $4 glyBURIDE 5 mg Tab 63739-0119-10 1 tab(s) $9 $0 $9 $5 glyBURIDE micronized 3 mg Tab 00378-1125-01 1 tab(s) $8 $0 $8 $5 glycerin adult Supp 00132-0079-12 1 supp $4 $0 $4 $2 glycopyrrolate 0.2 mg/mL Soln 00517-4620-25 1 mL $61 $0 $61 $36 glycopyrrolate 1 mg Tab 60687-0458-01 1 tab(s) $12 $0 $12 $7 glycopyrrolate 1 mg Tab 60687-0270-01 1 tab(s) $12 $0 $12 $7 gramicidin/neomycin/polymyxin B ophthalmic 0.025 mg-1.75 mg-10000 units/mL Soln 00081-0728-69 1 drop(s) $8 $0 $8 $5 gramicidin/neomycin/polymyxin B ophthalmic 0.025 mg-1.75 mg-10000 units/mL Soln 24208-0790-62 1 drop(s) $208 $0 $208 $125 guaiFENesin 100 mg/5 mL LIQ 50383-0063-11 10 mL $9 $0 $9 $5 guaiFENesin 100 mg/5 mL LIQ 50383-0063-12 10 mL $9 $0 $9 $5 guaiFENesin 600 mg ER Ta 63824-0008-61 1 tab(s) $6 $0 $6 $4 guaiFENesin ER Tab 600 mg ER Tablet 68084-0572-01 1 tab(s) $10 $0 $10 $6 guaifenesin-pseudoephedrine 600 mg-120 mg ER Tab 00247-0176-02 1 tab(s) $22 $0 $22 $13 guanFACINE 1 mg Tab 00591-0444-01 1 tab(s) $9 $0 $9 $5 guanFACINE 1 mg Tab 68084-0748-25 1 tab(s) $10 $0 $10 $6 guanFACINE 2 mg Tab 65162-0713-10 1 tab(s) $12 $0 $12 $7 guanFACINE 2 mg Tab 00591-0453-01 1 tab(s) $11 $0 $11 $7 guanFACINE 2 mg Tab 00378-1190-01 1 tab(s) $11 $0 $11 $7 guar gum Chew Tab 00067-0047-36 1 tab(s) $4 $0 $4 $3 guar gum REC Powder 00067-0042-48 1 scoop(s) $31 $0 $31 $19 haemophilus b conjugate (PRP-T) vaccine - REC I 49281-0545-03 0.5 mL $249 $0 $249 $150 haloperidol 0.5 mg Tab 51079-0733-01 1 tab(s) $4 $0 $4 $3 haloperidol 0.5 mg Tab 51079-0733-20 1 tab(s) $5 $0 $5 $3 haloperidol 1 mg Tab 00378-0257-01 1 tab(s) $6 $0 $6 $4 haloperidol 2 mg/mL Conc 00472-0766-94 1 mL $7 $0 $7 $4 haloperidol 2 mg/mL Conc 00121-0581-04 1 mL $7 $0 $7 $4 haloperidol 5 mg Tab 51079-0736-01 1 tab(s) $206 $0 $206 $123 heparin 10 units/mL Soln 00409-1151-12 30 mL $20 $0 $20 $12 heparin 10 units/mL Soln 00409-1151-70 30 mL $18 $0 $18 $11 heparin 10 units/mL Soln 00641-2442-45 30 mL $20 $0 $20 $12 heparin 1000 units/mL Soln 00409-2720-02 10 mL $26 $0 $26 $16 heparin 1000 units/mL Soln 00069-0058-01 10 mL $36 $0 $36 $22 heparin 1000 units/mL Soln 63323-0540-11 10 mL $72 $0 $72 $43 heparin 1000 units/mL Soln 67457-0385-99 10 mL $38 $0 $38 $23 heparin 5000 units/0.5 mL Soln 63323-0118-05 0.5 mL $103 $0 $103 $62 heparin 5000 units/0.5 mL Soln 00264-5705-10 0.5 mL $1,647 $0 $1,647 $988 heparin 5000 units/0.5 mL Soln 00641-6204-10 0.5 mL $109 $0 $109 $65

Page 85 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price heparin 5000 units/mL Soln 00641-0400-12 1 mL $19 $0 $19 $11 heparin 5000 units/mL Soln 25021-0402-01 1 mL $30 $0 $30 $18 heparin 5000 units/mL Soln 00409-2723-01 1 mL $20 $0 $20 $12 heparin 5000 units/mL Soln 00069-0059-03 1 mL $38 $0 $38 $23 heparin 5000 units/mL Soln 63323-0262-01 1 mL $44 $0 $44 $27 heparin flush 10 units/mL Soln 63807-0500-55 5 mL $27 $0 $27 $16 heparin flush 10 units/mL Soln 64253-0222-35 5 mL $33 $0 $33 $20 heparin flush 10 units/mL Soln 08290-3064-14 5 mL $12 $0 $12 $7 heparin flush 100 units/mL Soln 64253-0333-35 5 mL $34 $0 $34 $20 hepatitis A pediatric vaccine 720 units/0.5 mL preservative free Susp 58160-0825-11 0.5 mL $249 $0 $249 $149 hepatitis B adult vaccine 20 mcg/mL Susp 58160-0821-52 1 mL $442 $0 $442 $265 hepatitis B immune globulin - Soln 59730-4203-01 1 mL $1,136 $0 $1,136 $681 human papillomavirus vaccine - Susp 00006-4109-06 0.5 mL $1,079 $0 $1,079 $647 hydrALAZINE 10 mg Tab 00904-6440-61 1 tab(s) $4 $0 $4 $2 hydrALAZINE 25 mg Tab 62584-0733-01 1 tab(s) $5 $0 $5 $3 hydrALAZINE 25 mg Tab 51079-0075-20 1 tab(s) $7 $0 $7 $4 hydrALAZINE 50 mg Tab 62584-0734-01 1 tab(s) $6 $0 $6 $4 hydrALAZINE 50 mg Tab 00904-6442-61 1 tab(s) $4 $0 $4 $3 hydroCHLOROthiazide 12.5 mg Cap 00591-0347-01 1 cap(s) $6 $0 $6 $4 hydrochlorothiazide 12.5 mg Cap 00172-4870-10 1 cap(s) $6 $0 $6 $4 hydrochlorothiazide 12.5 mg Cap 51079-0776-01 1 cap(s) $184 $0 $184 $111 hydrochlorothiazide 12.5 mg Cap 51079-0776-20 1 cap(s) $6 $0 $6 $4 hydrochlorothiazide 12.5 mg Cap 68084-0398-01 1 cap(s) $5 $0 $5 $3 hydrochlorothiazide 25 mg Tab 68084-0086-01 1 tab(s) $4 $0 $4 $3 hydrochlorothiazide 25 mg Tab 68084-0086-11 1 tab(s) $4 $0 $4 $3 hydrochlorothiazide 25 mg Tab 51079-0049-20 1 tab(s) $4 $0 $4 $2 hydrochlorothiazide 25 mg Tab 63739-0128-10 1 tab(s) $4 $0 $4 $3 hydrochlorothiazide 25 mg Tab 00182-0556-89 1 tab(s) $4 $0 $4 $3 hydrochlorothiazide 25 mg Tab 00172-2083-00 1 tab(s) $4 $0 $4 $3 hydrochlorothiazide 25 mg Tab 00172-2083-60 1 tab(s) $4 $0 $4 $2 hydrochlorothiazide 25 mg Tab 00603-3856-21 1 tab(s) $4 $0 $4 $2 hydroCHLOROthiazide 25 mg Tab 16729-0183-01 1 tab(s) $4 $0 $4 $2 hydroCHLOROthiazide 50 mg Tab 16729-0184-01 1 tab(s) $4 $0 $4 $3 hydrochlorothiazide 50 mg Tab 23155-0139-01 1 tab(s) $14 $0 $14 $9 hydrochlorothiazide 50 mg Tab 00172-2089-10 1 tab(s) $15 $0 $15 $9 hydrochlorothiazide 50 mg Tab 00172-2089-60 1 tab(s) $4 $0 $4 $3 hydrochlorothiazide-triamterene 25 mg-37.5 mg Tab 68084-0750-25 1 tab(s) $9 $0 $9 $6 hydroCORTisone 10 mg Tab 60687-0511-01 1 tab(s) $15 $0 $15 $9 hydrocortisone 10 mg Tab 59762-0074-01 1 tab(s) $6 $0 $6 $3 hydrocortisone 10 mg Tab 42543-0141-01 1 tab(s) $7 $0 $7 $4 hydrocortisone 10 mg Tab 00009-0031-01 1 tab(s) $6 $0 $6 $4 hydrocortisone 10% Foam 00037-6830-15 1 app $3,069 $0 $3,069 $1,841 hydrocortisone 10% Foam 00091-0695-20 1 app $720 $0 $720 $432 hydrocortisone 250 mg REC I 00009-0909-08 2 mL $68 $0 $68 $41 hydrocortisone 5 mg Tab 42543-0140-50 1 tab(s) $6 $0 $6 $3 hydrocortisone 5 mg Tab 59762-0073-01 1 tab(s) $6 $0 $6 $3 hydroCORTisone 5 mg Tab 64380-0970-23 1 tab(s) $10 $0 $10 $6 hydrocortisone topical 0.5% Cream 51672-2010-02 1 app $46 $0 $46 $27 hydrocortisone topical 1% Cream 45802-0438-03 1 app $37 $0 $37 $22 hydrocortisone topical 1% Cream 00904-7623-31 1 app $29 $0 $29 $17 hydrocortisone topical 1% Cream 00168-0015-31 1 app $60 $0 $60 $36 hydrocortisone topical 1% Ointm 00472-0345-56 1 app $31 $0 $31 $19 hydrocortisone topical 2.5% Cream 00472-0337-30 1 app $86 $0 $86 $51 hydrocortisone/neomycin/polymyxin B otic 1%-0.35%-10000 units/mL Soln 24208-0631-10 1 drop(s) $224 $0 $224 $134 hydrocortisone/neomycin/polymyxin B otic 1%-0.35%-10000 units/mL Soln 61314-0646-10 1 drop(s) $224 $0 $224 $134 hydrocortisone/neomycin/polymyxin B otic 1%-0.35%-10000 units/mL Soln 61570-0034-10 1 drop(s) $485 $0 $485 $291 hydrocortisone/neomycin/polymyxin B Topical 0.5%-0.35%-10000 units/g Cream 61570-0032-75 1 app $585 $0 $585 $351

HYDROmorphone 2 mg Tab 42858-0301-25 1 tab(s) $10 $0 $10 $6 HYDROmorphone 4 mg Tab 42858-0302-25 1 tab(s) $10 $0 $10 $6 HYDROmorphone 8 mg Tab 59011-0458-10 1 tab(s) $29 $0 $29 $18 hydromorphone 8 mg Tab 42858-0303-01 1 tab(s) $12 $0 $12 $7 HYDROmorphone 8 mg Tab 13107-0109-01 1 tab(s) $13 $0 $13 $8 hydromorphone 8 mg Tab 00406-3249-01 1 tab(s) $13 $0 $13 $8 hydroquinone topical 4% Cream 45802-0980-64 1 EA $52 $0 $52 $31 hydroxocobalamin 1000 mcg/mL Soln 00591-2888-30 1 mL $17 $0 $17 $10 hydroxychloroquine 200 mg Tab 63304-0296-01 1 tab(s) $12 $0 $12 $7 hydroxychloroquine 200 mg Tab 68382-0096-01 1 tab(s) $12 $0 $12 $7 hydroxychloroquine 200 mg Tab 69238-1544-01 1 tab(s) $33 $0 $33 $20 hydroxyurea 300 mg Cap 00003-6336-17 1 cap(s) $10 $0 $10 $6 hydroxyurea 500 mg Cap 68084-0284-01 1 cap(s) $9 $0 $9 $6 hydrOXYzine hydrochloride 10 mg Tab 68084-0253-01 1 tab(s) $5 $0 $5 $3 hydrOXYzine hydrochloride 10 mg/5 mL Syrup 60432-0150-04 1 mL $6 $0 $6 $3 hydrOXYzine hydrochloride 25 mg Tab 63739-0486-10 1 tab(s) $5 $0 $5 $3 hydrOXYzine hydrochloride 25 mg Tab 00904-6617-61 1 tab(s) $5 $0 $5 $3 hydrOXYzine hydrochloride 25 mg Tab 42806-0160-01 1 tab(s) $10 $0 $10 $6 hydrOXYzine hydrochloride 25 mg Tab 42806-0160-05 1 tab(s) $9 $0 $9 $5 hydrOXYzine hydrochloride 25 mg/mL Soln 63323-0021-01 2 mL $29 $0 $29 $18 hydrOXYzine pamoate 25 mg Cap 68084-0847-01 1 cap(s) $5 $0 $5 $3

Page 86 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price hydrOXYzine pamoate 25 mg Cap 00185-0674-01 1 cap(s) $5 $0 $5 $3 hyoscyamine 0.125 mg Tab 68220-0112-10 1 tab(s) $11 $0 $11 $7 hyoscyamine 0.125 mg Tab 43199-0013-01 1 tab(s) $9 $0 $9 $5 hyoscyamine 0.375 mg ER Ta 43199-0014-01 1 tab(s) $14 $0 $14 $8 ibuprofen 100 mg/5 mL Susp 24385-0361-26 1 mL $38 $0 $38 $23 ibuprofen 100 mg/5 mL Susp 24385-0361-34 1 mL $38 $0 $38 $23 ibuprofen 100 mg/5 mL Susp 00472-2002-94 1 mL $89 $0 $89 $53 ibuprofen 200 mg Tab 00904-7914-61 1 tab(s) $4 $0 $4 $2 ibuprofen 200 mg Tab 63739-0134-01 1 tab(s) $4 $0 $4 $2 ibuprofen 400 mg Tab 63739-0672-10 1 tab(s) $4 $0 $4 $2 ibuprofen 400 mg Tab 60687-0446-01 1 tab(s) $5 $0 $5 $3 ibuprofen 400 mg Tab 68084-0658-01 1 tab(s) $5 $0 $5 $3 ibuprofen 400 mg Tab 00904-5853-61 1 tab(s) $148 $0 $148 $89 ibuprofen 600 mg Tab 00904-5854-61 1 tab(s) $5 $0 $5 $3 ibuprofen 600 mg Tab 00904-5186-60 1 tab(s) $4 $0 $4 $2 ibuprofen 600 mg Tab 00904-5186-61 1 tab(s) $5 $0 $5 $3 ibuprofen 600 mg Tab 68084-0703-01 1 tab(s) $5 $0 $5 $3 ibuprofen 600 mg Tab 60687-0457-01 1 tab(s) $6 $0 $6 $3 ibuprofen 600 mg Tab 62584-0747-01 1 tab(s) $6 $0 $6 $3 ibuprofen 600 mg Tab 62584-0747-11 1 tab(s) $6 $0 $6 $3 ibuprofen 600 mg Tab 63739-0684-10 1 tab(s) $4 $0 $4 $2 ibuprofen 600 mg Tab 63739-0443-10 1 tab(s) $5 $0 $5 $3 ibuprofen 600 mg Tab 51079-0282-20 1 tab(s) $5 $0 $5 $3 ibuprofen 600 mg Tab 55111-0683-05 1 tab(s) $5 $0 $5 $3 imipenem-cilastatin 500 mg-500 mg REC I 63323-0322-25 10 mL $173 $0 $173 $104 imipenem-cilastatin 500 mg-500 mg REC I 63323-0322-93 10 mL $113 $0 $113 $68 imiquimod topical 5% Cream 00168-0432-24 1 EA $240 $0 $240 $144 immune globulin intravenous 10% Soln 00944-2700-05 100 mL $9,129 $0 $9,129 $5,477 immune globulin intravenous 12 g REC I 44206-0418-12 200 mL $8,526 $0 $8,526 $5,116 incobotulinumtoxinA 100 unit(s) REC Injection- Own Supply 99345-0004-40 1 vial(s) $0 $0 $0 $0 incobotulinumtoxinA 50 unit(s) REC Injection- Own Supply 99345-0004-45 1 vial(s) $0 $0 $0 $0 indapamide 2.5 mg Tab 43975-0304-10 1 tab(s) $14 $0 $14 $8 indapamide 2.5 mg Tab 51079-0868-20 1 tab(s) $9 $0 $9 $5 indomethacin 25 mg Cap 51079-0190-01 1 cap(s) $6 $0 $6 $4 indomethacin 25 mg Cap 51079-0190-20 1 cap(s) $6 $0 $6 $4 indomethacin 25 mg Cap 31722-0542-01 1 cap(s) $6 $0 $6 $4 indomethacin 25 mg Cap 50268-0430-15 1 cap(s) $6 $0 $6 $4 indomethacin 50 mg Cap 50268-0431-15 1 cap(s) $8 $0 $8 $5 indomethacin 50 mg Cap 00378-0147-01 1 cap(s) $8 $0 $8 $5 indomethacin 75 mg ER Ca 64814-0695-60 1 cap(s) $21 $0 $21 $12 indomethacin 75 mg ER Ca 68084-0411-21 1 cap(s) $24 $0 $24 $14 indomethacin 75 mg ER Ca 10702-0016-06 1 cap(s) $24 $0 $24 $14 indomethacin 75 mg ER Capsule 68084-0411-11 1 cap(s) $24 $0 $24 $14 influenza virus vaccine, Inact 3 yrs & older 0.5 mL Susp 49281-0416-50 0.5 mL $298 $0 $298 $179 influenza virus vaccine, Inact 3 yrs & older 0.5 mL Susp 49281-0417-50 0.5 mL $153 $0 $153 $92 influenza virus vaccine, Inact 3 yrs & older 0.5 mL Susp [2015-2016 formula] 49281-0415-10 0.5 mL $119 $0 $119 $72 influenza virus vaccine, inactivated high-dose preservative-free quadrivalent Susp 49281-0120-65 0.7 mL $651 $0 $651 $390 influenza virus vaccine, inactivated preservative-free quadrivalent Susp 49281-0420-50 0.5 mL $313 $0 $313 $188 insulin glargine 100 units/mL Soln 00088-2220-33 0.01 mL $91 $0 $91 $55 insulin glargine 100 units/mL Soln 00088-2220-60 1 mL $103 $0 $103 $62 insulin inhalation, rapid acting 1 mg and 3 mg Powde 00069-0050-19 1 cap(s) $9 $0 $9 $5 insulin inhalation, rapid acting 1 mg and 3 mg Powde 00069-0050-53 1 cap(s) $8 $0 $8 $5 insulin isophane (NPH) human recombinant 100 units/mL Susp 00169-1834-11 10 mL $208 $0 $208 $125 insulin lispro 100 units/mL Soln 00002-8799-59 1 mL $257 $0 $257 $154 interferon beta-1a 22 mcg/0.5 mL Soln 44087-0022-03 0.5 mL $1,081 $0 $1,081 $649 interferon beta-1a 30 mcg/0.5 mL Kit 59627-0002-05 0.5 mL $40,150 $0 $40,150 $24,090 interferon beta-1a 44 mcg/0.5 mL Soln 44087-0044-03 0.5 mL $3,635 $0 $3,635 $2,181 ipratropium nasal 0.06% Spray 00054-0046-41 1 spray(s) $319 $0 $319 $191 irbesartan 150 mg Tab 33342-0048-07 1 tab(s) $24 $0 $24 $14 irbesartan 150 mg Tab 00955-1041-90 1 tab(s) $22 $0 $22 $13 irbesartan 150 mg Tab 00024-5851-30 1 tab(s) $49 $0 $49 $29 irbesartan 150 mg Tab 62332-0042-30 1 tab(s) $24 $0 $24 $14 irbesartan 150 mg Tab 62332-0042-90 1 tab(s) $24 $0 $24 $14 irbesartan 150 mg Tab 68084-0217-21 1 tab(s) $24 $0 $24 $15 irbesartan 75 mg Tab 68180-0410-06 1 tab(s) $23 $0 $23 $14 irbesartan 75 mg Tab 68180-0410-09 1 tab(s) $23 $0 $23 $14 irbesartan 75 mg Tab 33342-0047-10 1 tab(s) $23 $0 $23 $14 iron sucrose 20 mg/mL Soln 00517-2340-25 5 mL $428 $0 $428 $257 isoniazid 100 mg Tab 51079-0082-20 1 tab(s) $4 $0 $4 $2 isoniazid 300 mg Tab 51079-0083-01 1 tab(s) $6 $0 $6 $3 isoniazid 300 mg Tab 00185-4350-30 1 tab(s) $5 $0 $5 $3 isoniazid 50 mg/5 mL Syrup 46287-0009-01 1 mL $7 $0 $7 $4 isosorbide dinitrate 20 mg Tab 00781-1695-10 1 tab(s) $11 $0 $11 $7 isosorbide dinitrate 20 mg Tab 63739-0367-10 1 tab(s) $10 $0 $10 $6 isosorbide dinitrate 20 mg Tab 68084-0083-01 1 tab(s) $12 $0 $12 $7 isosorbide dinitrate 30 mg Tab 00143-1773-01 1 tab(s) $7 $0 $7 $4 isosorbide dinitrate 5 mg Tab 00781-1635-01 1 tab(s) $4 $0 $4 $3 isosorbide dinitrate 5 mg Tab 68001-0373-00 1 tab(s) $10 $0 $10 $6

Page 87 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price isosorbide dinitrate 5 mg Tab 68084-0894-25 1 tab(s) $8 $0 $8 $5 isosorbide mononitrate 20 mg Tab 67286-0771-01 1 tab(s) $16 $0 $16 $10 isosorbide mononitrate 20 mg Tab 67857-0702-01 1 tab(s) $16 $0 $16 $10 isosorbide mononitrate 20 mg Tab 62175-0107-01 1 tab(s) $9 $0 $9 $5 isosorbide mononitrate 20 mg Tab 00228-2620-11 1 tab(s) $8 $0 $8 $5 isosorbide mononitrate 60 mg ER Ta 68084-0592-01 1 tab(s) $17 $0 $17 $10 isosorbide mononitrate 60 mg ER Ta 62175-0119-37 1 tab(s) $14 $0 $14 $8 isosorbide mononitrate 60 mg ER Ta 58177-0238-11 1 tab(s) $12 $0 $12 $7 isosorbide mononitrate 60 mg ER Ta 00143-2260-01 1 tab(s) $13 $0 $13 $8 isosorbide mononitrate 60 mg ER Ta 50268-0452-15 1 tab(s) $17 $0 $17 $10 isradipine 5 mg Cap 16252-0540-01 1 cap(s) $2 $0 $2 $1 isradipine 5 mg Cap 52152-0264-01 1 cap(s) $2 $0 $2 $1 itraconazole 100 mg Cap 10147-1700-03 1 cap(s) $66 $0 $66 $39 itraconazole 100 mg Cap 00185-0550-30 1 cap(s) $66 $0 $66 $39 itraconazole 100 mg Cap 67877-0454-30 1 cap(s) $165 $0 $165 $99 itraconazole 250 mg Kit 50458-0298-01 0 $1,566 $0 $1,566 $940 K Phos/Na Phos 1.25 gm packet (neutraphos) 00017-4300-01 1 packet(s) $7 $0 $7 $4 ketoconazole 200 mg Tab 51672-4026-06 1 tab(s) $25 $0 $25 $15 ketoconazole topical 2% Cream 51672-1298-02 1 app $374 $0 $374 $224 ketoconazole topical 2% Shamp 10147-0750-04 1 app $201 $0 $201 $121 ketoprofen 75 mg Cap 00093-3195-01 1 cap(s) $11 $0 $11 $6 ketorolac 10 mg Tab 00093-0314-01 1 tab(s) $10 $0 $10 $6 ketorolac 10 mg Tab 00004-0273-01 1 tab(s) $12 $0 $12 $7 ketorolac 10 mg Tab 00378-1134-01 1 tab(s) $10 $0 $10 $6 ketorolac 10 mg Tab 58177-0301-04 1 tab(s) $10 $0 $10 $6 ketorolac ophthalmic 0.45% Soln 00023-3507-30 1 drop(s) $62 $0 $62 $37 ketorolac ophthalmic 0.5% Soln 47335-0220-90 1 drop(s) $753 $0 $753 $452 l-methylfolate 15 mg Tab 76439-0358-90 1 tab(s) $23 $0 $23 $14 labetalol 100 mg Tab 60687-0114-01 1 tab(s) $7 $0 $7 $4 labetalol 100 mg Tab 60687-0439-01 1 tab(s) $7 $0 $7 $4 labetalol 200 mg Tab 00904-5929-61 1 tab(s) $9 $0 $9 $5 labetalol 200 mg Tab 68382-0799-01 1 tab(s) $11 $0 $11 $7 labetalol 300 mg Tab 68382-0800-01 1 tab(s) $11 $0 $11 $7 labetalol 300 mg Tab 60687-0461-01 1 tab(s) $11 $0 $11 $7 labetalol 300 mg Tab 60687-0136-01 1 tab(s) $8 $0 $8 $5 labetalol 300 mg Tab 00172-4366-60 1 tab(s) $10 $0 $10 $6 labetalol 5 mg/mL Soln 00409-2267-20 1 mL $9 $0 $9 $5 lacosamide 10 mg/mL Soln 00131-5410-70 1 mL $14 $0 $14 $8 lacosamide 10 mg/mL Soln 00131-5410-71 1 mL $15 $0 $15 $9 lacosamide 100 mg Tab 00131-2478-35 1 tab(s) $86 $0 $86 $51 lactase 3000 units Tab 00904-5224-52 1 tab(s) $4 $0 $4 $3 lactobacillus rhamnosus GG - Cap 49100-0400-09 1 cap(s) $7 $0 $7 $4 lactulose 10 g/15 mL Syrup 50383-0779-31 30 mL $13 $0 $13 $8 lactulose 10 g/15 mL Syrup 50383-0779-32 1.5 mL $5 $0 $5 $3 lactulose 10 g/15 mL Syrup 00121-1154-30 30 mL $11 $0 $11 $7 lamiVUDine 100 mg Tab 60505-3250-06 1 tab(s) $111 $0 $111 $67 lamiVUDine 150 mg Tab 60687-0362-21 1 tab(s) $59 $0 $59 $35 lamiVUDine 150 mg Tab 50268-0459-15 1 tab(s) $65 $0 $65 $39 lamoTRIgine 100 mg Tab 63739-0516-10 1 tab(s) $20 $0 $20 $12 lamoTRIgine 200 mg Tab 29300-0114-16 1 tab(s) $42 $0 $42 $25 lamoTRIgine 200 mg Tab 51672-4133-04 1 tab(s) $44 $0 $44 $27 lamoTRIgine 200 mg Tab 69102-0320-01 1 tab(s) $39 $0 $39 $24 lamoTRIgine 25 mg Tab 68084-0318-01 1 tab(s) $4 $0 $4 $3 lamoTRIgine 25 mg Tab 29300-0111-01 1 tab(s) $32 $0 $32 $19 lamoTRIgine 25 mg Tab 00093-0039-01 1 tab(s) $31 $0 $31 $19 lansoprazole 15 mg DIS T 00781-5733-13 1 tab(s) $43 $0 $43 $26 lansoprazole 15 mg REC Granules 00300-7309-30 1 packet(s) $44 $0 $44 $27 lansoprazole 30 mg REC GRANULES 00300-7311-30 1 packet(s) $39 $0 $39 $23 lanthanum carbonate 250 mg Chew Tab 54092-0247-01 1 tab(s) $11 $0 $11 $7 latanoprost ophthalmic 0.005% Soln 61314-0547-01 1 drop(s) $674 $0 $674 $404 leflunomide 10 mg Tab 23155-0043-03 1 tab(s) $113 $0 $113 $68 leflunomide 10 mg Tab 13811-0677-30 1 tab(s) $46 $0 $46 $27 letrozole 2.5 mg Tab 16729-0034-10 1 tab(s) $124 $0 $124 $75 letrozole 2.5 mg Tab 51991-0759-33 1 tab(s) $125 $0 $125 $75 leucovorin 25 mg Tab 00054-4499-11 1 tab(s) $169 $0 $169 $101 leucovorin 5 mg Tab 00054-4496-13 1 tab(s) $17 $0 $17 $10 levalbuterol 0.63 mg/3 mL Soln 76204-0800-01 3 mL $22 $0 $22 $13 levalbuterol 0.63 mg/3 mL Soln 76204-0800-25 3 mL $22 $0 $22 $13 levalbuterol 0.63 mg/3 mL Soln 00378-9681-44 3 mL $55 $0 $55 $33 levalbuterol 1.25 mg/3 mL Soln 00378-9682-44 3 mL $55 $0 $55 $33 levalbuterol 1.25 mg/3 mL Soln 00093-4148-64 3 mL $55 $0 $55 $33 levalbuterol 1.25 mg/3 mL Soln 76204-0900-01 3 mL $22 $0 $22 $13 levalbuterol 1.25 mg/3 mL Soln 76204-0900-25 3 mL $22 $0 $22 $13 levalbuterol 45 mcg/inh Aeros 00591-2927-54 1 puff(s) $524 $0 $524 $314 levETIRAcetam 100 mg/mL Soln 60687-0249-67 5 mL $53 $0 $53 $32 levETIRAcetam 100 mg/mL Soln 00472-0235-16 1 mL $9 $0 $9 $5 levETIRAcetam 250 mg Tab 51079-0820-20 1 tab(s) $455 $0 $455 $273 levETIRAcetam 250 mg Tab 63739-0795-10 1 tab(s) $5 $0 $5 $3 levETIRAcetam 500 mg / 5 mL Soln 17856-0574-01 5 mL $138 $0 $138 $83

Page 88 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price levETIRAcetam 500 mg / 5 mL Soln 17856-0241-05 5 mL $138 $0 $138 $83 levETIRAcetam 500 mg Tab 43547-0222-15 1 tab(s) $27 $0 $27 $16 levETIRAcetam 500 mg Tab 00904-6052-61 1 tab(s) $25 $0 $25 $15 levETIRAcetam 500 mg Tab 00378-5615-05 1 tab(s) $27 $0 $27 $16 levETIRAcetam 500 mg Tab 68084-0870-01 1 tab(s) $8 $0 $8 $5 levETIRAcetam 500 mg Tab 68001-0403-03 1 tab(s) $27 $0 $27 $16 levETIRAcetam 500 mg Tab 68001-0403-07 1 tab(s) $27 $0 $27 $16 levETIRAcetam 500 mg/5 mL Soln 66689-0028-50 5 mL $51 $0 $51 $30 levETIRAcetam 750 mg ER Ta 68001-0114-06 1 tab(s) $48 $0 $48 $29 levETIRAcetam 750 mg ER Ta 00228-2975-06 1 tab(s) $48 $0 $48 $29 levETIRAcetam 750 mg Tab 00904-6053-61 1 tab(s) $32 $0 $32 $19 levOCARNitine 100 mg/mL Soln 50383-0171-04 1 mL $6 $0 $6 $4 levOCARNitine 330 mg Tab 54482-0144-07 1 tab(s) $10 $0 $10 $6 levOCARNitine 330 mg Tab 64980-0130-09 1 tab(s) $9 $0 $9 $5 levofloxacin 25 mg/mL Soln 17478-0107-20 1 mL $65 $0 $65 $39 levoFLOXacin 25 mg/mL Soln 55150-0156-20 1 mL $65 $0 $65 $39 levofloxacin 25 mg/mL Soln 55150-0157-30 1 mL $63 $0 $63 $38 levofloxacin 250 mg Tab 00904-6351-61 1 tab(s) $102 $0 $102 $61 levofloxacin 500 mg Tab 68084-0482-01 1 tab(s) $130 $0 $130 $78 levoFLOXacin 500 mg Tab 65862-0537-50 1 tab(s) $132 $0 $132 $79 levofloxacin 750 mg/150 mL Soln 00781-3343-09 150 mL $154 $0 $154 $93 levofloxacin 750 mg/150 mL Soln 25021-0132-83 150 mL $144 $0 $144 $86 levofloxacin 750 mg/150 mL Soln 00143-9720-24 150 mL $154 $0 $154 $93 levofloxacin ophthalmic 0.5% Soln 68669-0135-05 1 drop(s) $382 $0 $382 $229 levothyroxine 100 mcg (0.1 mg) Tab 51079-0442-20 1 tab(s) $6 $0 $6 $4 levothyroxine 100 mcg (0.1 mg) Tab 00527-1345-01 1 tab(s) $5 $0 $5 $3 levothyroxine 112 mcg (0.112 mg) Tab 42292-0039-20 1 tab(s) $8 $0 $8 $5 levothyroxine 125 mcg (0.125 mg) Tab 51079-0443-01 1 tab(s) $6 $0 $6 $4 levothyroxine 125 mcg (0.125 mg) Tab 69238-1836-01 1 tab(s) $8 $0 $8 $5 levothyroxine 137 mcg Tab 69238-1837-01 1 tab(s) $8 $0 $8 $5 levothyroxine 137 mcg Tab 60687-0563-01 1 tab(s) $9 $0 $9 $5 levothyroxine 150 mcg (0.15 mg) Tab 00527-1349-01 1 tab(s) $6 $0 $6 $3 levothyroxine 200 mcg (0.2 mg) Tab 69238-1840-01 1 tab(s) $9 $0 $9 $5 levothyroxine 25 mcg (0.025 mg) Tab 69238-1830-01 1 tab(s) $6 $0 $6 $4 levothyroxine 25 mcg (0.025 mg) Tab 00527-1341-01 1 tab(s) $5 $0 $5 $3 levothyroxine 300 mcg (0.3 mg) Tab 69238-1841-01 1 tab(s) $11 $0 $11 $6 levothyroxine 50 mcg (0.05 mg) Tab 00527-1342-01 1 tab(s) $5 $0 $5 $3 levothyroxine 50 mcg (0.05 mg) Tab 00074-4552-90 1 tab(s) $11 $0 $11 $7 levothyroxine 75 mcg (0.075 mg) Tab 00378-1805-77 1 tab(s) $7 $0 $7 $4 levothyroxine 88 mcg (0.088 mg) Tab 60687-0486-01 1 tab(s) $8 $0 $8 $5 levothyroxine 88 mcg (0.088 mg) Tab 00074-6594-90 1 tab(s) $10 $0 $10 $6 levothyroxine 88 mcg (0.088 mg) Tab 42292-0038-20 1 tab(s) $7 $0 $7 $4 lidocaine 1% preservative-free Soln 00143-9595-25 5 mL $29 $0 $29 $17 lidocaine 1% preservative-free Soln 55150-0162-05 5 mL $27 $0 $27 $16 lidocaine 2% preservative-free Soln 00409-4903-34 1 mL $13 $0 $13 $8 lidocaine 2% preservative-free Soln 00548-3390-00 1 mL $15 $0 $15 $9 lidocaine 5 mL Injection 63323-0495-05 5 mL $107 $0 $107 $64 lidocaine 5% film 5% Patch 00378-9055-93 1 patch(es) $35 $0 $35 $21 lidocaine hcl 2% mucous membrane oral Soln 00603-1393-64 15 mL $106 $0 $106 $64 lidocaine hcl 2% mucous membrane oral Soln 50383-0775-04 15 mL $50 $0 $50 $30 lidocaine topical 2% Gel 00591-3012-26 5 mL $63 $0 $63 $38 lidocaine topical 4% Film 41167-0058-40 1 patch(es) $19 $0 $19 $11 lidocaine topical 4% Film 46122-0450-21 1 patch(es) $19 $0 $19 $11 lidocaine topical 5% Cream 00496-0892-30 1 app $159 $0 $159 $96 lidocaine topical 5% Film 00591-2679-30 1 patch(es) $73 $0 $73 $44 lidocaine topical 5% Film 00603-1880-16 1 patch(es) $73 $0 $73 $44 lidocaine Topical 5% Film 63481-0687-01 1 patch(es) $65 $0 $65 $39 lidocaine Topical 5% Film 63481-0687-06 1 patch(es) $68 $0 $68 $41 lidocaine-prilocaine topical 2.5%-2.5% Cream 50383-0667-30 1 app $330 $0 $330 $198 lidocaine-prilocaine topical 2.5%-2.5% Cream 17478-0190-55 1 app $61 $0 $61 $36 lidocaine-prilocaine topical 2.5%-2.5% Cream 00168-0357-55 1 app $77 $0 $77 $46 lidocaine-prilocaine topical 2.5%-2.5% Cream 00115-1468-45 1 app $332 $0 $332 $199 linagliptin 5 mg Tab 00597-0140-30 1 tab(s) $84 $0 $84 $50 lindane Topical 1% Lotio 00472-0570-02 1 app $223 $0 $223 $134 lindane Topical 1% Shamp 00472-0572-02 1 app $227 $0 $227 $136 linezolid 2 mg/mL Soln 00409-4882-01 300 mL $534 $0 $534 $320 linezolid 600 mg Tab 60687-0309-21 1 tab(s) $850 $0 $850 $510 linezolid 600 mg Tab 67877-0419-84 1 tab(s) $1,234 $0 $1,234 $740 liothyronine 25 mcg Tab 42794-0019-12 1 tab(s) $11 $0 $11 $6 liothyronine 25 mcg Tab 00574-0222-01 1 tab(s) $10 $0 $10 $6 liothyronine 5 mcg Tab 42794-0018-12 1 tab(s) $9 $0 $9 $5 liraglutide 18 mg/3 mL Soln 00169-4060-13 3 mL $401 $0 $401 $241 lisinopril 10 mg Tab 00904-6485-61 1 tab(s) $7 $0 $7 $4 lisinopril 10 mg Tab 60687-0325-01 1 tab(s) $4 $0 $4 $3 lisinopril 20 mg Tab 51079-0983-20 1 tab(s) $10 $0 $10 $6 lisinopril 20 mg Tab 60687-0333-01 1 tab(s) $4 $0 $4 $3 lisinopril 20 mg Tab 68001-0335-00 1 tab(s) $10 $0 $10 $6 lisinopril 20 mg Tab 00904-6486-61 1 tab(s) $4 $0 $4 $2 lisinopril 20 mg Tab 00904-6799-61 1 tab(s) $4 $0 $4 $2

Page 89 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price lisinopril 40 mg Tab 51079-0984-20 1 tab(s) $13 $0 $13 $8 lisinopril 5 mg Tab 68001-0333-00 1 tab(s) $10 $0 $10 $6 lisinopril 5 mg Tab 68001-0333-08 1 tab(s) $10 $0 $10 $6 lithium 150 mg Cap 00054-2526-25 1 cap(s) $4 $0 $4 $3 lithium 150 mg Cap 00054-8526-25 1 cap(s) $5 $0 $5 $3 lithium 300 mg Cap 63739-0265-10 1 cap(s) $5 $0 $5 $3 lithium 300 mg ER Ta 00054-0021-25 1 tab(s) $6 $0 $6 $4 lithium 450 mg ER Ta 68084-0655-01 1 tab(s) $8 $0 $8 $5 loperamide 1 mg / 7.5 mL Susp 00904-6836-20 7.5 mL $38 $0 $38 $23 loperamide 2 mg Cap 00093-0311-01 1 cap(s) $7 $0 $7 $4 loperamide 2 mg Cap 51079-0690-01 1 cap(s) $6 $0 $6 $3 loperamide 2 mg Cap 51079-0690-19 1 cap(s) $5 $0 $5 $3 loperamide 2 mg Cap 51079-0690-20 1 cap(s) $8 $0 $8 $5 loperamide 2 mg Cap 60687-0229-01 1 cap(s) $9 $0 $9 $6 lopinavir-ritonavir 133.3 mg-33.3 mg Cap 00074-3959-77 1 cap(s) $33 $0 $33 $20 lopinavir-ritonavir 400 mg-100 mg/5 mL LIQ 00074-3956-46 1 mL $24 $0 $24 $14 loratadine 10 mg Tab 00904-6074-61 1 tab(s) $9 $0 $9 $5 loratadine 10 mg Tab 00904-5793-61 1 tab(s) $9 $0 $9 $5 loratadine 10 mg Tab 51079-0246-20 1 tab(s) $9 $0 $9 $5 loratadine 10 mg Tab 51079-0538-01 1 tab(s) $9 $0 $9 $5 loratadine 10 mg Tab 68084-0248-01 1 tab(s) $8 $0 $8 $5 loratadine 10 mg Tab 68084-0248-11 1 tab(s) $8 $0 $8 $5 loratadine 5 mg Chew 41100-0809-55 1 tab(s) $9 $0 $9 $5 loratadine 5 mg Chew 11523-4328-01 1 tab(s) $11 $0 $11 $6 LORazepam 0.5 mg Tab 68084-0736-01 1 tab(s) $7 $0 $7 $4 LORazepam 0.5 mg Tab 51079-0417-01 1 tab(s) $9 $0 $9 $6 LORazepam 0.5 mg Tab 51079-0417-20 1 tab(s) $9 $0 $9 $6 LORazepam 0.5 mg Tab 51079-0417-21 1 tab(s) $9 $0 $9 $6 LORazepam 0.5 mg Tab 00904-6007-60 1 tab(s) $9 $0 $9 $5 LORazepam 0.5 mg Tab 00591-0240-01 1 tab(s) $9 $0 $9 $5 lorazepam 1 mg Tab 64455-0064-01 1 tab(s) $15 $0 $15 $9 lorazepam 1 mg Tab 63739-0155-10 1 tab(s) $11 $0 $11 $6 LORazepam 1 mg Tab 60687-0355-01 1 tab(s) $6 $0 $6 $3 LORazepam 1 mg Tab 00591-0241-05 1 tab(s) $11 $0 $11 $6 LORazepam 1 mg Tab 00904-6008-61 1 tab(s) $5 $0 $5 $3 LORazepam 2 mg Soln 00121-0770-01 1 mL $14 $0 $14 $8 lorazepam 2 mg Tab 51079-0387-20 1 tab(s) $14 $0 $14 $8 LORazepam 2 mg/mL Conc 65162-0687-84 1 mL $16 $0 $16 $9 LORazepam 2 mg/mL Conc 00054-3532-44 1 mL $15 $0 $15 $9 LORazepam 2 mg/mL Conc 50383-0705-30 1 mL $16 $0 $16 $9 LORazepam 2 mg/mL Soln 17478-0040-01 1 mL $13 $0 $13 $8 LORazepam 2 mg/mL Soln 00641-6046-10 1 mL $10 $0 $10 $6 LORazepam 2 mg/mL Soln 00641-6048-25 1 mL $11 $0 $11 $7 LORazepam 2 mg/mL Soln 00409-6778-02 1 mL $14 $0 $14 $8 losartan 25 mg Tab 00904-6391-61 1 tab(s) $8 $0 $8 $5 losartan 25 mg Tab 68382-0135-16 1 tab(s) $15 $0 $15 $9 losartan 25 mg Tab 68084-0346-01 1 tab(s) $15 $0 $15 $9 losartan 25 mg Tab 65862-0201-90 1 tab(s) $15 $0 $15 $9 losartan 50 mg Tab 65862-0202-90 1 tab(s) $18 $0 $18 $11 losartan 50 mg Tab 65862-0202-99 1 tab(s) $18 $0 $18 $11 losartan 50 mg Tab 68084-0347-01 1 tab(s) $18 $0 $18 $11 losartan 50 mg Tab 68382-0136-16 1 tab(s) $18 $0 $18 $11 losartan 50 mg Tab 00781-5701-92 1 tab(s) $18 $0 $18 $11 loteprednol ophthalmic 0.5% Susp 24208-0299-15 1 drop(s) $630 $0 $630 $378 loteprednol ophthalmic 0.5% Susp 24208-0299-25 1 drop(s) $548 $0 $548 $329 loteprednol ophthalmic 0.5% Susp 68682-0299-10 1 drop(s) $3,603 $0 $3,603 $2,162 lovastatin 20 mg Tab 68001-0315-00 1 tab(s) $19 $0 $19 $12 loxapine 5 mg Cap 52544-0494-01 1 cap(s) $14 $0 $14 $8 lubiprostone 24 mcg Cap 64764-0240-60 1 cap(s) $30 $0 $30 $18 lurasidone 20 mg Tab 63402-0302-30 1 tab(s) $347 $0 $347 $208 LVP solution Dextrose 5% in Water Soln 00409-7100-67 100 mL $30 $0 $30 $18 LVP solution Dextrose 5% in Water Soln 00338-0017-02 250 mL $47 $0 $47 $28 LVP solution Dextrose 5% in Water Soln 00338-0017-04 1000 mL $30 $0 $30 $18 LVP solution Dextrose 5% in Water Soln 00338-0017-38 100 mL $30 $0 $30 $18 LVP solution Dextrose 5% with 0.45% NaCl Soln 00338-0085-03 500 mL $100 $0 $100 $60 LVP solution Dextrose 5% with 0.45% NaCl Soln 00338-0085-04 1000 mL $30 $0 $30 $18 LVP solution Dextrose 5% with 0.9% NaCl Soln 00409-7941-09 1000 mL $30 $0 $30 $18 LVP solution Lactated Ringers Injection Soln 00264-7750-00 1000 mL $30 $0 $30 $18 LVP solution Lactated Ringers Injection Soln 00264-7750-10 500 mL $49 $0 $49 $30 LVP solution Lactated Ringers Injection Soln 00338-0117-04 1000 mL $30 $0 $30 $18 LVP solution Sodium Chloride 0.45% Soln 00409-7985-09 1000 mL $100 $0 $100 $60 LVP solution Sodium Chloride 0.9% Soln 00409-7101-02 250 mL $47 $0 $47 $28 LVP solution Sodium Chloride 0.9% Soln 00409-7101-67 100 mL $44 $0 $44 $26 LVP solution Sodium Chloride 0.9% Soln 00409-7983-03 500 mL $65 $0 $65 $39 LVP solution Sodium Chloride 0.9% Soln 00409-7983-09 1000 mL $100 $0 $100 $60 LVP solution Sodium Chloride 0.9% Soln 00264-7800-09 1000 mL $30 $0 $30 $18 LVP solution Sodium Chloride 0.9% Soln 00264-7800-10 500 mL $100 $0 $100 $60 LVP solution Sodium Chloride 0.9% Soln 00264-1800-31 50 mL $68 $0 $68 $41 LVP solution Sodium Chloride 0.9% Soln 00264-1800-32 100 mL $100 $0 $100 $60

Page 90 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price LVP solution Sodium Chloride 0.9% Soln 00338-0553-18 100 mL $79 $0 $79 $47 LVP solution Sodium Chloride 0.9% Soln 00338-0049-02 250 mL $47 $0 $47 $28 LVP solution Sodium Chloride 0.9% Soln 00338-0049-04 1000 mL $30 $0 $30 $18 LVP solution Sodium Chloride 0.9% Soln 00338-0049-31 50 mL $44 $0 $44 $26 LVP solution Sodium Chloride 0.9% Soln 00338-0049-48 100 mL $100 $0 $100 $60 LVP solution Sodium Chloride 0.9% Soln 63323-0623-75 500 mL $65 $0 $65 $39 magnesium citrate 8.85% Soln 00869-0166-38 296 mL $108 $0 $108 $65 magnesium citrate - LIQ 00904-6043-77 296 mL $25 $0 $25 $15 magnesium gluconate 500 mg Tab 60258-0172-01 1 tab(s) $4 $0 $4 $2 magnesium hydroxide 8% Susp 66689-0053-99 30 mL $23 $0 $23 $14 magnesium hydroxide 8% Susp 00182-0833-39 30 mL $7 $0 $7 $4 magnesium hydroxide 8% Susp 00182-0833-40 30 mL $7 $0 $7 $4 magnesium hydroxide 8% Susp 00182-6084-39 30 mL $7 $0 $7 $4 magnesium lactate 84 mg ER Ta 59016-0420-19 1 tab(s) $5 $0 $5 $3 magnesium oxide 400 mg Tab 60258-0171-01 1 tab(s) $4 $0 $4 $3 magnesium oxide 400 mg Tab 64980-0339-01 1 tab(s) $4 $0 $4 $3 magnesium oxide 400 mg Tab 10006-0700-28 1 tab(s) $4 $0 $4 $2 magnesium sulfate - Powde 00869-3105-10 2 scoop(s) $8 $0 $8 $5 magnesium sulfate 2 g/50 mL-sterile water Soln 44567-0420-24 50 mL $189 $0 $189 $114 magnesium sulfate 2 g/50 mL-sterile water Soln 63323-0106-05 50 mL $186 $0 $186 $112 magnesium sulfate 50% Soln 63323-0064-23 1 mL $13 $0 $13 $8 magnesium sulfate 50% Soln 00409-1754-10 1 mL $11 $0 $11 $6 manganese chloride 0.1 mg/mL Soln 00409-4091-01 1 mL $30 $0 $30 $18 manganese sulfate 0.1 mg/mL Soln 00517-6410-25 1 mL $30 $0 $30 $18 Mask - Test 99345-0004-05 1 EA $0 $0 $0 $0 measles/mumps/rubella virus vaccine - REC I 00006-4681-00 0.5 mL $427 $0 $427 $256 meclizine 12.5 mg Tab 69618-0027-01 1 tab(s) $3 $0 $3 $2 meclizine 12.5 mg Tab 68084-0490-01 1 tab(s) $8 $0 $8 $5 meclizine 25 mg Tab 68084-0491-01 1 tab(s) $9 $0 $9 $5 meclizine 25 mg Tab 51079-0511-20 1 tab(s) $9 $0 $9 $5 meclizine 25 mg Tab 51079-0090-01 1 tab(s) $274 $0 $274 $164 meclizine 25 mg Tab 51079-0090-20 1 tab(s) $5 $0 $5 $3 medroxyPROGESTERone 10 mg Tab 00009-0050-02 1 tab(s) $14 $0 $14 $8 medroxyPROGESTERone 10 mg Tab 00555-0779-02 1 tab(s) $7 $0 $7 $4 medroxyPROGESTERone 150 mg/mL Susp 00009-0746-30 1 mL $467 $0 $467 $280 medroxyPROGESTERone 2.5 mg Tab 59762-3740-01 1 tab(s) $5 $0 $5 $3 medroxyPROGESTERone 5 mg Tab 00009-0286-03 1 tab(s) $11 $0 $11 $7 megestrol 40 mg Tab 51079-0435-01 1 tab(s) $11 $0 $11 $6 megestrol 40 mg Tab 51079-0435-20 1 tab(s) $11 $0 $11 $6 megestrol 40 mg Tab 63739-0165-10 1 tab(s) $10 $0 $10 $6 megestrol 40 mg/mL Susp 66689-0020-50 10 mL $35 $0 $35 $21 megestrol 40 mg/mL Susp 00121-4776-35 10 mL $35 $0 $35 $21 megestrol 400 mg/10 mL Susp 00121-4776-10 10 mL $73 $0 $73 $44 melatonin 1 mg Tab 74312-0028-32 1 tab(s) $4 $0 $4 $2 melatonin 1 mg Tab 80681-0041-00 1 tab(s) $3 $0 $3 $2 melatonin 3 mg Tab 87701-0408-13 1 tab(s) $4 $0 $4 $2 melatonin 3 mg Tab 68094-0110-61 1 tab(s) $5 $0 $5 $3 melatonin 3 mg Tab 20555-0036-00 1 tab(s) $4 $0 $4 $3 melatonin 5 mg Tab 50268-0533-15 1 tab(s) $6 $0 $6 $4 melatonin 5 mg Tab 87701-0408-14 1 tab(s) $4 $0 $4 $2 melatonin 5 mg Tab 77333-0520-10 1 tab(s) $5 $0 $5 $3 meloxicam 7.5 mg Tab 63739-0701-10 1 tab(s) $4 $0 $4 $3 memantine 10 mg Tab 00904-6506-61 1 tab(s) $10 $0 $10 $6 memantine 10 mg Tab 00045-6321-01 1 tab(s) $23 $0 $23 $14 memantine 10 mg Tab 00456-3210-11 1 tab(s) $23 $0 $23 $14 memantine 10 mg Tab 00456-3210-63 1 tab(s) $22 $0 $22 $13 memantine 2 mg/mL Soln 00456-3202-12 1 mL $13 $0 $13 $8 memantine 5 mg Tab 00456-3205-63 1 tab(s) $25 $0 $25 $15 memantine 5 mg Tab 00904-6505-61 1 tab(s) $6 $0 $6 $3 memantine 5 mg Tab 60687-0173-57 1 tab(s) $9 $0 $9 $5 meningococcal conjugate vaccine - Soln 49281-0589-05 0.5 mL $985 $0 $985 $591 meningococcal group B vaccine fully recombinant Susp 00005-0100-05 0.5 mL $1,268 $0 $1,268 $761 mercaptopurine 50 mg Tab 00054-4581-11 1 tab(s) $29 $0 $29 $17 mercaptopurine 50 mg Tab 00378-3547-52 1 tab(s) $31 $0 $31 $18 meropenem 1000 mg REC I 63323-0508-30 10 mL $193 $0 $193 $116 meropenem 1000 mg REC I 63323-0508-31 10 mL $232 $0 $232 $139 meropenem 500 mg REC I 63323-0507-20 10 mL $128 $0 $128 $77 meropenem 500 mg REC I 63323-0507-21 10 mL $147 $0 $147 $88 mesalamine 1000 mg Supp 58914-0501-56 1 supp $76 $0 $76 $46 mesalamine 1000 mg Supp 70710-1302-07 1 supp $259 $0 $259 $156 metaproterenol 5% Soln 00597-0071-75 1 mL $154 $0 $154 $92 metFORMIN 500 mg ER Ta 51224-0007-50 1 tab(s) $8 $0 $8 $5 metFORMIN 500 mg ER Ta 62756-0142-01 1 tab(s) $8 $0 $8 $5 metFORMIN 500 mg Tab 60687-0155-01 1 tab(s) $8 $0 $8 $5 metFORMIN 500 mg Tab 00904-6689-61 1 tab(s) $4 $0 $4 $2 metFORMIN 500 mg Tab 23155-0102-01 1 tab(s) $8 $0 $8 $5 metFORMIN 750 mg ER Ta 62756-0143-01 1 tab(s) $11 $0 $11 $7 metFORMIN 850 mg Tab 67877-0562-01 1 tab(s) $11 $0 $11 $7 metFORMIN ER 500 mg ER Tablet 50268-0531-15 1 tab(s) $4 $0 $4 $2

Page 91 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price methadone 10 mg Tab 00406-5771-62 1 tab(s) $8 $0 $8 $5 methadone 10 mg/5 mL Soln 00054-3556-63 5 mL $5 $0 $5 $3 methadone 10 mg/mL Conc 00054-3553-44 1 mL $11 $0 $11 $6 methadone 10 mg/mL Conc 66689-0694-30 1 mL $28 $0 $28 $17 methadone 5 mg Tab 00406-5755-01 1 tab(s) $7 $0 $7 $4 methadone 5 mg/5 mL Soln 66689-0711-16 1 mL $5 $0 $5 $3 methenamine 1 gm Tab 64720-0139-10 1 tab(s) $17 $0 $17 $10 methenamine hippurate 1 g Tab 64980-0119-01 1 tab(s) $15 $0 $15 $9 methenamine hippurate 1 g Tab 65862-0782-01 1 tab(s) $17 $0 $17 $10 methenamine hippurate 1 g Tab 00068-0277-61 1 tab(s) $15 $0 $15 $9 methenamine hippurate 1 g Tab 42571-0332-01 1 tab(s) $17 $0 $17 $10 methenamine mandelate 0.5 g Tab 00430-0166-24 1 tab(s) $7 $0 $7 $4 methimazole 10 mg Tab 49884-0641-01 1 tab(s) $9 $0 $9 $5 methimazole 10 mg Tab 68084-0276-01 1 tab(s) $9 $0 $9 $5 methocarbamol 500 mg Tab 70010-0754-01 1 tab(s) $7 $0 $7 $4 methocarbamol 500 mg Tab 31722-0533-01 1 tab(s) $7 $0 $7 $4 methocarbamol 750 mg Tab 60687-0568-01 1 tab(s) $6 $0 $6 $3 methotrexate 25 mg/mL Soln 61703-0350-38 1 mL $44 $0 $44 $27 methyldopa 250 mg Tab 51079-0200-01 1 tab(s) $6 $0 $6 $4 methyldopa 250 mg Tab 51079-0200-20 1 tab(s) $6 $0 $6 $3 methyldopa 250 mg Tab 16729-0030-01 1 tab(s) $6 $0 $6 $3 methylphenidate (30/70 release) 10 mg/24 hr ER Ca 00527-4579-37 1 cap(s) $45 $0 $45 $27 methylphenidate 10 mg Tab 00406-1144-01 1 tab(s) $8 $0 $8 $5 methylphenidate 10 mg Tab 31722-0174-01 1 tab(s) $12 $0 $12 $7 methylphenidate 10 mg Tab 00781-5749-01 1 tab(s) $8 $0 $8 $5 methylphenidate 10 mg/24 hr ER Ca 00093-5295-01 1 cap(s) $44 $0 $44 $26 methylphenidate 18 mg/24 hr ER Ta 00591-2715-01 1 tab(s) $48 $0 $48 $29 methylphenidate 18 mg/24 hr ER Tab 17314-5850-02 1 tab(s) $29 $0 $29 $17 methylphenidate 2.5 mg Chew 64980-0221-01 1 tab(s) $25 $0 $25 $15 methylphenidate 20 mg/24 hr ER Ca 00078-0370-05 1 cap(s) $26 $0 $26 $16 methylphenidate 20 mg/24 hr ER Capsule 00093-3230-01 1 cap(s) $80 $0 $80 $48 methylphenidate 36 mg/24 hr ER Ta 68084-0829-25 1 tab(s) $64 $0 $64 $38 methylphenidate 5 mg Tab 68084-0805-21 1 tab(s) $15 $0 $15 $9 methylphenidate 5 mg Tab 31722-0173-01 1 tab(s) $10 $0 $10 $6 methylphenidate 5 mg Tab 00781-5748-01 1 tab(s) $7 $0 $7 $4 methylphenidate ER 18 mg ER Tablet 50458-0585-01 1 tab(s) $52 $0 $52 $31 methylphenidate ER/24hr 20 mg/24 hr ER Capsule 70010-0013-01 1 cap(s) $96 $0 $96 $57 methylPREDNISolone 1 g REC I 63323-0265-30 16 mL $296 $0 $296 $177 methylPREDNISolone 125 mg preservative-free REC I 00009-0047-26 2 mL $89 $0 $89 $54 methylPREDNISolone 4 mg Tab 00009-0056-02 1 tab(s) $12 $0 $12 $7 methylPREDNISolone 4 mg Tab 00603-4593-21 1 tab(s) $13 $0 $13 $8 methylPREDNISolone 4 mg Tab 00904-6914-61 1 tab(s) $18 $0 $18 $11 methylPREDNISolone 4 mg Tab 68084-0149-01 1 tab(s) $18 $0 $18 $11 methylPREDNISolone 40 mg preservative-free REC I 00009-0039-28 1 mL $33 $0 $33 $20 methylPREDNISolone 40 mg preservative-free REC I 00009-0039-32 1 mL $33 $0 $33 $20 methylPREDNISolone 40 mg/mL Susp 00009-3073-01 1 mL $71 $0 $71 $43 methylPREDNISolone 40 mg/mL Susp 00703-0031-01 1 mL $41 $0 $41 $25 methylPREDNISolone 80 mg/mL Susp 00009-3475-01 1 mL $118 $0 $118 $71 metoclopramide 10 mg Soln 68094-0676-59 10 mL $768 $0 $768 $461 metoclopramide 10 mg Tab 68084-0676-01 1 tab(s) $5 $0 $5 $3 metoclopramide 10 mg Tab 63739-0482-10 1 tab(s) $5 $0 $5 $3 metoclopramide 10 mg Tab 00093-2203-01 1 tab(s) $4 $0 $4 $2 metoclopramide 5 mg/5 mL Syrup 66689-0031-50 10 mL $9 $0 $9 $6 metolazone 2.5 mg Tab 51079-0023-20 1 tab(s) $13 $0 $13 $8 metoprolol 1 mg/mL Soln 00143-9873-01 5 mL $358 $0 $358 $215 metoprolol 1 mg/mL Soln 00409-1778-35 5 mL $40 $0 $40 $24 metoprolol 1 mg/mL Soln 55390-0073-10 5 mL $25 $0 $25 $15 metoprolol 100 mg ER Ta 50268-0542-15 1 tab(s) $15 $0 $15 $9 metoprolol 100 mg ER Tablet 68084-0673-01 1 tab(s) $15 $0 $15 $9 metoprolol 100 mg Tab 51079-0802-20 1 tab(s) $9 $0 $9 $5 metoprolol 100 mg Tab 62584-0267-01 1 tab(s) $4 $0 $4 $2 metoprolol 25 mg Tab 62584-0265-01 1 tab(s) $4 $0 $4 $2 metoprolol 50 mg ER Ta 00904-6323-61 1 tab(s) $12 $0 $12 $7 metoprolol 50 mg Tab 00904-6341-61 1 tab(s) $8 $0 $8 $5 metoprolol 50 mg Tab 62584-0266-01 1 tab(s) $4 $0 $4 $2 metoprolol 50 mg Tab 57664-0166-52 1 tab(s) $7 $0 $7 $4 metoprolol SUCCINATE 25 mg ER Tablet 60687-0390-01 1 tab(s) $11 $0 $11 $6 metoprolol SUCCINATE 100 mg ER Tablet 60687-0413-01 1 tab(s) $15 $0 $15 $9 metroNIDAZOLE 250 mg Tab 60687-0526-01 1 tab(s) $7 $0 $7 $4 metroNIDAZOLE 500 mg Tab 60687-0550-01 1 tab(s) $10 $0 $10 $6 metroNIDAZOLE 500 mg Tab 60687-0424-01 1 tab(s) $10 $0 $10 $6 metroNIDAZOLE 500 mg Tab 68001-0365-00 1 tab(s) $8 $0 $8 $5 metroNIDAZOLE topical 0.75% Gel 68682-0455-70 1 app $1,073 $0 $1,073 $644 metroNIDAZOLE topical 1% Gel 00299-3820-60 1 app $1,429 $0 $1,429 $858 mexiletine 150 mg Cap 00527-4107-37 1 cap(s) $20 $0 $20 $12 mexiletine 150 mg Cap 00093-8739-01 1 cap(s) $9 $0 $9 $6 mexiletine 200 mg Cap 00093-8740-01 1 cap(s) $14 $0 $14 $8 micafungin 100 mg REC I 00469-3211-99 5 mL $1,636 $0 $1,636 $982 micafungin 50 mg REC I 00469-3250-50 5 mL $836 $0 $836 $501

Page 92 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price miconazole topical 100 mg Supp 00713-0197-57 1 supp $47 $0 $47 $28 miconazole topical 2% Cream 00472-0735-56 1 app $32 $0 $32 $19 midazolam 5 mg/mL preservative-free Soln 00409-2308-49 1 mL $17 $0 $17 $10 midodrine 10 mg Tab 49884-0874-01 1 tab(s) $36 $0 $36 $21 midodrine 2.5 mg Tab 60687-0387-01 1 tab(s) $4 $0 $4 $3 midodrine 5 mg Tab 00245-0212-11 1 tab(s) $31 $0 $31 $19 midodrine 5 mg Tab 00378-1902-01 1 tab(s) $20 $0 $20 $12 midodrine 5 mg Tab 49884-0849-01 1 tab(s) $20 $0 $20 $12 midodrine 5 mg Tab 60687-0398-01 1 tab(s) $9 $0 $9 $6 midodrine 5 mg Tab 60505-1321-01 1 tab(s) $20 $0 $20 $12 miglitol 50 mg Tab 00009-5013-01 1 tab(s) $9 $0 $9 $6 milrinone 1 mg/mL Soln 63323-0617-10 1 mL $74 $0 $74 $45 milrinone 200 mcg/mL-D5% Soln 00143-9719-10 0 $134 $0 $134 $80 mineral oil 100% LIQ 48433-0202-30 30 mL $11 $0 $11 $7 mineral oil 100% LIQ 54162-0190-16 1 mL $5 $0 $5 $3 mineral oil/petrolatum/phenylephrine topical 14%-74.9%-0.25% Ointm 45802-0188-16 1 app $40 $0 $40 $24 minocycline 100 mg Cap 60687-0336-65 1 cap(s) $12 $0 $12 $7 minocycline 100 mg Cap 65862-0211-50 1 cap(s) $26 $0 $26 $16 minocycline 50 mg Cap 63304-0694-01 1 cap(s) $15 $0 $15 $9 minocycline 50 mg Cap 00591-5694-01 1 cap(s) $15 $0 $15 $9 minoxidil 10 mg Tab 00591-5643-01 1 tab(s) $12 $0 $12 $7 minoxidil 10 mg Tab 49884-0257-01 1 tab(s) $15 $0 $15 $9 minoxidil 10 mg Tab 68084-0205-01 1 tab(s) $18 $0 $18 $11 minoxidil 2.5 mg Tab 68084-0204-01 1 tab(s) $15 $0 $15 $9 minoxidil 2.5 mg Tab 68084-0204-11 1 tab(s) $15 $0 $15 $9 minoxidil 2.5 mg Tab 00591-5642-01 1 tab(s) $7 $0 $7 $4 mirabegron 25 mg ER Ta 00469-2601-90 1 tab(s) $59 $0 $59 $36 mirtazapine 15 mg DIS T 57237-0011-06 1 tab(s) $19 $0 $19 $11 mirtazapine 15 mg Tab 68084-0119-01 1 tab(s) $22 $0 $22 $13 mirtazapine 30 mg DIS T 57237-0012-06 1 tab(s) $20 $0 $20 $12 mirtazapine 30 mg Tab 68084-0120-01 1 tab(s) $3 $0 $3 $2 Miscellaneous OTC Item 1 Tab 99345-0001-13 1 EA $37 $0 $37 $22 Miscellaneous Pt Own 1 Device 99345-0001-11 1 EA $0 $0 $0 $0 misoprostol 100 mcg Tab 68084-0040-01 1 tab(s) $10 $0 $10 $6 misoprostol 100 mcg Tab 59762-5007-01 1 tab(s) $9 $0 $9 $5 modafinil 100 mg Tab 60505-2526-03 1 tab(s) $189 $0 $189 $114 modafinil 100 mg Tab 00904-6791-04 1 tab(s) $83 $0 $83 $50 mometasone Topical 0.1% Ointm 00085-0370-01 1 app $234 $0 $234 $140 montelukast 10 mg Tab 68084-0875-01 1 tab(s) $40 $0 $40 $24 montelukast 4 mg Chew 50268-0573-15 1 tab(s) $28 $0 $28 $17 montelukast 5 mg Chew 00093-7425-98 1 tab(s) $41 $0 $41 $25 montelukast Chew Tab 5 mg Tab 50268-0574-15 1 tab(s) $31 $0 $31 $19 morphine 10 mg/12 to 24 hr ER Ca 00228-3501-06 1 cap(s) $35 $0 $35 $21 morphine 10 mg/5 mL Soln 00054-3785-63 1 mL $5 $0 $5 $3 morphine 10 mg/5 ml Soln 00054-0237-63 1 mL $275 $0 $275 $165 morphine 10 mg/5 mL Soln 68094-0001-62 5 mL $16 $0 $16 $10 morphine 100 mg/8 hr ER Ta 42858-0804-01 1 tab(s) $69 $0 $69 $41 morphine 15 mg/8 hr ER Ta 68084-0403-01 1 tab(s) $17 $0 $17 $10 morphine 15 mg/8 to 12 hr ER Ta 68084-0157-01 1 tab(s) $17 $0 $17 $10 morphine 20 mg/mL Conc 00406-8003-30 1 mL $10 $0 $10 $6 morphine 20 mg/mL Conc 00406-0830-12 1 mL $9 $0 $9 $5 morphine 20 mg/mL Conc 00054-0404-44 1 mL $10 $0 $10 $6 morphine 20 mg/mL Conc 66479-0560-12 1 mL $9 $0 $9 $5 morphine 20 mg/mL Conc 58177-0886-56 1 mL $18 $0 $18 $11 morphine 30 mg ER/8-12 hr Tab 68084-0404-01 1 tab(s) $17 $0 $17 $10 morphine 30 mg/8 to 12 hr ER Ta 68084-0158-01 1 tab(s) $15 $0 $15 $9 morphine 5 mg Soln 99345-0001-45 2.5 mL $15 $0 $15 $9 moxifloxacin ophthalmic 0.5% Soln 68180-0422-01 1 drop(s) $1,181 $0 $1,181 $709 multivitamin 1 tab(s) Tab 62107-0047-01 1 tab(s) $41 $0 $41 $25 multivitamin Multiple Vitamins Chew 00904-2621-70 1 tab(s) $4 $0 $4 $2 multivitamin Multiple Vitamins Soln 54643-5650-02 1 mL $15 $0 $15 $9 multivitamin Pediatric Multiple Vitamins LIQ 00870-4026-53 1 mL $84 $0 $84 $50 multivitamin Pediatric Multiple Vitamins LIQ 00087-0402-03 1 mL $6 $0 $6 $3 multivitamin Pediatric Multiple Vitamins Soln 54643-5646-01 1 mL $1,032 $0 $1,032 $619 multivitamin Pediatric Multiple Vitamins Soln 54643-5647-00 1 mL $1,032 $0 $1,032 $619 multivitamin Vitamin B Complex with C and Folic Acid Cap 60258-0162-01 1 cap(s) $8 $0 $8 $5 multivitamin Vitamin B Complex with C and Folic Acid Tab 13811-0515-10 1 tab(s) $6 $0 $6 $4 multivitamin with iron 1 tab(s) Tab 62107-0048-01 1 tab(s) $29 $0 $29 $18 multivitamin with minerals Therapeutic Multiple Vitamins with Minerals Tab 00904-5486-52 1 tab(s) $4 $0 $4 $3 multivitamin with minerals Therapeutic Multiple Vitamins with Minerals Tab 00005-4451-71 1 tab(s) $4 $0 $4 $2 mupirocin topical 2% Cream 00029-1527-22 1 app $1,198 $0 $1,198 $719 mupirocin topical 2% Ointm 68462-0180-22 1 app $307 $0 $307 $184 mycophenolate mofetil 250 mg Cap 70748-0186-01 1 cap(s) $30 $0 $30 $18 mycophenoLATE mofetil [Cellcept] 500 mg Tab 60687-0438-01 1 tab(s) $14 $0 $14 $8 mycophenolate mofetil 250 mg Cap 67877-0266-01 1 cap(s) $30 $0 $30 $18 mycophenolate mofetil 250 mg Cap 51079-0721-01 1 cap(s) $30 $0 $30 $18 mycophenolate mofetil 250 mg Cap 00093-7334-01 1 cap(s) $30 $0 $30 $18 mycophenolate mofetil 500 mg Tab 00378-4472-01 1 tab(s) $56 $0 $56 $34 mycophenolate mofetil 500 mg Tab 16729-0019-01 1 tab(s) $22 $0 $22 $13

Page 93 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price mycophenolate mofetil 500 mg Tab 00781-5175-01 1 tab(s) $56 $0 $56 $34 mycophenolate mofetil 500 mg Tab 64380-0725-06 1 tab(s) $56 $0 $56 $34 mycophenolate mofetil 500 mg Tab 67877-0225-01 1 tab(s) $57 $0 $57 $34 mycophenolate mofetil 500 mg Tab 68084-0801-01 1 tab(s) $14 $0 $14 $8 mycophenolic acid 180 mg EC Ta 68084-0907-21 1 tab(s) $37 $0 $37 $22 mycophenolic acid 180 mg EC Ta 16729-0261-29 1 tab(s) $34 $0 $34 $20 mycophenolic acid 360 mg EC Ta 16729-0189-29 1 tab(s) $65 $0 $65 $39 mycophenolic acid 360 mg EC Ta 60505-2966-07 1 tab(s) $65 $0 $65 $39 N95 Mask - Test 99345-0004-15 1 EA $0 $0 $0 $0 nadolol 40 mg Tab 51079-0813-01 1 tab(s) $11 $0 $11 $6 nadolol 40 mg Tab 51079-0813-20 1 tab(s) $11 $0 $11 $6 nadolol 40 mg Tab 00378-1171-01 1 tab(s) $10 $0 $10 $6 nadolol 40 mg Tab 00172-4236-60 1 tab(s) $10 $0 $10 $6 nafcillin 1 g REC I 00781-3124-95 0 $124 $0 $124 $74 nafcillin 2 g REC Inj 00781-3125-95 0 $125 $0 $125 $75 naloxegol 12.5 mg Tab 57841-1300-01 1 tab(s) $99 $0 $99 $59 naloxegol 25 mg Tab 57841-1301-01 1 tab(s) $99 $0 $99 $59 naloxone 0.4 mg/mL Soln 67457-0292-02 1 mL $177 $0 $177 $106 naloxone 0.4 mg/mL Soln 00641-6132-25 1 mL $92 $0 $92 $55 naloxone 0.4 mg/mL Soln 00590-0358-10 1 mL $31 $0 $31 $18 naloxone 0.4 mg/mL Soln 00409-1215-25 1 mL $135 $0 $135 $81 naproxen 250 mg Tab 50268-0594-15 1 tab(s) $9 $0 $9 $5 naproxen 375 mg Tab 69097-0854-12 1 tab(s) $10 $0 $10 $6 naproxen 500 mg Tab 68462-0190-01 1 tab(s) $12 $0 $12 $7 naproxen 500 mg Tab 60687-0491-01 1 tab(s) $12 $0 $12 $7 naproxen sodium 275 mg Tab 00093-0536-01 1 tab(s) $9 $0 $9 $5 nebivolol 5 mg Tab 00456-1405-30 1 tab(s) $19 $0 $19 $11 niacin 100 mg Tab 00182-0001-01 1 tab(s) $3 $0 $3 $2 niacin 100 mg Tab 00536-4076-01 1 tab(s) $4 $0 $4 $2 niacin 100 mg Tab 80681-0057-00 1 tab(s) $15 $0 $15 $9 niacin 1000 mg ER Ta 65162-0323-09 1 tab(s) $65 $0 $65 $39 niacin 1000 mg ER Ta 47335-0613-81 1 tab(s) $54 $0 $54 $32 niacin 1000 mg ER Ta 00074-3080-90 1 tab(s) $31 $0 $31 $19 niacin 500 mg ER Ta 68084-0756-35 1 tab(s) $42 $0 $42 $25 NIFEdipine 30 mg ER Ta 50268-0597-15 1 tab(s) $12 $0 $12 $7 NIFEdipine 30 mg ER Ta 51079-0400-20 1 tab(s) $12 $0 $12 $7 NIFEdipine 60 mg ER Ta 68084-0598-01 1 tab(s) $19 $0 $19 $12 NIFEdipine 60 mg ER Ta 50268-0598-15 1 tab(s) $18 $0 $18 $11 NIFEdipine 90 mg ER Ta 50268-0599-15 1 tab(s) $20 $0 $20 $12 niMODipine 30 mg Cap 69452-0209-20 1 cap(s) $127 $0 $127 $76 niMODipine 30 mg Cap 63739-0797-33 1 cap(s) $26 $0 $26 $16 nitrofurantoin macrocrystals 25 mg Cap 00149-0007-05 1 cap(s) $15 $0 $15 $9 nitrofurantoin macrocrystals 50 mg Cap 60687-0472-01 1 cap(s) $33 $0 $33 $20 nitrofurantoin macrocrystals 50 mg Cap 68001-0385-00 1 cap(s) $18 $0 $18 $11 nitrofurantoin macrocrystals-monohydrate 100 mg Cap 68001-0001-00 1 cap(s) $29 $0 $29 $17 nitrofurantoin macrocrystals-monohydrate 100 mg Cap 51079-0348-20 1 cap(s) $25 $0 $25 $15 nitrofurantoin monohydrate macrocrystals 100 mg Cap 51079-0348-01 1 cap(s) $25 $0 $25 $15 nitrofurantoin oral Susp 25 mg / 5 mL Susp 43386-0450-11 1 mL $27 $0 $27 $16 nitroglycerin 0.1 mg/hr ER Patch 00378-9102-93 1 patch(es) $19 $0 $19 $11 nitroglycerin 0.1 mg/hr Patch 00378-9102-16 1 patch(es) $19 $0 $19 $11 nitroglycerin 0.2 mg/hr ER Fi 00378-9104-93 1 EA $19 $0 $19 $12 nitroglycerin 0.2 mg/hr ER Fi 00904-5495-46 1 EA $19 $0 $19 $12 nitroglycerin 0.4 mg Tab 00071-0418-24 1 tab(s) $44 $0 $44 $26 nitroglycerin 0.4 mg Tab 68462-0639-45 1 tab(s) $176 $0 $176 $106 nitroglycerin 0.4 mg/hr ER Fi 68382-0310-30 1 patch(es) $23 $0 $23 $14 no medications 1 EA Device 99345-0001-40 1 EA $0 $0 $0 $0 non form Cap Cap 99345-0004-10 1 cap(s) $0 $0 $0 $0 Non Formulary TAB Med 1 EA 99999-9999-01 1 tab(s) $0 $0 $0 $0 Non-Formulary Narcotic (CSV only) 1 mg Tab 99345-0001-94 1 EA $0 $0 $0 $0 Non-Formulary Narcotic Storage Bin 99345-0001-61 1 EA $0 $0 $0 $0 nortriptyline 10 mg Cap 68084-0031-01 1 cap(s) $6 $0 $6 $4 nortriptyline 10 mg Cap 50268-0603-15 1 cap(s) $7 $0 $7 $4 nortriptyline 25 mg Cap 51672-4002-01 1 cap(s) $13 $0 $13 $8 nystatin 100000 units/mL Susp 00121-4810-40 5 mL $6 $0 $6 $4 nystatin 500,000 units/5 mL Oral susp 500,000 unit(s) / 5 mL Susp 17856-0538-01 5 mL $12 $0 $12 $7 nystatin 500,000 units/5 mL oral susp UD cup 68094-0599-58 5 mL $8 $0 $8 $5 nystatin topical 100000 units/g Cream 45802-0059-11 1 app $193 $0 $193 $116 nystatin topical 100000 units/g Cream 00713-0678-31 1 app $185 $0 $185 $111 nystatin topical 100000 units/g Cream 00472-0163-30 1 app $193 $0 $193 $116 nystatin topical 100000 units/g Ointm 00472-0166-30 1 app $193 $0 $193 $116 nystatin topical 100000 units/g Powde 00574-2008-15 1 app $200 $0 $200 $120 nystatin-triamcinolone topical 100000 units/g-0.1% Cream 00472-0150-30 1 app $54 $0 $54 $32 nystatin-triamcinolone topical 100000 units/g-0.1% Cream 68180-0545-02 1 app $1,127 $0 $1,127 $676 nystatin-triamcinolone topical 100000 units/g-0.1% Cream 51672-1263-01 1 app $69 $0 $69 $41 nystatin-triamcinolone topical 100000 units/g-0.1% Ointm 51672-1272-01 1 app $69 $0 $69 $41 nystatin-triamcinolone Topical 100000 units/g-0.1% Ointm 00003-0466-30 1 app $300 $0 $300 $180 octreotide 100 mcg Injection 00703-3311-01 1 mL $81 $0 $81 $49 octreotide 50 mcg/mL Soln 00703-3301-04 1 mL $43 $0 $43 $26 octreotide 50 mcg/mL Soln 00078-0180-01 1 mL $95 $0 $95 $57

Page 94 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price octreotide 50 mcg/mL Soln 63323-0365-01 1 mL $50 $0 $50 $30 octreotide 500 mcg/mL Soln 67457-0246-01 1 mL $290 $0 $290 $174 octreotide 500 mcg/mL Soln 63323-0377-01 1 mL $426 $0 $426 $256 ocular lubricant - Gel 58768-0790-36 1 app $65 $0 $65 $39 ocular lubricant - Gel 00065-8064-01 1 app $63 $0 $63 $38 ocular lubricant - Ointm 00904-6488-38 1 app $67 $0 $67 $40 ocular lubricant - Ointm 17478-0062-35 1 app $35 $0 $35 $21 ocular lubricant - Soln 00023-0506-01 1 drop(s) $10 $0 $10 $6 ocular lubricant preserved Soln 00065-0418-15 1 drop(s) $117 $0 $117 $70 ofloxacin ophthalmic 0.3% Soln 11980-0779-05 1 drop(s) $505 $0 $505 $303 ofloxacin otic 0.3% Soln 63395-0101-05 1 drop(s) $388 $0 $388 $233 ofloxacin otic 0.3% Soln 61314-0015-05 1 drop(s) $527 $0 $527 $316 OLANZapine 10 mg DIS T 59746-0307-32 1 tab(s) $30 $0 $30 $18 OLANZapine 10 mg REC I 00002-7597-01 2 mL $308 $0 $308 $185 OLANZapine 10 mg REC I 00517-0955-01 2 mL $297 $0 $297 $178 OLANZapine 10 mg Tab 68084-0740-01 1 tab(s) $139 $0 $139 $84 OLANZapine 15 mg Tab 68084-0528-01 1 tab(s) $207 $0 $207 $124 OLANZapine 15 mg Tab 55111-0167-30 1 tab(s) $15 $0 $15 $9 OLANZapine 15 mg Tab 00904-6286-06 1 tab(s) $203 $0 $203 $122 OLANZapine 2.5 mg Tab 00904-6283-61 1 tab(s) $78 $0 $78 $47 OLANZapine 5 mg Tab 60505-3111-00 1 tab(s) $92 $0 $92 $55 OLANZapine 5 mg Tab 68084-0723-01 1 tab(s) $76 $0 $76 $46 OLANZapine 5 mg Tab 00093-5768-56 1 tab(s) $92 $0 $92 $55 OLANZapine 5 mg Tab 00904-6284-61 1 tab(s) $92 $0 $92 $55 olmesartan 20 mg Tab 68462-0437-30 1 tab(s) $50 $0 $50 $30 olmesartan 20 mg Tab 62332-0132-30 1 tab(s) $45 $0 $45 $27 olmesartan 20 mg Tab 42292-0036-03 1 tab(s) $45 $0 $45 $27 olmesartan 40 mg Tab 65597-0104-30 1 tab(s) $17 $0 $17 $10 olmesartan 40 mg Tab 65862-0743-30 1 tab(s) $68 $0 $68 $41 olopatadine ophthalmic 0.1% Soln 60505-0575-01 1 drop(s) $1,806 $0 $1,806 $1,084 olopatadine ophthalmic 0.1% Soln 70069-0007-01 1 drop(s) $346 $0 $346 $208 omega-3 polyunsaturated fatty acids ethyl esters 1000 mg Cap 00093-5401-89 1 cap(s) $17 $0 $17 $10 omeprazole 10 mg DR Ca 68382-0411-01 1 cap(s) $28 $0 $28 $17 omeprazole 20 mg DR Ca 60505-0065-07 1 cap(s) $31 $0 $31 $19 omeprazole 20 mg DR Ca 00904-5684-61 1 cap(s) $25 $0 $25 $15 omeprazole 20 mg DRC 51079-0007-20 1 cap(s) $29 $0 $29 $18 ONAbotulinumtoxinA 100 unit(s) Injection 99999-9999-10 1 vial(s) $0 $0 $0 $0 ondansetron 4 mg / 5 mL Soln 54838-0555-50 1 mL $38 $0 $38 $23 ondansetron 2 mg/mL Soln 70860-0776-02 2 mL $24 $0 $24 $15 ondansetron 2 mg/mL Soln 55150-0125-02 2 mL $25 $0 $25 $15 ondansetron 2 mg/mL Soln 63323-0373-02 2 mL $27 $0 $27 $16 ondansetron 4 mg DIS T 00378-7732-93 1 tab(s) $153 $0 $153 $92 ondansetron 4 mg DIS T 57237-0077-10 1 tab(s) $153 $0 $153 $92 ondansetron 4 mg DIS T 68001-0246-04 1 tab(s) $153 $0 $153 $92 ondansetron 4 mg DIS T 68001-0246-17 1 tab(s) $158 $0 $158 $95 ondansetron 4 mg DIS T 65862-0390-10 1 tab(s) $153 $0 $153 $92 ondansetron 4 mg DIS Tablet 58177-0363-22 1 tab(s) $4,476 $0 $4,476 $2,685 ondansetron 4 mg Tab 58177-3633-75 1 tab(s) $4,476 $0 $4,476 $2,685 ondansetron 4 mg Tab 62576-0240-64 1 tab(s) $4,476 $0 $4,476 $2,685 ondansetron 4 mg Tab 68084-0220-01 1 tab(s) $164 $0 $164 $98 ondansetron 8 mg DIS T 68001-0247-17 1 tab(s) $261 $0 $261 $157 ondansetron 8 mg DIS T 00781-5239-64 1 tab(s) $252 $0 $252 $151 ondansetron 8 mg Tab 45963-0539-30 1 tab(s) $267 $0 $267 $160 ondansetron 8 mg Tab 68084-0221-01 1 tab(s) $271 $0 $271 $163 ondansetron 8 mg Tab 51079-0525-20 1 tab(s) $280 $0 $280 $168 ophthalmic irrigation, extraocular - Soln 58768-0727-20 1 app $66 $0 $66 $39 opium 10% (equivalent to morphine 10 mg/mL) Tinct 62559-0153-04 0.6 mL $49 $0 $49 $29 opium 10% (equivalent to morphine 10 mg/mL) Tinct 42799-0217-01 0.6 mL $49 $0 $49 $29 opium tincture 6 mg/0.6 mL Tincture 99345-0001-44 0.6 mL $31 $0 $31 $19 Ora Plus Susp 00574-0303-16 1 mL $5 $0 $5 $3 Ora Sweet Susp 00574-0304-16 1 mL $5 $0 $5 $3 oseltamivir 30 mg Cap 69238-1264-01 1 cap(s) $98 $0 $98 $59 oseltamivir 30 mg Cap 68180-0675-11 1 cap(s) $98 $0 $98 $59 oseltamivir 30 mg Cap 64380-0797-01 1 cap(s) $98 $0 $98 $59 oseltamivir 6 mg/mL REC P 70710-1165-06 1 mL $24 $0 $24 $14 oseltamivir 75 mg Cap 33342-0258-66 1 cap(s) $107 $0 $107 $64 oxacillin 1 g REC I 00015-7981-20 10 mL $251 $0 $251 $151 oxacillin 1 g REC I 00781-3099-95 10 mL $124 $0 $124 $74 oxacillin 1 g REC I 00781-9109-95 10 mL $124 $0 $124 $74 oxacillin 10 g REC I 00781-3103-95 10 mL $75 $0 $75 $45 oxacillin 10 g REC I 55150-0129-99 10 mL $138 $0 $138 $83 oxacillin 2 g/50 mL Soln 00338-1015-41 50 mL $56 $0 $56 $34 oxacillin 2 gm REC Injection 55150-0128-25 20 mL $206 $0 $206 $124 oxandrolone 10 mg Tab 68084-0425-21 1 tab(s) $105 $0 $105 $63 oxandrolone 2.5 mg Tab 49884-0301-01 1 tab(s) $43 $0 $43 $26 oxandrolone 2.5 mg Tab 00245-0271-11 1 tab(s) $45 $0 $45 $27 oxandrolone 2.5 mg Tab 00185-0271-01 1 tab(s) $43 $0 $43 $26 oxandrolone 2.5 mg Tab 68084-0424-21 1 tab(s) $53 $0 $53 $32 OXcarbazepine 150 mg Tab 62584-0142-01 1 tab(s) $13 $0 $13 $8

Page 95 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price OXcarbazepine 150 mg Tab 68084-0845-01 1 tab(s) $13 $0 $13 $8 OXcarbazepine 150 mg Tab 00054-0097-20 1 tab(s) $14 $0 $14 $8 OXcarbazepine 150 mg Tab 00078-0456-05 1 tab(s) $16 $0 $16 $10 oxybutynin 10 mg ER Tab 51079-0723-20 1 tab(s) $25 $0 $25 $15 oxybutynin 10 mg/24 hr ER Ta 64980-0210-01 1 tab(s) $17 $0 $17 $10 oxybutynin 10 mg/24 hr ER Ta 62175-0271-37 1 tab(s) $24 $0 $24 $14 oxybutynin 10 mg/24 hr ER Ta 68084-0610-21 1 tab(s) $25 $0 $25 $15 oxybutynin 5 mg ER Ta 00378-6605-01 1 tab(s) $25 $0 $25 $15 oxybutynin 5 mg ER Ta 51079-0722-20 1 tab(s) $26 $0 $26 $16 oxybutynin 5 mg Tab 68084-0400-01 1 tab(s) $4 $0 $4 $2 oxybutynin 5 mg/24 hours ER Ta 50268-0627-15 1 tab(s) $25 $0 $25 $15 oxyCODONE 10 mg CR Tablet 59011-0410-10 1 tab(s) $27 $0 $27 $16 oxyCODONE 15 mg ER Tablet 59011-0415-10 1 tab(s) $38 $0 $38 $23 oxyCODONE 15 mg Tab 68084-0975-01 1 tab(s) $18 $0 $18 $11 oxyCODONE 15 mg Tab 10702-0008-01 1 tab(s) $18 $0 $18 $11 oxycodone 15 mg Tab 00406-8515-01 1 tab(s) $10 $0 $10 $6 oxycodone 160 mg ER Tab 59011-0109-25 1 tab(s) $121 $0 $121 $72 oxyCODONE 40 mg ER Ta 59011-0440-20 1 tab(s) $63 $0 $63 $38 oxyCODONE 40 mg ER Ta 00591-2693-01 1 tab(s) $63 $0 $63 $38 oxycodone 5 mg Tab 00406-0552-01 1 tab(s) $8 $0 $8 $5 oxyCODONE 5 mg/5 mL Soln 66689-0401-50 5 mL $11 $0 $11 $7 oxycodone 5 mg/5 mL Soln 66689-0403-16 5 mL $6 $0 $6 $4 oxyCODONE 5 mg/5 mL Soln 60687-0406-77 5 mL $15 $0 $15 $9 oxyCODONE 5 mg/5 mL Soln 64950-0354-50 5 mL $6 $0 $6 $4 oxyCODONE 5 mg/5 mL Soln 00406-8556-05 5 mL $7 $0 $7 $4 oxyCODONE CR 20 mg Tab 59011-0420-10 1 tab(s) $47 $0 $47 $28 oxyCODONE CR 40 mg ER Tablet 63304-0683-01 1 tab(s) $74 $0 $74 $44 oxymetazoline 0.05% Spray 00904-6761-30 1 spray(s) $20 $0 $20 $12 oxymorphone 10 mg ER Ta 00115-1232-01 1 tab(s) $29 $0 $29 $17 oxymorphone 10 mg ER Ta 63481-0674-70 1 tab(s) $31 $0 $31 $18 oxymorphone 10 mg ER Ta 63481-0814-60 1 tab(s) $36 $0 $36 $22 oxymorphone 40 mg ER Ta 63481-0818-60 1 tab(s) $130 $0 $130 $78 oxymorphone 5 mg Tab 00054-0283-25 1 tab(s) $25 $0 $25 $15 oxymorphone 5 mg Tab 00406-1009-01 1 tab(s) $27 $0 $27 $16 oxyMORphone 5 mg Tab 10702-0070-06 1 tab(s) $30 $0 $30 $18 oxyMORphone 7.5 mg ER Ta 00115-1315-01 1 tab(s) $23 $0 $23 $14 oxyMORphone 7.5 mg ER Ta 00115-1315-13 1 tab(s) $30 $0 $30 $18 pamidronate 3 mg/mL Soln 67457-0430-10 10 mL $276 $0 $276 $166 pantoprazole 20 mg EC Ta 68084-0643-01 1 tab(s) $29 $0 $29 $17 pantoprazole 20 mg EC Ta 00378-6688-77 1 tab(s) $39 $0 $39 $23 pantoprazole 20 mg EC Ta 50268-0636-15 1 tab(s) $30 $0 $30 $18 pantoprazole 40 mg EC Ta 50268-0639-15 1 tab(s) $30 $0 $30 $18 pantoprazole 40 mg EC Ta 31722-0713-90 1 tab(s) $39 $0 $39 $23 pantoprazole 40 mg EC Ta 68084-0813-09 1 tab(s) $6 $0 $6 $4 pantoprazole 40 mg ECGR 62756-0071-64 1 packet(s) $117 $0 $117 $70 pantoprazole 40 mg REC I 00143-9300-10 10 mL $36 $0 $36 $22 pantoprazole 40 mg Tab 66993-0068-80 1 tab(s) $6 $0 $6 $4 papain urea chlorophyll Gladase C Oint 05048-0220-30 1 app $624 $0 $624 $374 papain urea Gladase Oint 05048-0100-30 1 app $391 $0 $391 $234 papain-urea Topical 0.5%-10%-10% Ointm 00064-3410-30 1 app $624 $0 $624 $374 papain-urea Topical 0.5%-10%-10% Spray 00064-3510-33 1 spray(s) $626 $0 $626 $375 papain-urea Topical 10%-10% Spray 00064-1001-33 1 spray(s) $390 $0 $390 $234 papain-urea Topical 830,000 units/g-10% Ointm 00064-1000-01 1 app $391 $0 $391 $234 papain-urea Topical 830,000 units/g-10% Ointm 00064-1000-07 1 app $110 $0 $110 $66 parenteral nutrition solution Amino Acids 10% (Aminosyn Sulfite-Free) Soln 00409-4191-05 1 mL $0 $0 $0 $0 parenteral nutrition solution Dextrose 10% in Water Soln 00264-7520-00 1000 mL $30 $0 $30 $18 parenteral nutrition solution Dextrose 70% in Water Soln 00338-0719-06 1 mL $1,032 $0 $1,032 $619 parenteral nutrition solution w/electrolytes Amino Acids 3% with Electrolytes 00264-1915-00 1000 mL $380 $0 $380 $228 (Procalamine) Soln paricalcitol 5 mcg/mL Soln 00074-1658-01 1 mL $213 $0 $213 $128 paroxetine 12.5 mg ER Tablet 42858-0703-03 1 tab(s) $19 $0 $19 $12 PARoxetine 10 mg Tab 00904-5676-61 1 tab(s) $22 $0 $22 $13 PARoxetine 10 mg Tab 68084-0044-01 1 tab(s) $21 $0 $21 $13 PARoxetine 10 mg Tab 68084-0044-11 1 tab(s) $21 $0 $21 $13 PARoxetine 20 mg Tab 51079-0774-20 1 tab(s) $22 $0 $22 $13 paroxetine 25 mg ER Ta 00378-2004-93 1 tab(s) $27 $0 $27 $16 paroxetine 25 mg ER Tablet 42858-0705-03 1 tab(s) $20 $0 $20 $12 Patient Own Med Stored in Pharmacy -- Test 99345-0004-00 1 EA $0 $0 $0 $0 Patient Own Narcotic Supply in CSV 0 Bag 99345-0001-83 1 EA $0 $0 $0 $0 penicillin G benzathine 2,400,000 units/4 mL Susp 60793-0702-10 4 mL $2,720 $0 $2,720 $1,632 penicillin G potassium 5,000,000 units REC I 00049-0520-22 1 mL $170 $0 $170 $102 penicillin G sodium 5000000 units REC I 00781-6153-94 1 mL $432 $0 $432 $259 penicillin G sodium 5000000 units REC I 00781-6153-95 1 mL $432 $0 $432 $259 pentoxifylline 400 mg ER Ta 00904-5448-61 1 tab(s) $5 $0 $5 $3 perampanel 12 mg Tab 62856-0282-30 1 tab(s) $164 $0 $164 $98 perampanel 4 mg Tab 62856-0274-30 1 tab(s) $273 $0 $273 $164 permethrin topical 1% Lotio 63736-0024-03 1 app $78 $0 $78 $47 permethrin topical 1% Lotio 63736-0024-04 1 app $66 $0 $66 $39 permethrin topical 5% Cream 00472-0242-60 1 app $874 $0 $874 $525

Page 96 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price petrolatum, white 100% Ointment 53329-0068-01 1 app $28 $0 $28 $17 Pharmacy Med Delivery Storage Tray 2 - Test 99345-0003-25 1 EA $0 $0 $0 $0 Pharmacy Med Delivery Storage Tray 3 - Test 99345-0003-30 1 EA $0 $0 $0 $0 phenazopyridine 100 mg Tab 69367-0162-04 1 tab(s) $21 $0 $21 $13 phenobarbital 100 mg Tab 00143-1458-01 1 tab(s) $6 $0 $6 $4 PHENobarbital 100 mg Tab 00143-1458-05 1 tab(s) $7 $0 $7 $4 PHENobarbital 15 mg Tab 51293-0691-01 1 tab(s) $7 $0 $7 $4 phenobarbital 15 mg Tab 51079-0094-01 1 tab(s) $5 $0 $5 $3 PHENobarbital 16.2 mg Tab 51293-0625-01 1 tab(s) $8 $0 $8 $5 PHENobarbital 16.2 mg Tab 00603-5165-21 1 tab(s) $5 $0 $5 $3 PHENobarbital 20 mg/5 mL Elixi 13517-0107-16 5 mL $6 $0 $6 $4 PHENobarbital 32.4 mg Tab 13517-0111-01 1 tab(s) $8 $0 $8 $5 PHENobarbital 32.4 mg Tab 00603-5166-21 1 tab(s) $5 $0 $5 $3 PHENobarbital 32.4 mg Tab 00904-6575-61 1 tab(s) $6 $0 $6 $4 PHENobarbital 60 mg Tab 75826-0140-10 1 tab(s) $8 $0 $8 $5 PHENobarbital 60 mg Tab 00143-1455-01 1 tab(s) $8 $0 $8 $5 PHENobarbital 64.8 mg Tab 51293-0627-01 1 tab(s) $10 $0 $10 $6 PHENobarbital 97.2 mg Tab 13517-0113-01 1 tab(s) $13 $0 $13 $8 phenol topical 1.4% Spray 00904-6305-21 1 spray(s) $20 $0 $20 $12 phenylephrine nasal 0.5% Soln 00024-1351-05 15 mL $32 $0 $32 $19 phenylephrine nasal 0.5% Spray 00024-1353-01 1 spray(s) $34 $0 $34 $20 phenylephrine nasal 1% Spray 00024-1352-02 1 spray(s) $35 $0 $35 $21 phenylephrine rectal ointment [Preparation H] 0.25%-3% Ointment 00536-1288-06 1 app $23 $0 $23 $14 phenylephrine topical 0.25% Supp 00573-2883-11 1 supp $8 $0 $8 $5 phenytoin 100 mg ER Ca 51672-4111-01 1 cap(s) $6 $0 $6 $3 phenytoin 100 mg ER Ca 51672-4111-03 1 cap(s) $6 $0 $6 $3 phenytoin 100 mg ER Cap 00071-0362-40 1 cap(s) $6 $0 $6 $4 phenytoin 100 mg ER Capsule 51079-0905-01 1 cap(s) $28 $0 $28 $17 phenytoin 100 mg ER Capsule 68084-0376-01 1 cap(s) $6 $0 $6 $4 phenytoin 25 mg/mL Susp 59762-0531-01 1 mL $6 $0 $6 $3 phenytoin 30 mg ER Cap 00071-0365-24 1 cap(s) $5 $0 $5 $3 phenytoin 50 mg Chew 60687-0156-25 1 tab(s) $11 $0 $11 $7 phenytoin 50 mg Chew Tab 00071-0007-24 1 tab(s) $6 $0 $6 $3 phytonadione 10 mg/mL Soln 00409-9158-25 1 mL $397 $0 $397 $238 pill pulverizer 1 Device 07685-5700-29 1 EA $26 $0 $26 $16 pill splitter 1 EA Device 07685-5700-58 1 EA $26 $0 $26 $16 pilocarpine 5 mg Tab 00527-1313-01 1 tab(s) $14 $0 $14 $8 pilocarpine 5 mg Tab 00228-2801-11 1 tab(s) $14 $0 $14 $8 pilocarpine 5 mg Tab 00054-0056-25 1 tab(s) $14 $0 $14 $8 pilocarpine ophthalmic 1% Soln 00998-0203-15 1 drop(s) $175 $0 $175 $105 pilocarpine ophthalmic 1% Soln 24208-0676-15 1 drop(s) $72 $0 $72 $43 pimavanserin 10 mg Tab 63090-0100-30 1 tab(s) $748 $0 $748 $449 pimavanserin 34 mg Cap 63090-0340-30 1 tab(s) $748 $0 $748 $449 pimecrolimus topical 1% Cream 00187-5100-01 1 app $1,823 $0 $1,823 $1,094 pioglitazone 15 mg Tab 33342-0054-07 1 tab(s) $50 $0 $50 $30 pioglitazone 15 mg Tab 60687-0391-01 1 tab(s) $12 $0 $12 $7 pioglitazone 45 mg Tab 33342-0056-10 1 tab(s) $81 $0 $81 $49 pioglitazone 45 mg Tab 00781-5422-31 1 tab(s) $81 $0 $81 $49 pioglitazone 45 mg Tab 00093-7273-98 1 tab(s) $81 $0 $81 $49 piperacillin-tazobactam 2 g-0.25 g REC I 00781-9210-95 0 $94 $0 $94 $56 piperacillin-tazobactam 2 g-0.25 g REC I 55150-0119-30 0 $109 $0 $109 $66 piperacillin-tazobactam 3 g-0.375 g REC I 63323-0300-30 0 $63 $0 $63 $38 piperacillin-tazobactam 3 g-0.375 g REC I 00781-9213-95 0 $137 $0 $137 $82 piperacillin-tazobactam 3 g-0.375 g REC I 00781-3113-95 0 $137 $0 $137 $82 piperacillin-tazobactam 3.375 gm Injection 00409-3385-13 0 $59 $0 $59 $35 piperacillin-tazobactam 4 g-0.5 g REC I 00781-3114-95 0 $227 $0 $227 $136 piperacillin-tazobactam 4 g-0.5 g REC I 25021-0166-48 0 $185 $0 $185 $111 piperacillin-tazobactam 4 g-0.5 g REC I 63323-0320-50 0 $179 $0 $179 $108 piperacillin-tazobactam 4 g-0.5 g REC I 67457-0523-45 0 $256 $0 $256 $154 piperacillin-tazobactam 4.5 gm Injection 00409-3390-04 0 $134 $0 $134 $80 piperacillin-TAZObactam 4.5 gm REC Injection 00781-9214-95 0 $227 $0 $227 $136 pneumococcal 13-valent conjugate vaccine - Susp 00005-1971-05 0.5 mL $1,421 $0 $1,421 $852 pneumococcal 23-valent vaccine - Soln 00006-4943-00 0.5 mL $264 $0 $264 $159 poliovirus vaccine, inactivated - Susp 49281-0860-10 0.5 mL $405 $0 $405 $243 polycarbophil 625 mg Tab 00536-4306-05 1 tab(s) $4 $0 $4 $2 polycarbophil 625 mg Tab 00536-4306-08 1 tab(s) $4 $0 $4 $2 polyethylene glycol 17 gm Powder 17856-0412-20 1 EA $20 $0 $20 $12 polyethylene glycol 238 gm Powder 04110-0820-73 1 EA $17,165 $0 $17,165 $10,299 polyethylene glycol 238 gm REC Powder 04110-0820-76 1 EA $9,657 $0 $9,657 $5,794 polyethylene glycol 3350 - REC P 68084-0430-98 1 EA $22 $0 $22 $13 polyethylene glycol 3350 - REC P 60687-0431-98 1 EA $22 $0 $22 $13 polyethylene glycol 3350 - REC P 52268-0800-02 1 EA $165 $0 $165 $99 polyethylene glycol 3350 - REC P 51079-0306-30 1 EA $16 $0 $16 $10 polyethylene glycol 3350 with electrolytes - REC P 00378-6669-40 4000 mL $5 $0 $5 $3 polymyxin B sulfate 500000 units REC I 70860-0103-10 0 $139 $0 $139 $83 polymyxin B-trimethoprim ophthalmic 10000 units-1 mg/mL Soln 17478-0703-11 1 drop(s) $131 $0 $131 $78 polymyxin B-trimethoprim ophthalmic 10000 units-1 mg/mL Soln 24208-0315-10 1 drop(s) $130 $0 $130 $78 posaconazole 100 mg EC Tablet 00527-2133-35 1 tab(s) $499 $0 $499 $300 potassium acid phosphate 500 mg Tab 00486-1111-05 1 tab(s) $7 $0 $7 $4

Page 97 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price potassium chloride 10 mEq ER Ta 00378-4561-77 1 tab(s) $7 $0 $7 $4 potassium chloride 10 mEq ER Ta 00574-0275-11 1 tab(s) $6 $0 $6 $4 potassium chloride 10 mEq ER Ta 00781-1526-01 1 tab(s) $7 $0 $7 $4 potassium chloride 10 mEq ER Tablet 66758-0160-13 1 tab(s) $8 $0 $8 $5 potassium chloride 10 mEq ER Tablet 60687-0466-01 1 tab(s) $7 $0 $7 $4 potassium chloride 20 mEq REC P 00603-4173-16 1 packet(s) $6 $0 $6 $3 potassium chloride 20 mEq/100 mL Soln 00338-0705-48 100 mL $70 $0 $70 $42 potassium chloride 20 mEq/15 mL LIQ 00121-1465-15 15 mL $11 $0 $11 $7 potassium chloride 20 mEq/15 mL LIQ 00054-8714-04 15 mL $8 $0 $8 $5 potassium chloride 20 mEq/15 mL LIQ 60687-0341-71 15 mL $121 $0 $121 $73 potassium chloride 20 mEq/15 mL LIQ 66689-0047-50 15 mL $1,645 $0 $1,645 $987 potassium citrate 10 mEq ER Ta 00591-2729-01 1 tab(s) $20 $0 $20 $12 potassium citrate 10 mEq ER Ta 00178-0610-01 1 tab(s) $7 $0 $7 $4 potassium phosphate 3 mmol/mL Soln 63323-0086-05 1 mL $33 $0 $33 $20 potassium phosphate-sodium phosphate 250 mg-45 mg-298 mg Tab 68084-0764-25 1 tab(s) $11 $0 $11 $6 pramipexole 0.125 mg Tab 00597-0183-90 1 tab(s) $20 $0 $20 $12 pramipexole 0.125 mg Tab 13668-0091-90 1 tab(s) $23 $0 $23 $14 pramipexole 0.25 mg Tab 13668-0092-90 1 tab(s) $23 $0 $23 $14 pramipexole 0.25 mg Tab 68084-0440-01 1 tab(s) $23 $0 $23 $14 pramipexole 0.25 mg Tab 68462-0331-90 1 tab(s) $26 $0 $26 $15 pramipexole 0.5 mg Tab 00597-0085-90 1 tab(s) $20 $0 $20 $12 pramipexole 1.5 mg Tab 13668-0095-90 1 tab(s) $23 $0 $23 $14 pramipexole 1.5 mg Tab 00555-0615-14 1 tab(s) $5 $0 $5 $3 pramipexole 1.5 mg Tab 00597-0191-90 1 tab(s) $22 $0 $22 $13 prasugrel 10 mg Tab 60505-4643-03 1 tab(s) $114 $0 $114 $68 pravastatin 10 mg Tab 60687-0169-01 1 tab(s) $25 $0 $25 $15 pravastatin 10 mg Tab 60505-0168-09 1 tab(s) $25 $0 $25 $15 pravastatin 20 mg Tab 00904-5892-61 1 tab(s) $20 $0 $20 $12 pravastatin 40 mg Tab 51079-0782-01 1 tab(s) $3,200 $0 $3,200 $1,920 pravastatin 40 mg Tab 51079-0782-20 1 tab(s) $35 $0 $35 $21 pravastatin 40 mg Tab 60687-0190-01 1 tab(s) $35 $0 $35 $21 pravastatin 40 mg Tab 68462-0197-90 1 tab(s) $35 $0 $35 $21 prazosin 1 mg Cap 00093-4067-01 1 cap(s) $6 $0 $6 $4 prazosin 1 mg Cap 68084-0996-01 1 cap(s) $15 $0 $15 $9 prednisoLONE 15 mg/5 mL Syrup 00603-1567-58 1 mL $6 $0 $6 $4 prednisoLONE 5 mg/5 mL LIQ 00451-2201-04 5 mL $6 $0 $6 $3 prednisoLONE ophthalmic acetate 0.12% Susp 11980-0174-05 1 drop(s) $182 $0 $182 $109 predniSONE 10 mg Tab 00054-0017-20 1 tab(s) $4 $0 $4 $3 predniSONE 10 mg Tab 00054-0017-25 1 tab(s) $4 $0 $4 $2 predniSONE 10 mg Tab 00182-1334-00 1 tab(s) $4 $0 $4 $2 predniSONE 10 mg Tab 00143-1473-01 1 tab(s) $4 $0 $4 $2 predniSONE 10 mg Tab 00143-1473-10 1 tab(s) $4 $0 $4 $2 predniSONE 10 mg Tab 45802-0303-67 1 tab(s) $5 $0 $5 $3 predniSONE 10 mg Tab 60687-0134-01 1 tab(s) $5 $0 $5 $3 predniSONE 10 mg Tab 63739-0208-10 1 tab(s) $6 $0 $6 $4 predniSONE 10 mg Tab 63739-0208-15 1 tab(s) $6 $0 $6 $4 predniSONE 10 mg tab 51079-0033-17 1 tab(s) $4 $0 $4 $2 predniSONE 20 mg Tab 59746-0175-06 1 tab(s) $13 $0 $13 $8 predniSONE 20 mg Tab 63739-0588-10 1 tab(s) $7 $0 $7 $4 predniSONE 20 mg Tab 60687-0145-01 1 tab(s) $5 $0 $5 $3 prednisone 5 mg EC Capsule 51079-0032-17 1 tab(s) $43 $0 $43 $26 predniSONE 5 mg Tab 60687-0122-01 1 tab(s) $5 $0 $5 $3 predniSONE 5 mg Tab 53489-0138-01 1 tab(s) $4 $0 $4 $2 predniSONE 5 mg/5 mL Soln 00054-3722-50 1 mL $6 $0 $6 $4 predniSONE 50 mg Tab 00054-0019-20 1 tab(s) $6 $0 $6 $3 predniSONE 50 mg Tab 00054-0019-25 1 tab(s) $5 $0 $5 $3 pregabalin 100 mg Cap 00071-1015-68 1 cap(s) $42 $0 $42 $25 pregabalin 100 mg Cap 60687-0506-01 1 cap(s) $16 $0 $16 $10 pregabalin 20 mg/mL Soln 67877-0457-47 1 mL $6 $0 $6 $3 pregabalin 25 mg Cap 60687-0473-01 1 cap(s) $16 $0 $16 $10 pregabalin 50 mg Cap 60687-0484-01 1 cap(s) $16 $0 $16 $10 pregabalin 75 mg Cap 00071-1014-68 1 cap(s) $39 $0 $39 $23 pregabalin 75 mg Cap 60687-0495-01 1 cap(s) $14 $0 $14 $9 pregabalin 75 mg Cap 69097-0956-05 1 cap(s) $52 $0 $52 $31 primidone 250 mg Tab 53746-0545-01 1 tab(s) $10 $0 $10 $6 primidone 50 mg Tab 53746054401 1 tab(s) $5 $0 $5 $3 primidone 50 mg Tab 00527-1301-01 1 tab(s) $7 $0 $7 $4 probenecid 500 mg Tab 00527-1367-01 1 tab(s) $10 $0 $10 $6 probenecid 500 mg Tab 00172-2190-60 1 tab(s) $18 $0 $18 $11 procainamide 250 mg Cap 00172-2345-60 1 cap(s) $8 $0 $8 $5 prochlorperazine 10 mg Tab 59746-0115-06 1 tab(s) $9 $0 $9 $6 prochlorperazine 25 mg Supp 00713-0135-12 1 supp $93 $0 $93 $56 prochlorperazine 5 mg Tab 00093-9643-01 1 tab(s) $7 $0 $7 $4 prochlorperazine 5 mg Tab 51079-0541-01 1 tab(s) $7 $0 $7 $4 prochlorperazine 5 mg Tab 51079-0541-20 1 tab(s) $7 $0 $7 $4 prochlorperazine 5 mg/mL Soln 55390-0077-10 1 mL $34 $0 $34 $21 prochlorperazine 5 mg/mL Soln 00703-7171-04 1 mL $75 $0 $75 $45 prochlorperazine 5 mg/mL Soln 00641-0491-25 1 mL $30 $0 $30 $18 progesterone 200 mg Cap 43598-0350-01 1 cap(s) $30 $0 $30 $18

Page 98 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price promethazine 12.5 mg Tab 68084-0154-01 1 tab(s) $7 $0 $7 $4 promethazine 25 mg Tab 68084-0155-01 1 tab(s) $7 $0 $7 $4 promethazine 25 mg Tab 68001-0162-00 1 tab(s) $7 $0 $7 $4 promethazine 25 mg Tab 51079-0895-20 1 tab(s) $7 $0 $7 $4 promethazine 25 mg Tab 00904-5840-61 1 tab(s) $10 $0 $10 $6 promethazine 6.25 mg/5 mL Syrup 57664-0146-34 5 mL $5 $0 $5 $3 promethazine 6.25 mg/5 mL Syrup 60432-0608-16 5 mL $5 $0 $5 $3 propafenone 150 mg Tab 62559-0230-01 1 tab(s) $14 $0 $14 $9 propafenone 150 mg Tab 68084-0361-01 1 tab(s) $10 $0 $10 $6 propranolol 10 mg Tab 00603-5482-21 1 tab(s) $6 $0 $6 $3 propranolol 10 mg Tab 50111-0467-01 1 tab(s) $6 $0 $6 $3 propranolol 10 mg Tab 00115-1659-01 1 tab(s) $6 $0 $6 $4 propranolol 20 mg Tab 50268-0701-15 1 tab(s) $7 $0 $7 $4 propranolol 20 mg Tab 60687-0306-01 1 tab(s) $4 $0 $4 $2 propranolol 40 mg Tab 50268-0702-15 1 tab(s) $8 $0 $8 $5 propranolol 40 mg Tab 60687-0295-01 1 tab(s) $12 $0 $12 $7 propylthiouracil 50 mg Tab 68084-0964-25 1 tab(s) $15 $0 $15 $9 pseudoephedrine 30 mg Tab 00904-5053-24 1 tab(s) $4 $0 $4 $2 psyllium husk packet 1 packet Packet 37000-0024-44 1 packet(s) $6 $0 $6 $3 pyrazinamide 500 mg Tab 61748-0012-09 1 tab(s) $12 $0 $12 $7 pyrazinamide 500 mg Tab 61748-0012-11 1 tab(s) $12 $0 $12 $7 pyridostigmine 180 mg ER Ta 68682-0301-30 1 tab(s) $170 $0 $170 $102 pyridostigmine 180 mg ER Ta 47781-0335-30 1 tab(s) $170 $0 $170 $102 pyridoxine 50 mg Tab 77333-0940-10 1 tab(s) $4 $0 $4 $3 pyridoxine 50 mg Tab 00536-4408-01 1 tab(s) $4 $0 $4 $2 pyrimethamine 25 mg Tab 00173-0201-55 1 tab(s) $7 $0 $7 $4 QUEtiapine 100 mg Tab 60687-0349-01 1 tab(s) $47 $0 $47 $28 QUEtiapine 200 mg ER Ta 00310-0282-60 1 tab(s) $87 $0 $87 $52 QUEtiapine 200 mg ER Ta 50742-0637-60 1 tab(s) $117 $0 $117 $70 QUEtiapine 200 mg ER Ta 49884-0807-02 1 tab(s) $121 $0 $121 $72 QUEtiapine 25 mg Tab 60687-0327-01 1 tab(s) $29 $0 $29 $17 QUEtiapine 25 mg Tab 67877-0242-01 1 tab(s) $30 $0 $30 $18 quinine 325 mg Cap 51079-0559-20 1 cap(s) $5 $0 $5 $3 racepinephrine 2.25% Soln 00487-5901-99 0.5 mL $17 $0 $17 $10 ramelteon 8 mg Tab 64764-0805-30 1 tab(s) $65 $0 $65 $39 ramipril 1.25 mg Cap 60687-0321-21 1 cap(s) $16 $0 $16 $10 ramipril 1.25 mg Cap 61570-0110-56 1 cap(s) $11 $0 $11 $7 ramipril 1.25 mg Cap 68084-0294-21 1 cap(s) $16 $0 $16 $10 ramipril 1.25 mg Cap 68180-0588-01 1 cap(s) $14 $0 $14 $8 ramipril 10 mg Cap 68084-0268-01 1 cap(s) $19 $0 $19 $12 ramipril 10 mg Cap 68001-0431-00 1 cap(s) $17 $0 $17 $10 ramipril 10 mg Cap 68001-0141-00 1 cap(s) $17 $0 $17 $10 ramipril 2.5 mg Cap 57237-0223-01 1 cap(s) $15 $0 $15 $9 ramipril 2.5 mg Cap 68084-0266-01 1 cap(s) $16 $0 $16 $10 ramipril 2.5 mg Cap 68084-0266-11 1 cap(s) $16 $0 $16 $10 ramipril 2.5 mg Cap 00054-0107-20 1 cap(s) $15 $0 $15 $9 ramipril 5 mg Cap 00054-0108-20 1 cap(s) $16 $0 $16 $10 ramipril 5 mg Cap 68084-0267-01 1 cap(s) $17 $0 $17 $10 ramipril 5 mg Cap 68001-0430-00 1 cap(s) $15 $0 $15 $9 ramipril 5 mg Cap 68001-0143-00 1 cap(s) $15 $0 $15 $9 ramipril 5 mg Cap 68180-0590-01 1 cap(s) $16 $0 $16 $10 ramipril 5 mg Cap 61570-0112-01 1 cap(s) $17 $0 $17 $10 ranolazine 500 mg ER Ta 67159-0112-03 1 tab(s) $29 $0 $29 $18 ranolazine 500 mg ER Tablet 61958-1001-01 1 tab(s) $30 $0 $30 $18 rasagiline 1 mg Tab 00378-1271-93 1 tab(s) $171 $0 $171 $102 riboflavin 100 mg Tab 79854-0201-95 1 tab(s) $4 $0 $4 $2 rifabutin 150 mg Cap 00013-5301-17 1 cap(s) $56 $0 $56 $34 rifampin 150 mg Cap 00185-0801-30 1 cap(s) $12 $0 $12 $7 rifampin 150 mg Cap 68084-0357-21 1 cap(s) $13 $0 $13 $8 rifampin 150 mg Cap 61748-0015-30 1 cap(s) $14 $0 $14 $8 rifAMPin 25 mg/mL Susp 99345-0003-95 1 mL $13 $0 $13 $8 rifampin 300 mg Cap 61748-0018-11 1 cap(s) $17 $0 $17 $10 rifAMPin 300 mg Cap 61748-0018-30 1 cap(s) $17 $0 $17 $10 rifampin 300 mg Cap 51079-0890-20 1 cap(s) $24 $0 $24 $14 rifampin 600 mg REC I 67457-0445-60 10 mL $1,358 $0 $1,358 $815 rifampin 600 mg REC Inj 00068-0597-01 10 mL $1,483 $0 $1,483 $890 Rifaximin 550 mg Tab 65649-0303-02 1 tab(s) $193 $0 $193 $116 riluzole 50 mg Tab 62756-0538-86 1 tab(s) $253 $0 $253 $152 riluzole 50 mg Tab 68084-0908-25 1 tab(s) $253 $0 $253 $152 rimabotulinumtoxinB 5000 units/mL Soln 10454-0710-10 0.5 mL $596 $0 $596 $358 rimabotulinumtoxinB 5000 units/mL Soln 10454-0711-10 1 mL $1,192 $0 $1,192 $715 risperiDONE 0.25 mg Tab 00904-6357-61 1 tab(s) $27 $0 $27 $16 risperiDONE 0.25 mg Tab 68084-0270-01 1 tab(s) $29 $0 $29 $18 risperidone 0.5 mg Tab 51079-0461-20 1 tab(s) $32 $0 $32 $19 risperiDONE 0.5 mg Tab 68084-0271-01 1 tab(s) $32 $0 $32 $19 risperiDONE 1 mg Tab 00904-6359-61 1 tab(s) $34 $0 $34 $20 risperiDONE 1 mg Tab 68084-0272-01 1 tab(s) $34 $0 $34 $20 risperiDONE 2 mg Tab 00904-6360-61 1 tab(s) $51 $0 $51 $30 risperidone 2 mg Tab 51079-0463-01 1 tab(s) $54 $0 $54 $33

Page 99 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price risperidone 2 mg Tab 51079-0463-20 1 tab(s) $54 $0 $54 $33 ritonavir 100 mg Tab 60687-0364-25 1 tab(s) $79 $0 $79 $47 ritonavir 100 mg Tab 65862-0687-30 1 tab(s) $65 $0 $65 $39 ritonavir 100 mg Tab 31722-0597-30 1 tab(s) $65 $0 $65 $39 ritonavir 100 mg Tab 00054-0407-13 1 tab(s) $65 $0 $65 $39 ritonavir 80 mg/mL Soln 00074-1940-63 1 mL $49 $0 $49 $29 rivaroxaban 10 mg Tab 50458-0580-10 1 tab(s) $62 $0 $62 $37 rivaroxaban 15 mg Tab 50458-0578-30 1 tab(s) $123 $0 $123 $74 rivaroxaban 15 mg Tab 50458-0578-90 1 tab(s) $74 $0 $74 $44 rivaroxaban 2.5 mg Tab 50458-0577-60 1 tab(s) $66 $0 $66 $40 rivaroxaban 20 mg Tab 50458-0579-30 1 tab(s) $123 $0 $123 $74 rivaroxaban 20 mg Tab 50458-0579-90 1 tab(s) $88 $0 $88 $53 rivastigmine 1.5 mg Cap 51991-0793-06 1 cap(s) $32 $0 $32 $19 rivastigmine 2 mg/mL Soln 00078-0339-31 1 mL $31 $0 $31 $19 rivastigmine 4.6 mg/24 hr ER Fi 00078-0501-61 1 patch(es) $60 $0 $60 $36 rivastigmine ER patch 4.6 mg/24 hr Patch 00781-7304-31 1 patch(es) $126 $0 $126 $76 rOPINIRole 0.25 mg Tab 00904-6373-61 1 tab(s) $7 $0 $7 $4 rOPINIRole 0.25 mg Tab 62332-0030-31 1 tab(s) $20 $0 $20 $12 rOPINIRole 1 mg Tab 68462-0255-01 1 tab(s) $20 $0 $20 $12 rOPINIRole 1 mg Tab 62332-0032-31 1 tab(s) $20 $0 $20 $12 rOPINIRole 1 mg Tab 00904-6374-61 1 tab(s) $9 $0 $9 $5 ropinirole 4 mg Tab 00007-4896-20 1 tab(s) $21 $0 $21 $12 rOPINIRole 4 mg Tab 68462-0258-01 1 tab(s) $21 $0 $21 $12 ropivacaine 0.2% Soln 63323-0285-10 10 mL $47 $0 $47 $28 ropivacaine 0.5% Soln 63323-0286-30 30 mL $191 $0 $191 $114 rosuvastatin 10 mg Tab 27808-0156-01 1 tab(s) $63 $0 $63 $38 rosuvastatin 10 mg Tab 60687-0245-01 1 tab(s) $51 $0 $51 $31 rosuvastatin 10 mg Tab 60505-4503-09 1 tab(s) $63 $0 $63 $38 rosuvastatin 20 mg Tab 60687-0256-01 1 tab(s) $51 $0 $51 $31 rosuvastatin 20 mg Tab 68462-0263-90 1 tab(s) $63 $0 $63 $38 rosuvastatin 20 mg Tab 16729-0286-15 1 tab(s) $63 $0 $63 $38 rosuvastatin 5 mg Tab 70377-0006-12 1 tab(s) $63 $0 $63 $38 rosuvastatin 5 mg Tab 60687-0234-01 1 tab(s) $51 $0 $51 $31 rotavirus vaccine monovalent REC P 58160-0854-52 1 mL $841 $0 $841 $505 saccharomyces boulardii lyo cap 250 mg Cap 04142-0000-07 1 cap(s) $8 $0 $8 $5 sacubitril-valsartan 24 mg-26 mg Tab 00078-0659-20 1 tab(s) $72 $0 $72 $43 sacubitril-valsartan 49 mg-51 mg Tab 00078-0777-20 1 tab(s) $72 $0 $72 $43 sacubitril-valsartan 97 mg-103 mg Tab 00078-0696-20 1 tab(s) $72 $0 $72 $43 salicylic acid-sulfur Topical 2%-2% Shamp 00072-2600-07 1 app $78 $0 $78 $47 Saliva Substitute 1 Spray 01015-8117-20 1 spray(s) $40 $0 $40 $24 saliva substitutes - Soln 48582-0802-20 15 mL $41 $0 $41 $25 saliva substitutes - Spray 00386-0009-75 1 app $76 $0 $76 $46 Sarna Lotion 07346-2062-85 1 app $71 $0 $71 $43 scopolamine 1 mg/72 hr ER Fi 00378-6470-99 1 patch(es) $149 $0 $149 $90 selegiline 5 mg Cap 60505-0055-01 1 cap(s) $19 $0 $19 $11 selenium 50 mcg Tab 00182-1138-01 1 tab(s) $4 $0 $4 $2 senna 10 ml 10 mL Syrup 59390-0125-41 1 mL $118 $0 $118 $71 senna 8.6 mg Tab 57896-0454-01 1 tab(s) $4 $0 $4 $2 senna 8.6 mg Tab 67618-0300-10 1 tab(s) $5 $0 $5 $3 senna 8.6 mg Tab 67618-0300-50 1 tab(s) $5 $0 $5 $3 senna 8.6 mg Tab 46122-0575-78 1 tab(s) $4 $0 $4 $2 senna 8.6 mg Tab 00904-6434-80 1 tab(s) $3 $0 $3 $2 senna 8.6 mg Tab 00904-6725-59 1 tab(s) $3 $0 $3 $2 senna 8.8 mg/5 mL Syrup 00904-6289-09 1 mL $5 $0 $5 $3 senna 8.8 mg/5 mL Syrup 00904-5452-09 1 mL $5 $0 $5 $3 senna 8.8 mg/5 mL Syrup 00904-6206-09 1 mL $5 $0 $5 $3 senna 8.8 mg/5 mL Syrup 00536-1275-59 1 mL $5 $0 $5 $3 senna 8.8 mg/5 mL Syrup 00536-1000-59 1 mL $5 $0 $5 $3 sennosides 17.6 mg / 10 mL Syrup 17856-1275-01 10 mL $13 $0 $13 $8 sennosides [UD] 17.6 mg / 10 mL Soln 17856-0462-01 10 mL $16 $0 $16 $9 sennosides 17.6 mg / 10 mL Soln 17856-8237-02 10 mL $15 $0 $15 $9 sennosides 17.6 mg / 10 mL Syrup 17856-0452-02 10 mL $16 $0 $16 $9 sertraline 100 mg Tab 68084-0182-01 1 tab(s) $6 $0 $6 $4 sertraline 20 mg/mL Conc 20 mg/mL Conc 64980-0409-06 1 mL $12 $0 $12 $7 sertraline 25 mg Tab 60687-0231-01 1 tab(s) $6 $0 $6 $4 sertraline 25 mg Tab 59762-4960-01 1 tab(s) $22 $0 $22 $13 sertraline 25 mg Tab 51079-0149-20 1 tab(s) $22 $0 $22 $13 sertraline 25 mg Tab 51079-0762-01 1 tab(s) $22 $0 $22 $13 sertraline 25 mg Tab 51079-0762-20 1 tab(s) $22 $0 $22 $13 sertraline 25 mg Tab 31722-0212-90 1 tab(s) $22 $0 $22 $13 sertraline 25 mg Tab 00049-4960-30 1 tab(s) $24 $0 $24 $14 sertraline 50 mg Tab 60687-0242-01 1 tab(s) $6 $0 $6 $4 sertraline 50 mg Tab 59762-4900-03 1 tab(s) $22 $0 $22 $13 sertraline 50 mg Tab 65862-0012-01 1 tab(s) $22 $0 $22 $13 sevelamer 800 mg Tab 68462-0447-18 1 tab(s) $57 $0 $57 $34 sevelamer 400 mg Tab 68462-0446-26 1 tab(s) $30 $0 $30 $18 sevelamer carbonate 0.8 g REC P 65862-0930-90 30 mL $126 $0 $126 $76 sevelamer carbonate 800 mg Tab 65162-0058-27 1 tab(s) $44 $0 $44 $27 sildenafil 20 mg Tab 68084-0869-21 1 tab(s) $12 $0 $12 $7

Page 100 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price sildenafil 20 mg Tab 00904-6671-06 1 tab(s) $10 $0 $10 $6 sildenafil 20 mg Tab 20 mg Tab 60687-0416-21 1 tab(s) $139 $0 $139 $83 silver sulfADIAZINE Topical 1% Cream 61570-0131-40 1 app $513 $0 $513 $308 silver sulfADIAZINE topical 1% Cream 61570-0131-55 1 app $117 $0 $117 $70 silver sulfADIAZINE topical 1% Cream 59762-0131-06 1 app $113 $0 $113 $68 silver sulfADIAZINE topical 1% Cream 67877-0124-40 1 app $456 $0 $456 $274 simethicone 40 mg/0.6 mL LIQ 62372-0630-15 0.6 mL $43 $0 $43 $26 simethicone 80 mg Chew 00536-1019-01 1 tab(s) $4 $0 $4 $2 simethicone 80 mg Chew 24385-0118-78 1 tab(s) $3 $0 $3 $2 simethicone 80 mg Chew 57896-0799-01 1 tab(s) $3 $0 $3 $2 simethicone 80 mg Chew 51645-0860-01 1 tab(s) $4 $0 $4 $2 simethicone 80 mg Chew tab 00182-8643-00 1 tab(s) $110 $0 $110 $66 simethicone 80 mg Chew Tab 00182-8643-89 1 tab(s) $4 $0 $4 $3 simple syrup 38779-1779-08 1 mL $5 $0 $5 $3 simvastatin 10 mg Tab 00904-5800-61 1 tab(s) $20 $0 $20 $12 simvastatin 10 mg Tab 51079-0454-20 1 tab(s) $22 $0 $22 $13 simvastatin 10 mg Tab 68084-0511-01 1 tab(s) $22 $0 $22 $13 simvastatin 20 mg Tab 68084-0512-01 1 tab(s) $10 $0 $10 $6 simvastatin 20 mg Tab 65862-0052-90 1 tab(s) $36 $0 $36 $22 simvastatin 20 mg Tab 55111-0199-90 1 tab(s) $36 $0 $36 $22 simvastatin 20 mg Tab 00904-5801-61 1 tab(s) $33 $0 $33 $20 simvastatin 40 mg Tab 00904-5802-61 1 tab(s) $33 $0 $33 $20 simvastatin 40 mg Tab 31722-0513-90 1 tab(s) $36 $0 $36 $22 simvastatin 40 mg Tab 60687-0210-01 1 tab(s) $36 $0 $36 $22 simvastatin 80 mg Tab 68084-0165-01 1 tab(s) $36 $0 $36 $22 simvastatin 80 mg Tab 55111-0268-90 1 tab(s) $36 $0 $36 $22 simvastatin 80 mg Tab 16729-0007-15 1 tab(s) $36 $0 $36 $22 sirolimus 0.5 mg Tab 68382-0520-01 1 tab(s) $61 $0 $61 $37 sirolimus 1 mg Tab 68084-0915-25 1 tab(s) $118 $0 $118 $71 sirolimus 1 mg Tab 00008-1041-05 1 tab(s) $64 $0 $64 $39 sirolimus 1 mg Tab 00008-1041-10 1 tab(s) $93 $0 $93 $56 sirolimus 1 mg/mL Soln 66689-0347-02 1 mL $250 $0 $250 $150 sitagliptin 100 mg Tab 00006-0277-28 1 tab(s) $36 $0 $36 $22 sitagliptin 25 mg Tab 00006-0221-28 1 tab(s) $48 $0 $48 $29 sodium acetate 2 mEq/mL Soln 00409-7299-25 1 mL $9 $0 $9 $5 sodium bicarbonate 650 mg Tab 00677-0131-10 1 tab(s) $3 $0 $3 $2 sodium bicarbonate 650 mg Tab 66553-0008-01 1 tab(s) $4 $0 $4 $2 sodium bicarbonate 650 mg Tab 64980-0182-10 1 tab(s) $3 $0 $3 $2 sodium bicarbonate 8.4% Soln 00548-3352-00 50 mL $57 $0 $57 $34 sodium biphosphate-sodium phosphate 48%-18% Soln 00132-0107-01 5 mL $49 $0 $49 $29 sodium biphosphate-sodium phosphate 48%-18% Soln 00132-0108-03 5 mL $30 $0 $30 $18 sodium biphosphate-sodium phosphate 48%-18% Soln 00132-0109-15 5 mL $49 $0 $49 $29 sodium biphosphate-sodium phosphate 7 g-19 g Enema 00904-6320-78 133 mL $12 $0 $12 $7 sodium chloride 0.9% Soln 00378-6985-01 3 mL $11 $0 $11 $6 sodium chloride 0.9% Soln 00487-9301-33 3 mL $9 $0 $9 $5 sodium chloride 1 g Tab 69367-0220-01 1 tab(s) $4 $0 $4 $3 sodium chloride 1 g Tab 00527-1116-10 1 tab(s) $4 $0 $4 $2 sodium chloride 23.4% Soln 63323-0088-61 1 mL $9 $0 $9 $6 sodium chloride 3% Soln 00378-6997-89 4 mL $10 $0 $10 $6 sodium chloride 7% Soln 83490-0207-60 4 mL $14 $0 $14 $8 sodium chloride, hypertonic, ophthalmic 2% Soln 00998-0504-15 1 drop(s) $131 $0 $131 $79 sodium chloride, hypertonic, ophthalmic 2% Soln 24208-0276-15 1 drop(s) $129 $0 $129 $77 sodium chloride, hypertonic, ophthalmic 5% Ointm 17478-0622-35 1 app $93 $0 $93 $56 sodium chloride, hypertonic, ophthalmic 5% Soln 17478-0623-12 1 drop(s) $93 $0 $93 $56 sodium chloride, hypertonic, ophthalmic 5% Soln 24208-0277-15 1 drop(s) $135 $0 $135 $81 sodium hyaluronate 10 mg/mL Soln 08024-0724-12 2 mL $146 $0 $146 $88 sodium hyaluronate 10 mg/mL Soln 08024-0724-20 2 mL $146 $0 $146 $88 sodium hyaluronate soln (Supartz) 10 mg/mL Soln 89130-4444-01 2.5 mL $1,945 $0 $1,945 $1,167 sodium hypochlorite topical 0.25% Soln 39328-0063-25 1 app $33 $0 $33 $20 sodium hypochlorite topical 0.5% Soln 39328-0062-50 1 app $33 $0 $33 $20 sodium phosphate 3 mmol/mL Soln 63323-0170-15 1 mL $25 $0 $25 $15 sodium polystyrene sulfonate 15 g/60 mL Susp 00054-0379-51 60 mL $63 $0 $63 $38 sodium zirconium cyclosilicate 10 g REC P 00310-1110-30 1 packet(s) $184 $0 $184 $110 sodium zirconium cyclosilicate 5 g REC P 00310-1105-30 1 packet(s) $184 $0 $184 $110 solifenacin 10 mg Tab 51248-0151-52 1 tab(s) $27 $0 $27 $16 solifenacin 10 mg Tab 60505-4703-03 1 tab(s) $96 $0 $96 $57 solifenacin 5 mg Tab 60505-4702-03 1 tab(s) $96 $0 $96 $58 solifenacin 5 mg Tab 60687-0499-21 1 tab(s) $16 $0 $16 $10 solifenacin 5 mg Tab 51248-0150-03 1 tab(s) $63 $0 $63 $38 sotalol 80 mg Tab 00603-5769-21 1 tab(s) $21 $0 $21 $12 spironolactone 25 mg Tab 59746-0216-01 1 tab(s) $6 $0 $6 $4 spironolactone 25 mg Tab 60687-0465-01 1 tab(s) $5 $0 $5 $3 spironolactone 25 mg Tab 63739-0544-10 1 tab(s) $6 $0 $6 $4 spironolactone 50 mg Tab 63739-0545-10 1 tab(s) $9 $0 $9 $5 spironolactone 50 mg Tab 60687-0476-01 1 tab(s) $7 $0 $7 $4 spironolactone 50 mg Tab 59746-0217-01 1 tab(s) $9 $0 $9 $5 sterile water - Soln 63323-0185-10 10 mL $14 $0 $14 $8 sterile water - Soln 00338-0003-44 1000 mL $30 $0 $30 $18 sterile water - Soln 00338-0004-04 1000 mL $30 $0 $30 $18

Page 101 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price sterile water - Soln 00338-0013-04 1 mL $0 $0 $0 $0 sterile water - Soln 00409-7139-09 1000 mL $30 $0 $30 $18 sterile water - Soln 00517-3020-25 20 mL $18 $0 $18 $11 sterile water - Soln 00409-4887-10 10 mL $13 $0 $13 $8 sterile water - Soln 00409-4887-20 20 mL $15 $0 $15 $9 sterile water - Soln 100 mL 00409-4887-99 100 mL $36 $0 $36 $22 sucralfate 1 g Tab 00093-2210-01 1 tab(s) $9 $0 $9 $5 sucralfate 1 g/10 mL Susp 68094-0171-59 10 mL $23 $0 $23 $14 sucralfate 1 g/10 mL Susp 66689-0790-50 10 mL $39 $0 $39 $23 sulfADIAZINE 500 mg Tab 00185-0757-01 1 tab(s) $13 $0 $13 $8 sulfamethoxazole-trimethoprim 800 mg-160 mg Tab 60687-0531-01 1 tab(s) $5 $0 $5 $3 sulfamethoxazole-trimethoprim 200 mg-40 mg/5 mL Susp 54879-0007-16 1 mL $5 $0 $5 $3 sulfamethoxazole-trimethoprim 400 mg-80 mg Tab 53746-0271-01 1 tab(s) $9 $0 $9 $5 sulfamethoxazole-trimethoprim 80 mg-16 mg/mL Soln 00703-9514-03 1 mL $14 $0 $14 $8 sulfamethoxazole-trimethoprim 80 mg-16 mg/mL Soln 00703-9526-01 1 mL $12 $0 $12 $7 sulfamethoxazole-trimethoprim 800 mg-160 mg Tab 00904-2725-61 1 tab(s) $6 $0 $6 $3 sulfasalazine 500 mg EC Ta 59762-0104-01 1 tab(s) $6 $0 $6 $4 sulfasalazine 500 mg EC Tab 00013-0102-01 1 tab(s) $7 $0 $7 $4 sulfasalazine 500 mg Tab 00013-0101-11 1 tab(s) $5 $0 $5 $3 sulfaSALAzine 500 mg Tab 50268-0730-15 1 tab(s) $7 $0 $7 $4 sulfasalazine 500 mg Tab 59762-5000-01 1 tab(s) $5 $0 $5 $3 sulfaSALAzine 500 mg Tab 59762-5000-05 1 tab(s) $5 $0 $5 $3 sumatriptan 25 mg Tab 62756-0520-69 1 tab(s) $185 $0 $185 $111 sumatriptan 25 mg Tab 68084-0339-97 1 tab(s) $55 $0 $55 $33 SUMAtriptan 25 mg Tab 65862-0146-36 1 tab(s) $185 $0 $185 $111 sumatriptan 25 mg Tab 00173-0735-00 1 tab(s) $187 $0 $187 $112 sumatriptan 6 mg Injection 25021-0703-60 0.5 mL $147 $0 $147 $88 SUMAtriptan 6 mg/0.5 mL Soln 55150-0173-05 0.5 mL $604 $0 $604 $362 sunitinib 12.5 mg Cap 00069-0550-38 1 cap(s) $501 $0 $501 $301 sunitinib 25 mg Cap 00069-0770-38 1 cap(s) $1,000 $0 $1,000 $600 suvorexant 20 mg Tab 00006-0335-30 1 tab(s) $93 $0 $93 $56 Sween cream 120 gm 01170-1002-15 1 app $33 $0 $33 $20 Synvisc Inj 05846-8009-01 1 EA $216 $0 $216 $129 tacrolimus 1 mg Cap 54288-0135-01 1 cap(s) $50 $0 $50 $30 tacrolimus 0.5 mg Cap 55111-0525-01 1 cap(s) $18 $0 $18 $11 tacrolimus 0.5 mg Cap 51079-0817-01 1 cap(s) $18 $0 $18 $11 tacrolimus 0.5 mg Cap 51079-0817-20 1 cap(s) $18 $0 $18 $11 tacrolimus 0.5 mg Cap 68084-0449-01 1 cap(s) $18 $0 $18 $11 tacrolimus 0.5 mg Cap 68084-0449-11 1 cap(s) $18 $0 $18 $11 tacrolimus 0.5 mg Cap 00781-2102-01 1 cap(s) $18 $0 $18 $11 tacrolimus 0.5 mg Cap 42291-0752-01 1 cap(s) $18 $0 $18 $11 tacrolimus 0.5 mg Cap 00378-2045-01 1 cap(s) $18 $0 $18 $11 tacrolimus 0.5 mg Cap 00469-0607-73 1 cap(s) $19 $0 $19 $11 tacrolimus 0.75 mg ER Ta 68992-3075-03 1 tab(s) $27 $0 $27 $16 tacrolimus 1 mg Cap 51079-0818-20 1 cap(s) $33 $0 $33 $20 tacrolimus 1 mg Cap 55111-0526-01 1 cap(s) $33 $0 $33 $20 tacrolimus 1 mg Cap 00469-0617-73 1 cap(s) $32 $0 $32 $19 tacrolimus 1 mg Cap 00378-2046-01 1 cap(s) $33 $0 $33 $20 tacrolimus 1 mg Cap 42291-0753-01 1 cap(s) $33 $0 $33 $20 tacrolimus 1 mg Cap 16729-0042-01 1 cap(s) $33 $0 $33 $20 tacrolimus 1 mg Cap 00781-2103-01 1 cap(s) $33 $0 $33 $20 tacrolimus 1 mg ER Ta 68992-3010-03 1 tab(s) $35 $0 $35 $21 tacrolimus 4 mg ER Ta 68992-3040-03 1 tab(s) $128 $0 $128 $77 tacrolimus 5 mg Cap 68084-0451-01 1 cap(s) $153 $0 $153 $92 tacrolimus 5 mg Cap 16729-0043-01 1 cap(s) $153 $0 $153 $92 tacrolimus topical 0.1% Ointm 68462-0534-65 1 app $3,659 $0 $3,659 $2,195 tacrolimus topical 0.1% Ointm 16729-0422-12 1 app $4,067 $0 $4,067 $2,440 tamoxifen 10 mg Tab 00591-2472-60 1 tab(s) $16 $0 $16 $10 tamoxifen 10 mg Tab 63739-0269-10 1 tab(s) $19 $0 $19 $12 tamoxifen 20 mg Tab 00591-2473-30 1 tab(s) $29 $0 $29 $17 tamsulosin 0.4 mg Cap 00228-2996-11 1 cap(s) $32 $0 $32 $19 tamsulosin 0.4 mg Cap 63739-0567-10 1 cap(s) $6 $0 $6 $4 tamsulosin 0.4 mg Cap 51079-0294-20 1 cap(s) $32 $0 $32 $19 tamsulosin 0.4 mg Cap 68382-0132-01 1 cap(s) $32 $0 $32 $19 tamsulosin 0.4 mg Cap 68084-0299-01 1 cap(s) $32 $0 $32 $19 tapentadol 100 mg ER Ta 69865-0245-02 1 tab(s) $101 $0 $101 $61 tapentadol 150 mg ER Ta 69865-0250-02 1 tab(s) $130 $0 $130 $78 tapentadol 250 mg ER Ta 69865-0265-01 1 tab(s) $203 $0 $203 $122 tapentadol 50 mg ER Ta 69865-0240-02 1 tab(s) $49 $0 $49 $29 tapentadol 50 mg Tab 24510-0050-10 1 tab(s) $58 $0 $58 $35 tapentadol 75 mg Tab 24510-0075-10 1 tab(s) $69 $0 $69 $41 tapentadol 75 mg Tab 50458-0830-02 1 tab(s) $20 $0 $20 $12 tapentadol 75 mg Tab 50458-0830-04 1 tab(s) $20 $0 $20 $12 tapentadol ER 50 mg ER Tablet 24510-0058-60 1 tab(s) $49 $0 $49 $30 tegaserod 6 mg Tab 00078-0356-80 1 tab(s) $23 $0 $23 $14 tegaserod 6 mg Tab 00078-0426-20 1 tab(s) $28 $0 $28 $17 temazepam 15 mg Cap 00228-2076-10 1 cap(s) $10 $0 $10 $6 temazepam 15 mg Cap 51079-0418-01 1 cap(s) $10 $0 $10 $6 temazepam 15 mg Cap 51079-0418-20 1 cap(s) $10 $0 $10 $6

Page 102 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price temazepam 7.5 mg Cap 00406-9960-01 1 cap(s) $12 $0 $12 $7 temozolamide 20 mg Cap 00085-1366-05 1 cap(s) $320 $0 $320 $192 temozolomide 100 mg Cap 00093-7601-41 1 cap(s) $1,628 $0 $1,628 $977 temozolomide 100 mg Cap 00781-2693-44 1 cap(s) $1,696 $0 $1,696 $1,017 temozolomide 20 mg Cap 16729-0049-54 1 cap(s) $389 $0 $389 $233 temozolomide 20 mg Cap 00085-1519-02 1 cap(s) $280 $0 $280 $168 temozolomide 20 mg Cap 00085-1244-01 1 cap(s) $242 $0 $242 $145 temozolomide 20 mg Cap 00085-1336-04 1 cap(s) $320 $0 $320 $192 temozolomide 5 mg Cap 00085-3004-04 1 cap(s) $91 $0 $91 $55 temozolomide 5 mg Cap 00093-7599-41 1 cap(s) $85 $0 $85 $51 tenofovir 300 mg Tab 69097-0533-02 1 tab(s) $41 $0 $41 $24 tenofovir 300 mg Tab 65862-0421-30 1 tab(s) $19 $0 $19 $12 terazosin 2 mg Cap 59746-0384-06 1 cap(s) $14 $0 $14 $8 terbinafine 250 mg Tab 65862-0079-30 1 tab(s) $89 $0 $89 $53 terbinafine topical 1% Cream 51672-2080-02 1 app $10 $0 $10 $6 terbutaline 5 mg Tab 68084-0257-21 1 tab(s) $9 $0 $9 $6 terbutaline 5 mg Tab 00115-2622-01 1 tab(s) $8 $0 $8 $5 terconazole topical 80 mg Supp 00062-5351-01 1 supp $372 $0 $372 $223 terconazole topical 80 mg Supp 45802-0717-08 1 supp $331 $0 $331 $199 testosterone 1% Gel 00051-8425-30 1 packet(s) $23 $0 $23 $14 testosterone 1% Gel 00051-8450-30 1 packet(s) $114 $0 $114 $68 testosterone 2 mg/24 hr ER Fi 52544-0076-54 1 EA $55 $0 $55 $33 testosterone 2 mg/24 hr Patch 00023-5990-60 1 EA $94 $0 $94 $57 testosterone 4 mg/24 hr Patch 52544-0077-54 1 EA $93 $0 $93 $56 testosterone 50 mg/5 g (1%) Gel 00591-3217-30 1 packet(s) $110 $0 $110 $66 testosterone 50 mg/5 g (1%) Gel 00832-1120-35 1 packet(s) $101 $0 $101 $61 testosterone cypionate 200 mg/mL Soln 00009-0086-01 1 mL $173 $0 $173 $104 testosterone cypionate 200 mg/mL Soln 00409-6562-01 1 mL $160 $0 $160 $96 tetanus-diphth toxoids (Td) adult/adol 2 units-2 units/0.5 mL Susp 13533-0131-01 0.5 mL $410 $0 $410 $246 tetanus-diphtheria toxoids (Td) 2 units-2 units/0.5 mL Susp 17478-0131-01 0.5 mL $338 $0 $338 $203 tetanus/diphth/pertuss (Tdap) adult/adol 5 units-2 units-15.5 mcg/0.5 mL Susp 49281-0400-15 0.5 mL $804 $0 $804 $483 tetracycline 125 mg/5 mL Susp 49884-0799-33 5 mL $6 $0 $6 $4 theophylline 200 mg Elixir 49708-0644-90 1 mL $6 $0 $6 $4 theophylline 200 mg ER Tab 50111-0482-01 1 tab(s) $6 $0 $6 $3 theophylline 300 mg ER Ta 62332-0025-31 1 tab(s) $32 $0 $32 $19 theophylline 80 mg/15 mL Elixi 00456-0644-16 1 mL $6 $0 $6 $4 thiamine 100 mg Tab 48433-0108-01 1 tab(s) $4 $0 $4 $3 thiamine 100 mg Tab 31604-0012-81 1 tab(s) $4 $0 $4 $2 thiamine 100 mg Tab 51645-0905-99 1 tab(s) $4 $0 $4 $2 thiamine 100 mg Tab 77333-0934-10 1 tab(s) $4 $0 $4 $2 thiamine 100 mg/mL Soln 67457-0196-02 2 mL $84 $0 $84 $50 thiamine 100 mg/mL Soln 63323-0013-09 2 mL $95 $0 $95 $57 tigecycline 50 mg REC I 00008-4990-02 5 mL $537 $0 $537 $322 tigecycline 50 mg REC I 63323-0960-10 5 mL $1,376 $0 $1,376 $825 tigecycline 50 mg REC Injection 00008-4990-20 5 mL $579 $0 $579 $347 timolol ophthalmic 0.25% Gel 61314-0224-05 1 drop(s) $199 $0 $199 $120 timolol ophthalmic 0.25% Gel 54569-4302-00 1 drop(s) $210 $0 $210 $126 timolol ophthalmic 0.5% Gel 61314-0225-05 1 drop(s) $418 $0 $418 $251 timolol ophthalmic maleate 0.25% Soln 60758-0802-10 1 drop(s) $60 $0 $60 $36 timolol ophthalmic maleate 0.5% Soln 68682-0045-25 1 drop(s) $2,468 $0 $2,468 $1,481 tiotropium 18 mcg Cap 00597-0075-75 1 cap(s) $636 $0 $636 $382 tizanidine 2 mg Tab 00378-0722-19 1 tab(s) $12 $0 $12 $7 tizanidine 2 mg Tab 68084-0775-21 1 tab(s) $15 $0 $15 $9 tizanidine 2 mg Tab 64720-0106-15 1 tab(s) $12 $0 $12 $7 tizanidine 2 mg Tab 60505-0251-03 1 tab(s) $12 $0 $12 $7 tizanidine 2 mg Tab (Zanaflex) 52152-0236-21 1 tab(s) $11 $0 $11 $7 tiZANidine 4 mg Tab 68084-0645-01 1 tab(s) $13 $0 $13 $8 tizanidine 4 mg tab 4 mg Tab 51079-0998-01 1 tab(s) $13 $0 $13 $8 TNF CONT 1 mL Soln 99999-9999-03 1 mL $49 $0 $49 $30 TNF INT 1 EA Injection 99999-9999-02 1 mL $63 $0 $63 $38 tobramycin 40 mg/mL Soln 67457-0428-30 1 mL $14 $0 $14 $8 tobramycin 60 mg/mL Soln 17478-0340-38 5 mL $448 $0 $448 $269 tobramycin 60 mg/mL Soln 47335-0171-49 5 mL $910 $0 $910 $546 tobramycin ophthalmic 0.3% Soln 70069-0131-01 1 drop(s) $105 $0 $105 $63 tolterodine 1 mg Tab 59762-0170-06 1 tab(s) $15 $0 $15 $9 tolterodine 1 mg Tab 00009-4541-01 1 tab(s) $22 $0 $22 $13 tolterodine 1 mg Tab 00009-4541-02 1 tab(s) $17 $0 $17 $10 tolterodine 1 mg Tab 00093-2056-06 1 tab(s) $26 $0 $26 $15 tolterodine 2 mg ER Ca 60687-0319-21 1 cap(s) $84 $0 $84 $50 tolterodine 2 mg Tab 59762-0800-02 1 tab(s) $26 $0 $26 $16 tolterodine 4 mg ER Ca 60687-0330-21 1 cap(s) $84 $0 $84 $50 tolvaptan 15 mg Tab 59148-0020-50 1 tab(s) $2,178 $0 $2,178 $1,307 topiramate 100 mg Tab 51079-0728-01 1 tab(s) $50 $0 $50 $30 topiramate 100 mg Tab 51079-0728-20 1 tab(s) $50 $0 $50 $30 topiramate 100 mg Tab 68084-0344-01 1 tab(s) $45 $0 $45 $27 topiramate 100 mg Tab 50458-0641-65 1 tab(s) $55 $0 $55 $33 topiramate 100 mg Tab 13668-0033-60 1 tab(s) $31 $0 $31 $18 topiramate 200 mg Tab 68084-0345-21 1 tab(s) $52 $0 $52 $31 topiramate 25 mg Cap 68382-0005-14 1 cap(s) $23 $0 $23 $14

Page 103 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price topiramate 25 mg Cap 50458-0645-65 1 cap(s) $25 $0 $25 $15 topiramate 25 mg Cap 00093-7336-06 1 cap(s) $23 $0 $23 $14 topiramate 50 mg Tab 68084-0343-21 1 tab(s) $33 $0 $33 $20 topiramate 50 mg Tab 68382-0139-14 1 tab(s) $38 $0 $38 $23 topiramate 50 mg Tab 68462-0153-60 1 tab(s) $33 $0 $33 $20 topiramate 50 mg Tab 31722-0279-60 1 tab(s) $37 $0 $37 $22 topiramate 6 mg/mL Susp 99345-0003-75 1 mL $13 $0 $13 $8 torsemide 10 mg Tab 62756-0762-88 1 tab(s) $8 $0 $8 $5 torsemide 10 mg Tab 31722-0530-01 1 tab(s) $8 $0 $8 $5 torsemide 10 mg Tab 50111-0916-01 1 tab(s) $8 $0 $8 $5 torsemide 10 mg Tab 51079-0025-20 1 tab(s) $9 $0 $9 $6 torsemide 10 mg Tab 00093-7128-01 1 tab(s) $8 $0 $8 $5 torsemide 100 mg Tab 50268-0757-15 1 tab(s) $23 $0 $23 $14 torsemide 100 mg Tab 31722-0532-01 1 tab(s) $24 $0 $24 $14 torsemide 100 mg Tab 62756-0764-88 1 tab(s) $24 $0 $24 $14 torsemide 100 mg Tab 60505-0235-01 1 tab(s) $24 $0 $24 $14 torsemide 20 mg Tab 62756-0763-88 1 tab(s) $9 $0 $9 $5 torsemide 20 mg Tab 68084-0539-01 1 tab(s) $9 $0 $9 $5 torsemide 20 mg Tab 68084-0539-11 1 tab(s) $9 $0 $9 $5 torsemide 20 mg Tab 50111-0917-01 1 tab(s) $9 $0 $9 $5 torsemide 20 mg Tab 51079-0026-01 1 tab(s) $9 $0 $9 $6 torsemide 20 mg Tab 51079-0026-20 1 tab(s) $9 $0 $9 $6 torsemide 20 mg Tab 00054-0077-25 1 tab(s) $9 $0 $9 $6 torsemide 5 mg Tab 50111-0915-01 1 tab(s) $8 $0 $8 $5 torsemide 5 mg Tab 50268-0754-15 1 tab(s) $8 $0 $8 $5 trace elements 1 mcg-0.1 mg-0.025 mg-1.0 mg/mL Soln 00517-9203-25 1 mL $11 $0 $11 $6 trace elements 4.0 mcg-0.4 mg-0.1 mg-1.0 mg/mL Soln 00517-7201-25 1 mL $13 $0 $13 $8 trace elements 4.0 mcg-0.4 mg-0.1 mg-1.0 mg/mL Soln 00517-7410-25 1 mL $12 $0 $12 $7 tramadol 100 mg ER Tablet 50458-0653-30 1 tab(s) $39 $0 $39 $23 traMADol 100 mg/24 hours ER Ta 47335-0859-83 1 tab(s) $30 $0 $30 $18 traMADOL 100 mg/24 hours ER Ta 49884-0821-11 1 tab(s) $30 $0 $30 $18 traMADol 100 mg/24 hours ER Ta 10370-0221-11 1 tab(s) $38 $0 $38 $23 traMADol 100 mg/24 hours ER Ta 68180-0697-06 1 tab(s) $30 $0 $30 $18 traMADol 50 mg Tab 68084-0808-01 1 tab(s) $9 $0 $9 $5 traMADol 50 mg Tab 65162-0627-10 1 tab(s) $9 $0 $9 $5 traMADol 50 mg Tab 57664-0377-08 1 tab(s) $9 $0 $9 $5 tranexamic acid 100 mg/mL Soln 39822-1001-07 1 mL $34 $0 $34 $20 traZODone 100 mg Tab 00904-6869-61 1 tab(s) $5 $0 $5 $3 traZODone 100 mg Tab 00904-6555-61 1 tab(s) $9 $0 $9 $5 traZODone 100 mg Tab 53489-0511-01 1 tab(s) $8 $0 $8 $5 traZODone 100 mg Tab 60687-0454-01 1 tab(s) $5 $0 $5 $3 traZODone 50 mg Tab 60687-0443-01 1 tab(s) $4 $0 $4 $3 traZODone 50 mg Tab 68382-0805-01 1 tab(s) $11 $0 $11 $6 traZODone 50 mg Tab 50111-0433-01 1 tab(s) $7 $0 $7 $4 tretinoin Topical 0.01% Gel 00062-0575-46 1 app $737 $0 $737 $442 tretinoin topical 0.025% Cream 00472-0117-20 1 app $902 $0 $902 $541 tretinoin Topical 0.05% Cream 00062-0175-12 1 app $442 $0 $442 $265 tretinoin topical 0.05% Cream 50224-0002-06 1 app $758 $0 $758 $455 triamcinolone topical 0.025% Cream 00603-7861-90 1 app $86 $0 $86 $52 triamcinolone topical 0.025% Ointm 00713-0229-80 1 app $53 $0 $53 $32 triamcinolone topical 0.1% Cream 45802-0064-05 1 app $167 $0 $167 $100 triamcinolone topical 0.1% Cream 45802-0064-35 1 app $47 $0 $47 $28 triamcinolone topical 0.1% Cream 67877-0251-45 1 app $231 $0 $231 $138 triamcinolone topical 0.1% Ointm 45802-0055-35 1 app $47 $0 $47 $28 triamcinolone topical 0.1% Paste 64980-0320-05 1 app $573 $0 $573 $344 triamcinolone topical 0.5% Cream 45802-0065-35 1 app $78 $0 $78 $47 triamterene 100 mg Cap 65197-0003-01 1 cap(s) $17 $0 $17 $10 triamterene 50 mg Cap 52817-0364-10 1 cap(s) $83 $0 $83 $50 triazolam 0.25 mg Tab 00054-4859-25 1 tab(s) $44 $0 $44 $26 trihexyphenidyl 2 mg Tab 00591-5335-10 1 tab(s) $4 $0 $4 $3 trihexyphenidyl 2 mg/5 mL Elixi 61748-0054-16 1 mL $5 $0 $5 $3 trimethobenzamide 300 mg Cap 53489-0376-01 1 cap(s) $14 $0 $14 $9 trimethoprim 100 mg Tab 43386-0330-01 1 tab(s) $8 $0 $8 $5 trimethoprim 100 mg Tab 50268-0775-15 1 tab(s) $8 $0 $8 $5 trospium 20 mg Tab 15456-0980-04 1 tab(s) $19 $0 $19 $12 trospium 20 mg Tab 00023-3513-60 1 tab(s) $17 $0 $17 $10 trospium 20 mg Tab 68462-0461-60 1 tab(s) $22 $0 $22 $13 tuberculin purified protein derivative 5 tuberculin units/0.1 mL Soln 49281-0752-22 0.1 mL $29 $0 $29 $17 ubiquinone 50 mg Cap 00904-5616-46 1 cap(s) $8 $0 $8 $5 urea topical 20% Cream 00536-1109-45 1 app $115 $0 $115 $69 ursodiol 300 mg Cap 51079-0383-01 1 cap(s) $20 $0 $20 $12 ursodiol 300 mg Cap 51079-0383-20 1 cap(s) $20 $0 $20 $12 ursodiol 300 mg Cap 64980-0139-01 1 cap(s) $22 $0 $22 $13 ursodiol 300 mg Cap 60687-0100-01 1 cap(s) $55 $0 $55 $33 ursodiol 300 mg Cap 68084-0213-01 1 cap(s) $19 $0 $19 $11 ursodiol 300 mg Cap 68084-0213-11 1 cap(s) $19 $0 $19 $11 ursodiol 300 mg Cap 00591-3159-01 1 cap(s) $21 $0 $21 $12 ursodiol 300 mg Cap 50268-0795-15 1 cap(s) $11 $0 $11 $7 ursodiol 300 mg Cap 00527-1326-01 1 cap(s) $21 $0 $21 $12

Page 104 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price ursodiol 60 mg/mL Susp 99345-0003-65 1 mL $13 $0 $13 $8 valACYclovir 1 g Tab 68084-0309-21 1 tab(s) $45 $0 $45 $27 valACYclovir 1 g Tab 65862-0449-90 1 tab(s) $86 $0 $86 $52 valACYclovir 1 g Tab 00378-4276-77 1 tab(s) $88 $0 $88 $53 valacyclovir 50 mg/mL Susp 99345-0003-70 1 mL $13 $0 $13 $8 valACYclovir 500 mg Tab 68084-0215-01 1 tab(s) $30 $0 $30 $18 valACYclovir 500 mg Tab 63739-0525-10 1 tab(s) $52 $0 $52 $31 valACYclovir 500 mg Tab 00378-4275-93 1 tab(s) $52 $0 $52 $31 valGANciclovir 450 mg Tab 31722-0832-60 1 tab(s) $435 $0 $435 $261 valganciclovir 450 mg Tab 68084-0965-25 1 tab(s) $1,028 $0 $1,028 $617 valproic acid 250 mg Cap 00591-4012-01 1 cap(s) $9 $0 $9 $5 valproic acid 250 mg Cap 00832-0310-11 1 cap(s) $10 $0 $10 $6 valproic acid 250 mg Cap 69452-0150-20 1 cap(s) $9 $0 $9 $5 valproic acid 250 mg/5 mL Syrup 60432-0621-16 1 mL $6 $0 $6 $3 valproic acid 250 mg/5 mL Syrup 68094-0193-61 5 mL $9 $0 $9 $5 valproic acid 250 mg/5 mL Syrup 68094-0193-62 5 mL $9 $0 $9 $5 valproic acid 250 mg/5 mL Syrup 00121-4675-05 5 mL $20 $0 $20 $12 valproic acid 500 mg/10 mL Syrup 68094-0701-62 10 mL $18 $0 $18 $11 valproic acid 500 mg/10 mL UD Syrup 68094-0701-59 10 mL $88 $0 $88 $53 valsartan 160 mg Tab 60687-0139-01 1 tab(s) $37 $0 $37 $22 valsartan 160 mg Tab 62332-0046-90 1 tab(s) $37 $0 $37 $22 valsartan 160 mg Tab 00078-0359-06 1 tab(s) $30 $0 $30 $18 valsartan 160 mg Tab 00078-0359-34 1 tab(s) $30 $0 $30 $18 valsartan 160 mg Tab 50268-0785-15 1 tab(s) $37 $0 $37 $22 valsartan 80 mg Tab 00078-0358-06 1 tab(s) $28 $0 $28 $17 valsartan 80 mg Tab 00078-0358-34 1 tab(s) $17 $0 $17 $10 valsartan 80 mg Tab 00378-5813-77 1 tab(s) $36 $0 $36 $21 valsartan 80 mg Tab 60687-0128-01 1 tab(s) $9 $0 $9 $5 valsartan 80 mg Tab 51660-0141-90 1 tab(s) $35 $0 $35 $21 vancomycin 1 g REC I 00409-6535-01 10 mL $120 $0 $120 $72 vancomycin 1 g REC I 00409-6533-01 10 mL $115 $0 $115 $69 vancomycin 250 mg Cap 66593-3126-02 1 cap(s) $222 $0 $222 $133 vancomycin 5 g REC I 00409-6509-01 50 mL $797 $0 $797 $478 vancomycin 500 mg REC I 63323-0221-10 5 mL $122 $0 $122 $73 vancomycin 500 mg REC I 00409-6534-01 5 mL $95 $0 $95 $57 vancomycin 750 mg REC I 00409-6531-02 7.5 mL $131 $0 $131 $78 vancomycin 750 mg REC I 67457-0705-75 7.5 mL $131 $0 $131 $78 Vancomycin Pharmacy to Dose - Bag 99345-0003-10 1 EA $0 $0 $0 $0 vasopressin 20 units/mL Soln 00517-1020-25 1 mL $44 $0 $44 $26 vasopressin 20 units/mL Soln 63323-0302-01 1 mL $59 $0 $59 $35 venlafaxine 150 mg ER Ca 68382-0036-16 1 cap(s) $37 $0 $37 $22 venlafaxine 25 mg Tab 00008-0701-08 1 tab(s) $20 $0 $20 $12 venlafaxine 25 mg Tab 00093-0199-01 1 tab(s) $16 $0 $16 $10 venlafaxine 25 mg Tab 50268-0798-15 1 tab(s) $17 $0 $17 $10 venlafaxine 37.5 mg ER Ca 68084-0698-01 1 cap(s) $28 $0 $28 $17 venlafaxine 37.5 mg ER Ca 59762-0180-02 1 cap(s) $31 $0 $31 $19 venlafaxine 37.5 mg ER Capsule 68084-0484-01 1 cap(s) $28 $0 $28 $17 venlafaxine 37.5 mg Tab 68084-0844-01 1 tab(s) $17 $0 $17 $10 venlafaxine 37.5 mg Tab 68084-0330-01 1 tab(s) $17 $0 $17 $10 venlafaxine 37.5 mg Tab 57237-0173-01 1 tab(s) $17 $0 $17 $10 venlafaxine 37.5 mg Tab 51079-0480-01 1 tab(s) $17 $0 $17 $10 venlafaxine 37.5 mg Tab 51079-0480-20 1 tab(s) $17 $0 $17 $10 venlafaxine 37.5 mg Tab 00093-7380-01 1 tab(s) $17 $0 $17 $10 venlafaxine 37.5 mg Tab 00008-0781-08 1 tab(s) $21 $0 $21 $12 venlafaxine 75 mg ER Ca 65862-0528-90 1 cap(s) $35 $0 $35 $21 venlafaxine 75 mg ER Ca 68382-0035-16 1 cap(s) $35 $0 $35 $21 venlafaxine 75 mg ER Capsule 00093-7385-98 1 cap(s) $35 $0 $35 $21 venlafaxine 75 mg Tab 68084-0856-01 1 tab(s) $18 $0 $18 $11 verapamil 100 mg/24 hours ER Ca 62175-0485-37 1 cap(s) $2 $0 $2 $1 verapamil 120 mg Tab 51079-0683-20 1 tab(s) $7 $0 $7 $4 verapamil 120 mg Tab 00378-0772-01 1 tab(s) $6 $0 $6 $4 verapamil 120 mg Tab 00904-2924-61 1 tab(s) $8 $0 $8 $5 verapamil 120 mg/12 hours ER Ta 57664-0116-88 1 tab(s) $15 $0 $15 $9 verapamil 120 mg/12 hours ER Ta 68462-0292-01 1 tab(s) $11 $0 $11 $6 verapamil 120 mg/24 hours ER Ca 00591-2880-01 1 cap(s) $15 $0 $15 $9 verapamil 180 mg/12 hours ER Ta 68462-0293-01 1 tab(s) $13 $0 $13 $8 verapamil 180 mg/12 hours ER Ta 57664-0117-88 1 tab(s) $19 $0 $19 $11 verapamil 180 mg/24 hours ER Ca 00591-2882-01 1 cap(s) $16 $0 $16 $9 verapamil 240 mg/12 hours ER Ta 68462-0260-01 1 tab(s) $14 $0 $14 $9 verapamil 240 mg/12 hours ER Ta 75834-0159-01 1 tab(s) $14 $0 $14 $9 verapamil 80 mg Tab 00904-2920-61 1 tab(s) $7 $0 $7 $4 verapamil 80 mg Tab 51079-0682-20 1 tab(s) $6 $0 $6 $4 vit. B Complex with C/folic acid/Biotin (nephro-vite Rx) - Tab 00023-5879-01 1 tab(s) $6 $0 $6 $4 Vitamin B Complex with Folic Acid Tab 00525-0906-90 1 tab(s) $8 $0 $8 $5 vitamin d 1,000 unit(s) Tab 03504-6001-05 1 tab(s) $0 $0 $0 $0 vitamin E 200 intl units Cap 10006-0700-43 1 cap(s) $4 $0 $4 $2 vitamin E 400 intl units Cap 00904-0274-60 1 cap(s) $4 $0 $4 $2 vitamin E 400 intl units Cap 00904-0274-60 1 cap(s) $4 $0 $4 $2 vitamin E 400 unit(s) Cap 87701-0407-54 1 cap(s) $4 $0 $4 $2

Page 105 of 106 NOTE: The following are a complete listing of Shirley Ryan AbilityLab charges as of Jan. 1, 2021.

Professional Description NDC DispVol CPT Revenue Code Facility Price Total Price Self Pay Price Price vitamin E 400 units Cap 03160-4011-60 1 cap(s) $15 $0 $15 $9 vitamin E with mixed tocopherols 400 intl units Cap 00536-4799-01 1 cap(s) $4 $0 $4 $2 vitamin E with mixed tocopherols 400 intl units Cap 00536-4799-10 1 cap(s) $4 $0 $4 $2 vitamin E with mixed tocopherols 400 intl units Cap 00536-5440-01 1 cap(s) $4 $0 $4 $2 voriconazole 200 mg Tab 68462-0573-30 1 tab(s) $536 $0 $536 $322 voriconazole 200 mg Tab 60687-0273-21 1 tab(s) $318 $0 $318 $191 voriconazole 40 mg/mL REC P 00049-3160-44 1 mL $137 $0 $137 $82 voriconazole 50 mg Tab 60687-0294-21 1 tab(s) $82 $0 $82 $49 warfarin 1 mg Tab 51672-4027-01 1 tab(s) $7 $0 $7 $4 warfarin 1 mg Tab 00056-0169-01 1 tab(s) $10 $0 $10 $6 warfarin 1 mg Tab 00056-0169-70 1 tab(s) $9 $0 $9 $5 warfarin 1 mg Tab 00056-0169-75 1 tab(s) $9 $0 $9 $6 warfarin 1 mg Tab 00832-1211-00 1 tab(s) $7 $0 $7 $4 warfarin 1 mg Tab 00832-1211-89 1 tab(s) $7 $0 $7 $4 warfarin 10 mg Tab 00832-1219-01 1 tab(s) $8 $0 $8 $5 warfarin 10 mg Tab 00832-1219-89 1 tab(s) $8 $0 $8 $5 warfarin 10 mg Tab 00056-0174-70 1 tab(s) $12 $0 $12 $7 warfarin 10 mg Tab 51672-4035-01 1 tab(s) $10 $0 $10 $6 warfarin 10 mg Tab 65162-0769-10 1 tab(s) $10 $0 $10 $6 warfarin 2 mg Tab 00832-1212-01 1 tab(s) $7 $0 $7 $4 warfarin 2.5 mg Tab 00832-1213-01 1 tab(s) $8 $0 $8 $5 warfarin 3 mg Tab 51672-4030-01 1 tab(s) $8 $0 $8 $5 warfarin 3 mg Tab 00832-1214-89 1 tab(s) $7 $0 $7 $4 warfarin 4 mg Tab 00056-0168-75 1 tab(s) $10 $0 $10 $6 warfarin 4 mg Tab 00093-1716-01 1 tab(s) $8 $0 $8 $5 warfarin 5 mg Tab 00056-0172-01 1 tab(s) $10 $0 $10 $6 warfarin 5 mg Tab 00056-0172-70 1 tab(s) $10 $0 $10 $6 warfarin 5 mg Tab 00056-0172-75 1 tab(s) $10 $0 $10 $6 warfarin 5 mg Tab 00832-1216-00 1 tab(s) $8 $0 $8 $5 warfarin 5 mg Tab 00832-1216-89 1 tab(s) $7 $0 $7 $4 warfarin 5 mg Tab 62584-0994-01 1 tab(s) $3 $0 $3 $2 warfarin 5 mg Tab 62584-0994-11 1 tab(s) $8 $0 $8 $5 warfarin 6 mg Tab 00093-1718-01 1 tab(s) $10 $0 $10 $6 warfarin 7.5 mg Tab 00056-0173-70 1 tab(s) $12 $0 $12 $7 warfarin 7.5 mg Tab 00832-1218-01 1 tab(s) $10 $0 $10 $6 warfarin 7.5 mg Tab 00555-0834-02 1 tab(s) $10 $0 $10 $6 warfarin 7.5 mg Tab 65162-0768-10 1 tab(s) $10 $0 $10 $6 warfarin 7.5 mg Tab 51672-4034-01 1 tab(s) $10 $0 $10 $6 wheat dextrin 100% REC P 00067-0044-38 0 $4 $0 $4 $2 Witch Hazel 1 pad Pad 01033-1000-09 1 app $738 $0 $738 $443 zaleplon 5 mg Cap 00008-0925-81 1 cap(s) $27 $0 $27 $16 zaleplon 5 mg Cap 64720-0322-10 1 cap(s) $2,561 $0 $2,561 $1,536 zaleplon 5 mg Cap 60793-0145-01 1 cap(s) $31 $0 $31 $19 zidovudine 100 mg Cap 65862-0107-01 1 cap(s) $17 $0 $17 $10 zidovudine 100 mg Cap 68084-0461-21 1 cap(s) $18 $0 $18 $11 zidovudine 300 mg Tab 68084-0462-21 1 tab(s) $13 $0 $13 $8 zidovudine 300 mg Tab 00378-6106-91 1 tab(s) $44 $0 $44 $26 zidovudine 50 mg/5 mL Syrup 00173-0113-18 5 mL $6 $0 $6 $4 zidovudine 50 mg/5 mL Syrup 65862-0048-24 5 mL $6 $0 $6 $4 zileuton 600 mg ER Ta 10122-0902-12 1 tab(s) $70 $0 $70 $42 zinc chloride 1 mg/mL Soln 00409-4090-01 10 mL $13 $0 $13 $8 zinc oxide topical 20% Ointm 00536-5700-98 1 app $12 $0 $12 $7 zinc sulfate 220 mg Cap 00394-0499-02 1 cap(s) $4 $0 $4 $2 zinc sulfate 220 mg Cap 00245-0080-11 1 cap(s) $4 $0 $4 $3 zinc sulfate 220 mg Cap 00731-0401-06 1 cap(s) $4 $0 $4 $2 zinc sulfate 220 mg Cap 77333-0983-10 1 cap(s) $5 $0 $5 $3 ziprasidone 20 mg Cap 60505-2528-06 1 cap(s) $63 $0 $63 $38 zoledronic acid 4 mg/5 mL Soln 25021-0801-66 1 mL $638 $0 $638 $383 zolpidem 5 mg Tab 00904-6082-61 1 tab(s) $37 $0 $37 $22 zolpidem 5 mg Tab 68084-0189-01 1 tab(s) $17 $0 $17 $10 zolpidem 6.25 mg ER Ta 68180-0779-01 1 tab(s) $47 $0 $47 $28 zolpidem 6.25 mg ER Ta 47335-0307-88 1 tab(s) $47 $0 $47 $28 zolpidem 6.25 mg ER Tablet 00228-3481-11 1 tab(s) $47 $0 $47 $28 zonisamide 100 mg Cap 51079-0768-20 1 cap(s) $17 $0 $17 $10 zonisamide 25 mg Cap 68462-0128-01 1 cap(s) $7 $0 $7 $4 zonisamide 50 mg Cap 68001-0243-00 1 cap(s) $11 $0 $11 $6 zonisamide 50 mg Cap 62756-0259-02 1 cap(s) $11 $0 $11 $6 zonisamide 50 mg Cap 00378-6726-01 1 cap(s) $11 $0 $11 $6

Page 106 of 106