SURGERY CENTER SUMMARY OF SERVICES AND AVERAGE PRICING

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1 SURGERY CENTER SUMMARY OF SERVICES AND AVERAGE PRICING Prices Include the Following: Facility, Surgeon, Anesthesia, immediate pre- and post-op care & surgical supplies. Implants, when applicable, are excluded, but will be added on to the final price at a maximum of 5% mark-up over actual invoice cost (invoice must be submitted for reimbursement). This facility requires a referral and may not provide all of the listed services. Please contact Medical Care Analyst at (888) for assistance with a referral to this facility. The listed services are for information purposes only and do not guarantee benefits are available. Please refer to the Plan Document or call to verify if a service is covered by your plan. ARTHROSCOPY Procedure Code Average Price SLAP Lesion Repair $ 6,000 Shoulder w/debridement (limited) $ 6,000 Debridement (extensive) $ 7,100 Distal Claviculectomy (Mumford) $ 6,000 Tibial Plateau Fracture Repair (Scope) $ 5,600 Knee $ 3,840 Knee with Lateral Release $ 4,460 Knee with Microfracture $ 4,460 Knee Foreign Body Removal $ 3,590 Knee Synovectomy, Major $ 3,590 Knee Debridement Chondroplasty $ 3,590 Knee with Meniscectomy 29880/29881 $ 3,590 Knee with Meniscal Repair $ 3,590 Shoulder 29806/29827 $ 6,000 Elbow $ 3,740 Wrist $ 4,150 Hip $ 5,300 Ankle $ 3,590 OPEN PROCEDURES KNEE Anterior Cruciate Ligament Repair $ 6,820 Posterior Cruciate Ligament Repair, Arthro-Aided $ 6,600 Collateral & Cruciate Ligament Repair $ 6,400 Medial Collateral Ligament $ 6,100 Osteochondral Autografts $ 6,000 Arthroplasty (uni) $ 20,000

2 Tibial Tubercle Osteotomy $ 6,165 Manipulation $ 1,900 SHOULDER Open Rotator Cuff Repair $ 6,160 Open Rotator Cuff Repair - Chronic $ 5,590 Repair/Reconstruction with Labral $ 6,000 Bankhart Stabilization $ 5,860 Distal Clavicle Excision 23120/23170 $ 4,600 Manipulation $ 1,900 Osteology Hardware Removal-Deep $ 2,700 HIP Total Hip Arthroplasty (Phy) $ 2,788 ELBOW Ulnar Nerve Transposition/Epicondylectomy 64718/24358 $ 4,460 Tenodesis $ 5,590 Humerus/Elbow with Tendon $ 4,590 WRIST/HAND Carpal Tunnel Release $ 2,620 Dupuytrens Contracture $ 2,810 Arthroplasty $ 4,480 Trigger Finger $ 2,630 Ganglion Excision $ 2,630 Fasciectomy $ 5,900 Excision of Lesion-Finger or Hand $ 2,630 ANKLE Achilles Repair $ 5,590 Secondary Repair (Watson-Jones or Brostrom) $ 4,690 FOOT Bunionectomy $ 4,050 Hammertoe (1) $ 2,350 Hammertoe (2) $ 2,910 Hammertoe (3) $ 3,355

3 Gastrocnemius Recession $ 4,050 Arthrodesis, great toe $ 4,000 Plantar Fasciotomy $ 3,030 Neuroma Excision $ 2,640 FRACTURES Closed Reduction and Casting-Radius $ 1,925 Open Treatment, fracture/separation 25608/25609 $ 6,250 Percutaneous Pinning - finger 1-2 pins $ 2,745 Ankle Fracture or Dislocation $ 6,000 Open Treatment of Metatarsal Fracture $ 6,000 Open Treatment of Phalangeal Shaft Fracture $ 3,700 OPEN REDUCTION INTERNAL FIXATION Closed Proximal Humeral Fracture $ 4,300 Open Treatment of Proximal Humeral Fracture $ 6,075 HARDWARE REMOVAL Simple $ 2,530 Complex $ 4,310 GENERAL SURGERY HERNIA - INCLUDES MESH Inguinal $ 3,200 Bilateral $ 4,150 Umbilical $ 3,100 Incisional $ 4,300 Cholecystectomy 47563/47562 $ 5,715 BREAST Mass - Excision/Biopsy $ 2,500 Mastectomy with or without Node Dissection $ 5,050 1st stage: Reconstruction w/expanders, single $ 5,080 1st stage: Reconstruction w/explanders, bilateral $ 7,000 2nd stage: w/implant placement, single $ 4,000 2nd stage: w/implant placement bilateral $ 5,250 MISCELLANEOUS Hermorrhoidectomy $ 3,250

4 Vein Stripping - Single $ 3,420 Vein Stripping - right and left $ 4,745 Central Venous Catheter $ 3,090 Neuroplasty - Ulnar Nerve Elbow $ 2,640 SPINE Microdiscectomy $ 8,650 Lumbar Laminectomy $ 9,200 Anterior Cervical Disc Fusion, One Level $ 15,100 Anterior Cervical Disc Fusion, Two Levels (add-on) $ 20,000 PAIN Lumbar Epidural Steroid $ 1,250 Cervical Epidural $ 1,400 Lumbar Sympathetic $ 1,600 Stellate Ganglion Block $ 1,100 Reblock for Acute Post-Op Pain $ 1,200 Epidural Blood Patch $ 1,100 Large Join Injection/Aspiration $ 350 Trigger Point Injection (1-2 Muscles) $ 150 Injection/Steroid, Lumbar, Epidural, Sacral (Single Level) $ 1,100 Injection/Steroid, Lumbar, Epidural, Sacral (Add. Level) $ 550 EYE Nasolacrimal Duct Probe, Single $ 1,820 Nasolacrimal Duct Probe, Right and Left $ 2,320 Strabismus, 1 or 2 Muscles $ 3,500 Strabismus, More than 2 Muscles $ 4,600 Chalazion $ 1,820 NECK Thyroidectomy 60210/60220/60225 $ 6,000 Lymph Node Excision/Biopsy $ 2,200 EAR Myringoplasty $ 2,450 Bilateral Myringotomy with Tubes $ 1,550

5 Tympanoplasty $ 4,910 Tympanoplasty - Mastoidectomy $ 6,650 Mastoidectomy $ 6,300 Inner Ear - Stapedectomy $ 5,240 Ossiculoplasty $ 4,900 Cochlear Implant $ 8,190 Foreign Body Removal-Peritoneal $ 1,550 NOSE Bilateral SMR Turbinate $ 3,080 Septoplasty $ 3,850 Septoplasty and Sinus/Turbinates 30520/30140 $ 5,360 Nasal Fracture Simple Closed $ 2,250 Nasal Fracture Complex Open $ 4,300 THROAT Tonsillectomy 42825/42826 $ 3,150 Adenoidectomy $ 2,450 Tonsillectomy and Adenoidectomy $ 3,495 Adenoidectomy and BMT 42830/69436 $ 3,100 Tonsillectomy and Adenoidectomy and BMT 42820/69436 $ 4,200 Frenulectomy $ 1,600 Uvulopalatopharyngoplasty (UPP) $ 5,195 Diagnostic Laryngoscopy with Biopsy $ 2,870 ORAL SURGERY Madibular Osteotomy $ 11,000 UROLOGY Mini-Arc Mid-Urethral Suspension $ 4,280 Anterior Repair $ 6,185 Posterior Repair $ 5,800 Hydrocelectomy (Unilateral) $ 3,450 Epididymectomy - Partial $ 3,450 Epididymectomy - Total $ 3,950 Testicular Biopsy $ 1,850 Vasovasostomy $ 4,950

6 Penile Prosthesis $ 14,125 Ultrasound and Biopsy of Prostate 55700/76942 $ 1,850 Lithotripsy of Kidney Stone $ 5,700 Scope Bladder/Ureter-Simple Removal Stone/Stent $ 1,100 Scope Bladder/Ureter-Break Up Kidney Stone $ 2,500 CYSTOSCOPY Cystoscopy $ 1,250 With Bilateral Retrograde Pyelogram $ 2,150 Stone Extraction/Stint $ 3,450 Transurethral Resection of Prostate (TURP) $ 3,450 GYNECOLOGY Hysterectomy (Includes Overnight Stay) $ 7,500 Tubal Reversal (Includes Overnight Stay) $ 8,500 GASTROINTESTINAL EGD 43235/43239 $ 2,100 EGD with Balloon $ 2,300 Screening Colonoscopy 45378/45379/45380 $ 2,400 Colonoscopies with Biopsies, Snares, etc thru $ 2,700 EGD (when combined with a Colonoscopy: add-on) 43235/43239/43248 $ 1,100

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