St Mary s Hospital Patient Pricing Information

St Mary s Hospital Patient Pricing Information The below charges represent Hospital charges only. These charges do not include charges for services provided by physicians or advanced practitioners (ex. anesthesiologists, attending physicians, emergency room physicians, hospitalists, pathologist, radiologists, surgeons, etc.). Emergency Department Charges The following represents the hospital charges for each level of emergency care provided to patients. The charges below do not include the fees for drugs, supplies or additional procedures that may be rendered during the emergency department visit. CPT Code Charge Level 1 99281 $ 256.00 Level 2 99282 $ 390.00 Level 3 99283 $ 614.00 Level 4 99284 $ 978.00 Level 5 99285 $ 1,462.00 Critical Care Visit 99291 $ 2,275.00 Operating Room Charges The following represents the hospital charges for each increment of surgery room and labor time that is provided at our hospital. The following list does not include charges for anesthesia, drugs, supplies or implants/devices for services rendered. ½ Hour $2,685.00 3 ¼ Hour $4,413.00 6 Hour $6,046.00 ¾ Hour $2,685.00 3 ½ Hour $4,580.00 6 ¼ Hour $6,046.00 1 Hour $2,685.00 3 ¾ Hour $4,754.00 6 ½ Hour $6,046.00 1 ¼ Hour $2,861.00 4 Hour $4,926.00 6 ¾ Hour $6,393.00 1 ½ Hour $3,201.00 4 ¼ Hour $5,014.00 7 Hour $6,393.00 1 ¾ Hour $3,378.00 4 ½ Hour $5,014.00 7 ¼ Hour $6,393.00 2 Hour $3,546.00 4 ¾ Hour $5,361.00 7 ½ Hour $6,393.00 2 ¼ Hour $3,723.00 5 Hour $5,361.00 7 ¾ Hour $6,393.00 2 ½ Hour $3,892.00 5 ¼ Hour $5,703.00 8 Hour $6,393.00 2 ¾ Hour $4,065.00 5 ½ Hour $5,703.00 8 ¼ Hour $6,393.00 3 Hour $4,238.00 5 ¾ Hour $6,046.00 8 ½ Hour $6,393.00 8 ¾ Hour + $7,773.00 Lithotripsy $15,527.00 Endoscopic Lithotrip Hom Laser $16,500.00

Recovery Room Charges The following represents the hospital charges for each increment of recovery room time that is provided at our hospital. Patients may have additional charges, Charge Rec Extensive 00-60 Minutes $ 963.00 Rec Extensive 61-75 Minutes $ 994.00 Rec Extensive 76-90 Minutes $ 1,201.00 Rec Extensive 91-105 Minutes $ 1,356.00 Rec Extensive 106-120 Minutes $ 1,755.00 Rec Extensive 121-135 Minutes $ 1,981.00 Rec Extensive 136-150 Minutes $ 2,200.00 Physical Therapy Charges The following charges reflect the hospital s 10 most common services offered by our Physical Therapy department. Patients may have additional charges, Aquatic Therapy Grp Per Visit 97150 $ 83.00 Electrical Stim Unattended 97014 $ 141.00 PT Evaluation Various $ 289.00 Gait/Stairs Train 15 Min 97116 $ 114.00 Lymph Drainage Ea 15 Min 97140 $ 114.00 Manual Therapy Ea 15 Min 97140 $ 114.00 Neuromuscular Re Ed Ea 15 Min 97112 $ 166.00 Traction-Mechanical 97012 $ 170.00 Ther Exercise 15 Min 97110 $ 114.00 Ultrasound/Phono Ea 15 Min 97035 $ 162.00 Occupational Therapy Charges The following charges reflect the hospital s 10 most common services offered by our Occupational Therapy department. Patients may have additional charges,

Fluidotherapy/Whirlpool 97022 $ 229.00 Manual Therapy Ea 15 Min 97140 $ 114.00 Massage Ea 15 Min 97124 $ 120.00 Nueromuscular Re Educ 15Min 97112 $ 166.00 OT Elec Stim UA 97014 $ 141.00 OT Evaluation Various $ 266.00 Paraffin Treatment 97018 $ 141.00 Ther Exercise 15 Min 97110 $ 114.00 Therapy Activity Ea 15 Min 97530 $ 114.00 Ultrasound 15 Min 97035 $ 162.00 Speech Therapy Charges The following charges reflect the services offered by our Speech Therapy department. Patients may have additional charges, Cognitive Therapy Ea 15 Min 97532 $ 223.00 Evaluate Speech Sound Production 92522 $ 244.00 Evaluation of Speech Fluency 92521 $ 300.00 Speech Eval Sound W/Lang Comp 92523 $ 504.00 Speech Swallowing Evaluation 92610 $ 447.00 Speech Therapy 92507 $ 243.00 Speech Videoflouroscopy 92611 $ 530.00 Swallowing Therapy 92526 $ 239.00 X-Ray and Radiological Charges The following charges reflect the hospital s 30 most common x-ray and radiological procedures. There may be additional supply and contract media charges depending on the procedure. Abd & Pelvis With Contrast 74177 $ 3,056.00 Abd & Pelvis Wo Contrast 74176 $ 2,910.00 Abdomen KUB/Flat Plate 74000 $ 394.00 Carotid Doppler Bilateral 93880 $ 1,405.00

Chest (1 View) 71010 $ 266.00 Chest (PA & LAT) 71020 $ 411.00 Complete Obstetric Exam 76805 $ 1,011.00 CT Angiography Chest 71275 $ 3,461.00 CT Chest W/O Contra 71250 $ 2,183.00 Dexa Axial Skeleton (Spine) 77080 $ 782.00 Foot 3+ Views Rt 73630 $ 428.00 Hand Rt 73130 $ 401.00 Head/Brain W/O Contrast 70450 $ 1,748.00 Kidney Bil (Renal) 76775 $ 659.00 Knee 3 Views Rt 73562 $ 466.00 Mammogram 2-d LT G0206 $ 831.00 Mammogram Screening G0202 $ 871.00 Pelvis 76856 $ 948.00 Pelvis Transvaginal 76830 $ 948.00 Preg Diag 1st Trimester 76801 $ 774.00 Renal (Kidneys) And Bladder 76770 $ 761.00 Shoulder Rt 73030 $ 464.00 Spine Cervical 72050 $ 664.00 Spine Lumbosacral 72110 $ 734.00 Tomosynthesis Breast Dx Bil 77062 $ 279.00 Tomosynthesis Breast Scr Bil 77063 $ 279.00 Transvaginal Early Pregnancy 76817 $ 1,011.00 Upper Abdomen 76705 $ 659.00 US Doppler Venous Lower/Lt 93971 $ 1,298.00 US Doppler Venous Lower/Rt 93971 $ 1,298.00 Laboratory Charges The following charges reflect the hospital s 30 most common laboratory tests. Amylase 82150 $ 136.00 APTT Act.Partial Thrombo.Time 85730 $ 47.00 B-Type Natriuretic Peptid 83880 $ 374.00 CBC W Complete Diff Automated 85025 $ 60.00

CBC Without Diff Automated 85027 $ 52.00 Comprehen Metabolic Panel 80053 $ 195.00 Creatine Kinase (CPK) 82550 $ 136.00 Culture Blood 87040 $ 185.00 Culture Quant Urine 87086 $ 62.00 Ferritin 82728 $ 275.00 Folic Acid 82746 $ 293.00 Glycohemoglobin (HgbA1c) 83036 $ 78.00 Gram Stain 87205 $ 91.00 Gross/Micro Level IV 88305 $ 424.00 Iron 83540 $ 52.00 Lactic Acid 83605 $ 177.00 Lipase 83690 $ 123.00 Lipid Panel 80061 $ 97.00 Magnesium 83735 $ 141.00 Manual Differential 85007 $ 78.00 Metabolic Panel Basic 80048 $ 144.00 Phosphorus 84100 $ 103.00 Pregnancy Test, Urine 81025 $ 134.00 Prothrombin Time (PT) w/ INR 85610 $ 33.00 T4 Free 84439 $ 185.00 Troponin 84484 $ 177.00 TSH 84443 $ 125.00 Urinalysis w/out Microscopic 81003 $ 53.00 Urinalysis with Microscopic 81001 $ 63.00 Vitamin B12 82607 $ 302.00 Cardiology Charges The following represents the hospital charges for the procedures for the Cardiology department. Patients may have additional charges, Card Event Recording 93270 $ 395.00

Comprehensive Eval W/O ECG 93797 $ 342.00 Cr Visit W/ECG 93798 $ 394.00 Echo Stress 93350 $ 1,216.00 Echo-2D/M-Mode 93306 $ 3,666.00 EKG - Regular 93005 $ 320.00 Holt Mon Data Analysis -SAM/SM 93226 $ 2,047.00 Holter Monitor-Hook-Up/Record 93225 $ 2,047.00 Stress Test 93017 $ 1,150.00 Transesophageal Tee 93312 $ 2,608.00 TTE-Reg W/ IV Contrast C8929 $ 3,038.00 Endoscopy Charges The following represents the hospital charges for the procedures for the Endoscopy department. Patients may have additional charges, Capsule Imaging Exam Sm Intest 91110 $ 4,505.00 Colon Diagnostic Various $ 2,275.00 Colon Flex With Hot Biopsy Various $ 2,719.00 Colonoscopy Flex W/Biopsy Various $ 2,538.00 Colonoscopy Flex W/Cont Bleed Various $ 3,327.00 Colonoscopy Flex W/Rem Polyp Various $ 3,408.00 Colonoscopy W/Ablation Various $ 3,398.00 Dilation Of Esophagus Various $ 1,306.00 EGD Diag W/Ablation Of Tumor Various $ 2,861.00 EGD Diag W/Ballon Dilat Esoph Various $ 1,918.00 EGD Diag W/Biopsy (Sing/Mult) Various $ 1,784.00 EGD Diag W/Control Of Bleeding Various $ 2,877.00 EGD Diag W/End Retro Rem Stone Various $ 4,601.00 EGD Diag W/Insert Guide Wire Various $ 2,083.00 EGD Diag W/Place Perc Gastro Various $ 2,864.00 EGD Diag W/Rem Tumor-Hot Biop Various $ 2,266.00 EGD Diag W/Rem Tumor-Snare Tec Various $ 2,408.00 EGD Diagnostic Various $ 1,588.00

EGD W/Inject Sclerosis Of Esop Various $ 2,923.00 ERCP Diag W/Endo Retro Insert Various $ 4,980.00 ERCP Diag W/Or W/O Spec Collec Various $ 3,418.00 ERCP W Stent Various $ 4,659.00 Esophageal Dilitation Rigid Various $ 969.00 Esophageal Motility 91010 $ 1,247.00 Flex Sigmoid Various $ 1,044.00 Flex Sigmoid W/Biopsy Various $ 1,306.00 Prolonged Esophageal Func Test 91038 $ 1,234.00 Tee-Placement Of Probe Various $ 529.00 Respiratory Charges The following represents the hospital charges for the procedures for the Respiratory department. Patients may have additional charges, Arterial Puncture 36600 $ 416.00 CPAP Treatment Initial 94660 $ 878.00 CPT Initial 94667 $ 322.00 CPT Subsequent Evalutation 94668 $ 200.00 HART Nebulizer/Initial Eval 94644 $ 201.00 Heart NEB EA ADD HR 94645 $ 75.00 Intubation Various $ 1,995.00 MDI Initial 94664 $ 251.00 MDI Subsequent Each Additional 94640 $ 166.00 Nebulizer TX, Initial 94664 $ 251.00 Oximetry Exercise 94761 $ 283.00 Oxygen Admin & Setup Various $ 519.00 Sputum Collect 94640 $ 278.00 Ventilator - 1st Day Charge 94002 $ 1,374.00 Ventilator - Subsequent Day 94003 $ 878.00 Coumadin Clinic Charges

The following represents the hospital charges for the procedures for the Coumadin Clinic department. Patients may have additional charges, Finger Stick 36416 $ 15.00 Level 1 Established Patient 99211 $ 166.00 Hyperbaric Charges The following represents the hospital charges for the procedures for the Hyperbaric department. Patients may have additional charges, HBOT Full Body Cham Per 30 Minutes 99183 $ 496.00 Incontinence/ Wound Care Charges The following charges reflect the hospital s 30 most common procedures for the Incontinence/ Wound Care departments. Patients may have additional charges, Apply Grft T/A/L <100 1st 25 15271 $ 926.00 Apply Total Contact Cast 29445 $ 870.00 Apply Unna Boot W/Proc 29580 $ 245.00 Bladder Scan 51798 $ 562.00 Chemical Cauterization 17250 $ 460.00 Cutting Benign Lesion 2 To 4 11056 $ 301.00 Debr Subcutaneious Tissue 11042 $ 888.00 Debridement Of Nail 1 to 5 11720 $ 275.00 Debridement Of Nail 6 Or More 11721 $ 275.00 Debridement Selective 97597 $ 545.00 Est Patient Level 1 99211 $ 166.00 Est Patient Level 2 99212 $ 215.00 Est Patient Level 3 99213 $ 284.00 Est Patient Level 4 99214 $ 424.00 Est Patient Level 5 99215 $ 562.00

Multilayer Compress Wrap Bilat 29581 $ 245.00 Nail Cutting 11719 $ 275.00 New Patient Level 2 99202 $ 320.00 New Patient Level 3 99203 $ 416.00 New Patient Level 4 99204 $ 554.00 New Patient Level 5 99205 $ 689.00 NH Subsequent Level 1 99307 $ 206.00 NH Subsequent Level 2 99308 $ 278.00 NH Subsequent Level 3 99309 $ 284.00 Nrsg Home Init Moderate 99305 $ 588.00 Nursing Home Init Complx 99306 $ 718.00 Pelvic Health Vaginal Irrig 57150 $ 150.00 Pelvic Health VLLP 51792 $ 1,587.00 Pessary Management 57160 $ 229.00 Unna Paste Boot Application 29580 $ 245.00 Uroflow Complex 51741 $ 483.00