AMENDMENT NUMBER la TO UNITED HEALTHCARE OF CALIFORNIA HOSPITAL SERVICES AGREEMENT (HMO, PPO, POS & SECURE HORIZONS) RECITALS

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1 AMENDMENT NUMBER la TO UNITED HEALTHCARE OF CALIFORNIA HOSPITAL SERVICES AGREEMENT (HMO, PPO, POS & SECURE HORIZONS) this Amendment Number 14 to the Hospital Services Agreement (HMO, PPO, POS & Secure Horizons) ("Amendment Number 14") is entered into effective as of January 1, 2013 by and between UHC of California d.b.a United Healthcare of California and formerly known as PacifiCare of California, a California corporation and Affiliates ("PacifiCare") and/or ("United"), and Adventist Health, a California non-profit religious corporation ("Hospital"), with respect to the following facts: RECITALS The parties have previously entered into a PacifiCare of California Hospital Services Agreement (HMO, PPO, POS and Secure Horizons) effective January 1, 2006 (the "Agreement") as amended. The purpose of this Amendment Number 13 is to amend the Agreement with Comrnercial and Medicare Payment rates and terms to be effective January 1, 2013 pursuant to this APA schedule. IN WITNESS WHEREOF, the parties hereto have executed this Amendment Number 14 in California. A D V EN TIST HEAJJK UHC OF CALIFORNIAD.B.A. UNITED HEALTHCARE OF CALIFORNIA By: (Signature) By: (S' ature) it Name P ease rint): Jeffrey Conklin, President ALIMC Name 4iNint ( : Date Signed by Adventist: /0-3/-1/ Adventist's Primary Mailing Address: 3602 Inland Empire Blvd., Suite C/10 G 2E, oftl,f ,Er\--- Title: V PI IV6-7-orze_ Pic_--\--. P.O Plaza Drive, Suite 150, M/S CA Cypress, CA City, State, Zip Code: Ontario, CA Facsimile Number: (909) Cypress, CA St r401 date (to be completed by United): UCI S - caz:m UNITEDIIEALTHCARE Amendment Commercial and Page 1 of 204

2 NOW, THEREFORE, in consideration of the foregoing, the parties hereto agree that the Agreement is hereby modified as specified below: 1. Section 2, of the All Payer Appendix, is hereby amended by deleting in its entirety Section 2 and replacing it with a new Section 2, attached hereto and incorporated into the Agreement. 2. Attachment 3, Facility Medicare Payer Appendix, Effective June 1, 2008, is hereby amended by deleting in its entirety Attachment 3, Facility Medicare Payor Appendix, and replacing it with a new Attachment 3, Facility Medicare Payor Appendix, attached hereto and incorporated into the Agreement. 3. Exhibit 2, of the PacifiCare of California Hospital Services Agreement, Attachment B, (Hospital Services Fee Schedule) for the Home Health and Home Infusion Therapy Services effective May 1, 2011 remains in effect 4. Agreement Remains in Full Force and Effect. Except as specifically amended by this Amendment, the Agreement shall continue in full force and effect. Page 2 of 204

3 SECTION 2 Glendale Adventist Medical Center-Commercial HMO & POS Effective January 1, 2013 through December 31, 2013 Payment for Covered Services 2.1 Payment. For Covered Services rendered by Facility to a Customer, Facility shall be paid by Payer the lesser of (1) Facility's Eligible Charges, less any applicable Customer Expenses, or (2) the contract rates herein, less any applicable Customer Expenses. Payment under this Appendix is subject to the requirements set forth in the Agreement regarding timely submission of a complete claim and compliance with applicable Protocols such as notification of Admission. 2.2 Inpatient Covered Services. For the provision of Covered Services to a Customer during an Admission, the contract rate is determined as described in this section 2.2. The contract rate for an Admission is the contract rate in effect on the date the Admission begins. Table 1A: Inpatient Service Category Table SERVICE CATEGORY Medical Refer to CMS list of MS-DRGs Surgical Refer to CMS list of MS-DRGs ICU-Intermediate/ CCU-Intermediate, Telemetry, DOU Includes the following Revenue Codes. Revenue Codes: 0206, 0214 ICU/CCU Includes the following Revenue Codes. Revenue Codes: , , 0219 PICU (Pediatric Intensive Care Unit) Revenue Code: 0203 Hospice^ Revenue Codes 0115, 0125, 0135, 0145, 0155, Nursery Normal Newborn: MS-DRG 795 Lower Level Neonate: MS-DRGs 789, 792, 794 Higher Level Neonate: MS-DRGs , 793 PAYMENT METHOD RATE $2,676 $3,714 $2,676 $4,415 $4,415 $685 $457 $4,415 $5,632 Page 3 of 204

4 SERVICE CATEGORY Obstetrics (Mother only) Vaginal delivery MS-DRGs , day stay case rate w/ per diem payment for additional days PAYMENT METHOD Per Case up to 2 days. beginning on day 3. RATE $4,551 $2,317 Cesarean Section MS-DRGs day stay case rate w/ per diem payment for additional days False Labor MS-DRG 780 Rehabilitation~^ MS-DRG: or Revenue Codes 0118, 0128, 0138, 0148, 0158 Hospital Sub-Acute Revenue Codes , 0199 Inpatient Skilled Nursing Services~ (see note ~ below) Bill Types Per Case up to 4 days. beginning on day 5. $6,829 $2,317 $1,948 $2,618 $760 $760 Aneursym Embolism Non Ruptured MS-DRGs Aneursym Embolism Ruptured MS-DRGs Carotid Stenting MS-DRGs Thrombolysis/Thrombolectomy MS-DRGs Bariatric Surgery MS-DRG: with ICD-9CM procedure codes 44.31, 44.38, 44.39, 44.5, 44.68, 44.69, Bariatric Surgery Add-on Case Rate Case Rate Case Rate Case Rate Case Rate 4 days 5+ days $49,015 $88,460 $27,138 $28,754 $20,995 $ 2,676 Notes to Table 1A*Covered Services rendered to a mother and her newborn child shall be paid as separate Admissions. ~ If Facility has a separate Inpatient Skilled Nursing unit, Hospice unit, or Rehabilitation unit, the charges for the Inpatient Skilled Nursing, Hospice, or Rehabilitation stay are to be submitted separately from the acute hospital stay. ^However, this service category does not apply where one of these revenue codes is billed in connection with Covered Services included in any Per Case Payment Method service category or any service category defined by MS-DRGs or any service category defined by Bill Types on this Inpatient Service Category Table or Section 3.6, or in connection with Covered Services listed on Table 1 B and Table 1 C. Additional information regarding MS-DRG s under this Appendix are applicable to the entire Appendix, including Table 1A, 1B and 1C. The following applies to MS-DRG s as used in this Appendix: -Reimbursement for a new, replacement, or modified MS-DRG code(s) will be at the existing contract rate for the appropriate MS-DRG(s) it replaced or modified, for the most current term of the Agreement. -All changes in the definition of MS-DRG s specified in the Medicare Final Rule shall be implemented under this Appendix on or before January 1, following publication in the Federal Register. Until changes in the definition are implemented under this Page 4 of 204

5 Appendix, the previous definitions will apply. Claims with discharge dates 10/1 and later, that are processed during the period in between the CMS effective date and United s implementation date will continue to have the previous MS-DRG grouper applied. Claims with discharge dates 10/1 and later, which process following United s implementation date for the MS-DRG grouper updates will have the new grouper applied. -In the event services within a MS-DRG in existence at the time this Agreement is executed are reclassified into new MS-DRG groupings, the or Case Rate reimbursement rate from the original MS-DRG(s) will apply to the succeeding MS-DRG groups for those procedures contained in the original MS-DRG(s), for the most current term of this Agreement. -All changes impacting reimbursement, due to the implementation of new, replacement, or modified MS-DRG code(s) will be revenue neutral. Facility has the right to appeal reimbursement, if Facility does not agree with the reimbursement affected by these changes, for the most current term of this Agreement. Table 1B - Inpatient Cardiac Services for which the contract rate will not be determined according to Table 1A. For an Admission that includes any of the following Inpatient Covered Services provided to a Customer, the contract rates for the entire Admission are determined as follows. MS-DRG DESCRIPTION PER CASE PAYMENT 001 w/icd , w/icd , Implant of Heart Assist System w MCC $ 82,108 Implant of Heart Assist System w/o MCC $ 82, Other Heart Assist System Implant $ 16, Cardiac Valve & Other Major Cardiothoracic Procedures with Cardiac Catheterization w MCC $ 27, Cardiac Valve & Other Major Cardiothoracic Procedures with Cardiac Catheterization w CC $ 27, Cardiac valve & Other Major Cardiothoracic Procedures with Cardiac Catheterization w/o CC/MCC $ 27, Cardiac Valve & Other Major Cardiothoracic Procedures without Cardiac Catheterization w MCC $ 27, Cardiac Valve & Other Major Cardiothoracic Procedures without Cardiac Catheterization w CC $ 27, Cardiac valve & Other Major Cardiothoracic Procedures without Cardiac Catheterization w/o CC/MCC $ 27, Cardiac Defibrillator Implant with Cardiac Catheterization with Acute Myocardial Infarction, Heart Failure or Shock w MCC 223 Cardiac Defibrillator Implant with Cardiac Catheterization with Acute Myocardial Infarction, Heart Failure or Shock w/o MCC $ 16,365 $ 16,365 Page 5 of 204

6 224 Cardiac Defibrillator Implant with Cardiac Catheterization without Acute Myocardial Infarction, Heart Failure or Shock w MCC $ 16,365 MS- DRG DESCRIPTION PER CASE PAYMENT 225 Cardiac Defibrillator Implant with Cardiac Catheterization without Acute Myocardial Infarction, Heart Failure or Shock w/o MCC 226 Cardiac Defibrillator Implant without Cardiac Catheterization w MCC 227 Cardiac Defibrillator Implant without Cardiac Catheterization w/o MCC 228 Other Cardiothoracic Procedures w MCC 229 Other Cardiothoracic Procedures w CC 230 Other Cardiothoracic Procedures w/o CC/MCC 231 Coronary Bypass with PTCA w MCC 232 Coronary Bypass with PTCA w/o MCC 233 Coronary Bypass with Cardiac Cath w MCC 234 Coronary Bypass with Cardiac Cath w/o MCC 235 Coronary Bypass without Cardiac Cath w MC 236 Coronary Bypass without Cardiac Cath w/o MCC 237 Major Cardiovascular Procedures w MCC 238 Major Cardiovascular Procedures w/o MCC 242 Permanent Cardiac Pacemaker Implant w MCC 243 Permanent Cardiac Pacemaker Implant w CC 244 Permanent Cardiac Pacemaker Implant w/o CC/MCC 245 AICD Lead & Generator Procedures 246 Percutaneous Cardiovascular Procedure with Drug-Eluting Stent with MCC 247 Percutaneous Cardiovascular Procedure with Drug-Eluting Stent w/o MCC 248 Percutaneous Cardiovascular Procedures with Non-drug Eluting Stent w MCC $ 16,365 $ 16,365 $ 16,365 $ 27,698 $ 27,698 $ 27,698 $ 27,698 $ 27,698 $ 27,698 $ 27,698 $ 27,698 $ 27,698 $ 27,698 $ 27,698 $ 16,365 $ 16,365 $ 16,365 $ 16,365 $ 9,820 $ 9,820 $ 9,820 Page 6 of 204

7 249 Percutaneous Cardiovascular Procedure with Non-Drug Eluting Stent w/o MCC 250 Percutaneous Cardiovascular Procedures without Coronary Artery Stent or AMI w MCC $ 9,820 $ 9,820 Page 7 of 204

8 MS- DESCRIPTION DRG 251 Percutaneous Cardiovascular Procedures without Coronary Artery Stent or AMI w/o MCC 252 Other Vascular Procedures w MCC 253 Other Vascular Procedures w CC 254 Other Vascular Procedures w/o CC/MCC 258 Cardiac Pacemaker Device Replacement w MCC 259 Cardiac Pacemaker Device Replacement w/o MCC PER CASE PAYMENT $ 9,820 $ 27,698 $ 27,698 $ 27,698 $ 16,365 $ 16, Cardiac Pacemaker Revision except Device Replacement w MCC $ 16, Cardiac Pacemaker Revision except Device Replacement w CC $ 16, Cardiac Pacemaker Revision except Device Replacement w/o CC/MCC $ 16, Acute Myocardial Infarction, Discharged alive w MCC $ 13, Acute Myocardial Infarction, Discharged alive w CC $ 13, Acute Myocardial Infarction, Discharged alive w/o CC/MCC $ 13, Acute Myocardial Infarction, Expired w MCC $ 13, Acute Myocardial Infarction, Expired w CC $ 13, Acute Myocardial Infarction, Expired w/o CC/MCC $ 13, Circulatory Disorders Except AMI with Cardiac Catheterization w MCC $ 13, Circulatory Disorders Except AMI with Cardiac Catheterization w/o MCC $ 13, Acute & Subacute Endocarditis w MCC $ 27, Acute & Subacute Endocarditis w CC $ 27, Acute & Subacute Endocarditis w/o CC/MCC $ 27,698 Page 8 of 204

9 Table 1C - Inpatient Musculoskeletal Services for which the contract rate will not be determined according to Table 1A. For an Admission that includes any of the following Inpatient Covered Services provided to a Customer, the contract rates for the entire Admission are determined as follows. MS- DESCRIPTION DRG 453 Combined Anterior/Posterior Spinal Fusion w MCC PER CASE PAYMENT $ 13, Combined Anterior/Posterior Spinal Fusion w CC $ 13, Combined Anterior/Posterior Spinal Fusion w/o CC/MCC $ 13, Spinal Fusion Except Cervical with Spinal Curve, Malignancy or 9+ $ 13,278 Fusions w MCC 457 Spinal Fusion Except Cervical with Spinal Curve, Malignancy or 9+ $ 13,278 Fusions w CC 458 Spinal Fusion Except Cervical with Spinal Curve, Malignancy or 9+ $ 13,278 Fusions w/o CC/MCC 459 Spinal Fusion Except Cervical w MCC $ 13, Spinal Fusion Except Cervical w/o MCC $ 13, Bilateral or Multiple Major Joint Procedures of Lower Extremity w MCC 462 Bilateral or Multiple Major Joint Procedures of Lower Extremity w/o MCC 466 Revision of Hip or Knee Replacement w MCC 467 Revision of Hip or Knee Replacement w CC 468 Revision of Hip or Knee Replacement w/o CC/MCC $ 24,351 $ 24,351 $ 12,171 $ 12,171 $ 12, Major Joint Replacement or Reattachment of Lower Extremity w MCC $ 12, Major Joint Replacement or Reattachment of Lower Extremity w/o MCC $ 12, Cervical Spinal Fusion w MCC $ 25, Cervical Spinal Fusion w CC $ 25, Cervical Spinal Fusion w/o CC/MCC $ 25, Hip & Femur Procedures Except Major Joint w MCC $ 11, Hip & Femur Procedures Except Major Joint w CC $ 11, Hip & Femur Procedures Except major joint w/o CC/MCC $ 11,500 Page 9 of 204

10 MS- DESCRIPTION PER CASE DRG PAYMENT 490 Back and Neck Procedures Except Spinal Fusion w CC/MCC or Disc Devices $ 25, Back and Neck Procedures Except Spinal Fusion w/o CC/MCC $ 25, Inpatient Outlier. When Eligible Charges for Covered Services rendered during a single Admission, not including any Eligible Charges for codes identified in Section 3.4 and/or 3.6, exceed $251,636 ( Inpatient Outlier Threshold ), the contract rate will be a Percentage Payment Rate of 37.1% of the Eligible Charges, for the entire Admission instead of the applicable contract rate set forth in section 2.2. For purposes of the Inpatient Outlier Threshold determination and for purpose of calculation of the Inpatient Outlier payment, all inpatient service categories are included, except Sub-Acute, Hospice, Skilled Nursing Services. Associated Eligible charges for Pass Throughs, if separately payable as Pass Throughs under section 2.2.2, and of this Appendix, are excluded from any Inpatient Outlier Threshold determination and from any calculation of the Inpatient Outlier payment High Cost Implantable Pass Through. High cost implantables (Revenue Code 0274, 0275, 0276, 0278) that are Covered Services and that have Eligible Charges greater than $2,931 per Revenue Code, are paid in addition to the contract rates set forth in this Appendix and shall be paid at a Percentage Payment Rate of 37.6% of the Eligible Charges for that Covered Service. If these additional costs are paid, then the associated Eligible Charges are excluded from any Inpatient Outlier Threshold determination and from any calculation of the Inpatient Outlier payment Inpatient High Cost Drug Pass Through. High cost drugs (Revenue Codes , 0343, 0344, 0634,0635 and 0636) that are Covered Services and that have Eligible Charges greater than $4,213per Revenue Code, are payable in addition to the contract rates set forth in this Appendix at a Percentage Payment Rate of 37.6% of the Eligible Charges for that Covered Service. If these additional costs are payable, then the associated Eligible Charges are excluded from any Inpatient Outlier Threshold determination and from any calculation of the Inpatient Outlier payment Inpatient High Cost Dialysis Pass Through. Dialysis (Revenue Codes 0809) that are Covered Services are payable in addition to the contract rates set forth in this Appendix at a Per Visit Payment of $3,307. If these additional costs are payable, then the associated Eligible Charges are excluded from any Inpatient Outlier Threshold determination and from any calculation of the Inpatient Outlier payment. 2.3 Outpatient Covered Service Categories Observation, Outpatient Therapeutic, Diagnostic, Emergency, Urgent Care Covered Services. For the provision of Observation, therapeutic, diagnostic, Emergency, and Urgent Care Covered Services rendered by Facility to a Customer on an outpatient basis (except for Outpatient Procedures addressed in section of this Appendix), the contract rate shall be determined according to this Section If more than one type of Covered Services for which a Per Visit or Payment applies is provided during one calendar day, Facility shall be paid the applicable Per Visit or Payment for each Covered Service; provided, however, if the Customer receives any Covered Service for which a Per Case Payment applies, all Covered Services which would otherwise be paid pursuant to a Per Visit or Payment, shall be included in the Per Case Payment. The contract rate for outpatient diagnostic and therapeutic Covered Services rendered by Facility to a Page 10 of 204

11 Customer, for which a Per Case, Per Visit or Payment is detailed on Table 2 below, will be determined according to the table. Table 2: Outpatient Diagnostic and Therapeutic Services Category Table OUTPATIENT DIAGNOSTIC AND THERAPEUTIC PAYMENT SERVICES METHOD RATE Rule Out Myocardial Infarction (Revenue Code 0762 with Principal ICD-9-CM Diagnosis Codes: Per Case , , , , V71.7) $ 3,990 False Labor Revenue Codes: , 0724, 0729 with Principal ICD-9-CM Per Case Diagnosis Codes $ 1,842 *Observation (Revenue Code: 0762) Per Case $ 2,045 Emergency (Revenue Codes: , 0459) Per Case $ 1,860 Urgent Care (Revenue Code: 0456) Per Case $ 1,842 Oncology Treatment Revenue Codes: 0280, 0289 $ 409 Laboratory (Revenue Codes: , 0309, 0923, 0925) $ 48 Pathology (Revenue Codes: , 0314, 0319) $ 108 Other Diagnostic Radiology (Revenue Codes , 0329) $ 216 Radiation Therapy (Revenue Code: 0330, 0333, 0339) $ 528 Chemotherapy Administration (Revenue Codes: , 0335) $ 418 Nuclear Medicine (Revenue Codes , 0349) $ 1,379 Computerized Tomography (CT) Scan (Revenue Codes , 0359) Imaging Services (Revenue Codes: 0400, 0409) ) Diagnostic and Screening Mammography (Revenue Codes: 0401, 0403) Ultrasound Imaging (Revenue Code: 0402) Positron Emission Tomography (Revenue Code: 0404) $ 1,755 $ 180 $ 297 $ 548 $ 5,754 Respiratory Services (Revenue Codes: 0410, 0412, 0419) $ 238 Hyperbaric (Revenue Code: 0413) $ 1,445 Physical Therapy (Revenue Codes: , 0429) $ 100 Occupational Therapy (Revenue Codes: , 0439) $ 100 Speech Therapy (Revenue Codes: , 0449) $ 100 Pulmonary Function (Revenue Codes: 0460, 0469) $ 205 Audiology (Revenue Codes: , 0479) $ 205 Cardiology (Revenue Code: 0480, 0489) $ 1,832 Cardiac Stress Test (Revenue Code: 0482) $ 923 Page 11 of 204

12 Echocardiology (Revenue Code: 0483) $ 205 Ambulance - Land (Revenue Codes: 0540, , ) Per Visit $ 421 Ambulance - Air (Revenue Code: 0545) Per Visit $ 9,413 Magnetic Resonance Imaging (Revenue Code: , , 0618, 0619) $ 1,866 Labor Room/Delivery Services (Revenue Code: , 0724, 0729 $ 175 EKG and ECG (Revenue Codes: 0730, 0739) $ 332 Holter Monitor/Telemetry (Revenue Codes: ) $ 920 EEG (Revenue codes 0740, 0749 without CPT codes ) $ 332 Hemodialysis (Revenue Code: , 0829) $ 350 Peritoneal Dialysis, CAPD and CCPD (Continuous Ambulatory Peritoneal Dialysis and Continuous Cycling Peritoneal Dialysis) $ 156 (Revenue Code: , , , 0859) Neuropsychological Testing and Biofeedback for NON- PSYCHIATRIC disorders only (Revenue Code: 0900, Per Visit $ ) Other Diagnostic Services (Revenue Codes: 0920, 0929 without CPT codes ) $ 170 Sleep Studies (Revenue Codes 0740, 0749, 0920, 0929 with CPT codes ) $ 3,226 Peripheral Vascular Lab (Revenue Code: 0921) $ 1,078 EMG (Revenue Code: 0922) $ 216 Allergy Testing (Revenue Code: 0924) $ 93 Other Therapeutic Services (Revenue Codes: 0940, 0949) $ 477 Education and Training (Revenue Code: 0942) $ 49 Cardiac Rehabilitation Therapy (Revenue Code: 0943) $ 59 Cyber Knife Initial Visit (Revenue Code 0333 with CPT Code G0339) Per Visit $ 15,513 Cyber Knife Subsequent Visit (Revenue Code 0333 with CPT Code G0340) Per Visit $ 6, Outpatient Procedures: This section applies to Covered Services rendered to Customer that involves a Procedure, as listed in Attachment 1 and Attachment 2 of this Appendix, performed in an outpatient unit of Facility ( Outpatient Procedure ). For Outpatient Procedures, the contract rate will be based on a designated group number, as set forth in the table below and as further described in this paragraph and Attachment 1. Unless otherwise specified in this Appendix, such payment, less any applicable Customer Expenses, shall be considered payment in full for all Covered Services rendered to Customer during an Outpatient Procedure. The group numbers below correspond with certain Outpatient Procedures identified in Attachment 1 and Attachment 2 to this Appendix. Facility is required to identify procedures by revenue code and CPT/HCPCS code to receive payment. United may revise the information in Attachment 1 and Attachment 2 based on updated Outpatient Procedure grouping information developed by CMS, which may be modified by United to include procedures that are not maintained by CMS, but are considered for payment under this Appendix in accordance with the California Provider Bill of Rights (currently set forth in Section of the California Health and Safety Code and Section of the California Insurance Code. The codes identified in Attachment 1, that are Covered Services, are considered eligible for payment under this section 2.3. Any changes to Attachment 1 and Attachment 2 must be provided in writing by United and mutually agreed to prior to implementation. Page 12 of 204

13 *The Observation rate set forth in this All Payor Appendix assumes that 20% of all Observation level of care cases have length of stays greater than 24 hours. Facility will provide United with an updated Observation length of stay mix each year and parties shall mutually agree to adjust the Observation rate either upward or downward accordingly. Exception Regarding Payment in Full. This Exception Regarding Payment in Full is applicable for PacifiCare of California HMO (Knox Keene Licensed) and PacifiCare PPO (PacifiCare Life Insurance, Inc. and PacifiCare Life Assurance, Inc.) members only and excludes all other UnitedHealthcare products. Collection of Charges from Third Parties: If a Member is entitled to payment from a third party (excluding a workers compensation carrier or primary insurance carrier under applicable Coordination of Benefits rules), PacifiCare of California assigns to Hospital for collection any claims or demands against such third parties for amounts due for Hospitals Services. Hospital agrees to act reasonably with respect to any assertion of third party liens permitted by California law and avoid any action, which would subject PacifiCare of California to any liability with respect to Hospital s pursuit of third party payment. Table 3A: Outpatient Procedure Grouper Outpatient Procedures (Revenue Codes 0360, 0361, 0369, 0481, 0490, 0499, 0750, 0759, 0790, 0799 and appropriate CPT or HCPCS Codes.) See Attachment 1 for Revenue Code and CPT or HCPCS code criteria. Group Number Per Case Payment 0 $ 1,842 1 $ 1,842 2 $ 1,909 3 $ 4,777 4 $ 6,137 5 $ 7,295 6 $ 8,320 7 $ 8,591 8 $ 8,861 9 $ 10, $ 51,639 Unlisted $ 1, Multiple Outpatient Procedures. When multiple Outpatient Procedures, including unlisted Outpatient Procedures, are performed on a Customer by Facility during one outpatient encounter, the contract rate is as follows: (1) the highest contract rate specified in section for which an Outpatient Procedure has been performed; plus (2) 50% of the contract rate specified in section for the Outpatient Procedure performed with the second highest contract rate. No additional payments for additional Outpatient Procedures performed during that outpatient encounter shall be made, except for qualifying exclusions listed herein; instead, such additional Outpatient Procedure will be considered to have been reimbursed as part of the contract rate for the first two Outpatient Procedures Multiple Per Case Payment Covered Services. If Observation, Emergency, and/or Urgent Care Covered Services are provided within a single outpatient encounter along with one or more Outpatient Procedures (as specified in section 2.3.2), reimbursement will be made for only the Outpatient Procedure; the Observation, Emergency, and/or Urgent Care service will be considered to have been reimbursed as part of the contract rate for the Outpatient Procedure. If the Customer receives any Covered Services for which a Per Case Payment applies, all Covered Services during a single outpatient encounter that would otherwise be paid pursuant to a Per Visit Payment, Payment, or Percentage Payment Rate shall instead be included in the Per Case Payment except for Covered Services eligible for reimbursement as a pass through under section or Page 13 of 204

14 If more than one Per Case Payment applies during a single outpatient encounter (as specified in section 2.3.1), the contract rate will be the rate applicable to the Covered Service with the highest ranking, as indicated in the Case Rate Service Ranking table below. No additional payments for additional Covered Services provided during that same single outpatient encounter, for which a Per Case Payment applies, shall be made; instead, such additional Covered Services will be considered to have been reimbursed as part of the contract rate for the Covered Service with the highest ranking Per Case Payment. If these Covered Services are rendered within a single outpatient encounter, then payment will be made only for the Covered Services indicated below and the other Covered Service will be considered to have been paid as part of the Covered Service. For purposes of this section 2.3.4, this table represents the case rate payment ranking. Services are ranked from the highest ranking to the lowest ranking, with Outpatient Procedures, as identified in Section 2.3.2, having the highest ranking. Case Rate Service Ranking Outpatient Procedures, as identified in Section Rule Out Myocardial Infarction False Labor Observation Emergency Room Urgent Care Outpatient High Cost Drugs. High cost drugs (Revenue Codes , 0343, 0344, 0634, 0635 and 0636) that are Covered Services and that have Eligible Charges greater than $4,213 per Revenue Code, are payable in addition to the contract rates set forth in this Appendix, at a Percentage Payment Rate of 37.6% of the Eligible Charges for that Covered Service Outpatient High Cost Implantable Pass Through. High cost implantables (Revenue Code 0274, 0275, 0276, 0278) that are Covered Services and that have Eligible Charges greater than $2,931 per Revenue Code, are paid in addition to the contract rates set forth in this Appendix and shall be paid at a Percentage Payment Rate of 37.6% of the Eligible Charges for that Covered Service. Page 14 of 204

15 SECTION 2 Glendale Adventist Medical Center-Commercial PPO, All Other Non HMO Effective January 1, 2013 through December 31, 2013 Payment for Covered Services 2.1 Payment. For Covered Services rendered by Facility to a Customer, Facility shall be paid by Payer the lesser of (1) Facility's Eligible Charges, less any applicable Customer Expenses, or (2) the contract rates herein, less any applicable Customer Expenses. Payment under this Appendix is subject to the requirements set forth in the Agreement regarding timely submission of a complete claim and compliance with applicable Protocols such as notification of Admission. 2.2 Inpatient Covered Services. For the provision of Covered Services to a Customer during an Admission, the contract rate is determined as described in this section 2.2. The contract rate for an Admission is the contract rate in effect on the date the Admission begins. Table 1A: Inpatient Service Category Table SERVICE CATEGORY Medical Refer to CMS list of MS-DRGs PAYMENT METHOD RATE $ 3,078 Surgical Refer to CMS list of MS-DRGs $ 4,197 ICU-Intermediate/ CCU-Intermediate, Telemetry, DOU Includes the following Revenue Codes. Revenue Codes: 0206, 0214 ICU/CCU Includes the following Revenue Codes. Revenue Codes: , , 0219 PICU (Pediatric Intensive Care Unit) Revenue Code: 0203 Hospice^ Revenue Codes 0115, 0125, 0135, 0145, 0155, Nursery Normal Newborn: MS-DRG 795 Lower Level Neonate: MS-DRGs 789, 792, 794 Higher Level Neonate: MS-DRGs , 793 $ 3,078 $ 4,993 $ 4,993 $ 752 $ 516 $ 5,010 $ 6,400 Page 15 of 204

16 SERVICE CATEGORY Obstetrics (Mother only) Vaginal delivery MS-DRGs , day stay case rate w/ per diem payment for additional days PAYMENT METHOD Per Case up to 2 days. beginning on day 3. RATE $ 5,147 $ 2,621 Cesarean Section MS-DRGs day stay case rate w/ per diem payment for additional days False Labor MS-DRG 780 Rehabilitation~^ MS-DRG: or Revenue Codes 0118, 0128, 0138, 0148, 0158 Hospital Sub-Acute Revenue Codes ,0199 Inpatient Skilled Nursing Services~ (see note ~ below) Bill Types Aneursym Embolism Non Ruptured MSDRGs Aneursym Embolism Ruptured MS DRGs Carotid Stenting MS DRGs Thrombolysis/Thrombolectomy MSDRGs Bariatric Surgery MS-DRG: with ICD-9CM procedure codes 44.31, 44.38, 44.39, 44.5, 44.68, 44.69, Bariatric Surgery Add-on Per Case up to 4 days. beginning on day 5. $ 7,724 $ 2,621 $ 2,175 $ 2,961 Case Rate Case Rate Case Rate Case Rate Case Rate 4 days 5+ days $ 861 $ 861 $ 55,440 $ 100,060 $ 30,696 $ 32,524 $ 23,724 $ 3078 Notes to Table 1A *Covered Services rendered to a mother and her newborn child shall be paid as separate Admissions. ~ If Facility has a separate Inpatient Skilled Nursing unit, Hospice unit, or Rehabilitation unit, the charges for the Inpatient Skilled Nursing, Hospice, or Rehabilitation stay are to be submitted separately from the acute hospital stay. ^However, this service category does not apply where one of these revenue codes is billed in connection with Covered Services included in any Per Case Payment Method service category or any service category defined by MS-DRGs or any service category defined by Bill Types on this Inpatient Service Category Table or Section 3.6, or in connection with Covered Services listed on Table 1 B and Table 1 C. Additional information regarding MS-DRG s under this Appendix are applicable to the entire Appendix, including Table 1A, 1B and 1C. Page 16 of 204

17 The following applies to MS-DRG s as used in this Appendix: -Reimbursement for a new, replacement, or modified MS-DRG code(s) will be at the existing contract rate for the appropriate MS-DRG(s) it replaced or modified, for the most current term of the Agreement. -All changes in the definition of MS-DRG s specified in the Medicare Final Rule shall be implemented under this Appendix on or before January 1, following publication in the Federal Register. Until changes in the definition are implemented under this Appendix, the previous definitions will apply. Claims with discharge dates 10/1 and later, that are processed during the period in between the CMS effective date and United s implementation date will continue to have the previous MS-DRG grouper applied. Claims with discharge dates 10/1 and later, which process following United s implementation date for the MS-DRG grouper updates will have the new grouper applied -In the event services within a MS-DRG in existence at the time this Agreement is executed are reclassified into new MS-DRG groupings, the or Case Rate reimbursement rate from the original MS-DRG(s) will apply to the succeeding MS-DRG groups for those procedures contained in the original MS-DRG(s), for the most current term of this Agreement. -All changes impacting reimbursement, due to the implementation of new, replacement, or modified MS-DRG code(s) will be revenue neutral. Facility has the right to appeal reimbursement, if Facility does not agree with the reimbursement affected by these changes, for the most current term of this Agreement. Table 1B - Inpatient Cardiac Services for which the contract rate will not be determined according to Table 1A. For an Admission that includes any of the following Inpatient Covered Services provided to a Customer, the contract rates for the entire Admission are determined as follows. MS-DRG DESCRIPTION PER CASE PAYMENT 001 w/icd , w/icd , Implant of Heart Assist System w MCC $ 90,000 Implant of Heart Assist System w/o MCC $ 90, Other Heart Assist System Implant $ 18, Cardiac Valve & Other Major Cardiothoracic Procedures with Cardiac Catheterization w MCC $ 31, Cardiac Valve & Other Major Cardiothoracic Procedures with $ 31,329 Cardiac Catheterization w CC 218 Cardiac valve & Other Major Cardiothoracic Procedures with Cardiac Catheterization w/o CC/MCC $ 31, Cardiac Valve & Other Major Cardiothoracic Procedures without Cardiac Catheterization w MCC $ 31, Cardiac Valve & Other Major Cardiothoracic Procedures without Cardiac Catheterization w CC $ 31,329 Page 17 of 204

18 221 Cardiac valve & Other Major Cardiothoracic Procedures without Cardiac Catheterization w/o CC/MCC $ 31, Cardiac Defibrillator Implant with Cardiac Catheterization with Acute Myocardial Infarction, Heart Failure or Shock w MCC 223 Cardiac Defibrillator Implant with Cardiac Catheterization with Acute Myocardial Infarction, Heart Failure or Shock w/o MCC 224 Cardiac Defibrillator Implant with Cardiac Catheterization without Acute Myocardial Infarction, Heart Failure or Shock w MCC $ 18,511 $ 18,511 $ 18,511 MS- DRG DESCRIPTION PER CASE PAYMENT 225 Cardiac Defibrillator Implant with Cardiac Catheterization without Acute Myocardial Infarction, Heart Failure or Shock $ 18,511 w/o MCC 226 Cardiac Defibrillator Implant without Cardiac Catheterization $ 18,511 w MCC 227 Cardiac Defibrillator Implant without Cardiac Catheterization $ 18,511 w/o MCC 228 Other Cardiothoracic Procedures w MCC $ 31, Other Cardiothoracic Procedures w CC $ 31, Other Cardiothoracic Procedures w/o CC/MCC $ 31, Coronary Bypass with PTCA w MCC $ 31, Coronary Bypass with PTCA w/o MCC $ 31, Coronary Bypass with Cardiac Cath w MCC 234 Coronary Bypass with Cardiac Cath w/o MCC $ 31,329 $ 31, Coronary Bypass without Cardiac Cath w MC $ 31, Coronary Bypass without Cardiac Cath w/o MCC $ 31, Major Cardiovascular Procedures w MCC $ 31, Major Cardiovascular Procedures w/o MCC $ 31, Permanent Cardiac Pacemaker Implant w MCC $ 18, Permanent Cardiac Pacemaker Implant w CC $ 18,511 Page 18 of 204

19 244 Permanent Cardiac Pacemaker Implant w/o CC/MCC $ 18, AICD Lead & Generator Procedures $ 18, Percutaneous Cardiovascular Procedure with Drug-Eluting Stent with MCC 247 Percutaneous Cardiovascular Procedure with Drug-Eluting Stent w/o MCC 248 Percutaneous Cardiovascular Procedures with Non-drug Eluting Stent w MCC 249 Percutaneous Cardiovascular Procedure with Non-Drug Eluting Stent w/o MCC 250 Percutaneous Cardiovascular Procedures without Coronary Artery Stent or AMI w MCC $ 11,108 $ 11,108 $ 11,108 $ 11,108 $ 11,108 Page 19 of 204

20 MS- DRG DESCRIPTION PER CASE PAYMENT 251 Percutaneous Cardiovascular Procedures without Coronary $ 11,108 Artery Stent or AMI w/o MCC 252 Other Vascular Procedures w MCC $ 31, Other Vascular Procedures w CC $ 31, Other Vascular Procedures w/o CC/MCC $ 31, Cardiac Pacemaker Device Replacement w MCC $ 18, Cardiac Pacemaker Device Replacement w/o MCC $ 18, Cardiac Pacemaker Revision except Device Replacement w $ 18,511 MCC 261 Cardiac Pacemaker Revision except Device Replacement w $ 18,511 CC 262 Cardiac Pacemaker Revision except Device Replacement w/o $ 18,511 CC/MCC 280 Acute Myocardial Infarction, Discharged alive w MCC $ 14, Acute Myocardial Infarction, Discharged alive w CC $ 14, Acute Myocardial Infarction, Discharged alive w/o CC/MCC $ 14, Acute Myocardial Infarction, Expired w MCC $ 14, Acute Myocardial Infarction, Expired w CC $ 14, Acute Myocardial Infarction, Expired w/o CC/MCC $ 14, Circulatory Disorders Except AMI with Cardiac $ 14,905 Catheterization w MCC 287 Circulatory Disorders Except AMI with Cardiac $ 14,905 Catheterization w/o MCC 288 Acute & Subacute $ 31,329 Endocarditis w MCC 289 Acute & Subacute Endocarditis w CC $ 31, Acute & Subacute Endocarditis w/o CC/MCC $ 31,329 Page 20 of 204

21 Table 1C - Inpatient Musculoskeletal Services for which the contract rate will not be determined according to Table 1A. For an Admission that includes any of the following Inpatient Covered Services provided to a Customer, the contract rates for the entire Admission are determined as follows. MS- DESCRIPTION PER CASE DRG PAYMENT 453 Combined Anterior/Posterior Spinal Fusion w MCC $ 15, Combined Anterior/Posterior Spinal Fusion w CC $ 15, Combined Anterior/Posterior Spinal Fusion w/o CC/MCC $ 15, Spinal Fusion Except Cervical with Spinal Curve, Malignancy or 9+ $ 15,018 Fusions w MCC 457 Spinal Fusion Except Cervical with Spinal Curve, Malignancy or 9+ $ 15,018 Fusions w CC 458 Spinal Fusion Except Cervical with Spinal Curve, Malignancy or 9+ $ 15,018 Fusions w/o CC/MCC 459 Spinal Fusion Except Cervical w MCC $ 15, Spinal Fusion Except Cervical w/o MCC $ 15, Bilateral or Multiple Major Joint Procedures of Lower Extremity w $ 27,543 MCC 462 Bilateral or Multiple Major Joint Procedures of Lower Extremity $ 27,543 w/o MCC 466 Revision of Hip or Knee Replacement w MCC $ 13, Revision of Hip or Knee Replacement w CC $ 13, Revision of Hip or Knee Replacement w/o CC/MCC $ 13, Major Joint Replacement or Reattachment of Lower Extremity w $ 13,766 MCC 470 Major Joint Replacement or Reattachment of Lower Extremity w/o $ 13,766 MCC 471 Cervical Spinal Fusion w MCC $ 28, Cervical Spinal Fusion w CC $ 28, Cervical Spinal Fusion w/o CC/MCC $ 28, Hip & Femur Procedures Except Major Joint w MCC $ 13, Hip & Femur Procedures Except Major Joint w CC $ 13, Hip & Femur Procedures Except major joint w/o CC/MCC $ 13, Back and Neck Procedures Except Spinal Fusion w CC/MCC or Disc Devices $ 28,796 Page 21 of 204

22 491 Back and Neck Procedures Except Spinal Fusion w/o CC/MCC $ 28, Inpatient Outlier. When Eligible Charges for Covered Services rendered during a single Admission, not including any Eligible Charges for codes identified in Section 3.4 and/or 3.6, exceed $251,636 ( Inpatient Outlier Threshold ), the contract rate will be a Percentage Payment Rate of 39.3% of the Eligible Charges, for the entire Admission instead of the applicable contract rate set forth in section 2.2. For purposes of the Inpatient Outlier Threshold determination and for purpose of calculation of the Inpatient Outlier payment, all inpatient service categories are included, except Sub-Acute, Hospice, Skilled Nursing Services. Associated Eligible charges for Pass Throughs, if separately payable as Pass Throughs under section 2.2.2, and of this Appendix, are excluded from any Inpatient Outlier Threshold determination and from any calculation of the Inpatient Outlier payment High Cost Implantable Pass Through. High cost implantables (Revenue Code 0274, 0275, 0276, 0278) that are Covered Services and that have Eligible Charges greater than $2,931 per Revenue Code, are paid in addition to the contract rates set forth in this Appendix and shall be paid at a Percentage Payment Rate of 40.5% of the Eligible Charges for that Covered Service. If these additional costs are paid, then the associated Eligible Charges are excluded from any Inpatient Outlier Threshold determination and from any calculation of the Inpatient Outlier payment Inpatient High Cost Drug Pass Through. High cost drugs (Revenue Codes , 0343, 0344, 0634,0635 and 0636) that are Covered Services and that have Eligible Charges greater than $4,213 per Revenue Code, are payable in addition to the contract rates set forth in this Appendix at a Percentage Payment Rate of 40.5% of the Eligible Charges for that Covered Service. If these additional costs are payable, then the associated Eligible Charges are excluded from any Inpatient Outlier Threshold determination and from any calculation of the Inpatient Outlier payment Inpatient High Cost Dialysis Pass Through. Dialysis (Revenue Codes 0809) that are Covered Services are payable in addition to the contract rates set forth in this Appendix at a Per Visit Payment of $3,774. If these additional costs are payable, then the associated Eligible Charges are excluded from any Inpatient Outlier Threshold determination and from any calculation of the Inpatient Outlier payment. 2.3 Outpatient Covered Service Categories Observation, Outpatient Therapeutic, Diagnostic, Emergency, Urgent Care Covered Services. For the provision of Observation, therapeutic, diagnostic, Emergency, and Urgent Care Covered Services rendered by Facility to a Customer on an outpatient basis (except for Outpatient Procedures addressed in section of this Appendix), the contract rate shall be determined according to this Section If more than one type of Covered Services for which a Per Visit or Payment applies is provided during one calendar day, Facility shall be paid the applicable Per Visit or Payment for each Covered Service; provided, however, if the Customer receives any Covered Service for which a Per Case Payment applies, all Covered Services which would otherwise be paid pursuant to a Per Visit or Payment, shall be included in the Per Case Payment. The contract rate for outpatient diagnostic and therapeutic Covered Services rendered by Facility to a Customer, for which a Per Case, Per Visit or Payment is detailed on Table 2 below, will be determined according to the table. Table 2: Outpatient Diagnostic and Therapeutic Services Category Table Page 22 of 204

23 OUTPATIENT DIAGNOSTIC AND THERAPEUTIC PAYMENT SERVICES METHOD Rule Out Myocardial Infarction (Revenue Code 0762 with Principal ICD-9-CM Diagnosis Codes: Per Case , , , , V71.7) False Labor Revenue Codes: , 0724, 0729 with Principal ICD-9-CM Per Case Diagnosis Codes *Observation (Revenue Code: 0762) Emergency (Revenue Codes: , 0459) Urgent Care (Revenue Code: 0456) Oncology Treatment Revenue Codes: 0280, 0289 Laboratory (Revenue Codes: , 0309, 0923, 0925) Pathology (Revenue Codes: , 0314, 0319) Per Case Per Case Per Case RATE $ 4,428 $ 2,044 $ 2,550 $ 2,110 $ 2,068 $ 460 $ 56 $ 122 Other Diagnostic Radiology (Revenue Codes , 0329) $ 242 Radiation Therapy (Revenue Code: 0330, 0333, 0339) $ 594 Chemotherapy Administration (Revenue Codes: , $ ) Nuclear Medicine (Revenue Codes , 0349) $ 1,548 Computerized Tomography (CT) Scan $ 1,972 (Revenue Codes , 0359) Imaging Services (Revenue Codes: 0400, 0409) ) $ 202 Diagnostic and Screening Mammography (Revenue Codes: 0401, 0403) $ 334 Ultrasound Imaging (Revenue Code: 0402) $ 613 Positron Emission Tomography (Revenue Code: 0404) $ 6,461 Respiratory Services (Revenue Codes: 0410, 0412, 0419) Hyperbaric (Revenue Code: 0413) Physical Therapy (Revenue Codes: , 0429) Occupational Therapy (Revenue Codes: , 0439) Speech Therapy (Revenue Codes: , 0449) $ 266 $ 1,623 $ 128 $ 112 $ 112 Page 23 of 204

24 Pulmonary Function (Revenue Codes: 0460, 0469) Audiology (Revenue Codes: , 0479) Cardiology (Revenue Code: 0480, 0489) Cardiac Stress Test (Revenue Code: 0482) Echocardiology (Revenue Code: 0483) Ambulance - Land (Revenue Codes: 0540, , ) Ambulance - Air (Revenue Code: 0545) Magnetic Resonance Imaging (Revenue Code: , , 0618, 0619) Labor Room/Delivery Services (Revenue Code: , 0724, 0729 EKG and ECG (Revenue Codes: 0730, 0739) Holter Monitor/Telemetry (Revenue Codes: ) EEG (Revenue codes 0740, 0749 without CPT codes ) Hemodialysis (Revenue Code: , 0829) Peritoneal Dialysis, CAPD and CCPD (Continuous Ambulatory Peritoneal Dialysis and Continuous Cycling Peritoneal Dialysis) (Revenue Code: , , , 0859) Neuropsychological Testing and Biofeedback for NON- PSYCHIATRIC disorders only (Revenue Code: 0900, ) Other Diagnostic Services (Revenue Codes: 0920, 0929 without CPT codes ) Sleep Studies (Revenue Codes 0740, 0749, 0920, 0929 with CPT codes ) Peripheral Vascular Lab (Revenue Code: 0921) EMG (Revenue Code: 0922) Allergy Testing (Revenue Code: 0924) Other Therapeutic Services (Revenue Codes: 0940, 0949) Education and Training (Revenue Code: 0942) Cardiac Rehabilitation Therapy (Revenue Code: 0943) Per Visit Per Visit $ 232 $ 232 $ 2,055 $ 1,037 $ 232 $ 463 $ 10,317 $ 2,096 $ 198 $ 373 $ 1,034 $ 373 $ 383 $ 170 Per Visit $ 351 $ 190 $ 3,621 $ 1,210 $ 242 $ 105 $ 536 $ 54 $ 67 Cyber Knife Initial Visit (Revenue Code 0333 with CPT Code G0339) Per Visit $ 17,220 Page 24 of 204

25 Cyber Knife Subsequent Visit (Revenue Code 0333 with CPT Code G0340) Per Visit $ 7, Outpatient Procedures: This section applies to Covered Services rendered to Customer that involves a Procedure, as listed in Attachment 1 and Attachment 2 of this Appendix, performed in an outpatient unit of Facility ( Outpatient Procedure ). For Outpatient Procedures, the contract rate will be based on a designated group number, as set forth in the table below and as further described in this paragraph and Attachment 1. Unless otherwise specified in this Appendix, such payment, less any applicable Customer Expenses, shall be considered payment in full for all Covered Services rendered to Customer during an Outpatient Procedure. The group numbers below correspond with certain Outpatient Procedures identified in Attachment 1 and Attachment 2 to this Appendix. Facility is required to identify procedures by revenue code and CPT/HCPCS code to receive payment. United may revise the information in Attachment 1 and Attachment 2 based on updated Outpatient Procedure grouping information developed by CMS, which may be modified by United to include procedures that are not maintained by CMS, but are considered for payment under this Appendix in accordance with the California Provider Bill of Rights (currently set forth in Section of the California Health and Safety Code and Section of the California Insurance Code. The codes identified in Attachment 1, that are Covered Services, are considered eligible for payment under this section 2.3. Any changes to Attachment 1 and Attachment 2 must be provided in writing by United and mutually agreed to prior to implementation. *The Observation rate set forth in this All Payor Appendix assumes that 20% of all Observation level of care cases have length of stays greater than 24 hours. Facility will provide United with an updated Observation length of stay mix each year and parties shall mutually agree to adjust the Observation rate either upward or downward accordingly. Exception Regarding Payment in Full. This Exception Regarding Payment in Full is applicable for PacifiCare of California HMO (Knox Keene Licensed) and PacifiCare PPO (PacifiCare Life Insurance, Inc. and PacifiCare Life Assurance, Inc.) members only and excludes all other UnitedHealthcare products. Collection of Charges from Third Parties: If a Member is entitled to payment from a third party (excluding a workers compensation carrier or primary insurance carrier under applicable Coordination of Benefits rules), PacifiCare of California assigns to Hospital for collection any claims or demands against such third parties for amounts due for Hospitals Services. Hospital agrees to act reasonably with respect to any assertion of third party liens permitted by California law and avoid any action, which would subject PacifiCare of California to any liability with respect to Hospital s pursuit of third party payment. Table 3A: Outpatient Procedure Grouper Outpatient Procedures (Revenue Codes 0360, 0361, 0369, 0481, 0490, 0499, 0750, 0759, 0790, 0799 and appropriate CPT or HCPCS Codes.) See Attachment 1 for Revenue Code and CPT or HCPCS code criteria. Group Number Per Case Payment 0 $ 2,079 1 $ 2,079 2 $ 2,143 3 $ 5,362 4 $ 6,888 5 $ 8,191 6 $ 9,342 7 $ 9,648 8 $ 9,948 Page 25 of 204

26 9 $ 11, $ 57,979 Unlisted $ 2, Multiple Outpatient Procedures. When multiple Outpatient Procedures, including unlisted Outpatient Procedures, are performed on a Customer by Facility during one outpatient encounter, the contract rate is as follows: (1) the highest contract rate specified in section for which an Outpatient Procedure has been performed; plus (2) 50% of the contract rate specified in section for the Outpatient Procedure performed with the second highest contract rate. No additional payments for additional Outpatient Procedures performed during that outpatient encounter shall be made, except for qualifying exclusions listed herein; instead, such additional Outpatient Procedure will be considered to have been reimbursed as part of the contract rate for the first two Outpatient Procedures Multiple Per Case Payment Covered Services. If Observation, Emergency, and/or Urgent Care Covered Services are provided within a single outpatient encounter along with one or more Outpatient Procedures (as specified in section 2.3.2), reimbursement will be made for only the Outpatient Procedure; the Observation, Emergency, and/or Urgent Care service will be considered to have been reimbursed as part of the contract rate for the Outpatient Procedure. If the Customer receives any Covered Services for which a Per Case Payment applies, all Covered Services during a single outpatient encounter that would otherwise be paid pursuant to a Per Visit Payment, Payment, or Percentage Payment Rate shall instead be included in the Per Case Payment except for Covered Services eligible for reimbursement as a pass through under section or If more than one Per Case Payment applies during a single outpatient encounter (as specified in section 2.3.1), the contract rate will be the rate applicable to the Covered Service with the highest ranking, as indicated in the Case Rate Service Ranking table below. No additional payments for additional Covered Services provided during that same single outpatient encounter, for which a Per Case Payment applies, shall be made; instead, such additional Covered Services will be considered to have been reimbursed as part of the contract rate for the Covered Service with the highest ranking Per Case Payment. If these Covered Services are rendered within a single outpatient encounter, then payment will be made only for the Covered Services indicated below and the other Covered Service will be considered to have been paid as part of the Covered Service. For purposes of this section 2.3.4, this table represents the case rate payment ranking. Services are ranked from the highest ranking to the lowest ranking, with Outpatient Procedures, as identified in Section 2.3.2, having the highest ranking. Case Rate Service Ranking Outpatient Procedures, as identified in Section Rule Out Myocardial Information False Labor Observation Emergency Room Urgent Care Outpatient High Cost Drugs. High cost drugs (Revenue Codes , 0343, 0344, 0634, 0635 and 0636) that are Covered Services and that have Eligible Charges greater than $4,213 per Revenue Code, are payable in addition to the contract rates set forth in this Appendix, at a Percentage Payment Rate of 40.5% of the Eligible Charges for that Covered Service Outpatient High Cost Implantable Pass Through. High cost implantables (Revenue Code 0274, 0275, 0276, 0278) that are Covered Services and that have Eligible Charges greater than $2,931 per Revenue Code, are paid in addition to the contract rates set forth in this Appendix and shall be paid at a Percentage Payment Rate of 40.5% of the Eligible Charges for that Covered Service. Page 26 of 204