Room and Board -- Per Day Charges

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Patient Price Information List Mansfield Hospital In compliance with state law, OhioHealth is providing this price list for Mansfield Hospital that contains our charges for room and board, emergency department, operating room, delivery, physical therapy and other procedures. The hospital's charges are the same for all patients, but a patient's responsibility may vary, depending on payment plans negotiated with individual health insurers. Uninsured or underinsured patients should consult with our admitting and billing staff to determine whether they qualify for discounts. These prices are correct as of January 1, 2016. Room and Board -- Per Day Routine care (Med/Surg; OB) $860.00 Med/Surg with Cardiac Monitoring $1,366.00 Coronary care - CVICU $3,213.00 Intensive care - ICU $2,385.00 CV/ICU Stepdown $1,366.00 Nursery $683.00 Nursery - Level 2 (Intensive Services) $1,155.00 Oncology $860.00 Psychiatric care $1,375.00 Rehab $1,139.00 Hospice Inpatient (Med/Surg) $860.00 Palliative Care $705.00 Hospice Respite Care $272.00 Labor and Delivery The following list does not include charges for anesthesia, drugs, or supplies required for a particular delivery room procedure. Fees for physician services or anesthesia administration are also not reflected, and will be billed separately by your physician. The delivery price represent an average charge. Normal Delivery (Mom) $8,867.00 Normal Newborn (Baby) $2,915.00 Cesarean Section Delivery $13,348.00 Labor Room per minute $1.50 Fetal Monitoring - Fetal Non-stress Test $537.00 Amniocentesis $264.00 Emergency Department Emergency Department charges are based on the level of emergency care provided to our patients. The levels, with level 1 representing basic emergency care, reflect the type and the intensity of care needed to provide treatment. The following charges do not include fees for drugs, supplies or additional ancillary procedures that may be required for a particular emergency treatment. They also do not include fees for Emergency Department physicians, who will bill separately for their services. Level 1 $155.00 Level 2 $222.00 Level 3 $365.00 Level 4 $673.00 Level 5 $1,050.00 Critical care $1,555.00 Level 2 Trauma Center - Activation $5,708.00 Level 1 Trauma Center - Activation $6,668.00

Operating Room Operating Room charges are based on the complexity level, with Level I being the most basic. The following list does not include charges for anesthesia, drugs, or supplies required for a particular procedure. Fees for physician services or anesthesia administration are also not reflected, and will be billed separately by the physician. Per Minute O.R. Level 1 $24.00 Level 2 $71.00 Level 3 $79.00 Level 4 $88.00 Level 5 $97.00 Level 6 $106.00 Physical Therapy The following charges reflect the most common services offered by our Physical Therapy department. Patients may have additional charges, depending on the services performed. Most Charge Units are based upon 15 minutes. Initial Evaluation 97001 $213.00 Re-Evaluation 97002 $112.00 Mechanical Traction 97012 $49.00 Whirlpool 97022 $84.00 Electrical Stimulation - Attended 97032 $61.00 Iontophoresis 15 Min 97033 $91.00 Therapeutic Exercise 15 Min 97110 $95.00 Neuromuscular Re-education 15 Min 97112 $95.00 Gait Training 15 Min 97116 $87.00 Manual Therapy 15 Min 97140 $95.00 Group Therapy 97150 $111.00 Functional Activity 15 Min 97530 $95.00 Self Care Management Training 15 Min 97535 $95.00 Wheelchair Management 15 Min 97542 $95.00 Wound Care Small (Less than 20 sq cm) 97597 $113.00 Physical Performance Test 15 min 97750 $66.00 Othotic Fitting Training 15 Min 97760 $73.00 Prosthetic Training 15 Min 97761 $84.00 Electrical Stimulation - Unattended G0283 $61.00 Shoulder Strapping 29240 $85.00 Ankle/ Foot Strapping 29540 $85.00 Occupational Therapy The following charges reflect the most common services offered by our Occupational Therapy department. Patients may have additional charges, depending on the services performed. Initial Evaluation 97003 $213.00 Clinical Driving Evaluation 97003 $459.00 Re-Evaluation 97004 $112.00 Thermal-Cryo Modality 97010 $38.00 Paraffin Bath 97018 $56.00 Whirlpool 97022 $84.00 Contrast Bath 15 Min 97034 $65.00 Ultrasound 15 Min 97035 $70.00 Therapeutic Exercises 15 Min 97110 $95.00 Neuromuscular Re-education 15 Min 97112 $95.00

Therapeutic Massage 15 Min 97124 $68.00 Manual Therapy 15 Min 97140 $95.00 Group Therapy 97150 $111.00 Therapeutic Activitites One-on-One 15 Min 97530 $95.00 Cognitive Integration 15 Min 97532 $95.00 Sensory Integration 15 Min 97533 $103.00 Self-Care Management Training 15 Min 97535 $95.00 Community/ Work Reintegration Training 15 Min 97537 $95.00 On the Road Training 15 Min 97537 $29.00 Othotic Fitting Training 15 Min 97760 $73.00 Leisure Assessment 15 Min 96150 $110.00 Recreation Conference $95.00 Static Short Arm Splint Application 29125 $167.00 Static Finger Splint Application 29130 $120.00 Dynamic Finger Splint Application 29131 $114.00 Cardiology and Pulmonary Therapy The following charges reflect the most common services offered by our Cardiology and Pulmonary Therapy departments. Patients may have additional charges, depending on the services performed. Arterial Puncture 36600 $94.00 Blood Gas, Oxygen Saturation Only 82805 $181.00 CPR 92950 $729.00 Holter Monitor Recording 93225 $421.00 Holter Monitor Scanning 93226 $380.00 Ventilator - Initial Day 94002 $1,014.00 Ventilator - Subsequent Day 94003 $606.00 Pulmonary Stress Testing - 6 Min Walk Test 94620 $163.00 Metered Dose Inhaler - Each 94640 $85.00 Spontaneous Aerosol Treatment - Each 94640 $85.00 CPAP - Daily 94660 $315.00 Pulmonary Function Test - Includes 3 Test $817.00 X-Ray and Radiological The following charges reflect the hospital's most common x-ray and radiological procedures. X-ray Chest 1 View 71010 $204.00 X-ray Chest 2 Views 71020 $275.00 X-ray Ribs Unilateral 2 Views 71100 $300.00 X-ray Cervical Spine 4-5 Views 72050 $452.00 X-ray Cervical Spine 6+ Views 72052 $441.00 X-ray Thoracic Spine 2 views 72070 $384.00 X-ray Lumbosacral 2-3 Views 72100 $318.00 X-Ray Pelvis 1-2 Views 72170 $213.00 X-ray Shoulder 1 View 73020 $266.00 X-ray Shoulder Complete 2+ Views 73030 $302.00 X-ray Elbow 3+ Views 73080 $294.00 X-ray Forearm 2 Views 73090 $261.00 X-ray Wrist Complete 3+ Views 73110 $282.00 X-ray Hand 2 Views 73120 $174.00 X-ray Knee 1-2 Views 73560 $259.00 X-ray Tibia and Fibula 2 Views 73590 $282.00 X-ray Ankle 2+ Views 73610 $278.00 X-ray Foot 3+ Views 73630 $289.00 X-ray Abdomen 1 View 74000 $250.00 X-ray Abdomen Complete 74020 $315.00 X-ray Acute Abdomen Series, Complete 74022 $421.00 Barium Swallow - Esophagus 74220 $477.00 Modified Barium Swallow 74230 $437.00 X-ray Small Intestine 74249 $1,079.00 Urography- Intravenous Pyelography 74400 $677.00

X-Ray and Radiological Continued Ultrasound Abdomen 76700 $916.00 Ultrasound Retroperitoneal Complete 76770 $804.00 Ultrasound Transvaginal 76830 $609.00 Ultrasound Pelvis 76856 $740.00 Ultrasound Extremity Nonvascular Complete 76881 $399.00 Screening Digital Mammogram - Bilateral G0202 $450.00 Screening Digital Mammogram - Unilateral G0202 $266.00 Diagnostic Digital Mammogram - Bilateral G0204 $533.00 Diagnostic Digital Mammogram - Unilateral G0206 $417.00 MRI Orbits Face & Neck without Contrast 70540 $2,066.00 MRI Orbits Face & Neck with & without Contrast 70542 $1,769.00 MRA Head without Contrast 70544 $1,816.00 MRA Neck with & without Contrast 70549 $2,349.00 MRI Brain without Contrast 70551 $2,486.00 MRI Brain with & without Contrast 70553 $3,035.00 MRI Cervical Spinal Canal without Contrast 72141 $2,998.00 MRI Thoracic Spine without Contrast 72146 $2,441.00 MRI Lumbar Spine without Contrast 72148 $2,870.00 MRI Cervical Spinal Canal with & without Contrast 72156 $3,643.00 MRI Thoracic Spine with & without Contrast 72157 $3,087.00 MRI Lumbar Spine with & without Contrast 72158 $3,412.00 MRI Pelvis without Contrast 72195 $2,515.00 MRI Pelvis with & without Contrast 72197 $3,141.00 MRI Upper Extremity with & without Contrast 73220 $2,701.00 MRI Lower Extremity without Contrast 73718 $2,448.00 MRI Lower Extremity with & without Contrast 73720 $2,838.00 MRI Abdomen with & without Contrast 74183 $2,863.00 MRA Abdomen with & without Contrast C8902 $2,625.00 CT Brain without Contrast 70450 $1,403.00 CT Brain with Contrast 70460 $1,463.00 CT Brain with & without Contrast 70470 $1,906.00 CT Orbit, Sella, Posterior Fossa or Ear with Contrast 70481 $1,815.00 CT Facial Bones without Contrast 70486 $1,268.00 CT Neck with Contrast 70491 $1,886.00 CT Chest without Contrast 71250 $1,372.00 CT Chest with Contrast 71260 $1,706.00 CT Chest with & without Contrast 71270 $1,742.00 CTA Chest (Non-coronary) with & without Contrast 71275 $2,010.00 CT Cervical Spine without Contrast 72125 $1,553.00 CT Lumbar Spine without Contrast 72131 $1,650.00 CTA Pelvis with & without Contrast 72191 $1,936.00 CT Pelvis without Contrast 72192 $1,508.00 CT Pelvis with Contrast 72193 $1,897.00 CT Abdomen without Contrast 74150 $1,536.00 CT Abdomen with Contrast 74160 $1,826.00 CT Abdomen with & without Contrast 74170 $2,164.00 CTA Abdomen with & without Contrast 74175 $1,788.00 CT Guidance for Needle Biopsy 77012 $1,537.00 CT Guidance Placement Radiation Fields 77014 $858.00 PET Imaging - Brain for Metabolic Evaluation 78608 $4,439.00 PET Imaging - Skull Base to Mid Thigh 78812 $3,646.00 PET Imaging - Whole Body 78813 $3,939.00 PET Imaging with CT Scan - Skull Base to Mid Thigh 78815 $5,209.00

Laboratory The following charges reflect the hospital's 30 most common laboratory procedures. For all lab specimens collected via blood draw, the venipuncture will be charged separately ($20). Chem 8 ( Basic Metabolic) 80048 $117.00 Comprehensive Metabolic Panel 80053 $219.00 Lipid Profile 80061 $156.00 Renal Function Panel 80069 $112.00 Hepatic Function Panel 80076 $130.00 Urinalysis without Microscopic 81003 $33.00 Amylase Serum 82150 $85.00 Creatinine Serum 82565 $39.00 Glucose 82947 $38.00 Hemoglobin A1C 83036 $102.00 Magnesium Serum 83735 $54.00 Myoglobin 83874 $170.00 Phosphorus Serum 84100 $47.00 Potassium Serum 84132 $30.00 Thyroxine T4 Free 84439 $131.00 Thyroid Stimulation Hormone 84443 $148.00 Troponin-I 84484 $102.00 Pregnancy Test Serum 84703 $70.00 Pregnancy Test Urine 84703 $70.00 Hematocrit 85014 $30.00 Hemoglobin 85018 $30.00 CBC (with Differential) 85025 $89.00 CBC (No Differential) 85027 $56.00 Hemogram 85027 $71.00 Prothrombin Time 85610 $37.00 Partial Thromboplastin Time 85730 $57.00 Blood Culture 87040 $122.00 Urine Culture 87086 $87.00 Sensitivity 87186 $73.00

BILLING PROCESS AND INFORMATION How You Can Help Thank you for choosing OhioHealth for your healthcare needs. At OhioHealth, we are committed to making the billing process as patient-friendly as possible. Here are some ways you can help the billing process go smoothly. Please give us complete health insurance information. In addition to your health insurance card, we may ask for a photo ID. If you have been seen at OhioHealth before, let us know if your personal information or insurance information has changed since your last visit. Please understand and follow the requirements of your health plan. Be sure to know your benefits, obtain proper authorization for services and submit referral claim forms if necessary. Many insurance plans require patients to pay a co-payment or deductible amount. You are responsible for paying co-payments required by your insurance provider and OhioHealth is responsible for collecting co-payments. Please come to your appointment prepared to make your co-payment. Please respond promptly to any requests from your insurance provider. You may receive multiple bills for your hospital visit, including your family doctor, specialists, physicians to read x-rays, give anesthesia, or do blood work. Insurance benefits are the result of your contract with your insurance company. We are a third-party to those benefits and may need your help with your insurance. If your insurance plan does not pay the bill within 90 days after billing, or your claim is denied, you will receive a statement from OhioHealth indicating the bill is now your responsibility. All bills sent to you are due upon receipt. OhioHealth does not charge interest on any amount not paid in full during the normal course of collection. Questions about Price and Billing Information Our goal is for each of our patients and their families to have the best healthcare experience possible. Part of our commitment is to provide you with information that helps you make wellinformed decisions about your own care. To ask questions or get more information about a bill for services you ve received, please contact our Customer Call Center at (419) 526-8428 or (800) 247-4243 Ext. #8428. If you need more information about the price of a future service, please call (419) 520-2764. A code is strongly encouraged when you call. You can obtain the code from the ordering physician.

You also can get more information about or services, high quality of care, convenient locations and prices at www.ohiohealth.com. Online Payment, Registration, & Scheduling For the convenience of our patients, a number of online services are available at www.ohiohealth.com. OhioHealth offers secure online payment for OhioHealth Mansfield, Shelby hospital and MedCentral Professional Foundation bills. With a private payment account, users may access tools to make the payment process easier and more manageable. OhioHealth also offers pre-registration and appointment requests through a secure online form at www.ohiohealth.com. Patients may pre-register for surgeries, admissions, outpatient procedures and tests at least three business days in advance. Patients may also pre-register for maternity services up to three months prior to their expected delivery date. Financial Assistance We are pleased to offer financial assistance to patients with limited resources and inadequate medical insurance coverage. Eligibility is determined by total family income/assets. The patient must agree to apply for other assistance available to pay hospital charges (Medicaid, Medicare, private insurance) before being discharged. OhioHealth s Charity Care Policy OhioHealth is a family of not-for-profit, faith-based hospitals and healthcare organizations. In Columbus, we have a unique healthcare system where all of the not-for-profit hospitals provide high quality care to everyone, regardless of their ability to pay. This system allows OhioHealth to provide one of the most compassionate charity care policies to individuals and families who cannot pay for medically necessary healthcare services they receive at our facilities. OhioHealth's charity care policy includes: Substantial charity care guidelines that provide free care for individuals and families who earn less than 200 percent of the federal poverty level. Sliding scale fees to provide substantially discounted care for individuals and families who are between 200 and 400 percent of the federal poverty level. Hardship policy for those patients who would not otherwise qualify for charity care but have unique circumstances. In many cases, OhioHealth offers interest free loans for up to one year to assist patients. In addition, OhioHealth has an uninsured discount policy for individuals without insurance who do not qualify for charity care. For more information, please contact our Customer Call Center at (419) 526-8428 or (800) 247-4243 Ext #8428.

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