Document:

Medical Group Participation Agreement

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Exhibit 10.21 
 Medical Group Participation Agreement 
 This Agreement is entered into by and between
United HealthCare Insurance Company, contracting on behalf of itself, United HealthCare of Texas, inc., PacifiCare of Texas, Inc., Evercare of Texas, LLC, and the other entities that are United’s Affiliates (collectively referred to as
“United”) and WhiteGlove Health, Inc. (“Medical Group”). 
 This Agreement is effective on the later of the following dates
(the “Effective Date”): 
 i)
                     or 
 ii) the first day of the first calendar month that begins at least 30 days after the date when this Agreement has been executed by all parties. 
 Through contracts with physicians and other providers of health care services, United maintains one or more networks of providers that are available to Customers. Medical Group is a provider of health
care services. 
 United wishes to arrange to make Medical Group’s services available to Customers. Medical Group wishes to provide such
services, under the terms and conditions set forth in this Agreement. 
 The parties therefore enter into this Agreement. 

Article I. 

Definitions 
 The
following terms when used in this Agreement have the meanings set forth below: 
 1.1 “Benefit Plan” means a certificate of
coverage, summary plan description, or other document or agreement, whether delivered in paper, electronic, or other format, under which a Payer is obligated to provide coverage of Covered Services for a Customer. 

1.2 “Covered Service” is a health care service or product for which a Customer is entitled to receive coverage from a Payer, pursuant to
the terms of the Customer’s Benefit Plan with that Payer. 
 1.3 “Customary Charge” is the fee for health care services
charged by Medical Group that does not exceed the fee Medical Group would ordinarily charge another person regardless of whether the person is a Customer. 
 1.4 “Customer” is a person eligible and enrolled to receive coverage from a Payer for Covered Services. 
 1.5 “Medical Group Physician” is a Doctor of Medicine (“M.D.”), or a Doctor of Osteopathy (“D.O.”), duly licensed and qualified under the laws of the jurisdiction in
which Covered Services are provided, who practices as a shareholder, partner, or employee of Medical Group, or who practices as a subcontractor of Medical Group. However, a subcontractor of Medical Group is a Medical Group Physician only with regard
to services rendered to patients of Medical Group and billed under Medical Group’s tax identification number. Additionally, a subcontractor is not a Medical Group Physician with regard to any services rendered in a physician’s office other
than those locations listed in Appendix 1. 
 1.6 “Medical Group Non-Physician Provider” is a surgical assistant, physician
assistant, nurse practitioner, physical therapist, occupational therapist, speech therapist, mental health provider, or licensed social worker, who is duly authorized under the laws of the jurisdiction in which Covered Services are provided, and who
renders Covered Services as an employee or subcontractor of Medical Group. However, a subcontractor of Medical Group is a Medical Group Non-Physician Provider only with regard to services rendered to patients of Medical Group and billed under
Medical Group’s tax identification number. Additionally, a subcontractor is not a Medical Group Non-Physician Provider with regard to any services rendered in a physician’s office other than those locations listed in Appendix 1.

 1.7 “Medical Group Professional” is a Medical Group Physician or a Medical Group
Non-Physician Provider. 
 1.8 “Payment Policies” are the guidelines adopted by United for calculating payment of claims under
this Agreement. The Payment Policies may change from time to time as discussed in section 7.4 of this Agreement. 
 1.9 “Payer”
is an entity obligated to a Customer to provide reimbursement for Covered Services under the Customer’s Benefit Plan, and authorized by United to access Medical Group’s services under this Agreement. 

1.10 “Protocols” are the programs, protocols and administrative procedures adopted by United or a Payer to be followed by Medical Group
in providing services and doing business with United and Payers under this Agreement. These Protocols may include, among other things, credentialing and recredentialing processes, utilization management and care management processes, quality
improvement, peer review, Customer grievance, concurrent review, or other similar United or Payer programs. The Protocols may change from time to time as discussed in section 5.4 of this Agreement. 

1.11 “United’s Affiliates” are those entities controlling, controlled by, or under common control with United HealthCare Insurance
Company. 
 Article II. 
 Representations and Warranties 
 2.1 Representations and Warranties of Medical
Group. Medical Group, by virtue of its execution and delivery of this Agreement, represents and warrants as follows: 
 (a) Medical Group is
a duly organized and validly existing legal entity in good standing under the laws of its jurisdiction of organization. 
 (b) Medical Group has
all requisite corporate power and authority to conduct its business as presently conducted, and to execute, deliver and perform its obligations under this Agreement. The execution, delivery and performance of this Agreement by Medical Group have
been duly and validly authorized by all action necessary under its organizational documents and applicable corporate law. 
 (c) The execution,
delivery and performance of this Agreement by Medical Group do not and will not violate or conflict with (i) the organizational documents of Medical Group, (ii) any material agreement or instrument to which Medical Group is a party or by
which Medical Group or any material part of its property is bound, or (iii) applicable law. Medical Group has the unqualified authority to bind, and does bind, itself and Medical Group Professionals to all of the terms and conditions of this
Agreement, including any Appendices, Attachments and Exhibits, as applicable. 
 (d) Medical Group has obtained and holds all registrations,
permits, licenses, and other approvals and consents, and has made all filings, that it is required to obtain from or make with all governmental entities under applicable law in order to conduct its business as presently conducted and to enter into
and perform its obligations under this Agreement. 
 (e) Medical Group has been given an opportunity to review the Protocols and Payment
Policies and acknowledges that it is bound by the Protocols and that claims under this Agreement will be paid in accordance with the Payment Policies. 
 (f) Each submission of a claim by Medical Group pursuant to this Agreement shall be deemed to constitute the representation and warranty by it to United that (i) the representations and warranties of
it set forth in this section 2.1 and elsewhere in this Agreement are true and correct as of the date the claim is submitted, (ii) it has complied with the requirements of this Agreement with respect to the Covered Services involved and the
submission of such claim, (iii) the charge amount set forth on the claim is the Customary Charge and (iv) the claim is a valid claim. 

 2.2 Representations and Warranties of United. United, by virtue of its execution and delivery of
this Agreement, represents and warrants as follows: 
 (a) United is a duly organized and validly existing legal entity in good standing under
the laws of its jurisdiction of organization. 
 (b) United has all requisite corporate power and authority to conduct its business as presently
conducted, and to execute, deliver and perform its obligations under this Agreement. The execution, delivery and performance of this Agreement by United have been duly and validly authorized by all action necessary under its organizational documents
and applicable corporate law. 
 (c) The execution, delivery and performance of this Agreement by United do not and will not violate or conflict
with (i) the organizational documents of United, (ii) any material agreement or instrument to which United is a party or by which United or any material part of its property is bound, or (iii) applicable law. 

(d) United has obtained and holds all registrations, permits, licenses, and other approvals and consents, and has made all filings, that it is required
to obtain from or make with all governmental entities under applicable law in order to conduct its business as presently conducted and to enter into and perform its obligations under this Agreement. 

Article III. 
 Applicability of this Agreement 
 3.1 Medical Group’s Services. This
Agreement applies to Medical Group’s practice locations set forth in Appendix 1. In the event Medical Group begins providing services at other locations (either by opening such locations itself, or by acquiring, merging or coming under common
ownership and control with an existing provider of services that was not already under contract with United or one of United’s Affiliates to participate in a network of health care providers), such additional locations will become subject to
this Agreement 30 days after United receives the notice required under section 5.7(v) of this Agreement. 
 Medical Group may transfer all or
some of its assets to another entity, if the result of such transfer would be that all or some of the Covered Services subject to this Agreement will be rendered by the other entity rather than by Medical Group, but only if Medical Group requests
that United approve the assignment of this Agreement as it relates to those Covered Services and only if the other entity agrees to assume this Agreement. This paragraph does not limit United’s right under section 10.4 of this Agreement to
elect whether to approve the assignment of this Agreement. 
 3.2 Payers and Benefit Plan types. United may allow Payers to access
Medical Group’s services under this Agreement for the Benefit Plan types described in Appendix 2. Appendix 2 may be modified by United upon 30 days written or electronic notice. 
 3.3 Services not covered under a Benefit Plan. This Agreement does not apply to services not covered under the applicable Benefit Plan. Medical Group may seek and collect payment from a Customer
for such services, provided that the Medical Group first obtain the Customer’s written consent. 
 This section does not authorize Medical
Group to bill or collect from Customers for Covered Services for which claims are denied or otherwise not paid. That issue is addressed in sections 7.5 and 7.8 of this Agreement. 
 3.4 Patients who are not Customers. This Agreement does not apply to services rendered to patients who are not Customers at the time the services were rendered. Section 7.6 of this Agreement
addresses circumstances in which claims for services rendered to such persons are inadvertently paid by a Payer. 
 3.5 Health Care.
Medical Group acknowledges that this Agreement and Customer Benefit Plans do not dictate the health care provided by Medical Group or Medical Group Professionals, or govern Medical Group’s or Medical Group Professional’s determination of
what care to provide its patients, even if those patients are Customers. The decision regarding what care is to be provided remains with Medical Group Professionals and with Customers, and not with United or any Payer. 

 3.6 Communication with Customers. Nothing in this Agreement is intended to limit Medical
Group’s or Medical Group Professional’s right or ability to communicate fully with a Customer regarding the Customer’s health condition and treatment options. Medical Group and Medical Group Professionals are free to discuss all
treatment options without regard to whether or not a given option is a Covered Service. Medical Group and Medical Group Professionals are free to discuss with a Customer any financial incentives Medical Group may have under this Agreement, including
describing at a general level the payment methodologies contained in this Agreement. 
 Article IV. 

Participation of Medical Group Professionals in United’s Network 

4.1 Medical Group Professionals as Participating Providers. Except as described under section 4.2, all Medical Group Professionals will
participate in United’s network. Medical Group has the authority to bind, and will bind, all new Medical Group Professionals to the obligations of this Agreement. 
 4.2 Medical Group Professionals who are not Participating Providers. The following Medical Group Professionals are not participating providers in United’s network: 

i) A Medical Group Physician (or a Medical Group Non-Physician Provider, in the event such provider is of a provider type that United credentials) who
has been denied participation in United’s credentialing program, whose credentialing application has not been submitted, or whose credentialing application remains pending; or 
 ii) A Medical Group Professional who has been terminated from participation in United’s network pursuant to section 4.5 of this Agreement. 
 4.3 Credentialing. Medical Group and Medical Group Physicians will participate in and cooperate with United’s credentialing program. Medical Group Non-Physician Providers will participate in
and cooperate with United’s credentialing program to the extent such Medical Group Non-Physician Providers are subject to credentialing by United. 
 4.4 New Medical Group Professionals. Medical Group will notify United at least 30 days before a physician becomes a Medical Group Physician. In the event that the Medical Group’s agreement
with the new Medical Group Physician provides for a starting date that would make it impossible for Medical Group to provide 30 days advance notice to United, then Medical Group will give notice to United within five business days after reaching
agreement with the new Medical Group Physician. In either case, the new Medical Group Physician will submit and complete a credentialing application to United within 30 days of the new Medical Group Physician’s agreement to join Medical Group,
unless the new Medical Group Physician already has been credentialed by United and is already a participant in United’s network. The requirements of this section 4.4 also apply to new Medical Group Non-Physician Providers who are subject to
credentialing by United. 
 4.5 Termination of a Medical Group Professional from United’s Network. United may terminate a Medical
Group Professional’s participation in United’s network, without terminating this Agreement, immediately upon becoming aware of any of the following: 
 i) material breach of this Agreement that is not cured by Medical Group Professional within 30 days after United provided notice to Medical Group of the breach; 

ii) the suspension, revocation, condition, limitation, qualification or other material restriction on a Medical Group Professional’s licenses,
certifications and permits by any government agency under which the Medical Group Professional is authorized to provide health care services; 

iii) the suspension, revocation, condition, limitation, qualification or other material restriction of a Medical Group Physician’s staff privileges
at any licensed hospital, nursing home or other facility at which the Medical Group Physician has staff privileges during the term of this Agreement; 

 iv) an indictment, arrest or conviction for a felony, or for any criminal charge related to the practice of
Medical Group Professional’s profession; 
 v) a sanction imposed by any governmental agency or authority, including Medicare or Medicaid;
or 
 vi) pursuant to United’s Credentialing Plan. 
 United will notify Medical Group of the Medical Group Professional’s termination according to the notice provision set forth in section 10.8 of this Agreement. 

4.6 Covered Services by Medical Group Professionals who are not Participating Providers. Medical Group will staff its service locations so that
Covered Services can appropriately be rendered to Customers by Medical Group Professionals who participate in United’s network. A Medical Group Professional who does not participate in United’s network, pursuant to section 4.2 of this
Agreement, will not render Covered Services to a Customer. 
 In the event Covered Services are rendered by a Medical Group Professional who
does not participate in United’s network, Medical Group and the Medical Group Professional will not submit a claim or other request for payment to United or Payer, and will not seek or accept payment from the Customer. 

Article V. 

Duties of Medical Group 
 5.1 Provide Covered Services. Medical Group will provide Covered Services to Customers. 

5.2 Nondiscrimination. Medical Group will not discriminate against any patient, with regard to quality of service or accessibility of services, on
the basis that the patient is a Customer. Medical Group will not require a Customer to pay a “membership fee” or other fee in order to access Medical Group for Covered Services (except for copayments, coinsurance and/or deductibles
provided for under Customer’s Benefit Plan) and will not discriminate against any Customer based on the failure to pay such a fee. 

5.3 Accessibility. Medical Group will provide or arrange for the provision of advice and assistance to Customers in emergency situations 24 hours
a day, seven days a week. 
 5.4 Cooperation with Protocols. Medical Group will cooperate with and be bound by United’s and
Payers’ Protocols. The Protocols include but are not limited to all of the following: 
  

	l.	Medical Group will use reasonable commercial efforts to direct Customers only to other providers that participate in United’s network, except as otherwise
authorized by United or Payer. 

  

	2.	If the Customer’s Benefit Plan requires the Customer to receive certain Covered Services from or upon referral by a primary care physician, all referral physicians
must adhere to the following additional protocols when those Covered Services are provided: 

  

	 	a.	Notify Customer’s primary care physician of referrals to other participating or nonparticipating providers. 

 

	 	b.	Covered Services must be provided pursuant to the terms and limitations of the referral notification issued by or on behalf of the Customer’s primary care
physician. 

  

	 	c.	If the Medical Group Physician providing the Covered Services is a referral physician, the Medical Group Physician must also notify the Customer’s primary care
physician of all admissions in accordance with the required time frames. 

  

	3.	Medical Group will provide notification for certain Covered Services, accept and return telephone calls from United staff, and respond to United requests for clinical
information, as required by United or Payer as described in the Protocols. 

 The Protocols will be made available to Medical Group online or upon request. Some or all Protocols also
may be disseminated in the form of an administrative manual or guide or in other communications. See Appendix 4 for additional information on the Protocols applicable to Customers enrolled in certain Benefit Plans. 

United may change the Protocols from time to time. United will use reasonable commercial efforts to inform Medical Group at least 30 days in advance of
any material changes to the Protocols. United may implement changes in the Protocols without Medical Group’s consent if such change is applicable to all or substantially all of the medical groups in United’s network located in the same
state as Medical Group and that practice the same specialty as Medical Group. Otherwise, changes to the Protocols proposed by United to be applicable to Medical Group are subject to the terms of section 10.2 of this Agreement that are applicable to
amendments. 
 5.5 Licensure. Medical Group and Medical Group Professionals will maintain, without material restriction, such licensure,
registration, and permits as are necessary to enable Medical Group and Medical Group Professionals to lawfully perform this Agreement. 
 5.6
Liability Insurance. Medical Group will assure that Medical Group and all Medical Group Professionals are covered by liability insurance. Except to the extent coverage is a state mandated placement, the liability coverage must be placed with
responsible, financially sound insurance carriers authorized or approved to write coverage in the state in which the Covered Services are provided. The liability insurance shall be, at a minimum, of the types and in the amounts set forth below.
Medical malpractice insurance shall be either occurrence or claims made with an extended period reporting option. Prior to the Effective Date of this Agreement and within 10 days of each policy renewal thereafter, Medical Group shall submit to
United in writing evidence of insurance coverage. 
  

			
	 TYPE OF INSURANCE
	  	 MINIMUM LIMITS

	Medical malpractice and/or professional liability insurance	  	Five Hundred Thousand Dollars ($500,000.00) per occurrence and 1 Million Dollars aggregate ($1,000,000.00), if Medical Group insures all Medical Group Professionals in a single
policy. This insurance requirement will also be satisfied if the Medical Group insures each Medical Group Professional separately, and the coverage for each Medical Group Professional is at least One Million Dollars ($1,000,000.00) per occurrence
and 3 Million Dollars ($3,000,000.00) aggregate.
		
	Commercial general and/or umbrella liability insurance	  	One Million Dollars ($1,000,000.00) per occurrence and aggregate.

 In lieu of purchasing the insurance coverage required in this section, Medical Group may, with the prior written approval of United, self-insure its medical malpractice and/or professional liability, as
well as its commercial general liability. Medical Group shall maintain a separate reserve for its self-insurance. If Medical Group will use the self-insurance option described in this paragraph, Medical Group will provide to United, prior to the
Effective Date, a statement verified by an independent auditor or actuary that its reserve funding levels and process of funding appears adequate to meet the requirements of this section and fairly represents the financial condition of the fund.
Medical Group will provide a similar statement during the term of this Agreement upon United’s request, which will be made no more frequently than annually. Medical Group will assure that its self-insurance fund will comply with applicable laws
and regulations. 
 5.7 Notice. Medical Group will give notice to United within 10 days after any event that causes Medical Group to be
out of compliance with section 5.5 or 5.6 of this Agreement, or of any change in Medical Group’s name, ownership, control, or Taxpayer Identification Number. This section does not apply to changes of ownership or control that result in Medical
Group being owned or controlled by an entity with which it was already affiliated prior to the change. In addition, Medical Group will give written notice to United within 10 days after it learns of any of the following: 

	 	i)	any suspension, revocation, condition, limitation, qualification or other material restriction on a Medical Group Professional’s licenses, certifications and
permits by any government agency under which a Medical Group Professional is authorized to provide health care services; 

  

	 	ii)	any suspension, revocation, condition, limitation, qualification or other material restriction of a Medical Group staff privileges at any licensed hospital, nursing
home or other facility at which a Medical Group Physician has staff privileges during the term of this Agreement; 

  

	 	iii)	indictment, arrest or conviction of a Medical Group Professional for a felony or for any criminal charge related to the practice of the Medical Group
Professional’s profession; 

  

	 	iv)	The departure of any Medical Group Professional from Medical Group; or 

  

	 	v)	any changes to the information contained in Appendix 1. 

 5.8 Customer consent to release of Medical Record Information. Medical Group will obtain any Customer consent required in order to authorize Medical Group to provide access to requested information
or records as contemplated in section 5.9 of this Agreement, including copies of the Medical Group’s medical records relating to the care provided to Customer. 
 5.9 Maintenance of and Access to Records. Medical Group will maintain adequate medical, financial and administrative records related to Covered Services rendered by Medical Group under this
Agreement, including claims records, for at least 6 years following the end of the calendar year during which the Covered Services are provided, unless a longer retention period is required by applicable law. Medical Group will provide access to
these records as follows: 
  

	 	i)	to United or its designees, in connection with United’s utilization management/care management, quality assurance and improvement and for claims and other
administrative obligations, including reviewing Medical Group’s compliance with the terms and provisions of this Agreement and appropriate billing practice. Medical Group will provide access during ordinary business hours fourteen days after a
request is made, except in cases of a United audit involving a fraud investigation or the health and safety of a Customer (in which case, access shall be given within 48 hours after the request) or of an expedited Customer appeal or grievance enable
United to reasonably meet the timelines for determining the appeal or grievance); and 

  

	 	ii)	to agencies of the government, in accordance with applicable law, to the extent such access is necessary to comply with regulatory requirements applicable to Medical
Group, United, or Payers. 

 Medical Group will cooperate with United on a timely basis in connection with any such audit
including, among other things, in the scheduling of and participation in an audit exit interview within 30 days of United’s request. 

Upon invoice from Medical Group, United will pay for copies of records requested by United in cases where United requests the records more than once and
the records are requested for some other purpose than claims processing, coverage determinations, or other routine health benefits administration. Payment will be made at a rate of 10 cents per page, not to exceed a total of 25 dollars per record,
unless a different rate is specified under state law. 
 5.10 Access to Data. Medical Group represents that in conducting its operations,
it collects and reviews certain quality data relating to care rendered by Medical Group that is reported in a manner which has been validated by a third party as having a clear, evidence-based link to quality or safety (e.g., AHRQ standards) or
which has been created by employer coalitions as proxies for quality (e.g., Leapfrog standards). 
 United recognizes that Medical Group has the
sole discretion to select the metrics which it will track from time to time and that Medical Group’s primary goal in so tracking is to advance the quality of patient care. If the information that Medical Group chooses to report on is available
in the public domain in a format that includes all data elements required by United, United will obtain quality information directly from the source to whom Medical Group reported. If the Medical Group does not report metrics in the public domain,
on a quarterly basis, Medical 

 
Group will share these metrics with United as tracked against a database of all commercial patients (including patients who are not United customers). United may publish this data to entities to
which United renders services or seeks to render services, and to Customers. 
 5.11 Compliance with law. Medical Group will comply with
applicable regulatory requirements, including but not limited to those relating to confidentiality of Customer medical information. 
 5.12
Electronic connectivity. When made available by United, Medical Group will do business with United electronically. Medical Group will use www.unitehealthcareonline.com to check eligibility status, claims status, and submit requests for
claims adjustments for Customers enrolled in products supported by www.unitedhealthcareonline.com. Medical Group agrees to use www.unitedhealthcareonline.com for additional functionalities (for instance, notification of admission)
after United informs Medical Group that such functionalities have become available for the applicable Customer. 
 5.13 Employees and
subcontractors. Medical Group will assure that its employees, affiliates and any individuals or entities subcontracted by Medical Group to render services in connection with this Agreement adhere to the requirements of this Agreement. The use of
employees, affiliates or subcontractors to render services in connection with this Agreement will not limit Medical Group’s obligations and accountability under this Agreement with regard to such services. 

For laboratory services, Medical Group will only be reimbursed for services that Medical Group is certified through the Clinical Laboratory Improvement
Amendments (CLIA) to perform, and Medical Group must not bill Customers for any laboratory services for which Medical Group lacks CLIA certification. 
 Article VI. 
 Duties of United and Payers 

6.1 Payment of Claims. As described in further detail in Article VII of this Agreement, Payers will pay Medical Group for rendering Covered
Services to Customers. 
 6.2 Liability Insurance. United will procure and maintain professional and general liability insurance and
other insurance, as United reasonably determines may be necessary, to protect United and United’s employees against claims, liabilities, damages or judgments that arise out of services provided by United or United’s employees under this
Agreement. 
 6.3 Licensure. United will maintain, without material restriction, such licensure, registration, and permits as are
necessary to enable United to lawfully perform this Agreement. 
 6.4 Notice. United will give written notice to Medical Group within 10
days after any event that causes United to be out of compliance with section 6.2 or 6.3 of this Agreement, or of any change in United’s name, ownership, control, or Taxpayer Identification Number. This section does not apply to changes of
ownership or control that result in United being owned or controlled by an entity with which it was already affiliated prior to the change. 

6.5 Compliance with law. United will comply with applicable regulatory requirements, including but not limited to those relating to
confidentiality of Customer medical information and those relating to prompt payment of claims to the extent those requirements are applicable. 

6.6 Electronic connectivity. United will do business with Medical Group electronically by providing eligibility status, claims status, and
accepting requests for claim adjustments, for those products supported online. United will communicate enhancements in online functionality as they become available, as described in Section 5.12, and will make information available as to which
products are supported online. 
 6.7 Employees and subcontractors. United will assure that its employees, affiliates and any individuals
or entities subcontracted by United to render services in connection with this Agreement adhere to the requirements of this Agreement. The use of employees, affiliates or subcontractors to render services in connection with this Agreement will not
limit United’s obligations and accountability under this Agreement with regard to such services. 

 Article VII. 
 Submission, Processing, and Payment of Claims 
 7.1 Form and content of
claims. Medical Group must submit claims for Covered Services in a manner and format prescribed by United, as further described in the Protocols. Unless otherwise directed by United, Medical Group shall submit claims using current CMS 1500 form
or its successor for paper claims and HIPAA standard professional or institutional claim formats for electronic claims, as applicable, with applicable coding including, but not limited to, ICD, CPT, Revenue and HCPCS coding. Medical Group will
submit claims only for services performed by Medical Group or Medical Group staff. Pass through billing is not payable under this Agreement. 

7.2 Electronic riling of claims. Within one year after the Effective Date of this Agreement, Medical Group will use electronic submission for all
of its claims under this Agreement that United is able to accept electronically. 
 7.3 Time to file claims. All information necessary to
process a claim must be received by United no more than 90 days from the date that Covered Services are rendered. In the event United requests additional information in order to process the claim, Medical Group will provide such additional
information within 90 days of United’s request. If Payer is not the primary payer, and Medical Group is pursuing payment from the primary payer, the 90 days filing limit will begin on the date Medical Group receives the claim response from the
primary payer. 
 7.4 Payment of claims. Payer will pay claims for Covered Services according to the lesser of Medical Group’s
Customary Charge or the applicable fee schedule (as further described in Appendix 3 to this Agreement), and in accordance with Payment Policies. 
 Claims for Covered Services subject to coordination of benefits will paid in accordance with the Customer’s Benefit Plan and applicable law. 
 The obligation for payment under this Agreement is solely that of Payer, and not that of United unless United is the Payer. 
 Ordinarily, fee amounts listed in Appendix 3 are based upon primary fee sources. United reserves the right to use gap-fill fee sources where primary fee sources are not available. 

United routinely updates its fee schedule in response to additions, deletions, and changes to CPT codes by the American Medical Association, price
changes for immunizations and injectable medications, and in response to similar changes (additions and revisions) to other service coding and reporting conventions that are widely used in the health care industry, such as those maintained by the
Centers for Medicaid and Medicare Services (for example HCPCS, etc.). 
 Ordinarily, United’s fee schedule is updated using similar
methodologies for similar services. United will not generally attempt to communicate routine maintenance of this nature and will generally implement updates within 90 days from the date of publication. 

United will give Medical Group 90 days written or electronic notice of non-routine fee schedule changes which will substantially alter the overall
methodology or reimbursement level of the fee schedule. In the event such changes will reduce Medical Groups overall reimbursement under this Agreement, Medical Group may terminate this Agreement by giving 60 days written notice to United, provided
that the notice is given by Medical Group within 30 days after the notice of the fee schedule change. 
 United will make its Payment Policies
available to Medical Group online or upon request. United may change its Payment Policies from time to time. 
 7.5 Denial of Claims for Not
Following Protocols, Not Filing Timely, or Lack of Medical Necessity. Payment may be denied in whole or in part if Medical Group does not comply with a Protocol or does not file a timely claim under section 7.3 of this Agreement. Payment may
also be denied for services provided that are determined by United to be medically unnecessary, and Medical Group may not bill the Customer for such services unless the 

 
Customer has, with knowledge of United’s determination of a lack of medical necessity, agreed in writing to be responsible for payment of those charges. 

In the event that payment of a claim is denied for lack of notification or for untimely filing, the denial will be reversed if Medical Group appeals
within 12 months after the date of denial and can show all of the following: 
  

	 	i)	that, at the time the Protocols required notification or at the time the claim was due, Medical Group did not know and was unable to reasonably determine that the
patient was a Customer, 

  

	 	ii)	that Medical Group took reasonable steps to learn that the patient was a Customer, and 

 

	 	iii)	that Medical Group promptly provided notification, or filed the claim, after learning that the patient was a Customer. 

7.6 Retroactive Correction of Information Regarding Whether Patient Is a Customer. Prior to rendering services, Medical Group will ask the patient
to present his or her Customer identification card. In addition, Medical Group may contact United to obtain the most current information on the patient as a Customer. 
 However, Medical Group acknowledges that such information provided by United is subject to change retroactively, under the following circumstances: (1) if United has not yet received information that
an individual is no longer a Customer; (2) if the individual’s Benefit Plan is terminated retroactively for any reason including, but not limited to, non-payment of premium; (3) as a result of the Customer’s final decision
regarding continuation of coverage pursuant to state and federal laws; or (4) if eligibility information United receives is later proven to be false. 
 If Medical Group provides health care services to an individual, and it is determined that the individual was not a Customer at the time the health care services were provided, those services shall not be
eligible for payment under this Agreement and any claims payments made with regard to such services may be recovered as overpayments under the process described in section 7.10 of this Agreement. Medical Group may then directly bill the individual,
or other responsible party, for such services. 
 7.7 Payment under this Agreement is Payment in Full. Payment as provided under section
7.4 of this Agreement, together with any co-payment, deductible or coinsurance for which the Customer is responsible under the Benefit Plan, is payment in full for a Covered Service. Medical Group will not seek to recover, and will not accept any
payment from Customer, United, Payer or anyone acting in their behalf, in excess of payment in full as provided in this section 7.7, regardless of whether such amount is less than Medical Group’s billed charge or Customary Charge. 

7.8 Customer “Hold Harmless.” Medical Group will not bill or collect payment from the Customer, or seek to impose a lien, for the
difference between the amount paid under this Agreement and Medical Group’s billed charge or Customary Charge, or for any amounts denied or not paid under this Agreement due to: 

 

	 	i)	Medical Group’s failure to comply with the Protocols, 

  

	 	ii)	Medical Group’s failure to file a timely claim, 

  

	 	iii)	Payer’s Payment Policies, 

  

	 	iv)	inaccurate or incorrect claim processing, 

  

	 	v)	insolvency or other failure by Payer to maintain its obligation to fund claims payments, if Payer is United, or is an entity required by applicable law to assure that
its Customers not be billed in such circumstances, or 

  

	 	vi)	a denial based on medical necessity or prior authorization, except as permitted under section 7.5. 

 This obligation to refrain from billing Customers applies even in those cases in which Medical Group
believes that United or Payer has made an incorrect determination. In such cases, Medical Group may pursue remedies under this Agreement against United or Payer, as applicable, but must still hold the Customer harmless. 

In the event of a default by a Payer other than those Payers covered by the above clause v), Medical Group may seek payment directly from the Payer or
from Customers covered by that Payer. However, Medical Group may do so only if it first inquires in writing to United as to whether the Payer has defaulted and, in the event that United confirms that Payer has defaulted (which confirmation will not
be unreasonably withheld), Medical Group then gives United 15 days prior written notice of Medical Group’s intent to seek payment from Payer or Customers. For purposes of this paragraph, a default is a systematic failure by a Payer to fund
claims payments related to Customers covered through that Payer; a default does not occur in the case of a dispute as to whether certain claims should be paid or the amounts that should be paid for certain claims. 

This section 7.8 and section 7.7 will survive the termination of this Agreement, with regard to Covered Services rendered prior to when the termination
takes effect. 
 7.9 Consequences for Failure to Adhere to Customer Protection Requirements. If Medical Group collects payment from,
brings a collection action against, or asserts a lien against a Customer for Covered Services rendered (other than for the applicable copayment, deductible or coinsurance), contrary to section 7.7 or 7.8 of this Agreement, Medical Group shall be in
breach of this Agreement. This section 7.9 will apply regardless of whether Customer or anyone purporting to act on Customer’s behalf has executed a waiver or other document of any kind purporting to allow Medical Group to collect such payment
from Customer. 
 In the event of such a breach, Payer may deduct, from any amounts otherwise due Medical Group, the amount wrongfully collected
from Customers, and may also deduct an amount equal to any costs or expenses incurred by the Customer, United or Payer in defending the Customer from such action and otherwise enforcing sections 7.7 through 7.9 of this Agreement. Any amounts
deducted by Payer in accordance with this provision shall be used to reimburse the Customer and to satisfy any costs incurred. The remedy contained in this paragraph does not preclude United from invoking any other remedy for breach that may be
available under this Agreement. 
 7.10 Correction of overpayments or underpayments of claims. In the event that either Party believes
that a claim has not been paid correctly, or that funds were paid beyond or outside of what is provided for under this Agreement, either party may seek correction of the payment except that Medical Group may not seek correction of a payment more
than 12 months after it was made. 
 Medical Group will repay overpayments within 30 days of notice of the overpayment. Medical Group will
promptly report any credit balance that it maintains with regard to any claim overpayment under this Agreement, and will return such overpayment to United within 30 days after posting it as a credit balance. 

Medical Group agrees that recovery of overpayments may be accomplished by offsets against future payments. 

7.11 Claims Payment Issues Arising from Departure of Medical Group Professionals from Medical Group. In the event a Medical Group Professional
departs from Medical Group and uncertainty arises as to whether Medical Group or some other entity is entitled to receive payment for certain services rendered by such former Medical Group Professional, the parties will cooperate with each other in
good faith in an attempt to resolve the situation appropriately. 
 In the event that Medical Group’s failure to give timely notice under
section 5.7 (iv) of this Agreement resulted in claims payments being made incorrectly to Medical Group, Medical Group shall promptly call the situation to United’s attention and return such payments to United. In the event Medical Group
fails to do so, United may hold Medical Group liable for any attorneys fees, costs, or administrative expenses incurred by United as a result. 

In the event that both Medical Group and some other entity assert a right to payment for the same service rendered by the former Medical Group
Professional, United may refrain from paying either entity until the payment obligation is clarified. Provided that United act in good faith, Medical Group will waive any right to receive interest or penalties Linder any applicable law relating to
the prompt payment of claims. 

 Article VIII. 
 Dispute Resolution 
 The parties will work together in good faith to resolve any and
all disputes between them (hereinafter referred to as “Disputes”) including but not limited to all questions of arbitrability, the existence, validity, scope or termination of the Agreement or any term thereof. 

If the parties are unable to resolve any such Dispute within 60 days following the date one party sent written notice of the Dispute to the other party,
and if either party wishes to pursue the Dispute, it shall thereafter be submitted to binding arbitration in accordance with the Commercial Dispute Procedures of the American Arbitration Association, as they may be amended from time to time (see ).
Unless otherwise agreed to in writing by the parties, the party wishing to pursue the Dispute must initiate the arbitration within one year after the date on which notice of the Dispute was given or shall be deemed to have waived its right to pursue
the dispute in any forum. 
 Any arbitration proceeding under this Agreement shall be conducted in Travis County, TX. The arbitrator(s) may
construe or interpret but shall not vary or ignore the terms of this Agreement and shall be bound by controlling law. The arbitrator(s) shall have no authority to award punitive, exemplary, indirect or special damages, except in connection with a
statutory claim that explicitly provides for such relief. 
 The parties expressly intend that any dispute relating to the business relationship
between them be resolved on an individual basis so that no other dispute with any third party(ies) may be consolidated or joined with our dispute. The parties agree that any arbitration ruling by an arbitrator allowing class action arbitration or
requiring consolidated arbitration involving any third party(ies) would be contrary to their intent and would require immediate judicial review of such ruling. 
 If the Dispute pertains to a matter which is generally administered by certain United procedures, such as a credentialing or quality improvement plan, the policies and procedures set forth in that plan
must be fully exhausted by Medical Group before Medical Group may invoke any right to arbitration under this Article VIII. 
 The decision of
the arbitrator(s) on the points in dispute will be binding, and judgment on the award may be entered in any court having jurisdiction thereof. The parties acknowledge that because this Agreement affects interstate commerce the Federal Arbitration
Act applies. 
 In the event that any portion of this Article or any part of this Agreement is deemed to be unlawful, invalid or unenforceable,
such unlawfulness, invalidity or unenforceability shall not serve to invalidate any other part of this Article or Agreement. In the event any court determines that this arbitration procedure is not binding or otherwise allows litigation involving a
Dispute to proceed, the parties hereby waive any and all right to trial by jury in, or with respect to, such litigation. Such litigation would instead proceed with the judge as the finder of fact. 

In the event a party wishes to terminate this Agreement based on an assertion of uncured material breach, and the other party disputes whether grounds
for such a termination exist, the matter will be resolved through arbitration under this Article VIII. While such arbitration remains pending, the termination for breach will not take effect. 
 This Article VIII governs any dispute between the parties arising before or after execution of this Agreement and shall survive any termination of the Agreement. 

Article IX. 

Term and Termination 
 9.1 Term. This Agreement shall take effect on the Effective Date. This Agreement shall have an initial term of one year and renew automatically for renewal terms of one year, until terminated
pursuant to section 9.2. 
 9.2 Termination. This Agreement may be terminated under any of the following circumstances: 

 

	 	i)	by mutual written agreement of the parties, 

	 	ii)	by either party, upon at least 90 days prior written notice, effective at the end of the initial term or effective at the end of any renewal term;

  

	 	iii)	by either party upon 60 days written notice in the event of a material breach of this Agreement by the other party, except that such a termination will not take effect
if the breach is cured within 60 days after notice of the termination; moreover, such termination may be deferred as further described in Article VIII of this Agreement; 

 

	 	iv)	by either party upon 10 days written notice in the event the other party loses licensure or other governmental authorization necessary to perform this Agreement, or
fails to have insurance as required under section 5.6 or section 6.2 of this Agreement; or 

  

	 	v)	by Medical Group, as described in section 7.4 of this Agreement in the event of a non-routine fee schedule change. 

9.3 Ongoing Services to Certain Customers After Termination Takes Effect. In the event a Customer is receiving any of the Covered Services listed
below, as of the date the termination takes effect, Medical Group will continue to render those Covered Services to that Customer and this Agreement will continue to apply to those Covered Services, after the termination takes effect, for the length
of time indicated below: 
  

			
	Inpatient Covered Services	  	30 days or until discharge, whichever comes first
		
	Pregnancy, Third Trimester - Low Risk	  	Through postpartum follow up visit
		
	Pregnancy, First, Second or Third Trimester - Moderate Risk and High Risk	  	Through postpartum follow up visit
		
	Non-surgical Cancer Treatment	  	30 days or a complete cycle of radiation or chemotherapy, whichever is greater
		
	End Stage Kidney Disease and Dialysis	  	30 days
		
	Symptomatic AIDS undergoing active treatment	  	30 days
		
	Circumstances where Payer is required by applicable law to provide transition coverage of services rendered by Medical Group after Medical Group leaves the provider network accessed
by Payer.	  	As applicable

 Article X. 

Miscellaneous Provisions 
 10.1 Entire Agreement. This Agreement is the entire agreement between the parties with regard to the subject matter herein, and supersedes any prior written or unwritten agreements between the
parties or their affiliates with regard to the same subject matter. 
 10.2 Amendment. This Agreement may only be amended in a writing
signed by both parties, except as provided in section 7.4 and subject to Medical Group’s termination rights described in section 9.2(v). Additionally, this Agreement may be unilaterally amended by United upon written notice to Medical Group in
order to comply with applicable regulatory requirements. United will provide at least 30 days notice of any such regulatory amendment, unless a shorter notice is necessary in order to accomplish compliance. 

10.3 Nonwaiver. The waiver by either party of any breach of any provision of this Agreement shall not operate as a waiver of any subsequent breach
of the same or any other provision. 
 10.4 Assignment. This Agreement may not be assigned by either party without the written consent of
the other party, except that this Agreement may be assigned by United to any of United’s Affiliates. 
 This Agreement may be assigned by
Medical Group to an entity affiliated with Medical Group common ownership, upon 30 days written notice to United. However no such assignment is permitted without United’s prior written consent if the impact of the assignment would be to cause
additional locations to become subject to this Agreement 

 
without United’s consent; circumstances in which additional locations would be made subject to this Agreement are governed by section 3.1 of this Agreement rather than by this section 10.4.

 10.5 Relationship of the Parties. The sole relationship between the parties to this Agreement is that of independent contractors. This
Agreement does not create a joint venture, partnership, agency, employment or other relationship between the parties. 
 10.6 No Third-Party
Beneficiaries. United and Medical Group are the only entities with rights and remedies under the Agreement. 
 10.7 Delegation.
United may delegate (but not assign) certain of its administrative duties under this Agreement to one or more other entities. No such delegation will relieve United of its obligations under this Agreement. 

10.8 Notice. Any notice required to be given under this Agreement shall be in writing, except in cases in which this Agreement specifically
permits electronic notice, or as otherwise permitted or required in the Protocols. All written or electronic notices shall be deemed to have been given when delivered in person, by electronic communication, by facsimile or, if delivered by
first-class United States mail, on the date mailed, proper postage prepaid and properly addressed to the appropriate party at the address set forth on the signature portion of this Agreement or to another more recent address of which the sending
party has received written notice. Notwithstanding the previous sentence, all notices of termination of this Agreement by either party must be sent by certified mail, return receipt requested. Each party shall provide the other with proper
addresses, facsimile numbers and electronic mail addresses of all designees that should receive certain notices or communication instead of that party. 
 10.9 Confidentiality. Neither party will disclose to a Customer, other health care providers, or other third parties any of the following information (except as required by an agency of the
government): 
  

	 	i)	any proprietary business information, not available to the general public, obtained by the party from the other party; 

 

	 	ii)	the specific reimbursement amounts provided for under this Agreement, except for purposes of administration of benefits. 

At least 48 hours before either party issues a press release, advertisement, or other media statement about the business relationship between the
parties, that party will give the other party a copy of the material the party intends to issue. 
 10.10 Governing Law. This Agreement
will governed by and construed in accordance with the laws of the state in which Medical Group renders Covered Services, and any other applicable law. 
 10.11 Regulatory Appendices. One or more regulatory appendix may be attached to this Agreement, setting forth additional provisions included in this Agreement in order to satisfy regulatory
requirements under applicable law. These regulatory appendices, and any attachments to them, are expressly incorporated into this Agreement and are binding on the parties to this Agreement. the event of any inconsistent or contrary language between
a regulatory appendix and any other part of this Agreement, including but not limited to appendices, amendments and exhibits, the provisions of the regulatory appendix will control, to the extent it is applicable. 

10.12 Severability. Any provision of this Agreement that is unlawful, invalid or unenforceable in any situation in any jurisdiction shall not
affect the validity or enforceability of the remaining provisions of this Agreement or the lawfulness validity or enforceability of the offending provision in any other situation or jurisdiction. 

10.13 Survival. Sections 5.9, 7.7, 7.8, Article VIII and sections 9.3 and 10.9 (for the last paragraph) of this Agreement will survive the
termination of this Agreement. 

 THIS AGREEMENT CONTAINS A BINDING ARBITRATION PROVISION THAT MAY BE ENFORCED BY THE PARTIES.

  

					
	WhiteGlove Health, Inc.	 		 	
			
	Signature    /s/ Robert Fabbio	 	Street	 	5300 Bee Caves, Building 1, Suite 100
			
	Print Name    Robert Fabbio	 	City:	 	Austin
			
	Title    CEO	 	State	 	TX             , Zip Code 78746
			
	D/B/A	 	Phone	 	512-329-8081
			
	Date    6/24/09	 	Email	 	bfabbio@housecallhealth.com

 United HealthCare Insurance Company, on behalf of itself, United HealthCare of Texas, Inc., PacifiCare of Texas, Inc.,
Evercare of Texas, LLC, and its other affiliates, as signed by its authorized representative: 
  

			
	Signature    /s/ Rick Everett	 	Signature
		
	Print Name    Rick Everett	 	Print Name
		
	Title    VP	 	Title
		
	Date     7/10/09	 	Date
                                    

 Address to be used for giving notice to United under the Agreement 

 

			
	Street	  	
	City	  	State        Zip

 Month and year in which Agreement is first effective
                                         
            

 THIS AGREEMENT CONTAINS A BINDING ARBITRATION PROVISION THAT MAY BE ENFORCED BY THE PARTIES.

  

					
	WhiteGlove Health, Inc.	 		 	
			
	Signature    /s/ Robert Fabbio	 	Street	 	5300 Bee Caves, Building 1, Suite 100
			
	Print Name    Robert Fabbio	 	City:	 	Austin
			
	Title    CEO	 	State	 	TX             , Zip Code 78746
			
	D/B/A	 	Phone	 	512-329-8081
			
	Date    6/24/09	 	Email	 	bfabbio@housecallhealth.com

 United HealthCare Insurance Company, on behalf of itself, United HealthCare of Texas, Inc., PacifiCare of Texas, Inc.,
Evercare of Texas, LLC, and its other affiliates, as signed by its authorized representative: 
  

			
	Signature	 	Signature
		
	Print Name	 	Print Name
		
	Title	 	Title
		
	Date
                                        
	 	Date
                                        

 Address to be used for giving notice to United under the Agreement 

 

			
	Street	  	
	City	  	State        Zip

 Month and year in which Agreement is first effective
                                         
            

 Attachments 
     X     Appendix 1: Medical Group Practice Locations 
     X     Appendix 2: Benefit Plan Descriptions 
     X     Appendix 3: Fee Schedule Sample 

    X     Appendix 4: PacifiCare Protocols 
     X     State Regulatory Requirements Appendix (list all states as applicable) 

Texas 

           Medicare Advantage Regulatory Requirements Appendix 

           Medicaid Regulatory Requirements Appendix 

    X     Other All Payer Appendix 

 Appendix 1 
 Medical Group Practice Locations 
 Medical Group attests that this Appendix identifies all
services and locations covered under this Agreement. 
 IMPORTANT NOTE: Medical Group acknowledges its obligation under Section 5.7 to
promptly report any change in Medical Group’s name or Taxpayer Identification Number. Failure to do so may result in denial of claims or incorrect payment. 
 BILLING ADDRESS 
 Practice Name: WhiteGlove Health, Inc. 

Street Address: 5300 Bee Caves Rd., Bldg-1, Suite 100 
 City: Austin State: Texas Zip: 78746 
 Tax ID Number (TIN): 20-8913858 

National Provider ID (NPI): 1609041003 

PRACTICE LOCATIONS (complete one for each service location) 
  

					
	 Clinic Name
	  	 Clinic Name
	  	 Clinic Name

			
	Street Address	  	Street Address	  	Street Address
	5300 Bee Caves Rd, Bldg 1, Ste 100	  		  	
	City	  	City	  	City
	Austin	  		  	
	State and Zip Code	  	State and Zip Code	  	State and Zip Code
	TX 78746	  		  	
	Phone Number	  	Phone Number	  	Phone Number
	512-329-8081	  		  	
	TIN (if different from above)	  	TIN (if different from above)	  	TIN (if different from above)
			
	National Provider ID (NPI)	  	National Provider ID (NPI)	  	National Provider ID (NPI)
			
	 Clinic Name
	  	 Clinic Name
	  	 Clinic Name

			
	Street Address	  	Street Address	  	Street Address
			
	City	  	City	  	City
			
	State and Zip Code	  	State and Zip Code	  	State and Zip Code
			
	Phone Number	  	Phone Number	  	Phone Number
			
	TIN (if different from above)	  	TIN (if different from above)	  	TIN (if different from above)
			
	National Provider ID (NPI)	  	National Provider ID (NPI)	  	National Provider ID (NPI)

 Appendix 2 
 Benefit Plan Descriptions 
 Medical Group will participate in the network of physicians and
other health care professionals and providers established by United (“Participating Providers”) for the Benefit Plan types described below: 
  

	•	 	 Benefit Plans where Customers are offered a network of Participating Providers and must select a Primary Physician. Such Benefit Plans may or may not
include an out-of-network benefit. 

  

	•	 	 Benefit Plans where Customers are offered a network of Participating Providers but are not required to select a primary physician. Such Benefit Plans
may or may not include an out-of-network benefit. 

  

	•	 	 Benefit Plans where Customers are not offered a network of Participating Providers from which they may receive Covered Services.

 Notwithstanding the above, this Agreement does not apply to the following: 

 

	•	 	 Capitation arrangements are when all of the following apply: 

 

	 	(i)	Medical Group (directly or through an IPA or other provider organization in which Medical Group is a participant) is part of a network for a United Affiliate; and

  

	 	(ii)	As part of that network, Medical Group arranges directly with the United Affiliate, or an IPA or another medical group or an other provider organization, for certain
designated services to be provided to members who are assigned to Medical Group or to the IPA or the other medical group or other provider organization (as the case may be) and who are covered by that United Affiliate’s Benefit Plans, and under
which either: 

  

	 	(a)	Medical Group is capitated or otherwise has financial responsibility; or 

  

	 	(b)	Medical Group is paid on a fee-for-service basis directly by the IPA or by the other medical group or other provider organization which has financial responsibility for
the service, at a rate agreed upon by Medical Group with that IPA or other medical group or other provider organization; and 

  

	 	(iii)	Medical Group provides those designated services to one of those assigned members. 

In such cases, the obligation for payment will be solely that of the medical group, IPA or other provider organization that has financial
responsibility for the service, and not that of United or the United Affiliate. 
 It is not a capitation arrangement when:

  

	 	(1)	Another medical group or an IPA or other provider organization is not affiliated with Medical Group, and is capitated by a United Affiliate for designated Covered
Services rendered to assigned Customers covered by a Benefit Plan issued by that United Affiliate; and 

  

	 	(2)	Medical Group provides those designated Covered Services to one of those assigned Customers, without having a contract or other arrangement with the other medical group
or the IPA or other provider organization for the terms under which those designated Covered Services are provided. 

 In such cases, this Agreement will apply and the medical group or IPA or other provider organization that has responsibility for the Covered Service will be considered the Payer. 

Note: Although the above capitation arrangements are excluded from this Agreement, there can be a separate agreement providing for Medical
Group’s participation in a network for such capitation arrangements. 

	•	 	 Medicare Benefit Plans that (A) are sponsored, issued or administered by any Payer and (B) replace, either partially or in its entirety, the
original Medicare coverage (Medicare Part A and Medicare Part B) issued to beneficiaries by the Centers for Medicare and Medicaid Services (“CMS”). Note: Although Medicare Benefit Plans, as described above, are excluded from this
Agreement, there can be a separate agreement between Carrier and Medical Group or Medical Group’s affiliates providing for Medical Group’s participation in a network for certain of those Medicare Benefit Plans.

  

	•	 	 Benefit Plans for Medicaid Customers. Note: Although Medicaid Benefit Plans are excluded from this Agreement, there can be a separate agreement between
the parties or between United Affiliates and the affiliates of Medical Group or other entity authorized to contract on behalf of Medical Group (such as an IPA agreement) providing for Medical Group’s participation in a network for those Benefit
Plans. 

  

	•	 	 Medicaid Benefit Plans marketed under the name UnitedHealthcare - Texas Star, as indicated by a reference to UnitedHealthcare - Texas Star on the face
of the valid identification card of any Customer eligible and enrolled in such a Benefit Plan. Note: Although Medicaid UnitedHealthcare - Texas Star Benefit Plans are excluded from this Agreement, there can be a separate agreement between United or
between United’s and Facility’s affiliates or other entity authorized to contract on behalf of Facility (such as an IPA agreement) providing for Facility participation in a network for those Benefit Plans. 

 

	•	 	 Medicare Advantage Private Fee-For-Service plans. 

  

	•	 	 Benefit Plans for Medicare Select 

  

	•	 	 Benefit Plans for workers’ compensation benefit programs. 

 Appendix 3 
 Fee Schedule Sample: Options PPO 
 Representative Options PPO Fee Schedule Sample for:
81349/81350 
 The provisions of this fee schedule apply to Covered Services by Medical Group to Customers covered by Benefit Plans marketed
under the name “Options PPO” and Benefit Plans where Customers are not offered a network of participating physicians and other health care professionals from which they may receive Covered Services. This fee schedule does not apply to
Covered Services rendered by Medical Group to Customers covered by Benefit Plans sponsored, issued or administered by a subsidiary of either PacifiCare Health Plan Administrators, Inc. or PacifiCare Health Systems, LLC. 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the Customer is responsible to pay under the Customer’s Benefit Plan will be subtracted from the listed amount in determining the
amount to be paid by the Payer. The actual payment amount is also subject to matters described in this Agreement, such as the Payment Policies. This information is subject to the confidentiality provisions of this Agreement. 

 Appendix 3 
 Fee Schedule Sample: Products other than Options PPO 
 Representative All-Payer Fee
Schedule Sample(s) for: 81349/81350 
 Unless another fee schedule to this Agreement applies specifically to a particular Benefit Plan as it
covers a particular Customer, the provisions of this fee schedule apply to Covered Services rendered by Medical Group to Customers covered by Benefit Plans sponsored, issued or administered by all Payers. 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the Customer is responsible to pay under the Customer’s Benefit Plan will be subtracted from the listed amount in determining the
amount to be paid by the Payer. The actual payment amount is also subject to matters described in this Agreement, such as the Payment Policies. This information is subject to the confidentiality provisions of this Agreement. 

 Appendix 4 
 PacifiCare Protocols 
 For Customers enrolled in Benefit Plans issued or administered by a
subsidiary of either PacifiCare Health Plan Administrators Inc. or PacifiCare Health Systems, LLC (“PacifiCare Customers”), Medical Group will be subject to the Protocols described in or made available through the PacifiCare Provider
Policy and Procedure Manual (“PacifiCare Manual”). When this Agreement refers to the Administrative Manual or Guide, it is also referring to the PacifiCare Manual. The PacifiCare Manual will be made available to Medical Group on line or
upon request. In the event of any conflict between this Agreement or the “UnitedHealthcare Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide” or other UnitedHealthcare administrative protocols, and
the PacifiCare Manual, in connection with any matter pertaining to a PacifiCare Customer, the PacifiCare Manual will govern, unless applicable statutes and regulations dictate otherwise. United may make changes to the Administrative Manual or Guide
or PacifiCare Manual or other administrative protocols upon 30 days’ electronic or written notice to Medical Group. 

 For reference purposes, the following fee schedules will be used to pay claims under this agreement:

  

					
	 PRODUCTS:
	  	 FEE SCHEDULES:
	  	 PROVIDER DESCRIPTION

			
	Commercial - Options PPO	  	 *  See All Payer Appendix
	  	 Austin/San Antonio Market

Service Delivery Area

			
	Commercial - All Other	  	 *  See All Payer Appendix
	  	 Austin/San Antonio Market

Service Delivery Area

 All Payer Appendix 

Provider Participation Agreement 
 APPLICABILITY 
 Unless another appendix to this Agreement applies specifically to a
particular Benefit Plan as it covers a particular Customer, the provisions of this Appendix apply to Covered Services rendered by Provider to Customers covered by Benefit Plans sponsored, issued or administered by all Payers. 

The terms and conditions of this Appendix, including but not limited to the contracted rates for reimbursement set forth herein, will remain in effect
for the initial term of the Agreement and for all subsequent renewals. 
 SECTION 1 

Definitions 
 Covered
Service: A health care service or product for which a Customer is entitled to receive coverage from a Payer, pursuant to the terms of the Customer’s Benefit Plan with that Payer. 
 Customary Charge: The fee for health care services charged by Ancillary Provider that does not exceed the fee Ancillary Provider would ordinarily charge another person regardless of whether the
person is a Customer. 
 Customer Expenses: Copayments, deductibles or coinsurance that are the financial responsibility of the Customer
according to the Customer’s Benefit Plan. 
 Encounter Rate: The payment made to Medical Group for Covered Services rendered to a
Customer during an encounter. Unless otherwise specified in this Appendix, such payment shall be considered payment in full, less any applicable Customer Expenses, for all Covered Services rendered to the Customer by the Medical Group. Payor shall
pay Medical Group for covered Health Services rendered to Customers the lesser of (1) Medical Group’s Customary Charge, less any applicable Member Expense or (2) the applicable Case Rate less any applicable Member Expense. 

 SECTION 2 
 Payment 
 For Covered Services rendered by Provider to a Customer, Provider shall be paid
by Payer the lesser of (1) Provider’s Customary Charges, less an applicable Customer Expenses, or (2) the contract rate set forth in Section 2 of this Appendix, less any applicable Customer Expenses. Payment under this Appendix
is subject to the requirements set forth in the Agreement regarding timely submission of a complete claim and compliance with applicable Protocols. 
  

							
	 Covered Services
	  	 PAYMENT

METHOD
	  	RATE	 
	 All Covered Services*
	  	Encounter Rate*	  	 	[****]	  

  

	*	The Encounter Rate Payment includes payment in full for all services and supplies billed during an entire patient encounter. 

The Encounter Rate will be paid, less any applicable Customer Expenses, for all Covered Services rendered to the Customer by the Medical Group, only once
every six months from the initial date of service to the Customer, or first date of service after a six month period has expired, whichever is later. All other services to be billed to $.01. 

SECTION 3 

Miscellaneous Provisions 

The rates established by the Agreement are all-inclusive and represent the entire payment for all Covered Services to the Customer. No additional
payments shall be made for any services or items covered under the Customer’s Benefit Plan and billed for separately by Provider. 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Commercial All Others 

Market Standard Specifications 
 Austin Market(s) 
 Specifications as of: 07/01/2009 

Report Date: 06/22/2009* 

AUSTN 81349 
  

									
	 Market
	  	 Mkt

Std

ID
	  	CMS
carrier
locality	  	Site of
Service	  	Linked
Schedule
ID
					
	 Austin
	  	AUSTN 81349	  	0000000	  	NonFac	  	AUSTN 81350

  

					
	 Type Of Service
	  	 Primary Fee Source
	  	Pricing Level
	 EVALUATION & MANAGEMENT
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 EVALUATION & MANAGEMENT - NEONATAL
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - INTEGUMENTARY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - MUSCULOSKELETAL
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - RESPIRATORY
	  	2008 CMS RBRVS (0800000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - CARDIOVASCULAR
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - HEMIC & LYMPHATIC
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - MEDIASTINUM & DIAPHRAGM
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - DIGESTIVE
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - URINARY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - MALE GENITAL
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - FEMALE GENITAL
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - MATERNITY & DELIVERY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - ENDOCRINE
	  	2008 CMS RBRVS (0000000) - Jan 2003 Conv Fctr	  	[****]
	 SURGERY - NERVOUS
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - EYE & OCULAR ADNEXA
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - AUDITORY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - BONE DENSITY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - CT
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - MAMMOGRAPHY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - MRI
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - MRA
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - NUCLEAR MEDICINE
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - PET SCANS
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIATION THERAPY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - ULTRASOUND
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 LAB - PATHOLOGY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 OFFICE LAB
	  	2008 CMS Clinical Lab Schedule - National Limit	  	[****]
	 CLINICAL LABORATORY
	  	2008 CMS Clinical Lab Schedule - National Limit	  	[****]
	 MEDICINE - OPHTHALMOLOGY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - CARDIOVASCULAR
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - ALLERGY & CLINICAL IMMUNOLOGY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - CHIROPRACTIC MANIPULATIVE TREATMENT
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - MODALITIES
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - THERAPIES & OTHER
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - OTHER
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - CHEMO ADMIN
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 OBSTETRICS - GLOBAL
	  	2008 CMS RBRVS (0000000)- Jan 2008 Conv Fctr	  	[****]
	 IMMUNIZATIONS
	  	Redbook J Code-CPT Code AWP	  	[****]
	 INJECTABLES/OTHER DRUGS
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - ONCOLOGY/ THERAPEUTIC CHEMO DRUGS
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - IVIG
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - SALINE & DEXTROSE SOLUTIONS
	  	CMS Drug Pricing	  	[****]
	 DME & SUPPLIES
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - RESPIRATORY
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - ORTHOTICS
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - PROSTHETICS
	  	2008 CMS DME Floor	  	[****]
	 AMBULANCE
	  	2008 CMS Ambulance Schedule - Urban (0000000)	  	[****]

 Hard Codes 

[****] 
 [****] 

[****] 
 [****] 

[****] 
 [****] 

Schedule Type: FFS 
 Unless specifically
indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the
customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such
as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement. 
 Note:
Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 
 Confidential and
Proprietary    Not for Distribution to Third Parties 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Commercial All Others 

Representative Fee Schedule Sample for Family Practice: AUSTN 81349 

Fee amounts as of: 07/01/2009 
 Report Date: 06/22/2009* 
 Site of Service - Linked Schedule ID: AUSTN
81350 
  

											
	 CPT
	  	Mod	 	 CPT Description
	  	 Type of Service
	  	Place of Service	  	Fee
						
	 17000
	  	00	 	 DSTRJ ALL PRML O
	  	 SURGERY - INTEGUMENTARY
	  	NonFee	  	[****]
	 20610
	  	00	 	 ARTHROCENTESIS A
	  	 SURGERY - MUSCULOSKELETAL
	  	NonFee	  	[****]
	 36415
	  	00	 	 COLLECTION OF VE
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	 59400
	  	00	 	 ROUTINE OB CARE
	  	 OBSTETRICS - GLOBAL
	  	NonFee	  	[****]
	 69210
	  	00	 	 RMVL IMPACTED CE
	  	 SURGERY - AUDITORY
	  	NonFee	  	[****]
	 71020
	  	00	 	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFee	  	[****]
	 71020
	  	26	 	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFee	  	[****]
	 71020
	  	TC	 	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFee	  	[****]
	 80050
	  	TC	 	 GENERAL HEALTH P
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	 80061
	  	00	 	 LIPID PANEL
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	 84443
	  	00	 	 THYROID STIMULAT
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	 85025
	  	00	 	 BLD COUNT: CMPL
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	 87880
	  	00	 	 IAADADOO STREPT
	  	 OFFICE LAB
	  	NonFee	  	[****]
	 90471
	  	00	 	 IMMUNIZATION ADM
	  	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	NonFee	  	[****]
	 90658
	  	00	 	 INFLUENZA VACCIN
	  	 IMMUNIZATIONS
	  	NonFee	  	[****]
	 90669
	  	00	 	 PNEUMOCOCCAL CON
	  	 IMMUNIZATIONS
	  	NonFee	  	[****]
	 93000
	  	00	 	 ECG-ROUTINE 12 L
	  	 MEDICINE - OTHER
	  	NonFee	  	[****]
	 93307
	  	00	 	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFee	  	[****]
	 93307
	  	26	 	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFee	  	[****]
	 93307
	  	TC	 	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFee	  	[****]
	 97110
	  	00	 	 THERAP 1/>AREAS
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFee	  	[****]
	 97140
	  	00	 	 MNL TX TECH I/MO
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFee	  	[****]
	 99202
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99203
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99204
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99205
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99211
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99212
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99213
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99214
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99215
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99222
	  	00	 	 INT HOSP-DAY EA
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99223
	  	00	 	 INT HOSP-DAY EA
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99232
	  	00	 	 SUBSQT HSP-DAY E
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99233
	  	00	 	 SUBSQT HSP-DAY E
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99238
	  	00	 	 HOSPITAL D/C DAY
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99243
	  	00	 	 OFFICE CNSLT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99244
	  	00	 	 OFC CNSLT NEW/ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99283
	  	00	 	 EMERG DEPT VISIT
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99284
	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99285
	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99385
	  	00	 	 1ST PREVENTIVE M
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 99386
	  	00	 	 1ST PREVENTIVE M
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 99391
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 99392
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 99393
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 99394
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 99395
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 99396
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 JO696
	  	00	 	 INJECTION CEFTRI
	  	 INJECTABLES/OTHER DRUGS
	  	NonFee	  	[****]

 Last Routine Maintenance Update:
07-01-2009 
 [****] 

[****] 
 [****] 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount
to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement.

 Note: Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 

Confidential and Proprietary    Not for Distribution to Third Parties 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Commercial All Others 

Market Standard Specifications 
 Austin Market(s) 
 Specifications as of: 07/01/2009 

Report Date: 06/22/2009* 

AUSTN 81350 
  

									
	 Market
	  	Mkt
Std
ID	  	CMS
carrier
locality	  	Site of
Service	  	Linked
Schedule
ID
					
	 Austin
	  	AUSTN 81350	  	0000000	  	Fac	  	AUSTN 81349

  

					
	 Type Of Service
	  	 Primary Fee Source
	  	Pricing Level
	 EVALUATION & MANAGEMENT
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 EVALUATION & MANAGEMENT - NEONATAL
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - INTEGUMENTARY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - MUSCULOSKELETAL
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - RESPIRATORY
	  	2008 CMS RBRVS (0800000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - CARDIOVASCULAR
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - HEMIC & LYMPHATIC
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - MEDIASTINUM & DIAPHRAGM
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - DIGESTIVE
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - URINARY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - MALE GENITAL
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - FEMALE GENITAL
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - MATERNITY & DELIVERY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - ENDOCRINE
	  	2008 CMS RBRVS (0000000) - Jan 2003 Conv Fctr	  	[****]
	 SURGERY - NERVOUS
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - EYE & OCULAR ADNEXA
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 SURGERY - AUDITORY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - BONE DENSITY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - CT
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - MAMMOGRAPHY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - MRI
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - MRA
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - NUCLEAR MEDICINE
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - PET SCANS
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIATION THERAPY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 RADIOLOGY - ULTRASOUND
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 LAB - PATHOLOGY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 OFFICE LAB
	  	2008 CMS Clinical Lab Schedule - National Limit	  	[****]
	 CLINICAL LABORATORY
	  	2008 CMS Clinical Lab Schedule - National Limit	  	[****]
	 MEDICINE - OPHTHALMOLOGY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - CARDIOVASCULAR
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - ALLERGY & CLINICAL IMMUNOLOGY
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - CHIROPRACTIC MANIPULATIVE TREATMENT
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - MODALITIES
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - THERAPIES & OTHER
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - OTHER
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 MEDICINE - CHEMO ADMIN
	  	2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr	  	[****]
	 OBSTETRICS - GLOBAL
	  	2008 CMS RBRVS (0000000)- Jan 2008 Conv Fctr	  	[****]
	 IMMUNIZATIONS
	  	Redbook J Code-CPT Code AWP	  	[****]
	 INJECTABLES/OTHER DRUGS
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - ONCOLOGY/ THERAPEUTIC CHEMO DRUGS
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - IVIG
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - SALINE & DEXTROSE SOLUTIONS
	  	CMS Drug Pricing	  	[****]
	 DME & SUPPLIES
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - RESPIRATORY
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - ORTHOTICS
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - PROSTHETICS
	  	2008 CMS DME Floor	  	[****]
	 AMBULANCE
	  	2008 CMS Ambulance Schedule - Urban (0000000)	  	[****]

 Hard Codes 

[****] 
 [****] 

[****] 
 [****] 

[****] 
 [****] 

Schedule Type: FFS 
 Unless specifically
indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the
customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such
as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement. 
 Note:
Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 
 Confidential and
Proprietary    Not for Distribution to Third Parties 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Commercial All Others 

Representative Fee Schedule Sample for Family Practice: AUSTN 81350 

Fee amounts as of: 07/01/2009 
 Report Date: 06/22/2009* 
 Site of Service - Linked Schedule ID: AUSTN
81349 
  

											
	 CPT
	  	Mod	 	 CPT Description
	  	 Type of Service
	  	Place of Service	  	Fee
						
	 17000
	  	00	 	 DSTRJ ALL PRML O
	  	 SURGERY - INTEGUMENTARY
	  	NonFee	  	[****]
	 20610
	  	00	 	 ARTHROCENTESIS A
	  	 SURGERY - MUSCULOSKELETAL
	  	NonFee	  	[****]
	 36415
	  	00	 	 COLLECTION OF VE
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	 59400
	  	00	 	 ROUTINE OB CARE
	  	 OBSTETRICS - GLOBAL
	  	NonFee	  	[****]
	 69210
	  	00	 	 RMVL IMPACTED CE
	  	 SURGERY - AUDITORY
	  	NonFee	  	[****]
	 71020
	  	00	 	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFee	  	[****]
	 71020
	  	26	 	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFee	  	[****]
	 71020
	  	TC	 	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFee	  	[****]
	 80050
	  	TC	 	 GENERAL HEALTH P
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	 80061
	  	00	 	 LIPID PANEL
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	 84443
	  	00	 	 THYROID STIMULAT
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	 85025
	  	00	 	 BLD COUNT: CMPL
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	 87880
	  	00	 	 IAADADOO STREPT
	  	 OFFICE LAB
	  	NonFee	  	[****]
	 90471
	  	00	 	 IMMUNIZATION ADM
	  	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	NonFee	  	[****]
	 90658
	  	00	 	 INFLUENZA VACCIN
	  	 IMMUNIZATIONS
	  	NonFee	  	[****]
	 90669
	  	00	 	 PNEUMOCOCCAL CON
	  	 IMMUNIZATIONS
	  	NonFee	  	[****]
	 93000
	  	00	 	 ECG-ROUTINE 12 L
	  	 MEDICINE - OTHER
	  	NonFee	  	[****]
	 93307
	  	00	 	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFee	  	[****]
	 93307
	  	26	 	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFee	  	[****]
	 93307
	  	TC	 	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFee	  	[****]
	 97110
	  	00	 	 THERAP 1/>AREAS
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFee	  	[****]
	 97140
	  	00	 	 MNL TX TECH I/MO
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFee	  	[****]
	 99202
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99203
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99204
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99205
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99211
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99212
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99213
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99214
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99215
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99222
	  	00	 	 INT HOSP-DAY EA
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99223
	  	00	 	 INT HOSP-DAY EA
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99232
	  	00	 	 SUBSQT HSP-DAY E
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99233
	  	00	 	 SUBSQT HSP-DAY E
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99238
	  	00	 	 HOSPITAL D/C DAY
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99243
	  	00	 	 OFFICE CNSLT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99244
	  	00	 	 OFC CNSLT NEW/ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99283
	  	00	 	 EMERG DEPT VISIT
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99284
	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99285
	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	 99385
	  	00	 	 1ST PREVENTIVE M
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 99386
	  	00	 	 1ST PREVENTIVE M
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 99391
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 99392
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 99393
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 99394
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 99395
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 99396
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	 JO696
	  	00	 	 INJECTION CEFTRI
	  	 INJECTABLES/OTHER DRUGS
	  	NonFee	  	[****]

 Last Routine Maintenance Update:
07-01-2009 
 [****] 

[****] 
 [****] 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount
to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement.

 Note: Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 

Confidential and Proprietary    Not for Distribution to Third Parties 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Additional Information About Your Fee Schedule 

AUSTN 81350 
 The purpose of this document is to
provide additional information about this fee schedule, including clarity about the fee sources used to derive fees and the type of routine maintenance changes that you can expect. 
 Primary Fee Source 
 The primary fee source is the main fee source used as the basis for
deriving the fee within each category of codes. For instance, if the fee schedule for a given category of codes is derived by applying a particular conversion factor to the relative value units (RVUs) in the CMS fee schedule, those CMS relative
value units are the primary fee source. 
 Alternate (Gap-Fill) Fee Source 
 Alternate (or “gap fill”) fee sources are used to fill gaps in the primary fee sources. For example, if a new CPT code has been created within the category of codes discussed above, and CMS has
not yet established an RVU value for that code, we use one of the sources that exist within the industry to fill that gap, such as but not limited to Ingenix Essential RBRVS. For that CPT code, we adopt the RVU value established by the gap fill-fee
source, and determine the fee schedule amount for that CPT code by applying to the gap-fill RVU the same conversion factor that we apply to the CMS RVU for those CPT codes that have CMS RVUs. At such time in the future as CMS publishes its own RVU
value for that CPT code, we would begin using the primary fee source, CMS, to derive the fee for that code and no longer use the alternate source. 
 Percent of Charge Default 
 In the event that a fee is not sourced by either the primary or
alternate fee source, such as services submitted using unclassified or miscellaneous codes, the codes are subject to correct coding review and may be priced at the default Percent of Charge indicated in the attached document(s). 

Fee Source Links 
  

	 	•	 	 CMS Relative Values and Fee Schedules: www.ems,hhs.gov 

 

	 	•	 	 MICROMEDEX Red Book: www.micromedex.com 

  

	 	•	 	 RJ Health Systems: www.reimbursementcodes.com 

  

	 	•	 	 Ingenix Essential RBRVS: www.ingenixonline.com 

 

	 	•	 	 American Society of Anesthesiologists: www.asahq.org 

 Site of Service 
 This fee schedule generally follows CMS guidelines for determining when
services are priced at the Facility or Nonfacility fee schedule (with the exception of services performed at Ambulatory Surgery Centers, POS 24, which will be priced at the Facility fee schedule). CMS guidelines can be located at the website
indicated above. 
 Routine Maintenance 
 United routinely updates its fee schedule in an effort to stay abreast of current coding practices widely used in the health care industry; in response to price changes for immunizations and injectable
medications; and to remain in compliance with the intent of the contractual agreement. Routine maintenance occurs when United mechanically incorporates revised information created by a third party that is the source for a portion of the fee
schedule. United will not generally attempt to communicate routine maintenance of this nature and will generally implement updates to be effective within 90 days from the date of final publication from one of our primary or alternate fee sources.
Providers may expect the following types of fee updates to their fee schedules: 

	 	a.	Annual Changes to Relative Value Units, Conversion Factors, or Flat Rate Fees 

 This fee schedule follows a “Stated Year” construction methodology. It is generally intended to lock in to the 2008 RVU, the January 2008 Conversion Factor, and the 2008 Flat Rate Fees (non-RVU
based fees such as Durable Medical Equipment fees) as the basis for deriving fees. Generally, any RVU, Conversion Factor, or Flat Rate Fee changes published in subsequent years by the primary and/or alternate fee sources will not be reflected in
this fee schedule. 
  

	 	b.	Price Changes for Immunizations and Injectable Medications 

 United routinely updates its fee schedule in response to price changes for immunizations and injectable medications published by the primary and/or alternate fee sources. United currently utilizes CMS
Drug Pricing and Thomson Micromedex Red Book AWP as its primary fee sources. The effective date of fee updates under this subsection b will be no later than the first day of the next calendar quarter after final publication by the fee source, except
that if that quarter begins less than 60 days after final publication, the effective date will be no later than the first day of the next calendar quarter. For example, if final publication by the fee source is on April 10, the fee update under
this subsection b will be effective no later than July 1, and if final publication by the fee source is on June 10, the fee update under this subsection c will be effective no later than October 1. For purposes of this paragraph, the
date of a claim is the date of service. 
  

	 	c.	CPT/HCPCS Changes and Other Ongoing Updates 

 United routinely updates its fee schedule in response to additions, deletions, and changes to CPT codes by the American Medical Association; HCPCS codes by the Centers for Medicaid and Medicare Services;
CMS changes to its annual update; and in response to similar changes (additions and revisions) to other service coding and reporting conventions that are widely used in the health care industry. Ordinarily, United’s fee schedule is updated
using the original construction methodology along with the then-current RVU of the published CPT code. The effective date of fee updates under this subsection c will be no later than the first day of the next calendar quarter after final publication
by the fee source, except that if that quarter begins less than 60 days after final publication, the effective date will be no later than the first day of the next calendar quarter. For example, if final publication by the fee source is on
April 10, the fee update under this subsection c will be effective no later than July 1, and if final publication by the fee source is on June 10, the fee update under this subsection c will be effective no later than October 1.
For purposes of this paragraph, the date of a claim is the date of service. 
 United is committed to providing transparency related to our fee
schedules. If you have questions about this fee schedule, please contact Network Management at the address and phone number on your network participation agreement or you may use our fee schedule look-up function on the web at
www.unitedhealthcareonline.com or contact our Voice Enabled Telephonic Self Service line at (877) 842-3210. 

 Options PPO 
 Market Standard Specifications 
 Austin Market(s) 

Specifications as of: 07/01/2009 
 Report Date: 06/22/2009* 
 AUSTN 81349 

 

									
	 Market
	  	Mkt
Std
ID	  	CMS
carrier
locality	  	Site of
Service	  	Linked
Schedule
ID
					
	 Austin
	  	AUSTN 81349	  	0000000	  	NonFac	  	AUSTN 81350

  

									
	 Type Of Service
	 	 Primary Fee Source
	  	Pricing Level
	 EVALUATION & MANAGEMENT
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 EVALUATION & MANAGEMENT - NEONATAL
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 EVALUATION & MANAGEMENT - PREVENTIVE
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - INTEGUMENTARY
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - MUSCULOSKELETAL
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - RESPIRATORY
	 	 2008 CMS RBRVS (0800000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - CARDIOVASCULAR
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - HEMIC & LYMPHATIC
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - MEDIASTINUM & DIAPHRAGM
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - DIGESTIVE
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - URINARY
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - MALE GENITAL
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY- FEMALE GENITAL
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - MATERNITY & DELIVERY
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - ENDOCRINE
	 	 2008 CMS RBRVS (0000000) - Jan 2003 Conv Fctr
	  	[****]
	 SURGERY - NERVOUS
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - EYE & OCULAR ADNEXA
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - AUDITORY
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - BONE DENSITY
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - CT
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - MAMMOGRAPHY
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - MRI
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - MRA
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - NUCLEAR MEDICINE
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - PET SCANS
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIATION THERAPY
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - ULTRASOUND
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 LAB - PATHOLOGY
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 OFFICE LAB
	 	 2008 CMS Clinical Lab Schedule - National Limit
	  	[****]
	 CLINICAL LABORATORY
	 	 2008 CMS Clinical Lab Schedule - National Limit
	  	[****]
	 MEDICINE - OPHTHALMOLOGY
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - CARDIOVASCULAR
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - ALLERGY & CLINICAL IMMUNOLOGY
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - CHIROPRACTIC MANIPULATIVE TREATMENT
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - MODALITIES
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB -THERAPIES & OTHER
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - OTHER
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - IMMUNIZATION ADMINISTRATION
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - CHEMO ADMIN
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 OBSTETRICS - GLOBAL
	 	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 IMMUNIZATIONS
	 	 Redbook J Code-CPT Code AWP
	  	[****]
	 INJECTABLES/OTHER DRUGS
	 	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - ONCOLOGY/ THERAPEUTIC CHEMO DRUGS
	 	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - IVIG
	 	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - SALINE & DEXTROSE SOLUTIONS
	 	 CMS Drug Pricing
	  	[****]
	 DME & SUPPLIES
	 	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - RESPIRATORY
	 	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - ORTHOTICS
	 	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - PROSTHETICS
	 	 2008 CMS DME Floor
	  	[****]
	 AMBULANCE
	 	 2008 CMS Ambulance Schedule - Urban (0000000)
	  	[****]

 Hard Codes 

[****] 
 [****] 

[****] 
 [****] 

[****] 
 [****] 

Schedule Type: FFS 
 Unless specifically
indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the
customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such
as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement. 
 Note:
Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 
 Confidential and
Proprietary    Not for Distribution to Third Parties 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Options PPO 
 Representative Fee Schedule Sample for Family Practice : AUSTN 81349 
 Fee
amounts as of: 07/01/2009 
 Report Date: 06/22/2009* 

Site of Service - Linked Schedule ID: AUSTN 81350 
  

											
	 CPT
	  	Mod	  	 CPT Description
	  	 Type of Service
	  	Place of Service	  	Fee
						
	17000	  	00	  	 DSTRJ ALL PRML O
	  	 SURGERY - INTEGUMENTARY
	  	NonFee	  	[****]
	20610	  	00	  	 ARTHROCENTESIS A
	  	 SURGERY - MUSCULOSKELETAL
	  	NonFee	  	[****]
	36415	  	00	  	 COLLECTION OF VE
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	59400	  	00	  	 ROUTINE OB CARE
	  	 OBSTETRICS - GLOBAL
	  	NonFee	  	[****]
	69210	  	00	  	 RMVL IMPACTED CE
	  	 SURGERY - AUDITORY
	  	NonFee	  	[****]
	71020	  	00	  	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFee	  	[****]
	71020	  	26	  	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFee	  	[****]
	71020	  	TC	  	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFee	  	[****]
	80050	  	TC	  	 GENERAL HEALTH P
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	80061	  	00	  	 LIPID PANEL
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	84443	  	00	  	 THYROID STIMULAT
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	85025	  	00	  	 BLD COUNT: CMPL
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	87880	  	00	  	 IAADADOO STREPT
	  	 OFFICE LAB
	  	NonFee	  	[****]
	90471	  	00	  	 IMMUNIZATION ADM
	  	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	NonFee	  	[****]
	90658	  	00	  	 INFLUENZA VACCIN
	  	 IMMUNIZATIONS
	  	NonFee	  	[****]
	90669	  	00	  	 PNEUMOCOCCAL CON
	  	 IMMUNIZATIONS
	  	NonFee	  	[****]
	93000	  	00	  	 ECG-ROUTINE 12 L
	  	 MEDICINE - OTHER
	  	NonFee	  	[****]
	93307	  	00	  	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFee	  	[****]
	93307	  	26	  	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFee	  	[****]
	93307	  	TC	  	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFee	  	[****]
	97110	  	00	  	 THERAP 1/>AREAS
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFee	  	[****]
	97140	  	00	  	 MNL TX TECH I/MO
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFee	  	[****]
	99202	  	00	  	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99203	  	00	  	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99204	  	00	  	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99205	  	00	  	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99211	  	00	  	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99212	  	00	  	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99213	  	00	  	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99214	  	00	  	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99215	  	00	  	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99222	  	00	  	 INT HOSP-DAY EA
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99223	  	00	  	 INT HOSP-DAY EA
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99232	  	00	  	 SUBSQT HSP-DAY E
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99233	  	00	  	 SUBSQT HSP-DAY E
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99238	  	00	  	 HOSPITAL D/C DAY
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99243	  	00	  	 OFFICE CNSLT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99244	  	00	  	 OFC CNSLT NEW/ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99283	  	00	  	 EMERG DEPT VISIT
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99284	  	00	  	 ER VISIT E&M HIG
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99285	  	00	  	 ER VISIT E&M HIG
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99385	  	00	  	 1ST PREVENTIVE M
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	99386	  	00	  	 1ST PREVENTIVE M
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	99391	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	99392	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	99393	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	99394	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	99395	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	99396	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	JO696	  	00	  	 INJECTION CEFTRI
	  	 INJECTABLES/OTHER DRUGS
	  	NonFee	  	[****]

 Last Routine Maintenance Update:
07-01-2009 
 [****] 
 [****]

 [****] 
 Unless specifically
indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the
customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such
as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement. 
 Note:
Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 
 Confidential and
Proprietary    Not for Distribution to Third Parties 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Options PPO 
 Market Standard Specifications 
 Austin Market(s) 

Specifications as of: 07/01/2009 
 Report Date: 06/22/2009* 
 AUSTN 81350 

 

									
	 Market
	  	Mkt
Std
ID	  	CMS
carrier
locality	  	Site of
Service	  	Linked
Schedule
ID
					
	 Austin
	  	AUSTN 81350	  	0000000	  	Fac	  	AUSTN 81349

  

									
	 Type Of Service
	  	 Primary Fee Source
	  	Pricing Level
	 EVALUATION & MANAGEMENT
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 EVALUATION & MANAGEMENT - NEONATAL
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - INTEGUMENTARY
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - MUSCULOSKELETAL
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - RESPIRATORY
	  	 2008 CMS RBRVS (0800000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - CARDIOVASCULAR
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - HEMIC & LYMPHATIC
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - MEDIASTINUM & DIAPHRAGM
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - DIGESTIVE
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - URINARY
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - MALE GENITAL
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY- FEMALE GENITAL
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - MATERNITY & DELIVERY
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - ENDOCRINE
	  	 2008 CMS RBRVS (0000000) - Jan 2003 Conv Fctr
	  	[****]
	 SURGERY - NERVOUS
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - EYE & OCULAR ADNEXA
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 SURGERY - AUDITORY
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - BONE DENSITY
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - CT
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - MAMMOGRAPHY
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - MRI
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - MRA
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - NUCLEAR MEDICINE
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - PET SCANS
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIATION THERAPY
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 RADIOLOGY - ULTRASOUND
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 LAB - PATHOLOGY
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 OFFICE LAB
	  	 2008 CMS Clinical Lab Schedule - National Limit
	  	[****]
	 CLINICAL LABORATORY
	  	 2008 CMS Clinical Lab Schedule - National Limit
	  	[****]
	 MEDICINE - OPHTHALMOLOGY
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - CARDIOVASCULAR
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - ALLERGY & CLINICAL IMMUNOLOGY
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - CHIROPRACTIC MANIPULATIVE TREATMENT
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - MODALITIES
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - THERAPIES & OTHER
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - OTHER
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 MEDICINE - CHEMO ADMIN
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 OBSTETRICS - GLOBAL
	  	 2008 CMS RBRVS (0000000) - Jan 2008 Conv Fctr
	  	[****]
	 IMMUNIZATIONS
	  	 Redbook J Code-CPT Code AWP
	  	[****]
	 INJECTABLES/OTHER DRUGS
	  	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - ONCOLOGY/ THERAPEUTIC CHEMO DRUGS
	  	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - IVIG
	  	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - SALINE & DEXTROSE SOLUTIONS
	  	 CMS Drug Pricing
	  	[****]
	 DME & SUPPLIES
	  	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - RESPIRATORY
	  	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - ORTHOTICS
	  	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - PROSTHETICS
	  	 2008 CMS DME Floor
	  	[****]
	 AMBULANCE
	  	 2008 CMS Ambulance Schedule - Urban (0000000)
	  	[****]

 [****] 

[****] 
 [****] 

[****] 
 [****] 

Anesthesia Rounding Option: Proration 

Schedule Type: FFS 
 Unless specifically
indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the
customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such
as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement. 
 Note:
Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 
 Confidential and
Proprietary    Not for Distribution to Third Parties 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Options PPO 
 Representative Fee Schedule Sample for Family Practice: AUSTN 81350 
 Fee
amounts as of: 07/01/2009 
 Report Date: 06/22/2009* 

Site of Service - Linked Schedule ID: AUSTN 81349 
  

											
	 CPT
	  	Mod	  	 CPT Description
	  	 Type of Service
	  	Place of Service	  	Fee
						
	17000	  	00	  	 DSTRJ ALL PRML O
	  	 SURGERY - INTEGUMENTARY
	  	NonFee	  	[****]
	20610	  	00	  	 ARTHROCENTESIS A
	  	 SURGERY - MUSCULOSKELETAL
	  	NonFee	  	[****]
	36415	  	00	  	 COLLECTION OF VE
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	59400	  	00	  	 ROUTINE OB CARE
	  	 OBSTETRICS - GLOBAL
	  	NonFee	  	[****]
	69210	  	00	  	 RMVL IMPACTED CE
	  	 SURGERY - AUDITORY
	  	NonFee	  	[****]
	71020	  	00	  	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFee	  	[****]
	71020	  	26	  	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFee	  	[****]
	71020	  	TC	  	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFee	  	[****]
	80050	  	TC	  	 GENERAL HEALTH P
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	80061	  	00	  	 LIPID PANEL
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	84443	  	00	  	 THYROID STIMULAT
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	85025	  	00	  	 BLD COUNT: CMPL
	  	 CLINICAL LABORATORY
	  	NonFee	  	[****]
	87880	  	00	  	 IAADADOO STREPT
	  	 OFFICE LAB
	  	NonFee	  	[****]
	90471	  	00	  	 IMMUNIZATION ADM
	  	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	NonFee	  	[****]
	90658	  	00	  	 INFLUENZA VACCIN
	  	 IMMUNIZATIONS
	  	NonFee	  	[****]
	90669	  	00	  	 PNEUMOCOCCAL CON
	  	 IMMUNIZATIONS
	  	NonFee	  	[****]
	93000	  	00	  	 ECG-ROUTINE 12 L
	  	 MEDICINE - OTHER
	  	NonFee	  	[****]
	93307	  	00	  	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFee	  	[****]
	93307	  	26	  	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFee	  	[****]
	93307	  	TC	  	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFee	  	[****]
	97110	  	00	  	 THERAP 1/>AREAS
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFee	  	[****]
	97140	  	00	  	 MNL TX TECH I/MO
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFee	  	[****]
	99202	  	00	  	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99203	  	00	  	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99204	  	00	  	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99205	  	00	  	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99211	  	00	  	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99212	  	00	  	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99213	  	00	  	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99214	  	00	  	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99215	  	00	  	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99222	  	00	  	 INT HOSP-DAY EA
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99223	  	00	  	 INT HOSP-DAY EA
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99232	  	00	  	 SUBSQT HSP-DAY E
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99233	  	00	  	 SUBSQT HSP-DAY E
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99238	  	00	  	 HOSPITAL D/C DAY
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99243	  	00	  	 OFFICE CNSLT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99244	  	00	  	 OFC CNSLT NEW/ES
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99283	  	00	  	 EMERG DEPT VISIT
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99284	  	00	  	 ER VISIT E&M HIG
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99285	  	00	  	 ER VISIT E&M HIG
	  	 EVALUATION & MANAGEMENT
	  	NonFee	  	[****]
	99385	  	00	  	 1ST PREVENTIVE M
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	99386	  	00	  	 1ST PREVENTIVE M
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	99391	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	99392	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	99393	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	99394	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	99395	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	99396	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFee	  	[****]
	JO696	  	00	  	 INJECTION CEFTRI
	  	 INJECTABLES/OTHER DRUGS
	  	NonFee	  	[****]

 Last Routine Maintenance Update:
07-01-2009 
 [****] 

[****] 
 [****] 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount
to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement.

 Note: Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 

Confidential and Proprietary    Not for Distribution to Third Parties 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Additional Information About Your Fee Schedule 

AUSTN 81350 
 The purpose of this document is to
provide additional information about this fee schedule, including clarity about the fee sources used to derive fees and the type of routine maintenance changes that you can expect. 
 Primary Fee Source 
 The primary fee source is the main fee source used as the basis for
deriving the fee within each category of codes. For instance, if the fee schedule for a given category of codes is derived by applying a particular conversion factor to the relative value units (RVUs) in the CMS fee schedule, those CMS relative
value units are the primary fee source. 
 Alternate (Gap-Fill) Fee Source 
 Alternate (or “gap fill”) fee sources are used to fill gaps in the primary fee sources. For example, if a new CPT code has been created within the category of codes discussed above, and CMS has
not yet established an RVU value for that code, we use one of the sources that exist within the industry to fill that gap, such as but not limited to Ingenix Essential RBRVS. For that CPT code, we adopt the RVU value established by the gap fill-fee
source, and determine the fee schedule amount for that CPT code by applying to the gap-fill RVU the same conversion factor that we apply to the CMS RVU for those CPT codes that have CMS RVUs. At such time in the future as CMS publishes its own RVU
value for that CPT code, we would begin using the primary fee source, CMS, to derive the fee for that code and no longer use the alternate source. 
 Percent of Charge Default 
 In the event that a fee is not sourced by either the primary or
alternate fee source, such as services submitted using unclassified or miscellaneous codes, the codes are subject to correct coding review and may be priced at the default Percent of Charge indicated in the attached document(s). 

Fee Source Links 
  

	 	•	 	 CMS Relative Values and Fee Schedules: www.ems,hhs.gov 

 

	 	•	 	 MICROMEDEX Red Book: www.micromedex.com 

  

	 	•	 	 RJ Health Systems: www.reimbursementcodes.com 

  

	 	•	 	 Ingenix Essential RBRVS: www.ingenixonline.com 

 

	 	•	 	 American Society of Anesthesiologists: www.asahq.org 

 Site of Service 
 This fee schedule generally follows CMS guidelines for determining when
services are priced at the Facility or Nonfacility fee schedule (with the exception of services performed at Ambulatory Surgery Centers, POS 24, which will be priced at the Facility fee schedule). CMS guidelines can be located at the website
indicated above. 
 Routine Maintenance 
 United routinely updates its fee schedule in an effort to stay abreast of current coding practices widely used in the health care industry; in response to price changes for immunizations and injectable
medications; and to remain in compliance with the intent of the contractual agreement. Routine maintenance occurs when United mechanically incorporates revised information created by a third party that is the source for a portion of the fee
schedule. United will not generally attempt to communicate routine maintenance of this nature and will generally implement updates to be effective within 90 days from the date of final publication from one of our primary or alternate fee sources.
Providers may expect the following types of fee updates to their fee schedules: 

	 	a.	Annual Changes to Relative Value Units, Conversion Factors, or Flat Rate Fees 

 This fee schedule follows a “Stated Year” construction methodology. It is generally intended to lock in to the 2008 RVU, the January 2008 Conversion Factor, and the 2008 Flat Rate Fees (non-RVU
based fees such as Durable Medical Equipment fees) as the basis for deriving fees. Generally, any RVU, Conversion Factor, or Flat Rate Fee changes published in subsequent years by the primary and/or alternate fee sources will not be reflected in
this fee schedule. 
  

	 	b.	Price Changes for Immunizations and Injectable Medications 

 United routinely updates its fee schedule in response to price changes for immunizations and injectable medications published by the primary and/or alternate fee sources. United currently utilizes CMS
Drug Pricing and Thomson Micromedex Red Book AWP as its primary fee sources. The effective date of fee updates under this subsection b will be no later than the first day of the next calendar quarter after final publication by the fee source, except
that if that quarter begins less than 60 days after final publication, the effective date will be no later than the first day of the next calendar quarter. For example, if final publication by the fee source is on April 10, the fee update under
this subsection b will be effective no later than July 1, and if final publication by the fee source is on June 10, the fee update under this subsection c will be effective no later than October 1. For purposes of this paragraph, the
date of a claim is the date of service. 
  

	 	c.	CPT/HCPCS Changes and Other Ongoing Updates 

 United routinely updates its fee schedule in response to additions, deletions, and changes to CPT codes by the American Medical Association; HCPCS codes by the Centers for Medicaid and Medicare Services;
CMS changes to its annual update; and in response to similar changes (additions and revisions) to other service coding and reporting conventions that are widely used in the health care industry. Ordinarily, United’s fee schedule is updated
using the original construction methodology along with the then-current RVU of the published CPT code. The effective date of fee updates under this subsection c will be no later than the first day of the next calendar quarter after final publication
by the fee source, except that if that quarter begins less than 60 days after final publication, the effective date will be no later than the first day of the next calendar quarter. For example, if final publication by the fee source is on
April 10, the fee update under this subsection c will be effective no later than July 1, and if final publication by the fee source is on June 10, the fee update under this subsection c will be effective no later than October 1.
For purposes of this paragraph, the date of a claim is the date of service. 
 United is committed to providing transparency related to our fee
schedules. If you have questions about this fee schedule, please contact Network Management at the address and phone number on your network participation agreement or you may use our fee schedule look-up function on the web at
www.unitedhealthcareonline.com or contact our Voice Enabled Telephonic Self Service line at (877) 842-3210. 

 Texas Regulatory Requirements Appendix 

In addition to our understandings in the agreement between you and us, there are certain additional items that Texas laws and regulations require to be
part of our contract. This appendix sets forth those items and is made part of the agreement between you and us. 
 These requirements apply to
all products or benefit contract sponsored, issued or administered by or accessed through us, to the extent such products are regulated under Texas laws applicable to HMOs, managed care, insurance and/or preferred provider organizations; provided,
however, that the requirements in this appendix will not apply to the extent they are preempted by the Medicare Modernization Act or other applicable law. 
 We each agree to be bound by the terms and conditions contained in this appendix. In the event of a conflict or inconsistency between this appendix and any term or condition contained in the agreement,
this appendix shall control, except with regard to benefit contracts outside the scope of this appendix. 
 This appendix will be deemed to be
updated to incorporate any changes to the laws and regulations referenced in this appendix, including any changes to definitions referenced herein, effective as of the date of such changes. 
 For the purposes of this appendix, “enrollee” means our customers who are enrolled in a benefit contract insured or administered by us or by a participating entity. 

Provisions for fully insured benefit contracts regulated under Texas HMO law: 
 1. Payment. Any financial incentive used or payment made directly or indirectly to you under any provision of this agreement between you and us is not made as an inducement to reduce or limit the
provision of medically necessary services to any enrollee. 
 2. Prompt Payment of Clean Claims. We or a participating entity will make
payment to you pursuant to the provisions of the Texas law. For instance, unless a longer time is permitted under applicable Texas law, not later than 30 days from the date we receive an electronic clean claim and not later than 45 days from the
date we receive a non-electronic clean claim, we or a participating entity will either: pay the total amount of the claim in accordance with this agreement; pay the portion of the claim that is not in dispute and notify you in writing why the
remaining portion of the claim is not being paid; pay the total amount of the claim in accordance with this agreement but notify you that the claim is subject to audit; request additional information from you within 30 days of receipt of a clean
claim, and then pay or deny the claim within the time required by law after we receive that information or you fail to timely provide it; or notify you in writing why we or the participating entity will not pay the claim. 

If you submit claims that are not clean: 
  

	•	 	 We will notify you within 30 days of receiving an electronic claim or within 45 days of receiving a non-electronic claim that it is not a clean claim;

  

	•	 	 You may be asked for additional information so that your claim may be adjudicated; or 

 

	•	 	 Your claim may be denied and you will be notified of the denial and the reason for it; or 

 

	•	 	 We may in our discretion pay or have the claim paid by the other applicable participating entity based on the information that you gave in addition to
the information we have. 

 A claim is complete or “clean” if it supplies all the information required by statute.
The Administrative Guide contains additional important information about clean claims, an address to submit claims, a phone number and internet address where you can contact us with questions regarding claims you have submitted, information
regarding any entity to whom we may have delegated claim payment functions, and the address and telephone number of any separate claims processing centers for specific types of claims or services. 

 We or a participating entity may not refuse to process or pay an electronically submitted clean claim,
because the claim is submitted together with or in a batch submission with a claim that is not a clean claim. 
 3. Timely Filing of Claims.
You must submit your claims within 95 days of the date of service. For a claim for which coordination of benefits applies, the 95-day period does not begin for submission of the claim to the secondary payer until you receive notice of the
payment or denial from the primary payer. If your claim is not submitted within this time frame, you will not be reimbursed for the services—and you may not charge your patient for them. If your failure to timely submit the claim is the result
of an information systems failure or a catastrophic event that substantially interferes with your normal business operations for more than two consecutive business days and about which you notify the Texas Department of Insurance as required by 28
Tex. Admin. Code §21.2819, we will extend the 95 day filing deadline by the number of days in which your business was unable to operate. In the event that you seek and receive a waiver from our electronic filing requirements under 28 Tex.
Admin. Code § 21.3701, you may submit non-electronic claims to the address shown in the Administrative Guide. 
 4. Duplicate
Claims. You may not submit duplicate claims for claims, (defined as a claim for payment made for the same patient on the same date of service for the same services) that are not clean for: 1) 45 days after you files those claims
non-electronically, and 2) 30 days after you files those claims electronically. 
 5. Penalties. If governing law requires us or the
participating entity to pay interest, billed charges, fees, costs or another penalty for a failure to pay your clean claim for covered services within a certain time frame, we will follow those requirements. The interest, billed charges, fees, costs
or other penalty required by law will be our only additional obligation for not satisfying a payment obligation to you in a timely manner. In addition, if we adjudicated a claim of yours that was not clean, there shall be no interest or other late
payment obligation to you even if we subsequently adjust the payment amount based on additional information that you provide or that we obtain. In accordance with Tex. Ins. Code § 843.342, we or the participating entity is not liable for a
penalty for failure to pay a clean claim: (1) if the failure to pay the claim is a result of a catastrophic event that substantially interferes with our normal business operations or those of the participating entity; or (2) if the claim
was paid in accordance with applicable law, but for less than the contracted rate, and: (A) you notify us of the underpayment after the 270th day after the date the underpayment was received; and (B) we or the participating entity pay the
balance of the claim on or before the 30th day after the date we receive the notice. 
 6. Corrective Adjustments for Overpayments.

 (a) In accordance with TAC § 21.2818, we or the participating entity may recover a refund from you due to overpayment
or completion of an audit, by adjusting future claim payments and/or by billing you for the amount of the overpayment, if (i) we notify you of the overpayment not later than the 180th day after the date of receipt of the overpayment; or
(ii) we notify you of the completion of an audit under TAC § 21.2809. Notification under subsection (i) of this section shall be in writing and shall include: (A) the specific claims and amounts for which a refund is due and
for each claim the basis and specific reasons for the request for refund; (B) notice of your right to appeal; and (C) the methods by which we or the participating entity intend to recover the refund. 

(b) If we disagree with a request for recovery of an overpayment, we will provide you with an opportunity to appeal, in accordance with
Tex. Ins. Code § 843.350 and 28 TAC § 21.2818, and we or the participating entity may not recover the overpayment until all appeal rights are exhausted. 
 (c) We or the participating entity may recover overpayments beyond the 180-day time frame mentioned above if the overpayment occurred as a result of fraudulent billing practices or a material
misrepresentation by you. 
 7. Information About and Limits on Using Fee Schedule and Reimbursement Methodology. Fee Schedule or coding
guideline changes which are intended to substantially alter the overall methodology or reimbursement level of the fee schedule or which result in a material change in payment to you for the same CPT Code, ICD diagnostic code or hospital-based
revenue code will be treated as an amendment to the agreement, and we will give you 90 days written notice of the changes. We will not make retroactive revisions to the coding guidelines and fee schedules. To request a written copy of our
reimbursement policies and methodologies that apply 

 
to specific procedures or services for which you will seek reimbursement under our agreement, or any other information you need to determine that you are being paid according to our agreement,
send your written request to Network Management, 1250 Capital of Texas Highway, South Building One, Suite 400 Austin, TX 78746. We will respond to your request within 30 days of receiving it. We will, at your request, provide the name, edition, and
model version of the software that we use to determine bundling and unbundling of claims. If we disclose fee schedule or reimbursement methodology to you, you may not use or disclose it for any purposes other than management of your practice,
billing activities, for your business operations or in communications with a governmental agency involved in the regulation of health care or insurance. 
 8. Enrollee Hold Harmless. As further described in this section, you shall hold an enrollee harmless for payment of the cost of covered health care services in the event that we or a participating
entity fails to pay you for such services. You hereby agree that in no event, including, but not limited to non-payment by us or a participating entity, or our insolvency or the insolvency of a participating entity, or breach of this agreement
between you and us, shall you bill, charge, collect a deposit from, seek compensation, remuneration, or reimbursement from, or have any recourse against an enrollee or persons other than us acting on an enrollee’s behalf for health care
services provided pursuant to this agreement between you and us. This provision shall not prohibit collection of supplemental charges or co-payment amounts from enrollee made in accordance with the terms of the applicable agreement between the
enrollee and us. You further agree that: (a) this provision shall survive the termination of this agreement between you and us regardless of the cause giving rise to termination and shall be construed to be for the benefit of the enrollee; and
that (b) this provision supersedes any oral or written contrary agreement now existing or hereafter entered into between you and an enrollee or person acting on an enrollee’s behalf. No amendment or modification of this provision shall be
effective earlier than fifteen (15) days following the Commissioner of the Texas Department of Insurance’s receipt of written notice of such proposed change. 
 9. Provisions Related to Termination. 
 (a) Notice of Termination. We
shall provide written notification of termination of this agreement between you and us to you at least ninety (90) days prior to the effective date of termination, except if termination is related to (i) imminent harm to enrollee health,
(ii) action against your license to practice or (iii) fraud or malfeasance, in which cases termination may be immediate. 
 (b) Advisory Review Panel Review of Proposed Termination. Prior to termination of this agreement between you and us, we shall give you a written explanation of the reasons for termination. Not
later than 30 days following receipt of the written notice of termination, you may request and shall receive a review of the proposed termination by an advisory review panel selected in accordance with the provisions of Tex. Ins. Code chpt. 843.306.
Such review shall be conducted within sixty (60) days of your request or, at your request, the review process shall be expedited. The decision of the advisory panel must be considered but is not binding on us. We shall provide you, upon
request, a copy of the recommendation of the advisory review panel and our determination. Notwithstanding the above provision, you are not entitled to and no review shall be provided in a case in which there is (a) imminent harm to enrollee
health, (b) an action by a state medical board, licensing board or other government agency that effectively impairs your ability to practice or (c) a case of fraud or malfeasance. 

(c) Notice to Enrollees of Provider Deselection and Termination. We must provide reasonable advance notification of an impending
termination to enrollees receiving care from you. Notice given at least thirty (30) days before the effective date of the termination shall be deemed reasonable; provided, however, that if your deselection or termination is for reasons related
to imminent harm to enrollees, notification may be given to enrollees immediately. If you are entitled to a review by us of our decision to terminate you pursuant to Texas Insurance Code, chpt. 843.306 and/or 843.307, we will not notify enrollees of
your impending deselection or termination until its effective date or the time the review panel makes its formal recommendation. 

(d) Continuation of Care for Enrollee Special Circumstance. Unless termination of this agreement between you and us is based upon
reasons relating to medical competence or professional behavior, we or the participating entity shall have a continuing obligation to reimburse you if you are treating an enrollee with special circumstance at no less than the rate provided in this
agreement between you and us. For 

 
purposes of this section, “special circumstance” means a condition with regard to which you reasonably believe that discontinuing care by you and transferring the enrollee’s care
to another provider could cause harm to the enrollee, such as a disability, acute condition, life-threatening illness, or pregnancy of more than twenty-four (24) weeks. You must identify the special circumstance and request that the enrollee be
permitted to continue treatment under your care. You must also agree not to seek payment from the enrollee of any amounts for which the enrollee would not be responsible if this agreement between you and we were still in effect. Any dispute
regarding the necessity for continued treatment by you shall be resolved pursuant to our dispute resolution procedures contained in the appeal procedure for medical necessity determinations as described in the provider manual or administrative
manual. If you are terminated, the obligation to reimburse you for ongoing treatment of an enrollee with special circumstance continues through: (a) the ninetieth (90th) day after the effective date of your termination; (b) nine
(9) months following the effective date of the termination for an enrollee who at the time of the termination has been diagnosed with a terminal illness; or (c) delivery of the child, immediate postpartum care, including a follow-up
checkup within the first six (6) weeks of delivery, for an enrollee who is past the twenty-fourth (24th) week of pregnancy at the effective date of the termination. 
 (e) Voluntary Termination by You. You may terminate this Agreement upon 30 days’ written notice if you provide us with such written notice within 30 days of receiving information requested
under Tex. Ins. Code chpt. 843.321, as described in section 7 above. You agree to cooperate with us to give enrollees the notice described in (c) above. 
 10. Posting of Complaint Procedure and Handling of Enrollee Complaints. You shall post in your office a notice to enrollees on the process for resolving complaints with us. Such notice shall
include the Texas Department of Insurance’s toll-free telephone number for filing complaints. We also provide a mechanism for the resolution of any complaints initiated by our Enrollees which provides for reasonable due process, including, in
an advisory role only, a review panel selected in compliance with the provisions of Tex. Ins. Code chpt. 843.255, as applicable. 
 11. No
Retaliatory Action. We shall not engage in any retaliatory action against you, including termination of or refusal to renew this agreement between you and us, because you have, on behalf of an enrollee, reasonably filed a complaint against us or
have appealed a decision made by us. 
 12. Capitation Payments. If reimbursement to you contains capitation payments, we shall comply
with the requirements of the Texas Insurance Code chpts. 843.315 and 843.316. 
 13. No Indemnification for Tort Liability. You and we
agree that nothing in this agreement between you and us shall be construed to require you to indemnify us for any tort liability resulting from our acts or omissions. 
 14. Provider Communication with Enrollees. Nothing in this agreement between you and us shall be construed to prohibit, attempt to prohibit, or discourage you from discussing with or communicating
to an enrollee, with respect to: (a) information or opinions regarding the enrollee’s health care, including medical condition or treatment options; (b) information or opinions regarding our provisions, terms, requirements, or
services as they relate to the enrollee’s medical needs; (c) the fact that this agreement between you and us has terminated or that you shall otherwise no longer be providing medical care or health care services under our products; or
(d) the fact that, if medically necessary covered services are not available through providers contracting with us, then we must, upon your request and within time appropriate to the circumstances relating to the delivery of the services and
the condition of the enrollee, but in no event to exceed five (5) business days after receipt of reasonably requested documentation, allow referral to an appropriate provider. Further, we may not in any way penalize, terminate, or refuse to
compensate (as provided under this agreement between you and us) you for communicating with a current, prospective or former patient, or a party designated by a patient, in any way protected by this section. 

15. Provisions Related to Emergency Services and Post-Stabilization Care. 
 (a) Definition of Emergency Care. You and we agree that for the purpose of providing health care services for enrollees under our benefit contracts, “emergency care” shall mean health
care services provided in a hospital emergency facility or comparable facility to evaluate and stabilize medical conditions of a recent onset and severity, including but not limited to severe pain, that would lead a prudent

 
layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to get immediate medical care could
result in: (1) placing the patient’s health in serious jeopardy; (2) serious impairment to bodily functions; (3) serious dysfunction of any bodily organ or part; (4) serious disfigurement; or (5) in the case of a
pregnant woman, serious jeopardy to the health of her fetus. 
 (b) Post-stabilization Care Approval. If we require prior
approval of post stabilization care requested by a treating provider following emergency services, we shall approve or deny such treatment within one hour of the time of the request. 
 16. Provisions Specific to Podiatrists. The provisions contained in this Section 16 apply only in the event that you are a podiatrist licensed by the Texas State Board of Podiatric Medical
Examiners. 
 (a) Request for Coding Guidelines and Payment Schedules. Within thirty (30) days after the date of your
request, we shall provide a copy of the coding guidelines and payment schedules applicable to the compensation that you shall receive under this agreement between you and us. 
 (b) No Unilateral Material Retroactive Change. We may not unilaterally make material retroactive revisions to the coding guidelines and payment schedules. 

(c) X-Rays and Orthotics. You may, practicing within the scope of the law regulating podiatry, furnish x-rays and nonprefabricated
orthotics covered by an applicable agreement between the enrollee and us. 
 Provisions for fully insured benefit contracts regulated by the
State of Texas but not subject to Texas HMO laws: 
 1. Other Contracts. You are not restricted from contracting with other insurers,
preferred provider plans, preferred provider organizations, or HMOs. 
 2. Quality Care. Any term or condition of this agreement between
you and us that limits your participation on the basis of quality shall be consistent with established standards of care for your profession. 

3. Provider Privileges. If you have hospital or institutional provider privileges and deliver a significant portion of care in a hospital or
institutional provider setting, this agreement between you and us may contain terms and conditions that include the possession of practice privileges at preferred hospitals or institutions. However, if no preferred hospital or institution offers
privileges to enrollees of a class of physicians or practitioners to which you belong, then the lack of such hospital or institutional provider privileges may not be a basis for denial of your participation as a preferred provider. 

4. Provider Billing. This agreement between you and us may prohibit you from billing an enrollee for unnecessary care if a physician or
practitioner panel has determined the care was unnecessary. However, you shall not be required to pay hospital, institutional, laboratory, x-ray or like charges resulting from the provision of services lawfully ordered by you, even though such
service may be determined to be unnecessary. 
 5. Enrollee Referrals. Nothing in this agreement between you and us shall be construed as
a restriction on the classes of physicians and practitioners who may refer an enrollee to another physician or practitioner. In the event that you make a referral for specialty care, nothing in this agreement between you and us shall be construed to
require you to bear the expenses of such referral in or out of the preferred provider panel. 
 6. No Inducement to Limit Medically Necessary
Services. This agreement between you and us does not contain any financial incentives to you, which act directly or indirectly as an inducement to limit medically necessary services. 

 7. Enrollee or Provider Complaints. We provide a mechanism for the resolution of complaints
initiated by an enrollee or you which provides for reasonable due process including, in an advisory role only, a review panel selected in compliance with the provisions of Tex. Ins. Code § 1301.055 and 28 Tex. Admin. Code §3.3706.

 8. Limit on Indemnification. You shall not be required to indemnify or hold us harmless from tort liability resulting from our acts or
omissions. 
 9. Discounted Fee Arrangements. If this agreement between you and us contains a discounted fee arrangement, an enrollee may
be billed only on the discounted fee and not the full charge. 
 10. Prompt Payment. We or a participating entity will make payment to
you pursuant to the provisions of the Texas law. For instance, unless a longer time is permitted under applicable Texas law, not later than 30 days from the date we receive an electronic clean claim and not later than 45 days from the date we
receive a non-electronic clean claim, we or a participating entity will either: pay the total amount of the claim in accordance with this agreement; pay the portion of the claim that is not in dispute and notify you in writing why the remaining
portion of the claim is not being paid; pay the total amount of the claim in accordance with this agreement but notify you that the claim is subject to audit; request additional information from you within 30 days of receipt of a clean claim, and
then pay or deny the claim within the time required by law after we receive that information or you fail to timely provide it; or notify you in writing why we or the participating entity will not pay the claim. 

If you submit claims that are not clean, 
  

	 	•	 	 We will notify you within 30 days of receiving an electronic claim or within 45 days of receiving a non-electronic claim that it is not a clean claim;

  

	 	•	 	 You may be asked for additional information so that your claim may be adjudicated; or 

 

	 	•	 	 Your claim may be denied and you will be notified of the denial and the reason for it; or 

 

	 	•	 	 We may in our discretion pay or have the claim paid by the other applicable participating entity based on the information that you gave in addition to
the information we have. 

 A claim is complete or “clean” if it supplies all the information required by statute.
The Administrative Guide contains additional important information about clean claims, an address to submit claims, a phone number and internet address where you can contact us with questions regarding claims you have submitted, information
regarding any entity to whom we may have delegated claim payment functions, and the address and telephone number of any separate claims processing centers for specific types of claims or services. 

11. Timely Filing of Claims. You must submit your claims within 95 days of the date of service. For a claim for which coordination of benefits
applies, the 95-day period does not begin for submission of the claim to the secondary payer until you receive notice of the payment or denial from the primary payer. If your claim is not submitted within this time frame, you will not be reimbursed
for the services—and you may not charge your patient for them. If your failure to timely submit the claim is the result of an information systems failure or catastrophic event that substantially interferes with your normal business operations
for more than two consecutive business days and about which you notify the Texas Department of Insurance as required by 28 Tex. Admin. Code §21.2819, we will extend the 95 day filing deadline by the number of days in which your business was
unable to operate. In the event that you seek and receive a waiver from our electronic filing requirements under 28 Tex. Admin. Code § 21.3701, you may submit non-electronic claims to the address shown in the Administrative Guide.

 12. Duplicate Claims. You may not submit duplicate claims for claims, (defined as a claim for payment made for the same patient on the
same date of service for the same services) that are not clean for: 1) 45 days after you files those claims non-electronically, and 2) 30 days after you files those claims electronically. 
 13. Penalties. If governing law requires us or the participating entity to pay interest, billed charges, fees, costs or another penalty for a failure to pay your clean claim for covered services
within a certain time frame, we will follow those requirements. The interest, billed charges, fees, costs or other penalty required by law will be the only 

 
additional obligation for not satisfying in a timely manner a payment obligation to you. In addition, if we adjudicated a claim of yours that was not clean, there shall be no interest or other
late payment obligation to you even if we subsequently adjust the payment amount based on additional information that you provide or that we obtain. In accordance with Tex. Ins. Code § 1301.137, neither we nor or the participating entity will
be liable for a penalty for failure to pay a clean claim: (1) if the failure to pay the claim is a result of a catastrophic event that substantially interferes with our normal business operations or those of the participating entity; or
(2) if the claim was paid in accordance with applicable law, but for less than the contracted rate, and: (A) you notify us of the underpayment after the 270th day after the date the underpayment was received; and (B) we or the
participating entity pay the balance of the claim on or before the 30th day after the date we receive the notice. 
 14. Corrective
Adjustments for Overpayments. 
 (a) In accordance with TAC § 21.2818, we or the participating entity may recover a
refund from you due to overpayment or completion of an audit, by adjusting future claim payments and/or by billing you for the amount of the overpayment, if: (i) we notify you of the overpayment not later than the 180th day after the date of
receipt of the overpayment; or (ii) we notify you of the completion of an audit under TAC § 21.2809. Notification under subsection (i) of this section shall be in writing and shall include: (A) the specific claims and
amounts for which a refund is due and for each claim the basis and specific reasons for the request for refund; (B) notice of your right to appeal; and (C) the methods by which you intend to recover the refund. 

(b) If you disagree with a request for recovery of an overpayment, we will provide you with an opportunity to appeal, in accordance with
Tex. Ins. Code § 1301.132 and 28 TAC § 21.2818, and we or the participating entity may not recover the overpayment until all appeal rights are exhausted. 
 (c) We or the participating entity may recover overpayments beyond the 180-day time frame mentioned above if the overpayment occurred as a result of fraudulent billing practices or a material
misrepresentation by you. 
 15. Information About and Limits on Using Fee Schedule and Reimbursement Methodology. Fee Schedule or coding
guideline changes which are intended to substantially alter the overall methodology or reimbursement level of the fee schedule or which result in a material change in payment to you for the same CPT Code, ICD diagnostic code or hospital-based
revenue code will be treated as an amendment to the contract, and we will give you 90 days written notice of the changes. We will not make retroactive revisions to the coding guidelines and fee schedules. To request a written copy of our
reimbursement policies and methodologies that apply to specific procedures or services for which you will seek reimbursement under this agreement, or any other information you need to determine that you are being paid according to this agreement,
send your written request to Network Management, 1250 Capital of Texas Highway, South Building One, Suite 400 Austin, TX 78746. We will respond to your request within 30 days of receiving it. We will, at your request, provide the name, edition, and
model version of the software that we use to determine bundling and unbundling of claims. If we disclose fee schedule or reimbursement methodology to you, you may not use or disclose it for any purposes other than management of your practice, to
submit bills, for your business operations or in communications with a governmental agency involved in the regulation of health care or insurance. 
 16. Protected Communications. You shall not be prohibited, penalized, retaliated against, or terminated for communicating information pursuant to Texas Insurance Code art. 3.70-3C §7(c).

 17. Use of Economic Profiling. If we conduct, use, or rely upon economic profiling to terminate you, you shall be informed of our
obligation to make available as requested by you, your economic profile, including written criteria by which your performance was measured in accordance with Texas Insurance Code art. 3.70-3C §3(h). 

18. Quality Assessment. If we engage in quality assessment, we shall do so through a panel of not less than three physicians selected by us from
among a list of physicians contracting with us. 
 19. Immunization or Vaccination Protocol. You are not required to issue an
immunization or vaccination protocol for an immunization or vaccination to be administered to an enrollee by a pharmacist. 

 20. Administration of Immunizations or Vaccinations. This agreement between you and us does not
prohibit a pharmacist from administering immunizations or vaccinations if such immunizations or vaccinations are administered in accordance with the Texas Pharmacy Act art. 4542a-1 and rules promulgated thereunder. 

21. Provisions Related to Emergency Services and Post-Stabilization Care 
 (a) Definition of Emergency Care. You and we agree that for the purpose of providing health care services for enrollees under our benefit contracts, “emergency care” shall mean health
care services provided in a hospital emergency facility or comparable facility to evaluate and stabilize medical conditions of a recent onset and severity, including but not limited to severe pain, that would lead a prudent layperson, possessing an
average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to get immediate medical care could result in: (1) placing the patient’s health in serious jeopardy;
(2) serious impairment to bodily functions; (3) serious dysfunction of any bodily organ or part; (4) serious disfigurement; or (5) in the case of a pregnant woman, serious jeopardy to the health of her fetus. 

(b) Post-stabilization Care Approval. If we require prior approval of post stabilization care requested by a treating provider
following emergency services, we shall approve or deny such treatment within one hour of the time of the request. 
 22. Provisions Related
to Termination. 
 (a) Notice of Termination. We shall provide written notification of termination of this agreement
between you and us to you at least ninety (90) days prior to the effective date of termination, except if termination is related to (i) imminent harm to enrollee health, (ii) action against your license to practice or
(iii) fraud, in which cases termination may be immediate. 
 (b) Advisory Review Panel Review of Proposed
Termination. Prior to termination of this agreement between you and us, we shall give you a written explanation of the reasons for termination. If you are a physician or practitioner, in accordance with 28 TAC § 3.3706 and Tex. Ins. Code
§ 1301.053(b), you may request and shall receive a review of the proposed termination by a selected advisory review panel. You must make the request in writing to us within 20 business days of receipt of the notification of our intent to
terminate, which shall include any relevant documentation. Such review shall be conducted within sixty (60) days of your request or, if requested by you pursuant to 28 TAC § 3.3706, the review process shall be expedited. The decision of
the advisory panel must be considered but is not binding on us. We shall provide you, upon request, a copy of the recommendation of the advisory review panel and our determination. Notwithstanding the above provision, you are not entitled to and no
review shall be provided in a case in which there is (a) imminent harm to enrollee health, (b) an action by a state medical board, licensing board or other government agency that effectively impairs your ability to practice or (c) a
case of fraud or malfeasance. 
 (c) Notice of Provider Termination to Enrollees. We must provide reasonable advance
notification of your impending termination to enrollees receiving care from you. Notice given at least thirty (30) days before the effective date of the termination shall be deemed reasonable; provided, however, that if your termination is for
reasons related to imminent harm to enrollees, notification of termination may be given to enrollees immediately. If you are entitled to a review by us of our decision to terminate you pursuant to Tex. Ins. Code Ann. § 1301.057, we will not
notify enrollees of your impending termination its effective date or until the time the review panel makes its formal recommendation, whichever is later. 
 (d) Continuation of Care for Enrollee Special Circumstance. Unless termination of this agreement between you and us is based upon reasons relating to medical competence or professional behavior, we
or the participating entity shall have a continuing obligation to reimburse you if you are treating an enrollee with special circumstance at no less than the rate provided in this agreement between you and us. For purposes of this section,
“special circumstance” means a condition with regard to which you reasonably believe that discontinuing care by you and transferring the enrollee’s care to another provider could cause harm to the enrollee, such as a disability, acute
condition, life-threatening illness, or pregnancy of more 

 
than twenty-four (24) weeks. You must identify the special circumstance and request that the enrollee be permitted to continue treatment under your care. You must also agree not to seek
payment from the enrollee of any amounts for which the enrollee would not be responsible if this agreement between you and we were still in effect. Any dispute regarding the necessity for continued treatment by you shall be resolved pursuant to our
dispute resolution procedures contained in the appeal procedure for medical necessity determinations as described in the provider manual or administrative manual. If you are terminated, the obligation to reimburse you for ongoing treatment of an
enrollee with special circumstance continues through: (a) the ninetieth (90th) day after the effective date of your termination; (b) nine (9) months following the effective date of the termination for an enrollee who at the time
of the termination has been diagnosed with a terminal illness; or (c) delivery of the child, immediate postpartum care, including a follow-up checkup within the first six (6) weeks of delivery, for an enrollee who is past the twenty-fourth
(24th) week of pregnancy at the effective date of the termination. 
 (e) Voluntary Termination by You. You may
terminate this Agreement upon 30 days’ written notice if you provide us with such written notice within 30 days of receiving information requested under 28 Tex. Admin. Code § 3.3703(a)(20), as described in section 15 above. You agree to
cooperate with us to give enrollees the notice described in (c) above. 
 23. No Retaliatory Action. We shall not engage in any
retaliatory action, including termination of or refusal to renew the agreement between you and us, against you because you have, on behalf of an enrollee, reasonably filed a complaint against us or have appealed a decision of ours. 

24. Provisions Specific to Podiatrists. The provisions contained in this section apply only in the event that Provider is a podiatrist licensed by
the Texas State Board of Podiatric Medical Examiners. 
 (a) Request for Coding Guidelines and Payment Schedules. Within
thirty (30) days after the date of your request, we shall provide a copy of the coding guidelines and payment schedules applicable to the compensation that you shall receive under the agreement. 

(b) No Unilateral Material Retroactive Change. We may not unilaterally make material retroactive revisions to the coding guidelines
and payment schedules. 
 (c) X-Rays and Orthotics. You may, practicing within the scope of the law regulating podiatry,
furnish x-rays and nonprefabricated orthotics covered by an enrollee’s benefit contract. 

 AMENDMENT 
 WhiteGlove Health, Inc. (“Medical Group”) is party to an agreement, effective 08/01/2009, (the “Agreement”) with United HealthCare Insurance Company and/or one or more of its
affiliates, (collectively referred to as “United”), under which Medical Group participates in UnitedHealthcare’s network of contracted participating providers. 
 The parties mutually desire to modify certain aspects of their business relationship. Accordingly, the parties hereby amend the Agreement, as follows: 

1. The effective date of this amendment is September 15, 2010. 
 2. To the extent this Amendment conflicts with the Agreement, this Amendment supersedes the conflicting provision of the Agreement. This Amendment further supersedes any provision of the Agreement to the
extent such provision goes beyond the provisions of this Amendment in excluding a Customer, Paver or Benefit Plan from accessing Medical Group’s services under the Agreement. 
 3. The following definitions supersede the same defined terms in the Agreement, and also supersede equivalent defined terms, in the event any exist in the Agreement. For example, the definition of
“Benefit Plan” in this Amendment supersedes the definition of “Benefit Contract”, the definition of “Covered Service” in this Amendment supersedes the definition of “Health Service”, the definition of
“Customer” in this Amendment supersedes the definition of “Member”, and the definition of “Payer” in this Amendment supersedes the definition of “Payor”. 

a. Benefit Plan means a certificate of coverage, summary plan descriptions or other document or agreement, whether delivered in
paper, electronic, or other format under which a Paver is obligated to provide coverage of Covered Services for a Customer. 
 b.
Covered Service is a health care service or product for which a Customer is entitled to receive coverage from a Payer, pursuant to the terms of the Customer’s Benefit Plan with that Payer. 

c. Customer is a person eligible and enrolled to receive coverage from a Payer for Covered Services. 

d. Payer is a person or entity obligated to a Customer to provide reimbursement for Covered Services under the Customer’s
Benefit Plan, and authorized by United to access Medical Group’s services under this Agreement. 
 e. United’s
Affiliates are those entities controlling, controlled by, or under common control with United HealthCare Insurance Company. 
 4. The
attached “Benefit Plan Descriptions Appendix” is added to the Agreement. Any similar attachment to the Agreement concerning the products, Benefit Plans or networks in which Medical Group will participate is hereby deleted and replaced with
this Appendix. 
 5. The following provision shall be added to the Agreement: 

PacifiCare Protocols. For Customers enrolled in Benefit Plans issued or administered by a subsidiary of either PacifiCare Health
Plan Administrators, Inc. or PacifiCare Health Systems, LLC (“PacifiCare Customers”). Medical Group will be subject to the Protocols described in or made available through the PacifiCare Provider Policy and Procedure Manual
(“PacifiCare Manual”). When this Agreement refers to the Administrative Manual or Guide, it is also referring to the PacifiCare Manual. The PacifiCare Manual will be made available to Medical Group on line or upon request. In the event of
any conflict between this Agreement or the UnitedHealthcare Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide or other UnitedHealthcare administrative protocols, and the PacifiCare Manual, in connection with
any matter pertaining to a PacifiCare Customer, the PacifiCare Manual will govern, unless applicable statutes and regulations dictate otherwise. United may make changes to the Administrative 

 
Manual or Guide or PacifiCare Manual or other administrative protocols upon 30 days’ electronic or written notice to Medical Group.” 

6. The following paragraph will be added to the Agreement and will replace any provision in the Agreement to the extent such provision directly conflicts
with it: 
 Payment may be denied in whole or in part if services provided are determined by United to be medically unnecessary,
and Medical Group may not bill the Customer for such services unless the Customer has, with knowledge of United’s determination of a lack of medical necessity, agreed in writing to be responsible for payment of those charges. 

7. The attached Texas Regulatory Requirements Appendix will be added to the agreement and will supersede and replace any previous regulatory requirements
appendix, addendum or provision in the Agreement. 
 8. Appendix 3 entitled Fee Schedule Sample is deleted in its entirety and replaced with the
following Appendix(cies) 3 Fee Schedule Samples and Fee Schedule Specifications. 
 9. Beginning July 1, 2011, rates for an initial visit
will be determined as follows: 
 If United averages [****] initial visits per month in the Applicable Reporting Period, the rate
shall be [****]. 
 If United averages [****] or more initial visits per month in the Applicable Reporting Period, the rate shall
be [****]. 
 If initial visits per month do not exceed [****] per month during the Applicable Reporting Period, the rate shall
be [****]. 
 10. The Applicable Reporting Period will be January 1 - May 31 for July 1 rate updates and July 1 -
November 30 for January 1 rate updates. 
 11. The PROVIDER DESCRIPTION Section of the Agreement reference page is hereby deleted and
replaced with the following, “Counties serviced by Medical Group in the State of Texas”. 
 12. A United group that has a direct
contract with WhiteGlove Health, Inc., either at the time of execution of this amendment or in the future from the permitted sales efforts of WhiteGlove House Call Health, for Covered Services is not covered by this Agreement during the term of the
agreement between the United group and WhiteGlove House Call Health. Inc. 
 A United group shall be defined as any group
accessing United’s network. 
 13. At the request of UHC, which is only to be when audited, WhiteGlove Health, Inc. will provide a list of
United groups contracted directly with WhiteGlove Health, Inc. UHC agrees to limit the use of that list to purposes related solely to claims audit and administration. 
 14. The Agreement term is for a one year from the Effective Date and can be terminated by either party after the one year term with a 120 day written notice. 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 All other provisions of the Agreement shall remain in full force and effect. 

IN WITNESS WHEREOF, the undersigned have executed this Amendment to be effective as of the date set forth above. 

 

	
	WhiteGlove Health, Inc., on behalf of Medical Group
	
	Signature    /s/ Robert Fabbio
	
	Print Name    Robert Fabbio
	
	Title    CEO
	
	Date    9/3/10

 United HealthCare Insurance Company, on behalf of itself, United HealthCare of Texas, Inc., PacifiCare of Texas, Inc.,
Exorcare of Texas, L.L.C. and no other affiliates, as signed by its authorized representative: 
  

			
	Signature    /s/ Rick Everett	 	Signature
		
	Print Name    Rick Everett	 	Print Name
		
	Title    VP	 	Title
		
	Date    9/3/10	 	Date

 AMENDMENT 
 WhiteGlove Health, Inc. (“Medical Group”) is party to an agreement, effective 08/01/2009, (the “Agreement”) with United HealthCare Insurance Company and/or one or more of its
affiliates, (collectively referred to as “United”), under which Medical Group participates in UnitedHealthcare’s network of contracted participating providers. 
 The parties mutually desire to modify certain aspects of their business relationship. Accordingly, the parties hereby amend the Agreement, as follows: 

1. The effective date of this amendment is September 15, 2010. 
 2. To the extent this Amendment conflicts with the Agreement, this Amendment supersedes the conflicting provision of the Agreement. This Amendment further supersedes any provision of the Agreement to the
extent such provision goes beyond the provisions of this Amendment in excluding a Customer, Paver or Benefit Plan from accessing Medical Group’s services under the Agreement. 
 3. The following definitions supersede the same defined terms in the Agreement, and also supersede equivalent defined terms, in the event any exist in the Agreement. For example, the definition of
“Benefit Plan” in this Amendment supersedes the definition of “Benefit Contract”, the definition of “Covered Service” in this Amendment supersedes the definition of “Health Service”, the definition of
“Customer” in this Amendment supersedes the definition of “Member”, and the definition of “Payer” in this Amendment supersedes the definition of “Payor”. 

a. Benefit Plan means a certificate of coverage, summary plan descriptions or other document or agreement, whether delivered in
paper, electronic, or other format under which a Paver is obligated to provide coverage of Covered Services for a Customer. 
 b.
Covered Service is a health care service or product for which a Customer is entitled to receive coverage from a Payer, pursuant to the terms of the Customer’s Benefit Plan with that Payer. 

c. Customer is a person eligible and enrolled to receive coverage from a Payer for Covered Services. 

d. Payer is a person or entity obligated to a Customer to provide reimbursement for Covered Services under the Customer’s
Benefit Plan, and authorized by United to access Medical Group’s services under this Agreement. 
 e. United’s
Affiliates are those entities controlling, controlled by, or under common control with United HealthCare Insurance Company. 
 4. The
attached “Benefit Plan Descriptions Appendix” is added to the Agreement. Any similar attachment to the Agreement concerning the products, Benefit Plans or networks in which Medical Group will participate is hereby deleted and replaced with
this Appendix. 
 5. The following provision shall be added to the Agreement: 

PacifiCare Protocols. For Customers enrolled in Benefit Plans issued or administered by a subsidiary of either PacifiCare Health
Plan Administrators, Inc. or PacifiCare Health Systems, LLC (“PacifiCare Customers”). Medical Group will be subject to the Protocols described in or made available through the PacifiCare Provider Policy and Procedure Manual
(“PacifiCare Manual”). When this Agreement refers to the Administrative Manual or Guide, it is also referring to the PacifiCare Manual. The PacifiCare Manual will be made available to Medical Group on line or upon request. In the event of
any conflict between this Agreement or the UnitedHealthcare Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide or other UnitedHealthcare administrative protocols, and the PacifiCare Manual, in connection with
any matter pertaining to a PacifiCare Customer, the PacifiCare Manual will govern, unless applicable statutes and regulations dictate otherwise. United may make changes to the Administrative 

 
Manual or Guide or PacifiCare Manual or other administrative protocols upon 30 days’ electronic or written notice to Medical Group.” 

6. The following paragraph will be added to the Agreement and will replace any provision in the Agreement to the extent such provision directly conflicts
with it: 
 Payment may be denied in whole or in part if services provided are determined by United to be medically unnecessary,
and Medical Group may not bill the Customer for such services unless the Customer has, with knowledge of United’s determination of a lack of medical necessity, agreed in writing to be responsible for payment of those charges. 

7. The attached Texas Regulatory Requirements Appendix will be added to the agreement and will supersede and replace any previous regulatory requirements
appendix, addendum or provision in the Agreement. 
 8. Appendix 3 entitled Fee Schedule Sample is deleted in its entirety and replaced with the
following Appendix(cies) 3 Fee Schedule Samples and Fee Schedule Specifications. 
 9. Beginning July 1, 2011, rates for an initial visit
will be determined as follows: 
 If United averages [****] initial visits per month in the Applicable Reporting Period, the rate
shall be [****]. 
 If United averages [****] or more initial visits per month in the Applicable Reporting Period, the rate shall
be [****]. 
 If initial visits per month do not exceed [****] per month during the Applicable Reporting Period, the rate shall
be [****]. 
 10. The Applicable Reporting Period will be January 1 - May 31 for July 1 rate updates and July 1 -
November 30 for January 1 rate updates. 
 11. The PROVIDER DESCRIPTION Section of the Agreement reference page is hereby deleted and
replaced with the following, “Counties serviced by Medical Group in the State of Texas”. 
 12. A United group that has a direct
contract with WhiteGlove Health, Inc., either at the time of execution of this amendment or in the future from the permitted sales efforts of WhiteGlove House Call Health, for Covered Services is not covered by this Agreement during the term of the
agreement between the United group and WhiteGlove House Call Health. Inc. 
 A United group shall be defined as any group
accessing United’s network. 
 13. At the request of UHC, which is only to be when audited, WhiteGlove Health, Inc. will provide a list of
United groups contracted directly with WhiteGlove Health, Inc. UHC agrees to limit the use of that list to purposes related solely to claims audit and administration. 
 14. The Agreement term is for a one year from the Effective Date and can be terminated by either party after the one year term with a 120 day written notice. 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 All other provisions of the Agreement shall remain in full force and effect. 

IN WITNESS WHEREOF, the undersigned have executed this Amendment to be effective as of the date set forth above. 

 

	
	WhiteGlove Health, Inc., on behalf of Medical Group
	
	Signature    /s/ Robert Fabbio
	
	Print Name    Robert Fabbio
	
	Title    CEO
	
	Date    9/3/10

 United HealthCare Insurance Company, on behalf of itself, United HealthCare of Texas, Inc., PacifiCare of Texas, Inc.,
Exorcare of Texas, L.L.C. and no other affiliates, as signed by its authorized representative: 
  

			
	Signature	 	Signature
		
	Print Name	 	Print Name
		
	Title	 	Title
		
	Date	 	Date

 Benefit Plan Descriptions Appendix 

United may allow Payers to access Medical Group’s services under this Agreement for the Benefit Plan types described below: 

 

	 	•	 	 Benefit Plans where Customers are offered a network of Participating Providers and must select a primary physician. Such Benefit Plans may or may not
include an out-of-network benefit. 

  

	 	•	 	 Benefit Plans where Customers are offered a network of Participating Providers but are not required to select a primary physician. Such Benefit Plans
may or may not include an out-of-network benefit. 

  

	 	•	 	 Benefit Plans where Customers are not offered a network of Participating Providers from which they may receive Covered Services.

 However, this Agreement does not apply to the following: 

 

	 	•	 	 Benefit Plans sponsored, issued or administered by any Payer where the Benefit Plan is intended to replace, either partially or in its entirety, the
traditional Medicare coverage (Medicare Part A and Medicare Part B) issued to beneficiaries by the Centers for Medicare and Medicaid Services. Note: Although Medicare Benefit Plans are excluded from this Agreement, there can be a separate
agreement between the parties or between United Affiliates and the affiliates of Medical Group or other entity authorized to contract on behalf of Medical Group (such as an IPA agreement) providing for Medical Group’s participation in a network
for those Benefit Plans. 

  

	 	•	 	 Benefit Plans for Medicaid Customers. Note: Although Medicaid Benefit Plans are excluded from this Agreement, there can be a separate agreement between
the parties or between United Affiliates and the affiliates of Medical Group or other entity authorized to contract on behalf of Medical Group (such as an IPA agreement) providing for Medical Group’s participation in a network for those Benefit
Plans. 

  

	 	•	 	 Medicare Advantage Private Fee-For-Service Plans 

  

	 	•	 	 Benefit Plans for Medicare Select 

  

	 	•	 	 Benefit Plans for workers’ compensation benefit programs. 

 Appendix 3 - Options PPO 

Representative Options PPO Fee Schedule Sample for: 81349/81350 
 The provisions of this fee schedule apply to Covered Services by Medical Group to Customers covered by Benefit Plans marketed under the name “Options PPO” and Benefit Plans where Customers are
not offered a network of participating physicians and other health care professionals from which they may receive Covered Services. This fee schedule does not apply to Covered Services rendered by Medical Group to Customers covered by Benefit Plans
sponsored, issued or administered by a subsidiary of either PacifiCare Health Plan Administrators, Inc. or PacifiCare Health Systems, LLC. 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the Customer is responsible to pay under the Customer’s Benefit Plan will be subtracted from the listed amount in determining the
amount to be paid by the Payer. The actual payment amount is also subject to matters described in this Agreement, such as the Payment Policies. This information is subject to the confidentiality provisions of this Agreement. 

 Market Standard Specifications 

Austin Market(s) 
 Specifications as of: 09/01/2010 
 Report Date: 09/03/2010*

 AUSTN 81349 
  

									
	 Market
	  	 Mkt

Std

ID
	  	CMS
carrier
locality	  	Site of
Service	  	 Linked

Schedule

ID

					
	 Austin
	  	AUSTN 81349	  	0000000	  	NonFac	  	AUSTN 81350

  

									
	 Type Of Service
	  	 Primary Fee Source
	  	Pricing Level
	 EVALUATION & MANAGEMENT
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 EVALUATION & MANAGEMENT - NEONATAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 EVALUATION & MANAGEMENT - NURSING FACILITY SVCS
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - INTEGUMENTARY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MUSCULOSKELETAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - RESPIRATORY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - CARDIOVASCULAR
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - HEMIC & LYMPHATIC
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MEDIASTINUM & DIAPHRAGM
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - DIGESTIVE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - URINARY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MALE GENITAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY- FEMALE GENITAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MATERNITY & DELIVERY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - ENDOCRINE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - NERVOUS
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - EYE & OCULAR ADNEXA
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - AUDITORY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - BONE DENSITY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - CT
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - MAMMOGRAPHY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - MRI
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - MRA
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - NUCLEAR MEDICINE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - PET SCANS
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - RADIATION THERAPY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - ULTRASOUND
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 LAB - PATHOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 OFFICE LAB
	  	 2008 CMS Clinical Lab Schedule - National Limit
	  	[****]
	 CLINICAL LABORATORY
	  	 2008 CMS Clinical Lab Schedule - National Limit
	  	[****]
	 MEDICINE - OPHTHALMOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - CARDIOVASCULAR
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - ALLERGY & CLINICAL IMMUNOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - CHIROPRACTIC MANIPULATIVE TREATMENT
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - MODALITIES
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB -THERAPIES & OTHER
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - OTHER
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - CHEMO ADMIN
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 OBSTETRICS - GLOBAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 IMMUNIZATIONS
	  	 Redbook J Code-CPT Code AWP
	  	[****]
	 INJECTABLES/OTHER DRUGS
	  	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - ONCOLOGY/ THERAPEUTIC CHEMO DRUGS
	  	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - IVIG
	  	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - SALINE & DEXTROSE SOLUTIONS
	  	 CMS Drug Pricing
	  	[****]
	 DME & SUPPLIES
	  	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - RESPIRATORY
	  	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - ORTHOTICS
	  	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - PROSTHETICS
	  	 2008 CMS DME Floor
	  	[****]
	 AMBULANCE
	  	 2008 CMS Ambulance Schedule - Urban (0000000)
	  	[****]

 Hard Codes 

[****] 
 [****] 

[****] 
 [****] 

[****] 
 [****] 

[****] 
 Unless specifically indicated
otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the customer is
responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such as the
payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement. 
 Note: Maintenance to
this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 
 Confidential and
Proprietary    Not for Distribution to Third Parties 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Representative Fee Schedule Sample for Family Practice: AUSTN 81349 

Fee amounts as of: 09/01/2010 
 Report Date: 09/03/2010* 
 Site of Service - Linked Schedule ID: AUSTN
81350 
  

											
	 CPT
	  	Mod	  	 CPT Description
	  	 Type of Service
	  	Place of Service	  	Fee
						
	17110	  	00	  	 DESTRUCTION BENI
	  	 SURGERY - INTEGUMENTARY
	  	NonFac	  	[****]
	20610	  	00	  	 ARTHROCENTESIS A
	  	 SURGERY - MUSCULOSKELETAL
	  	NonFac	  	[****]
	36415	  	00	  	 COLLECTION OF VE
	  	 CLINICAL LABORATORY
	  	NonFac	  	[****]
	59400	  	00	  	 ROUTINE OB CARE
	  	 OBSTETRICS - GLOBAL
	  	NonFac	  	[****]
	71020	  	00	  	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFac	  	[****]
	71020	  	26	  	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFac	  	[****]
	71020	  	TC	  	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFac	  	[****]
	80050	  	TC	  	 GENERAL HEALTH P
	  	 CLINICAL LABORATORY
	  	NonFac	  	[****]
	80053	  	00	  	 COMPRE METAB PAN
	  	 CLINICAL LABORATORY
	  	NonFac	  	[****]
	80061	  	00	  	 LIPID PANEL
	  	 CLINICAL LABORATORY
	  	NonFac	  	[****]
	85025	  	00	  	 BLD COUNT: CMPL
	  	 CLINICAL LABORATORY
	  	NonFac	  	[****]
	87850	  	00	  	 IAADADOO STREPT
	  	 OFFICE LAB
	  	NonFac	  	[****]
	90471	  	00	  	 IMMUNIZATION ADM
	  	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	NonFac	  	[****]
	90648	  	00	  	 HUMAN PAPILLOMA
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	90558	  	00	  	 INFLUENZA VACCIN
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	90715	  	00	  	 TOAP VACCINE 7 Y
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	90716	  	00	  	 VARICELLA VIRUS
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	90734	  	00	  	 MENINGOCOCCAL CO
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	93000	  	00	  	 ECG-ROUTINE 12 L
	  	 MEDICINE - OTHER
	  	NonFac	  	[****]
	83307	  	00	  	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFac	  	[****]
	93307	  	26	  	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFac	  	[****]
	93307	  	TC	  	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFac	  	[****]
	96372	  	00	  	 THERAPEUTIC PROP
	  	 MEDICINE - OTHER
	  	NonFac	  	[****]
	97110	  	00	  	 THERAP 1/>AREAS
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFac	  	[****]
	97140	  	00	  	 MNL TX TECH I/MO
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFac	  	[****]
	99202	  	00	  	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99203	  	00	  	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99204	  	00	  	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99205	  	00	  	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99211	  	00	  	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99212	  	00	  	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99213	  	00	  	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99214	  	00	  	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99215	  	00	  	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99223	  	00	  	 INT HOSP-DAY ES
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99232	  	00	  	 SUBSQT HSP-DAY E
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99233	  	00	  	 SUBSQT HOSP-DAY
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99243	  	00	  	 OFFICE CNSLT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99244	  	00	  	 OFC CNSLT NEW/ES
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99283	  	00	  	 EMERG DEPT VISIT
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99284	  	00	  	 ER VISIT E&M HIG
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99285	  	00	  	 ER VISIT E&M HIG
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99386	  	00	  	 1ST PREVENTIVE M
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99386	  	00	  	 1ST PREVENTIVE M
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99391	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99392	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99393	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99394	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99395	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99396	  	00	  	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]

 
 Last Routine Maintenance Update: 10-01-2010 
 [****] 

[****] 
 [****] 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount
to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement.

 Note: Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 

Confidential and Proprietary    Not for Distribution to Third Parties 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Market Standard Specifications 

Austin Market(s) 
 Specifications as of: 09/01/2010 
 Report Date: 09/03/2010*

 AUSTN 81350 
  

									
	 Market
	  	 Mkt

Std

ID
	  	CMS
carrier
locality	  	Site of
Service	  	 Linked

Schedule

ID

					
	 Austin
	  	AUSTN 81350	  	0000000	  	Fac	  	AUSTN 81349

  

									
	 Type Of Service
	  	 Primary Fee Source
	  	Pricing Level
	 EVALUATION & MANAGEMENT
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 EVALUATION & MANAGEMENT - NEONATAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 EVALUATION & MANAGEMENT - NURSING FACILITY SVCS
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - INTEGUMENTARY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MUSCULOSKELETAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - RESPIRATORY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - CARDIOVASCULAR
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - HEMIC & LYMPHATIC
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MEDIASTINUM & DIAPHRAGM
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - DIGESTIVE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - URINARY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MALE GENITAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY- FEMALE GENITAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MATERNITY & DELIVERY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - ENDOCRINE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - NERVOUS
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - EYE & OCULAR ADNEXA
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - AUDITORY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - BONE DENSITY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - CT
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - MAMMOGRAPHY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - MRI
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - MRA
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - NUCLEAR MEDICINE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - PET SCANS
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - RADIATION THERAPY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - ULTRASOUND
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 LAB - PATHOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 OFFICE LAB
	  	 2008 CMS Clinical Lab Schedule - National Limit
	  	[****]
	 CLINICAL LABORATORY
	  	 2008 CMS Clinical Lab Schedule - National Limit
	  	[****]
	 MEDICINE - OPHTHALMOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - CARDIOVASCULAR
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - ALLERGY & CLINICAL IMMUNOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - CHIROPRACTIC MANIPULATIVE TREATMENT
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - MODALITIES
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB -THERAPIES & OTHER
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - OTHER
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - CHEMO ADMIN
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 OBSTETRICS - GLOBAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 IMMUNIZATIONS
	  	 Redbook J Code-CPT Code AWP
	  	[****]
	 INJECTABLES/OTHER DRUGS
	  	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - ONCOLOGY/ THERAPEUTIC CHEMO DRUGS
	  	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - IVIG
	  	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - SALINE & DEXTROSE SOLUTIONS
	  	 CMS Drug Pricing
	  	[****]
	 DME & SUPPLIES
	  	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - RESPIRATORY
	  	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - ORTHOTICS
	  	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - PROSTHETICS
	  	 2008 CMS DME Floor
	  	[****]
	 AMBULANCE
	  	 2008 CMS Ambulance Schedule - Urban (0000000)
	  	[****]

 Hard Codes 

[****] 
 [****] 

[****] 
 [****] 

[****] 
 [****] 

Schedule Type: FFS 
 Unless specifically
indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the
customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such
as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement. 
 Note:
Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 
 Confidential and
Proprietary    Not for Distribution to Third Parties 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Representative Fee Schedule Sample for Family Practice: AUSTN 81350 

Fee amounts as of: 09/01/2010 
 Report Date: 09/03/2010* 
 Site of Service - Linked Schedule ID: AUSTN
81349 
  

											
	 CPT
	  	Mod	 	 CPT Description
	  	 Type of Service
	  	Place of Service	  	Fee
						
	17110	  	00	 	DESTRUCTION BENI	  	 SURGERY - INTEGUMENTARY
	  	NonFac	  	[****]
	20610	  	00	 	ARTHROCENTESIS A	  	 SURGERY - MUSCULOSKELETAL
	  	NonFac	  	[****]
	36415	  	00	 	COLLECTION OF VE	  	 CLINICAL LABORATORY
	  	NonFac	  	[****]
	59400	  	00	 	ROUTINE OB CARE	  	 OBSTETRICS - GLOBAL
	  	NonFac	  	[****]
	71020	  	00	 	RADEX CH 2 VIEWS	  	 RADIOLOGY
	  	NonFac	  	[****]
	71020	  	26	 	RADEX CH 2 VIEWS	  	 RADIOLOGY
	  	NonFac	  	[****]
	71020	  	TC	 	RADEX CH 2 VIEWS	  	 RADIOLOGY
	  	NonFac	  	[****]
	80050	  	TC	 	GENERAL HEALTH P	  	 CLINICAL LABORATORY
	  	NonFac	  	[****]
	80053	  	00	 	COMPRE METAB PAN	  	 CLINICAL LABORATORY
	  	NonFac	  	[****]
	80061	  	00	 	LIPID PANEL	  	 CLINICAL LABORATORY
	  	NonFac	  	[****]
	85025	  	00	 	BLD COUNT: CMPL	  	 CLINICAL LABORATORY
	  	NonFac	  	[****]
	87850	  	00	 	IAADADOO STREPT	  	 OFFICE LAB
	  	NonFac	  	[****]
	90471	  	00	 	IMMUNIZATION ADM	  	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	NonFac	  	[****]
	90648	  	00	 	HUMAN PAPILLOMA	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	90558	  	00	 	INFLUENZA VACCIN	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	90715	  	00	 	TOAP VACCINE 7 Y	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	90716	  	00	 	VARICELLA VIRUS	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	90734	  	00	 	MENINGOCOCCAL CO	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	93000	  	00	 	ECG-ROUTINE 12 L	  	 MEDICINE - OTHER
	  	NonFac	  	[****]
	83307	  	00	 	TTHRC R-T IMG 2D	  	 MEDICINE - CARDIOVASCULAR
	  	NonFac	  	[****]
	93307	  	26	 	TTHRC R-T IMG 2D	  	 MEDICINE - CARDIOVASCULAR
	  	NonFac	  	[****]
	93307	  	TC	 	TTHRC R-T IMG 2D	  	 MEDICINE - CARDIOVASCULAR
	  	NonFac	  	[****]
	96372	  	00	 	THERAPEUTIC PROP	  	 MEDICINE - OTHER
	  	NonFac	  	[****]
	97110	  	00	 	THERAP 1/>AREAS	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFac	  	[****]
	97140	  	00	 	MNL TX TECH I/MO	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFac	  	[****]
	99202	  	00	 	OFFICE OUTPT NEW	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99203	  	00	 	OFFICE OUTPT NEW	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99204	  	00	 	OFFICE OUTPT NEW	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99205	  	00	 	OFFICE OUTPT NEW	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99211	  	00	 	OFC/OUTPT E&M ES	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99212	  	00	 	OFC/OUTPT E&M ES	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99213	  	00	 	OFC/OUTPT E&M ES	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99214	  	00	 	OFC/OUTPT E&M ES	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99215	  	00	 	OFC/OUTPT E&M ES	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99223	  	00	 	INT HOSP-DAY ES	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99232	  	00	 	SUBSQT HSP-DAY E	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99233	  	00	 	SUBSQT HOSP-DAY	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99243	  	00	 	OFFICE CNSLT NEW	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99244	  	00	 	OFC CNSLT NEW/ES	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99283	  	00	 	EMERG DEPT VISIT	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99284	  	00	 	ER VISIT E&M HIG	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99285	  	00	 	ER VISIT E&M HIG	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	99386	  	00	 	1ST PREVENTIVE M	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99386	  	00	 	1ST PREVENTIVE M	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99391	  	00	 	PERIODIC PREVENT	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99392	  	00	 	PERIODIC PREVENT	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99393	  	00	 	PERIODIC PREVENT	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99394	  	00	 	PERIODIC PREVENT	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99395	  	00	 	PERIODIC PREVENT	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99396	  	00	 	PERIODIC PREVENT	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]

 
 Last Routine Maintenance Update: 10-01-2010 
 [****] 

[****] 
 [****] 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount
to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement.

 Note: Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 

Confidential and Proprietary    Not for Distribution to Third Parties 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Additional Information About Your Fee Schedule 

AUSTN 81350 
 The purpose of this document is to
provide additional information about this fee schedule, including clarity about the fee sources used to derive fees and the type of routine maintenance changes that you can expect. 
 Primary Fee Source 
 The primary fee source is the main fee source used as the basis for
deriving the fee within each category of codes. For instance, if the fee schedule for a given category of codes is derived by applying a particular conversion factor to the relative value units (RVUs) in the CMS fee schedule, those CMS relative
value units are the primary fee source. 
 Alternate (Gap-Fill) Fee Source 
 Alternate (or “gap fill”) fee sources are used to fill gaps in the primary fee sources. For example, if a new CPT code has been created within the category of codes discussed above, and CMS has
not yet established an RVU value for that code, we use one of the sources that exist within the industry to fill that gap, such as but not limited to Ingenix Essential RBRVS. For that CPT code, we adopt the RVU value established by the gap fill-fee
source, and determine the fee schedule amount for that CPT code by applying to the gap-fill RVU the same conversion factor that we apply to the CMS RVU for those CPT codes that have CMS RVUs. At such time in the future as CMS publishes its own RVU
value for that CPT code, we would begin using the primary fee source, CMS, to derive the fee for that code and no longer use the alternate source. 
 Percent of Charge Default 
 In the event that a fee is not sourced by either the primary or
alternate fee source, such as services submitted using unclassified or miscellaneous codes, the codes are subject to correct coding review and may be priced at the default Percent of Charge indicated in the attached document(s). 

Fee Source Links 
  

	 	•	 	 CMS Relative Values and Fee Schedules: www.ems,hhs.gov 

 

	 	•	 	 MICROMEDEX Red Book: www.micromedex.com 

  

	 	•	 	 RJ Health Systems: www.reimbursementcodes.com 

  

	 	•	 	 Ingenix Essential RBRVS: www.ingenixonline.com 

 

	 	•	 	 American Society of Anesthesiologists: www.asahq.org 

 Site of Service 
 This fee schedule generally follows CMS guidelines for determining when
services are priced at the Facility or Nonfacility fee schedule (with the exception of services performed at Ambulatory Surgery Centers, POS 24, which will be priced at the Facility fee schedule). CMS guidelines can be located at the website
indicated above. 
 Routine Maintenance 
 United routinely updates its fee schedule in an effort to stay abreast of current coding practices widely used in the health care industry; in response to price changes for immunizations and injectable
medications; and to remain in compliance with the intent of the contractual agreement. Routine maintenance occurs when United mechanically incorporates revised information created by a third party that is the source for a portion of the fee
schedule. United will not generally attempt to communicate routine maintenance of this nature and will generally implement updates to be effective within 90 days from the date of final publication from one of our primary or alternate fee sources.
Providers may expect the following types of fee updates to their fee schedules: 

	 	a.	Annual Changes to Relative Value Units, Conversion Factors, or Flat Rate Fees 

 This fee schedule follows a “Stated Year” construction methodology. It is generally intended to lock in to the 2008 RVU, the January 2008 Conversion Factor, and the 2008 Flat Rate Fees (non-RVU
based fees such as Durable Medical Equipment fees) as the basis for deriving fees. Generally, any RVU, Conversion Factor, or Flat Rate Fee changes published in subsequent years by the primary and/or alternate fee sources will not be reflected in
this fee schedule. 
  

	 	b.	Price Changes for Immunizations and Injectable Medications 

 United routinely updates its fee schedule in response to price changes for immunizations and injectable medications published by the primary and/or alternate fee sources. United currently utilizes CMS
Drug Pricing and Thomson Micromedex Red Book AWP as its primary fee sources. The effective date of fee updates under this subsection b will be no later than the first day of the next calendar quarter after final publication by the fee source, except
that if that quarter begins less than 60 days after final publication, the effective date will be no later than the first day of the next calendar quarter. For example, if final publication by the fee source is on April 10, the fee update under
this subsection b will be effective no later than July 1, and if final publication by the fee source is on June 10, the fee update under this subsection c will be effective no later than October 1. For purposes of this paragraph, the
date of a claim is the date of service. 
  

	 	c.	CPT/HCPCS Changes and Other Ongoing Updates 

 United routinely updates its fee schedule in response to additions, deletions, and changes to CPT codes by the American Medical Association; HCPCS codes by the Centers for Medicaid and Medicare Services;
CMS changes to its annual update; and in response to similar changes (additions and revisions) to other service coding and reporting conventions that are widely used in the health care industry. Ordinarily, United’s fee schedule is updated
using the original construction methodology along with the then-current RVU of the published CPT code. The effective date of fee updates under this subsection c will be no later than the first day of the next calendar quarter after final publication
by the fee source, except that if that quarter begins less than 60 days after final publication, the effective date will be no later than the first day of the next calendar quarter. For example, if final publication by the fee source is on
April 10, the fee update under this subsection c will be effective no later than July 1, and if final publication by the fee source is on June 10, the fee update under this subsection c will be effective no later than October 1.
For purposes of this paragraph, the date of a claim is the date of service. 
 United is committed to providing transparency related to our fee
schedules. If you have questions about this fee schedule, please contact Network Management at the address and phone number on your network participation agreement or you may use our fee schedule look-up function on the web at
www.unitedhealthcareonline.com or contact our Voice Enabled Telephonic Self Service line at (877) 842-3210. 

 Appendix 3 - Products other than Options PPO 

Representative All-Payer Fee Schedule Sample(s) for: 81349/81350 
 Unless another fee schedule to this agreement applies specifically to a particular benefit contract as it covers a particular customer, the provisions of this appendix apply to covered services rendered
by you to customers covered by benefit contracts sponsored, issued or administered by all participating entities. 
 Unless specifically
indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the
customer is responsible to pay under the customer’s benefit contract will be subtracted from the listed amount in determining the amount to be paid by the payer. The actual payment amount is also subject to matters described in this agreement,
such as the reimbursement policies. Please remember that this information is subject to the confidentiality provisions of this agreement. 

 Market Standard Specifications 

Austin Market(s) 
 Specifications as of: 09/01/2010 
 Report Date: 09/03/2010*

 AUSTN 81349 
  

									
	 Market
	  	Mkt
Std
ID	  	CMS
carrier
locality	  	Site of
Service	  	Linked
Schedule
ID
					
	 Austin
	  	AUSTN 81349	  	0000000	  	NonFac	  	AUSTN 81350

  

					
	 Type Of Service
	  	 Primary Fee Source
	  	Pricing Level
	 EVALUATION & MANAGEMENT
	  	2008 CMS RBRVS (0000000)	  	[****]
	 EVALUATION & MANAGEMENT - NEONATAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 EVALUATION & MANAGEMENT - NURSING FACILITY SVCS
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - INTEGUMENTARY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MUSCULOSKELETAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - RESPIRATORY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - CARDIOVASCULAR
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - HEMIC & LYMPHATIC
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MEDIASTINUM & DIAPHRAGM
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - DIGESTIVE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - URINARY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MALE GENITAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - FEMALE GENITAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MATERNITY & DELIVERY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - ENDOCRINE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - NERVOUS
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - EYE & OCULAR ADNEXA
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - AUDITORY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - BONE DENSITY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - CT
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - MAMMOGRAPHY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - MRI
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - MRA
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - NUCLEAR MEDICINE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - PET SCANS
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - RADIATION THERAPY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - ULTRASOUND
	  	2008 CMS RBRVS (0000000)	  	[****]
	 LAB - PATHOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 OFFICE LAB
	  	2008 CMS Clinical Lab Schedule - National Limit	  	[****]
	 CLINICAL LABORATORY
	  	2008 CMS Clinical Lab Schedule - National Limit	  	[****]
	 MEDICINE - OPHTHALMOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - CARDIOVASCULAR
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - ALLERGY & CLINICAL IMMUNOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - CHIROPRACTIC MANIPULATIVE TREATMENT
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - MODALITIES
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - THERAPIES & OTHER
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - OTHER
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - CHEMO ADMIN
	  	2008 CMS RBRVS (0000000)	  	[****]
	 OBSTETRICS - GLOBAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 IMMUNIZATIONS
	  	Redbook J Code-CPT Code AWP	  	[****]
	 INJECTABLES/OTHER DRUGS
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - ONCOLOGY/ THERAPEUTIC CHEMO DRUGS
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - IVIG
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - SALINE & DEXTROSE SOLUTIONS
	  	CMS Drug Pricing	  	[****]
	 DME & SUPPLIES
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - RESPIRATORY
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - ORTHOTICS
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - PROSTHETICS
	  	2008 CMS DME Floor	  	[****]
	 AMBULANCE
	  	2008 CMS Ambulance Schedule - Urban (0000000)	  	[****]

 Hard Codes 

[****] 
 [****] 

[****] 
 [****] 

[****] 
 [****] 

Schedule Type: FFS 
 Unless specifically
indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the
customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such
as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement. 
 Note:
Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 
 Confidential and
Proprietary    Not for Distribution to Third Parties 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Representative Fee Schedule Sample for Family Practice : AUSTN 81349 

Fee amounts as of: 09/01/2010 
 Report Date: 09/03/2010* 
 Site of Service - Linked Schedule ID: AUSTN
81350 
  

											
	 CPT
	  	Mod	 	 CPT Description
	  	 Type of Service
	  	Place of Service	  	Fee
						
	 17110
	  	00	 	 DESTRUCTION BENI
	  	 SURGERY - INTEGUMENTARY
	  	NonFac	  	[****]
	 20610
	  	00	 	 ARTHROCENTESIS A
	  	 SURGERY - MUSCULOSKELETAL
	  	NonFac	  	[****]
	 36415
	  	00	 	 COLLECTION OF VE
	  	 CLINICAL LABORATORY
	  	NonFac	  	[****]
	 59400
	  	00	 	 ROUTINE OB CARE
	  	 OBSTETRICS - GLOBAL
	  	NonFac	  	[****]
	 71020
	  	00	 	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFac	  	[****]
	 71020
	  	26	 	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFac	  	[****]
	 71020
	  	TC	 	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	NonFac	  	[****]
	 80050
	  	TC	 	 GENERAL HEALTH P
	  	 CLINICAL LABORATORY
	  	NonFac	  	[****]
	 80053
	  	00	 	 COMPRE METAB PAN
	  	 CLINICAL LABORATORY
	  	NonFac	  	[****]
	 80061
	  	00	 	 LIPID PANEL
	  	 CLINICAL LABORATORY
	  	NonFac	  	[****]
	 85025
	  	00	 	 BLD COUNT: CMPL
	  	 CLINICAL LABORATORY
	  	NonFac	  	[****]
	 87850
	  	00	 	 IAADADOO STREPT
	  	 OFFICE LAB
	  	NonFac	  	[****]
	 90471
	  	00	 	 IMMUNIZATION ADM
	  	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	NonFac	  	[****]
	 90648
	  	00	 	 HUMAN PAPILLOMA
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	 90558
	  	00	 	 INFLUENZA VACCIN
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	 90715
	  	00	 	 TOAP VACCINE 7 Y
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	 90716
	  	00	 	 VARICELLA VIRUS
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	 90734
	  	00	 	 MENINGOCOCCAL CO
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	 93000
	  	00	 	 ECG-ROUTINE 12 L
	  	 MEDICINE - OTHER
	  	NonFac	  	[****]
	 83307
	  	00	 	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFac	  	[****]
	 93307
	  	26	 	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFac	  	[****]
	 93307
	  	TC	 	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	NonFac	  	[****]
	 96372
	  	00	 	 THERAPEUTIC PROP
	  	 MEDICINE - OTHER
	  	NonFac	  	[****]
	 97110
	  	00	 	 THERAP 1/>AREAS
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFac	  	[****]
	 97140
	  	00	 	 MNL TX TECH I/MO
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFac	  	[****]
	 99202
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99203
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99204
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99205
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99211
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99212
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99213
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99214
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99215
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99223
	  	00	 	 INT HOSP-DAY ES
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99232
	  	00	 	 SUBSQT HSP-DAY E
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99233
	  	00	 	 SUBSQT HOSP-DAY
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99243
	  	00	 	 OFFICE CNSLT NEW
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99244
	  	00	 	 OFC CNSLT NEW/ES
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99283
	  	00	 	 EMERG DEPT VISIT
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99284
	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99285
	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION & MANAGEMENT
	  	NonFac	  	[****]
	 99386
	  	00	 	 1ST PREVENTIVE M
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	 99386
	  	00	 	 1ST PREVENTIVE M
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	 99391
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	 99392
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	 99393
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	 99394
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	 99395
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	 99396
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]

 
 Last Routine Maintenance Update: 10-01-2010 
 [****] 

[****] 
 [****] 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount
to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement.

 Note: Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 

Confidential and Proprietary    Not for Distribution to Third Parties 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Market Standard Specifications 

Austin Market(s) 
 Specifications as of: 09/01/2010 
 Report Date: 09/03/2010*

 AUSTN 81350 
  

									
	 Market
	  	Mkt
Std
ID	  	CMS
carrier
locality	  	Site of
Service	  	Linked
Schedule
ID
					
	 Austin
	  	AUSTN 81350	  	0000000	  	Fac	  	AUSTN 81349

  

					
	 Type Of Service
	  	 Primary Fee Source
	  	Pricing Level
	 EVALUATION & MANAGEMENT
	  	2008 CMS RBRVS (0000000)	  	[****]
	 EVALUATION & MANAGEMENT - NEONATAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 EVALUATION & MANAGEMENT - NURSING FACILITY SVCS
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - INTEGUMENTARY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MUSCULOSKELETAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - RESPIRATORY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - CARDIOVASCULAR
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - HEMIC & LYMPHATIC
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MEDIASTINUM & DIAPHRAGM
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - DIGESTIVE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - URINARY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MALE GENITAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - FEMALE GENITAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MATERNITY & DELIVERY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - ENDOCRINE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - NERVOUS
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - EYE & OCULAR ADNEXA
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - AUDITORY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - BONE DENSITY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - CT
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - MAMMOGRAPHY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - MRI
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - MRA
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - NUCLEAR MEDICINE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - PET SCANS
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - RADIATION THERAPY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - ULTRASOUND
	  	2008 CMS RBRVS (0000000)	  	[****]
	 LAB - PATHOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 OFFICE LAB
	  	2008 CMS Clinical Lab Schedule - National Limit	  	[****]
	 CLINICAL LABORATORY
	  	2008 CMS Clinical Lab Schedule - National Limit	  	[****]
	 MEDICINE - OPHTHALMOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - CARDIOVASCULAR
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - ALLERGY & CLINICAL IMMUNOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - CHIROPRACTIC MANIPULATIVE TREATMENT
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - MODALITIES
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - THERAPIES & OTHER
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - OTHER
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - CHEMO ADMIN
	  	2008 CMS RBRVS (0000000)	  	[****]
	 OBSTETRICS - GLOBAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 IMMUNIZATIONS
	  	Redbook J Code-CPT Code AWP	  	[****]
	 INJECTABLES/OTHER DRUGS
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - ONCOLOGY/ THERAPEUTIC CHEMO DRUGS
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - IVIG
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - SALINE & DEXTROSE SOLUTIONS
	  	CMS Drug Pricing	  	[****]
	 DME & SUPPLIES
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - RESPIRATORY
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - ORTHOTICS
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - PROSTHETICS
	  	2008 CMS DME Floor	  	[****]
	 AMBULANCE
	  	2008 CMS Ambulance Schedule - Urban (0000000)	  	[****]

 Hard Codes 

[****] 
 [****] 

[****] 
 [****] 

[****] 
 [****] 

Schedule Type: FFS 
 Unless specifically
indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the
customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such
as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement. 
 Note:
Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 
 Confidential and
Proprietary    Not for Distribution to Third Parties 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Representative Fee Schedule Sample for Family Practice: AUSTN 81350 

Fee amounts as of: 09/01/2010 
 Report Date: 09/03/2010* 
 Site of Service - Linked Schedule ID: AUSTN
81349 
  

											
	 CPT
	  	Mod	 	 CPT Description
	  	 Type of Service
	  	Place of Service	  	Fee
						
	 17110
	  	00	 	 DESTRUCTION BENI
	  	 SURGERY - INTEGUMENTARY
	  	Fac	  	[****]
	 20610
	  	00	 	 ARTHROCENTESIS A
	  	 SURGERY - MUSCULOSKELETAL
	  	Fac	  	[****]
	 36415
	  	00	 	 COLLECTION OF VE
	  	 CLINICAL LABORATORY
	  	Fac	  	[****]
	 59400
	  	00	 	 ROUTINE OB CARE
	  	 OBSTETRICS - GLOBAL
	  	Fac	  	[****]
	 71020
	  	00	 	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	Fac	  	[****]
	 71020
	  	26	 	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	Fac	  	[****]
	 71020
	  	TC	 	 RADEX CH 2 VIEWS
	  	 RADIOLOGY
	  	Fac	  	[****]
	 80050
	  	TC	 	 GENERAL HEALTH P
	  	 CLINICAL LABORATORY
	  	Fac	  	[****]
	 80053
	  	00	 	 COMPRE METAB PAN
	  	 CLINICAL LABORATORY
	  	Fac	  	[****]
	 80061
	  	00	 	 LIPID PANEL
	  	 CLINICAL LABORATORY
	  	Fac	  	[****]
	 85025
	  	00	 	 BLD COUNT: CMPL
	  	 CLINICAL LABORATORY
	  	Fac	  	[****]
	 87850
	  	00	 	 IAADADOO STREPT
	  	 OFFICE LAB
	  	Fac	  	[****]
	 90471
	  	00	 	 IMMUNIZATION ADM
	  	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	Fac	  	[****]
	 90648
	  	00	 	 HUMAN PAPILLOMA
	  	 IMMUNIZATIONS
	  	Fac	  	[****]
	 90558
	  	00	 	 INFLUENZA VACCIN
	  	 IMMUNIZATIONS
	  	Fac	  	[****]
	 90715
	  	00	 	 TOAP VACCINE 7 Y
	  	 IMMUNIZATIONS
	  	Fac	  	[****]
	 90716
	  	00	 	 VARICELLA VIRUS
	  	 IMMUNIZATIONS
	  	Fac	  	[****]
	 90734
	  	00	 	 MENINGOCOCCAL CO
	  	 IMMUNIZATIONS
	  	Fac	  	[****]
	 93000
	  	00	 	 ECG-ROUTINE 12 L
	  	 MEDICINE - OTHER
	  	Fac	  	[****]
	 83307
	  	00	 	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	Fac	  	[****]
	 93307
	  	26	 	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	Fac	  	[****]
	 93307
	  	TC	 	 TTHRC R-T IMG 2D
	  	 MEDICINE - CARDIOVASCULAR
	  	Fac	  	[****]
	 96372
	  	00	 	 THERAPEUTIC PROP
	  	 MEDICINE - OTHER
	  	Fac	  	[****]
	 97110
	  	00	 	 THERAP 1/>AREAS
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	Fac	  	[****]
	 97140
	  	00	 	 MNL TX TECH I/MO
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	Fac	  	[****]
	 99202
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99203
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99204
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99205
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99211
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99212
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99213
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99214
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99215
	  	00	 	 OFC/OUTPT E&M ES
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99223
	  	00	 	 INT HOSP-DAY ES
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99232
	  	00	 	 SUBSQT HSP-DAY E
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99233
	  	00	 	 SUBSQT HOSP-DAY
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99243
	  	00	 	 OFFICE CNSLT NEW
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99244
	  	00	 	 OFC CNSLT NEW/ES
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99283
	  	00	 	 EMERG DEPT VISIT
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99284
	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99285
	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION & MANAGEMENT
	  	Fac	  	[****]
	 99386
	  	00	 	 1ST PREVENTIVE M
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	 99386
	  	00	 	 1ST PREVENTIVE M
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	 99391
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	 99392
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	 99393
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	 99394
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	 99395
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	 99396
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]

 
 Last Routine Maintenance Update: 10-01-2010 
 [****] 

[****] 
 [****] 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount
to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement.

 Note: Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 

Confidential and Proprietary    Not for Distribution to Third Parties 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Additional Information About Your Fee Schedule 

AUSTN 81350 
 The purpose of this document is to
provide additional information about this fee schedule, including clarity about the fee sources used to derive fees and the type of routine maintenance changes that you can expect. 
 Primary Fee Source 
 The primary fee source is the main fee source used as the basis for
deriving the fee within each category of codes. For instance, if the fee schedule for a given category of codes is derived by applying a particular conversion factor to the relative value units (RVUs) in the CMS fee schedule, those CMS relative
value units are the primary fee source. 
 Alternate (Gap-Fill) Fee Source 
 Alternate (or “gap fill”) fee sources are used to fill gaps in the primary fee sources. For example, if a new CPT code has been created within the category of codes discussed above, and CMS has
not yet established an RVU value for that code, we use one of the sources that exist within the industry to fill that gap, such as but not limited to Ingenix Essential RBRVS. For that CPT code, we adopt the RVU value established by the gap fill-fee
source, and determine the fee schedule amount for that CPT code by applying to the gap-fill RVU the same conversion factor that we apply to the CMS RVU for those CPT codes that have CMS RVUs. At such time in the future as CMS publishes its own RVU
value for that CPT code, we would begin using the primary fee source, CMS, to derive the fee for that code and no longer use the alternate source. 
 Percent of Charge Default 
 In the event that a fee is not sourced by either the primary or
alternate fee source, such as services submitted using unclassified or miscellaneous codes, the codes are subject to correct coding review and may be priced at the default Percent of Charge indicated in the attached document(s). 

Fee Source Links 
  

	 	•	 	 CMS Relative Values and Fee Schedules: www.ems,hhs.gov 

 

	 	•	 	 MICROMEDEX Red Book: www.micromedex.com 

  

	 	•	 	 RJ Health Systems: www.reimbursementcodes.com 

  

	 	•	 	 Ingenix Essential RBRVS: www.ingenixonline.com 

 

	 	•	 	 American Society of Anesthesiologists: www.asahq.org 

 Site of Service 
 This fee schedule generally follows CMS guidelines for determining when
services are priced at the Facility or Nonfacility fee schedule (with the exception of services performed at Ambulatory Surgery Centers, POS 24, which will be priced at the Facility fee schedule). CMS guidelines can be located at the website
indicated above. 
 Routine Maintenance 
 United routinely updates its fee schedule in an effort to stay abreast of current coding practices widely used in the health care industry; in response to price changes for immunizations and injectable
medications; and to remain in compliance with the intent of the contractual agreement. Routine maintenance occurs when United mechanically incorporates revised information created by a third party that is the source for a portion of the fee
schedule. United will not generally attempt to communicate routine maintenance of this nature and will generally implement updates to be effective within 90 days from the date of final publication from one of our primary or alternate fee sources.
Providers may expect the following types of fee updates to their fee schedules: 

	 	a.	Annual Changes to Relative Value Units, Conversion Factors, or Flat Rate Fees 

 This fee schedule follows a “Stated Year” construction methodology. It is generally intended to lock in to the 2008 RVU, the January 2008 Conversion Factor, and the 2008 Flat Rate Fees (non-RVU
based fees such as Durable Medical Equipment fees) as the basis for deriving fees. Generally, any RVU, Conversion Factor, or Flat Rate Fee changes published in subsequent years by the primary and/or alternate fee sources will not be reflected in
this fee schedule. 
  

	 	b.	Price Changes for Immunizations and Injectable Medications 

 United routinely updates its fee schedule in response to price changes for immunizations and injectable medications published by the primary and/or alternate fee sources. United currently utilizes CMS
Drug Pricing and Thomson Micromedex Red Book AWP as its primary fee sources. The effective date of fee updates under this subsection b will be no later than the first day of the next calendar quarter after final publication by the fee source, except
that if that quarter begins less than 60 days after final publication, the effective date will be no later than the first day of the next calendar quarter. For example, if final publication by the fee source is on April 10, the fee update under
this subsection b will be effective no later than July 1, and if final publication by the fee source is on June 10, the fee update under this subsection c will be effective no later than October 1. For purposes of this paragraph, the
date of a claim is the date of service. 
  

	 	c.	CPT/HCPCS Changes and Other Ongoing Updates 

 United routinely updates its fee schedule in response to additions, deletions, and changes to CPT codes by the American Medical Association; HCPCS codes by the Centers for Medicaid and Medicare Services;
CMS changes to its annual update; and in response to similar changes (additions and revisions) to other service coding and reporting conventions that are widely used in the health care industry. Ordinarily, United’s fee schedule is updated
using the original construction methodology along with the then-current RVU of the published CPT code. The effective date of fee updates under this subsection c will be no later than the first day of the next calendar quarter after final publication
by the fee source, except that if that quarter begins less than 60 days after final publication, the effective date will be no later than the first day of the next calendar quarter. For example, if final publication by the fee source is on
April 10, the fee update under this subsection c will be effective no later than July 1, and if final publication by the fee source is on June 10, the fee update under this subsection c will be effective no later than October 1.
For purposes of this paragraph, the date of a claim is the date of service. 
 United is committed to providing transparency related to our fee
schedules. If you have questions about this fee schedule, please contact Network Management at the address and phone number on your network participation agreement or you may use our fee schedule look-up function on the web at
www.unitedhealthcareonline.com or contact our Voice Enabled Telephonic Self Service line at (877) 842-3210. 

 Market Standard Specifications 

Austin Market(s) 
 Specifications as of: 10/15/2010 
 Report Date: 09/03/2010*

 AUSTN 81349 
  

									
	 Market
	  	Mkt
Std
ID	  	CMS
carrier
locality	  	Site of
Service	  	Linked
Schedule
ID
					
	 Austin
	  	AUSTN 81349	  	0000000	  	NonFac	  	AUSTN 81350

  

					
	 Type Of Service
	  	 Primary Fee Source
	  	Pricing Level
	 EVALUATION & MANAGEMENT
	  	2008 CMS RBRVS (0000000)	  	[****]
	 EVALUATION & MANAGEMENT - NEONATAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 EVALUATION & MANAGEMENT - NURSING FACILITY SVCS
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - INTEGUMENTARY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MUSCULOSKELETAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - RESPIRATORY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - CARDIOVASCULAR
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - HEMIC & LYMPHATIC
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MEDIASTINUM & DIAPHRAGM
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - DIGESTIVE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - URINARY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MALE GENITAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - FEMALE GENITAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MATERNITY & DELIVERY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - ENDOCRINE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - NERVOUS
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - EYE & OCULAR ADNEXA
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - AUDITORY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - BONE DENSITY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - CT
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - MAMMOGRAPHY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - MRI
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - MRA
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - NUCLEAR MEDICINE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - PET SCANS
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - RADIATION THERAPY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - ULTRASOUND
	  	2008 CMS RBRVS (0000000)	  	[****]
	 LAB - PATHOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 OFFICE LAB
	  	2008 CMS Clinical Lab Schedule - National Limit	  	[****]
	 CLINICAL LABORATORY
	  	2008 CMS Clinical Lab Schedule - National Limit	  	[****]
	 MEDICINE - OPHTHALMOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - CARDIOVASCULAR
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - ALLERGY & CLINICAL IMMUNOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - CHIROPRACTIC MANIPULATIVE TREATMENT
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - MODALITIES
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - THERAPIES & OTHER
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - OTHER
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - CHEMO ADMIN
	  	2008 CMS RBRVS (0000000)	  	[****]
	 OBSTETRICS - GLOBAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 IMMUNIZATIONS
	  	Redbook J Code-CPT Code AWP	  	[****]
	 INJECTABLES/OTHER DRUGS
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - ONCOLOGY/ THERAPEUTIC CHEMO DRUGS
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - IVIG
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - SALINE & DEXTROSE SOLUTIONS
	  	CMS Drug Pricing	  	[****]
	 DME & SUPPLIES
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - RESPIRATORY
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - ORTHOTICS
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - PROSTHETICS
	  	2008 CMS DME Floor	  	[****]
	 AMBULANCE
	  	2008 CMS Ambulance Schedule - Urban (0000000)	  	[****]

 Hard Codes 

[****] 
 [****] 

[****] 
 [****] 

[****] 
 [****] 

Schedule Type: FFS 
 Unless specifically
indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the
customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such
as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement. 
 Note:
Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 
 Confidential and
Proprietary    Not for Distribution to Third Parties 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Representative Fee Schedule Sample for: AUSTN 81349 

Fee amounts as of: 10/15/2010 
 Report Date: 09/03/2010* 
 Site of Service - Linked Schedule ID: AUSTN
81350 
  

											
	 CPT
	  	Mod	 	 CPT Description
	  	 Type of Service
	  	Place of Service	  	Fee
						
	 45378
	  	00	 	 COLONOSCOPY FLEX
	  	 SURGERY - DIGESTIVE
	  	NonFac	  	[****]
	 45350
	  	00	 	 COLONOSCOPY FLEX
	  	 SURGERY - DIGESTIVE
	  	NonFac	  	[****]
	 59400
	  	00	 	 ROUTINE OB CARE
	  	 OBSTETRICS - GLOBAL
	  	NonFac	  	[****]
	 58510
	  	00	 	 ROUTINE OB CARE
	  	 OBSTETRICS - GLOBAL
	  	NonFac	  	[****]
	 77418
	  	00	 	 INTENS MOD TX DE
	  	 RADIOLOGY - RADIATION THERAPY
	  	NonFac	  	[****]
	 88308
	  	00	 	 LEVEL IV - SURG
	  	 LAB-PATHOLOGY
	  	NonFac	  	[****]
	 88305
	  	26	 	 LEVEL IV - SURG
	  	 LAB-PATHOLOGY
	  	NonFac	  	[****]
	 88306
	  	TC	 	 LEVEL IV - SURG
	  	 LAB-PATHOLOGY
	  	NonFac	  	[****]
	 90471
	  	00	 	 IMMUNIZATION ADM
	  	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	NonFac	  	[****]
	 90649
	  	00	 	 HUMAN PAPILLOMA
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	 90669
	  	00	 	 PNEUMOCOCCAL CON
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	 90680
	  	00	 	 ROTAVIRUS VACCIN
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	 00716
	  	00	 	 VARICELLA VIRUS
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	 92014
	  	00	 	 OPN MEDICAL XM&E
	  	 MEDICINE-OPHTHALMOLOGY
	  	NonFac	  	[****]
	 93000
	  	00	 	 ECG-ROUTINE 12l
	  	 MEDICINE-OTHER
	  	NonFac	  	[****]
	 93307
	  	00	 	 TTHRC R-T IMG 2D
	  	 MEDICINE-CARDIOVASCULAR
	  	NonFac	  	[****]
	 93307
	  	26	 	 TTHRC R-T IMG 2D
	  	 MEDICINE-CARDIOVASCULAR
	  	NonFac	  	[****]
	 93307
	  	TC	 	 TTHRC R-T IMG 2D
	  	 MEDICINE-CARDIOVASCULAR
	  	NonFac	  	[****]
	 97110
	  	00	 	 THERAP TO AREAS
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFac	  	[****]
	 90910
	  	00	 	 CMT SPI 1-2 REGI
	  	 MEDICINE-CHIROPRACTIC MANIPULATIVE TREATMENT
	  	NonFac	  	[****]
	 98941
	  	00	 	 CMT SPI 3-4 REGI
	  	 MEDICINE-CHIROPRACTIC MANIPULATIVE TREATMENT
	  	NonFac	  	[****]
	 93202
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99203
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99204
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99206
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99212
	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99213
	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99214
	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99215
	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99223
	  	00	 	 INIT HOSP-DAY E1
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99232
	  	00	 	 SUBSQT HSP-DAY E
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99233
	  	00	 	 SUBSQT HSP-DAY
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99243
	  	00	 	 OFFICE CNSLT NEW
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99244
	  	00	 	 OFC CNSLT NEW/ES
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99245
	  	00	 	 OFC CNSLT NEW/ES
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99283
	  	00	 	 EMERG DEPT VISIT
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99284
	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99285
	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	 99391
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	 99392
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	 99393
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	 99394
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	 99395
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	 99398
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	 J1745
	  	00	 	 INJECTION INFLUX
	  	 INJECTABLE-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	NonFac	  	[****]
	 J2505
	  	00	 	 INJECTION PEGFIL
	  	 INJECTABLE-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	NonFac	  	[****]
	 J9035
	  	00	 	 INJECTION BEVACI
	  	 INJECTABLE-ONCOLOGY/THERAPEUTIC-CHEMO-DRUGS
	  	NonFac	  	[****]
	 J0283
	  	00	 	 INJECTION OXALP
	  	 INJECTABLES-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	NonFac	  	[****]
	 J9310
	  	00	 	 INJECTION, RITUX
	  	 INJECTABLES-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	NonFac	  	[****]
	 j9355
	  	00	 	 INJECTION, TRAST
	  	 INJECTABLES-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	NonFac	  	[****]

 Last Routine Maintenance Update:
10-01-2010 
 [****] 

[****] 
 [****] 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount
to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement.

 Note: Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 

Confidential and Proprietary    Not for Distribution to Third Parties 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Market Standard Specifications 

Austin Market(s) 
 Specifications as of: 10/15/2010 
 Report Date: 09/03/2010*

 AUSTN 81350 
  

									
	 Market
	  	Mkt
Std
ID	  	CMS
carrier
locality	  	Site of
Service	  	Linked
Schedule
ID
					
	 Austin
	  	AUSTN 81350	  	0000000	  	NonFac	  	AUSTN 81349

  

					
	 Type Of Service
	  	 Primary Fee Source
	  	Pricing Level
	 EVALUATION & MANAGEMENT
	  	2008 CMS RBRVS (0000000)	  	[****]
	 EVALUATION & MANAGEMENT - NEONATAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 EVALUATION & MANAGEMENT - NURSING FACILITY SVCS
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - INTEGUMENTARY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MUSCULOSKELETAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - RESPIRATORY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - CARDIOVASCULAR
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - HEMIC & LYMPHATIC
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MEDIASTINUM & DIAPHRAGM
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - DIGESTIVE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - URINARY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MALE GENITAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - FEMALE GENITAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - MATERNITY & DELIVERY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - ENDOCRINE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - NERVOUS
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - EYE & OCULAR ADNEXA
	  	2008 CMS RBRVS (0000000)	  	[****]
	 SURGERY - AUDITORY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - BONE DENSITY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - CT
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - MAMMOGRAPHY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - MRI
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - MRA
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - NUCLEAR MEDICINE
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - PET SCANS
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - RADIATION THERAPY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 RADIOLOGY - ULTRASOUND
	  	2008 CMS RBRVS (0000000)	  	[****]
	 LAB - PATHOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 OFFICE LAB
	  	2008 CMS Clinical Lab Schedule - National Limit	  	[****]
	 CLINICAL LABORATORY
	  	2008 CMS Clinical Lab Schedule - National Limit	  	[****]
	 MEDICINE - OPHTHALMOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - CARDIOVASCULAR
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - ALLERGY & CLINICAL IMMUNOLOGY
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - CHIROPRACTIC MANIPULATIVE TREATMENT
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - MODALITIES
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - THERAPIES & OTHER
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - OTHER
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	2008 CMS RBRVS (0000000)	  	[****]
	 MEDICINE - CHEMO ADMIN
	  	2008 CMS RBRVS (0000000)	  	[****]
	 OBSTETRICS - GLOBAL
	  	2008 CMS RBRVS (0000000)	  	[****]
	 IMMUNIZATIONS
	  	Redbook J Code-CPT Code AWP	  	[****]
	 INJECTABLES/OTHER DRUGS
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - ONCOLOGY/ THERAPEUTIC CHEMO DRUGS
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - IVIG
	  	CMS Drug Pricing	  	[****]
	 INJECTABLES - SALINE & DEXTROSE SOLUTIONS
	  	CMS Drug Pricing	  	[****]
	 DME & SUPPLIES
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - RESPIRATORY
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - ORTHOTICS
	  	2008 CMS DME Floor	  	[****]
	 DME & SUPPLIES - PROSTHETICS
	  	2008 CMS DME Floor	  	[****]
	 AMBULANCE
	  	2008 CMS Ambulance Schedule - Urban (0000000)	  	[****]

 Hard Codes 

[****] 
 [****] 

[****] 
 [****] 

[****] 
 Schedule Type: FFS 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount
to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement.

 Note: Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 

Confidential and Proprietary    Not for Distribution to Third Parties 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Representative Fee Schedule Sample for: AUSTN 81350 

Fee amounts as of: 10/15/2010 
 Report Date: 09/03/2010* 
 Site of Service - Linked Schedule ID: AUSTN
81349 
  

											
	 CPT
	  	Mod	 	 CPT Description
	  	 Type of Service
	  	Place of Service	  	Fee
						
	 45378
	  	00	 	 COLONOSCOPY FLEX
	  	 SURGERY - DIGESTIVE
	  	Fac	  	[****]
	 45350
	  	00	 	 COLONOSCOPY FLEX
	  	 SURGERY - DIGESTIVE
	  	Fac	  	[****]
	 59400
	  	00	 	 ROUTINE OB CARE
	  	 OBSTETRICS - GLOBAL
	  	Fac	  	[****]
	 58510
	  	00	 	 ROUTINE OB CARE
	  	 OBSTETRICS - GLOBAL
	  	Fac	  	[****]
	 77418
	  	00	 	 INTENS MOD TX DE
	  	 RADIOLOGY - RADIATION THERAPY
	  	Fac	  	[****]
	 88308
	  	00	 	 LEVEL IV - SURG
	  	 LAB-PATHOLOGY
	  	Fac	  	[****]
	 88305
	  	26	 	 LEVEL IV - SURG
	  	 LAB-PATHOLOGY
	  	Fac	  	[****]
	 88306
	  	TC	 	 LEVEL IV - SURG
	  	 LAB-PATHOLOGY
	  	Fac	  	[****]
	 90471
	  	00	 	 IMMUNIZATION ADM
	  	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	Fac	  	[****]
	 90649
	  	00	 	 HUMAN PAPILLOMA
	  	 IMMUNIZATIONS
	  	Fac	  	[****]
	 90669
	  	00	 	 PNEUMOCOCCAL CON
	  	 IMMUNIZATIONS
	  	Fac	  	[****]
	 90680
	  	00	 	 ROTAVIRUS VACCIN
	  	 IMMUNIZATIONS
	  	Fac	  	[****]
	 00716
	  	00	 	 VARICELLA VIRUS
	  	 IMMUNIZATIONS
	  	Fac	  	[****]
	 92014
	  	00	 	 OPN MEDICAL XM&E
	  	 MEDICINE-OPHTHALMOLOGY
	  	Fac	  	[****]
	 93000
	  	00	 	 ECG-ROUTINE 12l
	  	 MEDICINE-OTHER
	  	Fac	  	[****]
	 93307
	  	00	 	 TTHRC R-T IMG 2D
	  	 MEDICINE-CARDIOVASCULAR
	  	Fac	  	[****]
	 93307
	  	26	 	 TTHRC R-T IMG 2D
	  	 MEDICINE-CARDIOVASCULAR
	  	Fac	  	[****]
	 93307
	  	TC	 	 TTHRC R-T IMG 2D
	  	 MEDICINE-CARDIOVASCULAR
	  	Fac	  	[****]
	 97110
	  	00	 	 THERAP TO AREAS
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	Fac	  	[****]
	 90910
	  	00	 	 CMT SPI 1-2 REGI
	  	 MEDICINE-CHIROPRACTIC MANIPULATIVE TREATMENT
	  	Fac	  	[****]
	 98941
	  	00	 	 CMT SPI 3-4 REGI
	  	 MEDICINE-CHIROPRACTIC MANIPULATIVE TREATMENT
	  	Fac	  	[****]
	 93202
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99203
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99204
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99206
	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99212
	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99213
	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99214
	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99215
	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99223
	  	00	 	 INIT HOSP-DAY E1
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99232
	  	00	 	 SUBSQT HSP-DAY E
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99233
	  	00	 	 SUBSQT HSP-DAY
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99243
	  	00	 	 OFFICE CNSLT NEW
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99244
	  	00	 	 OFC CNSLT NEW/ES
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99245
	  	00	 	 OFC CNSLT NEW/ES
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99283
	  	00	 	 EMERG DEPT VISIT
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99284
	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99285
	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	 99391
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	 99392
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	 99393
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	 99394
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	 99395
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	 99398
	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	 J1745
	  	00	 	 INJECTION INFLUX
	  	 INJECTABLE-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	Fac	  	[****]
	 J2505
	  	00	 	 INJECTION PEGFIL
	  	 INJECTABLE-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	Fac	  	[****]
	 J9035
	  	00	 	 INJECTION BEVACI
	  	 INJECTABLE-ONCOLOGY/THERAPEUTIC-CHEMO-DRUGS
	  	Fac	  	[****]
	 J0283
	  	00	 	 INJECTION OXALP
	  	 INJECTABLES-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	Fac	  	[****]
	 J9310
	  	00	 	 INJECTION, RITUX
	  	 INJECTABLES-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	Fac	  	[****]
	 j9355
	  	00	 	 INJECTION, TRAST
	  	 INJECTABLES-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	Fac	  	[****]

 Last Routine Maintenance Update:
10-01-2010 
 [****] 

[****] 
 [****] 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount
to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement.

 Note: Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 

Confidential and Proprietary    Not for Distribution to Third Parties 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Additional Information About Your Fee Schedule 

AUSTN 81350 
 The purpose of this document is to
provide additional information about this fee schedule, including clarity about the fee sources used to derive fees and the type of routine maintenance changes that you can expect. 
 Primary Fee Source 
 The primary fee source is the main fee source used as the basis for
deriving the fee within each category of codes. For instance, if the fee schedule for a given category of codes is derived by applying a particular conversion factor to the relative value units (RVUs) in the CMS fee schedule, those CMS relative
value units are the primary fee source. 
 Alternate (Gap-Fill) Fee Source 
 Alternate (or “gap fill”) fee sources are used to fill gaps in the primary fee sources. For example, if a new CPT code has been created within the category of codes discussed above, and CMS has
not yet established an RVU value for that code, we use one of the sources that exist within the industry to fill that gap, such as but not limited to Ingenix Essential RBRVS. For that CPT code, we adopt the RVU value established by the gap fill-fee
source, and determine the fee schedule amount for that CPT code by applying to the gap-fill RVU the same conversion factor that we apply to the CMS RVU for those CPT codes that have CMS RVUs. At such time in the future as CMS publishes its own RVU
value for that CPT code, we would begin using the primary fee source, CMS, to derive the fee for that code and no longer use the alternate source. 
 Percent of Charge Default 
 In the event that a fee is not sourced by either the primary or
alternate fee source, such as services submitted using unclassified or miscellaneous codes, the codes are subject to correct coding review and may be priced at the default Percent of Charge indicated in the attached document(s). 

Fee Source Links 
  

	 	•	 	 CMS Relative Values and Fee Schedules: www.ems,hhs.gov 

 

	 	•	 	 MICROMEDEX Red Book: www.micromedex.com 

  

	 	•	 	 RJ Health Systems: www.reimbursementcodes.com 

  

	 	•	 	 Ingenix Essential RBRVS: www.ingenixonline.com 

 

	 	•	 	 American Society of Anesthesiologists: www.asahq.org 

 Site of Service 
 This fee schedule generally follows CMS guidelines for determining when
services are priced at the Facility or Nonfacility fee schedule (with the exception of services performed at Ambulatory Surgery Centers, POS 24, which will be priced at the Facility fee schedule). CMS guidelines can be located at the website
indicated above. 
 Routine Maintenance 
 United routinely updates its fee schedule in an effort to stay abreast of current coding practices widely used in the health care industry; in response to price changes for immunizations and injectable
medications; and to remain in compliance with the intent of the contractual agreement. Routine maintenance occurs when United mechanically incorporates revised information created by a third party that is the source for a portion of the fee
schedule. United will not generally attempt to communicate routine maintenance of this nature and will generally implement updates to be effective within 90 days from the date of final publication from one of our primary or alternate fee sources.
Providers may expect the following types of fee updates to their fee schedules: 

	 	a.	Annual Changes to Relative Value Units, Conversion Factors, or Flat Rate Fees 

 This fee schedule follows a “Stated Year” construction methodology. It is generally intended to lock in to the 2008 RVU, the January 2008 Conversion Factor, and the 2008 Flat Rate Fees (non-RVU
based fees such as Durable Medical Equipment fees) as the basis for deriving fees. Generally, any RVU, Conversion Factor, or Flat Rate Fee changes published in subsequent years by the primary and/or alternate fee sources will not be reflected in
this fee schedule. 
  

	 	b.	Price Changes for Immunizations and Injectable Medications 

 United routinely updates its fee schedule in response to price changes for immunizations and injectable medications published by the primary and/or alternate fee sources. United currently utilizes CMS
Drug Pricing and Thomson Micromedex Red Book AWP as its primary fee sources. The effective date of fee updates under this subsection b will be no later than the first day of the next calendar quarter after final publication by the fee source, except
that if that quarter begins less than 60 days after final publication, the effective date will be no later than the first day of the next calendar quarter. For example, if final publication by the fee source is on April 10, the fee update under
this subsection b will be effective no later than July 1, and if final publication by the fee source is on June 10, the fee update under this subsection c will be effective no later than October 1. For purposes of this paragraph, the
date of a claim is the date of service. 
  

	 	c.	CPT/HCPCS Changes and Other Ongoing Updates 

 United routinely updates its fee schedule in response to additions, deletions, and changes to CPT codes by the American Medical Association; HCPCS codes by the Centers for Medicaid and Medicare Services;
CMS changes to its annual update; and in response to similar changes (additions and revisions) to other service coding and reporting conventions that are widely used in the health care industry. Ordinarily, United’s fee schedule is updated
using the original construction methodology along with the then-current RVU of the published CPT code. The effective date of fee updates under this subsection c will be no later than the first day of the next calendar quarter after final publication
by the fee source, except that if that quarter begins less than 60 days after final publication, the effective date will be no later than the first day of the next calendar quarter. For example, if final publication by the fee source is on
April 10, the fee update under this subsection c will be effective no later than July 1, and if final publication by the fee source is on June 10, the fee update under this subsection c will be effective no later than October 1.
For purposes of this paragraph, the date of a claim is the date of service. 
 United is committed to providing transparency related to our fee
schedules. If you have questions about this fee schedule, please contact Network Management at the address and phone number on your network participation agreement or you may use our fee schedule look-up function on the web at
www.unitedhealthcareonline.com or contact our Voice Enabled Telephonic Self Service line at (877) 842-3210. 

 Market Standard Specifications 

Austin Market(s) 
 Specifications as of: 10/15/2010 
 Report Date: 09/03/2010*

 AUSTN 81349 
  

													
	 Market
	  	Mkt
Std
ID	  	CMS
carrier
locality	 	  	Site of
Service	 	  	Linked
Schedule
ID
					
	 Austin
	  	AUSTN 81349	  	 	0000000	  	  	 	NonFac	  	  	AUSTN 81350

  

									
	 Type Of Service
	  	 Primary Fee Source
	  	Pricing Level
	 EVALUATION & MANAGEMENT
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 EVALUATION & MANAGEMENT - NEONATAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 EVALUATION & MANAGEMENT - NURSING FACILITY SVCS
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - INTEGUMENTARY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MUSCULOSKELETAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - RESPIRATORY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - CARDIOVASCULAR
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - HEMIC & LYMPHATIC
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MEDIASTINUM & DIAPHRAGM
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - DIGESTIVE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - URINARY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MALE GENITAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - FEMALE GENITAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MATERNITY & DELIVERY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - ENDOCRINE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - NERVOUS
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - EYE & OCULAR ADNEXA
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - AUDITORY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - BONE DENSITY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - CT
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - MAMMOGRAPHY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - MRI
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - MRA
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - NUCLEAR MEDICINE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - PET SCANS
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - RADIATION THERAPY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - ULTRASOUND
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 LAB - PATHOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 OFFICE LAB
	  	 2008 CMS Clinical Lab Schedule - National Limit
	  	[****]
	 CLINICAL LABORATORY
	  	 2008 CMS Clinical Lab Schedule - National Limit
	  	[****]
	 MEDICINE - OPHTHALMOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - CARDIOVASCULAR
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - ALLERGY & CLINICAL IMMUNOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - CHIROPRACTIC MANIPULATIVE TREATMENT
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - MODALITIES
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB -THERAPIES & OTHER
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - OTHER
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - CHEMO ADMIN
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 OBSTETRICS - GLOBAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 IMMUNIZATIONS
	  	 Redbook J Code-CPT Code AWP
	  	[****]
	 INJECTABLES/OTHER DRUGS
	  	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - ONCOLOGY/ THERAPEUTIC CHEMO DRUGS
	  	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - IVIG
	  	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - SALINE & DEXTROSE SOLUTIONS
	  	 CMS Drug Pricing
	  	[****]
	 DME & SUPPLIES
	  	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - RESPIRATORY
	  	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - ORTHOTICS
	  	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - PROSTHETICS
	  	 2008 CMS DME Floor
	  	[****]
	 AMBULANCE
	  	 2008 CMS Ambulance Schedule - Urban (0000000)
	  	[****]

 Hard Codes 

[****] 
 [****] 

[****] 
 [****] 

[****] 
 [****] 

Schedule Type: FFS 
 Unless specifically
indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the
customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such
as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement. 
 Note:
Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 
 Confidential and
Proprietary    Not for Distribution to Third Parties 
  

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Representative Fee Schedule Sample for: AUSTN 81349 

Fee amounts as of: 10/15/2010 
 Report Date: 09/03/2010* 
 Site of Service - Linked Schedule ID: AUSTN
81350 
  

											
	 CPT
	  	Mod	 	 CPT Description
	  	 Type of Service
	  	Place of Service	  	Fee
						
	45378	  	00	 	 COLONOSCOPY FLEX
	  	 SURGERY - DIGESTIVE
	  	NonFac	  	[****]
	45350	  	00	 	 COLONOSCOPY FLEX
	  	 SURGERY - DIGESTIVE
	  	NonFac	  	[****]
	59400	  	00	 	 ROUTINE OB CARE
	  	 OBSTETRICS - GLOBAL
	  	NonFac	  	[****]
	58510	  	00	 	 ROUTINE OB CARE
	  	 OBSTETRICS - GLOBAL
	  	NonFac	  	[****]
	77418	  	00	 	 INTENS MOD TX DE
	  	 RADIOLOGY - RADIATION THERAPY
	  	NonFac	  	[****]
	88308	  	00	 	 LEVEL IV - SURG
	  	 LAB-PATHOLOGY
	  	NonFac	  	[****]
	88305	  	26	 	 LEVEL IV - SURG
	  	 LAB-PATHOLOGY
	  	NonFac	  	[****]
	88306	  	TC	 	 LEVEL IV - SURG
	  	 LAB-PATHOLOGY
	  	NonFac	  	[****]
	90471	  	00	 	 IMMUNIZATION ADM
	  	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	NonFac	  	[****]
	90649	  	00	 	 HUMAN PAPILLOMA
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	90669	  	00	 	 PNEUMOCOCCAL CON
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	90680	  	00	 	 ROTAVIRUS VACCIN
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	00716	  	00	 	 VARICELLA VIRUS
	  	 IMMUNIZATIONS
	  	NonFac	  	[****]
	92014	  	00	 	 OPN MEDICAL XM&E
	  	 MEDICINE-OPHTHALMOLOGY
	  	NonFac	  	[****]
	93000	  	00	 	 ECG-ROUTINE 12l
	  	 MEDICINE-OTHER
	  	NonFac	  	[****]
	93307	  	00	 	 TTHRC R-T IMG 2D
	  	 MEDICINE-CARDIOVASCULAR
	  	NonFac	  	[****]
	93307	  	26	 	 TTHRC R-T IMG 2D
	  	 MEDICINE-CARDIOVASCULAR
	  	NonFac	  	[****]
	93307	  	TC	 	 TTHRC R-T IMG 2D
	  	 MEDICINE-CARDIOVASCULAR
	  	NonFac	  	[****]
	97110	  	00	 	 THERAP TO AREAS
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	NonFac	  	[****]
	90910	  	00	 	 CMT SPI 1-2 REGI
	  	 MEDICINE-CHIROPRACTIC MANIPULATIVE TREATMENT
	  	NonFac	  	[****]
	98941	  	00	 	 CMT SPI 3-4 REGI
	  	 MEDICINE-CHIROPRACTIC MANIPULATIVE TREATMENT
	  	NonFac	  	[****]
	93202	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99203	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99204	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99206	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99212	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99213	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99214	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99215	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99223	  	00	 	 INIT HOSP-DAY E1
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99232	  	00	 	 SUBSQT HSP-DAY E
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99233	  	00	 	 SUBSQT HSP-DAY
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99243	  	00	 	 OFFICE CNSLT NEW
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99244	  	00	 	 OFC CNSLT NEW/ES
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99245	  	00	 	 OFC CNSLT NEW/ES
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99283	  	00	 	 EMERG DEPT VISIT
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99284	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99285	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION& MANAGEMENT
	  	NonFac	  	[****]
	99391	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99392	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99393	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99394	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99395	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	99398	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	NonFac	  	[****]
	J1745	  	00	 	 INJECTION INFLUX
	  	 INJECTABLE-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	NonFac	  	[****]
	J2505	  	00	 	 INJECTION PEGFIL
	  	 INJECTABLE-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	NonFac	  	[****]
	J9035	  	00	 	 INJECTION BEVACI
	  	 INJECTABLE-ONCOLOGY/THERAPEUTIC-CHEMO-DRUGS
	  	NonFac	  	[****]
	J0283	  	00	 	 INJECTION OXALP
	  	 INJECTABLES-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	NonFac	  	[****]
	J9310	  	00	 	 INJECTION, RITUX
	  	 INJECTABLES-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	NonFac	  	[****]
	j9355	  	00	 	 INJECTION, TRAST
	  	 INJECTABLES-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	NonFac	  	[****]

 Last Routine Maintenance Update:
10-01-2010 
 [****] 

[****] 
 [****] 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount
to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement.

 Note: Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 

Confidential and Proprietary    Not for Distribution to Third Parties 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Market Standard Specifications 

Austin Market(s) 
 Specifications as of: 10/15/2010 
 Report Date: 09/03/2010*

 AUSTN 81350 
  

													
	 Market
	  	 Mkt

Std

ID
	  	CMS
carrier
locality	 	  	Site of
Service	 	  	 Linked

Schedule

ID

					
	 Austin
	  	AUSTN 81350	  	 	0000000	  	  	 	NonFac	  	  	AUSTN 81349

  

									
	 Type Of Service
	  	 Primary Fee Source
	  	Pricing Level
	 EVALUATION & MANAGEMENT
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 EVALUATION & MANAGEMENT - NEONATAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 EVALUATION & MANAGEMENT - PREVENTIVE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 EVALUATION & MANAGEMENT - NURSING FACILITY SVCS
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - INTEGUMENTARY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MUSCULOSKELETAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - RESPIRATORY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - CARDIOVASCULAR
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - HEMIC & LYMPHATIC
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MEDIASTINUM & DIAPHRAGM
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - DIGESTIVE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - URINARY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MALE GENITAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - FEMALE GENITAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - MATERNITY & DELIVERY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - ENDOCRINE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - NERVOUS
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - EYE & OCULAR ADNEXA
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 SURGERY - AUDITORY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - BONE DENSITY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - CT
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - MAMMOGRAPHY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - MRI
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - MRA
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - NUCLEAR MEDICINE
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - PET SCANS
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - RADIATION THERAPY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 RADIOLOGY - ULTRASOUND
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 LAB - PATHOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 OFFICE LAB
	  	 2008 CMS Clinical Lab Schedule - National Limit
	  	[****]
	 CLINICAL LABORATORY
	  	 2008 CMS Clinical Lab Schedule - National Limit
	  	[****]
	 MEDICINE - OPHTHALMOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - CARDIOVASCULAR
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - ALLERGY & CLINICAL IMMUNOLOGY
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - CHIROPRACTIC MANIPULATIVE TREATMENT
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB - MODALITIES
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - PHYSICAL MED AND REHAB -THERAPIES & OTHER
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - OTHER
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 MEDICINE - CHEMO ADMIN
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 OBSTETRICS - GLOBAL
	  	 2008 CMS RBRVS (0000000)
	  	[****]
	 IMMUNIZATIONS
	  	 Redbook J Code-CPT Code AWP
	  	[****]
	 INJECTABLES/OTHER DRUGS
	  	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - ONCOLOGY/ THERAPEUTIC CHEMO DRUGS
	  	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - IVIG
	  	 CMS Drug Pricing
	  	[****]
	 INJECTABLES - SALINE & DEXTROSE SOLUTIONS
	  	 CMS Drug Pricing
	  	[****]
	 DME & SUPPLIES
	  	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - RESPIRATORY
	  	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - ORTHOTICS
	  	 2008 CMS DME Floor
	  	[****]
	 DME & SUPPLIES - PROSTHETICS
	  	 2008 CMS DME Floor
	  	[****]
	 AMBULANCE
	  	 2008 CMS Ambulance Schedule - Urban (0000000)
	  	[****]

 Hard Codes 

[****] 
 [****] 

[****] 
 [****] 

[****] 
 Schedule Type: FFS 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount
to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement.

 Note: Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 

Confidential and Proprietary    Not for Distribution to Third Parties 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Representative Fee Schedule Sample for: AUSTN 81350 

Fee amounts as of: 10/15/2010 
 Report Date: 09/03/2010* 
 Site of Service - Linked Schedule ID: AUSTN
81349 
  

											
	 CPT
	  	Mod	 	 CPT Description
	  	 Type of Service
	  	Place of Service	  	Fee
						
	45378	  	00	 	 COLONOSCOPY FLEX
	  	 SURGERY - DIGESTIVE
	  	Fac	  	[****]
	45350	  	00	 	 COLONOSCOPY FLEX
	  	 SURGERY - DIGESTIVE
	  	Fac	  	[****]
	59400	  	00	 	 ROUTINE OB CARE
	  	 OBSTETRICS - GLOBAL
	  	Fac	  	[****]
	58510	  	00	 	 ROUTINE OB CARE
	  	 OBSTETRICS - GLOBAL
	  	Fac	  	[****]
	77418	  	00	 	 INTENS MOD TX DE
	  	 RADIOLOGY - RADIATION THERAPY
	  	Fac	  	[****]
	88308	  	00	 	 LEVEL IV - SURG
	  	 LAB-PATHOLOGY
	  	Fac	  	[****]
	88305	  	26	 	 LEVEL IV - SURG
	  	 LAB-PATHOLOGY
	  	Fac	  	[****]
	88306	  	TC	 	 LEVEL IV - SURG
	  	 LAB-PATHOLOGY
	  	Fac	  	[****]
	90471	  	00	 	 IMMUNIZATION ADM
	  	 MEDICINE - IMMUNIZATION ADMINISTRATION
	  	Fac	  	[****]
	90649	  	00	 	 HUMAN PAPILLOMA
	  	 IMMUNIZATIONS
	  	Fac	  	[****]
	90669	  	00	 	 PNEUMOCOCCAL CON
	  	 IMMUNIZATIONS
	  	Fac	  	[****]
	90680	  	00	 	 ROTAVIRUS VACCIN
	  	 IMMUNIZATIONS
	  	Fac	  	[****]
	00716	  	00	 	 VARICELLA VIRUS
	  	 IMMUNIZATIONS
	  	Fac	  	[****]
	92014	  	00	 	 OPN MEDICAL XM&E
	  	 MEDICINE-OPHTHALMOLOGY
	  	Fac	  	[****]
	93000	  	00	 	 ECG-ROUTINE 12l
	  	 MEDICINE-OTHER
	  	Fac	  	[****]
	93307	  	00	 	 TTHRC R-T IMG 2D
	  	 MEDICINE-CARDIOVASCULAR
	  	Fac	  	[****]
	93307	  	26	 	 TTHRC R-T IMG 2D
	  	 MEDICINE-CARDIOVASCULAR
	  	Fac	  	[****]
	93307	  	TC	 	 TTHRC R-T IMG 2D
	  	 MEDICINE-CARDIOVASCULAR
	  	Fac	  	[****]
	97110	  	00	 	 THERAP TO AREAS
	  	 MEDICINE-PHYSICAL MED AND REHAB-THERAPIES&OTHER
	  	Fac	  	[****]
	90910	  	00	 	 CMT SPI 1-2 REGI
	  	 MEDICINE-CHIROPRACTIC MANIPULATIVE TREATMENT
	  	Fac	  	[****]
	98941	  	00	 	 CMT SPI 3-4 REGI
	  	 MEDICINE-CHIROPRACTIC MANIPULATIVE TREATMENT
	  	Fac	  	[****]
	93202	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99203	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99204	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99206	  	00	 	 OFFICE OUTPT NEW
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99212	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99213	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99214	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99215	  	00	 	 OFFICE OUTPT E&MES
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99223	  	00	 	 INIT HOSP-DAY E1
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99232	  	00	 	 SUBSQT HSP-DAY E
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99233	  	00	 	 SUBSQT HSP-DAY
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99243	  	00	 	 OFFICE CNSLT NEW
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99244	  	00	 	 OFC CNSLT NEW/ES
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99245	  	00	 	 OFC CNSLT NEW/ES
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99283	  	00	 	 EMERG DEPT VISIT
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99284	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99285	  	00	 	 ER VISIT E&M HIG
	  	 EVALUATION& MANAGEMENT
	  	Fac	  	[****]
	99391	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	99392	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	99393	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	99394	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	99395	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	99398	  	00	 	 PERIODIC PREVENT
	  	 EVALUATION& MANAGEMENT - PREVENTIVE
	  	Fac	  	[****]
	J1745	  	00	 	 INJECTION INFLUX
	  	 INJECTABLE-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	Fac	  	[****]
	J2505	  	00	 	 INJECTION PEGFIL
	  	 INJECTABLE-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	Fac	  	[****]
	J9035	  	00	 	 INJECTION BEVACI
	  	 INJECTABLE-ONCOLOGY/THERAPEUTIC-CHEMO-DRUGS
	  	Fac	  	[****]
	J0283	  	00	 	 INJECTION OXALP
	  	 INJECTABLES-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	Fac	  	[****]
	J9310	  	00	 	 INJECTION, RITUX
	  	 INJECTABLES-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	Fac	  	[****]
	j9355	  	00	 	 INJECTION, TRAST
	  	 INJECTABLES-ONCOLOGY/THERAPEUTIC CHEMO DRUGS
	  	Fac	  	[****]

 Last Routine Maintenance Update:
10-01-2010 
 [****] 

[****] 
 [****] 

Unless specifically indicated otherwise, amounts listed in the fee schedule represent global fees and may be subject to reductions based on appropriate
modifier (for example, professional and technical modifiers). Any co-payment, deductible or coinsurance that the customer is responsible to pay under the customers benefit contract will be subtracted from the listed amount in determining the amount
to be paid by the payer. The actual payment amount is also subject to matters described in this agreement, such as the payment policies. Please remember that this information is subject to the confidentiality provisions of this agreement.

 Note: Maintenance to this fee schedule occurs routinely and may still occur after the report date for the fee amounts selected. 

Confidential and Proprietary    Not for Distribution to Third Parties 

 

	[****]	Certain information on this page has been omitted and filed separately with the Commission. Confidential treatment has been requested with respect to the omitted
portions. 

 Additional Information About Your Fee Schedule 

AUSTN 81350 
 The purpose of this document is to
provide additional information about this fee schedule, including clarity about the fee sources used to derive fees and the type of routine maintenance changes that you can expect. 
 Primary Fee Source 
 The primary fee source is the main fee source used as the basis for
deriving the fee within each category of codes. For instance, if the fee schedule for a given category of codes is derived by applying a particular conversion factor to the relative value units (RVUs) in the CMS fee schedule, those CMS relative
value units are the primary fee source. 
 Alternate (Gap-Fill) Fee Source 
 Alternate (or “gap fill”) fee sources are used to fill gaps in the primary fee sources. For example, if a new CPT code has been created within the category of codes discussed above, and CMS has
not yet established an RVU value for that code, we use one of the sources that exist within the industry to fill that gap, such as but not limited to Ingenix Essential RBRVS. For that CPT code, we adopt the RVU value established by the gap fill-fee
source, and determine the fee schedule amount for that CPT code by applying to the gap-fill RVU the same conversion factor that we apply to the CMS RVU for those CPT codes that have CMS RVUs. At such time in the future as CMS publishes its own RVU
value for that CPT code, we would begin using the primary fee source, CMS, to derive the fee for that code and no longer use the alternate source. 
 Percent of Charge Default 
 In the event that a fee is not sourced by either the primary or
alternate fee source, such as services submitted using unclassified or miscellaneous codes, the codes are subject to correct coding review and may be priced at the default Percent of Charge indicated in the attached document(s). 

Fee Source Links 
  

	 	•	 	 CMS Relative Values and Fee Schedules: www.ems,hhs.gov 

 

	 	•	 	 MICROMEDEX Red Book: www.micromedex.com 

  

	 	•	 	 RJ Health Systems: www.reimbursementcodes.com 

  

	 	•	 	 Ingenix Essential RBRVS: www.ingenixonline.com 

 

	 	•	 	 American Society of Anesthesiologists: www.asahq.org 

 Site of Service 
 This fee schedule generally follows CMS guidelines for determining when
services are priced at the Facility or Nonfacility fee schedule (with the exception of services performed at Ambulatory Surgery Centers, POS 24, which will be priced at the Facility fee schedule). CMS guidelines can be located at the website
indicated above. 
 Routine Maintenance 
 United routinely updates its fee schedule in an effort to stay abreast of current coding practices widely used in the health care industry; in response to price changes for immunizations and injectable
medications; and to remain in compliance with the intent of the contractual agreement. Routine maintenance occurs when United mechanically incorporates revised information created by a third party that is the source for a portion of the fee
schedule. United will not generally attempt to communicate routine maintenance of this nature and will generally implement updates to be effective within 90 days from the date of final publication from one of our primary or alternate fee sources.
Providers may expect the following types of fee updates to their fee schedules: 

	 	a.	Annual Changes to Relative Value Units, Conversion Factors, or Flat Rate Fees 

 This fee schedule follows a “Stated Year” construction methodology. It is generally intended to lock in to the 2008 RVU, the January 2008 Conversion Factor, and the 2008 Flat Rate Fees (non-RVU
based fees such as Durable Medical Equipment fees) as the basis for deriving fees. Generally, any RVU, Conversion Factor, or Flat Rate Fee changes published in subsequent years by the primary and/or alternate fee sources will not be reflected in
this fee schedule. 
  

	 	b.	Price Changes for Immunizations and Injectable Medications 

 United routinely updates its fee schedule in response to price changes for immunizations and injectable medications published by the primary and/or alternate fee sources. United currently utilizes CMS
Drug Pricing and Thomson Micromedex Red Book AWP as its primary fee sources. The effective date of fee updates under this subsection b will be no later than the first day of the next calendar quarter after final publication by the fee source, except
that if that quarter begins less than 60 days after final publication, the effective date will be no later than the first day of the next calendar quarter. For example, if final publication by the fee source is on April 10, the fee update under
this subsection b will be effective no later than July 1, and if final publication by the fee source is on June 10, the fee update under this subsection c will be effective no later than October 1. For purposes of this paragraph, the
date of a claim is the date of service. 
  

	 	c.	CPT/HCPCS Changes and Other Ongoing Updates 

 United routinely updates its fee schedule in response to additions, deletions, and changes to CPT codes by the American Medical Association; HCPCS codes by the Centers for Medicaid and Medicare Services;
CMS changes to its annual update; and in response to similar changes (additions and revisions) to other service coding and reporting conventions that are widely used in the health care industry. Ordinarily, United’s fee schedule is updated
using the original construction methodology along with the then-current RVU of the published CPT code. The effective date of fee updates under this subsection c will be no later than the first day of the next calendar quarter after final publication
by the fee source, except that if that quarter begins less than 60 days after final publication, the effective date will be no later than the first day of the next calendar quarter. For example, if final publication by the fee source is on
April 10, the fee update under this subsection c will be effective no later than July 1, and if final publication by the fee source is on June 10, the fee update under this subsection c will be effective no later than October 1.
For purposes of this paragraph, the date of a claim is the date of service. 
 United is committed to providing transparency related to our fee
schedules. If you have questions about this fee schedule, please contact Network Management at the address and phone number on your network participation agreement or you may use our fee schedule look-up function on the web at
www.unitedhealthcareonline.com or contact our Voice Enabled Telephonic Self Service line at (877) 842-3210. 

 Texas Regulatory Requirements Appendix 

This Texas Regulatory Requirements Appendix (the “Appendix”) is made part of the Agreement entered into by and among United HealthCare
Insurance Company, contracting on behalf of itself, United HealthCare of Texas, Inc., PacifiCare of Texas, Inc., Evercare of Texas, LLC, and the other entities that are United’s Affiliates (collectively referred to as “United”)
and the health care professional or entity named in the Agreement (“Provider”). 
 This Appendix applies to all products or benefit
plans sponsored, issued or administered by or accessed through United, to the extent such products are regulated under Texas laws applicable to HMOs, managed care, insurance and/or preferred provider organizations; provided, however, that the
requirements in this Appendix will not apply to the extent they are preempted by the Medicare Modernization Act or other applicable law. 

United and Provider each agree to be bound by the terms and conditions contained in this Appendix. In the event of a conflict or inconsistency between
this Appendix and any term or condition contained in the Agreement, this Appendix shall control, except with regard to Benefit Plans outside the scope of this Appendix. 
 This Appendix will be deemed to be updated to incorporate any changes to the laws and regulations referenced herein, including any changes to definitions referenced herein, effective as of the date of
such changes. 
 Unless otherwise defined in this Appendix, all capitalized terms contained in the Appendix shall be defined as set forth in the
Agreement. 
 Provisions applicable to fully insured Benefit Plans regulated under Texas HMO law: 

1. Payment. Any financial incentive used or payment made directly or indirectly to Provider under any provision of this Agreement is not made as an
inducement to reduce or limit the medically necessary services to any Customer. 
 2. Prompt Payment of Clean Claims. United or Payer, as
applicable, will make payment to Provider pursuant to the provisions of the Texas law. For instance, unless a longer time is permitted under applicable Texas law, not later than 30 days from the date United receive an electronic clean claim and not
later than 45 days from the date United receives a non-electronic clean claim, United or Payer will either: pay the total amount of the claim in accordance with this Agreement; pay the portion of the claim that is not in dispute and notify Provider
in writing why the remaining portion of the claim is not being paid; pay the total amount of the claim in accordance with this Agreement but notify Provider that the claim is subject to audit; request additional information from Provider within 30
days of receipt of a clean claim, and then pay or deny the claim within the time required by law after United receives that information or Provider fails to timely provide it; or notify Provider in writing why United or Payer will not pay the claim.

 If Provider submits claims that are not clean: 
  

	 	•	 	 We will notify Provider within 30 days of receiving an electronic claim or within 45 days of receiving a non-electronic claim that it is not a clean
claim; 

  

	 	•	 	 You may be asked for additional information so that Provider’s claim may be adjudicated; or 

 

	 	•	 	 Provider’s claim may be denied and Provider will be notified of the denial and the reason for it; or 

 

	 	•	 	 United may in its discretion pay or have the claim paid by the other applicable Payer based on the information that you gave in addition to the
information United has. 

 A claim is complete or “clean” if it supplies all the information required by statute.
The Administrative Guide contains additional important information about clean claims, an address to submit claims, a phone number and internet address where Provider can contact United with questions regarding claims Provider has submitted,

 
information regarding any entity to whom United may have delegated claim payment functions, and the address and telephone number of any separate claims processing centers for specific types of
claims or services. 
 United or Payer may not refuse to process or pay an electronically submitted clean claim, because the claim is submitted
together with or in a batch submission with a claim that is not a clean claim. 
 3. Timely Filing of Claims. Provider must submit its
claims within 95 days of the date of service. For a claim submitted by an institutional provider; the 95-day period does not begin until the date of discharge. For a claim for which coordination of benefits applies, the 95-day period does not begin
for submission of the claim to the secondary payer until Provider receives notice of the payment or denial from the primary payer. If Provider’s claim is not submitted within this time frame, Provider will not be reimbursed for the services and
Provider may not charge its patient for therm. If Provider’s failure to timely submit the claim is the result of an information systems failure or a catastrophic event that substantially interferes with Provider’s normal business
operations for more than two consecutive business days and about which Provider notifies the Texas Department of Insurance as required by 28 Tex. Admin. Code §21.2819, United will extend the 95 day filing deadline by the number of days in which
Provider’s business was unable to operate. In the event that Provider seeks and receives a waiver from United’s electronic filing requirements under 28 Tex. Admin. Code § 21.3701, Provider may submit non-electronic claims to the
address shown in the Administrative Guide. 
 4. Duplicate Claims. Provider may not submit duplicate claims for claims, (defined as a
claim for payment made for the same patient on the same data of service for the same services) that are not clean for: 1) 45 days after Provider files those claims non-electronically, and 2) 30 days after Provider files those claims electronically.

 5. Penalties. If governing law requires United or Payer to pay interest, billed charges, fees, costs or another penalty for a failure
to pay Provider’s clean claim for covered services within a certain time frame, United will follow those requirements. The interest, billed charges, fees, costs or other penalty required by law will be the only additional obligation for not
satisfying in a timely manner a payment obligation to Provider. In addition, if United adjudicated a claim of Provider’s that was not clean, there ,shall be no interest or other late payment obligation to Provider even if United subsequently
adjusts the payment amount based on additional information that Provider provides or that United obtains. In accordance with Tex. Ins. Code § 843.342, United or Payer is not liable for a penalty for failure to pay a clean claim. (1) if the
failure to pay the claim is a result of a catastrophic event that substantially interferes with the normal business operations of United or Payer; or (2) if the claim was paid in accordance with applicable law, but for less than the contracted
rate, and: (A) Provider notifies the United of the underpayment after the 270th day after the date the underpayment was received; and (B) United or Payer pays the balance of the claim on or before the 30th day after the date United
receives the notice. 
 6. Corrective Adjustments for Overpayments. 

(a) In accordance with TAC § 21.2818, United or Payer may recover a refund from Provider due to overpayment or completion of an
audit, by adjusting future claim payments and/or by billing Provider for the amount of the overpayment, if (i) United notifies Provider of the overpayment not later than the 180th day after the date of receipt of the overpayment; or
(ii) United notifies Provider of the completion of an audit under TAC § 21.2809. Notification under subsection (i) of this section shall be in writing and shall include: (A) the specific claims and amounts for which a refund is
due and for each claim the basis and specific reasons for the request for refund; (B) notice of Provider’s right to appeal; and (C) the methods by which United intends to recover the refund. 

(b) If Provider disagrees with a request for recovery of an overpayment, United shall provide Provider with an opportunity to appeal, in
accordance with Tex. Ins. Code § 843.350 and 28 TAC § 21.28 18, and United or Payer may not recover the overpayment until all appeal rights are exhausted. 
 (c) United or Payer may recover overpayments beyond the 180-day time frame mentioned above if the overpayment occurred as a result of fraudulent billing practices or a material misrepresentation by
Provider. 

 7. Information About and Limits on Using Fee Schedule and Reimbursement Methodology. Fee schedule or
coding guideline changes which are intended to substantially alter the overall methodology or reimbursement level of the fee schedule or which result in a material change in payment to Provider for the same CPT Code, ICD diagnostic code or
hospital-based revenue code will be treated as an amendment to the Agreement, and United will give Provider 90 days written notice of the changes. United will not make retroactive revisions to the coding guidelines and fee schedules. To request a
written copy of United’s reimbursement policies and methodologies that apply to specific procedures or services for which Provider will seek reimbursement under this Agreement, or any other information Provider needs to determine that Provider
is being paid according to this Agreement, Provider should send a written request to Network Management, 1250 Capital of Texas Highway, South Building One, Suite 400 Austin, TX 78746. United will respond to Provider’s request within 30 days of
receiving it. United will, at request of Provider, provide the name, edition, and model version of the software that the United uses to determine bundling and unbundling of claims. If United discloses fee schedule or reimbursement methodology to
Provider, Provider may not use or disclose it for any purposes other than management of Provider’s practice, billing activities, for Provider’s business operations or in communications with a governmental agency involved in the regulation
of health care or insurance. 
 8. Customer Hold Harmless. As further described in this section, Provider shall hold a Customer harmless
for payment of the cost of covered health services in the event that Payer or United fails to pay the Provider for such services. Provider hereby agrees that in no event, including, but not limited to non¬payment by Payer or United, or United
insolvency, or breach of this Agreement, shall Provider bill, charge, collect a deposit from, seek compensation, remuneration, or reimbursement from, or have any recourse against Customer or persons other than United acting on Customer’s behalf
for services provided pursuant to this Agreement. This provision shall not prohibit collection of copayments, deductibles or coinsurance for which Customer is responsible in accordance with the terms of the Benefit Plan. Provider further agrees
that: (a) this provision shall survive the termination of this Agreement regardless of the cause giving rise to termination and shall be construed to be for the benefit of the Customer, and that (b) this provision supersedes any oral or
written contrary agreement now existing or hereafter entered into between Provider and Customer or person acting on Customer’s behalf- No amendment or modification of this provision shall be effective earlier than fifteen (15) days
following the Commissioner of the Texas Department of Insurance’s receipt of written notice of such proposed change. 
 9. Provisions
Related to Termination. 
 (a) Notice of Termination to Provider. United shall provide written notification of
termination of this Agreement to Provider at least ninety (90) days prior to the effective date of termination, except if termination is related to (i) imminent harm to Customer health, (ii) action against Provider’s license to
practice or (iii) fraud or malfeasance, in which cases termination may be immediate. 
 (b) Advisory Review Panel Review
of Proposed Termination. Prior to termination of this Agreement. United shall give Provider a written explanation of the reasons for termination. Not later than 30 days following receipt of the written notice of termination Provider may request
and shall receive a review of the proposed termination by an advisory review panel selected in accordance with the provisions of Tex. Ins. Code chpt. 843.306. Such review shall be conducted within sixty (60) days of Provider’s request or,
if requested by Provider, the review process shall be expedited. The decision of the advisory panel must be considered but is not binding on United. United shall provide Provider, upon request, a copy of the recommendation of the advisory review
panel and United’s determination. Notwithstanding the above provision, Provider is not entitled to and no review shall be provided in a case in which there is (a) imminent harm to Customer health, (b) an action by a state medical
board, licensing board or other government agency that effectively impairs the Provider’s ability to practice or (c) a case of fraud or malfeasance. 
 (c) Notice to Customers of Provider Deselection and Termination. United must provide reasonable advance notification of an impending termination of Provider to Customers receiving care from
Provider. Notice given at least thirty (30) days before the effective date of the termination shall be deemed reasonable; provided, however, that if Provider is deselected or terminated for reasons related to imminent harm to Customers,
notification of the deselection or termination may be given to Customers immediately. If Provider is entitled to a review by United of its decision to deselect or terminate Provider pursuant to

 
Texas Insurance Code chpts. 843.306 and/or 843.307, United will not notify Customers of Provider’s impending deselection or termination until its effective date or until the time the review
panel makes its formal recommendation. 
 (d) Continuation of Care for Customer Special Circumstance. Unless termination
of this Agreement is based upon reasons of medical competence or professional behavior, United or Payer shall have a continuing obligation to reimburse Provider if Provider is treating a Customer with special circumstance at no less than the rate
provided in this Agreement. For purposes of this section, “special circumstance” means a condition with regard to which Provider reasonably believes that discontinuing care by Provider and transferring the Customer’s. care to another
provider could cause harm to the Customer, such as a disability, acute condition, life threatening illness, or pregnancy of more than twenty-four (24) weeks. Provider must identify the special circumstance and request that the Customer be
permitted to continue treatment under the Provider’s care. Provider must also agree not to seek payment from the Customer of any amounts for which the Customer would not be responsible if this Agreement were still in effect. Any dispute
regarding the necessity for continued treatment by Provider shall be resolved pursuant to United’s dispute resolution procedures contained in the appeal procedure for medical necessity determinations as described in the provider manual or
administrative manual. The obligation of United or Payer to reimburse a terminated Provider for ongoing treatment of a Customer with special circumstance continues through: (a) the ninetieth (90°) day after the effective date of the
termination; (b) nine (9) months following the effective date of the termination for a Customer who at the time of the termination has been diagnosed with a terminal illness; or (c) delivery of the child, immediate postpartum care,
including a follow-up checkup within the first six (6) weeks of delivery, for a Customer who is past the twenty-fourth (24th) week of pregnancy at the effective date of the termination. 

(e) Voluntary Termination by Provider. Provider may also terminate this Agreement upon 30 days’ written notice if Provider
provides United with such written notice within 30 days of receiving the information requested under Tex. Ins. Code chpt. 843.321, as described in section 7 above. Provider agrees to cooperate with United to give Customers the notice described in
(c) above. 
 10. Posting of Complaint Procedure and Handling of Customer Complaints. Provider shall post in Provider’s office
a notice to Customers on the process for resolving complaints with United or Payer. Such notice shall include the Texas Department of Insurance’s toll-free telephone number for filing complaints. United also provides a mechanism for the
resolution of any complaints initiated by Customers which provides for reasonable due process, including, in an advisory role only, a review panel selected in compliance with the provisions of Tex. Ins. Code chpt 843.255, as applicable. 

11. No Retaliatory Action. United shall not engage in any retaliatory action, including termination of or refusal to renew this Agreement, against
Provider because Provider has, on behalf of a Customer, reasonably tiled a complaint against United or has appealed a decision of United. 

12. Capitation Payments. If reimbursement to Provider contains capitation payments, United shall comply with the requirements of the Texas Ins.
Code chpts. 843.315 and 843.316. 
 13. No Indemnification for Tort Liability. Provider and United agree that nothing in this Agreement
shall be construed to require Provider to indemnify United for any tort liability resulting from acts or omissions of United. 
 14. Provider
Communication with Customers. Nothing in this Agreement shall be construed to prohibit, attempt to prohibit, or discourage Provider from discussing with or communicating to a Customer, with respect to: (a) information or opinions regarding
Customer’s health care, including medical condition or treatment options; (b) information or opinions regarding the provisions, terms, requirements, or services of United as they relate to the Customer’s medical needs; (c) the
fact that this Agreement has terminated or that Provider shall otherwise no longer be providing medical care or health care services under United’s products; or (d) the fact that, if medically necessary covered services are not available
through providers contracting with United, then United must, upon the request of Provider and within time appropriate to the circumstances relating to the delivery of the services and the condition of the Customer, but in no event to exceed five
(5) business days after receipt of reasonably requested documentation, allow referral to an appropriate provider. Further, United may not in any way penalize, terminate, or 

 
refuse to compensate (as provided under this Agreement) Provider for communicating with a current, prospective or former patient, or a party designated by a patient, in any way protected by this
section. 
 15. Provisions Related to Emergency Services and Post-stabilization Care. 

(a) Definition of Emergency Care. Provider agrees that for the purposes of providing health care services to Customers under
United’s Benefit Plans, “emergency care” shall mean health care services provided in a hospital emergency facility or comparable facility to evaluate and stabilize medical conditions of a recent onset and severity, including but not
limited to severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness or injury is of such a nature that failure to get immediate medical care could result
in: (1) placing the patient’s health in serious jeopardy; (2) serious impairment to bodily functions; (3) serious dysfunction of any bodily organ or part; (4) serious disfigurement; or (5) in the case of a pregnant
woman, serious jeopardy to the health of her fetus. 
 (b) Post-stabilization Care Approval. If United requires prior
approval of post-stabilization care requested by a treating physician or health care professional following emergency services, and if such health care services are for Customers covered under Benefit Plans regulated by Texas law, United will
approve or deny such treatment within one hour of the time of the request. 
 16. Provisions Specific to Podiatrists. The provisions
contained in this section apply only in the event that Provider is a podiatrist licensed by the Texas State Board of Podiatric Medical Examiners. 
 (a) Request for Coding Guidelines and Payment Schedules. Within thirty (30) days after the date of Provider’s request, United shall provide a copy of the coding guidelines and payment
schedules applicable to the compensation that the Provider shall receive under this Agreement. 
 (b) No Unilateral Material
Retroactive Change. United may not unilaterally make material retroactive revisions to the coding guidelines and payment schedules. 
 (c) X-Rays and Orthotics. Provider may, practicing within the scope of the law regulating podiatry, furnish x-rays and nonprefabricated orthotics covered by a Benefit Plan. 

Provisions applicable to fully insured Benefit Plans regulated by the State of Texas but not subject to Texas HMO laws: 

1. Other Contracts. Provider is not restricted from contracting with other insurers, preferred provider plans, preferred provider organizations, or
HMOs. 
 2. Quality Care. Any term or condition of this Agreement that limits Provider’s participation on the basis of quality shall
be consistent with established standards of care for Provider’s profession. 
 3. Provider Privileges. If Provider has hospital or
institutional provider privileges and delivers a significant portion of care in a hospital or institutional provider setting, this Agreement may contain terms and conditions that include the possession of practice privileges at preferred hospitals
or institutions. However, if no preferred hospital or institution offers privileges to members of a class of physicians or practitioners to which Provider belongs, then the lack of such hospital or institutional provider privileges may not be a
basis for denial of Provider’s participation as a preferred provider. 
 4. Provider Billing. This Agreement prohibits Provider from
billing the Customer for unnecessary care if a physician or practitioner panel has determined the care was unnecessary. However, Provider shall not be required to pay hospital, institutional, laboratory, x-ray or like charges resulting from the
provision of services lawfully ordered by Provider, even though such service may be determined to be unnecessary. 
 5. Customer Referrals.
Nothing in this Agreement shall be construed as a restriction on the classes of physicians and practitioners who may refer a Customer to another physician or practitioner. In the event that

 
Provider makes a referral for specialty care, nothing in this Agreement shall be construed to require Provider to bear the expenses of such referral in or out of the preferred provider panel.

 6. No Inducement to Limit Medically Necessary Services. This Agreement does not contain any financial incentives to Provider that act
directly or indirectly as an inducement to limit medically necessary services. 
 7. Customer or Provider Complaints. United provides a
mechanism for the resolution of complaints initiated by a Customer or Provider which provides for reasonable due process including, in an advisory role only, a review panel selected in compliance with the provisions of Tex. Ins. Code § 1301.055
and 28 Tex. Admin. Code § 3.3705. 
 8. Limit on Indemnification. Provider shall not be required to indemnify or hold United
harmless from tort liability resulting from acts or omissions of United. 
 9. Discounted Fee Arrangements. If this Agreement contains a
discounted fee arrangement, the Customer may be billed only on the discounted fee and not the full charge. 
 10. Prompt Payment. United
or Payer, as applicable, will make payment to Provider pursuant to the provisions of the Texas law. For instance, unless a longer time is permitted under applicable Texas law, not later than 30 days from the date United receives an electronic clean
claim and not later than 45 days from the date United receives a non-electronic clean claim, United or Paver will either: pay the total amount of the claim in accordance with. this Agreement; pay the portion of the claim that is not in dispute and
notify Provider in writing why the remaining portion of the claim is not being paid; pay the total amount of the claim in accordance with this Agreement but notify Provider that the claim is subject to audit; request additional information from
Provider within 30 days of receipt of a clean claim, and then pay or deny the claim within the time. required by law after United receives that information or Provider fails to timely provide it: or notify Provider in writing why United or Payer
will not pay the claim. 
 If Provider submits claims that are not clean, 

 

	 	•	 	 United will notify Provider within 30 days of receiving an electronic claim or within 45 days of receiving a non-electronic claim that it is not a
clean claim; 

  

	 	•	 	 Provider may be asked for additional information so that Provider’s claim may be adjudicated; or 

 

	 	•	 	 Provider’s claim may be denied and Provider will be notified of the denial and the reason for it; or 

 

	 	•	 	 United may in its discretion pay or have the claim paid by an applicable Payer based on the information that Provider gave in addition to the
information United has. 

 A claim is complete or “clean” if it supplies all the information required by statute.
The Administrative Guide contains additional important information about clean claims, an address to submit claims, a phone number and internet address where Provider can contact United with questions regarding claims Provider has submitted,
information regarding any entity to whom United may have delegated claim payment functions, and the address and telephone number of any separate claims processing centers for specific types of claims or services. 

11. Timely Filing of Claims. Provider must submit Provider’s claims within 95 days of the date of service. For a claim submitted by an
institutional provider, the 95-day period does not begin until the date of discharge. For a claim for which coordination of benefits applies, the 95-day period does not begin for submission of the claim to the secondary payer until Provider receives
notice-of the payment or denial from the primary payer. If Provider’s claim is not submitted within this time frame; Provider will not be reimbursed for the services and Provider may not charge Provider’s patient for them. If
Provider’s failure to timely submit the claim is the result of an information systems failure or catastrophic event that substantially interferes with Provider’s normal business operations for more than two consecutive business days and
about which Provider notifies the Texas Department of Insurance as required by 28 Tex. Admin. Code § 21.2819, United will extend the 95 day filing deadline by the number of days in which Provider’s business was unable to operate- In the
event that Provider seeks and receives a waiver from 

 
United’s electronic filing requirements under 28 Tex. Admin. Code § 21,3701, Provider may submit non-electronic claims to the address shown in the Administrative Guide. 

12. Duplicate Claims. Provider may not submit duplicate claims for claims, (defined as a claim for payment made for the same patient on the same
date of service for the same services) that are not clean for: 1) 45 days after Provider files those claims non-electronically, and 2) 30 days after Provider files those claims electronically. 

13. Penalties. If governing law requires United or Payer to pay interest, billed charges, fees, costs or another penalty for a failure to pay
Provider’s clean claim for covered services within a certain time frame, United will follow those requirements. The interest, billed charges, fees, costs or other penalty required by law will be the only additional obligation for not satisfying
in a timely manner a payment obligation to Provider. In addition, if United adjudicated a claim of Provider’s that was not clean, there shall be no interest or other late payment obligation to Provider even if United subsequently adjusts the
payment amount based on additional information that Provider provides or that United obtains. In accordance with Tex. Ins. Code § 1301.137, United or Payer is not liable for a penalty for failure to pay a clean claim: (1) if the failure to
pay the claim is a result of a catastrophic event that substantially interferes with the normal business operations of United or Payer, or (2) if the claim was paid in accordance with applicable law, but for less than the contracted rate, and:
(A) Provider notifies the United of the underpayment after the 270th day after the date the underpayment was received; and (B) United or Payer pays the balance of the claim on or before the 30th day after the date United receives the
notice. 
 14. Corrective Adjustments for Overpayments. 
 (a) In accordance with TAC § 21.2818, United or Payer may recover a refund from Provider due to overpayment or completion of an audit, by adjusting future claim payments and/or by billing Provider
for the amount of the. overpayment, if: (i) United notifies Provider of the overpayment not later than the 180th day after the date of receipt of the overpayment; or (ii) United notifies Provider of the completion of an audit under TAC
§ 21.2809. Notification under subsection (i) of this section shall be in writing and shall include: (A) the specific claims and amounts for which a refund is due and for each claim the basis and specific reasons for the request for
refund; (B) notice of Provider’s right to appeal; and (C) the methods by which United intends to recover the refund. 
 (b) If Provider disagrees with a request for recovery of an overpayment, United shall provide Provider with an opportunity to appeal, in accordance with Tex. Ins. Code § 1301.132 and 28 TAC §
21.2818, and United or Payer may not recover the overpayment until all appeal rights are exhausted. 
 (c) United or Payer may
recover overpayments beyond the 18O-day time frame mentioned above if the overpayment occurred as a result of fraudulent billing practices or a material misrepresentation by Provider. 
 15. Information About and Limits on Using Fee Schedule and Reimbursement Methodology. Fee schedule or coding guideline changes which are intended to substantially alter the overall methodology or
reimbursement level of the fee schedule or which result in a material change in payment to Provider for the same CPT Code, ICD diagnostic code or hospital-based revenue code will be treated as an amendment to the contract, and United will give
Provider 90 days written notice of the changes. United will not make retroactive revisions to the coding guidelines and fee schedules. To request a written copy of United’s reimbursement policies and methodologies that apply to specific
procedures or services for which Provider will seek reimbursement under this Agreement, or any other information Provider needs to determine that Provider is being paid according to this Agreement. Provider should send a written request to Network
Management, 1250 Capital of Texas Highway, South Building One, Suite 400 Austin, TX 78746. United will respond to Provider’s request within 30 days of receiving it. United will, on request of Provider, provide the name, edition, and model
version of the software that the United uses to determine bundling and unbundling of claims. If United discloses fee schedule or reimbursement methodology to Provider, Provider may not use or disclose it for any purposes other than management of
Provider’s practice, to submit bills, for Provider’s business operations or in communications with a governmental agency involved in the regulation of health care or insurance. 

 16. Protected Communications. Provider shall not be prohibited, penalized, retaliated against, or
terminated for communicating items pursuant to Tex. Ins. Code Ann. § 1301.067. 
 17. Use of Economic Profiling. If United conducts,
uses, or relies upon economic profiling to terminate Provider, Provider shall be informed of United’s obligation to make available as requested by Provider, Provider’s economic profile, including written criteria by which the
Provider’s performance was measured in accordance with Tex. Ins. Code Ann. § 1301.058. 
 18. Quality Assessment. If United
engages in quality assessment, United shall do, so through a panel of not less than three physicians selected by United from among a list of physicians contracting with United. 
 19. Immunization or Vaccination Protocol. Provider is not required to issue an immunization or vaccination protocol for an immunization or vaccination to be administered to a Customer by a
pharmacist. 
 20. Administration of Immunizations or Vaccinations. This Agreement does not prohibit a pharmacist from administering
immunizations or vaccinations if such immunizations or vaccinations are administered in accordance with the Texas Pharmacy Act art. 4542a-1 and rules promulgated thereunder. 
 21. Provisions Related to Emergency Services and Post-stabilization Care. 

(a) Definition of Emergency Care. Provider agrees that for the purposes of providing health care services to Customers under
Benefit Plans, “emergency care” shall mean health care services provided in a hospital emergency facility or comparable facility to evaluate and stabilize medical conditions of a recent onset and severity, including but not limited to
severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness or injury is of such a nature that failure to get immediate medical care could result in
(1) placing the patient’s health in serious jeopardy; (2) serious impairment to bodily functions; (3) serious dysfunction of any bodily organ or part; (4) serious disfigurement; or (5) in the case of a pregnant woman,
serious jeopardy to the health of her fetus. 
 (b) Post-stabilization Care Approval. If United requires prior approval of
post-stabilization care requested by a treating physician or health care professional following emergency services, and if such health care services are for Customers covered under Benefit Plans regulated by Texas law, United will approve or deny
such treatment within one hour of the time of the request. 
 22. Provisions Related to Termination. 

(a) Notice of Termination to Provider. United shall provide written notification of termination of this Agreement to Provider at
least ninety (90) days prior to the effective date of termination, except if termination is related to (i) imminent harm to Customer health, (ii) action against Provider’s license to practice or (iii) fraud, in which cases
termination may be immediate. 
 (b) Advisory Review Panel Review of Proposed Termination. Prior to termination of this
Agreement, United shall give Provider a written explanation of the reasons for termination. If Provider is a physician or practitioner, in accordance with 28. TAC § 3.3706 and Tex. Ins. Code § 1301.053(b), Provider may request and shall
receive a review of the proposed termination by a selected advisory review panel. Provider must make the request in writing to United within 20 business days of receipt of the notification of United’s intent to terminate, which shall include
any relevant documentation. Such review shall be conducted within sixty (60) days of Provider’s request or, if requested by Provider pursuant to 28 TAC § 3.3706, the review process shall be expedited. The decision of the advisory
panel must be considered but is not binding on United. United shall provide Provider, upon request, a copy of the recommendation of the advisory review panel and United’s determination. Notwithstanding the above provision, Provider is not
entitled to and no review shall be provided in a case in which there is (a) imminent harm to Customer health, (b) an action by a state medical board, licensing board or other government agency that effectively impairs the Provider’s
ability to practice or (c) a case of fraud or malfeasance. 

 (c) Notice of Provider Termination to Customers. United must provide reasonable
advance notification of an impending termination of Provider to Customers receiving care from Provider. Notice given at least thirty (30) days before the effective date of the termination shall be deemed reasonable; provided, however, that if
termination of Provider is for reasons related to imminent harm to Customers, notification of termination may be given, to Customers immediately. If Provider is entitled to a review by United of its decision to terminate Provider pursuant to Tex.
Ins. Code Ann. § 1301.057, United will not notify Customers of Provider’s impending termination until its effective date or until the time the review panel makes its formal recommendation, whichever is later. 

(d) Continuation of Care for Customer Special Circumstance. Unless termination of this Agreement is based upon reasons of medical
competence or professional behavior, United or Payer shall have a continuing obligation to reimburse Provider if Provider is treating a Customer with special circumstance at no less than the rate provided in this Agreement. For purposes of this
section, “special circumstance” means a condition with regard to which Provider reasonably believes that discontinuing care by Provider and transferring the Customer’s care to another provider could cause harm to the Customer, such as
a disability, acute condition, life threatening illness, or pregnancy of more than twenty-four (24) weeks. Provider must identify the special circumstance and request that the Customer be permitted to continue treatment under the
Provider’s care. Provider must also agree not to seek payment from the Customer of any amounts for which the Customer would not be responsible if this Agreement were still in effect. Any dispute regarding the necessity for continued treatment
by Provider shall be resolved pursuant to United’s dispute resolution procedures contained in the appeal procedure for medical necessity determinations as described in the provider manual or administrative manual. The obligation of United or
Payer to reimburse a terminated Provider for ongoing treatment of a Customer with special circumstance continues through: (a) the ninetieth (90th) day after the effective date of the termination; (b) nine (9) months following the
effective date of the termination for a Customer who at the time of the termination has been diagnosed with a terminal illness; or (c) delivery of the child, immediate postpartum care, including a follow-up checkup within the first six
(6) weeks of delivery, for a Customer who is past the twenty-fourth (24th) week of pregnancy at the effective date of the termination. 
 (e) Voluntary Termination by Provider. Provider may also terminate this Agreement upon 30 days’ written notice if Provider provides United with such written notice within 30 days of receiving
the information requested under 28 Tex. Admin. Code § 3.3703(a)(20), as described in section 15 above. Provider agrees to cooperate with United to give Customers the notice described in (c) above. 

23. No Retaliatory Action. United shall not engage in any retaliatory action, including termination of or refusal to renew this Agreement, against
Provider because Provider has, on behalf of a Customer, reasonably filed a complaint against United or has appealed a decision of United. 

24. Provisions Specific to Podiatrists. The provisions contained in this section apply only in the event that Provider is a podiatrist licensed by
the Texas State Board of Podiatric Medical Examiners. 
 (a) Request for Coding Guidelines and Payment Schedules. Within
thirty (30) days after the date of Provider’s request, United shall provide a copy of the coding guidelines and payment schedules applicable to the compensation that the Provider shall receive under this Agreement. 

(b) No Unilateral Material Retroactive Change. United may not unilaterally make material retroactive revisions to the coding
guidelines and payment schedules. 
 (c) X-Rays and Orthotics. Provider may, practicing within the scope of the law
regulating podiatry, furnish x-rays and nonprefabricated orthotics covered by a Benefit Plan.Form of Debt Security

 Exhibit 4.3 
 (Face of [Note/Debenture]) 
 [Include for global securities -] THIS IS A GLOBAL SECURITY
WITHIN THE MEANING OF THE INDENTURE HEREINAFTER REFERRED TO AND IS REGISTERED IN THE NAME OF THE DEPOSITARY OR A NOMINEE OF THE DEPOSITARY. THIS GLOBAL SECURITY IS EXCHANGEABLE FOR [NOTE/DEBENTURE]S (AS DEFINED BELOW) REGISTERED IN THE NAME OF A
PERSON OTHER THAN THE DEPOSITARY OR ITS NOMINEE ONLY IN THE LIMITED CIRCUMSTANCES DESCRIBED IN THE INDENTURE, AND MAY NOT BE TRANSFERRED EXCEPT AS A WHOLE BY THE DEPOSITARY TO A NOMINEE OF THE DEPOSITARY, BY A NOMINEE OF THE DEPOSITARY TO THE
DEPOSITARY OR ANOTHER NOMINEE OF THE DEPOSITARY OR BY THE DEPOSITARY OR ANY SUCH NOMINEE TO A SUCCESSOR DEPOSITARY OR A NOMINEE OF SUCH A SUCCESSOR DEPOSITARY. UNLESS THIS GLOBAL SECURITY IS PRESENTED BY AN AUTHORIZED REPRESENTATIVE OF THE
DEPOSITORY TRUST COMPANY (55 WATER STREET, NEW YORK, NEW YORK) (“DTC”) TO THE COMPANY (AS DEFINED BELOW) OR ITS AGENT FOR REGISTRATION OF TRANSFER, EXCHANGE OR PAYMENT, AND ANY [NOTE/DEBENTURE] ISSUED IS REGISTERED IN THE
NAME OF CEDE & CO. OR IN SUCH OTHER NAME AS IS REQUESTED BY AN AUTHORIZED REPRESENTATIVE OF DTC (AND ANY PAYMENT IS MADE TO CEDE & CO. OR TO SUCH OTHER ENTITY AS IS REQUESTED BY AN AUTHORIZED REPRESENTATIVE OF DTC), ANY TRANSFER,
PLEDGE OR OTHER USE HEREOF FOR VALUE OR OTHERWISE BY OR TO ANY PERSON IS WRONGFUL INASMUCH AS THE REGISTERED OWNER HEREOF, CEDE & CO., HAS AN INTEREST HEREIN. 
 CUSIP:              
 ISIN:                 
 eBay Inc. 
     % [Note/Debenture]s due
     

			
	No.	 	$                       

 eBay Inc., a Delaware corporation, for value received promises to pay to
             or registered assigns, the principal sum of              Dollars on
            . 
 Interest Payment Dates:
             and             . 
 Record Dates:              and             . 

Reference is hereby made to the further provisions of this [Note/Debenture] contained on the reverse hereof, which will for all purposes
have the same effect as if set forth at this place. 
  

			
	eBay Inc.
		
	 By:
	 	  

		 	Name:
		 	Title:

 This is one of the     % 
 [Note/Debenture]s due         referred to in 
 the
within-mentioned Indenture: 
 Dated: 

Wells Fargo Bank, National Association, 
 as
Trustee 
  

			
		
	 By:
	 	  

		 	Authorized Signatory

  
 2 

 (Reverse of [Note/Debenture]) 

    % [Note/Debenture]s due          

Terms, whether or not capitalized, which are defined in the Indenture referred to below and used in this [Note/Debenture] (as defined
below) have the respective meanings assigned to them in the Indenture referred to below unless otherwise indicated. 
 1.
INTEREST. eBay Inc., a Delaware corporation (the “Company,” which term includes its successors under the Indenture), promises to pay interest on the principal amount of this [Note/Debenture] at the rate of
    % per annum from the date hereof until maturity. The Company will pay interest semi-annually in arrears on          and
         of each year (each an “Interest Payment Date”), commencing         . Interest on this [Note/Debenture] will accrue from
the most recent date to which interest has been paid or duly provided for or, if no interest has been paid or duly provided for, from the date of issuance; provided that if there is no existing default in the payment of interest, and if this
[Note/Debenture] is authenticated between a Record Date (as defined below) and the next succeeding Interest Payment Date, interest will accrue from such next succeeding Interest Payment Date; and provided, further, that the first Interest
Payment Date will be         . The Company will pay interest (including post-petition interest in any proceeding under any Bankruptcy Law) on overdue principal at the per annum rate equal to the
interest rate on this [Note/Debenture] to the extent lawful; and it will pay interest (including post-petition interest in any proceeding under any Bankruptcy Law) on overdue installments of interest at the same per annum rate to the extent lawful.
Interest will be computed on the basis of a 360-day year of twelve 30-day months. 
 2. METHOD OF PAYMENT. The Company
will pay interest on the [Note/Debenture]s due on any Interest Payment Date to the persons who are registered Holders of [Note/Debenture]s at the close of business on the          or
         (each a “Record Date”), as the case may be, next preceding such Interest Payment Date, except as provided in Section 2.14 of the Base Indenture (as defined below)
with respect to defaulted interest. Principal of and interest on the [Note/Debenture]s will be payable at the office or agency of any Paying Agent or, at the option of the Company, payment of interest may be made by check mailed to the Holders of
the [Note/Debenture]s at their respective addresses set forth in the register of Holders of [Note/Debenture]s; provided that payments of principal of and interest on [Note/Debenture]s that are Global Securities registered in the name of a
Depositary or its nominee will be made by wire transfer of immediately available funds. Such payments will be in Dollars. 
 3.
PAYING AGENT AND REGISTRAR. Initially, Wells Fargo Bank, National Association, the Trustee under the Indenture, will act as Paying Agent and Registrar for the [Note/Debenture]s. The Company may change any Paying Agent or Registrar, and may
appoint additional Paying Agents, Service Agents and co-Registrars, without notice to any Holder. In addition, the Company or any of its Subsidiaries may act in any such capacity. 

4. INDENTURE. This [Note/Debenture] is one of a duly authorized Series of Securities (herein called the
“[Note/Debenture]s”) of the Company issued under an indenture (the “Base Indenture”) dated as of October 28, 2010 between the Company and the Trustee, as amended and supplemented by the
Supplemental Indenture dated as of October 28, 2010 between the Company and the Trustee (the “Supplemental Indenture;” the Base Indenture, as amended and supplemented by the Supplemental Indenture and any other
supplemental indentures thereto, is hereinafter called the “Indenture”). The terms of the [Note/Debenture]s include those stated in the Indenture and those made part of the Indenture by reference to the Trust Indenture Act of
1939, as amended. The [Note/Debenture]s are subject to all such terms, and Holders are referred to the Indenture and such Act for a statement of such terms. To the extent any provision of this [Note/Debenture] or the Supplemental Indenture conflict
with any provision of the Base Indenture, the provisions of this [Note/Debenture] or the Supplemental Indenture, as the case may be, will govern and be controlling. As provided in the Indenture, the Company may, at its option and without the consent
of or notice to Holders of the [Note/Debenture]s, reopen this Series of Securities and issue additional [Note/Debenture]s of this Series as provided in the Indenture. 
 5. [OPTIONAL REDEMPTION.] 
 [To be deleted or revised as
applicable—] The [Note/Debenture]s are redeemable at the option of the Company, [at any time or from time to time,] [at any time or from time to time prior to         ,] either in whole or in
part, at a redemption price equal to the greater of: 
 (a) 100% of the principal amount of the [Note/Debenture]s to be redeemed,
and 
 (b) the sum of the present values of the remaining scheduled payments of principal of and interest on the
[Note/Debenture]s to be redeemed (exclusive of interest accrued to the applicable redemption date) discounted to such redemption date on a semi-annual basis (assuming a 360-day year consisting of twelve 30-day months) at the Treasury Rate plus
         basis points, 

  
 3 

 
plus, in the case of both clauses (a) and (b) above, accrued and unpaid interest on the principal amount of the [Note/Debenture]s being redeemed to such redemption date[; provided that,
notwithstanding the foregoing, payments of interest on [Note/Debenture]s that are due and payable on any Interest Payment Dates falling on or prior to a date fixed for redemption of the [Note/Debenture]s will be payable to the Holders of such
[Note/Debenture]s registered as such at the close of business on the relevant Record Dates according to their terms and the terms and provisions of the Indenture]. 
 [On and after         , the [Note/Debenture]s are redeemable at the option of the Company, at any time or from time to time, either in whole or in part, at a
redemption price equal to 100% of the principal amount of the [Note/Debenture]s to be redeemed, plus accrued and unpaid interest on the principal amount of the [Note/Debenture]s being redeemed to such redemption date.] 

[Notwithstanding the foregoing, payments of interest on [Note/Debenture]s that are due and payable on any Interest Payment Dates falling
on or prior to a date fixed for redemption of the [Note/Debenture]s will be payable to the Holders of such [Note/Debenture]s registered as such at the close of business on the relevant Record Dates according to their terms and the terms and
provisions of the Indenture.] 
 As used in this Section 5, the following terms have the meanings specified below:

 “Comparable Treasury Issue” means, with respect to any redemption date for the [Note/Debenture]s, the United States
Treasury security selected by the Quotation Agent as having an actual or interpolated maturity comparable to the remaining term of the [Note/Debenture]s that would be utilized, at the time of selection and in accordance with customary financial
practice, in pricing new issues of corporate debt securities of comparable maturity to the remaining term of the [Note/Debenture]s. 
 “Comparable Treasury Price” means, with respect to any redemption date for the [Note/Debenture]s, (1) the arithmetic average of the Reference Treasury Dealer Quotations for such redemption
date after excluding the highest and lowest such Reference Treasury Dealer Quotations; (2) if the Quotation Agent obtains fewer than         such Reference Treasury Dealer Quotations, the
arithmetic average of all such Reference Treasury Dealer Quotations for such redemption date; or (3) if the Quotation Agent obtains only one such Reference Treasury Dealer Quotation, such Reference Treasury Dealer Quotation for such redemption
date. 
 “Quotation Agent” means, for purposes of determining the redemption price of the [Note/Debenture]s to be
redeemed on any redemption date, any primary U.S. Government securities dealer in New York City (a “Primary Treasury Dealer”) selected by the Company. 
 “Reference Treasury Dealers” means, with respect to any redemption date for the [Note/Debenture]s,
                    ,          and          or
their respective successors, as the case may be (provided, however, that if any such firm or any such successor, as the case may be, shall cease to be a Primary Treasury Dealer, another Primary Treasury Dealer shall be substituted therefor by
the Company) and any other Primary Treasury Dealer or Primary Treasury Dealers selected by the Quotation Agent after consultation with the Company. 
 “Reference Treasury Dealer Quotation” means, with respect to each Reference Treasury Dealer and any redemption date for the [Note/Debenture]s, the arithmetic average, as determined by the
Quotation Agent, of the bid and asked prices for the Comparable Treasury Issue (expressed in each case as a percentage of its principal amount) quoted in writing to the Quotation Agent by such Reference Treasury Dealer at 5:00 p.m., New York City
time, on the third Business Day preceding such redemption date. As used in the preceding sentence, the term “Business Day” means any day except a Saturday, Sunday or other day on which banking institutions in The City of New York are
authorized or obligated by law, regulation or executive order to close. 
 “Treasury Rate” means, with respect to any
redemption date for the [Note/Debenture]s, the rate per annum equal to the semi-annual equivalent yield to maturity or interpolated yield to maturity of the Comparable Treasury Issue, calculated using a price for the Comparable Treasury Issue
(expressed as a percentage of its principal amount) equal to the Comparable Treasury Price for such redemption date. 

  
 4 

 If less than all of the [Note/Debenture]s are to be redeemed, the Trustee shall select the
[Note/Debenture]s (or portions thereof) to be redeemed in any manner that the Trustee deems fair and appropriate, which may provide for the selection for redemption of a portion of the principal amount of any [Note/Debenture] equal to an authorized
denomination as provided in the next sentence. [Note/Debenture]s or portions thereof shall be redeemable in a minimum of $2,000 in principal amount and integral multiples of $1,000 in principal amount in excess thereof, provided that the
remaining principal amount of any [Note/Debenture] redeemed in part shall be $2,000 or an integral multiple of $1,000 in excess thereof. 
 Notice of any redemption shall be mailed at least 30 days but not more than 60 days before the redemption date to each Holder of the [Note/Debenture]s to be redeemed at its registered address and as
otherwise provided in the Indenture. 
 Unless the Company defaults in payment of the redemption price, on and after the
redemption date interest shall cease to accrue on the [Note/Debenture]s or portions thereof called for redemption. 
 Any
redemption of [Note/Debenture]s shall be made in accordance with the other provisions of the Indenture. 
 Calculation of the
redemption price shall not be a duty or obligation of the Trustee. 
 6. [NO MANDATORY REDEMPTION. The Company shall not
be required to make mandatory redemption or sinking fund payments with respect to the [Note/Debenture]s and the [Note/Debenture]s shall not be subject to repurchase by the Company at the option of Holders.] 

7. DENOMINATIONS, TRANSFER, EXCHANGE. The [Note/Debenture]s are in registered form without coupons in denominations of $2,000 and
integral multiples of $1,000 in excess thereof. The [Note/Debenture]s may be transferred or exchanged only by surrender thereof to the Registrar or a co-Registrar in compliance with the Indenture and either the reissuance by the Company of the
surrendered [Note/Debenture] to the new Holder or the issuance by the Company of a new [Note/Debenture] to the new Holder or, in the case of an exchange, the exchanging Holder. The Registrar, any co-Registrar and the Trustee may require a Holder,
among other things, to furnish appropriate endorsements and transfer documents and the Company may require a Holder to pay any taxes and governmental charges permitted by the Indenture. Neither the Company, the Registrar nor any co-Registrar shall
be required to (a) issue, register the transfer of, or exchange [Note/Debenture]s during the period beginning at the opening of business fifteen days immediately preceding the mailing of a notice of redemption of the [Note/Debenture]s selected
for redemption and ending at the close of business on the day of such mailing, or (b) to register the transfer of or exchange [Note/Debenture]s selected, called or being called for redemption, except any portion thereof not so selected, called
or being called. 
 8. PERSONS DEEMED OWNERS. The Company, the Trustee and each Agent may treat the Holder in whose name
a [Note/Debenture] is registered as the owner thereof for the purpose of receiving payment and for all other purposes, and neither the Company, the Trustee nor any Agent shall be affected by any notice to the contrary. 

9. AMENDMENT, SUPPLEMENT AND WAIVER. Subject to certain exceptions, the Indenture and the [Note/Debenture]s may be amended and
supplemented with the consent of the Holders of at least a majority in principal amount of the [Note/Debenture]s then outstanding (including, without limitation, consents obtained in connection with a tender offer or exchange offer for the
[Note/Debenture]s), and compliance with any provision of the Indenture or the [Note/Debenture]s may be waived with the consent of the Holders of a majority in principal amount of the then outstanding [Note/Debenture]s (including, without limitation,
waivers obtained in connection with a tender offer or exchange offer for the [Note/Debenture]s). Without notice to or the consent of any Holder of a [Note/Debenture], the Indenture and the [Note/Debenture]s may be amended and supplemented as
provided in the Indenture, including, without limitation, to cure any ambiguity, defect or inconsistency or make any change that does not adversely affect the rights of any Holder of [Note/Debenture]s in any material respect. 

  
 5 

 10. DEFAULTS AND REMEDIES. If an Event of Default with respect to the
[Note/Debenture]s occurs and is continuing, the Trustee or the Holders of not less than 25% in principal amount of the outstanding [Note/Debenture]s may declare the principal of and accrued and unpaid interest on the outstanding [Note/Debenture]s to
be due and payable immediately or, solely in the case of an Event of Default relating to specified events of bankruptcy or insolvency with respect to the Company, such principal and accrued and unpaid interest shall ipso facto become due and
payable. As provided in the Indenture, the Holders of not less than a majority in principal amount of the outstanding [Note/Debenture]s may waive (including waivers obtained in connection with a tender offer or exchange offer for the
[Note/Debenture]s) any past Default with respect to the [Note/Debenture]s and its consequences, subject to exceptions specified in the Indenture, and may rescind and annul any acceleration of the [Note/Debenture]s and its consequences. Holders of
the [Note/Debenture]s may not enforce the Indenture or the [Note/Debenture]s except as provided in the Indenture. 
 11.
TRUSTEE DEALINGS WITH COMPANY. The Trustee in its individual or any other capacity may become the owner or pledgee of the [Note/Debenture]s and may otherwise deal with the Company or an Affiliate of the Company with the same rights it would
have if it were not Trustee. 
 12. NO RECOURSE AGAINST OTHERS. A director, officer, employee or stockholder, as such, of
the Company will not have any liability for any obligations of the Company under the [Note/Debenture]s or the Indenture or for any claim based on, in respect of or by reason of such obligations or their creation. Each Holder of [Note/Debenture]s by
accepting a [Note/Debenture] waives and releases all such liability. The waiver and release are part of the consideration for the issuance of the [Note/Debenture]s. 
 13. AUTHENTICATION. This [Note/Debenture] will not be valid until authenticated by the manual signature of the Trustee or an authenticating agent. 

14. GOVERNING LAW. This [Note/Debenture] shall be governed by, and construed in accordance with, the internal laws of the State of
New York applicable to agreements made and to be performed in such State, without regard to the conflict of laws provisions thereof. 
 15. LEGAL DEFEASANCE, COVENANT DEFEASANCE AND DISCHARGE. As provided in the Indenture, the Company may, at its option, effect legal defeasance and covenant defeasance with respect to the
[Note/Debenture]s and, insofar as concerns the [Note/Debenture]s, satisfaction and discharge of the Indenture, all on the terms and subject to the conditions set forth in the Indenture. 

16. ABBREVIATIONS. Customary abbreviations may be used in the name of a Holder or an assignee, such as: TEN COM (= tenants in
common), TEN ENT (= tenants by the entireties), JT TEN (= joint tenants with right of survivorship and not as tenants in common), CUST (= Custodian), and U/G/M/A (= Uniform Gifts to Minors Act). 

17. CUSIP NUMBERS. Pursuant to a recommendation promulgated by the Committee on Uniform Security Identification Procedures, the
Company has caused CUSIP numbers to be printed on the [Note/Debenture]s and the Trustee may use CUSIP numbers in notices of redemption as a convenience to Holders. No representation is made as to the accuracy of such numbers either as printed on the
[Note/Debenture]s or as contained in any notice of redemption and reliance may be placed only on the other identification numbers placed thereon. 

  
 6 

 ASSIGNMENT FORM 

To assign this [Note/Debenture], fill in the form below: 

 

			
	(I) or (we) assign and transfer this [Note/Debenture] to:	 	  

		 	(Insert assignee’s legal name)

					
	
	  

		 	(Insert assignee’s soc. sec. tax I.D. no.)	 	
	  

	  

	  

	  

	(Print or type assignee’s name, address and zip code)

									
	and irrevocably appoint	 	  

	to transfer this [Note/Debenture] on the books of the Company. The agent may substitute another to act for him.

Date:                     

 

	
	Your
Signature:                                       
                   
	 (sign exactly as your name(s) appear(s)

on the face of this [Note/Debenture])   

	
	Tax Identification
No:                                        
        
	
	Signature
Guarantee:                                       
           

 Signatures must be guaranteed by an “eligible guarantor institution” meeting the requirements of the
Registrar, which requirements include membership or participation in the Security Transfer Agent Medallion Program (“STAMP”) or such other “signature guarantee program” as may be determined by the Registrar in
addition to, or in substitution for, STAMP, all in accordance with the Securities Exchange Act of 1934, as amended. 

  
 7

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00192-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00192-of-00352.parquet"}]]