Avita Health System is dedicated to providing an extraordinary patient experience. This includes offering fair and competitive prices to our patients.

The information provided in this document is in compliance with state and federal laws to provide standard charges (1) as they appear in our chargemaster and (2) for the diagnosis- related groups (DRGs) performed by Avita Health System.

Avita can estimate your cost of services:

While hospital charges are the same for all patients, your patient responsibility may vary based on many factors.

The lists in this document are not helpful tools for patients to comparison shop between hospitals or to estimate what health care services are going to cost them out of their own pocket.

For more information about the cost of your care, please contact our Customer Service team so they can provide a personalized estimate for services and to discuss Avita’s payment options. (a) Via the MyChart website: Submit a technical billing inquiry or customer service request (b) Call our Customer Service team: 419-468-0512 (toll free 1-833-462-8428) Monday thru Friday 8:00a-5:00p (c) Visit any Avita hospital: Financial Counselors are available Monday thru Friday 8:00a-4:30p

08-06-2019-A-PAC-057 Page 1 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 175968 Pocket, Endo Detachable $ 244.92 175972 Straight Zipwire Hydrophilic Guidewire (150Cm .035In/.89Mm) $ 113.16 176880 Amplatz Super Stiff 0.035/260 Cm $ 610.41 177516 Foam Insert For Prone Positioner $ 79.77 177766 Suture 3-0 Silk Strands Black Braided 18" $ 301.29 178663 Tx2 Procedure Pack $ 2,535.00 178664 Lithovue $ 5,055.00 178665 Apligraft $ 3,885.00 182486 Sagittal Blade Flared 48.1 X 0.97 X 90.7 Mm 2108 Series $ 106.11 182487 Arthrex Fiberwire Scissors $ 525.00 182512 Holium 1000 Fortec Fiber $ 1,360.00 183552 Endopath 10Mm Anvil Grasper $ 276.93 185305 Midas Rex 6Mm Burrs (Green) $ 690.00 185306 Midas Rex Dissecting Tool Carbide 3Mm (Peach) $ 786.00 185307 Midas Rex Legend Diamond Wheel 25.4Mm (Peach) $ 648.00 185308 Midas Rex 5Mm Burr (Orange) $ 738.00 185309 Midas Rex 7.5Mm Burr (Orange) $ 738.00 185310 Midas Rex 4Mm Ball (Grey) $ 594.00 187183 Endopath Echelon Endoscopic Lcr W Gst 60Mm Green $ 547.50 187192 Endopath Echelon Endoscopic Lcr W Gst 60Mm Blue $ 547.50 187194 Circular Stapler Curved Ils Long Length 25Mm $ 1,058.31 187195 Endopath Echelon Endoscopic Lcr W Gst 60Mm Gold $ 547.50 187196 Endopath Echelon Endoscopic Lcr W Gst 60Mm Black $ 547.50 187197 Endopath Echelon Endoscopic Lcr W Gst 60Mm White $ 480.27 187198 Harmonic Ace 7 Shears With Advanced Hemostasis $ 1,933.47 187199 Echelon Flex Powered Plus Stapler Long Length 440Mm $ 1,300.53 188801 Lateral Traction Arm Sleeves $ 144.00 188805 Dualmesh Plush 15.0 Cm X 19.0 Cm $ 2,808.00 190418 Ureteral Stent 6X26 Contour $ 342.00 190423 Navigator Ureteral Access Sheath Set 11Fr/13Fr X 36Cm $ 371.76 191342 Biocomposite Achilles Speedbridge $ 5,220.00 191347 Laser Fiber Tractip $ 1,382.25 191349 Zero Tip Basket 5 X 3.0 Fr $ 537.00 191351 Encore Inflator $ 102.00 191354 Forceps Piranha Biopsy $ 971.70 191849 Interpulse With Suction Tubing Handpiece Set $ 85.74 191860 Ez Ifs - Endo $ 885.00 191897 Disposable Lap Metx Scissors 45 Cm $ 1,398.00 191913 Stapler 25Mm Single Use W/4.8Mm $ 3,179.73 191915 Suture Surgidac Endo Stitch 2-0 $ 180.00 191916 Suture Vloc 90 3/0 Violet 9 V-20 $ 93.81 191919 Seam Guard Bariatric $ 515.49 191920 Misonix Bone Scalpel $ 1,619.40 191922 Trocar Endopath Excel Bladeless 15M $ 367.26 193005 Airtap Patient Repositioning System $ 525. 00 193006 Mats Mobile Air Transfer System $ 270.00 193043 Minerva Surgical Handpiece Disposable $ 3,150.00 193045 Flex Support 2009 Compression Bra Sz 32 $ 79.59 193046 Flex Support 2009 Compression Bra Sz 38 $ 101.19 193047 Bra Compression Size 40 White $ 93.63 193048 Flex Support 2009 Compression Bra Sz 44 $ 79.59 193054 Electrode, Abc Dissecting Blade $ 270.33 193057 Dualmesh Plus 18.0Cm X 24.0Cm $ 4,044.00 193059 Hifi Suture With Double Armed Meniscal Needle $ 247.47 193894 Misonix Irrg Tube Set $ 150.00 193895 Misonix Bone Shaver $ 1,529.40 195479 Amplatz Type Renal Dilator/Sheath Set $ 659.28 195480 Sp Tube Introducer Set $ 269.34 195482 Biocue Platelet Concentration Kit $ 3,003.00 195492 Sponge Lap Wash Band Nonsterile $ 241.74 195493 Dakota Basket $ 630.00 195494 Retrieval Basket, Zero Tip 1.9F X 120Cm $ 615.00 195495 Catheter, Ureteral 8/10 Dialator $ 152.52 195501 Catheter, Uretera Dual Lumen Catheter $ 209.10 195503 Scope, Lithovue $ 4,500.00 195504 Endopath 10Bb Babcock W/Handle $ 408.99 195505 Flex 45Mm Reload-Blue 6 Row, 1.5Mm Closed $ 747.60 195507 Large Mesh, Hernia Repair $ 947.52 195510 Stimublast Dbm Putty $ 1,320.00 195511 Stimublast Dbm 5Cc $ 2,400.00 195512 Stimublast Dbm 10Cc $ 3,885.00

02-19-2019-A-PAC-057 Page 2 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 195513 Stent, Ureteral 6 X 20 Contour $ 342.00 195514 Stent, Ureteral 6 X 22 Contour $ 342.00 195515 Stent, Ureteral 6 X 24 Contour $ 342.00 195516 Stent, Ureteral 6 X 28 Contour $ 342.00 195517 Clip Duraclip Repositional Hemost $ 375.00 195857 Mesh, Ventralex Medium Hernia $ 2,115.00 195861 Navigator Hd 13/15 X 46 Cm $ 371.76 195865 Polaris Ultra Stent 5Fr X 28Cm $ 430.50 195867 Polaris Ultra Stent 6Fr X 24Cm $ 430.50 195872 Polaris Ultra Stent 6Fr X 26Cm $ 430.50 195873 Feeding Tube Gastrostomy Mic 18Fr $ 114.36 195878 Tube Gastrostomy Mic 22Fr $ 114.36 196624 Tube, Feeding 24 Fr Mic J $ 389.70 196628 Tube, Feeding 22 Fr Mic J $ 982.80 196630 Rt 380 Nail $ 6,781.50 196631 4.2 X 180 Drill $ 405.60 196635 115Mm Lag $ 1,612.05 197142 Securestrap 5Mm Absorbable Strap Fixation Device $ 1,924.38 197760 Stapler Reload 60Mm Gold Endop $ 573.51 197922 Ventralex St Large $ 2,490.00 199295 Gateway Advantage Adapter $ 489.60 199299 Navigator, Hd, 11/13 Fr X 28 Cm $ 371.76 200769 2.5" Silver Soaker Catheters $ 138.00 200771 Fw Bpb #2 Suture Purcase By Box Of 12 Only $ 105.00 200774 Retractor, Vagina Cervical $ 280.08 200782 Ventrio St Hernia Patch Large Cir $ 2,910.00 200786 Uretheral Sheath Set, Navigator Hd 11/F X 28Cm $ 74.34 200789 Toric Upgraded Lens $ 366.00 200790 Eye Pack $ 1,647.00 200791 Standard Lens $ 150.00 200793 Multifocal Lens $ 766.00 200934 Ventrio St Hernia Patch Small Ova 3.1" X 4.7" $ 2,665.62 201091 Cordis Lt Newton Straight Tip .035 150Cm Wire $ 118. 23 201092 Cordis Standard Straight Tip Wire .035 150Cm $ 487. 05 201096 Saber Balloon 3X40 $ 285.00 201099 Cordis .035 260 Straight Guide Wire $ 78. 00 201103 6X30 Saber Balloon $ 1,201.50 201112 8F Angio-Seal Vip $ 247.53 201113 6F/7F Mynxgrip Closure Device $ 66.00 201397 Atrium Prolite Mesh Sheet 10" X 14" $ 411.00 202787 Bost Amplatz .035 Super Stiff Guidewire $ 78.72 203553 132 Degree Cemented Hip Stem $ 25,500.00 206926 Contour Load Cvr Cutter Thick $ 915.30 206927 Stapler Contour Cvd Cutter Reg $ 1,533.66 214932 Margin Markers Sterile Ink Set $ 381.00 215296 Suture, Vloc 180-09.5 Gs-21 $ 96.00 218053 Dual Cut Sagittal Blade 11X1.19X90Mm $ 363.00 218171 Avi Laparascopic Cholangiography Sets $ 458.58 227924 Silicone Tympanostomy Tubes 12X10X1.14 $ 80.91 227925 Laser-Flex Cuffed Endotracheal Tubes 5.0Mm $ 184.83 227927 Laser-Flex Cuffed Endotracheal Tubes 5.5Mm $ 184.83 227929 Laser-Flex Cuffed Endotracheal Tubes 4.5Mm $ 184.83 227932 Laser-Flex Cuffed Endotracheal Tubes 6.0Mm $ 184.83 227935 Laser-Flexed Uncuffed Endotracheal Tubes 3.0Mm $ 179.73 227936 Laser-Flex Uncuffed Endotracheal Tubes 3.5Mm $ 179.73 227938 Laser-Flex Uncuffed Endotrach Tubes 4.0Mm $ 179.73 227941 Manujet Iii Kit W/Jet Ventilation Catheter $ 153.99 229443 Miloop $ 390.00 229450 Ligasure Retractable L-Hook Sealer/Divider $ 2,013.00 230026 Malygun Ring $ 465.00 231338 Novasure Advanced Device $ 3,228.00 232225 6" Coated Needle W/Extended Insulation $ 1,023.00 232226 Stratafix Symmetric Pds Plus Violet 45Cm Ct-1 $ 69.00 232649 Ventralight 6"X8" $ 3,735.00 232664 Ventralight Mesh 7"X9" $ 4,725.00 232665 Ventralight Mesh 6" $ 2,662.50 232666 Ventralight Mesh 6"X10" $ 4,275.00 232667 Ventralight Mesh 6"X8" $ 5,010.00 232668 Ventralight Mesh 7"X9" W/Positioning System $ 4,725.00 232669 Ventralight Mesh 8" $ 4,650.00 232670 Escape Basket $ 730.47

02-19-2019-A-PAC-057 Page 3 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 235659 Wolf Cutting Loop 24 Fr $ 180.00 238848 Cadiere Forceps $ 6,000.00 238854 Small Hub (Sabre) 3.0 Mm X 7 Cm $ 198.00 238855 Burr,Round, 10 Flute, 3.0Mm $ 198.00 238861 Burr, Round, Sj, 8 Flute, 3.0Mm $ 198.00 238862 Sabre, Sj, 3.0Mm X 7Cm $ 198.00 238863 Prograsp Forceps $ 6,000.00 238864 Bioabsorbable Staple Line Reinforcement Circular Stapler $ 1,056.00 240309 Babcock, 10Mm X 33Cm Length $ 1,285.86 240312 Blade Handle #3 Round 10Cm $ 69.60 244340 Kit,Palindrome, Ruby, 28/45 Vt $ 1,398.00 244502 Guidewire, Diagnostic 0.018" Dia 65 Cm Angled Tip, Fixed Core $ 198.00 245905 Pak Splint, Nasal, Denver, Alum, Slf-Adhes, Lg $ 87.00 245907 Pak Splint, Nasal, Denver, Alum, Slf-Adhes, Md $ 87.00 245909 Nano Anchor 7 X 25 Cm $ 87.00 247699 Urolift System $ 2,925.00 249064 Polypro 36" Size 0 (Tapercut/Curved) $ 110.85 249068 Upsylon Y-Mesh Kit $ 2,988.57 249071 Capio Slim Box 1 $ 1,530.75 249073 Colpassist $ 923.73 249074 Endo Pocket Specimen Bag 7" X 9" 1500Ml 12Mm $ 231.00 249075 Aireseal 12Mm Access Port Bladeless Tip $ 254.67 249102 Airseal 5Mm Low Profile Bladeless $ 244.89 249107 8Mm Bladless Obturator (Disposable $ 90.00 12000001 HC MED/SURG $ 702.00 12000004 HC CCH SWING BED $ 526.00 12800001 HC REHAB $ 891.00 17000001 HC NURSERY $ 702.00 20000001 HC ICU $ 1,464.00 20600001 HC INTERMEDIATE CARE $ 1,111.00 25000041 HC CCH SEVOFLURANE PER 15 MIN $ 177.00 25000042 HC CCH DESFLURANE PER 15 MIN $ 219.00 25000043 HC CCH ISOFLURANE PER 15 MIN $ 30.00 26000001 HC HYDRATION INITIAL HOUR $ 254.00 26000002 HC HYDRATION EACH ADDITIONAL HOUR $ 42.00 26000003 HC IV INFUSION NON-CHEMO INITIAL HOUR $ 282.00 26000004 HC IV INFUSION NON-CHEMO EACH ADDITIONAL HOUR $ 26.00 26000005 HC IV INFUSION NON-CHEMO SEQUENTIAL NEW DRUG/SUBSTANCE $ 27.00 26000007 HC IV PUSH NON-CHEMO INITIAL $ 86.00 26000008 HC IV PUSH NON-CHEMO SEQUENTIAL DIFFERENT DRUG $ 105.00 26000009 HC IV PUSH NON-CHEMO SEQUENTIAL SAME DRUG $ 105.00 26000010 HC REFILL & MAINTENANCE OF PORTABLE PUMP $ 216.00 26000011 HC IV INFUSION CONCURRENT $ 27.00 27000003 HC CCH OXYGEN SERVICE PER DAY $ 197.00 27000043 HC OXYGEN SERVICE PER VISIT $ 55.00 27000073 HC SANE SUPPLY $ 58. 00 27000151 HC CCH YANKEE BIONICS CUSTOM BRACE $ 4,724.00 27200001 HC SUP TO EAP SUPPLY STERILE $ 69.00 27200009 HC SET CHEST DRAINAGE-SAHARA $ 164.00 27200010 HC TUBE TRACH SHILEY #6 CUFFED $ 266.00 27200019 HC SHEATH PINNACLE 7FR ST RSR04 $ 54.00 27200974 HC TUBE TRACH SHILEY #8 CUFFED $ 219.00 27201085 HC KIWI OMNICUP - VACUUM DELIVERY $ 130.00 27201385 HC CCH SUCTION ORAL CARE Q2 SYSTEM $ 102.00 27201533 HC CATHETER BALL CONQUEST CQ7574 $ 656.00 27201534 HC CATHETER BALL CONQUEST CQ7584 $ 656.00 27201535 HC CATHETER BALL CONQUEST CQ7594 $ 656.00 27201536 HC CATHETER BALL CONQUEST CQ75104 $ 656.00 27201705 HC CATHETER EPISTAXIS $ 186.00 27202757 HC CATH BALL CONQUEST $ 656.00 27204915 HC LENS MORGAN $ 123.00 27205252 HC TOURNIQUET COMBAT CAT $ 123.00 27205420 HC PILLOW ABDUCTION MEDIUM 6X15X22 $ 106.00 27206081 HC CCH AMBU BAG ADULT $ 49.00 27206168 HC CCH BREAST PUMP $ 142.00 27206211 HC CCH CATHETER THORACIC $ 48.00 27206283 HC CCH DERMABOND $ 345.00 27206317 HC CCH DRESSING PROMOGRAN $ 35.00 27206344 HC CCH ELECTRODES ADHESIVE $ 1,402.00 27206393 HC CCH GAIT BELT 72" $ 97.00 27206584 HC CCH NITRO TUBING $ 32.00

02-19-2019-A-PAC-057 Page 4 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 27206673 HC CCH PRISMA DRESSING $ 41.00 27206676 HC CCH PROFORE MULTILAYER COMPRESSION SYSTEM $ 60.00 27206747 HC CCH SPRING GUIDE WIRE $ 179.00 27206754 HC CCH STATLOCK DEVICE $ 28.00 27206852 HC CCH UNNA BOOT $ 36.00 27206921 HC CCH BAIR HUGGER BLANKET $ 28.00 27206924 HC CCH CHLORAPREP 26ML $ 32.00 27206957 HC CCH OXYHOOD $ 152.00 27207048 HC CCH TUBE GASTROSTOMY FEEDING 20FR $ 186.00 27207101 HC CCH SET PNEUMOTHORAX WAYNE 14FR $ 710.00 27207102 HC CCH TRAY WAYNE PNEUMOTHORAX 14FR $ 800.00 27207103 HC CCH SET TROCAR WAYNE PNEUMOTHORAX 14FR 16.5CM $ 701.00 27207104 HC CCH GOWN BAIR PAWS FLEX WITH BOOTIES $ 80.00 27207105 HC CCH GOWN BAIR PAWS ADULT $ 48.00 27207106 HC CCH SENSOR SPO2 NEONATAL LNCS MASIMO $ 50.00 27207107 HC CCH BRA SHAPER $ 161.00 27207108 HC CCH BRA COMPRESSION & FLEX SUPPORT $ 129.00 27207109 HC CCH BRA COMPRESSION SIZE 32 WHITE $ 135.00 27207110 HC CCH BRA COMPRESSION WHITE SZ 44 $ 108.00 27207111 HC CCH SENSOR OXIMETER ADULT DISPOSABLE $ 40.00 27207112 HC CCH SENSOR SPO2 LNCS ADULT $ 49.00 27207113 HC CCH SENSOR OXIMETER PED LNCS $ 765.00 27207114 HC CCH DETECTOR MINI STAT C02 END TIDAL C02 $ 77.00 27207115 HC CCH DETECTOR CO2 END TIDIAL TEMP CONTROLLED BELOW 75 $ 45.00 27207116 HC CCH DETECTOR CO2 STATCO2 ADULT $ 77.00 27207117 HC CCH DETECTOR CO2 EASY PEDIATRIC $ 35.00 27207118 HC CCH STOCKING TED THIGH HIGH XXL $ 50.00 27207119 HC CCH STOCKING TED THIGH HIGH XL $ 49.00 27207120 HC CCH STOCKING TED THIGH HIGH SM/MED $ 28.00 27207121 HC CCH STOCKING TED THIGH HIGH L $ 28.00 27207122 HC CCH STOCKING TED THIGH HIGH XXXL $ 35.00 27207123 HC CCH COVER FOOT AVI ANY SIZE $ 273.00 27207124 HC CCH CHAIR SENSOR $ 74.00 27207125 HC CCH NET ROTH FOREIGN BODY RETRIEVL $ 384.00 27207126 HC CCH C-QUR V-PATCH MEDIUM 6.2X2.5CM $ 1,524.00 27207127 HC CCH MEDLINE DIRECT INTERIOR PACK $ 1,620.00 27207128 HC CCH TUBE TRACH CUFFED ORAL RAE 5.5 $ 33.00 27207129 HC CCH TUBE TRACH CUFFED ANY SZ $ 88.00 27207130 HC CCH PACK CUSTOM BEACH CHAIR SHOULD $ 410.00 27207131 HC CCH CANNULA PASSPORT BUTTON $ 32.00 27207132 HC CCH CATH COUDE 18 FR 5CC/30CC BARD $ 49.00 27207133 HC CCH TRAY CENTRAL LINE DRESSING $ 62.00 27207134 HC CCH SENSOR SOMA ADULT $ 307.00 27207135 HC CCH BLADE TRICUT SINUS #18-84004HR $ 699.00 27207136 HC CCH BELT GAIT $ 27.00 27207137 HC CCH CUSHION/FOAM RING (DONUT) $ 36. 00 27207138 HC CCH HEEL-ELBOW PROTECTOR $ 30.00 27207139 HC CCH NERVE STIMULATOR #6201 $ 239.00 27207140 HC CCH LTA KIT $ 29.00 27207141 HC CCH PACK EENT II $ 68.00 27207142 HC CCH SPLINT FINGER THUMB ADA 1942 $ 42.00 27207143 HC CCH MASK AUROONCE LARYNEAL $ 29.00 27207144 HC CCH MASK LMA REINFORCED 50KG-70KG $ 77.00 27207145 HC CCH MASK LMA ENDOTRACHEAL LMA FASTRACK 7.0 MM $ 274.00 27207146 HC CCH MASK AIRWAY LMA FASTRACK MULTIPACK SET $ 4,396.00 27207147 HC CCH MASK LMA FASTRACK $ 1,799.00 27207148 HC CCH MASK LARYNGEAL DISP $ 29.00 27207149 HC CCH TUBE ENDO BRONCHO DOUBLE LUMEN $ 298.00 27207150 HC CCH CAUTERY FINE TIP HIGH-TEMP $ 37.00 27207151 HC CCH BLADE KURZ PRECISE KLINGEN STERILE $ 49.00 27207152 HC CCH BASKET RETRIEVAL NITINOL 2.4FR TIP ZERO $ 730.00 27207153 HC CCH BASKET STONE RETRIEVAL ZERO TIP NITINOL 1.9FX120CM $ 769.00 27207154 HC CCH MODULE INTUBATION VARIOUS $ 183.00 27207155 HC CCH MODULE INTUBATION $ 183.00 27207156 HC CCH MODULE I.V. DELIVERY $ 175.00 27207157 HC CCH REAMER CORING 9MM $ 769.00 27207158 HC CCH REAMER FULL THICKNESS 9MM DISP $ 753.00 27207159 HC CCH DRESSING RAPID RHINO NASAL 5.5 $ 163.00 27207160 HC CCH DRESSING RAPID RHINO NASAL 4.5 $ 163.00 27207161 HC CCH DRESSING RAPID RHINO NASAL 7.5 $ 173.00 27207162 HC CCH DISPOSIBLE TOURNIQUET SZ 9 $ 80.00

02-19-2019-A-PAC-057 Page 5 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 27207163 HC CCH DISPOSIBLE TOURNIQUET SZ 12 $ 86.00 27207164 HC CCH DISPOSIBLE TOURNIQUET SZ 15 $ 90.00 27207165 HC CCH DISPOSIBLE TOURNIQUET SZ 18 $ 106.00 27207166 HC CCH DISPOSIBLE TOURNIQUET SZ 24 $ 102.00 27207167 HC CCH DISPOSIBLE TOURNIQUET SZ 30 $ 110.00 27207168 HC CCH DISPOSIBLE TOURNIQUET SZ 55 $ 118.00 27207169 HC CCH DISPOSIBLE TOURNIQUET SZ 44 $ 134.00 27207170 HC CCH HEMO-O-LOK CLIP $ 156.00 27207171 HC CCH TRAY AMNIOCENTESIS $ 55.00 27207172 HC CCH TRAY CATHETER INSERT W/O FOLEY $ 95.00 27207173 HC CCH TRAY FOLEY CATHETER $ 69.00 27207174 HC CCH TRAY LUMBAR PUNCTURE ADULT 20 X 3.5 $ 46.00 27207175 HC CCH TRAY LUMBAR PUNCTURE PEDS 21 X 2.5 $ 50.00 27207176 HC CCH BLANKET LOWER BODY #PD-1105 $ 28.00 27207177 HC CCH NEEDLE EPIDURAL TUOGHY $ 30.00 27207178 HC CCH NEEDLE EPIDURAL TUOGHY LONG $ 50.00 27207179 HC CCH SYRINGE GLASS BRAUN $ 33.00 27207180 HC CCH CANNULA NEUROTHERM 20 GA 10CM $ 70.00 27207181 HC CCH PAD HYPER/HYPO THERAPY $ 27.00 27207182 HC CCH TRAY BONE MARROW $ 121.00 27207183 HC CCH ELECTRODE QUIK COMBO EDGE $ 135.00 27207184 HC CCH ORAL CARE SYSTEM $ 141.00 27207185 HC CCH DRAIN CHEST HEIMLICK $ 138.00 27207186 HC CCH DRAIN CHEST HEIMLICK VALVE SET $ 360.00 27207187 HC CCH SEGURA STONE BASKET #SB4460 $ 722.00 27207188 HC CCH SNARE SMALL OVAL $ 53.00 27207189 HC CCH SNARE MICROELITE $ 5,913.00 27207190 HC CCH SUSPENSORY W/LEG STRAP $ 49.00 27207191 HC CCH KIT TRANSCERVICAL INTRAUTERINE $ 110.00 27207192 HC CCH ANESTH BREATH CIRCUIT/ADULT/OH $ 46.00 27207193 HC CCH ANESTH BREATHING CIRC/PED $ 34.00 27207194 HC CCH BLADE OSCILLATING SAW $ 44.00 27207195 HC CCH ADHESIVE LIQUIBAND SKIN $ 92.00 27207196 HC CCH SET CONTINU NERVE BLOCK 18G X6 $ 151.00 27207197 HC CCH BIOPSY FORCEP GI $ 54.00 27207201 HC CCH GEL ULTRASOUND COVER 6X96 $ 27.00 27207202 HC CCH CATH PAJUNK E-CATH ACC TSUI $ 166.00 27207203 HC CCH CORD ACMI DAC DISP ACTIVE $ 93.00 27207204 HC CCH PUDDLE VAC FLOOR SUCTION #9321 $ 76.00 27207205 HC CCH TRAY SPINAL ANESTHESIA $ 80.00 27207206 HC CCH TRAY SPINAL PORTEX $ 54.00 27207207 HC CCH BITE BLOCK DISP STD. SIZE $ 48.00 27207208 HC CCH BITE BLOCK DISP SMALL $ 48.00 27207209 HC CCH ARTHROGRAM TRAY $ 55.00 27207210 HC CCH SAW BLADE AG1/AGC/AVC/AL1 $ 173.00 27207211 HC CCH ARISTA FLEXITIP APPLICATOR $ 77. 00 27207212 HC CCH INSORB SKIN STAPLER $ 218.00 27207213 HC CCH SUTURE CHR GUT 4-0 PS-4 18 INCH $ 36.00 27207214 HC CCH SUTURE CHROMIC GUT 4-0 $ 83.00 27207215 HC CCH SUTURE SILK SH 3-0 30IN $ 239.00 27207216 HC CCH SUTURE SILK BLK 2-0 12/18IN $ 27.00 27207217 HC CCH SUTURE VICRYL UNDYED SH 2-0 27IN $ 266. 00 27207218 HC CCH SUTURE VICRYL VLT CT 3-0 36IN $ 28.00 27207219 HC CCH SUTURE ETHIBOND CT-1 0 30 $ 30.00 27207220 HC CCH SUTURE VICRYL VLT CT-3 3-0 27IN $ 28.00 27207221 HC CCH SUTURE PROLENE KS 2-0 30IN $ 44.00 27207222 HC CCH SUTURE SLIK BLK BRD 2-0 12/30IN $ 41.00 27207223 HC CCH SUTURE CHROMIC GUT CT-1 2-0 27 $ 487.00 27207224 HC CCH SUTURE CHROMIC GUT CT-1 2-0 27IN $ 494.00 27207225 HC CCH SUTURE CHROMIC GUT SH $ 56.00 27207226 HC CCH SUTURE VICRYL UNDYED PS-2 4-0 18IN $ 576.00 27207227 HC CCH SUTURE SILK 2-0 30IN BLK $ 37.00 27207228 HC CCH SUTURE VICRYL 2-0 27IN $ 27.00 27207229 HC CCH SUTURE VICRYL VLT V-34 2-0 36IN $ 45.00 27207230 HC CCH SUTURE VICRYL VLT V-34 1 36IN $ 42.00 27207231 HC CCH SUTURE VICRYL VLT V-34 0 36IN $ 42.00 27207232 HC CCH SUTURE ETHILON PS-1 3-0 18IN $ 566.00 27207233 HC CCH SUTURE PROLENE PS-2 4-0 18IN $ 246.00 27207234 HC CCH SUTURE PROLENE 3-0 36 MH MH $ 32.00 27207235 HC CCH SUTURE VICRYL VLT PS-5 5-0 18IN $ 233.00 27207236 HC CCH SUTURE ETHILON PS-2 4-0 18IN $ 205.00

02-19-2019-A-PAC-057 Page 6 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 27207237 HC CCH SUTURE ETHILON P-3 18IN $ 195.00 27207238 HC CCH SUTURE ETHILON P-3 5-0 18IN $ 181.00 27207239 HC CCH SUTURE PROLENE 6-0 24 IN $ 74.00 27207240 HC CCH SUTURE PROLENE 5-0 PC3 $ 26.00 27207241 HC CCH SUTURE TICRON 3-0 $ 45.00 27207242 HC CCH SUTURE VICRYL 2-0 COATED BRAIDED $ 61.00 27207243 HC CCH SUTURE PROLENE 4-0 RB-1 $ 41.00 27207244 HC CCH SUTURE PROLENE 4-0 $ 42.00 27207245 HC CCH SUTURE SILK CR SH 2-0 8/18 $ 47.00 27207246 HC CCH SUTURE SILK CR SH 2-0 8/18IN $ 48.00 27207247 HC CCH SUTURE GORTEX $ 122.00 27207248 HC CCH SUTURE CV-0 $ 122.00 27207249 HC CCH SUTURE ETHILON 10-0 $ 88.00 27207250 HC CCH SUTURE NYLON 8-0 (NON-STOCK) $ 70.00 27207251 HC CCH SUTURE VICRYL 3-0 CTD CR/CT 1 $ 62.00 27207252 HC CCH SUTURE VICRYL VLT CR SH-1 3-0 8/18IN $ 57.00 27207253 HC CCH SUTURE ETHIBOND GRN BRD CR MO-7 0 8 X 18IN $ 74.00 27207254 HC CCH SUTURE VICRYL VLT CR CT-1 0 8/18IN $ 62. 00 27207255 HC CCH SUTURE ICRYL VLT CR CT-1 1 8/18IN $ 59.00 27207256 HC CCH SUTURE VICRYL VLT CR CT-1 2-0 8/18IN $ 57.00 27207257 HC CCH SUTURE CHROMIC GUT 6-0 $ 37.00 27207258 HC CCH SUTURE ETHIBOND 5 $ 102.00 27207259 HC CCH SUTURE ETHIBOND 0 CR/CT-2 8-18 $ 57.00 27207260 HC CCH SUTURE ETHIBOND CT-1 0 30IN $ 296.00 27207261 HC CCH SUTURE PROLENE 6-0 $ 30.00 27207262 HC CCH SUTURE PROLENE 6-0 (NON-STOCK) $ 69.00 27207263 HC CCH SUTURE PROLENE 7-0 (NON-STOCK) $ 148.00 27207264 HC CCH STAPLER SKIN #PPW35 $ 104.00 27207265 HC CCH SKIN STAPLER PROXIMATE III $ 26.00 27207266 HC CCH FORCEP DISP BX HOT 000852 $ 184.00 27207267 HC CCH ENOCLIP DISP APPLIER MED/LG $ 427.00 27207268 HC CCH CURVED INTRALUM STAPLR/252933 $ 1,235.00 27207269 HC CCH TROCAR DILATING TIP 5MM D5LT $ 172.00 27207270 HC CCH TROCAR BLADELESS XCEL 11MM B11 $ 208.00 27207271 HC CCH TROCAR BLADELESS 5MM #B5LT $ 179.00 27207272 HC CCH TROCAR BLADELESS 12MM #B12LT $ 214.00 27207273 HC CCH ENDOCLIP MEDIUM ( PAR 2 EA. ) $ 748.00 27207274 HC CCH APPLIER ENDO LIGAMAX5 MED/LRG 5MM $ 734.00 27207275 HC CCH CUTTER LINEAR 7MM TLC75 $ 669.00 27207276 HC CCH RELOAD LINEAR CUTTER TCR75 $ 279.00 27207277 HC CCH TISSEEL SPRAY SET $ 254.00 27207278 HC CCH TRAY TURKEL THORACENTESIS $ 1,654.00 27207279 HC CCH TRAY THORACENTESIS PLEURA-SEAL $ 196.00 27207280 HC CCH CATH FOLEY 2-WAY PED 3CC $ 32.00 27207281 HC CCH CATH FOLEY LTX RED 2-WAY LUB COUDE 18FR 5CC $ 54.00 27207282 HC CCH CATH FOLEY 3-WAY 30CC $ 42.00 27207283 HC CCH CATH ORAL SUCTION $ 30.00 27207284 HC CCH GLIDEWIRE 180CM/.035 ANGLED W/3CM TAPER $ 228.00 27207285 HC CCH GLIDEWIRE 260CM/.035 ANGLED W/3CM TAPER $ 204.00 27207286 HC CCH GLIDEWIRE 180CM/.035 STIFF $ 214.00 27207287 HC CCH GLIDEWIRE 260CM/.035 STIFF $ 228.00 27207288 HC CCH CATH URETERAL ACCESS 6FR 2.0 $ 55.00 27207289 HC CCH CATH URETERAL ACCESS 6FR 2.0 MM $ 446.00 27207290 HC CCH CATH URETERAL ACCESS 6FR 2.0 MM OPEN END $ 499.00 27207291 HC CCH TUBE ENDO MICROCUFF ORAL PED ETT 3.5 $ 41.00 27207292 HC CCH TUBE ENDO MICROCUFF ORAL PED ETT 3.0 $ 84.00 27207293 HC CCH TUBE ENDO REINFORCED $ 89.00 27207294 HC CCH TUBE ENDOTRACHEAL REINFORCED 6.5MM $ 88.00 27207295 HC CCH TRAY QUICK TRACH $ 534.00 27207296 HC CCH CURETTE W/VACULOK SYRINGE URTERINE EXPLORE $ 26.00 27207297 HC CCH AIRWAY ONLY AIR Q BLOCKER $ 90.00 27207298 HC CCH KIT AIRWAY AIR Q BLOCKER $ 121.00 27207299 HC CCH ARTHROSCOPY PACK #NCOH03GO $ 152.00 27207300 HC CCH DELIVERY ROOM PACK $ 57.00 27207301 HC CCH PACK EXTREMITY NCOHO5GO $ 228.00 27207302 HC CCH STOCKINETTE IMPERVIOUS/ANY SZ $ 28.00 27207303 HC CCH TRAY CARDIOVASCULAR AVID $ 326.00 27207304 HC CCH TRAY TOTAL KNEE AVID GACH013 $ 590.00 27207305 HC CCH TRAY TOTAL HIP AVID GACH012 $ 475.00 27207306 HC CCH NEEDLE SUREFIRE SCORPION ARTHR $ 541.00 27207307 HC CCH MICRO AIRE BLADE 126 136 $ 70.00

02-19-2019-A-PAC-057 Page 7 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 27207308 HC CCH ANCHOR SUTURE BIO CORKSCREW 5.5MM WITH NEEDLES $ 1,107.00 27207309 HC CCH CORKSCREW BIO 6.5 $ 1,256.00 27207310 HC CCH SUTURE TAK BIOCOMPOSITE $ 1,143.00 27207311 HC CCH SUTURE TAK MICRO BIO $ 1,219.00 27207312 HC CCH SUTURE TAK MINI BIO 8.5MM W NEEDLES $ 198.00 27207313 HC CCH SYS IMPLANT SPEEDBRIDGE $ 5,496.00 27207314 HC CCH PACKING ORTHO-DRI ABSORBENT $ 207.00 27207315 HC CCH BUR OVAL MED CARBIDE 5.5 X 10 $ 77.00 27207316 HC CCH BURR CUTTING #3 $ 617.00 27207317 HC CCH PULSAVAC PLUS $ 170.00 27207318 HC CCH QUICK-VAC MIXING BOWL $ 243.00 27207319 HC CCH SAGITTAL BLADE-HIP #25075089TF $ 149.00 27207320 HC CCH DBL SIDED REDIP-KNEE #12076101 $ 164.00 27207321 HC CCH SAGITTAL BLADE-UNI KNEE $ 146.00 27207322 HC CCH PALACOS LVG $ 1,154.00 27207323 HC CCH FEMORAL BONE CEMENT PREP KIT $ 497.00 27207324 HC CCH CRADLE FOAM ARM $ 61.00 27207325 HC CCH TRAP DIGIT SMALL $ 72.00 27207326 HC CCH KIT TFCC MENDER $ 460.00 27207327 HC CCH BLADE FULL RADIUS 2.9 MM $ 214.00 27207328 HC CCH SET DISP INSTRUMENT AR-1322DS $ 676.00 27207329 HC CCH R12-9418 BUCK CEMENT RETRISTR $ 436.00 27207330 HC CCH SEAL PRESSURING HOWMEDICA $ 191.00 27207331 HC CCH Z5059-13 FEMORAL BONE BRUSH $ 90.00 27207332 HC CCH BLADE SHAVER GATOR 3.5 $ 209.00 27207333 HC CCH BLADE GATOR ARTHROSCOPY 4.2MM $ 39.00 27207334 HC CCH BLADE ARTHROSCOPY 4.2 MAKO ( PAR 2 BX ) $ 242.00 27207335 HC CCH BLADE ARTHROSCOPY 5.5 ULTRACUT ( PAR 2 BX ) $ 337.00 27207336 HC CCH VAPR S90 W/HAND CTRL #228370 $ 1,170.00 27207337 HC CCH RASP RECROCATING W5.5 X L1.5 $ 184.00 27207338 HC CCH RASP RECIPROCATING $ 184.00 27207339 HC CCH BLADE TPS LG MED STRYKER $ 228.00 27207340 HC CCH BLADE SAW WITH STOP TPS $ 186.00 27207341 HC CCH BLADE SAGITTAL SAW ANY STRYKER $ 167.00 27207342 HC CCH KNIFE GRAFT ACL .9MM $ 643.00 27207343 HC CCH KNIFE GRAFT ACL 10MM $ 561.00 27207344 HC CCH CUTTER SUTURE FAST FIX MENISCAL KNOT $ 541.00 27207345 HC CCH ANCHOR SUTURE PUSHLOCK BIOCOMPOSITE $ 1,499.00 27207346 HC CCH BRACE ULTRASLING II SHOULDER $ 191.00 27207347 HC CCH STRAP CLAVICLE 3-WAY SM W/VELCRO $ 39.00 27207348 HC CCH STRAP CLAVICLE CONTOUR XLG $ 30.00 27207349 HC CCH COLLAR STIFNECK BABY NO NECK $ 42.00 27207350 HC CCH COLLAR CERVICAL STIFNECK ADULT $ 44.00 27207351 HC CCH ABDOMINAL BINDER/ANY SIZE $ 85.00 27207352 HC CCH BUCKS TRACTION/ANY SIZE $ 46.00 27207353 HC CCH DRESSING SMALL VAC SIMPLACE $ 190. 00 27207354 HC CCH DERMABOND SKIN CLOSURE 60 CM $ 526.00 27207355 HC CCH DRESSING DUODERM SIG 8X9 SACRA $ 48.00 27207356 HC CCH DRESSING AQUACEL AG 4X4 FOAM $ 46.00 27207357 HC CCH DRESSING AQUACEL AG EXTRA HYDROFIBER 4 X 5IN $ 40.00 27207358 HC CCH DRESSING MAXORB EXTRA AG ROPE $ 28.00 27207359 HC CCH DRESSING ARGLAES FILM $ 28.00 27207360 HC CCH AQUACEL AG HYDRO FIBER WITH SILVER 3.5 X 10IN $ 172.00 27207361 HC CCH AQUACELL AG 3.5 X 10 DR FOSTER $ 170.00 27207362 HC CCH AQUACELL AG SURGICAL HYDROFIBER SILVER 3.5 X 14IN $ 189.00 27207363 HC CCH AQUACEL AG HYDRO FIBER WITH SILVER 3.5 X 14IN $ 191.00 27207364 HC CCH BANDAGE ESMARK 6 X 12 $ 29.00 27207365 HC CCH GATOR BLADE $ 274.00 27207366 HC CCH DRESSING MEDIUM GRANUFOAM VAC $ 222.00 27207367 HC CCH KIT CATH RADIAL ARTERY AK04020 $ 78.00 27207368 HC CCH UMBILICAL VESSEL ARGYLE $ 71.00 27207369 HC CCH NEEDLE INSULATED STIMUPLEX W/EXT SET 22GA X2 $ 38.00 27207370 HC CCH NEEDLE INSULATED STIMUPLEX W/EXT SET 20GA X2 $ 70.00 27207371 HC CCH NEEDLE INSULATED STIMUPLEX W/EXT SET 21GA X4 $ 63.00 27207372 HC CCH NEEDLE INSULATED STIMUPLEX 21 X 4 $ 55.00 27207373 HC CCH NEEDLE SETS EZ I/O 15GA $ 507.00 27207374 HC CCH NEEDLE BIOPSY 14GA $ 131.00 27207375 HC CCH CATH/IV/TWO LUMEN ARROE 01100- $ 45.00 27207376 HC CCH NEEDLE GRIPPER PLUS 20X1 $ 27.00 27207377 HC CCH NEEDLE SPINAL CHIBA-TYPE 6IN $ 59.00 27207378 HC CCH NEEDLE SPINAL 18G $ 54.00

02-19-2019-A-PAC-057 Page 8 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 27207379 HC CCH NEEDLE SPINAL PEN POINT LONG 25G X 5 $ 29.00 27207380 HC CCH CLEARLINK BLOOD Y SET $ 30.00 27207381 HC CCH OPTHO-BURR $ 223.00 27207382 HC CCH OPTHO-BURR OVAL 4 X 8 $ 69.00 27207383 HC CCH OPTHO-BURR TIP 1 MM $ 41.00 27207384 HC CCH AMPLATZ GUIDE WIRE $ 128.00 27207385 HC CCH INFUSER PRESSURE DISPOSABLE BAG W/HOOK 500CC $ 96.00 27207386 HC CCH SHEATH PINNACLE 5FR $ 51.00 27207387 HC CCH SHEATH PINNACLE 6FR $ 51.00 27207388 HC CCH BLLN CATH SENSATION PLUS 7.5FR 40CC $ 2,899.00 27207389 HC CCH BLLN CATH SENSATION PLUS 8FR 50CC $ 2,899.00 27207390 HC CCH KIT INSERTION 7.5 FR 40CC $ 552.00 27207391 HC CCH KIT INSERTION 5FR 50CC $ 552.00 27207392 HC CCH GUIDEWIRES EXTRA 0.025"X145CM 3MM J PTFE STAINLESS STEEL $ 112.00 27207393 HC CCH D-STAT RAD-BAND $ 243.00 27207394 HC CCH SUPPORT XTEND WRIST $ 54.00 27207395 HC CCH PACK CARDIAC CATH MEDLINE $ 226.00 27207396 HC CCH KIT MICROPUNTURE 0.018"X40CM SS/SS 21GX7CM $ 107.00 27207397 HC CCH KIT MICROPUNTURE 0.018"X40CM NT/PD 21GX7CM $ 117.00 27207398 HC CCH KIT MICROPUNTURE 0.018"X40CM SS/SS 21G $ 166.00 27207400 HC CCH TUBING HIGH PRESSURE MERIT $ 29.00 27207401 HC CCH KIT MANIFOLD MERIT $ 130.00 27207402 HC CCH MULTIPAK INFINTI $ 125.00 27207403 HC CCH CATH INFINITI 4FR $ 48.00 27207404 HC CCH SYRINGE (ACIST) $ 107.00 27207405 HC CCH MANIFOLD (ACIST) $ 85.00 27207406 HC CCH CONTROLLER HAND (ACIST) $ 118.00 27207407 HC CCH ANGIO-SEAL 6-7FR $ 660.00 27207408 HC CCH FEMOSTOP GOLD COMPRESSION ASSIST DEVICE $ 307.00 27207409 HC CCH CATH GUIDELINER $ 1,499.00 27207410 HC CCH CATH LANGSTON DUAL LUMEN PIG 6F $ 483.00 27207411 HC CCH INTRODUCER PERFORMER FR14 BLUE 14.0-38-30-RB SET CHECK-FLO $ 411.00 27207412 HC CCH CATH INFINITI TL JL 4.5 F6 100CM $ 85.00 27207413 HC CCH CATH INFINITI TL JL 3.5 F6 100CM $ 72.00 27207414 HC CCH CATH INFINITI TL JR 3.5 F6 100CM $ 78.00 27207415 HC CCH CATH INFINITI TL JL 4 F6 100CM $ 76.00 27207416 HC CCH CATH INFINITI 3DRC F5 100CM $ 76.00 27207417 HC CCH INFUSER PRESSURE W/HOOK 1000ML $ 105.00 27207418 HC CCH CATH PACEL BIPOLAR PACING $ 313.00 27207419 HC CCH CATH PACEL BIPOLAR PACING KIT $ 355.00 27207420 HC CCH CATH JACKY RADIAL 5FR 100CM $ 198.00 27207421 HC CCH COPE MANDRIL WIRE 60CM $ 151.00 27207422 HC CCH KIT IVC RETRIEVAL $ 1,125.00 27207423 HC CCH J-WIRE 150CM .035 CORDIS $ 27.00 27207424 HC CCH SHEATH 6FR DESTINATION 45CM STRAIGHT $ 404.00 27207425 HC CCH SHEATH 6FR PINNACLE 25CM $ 106. 00 27207426 HC CCH D-STAT FEMORAL $ 146.00 27207427 HC CCH CATH JACKY DIAG RADIAL 6FR $ 198.00 27207456 HC CCH BLOOD VAMP 60IN $ 407.00 27207457 HC CCH GUIDEWIRE ANGLED 150CM $ 184.00 27207458 HC CCH BAG AMBU PED $ 369.00 27207459 HC CCH BAG INFUSER PRESSURE 1000ML $ 71.00 27207460 HC CCH BAGS GEL $ 218.00 27207461 HC CCH BINDER ABDOMINAL $ 43.00 27207462 HC CCH BLADE STERILE SURGICAL $ 74.00 27207463 HC CCH CATH FOLEY IRRIGATION $ 80.00 27207464 HC CCH ELECTRODE EKG FAST PATCH $ 91.00 27207465 HC CCH ELECTRODE W/QUIK-COMBO CONNECT $ 126.00 27207466 HC CCH KIT 1000 ML DRAINAGE PLEURX $ 326.00 27207467 HC CCH KIT 8.5FR PERC INTRODUCER SHEATH $ 191.00 27207468 HC CCH KIT DRESSING GRANUFOAM VAC SIM $ 344.00 27207469 HC CCH KIT DRESSING MED GRANUFOAM SIL $ 292.00 27207470 HC CCH KIT DRESSING VAC GRANUFOAM BRI $ 248.00 27207471 HC CCH KIT TRANSDUCER SINGLE LINE DTX PLUS $ 79.00 27207472 HC CCH KIT DIRECT VISION CATHETER $ 175.00 27207473 HC CCH KIT DRESSING VAC GRANU FOAM $ 288.00 27207474 HC CCH LEADWIRE DUAL CONNECT DISP $ 77.00 27207475 HC CCH MODULE BROSELOW $ 175.00 27207476 HC CCH MULTISTICK 10SG REAGENT $ 147.00 27207477 HC CCH OXISENSOR INFANT DISP MASIMO $ 55.00 27207478 HC CCH PREVALON PRESSURE RELIEVING HEAL PROTECTOR $ 259.00

02-19-2019-A-PAC-057 Page 9 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 27207479 HC CCH FIBERGLASS SPLINT SYSTEM $ 167.00 27207480 HC CCH SET SCD CONTROLLER TUBING 7' $ 231.00 27207481 HC CCH STRAIGHT ZIPWIRE HYDROPHILIC GUIDEWIRE (150CM .035IN/.89MM) $ 184.00 27207482 HC CCH SUR-FIT NATURA DRAINABLE POUCH 10 OPAQUE 1 1/2 $ 49.00 27207483 HC CCH TRAY 13FR 10CM THORACIC VENT FOR PNEUMOTHORAX $ 1,075.00 27207484 HC CCH TRAY LACERATION W/LIDOCAINE $ 49.00 27207485 HC CCH TRAY THORACENTESIS/PARACENTESIS $ 133.00 27207486 HC CCH TRAY PERICARDIOCENTESIS PIGTAIL CATHETER $ 771.00 27207487 HC CCH TRUVUESW060 TURVUE STD HEEL PROTECTOR W/WD $ 185.00 27207488 HC CCH TUBE TRACH CUFFED LOW PRESSURE $ 219.00 27207489 HC CCH TUBE 12FR FEEDING $ 61.00 27207490 HC CCH TUBING ASSEMBLY A-V IMPULS SYSTEM $ 123.00 27207491 HC CCH WRAP COMPRESSION WITH GEL HIP $ 188.00 27207492 HC CCH WRAP COMPRESSION WITH GEL KNEE $ 185.00 27207493 HC CCH X RX KIT RADIAL ARTERY CATHETER $ 85.00 27207500 HC CCH RESPIRATORY AEROCHAMBER PLUS $ 30.00 27207504 HC CCH ADHESIVE TOPICAL SKIN SWIFTSET $ 127.00 27207505 HC CCH SYRINGE DUAL HEAD 200ML QUICK FILL TUBE $ 54.00 27207506 HC CCH CLEAR CHEST BAND ANY SIZE $ 302.00 27207507 HC CCH BIOPSY TRAY DISPOSABLE KIT $ 48.00 27207510 HC CCH MASK BIPAP PERFORMA W/ HEADGEAR SM $ 166.00 27207515 HC CCH BIPAP CIRCUIT $ 34.00 27207516 HC CCH INSTA/VENT + RADIOAEROSOL UNIT $ 179.00 27207532 HC CCH FINGER SPLINT/VELCRO (BREG) $ 42.00 27207533 HC CCH GLIDESCOPE BLADE $ 88.00 27207534 HC CCH SPINAL NEEDLE - VARIOUS SIZES $ 85.00 27207535 HC CCH DRAINAGE CHEST PLEUR-EVAC SAHARA $ 149.00 27207536 HC CCH POWER LOC INFUSION SET $ 67.00 27207537 HC CCH ORTHOGLASS SPLINT PER INCH $ 6.00 27207538 HC CCH EMERGENCY CRICOTHYROTOMY CATH KIT $ 1,742.00 27207539 HC CCH THORACENTESIS/PERICARDIOCENTESIS TRAY $ 133.00 27207540 HC CCH ARROWGUARD BLUE PLUS PRESSURE INJ TRIPLE LUMEN MULTI LUMEN CVC KIT $ 191.00 27207541 HC CCH ANGIO DYNAMICS DOUBLE LUMEN CATHETER $ 763.00 27207563 HC CCH EXPIRATORY FILTER $ 56.00 27207564 HC CCH HOLLISTER $ 37.00 27207565 HC CCH BALLARD $ 30.00 27207566 HC CCH ADULT AMBU BAG $ 48.00 27207567 HC CCH ADULT CO2 DETECTOR $ 45.00 27207597 HC CCH BAG SOLUTION CHLORIDE 0.9% 5000ML $ 49.00 27207598 HC CCH BAG DRAIN W/ URINE METER $ 32.00 27207599 HC CCH MEROCEL PACKING POPE 10CM $ 137.00 27207600 HC CCH TROCAR CATHETER STERILE 23FR $ 80.00 27207601 HC CCH TUBE TRACH SHILEY ADULT REGSZ8 $ 219.00 27207602 HC CCH UNIVERSAL THUMB SPLINT LARGE $ 83.00 27207603 HC CCH ATOMIZATION DEVICE MUCOSAL LL 3ML S $ 33.00 27207641 HC CCH NEEDLE - POWER PORT HUBER NEEDLES $ 68. 00 27207642 HC CCH NEEDLE - GRIPPER NEEDLE - 20 GUAGE X 3/4" $ 27.00 27207643 HC CCH NEEDLE - GRIPPER NEEDLE - 20 GUAGE X 1 1/4" $ 27.00 27207644 HC CCH SYRINGE FLUSH - 10ML SALINE FLUSH $ 34.00 27207645 HC CCH SET 5IN EXTENSION LS Y-TYPE $ 32.00 27207647 HC CCH NEEDLE HUBER WINGED INFUSION SET 20 GA X 1 1/2" $ 42.00 27207648 HC CCH TOURNIQUET $ 29.00 27207652 HC CCH SET BLOOD AND FLUID ADMINISTRATION $ 344.00 27207654 HC CCH FLUTED MATCHSTICK 3MM $ 408.00 27207655 HC CCH 6" DOUBLE ACE WRAP $ 34.00 27207656 HC CCH BOVIE TIP 4" TEFLON $ 29.00 27207657 HC CCH ALLIGATOR CLIP 5 LEAD ECG CABLE 24" $ 437.00 27207658 HC CCH BLOOD SAMPLING 60IN VAMP POLE MOUNT $ 407.00 27207659 HC CCH 740 VENTILATOR EXPIRATORY FILTERS $ 41.00 27207660 HC CCH CANNULA ABLATION 20GA 100/5-SHARP CURVED $ 70.00 27207661 HC CCH ANESTHESIA BREATHING CIRCUITS $ 27.00 27207662 HC CCH ANCHOR PAIN $ 1,265.00 27207663 HC CCH AQUACELL AG 4X4 $ 41.00 27207664 HC CCH BAG 2500ML DRAINAGE W/350ML UR $ 30.00 27207665 HC CCH AQUAPLAST ROYAL BLUE CASTING MATERIAL 1/8 X 18 X 24 $ 247.00 27207666 HC CCH AQUAPLAST SILVER CASTING MATERIAL $ 340.00 27207667 HC CCH BAG RESUSCITATION ADULT MANUAL $ 48.00 27207669 HC CCH BAGS GEL 3+ HOUR $ 218.00 27207670 HC CCH BAND CUDDLES SYSTEM $ 27.00 27207671 HC CCH BANDAGE MEDICOPASTE DOME PASTE $ 32.00 27207672 HC CCH BARRIER 2.5OZ MOISTURE CRITIC- $ 25.00

02-19-2019-A-PAC-057 Page 10 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 27207673 HC CCH ABDOMINAL BINDER $ 43.00 27207674 HC CCH BLADE 1IN ULTRACLEAN W/EXTENDE $ 27.00 27207675 HC CCH BANDAGE TUBIGRIP 3IN X 33FT $ 133.00 27207676 HC CCH BELT RESPIRATORY EFFORT W/ SENSOR $ 1,009.00 27207677 HC CCH BLADE 21 STERILE SURGICL $ 82.00 27207679 HC CCH BLOCKER ENDO BRONCHEAL $ 707.00 27207680 HC CCH CANNULA 20G ACTIVE TIP CURVED ANY SIZE $ 100.00 27207681 HC CCH CANNULA DISPOSABLE INNER ANY SIZE $ 61.00 27207682 HC CCH BRACE KNEE POST-OP COOL VERSION $ 330.00 27207683 HC CCH CARTRIDGE TEST IST CEL I STAT $ 36.00 27207684 HC CCH CATH 16 FR ANY CC $ 42.00 27207685 HC CCH CANISTER 500ML INFOVAC W/O GEL $ 172.00 27207686 HC CCH CATH 20 FR ANY CC $ 44.00 27207687 HC CCH CATH 22 FR ANY CC $ 42.00 27207688 HC CCH CATH 24 FR ANY CC $ 41.00 27207689 HC CCH CATHETER PLEURAL PLEURX $ 2,512.00 27207690 HC CCH CATHETER 14 FR SUCTION SYSTEM $ 30.00 27207691 HC CCH CHAMBER AERO PLUS ZSTAT $ 29.00 27207692 HC CCH CIDEX OPA SOLUTION TEST STRIPS $ 177.00 27207693 HC CCH CIRCUIT VENTILATOR BIPAP $ 34.00 27207694 HC CCH CATHETER SUCTION 14FR SINGLE LUMEN $ 35.00 27207695 HC CCH CATHETER BRONCHO LEFT 37 FR $ 230.00 27207696 HC CCH CHLOREXIDINE GLUCONATE WIPES $ 28.00 27207697 HC CCH CLIK X ANCHOR STERILE KIT PAIN $ 1,265.00 27207698 HC CCH CLIPPER 3M $ 190.00 27207699 HC CCH CONTAINER 1000ML EMPTY EVACUATED GLASS $ 48.00 27207700 HC CCH NEEDLE 18GA CONTI PLEX TUOBY NERVE BLOCK SET $ 137.00 27207701 HC CCH DRESSING 1.5OZ HYDROGEL SILVAS $ 78.00 27207702 HC CCH COVER TRANSDUCER CIV FLEX $ 65.00 27207703 HC CCH CUFF CALF MED DISP VENAFLOW $ 65.00 27207704 HC CCH DEVICE FIXATE SUTURING PAIN $ 2,470.00 27207705 HC CCH DRESSING ALLEVYN HEEL TEMP CONTROLLED 77F $ 40.00 27207706 HC CCH ELECTRODE CLOTH W/SOLID GEL $ 67.00 27207707 HC CCH ABDOMINAL LAP PACK DYNJ50057A $ 166.00 27207708 HC CCH ELECTRODE ECG Q-TRACE 5400 SER $ 113.00 27207709 HC CCH ELECTRODE NICOLET BRAND GOLD CUT $ 38.00 27207710 HC CCH FLEXI-FORM III PULSE OXIMETRY DISPOSABLE SENSOR $ 78.00 27207711 HC CCH FILTER EXHALATION SPU DX800 - 840 $ 56.00 27207712 HC CCH FINGER ICE $ 46.00 27207714 HC CCH GUIDEWIRE FIXED CORE SAFE-T J-CURVED $ 56.00 27207715 HC CCH GEL 4OZ SKIN PREP NUPREP $ 109.00 27207716 HC CCH OPTIFOAM DRESSING 4X4 $ 61.00 27207717 HC CCH KIT 100CC EVACUATOR WOUND SUCTION SILICONE $ 45.00 27207718 HC CCH FREELINK REMOTE CONTROL KIT PAIN $ 2,778.00 27207719 HC CCH HEMOSTAT ARIST ABSORABABLE $ 1,003.00 27207720 HC CCH HOLDER TUBE ENDOTRACHEAL $ 37. 00 27207721 HC CCH HOOK SELF ADHESIVE 25 YD 1" $ 110.00 27207722 HC CCH INSTRUMENT BIOPSY FULL CORE $ 186.00 27207723 HC CCH KIT LEAD EXTENSION 25CM PAIN $ 2,055.00 27207724 HC CCH MARKER SKIN FINE TIP $ 155.00 27207725 HC CCH MASK RESPIRATOR TYPE N95 REGUL $ 62.00 27207726 HC CCH METER FLOW PEAK POCKETPEAK UNI $ 37.00 27207727 HC CCH KIT REMOTE CONTROL PAIN $ 2,778.00 27207728 HC CCH NEEDLE 19GA X 1IN POWERLOC W/Y-SITE $ 68.00 27207729 HC CCH KIT HEMOVAC 400ML 1/8 PVC DRAIN $ 85.00 27207730 HC CCH PACK ABDOMINAL LAP LF $ 238.00 27207731 HC CCH LANCET SAFE-T-PRO SINGLE USE $ 106.00 27207732 HC CCH PACK C-SECTION CUSTOM $ 453.00 27207733 HC CCH LOOP ROLYAN NON ADHESIVE 2" NAVY BLUE 25YD $ 194.00 27207734 HC CCH MASIMO SET INFANT SPO2 ADHESIVE SENSOR DISPOSABLE $ 59.00 27207735 HC CCH MASK FACE ADULT LARGE W/ HEAD $ 134.00 27207736 HC CCH MASK SZ 3 LARYNGEAL DISP $ 29.00 27207737 HC CCH MASK ANTIFOG $ 59.00 27207738 HC CCH MASK BIPAP PERFORMA W/ HEADGEAR MED $ 125.00 27207739 HC CCH MASK BIPAP PERFORMA W/ HEADGEAR LG $ 167.00 27207740 HC CCH PAD VAC SYSTEM SENSA-TRAC 5/CA $ 153.00 27207741 HC CCH PASTE 20Z OSTOMY $ 27.00 27207742 HC CCH PASTE 4 X 360 DOME $ 38.00 27207743 HC CCH MEDFIX TAPE 4IN $ 27.00 27207744 HC CCH MINDRAY ADULT SINGLE USE PULSE OX SENSORS $ 43.00 27207745 HC CCH NEEDLE ECHOGENIX STIMUPLEX $ 61.00

02-19-2019-A-PAC-057 Page 11 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 27207746 HC CCH NEEDLE BRAUN PERIFIX 18GAX6" TOUHY $ 35.00 27207747 HC CCH SCRUB 1000ML SURGCL 4% CHG END $ 34.00 27207748 HC CCH SENSOR MATTRESS 30 DAY DISP $ 87.00 27207750 HC CCH SET PCA MINIBORE TUBING $ 27.00 27207751 HC CCH NEEDLE SPINAL QUINCKE 25GX3.5 $ 26.00 27207752 HC CCH SET Y-TYPE TUR-BLADDER IRRIGATION $ 36.00 27207754 HC CCH OPTIFOAM DRESSING 6X6 $ 30.00 27207755 HC CCH PAIN LINEAR LEAD $ 463.00 27207756 HC CCH STERI-PROBE RECTAL/ESOPHAGEL PROBE $ 26.00 27207757 HC CCH PASSPORT 2 PINCH LEAD 3 LEAD WIRE SET 24IN $ 258.00 27207758 HC CCH PREP LEMON $ 35.00 27207759 HC CCH PROBE RFA FOR OWL $ 70.00 27207760 HC CCH PULLEY SHOULDER HOME RANGER $ 43.00 27207761 HC CCH PUTTY FIRM BLUE THERAPY 5LBS $ 40.00 27207762 HC CCH PUTTY THERAPY FIRM BLUE 1LB $ 74.00 27207763 HC CCH PUTTY THERAPY MEDIUM GREEN 5LBS $ 179.00 27207765 HC CCH PUTTY THERAPY SOFT YELLOW 1LB $ 42.00 27207766 HC CCH CATHETER DRAINAGE KIT 6FR X 10 SAFE-T-CENTESIS $ 237.00 27207767 HC CCH SCISSORS SUTURE $ 237.00 27207768 HC CCH SENSOR SENSE BINAPS THERMI $ 246.00 27207769 HC CCH INFUSION POWER SET 20GA X 1.5IN $ 69.00 27207770 HC CCH TUBING SET FLUID ADMINISTRATION LARGE BORE 3/16 $ 55.00 27207771 HC CCH SHEET TRANSVERSE LAPAROTOMY $ 27.00 27207772 HC CCH OPTIFOAM AG 4X4 $ 35.00 27207773 HC CCH TROPIC PAC MOIST HEAT PACKS CONTOUR CERVICAL 24 X 6-1/6 $ 45.00 27207774 HC CCH TRAP 10FR MUCOUS CENTURIAN $ 35.00 27207775 HC CCH TRAY 8FR PNEUMOTHORAX $ 432.00 27207777 HC CCH SPINE PACK $ 308.00 27207778 HC CCH TUBING 100FT FLAT PACK CORRUGATED BLUE $ 48.00 27207779 HC CCH TUBING 7MM 100FT CONNECTING NO $ 37.00 27207780 HC CCH SPLINT 20IN KNEE SUPER XLG $ 57.00 27207781 HC CCH SPRAY COLD CRAMER $ 39.00 27207782 HC CCH STIMUPLEX HNS 12 LEAD $ 197.00 27207783 HC CCH STRAP CHIN CPAP LARGE $ 63.00 27207784 HC CCH TUBE NASOGASTRIC W/FILTER $ 25.00 27207785 HC CCH SUPPORT 36 - 42IN CLAVICLE LG HEAVY PADDED $ 29.00 27207786 HC CCH SUPPORT KNEE HINGED WRAP AROUND CMO 3XL $ 128.00 27207787 HC CCH SUTURE VICRYL 2-0 $ 80.00 27207788 HC CCH SUTURE VICRYL 3-0 $ 70.00 27207789 HC CCH SUTURE PERMA HAND SILK 0 CTI $ 49.00 27207790 HC CCH SYSTEM WOUND DEBRIDEMENT $ 254.00 27207791 HC CCH SYSTEM C-PAP $ 110.00 27207792 HC CCH TAPE MEDIPORE 4" $ 33.00 27207793 HC CCH CATH 18 FR ANY CC $ 40.00 27207794 HC CCH THERABAND GREEN LEVEL 3 $ 247.00 27207795 HC CCH TRAY 16FR FOLEY IC CATH W/ 200 $ 82. 00 27207796 HC CCH TRAY PREP SKIN W/CHG LF $ 28.00 27207797 HC CCH TRAY EPIDURAL CONTINUOUS BRAUN $ 90.00 27207798 HC CCH EXPIRATORY MUSCLE STRENGTH TRAINER $ 221.00 27207799 HC CCH CUP DRINKING 10CC PROVALE $ 167.00 27207800 HC CCH CUP DRINKING 5CC PROVALE $ 173.00 27207810 HC CCH WOUND VAC PICO DRESSING 10X20CM STERILE PUMP DISP NEG PRESSURE $ 879.00 27207811 HC CCH X RX TRAY SPINAL WHITACRE 25G W/O LIDOCAINE OR DEXTROSE $ 54.00 27207813 HC CCH TUBE TRACH W/ CUFF & INNER CANNULA $ 179.00 27207820 HC CCH GEL WOUND SOLOSITE HYDROGEL 3 OZ TUBE $ 27.00 27207821 HC CCH SPRAY ASEPTI-HB DISINFECTANT 12-32 - SUBSTITUTED $ 30.00 27207824 HC CCH TRIPLE HELIX COLLAGEN POWDER 1 GRAM PKT (5/PK) $ 44.00 27207825 HC CCH ELASTIC NET SIZE 1 STRETCH $ 45.00 27207826 HC CCH ELASTICE NET SIZE 2 $ 49.00 27207827 HC CCH SILVASORB GEL $ 84.00 27207828 HC CCH DRESSING WOUND PRIMARY CONTACT 1.5X8 PROCELLERA ANTIMICROBIAL $ 106.00 27207829 HC CCH BANDAGE SCISSORS $ 112.00 27207830 HC CCH RX VASHE WOUND THERAPY 475 ML BOTTLE $ 122.00 27207831 HC CCH ENDOZIME $ 208.00 27207832 HC CCH ASEPTI HB DISINFECTANT $ 306.00 27207833 HC CCH PROCELLERA $ 41.00 27207835 HC CCH DRESSING OPTIFOAM NON ADHESIVE $ 53.00 27207836 HC CCH PROMOD $ 85.00 27207837 HC CCH OXEPA $ 81.00 27207838 HC CCH VITAL HIGH PROTEIN 1.2 CALORIE $ 58.00 27207839 HC CCH VITAL HIGH PROTEIN 1.5 CALORIE $ 58.00

02-19-2019-A-PAC-057 Page 12 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 27207840 HC CCH MYSTIC II SOFT BELL CUP $ 180.00 27207841 HC CCH COOK BAKRI POSTPARTUM BALLOON W/RAPID INSTILLATION $ 933.00 27207842 HC CCH MINI PEDIATRIC STAT C02 END TIDAL C02 DETECTOR $ 77.00 27207843 HC CCH AROMCOT FINGER COT W/HOOK $ 29.00 27207850 HC CCH CHEMO PREP CHARGE $ 55.00 27207851 HC CCH CHEMO TUBING CHARGE $ 49.00 27207852 HC CCH CHEMO VIAL ADAPTER CHARGE $ 25.00 27207855 HC CCH GLIDE SCOPE STAT $ 111.00 27207856 HC CCH TUBING W/ FILTER HOT-LINE $ 48.00 27207857 HC CCH STIMPLEX HNS12 NERVE STIMULATOR WITH SENSE $ 2,536.00 27207858 HC CCH PICC TRIPLE LUMEN CT LINE INSERTION KIT $ 591.00 27207859 HC CCH ENEMA DELIVERY SYSTEM SUPER XL $ 200.00 27207860 HC CCH VACUUM -ASSISTED BIOPSY SYSTEM MAMMOTOME ELITE TETHERLESS $ 1,616.00 27207861 HC CCH CATHETER SKATER ALL PURPOSE LOCKING PIGTAIL $ 384.00 27207862 HC CCH CATHETER DRAINAGE SKATER ALL PURPOSE $ 384.00 27207863 HC CCH NEEDLE CO-AXIAL INTRODUCER 17G X 11.8 CM $ 74.00 27207864 HC CCH NEEDLE BIOPSY BREAST 7.5CM X 20GA $ 144.00 27207865 HC CCH PICC LINE STATLOCK STABILIZATION DEVICE FOAM $ 54.00 27207866 HC CCH DRESSING BIOPATCH 3/4 ANTIMICROBIAL $ 43.00 27207867 HC CCH 12FT EXTENSION CABLE W/ ALLIGATOR CLIP $ 109.00 27207868 HC CCH EVICEL FIBRIN SEALANT HUMAN 5 ML KIT $ 2,281.00 27207869 HC CCH NEEDLE ACCUGRID 4.5" $ 106.00 27207870 HC CCH NEEDLE HOMER BREAST BIOPSY 3.0CMX20GA $ 155.00 27207875 HC CCH SLING SINGLE PATIENT W/ HEAD SUPPORT ANY SIZE $ 189.00 27207888 HC CCH KIT DISPOSABLE MRI FOR 65/115 MR INJECTOR SYSTEM $ 63.00 27207889 HC CCH GAIT BELT 96" BARIATRIC $ 186.00 27207899 HC CCH MCKELOR PHOENIX SOFTGOOD SET FOR CPM MACHINE $ 190.00 27207900 HC CCH MEDLINE 35WA DISPOSABLE SKIN STAPLER $ 29.00 27207901 HC CCH SPONGE BOWL PW-PA-70 $ 51.00 27207902 HC CCH AMBU DISP MANOMETER $ 28.00 27207903 HC CCH TRANSWARMER INFANT MATTRESS 10INX16IN $ 53.00 27207904 HC CCH AMBU DISPOSABLE PRESSURE MANOMETER SINGLE PT USE $ 29.00 27207943 HC CCH MATS MOBILE AIR TRANSFER SYSTEM $ 368.00 27207944 HC CCH AIRTRAP PATIENT REPOSITIONING SYSTEM $ 676.00 27208007 HC CCH DRESSING BIOPATCH 1 IN DISK 4MM $ 93.00 27208008 HC CCH AIRWAY CANNULA CONNECT BODAI DOUBLE SWIVEL $ 37.00 27208020 HC CCH CIRCUMCISION PLASTICBELL DEVICE $ 38.00 27208021 HC CCH MASK; FACE FLEXIBLE 0 PREEMIE $ 44.00 27208022 HC CCH ADULT ELECTRODES $ 57.00 27208023 HC CCH FILTER DRAGER 4/PK $ 72.00 27208084 HC CCH MASK FIT LIFE LG W/ HEAD GEAR $ 146.00 27208166 HC CCH VASOPRESS CALF GREEN GARMENT BARIATRIC $ 101.00 27208167 HC CCH VASOPRESS CALF GREEN GARMENT LARGE $ 87.00 27208168 HC CCH VASOPRESS FOOT GARMENT L-R OVER SIZE 13 $ 146.00 27208169 HC CCH VASOPRESS FOOT GARMENT L-R UP TO SIZE 13 $ 134.00 27208170 HC CCH VASOPRESS CALF GREEN GARMENT MEDIUM $ 78. 00 27208207 HC CCH CIRCUIT NEONATAL PATIENT TPIECE DESPOSABLE $ 65.00 27208209 HC CCH PROBE SKIN TEMPERATURE SINGLE PATIENT USE $ 42.00 27208213 HC CCH CAST LONG ARM ADULT; FIBERGLASS $ 350.00 27208214 HC CCH CAST LONG ARM PEDIATRIC; FIBERGLASS $ 350.00 27208215 HC CCH CAST SHORT ARM ADULT; FIBERGLASS $ 289.00 27208216 HC CCH CAST SHORT ARM PEDIATRIC; FIBERGLASS $ 120.00 27208217 HC CCH CAST LONG LEG ADULT; FIBERGLASS $ 550.00 27208218 HC CCH CAST LONG LEG PEDIATRIC; FIBERGLASS $ 450.00 27208219 HC CCH CAST SHORT LEG ADULT; FIBERGLASS $ 450.00 27208220 HC CCH CAST SHORT LEG PEDIATRIC; FIBERGLASS $ 320.00 27208401 HC CCH CVD CANNULA 20G 150MM $ 224.00 27208408 HC CCH NEEDLE TOUHY EPIDURAL 16G X 3.5 IN $ 51.00 27208416 HC CCH NEEDLE TOUHY 17GX3.5 $ 47.00 27208417 HC CCH SLEEVE HINGED ELBOW SMALL $ 208.00 27208418 HC CCH SLEEVE HINGED ELBOW MED/LARGE $ 172.00 27208419 HC CCH SYSTEM CORFIT 7000 XLG $ 132.00 27208420 HC CCH FLEXIBLE SOCK AND STOCKING AID $ 31.00 27208421 HC CCH SYTEM CORFIT 7000 XXL/SMALL $ 119.00 27208422 HC CCH SYSTEM CORFIT 7000 REG WHITE $ 128.00 27208423 HC CCH SWEDISH AFO SPLINT MENS $ 110.00 27208424 HC CCH AFO SPLINT WOMENS $ 110.00 27208425 HC CCH SUPPORT WRAP AROUND KNEE HIGH CMO XL/2XL $ 128.00 27208426 HC CCH SUPPORT WRAP AROUND KNEE HIGH CMO XSM/SM $ 123.00 27208427 HC CCH SUPPORT WRAP AROUND KNEE HIGH CMO MED/GL $ 123.00 27208428 HC CCH LEG LIFTER 29" RIGID $ 44.00

02-19-2019-A-PAC-057 Page 13 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 27208429 HC CCH SELF WIPE TOILET AID $ 185.00 27208430 HC CCH DRESSING STICK DREDD EZ 24" PLASTIC SHOEHORN $ 39.00 27208431 HC CCH REACHER 32"LONG FEATHER REACH $ 39.00 27208432 HC CCH FREEDOM FUNCTIONAL POSITION SPLINT $ 283.00 27208433 HC CCH LIGHT WEIGHT WRIST IMMOBILIZER MED $ 130.00 27208434 HC CCH LIGHT WEIGHT WRIST IMMOBILIZER SM/LG $ 97.00 27208435 HC CCH GLOVE PRESSURE BIOFORM OPEN TIP $ 97.00 27208436 HC CCH GLOVE 3/4 FINGER FULL ARM LENGTH RIGHT $ 29.00 27208437 HC CCH GLOVE 3/4 FINGER OVER THE WRIST LENGTH LEFT MED $ 34.00 27208438 HC CCH MITTS WASH TERRY CLOTH ANTIMICROBIAL LARGE $ 68.00 27208439 HC CCH GLOVE 3/4 FINGER OVER THE WRIST LENGTH LARGE $ 43.00 27208440 HC CCH AID SOCK TWO HANDLED MOLDED NORCO $ 72.00 27208446 HC CCH SHOULDER ORTHOSIS CAP DESIGN W/O JOINTS CUSTOM $ 2,436.00 27208450 HC CCH KIT PICO NPWT 8"X8" W/PUMP 20X20CM STERILE $ 876.00 27208451 HC CCH KIT PICO NPWT 4"X8 W/PUMP 10X20CM STERILE $ 876.00 27208452 HC CCH KIT PICO NPWT 6"X8 W/PUMP 15X20 CM STERILE $ 876.00 27208453 HC CCH DRESSING VAC WHITEFOAM SMALL SINGLE USE LATEX FREE $ 78.00 27208501 HC CCH DISPOSABLE SKIN PROBES $ 64.00 27208514 HC CCH SPLINT EXTENSION SOFT STRETCH XL $ 112.00 27208515 HC CCH SYSTEM PICO NPWT MULTISITE $ 888.00 27208516 HC CCH BINDER ABDOMINAL 3 PANEL 9" 72-84" $ 45.00 27208517 HC CCH BINDER ABDOMINAL COMFORT 12" 72-96" $ 61.00 27208518 HC CCH BINDER ABDOMINAL 3 PANEL 9" 86-105" 4XL $ 89.00 27208540 HC CCH TEMPORARY PACEMAKER TRAY $ 715.00 27208541 HC CCH TEMPORARY EXTERNAL SURGICAL SHOUDED CABLE $ 308.00 27208559 HC CCH WOUND CLOT HEMOSTATIC GAUZE $ 82.00 27208596 HC CCH CATHETER THERACATH EPIDURAL 19GA W/SNAPLOCK ADAPTER $ 22.00 27208609 HC CCH DRESSING ADHSV ECLYPS ADH 3.9 X 3.9" $ 25.00 27208610 HC CCH DRESSING ADHSV ECLYPS ADH 5.9 X 5.9" $ 49.00 27208611 HC CCH DRESSING ADHSV ECLYPS ADH 4X8 OVAL $ 47.00 27208627 HC CCH CANNULA 20G 100MM/5MM ACTIVE TIP CURVED $ 99.00 27208628 HC CCH CANNULA 20G 100MM/10MM ACTIVE TIP CURVED $ 107.00 27208629 HC CCH CANNULA 20G 150MM/10MM ACTIVE TIP CURVED $ 103.00 27208630 HC CCH CVD CANNULA 150MM 20G 5MM $ 235.00 27208631 HC CCH BIOSY DEVICE 3.7MM X 13CM X 20MM $ 892.00 27208632 HC CCH FIRING PETITE BIOPSY DEVICE 3.7MM X 13CM X 12MM $ 892.00 27208633 HC CCH NEEDLE GUIDE 3.7MM (9G) $ 44.00 27208634 HC CCH EVIVA MARKER BIOSPY "TOP HAT" $ 306.00 27208635 HC CCH EVIVA MARKER BIOSPY "CORK" $ 288.00 27208666 HC CCH STEREOTATIC BREAST BIOPSY PACK $ 38.00 27208700 HC CCH GUIDEWIRE DIAGNOSTIC 0.018" DIA 65 CM ANGLED TIP FIXED CORE $ 66.00 27208729 HC CCH TUBE MIC GASTROSTOMY ADULT 20FR $ 144.00 27219039 HC BARRX CATH 360 EXPRESS $ 4,199.00 27219041 HC CCH SHIRLEY PHONATE SPEAKING VALVE W/OXYGEN $ 36.00 27219042 HC CCH TRACH/VENT SWALLOWING/SPEAKING VALVE-PURPLE $ 75.00 27219043 HC CCH MULTIBOOT STANDARD PODUS MED/LG $ 318. 00 27219044 HC CCH DUAL SYRINGE QUAD-PAK W/LG SALINE SPIKE & SM CONTRAST SPIKE $ 66.00 27219046 HC CCH TRAY PROCEDURAL AMNIOCENTESIS 20GA X 3.5IN $ 75.00 27219047 HC CCH NEEDLE YUEH CENTESIS DISPOSABLE CATH $ 107.00 27400193 HC CUSTOM AFO $ 516.00 27400222 HC ORTHOSIS ULNAR DEVIATION $ 69.00 27400433 HC CCH SUPPORT MOTHER TO BE MATERNITY SM $ 72.00 27400434 HC CCH SUPPORT MOTHER TO BE MATERNITY M $ 81.00 27400435 HC CCH SUPPORT MATURINTY MOTHER-TO-BE WITH OUT INSERT $ 76.00 27400436 HC CCH SHOULDER IMMOBILIZER $ 40.00 27400437 HC CCH SPLINT WRIST LASER 10IN RT/LT $ 64.00 27400438 HC CCH SPLINT WRIST LASER 10IN RT $ 38.00 27400439 HC CCH SPLINT WRIST/ FOREARM $ 28.00 27400440 HC CCH SPLINT WRIST/ FOREARM UNIVERSAL $ 29.00 27400441 HC CCH BRACE KNEE POLAR CARE CUBE COOLER XLG $ 405.00 27400442 HC CCH BRACE KNEE HINGED DONJOY ECON MEDIUM $ 194.00 27400443 HC CCH BRACE KNEE HINGED DONJOY ECON LARGE $ 189.00 27400444 HC CCH SPLINT AIR/GEL ANKLE UNIVERSAL $ 63.00 27400445 HC CCH HAND FINGER ORTHOTIC FLEXION GLOVE W/ ELASTIC FINGER CONTROL PREFABRICATED $ 163.00 27400446 HC CCH HAND FINGER ORTHOTIC W/O JOINTS PREFABRICATED $ 147.00 27400447 HC CCH FINGER ORTHOTIC PIP/DIP W/O JOINT/SPRING EXTENSION/FLEXION PREFABRICATED $ 66.00 27400448 HC CCH SHOULDER-ELBOW-WRIST-HAND ORTHOTIC ABDUCTION POSITIONING W/O JOINTS CUSTOM INCLUDES F & A $ 2,132.00 27400449 HC CCH SHOULDER-ELBOW-WRIST-HAND ORTHOTIC CAP DESIGN W/ JOINTS CUSTOM INCLUDES F & A $ 2,035.00 27400450 HC CCH SHOULDER-ELBOW-WRIST-HAND ORTHOTIC CAP DESIGN W/O JOINTS CUSTOM INCLUDES F & A $ 1,840.00 27400451 HC CCH ADDITION TO UPPER EXTREMITY ORTHOTIC/SOCK/FRACTURE EACH $ 78.00 27400452 HC CCH ELBOW ORTHOTIC W/O JOINTS CUSTOM FABRICATED INCLUDES F & A $ 440.00

02-19-2019-A-PAC-057 Page 14 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 27400453 HC CCH ELBOW ORTHOTIC W/ LOCKING JOINTS PREFABRICATED INCLUDES F & A $ 762.00 27400454 HC CCH ELBOW-WRIST-HAND ORTHOTIC W/O JOINTS CUSTOM INCLUDES F & A $ 1,140.00 27400455 HC CCH ELBOW-WRIST-HAND ORTHOTIC W/ JOINTS CUSTOM INCLUDES F & A $ 1,194.00 27400456 HC CCH WRIST-HAND-FINGER ORTHOTIC W/ JOINTS CUSTOM INCLUDES F & A $ 692.00 27400457 HC CCH WRIST-HAND-FINGER ORTHOTIC W/O JOINTS PREFABRICATED $ 382.00 27400458 HC CCH WRIST-HAND-FINGER ORTHOTIC W/O JOINTS CUSTOM INCLUDES F & A $ 543.00 27400459 HC CCH WRIST-HAND ORTHOTIC W/ JOINTS CUSTOM INCLUDES F & A $ 1,512.00 27400460 HC CCH WRIST-HAND ORTHOTIC W/O JOINTS CUSTOM INCLUDES F & A $ 773.00 27400461 HC CCH WRIST-HAND ORTHOTIC PREFABRICATED $ 112.00 27400462 HC CCH HAND-FINGER ORTHOTIC W/O JOINTS CUSTOM INCLUDES F & A $ 414.00 27400463 HC CCH HAND-FINGER ORTHOTIC W/ JOINTS CUSTOM INCLUDES F & A $ 490.00 27400464 HC CCH HAND-FINGER ORTHOTIC W/O JOINTS PREFABRICATED $ 167.00 27400465 HC CCH FINGER ORTHOTIC PIP/DIP W/ JOINTS PREFABRICATED $ 102.00 27400466 HC CCH HAND-FINGER ORTHOTIC W/ JOINTS PREFABRICATED $ 55.00 27400467 HC CCH FINGER ORTHOTIC W/O JOINTS CUSTOM INCLUDES F & A $ 334.00 27400468 HC CCH FINGER ORTHOTIC W/ JOINTS CUSTOM INCLUDES F & A $ 337.00 27400469 HC CCH ARCH SUP ORTH FORMED PT FOOT $ 368.00 27800310 HC CATHETER PLEURAL PLEURX 50-7000B $ 2,562.00 27800397 HC SHEATH PINNACLE 8FRX11CM $ 51.00 27804174 HC MARKER TISSUE HYDROMARK $ 394.00 27804175 HC CCH IMPLANT SYSTEM ESSURE PERMANENT BIRTH CONTROL $ 4,631.00 27804176 HC CCH PROLITE MESH 2X4 $ 270.00 27804177 HC CCH PROLOOP MESH SZ LARGE #30902 $ 642.00 27804178 HC CCH PROLOOP MESH SZ XL #30903 $ 642.00 27804179 HC CCH STENT URETERAL POLARIS ULTRA 5FR X 22CM $ 554.00 27804180 HC CCH STENT CONTOUR $ 440.00 27804181 HC CCH PICC BIOFLO ALL LUMEN ANY SIZE $ 848.00 27804182 HC CCH GRAFT VSCLR PROPATEN HT064050A $ 5,477.00 27804183 HC CCH SCREWBONE ACUTRAK 2 FIXATION SYS SZ $ 1,380.00 27804184 HC CCH SCREW ARTHREX INTERF ALL SZ $ 389.00 27804185 HC CCH PIN STEINMAN THREADED SINGLE DIAMOND 5/64 IN 2.0MM $ 40.00 27804186 HC CCH PIN STEINMAN THREADED DOUBLE DIAMOND 5/64 IN 2.0MM $ 46.00 27804187 HC CCH PIN STEINMAN THREADED SINGLE DIAMOND 1/8 IN 3.2MM $ 57.00 27804188 HC CCH PIN STEINMAN THREADED DOUBLE 1/8 IN 3.2MM $ 67.00 27804189 HC CCH PIN STEINMAN THREADED SINGLE DIAMOND 5/32 IN 4.0MM $ 75.00 27804190 HC CCH PIN STEINMAN THREADED DOUBLE DIAMOND 5/32 IN 4.0MM $ 76.00 27804191 HC CCH KWIRE DOUBLE TROCAR 4IN $ 86.00 27804192 HC CCH KWIRE 4INCH 0.062 $ 64.00 27804193 HC CCH KWIRE SHORT DOUBLE END $ 66.00 27804194 HC CCH KWIRE DOUBLE END TROCAR .062X4 $ 69.00 27804195 HC CCH KWIRE GAMMA NAIL $ 294.00 27804196 HC CCH GRAFT VASCLR PROPATEN HT084050A $ 5,477.00 27804197 HC CCH SCHON DBL LUMEN CATH $ 841.00 27804198 HC CCH PICC CT KIT SINGLE LUMEN 4FR $ 806.00 27804199 HC CCH PICC KIT TRIPLE LUMEN 6FR $ 863.00 27804200 HC CCH PICC TANDEM DL BIOFLO 5F $ 647. 00 27804201 HC CCH PICC TANDEM SL BIOFLO 4F $ 601.00 27804202 HC CCH CATH SWAN-GANZ THERMODILUTION 7FR $ 315.00 27804203 HC CCH FILTER IVC FEMORAL CELECT $ 3,859.00 27804239 HC CCH KIT CVC MULTILUMEN W/SYRINGE LTX $ 256.00 27804240 HC CCH SCHON XL CATHERTER SETS 15 CM VESSEL $ 841.00 27804241 HC CCH X RX KIT TRIPLE-LUMEN 8IN 7FR PRESSURE INJECTABLE CATHERIZATION $ 413.00 27804242 HC CCH X RX TRAY HP MAHURKAR 12X20 DIALYSIS CATHETER $ 580.00 27804243 HC CCH X RX TRAY HP MAHURKAR TRIPLE LUMEN ACUTE DIALYSIS CATHETER STRAIGHT $ 580.00 27804311 HC CCH NOVI IPG PAIN $ 50,318.00 27804312 HC CCH PAIN INFINION 16 LEAD 50CM $ 8,496.00 27804313 HC CCH PAIN INFINION 16 LEAD KIT $ 9,878.00 27804316 HC CCH PAIN PRECISION SPECTRA KIT $ 50,318.00 27804317 HC CCH PAIN PRECISION CHARGING SYSTEM $ 4,631.00 27804318 HC CCH PAIN SPLITTER $ 3,704.00 27804430 HC CCH RUBBER PESSARY ANY TYPE $ 45.00 27804431 HC CCH NON-RUBBER PESSARY ANY TYPE $ 75.00 27804432 HC CCH DURAGEN SECURE DURAL REGENERATION MATRIX 2X2 $ 2,603.00 27804515 HC CCH CLIP DURACLIP REPOSITIONAL HEMOSTAT $ 483.00 27804516 HC CCH BIOFLO MIDLINE CATHETER MAX BARRIER W/ 2 GUIDE WIRES 4FR SINGLE $ 599.00 30000001 HC VENIPUNCTURE $ 24.00 30000001 HC VENIPUNCTURE $ 7.00 30000002 HC COLLECT BLOOD FROM IMPLANTABLE VENOUS DEVICE $ 24.00 30000003 HC COLLECT BLOOD FROM CVC/PICC/MIDLINE $ 92.00 30000004 HC ARTERIAL PUNCTURE- BLOOD FOR DX $ 119.00 30000014 HC RBC AB SCRN; EA TECHIQ $ 95.00

02-19-2019-A-PAC-057 Page 15 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

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Price as of Code Description 07/01/2019 30000017 HC BLOOD TYPING; ABO $ 32.00 30000018 HC BLD TYPE; AG SCRN W REAGENT $ 81.00 30000019 HC BLD TYPE; RBC AG NOT ABO/RHD $ 39.00 30000036 HC DIRECT COOMBS $ 55.00 30000050 HC CAPILLARY BLOOD DRAW $ 24.00 30000075 HC AB ID/ RBC/ EA PANEL EA TECHN $ 138.00 30000076 HC BLOOD TYPING; RH D $ 32.00 30000077 HC CCH CROSSMATCH; AHG $ 82.00 30000094 HC CCH SPECIMEN HANDLING FROM PATIENT TO LABORATORY $ 32.00 30000095 HC COMPATIBILTY TEST; SPIN $ 104.00 30100001 HC LIPID PANEL $ 175.00 30100001 HC LIPID PANEL $ 37.00 30100001 HC LIPID PANEL $ 3.00 30100005 HC SO AMITRIPTYLINE 1 OR 2 $ 125.00 30100006 HC CARBAMAZEPINE; TOTAL $ 118.00 30100009 HC DIGOXIN TOTAL $ 74.00 30100010 HC VALPROIC ACID (DIPROPYLACETIC ACID) TOTAL $ 75.00 30100013 HC GENTAMICIN $ 151.00 30100018 HC LITHIUM $ 81.00 30100019 HC SO NORTRIPTYLINE 1 OR 2 $ 66.00 30100021 HC PHENYTOIN; TOTAL $ 108.00 30100023 HC SO PRIMIDONE $ 62.00 30100026 HC SO SIROLIMUS $ 318.00 30100027 HC SALICYLATE 1 OR 2 $ 61.00 30100029 HC THEOPHYLLINE $ 102.00 30100031 HC VANCOMYCIN $ 75.00 30100033 HC ACETAMINOPHEN 1 OR 2 $ 154.00 30100035 HC QUANT SERUM ACETONES/KETONES $ 112.00 30100040 HC ASSAY OF SERUM ALBUMIN $ 30.00 30100042 HC MICROALBUMIN; URINE; QUAN $ 68.00 30100043 HC ETHANOL (ALCOHOL); BREATH $ 51.00 30100044 HC SO ALDOLASE $ 51.00 30100054 HC SO AMINO ACIDS; 2-5 QUAN EA $ 121.00 30100056 HC AMMONIA $ 148.00 30100059 HC SO ANGIOTENSIN I CONVERING ENZYME $ 59.00 30100064 HC BILIRUBIN; TOTAL $ 46.00 30100065 HC BILIRUBIN; DIRECT $ 48.00 30100068 HC OCCULT BLOOD 1-3 TESTS $ 11.02 30100069 HC VITAMIN D; 25 HYDROXY $ 81.00 30100071 HC CALCIUM; TOTAL $ 37.00 30100071 HC CALCIUM; TOTAL $ 3.00 30100072 HC CALCIUM; IONIZED $ 107.00 30100073 HC CALCIUM; URINE QUAN TIMED $ 64.00 30100076 HC CARBON DIOXIDE (CO2) $ 26.00 30100077 HC ASSAY CARBOXYHB QUANT $ 70.00 30100078 HC CARCINOEMBRYONIC ANTIGEN (CEA) $ 140. 00 30100078 HC CARCINOEMBRYONIC ANTIGEN (CEA) $ 133.00 30100082 HC CHLORIDE; BLOOD $ 24.00 30100086 HC SERUM/WB TOT CHOLEST $ 33.00 30100091 HC SO CHROMIUM $ 123.00 30100092 HC SO CITRATE $ 64.00 30100093 HC SO COLLAGEN CROSS LINKS - A $ 210.00 30100094 HC SO COPPER $ 92.00 30100095 HC SO CORTISOL; FREE $ 353.00 30100099 HC CPK; TOTAL $ 55.00 30100102 HC CREATININE; BLOOD $ 38.00 30100102 HC CREATININE; BLOOD $ 16.00 30100102 HC CREATININE; BLOOD $ 3.00 30100103 HC CREATININE; CLEARANCE $ 92.00 30100107 HC VITAMIN B-12 LEVEL $ 162.00 30100109 HC SO DHEA $ 381.00 30100114 HC SO VIT D 1- 25-DIHYDROXY $ 180.00 30100118 HC SO ESTRONE $ 98.00 30100123 HC FERRITIN $ 76.00 30100124 HC FETAL FIBRONECTIN CV SEMIQUAN $ 276.00 30100126 HC FOLIC ACID; SERUM $ 104.00 30100129 HC SO IGG 1/2/3/OR 4 EACH $ 83.00 30100131 HC BLOOD GAS; MIXED WO O2 SAT $ 251.00 30100133 HC BLOOD GASES O2 SAT ONLY $ 29.00 30100139 HC GLUCOSE; BLOOD REAGENT STRIP $ 27.00 30100139 HC GLUCOSE; BLOOD REAGENT STRIP $ 10.00

02-19-2019-A-PAC-057 Page 16 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 30100140 HC GLUCOSE; POST GLUCOSE DOSE $ 58.00 30100141 HC GLUCOSE TOLERANCE TEST; INCL 3 SPECIMENS $ 254.00 30100142 HC GLUCOSE TOLERANCE TEST EA ADD'L SPECIMEN $ 53.00 30100143 HC SO G6PD; QUANTITATIVE $ 69.00 30100145 HC GLUTAMYLTRANSFERASE GAMMA $ 82.00 30100145 HC GLUTAMYLTRANSFERASE GAMMA $ 3.00 30100146 HC SO GLYCATED PROTEIN - A $ 28.00 30100153 HC HGB; GLYCOSYLATED (A1C) $ 119.00 30100153 HC HGB; GLYCOSYLATED (A1C) $ 29.00 30100153 HC HGB; GLYCOSYLATED (A1C) $ 27.00 30100153 HC HGB; GLYCOSYLATED (A1C) $ 30.00 30100160 HC SO 5-HIAA $ 82.00 30100161 HC SO HYDROXYPROGESTERONE; 17-D $ 63.00 30100165 HC IRON $ 76.00 30100168 HC LACTATE (LACTIC ACID) $ 79.00 30100169 HC LACTATE DEHYDROGENASE (LD) (LDH) $ 74.00 30100174 HC LIPASE $ 69.00 30100175 HC SO ASSAY OF LIPOPROTEIN (A) $ 64.00 30100177 HC SO LIPOPROTEIN BLD BY NMR $ 174.00 30100178 HC LIPOPROTEIN; HDL $ 95.00 30100179 HC ASSAY OF BLOOD LIPOPROTEIN $ 57.00 30100180 HC MAGNESIUM $ 61.00 30100181 HC SO METANEPHRINES $ 142.00 30100182 HC SO METHADONE $ 19.00 30100184 HC MYOGLOBIN $ 139.00 30100186 HC NATRIUERETIC PEPTIDE $ 342.00 30100206 HC SO ORGANIC ACID- SINGLE QUANT $ 90.00 30100208 HC BLOOD OSMOLALITY $ 55.00 30100209 HC OSMOLALITY; URINE $ 55.00 30100211 HC SO OXALATE - A $ 56.00 30100212 HC PARATHORMONE $ 280.00 30100215 HC ALKALINE PHOSPHATASE $ 48.00 30100216 HC SO ETHOSUXIMIDE $ 53.00 30100217 HC PHOSPHATE INORGANIC $ 58.00 30100220 HC SO PORPHOBILINOGEN- URINE; QUAN $ 42.00 30100221 HC SO QUAN URINE PORPHYRINS $ 80.00 30100223 HC ASSAY OF SERUM POTASSIUM $ 27.00 30100223 HC ASSAY OF SERUM POTASSIUM $ 3.00 30100225 HC PREALBUMIN $ 129.00 30100229 HC PSA; TOTAL $ 146.00 30100229 HC PSA; TOTAL $ 30.00 30100229 HC PSA; TOTAL $ 25.00 30100230 HC SO PSA; FREE $ 83.00 30100231 HC ASSAY OF PROTEIN; SERUM $ 29.00 30100233 HC URINE TOTAL PROTEIN $ 48.00 30100234 HC TOTAL PROTEIN; OTHER SPECIMEN $ 38. 00 30100240 HC SO VITAMIN B6 $ 110.00 30100247 HC SO SEX HORMONE BINDING GLOBULIN $ 69.00 30100249 HC ASSAY OF SERUM SODIUM $ 25.00 30100249 HC ASSAY OF SERUM SODIUM $ 3.00 30100250 HC SODIUM; URINE $ 66.00 30100254 HC SO SUGARS; SINGLE QUAL- EA SPECIMEN $ 55.00 30100262 HC FREE THYROXINE $ 63.00 30100263 HC SO THYROXINE BINDING GLOBULIN $ 132.00 30100264 HC THYROID STIMULATING HORMONE $ 182.00 30100264 HC THYROID STIMULATING HORMONE $ 50.00 30100264 HC THYROID STIMULATING HORMONE $ 15.00 30100265 HC SO THYROID STIMULATING IMMUNOGLOBULINS $ 105.00 30100266 HC SO TOCOPHEROL ALPHA (VIT E) $ 63.00 30100267 HC AST OR SGOT $ 59.00 30100267 HC AST OR SGOT $ 16.00 30100268 HC TRANSFERASE; ALANINE AMINO $ 61.00 30100268 HC TRANSFERASE; ALANINE AMINO $ 16.00 30100268 HC TRANSFERASE; ALANINE AMINO $ 3.00 30100269 HC TRANSFERRIN $ 163.00 30100270 HC TRIGLYCERIDES $ 49.00 30100273 HC T3; FREE $ 170.00 30100275 HC TROPONIN QUAN $ 125.00 30100276 HC UREA NITROGEN; QUAN $ 30.00 30100276 HC UREA NITROGEN; QUAN $ 12.00 30100276 HC UREA NITROGEN; QUAN $ 3.00

02-19-2019-A-PAC-057 Page 17 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 30100277 HC UREA NITROGEN; URINE $ 56.00 30100278 HC URIC ACID; BLOOD $ 55.00 30100279 HC URIC ACID; NOT BLOOD $ 40.00 30100281 HC SO VMA- URINE $ 106.00 30100282 HC SO VASOPRESSIN $ 96.00 30100283 HC SO VITAMIN A $ 126.00 30100286 HC SO ZINC $ 76.00 30100289 HC SO BILE ACIDS; TOTAL $ 49.00 30100294 HC SO ARSENIC $ 198.00 30100295 HC SO CATECHOLAMINES; FRACTIONATED $ 289.00 30100296 HC SO ALDOSTERONE $ 194.00 30100297 HC AMYLASE $ 68.00 30100299 HC SO CHEMILUMINESCENT ASSAY $ 102.00 30100301 HC SO ALPHA-1-ANTITRYPSIN; TOTAL $ 90.00 30100302 HC SO BETA-2 MICROGLOBULIN $ 182.00 30100305 HC CREATININE; NOT BLOOD $ 51.00 30100310 HC SO ESTROGENS; TOTAL $ 105.00 30100311 HC SO ESTRIOL $ 183.00 30100314 HC GLUCOSE; QUAN BLOOD $ 42.00 30100314 HC GLUCOSE; QUAN BLOOD $ 12.00 30100314 HC GLUCOSE; QUAN BLOOD $ 3.00 30100315 HC SO CC/MS; QUAN SS & MP - A $ 269.00 30100316 HC SO CRYOGLOBULIN - QUAL/SEMI QUAN $ 44.00 30100318 HC SO ASSAY IGA/IGD/IGM EACH $ 62.00 30100319 HC OCCULT BLOOD; FECES $ 16.02 30100333 HC SO RIA NONANTIBODY - A $ 233.00 30100334 HC SO IMMUNOASSAY QUANT NOS NONAB - A $ 312.00 30100335 HC SO ASSAY OF HOMOCYSTINE $ 139.00 30100337 HC SO IMMUNOASSAY- NONANTIBODY - A $ 232.00 30100338 HC SO INSULIN; TOTAL $ 77.00 30100341 HC SO LEAD - A $ 63.00 30100346 HC SO MERCURY; QUAN $ 166.00 30100373 HC SO ALKALINE PHOSPHATASE ISOENZYM $ 169.00 30100378 HC SO TESTOSTERONE; TOTAL $ 120.00 30100379 HC SO THIAMINE (VITAMIN B-1) $ 246.00 30100381 HC SO THYROGLOBULIN $ 192.00 30100386 HC HCG; QUAN $ 180.00 30100387 HC HCG; QUAL $ 79.00 30100393 HC SO RENIN $ 148.00 30100394 HC SO TESTOSTERONE; FREE $ 167.00 30100395 HC SO THYROXINE; TOTAL $ 75.00 30100402 HC SO NEPHELOMETRY EA ANALYTE NES $ 93.00 30100403 HC SO NICOTINE $ 48.00 30100403 HC SO NICOTINE $ 186.00 30100407 HC METABOLIC PANEL TOTAL CA $ 174.00 30100407 HC METABOLIC PANEL TOTAL CA $ 23. 00 30100408 HC ELECTROLYTE PANEL $ 70.00 30100408 HC ELECTROLYTE PANEL $ 14.00 30100409 HC COMPREHEN METABOLIC PANEL $ 330.00 30100409 HC COMPREHEN METABOLIC PANEL $ 32.00 30100410 HC RENAL FUNCTION PANEL $ 210.00 30100412 HC HEPATIC FUNCTION PANEL $ 235.00 30100412 HC HEPATIC FUNCTION PANEL $ 19.00 30100413 HC SO CYCLOSPORINE $ 106.00 30100414 HC SO PHENOBARBITAL $ 78.00 30100417 HC SO CERULOPLASMIN $ 50.00 30100419 HC SO ASSAY OF IGE $ 124.00 30100420 HC SO GLUCOSE- BODY FLUID; OTHER THAN BLOOD $ 46.00 30100422 HC SO GROWTH HORMONE- HUMAN $ 57.00 30100423 HC SO HGB- FRACT & QUAN; EP $ 107.00 30100434 HC SO SEROTONIN $ 380.00 30100435 HC SO T3; TOTAL $ 95.00 30100438 HC SO ERYTHROPOIETIN $ 130.00 30100440 HC SO ALPHA-FETOPROTEIN- SERUM $ 105.00 30100442 HC CKMB $ 92.00 30100485 HC SO ESTRADIOL $ 114.00 30100487 HC SO CORTISOL-TOTAL $ 112.00 30100538 HC CCH IRON BINDING CAPACITY $ 87.00 30100551 HC SO SOMATOMEDIN $ 100.00 30100568 HC SO DRUG SCREEN QUANT CLOZAPINE $ 74.00 30100571 HC SO DRUG SCREEN QUANT EVEROLIMUS $ 175.00

02-19-2019-A-PAC-057 Page 18 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 30100572 HC SO GABAPENTIN WHOLE BLOOD/SERUM/PLASMA $ 268.00 30100574 HC SO DRUG SCREEN QUAN LAMOTRIGINE $ 280.00 30100576 HC SO DRUG SCRN QUAN LEVETIRACETAM - A $ 172.00 30100580 HC SO DRUG SCRN QUANT OXCARBAZEPIN $ 280.00 30100602 HC SO ALBUMIN; QUAN $ 61.00 30100609 HC SO HAPTOGLOBIN; QUAN $ 82.00 30100616 HC SO DRUG TEST PRESUMPTIVE ANY DRUG CLASS ANY DEVICE/PROCEDURE BY INSTRUMENT ANALYZER $ 19.00 30100621 HC ALCOHOLS $ 82.00 30100622 HC SO ALCOHOLS $ 19.00 30100630 HC SO AMPHETAMINES 5 OR MORE $ 19.00 30100643 HC SO BENZODIAZEPINES 1-12 $ 19.00 30100647 HC SO BUPRENORPHINE $ 19.00 30100654 HC SO COCAINE $ 38.00 30100655 HC SO FENTANYL $ 19.00 30100656 HC SO GABAPENTINE NON-BLOOD $ 19.00 30100658 HC SO KETAMINE AND NORKETAMINE $ 19.00 30100660 HC SO METHYLENEDIOXYAMPHETAMINES (MDA/MDEA/MDMA) $ 19.00 30100661 HC SO METHYLPHENIDATE $ 19.00 30100663 HC SO OPIATES 1 OR MORE $ 19.00 30100669 HC SO OPIOIDS AND OPIATE ANALOGS 5 OR MORE $ 19.00 30100671 HC SO OXYCODONE $ 19.00 30100672 HC SO PREGABALIN $ 19.00 30100674 HC SO PROPOXYPHENE $ 19.00 30100676 HC SO SEDATIVE HYPNOTICS (NON-BENZODIAZEPINES) $ 19.00 30100679 HC SO STIMULANTS SYNTHETIC $ 19.00 30100680 HC SO TAPENTADOL $ 19.00 30100688 HC SO DRUG/SUBSTANCE NOS 7 OR MORE $ 19.00 30100735 HC SO ANTIDEPRESSANT NOT SPECIFIED $ 19.00 30100745 HC LACTOFERRIN FECAL (QUAL) $ 96.00 30100753 HC SO INORGANIC PHOSPHATE $ 53.00 30100754 HC SO POTASSIUM $ 43.00 30100793 HC ASSAY PH BODY FLUID NOS $ 42.00 30100814 HC SO HEAVY METAL; QUAN - A $ 123.00 30100815 HC SO TOPIRAMATE $ 117.00 30100819 HC CCH SO PHENYTOIN; FREE $ 125.00 30100820 HC CCH SO TACROLIMUS $ 249.00 30100822 HC CCH SO ACTH $ 562.00 30100823 HC SO CALCITONIN $ 63.00 30100831 HC CCH SO DHEA-S $ 248.00 30100832 HC CCH SO FAT OR LIPIDS FECES; QUAL $ 51.00 30100835 HC CCH SO FOLIC ACID; RBC $ 75.00 30100836 HC CCH SO GASTRIN $ 80.00 30100837 HC CCH SO GONADOTROPIN; FSH $ 108.00 30100838 HC CCH SO GONADOTROPIN; LUTEINIZING HORMONE $ 114.00 30100839 HC CCH SO HEMOSIDERIN; QUALITATIVE $ 30.00 30100846 HC CCH SO ORGANIC ACIDS; TOTAL QUANTITATIVE EACH SPECIMEN $ 121. 00 30100847 HC CCH SO BLOOD OSMOLALITY $ 96.00 30100851 HC CCH SO PROGESTERONE $ 124.00 30100852 HC CCH SO PROLACTIN ASSAY $ 120.00 30100856 HC CCH SO PROTEIN; EP FRACT & QUAN $ 59.00 30100857 HC CCH SO PROTEIN E-PHORESIS/URINE/CSF $ 68.00 30100859 HC CCH SO NON-URINE SPECIFIC GRAVITY $ 30.00 30100861 HC CCH SO T3 OR T4 OR THYROID HORMONE $ 48.00 30100862 HC CCH SO C-PEPTIDE $ 232.00 30100864 HC CCH BILIRUBIN TOTAL TRANSCUTANEOUS $ 42.00 30100869 HC CCH BLOOD GLUCOSE MONITORING $ 32.00 30100869 HC CCH BLOOD GLUCOSE MONITORING $ 20.02 30100876 HC SO IMMUNOASSAY- NONANTIBODY - B $ 57.00 30100882 HC SO DRUG TEST PRESUMPTIVE INSTRUMENT OBSERVATION $ 19.00 30100884 HC CCH BASIC METABOLIC PANEL IONIZED CA $ 269.00 30100885 HC CCH DRUG TEST PRESUMPTIVE DIRECT OPTICAL OBSERVATION $ 149.00 30100885 HC CCH DRUG TEST PRESUMPTIVE DIRECT OPTICAL OBSERVATION $ 40.38 30100886 HC CCH SO ANALGESICS NON-OPIOID 6 OR MORE $ 19.00 30100887 HC CCH SO ANTIDEPRESSANTS SEROTONERGIC CLASS 6 OR MORE $ 19.00 30100888 HC CCH SO ANTIDEPRESSANTS TRICYCLIC 6 OR MORE $ 19.00 30100889 HC CCH SO ANTIEPILEPTICS NOS 7 OR MORE $ 19.00 30100890 HC CCH SO ANTIPSYCHOTICS NOS 7 OR MORE $ 19.00 30100891 HC SO BENZODIAZEPINES 1-12 - B $ 70.00 30100892 HC CCH SO SKELETAL MUSCLE RELAXANTS 3 OR MORE $ 19.00 30100893 HC CCH SO OCCULT BLOOD; OTHER SOURCES $ 56.00 30100894 HC CCH SO OCCULT BLOOD FECES 1-3 TESTS $ 39.00

02-19-2019-A-PAC-057 Page 19 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 30100895 HC CCH SO CALCULUS; QUANTITATIVE ANALYSIS $ 63.00 30100896 HC CCH SO CATECHOLAMINES BLOOD $ 224.00 30100897 HC CCH SO CHLORIDE; URINE $ 59.00 30100898 HC CCH CPK; ISOENZYMES $ 174.00 30100899 HC CCH SO HEAVY METAL QUALITATIVE ANY NUMBER ANALYTES $ 182.00 30100900 HC CCH PHENYLALANINE BLOOD $ 132.00 30100901 HC SO PLACENTA ALPHA MICRO IG C/V $ 223.00 30100902 HC CCH SO DRUG SCREEN MECONIUM $ 123.00 30100903 HC CCH SO DRUG SCREEN 10 TEST $ 106.00 30100904 HC CCH SO DRUG ABUSE SCREEN 5 $ 106.00 30100905 HC CCH SO CORDSTAT 13 $ 29.00 30100906 HC CCH SO CORDSTAT 12 $ 29.00 30100907 HC CCH SO CORDSTAT 9 $ 34.00 30100908 HC CCH SO CORDSTAT 7 $ 39.00 30100909 HC CCH SO CORDSTAT 5 $ 50.00 30100910 HC CCH SO DARVOCET $ 96.00 30100911 HC CCH SO SULFONYLUREA HYPOGLYSEMIC $ 96.00 30100912 HC CCH SO BARBITIRATES $ 99.00 30100913 HC CCH SO DRUG SCREEN W/ALC $ 106.00 30100914 HC CCH SO PHENCYLIDINE $ 113.00 30100915 HC CCH SO TRICYCLICS $ 123.00 30100916 HC CCH SO DRUG SCREEN ER EACH DRG GROUP $ 123.00 30100917 HC CCH SO DESIPRAMINE (NORPRAMIN) $ 181.00 30100918 HC CCH SO COMA/OVERDOSE PROFILE III $ 106.00 30100919 HC CCH TOXICOLOGY SCREEN $ 149.00 30100920 HC CCH SO CORDSTAT ETOH $ 229.00 30100921 HC CCH SO ACETYCHOLINE RECEPTIVE AB $ 102.00 30100922 HC SO RIA NONANTIBODY - B $ 1,114.00 30100923 HC CCH SO DRUG TEST DEFINITIVE 22 OR MORE DRUG CLASSES PER DAY $ 555.00 30100967 HC CCH GLYCATED PROTEIN $ 56.00 30100967 HC CCH GLYCATED PROTEIN $ 53.00 30101023 HC CCH MICROALBUMIN; URINE; SEMI QUAN $ 17.02 30200002 HC SO ALLERG SP IGG QUAN OR SEMIQUAN $ 129.00 30200007 HC C-REACTIVE PROTEIN $ 105.00 30200009 HC SO BETA 2 GLYCOPROTEIN I AB- EA $ 129.00 30200023 HC QUAL HETEROPHILE AB $ 62.00 30200023 HC QUAL HETEROPHILE AB $ 23.14 30200026 HC SO ENA- ANY METHOD - A $ 168.00 30200029 HC SO INSULIN AB $ 230.00 30200043 HC SKIN TEST; TB/ ID $ 39.00 30200043 HC SKIN TEST; TB/ ID $ 18.43 30200046 HC SO AB; BACTERIUM- NES $ 93.00 30200049 HC SO AB; LYME'S (WB) CONFIRM - A $ 68.00 30200054 HC SO AB; CHLAMYDIA- IGM $ 62.00 30200056 HC SO AB; CYRPTOCOCCUS $ 76.00 30200064 HC SO AB; EB- EARLY AG VIRUS $ 61. 00 30200065 HC SO AB; EBNA $ 55.00 30200072 HC SO AB; HSV- NON-SPECIFIC $ 85.00 30200088 HC SO AB; PARVOVIRUS $ 189.00 30200096 HC SO TREPONEMA PALLIDUM $ 57.00 30200108 HC SO ALLERGEN SPECIFIC IGE- EA - A $ 36.00 30200111 HC SO HEP PLT AGGREGATING FACTOR $ 329.00 30200113 HC SO COMPLEMENT- EACH $ 158.00 30200116 HC SO FLUORESCENT NONINF AGENT AB- EA - A $ 180.00 30200118 HC SO CA 15-3 (27.29) $ 112.00 30200125 HC SO IMMUNOFIXATION- FLUID $ 101.00 30200126 HC SO INHIBIN A $ 321.00 30200127 HC SO ISLET CELL ANTIBODY - A $ 216.00 30200129 HC SO TB TEST- CELL IMMUN MEASURE $ 146.00 30200131 HC SYPHILIS TEST $ 50.00 30200134 HC SO ASPERGILLUS ANTIBODY $ 32.00 30200136 HC SO CHLAMYDIA ANTIBODY $ 137.00 30200138 HC SO CYTOMEGALOVIRUS AB $ 145.00 30200139 HC SO CYTOMEGALOVIRUS IGM AB $ 145.00 30200140 HC SO ENTEROVIRUS $ 70.00 30200142 HC SO AB; HELICOBACTER PYLORI $ 71.00 30200149 HC SO HERPES SIMPLEX- TYPE I $ 139.00 30200151 HC SO HISTOPLASMA ANTIBODY $ 117.00 30200153 HC SO HEPATITIS B CORE AB- TOTAL $ 75.00 30200154 HC SO HEPATITIS B SURF AB $ 59.00 30200156 HC SO MUMPS ANTIBODY $ 100.00

02-19-2019-A-PAC-057 Page 20 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 30200159 HC RUBELLA ANTIBODY $ 56.00 30200161 HC SO VARICELLA ZOSTER ANTIBODY $ 108.00 30200162 HC SO VIRAL ANTIBODY NOS - A $ 114.00 30200163 HC SO HEPATITIS C ANTIBODY $ 79.00 30200165 HC SO HLA TYPING- EA ANTIGEN $ 118.00 30200168 HC SO CARDIOLIPIN AB- EA IG CLASS $ 126.00 30200169 HC SO FLUORESCENT AB; TITER- EA AB - A $ 170.00 30200170 HC SO IA- QUANT; CA 19-9 $ 64.00 30200171 HC SO AB; LYME'S DISEASE $ 131.00 30200172 HC SO AB; HSV II $ 223.00 30200173 HC SO AB; MYCOPLASMA $ 77.00 30200174 HC SO AB; RUBEOLA $ 159.00 30200176 HC C-REACTIVE PROTEIN HS $ 154.00 30200177 HC SO COMPLEMENT; TOT HEMOLYTIC $ 183.00 30200182 HC SO AB; EB VCA $ 108.00 30200184 HC SO AB; TOXOPLASMA $ 64.00 30200185 HC SO AB; TOXOPLASMA IGM $ 83.00 30200194 HC SO ANTINUCLEAR AB (ANA) $ 93.00 30200195 HC SO DNA AB; NATIVE OR DS $ 173.00 30200197 HC SO BLASTOMYCES ANTIBODY $ 34.00 30200198 HC SO COCCIDIOIDES ANTIBODY $ 117.00 30200199 HC SO PLATELET ASSOCIATED IG ASSAY $ 131.00 30200200 HC SO RICHETTISIAE ANTIBODY - A $ 85.00 30200201 HC SO AB; LEGIONELLA $ 90.00 30200205 HC SO AB; THYROGLOBULIN $ 96.00 30200215 HC CCH RHEUMATOID FACTOR; QUALITATIVE $ 68.00 30200223 HC SO AB HBCAB IGM AB $ 104.00 30200224 HC ASO; TITER $ 76.00 30200228 HC SO HEPATITIS A ANTIBODY $ 83.00 30200229 HC SO HEPATITIS A IGM ANTIBODY $ 71.00 30200230 HC SO IEP;SERUM $ 79.00 30200233 HC ANTIBODY; HIV-1 $ 101.00 30200239 HC CCH ASO; SCREEN $ 69.00 30200241 HC CCH SO CCP ANTIBODY $ 172.00 30200242 HC CCH SO IA-QUANT; CA 125 $ 108.00 30200245 HC CCH SO T CELLS; ABSOLUTE CD4 COUNT $ 160.00 30200246 HC CCH SO MICROSOMAL AB EACH $ 193.00 30200250 HC CCH SO AB; HBEAB $ 117.00 30200255 HC CCH SO T CELLS; TOTAL COUNT $ 311.00 30200256 HC CCH SO T CELLS; ABSOL CD4 AND CD8 $ 129.00 30200261 HC CCH SO MONONUCLEAR CELL ANTIGEN $ 357.00 30200280 HC SO HLA-DR MULTIPLE ANTIGEN TYPING $ 268.00 30500001 HC BL SMEAR W/ DIFF WBC COUNT $ 36.00 30500002 HC HEMATOCRIT $ 53.00 30500003 HC HEMOGLOBIN $ 32.00 30500003 HC HEMOGLOBIN $ 17. 70 30500004 HC CBC EDIFF & PLATELET $ 92.00 30500004 HC CBC EDIFF & PLATELET $ 24.00 30500004 HC CBC EDIFF & PLATELET $ 3.00 30500005 HC AUTOMATED RETICULOCYTE COUNT $ 42.00 30500006 HC PLATELET COUNT $ 59.00 30500007 HC SO CHROMOGENIC SUBSTRATE ASSAY $ 229.00 30500013 HC SO CLOTTING: FACTOR VIII- VW FACTOR AG $ 366.00 30500021 HC SO ANTITHROMBIN III ANTIGEN ASSAY $ 230.00 30500022 HC SO CLOTTING INHIBITOR; PROTEIN C; AG $ 279.00 30500024 HC SO CLOTTING INHIBITOR; PROTEIN S- TOTAL $ 117.00 30500025 HC SO PROTEIN S- FREE $ 122.00 30500026 HC SO ACTIVATED PROTEIN C RESISTANCE $ 123.00 30500028 HC COAG TIME; ACTIVATED $ 39.00 30500030 HC FIBRINOGEN; ACTIVITY $ 80.00 30500037 HC SO MURAMIDASE $ 193.00 30500040 HC PROTHOMBIN TIME $ 44.00 30500040 HC PROTHOMBIN TIME $ 12.00 30500043 HC NONAUTO ERYTHROCYTE SED RATE $ 46.00 30500047 HC PTT; PLASMA OR WHOLE BLOOD $ 58.00 30500048 HC PTT; SUBSTITUTION PLASMA FRACTIONS EA $ 81.00 30500051 HC CBC & PLATELET $ 64.00 30500052 HC WBC COUNT $ 53.00 30500057 HC FETAL SCREEN; RBC $ 149.00 30500058 HC HEPARIN ASSAY $ 56.00 30500058 HC HEPARIN ASSAY $ 53.00

02-19-2019-A-PAC-057 Page 21 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 30500065 HC SO PHOSPHOLIPID- HEXAGONAL $ 142.00 30500066 HC CCH BLEEDING TIME $ 49.00 30500070 HC SO FUNCTIONAL PLASMINOGEN $ 80.00 30500081 HC CCH BLOOD SMEAR PERIPHERAL $ 50.00 30500084 HC CCH SO CLOTTING; FACTOR VIII $ 328.00 30500085 HC CCH SO CLOTTING; FACTOR VIII RISTOCETIN COFACT $ 257.00 30500086 HC CCH SO CLOTTING; FACTOR X $ 123.00 30500088 HC CCH SO CLOTTING INHIBITOR; PROTEIN C ACTIVITY $ 211.00 30500091 HC CCH SO RUSSELL VIPER VENOM TIME; DILUTED $ 81.00 30500093 HC CCH SO THROMBIN TIME; PLASMA $ 39.00 30500095 HC CCH SO FIBRIN DEGRADATION PRODUCTS - QUAL/SEMIQUAN $ 71.00 30500096 HC CCH SO THROMBOPLASTIN INHIBITION TISSUE $ 256.00 30500097 HC CCH SO PTT; SUBSTITUTION PLASMA FRACTIONS EA $ 117.00 30600003 HC AEROB BACTERIAL BLOOD CULTURE $ 105.00 30600004 HC AEROB BACTERIAL CULTURE STOOL $ 118.00 30600005 HC AEROB STOOL CULTR; ADDTL PATHOG EA PLATE $ 108.00 30600006 HC BACTERIAL CULTURE; OTHER SOURCE $ 108.00 30600006 HC BACTERIAL CULTURE; OTHER SOURCE $ 28.00 30600010 HC AEROBIC BACT CULT; ADDTL ID $ 70.00 30600011 HC URINE BACTERIA CULTURE $ 101.00 30600032 HC MICROBE SUSCEPTIBLE; MIC $ 86.00 30600032 HC MICROBE SUSCEPTIBLE; MIC $ 26.00 30600035 HC SMEAR - GRAM OR GIEMSA $ 46.00 30600037 HC SMEAR - INFECTIOUS WET MOUNT $ 49.00 30600037 HC SMEAR - INFECTIOUS WET MOUNT $ 51.41 30600038 HC KOH FOR FUNGI/PARASITES/MITES $ 50.00 30600048 HC CRYPTOSPORIDIUM AG EIA $ 119.00 30600051 HC SO HPYLORI STOOL- EIA $ 192.00 30600058 HC RESP SYNCYTIAL AG EIA $ 139.00 30600058 HC RESP SYNCYTIAL AG EIA $ 113.56 30600066 HC SO CYTOMEGALOV AMPLIF NA PROBE $ 166.00 30600067 HC CYTOMEGALOVIRUS NA QUAN $ 263.00 30600071 HC SO HEP-B NA QUAN $ 529.00 30600085 HC INFLUENZA IA W DIRECT OPTICAL $ 26.02 30600090 HC SO CONCENTRATION FOR INFECT AGENT $ 51.00 30600091 HC CULTURE- PRESUMPTIVE PATHOG SCREEN $ 77.00 30600098 HC SO GIARDIA AG- EIA $ 102.00 30600099 HC SO HEPATITIS B SURFACE AG- EIA $ 59.00 30600100 HC INFECTIOUS AGENT ANTIGEN - MULTI STEP $ 112.00 30600103 HC SO CHLAMYDIA TRACHOMATIS AMPLIF NA PROBE $ 150.00 30600105 HC SO HEP-C REVERSE TRANSCRIPTION AMPLIF NA PROBE $ 231.00 30600106 HC SO HEP-C REVERSE TRANSCRIPTION & NA QUAN $ 813.00 30600108 HC SO HIV-1 REVERSE TRANSCRIPTION & NA QUAN $ 646.00 30600111 HC SO NEISSERIA; AMPLIF NA PROBE $ 106.00 30600115 HC SO NA QUAN; NOS AGENT $ 568.00 30600116 HC DNA/RNA; MULTI ORG - AMP PR $ 290. 00 30600119 HC SO HEPATITIS C - DNA OR RNA $ 390.00 30600125 HC SO FUNGUS CULTURE DEF ID- YEAST $ 120.00 30600130 HC DNA/RNA AMPLIFIED PROBE $ 149.00 30600133 HC SO HOMOGENIZ TISS FOR CULTURE $ 72.00 30600133 HC SO HOMOGENIZ TISS FOR CULTURE $ 69.00 30600134 HC SO OVA & PARASITES DIR SMR W ID $ 83.00 30600138 HC SO VIRUS ISOLATE; TISSUE CULT INOC $ 90.00 30600144 HC C DIFF AMPLIFIED PROBE $ 149.00 30600146 HC INFLUENZA DNA AMP PROBE 1ST 2 TYPES $ 389.00 30600156 HC HERPES S AMPLIF NA PROBE $ 137.00 30600156 HC HERPES S AMPLIF NA PROBE $ 130.00 30600165 HC CCH BACT CULTURE - URINE; QUAN COUNT $ 93.00 30600165 HC CCH BACT CULTURE - URINE; QUAN COUNT $ 25.00 30600167 HC CCH STREP A ASSAY W/ OPTIC $ 139.00 30600167 HC CCH STREP A ASSAY W/ OPTIC $ 86.90 30600174 HC CCH RSV ASSAY W/ OPTIC $ 247.00 30600174 HC CCH RSV ASSAY W/ OPTIC $ 223.00 30600177 HC SO TRICHOMONAS VAGINALIS AMPLIF - A $ 128.00 30600193 HC SO HPV HIGH-RISK TYPES $ 159.00 30600195 HC SO HPV TYPES 16 & 18 ONLY $ 159.00 30600198 HC STREP A AMPLIF NA PROBE $ 194.00 30600207 HC CCH SO FUNGUS CULTURE; NOT BLOOD $ 59.00 30600209 HC CCH SO CULTURE ACID-FAST BACILLI; ISOL & ID $ 80.00 30600211 HC CCH SO SMEAR; FLUORESCENT OR AFB STAIN $ 79.00 30600216 HC CCH SO HEPATITIS BE AG EIA $ 112.00

02-19-2019-A-PAC-057 Page 22 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 30600218 HC CCH INFLUENZA A OR B ANTIGEN $ 126.00 30600218 HC CCH INFLUENZA A OR B ANTIGEN $ 32.88 30600219 HC CCH ROTAVIRUS ANTIGEN $ 85.00 30600222 HC CCH INFECTIOUS AGENT ANTIGEN - MULTI STEP MULTIPLE ORGANISMS $ 112.00 30600234 HC CCH BACTERIAL CULTURE QUANTITATIVE ANAEROBIC W/ ISOLATION $ 108.00 30600235 HC CCH SO PINWORM EXAM $ 46.00 30600236 HC CCH SO B PERTUSSIS/PARAPERTUSSIS AG BY DFA $ 71.00 30600237 HC CCH SO CRYPTOCOCCUS NEOFORM AG EIA $ 56.00 30600238 HC CCH SO INFLUENZA DNA AMP PROBE TECHNIQUE EACH TYPE/SUBTYPE $ 389.00 30600241 HC CCH URINE BACTERIA CULTURE EA ADDITIONAL $ 34.00 30600242 HC CCH SO CHLAMYDIA TRACHOMATIS AMPLIF NA PROBE $ 76.00 30600243 HC CCH SO HPV HIGH-RISK TYPES $ 159.00 30600249 HC CCH TRICHOMONAS ASSAY WITH OPTIC $ 32.66 30700002 HC URINALYSIS TOTAL AUTOMATED W/ MICRO $ 38.00 30700002 HC URINALYSIS TOTAL AUTOMATED W/ MICRO $ 10.00 30700002 HC URINALYSIS TOTAL AUTOMATED W/ MICRO $ 8.70 30700003 HC URINALYSIS TOTAL NON-AUTOMATED W/O MICRO $ 43.00 30700003 HC URINALYSIS TOTAL NON-AUTOMATED W/O MICRO $ 28.02 30700004 HC URINALYSIS TOTAL AUTOMATED W/O MICRO $ 27.00 30700004 HC URINALYSIS TOTAL AUTOMATED W/O MICRO $ 17.02 30700005 HC URINALYSIS MICROSCOPIC ONLY $ 36.00 30700007 HC URINE PREGNANCY; VISUAL COLOR $ 75.00 30700007 HC URINE PREGNANCY; VISUAL COLOR $ 18.02 30900001 HC EXAM; SYNOVIAL FLUID CRYSTALS $ 71.00 30900003 HC CELL COUNT FLUID $ 58.00 30900004 HC CELL COUNT W/ DIFF FLUID $ 56.00 30900014 HC OCCULT BLD FHG QUAL 1-3 $ 72.00 30900015 HC CCH SEMEN ANALYSIS SPERM DETECTION $ 126.00 31000059 HC SP CONSULT; 1ST TB W/ FS SGL SP $ 276.00 31000060 HC SP CONSULT; EA ADDL TB W/ FS $ 142.00 31000082 HC CCH INTRAOP PATHOLOGY CONSULT $ 943.00 31000083 HC CCH INTRAOP CYTOLOGIC PATHOLOGY CONSULT INITIAL $ 113.00 31000084 HC CCH INTRAOP CYTOLOGIC PATHOLOGY CONSULT EACH ADDITIONAL $ 113.00 31000085 HC CCH SO AVI CYSTIC FIBRO GENE ANAYSIS $ 281.00 31000086 HC CCH SO AVI PROTHROMBIN GENE ANALYSIS $ 269.00 31000087 HC CCH SO AVI LEIDEN FACTOR V GENE ANALYSIS $ 336.00 31000088 HC CCH SO AVI FRAGILE X CHROMOSOME HIGH RERS $ 672.00 31000089 HC CCH SO AVI HEMOCHROMATOSIS GENE ANALYSIS $ 616.00 31000090 HC CCH SO AVI IGH GENE REARRANGE AMP METH $ 1,080.00 31000091 HC CCH SO AVI MTHFR GENE ANALYSIS $ 217.00 31000092 HC CCH SO AVI UNLISTED MOLECULAR PATHOLOGY $ 3,119.00 31000093 HC CCH CONSULTATION AND REPORT REFERRED SLIDES $ 379.00 31000121 HC CCH AVI SO BCR-ABL ANALYSIS $ 337.00 31000122 HC CCH HLA TYPING 1 ANTIGEN LOW RESOLUTION $ 261.00 31000373 HC CCH SO TISSUE CULTURE; BM BLOOD CELLS $ 237.00 31000374 HC CCH SO BONEMARROW CYTOGENETICS $ 680. 00 31000382 HC SO CHROMOSONE ANALYSIS; 15-20 CELLS $ 672.00 31000384 HC CCH SO CHROM ANALYSIS; 20-25 CELLS $ 235.00 31000471 HC CCH SO CHROMOSOME ANALYSIS AMN F III $ 229.00 31000472 HC SO CHROM ANALY; ADDTL KARYOT EA STUDY $ 60.00 31100001 HC CYTOPATH CELL ENHANCE TECH $ 123.00 31100004 HC CP SMR PREP SCRN INT $ 123.00 31100005 HC EVAL OF FNA; IMMED ADEQ $ 309.00 31100029 HC EVAL OF FNA; INT & REP $ 146.00 31100031 HC CYTOPATH FL NONGYN SMEARS $ 112.00 31100032 HC CP CONCENTR TECH SMEAR $ 117.00 31100040 HC CCH SO CP CERV/VAG; ATL; MANUAL SCRN (DIAGNOSTIC) $ 102.00 31100043 HC CCH SO CYTOPATH C/V AUTO FLUID REDO (DIAGNOSTIC) $ 180.00 31100050 HC CCH SO CYTOPATH C/V AUTO THIN LAYER PREP W/ MANUAL SCREEN & RESCREEN $ 83.00 31100051 HC CCH SO AVI FLOW CYTOMETRY 1ST MARKER $ 105.00 31100052 HC CCH SO AVI FLOW CYTOMETRY EA ADDL MARKER $ 98.00 31100129 HC CCH CYTOPATHOLOGY BETHESDA PAP MANUAL SCREEN $ 28.78 31200001 HC SURG PATH LEVEL I GROSS ONLY $ 146.00 31200002 HC SURG PATH LEVEL II $ 146.00 31200003 HC SURG PATH LEVEL III $ 206.00 31200004 HC SURG PATH LEVEL V $ 515.00 31200005 HC SURG PATH LEVEL VI $ 684.00 31200006 HC DECALCIFCATION $ 36.00 31200013 HC SO SPECIAL STAINS GROUP 2 $ 86.00 31200022 HC SURG PATH LEVEL IV EXCEPT PROSTATE NEEDLE BIOPSY $ 276.00 31200051 HC CCH SO SPECIAL STAINS GROUP 1 $ 58.00

02-19-2019-A-PAC-057 Page 23 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 31200052 HC CCH SO AVI IMMUNOHISTO/CYTO CHEM EACH ADDL SINGLE ANTIBODY STAIN $ 176.00 31200053 HC CCH SO AVI MORPH ANALYSIS QUANTATIVE AB EACH STAIN $ 166.00 31200054 HC CCH SO AVI COMPUTER MORPHOMETRIC ANALYSIS PER SPECIMEN SINGLE $ 208.00 31200055 HC CCH SO AVI INSITU HYBRIDIZATION (FISH) PER SPECIMAN MULTIPLEX EACH $ 166.00 31200056 HC CCH SO AVI MORPHOMETRIC ANALYSIS (FISH) $ 211.00 31200057 HC CCH SO AVI MORPHOMETRIC ANALYSIS (FISH)SI $ 211.00 31200058 HC CCH SO AVI MORPHOMETRIC ANALYSIS (FISH)MU $ 396.00 31200061 HC CCH SO AVI IMMUNOHISTO/CYTO CHEM INITIAL SINGLE ANTIBODY STAIN $ 176.00 32000002 HC RADIOLOGY EXAM EYE FOR FB DETECTION $ 289.00 32000004 HC RADIOLOGY EXAM MANDIBLE COMPLETE- MIN 4 VIEWS $ 268.00 32000005 HC RADIOLOGY EXAM MASTOIDS < 3 VIEWS PER SIDE $ 278.00 32000008 HC RADIOLOGY EXAM FACIAL BONES < 3 VIEWS $ 331.00 32000009 HC RADIOLOGY EXAM FACIAL BONES COMPLETE- MIN 3 VIEWS $ 503.00 32000010 HC RADIOLOGY EXAM NASAL BONES COMPLETE-MIN 3 VIEWS $ 390.00 32000011 HC RADIOLOGY EXAM OPTIC FORAMINA $ 311.00 32000012 HC RADIOLOGY EXAM ORBITS COMPLETE- MIN 4 VIEWS $ 168.00 32000013 HC RADIOLOGY EXAM PARANASAL SINUSES < 3 VIEWS $ 246.00 32000014 HC RADIOLOGY EXAM PARANASAL SINUSES COMPLETE- MIN 3 VIEWS $ 651.00 32000016 HC RADIOLOGY EXAM SKULL < 4 VIEWS $ 561.00 32000017 HC RADIOLOGY EXAM SKULL COMPLETE- MIN 4 VIEWS $ 572.00 32000021 HC RADIOLOGY EXAM TMJ OPEN & CLOSED BILATERAL $ 488.00 32000024 HC RADIOLOGY EXAM NECK SOFT TISSUE $ 355.00 32000028 HC RADIOLOGY EXAM RIBS UNILATERAL 2 VIEWS $ 343.00 32000029 HC RADIOLOGY EXAM RIBS UNILATERAL W/ PA CHEST MIN 3 VIEWS $ 473.00 32000030 HC RADIOLOGY EXAM RIBS BILATERAL 3 VIEWS $ 606.00 32000031 HC RADIOLOGY EXAM RIBS BILATERAL W/ PA CHEST MIN 4 VIEWS $ 607.00 32000032 HC RADIOLOGY EXAM STERNUM MIN 2 VIEWS $ 459.00 32000033 HC RADIOLOGY EXAM STERNOCLAVICULAR JOINT MIN 3 VIEWS $ 235.00 32000035 HC RADIOLOGY EXAM SPINE SINGLE VIEW- SPECIFY LEVEL $ 251.00 32000036 HC RADIOLOGY EXAM CERVICAL SPINE 2 OR 3 VIEWS $ 438.00 32000037 HC RADIOLOGY EXAM CERVICAL SPINE 4 OR 5 VIEWS $ 589.00 32000038 HC RADIOLOGY EXAM CERVICAL SPINE 6 OR MORE VIEWS $ 668.00 32000040 HC RADIOLOGY EXAM THORACIC SPINE 2 VIEWS $ 426.00 32000041 HC RADIOLOGY EXAM THORACIC SPINE 3 VIEWS $ 510.00 32000045 HC RADIOLOGY EXAM LUMBOSACRAL SPINE 2 OR 3 VIEWS $ 443.00 32000046 HC RADIOLOGY EXAM LUMBOSACRAL SPINE MIN 4 VIEWS $ 579.00 32000047 HC RAD EXAM LS SPINE COMPLETE W/ BENDING MIN 6 VIEWS $ 687.00 32000048 HC RADIOLOGY EXAM LUMBOSACRAL BENDING ONLY 2 OR 3 VIEWS $ 551.00 32000049 HC RADIOLOGY EXAM PELVIS 1 OR 2 VIEWS $ 230.00 32000050 HC RADIOLOGY EXAM PELVIS COMPLETE- MIN 3 VIEWS $ 407.00 32000052 HC RADIOLOGY EXAM SACROILIAC JOINT 3 OR MORE VIEWS $ 399.00 32000053 HC RADIOLOGY EXAM SACRUM & COCCYX MIN 2 VIEWS $ 453.00 32000056 HC MYELOGRAPHY LUMBOSACRAL $ 715.00 32000057 HC MYELOGRAPHY 2 OR MORE REGIONS $ 1,072.00 32000061 HC RADIOLOGY EXAM CLAVICLE- COMPLETE $ 381.00 32000061 HC RADIOLOGY EXAM CLAVICLE- COMPLETE $ 758. 00 32000062 HC RADIOLOGY EXAM SCAPULA- COMPLETE $ 417.00 32000063 HC RADIOLOGY EXAM SHOULDER 1 VIEW $ 336.00 32000064 HC RADIOLOGY EXAM SHOULDER COMPLETE- MIN 2 VIEWS $ 344.00 32000064 HC RADIOLOGY EXAM SHOULDER COMPLETE- MIN 2 VIEWS $ 977.00 32000065 HC ARTHROGRAPHY SHOULDER $ 701.00 32000066 HC RADIOLOGY EXAM ACROMIOCLAVICULAR JOINTS BILATERAL $ 528.00 32000067 HC RADIOLOGY EXAM HUMERUS MIN 2 VIEWS $ 311.00 32000068 HC RADIOLOGY EXAM ELBOW 2 VIEWS $ 240.00 32000069 HC RADIOLOGY EXAM ELBOW COMPLETE- MIN 3 VIEWS $ 765.00 32000069 HC RADIOLOGY EXAM ELBOW COMPLETE- MIN 3 VIEWS $ 423.00 32000071 HC RADIOLOGY EXAM FOREARM 2 VIEWS $ 363.00 32000072 HC RADIOLOGY EXAM WRIST 2 VIEWS $ 274.00 32000072 HC RADIOLOGY EXAM WRIST 2 VIEWS $ 575.00 32000073 HC RADIOLOGY EXAM WRIST COMPLETE- MIN 3 VIEWS $ 770.00 32000073 HC RADIOLOGY EXAM WRIST COMPLETE- MIN 3 VIEWS $ 344.00 32000074 HC ARTHROGRAPHY WRIST $ 701.00 32000075 HC RADIOLOGY EXAM HAND 2 VIEWS $ 319.00 32000075 HC RADIOLOGY EXAM HAND 2 VIEWS $ 636.00 32000076 HC RADIOLOGY EXAM HAND MIN 3 VIEWS $ 319.00 32000076 HC RADIOLOGY EXAM HAND MIN 3 VIEWS $ 678.00 32000077 HC RADIOLOGY EXAM FINGER(S) MIN 2 VIEWS $ 256.00 32000077 HC RADIOLOGY EXAM FINGER(S) MIN 2 VIEWS $ 512.00 32000081 HC ARTHROGRAPHY HIP $ 593.00 32000084 HC RADIOLOGY EXAM KNEE 1 OR 2 VIEWS $ 303.00 32000084 HC RADIOLOGY EXAM KNEE 1 OR 2 VIEWS $ 605.00

02-19-2019-A-PAC-057 Page 24 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 32000085 HC RADIOLOGY EXAM KNEE 3 VIEWS $ 348.00 32000085 HC RADIOLOGY EXAM KNEE 3 VIEWS $ 691.00 32000086 HC RADIOLOGY EXAM KNEE COMPLETE- 4 OR MORE VIEWS $ 490.00 32000086 HC RADIOLOGY EXAM KNEE COMPLETE- 4 OR MORE VIEWS $ 881.00 32000087 HC RADIOLOGY EXAM KNEES BILATERAL STANDING AP $ 303.00 32000089 HC RADIOLOGY EXAM TIBIA FIBULA 2 VIEWS $ 617.00 32000089 HC RADIOLOGY EXAM TIBIA FIBULA 2 VIEWS $ 311.00 32000090 HC RADIOLOGY EXAM ANKLE 2 VIEWS $ 618.00 32000091 HC RADIOLOGY EXAM ANKLE COMPLETE- MIN 3 VIEWS $ 336.00 32000091 HC RADIOLOGY EXAM ANKLE COMPLETE- MIN 3 VIEWS $ 790.00 32000093 HC RADIOLOGY EXAM FOOT 2 VIEWS $ 356.00 32000093 HC RADIOLOGY EXAM FOOT 2 VIEWS $ 712.00 32000094 HC RADIOLOGY EXAM FOOT COMPLETE- MIN 3 VIEWS $ 337.00 32000094 HC RADIOLOGY EXAM FOOT COMPLETE- MIN 3 VIEWS $ 746.00 32000095 HC RADIOLOGY EXAM CALCANEUS MIN 2 VIEWS $ 338.00 32000096 HC RADIOLOGY EXAM TOE(S) MIN 2 VIEWS $ 335.00 32000097 HC RADIOLOGY EXAM ABDOMEN SINGLE VIEW $ 353.00 32000099 HC RADIOLOGY EXAM COMPLETE ACUTE ABDOMEN SERIES $ 485.00 32000101 HC RADIOLOGY EXAM ESOPHAGUS $ 531.00 32000102 HC RADIOLOGY VIDEORADIOGRAPHY SWALLOWING FUNCTION $ 375.00 32000103 HC RADIOLOGY EXAM UPPER GI WITHOUT KUB $ 731.00 32000104 HC RADIOLOGY EXAM UPPER GI W/ SMALL INTESTINE $ 1,131.00 32000105 HC RADIOLOGY EXAM UPPER GI W/ AIR CONTRAST W/O KUB $ 761.00 32000106 HC RADIOLOGY EXAM UPPER GI W/ AIR CONTRAST W/ SMALL BOWEL FOLLOW-THROUGH $ 496.00 32000107 HC RADIOLOGY EXAM SMALL INTESTINE $ 611.00 32000110 HC RADIOLOGY EXAM COLON BARIUM ENEMA $ 473.00 32000111 HC RADIOLOGY EXAM COLON AIR CONTRAST W/ BARIUM $ 1,074.00 32000113 HC CHOLANGIOGRAPHY PANCREATOGRAPHY INTRAOPERATIVE $ 639.00 32000125 HC RADIOLOGY UROGRAPHY INTRAVENOUS $ 1,083.00 32000128 HC RADIOLOGY RETROGRADE UROGRAPHY $ 1,938.00 32000128 HC RADIOLOGY RETROGRADE UROGRAPHY $ 54.00 32000130 HC RADIOLOGY CYSTOGRAPHY MIN 3 VIEWS $ 324.00 32000132 HC RADIOLOGY VOIDING URETHROCYSTOGRAPHY $ 1,026.00 32000136 HC RADIOLOGY HYSTEROSALPINGOGRAPHY $ 720.00 32000189 HC RADIOLOGY FLUOROSCOPY UP TO 1 HOUR $ 637.00 32000189 HC RADIOLOGY FLUOROSCOPY UP TO 1 HOUR $ 25.50 32000192 HC RADIOLOGY SURGICAL SPECIMEN $ 264.00 32000194 HC 3D RENDERING POSTPROCESSING W/O INDEPENDENT WORKSTATION DIAG RAD $ 375.00 32000197 HC RADIOLOGY FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE $ 378.00 32000198 HC RADIOLOGY FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT $ 61.00 32000199 HC RADIOLOGY FLUOROSCOPIC GUIDANCE FOR SPINAL INJECTION $ 230.00 32000204 HC RADIOLOGY BONE AGE STUDY $ 356.00 32000205 HC RADIOLOGY BONE LENGTH STUDIES $ 305.00 32000206 HC RADIOLOGY OSSEOUS SURVEY- LIMITED $ 931.00 32000207 HC RADIOLOGY OSSEOUS SURVEY- COMPLETE $ 833.00 32000209 HC RADIOLOGY BONE DENSITY STUDY AXIAL $ 432. 00 32000220 HC RADIOLOGY X-RAY ARM INFANT 2+ VIEWS $ 303.00 32000220 HC RADIOLOGY X-RAY ARM INFANT 2+ VIEWS $ 757.00 32000226 HC CCH RADIOLOGY EXAM NOSE TO RECTUM FOR FB SINGLE VIEW CHILD $ 172.00 32000227 HC CCH RADIOLOGY EXAM OSSEOUS SURVEY INFANT $ 319.00 32000228 HC RADIOLOGY EXAM LOWER EXTREMITY; INFANT 2 VIEWS $ 399.00 32000228 HC RADIOLOGY EXAM LOWER EXTREMITY; INFANT 2 VIEWS $ 291.00 32000231 HC RADIOLOGY VERTEBRAL FX ASSESSMENT $ 296.00 32000232 HC RADIOLOGY EXAM SPINE ENTIRE THORACIC AND LUMBAR 1 VIEW $ 198.00 32000233 HC RADIOLOGY EXAM SPINE ENTIRE THORACIC AND LUMBAR 2 OR 3 VIEWS $ 826.00 32000234 HC RADIOLOGY EXAM SPINE ENTIRE THORACIC AND LUMBAR 4 OR 5 VIEWS $ 855.00 32000235 HC RADIOLOGY EXAM SPINE ENTIRE THORACIC AND LUMBAR MINIMUM 6 VIEWS $ 933.00 32000236 HC RADIOLOGY EXAM HIP W/ PELVIS WHEN PERFORMED UNILATERAL 1 VIEW $ 236.00 32000237 HC RADIOLOGY EXAM HIP W/ PELVIS WHEN PERFORMED UNILATERAL 2 -3 VIEWS $ 270.00 32000238 HC RADIOLOGY EXAM HIP W/ PELVIS WHEN PERFORMED UNILATERAL MINIMUM 4 VIEWS $ 490.00 32000239 HC RADIOLOGY EXAM HIP W/ PELVIS WHEN PERFORMED BILATERAL 2 VIEWS $ 557.00 32000240 HC RADIOLOGY EXAM HIP W/ PELVIS WHEN PERFORMED BILATERAL 3-4 VIEWS $ 374.00 32000241 HC RADIOLOGY EXAM HIP W/ PELVIS WHEN PERFORMED BILATERAL MINIMUM 5 VIEWS $ 889.00 32000242 HC RADIOLOGY EXAM FEMUR 1 VIEW $ 296.00 32000243 HC RADIOLOGY EXAM FEMUR MINIMUM 2 VIEWS $ 343.00 32000243 HC RADIOLOGY EXAM FEMUR MINIMUM 2 VIEWS $ 684.00 32000248 HC RADIOLOGY EXAM ABDOMEN 2 VIEWS $ 432.00 32000249 HC RADIOLOGY EXAM ABDOMEN 3 OR MORE VIEWS $ 541.00 32300001 HC RADIOLOGY AORTOGRAPHY THORACIC $ 5,338.00 32300002 HC RADIOLOGY AORTOGRAPHY ABDOMINAL $ 5,338.00 32300003 HC RADIOLOGY AORTOGRAPHY ABDOMINAL W/ FEMORAL RUN-OFF $ 5,338.00

02-19-2019-A-PAC-057 Page 25 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 32300014 HC RADIOLOGY ANGIOGRAPHY EXTREMITY UNILATERAL $ 5,338.00 32300015 HC RADIOLOGY ANGIOGRAPHY EXTREMITY BILATERAL $ 5,338.00 32300018 HC RADIOLOGY ANGIOGRAPHY VISCERAL $ 5,338.00 32400001 HC RADIOLOGY X-RAY CHEST SINGLE VIEW $ 242.00 32400002 HC RADIOLOGY X-RAY CHEST 2 VIEWS $ 253.00 32400004 HC RADIOLOGY X-RAY CHEST MIN 4 VIEWS $ 211.00 32400006 HC RADIOLOGY X-RAY CHEST 3 VIEWS $ 337.00 33100001 HC CHEMO ADMIN SQ/IM NON-HORMONAL $ 176.00 33100002 HC CHEMO ADMIN SQ/IM HORMONAL $ 107.00 33100005 HC CHEMO ADMIN INITIAL IV PUSH $ 410.00 33100006 HC CHEMO ADMIN EACH ADDITIONAL IV PUSH $ 173.00 33300006 HC SIMULATION-AIDED FIELD SETTING COMPLEX $ 1,208.00 33300018 HC TREATMENT DEVICES SIMPLE $ 148.00 33300054 HC INTERSTITIAL RADIATION APPLICATION COMPLEX NON-PROSTATE $ 782.00 33500001 HC CHEMO ADMIN IV INITIAL UP TO 1 HOUR $ 515.00 33500002 HC CHEMO ADMIN IV EACH ADDITIONAL HOUR $ 88.00 33500003 HC CHEMO ADMIN IV PROLONGED INFUSION W/ IMPLANTABLE PUMP $ 992.00 33500004 HC CHEMO ADMIN IV SEQUENTIAL UP TO 1 HOUR $ 99.00 34000002 HC NUC MED BONE MARROW IMAGING LIMITED $ 1,851.00 34100008 HC NUC MED PARATHYROID PLANAR IMAGING INCLUDING SUBTRACTION WHEN PERFORMED $ 858.00 34100010 HC NUC MED BONE MARROW IMAGING WHOLE BODY $ 1,391.00 34100014 HC NUC MED LYMPHATIC AND LYMPH NODE IMAGING $ 1,660.00 34100025 HC NUC MED GASTRIC EMPTYING STUDY $ 1,654.00 34100026 HC NUC MED ACUTE GI BLOOD LOSS IMAGING $ 733.00 34100029 HC NUC MED BONE JOINT IMAGING- LIMITED $ 1,251.00 34100031 HC NUC MED BONE JOINT IMAGING WHOLE BODY $ 1,811.00 34100032 HC NUC MED BONE IMAGING 3 PHASE STUDY $ 2,126.00 34100036 HC NUC MED MYOCARDIAL PERFUSION SPECT SINGLE REST OR STRESS $ 3,095.00 34100037 HC NUC MED MYOCARDIAL PERFUSION SPECT MULTIPLE REST OR STRESS $ 4,334.00 34100037 HC NUC MED MYOCARDIAL PERFUSION SPECT MULTIPLE REST OR STRESS $ 1,208.00 34100044 HC NUC MED CARDIAC BLOOD POOL SINGLE WALL MOTION + EF $ 2,050.00 34100048 HC NUC MED PULMONARY PERFUSION IMAGING PARTICULATE $ 709.00 34100072 HC NUC MED INFLAMMATORY PROCESS LOCALIZATION W/ RADIOPHARM- LIMITED $ 1,697.00 34100073 HC NUC MED INFLAMMATORY PROCESS LOCALIZATION W/ RADIOPHARM- WHOLE BODY $ 1,924.00 34100078 HC NUC MED HEPATOBILIARY SYSTEM IMAGING INCL GALLBLADDER $ 1,155.00 34100079 HC NUC MED HEPATOBILIARY SYSTEM IMAGING INCL GALLBLADDER W/ DRUG $ 1,759.00 34100081 HC NUC MED PULMONARY VENTILATION AND PERFUSION IMAGING $ 3,209.00 34100084 HC THYROID UPTAKE SINGLE OR MULTIPLE W/QUANTITATIVE MEASUREMENTS $ 846.00 34100086 HC THYROID UPTAKE SINGLE OR MULTIPLE W/QUANTITATIVE MEASUREMENTS W OR W/O VASCULAR FLOW $ 2,306.00 34100087 HC PARATHYROID PLANAR W/ OR W/O SUBTRACTION W/ SPECT $ 1,611.00 34100089 HC CCH NUC MED KIDNEY IMAGE MORPHOLOGY W/ VASC FLOW FUNCTION & PHARMOCOLOGIC INTERVENTION SGL STUDY $ 2,657.00 34300004 HC CCH TC99M MEDRONATE =< 30 MCI $ 75.00 34300005 HC TL201 THALLIUM PER 1 MCI $ 82.00 34300011 HC CCH IODINE I-123 SOD IODIDE PER 100 UCI TO 999 UCI $ 187.00 34300016 HC CCH TC99M MEBROFENIN =< 15 MCI $ 340.00 34300022 HC IN111 OXYQUINOLINE PER 0.5 MCI $ 2,001.00 34300024 HC TC99M SUCCIMER =< 10 MCI $ 279.00 34300025 HC F18 FDG =< 45 MCI $ 1,296.00 34300028 HC CCH TC99M LABELED RBC =< 30 MCI $ 408.00 34300029 HC CCH TC99M MERTIATIDE =< 15 MCI $ 531.00 34300039 HC CCH TCM99M SULFUL COLLOID =< 20MCI $ 132.00 35000001 HC CTA HEAD W/ CONTRAST AND POSTPROCESSING $ 2,562.00 35000002 HC CTA NECK W/ CONTRAST AND POSTPROCESSING $ 3,164.00 35000003 HC CTA CHEST (NON-CORONARY) W/ CONTRAST AND POSTPROCESSING $ 2,514.00 35000004 HC CT CERVICAL SPINE W/O CONTRAST $ 1,718.00 35000005 HC CT CERVICAL SPINE W/ CONTRAST $ 2,709.00 35000006 HC CT CERVICAL SPINE W/ & W/O CONTRAST $ 2,867.00 35000007 HC CT THORACIC SPINE W/ CONTRAST $ 2,633.00 35000008 HC CT THORACIC SPINE W/ & W/O CONTRAST $ 3,010.00 35000009 HC CT LUMBAR SPINE W/ CONTRAST $ 2,986.00 35000010 HC CT LUMBAR SPINE W/ & W/O CONTRAST $ 2,977.00 35000011 HC CTA PELVIS W/ CONTRAST AND POSTPROCESSING $ 2,588.00 35000013 HC CTA LOWER EXTREMITY W/ CONTRAST AND POSTPROCESSING $ 1,906.00 35000014 HC CTA ABDOMEN W/ CONTRAST AND POSTPROCESSING $ 5,131.00 35000019 HC CTA ABDOMINAL AORTA W/ BILATERAL ILIOFEMORAL RUN-OFF & POSTPROCESSING $ 4,502.00 35000020 HC PLACEMENT PERCUTANEOUS DRAINAGE CATHETER CT $ 917.00 35000021 HC 3D RENDERING POSTPROCESSING W/O INDEPENDENT WORKSTATION CT $ 375.00 35000022 HC 3D RENDERING POSTPROCESSING W/ INDEPENDENT WORKSTATION CT $ 748.00 35000024 HC CT GUIDED NEEDLE PLACEMENT $ 3,807.00 35000028 HC CTA ABDOMEN AND PELVIS W/ CONTRAST AND POSTPROCESSING $ 4,222.00 35100002 HC CT HEAD/BRAIN W/O CONTRAST $ 1,476.00

02-19-2019-A-PAC-057 Page 26 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 35100003 HC CT HEAD/BRAIN W/ CONTRAST $ 1,282.00 35100004 HC CT HEAD/BRAIN W/ & W/O CONTRAST $ 1,973.00 35100005 HC CT ORBIT SELLA POSTERIOR FOSSA EAR W/O CONTRAST $ 1,293.00 35100006 HC CT ORBIT SELLA POSTERIOR FOSSA EAR W/ CONTRAST $ 1,421.00 35100007 HC CT ORBIT SELLA POSTERIOR FOSSA EAR W/ & W/O CONTRAST $ 1,913.00 35100008 HC CT MAXILLOFACIAL W/O CONTRAST $ 2,188.00 35100009 HC CT MAXILLOFACIAL W/ CONTRAST $ 2,418.00 35100010 HC CT MAXILLOFACIAL W/ & W/O CONTRAST $ 2,660.00 35100011 HC CT NECK W/O CONTRAST $ 2,620.00 35100012 HC CT NECK W/ CONTRAST $ 3,099.00 35100013 HC CT NECK W/ & W/O CONTRAST $ 3,533.00 35200001 HC CT THORAX W/O CONTRAST $ 1,862.00 35200002 HC CT THORAX W/ CONTRAST $ 2,241.00 35200003 HC CT THORAX W/ & W/O CONTRAST $ 2,865.00 35200004 HC CT THORACIC SPINE W/O CONTRAST $ 2,369.00 35200005 HC CT LUMBAR SPINE W/O CONTRAST $ 2,369.00 35200006 HC CT PELVIS W/O CONTRAST $ 1,799.00 35200007 HC CT PELVIS W/ CONTRAST $ 2,817.00 35200008 HC CT PELVIS W/ & W/O CONTRAST $ 2,451.00 35200009 HC CT UPPER EXTREMITY W/O CONTRAST $ 1,307.00 35200010 HC CT UPPER EXTREMITY W/ CONTRAST $ 1,127.00 35200011 HC CT UPPER EXTREMITY W/ & W/O CONTRAST $ 1,267.00 35200012 HC CT LOWER EXTREMITY W/O CONTRAST $ 1,768.00 35200013 HC CT LOWER EXTREMITY W/ CONTRAST $ 1,785.00 35200014 HC CT LOWER EXTREMITY W/ & W/O CONTRAST $ 1,551.00 35200015 HC CT ABDOMEN W/O CONTRAST $ 1,617.00 35200016 HC CT ABDOMEN W/ CONTRAST $ 3,671.00 35200017 HC CT ABDOMEN W/ & W/O CONTRAST $ 3,753.00 35200020 HC CT ABDOMEN & PELVIS W/O CONTRAST $ 2,370.00 35200021 HC CT ABDOMEN & PELVIS W/ CONTRAST $ 3,494.00 35200022 HC CT ABDOMEN & PELVIS W/ & W/O CONTRAST $ 4,745.00 35200025 HC LOW DOSE CT LUNG SCREENING $ 473.00 36000027 HC OR LEVEL I 0-30 MINS $ 2,397.00 36000028 HC OR LEVEL I EACH ADDL 15 MINS $ 1,297.00 36000029 HC OR LEVEL II 0-30 MINS $ 2,722.00 36000030 HC OR LEVEL II EACH ADDL 15 MINS $ 1,460.00 36000031 HC OR LEVEL III 0-30 MINS $ 2,976.00 36000032 HC OR LEVEL III EACH ADDL 15 MINS $ 1,552.00 36000033 HC OR LEVEL IV 0-30 MINS $ 3,289.00 36000034 HC OR LEVEL IV EACH ADDL 15 MINS $ 1,703.00 36000035 HC OR LEVEL V 0-30 MINS $ 3,589.00 36000036 HC OR LEVEL V EACH ADDL 15 MINS $ 1,852.00 36000037 HC CANCELLED PROCEDURE IN OR $ 1,158.00 37000001 HC ANESTHESIA FOR ECT $ 290.00 37000008 HC GENERAL ANESTHESIA FIRST 30 MINS $ 296.00 37000009 HC GENERAL ANESTHESIA EACH ADDL 15 MINS $ 148. 00 37000010 HC REGIONAL ANESTHESIA $ 280.00 37000011 HC MONITORED ANESTHESIA CARE/MAC FIRST 30 MINS $ 267.00 37000012 HC MONITORED ANESTHESIA CARE/MAC EACH ADDL 15 MINS $ 132.00 37000013 HC CCH MOD SEDATION EACH ADDL 15 MINS DIFFERENT MD $ 148.00 37000018 HC CCH MOD SEDATION < 5 YRS INITIAL 15 MINS SAME MD $ 148.00 37000019 HC MOD SEDATION EA ADDL 15 MINS SAME MD $ 148.00 37000020 HC MOD SEDATION > 5 YRS INITIAL 15 MINS SAME MD $ 148.00 37000022 HC CCH MOD SEDATION <5 YEARS INITIAL 15 MINS DIFFERENT MD $ 148.00 37000024 HC CCH MOD SEDATION > 5 YRS EA INITIAL 15 MINS DIFFERENT MD $ 148.00 39000003 HC PROCESSING CRYOPRECIPITATE EACH UNIT $ 740.00 39000004 HC PROCESSING LEUKOCYTE POOR BLOOD EACH UNIT $ 471.00 39000006 HC PROCESSING PLATELET CONCENTRATE EACH UNIT $ 167.00 39000019 HC PROCESSING PLATELETS PHERESIS LEUKO REDUCED EACH UNIT $ 1,174.00 39000023 HC PROCESSING RBC LEUKO REDUCED IRRADIATED EACH UNIT $ 543.00 39000030 HC PROCESSING FFP BETWEEN 8-24 HRS OF COLLECTION EACH UNIT $ 159.00 39000036 HC CCH SO PROCESSING LEUKOCYTE POOR BLOOD EACH UNIT $ 446.00 39100001 HC TRANSFUSION BLOOD OR BLOOD COMPONENTS $ 687.00 39100002 HC CCH TRANSFUSION BLOOD OR BLOOD COMPONENTS LEVEL 2 $ 687.00 40100004 HC MAMMOGRAM DIAGNOSTIC BILATERAL INCLUDING CAD $ 582.00 40100005 HC MAMMOGRAM DIAGNOSTIC UNILATERAL INCLUDING CAD $ 448.00 40100006 HC DIAGNOSTIC MAMMO TOMO UNILATERAL $ 79.00 40100007 HC DIAGNOSTIC MAMMO TOMO BILATERAL $ 79.00 40200001 HC PLACEMENT PERCUTANEOUS DRAINAGE CATHETER US $ 918.00 40200004 HC US ECHOENCEPHALOGRAPHY $ 359.00 40200007 HC US HEAD AND NECK $ 478.00

02-19-2019-A-PAC-057 Page 27 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 40200008 HC US CHEST $ 528.00 40200010 HC US ABDOMINAL COMPLETE $ 952.00 40200011 HC US ABDOMINAL LIMITED $ 693.00 40200012 HC US RETROPERITONEAL COMPLETE $ 691.00 40200013 HC US RETROPERITONEAL LIMITED $ 723.00 40200015 HC US 1ST TRIMESTER TRANSABDOMINAL $ 484.00 40200016 HC US 1ST TRIMESTER TRANSABDOMINAL EACH ADDITIONAL FETUS $ 88.00 40200017 HC US OB AFTER 1ST TRIMESTER TRANSABDOMINAL $ 1,301.00 40200018 HC US OB AFTER 1ST TRIMESTER TRANSABDOMINAL EACH ADDITIONAL FETUS $ 167.00 40200019 HC US OB TRANSABDOMINAL W/ DETAILED FETAL EXAM $ 854.00 40200021 HC US 1ST TRIMESTER W/ FETAL NUCHAL TRANSLUCENCY $ 217.00 40200023 HC US OB LIMITED 1 OR MORE FETUSES $ 500.00 40200024 HC US OB FOLLOW-UP TRANSABDOMINAL PER FETUS $ 267.00 40200025 HC US OB TRANSVAGINAL $ 422.00 40200026 HC US BPP W/ NON-STRESS TEST $ 365.00 40200027 HC US BPP W/O NON-STRESS TEST $ 252.00 40200028 HC US UMBILICAL ARTERY DOPPLER $ 55.00 40200033 HC US GUIDANCE FOR VASCULAR ACCESS $ 434.00 40200034 HC US TRANSVAGINAL $ 643.00 40200035 HC US PELVIC COMPLETE $ 548.00 40200036 HC US PELVIC LIMITED $ 274.00 40200037 HC US SCROTUM $ 562.00 40200038 HC US TRANSRECTAL $ 822.00 40200038 HC US TRANSRECTAL $ 164.00 40200040 HC US GUIDANCE FOR INTERSTITIAL RADIOELEMENT APPLICATION $ 193.00 40200043 HC US AAA SCREENING $ 524.00 40200051 HC US GUIDANCE FOR NEEDLE PLACEMENT $ 2,562.00 40200051 HC US GUIDANCE FOR NEEDLE PLACEMENT $ 107.50 40200054 HC US COMPLETE JOINT W/IMAGING $ 423.00 40200055 HC US LIMITED JOINT W/IMAGING $ 490.00 40200059 HC US OPHTHALMIC CORNEAL PACHYMETRY $ 28.50 40200063 HC US BREAST UNILATERAL COMPLETE $ 1,362.00 40200063 HC US BREAST UNILATERAL COMPLETE $ 680.00 40200064 HC US BREAST UNILATERAL LIMITED $ 365.00 40200065 HC SALINE INFUSION SONOHYSTEROGRAPHY $ 632.00 40300003 HC MAMMOGRAM SCREENING BILATERAL INCLUDING CAD $ 214.00 40300005 HC SCREENING BREAST TOMOSYNTHESIS DIGITAL BILATERAL $ 79.00 40400003 HC PET BRAIN METABOLIC EVAL $ 5,988.00 40400005 HC PET CT SKULL BASE TO MID-THIGH $ 7,151.00 40400006 HC PET CT WHOLE BODY $ 6,500.00 40400008 HC PET CT BRAIN LIMITED DX EARLY ONSET ALZHEIMERS $ 5,311.00 41000001 HC VENTILATOR INITIAL DAY $ 312.00 41000002 HC VENTILATOR EACH SUBSEQUENT DAY $ 394.00 41000007 HC METERED DOSE INHALER TREATMENT $ 42.00 41000010 HC AEROSOL OR NEBULIZER TREATMENT $ 42.00 41000018 HC CPAP OR BIPAP $ 250. 00 41000027 HC DEMO & EVAL OF AEROSOL MDI NEB OR IPPB $ 63.00 41000028 HC MANUAL CHEST WALL MANIPULATION (PEP) INITIAL $ 328.00 41000029 HC MANUAL CHEST WALL MANIPULATION (PEP) SUBSEQUENT $ 66.00 41000033 HC PULMONARY EXERCISE SESSION GROUP $ 124.00 41000045 HC INTUBATION ENDOTRACHEAL EMERGENT $ 664.00 41000047 HC MECHANICAL CHEST WALL OSCILLATION PER SESSION $ 215.00 41000048 HC CCH NASOTRACHEAL CATHETER ASPIRATION $ 166.00 41000050 HC CCH ATTENDANCE AT DELIVERY &/OR STABILIZATION $ 624.00 41000051 HC CCH INTERMITTENT SUCTION $ 59.00 41000052 HC CCH INPATIENT STABILIZATION $ 461.00 41300001 HC HYPERBARICS FULL BODY PER 30 MINUTE INTERVAL $ 485.00 42000001 HC STRAPPING SHOULDER $ 84.00 42000004 HC STRAPPING HIP $ 140.00 42000005 HC STRAPPING KNEE $ 70.00 42000006 HC STRAPPING ANKLE AND/OR FOOT $ 66.00 42000011 HC TRACTION MECHANICAL $ 102.00 42000011 HC TRACTION MECHANICAL $ 23.00 42000012 HC VASOPNEUMATIC DEVICES $ 110.00 42000012 HC VASOPNEUMATIC DEVICES $ 40.00 42000013 HC PARAFFIN BATH $ 81.00 42000013 HC PARAFFIN BATH $ 28.00 42000014 HC WHIRLPOOL $ 129.00 42000016 HC ELECTRICAL STIMULATION EACH 15 MINS $ 125.00 42000017 HC IONTOPHORESIS EACH 15 MINS $ 183.00 42000019 HC ULTRASOUND EACH 15 MINS $ 132.00

02-19-2019-A-PAC-057 Page 28 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 42000021 HC THERAPEUTIC EXERCISES ROM & FLEXIBILITY EACH 15 MINS $ 110.00 42000021 HC THERAPEUTIC EXERCISES ROM & FLEXIBILITY EACH 15 MINS $ 43.50 42000022 HC NEUROMUSCULAR REEDUCATION EACH 15 MINS $ 108.00 42000023 HC AQUATIC THERAPY EACH 15 MINS $ 121.00 42000023 HC AQUATIC THERAPY EACH 15 MINS $ 85.00 42000024 HC GAIT TRAINING EACH 15 MINS $ 95.00 42000024 HC GAIT TRAINING EACH 15 MINS $ 44.00 42000025 HC MASSAGE EACH 15 MINS $ 125.00 42000025 HC MASSAGE EACH 15 MINS $ 43.00 42000026 HC MANUAL THERAPY TECHNIQUES EACH 15 MINS $ 174.00 42000026 HC MANUAL THERAPY TECHNIQUES EACH 15 MINS $ 46.00 42000027 HC THERAPEUTIC PROCEDURE GROUP $ 51.00 42000027 HC THERAPEUTIC PROCEDURE GROUP $ 18.00 42000028 HC THERAPEUTIC ACTIVITIES DIRECT EACH 15 MINS $ 102.00 42000028 HC THERAPEUTIC ACTIVITIES DIRECT EACH 15 MINS $ 60.00 42000029 HC DEVELOPMENT COGNITIVE SKILLS DIRECT EACH 15 MINS $ 34.00 42000030 HC SENSORY INTEGRATIVE TECHNIQUES DIRECT EACH 15 MINS $ 113.00 42000030 HC SENSORY INTEGRATIVE TECHNIQUES DIRECT EACH 15 MINS $ 42.00 42000031 HC SELF CARE/HOME MGMT DIRECT EACH 15 MINS $ 77.00 42000031 HC SELF CARE/HOME MGMT DIRECT EACH 15 MINS $ 58.00 42000032 HC COMMUNITY/WORK REINTEGRATION TRAINING DIRECT EACH 15 MINS $ 44.00 42000033 HC WHEELCHAIR MGMT EACH 15 MINS $ 87.00 42000033 HC WHEELCHAIR MGMT EACH 15 MINS $ 45.00 42000034 HC WORK HARDENING/CONDITIONING INITIAL 2 HOURS $ 147.00 42000039 HC ASSISTIVE TECHNOLOGY ASSESSMENT DIRECT EACH 15 MINS $ 58.00 42000040 HC ORTHOTIC MGMT & TRAINING INITIAL EACH 15 MIN $ 123.00 42000040 HC ORTHOTIC MGMT & TRAINING INITIAL EACH 15 MIN $ 90.00 42000041 HC PROSTHETIC TRAINING UPPER/LOWER EXTREMITY INITIAL EACH 15 MINS $ 100.00 42000041 HC PROSTHETIC TRAINING UPPER/LOWER EXTREMITY INITIAL EACH 15 MINS $ 126.00 42000043 HC ELECTRICAL STIMULATION NON-WOUND CARE $ 70.00 42000044 HC BWC WORK CONDITIONING PER 15 MIN BY PT $ 69.00 42000045 HC PHYSICAL PERFORMANCE TEST W/ REPORT EACH 15 MINS $ 127.00 42000048 HC CANALITH REPOSITIONING PER DAY $ 156.00 42000049 HC PT MOBILITY WALKING & MOVING AROUND CURRENT STATUS $ 0.01 42000050 HC PT MOBILITY WALKING & MOVING AROUND PROJECTED GOAL STATUS $ 0.01 42000051 HC PT MOBILITY WALKING & MOVING AROUND DISCHARGE STATUS $ 0.01 42000052 HC PT CHANGING & MAINTAINING BODY POSITION CURRENT STATUS $ 0.01 42000053 HC PT CHANGING & MAINTAINING BODY POSITION PROJECTED GOAL STATUS $ 0.01 42000054 HC PT CHANGING & MAINTAINING BODY POSITION DISCHARGE STATUS $ 0.01 42000055 HC PT CARRYING MOVING & HANDLING OBJECTS CURRENT STATUS $ 0.01 42000056 HC PT CARRYING MOVING & HANDLING OBJECTS PROJECTED GOAL STATUS $ 0.01 42000057 HC PT CARRYING MOVING & HANDLING OBJECTS DISCHARGE STATUS $ 0.01 42000058 HC PT SELF CARE CURRENT STATUS $ 0.01 42000059 HC PT SELF CARE PROJECTED GOAL STATUS $ 0.01 42000061 HC PT OTHER PHYSICAL OR OCCUPATIONAL PRIMARY CURRENT STATUS $ 0.01 42000062 HC PT OTHER PHYSICAL OR OCCUPATIONAL PRIMARY PROJECTED GOAL STATUS $ 0. 01 42000063 HC PT OTHER PHYSICAL OR OCCUPATIONAL PRIMARY DISCHARGE STATUS $ 0.01 42000069 HC CCH CONTINUOUS PASSIVE MOTION ADJUST EACH 15 MINS $ 110.00 42000073 HC CCH DEBRIDEMENT WOUND SELECTIVE 1ST 20 SQ CM BY PT $ 351.00 42000079 HC CCH BWC WORK SITE THERAPY BY PT EACH 15 MINS $ 91.00 42000081 HC CCH BWC FUNCTIONAL JOB ANALYSIS BY PT $ 91.00 42000082 HC CCH MANUAL THERAPY TECHNIQUES W/ ASTYM EACH 15 MINS $ 174.00 42000084 HC CCH PT PATIENT EDUCATION & TRAINING $ 93.00 42000085 HC CCH ELECTRIC STIMULATION THERAPY 1+ AREAS BY PT $ 30.00 42000086 HC CCH DRY NEEDLING $ 103.00 42000087 HC CCH PT VISIT/PROCEDURE $ 70.00 42000087 HC CCH PT VISIT/PROCEDURE $ 74.00 42000087 HC CCH PT VISIT/PROCEDURE $ 65.00 42000087 HC CCH PT VISIT/PROCEDURE $ 78.00 42000087 HC CCH PT VISIT/PROCEDURE $ 85.00 42000087 HC CCH PT VISIT/PROCEDURE $ 75.00 42000087 HC CCH PT VISIT/PROCEDURE $ 80.00 42000087 HC CCH PT VISIT/PROCEDURE $ 60.00 42000088 HC CCH PTA VISIT $ 70.00 42000089 HC CCH PT VISIT/MEDICARE $ 80.00 42000090 HC CCH PT VISIT/MEDICAID $ 65.00 42000090 HC CCH PT VISIT/MEDICAID $ 60.00 42000091 HC CCH PT VISIT/AET/CSI $ 68.00 42000092 HC CCH CASTING $ 87.00 42400002 HC PT RE-EVALUATION $ 105.00 42400005 HC PT EVALUATION LOW COMPLEXITY $ 248.00

02-19-2019-A-PAC-057 Page 29 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 42400006 HC PT EVALUATION MODERATE COMPLEXITY $ 305.00 42400007 HC PT EVALUATION HIGH COMPLEXITY $ 363.00 43000006 HC PARAFFIN BATH BY OT $ 85.00 43000007 HC WHIRLPOOL BY OT $ 129.00 43000008 HC ELECTRICAL STIMULATION EACH 15 MINS BY OT $ 125.00 43000009 HC IONTOPHORESIS EACH 15 MINS BY OT $ 183.00 43000010 HC ULTRASOUND EACH 15 MINS BY OT $ 132.00 43000011 HC THERAPEUTIC EXERCISES ROM & FLEXIBILITY EACH 15 MINS BY OT $ 110.00 43000012 HC NEUROMUSCULAR REEDUCATION EACH 15 MINS BY OT $ 108.00 43000014 HC MANUAL THERAPY TECHNIQUES EACH 15 MINS BY OT $ 174.00 43000015 HC SENSORY INTEGRATIVE TECHNIQUES DIRECT EACH 15 MINS BY OT $ 113.00 43000019 HC ORTHOTIC MGMT & TRAINING INITIAL EACH 15 MINS BY OT $ 123.00 43000022 HC ELECTRICAL STIMULATION NON-WOUND CARE BY OT $ 70.00 43000023 HC THERAPEUTIC ACTIVITIES DIRECT- EACH 15 MINUTES BY OT $ 102.00 43000024 HC COGNITIVE SKILLS DEV DIRECT EACH 15 MINS BY OT $ 76.00 43000026 HC SELF CARE/HOME MGMT DIRECT EACH 15 MINS BY OT $ 77.00 43000027 HC COMMUNITY/WORK REINTEGRATION DIRECT EACH 15 MINS BY OT $ 96.00 43000029 HC VASOPNEUMATIC DEVICES BY OT $ 110.00 43000030 HC MASSAGE EACH 15 MINS BY OT $ 125.00 43000037 HC OT MOBILITY WALKING & MOVING AROUND CURRENT STATUS $ 0.01 43000038 HC OT MOBILITY WALKING & MOVING AROUND PROJECTED GOAL STATUS $ 0.01 43000039 HC OT MOBILITY WALKING & MOVING AROUND DISCHARGE STATUS $ 0.01 43000043 HC OT CARRYING MOVING & HANDLING OBJECTS CURRENT STATUS $ 0.01 43000044 HC OT CARRYING MOVING & HANDLING OBJECTS PROJECTED GOAL STATUS $ 0.01 43000045 HC OT CARRYING MOVING & HANDLING OBJECTS DISCHARGE STATUS $ 0.01 43000046 HC OT SELF CARE CURRENT STATUS $ 0.01 43000047 HC OT SELF CARE PROJECTED GOAL STATUS $ 0.01 43000048 HC OT SELF CARE DISCHARGE STATUS $ 0.01 43000049 HC OT OTHER PHYSICAL OR OCCUPATIONAL PRIMARY CURRENT STATUS $ 0.01 43000050 HC OT OTHER PHYSICAL OR OCCUPATIONAL PRIMARY PROJECTED GOAL STATUS $ 0.01 43000051 HC OT OTHER PHYSICAL OR OCCUPATIONAL PRIMARY DISCHARGE STATUS $ 0.01 43000070 HC CCH DEBRIDEMENT WOUND SELECTIVE 1ST 20 SQ CM BY OT $ 351.00 43000083 HC CCH DEBRIDEMENT WOUND SELECTIVE EA ADDL 20 SQ CM $ 351.00 43000084 HC CCH OT VISIT/PROCEDURE $ 70.00 43000084 HC CCH OT VISIT/PROCEDURE $ 78.00 43000084 HC CCH OT VISIT/PROCEDURE $ 74.00 43000084 HC CCH OT VISIT/PROCEDURE $ 65.00 43000084 HC CCH OT VISIT/PROCEDURE $ 85.00 43000084 HC CCH OT VISIT/PROCEDURE $ 75.00 43000084 HC CCH OT VISIT/PROCEDURE $ 80.00 43000084 HC CCH OT VISIT/PROCEDURE $ 60.00 43000085 HC CCH OTA VISIT $ 70.00 43000086 HC CCH OT VISIT/MEDICARE $ 80.00 43000087 HC CCH OT VISIT/MEDICAID $ 65.00 43000087 HC CCH OT VISIT/MEDICAID $ 60.00 43000088 HC CCH OT VISIT/AET/CSI $ 68. 00 43400005 HC OT RE-EVALUATION $ 105.00 43400007 HC OT EVALUATION LOW COMPLEXITY $ 248.00 43400008 HC OT EVALUATION MODERATE COMPLEXITY $ 305.00 43400008 HC OT EVALUATION MODERATE COMPLEXITY $ 85.00 43400009 HC OT EVALUATION HIGH COMPLEXITY $ 363.00 44000002 HC SPEECH THERAPY GROUP $ 101.00 44000003 HC SWALLOWING DYSFUNCTION TREATMENT $ 254.00 44000004 HC PURE TONE HEARING SCREENING $ 36.00 44000011 HC DEVELOPMENT COGNITIVE SKILLS DIRECT EACH 15 MINS BY ST $ 76.00 44000013 HC SLP SWALLOWING CURRENT STATUS $ 0.01 44000014 HC SLP SWALLOWING PROJECTED GOAL STATUS $ 0.01 44000015 HC SLP SWALLOWING DISCHARGE STATUS $ 0.01 44000016 HC SLP MOTOR SPEECH CURRENT STATUS $ 0.01 44000017 HC SLP MOTOR SPEECH PROJECTED GOAL STATUS $ 0.01 44000020 HC SLP SPOKEN LANGUAGE COMPREHENSION PROJECTED GOAL STATUS $ 0.01 44000022 HC SLP SPOKEN LANGUAGE EXPRESSION CURRENT STATUS $ 0.01 44000023 HC SLP SPOKEN LANGUAGE EXPRESSION PROJECTED GOAL STATUS $ 0.01 44000024 HC SLP SPOKEN LANGUAGE EXPRESSION DISCHARGE STATUS $ 0.01 44000031 HC SLP VOICE CURRENT STATUS $ 0.01 44000032 HC SLP VOICE PROJECTED GOAL STATUS $ 0.01 44000033 HC SLP VOICE DISCHARGE STATUS $ 0.01 44000037 HC COGNITIVE TEST PER HOUR BY ST $ 217.00 44000038 HC CCH SPEECH THERAPY/LANGUAGE DEVELOPMENT EDUC INDIV $ 191.00 44000041 HC CCH SPEECH/AUDIOLOGIC THERAPY PATIENT EDUCATION & TRAINING $ 112.00 44000042 HC CCH ELECTRICAL STIMULATION EACH 15 MINS BY SP $ 135.00

02-19-2019-A-PAC-057 Page 30 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 44000043 HC CCH LARYNGOSCOPY W/ STROBOSCOPY BY SP $ 402.00 44000044 HC CCH ST VISIT $ 85.00 44000044 HC CCH ST VISIT $ 70.00 44000044 HC CCH ST VISIT $ 90.00 44000045 HC CCH SPEECH/AUDIOLOGIC DEVELOPMENTAL TESTING INTERPRETATION & REPORT FIRST HOUR $ 599.00 44000047 HC CCH ST VISIT/MEDICAID $ 60.00 44000049 HC CCH SPEECH/AUDIOLOGIC DEVELOPMENTAL TESTING INTERPRETATION & REPORT EA ADDL 30 MIN $ 299.00 44400004 HC SWALLOWING EVALUATION $ 454.00 44400005 HC MOTION FLUOROSCOPIC SWALLOWING EVALUATION $ 403.00 44400006 HC APHASIA ASSESSMENT PER HOUR $ 399.00 44400007 HC EVALUATION FOR USE/FIT OF VOICE PROSTHETIC DEVICE $ 403.00 44400008 HC EVALUATION RX FOR SPEECH DEVICE FIRST HOUR $ 393.00 44400010 HC ENDOSCOPIC SWALLOWING EVALUATION $ 403.00 44400011 HC SPEECH EVALUATION FLUENCY $ 400.00 44400012 HC SPEECH EVALUATION SOUND PRODUCTION $ 400.00 44400013 HC SPEECH EVALUATION SOUND PRODUCTION W/ LANGUAGE COMPREHENSION AND EXPRESSION $ 400.00 44400014 HC BEHAVIORAL AND QUALITATIVE ANALYSIS OF VOICE AND RESONANCE $ 400.00 44400020 HC CCH ENDOSCOPIC SWALLOWING EVALUATION INTERPRETATION AND REPORT $ 37.50 45000001 HC EMERGENCY ROOM LEVEL 1 $ 193.00 45000002 HC EMERGENCY ROOM LEVEL 2 $ 336.00 45000003 HC EMERGENCY ROOM LEVEL 3 $ 477.00 45000004 HC EMERGENCY ROOM LEVEL 4 $ 764.00 45000005 HC EMERGENCY ROOM LEVEL 5 $ 1,139.00 45000006 HC EMERGENCY ROOM CRITICAL CARE $ 1,667.00 45000007 HC SANE COLLECTION $ 447.00 45000014 HC CCH EMERGENCY ROOM PROCEDURE LEVEL 1 $ 156.00 45000015 HC CCH EMERGENCY ROOM PROCEDURE LEVEL 2 $ 321.00 45000016 HC CCH EMERGENCY ROOM PROCEDURE LEVEL 3 $ 416.00 45000017 HC CCH EMERGENCY ROOM PROCEDURE LEVEL 4 $ 684.00 45000018 HC CCH EMERGENCY ROOM CRITICAL CARE EA ADDL 30 MINUTES $ 634.00 46000001 HC SPIROMETRY VITAL CAPACITY W/ OR W/O MAXIMAL VOLUNTARY VENTILATION $ 479.00 46000001 HC SPIROMETRY VITAL CAPACITY W/ OR W/O MAXIMAL VOLUNTARY VENTILATION $ 93.00 46000002 HC BRONCHODILATION RESPONSE PRE & POST BRONCHODILATOR ADMIN $ 888.00 46000012 HC PULMONARY STRESS TEST (6 MIN WALK) $ 319.00 46000021 HC PULSE OXIMETRY FOR O2 SAT SINGLE $ 30.00 46000022 HC PULSE OXIMETRY FOR O2 SAT MULTIPLE $ 50.00 46000023 HC PULSE OXIMETRY FOR O2 SAT CONTINUOUS $ 182.00 46000024 HC CARBON DIOXIDE DETERMINATION BY INFRARED $ 30.00 46000029 HC PULMONARY FUNCTION TEST PLETHYSMOGRAPHY $ 181.00 46000030 HC PULMONARY FUNCTION TEST BY GAS $ 326.00 46000031 HC PULMONARY FUNCTION TEST OSCILLOMETRY $ 19.00 46000032 HC DIFFUSING CAPACITY $ 181.00 46000033 HC CAR SEAT/BED TESTING INFANT TO 1 YR 60 MIN $ 131.00 46000034 HC CAR SEAT/BED TESTING INFANT TO 1 YR EA ADDL 30 MIN $ 59.00 46000036 HC CCH ATTENDANCE AT DELIVERY $ 276.00 47100001 HC AUDITORY EVOKED RESPONSE COMPREHENSIVE $ 678. 00 47100002 HC AUDITORY EVOKED RESPONSE LIMITED $ 299.00 47100003 HC EVOKED OTOACOUSTIC EMISSIONS LIMITED $ 198.00 47100004 HC TYMPANOMETRY & REFLEX THRESHOLD MEASUREMENTS $ 172.00 47100005 HC PURE TONE AUDIOMETRY AIR ONLY $ 98.00 47100006 HC PURE TONE AUDIOMETRY AIR & BONE $ 194.00 47100007 HC SPEECH AUDIOMETRY THRESHOLD $ 143.00 47100009 HC AUDIOMETRY THRESHOLD EVAL W/ SPEECH RECOGNITION $ 218.00 47100010 HC TYMPANOMETRY IMPEDANCE TESTING $ 135.00 47100010 HC TYMPANOMETRY IMPEDANCE TESTING $ 23.00 47100011 HC ACOUSTIC IMMITTANCE TEST W/ TYMPANOMETRY/ACOUSTIC REFLEX/DECAY $ 217.00 47100018 HC CCH EVOKED OTOACOUSTIC EMISSIONS SCREENING AUTOMATED ANALYSIS $ 217.00 47100019 HC CCH HEARING AID CHECK MONAURAL $ 95.00 47100019 HC CCH HEARING AID CHECK MONAURAL $ 85.00 47100020 HC CCH PURE TONE HEARING SCREENING $ 124.00 48000001 HC CPR $ 782.00 48000002 HC CARDIOVERSION ELECTIVE $ 1,488.00 48000005 HC PACEMAKER SINGLE LEAD PROGRAMMING & ADJUSTMENT $ 132.00 48000006 HC PACEMAKER DUAL LEAD PROGRAMMING & ADJUSTMENT $ 156.00 48000006 HC PACEMAKER DUAL LEAD PROGRAMMING & ADJUSTMENT $ 95.00 48000007 HC PACEMAKER MULTI LEAD PROGRAMMING & ADJUSTMENT $ 146.00 48000008 HC ICD SINGLE LEAD PROGRAMMING & ADJUSTMENT $ 161.00 48000009 HC ICD DUAL LEAD PROGRAMMING & ADJUSTMENT $ 183.00 48000010 HC ICD MULTI LEAD PROGRAMMING & ADJUSTMENT $ 188.00 48000011 HC ILR PROGRAMMING & ADJUSTMENT $ 120.00 48000012 HC PACEMAKER EVALUATION PRE/POST-OP $ 167.00

02-19-2019-A-PAC-057 Page 31 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 48000013 HC ICD EVALUATION PROGRAMMING PRE/POST-OP $ 204.00 48000014 HC PACEMAKER INTERROGATION IN-PERSON $ 130.00 48000015 HC ICD INTERROGATION $ 172.00 48000016 HC ICM INTERROGATION $ 90.00 48000017 HC ILR INTERROGATION $ 110.00 48000018 HC WEARABLE DEFIBRILLATOR SYSTEM INTERROGATION $ 201.00 48000019 HC PACEMAKER EVALUATION TRANSTELEPHONIC UP TO 90 DAYS $ 162.00 48000020 HC PACEMAKER OR ICD INTERROGATION REMOTE UP TO 90 DAYS $ 155.00 48000021 HC ICM OR ILR INTERROGATION REMOTE UP TO 30 DAYS $ 168.00 48000031 HC BUNDLE OF HIS RECORDING $ 3,942.00 48000032 HC INTRA-ATRIAL RECORDING $ 3,845.00 48000033 HC RIGHT VENTRICULAR RECORDING $ 3,344.00 48000034 HC MULTIPLE SITE TACHYCARDIA MAPPING $ 5,224.00 48000035 HC INTRA-ATRIAL PACING $ 4,173.00 48000036 HC INTRAVENTRICULAR PACING $ 3,099.00 48000037 HC INTRACARDIAC EP 3D MAPPING $ 7,785.00 48000038 HC ATRIAL ELECTROGRAM ESOPHAGEAL RECORDING $ 1,198.00 48000040 HC ARRHYTHMIA INDUCTION BY ELECTRICAL PACING $ 3,583.00 48000041 HC EP EVALUATION COMPREHENSIVE W/O INDUCTION RA & RV $ 9,755.00 48000042 HC EP EVALUATION COMPREHENSIVE W/ INDUCTION RA & RV $ 11,482.00 48000043 HC EP EVALUATION COMPREHENSIVE W/ INDUCTION LA $ 7,478.00 48000044 HC EP EVALUATION COMPREHENSIVE W/ INDUCTION LV $ 7,680.00 48000045 HC PACING AFTER IV DRUG INFUSION $ 7,680.00 48000046 HC EP THERAPY EFFECTIVENESS STUDY W/ INDUCTION $ 8,041.00 48000047 HC ICD LEAD EVALUATION AT IMPLANT OR REPLACEMENT $ 2,542.00 48000048 HC ICD LEAD & GENERATOR EVALUATION AT IMPLANT OR REPLACEMENT $ 2,938.00 48000049 HC ICD LEAD EVALUATION $ 3,101.00 48000053 HC TILT TABLE EVALUATION $ 1,737.00 48000054 HC ECHO INTRACARDIAC $ 4,757.00 48000056 HC ANTITACHYCARDIA PACEMAKER ANALYSIS $ 749.00 48000066 HC INSERT SUBQ DEFIBRILLATOR ELECTRODE $ 9,423.00 48000071 HC REPOSITIONING SUBQ IMPLANTABLE DEFIB ELECTRODE $ 6,254.00 48000072 HC EVALUATION INTERROGATION DEVICE IMPLANTABLE SUBQ $ 158.00 48000073 HC PROGRAMMING DEVICE EVALUATION SUBQ LEAD DEFIBRILLAROR SYSTEM $ 142.00 48000080 HC INSERT/REPLACE SUBQ IMPLANTABLE DEFIBRILLATOR SYSTEM W/ INSERTION SUBQ ELECTRODE $ 37,299.00 48000084 HC CCH CARDIOVERSION ELECTIVE INTERNAL $ 1,416.00 48100001 HC CORONARY THROMBECTOMY PERCUTANEOUS MECHANICAL $ 7,910.00 48100003 HC ENDOLUMINAL OPTICAL COHERENCE TOMOGRAPHY/IVUS INITIAL VESSEL $ 4,566.00 48100004 HC ENDOLUMINAL OPTICAL COHERENCE TOMOGRAPHY/IVUS EA ADDL VESSEL $ 2,665.00 48100038 HC IV CORONARY DOPPLER INITIAL VESSEL $ 3,330.00 48100039 HC IV CORONARY DOPPLER EACH ADDL VESSEL $ 1,769.00 48100044 HC LHC W/ LV & CORONARY ANGIO $ 13,140.00 48100045 HC LHC W/ LV $ 8,241.00 48100046 HC LHC W/ LV & CORONARY & BYPASS GRAFT ANGIO $ 14,429.00 48100047 HC INJ DURING HEART CATH FOR SUPRAVALVULAR AORTOGRAPHY $ 1,301.00 48100048 HC RHC $ 8,241.00 48100049 HC RHC W/ CORONARY ANGIO $ 12,690.00 48100050 HC RHC W/ CORONARY & BYPASS GRAFT ANGIO $ 13,420.00 48100051 HC RHC & LHC W/ LV $ 12,888.00 48100052 HC RHC & LHC W/ LV & CORONARY ANGIO $ 14,672.00 48100053 HC RHC & LHC W/ LV & CORONARY & BYPASS ANGIO $ 15,851.00 48100054 HC CORONARY ARTERY ANGIO $ 10,077.00 48100055 HC CORONARY & BYPASS GRAFT ANGIO $ 11,134.00 48100062 HC INJ DURING HEART CATH FOR RV OR RA ANGIO $ 1,848.00 48100063 HC INJ DURING HEART CATH FOR PULMONARY ANGIO $ 1,702.00 48100064 HC ANGIOPLASTY ILIAC ARTERY INITIAL VESSEL $ 7,218.00 48100065 HC INSERTION STENT ILIAC ARTERY INITIAL VESSEL $ 7,218.00 48100066 HC ANGIOPLAST ILIAC ARTERY EACH ADDL VESSEL $ 5,965.00 48100067 HC INSERTION STENT ILIAC ARTERY EACH ADDL VESSEL $ 5,965.00 48100068 HC ANGIOPLASTY FEM/POP ARTERY EACH VESSEL $ 7,218.00 48100069 HC ATHERECTOMY FEM/POP ARTERY EACH VESSEL $ 11,411.00 48100070 HC INSERTION STENT FEM/POP ARTERY EACH VESSEL $ 15,957.00 48100071 HC ATHERECTOMY & STENT INSERTION FEM/POP ARTERY EACH VESSEL $ 15,196.00 48100072 HC ANGIOPLASTY TIBIAL/PERONEAL ARTERY INITIAL VESSEL $ 5,965.00 48100073 HC ATHERECTOMY TIBIAL/PERONEAL ARTERY INITIAL VESSEL $ 15,957.00 48100075 HC ATHERECTOMY & STENT INSERTION TIBIAL/PERONEAL ARTERY INITIAL VESSEL $ 15,196.00 48100076 HC ANGIOPLASTY TIBIAL/PERONEAL ARTERY EACH ADDL VESSEL $ 6,595.00 48100078 HC INSERTION STENT TIBIAL/PERONEAL ARTERY EACH ADDL VESSEL $ 6,339.00 48100092 HC PTCA SINGLE MAJOR ARTERY/BRANCH $ 14,590.00 48100093 HC PTCA EACH ADDL MAJOR ARTERY/BRANCH $ 11,435.00 48100094 HC ATHERECTOMY W/ OR W/O ANGIOPLASTY SINGLE MAJOR ARTERY/BRANCH $ 23,218.00

02-19-2019-A-PAC-057 Page 32 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 48100095 HC ATHERECTOMY W/ OR W/O ANGIOPLASTY EACH ADDL BRANCH OF MAJOR ARTERY $ 17,430.00 48100096 HC INSERTION NON-DES W/ OR W/O ANGIOPLASTY SINGLE MAJOR ARTERY/BRANCH $ 20,503.00 48100097 HC INSERTION NON-DES W/ OR W/O ANGIOPLASTY EACH ADDL BRANCH MAJOR ARTERY $ 16,510.00 48100098 HC INSERTION NON-DES W/ATHERECTOMY W/ OR W/O ANGIOPLASTY SINGLE MAJOR ARTERY/BRANCH $ 23,324.00 48100099 HC INSERTION NON-DES W/ ATHERECTOMY W/ OR W/O ANGIOPLASTY EACH ADDL BRANCH MAJOR ARTERY $ 12,993.00 48100100 HC REVASCULARIZE CABG W/ OR W/O NON-DES ATHERECTOMY ANGIOPLASTY DISTAL PROTECT SGL VESSEL $ 21,312.00 48100101 HC REVASCULARIZE CABG W/ OR W/O NON-DES ATHERECTOMY ANGIOPLASTY DISTAL PROTECT EA ADDL BRANCH CABG $ 17,583.00 48100102 HC REVASCULARIZE ACUTE OCCL DURING AMI W/ OR W/O NON-DES ATHERECTOMY ANGIOPLASTY ASP THROMB SGL VES $ 20,567.00 48100103 HC REVASCULARIZE CHRONIC TOTAL OCCL W/ OR W/O NON-DES ATHERECTOMY ANGIOPLASTY SGL VES $ 21,850.00 48100104 HC REVASCULARIZE CHRONIC TOTAL OCCL W/ OR W/O NON-DES ATHERECTOMY ANGIOPLASTY EA ADDL VESSEL $ 17,752.00 48100109 HC INSERTION DES W/ OR W/O ANGIOPLASTY SINGLE MAJOR ARTERY/BRANCH $ 23,942.00 48100110 HC INSERTION DES W/ OR W/O ANGIOPLASTY EACH ADDL BRANCH MAJOR ARTERY $ 19,876.00 48100111 HC INSERTION DES W/ ATHERECTOMY W/ OR W/O ANGIOPLASTY SINGLE MAJOR ARTERY/BRANCH $ 26,279.00 48100112 HC INSERTION DES W/ ATHERECTOMY W/ OR W/O ANGIOPLASTY EACH ADDL BRANCH MAJOR ARTERY $ 21,084.00 48100113 HC REVASCULARIZE CABG W/ OR W/O DES ATHERECTOMY ANGIOPLASTY DISTAL PROTECT SGL VESSEL $ 24,318.00 48100114 HC REVASCULARIZE CABG W/ OR W/O DES ATHERECTOMY ANGIOPLASTY DISTAL PROTECT EA ADDL BRANCH CABG $ 19,490.00 48100115 HC REVASCULARIZE ACUTE OCCL DURING AMI W/ OR W/O DES ATHERECTOMY ANGIOPLASTY ASP THROMB SGL VES $ 26,245.00 48100116 HC REVASCULARIZE CHRONIC TOTAL OCCL W/ OR W/O DES ATHERECTOMY ANGIOPLASTY SGL VES $ 25,493.00 48100117 HC REVASCULARIZE CHRONIC TOTAL OCCL W/ OR W/O DES ATHERECTOMY ANGIOPLASTY EA ADDL VESSEL $ 20,483.00 48100119 HC EVALUATION SUBQ IMPLANTABLE DEFIBRILLATOR $ 2,861.00 48100125 HC INSERTION VAD PERCUTANEOUS W/RAD S&I ARTERIAL ONLY $ 8,107.00 48100135 HC INTRACORONARY INFUSION ALLOGENEIC CARDIOSPHERE-DERIVED CELLS $ 1,608.00 48100147 HC REMOVAL IABP PERCUTANEOUS $ 3,829.00 48100152 HC CORONARY THROMBECTOMY PERC ASPIRATION STAND ALONE $ 12,423.00 48100166 HC CCH INSERTION IAB ASSIST DEVICE VIA FEMORAL ARTERY OPEN $ 3,829.00 48100167 HC CCH REMOVAL IAB ASSIST DEVICE INCL REPAIR FEMORAL ARTERY $ 3,829.00 48100168 HC CCH INSERTION IAB ASSIST DEVICE VIA ASCENDING AORTA $ 3,829.00 48100169 HC CCH REMOVAL IAB ASSIST DEVICE INCL REPAIR ASCENDING AORTA $ 3,829.00 48200001 HC STRESS TEST W/ CONTINUOUS EKG MONITORING $ 1,057.00 48200002 HC CCH MINI STRESS TEST $ 1,110.00 48300001 HC ECHO COMPLETE CONGENITAL ANOMALIES W/O CONTRAST $ 1,651.00 48300002 HC ECHO F/U OR LTD CONGENITAL ANOMALIES W/O CONTRAST $ 1,035.00 48300003 HC ECHO COMPLETE W/ DOPPLER W/O CONTRAST $ 1,437.00 48300004 HC ECHO COMPLETE W/ BUBBLE STUDY $ 1,510.00 48300007 HC CONTRAST ADMIN FOR STRESS ECHO $ 307.00 48300010 HC ECHO F/U OR LTD W/ CONTRAST $ 537.00 48300013 HC ECHO COMPLETE W/ DOPPLER W/ CONTRAST $ 1,702.00 48300016 HC ECHO DOPPLER LIMITED OR FOLLOW-UP $ 287.00 48300017 HC ECHO M-MODE COMPLETE W/O CONTRAST $ 810.00 48300018 HC ECHO M-MODE FOLLOW-UP OR LIMITED $ 564.00 48300019 HC ECHO STRESS $ 2,355.00 48300020 HC TEE COMPLETE $ 2,432.00 48300024 HC TTE W OR W/O CONTR CONT ECG $ 2,183.00 49000003 HC REMOVAL FB SUBCUTANEOUS SIMPLE $ 95.00 49000006 HC PUNCTURE ASPIRATION ABSCESS HEMATOMA OR CYST $ 286.00 49000024 HC DRESSING/DEBRIDEMENT PARTIAL THICKNESS BURN < 5% TBSA $ 351. 00 49000028 HC PUNCTURE ASPIRATION BREAST CYST $ 259.00 49000037 HC BX BONE TROCAR/NEEDLE SUPERFICIAL $ 476.00 49000051 HC INJECTION FOR SHOULDER ARTHROGRAPHY $ 85.00 49000053 HC INJECTION FOR WRIST ARTHROGRAPHY $ 81.00 49000060 HC BRONCHOSCOPY DIAGNOSTIC $ 5,600.00 49000061 HC BRONCHOSCOPY W/ BRUSHINGS $ 5,600.00 49000061 HC BRONCHOSCOPY W/ BRUSHINGS $ 532.50 49000062 HC BRONCHOSCOPY W/ BAL $ 5,600.00 49000063 HC BRONCHOSCOPY W/ BRONCH OR ENDOBRONCHIAL BX $ 5,600.00 49000064 HC BRONCHOSCOPY W/ TRANSBRONCH LUNG BX SINGLE LOBE $ 10,722.00 49000065 HC BRONCH W/ TRANSBRONCH NEEDLE ASP TRACHEA/MAIN STEM/LOBAR BRONCHUS $ 10,722.00 49000066 HC BRONCHOSCOPY W/ DILATION OR CLOSED REDUCTION FX $ 10,722.00 49000067 HC BRONCHOSCOPY W/ INSERTION TRACHEAL STENT $ 10,723.00 49000068 HC BRONCHOSCOPY W/ TRANSBRONCH LUNG BX EACH ADDL LOBE $ 10,723.00 49000069 HC BRONCHOSCOPY W/ TRANSBRONCH NEEDLE ASP EACH ADDL LOBE $ 10,723.00 49000070 HC BRONCHOSCOPY W/ REMOVAL FB $ 5,600.00 49000071 HC BRONCHOSCOPY W/ PLACEMENT BRONCHIAL STENT INITIAL BRONCHUS $ 5,600.00 49000073 HC BRONCHOSCOPY W/ REVISION STENT $ 5,600.00 49000074 HC BRONCHOSCOPY W/ DESTRUCTION TUMOR OR RELIEF STENOSIS $ 10,722.00 49000075 HC BRONCHOSCOPY W/ CATH PLACEMENT FOR RADIOTHERAPY $ 5,600.00 49000076 HC BRONCHOSCOPY W/ ASP TRACHEOBRONCHIAL TREE INITIAL $ 5,600.00 49000077 HC BRONCHOSCOPY W/ASP TRACHEOBRONCHIAL TREE SUBSEQUENT SAME STAY $ 5,601.00 49000080 HC BX LUNG MEDIASTINUM PERCUTANEOUS NEEDLE $ 1,160.00 49000086 HC PERICARDIOCENTESIS INITIAL $ 1,410.00 49000087 HC PERICARDIOCENTESIS SUBSEQUENT $ 1,410.00

02-19-2019-A-PAC-057 Page 33 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 49000088 HC INSERT/REPLACE PM W/ TRANSVENOUS ELECTRODE ATRIAL $ 13,090.00 49000089 HC INSERT/REPLACE PM W/ TRANSVENOUS ELECTRODE VENTRICLE $ 13,449.00 49000090 HC INSERT/REPLACE PM W/ TRANSVENOUS ELECTRODE ATRIAL & VENTRICLE $ 15,549.00 49000091 HC INSERT/REPLACE TEMP SINGLE CHAMBER TRANSVENOUS ELECTRODE $ 7,798.00 49000092 HC INSERT/REPLACE TEMP DUAL CHAMBER TRANSVENOUS ELECTRODE $ 8,590.00 49000093 HC INSERT PM GENERATOR ONLY W/ EXISTING SINGLE LEAD $ 11,105.00 49000094 HC INSERT PM GENERATOR ONLY W/ EXISTING DUAL LEADS $ 12,299.00 49000095 HC UPGRADE SINGLE TO DUAL PM $ 16,699.00 49000096 HC REPOSITION TRANSVENOUS PM OR ICD ELECTRODE $ 5,272.00 49000097 HC INSERT SINGLE TRANSVENOUS ELECTRODE PM OR ICD $ 8,481.00 49000098 HC INSERT 2 TRANSVENOUS ELECTRODE PM OR ICD $ 9,151.00 49000101 HC RELOCATION SKIN POCKET PM $ 4,354.00 49000102 HC RELOCATION SKIN POCKET ICD $ 4,245.00 49000103 HC INSERT LEFT VENT PACING ELECTRODE PREVIOUSLY IMPLANTED PM OR ICD $ 14,601.00 49000104 HC INSERT LEFT VENT PACING ELECTRODE DURING IMPLANT OF PM OR ICD $ 14,721.00 49000105 HC REPOSITION PREVIOUSLY IMPLANTED CARDIAC VENOUS SYSTEM ELECTRODE $ 5,250.00 49000106 HC REMOVAL PM PULSE GENERATOR $ 5,292.00 49000110 HC INSERT ICD GENERATOR W/ EXISTING SINGLE LEAD $ 18,937.00 49000111 HC REMOVAL ICD GENERATOR ONLY $ 5,396.00 49000113 HC INSERT/REPLACE SINGLE OR DUAL ICD LEADS & GENERATOR $ 33,525.00 49000117 HC IMPLANT SUBCUTANEOUS CARDIAC RHYTHM MONITOR $ 8,892.00 49000118 HC REMOVAL SUBCUTANEOUS CARDIAC RHYTHM MONITOR $ 2,766.00 49000119 HC INSERTION IABP PERCUTANEOUS $ 3,829.00 49000128 HC DELIVERY ENDOVASCULAR PROSTHESIS OPEN FEMORAL UNILATERAL $ 13,451.00 49000129 HC PLACEMENT FEM-FEM GRAFT DURING ENDO AAA REPAIR $ 249.00 49000151 HC INTRODUCTION NEEDLE OR INTRACATHETER VEIN $ 210.00 49000152 HC INJECTION FOR EXTREMITY PSEUDOANEURYSM $ 301.00 49000162 HC INTRODUCTION NEEDLE OR INTRACATHETER EXTREMITY ARTERY $ 315.00 49000164 HC INTRODUCTION NEEDLE OR INTRACATHETER AORTA $ 315.00 49000165 HC CATH PLACE ARTERY EACH 1ST ORDER THORACIC/BRACHIOCEPHALIC BRCH $ 315.00 49000169 HC CATH PLACE ARTERY EACH 1ST ORDER ABD/PELVIC/LE BRCH $ 315.00 49000170 HC CATH PLACE ARTERY INITIAL 2ND ORDER ABD/PELVIC/LE BRCH $ 440.00 49000171 HC CATH PLACE ARTERY INITIAL 3RD ORDER+ ABD/PELVIC/LE BRCH $ 503.00 49000181 HC INSERTION TUNNELED CVC W/O PORT/PUMP >5 YEARS OLD $ 3,258.00 49000182 HC INSERTION TUNNELED CENTRAL VAD W/ PORT >5 YEARS OLD $ 2,512.00 49000186 HC INSERTION PICC W/O PUMP/PORT > 5 YEARS OLD $ 2,625.00 49000194 HC REPLACE PICC W/O PUMP/PORT $ 630.00 49000202 HC ARTERIAL CATHETERIZATION PERCUTANEOUS $ 596.00 49000221 HC TRANSCATH PLACE INTRAVASC STENT CERV/CAROTID W/ EMBOLIC PROTECTION $ 12,324.00 49000238 HC BX LYMPH NODE NEEDLE SUPERFICIAL $ 1,605.00 49000252 HC BX LIVER NEEDLE PERCUTANEOUS $ 559.00 49000299 HC BX RENAL PERCUTANEOUS $ 891.00 49000320 HC INJECTION CYSTOGRAPHY/VOIDING URETHROCYSTOGRAPHY $ 88.00 49000321 HC INJECTION RETROGRADE URETHROCYSTOGRAPHY $ 216.00 49000322 HC CYSTOURETHROSCOPY $ 365.00 49000322 HC CYSTOURETHROSCOPY $ 368. 00 49000329 HC CYSTOURETHROSCOPY W/ REMOVAL FB/CALCULUS/STENT SIMPLE $ 618.00 49000347 HC ELECTRODESICCATION LESION PENIS SIMPLE $ 233.00 49000358 HC HYSTEROSALPINGOGRAPHY OR SALINE INFUSION SONOHYSTEROGRAOPHY $ 84.00 49000366 HC BX THYROID PERCUTANEOUS NEEDLE CORE $ 996.00 49000375 HC LUMBAR PUNCTURE DIAGNOSTIC $ 392.00 49000376 HC INJECTION/EPIDURAL BLOOD/CLOT PATCH $ 1,423.00 49000377 HC INJECTION MYELOGRAPHY AND/OR CT LUMBAR $ 97.00 49000389 HC DESTRUCTION NEUROLYTIC AGENT OTHER PERIPHERAL NERVE $ 1,026.00 49000390 HC INJECTION SACROILIAC JOINT W/ ARTHROGRAPHY & GUIDANCE $ 1,108.00 49000418 HC BONE MARROW ASPIRATION(S) $ 419.00 49000419 HC BONE MARROW BIOPSY(IES) $ 370.00 49000420 HC BONE MARROW ASPIRATION(S) AND BIOPSY(IES) $ 148.00 49000425 HC INJECTION FOR SENTINEL NODE IDENTIFICATION $ 772.00 49000432 HC DESTRUCTION BY NEUROLYTIC AGENT (RFA) CERVICAL/THORACIC PARAVERT JOINT NERVE SINGLE JOINT $ 3,092.00 49000433 HC DESTRUCTION BY NEUROLYTIC AGENT (RFA) LUMBAR/SACRAL PARAVERT JOINT NERVE SINGLE JOINT $ 2,231.00 49000434 HC DESTRUCTION BY NEUROLYTIC AGENT (RFA) LUMBAR/SACRAL PARAVERT JOINT NERVE EA ADDL JOINT $ 2,805.00 49000434 HC DESTRUCTION BY NEUROLYTIC AGENT (RFA) LUMBAR/SACRAL PARAVERT JOINT NERVE EA ADDL JOINT $ 1,467.00 49000435 HC DESTRUCTION BY NEUROLYTIC AGENT (RFA) CERVICAL/THORACIC PARAVERT JOINT NERVE EA ADDL JOINT $ 2,930.00 49000439 HC INSERT PM PULSE GENERATOR ONLY W/ MULTI LEADS $ 13,750.00 49000440 HC INSERT ICD GENERATOR W/EXISTING DUAL LEADS $ 28,306.00 49000441 HC INSERT ICD GENERATOR W/ EXISTING MULTI LEADS $ 33,977.00 49000442 HC INSERT CATH RENAL ARTERY SELECTIVE UNILATERAL (FIRST ORDER) $ 5,702.00 49000447 HC INSERT ENDOVASCULAR VENA CAVA FILTER $ 6,153.00 49000449 HC REMOVAL ENDOVASCULAR VENA CAVA FILTER $ 7,056.00 49000453 HC ABDOMINAL PARACENTESIS W/ IMAGING GUIDANCE $ 460.00

02-19-2019-A-PAC-057 Page 34 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 49000455 HC REPLACEMENT PM DUAL LEAD GENERATOR ONLY $ 14,015.00 49000456 HC REPLACEMENT PM MULTI LEAD GENERATOR ONLY $ 16,139.00 49000457 HC REPLACEMENT ICD SINGLE LEAD GENERATOR ONLY $ 29,805.00 49000458 HC REPLACEMENT ICD DUAL LEAD GENERATOR ONLY $ 30,986.00 49000459 HC REPLACEMENT ICD MULTI LEAD GENERATOR ONLY $ 33,084.00 49000460 HC REPLACEMENT PM SINGLE LEAD GENERATOR ONLY $ 13,169.00 49000649 HC TRACHEOBRONCHOSCOPY $ 303.50 49000659 HC THORACENTESIS W/ IMAGING GUIDANCE $ 1,340.00 49000661 HC INFUSION ARTERIAL FOR THROMBOLYSIS NON-CORONARY INITIAL DAY W/ RAD S&I $ 2,346.00 49000662 HC INFUSION VENOUS FOR THROMBOLYSIS INITIAL DAY W/ RAD S&I $ 2,910.00 49000663 HC INFUSION FOR THROMBOLYSIS NON-CORONARY SUBSEQUENT DAY W/ RAD S&I $ 5,131.00 49000664 HC INFUSION FOR THROMBOLYSIS NON-CORONARY W/ CESSATION OF THROMBOLYSIS SUBSEQUENT DAY W/ RAD S&I $ 5,068.00 49000665 HC PLACE CATH THORACIC AORTA W/ANGIO EXTRACRANIAL CAROTID/VERTEBRAL/INTRACRANIAL VESSEL W/RAD S&I $ 6,366.00 49000666 HC PLACE CATH COMMON CAROTID/INNOMINATE W/ANGIO IPSILATERAL EXTRACRANIAL CAROTID UNILAT & RAD S&I $ 6,366.00 49000667 HC PLACE CATH COMMON CAROTID/INNOMINATE W/ ANGIO IPSILATERAL INTRACRANIAL CAROTID UNILAT & RAD S&I $ 15,405.00 49000669 HC PLACE CATH SUBCLAVIAN OR INNOMINATE W/ ANGIO IPSILATERAL VERTEBRAL & RAD S&I $ 6,366.00 49000672 HC TRANSCATHETER RETRIEVAL INTRAVASCULAR FB W/ OR W/O IMAGING & RAD S&I $ 5,670.00 49000674 HC INSERTION INDWELLING CATHETER PERCUTANEOUS FOR PLEURAL DRAINAGE W/ IMAGING GUIDANCE $ 4,081.00 49000676 HC INJECTION NERVE FEMORAL FOR PAIN MGMT $ 918.00 49000677 HC INJECTION NERVE SCIATIC FOR PAIN MGMT $ 572.00 49000688 HC IMPLANT NEUROSTIMULATOR ELECTRODES PERCUTANEOUS EPIDURAL $ 1,568.00 49000688 HC IMPLANT NEUROSTIMULATOR ELECTRODES PERCUTANEOUS EPIDURAL $ 1,045.00 49000690 HC INCISION OF LINGUAL FRENUM (FRENOTOMY) $ 498.00 49000693 HC INJECTION NERVE FACIAL FOR PAIN MGMT $ 475.00 49000694 HC INJECTION NERVE GREATER OCCIPITAL FOR PAIN MGMT $ 523.00 49000694 HC INJECTION NERVE GREATER OCCIPITAL FOR PAIN MGMT $ 648.00 49000698 HC INJECTION NERVE SUPRASCAPULAR FOR PAIN MGMT $ 644.00 49000700 HC INJECTION NERVE INTERCOSTAL MULTIPLE FOR PAIN MGMT $ 1,265.00 49000707 HC BREAST BX W/ LOCALIZATION DEVICE & IMAGING OF SPECIMEN FIRST LESION W/ STEREOTACTIC GUIDANCE $ 3,512.00 49000708 HC BREAST BX W/ LOCALIZATION DEVICE & IMAGING OF SPECIMEN EA ADDL LESION W/ STEREOTACTIC GUIDANCE $ 2,268.00 49000709 HC BREAST BX W/ LOCALIZATION DEVICE & IMAGING OF SPECIMEN FIRST LESION W/ US GUIDANCE $ 3,200.00 49000710 HC BREAST BX W/ LOCALIZATION DEVICE & IMAGING OF SPECIMEN EA ADDL LESION W/ US GUIDANCE $ 1,575.00 49000713 HC PRE-OP PLACEMENT BREAST LOCALIZATION DEVICE FIRST LESION W/ MAMMOGRAPHIC GUIDANCE $ 1,574.00 49000721 HC TRANSCATH PLCMT INTRAVAS STENT OPEN/PERC NONCOR/CAROTID/VERTEBRAL/LE/INTRACRAN INI ART W/ RAD S&I $ 7,536.00 49000723 HC TRANSCATH PLCMT INTRAVAS STENT W/ ANGIOPLASTY SAME VESSEL OPEN/PERC INI VEIN W/ RAD S&I $ 7,536.00 49000730 HC DRAINAGE CATHETER PERCUTANEOUS PERITONEAL/RETROPERITONEAL $ 2,284.00 49000734 HC PLACEMENT EPIDURAL CERVICAL/THORACIC FOR CONT INFUSION FOR PAIN MGMT W/O IMAGING GUIDANCE $ 1,118.00 49000739 HC INSERT/REPLACE MICRA TRANSCATHETER PACING STUDY $ 26,366.00 49000782 HC INTRAVASCULAR US NON-CORONARY W/ RAD S&I INITIAL VESSEL $ 3,985.00 49000783 HC INTRAVASCULAR US NON-CORONARY W/ RAD S&I EACH ADDL VESSEL $ 2,856.00 49000838 HC INJECTION NERVE STELLATE GANGLION (CERVICAL SYMPATHETIC) FOR PAIN MGMT $ 657.00 49000840 HC INJECTION NERVE LUMBAR OR THORACIC (PARAVERTEBRAL SYMPATHETIC) FOR PAIN MGMT $ 711.00 49000841 HC INJECTION EPIDURAL OR SUBARACHNOID CERVICAL OR THORACIC FOR PAIN MGMT W/O IMAGING GUIDANCE $ 4,478.00 49000842 HC INJECTION EPIDURAL OR SUBARACHNOID LUMBAR OR SACRAL (CAUDAL) FOR PAIN MGMT W/O IMAGING GUIDANCE $ 4,388.00 49000843 HC INJ ANESTHETIC/STEROID EPIDURAL W/ IMG GUID CERVICAL OR THORACIC SINGLE LEVEL FOR PAIN MGMT $ 1,718.00 49000845 HC INJECTION PARAVERTEBRAL FACET JOINT W/ IMG GUID CERVICAL OR THORACIC SINGLE LEVEL FOR PAIN MGMT $ 1,914.00 49000845 HC INJECTION PARAVERTEBRAL FACET JOINT W/ IMG GUID CERVICAL OR THORACIC SINGLE LEVEL FOR PAIN MGMT $ 2,873.00 49000846 HC INJECTION PARAVERTEBRAL FACET JOINT W/ IMG GUID CERVICAL OR THORACIC SECOND LEVEL FOR PAIN MGMT $ 1,437.00 49000846 HC INJECTION PARAVERTEBRAL FACET JOINT W/ IMG GUID CERVICAL OR THORACIC SECOND LEVEL FOR PAIN MGMT $ 1,011.00 49000847 HC INJECTION PARAVERTEBRAL FACET JOINT W/ IMG GUID CERVICAL OR THORACIC THIRD + LEVELS FOR PAIN MGMT $ 466.00 49000847 HC INJECTION PARAVERTEBRAL FACET JOINT W/ IMG GUID CERVICAL OR THORACIC THIRD + LEVELS FOR PAIN MGMT $ 375.00 49000848 HC INJECTION PARAVERTEBRAL FACET JOINT W/ IMG GUID LUMBAR OR SACRAL SINGLE LEVEL FOR PAIN MGMT $ 1,914.00 49000848 HC INJECTION PARAVERTEBRAL FACET JOINT W/ IMG GUID LUMBAR OR SACRAL SINGLE LEVEL FOR PAIN MGMT $ 2,873.00 49000849 HC INJECTION PARAVERTEBRAL FACET JOINT W/ IMG GUID LUMBAR OR SACRAL SECOND LEVEL FOR PAIN MGMT $ 512.00 49000849 HC INJECTION PARAVERTEBRAL FACET JOINT W/ IMG GUID LUMBAR OR SACRAL SECOND LEVEL FOR PAIN MGMT $ 343.00 49000850 HC INJECTION PARAVERTEBRAL FACET JOINT W/ IMG GUID LUMBAR OR SACRAL THIRD + LEVELS FOR PAIN MGMT $ 353.00 49000850 HC INJECTION PARAVERTEBRAL FACET JOINT W/ IMG GUID LUMBAR OR SACRAL THIRD + LEVELS FOR PAIN MGMT $ 436.00 49000851 HC INJECTION SACROILIAC JOINT W/ ARTHROGRAPHY FOR PAIN MGMT $ 1,108.00 49000854 HC EXTERNAL CEPHALIC VERSION $ 1,179.00 49000855 HC PLACEMENT EPIDURAL LUMBAR/SACRAL CONT INFUSION FOR PAIN MGMT W/O IMAGING GUIDANCE $ 1,021.00 49000858 HC INJECTION ANESTHETIC AGENT SPHENOPALATINE GANGLION $ 347.00 49000873 HC INJECTION EPIDURAL OR SUBARACHNOID CERVICAL OR THORACIC FOR PAIN MGMT W/ IMAGING GUIDANCE $ 4,961.00 49000875 HC INJECTION EPIDURAL OR SUBARACHNOID LUMBAR OR SACRAL (CAUDAL) FOR PAIN MGMT W/ IMAGING GUIDANCE $ 4,475.00 49000889 HC CCH I&D DEEP ABSCESS SOFT TISSUE NECK/THORAX $ 1,137.00 49000890 HC CCH PERC INTRADISCAL ELECTROTHERMAL ANNULOPLASTY W/ FLUORO SINGLE LEVEL $ 12,621.00 49000891 HC CCH TENOTOMY SHOULDER SINGLE TENDON $ 3,951.00 49000892 HC CCH CYSTOURETHROSCOPY W/ FULGURATION TRIGONE $ 5,093.00 49000893 HC CCH REMOVAL SPINAL NEUROSTIMULATOR ELECTRODE PERC ARRAY INCLUDES FLUORO $ 2,743.00 49000894 HC CCH REVISION INCLUDES REPLACEMENT OF SPINAL NEUROSTIMULATOR ELECTRODE PERC ARRAY INCLUDES FLUORO $ 3,999.00 49000895 HC CCH INSERT/REPLACE SPINAL NEUROSTIMULATOR PULSE GENERATOR/RECEIVER DIRECT/INDUCTIVE COUPLING $ 1,212.00 49000896 HC CCH REVISION/REMOVAL IMPLANTED SPINAL NEUROSTIMULATOR PULSE GENERATOR/RECEIVER $ 1,140.00

02-19-2019-A-PAC-057 Page 35 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 49000897 HC CCH THROMBOENDARTECTOMY NECK INCISION $ 7,895.00 49000898 HC CCH US DRAINAGE CATHETER PERCUTANEOUS PERITONEAL/RETROPERITONEAL $ 674.00 49000981 HC FINE NEEDLE ASPIRATION BX W/ ULTRASOUND GUIDANCE FIRST LESION $ 574.00 49000982 HC FINE NEEDLE ASPIRATION BX W/ ULTRASOUND GUIDANCE EACH ADDL LESION $ 288.00 49000983 HC FINE NEEDLE ASPIRATION BX W/ FLUORO GUIDANCE FIRST LESION $ 627.00 49000984 HC FINE NEEDLE ASPIRATION BX W/ FLUORO GUIDANCE EACH ADDL LESION $ 314.00 49000985 HC FINE NEEDLE ASPIRATION BX W/ CT GUIDANCE FIRST LESION $ 679.00 49000986 HC FINE NEEDLE ASPIRATION BX W/ CT GUIDANCE EACH ADDL LESION $ 340.00 49000987 HC FINE NEEDLE ASPIRATION BX W/ MRI GUIDANCE FIRST LESION $ 732.00 49000988 HC FINE NEEDLE ASPIRATION BX W/ MRI GUIDANCE EACH ADDL LESION $ 366.00 49000992 HC CCH EXPLORATION FEMORAL ARTERY $ 6,510.00 49000993 HC CCH EXPLORATION OTHER VESSELS $ 6,300.00 49000996 HC INSERTION PICC W/O PUMP/PORT W/IMAGING > 5 YEARS OLD $ 2,625.00 49000998 HC INSERTION PLEURAL CATH W/ CUFF $ 5,025.00 49000999 HC CCH REDUCTION CLOSED NASAL FX W/ STABLIZATION $ 556.50 51000001 HC CLINIC VISIT NEW PT LEVEL 1 $ 95.00 51000001 HC CLINIC VISIT NEW PT LEVEL 1 $ 55.00 51000002 HC CLINIC VISIT NEW PT LEVEL 2 $ 169.00 51000002 HC CLINIC VISIT NEW PT LEVEL 2 $ 85.50 51000003 HC CLINIC VISIT NEW PT LEVEL 3 $ 246.00 51000003 HC CLINIC VISIT NEW PT LEVEL 3 $ 120.00 51000004 HC CLINIC VISIT NEW PT LEVEL 4 $ 377.00 51000004 HC CLINIC VISIT NEW PT LEVEL 4 $ 166.00 51000005 HC CLINIC VISIT NEW PT LEVEL 5 $ 466.00 51000005 HC CLINIC VISIT NEW PT LEVEL 5 $ 194.50 51000006 HC CLINIC VISIT ESTABLISHED PT LEVEL 1 $ 32.00 51000006 HC CLINIC VISIT ESTABLISHED PT LEVEL 1 $ 28.00 51000007 HC CLINIC VISIT ESTABLISHED PT LEVEL 2 $ 99.00 51000007 HC CLINIC VISIT ESTABLISHED PT LEVEL 2 $ 55.00 51000008 HC CLINIC VISIT ESTABLISHED PT LEVEL 3 $ 165.00 51000008 HC CLINIC VISIT ESTABLISHED PT LEVEL 3 $ 79.00 51000009 HC CLINIC VISIT ESTABLISHED PT LEVEL 4 $ 242.00 51000009 HC CLINIC VISIT ESTABLISHED PT LEVEL 4 $ 111.00 51000010 HC CLINIC VISIT ESTABLISHED PT LEVEL 5 $ 326.00 51000010 HC CLINIC VISIT ESTABLISHED PT LEVEL 5 $ 142.50 51000043 HC FINE NEEDLE ASPIRATION BX FIRST LESION $ 229.00 51000044 HC I&D ABSCESS SIMPLE $ 407.00 51000044 HC I&D ABSCESS SIMPLE $ 162.00 51000045 HC I&D ABSCESS COMPLICATED $ 118.00 51000046 HC I&D HEMATOMA SEROMA OR FLUID $ 1,471.00 51000046 HC I&D HEMATOMA SEROMA OR FLUID $ 333.00 51000052 HC DEBRIDEMENT SUBQ TISSUE 1ST 20 SQ CM $ 1,079.00 51000053 HC DEBRIDEMENT MUSCLE/FASCIA 1ST 20 SQ CM $ 920.00 51000054 HC DEBRIDEMENT BONE 1ST 20 SQ CM $ 1,563.00 51000055 HC REMOVAL CORN OR CALLUS 1 LESION $ 175.00 51000055 HC REMOVAL CORN OR CALLUS 1 LESION $ 80. 50 51000058 HC DEBRIDEMENT NAILS 1-5 $ 270.00 51000065 HC INSERTION NON-BIODEGRADABLE DRUG DELIVERY IMPLANT $ 186.50 51000073 HC CHEMICAL CAUTERIZATION TISSUE $ 210.00 51000073 HC CHEMICAL CAUTERIZATION TISSUE $ 154.50 51000078 HC TRIGGER POINT INJECTION 1-2 MUSCLES $ 198.00 51000078 HC TRIGGER POINT INJECTION 1-2 MUSCLES $ 70.50 51000079 HC TRIGGER POINT INJECTION 3+ MUSCLES $ 226.00 51000079 HC TRIGGER POINT INJECTION 3+ MUSCLES $ 82.50 51000097 HC APPLICATION CONTACT LEG CAST $ 662.00 51000100 HC UNNA BOOT STRAPPING $ 429.45 51000100 HC UNNA BOOT STRAPPING $ 183.00 51000101 HC APPLICATION MULTI-LAYER WOUND COMPRESSION BELOW KNEE $ 181.00 51000103 HC NASAL ENDOSCOPY DIAGNOSTIC $ 505.50 51000104 HC NASAL/SINUS ENDOSCOPY W/ BX DEBRIDEMENT OR POLYPECTOMY $ 502.00 51000110 HC LARYNGOSCOPY FLEXIBLE DIAGNOSTIC $ 235.00 51000111 HC LARYNGOSCOPY W/ STROBOSCOPY $ 334.00 51000125 HC DESTRUCTION LESION VULVA SIMPLE $ 232.00 51000128 HC BX VAGINA SIMPLE $ 222.00 51000132 HC COLPOSCOPY CERVIX $ 139.00 51000133 HC COLPOSCOPY CERVIX W/ BX & ENDOCERVICAL CURETTAGE $ 184.00 51000143 HC INJECTION ANESTHETIC PERIPHERAL NERVE OR BRANCH $ 394.00 51000143 HC INJECTION ANESTHETIC PERIPHERAL NERVE OR BRANCH $ 592.00 51000144 HC INJECTION(S) TRANSFORAMINAL LUMBAR SACRAL SINGLE LEVEL $ 2,596.00 51000144 HC INJECTION(S) TRANSFORAMINAL LUMBAR SACRAL SINGLE LEVEL $ 1,734.00 51000145 HC INJECTION(S) TRANSFORAMINAL LUMBAR SACRAL EACH ADDL LEVEL $ 764.00

02-19-2019-A-PAC-057 Page 36 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 51000150 HC REMOVAL IMPACTED CERUMEN UNILATERAL $ 78.50 51000153 HC DEBRIDEMENT WOUND SELECTIVE 1ST 20 SQ CM $ 351.00 51000154 HC DEBRIDEMENT WOUND SELECTIVE EA ADDL 20 SQ CM $ 351.00 51000155 HC DEBRIDEMENT WOUND NON-SELECTIVE $ 146.00 51000158 HC REMOVAL FB SUBCUTANEOUS COMPLICATED $ 549.00 51000175 HC CANCELLED PROCEDURE IN PREOP $ 827.00 51000177 HC INJECTION TENDON SHEATH LIGAMENT APONEUROSIS $ 209.00 51000177 HC INJECTION TENDON SHEATH LIGAMENT APONEUROSIS $ 70.00 51000178 HC ARTHROCENTESIS JOINT/BURSA SMALL W/O ULTRASOUND GUIDANCE $ 53.00 51000179 HC ARTHROCENTESIS JOINT/BURSA INTERMEDIATE W/O ULTRASOUND GUIDANCE $ 143.00 51000179 HC ARTHROCENTESIS JOINT/BURSA INTERMEDIATE W/O ULTRASOUND GUIDANCE $ 69.50 51000180 HC ARTHROCENTESIS JOINT/BURSA MAJOR W/O ULTRASOUND GUIDANCE $ 407.00 51000180 HC ARTHROCENTESIS JOINT/BURSA MAJOR W/O ULTRASOUND GUIDANCE $ 97.00 51000181 HC ASPIRATION & INJECTION BONE CYST $ 555.00 51000181 HC ASPIRATION & INJECTION BONE CYST $ 503.50 51000182 HC DECLOTTING VAD OR CATH $ 321.00 51000183 HC INSERTION STRAIGHT CATH (NON-INDWELLING) $ 117.00 51000184 HC INSERTION FOLEY CATH SIMPLE (INDWELLING) $ 81.00 51000184 HC INSERTION FOLEY CATH SIMPLE (INDWELLING) $ 163.00 51000185 HC INSERTION FOLEY CATH COMPLICATED (INDWELLING) $ 241.00 51000186 HC CHANGE CYSTOSTOMY TUBE SIMPLE $ 184.00 51000189 HC BLADDER INSTILLATION CHEMO $ 406.00 51000189 HC BLADDER INSTILLATION CHEMO $ 175.00 51000193 HC IRRIGATION VAD (PORT FLUSH) $ 81.00 51000202 HC DEBRIDEMENT SUBCUT TISSUE EA ADDL 20 CM $ 562.00 51000205 HC REMOVAL CORN OR CALLUS 2-4 LESIONS $ 62.00 51000206 HC REMOVAL CORN OR CALLUS >4 LESIONS $ 131.50 51000208 HC EXC BEN LESION TRUNK/EXTREMITIES 0.6-1.0 CM $ 242.50 51000209 HC EXC BEN LESION TRUNK/EXTREMITIES 1.1-2.0 CM $ 268.00 51000210 HC EXC BEN LESION TRUNK/EXTREMITIES 2.1-3.0 CM $ 291.50 51000211 HC EXC BEN LESION TRUNK/EXTREMITIES 3.1-4.0 CM $ 277.00 51000224 HC REP SIMP SC/NE/AX/GEN/TR/EXT 2.6-7.5 CM $ 118.50 51000226 HC REP SIMP SC/NE/AX/GEN/TR/EXT 12.6-20.0 CM $ 276.50 51000236 HC TREATMENT WOUND DEHISCENCE SIMPLE CLOSURE $ 350.00 51000239 HC ASPIRATION/INJECTION GANGLION CYST $ 82.50 51000256 HC INJECTION NERVE BLOCK ILIOINGUINAL/ILIOHYPOGASTRIC $ 462.00 51000283 HC DISCISSION SEC MEMB CATARACT BY LASER $ 967.00 51000285 HC INJECTION INTRAVITREAL OF DRUG $ 270.68 51000338 HC EYE EXAM COMPREHENSIVE NEW PT $ 257.00 51000340 HC EYE EXAM COMPREHENSIVE ESTABLISHED PT $ 225.00 51000341 HC GONIOSCOPY $ 33.00 51000342 HC TOPOGRAPHY CORNEAL $ 79.00 51000346 HC EXAMINATION VISUAL FIELD EXTENDED $ 141.00 51000349 HC COMPTRZ OPHTHALMIC DX IMAGING OPTIC NERVE $ 81.00 51000350 HC COMPTRZ OPHTHALMIC DX IMAGING RETINA $ 84.00 51000351 HC OPTICAL COHERENCE BIOMETRY W/ IOL POWER CALC $ 218. 00 51000357 HC FUNDUS PHOTOGRAPHY $ 146.00 51000384 HC ACNE SURGERY $ 182.00 51000394 HC DESTRUCTION LESIONS BENIGN UP TO 14 LESIONS $ 212.00 51000395 HC DESTRUCTION LESIONS BENIGN > 15 LESIONS $ 239.50 51000419 HC COLPOSCOPY OF VULVA $ 185.00 51000422 HC COLPOSCOPY VAGINA W/ BX VAGINA/CERVIX $ 172.00 51000423 HC COLPOSCOPY CERVIX W/ LOOP CONIZATION OF CERVIX $ 544.00 51000437 HC EXC BEN LESION SC/NE/HA/FE/GEN <0.5 CM $ 199.50 51000438 HC EXC BEN LESION SC/NE/HA/FE/GEN 0.6-1.0 CM $ 395.00 51000439 HC EXC BEN LESION SC/NE/HA/FE/GEN 1.1-2.0 CM $ 270.00 51000444 HC APPLY HIGH COST SKIN SUBSTITUTE (TRUNK/ARM/LEG) AREA UP TO 100 SQ CM FIRST 25 SQ CM $ 648.00 51000445 HC APPLY HIGH COST SKIN SUBSTITUTE (TRUNK/ARM/LEG) AREA UP TO 100 SQ CM EA ADDL 25 SQ CM $ 251.00 51000446 HC APPLY HIGH COST SKIN SUBSTITUTE (FACE/NE/HND/FT/GEN) TOT WND <100 SQ CM FIRST 25 SQ CM $ 681.00 51000449 HC FITTING CONTACT LENS FOR TX OCULAR SURFACE $ 48.00 51000488 HC COLPOSCOPY CERVIX W/ BX $ 187.00 51000496 HC CHEMODENERVATION MUSCLE NECK EXCL LARYNX UNILATERAL $ 634.00 51000514 HC CHEMODENERVATION MUSCLES FACIAL/TRIGEM/CERV SP/ACCESS NERVES BILATERAL $ 604.00 51000515 HC INJECTION TENDON ORIGIN/INSERTION SINGLE $ 212.00 51000515 HC INJECTION TENDON ORIGIN/INSERTION SINGLE $ 74.00 51000516 HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT $ 299.50 51000534 HC ARTHROCENTESIS JOINT/BURSA SMALL W/ ULTRASOUND GUIDANCE $ 1,216.00 51000534 HC ARTHROCENTESIS JOINT/BURSA SMALL W/ ULTRASOUND GUIDANCE $ 32.50 51000535 HC ARTHROCENTESIS JOINT/BURSA INTERMEDIATE W/ ULTRASOUND GUIDANCE $ 1,216.00 51000535 HC ARTHROCENTESIS JOINT/BURSA INTERMEDIATE W/ ULTRASOUND GUIDANCE $ 38.50 51000536 HC ARTHROCENTESIS JOINT/BURSA MAJOR W/ ULTRASOUND GUIDANCE $ 1,216.00

02-19-2019-A-PAC-057 Page 37 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 51000536 HC ARTHROCENTESIS JOINT/BURSA MAJOR W/ ULTRASOUND GUIDANCE $ 154.00 51000544 HC REMOVAL FB EXTERNAL AUDITORY CANAL W/O ANESTHESIA $ 204.75 51000550 HC EXC MAL LESION TRUNK/EXTREMITIES > 4.0 CM $ 499.50 51000557 HC EXC MAL LESION F/E/E/N/L 0.6 -1.0 CM $ 37.50 51000558 HC EXC MAL LESION F/E/E/N/L 1.1 - 2.0 CM $ 32.00 51000559 HC EXC MAL LESION F/E/E/N/L 2.1 - 3.0 CM $ 34.00 51000573 HC DESTRCT MAL LESION F/E/E/N/L/MM 1.1 - 2.0 CM $ 388.00 51000595 HC REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL $ 37.50 51000604 HC NASAL/SINUS ENDOSCOPY W/ DILATION FRONTAL SINUS OSTIUM $ 5,688.50 51000605 HC INJECTION THERAPEUTIC CARPAL TUNNEL $ 123.00 51000605 HC INJECTION THERAPEUTIC CARPAL TUNNEL $ 102.00 51000615 HC CCH VISUAL ACUITY SCREENING - JAEGER $ 9.00 51000644 HC CCH MTM OUTCOMES $10 FEE $ 20.00 51000645 HC CCH MTM OUTCOMES $2 FEE $ 2.00 51000646 HC CCH REMOVAL SKIN TAGS <=15 LESIONS $ 134.50 51000647 HC CCH REMOVAL SKIN TAGS ADDON =< 15 LESIONS $ 20.50 51000648 HC CCH SHAVE SKIN LESION TRUNK/EXTREMITIES <0.5 CM $ 85.00 51000649 HC CCH SHAVE SKIN LESION TRUNK/EXTREMITIES 0.6-1.0 CM $ 89.50 51000650 HC CCH SHAVE SKIN LESION TRUNK/EXTREMITIES 1.1-2.0 CM $ 320.50 51000651 HC CCH SHAVE SKIN LESION SC/NE/HA/FE/GEN 0.6-1.0 CM $ 29.00 51000652 HC CCH SHAVE SKIN LESION F/E/E/N/L <0.5 CM $ 262.50 51000653 HC CCH BIOPSY NAIL UNIT $ 208.00 51000654 HC CCH REPAIR NAIL BED $ 186.50 51000655 HC CCH REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULE $ 208.00 51000656 HC CCH DESTRUCTION PREMALIGNANT LESION; FIRST LESION $ 139.50 51000657 HC CCH DESTRUCTION PREMALIGNANT LESION; 2-14 LESIONS $ 13.00 51000658 HC CCH INJECTION ENZYME PALMAR FASCIAL CORD $ 67.00 51000659 HC CCH CONIZATION CERVIX W/ LOOP $ 368.00 51000660 HC CCH REFRACTION $ 39.00 51000661 HC CCH PROLONGED E&M/PSYCHOTHERAPY SERVICE OFFICE FIRST 60 MIN $ 115.00 51000662 HC CCH PROLONGED E&M/PSYCHOTHERAPY SERVICE OFFICE EA ADDL 30 MIN $ 106.00 51000663 HC CCH PROLONGED E&M SERVICE OFFICE W/O CONTACT FIRST 60 MIN $ 109.00 51000664 HC CCH PROLONGED E&M SERVICE OFFICE W/O CONTACT EA ADDL 30 MIN $ 55.00 51000665 HC CCH OFFICE CONSULTATION NEW/EST PT 15 MINUTES $ 72.50 51000666 HC CCH OFFICE CONSULTATION NEW/EST PT 30 MINUTES $ 124.00 51000667 HC CCH OFFICE CONSULTATION NEW/EST PT 40 MINUTES $ 164.00 51000668 HC CCH OFFICE CONSULTATION NEW/EST PT 60 MINUTES $ 217.50 51000669 HC CCH OFFICE CONSULTATION NEW/EST PT 80 MINUTES $ 259.00 51000670 HC CCH COMPLEX CHRONIC CARE W/O PT VISIT $ 145.00 51000671 HC CCH COMPLEX CHRONIC CARE EA ADDL 30 MIN $ 73.00 51000672 HC CCH ADVANCED DIRECTIVE CARE PLAN 30 MIN $ 98.00 51000677 HC CCH APPLY LONG LEG SPLINT $ 248.50 51000686 HC CCH DRAINAGE ABSCESS CYST HEMATOMA OF DENTOALVEOLAR STRUCTURES $ 821.50 51000687 HC CCH EXCISION TUMOR SOFT TISSUE SHOULDER <3 CM $ 954.50 51000690 HC CCH INCISION AND DRAINAGE DEEP ASCESS OR HEMATOMA; SHOULDER $ 970.00 51000691 HC CCH ANTIGENS-ALLERGEN IMMUN; SGL/MUL $ 38. 50 51000692 HC CCH EXCISION LESION FLOOR OF MOUTH $ 727.00 51000694 HC CCH CLOSED TREATMENT TARSAL BONE DISLOCATION $ 346.00 51000695 HC CCH DRAINAGE ABSCESS OR HEMATOMA OF EXTERNAL EAR $ 402.50 51000696 HC CCH APPLICATION CLUBFOOT LEG CAST $ 37.50 51000702 HC CCH BINOCULAR MICROSCOPY $ 68.00 51000704 HC CCH APPLY SHORT LEG SPLINT $ 135.00 51000711 HC BX SKIN TANGENITAL FIRST LESION $ 358.00 51000711 HC BX SKIN TANGENITAL FIRST LESION $ 222.50 51000712 HC BX SKIN TANGENITAL EACH ADDL LESION $ 117.50 51000713 HC BX SKIN PUNCH FIRST LESION $ 358.00 51000713 HC BX SKIN PUNCH FIRST LESION $ 279.50 51000714 HC BX SKIN PUNCH EACH ADDL LESION $ 133.00 51000715 HC BX SKIN INCISIONAL FIRST LESION $ 358.00 51000715 HC BX SKIN INCISIONAL FIRST LESION $ 338.00 51000716 HC BX SKIN INCISIONAL EACH ADDL LESION $ 156.00 51000722 HC CCH DEBRIDEMENT MASTOIDECTOMY CAVITY SIMPLE $ 155.00 51000723 HC CCH DEBRIDEMENT MASTOIDECTOMY CAVITY COMPLEX $ 486.50 51000724 HC CCH NASAL/SINUS ENDOSCOPY W/ DILATION MAXILLARY SINUS OSTIUM $ 5,654.50 51000725 HC CCH NASAL/SINUS ENDOSCOPY W/ DILATION SPHENOID SINUS OSTIUM $ 5,639.50 51000726 HC CCH EXCISION OR DESTRUCTION INTRANASAL LESION; INTERNAL APPROACH $ 2,210.00 51000727 HC CCH TYMPANIC MEMBRANE REPAIR $ 661.50 51000728 HC CCH MYRINGOPLASTY $ 1,398.00 51000729 HC CCH EXCISION AURAL POLYP $ 479.50 51000730 HC CCH LABYRINTHOTOMY W/ PERFUSION OF VESTIBULOACTIVE DRUG(S) TRANSCANAL $ 359.00 51000731 HC CCH EXCISION LESION OF PALATE UVULA W/ SIMPLE PRIMARY CLOSURE $ 596.00

02-19-2019-A-PAC-057 Page 38 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 51000732 HC CCH SINUSOTOMY MAXILLARY INTRANASAL $ 1,098.00 51000733 HC CCH CALORIC VESTIBULAR TEST W/ RECORDING BILATERAL $ 57.00 51000734 HC CCH FACIAL NERVE FUNCTION STUDIES $ 157.50 51000737 HC ULTRASOUND POST VOIDING URINE $ 105.00 51000737 HC ULTRASOUND POST VOIDING URINE $ 50.44 51000738 HC BLADDER IRRIGATION $ 420.00 51000738 HC BLADDER IRRIGATION $ 156.00 51000740 HC CCH NASAL/SINUS ENDOSCOPY W/ ETHMOIDECTOMY; TOTAL INCL SPHENOIDOTOMY $ 536.50 51000750 HC CCH IMMUNOTHERAPY 2 + INJECTIONS $ 27.50 51000751 HC CCH TRIM NONDYSTROPHIC NAILS ANY NUMBER $ 25.00 53100001 HC CCH OSTEOPATHIC MANIPULATION 3-4 BODY REGIONS $ 58.00 61000001 HC MRI TEMPROMANDIBULAR JOINT $ 3,354.00 61000002 HC MRI ORBIT FACE NECK W/O CONTRAST $ 2,770.00 61000003 HC MRI ORBIT FACE NECK W/ CONTRAST $ 3,292.00 61000004 HC MRI ORBIT FACE NECK W/ & W/O CONTRAST $ 2,909.00 61000005 HC MRI CHEST W/O CONTRAST $ 3,310.00 61000006 HC MRI PELVIS W/O CONTRAST $ 3,199.00 61000007 HC MRI PELVIS W/ CONTRAST $ 3,310.00 61000008 HC MRI PELVIS W/ & W/O CONTRAST $ 3,199.00 61000009 HC MRI UPPER EXTREMITY OTHER THAN JOINT W/ & W/O CONTRAST $ 3,199.00 61000010 HC MRI UPPER EXTREMITY JOINT W/O CONTRAST $ 3,366.00 61000011 HC MRI LOWER EXTREMITY OTHER THAN JOINT W/ & W/O CONTRAST $ 3,199.00 61000012 HC MRI LOWER EXTREMITY JOINT W/O CONTRAST $ 3,199.00 61000013 HC MRI ABDOMEN W/O CONTRAST $ 3,199.00 61000021 HC MR SPECTROSCOPY $ 487.00 61000026 HC MRI UPPER EXTREMITY OTHER THAN JOINT W/O CONTRAST $ 3,199.00 61000027 HC MRI UPPER EXTREMITY OTHER THAN JOINT W/ CONTRAST $ 6,946.00 61000028 HC MRI UPPER EXTREMITY JOINT W/ CONTRAST $ 6,599.00 61000028 HC MRI UPPER EXTREMITY JOINT W/ CONTRAST $ 3,300.00 61000029 HC MRI UPPER EXTREMITY JOINT W/ & W/O CONTRAST $ 3,506.00 61000030 HC MRI LOWER EXTREMITY OTHER THAN JOINT W/O CONTRAST $ 3,199.00 61000031 HC MRI LOWER EXTREMITY OTHER THAN JOINT W/ CONTRAST $ 1,995.00 61000032 HC MRI LOWER EXTREMITY JOINT W/ CONTRAST $ 2,372.00 61000032 HC MRI LOWER EXTREMITY JOINT W/ CONTRAST $ 4,747.00 61000033 HC MRI LOWER EXTREMITY JOINT W/ & W/O CONTRAST $ 3,506.00 61000034 HC MRI ABDOMEN W/ CONTRAST $ 3,967.00 61000035 HC MRI ABDOMEN W/ & W/O CONTRAST $ 6,587.00 61100001 HC MRI BRAIN W/O CONTRAST $ 2,909.00 61100002 HC MRI BRAIN W/ CONTRAST $ 3,422.00 61100003 HC MRI BRAIN W/ & W/O CONTRAST $ 3,528.00 61100006 HC MRI BRAIN INTRAOPERATIVE W/O CONTRAST $ 2,909.00 61100007 HC MRI BRAIN INTRAOPERATIVE W/ CONTRAST $ 3,422.00 61100008 HC MRI BRAIN INTRAOPERATIVE W/ & W/O CONTRAST $ 5,988.00 61200001 HC MRI SPINE W/O CONTRAST CERVICAL $ 3,372.00 61200002 HC MRI SPINE W/ CONTRAST CERVICAL $ 3,763.00 61200003 HC MRI SPINE W/O CONTRAST THORACIC $ 3,945.00 61200004 HC MRI SPINE W/ CONTRAST THORACIC $ 3,422.00 61200005 HC MRI SPINE W/O CONTRAST LUMBAR $ 3,516.00 61200006 HC MRI SPINE W/ CONTRAST LUMBAR $ 4,020.00 61200007 HC MRI SPINE W/ & W/O CONTRAST CERVICAL $ 6,587.00 61200008 HC MRI SPINE W/ & W/O CONTRAST THORACIC $ 6,587.00 61200009 HC MRI SPINE W/ & W/O CONTRAST LUMBAR $ 6,587.00 61400002 HC MRI CHEST W/ CONTRAST $ 3,765.00 61400003 HC MRI CHEST W/ & W/O CONTRAST $ 4,346.00 61500001 HC MRA HEAD W/O CONTRAST $ 2,909.00 61500002 HC MRA HEAD W/ CONTRAST $ 3,116.00 61500003 HC MRA HEAD W/ & W/O CONTRAST $ 5,836.00 61500004 HC MRA NECK W/O CONTRAST $ 3,354.00 61500005 HC MRA NECK W/ CONTRAST $ 2,909.00 61500006 HC MRA NECK W/ & W/O CONTRAST $ 5,988.00 61600003 HC MRA LOWER EXTREMITY W/ & W/O CONTRAST $ 2,909.00 61800004 HC MRA ABDOMEN W/O CONTRAST $ 2,770.00 61800005 HC MRA ABDOMEN W/ & W/O CONTRAST $ 3,199.00 63600003 HC IM ADULT HEP-A VACCINE $ 21.25 63600003 HC IM ADULT HEP-A VACCINE $ 74.00 63600004 HC IM ADULT HEPA-HEPB $ 22.00 63600004 HC IM ADULT HEPA-HEPB $ 21.25 63600007 HC TD VACCINE NO PRSRV >/=7 IM $ 86.00 63600007 HC TD VACCINE NO PRSRV >/=7 IM $ 0.01 63600008 HC TDAP VACCINE >7 IM $ 194.00 63600008 HC TDAP VACCINE >7 IM $ 0.01

02-19-2019-A-PAC-057 Page 39 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 63600010 HC PNEUMOCOCCAL VACCINE 23 VALENT >2 YRS SQ/IM $ 290.00 63600010 HC PNEUMOCOCCAL VACCINE 23 VALENT >2 YRS SQ/IM $ 0.01 63600011 HC ZOSTER VACCINE $ 737.00 63600011 HC ZOSTER VACCINE $ 21.25 63600012 HC HEPATITIS B VACCINE 3 DOSE IM $ 18.00 63600012 HC HEPATITIS B VACCINE 3 DOSE IM $ 21.25 63600013 HC HEPB VACC ILL PAT 4 DOSE IM $ 21.25 63600022 HC INJECTION ONABOTULINUMTOXINA 1 UNIT $ 19.14 63600023 HC ROCEPHIN INJECTION PER 250 MG $ 12.75 63600024 HC BETAMETHAZONE ACET 3MG & SOD PHOS 3MG $ 17.55 63600026 HC DEPO MEDROL 40 MG INJ $ 80.52 63600034 HC TRIAMCINOLONE ACET INJ NOS 10 MG $ 20.73 63600035 HC VITAMIN B-12 INJECTION UP TO 1000 MCG $ 80.00 63600035 HC VITAMIN B-12 INJECTION UP TO 1000 MCG $ 71.55 63600036 HC ETONOGESTREL CONTRACEPTIVE IMPLANT SYSTEM (NEXPLANON/IMPLANON) $ 2,543.70 63600037 HC SYNVISC OR SYNVISC ONE 1 MG $ 29.59 63600054 HC RANIBIZUMAB INJECTION 0.1MG $ 1,133.73 63600055 HC TRIAMCINOLONE A INJ PRS-FREE 1MG $ 10.25 63600063 HC DEXAMETHASONE INTRA IMPLANT 0.1MG $ 571.28 63600064 HC HEMOPHILUS INFLUENZA B VACCINE (HIB) PRP-T IM $ 0.01 63600064 HC HEMOPHILUS INFLUENZA B VACCINE (HIB) PRP-T IM $ 87.00 63600065 HC MENINGOCOCCAL CONJUGATE VACCINE IM $ 0.01 63600065 HC MENINGOCOCCAL CONJUGATE VACCINE IM $ 143.00 63600069 HC INJECTION LEUPROLIDE ACETATE 3.75 MG $ 3,013.17 63600072 HC PNEUMOCOCCAL VACCINE 13 VALENT IM $ 0.01 63600072 HC PNEUMOCOCCAL VACCINE 13 VALENT IM $ 568.00 63600112 HC CCH INFLUENZA VIRUS QUADRIVALENT SPLIT VIRUS PRESERVATIVE FREE 6-35 MONTHS INTRAMUSCULAR $ 0.01 63600112 HC CCH INFLUENZA VIRUS QUADRIVALENT SPLIT VIRUS PRESERVATIVE FREE 6-35 MONTHS INTRAMUSCULAR $ 84.00 63600113 HC INFLUENZA VIRUS VACCINE QUADRIVALENT SPLIT VIRUS PRESERVATIVE FREE 3+ YEARS INTRAMUSCULAR $ 0.01 63600113 HC INFLUENZA VIRUS VACCINE QUADRIVALENT SPLIT VIRUS PRESERVATIVE FREE 3+ YEARS INTRAMUSCULAR $ 84.00 63600124 HC SKIN SUBSTITUTE PER SQ CM; OASIS WOUND MATRIX 3X3.5CM (11 SQ CM) $ 79.00 63600151 HC SKIN SUBSTITUTE PER SQ CM; OASIS ULTRA TRI-LAYER 5X7CM (35 SQ CM) $ 40.00 63600152 HC MMR VACCINE $ 0.01 63600152 HC MMR VACCINE $ 22.00 63600158 HC LEVONORGESTREL INTRAUTERINE CONTRACEPTIVE 52MG (MIRENA) $ 2,431.50 63600159 HC INTRAUTERINE COPPER CONTRACEPTIVE (PARAGARD) $ 10.25 63600167 HC INJ RHO(D) IMMUNE GLOBULIN HUMAN IM OR IV 100 IU $ 407.00 63600167 HC INJ RHO(D) IMMUNE GLOBULIN HUMAN IM OR IV 100 IU $ 388.00 63600168 HC INJ MEDROXYPROGESTERONE ACETATE 1 MG $ 4.22 63600169 HC INJ DEXAMETHASONE SODIUM PHOSPHATE 1 MG $ 3.00 63600169 HC INJ DEXAMETHASONE SODIUM PHOSPHATE 1 MG $ 2.50 63600170 HC INJ METHYLPREDNISOLONE ACETATE 80 MG $ 126.71 63600190 HC METHYLPREDNISOLONE SODIUM SUCCINATE INJECTION UP TO 125MG $ 39.60 63600196 HC UNCLASSIFIED BIOLOGICS $ 182.50 63600209 HC CCH SKIN SUBSTITUTE PER SQ CM; APLIGRAF $ 143.00 63600219 HC HPV VACCINE NONAVALENT 2 OR 3 DOSE IM $ 0. 01 63600219 HC HPV VACCINE NONAVALENT 2 OR 3 DOSE IM $ 184.00 63600220 HC HEPB VACCINE ADOLESCENT 2 DOSE IM $ 21.25 63600221 HC HEPB VACCINE PEDIATRIC/ADOLESCENT 3 DOSE IM $ 51.00 63600221 HC HEPB VACCINE PEDIATRIC/ADOLESCENT 3 DOSE IM $ 0.01 63600222 HC INFLUENZA VACCINE QUADRIVALENT SPLIT VIRUS PRSRV FREE HIGH DOSE IM $ 22.00 63600222 HC INFLUENZA VACCINE QUADRIVALENT SPLIT VIRUS PRSRV FREE HIGH DOSE IM $ 21.25 63600223 HC CCH SKIN SUBSTITUTE PER SQ CM; PURAPLY AM $ 375.00 63600224 HC CCH VARICELLA VIRUS VACCINE $ 22.00 63600224 HC CCH VARICELLA VIRUS VACCINE $ 0.01 63600227 HC CCH RABIES IG INJECTION IM/SQ $ 524.00 63600227 HC CCH RABIES IG INJECTION IM/SQ $ 21.25 63600228 HC CCH RABIES IG HEAT TREATED $ 840.00 63600229 HC RSV MAB IM 50 MG $ 4,133.00 63600229 HC RSV MAB IM 50 MG $ 21.50 63600230 HC CCH HEP A VACCINE PED/ADOL 2 DOSE IM $ 159.00 63600230 HC CCH HEP A VACCINE PED/ADOL 2 DOSE IM $ 0.01 63600231 HC CCH HIB VACCINE PRP-OMP VACCINE 3 DOSE IM $ 15.00 63600231 HC CCH HIB VACCINE PRP-OMP VACCINE 3 DOSE IM $ 0.01 63600232 HC CCH HPV VACCINE 4 VALENT IM $ 0.01 63600232 HC CCH HPV VACCINE 4 VALENT IM $ 22.00 63600233 HC CCH HPV VACCINE 2 VALENT IM $ 190.00 63600233 HC CCH HPV VACCINE 2 VALENT IM $ 0.01 63600234 HC CCH IIV3 VACCINE SPLIT 0.25 ML IM $ 0.01 63600234 HC CCH IIV3 VACCINE SPLIT 0.25 ML IM $ 84.00 63600235 HC CCH IIV3 VACCINE SPLIT 0.5 ML IM $ 0.01

02-19-2019-A-PAC-057 Page 40 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 63600235 HC CCH IIV3 VACCINE SPLIT 0.5 ML IM $ 22.00 63600236 HC CCH LIIV3 VACCINE INTRANASAL $ 61.00 63600236 HC CCH LIIV3 VACCINE INTRANASAL $ 0.01 63600237 HC CCH INFLUENZA VACCINE QUADRIVALENT LIVE INTRANASAL $ 0.01 63600237 HC CCH INFLUENZA VACCINE QUADRIVALENT LIVE INTRANASAL $ 42.00 63600238 HC CCH RABIES VACCINE IM $ 684.00 63600238 HC CCH RABIES VACCINE IM $ 21.25 63600239 HC CCH ROTOVIRUS VACCINE PENTAVALENT 3 DOSE LIVE ORAL $ 22.00 63600239 HC CCH ROTOVIRUS VACCINE PENTAVALENT 3 DOSE LIVE ORAL $ 0.01 63600240 HC CCH ROTOVIRUS VACCINE ATTENUATED 2 DOSE LIVE ORAL $ 315.00 63600240 HC CCH ROTOVIRUS VACCINE ATTENUATED 2 DOSE LIVE ORAL $ 0.01 63600241 HC CCH DTAP IPV VACCINE 4-6 YRS IM $ 160.00 63600241 HC CCH DTAP IPV VACCINE 4-6 YRS IM $ 0.01 63600242 HC CCH DTAP HIB IP VACCINE IM $ 115.00 63600242 HC CCH DTAP HIB IP VACCINE IM $ 0.01 63600243 HC CCH DTAP VACCINE < 7 YRS IM $ 22.00 63600243 HC CCH DTAP VACCINE < 7 YRS IM $ 0.01 63600244 HC CCH LIVE MMR VACCINE SQ $ 0.01 63600244 HC CCH LIVE MMR VACCINE SQ $ 573.30 63600245 HC CCH POLIOVIRUS IPV SC/IM $ 91.00 63600245 HC CCH POLIOVIRUS IPV SC/IM $ 0.01 63600246 HC CCH DTAP HEP B IPV VACCINE IM $ 210.00 63600246 HC CCH DTAP HEP B IPV VACCINE IM $ 0.01 63600247 HC CCH MENINGOCOCCAL POLYSACCHARIDE VACCINE SQ $ 0.01 63600247 HC CCH MENINGOCOCCAL POLYSACCHARIDE VACCINE SQ $ 95.00 63600248 HC CCH MENB RECOMBINANT PROT VACCINE IM $ 21.25 63600248 HC CCH MENB RECOMBINANT PROT VACCINE IM $ 462.00 63600249 HC CCH MENB RECOMBINANT LIPOPROTEIN VACCINE IM $ 21.25 63600249 HC CCH MENB RECOMBINANT LIPOPROTEIN VACCINE IM $ 312.00 63600250 HC CCH COLLAGENASE CLOST HIST INJ 0.01 MG $ 133.32 63600251 HC CCH DENOSUMAB INJECTION 1 MG $ 49.27 63600253 HC CCH ESTRADIOL VALERATE INJ TO 10 MG $ 53.84 63600255 HC CCH UNCLASSIFIED DRUGS $ 163.00 63600256 HC CCH HYALGAN/SUPARTZ INJ PER DOSE $ 546.81 63600258 HC CCH HEP A VACCINE PED/ADOL 3 DOSE $ 0.01 63600259 HC CCH MENINGOCOCCAL VACCINE 4 DOSE < 18 MONTHS IM $ 21.25 63600260 HC CCH IIV ADJUVANT VACCINE IM $ 21.25 63600261 HC CCH IIV3 VACCINE PRESERVATIVE FREE INTRADERMAL $ 21.25 63600262 HC CCH CCIIV3 VACCINE PRESERVATIVE FREE 0.5 ML IM $ 21.25 63600263 HC CCH LAIV VACCINE PANDEMIC INTRANASAL $ 21.25 63600264 HC CCH IIV VACCINE PANDEMIC PRESERVATIVE FREE IM $ 21.25 63600265 HC CCH IIV VACCINE PANDEMIC ADJUVANTED IM $ 21.25 63600266 HC CCH RIV3 VACCINE PRESERVATIVE FREE IM $ 21.25 63600267 HC CCH RABIES VACCINE INTRADERMAL $ 21.25 63600268 HC CCH IIV4 VACCINE SPLIT 0.25 ML IM $ 21.25 63600269 HC CCH IIV4 VACCINE SPLIT 0.5 ML IM $ 21. 25 63600270 HC CCH TYPHOID VACCINE ORAL $ 21.25 63600271 HC CCH TYPHOID VACCINE IM $ 21.25 63600272 HC CCH DT VACCINE < 7 YRS IM $ 0.01 63600273 HC CCH YELLOW FEVER VACCINE LIVE SQ $ 21.25 63600274 HC CCH JAPANESE ENCEPHALITIS VACC INACTIVATED IM $ 21.25 63600275 HC CCH HEPB VACCINE 3 DOSE IMMUNSUP IM $ 21.25 63600276 HC CCH HEPB/HIB VACCINE IM $ 0.01 63600281 HC CCH BUDESONIDE NON-COMPOUNDED UP TO 0.5 MG $ 30.20 63600291 HC CCH ADRENALIN EPINEPHRINE INJ 0.1 MG $ 0.27 63600298 HC CCH EUFLEXXA INJ PER DOSE $ 899.00 63600298 HC CCH EUFLEXXA INJ PER DOSE $ 815.23 63600299 HC CCH INJ TESTOSTERONE CYPIONATE $ 1.00 63600299 HC CCH INJ TESTOSTERONE CYPIONATE $ 0.27 63600304 HC INJ MONOVISC PER DOSE $ 2,775.00 63600305 HC INJ HYMOVIS 1 MG $ 1,980.00 63600326 HC CCH DUROLANE INJECTION 1 MG $ 2,281.50 63600327 HC CCH TRIAMCINOLONE ACE XR INJECTION 1 MG $ 53.00 63600338 HC ORTHOVISC INJ PER DOSE $ 492.00 71000001 HC PHASE I RECOVERY FIRST 30 MINS $ 880.00 71000002 HC PHASE I RECOVERY EACH ADDL 15 MINS $ 396.00 71000003 HC PHASE II RECOVERY FIRST 30 MINS $ 252.00 71000004 HC PHASE II RECOVERY EACH ADDL 15 MINS $ 76.00 71000006 HC CCH RECOVERY EPIDURAL $ 165.00 71000007 HC CCH EXTENDED RECOVERY/HOUR ICU $ 64.00 71000008 HC CCH EXTENDED RECOVERY/HOUR $ 32.00

02-19-2019-A-PAC-057 Page 41 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 71000009 HC CCH IMAGING PROCEDURE RECOVERY $ 165.00 72200004 HC VAGINAL BIRTH $ 5,390.00 72200006 HC CCH VAGINAL BIRTH W/ RUPTURE OF MEMBRANE $ 4,064.00 72300001 HC NEONATAL CIRCUMCISION < 28 DAYS OLD $ 193.00 73000001 HC EKG 12-LEAD $ 146.00 73000001 HC EKG 12-LEAD $ 29.00 73000003 HC SIGNAL AVERAGED EKG $ 207.00 73000007 HC CCH WELCOME TO MEDICARE EKG W/ INTERPRETATION & REPORT $ 54.00 73100001 HC HOLTER MONITOR HOOK-UP UP TO 48 HOURS $ 224.00 73100002 HC HOLTER MONITOR SCAN UP TO 48 HOURS $ 573.00 73100003 HC EVENT RECORDER PATIENT ACTIVATED PER 30 DAYS $ 643.00 73100004 HC EXTERNAL ELECTROCARDIOGRAPHIC RECORDING >48 HOURS UP TO 21 DAYS $ 492.00 73100005 HC CCH EVENT MONITORING AND ANALYSIS $ 527.00 73100006 HC CCH EXT ELECTROCARDIOGRAPHIC RECORDING >48 HR UP TO 21 DAYS W/ RPT $ 558.00 73200002 HC WEARABLE TELEMETRY TECH SUPPORT PER 30 DAYS $ 1,276.00 74000001 HC MULTIPLE SLEEP LATENCY TEST ANY AGE $ 3,232.00 74000003 HC POLYSOMNOGRAPHY 4+ PARAMETERS AGE > 6 YRS $ 3,894.00 74000004 HC POLYSOMNOGRAPHY 4+ PARAMETERS W/ CPAP OR BI-LEVEL VENT AGE > 6 YRS $ 3,894.00 74000005 HC EEG 41-60 MINUTES $ 1,072.00 74000006 HC EEG > 1 HOUR $ 1,353.00 74000007 HC EEG AWAKE & DROWSY $ 838.00 74000008 HC EEG AWAKE & ASLEEP $ 1,029.00 74000009 HC EEG COMA OR SLEEP $ 1,163.00 74000010 HC EEG CEREBRAL DEATH EVALUATION $ 762.00 74000013 HC EEG MONITORING FOR CEREBRAL SEIZURES EACH 24 HOURS $ 1,660.00 74000014 HC EEG 24 HOURS $ 843.00 74000022 HC CCH SLEEP STUDY UNATTENDED W SIMULT RECORD HR/O2 SAT/RESP FLOW $ 1,704.00 75000001 HC ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC $ 3,086.00 75000002 HC ESOPHAGOSCOPY FLEXIBLE TRANSORAL W/ BX $ 5,886.00 75000003 HC ESOPHAGOSCOPY FLEXIBLE TRANSORAL W/ BAND LIGATION FOR ESOPHAGEAL VARICES $ 5,886.00 75000004 HC ESOPHAGOSCOPY FLEXIBLE TRANSORAL W/ REMOVAL FB $ 5,886.00 75000006 HC ESOPHAGOSCOPY FLEXIBLE TRANSORAL W/ BALLOON DILATION < 30MM $ 5,886.00 75000007 HC ESOPHAGOSCOPY FLEXIBLE TRANSORAL W/ ENDOSCOPIC ULTRASOUND $ 5,886.00 75000008 HC EGD FLEXIBLE TRANSORAL DIAGNOSTIC $ 3,086.00 75000009 HC EGD FLEXIBLE TRANSORAL W/ SUBMUCOSAL INJECTION $ 3,086.00 75000010 HC EGD FLEXIBLE TRANSORAL W/ ENDOSCOPIC ESOPHAGUS ULTRASOUND $ 5,886.00 75000011 HC EGD FLEXIBLE TRANSORAL W/ ULTRASOUND GUIDED FNA $ 5,886.00 75000012 HC EGD FLEXIBLE TRANSORAL W/ BX $ 3,086.00 75000013 HC EGD FLEXIBLE TRANSORAL W/ DRAINAGE PSEUDOCYST $ 11,072.00 75000014 HC EGD FLEXIBLE TRANSORAL W/ PLACEMENT TUBE/CATH $ 5,886.00 75000016 HC EGD FLEXIBLE TRANSORAL W/ SCLEROSIS VARICES $ 5,886.00 75000017 HC EGD FLEXIBLE TRANSORAL W/ BAND LIGATION VARICES $ 5,886.00 75000018 HC EGD FLEXIBLE TRANSORAL W/ DILATION GASTRIC OUTLET OBSTRUCTION $ 5,886.00 75000019 HC EGD FLEXIBLE TRANSORAL W/ PLACEMENT PERCUTANEOUS G-TUBE $ 5,886.00 75000020 HC EGD FLEXIBLE TRANSORAL W/ REMOVAL FB $ 3,086.00 75000021 HC EGD FLEXIBLE TRANSORAL W/ DILATION ESOPHAGUS OVER GUIDE WIRE $ 3,086.00 75000022 HC EGD FLEXIBLE TRANSORAL W/ BALLOON DILATION ESOPHAGUS <30MM $ 5,886.00 75000023 HC EGD FLEXIBLE TRANSORAL W/ REMOVAL TUMOR POLYP LESION BY HOT BX FORCEP $ 3,086.00 75000024 HC EGD FLEXIBLE TRANSORAL W/ REMOVAL TUMOR POLYP LESION BY SNARE $ 5,886.00 75000025 HC EGD FLEXIBLE TRANSORAL W/ CONTROL BLEEDING $ 5,886.00 75000028 HC EGD FLEXIBLE TRANSORAL W/ ENDOSCOPIC ULTRASOUND $ 5,886.00 75000039 HC DILATION ESOPHAGUS UNGUIDED SOUND OR BOUGIE $ 1,531.00 75000043 HC ENDO SMALL INTESTINE NO ILEUM DIAGNOSTIC $ 5,886.00 75000044 HC ENDO SMALL INTESTINE NO ILEUM W/ BX $ 5,886.00 75000045 HC ENDO SMALL INTESTINE NO ILEUM W/ REMOVAL FB $ 5,886.00 75000046 HC ENDO SMALL INTESTINE NO ILEUM W/ REMOVAL TUMOR POLYP LESION BY SNARE $ 5,886.00 75000047 HC ENDO SMALL INTESTINE NO ILEUM W/ CONTROL BLEEDING $ 5,886.00 75000048 HC ENDO SMALL INTESTINE NO ILEUM W/ ABLATION TUMOR POLYP LESION $ 5,886.00 75000049 HC ENDO SMALL INTESTINE NO ILEUM W/ PLACEMENT PERCUTANEOUS J-TUBE $ 5,887.00 75000050 HC ENDO SMALL INTESTINE NO ILEUM W/ CONVERSION G-TUBE TO J-TUBE $ 5,886.00 75000051 HC ENDO SMALL INTESTINE W/ ILEUM DIAGNOSTIC $ 5,886.00 75000052 HC ENDO SMALL INTESTINE W/ ILEUM W/ BX $ 5,886.00 75000053 HC ENDO SMALL INTESTINE W/ ILEUM W/ CONTROL BLEEDING $ 5,886.00 75000054 HC ILEOSCOPY THROUGH STOMA DIAGNOSTIC $ 3,087.00 75000056 HC ENDO SMALL INTESTINE POUCH DIAGNOSTIC $ 2,944.00 75000057 HC ENDO SMALL INTESTINE POUCH W/ BX $ 2,944.00 75000058 HC COLONOSCOPY THROUGH STOMA DIAGNOSTIC $ 2,944.00 75000059 HC COLONOSCOPY THROUGH STOMA W/ BX $ 3,872.00 75000060 HC COLONOSCOPY THROUGH STOMA W/ ABLATION TUMOR POLYP LESION $ 3,872.00 75000061 HC COLONOSCOPY THROUGH STOMA W/ STENT PLACEMENT $ 17,379.00 75000062 HC SIGMOIDOSCOPY RIGID DIAGNOSTIC $ 2,944.00

02-19-2019-A-PAC-057 Page 42 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 75000063 HC SIGMOIDOSCOPY RIGID W/ BX $ 3,872.00 75000064 HC SIGMOIDOSCOPY FLEXIBLE DIAGNOSTIC $ 2,944.00 75000065 HC SIGMOIDOSCOPY FLEXIBLE W/ BX $ 2,944.00 75000066 HC SIGMOIDOSCOPY FLEXIBLE W/ REMOVAL FB $ 3,872.00 75000067 HC SIGMOIDOSCOPY FLEXIBLE W/ REMOVAL TUMOR POLYP LESION BY HOT BX FORCEP $ 2,944.00 75000068 HC SIGMOIDOSCOPY FLEXIBLE W/ CONTROL BLEEDING $ 3,872.00 75000069 HC SIGMOIDOSCOPY FLEXIBLE W/ SUBMUCOSAL INJECTION $ 2,944.00 75000070 HC SIGMOIDOSCOPY FLEXIBLE W/ DECOMPRESSION $ 3,872.00 75000071 HC SIGMOIDOSCOPY FLEXIBLE W/ REMOVAL TUMOR POLYP LESION BY SNARE $ 3,872.00 75000072 HC SIGMOIDOSCOPY FLEXIBLE W/ ABLATION TUMOR POLYP LESION $ 3,872.00 75000073 HC SIGMOIDOSCOPY FLEXIBLE W/ TRANSENDOSCOPIC BALLOON DILATION $ 3,872.00 75000074 HC SIGMOIDOSCOPY FLEXIBLE W/ ULTRASOUND GUIDED FNA $ 3,872.00 75000075 HC SIGMOIDOSCOPY FLEXIBLE W/ STENT PLACEMENT $ 17,379.00 75000076 HC COLONOSCOPY FLEXIBLE DIAGNOSTIC $ 2,944.00 75000077 HC COLONOSCOPY FLEXIBLE W/ REMOVAL FB $ 3,872.00 75000078 HC COLONOSCOPY FLEXIBLE W/ BX $ 3,872.00 75000079 HC COLONOSCOPY FLEXIBLE W/ SUBMUCOSAL INJECTION $ 3,872.00 75000080 HC COLONOSCOPY FLEXIBLE W/ CONTROL OF BLEEDING $ 3,872.00 75000081 HC COLONOSCOPY FLEXIBLE W/ ABLATION TUMOR POLYP LESION $ 3,872.00 75000082 HC COLONOSCOPY FLEXIBLE W/ REMOVAL TUMOR POLYP LESION BY HOT BX FORCEP $ 3,872.00 75000083 HC COLONOSCOPY FLEXIBLE W/ REMOVAL TUMOR POLYP LESION BY SNARE $ 3,872.00 75000084 HC COLONOSCOPY FLEXIBLE W/ TRANSENDOSCOPIC BALLOON DILATION $ 3,872.00 75000085 HC COLONOSCOPY FLEXIBLE W/ STENT PLACEMENT $ 3,872.00 75000086 HC COLONOSCOPY FLEXIBLE W/ ENDOSCOPIC ULTRASOUND $ 3,872.00 75000087 HC COLONOSCOPY FLEXIBLE W/ ULTRASOUND GUIDED FNA $ 3,872.00 75000088 HC ESOPHAGEAL MOTILITY STUDY $ 1,494.00 75000092 HC REFLUX TEST MUCOSAL ATTACHED TELEMETRY ANALYSIS & REPORT $ 2,847.00 75000093 HC ESOPHAGEAL FUNCTION TEST < 1 HOUR ANALYSIS & REPORT $ 862.00 75000098 HC ENDOSCOPY CAPSULE ESOPHAGUS TO ILEUM $ 2,809.00 75000101 HC SIGMOIDOSCOPY FLEXIBLE SCREENING $ 2,946.00 75000102 HC COLONOSCOPY SCREENING HIGH RISK $ 2,946.00 75000103 HC COLONOSCOPY SCREENING $ 2,946.00 75000107 HC ESOPHAGOSCOPY FLEXIBLE TRANSORAL W/ DILATION VIA GUIDE WIRE $ 5,886.00 75000108 HC ESOPHAGOSCOPY FLEXIBLE TRANSORAL W/ US GUIDED FNA/BX $ 5,886.00 75000113 HC EGD FLEXIBLE TRANSORAL W/ THERMAL ENERGY DELIVERY $ 11,072.00 75000116 HC COLONOSCOPY STOMA W/ REMOVAL HOT BX FORCEPS $ 3,872.00 75000117 HC COLONOSCOPY STOMA W/REMOVAL BY SNARE $ 3,872.00 75000120 HC ESOPHAGOSCOPY FLEXIBLE TRANSORAL W/ OPTICAL ENDOMICROSCOPY $ 5,886.00 75000121 HC EGD FLEXIBLE TRANSORAL W/ OPTICAL ENDOMICROSCOPY $ 11,072.00 75000124 HC SIGMOIDOSCOPY FLEXIBLE W/ ENDOSCOPIC ULTRASOUND EXAM $ 3,872.00 75000125 HC ESOPHAGOSCOPY FLEXIBLE TRANSORAL W/ REMOVAL OF TUMOR BY SNARE $ 5,886.00 75000126 HC COLONOSCOPY THROUGH STOMA W/ CONTROL OF BLEEDING $ 3,872.00 75000127 HC ESOPHAGOSCOPY RIGID TRANSORAL DIAGNOSTIC $ 5,886.00 75000128 HC ESOPHAGOSCOPY RIGID TRANSORAL W/ SUBMUCOSAL INJECTION $ 5,886.00 75000129 HC ESOPHAGOSCOPY RIGID TRANSORAL W/ BX $ 5,886.00 75000130 HC ESOPHAGOSCOPY RIGID TRANSORAL W/ REMOVAL FB $ 5,886.00 75000131 HC ESOPHAGOSCOPY RIGID TRANSORAL W/ TRANSENDOSCOPIC BALLOON DILATION < 30MM $ 5,886.00 75000132 HC ESOPHAGOSCOPY RIGID TRANSORAL W/ DILATION VIA GUIDE WIRE $ 11,072.00 75000133 HC ESOPHAGOSCOPY FLEXIBLE TRANSNASAL DIAGNOSTIC $ 3,087.00 75000134 HC ESOPHAGOSCOPY FLEXIBLE TRANSNASAL W/ BX $ 3,087.00 75000135 HC ESOPHAGOSCOPY FLEXIBLE TRANSORAL W/ ENDOSCOPIC MUCOSAL RESECTION $ 5,886.00 75000136 HC ESOPHAGOSCOPY FLEXIBLE TRANSORAL W/ PLACEMENT OF ENDOSCOPIC STENT $ 5,886.00 75000137 HC ESOPHAGOSCOPY FLEXIBLE TRANSORAL W/ DILATION ESOPHAGUS BY BALLOON OR DILATOR $ 5,886.00 75000138 HC ESOPHAGOSCOPY FLEXIBLE TRANSORAL W/ DILATION ESOPHAGUS W/ BALLOON $ 5,886.00 75000139 HC ESOPHAGOSCOPY FLEXIBLE TRANSORAL W/ ABLATION TUMOR/POLYP OR OTHER LESION $ 11,072.00 75000140 HC EGD FLEXIBLE TRANSORAL W/ BALLOON DILATION ESOPHAGUS >30MM W/ FLUORO $ 5,886.00 75000141 HC EGD FLEXIBLE TRANSORAL W/ TRANSENDOSCOPIC US GUIDED TRANSMURAL INJECTION $ 5,886.00 75000142 HC EGD FLEXIBLE TRANSORAL W/ ENDOSCOPIC MUCOSAL RESECTION $ 5,886.00 75000143 HC EGD FLEXIBLE TRANSORAL W/ PLACEMENT ENDOSCOPIC STENT $ 5,886.00 75000144 HC EGD FLEXIBLE TRANSORAL W/ ABLATION TUMOR/POLYP OR OTHER LESIONS W/ PRE/POST DILATION $ 5,886.00 75000145 HC ERCP W/ PLCMT ENDO STENT INTO BILIARY/PANCREATIC DUCT W/ DILATION & SPHINCTEROTOMY EACH STENT $ 11,073.00 75000146 HC ERCP W/ REMOVAL FOREIGN BODY/STENT $ 11,072.00 75000147 HC ERCP W/ REMOVAL/EXCHANGE STENT W/ DILATION & SPHINCTEROTOMY EACH STENT EXCHANGED $ 11,073.00 75000148 HC ERCP W/ TRANS-ENDOSCOPIC BALLOON DILATION OF BILIARY/PANCREATIC DUCT/SPHINCTEROPLASTY EACH DUCT $ 11,072.00 75000149 HC ERCP W/ ABLATION TUMOR/POLYP OR OTHER LESION $ 11,072.00 75000152 HC COLONOSCOPY FLEXIBLE W/ ENDOSCOPIC MUCOSAL RESECTION $ 3,870.00 75000155 HC ESOPHAGOSCOPY FLEXIBLE TRANSORAL W/ SUBMUCOSAL INJECTION $ 5,886.00 75000156 HC ESOPHAGOSCOPY FLEXIBLE TRANSORAL W/ SCLEROSIS VARICES $ 5,886.00 75000157 HC ESOPHAGOSCOPY FLEXIBLE TRANSORAL W/ REMOVAL TUMOR POLYP LESION BY HOT BX FORCEP $ 5,886.00 75000158 HC SIGMOIDOSCOPY FLEXIBLE W/ BAND LIGATION $ 3,872.00 75000159 HC EGD FLEXIBLE TRANSORAL W/ ESOPHAGOGASTRIC FUNDOPLASTY INCL DUODENOSCOPY PARTIAL OR COMPLETE $ 8,829.00

02-19-2019-A-PAC-057 Page 43 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 75000165 HC COLONSCOPY FLEXIBLE W/ BAND LIGATION $ 2,903.00 75000167 HC CCH COLONOSCOPY THROUGH STOMA W/ BALLOON DILATION $ 3,688.00 76100094 HC NEGATIVE PRESSURE WOUND TX W/ DME <= 50 SQ CM $ 186.00 76100095 HC NEGATIVE PRESSURE WOUND TX W/ DME > 50 SQ CM $ 316.00 76100131 HC NEGATIVE PRESSURE WOUND TX DISPOSABLE NON-DME <= 50 SQ CM $ 626.00 76100132 HC NEGATIVE PRESSURE WOUND TX DISPOSABLE NON-DME > 50 SQ CM $ 756.00 76100134 HC CCH INJECTION ALLERGEN IMMUNOTHERAPY SINGLE $ 34.00 76100134 HC CCH INJECTION ALLERGEN IMMUNOTHERAPY SINGLE $ 27.50 76100135 HC CCH INJECTION ALLERGEN IMMUNOTHERAPY MULTIPLE $ 53.00 76100136 HC CCH DEVELOPMENTAL SCREEN W/ SCORING AND DOCUMENTATION $ 26.00 76200001 HC OBSERVATION $ 29.00 76200002 HC OBSERVATION $ 61.00 77000005 HC CCH CA SCREENING PELVIS & BREAST EXAM $ 69.00 77100001 HC VACCINE ADMINISTRATION INITIAL $ 25.00 77100001 HC VACCINE ADMINISTRATION INITIAL $ 21.25 77100002 HC VACCINE ADMINISTRATION EACH ADDITIONAL $ 14.00 77100002 HC VACCINE ADMINISTRATION EACH ADDITIONAL $ 25.00 77100003 HC INFLUENZA VACCINE ADMINISTRATION $ 25.00 77100004 HC PNEUMOCOCCAL VACCINE ADMINISTRATION $ 25.00 77100006 HC HEPATITIS B VACCINE ADMINISTRATION $ 25.00 77100009 HC CCH IM ADMINISTRATION < 18 YRS INITIAL $ 25.00 77100009 HC CCH IM ADMINISTRATION < 18 YRS INITIAL $ 21.25 77100010 HC CCH IM ADMINISTRATION < 18 YRS EA ADDL $ 25.00 77100011 HC CCH IMMUNIZATION ADMINISTRATION ORAL/NASAL INITIAL VACCINE $ 25.00 77100012 HC CCH IMMUNIZATION ADMINISTRATION ORAL/NASAL EA ADDL VACCINE $ 25.00 78001341 Suture, 3-0 Silk A184H $ 64.50 78100002 Mini Acutrak Screw 20.0 $ 1,122.00 78100003 Standard Acutrak Screw - 26.0 $ 1,122.00 78100004 1.7 T Plate Narrow $ 1,131.00 78100005 Rumi Ii $ 2,343.81 78100006 30.0 Std Acutrak Screw $ 1,122.00 78100007 Lncs Dci Adult Spo2 Reusable Sensor $ 384.60 78100008 6-Label Anesthesia Sheet, 1-1/2" X 1/2" $ 92.37 78100012 Quickpass Tendon Shuffle Small $ 255.00 78100014 Elizer Esling Shoulder Immobilizer $ 240.00 78100018 Prineo Dermabond 60Cm $ 408.42 78100019 Cancellous 15 (4-10Mm) $ 861.30 78100020 Cancellous 30 (4-10Mm) $ 1,503.90 78100021 Cancellous 15 (1-4Mm) $ 993.60 78100022 Eigr Saber Waveguide With Yankauer, Taper Tip $ 825.00 78100023 Accutrak Micro Screw 20.0 Micro $ 1,122.00 78100024 Ponto Plus, Left, Chroa Beige $ 13,425.00 78100025 Bard Eliminator Balloon 12Mm $ 314.70 78100029 Guide Drill, 3-4Mm $ 735.00 78100030 Wide Countersing, 4Mm $ 735.00 78100034 Medline Direct Interior Pack (Foster) $ 1,573.86 78100035 Femur Shaft Fz $ 6,334.38 78100036 Lemaitre Vascular Riddick Catheter $ 449.85 78100037 4302 Organ Tissue Scale $ 3,690.75 78100038 4 Wire Spiral Basket $ 81.18 78100040 Erbe Apc Probe Straight Fire $ 635.55 78100042 C-Qur Mesh 25.4Cm X 35.5 Cm $ 672.00 78100043 2 Orthocord $ 154.26 78100047 Large Needle Driver $ 6,600.00 78100048 Koh Cup Small 30 Cm $ 471.36 78100049 Koh Cup Medium 35 Cm $ 471.36 78100050 Koh Cup Large 40 Cm $ 471.36 78100051 Baxter Endoscopic Applicator 41Cm $ 182.67 78100052 Laryngeal Skimmer Point Angle Rotatable M4 27Cm (Grimes) $ 1,338.75 78100054 Hand Control, Hana $ 4,469.40 78100055 Pillings Maloneystyle Esophageal Bougie 52Fr $ 836.61 78100056 Pillings Maloneystyle Esophageal Bougie 56Fr $ 903.15 78100057 Pillings Maloneystyle Esophageal Bougie 44Fr $ 701.37 78100058 Pillings Maloneystyle Esophageal Bougie 48Fr $ 764.19 78100059 Pillings Maloneystyle Esophageal Bougie 40Fr $ 618.27 78100060 Pillings Maloneystyle Esophageal Bougie 36Fr $ 528.03 78100061 Pillings Maloneystyle Esophageal Bougie 32Fr $ 512.67 78100062 Pillings Maloneystyle Esophageal Bougie 28Fr $ 474.06 78100063 Datascope Db9 Spo2 Sensor $ 330.00 78100064 Shiley Pediactric Trach Tubes 4.0 $ 225.00 78100065 Shiley Pediactric Trach Tubes 4.5 $ 225.00

02-19-2019-A-PAC-057 Page 44 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 78100066 Shiley Pediactric Trach Tubes 5.0 $ 225.00 78100067 Trach Tubes Size 6 $ 225.00 78100068 Trach Tubes Size 10 $ 225.00 78100069 Ped Trach Tubes Size 5.5 $ 225.00 78100071 3.5 Cortex Screw $ 61.56 78100072 Semi-Tendinosus Tendon (4.5X210 Mm) Flexgraft $ 3,168.00 78100073 Allnside Pst Tib Ten-Sl(9.0X2200 Mm) I $ 3,251.25 78100074 O2 Flow Meter $ 109.17 78100076 Zimmer Reciprocating Saw Blade $ 100.98 78100077 Fromm Femur + Tibia Triangles $ 332.49 78100079 Fwplq Pat. Ligament W/Quad $ 17,565.00 78100080 Donut Head Pads (Adult) $ 282.21 78100081 Lachiewicz Fem Dis Impactor $ 897.87 78100082 Omega Connector Kurz $ 630.00 78100083 Kumar Cholangiography Clamp $ 2,055.00 78100084 Cdh33 Stapler $ 987.45 78100085 Endo-Scrub 2 Sheath, 4Mm, 30 Degree K. Storz Sharpsite Ac $ 160.38 78100086 Endo-Scrub 2 4Mm, 70 Degree K. Storz Sharpsite $ 160.38 78100088 Kurz Medical Tvfmi 13 X 6.0 X 0.25Mm $ 1,347.00 78100089 Synthes Drill Bit 4.0 X 260 $ 567.21 78100090 Snthes Drill Bit 3.2 X 330 $ 668.85 78100091 Synthes Drill Bit 4.2 X 330 $ 668.85 78100092 Mentor Saline Smmooth Round 325Cc $ 2,010.00 78100093 Surgicool Pulllover Toga 2Xl $ 219.66 78100095 Quintube Monitor Pack $ 61.92 78100096 10Cm Merocel Epistaxis Packing $ 63.00 78100098 Mips Surgery Kit $ 1,606.50 78100099 Mips Back-Up Surgery Kit $ 796.50 78100101 1.7 X10 Screw $ 196.29 78100103 Ponto Plus Power, Left, Mocca Brown $ 11,967.90 78100104 Ponto Streamer, Blacl $ 1,185.00 78100106 Micro Acutrak 2 Screw Sizer $ 102.00 78100107 Halo 360 Ablation Catheter $ 5,670.00 78100110 Esling Elizer Small/Medium (R) Shoulder Immobilizer $ 240.00 78100111 Esling Elizer Large/Xlarge (R) Shoulder Immobilizer $ 240.00 78100112 Esling Elizer Large/Xlarge (L) Shoulder Immobilizer $ 240.00 78100113 Esling Elizer Small/Medium (L) Shoulder Immobilizer $ 240.00 78100114 Davinci Robotic Bulldog Clamp (Urology) $ 2,838.00 78100115 Davinci Robotic Bulldog Clamp Curved (Urology) $ 3,054.00 78100119 6 Shelf System $ 321.75 78100120 Bite Block $ 60.00 78100121 Pulmonary Aspiration Needle With Side Hole $ 184.08 78100122 Gamma Nail Lag Screw, Ti 80Mm $ 1,402.20 78100123 Micro Acutrak 2 Bone Screw 10.0Mm $ 1,218.00 78100124 127 Degree Cemented Hip Stem $ 5,400.00 78100125 16 Hole Locking Medial Plate $ 2,688.00 78100126 Endomark Endoscopic Ink Marker $ 126.00 78100132 Stryker Hip Blade $ 174.75 78100133 Xc200: Ethicon Lapra-Ty Absorbable Suture Clips $ 250.35 78100134 Lapra-Ty Asorbable Suture Clip Applier, 33Cm Length $ 3,050.79 78100136 Trocar Bladed 11Mm/100Mm (Stab Sleeve Handled) $ 141.15 78100139 Roth Net Foreign Body Retreival $ 282.00 78100141 7Ba10-D-Mn #1 Diamond Burr $ 501.00 78100142 Ethicon Gst60W $ 538.05 78100143 Endo Retract 31Cm (Urology) Disposable $ 631.44 78100144 Floseal [Hemostatic Matrix] 10 Ml, 6 Pack (Urology) $ 1,207.56 78100145 Suture 2-0 9In V-Loc 90 Device Gs-21 (Urology) $ 104.10 78100146 2N05A: Cv-2 (Usp 0) Gore-Tex 36" Thx-26 Taper $ 73.26 78100148 Patella - Knee $ 1,500.00 78100149 Femur - Knee $ 6,420.00 78100150 Tibial Base - Knee $ 4,650.00 78100151 Insert - Knee $ 3,825.00 78100153 4-0 Fierloop 12In. W/ Needle $ 150.00 78100156 Olympus Air/Water Channel Cleaning Adapter $ 352.86 78100157 Y Mesh (Urology) $ 277.50 78100158 Acutrak 2 Fixation Sys. Size: 32.0Mm, 2 Standard Bone Screw $ 1,104.00 78100159 Acutrak 2 Fixation Sys. Size: 34.0Mm, 2 Standard Bone Screw $ 1,104.00 78100160 Acutrak 2 Fixation Sys. Size: 16.0Mm, 2 Standard Bone Screw $ 1,104.00 78100161 Acutrak 2 Fixation Sys. Size: 20.0Mm, 2 Standard Bone Screw $ 1,104.00 78100162 Pre-Filter Replacement Kit For System 1E Processor $ 532.80 78100163 Zerotip Niitinol Retrieval Basket 1.9F X 120Cm $ 615.00

02-19-2019-A-PAC-057 Page 45 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 78100164 Synovial Ronguer (Dawson) $ 517.50 78100165 I-125 Seeds Loaded $ 63.00 78100166 I-Seed I125 Therasleeve $ 84.00 78100167 Stabilization Needle Set $ 225.00 78100168 Handpiece $ 4,425.00 78100169 4.0 Jacobs $ 825.00 78100170 Trinkle/Ao Adapter $ 675.00 78100171 Pin Driver $ 840.00 78100172 Sagittal Saw $ 4,125.00 78100177 Laser Shield Ii Endotracheal Tube 6.5 $ 318.24 78100180 Procise Xp Tonsil & Adenoid Wand (Hunyadi) $ 780.00 78100181 Reflex 45 Turbinate Wand (Hunyadi) $ 654.75 78100182 Entact Septal Stapler (Hunyadi) $ 480.00 78100183 Stammberger Sinus Foam $ 201.00 78100185 Adflow, Bulb And Valve, Large (870Ln & 871) $ 103.56 78100186 Arthrex, 4.0Mm Excalibur $ 135.00 78100187 Bio-Composite 2.9 X 15.5 $ 1,200.00 78100188 Arthrex, 5.5 Double Cut $ 135.00 78100190 18.5Mm O.O. Flange Canal Sz 9-15Mm Femoral Cement Restrictor $ 805.65 78100191 2.0Mm Qfx Screw 12Mm $ 543.78 78100197 Reuter Bobbin Vent Tube Fluroplastic 1Mm Interflange 0.045 (1.14Mm I.D.) $ 73.92 78100199 Gamma, Long Nail $ 5,023.50 78100200 Gamma, Lag $ 1,402.20 78100202 Bra Compression 34 #F020093 $ 79.59 78100203 Bra Compression 42 $ 79.59 78100204 Innomed Stabilizing Clamp $ 1,029.93 78100205 Curves Rasp $ 2,381.10 78100208 Ellman Iec Nuetral Plate $ 546.00 78100209 Ellman Ball Electrode 2.36Mm Ball (Ghazoul) $ 243.00 78100210 Ellman Needle Electrode 3/8" Fine Wire (Ghazoul) $ 255.00 78100211 Suture With Needle V-Loc $ 105.45 78100212 Reddick-Saye Screw Retractor Kit $ 286.80 78100213 Zipwire 0.035 Angled $ 178.20 78100215 Achillles Ten-Bone Block (16X250Mm) $ 5,265.00 78100219 Insulated Iv Pressure Infuser Bag $ 471.42 78100220 Medex C-Fusor® Pressure Infusor Device 1000Ml $ 202.98 78100224 Gamma, Drill Ao Sterile 04,2X180Mm $ 338.40 78100229 Verro5130 $ 189.75 78100237 Polaris Ultra Stent - 6F X 26 $ 455.10 78100238 Polaris Ultrastent - 6F X 24 $ 455.10 78100239 Angled Zipwire Hydrophilic Guidewire (150Cm .035In/.89Mm) $ 113.16 78100240 Prograsp Forceps Davinci 8Mm $ 6,600.00 78100241 Zimmer Vacuum Foot Pump Ii $ 873.00 78100243 Advincula Delineator Uterine Manipilator Small $ 480.00 78100244 Advincula Delineator Uterine Manipilator Medium $ 480.00 78100245 Advincula Delineator Uterine Manipulator Large $ 480. 00 78100246 Rumi Ii Handle $ 2,343.81 78100247 011 X 180Mm X 130 Gamma Stryker $ 3,436.20 78100248 Halo Ablation 60 Cath $ 4,470.00 78100249 Halo Ablation 90 Cath $ 4,470.00 78100250 Marcon Colon Decompression Set .035In / 480Cm 7 Fr. 2.8Mm $ 432.00 78100256 Kit, Evac Silicone 100Cc Bard $ 79.14 78100257 Locator Nerve Vari-Stim Iii $ 370.53 78100258 Nasal Septal Button $ 273.00 78100259 Ta Premium 55 3.5Mm Auto Suture (Zaghlool) $ 579.51 78100260 Repair Kit For Dual Lumen Body Groshong/Cath Tech Cv $ 463.95 78100261 Medtronic 19Cm Antimicrobial Dialysis Catheter (Zaghlool) $ 1,245.00 78100262 Medtronic 23Cm Antimicrobial Dialysis Catheter (Zaghlool) $ 1,245.00 78100265 Olympus 21G Disposable Injector Nm $ 79.56 78100267 Bio-Swivelock Sp Vented, 5.5 Mm X 24.5 Mm, Self-Punching $ 1,200.00 78100272 7Ba30 #3 Cutting Burr $ 462.00 78100275 Ethicon Contour Curved Cutter Stapler (3.0Mm X 4.7Mm) (Zaghlool) $ 1,413.66 78100276 Ethicon 1 Endopouch Retriever (Zaghlool) $ 207.42 78100278 Ellman 3-Button Finger Switch Handpiece With Locking Chuck (Ghazoul) $ 1,818.00 78100283 Bio-Composite 2.9 X 12.5 $ 1,200.00 78100291 Brown/Gorski 8Mm Tibial Tray Hook W/Stand Slaphammer $ 1,539.39 78100292 Concise Cement Sculps Kit Disposable $ 104.34 78100293 Synthes 1.7 Cables With Crimp 750Mm Sterile (Dawson) $ 2,308.50 78100294 Midas Rex Oil Diffusers $ 91.50 78100296 Mindray, Spectrum Paitent Monitor Nibp, Spo2 (Masimo), 3 Lead Ecg $ 6,585.00 78100297 Arthrex Suture Lasso 25 Degree Tight Curve Right $ 420.00

02-19-2019-A-PAC-057 Page 46 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 78100300 Ligasure Maryland $ 1,567.50 78100301 All-Inside Ant Tib Ten-Sl-Zorc (8.5X200 Mm)-Sl $ 3,350.25 78100303 Spot Endoscopic Marker 5Ml Syringe $ 102.36 78100305 Sagittal Blade - Total Hip $ 119.94 78100306 C-Qur V-Patch 6.4Cm X 2.5" Meduim $ 1,282.74 78100307 Biocomposite Pushlock $ 1,200.00 78100309 Halo Barrx 360 Express Rfa Balloon Catheter $ 6,600.00 78100310 Powered Ethicon Stapler $ 1,180.83 78100313 Argon Single Function Handpiece (Ghazoul) $ 236.82 78100316 Roll 3In X 15Ft Fiberglass Splint System $ 159.39 78100317 Roll 4In X 15Ft Fiberglass Splint System $ 191.28 78100318 Roll 5In X 15Ft Fiberglass Splint System $ 239.10 78100325 Drainage Chest Pleur-Evac Sahara $ 101.25 78100326 Tube Sz4 Trach Cuffed Low Pressure $ 149.19 78100327 Tube Sz6 Trach Cuffed Low Pressure $ 149.19 78100328 Tube 10Mm Trach Cuffed Low Pressure $ 149.19 78100330 Catheter, Groshong Power Port $ 1,575.00 78100331 Linear Cutter Reload $ 277.26 78100332 Cutter, Reload Linear 55 Mm $ 186.72 78100335 Fiberwire 2 $ 66.00 78100336 Single Use Rotatable Clip Fixing Device $ 229.32 78100339 Ethicon Liga Clip 10Ml $ 327.36 78100340 Carter Thompson Ct Closure System $ 370.80 78100341 Sterillium Scrub $ 174.45 78100342 Schon Xl Catherter Sets 15 Cm Vessel $ 610.20 78100343 Pillow Abduction Med $ 62.07 78100345 Tube Trach Shiley Adult Regsz8 $ 149.19 78100346 Screw Aeutrak Standard 22.0Mm $ 1,122.00 78100350 Inflator Kit 18 In Kit Balloon, Nuvent Em Sinus Dialtion System $ 587.10 78100351 Cutting, #4 Dissecting Tool Medtronic $ 462.00 78100352 Pill Cam 10Pk $ 1,560.00 78100353 Wiresensor, 0.35 Straight Dual Flex $ 130.38 78100354 Stent, Polaris 5Fr X 26Cm $ 441.00 78100355 Stent, Polaris 5Fr X 24Cm $ 441.00 78100356 Stent, Percuflex 6Fr X 24Cm $ 240.00 78100357 Stent, Percuflex 6Fr X 26Cm $ 240.00 78100359 Telescoping, Trom Advance Standard Don Joy $ 322.20 78100360 Telescoping, Trom Advance Xlarge Don Joy $ 348.06 78100362 Manifold, Transposal Ultraflex Dornach $ 65.97 78100366 Forceps, Maryland Bipolar $ 8,100.00 78100367 Forceps, Fenestrated Bipolar $ 8,100.00 78100368 Hook, Permanent Cautery $ 6,000.00 78100371 Passport 2 Pinch Lead, 3 Lead Wire Set, 24In $ 175.50 78100372 Mesh, Mycro Plus 5 X 10Cm $ 432.00 78100373 Graft, 6Mm X 40Cm Standard Welled $ 3,117.00 78100374 Graft, 8Mm Ax-Bifemeral $ 7,434.00 78100375 Mesh, Reinforcement Bio A Tissue 8 X B $ 1,203.00 78100380 Suture, Mersilene 5Mm $ 388.89 78100381 Trocar Bladed Long 12Mm X 150Mm (Stab Sleeve) $ 163.32 78100382 Trocar, Bladed 12 Mm X 100Mm (Stab Sleeve) $ 193.26 78100383 Stapler Curved Intraluminal 29Mm $ 987.45 78100390 Lube, Electro Anti-Stick Solution 4 Ml $ 84.15 78100391 Catheter, 5F X 80Cm Embolectomy $ 227.04 78100392 Catheter, 3F X 80Cm Embolectomy $ 227.04 78100393 Catheter, 2F X 60 Cm Ebolectomy $ 351.30 78100394 Catheter, 4F X 80 Cm Embolectomy $ 227.04 78100395 Catheter, 6F X 80 Cm Embolectomy $ 227.04 78100396 Pack Surgcl Basic Vi $ 191.34 78100397 Kit, Pulsavac Plus Fan $ 119.94 78100399 Bowl, Mixing Quick-Vac 15 Pack $ 180.60 78100404 Blade, Dermetome Zimmer $ 141.00 78100405 Kit Cvc Multilumen W/Syringe Ltx $ 174.09 78100408 Sagittal Blade - Total Knee $ 107.10 78100411 Patella Blade - Total Knee $ 119.94 78100412 Pack Laparoscopy Lf $ 1,159.11 78100413 Pack Arthroscopy $ 948.75 78100414 Pack C-Section Custom $ 356.25 78100416 Tray Thoracentesis/Paracentesis $ 82.41 78100417 Pack Total Joint $ 844.56 78100423 Suture, Chromic Gut 7-0 $ 293.55 78100427 Suture, Prolene 5-0 18 In Blue $ 61.56

02-19-2019-A-PAC-057 Page 47 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 78100428 Mesh, Prolen 12X12 Hernia $ 1,428.81 78100432 Guide, Pin 2.8 Threaded $ 132.18 78100433 Screw, Threaded 16 Mm For Cannulated Set 7.3 75 $ 750.21 78100434 Screw, Threaded 16 Mm For Cannulated Set 7.3 90 $ 750.21 78100435 Screw, Threaded 32 Mm For Cannulated Set 7.3 90 $ 750.21 78100436 Screw, Threaded 32 Mm For Cannulated Set 7.3 95 $ 750.21 78100437 Screw, Threaded 16 Mm For Cannulated Set 7.3 95 $ 750.21 78100440 Screw, 3.5 Cortical 10 Mm $ 61.56 78100441 Screw, 3.5 Cortical 12 Mm $ 61.56 78100442 Screw, 3.5 Cortical 14 Mm $ 61.56 78100443 Screw, 3.5 Cortical 16 Mm $ 61.56 78100444 Screw, 3.5 Cortical 18 Mm $ 61.56 78100445 Screw, 3.5 Cortical 20 Mm $ 117.00 78100446 Screw, 3.5 Cortical 24 Mm $ 61.56 78100447 Screw, 3.5 Cortical 26 Mm $ 61.56 78100448 Screw, 3.5 Cortical 28 Mm $ 61.56 78100449 Screw, 3.5 Cortical 34 Mm $ 61.56 78100450 Screw, 3.5 Locking 14 Mm $ 363.81 78100451 Screw, 3.5 Locking 16 Mm $ 363.81 78100452 Screw, 3.5 Locking 18 Mm $ 363.81 78100453 Screw, 3.5 Locking 20 Mm $ 363.81 78100454 Screw, 3.5 Locking 24 Mm $ 363.81 78100455 Screw, 3.5 Locking 30 Mm $ 363.81 78100456 Screw, 3.5 Locking 40 Mm $ 363.81 78100457 Plate, 1/3 7 Hole 85 Mm Tubular With Collar $ 501.66 78100458 Plate, 1/3 8 Hole $ 526.50 78100459 Plate, 1/3 9 Hole 109 Mm Tubular With Collar $ 526.50 78100460 Plate, 1/3 10 Hole 121 Mm Tubular With Collar $ 526.50 78100461 Needle System, Fast Fix Curved $ 876.03 78100462 System, Straight Needle Fast-Fix $ 876.03 78100463 Filter, Steris Water $ 720.00 78100464 Tubing Arthroscopy 10 K Inflow/Out Flow $ 135.96 78100466 Cutter, Meniscus Merlin Gator 4.2 $ 185.55 78100467 Tip, Rumi White 6.7Mm Length 6 Cm $ 145.08 78100468 Tip, System Rumi 6.7Mm Length 8 Cm $ 145.08 78100469 Burr, Oval 6Mm $ 151.41 78100470 Cutter, Miniscus 5.5 $ 142.14 78100471 Battery Con Med Small $ 897.75 78100474 Electrode, Pediatric Quik Pace $ 151.20 78100475 Cannula, 7Mm Twist In $ 75.00 78100476 Needle, Multifire Scorpion $ 510.00 78100477 Anchors, 5.5 Swivelock $ 1,260.00 78100478 Fiberlink 2 $ 165.00 78100479 Cannula, Arthrex Passport Button 8Mmx4Cm $ 96.00 78100480 Cannula, Arthrex Passport Button 8Mmx3Cm $ 96.00 78100481 Kit, Disposable Acl Without Saw Blade $ 435. 00 78100482 Tape, Fiber 2Mm $ 150.00 78100483 Lasso, Suture Sd Cresent Arthrex $ 420.00 78100484 Anchor, Suture Bio Swivelock 4.75X24.5 $ 1,200.00 78100485 Anchors, 5.5 Non Punching $ 1,200.00 78100486 Swivelock, Peek 4.75 Self Pounding $ 1,200.00 78100487 Swivelock, Peek 5.5. Self Pounding $ 1,200.00 78100488 Tape, Tiger 2 2Mm $ 150.00 78100489 Tak, Suture 2.4X8.5 Bio-Composite Mini $ 975.00 78100490 Reamer, Coring 10Mm $ 615.00 78100491 2.3 X 6Mm Screw $ 133.20 78100493 Restraint, Allen Universal Head $ 66.00 78100494 Forceps, Ferris Smith Tissue $ 151.41 78100495 System, Cemex Fast Set $ 942.00 78100496 Module, Iv Delivery Pink/Red $ 108.00 78100497 Module, Iv Delivery Green $ 108.00 78100498 Module, Iv Delivery Blue $ 108.00 78100501 Pencil, Smoke Evacuator Gold Vac Open Cases $ 104.55 78100502 Manuplator, Vcare Dx Uterine $ 280.08 78100506 Probe, Incrementing Prass $ 513.36 78100507 Blade, Inferior Turbinate 2.0Mm $ 669.06 78100508 Sheath, Endo-Scrub 4Mm $ 168.48 78100509 Tube, Endotracheal Nim Reinforced Emg 7Mm $ 1,015.20 78100510 Splint, Nasal Doyle Ii $ 128.10 78100511 Electrode, Subdermal Nm Paired $ 278.76 78100512 Tracker, Patient Em Ent $ 525.36

02-19-2019-A-PAC-057 Page 48 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 78100513 Tracker, Instrument $ 411.84 78100515 Tubing, Irrigator Straight Shot To Xps Medium $ 81.09 78100516 Tip, Rumi 5.1 Mm X 3.75Cm Yellow $ 145.08 78100517 Tip, Rumi 5.1 Mm X 6 Cm Purple $ 145.08 78100518 Tip, Rumi 6.7 Mm X 12 Cm Orange $ 145.08 78100519 Tip, Rumi 6.7Mm X 10Cm $ 145.08 78100520 Sealant, Fibrin Tisseel 4Ml $ 500.28 78100521 Tray, Peg Ponsky Pull $ 8,220.00 78100522 Groshong, Single Lumen $ 840.00 78100524 Catheter, Groshong Dual Lumen $ 1,047.00 78100525 Glidewire, Zipwire Straight 0.035 $ 164.82 78100526 Procedure Set, Genesys Hta Procerva $ 3,450.00 78100527 Guidewire, Straight .038X150Cm $ 113.16 78100528 System, Solyx Sis $ 5,025.00 78100529 Stent, Variable Length Counter, 6.0 Fr $ 342.00 78100530 System, Advantage Fit $ 3,900.00 78100531 Kit, Catheter Uromax Balloon Dilator 18 Fr 4 Cm $ 829.02 78100532 Stent, Variable Length Ureteral $ 342.00 78100536 Set, Prostate Stabilization 18G X 20 Cm $ 118.50 78100537 Suture, Vloc 180 2-0 $ 91.05 78100538 Kit, Laparoscopic Care Advanced D-Help $ 133.86 78100539 Wire, Guide Halo Flexible $ 369.00 78100540 Catheter, Barrx Halo Channel Rfa Endo $ 4,369.26 78100541 Hemostat, Arist Absorabable $ 802.50 78100542 Tray, Cholecystectomy $ 753.15 78100543 Shears, Curved Harmonic Ace 36Cm $ 1,496.40 78100544 Trocar, Bladeless 12Mm X 100Mm (Blunt Tip) - Hasson $ 176.40 78100545 Trocar, Bladeless 5Mm X 150Mm $ 127.50 78100546 Cutter, Echelon Flex 60Mm Linear $ 1,104.03 78100547 Cutter, Echelon Flex 45 Mm Linear $ 1,095.99 78100548 Cutter, Echelon White Reload $ 440.10 78100549 Cutter, Proximate Linear 75Mm $ 519.93 78100552 Vapr Premiere 50 With Hand Control $ 525.00 78100553 Electrode, Vapr S90 With Hand Control $ 525.00 78100554 Sheild, Face T5 Hood With Peel Away $ 70.41 78100556 Cross Cut, Large Tear Rasp $ 380.13 78100558 Set, Interpulse Handpiece With High Flow Tip And Suction $ 133.65 78100559 Hood, Flyte With Peelaway $ 117.63 78100560 Blade, Saw Average Medium 25.01Mm $ 154.65 78100561 Labels, Veriad Sterile $ 92.40 78100562 Trocar, Bladeless 12Mm X 100Mm (Stab Sleeve) $ 143.55 78100563 Trocar Bladeless 5Mm X 100Mm (Stab Sleeve) $ 109.89 78100564 Applier, Endoscopic Ligaclip Large $ 344.49 78100565 Stapler, Skin Wide Rotating Head 35 $ 62.85 78100573 Adhesive, Advanced Dermabond $ 66.63 78100575 Trocar, Endopath Bladeless W/ Stability Sleeve $ 168. 72 78100577 Applier, Ligaclip Multiclip Medium $ 195.75 78100578 Cutter, 55Mm Linear With Safety Lock Out $ 348.39 78100579 Trocar, Bladed 5Mm X 100Mm (Stab Sleeve) $ 108.45 78100584 Endoloop Ligature Pds Ii $ 149.22 78100585 Stapler, Linear Proximate Reload For Tx60B $ 170.46 78100586 Cutter Ets-Flex Articulating Endo Linear 35Mm Vascular/Thin White $ 919.44 78100587 Stapler, Proximate 60Mm Blue $ 340.92 78100588 Stapler, 35Mm Vascular Thin Articulating $ 919.44 78100589 Cutter, Endo Gia Short 45 Articulating $ 1,110.66 78100590 Cutter, Reload Linear 35Mm $ 396.12 78100596 Suture Prolene 7-0 $ 83.19 78100608 Applier, Endoscopic Ligaclip Small $ 192.33 78100615 Kit, Hana Table Blue Foam Disposable (Non-Stock) $ 114.09 78100620 Blade, Knife, Carpal Tunnel $ 658.35 78100622 Drape, Lingeman 3-1 $ 78.39 78100624 Mesh, Proloop Plug 1.3 X 155 Medium $ 747.00 78100625 Mesh, Prolite Plug 3 X 6 Rectangle Oval Flat $ 105.00 78100626 Mesh, Proloop Plug No Onlay Large $ 417.00 78100627 Sheet, Prolit Mesh Plug Rectangle Oval Flat 2X4 $ 85.98 78100628 Sheet, Prolit Mesh Plug Square Round Flat 6X6 $ 91.62 78100629 Mesh, C. Qur 25.4 Cm X 35.5Cm 14 Inch $ 4,393.92 78100630 Port, Access 8 Mm Airseal $ 253.38 78100631 Port, Access 12Mm Airseal $ 262.65 78100633 Tip, Accesory Cover $ 60.00 78100634 Accessory Kit, Disposable 3 Arm $ 600.00

02-19-2019-A-PAC-057 Page 49 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 78100635 Obturator, Bladeless 8Mm $ 75.00 78100636 Sealer, Vessel $ 1,785.00 78100638 Powder, Spray Sclerosol Intrapleural Aerosol $ 444.00 78100639 Suction, Disposable Lap Irrigation $ 370.74 78100645 Electrode, Loop 24 Fr .015 $ 197.49 78100646 Pen, Buffalo Plume $ 77.10 78100647 Tubing Assembly A-V Impuls System $ 75.33 78100650 Multistick 10Sg Reagent $ 90.72 78100653 Capsule, Pill Cam Patency 5-Pack $ 90.00 78100656 Aspiration Kit $ 180.66 78100657 Speedband Superview Super 7 $ 825.00 78100658 Suture, Quill Monoderm 2 (45Cm X 45Cm) $ 83.94 78100661 Zimmer Disp Tourniquet Sz 24" $ 61.50 78100662 Zimmer Disp Tourniquet Sz 30" $ 66.60 78100663 Zimmer Disp Tourniquet Sz 34" $ 70.50 78100664 Zimmer Disp Tourniquet Sz 42" $ 81.00 78100665 Ttp-Variac System Total 0.2X3.0-7.0Mm $ 1,332.00 78100666 Ttp-Variac System Partial Titanium 0.2X1.75-4.5Mm $ 1,332.00 78100667 Zimmer Reciprocating Saw Blade 76Mml 12.5Mmw 0.64/1.00Mm $ 100.98 78100668 Zimmer Oscillating Saw Blade 90Mml 20Mmw 1.19Mm $ 119.94 78100669 Zimmer Oscillating Saw Blade 65Mml 30Mmw 0.89Mm $ 107.10 78100670 Zimmer Oscillating Saw Blade 105Mml 20Mmw 1.19Mmt $ 107.10 78100672 Suture, Quill Monoderm 0 (36Cm X 36Cm) $ 80.25 78100676 Super Multivac 50 W/Finger Switch $ 495.00 78100677 Super Turbovac 90 W/Finger Switch (Endo) $ 495.00 78100678 Sorbafix Absorable Fixation System 36Cm/15 Fasteners $ 1,470.00 78100680 Bilateral Knee Drape Sterile $ 120.63 78100683 Toga Pullover, Surgicool Flyte, Xl $ 86.88 78100684 Midas Rex 4Mm Burr (Green) $ 651.00 78100685 Instrument Ligasure Impact Open 36Mm - 18Cm $ 1,170.00 78100686 V-Loc 3-0 (180 Day) 12" (30Cm) $ 96.48 78100688 Arthrex 0-Fiberwire $ 66.00 78100689 Kit Trimano Beach Chair - Shoulder $ 225.00 78100691 Dermabond Prineo 22Cm $ 253.77 78100692 C-Qur V-Patch 4.3Cm X 1.7" Small $ 1,012.68 78100693 Standard Tip Stylet Iv Medtronic Malleable Suction Medium $ 1,200.00 78100694 Main Pump Tubing $ 183.00 78100695 C-Qur V-Patch 8.0Cm X 3.2" Large $ 1,667.43 78100698 Tenckhoff Peritoneal Catheter, Universal, 2 Cuffs 47Cm $ 142.26 78100699 Hug U -Vac Steep Trend Posistioner $ 7,497.00 78100700 Disposable Kit- Short Push Lock $ 525.00 78100701 Dornach Ultra Enzyme With Odor Ban $ 125.97 78100702 Plasma Blade 3.05 $ 975.00 78100703 Dissector 3.5Mm X 13Cm $ 135.00 78100704 Doublecut 4.0Mm X 13Cm $ 135.00 78100705 Acutrak 2 Fixation Sys. Size: 22.0Mm, 2 Mini Bone Screw $ 1,104.00 78100706 Acutrak 2 Fixation Sys. Size: 16.0Mm, 2 Micro Bone Screw $ 1,104.00 78100707 Nuvent Em Sinus Dilation System Enoid (6 X 17Mm) (Grimes) $ 1,100.10 78100708 Nuvent Em Sinus Dilation System Sphenoid (7 X 17Mm) (Grimes) $ 1,100.10 78100709 Nuvent Em Sinus Dilation System Maxillary (5 X 7Mm) (Grimes) $ 1,393.65 78100710 Nuvent Em Sinus Dilation System Maxillary (6 X 7Mm) (Grimes) $ 1,393.65 78100711 Nuvent Em Sinus Dilation System Maxillary(7 X 7Mm) (Grimes) $ 1,393.65 78100712 Nuvent Em Sinus Dilation System Frontal (6 X 17Mm) (Grimes) $ 2,861.40 78100713 Nuvent Em Sinus Dilation System Frontal (7 X 17Mm) (Grimes) $ 2,861.40 78100714 Kit Stabilization Shoulder (12) $ 201.00 78100716 Olympus Injector Force Max Colonoscope Needle $ 86.73 78100719 Arthrex Suctioner Ma $ 207.00 78100720 Large Coagulating Electrode- 22/24Fr $ 336.96 78100722 Esling Elizur Small/Medium (R) Shoulder Immobilizer $ 240.00 78100723 Esling Elizur Large/Xlarge (R) Shoulder Immobilizer $ 240.00 78100724 Esling Elizur Small/Medium (L) Shoulder Immobilizer $ 240.00 78100725 Esling Elizur Large/Xtra Lrg (L) Shoulder Immobilizer $ 240.00 78100728 V-Loc 4-0 (90-Day) 18" (45Cm) $ 105.45 78100730 Dilator, Balloon Pet Bard Eliminator 15 Mm 45 Fr $ 315.00 78100731 Burr, Oval 5.5 Mm 12 Flute $ 135.00 78100732 Excalibur 4.0Mm $ 135.00 78100733 Double Cut 5.5 $ 135.00 78100738 Fiberwire 5 $ 120.00 78100739 Seal, Cannula 8.5 Mm - 13Mm Davinci $ 120.00 78100744 Tube, Endotracheal Emg Reinforced $ 1,015.20 78100745 Lamina, Epi Disc Otologic $ 228.15

02-19-2019-A-PAC-057 Page 50 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 78100747 Stapler Echelon 35 Flex Powered $ 1,182.42 78100748 Reload White For Endopath Echelon $ 543.72 78100749 Pack Shoulder Beach Chair Custom $ 965.58 78100751 Kit Dressing Med Granufoam Sil $ 214.02 78100752 Electrode W/Quik-Combo Connect $ 78.75 78100753 Canister 500Ml Infovac W/O Gel $ 105.99 78100754 2.8 Drill Bit $ 243.00 78100755 2.8Mm X 5" Quick Release Surgibit Drill $ 162.00 78100757 27Mm Pins $ 264.60 78100758 3.5Mm A-L-D Tib Lk Pl6H R 98Mm $ 4,738.20 78100760 48Mm Pins $ 264.60 78100761 6.4 Lambotte Curved Osteotome $ 563.55 78100762 6.4 Lambotte Straight Osteotome $ 563.55 78100763 Accolade 127 Deg Hip $ 8,700.00 78100764 Accolade Ii - Hip $ 12,060.00 78100765 Accolade Ii - Hip $ 8,700.00 78100767 Accolade Ii 127 Deg Hip $ 8,700.00 78100768 Accolade Ii 127 Degree - Hip $ 8,700.00 78100769 Accolade Ii 132 Deg - Hip $ 12,060.00 78100770 Accolade Ii Sz8 127 Deg Hip $ 12,060.00 78100772 Acetabular Augment Size 54X15Mm Hip $ 8,654.10 78100773 Acutrak 2 Drill Long $ 645.00 78100781 Adapter Femoral Head +14Mm Hip $ 450.00 78100782 Adapter Sleeve - Hip $ 491.61 78100783 Agmt Block Posterior Sz E 5Mm Knee $ 3,895.50 78100784 Agmt Block Sz E 10Mm Knee $ 3,895.50 78100785 Baseplate - Knee $ 6,000.00 78100788 Baseplate - Knee $ 4,800.00 78100793 Baseplate Sz 6 - Knee $ 6,000.00 78100796 Baseplate Sz6 Knee $ 4,800.00 78100797 Biolox Delta Fem Head, 36Mm, +0Mm - Total Hip $ 3,450.00 78100798 Biolox Delta Option Fem Head - Hip $ 7,429.80 78100799 Biosure $ 633.45 78100800 Biosure Ha 7Mm X 25Mm $ 633.45 78100801 Biosure Ha 7Mm X 30Mm $ 633.45 78100802 Biosure Ha 8Mm X 25M $ 633.45 78100803 Bone Screw 18.0Mm $ 1,122.00 78100804 Bone Screw 34.0Mm $ 1,104.00 78100805 Bone Screw 6.5X25 Self Tap Hip $ 150.00 78100806 Bone Screw 6.5X30 Self Tap Hip $ 150.00 78100808 Bone Screw 6.5X35 Self-Tap Hip $ 150.00 78100809 Bone Screw 6.5X40 Self-Tap Hip $ 150.00 78100810 Bone Screw Standard 34.0Mm $ 1,104.00 78100811 Canal Sizes 9-12Mm-Cemented $ 364.80 78100812 Cannulated Screw 54Mm 4.0 $ 575.91 78100813 Cement Bone Femoral Prep Kit $ 385. 56 78100814 Cement Mixing System $ 768.00 78100815 Cement Mixing System - Foot $ 768.00 78100816 Clot Buster, Dornoch $ 199.44 78100817 Coblation Wands- Procise Xp $ 780.00 78100818 Coblation Wands- Ultra Flex $ 654.75 78100819 Cone Aa Body 40X35Mm Std Offest Hip $ 14,181.30 78100820 Coupler 6Mm - Knee $ 4,650.75 78100821 Coupler Offset 2Mm Knee $ 4,650.75 78100823 Cutter Suture Fast Fix Meniscal Knot $ 420.00 78100824 Delta Head 32Mm - Hip $ 3,720.00 78100825 Delta Head 32Mm/+4 Hip $ 2,700.00 78100826 Dermacarriers Ii $ 870.00 78100827 Distal Agmt Block Size E Knee $ 3,895.50 78100828 Distal Augment Blcok Sz D 5Mm Knee $ 3,895.50 78100829 Distal Centalizer 14Mm Hip $ 240.00 78100830 Dornach Ultra Enzyme With Odor Ban $ 503.88 78100832 Drill 1.5Mm - Trauma $ 393.84 78100835 Drill Bit $ 678.00 78100838 Drill Bit 2.5X125Mm Gold Trauma $ 408.66 78100840 Driver Bit Hex 4.5Mm Knee $ 1,260.00 78100841 Entact Septal Stapler (Hunyadi) $ 1,440.00 78100842 Evac Chemical Flow Sensor $ 525.00 78100843 Ex Long Micro Screw 30Mm $ 1,122.00 78100846 Fast Fix Straight Needle $ 1,275.00 78100847 Fast-Fix Curved Needle $ 1,275.00

02-19-2019-A-PAC-057 Page 51 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 78100848 Fast-Fix Reverse Curved Needle $ 1,275.00 78100849 Fem Component - Knee $ 5,100.00 78100850 Fem Component - Knee $ 5,100.00 78100853 Fem Component - Knee $ 7,500.00 78100858 Fem Head - Hip $ 3,450.00 78100860 Fem Head 36Mm Hip $ 3,450.00 78100861 Fem Head 36Mm, +0Mm $ 3,450.00 78100862 Fem Ps Cmt Ccr Std Sz 8 L Knee $ 7,350.00 78100863 Fem Wdg 5Mmsz3-4 Lng $ 4,251.00 78100864 Fem Wedge- Knee $ 4,251.00 78100865 Femur - Knee $ 7,350.00 78100866 Femer Component Cemented - Knee $ 5,100.00 78100868 Femoral - Knee $ 31,215.00 78100869 Femoral Component - Knee $ 5,100.00 78100872 Femoral Component Beaded W/Pa Knee $ 7,500.00 78100873 Femoral Constrained 5 Rt Knee $ 24,521.25 78100874 Femoral Cr Cmt Ccr Std Sz6 Knee $ 7,350.00 78100875 Femoral Cr Cmt Ccr Std Sz6 R Knee $ 7,350.00 78100876 Femoral Head - Hip $ 1,575.00 78100877 Femoral Head 28Mm Hip $ 1,575.00 78100878 Femoral Lps-Flex Sz E Lt Knee $ 7,350.00 78100879 Femoral Oxin Sz5 - Knee $ 10,889.94 78100880 Femoral Std Sz8 - Knee $ 7,350.00 78100881 Femoral Stem Hip $ 5,100.00 78100882 Femoral Sz 5 - Knee $ 31,215.00 78100883 Femoral Szf-Lt Knee $ 23,654.40 78100884 Femur $ 31,215.00 78100887 Femur - Knee $ 7,500.00 78100889 Femur - Knee $ 24,521.25 78100890 Femur - Knee $ 31,215.00 78100891 Femur Component - Knee $ 7,500.00 78100892 Femur Head - Hip $ 6,512.10 78100893 Femur Stem - Hip $ 5,100.00 78100894 Femur Sz 4 - Knee $ 31,215.00 78100897 Fitmore Hip Stem A $ 8,100.00 78100898 Fitmore Hip Stem B Ext Sz4 Hip $ 8,100.00 78100899 Fitmore Hip Stem C, Size 5 - Total Hip $ 10,740.00 78100902 Gamma Nail Lag Screw, Ti 100Mm $ 1,402.20 78100903 Gamma Nail Lag Screw, Ti 105Mm $ 1,402.20 78100905 Gamma Nail Lag Screw, Ti 75Mm $ 1,402.20 78100907 Gamma Nail Lag Screw, Ti 85Mm $ 1,402.20 78100908 Gamma Nail Lag Screw, Ti 90Mm $ 1,402.20 78100909 Gamma Nail Lag Screw, Ti 95Mm $ 1,402.20 78100910 Gamma Nail Locking Screw, 30Mm $ 326.40 78100911 Gamma Nail Locking Screw, 35Mm $ 326.40 78100912 Gamma Nail Locking Screw, 40Mm $ 326. 40 78100913 Gamma Nail, Ball Tipped Guide Wire $ 243.00 78100914 Gamma Nail, Closed Tube Clip $ 262.80 78100915 Gamma Nail, Drill Ao, 300Mm $ 315.60 78100916 Gamma Nail, K-Wire $ 216.00 78100918 Gamma, 04, 2X180Mm $ 595.20 78100919 Gamma, 05X45Mm $ 326.40 78100920 Gamma, Lag Screw Ti, 110Mm $ 1,402.20 78100922 Guide Pin Tro Pt 1.3X140 $ 67.65 78100923 Handpiece, Surgilave Plus With High Flow Trauma Tips $ 709.20 78100925 Hat-Trick Pip Fus 3.2 $ 2,730.00 78100928 Head - Hip $ 2,400.00 78100929 Head - Hip $ 2,700.00 78100932 Head 36Mm - Hip $ 1,050.00 78100934 Head Endo 45Mm Hip $ 1,150.80 78100935 Head Femoral 48Mm Hip $ 1,050.00 78100936 Healicoil $ 1,185.00 78100937 Hemispherical - Hip $ 2,400.00 78100938 Hemispherical 50Mm - Hip $ 4,500.00 78100942 Hemispherical Ha Solid Bk 58Mm Hip $ 2,400.00 78100943 High Flex Xlpe Sz 3-4 9Mm Knee $ 5,184.15 78100944 High Flow Tip $ 369.30 78100945 Hudson Modified Trinkle Adapter $ 2,221.59 78100946 Insert $ 16,875.00 78100949 Insert - Hip $ 2,850.00 78100950 Insert - Knee $ 3,300.00

02-19-2019-A-PAC-057 Page 52 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 78100965 Insert - Knee $ 15,825.00 78100966 Insert - Knee $ 16,875.00 78100969 Insert 10Mm - Knee $ 15,825.00 78100970 Insert 11Mm - Knee $ 3,300.00 78100971 Insert 11Mm - Knee $ 5,786.04 78100972 Insert 32Mm - Hip $ 4,200.00 78100973 Insert 36Mm Hip $ 2,850.00 78100974 Insert 9Mm - Knee $ 3,300.00 78100975 Insert Sz 4 16Mm Knee $ 3,300.00 78100976 Insert Sz 6 - Knee $ 3,300.00 78100977 Insert Sz 6 Knee $ 3,300.00 78100978 Insert Sz3 9Mm Knee $ 3,300.00 78100979 Insert Sz3-4 11Mm - Knee $ 16,875.00 78100980 Insert Sz4 11Mm Knee $ 3,300.00 78100981 Insert Sz5-6 - Knee $ 7,800.00 78100982 Insert Sz6 16Mm Knee $ 3,300.00 78100983 Insert Sz7 13Mm Knee $ 3,300.00 78100984 Irrigation Only Short Tip $ 369.00 78100985 Jrny Ii Cr Isrt Xlpe Rt Sz 3-4 9Mm Knee $ 15,330.00 78100986 Lcck Femoral Size D-Rt Knee $ 23,654.40 78100987 Lcck Femoral Sz E-Lt Knee $ 23,654.40 78100988 Lcck Femoral Sz E-Rt Knee $ 23,654.40 78100989 Legion Con Art Ins 9Mm Sz 1-2 $ 7,800.00 78100990 Lgn Hm St 5-6 5Mm Ltla-Rtmed - Knee $ 5,206.50 78100991 Lgn Hm St 5-6 5Mm Ltmd-Rtla - Knee $ 5,206.50 78100992 Lgn Ox Constrained Fem 4 Lt $ 24,521.25 78100993 Lgn Pressfit Stem 11Mm X 160Mm $ 4,660.50 78100994 Lgn Pressfit Stem 14Mm X 120Mm $ 4,533.75 78100995 Lgn Rev Tibia Base Sz 2 Lt $ 9,798.75 78100996 Lifelink Tissue Bank Cancellous 1-4Mm 30Cc $ 1,485.00 78100997 Lifelink Tissue Bank Cancellous 4-10Mm 30Cc $ 1,485.00 78100998 Liner - Hip $ 5,791.80 78100999 Liner - Hip $ 11,932.20 78101000 Liner Constrained 28Mm Hip $ 11,932.20 78101001 Liner Constrained Nn 36X62 Hip $ 11,932.20 78101002 Liner Neutral 36 X 54 Hip $ 3,630.00 78101003 Liner Neutral 36 X 56 Hip $ 3,630.00 78101004 Liner Neutral 36 X 60 Hip $ 3,630.00 78101005 Liner Neutral 36 X 52 Hip $ 3,630.00 78101006 Liner Neutral 36 X 58 Hip $ 3,630.00 78101007 Liner Neutral 36 X 62 Hip $ 3,630.00 78101008 Liner Neutral Pp 36 X 66 Hip $ 3,630.00 78101009 Locking Cortical Peg 26Mm $ 294.00 78101011 Locking Hexalobe Screw 20Mm $ 303.00 78101013 Locking Hexalobe Screw 26Mm $ 303.00 78101014 Locking Hexalobe Screw 28Mm $ 303. 00 78101015 Locking Hexalobe Screw 38Mm $ 303.00 78101016 Locking Hexalobe Screw 50Mm $ 366.00 78101018 Long Nail Kit R1.5, Ti, Right $ 6,781.50 78101019 Lps Flex Fixed Nsm Art Surf Ef 3-4 10Mm Knee $ 2,100.00 78101020 Lps-Flex Fixed Nsm Art Surf 12Mm - Knee $ 2,100.00 78101021 Lps-Flex Fixed Nsm Art Surf Ef 5-6 12Mm Knee $ 2,100.00 78101022 Lps-Flex Fixed Prolong Art Sur $ 3,000.00 78101023 Lps-Flex Fixed Prolong Art Sur Cd Knee $ 3,000.00 78101024 M/L Taper 15 Std Hip $ 6,450.00 78101025 Manifold, Transposal Ultraflex Dornach $ 1,583.28 78101028 Mis Headed Screw 27Mm $ 264.60 78101029 Mis Headed Screw 27Mm Knee $ 264.60 78101030 Mis Headed Screw 33M Knee $ 264.60 78101031 Mis Headed Screw 48Mm Knee $ 264.60 78101032 Mixevac Iii $ 1,659.90 78101034 Mixing System, 3 Dose Compact Vacuum Cement $ 317.94 78101035 Modular Endo Head 54Mm Hip $ 1,150.80 78101036 Multivac 50 $ 495.00 78101037 Nasal Tampon Rapid Rhino 5.5Cm $ 957.00 78101042 Non-Locking Hexalobe Screw 28Mm $ 195.00 78101043 Nsm Art Surf Ef 3-4 12Mm Knee $ 2,100.00 78101044 Olecranon Plate 3-Hole Lt $ 2,358.00 78101045 Packing, Absorbent, Ortho-Dri 8" $ 681.00 78101046 Paella Metal Backed Knee $ 2,100.00 78101048 Palacos Lv 1X40 Single $ 257.19

02-19-2019-A-PAC-057 Page 53 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 78101049 Palacos R 1X40 Single $ 297.00 78101050 Palacos R+G 1X40 Single With Gentamicin $ 941.97 78101051 Patella $ 2,214.90 78101052 Patella - Knee $ 1,125.00 78101054 Patella - Knee $ 2,100.00 78101066 Patella - Knee $ 1,958.10 78101068 Patella 32Mm Knee $ 1,125.00 78101069 Patella 32X10 Knee $ 2,100.00 78101070 Patella 35Mm - Knee $ 1,125.00 78101071 Patella 35X10 Knee $ 2,100.00 78101072 Patella 38Mm - Knee $ 1,125.00 78101073 Patella Blade - Total Knee $ 107.10 78101074 Patella Knee $ 2,100.00 78101075 Patella S36X10 Knee $ 5,367.00 78101076 Patella S9Mm Knee $ 1,125.00 78101077 Peg 12Mm Locking Cortical $ 294.00 78101081 Peg 28Mm $ 294.00 78101082 Peg Locking Cortical 14Mm $ 294.00 78101083 Peg Locking Cortical 18Mm $ 294.00 78101084 Peg Locking Cortical 2.3Mm $ 294.00 78101085 Peri-Loc 3.5Mm T20 Lock Screw 22Mm $ 320.76 78101086 Peri-Loc 3.5Mm T20 Lock Screw 24Mm $ 320.76 78101087 Peri-Loc 3.5Mm T20 Lock Screw 30Mm $ 320.76 78101088 Peri-Loc 3.5Mm T20 Lock Screw 34Mm $ 320.76 78101089 Pin 27Mm $ 213.03 78101090 Pin 27Mm $ 264.60 78101095 Pin 48Mm $ 264.60 78101098 Pin Headless - Knee $ 1,429.35 78101101 Pin Passing Drill Tip 381Mm $ 250.23 78101102 Pinaball Pin - Knee $ 1,429.35 78101104 Pins $ 264.60 78101109 Plate 5 Hole One Third Tub Ss Trauma $ 208.26 78101110 Plate 6-Hole Left Clavicle $ 3,273.00 78101111 Plate Distal Clavicle 12 Holes Left - Clavical $ 3,273.00 78101112 Plate Extension $ 1,701.00 78101113 Plate Humeral $ 5,190.00 78101121 Plate Narrow Right - Trauma $ 2,808.00 78101124 Pressfit Stem - Knee $ 4,660.50 78101125 Prolong Art Sur E 1-2 14Mm Knee $ 3,000.00 78101126 Ps Asf Ps 11Mm Ply R 6-9Cd Knee $ 2,100.00 78101127 Psm Asf Cr 12Mm Ve R 3-11Ef Knee $ 3,600.00 78101128 Psn Asf Cr 10Mm Knee $ 3,600.00 78101129 Psn Asf Cr 10Mm Ve L 3-11Ef Knee $ 3,600.00 78101130 Psn Asf Cr 10Mm Ve L 3-9 Cd Knee $ 3,600.00 78101131 Psn Asf Cr 10Mm Ve L 7-12Gh Knee $ 3,600.00 78101132 Psn Asf Cr 10Mm Ve R 3-11 Ef Knee $ 3,600.00 78101133 Psn Asf Cr 10Mm Ve R 7-12Gh Knee $ 3,600.00 78101134 Psn Asf Cr 11Mm - Knee $ 3,600.00 78101135 Psn Asf Cr 11Mm Ve L 3-9 Cd Knee $ 3,600.00 78101136 Psn Asf Cr 11Mm Ve R 3-9 Cd Knee $ 3,600.00 78101137 Psn Asf Cr 12Mm Ve L 3-11Ef Knee $ 3,600.00 78101138 Psn Asf Cr 12Mm Ve R 7-12Gh Knee $ 3,600.00 78101139 Psn Asf Cr 13Mm - Knee $ 3,600.00 78101141 Psn Asf Cr 18Mm Ve L 7-12Gh Knee $ 3,600.00 78101142 Psn Asf Ps 10Mm Ve L 6-9 Ef Knee $ 3,600.00 78101143 Psn Asf Uc 10Mm Ply L 4-11 Ef - Knee $ 2,100.00 78101144 Psn Fem Cr Cmt Ccr Nrw Sz8 Knee $ 7,350.00 78101145 Psn Fem Cr Cmt Ccr Std Sz 12 R Knee $ 7,350.00 78101146 Psn Fem Cr Cmt Ccr Std Sz7 L Knee $ 7,350.00 78101147 Psn Fem Cr Cmt Ccr Std Sz7 R Knee $ 7,350.00 78101148 Psn Fem Cr Cmt Ccr Std Sz9 L Knee $ 7,350.00 78101149 Psn Fem Cr Cmt Ccr Std Sz9 R Knee $ 7,350.00 78101150 Psn Fem Ps Cmt Ccr Std Sz6 R Knee $ 7,350.00 78101151 Psn Str Hyb St - Knee $ 6,300.00 78101152 Psn Tib Stem 5 Deg Sz C R Knee $ 3,300.00 78101153 Psn Tib Stm 5 Deg Sz D L Knee $ 3,300.00 78101154 Psn Tib Stm 5 Deg Sz E R Knee $ 3,300.00 78101155 Psn Tib Stm 5 Deg Sz F L Knee $ 3,300.00 78101156 Puros Demineralized Bone Putty 2Cc $ 1,183.20 78101157 Puros Demineralized Bone Putty 5Cc $ 2,470.95 78101158 Quick Release Burgibit Drill - Clavical $ 360.00

02-19-2019-A-PAC-057 Page 54 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 78101160 Repair Sm. Stryker Driver $ 4,470.00 78101161 Retrievers, Suture Hewson $ 1,217.52 78101162 Revision Tip $ 345.00 78101164 Rotating Hinge Articular Surface F Knee $ 6,499.50 78101165 Rotating Hinge Fem Sz F Knee $ 6,588.00 78101166 Sagittal Blade - Total Hip $ 91.80 78101168 Sagittal Blade Total Knees $ 177.87 78101169 Sagittal Blade Wide Medium ( Hips) $ 106.11 78101170 Saw Blade $ 380.13 78101171 Screw $ 432.00 78101186 Screw 32Mm $ 202.50 78101190 Screw 32Mm $ 630.00 78101191 Screw 40Mm $ 202.50 78101195 Screw 54Mm $ 630.00 78101196 Screw 60Mm $ 202.50 78101201 Screw Bone 12Mm - Trauma $ 339.33 78101202 Screw Cortex 26Mm $ 108.75 78101203 Screw Cortex 28Mm $ 117.00 78101204 Screw Cortical 52Mm - Trauma $ 81.90 78101205 Screw Dis Fem Wdg Sz5 5Mm Knee $ 4,611.75 78101206 Screw Hexalobe 10Mm - Clavical $ 411.00 78101207 Screw Hexalobe 12Mm - Clavical $ 411.00 78101208 Screw Hexalobe 14Mm - Clavical $ 411.00 78101209 Screw Lcoking 10Mm - Trauma $ 196.35 78101210 Screw Lcoking 14Mm - Trauma $ 421.20 78101211 Screw Locking 20Mm - Trauma $ 421.20 78101212 Screw Locking 22Mm - Trauma $ 421.20 78101215 Screw Mis 27Mm $ 264.60 78101220 Screw Non Toggling Cortical 20Mm $ 294.00 78101222 Screw Self Tap Cortical 3.5X42Mm Trauma $ 93.60 78101223 Screw Self Tap Cortical 3.5X46Mm Trauma $ 93.60 78101224 Service Labor Ultra $ 465.00 78101225 Set, Interpulse Handpiece With High Flow Tip And Suction $ 684.30 78101226 Shell Cluster Hole 52 Hip $ 3,900.00 78101227 Shell Cluster Hole 54 Hip $ 3,900.00 78101228 Shell Cluster Hole 56 Kk Hip $ 3,900.00 78101229 Shell Cluster-Hole 60Mm Hip $ 3,900.00 78101230 Shell Cluster-Hole 62 Nn Hip $ 3,900.00 78101231 Shell Inserter $ 2,925.00 78101232 Shell Multi-Hole 56 Hip $ 9,504.60 78101233 Shell Multi-Hole 58 Ll Hip $ 9,504.60 78101234 Shell Multi-Hole 62 Nn Hip $ 9,504.60 78101235 Shell Multi-Hole 66 Pp Hip $ 9,504.60 78101236 Shell Multi-Hole Hip $ 9,504.60 78101237 Spray Tip With Soft Cone Splash Shield $ 300.00 78101238 Stammberger Sinus Foam $ 402. 00 78101240 Stem - Hip $ 8,100.00 78101241 Stem - Knee $ 4,660.50 78101242 Stem 12Mm X 120Mm Knee $ 4,533.75 78101243 Stem 15Mm X 120Mm Knee $ 4,533.75 78101244 Stem Cemented 13X130 Extended Hip $ 5,100.00 78101245 Stem Ext 12Mm 145Mm Knee $ 5,703.60 78101246 Stem Fitmore Sz 1 Hip $ 8,100.00 78101247 Stem Hip B Ext Sz 5 Hip $ 8,100.00 78101248 Stem Offest Ext Knee $ 5,703.60 78101249 Stem Straight Knee $ 4,372.20 78101252 Stem Sz 9 Hip $ 8,100.00 78101253 Stemmed Tibial Plate Sz 2 Knee $ 3,000.00 78101254 Stemmed Tibial Plate Sz 3 Knee $ 3,000.00 78101255 Stemmed Tibial Plate Sz 5 Knee $ 3,000.00 78101256 Stemmed Tibial Plate Sz 6 Knee $ 3,000.00 78101257 Sterile Fluted Headless 1/8In Pin Knee $ 600.00 78101258 Stibial Stem 5 Deg Sz D R Knee $ 3,300.00 78101259 Straight Stem 145Mm Knee $ 4,372.20 78101260 Straight Stem 16Mm X 145Mm Knee $ 4,372.20 78101261 T Handle $ 1,560.00 78101262 Tap 145Mm - Trauma $ 522.81 78101263 Taper - Hip $ 2,700.00 78101264 Taper 11 Std Reduced Neck Length Hip $ 6,450.00 78101265 Taper 13.5 Std Hip $ 6,450.00 78101266 Taper 7.5 Std Reduced Neck Length Hip $ 6,450.00

02-19-2019-A-PAC-057 Page 55 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 78101267 Taper 9 Ext Reduced Neck Length Hip $ 6,450.00 78101268 Taper 9 Std Hip $ 6,450.00 78101269 Taper Ext Reduced Neck Length Hip $ 6,450.00 78101270 Taper Sleeve +0Mm Std Hip $ 542.40 78101271 Taper Stem 15 X 135Mm Hip $ 9,462.60 78101272 Taper Stem 15X135Mm Hip $ 9,462.60 78101273 Taper Stem 17X185Mm Hip $ 11,209.80 78101274 Tib Baseplate - Knee $ 2,850.00 78101275 Tibia - Knee $ 3,300.00 78101276 Tibia Base - Knee $ 9,798.75 78101278 Tibia Base - Knee $ 5,103.90 78101280 Tibia Base Sz4 - Knee $ 5,103.90 78101281 Tibia Stem - Knee $ 3,300.00 78101282 Tibial Augment Block 10Mm Sz 6 Knee $ 3,895.50 78101283 Tibial Augment Block 5Mm Sz 5 Knee $ 3,895.50 78101285 Tibial Base Sz 4 Rt Knee $ 9,798.75 78101286 Tibial Baseplate - Knee $ 4,380.00 78101287 Tibial Baseplate Cemented Knee $ 2,850.00 78101289 Tibial Insert - Knee $ 3,300.00 78101290 Tibial Insert - Knee $ 4,950.00 78101293 Tibial Insert Knee $ 4,950.00 78101294 Tibial Plate Sz 4 Knee $ 3,000.00 78101295 Tibial Retractor $ 453.00 78101296 Tibial Stem - Knee $ 3,300.00 78101298 Tibial Stem 5 Deg Sz G L Knee $ 3,300.00 78101299 Tibial Stem 5 Deg Sz H R Knee $ 3,300.00 78101300 Tibial Stem 5 Degree Knee $ 3,300.00 78101301 Tip Brush Femoral Hi-Cap $ 275.40 78101302 Tip, Disp E Probe 5Mm Spatula $ 1,268.10 78101303 Tip, Fan Pulsavac Plus $ 250.92 78101304 Tirathlon Cr Fem Compnent - Beaded W/Pa - Total Knee $ 7,500.00 78101305 Tls Surgical Drainage System 10Fr Drain Kit W/ Trocar $ 567.00 78101306 Triathlon Cr X3 Tibial Insert $ 3,300.00 78101307 Triathlon Tritanium Baseplate Size 7 - Total Kneee $ 6,000.00 78101308 Trident 10Z X3 Insert 36Mm Id Hip $ 2,850.00 78101309 Trident Hemispherical Ha Solid 50Mm Hip $ 2,400.00 78101310 Trident Hemispherical Ha Solid Bk 56Mm Hip $ 2,400.00 78101312 Trochanteric Nail Kit $ 3,436.20 78101313 Twist Drill Bit - Trauma $ 595.86 78101314 Ultra Cart Valve Pack Service Kit $ 4,485.00 78101315 Uni Headed Screw 48Mm $ 213.03 78101316 V40 Femoral Head $ 1,050.00 78101318 Versajet Ii $ 7,875.00 78101319 Versajet Ii Exact $ 7,875.00 78101320 Versys Cem/Rev/Calcar 13X170Mm Hip $ 18,091.50 78101322 Xl Body 78Mm Extended Offset Hip $ 14, 181.30 78101365 3.5 Locking Hexlobe Screws 10Mm $ 411.00 78101366 3.5 Locking Hexlobe Screws 16Mm $ 411.00 78101367 3.5 Locking Hexlobe Screws 18Mm $ 411.00 78101369 3.5 Locking Hexlobe Screws 22Mm $ 411.00 78101370 3.5 Locking Hexlobe Screws 24Mm $ 411.00 78101372 3.5 Locking Hexlobe Screws 8Mm $ 411.00 78101373 3.5 Locking Hexlobe Screws12Mm $ 411.00 78101374 3.5 Locking Hexlobe Screws14Mm $ 411.00 78101375 3.5 Non Locking Hexlobe Screws 14Mm $ 246.00 78101376 3.5 Non Locking Hexlobe Screws 16Mm $ 246.00 78101378 3.5 Non Locking Hexlobe Screws 20Mm $ 246.00 78101379 3.5 Non Locking Hexlobe Screws 22Mm $ 246.00 78101381 3.5 Non Locking Hexlobe Screws10Mm $ 246.00 78101382 3.5 Non Locking Hexlobe Screws 12Mm $ 246.00 78101383 3.5 Non Locking Hexlobe Screws 24Mm $ 246.00 78101384 3.5 Non Locking Hexlobe Screws 26Mm $ 246.00 78101393 Cemented Lat. Femoral 11.0 X 135 $ 5,865.00 78101445 Micro Ex Long Screw 22Mm $ 1,104.00 78101451 Vdr Proximal Narrow Left Plate $ 2,649.00 78101454 Vdr Narrow Left Plate $ 2,649.00 78101458 Vdr Proximal Narrow Right Plate $ 2,649.00 78101460 Vdr Narrow Right Plate $ 2,649.00 78101475 Vdr Proximal Standard Left Plate $ 2,649.00 78101478 Vdr Standard Left Plate $ 2,649.00 78101486 Vdr Proximal Standard Right Plate $ 2,649.00

02-19-2019-A-PAC-057 Page 56 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 78101488 Vdr Standard Right Plate $ 2,649.00 78101501 Wide Left Vdr Plate $ 2,649.00 78101503 Wide Right Prox Vdr Plate $ 2,649.00 78101515 Endo 11 Head 44Mm $ 1,230.00 78101516 Endo 11 Head 45Mm $ 1,230.00 78101518 Endo 11 Head 47Mm $ 2,238.00 78101519 Endo 11 Head 48Mm $ 2,238.00 78101521 Endo 11 Head 50Mm $ 2,238.00 78101522 Endo 11 Head 51Mm $ 2,280.00 78101523 Endo 11 Head 52Mm $ 2,238.00 78101525 Endo 11 Head 54Mm $ 2,238.00 78101527 Endo 11 Taper/Adapter Std Neck $ 597.00 78101533 Distal Centralizer 10Mm $ 936.00 78101534 Distal Centralizer 11Mm $ 936.00 78101535 Distal Centralizer 12Mm $ 936.00 78101536 Distal Centralizer 13Mm $ 516.00 78101541 Intramedullary Plug Med $ 768.00 78101705 Screw 40Mm - Spine $ 4,650.00 78101706 Screw 45Mm - Spine $ 4,650.00 78101707 Screw 50Mm - Spine $ 4,650.00 78101708 Rod 40Mm - Spine $ 1,350.00 78101709 Spacer 21Mm - Spine $ 13,200.00 78101710 I/C Graftchamber 10Cc - Spine $ 4,236.00 78101711 Access Kit 10G - Spine $ 600.00 78101712 Screw Conclus 16Mm - Ankle $ 150.00 78101713 14Mm Distraction Screw $ 3,000.00 78101724 Pin Mg 48Mm $ 213.03 78101749 Pin 33Mm $ 264.60 78101767 Femoral Head - Hip $ 3,450.00 78101768 Screw Locking 40Mm $ 1,074.00 78101769 Fitmore Hip Stem $ 8,100.00 78101770 Fitmore Hip Stem B - Hip $ 8,100.00 78101772 Deg Ti Cann Trna 170Mm $ 7,158.00 78101773 Liner 32Mm - Hip $ 5,556.00 78101774 Femoral Nail $ 476.79 78101775 Cann Ti 12Mm Right $ 5,459.19 78101776 Screw Locking 65Mm $ 717.00 78101777 Plate 2-Hole 90Mm $ 4,578.00 78101778 Plate 6Holes Left 85Mm $ 3,993.00 78101779 Hum Plate Medium $ 5,031.00 78101780 Hum Plate Short $ 5,190.00 78101781 Plate 3 Holes Right $ 2,268.78 78101782 Plate Fibula 5 Holes $ 3,906.00 78101783 Screw 12Mm $ 128.79 78101784 Screw 18Mm $ 128.79 78101785 Screw Locking 28Mm $ 717. 00 78101786 Screw Locking 46Mm $ 669.00 78101787 Screw Locking Angle 50Mm $ 669.00 78101788 Screw Locking 50Mm $ 717.00 78101792 Screw Locking 70Mm $ 669.00 78101793 Screw Locking 75Mm $ 669.00 78101795 Screw Locking 80Mm $ 669.00 78101796 Screw Locking Angle 85Mm $ 669.00 78101797 Plate Tibia 87Mm Left $ 6,759.00 78101798 Plate Tibia 6 Hole $ 6,831.00 78101800 Screw Locking 24Mm $ 418.05 78101801 Screw 16Mm $ 159.00 78101802 Screw Taping 10Mm $ 101.10 78101803 Screw Tapping 14Mm $ 101.10 78101804 Screw Tapping 16Mm $ 101.10 78101805 Screw 18Mm $ 159.00 78101807 Screw Locking 10Mm $ 630.00 78101809 Screw Locking 12Mm $ 399.96 78101810 Screw Locking 14Mm $ 630.00 78101811 Screw Locking 16Mm $ 630.00 78101815 Screw Locking 18Mm $ 630.00 78101822 Screw Locking 24Mm $ 630.00 78101823 Screw Locking 26Mm $ 630.00 78101824 Screw Locking 28Mm $ 630.00 78101825 Screw Locking 44Mm $ 630.00 78101826 Crimp Positioning Pin 5.0Mm $ 1,218.00

02-19-2019-A-PAC-057 Page 57 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 78101827 Femoral - Knee $ 9,654.00 78101828 Tibial Tray - Knee $ 7,560.00 78101829 Insert - Knee $ 3,144.00 78101830 4.0 X 22 Locking Screw $ 418.05 78101831 Gamma Nail, Reamur Shaft $ 550.50 78101834 Drill Bit $ 668.85 78101839 Drill Bit 4.2Mm $ 1,158.00 78101847 Drill Bit 145Mm $ 771.00 78101853 Guide Wire 290Mm $ 429.00 78101857 Drill Bit 16Mm $ 4,503.00 78101859 Biopsy Needle - Spine $ 300.00 78101860 Inflation System - Spine $ 450.00 78101861 Inflation System $ 450.00 78101881 Access Kit $ 600.00 78101887 Access Kit Side Opening - Spine $ 600.00 78101903 Biopsy Kit - Spine $ 300.00 78101916 Biosy Needle $ 300.00 78101918 Needle Biospy - Spine $ 300.00 78101924 Synflate Balloon $ 3,900.00 78101935 Balloon Small - Spine $ 3,900.00 78101946 Drill Bit 16Mm $ 3,942.00 78101947 Dbx Putty 1Cc $ 762.00 78101948 Screw Locking 28Mm $ 510.69 78101949 Screw Locking 30Mm $ 999.00 78101951 Screw Locking 32Mm $ 999.00 78101953 Screw Locking 36Mm $ 646.26 78101956 Screw Locking 38Mm $ 1,074.00 78101958 Screw Locking 40Mm $ 510.69 78101965 5.0Mm Ti Locking Screw W/T25Stardrive 48Mm F/Im Nail-Ster $ 999.00 78101966 Screw 52M $ 1,074.00 78101967 Screw 60Mm - Trauma $ 1,074.00 78101968 Screw 62Mm $ 510.69 78101969 Screw 78Mm - Trauma $ 1,074.00 78101970 End Cap Femoral Nail $ 726.00 78101973 Blade Spiral $ 1,595.37 78101974 Retrograde Femoral Nails - Trauma $ 2,589.00 78101975 Spiral Blade 70Mm $ 2,418.00 78101977 Blade 80Mm - Trauma $ 2,589.00 78101978 Femoral Nail $ 4,838.04 78101979 Femoral Nail $ 7,329.00 78101981 Femoral Nail - Trauma $ 7,845.00 78101983 10Mm/130 Deg Ti Cann $ 7,662.00 78101984 10Mm/130 Deg It Cann Trna 340Mm/Right $ 10,029.00 78101987 Ti Cann Tfna 170Mm $ 4,747.77 78101989 Cann 130 Deg Ti Right $ 10,029.00 78101991 Cann Ti 12Mm Left $ 5,459.19 78101992 130 Deg Ti Cann Tfna 340Mm $ 10,734.00 78101993 130 Deg Ti Cann Tfna $ 10,734.00 78101994 12Mm/130 Deg Ti Cann Tfna400Mm/Left-Sterile $ 10,029.00 78101995 Screw 100Mm $ 3,243.00 78101996 Helical Balde 85Mm $ 3,384.00 78101998 Blade Helical 90Mm $ 3,402.00 78102004 Blade Helical 95Mm $ 3,402.00 78102006 Blade Helical 100Mm $ 3,402.00 78102007 Blade Helical 100Mm $ 3,384.00 78102009 Blade Helical 105Mm $ 2,268.45 78102010 Tfna Helical Blade 10Mmsterile $ 3,384.00 78102011 Blade Helical 115Mm $ 2,268.45 78102012 Stem - Hip $ 7,920.00 78102036 Stem - Hip $ 6,627.00 78102107 Cp2 Laser - Plantar $ 3,735.00 78102110 Holmium Laser High Wattage $ 4,470.00 78102111 Holmium Laser High Wattage $ 2,445.00 78102114 Holmium Laser Low Wattage $ 1,893.00 78102118 Head - Hip $ 6,201.60 78102119 Screw 20Mm - Hip $ 426.00 78102120 Screw 40Mm - Hip $ 426.00 78102122 Xps Moxy Fiber - Turp $ 3,825.00 78102126 Holmium 365 Fortec Fiber $ 750.00 78102134 Delivery Fee $ 150.00 78102143 Weekend Fee $ 1,050.00

02-19-2019-A-PAC-057 Page 58 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 78102144 Distal Spacer - Hip $ 362.70 78102145 Holmium 550-2 Fortec Fiber $ 855.00 78102146 Holmium 365-0 Fortec Fiber $ 750.00 78102147 Holmium 200-2 Fortec Fiber $ 750.00 78102148 Shell 4 Hole - Hip $ 5,490.00 78102149 Wrench Torque - Spine $ 75.00 78102150 Max Ps Dcm Pib Brng 20X71/75Mm - Rev Knee $ 3,426.00 78102151 Lateral Centralizer 9Mm - Hip $ 7,425.00 78102152 Centralizer 9Mm - Trauma $ 7,425.00 78102157 Pin And Drill Set - Knee $ 330.63 78102158 Cannulated Reamer 2.7Mm $ 1,268.46 78102161 Femoral - Hip $ 15,081.00 78102162 Femoral - Hip $ 15,081.00 78102163 Femur - Hip $ 8,724.00 78102164 Femoral - Hip $ 8,724.00 78102167 Aug - Hip $ 10,159.20 78102168 Augment - Hip $ 10,159.20 78102173 Screw - Knee $ 330.00 78102178 Cup - Hip $ 13,145.25 78102182 Cup - Hip $ 10,756.20 78102189 Screw - Hip $ 330.00 78102203 Screw - Hip $ 213.00 78102208 Cup - Hip $ 3,000.00 78102238 Cup - Hip $ 2,922.00 78102334 Liner - Hip $ 6,762.60 78102335 Liner - Hip $ 8,657.25 78102336 Liner - Hip $ 3,630.00 78102357 Liner - Hip $ 2,709.00 78102447 Ring - Hip $ 1,328.55 78102448 Screw - Hip $ 777.75 78102450 Tibial Insert $ 3,750.00 78102451 Tibial Tray - Knee $ 20,354.10 78102454 Tibial Tray - Knee $ 16,654.95 78102462 Tib Tray - Knee $ 16,654.95 78102479 Sleeve - Knee $ 13,341.60 78102480 Wedge - Knee $ 8,045.25 78102482 Sleeve - Knee $ 11,319.45 78102486 Fem Sleeve - Knee $ 13,341.60 78102507 Sleeve - Knee $ 11,630.55 78102511 Stem Wedge - Knee $ 8,045.25 78102512 Step Wedge - Knee $ 6,460.35 78102543 Bb-Tak - Distal $ 214.50 78102544 Acumatch Acetabular Liner $ 2,262.00 78102546 Spacer - Hip $ 429.00 78102547 Head - Hip $ 1,800.00 78102549 Head - Hip $ 2,895.00 78102551 Head - Hip $ 3,330.00 78102559 Head - Hip $ 2,922.00 78102566 Femur - Hip $ 5,130.00 78102645 Cone - Hip $ 3,330.00 78102658 Insert - Hip $ 597.00 78102660 Endo Ii Taper Insert - Hip $ 597.00 78102666 Insert - Hip $ 327.00 78102670 Cenmex Genta High Visocity 40G - Hip $ 1,455.00 78102680 Biomet Tibial Locking Bar - Rev Knee $ 384.00 78102682 Cemex Genta System 80G - Hip $ 2,352.00 78102764 Femoral - Knee $ 6,420.00 78102771 Femur - Knee $ 5,130.00 78102883 Tibial Base - Knee $ 4,650.00 78102972 Tibail Base - Knee $ 4,650.00 78103015 Tibia - Knee $ 4,650.00 78103083 Insert - Hip $ 3,825.00 78103084 Insert - Knee $ 3,420.00 78103098 Tibial Insert - Knee $ 3,825.00 78103225 Insert $ 3,825.00 78103247 Patella - Knee $ 1,710.00 78103261 Patella - Knee $ 1,284.00 78103435 Insert - Knee $ 3,750.00 78103436 Tibial Tray - Knee $ 4,725.00 78103451 Screw - Hip $ 600.00 78103452 K-Wire 3Mm X 285Mm - Trauma $ 224.40

02-19-2019-A-PAC-057 Page 59 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 78103453 Guide Wire Ball Tip - Trauma $ 273.36 78103454 Drill Bit - Trauma $ 326.40 78103458 Modul 1 Inst Set - Implant Extraction Set $ 49,496.40 78103460 End Cap - Trauma $ 328.41 78103461 Tibial Nail - Trauma $ 4,031.37 78103462 Tibia Bridge - Knee $ 8,562.00 78103463 Screw Locking - Trauma $ 326.40 78103465 Echo Por Femoral 10X130 - Hip $ 26,226.00 78103466 Femur - Knee $ 4,704.00 78103468 Femoral - Knee $ 6,300.00 78103469 Reclaim - Hip $ 18,775.65 78103471 Body - Hip $ 18,775.65 78103475 Reclain Body - Wasted - Hip $ 15,362.10 78103481 Stem - Hip $ 15,697.80 78103485 Stem - Hip $ 16,444.95 78103486 Reclaim Stem - Hip $ 12,844.65 78103488 Dist Taper - Hip $ 15,697.80 78103490 Stem - Hip - Wasted $ 13,599.30 78103491 Stem - Hip $ 13,599.30 78103492 Insert - Knee $ 12,525.60 78103493 Patella - Knee $ 1,647.00 78103494 Screw Cortex 10Mm $ 160.50 78103495 Screw Cortex 16Mm $ 160.50 78103498 3.5Mm Cortex Screwself-Tapping 12Mm $ 108.75 78103510 Screw Cortex 20Mm $ 108.75 78103514 Screw, 3.5 Cortical 22 Mm $ 117.00 78103515 Screw Cortex 24Mm $ 108.75 78103520 3.5 Cortical Screw 30Mm $ 61.56 78103522 3.5 Cortical Screw X 32 $ 61.56 78103524 Screw 34 $ 108.75 78103526 Screw Cortex 36Mm $ 117.00 78103528 Screw Cortex 38Mm $ 108.75 78103530 Screw Cortex 40Mm $ 108.75 78103532 Screw Cortex 45Mm $ 108.75 78103533 Screw Cortex 50Mm $ 108.75 78103534 Screw Bone 10Mm $ 91.50 78103535 Screw Bone 12Mm $ 91.50 78103536 4.0Mm Cancellous Bone Screw Fully Threaded 16Mm $ 91.50 78103537 Screw Bone 18Mm $ 98.25 78103538 4.0Mm Cancellous Bone Screw Fully Threaded 20Mm $ 91.50 78103539 Screw Bone 30Mm $ 91.50 78103540 Screw 35Mm Cancellous Bone $ 91.50 78103541 Screw 40Mm Cancellous Bone $ 91.50 78103544 Bone Screw 55Mm - Trauma $ 91.50 78103545 Bone Screw 60Mm - Trauma $ 91.50 78103547 4.0Mm Cannulated Screw Short Thread 28Mm $ 915. 00 78103548 Screw Short 42Mm $ 915.00 78103549 Screw Short 44Mm $ 915.00 78103550 4.0 Cann. Short Thread Screw 46Mm $ 571.71 78103551 4.0 Set 48Mm Short Thread $ 571.71 78103552 4.0Mm Cannulated Screw Short Thread 50Mm $ 915.00 78103553 Screw Long 26Mm $ 915.00 78103554 Screw Long 38Mm $ 981.00 78103555 Screw 46Mm $ 981.00 78103556 7.3 Cann. 32Mm Thread 75Mmlength $ 825.00 78103557 Screw 85Mm $ 1,275.00 78103559 Screw Connulated 32Mm $ 1,275.00 78103560 Screw Locking 12Mm $ 558.00 78103563 3.5Mm Locking Screw-Slf-Tpngw/Stardrive (Tm) Recess 14Mm $ 558.00 78103566 3.5Mm Locking Screw Slf-Tpng/Stardrive Recess 16Mm $ 558.00 78103567 Screw 18Mm $ 558.00 78103568 Screw 22Mm $ 558.00 78103570 3.5 Locking Screw $ 363.81 78103572 3.5 Locking Screw 38Mm $ 363.81 78103573 3.5 Locking Screw 45Mm $ 363.81 78103574 Screw Conical Self-Taping 85Mm $ 609.00 78103575 Screw 52Mm $ 960.00 78103576 4.5 Cortical Screw X 22Mm $ 62.13 78103578 4.5 Cortical Screw X 24 $ 62.13 78103581 4.5 Cortical Screw X 26Mm $ 62.13 78103583 Screw Cortex 28Mm $ 62.13

02-19-2019-A-PAC-057 Page 60 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 78103585 Screw 30Mm $ 106.50 78103586 Screw 32Mm $ 106.50 78103588 Screw 36Mm $ 106.50 78103589 Screw 38Mm $ 106.50 78103590 Screw 40Mm $ 106.50 78103591 Screw Cortex 48Mm $ 106.50 78103592 Screw Bone 32Mm $ 172.50 78103597 Washer 13.0Mm $ 124.50 78103598 Plate 10 Holes $ 1,617.00 78103599 Plate 8 Hole $ 2,121.00 78103600 Plate Narrow Lcp 9 Holes 170Mm $ 1,462.02 78103604 Plate Tubular 69Mm $ 747.00 78103606 Plate Tubular 81Mm $ 762.00 78103607 Plate Humerus Long 8H Shaft $ 4,989.45 78103608 Plate 6 Holes 205Mm $ 7,341.00 78103609 3.5Mm Lcp Reconstruction Plat7 Holes 98Mm $ 2,313.00 78103610 Lcp Plate Recon. 8 H $ 1,590.87 78103611 Kit Vba Confidence - Spine $ 4,500.00 78103612 Confidence Vba Kit 11Cc - Spine $ 4,500.00 78103627 Confidence Bva Kit 11Cc - Spine $ 4,500.00 78103632 Adapter - Spine $ 600.00 78103633 Wire W/Trocar Point 150Mm $ 405.00 78103634 Kirschner Wire 1250Mm $ 405.00 78103635 Guide Wire 230Mm $ 174.00 78103636 Guide Wire 300Mm $ 223.50 78103637 Kirschner Wire - Trauma $ 756.00 78103638 Assembly - Hip $ 1,068.00 78103639 Cable With Crimp 750Mm $ 2,319.00 78103643 Cerclage Positioning Pin 4.5Mm $ 810.00 78103646 Stem - Hip $ 6,000.00 78103651 Humeral Stem - Hip $ 6,000.00 78103660 Stem - Knee $ 6,000.00 78103665 Plate Replicator - Hip $ 2,250.00 78103676 Screw Torque Defining - Hip $ 900.00 78103688 Screw - Hip $ 3,150.00 78103728 Screw 30Mm Locking Hex - Ankle $ 411.00 78103729 Screw Non Locking Hex 10Mm $ 246.00 78103776 Screw 12Mm Locking Hex - Ankle $ 411.00 78103777 Screw 14Mm Locking Hex - Ankle $ 411.00 78103778 Screw 26Mm Locking Hex - Ankle $ 411.00 78103780 Screw 12Mm Non Locking Hex - Ankle $ 246.00 78103781 Screw 18Mm Non Locking Hex - Ankle $ 246.00 78103782 Screw 24Mm Non Locking Hex - Ankle $ 246.00 78103783 Cable Multlead Trial - Spine $ 660.00 78103785 Patient Programmer $ 3,570.00 78103787 Stem - Hip $ 7,500.00 78103788 Stem Humeral - Hip $ 7,500.00 78103789 Neurostimulator $ 33,675.00 78103790 Ipg $ 33,675.00 78103792 Stem - Revision $ 7,500.00 78103793 Drill Bit 125Mm $ 372.00 78103806 2.5Mm Drill Bit/Qc/Gold 110Mm $ 330.00 78103813 2.8Mm Drill Bit/Qc 165Mm $ 411.00 78103814 Drill Bit 145Mm $ 206.76 78103819 Drill Bit 110Mm $ 351.00 78103821 Drill Bit 145Mm $ 324.00 78103823 Drill Bit 300Mm $ 2,133.00 78103827 2.7Mm Cannulated Drill Bit/Qc 160Mm $ 2,019.00 78103829 Head - Hip $ 4,125.00 78103842 Screw 40Mm - Hip $ 408.00 78103843 Drill Bit 70M - Hip $ 408.00 78103844 Glenoid - Hip $ 3,570.00 78103857 Drill Bit 125Mm $ 525.00 78103863 Glenosphere $ 4,200.00 78103864 Glenosphere - Knee $ 4,200.00 78103867 Tray Humeral Adapter - Knee $ 5,100.00 78103872 Glenoid Plate - Hip $ 4,500.00 78103882 Acrew Glenosphere - Knee $ 375.00 78103888 Screw Torque Defining - Hip $ 825.00 78103895 Screw 18 - Knee $ 375.00 78103902 Screw 22 - Knee $ 375.00

02-19-2019-A-PAC-057 Page 61 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 78103914 Screw - Hip $ 375.00 78103923 Liner Humeral - Hip $ 2,400.00 78103929 Humeral Liner - Knee $ 2,400.00 78103937 Drill Bit - Hip/Knee $ 750.00 78103939 Drill Bit W/Depth Mark 140Mm $ 678.00 78103943 Drill Bit 2.8Mm 200Mm/100Mm $ 503.91 78103946 350-3630 Breast Implant $ 2,010.00 78103947 Reaming Rod $ 849.00 78103951 3.0Mm Reaming Rod/950Mmw/Straight Ball Tip-Sterile $ 789.00 78103959 Long Nail Kit $ 5,023.50 78103960 Verify Testing Ens $ 1,200.00 78103961 Introducer Kit $ 840.00 78103970 3.2Mm Guide Wire 400Mm $ 438.00 78103977 Testing Cable $ 120.00 78103979 Patient Antenna $ 225.00 78103981 Prodigy Charging System - Spine $ 10,770.00 78103983 Protege 16-Channel Rechargeable - Spine $ 77,685.00 78103985 Patient Programmer - Spine $ 4,875.00 78103987 Tined Lead $ 10,245.00 78103989 Hydro Set Injectale Ha Bone Substitue Cement 5Cc $ 4,682.34 78103990 Osteotome-Round Medium - Hip $ 2,625.00 78103991 Osteotome Round Narrow $ 2,760.00 78103992 Straight Osteotome Long $ 2,625.00 78103993 Flexable Osteotome Round Narrow $ 2,760.00 78103994 Osteotome Flat Narrow Long $ 2,760.00 78103995 Accudriver Rental - Hip $ 4,500.00 78103999 Drill Bit 3.5 Mm $ 339.00 78104000 Ultra-Drive 120Mm Tip Extender $ 2,164.95 78104001 Ultra Drive 6Mm Plug Puller $ 2,164.95 78104002 Ultra Drive 7Mm Disk Drill $ 2,164.95 78104003 Ultra-Drive 9.5Mm Disk Drill $ 2,164.95 78104004 7Mm Long Porous Gouge $ 2,164.95 78104005 Ultra Drive 180Mm M/F Extender $ 2,164.95 78104006 Twist Drill - Hip $ 420.00 78104008 Trochanteric Reattachment Device $ 5,475.30 78104009 Hemispherical Ha 50Mm - Hip $ 4,500.00 78104012 Hemispherical 52Mm - Hip $ 2,400.00 78104014 Hemispherical 54Mm - Hip $ 2,400.00 78104018 Tprlc Type 1 - Hip $ 14,424.00 78104019 Sleeve - Hip $ 2,565.00 78104020 Sleeve - Hip $ 1,230.00 78104023 Screw Locking 13Mm - Trauma $ 196.35 78104024 Screw Lcoking 14Mm - Trauma $ 196.35 78104029 Femur - Knee $ 5,100.00 78104086 Baseplate Sz 4 - Knee $ 4,800.00 78104108 Insert Sz4 11Mm - Knee $ 3,300.00 78104196 Tibial Component - Knee $ 6,000.00 78104261 Stem - Hip $ 5,700.00 78104263 Screw Cross Pin 10Mm - Trauma $ 169.95 78104264 Screw Cross Pin 13Mm - Trauma $ 169.95 78104265 Screw Bone 6Mm - Trauma $ 133.20 78104266 Screw Bone 10Mm - Trauma $ 133.20 78104267 Accolade - Hip $ 5,400.00 78104269 Bone Plug - Hip $ 294.96 78104278 Insert 36Mm - Hip $ 2,850.00 78104281 Head 32Mm - Hip $ 5,844.00 78104282 Sleeve Type 1 - Hip $ 681.00 78104285 Optecure + Ccc - 1Cc $ 612.00 78104287 Optecure + Ccc-5Cc $ 2,889.00 78104288 Optecure+Ccc-10Cc $ 4,842.00 78104291 Optecure + Ccc-20Cc - Hip $ 8,604.00 78104292 Optecure+Ccc-1Cc $ 612.00 78104302 Accolade Ii 132 Deg - Hip $ 8,700.00 78104305 Accolade Ii 127 Deg - Hip $ 8,700.00 78104311 Endo Head 51Mm - Hip $ 900.00 78104312 Taper Sleeve - Hip $ 426.06 78104313 Plate Clavile 10 Hole - Clavicle $ 3,273.00 78104314 Plate Clavicle 10 Hole - Clavicle $ 3,273.00 78104317 Plate 8 Hole - Clavicle $ 3,273.00 78104336 Glide Plate 4 Hole - Ankle $ 1,440.00 78104337 Hook Plate 3-Hole - Ankle $ 1,755.00

02-19-2019-A-PAC-057 Page 62 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 78104340 Drill Tip Wire $ 135.33 78104346 Patella 29Mm - Knee $ 2,214.90 78104347 Patella - Knee $ 2,214.90 78104349 Pap-Pac $ 960.00 78104356 Hat-Trick Pip 2.7Mm - Trauma $ 2,730.00 78104357 Hat-Trick Pip $ 2,730.00 78104358 2Nd Asst Disp Knee Positioner - Knee $ 858.00 78104375 Adapter Quick Connect Speed Pin - Knee $ 1,143.00 78104387 Tibia Base Sz 2 - Knee $ 5,103.90 78104392 Tibia Base Sz 3 - Knee $ 5,103.90 78104394 Patella 32Mm - Knee $ 2,214.90 78104407 Fluted Headless 1/8" Pin 3.5" Long - Knee $ 600.00 78104469 Fluted Headless Pin - Knee $ 600.00 78104470 Pin Fluted Headless - Knee $ 600.00 78104471 Fem Component - Knee $ 600.00 78104472 Drill Long - Trauma $ 870.00 78104474 Drill Quick Release 2.0Mm $ 342.00 78104496 Quick Release Surgibit Drill - Clavical $ 372.00 78104509 Drill Long Extended - Trauma $ 867.00 78104510 Drill 2.0Mm - Ankle $ 432.00 78104511 Drill 2.8Mm - Ankle $ 432.00 78104512 Plate 3In - Ankle $ 102.00 78104513 Drill 2.7Mm - Ankle $ 444.00 78104514 Theraload $ 69.00 78104516 Stem - Knee $ 4,143.75 78104525 Stem - Knee $ 6,528.00 78104580 Aug Combo - Knee $ 4,174.35 78104585 Lo-Pro Screw Tmss 3.5X 14Mmcort $ 150.00 78104586 Lo-Pro Screw Tmss 3.5X 18Mmcort $ 150.00 78104587 Lo-Pro Screw Tmss 3.5X 24Mmcort $ 150.00 78104588 Lo-Pro Screw Tmss 3.5X 26Mmcort $ 150.00 78104589 Lo-Pro Lock Scrwss 3.5X 12Mm $ 495.00 78104590 Lo-Pro Lock Scrwss 3.5X 14Mm $ 495.00 78104591 Lo-Pro Lock Scrwss 3.5X 16Mm $ 495.00 78104592 2.5Mm Drill Bit $ 366.00 78104593 2.5Mm Drill Bit Calibrated $ 366.00 78104594 Locking Straight Plate Ss 6H $ 2,037.00 78104596 Guide Wire 150Mm $ 127.50 78104600 1.25Mm Threaded Guide Wire 150Mm $ 135.00 78104602 Taper Post $ 1,548.00 78104603 Post $ 1,548.00 78104604 Therasleeve $ 84.00 78104606 Insert - Knee $ 11,577.00 78104607 Patella - Knee $ 1,275.00 78104608 Blade - Knee $ 591.00 78104609 Pin - Knee $ 1,047.90 78104610 Pins - Knee $ 1,542.00 78104612 Femur - Knee $ 24,584.55 78104613 Femur - Knee $ 6,300.00 78104629 Femur - Knee $ 24,593.55 78104650 Femer - Knee $ 24,584.55 78104681 Insert - Knee $ 8,772.00 78104686 Fem Adapt - Knee $ 9,093.30 78104724 Adapt Bolt - Knee $ 1,275.00 78104743 Dist Aug - Knee $ 4,174.35 78104744 Post Aug - Knee $ 4,174.35 78104747 Post Augment - Knee $ 4,174.35 78104750 Augment - Knee $ 4,174.35 78104752 Dist Seg - Knee $ 4,174.35 78104756 Post Augment - Knee $ 3,352.05 78104778 Dist Augment - Knee $ 4,174.35 78104792 Insert - Knee $ 2,994.00 78104798 Insert - Knee $ 9,295.65 78104809 Tibial Insert - Knee $ 11,577.00 78104818 Insert - Knee $ 8,659.80 78104819 Insert - Knee $ 8,658.00 78104826 Insert - Knee $ 2,565.00 78104828 Tib Tray - Knee $ 13,198.80 78104829 Compound $ 9,018.00 78104830 15Mm 2.5*3.5Mm Df $ 9,018.00 78104831 Pin $ 567.00

02-19-2019-A-PAC-057 Page 63 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 78104832 Fixation $ 3,096.00 78104833 Phalangeal Scre $ 3,096.00 78104834 Component $ 7,470.00 78104835 Phalangeal Insert $ 7,470.00 78104836 Nerve Protector 10Mm X 40Mm $ 6,525.00 78104837 Humeral Head - Shoulder $ 5,250.00 78104838 7.5Mm Flipcutter $ 975.00 78104839 8Mm Flipcutter $ 975.00 78104840 8.5Mm Flipcutter $ 975.00 78104841 Flip Cutter Ii - Knee/Hip $ 975.00 78104842 Flipcutter Ii Short 7.5Mm $ 975.00 78104844 Flip Cutter Ii Short 8Mm - Reconstruction $ 975.00 78104847 Flip Cutter Ii Short 8.5Mm - Reconstruction $ 975.00 78104848 Flipcutter Ii Short 9Mm - Reconstruction $ 975.00 78104849 11Mm Disposable Full Thickness Reamer $ 585.00 78104850 11.5Mm Disposable Full Thickness Reamer $ 585.00 78104851 Drill 4.5Mm - Reconstruction $ 585.00 78104852 Drill 5Mm Cannulated $ 585.00 78104853 Drill 6Mm $ 585.00 78104854 7Mm Disposable Full Thickness Reamer $ 585.00 78104855 7.5Mm Disposable Full Thickness Reamer $ 585.00 78104856 8Mm Disposable Full Thickness Reamer $ 585.00 78104857 8.5Mm Disposable Full Thickness Reamer $ 585.00 78104858 Drill 9Mm $ 585.00 78104859 9Mm Disposable Full Thickness Reamer $ 585.00 78104860 Drill 9.5Mm Cannulated - Knee/Hip $ 585.00 78104861 9.5Mm Disposable Full Thickness Reamer $ 585.00 78104862 Suture Anchor Mini Corkscrew Ft $ 1,224.00 78104871 Suture Anchor - Distal $ 1,395.00 78104872 Kit Mini Stak - Distal $ 750.00 78104873 14Mm Spiked Washer $ 300.00 78104874 18Mm Spiked Washer $ 300.00 78104875 18Mm Smooth Washer $ 300.00 78104876 4.5 Post 40Mm $ 300.00 78104877 4.5 Post 45Mm $ 300.00 78104878 Bio-Comp Interfscrew $ 1,008.00 78104879 Interf Screw Full Thd $ 705.00 78104880 Screw, Interference 8X20 Mm $ 285.00 78104881 Screw Interf W/Disp Shth - Recon $ 1,008.00 78104882 Screw, Interference 8X25 Mm $ 285.00 78104883 Interference Screw 9 X 20Mm $ 345.00 78104884 Reamer Low Profile $ 837.00 78104885 Teno Screw Bio-Comp - Distal $ 1,608.00 78104886 Disps Kit For 3 X 8Mm Teno - Distal $ 858.00 78104887 Screw Tenodesis - Distal $ 1,479.00 78104888 Teno Screw Bio-Comp $ 1,479.00 78104889 Tenodesis Screw Bio-Comp $ 1,479.00 78104890 Teno Screw Bio-Comp - Recon $ 1,479.00 78104891 Acl Tightrope Rt - Acl Rec $ 1,050.00 78104892 Acl Tightrope $ 1,050.00 78104893 Acl Tightrope Rt W Deploying Suture - Recon $ 1,110.00 78104894 Tight Rope - Acl Recon $ 615.00 78104895 Tight Rope Implant - Acl Recon $ 789.00 78104896 Tightrope Button Extender $ 675.00 78104897 Screw Teno Peek $ 1,224.00 78104898 Temo Bio-Comp Swivelock - Reconstruction $ 1,866.00 78104899 Instrument Kit Fo Rtemo Screw $ 585.00 78104903 Kit Intbrace Lgmnt Repr Augmnt $ 2,925.00 78104904 3.5Mm Disposable Punch $ 225.00 78104906 Insert Kit - Recon $ 837.00 78104907 Impl Delivery Sysdistal Biceps Repr $ 2,550.00 78104908 Bio-Comp Swivelock 19.1Mm - Reconstruction $ 1,200.00 78104909 Speedbridge Triple Loaded Corkscrew Anchor $ 4,470.00 78104910 Speedgridge - Cuff $ 5,340.00 78104911 Speedbridge Kit W/Preloaded Fibertape $ 5,340.00 78104912 Suture Anchor - Slap $ 1,395.00 78104914 Kit For Fibertak Suture Anchor - Slap $ 837.00 78104916 Screw 20Mm - Distal $ 3,837.00 78104917 Drill Bit 2.4Mm - Distal $ 237.00 78104918 Drill Bit 3.5Mm $ 237.00 78104919 Speed C Crved Nel W/2Peek Imp $ 1,695.00

02-19-2019-A-PAC-057 Page 64 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 78104920 Knot Pucher Suture Cutter $ 537.00 78104921 Screw Inter-Ference $ 705.00 78104922 Biocomposite Interference Screw, Round Delta, 9 Mm X 28 Mm $ 705.00 78104923 Screw Bio-Comp Inter-Ference $ 705.00 78104924 Screw 50Mm - Distal $ 3,408.00 78104925 Glenoid Locki Screw - Shoulder $ 516.00 78104936 Cannula - Shoulder $ 108.00 78104937 5.75Mm Orange Smooth Cannula $ 75.00 78104938 Passport Button Cannula $ 96.00 78104942 Suture Bpb #2 - Shoulder $ 150.00 78104944 Suture Braid #2 - Shoulder $ 99.00 78104945 Fiberstick $ 750.00 78104946 Fibersnare #2 Fiberwire #2 $ 429.00 78104947 Tigerstick #2 Tigerwire - Acl Recon $ 214.50 78104948 Fiber Loop #2 Blue $ 214.50 78104951 Labral Tape $ 2,520.00 78104954 Needle Curved 26Mm - Shoulder $ 82.50 78104955 Suture Kit 572.00 $ 1,716.00 78104976 Excalibur 4.0Mm X 13Cm $ 135.00 78104977 Torpedo 4.0Mm X 13Cm $ 303.00 78104980 Burr Oval 13Cm $ 135.00 78104983 Doublecut 5.5Mm X 13Cm $ 135.00 78104993 Burr Oval 12 Flute 5.5Mm X 13Cm $ 135.00 78104995 Mini Scorpion - Distal $ 4,074.00 78104996 Micro Suture Lasso Straight - Shoulder $ 600.00 78104999 Screw 12Mm - Distal $ 474.00 78105000 Screw 14Mm - Distal $ 474.00 78105001 Screw 22Mm Cortex - Distal $ 474.00 78105002 Screw 24Mm Cortex - Distal $ 474.00 78105003 Screw 26Mm Cortex - Distal $ 474.00 78105004 Screw 28 Cortex - Distal $ 474.00 78105005 Screw 14Mm - Distal $ 600.00 78105006 Screw 16Mm - Distal $ 600.00 78105007 Screw 18Mm - Distal $ 600.00 78105009 Screw 20Mm - Distal $ 600.00 78105012 Screw 22Mm - Distal $ 600.00 78105015 Screw 24Mm - Distal $ 600.00 78105018 Screw 26Mm - Distal $ 600.00 78105019 Screw 3.5 Mini 20Mm - Distal $ 1,266.00 78105020 Qckfix Screw 42Mm - Distal $ 645.00 78105021 Guide Wire W/ Trocar Tip - Distal $ 64.50 78105024 G-Wire W/Trocar - Distal $ 64.50 78105025 Drill Bit - Distal $ 525.00 78105029 Drill Bit Cmp - Distal $ 585.00 78105031 Guide Wire Trocat Tip - Distal $ 94.50 78105032 Screw 18Mm - Distal $ 708. 00 78105033 Screw 20Mm - Distal $ 1,266.00 78105034 Screw 22Mm - Distal $ 708.00 78105035 Screw 24Mm - Distal $ 708.00 78105036 Screw 26Mm - Distal $ 708.00 78105037 Screw 30Mm - Distal $ 1,266.00 78105038 Screw 34Mm - Distal $ 708.00 78105039 Screw 38Mm - Distal $ 708.00 78105040 Screw 44Mm - Distal $ 1,266.00 78105041 Screw 48 - Distal $ 708.00 78105042 Screw 50Mm - Distal $ 708.00 78105043 Screw 52 - Distal $ 708.00 78105044 Screw 10Mm $ 495.00 78105045 Screw 10Mm - Ankle $ 495.00 78105047 Screw Locking 12Mm - Ankle $ 495.00 78105053 Screw 14Mm - Distal $ 495.00 78105058 Screw 16Mm - Distal $ 495.00 78105061 Screw 18Mm - Distal $ 495.00 78105062 Screw 24Mm $ 495.00 78105063 Screw 28Mm $ 495.00 78105065 Screw 32Mm - Distal $ 495.00 78105066 Screw 34Mm - Distal $ 495.00 78105068 Screw 36Mm - Distal $ 495.00 78105069 Screw 40Mm - Distal $ 495.00 78105070 Screw Conclus 10Mm - Ankle $ 150.00 78105071 Screw 10Mm Cort - Distal $ 150.00

02-19-2019-A-PAC-057 Page 65 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 78105073 Screw 12Mm Cort - Distal $ 150.00 78105076 Screw Tmss 14Mm Cort - Ankle $ 150.00 78105085 Screw 18Mm Cort - Distal $ 150.00 78105088 Screw 20Mm Cort - Distal $ 150.00 78105089 Screw 24Mm $ 150.00 78105090 Screw 26Mm Cortical $ 150.00 78105093 Screw 28Mm - Distal $ 150.00 78105095 Screw 30Mm - Distal $ 150.00 78105096 Screw 34Mm Cort $ 150.00 78105097 Screw 38 - Distal $ 150.00 78105098 Screw 50Mm - Distal $ 150.00 78105099 Screw 55Mm Cort - Distal $ 150.00 78105100 Screw 60Mm Cort - Distal $ 150.00 78105103 Screw Locking 10Mm - Distal $ 495.00 78105107 Screw Locking 12Mm - Distal $ 495.00 78105113 Screw Locking 14Mm - Distal $ 495.00 78105119 Screw 20Mm - Distal $ 495.00 78105120 Screw 22Mm $ 495.00 78105122 Screw 24Mm - Distal $ 495.00 78105123 Screw 28Mm - Distal $ 495.00 78105126 Screw 38Mm - Distal $ 495.00 78105128 Screw 14Mm Canclus - Distal $ 150.00 78105129 Screw 30Mm Cann - Ankle $ 708.00 78105131 Screw 50Mm Cannulated - Distal $ 708.00 78105132 Screw 55Mm Cann $ 708.00 78105135 Tightrope Repair Mini - Distal $ 2,250.00 78105137 Implant System Mini Tightrope 1.1Mm $ 2,250.00 78105138 Drill Bit 2.5Mm - Distal $ 204.00 78105142 Drill Bit 1.7Mm - Distal $ 339.00 78105147 Volar Distal Rad Plate 3 Hole - Distal $ 3,408.00 78105150 Distal Rad Plate 3Hole - Distal $ 3,408.00 78105152 Knotless T-Rope - Distal $ 3,774.00 78105161 Tight Rope Knotless - Distal $ 3,774.00 78105162 Screw 14Mm Cortical - Distal $ 474.00 78105163 Screw 16Mm Cortical - Distal $ 474.00 78105164 Cannulated Drill Bit - Distal $ 750.00 78105165 Screw 10Mm - Distal $ 474.00 78105167 Screw 12Mm - Distal $ 258.00 78105168 Screw 13Mm - Distal $ 258.00 78105169 Screw 14Mm $ 258.00 78105170 Screw 16Mm - Distal $ 258.00 78105174 Screw 18Mm - Distal $ 258.00 78105176 Screw Locking 3.5Mm X 16Mm - Distal $ 366.00 78105177 Guide Wire W/Trocar Tip $ 64.50 78105187 Guide Wire Trocar Tip 1.35Mm - Distal $ 87.00 78105193 Drill Bit 2.6Mm - Distal $ 525. 00 78105195 Drill Bit 2.5Mm - Distal $ 255.00 78105196 Drill Bit Calibrated - Ankle $ 408.00 78105202 Drill Bit 2.5Mm $ 366.00 78105205 Drill Bit $ 366.00 78105212 Drill Bit 2.5Mm Calibrated - Distal $ 255.00 78105216 Lock Distal Fibula Pltss Lft5H - Ankle $ 2,787.00 78105218 Fibula Plate Distal - Distal $ 2,358.00 78105219 Fibula $ 2,787.00 78105221 Plate 4Hole - Distal $ 1,929.00 78105222 Plate 6Hole - Distal $ 2,037.00 78105223 Plate 4H - Distal $ 966.00 78105224 Plate 5Hole - Distal $ 1,008.00 78105225 Plate Tubular Locking Third 7Hole $ 1,095.00 78105227 Plate 8H - Distal $ 1,137.00 78105228 Plate Locking Third Tubular - Distal $ 1,200.00 78105229 Drill Bit 2.0Mm - Distal $ 366.00 78105230 Plate - Distal $ 3,429.00 78105231 Drill Bit 3.0Mm - Distal $ 750.00 78105235 Drill Bit 4.5Mm - Distal $ 585.00 78105236 Screw 45Mm - Distal $ 750.00 78105238 Screw 50Mm - Distal $ 750.00 78105240 Screw 55Mm Cannulated - Distal $ 750.00 78105242 Screw 70Mm - Distal $ 750.00 78105244 Drill Bit 4Mm - Distal $ 810.00 78105245 Drill Bit - Distal $ 255.00

02-19-2019-A-PAC-057 Page 66 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 78105246 Plate 6 Hole - Distal $ 1,029.00 78105247 Drill Bit Cannulated 2.6Mm - Ankle $ 750.00 78105253 Drill Cannulated - Distal $ 525.00 78105255 Drill Cannulated 4.0Mm - Distal $ 525.00 78105256 Bone Tap 4.5Mm $ 750.00 78105258 Bone Tap 5.5Mm $ 525.00 78105260 Bone Tap Cannulated 6.0Mm - Distal $ 525.00 78105261 Guidewire - Distal $ 108.00 78105270 Drill Bit 2.0Mm - Distal $ 285.00 78105271 Plate Left 6Hole - Distal $ 7,887.00 78105272 Posterior Distal Plate 3Hole $ 4,266.00 78105273 Posterior Dist Fibial Plate 5Hole $ 3,516.00 78105274 Screw 18Mm Cannulated - Distal $ 1,074.00 78105276 Screw 18Mm - Distal $ 1,074.00 78105277 Screw Cann 75Mm $ 1,074.00 78105279 Screw 80Mm - Distal $ 1,074.00 78105282 Screw 18Mm 6.7X95 Cannulated - Distal $ 1,074.00 78105284 Cannulated Drill Bit 4.0Mm $ 585.00 78105293 Guide Wire - Distal $ 64.50 78105298 Screw 40Mm - Distal $ 3,408.00 78105299 Screw $ 3,408.00 78105300 Screw 50Mm $ 3,408.00 78105305 Hemeral Stem 5Mm - Shoulder $ 11,025.00 78105306 Humeral Stem 7Mm - Shoulder $ 12,525.00 78105307 Humeral Stem 10Mm - Shoulder $ 12,525.00 78105309 Glenoid Pe W/Peg Medium - Shoulder $ 4,725.00 78105310 Glenoid Large - Shoulder $ 4,725.00 78105312 Glenoid $ 4,725.00 78105313 Glenoid Small - Shoulder $ 5,145.00 78105315 Baseplate Medium - Shoulder $ 5,145.00 78105317 Screw Glenoid Peripheral Lock - Shoulder $ 360.00 78105318 Screw Lock - Shoulder $ 360.00 78105319 Usp Ii Humeral Head - Shoulder $ 5,250.00 78105320 Screw Central - Shoulder $ 510.00 78105321 Humeral Head 52/20 $ 5,250.00 78105323 Screw Cintral 20Mm - Shoulder $ 729.00 78105324 Screw Uni Rev - Shoulder $ 510.00 78105325 Stem - Shoulder $ 7,455.00 78105328 Cup - Shoulder $ 5,355.00 78105330 Cup Suture - Shoulder $ 5,355.00 78105331 Humeral Insert - Shoulder $ 3,045.00 78105334 Gleno - Shoulder $ 6,300.00 78105336 Reverse Gleno - Shoulder $ 6,300.00 78105338 Pin Set Univers - Shoulder $ 1,716.00 78105342 Screw Acutrak 2 Bone 28.0Mm $ 1,104.00 78105346 Osteosponge Strip $ 6,960.00 78105347 Peg Locking Cortical 24Mm - Trauma $ 294.00 78105350 Tandon 1/25/16 $ 1,938.00 78105351 Screw Cortical 16.0Mm - Clavicle $ 219.00 78105366 Locking Cortical Peg 20Mm $ 294.00 78105379 Locking Cortical Peg 22Mm $ 294.00 78105393 Locking Cortical Peg 24Mm $ 294.00 78105396 Screw Locking Cortical 16Mm $ 294.00 78105399 Screw Locking Cortical 18Mm $ 294.00 78105410 Screw 20Mm Locking Cortical $ 294.00 78105412 Screw 2.3Mm Locking Cortical $ 294.00 78105414 Screw 15Mm - Hip $ 1,116.00 78105415 Screw 20Mm - Hip $ 1,116.00 78105416 Screw 25Mm - Hip $ 1,116.00 78105417 Screw 30Mm - Hip $ 1,116.00 78105419 Mixing Bowl - Hip $ 72.00 78105431 Clarix - Tendon $ 10,185.00 78105433 D-Tip Tray Graspers/Dissectors $ 345.00 78105434 Liner - Hip $ 5,475.00 78105435 Charge - Esu $ 793.11 78105439 Tib Ten $ 3,350.25 78105440 Pre-Shaped Pat Lig 10-Zorc: Dr. Kerbs - 10/14/15 $ 9,521.70 78105442 Charge - Freight $ 270.00 78105443 Screw 16Mm $ 686.40 78105444 Plate 12Mm $ 1,232.40 78105445 Drill Bit 3.2 $ 826.80

02-19-2019-A-PAC-057 Page 67 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 78105446 Unledgable 1.6 $ 140.40 78105447 Charge - Gyn $ 730.71 78105448 W/Capital 2 $ 730.71 78105449 Hex Driver $ 591.00 78105451 W/Capital $ 577.71 78105453 W/Capital 2 $ 586.71 78105455 W/Capital $ 559.71 78105456 Cervical Disc Prosthesis $ 17,850.00 78105457 Cervial Disc Prosthesis - Spine $ 17,850.00 78105458 Anchoring Plate - Spine $ 4,875.00 78105470 Long Anchoring Plate - Spine $ 4,875.00 78105492 Implant Lordotic - Spine $ 4,875.00 78105493 Implant Lordotic 10Mm - Spine $ 4,875.00 78105497 Implant Lordotic 14 X 17 H7 - Spine $ 4,875.00 78105505 Lordotic Implant H 8Mm - Spine $ 4,875.00 78105523 Peek Optime Implant - Spine $ 4,875.00 78105525 Lordotic Implant H 10Mm - Spine $ 4,875.00 78105532 Peek Optima - Spine $ 4,875.00 78105536 Implant Lordotic 9Mm - Spine $ 4,875.00 78105538 Pour Plaque Agrafe - Spine $ 3,000.00 78105539 Staple 12M X 10Mm X 10Mm $ 3,873.00 78105540 Drill Bit 1.7Mm $ 1,434.00 78105542 Drill Quick Release 2.8Mm X 5" $ 243.00 78105555 Drill 2.0Mm - Clavicle $ 243.00 78105571 Mineralized Collagen Scaffold Sponge Strips - Spine $ 1,350.00 78105575 Osteomatrix Collagen Scafold - Spine $ 1,350.00 78105582 Mineralized Collagen Scaffold - Spine $ 3,150.00 78105583 Additional Time Per 1/4 Hr $ 75.00 78105585 Triflange - Hip $ 35,700.00 78105586 Sb936 $ 162.00 78105588 Charge - Shipping $ 237.00 78105589 Stem 46Mm $ 9,180.00 78105591 Stem 54Mm $ 9,180.00 78105592 Stem - Hip $ 9,180.00 78105595 High Release Knee Interspace Medium - Knee $ 9,180.00 78105598 High Release Knee Interspace-Ex Large $ 9,180.00 78105609 Prodedure 12/8/16 - Invoice Bro58268 $ 9,984.00 78105610 Procedure 12/8/16 - Invoice Bro058269 $ 9,732.00 78105612 Varistrand With X = 1-12 Seeds And 0 Or More Spacers $ 99.00 78105624 Theraload 82Xx Series $ 69.00 78105626 Therasleeve 92Xx Series $ 84.00 78105660 Screw 14Mm $ 294.00 78105661 Case $ 375.00 78105670 Bark Ankle & Randall Knee Pack $ 934.20 78105677 Bladeless Trocar 5Mm X 100Mm $ 659.40 78105679 Trocar, Bladeless 11Mm X 100Mm (Stab Sleeve Handled) $ 846. 93 78105687 Endopouch $ 210.18 78105692 Scissor, Long Curved, 5Mm $ 372.00 78105693 Lap Elec, L-Hook, 4Mm, 32Cm $ 90.00 78105699 Pack Lap Chole Lf $ 2,159.10 78105706 Traction Boot, Small, Left & Right $ 4,810.05 78105709 Conmed Hd4300 Arthroscope (4Mm, 30 Degree), W/ Sterilization Case $ 4,155.00 78105711 Olympus Cyf-5 Flexible Cystoscope, Sterrad Compatilble $ 12,000.00 78105713 Medtronic 4Mm, 0 Degree Sinuscope With Sterilization Case $ 4,755.00 78105714 Medtronic 4Mm, 30 Degree Sinuscope With Sterilization Case $ 4,755.00 78105715 Medtronic 4Mm, 70 Degree Sinuscope With Sterilization Case $ 4,755.00 78105721 Innomed Gelpad $ 1,764.21 78105726 Olympus 4 Wire Spiral Basket $ 640.50 78105727 Double Wide 6' Ace Bandage W/ Velcro Nonsterile $ 170.10 78105728 Wound Vac S.N. Vcok01649 $ 189.75 78105730 Wound Vac $ 189.75 78105731 Leg Positioner Table Clamp $ 557.04 78105739 Sleeve Avi Reg $ 203.46 78105740 Cover Foot Avi Rigid-Sole Lg $ 200.73 78105778 Plate, 1/3 5 Hole 61 Mm Tubular With Collar $ 490.35 78105779 Sling, Ultra Iii Medium $ 147.90 78105780 Sling, Ultra Iii Large $ 147.90 78105781 Strap, Ali 1 1/2 X 30 $ 125.28 78105783 Drape, Isolation Steri Large $ 306.96 78105792 Tray Thoracentesis Pleura-Seal $ 169.98 78105798 Pack Upper Extremity $ 941.85

02-19-2019-A-PAC-057 Page 68 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 78105799 Sleeve Scd Express Thigh Med $ 127.17 78105800 Sleeve Scd Express Thigh Sm $ 122.37 78105801 Sleeve Scd Express Thigh Lg $ 154.29 78105805 Electrode Pediatric Quickcombo $ 170.16 78105813 Catheter, Riddick Stiffer With Needle Introducer 4F $ 447.00 78105815 Endogator Hybrid Irrigation Tubing $ 73.50 78105816 Synthes 1.7 Cables W/Crimp 750Mm Sterile (Dawson) $ 2,308.50 78105818 Gamma, Long Nail Kit R1.5 Ti Left $ 326.40 78105820 Stapler, Powered Ethicon 45Mm 28 Cm Shaft $ 1,125.00 78105824 Livatec Sagittal Blade $ 94.50 78105825 Suture Anchor Biocomposite Suture Tak $ 4,800.00 78105826 System, Distal Bicep Repair Implant $ 2,550.00 78105827 Biocomposite Pushlock Suture Anchor $ 6,000.00 78105830 Catheter, 19G Kumar $ 101.25 78105831 Capsure Lap Inguinal Hernia Repair $ 2,363.25 78105832 Ligasure Maryland Medtronic $ 1,567.50 78105834 Randall Beach Chair Arthoscopy Pack $ 2,757.72 78105894 Proximate Stapler $ 348.21 78105899 Lap Disc $ 1,725.00 78105911 Dynj50057A Pack Abdominal Lap $ 102.03 78105912 Dynj50052A Pack Laparoscopy $ 172.71 78105913 Total Hip Tray Pack $ 368.37 78105914 Pack, Open Shoulder $ 264.81 78105915 Ortho Lower Extremity Pack $ 120.66 78105916 Arthroscopy Pack $ 94.11 78105917 Arhtroscopy Shoulder Tray $ 275.64 78105922 Endo Gia 45 Reloads $ 458.79 78105925 Adhesive 2Oz Liquid Mastisol $ 78.69 78105926 Osteotome Flexible Revision Gray 12Mm/120Mm $ 1,572.00 78105928 Brace Knee T-Scope Breg $ 251.46 78105940 Kurz Omega Connector For Total Prosthesis $ 615.00 78105950 Adson Micro Tissue Forceps Stainless Steel Straight 1X2 Teeth Tip Smooth Ja $ 183.39 78105954 Tray, Instrument 8 7/8 X 5 X 3 $ 203.70 78105955 Set, Dilators Uterine Hank $ 85.38 78105959 Roller Bar Electrode $ 335.97 78105960 Hydroxide, 10% Koh Potassium 25 Ml $ 70.83 78105962 Bags, Leuerlock Theraputic Phelb $ 60.78 78105968 Hand Piece, Harmonic $ 2,685.00 78105969 Blade, Retractor Charnley 6" Depth $ 1,003.65 78105970 Blade, Bender $ 96.00 78105973 Mallet, Combination $ 366.54 78105974 Retrievers, Suture Hewson $ 202.92 78105975 Hook, Bone $ 795.00 78105977 Burr, Cutting #2 Diamond $ 501.00 78105978 Blade, Sinus Tricut Str 13 Cm $ 916.32 78105980 Kit, Peel-Aart Introducer 8 Fr $ 390. 00 78105985 Rack, Mini K Wire $ 1,566.00 78105988 Pouch, Endocatch Specimen 10Mm $ 594.24 78105989 Reload Stapler, Linear Reloads $ 155.43 78105992 Suture, 5 Ethibond $ 62.40 78106005 Suture 2-0 36In Vicryl Vlt V-34 $ 332.37 78106006 Suture 5-0 18In Vicryl Vlt Ps-5 $ 167.88 78106009 Pack Lithotomy Pak Iv $ 190.56 78106022 Suture 3-0 36In Vicryl Vlt Ct $ 203.16 78106029 Suture 1 36In Vicryl Vlt V-34 $ 311.31 78106036 Double Sided Recip - Total Knee Nexgen $ 100.98 78106059 Pack Abdominal Lap Lf $ 161.73 78106065 Bone Cement, Mixing System, 3 Dose Compact Vacuum Cement $ 317.94 78106067 Bowl, Mixing Quick - Vac $ 165.00 78106068 Dissector, Curved With Monopolar Cautery 5Mm $ 228.66 78106075 Roll 2In X 15Ft Fiberglass Spl $ 102.66 78106077 Blade, Mini 7Cm Long 2.9Mm Abrader $ 140.91 78106081 Brace, Knee Polar Care Cube Cooler Xlg $ 315.00 78106082 Digit Trap Finger Grasping Device Large $ 803.40 78106084 Connector, Light Cord $ 153.90 78106085 Kit, Micro Bio Suture Tak Disposable $ 525.00 78106086 Tak, Suture Mini Bio 8.5Mm With Needles $ 135.00 78106087 Corkscrew, Bio 6.5 $ 1,005.00 78106088 Tak, Suture Micro Bio Composite 2.4X6.5 $ 975.00 78106090 Arm Support, Mcconnell $ 105.00 78106094 Manuplator, Cervical Large $ 246.48

02-19-2019-A-PAC-057 Page 69 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 78106096 Handpiece, Shaft Altrus 5Mm 36Cm $ 2,385.00 78106097 Blades, Sinus Tricut $ 543.66 78106098 Guidewire, Angled .035 $ 164.82 78106103 Clamp, Endo Lung $ 654.33 78106104 Suture, 2-0 Vloc 180 Gs-22 1/2 27Mm $ 91.05 78106105 Tip, Disp E Probe 5Mm Spatula $ 115.08 78106106 Blade, Saw For Total Hip 18X1.27X90M Sagtail $ 174.75 78106108 Seal, Small Pressurizing $ 129.93 78106109 Seal, Large Howmedica Pressurizing $ 129.93 78106110 Blade, Saw Stryker $ 102.93 78106111 Blade, Tps Lg Med Stryker $ 154.65 78106112 Blade, Saw Large Narrow $ 146.85 78106113 Blade, Saw With Stop Tps $ 114.63 78106116 Reload Stapler, Green Reload Endo $ 493.05 78106117 Reload Cutter, Linear Reload Cartridge Endo 45Mm $ 486.54 78106121 Applier Ligaclip Large $ 197.94 78106124 Stapler, Linear 30 Mm Tx30G Green $ 329.67 78106125 Ligature, 5Mm Mersilene $ 120.78 78106141 Grasper, Endoscopic 5 Mm $ 613.23 78106144 Suture, 7-0 Prolene $ 91.23 78106145 Drape, Table Pedigo Double Decker $ 116.04 78106151 Bra, Semi Shaper Size 36 With Velcro $ 99.00 78106152 Bra, Semi Shaper Size 38 With Velcro $ 99.00 78106153 System, Bc Permanent Essure $ 5,550.00 78106154 Tube Set, Airseal Tritumen Filtered Davinci $ 196.98 78106158 Tubes, Bevel Armstrong $ 62.91 78106170 Aquacel Ag Hydro Fiber With Silver 3.5 X 10In $ 106.05 78106177 Sling, Ultra Ii Sm $ 129.90 78106180 Sleeve Endopath Xcel Bladeless $ 83.31 78106181 Aquacel Ag Hydro Fiber W/Silver 3.5 X 6In $ 84.84 78106197 Tray Laparoscopy Custom $ 204.99 78106198 Tray Open Shoulder Custom $ 227.10 78106199 Tray Open Shoulder Custom $ 234.78 78106203 Leep 5Mm Ball For Cautery $ 330.30 78106204 Cutter Endoscopic Linear Long $ 813.03 78106211 Bra Compression Size 36 White $ 79.65 78106225 Fiberstick $ 150.00 78106226 Fiberloop $ 150.00 78106227 Fiberloop T $ 150.00 78106239 Ziptight Fixation System Ankle Syndesmosis $ 1,725.00 78106250 Adson Tissue Forceps, 1X2 Teeth, Std Ptt 6" $ 117.60 78106251 Flyte Surgicool Pullover Toga, 2X Large $ 86.88 78106252 Holder Surgi Or Needle 5In $ 67.20 78106253 Hydrogel Tape Strips (Baby Tape) $ 65.85 78106258 Titanium - Vocal-Fold-Medial-Implant Size 15.0 Mm $ 1,380.00 78106259 Aem Disposable Curved Scissors $ 266. 49 78106261 Bio-Comp Inter-Ference Screw $ 705.00 78106262 Biocomposite Intererence Screw $ 705.00 78106264 Curved Mosquitoes Forceps $ 78.00 78106265 Single Prong Skin Hook $ 133.11 78106267 Dynj50051A Foot & Ankle S $ 176.13 78106273 Flip Cutter 9Mm $ 975.00 78106276 Super Mulitvac 50 Ifs $ 495.00 78106278 Splint Orthoglass 1 $ 73.98 78106281 Microscope Drape $ 74.73 78106283 Carpal Tunnel Knife $ 658.35 78106286 Handpiece, Disposable Aqua Manty'S $ 1,843.02 78106292 Ethicon Endoloop $ 146.55 78106294 Ethicon Ecs Stapler 29 $ 1,185.66 78106295 Ethicon Ecs Stapler 33 $ 1,185.66 78106302 Polarcare Extra Pads $ 108.00 78106303 Catheter, Open End Ureteral Access 6Fr 2.0 Mm $ 387.00 78106304 Bit, Drill 3.0 $ 630.00 78106305 Packing, Absorbent, Ortho-Dri 8" $ 140.40 78106306 Applier, Clip Endoscopic Ligamax $ 570.57 78106309 Micropuncture Introducer Set 21G/7Cm 5F $ 81.00 78106310 Powerflex Pro 6X100X135 $ 432.00 78106315 Clearview Uterine Manipulator, With 7 Cm Tip, Spacer, Sound-Dilator $ 165.00 78106318 Trach/Vent Swallowing/Speaking Valve-Purple $ 201.15 78106319 Bladeless Trocar 11Mm $ 139.29 78106322 Cath Pleural Pleurx Kit $ 2,489.64

02-19-2019-A-PAC-057 Page 70 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 78106324 Bag Enema Snap-Cap $ 391.17 78106337 Suture 0 30In Ethibond Ct-1 $ 225.00 78106338 Suture 0 8 X 18In Ethibond Grn Brd Cr Mo-7 $ 540.99 78106339 Suture 0 8/18In Vicryl Vlt Cr Ct-1 $ 453. 18 78106340 Suture 1 8/18In Vicryl Vlt Cr Ct-1 $ 433.50 78106343 Suture 2-0 8/18In Vicryl Vlt Cr Ct-1 $ 417.33 78106346 Suture 3-0 8/18In Silk Cr Sh $ 348.42 78106347 Suture 4-0 18In Prolene Ps-2 $ 186.87 78106349 Suture 6-0 18In Ethilon P-3 $ 129.69 78106350 Suture 2-0 27In Vicryl Undyed Sh $ 202. 35 78106351 Suture 4-0 18In Vicryl Undyed Ps-2 $ 430. 92 78106364 Kit 1000 Ml Drainage Pleurx $ 239.13 78106380 Total Knee Tray Dr Foster $ 856.50 78106381 Total Hip Tray $ 1,089.09 78106384 3Mm Fluted Matchstick $ 316.80 78106392 Encision Disp 3/4" Curved Scissor Insert $ 266.49 78106397 Laparoscpy Pelviscopy Pack Iii $ 73.77 78106400 Skin Stapler Proximate Wide $ 63.69 78106401 Spine Pack $ 226.23 78106405 System Wound Debridement $ 185.85 78106407 Trocar 12Mm $ 145.47 78106414 Mesh, Pro-Loop ( X-Lg) $ 747.00 78106417 Catheter Cholangiogram 4 1/2Fr $ 153.18 78106423 Tourniquet, Stryker 18" Disposable $ 62.85 78106428 Tourniquet, Stryker 34" Disposable $ 76.05 78106439 Recrocating Rasp (W5.5 X L 1.5) $ 113.40 78106464 Electrode Cutting Loop 24Fr $ 691.68 78106465 Mixing System Revolution Cement W/O Nozzle $ 1,223.88 80100002 HC CCH SLED DIALYSIS $ 1,814.00 80100004 HC CCH HEMODIALYSIS UP TO 4 HR $ 1,814.00 80100005 HC CCH HEMODIALYSIS ADDITIONAL HR $ 80.00 80200001 HC CCH PERITONEAL DIALYSIS $ 1,386.00 88000003 HC HEMODIALYSIS $ 226.00 88000004 HC CCH HEMODIALYSIS REPEATED EVALUATION $ 323.00 88000005 HC CCH ESRD SERVICES 1 VISIT PER MONTH > 20 YEARS $ 1,135.00 90000005 HC PSYCH DX EVALUATION $ 70.57 90000007 HC CCH PSYCH EVALUATION OF RECORDS $ 155.00 91400001 HC CCH PSYTX COMPLEX INTERACTIVE $ 15.00 91400010 HC PSYCHOTHERAPY W/ PT 30 MINUTES $ 156.00 91400011 HC PSYCHOTHERAPY W/ PT 45 MINUTES $ 39.50 91400012 HC PSYCHOTHERAPY W/ PT 60 MINUTES $ 328.00 91400014 HC CCH PSYCHOTHERAPY W/ PT AND FAMILY W/ E&M 45 MINUTES $ 215.00 91600004 HC INTERVENTION HEALTH/BEHAVIOR EA 15 MIN FAMILY W/O PT $ 22.00 91800005 HC CCH COGNITIVE TEST PER HOUR $ 151.00 91800011 HC CCH PSYCH TESTING EVAL FIRST HOUR $ 77.00 91800012 HC CCH PSYCH TESTING EVAL EACH ADDL HOUR $ 57.00 91800013 HC CCH PSYCH OR NEUROPSYCH TESTING FIRST 30 MINUTES $ 81.50 91800014 HC CCH PSYCH OR NEUROPSYCH TESTING EACH ADDL 30 MINUTES $ 80.00 92000004 HC UROFLOWMETRY COMPLEX $ 122.00 92000008 HC FETAL NON-STRESS TEST $ 378.00 92000008 HC FETAL NON-STRESS TEST $ 79.00 92000025 HC ANALYSIS W/O PROGRAMMING NEUROSTIM BRAIN SPINAL OR PERIPHERAL $ 333.00 92000027 HC ANALYSIS & PROGRAMMING COMPLEX SPINAL/PERIPH NEUROSTIM 1ST HOUR $ 153.00 92000030 HC CYSTOMETROGRAM COMPLEX W/ URETHRAL & VOIDING PRESSURE $ 500.52 92000039 HC EMG ANAL/URETHR SPHINCTER OTHER THAN NEEDLE $ 427.00 92000040 HC INTRA-ABDOMINAL VOIDING PRESSURES $ 245.50 92000043 HC CCH ELECTR ANALYSIS NEUROSTIM PUSE GENERATOR GASTRIC INTRAOP W/PROG $ 62.00 92000044 HC CCH DYNAMIC FINE WIRE EMG DURING WALK/FUNC ACTIVITY 1 MUSCLE $ 13.00 92000049 HC CONTINUOUS GLUCOSE MONITORING $ 472.00 92000050 HC CCH CONTINUOUS GLUCOSE MONITORING ANALYSIS I&R $ 128.50 92100001 HC DUPLEX EXTRACRANIAL ARTERIES COMPLETE BILATERAL $ 727.00 92100003 HC LIMITED EXTREMITY STUDY UP TO 2 LEVELS BILATERAL $ 418.00 92100004 HC COMPLETE EXT STUDY 3+ LEVELS OR PROVOC FX MANEUVERS $ 457.00 92100005 HC COMPLETE LE STUDY AT REST AND STRESS BILATERAL $ 575.00 92100006 HC DUPLEX LE ARTERIES OR BYPASS GRAFTS COMPLETE BILATERAL $ 1,173.00 92100007 HC DUPLEX LE ARTERIES OR BYPASS GRAFTS UNILATERAL OR LIMITED $ 964.00 92100008 HC DUPLEX UE ARTERIES OR BYPASS GRAFTS COMPLETE BILATERAL $ 1,117.00 92100009 HC DUPLEX UE ARTERIES OR BYPASS GRAFTS UNILATERAL OR LIMITED $ 757.00 92100010 HC DUPLEX EXTREMITY VEINS COMPRESSION COMPLETE BILATERAL $ 1,344.00 92100011 HC DUPLEX EXTREMITY VEINS COMPRESSION UNILATERAL OR LIMITED $ 820.00 92100012 HC DUPLEX ABDOMEN PELVIS RETROPERITONEAL OR SCROTUM COMPLETE $ 1,172.00

02-19-2019-A-PAC-057 Page 71 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 92100013 HC DUPLEX ABDOMEN PELVIS RETROPERITONEAL OR SCROTUM LIMITED $ 837.00 92100014 HC DUPLEX AORTA INFERIOR VENA CAVEA ILIAC OR BYPASS GRAFT COMPLETE $ 949.00 92200001 HC EMG 1 EXTREMITY $ 402.00 92200001 HC EMG 1 EXTREMITY $ 155.00 92200002 HC EMG 2 EXTREMITIES $ 547.00 92200003 HC EMG 3 EXTREMITIES $ 627.00 92200004 HC EMG 4 EXTREMITIES $ 827.00 92200007 HC EMG CRANIAL NERVE MUSCLE UNILATERAL $ 411.00 92200009 HC EMG THORACIC NOT T1 OR T12 $ 254.00 92200020 HC NEUROMUSCULAR JUNCTION TESTING EACH NERVE $ 303.00 92200020 HC NEUROMUSCULAR JUNCTION TESTING EACH NERVE $ 180.00 92200022 HC NEEDLE EMG EA EXTREMITY LIMITED W/ NERVE CONDUCTION $ 274.00 92200022 HC NEEDLE EMG EA EXTREMITY LIMITED W/ NERVE CONDUCTION $ 125.00 92200023 HC NEEDLE EMG EA EXTREMITY COMPLETE W/ NERVE CONDUCTION $ 309.00 92200023 HC NEEDLE EMG EA EXTREMITY COMPLETE W/ NERVE CONDUCTION $ 105.00 92200024 HC NEEDLE EMG NON-EXTREMITY W/ NERVE CONDUCTION $ 207.00 92200024 HC NEEDLE EMG NON-EXTREMITY W/ NERVE CONDUCTION $ 54.00 92200025 HC NERVE CONDUCTION 1-2 STUDIES $ 254.00 92200025 HC NERVE CONDUCTION 1-2 STUDIES $ 113.00 92200026 HC NERVE CONDUCTION 3-4 STUDIES $ 368.00 92200026 HC NERVE CONDUCTION 3-4 STUDIES $ 113.00 92200027 HC NERVE CONDUCTION 5-6 STUDIES $ 457.00 92200027 HC NERVE CONDUCTION 5-6 STUDIES $ 113.00 92200028 HC NERVE CONDUCTION 7-8 STUDIES $ 502.00 92200028 HC NERVE CONDUCTION 7-8 STUDIES $ 113.00 92200029 HC NERVE CONDUCTION 9-10 STUDIES $ 696.00 92200029 HC NERVE CONDUCTION 9-10 STUDIES $ 210.00 92200030 HC NERVE CONDUCTION 11-12 STUDIES $ 912.00 92200030 HC NERVE CONDUCTION 11-12 STUDIES $ 210.00 92200031 HC NERVE CONDUCTION 13 OR MORE STUDIES $ 970.00 92200031 HC NERVE CONDUCTION 13 OR MORE STUDIES $ 210.00 94000019 HC INJECTION IM OR SQ $ 50.00 94000019 HC INJECTION IM OR SQ $ 75.00 94000024 HC PHLEBOTOMY THERAPEUTIC $ 124.00 94000024 HC PHLEBOTOMY THERAPEUTIC $ 118.00 94000038 HC APPLICATION ON BODY INJECTOR $ 105.00 94000039 HC CCH ACTINOTHERAPY $ 117.00 94000042 HC CCH INJECTION ANTIBIOTIC IM OR SQ $ 50.00 94200001 HC DIABETES TRAINING IND PER 30 MINS $ 75.00 94200002 HC DIABETES TRAINING GROUP PER 30 MINS $ 26.00 94200020 HC CCH SMOKING & TOBACCO USE CESSATION COUNSELING 3-10 MINS $ 44.00 94200026 HC MEDICAL NUTRITION THERAPY INDIVIDUAL INITIAL ASSESSMENT & INTERVENTION EACH 15 MINS $ 39.00 94200027 HC MEDICAL NUTRITION THERAPY INDIVIDUAL RE-ASSESSMENT & INTERVENTION EACH 15 MINS $ 44.00 94200028 HC MEDICAL NUTRITION THERAPY GROUP >2 INDIVIDUALS EACH 30 MINS $ 39.00 94200031 HC CCH DIABETES TRAINING GROUP PER 30 MIN 5-8 PTS $ 20.00 94200032 HC CCH SELF MGMT EDUC/TRAIN 1 PT $ 83. 00 94200033 HC CCH SELF MGMT EDUC/TRAIN 2-4 PT $ 117.00 94200034 HC CCH SELF MGMT EDUC/TRAIN 5-8 PT $ 150.00 94300002 HC CARDIAC REHAB W/ EKG PER SESSION $ 206.00 94800001 HC PULMONARY REHAB EXERCISE PER HOUR $ 140.00 94900002 HC CCH PULMONARY/CARDIAC REHAB WELLNESS MONTH $ 30.00 94900003 HC CCH PULMONARY/CARDIAC REHAB WELLNESS PARTIAL MONTH $ 15.00 Medication Abacavir Sulfate Tab 300 MG (Base Equiv) $ 53.28 Medication Abatacept For IV Soln 250 MG $ 3,327.05 Medication Acetaminophen IV Soln 10 MG/ML $ 137.70 Medication Acetaminophen Liquid 160 MG/5ML $ 19.85 Medication Acetaminophen Soln 160 MG/5ML $ 49.42 Medication Acetaminophen Suppos 120 MG $ 5.20 Medication Acetaminophen Suppos 325 MG $ 4.09 Medication Acetaminophen Suppos 650 MG $ 5.65 Medication Acetaminophen Susp 160 MG/5ML $ 24.75 Medication Acetaminophen Tab 325 MG $ 3.86 Medication Acetaminophen Tab 500 MG $ 3.86 Medication Acetaminophen w/ Codeine Soln 120-12 MG/5ML $ 28.12 Medication Acetaminophen w/ Codeine Tab 300-30 MG $ 5.51 Medication Acetazolamide Cap ER 12HR 500 MG $ 60.99 Medication Acetazolamide Sodium For Inj 500 MG $ 199.52 Medication Acetazolamide Tab 250 MG $ 36.12 Medication Acetic Acid Irrigation Soln 0.25% $ 35.57 Medication Acetylcholine Chloride Intraocular For Soln 20 MG (1:100) $ 384.79 Medication Acetylcysteine Inhal Soln 10% $ 40.21

02-19-2019-A-PAC-057 Page 72 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 Medication Acetylcysteine Inhal Soln 20% $ 86.36 Medication Acetylcysteine Inj 200 MG/ML $ 726.53 Medication Acyclovir Cap 200 MG $ 3.86 Medication Acyclovir Oint 5% $ 1,234.53 Medication Acyclovir Sodium For Inj 500 MG $ 179.19 Medication Acyclovir Sodium IV Soln 50 MG/ML $ 95.90 Medication Acyclovir Susp 200 MG/5ML $ 213.43 Medication Adenosine IV Soln 12 MG/4ML $ 93.49 Medication Adenosine IV Soln 3 MG/ML (Diagnostic) $ 757.13 Medication Adenosine IV Soln 6 MG/2ML $ 93.49 Medication Ado-Trastuzumab Emtansine For IV Soln 100 MG $ 8,954.30 Medication Ado-Trastuzumab Emtansine For IV Soln 160 MG $ 14,323.59 Medication Agalsidase beta For IV Soln 35 MG $ 18,185.16 Medication Agalsidase beta For IV Soln 5 MG $ 2,602.18 Medication Albumin Human Inj 25% $ 695.81 Medication Albumin Human Inj 5% $ 536.66 Medication Albuterol Sulfate Inhal Aero 108 MCG/ACT (90MCG Bas* $ 105.36 Medication Albuterol Sulfate Inhal Aero 108 MCG/ACT (90MCG Base Equiv) $ 114.18 Medication Albuterol Sulfate Soln Nebu 0.083% (2.5 MG/3ML) $ 4.16 Medication Albuterol Sulfate Soln Nebu 0.5% (5 MG/ML) $ 5.90 Medication Albuterol Sulfate Syrup 2 MG/5ML $ 41.48 Medication Alcohol Absolute Inj 98% $ 126.59 Medication Alendronate Sodium Tab 70 MG $ 15.40 Medication Alfentanil HCl IV Soln 1000 MCG/2ML (500 MCG/ML) (Base Eq) $ 63.97 Medication Allopurinol Tab 100 MG $ 5.57 Medication Allopurinol Tab 300 MG $ 8.76 Medication Alpha1-Proteinase Inhibitor (Human) Inj 1000 MG/50ML $ 1,413.16 Medication Alprazolam Tab 0.25 MG $ 5.51 Medication Alprazolam Tab 0.5 MG $ 5.51 Medication Alteplase For Inj 100 MG $ 26,362.59 Medication Alteplase For Inj 2 MG $ 592.50 Medication Alteplase For Inj 50 MG $ 13,184.05 Medication Alum & Mag Hydroxide-Simethicone Susp 200-200-20 MG/5ML $ 30.19 Medication Alum & Mag Hydroxide-Simethicone Susp 225-200-25 MG*Alum & Mag Hydroxide-Simethicone Susp 200-200-20 MG* $ 24.49 Medication Alvimopan Cap 12 MG $ 496.65 Medication Amantadine HCl Cap 100 MG $ 21.64 Medication Amantadine HCl Syrup 50 MG/5ML $ 19.85 Medication Amiloride HCl Tab 5 MG $ 9.20 Medication Amino Acid Electrolyte w/Cal Infusion 4.25% in D5W $ 188.68 Medication Amino Acid Electrolyte w/Cal Infusion 5% in D20W $ 198.03 Medication Amino Acid Infusion 4.25% in D25W $ 165.31 Medication Amino Acid Infusion 4.25% in D5W $ 165.31 Medication Amino Acid Infusion 5% in D20W $ 193.36 Medication Aminocaproic Acid Inj 250 MG/ML $ 58.22 Medication Aminophylline Inj 25 MG/ML $ 96.87 Medication Amiodarone HCl in Dextrose 4.14% IV Soln 360 MG/200ML $ 149. 40 Medication Amiodarone HCl in Dextrose 4.21% IV Soln 150 MG/100ML $ 114.96 Medication Amiodarone HCl Inj 150 MG/3ML (50 MG/ML) $ 33.52 Medication Amiodarone HCl Tab 200 MG $ 5.80 Medication Amitriptyline HCl Tab 10 MG $ 3.86 Medication Amitriptyline HCl Tab 25 MG $ 6.40 Medication Amlodipine Besylate Tab 5 MG (Base Equivalent) $ 3.86 Medication Ammonia Aromatic Inhalation $ 6.38 Medication Amoxicillin & K Clavulanate For Susp 400-57 MG/5ML $ 61.52 Medication Amoxicillin & K Clavulanate For Susp 600-42.9 MG/5ML $ 20.01 Medication Amoxicillin & K Clavulanate Tab 875-125 MG $ 18.61 Medication Amoxicillin (Trihydrate) Cap 250 MG $ 3.86 Medication Amoxicillin (Trihydrate) For Susp 125 MG/5ML $ 25.53 Medication Amoxicillin (Trihydrate) For Susp 250 MG/5ML $ 27.86 Medication Amphotericin B Liposome IV For Susp 50 MG $ 745.69 Medication Ampicillin & Sulbactam Sodium For Inj 1.5 (1-0.5) GM $ 66.56 Medication Ampicillin & Sulbactam Sodium For Inj 15 (10-5) GM $ 280.59 Medication Ampicillin & Sulbactam Sodium For Inj 3 (2-1) GM $ 69.59 Medication Ampicillin For Susp 125 MG/5ML $ 40.95 Medication Ampicillin Sodium For Inj 1 GM $ 33.26 Medication Ampicillin Sodium For Inj 2 GM $ 113.20 Medication Ampicillin Sodium For Inj 250 MG $ 32.41 Medication Ampicillin Sodium For IV Soln 2 GM $ 62.64 Medication Antipyrine-Benzocaine Otic Soln 54-14 MG/ML (5.4-1.4%) $ 59.28 Medication Apixaban Tab 2.5 MG $ 49.26 Medication Apixaban Tab 5 MG $ 49.26

02-19-2019-A-PAC-057 Page 73 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 Medication Apraclonidine HCl Ophth Soln 1% (Base Equivalent) $ 131.84 Medication Argatroban Inj 250 MG/2.5ML (Concentrate For IV Infusion) $ 3,939.44 Medication Aripiprazole Tab 5 MG $ 65.61 Medication Artificial Saliva - Solution $ 30.89 Medication Ascorbic Acid Tab 500 MG $ 3.86 Medication Aspirin Buffered (Ca Carb-Mg Carb-Mg Ox) Tab 325 MG $ 3.86 Medication Aspirin Chew Tab 81 MG $ 3.86 Medication Aspirin Suppos 300 MG $ 13.55 Medication Aspirin Suppos 600 MG $ 13.94 Medication Aspirin Tab 325 MG $ 3.86 Medication Aspirin Tab Delayed Release 325 MG $ 3.86 Medication Aspirin Tab Delayed Release 81 MG $ 3.86 Medication Aspirin-Al Hydro-Mg Hydro-Ca Carb Tab 325 MG $ 3.86 Medication Aspirin-Dipyridamole Cap ER 12HR 25-200 MG $ 68.94 Medication Atenolol Tab 25 MG $ 3.90 Medication Atezolizumab IV Soln 1200 MG/20ML $ 26,602.73 Medication Atezolizumab IV Soln 840 MG/14ML $ 18,623.56 Medication Atomoxetine HCl Cap 25 MG (Base Equiv) $ 85.97 Medication Atorvastatin Calcium Tab 10 MG (Base Equivalent) $ 5.80 Medication Atorvastatin Calcium Tab 20 MG (Base Equivalent) $ 6.58 Medication Atorvastatin Calcium Tab 40 MG (Base Equivalent) $ 6.58 Medication Atracurium Besylate IV Soln 100 MG/10ML $ 93.75 Medication Atropine Sulfate Inj 0.4 MG/ML $ 61.76 Medication Atropine Sulfate Inj 8 MG/20ML (0.4 MG/ML) $ 19.61 Medication Atropine Sulfate Ophth Soln 1% $ 451.38 Medication Atropine Sulfate Soln Prefill Syr 1 MG/10ML (0.1 MG/ML) $ 72.20 Medication Azacitidine For Inj 100 MG $ 937.79 Medication Azithromycin For Susp 200 MG/5ML $ 124.51 Medication Azithromycin IV For Soln 500 MG $ 65.21 Medication Azithromycin Tab 250 MG $ 23.88 Medication Aztreonam For Inj 1 GM $ 122.02 Medication Bacitracin Intramuscular For Soln 50000 Unit $ 94.62 Medication Bacitracin Oint 500 Unit/GM $ 22.55 Medication Bacitracin Ophth Oint 500 Unit/GM $ 389.54 Medication Bacitracin Zinc Oint 500 Unit/GM $ 34.20 Medication Bacitracin-Polymyxin-Neomycin-HC Ophth Oint 1% $ 210.61 Medication Baclofen Tab 10 MG $ 7.76 Medication BALANCED SALT SOLUTION 500 ML WITH 0.5 MG EPINEPHRINE $ 13.55 Medication Barium Sulfate For Susp 40% $ 19.85 Medication Barium Sulfate For Susp 96% $ 29.13 Medication Barium Sulfate For Susp 98% $ 77.79 Medication Barium Sulfate For Susp Enema Kit 96% $ 53.72 Medication Barium Sulfate Oral Paste 40% $ 19.85 Medication Barium Sulfate Oral/Rectal Susp 105% $ 149.47 Medication Barium Sulfate Susp 0.1% $ 44.69 Medication Barium Sulfate Susp 2% $ 29. 96 Medication Barium Sulfate Susp 2.1% $ 29.96 Medication Barium Sulfate Susp 24% $ 139.89 Medication Barium Sulfate Susp 40% $ 19.85 Medication Barium Sulfate Tab 700 MG $ 24.68 Medication BCG Live Intravesical For Susp 50 MG $ 152.37 Medication B-Complex w/ C & E + Zn Tab $ 3.86 Medication B-Complex w/ C & Folic Acid Cap 1 MG $ 11.01 Medication B-Complex w/ C & Folic Acid Tab $ 3.86 Medication Belatacept For IV Infusion 250 MG $ 2,839.44 Medication Belimumab For IV Soln 120 MG $ 1,557.55 Medication Belimumab For IV Soln 400 MG $ 5,178.80 Medication Belladonna Alkaloids & Opium Suppos 16.2-60 MG $ 128.42 Medication Bendamustine HCl For IV Soln 100 MG $ 8,906.05 Medication Bendamustine HCl For IV Soln 25 MG $ 2,230.65 Medication Bendamustine HCl IV Soln 100 MG/4ML (25 MG/ML) $ 7,414.54 Medication Bendamustine HCl IV Soln 45 MG/0.5ML (90 MG/ML) $ 3,186.65 Medication Benzocaine Mouth/Throat Aerosol 20% $ 120.33 Medication Benzocaine-Menthol Aerosol 20-0.5% $ 32.24 Medication Benzocaine-Menthol Lozenge 15-2.6 MG $ 19.85 Medication Benzocaine-Menthol Lozenge 15-3.6 MG $ 19.85 Medication Benzoin Compound Tincture $ 30.55 Medication Benzoin Tincture Spray $ 43.57 Medication Benzonatate Cap 100 MG $ 6.72 Medication Benztropine Mesylate Inj 1 MG/ML $ 145.76 Medication Benztropine Mesylate Tab 1 MG $ 6.29

02-19-2019-A-PAC-057 Page 74 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 Medication Betamethasone Sod Phosphate & Acetate Inj Susp 6 (3-3) MG/ML $ 125.71 Medication Betamethasone Valerate Cream 0.1% (Base Equivalent) $ 115.66 Medication Betaxolol HCl Ophth Soln 0.5% $ 206.54 Medication Bethanechol Chloride Tab 25 MG $ 11.24 Medication Bevacizumab IV Soln 100 MG/4ML (For Infusion) $ 2,392.35 Medication Bevacizumab IV Soln 400 MG/16ML (For Infusion) $ 9,552.85 Medication Bisacodyl Suppos 10 MG $ 12.83 Medication Bisacodyl Tab Delayed Release 5 MG $ 3.86 Medication Bismuth Subgallate Powder $ 2,944.81 Medication Bismuth Subsalicylate Susp 262 MG/15ML $ 23.17 Medication Bisoprolol Fumarate Tab 5 MG $ 10.25 Medication Bivalirudin Trifluoroacetate For IV Soln 250 MG (Base Equiv) $ 1,652.76 Medication Bleomycin Sulfate For Inj 15 Unit $ 183.78 Medication Bleomycin Sulfate For Inj 30 Unit $ 62.34 Medication Bortezomib For Inj 3.5 MG $ 4,806.50 Medication BRILLIANT BLUE G 0.25 MG/ML INTRAOCULAR SOLN $ 84.51 Medication Brimonidine Tartrate Ophth Soln 0.2% $ 81.16 Medication Budesonide Inhalation Susp 0.25 MG/2ML $ 52.45 Medication Budesonide Inhalation Susp 0.5 MG/2ML $ 61.34 Medication Bumetanide Inj 0.25 MG/ML $ 22.38 Medication Bumetanide Tab 1 MG $ 10.69 Medication Bupivacaine 0.75% in Dextrose Inj 8.25% $ 41.43 Medication Bupivacaine HCl Inj 0.25% $ 28.81 Medication Bupivacaine HCl Inj 0.5% $ 95.50 Medication Bupivacaine HCl Preservative Free (PF) Inj 0.25% $ 124.83 Medication Bupivacaine HCl Preservative Free (PF) Inj 0.5% $ 56.13 Medication Bupivacaine HCl Preservative Free (PF) Inj 0.75% $ 58.06 Medication Bupivacaine Inj 0.25% w/ Epinephrine 1:200000 (PF) $ 73.00 Medication Bupivacaine Inj 0.5% w/ Epinephrine 1:200000 (PF) $ 78.07 Medication Bupivacaine Liposome Inj 1.3% (13.3 MG/ML) $ 977.27 Medication Buprenorphine HCl Inj 0.3 MG/ML (Base Equiv) $ 89.17 Medication Bupropion HCl Tab ER 24HR 150 MG $ 39.37 Medication Buspirone HCl Tab 5 MG $ 3.86 Medication Butalbital-Acetaminophen-Caffeine Tab 50-325-40 MG $ 18.01 Medication Butamben-Tetracaine-Benzocaine Aerosol Spray 2-2-14% $ 191.28 Medication Cabazitaxel Inj 60 MG/1.5ML (For IV Infusion) $ 118,438.59 Medication Calcitonin (Salmon) Inj 200 Unit/ML $ 2,029.43 Medication Calcitonin (Salmon) Nasal Soln 200 Unit/ACT $ 292.63 Medication Calcitriol Cap 0.25 MCG $ 13.35 Medication Calcium Acetate (Phosphate Binder) Cap 667 MG (169 MG Ca) $ 16.36 Medication Calcium Carbonate (Antacid) Chew Tab 500 MG $ 9.36 Medication Calcium Carbonate-Vitamin D Tab 500 MG-200 Unit $ 11.67 Medication Calcium Chloride Inj 10% $ 107.81 Medication Calcium Gluconate Inj 10% $ 79.03 Medication Candida Albicans Skin Test Antigen $ 111.40 Medication Captopril Tab 12.5 MG $ 16. 10 Medication Captopril Tab 25 MG $ 17.30 Medication Carbachol Intraocular Inj 0.01% $ 159.66 Medication Carbamazepine Susp 100 MG/5ML $ 48.34 Medication Carbamazepine Tab 200 MG $ 10.91 Medication Carbamide Peroxide 6.5% Otic Soln $ 23.93 Medication Carbidopa & Levodopa Tab 10-100 MG $ 6.10 Medication Carbidopa & Levodopa Tab 25-100 MG $ 5.71 Medication Carbidopa & Levodopa Tab ER 50-200 MG $ 9.28 Medication Carboplatin IV Soln 150 MG/15ML $ 121.33 Medication Carboplatin IV Soln 450 MG/45ML $ 254.71 Medication Carboplatin IV Soln 50 MG/5ML $ 71.80 Medication Carboplatin IV Soln 600 MG/60ML $ 419.69 Medication Carboprost Tromethamine IM Soln 250 MCG/ML $ 1,067.03 Medication Carfilzomib For Inj 10 MG $ 1,164.40 Medication Carfilzomib For Inj 30 MG $ 3,482.20 Medication Carfilzomib For Inj 60 MG $ 6,958.88 Medication Carmustine For Inj 100 MG $ 662.87 Medication Carvedilol Tab 25 MG $ 3.86 Medication Carvedilol Tab 3.125 MG $ 3.86 Medication Carvedilol Tab 6.25 MG $ 3.86 Medication Cefazolin Sodium For Inj 1 GM $ 16.50 Medication Cefazolin Sodium-Dextrose IV Solution 1 GM/50ML-4% $ 44.10 Medication Cefazolin Sodium-Dextrose IV Solution 2 GM/100ML-4% $ 54.51 Medication Cefdinir For Susp 125 MG/5ML $ 20.24 Medication Cefepime HCl For Inj 1 GM $ 62.72

02-19-2019-A-PAC-057 Page 75 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 Medication Cefepime HCl For Inj 2 GM $ 119.04 Medication Cefotetan Disodium For Inj 1 GM $ 114.43 Medication Cefotetan Disodium for IV Soln 1 GM and Dextrose 3.58% 50 ML $ 72.47 Medication Cefotetan Disodium for IV Soln 2 GM and Dextrose 2.08% 50 ML $ 98.91 Medication Ceftaroline Fosamil for IV Soln 400 MG $ 742.29 Medication Ceftaroline Fosamil for IV Soln 600 MG $ 742.29 Medication Ceftazidime For Inj 1 GM $ 47.29 Medication Ceftriaxone Sodium For Inj 1 GM $ 15.15 Medication Ceftriaxone Sodium For Inj 10 GM $ 77.20 Medication Ceftriaxone Sodium For Inj 2 GM $ 28.41 Medication Ceftriaxone Sodium For Inj 250 MG $ 13.23 Medication Ceftriaxone Sodium For Inj 500 MG $ 29.62 Medication Cefuroxime Axetil For Susp 125 MG/5ML $ 44.97 Medication Cefuroxime Axetil Tab 250 MG $ 20.07 Medication Cefuroxime Sodium For Inj 750 MG $ 29.00 Medication Celecoxib Cap 100 MG $ 25.01 Medication Celecoxib Cap 200 MG $ 12.04 Medication Cephalexin Cap 250 MG $ 5.36 Medication Cephalexin Cap 500 MG $ 3.97 Medication Cephalexin For Susp 250 MG/5ML $ 118.56 Medication Certolizumab Pegol For Inj Kit 2 X 200 MG $ 12,966.16 Medication Cetuximab IV Soln 100 MG/50ML (2 MG/ML) $ 1,867.50 Medication Cetuximab IV Soln 200 MG/100ML (2 MG/ML) $ 3,729.49 Medication Charcoal Activated Liq $ 104.87 Medication Charcoal Activated-Sorbitol Liq $ 97.54 Medication Cherry Syrup $ 75.16 Medication Chlordiazepoxide HCl Cap 25 MG $ 7.37 Medication Chlordiazepoxide HCl Cap 5 MG $ 8.46 Medication Chlorhexidine Gluconate Soln 0.12% $ 48.16 Medication Chloroprocaine HCl Preservative Free (PF) Inj 3% $ 128.94 Medication Chlorpromazine HCl Inj 25 MG/ML $ 207.15 Medication Chlorpromazine HCl Inj 50 MG/2ML $ 146.32 Medication Cholecalciferol Tab 1000 Unit $ 3.86 Medication Cholestyramine Light Powder Packets 4 GM $ 22.17 Medication Cilostazol Tab 50 MG $ 9.90 Medication Cinacalcet HCl Tab 30 MG (Base Equiv) $ 127.92 Medication Ciprofloxacin HCl Ophth Soln 0.3% (Base Equivalent) $ 73.44 Medication Ciprofloxacin-Dexamethasone Otic Susp 0.3-0.1% $ 916.47 Medication Cisatracurium Besylate (PF) IV Soln 10 MG/5ML (2 MG/ML) $ 91.99 Medication Cisatracurium Besylate IV Soln 20 MG/10ML (2 MG/ML) $ 123.79 Medication Cisplatin Inj 100 MG/100ML (1 MG/ML) $ 174.28 Medication Cisplatin Inj 200 MG/200ML (1 MG/ML) $ 282.40 Medication Cisplatin Inj 50 MG/50ML (1 MG/ML) $ 105.06 Medication Citalopram Hydrobromide Tab 20 MG (Base Equiv) $ 3.86 Medication Clindamycin HCl Cap 150 MG $ 5.42 Medication Clindamycin Palmitate HCl For Soln 75 MG/5ML (Base * $ 234. 09 Medication Clindamycin Palmitate HCl For Soln 75 MG/5ML (Base Equiv) $ 201.25 Medication Clindamycin Phosphate in NaCl 0.9% IV Soln 600 MG/50ML $ 52.06 Medication Clindamycin Phosphate in NaCl 0.9% IV Soln 900 MG/50ML $ 61.08 Medication Clindamycin Phosphate Inj 300 MG/2ML $ 44.88 Medication Clindamycin Phosphate Inj 600 MG/4ML $ 33.73 Medication Clindamycin Phosphate Inj 900 MG/6MLClindamycin Phosphate Inj 300 MG/2ML $ 25.20 Medication Clindamycin Phosphate IV Soln 600 MG/4ML $ 40.86 Medication Clindamycin Phosphate IV Soln 900 MG/6ML $ 51.31 Medication Clobetasol Propionate Cream 0.05% $ 865.85 Medication Clonazepam Tab 0.5 MG $ 5.51 Medication Clonidine HCl Inj (For Epidural Infusion) 100 MCG/ML $ 201.86 Medication Clonidine HCl Tab 0.1 MG $ 3.86 Medication Clonidine TD Patch Weekly 0.1 MG/24HR $ 126.21 Medication Clonidine TD Patch Weekly 0.2 MG/24HR $ 210.78 Medication Clopidogrel Bisulfate Tab 75 MG (Base Equiv) $ 4.74 Medication Clotrimazole Cream 1% $ 65.73 Medication Clotrimazole Troche 10 MG $ 14.70 Medication Clotrimazole Vaginal Cream 1% $ 29.96 Medication Clotrimazole w/ Betamethasone Cream 1-0.05% $ 89.85 Medication Colchicine Tab 0.6 MG $ 46.57 Medication Colistimethate Sod For Inj 150 MG (Colistin Base Activity) $ 136.36 Medication Collagenase Clostridium Histolyticum For Inj 0.9 MG $ 8,674.01 Medication Collagenase Oint 250 Unit/GM $ 919.93 Medication Copper IUD $ 2,423.67 Medication Cosyntropin For Inj 0.25 MG $ 313.08

02-19-2019-A-PAC-057 Page 76 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 Medication Cross-Linked Hyaluronate Gel Prefilled Syringe 30 MG/3ML $ 2,925.64 Medication Cyanocobalamin Inj 1000 MCG/ML $ 61.67 Medication Cyanocobalamin Tab 1000 MCG $ 4.29 Medication Cyclobenzaprine HCl Tab 10 MG $ 3.86 Medication Cyclopentolate HCl Ophth Soln 1% $ 118.26 Medication Cyclophosphamide For Inj 1 GM $ 2,199.35 Medication Cyclophosphamide For Inj 2 GM $ 4,393.19 Medication Cyclophosphamide For Inj 500 MG $ 1,102.43 Medication Cyproheptadine HCl Tab 4 MG $ 8.60 Medication Dabigatran Etexilate Mesylate Cap 150 MG (Etexilate Base Eq) $ 44.64 Medication Dabigatran Etexilate Mesylate Cap 75 MG (Etexilate Base Eq) $ 44.64 Medication Dacarbazine For Inj 200 MG $ 96.04 Medication Dakin's Solution 0.5% $ 55.26 Medication Dantrolene Sodium For IV Soln 20 MG $ 316.15 Medication Daptomycin For IV Soln 500 MG $ 2,674.00 Medication Daratumumab IV Soln 100 MG/5ML $ 1,592.02 Medication Daratumumab IV Soln 400 MG/20ML $ 6,351.56 Medication Darbepoetin Alfa Soln Inj 60 MCG/ML $ 747.58 Medication Darbepoetin Alfa Soln Prefilled Syringe 100 MCG/0.5ML $ 2,323.64 Medication Darbepoetin Alfa Soln Prefilled Syringe 150 MCG/0.3ML $ 3,482.71 Medication Darbepoetin Alfa Soln Prefilled Syringe 200 MCG/0.4ML $ 4,641.77 Medication Darbepoetin Alfa Soln Prefilled Syringe 300 MCG/0.6ML $ 6,959.90 Medication Darbepoetin Alfa Soln Prefilled Syringe 40 MCG/0.4ML $ 932.76 Medication Darbepoetin Alfa Soln Prefilled Syringe 500 MCG/ML $ 11,596.16 Medication Darbepoetin Alfa Soln Prefilled Syringe 60 MCG/0.3ML $ 1,396.39 Medication Decitabine For Inj 50 MG $ 2,850.76 Medication Deferoxamine Mesylate For Inj 2 GM $ 239.17 Medication Deferoxamine Mesylate For Inj 500 MG $ 164.69 Medication Denosumab Inj 120 MG/1.7ML $ 6,845.31 Medication Denosumab Inj Soln Prefilled Syringe 60 MG/ML $ 3,656.59 Medication Desflurane Inhal Soln $ 625.86 Medication Desmopressin Acetate Inj 4 MCG/ML $ 123.61 Medication Dexamethasone Sod Phosphate Preservative Free Inj 10 MG/ML $ 28.49 Medication Dexamethasone Sodium Phosphate Inj 10 MG/ML $ 15.96 Medication Dexamethasone Sodium Phosphate Inj 100 MG/10ML $ 13.23 Medication Dexamethasone Sodium Phosphate Inj 120 MG/30ML $ 13.23 Medication Dexamethasone Sodium Phosphate Inj 20 MG/5ML $ 13.23 Medication Dexamethasone Sodium Phosphate Inj 4 MG/ML $ 15.15 Medication Dexamethasone Soln 0.5 MG/5ML $ 20.01 Medication Dexamethasone Tab 4 MG $ 11.96 Medication Dexmedetomidine HCl in NaCl 0.9% IV Soln 200 MCG/50ML $ 149.40 Medication Dexmedetomidine HCl in NaCl 0.9% IV Soln 400 MCG/100ML $ 262.61 Medication Dexpanthenol Inj 250 MG/ML $ 31.62 Medication Dexrazoxane HCl For Inj 250 MG (Base Equivalent) $ 826.92 Medication Dexrazoxane HCl For Inj 500 MG (Base Equivalent) $ 1,648.30 Medication Dextromethorphan-Guaifenesin Syrup 10-100 MG/5ML $ 22. 42 Medication Dextrose 10% w/ Sodium Chloride 0.2% $ 55.13 Medication Dextrose 5% in Lactated Ringers $ 55.13 Medication Dextrose 5% w/ Sodium Chloride 0.2% $ 55.13 Medication Dextrose 5% w/ Sodium Chloride 0.33% $ 55.13 Medication Dextrose 5% w/ Sodium Chloride 0.45% $ 55.13 Medication Dextrose 5% w/ Sodium Chloride 0.9% $ 55.13 Medication Dextrose Inj 10% $ 55.13 Medication Dextrose Inj 25% $ 72.68 Medication Dextrose Inj 5% $ 65.96 Medication Dextrose Inj 50% $ 69.79 Medication Diatrizoate Meglumine & Sodium Oral Soln 66-10% $ 278.41 Medication Diatrizoate Meglumine Inj 18% $ 153.68 Medication Diatrizoate Meglumine Urethral Soln 30% $ 213.90 Medication Diazepam Inj 5 MG/ML $ 117.60 Medication Diazepam Tab 2 MG $ 5.51 Medication Diazepam Tab 5 MG $ 5.51 Medication Dibucaine Oint 1% $ 39.96 Medication Dicyclomine HCl Cap 10 MG $ 7.05 Medication Dicyclomine HCl Inj 10 MG/ML $ 198.70 Medication Digoxin Immune Fab For Inj 40 MG $ 47,101.89 Medication Digoxin Inj 0.25 MG/ML $ 49.70 Medication Digoxin Tab 125 MCG (0.125 MG) $ 15.31 Medication Digoxin Tab 250 MCG (0.25 MG) $ 15.31 Medication Dihydroergotamine Mesylate Inj 1 MG/ML $ 484.05 Medication Diltiazem HCl Coated Beads Cap ER 24HR 120 MG $ 5.42

02-19-2019-A-PAC-057 Page 77 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 Medication Diltiazem HCl Coated Beads Cap ER 24HR 180 MG $ 5.57 Medication Diltiazem HCl IV Soln 125 MG/25ML (5 MG/ML) $ 13.23 Medication Diltiazem HCl IV Soln 25 MG/5ML (5 MG/ML) $ 14.54 Medication Diltiazem HCl IV Soln 50 MG/10ML (5 MG/ML) $ 14.62 Medication Diltiazem HCl Tab 30 MG $ 3.87 Medication Dimenhydrinate Chew Tab 50 MG $ 5.45 Medication Dimenhydrinate Inj 50 MG/ML $ 45.81 Medication Dimenhydrinate Tab 50 MG $ 3.86 Medication Dimercaprol Inj 100 MG/ML $ 654.67 Medication Dimethyl Sulfoxide Soln 50% $ 1,708.32 Medication Dinoprostone Vaginal Inserts 10 MG $ 1,231.93 Medication Dinoprostone Vaginal Suppos 20 MG $ 6,615.68 Medication Diphenhydramine HCl Elixir 12.5 MG/5ML $ 28.59 Medication Diphenhydramine HCl Inj 50 MG/ML $ 27.61 Medication Diphenhydramine HCl Liquid 12.5 MG/5ML $ 22.06 Medication Diphenhydramine HCl Tab 25 MG $ 3.86 Medication Diphenoxylate w/ Atropine Tab 2.5-0.025 MG $ 7.33 Medication Dipyridamole Tab 50 MG $ 5.63 Medication Divalproex Sodium Tab Delayed Release 250 MG $ 4.44 Medication Divalproex Sodium Tab ER 24 HR 250 MG $ 16.49 Medication Dobutamine HCl Inj 12.5 MG/ML $ 50.02 Medication Dobutamine Inj 2 MG/ML in D5W $ 115.86 Medication Docetaxel For Inj Conc 20 MG/ML $ 239.26 Medication Docetaxel Soln for IV Infusion 160 MG/16ML $ 1,488.06 Medication Docetaxel Soln for IV Infusion 20 MG/2ML $ 464.56 Medication Docusate Sodium Cap 100 MG $ 3.86 Medication Docusate Sodium Liquid 150 MG/15ML $ 7.84 Medication Dofetilide Cap 125 MCG (0.125 MG) $ 42.69 Medication Dofetilide Cap 250 MCG (0.25 MG) $ 22.45 Medication Dofetilide Cap 500 MCG (0.5 MG) $ 12.33 Medication Donepezil Hydrochloride Tab 10 MG $ 3.86 Medication Donepezil Hydrochloride Tab 5 MG $ 3.86 Medication Dopamine HCl Inj 40 MG/ML $ 20.62 Medication Dopamine Inj 1.6 MG/ML in D5W $ 60.89 Medication Dorzolamide HCl Ophth Soln 2% $ 141.38 Medication Doxazosin Mesylate Tab 2 MG $ 32.64 Medication Doxepin HCl Cap 25 MG $ 9.03 Medication Doxorubicin HCl Inj 2 MG/ML $ 169.14 Medication Doxorubicin HCl Liposomal Inj (For IV Infusion) 2 MG/ML $ 7,261.05 Medication Doxycycline Hyclate Cap 100 MG $ 28.12 Medication Doxycycline Hyclate For Inj 100 MG $ 128.60 Medication Droperidol Inj 2.5 MG/ML $ 13.23 Medication Duloxetine HCl Enteric Coated Pellets Cap 30 MG (Base Eq) $ 17.75 Medication Durvalumab Soln for IV Infusion 120 MG/2.4ML (50 MG/ML) $ 2,562.64 Medication Durvalumab Soln for IV Infusion 500 MG/10ML (50 MG/ML) $ 10,660.16 Medication Eculizumab IV Soln 300 MG/30ML (10 MG/ML) (For Infusion) $ 19, 541.87 Medication Edetate Calcium Disodium Inj 1 GM/5ML (200 MG/ML) $ 16,134.98 Medication Edetate Calcium Disodium Inj 500 MG/2.5ML (200 MG/ML) $ 369.84 Medication Elotuzumab For IV Soln 300 MG $ 5,651.06 Medication Elotuzumab For IV Soln 400 MG $ 7,532.84 Medication Emollient - Cream $ 19.85 Medication Emtricitabine-Tenofovir Disoproxil Fumarate Tab 200-300 MG $ 226.93 Medication Enalaprilat IV Inj 1.25 MG/ML $ 62.88 Medication Enoxaparin Sodium Inj 100 MG/ML $ 86.18 Medication Enoxaparin Sodium Inj 120 MG/0.8ML $ 137.04 Medication Enoxaparin Sodium Inj 150 MG/ML $ 88.57 Medication Enoxaparin Sodium Inj 30 MG/0.3ML $ 53.48 Medication Enoxaparin Sodium Inj 40 MG/0.4ML $ 69.31 Medication Enoxaparin Sodium Inj 60 MG/0.6ML $ 53.88 Medication Enoxaparin Sodium Inj 80 MG/0.8ML $ 70.03 Medication Ephedrine Sulfate Inj 50 MG/ML $ 43.06 Medication Epinephrine HCl Nasal Soln 0.1% $ 811.78 Medication Epinephrine Inj 30 MG/30ML $ 22.29 Medication Epinephrine PF Inj 1 MG/ML $ 47.69 Medication Epinephrine PF Soln Prefilled Syringe 1 MG/10ML (0.1 MG/ML) $ 53.72 Medication Epirubicin HCl IV Soln 200 MG/100ML (2 MG/ML) $ 634.46 Medication Epirubicin HCl IV Soln 50 MG/25ML (2 MG/ML) $ 220.56 Medication Epoetin Alfa Inj 10000 Unit/ML $ 805.92 Medication Epoetin Alfa Inj 2000 Unit/ML $ 210.53 Medication Epoetin Alfa Inj 20000 Unit/ML $ 1,606.34 Medication Epoetin Alfa Inj 3000 Unit/ML $ 313.00

02-19-2019-A-PAC-057 Page 78 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 Medication Epoetin Alfa Inj 4000 Unit/ML $ 415.47 Medication Epoetin Alfa-epbx Inj 10000 Unit/ML $ 428.51 Medication Epoetin Alfa-epbx Inj 2000 Unit/ML $ 127.17 Medication Epoetin Alfa-epbx Inj 3000 Unit/ML $ 160.21 Medication Epoetin Alfa-epbx Inj 4000 Unit/ML $ 211.77 Medication Epoetin Alfa-epbx Inj 40000 Unit/ML $ 1,326.90 Medication Eptifibatide IV Soln 20 MG/10ML (2 MG/ML) $ 672.19 Medication Eptifibatide IV Soln 200 MG/100ML (2 MG/ML) $ 3,899.01 Medication Ergocalciferol Cap 50000 Unit $ 14.57 Medication Eribulin Mesylate Inj 1 MG/2ML (0.5 MG/ML) $ 3,413.82 Medication Ertapenem Sodium For Inj 1 GM (Base Equivalent) $ 252.22 Medication Erythromycin Ethylsuccinate For Susp 200 MG/5ML $ 1,453.76 Medication Erythromycin Ophth Oint 5 MG/GM $ 81.01 Medication Erythromycin Tab Delayed Release 250 MG $ 48.97 Medication Escitalopram Oxalate Tab 10 MG (Base Equiv) $ 3.86 Medication Esmolol HCl Inj 100 MG/10ML $ 13.23 Medication Esmolol HCl-Sodium Chloride IV Soln 2500 MG/250ML $ 1,411.94 Medication Estradiol TD Patch Weekly 0.05 MG/24HR $ 89.00 Medication Estrogens Conjugated For Inj 25 MG $ 894.43 Medication Estrogens Conjugated Vaginal Cream 0.625 MG/GM $ 1,443.63 Medication Ethyl Chloride Aerosol Spray $ 122.96 Medication Etomidate IV Soln 2 MG/ML $ 102.73 Medication Etoposide Inj 100 MG/5ML (20 MG/ML) $ 80.80 Medication Etoposide Inj 500 MG/25ML (20 MG/ML) $ 224.53 Medication Ezetimibe Tab 10 MG $ 75.29 Medication F-18 FLUORODEOXYGLUCOSE $ 1,367.00 Medication Famotidine in NaCl 0.9% IV Soln 20 MG/50ML $ 44.10 Medication Famotidine Inj 20 MG/2ML $ 13.23 Medication Famotidine Inj 40 MG/4ML $ 13.23 Medication Famotidine Tab 20 MG $ 3.86 Medication Fat Emulsion IV Soln 20% $ 134.57 Medication Fat Emulsion Plant Based IV Emulsion 20% $ 134.57 Medication Fe Fumarate w/ B12-Vit C-FA-IFC Cap 110-0.015-75-0.5-240 MG $ 4.08 Medication Fenofibrate Tab 160 MG $ 33.30 Medication Fenofibrate Tab 54 MG $ 12.75 Medication Fentanyl Citrate Preservative Free (PF) Inj 100 MCG/2ML $ 16.54 Medication Fentanyl Citrate Preservative Free (PF) Inj 250 MCG/5ML $ 16.54 Medication Fentanyl TD Patch 72HR 100 MCG/HR $ 98.17 Medication Fentanyl TD Patch 72HR 12 MCG/HR $ 79.24 Medication Fentanyl TD Patch 72HR 25 MCG/HR $ 40.01 Medication Fentanyl TD Patch 72HR 50 MCG/HR $ 82.05 Medication Fentanyl TD Patch 72HR 75 MCG/HR $ 102.72 Medication Ferric Carboxymaltose IV Soln 750 MG/15ML (Fe Equivalent) $ 3,129.19 Medication Ferric Subsulfate Soln $ 66.64 Medication Ferrous Sulfate Elixir 220 MG/5ML (44 MG/5ML Elemental Fe) $ 19.85 Medication Ferrous Sulfate Tab 325 MG (65 MG Elemental Fe) $ 3. 86 Medication Ferumoxytol Inj 510 MG/17ML (30 MG/ML) (Elemental Fe) $ 2,913.88 Medication Fibrin Sealant Component Solution $ 420.00 Medication Filgrastim Inj 300 MCG/ML $ 948.43 Medication Filgrastim Inj 480 MCG/1.6ML (300 MCG/ML) $ 1,464.67 Medication Filgrastim-sndz Soln Prefilled Syringe 300 MCG/0.5ML $ 827.22 Medication Filgrastim-sndz Soln Prefilled Syringe 480 MCG/0.8ML $ 827.23 Medication Finasteride Tab 5 MG $ 12.12 Medication Flecainide Acetate Tab 100 MG $ 18.40 Medication Fluconazole For Susp 10 MG/ML $ 104.46 Medication Fluconazole in NaCl 0.9% Inj 100 MG/50ML $ 50.77 Medication Fluconazole in NaCl 0.9% Inj 200 MG/100ML $ 82.74 Medication Fluconazole in NaCl 0.9% Inj 400 MG/200ML $ 90.80 Medication Fluconazole Tab 100 MG $ 20.39 Medication Fluconazole Tab 50 MG $ 8.69 Medication Fludarabine Phosphate Inj 25 MG/ML $ 422.57 Medication Fludrocortisone Acetate Tab 0.1 MG $ 10.37 Medication Flumazenil IV Soln 0.5 MG/5ML (0.1 MG/ML) $ 26.40 Medication Fluocinonide Cream 0.05% $ 150.76 Medication Fluorescein Sodium Ophth Strips 0.6 MG $ 3.86 Medication Fluorescein Sodium Ophth Strips 1 MG $ 3.86 Medication Fluorouracil IV Soln 1 GM/20ML (50 MG/ML) $ 53.72 Medication Fluorouracil IV Soln 5 GM/100ML (50 MG/ML) $ 161.19 Medication Fluorouracil IV Soln 500 MG/10ML (50 MG/ML) $ 29.62 Medication Fluoxetine HCl Cap 10 MG $ 3.86 Medication Fluoxetine HCl Cap 20 MG $ 3.86

02-19-2019-A-PAC-057 Page 79 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 Medication Flurbiprofen Sodium Ophth Soln 0.03% $ 149.09 Medication Fluticasone Propionate Nasal Susp 50 MCG/ACT $ 113.88 Medication Fluticasone-Salmeterol Inhal Aerosol 115-21 MCG/ACT $ 825.86 Medication Fluticasone-Salmeterol Inhal Aerosol 230-21 MCG/ACT $ 162.10 Medication Fluticasone-Salmeterol Inhal Aerosol 45-21 MCG/ACT $ 112.86 Medication Folic Acid Inj 5 MG/ML $ 13.23 Medication Folic Acid Tab 1 MG $ 3.86 Medication Fomepizole Inj 1 GM/ML (For IV Infusion) $ 2,958.58 Medication Fondaparinux Sodium Subcutaneous Inj 2.5 MG/0.5ML $ 142.60 Medication Formoterol Fumarate Soln Nebu 20 MCG/2ML $ 77.96 Medication Fosaprepitant Dimeglumine For IV Infusion 150 MG (Base Eq) $ 1,007.73 Medication Fulvestrant Inj 250 MG/5ML $ 2,909.24 Medication Furosemide Inj 10 MG/ML $ 32.59 Medication Furosemide Tab 20 MG $ 3.86 Medication Furosemide Tab 40 MG $ 3.86 Medication GA-67 GALLIUM CITRATE $ 821.95 Medication Gabapentin Cap 100 MG $ 3.86 Medication Gabapentin Cap 300 MG $ 3.86 Medication Gabapentin Cap 400 MG $ 4.20 Medication Gabapentin Oral Soln 250 MG/5ML $ 16.02 Medication Gadobenate Dimeglumine IV Soln 529 MG/ML $ 227.25 Medication Gadodiamide Inj 287 MG/ML $ 332.31 Medication Gadodiamide IV Soln 287 MG/ML $ 400.28 Medication Gadopentetate Dimeglumine Inj 469.01 MG/ML $ 206.54 Medication Gelatin Absorbable MT Powder $ 292.60 Medication Gelatin Absorbable Sponge 12-7 MM $ 37.90 Medication Gelatin Absorbable Sponge Size 100 $ 130.39 Medication Gelatin Absorbable Sponge Size 50 $ 132.49 Medication Gelatin Adsorbable Ophth Film $ 672.43 Medication Gemcitabine HCl For Inj 1 GM $ 237.62 Medication Gemcitabine HCl For Inj 2 GM $ 385.94 Medication Gemcitabine HCl For Inj 200 MG $ 102.33 Medication Gemcitabine HCl Inj 2 GM/52.6ML (38 MG/ML) (Base Equiv) $ 348.84 Medication Gemcitabine HCl Inj 200 MG/5.26ML (38 MG/ML) (Base Equiv) $ 77.27 Medication Gemfibrozil Tab 600 MG $ 5.53 Medication Gentamicin Sulfate Inj 10 MG/ML $ 37.17 Medication Gentamicin Sulfate Inj 40 MG/ML $ 21.79 Medication Gentamicin Sulfate Ophth Oint 0.3% $ 119.75 Medication Gentamicin Sulfate Ophth Soln 0.3% $ 83.49 Medication GI COCKTAIL PREMADE $ 35.26 Medication Glimepiride Tab 2 MG $ 6.48 Medication Glipizide Tab 5 MG $ 5.28 Medication Glipizide Tab ER 24HR 2.5 MG $ 13.22 Medication Glipizide Tab ER 24HR 5 MG $ 8.04 Medication Glucagon HCl (rDNA) Diagnostic For Inj 1 MG (Base Equiv) $ 663.60 Medication Glucagon HCl Diagnostic For Inj 1 MG (Base Equiv) $ 659. 38 Medication Glucose Gel 40% $ 32.81 Medication Glucose-Vitamin C-Vitamin D Chew Tab $ 3.86 Medication Glyburide Tab 5 MG $ 4.15 Medication Glycerin Suppos 1.2 GM $ 8.28 Medication Glycerin Suppos 2 GM $ 8.48 Medication Glycerin-Hypromellose-PEG 400 Ophth Soln 0.2-0.36-1% $ 41.18 Medication Glycopyrrolate Inj 0.2 MG/ML $ 61.76 Medication Glycopyrrolate Inj 0.4 MG/2ML (0.2 MG/ML) $ 16.76 Medication Glycopyrrolate Inj 1 MG/5ML (0.2 MG/ML) $ 40.86 Medication Glycopyrrolate Inj 4 MG/20ML (0.2 MG/ML) $ 29.62 Medication Golimumab IV Soln 50 MG/4ML $ 5,451.95 Medication Goserelin Acetate Implant 10.8 MG $ 5,713.23 Medication Guaifenesin Liquid 100 MG/5ML $ 7.31 Medication Guaifenesin Syrup 100 MG/5ML $ 3.86 Medication Guaifenesin Tab ER 12HR 600 MG $ 10.32 Medication Guaifenesin-Codeine Soln 100-10 MG/5ML $ 8.52 Medication Haloperidol Lactate Inj 5 MG/ML $ 53.64 Medication Haloperidol Tab 1 MG $ 6.19 Medication Heparin Sod (Porcine)-NaCl IV Soln 1000 Unit/500ML-0.9% $ 44.10 Medication Heparin Sodium (Porcine) Inj 1000 Unit/ML $ 67.70 Medication Heparin Sodium (Porcine) Inj 5000 Unit/ML $ 16.36 Medication Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML $ 13.23 Medication Heparin Sodium (Porcine)-Dextrose IV Sol 25000 Unit/500ML-5% $ 55.13 Medication Hepatitis B Immune Globulin (Human) IM Inj Soln $ 1,932.94 Medication Hepatitis B Vaccine (Recombinant) Susp 10 MCG/0.5ML $ 114.98

02-19-2019-A-PAC-057 Page 80 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 Medication Hepatitis B Vaccine (Recombinant) Susp 5 MCG/0.5ML $ 143.95 Medication Hetastarch in Sodium Chloride Inj 6-0.9% $ 76.23 Medication Hyaluronidase Ovine Inj 200 Unit/ML $ 320.19 Medication Hydralazine HCl Inj 20 MG/ML $ 110.61 Medication Hydralazine HCl Tab 10 MG $ 4.43 Medication Hydralazine HCl Tab 25 MG $ 3.86 Medication Hydrochlorothiazide Tab 12.5 MG $ 4.93 Medication Hydrochlorothiazide Tab 25 MG $ 3.86 Medication Hydrocodone-Acetaminophen Soln 7.5-325 MG/15ML $ 24.12 Medication Hydrocodone-Acetaminophen Tab 5-325 MG $ 7.57 Medication Hydrocortisone Acetate Suppos 25 MG $ 75.55 Medication Hydrocortisone Cream 1% $ 19.85 Medication Hydrocortisone Cream 2.5% $ 26.46 Medication Hydrocortisone Oint 1% $ 20.85 Medication Hydrocortisone Rectal Cream 2.5% $ 252.87 Medication Hydrocortisone Sodium Succinate PF For Inj 100 MG $ 113.42 Medication Hydrocortisone Sodium Succinate PF For Inj 250 MG $ 115.10 Medication Hydrocortisone Sodium Succinate PF For Inj 500 MG $ 105.32 Medication Hydrocortisone-Aloe Vera Cream 1% $ 19.85 Medication Hydrogen Peroxide Soln 3% $ 19.85 Medication Hydromorphone HCl Preservative Free (PF) Inj 1 MG/MLHydromorphone HCl Inj 1 MG/ML $ 36.65 Medication Hydromorphone HCl Preservative Free (PF) Inj 2 MG/MLHydromorphone HCl Inj 2 MG/ML $ 16.54 Medication Hydromorphone HCl Tab 2 MG $ 5.51 Medication Hydromorphone HCl-NaCl Soln Pref Syr 0.5 MG/ML-0.9% $ 40.11 Medication Hydromorphone HCl-Sodium Chloride 0.9% Inj 6 MG/30ML $ 121.05 Medication Hydroxyzine HCl IM Soln 50 MG/ML $ 123.31 Medication Hydroxyzine HCl Syrup 10 MG/5ML $ 134.38 Medication Hydroxyzine HCl Tab 25 MG $ 5.28 Medication Hydroxyzine Pamoate Cap 25 MG $ 4.64 Medication Hylan Intra-articular Solution Prefilled Syringe 48 MG/6ML $ 3,897.36 Medication Hyoscyamine Sulfate Tab Disint 0.125 MG $ 8.77 Medication Hypromellose Gonioscopic Soln 2.5% $ 93.43 Medication Hypromellose Intraocular Soln 2% $ 243.82 Medication Ibandronate Sodium IV Soln 3 MG/3ML (Base Equivalent) $ 1,585.07 Medication Ibuprofen Susp 100 MG/5ML $ 41.19 Medication Ibuprofen Tab 400 MG $ 3.86 Medication Ibuprofen Tab 600 MG $ 4.06 Medication Ibutilide Fumarate Inj 1 MG/10ML $ 1,360.06 Medication Idarucizumab IV Soln 2.5 GM/50ML $ 5,246.76 Medication Imipenem-Cilastatin Intravenous For Soln 500 MG $ 143.39 Medication Immune Globulin (Human) IM Inj $ 341.00 Medication Immune Globulin (Human) IV or Subcutaneous Soln 10 GM/100ML $ 2,051.99 Medication Immune Globulin (Human) IV or Subcutaneous Soln 20 GM/200ML $ 4,619.01 Medication Immune Globulin (Human) IV or Subcutaneous Soln 5 GM/50ML $ 1,088.20 Medication Immune Globulin (Human) IV Soln 10 GM/100ML $ 2,833.22 Medication Immune Globulin (Human) IV Soln 20 GM/200ML $ 5,654.81 Medication Immune Globulin (Human) IV Soln 5 GM/50ML $ 1,421.97 Medication Indigotindisulfonate Sodium Inj 8 MG/ML $ 638.29 Medication Indium In-111 Oxyquinoline IV Soln 1 mCi/ML $ 6,602.00 Medication Indocyanine Green For Inj 25 MG $ 442.44 Medication Indomethacin Cap 25 MG $ 5.69 Medication Infliximab For IV Inj 100 MG $ 3,503.13 Medication Infliximab-dyyb For IV Inj 100 MG $ 2,839.62 Medication Influenza Vac Recomb HA Quad PF Soln Pref Syr 0.5 ML $ 211.35 Medication Influenza Virus Vac Split High-Dose PF Susp Pref Syr 0.5ML $ 211.35 Medication Influenza Virus Vac Split Quadrivalent Susp Pref Syr 0.25 ML $ 96.46 Medication Influenza Virus Vac Split Quadrivalent Susp Pref Syr 0.5ML $ 86.34 Medication Insulin Detemir Inj 100 Unit/ML $ 1,192.75 Medication Insulin Lispro Inj 100 Unit/ML $ 327.07 Medication Insulin Lispro Inj 100 Unit/MLInsulin Lispro Soln Pen-injector 100 Unit/MLInsulin Lispro Soln Cartridge 100 Unit/ML $ 327.07 Medication Insulin NPH (Human) (Isophane) Inj 100 Unit/ML $ 539.11 Medication Insulin NPH Isophane & Regular Human Inj 100 Unit/ML (70-30) $ 539.11 Medication Insulin Regular (Human) Inj 100 Unit/ML $ 539.11 Medication Interferon Alfa-2B For Inj 10000000 Unit $ 724.28 Medication Interferon Alfa-2B For Inj 18000000 Unit $ 1,299.32 Medication Iodine Solution $ 51.61 Medication Iodine Solution Strong 5% (Lugol's) $ 274.05 Medication Iodixanol Inj 320 MG/ML (Iodine Equivalent) $ 612.40 Medication Iohexol Inj 300 MG/ML $ 239.03 Medication Iohexol IV Soln 350 MG/ML $ 592.84 Medication Iopamidol Inj 41% $ 345.06

02-19-2019-A-PAC-057 Page 81 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 Medication Iopamidol IV Soln 76% $ 666.66 Medication Ipilimumab Soln for IV Infusion 200 MG/40ML (5 MG/ML) $ 87,235.60 Medication Ipilimumab Soln for IV Infusion 50 MG/10ML (5 MG/ML) $ 21,813.09 Medication Ipratropium Bromide Inhal Soln 0.02% $ 4.25 Medication Ipratropium-Albuterol Nebu Soln 0.5-2.5(3) MG/3ML $ 7.08 Medication Irinotecan HCl Inj 100 MG/5ML (20 MG/ML) $ 115.81 Medication Irinotecan HCl Inj 40 MG/2ML (20 MG/ML) $ 145.76 Medication Iron Dextran Inj 50 MG/ML (Elemental Iron) $ 117.28 Medication Iron Sucrose Inj 20 MG/ML (Fe Equiv) $ 229.91 Medication Isoflurane Inhal Soln $ 142.46 Medication Isoniazid Tab 100 MG $ 5.65 Medication Isopropyl Alcohol 70% $ 19.85 Medication Isosorbide Dinitrate Tab 10 MG $ 11.25 Medication Isosorbide Dinitrate Tab 20 MG $ 12.04 Medication Isosorbide Mononitrate Tab ER 24HR 30 MG $ 7.32 Medication Isosorbide Mononitrate Tab ER 24HR 60 MG $ 9.01 Medication Itraconazole Cap 100 MG $ 49.51 Medication Ixabepilone For IV Infusion 15 MG $ 3,438.74 Medication KCl 20 MEQ/L (0.15%) in Dextrose 5% & NaCl 0.45% Inj $ 55.13 Medication KCl 20 MEQ/L (0.15%) in Dextrose 5% & NaCl 0.9% Inj $ 55.13 Medication KCl 20 MEQ/L (0.15%) in NaCl 0.9% Inj $ 55.13 Medication Ketamine HCl Inj 50 MG/ML $ 16.54 Medication Ketoconazole Cream 2% $ 117.06 Medication Ketorolac Tromethamine IM Inj 60 MG/2ML (30 MG/ML) $ 13.79 Medication Ketorolac Tromethamine Inj 15 MG/ML $ 13.23 Medication Ketorolac Tromethamine Inj 30 MG/ML $ 19.57 Medication Ketorolac Tromethamine Ophth Soln 0.5% $ 19.85 Medication Ketorolac Tromethamine Tab 10 MG $ 12.68 Medication Labetalol HCl IV Soln 5 MG/ML $ 19.09 Medication Labetalol HCl Tab 100 MG $ 5.27 Medication Lactated Ringer's for Irrigation $ 55.13 Medication Lactated Ringer's Solution $ 55.13 Medication Lactulose Solution 10 GM/15ML $ 9.93 Medication Lamotrigine Tab 100 MG $ 4.06 Medication Lamotrigine Tab 25 MG $ 3.86 Medication Lansoprazole Tab Delayed Release Orally Disintegrating 30 MG $ 46.18 Medication Latanoprost Ophth Soln 0.005% $ 792.53 Medication Leucovorin Calcium For Inj 100 MG $ 115.81 Medication Leucovorin Calcium For Inj 200 MG $ 121.66 Medication Leucovorin Calcium For Inj 350 MG $ 110.02 Medication Leucovorin Calcium For Inj 500 MG $ 307.36 Medication Leuprolide Acetate (3 Month) For Inj Kit 22.5 MG $ 13,928.61 Medication Leuprolide Acetate (3 Month) For Subcutaneous Inj Kit 22.5MG $ 4,063.94 Medication Leuprolide Acetate (4 Month) For Inj Kit 30 MG $ 18,569.66 Medication Leuprolide Acetate (4 Month) For Subcutaneous Inj Kit 30 MG $ 5,416.76 Medication Leuprolide Acetate (6 Month) For Inj Kit 45 MG $ 27, 852.12 Medication Leuprolide Acetate (6 Month) For Subcutaneous Inj Kit 45 MG $ 8,122.35 Medication Leuprolide Acetate For Inj Kit 3.75 MG $ 3,900.12 Medication Levalbuterol HCl Soln Nebu 0.31 MG/3ML (Base Equiv) $ 34.94 Medication Levalbuterol HCl Soln Nebu 0.63 MG/3ML (Base Equiv) $ 26.83 Medication Levalbuterol HCl Soln Nebu 1.25 MG/3ML (Base Equiv) $ 34.94 Medication Levalbuterol HCl Soln Nebu Conc 1.25 MG/0.5ML (Base Equiv) $ 45.62 Medication Levetiracetam Inj 500 MG/5ML (100 MG/ML) $ 89.88 Medication Levetiracetam Oral Soln 100 MG/ML $ 8.57 Medication Levetiracetam Tab 500 MG $ 7.86 Medication Levobunolol HCl Ophth Soln 0.5% $ 144.60 Medication Levofloxacin in D5W IV Soln 250 MG/50ML $ 44.69 Medication Levofloxacin in D5W IV Soln 500 MG/100ML $ 44.10 Medication Levofloxacin in D5W IV Soln 750 MG/150ML $ 44.10 Medication Levofloxacin Tab 250 MG $ 6.19 Medication Levofloxacin Tab 500 MG $ 7.84 Medication Levoleucovorin Calcium For IV Inj 50 MG (Base Equiv) $ 239.26 Medication Levonorgestrel Tab 1.5 MG $ 138.95 Medication Levothyroxine Sodium For IV Inj 100 MCG $ 410.41 Medication Levothyroxine Sodium Tab 100 MCG $ 14.24 Medication Levothyroxine Sodium Tab 112 MCG $ 14.24 Medication Levothyroxine Sodium Tab 125 MCG $ 14.24 Medication Levothyroxine Sodium Tab 25 MCG $ 6.47 Medication Levothyroxine Sodium Tab 50 MCG $ 14.24 Medication Levothyroxine Sodium Tab 75 MCG $ 7.55 Medication Levothyroxine Sodium Tab 88 MCG $ 14.24

02-19-2019-A-PAC-057 Page 82 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 Medication Lidocaine (Bulk) Powder $ 114.58 Medication LIDOCAINE / PHENYLEPHRINE TOPICAL AVI $ 96.33 Medication LIDOCAINE 1% MPF, 1ML & PHENYLEPHRINE PF 1.5%, 1ML $ 125.00 Medication Lidocaine 5% in 7.5% Dextrose Intraspinal Soln $ 78.82 Medication Lidocaine HCl (Cardiac) IV PF Soln 100 MG/5ML (2%) $ 16.48 Medication Lidocaine HCl Gel 2% $ 47.38 Medication Lidocaine HCl IV Inj 20 MG/ML $ 27.45 Medication Lidocaine HCl Laryngotracheal Soln 4% $ 127.91 Medication Lidocaine HCl Local Inj 0.5% $ 50.10 Medication Lidocaine HCl Local Inj 1% $ 29.29 Medication Lidocaine HCl Local Inj 2% $ 32.35 Medication Lidocaine HCl Local Preservative Free (PF) Inj 0.5% $ 106.75 Medication Lidocaine HCl Local Preservative Free (PF) Inj 1% $ 17.80 Medication Lidocaine HCl Local Preservative Free (PF) Inj 1.5% $ 101.29 Medication Lidocaine HCl Local Preservative Free (PF) Inj 2% $ 73.90 Medication Lidocaine HCl Local Preservative Free (PF) Inj 4% $ 40.30 Medication Lidocaine HCl Ophth Gel 3.5% $ 110.33 Medication Lidocaine HCl Soln 4% $ 217.54 Medication Lidocaine HCl Urethral/Mucosal Gel 2% $ 42.95 Medication Lidocaine HCl Viscous Soln 2% $ 72.12 Medication Lidocaine HCl(Cardiac) IV PF Soln Pref Syr 100 MG/5ML (2%) $ 18.49 Medication Lidocaine Inj 0.5% w/ Epinephrine-1:200000 $ 54.52 Medication Lidocaine Inj 1% w/ Epinephrine-1:100000 $ 46.25 Medication Lidocaine Inj 1% w/ Epinephrine-1:200000 $ 88.19 Medication Lidocaine Inj 1.5% w/ Epinephrine-1:200000 $ 44.56 Medication Lidocaine Inj 2% w/ Epinephrine-1:100000 $ 39.98 Medication Lidocaine Inj 2% w/ Epinephrine-1:200000 $ 108.52 Medication Lidocaine IV Infusion in D5W Inj 4 MG/ML $ 44.10 Medication Lidocaine Oint 5% $ 931.43 Medication Lidocaine Patch 5% $ 49.80 Medication Lidocaine-Prilocaine Cream 2.5-2.5% $ 53.96 Medication Linezolid IV Soln 600 MG/300ML (2 MG/ML) $ 195.22 Medication Linezolid Tab 600 MG $ 511.56 Medication Lisinopril Tab 20 MG $ 4.29 Medication Lisinopril Tab 5 MG $ 3.87 Medication Lithium Carbonate Cap 300 MG $ 3.86 Medication Loperamide HCl Cap 2 MG $ 9.30 Medication Loperamide HCl Liq 1 MG/5ML (0.2 MG/ML) $ 28.34 Medication Loratadine Tab 10 MG $ 5.03 Medication Lorazepam Inj 2 MG/ML $ 16.54 Medication Lorazepam Tab 0.5 MG $ 5.51 Medication Lorazepam Tab 1 MG $ 5.51 Medication Losartan Potassium Tab 25 MG $ 7.20 Medication Losartan Potassium Tab 50 MG $ 8.77 Medication Loteprednol Etabonate Ophth Susp 0.5% $ 922.69 Medication Magnesium Citrate Soln $ 20. 72 Medication Magnesium Hydroxide Susp 400 MG/5ML $ 5.37 Medication Magnesium Oxide Tab 400 MG (241.3 MG Elemental Mg) $ 3.86 Medication Magnesium Sulfate in Dextrose 5% IV Soln 1 GM/100ML $ 48.90 Medication Magnesium Sulfate Inj 50% $ 18.21 Medication Magnesium Sulfate IV Soln 2 GM/50ML (40 MG/ML) $ 67.02 Medication Magnesium Sulfate IV Soln 20 GM/500ML (40 MG/ML) $ 44.10 Medication Magnesium Sulfate IV Soln 4 GM/100ML (40 MG/ML) $ 44.69 Medication Mannitol IV Soln 25% $ 41.27 Medication Measles Mumps & Rubella Virus Vaccines For Inj $ 327.95 Medication Meclizine HCl Tab 12.5 MG $ 7.01 Medication Medroxyprogesterone Acetate IM Susp 150 MG/ML $ 630.69 Medication Medroxyprogesterone Acetate Tab 5 MG $ 4.29 Medication Megestrol Acetate Susp 40 MG/ML $ 38.84 Medication Megestrol Acetate Tab 40 MG $ 4.64 Medication Memantine HCl Tab 10 MG $ 49.30 Medication Menthol-Methyl Salicylate Cream $ 19.85 Medication Menthol-Zinc Oxide Oint 0.44-20.625% $ 27.41 Medication Meperidine HCl Inj 10 MG/ML $ 74.73 Medication Meperidine HCl Inj 100 MG/ML $ 51.79 Medication Meperidine HCl Inj 25 MG/ML $ 55.53 Medication Meperidine HCl Inj 50 MG/ML $ 57.14 Medication Meperidine HCl Oral Soln 50 MG/5ML $ 22.05 Medication Meperidine HCl Tab 50 MG $ 10.03 Medication Mepivacaine HCl Inj 1.5% $ 79.51 Medication Mepivacaine HCl Inj 2% $ 75.01

02-19-2019-A-PAC-057 Page 83 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 Medication Mepivacaine HCl Preservative Free (PF) Inj 2% $ 66.25 Medication Meropenem IV For Soln 1 GM $ 141.09 Medication Metformin HCl Tab 500 MG $ 3.86 Medication Metformin HCl Tab ER 24HR 500 MG $ 4.41 Medication Methadone HCl Tab 10 MG $ 6.15 Medication Methadone HCl Tab 5 MG $ 5.80 Medication Methimazole Tab 10 MG $ 6.63 Medication Methocarbamol Tab 500 MG $ 4.24 Medication Methohexital Sodium For Inj 500 MG $ 36.21 Medication Methotrexate Sodium Inj PF 25 MG/MLMethotrexate Sodium Inj 50 mg/2 ml (25 mg/mL) $ 36.04 Medication Methotrexate Sodium Inj PF 50 MG/2ML (25 MG/ML) $ 13.23 Medication Methotrexate Sodium Tab 2.5 MG (Base Equiv) $ 29.12 Medication Methyl Salicylate Liquid $ 45.53 Medication Methyldopa Tab 250 MG $ 3.96 Medication Methylene Blue Inj 1% $ 691.90 Medication Methylergonovine Maleate Inj 0.2 MG/ML $ 141.73 Medication Methylnaltrexone Bromide Inj 12 MG/0.6ML (20 MG/ML) $ 300.91 Medication Methylphenidate HCl Tab 5 MG $ 14.96 Medication Methylprednisolone Acetate Inj Susp 40 MG/ML $ 90.46 Medication Methylprednisolone Acetate Inj Susp 80 MG/ML $ 106.67 Medication Methylprednisolone Sod Succ For Inj 1000 MG (Base Equiv) $ 223.34 Medication Methylprednisolone Sod Succ For Inj 125 MG (Base Equiv) $ 83.37 Medication Methylprednisolone Sod Succ For Inj 2000 MG (Base Equiv) $ 324.24 Medication Methylprednisolone Sod Succ For Inj 40 MG (Base Equiv) $ 53.88 Medication Methylprednisolone Sod Succ For Inj 500 MG (Base Equiv) $ 188.07 Medication Methylprednisolone Sodium Succinate For Inj 40 MG $ 53.88 Medication Methylprednisolone Tab 4 MG $ 13.31 Medication Metoclopramide HCl Inj 5 MG/ML $ 32.43 Medication Metoclopramide HCl Inj 5 MG/ML (Base Equivalent) $ 32.43 Medication Metoclopramide HCl Soln 5 MG/5ML (10 MG/10ML) $ 142.61 Medication Metoclopramide HCl Soln 5 MG/5ML (10 MG/10ML) (Base Equiv) $ 19.85 Medication Metoclopramide HCl Tab 10 MG (Base Equivalent) $ 3.86 Medication Metoclopramide HCl Tab 5 MG (Base Equivalent) $ 9.53 Medication Metolazone Tab 5 MG $ 32.42 Medication Metoprolol Succinate Tab ER 24HR 100 MG (Tartrate Equiv) $ 3.91 Medication Metoprolol Succinate Tab ER 24HR 25 MG (Tartrate Equiv) $ 11.65 Medication Metoprolol Succinate Tab ER 24HR 50 MG (Tartrate Equiv) $ 12.39 Medication Metoprolol Tartrate IV Soln 5 MG/5ML $ 27.16 Medication Metoprolol Tartrate Tab 25 MG $ 3.86 Medication Metoprolol Tartrate Tab 50 MG $ 3.86 Medication Metronidazole in NaCl 0.79% IV Soln 500 MG/100ML $ 44.10 Medication Metronidazole Tab 250 MG $ 6.13 Medication Miconazole Nitrate Vaginal Cream 2% $ 48.69 Medication Microfibrillar Collagen Hemostat Powder $ 739.68 Medication Midazolam HCl Inj 10 MG/10ML (Base Equivalent) $ 16.56 Medication Midazolam HCl Inj 2 MG/2ML (Base Equivalent) $ 16. 54 Medication Midazolam HCl Syrup 2 MG/ML (Base Equivalent) $ 511.92 Medication Midodrine HCl Tab 5 MG $ 13.63 Medication Mineral Oil $ 19.85 Medication Mineral Oil Light (Topical) $ 43.50 Medication Mirtazapine Tab 15 MG $ 5.32 Medication Mirtazapine Tab 30 MG $ 5.51 Medication Misoprostol Tab 100 MCG $ 15.42 Medication Misoprostol Tab 200 MCG $ 17.75 Medication Mitomycin For Inj 20 MG $ 1,898.29 Medication Mitomycin For IV Soln 20 MG $ 1,898.29 Medication Mitomycin For IV Soln 40 MG $ 3,791.07 Medication Mitomycin For IV Soln 5 MG $ 734.10 Medication Mitoxantrone HCl Inj Conc 20 MG/10ML (2 MG/ML) $ 1,226.45 Medication Montelukast Sodium Tab 10 MG (Base Equiv) $ 8.15 Medication Morphine Sulfate Inj 10 MG/MLMorphine Sulfate IV Soln PF 10 MG/MLMorphine Sulfate Inj PF 10 MG/ML $ 16.54 Medication Morphine Sulfate Inj 2 MG/ML $ 30.78 Medication Morphine Sulfate Inj 4 MG/ML $ 19.25 Medication Morphine Sulfate Inj 5 MG/ML $ 16.54 Medication Morphine Sulfate Inj PF 0.5 MG/ML $ 130.91 Medication Morphine Sulfate Inj PF 1 MG/ML $ 62.04 Medication Morphine Sulfate IV Soln 1 MG/ML $ 71.84 Medication Morphine Sulfate IV Soln PF 10 MG/MLMorphine Sulfate Inj 10 MG/MLMorphine Sulfate Inj PF 10 MG/ML $ 16.54 Medication Morphine Sulfate IV Soln PF 2 MG/MLMorphine Sulfate Inj PF 2 MG/ML $ 22.83 Medication Morphine Sulfate IV Soln PF 4 MG/MLMorphine Sulfate Inj PF 4 MG/ML $ 16.54 Medication Morphine Sulfate Oral Soln 10 MG/5ML $ 6.04

02-19-2019-A-PAC-057 Page 84 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 Medication Morphine Sulfate Oral Soln 100 MG/5ML (20 MG/ML) $ 5.51 Medication Morphine Sulfate Tab ER 15 MG $ 10.04 Medication Moxifloxacin HCl Ophth Soln 0.5% (Base Equiv) $ 678.78 Medication Multiple Vitamin Inj $ 117.08 Medication Multiple Vitamin Tab $ 3.86 Medication Multiple Vitamins w/ Minerals Tab $ 3.86 Medication Mupirocin Calcium Nasal Oint 2% $ 90.84 Medication Mupirocin Oint 2% $ 104.52 Medication Mycophenolate Mofetil For Oral Susp 200 MG/ML $ 53.40 Medication Na Nitrite Inj 300 MG/10ML &Na Thiosulf Inj 12.5 GM/50ML Kit $ 612.74 Medication Nadolol Tab 40 MG $ 40.48 Medication Nafcillin Sodium For Inj 1 GM $ 99.36 Medication Nafcillin Sodium For Inj 2 GM $ 130.48 Medication Nalbuphine HCl Inj 10 MG/ML $ 34.61 Medication Nalbuphine HCl Inj 20 MG/ML $ 55.54 Medication Naloxegol Oxalate Tab 12.5 MG (Base Equivalent) $ 77.49 Medication Naloxegol Oxalate Tab 25 MG (Base Equivalent) $ 39.85 Medication Naloxone HCl Soln Prefilled Syringe 2 MG/2ML $ 159.79 Medication Naproxen Tab 500 MG $ 4.98 Medication Natalizumab for IV Inj Conc 300 MG/15ML $ 19,162.43 Medication Nebivolol HCl Tab 10 MG (Base Equivalent) $ 33.07 Medication Nebivolol HCl Tab 5 MG (Base Equivalent) $ 49.52 Medication Neomycin Sulfate Tab 500 MG $ 28.58 Medication Neomycin-Bacitrac Zn-Polymyx 5(3.5)MG-400Unt-10000Unt Op Oin $ 185.79 Medication Neomycin-Bacitracin-Polymyxin Oint $ 38.47 Medication Neomycin-Polymy-Gramicid Op Sol 1.75-10000-0.025MG-UNT-MG/ML $ 206.81 Medication Neomycin-Polymyxin-Dexamethasone Ophth Oint 0.1% $ 88.87 Medication Neomycin-Polymyxin-Dexamethasone Ophth Susp 0.1% $ 95.18 Medication Neomycin-Polymyxin-HC Ophth Susp $ 533.36 Medication Neostigmine Methylsulfate IV Soln 10 MG/10 ML (1 MG/ML) $ 23.99 Medication Nepafenac Ophth Susp 0.1% $ 1,052.73 Medication Nesiritide For Inj 1.5 MG $ 3,175.75 Medication Niacin Tab ER 500 MG $ 6.03 Medication Niacin Tab ER 500 MG (Antihyperlipidemic) $ 35.13 Medication Nicardipine HCl IV Soln 2.5 MG/ML $ 116.58 Medication Nicardipine HCl IV Soln 20 MG/200ML in Sodium Chloride 0.86% $ 315.32 Medication Nicotine TD Patch 24HR 14 MG/24HR $ 22.60 Medication Nicotine TD Patch 24HR 21 MG/24HR $ 19.48 Medication Nicotine TD Patch 24HR 7 MG/24HR $ 22.60 Medication Nifedipine Cap 10 MG $ 16.73 Medication Nifedipine Tab ER 24HR 30 MG $ 15.07 Medication Nifedipine Tab ER 24HR Osmotic Release 30 MG $ 13.38 Medication Nitazoxanide Tab 500 MG $ 341.54 Medication Nitrofurantoin Monohydrate Macrocrystalline Cap 100 MG $ 30.77 Medication NITROGLYCERIN 1 MG IN 10 ML D5W PREMADE SYRINGE (CATH) $ 13.23 Medication Nitroglycerin IV Soln 200 MCG/ML in D5W $ 84. 85 Medication Nitroglycerin IV Soln 5 MG/ML $ 109.97 Medication Nitroglycerin Oint 2% $ 263.60 Medication Nitroglycerin SL Tab 0.4 MG $ 14.31 Medication Nitroglycerin TD Patch 24HR 0.1 MG/HR $ 10.78 Medication Nitroglycerin TD Patch 24HR 0.2 MG/HR $ 9.08 Medication Nitroglycerin TD Patch 24HR 0.4 MG/HR $ 10.15 Medication Nitroglycerin TL Soln 0.4 MG/SPRAY (400 MCG/SPRAY) $ 1,082.15 Medication Nitroprusside Sodium IV Soln 25 MG/ML $ 904.01 Medication Nivolumab IV Soln 100 MG/10ML $ 7,976.43 Medication Nivolumab IV Soln 240 MG/24ML $ 19,135.73 Medication Nivolumab IV Soln 40 MG/4ML $ 3,193.87 Medication Norepinephrine Bitartrate IV Soln 1 MG/ML (Base Equivalent) $ 117.09 Medication Nortriptyline HCl Cap 10 MG $ 6.78 Medication Nortriptyline HCl Cap 25 MG $ 4.12 Medication Nutritional Supplement Liquid $ 142.60 Medication Nystatin Cream 100000 Unit/GM $ 109.21 Medication Nystatin Susp 100000 Unit/ML $ 70.50 Medication Nystatin Topical Powder 100000 Unit/GM $ 159.90 Medication Obinutuzumab Soln for IV Infusion 1000 MG/40ML (25 MG/ML) $ 19,335.84 Medication Octreotide Acetate For IM Inj Kit 20 MG $ 12,778.41 Medication Octreotide Acetate For IM Inj Kit 30 MG $ 19,132.00 Medication Octreotide Acetate Inj 100 MCG/ML (0.1 MG/ML) $ 104.94 Medication Ofloxacin Ophth Soln 0.3% $ 444.58 Medication Olanzapine Tab 5 MG $ 5.72 Medication Olaratumab Soln for IV Infusion 500 MG/50ML (10 MG/ML) $ 7,361.23

02-19-2019-A-PAC-057 Page 85 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 Medication Omega-3-acid Ethyl Esters Cap 1 GM $ 40.86 Medication OnabotulinumtoxinA (Cosmetic) For Inj 100 Unit $ 1,805.51 Medication OnabotulinumtoxinA For Inj 100 Unit $ 1,805.51 Medication OnabotulinumtoxinA For Inj 200 Unit $ 3,605.50 Medication Ondansetron HCl Inj 4 MG/2ML (2 MG/ML) $ 14.75 Medication Ondansetron HCl Oral Soln 4 MG/5ML $ 38.69 Medication Ondansetron HCl Tab 4 MG $ 9.50 Medication Ondansetron HCl Tab 8 MG $ 11.54 Medication Ondansetron Orally Disintegrating Tab 4 MG $ 8.91 Medication Ophthalmic Irrigation Solution $ 28.68 Medication Ophthalmic Irrigation Solution - Intraocular $ 47.85 Medication Oprelvekin For Inj 5 MG $ 1,325.62 Medication Oral Vehicles - Syrup $ 75.16 Medication Orphenadrine Citrate Inj 30 MG/ML $ 92.98 Medication Orphenadrine Citrate Tab ER 12HR 100 MG $ 12.50 Medication Oseltamivir Phosphate Cap 30 MG (Base Equiv) $ 52.76 Medication Oseltamivir Phosphate Cap 75 MG (Base Equiv) $ 73.21 Medication Oseltamivir Phosphate For Susp 6 MG/ML (Base Equiv) $ 593.41 Medication Oxacillin Sodium For Inj 2 GM (Base Equivalent) $ 130.15 Medication Oxaliplatin IV Soln 100 MG/20ML $ 389.01 Medication Oxaliplatin IV Soln 50 MG/10ML $ 239.26 Medication Oxcarbazepine Tab 300 MG $ 8.20 Medication OXEPA PO LIQD $ 45.79 Medication Oxidized Cellulose Pads $ 494.72 Medication Oxybutynin Chloride Tab 5 MG $ 8.04 Medication Oxycodone HCl Soln 5 MG/5ML $ 50.72 Medication Oxycodone HCl Tab 5 MG $ 6.68 Medication Oxycodone HCl Tab ER 12HR Deter 10 MG $ 36.51 Medication Oxycodone HCl Tab ER 12HR Deter 20 MG $ 65.16 Medication Oxycodone w/ Acetaminophen Tab 5-325 MG $ 6.60 Medication Oxymetazoline HCl Nasal Soln 0.05% $ 19.85 Medication Oxytocin Inj 10 Unit/ML $ 17.48 Medication Paclitaxel IV Conc 30 MG/5ML (6 MG/ML) $ 109.40 Medication Paclitaxel IV Conc 300 MG/50ML (6 MG/ML) $ 501.38 Medication Paclitaxel Protein-Bound Particles For IV Susp 100 MG $ 4,132.65 Medication Palonosetron HCl IV Soln 0.25 MG/5ML (Base Equivalent) $ 819.55 Medication Pamidronate Disodium IV Soln 3 MG/ML $ 116.47 Medication Pamidronate Disodium IV Soln 9 MG/ML $ 149.50 Medication Panitumumab IV Soln 100 MG/5ML $ 3,668.57 Medication Panitumumab IV Soln 400 MG/20ML $ 14,657.77 Medication Pantoprazole Sodium EC Tab 40 MG (Base Equiv) $ 3.94 Medication Pantoprazole Sodium For Delayed Release Susp Packet 40 MG $ 72.62 Medication Pantoprazole Sodium For IV Soln 40 MG (Base Equiv) $ 57.74 Medication Papaverine HCl Inj 30 MG/ML $ 166.05 Medication Parenteral Electrolyte Conc $ 56.61 Medication Paricalcitol Cap 1 MCG $ 58. 60 Medication Paricalcitol IV Soln 2 MCG/ML $ 54.20 Medication Paroxetine HCl Tab 20 MG $ 5.32 Medication Patiromer Sorbitex Calcium For Susp Packet 8.4 GM (Base Eq) $ 130.12 Medication PB-Hyoscy-Atrop-Scopol Elix 16.2-0.1037-0.0194-0.0065 MG/5ML $ 70.62 Medication Pediatric Multiple Vitamin w/ C & FA Chew Tab $ 3.86 Medication PEG 3350-KCl-Na Bicarb-NaCl-Na Sulfate For Soln 236 GM $ 104.53 Medication Pegfilgrastim Soln Prefilled Syringe 6 MG/0.6ML $ 18,667.53 Medication Pegfilgrastim Soln Prefilled Syringe Kit 6 MG/0.6ML $ 18,667.53 Medication Pegfilgrastim-cbqv Soln Prefilled Syringe 6 MG/0.6ML $ 12,509.63 Medication Pegfilgrastim-jmdb Soln Prefilled Syringe 6 MG/0.6ML $ 12,509.63 Medication Pegloticase Inj 8 MG/ML (For IV Infusion) $ 64,536.44 Medication Pembrolizumab IV Soln 100 MG/4ML (25 MG/ML) $ 14,140.11 Medication Pemetrexed Disodium For IV Soln 500 MG (Base Equiv) $ 10,339.01 Medication Penicillin G Benzathine & Procaine Inj Susp 1200000 Unit/2ML $ 246.04 Medication Penicillin G Benzathine Intramuscular Susp 1200000 Unit/2ML $ 609.02 Medication Penicillin G Benzathine Intramuscular Susp 600000 Unit/ML $ 353.96 Medication Penicillin G Potassium For Inj 20000000 Unit $ 515.57 Medication Penicillin V Potassium For Soln 250 MG/5ML $ 49.37 Medication Penicillin V Potassium Tab 250 MG $ 7.54 Medication Pentoxifylline Tab ER 400 MG $ 4.66 Medication Perflutren Lipid Microsphere IV Susp 6.52 MG/ML (1.1 MG/ML) $ 13.23 Medication Permethrin Cream 5% $ 390.70 Medication Permethrin Creme Rinse 1% $ 43.58 Medication Perphenazine Tab 16 MG $ 5.92 Medication Pertuzumab Soln for IV Infusion 420 MG/14ML (30 MG/ML) $ 15,018.13

02-19-2019-A-PAC-057 Page 86 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 Medication Phenazopyridine HCl Tab 100 MG $ 19.26 Medication Phenobarbital Sodium Inj 130 MG/ML $ 208.17 Medication Phenobarbital Tab 32.4 MG $ 8.98 Medication Phenol Liquid 1.4% $ 21.79 Medication Phenol Swabs 89% $ 46.39 Medication Phenoxybenzamine HCl Cap 10 MG $ 325.64 Medication Phentolamine Mesylate For Inj 5 MG $ 1,340.76 Medication Phenylephrine HCl IV Soln 10 MG/ML $ 207.70 Medication Phenylephrine HCl Nasal Soln 0.5% $ 38.10 Medication Phenylephrine HCl Ophth Soln 10% $ 164.43 Medication Phenylephrine HCl Ophth Soln 2.5% $ 356.18 Medication Phenylephrine-NaCl Pref Syr 1 MG/10ML-0.9% (100 MCG/ML) $ 43.84 Medication Phenytoin Chew Tab 50 MG $ 18.96 Medication Phenytoin Sodium Extended Cap 100 MG $ 8.14 Medication Phenytoin Sodium Inj 50 MG/ML $ 16.44 Medication Phenytoin Susp 125 MG/5ML $ 129.63 Medication Physostigmine Salicylate Inj 1 MG/ML $ 113.45 Medication Phytonadione Inj 1 MG/0.5ML (2 MG/ML) $ 129.60 Medication Phytonadione Inj 10 MG/ML $ 231.04 Medication Phytonadione Tab 5 MG $ 227.55 Medication Pilocarpine HCl Ophth Soln 1% $ 313.44 Medication Pilocarpine HCl Ophth Soln 2% $ 320.34 Medication Pilocarpine HCl Ophth Soln 4% $ 335.30 Medication Pioglitazone HCl Tab 15 MG (Base Equiv) $ 11.24 Medication Piperacillin Sodium-Tazobactam Sodium For Inj 2-0.25 GM $ 60.71 Medication Piperacillin Sod-Tazobactam Na For Inj 3.375 GM (3-0.375 GM) $ 98.56 Medication Piperacillin Sod-Tazobactam Sod For Inj 2.25 GM (2-0.25 GM) $ 64.73 Medication Piperacillin Sod-Tazobactam Sod For Inj 4.5 GM (4-0.5 GM) $ 115.86 Medication Piperacillin Sod-Tazobactam Sod in Dex IV Sol 3-0.375GM/50ML $ 87.73 Medication Piperacillin Sod-Tazobactam Sod in Dex IV Soln 2-0.25GM/50ML $ 69.51 Medication Piperacillin Sod-Tazobactam Sod in Dex IV Soln 4-0.5GM/100ML $ 106.91 Medication Plasma Protein Fraction Inj 5% $ 258.81 Medication Pneumococcal 13-Valent Conjugate Vaccine Inj $ 797.83 Medication Pneumococcal Vaccine Polyvalent Inj 25 MCG/0.5ML $ 408.76 Medication Polyethylene Glycol 3350 Oral Packet $ 22.16 Medication Polymyxin B Sulfate For Inj 500000 Unit $ 95.90 Medication Polymyxin B-Trimethoprim Ophth Soln 10000 Unit/ML-0.1% $ 59.42 Medication Polysaccharide Iron Complex Cap 150 MG (Iron Equivalent) $ 3.86 Medication Polyvinyl Alcohol Ophth Soln 1.4% $ 31.86 Medication Pot Bicarbonate & Chloride Effer Tab 25 mEq $ 13.31 Medication Potassium & Sodium Phosphates Powder Pack 280-160-250 MG $ 7.49 Medication Potassium Acetate Inj 2 mEq/ML $ 31.06 Medication Potassium Bicarbonate Effer Tab 25 mEq $ 4.25 Medication POTASSIUM CHLORIDE IN LR 20MEQ/1000ML PREMADE $ 65.39 Medication POTASSIUM CHLORIDE IN NS 40MEQ/500ML PREMADE $ 76.23 Medication Potassium Chloride Inj 10 mEq/100ML $ 44. 10 Medication Potassium Chloride Inj 2 mEq/ML $ 42.43 Medication Potassium Chloride Inj 20 mEq/100ML $ 55.13 Medication Potassium Chloride Inj 40 mEq/100ML $ 55.13 Medication Potassium Chloride Microencapsulated Crys ER Tab 20 mEq $ 8.68 Medication Potassium Chloride Oral Soln 10% (20 MEQ/15ML) $ 89.81 Medication Potassium Chloride Tab ER 10 mEq $ 7.11 Medication Potassium Iodide Oral Soln 1 GM/ML $ 75.23 Medication Potassium Iodide Soln 1 GM/ML $ 75.23 Medication Potassium Phosphates Inj 15 mM/5ML (Phos) 22 mEq/5ML (K) $ 124.51 Medication Potassium Phosphates Inj 150 mM/50ML (Phos) 220 mEq/50ML (K) $ 53.72 Medication Potassium Phosphates Inj 45 mM/15ML (Phos) 66 mEq/15ML (K) $ 122.54 Medication Povidone-Iodine Oint 10% $ 19.85 Medication Povidone-Iodine Ophth Soln 5% $ 71.20 Medication Pramipexole Dihydrochloride Tab 0.5 MG $ 9.40 Medication Prasugrel HCl Tab 10 MG (Base Equiv) $ 73.74 Medication Pravastatin Sodium Tab 20 MG $ 9.05 Medication Prednisolone Acetate Ophth Susp 1% $ 568.98 Medication Prednisolone Sod Phosphate Oral Soln 15 MG/5ML (Base Equiv) $ 59.84 Medication Prednisone Tab 1 MG $ 4.38 Medication Prednisone Tab 10 MG $ 4.29 Medication Prednisone Tab 20 MG $ 6.72 Medication Prednisone Tab 5 MG $ 4.14 Medication Pregabalin Cap 25 MG $ 66.01 Medication Pregabalin Cap 50 MG $ 72.27 Medication Pregabalin Cap 75 MG $ 72.27

02-19-2019-A-PAC-057 Page 87 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 Medication Prenatal Vit w/ Fe Fumarate-FA Tab 60-1 MG $ 4.09 Medication Primidone Tab 50 MG $ 7.46 Medication Probiotic Product - Cap $ 10.29 Medication Procainamide HCl Inj 100 MG/ML $ 336.78 Medication Procainamide HCl Inj 500 MG/ML $ 173.07 Medication Prochlorperazine Edisylate Inj 10 MG/2ML $ 107.54 Medication Prochlorperazine Maleate Tab 5 MG (Base Equivalent) $ 6.14 Medication Prochlorperazine Suppos 25 MG $ 64.53 Medication Promethazine HCl Inj 25 MG/ML $ 20.37 Medication Promethazine HCl Suppos 12.5 MG $ 64.16 Medication Promethazine HCl Suppos 25 MG $ 64.16 Medication Promethazine HCl Syrup 6.25 MG/5ML $ 27.03 Medication Promethazine HCl Tab 12.5 MG $ 6.57 Medication Promethazine HCl Tab 25 MG $ 6.19 Medication Promethazine w/ Codeine Syrup 6.25-10 MG/5ML $ 56.52 Medication Propafenone HCl Tab 150 MG $ 6.68 Medication Proparacaine HCl Ophth Soln 0.5% $ 145.64 Medication Propofol IV Emul 1000 MG/100ML (10 MG/ML) $ 145.76 Medication Propofol IV Emul 200 MG/20ML (10 MG/ML) $ 13.23 Medication Propofol IV Emul 500 MG/50ML (10 MG/ML) $ 126.04 Medication Propranolol HCl Inj 1 MG/ML $ 86.42 Medication Propranolol HCl Tab 20 MG $ 7.13 Medication Propylthiouracil Tab 50 MG $ 23.26 Medication Protamine Sulfate Inj 10 MG/ML $ 40.42 Medication Prothrombin Complex Conc Human For Inj Kit 1000 Unit $ 24.07 Medication Prothrombin Complex Conc Human For Inj Kit 500 Unit $ 22.46 Medication Pseudoephed-Bromphen-DM Syrup 30-2-10 MG/5ML $ 106.47 Medication Pseudoephedrine HCl Tab 30 MG $ 5.51 Medication Psyllium Powder Packet 28% $ 5.79 Medication Psyllium Powder Packet 28.3% $ 6.34 Medication Pyridoxine HCl Tab 25 MG $ 3.86 Medication Pyridoxine HCl Tab 50 MG $ 3.86 Medication Quetiapine Fumarate Tab 100 MG $ 11.66 Medication Quetiapine Fumarate Tab 25 MG $ 7.78 Medication Rabies Immune Globulin (Human) Inj 1500 Unt/10ML(150 Unt/ML) $ 9,030.55 Medication Rabies Immune Globulin (Human) Inj 300 Unit/2ML (150 Unt/ML) $ 2,132.32 Medication Rabies Vaccine PCEC For Inj $ 1,415.09 Medication Racepinephrine HCl Soln Nebu 2.25% (Base Equivalent) $ 16.78 Medication Raltegravir Potassium Tab 400 MG (Base Equiv) $ 119.09 Medication Ramucirumab IV Soln 100 MG/10ML (For Infusion) $ 3,378.93 Medication Ranitidine HCl Syrup 15 MG/ML (75 MG/5ML) $ 283.37 Medication Ranolazine Tab ER 12HR 500 MG $ 41.86 Medication Rasburicase For IV Soln 1.5 MG $ 2,564.11 Medication Rasburicase For IV Soln 7.5 MG $ 12,798.83 Medication Ravulizumab-cwvz IV Soln 300 MG/30ML (10 MG/ML) $ 19,185.52 Medication Regadenoson IV Inj 0.4 MG/5ML (0.08 MG/ML) $ 733. 18 Medication Rifampin Cap 300 MG $ 12.95 Medication Risperidone Tab 0.25 MG $ 4.44 Medication Risperidone Tab 0.5 MG $ 5.42 Medication Rituximab IV Soln 100 MG/10ML $ 2,819.37 Medication Rituximab IV Soln 500 MG/50ML $ 14,074.82 Medication Rituximab-Hyaluronidase Human Inj 1400-23400 MG-Unit/11.7ML $ 19,702.37 Medication Rituximab-Hyaluronidase Human Inj 1600-26800 MG-Unit/13.4ML $ 22,516.19 Medication Rivaroxaban Tab 10 MG $ 97.11 Medication Rivaroxaban Tab 15 MG $ 97.11 Medication Rocuronium Bromide IV Soln 50 MG/5ML (10 MG/ML) $ 35.08 Medication Romiplostim For Inj 250 MCG $ 5,571.96 Medication Romiplostim For Inj 500 MCG $ 11,138.40 Medication Ropinirole Hydrochloride Tab 0.25 MG $ 7.07 Medication Ropinirole Hydrochloride Tab 1 MG $ 7.72 Medication Ropivacaine HCl Inj 10 MG/ML $ 130.70 Medication Ropivacaine HCl Inj 2 MG/ML $ 1,773.00 Medication Ropivacaine HCl Inj 5 MG/ML $ 121.86 Medication Rosiglitazone Maleate Tab 4 MG (Base Equiv) $ 29.65 Medication Rotavirus Vaccine Live Oral Pentavalent Soln $ 360.53 Medication Sacubitril-Valsartan Tab 24-26 MG $ 51.21 Medication Sacubitril-Valsartan Tab 49-51 MG $ 51.21 Medication Sacubitril-Valsartan Tab 97-103 MG $ 51.21 Medication Saline Injection Bacteriostatic $ 14.43 Medication Saline Nasal Spray 0.65% $ 19.85 Medication Scopolamine TD Patch 72HR 1 MG/3DAYS $ 101.77

02-19-2019-A-PAC-057 Page 88 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 Medication Sennosides Tab 8.6 MG $ 3.86 Medication Sennosides-Docusate Sodium Tab 8.6-50 MG $ 3.86 Medication Sertraline HCl Tab 50 MG $ 4.83 Medication Sevelamer HCl Tab 800 MG $ 47.05 Medication Sevoflurane Inhal Soln $ 532.59 Medication Sildenafil Citrate Tab 20 MG $ 13.50 Medication Silver Nitrate-Potassium Nitrate Applicator 75-25% $ 8.09 Medication Silver Sulfadiazine Cream 1% $ 213.52 Medication Simethicone Chew Tab 80 MG $ 3.86 Medication Simethicone Susp 40 MG/0.6ML $ 33.69 Medication Sincalide For Inj 5 MCG $ 393.50 Medication Sipuleucel-T Suspension for IV Infusion $ 167,195.67 Medication Sitagliptin Phosphate Tab 100 MG (Base Equiv) $ 72.52 Medication Sitagliptin Phosphate Tab 25 MG (Base Equiv) $ 72.52 Medication Sod Bicarb-Citric Acid-Simeth Gran Pack 2.21-1.53-0.04 GM $ 25.17 Medication Sod Ferric Gluc Cmplx in Sucrose IV Soln 12.5 MG/ML (Fe Eq) $ 249.42 Medication Sodium Acetate Inj 2 mEq/ML $ 30.90 Medication Sodium Bicarbonate IV Soln 4.2% $ 92.37 Medication Sodium Bicarbonate IV Soln 8.4% $ 580.76 Medication Sodium Bicarbonate Tab 650 MG $ 3.86 Medication Sodium Chloride Flush IV Soln 0.9% $ 115.81 Medication Sodium Chloride Inj 0.45% $ 55.13 Medication Sodium Chloride Inj 0.9% $ 13.23 Medication Sodium Chloride Inj 3% $ 44.10 Medication Sodium Chloride Irrigation Soln 0.9% $ 127.91 Medication Sodium Chloride IV Soln 0.45% $ 55.13 Medication Sodium Chloride IV Soln 0.9% $ 60.12 Medication Sodium Chloride IV Soln 3% $ 44.10 Medication Sodium Chloride IV Soln 4 mEq/ML (23.4%) $ 41.67 Medication Sodium Chloride Soln Nebu 0.9% $ 3.86 Medication Sodium Chloride Tab 1 GM $ 3.86 Medication Sodium Citrate & Citric Acid Soln 500-334 MG/5ML $ 19.70 Medication Sodium Hyaluronate Intra-articular Soln Pref Syr 20 MG/2ML $ 1,023.59 Medication Sodium Iodide I-123 Cap 3.7 MBq (100 Microcurie) $ 321.82 Medication Sodium Iodide I-123 Cap 7.4 MBq (200 Microcurie) $ 484.14 Medication Sodium Nitrite Inj 30 MG/ML $ 308.48 Medication Sodium Phosphates - Enema $ 21.59 Medication Sodium Phosphates - Enema (Pediatric) $ 14.39 Medication Sodium Phosphates Inj 15 mM/5ML (Phos) 20 mEq/5ML (Na) $ 94.52 Medication Sodium Phosphates Inj 45 mM/15ML (Phos) 60 mEq/15ML (Na) $ 159.86 Medication Sodium Polystyrene Sulfonate Oral Susp 15 GM/60ML $ 347.36 Medication Sodium Tetradecyl Sulfate Inj 3% $ 113.23 Medication Sodium Thiosulfate Inj 25% $ 316.15 Medication Sorbitol Irrigation Soln 3% $ 109.21 Medication Sotalol HCl Tab 80 MG $ 17.75 Medication Speciality Vitamin Product EC Tab $ 3. 86 Medication Spironolactone Tab 25 MG $ 4.44 Medication Streptozocin For Inj 1 GM $ 1,051.45 Medication Succinylcholine Chloride Inj 20 MG/ML $ 51.74 Medication Sucralfate Susp 1 GM/10ML $ 66.71 Medication Sucralfate Tab 1 GM $ 5.28 Medication Sufentanil Citrate Inj 100 MCG/2ML (50 MCG/ML) $ 22.94 Medication Sufentanil Citrate Inj 250 MCG/5ML (50 MCG/ML) $ 25.96 Medication Sugammadex Sodium IV 200 MG/2ML (Base Equivalent) $ 388.01 Medication Sulfacetamide Sodium Ophth Soln 10% $ 197.99 Medication Sulfacetamide Sodium-Prednisolone Ophth Susp 10-0.2% $ 19.85 Medication Sulfamethoxazole-Trimethoprim IV Soln 400-80 MG/5ML $ 181.38 Medication Sulfamethoxazole-Trimethoprim Susp 200-40 MG/5ML $ 363.19 Medication Sulfamethoxazole-Trimethoprim Tab 800-160 MG $ 4.77 Medication Sulfur ColloidTechnetium Tc 99m Sulfur Colloid Inj for Soln Kit $ 325.00 Medication Sumatriptan Succinate Inj 6 MG/0.5ML $ 143.39 Medication Sumatriptan Succinate Tab 50 MG $ 19.42 Medication Talc Intrapleural Powder 4 GM $ 547.93 Medication Tamoxifen Citrate Tab 10 MG (Base Equivalent) $ 6.85 Medication Tamsulosin HCl Cap 0.4 MG $ 7.95 Medication TC-99M CARDIOLITE (SESTAMIBI) $ 191.01 Medication TC-99M MACRO-AGGREGATED ALBUMIN $ 63.67 Medication TC-99M MAG3 (MERTIATIDE) $ 458.42 Medication Technetium Tc 99m Mebrofenin IV for Soln Kit $ 53.68 Medication Technetium Tc 99m Medronate IV for Soln Kit $ 63.67 Medication Technetium Tc 99m Na Pertechnetate for Soln Kit $ 213.02

02-19-2019-A-PAC-057 Page 89 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 Medication Technetium Tc 99m Pentetate IV for Soln Kit $ 31.33 Medication Technetium Tc 99m Sulfur Colloid Inj for Soln Kit $ 325.00 Medication Temazepam Cap 15 MG $ 5.51 Medication Temozolomide Cap 100 MG $ 801.10 Medication Temozolomide For IV Soln 100 MG $ 3,009.82 Medication Temsirolimus Soln For IV Infusion 25 MG/ML $ 4,297.94 Medication Terazosin HCl Cap 1 MG (Base Equivalent) $ 3.86 Medication Terazosin HCl Cap 5 MG (Base Equivalent) $ 5.04 Medication Terbutaline Sulfate Inj 1 MG/ML $ 104.72 Medication Terbutaline Sulfate Tab 2.5 MG $ 44.50 Medication Testosterone Cypionate IM Inj in Oil 200 MG/ML $ 47.90 Medication Tet Tox-Diph-Acell Pertuss Ad Inj 5-2.5-18.5 LF-LF-MCG/0.5ML $ 187.48 Medication Tetanus Immune Globulin (Human) Inj 250 Unit/ML $ 1,497.11 Medication Tetanus-Diphtheria Toxoids (Td) Inj 2-2 LF/0.5ML $ 120.80 Medication Tetanus-Diphtheria Toxoids (Td) Inj 5-2 LFU $ 156.94 Medication Tetracaine HCl Ophth Soln 0.5% $ 55.88 Medication Tetracycline HCl Cap 250 MG $ 47.36 Medication Thallous Chloride TL 201 Inj 1 mCi/ML $ 222.00 Medication Theophylline Tab ER 12HR 200 MG $ 7.66 Medication Theophylline Tab ER 12HR 300 MG $ 13.34 Medication Theophylline Tab ER 24HR 400 MG $ 14.08 Medication Thiamine HCl Inj 100 MG/ML $ 74.10 Medication Thiamine HCl Tab 100 MG $ 5.06 Medication Throat Lozenges - Lozenges $ 19.85 Medication Thrombin (Recombinant) For Soln 5000 Unit $ 340.84 Medication Thrombin For Soln 5000 Unit $ 286.27 Medication Ticagrelor Tab 90 MG $ 41.83 Medication Tigecycline For IV Soln 50 MG $ 603.77 Medication Timolol Maleate Ophth Soln 0.25% $ 23.19 Medication Timolol Maleate Ophth Soln 0.5% $ 33.70 Medication Tiotropium Bromide Monohydrate Inhal Cap 18 MCG (Base Equiv) $ 337.24 Medication Tizanidine HCl Tab 2 MG (Base Equivalent) $ 12.70 Medication Tobramycin Ophth Oint 0.3% $ 833.10 Medication Tobramycin Ophth Soln 0.3% $ 402.47 Medication Tobramycin Sulfate For Inj 1.2 GM $ 644.68 Medication Tobramycin Sulfate Inj 80 MG/2ML (40 MG/ML) (Base Equiv) $ 32.75 Medication Tobramycin-Dexamethasone Ophth Oint 0.3-0.1% $ 886.22 Medication Tobramycin-Dexamethasone Ophth Susp 0.3-0.1% $ 399.90 Medication Tocilizumab IV Inj 200 MG/10ML $ 3,276.14 Medication Tocilizumab IV Inj 400 MG/20ML $ 6,546.77 Medication Tocilizumab IV Inj 80 MG/4ML $ 1,313.76 Medication Tolterodine Tartrate Cap ER 24HR 2 MG $ 73.99 Medication Tolvaptan Tab 15 MG $ 1,352.35 Medication Topiramate Tab 25 MG $ 3.86 Medication Topotecan HCl For Inj 4 MG (Base Equiv) $ 3,472.22 Medication Trace Min (Cr-Cu-Mn-Se-Zn) Inj 4-400-100-20-1000 MCG/ML $ 112. 13 Medication Trace Min (Cr-Cu-Mn-Zn) Inj 4-400-100-1000 MCG/ML $ 165.72 Medication Tramadol HCl Tab 50 MG $ 5.51 Medication Tranexamic Acid IV Soln 1000 MG/10ML (100 MG/ML) $ 145.76 Medication Tranexamic Acid Tab 650 MG $ 44.42 Medication Trastuzumab For IV Soln 150 MG $ 4,672.98 Medication Trazodone HCl Tab 50 MG $ 3.86 Medication Triamcinolone Acetonide Cream 0.1% $ 66.62 Medication Triamcinolone Acetonide Inj Susp 40 MG/ML $ 24.31 Medication Triamcinolone Acetonide Oint 0.1% $ 32.77 Medication Triamcinolone Acetonide Ophth Inj 40 MG/ML $ 88.46 Medication Triamterene & Hydrochlorothiazide Tab 75-50 MG $ 9.15 Medication Trifluridine Ophth Soln 1% $ 695.00 Medication Trimethoprim Tab 100 MG $ 7.68 Medication Tropicamide Ophth Soln 1% $ 56.26 Medication Trospium Chloride Cap ER 24HR 60 MG $ 36.46 Medication Trypan Blue Ophth Soln 0.06% $ 217.26 Medication Trypsin w/ Castor Oil & Peruvian Balsam Oint $ 179.00 Medication Tuberculin PPD Inj 5 Unit/0.1ML $ 76.88 Medication Urea Packet 15 GM $ 36.21 Medication Ustekinumab Inj 45 MG/0.5ML $ 32,957.43 Medication Ustekinumab IV Soln 130 MG/26ML (5 MG/ML) (For IV Infusion) $ 4,797.47 Medication Valacyclovir HCl Tab 500 MG $ 34.35 Medication Valproate Sodium Inj 100 MG/ML $ 100.84 Medication Valproate Sodium Oral Soln 250 MG/5ML (Base Equiv) $ 19.85 Medication Valproate Sodium Syrup 250 MG/5ML (Base Equiv) $ 89.38

02-19-2019-A-PAC-057 Page 90 of 97 Avita Health System - Standard Hospital Charges as of 7/1/2019 The information provided below is a list of all hospital charges as they appear in our chargemaster, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Price as of Code Description 07/01/2019 Medication Valsartan Tab 80 MG $ 52.12 Medication Vancomycin HCl For Inj 500 MG $ 70.11 Medication Vancomycin HCl For IV Soln 1 GM (Base Equivalent) $ 93.97 Medication Vancomycin HCl For IV Soln 5 GM (Base Equivalent) $ 346.56 Medication Vancomycin HCl For IV Soln 500 MG (Base Equivalent) $ 70.11 Medication Vancomycin HCl-Dextrose IV Soln 1 GM/200ML-5% $ 99.24 Medication Vasopressin IV Soln 20 Unit/ML (For IV Infusion) $ 200.98 Medication Vecuronium Bromide For Inj 10 MG $ 73.81 Medication Vedolizumab For IV Solution 300 MG $ 18,815.58 Medication Venlafaxine HCl Cap ER 24HR 37.5 MG (Base Equivalent) $ 7.02 Medication Venlafaxine HCl Cap ER 24HR 75 MG (Base Equivalent) $ 4.87 Medication Venlafaxine HCl Tab 25 MG (Base Equivalent) $ 10.02 Medication Venlafaxine HCl Tab 37.5 MG (Base Equivalent) $ 8.77 Medication Venlafaxine HCl Tab 75 MG (Base Equivalent) $ 4.60 Medication Verapamil HCl IV Soln 2.5 MG/ML $ 121.78 Medication Verapamil HCl Tab 80 MG $ 3.86 Medication Verapamil HCl Tab ER 180 MG $ 5.80 Medication Verapamil HCl Tab ER 240 MG $ 22.73 Medication Vinblastine Sulfate Inj 1 MG/ML $ 206.86 Medication Vincristine Sulfate IV Soln 1 MG/ML $ 96.47 Medication Vinorelbine Tartrate Inj 10 MG/ML (Base Equiv) $ 145.76 Medication Vinorelbine Tartrate Inj 50 MG/5ML (10 MG/ML) (Base Equiv) $ 331.49 Medication VITAL AF 1.2 CAL PO LIQD $ 128.80 Medication Vitamin E Cap 400 Unit $ 3.86 Medication Vitamins A & D Oint $ 19.85 Medication Voriconazole For Inj 200 MG $ 577.65 Medication Warfarin Sodium Tab 1 MG $ 22.22 Medication Warfarin Sodium Tab 2 MG $ 23.10 Medication Warfarin Sodium Tab 2.5 MG $ 23.78 Medication Warfarin Sodium Tab 3 MG $ 23.87 Medication Warfarin Sodium Tab 4 MG $ 23.87 Medication Warfarin Sodium Tab 5 MG $ 24.65 Medication Warfarin Sodium Tab 6 MG $ 31.16 Medication Warfarin Sodium Tab 7.5 MG $ 32.13 Medication Water For Inject Bacteriostatic Benzyl Alcohol $ 14.91 Medication Water For Injection $ 52.92 Medication Water For Irrigation Sterile Irrigation Soln $ 27.39 Medication Water For IV Injection $ 55.13 Medication White Petrolatum-Mineral Oil Ophth Ointment $ 23.89 Medication Wound Dressings - Gel $ 91.65 Medication Zanamivir Aero Powder Breath Activated 5 MG/BLISTER $ 24.82 Medication Zidovudine IV Soln 10 MG/ML $ 142.02 Medication Zidovudine Syrup 10 MG/ML $ 31.36 Medication Zinc Oxide Cream 13% $ 24.62 Medication Zinc Oxide Oint 20% $ 23.79 Medication Ziprasidone HCl Cap 20 MG $ 29. 23 Medication Ziprasidone HCl Cap 40 MG $ 15.67 Medication Ziprasidone Mesylate For Inj 20 MG (Base Equivalent) $ 142.50 Medication Ziv-Aflibercept IV Soln 200 MG/8ML (For Infusion) $ 9,589.51 Medication Zoledronic Acid Inj Conc For IV Infusion 4 MG/5ML $ 250.41 Medication Zoledronic Acid IV Soln 4 MG/100ML $ 190.73 Medication Zoledronic Acid IV Soln 5 MG/100ML $ 714.86 Medication Zolpidem Tartrate Tab 5 MG $ 5.51 Medication Zoster Vaccine Live For Subcutaneous Susp 19400 Unit/0.65ML $ 899.10

02-19-2019-A-PAC-057 Page 91 of 97 Avita Health System - Average Standard Hospital Charges for Diagnosis-Related Groups (DRGs) as of 7/1/2019 The information provided below is a list of average hospital charges for diagnosis-related groups, in compliance with state and federal laws.

Please contact our Customer Service team for a free personalized estimate.

Average Price as DRG Description of 07/01/2019 004 Trach W Mv >96 Hrs Or Pdx Exc Face, Mouth & Neck W/O Maj O.R. $ 84,317.79 035 Carotid Artery Stent Procedure W Cc $ 40,314.79 036 Carotid Artery Stent Procedure W/O Cc/Mcc $ 48,436.04 039 Extracranial Procedures W/O Cc/Mcc $ 31,409.35 041 Periph/Cranial Nerve & Other Nerv Syst Proc W Cc Or Periph Neurostim $ 28,782.94 057 Degenerative Nervous System Disorders W/O Mcc $ 19,876.31 060 Multiple Sclerosis & Cerebellar Ataxia W/O Cc/Mcc $ 30,851.27 064 Intracranial Hemorrhage Or Cerebral Infarction W Mcc $ 22,142.29 065 Intracranial Hemorrhage Or Cerebral Infarction W Cc Or Tpa In 24 Hrs $ 25,488.24 066 Intracranial Hemorrhage Or Cerebral Infarction W/O Cc/Mcc $ 14,356.20 067 Nonspecific Cva & Precerebral Occlusion W/O Infarct W Mcc $ 45,572.76 068 Nonspecific Cva & Precerebral Occlusion W/O Infarct W/O Mcc $ 28,291.03 069 Transient Ischemia W/O Thrombolytic $ 20,935.12 070 Nonspecific Cerebrovascular Disorders W Mcc $ 28,556.99 071 Nonspecific Cerebrovascular Disorders W Cc $ 8,683.38 079 Hypertensive Encephalopathy W/O Cc/Mcc $ 10,460.03 084 Traumatic Stupor & Coma, Coma >1 Hr W/O Cc/Mcc $ 24,583.45 087 Traumatic Stupor & Coma, Coma <1 Hr W/O Cc/Mcc $ 11,035.80 092 Other Disorders Of Nervous System W Cc $ 13,539.45 093 Other Disorders Of Nervous System W/O Cc/Mcc $ 9,384.77 094 Bacterial & Tuberculous Infections Of Nervous System W Mcc $ 379,663.45 096 Bacterial & Tuberculous Infections Of Nervous System W/O Cc/Mcc $ 64,514.63 099 Non-Bacterial Infect Of Nervous Sys Exc Viral Meningitis W/O Cc/Mcc $ 42,075.15 100 Seizures W Mcc $ 9,675.54 101 Seizures W/O Mcc $ 13,269.54 102 Headaches W Mcc $ 23,954.64 103 Headaches W/O Mcc $ 21,609.66 122 Acute Major Eye Infections W/O Cc/Mcc $ 7,294.08 149 Dysequilibrium $ 11,231.85 153 Otitis Media & Uri W/O Mcc $ 9,657.60 158 Dental & Oral Diseases W Cc $ 19,103.69 163 Major Chest Procedures W Mcc $ 89,161.39 164 Major Chest Procedures W Cc $ 58,500.65 165 Major Chest Procedures W/O Cc/Mcc $ 46,032.31 166 Other Resp System O.R. Procedures W Mcc $ 28,730.32 167 Other Resp System O.R. Procedures W Cc $ 34,253.37 175 Pulmonary Embolism W Mcc $ 19,413.21 176 Pulmonary Embolism W/O Mcc $ 12,242.58 177 Respiratory Infections & Inflammations W Mcc $ 24,085.58 178 Respiratory Infections & Inflammations W Cc $ 17,539.60 179 Respiratory Infections & Inflammations W/O Cc/Mcc $ 16,828.84 180 Respiratory Neoplasms W Mcc $ 37,758.03 181 Respiratory Neoplasms W Cc $ 30,288.12 186 Pleural Effusion W Mcc $ 24,536.68 187 Pleural Effusion W Cc $ 18,616.45 188 Pleural Effusion W/O Cc/Mcc $ 15,197.20 189 Pulmonary Edema & Respiratory Failure $ 17,673.26 190 Chronic Obstructive Pulmonary Disease W Mcc $ 17,029.99 191 Chronic Obstructive Pulmonary Disease W Cc $ 14,086.58 192 Chronic Obstructive Pulmonary Disease W/O Cc/Mcc $ 10,191.86 193 Simple Pneumonia & Pleurisy W Mcc $ 20,093.44 194 Simple Pneumonia & Pleurisy W Cc $ 14,479.89 195 Simple Pneumonia & Pleurisy W/O Cc/Mcc $ 11,018.95 196 Interstitial Lung Disease W Mcc $ 17,026.53 197 Interstitial Lung Disease W Cc $ 19,106.68 199 Pneumothorax W Mcc $ 21,396.64 200 Pneumothorax W Cc $ 18,229.95 201 Pneumothorax W/O Cc/Mcc $ 7,074.98 202 Bronchitis & Asthma W Cc/Mcc $ 13,989.74 203 Bronchitis & Asthma W/O Cc/Mcc $ 10,730.47 204 Respiratory Signs & Symptoms $ 12,936.02 205 Other Respiratory System Diagnoses W Mcc $ 31,393.62 206 Other Respiratory System Diagnoses W/O Mcc $ 4,407.20 207 Respiratory System Diagnosis W Ventilator Support >96 Hours Or Peripheral Extracorporeal Membrane Oxygenation (Ecmo) $ 70,572.89

208 Respiratory System Diagnosis W Ventilator Support <=96 Hours $ 37,806.34 241 Amputation For Circ Sys Disorders Exc Upper Limb & Toe W/O Cc/Mcc $ 27,154.65

02-19-2019-A-PAC-057 Page 92 of 97 Avita Health System - Average Standard Hospital Charges for Diagnosis-Related Groups (DRGs) as of 7/1/2019 The information provided below is a list of average hospital charges for diagnosis-related groups, in compliance with state and federal laws.

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Average Price as DRG Description of 07/01/2019 242 Permanent Cardiac Pacemaker Implant W Mcc $ 40,008.28 243 Permanent Cardiac Pacemaker Implant W Cc $ 46,217.05 244 Permanent Cardiac Pacemaker Implant W/O Cc/Mcc $ 42,419.57 246 Percutaneous Cardiovascular Procedures W Drug-Eluting Stent W Mcc Or 4+ Arteries Or Stents $ 70,011.15 247 Perc Cardiovasc Proc W Drug-Eluting Stent W/O Mcc $ 67,251.31 252 Other Vascular Procedures W Mcc $ 17,986.95 253 Other Vascular Procedures W Cc $ 45,132.15 254 Other Vascular Procedures W/O Cc/Mcc $ 26,975.08 258 Cardiac Pacemaker Device Replacement W Mcc $ 81,812.34 260 Cardiac Pacemaker Revision Except Device Replacement W Mcc $ 31,550.05 264 Other Circulatory System O.R. Procedures $ 77,124.55 269 Aortic And Heart Assist Procedures Except Pulsation Balloon W/O Mcc $ 87,082.75 270 Other Major Cardiovascular Procedures W Mcc $ 85,495.39 271 Other Major Cardiovascular Procedures W Cc $ 63,020.01 272 Other Major Cardiovascular Procedures W/O Cc/Mcc $ 40,838.35 280 Acute Myocardial Infarction, Discharged Alive W Mcc $ 20,130.62 281 Acute Myocardial Infarction, Discharged Alive W Cc $ 19,368.61 282 Acute Myocardial Infarction, Discharged Alive W/O Cc/Mcc $ 11,898.12 283 Acute Myocardial Infarction, Expired W Mcc $ 13,004.57 284 Acute Myocardial Infarction, Expired W Cc $ 13,929.02 286 Circulatory Disorders Except Ami, W Card Cath W Mcc $ 27,227.77 287 Circulatory Disorders Except Ami, W Card Cath W/O Mcc $ 29,545.11 288 Acute & Subacute Endocarditis W Mcc $ 33,474.96 291 Heart Failure & Shock W Mcc Or Peripheral Extracorporeal Membrane Oxygenation (Ecmo) $ 20,716.82 292 Heart Failure & Shock W Cc $ 15,239.26 293 Heart Failure & Shock W/O Cc/Mcc $ 9,869.70 296 Cardiac Arrest, Unexplained W Mcc Or Peripheral Extracorporeal Membrane Oxygenation (Ecmo) $ 5,525.19 299 Peripheral Vascular Disorders W Mcc $ 23,522.46 300 Peripheral Vascular Disorders W Cc $ 12,160.31 301 Peripheral Vascular Disorders W/O Cc/Mcc $ 11,749.58 303 Atherosclerosis W/O Mcc $ 14,498.00 304 Hypertension W Mcc $ 20,223.08 305 Hypertension W/O Mcc $ 11,490.43 306 Cardiac Congenital & Valvular Disorders W Mcc $ 8,746.48 308 Cardiac Arrhythmia & Conduction Disorders W Mcc $ 22,530.65 309 Cardiac Arrhythmia & Conduction Disorders W Cc $ 13,672.62 310 Cardiac Arrhythmia & Conduction Disorders W/O Cc/Mcc $ 10,585.37 311 Angina Pectoris $ 11,719.06 312 Syncope & Collapse $ 16,691.18 313 Chest Pain $ 13,149.07 314 Other Circulatory System Diagnoses W Mcc $ 17,865.14 315 Other Circulatory System Diagnoses W Cc $ 11,110.41 316 Other Circulatory System Diagnoses W/O Cc/Mcc $ 8,644.72 326 Stomach, Esophageal & Duodenal Proc W Mcc $ 62,893.72 327 Stomach, Esophageal & Duodenal Proc W Cc $ 39,023.54 329 Major Small & Large Bowel Procedures W Mcc $ 85,211.96 330 Major Small & Large Bowel Procedures W Cc $ 61,706.66 331 Major Small & Large Bowel Procedures W/O Cc/Mcc $ 48,028.94 335 Peritoneal Adhesiolysis W Mcc $ 40,775.37 336 Peritoneal Adhesiolysis W Cc $ 36,152.83 339 Appendectomy W Complicated Principal Diag W Cc $ 29,548.42 340 Appendectomy W Complicated Principal Diag W/O Cc/Mcc $ 34,316.24 342 Appendectomy W/O Complicated Principal Diag W Cc $ 28,258.32 343 Appendectomy W/O Complicated Principal Diag W/O Cc/Mcc $ 30,280.23 344 Minor Small & Large Bowel Procedures W Mcc $ 38,318.24 346 Minor Small & Large Bowel Procedures W/O Cc/Mcc $ 18,005.41 349 Anal & Stomal Procedures W/O Cc/Mcc $ 18,721.28 352 Inguinal & Femoral Hernia Procedures W/O Cc/Mcc $ 26,544.75 353 Hernia Procedures Except Inguinal & Femoral W Mcc $ 82,453.51 354 Hernia Procedures Except Inguinal & Femoral W Cc $ 12,928.27 355 Hernia Procedures Except Inguinal & Femoral W/O Cc/Mcc $ 38,421.10 358 Other Digestive System O.R. Procedures W/O Cc/Mcc $ 34,474.12 371 Major Gastrointestinal Disorders & Peritoneal Infections W Mcc $ 31,505.42 372 Major Gastrointestinal Disorders & Peritoneal Infections W Cc $ 13,890.30 373 Major Gastrointestinal Disorders & Peritoneal Infections W/O Cc/Mcc $ 10,956.06 375 Digestive Malignancy W Cc $ 9,504.76 377 G.I. Hemorrhage W Mcc $ 22,822.47

02-19-2019-A-PAC-057 Page 93 of 97 Avita Health System - Average Standard Hospital Charges for Diagnosis-Related Groups (DRGs) as of 7/1/2019 The information provided below is a list of average hospital charges for diagnosis-related groups, in compliance with state and federal laws.

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Average Price as DRG Description of 07/01/2019 378 G.I. Hemorrhage W Cc $ 15,763.38 379 G.I. Hemorrhage W/O Cc/Mcc $ 11,990.87 380 Complicated Peptic Ulcer W Mcc $ 13,104.66 381 Complicated Peptic Ulcer W Cc $ 10,303.28 382 Complicated Peptic Ulcer W/O Cc/Mcc $ 10,576.87 385 Inflammatory Bowel Disease W Mcc $ 17,122.33 386 Inflammatory Bowel Disease W Cc $ 17,642.86 387 Inflammatory Bowel Disease W/O Cc/Mcc $ 8,201.08 388 G.I. Obstruction W Mcc $ 17,272.36 389 G.I. Obstruction W Cc $ 13,420.43 390 G.I. Obstruction W/O Cc/Mcc $ 10,339.51 391 Esophagitis, Gastroent & Misc Digest Disorders W Mcc $ 24,588.25 392 Esophagitis, Gastroent & Misc Digest Disorders W/O Mcc $ 11,714.81 393 Other Digestive System Diagnoses W Mcc $ 25,810.63 394 Other Digestive System Diagnoses W Cc $ 22,559.32 395 Other Digestive System Diagnoses W/O Cc/Mcc $ 19,229.49 414 Cholecystectomy Except By Laparoscope W/O C.D.E. W Mcc $ 99,257.92 415 Cholecystectomy Except By Laparoscope W/O C.D.E. W Cc $ 80,102.14 417 Laparoscopic Cholecystectomy W/O C.D.E. W Mcc $ 41,094.94 418 Laparoscopic Cholecystectomy W/O C.D.E. W Cc $ 38,497.84 419 Laparoscopic Cholecystectomy W/O C.D.E. W/O Cc/Mcc $ 29,030.80 432 Cirrhosis & Alcoholic Hepatitis W Mcc $ 15,215.88 436 Malignancy Of Hepatobiliary System Or Pancreas W Cc $ 12,956.94 438 Disorders Of Pancreas Except Malignancy W Mcc $ 16,417.66 439 Disorders Of Pancreas Except Malignancy W Cc $ 13,348.43 440 Disorders Of Pancreas Except Malignancy W/O Cc/Mcc $ 10,351.53 441 Disorders Of Liver Except Malig,Cirr,Alc Hepa W Mcc $ 16,358.02 442 Disorders Of Liver Except Malig,Cirr,Alc Hepa W Cc $ 19,644.76 443 Disorders Of Liver Except Malig,Cirr,Alc Hepa W/O Cc/Mcc $ 9,797.47 444 Disorders Of The Biliary Tract W Mcc $ 25,015.99 445 Disorders Of The Biliary Tract W Cc $ 29,827.56 446 Disorders Of The Biliary Tract W/O Cc/Mcc $ 8,568.86 453 Combined Anterior/Posterior Spinal Fusion W Mcc $ 252,240.56 454 Combined Anterior/Posterior Spinal Fusion W Cc $ 82,125.76 460 Spinal Fusion Except Cervical W/O Mcc $ 53,367.99 462 Bilateral Or Multiple Major Joint Procs Of Lower Extremity W/O Mcc $ 63,645.93 463 Wnd Debrid & Skn Grft Exc Hand, For Musculo-Conn Tiss Dis W Mcc $ 50,784.65 464 Wnd Debrid & Skn Grft Exc Hand, For Musculo-Conn Tiss Dis W Cc $ 58,669.13 465 Wnd Debrid & Skn Grft Exc Hand, For Musculo-Conn Tiss Dis W/O Cc/Mcc $ 46,595.49 467 Revision Of Hip Or Knee Replacement W Cc $ 89,249.47 468 Revision Of Hip Or Knee Replacement W/O Cc/Mcc $ 87,729.38 469 Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity W Mcc Or Total Ankle Replacement $ 46,997.58 470 Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity W/O Mcc $ 43,054.23 473 Cervical Spinal Fusion W/O Cc/Mcc $ 57,633.52 474 Amputation For Musculoskeletal Sys & Conn Tissue Dis W Mcc $ 25,756.75 475 Amputation For Musculoskeletal Sys & Conn Tissue Dis W Cc $ 84,195.68 477 Biopsies Of Musculoskeletal System & Connective Tissue W Mcc $ 31,812.69 480 Hip & Femur Procedures Except Major Joint W Mcc $ 42,852.20 481 Hip & Femur Procedures Except Major Joint W Cc $ 38,007.03 482 Hip & Femur Procedures Except Major Joint W/O Cc/Mcc $ 40,010.78 483 Major Joint/Limb Reattachment Procedure Of Upper Extremities $ 52,385.60 486 Knee Procedures W Pdx Of Infection W Cc $ 46,220.36 488 Knee Procedures W/O Pdx Of Infection W Cc/Mcc $ 26,107.37 489 Knee Procedures W/O Pdx Of Infection W/O Cc/Mcc $ 38,123.10 493 Lower Extrem & Humer Proc Except Hip,Foot,Femur W Cc $ 45,290.53 494 Lower Extrem & Humer Proc Except Hip,Foot,Femur W/O Cc/Mcc $ 46,803.42 496 Local Excision & Removal Int Fix Devices Exc Hip & Femur W Cc $ 38,070.51 498 Local Excision & Removal Int Fix Devices Of Hip & Femur W Cc/Mcc $ 44,449.56 499 Local Excision & Removal Int Fix Devices Of Hip & Femur W/O Cc/Mcc $ 33,622.89 501 Soft Tissue Procedures W Cc $ 27,852.65 502 Soft Tissue Procedures W/O Cc/Mcc $ 39,141.27 503 Foot Procedures W Mcc $ 32,528.61 504 Foot Procedures W Cc $ 26,927.33 505 Foot Procedures W/O Cc/Mcc $ 31,462.78 507 Major Shoulder Or Elbow Joint Procedures W Cc/Mcc $ 29,786.29 511 Shoulder,Elbow Or Forearm Proc,Exc Major Joint Proc W Cc $ 33,252.11 517 Other Musculoskelet Sys & Conn Tiss O.R. Proc W/O Cc/Mcc $ 32,987.36

02-19-2019-A-PAC-057 Page 94 of 97 Avita Health System - Average Standard Hospital Charges for Diagnosis-Related Groups (DRGs) as of 7/1/2019 The information provided below is a list of average hospital charges for diagnosis-related groups, in compliance with state and federal laws.

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Average Price as DRG Description of 07/01/2019 520 Back & Neck Proc Exc Spinal Fusion W/O Cc/Mcc $ 42,753.87 534 Fractures Of Femur W/O Mcc $ 24,080.63 535 Fractures Of Hip & Pelvis W Mcc $ 18,257.75 536 Fractures Of Hip & Pelvis W/O Mcc $ 13,232.65 539 Osteomyelitis W Mcc $ 8,958.45 540 Osteomyelitis W Cc $ 14,937.05 541 Osteomyelitis W/O Cc/Mcc $ 23,028.52 542 Pathological Fractures & Musculoskelet & Conn Tiss Malig W Mcc $ 18,757.51 543 Pathological Fractures & Musculoskelet & Conn Tiss Malig W Cc $ 24,067.00 544 Pathological Fractures & Musculoskelet & Conn Tiss Malig W/O Cc/Mcc $ 13,581.83 546 Connective Tissue Disorders W Cc $ 21,860.11 548 Septic Arthritis W Mcc $ 23,968.20 549 Septic Arthritis W Cc $ 5,098.65 551 Medical Back Problems W Mcc $ 38,925.65 552 Medical Back Problems W/O Mcc $ 9,007.67 554 Bone Diseases & Arthropathies W/O Mcc $ 11,156.78 555 Signs & Symptoms Of Musculoskeletal System & Conn Tissue W Mcc $ 24,353.20 556 Signs & Symptoms Of Musculoskeletal System & Conn Tissue W/O Mcc $ 20,331.26 558 Tendonitis, Myositis & Bursitis W/O Mcc $ 16,362.92 559 Aftercare, Musculoskeletal System & Connective Tissue W Mcc $ 46,466.18 560 Aftercare, Musculoskeletal System & Connective Tissue W Cc $ 11,255.49 561 Aftercare, Musculoskeletal System & Connective Tissue W/O Cc/Mcc $ 16,679.82 563 Fx, Sprn, Strn & Disl Except Femur, Hip, Pelvis & Thigh W/O Mcc $ 20,079.23 565 Other Musculoskeletal Sys & Connective Tissue Diagnoses W Cc $ 17,415.76 566 Other Musculoskeletal Sys & Connective Tissue Diagnoses W/O Cc/Mcc $ 7,116.93 570 Skin Debridement W Mcc $ 40,326.38 571 Skin Debridement W Cc $ 33,343.02 572 Skin Debridement W/O Cc/Mcc $ 25,461.03 579 Other Skin, Subcut Tiss & Breast Proc W Mcc $ 20,681.41 580 Other Skin, Subcut Tiss & Breast Proc W Cc $ 37,695.39 581 Other Skin, Subcut Tiss & Breast Proc W/O Cc/Mcc $ 19,273.40 585 Breast Biopsy, Local Excision & Other Breast Procedures W/O Cc/Mcc $ 19,263.42 600 Non-Malignant Breast Disorders W Cc/Mcc $ 9,524.77 601 Non-Malignant Breast Disorders W/O Cc/Mcc $ 3,705.75 602 Cellulitis W Mcc $ 25,751.13 603 Cellulitis W/O Mcc $ 13,294.37 605 Trauma To The Skin, Subcut Tiss & Breast W/O Mcc $ 8,632.09 607 Minor Skin Disorders W/O Mcc $ 38,009.27 616 Amputat Of Lower Limb For Endocrine,Nutrit,& Metabol Dis W Mcc $ 75,953.48 619 O.R. Procedures For Obesity W Mcc $ 75,447.34 620 O.R. Procedures For Obesity W Cc $ 56,108.48 621 O.R. Procedures For Obesity W/O Cc/Mcc $ 48,588.68 623 Skin Grafts & Wound Debrid For Endoc, Nutrit & Metab Dis W Cc $ 29,634.35 627 Thyroid, Parathyroid & Thyroglossal Procedures W/O Cc/Mcc $ 40,335.62 628 Other Endocrine, Nutrit & Metab O.R. Proc W Mcc $ 49,658.74 629 Other Endocrine, Nutrit & Metab O.R. Proc W Cc $ 50,021.17 637 Diabetes W Mcc $ 19,019.36 638 Diabetes W Cc $ 12,448.17 639 Diabetes W/O Cc/Mcc $ 10,417.87 640 Misc Disorders Of Nutrition,Metabolism,Fluids/Electrolytes W Mcc $ 22,614.70 641 Misc Disorders Of Nutrition,Metabolism,Fluids/Electrolytes W/O Mcc $ 14,574.89 642 Inborn And Other Disorders Of Metabolism $ 13,343.16 644 Endocrine Disorders W Cc $ 25,442.20 645 Endocrine Disorders W/O Cc/Mcc $ 12,813.75 664 Minor Bladder Procedures W/O Cc/Mcc $ 30,223.12 669 Transurethral Procedures W Cc $ 24,790.40 670 Transurethral Procedures W/O Cc/Mcc $ 21,051.16 673 Other Kidney & Urinary Tract Procedures W Mcc $ 29,433.00 682 Renal Failure W Mcc $ 26,506.17 683 Renal Failure W Cc $ 16,704.35 684 Renal Failure W/O Cc/Mcc $ 9,646.13 689 Kidney & Urinary Tract Infections W Mcc $ 21,443.01 690 Kidney & Urinary Tract Infections W/O Mcc $ 13,930.69 691 Urinary Stones W Esw Lithotripsy W Cc/Mcc $ 10,628.20 693 Urinary Stones W/O Esw Lithotripsy W Mcc $ 25,786.86 694 Urinary Stones W/O Esw Lithotripsy W/O Mcc $ 16,537.21 696 Kidney & Urinary Tract Signs & Symptoms W/O Mcc $ 15,263.98

02-19-2019-A-PAC-057 Page 95 of 97 Avita Health System - Average Standard Hospital Charges for Diagnosis-Related Groups (DRGs) as of 7/1/2019 The information provided below is a list of average hospital charges for diagnosis-related groups, in compliance with state and federal laws.

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Average Price as DRG Description of 07/01/2019 698 Other Kidney & Urinary Tract Diagnoses W Mcc $ 19,292.64 699 Other Kidney & Urinary Tract Diagnoses W Cc $ 15,657.56 700 Other Kidney & Urinary Tract Diagnoses W/O Cc/Mcc $ 23,954.52 726 Benign Prostatic Hypertrophy W/O Mcc $ 8,630.04 728 Inflammation Of The Male Reproductive System W/O Mcc $ 9,067.79 742 Uterine & Adnexa Proc For Non-Malignancy W Cc/Mcc $ 72,195.24 743 Uterine & Adnexa Proc For Non-Malignancy W/O Cc/Mcc $ 30,506.95 757 Infections, Female Reproductive System W Mcc $ 21,324.73 759 Infections, Female Reproductive System W/O Cc/Mcc $ 7,049.12 760 Menstrual & Other Female Reproductive System Disorders W Cc/Mcc $ 9,824.89 765 Cesarean Section W Cc/Mcc $ 20,770.76 766 Cesarean Section W/O Cc/Mcc $ 16,322.28 767 Vaginal Delivery W Sterilization &/Or D&C $ 11,536.15 768 Vaginal Delivery W O.R. Proc Except Steril &/Or D&C $ 5,945.39 770 Abortion W D&C, Aspiration Curettage Or Hysterotomy $ 5,316.72 774 Vaginal Delivery W Complicating Diagnoses $ 8,423.78 775 Vaginal Delivery W/O Complicating Diagnoses $ 6,911.17 776 Postpartum & Post Abortion Diagnoses W/O O.R. Procedure $ 7,917.72 777 Ectopic Pregnancy $ 34,766.97 781 Other Antepartum Diagnoses W Medical Complications $ 6,603.74 782 Other Antepartum Diagnoses W/O Medical Complications $ 1,298.72 784 Cesarean Section W Sterilization W Cc $ 16,068.62 785 Cesarean Section W Sterilization W/O Cc/Mcc $ 16,833.08 786 Cesarean Section W/O Sterilization W Mcc $ 19,775.81 787 Cesarean Section W/O Sterilization W Cc $ 17,956.84 788 Cesarean Section W/O Sterilization W/O Cc/Mcc $ 16,414.04 789 Neonates, Died Or Transferred To Another Acute Care Facility $ 2,704.94 791 Prematurity W Major Problems $ 5,497.54 792 Prematurity W/O Major Problems $ 2,901.52 793 Full Term Neonate W Major Problems $ 2,693.75 794 Neonate W Other Significant Problems $ 2,549.66 795 Normal Newborn $ 2,155.34 803 Other O.R. Proc Of The Blood & Blood Forming Organs W Cc $ 30,339.64 805 Vaginal Delivery W/O Sterilization/D&C W Mcc $ 11,069.43 806 Vaginal Delivery W/O Sterilization/D&C W Cc $ 7,702.73 807 Vaginal Delivery W/O Sterilization/D&C W/O Cc/Mcc $ 6,992.12 808 Major Hematol/Immun Diag Exc Sickle Cell Crisis & Coagul W Mcc $ 24,069.38 809 Major Hematol/Immun Diag Exc Sickle Cell Crisis & Coagul W Cc $ 19,414.36 810 Major Hematol/Immun Diag Exc Sickle Cell Crisis & Coagul W/O Cc/Mcc $ 16,862.88 811 Red Blood Cell Disorders W Mcc $ 22,576.92 812 Red Blood Cell Disorders W/O Mcc $ 13,407.24 813 Coagulation Disorders $ 5,380.64 814 Reticuloendothelial & Immunity Disorders W Mcc $ 13,032.24 815 Reticuloendothelial & Immunity Disorders W Cc $ 4,476.75 833 Other Antepartum Diagnoses W/O O.R. Procedure W/O Cc/Mcc $ 12,114.15 853 Infectious & Parasitic Diseases W O.R. Procedure W Mcc $ 79,992.86 854 Infectious & Parasitic Diseases W O.R. Procedure W Cc $ 58,218.78 856 Postoperative Or Post-Traumatic Infections W O.R. Proc W Mcc $ 51,101.20 857 Postoperative Or Post-Traumatic Infections W O.R. Proc W Cc $ 30,131.15 862 Postoperative & Post-Traumatic Infections W Mcc $ 26,768.56 863 Postoperative & Post-Traumatic Infections W/O Mcc $ 9,176.16 864 Fever And Inflammatory Conditions $ 12,341.01 870 Septicemia Or Severe Sepsis W Mv >96 Hours Or Peripheral Extracorporeal Membrane Oxygenation (Ecmo) $ 87,702.54 871 Septicemia Or Severe Sepsis W/O Mv >96 Hours W Mcc $ 29,477.98 872 Septicemia Or Severe Sepsis W/O Mv >96 Hours W/O Mcc $ 17,332.40 886 Behavioral & Developmental Disorders $ 182.00 896 Alcohol/Drug Abuse Or Dependence W/O Rehabilitation Therapy W Mcc $ 25,026.30 897 Alcohol/Drug Abuse Or Dependence W/O Rehabilitation Therapy W/O Mcc $ 8,013.36 902 Wound Debridements For Injuries W Cc $ 21,364.87 908 Other O.R. Procedures For Injuries W Cc $ 25,300.14 909 Other O.R. Procedures For Injuries W/O Cc/Mcc $ 18,505.68 913 Traumatic Injury W Mcc $ 25,467.08 914 Traumatic Injury W/O Mcc $ 6,336.04 915 Allergic Reactions W Mcc $ 37,754.71 917 Poisoning & Toxic Effects Of Drugs W Mcc $ 26,436.86 918 Poisoning & Toxic Effects Of Drugs W/O Mcc $ 10,292.86 920 Complications Of Treatment W Cc $ 17,445.69

02-19-2019-A-PAC-057 Page 96 of 97 Avita Health System - Average Standard Hospital Charges for Diagnosis-Related Groups (DRGs) as of 7/1/2019 The information provided below is a list of average hospital charges for diagnosis-related groups, in compliance with state and federal laws.

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Average Price as DRG Description of 07/01/2019 921 Complications Of Treatment W/O Cc/Mcc $ 14,604.18 922 Other Injury, Poisoning & Toxic Effect Diag W Mcc $ 21,578.31 940 O.R. Proc W Diagnoses Of Other Contact W Health Services W Cc $ 4,663.56 941 O.R. Proc W Diagnoses Of Other Contact W Health Services W/O Cc/Mcc $ 66,676.85 947 Signs & Symptoms W Mcc $ 16,879.81 948 Signs & Symptoms W/O Mcc $ 14,876.41 949 Aftercare W Cc/Mcc $ 46,503.40 951 Other Factors Influencing Health Status $ 103.00 981 Extensive O.R. Procedure Unrelated To Principal Diagnosis W Mcc $ 73,663.94 982 Extensive O.R. Procedure Unrelated To Principal Diagnosis W Cc $ 43,535.64 983 Extensive O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc $ 35,898.63 987 Non-Extensive O.R. Proc Unrelated To Principal Diagnosis W Mcc $ 38,059.35 988 Non-Extensive O.R. Proc Unrelated To Principal Diagnosis W Cc $ 35,913.86 989 Non-Extensive O.R. Proc Unrelated To Principal Diagnosis W/O Cc/Mcc $ 8,624.49

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