CPT Description Plain Language Description Average Charge HEP B IG IM RABIES IMMUNE GLOBULIN INTRAMUSCULAR OR

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1 OTHER THERAPEUTIC PROCEDURES AND DIAGNOSTIC TESTING EMERGENCY ROOM, IV THERAPY, CARDIAC CATHETERIZATION, EKG, EEG, VACCINATION, ARTERIAL AND VASCULAR STUDIES For the Time Period : 10/01/16 and 09/30/2017 IF YOU ARE COVERED BY HEALTH INSURANCE, YOU ARE STRONGLY ENCOURAGED TO CONSULT WITH YOUR HEALTH INSURER TO DETERMINE ACCURATE INFORMATION ABOUT YOUR FINACIAL RESPONSIBILITY FOR A PARTICULAR HEALTH CARE SERVICE PROVIDED AT THIS HEALTHCARE FACILITY. IF YOU ARE NOT COVERED BY HEALTH INSURANCE YOU ARE STRONGLY ENCOURAGED TO CONTACT THE BUSINESS OFFICE AT (719) OR TOLL FREE AT TO DISCUSS PAYMENT OPTIONS PRIOR TO RECEIVING A HEALTH CARE SERVICE FROM THIS HEALTH CARE FACILITY SINCE POSTED HEALTHCARE SERVICES MAY NOT REFLECT THE ACTUAL AMOUNT OF YOUR FINANCIAL Note: 1. The pricing on this page is for diagnostic and therapeutic procedures listed only. It is not combined pricing with other testing 2. Charging is based on the Length of Stay, amount of supplies used, therapies provided, testing given as well as other care provided 3. This pricing is an average charge and not intended to be the exact charge for any particular patient 4. The average charge shown is an estimate and that actual charges for the service depend on the cir 5. Any discount is negotiated by the insurance provider. Most insurance providers should be able to tell their members what financia responsibility they will have. 6. Patients without insurance are able to receive a discount equal to the insurance provider with the lowest negotiated discount CPT Description Plain Language Description Average Charge HEP B IG IM RABIES IMMUNE GLOBULIN INTRAMUSCULAR OR 2, SUBCUTANEOUS RABIES IG IM/SC RABIES IMMUNE GLOBULIN INTRAMUSCULAR OR 13, SUBCUTANEOUS IMMUNIZATION ADMIN IMUNIZATION ADMINISTRATION - INITIAL IMMUNIZATION ADMIN EACH ADD IMMUNIZATION ADMINISTRATION EACH ADD'L VACCINE RABIES VACCINE IM RABIES VACCINE INTRAMUSCULAR IIV4 VACC NO PRSV 0.25 ML IM INFLUENZA VACCINE, PRESERVATIVE FREE.25 ML IIV4 VACC NO PRSV 0.5 ML IM INFLUENZA VACCINE, PRESERVATIVE FREE.5 ML 26.33

2 90714 TD VACC NO PRESV 7 YRS+ IM TETUNUS, DIPTHERIA TOXIODS VACCINE OLDER THAN 7 YRS - PRESERVATIVE FREE TDAP VACCINE 7 YRS/> IM TETUNUS, DIPTHERIA TOXIODS VACCINE OLDER THAN 7 YRS PPSV23 VACC 2 YRS+ SUBQ/IM PNEUMOCOCAL POLYSACCHARIDE VACCINE 23 VALENT ADULT OT IMMUNOSUPRESSED, GREATER THAN 2 YRS HEPB VACCINE 3 DOSE ADULT IM HEPATITIS B VACCINE ADULT DOSAGE - 3 TIMES INTRAMUSCULAR PSYTX W PT 45 MINUTES PSYCOTHERAPY W/PATIENT - 30 MINS FAMILY PSYTX W/PT 50 MIN FAMILY PSYCOTHERAPY W/PATIENT PRESENT - 50 MINS DIALYSIS ONE EVALUATION DIALYSISPROCEDURE OTHER THAN HEMODIALYSIS- ONE 1, EVALUATION ESOPHAGUS MOTILITY STUDY ESOPOGEAL MOTILITY STUDY 3, GASTROESOPHAGEAL REFLUX TEST GASTROESOPHAGEAL, ESOPHAGAS REFLUS TEST 4, G-ESOPH REFLX TST W/ELECTROD GASTROESOPHAGEAL, ESOPHAGAS REFLUS TEST W/PH 4, ELECTRODE GI TRACT CAPSULE ENDOSCOPY GI TRACT CAPSULE ENDOSCOPY 4, GASTROENTEROLOGY PROCEDURE GENERAL GASTROENTEROLOGIC PROCEDURE NASOPHARYNGOSCOPY NASOPHARRYNGOSCOPY WITH ENDOSCPE HEART/LUNG RESUSCITATION CPR CARDIOPULONARY RESUSITATION - CPR 4, CARDIOVERSION ELECTRIC EXT CARDIOVERSION - USING ELECTRODES 5, ENDOLUMINL IVUS OCT C 1ST INTRAVASCULAR ULTRASOUND - ENDOLUMINAL - INITIAL 1, PROCEDURE ENDOLUMINL IVUS OCT C EA INTRAVASCULAR ULTRASOUND - ADD'L VESSEL 1, ELECTROCARDIOGRAM TRACING ELECTROCARDIOGRAM TRACING ONLY CARDIOVASCULAR STRESS TEST CARDIOVASCULAR STRESS TEST TRACING ONLY W/OUT 1, INTERPRETAION OR REPORT RHYTHM ECG TRACING RHYTHM ELECTROCADIOGRAM W/OUT INTERPRETATION OR REPORT ECG MONIT/REPRT UP TO 48 HRS ELECTROCARDIOGRAM UP TO 48 HRS RECORDING - CONNECTION AND DISCONNECTION

3 93270 REMOTE 30 DAY ECG REV/REPORT ELECTROCARDIOGRAM 30 DAY REMOTE RECORDING CONNECTION AND DISCONNECTION ECG/MONITORING AND ANALYSIS ELETROCARDIOGRAM - TRANSMISSION & ANALYSIS ECHO TRANSTHORACIC TRANSTHORACIC ECHOCARDIAGRAM - COMPLETE 3, TTE W/DOPPLER COMPLETE ECHOCARDIOGRAPHY, TRANSTHORACIC - COMPLETE 2, STUDY, WITH DOPPLAR TTE W/O DOPPLER COMPLETE ECHOCARDIOGRAPHY, TRANSTHORACIC - COMPLETE 2, STUDY, NO DOPPLAR TTE F-UP OR LMTD ECHOCARDIOGRAPHY, TRANSTHORACIC - FOLLOW UP OR 1, LIMITED STUDY ECHO TRANSESOPHAGEAL TRANSESOPHAGEAL ECHOCARDIAGRAPHY - TEE 3, DOPPLER ECHO EXAM HEART DOPPLAR ECHOCARDIOGRAPHY HEART 1, DOPPLER COLOR FLOW ADD-ON DOPPLAR ECHOCARDIOGRAPHY COLOR FLOW MAPPING - 1, ADD'L TO PRIMARY PROCEDURE STRESS TTE COMPLETE ECHOCARDIOGRAPHY, TRANSTHORACIC 2D W/CONTIUOUS 2, ELETROCARDIOGRAPIC MONITORING RIGHT HEART CATH RIGHT HEART CATHETERIZATION 9, LEFT HRT CATH W/VENTRCLGRPHY LEFT HEART CATHETERIZATION W/VENTRICULAROGRAPHY 14, RL HRT CATH W/VENTRICLGRPHY COMBINED RIGHT & LEFT HEART CATHETERIZATION - VENTRICULAROGRAPHY, BYPASS GRAFT ANGIOGRAPHY CORONARY ARTERY ANGIO SI CATHETER PLACEMENT IN CORONARY ARTERY FOR CORONARY ANGIOGRAPHY CORONARY ART/GRFT ANGIO SI CORONARY ANGIOGRAPHY W/CATH PLACEMENT(S) IN BYPASS GRAFTS FOR BY PASS GRAFT ANGIOGRAPHY L HRT ARTERY/VENTRICLE ANGIO LEFT HEART CATHETERIZATION - VENTRICULAROGRAPHY, BYBASS GRAFT ANGIOGRAPHY L HRT ART/GRFT ANGIO LEFT HEART CATHETERIZATION - VENTRICULAROGRAPHY, BYBASS GRAFT ANGIOGRAPHY 27, , , , ,612.40

4 93460 RL HRT ART/VENTRICLE ANGIO RIGHT/LEFT HEART CATHETERIZATION - VENTRICULAROGRAPHY, BYPASS GRAFT ANGIOGRAPHY RL HRT ART/VENTRICLE ANGIO RIGHT/LEFT HEART CATHETERIZATION - VENTRICULAROGRAPHY, BYPASS GRAFT ANGIOGRAPHY 28, , L HRT CATH TRNSPTL PUNCTURE LEFT HEART CATHETERIZATION BY TRANSSEPITAL 5, PUNCTURE INJECT SUPRVLV AORTOGRAPHY INJECTION OF SUPRAVALVULAR AORTOGRAPHY - ADD'L TO 1, PRIMARY PROCEDURE HEART FLOW RESERVE MEASURE INTRAVASCULAR DOPPAL VELOCITY &/OR PRESSURE 1, DERIVED CORONARY FLOW HEART FLOW RESERVE MEASURE EACH ADD'L VESSAL - ADD'L TO PRIMARY PROCEDURE 1, TRANSCATH CLOSURE OF ASD PERCUTANIOUS TRANSCATHTER CLOUSER OF CONGENITAL 24, DEFECT BUNDLE OF HIS RECORDING BUNDLE OF HIS RECORDING 7, INTRA-ATRIAL RECORDING INTRA-ATRIAL RECORDING 5, RIGHT VENTRICULAR RECORDING RIGHT VENTRICULAR RECORDING 5, MAP TACHYCARDIA ADD-ON MAP TACHYCARDIA ADD-ON 2, INTRA-ATRIAL PACING INTRA-ATRIAL PACING 5, INTRAVENTRICULAR PACING INTRAVENTRICULAR PACING 5, ELECTROPHYS MAP 3D ADD-ON INTRACARDIAC ELECTROPHYSIOLOGIC 3D MAPPING ADD'L 10, TO PRIMARY PROCEDURE ELECTROPHYSIOLOGY EVALUATION COMPERHANSIVE ELECTROPHYSIOLOGIC EVALUATION 20, W/INSERTION & REPOSITION OF MULTIPLE ELECTRODES - PRIMARY PROCEDURE ELECTROPHYSIOLOGY EVALUATION LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM - ADD'L TO PRIMARY PROCEDURE 2, ELECTROPHYSIOLOGY EVALUATION LEFT VENTRICULAR PACING ADD'L TO PRIMARY PROCEDURE STIMULATION PACING HEART PROGRAMED STIMULATION AND PACING AFTER IV DRUG INFUSION 2, ,685.36

5 93642 ELECTROPHYSIOLOGY EVALUATION ELECTROPHYSIOLOGIC EVAL OF SINGLE DUAL CHAMBER TRANSVENOUS PAGING CARDIOVERTER -DEFIBRULATOR ABLATE HEART DYSRHYTHM FOCUS INTRACARDIAC CATHER ABLATION OF ATRIOVENTRICULAR NODE FUNCTION EP ABLATE SUPRAVENT ARRHYT COMPERHANSIVE ELECTROPHYSIOLOGIC EVALUATION W/INSERTION & REPOSITION OF MULTIPLE ELECTRODES EP ABLATE VENTRIC TACHY INTRACARDIAC CATHETER ABLATION OF DISCRETE MECH OF ARRHYTHMIA - PRIMARY ABLATION ABLATE ARRHYTHMIA ADD ON INTRACARDIAC CATHETER ABLATION OF DISCRETE MECH OF ARRHYTHMIA - ADDED AFTER PRIMARY ABLATION TX ATRIAL FIB PULM VEIN ISOL COMPREHENSIVE ELETROPHYSIOLOGIC EVAL INCLUDING TRANSEPTAL CATHETERIAZATION, INSERT & REPOSITION ELECTRODES TX L/R ATRIAL FIB ADDL ADD'L LINEAR OR FOCAL INTRACARDIAC CATHETER ABLATION TILT TABLE EVALUATION EVAL OF CARDIAC FUNCTION WITH TILT TABLE EVAL, CONINUOUS ECG MONITORING INTRACARDIAC ECG (ICE) INTRACARDIAC ECHOCARDIOGRAPHY DURING THERAPEUTIC.DIAGNOSTIC INTERVENTION EXTRACRANIAL BILAT STUDY DUPLEX SCAN OF ESCTRACRANIAL ARTERIES, COMPLETE - BILATERAL UPR/L XTREMITY ART 2 LEVELS NONINVASIVE PHYSIOLOGIC STUDIES, UPPER OR LOWER EXTREMITIES ARTERIES - 1 TO 2 LEVELS UPR/LXTR ART STDY 3+ LVLS NONINVASIVE PHYSIOLOGIC STUDIES, UPPER OR LOWER EXTREMITIES ARTERIES - BILATERAL 3 OR MORE LEVELS LWR XTR VASC STDY BILAT NONINVASIVE PHYSIOLOGIC STUDIES, LOWER EXTREMITIES ARTERIES BILATERAL LOWER EXTREMITY STUDY DUPLEX SCAN OF LOWER EXTREMITY - BILATERAL OR COMPLETE STUDY 1, , , , , , , , , , , , ,790.82

6 93926 LOWER EXTREMITY STUDY DUPLEX SCAN OF LOWER EXTREMITY - UNILATERAL OR 1, LIMITED STUDY EXTREMITY STUDY DUPLEX SCAN OF EXTREMITY VEINS - COMPLETE BILATERAL 3, STUDY VASCULAR STUDY DUPLEX SCAN OF ARTERIAL & VENOUS INFLOW AND 2, OUTFLOW - COMPLETE STUDY VASCULAR STUDY DUPLEX SCAN OF ARTERIAL & VENOUS INFLOW AND OUTFLOW - LIMITED STUDY VASCULAR STUDY DUPLEX SCAN OF AORTA, INFERIOR VENA 2, CAVA COMPLETE STUDY DOPPLER FLOW TESTING DUPLEX SCAN OF HEMODIALYSIS ACCESS 1, VENT MGMT INPAT INIT DAY VENTILATOR MANAGEMENT - INITIATION - 1ST DAY 3, VENT MGMT INPAT SUBQ DAY VENTILATOR MANAGEMENT - EACH ADD'L DAY 3, BREATHING CAPACITY TEST SPIROMETRY, INCLUDING GRAPHIC RECORD & MEASUREMENTS EVALUATION OF WHEEZING BRONCHODILATION RESPONSIVENESS EVALUATION - 1, SPIROMETRY PRE & POST BRONCHODILATOR ADMIN EVALUATION OF WHEEZING BRONCHOSPASM PROVACATION EVALUATION, MULTI DETERMINATIONS AIRWAY INHALATION TREATMENT PRESURIZED OR NONPRESSURIZED INHALATION TREATMENT CBT 1ST HOUR CONTINUOUS INHALATION TREATMENT W/AEROSAL MEDICATION - 1ST HR CBT EACH ADDL HOUR CONTINUOUS INHALATION TREATMENT W/AEROSAL MEDICATION - EACH ADD'L HR POS AIRWAY PRESSURE CPAP CONTINUOUS POSATIVE AIRWAY PRESSURE (CPAP) 1, CHEST WALL MANIPULATION CHEST WALL MANIPULATION - INITIAL CHEST WALL MANIPULATION CHEST WALL MANIPULATION - SUBSEQUENT 1, MECHANICAL CHEST WALL OSCILL MECHANICAL CHEST WALL OSCILLATION TO FACILITATE 1, LUNG FUNCTION PULM FUNCT TST PLETHYSMOGRAP PLETHYSMOGRAPHY - PULMONARY FUNCTION TEST CO/MEMBANE DIFFUSE CAPACITY CARBON MONOXIDE DIFFUSING CAPACITY MEASURE BLOOD OXYGEN LEVEL MEASURE BLOOD OXYGEN LEVEL CONTINUOUS OVERNIGHT MONITORING

7 94799 PULMONARY SERVICE/PROCEDURE GENERAL PULMONARY SERVICE OR PROCEDURE GLUCOSE MONITORING CONT CONTINUOUS GLUCOSE MONITORING MULTIPLE SLEEP LATENCY TEST MULTIPLE SLEEP LATENCY TEST - MAINTENANCE OF 4, WAKEFULNESS SLEEP STUDY UNATTRESP EFFT SLEEP STUDY UNATTENDED, SIMMULTANIOUS RECORDING OF HEART, RESP, O2, RESP AIR FLOW SLEEP STUDY ATTENDED SLEEP STUDY ATTENDED 2, POLYSOM 6/> YRS 4/> PARAM POLYSOMNOGRAPHY, MORE THAN 6 YRS W/OUT CPAP 3, MORE THAN 4 PARAMETERS POLYSOM 6/>YRS CPAP 4/> PARM POLYSOMNOGRAPHY, MORE THAN 6 YRS W/CPAP MORE 4, THAN 4 PARAMETERS EEG MINUTES ELECTROENCEPHALOGRAM - MONITORED, MIN 2, EEG OVER 1 HOUR ELECTROENCEPHALOGRAM - MONITORED OVER 1 HR 4, EEG AWAKE AND DROWSY ELECTROENCEPHALOGRAM - AWAKE AND DROWSY 2, EEG AWAKE AND ASLEEP ELECTROENCEPHALOGRAM - AWAKE AND ASLEEP 2, RANGE OF MOTION MEASUREMENTS NEEDLE ELECTROMYOGRAPHY, HAND MUSCLE TEST ONE LIMB NEEDLE ELECTROMYOGRAPHY, ONE LIMB MUSC TST DONE W/NERV TST LIM NEEDLE ELECTROMYOGRAPHY, EACH EXTREMITY, LIMITED, RELATED PARASPINAL AREAS MUSC TEST DONE W/N TEST COMP NEEDLE ELECTROMYOGRAPHY, EACH EXTREMITY, COMPLETE 5 OR MORE MUSCLES NVR CNDJ TST 1-2 STUDIES NERVE CONDUCTION STUDIES 1-2 STUDIES NRV CNDJ TST 3-4 STUDIES NERVE CONDUCTION STUDIES 3-4 STUDIES VISUAL EVOKED POTENTIAL TEST VISUAL EVOKED POTENTIAL TEST 1, EEG MONITORING/VIDEORECORD VIDEO RECORDED EEG MONITORING RECORDING AND 7, INTERP - 24 HRS EEG MONITORING/COMPUTER COMPUTERIZED EEG MONITORING RECORDING AND 7, INTERP - 24 HRS CANALITH REPOSITIONING PROC CANALITH REPOSITIONING PROCEDURE HYDRATION IV INFUSION INIT IV INFUSION FOR HYDRATION- 30 MIN TO 1 HOUR HYDRATE IV INFUSION ADD-ON IV INFUSION FOR HYDRATION- ADD'L 1 HOUR THER/PROPH/DIAG IV INF INIT THERAPUETIC, DIAGNOSTIC IV INFUSION - 1 HOUR - INTIAL

8 96366 THER/PROPH/DIAG IV INF ADDON THERAPUETIC, DIAGNOSTIC IV INFUSION - ADD'L 1 HOUR TX/PROPH/DG ADDL SEQ IV INF THERAPUETIC, DIAGNOSTIC IV INFUSION CONNCURRENT TO OTHER INFUSION -ADD'L SEQUENCE THER/DIAG CONCURRENT INF THERAPUETIC, DIAGNOSTIC IV INFUSION CONNCURRENT TO OTHER INFUSION THER/PROPH/DIAG INJ SC/IM THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION - INITIAL - DRUG NOT INCLUDED THER/PROPH/DIAG INJ IV PUSH IV PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG - DRUG NOT INCLUDED TX/PRO/DX INJ NEW DRUG ADDON THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION - ADD'L ADMINISTRATION DRUG NOT INCLUDED - NEW DRUG TX/PRO/DX INJ SAME DRUG ADON THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION - ADD'L ADMINISTRATION DRUG NOT INCLUDED CHEMO IV INFUSION 1 HR CHEMOTHERAPY IV INFUSION - UP TO 1 HOUR 1, CHEMO IV INFUSION ADDL HR CHEMOTHERAPY IV INFUSION ADD'L TIME- UP TO 1 HOUR CHEMO IV INFUS EACH ADDL SEQ CHEMOTHERAPY IV INFUSION DIFFERENT SUBSTANCE ADD'L TIME UP TO 1 HOUR IRRIG DRUG DELIVERY DEVICE IRRIGATION OF IMPLANTABLE VENOUS ACCESS DEVICE FOR DRUG DELIVERY RMVL DEVITAL TIS 20 CM/< WOUND DEBRIDEMENT 1ST 20 CM OR LESS - INITIAL RMVL DEVITAL TIS ADDL 20CM/< WOUND DEBRIDEMENT 1ST 20 CM OR LESS - EACH ADD'L CM NEG PRESS WOUND TX </=50 CM NEGATIVE PRESSURE WOUND THERAPY - LESS THAN 50 CM NEG PRESS WOUND TX >50 CM NEGATIVE PRESSURE WOUND THERAPY - MORE THAN CM MEDICAL NUTRITION INDIV IN MEDICAL NUTRITION THERAPY - INITIAL MED NUTRITION INDIV SUBSEQ MEDICAL NUTRITION THERAPY - REASSESSMENT OSTEOPATH MANJ 1-2 REGIONS OSTOPATHIC MANIPULATION 1 TO 2 REGIONS 45.00

9 99143 MOD CS BY SAME PHYS, < 5 YRS MODERATE SEDATION PERFORMED BY THE SAME MD INITIAL 15 MINUTES LESS THAN 4 YEARS OLD MOD CS BY SAME PHYS, 5 YRS + MODERATE SEDATION PERFORMED BY THE SAME MD INITIAL 15 MINUTES OVER 4 YEARS OLD MOD SED SAME PHYS/QHP <5 YRS MODERATE SEDATION PERFORMED BY THE SAME MD INITIAL 15 MINUTES LESS THAN 4 YEARS OLD MOD SED SAME PHYS/QHP 5/>YRS MODERATE SEDATION PERFORMED BY THE SAME MD INITIAL 15 MINUTES OVER 4 YEARS OLD MOD SED SAME PHYS/QHP EA MODERATE SEDATION PERFORMED BY THE SAME MD EACH ADD'L 15 MINUTES PHLEBOTOMY THERAPEUTIC PHLEBOTOMY (BLOOD DRAW) EMERGENCY DEPT VISIT EMERGENCY DEPT VISIT - LEVEL EMERGENCY DEPT VISIT EMERGENCY DEPT VISIT - LEVEL EMERGENCY DEPT VISIT EMERGENCY DEPT VISIT - LEVEL 3 1, EMERGENCY DEPT VISIT EMERGENCY DEPT VISIT - LEVEL 4 2, EMERGENCY DEPT VISIT EMERGENCY DEPT VISIT - LEVEL 5 5, CRITICAL CARE FIRST HOUR TRUAMA CARE - 1ST HOUR 11, CRITICAL CARE ADDL 30 MIN TRUAMA CARE - EACH 30 MINUTES AFTER 1 HOUR 2,101.73

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