InterMed, Portland, ME InterMed Billing Office (207) Page 1 of 8

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1 *These are InterMed s for the procedures listed. Your cost may be different depending on your I&D ABSCESS SIMPLE (CARBUNCLE, CUTANEIUS, SUBCUTANEOUS,CYS $ BIOPSY, SKIN, PUNCH OR SHAVE $ BIOPSY SKIN EA. ADDL. LESION $ SKIN TAG EXCISION,UP TO 15 LESIONS $ SHAV.EPIDERM.LES.TRUNK,SRM,LEG <.5CM $ EXC. BEN. LES CM TRUNK,ARM,LEG $ EXC. MALIGNANT LESION 1.1 TO 2.0 CM $ TRIMMING OF NONDYSTROPHIC NAILS,ANY NO. $ INJECTION; INTRALESIONAL;UP TO/INCLU 7 $ INSERT DRUG IMPLANT DEVICE $ LACERATION REPAIR (SCALP,TRUNK,ARMS,LEGS) LAYERED; CM $ PREMALIGNANT LESION DESTRUCTION ANY METHOD (E.G. AK) $ DESTRUCTION/LESION,2-14 $ DESTRUCTION/LESION:15 OR MORE LESIONS $ WART OR BENIGN LESION DESTRUCTION BY ANY METHOD $ DEST MALIG LESION ANY METH TRUNK/.6-1CM $ DEST MALIG LESION ANY METH TRUNK/1.1-2CM $ INJECTION,SINGLE TENDON ORIGIN,INSERTION $ ASPIRATION AND/OR INJ. INTERMED.JOINT $ DRAIN/INJ MEDIUM JOINT/BURSA W/US $ ASPIRATION AND OR INJ MAJOR JOINT/BURSA $ DRAIN/INJ LARGE JOINT/BURSA W/US $ APPL. SHORT ARM CAST ELBOW TO FINGER $ REMOVAL OF TURBINATE BONES $ REPAIR OF NASAL SEPTUM $ CONTROL NASAL HEMORR. ANT. SIMP. $ NASAL ENDOSCOPY, DX $ NASAL/SINUS ENDOSCOPY, SURG $ DIAGNOSTIC LARYNGOSCOPY $ VENIPUNCTURE/ROUTINE $ ANOSCOPY $ BLADDER IRRIGATION, SIMPLE $ CYSTOSCOPY CHEMODENERVATION $ STRAIGHT CATHETERIZATION FOR RESIDUAL UR $ CIRCUMCISION $ COLPOSCOPY WITH BX CX AND ENDOCX CURR $ COLPOSCOPY CERVIX,WITH ENDOCER CURRETTAG $ CONIZATION OF CERVIX,LOOP ELEC EXCISION $ ENDOMETRIAL BIOPSY $ INSERTION IUD $ REMOVAL IUD $ IUI $ SPERM WASHING FOR ARTIFICIAL INSEMINATIO $ HYSTEROSCOPY,SURG;W/BIOPSY A/O POLYPECTO $ TLH W/T/O 250 G OR LESS $ FETAL NON STRESS TEST $111 InterMed, Portland, ME InterMed Billing Office (207) Page 1 of 8

2 *These are InterMed s for the procedures listed. Your cost may be different depending on your ANTE/POST PARTUM CARE W/NORM VAG DELIV. $ ROUTINE OB CARE.CSECTION,POSTPARTUM CARE $ REMOVAL IMPACTED CERUMEN, UNILATERAL, W/ INSTRUMENT $ TYMPANOSTOMY VENTILATING TUBE, GENERAL ANESTH $ TC CT,HEAD OR BRAIN;W/O CONTRAST $ TC CT,MAXILLOFACIALAREA,W/O CONTRAST $ TC CT,SOFT TISSUE NECK,WITH CONTRAST $ TC MRA;HEAD,W/OUT CONTRAST $ TC MRI;BRAIN(INCLUDING STEM),W/OUT CONTRAST $ TC MRI BRAIN;W/O THEN W/CONTRAST $ CHEST SINGLE VIEW $ TC CHEST PA&LAT $ TC RIB UNILAT INCL. PA CHEST $ TC CT,THORAX,W/O CONTRAST $ TC CT,THORAX,WITH CONTRAST $ TC CT,ANGIOGRAPHY,CHEST WITH AND W/O CONTRA $ TC C-SPINE MINIMUM OF 4 VIEWS $ TC RAD EXAM, THORACIC,3 VIEWS $ TC AP&LAT LS SPINE $ TC AP&LAT LS SPINE W/ OBLIQUES $ TC LS SPINE,WITH FLEX EXTENSION $ TC MRI;SPINAL CANAL&CONTENTS,CERVICAL,W/OUT $ TC MRI;SPINAL CANAL&CONTENTS,LUMBAR,W/O $ TC MRI;SPINAL CANAL&CONTENTS,LUMBAR,W & W/O $ TC SACRUM AND COCCYX $ TC COLLARBONE XRAY (CLAVICLE) $ TC COMPLETE SHOULDER MINIMUM 2 VIEWS $ TC ELBOW PA & LAT $ TC COMPLETE ELBOW MINIMUM 3 VIEWS $ TC FOREARM INCL. 1 JOINT $ TC COMPLETE WRIST MINIMUM 3 VIEWS $ TC HAND 3 OR MORE VIEWS $ TC FINGERS $ TC MRI;ANY JOINT UPPER EXTREMITY (SHLD)W/O $ TC HIP UNILAT MIN. 2 VIEWS W/AP PELVIS $ TC HIPS BILAT 2 VIEWS W/ AP PELVIS $ TC RAD EXAM KNEE;THREE VIEWS $ TC RAD EXAM KNEE;COMPLT 4/MORE VIEWS $ TC TIBIA FIBULA W/ 1 JOINT $ TC COMPLETE ANKLE MINIMUM OF 3 VIEWS $ TC COMPLETE FOOT MINIMUM 3 VIEWS $ TC TOES $ TC MRI;LOWER EXTREMITY OTH THN JOINT,W/O $ TC MRI;ANY JNT LOWER EXTREMITY W/O $ TC ABDOMEN SINGLE VIEW $ TC MULTIPLE VIEWS ABDOMEN $77 InterMed, Portland, ME InterMed Billing Office (207) Page 2 of 8

3 *These are InterMed s for the procedures listed. Your cost may be different depending on your TC CT,ABDOMEN,WITH CONTRAST $ TC CT ABDOM & PELVIS W/O CONTRAST $ TC CT ABDOM & PELVIS WITH CONTRAST $ TC CT ABDOM & PELVIS WITH AND W/O CONTRAST $ TC MRI;ABDOMEN,W&W/O CONTRAST $ FLUOROSCOPE EXAMINATION $ D RENDERING W/INT,REPORT,REQ IMAGE POST $ TC THYROID,PARATHYROID,PARIOTID GLANDS $ TC ULTRASOUND BREAST LIMITED BILATERAL $ TC ABDOMINAL,COMPLETE,I.E.LIVER,BILIARY SYS $ TC ABDOMEN,LIMITED FOLLOW-UP $ TC RETROPERITONEUM,I.E. KIDNEYS,URETERS,BLA $ TC RETROPERITONEUM,LIMITED FOLLOW-UP $ TC US,PREGNANT UTERUS,1ST TRIMESTER $ PREGNANCY,COMP 1ST,2ND AND 3RD TRIMESTER $ ULTRASOUND/DETAILED FETAL ANATOMIC EXAM $ PREGNANCY,LIMITED, I.E. FET HEARTBEAT $ PREGNANCY,FOLLOW-UP $ US,PREGNANT UTERUS,REAL TIME,TRANSVAGINA $ TC US,PREGNANT UTERUS,REAL TIME,TRANSVAGINA $ FETAL BIOPHYSICAL PROFILE;W/O NON STRESS,(PHYSICIAN) $ DOPPLER VELOCIMETRY FETAL;UMB ART $ DOPPLER VELOCIMETRY FETAL;MCA $ TRANSVAGINAL, ONLY $ TC TRANSVAGINAL ULTRASOUND $ TC PELVIS,NONOBSTETRICAL,COMP INCLUDES TRAN $ TC PELVIS, TRANSABDOMINAL ONLY $ TC SCROTUM AND CONTENTS $ TC EXTREMITY,NONVASCULAR REAL TIME,COMPLETE $ EXTREMITY,NONVASCULAR,LIMITED,ANATOMIC SPECIFIC $ ULTRASOUND GUIDANCE NEEDLE PLACEMENT IMAGING SUPERVIS $ TC CAD MAMMOGRAM $ TC COMP SCREEN MAMMOGRAM ADD-ON $ BONE DENSITY STUDY;AXIAL SKELETON $ TC HEPATOBILIARY SYSTEM IMAGING WITH PHARMACOLOGIC QUANTIT MEAS $ HT MUSCLE IMAGE SPECT, MULT $ BASIC METABOLIC PANEL (2000) $ GENERAL HEALTH PANEL $ COMPREHENSIVE METABOLIC PANEL (2000) $ LIPID PROFILE T.CHOL/TRIG/HDL/LDL RATIO $ RENAL FUNCTION PANEL $ HEPATIC PANEL $ URINALYSIS AUTOMATED WITH MICRO $ U/A W/O MICROSCOPY $ URINALYSIS MICROSCOPIC ONLY $ ALBUMIN, SERUM $8 InterMed, Portland, ME InterMed Billing Office (207) Page 3 of 8

4 *These are InterMed s for the procedures listed. Your cost may be different depending on your URINE,MICROALBUMIN,QUANTITATIVE $ SERUM AMYLASE $ BILIRUBIN, TOTAL $ BILIRUBIN;DIRECT $ ASSAY TEST FOR BLOOD, FECAL $ OH VITAMIN D3 $ SERUM CALCIUM $ SERUM CHOLESTEROL $ CPK $ CREATININE $ HR. URINE FOR CREAT CLEARANCE $ B12 LAB $ ESTRADIOL LEVEL $ FERRITIN $ BLOOD GLUCOSE $ BS POST GLUCOSE DOSE $ HR GTT $ FSH $ LUTEINIZING HORMONE LEVEL $ H PYLORI DRUG ADMIN/COLLECT $ GLYCOSOLATED HGB $ SERUM IRON $ TOTAL IRON BINDING CAPACITY $ LEVEL,BLOOD LEAD $ LIPASE $ HDL $ DIRECT MEASUREMENT;LDL CHOLESTEROL $ MAGNESIUM LEVEL $ NATRIURETIC PEPTIDE $ LEVEL, PARATHYROID HORME $ ALKALINE PHOSPHATASE $ SERUM PHOSPHOROUS $ POTASSIUM $ PROLACTIN LEVEL $ PROSTATIC SPECIFIC ANTIGEN $ TESTOSTERONE LEVEL $ FT4 $ TSH $ SGOT $ SGPT $ SERUM TRIGLYCERIDES $ TROPONIN,QUANTITATIVE $ BUN $ URIC ACID $ GONADOTROPIN;CHORIONIC,QUANTITATIVE $ GONADOTROPIN;CHORIONIC,QUALITATIVE $19 InterMed, Portland, ME InterMed Billing Office (207) Page 4 of 8

5 *These are InterMed s for the procedures listed. Your cost may be different depending on your HEMATOCRIT/AUTOMATED $ HEMOGLOBIN $ CBC/AUTOMATED DIFF $ PLATELET,AUTOMATED $ D-DIMER,QUANTITATIVE $ PROTHROMBIN TIME $ ESR $ C REACTIVE PROTEIN $ HIGH SENSITIVITY C-REACTIVE PROTEIN $ MONOSPOT $ TB TEST, CELL IMMUN MEASURE $ PPD $ VDRL/ART $ LYME TITRE $ HIV 1&2 ANTIGEN $ HEP B SURFACE ANTIBODY $ MUMPS TITRE $ RUBELLA TITRE $ RUBEOLA TITRE $ TREPONEMA PALLIDUM $ VARICELLA/ZOSTER TITRE $ CULTURE,PRESUMPTIVE,PATHOGENIC,SCREEN $ CULTURE BACT. URINE QUAL., COL CT. $ WET MOUNT $ KOH (TISSUE EXAM FOR FUNGI) $ HEPATITIS B SURFACE ANTIGEN $ CHLAMYDIA TRACHOMATIS,AMPLIFIED PROBE $ NEISSERIA GONORRHOEAE,AMPLIFIED PROBE $ TRICHOMONAS VAGINALIS AMPLIF $ INFLUENZA ANTIGEN $ HIV ANTIGEN W/HIV ANTIBODIES $ STREP A SCREENING $ AGENT NOS ASSAY W/OPTIC $ PRIVATE IMMUNIZATION ADMINISTRATION ; FIRST INJECTION $ PRIVATE IMMUNIZATION ADMINISTRATION/ EACH ADDITIONAL ADMINIS $ PRIVATE NASAL IMMUNIZATION ADMINISTRATION $ PRIVATE ORAL IMMUNIZATION ADMINISTRATION $ VACCINE Hepatitis A vaccine, adult dosage $ VACCINE Hepatitis A vaccine, pediatric/adolescent dosage-2 dose schedule $ VACCINE Hepatitis A vaccine, pediatric/adolescent dosage-3 dose schedule $ VACCINE Haemophilus influenzae type b vaccine (Hib), $ VACCINE Hemophilus influenza B vaccine $ VACCINE Gardasil, HPV, quadrivalent $ VACCINE Gardasil 9, HPV $ VACCINE Influenza virus vaccine, for 3 years of age and older $ VACCINE Influenza virus vaccine, split virus, preservative free $60 InterMed, Portland, ME InterMed Billing Office (207) Page 5 of 8

6 *These are InterMed s for the procedures listed. Your cost may be different depending on your VACCINE Pneumococcal, (PCV) $ VACCINE Influenza, live intranasal,quadrivalent $ VACCINE Influenza, inj. Quad PF $ VACCINE Fluzone High-Dose $ VACCINE Typhoid vaccine, live, oral $ VACCINE Typhoid vaccine, Vi capsular polysaccharide (ViCPs) $ KINRIX DTAP-IPV VACC 4-6 YR IM $ PENTACEL: DTAP-HIB-IP PRIVATE - IM $ VACCINE DTaP $ VACCINE MMR $ MMRV PROQUAD PRIVATE $ VACCINE IPV $ VACCINE Td $ VACCINE Tdap $ VACCINE Varicella $ VACCINE Yellow fever $ PEDIARIX DTAP-HEP B-IPV PRIVATE IM $ VACCINE PPV23 $ VACCINE Meningococcal conjugate vaccine $ VACCINE Zoster (shingles) $ VACCINE Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule) $ VACCINE Hepatitis B vaccine, adult dosage $ AUDIOMETRY-SCREEN $ AUDIOMETRY $ SPEECH THRESHOLD AUDIOMETRY $ SPEECH AUDIOMETRY, COMPLETE $ COMPREHENSIVE HEARING TEST $ TYMPANOMETRY $ VISUAL AUDIOMETRY (VRA) $ EKG W/ INTERPRETATION $ Cardiovascular stress test $ HOLTER MONITOR 24 HR INTERMED MIDMARK $ HOLTER MONITOR 48 HR PLACEMENT ONLY PHILLIPS $ HOLTER MONITOR PHILLIPS REVIEW & INTERPRETATION ONLY $ EVENT MONITOR PHILLIPS GLOBAL $ ECHOCARDIOGRAPHY, TRANSTHORACIC, WITH DOPPLER(S), COMPLETE $ TC ECHOCARDIOGRAPHY, TRANSTHORACIC, W/DOPPLERS, COMPLETE $ STRESS TEST WITH ECHO AND EKG MONITORING, PHYSICIAN SUPERVIS $ TC CAROTID DUPLEX,COMPLETE BILATERAL STUDY $ TC DUPLEX EXTREMITY VEINS,COMP VENOUS STUDY $ TC DUPLEX EXTREMITY VEINS, LIMITED VENOUS $ TC DUPLEX SCAN ART INFLOW/VEN OUTF LIMITED $ SPIROMETRY W/O BRONCHODILATORS $ SPIROMETRY W/ BRONCHODILATORS $ NEBULIZER INHALATION THERAPY $ OXYGEN SATURATION NONINVASIVE,SINGLE $8 InterMed, Portland, ME InterMed Billing Office (207) Page 6 of 8

7 *These are InterMed s for the procedures listed. Your cost may be different depending on your GLUCOSE MONITORING, CONT $ GLUC MONITOR, CONT, PHYS I&R $ CANALITH REPOSITIONING PROC $ DEVELOPMENTAL TEST, LIM $ INTRAVENOUS INFUSION $ THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION; SUBCU OR $ PHOTODYNAMIC TX, SKIN $ PHOTOCHEMOTHERAPY;TAR & UV B,OR PETROLAT $ PHOTCHEMOTHERAPY;PSORALENS AND (PUVA) $ PT EVALUATION $ PT RE-EVALUATION $ HOT OR COLD PACKS $ MECHANICAL TRACTION $ ELECTRIC STIMULATION UNATTENDED $ ELECTRICAL STIMULATION $ IONTOPHORESIS, EACH 15 MIN $ ULTRASOUND THERAPY $ PHONOPHORESIS UP TO 15 MIN $ THERAPEUTIC EXERCISE $ NEUROMUSCULAR THERAPY $ MANUAL THERAPY (TRACTION,MANIPULATION) $ THERAPEUTIC ACTIVITIES $ OSTEOPATHIC MANIP TREAT 3-4 BODY REGIONS $ OSTEOPATHIC MANIP TREAT 5-6 BODY REGIONS $ OSTEOPATHIC MANIP TREAT 7-8 BODY REGIONS $ SPECIAL REPORTS $ APP TOPICAL FLUORIDE VARNISH $ NEW PT LEVEL 1 $ NEW PT LEVEL 2 $ NEW PT LEVEL 3 $ NEW PT LEVEL 4 $ NEW PT LEVEL 5 $ OFFICE VISIT/LEVEL 1 $ OFFICE VISIT/LEVEL 2 $ OFFICE VISIT/LEVEL 3 $ OFFICE VISIT/LEVEL 4 $ OFFICE VISIT/LEVEL 5 $ OBSERVATION CARE DISCHARGE $ INIT. HOSP LEVEL 1 $ INIT. HOSP. LEVEL 2 $ INIT. HOSP LEVEL 3 $ SUBS. HOSP LEVEL 1 $ SUBS. HOSP LEVEL 2 $ SUBS. HOSP LEVEL 3 $ OBSERVATION/ADM & DIS SAME DAY/LEVEL 1 $ HOSP.DISCH 30 MIN OR LESS $166 InterMed, Portland, ME InterMed Billing Office (207) Page 7 of 8

8 *These are InterMed s for the procedures listed. Your cost may be different depending on your HOSP DISCHARGE MORE THAN 30 MINUTES $ OP CONSULT LVL 1 EST $ OP CONSULT LEVEL 2 EST $ OP CONSULT LEVEL 3 EST $ OP CONSULT LEVEL 4 NEW $ OP CONSULT LEVEL 5 NEW $ IP CONSULT LEVEL 3 $ IP CONSULT LEVEL 4 $ IP CONSULT LEVEL 5 $ PREV. CARE BIRTH TO 12 MONTHS NEW PT. $ PREV. CARE 1-4 YEARS NEW PATIENT $ PREV. CARE NEW PT YEARS $ PREV/CARE UNDER 18 $ PREVENTIVE NEW PT.(18-39) $ PREVENTIVE NEW PT. (40-64) $ PREVENTIVE NEW PT.COMP.(65+) $ PREV. CARE EST. PT 0-12 MONTHS $ PREV. CARE EST. PT. 1-4 YRS. $ PREV CARE,EST 5-11 $ PREVENTIVE EST.PT. (12-17) $ PREVENTIVE EST.PT.(18-39 YRS) $ PREVENTIVE EST.PT.(40-64) $ PREVENTIVE EST.PT.(65+) $ PREV. MED. COUNSELLING 15 MINS. $ TRAVEL CLINIC CONSULTATION; 30 MINUTES $ SMOKING CESSATION 3-10 MIN COUNSELING $ NEWBORN HOSPITAL ADMISSION FOR NORMAL NEWBORN $ NEWBORN, NORMAL, SUBSEQUENT HOSPITAL CARE $ TRANSITIONAL CARE MGMT MODERATE COMPLEXITY $ TRANSITIONAL CARE MGMT HIGH COMPLEXITY $522 InterMed, Portland, ME InterMed Billing Office (207) Page 8 of 8