Samaritan Hospital Patient Pricing Information

Samaritan 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.). Room and Board Per Day Charges The following represents the hospital charges for room and care services only. The charges below do not include the fees for drugs, non-routine supplies and procedures that may be rendered during the inpatient visit. Charge Medical/Surgical Semi Private Medical/Surgical Private Psychiatry Intensive Care $ 1,540.00 $ 1,624.00 $ 1,496.00 $ 2,785.00 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 $ 724.00 Level 2 99282 $ 724.00 Level 3 99283 $ 510.00 Level 4 99284 $ 439.00 Level 5 99285 $ 457.00 Critical Care 99291 $ 837.00 Critical Care- Additional 30 Min 99292 $ 162.00 SANE 99285 $ 1,216.00 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.

Level 1 OR 1/2 Hour $2,743.00 OR 3 Hours $6,925.00 OR 3/4 Hour $3,033.00 OR 3 1/4 Hours $7,360.00 OR 1 Hour $3,464.00 OR 3 1/2 Hours $7,791.00 OR 1 1/4 Hours $3,898.00 OR 3 3/4 Hours $8,225.00 OR 1 1/2 Hours $4,331.00 OR 4 Hours $8,944.00 OR 1 3/4 Hours $4,763.00 OR 4 1/4 Hours $8,944.00 OR 2 Hours $5,195.00 OR 4 3/4 Hours $8,944.00 OR 2 1/4 Hours $5,627.00 OR 5 3/4 Hours $8,944.00 OR 2 1/2 Hours $6,062.00 OR 6 Hours $8,944.00 OR 2 3/4 Hours $6,495.00 Level 2 OR 1/2 Hour $2,817.00 OR 3 Hours $7,142.00 OR 5 1/2 Hours $9,308.00 OR 3/4 Hour $3,250.00 OR 3 1/4 Hours $7,576.00 OR 5 3/4 Hours $9,308.00 OR 1 Hour $3,682.00 OR 3 1/2 Hours $8,010.00 OR 6 Hours $9,308.00 OR 1 1/4 Hours $4,116.00 OR 3 3/4 Hours $8,586.00 OR 6 1/4 Hours $9,308.00 OR 1 1/2 Hour $4,548.00 OR 4 Hours $9,308.00 OR 6 3/4 Hours $9,308.00 OR 1 3/4 Hours $4,981.00 OR 4 1/4 Hours $9,308.00 OR 7 3/4 Hours $9,308.00 OR 2 Hours $5,412.00 OR 4 1/2 Hours $9,308.00 OR 8 1/2 Hours $9,308.00 OR 2 1/4 Hours $5,846.00 OR 4 3/4 Hours $9,308.00 OR 9 1/4 Hours $9,308.00 OR 2 1/2 Hours $6,277.00 OR 5 Hours $9,308.00 OR 10 1/2 Hours $9,308.00 OR 2 3/4 Hours $6,711.00 OR 5 1/4 Hours $9,308.00 OR 13 Hours $9,308.00 DaVinci Robot $5,000.00 Recovery Room Charges The following represents the hospital charges for each level of recovery care provided to patients. Patients may have additional charges, depending on the services performed. Charge Rec Room Level A $ 66.00 Rec Room Level B $ 123.00 Rec Room Level C $ 194.00 Rec Room Level D $ 256.00 Rec Room Level E $ 256.00 Rec Room Level F $ 469.00 Rec Room Level G $ 699.00 Rec Room Level H $ 973.00 Rec Room Level I $ 469.00 Rec Room Level J $ 927.00

Rec Room Level K $ 1,386.00 Rec Room Level L $ 1,843.00 Rec Room Level M $ 699.00 Rec Room Level N $ 1,386.00 Rec Room Level 0 $ 2,077.00 Rec Room Level P $ 2,765.00 Physical Therapy Charges The following charges reflect the 10 most common services offered by our Physical Therapy department. Patients may have additional charges, depending on the services performed. Elec Stim UA 97014 $ 119.00 Gait/Stairs Train 15 Min 97116 $ 72.00 Heat Pack 97010 $ 34.00 Manual Therapy 15 Min 97140 $ 76.00 PT Evaluation Various $ 258.00 PT Re-Evaluation 97164 $ 94.00 PT Self Care Management 15 Min 97535 $ 86.00 Ther Exercise 15 Min 97110 $ 83.00 Therapeutic Activities 97530 $ 84.00 Ultrasound 15 Min 97035 $ 40.00 Occupational Therapy Charges The following charges reflect the 10 most common services offered by our Occupational Therapy department. Patients may have additional charges, depending on the services performed. ADL Training 15 Min 97535 $ 86.00 Manual Therapy 15 Min 97140 $ 76.00 Orthotic Fab 97760 $ 83.00 Orthotic Training 97760 $ 89.00 OT Evaluation Various $ 171.00 OT Nueromuscular Re Educ 15Min 97112 $ 83.00 OT Re-Evaluation 97168 $ 89.00

Perc/Cog Training 15 Min 97532 $ 73.00 Ther Exercise 15 Min 97110 $ 83.00 Therap Activity 15 Min 97530 $ 84.00 Speech Therapy Charges The following charges reflect the services offered by our Speech Therapy department. Patients may have additional charges, depending on the services performed. Aphasia Assessment Per Hour 96105 $ 317.00 Behav-Qualitative Analys Voice 92524 $ 536.00 Eval Speech Sound Prod 92522 $ 536.00 Eval Speech Sound W Lang Comp 92523 $ 713.00 Speech Swallowing Evaluation 92610 $ 320.00 Speech Swallowing Therapy 92526 $ 349.00 Speech Therapy 92507 $ 306.00 Speech Videoflouroscopy 92611 $ 340.00 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 $ 3,727.00 Abd/Pelvis Without Contrast 74176 $ 3,183.00 Abdomen 2 Postion 74020 $ 374.00 Abdomen KUB/Flat Plate 74000 $ 394.00 Carotid Doppler Bil 93880 $ 1,930.00 Chest (1 View) 71010 $ 122.00 Chest (PA & LAT) 71020 $ 387.00 Chest W Contrast 71260 $ 1,987.00 Chest W/O Contrast 71250 $ 1,757.00 CT Angiography Chest 71275 $ 1,436.00 Duplex Scan Art/Vein Abd 93975 $ 564.00 Head/Brain W Contrast 70460 $ 1,669.00 Head/Brain W/O Contrast 70450 $ 1,636.00

Ird Rel Surg Procedure 0-30 Various $ 3,579.00 Kidney Bil (Renal) 76775 $ 1,564.00 Knee 3 Views Rt 73562 $ 338.00 Knee 3 Views Lt 73562 $ 338.00 Pelvis Transvaginal 76830 $ 1,237.00 Pelvis With Doppler 76856 $ 1,021.00 Renal (Kidneys) And Bladder 76770 $ 1,789.00 Ruq Biliary 76705 $ 1,021.00 Shoulder Lt 73030 $ 371.00 Shoulder Rt 73030 $ 371.00 Soft Tissue Head/Neck 76536 $ 481.00 Spine Cervical W/O Contrast 72125 $ 1,633.00 Spine Lumbar 2-3 View 72100 $ 504.00 Stress Test With CCA 93017 $ 1,342.00 US Doppler Venous Lower/Bil 93970 $ 1,684.00 US Doppler Venous Lower/Lt 93971 $ 1,328.00 US Doppler Venous Lower/Rt 93971 $ 1,328.00 Laboratory Charges The following charges reflect the hospital s 30 most common laboratory tests. Basic Metabolic Panel 80048 $ 104.00 CBC w/ Automated Differential 85025 $ 80.00 CBC Without Diff 85027 $ 80.00 Comprehensive Metabolic Pan 80053 $ 159.00 Culture Blood 87040 $ 235.00 Culture Quant Urine 87086 $ 212.00 Culture Throat 87081 $ 156.00 Drug Scr Cls A Inst Test P/Day 80307 $ 323.00 Erythrocyte Sedimentation Rate 85651 $ 104.00 Glucose Nova 82947 $ 79.00 Glycohemoglobin (HgbA1c) 83036 $ 72.00 Gram Stain 87205 $ 54.00 Gross/Micro Level IV 88305 $ 512.00

Identification - Urine 87088 $ 46.00 Lipase 83690 $ 75.00 Lipid Panel 80061 $ 99.00 Magnesium 83735 $ 81.00 Manual Differential 85007 $ 59.00 Microalbumin, Random Urine 82043 $ 90.00 Phosphorus 84100 $ 76.00 Prothrombin Time (PT) w/ INR 85610 $ 103.00 Sensitivity MIC 87186 $ 73.00 Sero Agglu Grping - Antisera 87147 $ 26.00 T4 Free 84439 $ 137.00 Troponin 84484 $ 221.00 TSH 84443 $ 137.00 Urinalysis w/out Microscopic 81003 $ 66.00 Urinalysis with Microscopic 81001 $ 90.00 Vitamin B12 82607 $ 203.00 Vitamin D 25-Hydroxy SPH 82306 $ 212.00 Cardiac Cath Charges The following represents the hospital charges for the 30 most common procedures for the Cardiology department. Patients may have additional charges, depending on the services performed. 2D/M Mode Echocardio 93306 $ 3,541.00 Abdominal Aorogram 75625 $ 6,211.00 Cardioversion 92960 $ 1,297.00 Coronary (S) Angio Only 93454 $ 10,341.00 Coronary W/ Lft Heart 93458 $ 10,341.00 Coronary W/ Lft Heart & Bypass 93459 $ 10,341.00 Coronary W/ Rt & Lt Heart 93460 $ 10,341.00 Diagnostic Init Cath Placement Various $ 766.00 Ext Bilateral Angio 75716 $ 6,211.00 Ext Unilateral Angio Left 75710 $ 6,211.00 Ext Unilateral Angio Right 75710 $ 6,211.00 Inject Aorta 93567 $ 75.00

Interv Angio Init Stent Various $ 30,422.00 IVUS-Non Coronary Various $ 373.00 IVUS-Non Coronary S&I 75945 $ 934.00 IVUS-Non Coronary S&I-Ea Add 75946 $ 705.00 IVUS-Non Coronary, Ea Add Various $ 373.00 LC-Des-Stent 1 Art/Branch 92928 $ 14,010.00 LD-Des-Stent 1 Art/Branch 92928 $ 14,010.00 Limited Echocardiogram 93308 $ 1,880.00 Place Angioseal GO269 $ 176.00 RC-Des-Revas Stemi Initial Ves 92941 $ 14,010.00 RC-Des-Stent 1 Art/Branch 92928 $ 14,010.00 Reveal Insertion 33282 $ 19,957.00 Tilt Table Study 93660 $ 927.00 Trans Venous Pacemaker Insert Various $ 19,442.00 Transesophageal Echo 93312 $ 1,546.00 Vein Arm/Leg Unilateral 75820 $ 2,787.00 Vein Arms/Legs Bilateral 75822 $ 2,787.00 Venography Caval Infrr S&I 75825 $ 7,685.00 Cardiology Charges The following represents the hospital charges for the procedures for the Cardiology department. Patients may have additional charges, depending on the services performed. Card Event Recording 93270 $ 796.00 EKG 93005 $ 223.00 Holt Mon Data Analysis 93226 $ 900.00 Holter Monitor-Hook-Up/Record 93225 $ 433.00 Stress Test-AAC 93017 $ 1,055.00 Stress Test-CCA 93017 $ 1,206.00 Endoscopy Charges The following represents the hospital charges for the procedures for the Endoscopy department. Patients may have additional charges, depending on the services performed.

EBUS Service Various $ 6,403.00 GI Service Various $ 4,553.00 Glucose Fingerstick 82962 $ 79.00 Infusion Non Chemo 1 Hour 96365 $ 365.00 Injection IV 96374 $ 257.00 Nebulizer Treatment 94640 $ 107.00 Nebulizer Tx, Initial 94664 $ 140.00 Sequential Infusion Addl 96367 $ 192.00 Radiation Therapy Charges The following represents the hospital charges for the 30 most common procedures for the Radiation Therapy department. Patients may have additional charges, depending on the services performed. 3D Treatment Planning 77295 $ 3,585.00 Brachy 1 Channel 77770 $ 4,493.00 Brachy Therapy Or Implant 76965 $ 679.00 CT For Radiation Planning 77014 $ 870.00 Dosimetry Basic 77300 $ 791.00 Dosimetry Special PDM TLD Etc 77331 $ 423.00 Guid Loc Target Rad Treat Del 77387 $ 324.00 IMRT Delivery 77385 $ 1,439.00 IMRT Planning 77301 $ 5,046.00 Intensity Modul Rad Tx Dlvr Co 77386 $ 1,439.00 Intensity Modul Rad Tx Dlvr SI 77385 $ 1,439.00 Interstitial 11+ Ribn/Source 77778 $ 1,838.00 Isodose Plan Brachy Complex 77318 $ 912.00 Isodose Plan Rad Complex 77307 $ 1,099.00 Meas Prostate Pr Brachy Seed 76873 $ 394.00 Port Verification Films 77417 $ 503.00 Preport Films 77280 $ 507.00 Simulation Complex 77290 $ 1,815.00 Simulation Intermediate 77285 $ 911.00 Special Med Physics Consult 77370 $ 593.00 Special Treatment Procedure 77470 $ 1,861.00

Superv/Handle/Load Element 77790 $ 233.00 Therapy Evaluation Initial Vis 99201 $ 146.00 Therapy Evaluation Re-Visit 99211 $ 146.00 Treatment >1 Mev Complex 77412 $ 1,056.00 Treatment Devices - IMRT 77338 $ 1,572.00 Treatment Devices Complex 77334 $ 1,572.00 Treatment Devices Intermed 77333 $ 828.00 Treatment Devices Simple 77332 $ 408.00 Weekly Physics Review Qa 77336 $ 367.00 Mental Health OP Charges The following represents the hospital charges for the 30 most common procedures for the Mental Health OP departments. Patients may have additional charges, depending on the services performed. BH Geropsych Assessmnt BH MH Assessmnt BH MICA Assessmnt Fac Ind Psychother 30 Min Fac Ind Psychother 45 Min Fac Psych DX Eval Group Therapy Facility MD Est Pt Assess Lev 1 MD Est Pt Assess Lev 2 MD Est Pt Assess Lev 3 MD Est Pt Assess Lev 4 MD Ind Psychother 30 Min MD Ind Psychother 45 Min MD Ind Psychother 60 Min MD Office Visit Level 2 MD Office Visit Level 3 MD Office Visit Level 4 MD Psych Dx Eval MSW Family Therapy W/Pt MSW Group Therapy 90791 $ 467.00 90791 $ 467.00 90791 $ 467.00 90832 $ 301.00 90834 $ 419.00 90791 $ 419.00 90853 $ 226.00 99211 $ 201.00 99212 $ 317.00 99213 $ 351.00 99214 $ 489.00 90832 $ 301.00 90834 $ 419.00 90837 $ 419.00 99212 $ 317.00 99213 $ 351.00 99214 $ 489.00 90791 $ 419.00 90847 $ 556.00 90853 $ 241.00

MSW Ind Psychother 30 Min MSW Ind Psychother 45 Min MSW Ind Psychother 60 Min MSW Psych Dx Eval NP Est Pt Assess Lev 1 NP Est Pt Assess Lev 2 NP Est Pt Assess Lev 3 NP Est Pt Assess Lev 4 PHD Psych Testing/Hr Therapeutic Injections 90832 $ 301.00 90834 $ 419.00 90837 $ 419.00 90791 $ 419.00 99211 $ 201.00 99212 $ 317.00 99213 $ 351.00 99214 $ 489.00 96101 $ 668.00 96372 $ 123.00