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Home My WebLink AboutContract 50597-A16Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CSC No. 50597-A16 CONFIDENTIAL AND PROPRIETARY SIXTEENTH AMENDMENT TO MASTER SERVICES AGREEMENT This Sixteenth Amendment to Master Services Agreement (the "Amendment") is entered into to be effective as of January 1, 2025 (the "Amendment Effective Date"), by and between City of Fort Worth, a municipal corporation organized and existing under the laws of the State of Texas and having its principal place of business at 100 Fort Worth Trail, Fort Worth, TX 76102 ("Employer"), and UT Southwestern Accountable Care Network d/b/a Southwestern Health Resources Accountable Care Network ("SWHR ACN"), and Texas Health Resources, a Texas nonprofit corporation ("THR"). Employer, SWHR ACN and THR are each a "Party" and together the "Parties." WHEREAS, the Parties entered into a Master Services Agreement, effective January 1, 2018 (the "Agreement"); and WHEREAS, the Parties desire to amend the Agreement effective January 1, 2025 to amend the annual and monthly rate, add new THR facilities, and to make the annual adjustment to reimbursement. NOW, THEREFORE, for and in consideration of the mutual promises and covenants set forth herein, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the Parties agree as follows: Effective upon the Amendment Effective Date, the parties hereby amend the Agreement as follows: 1. Article 1 E. Clinic Fee is hereby amended as follows: E. Clinic Fee means effective January 1, 2025, the sum of $3.256.916.49 which shall be invoiced at a monthly amount of $271,409.71 and annual adjustment as provided by Section 2.2(a) below. 2. Exhibit 1 is deleted in its entirety and replaced with the attached Exhibit 1 hereto and incorporated by reference to update rates: • Table 3 - Rates for Sports Medicine/ PRP/BMAC program 3. Exhibit 3 is deleted in its entirety and replaced with the attached Exhibit 3 to add: • UPNT Surgery, LLC dba Surgical Centers of North Texas — Arlington, effective 9/l/2024 • UPNT Surgery, LLC dba Surgical Centers of North Texas - Fort Worth, effective 9/l/2024 4. Exhibit 4 and its sub attachments are deleted in their entirety and replaced with the attached Exhibit 4 and its sub attachments to update reimbursement rates. 5. Unless otherwise defined herein, capitalized terms used in this Amendment have the same meaning as in the Agreement. 6. All other terms, provisions, conditions, covenants and recitals of the Agreement not expressly amended herein shall remain in full force and effect. OFFICIAL RECORD CITY SECRETARY FT. WORTH, TX Sixteenth Amendment to Master Services Agreement Page 1 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CONFIDENTIAL AND PROPRIETARY IN WITNESS WHEREOF, the Parties have caused this Agreement to be executed by their authorized representatives effective as of the date set forth above, intending to be legally bound hereby. UT SOUTHWESTERN ACCOUNTABLE CARE NETWORK D/B/A Southwestern Health Resources Accountable Care Network (SWHR ACN): DocuSed byI By: 1`0� 1"""n58444'D399... Name: Jenny Reed Title: SEO, Southwestern Health Resources Date: 11/20/2024 1 1:00 PM CST Texas Health Resources (THR) �D1ocuSigned by: 1tn�teSCi.9 By: '--E660E2F7ECA245C... Name: Winjie Miao Title: SEVP/Chief Operating Officer Date: 11/22/2024 1 1:42 PM PST Texas Health Resources (THR) By: F�DocuSigne--d/I''b11yyI: --�'�.� �'"" & M.(�A.Orl t,r B5B33A2BD6434454... Name: Rick McWhorter Title: SEVP / Chief Financial Officer Date: 11/22/2024 1 1:33 PM PST Sixteenth Amendment to Master Services Agreement Page 2 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CONFIDENTIAL AND PROPRIETARY ACCEPTED AND AGREED: City of Fort Worth CP � By: Jesica McEachern Name: Title: Assistant City Manager Date: Dec 20, 2024 APPROVAL RECOMMENDED: By: Name: Joanne Hinton Title: Interim HR Asst Dir 4.04444nq ATTEST:oRt�od°d By. ��o osd°— Name: Jannette Goodall GP * 00o a * d o � Title: City Secretary °a�� aEonSaaa CONTRACT COMPLIANCE MANAGER: By signing I acknowledge that I am the person responsible for the monitoring and administration of this contract, including ensuring all performance and reporting requirements. By: NW`F� Name: Meagan Hailey Title: Interim Benefits Manager APPROVED AS TO FORM AND LEGALITY: By: Name: Jessika Williams Title: Assistant City Attorney CONTRACT AUTHORIZATION: M&C: N/A Date Approved: N/A N/A Form 1295 Certification No.: OFFICIAL RECORD CITY SECRETARY FT. WORTH, TX Sixteenth Amendment to Master Services Agreement Page 3 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CONFIDENTIAL AND PROPRIETARY EXHIBIT 1 HEALTH CENTER AND SATELLITE CLINIC LOCATIONS AND CLINIC FEE SERVICES Health Centers (dedicated to City of Ft. Worth Covered Persons) Location 1 City of Fort Worth Employee Health Center - Lake Worth 2 City of Fort Worth Employee Health Center - Magnolia 3 City of Fort Worth Employee Health Center - Huguley 4 City of Fort Worth Employee Health Center — Riverside Address 4701 Boat Club Road, #325 Ft. Worth, TX 76135 1320 Hemphill St., Suite 350 Ft. Worth, TX 76104 12001 South Freeway, Suite 208 Burleson, TX 76028 100 Forest Park Blvd., Suite 120 Ft. Worth, TX 76102 Satellite Clinics (available clinics to City of Ft. Worth Covered Persons) Location Address 1 Hoffman Family Practice 2730 SW Wilshire Blvd. Associates Burleson, TX 76028 2 Family Medical Center 7001 Granbury Rd. Southwest Ft. Worth, TX 76133 3 Cornerstone Family and Sports 100 Bourland Rd., Suite 170 Keller, TX 75248 4 Texas Health Family Care- 101 Crown Point Blvd., Suite 200 Willow Park Willow Park, TX 76087 5 Texas Health Family Care 3024 Hwy 121 Bedford, TX 76021 6 Texas Health Family Care 9655 Red Dirt Rd Fort Worth, TX 76123 Tax ID 75-2613493 75-2613493 75-2613493 75-2613493 Tax ID 75-2613493 75-2613493 75-2613493 75-2613493 75-2613493 75-2613493 Sixteenth Amendment to Master Services Agreement Page 4 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CONFIDENTIAL AND PROPRIETARY CLINIC FEE SERVICES a. The Clinic Fee includes the following Clinic Fee Services: Clinic Fee Services Primary care and lab services as listed in Table 1 Clinic Fee Services and Injections shall be provided at the Health Centers and Satellite Clinics. Typical services include: • Abdominal Pain • Abrasion • Bronchitis • Cold • Constipation • Contusion • Couth • Dermatitis • Diarrhea • Dizziness • Elevated Blood Pressure • Headache • Heartburn • Hives • Influenza • Joint Pain • Minor Laceration • Minor Injuries • Muscle Strain • Nausea • Neck Pain • Nose Bleed • Painful Urination/UTI • Palpitations • Wellness Exams • Chronic Disease Management • Radiology services are excluded from Clinic Fee Services. • Any additional Covered Services (other than Table 1 - Clinic Fee Services and Injections) will be billed directly to the Employer or ASO. Payment shall be at the contracted rate between SWHR ACN and ASO. Parties understand and agree that the rates above are subject to applicable Covered Person deductible as set forth in the Covered Person's Health Benefit Plan. • Preventive care, if provided in the Health Centers and Satellite Clinics and defined in the Accountable Care Act, shall be $0 to the Covered Person per the Employer's Benefit Plan. Sixteenth Amendment to Master Services Agreement Page 5 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CONFIDENTIAL AND PROPRIETARY Table 1 - Clinic Fee Services and Injections CPT/ CPT Description CPT/ CPT Description HCPCS HCPCS Code Code Incision & Drainage of Abscess / 20600 Joint injection or aspiration — Small 10060 Wound Simple or Single with or Joint w/o Packing 20605 Joint injection or aspiration — Incision & Drainage of Abscess / Medium Joint 10061 Wound Complicated or Multiple 20610 Joint injection or aspiration —Large with Packing Joint 10160 Puncture Aspiration of abscess, 36415 Venipuncture Routine hematoma, bulla, or cyst Cerumen Removal - 1 ear, if doing 11102 Shave Biopsy of Skin, single lesion 69209 both use mod 50 (provider must 11103 Shave Biopsy of Skin, each perform) additional lesion Cerumen Removal with 11104 Punch Biopsy of Skin, single lesion 69210 instrumentation - 1 ear, if doing 11105 Punch Biopsy of Skin, each both use mod 50 additional lesion 80048 BMP - Basic Metabolic Panel 11200 Skin Tag Removal up to and 80050 General Health Panel including 15 lesions 80053 CMP - Comprehensive Metabolic 11201 Skin Tag Removal — charge for each Panel additional 10 lesions 80061 Lipid Panel 11300 Shave Skin Lesion / Trunk, arms, 80076 Hepatic Function Panel legs (no sutures) 0.5 cm or less 81001 Urinalysis w/ Scope 11301 Shave Skin Lesion / Trunk, arms, 81003 Urine Dip (In-house) legs (No sutures) 0.6 to 1.0 cm 81025 Urine Pregnancy Test (In-house) 11305 Shave Skin Lesion / Scalp, neck, 82043 Urine Microalbumin - Quant (Send hands, feet, genitalia 0.5 cm or less out) 11306 Shave Skin Lesion / Scalp, neck, 82044 Urine Microalbumin (In-house) hands, feet, genitalia 0.6 to 1.0 cm 82274 Fecal Immunochemical Test (OC 11400 Excision, Benign Skin Lesion / Light Fit) Trunk, arms, legs 0.5cm or less 82306 Vitamin D, 25 Hydroxy 11401 Excision, Benign Skin Lesion / 82570 Urine Creatinine Trunk, arms, legs 0.6 to 1.0 cm 82728 Ferritin 11402 Excision, Benign Skin Lesion / 82947 Glucose (Send out) Trunk, arms, legs 1.1 to 2.0 cm Glucose Finger Stick / Hemocue Excision, Benign Skin Lesion / 82962 (In-house) 11420 Scalp, neck, hands, feet, genitalia FSH - Follicle Stimulating 0.5 cm or less 83001 Hormone 11740 Evacuation of Subungual 83036 HbAIc (Send out) Hematoma 83037 HbAIc (In-house) 12001 Laceration Repair of Superficial 83540 Iron Wound - Simple 2.5 cm or less � 83550 Iron Binding Capacity - TIBC 17000 Destruction of premalignant lesion 84132 Potassium (cryo); first lesion � 84153 PSA -Prostate Specific Antigen 17003 Destruction of premalignant lesion 84403 Testosterone Total (cryo); 2nd thru 14 lesions � 84436 Thyroxine; Total T4 17110 Destruction of benign lesions other � 84439 Thyroxine; Free T4 than skin tags (cry) up to 141esions -Thyroid Stimulating Destruction of benign lesions other 84443 H or Hormone 17111 than skin tags (cry) 15 or more 84550 Uric Acid lesions Sixteenth Amendment to Master Services Agreement Page 6 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CONFIDENTIAL AND PROPRIETARY CPT/ CPT Description CPT/ CPT Description HCPCS HCPCS Code Code 84702 Pregnancy Test - HCG Quant (Send 99214 Office / Outpatient Visit, Est out) 99215 Office / Outpatient Visit, Est 85025 CBC w/ Diff 99384 Preventative Visit, new, age 12-17 85610 PT/INR (Send out & In-house) 99385 Preventative Visit, new, age 18-39 86803 Hepatitis C 99386 Preventative Visit, new, age 40-64 87070 Culture - Wound 99387 Preventative Visit, new, age 65+ yrs 87086 Urine C&S (active covered persons) 87186 Strep Throat - Culture (Send out) 99394 Preventative Visit, est. age 12-17 87426 COVID-19 Antigen Testing 99395 Preventative Visit, est. age 18-39 87481 Candida, DNA, AMP Probe 99396 Preventative Visit, est. age 40-64 87491 Chlamydia - Culture 99397 Preventative Visit, est. age 65+ yrs 87510 Gardnerella - Detect agent NOS, (active covered persons) DNA, AMP Preventative Counseling, indiv - 15 87591 Gonorrhea - Culture 99401 min 87624 HPV - Human Papilloma Virus 99402 Preventative Counseling, indiv - 30 87635 COVID-19 Infectious Agent min Testing 99406 Tobacco cessation counseling, 87637 COVID-19 Flu Testing intermediate 3-10 min 87804 Influenza A & B Nasal Swab (In- 99407 Tobacco Counseling > 10 Minutes house) 2028F Diabetic Foot Exam 87880 Rapid Strep (In-house) A4550 Surgical Tray 88175 Thin Prep Pap (Test code 58315 for A7003 Nebulizer Administration Set (Bill Thin Prep Only) with 94640 & J-code for medicine) 90471 Admin - Immunization/ Vaccine/ JO171 Epinephrine Ampule First or Single Ini J0696 Rocephin (Ceftriaxone) per 250 mg 90472 Admin - Immunization / Vaccine / Jl 030 Depo-Medrol (Methylprednisolone) Additional Ini 40 mg 90714 Tetanus & Diphtheria Toxoids J1040 Depo-Medrol (Methylprednisolone) Absorbed, Td 80 mg 93000 EKG w/ interpretation J1071 Testosterone cypionate, 1 mg 94010 Spirometry, including graphic J1100 Dexamethasone (Decadron) record J1200 Benadryl (Diphenhydramine) 94060 Spirometry, Pre and Post 50mg/ml Bronchodilator J1885 Toradol (Ketorolac) per 15mg 94640 Nebulizer Updraft Treatment (Bill J2550 Promethazine (Phenergan) up to with A7003 & J-code for medicine) 50mg 96372 Admin — Therapeutic Injection / IM J3301 Kenalog (Triamcinolone) per 10mg / Subcutaneous J3420 Vitamin B-12 (Cyanocobalamin) 99000 Lab Handling Fee J3490 Lidocaine 1% 99024 Post -op Follow Up visit during J3490 Lidocaine w/ Epi 1% global period - no charge J3490 Lidocaine 2% 99201 Office / Outpatient visit, new J3490 Lidocaine w/ Epi 2% 99202 Office / Outpatient visit, new Albuterol Inhalation Solution 99203 Office / Outpatient visit, new J7613 0.083% 99204 Office / Outpatient visit, new J7620 DuoNeb (Albuterol/Ipratropium) 99205 Office / Outpatient visit, new Ipratropium Bromide Inhalation 99211 Office / Outpatient Visit, Est J7644 Solution 0.02% 99212 Office / Outpatient Visit, Est Removal of Sutures - Not placed by 99213 Office / Outpatient Visit, Est S0630 us Sixteenth Amendment to Master Services Agreement Page 7 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CONFIDENTIAL AND PROPRIETARY Table 3 - Rates for Sports Medicine/ PRP/BMAC program ASO agrees to reimburse SWHR ACN for Sports Medicine/PRP/BMAC as follows: Injection CPT/HCPCS Code Injection Description Expected Reimbursement ACP PRP (Arthrex) 0232T 1 joint (1st & 2nd injection) $656.00 0232T 3rd injection w/discount $328.00 0232T 2 Joints $874.00 0232T 2 joints (3rd injection discount $437.00 PRP Codes (Greyledge) 0232T 1 joint (1st & 2nd injection) $1,093.00 0232T 3rd injection w/discount $546.00 0232T 2 joints (1st & 2nd injection) $1,311.00 0232T 3rd injection w/discount $656.00 BMAC (Greyledge) 0232T 1 joint (1st & 2nd injection) $3,278.00 0232T 3rd injection w/discount $1,639.00 0232T 2 joint (1st & 2nd injection) $3,497.00 0232T 3rd injection w/discount $1,858.00 Amnion (Arthrex) 20999 1 joint (1st & 2nd injection) $3,278.00 20999 3rd injection w/discount $1,639.00 20999 2 joint (1st & 2nd injection) $3,497.00 20999 3rd injection w/discount $1,858.00 Nudyn (Fidia) 20999 1 joint (1st & 2nd Injection) 1 ml $1,748.00 20999 1 joint 3rd injection w/discount $874.00 20999 2 joints (1st & 2nd Injection) 2 ml $1,967.00 20999 2 joints 3rd injection w/discount $984.00 Parties understand and agree that the rates above are subject to applicable Covered Person deductible as set forth in the Covered Person's Health Benefit Plan. Sixteenth Amendment to Master Services Agreement Page 8 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CONFIDENTIAL AND PROPRIETARY EXHIBIT 3 LIST OF THR PARTICIPATING FACILITIES A. Hospitals and Long Term Acute Care Hospitals THR Facility Service Address & Claims Payment Tax ID Facility Rate Phone Number Address & Phone Number Type Exhibit # Number 1 Texas Health 800 W Randol Mill PO Box 910818 75-0972805 Hospital 4 Arlington Memorial Road Dallas, TX 75391-0818 Hospital Arlington, TX 76012 817-960-6130 817-960-6100 2 Texas Health 1301 Pennsylvania 500 East Border St. 75-1648589 LTAC 4A Specialty Hospital Ave. 4th Floor Main #124 Fort Worth Ft. Worth, TX 76104 Arlington, TX 76010- 817-878-5500 7498 817-570-8500 3 Texas Health Harris 411 N. Belknap PO Box 916078 75-1752253 Hospital 4 Methodist Hospital Stephenville, TX Ft. Worth, TX 76191- Stephenville 76401 6078 254-965-1500 817-570-8500 4 Texas Health Harris 1301 Pennsylvania PO Box 916063 75-6001743 Hospital 4 Methodist Hospital Ave., Ft Worth, TX 76191- Fort Worth Ft. Worth, TX 76104 6063 817-882-2000 817-570-8500 5 Texas Health Harris 6100 Harris Parkway PO Box 916047 75-2678857 Hospital 4 Methodist Hospital Ft Worth, TX 76132 Ft Worth, TX 76191- Southwest Fort Worth 817-433-5000 6047 817-570-8500 6 Texas Health Harris 1600 Hospital PO Box 916060 75-1438726 Hospital 4 Methodist Hospital Parkway Ft. Worth, TX 76191- Hurst-Euless-Bedford Bedford, TX 76022 6060 817-848-4000 817-570-8500 7 Texas Health Harris 108 Denver Trail PO Box 916066 75-1748586 Hospital 4 Methodist Hospital Azle, TX 76020 Ft Worth, TX 76191- Azle 817-444-8600 6066 817-570-8500 8 Texas Health 1105 N. Central PO Box 910175 75-2890358 Hospital 4 Presbyterian Hospital Expressway Dallas, TX 75391-0175 Allen Allen, TX 75013 214-345-7260 972-747-1000 9 Texas Health 8200 Walnut Hill PO Box 910115 75-1047527 Hospital 4 Presbyterian Hospital Lane Dallas, TX 75391-0115 Dallas Dallas, TX 75231 214-345-7260 214-345-6789 10 Texas Health 850 Ed Hall Drive PO Box 910206 75-2771437 Hospital 4 Presbyterian Hospital Kaufinan, TX 75142 Dallas, TX 75391-0206 Kaufinan 972-932-7200 214-345-7260 11 Texas Health 6200 West Parker PO Box 910156 75-2770738 Hospital 4 Presbyterian Hospital Road Dallas, TX 75391-0156 Plano Plano, TX 75093 214-345-7260 972-981-8000 Sixteenth Amendment to Master Services Agreement Page 9 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CONFIDENTIAL AND PROPRIETARY THR Facility Service Address & Claims Payment Tax ID Facility Rate Phone Number Address & Phone Number Type Exhibit # Number 12 Texas Health Harris 201 Walls Dr. PO Box 916051 75-1977850 Hospital 4 Methodist Hospital Cleburne, TX 76033 Ft Worth, TX 76191- Cleburne 817-641-2551 6051 817-570-8500 13 Texas Health 3000 Interstate 35 North PO BOX 731467 43-2008974 Hospital 4 Presbyterian Hospital Denton, TX, 76201 Dallas, TX, 75373-1467 Denton 940-898-7000 940-898-7172 14 Southlake Specialty 1545 E. Southlake Blvd P. O. Box 735801 02-0555370 Hospital 4 Hospital L.L.C., d/b/a Southlake, TX, 76092 Dallas, TX, 75373-5801 Texas Health Harris 817-748-8700 800-890-6034 Methodist Hospital Southlake 15 Texas Institute for 7115 Greenville P. O. Box 676249 77-0628004 Hospital 4 Surgery, L.L.P., d/b/a Avenue, Suite 100 Dallas, TX, 75267-6249 Texas Institute for Dallas, TX, 75231 972-419-1535 Surgery at Texas 214-647-5300 Health Presbyterian Dallas 16 Physicians Medical 6020 W. Parker Road P. O. Box 735589 48-1281376 Hospital 4 Center, L.L.C., d/b/a Plano, TX, 75093 Dallas, TX, 75373-5589 Texas Health Center 972-403-2700 800-890-6034 for Diagnostics & Surgery Plano 17 Rockwall Regional 3150 Horizon Road P. O. Box 735800 20-2848116 Hospital 4 Hospital, LLC d/b/a Rockwall, TX 75032 Dallas, TX 75373-5800 Texas Health 469-698-1000 800-890-6034 Presbyterian Hospital Rockwall 18 USMD Hospital at 801 Interstate 20 W PO Box 732156 73-1662763 Hospital 4 Arlington, LP Arlington, TX 76017 Dallas, TX 73573-2156 817-472-3535 817-576-0022 19 Flower Mound 4400 Long Prairie Rd PO Box 735799 26-0684968 Hospital 4 Hospital Partners Flower Mound, TX Dallas, TX 75373-5799 d/b/a Texas Health 75028 800-890-6034 Presbyterian Hospital 469-322-7000 Flower Mound 20 AMH Cath Labs LLC 811 Wright Street PO Box 975621 20-3003947 Hospital 4 d/b/a Texas Health Arlington, TX 76012 Dallas, TX 75397-5621 Heart & Vascular 817-960-3500 817-960-6130 Hospital Arlington 21 Texas Health 11801 South Freeway P.O. Box 951571 45-2694620 Hospital 4 Huguley, Inc. d/b/a Burleson, TX 76028 Dallas, Texas 75395 Texas Health 817-293-9110 817-551-2739 Huguley Hospital Fort Worth South 22 Texas Health Harris 10864 Texas Health P.O. Box 731778 45-1502252 Hospital 4 Methodist Hospital Trail Dallas, TX 75373-1778 Alliance Fort Worth, TX 76244 800-890-6034 682-212-2000 Sixteenth Amendment to Master Services Agreement Page 10 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CONFIDENTIAL AND PROPRIETARY THR Facility Service Address & Claims Payment Tax ID Facility Rate Phone Number Address & Phone Number Type Exhibit # Number 23 Texas Health 12400 Dallas PO BOX 734468 83-1954982 Hospital 4 Hospital Frisco Parkway Dallas, TX 75373- Frisco, TX 75033 4468 469-495-2000 800-890-6034 24 Texas Health 2300 Lone Star Road PO BOX 946900 83-1869297 Hospital 4 Hospital Mansfield Mansfield, TX 76063 Atlanta, GA 30394- 682-341-5000 6900 817-551-2739 B. Ancillary Facilities THR Facility Service Address & Claims Payment Tax ID Facility Rate Phone Number Address & Phone Number Type Exhibit # Number 1 SWDIC Imaging 8230 Walnut Hill PO Box 678146, 75-2008026 Imaging/ 4C Center Partnership, Lane, Building 3, Dallas, TX 75267- Radiology LLP, d/b/a Suite 100, Dallas TX 8146 Center Southwest 75231 214-345-2098 Diagnostic Imaging 214-345-6905 Center 2 The Center for 8196 Walnut Hill PO Box 678182, 11-3699951 Imaging/ 4C Molecular Imaging Lane, Suite LL30, Dallas, TX 75267- Radiology Limited Dallas, TX 75227 8182 Center Partnership d/b/a 214-345-8300 214-345-2098 (PET/CT Southwest Scans) Diagnostic Center for Molecular Imaging 3 Denton Surgery 207 N. Bonnie Brae, PO Box 844214 47-0926556 Ambulatory 4B Center, LLC d/b/a Denton, TX 76201 Dallas, TX 75284- Surgery Texas Health 940-383-7100 4214 Center Surgery Center 940-383-7102 Denton 4 Women's Specialty 8230 Walnut Hill PO Box 650814 26-2310072 Ambulatory 4B Surgery Center of Lane, Suite 101 Dallas, TX 75265 Surgery Dallas LLC d/b/a Dallas, TX 75231 214-345-6747 Center Texas Health 214-345-6747 Women's Specialty Surgery Center Dallas 5 Health Imaging 710 Hunters Row Ct PO Box 5343 27-1385885 Imaging/ 4C Partners LLC d/b/a Mansfield, TX 76063- Denver, CO 80217- Radiology Envision Imaging 4001 5343 Center at Hunters Row 817-453- 7444 866-965-1093 6 Health Imaging 12201 Merit DR Suite PO Box 5343 27-1385885 Imaging/ 4C Partners LLC d/b/a 100 Denver, CO 80217- Radiology Envision Imaging Dallas, TX 75251- 5343 Center of Dallas 2122 866-965-1093 214-276-0050 Sixteenth Amendment to Master Services Agreement Page 11 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CONFIDENTIAL AND PROPRIETARY THR Facility Service Address & Claims Payment Tax ID Facility Rate Phone Number Address & Phone Number Type Exhibit # Number 7 Health Imaging 1111 Raintree Cir, Ste. PO Box 5343 27-1385885 Imaging/ 4C Partners LLC d/b/a 100 Denver, CO 80217- Radiology Envision Imaging Allen, TX 75013-4903 5343 Center of Allen 972-747-8300 866-965-1093 8 Health Imaging 3211 Internet Blvd, PO Box 5343 27-1385885 Imaging/ 4C Partners LLC d/b/a Suite 120 Denver, CO 80217- Radiology Envision Imaging Frisco, TX 75034- 5343 Center of Frisco 1948 866-965-1093 972-334-0908 9 Health Imaging 10840 Texas Health PO Box 5343 27-1385885 Imaging/ 4C Partners LLC d/b/a Trail Suite 140 Denver, CO 80217- Radiology Envision Imaging Fort Worth, TX 5343 Center North Fort Worth 76244 866-965-1093 817-741-0008 10 Health Imaging 6957 W. Plano Pkwy PO Box 5343 27-1385885 Imaging/ 4C Partners, LLC d/b/a Plano, TX 75093 Denver, CO 80217- Radiology Envision Imaging 972-395-7533 5343 Center of Plano 866-965-1093 11 Health Imaging 2911 Oak Park Circle PO Box 5343 27-1385885 Imaging/ 4C Partners, LLC d/b/a Fort Worth, TX 76109 Denver, CO 80217- Radiology Envision Imaging 817-923-6858 5343 Center of Hulen 866-965-1093 12 THR/STT 3142 Horizon Road, 1340 Main Street, 26-2429878 Ambulatory 4B Rockwall ASC, Suite 100, Rockwall, Suite 100, Surgery LLC TX 75032 Grapevine, TX Center d/b/a Texas Health 972-772-9600 76051 Spine Surgery 682-651-1908 Center Rockwall 13 THR/STT 290 Miron Road, 1340 Main Street, 20-1728912 Ambulatory 4B Southlake ASC, Southlake, TX 76092 Suite 100, Surgery LLC 817-442-9300 Grapevine, TX Center d/b/a Texas Health 76051 Spine Surgery 682-651-1908 Center Southlake 14 Health Imaging 3920 W. Wheatland PO Box 5343 27-1385885 Imaging/ 4C Partners, Road, Ste 120 Denver, CO 80217- Radiology LLC d/b/a Dallas, TX 75237 5343 Center Envision Imaging 972-820-8050 866-965-1093 of Desoto 15 Health Imaging 925 W. Royal Lane, PO Box 5343 27-1385885 Imaging/ 4C Partners, Suite 100 Denver, CO 80217- Radiology LLC d/b/a Irving, TX 75039 5343 Center Envision Imaging 214-483-6200 866-965-1093 of Las Colinas Sixteenth Amendment to Master Services Agreement Page 12 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CONFIDENTIAL AND PROPRIETARY THR Facility Service Address & Claims Payment Phone Number Address & Phone Number 16 Texas Health 10840 Texas Health PO Box 731893 Surgery Center Trail, Suite 100 Alliance, LLC Fort Worth, TX d/b/a 76244 Texas Health 877-410-6290 Surgery Center Alliance 17 Surgical Caregivers 2001 West Rosedale of Fort Worth, L.P. Street d/b/a Texas Health Fort Worth TX 76104 Surgery Center 817-877-4777 Fort Worth Midtown 18 Greenville Surgery 7150 Greenville Center, Ltd., d/b/a Avenue, Texas Health Ste 200 Surgery Center Dallas, TX 75231 Dallas 214-891-0466 19 Texas Health Craig 8080 State Highway Ranch Surgery 121, Suite 100 Center LLC d/b/a McKinney, TX 75070 Texas Health 972-521-5600 Surgery Center Craig Ranch 20 Texas Health 5000 Long Prairie Flower Mound Road, Suite 202 Orthopedic Surgery Flower Mound, TX Center LLC. 75028 d/b/a Texas Health 469-240-8540 Orthopedic Surgery Center — Flower Mound 21 Cleburne Surgical 2010 W Katherine P Center, LLC d/b/a Raines Blvd Texas Health Suite 100 Surgery Center Cleburne, TX 76033 Cleburne 817-645-0811 22 Health Imaging 815 Pennsylvania Partners, LLC d/b/a Avenue Envision Imaging Fort Worth, TX 76104 at Pennsylvania 817-321-0300 23 Health Imaging 1600 Central Drive, Partners, LLC d/b/a Ste 195 Envision Imaging Bedford, TX 76022 of Bedford 817-803-0100 Dallas TX 75373- 1893 800-890-6034 2001 West Rosedale Street Fort Worth, TX 76104 817-877-4777 7150 Greenville Avenue, Ste 200 Dallas, TX 75231 214-891-0466 8080 State Highway 121, Suite 100 McKinney, TX 75070 214-547-2700 5000 Long Prairie Road Suite 202 Flower Mound, TX 75028 469-240-8540 2010 W Katherine P Raines Blvd Suite 100 Cleburne, TX 76033 817-645-0811 PO Box 5343 Denver, CO 80217- 5343 866-965-1093 PO Box 5343 Denver, CO 80217- 5343 866-965-1093 Tax ID Facility Number Type 80-0800294 Ambulatory Surgery Center 75-1925497 Ambulatory Surgery Center 74-2411643 Ambulatory Surgery Center 38-3897811 Ambulatory Surgery Center 80-0866449 Ambulatory Surgery Center 20-3742012 Ambulatory Surgery Center 27-1385885 Imaging/ Radiology Center 27-1385885 Imaging/ Radiology Center Rate Exhibit # m m HE W. HE 4C 4C 24 Health Imaging 203 Walls Drive, Suite PO Box 5343 27-1385885 Imaging/ 4C Partners, LLC d/b/a 101 Denver, CO 80217- Radiology Envision Imaging Cleburne, TX 76033 5343 Center of Cleburne 817-517-2600 866-965-1093 Sixteenth Amendment to Master Services Agreement Page 13 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CONFIDENTIAL AND PROPRIETARY THR Facility Service Address & Claims Payment Tax ID Facility Rate Phone Number Address & Phone Number Type Exhibit # Number 25 Health Imaging 801 Road to Six Flags PO Box 5343 27-1385885 Imaging/ 4C Partners, LLC d/b/a West, Ste 106 Denver, CO 80217- Radiology Envision Imaging Arlington, TX 76012 5343 Center of North Arlington 817-265-1099 866-965-1093 26 Health Imaging 525 East Southlake PO Box 5343 27-1385885 Imaging/ 4C Partners, LLC d/b/a Blvd. Denver, CO 80217- Radiology Envision Imaging Southlake, TX 76092 5343 Center at Southlake 817-424-5872 866-965-1093 27 Health Imaging 4601 Matlock Road PO Box 5343 27-1385885 Imaging/ 4C Partners, LLC d/b/a Arlington, TX 76018 Denver, CO 80217- Radiology Envision Imaging 817-375-3170 5343 Center of South Arlington 866-965-1093 28 Health Imaging 1800 N. Lake Forest PO Box 5343 27-1385885 Imaging/ 4C Partners, Dr., Suite 100 Denver, CO 80217- Radiology LLC d/b/a McKinney, TX 75071 5343 Center Envision Imaging 469-420-9077 866-965-1093 of McKinney 29 Fort Worth 900 W. Magnolia, 900 W. Magnolia, 77-0368346 Ambulatory 4B Endoscopy Suite 101 Suite 101 Surgery Centers, LLC Fort Worth, TX 76104 Fort Worth, TX Center d/b/a Fort Worth 817-332-6500 76104 Endoscopy Center 817-332-6500 30 Fort Worth 6445 Harris Parkway, 6445 Harris 77-0368346 Ambulatory 4B Endoscopy Suite 150 Parkway, Suite 150 Surgery Centers, LLC Fort Worth, TX 76132 Fort Worth, TX Center d/b/a Southwest 817-423-2888 76132 Fort Worth 817- 423-2888 Endoscopy Center 31 North Dallas 17980 Dallas 17980 Dallas 27-2248103 Ambulatory 4B Surgical Center, Parkway, Suite 100, Parkway, Suite 100, Surgery LLC d/b/a Texas Dallas, Texas 75287 Dallas, Texas 75287 Center Health Surgery 972-913-7715 972-913-7715 Center Addison 32 Wilson Creek 8855 Synergy Drive 8855 Synergy Drive 27-4815683 Ambulatory 4B Surgical Center McKinney, TX 75070 McKinney, TX Surgery LLC d/b/a 972-632-3811 75070 Center Stonebridge 972-632-3811 Surgery Center 33 Texas Health 17950 Preston Road, PO Box 840046 20-3991622 Ambulatory 4B Surgery Center Suite 75 Dallas, TX 75284 Surgery Preston Plaza, LLC Dallas, TX 75252 972-267-5400 Center d/b/a Texas Health 972-267-5400 Surgery Center Preston Plaza 34 Ophthalmology 10740 North Central 10740 North Central 26-1914835 Ambulatory 4B Surgery Center of Expressway, Suite 400 Expressway, Suite Surgery Dallas, LLC d/b/a Dallas, TX 75231 400 Center Ophthalmology 214-750-9288 Dallas, TX 75231 Surgery Center of 214-750-9288 Dallas Sixteenth Amendment to Master Services Agreement Page 14 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CONFIDENTIAL AND PROPRIETARY THR Facility Service Address & Phone Number 35 Arlington Surgery 918 N. Davis Drive Center, LLC d/b/a Arlington, TX 76012 Texas Health 817-860-9933 Surgery Center Arlington 36 Park Hill Surgery 3455 Locke Avenue Center, LLC d/b/a Suite 100 Texas Health Fort Surgery Center Worth TX 76107- Park Hill 5747 817-585-1900 37 Texas Health 1605 Airport Freeway Surgery Center Suite 100 Bedford, LLC d/b/a Bedford, Texas 76021 Texas Health 817-585-1900 Surgery Center Bedford 38 Texas Health Spine 1120 Raintree Circle, Surgery Center Suite 100 Allen, LLC Allen, TX 75013 817-442-9300 39 Texas Health 12001 South Freeway, Huguley Surgery Suite 101 Center, LLC Burleson, TX 76028 817-615-4400 40 Texas Health 3144 Horizon Road, Surgery Center Suite # 120 Rockwall, LLC Rockwall, TX 75032 d/b/a Texas Health 972 - 845-1469 Surgery Center Rockwall Texas Health 9848 North Beach St 41 Orthopedic Surgery Fort Worth, TX 76244 Center Alliance, 682-312-6464 LLC dba Texas Health Orthopedic Surgery Center Heritage 42 Health Imaging Partners LLC dba Envision Imaging at Bryant Irvin 43 Texas Health Surgery Center Irving, LLC 44 Health Imaging Partners, LLC dba Envision Imaging of Denton Claims Payment Address & Phone Number 918 N. Davis Drive Arlington, TX 76012 972.421.4813 3455 Locke Avenue Suite 100 Fort Worth, TX 76107-5747 817-585-1900 1605 Airport Freeway, Ste 100 Bedford, Texas 76021 817-585-1900 1340 Main Street, Suite 100 Grapevine, TX 76051 682-651-1908 PO Box 947581 Atlanta, GA 30394- 7581 817-551-2739 3144 Horizon Road, Suite #120 Rockwall, TX 75032 972 - 845-1469 9848 North Beach Fort Worth, TX 76244 682-312-6464 5701 Bryant Irvin PO Box 5343 Road, Suite 101 Denver, CO 80217- Fort Worth, TX 76132 5343 817-225-3600 866-965-1093 2120 North 2120 North MacArthur Blvd, Suite MacArthur Blvd, 200 Suite 200 Irving, TX 75061 Irving, TX 75061 972-438-5232 972-438-5232 2214 Emery St, PO Box 5343 Building 6 Denver, CO 80217- Denton, TX 76201 5343 940-536-0500 866-965-1093 Tax ID Facility Number Type 75-2055800 Ambulatory Surgery Center 45-1484375 Ambulatory Surgery Center 82-1307876 Ambulatory Surgery Center 30-0957868 Ambulatory Surgery Center 82-1289045 Ambulatory Surgery Center 47-4425996 Ambulatory Surgery Center 81-4977249 Ambulatory Surgery Center 27-1385885 Imaging/ Radiology Center 83-1085415 Ambulatory Surgery Center 27-1385885 Imaging/ Radiology Center Rate Exhibit # HE m m HE W. W. 4C 4C Sixteenth Amendment to Master Services Agreement Page 15 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CONFIDENTIAL AND PROPRIETARY THR Facility Service Address & Claims Payment Tax ID Facility Rate Phone Number Address & Phone Number Type Exhibit # Number 45 Health Imaging 490 US HWY 80 E, PO Box 5343 27-1385885 Imaging/ 4C Partners LLC dba Suite 300 Denver, CO 80217- Radiology Envision Imaging Sunnyvale, TX 75182- 5343 Center of Sunnyvale 9212 866-965-1093 940-536-0500 46 Texas Health Spine 10900 Founders 1340 Main Street, 32-0571301 Ambulatory 4B Surgery Center Way Suite 100 Suite 100 Surgery Alliance, LLC Fort Worth, TX 76244 Grapevine, TX Center 682-651-1908 76051 682-651-1908 47 Walnut Hill 5494 Glen Lakes Dr 5494 Glen Lakes Dr 36-4499777 Ambulatory 4B Surgery Center, Dallas, TX 75231 Dallas, TX 75231 Surgery LLC 817-784-6771 817-784-6771 Center 48 South Arlington 350 East I-20 350 East I-20 75-2723958 Ambulatory 4B Surgical Providers, Suite 200 Suite 200 Surgery LLC, d/b/a Same Arlington, TX 76018 Arlington, TX Center Day Surgicare 817-784-6771 76018 817-784-6771 49 Texas Health 6317 Harris Parkway, 6317 Harris 84-3814490 Ambulatory 4B Surgery Center Suite 200 Parkway, Suite 200 Surgery Southwest Fort Fort Worth, TX 76132 Fort Worth, TX Center Worth, LLC d/b/a 833-712-0756 76132 Texas Health Joint 833-712-0756 Replacement Surgery Center 50 Health Imaging 801 Woodbridge PO Box 5343 27-1385885 Imaging/ 4C Partners LLC d/b/a Pkwy, Suite 105 Denver, CO 80217- Radiology Envision Imaging Wylie, TX 75098 5343 Center of Wylie 469-649-0004 866-965-1093 51 Health Imaging 714 Hunters Row PO Box 5343 27-1385885 Imaging/ 4C Partners LLC dba Court, Mansfield, TX Denver, CO 80217- Radiology Envision Imaging — 76063 5343 Center Women's Imaging 469-591-1414 866-965-1093 Mansfield 52 Texas Health 5900 Altamesa Blvd., 5900 Altamesa 85-1225852 Ambulatory 4B Surgery Center Suite 101, Fort Worth, Blvd., Suite 101, Surgery Chisholm Trail, TX 76132 Fort Worth, TX Center LLC d/b/a Texas 833-457-1942 76132 Health Surgery 833-457-1942 Center Chisholm Trail 53 Mansfield 647 N. Miller Road, 647 N. Miller Road, 86-1354607 Ambulatory 4B Endoscopy Center Mansfield, TX 76063 Mansfield, TX Surgery LLC 817-415-9670 76063 Center 817-415-9670 54 Cross Timbers 1001 N. Waldrop 1001 N. Waldrop 75-2862780 Ambulatory 4B Surgery Center Drive, Suite 705, Drive, Suite 705, Surgery LLC, d/b/a North Arlington, TX 76012 Arlington, TX Center Texas GI Center 817-265-4844 76012 817-265-4844 Sixteenth Amendment to Master Services Agreement Page 16 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CONFIDENTIAL AND PROPRIETARY THR Facility Service Address & Claims Payment Tax ID Facility Rate Phone Number Address & Phone Number Type Exhibit # Number 55 Health Imaging 12950 Dallas PO Box 5343 27-1385885 Imaging/ 4C Partners LLC dba Parkway, Suite 300 Denver, CO 80217- Radiology Envision Imaging Frisco, TX 75034 5343 Center North Frisco 972-805-4700 866-965-1093 56 Health Imaging 5900 Altamesa Blvd, PO Box 5343 27-1385885 Imaging/ 4C Partners LLC dba Suite 103 Denver, CO 80217- Radiology Envision Imaging Fort Worth, TX 76132 5343 Center Southwest Fort 817-592-5400 866-965-1093 Worth 57 Willow Park 130 Jimma Dr., Ste B 130 Jimma Dr., Ste 88-1643733 Ambulatory 4B Endoscopy Willow Park, TX B Surgery Center,LLC 76087 Willow Park, TX Center 833-974-1578 76087 833-974-1578 58 Castle Hills 4221 Medical Pkwy 4221 Medical Pkwy 81-3020487 Ambulatory 4B Surgicare, LLC Bldg 100, Ste 100 Bldg 100, Ste 100 Surgery Carrollton, TX 75010 Carrollton, TX Center 972-939-2141 75010 972-939-2141 59 Texas Health 120 Jimma Drive 120 Jimma Drive 84-1953918 Ambulatory 4B Surgery Center Willow Park, TX Willow Park, TX Surgery Willow Park, LLC 76087 76087 Center d/b/a Texas Health 833-839-0007 855-405-8269 Orthopedic & Spine Surgery Center 60 Health Imaging 5500 Greenville Ave., PO Box 5343 27-1385885 Imaging/ 4C Partners LLC dba #1100 Denver, CO 80217- Radiology Envision Imaging Dallas, TX 75206 5343 Center Old Town 469-648-3700 866-965-1093 61 Central Park 411 Central Park Dr. 411 Central Park Dr. 16-1705322 Ambulatory 4B Surgery Center Arlington, TX 76014 Arlington, TX Surgery 817-784-8300 76014 Center 817-784-8300 62 Health Imaging 4640 Long Prairie Rd., PO Box 5343 27-1385885 Imaging/ 4C Partners LLC dba #310 Denver, CO 80217- Radiology Envision Imaging Flower Mound, TX 5343 Center Flower Mound 75028 866-965-1093 469-902-6500 63 Health Imaging 1861 N Central Expy, PO Box 5343 27-1385885 Imaging/ 4C Partners LLC dba Ste 500 Denver, CO 80217- Radiology Envision Imaging Plano, TX 75075-6971 5343 Center East Plano 972-353-7100 866-965-1093 64 Health Imaging 2101 Westpark Ct., PO Box 5343 27-1385885 Imaging/ 4C Partners LLC dba Ste 390 Denver, CO 80217- Radiology Envision Imaging Euless TX 76040 5343 Center Euless 972-353-7444 866-965-1093 Sixteenth Amendment to Master Services Agreement Page 17 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CONFIDENTIAL AND PROPRIETARY THR Facility Service Address & Claims Payment Tax ID Facility Rate Phone Number Address & Phone Number Type Exhibit # Number 65 UPNT Surgery, 2400 Matlock Rd. 2400 Matlock Rd. 37-1939831 Imaging/ 4C LLC dba Surgical Arlington, TX 76015 Arlington, TX Radiology Centers of North 817-865-1771 76015 Center Texas — Arlington 817-865-1771 66 UPNT Surgery, 6801 Oakmont Blvd., 2400 Matlock Rd. 37-1939831 Imaging/ 4C LLC dba Surgical #103 Arlington, TX Radiology Centers of North Fort Worth, TX 76132 76015 Center Texas - Fort Worth 817-886-8157 817-865-1771 C. Behavioral Health Facilities THR Facility Service Address & Claims Payment Tax ID Facility Rate Phone Number Address & Phone Number Type Exhibit # Number 1 Texas Health Harris Methodist Hospital Hurst -Euless- 2717 Tibbets Drive PO Box 916060 Bedford d/b/a Texas Bedford, TX 76022 Fort Worth TX 75-1438726 Behavioral 4 Health Springwood 817-848-7771 76191-6060 Health Behavioral Health 817-570-8500 Hospital 2 Texas Health Harris Methodist Hospital Hurst -Euless- N Beach St. PO Box 916060 Bedford d/b/a Texas Fort Worth, TX Fort Worth, TX 75-1438726 Behavioral Health Behavioral 76244 817-693-2527 76191-6060 Health 4 Health Center 817-570-8500 Alliance 3 Texas Health Harris Methodist Hospital Hurst -Euless- 3100 West Southlake PO Box 916060 Bedford d/b/a Texas Blvd, Suite 120 Fort Worth, TX 75-1438726 Behavioral 4 Health Behavioral Southlake, TX 76092 76191-6060 Health Health Center 682-812-6130 817-570-8500 Southlake 4 Texas Health Harris Methodist Hospital 2630 West Freeway, Hurst -Euless- Suite 132 PO Box 916060 Bedford d/b/a Texas Fort Worth, TX Fort Worth, TX 75-1438726 Behavioral Health Behavioral 76102 76191-6060 Health 4 Health Center 682-236-3661 817-570-8500 Southwest Fort Worth Sixteenth Amendment to Master Services Agreement Page 18 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CONFIDENTIAL AND PROPRIETARY THR Facility Service Address & Claims Payment Tax ID Facility Rate Phone Number Address & Phone Number Type Exhibit # Number 5 Texas Health Presbyterian 2929 Carlisle Street Hospital Dallas PO Box 910115 Suite d/b/a Dallas TX 75391- 75-1047527 Behavioral Dallas, T 7 4 Texas Health , 0115 Health Behavioral Health - 214-3452916 214-345-7260 Center Uptown Dallas 6 Texas Health Huguley, Inc 11801 South Freeway PO Box 951571 45-2694620 Behavioral dba Texas Health Burleson, TX 76028 Dallas, TX 75395 4 Health Huguley Hospital 817-568-3336 817-551-2721 Fort Worth South 7 Texas Health Presbyterian 8200 Walnut Hill PO BOX 910115 Hospital Dallas Lane Dallas, TX 75391- 75-1047527 Behavioral 4 d/b/a Texas Health Dallas, TX 75231 0115 Health Behavioral Health 214-345-7355 214-345-7260 Hospital Dallas 8 Texas Health Presbyterian 890 Rockwall PO BOX 910115 Hospital Dallas Parkway, Suite 115 Dallas, TX 75391- 75-1047527 Behavioral 4 d/b/a Texas Health Rockwall TX, 75032 0115 Health Behavioral Health 214-345-8799 214-345-7260 Center Rockwall 9 Texas Health Presbyterian 6110 W. Parker Rd. PO Box 910156 Hospital Plano Plano TX 75093 Dallas, TX 75391- 75-2770738 Behavioral 4 d/b/a Texas Health 0156 Health Seay Behavioral 972-981-8301 214-345-7260 Health Hospital 10 Texas Health Presbyterian 5858 Main St. #101 PO Box 910156 Hospital Plano Dallas, TX 75391- 75-2770738 Behavioral Frisco TX 75034 4 d/b/a Texas Health 0156 Health Behavioral Health 972-981-4214 214-345-7260 Center Frisco 11 Texas Health 3661 North Plano Presbyterian Road Suite # 2100 PO Box 910156 Hospital Plano Dallas, TX 75391- Behavioral Richardson 75-2770738 4 d/b/a Texas Health 0156 Health Behavioral Health TX 75082 214-345-7260 Center Richardson 81-4 972-981-4214 12 Texas Health Harris Methodist Hospital 1001 N. Waldrop PO Box 916060 Hurst -Euless- Drive, Suite 510 Fort Worth, TX 75-1438726 Behavioral Bedford d/b/a Texas 4 Arlington, TX 76012 76191-6060 Health Health Behavioral 817-960-6540 817-960-6540 Health Center Arlington Sixteenth Amendment to Master Services Agreement Page 19 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CONFIDENTIAL AND PROPRIETARY THR Facility Service Address & Claims Payment Tax ID Facility Rate Phone Number Address & Phone Number Type Exhibit # Number 13 Texas Health Presbyterian 1105 N. Central PO Box 910175 Hospital Plano Expressway, #2310 Dallas, TX 75391- Behavioral 75-2770738 4 d/b/a Texas Health Allen TX 75013 0175 Health Behavioral Health 972-908-2304 817-570-8500 Center Allen 14 Texas Health Harris Methodist Hospital 1011 Surrey Lane, PO Box 916060 Hurst -Euless- #103 Fort Worth TX 75-1438726 Behavioral Bedford d/b/a Texas Flower Mound TX 4 76191-6060 Health Health Behavioral 75022 817-570-8500 Health Center 972-543-3950 Flower Mound 15 Texas Health Recovery and 240 North Miller Rd. PO Box 733551 Wellness Center dba Mansfield TX 76063 Dallas TX 75373- 81-2813227 Behavioral 4 The Addiction 3551 Health Recovery Center by (682) 812-6150 817-570-8500 Texas Health D. Urgent Care Centers THR Facility Service Address & Claims Payment Tax ID Facility Rate Phone Number Address & Phone Number Type Exhibit # Number 1 Texas Health Urgent 3805 W University PO Box 735421 81-4317635 Urgent 4D Care DBA Texas Drive, Suite 100 Dallas, TX 75373-5421 Care Health Breeze Urgent McKinney, TX 800-890-6034 Center Care 75074-2944 469-495-9102 2 Texas Health Urgent 125 Davis Blvd PO Box 735421 81-4317635 Urgent 4D Care DBA Texas Southlake, TX 76092 Dallas, TX 75373-5421 Care Health Breeze Urgent 682-212-9104 800-890-6034 Center Care 3 Texas Health Urgent 4635 Frankford Road PO Box 735421 81-4317635 Urgent 4D Care DBA Texas Dallas, TX 75287 Dallas, TX 75373-5421 Care Health Breeze Urgent 469-495-9106 800-890-6034 Center Care 4 Texas Health Urgent 2855 Preston Road PO Box 735421 81-4317635 Urgent 4D Care DBA Texas Frisco TX 75034 Dallas, TX 75373-5421 Care Health Breeze Urgent Phone: 469-495-9118 800-890-6034 Center Care 5 Texas Health Urgent 2552 Eldorado Pkwy, PO Box 735421 81-4317635 Urgent 4D Care DBA Texas Suite 550 Dallas, TX 75373-5421 Care Health Breeze Urgent Frisco, TX 75033 800-890-6034 Center Care Phone: 469-495-9114 Sixteenth Amendment to Master Services Agreement Page 20 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CONFIDENTIAL AND PROPRIETARY THR Facility Service Address & Claims Payment Tax ID Facility Rate Phone Number Address & Phone Number Type Exhibit # Number 6 Texas Health Urgent 4630 Long Prairie Rd PO Box 735421 81-4317635 Urgent 4D Care DBA Texas Suite 210 Dallas, TX 75373-5421 Care Health Breeze Urgent Flower Mound, TX 800-890-6034 Center Care 75028 Phone:469-495-9112 7 Texas Health Urgent 7001 S Custer Rd, PO Box 735421 81-4317635 Urgent 4D Care DBA Texas Suite 900 Dallas, TX 75373-5421 Care Health Breeze Urgent McKinney TX 75070 800-890-6034 Center Care Phone: 469-495-9116 8 Texas Health Urgent 6411 E Northwest PO Box 735421 81-4317635 Urgent 4D Care DBA Texas Hwy, Suite 120 Dallas, TX 75373-5421 Care Health Breeze Urgent Dallas, TX 75231- 800-890-6034 Center Care 8007 469-495-9110 9 Texas Health Urgent 6225 N Josey Lane, PO Box 735421 81-4317635 Urgent 4D Care DBA Texas Suite L100 Dallas, TX 75373-5421 Care Health Breeze Urgent Lewisville, TX 800-890-6034 Center Care 75056-2481 469-495-9128 10 Texas Health Urgent 5964 Parker Road, PO Box 735421 81-4317635 Urgent 4D Care DBA Texas Suite 100 Dallas, TX 75373-5421 Care Health Breeze Urgent Plano, TX 75093- 800-890-6034 Center Care 7788 469-495-9122 11 Texas Health Urgent 4135 Belt Line Road PO Box 735421 81-4317635 Urgent 4D Care DBA Texas Suite 124 Dallas, TX 75373-5421 Care Health Breeze Urgent Addison, TX 75001- 800-890-6034 Center Care 5879 469-495-9126 12 Texas Health Urgent 130 N Denton Tap PO Box 735421 81-4317635 Urgent 4D Care DBA Texas Road Dallas, TX 75373-5421 Care Health Breeze Urgent Coppell, TX 75019- 800-890-6034 Center Care 2155 469-495-9130 13 Texas Health Urgent 140 S Custer Road, PO Box 735421 81-4317635 Urgent 4D Care DBA Texas Suite 100, Dallas, TX 75373-5421 Care Health Breeze Urgent McKinney, TX 800-890-6034 Center Care 75072 469-495-9124 14 Texas Health Urgent 5252 Golden PO Box 735421 81-4317635 Urgent 4D Care DBA Texas Triangle Blvd., Suite Dallas, TX 75373-5421 Care Health Breeze Urgent 500, Fort Worth, TX 800-890-6034 Center Care 76244 682-212-9134 15 Texas Health Urgent 499 S Hwy 78, Suite PO Box 735421 81-4317635 Urgent 4D Care DBA Texas 100, Wylie, TX Dallas, TX 75373-5421 Care Health Breeze Urgent 75098-3946 800-890-6034 Center Care 469-495-9138 16 Texas Health Urgent PO Box 735421 81-4317635 Urgent 4D Care DBA Texas 6969 Arapaho Road, Dallas, TX 75373-5421 Care Health Breeze Urgent g Dallas, TX 75248 800-890-6034 Center 469-495-9132 Care Sixteenth Amendment to Master Services Agreement Page 21 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E THR Facility Service Address & Phone Number 17 Texas Health Urgent 805 W McDermott Care DBA Texas Drive, Suite 200, Health Breeze Urgent Allen, TX 75013 Care 469-495-9136 18 Texas Health Urgent Care DBA Texas 4600 Teasley Lane Health Breeze Urgent Denton, TX 76210 940-307-1020 Care 19 Texas Health Urgent 5937 Donnelly Ave. Care DBA Texas Fort Worth, TX Health Breeze Urgent 76107 Care 682-212-9140 20 Texas Health Urgent 2100 N Collins St, Care DBA Texas Ste 120 Health Breeze Urgent Arlington, Fort Care Worth, TX 76011 682-212-9144 21 Texas Health Urgent Care DBA Texas 2235 S Goliad St., Health Breeze Urgent Ste 110 Care Rockwall, TX 75032 469-495-9142 CONFIDENTIAL AND PROPRIETARY Claims Payment Tax ID Facility Rate Address & Phone Number Type Exhibit # Number PO Box 735421 81-4317635 Urgent 4D Dallas, TX 75373-5421 Care 800-890-6034 Center PO Box 735421 Dallas, TX 75373-5421 800-890-6034 PO Box 735421 Dallas, TX 75373-5421 800-890-6034 PO Box 735421 Dallas, TX 75373-5421 800-890-6034 PO Box 735421 Dallas, TX 75373-5421 800-890-6034 22 Texas Health Urgent I I I W Debbie Ln., PO Box 735421 Care DBA Texas Ste 101 Dallas, TX 75373-5421 Health Breeze Urgent Mansfield, TX 76063 800-890-6034 Care 682-212-9148 23 Texas Health Urgent 420 E Pleasant Run PO Box 735421 Care DBA Texas Rd., Ste 330 Dallas, TX 75373-5421 Health Breeze Urgent Cedar Hill, TX 75104 800-890-6034 Care 469-495-9150 24 Texas Health Urgent 1225 E Belt Line Rd., PO Box 735421 Care DBA Texas Ste 200 Dallas, TX 75373-5421 Health Breeze Urgent Richardson, TX 800-890-6034 Care 75081 469-495-9154 25 Texas Health Urgent 4480 Bryant Irvin Rd PO Box 735421 Care DBA Texas Fort Worth, TX Dallas, TX 75373-5421 Health Breeze Urgent 76132 800-890-6034 Care 682-212-9160 26 Texas Health Urgent 12601 South Frwy, PO Box 735421 Care DBA Texas Ste 110 Dallas, TX 75373-5421 Health Breeze Urgent Burleson, TX 800-890-6034 Care 76028-7184 682-212-9146 27 Texas Health Urgent PO Box 735421 Care DBA Texas Oak Lawn Ave. Dallas, TX 75373-5421 Health Breeze Urgent Dall Dallas, 800-890-6034 75219-4107 Care 469-495-9162 81-4317635 Urgent Care Center 81-4317635 Urgent Care Center 81-4317635 Urgent Care Center 81-4317635 Urgent Care Center 81-4317635 Urgent Care Center 81-4317635 Urgent Care Center 81-4317635 Urgent Care Center 81-4317635 Urgent Care Center 81-4317635 Urgent Care Center 81-4317635 Urgent Care Center 4D 4D 4D CM 4D 4D 4D 4D 4D 4D Sixteenth Amendment to Master Services Agreement Page 22 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CONFIDENTIAL AND PROPRIETARY THR Facility Service Address & Claims Payment Tax ID Facility Rate Phone Number Address & Phone Number Type Exhibit # Number 28 Texas Health Urgent 1980 S Main St. PO Box 735421 81-4317635 Urgent 4D Care DBA Texas Weatherford, TX Dallas, TX 75373-5421 Care Health Breeze Urgent 76086-5508 800-890-6034 Center Care 817-598-5616 29 Texas Health Urgent 3210 Milrany Ln, PO Box 735421 81-4317635 Urgent 4D Care DBA Texas Ste 100 Dallas, TX 75373-5421 Care Health Breeze Urgent Melissa, TX 75454 800-890-6034 Center Care 469-495-9164 30 Texas Health Urgent 726 W Belt Line Rd. PO Box 735421 81-4317635 Urgent 4D Care DBA Texas Desoto, TX Dallas, TX 75373-5421 Care Health Breeze Urgent 75115-4000 800-890-6034 Center Care 469-495-9152 • Facility list is subject to change as new locations are added to THR. • THR shall provide Employer with an updated list of facilities at least quarterly. Sixteenth Amendment to Master Services Agreement Page 23 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CONFIDENTIAL AND PROPRIETARY FACILITY SERVICES AGREEMENT EXHIBIT 4 Employer Payment Exhibit Facility Type: THR Hospital Effective Date of this Appendix: January 1, 2025 through December 31, 2025 APPLICABILITY The provisions of this Appendix apply to Covered Services rendered by THR at THR locations identified in Appendix 1 to Covered Persons covered by Employer Benefit Plans. SECTION 1 Definitions Unless otherwise defined in this Section 1, capitalized terms used in this Appendix have the meanings assigned to them in the Agreement. Admission: The admittance of a Covered Person to a licensed hospital bed, excluding Observation. Admission applies only to those services provided by order of a Physician. Covered Service: A health care service or product for which a Covered Person is entitled to receive coverage from a Payor, pursuant to the terms of the Covered Person's Benefit Plan with that Payor. Billed Charge: The fee for health care services charged by THR that does not exceed the fee THR would ordinarily charge another person regardless of whether the person is a Covered Person. For purposes of this Agreement, Billed Charge shall not include or take into account any reduction of or discount to the Billed Charge that THR charges to patients of THR who cannot afford their hospital bills, including charges determined under THR's charity care policy or a program for the uninsured. In the event THR desires to establish a separate or alternate charge master for the uninsured, THR will provide at least 30 days prior notice to Payor and, if requested by Payor, will meet with Payor to explain the program and intended use of the alternate charge master and address any concerns Payor has relating to this Agreement. Covered Person Expenses: Copayments, deductibles, coinsurance and non -covered services that are the financial responsibility of the Covered Person according to the Covered Person's Benefit Plan. Eligible Charges: The Billed Charge for Covered Services. Percentage Payment Rate: The percentage applied to THR's Eligible Charge to determine the contract rate for those Covered Services for which the contract rate is calculated as a percentage of Eligible Charges. This shall be referred to as "PPR" in this Appendix. Sixteenth Amendment to Master Services Agreement Page 24 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CONFIDENTIAL AND PROPRIETARY SECTION 2 Contract Rate for Covered Services Table C-1: THR Hospital Rates INPATIENT SERVICE CATEGORY PAYMENT RATE METHOD All Inpatient Services PPR 47.0% OUTPATIENT SERVICE CATEGORY PAYMENT RATE METHOD All Outpatient Services PPR 47.0% 2.1 THR-based Physician and Other Provider Charges. All Charges, other than those billed by THR or included in the contract rates set forth in this Appendix Section 1, for professional services provided by THR-based providers are paid in addition to the contract rates set forth in this Appendix. If THR bills for professional services, then THR will submit the bill under a CMS 1500 form which will be adjudicated according to a separate group agreement. Sixteenth Amendment to Master Services Agreement Page 25 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CONFIDENTIAL AND PROPRIETARY FACILITY SERVICES AGREEMENT EXHIBIT 4A Employer Payment Appendix for Long Term Acute Care Hospitals Effective January 1, 2025 through December 31, 2025 Texas Health Specialty Hospital Fort Worth APPLICABILITY The provisions of this Appendix apply to Covered Services rendered by THR at THR locations identified in Appendix 1 to Covered Persons covered by Employer Benefit Plans. SECTION 1 Definitions Unless otherwise defined in this Section 1, capitalized terms used in this Appendix have the meanings assigned to them in the Agreement. Admission: The admittance of a Covered Person to a licensed hospital bed, excluding Observation. Admission applies only to those services provided by order of a Physician. Covered Service: A health care service or product for which a Covered Person is entitled to receive coverage from a Payor, pursuant to the terms of the Covered Person's Benefit Plan with that Payor. Billed Charge: The fee for health care services charged by THR that does not exceed the fee THR would ordinarily charge another person regardless of whether the person is a Covered Person. For purposes of this Agreement, Billed Charge shall not include or take into account any reduction of or discount to the Billed Charge that THR charges to patients of THR who cannot afford their hospital bills, including charges determined under THR's charity care policy or a program for the uninsured. In the event THR desires to establish a separate or alternate charge master for the uninsured, THR will provide at least 30 days prior notice to Payor and, if requested by Payor, will meet with Payor to explain the program and intended use of the alternate charge master and address any concerns Payor has relating to this Agreement. Covered Person Expenses: Copayments, deductibles, coinsurance and non -covered services that are the financial responsibility of the Covered Person according to the Covered Person's Benefit Plan. Eligible Charges: The Billed Charge for Covered Services. Percentage Payment Rate: The percentage applied to THR's Eligible Charge to determine the contract rate for those Covered Services for which the contract rate is calculated as a percentage of Eligible Charges. This shall be referred to as "PPR" in this Appendix. Sixteenth Amendment to Master Services Agreement Page 26 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CONFIDENTIAL AND PROPRIETARY SECTION 2 Contract Rate for Covered Services Table C-3: LTAC Rates PAYMENT INPATIENT SERVICE CATEGORY RATE METHOD All Inpatient Services PPR 38.0% PAYMENT OUTPATIENT SERVICE CATEGORY RATE METHOD All Outpatient Services PPR 38.0% 2.1 THR-based Physician and Other Provider Charges. All Charges, other than those billed by THR or included in the contract rates set forth in this Appendix Section 1, for professional services provided by THR-based providers are paid in addition to the contract rates set forth in this Appendix. If THR bills for professional services, then THR will submit the bill under a CMS 1500 form which will be adjudicated according to a separate group agreement. Sixteenth Amendment to Master Services Agreement Page 27 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CONFIDENTIAL AND PROPRIETARY FACILITY SERVICES AGREEMENT EXHIBIT 4B Employer Payment Appendix Facility Type: Ambulatory Surgery Centers Effective Date of this Appendix: January 1, 2025 through December 31, 2025 APPLICABILITY The provisions of this Appendix apply to Covered Services rendered by THR at THR locations identified in Exhibit A to Covered Persons covered by Employer Benefit Plans. SECTION 1 Definitions Unless otherwise defined in this Section 1, a capitalized term used in this Appendix shall have the meanings assigned to them in this Agreement. Covered Service: A health care service or product for which a Covered Person is entitled to receive coverage from a Payor, pursuant to the terms of the Covered Person's Benefit Plan with that Payor. Billed Charge: The fee for health care services charged by THR that does not exceed the fee THR would ordinarily charge another person regardless of whether the person is a Covered Person. For purposes of this Agreement, Billed Charge shall not include or take into account any reduction of or discount to the Billed Charge that THR charges to patients of THR who cannot afford their hospital bills, including charges determined under THR's charity care policy or a program for the uninsured. In the event THR desires to establish a separate or alternate charge master for the uninsured, THR will provide at least 30 days prior notice to Payor and, if requested by Payor, will meet with Payor to explain the program and intended use of the alternate charge master and address any concerns Payor has relating to this Agreement. Covered Person Expenses: Copayments, deductibles, coinsurance and non -covered services that are the financial responsibility of the Covered Person according to the Covered Person's Benefit Plan. Eligible Charges: The Billed Charge for Covered Services. Percentage Payment Rate: The percentage applied to THR's Eligible Charge to determine the contract rate for those Covered Services for which the contract rate is calculated as a percentage of Eligible Charges. This shall be referred to as "PPR" in this Appendix. Physician: A Doctor of Medicine ("M.D.") or a Doctor of Osteopathy ("D.O.") or another health care professional as authorized under state law, facility bylaws and applicable Benefit Plan to refer patients to THRTHR for Covered Services. Sixteenth Amendment to Master Services Agreement Page 28 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CONFIDENTIAL AND PROPRIETARY SECTION 2 Contract Rate for Covered Services Table C-4: Ambulatory Surgery Center Rates OUTPATIENT SERVICE CATEGORY All Outpatient Services PAYMENT RATE METHOD PPR 47.0 % 2.1 THR-based Physician and Other Provider Charges. All Charges, other than those billed by THR or included in the contract rates set forth in this Appendix Section 1, for professional services provided by THR-based providers are paid in addition to the contract rates set forth in this Appendix. If THR bills for professional services, then THR will submit the bill under a CMS 1500 form which will be adjudicated according to a separate group agreement. Sixteenth Amendment to Master Services Agreement Page 29 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CONFIDENTIAL AND PROPRIETARY FACILITY SERVICES AGREEMENT EXHIBIT 4C Employer Payment Appendix Facility Type: Freestanding Radiology Centers Effective Date of this Appendix: January 1, 2025 through December 31, 2025 APPLICABILITY The provisions of this Appendix apply to Covered Services rendered by THR at THR locations identified in Exhibit A to Covered Persons covered by Employer Benefit Plans. SECTION 1 Definitions Unless otherwise defined in this Section 1, a capitalized term used in this Appendix shall have the meanings assigned to them in this Agreement. Covered Service: A health care service or product for which a Covered Person is entitled to receive coverage from a Payor, pursuant to the terms of the Covered Person's Benefit Plan with that Payor. Billed Charge: The fee for health care services charged by THR that does not exceed the fee THR would ordinarily charge another person regardless of whether the person is a Covered Person. For purposes of this Agreement, Billed Charge shall not include or take into account any reduction of or discount to the Billed Charge that THR charges to patients of THR who cannot afford their hospital bills, including charges determined under THR's charity care policy or a program for the uninsured. In the event THR desires to establish a separate or alternate charge master for the uninsured, THR will provide at least 30 days prior notice to Payor and, if requested by Payor, will meet with Payor to explain the program and intended use of the alternate charge master and address any concerns Payor has relating to this Agreement. Covered Person Expenses: Copayments, deductibles, coinsurance and non -covered services that are the financial responsibility of the Covered Person according to the Covered Person's Benefit Plan. Eligible Charges: The Billed Charge for Covered Services. Percentage Payment Rate: The percentage applied to THR's Eligible Charge to determine the contract rate for those Covered Services for which the contract rate is calculated as a percentage of Eligible Charges. This shall be referred to as "PPR" in this Appendix. Physician: A Doctor of Medicine ("M.D.") or a Doctor of Osteopathy ("D.O.") or another health care professional as authorized under state law, facility bylaws and applicable Benefit Plan to refer patients to THRTHR for Covered Services. Sixteenth Amendment to Master Services Agreement Page 30 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CONFIDENTIAL AND PROPRIETARY SECTION 2 Contract Rate for Covered Services Table C-5: Freestanding Radiology Center Rates. OUTPATIENT SERVICE CATEGORY PAYMENT RATE METHOD CT (Revenue Codes: 350-352, 359) Per Unit $786 MRI/MRA ( Revenue Codes: 610-612, 614-616, 618-619) Per Unit $1,154 PET Scan (Revenue Code: 404) Per Unit $3,300 Mammogram (Revenue Codes: 401, 403) Per Unit $388 All Other Services PPR 31.0% 2.1 THR-based Physician and Other Provider Charges. All Charges, other than those billed by THR or included in the contract rates set forth in this Appendix Section 1, for professional services provided by THR-based providers are paid in addition to the contract rates set forth in this Appendix. If THR bills for professional services, then THR will submit the bill under a CMS 1500 form which will be adjudicated according to a separate group agreement. Sixteenth Amendment to Master Services Agreement Page 31 of 32 Docusign Envelope ID: 7F4252DD-B301-4901-BEE4-16611372AB5E CONFIDENTIAL AND PROPRIETARY FACILITY SERVICES AGREEMENT EXHIBIT 4D Employer Payment Appendix Facility Type: Urgent Care Centers Effective Date of this Appendix: January 1, 2025 through December 31, 2025 SERVICES: Facility agrees to provide urgent office -based medical services, stat laboratory and plain x-ray film services, minor surgical procedures, closed treatment of fractures as is clinically prudent, and injectables as clinically indicated. Follow-up care shall be directed to the member's Primary Care Physician. OUTPATIENT RATES: Global Fee Urgent Care Centers HCPC Codes: S9083 All Services not otherwise identified Definitions: RATE TERM AND CONDITIONS: $185.00 Once Per Unique Code Per Service Date Not Reimbursed a) Facility agrees to accept an "All -Inclusive Visit Rate" as payment in full for all Covered Services including but not limited to diagnostic laboratory and radiology, procedures, injectables, and durable medical equipment provided to Members during the urgent care visit. Facility must utilize the codes set forth in the rate section above. b) All Rates are inclusive of any applicable Member Copayment, Coinsurance, Deductible and any applicable tax including but not limited to sales tax. Provider shall be paid at the applicable contracted rate. Sixteenth Amendment to Master Services Agreement Page 32 of 32