Initial Hospital Care/Day. Subsequent Hospital Care/Day

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1 Inpatient Charges Daily Room Rates CM CM Intensive Care $4,305 Maternity $1,137 Cardiovascular Care $3,338 Newborn Care $669 Medical/Surgical $1,297 NICU $2,938 Hospital Care Hospital New Patient Consult Level 1 $90.50 Level 2 $ Level 3 $ Level 4 $ Level 5 $ Initial Hospital Care/Day 30 Minutes $ Minutes $ Minutes $ Subsequent Hospital Care/Day 20 Minutes $ Minutes $ Minutes $ Emergency Department Charges Level Facility Charge ED Level 1 $ ED Level 2 $ ED Level 3 $ ED Level 4 $667.25

2 ED Level 5 $1, Critical Care - 1st Hour $1, Critical Care - each additional 1/2 hour $ Central Maine Medical Center Top 10 MS-DRGS MS DRG Description Average Charges 871 SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC $28, MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC $31, VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES $9, NORMAL NEWBORN $2, HEART FAILURE SHOCK W MCC $21, CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC $17, NEONATE W OTHER SIGNIFICANT PROBLEMS $4, PERC CARDIOVASC PROC W DRUG- ELUTING STENT W/O MCC $68, ESOPHAGITIS GASTROENT MISC DIGEST DISORDERS W/O MCC $14, O.R. PROCEDURES FOR OBESITY W/O CC/MCC $41,560.00

3 Central Maine Medical Center Provider Based Practice Charges New Patients Established Patients Office Visits Facility Level 1 $59.25 $56.25 Level 2 $ $77.00 Level 3 $ $77.00 Level 4 $ $98.75 Level 5 $ $ Office Visits Facility Level 1 $33.25 $56.25 Level 2 $58.25 $77.00 Level 3 $72.75 $77.00 Level 4 $ $98.75 Level 5 $ $ Physicals Age 0-1 $ Age 1-4 $ Age 5-11 $ Age $ Age $ Age $ Age 64+ $ Physicals Age 0-1 $ Age 1-4 $ Age 5-11 $ Age $ Age $ Age $ Age 64+ $ Consults Outpatient Hospital Consult Level 1 $ Level 2 $ Level 3 $ Level 4 $ Level 5 $ Office Consult 30 Minutes $ Minutes $ Minutes $ Minutes $ Minutes $376.50

4 Initial Inpatient Consult 20 Minutes $ Minutes $ Minutes $ Minutes $ Minutes $ Central Maine Medical Center

5 Radiology Charges Central Maine Medical Center CPT DESCRIPTION CM CPT DESCRIPTION CM XR Skull 1-3 Views $ CT Angio Lower Ext RT w+wo Contrast $1, XR Skull Complete 4 Views $ XR UGI Series wo KUB $ CT Head wo Contrast $1, CT CCTA w+wo Dye Quan Calcium $ CT Head w+wo Contrast $1, US Breasts Limited $ CT Orbit wo Contrast $1, US AAA Screening $ CT Axial or Coronal Face wo Contrast $ US Retroperitoneal Complete $ XR Ribs Right w PA Chest $ US Left Ext Comp $ XR Cervical Spine $ US Right Ext Comp $ XR Lumbar Spine AP + Lateral $ US Left Ext Ltd $ CT Pelvis wo Contrast $1, US Right Ext Ltd $ CT Pelvis w Contrast $1, CT Bone Length Study $ CT Pelvis w+wo Contrast $1, NM Tumor Imaging SPECT $1, CT Angio Low Ext Bilat w+wo Contrast $2, NM Tumor Imaging WB Multi $1, CT Angio Lower Ext LT w+wo Contrast $1, Cardiovascular Stress Test Tracing $ contractual reimbursement rates, deductible, copay, and coinsurance. the physician, the condition of the patient, unexpected complications, or additional procedures required. These charges are to be considered estimates only and are not a guarantee of final costs. These are hospital charges only except where indicated. Other fees and charges are not

6 Central Maine Medical Center Lab Charges CPT DESCRIPTION CM CPT DESCRIPTION CM $ Basic Metabolic $ Hepatitis B surface Antibody $ Coronary Risk Panel $ Mumps IgG Ab $ Carbamazepine Level $ Rubella IgG Ab $ Urine Test $ Rubeola IgG Ab $ Urnls Dip Stick $ Varicella IgG Ab $ Pregnancy Test $ Chlamydia $ Hemoccult $ HIV $ Occult Blood FIT, Stool $ Gonorrhea $ Mixed Blood Gas $ HPV High Risk Screen by TMA $ Glucose Test $ Strep Test $ Follicle Stimulating Hormone $ Anti Mullerian Hormone $ GM1 Antibody Panel $ Progesterone Level $ Testosterone Level $ Blood Urea Nitrogen $35.50 contractual reimbursement rates, deductible, copay, and coinsurance. the physician, the condition of the patient, unexpected complications, or additional procedures required. These charges are to be considered estimates only and are not a guarantee of final costs. These are hospital charges only except where indicated. Other fees and charges are not

7 Central Maine Medical Center CDM ADMINISTRATION FEE IMMUN ADMIN VACCINE IMMN ADMN EA AD NON IMMU ADMIN ORAL IMADM INTRANSL/ORAL EA VACCINE contractual reimbursement rates, deductible, copay, and coinsurance. the physician, the condition of the patient, unexpected complications, or additional procedures required. These charges are to be considered estimates only and are not a guarantee of final costs. These are hospital charges only except where indicated. Other fees and charges are not