99202 Office visit new patient, problem expanded $ Smoking and tobacco use cessation counseling visit $37.30

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MILBRIDGE MEDICAL CENTER FAMILY PRACTICE 24 SCHOOL ST, MILBRIDGE ME 99202 Office visit new patient, problem expanded $140.90 99406 Smoking and tobacco use cessation counseling visit $37.

1 MILBRIDGE MEDICAL CENTER FAMILY PRACTICE 24 SCHOOL ST, MILBRIDGE ME Office visit new patient, problem expanded $ Smoking and tobacco use cessation counseling visit $ Preventive medicine established patient 65 and over $ Postoperative follow-up visit $0.00 J1100 Injection, dexamethasone sodium phosphate, 1 mg $ Office visit established patient, minimal $ Streptococcus, group A $ D Tdap, 7 years or older $ Preventive medicine established patient yrs old $ Immunization administration each additional vaccine $16.00 J3420 Injection, vitamin B-12 cyanocobalamin, up to 1,000 mcg $ Prothrombin time $ Handling and/or conveyance of specimen for transfer from the physician's office to a laboratory $ Preventive medicine established patient yrs old $ Immunization administration 1 vaccine $ Office visit established patient, focused $ Urinalysis, by dip $ Routine venipuncture $15.00

2 99213 Office visit established patient, expanded problem $ Office visit new patient, detailed examination $ Removal impacted cerumen $64.25 PAIN MANAGEMENT OFFICE PRACTICE 229 MAIN STREET, MACHIAS ME- REID EMERY MEDICAL BUILDING Injection(s), diagnostic or therapeutic agent, paravertebral facet joint $ Injection(s), diagnostic or therapeutic agent, paravertebral facet joint $ Injection(s), diagnostic or therapeutic agent, paravertebral facet joint $ Office visit new patient, comprehensive exam $ Injection(s), of diagnostic or therapeutic substance(s) $ Office visit established patient, expanded problem $99.85 ENT/OTOLARYNGOLOGY OFFICE PRACTICE 229 MAIN STREET- MACHIAS ME- REID EMERY MEDICAL BUILDING Postoperative follow-up visit $ Tympanostomy, general anesthesia $ Microscopic ear exam $ Tympanometry $ Removal impacted cerumen $ Pure tone audiometry (threshold); air only $ 34.20

3 31231 Nasal endoscopy, diagnostic $ Office visit established patient, focused $ Laryngoscopy, flexible fiberoptic; diagnostic $ Office visit established patient, expanded problem $ Office visit new patient, detailed examination $ PEDIATRIC OFFICE PRACTICE 11 HOSPITAL DRIVE, MACHIAS, ME Immunization administration by intranasal or oral route $ Inhalation treatment with an aerosol generator, nebulizer, inhaler $ Office visit established patient, minimal $ Destruction of benign lesions up to 14 lesions $ Urinalysis, by dip $ Routine venipuncture $ Removal impacted cerumen $ Respiratory flow volume loop $ Preventive medicine established patient yrs old $ Streptococcus, group A $ Blood count; hemoglobin (Hgb) $ Collection of capillary blood specimen $11.00 D1206 Dental Flouride Varnish $ Handling and/or conveyance of specimen for transfer from the Physician s office to a laboratory $20.55

4 99393 Preventive medicine established patient 4-11 yrs old $ Immunization administration by intranasal or oral route; 1 vaccine $ Preventive medicine established patient 1-4 yrs old $ Preventive medicine established patient infant $ Office visit established patient, focused $ Immunization administration 1 vaccine $ Pulse oximetry for oxygen saturation; single determination $ Immunization administration each additional vaccine $ Office visit established patient, expanded problem $ Subsequent hospital care, per day, for evaluation and $ management of normal newborn Initial hospital or birthing center care, per day, for evaluation $ and management of normal newborn infant Hospital discharge day management; 30 minutes or less $ Physician standby service, requiring prolonged physician $68.35 attendance, each 30 minutes GENERAL SURGERY OFFICE PRACTICE 229 MAIN STREET, MACHIAS ME- REID EMERY MEDICAL BUILDING Office visit new patient, comprehensive exam $ Office visit established patient, expanded problem $ EGD with Biopsy, single or multiple $

5 45380 Colonoscopy with biopsy, single or multiple $ Colonoscopy with removal of tumor, polyp or lesion by hot biopsy forceps or bipolar cautery $ Colonoscopy with removal of tumor, polyp or lesion by snare $ Laparoscopic Cholecystectomy $ Office visit new patient, detailed exam $ Initial hospital care, moderate complexity $ Subsequent hospital care, moderate complexity $ Office visit consultation, detailed exam $ Office visit consultation, comprehensive exam $ Handling and/or conveyance of specimen for transfer from the $20.55 Physician s office to a laboratory OBSTETRICS / GYNECOLOGY OFFICE PRACTICE WOMEN S HEALTH CENTER 11 HOSPITAL DRIVE, MACHIAS, ME Office visit new patient, comprehensive exam $ D Tdap, 7 years or older $ J1885 Ketorolac Tromethamine, TORADOL, PER 15 MG $ Office visit new patient, detailed examination $ Administration of subcutaneous injection $ Ultrasound, pregnant uterus limited $ Preventive medicine established patient yrs old $ Handling and/or conveyance of specimen for transfer from the

6 physician's office to a laboratory $ Preventive medicine established patient yrs old $ Urine pregnancy test, by visual color comparison methods $ Fetal non-stress test $ Urinalysis, by dip $ Office visit established patient, expanded problem $ Laparoscopy, surgical, with total hysterectomy, uterus <250 g $ Routine obstetric care including antepartum care, vaginal delivery $ and postpartum care Routine obstetric care including antepartum care, cesarean delivery $ and postpartum care J7300 IUD MIRENA $ FAMILY PRACTICE REID EMERY MEDICAL BUILDING 229 MAIN STREET, MACHIAS ME- REID EMERY MEDICAL BUILDING OMT; 1-2 body regions $ Preventive medicine established patient yrs old $ Destruction of benign lesions up to 14 lesions $ Removal impacted cerumen $ Office visit new patient, detailed examination $ J1885 Ketorolac Tromethamine, TORADOL, PER 15 MG $ OMT; 3-4 body regions $95.75

7 99406 Smoking and tobacco use cessation counseling visit $ Arthrocentesis major joint or bursa (eg, shoulder, hip, knee joint,) $ D Tdap, 7 years or older $ Office visit est patient, minimal $ Preventive medicine established patient yrs old $ Urinalysis, by dip $ Immunization administration 1 vaccine $ Administration of subcutaneous injection $ Glucose; blood $12.15 J3301 Injection, triamcinolone acetonide, 10 mg $ Handling and/or conveyance of specimen for transfer from the physician's office to a laboratory $ Routine venipuncture $ Prothrombin time $ Lipid panel $ Office visit established patient, focused $ Collection of capillary blood specimen $11.00 J3420 Injection, vitamin B-12 cyanocobalamin, up to 1,000 mcg $ Office visit established patient, expanded problem $ Influenza virus vaccine $ Pneumococcal conjugate vaccine, 13 valent, Prevnar $ Immunization administration each additional vaccine $ Destruction premalignant lesions; second through 14 lesions each $44.70

8 99204 Office visit new patient, comprehensive exam $ UROLOGY OFFICE PRACTICE 229 MAIN STREET, MACHIAS ME- REID EMERY MEDICAL BUILDING Office visit new patient, detailed exam $ Cystourethroscopy $ Office visit established patient, focused $ Office visit established patient, expanded problem $ Handling and/or conveyance of specimen for transfer $ from the physician's office to a laboratory Office visit new patient, comprehensive exam $ Bladder irrigation and/or instillation $ Revised INPATIENT COST FOR DECH TOP ADMISSIONS- prices effective HOSPITAL DRIVE, MACHIAS, ME 775 Vaginal Delivery $ 8, Normal Newborn $ 1, Neonate w significant problems $ 2, Simple pneumonia and pleurisy with CC $ 15, Simple pneumonia and pleurisy without CC $ 13,652.12

9 765 Cesarean section $ 17, Gastroenteritis and misc. digestive disorder $ 13, COPD without CC $ 11, Major Joint Replacement $ 44, COPD with MCC $ 18, Kidney and UTI $ 9, Heart Failure and Shock with CC/MCC $ 13, Cellulitis without MCC $ 12, COPD with MCC $ 19, Heart failure and shock with CC $ 16, Cesarean section with CC/MCC $ 18, Alcohol/Drug abuse or dependence w/o rehab $ 12, Pulmonary edema and resp failure $ 13, Simple pneumonia and pleurisy with MCC $ 19, Vaginal delivery w/ complicating diagnosis $ 10, Acute MI without CC/MCC $ Cardiac arrhythmia $ 14, GI obstruction with CC $ 15, GI obstruction without CC MCC $ 12, Heart Failure and Shock with MCC $ 12, *Bed rate for 2016 is $1, **Swing bed rate is $ *Nursery rate is $

10 OUTPATIENT SURGICAL PROCEDURES 11 HOSPITAL DRIVE, MACHIAS, ME Colonoscopy with polypectomy $ Surgeon $ EGD with biopsy $ Surgeon $ Cystoscopy $ Surgeon $ Myringotomy $ Surgeon $ Laparoscopic cholecystectomy $15, Surgeon $ Hemorrhoid ligation $ Surgeon $ D&C $ Surgeon $ Carpal Tunnel Release $ Surgeon $ Prostate Needle Biopsy $ Surgeon $ Endometrial ablation $ Surgeon $ Septoplasty $ Surgeon $ Tonsillectomy and adenoidectomy $ Surgeon $ Laparoscopic incisional hernia repair $ Surgeon $ Adenoidectomy $ Surgeon $456.00

11 Supracervical hysterectomy $ Surgeon $ Vasectomy $ Surgeon $ Circumcision, non-infant $ Surgeon $ Laparoscopic umbilical hernia repair $ Surgeon $ Prices above include anesthesia, which is charged at the rate of $20.00 per minute for a CRNA and $20.35 for an anesthesiologist. EMERGENCY ROOM FEES 11 HOSPITAL DRIVE, MACHIAS, ME Emergency Room Fee Brief: $ Emergency Room Fee Comprehensive: $ Emergency Room Fee Critical Care: $ Emergency Room Fee Extended: $ Emergency Room Fee Intermediate: $ Emergency Room Fee Limited: $ Apply Cast (Most) $ Control Nosebleed $ Excise Lesion (Based on cm and body part) $ to $ Treatment of Most Fractures $ Injection IV $ Injection Subcutaneous or Intra muscular $ Repair of Laceration (Most) $

12 Remove Foreign Body Cornea $ Ankle Strapping $ I & D Cyst $ I & D Hematoma $ Small Burn Treatment $ Remove Foreign Body Eye $ Ear Syringing $ EMERGENCY PHYSICIAN FEES 11 HOSPITAL DRIVE, MACHIAS, ME Physician Fee Brief $ Physician Fee Comprehensive $ Physician Fee Extended $ Physician Fee Intermediate $ Physician Fee Limited $ Critical Care First Hour $ Apply Cast $ to $ Control Nosebleed $ to $ Excise Lesion $ to $ Treatment of Fracture $ to $ Repair of Laceration $ to $ Remove Foreign Body Cornea $ Ankle Strapping $ I & D Cyst $

13 I & D Hematoma $ Small Burn Treatment $ Remove Foreign Body Eye $ Ear Syringing $ Please Note: The cost of emergency room services may vary significantly from the amount noted above for a variety of reasons, some of which are noted below: These estimates do not consider radiologist, other laboratory or pathology charges. Actual services provided may be different from the estimated amount because of change of diagnosis. Diagnostic tests and supplies used during a visit to the emergency department are separate charges. Changes may arise in the patient s condition necessitating more or less care and/or supplies. Physician procedures can influence the length of time and supplies used for a procedure.

LABORATORY PROCEDURES IMAGING/RADIOLOGY PROCEDURES THERAPY GVH EMERGENCY DEPARTMENT PROCECURES

LABORATORY PROCEDURES IMAGING/RADIOLOGY PROCEDURES THERAPY GVH EMERGENCY DEPARTMENT PROCECURES PROCEDURE CHARGES / HOSPITAL may vary depending on circumstances. Prices subject to change. LABORATORY PROCEDURES Basic Metabolic Panel $112.00 80048 Comprehensive Metabolic Panel $140.00 80053 UA Micro