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Home My WebLink AboutCORRESPONDENCE - RFP - P682 RENEWALS (2)Administrative Services Purchasing Division y of Fort Collins July 25, 2000 Ms. Kelly Redpath Sloans Lake Managed Care 1355 South Colorado Blvd., STE 902 Denver, CO 80222 Re: Proposal #P-682, PPO and Utilization Management Dear Ms. Redpath: The City of Fort Collins wishes to extend the agreement term for the above captioned proposal. The term will be extended for one (1) additional year, January 1, 2001 through December 31, 2001. If renewal at current fees is not acceptable for the PPO plan network access fees and case management services, effective January 1, 2001, and you are requesting a change in fees, you must provide the calculations that are used to develop these new fees. Please also send copies to Vincent Pascale, at the City of Fort Collins Human Resources and Phil Goldstein of William M. Mercer, Inc. If the renewal at current rates is acceptable to your firm, please sign this letter in the space provided and return it to the City of Fort Collins, Purchasing Division, P. O. Box 580, Fort Collins, CO 85022. Please respond in the next 15 days. If you have any questions regarding this matter, please contact Rick Tensley, CPPB at (970) 416-2247. incerely, es B. O'Neill II, CPPO, ector of Purchasing and Risk Management Signature . Date (Please indicate your desire to renew Proposal #682 by signing this letter and returning it to Purchasing Division within the next fifteen days.) cc: Mr. Vincent Pascale, Human Resources, City of Ft. Collins, PO Box 580, Ft. Collins CO 80522 Mr. Phil Goldstein, William M. Mercer, Inc. 370 17th St. STE 4000, Denver, CO 80202 256 W. Mountain Avenue • P.O. Box 580 • Fort Collins, CO 80522-0580 • (970) 221-6775 • FAX (970) 221-6707 EXHIBIT A The Network Alliance Page 18 L5696 AK/KD, PELVIC JOINT 137.37 L5697 AK/KD, PELVIC BAND 64.93 L5600 PREP,HD/HP,LAM SKT,MLD PT MDL 3301.24 L5698 AK/KD, SILESIAN BANDAGE 77.45 L5610 AK,ENDO, HYDRACADENCE SYSTEM 1990.62 L5699 SHOULDER HARNESS 138.43 L5611 AK/KD,ENDO,4-BAR LINKAGE,W/FRI 1594.94 L5700 BK REPLACE SKT,MLD PT MDL 2106.77 L5613 AK/KD,ENDO,4-BAR LINKAGE,W/HYD 2281.02 L5701 AK REPLACE SKT,MLD PT MDL 2811.92 L5614 AK/KD,EXO,4-BAR LINKAGE, W/PNEU 1273.94 L5702 HD REPLACE SKT, MLD, WHIP IT 3875.66 L5616 AK,ENDO,UNIV MUTIPLEX W/mcn 1324.04 L5704 BK CUST SHAPE REPLCMNT CVR 439.64 L5617 AK/BK QUICK CHG SELF ALGN UNIT 421.09 - L5705 AK CUST SHAPE REPLCMNT CVR _ 746.49 L5628 SYMES, TEST SOCKET - 206.41 L5706 KD CUST SHAPE REPLCMNT CVR 736.55 L.5622 BK, TEST SOCKET 269.46 L5707 HD CUST SHAPE REPLCMNT CVR 1016.24 L.5622 TEST SOCKET 270.76 L,5710 EXO, SGL AXIS MANUAL LOCK KNEE 315.10 L5624 AK, AK, TEST SOCKET L5711 EXO,SGL AXIS, MAN LOCK,ULTR 387.67 L5628 HD, TEST SOCKET 353.98 353.46 L5712 EXO,SGL AXIS,(SAFETY KNEE) 319.92 IS628 HI', TEST SOCKET 358.46 L5714 EXO,VAR FRICTION SWG PHAS CTRL 376.82 L5629 BK, ACRYLIC SOCKET 235.95 L5716 EXO,POLYCEN,MECH STANCE PHASE_ 721.49 L5630 SYMES, EXP WALL SOCKET 363.87 L5718 EXO,POLYCEN,FRCTN SW&STANCE 901.79 L5631 AK/KD, ACRYLIC SOCKET 326.21 L5722 EXO,PNEUM SWG,FRCTN STANCE PH 745.73 L5632 SYMES TYPE, PTB BRIM SOCKET 202.67 L9724 EXO,FLUID SWING PHASE CONTROL 1171.30 L5634 SYMES,POST OPEN(CANADIAN) SKT 301.12 L5726 EXO,EXT ITS FLUID SWNG PH CTRL 1291.53 L5636 SYMES, MEDIAL OPEN SOCKET 252.23 L5728 EXO,FLUID S&S PHASE CTL 2126.57 L5637 BK, TOTAL CONTACT 214.49 L5780 EXO,PNEUM/HYDRA PNEU, SWNG 853.30 L5638 BK, LEATHER SOCKET 481.76 L5785 EXO, BK, ULTRALIGHT MATERIAL 385.74 L5639 BK, WOOD SOCKET 1109.88 L5790 EXO, AK, ULTRALIGHT MATERIAL 533.84 L5640 KD, LEATHER SOCKET 632.99 L5795 EXO, HD, ULTRALIGHT MATERIAL 797.15 L5642 AK, LEATHER SOCKET 613.32 L.5810 ENDO,SGL AXIS MAN LOCK KNEE 401.31 L5643 HD, FLEX INNER SOCKET,EXT FRAM 1540.76 L5811 ENDO,SGL AXIS,MAN LOCK,ULTRALT 701.37 L5644 AK, WOOD SOCKET 584.70 L.5812 ENDO, SOL AXIS,S/S( SAFETY KNE 516.29 L5645 BK,FLEX INNER SOCKET,EXT FRAME 789.85 L5814 ENDO,POLYCEN,FLUID SWG PH CTRL 2803.77 L5646 BK, AIR CUSHION SOCKET 526.90 L5816 ENDO,POLYCEN,MECH STNC PHS LOC 841.87 L5647 BK, SUCTION SOCKET 721.09 L5818 ENDO,POLYCEN,FRIC S/S PHSE CON 950.65 L5648 AK, AIR CUSHION SOCKET 651.74 L5822 ENDO,PNEU SWG FRIC STANCE CON 1398.37 L5649 ISCHIAL CONT, NARROW ML SOCKET 1573.96 L5824 ENDO,FLUID SWG PHASE CONTROL 1518.11 L5650 AK/KD, TOTAL CONTACT 483.26 - L5828 ENDO,FLUID S/S PHASE CONTROL 2357.64 L5651 AK,FLEX INNER SOCKET,EXT FRAME 1188.81 L5830 ENDO,PNEUM/SWING PHASE CTRL 1408.81 L5652 AK/KD, SUCTION SUSPENSION 431.59 L5840 ENDO MULTIAXIAL PHEUM/SWG PHAS 2897.43 1.5653 KD, EXPANDABLE WALL SOCKET 576.13 --0845 ENDO,ADJ STANCE FLEX,KNEE-SHIN 1353.14 L5654 SYMES, SOCKET INSERT,(KEMBLO,P 247.54 L5846 ENDO,MICROPROC CNTRL,SWG PHASE 4079.54 L5655 BK,SOCKET INSERT,(KEMBLO,PELIT 196.92 L5850 ENDO,AK/HD, KNEE EXTEN ASSIST 126.64 L5656 KD,SOCKET INSERT,(KEMBLO,PELIT 284.20 - L5855 HD,MECHANICAL HIP EXTEN ASSIST 303.97 L5658 AK,SOCKET INSERT,(KEMBLO,PELIT 309.43 L5910 ENDO, BK, ALIGNABLE SYSTEM 358.53 L5660 SYMES,SOCKT INSERT,SILICONE GE 434.90 15920 ENDO, AK/KD, ALIGNABLE SYSTEM 521.63 L5661 SYMES,INSERT,MULTIDUROMETER 451.81 L5925 ENDO AK,KD,HD MANUAL LOCK 332.62 L5662 BK, SOCKET INSERT, SILICONE GE 440.92 L5930 ENDO,HIGH ACTIVITY CNTRL FRAME 2533.14 L5663 KD, SOCKET INSERT, SILICONE GE 582.83 L5940 ENDO, BK, ULTRALIGHT MATERIAL 496.55 L5664 AK, SOCKET INSERT, SILICONE GE 521.12 L5950 ENDO, AK, ULTRALIGHT MATERIAL 600.17 L5665 BK,SCKT INSERT,MULTIDUROMETER 380.15 L5960 ENDO, HD, ULTRALIGHT MATERIAL 715.74 L5666 BK, CUFF SUSPENSION 51.97 L5962 BK, SURFACE COVERING(NEW SKIN) 555.96 L5667 BK/AK,SUCTION SUSP W%LOCK MECH -1399.93 L5964 AK, SURFACE COVERING(NEW SKIN) 785.67 L5668 BK, MOLDED DISTAL CUSHION 74.97 L5966 HD, SURFACE COVERING(NEW SKIN) _ 999.09 L5669 BK/AK,SUCTION SUSP W/O LOCK 905.58 L5970 EXTERNAL KEEL, SACH FOOT 168.58 I5670 BK,MOLDED SUPRACOND SUSP(PTS) 268.61 L5972 FLEX KEEL FOOT (SAFE,STEN OR E 326.87 L5672 BK,REM MEDIAL BRIM SUSPENSION 295.19 L5974 SINGLE AXIS ANKLE/FOOT 175.43 L5674 BK,LATEX SLEEVE/EQ SUS, EA_ 50.47 L5976 ENERGY STORING FOOT(SEATTLE,CC 448.93 L5675 BK,LATEX SLEEVE/EQ SUS,HD 64.75 L5978 MULTIAXIAL ANKLE/FOOT 216.67 L5676 BK, KNEE JOINTS, SGL AXIS, PAI 332.73 L5979 MULTIAXIAL ANKLE/FOOT,DYN RESP 2050.65 L5677 BK, KNEE JOINTS,POLYCENTRIC,PA 366.07 L5980 FLEX FOOT SYSTEM 3670.35 L5678 BK, JOINT COVERS, PAIR 38.37 L5981 FLEX WALK SYSTEM, OR EQUAL 2398.49 L5680 BK, THIGH LACER, NON -MOLDED 275.89 L5982 EXO, AXIAL ROTATION UNIT 572.29 L5682 BK,THIGH LACER,GLUT/ISCH,MOLDE 464.32 L5984 ENDO, AXIAL ROTATION UNIT 447.84 L5684 BK, FORK STRAP 36.43 L5985 ALL LEP ENDO, DYNAMIC PYLON 212.50 L5686 BK, BACK CHECK (EXT CTRL) 44.81 L5986 MULTIAXIAL ROTATION UNIT (MCP) 627.29 L5688 BK, WAIST BELT, WEBBING 45.35 L5987 SHANK FOOT SYS/VERT LOAD PYLON 5430.87 L5690 BK, WAIST BELT, PADDED & LINED 72'65 L6000 ROBIN AIDS. THUMB REMAINING 986.48 L5692 AK, PELVIC CONTROL BELT, LIGHT 102.09 L6010 ROBIN A1DS.LTL/RNG FNGR REMANG 1168.77 L5694 AK,PELVIC CTL BELT, PADDED/LIN 150.16 L6020 ROBIN AIDS.NO FINGERS REMAING 1040.48 L5695 AK, NEOPRENE/EQ SUS SLEEVE 147.19 EXHIBIT A The Network Alliance Page 19 L6700 HOOK, DORRANCE/EQUAL; #3 513.51 L6050 WD,MOLD SKT,FLEX ELBOW,TRICEP 1517.74 L6705 HOOK, DORRANCE/EQUAL, #5 269.80 L6055 WD,MOLD SKT,FLEX ELB W/EXPAN I 2101.29 L6710 HOOK, DORRANCE/EQUAL, #5X 324.49 L6100 BE,MOLD SKT,FLEX ELBOW HE,TRI 1502.28 L6715 HOOK, DORRANCE/EQUAL, #5XA 339.37 L6720 HOOK, DORRANCE/EQUAL, #6 844.51 L6110 BE,MOLD SKT,MUENSTER/NW SUSP 1550.42 L6725 HOOK, DORRANCE/EQUAL, #7 395.72 L6120 BE,DBL WALL SPLIT SKT,STEP UP 1946.60 L6130 BE,SPLT SCKT,STUMP ACTVD LOCK 2100.16 L6730 HOOK, DORRANCE/EQUAL, #7LO 531.70 L6200 ED,MOLD SKT,OUTSIDE LCKG HINGE 2263.88 L6735 HOOK, DORRANCE/EQUAL, #8 288.26 L6250 ED,MLD SKLL INTERHING___ 74 L6740 HOOK, DORRANCEBQUAL, #8X 384.57 L6300 SK LOCK ELBOW LOCK AE,DBL WALL SLDR _2772 2955.58 __�6745-HOGK-, Do 87 L6750 HOOK, DORRANCE/EQUAL, #10P 339.12 L6310 B SD,PAS SKT,SHLDR BLKHD,HUM SEC 2253.02 L6755 HOOK, DORRANCE/EQUAL, #10X 327.73 L6310 SD,PASSNE RESTORATIOULDER L6320 AP CAP SD,PASSIVECAP 1352.64 L6765 HOOK, DORRANCE/EQUAL, #12P 319.52 L6360 HOR,B ,SHOULDER SECT INTERSCAP THOR,BSSIVE 3395.99 L6770 HOOK, DORRANCE/EQUAL, #99X 331.34 L6370 R ST INTRSCAP THOR,PS S REST,COM 2364.82 2364.82 L6775 HOOK, DORRANCE/EQUAL, #555 372.23 L6380 INTRSCP ASS RES C L6780 HOOK, DORRANCE OR EQ,#SS555 386.90 L6382 C OR BE IPOP, WRIST DISARTIC OR BE WRIST DIS 864.536 L6790 HOOK, ACCU HOOK OR EQUAL 347.08 L6382 IPOP, ELBOW DR RTIC AE 1175.0 1629.46 L6795 HOOK,2 LOAD, OR EQUAL 943.98 L6384 E IPOP, SHOULDER OR INTERSCAP t629.46 L6800 HOOK, APRL VC, OR EQUAL 927.19 L6386 EACH ADD CAST CHG(UPPER EX) 298.15 L6805 MODIFIER WRIST FLEXION UNIT 2 64.38 L6388 RIGID DRESSING ONLY(UPPER EX) 375.37 L6806 HOOK, TRS GRIP, VC, OR EQUAL 1220.99 L6450 BE PROS,ENDO,W/SOFT TISSUE SHA L6807 HOOK, TRS ADEPT, CHILD VC(OR E 978.35 L6500 ED PROS,ENDO,W/SOFT TISSUE SHA 3052.02 3001.32 L6808 HOOK, TRS ADEPT, INF VC,OR EQU 932.49 L6550 AE PROS,ENDO,W/SOFT TISSUE SHA 3754.04 L6809 HOOK, TRS SUPERSPORT,PASSIVE 361.49 L6570 TISSUE SHA 3906.02 L6810 PINCHER TOOL, OTTO BOCK OR EQ 163.46 L6570 IN ERSCAPROS,ENDO,W/SOFT INTERSCAP ENDO,WISFT TISSUE SH 3906.02 L6825 HAND, DORRANCE, VO 864.26 L6580 WDBE, PREP PROS, MLD PT MDL 1396.61 L6830 HAND, APRL VC 1340.54 L6582 WDBE, PREP PROS,DIRECT FORM 1362.44 L6830 HAND, SIERRA, VO 1340.54 5.0 L6584 ED/AE, PREP PROS, MLD PT MDL 1519.64 L6835 HAND, BECKER IMPERIAL 76 762.84 L6586 ED/AE, PREP PROS,DIRECT FORM 1581.10 L6840 LOCK HAND, BECKER LOCK GRIP 635.71 L6588 SD/INSCAP PREP PROS, MLD PT MD 2098.53 L6845 HAND, BECKER PLYLIT E 78.6 L6590 SD/INSCAP PREP PROS,DIRECT 2104.70 L6850 HAND, ROBINS AID, 7 .22 L6600- POLYCENTRIC HINGE, PAIR 139.26 L6855 HAND, ROBINS AID, VO SOFT 65 L6605 SINGLE PIVOT HINGE, PAIR 125.84 L6860 HAND, PASSIVE HAND 274..9 97 L6615 FLEXIBLE METAL HINGE, PAIR 144.96 L6867 HAND, DETROIT INFANT HAND(MECH 713.28 L6616 DISCONNECT LOCKING WRIST UNIT 144.96 L6868 HAND, PASSIVE INFANT HAND 178.00 L6616 ADDITIONAL DISCONNECT INSERT L6870 __HAND, CHILD MITT 214.70 L6623 FLEXIO WRIST UNIT 252.5 L6872 HAND, NYU CHILD HAND 866.32 L6623 SPRG ASST ROTATIONAL WRIST STR OTI TI 476.25 L6873 HAND, MECHANICAL INFANT HAND 347.31 L6625 ROTATION WRIST W/CABLE LOCK 394.97 394.87 L6875 HAND, BOCK, VC 577.07 L6628 QUICK DISCONNECT HOOK ADAPTER 474.22 L6880 HAND, BOCK, VO 435.46 L6629 QUICK DISCON LAM COLL W/CP PC 136.10 L680 GLOVE FOR HAND, PRODUCTION 134.46 92 L6630 STAINLESS STEEL, ANY WRIST 160.01 L6895 GLOVE FOR HAND, CUSTOM 423.74 L6632 LATEX SUSPENSION SLEEVE, EACH 64.32 L6900 PRTL HND/GLVE, THMB/FNGR RMNG 1121.43 L6635 LIFT ASSIST FOR ELBOW 153.80 L6905 PRTL HND/GLVE,MTPL FNGR RMNG 1090.06 L6637 NUDGE CONTROL ELBOW LOCK 272.61 L6910 PRTL HNDlGLVE,NO FNGRS RMNG 1061.95 L6640 SHOULDER ABD JOINT, PAIR 217.77 L6915 REPLACEMENT GLOVE, PRTL HAND 464.79 L6641 EXCURSION AMPLIFIER,PULLEY TYP 119.86 L6920 WD, SWITCH CTRL,OTTO BOCK/EQ 6023.02 L6642 - EXCURSION AMPLIFIER,LEVER TYPE 161.44 L6925 -WD, MYOELEC CTRL,OTTO BOCK/EQ 6496.04- L6645 SHOULDER FLEX/ABD JOINT, EACH 237.01 _ L6930 BE, SWITCH CTRL,OTTO BOCK/EQ 6328.36 L6650 SHOULDER UNIVERSAL JOINT,EACH 251.31 L6935 BE, MYOELEC CTRL,OTTO BOCIUEQ 6794.27 L6655 STANDARD CONTROL CABLE, EXTRA 55.77 L6940 ED, SWITCH CTRL,OTTO BOCK/EQ 8685.33 L6660 HEAVY DUTY CONTROL CABLE 69.80 L6945 ED, MYOELEC CTRL,OTTO BOCK/EQ 10104.37 L6665 TEFLON, OR EQUAL,CABLE LINING 34.19 L6950 AE,SWITCH CTRL,O BOCK/EQUAL 9872.10 L6670 HOOK TO HAND,CABLE ADAPTER 35.61 - L6955 AE,MYO CTRL,OTTOBOCK ELECTROD 11823.18 L6675 HARNESS, TY L6960 SD,SWITCH CTRL,O BOCK/EQUAL 11924.57 L6676 FIGURE HARNESS, FIGURE MINGLE 89.16 L6965 SD,MYO CTRL,OTTOBOCK ELECTROD 12919.62 L6680 CONTRCONTROL HARNESS, FIGURE B,E CONTROL 105.1 182.15 L6970 INTERSCAP/THOR SWITCH TERM DEV 13079.12 L6682 TEST SOCKET, WD/BE 198.86 L6975 INTERSCAP/THOR MYOELE TERM DEV 14012.96 L6684 TEST SOCKET, ED/AE 182.69 L7010 ELEC HAND,OTTO BOCK,SWITCH CTL '_711.66 L6686 TEST SOCKET, SD/INTERSCAP THOR L7015 ELEC HAND,SYS TEKNIK,VAR VILLG 4361.13 L6687 SUCTION SOCKET 438.31 L7020 ELEC GREIFFER,OTTO BOCK,SW CTL ''592.60 L6688 FRAME TYPE SOCKET, BE/WD 571.00 L7025 ELEC HAND,OTTOBOCK,MYO CTL 2549.58 L6689 FRAME TYPE SOCKET, 393.30 L7030 ELEC HAND,SYS TEKNIK,MYO CTL 4273.00 L6690 SO FRAME TYPE SOCKET, SD 667.01 L7035 ELEC GREIFER,OTTOBOCK, MYO 2679.66 L0691 FRAME TYPE INTERSCAP THOR 510.51 L7040 PREHENS ACTUATOR,HOSMER,SW CTL 2093.08 LG691 REMOVABLE INSERT, EACH INSESCKRT, 256.28 256.28 L7045 ELEC HOOK,CHILD,MICH, SW CTL 1200.03 L6692 SILICONE GEL INSERT OR EQUAL, 519.48 EXHIBIT A The Network Alliance Page 22 RESPIRATORY SERVICES — SLMC PPO Effective 11/1/98 MONTHLY RENTAL Concentrator-Invacare Mobile Air E1400 185.00 Concentrator- Invacare Mobile Air E1400 185.00 (w/oxygen sensing device) Home Sleep Study Physician Interpretation/Home Sleep Study NPPV — Non -Invasive Positive E0453 500.00 PressureVentilation ♦ Respiratory personnel are available 24 hours a day, 365 days a year PURCHASE 1,295.00 1,480.00 1,200.00 200.00 3,500.00 EXOGYN - ULTRASONIC BONE HEALING SYSTEM —SLMC PPO Effective II/1/98 The Exogen 2000 is a low intensity, pulsed ultrasound therapy that provides micro -mechanical forces to a fracture. This non -thermal ultrasound device is specifically programmed to promote accelerated fracture healing, but does not increase the temperature of the tissue, and therefore can be administered by the patient at home in daily 20 minute treatments. PRODUCT DESCRIPTION EXOGEN 2000 Ultrasonic Bone Healing Device - one time flat rate For Multiple Fracture Locations Pricing includes: — All necessary shipping supplies and costs I Physician Instruction Set 1 Patient Instruction Set 1 Main Operating Unit (MOU) 1 Treatment Head Module 1 Coupling Gel CONTRACTED RATE $ 2,975.00 500.00 1 Accessory Pack containing the following: 1 Template Cutting Guide 1 Target Ring Locator I Retaining Alignment Fixture (RAF) I RAF Cap Assembly 1 Felt Pad Blocks Assembly 1 Velcro Strap Performance Guarantee: EXOGEN guarantees that Exogen 2000 will provide healing of complex, difficult fractures -and/or in patients with factors known to interfere with the healing process. If healing is not achieved after 120 days of use (based on conditions below), the Exogen 2000 reimbursement fee paid will be refunded. ♦ Patient must be at least 80% compliant with the recommended daily treatment regimen of twenty (20) minutes per day per fracture site. ♦ Documented evidence of no progress to healing after 120 days of use at 80% patient compliance. North Denver Surgical Center Tax ID #84-1031869 Negotiated Rates When Covered Services are provided to a Covered Individual, the following discount applies: RATES: Twenty percent (20%) discount off billed charges to a maximum of $1,200.00 allowable per date of service. SCOPE OF SERVICE: The discounted rate includes all routine and specialized services provided by and performed by the facility's staff while at the facility. - — . INPATIENT:_ Medical/Surgical Pediatrics ICU/CCU OB (mother/well baby) Rehabilitation Psychiatric Substance Abuse EXMIT A North Suburban Medical Center Tax ID #84-1321373 Per Diems $1,124.00 $ 963.00 $1,749.00 $1,070.00 $ 749.00 $ 535.00 $ 407.00 STOPLOSS: DRG 104-107 with total billed charges over $70,000.00 shall be paid at seventy- five percent (75 %) of total billed charges. All other cases with total billed charges over $50,000.00 shall be paid at seventy-five percent (75 %) of total billed charges. Payment of claims when per diem rates apply will be based on the lesser of (a) per diem rates, or (b) billed charges. OUTPATIENT: Twenty percent (20%) discount off total billed charges EXHIBIT A Northcare Providers HOSPITALS & SURGERY CENTERS: East Morgan County Hospital -Tax ID #84-0826336 ENT SurgiCenter-Tax ID #84-1044127 Estes Park Medical Center -Tax ID #84-0601621 Haxtun Hospital Dist. -Tax ID #84-0574271 McKee Medical Center -Tax ID #84-0826332 Melissa Memorial Hospital -Tax ID #84-6014138 North Colorado Medical Center -Tax ID#84-1287638 Sterling Reg Med Center-TaID--#84 0826331 - Wray Community District Hosp.-Tax ID #84-0370617 Yuma District Hospital -Tax ID #84-0420041 The above facilities commit to the following discounts: 1. The above Hospitals agree to a discount of three percent (3 %) off total billed charges for services rendered both inpatient and outpatient. 2. The following Surgery Center: ENT SurgiCenter agrees to a discount of five percent (5 %) off total billed charges. The Northcare Hospitals will discount total billed charges by the above percentage when the Participating Plan is primary carrier on a claim. When the Participating Plan is not primary carrier on a claim the Northcare Hospitals will discount, by the above percentage, the remaining balance after subtraction of the primary carrier's payment. SKILLED NURSING: Bonnell Good Samaritan Center -Tax ID #45-0228055 708 22nd Street / P.O. Box 1508 Greeley, CO 80631-1508 970-352-6082 1. Custodial Care: $150.00 per diem 2. Level I - Skilled Nursing Care: $225.00 per diem 3. Level 11- Rehabilitation Skilled Nursing: a. 1 hour of therapy, 6 days per week; any combination of modalities: $300.00 b. 1 1h hours of therapy per day, 6 days per week_any combination of modalities: $330.00 - c. 2 hours of therapy per day, 6 days per week; any combination of modalities: - $375.00 4. Level III (Patients who meet Level I requirements with the following additional services: IV or TPN administration, contact isolation patients, specialized trachestomy care: $375.00 5. Level IV - Subacute Program: a. Physical/Occupational/Speech therapies -in excess of 2'/2 hours of therapy per day, 6 days per week: $475.00 b. Respiraory therapy in excess of 21h hours per day: $650.00 6. Level V - Ventilator Dependent Patients: $700.00 7. Level VI - Respiratory Islationn: $800.00 EXHIBIT A Orthopaedic Center of the Rockies Tax ID #84-0593455 Negotiated Rates Orthopaedic Center of the -Rockies -commits to the following discount& - Outpatient Facility Fee - a ten percent_ (10%) discount off billed charges shall apply to all Outpatient Facility Fees. Includes the following location: Orthopaedic Center of the Rockies 2500 East Prospect Road Ft. Collins, CO 80525 EXHIBIT A Orthopedic Rehab (formerly Rocky Mountain Biomech Orthotics) Services Provided by David Hardcastle Tax ID #84-1360060 1.0100 Cerv, Cranio, Helmet Molded/Patient Model 424.63 L0972 LSO- Corset Front 72.55 L0110 Cerv, Craniostenosis, Helmet, Non -Molded 93.52 L0974 TLSO- Full Corset 118.42 L0120 Cerv, Flexible, Non -Adjustable (foam collar) _ 18.10 L0976 LSO- Full Corset 138.49 L0130 Cerv, Flexible, Thermo Collar, Molded/Patient 105.44 L.0978 Axillary Crutch Extension 125,66 L 0140 Cerv, Semi -Rigid, Adjustable (plastic collar) 51.21 L0980 Peroneal Straps- Pair 11,33 1.0150 Cerv, Semi -Rigid, Adjustable Molded Chin Cup 71.71 L0982 Stocking Supporter Grips- Set of four 11.00 L0160 Cerv, Semi -Rigid, Wire Frame Occi/Mand Support 100.02 1.1000 CTLSO (Milwaukee) 1609.74 L0170 Cerv, Collar, Molded to Patient Model 415.45 L1010 Addition to CTLSO 44.88 L0172 Cerv, Collar, Semi -Rigid Thermo Foam- 2 pc 97.40 L1020 Add to CTLSO or Scoliosis Orthosis (Kyphosis pad) 57.59 L 0174 Cerv, Collar, Semi -Rigid Thermo Foam- 2 pc w/thor 233.73 L1025 Add to CTLSO/Scoliosis Orth- Kyphosis pad -floating 84.51 L0180 Cerv, Mutt Post Collar, Occi/Mand Supports 241.23 L1030 Add to CTLSO/Scoliosis Orth- Lumbar Bolster Pad 41.90 L0190 Cerv, Mutt Post Collar, Occi/Mand Supports 314.13 L1040 Add to CTLSO/Scoliosis Orthosis- Lumbar 50.53 L0200 Cerv, Mutt Post Collar, Occi/Mand Supports 372.95 L1050 Add to CTLSO/Scoliosis Orthosis- Sternal Pad 55.61 L0210 Thoracic, Rib Belt, Custom Fitted 29:25 L1060 Add to CTLSO/Scoliosis Orthosis- Thoracic Pad 63.14 L0220 Thoracic, Rib Belt, Custom Fabricated 77.44 L1070 Add to CTLSO/Scoliosis Orthosis- Trapezius Sling 59.58 L0300 Thoracic, Lumbar-Sacral-Orthosis (TLSO) Flexible 115.64 L1080 Add to CTLSO/Scoliosis Orthosis- Outrigger 47.22 L0310 TLSO, Flexible, Custom Fabricated_ 218.01 L1085 Add to CTLSO/Scoliosis Orthosis- Outrigger- Bilat 100.00 L0315 TLSO, Flexible, Elastic type 172.49 L1090 Add to CTLSO/Sciolosis Orthosis- Lumbar Sling 61.97 L0317 TLSO, Flexible, Hyperextension, Elastic type 272.69 L1100 Add to CTLSO/Sciolosis Ordiosis- Ring Flange 104.83 L0320 TLSO, Anterior -Posterior Control, w/apron front 251.78 L1110 Add to CTLSO/Scoliosis Orthosis- Ring Flange 168.90 L0330 TLSO, Ant -Post -Lateral Control, w/apron from 301.50 LI120 Add to CTLSO/Scoliosis Orthosis- Cover for Upright 26.05 L0340 TLSO, Anterior -Posterior -Lateral- Rotary Control 437.58 L1200 TLSO- Inclusive of Furnishing Initial 1296.15 L0350 TLSO, Ant-Post-Lat-Rot Control, Flex Comp Jacket 703.05 L1210 Addition to TLSO- Lateral Thoracic Extension 240.59 L0360 TLSO, Ant-Post-Lat-Roc Control, Flex Comp Jacket 1183.13 L1220 Addition to TLSO- Anterior Thoracic Extension 145.24 L0370 TLSO, Ant-Post-Lat-Rot Control, Hyperextension 265.15 L1230 Addition to TLSO- Milwaukee Type Superstructure 485.95 L0380 TLSO, Ant-Post-Lat-Rot Control, w/Extensions 425.92 L1240 Addition to TLSO- Lumbar Derotation Pad 50.02 L0390 TLSO, Ant-Post-Lat Control (Body Jacket) 1222.63 L1250 Addition to TLSO- Anterior Asis Pad 46.29 L0400 TLSO, Ant -Post -Lai Control (Body Jacket -molded) 1358.32 L1260 Addition -to TLSO- Anterior Thoracic Derotation Pad 48.76 L0410 TLSO, AntPost-Lat Control (Body Jacket-2 pc) 1529.15 L1270 Addition to TLSO- Abdominal Pad 49.57 L0420 TLSO, Ant-Post-Lat Control (Body Jacket-2 pc) 1592.30 L1280 Addition to TLSO- RIB Gusset- Elastic- each 55.57 L.0430 TLSO, Ant Post-Lat Cont(Body Jacket-w/interface) 1145.00 L1290 Addition to TLSO- Laterial Trochantedc Pad 50.12 L0440 TLSO, Ant -Post -Lan Cont (Body Jacket-w/overlap) 744.85 L1300 Other Scol Proc-Body Jacket Molded/Patient Model 1444.11 L0500 Lumbar-Sacral-Orthosis (LSO)- Flexible 88.44 L1310 Other Scol Proc- Post -Operative Body Jacket 1491.36 L0510 LSO, Flexible, Custom Fabricated 177.80 L1500 Thor -Hip -Knee -Ankle Orth(THKAO)-Mobility Frame 1355.97 L0515 LSO, Flexible, Elastic Type w/Rigid Posterior 138.56 L15IO THKAO- Standing Frame 1027.70 L0520 LSO, Ant-Post-Lat Control (Knight, Wilcox types) 274.16 L1520 THKAO- Swivel Walker 1487.44 L0530 LSO, Ant -Post Control (Macausland type) - 356.67 L1600 Hip Orthosis (HO)- Abduction Control/ Hip Its 89.33 L0540 LSO, Lumbar Flexion (Williams Flexion type) 370.62 L1610 _ HO- Abduction Control/Hip Jts-Flex-Frejka Cover 28.62 L0550 LSO, Ant -Post -Lateral Control (Batty Jacket) - 1070.27 L1620 HO- Abduction Control/Hip Its-Flex-Pavlik Harness 88.26 L0560 LSO, Ant-Post-Lat Control (Body Jacket -molded) 1-190.63 L1630 HO- Abduction Control/Hip Jts-Semi-Flex (VonRosen) -111.31 L0565- LSO, Ant-Post-Lat Cont (Body Jacket -custom fit) 748.77 L1640 HO- Abduct Control/Hip Jts-Pelvic Band/Spread Bar) 358.34 L0600 Sacroiliac, Flexible- Custom Fitted 79.10 L1650 HO- Abduction Control/Hip Jts- Adj- Custom Fitted 167.24 L0610 Sacroiliac, Flexible- Custom Fabricated 169.90 L1660 HO- Abduction Control/Hip Jts-Plastic- Custom Fit 109.07 L0620 Sacroiliac, Semi -Rigid- w/apron front 274.75 L1680 HO- Abduction Control/Hip Jts-Dynamic-Pelvic Cont 802.72 1,0700 Cervical_Thomcic-Lumbar-Sacral-Orthoses (CTLSO) 1323.25 L1685 HO- Abd Control/Hip Jts-Post Op Hip Abd Type 757.26 L0710 CTLSO, Anterior -Posterior -Lateral Control 1557.28 L1686 HO- Abduction Control/Hip Jts-Post Op Custom 685.74 L0810 Halo Procedure-Cery Halo incorp into Jacket 1677.11 L1700 Legg Perthes Orthosis- Toronto Type 996.07 L0820 Hato Proc-Cery Halo incorp/plaster body jacket 1423.34 L1710 Legg Perthes Orthosis- Newington Type 1159.26 L0830 Halo Proc-Cery Halo incorp into Milwaukee type 2053.61 L1720 Legg Perthes Orthosis- Trilateral (Tachoijan type) 902.99 L0860 Addition to Halo Proc-Magnetic Reasonance Image 1093.09 L1730 Legg Perthes Orthosis- Scottish Rite type 739.21 L0900 Torso Support- Ptosis Support- Custom Fitted 107.89 L1750 Legg Perthes Orthosis- Sling (Sane Brown type) 127.42 L0910 Torso Support- Ptosis Support- Custom Fabricated 220.33 L1755 Legg Perthes Orthosis- Patten Bottom type 1070.23 L0920 Torso Support -Pendulous Abdomen Support- Fitted 126.46 L1800 Knee Orthosis (KO)- Elastic w/stays 42.51 L0930 Torso Support -Pend Abdomen Support -Fabricated 246.04 L1810 KO- Elastic w/joints 68.89 L0940 Torso Support -Post Surgical Support -Custom Fitted 101.33 L1815 KO- Elastic w/Condylar Pads 63.19 L0950 Torso Support -Post Surgical Support- Fabricated 221.54 L1820 KO- Elastic w/Condylar Pads & Joints 97.93 L0960 Torso Support -Post Surgical Support- Pads 44.95 L0970 TLSO- Corset Front 99.60 EXHIBIT A Orthopedic Rehab Page 2 L2260 Add/Lower Extremity -Reinforced Solid Stirrup 169.83 L2265 Add/Lower Extremity-Lorig Tongue Stirrup 78.57 L1925 KO- Elastic Knee Cap 35.78 L2270 Add/Lower Extremity-VarusfValgus Correct 41.36 L1830 KO- Immobilizer- Camas Longitudinal 63.60 L2280 Add/Lower Extremity -Molded Inner Boot 326.69 L1832 KO- Adjustable Knee Jts- Rigid Support- Custom Fit 397.49 L2300 Add/Lower Extremity -Abduction Bar-Bilat Hip 172.07 L1834 KO- w/o Knee Jt- Rigid- Molded to Patient Model 534.33 L2310 Add/Lower Extremity -Abduction Bar -Straight 102.94 L1840 KO- Derotation- Medial -Lateral -Ant Cmc Lig-Fitted 602.30 12320 Add/Lower Extremity -Non Molded Lacer 136.31 L1845 KO- Double Upright -Thigh & Calf- Adj Flexion 555.74 L2330 Add/Lower Extremity -Lacer Molded/Padent Model 282.23 L1846 KO- Double Upright-Tbigh/Calf-w/adjust Flexion 688.11 L2335 Add/Lower Extremity -Anterior Swing Band 161.11 L1850 .._ _ KO- Swedish tytx.- 232 05 z2340 Add/Lower o .. er a""-_:r Pro _Tibial Shell --Molded 28&.88 L1855 KO- Molded Plastic -Thigh & Calf- doub upr knee jt 721.09 L2350 Add/Lower Extremity -Prosthetic Type -Molded 612.42 L1858 KO- Molded Plastic-Polycentric Knee It (knee pads) 893.78 L2360 Add/Lower Extremity-Etended Steel Shank 38,75 L1860 KO- Modification/Supracondylar Prosthetic Socket 749.04 12370 Add to Lower Extremity- Patten Bomom 167.25 L1870 KO- Double Upright- Thigh & Calf Lacers- Molded 687.45 I.2375 Add/Lower Extremity -Torsion Control -Ankle A 72.58 L1880 KO- Double Upright- Non -molded Thigh/Calf Lacers 483.55 L2380 Add/Lower Extrem-Tors Control -Straight Knee it 104.67 L1900 Ankle -Foot Orthosis (AFO)- Spring Wire 231.15 I2385 Add/Lower Extrem-Straight Knee It -Heavy Duty 119.60 L1902 AFO- Ankle Gauntlet Custom Fitted 51.82 U390 Add/Lower Extremity -Offset Knee Jt-ea jt 94.57 L1904 AFO- Molded Ankle Gauntlet- Molded/Patient Model 327.83 I2395 Add/Lower Extremity -Offset Knee A -Heavy Duty 134.73 LIM AFO- Multiliga>mmus Ankle Support 102.67 12405 Add to Knee JdDrop Lock- ea jt 43.07 L1910 AFO- Post- Single Bar- Clasp Attach/Shoe Counter 201.07 L2415 Add to Knee Jt- Cam Lock (Swiss, French, Bail) 119.17 L1920 AFO- Single Upright w/Static or Adjus Stop 303.44 12425 Add/Knee Jt- Disc or Dial Lock-Adj Knee Flexion 119.74 L1930 AFO- Custom Fitted - Plastic 164.43 L2435 Add/Knee Jt- Polycentric Jt- ea jt 108.03 L1940 AFO- Molded to Patient Model- Plastic 321.82 L2492 Add/Knee Jt- Lift Loop for Drop Lock Ring 79.66 L1945 AFO- Mold/Patient Model -Plastic -Rigid Am Fib Sect 620.69 L2500 Add/Lower Extremity -Thigh/ Weight Beating 219.41 L1950 AFO- Spiral- Molded to Patient Model (IRM type) 548.35 L2510 Add/Lower Extremity-Thigh/Wt Beating -Molded 476.91 L1960 AFO- Posterior Solid Ankle- Molded/Patient Model 362.99 L2520 Add/Lower Extremity-Thigh/Wt Bearing -Custom 328.35 L1970 AFO- Plastic Moded to Patient Model- Ankle Joint 498.06 L2525 Add/Lower Extremity-Thigh/Wt Bearing-Lcchial $98.17 L1980 AFO- Single Upright Free Plantar Dorsiflexion 267.38 12526 Add/Lower Extremity-Thigh/Wt Bearing -Ischia( 573.89 L1990 AFO- Double Upright Free Plantar Dorsiflexion 286.98 L2530 Add/Lower Extremity-Thigh/Wt Bear -Non Molded 197.62 L2000 Knee-Ankle-Foot-0Ntoses (KAFO)- Single Upright 746.65 L2540 Add/Lower Extremity-Thigh/Wt Bear -Molded 305.52 L2010 KAFO- Single Upright- Thigh & Calf Bands 703.18 L2550 Add/Lower Extremity-Thigh/Wt Bear -High Roll Cuff 255.65 L2020 KAFO- Double Upright- Thigh & Calf Bands 754.91 L2570 Add/Lower Extremity -Pelvic Control -Hip A 307.55 L2030 KAFO-Doub Upright -Solid Stirrup-Thigh/Calf Bands 665.13 L2580 Add/Lower Extremity -Pelvic Control -Pelvic Sling 360.10 L2036 KAFO- Full Plastic-Doub Upright- Free Knee -Mold 1530.34 L2600 Add/Lower Extrem-Pelvic Cont-Hip A-Clevis type 175.90 L2037 KAFO- Full Plastic -Single Upright -Free Knee -Mold 1078.23 L2610 Add/Lower Extrem-Pelvic Cont-Hip R-Thrust 191.11 L2038 KAFO- Full Plastic -w/o Knee Jt-Molded to Patient 939.78 L2620 Add/Lower Extrem-Pelvic Cont-Hip Jt-Heavy Duty 191.75 L2040 Hip -Knee -Ankle -Ft Orthosis(HKAFO)-Torsion Cont 152.41 L2622 Add/Lower Extrem-Pelvic Cont-Hip Jt-Adjust Flex 203.61 L2050 HKAFO- Torsion Control- Bilateral Cables- Hip 396.22 L2624 Add/Lower Extrem-Pelvic Cont-Hip It -Adjust Flex _ 212.62 L2060 HKAFO- Tors Cont- Bilat Cables-Ballbear Hip it 438.41 L2627 Add/Lower Extrem-Pelvic Cont-Plastic-Molded 1358.21 L2070 HKAFO- Torsion Control- Unilateral Rotation Straps 87.38 L2628 Add/Lower Extrem-Pelvic Cont-Metal Frame 1301.74 L2080 HKAFO- Torsion Control- Unilat Torsion Cable -Hip 256.35 L2630 Add/Lower Extrem-Pelvic Cont-BandfRelt-Unilat 217.89 L2090 HKAFO- Torsion Control- Unilat Torsion Cable -Ball 345.37 L2640 Add/Lower Extrem-Pelvic Cont-Band/Belt-Bilat 234.95 L2102 Ankle-Foot-Orthosis (AFO)- FX Orthosis-Tibial FX 310.89 L2650 Add/Lower Extrem-Pelvic/Thoracic Cont-Gluteal Pad 78.57 L2104 AFO- FX Orthosis-Tibial FX Cast Orthosis 327.12 L2660 Add/Lower Extrem-Thoracic Cont-Thoracic Band 155.07 L2106 AFO- FX Ordwsis-Tibial FX Cast Orthosis-Thermo 437.27 L2670 Add/Low Extrem-Thoracic Cont-Pataspinal Upright 145.10 L2108 AFO- FX Orthosis-Tibial FX Cast Orthosis-Molded 908.35 L2680 Add/Low Extrem-Thoracic Cont-Lat Support Upright 133.50 L2112 AFO- FX Orthosis-Tibial FX Orth-Soft Custom Fit 316.89 L2750 Add/Lower Extrem-Orthosis-Plating Chrome -per bar 53.06 L2114 AFO- FX Orthosis-Tibial FX Orth-Semi-Rigid Fit 410.24 12760 Add/Lower Extrem-Ordmis-Extension Qer bar 52.33 L2116 AFO- FX Ordlosis-Tibial FX Orth-Rigid Custom Fit. _ 45&.69 L2770 Ad&Lower Extrem-Orthosis-Stainless Steel -per bar 50.15 L2122 Knee -Ankle -Foot- Orthosis (KAFO) FX Orthosis 531.33 L2780 Add/Lower Extrem-Orthosis-Non Corrosive Finish 43.50 L2124 KAFO- FX Orthosis-Femoral FX Cast-Orth-Synth 658.65 L2785 Add/Lower Extrem-Orthosis-Drop Lock Retainer, ea 20.62 L2126 KAFO- FX Orthosis-Femoral FX Cast Orth-Thermo 865.34 L2795 Add/Low Extrem-Orthosis-Knee Cont-Full Kneecap 55.74 L2128 KAFO- FX Orthosis-Femoral FX Cast Orth-Molded 1170.10 L2800 Add/Low Extrem-Orthosis-Knee Cont-Medial _ 69.89 L2132 KAFO- FX Orthosis-Fem FX Cast Orrh-Soft Fitted 621.98 L2810 Add/Low Extrem-Orthosis-Knee Cont-Condylar Pad 49.53 L2134 KAFO- FX Orth-Fem FX Cast Orth-Semi Rigid Fit_ 649.12 L2820 Add/Low Extrem-Orthosis-Soft Interface -Mold Platt 67.24 L2136 KAFO- FX Orth-Fem FX Cast Orth-Rigid Custom 847.96 L2830 Add/Low Extrem-Orthosis-Soft Interface -Mold Plast 82.27 L2180 Add to Lower Extremity FX Orthosis-Plastic Shoe 90.87 L2840 Add/Low Extrem-Orthosis-Tibial Length Sock-FX 27.71 L2I82 Add/Lower Extremity FX Orth-Drop Lock Knee Jt 60.62 L2850 Add/Low Extrem-Orthosis-Femoral Length Sock-FX 51.81 L2184 Add/Lower Extremity FX Orth-Limit Motion Knee A 85.39 L3215 Orthopedic Footwear -Ladies Shoes -Oxford 82.65 L2186 Add/Lower Extrem FX Orth-Adjust Motion Knee It 111.43 L3219 Orthopedic Footwear -Mons Shoes -Oxford 105.32 L2188 AddlLower Extrem FX Orth-Quadrilaterial Brim 191.42 L3650 Shoulder Orthosis (SO)- Figure of "8" Design 38.53 L2I90 Add/Lower Extremity FX Orth-Waist Belt 59.66 L3660 SO -Figure of "S" Design-Abd Restrainer -Canvas 68.68 L2192 Add/Lower Extremity FX Orth-Hip Jt-Pelvic Band 236.71 L3670 SO-Acromio/Clavicular-Canvas & Webbing type 72.68 L.2200 Add/Lower Extremity -Limited Akle Mo6onea jt 39.09 L3700 Elbow Orthosis (EO)- Elastic w/stays 45.77 L2210 Add/Lower Extremiry-Dorsiflexion Assist 56.93 L3710 EO- Elastic w/Metal Joints 78.89 L2220 Add/Lower Extremity-Dorsiflexion & Plantar Flex 63.44 L3720 EO- Double Upright/Forearm/Arm Cuffs 428.92 L2230 Add/Lower Extremity -Split Flat Caliper Stirrups 55.59 L3730 EO- Double Upright w/Foreamt/Amt Cuffs-Exten 574.61 12240 Add/Lower Extremity -Round Caliper & Plate Attach 57.69 L3740 EO- Double Upright w/Forearm/Arm Cuffs -Adjust 676.38 L2250 Add/Lower Extremity -Foot Plate, Molded to Patient 286.96 .-_N EXHIBIT A Orthopedic Rehab Page 3 L4055 Replace Non -Molded Calf Lacer ' 171.49 L4060 Replace High Roll Cuff 282.72 L3800 Wrist-Hand-Finger-Orthoses-(WHFO)Short Opponens 165.70 L4070 Replace Proximal/Distal Upright for KAFO 208.51 L3805 WHFO- Long Opponens- No Attachment 268.48 L4080 Replace Metal Bands KAFO- Proximal Thigh 67.30 L3810 WHFO- Add to Short/Long Opponens-Thumb Abd 55.78 L4090 Replace Metal Bands KAFO-AFO-Calf/Distal Thigh 62.46 L3815 WHFO- Add to Short/Long Opponens-2nd M P 51.58 L4100 Replace Leather Cuff KAFO- Proximal Thigh 69.46 L3820 WHFO- Add to Short/Long Opponens- I P Exten 83.78 L4110 Replace Leather Cuff KAFO- Calf/Distal Thigh 58.50 L3825 WHFO-Add in Short/Long Opponens-MP Exten-Stop 53.80 L.4130 Replace Pretibial Shell 331.45 L3830 WHFO=Add to Short/Long Oppon- MP Exten-Assist 65.68 L.4310 Multi-Podus/Equal Otthotic Preparatory Mgmt 332.61 L3835 WHFO-Add to_Shgrt(Long Qorwn_ MP Spring 69.56 L.4320 Add to AFO-Multi-Podus Orthotic Prep Mgmt 97.96 _ L3840 WHFO-Add to Short/Long Oppon- Spring Swivel 45.03 L4350 Pneumatic Ankle control Splint-Aircast or Equal 58.71 L3845 WHFO-Add to ShordLong Oppon-Thumb IP Exten 65.99 L4360 Pneumatic Walking Splint- Aircast or Equal 197.21 L3850 WHFO-Add to Short/Long Oppon-Action Wrist 80.29 L4370 Pneumatic Full Leg Splint-Aircast or Equal 134.93 1,3855 WHFO-Add to Short/Long Oppon-Adjust MP -Flex 83.43 L4380 Pneumatic Knee Splint- Aircast or Equal 69.81 L3860 WHFO-Add to ShortlLong Oppon-Adjust MP 116.44 L 5000 Partial Foot -Shoe Insert w/Longitudinal Arch 340.02 L3900 WHFO- Dynamic Flexor Hinge-Rec Wrist Exten 873.49 L5010 Partial Foot -Molded Socket- Ankle Height 1026.48 L3901 WHFO- Dynamic Flexor Hinge-Rec Wrist Exten 1156.64 L5020 Partial Foot -Molded Socket- Tibial Tubercle Ht 18M.31 U902 WHFO- External Powered- Compressed Gas 1851.16 L5050 Ankle- Symes- Molded Socket- sach foot 1751.76 L3904 WHFO- External Powered- Electric 2202.58 L.5060 Ankle- Symes-Metal Frame -Molded Leather Socket 2293.58 L3906 WHFO- Wrist Gauntlet- Molded to Patient Model 269.24 L5100 Below Knee- Molded Socket- Skin- Bach foot 1606.06 L3907 WHFO- Wrist Gauntlet- w/Thumb Spica 322.88 L5105 Below Knee -Plastic Socket -As & Thigh Lacer 2645.72 L3908 WHFO- Wrist Extension Control Cock -Up -Canvas 42.17 L5150 Knee Disarticulation-Molded Socket-Ext Its 2735.46 L3910 WHFO- Swanson Design 290.41 L5160 Knee Disarticulation-Molded Socket -Bent Knee 2965.83 L3912 WHFO- Flexion Glove w/ Elastic Finger Control 72.06 L5200 Above Knee- Molded Socket- Single Axis 2391.06 L3914 WHFO- Wrist Extension Cock -Up 55.24 L5210 Above Knee -Short Prosthe-No Knee It -Foot Blocks 1901.57 L3916 W -IFO- Wrist Extension Cock -Up w/Outrigger 80.79 L5220 Above Knee -Short Prosthe-No Knee Jt-Articulated 2125.36 L3918 WHFO- Knuckle Bender 50.45 L5230 Above Knee -for Proximal Femoral Focal Deficiency 3559.43 L3920 WHFO- Knuckle Bender w/Outrigger 63.13 - L5250 Hip Disarticulation-Canadian type -Hip it 4368.74 L3922 WHFO- Knuckle Bender- 2 Segment to Flex its 63.54 L5270 Hip Disarticulation-Tilt Table type -Locking It 4191.98 L3924 WHFO- Oppenheimer 69.02 L5280 Hemipelvecomy-Canadian type -Hip it 4577.49 L3926 WHFO- Thomas Suspension 60.36 L5300 Below Knee -Molded Socket-Sach Foot 1959.95 L3928 WHFO- Finger Extension w/Clock Spring 37.46 L5310 Knee Disarticulation- Molded Socket-Sach Foot 3345.10 L3930 WHFO- Finger Extension w/Wrist Support 40.44 L5320 Above Knee- Molded Socket-Sach Foot 2953.15 L3932 WHFO- Safety Pin- Spring Wire 29.94 L5330 Hip Disarticulation-Canadian type -Molded Socket 4854.58 L3934 WHFO- Safety Pin- Modified 31.24 L5340 Hemipelvecomy-Canadian type -Molded Socket 5295.13 L3936 V rHFO- Palmer 57.47 L5400 Immediate Post Surg/Early Fitting -Rigid Dressing 997.03 L3938 WHFO- Dorsal Wrist 59.35 L5410 Immediate Post Surgical or Early Fitting 289.92 L3940 WHFO- Dorsal Wrist w/Outrigger Attachment - 68.79 L5420 Immediate Post Surg/Earty Fitting -Rigid Dressing - 1279.05 L3942 WHFO- Reverse Knuckle Bender 48.95 L5430 Immediate Post Surg-Early Fitting -Initial Appli 346.05 L3944 WHFO- Reverse Knuckle Bender w/Outrigger 63.52 L5450 Immed Post Surg/Early Fitting -Non Wt Bearing 368.57 L3946 WHFO- Composite Elastic 57.63 L5460 Immed Post Surg/Early Fitting -Application 491.89 L3948 WHFO- Finger Knuckle Bender 35.45 L5500 Initial -Below Knee PTB type Socket 1198.96 L3950 WHFO- Comb Oppenheimer w/Knuckle Bender 97.85 L5505 Initial -Above Knee- Ischia[ Level Socket 1491.50 L3952 WHFO- Comb Oppenheimer w/Rev Knuckle Bender 109.09 L5510 Preparatory Below Knee PTB type Socket-USMC 1253.35 L3954 WHFO- Spreading Hand 67.81 L5520 Preparatory Below Knee PTB type Socket-USMC 1086.42 I3960 Shoulder -Elbow -Wrist Hand Orthosis (SEWHO) 486.65 L5530 Preparatory Below Knee PTB type Socket-USMC 1516.23 L3962 SEWHO- Abduction Position- ERBS Palsey Design 450.96 1.5535 Preparatory Below Knee PTB type Socket-USMC- 1168.91 L3963 SEWHO- Molded w/Articulating Elbow Joint 1059.62 L5540 Preparatory Below Knee PTB type Socket-USMC 1589.96 L3964 SEWHO- Mobile Arm Support-Attach/wheetchair 479.22 L5560 Preparatory Above Knee-Isctiral Level Socket 1783.27 L3965 SEWHO- Radial Arm Support-Attach/wheerchair 759.66 L5570 Preparatory Above Knee-Ischial Level Socket 1878.97 L3966 SEWHO- Mobile Arm Support-Attach/wheetchair 596.57 L5580 Preparatory Above Knee-Ischial Level Socket 2173.47- L3968 SEWHO- Mobile Arm Support-Attach/wheelchair 675.64 L5585 Preparatory Above Knee-Ischial Level Socket 2166.80 L3969 SEWHO- Mobile Arm Supp-Monosuspen-Arm/Hand 493.67 L5590 Preparatory Above Knee-Ischial Level Socket 2225.66 L3970 SEWHO- Addition/Mobile Arm Supp-Elevate Arm 208.72 L5595 Preparatory- Hip Disarticulation-Hemipelvectomy 2766.69 L3972 SEWHO- Addition/Mobile Arm Supp-Offset/Lat 167.42 L5600 Prep -Hip Disardculation-Hemipelvectomy-Pylon 3077,96 L3974 SEWHO- Addition/Mobile Arm Supp-Supinator 106.27 L5610 Add to Lower Extremiry-Above Knee-Hydracadence 1734.10 L3980 Upper Extremity FX Orthosis- Humeral 198.15 L5611 Add to Lower Extremity -Above Knee-Disarticulation 1353.08 L3982 Upper Extremity FX Orthosis- Radius/Ulnar 279.57 L5613 Add to Lower Extremity -Above Knee-Disarticulation 1930.75 L3984 Upper Extremity FX Orthosis- Wrist 266.73 L5616 Add to Lower Extremity -Above Knee-Univ Multiplex 1255.43 L3985 Upper Extremity FX Orthosis- Forearm/Hand 389.60 L5618 Add to Lower Extrenilty-Test Socket-Symes 194.53 L 3986 Upper Extremity FX Orthosis- Combination 361.48 L5620 Add to Lower Extremity -Test Socket -Below Knee 195.62 L3995 Add/Upper Extrem Orthosis- Sock FX or Equal 21.06 L5622 Add to Lower Extremity -Test Socket-Disarticulation 251.36 L4000 Replace Girdle for Milwaukee Orthosis 862.45 L5624 Add to Lower Extremity -Test Socket -Above Knee 273.61 LA010 Replace Trilateral Socket Brim 444.59 L5626 Add/Lower Extrem-Test Socket -Hip Disarticulation 329.89 L4020 Replace Quadrilateral Socket Brim- Molded 569.88 L5628 Add,'Lower Extremiry-Test Socket-Hemipelvectomy 333.44 L4030 Replace Quadrilateral Socket Brim- Custom Fit 330.13 L5629 Add/Lower Extremity -Below Knee -Acrylic Socket 216.80 L4040 Replace Molded Thigh Lacer 284.18 L5630 Add/Low Exrrem-Symes type -Expand Wall Socket 313.13 L4045 Replace Non -Molded Thigh Lacer 238.94 L5631 Add/Low Extrem-Above Knee -Acrylic Sock 299.97 L4050 Replace Molded Calf Lacer 274.39 July 11, 2000 Ms. Kelly Redpath Sloans Lake Managed Care 1355 South Colorado Boulevard Suite 902 Denver, Colorado 80222 Subject: City of Fort Collins - January 1, 2001 Renewal Dear Kelly: As you are aware, the City of Fort Collins' (the City) medical plans renew effective January 1, 2001. Please provide us with the renewal for the PPO plan network access fees and case management services, effective January 1, 2001. In addition to receiving the new access fees, we would like to see the calculations that are used to develop these new fees. We need to receive this renewal as soon as possible. Please also send copies of the renewal to Vincent Pascale at the City, and Phil Goldstein of William M. Mercer, Inc. at the following address: 370 17th Street, Suite 4000 Denver, Colorado 80202 If you have any questions, please call me at (970) 221-6779. Sincerely, James B. O'Neill II, CPPO PEG:GLR:Ikb Copy: Mr. Vincent Pascale Mr. Phil Goldstein G:\Prectice\H&g\CityF[C\Pricingl20011slmc622.doc EXHIBIT A Orthopedic Rehab Page 4 L5811 Add -Endo Knee -Shin Syst-Single Axis -Ultra Light 596.89 L5812 Add -Endo Knee -Shin Syst-Sing Axis -Friction Swing 515.01 L5632 Add/Low Extrem-Symes type-PTB Brim Design 201.47 L5816 Add -Endo Knee -Shin Syst-Poly-Meth Stance 772.53 L5634 Add/Low Extrem-Symes type -Canadian Socket 278.90 L5818 Add -Endo Knee -Shin Syst-Poly-Friction Swing 889.99 L5636 Add/Low Extrem-Symes type -Medial Open Socket 233.22 L5822 Add -Endo Knee -Shin Syst-Sing Axis-Pneumat Swing 1492.30 L5637 Add/Low Extrem-Below Knee -Total Contact 208.49 L5824 Add -Endo Knee -Shin Syst-Single Axis -Fluid Swing 1430.30 L5638 Add/Low Extrem-Below Knee -Leather Socket 447.02 L5828 Add -Endo Knee -Shin Syst-Single Axis -Fluid Swing 2249.72 L5639 Add/Low Extrem-Below Knee -Wood Socket 1006.71 L5830 Add -Endo Knee -Shin Syst-Single Axis -Pneumatic 1340.43 L5640 Add/Low Extrem-Knee Disarticul-Leather Socket 585.25 L5850 Add-Endoskeletal Syst-Above Knee or Hip Disart 114.60 L5642 Add/Low Extrem-Above Knee -Leather Socket---- - 578.16- -- r ce,- � "- �azndeSyst Balsw K+teo Aligaabl0 system 379.41 L5643 Add/Low Extrem-Hip Disardcul-Flex Inner Socket 1346.53 L5920 Add -Endo Syst-Above Knee or Hip Disarticulation 482.75 L5644 Add/Low Extrem-Above Knee -Wood Socket 548.63 L5940 Add-Endoskeletal Syst-Below Knee -Ultra Lt Mat 466.64 L5645 Add/Low Extrem-Below Knee -Flex Inner Socket 721.60 L5950 Add-Endoskeletal Syst-Above Knee -Ultra Lt Mat 535.38 L5646 Add/Low Extrem-Below Knee -Air Cushion Socket 418.04 L5960 Add -Endo Syst-Hip Disarliculation-Ultra Lt Mat 679.53 L5647 Add/Low Extrem-Below Knee Suction Cup 725.05 1,5962 Add-Endoskid Sys Below Knee, Flex Prtc Srf-eg. 711/97 481.92 L5648 Add/Low Extrem Above Knee - Air Cushion Socket 617.28 L5970 All Lower Extremity Prostheses-Foa/Sach Foot 171.43 L5649 Add/Low Extrem-Ischial Containment 1383.16 L5972 All Lower Extremity Prostheses -Flex Keel Foot 292.80 U650 Add/Low Extrem-Total Coact -Above Knee - 465.11 L5974 All Lower Extremity Prostheses -Foot -Sing Axis 174.62 L5651 Add/Low Extrem-Above Knee -Flex Inner Socket 1120.34 L5976 All Lower Extrem Prostheses -Energy Storing Foot 445.28 L5652 Add/Low Extrem-Suction Suspension -Above Knee 414.04 L5978 All Lower Extrem Prostheses -Foot -Multiaxial 211.26 L5653 Add/Low Extrem-Knee Disarticul-Expand Socket 545.28 L5980 All Lower Extrem Prostheses -Flex Foot System 3404.20 15654 Add/Low Extrem-Socket Insert-Symes 257.36 L5982 All Exo Lower Extrem Prostheses -Axial Rotation 550.45 L5655 Add/Low Extrem-Socket Insert -Below Knee 205.39 L5984 All Endo Lower Extrem Prostheses -Axial Rotation 419.49 L-5656 Add/Low Extrem-Socket Insert -Knee Disarticulation 275.23 11986 All Lower Extrem Prostheses -Multi Axial Rotation 557.97 L5658 Add/Low Extrem-Socket Insert -Above Knee 306.59 L6000 Partial Hand -Robin Aids -Thumb Remaining 930.08 L5660 Adda ow Extrem-Socket Imert-Sjymes-Silicone Gel 406.44 L6010 Partial Hand -Robin Aids -Little &/or Ring Finger 1081.72 L5661 Add/Low Extrem-Socket Im-Multi-Durometer Symes 418.07 L6020 Partial Hand -Robin Aids -No Finger Remaining 994.73 L5662 Add/Low Extrem-Socket Ins -Below Knee-Sil Gel 431.71 L6050 Wrist Disart-Molded Socket--l1ex Elbow Hinges 1483.57 L5663 Add/Low Extrem-Socket Ins-Disarticl-Sil Gel 494.32 L6055 Wrist Disart-Molded Socket w/Expand Interface 1982.76 L5664 Add/Low Extrem-Socket Ins -Above Knee-Sil Gel 467.20 L6100 Below Elbow -Molded Socket Flex Elbow Hinge 1453.79 L5665 Add/Low Extrem-Socket Ins-Multi-Duro-Below Knee 353.93 L6110 Below Elbow -Molded SkKMuenster/Northwestem) 1540.63 L5666 Add/Low Extrem Below Knee -Cuff Suspension 46.97 L6120 Below Elbow -Molded Double Wall Split Socket 1737.63 L5667 Add/Low Ext Below/Above Knee-Sckt Ins etc-e f. 7/1/97 1213.49 L6130 Below Elbow -Molded Dbl Wall Spt Skt-Stump Act 1921.58 L5668 Add/Low Extrem-Below Knee -Mold Distal Cushion 68.08 L6200 Elbow Disarticulation-Outside Locking Hinge 2076.53 - L5670 Add/Low Extrem-Below Knee -Molded Supracondylar 246.02 L6205 Elbow Disarticulation-Expandable Interface 2533.01 L5672 Add/Low Extrem-Below Knee -Rem Med Brim Susp 285.16 L6250 Above Elbow -Molded Dbl Wall Skt-Int Luck Elbow 1960.48 L5674 Add/Low Extrem-Below Knee -Latex Sleeve Susp 49.73 L6300 Shoulder Disarticulation -Molded Socket 2732.90 L5675 Add/Low Extrem-Below Knee -Latex Sleeve Susp 65.58 L6310 Shoulder Disarticulation-Passive Rector -Complete 2099.66 L5676 Add/Low Extrem-Below Knee -Knee Jts-Single Axis 327.47 L6320 Shoulder Disarticulation-Passive Resor-Cap only 1272.74 L5677 Add/Low Extrem-Below Knee -Knee Jts-Polycentric 344.72 L6350 Interscapular Thoracic -Molded Socket 3378.91 L5678 Add/Low Extrem-Below Knee-Jt Covers -Pair 35.76 L6360 Imarscapular Thoracic -Passive Restor-Complete 2184.59 L5680 Add/Low Extrem-Below Knee -Thigh Lacer 278.13 L6370 Interscapular Thoracic -Passive Restor-Cap only 1435.74 L SM Add/Low Extrem-Belem Knee -Thigh Lacer-Gluteal 458.68 L6380 Immediate Post Surg/Early Fitting -Rigid 845.53 L.5684 Add/Low Extrem-Below Knee -Fork Strap 36.10 L.6382 Immediate Post Surg/Early Fitting -Rigid 1137.81 L5686 Add/Low Extrem-Below Knee -Back Check 40.02 L6384 Immediate Post Surg/Early Fitting -Rigid 1526.79 L5688 Add/Low Extrem-Below Knee -Waist Belt -Webbing 42.15 L6386 Immed Post Surg/Early Fitting -ea add cast change 300.82 L5690 Add/Low Extrem-Below Knee -Waist Belt -Padded 67.39 L6388 Inured Post SurglEarly Fitting -Rigid Dressing only 396.17 L5692 Add/Low Ext-Above Knee-Peiv Cont Belt -Light 101.93 L6400 Below Elbow -Molded Socket-Endoskeletal Syst 2147.03 L.5694 Add/Low Ext-Above Knee-Peiv Com Belt -Padded 147.86 L6450 Elbow Disarticulation-Molded Socket -Endo Syst 2700.38 L 5695 Add/Low Extrem-Above Knee-Pelvic.Control 137.63 L6500 Above Elbow -Molded Socket -Endo Syst-Soft Prosth 2845.92 L 5696 Add/Low, Extrem-Above Knee-Disat-Pelvic It 126.98 - L6550 Shoulder Disarticulation-Molded Socket -Endo Syst 3418.45 L5697 AddfLow Extrem-Above Knee-Disart-Pelvic Band 55.46 L6570 Interscapular thoracic -Molded Socket -Endo Syst 3624.73 L5698 Add/Low Extrem-Above Knee-Disart-Silesian 72.77 L6580 Prep -Wrist DisartBelow Elbow -Plastic Socket 1344.38 L5699 - All Lower Extremity Prostheses -Shoulder Harness 127.73 L6582 Prep -Wrist DisartBelow Elbow -Single Wall Ski 1285.45 L5710 Add- Exoskeletal Knee -Shin System -Single Axis 302.80 L6584 Prep -Elbow DisartlBelow Elbow -Plastic Socket 1426.56 1,5711 Add-Exoskeletal Knee -Skin System -Single Axis 363.12 L6586 Prep -Elbow Disarr/Above Elbow -Single Wall Ski 1392.76 L5712 Add-Exoskeletal Knee -Shin System -Friction Swing 320.23 L6588 Prep -Shoulder Disardlnterscapular Thoracic 1964.22 L5714 Add-Exoskeletal Knee -Shin System -Variable Friction 352.66 L6590 Prep -Shoulder Disarniterscapular Thoracic 1862.28 L5716 Add-Exoskeletal Knee -Shin System-Polycentric-Meth 672.20 L 6600 Upper Extremity Additions-Polycentric Hinge 128.68 L5718 Add-Exoskeleud Knee -shin System-Poly-Frict Swing 845.01 L6605 Upper Extremity Additions -Single Pivot Hinge 128.88 L5722 Add-Exo Knee -Shin Syst-Single Axis-Pneumat Swing 765.22 L6610 Upper Extremity Additions -Flexible Metal Hinge 131.19 L5724 Add-Exo Knee -Shin Syst-Single Axis -Fluid Swing 1141.59 L6615 Upper Extremity Add -Disconnect Locking Wrist Unit 126.99 L5726 Add-Exo Knee -Shin Syst-Single Axis-Ext Jts 1224.21 L6616 Upper Extremity Add -Disconnect Insert 44.92 L5728 Add-Exo Knee -Shin Syst-Single Axis -Fluid Swing 2193.36 L6620 Upper Extremity Add -Flexion Friction Wrist Unit 247.64 L5780 Add-Exo Knee -Shin Syst-Single Axis -Pneumatic 839.89 L6623 Upper Extremity Add -Spring Asst Rotational Unit 445.01 L5785 Add-Exoskeleml Syst-Below Knee -Ultra Lt Mat 357.87 L6625 Up Extrem Add -Rotation Wrist Union w/Cable Lock 357.I 7 L 5790 Add-Exoskeletal Syst-Above Knee -Ultra Lt Mat 498.66 L6628 Upper Extrem Add -Quick Disconnect Hook Adapter 440.11 L5795 Add-Exoskeleml Syst-Hip Disart-Ultra Lt Mai 721.12 L6629 Upper Extrem Add -Quick Discon Lamination Collar 133.80 L5810 Add -Endo Knee -Shin Syst-Single Axis -Manual Lock 399.46 EXHIBIT A Orthopedic Rehab Page 5 L6890 Terminal Device -Glove for above Hands -Production 133.22 L6895 Terminal Device -Glove for above Hands -Custom 445.66 L6630 Upper Extrem Add -Stainless Steel -any Wrist 150.44 L6900 Hand Restor (Casts, shading included) Partial Hand 1043.33 L6632 Upper Extrem Add -Latex Suspension Sleeve 60.83 L6905 Hand Restor (Casts, shading, measurements inc) 1020.05 L6635 Upper Extremity Addition -Lift Assist for Elbow 152.29 L6910 Hand Restor (Casts, shading, measurements inc) 1021.62 L6637 Upper Extremity Add -Nudge Control Elbow Lock 251.68 L6915 Hand Restor (Shading & Measurements inc) 431.58 L6640 Upper Extrem Add -Shoulder Abduction It -Pair 221.13 L6920 Wrist Disarticulation-Self Susp Inner Socket 5199.61 L6641 Upper Extrem Add -Excursion Amplifier -Pulley type 129.60 L6925 Wrist Disarticulation-Self Susp Inner Socket 5605.75 L6642 Upper Extrem Add -Excursion Amplifier -Lever type 149.96 L6930 Below Elbow-Ext Power -Self Susp Inner Socket 5593.49 L6645 Upt)er Extrem Add -Shoulder Flexion -Abduction It 219.93 L6935 Below Elbow-Ext Power -Self Susp Inner Socket 6140.66 _ L6650 Upper Extrem Add -Shoulder Universal It - 232.37 L6940 Elbow Disart-Ext Power -Molded Inner Socket 8112.35 L6655 Upper Extrem Add -Standard Control Cable 53.35 L6945 Elbow Disart-Ext Power -Molded Inner Socket 8962.66 L6660 Upper Extrem Add -Heavy Duty Control Cable 64.77 L6950 Above Elbow-Ext Power -Molded Inner Socket 9601.98 L6665 Upper Extrem Add -Teflon or Equal Cable Lining 31.14 L6955 Above Elbow-Ext Power -Molded Inner Socket 11418.15 L6670 Upper Extrem Add -Hook to Hand -Cable Adapter 32.56 L6960 Shoulder Disart-Ext Power -Molded Inner Socket 9897.06 L6672 Upper Extrem Add-Hamess-Chest/Shoulder-Saddle 153.88 L6965 Shoulder Disart-Ext Power -Molded Inner Socket 11005.94 L6675 Upper Extrem Add-Hamess-Figure "8" type -Single 80.42 L6970 Interscap•Thorac-Ext Power -Molded Inner Socket 10969.32 L6676 Upper Extrem Add -Harness -Figure "8" type -Dual 103.69 L6975 Interscap-Thorac-Ext Power -Molded Inner Socket 11945.66 L6680 Upper Extrem Add -Test Socket -Wrist Disarticuladon 180.23 L7010 Electronic Hand -Otto Bock-Steeper/Equal-Switch 2478.00 L6682 Upper Extrem Add -Test Socket -Elbow Disarticulation 194.74 L7015 Electronic Hand -System Teknik-Switch Controlled 4082.78 L6684 Upper Extrem Add -Test Socket -Shoulder Disart 255.74 L7020 Electronic Greifer-Otto Bock -Switch Controlled 2483.42 L6686 Upper Extremity Addition -Suction Socket 405.04 L7025 Electronic Hand -Otto Bock-Myoelectronically Cont 2435.18 L6687 Upper Extrem Add -Frame Skt-Below Elbow/Wrist 528.07 L7030 Electronic Hand -System Teknik-Myolectron Cont 3994.80 L6688 Upper Extrem Add -Frame Skt-Above Elbow/Wrist 372.98 L7035 Electronic Greifer-Otto Bock-Mycelectron Cont 2515.33 L6689 Upper Extrem Add -Frame Skt-Shoulder Disart 571.14 L7040 Prehensile Actuator-Hosmer-Switch Controlled 1926.27 L6690 Upper Extrem Add -Frame Skt-Interscapular-Thoracic 475.27 L7045 Electronic Hook -Child -Michigan -Switch Controlled 1067.51 L6691 Upper Extrem Add -Removable Insert- each 234.49 L7160 Electronic Elbow -Boston -Switch Controlled 10328.77 L6692 Upper ExtrenrAdd-Silicone Gel Insert 485.76 L7165 Electronic Elbow-Boston-Myoelectronically Cont 12500.36 L6700 Terminal Device-Hook-Dorrame/Equal-Model #3 477.58 L7170 Electronic Elbow-Hosmer-Switch Controlled 4254.35 L6705 Terminal Device-Hook-Dorrance/Equal-Model #5 275.14 L7180 Electronic Elbow-Utah-Myoelectronically Cont 25018.55 L6710 Terminal Device-Hook-Dorrance/Equal-Model #5X 315.55 L7185 Electron Elbow-Adol- Variety Village -Switch Cont 4411.22 L6715 Terminal Device-Hook-Dortattce/Equal-Model #5XA 321.32 L7186 Electronic Elbow -Child -Variety Vill-Switch Cont 8031.16 L6720 Terminal Device-Hook-Dorrance/Equal-Model #6 788.30 L7190 Electronic Elbow -Adolescent -Variety Village 5547.72 L6725 Terminal Device-Hook-Dorrance/Equal-Model #7 369.09 L7191 Electronic Elbow-Child-VarietyVill-Myo Cont 7803.50 L6730 Terminal Device-Hook-Dorrance/Equal-Model #71,0 535.16 L7260 Electronic Wrist Rotator -Otto Bock/Equal 1636.47 L6735 Terminal Device-Hook-Dorrance/Bqual-Model #8 277.36 L7261 Electronic Wrist Rotator for Ural Arm 3073.58 L6740 Terminal Device-Hook-Dorrance/Equal-Model #8X 359.47 L7266 Servo Control- Steeper or Equal 693.62 L6745 - Terminal Device-Hook-Dorrance/Equal-Model #88X 329.00 L7272 Analogue Control- UNB or Equal 1540.26 L6750 Terminal Device-Hook-Dorrance/Equal-Model #10P 321.21 L7274 Proportional Control-12 Volt-Utah/Equal 455638 L6755 Terminal Device-Hook-Dorrance/Equal-Model #10X 314.31 L7360 Six Volt Battery- Otto Bock or Equal -each 157.41 L6765 Terminal Device-Hook-Dorrance/Equal-Model #12P 302.23 L7362 Battery Charger- Six Volt- Otto Bock or Equal 231.15 L6770 Terminal Device-Hook-Dorrance/Equal-Model #99X 324.04 L7364 Twelve Volt Battery -Utah or Equal- each _ 278.20 L6775 Terminal Device-Hook-Dor-rance/Equal-Model #555 355.94 L7366 Battery Charger -Twelve Volt- Utah or Equal 381.15 L6780 Term Device-Hook-Dorrance/Equal-Model #SS555 380.43 L8000 Breast Prosthesis- Mastecromy Bra 25.41 L6790 Terminal Device-Hook-Accu Hook/Equal 340.29 L8010 Breast Prosthesis- Mastecromy Sleeve 54.07 L6795 Terminal Device-Hook-2 Load or Equal 901.30 L8020 Breast Prosthesis- Mastectomy Form 140.48 L6800 Terminal Device-Hook-APRL VC or Equal 864.90 L8030-- Breast Prosthesis- Silicone or Equal 239.79 L6805 Terminal Device Modifier Wrist Flexion Unit 263.66 L8300 Truss- Single w/Standard Pad 69.41 L6806 Terminal Device-Hook-TRS-Grip-VC - 91434 L8310 Truss- Double w/Standard Pads 113.43 E6807 _ Terminal Device-Hook-TRS Adept -Child -VC 906.72 L8320 Truss- Addition to Standard Pad- Water Pad _ 37.39 L6808 Terminal Device-Hook-TRS Adept-Infant-FC 788.19 L8330 Truss- Addition to Standard Pad- Scrotal Pad - 33.65 L6809 Terminal Device-Houk-TRS Super Sport -Passive 340.80 L8400 Prosthetic Sheath- Below Knee- each 11.08 L6810 Terminal Device -Pincher Tool Otto Bock/Equal 172.45 1_8410 Prosthetic Sheath- Above Knee- each 16.90 L6825 Terminal Device -Hand- Dorrance-VO 85433 L8415 Prosthetic Sheath- Upper Limb- each 15.90 L6830 Terminal Device -Hand- APRL-VC 1246.31 L8420 Prosthetic Sock- Wool- Below Knee- each 13.56 - L6835 Terminal Device -Hand- Sierra-VO 1072.57 L8430 Prosthetic Sock- Wool- Above Knee- each - 15.76 L6840 Terminal Device -Hand- Becker Imperial 685.03 L8435 Prosthetic Sock- Wool- Upper Limb- each 14.76 L6845 Terminal Device -Hand- Becker Lock Grip 600.32 L8440 Prosthetic Shrinker- Below Knee- each 28.86 L6850 Terminal Device -Hand- Becker Plylite 543.94 L8460 Prosthetic Shrinker- Above Knee- each 45.65 L6855 Terminal Device -Hand- Robin Aids- VO 744.81 L8465 Prosthetic Shrinker- Upper Limb- each 35.33 L6860 Terminal Device -Hand- Robin Aids- VO Soft 618.71 L8470 Stump Sock- Single Ply- Fining- Below Knee -each 6.33 L6865 Terminal Device -Hand- Passive Hand 288.22 L8480 Stump Sock- Single Ply 8.51 L6867 Terminal Device -hand- Dermit Infant Hand 662.80 L8500 Artificial Larynx- any type 460.35 L6868 Terminal Device -Hand- Passive Infant Hand 171.21 L8501 Tracheostomy Speaking Valve 81.61 L6870 Terminal Device -Hand- Child Mitt 197.62 L6872 Terminal Device -Hand- NYU Child Hand 846.36 L6873 Terminal Devicc-Hand- Mechanical Infant Hand 321.87 L6875 Terminal Device -Hand- Bock- VC 586.13 L6880 Terminal Devicc-Haim- Bock- VO 398.97 1*.411I:T1117.\ Parker Valley Hope Tax ID #48-0728186 A. Residential Inpatient Program: Per. diem__include5 inpatient-t=tu=t program with room board alb theservices, psychological testing/evaluation, admission physical, normal lab and medication (excludes those medicines not part of physician's standing orders), radiology. Spouse/significant other participation is up to five (5) days. Length of Stay Per Diem First 10 days $250.00 Day 11 through 20 $180.00 Day 21 or more $100.00 B. Intensive Outpatient/Day Treatment Program: Admissions accepted any weekday, patient must be ambulatory with detoxification completed prior to admission to day care. Per diem includes all therapeutic services, psychological testing/evaluation, admission physical, normal lab and medication (excludes those medicines not part of physician's standing orders), radiology. Drug screens taken during program at cost. Nursing staff on duty, lunch provided. Spouse/significant other participation is up to five (5) days. Length of Stay Per Diem First 10 Days $225.00 Day 11 to 20 $155.00 Day 21 or more $ 75.00 C. Non-HosRital Detoxification: Includes 24-hour nursing staff supervision, physician consultation, room/board, all therapeutic services, psychological-testing/evaluation, admission physical, normal lab and medication (excludes those medicines not part of physician's standing orders), radiology. Per Diem $225.00 Payment of claims when per diem rates apply will be based on the lesser of (a) per diem rates, or (b) billed charges. EXHIBIT A Penrose -St. Francis Healthcare System Tax ID #84-0405257 Includes services at Penrose Penrose Community, and St. Francis Hospitals. I. Inpatient Service Rate Medical (1) $1,000 per diem Surgical $1,350 per diem Pediatrics $1,000 per diem Obstetrics -Vaginal Delivery (2) $1,150 per diem Obstetrics-C Section (2) $1,250 per diem Boarder Baby (3) $ 350 per diem Psych -Child $ 370 per diem Psych -Adult $ 580.per diem Skilled Nursing Facility (5) $ 400 per diem Trauma $1,300 per diem Rehabilitation (7) $1,000 per diem ICU/CCU $2,000 per diem ICN/Level II Nursery (4) _ _ $1,700 per diem Adolescent Treatment Facility (6) $ 370 per diem Heart Cases $2,200 per diem (DRGs 104-107, 112, 115-118 & 124-125) (1) Any service currently provided by Hospital which is not listed above will be reimbursed at the Medical rate. However, new rates will be negotiated for any new service established by the Hospital after the effective date of the contract. (2) OB rate includes mother and well baby while both are in hospital. (3) Applies to all non-ICN infants (ie., boarder or sick baby). (4) The Level II nursery rates applies to infants in the intensive care unit (including intermediate intensive care at PCH). (5) Skilled Nursing Facility: Glockner/Fransican Inn - Penrose Hospital _ 2215 N.-Cascade Ave. - Colorado Springs, CO 80907 (6) Residential (Adolescent Treatment): Brockhurst Program - St. Francis Health Center (7) Rehabilitation: Capron Institute for Rehabilitation - Penrose Hospital 2215 N. Cascade Avenue Colorado Springs, CO 80903 STOP -LOSS If total charges exceed $35,000 reimbursement will be 80% of total billed charges in lieu of per diem. Reimbursement Can Payment of claim when per diem rates apply will be based on the lesser of (a) per diem rates, or (b) billed charges. EXHIBIT A Penrose -St. Francis Healthcare System Page 2 II. Outpatient All O/P services, 25 % off billed charges III. Total Healthcare dba Surgery --Ltd.- Total Healthcare dba Surgery Ltd. 10% off billed charges 320 E. Fontanero, Ste. 101 Colorado Springs, CO 80907 Tax ID #84-0927232 IV. Langstaff -Brown Medical Center The following location is covered under this Agreement and is considered to be part of the Penrose -St. Francis Healthcare System. A discount of 5% off billed charges should be taken on those provider who have been credentialed and are considered to be in network. They are covered under the Interstate Health Services Tax ID #84-0405257. Langstaff -Brown Medical Center Hwys 67 & 24 Woodland Park, CO 80863 V. LATE PAYMENTS Payments from the Participating Plan are due to Hospital within 30 days of bill date. Hospital agrees to notify Participating Plan of any late payments. If payment is not made within 45 days of the bill date, then the Participating Plan shall pay 100 % of the billed amount. This provision shall apply only to clean claims, or not requiring material additional information for which the Participating Plan is primary carrier. The Participating Plan agrees that all claim appealsproperly submitted to SLMC for consideration cf the Participating -Provider's allowable amount, which is based on Exhibits A and B; shall be adjusted by the Participating Plan's claim administrator, if applicable, within thirty (30) days of receipt of the claim appeal by the Participating Plan's claim administrator. If SLMC receives claim appeals that exceed one percent (1 %) of the Participating Plan's total claim volume based on the claim report referred to in Section 4.2. the Participating Plan shall be charged fifty dollars ($50.00) for each claim appeal received as a result of incorrect Repricing by the Participating Plan's claim administrator SLMC shall be responsible for sending the Participating Plan an itemized statement on a monthly basis. The Participating Plan shall remit payment to SLMC within thirty (30) days of receipt of the itemized statement. EXHIBIT A Pikes Peak Pain Program Tax ID #84-1273376 Negotiated Rates _Pikes Peak Pain Program rates will be allowed as follows: Code: Amount 97799 Initial Evaluation $ 500.00 99199PP Phoenix Program $3,300 per week Usual length of program is 3 weeks, full days 99199MP Modified Phoenix Program $1,650 per week Usual length of program is 6 weeks, half days 99199AP AIR Program 15 % discount Customized program • Physician services will be billed separately and allowed according to the most current version of McGraw Hill RVS. • All other services, except physician services 15 % off billed charges EXHIBIT A Platte Valley Medical Center Tax ID #84-0482695 Negotiated Rates Platte yalley Medical CenteLcommits to the following discounts: 1. Inpatient Services - A ten (10%) percent discount from billed charges shall apply to all inpatient services rendered. 2. Outpatient Services - A ten (10%) percent discount from billed charges shall apply to all outpatient services rendered. The Medical Center will discount total billed charges by the above percentage when the Participating Plan is primary carrier on a claim. When the Participating Plan is not primary carrier on a claim the Medical Center will discount, by the above percentage, the remaining balance after subtraction of the primary carrier's payment. "�*\ EXHIBIT A PorterCare Hospital PorterCare Hospital -Littleton Tax ID #84-0438224 INPATIENT SERVICES: Service: Medical/Surgical Pediatrics ICU/CCU Neonatal Level II OB (mother/well baby) Boarder Baby Rehabilitation Transitional Care Hospice (Billed by Porter Hospice) Acute Residential Psychiatric Substance Abuse Per Diem: $1,050.00 $ 900.00 $1,635.00 $1,250.00 $1,000.00 $ 275.00 $ 700.00 $ 500.00 $ 475.00 $ 195.00 $ 500.00 $ 380.00 Transplants kidney, kidney/pancreas and liver are excluded from the above inpatient rates, and are to be paid with a discount of twenty percent (20%) aff total billed charges. Payment of claims when per diem rates apply will be based on the lesser of (a) per diem rates, or (b) billed charges. STOP LOSS: DRG 104-107 with total billed charges over $70,000.00 shall be paid at seventy- five percent (75%) of total billed charges. All other cases with total billed charges over $50,000.00 shall be paid at seventy-five percent-(75 %) of total billed charges. TPA (Activase) shall be reimbursed in addition to other applicable charges at the rate of $2,222.00 per 100 milligrams. — OUTPATIENT SERVICES: Twenty percent (20%) discount off billed charges EXHIBIT A Poudre Care Connection, Inc. (Formerly Poudre Valley Hospital District's Home Health Services) Tax ID #84-1117603 Service R.N. Nursing L.P.N. Nursing Therapies (Physical, Speech & Occupational) Medical Social Services Home Health Aide Per Visit Rate (2 Hr.) $ 80.00 $ 55.00 $ 75.00 $100.00 $ 45.00 The compensation paid to Provider shall be as stated below on a per diem basis plus the average wholesale price (AWP) of each medication. AWP pricing shall be that in effect of the most current issue of "REDBOOK", a standard industry publication. Antibiotic Therapy - Per diem Rate Single Drug $120.00 Two Drugs $180.00 Hydration Therapy Per Diem Rate Hydration Therapy — - 1 Liter $ 70.00 2 Liter $ 80.00 3 Liter $ 90.00 Hweralimentation Therapy Per Diem Rate TPN Therapy 1 Liter $150.00 TPN Therapy 2 Liter _ $185.00- - TPN Therapy 3 Liter $200.00 - Enteral Nutrition Per Diem Rate — Enterals 1-1600 ml/day - $ 30.00 Su lies Discount All Supplies 15 % discount off total billed charges (effective 9/1/95) The per diem rate includes all professional and ancillary items reasonably related to the specific IV/nutritional therapy being performed. EXHIBIT A Poudre Valley Hospital Tax ID #84-1262971 Negotiated Rates Poudre Valley Hospital commits to the following discounts: 1. Inpatient Services - A two (2) percent discount from the amount payable by the Participating Plan shall apply to all inpatient services rendered and will not include amounts owed by Covered Individual. 2. Outpatient Services - A two (2) percent discount from the -amount payable by the Participating Plan shall apply to all outpatient services rendered and will not include amounts owed by Covered Individual. Time Frame for Claims Payment Discount is subject to payment being received within twenty (20) days from date of receipt of the billing form. The Participating Plan agrees to remit payments due from them within twenty (20) days of receipt of the Hospital billing by the Participating Plan's claims administrator on claims not requiring additional information for processing of the claim or claims not involving coordination of benefits.. For processing of a claim when the Participating Plan is secondary carrier or when additional information is required, the Participating Plan agrees -to remit -payments due from them within twenty (20) days of receipt of the information by the Participating Plan's claims administrator required to process the claim. If a claim is not paid within the time frame specified above, Pourdre Valley Hospital's Negotiated Rate shall not apply and no discount will be taken on the claim by the Participating Plan's claims administrator. The Participating Plan agrees that all claim appeals properly submitted to SLMC for consideration of the Participating Provider's allowable amount, which is based on Exhibits A and B, shall be adjusted by the Participating Plan's claim administrator, if applicable, within thirty (30) days of receipt of the claim appeal by the Participating Plan's claim administrator. If SLMC -receives claim appeals that exceed one percent (1 %) of the Participating Plan's total claim volume based on the claim report referred to in Section 4.2, the Participating Plan shall be charged fifty dollars ($50.00) for each claim appeal received as a result of incorrect Repricing by the Participating Plan's claim administrator SLMC shall be responsible for sending the Participating Plan -an itemized statement on a monthly basis. The Participating Plan shall remit payment to SLMC within thirty (30) days of receipt of the itemized statement. EXHIBIT A The Network Alliance Page 11 EQUIPMENT/SUPPLIES DESCRIPTION -HCPC CODE CONTRACTED PRICE TENS: ECONOMY TENS E0730 $ 100.00 ECONOMY RENTAL -----E0730RR---_— STAODYN MAXIMA H E0730 $ 350.00 STAODYN MAXIMA III E0730 $ 495.00 STAODYN NUWAVE E0730 $ 495.00 MONTHLY RENTAL E0730RR $ 39.00 NMS.- STAODYN EMS+2 E0745 $ 650.00 EMS+2 RENTAL E0745RR $ 75.00 STANDARD NMS E0745 $ 550.00 STANDARD RENTAL E074M $ 75.00 PGS.- STAODYN SPORTX E0745 $ 595.00 SPORTX RENTAL E0745RR $ 63.00 PGS 3000 E0745 _ _ $ 950.00 PGS 3000 RENTAL E0745RR $ 150.00 SURFACE EMG: PATHWAY MR-20 E0746 $1,195.00 MR-20 RENTAL E0746RR $ 300.00 INTERFERENTL4L: QUAD IF4 E1399 _ $1,125.00 QUAD IF4 RENT E1399RR $ 150.00 OTHER: PERINEONOMETER II- Vag Probe E1399 $ 88.00 PERINEONOMETER III - Vag Probe E1399 $ 99.00 PERINEONOMETER - Rec. Probe E1399 $ 75.00 REFURBISHMENT OF TENS, NMS & PGS UNITS $ 85.00 ADDITIONAL SUPPLIES/ACCESSORIES: 30% discount from billed cc arges ****2 MONTHS RENTAL WILL APPLY TOWARD PURCHASE**** 13OfM - Presbyterian St. Luke's Medical Center Tax ID #84-1321373 INPATIENT: Medical Surgical ICU/CCU Pediatrics OB-Normal 1-Day Case Rate (Inc. Level 1) OB-C/Section 3 Day Case Rate (Inc. Level 1) Additional OB Days (Inc. Level I) Level I Nursery (Boarder Baby) Level II NICU Level III NICU Cardiac Services (DRG 104-111) Chemical Dependency Services: Detoxification - Adult & Adolescent Transitional Care Unit Transplants All Other Inpatient Services PER DIEMS $ 972.00 $1,235.00 $1,850.00 $1,028.00 $1,491.00 $3,699.00 $ 822.00 $ 292.00 $1,288.00 $1,851.00 $2,262.00 $ 389.00 $ 463.00 (see page 2 & 3) 25 % discount off billed charges STOPLOSS: In the event that total billed charges exceed $40,000, reimbursement shall be _ calculated at thirty percent (30%) discount off total billed charges. Payment of claims when per diem rates apply will be based on the lesser of (a) per diem rates, or (b) billed charges. OUTPATIENT: Ambulatory Surgery 25 % discount off billed charges 23 Hour Observation $49 per hour up to the Medical per diem rate All Other Outpatient 25 % discount off billed charges EXHIBIT A Presbyterian St. Luke's Medical Center Page 2 TRANSPLANT CENTER RATES: Service Rates Kidney Transplant Cadaveric $ 58,300.00* (days 1-15) iving Related $ 56,180.00* (days 1-15) Pancreas Transplant $ 77,380.00 (days 1-17) Kidney/Pancreas Transplant $121,900.00 (days 1-20) Heart Transplant $104,940.00* (days 1-15) Lung Transplant $134,620.00 (days 1-21) Heart/Lung Transplant $174,900.00 (days 1-21) Bone Marrow Transplant Allogenic $127,200.00* (days 1-40) Autologous $111,300.00* (days 1-40) Outpatient BMT $ 90,100.00 to $ 79,500.00** *Includes Physician Fees All Pre -Transplant Evaluations will be paid at 70 % of billed charges. Clinic Visits will be paid at 70% of billed charges. Post -Transplant Evaluations will be paid at 75 % of billed charges. Organ Procurement: All solid organ case rates will include the costs associated with organ procurement. Day one of the case rate will begin on the earliest of: (A) The day of surgery or (B) One day prior to surgery. Any inpatient charges which occur (1) prior to one day before the surgery or (2) after the last day of the negotiated case rate shall be paid at per diem rates of: Med/Surg = $1,378.00 ICU/CCU = $2,067.00 Physician Fees: Presbyterian St. Luke's Medical Center has negotiated, on behalf of SLMC, a standard thirty percent (30%) discount off billed charges on all professional fees where they are not included in a bundled price for inpatient hospitalization. — A bundled price has been established for heart and kidney transplants. The price includes all ancillary, professional and technical services associated with the inpatient stay. The professional component consists of the core group of physicians that represent the majority of physician services required for the transplant. The physicians represented in the package include: Surgeon - Assistant Surgeon - Anesthesiology - Pathology -Radiology - Nephrology/Cardiology - Interpretive Services NOTE: For any other physician fees not listed, Presbyterian St. Luke's Medical Center will guarantee a discount of thirty percent (30%) off billed charges. EXHIBIT A Presbyterian St. Luke's Medical Center Page 3 For bone marrow transplantation, the case rates include the attending physician/surgeon and the assistant surgeon for all charges incurred from the date of admission to the date of discharge. All other professional fees, such as consultants or radiologists, will be paid at seventy percent (70%) of billed charges. NOTE: -Bone Marrow and/Ste Fia Uell collection is not included in the case rate. ** Outpatient Bone Marrow Transplantation (BMT) (Days -8 to 21+) The outpatient package rate encompasses the entire continuum of care and includes both outpatient and inpatient services. The rate begins with the placement of the Quinton catheter, continues through comprehensive outpatient physician/facility services (care under BMT team which does not include referring physician services), chemotherapy* (day minus eight [-8]), reinfusion, and twenty-one (21) days post -transplant care. Inpatient services include up to nine (9) days of hospitalization. The outpatient rate includes, but is not limited to the following services: -BMT Surgeon -Anesthesiology -BMT Asst. Surgeon -Pathology -Cardiac Surgeon -Infectious Disease -Radiology -Psychiatry (2 visits) -Home Health -Home Pharmacy -On Sight Living (for both patient & care giver if necessary) -Pre-evaluation Testing Including Psychosocial Patient/Family Counseling -Stem-cell Collection and Cryopreservation -Quinton Line Placement -Hickman Line Placement -High Dose Chemotherapy Administration - - -Stem Cell Rescue -Twenty-one (21 +) Days of Post -transplant Care *The package rate only includes chemotherapy administration directly associated with the bone marrow transplant. It will not include standard or salvage chemotherapy before the transplant, even if the Quinton catheter has been placed. — Outpatient BMT P-ackaee Pricing Explanation: Base Rate 1 Patient Per Year $90,100.00 Preferred Pricing 2-3 Patients Per Year $84,800.00 4+ Patients Per Year $79,500.00 Hospitalization Days 1-9 are included in the rate Days 10+ will be reimbursed to the Contracting Facility at $2,120/day not to exceed the inpatient Autologous case rate. �' EXHIBIT A Presbyterian St. Luke's Medical Center Page 4 READMISSIONS (NON -TRANSPLANT): Description Per Diem —1GIe id c urgica Adult or Ped) $1,378.00 ICU (Adult or Ped-PICU) $2,067.00 All professional fees will be paid at seventy percent (70 %) of billed charges Exclusions Immuno Globulin IV Parental Nutrition Acyclovir Sodium Cyclosporin Allowable shall be Hopsital cost plus twenty percent (20%). Payment of claims when per diem rates apply will be based on the lesser of (a) per diem rates, or (b) billed charges. EXHIBIT A Provenant Health Partners A. Inpatient Per Diem Rates: As full compensation to Hospital for all Covered Services that are inpatient services, Participating Plan shall make an all-inclusive payment to Hospital at the following rates, less applicable Copayments, Coinsurance, and Deductible amounts for which the Covered Individual is responsible: 1. Includes services at: St. Anthony Hospital Central and St. Anthony Hospital North - Tax ID #84-0405257: 2. tj Service: Medical/Surgical Maternity C-Section Delivery Vaginal Delivery Level II Nursery ICU/CCU Psychiatric Open Heart Surgery - _ (DRG's 104 through 112) Per Diem Rate: $1,225 $1,250 (Mom) $ 350 (per Baby) $1,250 (Mom) $ 350 (per Baby per day) $1,400 - $1,900 $ 500 $2,200 for 10 days then the appropriate per diem rate. STOP LOSS: All cases with total billed charges over $35,000 shall be paid at sixty-five percent (65 %) of total billed charges. Provenant Senior Life Center (Formerly St. Anthony's Pavilion) - Tax ID 84-0405257: Service: Rehabilitation Per Diem Rate: $700 STOP LOSS: All cases with total billed charges over $35,000 shall be paid at sixty-five percent (65%) of total billed charges. Provenant Acute Long Stay Hospital (PALS) - Tax ID #84-1236651 Service Inpatient Per Diem Rate: $650 STOP LOSS: All cases with total billed charges over $35,000 shall be paid at sixty-five percent (65%) of total billed charges. 4. All Other Inpatient Services 25 % off total billed charges Payment to the Hospital for the services listed above will be the rates that appear above or billed charges, whichever is less. EXHIBIT A Provenant Health Partners Page 2 Inpatient services covered by these rates include semi -private or private room (when medically necessary) and board, nursing services and all ancillary services typically billed by the Hospital. The rates do not include professional services of Hospital's hospital -based physicians. Prosthetic devices are provided in addition to these rates at ninety percent (90%) of the Hospital's standard charge for such devices. For the purpose of this Agreement, a "Hospital Inpatient Day" means each day, or portion of a day, that a Covered Individual is a registered bed patient in Hospital under the care or direction of a physician. The day of admission, but not the day of discharge, shall be counted as a Hospital Inpatient Day. B. Outpatient Hospital Services: Includes all outpatient services provided at: Tax ID #84-0405257 St. Anthony Hospital Central St. Anthony Hosital North Provenant Senior Life -Canter Provenant Medical/Surgical Center -Summit St. Anthony Urgent Care Center-Blackhawk St. Anthony Medical Center -Granby Tax ID #8440402711 Provenant Health Services East St. Anthony Urgent Care Center -Evergreen St. Anthony Medical Center -Winter Park Including, but not limited to emergency, laboratory, x-ray and other imaging services, other diagnostic studies such as stress tests, physical therapy, radiation therapy and chemotherapy provided at the Hospital, Participating Plan shall compensate Hospital at the rate of seventy-five percent (75%) of the Hospital's standard rate schedule. Prosthetic devices are provided in addition to these rates at ninety percent (90%) of Hospital's standard charges for such devices. HOSPITAL POLICY: It is the Hospital's policy to submit claims to the Participating Plan on an interim basis for Covered Individuals who are continuously hospitalized and will provide for the immediate payment of 80% of any disputed bill. Payment of 80% of any disputed bill must be complete prior to the commencement of any audit conducted with respect to the bill. It is the Hospital's_ policy that in the event Participating Plan is chronically late in payment or when the Hospital reasonably believes that payment is in jeopardy because of apparent insolvency of the Participating Plan, Hospital. may require advance deposits or a payment bond or guarantee by a solvent source prior to non -emergency admissions of Covered Individuals and that in the event of chronic late payment or apparent insolvency Participating Plan shall at the written request of Hospital provide Hospital with all relevant, current financial information concerning the Participating Plan requested by the Hospital. SLMC does not guarantee that the Participating Plan will comply with the above Hospital policies. EXHIBIT A Prowers Medical Center Tax ID #84-0584583 -.. Negotiated Rate Prowers Medical--Center-agrees-to--a-diseourzt--af--s�reen"6-mom-^wed charges for services rendered both inpatient and outpatient. EXHIBIT A Quantum Medical, Inc. Tax ID #84-1174882 DEVICE RENTAL FEE PURCHASE PRICE EMS 250 neuromuscle $140.00 $956.00 stimulator, 4 channel Rheologic 1 neuromuscle $140.00 $956.00 stimulator, 4 channel LB2000 cranial electro- $140.00 $956.00 therapy stimulator Superior 11 neuromuscle $116.00 $636.00 stimulator, 2 channel Electrodes (4 in a Packagel - $18.50 each 2 Packages Per Month - $37.00 _ 4 Packages Per Month - $74.00 Lead wire - No Charge First Tube of Gel - Free -- - Second Tube Approximately $3.50 EXHIBIT A Rangely District Hospital Tax ID #84-6014785 The allowable amount shall be billed charges. Rangely District Hospital has agreed to establish the level of charges for their services at the beginning of each contract year (based on the contract between CT MCanri Ran ely nistrict Hospital) and guarantee such charge levels for the remainder of that year. EIH3IBIT A The Rehabilitation Hospital of Colorado Springs Tax ID #25-1612420 Per DiemRates Diagnosis Related Rate General Rehabilitation Diagnoses $ 750.00 Acquired Brain Injury $ 900.00 Head Trauma and Spinal Cord Diagnoses $ 960.00 Ventilator Weaning $1,200.00 These rates are all-inclusive with the exception of the following services: - -1. Physician fees 2. CAT Scans 3. MRI's 4. Ambulance Service 5. Hearing Aids 6. Orthotics and Prosthetics 7. Special Nursing (e.e. one-on-one nursing/sitters as clinically indicated by a physician) _ - 8. EEG's 9. EMG's 10. All other diagnostic procedures performed outside of the Hospital 11. Durable Medical Equipment 12. Neuropsychological Evaluation Outpatient — Outpatient services are allowed at 85 % of billed charges. EXHIBIT A The Network Alliance Page 12 HOME HEALTH NURSING - OUTLYING AREA FEE SCHEDULE INTERMTTTENT VISIT (0-2 hrs) Registered Nurse (Hi -Tech) Registered Nurse (Primary nursing) Licensed Practical Nurse Mental Health Worker Home Health Aide Physical Therapist Occupational Therapist Speech Therapist Medical Social Worker HOURLY NURSING RATES: Registered Nurse (Hi -Tech) Registered Nurse (Primary Nursing) Licensed Practical Nurse Mental Health Worker Home Health Aide Personal Care/Companion HOLIDAY RATES: OUTLYING MODIFIER RATES SRHV-OL $81.00 RNHV-OL $76.00 LPHV-OL $44.00 MHWV-OL $38.00 HHAV-OL $31.00 SRHH-OL $79•00 OTHV-OL $79.00 STHV-OL $79•00 MSWV-OL $93.00 RATES SRH-OL $40.00 RNH-OL $35.00 LPH-OL $20.00 MHW-OL $16.00 HHA-OL $14.00 COMP-OL $11.00 - — The following holidays will be billed at time and one half - (holiday rates are in effect from 1 1pm on the eve of the holiday through I Ipm on the actual date of the holiday): New Year's Day Memorial Day Independence Day Labor Day Thanksgiving Day Christmas Day CARDIAC MONITORING - Effective IVII98 CARDIAC EVENT MONITORING - Includes delivery and retrieval of monitoring device, supplies for 30 days usage, 24 hour attended monitoring and technical analysis, report generation and patient education for a 30 day period: CODE RATE Monitoring, receipt of 932711G0006 $250.00 transmission & analysis — Hook up & training 93270/G0005 -5 40.00 PACEMAKER FOLLOW UP - Includes scheduled monitoring (according to Medicare guidelines), 24 hour emergency call, patient training and report generation, without physician interpretation: - Single chamber telephonic analysis 93736 $ 35.00 Dual chamber telephonic analysis 93733 $ 45.00 HOLTER MONITORING - Includes delivery and retrieval of monitor, technical scanning and analysis of tape, & generation of report to physician, per 24 hour period: Microprocessor -based analysis w/report 93232 $ 90.00 EXHIBIT A Rio Grande Hospital Tax ID #84-1276376 Rio Grande Hospital agrees to a five percent (5 %) discount off total billed charges for both inpatient and.outpatient_sPncirP.q EXHIBIT A Rocky Mountain Cancer Centers Tax ID # 84-1251368 Outpatient Blood and Marrow Transplant Program Case Rates: Preferred Pricing $85,000 The Outpatient Blood and Marrow Transplant Program Case Rate begins with the placement of the Apheresis Catheter. The termination point of the case rate is 28 days post -transplant. The case rate contains the following components: Professional Charges Office visits with Transplant Physician; PBSC/Apheresis and Collection; Unlimited Nursing Assessments; Clinical psychosocial patient/family counseling; Physician monitoring/supervision of chemotherapy administration; Physician interpretations of laboratory tests; Case Conferences between Transplant Physician & Primary Care Physician. Technical Charges Administration of chemotherapy agents; Pharmacy services to include mixing, compounding, and other services related to chemotherapy treatment; Nursing services to include assessments, monitoring and administration of chemotherapy agents, administration of Neupogen therapy, and line maintenance; Facility Costs including up to 7 days hospitalization for post -transplant neutropenic fever and other regimen -related complications. Laboratory Charges Inclusive for all tests up to and including the 28-day post stem cell infusion Drugs and Biologicals Chemotherapy agents; Colony stimulating factors to include Erythropoietin, Neupogen, Leukine; Electrolyte and fluid replacement; Antiemetics; Antibiotics; Nutritional therapy. Home Health Care Home nursing visits; Infusion related to Blood and Marrow transplant; On -Site Living; Room and Board for patient/caregiver(s) Tor .30 days of —on -site living -At Park Avenue Towers located close to _ Rocky Mountain Cancer Centers; 24-hour caregiver availability to all patients. EXHIBIT A Rocky Mountain Gamma Knife Center Tax ID #84-1191615 Stereotactic Radiosurgery Case Rates: Preferred Pricing 1-6 patients $25,000 7-12 patients $231000'- 12 or more patients $21,000 The above case rates will be determined by total SLMC patients during each annual contract term between Rocky Mountain Gamma Knife Center and SLMC. Rocky Mountain Gamma Knife Center is responsible for tracking total patients and will bill the appropriate case rate based on this volume along with its usual and customary charges. The Stereotactic Radiosurgery Case Rate includes the following professional and technical/hospital charges related to a one day inpatient stay. No other claims will be incurred related to this service. Should the patient require additional days stay in the hospital due to unrelated medical conditions, these will be issued by St. Anthony's Central Hospital Centura Health, in accordance with their existing contract with PPO. Professional Component All neurological, radiation oncology, medical physics, radiology, and anesthesia (if applicable) charges. — — Technical Component Gamma Knife technical charge and all hospital charges relating to the one day inpatient Gamma Knife_ procedure. Claims Processing All claims will be reimbursed within 60 days of receipt of a claim, not requiring additional information, including COB, from Participating Group. Failure to reimburse within this., time period will result in the application of billed charges. Should a Gamma Knife treatment be aborted (too many tumors, too big, etc.), Payor will be billed for charges incurred to the point of abortion. These include admit, MRI, headframe placement and any professional consultations. EXHIBIT A Rocky Mountain Rehabilitation Institute Tax ID #84-1321505 Inpatient: Per Diems: Ventilator $1,100.00 Brain Injury $ 850.00 General Rehabilitation $ 700.00 SubAcute Unit $ 575.00 Payment of claims when per diem rates apply will be based on the lesser of (a) per diem rates, or (b) billed charges. These rates are all-inclusive with the exception of the following services: 1. Physician fees 2. CAT Scans 3. MRI's 4. Ambulance Service 5. Hearing Aids 6. Orthotics and Prosthetics 7. Special Nursing (e.e. one-on-one nursing/sitters as clinically indicated by a physician) 8. EEG's 9. EMG's 10. All other diagnostic procedures performed outside of the Hospital 11. Durable Medical Equipment _ 12. Neuropsychological Evaluation —Outpatient - 20% discount off total billed charges EXHIBIT A Rose Medical Center Tax ID #84-1321373 INPATIENT: -__ Medical Surgical Normal Delivery, Including Normal Newborn C-Section, Including Normal Newborn Boarder Baby and Multiple Births Level II NICU Level III NICU ICU/CCU Cardiovascular Surgery/Cardiac Cath/ Athrectomy/PTCA or any other Cardiac Cath Lab procedure that results in admission. Per Diem $1,085.00 $1,299.00 $2,793.00 case rate $5,300.00 case rate $ 277.00 $1,441.00 $1,856.00 $1,892.00 30 % discount off billed charges Spinal Procedures (DRG's 496 through 500) 30% discount off billed charges STOPLOSS: In the event that total billed charges exceed $31,500.00, reimbursement will be calculated at a twenty-five percent (25 %) off total billed charges. In the event that a newborn is in NICU level II or III, the per diem will begin accruing on the date newborn enters NICU and shall continue until discharge. Payment of claims when per diem rates apply will be based on the lesser of (a) per diem rates, or (b) billed charges. OUTPATIENT: Reimbursement will be calculated at a twenty-five percent (25 %) -discount off total billed charges. EXHIBIT A Routt Memorial Hospital, Inc. Tax ID #84-0398876 Routt Memorial Hospital agrees to a discount of two percent (2%) off billed charges for services rendered inpatient and outpatient. EXHIBIT A San Luis Valley Medical P.C. Tax ID #84-0610449 San Luis Valley Medical P.C. agrees to a discount of ten percent (10%) off billed ambulatory surgery center facility, charges. San Luis Valley Medical P.C. agrees to the following discount for the technical portion of all radiology and pathology charges: SLMC's conversion factor times the McGraw Hill RVS_ unit value as it is stated in this Participation Agreement. EXHIBIT A San Luis Valley Regional Medical Center Tax ID #84-0255530 Negotiated Rates San Luis Valley Regional Medical Center commits to the following discounts: 1. Inpatient Services - A fifteen percent (15 %) discount from billed charges shall apply to all inpatient services rendered. 2. Outpatient Services - A fifteen percent (15 %) discount from billed charges shall apply to all outpatient services rendered. EXHIBIT A Sedgwick County Hospital Tax ID #84-0816593 Sedgwick County Hospital agrees to a discount of five percent (5 %) off billed charges for services ren rl ered-inpatient-mul-outp atien tr Effective 1/1/99 EXHIBIT A The Englewood ASC, LLC, dba South Denver Endoscopy Center Tax ID #62-1734003 South Denver Endoscopy Center (Ambulatory Treatment Facility) services which are rendered to Covered Individuals by South Denver Endoscopy Center (Ambulatory Treatment Facility), shall be reimbursed at the rates listed below using current CPT procedural terminology and codes: Group I CPT codes shall be reimbursed at $420.00* (see below for multiple procedure guidelines). 43200 43216 43235 44380 44389 45305 45320 45334 46606 43202 43217 43450 44382 44390 45307 45321 45337 46608 43204 43219 43453 44385 44394 45308 45331 45339 46610 43205 43220 43760 44386 45300 45315 45332 46600 47000 43215 43226 44100 44388 45303 45317 45333 46604 Group H CPT codes shall be reimbursed at $525.00* (see below for multiple procedure guidelines). 43227 43245 43251 43263 43456 44364 44378 45379 49080 43228 43246 43255 43267 43458 44365 44391 45380 43239 43247 43258 43268 43750 44372 44392 45382 43241 43248 43260 43269 43761 44373 44393 45383 43243 43249 43261 43271 44360 44376 44500 45384 43244 43250 43262 43272— 44361 44377 45378 45385 *All inclusive global allowance, for tcQWcal services, to include the procedure, room use, medications, IV's, monitoring and recovering time. CPT Code 45330 shall be reimbursed at $50.00 for use of the facility. OUTLIERS: Multiple Procedures: The Participating Plan shall allow 100% of the Negotiated Rate for the first procedure, 50%-_of the Negotiated Rate for the second procedure and 25% of the Negotiated Rate for each procedure thereafter. Payment of claims will be based on the lesser of (a) the Negotiated Rate or (b) the standard fee. The Negotiated Rates do not include professional fees. South Denver Endoscopy Center has agreed to not charge a facility (Ambulatory Treatment Facility) fee for the services listed below and to only bill the applicable standard professional fee: It has been agreed that no technical charges has been assigned for the following services: 90900 90911 91010 91011 91012 91030 91033 91122 91233 EXHIBIT A The Network Alliance Page 13 DYNASPLINT SYSTEMS, INC. - Effective 1111/98 MODEL N DESCRIPTION HCPC CODE RENTAL PURCHASE PRICE 10-100 Elbow Extension E1800A $211.50 $1,350.00 20-100 Elbow Flexion E1800B _ _ $211.50 __ ____ $1,350.00__. 10-300 Elbow Extension Neuro E1800C $211.50 $1,350.00 10-500 Elbow Extension -- Peds _ E1800D $211.50 $1,350.00 20-500 Elbow Flexion —Peds E1800E $211.50 $1,350.00 10-200 Knee Extension E1810A $211.50 $1,350.00 20-200 Knee Flexion E1810B $211.50 $1,350.00 10-400 Knee Flexion Neuro E1810C $211.50 $1,350.00 10-550 Knee Extension -- Peds E1810D $211.50 $1,350.00 20-500 Knee Flexion - Peds E1810E $211.50 $1,350.00 BKA Knee Extension E181OF $211.50 $1,350.00 10-203 Dbl-Jointed Knee Extension E1810G $265.50 $1,710.00 10-600 Wrist Extension E1805A $211.50 $1,350.00 20-600 Wrist Flexion E1805B $211.50 $1,350.00 10-650 Wrist Extension — Neuro E1805C $211.50 $1,350.00 10-630 Wrist Extension -- Peds E1805D $211.50 $1,350.00 21-100 Toe Metatarsal Phalan eal Flexion E1830A $211.50 $1,350.00 11-100 Toe Metatarsal Phalan eal Extension E1830B $211.50 $1,350.00 11-300 Hand Metacarpophalangeal Extension _ E1805E $211.50 $1,350.00 21-300 Hand Metacarpophalangeal Flexion E1805F $211.50 $1,350.00 10-700 Ankle Dorsi -- Flexion E1815A $211.50 $1,350.00 10-730 Ankle Dorsi-- Flexion - Peds E1815B $211.50 $1,350.00 10-777 Platform Shoe n/a n/a $255.00 10-800 Proximal Interphalangeal E1825A $211.50 $1,350.00 10-850 Proximal Interphalangeal Flexion E1825B $211.50 - $t,350.00 10-221 Knee Exten or Flexion Tibial n/a n/a $1,350.00 10-777 Ankle Dorsi Exten or Flexion n/a n/a $1,530.00 11-200 Shoulder LPS System n/a Fitting Fee - Shoulder LPS System only $495.00 $4,995.00 $100.00 ♦ Prices include: DynaSplint Unit Complete Cuffing Kit Customized Fitting by Consultant Postage paid mailer for rental return Follow Up w/Physician & Therapist Replacement Cuffing Kit, if necessary ♦ All Paid rentals apply toward purchase ♦ All fitting fees are included EXHIBIT A Southeast Colorado Hospital Tax ID #84-0592527 Southeast Colorado Hospital commits to a two percent (2%) discount off billed charges for services —= rendered inpatient and outpatient. EXHIBIT A Southwest Memorial Hospital Tax ID ##84-0692090 Southwest Memorial Hospital agrees to a twelve percent (12%) discount off total billed charges for all inpatient and outpatient care. ID CARDS: If the Participating Plan's identification card does not clearly show the SLMC name and/or logo, Southwest Memorial Hospital is not obligated to accept the above Negotiated Rate. EXHIBIT A Spalding Rehabilitation Hospitals Tax ID #84-1321505 Inpatient: Per Diems: Ventilator $1,100.00 Brain Injury $ 850.00 General Rehab $ 700.00 SubAcute Unit $ 575.00 Payment of claims when per diem rates apply will be based on the lesser of (a) per diem rates, or (b) billed charges. The daily per diem rate is inclusive of the following: 1. Room and Board 6. All Respiratory Services 2. Routine Lab 7. All Pharmacy** 3. Routine X-ray 8. Nutritional Services 4. All Physical, Occupational & 9. Central Services Supplies Speech Evaluations and Therapy 10. Family Services 5. Psychological Services 11. EKG, as ordered The daily per diem rate does NOT include: 1. Physician professional charges 2. CAT Scans, MRI Studies and EEG's 3. DME 4. Ambulance Service 5. Private Duty Nursing 6. All Third Generation and Successive Antibiotics 7. Renal Dialysis _ 8. Braces and Prosthetics > $250 *9._Surgical Charges (subacute unit only) _ Patient days are defined as any adult and pediatric patient day. A patient day shall include the day a patient is admitted prior to 12:00 a.m., but excludes the day a patient is discharged from the Hospital. A patient admitted and discharged/expired on the same day will be counted as one patient day. _ **Pharmacy will include all medications related to the primary incident for which this rehabilitation is associated. Medications for pre-existing conditions of long standing will not be covered. ,-� EXHIBIT A Spalding Rehabilitation Hospitals Page 2 Outpatient: 20% off total billed charges Spalding Rehabilitation Hospitals (Includes the following locations): Spalding Spalding Cheyenne at Rose Medical Center at United Medical Center East 4567 E. 9 h Avenue 2600 East 18th Street Denver, CO 80220 Cheyenne, WY 82001-3790 303-320-2121 307-633-7300 Spalding Downtown Spalding Longmont (CORF) at Presbyterian St. Lukes' Medical Center 630 Coffman Street - 1719 East 19th Avenue Longmont, CO 80501 Denver, CO 80218 303-678-8915 303-839-6293 Spalding Rehabilitation Hospital Spalding West 900 Potomac at Lutheran Medical Center Aurora, CO_80011 _ 8300 W. 38th Avenue — 303-367-1166 Wheat Ridge, CO 80033 303-467-8740 EXHIBIT A St. Mary -Corwin Regional Medical Center Tax ID #84-0405257 Negotiated Rates St. Mary -Corwin Hospital agrees to, a 10 % discount off total billed charges if a clean bill is paid according to the time frame shown below: TIME FRAME FOR CLAIMS PAYMENT: "Clean Bill" means a properly completed billing on a form provided by Hospital containing appropriate payment information without requiring additional material information. Hospital shall submit to Participating Plan or their claim administrator Clean Bills setting forth Hospital's charges for all Covered Services provided to Covered Individuals. If Participating Plan or its claim administrator contends that a bill submitted by Hospital is not a Clean Bill, Participating Plan or their claim administrator shall notify Hospital in writing of such contention within fifteen (15) days of receipt of such bill by Participating Plan or its claim administrator, and such notice shall specify with particularity the information or data which is necessary to finalize such bill as a Clean Bill. If the Participating Plan or its claim administrator does not provide such written notice to Hospital within fifteen (15) days of receipt of Hospital's bill, then Hospital's bill shall be deemed, and conclusively presumed, to be a Clean Bill. Hospital bills shall be deemed to be received by Participating Plan or its claim administrator on the sooner of (a) the date of actual receipt of (b) five (5) days after the mailing -date of such bills. - — Within thirty (30) days after receipt of a Clean Bill and receipt of the information required by the Participating Plan's claims administrator to process the -claim, Participating Plan or their claim administrator shall pay to Hospital the amounts due Hospital in accordance with the discount shown above__. Hospital's bills shall be deemed timely when paid by Participating Plan or its claim administrator within such thirty -day period or the date of the postmark properly addressed, postage pre- paid envelope containing payment is within such thirty -day period. Payments of Clean Bills are not delinquent if payment is received by Hospital within thirty (30) days after teceipt of a Clean Bill and receipt of the information required by the Participating Plan's claims administrator to process the claim. For all Clean Bills not paid within thirty (30) calendar days after receipt by Participating Plan or their claim administrator, the rates specified in this Exhibit A shall be inapplicable to the services reflected in delinquent bills, and Participating Plan or its claim administrator shall pay in full Hospital's charges for Covered Services specified in such bills. EXHIBIT A St. Mary's Hospital and Medical Center Grand Junction Tax ID #84-0425720 Negotiated Rates St. Mary's Hospital and Medical Center commits to the following discounts: 1. Inpatient Services - A two (2) percent discount from billed charges shall apply to all inpatient services rendered. 2. Outpatient Services - A two (2) percent discount from billed charges shall apply to all outpatient services rendered. EXHMIT A St. Thomas More Hospital and Progressive Care Center Tax ID #84-0405257 Negotiated Rates St. Thomas More Hospital and Progressive Care Center commits to the following discounts: 1. Inpatient Services - A three percent (3 %) discount from billed charges shall apply to all inpatient services rendered. 2. Outpatient Services - A three percent (3 %) discount from billed charges shall apply to all outpatient services rendered. .4 O i St. Vincent General Hospital Tax ID #84-0424585 Negotiated Rates St. Vincent General Hospital agrees to discount total billed charges by_5% percent (5%) on the claim for inpatient and outpatient services. St. Vincent General Hospital will discount total billed charges by the above percentage when the Participating Plan is primary carrier on a claim. When the Participating Plan is not the primary carrier on a claim, St. Vincent General Hospital will discount, by the above percentage, the remaining balance after subtraction of the primary carrier's payment. EXHIBIT A Surgery Center of Northern Colorado, LLC Tax ID #84-1420378 I. Rates Surgery Center of Northern Colorado will accept from the Participating Plan the following____. agreed upon Negotiated Rate, less any applicable Copayment, Coinsurance or Deductible: 20 °%v discount from billed charges to a maximum allowable of $1,200 per date of service II. Scope of Service The all inclusive rates include all routine and specialized services provided by and performed by Surgery Center of Northern Colorado staff while at this facility. III. Exclusion from $1,200 maximum allowable When implants are Covered Services, Participating Plan will reimburse Surgery Center of Northern Colorado, for any implants not already included in the primary procedure, at invoice cost plus ten percent (10%). 0 INPATIENT: EXHIBIT A Swedish Medical Center Tax ID #84-1321373 Per Diems Medical/Surgical $1,124.00 Pediatrics $ 963.00 ICU/CCU $1,749.00 OB (mother/well baby) $1, 070.00 Rehabilitation $ 749.00 Psychiatric $ 535.00 Substance Abuse $ 407.00 STOPLOSS: DRG 104-107 with total billed charges over $70,000.00 shall be paid at seventy- five percent (75 %) of total billed charges. All other cases with total billed charges over $50,000.00 shall be paid at seventy-five percent (75 %) of total billed charges. Payment of claims when per diem rates apply will be based on the lesser of (a) per diem rates, or (b) billed charges. OUTPATIENT: Twenty percent (20%) discount off total billed charges EXHIBIT A The Network Alliance Page 14 EBI - BONE GROWTH STIMULATOR - SLMC PPO Effective 11/l/98 PRODUCT HCPC CODE CONTRACT RATE EBI Bone Healing System A4565-A4590 $ 2,990.00 EBIce Cold Therapy Products E0237 360.00 All Soft goods (various) 30% discount from billed charges Pricing Includes: Initial assessment by EBI field representative Utilization Review by EBIMS' Medical Department Production and Calibration of customized treatment system Shipment of treatment unit to the prescribing physician's office. Assistance to Physician be EBI re: patient Fitting, application & education Warranty of each treatment system for entire treatment period. Repairs or replacement, if necessary Access to EBI Orthopedic Panel for consultation HOME HEALTH NURSING -. OUTLYING AREA Effective 11/1/98 , RATE PICC line placement including supplies $ 248.00 Midline placement including supplies 193.00 MILEAGE: Mileage will be reimbursed with appropriate documentation $ _35/mile INTEGRATED MEDICAL, INC. - SLMC PPO Effective 1111/98 The prices below represent specialized pricing for the products listed. Additional products provided will be allowed at a 25% discount from billed charges. PRODUCT HCPC CODE RENTAL RATE* PURCHASE PRICE Lumiscope TENS E0730A $ 19.00 $ 60.00 Solitens -- E0730B 39.00 149.00 TENSPRO E0730C 55.00 289.00 MEDA CROWN E0730D 39.00 425.00 MEDA Muscle Stimulator -E0745A $ 45.00 $ 495.00 - BMR Neurotech MS E0745B 79.00 795.00 Saunders HomeTrac E0948 $ 99.00 $ 465-:00 Pronex Cervical L0170 _ 75.00 395.00 Saunders Home Lumbar STX E0900A $ 120.00 $ 895.00 Lossing Backtrac E0900B 79.00 682.00 *All Rentals - Two months rental will be applied to purchases N EXHIBIT A Vail Valley Medical Center Tax ID #84-0563230 - Vail Valley Medical Center agrees to a discount of five percent (5 %) off total billed charges for Covered Services. Vail Valley Medical Center will discount total billed charges, for Covered Services, by the above percentage when the Participating Plan is primary carrier on a claim. When the Participating Plan is not primary carrier on a claim Vail Valley Medical Center will discount, by the above percentage, the remaining balance after subtraction of the primary carrier's payment. EXHIBIT A Valley View Hospital Tax ID #84-0446259 Valley View Hospital agrees to a discount of four percent (4%) off total billed charges for services rendered inpatient and outpatient. EXHIBIT A Weisbrod Memorial County Hospital and Nursing Home Tax ID Number: 84-0537008 Negotiated Rates Weisbrod Memorial County Hospital and Nursing Home commits to the following -discounts - 1. Inpatient Services - A two percent (2 %) discount from billed charges shall apply to all inpatient services rendered. 2. Outpatient Services - A two percent (2%) discount from billed charges shall apply to all outpatient services rendered. The Hospital will discount total billed charges by the above percentage when the Participating Plan is primary carrier on a claim. When the Participating Plan is not primary carrier on a claim the Hospital will discount, by the above percentage, the remaining balance after subtraction of the primary carrier's payment. —� EXHIBIT B The following time frame for payment of claims shall apply to all Participating Providers listed on the following Exhibit B. pages. Any time frame language which may appear on a specific Participating Provider's Exhibit B shall supersede this language. TIME FRAME FOR PAYMENT OF CLAIMS: The Participating Plan agrees that claims submitted on behalf of Covered Individuals shall be considered for payment within the time frames listed below by their claim administrator. If claims are not paid or applied to Deductible, Copayment and out-of-pocket amounts within the time frame described below, the claim shall not be eligible for the Participating Provider's Negotiated Rate and no discount will be taken on the claim by the Participating Plan's claim administrator. If a claim is denied, the Participating Plan agrees that its claim administrator shall notify the Participating Provider within the time frames described below. A claim shall be considered received by the Participating Plan's claim admuristrator the day it is physically and electronically delivered to their place of business. If the Participating Plan's claim administrator does not record the actual day the claim is physically received at its place of business, the received date shall be five (5) days from the date the claim was mailed to the Participating Plan's claim administrator based on either the Participating Provider's or SLMC's record of mailing. 1. For claims not requiring additional information the time frame shall be within thirty (30) days of receipt of the claim by the Participating Plan's claim administrator. 2. For claims that require additional information to determine if they are reimbursable according to the Participating Plan's benefit provisions, the time frame shall be within thirty (30) days of receipt of the information by the Participating Plan's claim administrator. Participating Plan agrees that its claim administrator will acknowledge receipt of a pending claim and notify the Participating Provider of its pending status within thirty (30) days of receipt of the claim. 3. The Participating Plan agrees that all claim appeals properly submitted to SLMC for consideration of the Participating Provider's allowable amount, which is based on Exhibits B, shall be adjusted by the Participating Plan's claim administrator, if applicable, within thirty (30) days of receipt of the claim appeal by the Participating Plan's claim administrator. Participating Plan agrees that its claim administrator shall maintain a Repricing quality of no less than ninety percent (98%). If claims are not Repriced in accordance with Exhibits B and it results in an incorrect claim payment to the Participating Provider, the Negotiated Rate shall not apply. PPO17/PAR-WE-UR/CITY OF FT COLLINS/10.13.98/jg EXHIBIT B The Participating Plan has access to the Participating Provider networks listed below: Sloans Lake Managed Care, Inc. (includes SLMC, FSL, GSL, MSL, SLE, SUN, SLP, SSL and THC) 1355 South Colorado Blvd., Suite 902 Denver, CO 80222 Aspen Health Plus, Inc. (AHP) Boulder Valley IPA (BVIP) Central Rockies Physician Practice Associates (CRPP) Centura Health Mercy Medical Center Managed Care Network (MHS) (formerly Mercy Health Systems, a PHO) Cherry Creek Associated Physicians (CCAP) The Colorado Network, Inc. (TCN) Community Health Providers Organization Inc. (CHPO) Ft. Collins IPA (FCIP) Montrose Community Health Plan (MCHP) Mountain Medical Physicians (MMA) Northcare (NC) Northern Colorado Medical Practice Association (NCMP) Pueblo Regional Medical Group (PCI) PRO Behavioral Health (PRO) Roaring Fork Valley Physicians IPA (RFIP) Southwest Memorial PHO dba Southwest Healthnet (SWHN) Valley View Hospital Based Physicians (WI) PPO17/PAR-WE-UR/CrrY OF FT COLLINS/11.20.98/jg EXHIBIT B PARTICIPATING PROVIDER FEES The conversion factors on this Exhibit B apply to the Participating Provider networks listed below: Sloans Lake Managed Care, Inc. (SLMC) - Sloans Lake/Colorado Springs (SLMC) - Sloans Lake E Schedule (SLE) - Sloans Lake FN Schedule (SLFN) - Sloans Lake P Schedule (SLP) - Sloans Lake THC Schedule - Boulder Valley IPA (BVIP) - Cherry Creek Associated Physicians (CCAP) - Mountain Medical Physicians (MMA) - Northern Colorado Medical Practice Association (NCMP) RVP: - The most current version of the St. Anthony Publishing Relative Value for Physicians (RVP) and Guidelines (formerly known as McGraw-Hill RVS). Anesthesia shall include the St. Anthony Publishing RVP unit value plus time units. - July and December updates implemented on September 1st and February 1st respectively - Codes modified and approved by SLMC (Notification of CPT code modifications will be sent to the Participating Plan's claims administrator.) CONVERSION FACTORS: SLMC SLE SUN SLP THC BVIP CCAP MMA NCMP Medicine $ 5.95 Surgery $74.00 OB GYN (59400-59581 & 59610-59622) $78.00 59400 $1,700 59510 $1,950 Anesthesia $36.00 Radiology $15.00 Pathology - Clinical $ 9.75 Pathology - Surgical(88300-88399) $14.50 Participating Provider charges payable by the Participating Plan shall be based on the lesser of the Participating Provider's customary charge or the relative value study times the appropriate conversion factor. SLMC can provide claim review for the following IThe fee for these services will be negotiated.): 1. RNE cpt codes 2. BR cpt codes 3. Unlisted procedures 4. Multiple surgeries 5. Medical necessity PPOITPAR-WE-UR/CITY OF FT COLLINS111.20.98/k EXHIBIT B RVP: PARTICIPATING PROVIDER FEES Sloan Lake / Front Range Region (FSL) - The most current version of the St. Anthony Publishing Relative Value for Physicians (RVP) and Guidelines (formerly known as McGraw-Hill RVS). Anesthesia shall include the St. Anthony Publishing RVP unit value plus time units. - July and December updates implemented on September 1st and February lst respectively - Codes modified and approved by SLMC (Notification of CPT code modifications will be sent to the Participating Plan's claims administrator.) CONVERSION FACTORS FSL Medicine $ 6.25 Surgery $ 77.50 Obstetrics (59400-59581 & 59610-59622) $ 81.00 59400 $1,800.00 59510 $2,100.00 Anesthesiology $ 36.00 Radiology $ 17.00 Pathology - Clinical $ 11.00 Pathology - Surgical (88300-88399) $ 15.50 Provider charges payable by the Participating Plan shall be based on the lesser of the provider's customary charge or the relative value study times the appropriate conversion factor. SLMC can provide claim review for the following ,{The fee for these services will be negotiated.): 1. RNE cpt codes 2. BR cpt codes 3. Unlisted procedures 4. Multiple surgeries 5. Medical necessity PPOMPAR-WE-URIMY OF FT COLLINS111.20.98/k RVP: EXHIBIT B PARTICIPATING PROVIDER FEES Sloans Lake GSL Schedule (GSL) - The most current version of the St. Anthony Publishing Relative Value for Physicians (RVP) and Guidelines (formerly known as McGraw-Hill RVS). Anesthesia shall include the St. Anthony Publishing RVP unit value plus time units. - July and December updates implemented on September 1st and February lst respectively - Codes modified and approved by SLMC (Notification of CPT code modifications will be sent to the Participating Plan's claims administrator.) CONVERSION FACTORS GSL Medicine $ 6.25 Surgery $ 79.00 Obstetrics (59400-59581 & 59610-59622) $ 81.00 59400 $1,800.00 59510 $2,100.00 Anesthesiology $ 40.00 Radiology $ 17.00 Pathology - Clinical $ 11.00 Pathology - Surgical (88300-88399) $ 15.50 Provider charges payable by the Participating Plan shall be based on the lesser of the provider's customary charge or the relative value study times the appropriate conversion factor. SLMC cannrovide claim review for the followine IThe fee for these services will be negotiated.): 1. RNE cpt codes 2. BR cpt codes 3. Unlisted procedures 4. Multiple surgeries 5. Medical necessity PPOMPAR-WE-UR/CITY OF FT COLLINS/11.20.98/jg EXHIBIT B IMA PARTICIPATING PROVIDER FEES Sloans Lake / Mountain Range Region (MSL) The most current version of the St. Anthony Publishing Relative Value for Physicians (RVP) and Guidelines (formerly known as McGraw-Hill RVS). Anesthesia shall include the St. Anthony Publishing RVP unit value plus time units. July and December updates implemented on September 1st and February 1st respectively Codes modified and approved by SLMC (Notification of CPT code modifications will be sent to the Participating Plan's claims administrator.) CONVERSION FACTORS MSL Medicine $ 6.30 Surgery $ 83.00 Obstetrics (59400-59581 & 59610-59622) $ 83.00 59400 $1,800.00 59510 $2,100.00 Anesthesiology $ 40.00 Radiology $ 19.00 Pathology - Clinical $ 11.75 Pathology - Surgical (88300-88399) $ 15.75 Provider charges payable by the Participating Plan shall be based on the lesser of the provider's customary charge or the relative value study times the appropriate conversion factor. SLMC can provide claim review for the following (The fee for these services will be negotiated.): 1. RNE cpt codes 2. BR cpt codes 3. Unlisted procedures 4. Multiple surgeries 5. Medical necessity PPOMPAR-WE-UR/CITY OF Fr COLLINS/11.20.98/jg RVP: EXHIBIT B PARTICIPATING PROVIDER FEES Steamboat Sloans Lake (SSL) The most current version of the St. Anthony Publishing Relative Value for Physicians (RVP) and Guidelines (formerly known as McGraw-Hill RVS). Anesthesia shall include the St. Anthony Publishing RVP unit value plus time units. July and December updates implemented on September 1st and February 1st respectively Codes modified and approved by SLMC (Notification of CPT code modifications will be sent to the Participating Plan's claims administrator.) CONVERSION FACTORS SSL Medicine $ 6.30 Surgery $ 95.00 Obstetrics (59400-59581 & 59610-59622) $ 95.00 59400 $1,900.00 59510 $2,100.00 Anesthesiology $ 45.00 Radiology $ 19.00 Pathology - Clinical $ 11.75 Pathology - Surgical (88300-88399) $ 15.75 Provider charges payable by the Participating Plan shall be based on the lesser of the provider's customary charge or the relative value study times the appropriate conversion factor. SLMC can provide claim review for the following (The fee for these services will be negotiated.): 1. RNE cpt codes 2. BR cpt codes 3. Unlisted procedures 4. Multiple surgeries 5. Medical necessity PP017/PAR-WE-UR/CITY OF FT COLLINS/ 11.20.98/jg EXHIBIT A The Network Alliance Page 15 Orthotics 8i Prosthetics Effective 11 / 1 /98 1,0100 HELMET,MOLDED TO PT MODEL $ 441.28 1.1000 CTLSO, (MILWAUKEE), INCLUSIVE 1648.70 1,0110 HELMET, NON -MOLDED 100.12 1.1010 ADD.TO CTLSO, AXILLA SLING 46.77 L0120 CERVICAL, NON-ADJ FOAM COLLAR 18.49 L1020 ADD.TO CTLSO, KYPHOSIS PAD 60.24 L0130 THERMOPLASTIC COLLAR,MLD TO PT 113.69 L1025 ADD.TO CTLSO,KYPH PAD,FLOATNG 86.90 L0140 SEMI -RIGID ADJ PLASTIC COLLAR --. - - 50.38 - - L1Q30-- ADD;T"T' SQ T *T RaOLST€IL_ - 44 33 L0150 SEMI-RIGID,CHIN CUP COLLAR 75.31 L1040 ADD.TO CTLSO, LUMBAR RIB PAD 54.37 L0160 CERVICAL,SEMI-RIGID, WIRE FRAM 109.15 L1050 ADD.TO CTLSO, STERNAL PAD 58.02 L0170 CERVICAL,SEMI-RIGID, MLD TO PT 449.43 L1060 ADD.TO CTLSO, THORACIC PAD 66.65 L0172 CERV COLLAR,SEMI-RIGID,2 PC 91.91 L1070 ADD.TO CTLSO, TRAPEZE SLING 62.71 L0174 CERV COLLAR,SEMI-RGD,2 PC,W/EX 223.92 L1080 ADD. TO CTLSO, OUTRIGGER 49.57 L0I80 CERVICAL COLLAR, MULTIPLE POST 258.22 L1085 ADD. TO CTLSO,OUTRIGGER, W/EXT 107.27 L0190 CERV,MULTIPOST COLLAR (SOMI) 358.46 L1090 ADD. TO CTLSO, LUMBAR SLING 68.98 L0200 CERV,MULTIPOST COLLAR W/EXT 389.27 L1100 ADD. TO CTLSO, RING FLANGE 110.82 L0210 THORACIC, RIB BELT 30.86 L1110 ADD. TO CTLSO,RING FLANGE,MLD 177.98 L0220 THORACIC RIB BELT, CUSTOM FAB 85.35 L1120 ADD.TO CTLSO,COVERS FOR UPRTS 29.92 L0300 TL SURGICAL SUPPORT 121.12 L1200 TLSO,INCL OF IMT ORTH ONLY 1309.41 L0310 TL SURGICAL SUPPORT, CUST FAB 229.72 L1210 ADD.TO TLSO, LAT-THORACIC EXT 243.13 L0315 TL SUPPORT W/RIGID POST INSERT 183.26 L1220 ADD.TO TLSO, ANT THORACIC EXT 160.97 L0317 TL SUPPORT, HYPEREXT,W/INSERT 302.17 L1230 ADD.TO TLSO, MILW SUPERSTRUCT 526.55 L0320 TLSO,(TAYLOR TYPE)W/APRON FRNT 272.03 L1240 ADD.TO TLSO, LUMBAR DEROT PAD 54.11 L0330 TLSO,(KNIGHT-TAYLOR TYPE) 319.44 L1250 ADD.TO TLSO, ANTERIOR ASIS PAD 50.35 L0340 TLSO,(ARNOLD,MAGNUSON TYPE) 454.94 L1260 ADD.TO TLSO, ANT THORAC DEROT 52.72 L0350 TLSO, FLEX -COMP JACKET,CUST FIT 667.06 L1270 ADD.TO TLSO, ABDOMINAL PAD - - 53.99 L0360 TLSO,FLEX-COMP JACKET,CUS FAB 1160.80 L1280 ADD.TO TLSO, RIB GUSSET, ELAST 60.12 L0370 TLSO, HYPEREXT (JEWETT,CASH) 281.78 L1290 ADD.TO TLSO, LAT TROCHANTER PA 54.77 L0380 TLSO, APLR CONTROL,W/EXTENSION 433.66 L1300 OTHER SCOLI, JCKT, MLD TO PT M 1446.67 L0390 TLSO,MOLDED TO PATIENT MODEL 1233.11 L1310 OTHER SCOLI, JACKET, POST -OP 1531,92 L0400 TLSO,MOLDED TO PT MODEL, LINED 1378.81 L1500 THKAO, MOBILITY FRAME 1450.37 L0410 TLSO,2 PC,MOLDED TO PT MODEL 1488.13 L1510 THKAO, STANDING FRAME 1075.47 L0420 - TLSO,2 PC,MLD TO PT MODEL,LINE 1507.80 L1520 THKAO, SWIVEL WALKER 1622.28 L0430 TLSO,CUSTOM FIT, LINED 1056.19 L1600 HO, ABDUCTION, (FREJKA TYPE) 91.84 L0440 TLSO,SPRING STEEL FRNT,CUST Fl 780.73 L1610 HO, ABDUCTION, (FREJKA COVER) 30.59 L0500 LS SURGICAL SUPPORT 94.51 L1620 HO, ABDUCTION, (PAVLIK HARNESS 93.37 L0510 LS SURGICAL SUPPORT,CUST FAB 192.08 L1630 HO,ABDUCTION, (VON ROSEN TYPE) 118.09 L0515 LS SUPPORT W/RIGID INSERT 139.04 L1640 HO, ABD, PELVIC BAND, THIGH CU 394.54 L0520 LSO,(KNIGHT,WILCOX)W/APRON FRT 290.27 L1650 HO, ABDUCTION, (ILFELD TYPE) 181.80 L0530 LSO,(MACAUSLAND)W/APRON FRONT 370.46 L1660 HO, ABDUCTION, PLASTIC,STATIC 119.26 L0540 LSO,LUMBAR FLEXION (WILLIAMS) 371.49 L1680 HO, ABDUCTION, (RANCHO TYPE) 849.10 L0550 LSO, MOLDED TO PATIENT MODEL 1080.11 L1685 HQ ABDUCTION, POST -OP, CUST F 828.93 L0560 LSO,MOLDED TO PT MODEL, LINED 1209.15 L1686 HO, ABDUCTION,POST-OP,CUST FAB 716.48 L0565 LSO, CUSTOM FIT 781.47 L1700 LEGG PERTHES ORTH, (TORONTO) 1064.21 L0600 SACROILIAC SURGICAL SUPPORT 79.51 L1710 LEGG PERTHES ORTH, (NEWINGTON) 1245.78 L0610 SACROILIAC SURG SUPP,CUST FAB 180.03 L1720 LEGG PERTHES ORTH, TRILATERAL 918.30 L0620 SACROILIAC,SEMI-RGD(GOLDTHWAIT 295.05 L1730 LEGG PERTHES ORTH (SCOTT RITE 790.04 L0700 CTLSO, MINERVA TYPE, CUST MOLD _ 1425.27 L1750 LEGG PERTHES SLING, SAM BROWNE 137.11 L0710 CTLSO, MINERVA TYPE,CUST, LINE 1663.19 L1755 -LEGG PERTHES ORTH, PATTEN BOTT 1103.34 L0810 HALO PROC., IN JACKET VEST 1877.94 L1800 KO, ELASTIC WITH STAYS 46.36 L0820 HALO PROC., IN PLASTER JACKET 1624.67 LI810 KO, ELASTIC WITH JOINTS 70.36 L0830 HALO PROC, IN MILWAUKEE ORTH 2185.28 L1815 KO, ELASTIC TYPE, CONDYLR PADS 67.51 L0860 HALO ADD -ON MRI COMPATIBLE SYS 1131.95 LI820 KO, ELASTIC TYPE,COND.PADS,JNT 98.81 L0900 PTOSIS SUPPORT 111.58 L1825 KNEE ORTHOSIS, ELASTIC KNEE CA 38.32 L0910 PTOSIS SUPPORT, CUSTOM FAB 242.29 L1830 KNEE IMMOBILIZER, LONGITUDINAL 64.38 L0920 PENDULOUS AB SUPPORT, CUS FIT 118.28 L1832 KO, ADJ.KNEE JOINT, POSITIONAL 423.69 L0930 PENDULOUS AB SUPPORT,CUS FAB 263.66 L1834 KO, W/O KNEE IT, RGD,MLD PT MD 571.44 L0940 POST SURGICAL SUPPORT 110.19 LIM KO, DEROT, ACL. CUST FAB, PT M 640.77 L0950 POST SURGICAL SUPP CUSTOM FAB 239.90 L1844 KO, SGL UPRT, ADJ, MOLD PT MDL 1250.90 L0960 POST SURG SUPP, PADS (POST SUP 48.14 L1845 KO, DBL UPRT, ADJ, CUST FIT 588.30 L0970 TLSO, CORSET FRONT 106.20 L1846 KO, DBL UPRT, ADJ, MOLD PT MDL 739.88 L0972 LSO, CORSET FRONT 77.14 L1850 KO, SWEDISH TYPE 228.44 L0974 TLSO, FULL CORSET 124.77 L1855 KO,PLST,DBL UP.JTS,MLD PT MDL 765.79 L0976 LSO FULL CORSET 141.37 L1858 KO,MOLDED,POLYCENT. KNEE(CTI) 922.45 L0978 AXILLARY CRUTCH EXTENSION 134.15 L0980 PERONEAL STRAPS, PAIR 12.17 L0982 STOCKING SUPPORT GRIPS,SET 4 11.35 L0984 PROTECTIVE BODY SOCK (SPINAL) 46.44 EXHIBIT B RVP: PARTICIPATING PROVIDER FEES Aspen Health Plus, Inc. - (AHP) - The most current version of the St. Anthony Publishing Relative Value for Physicians (RVP) and Guidelines (formerly known as McGraw-Hill RVS). Anesthesia shall include the St. Anthony Publishing RVP unit value plus time units. - July and December updates implemented on September 1st and February 1st respectively - Codes modified and approved by SLMC (Notification of CPT code modifications will be sent to the Participating Plan's claims administrator.) CONVERSION FACTORS Medicine Surgery Obstetrics (59400-59581 & 59610-59622) 59400 59510 Anesthesiology Radiology Pathology - Clinical/Anatomical Pathology - Surgical $ 7.10 $ 95.00 $ 95.00 $2,200.00 $2,250.00 $ 40.80 $ 21.00 $ 12.45 $ 16.50 Provider charges payable by the Participating Plan shall be based on the lesser of the provider's customary charge or the relative value study times the appropriate conversion factor. SLMC can provide claim review for the following fThe fee for these services will be negotiated.): 1. RNE cpt codes 2. BR cpt codes 3. Unlisted procedures 4. Multiple surgeries 5. Medical necessity NOTE: If the Participating Plan's ID card does not clearly show the SLMC name and/or logo the Aspen Health Plus, Inc. Participating Provider is not obligated to accept the above discounts. PPOMPAR-WE-UR/CITY OF Fr COLLINS/11.20.98/jg RVP: EXHIBIT B PARTICIPATING PROVIDER FEES Central Rockies Physician Practice Association - (CRPP) (Eagle and Summit County) - The most current version of the St. Anthony Publishing Relative Value for Physicians (RVP) and Guidelines (formerly known as McGraw-Hill RVS). Anesthesia shall include the St. Anthony Publishing RVP unit value plus time units. - July and December updates implemented on September 1st and February 1st respectively - Codes modified and approved by SLMC (Notification of CPT code modifications will be sent to the Participating Plan's claims administrator.) CONVERSION FACTORS: Medicine Surgery OB GYN (59400-59581 & 59610-59622) 59400 59510 Anesthesia Radiology Pathology - Clinical Pathology - Surgical (88300-88399) Non MD/DO Asst. Surgeons $ 6.25 $85.00 $86.00 $1,800 $2,250 $40.00 $19.25 $11.75 $15.75 20 % of the Surgical PPO Allowable The CRPPA reimbursement schedule listed above shall only apply to services performed at the CRPPA Participating Provider's Eagle and Summit County addresses. If a Participating Provider is also a SLMC Participating Provider, listed in any area outside of Eagle or Summit County, that Participating Provider shall be paid at the SLMC reimbursement schedule for any services performed outside of Eagle or Summit County. For Participating Providers who are listed as both a CRPPA and a SLMC Participating Provider, SLMC reimbursement schedule shall be paid to that Participating Provider if the Participating Plan is participating with SLMC and not participating with CRPPA. Participating Provider charges payable by the Participating Plan shall be based on the lesser of the Participating Provider's customary charge or the relative value study times the appropriate conversion factor. SLMC can provide claim review for the following (The fee for these services will be negotiated): 1. RNE cpt codes 2. BR cpt codes 3. Unlisted procedures 4. Multiple surgeries 5. Medical necessity NOTE: If the Participating Plan's ID card does not clearly show the SLMC name and/or logo, the Central Rockies Physician Practice Association Participating Provider is not obligated to accept the above discounts. PPOITPAR-WE-UR/CITY OF FT COLLINS/11.20.98/jg RVP: EXHIBIT B PARTICIPATING PROVIDER FEES Centura Health Mercy Medical Center Managed Care Network (MHS) (formerly Mercy Health System, a PHO) Durango - The most current version of the St. Anthony Publishing Relative Value for Physicians (RVP) and Guidelines (formerly known as McGraw-Hill RVS). Anesthesia shall include the St. Anthony Publishing RVP unit value plus time units. - July and December updates implemented on September 1st and February 1st respectively - Codes modified and approved by SLMC (Notification of CPT code modifications will be sent to the Participating Plan's claims administrator.) CONVERSION FACTORS: Medicine $ 6.05 Surgery $ 86.50 Obstetrics (59400-59581 & 59610-59622) $ 85.00 59400 $1,750.00 59510 $2,100.00 Anesthesiology $ 38.50 Radiology $ 19.00 Pathology - Clinical $ 11.00 Pathology - Surgical (88300-88399) $ 15.50 Participating Provider charges payable by the Participating Plan shall be based on the lesser of the Participating Provider's customary charge or the relative value study times the appropriate conversion factor. SLMC can provide claim review for the following (The fee for these services will be negotiated.): 1. RNE cpt codes 2. BR cpt codes 3. Unlisted procedures 4. Multiple surgeries 5. Medical necessity NOTE: If the Participating Plan's ID card does not clearly show the SLMC name and/or logo, the MHS Participating Provider is not obligated to accept the above discount. The above discounts shall not be taken by the Participating Plan's claims administrator, if the Participating Plan's benefit design does not offer a financial incentive to use a Participating Provider. (i.e. differential in benefit reimbursement between an in network and out of network provider) PPOMPAR-WE-UR/CrrY OF FT COLLI14SIl1.20.98/jg MR EXHIBIT B PARTICIPATING PROVIDER FEES The Colorado Network, Inc. - (TCN) Rifle The most current version of the St. Anthony Publishing Relative Value for Physicians (RVP) and Guidelines (formerly known as McGraw-Hill RVS). Anesthesia shall include the St. Anthony Publishing RVP unit value plus time units. July and December updates implemented on September 1st and February 1st respectively Codes modified and approved by SLMC (Notification of CPT code modifications will be sent to the Participating Plan's claims administrator.) CONVERSION FACTORS: Medicine $ 6.05 Surgery $85.00 Obstetrics (59400-59581 & 59610-59622) $85.00 59400 $1,800 59510 $2,100 Anesthesiology $36.00 Radiology $19.00 Pathology - Clinical $11.50 Pathology - Surgical (88300-88399) $15.50 Participating Provider charges payable by the Participating Plan shall be based on the lesser of the Participating Provider's customary charge or the relative value study times the appropriate conversion factor. SLNIC can provide claim review for the followin¢ (The fee for these services will be negotiated.): 1. RNE cpt codes 2. BR cpt codes 3. Unlisted procedures 4. Multiple surgeries 5. Medical necessity NOTE: If the Participating Plan's ID card does not clearly show the SLMC name and/or logo, the Colorado Network Participating Provider is not obligated to accept the above discounts PPOMPAR-WE-UR/CITY OF FT COLLINS/H.20.98/jg EXHIBIT B RVP: PARTICIPATING PROVIDER FEES Community Health Providers Organization Inc. - (CHPO) (Grand Junction) - The most current version of the St. Anthony Publishing Relative Value for Physicians (RVP) and Guidelines (formerly known as McGraw-Hill RVS). Anesthesia shall include the St. Anthony Publishing RVP unit value plus time units. - July and December updates implemented on September 1st and February 1st respectively - Codes modified and approved by SLMC (Notification of CPT code modifications will be sent to the Participating Plan's claims administrator.) CONVERSION FACTORS: Medicine $ 6.20 Surgery $ 79.00 Obstetrics (59400-59581 & 59610-59622) $ 85.00 59400 $1,800.00 59510 $2,100.00 Anesthesiology $ 37.00 Radiology $ 18.00 Pathology - Clinical $ 18.00 Pathology - Surgical (88300-88399) $ 18.00 Participating Provider charges payable by the Participating Plan shall be based on the lesser of the Participating Provider's customary charge or the relative value study times the appropriate conversion factor. SLMC can provide claim review for the following (The fee for these services will be negotiated.): 1. RNE cpt codes 2. BR cpt codes 3. Unlisted procedures 4. Multiple surgeries 5. Medical necessity PPO I 7/PAR-WE-UR/CITY OF FT COLLINS/ 11.20.98/jg RVP: EXHIBIT B PARTICIPATING PROVIDER FEES Fort Collins IPA - (FCIP) - The most current version of the St. Anthony Publishing Relative Value for Physicians (RVP) and Guidelines (formerly known as McGraw-Hill RVS). Anesthesia shall include the St. Anthony Publishing RVP unit value plus time units. - July and December updates implemented on September 1st and February 1st respectively - Codes modified and approved by SLMC (Notification of CPT code modifications will be sent to the Participating Plan's claims administrator.) CONVERSION FACTORS: Medicine $ 6.55 Physical Medicine (97001-97799) $ 5.95 Surgery $79.50 Obstetrics (59400-59581 & 59610-59622) $80.10 59400 $1,865 59510 $2,210 Anesthesiology $36.55 Radiology $17.65 Pathology - Clinical $10.50 Pathology - Surgical (88300-88399) $15.50 Participating Provider charges payable by the Participating Plan shall be based on the lesser of the Participating Provider's customary charge or the relative value study times the appropriate conversion factor. SLMC can provide claim review for the following (The fee for these services will be negotiated.): 1. RNE cpt codes 2. BR cpt codes 3. Unlisted procedures 4. Multiple surgeries 5. Medical necessity PPO17/P.AR-WE-UR/CITY OF FT COLLINS/ I1.20.98/jg EXHIBIT B RVP: PARTICIPATING PROVIDER FEES Montrose Community Health Plan - (MCHP) - The most current version of the St. Anthony Publishing Relative Value for Physicians (RVP) and Guidelines (formerly known as McGraw-Hill RVS). Anesthesia shall include the St. Anthony Publishing RVP unit value plus time units. - July and December updates implemented on September 1 st and February 1 st respectively - Codes modified and approved by SLMC (Notification of CPT code modifications will be sent to the Participating Plan's claims administrator.) CONVERSION FACTORS: Medicine $ 6.05 Surgery $85.00 Obstetrics(59400-59581 & 59610-59622) $85.00 59400 $1,800 59510 $2,100 Anesthesiology $36.00 Radiology $19.00 Pathology - Clinical $11.50 Pathology - Surgical (88300-88399) $15.50 Participating Provider charges payable by the Participating Plan shall be based on the lesser of the Participating Provider's customary charge or the relative value study times the appropriate conversion factor. SLMC can provide claim review for the following (The fee for these services will be negotiated.): 1. RNE cpt codes 2. BR cpt codes 3. Unlisted procedures 4. Multiple surgeries 5. Medical necessity NOTE: If the Participating Plan's ID card does not clearly show the SLMC name and/or logo, the MCHP Participating Provider is not obligated to accept the above discounts. PP017/PAR•WE-UR/CrrY OF Fr COLLINS/ I 1.20.98/jg RVP: EXHIBIT B PARTICIPATING PROVIDER FEES Northcare Physicians - (NC) - The most current version of the St. Anthony Publishing Relative Value for Physicians (RVP) and Guidelines (formerly known as McGraw-Hill RVS). Anesthesia shall include the St. Anthony Publishing RVP unit value plus time units. - July and December updates implemented on September 1st and February 1st respectively - Codes modified and approved by SLMC (Notification of CPT code modifications will be sent to the Participating Plan's claims administrator.) CONVERSION FACTORS: Medicine $ 6.25 Surgery $77.50 OB GYN (59400-59581 & 59610-59622) $81.00 59400 $1,800 59510 $2,010 Anesthesia $36.00 Radiology $17.00 Pathology - Clinical $10.50 Pathology - Surgical (88300-88399) $15.50 Participating Provider charges payable by the Participating Plan shall be based on the lesser of the Participating Provider's customary charge or the relative value study times the appropriate conversion factor. SLMC can provide claim review for the following (The fee for these services will be negotiated.): 1. RNE cpt codes 2. BR cpt codes 3. Unlisted procedures 4. Multiple surgeries 5. Medical necessity PPOITPAR-WE-UR/CITY OF FT COLLINS/I 1.20.98/jg EXIIIBIT B RVP: PARTICIPATING PROVIDER FEES Preferred Choice, Inc. - (PCI) (Pueblo) - The most current version of the St. Anthony Publishing Relative Value for Physicians (RVP) and Guidelines (formerly known as McGraw-Hill RVS). Anesthesia shall include the St. Anthony Publishing RVP unit value plus time units. - July and December updates implemented on September 1st and February 1st respectively - Codes modified and approved by SLMC (Notification of CPT code modifications will be sent to the Participating Plan's claims administrator.) CONVERSION FACTORS: Medicine $ 6.25 Surgery $75.00 Obstetrics (59400-59581 & 59610-59622) $82.00 59400 $1,800 59510 $2,100 Anesthesiology $36.00 Radiology $18.25 Pathology - Clinical $12.25 Pathology - Anatomical (88000-88299) $16.50 Participating Provider charges payable by the Participating Plan shall be based on the lesser of the Participating Provider's customary charge or the relative value study times the appropriate conversion factor. SLMC can provide claim review for the following (The fee for these services will be negotiated.): 1. RNE cpt codes 2. BR cpt codes 3. Unlisted procedures 4. Multiple surgeries 5. Medical necessity PPOMPAR-WE-UR/CITY OF FT COLLINS/11.20.98/jg EXHIBIT B PARTICIPATING PROVIDER FEES PRO Behavioral Health - (PRO) Access to this group of providers is through the direct Sloans Lake Managed Care physician network (SLMC). PRO Behavioral Health has been given a separate identifying region (PRO) due to the difference in conversion factors. RVP: - The most current version of the St. Anthony Publishing Relative Value for Physicians (RVP) and Guidelines (formerly known as McGraw-Hill RVS). Anesthesia shall include the St. Anthony Publishing RVP unit value plus time units. - July and December updates implemented on September 1st and February 1st respectively - Codes modified and approved by SLMC (Notification of CPT code modifications will be sent to the Participating Plan's claims administrator.) CONVERSION FACTORS: PROI, 2 & 3 PRO1 = MD / DO Level PRO2 = Psychology Level PR03 = Masters Level PROA (all providers) PROB (all providers) PROC (all providers) PROD (all providers) PROE (all providers) CPT Codes 90801-90899 $5.25 $4.65 $4.00 $6.70 $6.25 $6.55 $6.20 $6.05 All Other 90000 CPT Codes $5.95 $5.95 $5.95 $6.70 $6.25 $6.55 $6.20 $6.05 Participating Provider charges payable by the Participating Plan shall be based on the lesser of the Participating Provider's customary charge or the relative value study times the appropriate conversion factor. SLMC can provide claim review for the following (The fee for these services will be negotiated.): 1. RNE cpt codes 2. BR cpt codes 3. Unlisted procedures 4. Multiple surgeries 5. Medical necessity PPO17/PAR-WE-UR/CrrY OF FT COLLINS/ 11.20.98/jg EXHIBIT A The Network Alliance Page 16 L1860 KO,MOD.SUPRACONDYL SOCKET,(SK) 747.79 L2310 ABDUCTION BAR, STRAIGHT 93.05 L1870 KO,DBL UP,JTS, LACE,MLD PT MDL 729.30 L2320 NON MOLDED LACER 182.97 L1880 KO,DBL UP,JTS,LACE,NON-MOLD 498.51 L2330 LACER, MOLDED TO PT MODEL 301.61 L1885 KO,SGL/DBL UP,OW/FUNC ACTIRES 777.26 L2335 ANTERIOR SWING BAND 166.12 L1900 AFO,SPRING WIRE, DFACALF BAND 205.01 L2340 PRE -TIBIAL SHELL, MLD PT MDL 311.46 L1902 AFO, ANKLE GAUNTLET 55.63 L2350 PROS TYPE -BK- SOCKET (PTB/AFO 725.28 L1904 AFO, ANKLE GAUNTLET MLDPTMD - -- - 327.71 ---- L2360- - EXTENDED STEEL SHANK--- 4009 L1906 AFO,MULTILIGAMENTUS SUPPORT 111.75 L2370 PATTEN BOTTOM 178.90 L1910 AFO,POSTERIOR, SGL BAR, CLASP 188.43 L2375 TORS CTRL, ANKLE JT&HALF SLD S 78.74 L1920 AFO,SGL UP(PHELPS OR PERLSTEIN 306.42 L2380 TORS CTRL, STRAIGHT KNEE JOINT 114.39 L1930 AFO, PLASTIC 179.94 L2385 STRAIGHT KNEE JOINT,HEAVY DUTY 124.45 L1940 AFO, MLD PT MDL, PLASTIC 344.64 L2390 OFFSET KNEE JOINT, EACH JT 101.71 L1945 AFO, MLD PT MDL, FLOOR REACTI 663.78 L2395 OFFSET KNEE IT, HEAVY DUTY, EA 129.55 L1950 AFO, SPIRAL, MLD PT MDL, IRM 561.59 1,2397 SUSPENSION SLEEVE 89.75 L1960 AFO,-MLD PT MDL, SOLID ANKLE 386.28 L2405 DROP LOCK, EACH JOINT 47.29 L1970 AFO,PLASTIC, MLD PT MDL, W/JTS 520.96 L2415 CAM LOCK(SWISS,BAIL),EACH IT 132.48 L1980 AFO,SGL UP, FREE ANKLE, SLD ST 275.77 L2425 DISCIDIAL LOCK ADJ KNEE FLEXI 151.63 L1990 AFO, DBL UP, FREE ANKLE,SLD ST 310.64 L2430 RATCHET LOCK,ACT/PROG EXT,EA 74.06 L2000 KAFO,SGL UP, FREE KNEE/ANKLE 732.34 L2435 POLYCENTRIC KNEE JOINT, EACH J 115.33 L2010 KAFO, SGL UP, ANKL/NO KNEE JT 753.91 L2492 LIFT LOOP FOR DROP LOCK RING 88.98 L2020 KAFO,DBL UP,FREE KNEE/ANKLE,DB 813.72 L2500 GLUT/ISCHIAL WGHT BEARING, RIN 219.85 L2030 KAFO,DBL.UP,FREE.ANKLE,NO KN J 705.97 L2510 QUADRILATERAL BRIM, MOLDED 506.20 L2035 KAFO, Plastic,molded. 130.52 L2520 QUADRILATERAL BRIM, CUSTOM FIT 343.59 L2036 KAFO,PLASTIC, DBL UP,CUST MOLD 1419.28 L2525 NARROW ML BRIM, CUSTOM MOLD 955.14 L2037 KAFC,PLASTIC,SGL UP,CUST MOLD 1160.73 L2526 NARROW ML BRIM, CUSTOM FIT 618.28 L2038 KAFO,PLASTIC,W/O KNEE(LIVELY) 996.36 L2530 THIGH LACER, NON -MOLDED 218.32 L2039 KAFO,PLASTIC,SGL UP,POLY-AX HN 1674.50 L2540 THIGH LACER, MOLDED TO PATIENT 334.42 L2040 TORSION CTRL,ROTAT STRAPS,BAND 160.78 L2550 HIGH ROLL CUFF 266.86 L2050 TORSION CNTRL,BIL CABLESMIP J 367.31 L2570 HIP JOINT,CLEVIS TYPE,2 POS,EA 331.93 L2060 TORSION CTRL,BIL CABLES,BALL B 412.45 L2580 PELVIC SLING 423.03 L2070 TORSION CNTRL,UNIL ROT STRAP 93.72 L2600 HIP JOINT,CLEVIS TYPE,FREE, EA 155.41 L2080 TORSION CNTRL,UNIL CABLES J 250.65 L2610 HIP JOINT,CLEVIS TYPE,LOCK, EA 177.17 L2090 TORSION CNTRL,UNIL CABLE,BALL 339.72 L2620 HIP JOINT, HEAVY DUTY, EACH 186.33 L2102 FRACTURE QRTH,TIBIAL, PLASTER 328.96 L2622 HIP JOINT, ADJ FLEXION, EACH 213.70 L2104 FRACTURE ORTH,TIBIAL,SYNTHETIC 343.96 L2624 HIP JOINT, ADJ FLEX/EXTEN, EAC 230.77 L2106 FRACTURE ORTH,TIBIAL,THERMOPL 473.92 L2627 RECIP HIP JOINT & CABLES,MOLDE 1592.88 L2108 FRACTURE ORTH,TIBIAL,MLD PT MD 847.91 L2628 RECIP HIP JOINT & CABLES ,META 1556.74 L2112 FRACTURE ORTH,TIBIAL, SOFT 325.13 L2630 PELVIC CTL BAND & BELT, UNIL 230.08 L2114 FRACTURE ORTH,TIBIAL, SEMI -RIG 407.82 L2640 PELVIC CTL BAND & BELT, BIL 234.19 L2116 FRACTURE ORTH,TIBIAL, RIGID-- 496.12 L2650 GLUTEAL PAD 83.63 173.18 L2122 FRACTURE ORTH,FEMORAL,PLASTER 571.55 L2660 THORACIC BAND 158.50 L2124 FRACTURE ORTH,FEMORAL,SYNTHE 682.67 L2670 PARASPINAL UPRIGHTS L2126 FRACTURE ORTH,FEMORAL,THERMO 937.10 L2680 LATERAL SUPPORT UPRIGHTS 145.41 L2128 FX ORTH,FEMORAL,MLD PT MDL 1194.97 L2750 CHROMEINICKEL PLATING,PER BAR 58.25 L2132 FRACTURE ORTH,FEMORAL,SOFT 726.98 L2755 CARBON GRAPHITE LAMINATION 98.44 L2134 FRACTURE ORTH,FEMORAL;SEMI-RIG 674.01 L2760 GROWTH EXTENSION, PER BAR 56.45 _ L2136 -FRACTURE ORTH,FEMORAL, RIGID 926.32 L2770 STAINLESS STEEL, PER BAR OR IT 57.37 L2180 PLASTIC SHOE INSERT W/JOINTS(F 106.28 L2780 NON -CORROSIVE FINISH, PER BAR 47.16 L2182 DROP LOCK KNEE JOINTS(FX ORTH) 68.00 L2785 DROP LOCK RETAINER, EACH 22.09 L2184 LIMITED MOTION KNEE JOINT (FX) 94.57 L2795 FULL KNEE CAP 59.21 L2186 ADJ MOTION KNEE JT(LERMAN),(FX 125.62 L2800 KNEE CAP, MEDIAL/ LATERAL PULL 81.52 L2188 QUADRILATERAL BRIM TX ORTH) 208.71 L2810 L2820 CONDYLAR PAD SOFT INTERFACE, BK SECTION 54.43 80.69 L2190 WAIST BELT (FX ORTH) HIP JT,PELVIC BAND,THIGH FLG(F 63.01 248.48 L2830 SOFT INTERFACE, AK SECTION 87.30 L2192 L2200 LIMITED ANKLE MOTION, EA JOINT 44.18 L2840 FRACTURE SOCK, TIBIAL, EACH 30.45 L2210 DORSIFLEX ASS/PLANTAR FLEX RES 62.46 L2850 FRACTURE SOCK, FEMORAL, EACH 55.41 L2220 DORSI/PLANTARFLEX/ASSIST/RESIS 73.94 L2860 CONC ADJ TORSION MECH,KNEE/ANK 276.75 L2230 SPLIT FLAT CALIPER PLATE & ATT 58.33 L3224 WOMAN'S OXFORD. ATT TO BRACE 42.61 L2240 ROUND CALIPER & PLATE 58.28 L3225 MAN'S OXFORD, ATT TO BRACE 56.86 L2250 FOOT PLATE,MLD PT MDL 293.15 L3649 UNLISTED PROCED. FOR FOOT ORTHO By Report L2260 REIN. SOLID STIRRUP(SCOTT-CRAI 159.75 L3650 SO,FIG-8 ABDUCTION RESTRAINER 40.44 L2265 LONG TONGUE STIRRUP 82.07 L3660 SO,FIG-8 ABDUCTION,CANVAS/WEB 91.48 77.11 L2270 T-STRAP, PADDED & LINED 41.10 L3670 SO, ACROMIO/CLAVICULAR 47.60 L2275 VARUS/VALGUS CORRECT, PLASTIC 103.81 L3700 EO, ELASTIC WITH STAYS 84.30 L2280 MOLDED INNER BOOT 315.56 L3710 EO, ELASTIC W/METAL JOINTS,DBL L2300 ABDUCTION BAR, JOINTED, ADJ 187.63 EXHIBIT B RVP: PARTICIPATING PROVIDER FEES Roaring Fork Valley Physicians IPA - (RFIP) Garfield County - The most current version of the St. Anthony Publishing Relative Value for Physicians (RVP) and Guidelines (formerly known as McGraw-Hill RVS). Anesthesia shall include the St. Anthony Publishing RVP unit value plus time units. - July and December updates implemented on September 1st and February 1st respectively - Codes modified and approved by SLMC (Notification of CPT code modifications will be sent to the Participating Plan's claims administrator.) CONVERSION FACTORS: Medicine $ 6.70 Surgery $ 90.00 Obstetrics (59400-59581 & 59610-59622) $ 89.00 59400 $1,950.00 59510 $2,150.00 Anesthesiology $ 40.00 Radiology $ 21.00 Pathology (80000-87999) $ 12.00 Pathology (88000-89399) $ 15.50 Participating Provider charges payable by the Participating Plan shall be based on the lesser of the Participating Provider's customary charge or the relative value study times the appropriate conversion factor. SLMC can provide claim review for the following (The fee for these services will be negotiated.): 1. RNE cpt codes 2. BR cpt codes 3. Unlisted procedures 4. Multiple surgeries 5. Medical necessity NOTE: If the Participating Plan's ID card does not clearly show the SLMC name and/or logo, the Roaring Fork Valley Physician IPA Participating Provider is not obligated to accept the above discounts. The above discounts shall not be taken by the Participating Plan's claims administrator, if the Participating Plan's benefit design does not offer a financial incentive to use a Participating Provider. (i.e. differential in benefit reimbursement between an in network and out of network provider) PPOMPAR-WE-UR/CITY OF FT COLLINS/11.20.98/jg RVP: EXHIBIT B PARTICIPATING PROVIDER FEES Southwest Memorial PHO dba Southwest Healthnet - (SWHN) Cortez - The most current version of the St. Anthony Publishing Relative Value for Physicians (RVP) and Guidelines (formerly known as McGraw-Hill RVS). Anesthesia shall include the St. Anthony Publishing RVP unit value plus time units. - July and December updates implemented on September 1st and February 1st respectively - Codes modified and approved by SLMC (Notification of CPT code modifications will be sent to the Participating Plan's claims administrator.) CONVERSION FACTORS: Medicine $ 6.05 Surgery $85.00 Obstetrics (59400-59581 & 59610-59622) $85.00 59400 $1,800 59510 $2,100 Anesthesiology $36.00 Radiology $19.00 Pathology - Clinical $11.50 Pathology - Surgical (88300-88399) $15.50 Participating Provider charges payable by the Participating Plan shall be based on the lesser of the Participating Provider's customary charge or the relative value study times the appropriate conversion factor. SLMC can provide claim review for the following (The fee for these services will be negotiated.): 1. RNE cpt codes 2. BR cpt codes 3. Unlisted procedures 4. Multiple surgeries 5. Medical necessity NOTE: If the Participating Plan's ID card does not clearly show the SLMC name and/or logo, the Southwest Healthnet Participating Provider is not obligated to accept the above discounts. PPOITPAR-WE-UR/CITY OF Fr COLLINS/11.20.98/jg EY=IT B RVP: PARTICIPATING PROVIDER FEES Valley View Hospital Based Physicians - (VVII) - The most current version of the St. Anthony Publishing Relative Value for Physicians (RVP) and Guidelines (formerly known as McGraw-Hill RVS). Anesthesia shall include the St. Anthony Publishing RVP unit value plus time units. - July and December updates implemented on September 1st and February 1st respectively - Codes modified and approved by SLMC (Notification of CPT code modifications will be sent to the Participating Plan's claims administrator.) CONVERSION FACTORS: Medicine Surgery Obstetrics (59400-59581 & 59610-59622) 59400 59510 Anesthesiology Radiology Pathology - Clinical Pathology - Surgical (88300-88399) $ 6.70 $90.00 $89.00 $1,950 $2,150 $40.00 $21.00 $12.00 $15.50 Participating Provider charges payable by the Participating Plan shall be based on the lesser of the Participating Provider's customary charge or the relative value study times the appropriate conversion factor. SLMC can provide claim review for the following (The fee for these services will be negotiated.): 1. RNE cpt codes 2. BR cpt codes 3. Unlisted procedures 4. Multiple surgeries 5. Medical necessity PP0171PAR-WE-UR/CITY OF FT COLLINS/11.20.98fg EXHIBIT C ENROLLMENT DATA Data Element Description Subscriber Number Family ID/Alphanumeric Member Number Member suffix: 01 = Primary 02 = Spouse 03-89 = Dependents 90-99 = Other Numeric Subscriber SS# Contract holder social security number used to identify families/Numeric Group Number Employer group number/Alphanumeric Last Name Members last name/Alphanumeric First Name — Members first name/Alphanumeric Initial _ Members middle initial/Alpha — Address Members home address required for subscribers/Alphanumeric City Members city required for subscribers/Alphanumeric State Members state abbreviation required for subscribers/Alphanumeric Zip code Members zip code required for subscribers/Alphanumeric Phone Subscribers home phone number and Members if different than the subscribers/Numeric - Sex M = Male F = Female/Alpha Member SS# Members social security number/Numeric PPOMPAR-WE-URICITY OF FT COLLINS/10.13.98/jg EXHIBIT C Page 2 Data Element Description Relationship Relationship to subscriber: P = Primary S = Spouse D = Dependent 0 = Other Alpha Birth Date Members date of birth Format = MM-DD-YYYY/Alphanumeric Status Record status: C = Change E = Enrollment D = Disenrollment Alpha Enroll Date Effective date of coverage/Alphanumeric Disenroll Date Ending date of coverage/Alphanumeric Change Change flag to indicate what demographical information has changed. Required for "C" status. Policy Number Subscribers policy number/Alphanumeric PPOMPAR-WE-UR/CITY OF FT COLLINS/10.13.98/jg EXHIBIT A The Network Alliance Page 17 L4010 REPLACE TRILATERAL SOCKET BRIM 506.98 L4020 REPL QUAD. SOCKET BRIM,CUST FA 600.24 L3720 EO,DBL UP W/FOREARM CUFF,FREE 446.04 L4030 REPL QUAD SOCKET BRIM,CUST FIT 351.84 L3730 EO,DBL UPR, EXT/FLX ASSIST 614.74 L4040 REPLACE MOLDED THIGH LACER 296.95 L3740 EO,DBL UP, ADI, POS LOCK W/CTR EO,DBL 728.81 L4045 REPLACE NON -MOLDED THIGH LACER 275.15 L3740 WHFOSHORT OPPONENS,NO ATT 128.81 L405 REPLACE MOLDED CALF LACER .71 L3805 WHFO,LONG OPPENENS,NO ATTACH. 257.72 L40 5 REPLACE NON MOLDED CALF LACER 186.30 L3810 WHFO,ADD,THUMB ABD "C" BAR 58.92 �60 7 REPLACE HIGH ROLL CUFF 295.29 L3815 WHFO, ADD, 2ND MP ABD ASSIST- -----54.70 - _ L4080 REPL AL&DIPTAL UPRTZ�iH I 96.12 L3820 WHFO,ADD IP EXT ASSIST,MP STOP 93.96 L4080 IGH METAL THIGH REPL METAL 49 L3825 WHFO,ADD MP EXTENSION STOP 58.93 L4100 DISTAL THIGH REPL CALF OR DISTAL THIGH BAND 62.93 L3830 WHFO, ADD, MP EXT ASSIST 70.66 L4110 REPL LEATHER CUFF,DIST THIGH 72.69 L3835 WHFO,ADD, MP SPRING EXT ASSIST 70.11 IA130 REPL LEATHER CUFF, THIGH/C 59.89 L3840 WHFO,ADD, SPRING SWIVEL THUMB 52.88 L4205 SHELL REPLACE PR£TIBIAI SHELL 397.3 L3845 WHFO,ADD,THMB IP EXT ASST, MP 73.17 L4310 O C LABOR MIN) 15.31 179.2 L3850 WHO,ADD,ACTION WRIST WITH DFA 91.17 L4320 -P MULTI-PODUS OR EQUAL ORTHOTIC MULTIQ L3S55 WHFO,ADD, ADJ MP FLEXION CTRL 100.41 L4320 MULTI-PODUS,A EX FOOT POSI 115.06 L3960 WHFO,ADD,ADJ MP FLEX CTRL & IP 128.85 L4360 SPLINT PNEUM ANKLE SPLINT 62.29 L3890 CONC. ADJ TORSION STYLE MECHAN 276.75 L4370 T (AIRCARCAST) PNEUM WALKING SPLINT (AIRCAST) 208.2 L3900 WHFO, FLXR HGE,RECIP WR, WR DR 882.39 L4380 PNEUMATIC FULL LEG SPLINT 144.31 144.31 L3901 WHFO,FLXR HG£,RECIP WR, CAB DR 1404.11 L4380 PNEUMATIC KNEE SPLINT 74.85 L3902 WHFO,EXT POWER,COMPRESS GAS 2183.36 L4392 REPL SOFT INTERFACE,ANKLE ODUS 117.62 L3904 WHFO,EXT POWER, ELECTRIC 2662.69 L4394 REPL SOFT INTERFACE,ANKLE .41 12.41 L3906 W'HO,WRIST GAUNLET, MOLDED TO P 278.88 L4394 SP REPL SOFT FT SP 12.71 L3907 WHFO,WRIST GAUNLET/THUMB SPICA 346.40 IA398 CONTRACTURE ANKLE CONTRACTURE SPLINT 124.17 L3908 WHO,COCKUP SPLINT, NON -MOLDED 40.86 L5000 FOOT DROP SPLT,RT POI DER L3910 WHFO, SWANSON DESIGN 302.09 L5010 PARTL FOOT, W/T FILLER 375.1 L3912 HFO, FLEXION GLOVE W/ELASTIC F64.67 L5020 ANKLE HGHT FQ PARTL FOOT, ANKLE,TOE 991.59 L3914 WHO, WRIST EXTENSION COCK -UP 58.45 L5050 FILLER PARTLS,SYMEIB TUB,TOE FILLER 1739.8 1848.41 L3916 WHFO,WRIST EXT COCK -UP, W/OUTR 86.61 L5060 ANKLES,SYMES, MOLDED SOCKET, L3918 HFO,KNUCKLE BENDER 53.45 L5100 ANKLE SYMES, SKT, ARCHTIC 505.35 2725.55 L3920 HFO,KNUCKLE BENDER W/OUTRIG 66.78 L5105 D SO FOOT BK O SOCKETIGH L3922 HFO, KNUCKLE BENDER, 2 SEGMENT 66.68 L5150 THIGH LACE PLASTIEXO,MSCK L BK,MOLD C SC 829.40 2887.81 L3924 WHFO,OPPENHEINER 72.71 L5160 KD,MOLDED TEXT KNEE L3926 WHFO,THOMAS SUSPENSION SPLINT 63.31 L5200 ,SACJTS,SHI KNEXT EXO, XT 3180.26 3152.64 L3928 HFO,FINGER EXTENSION,W/ CLOCK 39.69 L5210 MOLENTD SCKT,SGL AXIS N AK MOLD SCKTNEE AXIS AK L3930 WHFO,FINGER EXTENSION,W/WRIST 41.96 L5220 "STUEXO, AK "STUBHIES", NO KNEE FO 1941.90 1237.53 L3932 FO, SAFETY PIN, SPRING WIRE 32.05 L5230 TEDJT,AO AK"STUBBIES"-ARTICULATED L3934 FO, SAFETY PIN,MODIFIED 32.86 L5230 NST ,SA AK,EXO,CAN KJT, A 3765.94 L3936 WHFO, PALMER 60.75 L5270 I PE.HIRICT HD,EXO,CANADIAN TYPE,HIP 4838.78 4413.88 L3938 WHFO, DORSAL WRIST 63.61 L5280 HIP HD,TILT TABLE TYPE,L HIP L3940 WHFO, DORSAL WRIST-W/OUTRIGGER 73.31 L5300 JT,SA 5013.78 L3942 HFO,REVERS'E KNUCKLE BENDER 54.36 L5310 BK,ENDO,MOLD SCKT,SACH FOOT BK,CANADIAN SCKT,S CH FOOT 2158.38 L3944 HFO,REV KNUCKLE BENDER W/OUTRI 66.97 L5310 KD,ENDO,MOLD SKT,SACH FOOT 3444.29 3147.97 L3946 HFO,COMPOSITE ELASTIC 60.43 L5330 AK,ENDO,MOLD CH FOOT L3948 HFO, FINGER KNUCKLE BENDER 37.58 L5340 IAN T HD CANADIAN TYPE,SACH FOO 5175.66 5520.00 L3950 WHFO, COMBINATION OPPENHEIMER, 102.26 L5440 HP ENDO, FOO 5520.00 L3952 WHFO,COMBINATION OPPENHEIMER, 113.50 L5400 ESSINACH IPOP,BK,EAC RIGID DRESSING,CA - P,BK,I IT RIGID L3954 HFO,SPREADING HAND - 75.31 L5420 IPOP,BK/KD,l ADD'L CAST CHANGE 311.17 10.21 3269.2 L3960 SEWHO, AIRPLANE DESIGN 501.17 L5430 IPOP,AK/KD,I RIGID DRESSING L3962 SEWHO,ABD POSITION, ERB PALSY 489.29 L5430 A IPOP,AK,KD,EA ADD'L GAIT 373.610 363.75 L3963 SEWHO.MOLDED W/ARTIC ELBOW 1137.68 L5460 RIGIDHANG IPOP,BK,NON-WGHT BEARING RIGID L3964 SEO,MOBILE ARM SUPP,ATT TO WC, 592.43 L5460 IPOP,AK,NON-WGHT BEARING RIGID 426.04 426.Q4 L3965 SEO,RAD ARM SUPP,ATT TO WC, AD 945.35 L5500 INIT,BK,PTB,NON-ALIGN,USMC/EQ, 1256.13 1.3966 SEO, MOB ARM SUP,ATT TO WC, RE 712.17 L5505 INIT,AK/KD, NON-ALIGN,PLASTER. 1462.17 L3968 SEO,MOB ARM SUP, FRICTION ARM 766.05 L5510 PREP,BK,PTB,NON-ALIGN,USMC/EQ. 1251.55 L3969 SEO, MOB ARM SUP, YOKE TYPE AR 630.23 L5520 PREP,BK,PTB,NON-ALIGN,THERb10.D 1067.67 L3970 O SEO,ADD, ELEVATING PROXIMAL AR ELEVATING 252.10 L5530 PREP,BK,PTB,NON-ALIGN THRMO,NIL 1405.09 L3970 SEO,ADD, R ROCKER FFSET/TOR 160.30 L5535 PREP,BK,PTB,NON-ALIGN,PRE-FAB, 1259.04 L3972 SEO, ADD, UPINATO 160.31 135.97 L5540 PREP,BK,PTB,NON-ALIGN,LAM SKT. 1508.16 L3974 HUMERAL FRACTURE HUMERAL L5560 PREP,AK/KD,NON-ALIGN,USMC/EQ.P 1763.15 L3982 FRACTURE ORTHOSIS, 210.82 L5570 PREP,AK/KD,NON-ALIGN,THER.MO,DI 1908.06 L3982 FRACTURE ORTHOSIS, WRIST 260.66 269.71 L5580 PREP,AK/KD,NON-ALIGN,THRMO.MLD 2143.18 L3984 FRACTURE ORTH,FOREARIST WRIST L5590 PREP,AK/KD,NON-ALIGN, FAB.. 2148.82 L3986 FRACTURE ORTH,HUM/RAD/ULN/WR 382.23 L5595 LA PREP,AK/KD,NON-ALIGN, LAM SKT. 7940 2989.45 L3995 FRACTURE SOCK, UPPER EXT, EACH 22.30 L5595 L PREP,HD/HP,THRMO,MLD PT MDL 2989.45 L4000 REPLACE MILWAUKEE GIRDLE 1007.72