State of Utah Durable Medical Equipment US MED LLC 451 N Main Alpine Home Medical Phone Number Only Milford UT

State of Utah Durable Medical Equipment US MED LLC 451 N Main Alpine Home Medical Phone Number Only Milford UT. 84751 Beaver County Phone Number Only p 800.787.6331 p 435.438.7280 p 800.686.7993 Breast Pumps United States Medical Hospital Affiliation Alpine Home Medical CCS Medical Supply - Beaver Valley Hospital Phone Number Only Phone Number Only Phone Number Only - Milford Valley Hospital p 800.686.7993 p 800.726.9811 p 877.840.8218 Home Health Agency Edgepark Care Rehab and Orthopedic Family Practice Beaver Valley Home Health Phone Number Only Products (Muscle Oakden, R W MD 1109 W 100 W p 800.321.0591 Stimulators) Beaver Medical Clinic Ste 102 Phone Number Only 1059 N 100 W Beaver UT. 84713 Cardiac Monitoring p 800.487.9644 Beaver UT. 84713 p 435.438.5481 Remote Cardiac Services p 435.438.7280 Phone Number Only DJO Global Hospice p 800.367.0300 Phone Number Only Milford Medical Clinic Beaver Valley Hospice p 800.336.6569 451 N Main 1109 W 100 W eCardio Diagnostics Milford UT. 84751 Ste 102 Phone Number Only Dynasplint Systems Inc p 435.387.2471 Beaver UT. 84713 p 888.400.3522 Phone Number Only p 435.438.5481 p 800.638.6771 Hospital Affiliation Cardiology - Beaver Valley Hospital Hospital Dahl, Charles F MD EBI LLC (Bone Stimulators) - Milford Valley Hospital Beaver Valley Hospital Revere Health Phone Number Only 1109 N 100 W 1109 N 100 W p 800.526.2579 Smith, Lance C MD Beaver UT. 84713 Beaver UT. 84713 Milford Medical Clinic p 435.438.7100 p 801.373.4366 Edgepark 1059 N 100 W Phone Number Only Beaver UT. 84713 Millford Valley Hospital Hospital Affiliation p 800.321.0591 p 435.387.2471 850 N Main St - Timpanogos Regional Hospital Milford UT. 84751 - Mountain View Hospital Empi Inc (Neuromuscular Parowan Medical Clinic p 435.387.2411 (UT) Stimulator) 450 E Clinic Way Phone Number Only Parowan UT. 84713 Laboratory Jones, Jamison C MD p 800.328.2536 p 435.477.3344 Dominion Diagnostics Revere Health Phone Number Only 1059 N 100 W KCI USA Inc (Wound Vac Milford Medical Clinic p 877.734.9600 Beaver UT. 84713 Only) 451 N Main p 435.383.9009 Phone Number Only Milford UT. 84713 LabCorp of America p 800.275.4524 p 435.438.7280 Holdings Hospital Affiliation Phone Number Only - St George Regional Hospital Orthofix Inc (Bone Growth Hospital Affiliation p 888.522.2677 Stimulators Physicians - Beaver Valley Hospital Diabetic Supplies Only) - Milford Valley Hospital Mental Health CCS Medical Phone Number Only Langford, Scott A LCSW Phone Number Only p 800.535.4492 Smith, Rhett R MD Beaver Valley Hospital p 800.726.9811 Milford Medical Clinic 1109 N 100 W Pacific Medical Inc 1059 N 100 W Beaver UT. 84713 Edgepark Phone Number Only Beaver UT. 84713 p 435.438.7183 Phone Number Only p 800.726.9180 p 435.438.7280 p 800.321.0591 Occupational Therapy RespirTech 850 N Main St Concentra Medical Centers Roche Insulin Delivery Phone Number Only Milford UT. 84751 2390 Redwood Rd Systems Inc p 800.793.1261 p 435.387.2471 West Valley City UT. 84419 Phone Number Only p 888.997.2669 p 800.280.7801 Roche Insulin Delivery Hospital Affiliation Systems Inc - Bear River Valley Hospital Orthopedic Surgery US MED LLC Phone Number Only *Robinson, Ben C Phone Number Only p 800.280.7801 Smith, Roger H MD Sevier Valley Specialty - p 800.787.6331 Milford Medical Clinic Orthopedics - Beaver Smith Nephew Inc (Muscle 1059 N 100 W 1059 N 100 W United States Medical Stimulators) Beaver UT. 84713 Beaver UT. 84713 Supply Phone Number Only p 435.387.2471 p 435.893.0800 Phone Number Only p 800.821.5700 p 877.840.8218 Hospital Affiliation - Cedar City Hospital - Sanpete Valley Hospital

1 *The PPO Agreement with this provider is expressly between the Third Party Administrator or Trust Fund and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Physical Therapy Fujiwara, Mina BCBA Knudson, Mani BCBA Metzger, Debbie BCBA Concentra Medical Centers Utah Behavior Services Utah Behavior Services Utah Behavior Services 2390 Redwood Rd 35 Skyline Dr 35 Skyline Dr 35 Skyline Dr West Valley City UT. 84419 Ste 103 Ste 103 Ste 103 p 888.997.2669 Brigham City UT. 84302 Brigham City UT. 84302 Brigham City UT. 84302 p 801.255.5131 p 801.255.5131 p 801.255.5131 Podiatry Clark, Gary W DPM Green, Rachal BCBA,LCSW Kulow, Kacylia BCBA Nadalsky, Michelle Gary W Clark DPM Utah Behavior Services Utah Behavior Services BCBA,SSW 444 S Main St 35 Skyline Dr 35 Skyline Dr Utah Behavior Services Milford UT. 84751 Ste 103 Ste 103 35 Skyline Dr p 888.437.3668 Brigham City UT. 84302 Brigham City UT. 84302 Ste 103 p 801.255.5131 p 801.255.5131 Brigham City UT. 84302 55 N 400 E p 801.255.5131 Beaver UT. 84713 Gressmen, Casey BCBA Lambertsen, Hope BCBA p 888.437.3668 Utah Behavior Services Utah Behavior Services Oblad, Cicily BCBA 35 Skyline Dr 35 Skyline Dr Utah Behavior Services Hospital Affiliation Ste 103 Ste 103 35 Skyline Dr - Cedar City Hospital Brigham City UT. 84302 Brigham City UT. 84302 Ste 103 p 801.255.5131 p 801.255.5131 Brigham City UT. 84302 Social Worker p 801.255.5131 Langford, Scott A LCSW Hanks, Julie BCBA Lee, Jennifer BCBA Beaver Valley Hospital Utah Behavior Services Utah Behavior Services Rae, Rebecca BCBA 1109 N 100 W 35 Skyline Dr 35 Skyline Dr Utah Behavior Services Beaver UT. 84713 Ste 103 Ste 103 35 Skyline Dr p 435.438.7183 Brigham City UT. 84302 Brigham City UT. 84302 Ste 103 p 801.255.5131 p 801.255.5131 Brigham City UT. 84302 Box Elder County p 801.255.5131 Hoffmann, Audrey PhD Lopez, Kitrina BCBA Aba Therapy Utah Behavior Services Utah Behavior Services Renda, Cheyenne R PhD Adolphson, Lillian 35 Skyline Dr 35 Skyline Dr Utah Behavior Services BCBA-D Ste 103 Ste 103 35 Skyline Dr Utah Behavior Services Brigham City UT. 84302 Brigham City UT. 84302 Ste 103 35 Skyline Dr p 801.255.5131 p 801.255.5131 Brigham City UT. 84302 Ste 103 p 801.255.5131 Brigham City UT. 84302 Hunt, Chelseigh BCBA Lowe, Kori BCBA p 801.255.5131 Utah Behavior Services Utah Behavior Services Rhodes, Tiffany BCBA 35 Skyline Dr 35 Skyline Dr Utah Behavior Services Aleman, Arianna BCBA Ste 103 Ste 103 35 Skyline Dr Utah Behavior Services Brigham City UT. 84302 Brigham City UT. 84302 Ste 103 35 Skyline Dr p 801.255.5131 p 801.255.5131 Brigham City UT. 84302 Ste 103 p 801.255.5131 Brigham City UT. 84302 Jensen, Julia P BCBA Madsen, Sara BCBA p 801.255.5131 Utah Behavior Services Utah Behavior Services Rockwell, Rene BCBA 35 Skyline Dr 35 Skyline Dr Utah Behavior Services Christianson, Grete BCBA Ste 103 Ste 103 35 Skyline Dr Utah Behavior Services Brigham City UT. 84302 Brigham City UT. 84302 Ste 103 35 Skyline Dr p 801.255.5131 p 801.255.5131 Brigham City UT. 84302 Ste 103 p 801.255.5131 Brigham City UT. 84302 Keller, Rebecca BCBA Maxwell, Kendra BCBA p 801.255.5131 Utah Behavior Services Utah Behavior Services Sagendorf, Emily BCBA 35 Skyline Dr 35 Skyline Dr Utah Behavior Services Corey, Spencer BCBA Ste 103 Ste 103 35 Skyline Dr Utah Behavior Services Brigham City UT. 84302 Brigham City UT. 84302 Ste 103 35 Skyline Dr p 801.255.5131 p 801.255.5131 Brigham City UT. 84302 Ste 103 p 801.255.5131 Brigham City UT. 84302 Kennedy, Anne BCBA McGuire, Amy BCBA p 801.255.5131 Utah Behavior Services Utah Behavior Services Sanders, Sarah BCBA 35 Skyline Dr 35 Skyline Dr Utah Behavior Services Deceuster, Rachael BCBA Ste 103 Ste 103 35 Skyline Dr Utah Behavior Services Brigham City UT. 84302 Brigham City UT. 84302 Ste 103 35 Skyline Dr p 801.255.5131 p 801.255.5131 Brigham City UT. 84302 Ste 103 p 801.255.5131 Brigham City UT. 84302 p 801.255.5131

2 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Smith, Erica BCBA Wulfenstein, Lee BCBA Center *Otrusinik, Rudolf MD Utah Behavior Services Utah Behavior Services - Brigham City Community Bear River Valley Hospital 35 Skyline Dr 35 Skyline Dr Hospital 905 N 1000 W Ste 103 Ste 103 - Davis Hospital Tremonton UT. 84337 Brigham City UT. 84302 Brigham City UT. 84302 - Cache Valley Hospital p 435.207.4500 p 801.255.5131 p 801.255.5131 Asay, Ronald W MD Bear River Specialists Smith, Saige LPC Yang, Danielle BCBA Mountainstar Cardiology St 935 N 1000 W Utah Behavior Services Utah Behavior Services Marks Tremonton UT. 84337 35 Skyline Dr 35 Skyline Dr 970 Medical Dr p 435.207.4800 Ste 103 Ste 103 Ste 311 Brigham City UT. 84302 Brigham City UT. 84302 Brigham City UT. 84302 Hospital Affiliation p 801.255.5131 p 801.255.5131 p 801.479.0184 - Logan Regional Hospital

Snow, Lauren BCBA Allergy And Immunology Hospital Affiliation *Tom, Cindy W MD Utah Behavior Services *Dickson, Scott D DO - Timpanogos Regional Hospital Bear River Valley Hospital 35 Skyline Dr Bear River Specialists - Mountain View Hospital Physicians Ste 103 935 N 1000 W (UT) 905 N 1000 W Brigham City UT. 84302 Tremonton UT. 84337 Tremonton UT. 84337 p 801.255.5131 p 435.207.4800 *Collado, Sergio MD p 435.207.4500 Bear River Valley Hospital Stevens, Nicole Audiology Physicians Hospital Affiliation BCBA,LMFT Braunberger, Kerry S AUD 905 N 1000 W - Logan Regional Hospital Utah Behavior Services Eartech Audiology Tremonton UT. 84337 35 Skyline Dr 950 S Medical Dr p 435.207.4500 Yaganti, Vamsee M MD Ste 103 Ste 103 Mountainstar Cardiology St Brigham City UT. 84302 Brigham City UT. 84302 Bear River Specialists Marks p 801.255.5131 p 801.399.9955 935 N 1000 W 970 Medical Dr Tremonton UT. 84337 Ste 311 35 Skyline Dr Clawson, Terry D AUD p 435.207.4800 Brigham City UT. 84302 Ste 103 Eartech Audiology p 801.479.0184 Brigham City UT. 84302 950 S Medical Dr Domanski, Damian J MD p 801.255.5131 Ste 103 Mountainstar Cardiology St Zebrack, James S MD Brigham City UT. 84302 Marks Mountainstar Cardiology St Whatcott, Natalie p 801.399.9955 970 Medical Dr Marks BCBA,SSW Ste 311 970 Medical Dr Utah Behavior Services Robinson, Dave AUD Brigham City UT. 84302 Ste 311 35 Skyline Dr Robinson Audiology p 801.479.0184 Brigham City UT. 84302 Ste 103 862 S Main St p 801.479.0184 Brigham City UT. 84302 Ste 7 Forstall, Peter G MD p 801.255.5131 Brigham City UT. 84302 Mountainstar Cardiology St Hospital Affiliation p 435.723.2727 Marks - St Marks Hospital Wills, Brooke BCBA 970 Medical Dr - Lone Peak Hospital Utah Behavior Services Breast Pumps Ste 311 - Timpanogos Regional Hospital 35 Skyline Dr Alpine Home Medical Brigham City UT. 84302 Ste 103 Phone Number Only p 801.479.0184 Certified Nurse Midwife Brigham City UT. 84302 p 800.686.7993 Overson, Christy A CNM p 801.255.5131 Hospital Affiliation Brigham Center for Womens Edgepark - Ogden Regional Medical Health Wilson, Megan BCBA Phone Number Only Center 970 Medical Dr Utah Behavior Services p 800.321.0591 - Brigham City Community Ste 202 35 Skyline Dr Hospital Brigham City UT. 84302 Ste 103 Cardiac Monitoring - Davis Hospital p 435.695.2273 Brigham City UT. 84302 Remote Cardiac Services - Cache Valley Hospital p 801.255.5131 Phone Number Only 984 S Medical Dr p 800.367.0300 Nielson, Kenneth G MD Ste 4 Woodall, Clifford BCBA Mountainstar Cardiology St Brigham City UT. 84302 Utah Behavior Services eCardio Diagnostics Marks p 435.695.2273 35 Skyline Dr Phone Number Only 970 Medical Dr Ste 103 p 888.400.3522 Ste 311 Hospital Affiliation Brigham City UT. 84302 Brigham City UT. 84302 - Brigham City Community p 801.255.5131 Cardiology p 801.479.0184 Hospital Almony, Gregory T MD - Ogden Regional Medical Mountainstar Cardiology St Hospital Affiliation Center Marks - St Marks Hospital 970 Medical Dr - Lone Peak Hospital Ste 311 - Timpanogos Regional Hospital Brigham City UT. 84302 p 801.479.0184

Hospital Affiliation 3 *The PPO Agreement with this provider is expressly between- Ogden the Regional Third Party Medical Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Chiropractic King, Kelsey LCSW Dermatology US MED LLC Hoopes, Jeremiah DC Utah Behavior Services *Hanson, Nathan W MD Phone Number Only Body Needs 35 Skyline Dr Bear River Specialists p 800.787.6331 770 S 200 E Ste 103 935 N 1000 W Brigham City UT. 84302 Brigham City UT. 84302 Tremonton UT. 84337 United States Medical p 435.723.0517 p 801.255.5131 p 435.207.4800 Supply Phone Number Only Counseling Lofthouse, Chelsea ACMHC Hospital Affiliation p 877.840.8218 Acevedo, Carlos ACMHC Utah Behavior Services - Logan Regional Hospital Utah Behavior Services 35 Skyline Dr Durable Medical Equipment 35 Skyline Dr Ste 103 Heaton, Jared DO Advantage Medical Supply Ste 103 Brigham City UT. 84302 Rocky Mountain Dermatology 590 Greenwood Dr Brigham City UT. 84302 p 801.255.5131 1030 Medical Dr Brigham City UT. 84302 p 801.255.5131 Ste A p 435.734.0488 Lovelace, Scott LCMHC Brigham City UT. 84302 Archuleta, Jason LCSW Utah Behavior Services p 801.827.9100 Alpine Home Medical Utah Behavior Services 35 Skyline Dr Phone Number Only 35 Skyline Dr Ste 103 Hospital Affiliation p 800.686.7993 Ste 103 Brigham City UT. 84302 - Lakeview Hospital Brigham City UT. 84302 p 801.255.5131 CCS Medical p 801.255.5131 MacDonald, Scott MD Phone Number Only Openshaw, D. K LCSW Rocky Mountain Dermatology p 800.726.9811 Arrington, John W LMFT 295 W Schiess Ct 1030 Medical Dr Associated Garland UT. 84312 Ste A Care Rehab and Orthopedic Psychotherapists p 435.753.7332 Brigham City UT. 84302 Products (Muscle 120 N Main St p 801.827.9100 Stimulators) Brigham City UT. 84302 Salsberry, Maria CSW Phone Number Only p 435.723.2881 Utah Behavior Services *McCaughey, Cort D MD p 800.487.9644 35 Skyline Dr Bear River Specialists Ayotte, Diana S LPC Ste 103 935 N 1000 W DJO Global Serendipity Brigham City UT. 84302 Tremonton UT. 84337 Phone Number Only 102 N Main St p 801.255.5131 p 435.207.4800 p 800.336.6569 Ste 301 Brigham City UT. 84302 Stasiuk, John A LMFT Hospital Affiliation Dynasplint Systems Inc p 435.723.2881 Utah Behavior Services - Logan Regional Hospital Phone Number Only 35 Skyline Dr p 800.638.6771 Black, Jed CMHC Ste 103 Urry, Larry E MD Utah Behavior Services Brigham City UT. 84302 950 S 500 W EBI LLC (Bone Stimulators) 35 Skyline Dr p 801.255.5131 Ste 103 Phone Number Only Ste 103 Brigham City UT. 84302 p 800.526.2579 Brigham City UT. 84302 Williams, Jason J LMFT p 800.914.9259 p 801.255.5131 Associated Edgepark Psychotherapists Young, Robert P MD Phone Number Only Christensen, John C LMFT 120 N Main St Rocky Mountain Dermatology p 800.321.0591 Associated Brigham City UT. 84302 1030 Medical Dr Psychotherapists p 435.723.2881 Ste A Empi Inc (Neuromuscular 120 N Main St Brigham City UT. 84302 Stimulator) Brigham City UT. 84302 Dentist p 801.827.9100 Phone Number Only p 435.723.2881 Lauritzen, Christopher S p 800.328.2536 DDS Hospital Affiliation Cox, Patrick LPC Community Health Centers - Logan Regional Hospital KCI USA Inc (Wound Vac Utah Behavior Services 440 W 600 N Only) 35 Skyline Dr Tremonton UT. 84337 Diabetic Supplies Phone Number Only Ste 103 p 844.248.4110 CCS Medical p 800.275.4524 Brigham City UT. 84302 Phone Number Only p 801.255.5131 980 S 500 W p 800.726.9811 Orthofix Inc (Bone Growth Ste 1 Stimulators Physicians Goss, Angela CSW Brigham City UT. 84302 Edgepark Only) Utah Behavior Services p 435.723.8276 Phone Number Only Phone Number Only 35 Skyline Dr p 800.321.0591 p 800.535.4492 Ste 103 Hospital Affiliation Brigham City UT. 84302 - University of Utah Hospital Roche Insulin Delivery Pacific Medical Inc p 801.255.5131 Systems Inc Phone Number Only Phone Number Only p 800.726.9180 p 800.280.7801

4 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. RespirTech Family Practice *Gardner, Ricky L MD Keller, Bruce W MD Phone Number Only Allen, Lindee P NP Bear River Valley Hospital Brigham Medical Clinic p 800.793.1261 Brigham Medical Clinic 905 N 1000 W 600 W Hospital Rd 600 W Hospital Rd Tremonton UT. 84337 Brigham City UT. 84302 Roche Insulin Delivery Brigham City UT. 84302 p 435.207.4500 p 435.734.2041 Systems Inc p 435.734.2041 Phone Number Only Bear River *Kottsick, Summer R NP p 800.280.7801 *Allison, Camille H MD 935 N 1000 W Bear River Valley Hospital Bear River Valley Hospital Tremonton UT. 84337 Physicians Smith Nephew Inc (Muscle 905 N 1000 W p 435.207.4800 905 N 1000 W Stimulators) Tremonton UT. 84337 Tremonton UT. 84337 Phone Number Only p 435.207.4500 Goble, Deserae J MD p 435.207.4500 p 800.821.5700 Deserae J Goble MD PC Hospital Affiliation 1950 S Hwy 89 Bear River US MED LLC - Sanpete Valley Hospital Brigham City UT. 84302 935 N 1000 W Phone Number Only p 435.363.7853 Tremonton UT. 84337 p 800.787.6331 *Barker, Lance MD p 435.207.4800 Bear River Valley Hospital *Harris, Marcus D DO United States Medical 905 N 1000 W Bear River Clinic Hospital Affiliation Supply Tremonton UT. 84337 935 N 1000 W - Bear River Valley Hospital Phone Number Only p 435.207.4500 Tremonton UT. 84337 - Logan Regional Hospital p 877.840.8218 p 435.207.4800 Medical Arts Center Clinic Lakin, Bobbi MD Ear Nose And Throat 984 Medical Dr Hospital Affiliation Community Health Centers *Keyser, Jeffrey S MD Ste 1 - Oneida County Hospital 440 W 600 N Bear River Specialists Brigham City UT. 84302 Tremonton UT. 84337 935 N 1000 W p 435.723.5248 Hazelwood, Cynthia L NP p 844.248.4110 Tremonton UT. 84337 Alpine Orthopaedic p 435.207.4800 Hospital Affiliation Specialists 980 S 500 W - Brigham City Community 1030 S Medical Dr Ste 1 Hospital Affiliation Hospital Ste A Brigham City UT. 84302 - Logan Regional Hospital - Oneida County Hospital Brigham City UT. 84302 p 435.723.8276 p 435.723.9700 Major, Michael S MD Bear River Medical Arts Lee, Suzanne E MD Revere Health 300 W 1400 S Hobbs, Sydnie M APRN Community Health Centers 910 S 500 W Garland UT. 84312 Box Elder Community Health 980 S 500 W Ste 103 p 435.257.2469 Center Brigham City UT. 84302 Brigham City UT. 84302 5 W 200 N p 435.723.8276 p 801.465.4813 Claris Health Brigham City UT. 84302 1040 Medical Dr p 435.755.6061 Hospital Affiliation Hospital Affiliation Brigham City UT. 84302 - Jordan Valley Medical - Brigham City Community p 801.310.5800 *Hughes, Melanie C APRN Center West Valley Campus Hospital Bear River Valley Hospital - Ogden Regional Medical Community Health Centers 905 N 1000 W Lish, Jeffrey R MD Center 440 W 600 N Tremonton UT. 84337 Medical Arts Center Clinic Tremonton UT. 84337 p 435.207.4500 984 Medical Dr Electrophysiology p 844.248.4110 Ste 1 Forstall, Peter G MD Hospital Affiliation Brigham City UT. 84302 Mountainstar Cardiology St 980 S 500 W - Bear River Valley Hospital p 435.723.5248 Marks Ste 1 970 Medical Dr Brigham City UT. 84302 *Jenkins, Jonathan T MD Hospital Affiliation Ste 311 p 435.723.8276 Bear River - Brigham City Community Brigham City UT. 84302 935 N 1000 W Hospital p 801.479.0184 Fonnesbeck, Brant W DO Tremonton UT. 84337 Box Elder Community Health p 435.207.4800 *Lofgran, Brian C MD Hospital Affiliation Center Bear River Valley Hospital - Ogden Regional Medical 5 W 200 N Jennings, Caitlyn R PA 905 N 1000 W Center Brigham City UT. 84302 Vista Neurology Tremonton UT. 84337 - Brigham City Community p 435.755.6061 Specialists p 435.207.4500 Hospital 935 N 1000 W - Davis Hospital Bear River Valley Hospital Tremonton UT. 84337 *Miller, Todd J MD - Cache Valley Hospital 905 N 1000 W p 435.787.8146 Bear River Valley Hospital Tremonton UT. 84337 905 N 1000 W p 435.207.4500 Tremonton UT. 84337 p 435.207.4500 Hospital Affiliation - Bear River Valley Hospital - Logan Regional Hospital 5 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Bear River *Spencer, Matthew S MD General Surgery Home Health Agency 935 N 1000 W Bear River Valley Hospital Ashdown, Jan M MD CNS Community Nursing Tremonton UT. 84337 905 N 1000 W Ashdown Surgical Services p 435.207.4800 Tremonton UT. 84337 950 S 500 W Phone Number Only p 435.207.4500 Ste 104 Snowville UT. 84336 Hospital Affiliation Brigham City UT. 84302 p 800.501.0014 - Bear River Valley Hospital *Taylor, Blake S DO p 435.723.1114 - Oneida County Hospital Bear River Hospice Alliance 935 N 1000 W Hospital Affiliation 345 N Main Nagao, Scott M DO Tremonton UT. 84337 - Franklin County Medical Ste B Medical Arts Center Clinic p 435.207.4800 Center Brigham City UT. 84302 984 Medical Dr p 435.723.4404 Ste 1 Hospital Affiliation Hillam, Joseph D MD Brigham City UT. 84302 - Bear River Valley Hospital 990 S Medical Dr *Intermountain Homecare p 435.723.5248 Ste U2 *Home Health Tremonton Taylor, James R MD Brigham City UT. 84302 23 N 200 E Olsen, Sean L NP Brigham Medical Clinic p 435.734.9439 Tremonton UT. 84337 Bear River Medical Arts 600 W Hospital Rd p 435.207.4500 300 W 1400 S Brigham City UT. 84302 *Murphy, Kevin A MD Garland UT. 84312 p 435.734.2041 Bear River Specialists Hospice p 435.257.2469 935 N 1000 W Alpine Hospice Inc Hospital Affiliation Tremonton UT. 84337 95 N 100 E Redmond, Tiffany M PA-C - Brigham City Community p 435.207.4800 Brigham City UT. 84302 Box Elder Community Health Hospital p 435.734.1300 Center Hospital Affiliation 5 W 200 N Walker, Douglas C DO - Oneida County Hospital CNS Community Nursing Brigham City UT. 84302 300 W 1400 S Services p 435.723.7999 Garland UT. 84312 Walker, Derrick DO Phone Number Only p 435.257.3684 Brigham Center for Womens Snowville UT. 84336 Robertson, Glenn l MD Health p 800.501.0014 Box Elder Community Health Hospital Affiliation 970 Medical Dr Center - Bear River Valley Hospital Ste 202 Hospice Alliance 5 W 200 N Brigham City UT. 84302 345 N Main Brigham City UT. 84302 Watkins, Justin B DO p 435.695.2273 Ste B p 435.755.6061 Medical Arts Center Clinic Brigham City UT. 84302 984 Medical Dr 984 S Medical Dr p 435.723.4404 Schow, Jan-Erik MD Ste 1 Ste 4 Bear River Medical Arts Brigham City UT. 84302 Brigham City UT. 84302 *Intermountain Homecare 300 W 1400 S p 435.723.5248 p 435.723.0329 *Home Health Tremonton Garland UT. 84312 23 N 200 E p 435.257.2469 Weeks Juber, Jessica M PA Wride, Noah L MD Tremonton UT. 84337 Box Elder Community Health Brigham Center for Womens p 435.207.4500 Hospital Affiliation Center Health - Bear River Valley Hospital 5 W 200 N 970 Medical Dr Hospital Brigham City UT. 84302 Ste 202 *Bear River Valley Hospital Shaw, Michael C MD p 435.723.7999 Brigham City UT. 84302 905 N 1000 W Mountain Top Medical p 435.695.2273 Tremonton UT. 84337 140 E 1000 S Whetton, Bryan D PA-C p 435.207.4500 Ste B2 Box Elder Community Health Gynecology Brigham City UT. 84302 Center Bailey, Stanton A MD Brigham City Community p 435.723.5248 5 W 200 N Brigham Center for Womens Hospital Brigham City UT. 84302 Health 950 Medical Dr Hospital Affiliation p 435.723.7999 970 Medical Dr Brigham City UT. 84302 - Brigham City Community Ste 202 p 435.734.9471 Hospital Wilding, Gregg H MD Brigham City UT. 84302 Brigham Medical Clinic p 435.695.2273 Internal Medicine *Spencer, Jesse N MD 600 W Hospital Rd Beard, Lynn Q MD Bear River Valley Hospital Brigham City UT. 84302 984 S Medical Dr Medical Arts Center Clinic 905 N 1000 W p 435.734.2041 Ste 4 984 Medical Dr Tremonton UT. 84337 Brigham City UT. 84302 Ste 1 p 435.207.4500 Gastroenterology p 435.695.2273 Brigham City UT. 84302 Hillam, Joseph D MD p 435.723.5248 990 S Medical Dr Hospital Affiliation Ste U2 - Central Valley Medical Hospital Affiliation Brigham City UT. 84302 Center - Brigham City Community p 435.734.9439 - Gunnison Valley Hospital Hospital

6 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Domanski, Damian J MD Yen, Chi Gang MD Archuleta, Jason LCSW Christianson, Grete BCBA Mountainstar Cardiology St Mountainstar Cardiology St Utah Behavior Services Utah Behavior Services Marks Marks 35 Skyline Dr 35 Skyline Dr 970 Medical Dr 970 Medical Dr Ste 103 Ste 103 Ste 311 Ste 311 Brigham City UT. 84302 Brigham City UT. 84302 Brigham City UT. 84302 Brigham City UT. 84302 p 801.255.5131 p 801.255.5131 p 801.479.0184 p 801.479.0184 Arrington, John W LMFT Coburn, Alison MSW Keihanian, Mana MD Interventional Cardiology Associated Utah Behavior Services Mountainstar Cardiology St Yaganti, Vamsee M MD Psychotherapists 35 Skyline Dr Marks Mountainstar Cardiology St 120 N Main St Ste 103 970 Medical Dr Marks Brigham City UT. 84302 Brigham City UT. 84302 Ste 311 970 Medical Dr p 435.723.2881 p 801.255.5131 Brigham City UT. 84302 Ste 311 p 801.479.0184 Brigham City UT. 84302 Ayotte, Diana S LPC Corey, Spencer BCBA p 801.479.0184 Serendipity Utah Behavior Services Markeson, John R MD 102 N Main St 35 Skyline Dr Brigham Internal Medicine Yen, Chi Gang MD Ste 301 Ste 103 950 S Medical Dr Mountainstar Cardiology St Brigham City UT. 84302 Brigham City UT. 84302 Ste 106 Marks p 435.723.2881 p 801.255.5131 Brigham City UT. 84302 970 Medical Dr p 435.734.4088 Ste 311 Birch, Kelly LCSW Cox, Patrick LPC Brigham City UT. 84302 Utah Behavior Services Utah Behavior Services Hospital Affiliation p 801.479.0184 35 Skyline Dr 35 Skyline Dr - Brigham City Community Ste 103 Ste 103 Hospital Laboratory Brigham City UT. 84302 Brigham City UT. 84302 Dominion Diagnostics p 801.255.5131 p 801.255.5131 Nalabothu, Poorna L MD Phone Number Only Mountainstar Cardiology St p 877.734.9600 Black, Jed CMHC *Cummins, Karin A LCSW Marks Utah Behavior Services Bear River 970 Medical Dr LabCorp of America 35 Skyline Dr 935 N 1000 W Ste 311 Holdings Ste 103 Tremonton UT. 84337 Brigham City UT. 84302 Phone Number Only Brigham City UT. 84302 p 435.207.4800 p 801.479.0184 p 888.522.2677 p 801.255.5131 Deceuster, Rachael BCBA Redd, Edward H MD Mental Health Bunting, Catherine CSW Utah Behavior Services Community Health Centers Acevedo, Carlos ACMHC Utah Behavior Services 35 Skyline Dr 440 W 600 N Utah Behavior Services 35 Skyline Dr Ste 103 Tremonton UT. 84337 35 Skyline Dr Ste 103 Brigham City UT. 84302 p 844.248.4110 Ste 103 Brigham City UT. 84302 p 801.255.5131 Brigham City UT. 84302 p 801.255.5131 Hospital Affiliation p 801.255.5131 Fujiwara, Mina BCBA - Logan Regional Hospital Chavez, Johanna LCSW Utah Behavior Services Adolphson, Lillian Community Health Centers 35 Skyline Dr Wilding, David G MD BCBA-D 440 W 600 N Ste 103 Brigham Medical Clinic Utah Behavior Services Tremonton UT. 84337 Brigham City UT. 84302 600 W Hospital Rd 35 Skyline Dr p 844.248.4110 p 801.255.5131 Brigham City UT. 84302 Ste 103 p 435.734.2041 Brigham City UT. 84302 980 S 500 W Goss, Angela CSW p 801.255.5131 Brigham City UT. 84302 Utah Behavior Services Hospital Affiliation p 435.723.8276 35 Skyline Dr - Brigham City Community Aleman, Arianna BCBA Ste 103 Hospital Utah Behavior Services Cho, Jaeyong MSW Brigham City UT. 84302 35 Skyline Dr Utah Behavior Services p 801.255.5131 Yaganti, Vamsee M MD Ste 103 35 Skyline Dr Mountainstar Cardiology St Brigham City UT. 84302 Ste 103 Green, Rachal BCBA,LCSW Marks p 801.255.5131 Brigham City UT. 84302 Utah Behavior Services 970 Medical Dr p 801.255.5131 35 Skyline Dr Ste 311 Arballo, Jennifer CSW Ste 103 Brigham City UT. 84302 Utah Behavior Services Christensen, John C LMFT Brigham City UT. 84302 p 801.479.0184 35 Skyline Dr Associated p 801.255.5131 Ste 103 Psychotherapists Brigham City UT. 84302 120 N Main St p 801.255.5131 Brigham City UT. 84302 p 435.723.2881

7 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Gressmen, Casey BCBA King, Kelsey LCSW Luna, Janette M LCSW Nielsen, Stephanie MSW Utah Behavior Services Utah Behavior Services Utah Behavior Services Utah Behavior Services 35 Skyline Dr 35 Skyline Dr 35 Skyline Dr 35 Skyline Dr Ste 103 Ste 103 Ste 103 Ste 103 Brigham City UT. 84302 Brigham City UT. 84302 Brigham City UT. 84302 Brigham City UT. 84302 p 801.255.5131 p 801.255.5131 p 801.255.5131 p 801.255.5131

Hartman, Troy LCSW Knudson, Mani BCBA Madsen, Sara BCBA Oblad, Cicily BCBA 607 N 800 W Utah Behavior Services Utah Behavior Services Utah Behavior Services Brigham City UT. 84302 35 Skyline Dr 35 Skyline Dr 35 Skyline Dr p 435.730.7527 Ste 103 Ste 103 Ste 103 Brigham City UT. 84302 Brigham City UT. 84302 Brigham City UT. 84302 Hexum, Julie MSW p 801.255.5131 p 801.255.5131 p 801.255.5131 Utah Behavior Services 35 Skyline Dr Kulow, Kacylia BCBA Mason, Patricia A LCSW Openshaw, D. K LCSW Ste 103 Utah Behavior Services 435 E 700 S 295 W Schiess Ct Brigham City UT. 84302 35 Skyline Dr Brigham City UT. 84302 Garland UT. 84312 p 801.255.5131 Ste 103 p 435.723.5600 p 435.753.7332 Brigham City UT. 84302 Hoffmann, Audrey PhD p 801.255.5131 Maxwell, Kendra BCBA Phillips, Allison Utah Behavior Services Utah Behavior Services LCSW,BCBA 35 Skyline Dr Lambertsen, Hope BCBA 35 Skyline Dr Utah Behavior Services Ste 103 Utah Behavior Services Ste 103 35 Skyline Dr Brigham City UT. 84302 35 Skyline Dr Brigham City UT. 84302 Ste 103 p 801.255.5131 Ste 103 p 801.255.5131 Brigham City UT. 84302 Brigham City UT. 84302 p 801.255.5131 Holmes, Alisha MSW p 801.255.5131 McGill, Katie MSW Utah Behavior Services Utah Behavior Services Powell, Clark Randy LCSW 35 Skyline Dr Lee, Jennifer BCBA 35 Skyline Dr Utah Behavior Services Ste 103 Utah Behavior Services Ste 103 35 Skyline Dr Brigham City UT. 84302 35 Skyline Dr Brigham City UT. 84302 Ste 103 p 801.255.5131 Ste 103 p 801.255.5131 Brigham City UT. 84302 Brigham City UT. 84302 p 801.255.5131 Hunt, Chelseigh BCBA p 801.255.5131 McGuire, Amy BCBA Utah Behavior Services Utah Behavior Services Rae, Rebecca BCBA 35 Skyline Dr Lofthouse, Chelsea ACMHC 35 Skyline Dr Utah Behavior Services Ste 103 Utah Behavior Services Ste 103 35 Skyline Dr Brigham City UT. 84302 35 Skyline Dr Brigham City UT. 84302 Ste 103 p 801.255.5131 Ste 103 p 801.255.5131 Brigham City UT. 84302 Brigham City UT. 84302 p 801.255.5131 Jensen, Julia P BCBA p 801.255.5131 Metzger, Debbie BCBA Utah Behavior Services Utah Behavior Services Renda, Cheyenne R PhD 35 Skyline Dr Lopez, Kitrina BCBA 35 Skyline Dr Utah Behavior Services Ste 103 Utah Behavior Services Ste 103 35 Skyline Dr Brigham City UT. 84302 35 Skyline Dr Brigham City UT. 84302 Ste 103 p 801.255.5131 Ste 103 p 801.255.5131 Brigham City UT. 84302 Brigham City UT. 84302 p 801.255.5131 Johnston, Harmony MSW p 801.255.5131 Nadalsky, Michelle Utah Behavior Services BCBA,SSW Roche, Miriam MSW 35 Skyline Dr Lovelace, Scott LCMHC Utah Behavior Services Utah Behavior Services Ste 103 Utah Behavior Services 35 Skyline Dr 35 Skyline Dr Brigham City UT. 84302 35 Skyline Dr Ste 103 Ste 103 p 801.255.5131 Ste 103 Brigham City UT. 84302 Brigham City UT. 84302 Brigham City UT. 84302 p 801.255.5131 p 801.255.5131 Keller, Rebecca BCBA p 801.255.5131 Utah Behavior Services Neff, Michal A CSW,SUDC Rockwell, Rene BCBA 35 Skyline Dr Lowe, Kori BCBA Utah Behavior Services Utah Behavior Services Ste 103 Utah Behavior Services 35 Skyline Dr 35 Skyline Dr Brigham City UT. 84302 35 Skyline Dr Ste 103 Ste 103 p 801.255.5131 Ste 103 Brigham City UT. 84302 Brigham City UT. 84302 Brigham City UT. 84302 p 801.255.5131 p 801.255.5131 Kennedy, Anne BCBA p 801.255.5131 Utah Behavior Services 35 Skyline Dr Ste 103 Brigham City UT. 84302 p 801.255.5131

8 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Sagendorf, Emily BCBA Snow, Lauren BCBA Williams, Jason J LMFT *Jensen, Tim L OT Utah Behavior Services Utah Behavior Services Associated Bear River Valley Hospital 35 Skyline Dr 35 Skyline Dr Psychotherapists Physicians Ste 103 Ste 103 120 N Main St 905 N 1000 W Brigham City UT. 84302 Brigham City UT. 84302 Brigham City UT. 84302 Tremonton UT. 84337 p 801.255.5131 p 801.255.5131 p 435.723.2881 p 435.207.4500

Salsberry, Maria CSW Stasiuk, John A LMFT Wills, Brooke BCBA Hospital Affiliation Utah Behavior Services Utah Behavior Services Utah Behavior Services - Bear River Valley Hospital 35 Skyline Dr 35 Skyline Dr 35 Skyline Dr Ste 103 Ste 103 Ste 103 Larson, Jacob K OT Brigham City UT. 84302 Brigham City UT. 84302 Brigham City UT. 84302 Summit Hand Therapy p 801.255.5131 p 801.255.5131 p 801.255.5131 1030 Medical Dr Brigham City UT. 84302 Sanders, Sarah BCBA Stevens, Nicole Wilson, Megan BCBA p 801.773.2633 Utah Behavior Services BCBA,LMFT Utah Behavior Services 35 Skyline Dr Utah Behavior Services 35 Skyline Dr Ophthalmology Ste 103 35 Skyline Dr Ste 103 Turner, Scott D MD Brigham City UT. 84302 Ste 103 Brigham City UT. 84302 Brigham Eye Specialists p 801.255.5131 Brigham City UT. 84302 p 801.255.5131 990 S Medical Dr p 801.255.5131 Ste GL3 Shumway, Brett PSYD Woodall, Clifford BCBA Brigham City UT. 84302 Utah Behavior Services Suarez, Alex LCSW Utah Behavior Services p 435.734.2097 35 Skyline Dr Utah Behavior Services 35 Skyline Dr Ste 103 35 Skyline Dr Ste 103 Hospital Affiliation Brigham City UT. 84302 Ste 103 Brigham City UT. 84302 - Brigham City Community p 801.255.5131 Brigham City UT. 84302 p 801.255.5131 Hospital p 801.255.5131 - Ogden Regional Medical Siebert, Tatum LCPC Wulfenstein, Lee BCBA Center Utah Behavior Services 35 Skyline Dr Utah Behavior Services 35 Skyline Dr Ste 103 35 Skyline Dr Optometry Ste 103 Brigham City UT. 84302 Ste 103 Clark, Michael C OD Brigham City UT. 84302 p 801.255.5131 Brigham City UT. 84302 Brigham Eye Specialists p 801.255.5131 p 801.255.5131 990 S Medical Dr Ward, Cori APRN Ste G-3 Skousen, Thomas MSW Utah Behavior Services Yang, Danielle BCBA Brigham City UT. 84302 Utah Behavior Services 35 Skyline Dr Utah Behavior Services p 435.734.2097 35 Skyline Dr Ste 103 35 Skyline Dr Ste 103 Brigham City UT. 84302 Ste 103 Harrison, William L OD Brigham City UT. 84302 p 801.255.5131 Brigham City UT. 84302 547 S Main St p 801.255.5131 p 801.255.5131 Brigham City UT. 84302 Whatcott, Natalie p 435.723.2144 Slater, Courtney MSW BCBA,SSW Obstetrics And Gynecology Utah Behavior Services Utah Behavior Services Bailey, Stanton A MD Olson, Joseph C OD 35 Skyline Dr 35 Skyline Dr Brigham Center for Womens Eye and Vision Care Ste 103 Ste 103 Health 547 S Main St Brigham City UT. 84302 Brigham City UT. 84302 970 Medical Dr Brigham City UT. 84302 p 801.255.5131 p 801.255.5131 Ste 202 p 435.723.2144 Brigham City UT. 84302 Smith, Erica BCBA *Whisler, Anna LCSW p 435.695.2273 Purcell, Lynn R OD Utah Behavior Services Bear River Bear River Eye Center 35 Skyline Dr 935 N 1000 W 984 S Medical Dr 495 W 600 N Ste 103 Tremonton UT. 84337 Ste 4 Tremonton UT. 84337 Brigham City UT. 84302 p 435.207.4800 Brigham City UT. 84302 p 435.257.7436 p 801.255.5131 p 435.695.2273 Hospital Affiliation Hospital Affiliation Smith, Saige LPC - Bear River Valley Hospital Hospital Affiliation - Bear River Valley Hospital Utah Behavior Services - Central Valley Medical 35 Skyline Dr Wilkinson, Thomas A PSYD Center Purcell, Phillip L OD Ste 103 Box Elder Community Health - Gunnison Valley Hospital Bear River Eye Center Brigham City UT. 84302 Center 495 W 600 N p 801.255.5131 5 W 200 N Occupational Therapy Tremonton UT. 84337 Brigham City UT. 84302 Concentra Medical Centers p 435.257.7436 p 435.755.6061 2390 Redwood Rd West Valley City UT. 84419 p 888.997.2669

9 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Reed, Paul E OD - Logan Regional Hospital Tashjian, Robert Z MD Hills, Ammon A DO Perry EyeCare - Jordan Valley Medical University of Utah Health Alpine Orthopaedic 2480 S Hwy 89 Center West Valley Campus 1950 S Hwy 89 Specialists Ste B Perry UT. 84302 1030 S Medical Dr Perry UT. 84302 Goble, E Marlowe MD p 435.723.0540 Ste A p 435.239.8756 1950 S Hwy 89 Brigham City UT. 84302 Brigham City UT. 84302 Hospital Affiliation p 435.723.9700 Terry, Larry D OD p 435.787.8467 - University of Utah Hospital Box Elder Family Vision Hospital Affiliation Clinic Higbee, Daniel D DO Pain Management - Logan Regional Hospital 34 S Main St Sumko-Bitner Orthopaedics Garg, Vikas MD - Cache Valley Hospital Brigham City UT. 84302 & Sports Medicine Clinic Advanced Spine and Pain - Brigham City Community p 435.723.2485 935 N 1000 W Specialists Hospital Tremonton UT. 84337 950 S 500 W Zilles, Jeffrey D DO p 435.723.5430 Ste 103A Pugsley, Jacob B DO Bear River Eye Center Brigham City UT. 84302 Alpine Orthopaedic 495 W 600 N 990 S Medical Dr p 435.713.9681 Specialists Tremonton UT. 84337 Ste G4 1030 S Medical Dr p 435.257.7436 Brigham City UT. 84302 Hospital Affiliation Ste A p 435.734.2151 - Lone Peak Hospital Brigham City UT. 84302 Oral And Maxillofacial Surgery - Evanston Regional Hospital p 435.723.9700 Anderson, Gregory E DDS Hospital Affiliation - Brigham City Community 1335 S Main St - Brigham City Community Hospital Hospital Affiliation Ste 102 Hospital - Brigham City Community Garland UT. 84312 - Bear River Valley Hospital Richardson, Brian F MD Hospital p 435.755.5000 Vista Neurology - Cache Valley Hospital Peterson, Travis A DO Specialists Hospital Affiliation Sumko-Bitner Orthopaedics 935 N 1000 W Physical Therapy - Logan Regional Hospital & Sports Medicine Tremonton UT. 84337 Back@Work Physical Therapy - Brigham City Community 990 S Medical Dr p 435.787.8146 470 W Main St Hospital Ste G-4 Tremonton UT. 84337 - Cache Valley Hospital Brigham City UT. 84302 Hospital Affiliation p 435.213.3850 p 435.734.2151 - Logan Regional Hospital Jessen, Gregory S DDS Baldwin, Matthew D DPT 30 E 700 S Hospital Affiliation Pediatrics Back@Work Physical Therapy Brigham City UT. 84302 - Brigham City Community Buchanan, Marcus P MD 470 W Main St p 800.860.6260 Hospital Brigham Pediatrics Tremonton UT. 84337 - Bear River Valley Hospital 980 Medical Dr p 435.213.3850 Hospital Affiliation Ste 2 - Ogden Regional Medical Rowley, David M MD Brigham City UT. 84302 Beecher, Alex DPT Center Alpine Orthopaedic p 435.734.2433 Orthopaedic Therapy And Specialists Sports Performance LLC Orthopedic Surgery 1030 S Medical Dr Hospital Affiliation 1030 S Medical Dr Bitner, Mathew F MD Ste A - Brigham City Community Ste B Sumko-Bitner Orthopaedics Brigham City UT. 84302 Hospital Brigham City UT. 84302 & Sports Medicine Clinic p 435.723.9700 p 435.538.5111 935 N 1000 W Lloyd, Carey D MD Tremonton UT. 84337 Hospital Affiliation Brigham Pediatrics Colvin, Roger L PT p 435.734.2151 - Logan Regional Hospital 980 Medical Dr RLC Physical Therapy and Ste 2 Rehab 990 S Medical Dr Sumko, Michael H DO Brigham City UT. 84302 990 S Medical Dr Ste G4 Sumko & Bitner Orthopedic p 435.734.2433 Ste U 4 Brigham City UT. 84302 Clinic Brigham City UT. 84302 p 435.734.2151 935 N 1000 W Hospital Affiliation p 435.723.6487 Tremonton UT. 84337 - Brigham City Community Hospital Affiliation p 435.723.5430 Hospital Concentra Medical Centers - Brigham City Community 2390 Redwood Rd Hospital 990 S Medical Dr Physical Medicine And Rehabilitation West Valley City UT. 84419 - Bear River Valley Hospital Ste G4 Hess, Brian PA-C p 888.997.2669 Brigham City UT. 84302 Alpine Orthopaedic Felix, Brent A MD p 435.734.2151 Specialists *Cottle, Jay E PT Alpine Orthopaedic 1030 S Medical Dr Bear River Valley Hospital Specialists Hospital Affiliation Ste A 905 N 1000 W 1030 S Medical Dr - Brigham City Community Brigham City UT. 84302 Tremonton UT. 84337 Ste A Hospital p 435.723.9700 p 435.207.4500 Brigham City UT. 84302 - Bear River Valley Hospital p 435.787.2000

Hospital Affiliation - Brigham City Community Hospital 10 *The PPO- St AgreementMarks Hospital with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Felix, Travis D DPT Fawson, Lorell B DPM Willow Glen Health & Rehab *Cummins, Karin A LCSW Orthopaedic Therapy & 935 N 1000 W 775 N 200 E Bear River Sports Performance Tremonton UT. 84337 Brigham City UT. 84302 935 N 1000 W 1030 S Medical Dr p 435.279.9995 p 435.723.7777 Tremonton UT. 84337 Ste B p 435.207.4800 Brigham City UT. 84302 Sautter, Travis L DPM Sleep Disorders Center p 435.538.5111 Cook & Sautter Foot & Sleep Dx Hartman, Troy LCSW Ankle 515 W Forest St 607 N 800 W *Herzog, Carol PT 935 N 1000 W Ste B1 Brigham City UT. 84302 Bear River Valley Hospital Tremonton UT. 84337 Brigham City UT. 84302 p 435.730.7527 905 N 1000 W p 435.752.9011 p 435.723.0868 Tremonton UT. 84337 Hexum, Julie MSW p 435.207.4500 990 S Medical Dr Sleep Medicine Utah Behavior Services Ste U3 Sleep Dx 35 Skyline Dr *Johnson, Patrick A PT Brigham City UT. 84302 515 W Forest St Ste 103 Bear River Valley Hospital p 435.734.9623 Ste B1 Brigham City UT. 84302 Physicians Brigham City UT. 84302 p 801.255.5131 905 N 1000 W Psychiatry p 435.723.0868 Tremonton UT. 84337 Ward, Cori APRN Holmes, Alisha MSW p 435.207.4500 Utah Behavior Services Social Worker Utah Behavior Services 35 Skyline Dr Arballo, Jennifer CSW 35 Skyline Dr Thompson, Lori R DPT Ste 103 Utah Behavior Services Ste 103 Life Elevated Physical Brigham City UT. 84302 35 Skyline Dr Brigham City UT. 84302 Therapy p 801.255.5131 Ste 103 p 801.255.5131 750 W 1075 S Brigham City UT. 84302 Ste E Psychology p 801.255.5131 Johnston, Harmony MSW Brigham City UT. 84302 Shumway, Brett PSYD Utah Behavior Services p 435.230.1062 Utah Behavior Services Birch, Kelly LCSW 35 Skyline Dr 35 Skyline Dr Utah Behavior Services Ste 103 Podiatry Ste 103 35 Skyline Dr Brigham City UT. 84302 Cook, Gregory B DPM Brigham City UT. 84302 Ste 103 p 801.255.5131 Cook & Sautter Foot & p 801.255.5131 Brigham City UT. 84302 Ankle p 801.255.5131 Luna, Janette M LCSW 935 N 1000 W Siebert, Tatum LCPC Utah Behavior Services Tremonton UT. 84337 Utah Behavior Services Bunting, Catherine CSW 35 Skyline Dr p 435.752.9011 35 Skyline Dr Utah Behavior Services Ste 103 Ste 103 35 Skyline Dr Brigham City UT. 84302 990 S Medical Dr Brigham City UT. 84302 Ste 103 p 801.255.5131 Ste U3 p 801.255.5131 Brigham City UT. 84302 Brigham City UT. 84302 p 801.255.5131 Mason, Patricia A LCSW p 435.734.9623 Wilkinson, Thomas A PSYD 435 E 700 S Box Elder Community Health Chavez, Johanna LCSW Brigham City UT. 84302 Hospital Affiliation Center Community Health Centers p 435.723.5600 - Logan Regional Hospital 5 W 200 N 440 W 600 N - Brigham City Community Brigham City UT. 84302 Tremonton UT. 84337 McGill, Katie MSW Hospital p 435.755.6061 p 844.248.4110 Utah Behavior Services - Cache Valley Hospital 35 Skyline Dr Pulmonology 980 S 500 W Ste 103 Cook, W Bryce DPM Majoskey, Ashley M PA Brigham City UT. 84302 Brigham City UT. 84302 Foot Clinic of Logan Mountainstar Cardiology St p 435.723.8276 p 801.255.5131 990 S Medical Dr Marks Ste 3 970 Medical Dr Cho, Jaeyong MSW Neff, Michal A CSW,SUDC Brigham City UT. 84302 Ste 311 Utah Behavior Services Utah Behavior Services p 435.734.9623 Brigham City UT. 84302 35 Skyline Dr 35 Skyline Dr p 801.479.0184 Ste 103 Ste 103 Cook & Sautter Foot & Brigham City UT. 84302 Brigham City UT. 84302 Ankle Hospital Affiliation p 801.255.5131 p 801.255.5131 990 S Medical Dr - St Marks Hospital Ste U3 Coburn, Alison MSW Nielsen, Stephanie MSW Brigham City UT. 84302 Skilled Nursing Facility Utah Behavior Services Utah Behavior Services p 435.734.9623 Pioneer Care Center 35 Skyline Dr 35 Skyline Dr 815 S 200 W Ste 103 Ste 103 Brigham City UT. 84302 Brigham City UT. 84302 Brigham City UT. 84302 p 435.723.5289 p 801.255.5131 p 801.255.5131

11 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Openshaw, D. K LCSW Urgent Care *Jensen, Steven R AUD Logan Regional Hospital Hospital 295 W Schiess Ct Box Elder Community Health Logan Regional Hospital 1400 N 500 E - Davis Hospital Garland UT. 84312 Center 1400 N 500 E Logan UT. 84341 - Cache Valley Hospital p 435.753.7332 5 W 200 N Logan UT. 84341 p 435.716.1000 Brigham City UT. 84302 p 435.716.1000 Phillips, Allison p 435.723.7999 Breast Pumps LCSW,BCBA Larsen, Jeff AUD Alpine Home Medical Utah Behavior Services Urology USU Speech Language 1395 N 400 E 35 Skyline Dr *Luzny, Patrik MD Hearing Center Logan UT. 84341 Ste 103 Bear River Valley Hospital 1000 Old Main Hill p 435.774.4500 Brigham City UT. 84302 Physicians Logan UT. 84322 p 801.255.5131 905 N 1000 W p 435.797.1346 Phone Number Only Tremonton UT. 84337 p 800.686.7993 Powell, Clark Randy LCSW p 435.207.4500 Munoz, Karen AUD Utah Behavior Services USU Speech Language Edgepark 35 Skyline Dr Bear River Specialists Hearing Center Phone Number Only Ste 103 935 N 1000 W 1000 Old Main Hill p 800.321.0591 Brigham City UT. 84302 Tremonton UT. 84337 Logan UT. 84322 p 801.255.5131 p 435.207.4800 p 435.797.1346 Cardiac Monitoring Remote Cardiac Services Roche, Miriam MSW Hospital Affiliation Pitt, Cache L AUD Phone Number Only Utah Behavior Services - Logan Regional Hospital USU Speech Language p 800.367.0300 35 Skyline Dr Hearing Center Ste 103 Cache County 1000 Old Main Hill eCardio Diagnostics Brigham City UT. 84302 Logan UT. 84322 Phone Number Only p 801.255.5131 Aba Therapy p 435.797.1346 p 888.400.3522 Chrysalis Utah Skousen, Thomas MSW 545 W 465 N Porter, Amy AUD Cardiology Utah Behavior Services Ste 100 USU Speech Language Almony, Gregory T MD 35 Skyline Dr Providence UT. 84332 Hearing Center MountainStar Cardiology St Ste 103 p 801.655.4950 1000 Old Main Hill Marks LLC Brigham City UT. 84302 Logan UT. 84322 2380 N 400 E p 801.255.5131 Hunsaker, Jacob C LMFT p 435.797.1346 Ste G Cache Valley Community Logan UT. 84341 Slater, Courtney MSW Health Center North M-F Preston, Elizabeth AUD p 801.476.6900 Utah Behavior Services 8am-6:30pm S 9am-3pm USU Speech Language 35 Skyline Dr 1515 N 400 E Hearing Center Northern Utah Ste 103 Ste 104 1000 Old Main Hill Cardiovascular Associates Brigham City UT. 84302 Logan UT. 84341 Logan UT. 84322 2380 N 400 E p 801.255.5131 p 435.755.6061 p 435.797.1346 Logan UT. 84341 p 801.479.0184 Suarez, Alex LCSW Lee, Courtney BCBA Robinson, Dave AUD Utah Behavior Services Chrysalis Utah Robinson Audiology Hospital Affiliation 35 Skyline Dr 545 W 465 N 575 E 1400 N - Ogden Regional Medical Ste 103 Ste 100 Ste 140 Center Brigham City UT. 84302 Providence UT. 84332 Logan UT. 84341 - Brigham City Community p 801.255.5131 p 801.655.4950 p 435.753.7171 Hospital - Davis Hospital *Whisler, Anna LCSW Allergy And Immunology Stevenson, Robert L AUD - Cache Valley Hospital Bear River *Dickson, Scott D DO Bridgerland Audiology and 935 N 1000 W Budge Clinic Surgical Hearling Aids Douglas, Wendy S APRN Tremonton UT. 84337 Specialists 293 S Main St University of Utah Health p 435.207.4800 1350 N 500 E Logan UT. 84321 550 E 1400 N Logan UT. 84341 p 435.753.4133 Ste K Hospital Affiliation p 435.792.1940 Logan UT. 84341 - Bear River Valley Hospital *Uyematsu, Jennifer A AUD p 435.716.2917 South Cache Valley Clinic Budge Clinic Surgical Sports Medicine 190 S Hwy 165 Specialists 550 E 1400 N Crum, Ashley A MD Providence UT. 84332 1350 N 500 E Logan UT. 84341 Alpine Orthopaedic p 435.755.3300 Logan UT. 84341 p 435.716.2917 Specialists p 435.752.1693 1030 S Medical Dr Audiology Forstall, Peter G MD Ste A Jensen, Heather AUD Northern Utah Brigham City UT. 84302 USU Speech Language Cardiovascular Associates p 435.723.9700 Hearing Center 2380 N 400 E 1000 Old Main Hill Logan UT. 84341 Logan UT. 84322 p 801.479.0184 p 435.797.1346 Hospital Affiliation - Ogden Regional Medical Center 12 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. -10/01/2021 Brigham 05:46:46 City Community **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Garr, Robert J DO Chiropractic Bingham, Sharon J LMFT Jones, Stacy H LMFT Cache Valley Heart Clinic Crawford, Ira J DC The Family Place Keystone Family Solutions 1300 N 500 E Smithfield Chiropractic 10 N 600 E 95 W 100 S Ste 320 1177 S Main St Hyrum UT. 84319 Ste 102 Logan UT. 84341 Smithfield UT. 84335 p 435.752.8880 Logan UT. 84321 p 435.716.2200 p 435.563.6887 p 435.216.9937 1525 N 260 W Hospital Affiliation Fullmer, Thomas O DC Logan UT. 84341 Killila, Maureen LPC - Mountain West Medical Advanced Spine and Health p 435.752.8880 186 E 1800 N Center Center of Cache Valley Ste B 1652 S Hwy 165 10 N 600 E North Logan UT. 84321 *Otrusinik, Rudolf MD Ste B Hyrum UT. 84319 p 435.770.7123 Cache Valley Heart Clinic Providence UT. 84332 p 435.752.8880 1300 N 500 E p 435.752.5522 King, Pamela LMFT Ste 320 1525 N 260 W Pamela King LMFT Logan UT. 84341 Gibbons, Jeremy D DC Logan UT. 84341 186 E 1800 N p 435.716.2200 Gibbons Chiropractic p 435.752.8880 Ste 2 1177 S Main St Logan UT. 84341 Logan Regional Hospital Smithfield UT. 84335 502 S Main St p 435.787.4517 1400 N 500 E p 435.563.2514 Smithfield UT. 84335 Logan UT. 84341 p 435.752.8880 274 N Main St p 435.716.1000 Hoopes, Joshua R DC Logan UT. 84321 Smithfield Chiropractic Christensen, Jud LMFT p 435.787.4517 Hospital Affiliation 1177 S Main St The Family Place - Logan Regional Hospital Smithfield UT. 84335 1525 N 260 W Krambule, Sandra A LMFT p 435.563.6887 Logan UT. 84341 Sandra A Krambule LMFT *Tom, Cindy W MD p 435.752.8880 580 N Main St Cache Valley Heart Clinic Johnson, Karson DC Ste 250-C 1300 N 500 E Alpine Chiropractic Inc. Danielson, Tricia LMFT Logan UT. 84321 Ste 320 1415 N 400 E Tricia H Danielson, LMFT p 435.881.7966 Logan UT. 84341 Logan UT. 84341 186 E 1800 N p 435.716.2200 p 435.760.6236 Ste 1 Kunz, Meghan np Logan UT. 84341 95 W 100 S Logan Regional Hospital LeFevre, Evan J DC p 435.213.3062 Ste 108 Physicians Evan J LeFevre DC PC Logan UT. 84321 1400 N 500 E 1415 N 400 E 60 E Center St p 435.881.4867 Logan UT. 84341 Ste A Ste 201 p 435.716.1000 Logan UT. 84341 Logan UT. 84321 Kwin, Leslie W LMFT p 435.752.4747 p 435.213.3062 Leslie W Kwin LMFT Hospital Affiliation 44 N Hwy 91 - Logan Regional Hospital Misustin, James L DC Finley, Paul D LMFT Ste 1 Peterson Chiropractic Logan River Counseling Richmond UT. 84333 Certified Nurse Midwife 1415 N 400 E 60 E Center St p 435.535.5784 *Bearnso, Camra J CNM Ste A Ste 103 Budge Clinic Obstetrics & Logan UT. 84341 Logan UT. 84321 60 E Center St Gynecology p 435.753.2840 p 435.754.9399 Ste 103 1400 N 500 E Logan UT. 84321 Logan UT. 84341 Stucky, Jon L DC Gunn, Miriam LMFT p 435.535.5784 p 435.716.1920 Stucky Chiropractic PC North Logan Therapy 130 N 800 E Associates Michael, Dolores D Hospital Affiliation Hyrum UT. 84319 186 E 1800 N Cache Valley Community - Mountain Point Medical p 435.245.3500 Logan UT. 84341 Health Center Center p 435.770.6025 1515 N 400 E Counseling Ste 104 *Hepner, Stacy A CNM Aller, Ty B LMFT Harris, Sharon LMFT Logan UT. 84341 Budge Clinic Obstetrics Ty B Aller, LMFT New Paths Counseling p 435.755.6061 and Gynecology 545 W 465 N 60 E Center St 1400 N 500 E Ste 130 Ste 109 Wholelife Family Wellness Logan UT. 84341 Providence UT. 84332 Logan UT. 84341 Clinic of Providence p 435.716.1920 p 385.200.3993 p 435.213.3062 169 N Gateway Dr Ste 170 *Powell, Justine CNM Beus, Parker R LCSW Hinds, Charles K LMFT Providence UT. 84332 Budge Clinic Obstetrics Veritas Mental Health Hinds Counseling p 435.213.3597 and Gynecology 664 N Main St 184 N 100 E 1400 N 500 E Ste 101 Ste C Logan UT. 84341 Logan UT. 84321 Logan UT. 84321 p 435.716.1920 p 435.279.0001 p 435.752.4646

Hospital Affiliation - Logan Regional Hospital 13 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Nielson, Jeannine D LMFT Sondergaard, Laurin LMFT James, Travis DO Roche Insulin Delivery Family Institute of Laurin Sondergaard LMFT Providence Dermatology Systems Inc Northern Utah 545 W 465 N 169 N Gateway Dr Phone Number Only 190 E Ctr St Ste 130 Ste 100 p 800.280.7801 Logan UT. 84321 Providence UT. 84332 Providence UT. 84332 p 435.755.6707 p 435.554.8617 p 435.554.1182 US MED LLC Phone Number Only Nielson, Lance R Spendlove, Rex A CMHC Hospital Affiliation p 800.787.6331 LMFT,CMHC Lifetech Consulting Group - Logan Regional Hospital The Family Place 1635 N 200 E - Cache Valley Hospital United States Medical 1525 N 260 W Logan UT. 84341 Supply Logan UT. 84341 p 435.755.7654 MacDonald, Scott MD Phone Number Only p 435.752.8880 Rocky Mountain Dermatology p 877.840.8218 Stephenson, Heather M LPC 1760 N 200 E Oka, Megan LMFT Spring Tree Counseling Ste 101 Dialysis Center Megan Oka LMFT 95 W 100 S Logan UT. 84341 *Logan Regional Dialysis 60 E Center St Ste 101 p 435.787.0560 *Center Logan UT. 84321 Logan UT. 84321 1400 N 500 E p 435.213.3062 p 435.414.6230 Maughan, Cory B DO Logan UT. 84341 Providence Dermatology p 435.716.5314 Openshaw, Jeffrey D LMFT Dermatology 169 N Gateway Dr Enlightened Perspectives Hadley, Michael L MD Ste 100 Durable Medical Equipment 295 Schiess Ct Kelly W Hubbard, MD Providence UT. 84332 Advantage Medical Supply Logan UT. 84321 2380 N 400 E p 435.554.1182 1400 N 550 E p 801.574.8530 Ste B Ste JB Logan UT. 84341 Hospital Affiliation Logan UT. 84341 Price, Cristine LPC p 435.753.1600 - Logan Regional Hospital p 435.774.4196 Health Healing & Wholeness - Cache Valley Hospital 517 W 100 N Hospital Affiliation Alpine Home Medical Ste 202 - Lakeview Hospital *McCaughey, Cort D MD 1395 N 400 E Providence UT. 84332 Budge Clinic Dermatology Logan UT. 84341 p 435.915.6915 *Hanson, Nathan W MD 1350 N 500 E p 435.774.4500 Budge Clinic Dermatology Logan UT. 84341 Pye, Doriann S CMHC 1350 N 500 E p 435.716.1770 Phone Number Only DSP Counseling and Logan UT. 84341 p 800.686.7993 Consulting p 435.716.1770 Hospital Affiliation 965 S 100 W - Logan Regional Hospital Apria Healthcare LLC Ste 204 Hospital Affiliation 165 E 1400 N Logan UT. 84321 - Logan Regional Hospital Young, Robert P MD Ste D p 801.525.4645 Rocky Mountain Dermatology Logan UT. 84341 Heaton, Jared DO 1760 N 200 E p 435.752.2100 Ramboz, Bryan D LMFT Rocky Mountain Dermatology Ste 101 Family Institute of 1760 N 200 E Logan UT. 84341 CCS Medical Northern Utah Ste 101 p 435.787.0560 Phone Number Only 190 E Center St Logan UT. 84341 p 800.726.9811 Logan UT. 84321 p 435.787.0560 Hospital Affiliation p 435.752.1976 - Logan Regional Hospital CNS Respiratory Services - Hospital Affiliation Providence Robinson, David LMFT - Lakeview Hospital Diabetic Education 221 N Gateway Dr Unit G Cache Valley Community Cache Valley Endocrine & Providence UT. 84332 Health Center North Hubbard, Kelly W MD Diabetes Center p 435.752.3355 1515 N 400 E Kelly W Hubbard, MD 2150 N Main St Ste 104 2380 N 400 E Ste 10 Cache Valley Oxygen Logan UT. 84341 Ste B Logan UT. 84341 1395 N 400 E p 435.755.6061 North Logan UT. 84341 p 435.716.8765 Ste A p 435.752.5741 Logan UT. 84341 Smith, Heather M Diabetic Supplies p 435.752.2227 North Logan Therapy 530 W 465 N CCS Medical Associates Ste 701 Phone Number Only Care Rehab and Orthopedic 186 E 1800 N Providence UT. 84332 p 800.726.9811 Products (Muscle Logan UT. 84341 p 435.752.5741 Stimulators) p 512.981.5641 Edgepark Phone Number Only Hospital Affiliation Phone Number Only p 800.487.9644 - Logan Regional Hospital p 800.321.0591

14 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. DJO Global Smith Nephew Inc (Muscle Electrophysiology Sterling Urgent Care & Phone Number Only Stimulators) Forstall, Peter G MD Family Medicine p 800.336.6569 Phone Number Only Northern Utah 700 S Hwy 91 p 800.821.5700 Cardiovascular Associates Richmond UT. 84333 Dynasplint Systems Inc 2380 N 400 E p 435.294.3215 Phone Number Only US MED LLC Logan UT. 84341 p 800.638.6771 Phone Number Only p 801.479.0184 Ballingham, David J PA p 800.787.6331 Cache Valley Community EBI LLC (Bone Stimulators) Hospital Affiliation Health Center North Phone Number Only United States Medical - Ogden Regional Medical 1515 N 400 E p 800.526.2579 Supply Center Ste 104 Phone Number Only - Brigham City Community Logan UT. 84341 Edgepark p 877.840.8218 Hospital p 435.245.6988 Phone Number Only - Davis Hospital p 800.321.0591 Ear Nose And Throat - Cache Valley Hospital Cache Valley Community Bennion, Jeffrey G MD Health Center South Empi Inc (Neuromuscular Cache Valley Ear Nose & Endocrinology 517 W 100 N Stimulator) Throat Cache Valley Endocrine & Ste 110 Phone Number Only 169 N Gateway Dr Diabetes Center Providence UT. 84332 p 800.328.2536 Ste 120 2150 N Main St p 435.755.6061 Providence UT. 84332 Ste 10 *Intermountain Homecare p 435.753.7880 Logan UT. 84341 Barnes, Layne S DO *Medical Equipment and p 435.716.8765 MountainStar Medical Group *Supply Logan 2380 N 400 E Cache Valley 1300 N 200 E Ste D Family Practice 2380 N 400 E Ste 106 Logan UT. 84341 *Aamodt, David S MD Ste A Logan UT. 84341 p 435.753.7880 North Cache Valley Logan UT. 84341 p 435.716.5396 InstaCare p 435.713.1300 Hospital Affiliation 4088 N Hwy 91 Jenco Prosthetics and - Logan Regional Hospital Hyde Park UT. 84318 382 W 280 N Orthotics - Franklin County Medical p 435.563.4888 Providence UT. 84332 1153 N Main St Center p 435.752.0334 Ste B-140 Adams, Michael D MD Logan UT. 84341 Blotter, James W MD Cache Valley Community Be Well Medical p 435.750.6579 Cache Valley Ear Nose & Health Center North 3935 N 75 W Throat 1515 N 400 E Hyde Park UT. 84318 KCI USA Inc (Wound Vac 169 N Gateway Dr Ste 104 p 435.359.0720 Only) Ste 120 Logan UT. 84341 Phone Number Only Providence UT. 84332 p 435.755.6061 Boyer, Ben FNP p 800.275.4524 p 435.753.7880 Cache Valley Community Cache Valley Community Health Center North Orthofix Inc (Bone Growth 2380 N 400 E Health Center South 1515 N 400 E Stimulators Physicians Ste D 517 W 100 N Ste 104 Only) Logan UT. 84341 Ste 110 Logan UT. 84341 Phone Number Only p 435.753.7880 Providence UT. 84332 p 435.755.6061 p 800.535.4492 p 435.755.6061 Hospital Affiliation Cache Valley Community Pacific Medical Inc - Logan Regional Hospital Hospital Affiliation Health Center South Phone Number Only - Evanston Regional Hospital 517 W 100 N p 800.726.9180 *Keyser, Jeffrey S MD Ste 110 Budge Clinic Surgical Anderson, Jacob NP Providence UT. 84332 RespirTech Specialists Sterling Urgent Care & p 435.755.6061 Phone Number Only 1350 N 500 E Family Medicine Logan p 800.793.1261 Logan UT. 84341 South Bridge Utah Medical Group p 435.752.1693 1201 S Main St 1015 E 100 N Roche Insulin Delivery Ste 110 Logan UT. 84321 Systems Inc Hospital Affiliation Logan UT. 84321 p 888.853.8973 Phone Number Only - Logan Regional Hospital p 435.787.8504 p 800.280.7801 Brown, Todd A MD *Wilson, Matthew A MD Sterling Urgent Care & 291 S Main St Rocky Mountain Artificial Budge Clinic Surgical Family Medicine Logan Ste C Limb & Brace Specialists North Smithfield UT. 84335 1515 N 400 E 1350 N 500 E 630 E 1400 N p 435.563.6211 Ste 100 Logan UT. 84341 Ste 150 Logan UT. 84341 p 435.752.1693 Logan UT. 84321 Hospital Affiliation p 435.753.5100 p 435.915.4465 - Logan Regional Hospital

15 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Buck, Ryan APRN Cache Valley Community Logan InstaCare Isaacson, Bruce A MD Budge Clinic Health Center South 412 N 200 E 550 E 1400 N Anticoagulation 517 W 100 N Logan UT. 84321 Ste Z 1350 N 500 E Ste 110 p 435.713.2710 Logan UT. 84341 Logan UT. 84341 Providence UT. 84332 p 435.755.5799 p 435.752.0422 p 435.755.6061 Hospital Affiliation - Oneida County Hospital Hospital Affiliation Buys, Kristin PA *Clark, Thomas H MD - Logan Regional Hospital Cache Valley Community Logan Clinic Harris, Matthew MD Health Center North 412 N 200 E Sterling Urgent Care & Jennings, Caitlyn R PA 1515 N 400 E Logan UT. 84321 Family Medicine Logan Cache Valley Community Ste 104 p 435.713.2800 South Health Center South Logan UT. 84341 1201 S Main St 517 W 100 N p 435.755.6061 Hospital Affiliation Ste 110 Ste 110 - Logan Regional Hospital Logan UT. 84321 Providence UT. 84332 Cache Valley Community p 435.787.8504 p 435.755.6061 Health Center South Firth, Ronald M MD 517 W 100 N Bridge Utah Medical Group Sterling Urgent Care & Vista Neurology Ste 110 1015 E 100 N Family Medicine Logan Specialists Providence UT. 84332 Logan UT. 84321 North 630 E 1400 N p 435.755.6061 p 888.853.8973 630 E 1400 N Ste 135 Ste 150 Logan UT. 84321 *Call, Nathan H MD Hospital Affiliation Logan UT. 84321 p 435.787.8146 Budge Clinic Pediatrics - Logan Regional Hospital p 435.915.4465 1350 N 500 E Johnson, Corey B MD Logan UT. 84341 *Goates, Brad M MD Sterling Urgent Care & 565 W 465 N p 435.792.1940 Logan Clinic Family Medicine Ste 130 412 N 200 E 700 S Hwy 91 Providence UT. 84332 Hospital Affiliation Logan UT. 84321 Richmond UT. 84333 p 435.753.2842 - Logan Regional Hospital p 435.713.2800 p 435.294.3215 Hospital Affiliation *Carlson, Brian W MD Hospital Affiliation Hazelwood, Cynthia L NP - Logan Regional Hospital Logan Clinic - Logan Regional Hospital Alpine Orthopaedic 412 N 200 E Specialists Martin, Colby PA Logan UT. 84321 Goble, Deserae J MD 2310 N 400 E Cache Valley Community p 435.713.2800 Deserae J Goble MD PC Ste A Health Center South 1451 N 200 E Logan UT. 84341 517 W 100 N Hospital Affiliation Ste 250 p 435.787.2000 Ste 110 - Logan Regional Hospital Logan UT. 84341 Providence UT. 84332 p 435.363.7853 Hobbs, Sydnie M APRN p 435.755.6061 Carlson, Vera B MD Cache Valley Community Peachtree Family Medicine *Harris, Gary L MD Health Center North Mathews, James D DO 169 Springcreek Pkwy North Cache Valley Clinic 1515 N 400 E MountainStar Providence Ste 170 4088 N Hwy 91 Ste 104 Family Medicine Providence UT. 84332 Hyde Park UT. 84318 Logan UT. 84341 382 W 280 N p 435.752.5553 p 435.563.4900 p 435.245.6988 Providence UT. 84332 p 435.752.0330 Cache Valley Vein Hospital Affiliation Cache Valley Community 565 W 465 N - Logan Regional Hospital Health Center South Hospital Affiliation Ste 130 517 W 100 N - Logan Regional Hospital Providence UT. 84332 *Harris, Marcus D DO Ste 110 p 435.753.2842 Budge Clinic Family Providence UT. 84332 Morgan, Christopher J NP Medicine p 435.755.6061 Cache Valley Endocrine & Hospital Affiliation 1350 N 500 E Diabetes Center - Logan Regional Hospital Logan UT. 84341 Howard, DNell B FNP 2150 N Main St - Cache Valley Hospital p 435.716.1150 291 S Main St Ste 10 Ste C Logan UT. 84341 Carr, Ryan PA North Cache Valley Smithfield UT. 84335 p 435.716.8765 Cache Valley Community InstaCare p 435.563.6211 Health Center North 4088 N Hwy 91 *Olaveson, Kurt A MD 1515 N 400 E Hyde Park UT. 84318 North Cache Valley Clinic North Cache Valley Clinic Ste 104 p 435.563.4888 4088 N Hwy 91 4088 N Hwy 91 Logan UT. 84341 Hyde Park UT. 84318 Hyde Park UT. 84318 p 435.755.6061 p 435.563.4900 p 435.563.4900

Hospital Affiliation Hospital Affiliation - Logan Regional Hospital - Logan Regional Hospital

16 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Orians, Mary E FNP Schultz, Tiffany APRN Cache Valley Community *Garg, Vikram MD Mary E Orians FNP Spring Creek Medical Health Center South Budge Clinic GI 1177 S Main St Center 517 W 100 N 1350 N 500 E Smithfield UT. 84335 267 N Spring Creek Pkwy Ste 110 Logan UT. 84341 p 435.563.6367 Providence UT. 84332 Providence UT. 84332 p 435.716.1260 p 435.792.9400 p 435.755.6061 Hospital Affiliation Hospital Affiliation - Logan Regional Hospital *Sharp, Daniel S MD *Wallace, Seth B MD - Logan Regional Hospital Logan Clinic Budge Clinic Medical *Patterson, Robert G MD 412 N 200 E Specialists Larsen, Bryan R MD South Cache Valley Clinic Logan UT. 84321 1350 N 500 E Northern Ut Gastro & 190 S Hwy 165 p 435.713.2800 Logan UT. 84341 Endoscopy Specialists Providence UT. 84332 p 435.716.1980 630 E 1400 N p 435.755.3300 Skates, Andrea L APRN Logan UT. 84341 Cache Valley Community Hospital Affiliation p 435.787.0270 Hospital Affiliation Health Center North - Jordan Valley Medical - Logan Regional Hospital 1515 N 400 E Center Hospital Affiliation Ste 104 - Mountain West Medical - Logan Regional Hospital Redmond, Tiffany M PA-C Logan UT. 84341 Center Cache Valley Community p 435.755.6061 *Moore, Frederick S MD Health Center North Welter, Matthew J MD Budge Clinic GI 1515 N 400 E Be Well Medical Matthew J Welter MD PC 1350 N 500 E Ste 104 3935 N 75 W 1219 N 400 E Logan UT. 84341 Logan UT. 84341 Hyde Park UT. 84318 Logan UT. 84341 p 435.716.1260 p 435.755.6061 p 435.359.0720 p 435.932.2025 Hospital Affiliation Cache Valley Community Cache Valley Community Hospital Affiliation - Logan Regional Hospital Health Center South Health Center South - Logan Regional Hospital 517 W 100 N 517 W 100 N *Rasmuson, Becky NP Ste 110 Ste 110 Werner, Rebecca A NP Budge Clinic GI Providence UT. 84332 Providence UT. 84332 Spring Creek Medical 1350 N 500 E p 435.755.6061 p 435.755.6061 Center Logan UT. 84341 267 N Spring Creek Pkwy p 435.716.1260 Roberts, Lisa APRN Starr, Jeremy C DO Providence UT. 84332 Spring Creek Medical Cache Valley Community p 435.792.9400 Hospital Affiliation Center Health Center North - Logan Regional Hospital 267 N Spring Creek Pkwy 1515 N 400 E Wootton, George C FNP Providence UT. 84332 Ste 104 Utah State University for General Surgery p 435.792.9400 Logan UT. 84341 Persons with Disabilities *Anderson, Allan D MD p 435.755.6061 Biomedic Budge Clinic General Sage Functional Medicine 6802 Old Main Hill Surgery Center Stevens, Richard T MD Logan UT. 84322 1350 N 500 E 55 E 100 N MountainStar Cache Valley p 435.797.2750 Logan UT. 84341 Ste 303 Medical Group p 435.716.1950 Logan UT. 84321 382 W 280 N Hospital Affiliation p 435.760.7078 Providence UT. 84332 - Logan Regional Hospital Hospital Affiliation p 435.752.0330 - Logan Regional Hospital Robertson, Glenn l MD Gastroenterology Cache Valley Community Hospital Affiliation *Braden, Geoffrey L MD Hansen, Mark T MD Health Center North - Logan Regional Hospital Budge Clinic GI MountainStar Medical 1515 N 400 E 1350 N 500 E Group-Cache Valley. LLC Ste 104 Treehouse Pediatrics and Logan UT. 84341 2380 N 400 E Logan UT. 84341 Family Care p 435.716.1260 Ste A p 435.755.6061 1325 N 600 E Logan UT. 84341 Ste 101 Hospital Affiliation p 435.713.1300 Cache Valley Community Logan UT. 84341 - Logan Regional Hospital Health Center South p 435.750.5599 Hospital Affiliation 517 W 100 N Davis, Dirk R MD - Logan Regional Hospital Ste 110 Troesoyer, Ian M FNP Northern Ut Gastro & Providence UT. 84332 Cache Valley Community Endoscopy Specialists *Harker, David L MD p 435.755.6061 Health Center North 630 E 1400 N Budge Clinic General 1515 N 400 E Ste 100A Surgery Ste 104 Logan UT. 84341 1350 N 500 E Logan UT. 84341 p 435.787.0270 Logan UT. 84341 p 435.245.6988 p 435.716.1950 Hospital Affiliation - Logan Regional Hospital Hospital Affiliation - Logan Regional Hospital 17 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Marshall, Gregg A 1325 N 600 E Noorda, Barry A MD Cache Valley Community Budge Clinic General Ste 102 Cache Valley Womens Center Health Center South Surgery Logan UT. 84341 1325 N 600 E 517 W 100 N 1350 N 500 E p 435.753.9999 Ste 102 Ste 110 Logan UT. 84341 Logan UT. 84341 Providence UT. 84332 p 435.716.1950 Craig, Kristin F MD p 435.753.9999 p 435.755.6061 MountainStar Medical Hospital Affiliation Group-Cache Valley Hospital Affiliation Hospital Affiliation - Logan Regional Hospital 2380 N 400 E - Logan Regional Hospital - Logan Regional Hospital Ste A *McKenna, Logan R MD Logan UT. 84341 *Olsen, Tandy G MD *Wheelwright, Steven R DO Budge Clinic General p 435.713.1300 Budge Clinic Obstetrics Budge Clinic Obstetrics Surgery and Gynecology and Gynecology 1350 N 500 E MountainStar Cache Valley 1400 N 500 E 1400 N 500 E Logan UT. 84341 Medical Group Logan UT. 84341 Logan UT. 84341 p 435.716.1950 382 W 280 N p 435.716.1920 p 435.716.1920 Providence UT. 84332 *Peterson, Justin A MD p 435.752.0330 Hospital Affiliation Hospital Affiliation Budge Clinic General - Logan Regional Hospital - Davis Hospital Surgery Hospital Affiliation 1350 N 500 E - Logan Regional Hospital *Petersen, Chase B MD Health Department Logan UT. 84341 Budge Clinic Obstetrics Bear River Health p 435.716.1950 Fowers, Gary K MD and Gynecology Department Cache Valley Womens Center 1400 N 500 E 655 E 1300 N Genetic Counseling 1325 N 600 E Logan UT. 84341 Logan UT. 84341 *Mladucky, Janessa K GC Ste 102 p 435.716.1920 p 435.792.6500 Logan Maternal Fetal Logan UT. 84341 Medicine p 435.753.9999 Hospital Affiliation Hematology And Oncology 1400 N 500 E - Logan Regional Hospital Ben-Jacob, Ali MD Logan UT. 84341 Hospital Affiliation - Bear River Valley Hospital 1281 N 600 E p 435.716.1958 - Logan Regional Hospital Logan UT. 84341 Planned Parenthood p 435.752.5999 Gynecology Kirkman, David A MD Association of Utah Ahlstrom, Jon W MD Cache Valley Womens Center 550 N 1 Main Hospital Affiliation 550 E 1400 N 1325 N 600 E Ste 17 - Logan Regional Hospital Ste I Ste 102 Logan UT. 84321 Logan UT. 84341 Logan UT. 84341 p 435.753.0724 *Gilbert, M H MD p 435.753.1545 p 435.753.9999 Logan Cancer Clinic *Smith, Erica L MD 1350 N 500 E Hospital Affiliation Hospital Affiliation Budge Clinic Obstetrics Logan UT. 84341 - Logan Regional Hospital - Logan Regional Hospital and Gynecology p 435.716.1130 - Ogden Regional Medical 1400 N 500 E Center *McCulloch, Kimberly D MD Logan UT. 84341 Hospital Affiliation - Cache Valley Hospital Budge Clinic Obstetrics p 435.716.1920 - St George Regional Hospital and Gynecology Bertoldo, Nathan R MD 1400 N 500 E Hospital Affiliation *Lin, Karen Y MD Valley Obstetrics & Logan UT. 84341 - Logan Regional Hospital Logan Cancer Clinic Gynecology p 435.716.1920 1350 N 500 E 1515 N 400 E Wade, Kenneth A PA Logan UT. 84341 Ste 105 Hospital Affiliation Cache Valley Womens Center p 435.716.1130 Logan UT. 84341 - Logan Regional Hospital 1325 N 600 E p 801.756.9635 Ste 102 Hospital Affiliation Nielsen, Florin R MD Logan UT. 84341 - St George Regional Hospital Blackett, Anne S DO Cache Valley Community p 435.753.9999 Cache Valley Womens Center Health Center North *Reese, Zachary L MD 1325 N 600 E 1515 N 400 E Hospital Affiliation Logan Cancer Clinic Ste 102 Ste 104 - Logan Regional Hospital 1350 N 500 E Logan UT. 84341 Logan UT. 84341 Logan UT. 84341 p 435.753.9999 p 435.755.6061 Wells, Janelle M MD p 435.716.1130 Cache Valley Community Hospital Affiliation Hospital Affiliation Health Center North Hospital Affiliation - Logan Regional Hospital - Logan Regional Hospital 1515 N 400 E - St George Regional Hospital Ste 104 - Cedar City Hospital Logan UT. 84341 p 435.755.6061

18 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Sliesoraitis, Sarunas DO Hospice Internal Medicine *Garr, Robert J DO Logan Cancer Clinic Alpine Hospice Inc Assiago, Marcellus S MD Cache Valley Heart Clinic 1350 N 500 E 277 N Spring Creek Pkwy University of Utah Health 1300 N 500 E Logan UT. 84341 Providence UT. 84332 550 E 1400 N Ste 320 p 435.716.1130 p 435.753.7001 Ste K Logan UT. 84341 Logan UT. 84341 p 435.716.2200 Hospital Affiliation CNS Community Nursing p 435.716.2917 - Logan Regional Hospital Services Hospital Affiliation 221 N Gateway Dr Hospital Affiliation - Mountain West Medical *Tudor, Brian P MD Ste G - University of Utah Hospital Center Logan Cancer Clinic Providence UT. 84332 - Davis Hospital 1350 N 500 E p 800.501.0014 *Gilbert, M H MD Logan UT. 84341 *Brant, Jamie L MD Logan Cancer Clinic p 435.716.1130 Hospice Alliance Logan Cancer Clinic 1350 N 500 E 965 S 100 W 1281 N 600 E Logan UT. 84341 Hospital Affiliation Ste 204 Logan UT. 84341 p 435.716.1130 - St George Regional Hospital Logan UT. 84321 p 435.716.1130 - Cedar City Hospital p 435.753.0707 Hospital Affiliation Hospital Affiliation - St George Regional Hospital *Wilcox, Ryan E MD *Intermountain Homecare - University of Utah Hospital Logan Cancer Clinic *Hospice Logan *Hirst, Russell N MD 1350 N 500 E 550 E 1400 N *Brown, Nordell T MD Logan Regional Hospital Logan UT. 84341 Ste G Budge Clinic Pediatrics 1400 N 500 E p 435.716.1130 Logan UT. 84341 1350 N 500 E Logan UT. 84341 p 435.716.5477 Logan UT. 84341 p 435.716.1000 Hospital Affiliation p 435.792.1940 - St George Regional Hospital Rocky Mountain Home Care Hospital Affiliation - Cedar City Hospital 165 E 1400 N Hospital Affiliation - Logan Regional Hospital Ste 230 - Logan Regional Hospital Home Health Agency Logan UT. 84321 *Huffman, Jeffrey M MD CNS Community Nursing p 801.693.2300 *Chambers, Bradley A DO Budge Clinic Internal Services Budge Clinic Internal Medicine 221 N Gateway Dr Rocky Mountain Hospice Medicine 1350 N 500 E Ste G 165 E 1400 N 1350 N 500 E Logan UT. 84341 Providence UT. 84332 Ste 230 Logan UT. 84341 p 435.792.1980 p 800.501.0014 Logan UT. 84341 p 435.792.1980 p 435.753.8220 Hospital Affiliation Hospice Alliance Logan Hospitalists - Logan Regional Hospital 965 S 100 W Sunshine Terrace 1400 N 500 E Ste 204 Foundation Logan UT. 84341 *Nash, Robert M MD Logan UT. 84321 248 W 300 N p 435.716.1000 Budge Clinic Internal p 435.753.0707 Logan UT. 84321 Medicine p 435.752.0411 Hospital Affiliation 1350 N 500 E *Intermountain Homecare - Logan Regional Hospital Logan UT. 84341 *Home Health Logan Hospital p 435.792.1980 550 E 1400 N Cache Valley Hospital *Faux, David S MD Ste G 2380 N 400 E Budge Clinic Internal Hospital Affiliation Logan UT. 84341 Logan UT. 84341 Medicine - Logan Regional Hospital p 435.716.5477 p 435.713.9700 1350 N 500 E Logan UT. 84341 O Very, Bruce A MD Rocky Mountain Home Care *Logan Regional Hospital p 435.792.1980 Treehouse Pediatrics and 165 E 1400 N 500 E 1400 N Family Care Ste 230 Logan UT. 84341 Hospital Affiliation 1325 N 600 E Logan UT. 84321 p 435.716.1000 - Logan Regional Hospital Ste 101 p 801.693.2300 Logan UT. 84341 Hyperbaric Medicine *Francis, Michael R DO p 435.750.5599 Sunshine Terrace *Nail, Steven MD Budge Clinic Internal Foundation Logan Hyperbaric and Wound Medicine Hospital Affiliation 248 W 300 N Care 1350 N 500 E - Logan Regional Hospital Logan UT. 84321 1400 N 500 E Logan UT. 84341 p 435.752.0411 Logan UT. 84341 p 435.792.1980 *Redd, Edward H MD p 435.716.2250 Logan Regional Hospital Hospital Affiliation 1400 N 500 E Hospital Affiliation - Logan Regional Hospital Logan UT. 84341 - Logan Regional Hospital p 435.716.1000

Hospital Affiliation - Logan Regional Hospital 19 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Salisbury, Steven S MD *Chase, Victoria L MD Beus, Parker R LCSW Chrysalis Utah 1300 N 500 E Logan Maternal Fetal Veritas Mental Health 545 W 465 N Ste 370 Medicine 664 N Main St Ste 100 Logan UT. 84341 1400 N 500 E Ste 101 Providence UT. 84332 p 435.755.2100 Logan UT. 84341 Logan UT. 84321 p 801.655.4950 p 435.716.1958 p 435.279.0001 Hospital Affiliation Cothran, Aaron D LCSW - Logan Regional Hospital Mental Health Bingham, Sharon J LMFT Ora Counseling Aller, Ty B LMFT The Family Place 115 Golf Course Rd *Schmidt, Paul DO Ty B Aller, LMFT 10 N 600 E Ste A Budge Clinic Internal 545 W 465 N Hyrum UT. 84319 Logan UT. 84321 Medicine Ste 130 p 435.752.8880 p 435.279.6036 1350 N 500 E Providence UT. 84332 Logan UT. 84341 p 385.200.3993 1525 N 260 W Danielson, Tricia LMFT p 435.792.1980 Logan UT. 84341 Tricia H Danielson, LMFT Anderson, Kent W PhD p 435.752.8880 186 E 1800 N Hospital Affiliation Mount Logan Clinic Ste 1 - Logan Regional Hospital 545 W 465 N Boghosian, Sara PhD Logan UT. 84341 Ste 130 Pediatric Behavioral p 435.213.3062 *Stones, Michael J MD Providence UT. 84332 Health Budge Clinic Internal p 435.752.7627 246 E 1260 N 60 E Center St Medicine Logan UT. 84341 Ste 201 1350 N 500 E Archibald, Phillip LCSW p 435.750.6300 Logan UT. 84321 Logan UT. 84341 Cache Valley Community p 435.213.3062 p 435.792.1980 Health Center North Sorenson Legacy Foundation 1515 N 400 E Center for Clinical DeBerard, Michael S PhD Hospital Affiliation Ste 104 Excellence Advanced Spine and Pain - Logan Regional Hospital Logan UT. 84341 6405 Old Main Hill Specialists p 435.245.6988 Logan UT. 84322 2380 N 400 E Laboratory p 000.000.0000 Ste A Dominion Diagnostics Cache Valley Community Logan UT. 84341 Phone Number Only Health Center South Bruce R Johns, PhD PC p 435.713.9681 p 877.734.9600 517 W 100 N 246 E 1260 N Ste 110 Logan UT. 84341 286 N Gateway Dr LabCorp of America Providence UT. 84332 p 435.750.6300 Providence UT. 84332 Holdings p 435.755.6061 p 435.713.9681 Phone Number Only The Family Place p 888.522.2677 *Barker, Eric M MD 10 N 600 E Elder, Melanie LCSW Logan Psychiatry Hyrum UT. 84319 Melanie Elder LCSW Lithotripsy 1350 N 500 E p 435.752.8880 186 E 1800 N Western Intermountain Logan UT. 84341 Logan UT. 84341 Lithotripsy p 435.716.1280 1525 N 260 W p 435.213.3062 550 E 1400 N Logan UT. 84341 Logan UT. 84341 Dayspring Clinic - Logan p 435.752.8880 Fenton, Kelsey LCSW p 801.779.4955 550 E 1400 N Veritas Mental Health Ste T 502 S Main St 664 N Main Maternal And Fetal Medicine Logan UT. 84341 Smithfield UT. 84335 Ste 101 *Andres, Robert L MD p 435.716.1664 p 435.752.8880 Logan UT. 84321 Logan Maternal and Fetal p 435.828.7594 Medicine Barnard, Paige D APRN Christensen, Jud LMFT 1400 N 500 E Logan Mental Health and The Family Place Finley, Paul D LMFT Logan UT. 84341 Wellness 1525 N 260 W Logan River Counseling p 435.716.1958 95 S 100 W Logan UT. 84341 60 E Center St Ste 108 p 435.752.8880 Ste 103 Hospital Affiliation Logan UT. 84321 Logan UT. 84321 - University of Utah Hospital p 435.881.4867 *Christensen, Tyler J PhD p 435.754.9399 Logan Psychiatry *Campbell, Heather D MD Bean, Kindra G MSW 1350 N 500 E *Fraleigh, Lisa A DO Logan Maternal and Fetal The Family Place Logan UT. 84341 Logan Regional Hospital Medicine 1525 N 260 W p 435.716.1280 1400 N 500 E 1400 N 500 E Logan UT. 84341 Logan UT. 84341 Logan UT. 84341 p 435.752.8880 Christian, David E PhD p 435.716.1000 p 435.716.1958 David Christian PHD PC 629 S 575 W Hospital Affiliation Logan UT. 84321 - University of Utah Hospital p 435.787.2111

20 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Cache Valley Community Harris, Sharon LMFT Jones, Stacy H LMFT *Martinez, Angela M LCSW Health Center North New Paths Counseling Keystone Family Solutions Logan Psychiatry 1515 N 400 E 60 E Center St 95 W 100 S 1350 N 500 E Ste 104 Ste 109 Ste 102 Logan UT. 84341 Logan UT. 84341 Logan UT. 84341 Logan UT. 84321 p 435.716.1280 p 435.755.6061 p 435.213.3062 p 435.216.9937 *McCann, Jeffrey L MD Lisa A Fraleigh Hedelius, Matthew T LCSW Killila, Maureen LPC Logan Psychiatry 965 S 100 W Comprehensive Treatment 186 E 1800 N 1350 N 500 E Ste 204 Clinic Ste B Logan UT. 84341 Logan UT. 84321 40 W Cache Valley Blvd North Logan UT. 84321 p 435.716.1280 p 435.213.3797 Ste 10A p 435.770.7123 Logan UT. 84341 Logan Inpatient Psychiatry Hospital Affiliation p 435.787.2272 King, Pamela LMFT 1400 N 500 E - Logan Regional Hospital Pamela King LMFT Logan UT. 84341 Hilton, Jeremy C LCSW 186 E 1800 N p 435.752.0422 Frazier, Monique R Mt Logan Clinic Ste 2 Monique Frazier PhD, PC 246 E 1260 N Logan UT. 84341 Hospital Affiliation 246 E 1260 N Logan UT. 84341 p 435.787.4517 - Logan Regional Hospital Logan UT. 84341 p 435.750.6300 p 435.750.6300 274 N Main St Michael, Dolores D Hinds, Charles K LMFT Logan UT. 84321 Cache Valley Community Freestone, A T PSYD Hinds Counseling p 435.787.4517 Health Center Comprehensive Treatment 184 N 100 E 1515 N 400 E Clinic Ste C Krambule, Sandra A LMFT Ste 104 40 W Cache Valley Blvd Logan UT. 84321 Sandra A Krambule LMFT Logan UT. 84341 Ste 10A p 435.752.4646 580 N Main St p 435.755.6061 Logan UT. 84341 Ste 250-C p 435.787.2272 Jackson, Dana LCSW Logan UT. 84321 Wholelife Family Wellness Dana M Jackson LCSW p 435.881.7966 Clinic of Providence Gunn, Miriam LMFT 186 E 1800 N 169 N Gateway Dr North Logan Therapy Ste 1 Kunz, Meghan np Ste 170 Associates Logan UT. 84341 95 W 100 S Providence UT. 84332 186 E 1800 N p 435.213.3062 Ste 108 p 435.213.3597 Logan UT. 84341 Logan UT. 84321 p 435.770.6025 Jardine, Nichole L LCSW p 435.881.4867 Nielson, Jeannine D LMFT Nichole Jardine LCSW PLLC Family Institute of *Gunnell, Phillip B DO 274 N Main St Kwin, Leslie W LMFT Northern Utah Logan Psychiatry Logan UT. 84321 Leslie W Kwin LMFT 190 E Ctr St 1350 N 500 E p 435.753.1600 44 N Hwy 91 Logan UT. 84321 Logan UT. 84341 Ste 1 p 435.755.6707 p 435.716.1280 Johns, Bruce PhD Richmond UT. 84333 Mt Logan Clinic p 435.535.5784 Oka, Megan LMFT Logan Inpatient Psychiatry 246 E 1260 N Megan Oka LMFT 1400 N 500 E Logan UT. 84341 60 E Center St 60 E Center St Logan UT. 84341 p 435.750.6300 Ste 103 Logan UT. 84321 p 435.752.0422 Logan UT. 84321 p 435.213.3062 Johnson, McKinsey LCSW p 435.535.5784 Hospital Affiliation Mt Logan Clinic Openshaw, Jeffrey D LMFT - Logan Regional Hospital 246 E 1260 N Lee, Courtney BCBA Enlightened Perspectives - Logan Regional Hospital Logan UT. 84341 Chrysalis Utah 295 Schiess Ct p 435.750.6300 545 W 465 N Logan UT. 84321 Hancock, Ian R LCSW Ste 100 p 801.574.8530 Cache Valley Therapy Veritas Mental Health Providence UT. 84332 Services 664 N Main p 801.655.4950 Pacheco, Analee LCSW 186 E 1800 N Ste 101 The Family Place Logan UT. 84341 Logan UT. 84321 *Logan Psychiatry 1275 N 200 W p 435.557.0460 p 435.554.8118 1300 N 500 E Logan UT. 84341 Logan UT. 84341 p 435.752.8880 Hancock, Kyle M PhD Johnson, SueZan p 435.716.5790 Kyle Max Hancock, PhD, PC Bear Lake Community Health 502 S Main St 246 E 1260 N Center *Logan Inpatient Psychiatry Smithfield UT. 84335 Logan UT. 84341 1515 N 400 E 1400 N 500 E p 435.752.8880 p 435.750.6300 Ste 104 Logan UT. 84341 Logan UT. 84341 p 435.752.0422 p 435.755.6061

21 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Price, Cristine LPC Sorenson, Carl J LCSW Wimmer, Jan LCSW Neurology Health Healing & Wholeness Resilience Counseling Jan Wimmer LCSW Harris, Wade S MD 517 W 100 N Services 186 E 1800 N Logan Regional Hospital Ste 202 580 N Main St Ste 2 1400 N 500 E Providence UT. 84332 Ste 250-A Logan UT. 84341 Logan UT. 84341 p 435.915.6915 Logan UT. 84321 p 435.213.3062 p 435.716.5709 p 435.612.0788 Pye, Doriann S CMHC Neonatology Hospital Affiliation DSP Counseling and Spendlove, Rex A CMHC *Andres, Robert L MD - West Valley Medical Center Consulting Lifetech Consulting Group Logan Maternal and Fetal 965 S 100 W 1635 N 200 E Medicine Integrated Pain Ste 204 Logan UT. 84341 1400 N 500 E Consultants Logan UT. 84321 p 435.755.7654 Logan UT. 84341 286 N Gateway Dr p 801.525.4645 p 435.716.1958 Ste 201 Stephenson, Heather M LPC Providence UT. 84332 Ramboz, Bryan D LMFT Spring Tree Counseling Hospital Affiliation p 801.689.3389 Family Institute of 95 W 100 S - University of Utah Hospital Northern Utah Ste 101 *Lovell, Joshua A DO 190 E Center St Logan UT. 84321 Nephrology Budge Clinic Medical Logan UT. 84321 p 435.414.6230 Assiago, Marcellus S MD Specialists p 435.752.1976 University of Utah Health 1350 N 500 E Trice, Jill A LCSW 550 E 1400 N Logan UT. 84341 Randall, Marque PhD 1755 N 400 E Ste K p 435.716.1980 1300 N 200 E Ste 103 Logan UT. 84341 Ste 114A Logan UT. 84341 p 435.716.2917 Hospital Affiliation Logan UT. 84341 p 435.760.6721 - Logan Regional Hospital p 435.753.2687 Hospital Affiliation *Weber, Samuel R MD - University of Utah Hospital Nelson, Alex J MD *Roberge, Darrell A DO Logan Psychiatry - Davis Hospital Integrated Pain Logan Psychiatry 1350 N 500 E Consultants 1350 N 500 E Logan UT. 84341 Horowitz, Bruce L MD 286 N Gateway Dr Logan UT. 84341 p 435.716.1280 University of Utah Health Ste 201 p 435.716.1280 550 E 1400 N Providence UT. 84332 *Weigand, Ken G PhD Ste K p 801.689.3389 Hospital Affiliation Logan Psychiatry Logan UT. 84341 - Logan Regional Hospital 1350 N 500 E p 435.716.2917 Hospital Affiliation Logan UT. 84341 - Lakeview Hospital Robinson, David LMFT p 435.716.1280 Hospital Affiliation - Timpanogos Regional Hospital Cache Valley Community - University of Utah Hospital Health Center North *Whisler, Anna LCSW - Davis Hospital Obstetrics And Gynecology 1515 N 400 E Logan Psychiatry Ahlstrom, Jon W MD Ste 104 1350 N 500 E Patcha, Kishore MD 550 E 1400 N Logan UT. 84341 Logan UT. 84341 University of Utah Health Ste I p 435.755.6061 p 435.716.1280 550 E 1400 N Logan UT. 84341 Ste K p 435.753.1545 Shepherd, AmberLee A LCSW Hospital Affiliation Logan UT. 84341 186 E 1800 N - Bear River Valley Hospital p 435.716.2917 Hospital Affiliation Logan UT. 84341 - Logan Regional Hospital p 435.213.3062 Wilkinson, Thomas A PSYD Smith, Trevor R MD - Ogden Regional Medical Cache Valley Community University of Utah Health Center Smith, Heather M Health Center North 550 E 1400 N - Cache Valley Hospital North Logan Therapy 1515 N 400 E Ste K Associates Ste 104 Logan UT. 84341 *Andres, Robert L MD 186 E 1800 N Logan UT. 84341 p 435.716.2917 Logan Maternal and Fetal Logan UT. 84341 p 307.789.8920 Medicine p 512.981.5641 550 E 1400 N 1400 N 500 E Cache Valley Community Logan UT. 84341 Logan UT. 84341 Sondergaard, Laurin LMFT Health Center South p 435.716.2917 p 435.716.1958 Laurin Sondergaard LMFT 517 W 100 N 545 W 465 N Ste 110 Hospital Affiliation Hospital Affiliation Ste 130 Providence UT. 84332 - University of Utah Hospital - University of Utah Hospital Providence UT. 84332 p 435.755.6061 p 435.554.8617

22 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Bertoldo, Nathan R MD *McCulloch, Kimberly D MD Wade, Kenneth A PA *Blotter, J G OT Valley Obstetrics & Budge Clinic Obstetrics Cache Valley Womens Center Logan Regional Hospital Gynecology and Gynecology 1325 N 600 E 1400 N 500 E 1515 N 400 E 1400 N 500 E Ste 102 Logan UT. 84341 Ste 105 Logan UT. 84341 Logan UT. 84341 p 435.716.1000 Logan UT. 84341 p 435.716.1920 p 435.753.9999 p 801.756.9635 *Carling, Diane OT Hospital Affiliation Hospital Affiliation Logan Regional Hospital Blackett, Anne S DO - Logan Regional Hospital - Logan Regional Hospital 1400 N 500 E Cache Valley Womens Center Logan UT. 84341 1325 N 600 E Nielsen, Florin R MD Wells, Janelle M MD p 435.716.1000 Ste 102 Cache Valley Community Cache Valley Community Logan UT. 84341 Health Center North Health Center North Christensen, Brock K OTR p 435.753.9999 1515 N 400 E 1515 N 400 E AquaWorx Physical Therapy Ste 104 Ste 104 and Fitness Hospital Affiliation Logan UT. 84341 Logan UT. 84341 209 W 300 N - Logan Regional Hospital p 435.755.6061 p 435.755.6061 Logan UT. 84321 p 435.716.8535 1325 N 600 E Hospital Affiliation Cache Valley Community Ste 102 - Logan Regional Hospital Health Center South Concentra Medical Centers Logan UT. 84341 517 W 100 N 2390 Redwood Rd p 435.753.9999 Noorda, Barry A MD Ste 110 West Valley City UT. 84419 Cache Valley Womens Center Providence UT. 84332 p 888.997.2669 *Campbell, Heather D MD 1325 N 600 E p 435.755.6061 Logan Maternal and Fetal Ste 102 *Holt, Debbie L OT Medicine Logan UT. 84341 Hospital Affiliation Budge Clinic 1400 N 500 E p 435.753.9999 - Logan Regional Hospital 1300 N 500 E Logan UT. 84341 Logan UT. 84341 p 435.716.1958 Hospital Affiliation *Wheelwright, Steven R DO p 435.716.2880 - Logan Regional Hospital Budge Clinic Obstetrics Hospital Affiliation and Gynecology Peck, Sheridan L OT - University of Utah Hospital *Olsen, Tandy G MD 1400 N 500 E Teamworks! Therapy LLC Budge Clinic Obstetrics Logan UT. 84341 642 N 1000 W Craig, Kristin F MD and Gynecology p 435.716.1920 Logan UT. 84321 MountainStar Medical 1400 N 500 E p 435.753.1556 Group-Cache Valley Logan UT. 84341 Hospital Affiliation 2380 N 400 E p 435.716.1920 - Davis Hospital *Winn, Ryan E OT Ste A Budge Clinic Logan UT. 84341 Hospital Affiliation Occupational Therapy 1300 N 500 E p 435.713.1300 - Logan Regional Hospital *Andersen, Jay P OT Logan UT. 84341 Budge Clinic p 435.716.2880 MountainStar Cache Valley *Petersen, Chase B MD 1300 N 500 E Medical Group Budge Clinic Obstetrics Logan UT. 84341 Oncology 382 W 280 N and Gynecology p 435.716.2880 Ben-Jacob, Ali MD Providence UT. 84332 1400 N 500 E 1281 N 600 E p 435.752.0330 Logan UT. 84341 Logan Regional Hospital Logan UT. 84341 p 435.716.1920 1400 N 500 E p 435.752.5999 Hospital Affiliation Logan UT. 84341 - Logan Regional Hospital Hospital Affiliation p 435.716.1000 Hospital Affiliation - Logan Regional Hospital - Logan Regional Hospital Fowers, Gary K MD - Bear River Valley Hospital North Cache Physical Cache Valley Womens Center Therapy *Haslem, Derrick S MD 1325 N 600 E Planned Parenthood 4088 N Hwy 91 Logan Cancer Clinic Ste 102 Association of Utah Hyde Park UT. 84318 1350 N 500 E Logan UT. 84341 550 N 1 Main p 435.563.4848 Logan UT. 84341 p 435.753.9999 Ste 17 p 435.716.1130 Logan UT. 84321 Benson, Jordan C OTR Hospital Affiliation p 435.753.0724 AquaWorx Physical Therapy Hospital Affiliation - Logan Regional Hospital and Fitness - St George Regional Hospital *Smith, Erica L MD 209 W 300 N - Cedar City Hospital Kirkman, David A MD Budge Clinic Obstetrics Logan UT. 84321 Cache Valley Womens Center and Gynecology p 435.716.8535 *Johnson, Richard A DO 1325 N 600 E 1400 N 500 E Logan Cancer Clinic Ste 102 Logan UT. 84341 1350 N 500 E Logan UT. 84341 p 435.716.1920 Logan UT. 84341 p 435.753.9999 p 435.716.1130 Hospital Affiliation Hospital Affiliation - Logan Regional Hospital Hospital Affiliation - Logan Regional Hospital - Logan Regional Hospital 23 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Nadauld, Lincoln MD Howard, James G MD Parry, Matthew D OD Optometry Logan Cancer Clinic Retina Associates of Utah Cache Valley Eye Broschinsky, Nathan D OD 1350 N 500 E 272 1/2 N Main St Associates PLLC The Eye Pros Logan UT. 84341 Logan UT. 84321 1300 N 500 E 1475 N Main St p 435.716.1130 p 801.312.2020 Ste 350 Ste 103 Logan UT. 84341 Logan UT. 84341 Hospital Affiliation Hospital Affiliation p 435.752.7445 p 435.563.2020 - St George Regional Hospital - St Marks Hospital - Davis Hospital Hospital Affiliation Cole, Michael W OD *Rhodes, Terence MD - Logan Regional Hospital Child and Family EyeCare Logan Cancer Clinic Karren, Landon J DO Center 1350 N 500 E Northern Utah Eye Center Raymond, J S MD 981 S Main Logan UT. 84341 550 E 1400 N 550 E 1400 N Ste 220 p 435.716.1130 Ste P Ste P Logan UT. 84321 Logan UT. 84341 Logan UT. 84341 p 435.363.2980 Hospital Affiliation p 435.752.2020 p 435.752.2020 - St George Regional Hospital Cromwell, Jeffrey L OD 550 E 1400 N Hospital Affiliation Eye Care for You *Tudor, Brian P MD Ste Q - Logan Regional Hospital 1300 N 200 E Logan Cancer Clinic Logan UT. 84341 Ste 104 1350 N 500 E p 435.752.2020 Siler, Jon A MD Logan UT. 84321 Logan UT. 84341 Cache Valley Eye p 435.752.6453 p 435.716.1130 Knudsen, Victoria M MD Associates PLLC Retina Associates of Utah 1300 N 500 E Cromwell, Phillip G OD Hospital Affiliation 810 S 100 W Ste 350 Eye Care for You - St George Regional Hospital Ste C Logan UT. 84341 1300 N 200 E - Cedar City Hospital Logan UT. 84321 p 435.752.7445 Ste 104 p 435.750.1010 Logan UT. 84321 Ophthalmology Hospital Affiliation p 435.752.6453 Brinton, Gregory S MD Hospital Affiliation - Logan Regional Hospital Retina Associates of Utah - St Marks Hospital Ellsworth, Kevin M OD 272 1/2 N Main St - Davis Hospital Swartz, Mano MD 395 E 1400 N Logan UT. 84321 Retina Associates of Utah Ste B p 801.312.2020 Kwun, Robert MD 272 1/2 N Main St Logan UT. 84341 Retina Associates of Utah Logan UT. 84321 p 435.752.5585 Hospital Affiliation 272 1/2 N Main St p 801.312.2020 - St Marks Hospital Logan UT. 84321 Freeman, Rebecca OD - Davis Hospital p 801.312.2020 Waterman, David G MD Northern Utah Eye Center Cache Valley Eye 550 E 1400 N Northern Utah Eye Center Hospital Affiliation Associates PLLC Ste P 550 E 1400 N - St Marks Hospital 1300 N 500 E Logan UT. 84341 Ste P - Davis Hospital Ste 350 p 435.752.2020 Logan UT. 84341 Logan UT. 84341 p 435.752.2020 Monson, Bryan K MD p 435.752.7445 550 E 1400 N Logan Eye Institute Ste Q 550 E 1400 N 810 S 100 W Hospital Affiliation Logan UT. 84341 Ste Q Ste 100 - Logan Regional Hospital p 435.752.2020 Logan UT. 84341 Logan UT. 84321 p 435.752.2020 p 435.752.2020 Winward, Kirk E MD Gibson, Gustaf I OD Retina Associates of Utah 1155 N 320 W Hammond, Matthew D MD Nilson, Christian D MD 272 1/2 N Main St Logan UT. 84341 Logan Eye Institute Northern Utah Eye Center Logan UT. 84321 p 435.787.9273 810 S 100 W 550 E 1400 N p 801.312.2020 Ste 100 Ste P 145 W Cache Valley Blvd Logan UT. 84321 Logan UT. 84341 Hospital Affiliation Logan UT. 84341 p 435.752.2020 p 435.752.2020 - St Marks Hospital p 435.787.9273 - Davis Hospital Hospital Affiliation 550 E 1400 N Helman, Andrew OD - Logan Regional Hospital Ste Q Young, Steven R MD Standard Optical - Franklin County Medical Logan UT. 84341 1300 N 500 E 1153 N Main St Center p 435.752.2020 Ste 220 Ste A 120 Logan UT. 84341 Logan UT. 84341 Hospital Affiliation p 435.753.5220 p 435.752.2092 - Logan Regional Hospital - Cache Valley Hospital Hospital Affiliation - Franklin County Medical - Logan Regional Hospital Center

24 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Henderson, Lance D OD Oral And Maxillofacial Surgery Finlayson, Terry I MD Larson, Brad J MD Eye Care for You Anderson, Gregory E DDS Alpine Orthopaedic Alpine Orthopaedic 1300 N 200 E 1395 N 400 E Specialists Specialists Ste 104 Ste B 2310 N 400 E 2310 N 400 E Logan UT. 84321 Logan UT. 84341 Ste A Ste A p 435.752.6453 p 435.755.5000 North Logan UT. 84341 Logan UT. 84341 p 435.787.2000 p 435.787.2000 Jetton, Heather M OD Hospital Affiliation Logan Eye Institute - Logan Regional Hospital Hospital Affiliation Hospital Affiliation 810 S 100 W - Brigham City Community - Logan Regional Hospital - Brigham City Community Ste 100 Hospital Hospital Logan UT. 84321 - Cache Valley Hospital Goble, E Marlowe MD - Logan Regional Hospital p 435.752.2020 2380 N 400 E - Cache Valley Hospital Matson, Scott DMD Logan UT. 84341 Hospital Affiliation Logan Oral Surgery p 435.787.8467 *Murray, David P MD - Logan Regional Hospital 3125 N Main St Logan Regional Orthopedics Ste 103 Hicken, Gregory J MD 1350 N 500 E Kofoed, Lavar W OD Logan UT. 84341 Alpine Orthopaedic Logan UT. 84341 The Eye Pros p 435.754.7130 Specialists p 435.716.2800 1475 N Main St 2310 N 400 E Ste 103 Hospital Affiliation Ste A Hospital Affiliation Logan UT. 84341 - Logan Regional Hospital Logan UT. 84341 - Logan Regional Hospital p 435.563.2020 p 435.787.2000 Orthopedic Surgery Nelson, Keith J MD Lewis, Todd J OD Casperson, Douglas K PA-C Hospital Affiliation Alpine Orthopaedic Logan Eye Institute Alpine Orthopaedic - Brigham City Community Specialists 810 S 100 W Specialists Hospital 2310 N 400 E Ste A 2310 N 400 E - Franklin County Medical Ste A Logan UT. 84321 Ste A Center Logan UT. 84341 p 435.752.2000 North Logan UT. 84341 - Cache Valley Hospital p 435.787.2000 p 435.787.2000 Myers, Rochelle A OD *Higginbotham, Thomas O MD Hospital Affiliation Standard Optical Hospital Affiliation Logan Regional Orthopedics - Brigham City Community 1153 N Main St - Logan Regional Hospital 1350 N 500 E Hospital Ste A 120 Logan UT. 84341 - Logan Regional Hospital Logan UT. 84341 Delange, Lance FNP p 435.716.2800 - Cache Valley Hospital p 435.752.2092 Alpine Orthopaedic Specialists South Cache Valley Clinic *Olson, Matthew R DO Logan Eye Institute 2310 N 400 E 190 S Hwy 165 Logan Regional Orthopedics 810 S 100 W Ste A Providence UT. 84332 1350 N 500 E Ste A North Logan UT. 84341 p 435.755.3300 Logan UT. 84341 Logan UT. 84321 p 435.787.2000 p 435.716.2800 p 435.787.7200 Hospital Affiliation Hospital Affiliation - Logan Regional Hospital Peterson, David E MD Rees, Alan T OD - Brigham City Community Alpine Orthopaedic Baldwin Optical Hospital *Hooley, Eric W MD Specialists 1451 N 200 E - Cache Valley Hospital Logan Regional Orthopedics 2310 N 400 E Ste 195 1350 N 500 E Ste A Logan UT. 84341 Felix, Brent A MD Logan UT. 84341 Logan UT. 84341 p 801.776.2020 Alpine Orthopaedic p 435.716.2800 p 435.787.2000 Specialists Seeholzer, Jeff H OD 2310 N 400 E Hospital Affiliation Robinett, Zachary MD 124 N Main St Ste A - Logan Regional Hospital Cache Valley Ear Nose & Logan UT. 84321 North Logan UT. 84341 Throat p 435.752.5334 p 435.787.2000 *King, Bryan C MD 169 N Gateway Dr Logan Regional Orthopedics Ste 120 Smith, David A OD Hospital Affiliation 1350 N 500 E Providence UT. 84332 276 N Spring Creek Pkwy - Brigham City Community Logan UT. 84341 p 435.753.7880 Providence UT. 84332 Hospital p 435.716.2800 p 435.713.4444 - St Marks Hospital 2380 N 400 E - Logan Regional Hospital Hospital Affiliation Ste D Standard Optical Mon-Fri - Jordan Valley Medical - Logan Regional Hospital Logan UT. 84341 9am-7pm Sat 8am-5pm Center West Valley Campus p 435.753.7880 1153 N Main St Ste A-120 Hospital Affiliation Logan UT. 84321 - Cache Valley Hospital p 435.752.2092 - Logan Regional Hospital

25 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Rowley, David M MD Garg, Vikas MD Obray, Rick W MD *Pilcher, Thomas A MD Alpine Orthopaedic Interventional Spine & Vista Neurology Logan Regional Hospital Specialists Pain Management Specialists 1400 N 500 E 2310 N 400 E 1337 N 1400 E 630 E 1400 N Logan UT. 84341 Ste A Logan UT. 84341 Ste 135 p 435.716.5571 Logan UT. 84341 p 801.262.7246 Logan UT. 84321 p 435.787.2000 p 435.787.8146 Hospital Affiliation Advanced Spine and Pain - Primary Childrens Hospital Hospital Affiliation Specialists Hospital Affiliation - Lone Peak Hospital - Logan Regional Hospital 2380 N 400 E - St George Regional Hospital Ste A Ware, Adam L MD Vernon, Brian A MD Logan UT. 84341 Richardson, Brian F MD University of Utah Health Alder Grove Orthopedic p 435.713.9681 Vista Neurology 500 E 1400 N Spine Specialists Logan UT. 84341 630 E 1400 N Interventional Spine & 630 E 1400 N p 801.213.3599 Ste 118 Pain Management Ste 135 Logan UT. 84341 286 N Gateway Dr Logan UT. 84341 550 E 1400 N p 435.799.7953 Ste 201 p 435.787.8146 Logan UT. 84341 Providence UT. 84332 p 801.213.3599 Hospital Affiliation p 435.932.6125 Hospital Affiliation - Logan Regional Hospital - Logan Regional Hospital Pediatric Endocrinology - Cache Valley Hospital Advanced Spine and Pain Clements, Scott A MD Specialists Palliative Care University of Utah Health Werner, Whitney M PA 286 N Gateway Dr *Brant, Jamie L MD 1350 N 500 E Alpine Orthopaedic Providence UT. 84332 Logan Cancer Clinic Logan UT. 84341 Specialists p 435.713.9681 1281 N 600 E p 801.581.2955 2310 N 400 E Logan UT. 84341 Ste A Hospital Affiliation p 435.716.1130 Hospital Affiliation North Logan UT. 84341 - Lone Peak Hospital - University of Utah Hospital p 435.787.2000 - Evanston Regional Hospital Hospital Affiliation - Brigham City Community - University of Utah Hospital Smego, Allison MD Hospital Affiliation Hospital University of Utah Health - Logan Regional Hospital Firth, Ronald M MD 1350 N 500 E Integrated Pain Bridge Utah Medical Group Logan UT. 84341 Orthotics And Prosthetics Consultants 1015 E 100 N p 801.213.3599 Jenco Prosthetics and 286 N Gateway Dr Logan UT. 84321 Orthotics Ste 201 p 888.853.8973 Hospital Affiliation 1153 N Main St Providence UT. 84332 - Primary Childrens Hospital Ste B-140 p 801.689.3389 Hospital Affiliation Logan UT. 84341 - Logan Regional Hospital Pediatrics p 435.750.6579 Nelson, Alex J MD Armstrong, Craig W MD Integrated Pain Pediatric Behavioral Health Primary Care Pediatrics Rocky Mountain Artificial Consultants Hancock, Kyle M PhD 2380 N 400 E Limb & Brace 286 N Gateway Dr Kyle Max Hancock, PhD, PC Ste C 1515 N 400 E Ste 201 246 E 1260 N North Logan UT. 84341 Ste 100 Providence UT. 84332 Logan UT. 84341 p 435.753.7337 Logan UT. 84341 p 801.689.3389 p 435.750.6300 p 435.753.5100 Hospital Affiliation Hospital Affiliation Pediatric Cardiology - Logan Regional Hospital Pain Management - Lakeview Hospital Etheridge, Susan P MD Despain, Devin DO - Timpanogos Regional Hospital University of Utah Health Bell, Ryan R MD Interventional Spine & 550 E 1400 N Treehouse Pediatrics and Pain Management Obray, Jon B MD Logan UT. 84341 Family Care 1337 N 1400 E Vista Neurology p 801.213.3599 1325 N 600 E Logan UT. 84341 Specialists Ste 101 p 801.262.7246 630 E 1400 N *Hoffman, James L MD Logan UT. 84341 Ste 135 Logan Regional Hospital p 435.750.5599 Frieden, Derek L MD Logan UT. 84321 1400 N 500 E Vista Neurology p 435.787.8146 Logan UT. 84341 Hospital Affiliation Specialists p 435.716.5571 - Logan Regional Hospital 630 E 1400 N Hospital Affiliation Ste 135 - St George Regional Hospital Hospital Affiliation *Bowles, Austin J MD Logan UT. 84321 - Timpanogos Regional Hospital Budge Clinic Pediatrics p 435.787.8146 1350 N 500 E Logan UT. 84341 Hospital Affiliation p 435.792.1940 - St George Regional Hospital

26 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Brown, Nordell T MD *Martin-Garg, Prafulla D Treehouse Pediatrics and Hills, Ammon A DO Budge Clinic Pediatrics *MD Family Care Alpine Orthopaedic 1350 N 500 E Budge Clinic Pediatrics 1325 N 600 E Specialists Logan UT. 84341 1350 N 500 E Ste 101 2310 N 400 E p 435.792.1940 Logan UT. 84341 Logan UT. 84341 Ste A p 435.792.1940 p 435.750.5599 Logan UT. 84341 Hospital Affiliation p 435.787.2000 - Logan Regional Hospital Hospital Affiliation Vernon, Yohanna S MD - Logan Regional Hospital Alder Grove Pediatrics Hospital Affiliation *Carver, Jeanlee F APRN 630 E 1400 N - Logan Regional Hospital Primary Childrens Hospital McKenna, Russel T DO Ste 118 - Cache Valley Hospital 1362 N 400 W Treehouse Pediatrics and Logan UT. 84341 - Brigham City Community Logan UT. 84341 Family Care p 435.799.7953 Hospital p 435.753.7017 1325 N 600 E Ste 101 *Visick, Michael K MD Ostler, Joseph MD Hospital Affiliation Logan UT. 84341 Budge Clinic Pediatrics Bridge Utah Medical Group - Primary Childrens Hospital p 435.750.5599 1350 N 500 E 1015 E 100 N - Lakeview Hospital Logan UT. 84341 Logan UT. 84321 - Ogden Regional Medical Hospital Affiliation p 435.792.1940 p 888.853.8973 Center - Logan Regional Hospital Hospital Affiliation Peterson, Cameron G MD *Dallon, Chad W MD O Very, Bruce A MD - Logan Regional Hospital Bridge Utah Medical Group Budge Clinic Pediatrics Treehouse Pediatrics and 1015 E 100 N 1350 N 500 E Family Care Wilson, Cody R DO Logan UT. 84321 Logan UT. 84341 1325 N 600 E Primary Care Pediatrics p 888.853.8973 p 435.792.1940 Ste 101 2380 N 400 E Logan UT. 84341 Ste C Hospital Affiliation Ethington, Bradley MD p 435.750.5599 Logan UT. 84341 - Logan Regional Hospital Primary Care Pediatrics p 435.753.7337 2380 N 400 E Hospital Affiliation *Swenson, Jonathan B MD Ste C - Logan Regional Hospital Hospital Affiliation Logan Regional Orthopedics Logan UT. 84341 - Logan Regional Hospital 1350 N 500 E p 435.753.7337 *Rogers, Matt N MD Logan UT. 84341 Budge Clinic Pediatrics Physical Medicine And Rehabilitation p 435.716.2800 Hospital Affiliation 1350 N 500 E Bridge Utah Medical Group - Cache Valley Hospital Logan UT. 84341 1015 E 100 N Hospital Affiliation - Logan Regional Hospital p 435.792.1940 Logan UT. 84321 - Logan Regional Hospital p 888.853.8973 *Horkley, Tyson S MD Hospital Affiliation Physical Therapy Budge Clinic Pediatrics - Logan Regional Hospital Clegg, Michael L MD *Allred, Breeann V PT 1350 N 500 E Alpine Orthopaedic Budge Clinic Logan UT. 84341 *Sandgren, Daniel M DO Specialists 1300 N 500 E p 435.792.1940 Budge Clinic Pediatrics 2310 N 400 E Logan UT. 84341 1350 N 500 E Ste A p 435.716.2880 Hospital Affiliation Logan UT. 84341 North Logan UT. 84341 - Logan Regional Hospital p 435.792.1940 p 435.787.2000 Back@Work Physical Therapy 630 E 1400 N Jorgensen, Nina G MD Hospital Affiliation Hospital Affiliation Ste 140 Primary Care Pediatrics - Logan Regional Hospital - Logan Regional Hospital Logan UT. 84341 2380 N 400 E - Franklin County Medical p 435.213.3850 Ste C *Stacie, Mecham W APRN Center North Logan UT. 84341 Primary Childrens Hospital - Cache Valley Hospital 939 S State Hwy 89 Unit 3 p 435.753.7337 1362 N 400 W Logan UT. 84321 Logan UT. 84341 Fyans, Joseph C MD p 435.238.7217 Hospital Affiliation p 435.753.7017 Bridge Utah Medical Group - Logan Regional Hospital 1015 E 100 N Baldwin, Matthew D DPT Primary Care Pediatrics Logan UT. 84321 Back@Work Physical Therapy Labrum, Barrett P DO 2380 N 400 E p 888.853.8973 939 S State Hwy 89 Unit 3 Primary Care Pediatrics Ste C Logan UT. 84321 2380 N 400 E Logan UT. 84341 Hess, Brian PA-C p 435.216.4343 Ste C p 435.753.7337 Alpine Orthopaedic Logan UT. 84341 Specialists Berryhill, John H MPT p 435.753.7337 Hospital Affiliation 2310 N 400 E John Berryhill Physical - Primary Childrens Hospital Ste A Therapy Hospital Affiliation Logan UT. 84341 70 S Main St - Logan Regional Hospital p 435.787.2000 Smithfield UT. 84335 p 435.563.0750

27 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Boyce, Neal S PT Concentra Medical Centers *Greenwood, Brandon D PT *Sandberg, Gregory S DPT Budge Clinic 2390 Redwood Rd Logan Regional Hospital Budge Clinic 1300 N 500 E West Valley City UT. 84419 1400 N 500 E 1300 N 500 E Logan UT. 84341 p 888.997.2669 Logan UT. 84341 Logan UT. 84341 p 435.716.2880 p 435.716.1000 p 435.716.2880 *Dahle, Shaun P PT Bressel, Megan E PT Budge Clinic Hanyak, Eric M PT Logan Regional Hospital Spring Creek Medical 1300 N 500 E AquaWorx Physical Therapy Physicians Center Logan UT. 84341 and Fitness 1400 N 500 E 267 N Spring Creek Pkwy p 435.716.2880 209 W 300 N Logan UT. 84341 Providence UT. 84332 Logan UT. 84321 p 435.716.1000 p 435.792.9400 Despain, Spencer C DPT p 435.716.8535 Back@Work Physical Therapy North Cache Physical *Campbell, Erin M PT 630 E 1400 N *Harrison, Sarah PT Therapy Budge Clinic Ste 140 Physical Therapy 4088 N Hwy 91 1300 N 500 E Logan UT. 84341 1300 N 500 E Hyde Park UT. 84318 Logan UT. 84341 p 435.213.3850 Ste 130 p 435.563.4848 p 435.716.2880 Logan UT. 84341 Doucette, Susan A DPT p 435.716.2880 Hospital Affiliation North Cache Physical Logan Physical Therapy PC - Logan Regional Hospital Therapy 2310 N 400 E Knowles Smith, Angela PT 4088 N Hwy 91 Ste C AquaWorx Physical Therapy Schroeder, Gregory P DPT Hyde Park UT. 84318 North Logan UT. 84341 and Fitness Back@Work Physical Therapy p 435.563.4900 p 435.752.5200 209 W 300 N 939 S State Hwy 89 Unit 3 Logan UT. 84321 Logan UT. 84321 Campbell, Todd P DPT Doyle, Ryan PT p 435.716.8535 p 435.238.7217 Teamworks! Therapy LLC Springcreek Medical Center 642 N 1000 W 267 N Springcreek Pkwy *Larsen, Brian T PT Severe, Stephen K DPT Ste 107 Providence UT. 84332 Budge Clinic AquaWorx Physical Therapy Logan UT. 84321 p 435.792.9400 1300 N 500 E and Fitness p 435.753.1556 Logan UT. 84341 209 W 300 N *Edwards, Charlie G DPT p 435.716.2880 Logan UT. 84321 *Carlson, Jessica PT Logan Regional Hospital p 435.716.8535 Budge Clinic Pediatric Rehab Malan, Vernon R DPT 1300 N 500 E 550 E 1400 N Gateway Physical Therapy *Slater, Candace L DPT Logan UT. 84341 Ste W and Sports Rehab Logan Regional Hospital p 435.716.2880 Logan UT. 84341 169 N Gateway Dr Pediatric Rehab p 435.716.6440 Ste 160 550 E 1400 N North Cache Physical Providence UT. 84332 Ste W Therapy Hospital Affiliation p 435.799.3111 Logan UT. 84341 4088 N Hwy 91 - Logan Regional Hospital p 435.716.6440 Hyde Park UT. 84318 Mumford, Michael C PT p 435.563.4848 Gibbs, Amy H PT AquaWorx Physical Therapy Hospital Affiliation Spring Creek Medical and Fitness - Logan Regional Hospital Chase, Darin A PT Center 209 W 300 N Gateway Physical Therapy 267 N Spring Creek Pkwy Logan UT. 84321 Spainhower, Madison DPT and Sports Rehab Providence UT. 84332 p 435.716.8535 Madison Spainhower DPT 169 N Gateway Dr p 435.792.9400 209 W 300 N Ste 160 Porter, Camille DPT Logan UT. 84321 Providence UT. 84332 Godfrey, Ryan OT Gateway Physical Therapy p 435.716.8535 p 435.799.3111 Cache Valley Hand Therapy and Sports Rehab 2310 N 400 E 169 N Gateway Dr Taylor, Michael E PT Christensen, Andrew R PT Ste D Ste 160 Spring Creek Medical AquaWorx Physical Therapy Logan UT. 84341 Providence UT. 84332 Center and Fitness p 435.774.8562 p 435.799.3111 267 N Spring Creek Pkwy 209 W 300 N Providence UT. 84332 Logan UT. 84321 *Greene, Wess R PT *Ross, George L PT p 435.792.9400 p 435.716.8535 Budge Clinic Logan Regional Hospital 1300 N 500 E 1400 N 500 E *Walker, Tracy L PT *Cole, John D PT Logan UT. 84341 Logan UT. 84341 Logan Regional Hospital Logan Regional Hospital p 435.716.2880 p 435.716.1000 1400 N 500 E 1400 N 500 E Logan UT. 84341 Logan UT. 84341 p 435.716.1000 p 435.716.1000

28 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. North Cache Physical Podiatry Dayspring Clinic - Logan Therapy Bell, David D DPM Huff, Daniel J DPM 550 E 1400 N 4088 N Hwy 91 1219 N 400 E Foot and Ankle Center of Ste T Hyde Park UT. 84318 Logan UT. 84341 Providence Logan UT. 84341 p 435.563.4848 p 435.753.7000 272 N Spring Creek Pkwy p 435.716.1664 Providence UT. 84332 *Young, Nathan A PT Hospital Affiliation p 435.787.1023 Barnard, Paige D APRN Logan Regional Hospital - Logan Regional Hospital Logan Mental Health and 1400 N 500 E Hospital Affiliation Wellness Logan UT. 84341 Burgon, Andrew H DPM - Logan Regional Hospital 95 S 100 W p 435.716.1000 Foot and Ankle Center of Ste 108 Providence *Pedersen, Curtis C DPM Logan UT. 84321 Plastic Surgery 272 N Spring Creek Pkwy Logan Regional Orthopedics p 435.881.4867 Andersen, Blaine P MD Providence UT. 84332 1350 N 500 E Refine the Body p 435.787.1023 Logan UT. 84341 *Fraleigh, Lisa A DO 1300 N 500 E p 435.716.2800 Logan Regional Hospital Ste 260 Buttars, Russell J DPM 1400 N 500 E Logan UT. 84341 Daniel J Huff Podiatry DPM Logan Hyperbaric and Wound Logan UT. 84341 p 435.753.3400 272 N Spring Creek Pkwy Care p 435.716.1000 Providence UT. 84332 1400 N 500 E Hospital Affiliation p 435.787.1023 Logan UT. 84341 Cache Valley Community - Logan Regional Hospital p 435.716.2250 Health Center North - Brigham City Community Cook, Gregory B DPM 1515 N 400 E Hospital Cook & Sautter Foot & Hospital Affiliation Ste 104 - Cache Valley Hospital Ankle - Logan Regional Hospital Logan UT. 84341 550 E 1400 N p 435.755.6061 Bennion, Jeffrey G MD Ste B Richman, Brian H DPM Cache Valley Ear Nose & Logan UT. 84321 550 E 1400 N Lisa A Fraleigh Throat p 435.752.9011 Ste N 965 S 100 W 169 N Gateway Dr Logan UT. 84341 Ste 204 Ste 120 Hospital Affiliation p 435.752.1038 Logan UT. 84321 Providence UT. 84332 - Logan Regional Hospital p 435.213.3797 p 435.753.7880 - Brigham City Community Hospital Affiliation Hospital - Davis Hospital Hospital Affiliation 2380 N 400 E - Cache Valley Hospital - Logan Regional Hospital - Logan Regional Hospital Ste D - Lakeview Hospital Logan UT. 84341 Cook, W Bryce DPM *Gunnell, Phillip B DO p 435.753.7880 Foot Clinic of Logan *Rigby, Ryan B DPM Logan Psychiatry 550 E 1400 N Logan Regional Orthopedics 1350 N 500 E Hospital Affiliation Ste B 1350 N 500 E Logan UT. 84341 - Logan Regional Hospital Logan UT. 84341 Logan UT. 84341 p 435.716.1280 - Franklin County Medical p 435.752.9011 p 435.716.2800 Center Logan Inpatient Psychiatry David G Edwards DPM PC Sautter, Travis L DPM 1400 N 500 E Blotter, James W MD 1651 Saddle Hill Dr Cook & Sautter Foot & Logan UT. 84341 Cache Valley Ear Nose & Logan UT. 84321 Ankle p 435.752.0422 Throat p 435.770.2442 550 E 1400 N 169 N Gateway Dr Ste B Hospital Affiliation Ste 120 Edwards, David G DPM Logan UT. 84341 - Logan Regional Hospital Providence UT. 84332 David G Edwards DPM PC p 435.752.9011 - Logan Regional Hospital p 435.753.7880 1651 Saddle Hill Dr Logan UT. 84321 Willmore, James T DPM *Logan Psychiatry 2380 N 400 E p 435.770.2442 James T Willmore DPM 1300 N 500 E Ste D 272 N Spring Creek Pkwy Logan UT. 84341 Logan UT. 84341 Hospital Affiliation Providence UT. 84332 p 435.716.5790 p 435.753.7880 - Logan Regional Hospital p 435.787.1023 *Logan Inpatient Psychiatry Hospital Affiliation Heninger, Spencer B DPM Hospital Affiliation 1400 N 500 E - Logan Regional Hospital Alpine Orthopaedic - Cache Valley Hospital Logan UT. 84341 Specialists - Logan Regional Hospital p 435.752.0422 *Isom, Casey N MD 2310 N 400 E Isom Plastic Surgery Ste A Psychiatry *McCann, Jeffrey L MD 1350 N 500 E Logan UT. 84341 *Barker, Eric M MD Logan Psychiatry Ste 310 p 435.787.2000 Logan Psychiatry 1350 N 500 E Logan UT. 84341 1350 N 500 E Logan UT. 84341 p 435.787.1108 Hospital Affiliation Logan UT. 84341 p 435.716.1280 - Brigham City Community p 435.716.1280 Hospital Affiliation Hospital - Logan Regional Hospital - Logan Regional Hospital - Franklin County Medical Center 29 *The PPO Agreement with this provider is expressly between- Cache the Valley Third PartyHospital Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Logan Inpatient Psychiatry DeBerard, Michael S PhD *Barney, Brandon M MD Radiology 1400 N 500 E Advanced Spine and Pain Logan Radiation Oncology *Budge Clinic Radiology Logan UT. 84341 Specialists 500 E 1400 N 1350 N 500 E p 435.752.0422 2380 N 400 E Logan UT. 84341 Logan UT. 84341 Ste A p 435.716.1000 p 435.753.0401 Hospital Affiliation Logan UT. 84341 - Logan Regional Hospital p 435.713.9681 *Cannon, George M MD Strobel, John J MD Logan Radiation Oncology Cache Valley Vein *Roberge, Darrell A DO 286 N Gateway Dr 500 E 1400 N 565 W 465 N Logan Psychiatry Providence UT. 84332 Logan UT. 84341 Ste 130 1350 N 500 E p 435.713.9681 p 435.716.1000 Providence UT. 84332 Logan UT. 84341 p 435.753.2842 p 435.716.1280 Frazier, Monique R *Clark, Jay A MD Monique Frazier PhD, PC Logan Radiation Oncology Hospital Affiliation Hospital Affiliation 246 E 1260 N 500 E 1400 N - Bear River Valley Hospital - Logan Regional Hospital Logan UT. 84341 Logan UT. 84341 - Cache Valley Hospital p 435.750.6300 p 435.716.1000 *Weber, Samuel R MD Rheumatology Logan Psychiatry Freestone, A T PSYD *Evans, Jaden D MD *Meier, Adam T MD 1350 N 500 E Comprehensive Treatment Logan Radiation Oncology Budge Clinic Medical Logan UT. 84341 Clinic 500 E 1400 N Specialists p 435.716.1280 40 W Cache Valley Blvd Logan UT. 84341 1350 N 500 E Ste 10A p 435.716.1000 Logan UT. 84341 Psychology Logan UT. 84341 p 435.716.1980 Anderson, Kent W PhD p 435.787.2272 *Grant, Jonathan D MD Mount Logan Clinic Logan Radiation Oncology Hospital Affiliation 545 W 465 N Johns, Bruce PhD 500 E 1400 N - Logan Regional Hospital Ste 130 Mt Logan Clinic Logan UT. 84341 Providence UT. 84332 246 E 1260 N p 435.716.1000 *Walker, Corey W MD p 435.752.7627 Logan UT. 84341 Budge Clinic Medical p 435.750.6300 *Hunter, Grant K MD Specialists Boghosian, Sara PhD Logan Radiation Oncology 1350 N 500 E Pediatric Behavioral Randall, Marque PhD 500 E 1400 N Logan UT. 84341 Health 1300 N 200 E Logan UT. 84341 p 435.716.1980 246 E 1260 N Ste 114A p 435.716.1000 Logan UT. 84341 Logan UT. 84341 Hospital Affiliation p 435.750.6300 p 435.753.2687 Hospital Affiliation - Logan Regional Hospital - Logan Regional Hospital Sorenson Legacy Foundation *Weigand, Ken G PhD Skilled Nursing Facility Center for Clinical Logan Psychiatry *Lee, Robert J MD Rocky Mountain Care - Excellence 1350 N 500 E Logan Radiation Oncology Logan 6405 Old Main Hill Logan UT. 84341 500 E 1400 N 1480 N 400 E Logan UT. 84322 p 435.716.1280 Logan UT. 84341 Logan UT. 84341 p 000.000.0000 p 435.716.1000 p 435.750.5501 Wilkinson, Thomas A PSYD Bruce R Johns, PhD PC Cache Valley Community Hospital Affiliation Logan Nursing and 246 E 1260 N Health Center North - St Marks Hospital Rehabilitation Logan UT. 84341 1515 N 400 E - Jordan Valley Medical 1480 N 400 E p 435.750.6300 Ste 104 Center Logan UT. 84341 Logan UT. 84341 - Lone Peak Hospital p 435.750.5501 *Christensen, Tyler J PhD p 307.789.8920 Logan Psychiatry *Sause, William T MD Sunshine Terrace 1350 N 500 E Cache Valley Community Logan Radiation Oncology Foundation Logan UT. 84341 Health Center South 500 E 1400 N 248 W 300 N p 435.716.1280 517 W 100 N Logan UT. 84341 Logan UT. 84321 Ste 110 p 435.716.1000 p 435.752.0411 Christian, David E PhD Providence UT. 84332 David Christian PHD PC p 435.755.6061 Hospital Affiliation Sleep Medicine 629 S 575 W - Salt Lake Regional Medical Harris, Wade S MD Logan UT. 84321 Radiation Oncology Center Logan Regional Hospital p 435.787.2111 *Avizonis, Vilija MD 1400 N 500 E Logan Radiation Oncology *Whipple, Gary L MD Logan UT. 84341 500 E 1400 N Logan Radiation Oncology p 435.716.5709 Logan UT. 84341 500 E 1400 N p 435.716.1000 Logan UT. 84341 Hospital Affiliation p 435.716.1000 - West Valley Medical Center Hospital Affiliation - St Marks Hospital 30 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Social Worker Hilton, Jeremy C LCSW Trice, Jill A LCSW Evans, Deborah SLP Archibald, Phillip LCSW Mt Logan Clinic 1755 N 400 E USU Speech Language Cache Valley Community 246 E 1260 N Ste 103 Hearing Center Health Center North Logan UT. 84341 Logan UT. 84341 1000 Old Main Hill 1515 N 400 E p 435.750.6300 p 435.760.6721 Logan UT. 84322 Ste 104 p 435.797.1346 Logan UT. 84341 Jackson, Dana LCSW *Whisler, Anna LCSW p 435.245.6988 Dana M Jackson LCSW Logan Psychiatry *Hunsaker, Lindsey SLP 186 E 1800 N 1350 N 500 E Logan Regional Hospital Cache Valley Community Ste 1 Logan UT. 84341 Physicians Health Center South Logan UT. 84341 p 435.716.1280 1400 N 500 E 517 W 100 N p 435.213.3062 Logan UT. 84341 Ste 110 Hospital Affiliation p 435.716.1000 Providence UT. 84332 Jardine, Nichole L LCSW - Bear River Valley Hospital p 435.755.6061 Nichole Jardine LCSW PLLC *Jorgensen, Andrea E SLP 274 N Main St *Wilkinson, Rachel LCSW Logan Regional Hospital Bean, Kindra G MSW Logan UT. 84321 Dayspring Clinic - Logan Physicians The Family Place p 435.753.1600 550 E 1400 N 1400 N 500 E 1525 N 260 W Ste T Logan UT. 84341 Logan UT. 84341 Johnson, McKinsey LCSW Logan UT. 84341 p 435.716.1000 p 435.752.8880 Mt Logan Clinic p 435.716.1664 246 E 1260 N Hospital Affiliation Cothran, Aaron D LCSW Logan UT. 84341 Wimmer, Jan LCSW - Logan Regional Hospital Ora Counseling p 435.750.6300 Jan Wimmer LCSW 115 Golf Course Rd 186 E 1800 N *Parker, Michelle A SLP Ste A Veritas Mental Health Ste 2 Budge Clinic Surgical Logan UT. 84321 664 N Main Logan UT. 84341 Specialists p 435.279.6036 Ste 101 p 435.213.3062 1350 N 500 E Logan UT. 84321 Logan UT. 84341 Elder, Melanie LCSW p 435.554.8118 Speech Therapy p 435.752.1693 Melanie Elder LCSW Amundson, Deborah SLP 186 E 1800 N Johnson, SueZan USU Speech Language Hospital Affiliation Logan UT. 84341 Bear Lake Community Health Hearing Center - Logan Regional Hospital p 435.213.3062 Center 1000 Old Main Hill 1515 N 400 E Logan UT. 84322 Preston, Arron SLP Fenton, Kelsey LCSW Ste 104 p 435.797.1346 USU Speech Language Veritas Mental Health Logan UT. 84341 Hearing Center 664 N Main p 435.755.6061 Andrus, Jill R SLP 1000 Old Main Hill Ste 101 USU Speech Language Logan UT. 84322 Logan UT. 84321 *Martinez, Angela M LCSW Hearing Center p 435.797.1346 p 435.828.7594 Logan Psychiatry 1000 Old Main Hill 1350 N 500 E Logan UT. 84322 *Whitworth, Harmony H SLP Freestone, A T PSYD Logan UT. 84341 p 435.797.1375 Budge Clinic Comprehensive Treatment p 435.716.1280 1300 N 500 E Clinic Bingham, Chad S SLP Logan UT. 84341 40 W Cache Valley Blvd Pacheco, Analee LCSW USU Speech Language p 435.716.2880 Ste 10A The Family Place Hearing Center Logan UT. 84341 1275 N 200 W 1000 Old Main Hill Sports Medicine p 435.787.2272 Logan UT. 84341 Logan UT. 84322 *Campbell, Darren E MD p 435.752.8880 p 435.797.1375 Logan Regional Orthopedics Hancock, Ian R LCSW 1350 N 500 E Cache Valley Therapy 502 S Main St Dutson, Eric D CCC-SLP Logan UT. 84341 Services Smithfield UT. 84335 AquaWorx Physical Therapy p 435.716.2800 186 E 1800 N p 435.752.8880 and Fitness Logan UT. 84341 209 W 300 N Crum, Ashley A MD p 435.557.0460 Shepherd, AmberLee A LCSW Logan UT. 84321 Alpine Orthopaedic 186 E 1800 N p 435.716.8535 Specialists Hedelius, Matthew T LCSW Logan UT. 84341 2310 N 400 E Comprehensive Treatment p 435.213.3062 Elsweiler, Anne SLP Ste A Clinic USU Speech Language Logan UT. 84341 40 W Cache Valley Blvd Sorenson, Carl J LCSW Hearing Center p 435.787.2000 Ste 10A Resilience Counseling 1000 Old Main Hill Logan UT. 84341 Services Logan UT. 84322 p 435.787.2272 580 N Main St p 435.797.1375 Ste 250-A Logan UT. 84321 p 435.612.0788

31 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Harrison, Tye B Sterling Urgent Care & Breast Pumps Diabetic Supplies Logan Regional Orthopedics Family Medicine Logan Alpine Home Medical CCS Medical 1350 N 500 E North Phone Number Only Phone Number Only Logan UT. 84341 630 E 1400 N p 800.686.7993 p 800.726.9811 p 435.716.2800 Ste 150 Logan UT. 84321 Edgepark Edgepark Hospital Affiliation p 435.915.4465 Phone Number Only Phone Number Only - Logan Regional Hospital p 800.321.0591 p 800.321.0591 Sterling Urgent Care & *Liddle, David G MD Family Medicine Cardiac Monitoring Roche Insulin Delivery Logan Regional Orthopedics 700 S Hwy 91 Remote Cardiac Services Systems Inc 1350 N 500 E Richmond UT. 84333 Phone Number Only Phone Number Only Logan UT. 84341 p 435.294.3215 p 800.367.0300 p 800.280.7801 p 435.716.2800 Urology eCardio Diagnostics US MED LLC Hospital Affiliation *Bassett, Mitchell R MD Phone Number Only Phone Number Only - Logan Regional Hospital Budge Clinic Surgical p 888.400.3522 p 800.787.6331 Specialists Substance Abuse Facility 1350 N 500 E Cardiology United States Medical *DaySpring Substance Abuse Logan UT. 84341 Cragun, David T MD Supply *Treatment Facility p 435.752.1693 Revere Health Phone Number Only 550 E 1400 N 230 N Hospital Dr p 877.840.8218 Ste T Hospital Affiliation Ste 5 Logan UT. 84341 - Logan Regional Hospital Price UT. 84501 Dialysis Center p 435.716.1320 p 801.373.4366 Castleview Dialysis Center Larsen, Ryan H MD 230 N Hospital Dr Urgent Care Urology Clinic of Logan Hospital Affiliation Price UT. 84501 Cache Valley Community 550 E 1400 N - Mountain View Hospital p 435.637.8696 Health Center North M-F Ste J (UT) 8am-6:30pm S 9am-3pm Logan UT. 84341 - Timpanogos Regional Hospital Dietician 1515 N 400 E p 435.753.1171 Ware, Suzanne O RD Ste 104 Chiropractic University of Utah Health Logan UT. 84341 Hospital Affiliation Terry, Kelly D DC 230 N Hospital Dr p 435.755.6061 - Logan Regional Hospital Southeast Chiropractic Ste 1 - Brigham City Community 55 N 600 E Price UT. 84501 Cache Valley Community Hospital Price UT. 84501 p 801.637.8696 Health Center South - Franklin County Medical p 435.637.4621 517 W 100 N Center Durable Medical Equipment Ste 110 - Cache Valley Hospital Counseling Alpine Home Medical Providence UT. 84332 Carter, Sabrina K NP Phone Number Only p 435.755.6061 *Luzny, Patrik MD Positive Pathways p 800.686.7993 Budge Clinic Surgical 23 Carbon County *Logan InstaCare Specialists Ste 21 Apria Healthcare LLC 412 N 200 E 1350 N 500 E Price UT. 84501 60 S 700 E Logan UT. 84321 Logan UT. 84341 p 435.299.5003 Ste 1 p 435.713.2710 p 435.752.1693 Price UT. 84501 Heugly, Kara L LPC p 435.637.9500 *Logan WorkMed M-F 8am-5pm Hospital Affiliation Kara Heugly Counseling 412 N 200 E - Logan Regional Hospital 70 W Main CCS Medical Logan UT. 84321 Price UT. 84501 Phone Number Only p 435.713.2850 Carbon County p 435.637.0171 p 800.726.9811

*North Cache Valley Ambulatory Surgery Center Dermatology CNS Respiratory Services - *InstaCare Castleview Surgical Center Peterson, Chad R DO Price 4088 N Hwy 91 200 N Fairgrounds Rd Aspen Dermatology 480 S Carbon Ave Hyde Park UT. 84318 Ste 1 227 N Westwood Blvd Price UT. 84501 p 435.563.4888 Price UT. 84501 Price UT. 84501 p 435.613.8887 p 435.637.1744 p 801.794.1490 Sterling Urgent Care & Care Rehab and Orthopedic Family Medicine Logan Audiology Hospital Affiliation Products (Muscle South Hanson, Ryan M AUD - Mountain View Hospital Stimulators) 1201 S Main St 945 W Hospital Dr (UT) Phone Number Only Ste 110 Ste 1 p 800.487.9644 Logan UT. 84321 Price UT. 84501 p 435.787.8504 p 435.637.4327

32 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. DJO Global Ear Nose And Throat Epstein, Angela PA Lauridsen, Clinton D DO Phone Number Only Lyman, Erik M MD Castleview Urgent Care Castleview Family Medicine p 800.336.6569 Eastern Utah Ear Nose and 317 E 100 N 945 W Hospital Dr Throat Price UT. 84501 Ste 7 Dynasplint Systems Inc 945 W Hospital Dr p 435.637.5061 Price UT. 84501 Phone Number Only Ste 1 p 435.637.6348 p 800.638.6771 Price UT. 84501 Etzel, Glenn T MD p 435.637.4327 Revere Health Hospital Affiliation EBI LLC (Bone Stimulators) 230 N Hospital Dr - Castleview Hospital Phone Number Only Hospital Affiliation Ste 5 p 800.526.2579 - Castleview Hospital Price UT. 84501 Mathis, Donna D FNP - Castleview Hospital p 435.637.9545 Gagon Family Medicine + Edgepark Urgent Care Phone Number Only Family Practice Hospital Affiliation 377 N Fairgrounds Rd p 800.321.0591 Bloomer, Tiffany M MD - Castleview Hospital Price UT. 84501 The Helper Clinic p 435.613.2200 Empi Inc (Neuromuscular 125 S Main St Frazier, Mark A MD Stimulator) Helper UT. 84526 Mark Frazier Medical LLC Morgan, Max G MD Phone Number Only p 435.472.7000 300 N Hospital Dr Gagon Family Medicine + p 800.328.2536 Price UT. 84501 Urgent Care Brady, Matthew F MD p 435.637.4800 377 N Fairgrounds Rd KCI USA Inc (Wound Vac Eastern Utah Family Price UT. 84501 Only) Medicine Hospital Affiliation p 435.613.2200 Phone Number Only 280 N Hospital Dr - Castleview Hospital p 800.275.4524 Ste 4 Morrison, Marvin J MD Price UT. 84501 Gagon, Shane D MD The Helper Clinic Lincare p 435.637.3584 Gagon Family Medicine + 125 S Main St 268 S Hwy 55 Urgent Care Helper UT. 84526 Price UT. 84501 Hospital Affiliation 377 N Fairgrounds Rd p 435.472.7000 p 435.637.3511 - Castleview Hospital Price UT. 84501 p 435.613.2200 Carbon Medical Service Orthofix Inc (Bone Growth Callahan, Timothy A PA-C Association Stimulators Physicians Eastern Utah Family Hospital Affiliation 305 Ctr St Only) Medicine - Castleview Hospital East Carbon UT. 84520 Phone Number Only 280 N Hospital Dr p 435.888.4411 p 800.535.4492 Ste 5 Halk, Haven APRN Price UT. 84501 Helper Clinic Perkins, Douglas S DO Pacific Medical Inc p 435.637.3584 125 S Main St The Helper Clinic Phone Number Only Helper UT. 84526 125 S Main St p 800.726.9180 The Helper Clinic p 435.472.7000 Helper UT. 84526 125 S Main St p 435.472.7000 RespirTech Helper UT. 84526 Carbon Medical Service Phone Number Only p 435.472.7000 Association Carbon Medical Service p 800.793.1261 331 Hwy 123 Association Gagon Family Medicine + Sunnyside UT. 84539 305 Ctr St Roche Insulin Delivery Urgent Care p 435.888.4411 East Carbon UT. 84520 Systems Inc 377 N Fairgrounds Rd p 435.888.4411 Phone Number Only Price UT. 84501 Herrera, Kourtney A MD p 800.280.7801 p 435.613.2200 The Helper Clinic Potter, Sterling G MD 125 S Main St 945 W Hospital Dr Smith Nephew Inc (Muscle Chamberlain, Cris NP Helper UT. 84526 Ste 2 Stimulators) Castleview Surgical p 435.472.7000 Price UT. 84501 Phone Number Only Associates p 435.637.6190 p 800.821.5700 280 N Hospital Dr Carbon Medical Service Ste 5 Association Hospital Affiliation US MED LLC Price UT. 84501 305 Ctr St - Castleview Hospital Phone Number Only p 435.637.4590 East Carbon UT. 84520 p 800.787.6331 p 435.888.4411 Quinton, Connie K FNP Clark, Michael D NP Castle Country Clinic United States Medical Castleview Physician Hunt, Jeannee L PA-C 453 E Main Supply Practice Gagon Family Medicine + Ste 300 Phone Number Only 317 E 100 N Urgent Care Price UT. 84501 p 877.840.8218 Price UT. 84501 377 N Fairgrounds Rd p 435.613.9466 p 435.637.5061 Price UT. 84501 p 435.613.2200

Hospital Affiliation - Castleview Hospital 33 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Taylor, Dylan R MD Pendergrass, Danielle K Larsen, Eugene D DO LabCorp of America The Helper Clinic NP Pine Top Medical Holdings 125 S Main St Eastern Utah Womens Health 280 N Hospital Dr Phone Number Only Helper UT. 84526 77 S 600 E Ste 4 p 888.522.2677 p 435.472.7000 Ste B Price UT. 84501 Price UT. 84501 p 435.637.5690 Mental Health Carbon Medical Service p 435.637.0313 Carter, Sabrina K NP Association 284 N Hospital Dr Positive Pathways 305 Ctr St Health Department Ste 2 23 Carbon County East Carbon UT. 84520 Southeastern Utah District Price UT. 84501 Ste 21 p 435.888.4411 Health Department p 435.637.5690 Price UT. 84501 28 S 100 E p 435.299.5003 Tillotson, Shadrick W MD Price UT. 84501 Castleview Hospitalist The Helper Clinic p 435.637.3671 300 N Hospital Dr Cowan, John G LCSW 125 S Main St Price UT. 84501 Gray Matters Counseling Helper UT. 84526 Home Health Agency p 435.637.4800 23 S Carbon Ave p 435.472.7000 CNS Community Nursing Ste 5 Services Hospital Affiliation Price UT. 84501 Carbon Medical Service 480 S Carbon Ave - Castleview Hospital p 435.650.9008 Association Price UT. 84501 - Ashley Valley Regional 305 Ctr St p 877.613.8887 Medical Center Earl, Heath D PhD East Carbon UT. 84520 Price Neuropsychological p 435.888.4411 Hospice Nichols, David A MD Clinic CNS Community Nursing Castleview Hospitalist 945 W Hospital Dr Warr, Bryce K DO Services 300 N Hospital Dr Ste 7 & 8 Eastern Utah Family 480 S Carbon Ave Price UT. 84501 Price UT. 84501 Medicine Price UT. 84501 p 435.637.4800 p 435.630.1499 317 E 100 N p 877.613.8887 Price UT. 84501 Hospital Affiliation Heugly, Kara L LPC p 435.637.3584 Hospital - Castleview Hospital Kara Heugly Counseling Castleview Hospital 70 W Main General Surgery 300 N Hospital Dr Pitchforth, Janis NP Price UT. 84501 Pressett, Jon S MD Price UT. 84501 Pine Top Medical p 435.637.0171 Castleview Surgical p 435.637.4800 280 N Hospital Dr Associates Ste 4 Keil, Christopher D SSW 280 N Hospital Dr Internal Medicine Price UT. 84501 The Helper Clinic Ste 5 Brann, William M MD p 435.637.5690 125 S Main St Price UT. 84501 Castleview Cardiology Helper UT. 84526 p 435.637.4590 945 W Hospital Dr Thayn, David MD p 435.472.7000 Ste 3 Desert Rock Internal Hospital Affiliation Price UT. 84501 Medicine and Pediatrics Carbon Medical Service - Castleview Hospital p 435.637.4278 945 W Hospital Dr Association Ste 4 331 Hwy 123 Gynecologic Oncology Hospital Affiliation Price UT. 84501 Sunnyside UT. 84539 Gagon, Shane D MD - Jordan Valley Medical p 435.637.7800 p 435.888.4411 Gagon Family Medicine + Center Urgent Care - Salt Lake Regional Medical Hospital Affiliation Moynier, Dannette LCSW 377 N Fairgrounds Rd Center - Castleview Hospital 1483 Independence Ave Price UT. 84501 - Evanston Regional Hospital Price UT. 84501 p 435.613.2200 - Castleview Hospital Thayn, Paul A MD p 435.650.3013 Castleview Hospitalist Hospital Affiliation Eppich, Irel S MD 300 N Hospital Dr 375 S Carbon Ave - Castleview Hospital University of Utah Health Price UT. 84501 Price UT. 84501 230 N Hospital Dr p 435.637.4800 p 435.650.3013 Gynecology Ste 1 Bradshaw, David MD Price UT. 84501 Hospital Affiliation Castleview Physician 280 N Hospital Dr p 801.637.8696 - Castleview Hospital Practices Ste 4 945 W Hospital Dr Price UT. 84501 Hospital Affiliation Laboratory Ste 7 p 435.613.2229 - University of Utah Hospital Dominion Diagnostics Price UT. 84501 - Mountain View Hospital Phone Number Only p 435.637.6734 Hospital Affiliation (UT) p 877.734.9600 - Castleview Hospital - Timpanogos Regional Hospital

34 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Patterson, Mellie F LCSW Obstetrics And Gynecology Cook, Barry P OD Pediatrics ISAT Bradshaw, David MD 92 N 400 E Criddle, Charles Travis 23 S Carbon Ave 280 N Hospital Dr Price UT. 84501 DO Ste 10 Ste 4 p 435.637.6290 Puzzlie Pediatrics Price UT. 84501 Price UT. 84501 230 N Hospital Dr Bldg 3 p 435.637.4852 p 435.613.2229 Jensen, Shane R OD Ste 3 Eastern Utah Eye Price UT. 84501 Thornton, Jan LCSW Hospital Affiliation Physicians p 435.637.1100 Mind-full Healing PLLC - Castleview Hospital 200 N Fairgrounds Rd 2420 S 190 E Price UT. 84501 Garvin, Daniel MD Price UT. 84501 Brady, Matthew F MD p 435.637.8689 Castleview Pediatric p 435.749.2584 Eastern Utah Family Clinic Medicine Livingston, Mason G OD 590 E 100 N 375 S Carbon Ave 280 N Hospital Dr Southeastern Utah Eye Ste 4 Price UT. 84501 Ste 4 Clinic Price UT. 84501 p 435.749.2584 Price UT. 84501 54 E 100 N p 435.637.1100 p 435.637.3584 Price UT. 84501 Towndrow, Heather LCSW p 435.637.2414 Madsen, Edward K MD Internal Resolutions Hospital Affiliation Pediatric Clinic 42 S Main St - Castleview Hospital Saccomanno, Judy O OD 590 E 100 N Ste 3 Southeastern Utah Eye Ste 4 Helper UT. 84526 Pendergrass, Danielle K Clinic Price UT. 84501 p 385.243.1744 NP 54 E 100 N p 435.637.7551 Eastern Utah Womens Health Price UT. 84501 Nephrology 77 S 600 E p 435.637.2414 Hospital Affiliation Eppich, Irel S MD Ste B - Castleview Hospital University of Utah Health Price UT. 84501 Tuttle, Steven O OD - Castleview Hospital 230 N Hospital Dr p 435.637.0313 Castle Valley Eyecare Ste 1 69 E Main St Physical Therapy Price UT. 84501 Occupational Therapy Price UT. 84501 Concentra Medical Centers p 801.637.8696 Concentra Medical Centers p 435.637.2000 2390 Redwood Rd 2390 Redwood Rd West Valley City UT. 84419 Hospital Affiliation West Valley City UT. 84419 Orthopedic Surgery p 888.997.2669 - University of Utah Hospital p 888.997.2669 Jensen, Kelly D DO - Mountain View Hospital Advance Surgical Gagon, Michael MPT (UT) Ophthalmology Assoicates ProRehab Physical Therapy - Timpanogos Regional Hospital Byers, Timothy MD 280 N Hospital Dr 590 E 100 N Eastern Utah Eye Ste 3 Ste 1-2 Kakani, Siddhartha MD Physicians Price UT. 84501 Price UT. 84501 University of Utah Health 200 N Fairgrounds Rd p 435.637.2663 p 435.613.1500 230 N Hospital Dr Ste 2 Ste 1 Price UT. 84501 Hospital Affiliation Nelson, David E MPT Price UT. 84501 p 435.637.8689 - Castleview Hospital ProRehab Physical Therapy p 801.637.8696 590 E 100 N Hospital Affiliation Justesen, Scott C MD Ste 12 Hospital Affiliation - Castleview Hospital Castle Country Orthopedics Price UT. 84501 - University of Utah Hospital & Sports p 435.613.1500 Hansen, Jeffrey E MD 377 N Fairgrounds Rd Romney, Pace G MD Eastern Utah Eye Price UT. 84501 Ohlwiler, Jeffrey N MSPT University of Utah Health Physicians p 435.613.6600 ProRehab Physical Therapy 230 N Hospital Dr 200 N Fairgrounds Rd 200 Park Place Ste 1 Ste 2 Hospital Affiliation East Carbon UT. 84520 Price UT. 84501 Price UT. 84501 - Castleview Hospital p 435.613.1500 p 801.373.0167 p 435.637.8689 Pain Management 590 E 100 N Hospital Affiliation Hospital Affiliation Beecher, Russell O DO Ste 1-2 - University of Utah Hospital - Castleview Hospital Eastern Utah Physical Price UT. 84501 Medicine & Pain Center p 435.613.1500 Neurology Optometry 230 N Hospital Dr Buchanan, Thomas M MD Callahan, Cori D OD Ste 2 Player, Kirk R DPT Castleview Hosptial Southeastern Utah Eye Price UT. 84501 ProRehab Physical Therapy 300 N Hospital Dr Clinic p 435.613.7246 590 E 100 N Price UT. 84501 54 E 100 N Ste 1-2 p 435.781.8464 Price UT. 84501 Hospital Affiliation Price UT. 84501 p 435.637.2414 - Castleview Hospital p 435.613.1500 Hospital Affiliation - Ashley Valley Regional Medical Center - Castleview Hospital 35 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Terry, Michael J DPT Keil, Christopher D SSW Cibola County Care Rehab and Orthopedic ProRehab Physical Therapy The Helper Clinic Products (Muscle 200 Park Place 125 S Main St Breast Pumps Stimulators) East Carbon UT. 84520 Helper UT. 84526 Alpine Home Medical Phone Number Only p 435.613.1500 p 435.472.7000 Phone Number Only p 800.487.9644 p 800.686.7993 590 E 100 N Carbon Medical Service DJO Global Ste 1-2 Association Edgepark Phone Number Only Price UT. 84501 331 Hwy 123 Phone Number Only p 800.336.6569 p 435.613.1500 Sunnyside UT. 84539 p 800.321.0591 p 435.888.4411 Dynasplint Systems Inc Podiatry Cardiac Monitoring Phone Number Only Griffeth, Brian J DPM Moynier, Dannette LCSW Remote Cardiac Services p 800.638.6771 Castle Country Care Center 1483 Independence Ave Phone Number Only Inc Price UT. 84501 p 800.367.0300 EBI LLC (Bone Stimulators) 1340 W 300 N p 435.650.3013 Phone Number Only Price UT. 84501 eCardio Diagnostics p 800.526.2579 p 435.637.9213 375 S Carbon Ave Phone Number Only Price UT. 84501 p 888.400.3522 Edgepark Eastern Utah Physical p 435.650.3013 Phone Number Only Medicine and Pain Center Diabetic Supplies p 800.321.0591 230 N Hospital Dr Castleview Physician CCS Medical Ste 2 Practices Phone Number Only Empi Inc (Neuromuscular Price UT. 84501 945 W Hospital Dr p 800.726.9811 Stimulator) p 435.613.7246 Ste 7 Phone Number Only Price UT. 84501 Edgepark p 800.328.2536 Castle Valley Foot and p 435.637.6734 Phone Number Only Ankle Specialist p 800.321.0591 KCI USA Inc (Wound Vac 250 N Fairgrounds Rd Patterson, Mellie F LCSW Only) Ste 3 ISAT Roche Insulin Delivery Phone Number Only Price UT. 84501 23 S Carbon Ave Systems Inc p 800.275.4524 p 435.637.6797 Ste 10 Phone Number Only Price UT. 84501 p 800.280.7801 Orthofix Inc (Bone Growth Hospital Affiliation p 435.637.4852 Stimulators Physicians - Castleview Hospital US MED LLC Only) Thornton, Jan LCSW Phone Number Only Phone Number Only Psychology Mind-full Healing PLLC p 800.787.6331 p 800.535.4492 Earl, Heath D PhD 2420 S 190 E Price Neuropsychological Price UT. 84501 United States Medical Pacific Medical Inc Clinic p 435.749.2584 Supply Phone Number Only 945 W Hospital Dr Phone Number Only p 800.726.9180 Ste 7 & 8 375 S Carbon Ave p 877.840.8218 Price UT. 84501 Price UT. 84501 RespirTech p 435.630.1499 p 435.749.2584 Dietician Phone Number Only Day, Barbara RD p 800.793.1261 Skilled Nursing Facility Towndrow, Heather LCSW University of Utah Health Pinnacle Nursing and Internal Resolutions 8750 S Sandy Pkwy Roche Insulin Delivery Rehabilitation Center 42 S Main St Sandy UT. 87040 Systems Inc 1340 E 300 N Ste 3 p 801.233.8745 Phone Number Only Price UT. 84501 Helper UT. 84526 p 800.280.7801 p 435.637.9213 p 385.243.1744 Hospital Affiliation - University of Utah Hospital Smith Nephew Inc (Muscle Parkdale Health and Rehab Urgent Care Stimulators) 250 E 600 N Gagon Family Medicine + Durable Medical Equipment Phone Number Only Price UT. 84501 Urgent Care Alpine Home Medical p 800.821.5700 p 435.637.2621 377 N Fairgrounds Rd Phone Number Only Price UT. 84501 p 800.686.7993 US MED LLC Social Worker p 435.613.2200 Phone Number Only Cowan, John G LCSW CCS Medical p 800.787.6331 Gray Matters Counseling Urology Phone Number Only 23 S Carbon Ave Snihurowych, Walter M MD p 800.726.9811 United States Medical Ste 5 250 N Fairgrounds Rd Supply Price UT. 84501 Ste 2 Phone Number Only p 435.650.9008 Price UT. 84501 p 877.840.8218 p 435.637.4048

Hospital Affiliation - Castleview Hospital - Uintah Basin Medical Center 36 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Internal Medicine Diabetic Supplies Orthofix Inc (Bone Growth Edgepark Habib, Arsalan N MD CCS Medical Stimulators Physicians Phone Number Only University of Utah Health Phone Number Only Only) p 800.321.0591 8750 S Sandy Pkwy p 800.726.9811 Phone Number Only Sandy UT. 87040 p 800.535.4492 Cardiac Monitoring p 801.233.8745 Edgepark Remote Cardiac Services Phone Number Only Pacific Medical Inc Phone Number Only Hospital Affiliation p 800.321.0591 Phone Number Only p 800.367.0300 - St Marks Hospital p 800.726.9180 - University of Utah Hospital Roche Insulin Delivery eCardio Diagnostics Systems Inc RespirTech Phone Number Only Laboratory Phone Number Only Phone Number Only p 888.400.3522 Dominion Diagnostics p 800.280.7801 p 800.793.1261 Phone Number Only Diabetic Supplies p 877.734.9600 US MED LLC Roche Insulin Delivery CCS Medical Phone Number Only Systems Inc Phone Number Only LabCorp of America p 800.787.6331 Phone Number Only p 800.726.9811 Holdings p 800.280.7801 Phone Number Only United States Medical Edgepark p 888.522.2677 Supply Smith Nephew Inc (Muscle Phone Number Only Phone Number Only Stimulators) p 800.321.0591 Nephrology p 877.840.8218 Phone Number Only Habib, Arsalan N MD p 800.821.5700 Roche Insulin Delivery University of Utah Health Durable Medical Equipment Systems Inc 8750 S Sandy Pkwy Alpine Home Medical US MED LLC Phone Number Only Sandy UT. 87040 Phone Number Only Phone Number Only p 800.280.7801 p 801.233.8745 p 800.686.7993 p 800.787.6331 US MED LLC Hospital Affiliation CCS Medical United States Medical Phone Number Only - St Marks Hospital Phone Number Only Supply p 800.787.6331 - University of Utah Hospital p 800.726.9811 Phone Number Only p 877.840.8218 United States Medical Occupational Therapy Care Rehab and Orthopedic Supply Concentra Medical Centers Products (Muscle Laboratory Phone Number Only 2390 Redwood Rd Stimulators) Dominion Diagnostics p 877.840.8218 West Valley City UT. 84419 Phone Number Only Phone Number Only p 888.997.2669 p 800.487.9644 p 877.734.9600 Durable Medical Equipment Alpine Home Medical Physical Therapy DJO Global LabCorp of America Phone Number Only Concentra Medical Centers Phone Number Only Holdings p 800.686.7993 2390 Redwood Rd p 800.336.6569 Phone Number Only West Valley City UT. 84419 p 888.522.2677 CCS Medical p 888.997.2669 Dynasplint Systems Inc Phone Number Only Phone Number Only Occupational Therapy p 800.726.9811 Coconino County p 800.638.6771 Concentra Medical Centers 2390 Redwood Rd Care Rehab and Orthopedic Breast Pumps EBI LLC (Bone Stimulators) West Valley City UT. 84419 Products (Muscle Alpine Home Medical Phone Number Only p 888.997.2669 Stimulators) Phone Number Only p 800.526.2579 Phone Number Only p 800.686.7993 Physical Therapy p 800.487.9644 Edgepark Concentra Medical Centers Edgepark Phone Number Only 2390 Redwood Rd DJO Global Phone Number Only p 800.321.0591 West Valley City UT. 84419 Phone Number Only p 800.321.0591 p 888.997.2669 p 800.336.6569 Empi Inc (Neuromuscular Cardiac Monitoring Stimulator) Daggett County Dynasplint Systems Inc Remote Cardiac Services Phone Number Only Phone Number Only Phone Number Only p 800.328.2536 Breast Pumps p 800.638.6771 p 800.367.0300 Alpine Home Medical KCI USA Inc (Wound Vac Phone Number Only EBI LLC (Bone Stimulators) eCardio Diagnostics Only) p 800.686.7993 Phone Number Only Phone Number Only Phone Number Only p 800.526.2579 p 888.400.3522 p 800.275.4524

37 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Edgepark Physical Therapy Butler, Erin BCBA Dobson, Nicole BCBA Phone Number Only Concentra Medical Centers Neurobehavioral Center for ABS Kids p 800.321.0591 2390 Redwood Rd Growth 2940 Church St West Valley City UT. 84419 327 W Gordon Ave Ste 204 Empi Inc (Neuromuscular p 888.997.2669 Ste 2 Layton UT. 84040 Stimulator) Layton UT. 84041 p 801.935.4171 Phone Number Only Davis County p 801.683.1062 p 800.328.2536 Downer, Tilly BCaBA Aba Therapy 415 S Medical Dr ABS Kids KCI USA Inc (Wound Vac Allen, Julie BCBA Ste D101 2940 Church St Only) ABS Kids Bountiful UT. 84010 Ste 204 Phone Number Only 2940 Church St p 801.683.1062 Layton UT. 84040 p 800.275.4524 Ste 204 p 801.935.4171 Layton UT. 84040 Cahoon, Stephanie BCBA Orthofix Inc (Bone Growth p 801.935.4946 ABS Kids Dufek, Brandi BCBA Stimulators Physicians 2940 Church St ABS Kids Only) 2940 Church St Ste 204 2940 Church St Phone Number Only Ste 204 Layton UT. 84040 Ste 204 p 800.535.4492 Layton UT. 84040 p 801.935.4171 Layton UT. 84040 p 801.935.4171 p 801.935.4171 Pacific Medical Inc Cardinal, Jennifer R PhD, Phone Number Only Baird, Jessica BCaBA BCBA Dwyer, Molly M BCBA p 800.726.9180 ABS Kids Neurobehavioral Center for Neurobehavioral Center For 2940 Church St Growth Growth RespirTech Ste 204 327 W Gordon Ave 327 W Gordon Ave Phone Number Only Layton UT. 84040 Ste 2 Ste 2 p 800.793.1261 p 801.935.4171 Layton UT. 84041 Layton UT. 84041 p 801.683.1062 p 801.683.1062 Roche Insulin Delivery Baylis, Allison BCBA Systems Inc ABS Kids 415 S Medical Dr 415 S Medical Dr Phone Number Only 2940 Church St Ste A101 Ste D101 p 800.280.7801 Ste 204 Bountiful UT. 84010 Bountiful UT. 84010 Layton UT. 84040 p 801.683.1062 p 801.683.1062 Smith Nephew Inc (Muscle p 801.935.4171 Stimulators) 415 S Medical Dr Fox, Bryanna BCBA Phone Number Only Bodily, Madison BCBA Ste D101 ABS Kids p 800.821.5700 ABS Kids Bountiful UT. 84010 2940 Church St 2940 Church St p 801.683.1062 Ste 204 US MED LLC Ste 204 Layton UT. 84040 Phone Number Only Layton UT. 84040 Corry, Bradley BCBA p 801.935.4946 p 800.787.6331 p 801.935.4171 ABS Kids 2940 Church St Garlock, John T BCBA United States Medical Bouchelle, Elizabeth Ste 204 ABS Kids Supply BCBA Layton UT. 84040 2940 Church St Phone Number Only ABS Kids p 801.935.4946 Ste 204 p 877.840.8218 2940 Church St Layton UT. 84040 Ste 204 Cummings, Tara BCBA p 801.935.4946 Laboratory Layton UT. 84040 ABS Kids Dominion Diagnostics p 801.935.4946 2940 Church St Garrett-Baker, Amanda Phone Number Only Ste 204 BCBA p 877.734.9600 Bray, Kristl BCBA Layton UT. 84040 ABS Kids ABS Kids p 801.935.4171 2940 Church St LabCorp of America 2940 Church St Ste 204 Holdings Ste 204 De La Torre, Sandra BCBA Layton UT. 84040 Phone Number Only Layton UT. 84040 ABS Kids p 801.935.4171 p 888.522.2677 p 801.935.4171 2940 Church St Ste 204 Gibson, Crystal BCBA Occupational Therapy Burton, Brianna BCBA Layton UT. 84040 ABS Kids Concentra Medical Centers ABS Kids p 801.935.4171 2940 Church St 2390 Redwood Rd 2940 Church St Ste 204 West Valley City UT. 84419 Ste 204 Devlin, Charissa BCBA Layton UT. 84040 p 888.997.2669 Layton UT. 84040 ABS Kids p 801.935.4946 p 801.935.4171 2940 Church St Ste 204 Layton UT. 84040 p 801.935.4171

38 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Goldberg, Annie BCBA Heath, Nicholas BCBA Jensen, Melissa BCBA Makowski, Alexandra BCBA ABS Kids ABS Kids ABS Kids ABS Kids 2940 Church St 2940 Church St 2940 Church St 2940 Church St Ste 204 Ste 204 Ste 204 Ste 204 Layton UT. 84040 Layton UT. 84040 Layton UT. 84040 Layton UT. 84040 p 801.935.4946 p 801.935.4171 p 801.935.4946 p 801.935.4171

Goyal, Anu BCBA Henshaw, Brandon J BCBA Jones, Lisa BCBA Malone, Sara BCBA Neurobehavioral Center For Neurobehavioral Center for ABS Kids ABS Kids Growth Growth 2940 Church St 2940 Church St 327 W Gordon Ave 327 W Gordon Ave Ste 204 Ste 204 Ste 2 Ste 2 Layton UT. 84040 Layton UT. 84040 Layton UT. 84041 Layton UT. 84041 p 801.935.4946 p 801.935.4171 p 801.683.1062 p 801.683.1062 Jones, Tonya BCBA Mattingly, Mary BCBA 415 S Medical Dr 415 S Medical Dr ABS Kids ABS Kids Ste D101 Ste D101 2940 Church St 2940 Church St Bountiful UT. 84010 Bountiful UT. 84010 Ste 204 Ste 204 p 801.683.1062 p 801.683.1062 Layton UT. 84040 Layton UT. 84040 p 801.935.4171 p 801.935.4946 Green, Courtney BCBA Hicks, Kenneth BCBA ABS Kids ABS Kids Kennedy, Courtney BCBA Meier, Heather BCBA 2940 Church St 2940 Church St ABS Kids ABS Kids Ste 204 Ste 204 2940 Church St 2940 Church St Layton UT. 84040 Layton UT. 84040 Ste 204 Ste 204 p 801.935.4171 p 801.935.4946 Layton UT. 84040 Layton UT. 84040 p 801.935.4171 p 801.935.4171 Guerrieri, Joseph BCBA Hitesman, Jennilyn BCBA ABS Kids iBehave Therapy Group Klinkefus, Nick BCBA Mendoza, Emily BCaBA 2940 Church St 2985 N 935 E ABS Kids ABS Kids Ste 204 Ste 7 2940 Church St 2940 Church St Layton UT. 84040 Layton UT. 84040 Ste 204 Ste 204 p 801.935.4946 p 801.771.0273 Layton UT. 84040 Layton UT. 84040 p 801.935.4946 p 801.935.4946 Hadnagy-Roch, Alexis Hodgkin, Cameron BCBA BCBA ABS Kids Kramer, Andrea BCBA Moosman, Julie BCBA ABS Kids 2940 Church St ABS Kids ABS Kids 2940 Church St Ste 204 2940 Church St 2940 Church St Ste 204 Layton UT. 84040 Ste 204 Ste 204 Layton UT. 84040 p 801.935.4946 Layton UT. 84040 Layton UT. 84040 p 801.935.4171 p 801.935.4946 p 801.935.4946 Hoffman, Lindsey BCBA Harris, Kaitlyn BCBA ABS Kids Lentchner, Kari BCBA Morris, Tracee BCBA ABS Kids 2940 Church St ABS Kids ABS Kids 2940 Church St Ste 204 2940 Church St 2940 Church St Ste 204 Layton UT. 84040 Ste 204 Ste 204 Layton UT. 84040 p 801.935.4946 Layton UT. 84040 Layton UT. 84040 p 801.935.4946 p 801.935.4946 p 801.935.4946 Hooton, Amy BCBA Hawkins, Jeffrey BCBA ABS Kids Lopes, Erika BCBA Murphy, H Nicole BCBA ABS Kids 2940 Church St ABS Kids ABS Kids 2940 Church St Ste 204 2940 Church St 2940 Church St Ste 204 Layton UT. 84040 Ste 204 Ste 204 Layton UT. 84040 p 801.935.4171 Layton UT. 84040 Layton UT. 84040 p 801.935.4946 p 801.935.4171 p 801.935.4946 Jacobsen, Maren BCBA Hayes, Christa J BCBA ABS Kids Madsen, Sara BCBA Navas, Barbara BCBA ABS Kids 2940 Church St ABS Kids ABS Kids 2940 Church St Ste 204 2940 Church St 2940 Church St Ste 204 Layton UT. 84040 Ste 204 Ste 204 Layton UT. 84040 p 801.935.4946 Layton UT. 84040 Layton UT. 84040 p 801.935.4171 p 801.935.4946 p 801.935.4946

39 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Newman, Felicia BCBA Ossmen, Jordan BCBA Robles, Richard BCBA Shumway, Luisa BCBA ABS Kids ABS Kids ABS Kids ABS Kids 2940 Church St 2940 Church St 2940 Church St 2940 Church St Ste 204 Ste 204 Ste 204 Ste 204 Layton UT. 84040 Layton UT. 84040 Layton UT. 84040 Layton UT. 84040 p 801.935.4171 p 801.935.4946 p 801.935.4946 p 801.935.4171

Nicols, Jenissa BCBA Parsons, Rita M BCBA Rogers, Jennifer PSYD Simancas (Monago), ABS Kids ABS Kids ABS Kids Letisia A BCBA 2940 Church St 2940 Church St 2940 Church St ABS Kids Ste 204 Ste 204 Ste 204 2940 Church St Layton UT. 84040 Layton UT. 84040 Layton UT. 84040 Ste 204 p 801.935.4946 p 801.935.4171 p 801.935.4946 Layton UT. 84040 p 801.935.4171 Nordello, Nicole E BCBA Paz, Corinna G BCBA Rosado, Leah BCBA iBehave Therapy Group Neurobehavioral Center for ABS Kids Sivertson, Savannah BCBA 2985 N 935 E Growth 2940 Church St ABS Kids Ste 7 327 W Gordon Ave Ste 204 2940 Church St Layton UT. 84040 Ste 2 Layton UT. 84040 Ste 204 p 801.771.0273 Layton UT. 84041 p 801.935.4946 Layton UT. 84040 p 801.683.1062 p 801.935.4171 Northup, Kathryn BCBA Roskelley, Hannah BCBA ABS Kids 415 S Medical Dr ABS Kids Skibitsky, Jeffrey BCBA 2940 Church St Ste D101 2940 Church St ABS Kids Ste 204 Bountiful UT. 84010 Ste 204 2940 Church St Layton UT. 84040 p 801.683.1062 Layton UT. 84040 Ste 204 p 801.935.4171 p 801.935.4171 Layton UT. 84040 Pickering, Jaclyn BCBA p 801.935.4946 OQuinn, Casey L BCBA Neurobehavioral Center for Roth, Natalie PhD Neurobehavioral Center for Growth ABS Kids Smith, Ashlin BCBA Growth 327 W Gordon Ave 2940 Church St ABS Kids 327 W Gordon Ave Ste 2 Ste 204 2940 Church St Ste 2 Layton UT. 84041 Layton UT. 84040 Ste 204 Layton UT. 84041 p 801.683.1062 p 801.935.4946 Layton UT. 84040 p 801.683.1062 p 801.935.4171 415 S Medical Dr Sands, Allison BCBA 415 S Medical Dr Ste D101 ABS Kids Smith, Hannah BCBA Ste D101 Bountiful UT. 84010 2940 Church St ABS Kids Bountiful UT. 84010 p 801.683.1062 Ste 204 2940 Church St p 801.683.1062 Layton UT. 84040 Ste 204 Plautz, Hailey C BCBA p 801.935.4171 Layton UT. 84040 Ogden, Stephanie BCBA Neurobehavioral Center For p 801.935.4946 ABS Kids Growth Schifano, Brytni BCBA 2940 Church St 327 W Gordon Ave ABS Kids Sorenson, Cassie BCBA Ste 204 Ste 2 2940 Church St ABS Kids Layton UT. 84040 Layton UT. 84041 Ste 204 2940 Church St p 801.935.4171 p 801.683.1062 Layton UT. 84040 Ste 204 p 801.935.4946 Layton UT. 84040 Ortiz-Perez, Marco BCBA 415 S Medical Dr p 801.935.4171 ABS Kids Ste D101 Schuknecht, Kelly BCBA 2940 Church St Bountiful UT. 84010 ABS Kids Stephens, Kaylie BCBA Ste 204 p 801.683.1062 2940 Church St ABS Kids Layton UT. 84040 Ste 204 2940 Church St p 801.935.4171 Ringger, Brett BCBA Layton UT. 84040 Ste 204 ABS Kids p 801.935.4946 Layton UT. 84040 Ossmen, Caitlin BCBA 2940 Church St p 801.935.4946 ABS Kids Ste 204 Shields, Haley B BCBA 2940 Church St Layton UT. 84040 ABS Kids Stevenson, Victoria A Ste 204 p 801.935.4946 2940 Church St BCBA Layton UT. 84040 Ste 204 ABS Kids p 801.935.4171 Robinson, Jerianne BCBA Layton UT. 84040 2940 Church St ABS Kids p 801.935.4171 Ste 204 2940 Church St Layton UT. 84040 Ste 204 p 801.935.4946 Layton UT. 84040 p 801.935.4171

40 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Stotts, Jonas BCBA Wagner, Brenna BCBA Hendershot, Richard W MD University of Utah Health ABS Kids ABS Kids Granger Medical 165 N University Ave 2940 Church St 2940 Church St Specialists Farmington UT. 84025 Ste 204 Ste 204 1551 S Renaissance Town p 801.213.3200 Layton UT. 84040 Layton UT. 84040 Dr p 801.935.4946 p 801.935.4171 Ste 370 Mountain West Ear Nose and Bountiful UT. 84010 Throat Tabara, Jackqueline BCBA Western, Shasta BCBA p 801.797.9033 2255 N 1700 W ABS Kids ABS Kids Ste 200 2940 Church St 2940 Church St Hospital Affiliation Layton UT. 84041 Ste 204 Ste 204 - Park City Hospital p 801.776.2180 Layton UT. 84040 Layton UT. 84040 p 801.935.4946 p 801.935.4946 Jones, Douglas H MD Boman, Tel S AUD Tanner Memorial Clinic Mountain West Ear Nose and Taylor, Amanda BCBA Weston, Sophia BCBA 1477 N 2000 W Throat ABS Kids ABS Kids Clearfield UT. 84015 1551 S Renaissance Towne 2940 Church St 2940 Church St p 801.773.4840 Dr Ste 204 Ste 204 Ste 310 Layton UT. 84040 Layton UT. 84040 2121 N 1700 W Bountiful UT. 84010 p 801.935.4946 p 801.935.4946 Layton UT. 84041 p 801.295.5581 p 801.773.4840 Taylor, Mark BCBA Williams, Carley R BCBA 2255 N 1700 W ABS Kids iBehave Therapy Group Hospital Affiliation Ste 200 2940 Church St 2985 N 935 E - Davis Hospital Layton UT. 84041 Ste 204 Ste 7 - Lakeview Hospital p 801.776.2180 Layton UT. 84040 Layton UT. 84040 p 801.935.4171 p 801.771.0273 Ambulatory Surgery Center *Bunker, Michelle AUD Bountiful Surgery Center Primary Childrens Hospital Thomas, Jonathon (JT) Winslow, Tatum BCBA 620 E Medical Dr 280 N Main St BCBA ABS Kids Ste 200 Bountiful UT. 84010 ABS Kids 2940 Church St Bountiful UT. 84010 p 801.662.4949 2940 Church St Ste 204 p 801.296.2122 Ste 204 Layton UT. 84040 Chipman, Sarah A AUD Layton UT. 84040 p 801.935.4946 Mountain West Surgery Tanner Memorial Clinic p 801.935.4171 Center 2121 N 1700 W Yarger, Jesse BCBA 1551 S Renaissance Towne Layton UT. 84041 Thurgood, Brook BCBA Neurobehavioral Center for Dr p 801.773.4840 ABS Kids Growth Ste 200 2940 Church St 327 W Gordon Ave Bountiful UT. 84010 Choules, Coralee AUD Ste 204 Ste 2 p 801.383.1111 University Of Utah Health Layton UT. 84040 Layton UT. 84041 165 N University Ave p 801.935.4946 p 801.683.1062 Hospital Affiliation Farmington UT. 84025 - Mountain View Hospital p 801.213.3200 Traeden, Heather BCBA 415 S Medical Dr (UT) Neurobehavioral Center for Ste D101 Hospital Affiliation Growth Bountiful UT. 84010 Audiology - University of Utah Hospital 327 W Gordon Ave p 801.683.1062 *Anthony, Meghan M AUD Ste 2 Primary Childrens Rehab *Despain, Natalie AUD Layton UT. 84041 Young, Jeanelle BCBA 201 W Layton Pkwy 3rd Fl Primary Childrens Rehab p 801.683.1062 ABS Kids Layton UT. 84041 201 W Layton Pkwy 3rd Fl 2940 Church St p 801.543.6630 Layton UT. 84041 415 S Medical Dr Ste 204 p 801.543.6630 Ste D101 Layton UT. 84040 Arnold, Krystal AUD Bountiful UT. 84010 p 801.935.4946 Ogden Clinic - Mountain 280 N Main St p 801.683.1062 West ENT Bountiful UT. 84010 iBehave Therapy Group 2255 N 1700 W p 801.662.4949 Turner, Meghan BCBA 2985 N 935 E Ste 200 ABS Kids Ste 7 Layton UT. 84041 Hospital Affiliation 2940 Church St Layton UT. 84040 p 801.776.2180 - Primary Childrens Hospital Ste 204 p 801.771.0273 Layton UT. 84040 Barwick, Niki L AUD Hayes, Fiona M Aud p 801.935.4946 Allergy And Immunology Mountain West Ear Nose and University of Utah Health Firszt, Rafael MD Throat 165 N University Ave Tanner Memorial Clinic 1551 S Renaissance Towne Farmington UT. 84025 2121 N 1700 W Dr p 801.213.3200 Layton UT. 84041 Ste 310 p 801.773.4840 Bountiful UT. 84010 Hospital Affiliation p 801.295.5581 - University of Utah Hospital Hospital Affiliation - University of Utah Hospital 41 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Hendriksen, Nathan E AUD 280 N Main St Turgoose, Aaron C AUD Crouch, Jessica S PA University of Utah Health Bountiful UT. 84010 Lakeside Audiology University of Utah Health 165 N University Ave p 801.662.4949 1240 E Hwy 193 165 N University Ave Farmington UT. 84025 Ste G-2 Farmington UT. 84025 p 801.213.3200 Page, Andrea S AUD Layton UT. 84040 p 801.213.8841 University Of Utah Health p 801.444.0300 Hogge, Jennifer A AUD 165 N University Ave 26 S Main St Tanner Memorial Clinic Farmington UT. 84025 74 E 500 S Centerville UT. 84014 2121 N 1700 W p 801.213.3200 Ste 112 p 801.693.7900 Layton UT. 84041 Bountiful UT. 84010 p 801.773.4840 Hospital Affiliation p 801.294.6200 Hospital Affiliation - University of Utah Hospital - University of Utah Hospital Horn, Mary L Aud Udy, Mitchell R AUD University of Utah Health Pay, Amanda AUD University of Utah Health Douglas, Wendy S APRN 165 N University Ave Mountain West Ear Nose and 165 N University Ave University of Utah Health Farmington UT. 84025 Throat Farmington UT. 84025 724 W 500 S p 801.213.3200 1551 S Renaissance Towne p 801.213.3200 Ste 300 Dr West Bountiful UT. 84087 Hospital Affiliation Ste 310 Hospital Affiliation p 801.296.9091 - University of Utah Hospital Bountiful UT. 84010 - University of Utah Hospital p 801.295.5581 942 S Main St Johnson, Kathryn M AuD Breast Pumps Layton UT. 84041 University of Utah Health 2255 N 1700 W Alpine Home Medical p 801.593.9111 165 N University Ave Ste 200 Phone Number Only Farmington UT. 84025 Layton UT. 84041 p 800.686.7993 Forstall, Peter G MD p 801.213.3200 p 801.776.2180 Northern Utah Edgepark Cardiovascular Associates Hospital Affiliation Pergler, Harold R AUD Phone Number Only 1407 N 2000 W - University of Utah Hospital Bountiful Hearing Center p 800.321.0591 Ste B 575 E Medical Dr Clearfield UT. 84015 *Layton, Ranae L AUD Bountiful UT. 84010 Cardiac Monitoring p 801.773.3191 Primary Childrens Hospital p 801.295.9644 Remote Cardiac Services 280 N Main St Phone Number Only Hospital Affiliation Bountiful UT. 84010 *Sorensen, Tyler D AUD p 800.367.0300 - Ogden Regional Medical p 801.662.4949 Primary Childrens Rehab Center 201 W Layton Pkwy 3rd Fl eCardio Diagnostics - Brigham City Community Loveland, Kelli L AUD Layton UT. 84041 Phone Number Only Hospital Ogden Clinic - Mountain p 801.543.6630 p 888.400.3522 - Davis Hospital West ENT - Cache Valley Hospital 1551 S Renaissance Towne 280 N Main St Cardiology Dr Bountiful UT. 84010 Almony, Gregory T MD Fronk, Daniel MD Ste 310 p 801.662.4949 Northern Utah Utah Cardiology Bountiful UT. 84010 Cardiovascular Associates 444 W Bourne Cir p 801.295.5581 *Stone, Caitlin R AUD 1407 N 2000 W Ste 200 Primary Childrens Rehab Ste B Farmington UT. 84025 2255 N 1700 W 280 N Main St Clearfield UT. 84015 p 801.776.0174 Ste 200 Bountiful UT. 84010 p 801.773.3191 Layton UT. 84041 p 801.662.4949 Hospital Affiliation p 801.776.2180 Hospital Affiliation - Davis Hospital Stone, Katie S AUD - Ogden Regional Medical - Lakeview Hospital Lund, E Jolene AUD University of Utah Health Center University Of Utah Health 165 N University Ave - Brigham City Community Hacking, Scott B MD 165 N University Ave Farmington UT. 84025 Hospital Northern Utah Farmington UT. 84025 p 801.213.3200 - Davis Hospital Cardiovascular Associates p 801.213.3200 - Cache Valley Hospital 1407 N 2000 W Hospital Affiliation Ste B Hospital Affiliation - University of Utah Hospital Asay, Ronald W MD Clearfield UT. 84015 - University of Utah Hospital MountainStar Cardiology St p 801.773.3191 *Tubaugh, Lindsey AUD Marks *Moncrief, Laura R AUD Primary Childrens Rehab 1407 N 2000 W Hospital Affiliation Primary Childrens Rehab 280 N Main St Ste B - St Marks Hospital 201 W Layton Pkwy Bountiful UT. 84010 Clearfield UT. 84015 - Lone Peak Hospital Layton UT. 84041 p 801.662.4949 p 801.773.3191 - Timpanogos Regional Hospital p 801.543.6630 Hospital Affiliation Hospital Affiliation - Primary Childrens Hospital - Timpanogos Regional Hospital - Mountain View Hospital (UT) 42 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Humiston, Daniel J MD Mulamalla, Roja MD Tuday, Eric C MD Cole, Erin J CNM Davis Regional EKG Group Utah Cardiology University of Utah Health University of Utah Health 1492 W Antelope Dr 444 W Bourne Cir 165 N University Ave 165 N University Ave Layton UT. 84041 Ste 200 Farmington UT. 84025 Farmington UT. 84025 p 801.825.9561 Farmington UT. 84025 p 801.213.4500 p 801.581.4014 p 801.776.0174 Utah Cardiology Hospital Affiliation Hospital Affiliation 444 W Bourne Cir Hospital Affiliation - University of Utah Hospital - University of Utah Hospital Ste 200 - Davis Hospital Farmington UT. 84025 *Wahl, Jessica K OT Comstock, Carie CNM p 801.776.0174 *Nelson, Michelle SLP Primary Childrens Rehab Tanner Memorial Clinic Primary Childrens Rehab 201 W Layton Pkwy 3rd Fl 2121 N 1700 W Hospital Affiliation 201 W Layton Pkwy 3rd Fl Layton UT. 84041 Layton UT. 84041 - Davis Hospital Layton UT. 84041 p 801.543.6630 p 801.773.4840 - Lakeview Hospital p 801.543.6630 - Salt Lake Regional Medical West, Scott H MD Dearden, Vivian CNM Center Nielson, Kenneth G MD Utah Cardiology Rocky Mountain Womens Northern Utah 444 W Bourne Cir Health Center Ibrahim, Majd MD Cardiovascular Associates Ste 200 1580 W Antelope Dr University of Utah Health 1407 N 2000 W Farmington UT. 84025 Ste 290 165 N University Ave Ste B p 801.776.0174 Layton UT. 84041 Farmington UT. 84025 Clearfield UT. 84015 p 801.776.0880 p 801.213.4500 p 801.773.3191 Hospital Affiliation - Lakeview Hospital Hospital Affiliation Hospital Affiliation MountainStar Cardiology St - Ogden Regional Medical - Davis Hospital - University of Utah Hospital Marks Center 2132 N 1700 W - Davis Hospital Ellis, Jessica A CNM Jetter, Tawni L APRN Ste 200 - Salt Lake Regional Medical University of Utah Health University of Utah Health Layton UT. 84041 Center 165 N University Ave 165 N University Ave p 801.776.0171 Farmington UT. 84025 Farmington UT. 84025 Yaganti, Vamsee M MD p 801.581.4014 p 801.213.8841 Hospital Affiliation Northern Utah - St Marks Hospital Cardiovascular Associates Hospital Affiliation 26 S Main St - Lone Peak Hospital 1407 N 2000 W - University of Utah Hospital Centerville UT. 84014 - Timpanogos Regional Hospital Ste B p 801.693.7900 Clearfield UT. 84015 Elmore, Christina CNM Olsen, Stephanie L MD p 801.773.3191 University of Utah Health Johnson, Kira D PA Utah Cardiology 165 N University Ave University of Utah Health 444 W Bourne Cir Zebrack, James S MD Farmington UT. 84025 165 N University Ave Ste 200 Northern Utah p 801.213.4500 Farmington UT. 84025 Farmington UT. 84025 Cardiovascular Associates p 801.581.6709 p 801.776.0174 1407 N 2000 W Hospital Affiliation Ste B - University of Utah Hospital Kim, Christopher Y MD Hospital Affiliation Clearfield UT. 84015 Utah Cardiology - Lakeview Hospital p 801.773.3191 Himes, Annette R CNM 444 W Bourne Cir - Davis Hospital Tanner Memorial Clinic Ste 200 Hospital Affiliation 2121 N 1700 W Farmington UT. 84025 Reddy, Bhavananda T MD - St Marks Hospital Layton UT. 84041 p 801.776.0174 Utah Cardiology - Lone Peak Hospital p 801.773.4840 444 W Bourne Cir - Timpanogos Regional Hospital Hospital Affiliation Ste 200 Meidell, Emily CNM - Davis Hospital Farmington UT. 84025 Certified Nurse Midwife Rocky Mountain Womens - Lakeview Hospital p 801.776.0174 Barnes, Lisa E CNM Health Center - Ogden Regional Medical University of Utah Health 1580 W Antelope Dr Center Hospital Affiliation 165 N University Ave Ste 290 - Salt Lake Regional Medical - Lakeview Hospital Farmington UT. 84025 Layton UT. 84041 Center - Davis Hospital p 801.581.4014 p 801.776.0880 - Salt Lake Regional Medical Konesavanh, Soutsada N PA Center Hospital Affiliation Miller, Paige E CNM University of Utah Health - St Marks Hospital - University of Utah Hospital University of Utah Health 26 S Main St 165 N University Ave Centerville UT. 84014 Talwar, Sandeep MD Cohen, Susanna R CNM Farmington UT. 84025 p 801.693.7900 Utah Cardiology University of Utah Health p 801.581.4014 444 W Bourne Cir 165 N University Ave Hospital Affiliation Ste 200 Farmington UT. 84025 Hospital Affiliation - University of Utah Hospital Farmington UT. 84025 p 801.213.4500 - University of Utah Hospital p 801.776.0174 Hospital Affiliation Hospital Affiliation - University of Utah Hospital - Davis Hospital 43 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Scott, Heather CNM Brown, Jared T DC Counseling Bell, Naomia M CMHC Rocky Mountain Womens Integrated Functional Albright, Michael LMFT Military & Veteran Health Center Medicine Ascendant Behavioral Counseling Center 1580 W Antelope Dr 458 N 500 W Health 360 S Fort Ln Bldg C, Ste 290 Bountiful UT. 84010 1133 N Main Ste 111 Layton UT. 84041 p 801.292.9355 Ste 128 Layton UT. 84041 p 801.776.0880 Layton UT. 84041 p 385.231.8387 Elmore, Tyler R DC p 801.872.5516 Stuart, Mari R CNM Syracuse Chiropractic and Bergeson, Stephanie K Ogden Clinic Health Center Alfieri, Ashley LPC CMHC 201 W Layton Pkwy 1013 W 2700 S The OCD And Anxiety Resilient Solutions Inc Ste 420 Syracuse UT. 84075 Treatment Center 1355 N Main St Layton UT. 84041 p 801.774.7540 1459 N Main St Ste 1 p 801.475.3000 Ste 100 Bountiful UT. 84010 Frogley, Cory M DC Bountiful UT. 84010 p 801.707.9612 Hospital Affiliation Integrated Functional p 801.298.2000 - Ogden Regional Medical Medicine Bingham, Bryan D LMFT Center 458 N 500 W Allred, Debbi CMHC 377 N Marshall Way Bountiful UT. 84010 Neurobehavioral Center for Ste 1-M Whiting, Christina M CNM p 801.292.9355 Growth Layton UT. 84041 University of Utah Health 327 W Gordon Ave p 801.589.2438 165 N University Ave George, Dallas DC Ste 2 Farmington UT. 84025 Community Chiropractic Inc Layton UT. 84041 Bradley, Jessica L CMHC p 801.581.4014 395 N 200 W p 801.683.1062 Valley Behavioral Health Bountiful UT. 84010 1785 E 1450 S Hospital Affiliation p 801.295.6667 415 S Medical Dr Ste 300 - University of Utah Hospital Ste A101 Clearfield UT. 84015 George, Dan G DC Bountiful UT. 84010 p 888.949.4864 Yale, Jocelyn S CNM Community Chiropractic Inc p 801.683.1062 University of Utah Health 395 N 200 W Buckner, Rachelle LCMHC 165 N University Ave Bountiful UT. 84010 415 S Medical Dr Resilient Solutions Farmington UT. 84025 p 801.295.6667 Ste D101 1355 N Main St p 801.581.4014 Bountiful UT. 84010 Ste 1 Hales, Daryl DC p 801.683.1062 Bountiful UT. 84010 Hospital Affiliation 360 S State St p 801.259.3883 - University of Utah Hospital Ste A Anderson, Larry A LPC Clearfield UT. 84015 Resilient Solutions Bunker, Brandon CMHC Zaugg, Laura M CNM p 801.773.1821 1355 N Main St Aspen Ridge Counseling Lakeview OB/GYN Clinic Ste 1 585 W 500 S 620 E Medical Dr Hendricks, Daniel L DC Bountiful UT. 84010 Ste 200 Ste 340 Layton Chiropractic Clinic p 801.558.2788 Bountiful UT. 84010 Bountiful UT. 84010 1025 N Main St p 801.990.4300 p 801.299.2229 Layton UT. 84041 Andrews, Becky P LPC p 801.544.4333 Resilient Solutions Inc Callister, Paul T CMHC Hospital Affiliation 1355 N Main St Paul Callister Counseling - Lakeview Hospital Hendricks, Sidney DC Ste 1 PLLC - Davis Hospital Wasatch Chiropractic Bountiful UT. 84010 533 W 2600 S Clinic p 801.259.3883 Ste 340 duBois Hollander, Emily 352 S 200 W Bountiful UT. 84010 CNM Ste 2 Bargar, Sarah A LCSW p 801.755.5138 University of Utah Health Farmington UT. 84025 Grandview Family 165 N University Ave p 801.451.7900 Counseling Carbajal, Stephanie LMFT Farmington UT. 84025 1576 S 500 W 2317 N Hill Field Rd p 801.581.4014 Sanders, Ronald E Ste 202 Ste 103 Sanders Chiropractic and Bountiful UT. 84010 Layton UT. 84041 Hospital Affiliation Wellness p 801.406.9002 p 801.525.4645 - University of Utah Hospital 180 W Gordon Ave Layton UT. 84041 Beardall, Bridgez CMHC 2636 N Hill Field Rd Chiropractic p 801.546.4500 Aspen Ridge Counseling Ste 5 Bowden, Corey DC 585 W 500 S Layton UT. 84041 Advanced Spinal Wersland, Kirk R DC Ste 200 p 801.719.1803 Rehabilitation Integrated Functional Bountiful UT. 84010 1649 W Antelope Dr Medicine p 801.990.4300 Layton UT. 84041 458 N 500 W p 801.444.1230 Bountiful UT. 84010 p 801.292.9355

44 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Christensen, David F LMFT Edwards, Jennifer CMHC Hackett, Emily J CMHC Holmes, Cody LPC Family Therapy Center of Jennifer S Edwards CMHC Tanner Memorial Clinic The OCD And Anxiety Utah 1730 E 3100 N 2121 N 1700 W Treatment Center 240 N East Promontory Ste 2 Layton UT. 84041 1459 N Main St Ste 234 Layton UT. 84040 p 801.773.4840 Ste 100 Farmington UT. 84025 p 801.200.3470 Bountiful UT. 84010 p 385.243.0012 Hall, Dustin J LCSW p 801.298.2000 Ellis, John LMFT 1459 N Main St Connelly, Matthew R LMFT Cedar Psychiatry Bountiful UT. 84010 Hughes, Kathryn M LCSW Matthew R Connelly LMFT 2950 N Church St p 801.706.7607 Grandview Family 2317 N Hill Field Rd Ste 101 Counseling Ste 103 Layton UT. 84040 Hamilton, Cari B CMHC 1576 S 500 W Layton UT. 84041 p 801.369.8989 Tanner Memorial Clinic Ste 202 p 801.525.4645 2121 N 1700 W Bountiful UT. 84010 England, Kimberly CMHC Layton UT. 84041 p 801.406.9002 2363 N Hill Field Rd Alliant Behavioral Health p 801.773.4840 Ste 7 of Utah LLC Hurst, Shane F LMFT Layton UT. 84041 255 N Adamswood Rd Hancock, Lacey LMHC Hurst Counseling p 801.525.4645 Layton UT. 84040 Valley Behavioral Health 2317 N Hill Field Rd p 385.888.9040 1785 E 1450 S Ste 103 DK Counseling and Ste 300 Layton UT. 84041 Consulting Fitch, Mike LPC Clearfield UT. 84015 p 801.668.8650 1290 S 500 W Aspire Counseling and p 888.949.4864 Ste 300 Consulting 2363 N Hill Field Rd Bountiful UT. 84010 2317 N Hill Field Rd Hargrave, Dina S CMHC Ste S p 435.757.9245 Ste 7 Neurobehavioral Center for Layton UT. 84041 Layton UT. 84041 Growth p 801.668.8650 Daniels, Marianne CMHC p 801.660.0638 415 S Medical Dr Cedar Psychiatry Ste D101 Jaramillo, Leah LMFT 2950 N Church St Forsman, Monica CMHC Bountiful UT. 84010 The OCD And Anxiety Ste 101 Monica Forsman Inc p 801.683.1062 Treatment Center Layton UT. 84040 240 N E Promontory 1459 N Main St p 801.369.8989 Ste 200 Hernandez, June Lee CMHC Ste 100 Farmington UT. 84025 Valley Behavioral Health Bountiful UT. 84010 Dastrup, Karen L LMFT p 801.604.5040 1785 E 1450 S p 801.298.2000 Valley Behavioral Health Clearfield UT. 84015 1785 E 1450 S Franco, Jennifer LCSW p 888.949.4864 K2 Counseling & Consulting Ste 300 Grandview Family 1730 E 3100 N Clearfield UT. 84015 Counseling Hernandez, Kelsey A LCSW Ste 2 p 888.949.4864 1576 S 500 W The OCD And Anxiety Layton UT. 84040 Ste 202 Treatment Center p 801.525.4645 Dunham, Matthew G LCMHC Bountiful UT. 84010 1459 N Main St Center for Growth and p 801.406.9002 Ste 100 2317 N Hill Field Rd Potential Bountiful UT. 84010 Ste 103 1785 E 1450 S Froerer, Jared D LPC p 801.298.2000 Layton UT. 84041 Ste 250 Aspen Ridge Counseling p 801.525.4645 Clearfield UT. 84015 585 W 500 S Kelsey A Hernandez CMHC p 801.773.0535 Ste 200 2317 N Hill Field Rd 2363 N Hill Field Rd Bountiful UT. 84010 Ste 103 Ste 5 Dunham Counseling Services p 801.990.4300 Layton UT. 84041 Layton UT. 84041 283 N 300 W p 801.896.7559 p 801.628.5577 Ste 501 Hospital Affiliation Kaysville UT. 84037 - Mountain West Medical Hinkle, Angela L LMFT Kaloudis, Kathleen M CMHC p 801.513.5694 Center Valley Behavioral Health 189 S State St 1785 E 1450 S Ste 230 Edwards, Aanika LCSW Gardner, Monica L LMFT Ste 300 Clearfield UT. 84015 Resilient Solutions 1199 S Main St Clearfield UT. 84015 p 801.201.7050 1355 N Main St Ste 105 p 888.949.4864 Ste 1 Centerville UT. 84014 Kearl, Denise E Bountiful UT. 84010 p 801.815.2112 Hobby, Esperanza A LMFT DK Counseling and p 801.652.8992 Valley Behavioral Health Consulting Gregory, Hillary 1785 E 1450 S 1290 S 500 W The OCD And Anxiety Ste 300 Ste 300 Treatment Center Clearfield UT. 84015 Bountiful UT. 84010 1459 N Main St p 888.949.4864 p 435.757.9245 Ste 100 Bountiful UT. 84010 p 801.298.2000 45 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Kinikini, Karson S CMHC Neurobehavioral Center for Ringold, Patricia LPC Titensor, Steven D LMFT K2 Counseling & Consulting Growth Alliant Behavioral Health Titensor Enterprises 1730 E 3100 N 415 S Medical Dr of Utah LLC 2205 S 800 W Ste 2 Ste D101 255 N Adamswood Rd Woods Cross UT. 84087 Layton UT. 84040 Bountiful UT. 84010 Layton UT. 84040 p 801.298.0336 p 801.525.4645 p 801.683.1062 p 385.888.9040 Todd, Jessica J CMHC 2317 N Hill Field Rd Moyle, Natalie LMHC Russett, Ebbie I CMHC Neurobehavioral Center for Ste 103 Stepstone Connect Valley Behavioral Health Growth Layton UT. 84041 837 S 500 W 1785 E 1450 S 327 W Gordon Ave p 801.525.4645 Ste 102 Clearfield UT. 84015 Ste 2 Bountiful UT. 84010 p 888.949.4864 Layton UT. 84041 2363 N Hill Field Rd p 801.888.3843 p 801.683.1062 Ste 5 Seiler, Edward A CMHC Layton UT. 84041 Murray, Lillie LCSW Valley Behavioral Health 415 S Medical Dr p 801.628.5577 Quantum Counseling 1785 E 1450 S Ste D101 2317 N Hill Field Rd Ste 300 Bountiful UT. 84010 Kirschner, Rebecca CMHC Ste 103 Clearfield UT. 84015 p 801.683.1062 Valley Behavioral Health Layton UT. 84041 p 888.949.4864 1785 E 1450 S p 801.674.9516 Tracy, Robin CMHC Ste 300 Smith, Deanna LCSW Aspen Ridge Counseling Clearfield UT. 84015 Negrette, Michael A LMFT The OCD And Anxiety 585 W 500 S p 888.949.4864 NCS Treatment Center Ste 200 475 N 300 W 1459 N Main St Bountiful UT. 84010 Knapp, Jaclyn K LPC Ste 14 Ste 100 p 801.990.4300 Davis Mental Health Kaysville UT. 84037 Bountiful UT. 84010 415 Medical Dr D101 p 801.390.3210 p 801.298.2000 Verna, Christin LMFT Bountiful UT. 84010 Stepstone Connect p 801.643.5225 Page, Tricia CMHC Stephenson, Sue A CMHC 837 S 500 W The OCD And Anxiety Alliant Behavioral Health Ste 102 Lunt, Andrea LMFT Treatment Center of Utah LLC Bountiful UT. 84010 Resilient Solutions 1459 N Main St 255 N Adamswood Rd p 801.888.3843 1355 N Main St Ste 100 Layton UT. 84040 Ste 1 Bountiful UT. 84010 p 385.888.9040 Walker, David R CMHC Bountiful UT. 84010 p 801.298.2000 Valley Behavioral Health p 801.815.1269 Stepstone Connect 1785 E 1450 S Palmer, Derick CMHC 837 S 500 W Ste 300 Maestas, Rio CSW Stepstone Connect Ste 102 Clearfield UT. 84015 The OCD And Anxiety 837 S 500 W Bountiful UT. 84010 p 888.949.4864 Treatment Center Ste 102 p 801.888.3843 1459 N Main St Bountiful UT. 84010 Wall, Nicole R CMHC Ste 100 p 801.888.3843 Stringham, Karen Resilient Solutions Inc Bountiful UT. 84010 The OCD And Anxiety 1355 N Main St p 801.298.2000 Pedersen, Tamera CMHC Treatment Center Ste 1 Resilient Solutions 1459 N Main St Bountiful UT. 84010 Mason, Gregory A LPC 1355 N Main St Ste 100 p 801.660.5233 New Vision Counseling Ste 1 Bountiful UT. 84010 Center Bountiful UT. 84010 p 801.298.2000 Wasatch Psychological 475 N 300 W p 801.718.2559 Services Ste 14, Kaysville Summit, Natalie LMHC 240 N East Promontory Professional Pl Prescott, Ashley LCMHC Stepstone Connect Ste 200 Kaysville UT. 84037 Aspen Ridge Counseling 837 S 500 W Farmington UT. 84025 p 801.690.3502 585 W 500 S Ste 102 p 801.590.0525 Ste 200 Bountiful UT. 84010 Mathis, Nicholas CMHC Bountiful UT. 84010 p 801.888.3843 Welling, Andrea CMHC Neurobehavioral Center For p 801.990.4300 Espire Counseling Services Growth Thompson, Michael S LMFT 2317 N Hill Field Rd 327 W Gordon Ave Ranks, Georgann LPC Valley Behavioral Health Ste 103 Ste 2 Alliant Behavioral Health 1785 E 1450 S Layton UT. 84041 Layton UT. 84041 of Utah LLC Ste 300 p 801.525.4645 p 801.683.1062 255 N Adamswood Rd Clearfield UT. 84015 Layton UT. 84040 p 888.949.4864 Winward, Karen LPC p 385.888.9040 Valley Behavioral Health 1785 E 1450 S Ste 300 Clearfield UT. 84015 p 888.949.4864

46 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Woodard, Jeness L LCSW 1560 S Renaissance Towne Martineau, Michael R MD Ramirez, Lori K MD University of Utah Health Dr Tanner Memorial Clinic Ogden Clinic 165 N University Ave Ste 210 2121 N 1700 W 1560 S Renaissance Towne Farmington UT. 84025 Bountiful UT. 84010 Layton UT. 84041 Dr p 801.213.3200 p 801.397.6100 p 801.773.4840 Ste 210 Bountiful UT. 84010 26 S Main St Ogden Clinic - Davis Hospital Affiliation p 801.397.6100 Centerville UT. 84014 Family Physicians - Davis Hospital p 801.693.7900 3225 W Gordon Ave Ogden Clinic - Davis Ste 1 Mathis, Jason G MD Family Physicians Zimmerman, Rita M CMHC Layton UT. 84041 University of Utah Health 3225 W Gordon Ave Neurobehavioral Center for p 801.397.6150 165 N University Ave Ste 1 Growth Farmington UT. 84025 Layton UT. 84041 327 W Gordon Ave Hospital Affiliation p 801.581.2955 p 801.397.6150 Ste 2 - Lakeview Hospital Layton UT. 84041 26 S Main St Secrest, Aaron M MD p 801.683.1062 Hadley, Michael L MD Centerville UT. 84014 University of Utah Health Ogden Clinic p 801.693.7900 165 N University Ave 415 S Medical Dr 145 S 3000 W Farmington UT. 84025 Ste D101 West Point UT. 84015 Hospital Affiliation p 801.581.2955 Bountiful UT. 84010 p 801.475.3960 - University of Utah Hospital p 801.683.1062 Hospital Affiliation 1560 S Renaissance Towne Maughan, Cory B DO - University of Utah Hospital Dermatology Dr Dermatology and Aesthetics Bahr, Brooks A MD Ste 210 Center of Utah Vanderhooft, Sheryll L MD Bahr Dermatology Bountiful UT. 84010 1222 W Legacy Crossing University of Utah Health 460 S 200 W p 801.475.3000 Blvd 201 W Layton PKWY Bountiful UT. 84010 Ste 200 Layton UT. 84041 p 801.298.1514 Hospital Affiliation Centerville UT. 84014 p 801.662.1603 - Lakeview Hospital p 801.298.3802 Hospital Affiliation Walker, Jennifer PA-C - University of Utah Hospital Harris, Jordan R DO Hospital Affiliation Dermatology and Aesthetics Utah Valley Dermatology - Logan Regional Hospital Center of Utah Checketts, Scott R MD 680 E Main St - Cache Valley Hospital 1222 W Legacy Crossing Tanner Memorial Clinic Ste 201 Blvd 2121 N 1700 W Bountiful UT. 84010 Neuenschwander, Bradley G Ste 200 Layton UT. 84041 p 801.768.8800 DO Centerville UT. 84014 p 801.773.4840 Tanner Memorial Clinic p 801.298.3802 Heaton, Jared DO 2038 W 1900 S 380 N 400 W Rocky Mountain Dermatology Syracuse UT. 84075 425 Medical Dr Kaysville UT. 84037 320 W 500 S p 801.773.4840 Ste 218 p 801.773.4840 Ste 210 Bountiful UT. 84010 Bountiful UT. 84010 2121 N 1700 W p 801.298.3802 Hospital Affiliation p 801.827.9100 Layton UT. 84041 - Davis Hospital p 801.773.4840 Young, Robert P MD Hospital Affiliation Rocky Mountain Dermatology Curtis, Amy V MD - Lakeview Hospital Hospital Affiliation 320 W 500 S Dermatology and Aesthetics - Davis Hospital Ste 210 Center of Utah Innes, Matthew MD Bountiful UT. 84010 1222 W Legacy Crossing Tanner Memorial Clinic Nickle, S Brandon DO p 801.827.9100 Blvd 2121 N 1700 W Tanner Memorial Clinic Ste 200 Layton UT. 84041 2121 N 1700 W Hospital Affiliation Centerville UT. 84014 p 801.773.4840 Layton UT. 84041 - Logan Regional Hospital p 801.298.3802 p 801.773.4840 Dermatology and Aesthetics Diabetic Education 425 Medical Dr Center of Utah Hospital Affiliation Brown, Steven L DO Bountiful UT. 84010 1222 W Legacy Crossing - Davis Hospital Tanner Memorial Clinic p 801.298.3802 Blvd 2121 N 1700 W Ste 200 Nielsen, Joe R MD Layton UT. 84041 Hadley, Jason C MD Centerville UT. 84014 415 Medical Dr p 801.773.4840 Ogden Clinic p 801.298.3802 Ste D200 145 S 3000 W Bountiful UT. 84010 Hospital Affiliation West Point UT. 84015 p 801.292.6277 - Davis Hospital p 801.475.3960

47 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Diabetic Supplies Durable Medical Equipment Orthofix Inc (Bone Growth Bitner, John B MD CCS Medical Petersen Medical Stimulators Physicians Tanner Memorial Clinic Phone Number Only 870 W 300 N Only) 2121 N 1700 W p 800.726.9811 Ste 100 Phone Number Only Layton UT. 84041 Kaysville UT. 84037 p 800.535.4492 p 801.773.4840 Edgepark p 801.728.3333 Phone Number Only Pacific Medical Inc Hospital Affiliation p 800.321.0591 Alpine Home Medical Phone Number Only - Davis Hospital Phone Number Only p 800.726.9180 - Lakeview Hospital Roche Insulin Delivery p 800.686.7993 Systems Inc Precision Health Services Bradshaw, Joshua B MD Phone Number Only CCS Medical 2307 N Hill Field Rd Ogden Clinic - Mountain p 800.280.7801 Phone Number Only Ste 102 West ENT p 800.726.9811 Layton UT. 84041 1551 S Renaissance Towne US MED LLC p 801.266.0399 Dr Phone Number Only Care Rehab and Orthopedic Ste 310 p 800.787.6331 Products (Muscle RespirTech Bountiful UT. 84010 Stimulators) Phone Number Only p 801.295.5581 United States Medical Phone Number Only p 800.793.1261 Supply p 800.487.9644 2255 N 1700 W Phone Number Only Roche Insulin Delivery Ste 200 p 877.840.8218 DJO Global Systems Inc Layton UT. 84041 Phone Number Only Phone Number Only p 801.776.2180 Dialysis Center p 800.336.6569 p 800.280.7801 Farmington Bay Dialysis Crofts, Alicia K CCC-A Center Dynasplint Systems Inc Smith Nephew Inc (Muscle University of Utah Health 942 S Main St Phone Number Only Stimulators) 165 N University Ave Layton UT. 84041 p 800.638.6771 Phone Number Only Farmington UT. 84025 p 801.581.8578 p 800.821.5700 p 801.213.3200 EBI LLC (Bone Stimulators) Lakeside Dialysis Center Phone Number Only Total Respiratory Care Hospital Affiliation 532 S 500 W p 800.526.2579 1593 W 2350 S - University of Utah Hospital Bountiful UT. 84010 Ste C p 801.299.3470 Edgepark Woods Cross UT. 84087 Dahlstrom, Lisa CCC-A Phone Number Only p 801.298.8831 University of Utah Health Dietician p 800.321.0591 165 N University Ave Bird, Kelsey M RD US MED LLC Farmington UT. 84025 Ogden Clinic - Utah Spine Empi Inc (Neuromuscular Phone Number Only p 801.213.3200 1916 N 700 W Stimulator) p 800.787.6331 Ste 250 Phone Number Only Hospital Affiliation Layton UT. 84041 p 800.328.2536 United States Medical - University of Utah Hospital p 801.479.0312 Supply Hanger Clinic Phone Number Only Meacham, Ryan K MD Folkman, Kimberly RD 1660 W Antelope Dr p 877.840.8218 Tanner Memorial Clinic Tanner Memorial Clinic Ste 120 2121 N 1700 W 2121 N 1700 W Layton UT. 84041 Valley Home Medical Layton UT. 84041 Layton UT. 84041 p 801.917.2870 731 N McCormick Way p 801.773.4840 p 801.773.4840 Ste 1 *Intermountain Homecare Layton UT. 84041 Hospital Affiliation Gardner, Rachael RD *Medical Equipment and p 801.544.8866 - Davis Hospital Tanner Memorial Clinic *Supply Bountiful 2121 N 1700 W 1440 S 500 W Ear Nose And Throat Mellor, Robert L MD Layton UT. 84041 Bountiful UT. 84010 Alt, Jeremiah A MD Tanner Memorial Clinic p 801.773.4840 p 801.294.0636 University of Utah Health 2121 N 1700 W 165 N University Ave Layton UT. 84041 Van Noy, Calene RD KCI USA Inc (Wound Vac Farmington UT. 84025 p 801.773.4840 Tanner Memorial Clinic Only) p 801.213.3200 2121 N 1700 W Phone Number Only Hospital Affiliation Layton UT. 84041 p 800.275.4524 Hospital Affiliation - Davis Hospital p 801.773.4840 - University of Utah Hospital - Lakeview Hospital Lincare Weinert, Jean RD 1213 W Flint Medow Dr Ballingham, TeeMarie Mountain West Ear Nose and Tanner Memorial Clinic Ste 6 CCC-A Throat 2121 N 1700 W Kaysville UT. 84037 University of Utah Health 2255 N 1700 W Layton UT. 84041 p 801.444.9279 165 N University Ave Ste 200 p 801.773.4840 Farmington UT. 84025 Layton UT. 84041 p 801.213.3200 p 801.776.2180

Hospital Affiliation - University of Utah Hospital 48 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Oakley, Gretchen M MD VanLeeuwen, Richard N MD Endocrinology Family Practice University of Utah Health Tanner Memorial Clinic Al-Rayess, Khaldoun M MD Aardema, Critt F MD 165 N University Ave 2121 N 1700 W Tanner Memorial Clinic Tanner Memorial Clinic Farmington UT. 84025 Layton UT. 84041 2121 N 1700 W 2121 N 1700 W p 801.213.3200 p 801.773.4840 Layton UT. 84041 Layton UT. 84041 p 801.773.4840 p 801.773.4840 Hospital Affiliation Hospital Affiliation - University of Utah Hospital - Davis Hospital Hospital Affiliation Hospital Affiliation - Lakeview Hospital - Davis Hospital - Davis Hospital Prussin, Aaron J MD University of Utah Health Wilcox, Bryan K MD Aljammal, Jules MD Allred, Michael G MD 165 N University Ave Ogden Clinic - Mountain JC Aljammal, PLLC Tanner Memorial Clinic Farmington UT. 84025 West ENT 440 Medical Dr 2121 N 1700 W p 801.213.3200 1551 S Renaissance Towne Bountiful UT. 84010 Layton UT. 84041 Dr p 801.572.3433 p 801.773.4840 Hospital Affiliation Ste 310 - University of Utah Hospital Bountiful UT. 84010 Hospital Affiliation Hospital Affiliation p 801.295.5581 - Mountain Point Medical - Davis Hospital Richards, Bryan L MD Center Tanner Memorial Clinic 2255 N 1700 W - Utah Valley Hospital Anderson, Marc O MD 2121 N 1700 W Ste 200 Tanner Memorial Clinic Layton UT. 84041 Layton UT. 84041 Brown, Steven L DO 2121 N 1700 W p 801.773.4840 p 801.776.2180 Tanner Memorial Clinic Layton UT. 84041 2121 N 1700 W p 801.773.4840 Hospital Affiliation Hospital Affiliation Layton UT. 84041 - Davis Hospital - Davis Hospital p 801.773.4840 Hospital Affiliation - Lakeview Hospital - Lakeview Hospital - Davis Hospital Hospital Affiliation Skedros, Demetrios G MD Electrophysiology - Davis Hospital Anderson, Russell S DO Ogden Clinic - Mountain Forstall, Peter G MD Medallus Medical West ENT Northern Utah Schlegel, Amnon MD,PhD 1868 N 1200 W 1551 S Renaissance Towne Cardiovascular Associates University of Utah Health Layton UT. 84041 Dr 1407 N 2000 W 165 N University Ave p 801.614.9030 Ste 310 Ste B Farmington UT. 84025 Bountiful UT. 84010 Clearfield UT. 84015 p 801.213.3200 Hospital Affiliation p 801.295.5581 p 801.773.3191 - Davis Hospital Hospital Affiliation 2255 N 1700 W Hospital Affiliation - University of Utah Hospital Anisman, David E MD Ste 200 - Ogden Regional Medical University of Utah Health Layton UT. 84041 Center Sharma, Anu MD 165 N University Ave p 801.776.2180 - Brigham City Community University of Utah Health Farmington UT. 84025 Hospital 165 N University Ave p 801.213.8841 Hospital Affiliation - Davis Hospital Farmington UT. 84025 - Davis Hospital - Cache Valley Hospital p 801.213.3200 Hospital Affiliation - Lakeview Hospital - University of Utah Hospital Steinberg, Benjamin A MD Hospital Affiliation Stock, Curt R MD University of Utah Health - University of Utah Hospital Archibald, Randall PA Ogden Clinic - Mountain 165 N University Ave MountainStar Layton Family West ENT Farmington UT. 84025 Tobery, Ted MD Medicine 1551 S Renaissance Towne p 801.581.6709 Davis Multi-Speciality 2950 N Church St Dr Clinic Ste 200 Ste 310 Hospital Affiliation 1492 W Antelope Dr Layton UT. 84040 Bountiful UT. 84010 - University of Utah Hospital Ste 203 p 801.546.9441 p 801.295.5581 Layton UT. 84041 Talwar, Sandeep MD p 801.773.7500 Arrington, Sara J APRN 2255 N 1700 W Utah Cardiology Heart and Soul Family Ste 200 444 W Bourne Cir Hospital Affiliation Medicine Layton UT. 84041 Ste 200 - Salt Lake Regional Medical 3024 W 300N p 801.776.2180 Farmington UT. 84025 Center Ste C p 801.776.0174 Clearfield UT. 84015 Hospital Affiliation Wahl, Matthew P MD p 385.393.8224 - Davis Hospital Hospital Affiliation University of Utah Health - Lakeview Hospital - Davis Hospital 165 N University Ave Hospital Affiliation Farmington UT. 84025 - Davis Hospital p 801.213.3200

Hospital Affiliation - University of Utah Hospital 49 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Baham, Ethan P DO Blaser, Brett E DO Butler, Warren L MD Christian, Mark E MD Tanner Memorial Clinic Orn Industries LLC Tanner Memorial Clinic Ogden Clinic - Cope Family 2121 N 1700 W 722 W Shepard Ln 2038 W 1900 S Medicine Layton UT. 84041 Ste 102 Syracuse UT. 84075 185 S 400 E p 801.773.4840 Farmington UT. 84025 p 801.773.4840 Ste 100 p 385.988.3965 Bountiful UT. 84010 Barker, Layne T MD Hospital Affiliation p 801.397.6200 Tanner Memorial Clinic Bledsoe, James A DO - Davis Hospital 2038 W 1900 S Tanner Memorial Clinic 620 S Medical Dr Syracuse UT. 84075 2121 N 1700 W Butters, David E DO Ste 150 p 801.773.4840 Layton UT. 84041 Wasatch Peak Family Bountiful UT. 84010 p 801.773.4840 Practice p 801.298.4112 Hospital Affiliation 1580 W Antelope Dr - Davis Hospital Hospital Affiliation Ste 200 Hospital Affiliation - Ogden Regional Medical Layton UT. 84041 - Lakeview Hospital Barney, Douglas P MD Center p 801.773.4770 Hyperbaric and Wound Care - Davis Hospital Cline, Spencer DO Center Hospital Affiliation Tanner Memorial Clinic 2132 N 1700 W Blythe, Michael S PA-C - Davis Hospital 444 W Bourne Cir Ste 100 Tucker Medical Group Farmington UT. 84025 Layton UT. 84041 440 Medical Dr CAS Healthcare and p 801.773.4840 p 801.807.7900 Ste 2 Wellness Bountiful UT. 84010 1448 N 2000 W Cobb, Nadia M PA Hospital Affiliation p 801.638.8446 Ste 10 University of Utah Health - Davis Hospital Clearfield UT. 84015 26 S Main St Broadbent, Daniel MD p 801.896.0847 Centerville UT. 84014 Barrett, John W MD Ogden Clinic - Davis p 801.693.7900 University of Utah Health Family Physicians Cardon, Scott MD 165 N University Ave 3225 W Gordon Ave Tanner Memorial Clinic Hospital Affiliation Farmington UT. 84025 Ste 1 2121 N 1700 W - University of Utah Hospital p 801.213.8841 Layton UT. 84041 Layton UT. 84041 p 801.397.6150 p 801.773.4840 Cook, Johnnie V MD Hospital Affiliation Tanner Memorial Clinic - University of Utah Hospital Ogden Clinic Hospital Affiliation 2121 N 1700 W 991 W Shepard Ln - Davis Hospital Layton UT. 84041 Baxter, Mark E MD Ste 200 p 801.773.4840 Tanner Memorial Clinic Farmington UT. 84025 Cetton, Gregory A MD 2121 N 1700 W p 801.475.3000 University of Utah Health Hospital Affiliation Layton UT. 84041 165 N University Ave - Davis Hospital p 801.773.4840 Hospital Affiliation Farmington UT. 84025 - Ogden Regional Medical p 801.213.8841 Cope, David G MD Hospital Affiliation Center Ogden Clinic - Cope Family - Davis Hospital - Lakeview Hospital Hospital Affiliation Medicine - Davis Hospital - University of Utah Hospital 185 S 400 E Beus, Michael L MD Ste 100 Tanner Memorial Clinic Burt, Rebecca APRN Chappell, Daniel H DO Bountiful UT. 84010 2121 N 1700 W University of Utah Health Tanner Memorial Clinic p 801.397.6200 Layton UT. 84041 165 N University Ave 444 W Bourne Cir p 801.773.4840 Farmington UT. 84025 Farmington UT. 84025 Hospital Affiliation p 801.213.3200 p 801.773.4840 - Lakeview Hospital Hospital Affiliation - Davis Hospital 26 S Main St Ogden Clinic Curran, Rebecca L MD Centerville UT. 84014 991 W Shepard Ln University of Utah Health Bishop, Scott R MD p 801.693.7900 Ste 200 26 S Main St Tanner Memorial Clinic Farmington UT. 84025 Centerville UT. 84014 2038 W 1900 S Hospital Affiliation p 801.397.6080 p 801.693.7900 Syracuse UT. 84075 - University of Utah Hospital p 801.773.4840 Child, Dustin MD Hospital Affiliation Burtenshaw, Brett T MD Tanner Memorial Clinic - University of Utah Hospital 2121 N 1700 W Tanner Memorial Clinic Mon-Fri 5pm-8pm Sat Layton UT. 84041 2038 W 1900 S 9am-3pm Davis County Health Dept p 801.773.4840 Syracuse UT. 84075 380 N 400 W 140 E Ctr St 2nd Fl p 801.773.4840 Kaysville UT. 84037 Clearfield UT. 84015 Hospital Affiliation p 801.773.4840 p 801.773.8834 - Davis Hospital Hospital Affiliation - Davis Hospital Hospital Affiliation - Davis Hospital

50 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 596 W 750 S Eclipse Medical LLC - The Francis, Joseph A MD Greenwood, Jessica L MD Woods Cross UT. 84087 Health Spot Davis Medical Group University of Utah Health p 801.298.3919 1660 W Antelope Dr 349 N Flint St 165 N University Ave Ste 320 Ste 101 Farmington UT. 84025 Davis, Christopher DO Layton UT. 84041 Kaysville UT. 84037 p 801.213.8841 Ogden Clinic - Davis p 801.820.5414 p 801.927.3080 Family Physicians Hospital Affiliation 3225 W Gordon Ave Erickson, Scott MD Hospital Affiliation - Salt Lake Regional Medical Ste 1 440 Medical Dr - Davis Hospital Center Layton UT. 84041 Ste 4 - University of Utah Hospital p 801.475.3000 Bountiful UT. 84010 Fredman, Zachary MD p 801.294.8288 University Of Utah Health Gregoire, Richard J MD Hospital Affiliation 26 S Main St Midtown Community Health - Davis Hospital Hospital Affiliation Centerville UT. 84014 Center - Lakeview Hospital p 801.693.7900 22 S State St DeGrauw, Jeffery L MD Ste 1007 Wasatch Peak Family Farnsworth, David D MD Hospital Affiliation Clearfield UT. 84015 Practice Tanner Memorial Clinic - University of Utah Hospital p 801.393.5355 1580 W Antelope Dr 1750 E 3100 N Ste 200 Layton UT. 84040 Freedom Healthcare Hospital Affiliation Layton UT. 84041 p 801.773.4840 3080 N 1700 E - Ogden Regional Medical p 801.773.4770 Ste B Center 2038 W 1900 S Layton UT. 84040 Hospital Affiliation Syracuse UT. 84075 p 801.825.6597 Hanna, Allison DO - Davis Hospital p 801.773.4840 Wade Family Medicine Freestone, Allen A MD 557 W 2600 S Dixon, Tyler C DO Hospital Affiliation Wade Family Medicine Bountiful UT. 84010 Tanner Memorial Clinic - Davis Hospital 557 W 2600 S p 801.298.9155 1477 N 2000 W Bountiful UT. 84010 Clearfield UT. 84015 Fife, Jason R DO p 801.298.9155 Healey, Curtis M MD p 801.773.4840 Tanner Memorial Clinic Tanner Memorial Clinic 380 N 400 W Hospital Affiliation 2121 N 1700 W Hospital Affiliation Kaysville UT. 84037 - Lakeview Hospital Layton UT. 84041 - Davis Hospital p 801.773.4840 p 801.773.4840 - Oneida County Hospital Gadd, Sarah J NP Hospital Affiliation Ogden Clinic Hibbard, Julie C MD Dodenbier, Cindie G CFNP - Davis Hospital 991 W Shepard Ln Tanner Memorial Clinic Life Spring Pain Ste 200 1750 E 3100 N Management Flinders, Kurt T DO Farmington UT. 84025 Layton UT. 84040 275 W 200 N Tanner Memorial Clinic p 801.397.6080 p 801.773.4840 Ste 7 1477 N 2000 W Kaysville UT. 84037 Clearfield UT. 84015 Gardner, Kevin L MD Hospital Affiliation p 801.546.1300 p 801.773.4840 Wasatch Peak Family - Davis Hospital Practice Doucette, Cassidy APRN Hospital Affiliation 1580 W Antelope Dr Hobbs, Rachel B MD University of Utah Health - Davis Hospital Ste 200 Tanner Memorial Clinic 165 N University Ave Layton UT. 84041 2121 N 1700 W Farmington UT. 84025 Foote, Stephen M DO p 801.773.4770 Layton UT. 84041 p 801.213.3200 Tanner Memorial Clinic p 801.773.4840 2038 W 1900 S Hospital Affiliation Hospital Affiliation Syracuse UT. 84075 - Davis Hospital Hospital Affiliation - University of Utah Hospital p 801.773.4840 - Davis Hospital Gertge, Robert PA-C Drescher, Ronald G PA-C Hospital Affiliation MountainStar Layton Family Hogan, Eric DO Tanner Memorial Clinic - Davis Hospital Medicine Tanner Memorial Clinic 1477 N 2000 W 2950 N Church St 1477 N 2000 W Clearfield UT. 84015 Fowers, Jody L APRN Ste 200 Clearfield UT. 84015 p 801.773.4840 MountainStar Layton Family Layton UT. 84040 p 801.773.4840 Medicine p 801.771.7700 Durtschi, Ronald D MD 2950 N Church St Hospital Affiliation Bonnell Clearfield Medical Ste 200 Green, James DO - Davis Hospital Clinic Layton UT. 84040 Legacy Point Family Bldg H 11 Freeport Ctr p 801.546.9441 Medicine Clearfield UT. 84016 81 N 2000 W p 801.774.3265 Ste F-2 Clearfield UT. 84015 Hospital Affiliation p 801.614.5140 - Davis Hospital 51 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Horning, Ryan R PA-C Jorgensen, Mark S MD Marchand, Kolleen PA-C Morrill, Arnold B DO Wee Care Pediatrics Tanner Memorial Clinic Tanner Memorial Clinic University of Utah Health 1792 W 1700 S 1477 N 2000 W 380 N 400 W 165 N University Ave Ste 102 Clearfield UT. 84015 Kaysville UT. 84037 Farmington UT. 84025 Syracuse UT. 84075 p 801.773.4840 p 801.773.4840 p 801.213.8841 p 801.773.8644 Hospital Affiliation Martindale, Brett W MD Hospital Affiliation 2084 N 1700 W - Davis Hospital Ogden Clinic - Davis - University of Utah Hospital Ste A Family Physicians Layton UT. 84041 Kendell, Patrick J MD 3225 W Gordon Ave Morris, Jared A DO p 801.773.8644 Tanner Memorial Clinic Ste 1 Tanner Memorial Clinic 2121 N 1700 W Layton UT. 84041 2121 N 1700 W 934 S Main St Layton UT. 84041 p 801.475.3000 Layton UT. 84041 Ste 8 p 801.773.4840 p 801.773.4840 Layton UT. 84041 Ogden Clinic p 801.773.8644 Hospital Affiliation 537 N Kays Dr Hospital Affiliation - Davis Hospital Kaysville UT. 84037 - Davis Hospital Hospital Affiliation p 801.475.3500 - Mountain West Medical Kirkham, Mark D MD MountainStar Layton Family Center Tanner Memorial Clinic 991 W Shepard Ln Medicine 1750 E 3100 N Ste 200 2950 N Church St Jasmer, Dustin C APRN Layton UT. 84040 Farmington UT. 84025 Ste 200 2317 N Hill Field Rd p 801.773.4840 p 801.397.6080 Layton UT. 84040 Layton UT. 84041 p 801.771.7700 p 801.525.4645 Kirkham, Michael D MD Melville, Brian T DO Tanner Memorial Clinic Turning Point Centers Naylor, Susan (Marie) M Jasmer Health 380 N 400 W 521 N Sportsplex Dr NP 555 N Fairfield Rd Kaysville UT. 84037 Kaysville UT. 84037 Eclipse Medical LLC - The Layton UT. 84041 p 801.773.4840 p 801.576.0745 Health Spot p 801.784.9555 1660 W Antelope Dr Hospital Affiliation Merrell, Stephen C MD Ste 320 Jenkins, Hans DO - Davis Hospital Tanner Memorial Clinic Layton UT. 84041 Orn Industries, LLC 444 W Bourne Cir p 801.820.5414 722 W Shepard Ln Knox, Jordan M MD Farmington UT. 84025 Ste 102 University of Utah Health p 801.773.4840 Hospital Affiliation Farmington UT. 84025 26 S Main St - Davis Hospital p 801.388.5129 Centerville UT. 84014 Monson, Nicholas DO p 801.693.7900 University of Utah Health Nelson, Courtney R DO Hospital Affiliation 165 N University Ave Wasatch Peak Family - Ogden Regional Medical Hospital Affiliation Farmington UT. 84025 Practice Center - University of Utah Hospital p 801.213.3200 1580 W Antelope Dr - Lakeview Hospital Ste 200 - Davis Hospital Larsen, Benjamin MD Hospital Affiliation Layton UT. 84041 Tanner Memorial Clinic - Davis Hospital p 801.773.4770 Jones, Kyle B MD 2121 N 1700 W University of Utah Health Layton UT. 84041 Moranda, Emily PA-C Hospital Affiliation 165 N University Ave p 801.773.4840 Wasatch Peak Family - Davis Hospital Farmington UT. 84025 Practice p 801.213.8841 Lenthe, Mark R DO 1580 W Antelope Dr Nelson, Jeffery S DO Tanner Memorial Clinic Ste 200 Freedom Healthcare 26 S Main St 2121 N 1700 W Layton UT. 84041 1448 N 2000 W Centerville UT. 84014 Layton UT. 84041 p 801.773.4770 Ste 11 p 801.693.7900 p 801.773.4840 Clearfield UT. 84015 Morrell, Stephen L MD p 801.613.2711 Hospital Affiliation Hospital Affiliation Tanner Memorial Clinic - University of Utah Hospital - Davis Hospital 380 N 400 W Neville, Roark B MD Kaysville UT. 84037 Ogden Clinic - Davis Jorgensen, Jesse A PA Lozano, Melanie V PA p 801.773.4840 Family Physicians University of Utah Health Wasatch Peak Family 3225 W Gordon Ave 26 S Main St Practice Hospital Affiliation Ste 1 Centerville UT. 84014 1580 W Antelope Dr - Davis Hospital Layton UT. 84041 p 801.693.7900 Ste 200 p 801.475.3000 Layton UT. 84041 Hospital Affiliation p 801.773.4770 Hospital Affiliation - University of Utah Hospital - Davis Hospital

52 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Noble, Nicholas M DO 934 S Main St Ogden Clinic - Utah Spine Skalka, David NP Davis Medical Group - Ste 8 1916 N 700 W Davis Behavioral Health Kaysville Layton UT. 84041 Ste 250 Unit - Layton 349 N Flint St p 801.773.8644 Layton UT. 84041 1600 W Antelope Dr Ste 101 p 801.479.0312 Layton UT. 84041 Kaysville UT. 84037 Hospital Affiliation p 801.807.1000 p 801.927.3088 - Bear River Valley Hospital Ogden Clinic - Davis - Davis Hospital Family Physicians Smith, Kurtis R APRN Ogden Clinic Cope Family 3225 W Gordon Ave Wee Care Pediatrics Medicine Peterson, Bryce K MD Ste 1 2084 N 1700 W 620 Medical Dr Ogden Clinic - Cope Family Layton UT. 84041 Ste A Bountiful UT. 84010 Medicine p 801.397.6150 Layton UT. 84041 p 801.298.4112 185 S 400 E p 801.773.8644 Ste 100 Hospital Affiliation Ortiz-Pacheco, Clarivette Bountiful UT. 84010 - Davis Hospital 934 S Main St MD p 801.397.6200 Ste 8 University of Utah Health Robins, Mont C PA Layton UT. 84041 26 S Main St Hospital Affiliation MountainStar Layton Family p 801.773.8644 Centerville UT. 84014 - Lakeview Hospital Medicine p 801.693.7900 2950 N Church St Sorweid, Michelle R DO Piper, Jaclyn J APRN Ste 200 University of Utah Health Hospital Affiliation University of Utah Health Layton UT. 84040 430 W 400 N - University of Utah Hospital 165 N University Ave p 801.546.9441 Bountiful UT. 84010 Farmington UT. 84025 p 801.581.2628 Ostarcevic, Emily FNP p 801.213.4246 Rodgers, Brian J DO Wee Care Pediatrics 425 Medical Dr Hospital Affiliation 2084 N 1700 W Pohl, Susan D MD Ste 205 - University of Utah Hospital Ste A University of Utah Health Bountiful UT. 84010 Layton UT. 84041 165 N University Ave p 801.298.3812 Spiess, Saskia MD p 801.773.8644 Farmington UT. 84025 University Of Utah Health p 801.213.3200 Hospital Affiliation 26 S Main St 934 S Main St - Lakeview Hospital Centerville UT. 84014 Ste 8 26 S Main St p 801.693.7900 Layton UT. 84041 Centerville UT. 84014 *Rymer, Karen R APRN p 801.773.8644 p 801.693.7900 Primary Childrens Hospital Hospital Affiliation 98 S 100 E - Salt Lake Regional Medical Overdiek, Kirk R FNP Hospital Affiliation Farmington UT. 84025 Center Wee Care Pediatrics - University of Utah Hospital p 801.451.3560 1792 W 1700 S Stelter, Casey L MD Ste 102 Prince, Victoria L MD,PhD Hospital Affiliation MountainStar Layton Family Syracuse UT. 84075 University of Utah Health - Primary Childrens Hospital Medicine p 801.927.1634 165 N University Ave 2950 N Church St Farmington UT. 84025 Salmon, Cheryl NP Ste 200 2084 N 1700 W p 801.213.3200 CAS Healthcare and Layton UT. 84040 Ste A Wellness p 801.771.7700 Layton UT. 84041 26 S Main St 1448 N 2000 W p 801.773.8644 Centerville UT. 84014 Ste 10 Hospital Affiliation p 801.693.7900 Clearfield UT. 84015 - Davis Hospital 934 S Main St p 801.896.0847 Ste 8 Hospital Affiliation Stevens, Andrew MD Layton UT. 84041 - University of Utah Hospital Hospital Affiliation Tanner Memorial Clinic p 801.773.8644 - Ogden Regional Medical 2038 W 1900 S Richardson, Charles D MD Center Syracuse UT. 84075 Pace, Brad PA Tanner Memorial Clinic p 801.773.4840 Wee Care Pediatrics 2121 N 1700 W Schaelling, Michael P MD 1792 W 1700 S Layton UT. 84041 Tanner Memorial Clinic Stewart, Ryan L MD Ste 102 p 801.773.4840 380 N 400 W Tanner Memorial Clinic Syracuse UT. 84075 Kaysville UT. 84037 2038 W 1900 S p 801.773.8644 Hospital Affiliation p 801.773.4840 Syracuse UT. 84075 - Davis Hospital p 801.773.4840 2084 N 1700 W Hospital Affiliation Ste A Rigby, Rohn C MD - Davis Hospital Hospital Affiliation Layton UT. 84041 Ogden Clinic - Davis Hospital p 801.773.8644 1560 S Renaissance Towne Dr Ste 210 Bountiful UT. 84010 p 801.397.6100 53 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Sullivan, Erika A MD Tillotson, Shadrick W MD Wayment, Nadya P MD Ogden Clinic University of Utah Health Cedar Psychiatry Tanner Memorial Clinic 991 W Shepard Ln 26 S Main St 2950 N Church St 2121 N 1700 W Ste 200 Centerville UT. 84014 Ste 101 Layton UT. 84041 Farmington UT. 84025 p 801.693.7900 Layton UT. 84040 p 801.773.4840 p 801.397.6080 p 801.369.8989 Hospital Affiliation Hospital Affiliation Yeates, Michael C DO - University of Utah Hospital UUHC Davis Center - Ogden Regional Medical Tanner Memorial Clinic 1492 W Antelope Center 2121 N 1700 W Syddall, Tracy R PA-C Ste 150 Layton UT. 84041 University of Utah Health Layton UT. 84041 Weida, Avery FNP p 801.773.4840 26 S Main St p 801.776.7804 Eclipse Medical LLC - The Centerville UT. 84014 Health Spot 380 N 400 W p 801.693.7900 UUHC Centerville Clinic 1660 W Antelope Dr Kaysville UT. 84037 26 S Main St Ste 320 p 801.773.4840 Hospital Affiliation Centerville UT. 84014 Layton UT. 84041 - Jordan Valley Medical p 801.693.7900 p 801.820.5414 Hospital Affiliation Center - Davis Hospital - University of Utah Hospital Vanstaden, Gavin N MD White, Charles D MD University of Utah Health University of Utah Health Gastroenterology Tanner Memorial Clinic 165 N University Ave 165 N University Ave Canale, Christopher C MD Mon-Fri 5pm-8pm Sat Farmington UT. 84025 Farmington UT. 84025 Utah Gastroenterology 9am-3pm p 801.213.8841 p 801.213.8841 620 E Medical Dr 2038 W 1900 S Ste 205 Syracuse UT. 84075 Woodmead Medical Clinic 26 S Main St Bountiful UT. 84010 p 801.773.4840 3263 S Hwy 89 Centerville UT. 84014 p 801.298.0057 Ste 300 p 801.693.7900 2121 N 1700 W Bountiful UT. 84010 Hospital Affiliation Layton UT. 84041 p 801.296.0600 Hospital Affiliation - Lakeview Hospital p 801.773.4840 - University of Utah Hospital Vroman, Stacy T PA Doxey, Brett W MD 380 N 400 W University of Utah Health Whittier, Cassie L MD Utah Gastroenterology Kaysville UT. 84037 165 N University Ave Tanner Memorial Clinic 620 E Medical Dr p 801.773.4840 Farmington UT. 84025 1750 E 3100 N Ste 205 p 801.213.8841 Layton UT. 84040 Bountiful UT. 84010 Tanner, Carol S PA-C p 801.773.4840 p 801.298.0057 Cedar Psychiatry 26 S Main St 2950 N Church St Centerville UT. 84014 Hospital Affiliation Hospital Affiliation Ste 101 p 801.693.7900 - Davis Hospital - Lakeview Hospital Layton UT. 84040 - Lone Peak Hospital p 801.369.8989 Wade, Ralph D DO Winn, Darin MD Wade Family Medicine Ogden Clinic - Davis Fang, John C MD Thomas, Kelly L DO 557 W 2600 S Family Physicians University of Utah Health University of Utah Health Bountiful UT. 84010 3225 W Gordon Ave 165 N University Ave 165 N University Ave p 801.298.9155 Ste 1 Farmington UT. 84025 Farmington UT. 84025 Layton UT. 84041 p 801.213.3200 p 801.213.8841 Hospital Affiliation p 801.397.6150 - Lakeview Hospital Hospital Affiliation Hospital Affiliation Woolf, Kurtis A MD - University of Utah Hospital - University of Utah Hospital Wang, Ziyi MD Ogden Clinic Lakeview Internal Medicine 145 S 3000 W Gessel, Luke M MD Thurston, McKennan J MD 140 N Union Ave West Point UT. 84015 University of Utah Health Tanner Memorial Clinic Ste 300 p 801.475.3960 165 N University Ave 1750 E 3100 N Farmington UT. 84025 Farmington UT. 84025 Layton UT. 84040 p 801.299.3890 Ogden Clinic - Cope Family p 801.213.3200 p 801.773.4840 Medicine 444 W Bourne Cir 185 S 400 E Hospital Affiliation 2121 N 1700 W Ste 101 Ste 100 - University of Utah Hospital Layton UT. 84041 Farmington UT. 84025 Bountiful UT. 84010 p 801.773.4840 p 801.294.9333 p 801.397.6200 Kashani, Amir MD University of Utah Health Hospital Affiliation Ward, Raymond P MD Ogden Clinic - Davis 165 N University Ave - Davis Hospital Ogden Clinic - Cope Family Family Physicians Farmington UT. 84025 Medicine 3225 W Gordon Ave p 801.213.3200 185 S 400 E Ste 1 Ste 100 Layton UT. 84041 Bountiful UT. 84010 p 801.397.6150 p 801.397.6200

Hospital Affiliation - Lakeview Hospital 54 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Kiyomura, Robert S MD Vandersteen, Joshua G DO English, Christopher S MD Larsen, Wade B MD 2084 N 1700 W Ogden Clinic Mountain Orthopaedics Neuroscience & Ste B 201 W Layton Pkwy 1551 S Renaissance Towne Rehabilitation Specialists Layton UT. 84041 Ste 420 Dr - Layton p 801.773.9710 Layton UT. 84041 Ste 400 1492 W Antelope Dr p 801.475.3000 Bountiful UT. 84010 Ste 203 Moore, David R MD p 801.295.7200 Layton UT. 84041 Utah Gastroenterology Hospital Affiliation p 801.773.7500 620 E Medical Dr - Davis Hospital 201 W Layton Pkwy Ste 205 Ste 400 Salt Lake Surgical Bountiful UT. 84010 Walker, Michael J MD Layton UT. 84041 Services p 801.299.0057 University of Utah Health p 801.295.7200 1492 W Antelope Dr 165 N University Ave Ste 209 Hospital Affiliation Farmington UT. 84025 Hospital Affiliation Layton UT. 84041 - Lakeview Hospital p 801.213.3200 - Davis Hospital p 385.429.3535 - Lakeview Hospital Parbhu, Sheeva K MD Hospital Affiliation Davis Behavioral Health University Of Utah Health - University of Utah Hospital Goodwin, Mackenzie L MD Unit - Layton 165 N University Ave Steward Specialty Surgery 1600 W Antelope Dr Farmington UT. 84025 General Surgery of Utah Layton UT. 84041 p 801.213.3200 Baker, Scott MD 1492 W Antelope Dr p 801.807.1000 Neuroscience & Ste 203 Hospital Affiliation Rehabilitation Specialists Layton UT. 84041 Hospital Affiliation - University of Utah Hospital - Layton p 801.773.7500 - Davis Hospital 1492 W Antelope Dr - Lakeview Hospital Peterson, Kathryn A MD Ste 203 Davis Surgical Associates University of Utah Health Layton UT. 84041 1580 W Antelope Dr Morrell, David G MD 165 N University Ave p 801.773.7500 Ste 130 B Tanner Memorial Clinic Farmington UT. 84025 Layton UT. 84041 2121 N 1700 W p 801.213.3200 Salt Lake Surgical p 801.728.9259 Layton UT. 84041 Services p 801.773.4840 Hospital Affiliation 1492 W Antelope Dr 1580 W Antelope Dr - University of Utah Hospital Ste 209 Ste 80 Hospital Affiliation Layton UT. 84041 Layton UT. 84041 - Davis Hospital Poole, Jeffrey S MD p 385.429.3535 p 801.728.9555 Tanner Memorial Clinic Mulcock, Marie K PA-C 2121 N 1700 W Davis Hospital and Medical Davis Hospital and Medical University of Utah Health Layton UT. 84041 Center Center 165 N University Ave p 801.773.4840 1600 W Antelope Dr 1600 W Antelope Dr Farmington UT. 84025 Layton UT. 84041 Layton UT. 84041 p 801.213.3200 Hospital Affiliation p 801.820.3730 p 801.820.3730 - Davis Hospital Hospital Affiliation - Ogden Regional Medical Hospital Affiliation Hospital Affiliation - University of Utah Hospital Center - Davis Hospital - Davis Hospital Oberg, Jon C MD Pugh, Brian W DO Barker, Rodney J MD Jensen, Joseph W DO Tanner Memorial Clinic Tanner Memorial Clinic University of Utah Health Davis Surgical Associates 2121 N 1700 W 2121 N 1700 W 165 N University Ave 1580 W Antelope Dr Layton UT. 84041 Layton UT. 84041 Farmington UT. 84025 Ste 130 B p 801.773.4840 p 801.773.4840 p 801.213.3200 Layton UT. 84041 p 801.728.9259 Hospital Affiliation Hospital Affiliation Hospital Affiliation - Davis Hospital - Ogden Regional Medical - University of Utah Hospital Davis Surgical Assoc - Lakeview Hospital Center 1580 W Antelope Dr - Davis Hospital Cox, Jordy MD Ste 130 Syddall, Tracy R PA-C Heart and Lung Institute Layton UT. 84041 University of Utah Health Redd, Matthew K DO of Utah p 801.728.9555 26 S Main St Tanner Memorial Clinic 444 W Bourne Cir Centerville UT. 84014 2121 N 1700 W Ste 200 Hospital Affiliation p 801.693.7900 Layton UT. 84041 Farmington UT. 84025 - Ogden Regional Medical p 801.773.4840 p 801.299.7155 Center Hospital Affiliation - Davis Hospital - Jordan Valley Medical Hospital Affiliation - Lakeview Hospital Center - Ogden Regional Medical - University of Utah Hospital Center - Davis Hospital

55 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Thomas, Casey DO Genetic Counseling Boheen, Karen DO Larson, Alexander J MD Salt Lake Surgical Palmquist, Rachel N MD Antelope Womens Center Ogden Clinic Services University of Utah Health 2132 N 1700 W 201 W Layton Pkwy 1492 W Antelope Dr 201 W Layton Pkwy Ste 300 Ste 420 Ste 209 Ste 3D Layton UT. 84041 Layton UT. 84041 Layton UT. 84041 Layton UT. 84041 p 801.728.0600 p 801.475.3000 p 385.429.3535 p 801.213.359 Hospital Affiliation Hospital Affiliation Hospital Affiliation Hospital Affiliation - Davis Hospital - Ogden Regional Medical - Davis Hospital - University of Utah Hospital - Ogden Regional Medical Center Center Todd, Russell H MD Wong, Kristen GC Leavitt, Jarin K MD Lakeview Urology and University Of Utah Health Empey, Ryan B MD Tanner Memorial Clinic General Surgery 201 W Layton Pkwy Lakeview OB/GYN Clinic 2121 N 1700 W 620 E Medical Dr Ste 3D 620 E Medical Dr Layton UT. 84041 Ste 150 Layton UT. 84041 Ste 340 p 801.773.4840 Bountiful UT. 84010 p 801.213.3599 Bountiful UT. 84010 p 801.298.3247 p 801.299.2229 Hospital Affiliation Hospital Affiliation - Davis Hospital Hospital Affiliation - University of Utah Hospital Hospital Affiliation - Lakeview Hospital - Jordan Valley Medical Martin, Jared C MD Geriatrics Center Rocky Mountain Womens VanWagoner, Zachary D MD Beattie, Miriam D NP Health Center Tanner Memorial Clinic University of Utah Health Ferguson, Daniel R MD 1580 W Antelope Dr 2121 N 1700 W 430 W 400 N Ogden Clinic Ste 290 Layton UT. 84041 Bountiful UT. 84010 201 W Layton Pkwy Layton UT. 84041 p 801.773.4840 p 801.581.2628 Ste 420 p 801.776.0880 Layton UT. 84041 Hospital Affiliation Hospital Affiliation p 801.475.3100 Hospital Affiliation - Timpanogos Regional Hospital - University of Utah Hospital - Davis Hospital - Davis Hospital Hospital Affiliation Johnson, Sherman B MD - Salt Lake Regional Medical Meek, Steven C MD Wilson, Peter V MD AccuHeal Wound Care Center Tanner Memorial Clinic Davis Surgical Associates 747 Sheringham Ct 2121 N 1700 W 1580 W Antelope Dr Farmington UT. 84025 Gerard, Claudia G CNM Layton UT. 84041 Ste 130 B p 801.964.2008 University of Utah Health p 801.773.4840 Layton UT. 84041 165 N University Ave p 801.728.9259 Joseph, Laurene MD Farmington UT. 84025 Hospital Affiliation University of Utah Health p 801.581.4014 - Davis Hospital 1580 W Antelope Dr 165 N University Ave Ste 130 Farmington UT. 84025 Hospital Affiliation Metz, Torri MD Layton UT. 84041 p 801.213.8841 - University of Utah Hospital University of Utah Health p 801.728.9555 165 N University Ave Gynecology Hurst, Craig L MD Farmington UT. 84025 Davis General Surgery Archer, Cullen J MD 2132 N 1700 W p 801.213.3200 1580 W Antelope Dr Rocky Mountain Womens Ste 300 Ste 80 Health Center Layton UT. 84041 Miller, Ryan D DO Layton UT. 84041 1580 W Antelope Dr p 801.774.8714 Tanner Memorial Clinic p 801.820.7655 Ste 290 2121 N 1700 W Layton UT. 84041 Hospital Affiliation Layton UT. 84041 Hyperbaric and Wound Care p 801.776.0880 - Davis Hospital p 801.773.4840 Center @ Davis Hospital - Ogden Regional Medical 2132 N 1700 W Arogyasami, Susan A MD Center Hospital Affiliation Ste 100 Rocky Mountain Womens - Davis Hospital Layton UT. 84041 Health Center Johnson, Bryant L DO - Lakeview Hospital p 801.807.7900 1580 W Antelope Dr Tanner Memorial Clinic Ste 290 2121 N 1700 W Muscolino, Gina M MD Hospital Affiliation Layton UT. 84041 Layton UT. 84041 Lakeview OB/GYN Clinic - Davis Hospital p 801.776.0880 p 801.773.4840 620 E Medical Dr - Ogden Regional Medical Ste 340 Center Hospital Affiliation Johnson, Steven L MD Bountiful UT. 84010 - Davis Hospital Tanner Memorial Clinic p 801.299.2229 2121 N 1700 W Layton UT. 84041 Hospital Affiliation p 801.773.4840 - Lakeview Hospital

Hospital Affiliation - Davis Hospital 56 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Ostler, Leslie A MD Stevenson, Camille MD Hematology And Oncology Samuelson, Scott J MD University of Utah Health Tanner Memorial Clinic Gilcrease, Glynn W MD Utah Cancer Specialists 165 N University Ave 2121 N 1700 W University of Utah Health 520 E Medical Dr Farmington UT. 84025 Layton UT. 84041 165 N University Ave Ste 340 p 801.213.3200 p 801.773.4840 Farmington UT. 84025 Bountiful UT. 84010 p 801.213.3200 p 801.296.6665 Hospital Affiliation Hospital Affiliation - St Marks Hospital - Davis Hospital Hospital Affiliation Hospital Affiliation - Lakeview Hospital - University of Utah Hospital - Jordan Valley Medical Porter, Ryan G MD Center Lakeview OB/GYN Clinic Sumsion, Kevin S MD Gray, Carl R MD - Davis Hospital 620 E Medical Dr Tanner Memorial Clinic Utah Hematology Oncology - Lakeview Hospital Ste 340 2121 N 1700 W 2132 N 1700 W - Salt Lake Regional Medical Bountiful UT. 84010 Layton UT. 84041 Ste 301 Center p 801.299.2229 p 801.773.4840 Layton UT. 84041 p 801.775.9990 Sborov, Douglas W MD Riley, Tiffany PA-C Hospital Affiliation University of Utah Health Shepard Creek OBGYN - Davis Hospital Hospital Affiliation 165 N University Ave 670 W Shepard Ln - Ogden Regional Medical Farmington UT. 84025 Ste 103 Hand Surgery Center p 801.585.2626 Farmington UT. 84025 Huish, Steven B MD - Davis Hospital p 801.447.3377 Mountain Orthopaedics Hospital Affiliation 1551 Renaissance Towne Dr Henry, Norah L MD - University of Utah Hospital Hospital Affiliation Ste 400 University of Utah Health - Davis Hospital Bountiful UT. 84010 165 N University Ave Stinnett, Jason M MD p 801.295.7200 Farmington UT. 84025 Utah Cancer Specialists Rinne, Kirsti APRN p 801.213.3200 1492 W Antelope Dr University of Utah Health 2086 N 1700 W Ste 1255 165 N University Ave Layton UT. 84041 Hospital Affiliation Layton UT. 84041 Farmington UT. 84025 p 801.295.7200 - University of Utah Hospital p 801.525.3022 p 801.213.4500 Hospital Affiliation Johnson, Harold M MD Hospital Affiliation Hospital Affiliation - Lakeview Hospital Utah Hematology Oncology - Davis Hospital - University of Utah Hospital - Davis Hospital 2132 N 1700 W - Jordan Valley Medical Ste 301 Center West Valley Campus Rockenfield, Terra L PA Larsen, Kenna MD Layton UT. 84041 - Lakeview Hospital MountainStar Layton Family Tanner Memorial Clinic p 801.775.9990 - Salt Lake Regional Medical Medicine 1750 E 3100 N Center 2950 N Church St Layton UT. 84040 Hospital Affiliation Ste 200 p 801.773.4840 - Ogden Regional Medical Venniyil Radhakrishnan, Layton UT. 84040 Center Sabarinath MD p 801.546.9441 Hospital Affiliation - Davis Hospital University of Utah Health - Ogden Regional Medical 165 N University Ave Rynearson, Scott A DO Center Maughan, Benjamin L MD Farmington UT. 84025 Ogden Clinic - Davis Hospital University of Utah Health p 801.213.3200 201 W Layton Pkwy 165 N University Ave Ste 420 McGiven, Ryan D OT Farmington UT. 84025 Hospital Affiliation Layton UT. 84041 Summit Hand Therapy p 801.213.3200 - University of Utah Hospital p 801.475.3000 1448 N 2000 W Ste 7 Hospital Affiliation Home Health Agency Hospital Affiliation Clearfield UT. 84015 - University of Utah Hospital CNS Community Nursing - Ogden Regional Medical p 801.773.2633 Services Center Ormsby, Wayne MD 1492 W Antelope Dr 1992 W Antelope Dr Utah Cancer Specialists Ste 205 Snider, Malorie MD Ste 1-D 520 E Medical Dr Layton UT. 84041 Tanner Memorial Clinic Layton UT. 84041 Ste 340 p 888.882.4678 2121 N 1700 W p 801.773.2633 Bountiful UT. 84010 Layton UT. 84041 p 801.296.6665 Harmony Home Health and p 801.773.4840 Sellers, Daniel S MD Hospice 620 Medical Dr Hospital Affiliation 1424 Legend Hills Dr Spencer, Neil O MD Ste 310 - Davis Hospital Ste 110 Shepard Creek OBGYN Bountiful UT. 84010 Clearfield UT. 84015 670 W Shepard Ln p 801.295.6554 p 877.463.3322 Ste 103 Farmington UT. 84025 p 801.447.3377

Hospital Affiliation - Davis Hospital - Ogden Regional Medical Center 57 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Lifetouch Home Health Lakeview Hospital 532 S 500 W Burtenshaw, Bruce F MD 545 W 600 S 630 Medical Dr Bountiful UT. 84010 Tanner Memorial Clinic Bountiful UT. 84010 Bountiful UT. 84010 p 801.299.3470 2121 N 1700 W p 801.683.9541 p 801.292.6231 Layton UT. 84041 724 W 500 S p 801.773.4840 Pinnacle Home Health Inc Imaging Center Ste 300 Phone Number Only Open Imaging - Layton West Bountiful UT. 84087 Hospital Affiliation p 801.274.0299 2071 N Layton p 801.296.9091 - Davis Hospital Ste 100 Rocky Mountain Home Care Layton UT. 84041 942 S Main St Chabot, Matthew R MD 576 W 900 S p 801.825.4040 Layton UT. 84041 University of Utah Health Ste 105 p 801.593.9111 165 N University Ave Bountiful UT. 84010 Internal Medicine Farmington UT. 84025 p 801.693.2300 Al-Rayess, Khaldoun M MD Hospital Affiliation p 801.213.8841 Tanner Memorial Clinic - University of Utah Hospital South Davis Home Health 2121 N 1700 W - Davis Hospital Hospital Affiliation 481 S 400 E Layton UT. 84041 - University of Utah Hospital Bountiful UT. 84010 p 801.773.4840 Austad, Gregory T MD p 801.298.8983 Tanner Memorial Clinic Christian, Grant L MD Hospital Affiliation 2121 N 1700 W 425 Medical Dr Hospice - Davis Hospital Layton UT. 84041 Ste 118 CNS Community Nursing p 801.773.4840 Bountiful UT. 84010 Services Aldrich, Brock DO p 801.292.1422 1492 W Antelope Dr Tanner Memorial Clinic Hospital Affiliation Ste 205 2121 N 1700 W - Davis Hospital Hospital Affiliation Layton UT. 84041 Layton UT. 84041 - Lakeview Hospital p 888.882.4678 p 801.773.4840 Barklow, Jeff A MD Nephrology Associates of Chua, Milton M MD Harmony Home Health and Alexander, Gary J MD Utah University of Utah Health Hospice Tanner Memorial Clinic 572 W 750 S 165 N University Ave 1424 Legend Hills Dr 2121 N 1700 W Bountiful UT. 84010 Farmington UT. 84025 Ste 110 Layton UT. 84041 p 801.288.2634 p 801.213.3200 Clearfield UT. 84015 p 801.773.4840 p 877.463.3322 Hospital Affiliation Hospital Affiliation Hospital Affiliation - St Marks Hospital - University of Utah Hospital Horizon Hospice - Davis Hospital - Jordan Valley Medical Specialists Center West Valley Campus Coles, Andrew E MD 70 W Gentile Anand, Sanjiv MD - Salt Lake Regional Medical Tanner Memorial Clinic Layton UT. 84040 Nephrology Associates of Center 2121 N 1700 W p 801.294.8600 Utah Layton UT. 84041 572 W 750 S Biddulph, Glen F MD p 801.773.4840 Rocky Mountain Home Care Bountiful UT. 84010 Tanner Memorial Clinic 576 W 900 S p 801.288.2634 2121 N 1700 W Hospital Affiliation Ste 105 Layton UT. 84041 - Davis Hospital Bountiful UT. 84010 Hospital Affiliation p 801.773.4840 p 801.693.2300 - Salt Lake Regional Medical Coles, Catherine MD Center Hospital Affiliation Tanner Memorial Clinic Rocky Mountain Hospice - Jordan Valley Medical - Davis Hospital 2121 N 1700 W 576 W 900 S Center Layton UT. 84041 Ste 106 - St Marks Hospital Brant, Jamie L MD p 801.773.4840 Bountiful UT. 84010 University of Utah Health p 435.753.8220 Assiago, Marcellus S MD 165 N University Ave Hospital Affiliation University of Utah Health Farmington UT. 84025 - Davis Hospital South Davis Home Health & 165 N University Ave p 801.213.4246 Hospice Farmington UT. 84025 DeRemer, Kathleen R MD 481 S 400 E p 801.581.6709 Hospital Affiliation Layton Specialty Clinic Bountiful UT. 84010 - University of Utah Hospital 2950 N Church St p 801.298.4438 201 W Layton Pkwy Ste 101-A Layton UT. 84041 Burdett, Graham H PA-C Layton UT. 84040 Hospital p 801.543.6000 Tucker Medical Group p 801.771.7202 Davis Hospital 440 Medical Dr 1600 W Antelope Dr 2132 N Robins Dr Ste 2 Hospital Affiliation Layton UT. 84041 Ste 120 Bountiful UT. 84010 - Ogden Regional Medical p 801.807.1000 Layton UT. 84041 p 801.638.8446 Center p 801.779.6106

58 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Dickson, Landon E MD Gopinath, Arasu MD Jensen, Joseph D MD Mansfield, Justin W MD Nephrology Associates of Nephrology Associates of 425 Medical Dr Tanner Memorial Clinic Utah Utah Ste 116 2121 N 1700 W 572 W 750 S 572 W 750 S Bountiful UT. 84010 Layton UT. 84041 Bountiful UT. 84010 Bountiful UT. 84010 p 801.292.7250 p 801.773.4840 p 801.288.2634 p 801.288.2634 Hospital Affiliation Hospital Affiliation Hospital Affiliation Hospital Affiliation - Lakeview Hospital - Davis Hospital - Salt Lake Regional Medical - St Marks Hospital Center - Jordan Valley Medical Jones, Douglas H MD Morris, Donald R MD - Jordan Valley Medical Center West Valley Campus Tanner Memorial Clinic Nephrology Associates of Center - Salt Lake Regional Medical 1477 N 2000 W Utah - St Marks Hospital Center Clearfield UT. 84015 572 W 750 S p 801.773.4840 Bountiful UT. 84010 UUHC Centerville Clinic Hansen, Val R MD p 801.288.2634 26 S Main St 425 Medical Dr 2121 N 1700 W Centerville UT. 84014 Ste 110 Layton UT. 84041 Hospital Affiliation p 801.693.7900 Bountiful UT. 84010 p 801.773.4840 - St Marks Hospital p 801.295.9467 - Jordan Valley Medical Fang, John C MD Hospital Affiliation Center West Valley Campus University of Utah Health Hospital Affiliation - Davis Hospital - Salt Lake Regional Medical 165 N University Ave - Lakeview Hospital - Lakeview Hospital Center Farmington UT. 84025 p 801.213.3200 Hendershot, Richard W MD Joseph, Laurene MD Nalabothu, Poorna L MD Granger Medical University of Utah Health Northern Utah Hospital Affiliation Specialists 165 N University Ave Cardiovascular Associates - University of Utah Hospital 1551 S Renaissance Town Farmington UT. 84025 1407 N 2000 W Dr p 801.213.8841 Ste B Freeman, Andrew L MD Ste 370 Clearfield UT. 84015 University of Utah Health Bountiful UT. 84010 Khan, Sohail MD p 801.773.3191 165 N University Ave p 801.797.9033 Northern Utah Farmington UT. 84025 Cardiovascular Associates Oaks, Joshua B MD p 801.213.3200 Hospital Affiliation 1407 N 2000 W 520 E Medical Dr - Park City Hospital Ste B Ste 300 Fronk, Daniel MD Clearfield UT. 84015 Bountiful UT. 84010 Utah Cardiology Indahyung, Ruth M MD p 801.773.3191 p 801.292.1422 444 W Bourne Cir Nephrology Associates of Ste 200 Utah Hospital Affiliation Qadir, Hammad MD Farmington UT. 84025 572 W 750 S - Wyoming Medical Center Kidney and Hypertension p 801.776.0174 Bountiful UT. 84010 Institute of Utah PLLC p 801.288.2634 Kim, Christopher Y MD 2132 N 1700 W Hospital Affiliation Utah Cardiology Ste 110 - Davis Hospital Hospital Affiliation 444 W Bourne Cir Layton UT. 84041 - Lakeview Hospital - St Marks Hospital Ste 200 p 801.779.3500 - Jordan Valley Medical Farmington UT. 84025 Gardner, Gregory MD Center p 801.776.0174 Hospital Affiliation Davis Multi-Speciality - Salt Lake Regional Medical - Jordan Valley Medical Clinic Center Hospital Affiliation Center 1492 W Antelope Dr - Davis Hospital - Jordan Valley Medical Ste 203 Jansen, Kevin MD - Lakeview Hospital Center West Valley Campus Layton UT. 84041 Nephrology Associates of - Ogden Regional Medical - Salt Lake Regional Medical p 801.773.7500 Utah Center Center 572 W 750 S - Salt Lake Regional Medical Adult Behavioral Health Bountiful UT. 84010 Center Samuelson, Scott J MD Unit Davis - IP p 801.288.2634 Utah Cancer Specialists 1600 W Antelope Dr Lau, Sey M MD 520 E Medical Dr Layton UT. 84041 Hospital Affiliation Nephrology Associates of Ste 340 p 801.350.4253 - St Marks Hospital Utah Bountiful UT. 84010 - Jordan Valley Medical 572 W 750 S p 801.296.6665 Bonnell Clearfield Medical Center West Valley Campus Bountiful UT. 84010 Clinic - Salt Lake Regional Medical p 801.288.2634 Hospital Affiliation Bldg H 11 Freeport Ctr Center - Jordan Valley Medical Clearfield UT. 84016 Hospital Affiliation Center p 801.774.3265 - St Marks Hospital - Davis Hospital - Jordan Valley Medical - Lakeview Hospital Hospital Affiliation Center West Valley Campus - Salt Lake Regional Medical - Davis Hospital - Salt Lake Regional Medical Center Center 59 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Shields, Russell B MD UUHC Davis Center - Salt Lake Regional Medical Sullivan, Amy E MD 425 Medical Dr 1492 W Antelope Center University of Utah Health Ste 108 Ste 150 165 N University Ave Bountiful UT. 84010 Layton UT. 84041 Yaganti, Vamsee M MD Farmington UT. 84025 p 801.292.8444 p 801.776.7804 Northern Utah p 801.581.8425 Cardiovascular Associates Southworth, Scott MD UUHC Centerville Clinic 1407 N 2000 W Hospital Affiliation Tucker Medical Group 26 S Main St Ste B - Davis Hospital 440 Medical Dr Centerville UT. 84014 Clearfield UT. 84015 - Salt Lake Regional Medical Ste 2 p 801.693.7900 p 801.773.3191 Center Bountiful UT. 84010 - University of Utah Hospital p 801.638.8446 Vandersteen, Joshua G DO Laboratory Ogden Clinic Dominion Diagnostics Mental Health Facility Lakeview Intermal Medicine 201 W Layton Pkwy Phone Number Only Cold Creek Behavioral and Surgery Ste 420 p 877.734.9600 Health 520 E Medical Dr Layton UT. 84041 521 N Sportsplex Dr Ste 200 p 801.475.3000 Interpath Kaysville UT. 84037 Bountiful UT. 84010 576 W 900 S p 801.593.6777 p 801.294.9338 Hospital Affiliation Ste 105 - Davis Hospital Bountiful UT. 84010 Northern Utah Counseling Hospital Affiliation p 801.298.4214 -Not all services covered, - Lakeview Hospital Williams, Tyler R MD please contact your Tanner Memorial Clinic LabCorp of America administrator Taylor, R Robert MD 2121 N 1700 W Holdings 1387 W 1800 N Tanner Memorial Clinic Layton UT. 84041 Phone Number Only Clearfield UT. 84015 2121 N 1700 W p 801.773.4840 p 888.522.2677 p 801.779.0095 Layton UT. 84041 p 801.773.4840 444 W Bourne Cir MSCL at Medical Drive Mental Health Farmington UT. 84025 425 S Medical Dr Aguayo, Patricia MD Hospital Affiliation p 801.773.4840 Ste 120 University of Utah Health - Davis Hospital Bountiful UT. 84010 291 S 200 W Yaganti, Vamsee M MD p 801.295.5602 Farmington UT. 84025 Tien, Dave MD Northern Utah p 801.213.3200 Nephrology Associates of Cardiovascular Associates Quest Diagnostics Utah 1407 N 2000 W 1660 W Antelope Dr Hospital Affiliation 572 W 750 S Ste B Ste 230 - University of Utah Hospital Bountiful UT. 84010 Clearfield UT. 84015 Layton UT. 84041 p 801.288.2634 p 801.773.3191 p 801.779.2313 Albright, Michael LMFT Ascendant Behavioral Hospital Affiliation Zaugg, Valerie MD Long Term Acute Care Facility Health - St Marks Hospital Tanner Memorial Clinic Western Peaks Specialty 1133 N Main - Jordan Valley Medical 2121 N 1700 W Hospital Ste 128 Center West Valley Campus Layton UT. 84041 485 E 500 S Layton UT. 84041 - Salt Lake Regional Medical p 801.773.4840 Bountiful UT. 84010 p 801.872.5516 Center p 801.295.2361 Hospital Affiliation Alexander, Karolee LCSW Tucker, Brady J MD - Davis Hospital Maternal And Fetal Medicine Center for Growth and Tanner Memorial Clinic Daniels, Marianne CMHC Potential 2121 N 1700 W Interventional Cardiology Cedar Psychiatry 1785 E 1450 S Layton UT. 84041 Khan, Sohail MD 2950 N Church St Ste 250 p 801.773.4840 Northern Utah Ste 101 Clearfield UT. 84015 Cardiovascular Associates Layton UT. 84040 p 801.773.0535 Tucker, Stephen MD 1407 N 2000 W p 801.369.8989 Tucker Medical Group Ste B Alfieri, Ashley LPC 440 Medical Dr Clearfield UT. 84015 Silver, Robert M MD The OCD And Anxiety Ste 2 p 801.773.3191 University of Utah Health Treatment Center Bountiful UT. 84010 165 N University Ave 1459 N Main St p 801.638.8446 Hospital Affiliation Farmington UT. 84025 Ste 100 - Wyoming Medical Center p 801.581.8425 Bountiful UT. 84010 460 W 2600 S p 801.298.2000 Bountiful UT. 84010 Kim, Christopher Y MD Hospital Affiliation p 801.660.8687 Utah Cardiology - University of Utah Hospital Allen, Julie BCBA 444 W Bourne Cir - Davis Hospital ABS Kids Ste 200 2940 Church St Farmington UT. 84025 Ste 204 p 801.776.0174 Layton UT. 84040 p 801.935.4946 Hospital Affiliation - Davis Hospital - Lakeview Hospital - Ogden Regional Medical 60 *The PPO Agreement with this provider is expressly betweenCenter the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Alliant Behavioral Health Baird, Jessica BCaBA Bodily, Madison BCBA Bullock, Emily Y PSYD of Utah LLC ABS Kids ABS Kids Bullock Psychological 255 N Adamswood Rd 2940 Church St 2940 Church St Services Layton UT. 84040 Ste 204 Ste 204 240 N East Promontory p 385.888.9040 Layton UT. 84040 Layton UT. 84040 Ste 200 p 801.935.4171 p 801.935.4171 Farmington UT. 84025 Allred, Debbi CMHC p 801.844.1615 Neurobehavioral Center for Bargar, Sarah A LCSW Bonebrake, Kathleen M MD Growth Grandview Family University Of Utah Health Bunker, Brandon CMHC 327 W Gordon Ave Counseling 291 S 200 W Aspen Ridge Counseling Ste 2 1576 S 500 W Farmington UT. 84025 585 W 500 S Layton UT. 84041 Ste 202 p 801.213.3200 Ste 200 p 801.683.1062 Bountiful UT. 84010 Bountiful UT. 84010 p 801.406.9002 Hospital Affiliation p 801.990.4300 415 S Medical Dr - University of Utah Hospital Ste A101 Barusch, Nathaniel MD Burton, Brianna BCBA Bountiful UT. 84010 Cedar Psychiatry Bouchelle, Elizabeth ABS Kids p 801.683.1062 2950 N Church St BCBA 2940 Church St Ste 101 ABS Kids Ste 204 415 S Medical Dr Layton UT. 84040 2940 Church St Layton UT. 84040 Ste D101 p 801.369.8989 Ste 204 p 801.935.4171 Bountiful UT. 84010 Layton UT. 84040 p 801.683.1062 Hospital Affiliation p 801.935.4946 Butler, Erin BCBA - Mountain View Hospital Neurobehavioral Center for ABS Kids (UT) Bradford, Lisa LCSW Growth 2940 Church St - Utah Valley Hospital Resilient Solutions Inc 327 W Gordon Ave Ste 204 1355 N Main St Ste 2 Layton UT. 84040 Baylis, Allison BCBA Ste 1 Layton UT. 84041 p 801.935.4171 ABS Kids Bountiful UT. 84010 p 801.683.1062 2940 Church St p 801.259.3883 Anderson, Larry A LPC Ste 204 415 S Medical Dr Resilient Solutions Layton UT. 84040 Bradley, Jessica L CMHC Ste D101 1355 N Main St p 801.935.4171 Valley Behavioral Health Bountiful UT. 84010 Ste 1 1785 E 1450 S p 801.683.1062 Bountiful UT. 84010 Bell, Naomia M CMHC Ste 300 p 801.558.2788 Military & Veteran Clearfield UT. 84015 Cahoon, Stephanie BCBA Counseling Center p 888.949.4864 ABS Kids Andrews, Becky P LPC 360 S Fort Ln Bldg C, 2940 Church St Resilient Solutions Inc Ste 111 Braun, Daniel S LCSW Ste 204 1355 N Main St Layton UT. 84041 Wasatch Pediatrics - Layton UT. 84040 Ste 1 p 385.231.8387 Farmington p 801.935.4171 Bountiful UT. 84010 491 W Bourne Cir p 801.259.3883 Bergeson, Stephanie K Farmington Fields Bldg 1 Callister, Paul T CMHC CMHC Farmington UT. 84025 Paul Callister Counseling Anson, Marc L LCSW Resilient Solutions Inc p 801.939.9111 PLLC Anson Family Counseling 1355 N Main St 533 W 2600 S LLC Ste 1 Wasatch Pediatrics - Ste 340 1141 W 3090 S Bountiful UT. 84010 Bountiful (Grow Up Great) Bountiful UT. 84010 Syracuse UT. 84075 p 801.707.9612 620 E Medical Dr p 801.755.5138 p 385.439.1926 Ste 100 Bingham, Bryan D LMFT Bountiful UT. 84010 Capel, Adam B LCSW Applewhite, Kimberly C 377 N Marshall Way p 801.295.2888 Wellsprings Clinic PsyD Ste 1-M 425 Medical Dr University of Utah Health Layton UT. 84041 Bray, Kristl BCBA Ste 109 291 S 200 W p 801.589.2438 ABS Kids Bountiful UT. 84010 Farmington UT. 84025 2940 Church St p 801.641.8569 p 801.213.3200 Birnkrant, Jonathan D MD Ste 204 University of Utah Health Layton UT. 84040 Carbajal, Stephanie LMFT Hospital Affiliation 291 S 200 W p 801.935.4171 2317 N Hill Field Rd - University of Utah Hospital Farmington UT. 84025 Ste 103 p 801.213.3200 Buckner, Rachelle LCMHC Layton UT. 84041 Ascendant Behavioral Resilient Solutions p 801.525.4645 Health Hospital Affiliation 1355 N Main St 1133 N Main - University of Utah Hospital Ste 1 Ste 128 Bountiful UT. 84010 Layton UT. 84041 p 801.259.3883 p 801.872.5516

61 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 2636 N Hill Field Rd Corgiat, Mark D PhD Dobson, Nicole BCBA Edgington, Carl PhD Ste 5 1916 N 700 W ABS Kids ABS Kids Layton UT. 84041 Ste 190 2940 Church St 2940 Church St p 801.719.1803 Layton UT. 84041 Ste 204 Ste 204 p 801.820.6169 Layton UT. 84040 Layton UT. 84040 Cardinal, Jennifer R PhD, p 801.935.4171 p 801.935.4946 BCBA Corry, Bradley BCBA Neurobehavioral Center for ABS Kids Docherty, Anna R PhD Edwards, Aanika LCSW Growth 2940 Church St University of Utah Health Resilient Solutions 327 W Gordon Ave Ste 204 291 S 200 W 1355 N Main St Ste 2 Layton UT. 84040 Farmington UT. 84025 Ste 1 Layton UT. 84041 p 801.935.4946 p 801.213.3200 Bountiful UT. 84010 p 801.683.1062 p 801.652.8992 Cummings, Tara BCBA Hospital Affiliation 415 S Medical Dr ABS Kids - University of Utah Hospital Edwards, Jennifer CMHC Ste A101 2940 Church St Jennifer S Edwards CMHC Bountiful UT. 84010 Ste 204 Dorsey Lamoreaux, Alina 1730 E 3100 N p 801.683.1062 Layton UT. 84040 LCSW Ste 2 p 801.935.4171 The OCD And Anxiety Layton UT. 84040 415 S Medical Dr Treatment Center p 801.200.3470 Ste D101 DK Counseling and 1459 N Main St Bountiful UT. 84010 Consulting Ste 100 Eldredge, David G LCSW p 801.683.1062 1290 S 500 W Bountiful UT. 84010 University of Utah Health Ste 300 p 801.298.2000 165 N University Ave Champlin, Timothy M CSW Bountiful UT. 84010 Farmington UT. 84025 Valley Behavioral Health p 435.757.9245 Downer, Tilly BCaBA p 801.213.8841 1785 E 1450 S ABS Kids Ste 380 Daich, Nathan G LCSW 2940 Church St Hospital Affiliation Clearfield UT. 84015 Aspire Counseling Ste 204 - Primary Childrens Hospital p 888.949.4864 2317 N Hill Field Rd Layton UT. 84040 Ste 103 p 801.935.4171 Elliott, Hannah LCSW Christensen, David F LMFT Layton UT. 84041 University of Utah Health Family Therapy Center of p 435.225.6520 Dufek, Brandi BCBA 165 N University Ave Utah ABS Kids Farmington UT. 84025 240 N East Promontory Dario, Joel S NP 2940 Church St p 801.213.8841 Ste 234 Valley Behavioral Health Ste 204 Farmington UT. 84025 1785 E 1450 S Layton UT. 84040 Ellis, John LMFT p 385.243.0012 Clearfield UT. 84015 p 801.935.4171 Cedar Psychiatry p 888.949.4864 2950 N Church St Christiansen, Benjamin D Dunham, Matthew G LCMHC Ste 101 PSYD Dastrup, Karen L LMFT Center for Growth and Layton UT. 84040 Tanner Memorial Clinic Valley Behavioral Health Potential p 801.369.8989 2121 N 1700 W 1785 E 1450 S 1785 E 1450 S Layton UT. 84041 Ste 300 Ste 250 Empey, Dallas PhD p 801.773.4840 Clearfield UT. 84015 Clearfield UT. 84015 240 N East Promontory p 888.949.4864 p 801.773.0535 Ste 200 890 N Heritage Park Blvd Farmington UT. 84025 Ste 104 De La Torre, Sandra BCBA Dunham Counseling Services p 801.644.9244 Layton UT. 84041 ABS Kids 283 N 300 W p 801.784.7605 2940 Church St Ste 501 England, Kimberly CMHC Ste 204 Kaysville UT. 84037 Alliant Behavioral Health Hospital Affiliation Layton UT. 84040 p 801.513.5694 of Utah LLC - Davis Hospital p 801.935.4171 255 N Adamswood Rd Dwyer, Molly M BCBA Layton UT. 84040 Connelly, Matthew R LMFT DeBerard, Michael S PhD Neurobehavioral Center For p 385.888.9040 Matthew R Connelly LMFT Advanced Spine and Pain Growth 2317 N Hill Field Rd Specialists 327 W Gordon Ave Evans, Lyndsey M PhD Ste 103 1600 W Antelope Dr Ste 2 Neurobehavioral Center for Layton UT. 84041 Layton UT. 84041 Layton UT. 84041 Growth p 801.525.4645 p 801.299.6824 p 801.683.1062 327 W Gordon Ave Ste 2 2363 N Hill Field Rd Devlin, Charissa BCBA 415 S Medical Dr Layton UT. 84041 Ste 7 ABS Kids Ste D101 p 801.683.1062 Layton UT. 84041 2940 Church St Bountiful UT. 84010 p 801.525.4645 Ste 204 p 801.683.1062 Layton UT. 84040 p 801.935.4171

62 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 415 S Medical Dr Froerer, Jared D LPC Goldberg, Annie BCBA Hales, Mark T LCSW Ste A101 Aspen Ridge Counseling ABS Kids 735 S 1750 W Bountiful UT. 84010 585 W 500 S 2940 Church St Syracuse UT. 84075 p 801.683.1062 Ste 200 Ste 204 p 801.389.2112 Bountiful UT. 84010 Layton UT. 84040 415 S Medical Dr p 801.990.4300 p 801.935.4946 Hall, Dustin J LCSW Ste D101 1459 N Main St Bountiful UT. 84010 Hospital Affiliation Goyal, Anu BCBA Bountiful UT. 84010 p 801.683.1062 - Mountain West Medical Neurobehavioral Center For p 801.706.7607 Center Growth Fitch, Mike LPC 327 W Gordon Ave Hamilton, Cari B CMHC Aspire Counseling and Gaines, Matthew M DO Ste 2 Tanner Memorial Clinic Consulting MountainStar Behavioral Layton UT. 84041 2121 N 1700 W 2317 N Hill Field Rd Health p 801.683.1062 Layton UT. 84041 Ste 7 630 Medical Dr p 801.773.4840 Layton UT. 84041 Bountiful UT. 84010 415 S Medical Dr p 801.660.0638 p 801.299.2200 Ste D101 Hampton, Kathryn M LCSW Bountiful UT. 84010 725 N 300 E Forsman, Monica CMHC Gardner, Monica L LMFT p 801.683.1062 Bountiful UT. 84010 Monica Forsman Inc 1199 S Main St p 801.698.6079 240 N E Promontory Ste 105 Green, Courtney BCBA Ste 200 Centerville UT. 84014 ABS Kids Hancock, Lacey LMHC Farmington UT. 84025 p 801.815.2112 2940 Church St Valley Behavioral Health p 801.604.5040 Ste 204 1785 E 1450 S Garlock, John T BCBA Layton UT. 84040 Ste 300 Fox, Bryanna BCBA ABS Kids p 801.935.4171 Clearfield UT. 84015 ABS Kids 2940 Church St p 888.949.4864 2940 Church St Ste 204 Gregory, Hillary Ste 204 Layton UT. 84040 The OCD And Anxiety Hansen, Brooke RN Layton UT. 84040 p 801.935.4946 Treatment Center Valley Behavioral Health p 801.935.4946 1459 N Main St 1785 E 1450 S Garrett-Baker, Amanda Ste 100 Ste 380 Francis, Gina D LCSW BCBA Bountiful UT. 84010 Clearfield UT. 84015 Francis Counseling Center ABS Kids p 801.298.2000 p 888.949.4864 82 E Antelope Dr 2940 Church St Layton UT. 84041 Ste 204 Guerrieri, Joseph BCBA Harding, Stephanie LCSW p 801.298.2000 Layton UT. 84040 ABS Kids Comprehensive p 801.935.4171 2940 Church St Psychological Services Franco, Jennifer LCSW Ste 204 2950 Church St Grandview Family Gibbs, Paula K MD Layton UT. 84040 Ste 101A Counseling University of Utah Health p 801.935.4946 Layton UT. 84040 1576 S 500 W 165 N University Ave p 801.483.1600 Ste 202 Farmington UT. 84025 Hackett, Emily J CMHC Bountiful UT. 84010 p 801.581.7951 Tanner Memorial Clinic Hargrave, Dina S CMHC p 801.406.9002 2121 N 1700 W Neurobehavioral Center for Hospital Affiliation Layton UT. 84041 Growth Freeman, Brenner L MD - University of Utah Hospital p 801.773.4840 415 S Medical Dr University of Utah Health Ste D101 165 N University Ave Gibson, Crystal BCBA Hadnagy-Roch, Alexis Bountiful UT. 84010 Farmington UT. 84025 ABS Kids BCBA p 801.683.1062 p 801.581.7951 2940 Church St ABS Kids Ste 204 2940 Church St Harmon, Jordan LCSW University Of Utah Health Layton UT. 84040 Ste 204 Cedar Psychiatry 291 S 200 W p 801.935.4946 Layton UT. 84040 2950 N Church St Farmington UT. 84025 p 801.935.4171 Ste 101 p 801.213.3200 Gloshen, Tonya S LCSW Layton UT. 84040 Serenity Counseling Hakes, Chris C LCSW p 801.369.8989 Hospital Affiliation Services Aspen Ridge Counseling - University of Utah Hospital 890 N Heritage Park Blvd 585 W 500 S Hospital Affiliation Ste 104 Ste 200 - Mountain View Hospital Freimer, Martin MD Layton UT. 84041 Bountiful UT. 84010 (UT) University of Utah Health p 801.556.8080 p 801.990.4300 - Utah Valley Hospital 291 S 200 W Farmington UT. 84025 p 801.213.3200

Hospital Affiliation - Salt Lake Regional Medical Center - University of Utah Hospital 63 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Harris, Kaitlyn BCBA Hernandez, June Lee CMHC Hoff, Troy C DO,PhD Imus, Austin B DO ABS Kids Valley Behavioral Health University of Utah Health Austin B Imus DO 2940 Church St 1785 E 1450 S 291 S 200 W 1433 N 1075 W Ste 204 Clearfield UT. 84015 Farmington UT. 84025 Ste 120 Layton UT. 84040 p 888.949.4864 p 801.213.3200 Farmington UT. 84025 p 801.935.4946 p 801.923.8044 Hernandez, Kelsey A LCSW Hospital Affiliation Harrop, Elizabeth A APRN The OCD And Anxiety - University of Utah Hospital Jackson, Amanda LCSW Ascendant Behavioral Treatment Center Cedar Psychiatry Health 1459 N Main St Hoffman, Lindsey BCBA 2950 N Church St 1133 N Main Ste 100 ABS Kids Ste 101 Ste 128 Bountiful UT. 84010 2940 Church St Layton UT. 84040 Layton UT. 84041 p 801.298.2000 Ste 204 p 801.369.8989 p 801.872.5516 Layton UT. 84040 Kelsey A Hernandez CMHC p 801.935.4946 Jackson, Melanie LCSW Alliant Behavioral Health 2317 N Hill Field Rd Resilient Solutions Inc of Utah LLC Ste 103 Holmes, Cody LPC 1355 N Main St 255 N Adamswood Rd Layton UT. 84041 The OCD And Anxiety Ste 1 Layton UT. 84040 p 801.896.7559 Treatment Center Bountiful UT. 84010 p 385.888.9040 1459 N Main St p 801.721.1013 Hess, Leeanne M LCSW Ste 100 Hatch, J S PsyD University of Utah Health Bountiful UT. 84010 Jacobs, Victoria FNP University of Utah Health 291 S 200 W p 801.298.2000 Valley Behavioral Health 291 S 200 W Farmington UT. 84025 1785 E 1450 S Farmington UT. 84025 p 801.213.3200 Hood, Tonya M APRN Ste 300 p 801.213.3200 Tonya Hood PMHNP LLC Clearfield UT. 84015 Hospital Affiliation 283 N 300 W p 888.949.4864 Hospital Affiliation - University of Utah Hospital Ste 501 - University of Utah Hospital Kaysville UT. 84037 Jacobsen, Maren BCBA Hicks, Kenneth BCBA p 801.513.1569 ABS Kids Hawkins, Jeffrey BCBA ABS Kids 2940 Church St ABS Kids 2940 Church St Hooton, Amy BCBA Ste 204 2940 Church St Ste 204 ABS Kids Layton UT. 84040 Ste 204 Layton UT. 84040 2940 Church St p 801.935.4946 Layton UT. 84040 p 801.935.4946 Ste 204 p 801.935.4946 Layton UT. 84040 Jaramillo, Leah LMFT Higgins, Michael P LCSW p 801.935.4171 The OCD And Anxiety Hayes, Christa J BCBA University of Utah Health Treatment Center ABS Kids 165 N University Ave Howick, Brennan P CSW 1459 N Main St 2940 Church St Farmington UT. 84025 Valley Behavioral Health Ste 100 Ste 204 p 801.213.8841 1785 E 1450 S Bountiful UT. 84010 Layton UT. 84040 Ste 300 p 801.298.2000 p 801.935.4171 26 S Main St Clearfield UT. 84015 Centerville UT. 84014 p 888.949.4864 Javellana, Carmela md Heath, Nicholas BCBA p 801.693.7900 Neurobehavioral Center for ABS Kids Hughes, Kathryn M LCSW Growth 2940 Church St Hitesman, Jennilyn BCBA Grandview Family 415 S Medical Dr Ste 204 iBehave Therapy Group Counseling Ste A101 Layton UT. 84040 2985 N 935 E 1576 S 500 W Bountiful UT. 84010 p 801.935.4171 Ste 7 Ste 202 p 801.683.1062 Layton UT. 84040 Bountiful UT. 84010 Henshaw, Brandon J BCBA p 801.771.0273 p 801.406.9002 415 S Medical Dr Neurobehavioral Center for Ste D101 Growth Hobby, Esperanza A LMFT Hurst, Shane F LMFT Bountiful UT. 84010 327 W Gordon Ave Valley Behavioral Health Hurst Counseling p 801.683.1062 Ste 2 1785 E 1450 S 2317 N Hill Field Rd Layton UT. 84041 Ste 300 Ste 103 Jensen, Jill CSW p 801.683.1062 Clearfield UT. 84015 Layton UT. 84041 The OCD And Anxiety p 888.949.4864 p 801.668.8650 Treatment Center 415 S Medical Dr 1459 N Main St Ste D101 Hodgkin, Cameron BCBA 2363 N Hill Field Rd Ste 100 Bountiful UT. 84010 ABS Kids Ste S Bountiful UT. 84010 p 801.683.1062 2940 Church St Layton UT. 84041 p 801.298.2000 Ste 204 p 801.668.8650 Layton UT. 84040 p 801.935.4946

64 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Jensen, Melissa BCBA ABS Kids Kinikini, Karson S CMHC Leggitt, Valerie LCSW ABS Kids 2940 Church St K2 Counseling & Consulting Aspen Ridge Counseling 2940 Church St Ste 204 1730 E 3100 N 585 W 500 S Ste 204 Layton UT. 84040 Ste 2 Ste 200 Layton UT. 84040 p 801.935.4946 Layton UT. 84040 Bountiful UT. 84010 p 801.935.4946 p 801.525.4645 p 801.990.4300 Jones, Tonya BCBA Jensen, Tyson LCSW ABS Kids 2317 N Hill Field Rd Lentchner, Kari BCBA Aspen Ridge Counseling 2940 Church St Ste 103 ABS Kids 585 W 500 S Ste 204 Layton UT. 84041 2940 Church St Ste 200 Layton UT. 84040 p 801.525.4645 Ste 204 Bountiful UT. 84010 p 801.935.4171 Layton UT. 84040 p 801.990.4300 2363 N Hill Field Rd p 801.935.4946 K2 Counseling & Consulting Ste 5 Johnson, Clark MD 1730 E 3100 N Layton UT. 84041 Lewis, Gina Adult Behavioral Health Ste 2 p 801.628.5577 Adult Behavioral Health Unit Davis - IP Layton UT. 84040 Unit Davis - IP 1600 W Antelope Dr p 801.525.4645 Kirschner, Rebecca CMHC 1600 W Antelope Dr Layton UT. 84041 Valley Behavioral Health Layton UT. 84041 p 801.350.4253 2317 N Hill Field Rd 1785 E 1450 S p 801.350.4253 Ste 103 Ste 300 Hospital Affiliation Layton UT. 84041 Clearfield UT. 84015 Lopes, Erika BCBA - Davis Hospital p 801.525.4645 p 888.949.4864 ABS Kids 2940 Church St Johnson, Lisa LCSW 2363 N Hill Field Rd Klinkefus, Nick BCBA Ste 204 Lisa D.S. Johnson, LLC Ste 5 ABS Kids Layton UT. 84040 2317 N Hill Field Rd Layton UT. 84041 2940 Church St p 801.935.4171 Ste 103 p 801.628.5577 Ste 204 Layton UT. 84041 Layton UT. 84040 Lopez, Marta LCSW p 801.388.2219 Kaloudis, Kathleen M CMHC p 801.935.4946 University of Utah Health 189 S State St 165 N University Ave Jones, Heather C LCSW Ste 230 Knapp, Jaclyn K LPC Farmington UT. 84025 University of Utah Health Clearfield UT. 84015 Davis Mental Health p 801.213.3200 291 S 200 W p 801.201.7050 415 Medical Dr D101 Farmington UT. 84025 Bountiful UT. 84010 26 S Main St p 801.213.3200 Kay, Steven J PSYD p 801.643.5225 Centerville UT. 84014 Kay Psychological & p 801.693.7900 Hospital Affiliation Consulting PC Kohler, Shawn J MD - University of Utah Hospital 1601 N Hill Field Rd University of Utah Health Hospital Affiliation Layton UT. 84041 291 S 200 W - University of Utah Hospital Jones, Lachelle LCSW p 801.776.1303 Farmington UT. 84025 Wasatch Pediatrics - p 801.213.3200 Loveland, Matthew T LCSW Farmington Kay, Theresa S PhD New Directions Counseling 491 W Bourne Cir Kay Psychological & Hospital Affiliation 31 W Ctr St Farmington Fields Bldg 1 Consulting PC - University of Utah Hospital Kaysville UT. 84037 Farmington UT. 84025 1601 N Hill Field Rd p 801.660.5557 p 801.939.9111 Layton UT. 84041 Kramer, Andrea BCBA p 801.776.1303 ABS Kids Lunt, Andrea LMFT Wasatch Pediatrics - 2940 Church St Resilient Solutions Bountiful (Grow Up Great) Kearl, Denise E Ste 204 1355 N Main St 620 E Medical Dr DK Counseling and Layton UT. 84040 Ste 1 Ste 100 Consulting p 801.935.4946 Bountiful UT. 84010 Bountiful UT. 84010 1290 S 500 W p 801.815.1269 p 801.295.2888 Ste 300 Lancaster, Steven LCSW Bountiful UT. 84010 Solstone Counseling Mack, Kimberly LCSW Jones, Lisa PhD p 435.757.9245 1353 N 1075 W Ascendant Behavioral Lisa Jones, PhD Ste 204 Health 1433 N 1075 W Kennedy, Courtney BCBA Farmington UT. 84025 1133 N Main Ste 120 ABS Kids p 385.280.2384 Ste 128 Farmington UT. 84025 2940 Church St Layton UT. 84041 p 385.399.3696 Ste 204 University of Utah Health p 801.872.5516 Layton UT. 84040 291 S 200 W p 801.935.4171 Farmington UT. 84025 p 801.213.3200

65 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Madsen, Sara BCBA Mason, Gregory A LPC Meier, Heather BCBA Morris, Tracee BCBA ABS Kids New Vision Counseling ABS Kids ABS Kids 2940 Church St Center 2940 Church St 2940 Church St Ste 204 475 N 300 W Ste 204 Ste 204 Layton UT. 84040 Ste 14, Kaysville Layton UT. 84040 Layton UT. 84040 p 801.935.4946 Professional Pl p 801.935.4171 p 801.935.4946 Kaysville UT. 84037 Maestas, Rio CSW p 801.690.3502 Mendoza, Emily BCaBA Moulton, David L MD The OCD And Anxiety ABS Kids University of Utah Health Treatment Center Mathis, Nicholas CMHC 2940 Church St 291 S 200 W 1459 N Main St Neurobehavioral Center For Ste 204 Farmington UT. 84025 Ste 100 Growth Layton UT. 84040 p 801.213.3200 Bountiful UT. 84010 327 W Gordon Ave p 801.935.4946 p 801.298.2000 Ste 2 Hospital Affiliation Layton UT. 84041 Merrill, Jordan W MD - University of Utah Hospital Makowski, Alexandra BCBA p 801.683.1062 University of Utah Health ABS Kids 291 S 200 W Mower, Richard K PhD 2940 Church St Neurobehavioral Center for Farmington UT. 84025 Richard King Mower Ste 204 Growth p 801.213.3200 505 S Main St Layton UT. 84040 415 S Medical Dr Bountiful UT. 84010 p 801.935.4171 Ste D101 Milligan, Margaret LCSW p 801.292.6101 Bountiful UT. 84010 Wasatch Pediatrics - Malone, Sara BCBA p 801.683.1062 Farmington Moyle, Natalie LMHC ABS Kids 491 W Bourne Cir Stepstone Connect 2940 Church St Mattingly, Mary BCBA Farmington Fields Bldg 1 837 S 500 W Ste 204 ABS Kids Farmington UT. 84025 Ste 102 Layton UT. 84040 2940 Church St p 801.939.9111 Bountiful UT. 84010 p 801.935.4171 Ste 204 p 801.888.3843 Layton UT. 84040 Wasatch Pediatrics - Mansour, Emma PhD p 801.935.4946 Bountiful (Grow Up Great) Mullaney, Edward LCSW Life Matters: Counseling 620 E Medical Dr University of Utah Health and Psychological Services McFadden, Molly Q LCSW Ste 100 165 N University Ave 1433 N 1075 W University of Utah Health Bountiful UT. 84010 Farmington UT. 84025 Ste 120 26 S Main St p 801.295.2888 p 801.213.8841 Farmington UT. 84025 Centerville UT. 84014 p 801.483.2447 p 801.693.7900 Milne, Wade O LCSW 26 S Main St University of Utah Health Centerville UT. 84014 Manwaring, Todd LCSW McFarland, Maryanne LCSW 291 S 200 W p 801.693.7900 The OCD And Anxiety LeafCrest Counseling Farmington UT. 84025 Treatment Center 506 S Main p 801.213.3200 Murphy, H Nicole BCBA 1459 N Main St Ste 100 ABS Kids Ste 100 Bountiful UT. 84010 Hospital Affiliation 2940 Church St Bountiful UT. 84010 p 801.510.6864 - St George Regional Hospital Ste 204 p 801.298.2000 Layton UT. 84040 Medina-Salvatore, Nicole Moosman, Julie BCBA p 801.935.4946 Marcum, James M MD PSYD ABS Kids Cedar Psychiatry Neurobehavioral Center for 2940 Church St Murray, Lillie LCSW 2950 N Church St Growth Ste 204 Quantum Counseling Ste 101 327 W Gordon Ave Layton UT. 84040 2317 N Hill Field Rd Layton UT. 84040 Ste 2 p 801.935.4946 Ste 103 p 801.369.8989 Layton UT. 84041 Layton UT. 84041 p 801.683.1062 Morrell-Hughes, Barbara p 801.674.9516 Margolis, Amber LCSW LCSW University of Utah Health 415 S Medical Dr 327 W Gordon Ave Navas, Barbara BCBA 165 N University Ave Ste A101 Ste 2 ABS Kids Farmington UT. 84025 Bountiful UT. 84010 Layton UT. 84041 2940 Church St p 801.213.3200 p 801.683.1062 p 801.726.1388 Ste 204 Layton UT. 84040 26 S Main St Neurobehavioral Center For Morris, Josh Phd p 801.935.4946 Centerville UT. 84014 Growth University Of Utah Health p 801.693.7900 415 S Medical Dr 291 S 200 W Negrette, Michael A LMFT Ste D101 Farmington UT. 84025 NCS Bountiful UT. 84010 p 801.213.3200 475 N 300 W p 801.683.1062 Ste 14 Hospital Affiliation Kaysville UT. 84037 - University of Utah Hospital p 801.390.3210

66 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Nelson, Michelle M LCSW Northup, Kathryn BCBA Page, Tricia CMHC 415 S Medical Dr University of Utah Health ABS Kids The OCD And Anxiety Ste D101 165 N University Ave 2940 Church St Treatment Center Bountiful UT. 84010 Farmington UT. 84025 Ste 204 1459 N Main St p 801.683.1062 p 801.213.3200 Layton UT. 84040 Ste 100 p 801.935.4171 Bountiful UT. 84010 Pedersen, Tamera CMHC 26 S Main St p 801.298.2000 Resilient Solutions Centerville UT. 84014 OQuinn, Casey L BCBA 1355 N Main St p 801.693.7900 Neurobehavioral Center for Pagel, Kristen L MD Ste 1 Growth University of Utah Health Bountiful UT. 84010 Hospital Affiliation 327 W Gordon Ave 291 S 200 W p 801.718.2559 - University of Utah Hospital Ste 2 Farmington UT. 84025 Layton UT. 84041 p 801.213.3200 Perovich, John D PhD Newberry, Diana L LCSW p 801.683.1062 Center for Growth and Heritage Counseling, PLLC Hospital Affiliation Potential 1747 Heritage Ln 415 S Medical Dr - University of Utah Hospital 1785 E 1450 S Ste B103 Ste D101 Ste 250 Syracuse UT. 84075 Bountiful UT. 84010 Painter, Lindsey CSW Clearfield UT. 84015 p 801.525.6975 p 801.683.1062 The OCD And Anxiety p 801.773.0535 Treatment Center Newbold, David PhD OReilly, Laree C MSW 1459 N Main St Perry, Jill PSYD David Newbold & Associates Neurobehavioral Center for Ste 100 Bullock Psychological 370 S 500 E Growth Bountiful UT. 84010 Services Ste 180 327 W Gordon Ave p 801.298.2000 240 N East Promontory Clearfield UT. 84015 Ste 2 Ste 200 p 801.776.1954 Layton UT. 84041 Palmer, Derick CMHC Farmington UT. 84025 p 801.683.1062 Stepstone Connect p 801.923.1366 Newman, Felicia BCBA 837 S 500 W ABS Kids 415 S Medical Dr Ste 102 Waves of Change Counseling 2940 Church St Ste D101 Bountiful UT. 84010 375 N Main St Ste 204 Bountiful UT. 84010 p 801.888.3843 Ste 202 Layton UT. 84040 p 801.683.1062 Kaysville UT. 84037 p 801.935.4171 Paredes-Mora, Rocio F p 385.231.1500 Ogden, Stephanie BCBA LCSW Nicols, Jenissa BCBA ABS Kids RPM Counseling Services Peterson, Paul J LCSW ABS Kids 2940 Church St 845 S Main St The OCD And Anxiety 2940 Church St Ste 204 Ste C-5 Treatment Center Ste 204 Layton UT. 84040 Bountiful UT. 84010 1459 N Main St Layton UT. 84040 p 801.935.4171 p 801.554.2554 Ste 100 p 801.935.4946 Bountiful UT. 84010 Ortiz-Perez, Marco BCBA Parker, Cindie LCSW p 801.298.2000 Nielsen, F Ann LCSW ABS Kids 236 W 1400 N Ann Nielsen, MSW, LCSW 2940 Church St Bountiful UT. 84010 Pickering, Jaclyn BCBA 1433 N 1075 W Ste 204 p 801.309.8170 Neurobehavioral Center for Ste 120 Layton UT. 84040 Growth Farmington UT. 84025 p 801.935.4171 Parsons, Rita M BCBA 327 W Gordon Ave p 801.520.0073 ABS Kids Ste 2 Ossip, Elizabeth LCSW 2940 Church St Layton UT. 84041 Nielsen, Natalie A LCSW Stepstone Connect Ste 204 p 801.683.1062 Tranquility of Mind 837 S 500 W Layton UT. 84040 2363 N Hill Field Rd Ste 102 p 801.935.4171 415 S Medical Dr Ste 6 Bountiful UT. 84010 Ste D101 Layton UT. 84041 p 801.888.3843 Paul, Derai LCSW Bountiful UT. 84010 p 801.928.8973 DP Counseling p 801.683.1062 Ossmen, Caitlin BCBA 2363 N Hill Field Rd Nordello, Nicole E BCBA ABS Kids Ste 7 Plautz, Hailey C BCBA iBehave Therapy Group 2940 Church St Layton UT. 84041 Neurobehavioral Center For 2985 N 935 E Ste 204 p 801.589.1822 Growth Ste 7 Layton UT. 84040 327 W Gordon Ave Layton UT. 84040 p 801.935.4171 Paz, Corinna G BCBA Ste 2 p 801.771.0273 Neurobehavioral Center for Layton UT. 84041 Ossmen, Jordan BCBA Growth p 801.683.1062 ABS Kids 327 W Gordon Ave 2940 Church St Ste 2 Ste 204 Layton UT. 84041 Layton UT. 84040 p 801.683.1062 p 801.935.4946

67 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 415 S Medical Dr Robison, Reid J MD 415 S Medical Dr Scott, Dennis M LCSW Ste D101 Cedar Psychiatry Ste D101 1454 N Hillfield Rd Bountiful UT. 84010 2950 N Church St Bountiful UT. 84010 Ste 1 p 801.683.1062 Ste 101 p 801.683.1062 Layton UT. 84041 Layton UT. 84040 p 801.593.6000 Plummer, Kristine LCSW p 801.369.8989 Russett, Ebbie I CMHC Resilient Solutions Inc Valley Behavioral Health Scoville, Stephen L FNP-C 1355 N Main St Hospital Affiliation 1785 E 1450 S Life Spring Pain Ste 1 - Mountain View Hospital Clearfield UT. 84015 Management Bountiful UT. 84010 (UT) p 888.949.4864 275 W 200 N p 801.336.6363 - Utah Valley Hospital Ste 7 Salais Roden, Teresa S Kaysville UT. 84037 Porschatis, Amber M LCSW Robles, Richard BCBA LCSW p 801.546.1300 University of Utah Health ABS Kids Salais Counseling 165 N University Ave 2940 Church St 2363 N Hill Field Rd Seiler, Edward A CMHC Farmington UT. 84025 Ste 204 Ste 6 Valley Behavioral Health p 801.213.3200 Layton UT. 84040 Layton UT. 84041 1785 E 1450 S p 801.935.4946 p 801.525.4645 Ste 300 26 S Main St Clearfield UT. 84015 Centerville UT. 84014 Rogers, Jennifer PSYD Sanders, Bart p 888.949.4864 p 801.693.7900 ABS Kids Adult Behavioral Health 2940 Church St Unit Davis - IP Sharifan, Tara PSYD Prescott, Ashley LCMHC Ste 204 1600 W Antelope Dr Busy Bee Pediatrics Aspen Ridge Counseling Layton UT. 84040 Layton UT. 84041 520 E Medical Dr 585 W 500 S p 801.935.4946 p 801.350.4253 Ste 301 Ste 200 Bountiful UT. 84010 Bountiful UT. 84010 Rogers, Kate Phd Hospital Affiliation p 801.292.1464 p 801.990.4300 The OCD And Anxiety - Davis Hospital Treatment Center Shields, Haley B BCBA Ranks, Georgann LPC 1459 N Main St Sands, Allison BCBA ABS Kids Alliant Behavioral Health Ste 100 ABS Kids 2940 Church St of Utah LLC Bountiful UT. 84010 2940 Church St Ste 204 255 N Adamswood Rd p 801.298.2000 Ste 204 Layton UT. 84040 Layton UT. 84040 Layton UT. 84040 p 801.935.4171 p 385.888.9040 Rosado, Leah BCBA p 801.935.4171 ABS Kids Shumway, Luisa BCBA Ringger, Brett BCBA 2940 Church St Sathiyanathan, Nisha ABS Kids ABS Kids Ste 204 LCSW 2940 Church St 2940 Church St Layton UT. 84040 The OCD And Anxiety Ste 204 Ste 204 p 801.935.4946 Treatment Center Layton UT. 84040 Layton UT. 84040 1459 N Main St p 801.935.4171 p 801.935.4946 Roskelley, Hannah BCBA Ste 100 ABS Kids Bountiful UT. 84010 Sill, Lynne LCSW Ringold, Patricia LPC 2940 Church St p 801.298.2000 The OCD And Anxiety Alliant Behavioral Health Ste 204 Treatment Center of Utah LLC Layton UT. 84040 Schifano, Brytni BCBA 1459 N Main St 255 N Adamswood Rd p 801.935.4171 ABS Kids Ste 100 Layton UT. 84040 2940 Church St Bountiful UT. 84010 p 385.888.9040 Roth, Natalie PhD Ste 204 p 801.298.2000 ABS Kids Layton UT. 84040 Robertson, Russell LCSW 2940 Church St p 801.935.4946 Simancas (Monago), Reflections Counseling Ste 204 Letisia A BCBA 2317 N Hill Field Rd Layton UT. 84040 Schuknecht, Kelly BCBA ABS Kids Ste 103 p 801.935.4946 ABS Kids 2940 Church St Layton UT. 84041 2940 Church St Ste 204 p 801.690.0951 Russell Stamp, Mindy M Ste 204 Layton UT. 84040 PhD Layton UT. 84040 p 801.935.4171 Robinson, Jerianne BCBA Neurobehavioral Center for p 801.935.4946 ABS Kids Growth Sivertson, Savannah BCBA 2940 Church St 327 W Gordon Ave Schwebach, Adam PhD ABS Kids Ste 204 Ste 2 NeuroPsychology of Utah 2940 Church St Layton UT. 84040 Layton UT. 84041 275 N 300 W Ste 204 p 801.935.4171 p 801.683.1062 Ste 404 Layton UT. 84040 Kaysville UT. 84037 p 801.935.4171 p 801.614.5866

68 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Skibitsky, Jeffrey BCBA Stepstone Connect Taylor, Trevor D PSYD Titensor, Steven D LMFT ABS Kids 837 S 500 W Tanner Memorial Clinic Titensor Enterprises 2940 Church St Ste 102 1477 N 2000 W 2205 S 800 W Ste 204 Bountiful UT. 84010 Clearfield UT. 84015 Woods Cross UT. 84087 Layton UT. 84040 p 801.888.3843 p 801.773.4840 p 801.298.0336 p 801.935.4946 Stevenson, Victoria A 2121 N 1700 W Todd, Jessica J CMHC Skinner, Ageuda LCSW BCBA Layton UT. 84041 Neurobehavioral Center for 447 N 300 W ABS Kids p 801.773.4840 Growth Ste 6 2940 Church St 327 W Gordon Ave Kaysville UT. 84037 Ste 204 Tellesbo, Sarah M LCSW Ste 2 p 801.828.5189 Layton UT. 84040 Cedar Psychiatry Layton UT. 84041 p 801.935.4946 2950 N Church St p 801.683.1062 Smith, Ashlin BCBA Ste 101 ABS Kids Stotts, Jonas BCBA Layton UT. 84040 415 S Medical Dr 2940 Church St ABS Kids p 801.369.8989 Ste D101 Ste 204 2940 Church St Bountiful UT. 84010 Layton UT. 84040 Ste 204 Tenney, Joseph T LCSW p 801.683.1062 p 801.935.4171 Layton UT. 84040 Valley Behavioral Health p 801.935.4946 1785 E 1450 S Tracy, Robin CMHC Smith, Deanna LCSW Ste 300 Aspen Ridge Counseling The OCD And Anxiety Stringham, Karen Clearfield UT. 84015 585 W 500 S Treatment Center The OCD And Anxiety p 888.949.4864 Ste 200 1459 N Main St Treatment Center Bountiful UT. 84010 Ste 100 1459 N Main St Thatcher, Benjamin T DO p 801.990.4300 Bountiful UT. 84010 Ste 100 Valley Behavioral Health p 801.298.2000 Bountiful UT. 84010 1785 E 1450 S Traeden, Heather BCBA p 801.298.2000 Ste 300 Neurobehavioral Center for Smith, Hannah BCBA Clearfield UT. 84015 Growth ABS Kids Sugden, Steven G MD p 888.949.4864 327 W Gordon Ave 2940 Church St University of Utah Health Ste 2 Ste 204 291 S 200 W The OCD and Anxiety Layton UT. 84041 Layton UT. 84040 Farmington UT. 84025 Treatment Center p 801.683.1062 p 801.935.4946 p 801.213.3200 1459 N Main St Bountiful UT. 84010 415 S Medical Dr Sorenson, Cassie BCBA Hospital Affiliation p 801.298.2000 Ste D101 ABS Kids - University of Utah Hospital Bountiful UT. 84010 2940 Church St Thomas, Jonathon (JT) p 801.683.1062 Ste 204 Summit, Natalie LMHC BCBA Layton UT. 84040 Stepstone Connect ABS Kids Tucker, Richard L LCSW p 801.935.4171 837 S 500 W 2940 Church St Tucker Counseling Ste 102 Ste 204 1436 Legend Hills Dr Steed, Lisa M LCSW Bountiful UT. 84010 Layton UT. 84040 Ste 333 Resilient Solutions Inc p 801.888.3843 p 801.935.4171 Clearfield UT. 84015 1355 N Main St p 801.644.7129 Ste 1 Tabara, Jackqueline BCBA Thompson, Michael S LMFT Bountiful UT. 84010 ABS Kids Valley Behavioral Health Turner, Meghan BCBA p 801.259.3883 2940 Church St 1785 E 1450 S ABS Kids Ste 204 Ste 300 2940 Church St Stephens, Kaylie BCBA Layton UT. 84040 Clearfield UT. 84015 Ste 204 ABS Kids p 801.935.4946 p 888.949.4864 Layton UT. 84040 2940 Church St p 801.935.4946 Ste 204 Taylor, Amanda BCBA Thompson, Victoria LCSW Layton UT. 84040 ABS Kids Tanner Memorial Clinic Twu, Jesse p 801.935.4946 2940 Church St 1477 N 2000 W Adult Behavioral Health Ste 204 Clearfield UT. 84015 Unit Davis - IP Stephenson, Sue A CMHC Layton UT. 84040 p 801.773.4840 1600 W Antelope Dr Alliant Behavioral Health p 801.935.4946 Layton UT. 84041 of Utah LLC Thurgood, Brook BCBA p 801.350.4253 255 N Adamswood Rd Taylor, Mark BCBA ABS Kids Layton UT. 84040 ABS Kids 2940 Church St Hospital Affiliation p 385.888.9040 2940 Church St Ste 204 - Davis Hospital Ste 204 Layton UT. 84040 Layton UT. 84040 p 801.935.4946 p 801.935.4171

69 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Uckerman, Clifton R LCSW Wall, Nicole R CMHC Willard, Holly LCSW 415 S Medical Dr Ascendant Behavioral Resilient Solutions Inc Grandview Family Ste D101 Health 1355 N Main St Counseling Bountiful UT. 84010 1133 N Main Ste 1 1576 S 500 W p 801.683.1062 Ste 128 Bountiful UT. 84010 Ste 202 Layton UT. 84041 p 801.660.5233 Bountiful UT. 84010 Young, Jeanelle BCBA p 801.872.5516 p 801.406.9002 ABS Kids Wark, Heather MD 2940 Church St Valdez, Danielle LCSW Davis Behavioral Health Williams, Carley R BCBA Ste 204 University of Utah Health Unit - Layton iBehave Therapy Group Layton UT. 84040 26 S Main St 1600 W Antelope Dr 2985 N 935 E p 801.935.4946 Centerville UT. 84014 Layton UT. 84041 Ste 7 p 801.693.7900 p 801.807.1000 Layton UT. 84040 Zimmerman, Rita M CMHC p 801.771.0273 Neurobehavioral Center for Hospital Affiliation Wasatch Psychological Growth - University of Utah Hospital Services Williamson, Jessica CSW 327 W Gordon Ave 240 N East Promontory The OCD And Anxiety Ste 2 Van Leeuwen, Benjamin MD Ste 200 Treatment Center Layton UT. 84041 Tanner Memorial Clinic Farmington UT. 84025 1459 N Main St p 801.683.1062 2121 N 1700 W p 801.590.0525 Ste 100 Layton UT. 84041 Bountiful UT. 84010 415 S Medical Dr p 801.773.4840 Watson, Sandy K LCSW p 801.298.2000 Ste D101 466 N Main St Bountiful UT. 84010 Hospital Affiliation Ste 201C Winslow, Tatum BCBA p 801.683.1062 - Davis Hospital Clearfield UT. 84015 ABS Kids p 801.776.6906 2940 Church St Nephrology Verna, Christin LMFT Ste 204 Anand, Sanjiv MD Stepstone Connect Welling, Andrea CMHC Layton UT. 84040 Nephrology Associates of 837 S 500 W Espire Counseling Services p 801.935.4946 Utah Ste 102 2317 N Hill Field Rd 572 W 750 S Bountiful UT. 84010 Ste 103 Winward, Karen LPC Bountiful UT. 84010 p 801.888.3843 Layton UT. 84041 Valley Behavioral Health p 801.288.2634 p 801.525.4645 1785 E 1450 S Vezie, Linda LCSW Ste 300 Hospital Affiliation University of Utah Health Western, Shasta BCBA Clearfield UT. 84015 - Salt Lake Regional Medical 165 N University Ave ABS Kids p 888.949.4864 Center Farmington UT. 84025 2940 Church St - Jordan Valley Medical p 801.213.8841 Ste 204 Wise, Kirt D LCSW Center Layton UT. 84040 New Directions Counseling - St Marks Hospital 26 S Main St p 801.935.4946 Services Centerville UT. 84014 31 W Ctr St Assiago, Marcellus S MD p 801.693.7900 Weston, Sophia BCBA Kaysville UT. 84037 University of Utah Health ABS Kids p 801.660.5557 165 N University Ave Wagner, Brenna BCBA 2940 Church St Farmington UT. 84025 ABS Kids Ste 204 Wood, Felicia LCSW p 801.581.6709 2940 Church St Layton UT. 84040 Aspen Ridge Counseling Ste 204 p 801.935.4946 585 W 500 S 201 W Layton Pkwy Layton UT. 84040 Ste 200 Layton UT. 84041 p 801.935.4171 Whitlock, Megan J LCSW Bountiful UT. 84010 p 801.543.6000 University of Utah Health p 801.990.4300 Walker, David R CMHC 26 S Main St 2132 N Robins Dr Valley Behavioral Health Centerville UT. 84014 Woodard, Jeness L LCSW Ste 120 1785 E 1450 S p 801.693.7900 University of Utah Health Layton UT. 84041 Ste 300 165 N University Ave p 801.779.6106 Clearfield UT. 84015 Hospital Affiliation Farmington UT. 84025 p 888.949.4864 - University of Utah Hospital p 801.213.3200 532 S 500 W Bountiful UT. 84010 Wall, Ainsley C MSW Wilkes, Ryan W PSYD 26 S Main St p 801.299.3470 Aspire Counseling and Wasatch Psychological Centerville UT. 84014 Consulting Services p 801.693.7900 724 W 500 S 2317 N Hill Field Rd 240 N East Promontory Ste 300 Ste 103 Ste 200 Yarger, Jesse BCBA West Bountiful UT. 84087 Layton UT. 84041 Farmington UT. 84025 Neurobehavioral Center for p 801.296.9091 p 801.814.1074 p 801.590.0525 Growth 327 W Gordon Ave Ste 2 Layton UT. 84041 p 801.683.1062 70 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 942 S Main St Horowitz, Bruce L MD Lavasani, Tooran APRN Smith, Trevor R MD Layton UT. 84041 University of Utah Health University of Utah Health University of Utah Health p 801.593.9111 1600 W Antelope Dr 532 S 500 W 1600 W Antelope Dr Layton UT. 84041 Bountiful UT. 84010 Layton UT. 84041 Hospital Affiliation p 801.807.1000 p 801.299.3470 p 801.807.1000 - University of Utah Hospital - Davis Hospital 165 N University Ave 942 S Main St 201 W Layton Pkwy Farmington UT. 84025 Layton UT. 84041 Layton UT. 84041 Barklow, Jeff A MD p 801.593.9111 p 801.593.9111 p 801.543.6000 Nephrology Associates of Utah 201 W Layton Pkwy Hospital Affiliation 2132 N Robins Dr 572 W 750 S Layton UT. 84041 - University of Utah Hospital Ste 120 Bountiful UT. 84010 p 801.543.6000 Layton UT. 84041 p 801.288.2634 McDonald, Ryan P MD p 801.779.6106 532 S 500 W Kidney and Hypertension Hospital Affiliation Bountiful UT. 84010 Institute of Utah PLLC 532 S 500 W - St Marks Hospital p 801.299.3470 2132 N 1700 W Bountiful UT. 84010 - Jordan Valley Medical Ste 110 p 801.299.3470 Center West Valley Campus 942 S Main St Layton UT. 84041 - Salt Lake Regional Medical Layton UT. 84041 p 801.476.3400 724 W 500 S Center p 801.593.9111 Ste 300 Hospital Affiliation West Bountiful UT. 84087 Dantis Tan, Minerva NP Hospital Affiliation - Davis Hospital p 801.296.9091 Nephrology Associates of - University of Utah Hospital - Lakeview Hospital Utah - Davis Hospital - Ogden Regional Medical 942 S Main St 572 W 750 S Center Layton UT. 84041 Bountiful UT. 84010 Indahyung, Ruth M MD p 801.593.9111 p 801.288.2634 Nephrology Associates of Morris, Donald R MD Utah Nephrology Associates of Hospital Affiliation Dickson, Landon E MD 572 W 750 S Utah - University of Utah Hospital Nephrology Associates of Bountiful UT. 84010 572 W 750 S Utah p 801.288.2634 Bountiful UT. 84010 Tien, Dave MD 572 W 750 S p 801.288.2634 Nephrology Associates of Bountiful UT. 84010 Hospital Affiliation Utah p 801.288.2634 - St Marks Hospital Hospital Affiliation 572 W 750 S - Jordan Valley Medical - St Marks Hospital Bountiful UT. 84010 Hospital Affiliation Center - Jordan Valley Medical p 801.288.2634 - Salt Lake Regional Medical - Salt Lake Regional Medical Center West Valley Campus Center Center - Salt Lake Regional Medical Hospital Affiliation - Jordan Valley Medical Center - St Marks Hospital Center Jansen, Kevin MD - Jordan Valley Medical - St Marks Hospital Nephrology Associates of Patcha, Kishore MD Center West Valley Campus Utah University Of Utah Health - Salt Lake Regional Medical UUHC Centerville Clinic 572 W 750 S 1600 W Antelope Dr Center 26 S Main St Bountiful UT. 84010 Layton UT. 84041 Centerville UT. 84014 p 801.288.2634 p 801.807.1000 Yenchek, Robert H MD p 801.693.7900 University of Utah Health Hospital Affiliation 165 N University Ave 165 N University Ave Gopinath, Arasu MD - St Marks Hospital Farmington UT. 84025 Farmington UT. 84025 Nephrology Associates of - Jordan Valley Medical p 801.581.6709 p 801.581.6709 Utah Center West Valley Campus 572 W 750 S - Salt Lake Regional Medical 201 W Layton Pkwy 532 S 500 W Bountiful UT. 84010 Center Layton UT. 84041 Bountiful UT. 84010 p 801.288.2634 p 801.543.6000 p 801.299.3470 Lau, Sey M MD Hospital Affiliation Nephrology Associates of Qadir, Hammad MD 724 W 500 S - St Marks Hospital Utah Kidney and Hypertension Ste 300 - Jordan Valley Medical 572 W 750 S Institute of Utah PLLC West Bountiful UT. 84087 Center West Valley Campus Bountiful UT. 84010 2132 N 1700 W p 801.296.9091 - Salt Lake Regional Medical p 801.288.2634 Ste 110 Center Layton UT. 84041 942 S Main St Hospital Affiliation p 801.779.3500 Layton UT. 84041 - St Marks Hospital p 801.593.9111 - Jordan Valley Medical Hospital Affiliation Center West Valley Campus - Jordan Valley Medical Hospital Affiliation - Salt Lake Regional Medical Center - University of Utah Hospital Center - Jordan Valley Medical Center West Valley Campus - Salt Lake Regional Medical Center 71 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Neurology Nelson, Gary R MD Summerfield, Robert A MD Dailey, Andrew T MD Candee, Meghan S MD University of Utah Health Tanner Memorial Clinic University of Utah Health University of Utah Health 201 W Layton Pkwy 2121 N 1700 W 165 N University Ave 201 W Layton Pkwy Ste 3D Layton UT. 84041 Farmington UT. 84025 Ste 3D Layton UT. 84041 p 801.773.4840 p 801.581.6909 Layton UT. 84041 p 801.213.3599 p 801.213.3599 Hospital Affiliation Hospital Affiliation Hospital Affiliation - Davis Hospital - University of Utah Hospital Hospital Affiliation - University of Utah Hospital - University of Utah Hospital Zielinski, Brandon A Grandhi, Ramesh MD Rastogi, Komal MD MD,PhD University of Utah Health Filloux, Francis M MD Davis Multi-Specialty - University of Utah Health 1492 W Antelope Dr University of Utah Health Layton 201 W Layton Pkwy Ste 203 201 W Layton Pkwy 1492 W Antelope Dr Ste 3D Layton UT. 84041 Ste 3D Ste 203 Layton UT. 84041 p 801.773.7500 Layton UT. 84041 Layton UT. 84041 p 801.213.3599 p 801.213.3599 p 801.773.7800 Hospital Affiliation Hospital Affiliation - University of Utah Hospital Hospital Affiliation Hospital Affiliation - University of Utah Hospital - Primary Childrens Hospital - Davis Hospital Kendall, Richard W DO Neuropsychology University of Utah Health Frazier, Sara E PA Reichert, Walter H MD Christiansen, Benjamin D 165 N University Ave Tanner Memorial Clinic University of Utah Health PSYD Farmington UT. 84025 2121 N 1700 W 165 N University Ave Tanner Memorial Clinic p 801.213.6642 Layton UT. 84041 Farmington UT. 84025 2121 N 1700 W p 801.773.4840 p 801.585.6387 Layton UT. 84041 Hospital Affiliation p 801.773.4840 - Salt Lake Regional Medical Integrated Pain Hospital Affiliation Center Consultants - Jordan Valley Medical 890 N Heritage Park Blvd - University of Utah Hospital 890 W Heritage Park Blvd Center Ste 104 Ste 101 - Jordan Valley Medical Layton UT. 84041 Kilburg, Craig J MD Layton UT. 84041 Center West Valley Campus p 801.784.7605 University Of Utah Health p 801.689.3389 1600 W Antelope Dr Sadiq, Mohamed H MD Hospital Affiliation Layton UT. 84041 Juster Switlyk, Kelsey R Tanner Memorial Clinic - Davis Hospital p 801.807.1000 MD 2121 N 1700 W University of Utah Health Layton UT. 84041 Neurosurgery Hospital Affiliation 165 N University Ave p 801.773.4840 Bisson, Erica F MD - University of Utah Hospital Farmington UT. 84025 University of Utah Health p 801.581.6709 Hospital Affiliation 165 N University Ave Kura, Bhavani MD - Davis Hospital Farmington UT. 84025 University Of Utah Health Hospital Affiliation - Lakeview Hospital p 801.581.6909 1600 W Antelope Dr - University of Utah Hospital - Ogden Regional Medical Layton UT. 84041 Center Hospital Affiliation p 801.807.7140 Nelson, Alex J MD - University of Utah Hospital Advanced Spine and Pain Shoari, Mohammad MD Hospital Affiliation Specialists Davis Multi-Speciality Chavez, Juneyoung L MD - University of Utah Hospital 520 E Medical Dr Clinic University of Utah Health Ste 220 1492 W Antelope Dr 1492 W Antelope Dr Mazur, Marcus D MD Bountiful UT. 84010 Ste 203 Ste 203 University of Utah Health p 801.299.6824 Layton UT. 84041 Layton UT. 84041 165 N University Ave p 801.505.5370 p 801.773.7500 Farmington UT. 84025 Integrated Pain p 801.581.6909 Consultants Hospital Affiliation Hospital Affiliation 890 W Heritage Park Blvd - Salt Lake Regional Medical - University of Utah Hospital Hospital Affiliation Ste 101 Center - Davis Hospital - University of Utah Hospital Layton UT. 84041 - Jordan Valley Medical p 801.689.3389 Center Clyde, Brent L MD Smith, Bryson MD Wasatch Neurological Ogden Clinic - Utah Spine Hospital Affiliation Stakebake, Eric F PA-C Surgery PC 1916 N 700 W - Lakeview Hospital Glacier Peak Pain Care 3401 S Hwy 89 Ste 250 - Timpanogos Regional Hospital 1407 N 2000 W Bountiful UT. 84010 Layton UT. 84041 Ste G p 801.295.2438 p 801.479.0312 Clearfield UT. 84015 p 385.333.7123 Hospital Affiliation Hospital Affiliation - Davis Hospital - Ogden Regional Medical - Evanston Regional Hospital Center - Davis Hospital 72 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Taussky, Philipp MD Feige, Jennifer MD Hill, Audra MD Meek, Steven C MD University of Utah Health University of Utah Health University of Utah Health Tanner Memorial Clinic 1492 W Antelope Dr 165 N University Ave 165 N University Ave 2121 N 1700 W Ste 203 Farmington UT. 84025 Farmington UT. 84025 Layton UT. 84041 Layton UT. 84041 p 801.213.3200 p 801.587.1950 p 801.773.4840 p 801.773.7500 Hospital Affiliation Hospital Affiliation Hospital Affiliation Hospital Affiliation - Salt Lake Regional Medical - University of Utah Hospital - Davis Hospital - University of Utah Hospital Center - Davis Hospital Hurst, Craig L MD Merrell, Stephen C MD Ferguson, Daniel R MD 2132 N 1700 W Tanner Memorial Clinic Obstetrics And Gynecology Ogden Clinic Ste 300 444 W Bourne Cir Adelman, Marisa R MD 201 W Layton Pkwy Layton UT. 84041 Farmington UT. 84025 University of Utah Health Ste 420 p 801.774.8714 p 801.773.4840 165 N University Ave Layton UT. 84041 Farmington UT. 84025 p 801.475.3100 Hospital Affiliation Metz, Torri MD p 801.213.3200 - Davis Hospital University of Utah Health Hospital Affiliation - Ogden Regional Medical 165 N University Ave Hospital Affiliation - Salt Lake Regional Medical Center Farmington UT. 84025 - University of Utah Hospital Center p 801.213.3200 Johnson, Bryant L DO Archer, Cullen J MD Forrest, Sarah MD Tanner Memorial Clinic Miller, Ryan D DO Rocky Mountain Womens Rocky Mountain Womens 2121 N 1700 W Tanner Memorial Clinic Health Center Health Center Layton UT. 84041 2121 N 1700 W 1580 W Antelope Dr 1580 W Antelope Dr p 801.773.4840 Layton UT. 84041 Ste 290 Ste 280 p 801.773.4840 Layton UT. 84041 Layton UT. 84041 Johnson, Steven L MD p 801.776.0880 p 801.776.0880 Tanner Memorial Clinic Hospital Affiliation 2121 N 1700 W - Davis Hospital Arogyasami, Susan A MD 1580 W Antelope Dr Layton UT. 84041 - Lakeview Hospital Rocky Mountain Womens Ste 290 p 801.773.4840 Health Center Layton UT. 84041 Muscolino, Gina M MD 1580 W Antelope Dr p 801.773.7399 Hospital Affiliation Lakeview OB/GYN Clinic Ste 290 - Davis Hospital 620 E Medical Dr Layton UT. 84041 Hospital Affiliation Ste 340 p 801.776.0880 - Davis Hospital Larson, Alexander J MD Bountiful UT. 84010 Ogden Clinic p 801.299.2229 Hospital Affiliation Gerard, Claudia G CNM 201 W Layton Pkwy - Davis Hospital University of Utah Health Ste 420 Hospital Affiliation 165 N University Ave Layton UT. 84041 - Lakeview Hospital Blauer, Keith Farmington UT. 84025 p 801.475.3000 Reproductive Care Center p 801.581.4014 Ostler, Leslie A MD 1725 E 1450 S Hospital Affiliation University of Utah Health Ste 300 Hospital Affiliation - Ogden Regional Medical 165 N University Ave Clearfield UT. 84015 - University of Utah Hospital Center Farmington UT. 84025 p 801.784.5484 p 801.213.3200 Gordon, Carrie A MD Leavitt, Jarin K MD Boheen, Karen DO Ogden Clinic Tanner Memorial Clinic Hospital Affiliation Antelope Womens Center 201 W Layton Pkwy 2121 N 1700 W - St Marks Hospital 2132 N 1700 W Ste 4C Layton UT. 84041 Ste 300 Layton UT. 84041 p 801.773.4840 Porter, Ryan G MD Layton UT. 84041 p 801.475.3100 Lakeview OB/GYN Clinic p 801.728.0600 Hospital Affiliation 620 E Medical Dr Harker, Melani MD - Davis Hospital Ste 340 Hospital Affiliation University of Utah Health Bountiful UT. 84010 - Davis Hospital 165 N University Ave Martin, Jared C MD p 801.299.2229 - Ogden Regional Medical Farmington UT. 84025 Rocky Mountain Womens Center p 801.213.3200 Health Center Reproductive Care Center 1580 W Antelope Dr 1725 E 1450 S Empey, Ryan B MD Hospital Affiliation Ste 290 Ste 300 Lakeview OB/GYN Clinic - Salt Lake Regional Medical Layton UT. 84041 Clearfield UT. 84015 620 E Medical Dr Center p 801.776.0880 p 801.784.5484 Ste 340 Bountiful UT. 84010 Hospital Affiliation p 801.299.2229 - Davis Hospital

Hospital Affiliation - Jordan Valley Medical Center 73 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Riley, Tiffany PA-C Stevenson, Camille MD Cefalo, Aarone M OT *Duffin, Valerie J OT Shepard Creek OBGYN Tanner Memorial Clinic Ability Innovations Primary Childrens Rehab 670 W Shepard Ln 2121 N 1700 W 365 W 1550 N 201 W Layton Pkwy 3rd Fl Ste 103 Layton UT. 84041 Ste H Layton UT. 84041 Farmington UT. 84025 p 801.773.4840 Layton UT. 84041 p 801.543.6630 p 801.447.3377 p 801.618.7903 Hospital Affiliation Primary Childrens Hospital Hospital Affiliation - Davis Hospital Cohen, Rachel A OT 280 N Main St - Davis Hospital - Lakeview Hospital Ability Innovations Bountiful UT. 84010 365 W 1550 N p 801.662.4949 Rinne, Kirsti APRN Sullivan, Amy E MD Ste H University of Utah Health University of Utah Health Layton UT. 84041 Hospital Affiliation 165 N University Ave 165 N University Ave p 801.618.7903 - Primary Childrens Hospital Farmington UT. 84025 Farmington UT. 84025 p 801.213.4500 p 801.581.8425 Concentra Medical Centers Ellis, Zachery OTR/L 2086 N 1700 W Summit Hand Therapy Hospital Affiliation Hospital Affiliation Ste A 1448 N 2000 W - University of Utah Hospital - Davis Hospital Layton UT. 84041 Ste 7 - Salt Lake Regional Medical p 888.997.2669 Clinton UT. 84015 Rockenfield, Terra L PA Center p 801.773.2633 MountainStar Layton Family - University of Utah Hospital 2390 Redwood Rd Medicine West Valley City UT. 84419 1992 W Antelope Dr 2950 N Church St Sumsion, Kevin S MD p 888.997.2669 Ste 1-D Ste 200 Tanner Memorial Clinic Layton UT. 84041 Layton UT. 84040 2121 N 1700 W *Coyle, Taelor K OT p 801.773.2633 p 801.546.9441 Layton UT. 84041 Primary Childrens Rehab p 801.773.4840 201 W Layton Pkwy 3rd Fl *Falck, Mckenzie D OT Rynearson, Scott A DO Layton UT. 84041 Primary Childrens Rehab Ogden Clinic Hospital Affiliation p 801.543.6630 201 W Layton Pkwy 3rd FL 201 W Layton Pkwy - Davis Hospital Layton UT. 84041 Ste 420 280 N Main St p 801.543.6630 Layton UT. 84041 Occupational Therapy Bountiful UT. 84010 p 801.475.3000 *Altemus, Clara L OT p 801.662.4949 280 N Main St Primary Childrens Rehab Bountiful UT. 84010 Hospital Affiliation 201 W Layton Pkwy 3rd Fl Hospital Affiliation p 801.662.4949 - Ogden Regional Medical Layton UT. 84041 - Primary Childrens Hospital Center p 801.543.6630 *Fong, Jennifer OT DeLong, Samuel OT Primary Childrens Rehab Silver, Robert M MD Hospital Affiliation Summit Hand Therapy 201 W Layton Pkwy 3rd Fl University of Utah Health - Primary Childrens Hospital 1448 N 2000 W Layton UT. 84041 165 N University Ave Ste 7 p 801.543.6630 Farmington UT. 84025 *Browning, Stacey B OT Clearfield UT. 84015 p 801.581.8425 Primary Childrens Rehab p 801.773.2633 280 N Main St 201 W Layton Pkwy 3rd Fl Bountiful UT. 84010 Hospital Affiliation Layton UT. 84041 1551 S Renaissance Towne p 801.662.4949 - University of Utah Hospital p 801.543.6630 Dr - Davis Hospital Ste 440 Hospital Affiliation 280 N Main St Bountiful UT. 84010 - Primary Childrens Hospital Snider, Malorie MD Bountiful UT. 84010 p 801.773.2633 Tanner Memorial Clinic p 801.662.4949 *Halsey, Brynnan T OT 2121 N 1700 W 1992 W Antelope Dr Primary Childrens Rehab Layton UT. 84041 *Bubb, Nellie OT Ste 1-D 201 W Layton Pkwy 3rd Fl p 801.773.4840 Primary Childrens Rehab Layton UT. 84041 Layton UT. 84041 201 W Layton Pkwy 3rd Fl p 801.773.2633 p 801.543.6630 Spencer, Neil O MD Layton UT. 84041 Shepard Creek OBGYN p 801.543.6630 DeTemple, Kathrine M OT Jensen, Brian D OT 670 W Shepard Ln University of Utah Health Summit Hand Therapy Ste 103 280 N Main St 165 N University Ave 1448 N 2000 W Farmington UT. 84025 Bountiful UT. 84010 Farmington UT. 84025 Ste 7 p 801.447.3377 p 801.662.4949 p 801.213.3200 Clearfield UT. 84015 p 801.773.2633 Hospital Affiliation Burman-Newby, Sara OT Hospital Affiliation - Davis Hospital University of Utah Health - University of Utah Hospital - Ogden Regional Medical 165 N University Ave Center Farmington UT. 84025 p 801.213.3200

Hospital Affiliation - University of Utah Hospital 74 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 1992 W Antelope Dr *McQueen, Patrice OT *Smith, Katrina OT Insight Laser & Cataract Ste 1-D Primary Childrens Rehab Primary Childrens Rehab Eye Specialist Layton UT. 84041 201 W Layton Pkwy 201 W Layton Pkwy 2255 N 1700 W p 801.773.2633 Layton UT. 84041 Layton UT. 84041 Layton UT. 84041 p 801.543.6630 p 801.543.6630 p 801.773.0690 Keizer, Lana OT University of Utah Health 280 N Main St 280 N Main St Hospital Affiliation 165 N University Ave Bountiful UT. 84010 Bountiful UT. 84010 - University of Utah Hospital Farmington UT. 84025 p 801.662.4949 p 801.662.4949 - Davis Hospital p 801.213.3200 - St Marks Hospital *Pratt, Seth OT *Smith, Sarah OT *Kunkel, Mary K OT Primary Childrens Rehab Primary Childrens Rehab Oncology Primary Childrens Rehab 201 W Layton Pkwy 3rd Fl 201 W Layton Pkwy Gray, Carl R MD 201 W Layton Pkwy 3rd Fl Layton UT. 84041 Layton UT. 84041 Utah Hematology Oncology Layton UT. 84041 p 801.543.6630 p 801.543.6630 2132 N 1700 W p 801.543.6630 Ste 301 280 N Main St 280 N Main St Layton UT. 84041 280 N Main St Bountiful UT. 84010 Bountiful UT. 84010 p 801.775.9990 Bountiful UT. 84010 p 801.662.4949 p 801.662.4949 p 801.662.4949 Hospital Affiliation Hospital Affiliation Hospital Affiliation - Ogden Regional Medical Hospital Affiliation - Logan Regional Hospital - Primary Childrens Hospital Center - Primary Childrens Hospital - Davis Hospital Reynolds, Lacey B OT *Stauffer, Deborah A OT Larson, Jacob K OT Ability Innovations Primary Childrens Rehab Samuelson, Scott J MD Summit Hand Therapy 365 W 1550 N 201 W Layton Pkwy 3rd Fl Utah Cancer Specialists 1992 W Antelope Dr Layton UT. 84041 Layton UT. 84041 520 E Medical Dr Ste 1-D p 801.618.7903 p 801.543.6630 Ste 340 Layton UT. 84041 Bountiful UT. 84010 p 801.773.2633 *Robinson, Auston OT 280 N Main St p 801.296.6665 Primary Childrens Rehab Bountiful UT. 84010 Leslie, Leslye A OT 201 W Layton Pkwy 3rd Fl p 801.662.4949 Hospital Affiliation University of Utah Health Layton UT. 84041 - Jordan Valley Medical 165 N University Ave p 801.543.6630 Hospital Affiliation Center Farmington UT. 84025 - Primary Childrens Hospital - Davis Hospital p 801.213.3200 280 N Main St - Lakeview Hospital Bountiful UT. 84010 *Thompson, Robyn M OT - Salt Lake Regional Medical Hospital Affiliation p 801.662.4949 Primary Childrens Rehab Center - University of Utah Hospital 201 W Layton Pkwy 3rd Fl Ross, Kimberly M OT Layton UT. 84041 Stinnett, Jason M MD Manwill, Joel M OT University of Utah Health p 801.543.6630 Utah Cancer Specialists Childrens Ability Services 165 N University Ave 1492 W Antelope Dr LLC Farmington UT. 84025 280 N Main St Ste 1255 3080 N Fairfield Rd p 801.213.3200 Bountiful UT. 84010 Layton UT. 84041 Layton UT. 84041 p 801.662.4949 p 801.525.3022 p 801.390.4947 *Shackelford, Rachel *MOT,OTR/L Hospital Affiliation Hospital Affiliation 3327 N 1050 E Primary Childrens Rehab - Primary Childrens Hospital - Davis Hospital Layton UT. 84040 201 W Layton Pkwy 3rd Fl - Jordan Valley Medical p 801.390.4947 Layton UT. 84041 *Walker, Kristin D OT Center West Valley Campus p 801.543.6630 Primary Childrens Rehab - Lakeview Hospital McGiven, Ryan D OT 201 W Layton Pkwy 3rd Fl - Salt Lake Regional Medical Summit Hand Therapy 280 N Main St Layton UT. 84041 Center 1448 N 2000 W Bountiful UT. 84010 p 801.543.6630 Ste 7 p 801.662.4949 1492 W Antelope Dr Clearfield UT. 84015 280 N Main St Ste 125 p 801.773.2633 Sidwell, Nicholas K OT Bountiful UT. 84010 Layton UT. 84041 Ability Innovations p 801.662.4949 p 801.525.3022 1992 W Antelope Dr 365 W 1550 N Ste 1-D Layton UT. 84041 Oculoplastic Surgery Wei, Mei MD Layton UT. 84041 p 801.618.7903 Patel, Bhupendra C MD University of Utah Health p 801.773.2633 Davis Surgical Center 165 N University Ave 1544 W Antelope Dr Farmington UT. 84025 Layton UT. 84041 p 801.213.3200 p 801.773.0690 Hospital Affiliation - University of Utah Hospital

75 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Ophthalmology Hansen, Brock C MD Kwun, Robert MD Poll, Jed T MD Alldredge, Claron D MD Utah Eye Centers Retina Associates of Utah Utah Eye Centers Utah Eye Centers 214 W 1500 S 1660 W Antelope Dr 214 W 1500 S 214 W 1500 S Ste 300 Ste 325 Ste 300 Ste 300 Bountiful UT. 84010 Layton UT. 84041 Bountiful UT. 84010 Bountiful UT. 84010 p 801.476.0494 p 801.775.8222 p 801.476.0494 p 801.476.0494 Hospital Affiliation Hospital Affiliation Hospital Affiliation Hospital Affiliation - Ogden Regional Medical - St Marks Hospital - Lakeview Hospital - Ogden Regional Medical Center - Davis Hospital - Ogden Regional Medical Center Center - Davis Hospital Hess, Christian L MD Law, Nathan OD Insight Eye Specialists Mountain View Eye Center Richards, Trent D MD Anderson, Bradley J MD 2255 N 1700 W 1580 W Antelope Dr Tanner Memorial Clinic Utah Eye Centers Ste 100 Ste 175 2121 N 1700 W 214 W 1500 S Layton UT. 84041 Layton UT. 84041 Layton UT. 84041 Ste 300 p 801.773.0690 p 801.773.2233 p 801.773.4840 Bountiful UT. 84010 p 801.476.0494 Hospital Affiliation Hospital Affiliation Hospital Affiliation - Davis Hospital - Davis Hospital - Davis Hospital Brinton, Eric P MD Retina Associates of Utah Hill, Mark L MD Nelson, Laurence M MD Simpson, Rachel G MD 2132 N 1700 W Insight Eye Specialists Tanner Memorial Clinic University of Utah Health Ste 130 2255 N 1700 W 2121 N 1700 W 165 N University Ave Layton UT. 84041 Ste 100 Layton UT. 84041 Farmington UT. 84025 p 801.357.7999 Layton UT. 84041 p 801.773.4840 p 801.581.2352 p 801.773.0690 Brinton, Gregory S MD Hospital Affiliation Hospital Affiliation Retina Associates of Utah Hospital Affiliation - Davis Hospital - University of Utah Hospital 2132 N 1700 W - Davis Hospital Layton UT. 84041 Owen, Leah MD,PhD Swartz, Mano MD p 801.357.7999 Howard, James G MD University of Utah Health Retina Associates of Utah Retina Associates of Utah 165 N University Ave 1660 W Antelope Dr Hospital Affiliation 2132 N 1700 W Farmington UT. 84025 Ste 325 - St Marks Hospital Ste 130 p 801.581.2352 Layton UT. 84041 - Davis Hospital Layton UT. 84041 p 801.775.8222 p 801.357.7999 Hospital Affiliation Coombs, Peter G MD - University of Utah Hospital 2132 N 1700 W Utah Eye Centers Hospital Affiliation Ste 130 214 W 1500 S - St Marks Hospital Patel, Bhupendra C MD Layton UT. 84041 Ste 300 - Davis Hospital Davis Surgical Center p 801.775.8222 Bountiful UT. 84010 1544 W Antelope Dr p 801.476.0494 Jardine, Griffin J MD Layton UT. 84041 Treft, Robert L MD University of Utah Health p 801.773.0690 Mountain View Eye Center Hospital Affiliation 165 N University Ave 1580 W Antelope Dr - Ogden Regional Medical Farmington UT. 84025 Insight Laser & Cataract Ste 175 Center p 801.581.2352 Eye Specialist Layton UT. 84041 2255 N 1700 W p 801.773.2233 Daynes, Todd E MD Hospital Affiliation Layton UT. 84041 520 E Medical Dr - University of Utah Hospital p 801.773.0690 Hospital Affiliation Ste 201 - Davis Hospital Bountiful UT. 84010 Knudsen, Victoria M MD Hospital Affiliation p 801.294.8855 Retina Associates of Utah - University of Utah Hospital University of Utah Dept of 2132 N 1700 W - Davis Hospital Ophthalmology Hospital Affiliation Ste 130 - St Marks Hospital 1492 W Antelope - Lakeview Hospital Layton UT. 84041 Ste 150 - St Marks Hospital p 801.357.7999 Peterson, Jared MD Layton UT. 84041 - Mountain West Medical Mountain View Eye Center p 801.776.7804 Center Hospital Affiliation 1580 W Antelope Dr - St Marks Hospital Ste 175 Wallin, Trevin R MD Dries, David C MD - Davis Hospital Layton UT. 84041 Insight Eye Specialists University of Utah Health p 801.773.2233 2255 N 1700 W 165 N University Ave Ste 100 Farmington UT. 84025 Hospital Affiliation Layton UT. 84041 p 801.581.2352 - Davis Hospital p 801.773.0690

Hospital Affiliation Hospital Affiliation - University of Utah Hospital - Davis Hospital 76 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Washburn, Michael D MD Bateman, Camron J OD Helman, Andrew OD Millet, Curtis W OD Insight Eye Specialists Farmington Vision Clinic Standard Optical Standard Optical 2255 N 1700 W 57 N Main St 1076 Layton Hills Mall 81 N 2000 W Ste 100 Farmington UT. 84025 Ste 2090 Ste F1 Layton UT. 84041 p 801.447.4393 Layton UT. 84041 Clearfield UT. 84015 p 801.773.0690 p 801.546.0255 p 801.546.0255 Bruderer, Paul C OD Hospital Affiliation Tanner Memorial Clinic 140 W 500 S Morgan, Alan OD - Davis Hospital 2121 N 1700 W Bountiful UT. 84010 University of Utah Health Layton UT. 84041 p 801.292.0479 165 N University Ave Wilcox, Michael B MD p 801.773.4840 Farmington UT. 84025 Utah Eye Centers Holt, Justin C OD p 801.581.2352 214 W 1500 S David, James R OD West Point Eye Center Ste 300 Layton Visual Center 81 N 2000 W Myers, Rochelle A OD Bountiful UT. 84010 180 W Gordon Ave Ste F-1 Standard Optical p 801.476.0494 Ste E1 Clearfield UT. 84015 81 N 2000 W Layton UT. 84041 p 801.825.9732 Ste F1 Hospital Affiliation p 801.546.2481 Clearfield UT. 84015 - Lakeview Hospital Jensen, Denmark R OD p 801.546.0255 - Ogden Regional Medical Edmunds, Franklin M OD Layton Visual Center Center Standard Optical 180 W Gordon Ave Nickle, Chelle OD 81 N 2000 W Ste E1 Farmington Vision Clinic Wing, Robert W MD Ste F1 Layton UT. 84041 57 N Main St Utah Eye Centers Clearfield UT. 84015 p 801.546.2481 Farmington UT. 84025 214 W 1500 S p 801.546.0255 p 801.447.4393 Ste 300 Jepsen, Nolan OD Bountiful UT. 84010 Ellison, John N OD Mountain View Eye Center Nielsen, Victoria OD p 801.476.0494 Standard Optical 1580 W Antelope Dr Clinton Family Vision 1076 Layton Hills Mall Ste 175 2028 W 2220 N Hospital Affiliation Ste 2090 Layton UT. 84041 Clearfield UT. 84015 - Lakeview Hospital Layton UT. 84041 p 801.773.2233 p 801.779.0708 - Davis Hospital p 801.546.0255 Judkins, Michael M OD Pace, Daniel W OD Winward, Kirk E MD Farr, Devin B OD Clinton Family Vision Family Vision Care of Retina Associates of Utah Utah Eye Centers 1448 N 2000 W Bountiful 1660 W Antelope Dr 214 W 1500 S Ste 11 70 N Main St Ste 325 Ste 300 Clinton UT. 84015 Ste 102 Layton UT. 84041 Bountiful UT. 84010 p 801.779.0708 Bountiful UT. 84010 p 801.873.8462 p 801.476.0494 p 801.292.1408 Knowles, Duane C OD 2132 N 1700 W Fielden, Clark E OD Standard Optical Clinton Family Vision Ste 130 Clinton Family Vision 140 W 5th S 2028 W 2220 N Layton UT. 84041 1448 N 2000 W Bountiful UT. 84010 Clearfield UT. 84015 p 801.357.7999 Ste 11 p 801.292.0479 p 801.779.0708 Clearfield UT. 84015 Hospital Affiliation p 801.779.0708 81 N 2000 W Purdy, Russell OD - St Marks Hospital Ste F1 Standard Optical - Davis Hospital Gibson, Roy R OD Clearfield UT. 84015 1076 Layton Hills Mall 1055 W Hill Field Rd p 801.546.0255 Ste 2090 Zaugg, Brian E MD Layton UT. 84041 Layton UT. 84041 University of Utah Health p 801.444.7167 Kofoed, Lavar W OD p 801.546.0255 165 N University Ave The Eye Pros Farmington UT. 84025 The Eye Pros 1986 N Hill Field Rd 81 N 2000 W p 801.581.2352 1986 N Hill Field Rd Ste 5 Ste F1 Ste 5 Layton UT. 84041 Clearfield UT. 84015 Hospital Affiliation Layton UT. 84041 p 801.823.1530 p 801.546.0255 - University of Utah Hospital p 801.823.1530 Mannen, Megan OD Rees, Alan T OD Optometry Gummow, Alan B OD Clinton Family Vision 1706 N Heritage Park Blvd Allen, Scott OD Eye Site of Utah 2028 W 2220 N Ste 5 307 N 300 W 307 N 300 W Clearfield UT. 84015 Layton UT. 84041 Ste 302 Ste 302 p 801.779.0708 p 801.776.2020 Kaysville UT. 84037 Kaysville UT. 84037 p 801.444.9977 p 801.444.9977

77 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Roberts, Joshua OD UUHC Centerville Clinic 625 W 500 S 65 W 400 N Standard Optical 26 S Main St Ste 204 Ste 102 81 N 2000 W Centerville UT. 84014 Bountiful UT. 84010 Bountiful UT. 84010 Ste F1 p 801.693.7900 p 801.298.2242 p 801.299.8531 Clearfield UT. 84015 p 801.546.0255 Wilkes, Robert M OD Hospital Affiliation Hospital Affiliation Bountiful Eye Care - Davis Hospital - Ogden Regional Medical Schmitt, Marc L OD 140 S Main St - Lakeview Hospital Center Clinton Family Vision Bountiful UT. 84010 - Lakeview Hospital 2028 W 2220 N p 801.295.2020 Hall, Vance P DMD Clearfield UT. 84015 Oral & Maxillofacial Orthopedic Surgery p 801.779.0708 Wilkins, Court R OD Surgeons of Utah Chalmers, Peter N MD Utah Eye Centers 2297 N Hill Field Rd Bldg University of Utah Health Smith, Douglas R OD 214 W 1500 S A 165 N University Ave Bountiful Vision Plaza Ste 300 Ste 105 Farmington UT. 84025 311 E 500 S Bountiful UT. 84010 Layton UT. 84041 p 801.213.3200 Bountiful UT. 84010 p 801.476.0494 p 801.779.0506 p 801.295.4441 Hospital Affiliation Oral And Maxillofacial Surgery 65 W 400 N - University of Utah Hospital Standard Optical Mon-Fri Broadbent, Michael DMD Ste 102 10am-9pm Sat 9am-9pm Oral & Maxillofacial Bountiful UT. 84010 David W Stevens MD PC 1076 Layton Hills Mall Surgeons of Utah p 801.299.8531 1551 Renaissance Towne Dr Ste 2090 2297 N Hill Field Rd Bldg Ste 540 Layton UT. 84041 A Hospital Affiliation Bountiful UT. 84010 p 801.546.0255 Ste 105 - Ogden Regional Medical p 801.294.7246 Layton UT. 84041 Center Standard Optical Mon-Fri p 801.779.0506 Dee, Michael S MD 9am-7pm Sat 8am-5pm Jessen, Gregory S DDS Tanner Memorial Clinic 140 W 500 S 65 W 400 N 1448 N 2000 W 1750 E 3100 N Bountiful UT. 84010 Ste 102 Ste 12 Layton UT. 84040 p 801.292.0479 Bountiful UT. 84010 Clearfield UT. 84015 p 801.773.4840 p 801.299.8531 p 801.479.8201 Taylor, Mark A OD Hospital Affiliation Wasatch Eye & Optical Hospital Affiliation Hospital Affiliation - Davis Hospital 128 N Main St - Ogden Regional Medical - Ogden Regional Medical - Ogden Regional Medical Kaysville UT. 84037 Center Center Center p 801.543.2525 - Lakeview Hospital Liston, Todd DDS Donigan, Jonathan A MD 1792 W 1700 S Chandler, Jason G DMD Oral & Maxillofacial Tanner Memorial Clinic Ste 202 Oral & Maxillofacial Surgeons of Utah 2121 N 1700 W Syracuse UT. 84075 Surgeons of Utah 2297 N Hill Field Rd Bldg Layton UT. 84041 p 801.774.8707 2297 N Hill Field Rd Bldg A p 801.773.4840 A Ste 105 Tipton, Jeffrey P OD Ste 105 Layton UT. 84041 Hospital Affiliation Dr Jeffrey Tipton OD PC Layton UT. 84041 p 801.779.0506 - Davis Hospital 1632 N 2000 W p 801.779.0506 - Lakeview Hospital Clearfield UT. 84015 65 W 400 N p 801.779.3805 65 W 400 N Ste 102 Edwards, John C MD Ste 102 Bountiful UT. 84010 Mountain Orthopaedics Turner, Glen OD Bountiful UT. 84010 p 801.299.8531 1551 Renaissance Towne Dr The Eye Pros p 801.299.8531 Ste 400 1986 N Hill Field Rd Hospital Affiliation Bountiful UT. 84010 Ste 5 Hospital Affiliation - Ogden Regional Medical p 801.295.7200 Layton UT. 84041 - Ogden Regional Medical Center p 801.823.1530 Center - Lakeview Hospital Mountain Orthopedics - Lakeview Hospital 2086 N 1700 W UUHC Davis Center McCormick, Adam DDS Layton UT. 84041 1492 W Antelope DeDecker, Dennis L DDS Oral & Maxillofacial p 801.295.7200 Ste 150 2185 N 1700 W Surgeons of Utah Layton UT. 84041 Ste 204 2297 N Hill Field Rd Bldg Hospital Affiliation p 801.776.7804 Layton UT. 84041 A - Lakeview Hospital p 801.773.9790 Ste 105 - Davis Hospital Layton UT. 84041 p 801.392.7176

78 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. English, Christopher S MD Hess, Michael M MD Johnston, Eric C MD McQueen, Jordan R PA-C Mountain Orthopaedics Mountain Orthopedics Mountain Orthopaedics Hofmann Arthritis 1551 S Renaissance Towne 1551 Renaissance Towne Dr 1551 Renaissance Towne Dr Institute Dr Ste 400 Ste 400 1492 W Antelope Dr Ste 400 Bountiful UT. 84010 Bountiful UT. 84010 Ste 110 Bountiful UT. 84010 p 801.295.7200 p 801.295.7200 Layton UT. 84041 p 801.295.7200 p 801.355.6468 2086 N 1700 W 2086 N 1700 W 201 W Layton Pkwy Layton UT. 84041 Layton UT. 84041 Hospital Affiliation Ste 400 p 801.295.7200 p 801.295.7200 - Salt Lake Regional Medical Layton UT. 84041 Center p 801.295.7200 Hospital Affiliation Hospital Affiliation - Davis Hospital - Lakeview Hospital - Lakeview Hospital - Lone Peak Hospital Hospital Affiliation - Davis Hospital Hickman, Joshua M MD Kazmers, Nikolas H MD Mihlfeith, Catherine M - Lakeview Hospital Mountain Orthopaedics University of Utah Health PA-C 1551 Renaissance Towne Dr 165 N University Ave University of Utah Health Ferikes, Alex MD Ste 400 Farmington UT. 84025 165 N University Ave Davis Orthopedics And Bountiful UT. 84010 p 801.213.3200 Farmington UT. 84025 Sports Medicine - Clinton p 801.295.7200 p 801.213.8841 1407 N 2000 W Hospital Affiliation Ste F 2086 N 1700 W - University of Utah Hospital 26 S Main St Clinton UT. 84015 Layton UT. 84041 Centerville UT. 84014 p 801.773.3902 p 801.295.7200 Klatt, Joshua W MD p 801.693.7900 University of Utah Health Davis Orthopedics & Sports Hospital Affiliation 201 W Layton Pkwy Hospital Affiliation Medicine - Lakeview Hospital Ste 3B - University of Utah Hospital 2132 N 1700 W Layton UT. 84041 Ste 230 Hofmann, Aaron A MD p 801.662.5600 Mitchell, Chase MD Layton UT. 84041 Hofmann Arthritis Tanner Memorial Clinic p 801.773.3900 Institute Larsen, Kenna MD 1750 E 3100 N 1492 W Antelope Dr Tanner Memorial Clinic Layton UT. 84040 Heflin, John MD Ste 110 1750 E 3100 N p 801.773.4840 University of Utah Health Layton UT. 84041 Layton UT. 84040 201 W Layton Pkwy p 801.355.6468 p 801.773.4840 Hospital Affiliation Ste 3B - Davis Hospital Layton UT. 84041 Hospital Affiliation Hospital Affiliation p 801.662.5600 - University of Utah Hospital - Ogden Regional Medical Mock, Brady K MD - Davis Hospital Center Ogden Clinic - Davis Hendry, Travis M MD - Lone Peak Hospital - Davis Hospital Family Physicians Travis M Hendry MD - Salt Lake Regional Medical 3225 W Gordon Ave 1551 S Renaissance Towne Center Law, Jesua DO Ste 1 Dr Hofmann Arthritis Layton UT. 84041 Ste 400 Holmes, Stephanie M MD Institute p 801.397.6150 Bountiful UT. 84010 University of Utah Health 1492 W Antelope Dr p 801.295.7200 201 W Layton Pkwy Ste 110 Murray, R Pepper MD Ste 3B Layton UT. 84041 Mountain Orthopaedics 201 W Layton Pkwy Layton UT. 84041 p 801.355.6468 1551 Renaissance Towne Dr Ste 400 p 801.662.5600 Ste 400 Layton UT. 84041 Madsen, Wes Y MD Bountiful UT. 84010 p 801.295.7200 Hospital Affiliation Tanner Memorial Clinic p 801.295.7200 - University of Utah Hospital 2121 N 1700 W Hospital Affiliation Layton UT. 84041 2086 N 1700 W - Lakeview Hospital Huish, Steven B MD p 801.773.4840 Layton UT. 84041 - Ogden Regional Medical Mountain Orthopaedics p 801.295.7200 Center 1551 Renaissance Towne Dr Hospital Affiliation Ste 400 - Davis Hospital Hospital Affiliation Hennessey, Theresa A MD Bountiful UT. 84010 - Lakeview Hospital University of Utah Health p 801.295.7200 Mangiapani, Daniel 201 W Layton Pkwy Hofmann Arthritis Nickisch, Florian MD Ste 3B 2086 N 1700 W Institute University of Utah Health Layton UT. 84041 Layton UT. 84041 1492 W Antelope Dr 165 N University Ave p 801.662.5600 p 801.295.7200 Ste 110 Farmington UT. 84025 Layton UT. 84041 p 801.213.3200 Hospital Affiliation p 801.355.6468 - Lakeview Hospital Hospital Affiliation - Davis Hospital Hospital Affiliation - University of Utah Hospital - Davis Hospital 79 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Powell, Brian D MD Sumko, Daniel DO Woiczik, Marcella R MD Integrated Functional Mountain Orthopaedics Tanner Memorial Clinic University of Utah Health Medicine 1551 S Renaissance Towne 1750 E 3100 N 201 W Layton Pkwy 458 N 500 W Dr Layton UT. 84040 Ste 3B Bountiful UT. 84010 Ste 400 p 801.773.4840 Layton UT. 84041 p 801.292.9355 Bountiful UT. 84010 p 801.662.5600 p 801.295.7200 Hospital Affiliation Garg, Vikas MD - Davis Hospital Wooten, Clint J MD Advanced Spine and Pain Rice, Robert S MD Mountain Orthopaedics Specialists Tanner Memorial Clinic Svagr, Bohus MD 1551 S Renaissance Towne 1492 W Antelope Dr 2121 N 1700 W Tanner Memorial Clinic Dr Ste 110 Layton UT. 84041 2121 N 1700 W Ste 400 Layton UT. 84041 p 801.773.4840 Layton UT. 84041 Bountiful UT. 84010 p 801.299.6824 p 801.773.4840 p 801.295.7200 Hospital Affiliation 1600 W Antelope Dr - Davis Hospital Hospital Affiliation Yenna, Zachary MD Layton UT. 84041 - Lakeview Hospital - Davis Hospital Davis Orthopedics & Sports p 801.299.6824 Medicine - Clinton Saltzman, Charles L MD Thomas, Bruce E MD 1407 N 2000 W 520 E Medical Dr University of Utah Health Mountain View Orthopaedics Ste F Ste 100 201 W Layton Pkwy & Sports Medicine Clinton UT. 84015 Bountiful UT. 84010 Ste 3B 1477 N 2000 W p 801.773.3902 p 801.299.6824 Layton UT. 84041 Ste B p 801.662.5600 Clinton UT. 84015 Davis Orthopedics & Sports Hospital Affiliation p 801.475.5683 Medicine - Lone Peak Hospital Hospital Affiliation 2132 N 1700 W - Evanston Regional Hospital - University of Utah Hospital University of Utah Health Ste 230 - Brigham City Community 165 N University Ave Layton UT. 84041 Hospital Spina, Nicholas T MD Farmington UT. 84025 p 801.773.3900 University of Utah Health p 801.213.3200 Glacier Peak Pain Care 165 N University Ave Orthotics And Prosthetics 1407 N 2000 W Farmington UT. 84025 Hospital Affiliation Hanger Clinic Ste G p 801.213.3200 - Ogden Regional Medical 1660 W Antelope Dr Clearfield UT. 84015 Center Ste 120 p 385.333.7123 Hospital Affiliation Layton UT. 84041 - University of Utah Hospital Tyson, Jared J MD p 801.917.2870 Hooton, Kelly FNP-C Mountain Orthopaedics Life Spring Pain Stevens, David W MD 1551 S Renaissance Towne Pain Management Management David W Stevens MD PC Dr Baca, Kirsten MD 275 W 200 N 1551 Renaissance Towne Dr Ste 400 Glacier Peak Pain Care Ste 7 Ste 540 Bountiful UT. 84010 1407 N 2000 W Kaysville UT. 84037 Bountiful UT. 84010 p 801.295.7200 Ste G p 801.546.1300 p 801.294.7246 Clearfield UT. 84015 201 W Layton Pkwy p 385.333.7123 Hospital Affiliation Hospital Affiliation Ste 400 - Sevier Valley Hospital - Lakeview Hospital Layton UT. 84041 Hospital Affiliation - Davis Hospital p 801.295.7200 - Davis Hospital Humphreys, Benjamin R DO Tanner Memorial Clinic Stevens, Peter M MD Watson, Brent T MD Dodenbier, Cindie G CFNP 2121 N 1700 W University of Utah Health Davis Orthopedics And Life Spring Pain Layton UT. 84041 201 W Layton Pkwy Sports Medicine - Clinton Management p 801.773.4840 Ste 3B 1407 N 2000 W 275 W 200 N Layton UT. 84041 Ste F Ste 7 Hospital Affiliation p 801.662.5600 Clinton UT. 84015 Kaysville UT. 84037 - Davis Hospital p 801.773.3902 p 801.546.1300 Hospital Affiliation Integrated Pain - University of Utah Hospital Davis Orthopedics Earl, Brett J MD Consultants 2132 N 1700 W 1576 S 500 W 890 W Heritage Park Blvd Stotts, Alan K MD Ste 230 Ste 101 Ste 101 University of Utah Health Layton UT. 84041 Bountiful UT. 84010 Layton UT. 84041 201 W Layton Pkwy p 801.773.3900 p 801.303.7329 p 801.689.3389 Ste 3B Layton UT. 84041 Hospital Affiliation p 801.662.5600 - Davis Hospital - Ogden Regional Medical Hospital Affiliation Center - Primary Childrens Hospital

80 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Life Spring Pain Stevenson, Kim APRN Pediatric Behavioral Health Hogan, Whitnee MD Management Life Spring Pain Hess, Leeanne M LCSW University of Utah Health 275 W 200 N Management University of Utah Health 201 W Layton Pkwy Ste 7 275 W 200 N 291 S 200 W Ste 3D Kaysville UT. 84037 Ste 7 Farmington UT. 84025 Layton UT. 84041 p 801.546.1300 Kaysville UT. 84037 p 801.213.3200 p 801.213.3599 p 801.546.1300 Nelson, Alex J MD Hospital Affiliation Hospital Affiliation Advanced Spine and Pain Urie, Bradley A MD - University of Utah Hospital - University of Utah Hospital Specialists Pinnacle Pain Management 520 E Medical Dr 1992 W Antelope Dr Pediatric Cardiology Lindsay, Ian M MD Ste 220 Layton UT. 84041 Asaki, Sarah Y MD University of Utah Health Bountiful UT. 84010 p 385.393.0155 University of Utah Health 201 W Layton Pkwy p 801.299.6824 201 W Layton Pkwy Ste 3D Hospital Affiliation Ste 3D Layton UT. 84041 Integrated Pain - Lakeview Hospital Layton UT. 84041 p 801.213.3599 Consultants - Davis Hospital p 801.213.3599 890 W Heritage Park Blvd Hospital Affiliation Ste 101 Weston, Raul K MD Binka, Edem K MD - Primary Childrens Hospital Layton UT. 84041 Canyon Ridge Pain and University Of Utah Health p 801.689.3389 Spine 201 W Layton Pkwy Menon, Shaji C MD 1551 Renaissance Towne Dr Ste 3D University of Utah Health Hospital Affiliation Ste 460 Layton UT. 84041 201 W Layton Pkwy - Lakeview Hospital Bountiful UT. 84010 p 801.213.3599 Ste 3D - Timpanogos Regional Hospital p 801.294.7246 Layton UT. 84041 Hospital Affiliation p 801.213.3599 Obah, Christian C MD Hospital Affiliation - University of Utah Hospital Life Spring Pain - Lakeview Hospital Hospital Affiliation Management Boucek, Dana M MD - Primary Childrens Hospital 275 W 200 N Palliative Care University of Utah Health - Ogden Regional Medical Ste 7 Beck, Anna C MD 201 W Layton Pkwy Center Kaysville UT. 84037 University of Utah Health Ste 3D p 801.546.1300 165 N University Ave Layton UT. 84041 Niu, Mary C MD Farmington UT. 84025 p 801.213.3599 University of Utah Health Robison, Stacy K FNP p 801.213.3200 201 W Layton Pkwy Life Spring Pain Hospital Affiliation Ste 3D Management Hospital Affiliation - Primary Childrens Hospital Layton UT. 84041 275 W 200 N - University of Utah Hospital p 801.213.3599 Ste 7 Colquitt, John MD Kaysville UT. 84037 Brant, Jamie L MD University of Utah Health Hospital Affiliation p 801.546.1300 University of Utah Health 201 W Layton Pkwy - Primary Childrens Hospital 165 N University Ave Ste 3B - Primary Childrens Hospital Schow, Danna M FNP-C Farmington UT. 84025 Layton UT. 84041 Life Spring Pain p 801.213.4246 p 801.213.3599 Pinto, Nelangi M MD Management University of Utah Health 275 W 200 N Hospital Affiliation Cowley, Collin G MD 201 W Layton Pkwy Ste 7 - University of Utah Hospital Pediatrix Medical Group Ste 3D Kaysville UT. 84037 1600 W Antelope Dr Layton UT. 84041 p 801.546.1300 Pediatric Allergy And Immunology Layton UT. 84041 p 801.213.3599 Inman, Christi J MD p 801.807.1000 Scoville, Stephen L FNP-C University of Utah Health Hospital Affiliation Life Spring Pain 201 W Layton Pkwy 630 E Medical Dr - Primary Childrens Hospital Management Ste 3D Bountiful UT. 84010 - Ogden Regional Medical 275 W 200 N Layton UT. 84041 p 801.299.2200 Center Ste 7 p 801.213.3599 Kaysville UT. 84037 Hospital Affiliation Ploutz, Michelle S MD p 801.546.1300 Viera-Hutchins, Loida MD - Ogden Regional Medical University of Utah Health Tanner Memorial Clinic Center 201 W Layton Pkwy Shepherd, Joshua DO 2121 N 1700 W Ste 3D Davis Multi-Speciality Layton UT. 84041 Cox, Daniel A DO Layton UT. 84041 Clinic p 801.773.4840 University of Utah Health p 801.213.3599 1492 W Antelope Dr 201 W Layton Pkwy Ste 203 Hospital Affiliation Layton UT. 84041 Hospital Affiliation Layton UT. 84041 - Primary Childrens Hospital p 801.585.7676 - Primary Childrens Hospital p 801.773.7500 Hospital Affiliation Hospital Affiliation - Primary Childrens Hospital - Davis Hospital 81 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Ware, Adam L MD Jaramillo Castrillon, Ostrander, Betsy MD Makarewich, Christopher A University of Utah Health Catalina M MD University of Utah Health MD 201 W Layton Pkwy University of Utah Health 201 W Layton Pkwy University of Utah Health Ste 3D 201 W Layton Pkwy Ste 3D 201 W Layton Pkwy Layton UT. 84041 Ste 3D Layton UT. 84041 Ste 3B p 801.213.3599 Layton UT. 84041 p 801.213.3599 Layton UT. 84041 p 801.213.3599 p 801.662.5600 Weyhrauch, Derek L MD Sweney, Matthew T MD University Of Utah Health Hospital Affiliation University of Utah Health Hospital Affiliation 201 W Layton Pkwy - University of Utah Hospital 201 W Layton Pkwy - University of Utah Hospital Ste 3D Ste 3D Layton UT. 84041 Pohl, John F MD Layton UT. 84041 McClure, Philip K MD p 801.213.3599 University of Utah Health p 801.213.3599 University of Utah Health 201 W Layton Pkwy 201 W Layton Pkwy Hospital Affiliation Ste 3D Hospital Affiliation Ste 3B - University of Utah Hospital Layton UT. 84041 - Primary Childrens Hospital Layton UT. 84041 p 801.213.3599 p 801.662.5600 Pediatric Dermatology Wilson, Carey A MD Vanderhooft, Sheryll L MD Robson, Jacob O MD University of Utah Health Hospital Affiliation University of Utah Health University of Utah Health 201 W Layton Pkwy - University of Utah Hospital 201 W Layton PKWY 201 W Layton Pkwy Ste 3D Layton UT. 84041 Ste 3D Layton UT. 84041 Smith, John T MD p 801.662.1603 Layton UT. 84041 p 801.213.359 University of Utah Health p 801.213.3599 201 W Layton Pkwy Pediatric Ear Nose And Throat Hospital Affiliation Ste 3B Kelly, Steven M MD Wheeler, Justin C MD - University of Utah Hospital Layton UT. 84041 University of Utah Health University of Utah Health p 801.662.5600 165 N University Ave 201 W Layton Pkwy Pediatric Ophthalmology Farmington UT. 84025 Ste 3D Bullard, Michael L MD Pediatric Psychiatry p 801.213.3200 Layton UT. 84041 Utah Eye Centers Aguayo, Patricia MD p 801.213.3599 214 W 1500 S University of Utah Health 201 W Layton Pkwy Ste 300 291 S 200 W Ste 3D Pediatric Infectious Disease Bountiful UT. 84010 Farmington UT. 84025 Layton UT. 84041 Smith, Candice K MD p 801.476.0494 p 801.213.3200 p 801.662.1740 Tanner Memorial Clinic 2121 N 1700 W Hospital Affiliation Hospital Affiliation Hospital Affiliation Layton UT. 84041 - Lakeview Hospital - University of Utah Hospital - Primary Childrens Hospital p 801.773.4840 - Ogden Regional Medical Center Dwyer, Luke M MD Orlandi, Richard R MD Hospital Affiliation University Of Utah Health University of Utah Health - Davis Hospital Dries, David C MD 291 S 200 W 165 N University Ave University of Utah Health Farmington UT. 84025 Farmington UT. 84025 Pediatric Neurology 165 N University Ave p 801.213.3200 p 801.213.3200 Benedict, Susan L MD Farmington UT. 84025 University of Utah Health p 801.581.2352 Hospital Affiliation Hospital Affiliation 201 W Layton Pkwy - University of Utah Hospital - University of Utah Hospital Ste 3D Hospital Affiliation Layton UT. 84041 - University of Utah Hospital Kohler, Shawn J MD Pediatric Endocrinology p 801.213.3599 University of Utah Health Hamaker, Mark MD Pediatric Orthopedic Surgery 291 S 200 W University of Utah Health Espinoza, Audie C MD Hansen, Steven C OT Farmington UT. 84025 201 W Layton Pkwy University Of Utah Health Ability Innovations p 801.213.3200 Ste 3D 201 W Layton Pkwy 365 W 1550 N Layton UT. 84041 Ste 3D Layton UT. 84041 Hospital Affiliation p 801.213.3599 Layton UT. 84041 p 801.618.7903 - University of Utah Hospital p 801.213.3599 Hospital Affiliation Holmes, Stephanie M MD Pagel, Kristen L MD - Primary Childrens Hospital Hospital Affiliation University of Utah Health University of Utah Health - University of Utah Hospital 201 W Layton Pkwy 291 S 200 W Pediatric Gastroenterology Ste 3B Farmington UT. 84025 Guthery, Stephen L MD Manberg, Stephanie M DO Layton UT. 84041 p 801.213.3200 University of Utah Health University Of Utah Health p 801.662.5600 201 W Layton Pkwy 201 W Layton Pkwy Hospital Affiliation Ste 3D Ste 3D Hospital Affiliation - University of Utah Hospital Layton UT. 84041 Layton UT. 84041 - University of Utah Hospital p 801.213.3599 p 801.213.3599

Hospital Affiliation Hospital Affiliation - Primary Childrens Hospital - University of Utah Hospital 82 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Pediatric Rehabilitation University Of Utah Health Feola, Bonnie MD Darro, Natalie H DO 401 S 400 E Clark, Bradley J DO Busy Bee Pediatrics University Of Utah Health Bountiful UT. 84010 Ogden Clinic 520 E Medical Dr 401 S 400 E p 801.295.2361 145 S 3000 W Ste 301 Bountiful UT. 84010 West Point UT. 84015 Bountiful UT. 84010 p 801.295.2361 Bankhead, Emily APRN p 801.475.3960 p 801.292.1464 Wee Care Pediatrics *Flavin, Marisa H MD 2084 N 1700 W Daines, Emily MSN Hospital Affiliation Primary Childrens Rehab Ste A Busy Bee Pediatrics - Primary Childrens Hospital 201 W Layton Pkwy 3rd Fl Layton UT. 84041 520 E Medical Dr Layton UT. 84041 p 801.773.8644 Ste 301 Firszt, Rafael MD p 801.543.6630 Bountiful UT. 84010 Tanner Memorial Clinic Berger, Vicki L PA-C p 801.292.1464 2121 N 1700 W Hospital Affiliation Wee Care Pediatrics Layton UT. 84041 - Primary Childrens Hospital 2084 N 1700 W Eberhard, Brent MD p 801.773.4840 Ste A Tanner Memorial Clinic Pediatric Rheumatology Layton UT. 84041 2121 N 1700 W Hospital Affiliation Hersh, Aimee O MD p 801.773.8644 Layton UT. 84041 - University of Utah Hospital University of Utah Health p 801.773.4840 201 W Layton Pkwy 934 S Main St Forbush, Nathan MD Ste 3D Ste 8 Hospital Affiliation Tanner Memorial Clinic Layton UT. 84041 Layton UT. 84041 - Davis Hospital 2121 N 1700 W p 801.213.3599 p 801.738.8644 Layton UT. 84041 Edwards, Andrea MD p 801.773.4840 Hospital Affiliation Hospital Affiliation Wasatch Pediatrics - - Primary Childrens Hospital - Davis Hospital Bountiful (Grow Up Great) Hospital Affiliation 620 E Medical Dr - Davis Hospital Inman, Christi J MD Burnett, Kara F MD Ste 100 University of Utah Health Wasatch Pediatrics - Bountiful UT. 84010 Frischknect, Adam MD 201 W Layton Pkwy Bountiful (Grow Up Great) p 801.295.2888 Tanner Memorial Clinic Ste 3D 620 E Medical Dr 1477 N 2000 W Layton UT. 84041 Ste 100 Hospital Affiliation Clearfield UT. 84015 p 801.213.3599 Bountiful UT. 84010 - Lakeview Hospital p 801.773.4840 p 801.295.2888 James, Karen E MD Ellertson, Bryan MD Gabrielsen, Alvin A MD University of Utah Health Hospital Affiliation Tanner Memorial Clinic Wee Care Pediatrics 201 W Layton Pkwy - Lakeview Hospital 1750 E 3100 N 1580 W Antelope Dr Ste 3D Layton UT. 84040 Ste 100 Layton UT. 84041 Burton, Michael B DO p 801.773.4840 Layton UT. 84041 p 801.213.3599 Wee Care Pediatrics p 801.773.8644 934 S Main St Hospital Affiliation Hospital Affiliation Ste 8 - Davis Hospital 1792 W 1700 S - Primary Childrens Hospital Layton UT. 84041 - Ogden Region Medical Ste 102 p 801.773.8644 Center Syracuse UT. 84075 Stern, Sara M MD p 801.773.8644 University of Utah Health Hospital Affiliation Evans, Ryan N MD 201 W Layton Pkwy - Davis Hospital Tanner Memorial Clinic 2084 N 1700 W Ste 3D 380 N 400 W Ste A Layton UT. 84041 Busy Bee Pediatrics Kaysville UT. 84037 Layton UT. 84041 p 801.213.3599 520 E Medical Dr p 801.773.4840 p 801.773.8644 Ste 301 Hospital Affiliation Bountiful UT. 84010 Hospital Affiliation Hospital Affiliation - Primary Childrens Hospital p 801.292.1464 - Davis Hospital - Ogden Regional Medical Center Pediatrics Capps, Gina M MSN Fennell, James A MD - Davis Hospital Alvey, Justin C MD Busy Bee Pediatrics Wee Care Pediatrics University of Utah Health 520 E Medical Dr 1792 W 1700 S Giannini, Jacqueline K MD 201 W Layton Pkwy Ste 301 Ste 102 Wasatch Pediatrics - Ste 3D Bountiful UT. 84010 Syracuse UT. 84075 Bountiful (Grow Up Great) Layton UT. 84041 p 801.292.1464 p 801.927.1634 620 E Medical Dr p 801.213.3599 Ste 100 *Carver, Jeanlee F APRN 2084 N 1700 W Bountiful UT. 84010 Primary Childrens Hospital Ste A p 801.295.2888 98 S 100 E Layton UT. 84041 Farmington UT. 84025 p 801.773.8644 Hospital Affiliation p 801.451.3560 - Lakeview Hospital Hospital Affiliation Hospital Affiliation - Davis Hospital - Primary Childrens Hospital - Ogden Regional Medical - Lakeview Hospital Center - Ogden Regional Medical 83 *The PPO Agreement with this provider is expressly betweenCenter the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Gilsoul, Jennifer M MD Hildebrand, Pamela J MD Inman, Christi J MD 2084 N 1700 W Wee Care Pediatrics Wasatch Pediatrics - University of Utah Health Ste A 1792 W 1700 S Bountiful (Grow Up Great) 201 W Layton Pkwy Layton UT. 84041 Ste 102 620 E Medical Dr Ste 3D p 801.773.8644 Syracuse UT. 84075 Ste 100 Layton UT. 84041 p 801.927.1634 Bountiful UT. 84010 p 801.213.3599 934 S Main St p 801.295.2888 Ste 8 2084 N 1700 W Johnson, Adam D MSN Layton UT. 84041 Ste A Hospital Affiliation Busy Bee Pediatrics p 801.773.8644 Layton UT. 84041 - Lakeview Hospital 520 E Medical Dr p 801.773.8644 Ste 301 Miller-Ernest, Ronda NP Hoagland, Jason R MD Bountiful UT. 84010 Busy Bee Pediatrics Hospital Affiliation Tanner Memorial Clinic p 801.292.1464 520 E Medical Dr - Davis Hospital 380 N 400 W Ste 301 - Ogden Regional Medical Kaysville UT. 84037 Johnson, Sherman B MD Bountiful UT. 84010 Center p 801.773.4840 AccuHeal Wound Care p 801.292.1464 747 Sheringham Ct Groebs, Allison M MD Hospital Affiliation Farmington UT. 84025 Miller, Eleni W Wasatch Pediatrics - - Davis Hospital p 801.964.2008 University Of Utah Health Bountiful (Grow Up Great) 165 N University Ave 620 E Medical Dr Hoki, Robert S MD Judd, Earl R MD Farmington UT. 84025 Ste 100 Wee Care Pediatrics Wasatch Pediatrics - p 801.213.3200 Bountiful UT. 84010 1792 W 1700 S Farmington p 801.295.2888 Ste 102 491 W Bourne Cir Hospital Affiliation Syracuse UT. 84075 Farmington Fields Bldg 1 - University of Utah Hospital Hospital Affiliation p 801.773.8644 Farmington UT. 84025 - Lakeview Hospital p 801.939.9111 Moore, Melissa A MD 2084 N 1700 W University of Utah Health Hansen, Davin B PA-C Ste A Wasatch Pediatrics - 401 S 400 E Tanner Memorial Clinic Layton UT. 84041 Bountiful (Grow Up Great) Bountiful UT. 84010 2121 N 1700 W p 801.773.8644 620 E Medical Dr p 801.295.2361 Layton UT. 84041 Ste 100 p 801.773.4840 934 S Main St Bountiful UT. 84010 Hospital Affiliation Ste 8 p 801.295.2888 - University of Utah Hospital Harousseau, Mark MD Layton UT. 84041 University Of Utah Health p 801.773.8644 Hospital Affiliation Morrison, Paul MD 401 S 400 E - Lakeview Hospital Wasatch Pediatrics - Bountiful UT. 84010 Hospital Affiliation Farmington p 801.295.2361 - Davis Hospital Liou, Kathleen M MD 491 W Bourne Cir - Ogden Regional Medical Wasatch Pediatrics - Farmington Fields Bldg 1 Hospital Affiliation Center Bountiful (Grow Up Great) Farmington UT. 84025 - University of Utah Hospital 620 E Medical Dr p 801.939.9111 Husseman, Michael P MD Ste 100 Hawkes, Cody J DO Wee Care Pediatrics Bountiful UT. 84010 Wasatch Pediatrics - Wee Care Pediatrics 1792 W 1700 S p 801.295.2888 Bountiful (Grow Up Great) 1792 W 1700 S Ste 102 620 E Medical Dr Ste 102 Syracuse UT. 84075 Hospital Affiliation Ste 100 Syracuse UT. 84075 p 801.927.1634 - Lakeview Hospital Bountiful UT. 84010 p 801.773.8644 p 801.295.2888 2084 N 1700 W Loftus, Clark MD 2084 N 1700 W Ste A Wasatch Pediatrics - Hospital Affiliation Ste A Layton UT. 84041 Bountiful (Grow Up Great) - Lakeview Hospital Layton UT. 84041 p 801.773.8644 620 E Medical Dr p 801.773.8644 Ste 100 Nelson, Melanie MD Hospital Affiliation Bountiful UT. 84010 University Of Utah Health 934 S Main St - Davis Hospital p 801.295.2888 401 S 400 E Ste 8 - Ogden Regional Medical Bountiful UT. 84010 Layton UT. 84041 Center Hospital Affiliation p 801.295.2361 p 801.773.8644 - Lakeview Hospital Hutchinson, Adam MD Hospital Affiliation Hospital Affiliation Tanner Memorial Clinic Maxwell, Roderick D PA - University of Utah Hospital - Ogden Regional Medical 2121 N 1700 W Wee Care Pediatrics Center Layton UT. 84041 1792 W 1700 S - Davis Hospital p 801.773.4840 Ste 102 Syracuse UT. 84075 Hospital Affiliation p 801.773.8644 - Davis Hospital

84 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:46 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Nguyen, Amy L PA 2084 N 1700 W 2084 N 1700 W Wasatch Pediatrics - Wee Care Pediatrics Ste A Ste A Farmington 1792 W 1700 S Layton UT. 84041 Layton UT. 84041 491 W Bourne Cir Ste 102 p 801.773.8644 p 801.773.8644 Farmington Fields Bldg 1 Syracuse UT. 84075 Farmington UT. 84025 p 801.773.8644 934 S Main St 934 S Main St p 801.939.9111 Ste 8 Ste 8 2025 W 200 N Layton UT. 84041 Layton UT. 84041 Wasatch Pediatrics - Ste 2 p 801.773.8644 p 801.773.8644 Bountiful (Grow Up Great) Kaysville UT. 84037 620 E Medical Dr p 801.773.8644 Hospital Affiliation Hospital Affiliation Ste 100 - Ogden Regional Medical - Davis Hospital Bountiful UT. 84010 2084 N 1700 W Center - Ogden Regional Medical p 801.295.2888 Ste A - Davis Hospital Center Centerville UT. 84014 Webb, Kim CPNP p 801.776.8644 Ragsdale, Colton MD Smith, Candice K MD Busy Bee Pediatrics Wee Care Pediatrics Tanner Memorial Clinic 520 E Medical Dr Nye, Noel C DO 2084 N 1700 W 2121 N 1700 W Ste 301 Tanner Memorial Clinic Ste A Layton UT. 84041 Bountiful UT. 84010 2038 W 1900 S Layton UT. 84041 p 801.773.4840 p 801.292.1464 Syracuse UT. 84075 p 801.773.8644 p 801.773.4840 Hospital Affiliation Wee Care Pediatrics, 24 Rupp, Kirsten L MD - Davis Hospital hrs 7 days a week Hospital Affiliation University of Utah Health 1792 W 1700 S - Davis Hospital 165 N University Ave Tew, Jonathan MD Ste 102 Farmington UT. 84025 Wasatch Pediatrics - Syracuse UT. 84075 Owen, Robert E MD p 801.213.3200 Bountiful (Grow Up Great) p 801.773.8644 Tanner Memorial Clinic 620 E Medical Dr 2038 W 1900 S Hospital Affiliation Ste 100 Wee Care Pediatrics, Mon - Syracuse UT. 84075 - University of Utah Hospital Bountiful UT. 84010 Fri 9:00am - 5:30pm p 801.773.4840 p 801.295.2888 1792 W 1700 S Sharp, Lisa A FNP Syracuse UT. 84075 2121 N 1700 W Busy Bee Pediatrics Hospital Affiliation p 801.773.8644 Layton UT. 84041 520 E Medical Dr - Lakeview Hospital p 801.773.4840 Ste 301 Wee Care Pediatrics, 24 Bountiful UT. 84010 Torbeck, Jenna APRN hrs 7 days a week Hospital Affiliation p 801.292.1464 Wee Care Pediatrics 2025 W 200 N - Davis Hospital 1792 W 1700 S Ste 2 Sigg, Laurent C MD Ste 102 Kaysville UT. 84037 Pennington, Mary J MD Wee Care Pediatrics Syracuse UT. 84075 p 801.773.8644 Granger Medical 1792 W 1700 S p 801.927.1634 Specialists Ste 102 2084 N 1700 W 845 Overland Dr Syracuse UT. 84075 2084 N 1700 W Ste A North Salt Lake UT. 84054 p 801.927.1634 Ste A Layton UT. 84041 p 801.821.2445 Layton UT. 84041 p 801.773.8644 934 S Main St p 801.773.8644 Hospital Affiliation Ste 8 West-Ellis, Karen APRN - St Marks Hospital Layton UT. 84041 934 S Main St Wee Care Pediatrics p 801.773.8644 Ste 8 2084 N 1700 W Pohl, John F MD Layton UT. 84041 Ste A University of Utah Health Hospital Affiliation p 801.773.8644 Layton UT. 84041 201 W Layton Pkwy - Davis Hospital p 801.773.8644 Ste 3D - Ogden Regional Medical Tripp, George MD Layton UT. 84041 Center Tanner Memorial Clinic 934 S Main St p 801.213.3599 2121 N 1700 W Ste 8 Silas, Peter E MD Layton UT. 84041 Layton UT. 84041 Pruitt, Anthony G MD Wee Care Pediatrics p 801.773.4840 p 801.738.8644 Wee Care Pediatrics 1792 W 1700 S 1792 W 1700 S Ste 102 Hospital Affiliation Physical Medicine And Rehabilitation Ste 102 Syracuse UT. 84075 - Davis Hospital Brandt, William F MD Syracuse UT. 84075 p 801.927.1634 - Ogden Regional Medical Ogden Clinic p 801.927.1634 Center 1916 N 700 W Ste 250 Layton UT. 84041 p 801.479.0312

85 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Chen, Michael M DO Humphreys, Benjamin R DO Pepper, Michelle L MD Berke, Matthew PT Alta Pain Physicians Tanner Memorial Clinic Mountain Orthopaedics University of Utah Health 557 W 2600 S 2121 N 1700 W 1551 S Renaissance Towne 165 N University Ave Bountiful UT. 84010 Layton UT. 84041 Dr Farmington UT. 84025 p 801.462.2205 p 801.773.4840 Ste 400 p 801.213.3200 Bountiful UT. 84010 Cushman, Daniel M MD Hospital Affiliation p 801.295.7200 Hospital Affiliation University of Utah Health - Davis Hospital - University of Utah Hospital 165 N University Ave Hospital Affiliation Farmington UT. 84025 Kendall, Richard W DO - Davis Hospital Bieber, Jennifer D DPT p 801.213.6642 University of Utah Health - Lakeview Hospital Rhodes Physical Therapy 165 N University Ave 722 Shepherd Ln Hospital Affiliation Farmington UT. 84025 Shepherd, Douglas T MD Ste 105 - University of Utah Hospital p 801.213.6642 Ogden Clinic Farmington UT. 84025 1551 Renaissance Towne Dr p 801.447.9339 DeMordaunt, Dallin L Hospital Affiliation Ste 420 Davis Orthopedics and - Salt Lake Regional Medical Bountiful UT. 84010 *Bognar, Lindsay PT Sports Medicine - Clinton Center p 801.479.0312 Primary Childrens Rehab 1407 N 2000 W - University of Utah Hospital 201 W Layton Pkwy 3rd Fl Ste F Ogden Clinic - Cope Family Layton UT. 84041 Clinton UT. 84015 Morgan, Brian H MD Medicine p 801.543.6630 p 801.773.3902 Ogden Clinic - Utah Spine 185 S 400 E 1916 N 700 W Ste 100 280 N Main St Davis Orthopedics and Ste 250 Bountiful UT. 84010 Bountiful UT. 84010 Sports Medicine Layton UT. 84041 p 801.397.6200 p 801.662.4949 2132 N 1700 W p 801.479.0312 Ste 230 Ogden Clinic - Utah Spine Hospital Affiliation Layton UT. 84041 Hospital Affiliation 1916 N 700 W - Primary Childrens Hospital p 801.773.3900 - Ogden Regional Medical Ste 250 Center Layton UT. 84041 Bowser, Rick PT Hospital Affiliation p 801.479.0312 Aspen Ridge Physical - Davis Hospital Nickisch, Florian MD Therapy University of Utah Health Hospital Affiliation 2121 N 1700 W Derr, Michael J DO 165 N University Ave - Ogden Regional Medical Ste A Tanner Memorial Clinic Farmington UT. 84025 Center Layton UT. 84041 2121 N 1700 W p 801.213.3200 p 801.773.1350 Layton UT. 84041 Physical Therapy p 801.773.4840 Hospital Affiliation *Adamavich, Crystal L DPT Brooks, Carly DPT - University of Utah Hospital Primary Childrens Rehab University of Utah Health Hospital Affiliation 201 W Layton Pkwy 3rd FL 165 N University Ave - Davis Hospital Oka, Jeffery R MD Layton UT. 84041 Farmington UT. 84025 1551 S Renaissance Towne p 801.543.6630 p 801.213.3200 Green, Michael M DO Dr University of Utah Health Ste 400 280 N Main St Hospital Affiliation 201 W Layton Pkwy Bountiful UT. 84010 Bountiful UT. 84010 - Primary Childrens Hospital Layton UT. 84041 p 801.295.7200 p 801.662.4949 p 801.213.3599 Bullard, William J DPT 425 Medical Dr Ashdown, Susan C PT Mountain Land Hospital Affiliation Ste 108 Mountain Land Rehabilitation Inc - University of Utah Hospital Bountiful UT. 84010 Rehabilitation Inc 1188 Sportsplex Dr p 801.292.2500 2950 N Church St Ste 101 Hansen, Colby R MD Ste 102 Kaysville UT. 84037 University of Utah Health Hospital Affiliation Layton UT. 84040 p 801.547.1155 201 W Layton Pkwy - Lakeview Hospital p 801.547.9462 Layton UT. 84041 Bulloch, Joshua R DPT p 801.213.3599 Oki, Allison MD Back@Work Physical Therapy Mountain Land University of Utah Health 772 E 700 S Rehabilitation Inc Hospital Affiliation 201 W Layton Pkwy Ste 3 3225 W Gordon Ave - Primary Childrens Hospital Layton UT. 84041 Clearfield UT. 84015 Ste 3 - University of Utah Hospital p 801.213.3599 p 801.217.3755 Layton UT. 84041 - Salt Lake Regional Medical p 801.497.0800 Center Hospital Affiliation *Bentley, Bradford Scott S - Primary Childrens Hospital *PT - University of Utah Hospital Primary Childrens Rehab 280 N Main St Bountiful UT. 84010 p 801.662.4949

86 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Child, Bryan F PT Gerrard, Brynne N DPT Hansen, Bradley DPT Jackson, Brandi N DPT Precision EMG PLLC Mountain Land Layton Physical Therapy & Mountain Land 3225 W Gordon Ave Rehabilitation Inc Sports Medicine Inc Rehabilitation Inc Layton UT. 84041 2950 N Church St 1868 N 1200 W 3024 W 300 N p 801.725.2380 Ste 102 Ste A Ste A Layton UT. 84040 Layton UT. 84041 Clearfield UT. 84015 Concentra Medical Centers p 801.547.9462 p 801.728.4624 p 801.825.7500 2086 N 1700 W Ste A Glad, Jaclyn PT Harp, Jennifer K DPT Jenkins, Rusty L DPT Layton UT. 84041 University of Utah Health Mountain Land Wasatch Therapy Inc p 888.997.2669 165 N University Ave Rehabilitation Inc 1916 N 700 W Farmington UT. 84025 1477 N 2000 W Ste 240 2390 Redwood Rd p 801.213.3200 Ste A Layton UT. 84041 West Valley City UT. 84419 Clinton UT. 84015 p 801.784.7373 p 888.997.2669 Hospital Affiliation p 801.773.4191 - University of Utah Hospital *Jessup, Jesse C PT *Crandall, Rachel G PT *Hensiek, Renee A DPT Primary Childrens Rehab Primary Childrens Rehab Goff, Megan MPT Primary Childrens Rehab 201 W Layton Pkwy 3rd Fl 280 N Main St Mountain Land 201 W Layton Pkwy Layton UT. 84041 Bountiful UT. 84010 Rehabilitation Inc Layton UT. 84041 p 801.543.6630 p 801.662.4949 3225 W Gordon Ave p 801.543.6630 Ste 3 280 N Main St *De La Torre Alva, Linda M Layton UT. 84041 280 N Main St Bountiful UT. 84010 *DPT p 801.497.0800 Bountiful UT. 84010 p 801.662.4949 Primary Childrens Rehab p 801.662.4949 201 W Layton Pkwy 3rd Fl Goldsberry, Brandon R PT Johnson, Evan F DPT Layton UT. 84041 Wasatch Peak Physical Hospital Affiliation Mountain Land p 801.543.6630 Therapy - Primary Childrens Hospital Rehabilitation Inc 1492 W Antelope Dr 3225 W Gordon Ave 280 N Main St Ste 100 Hope, Dereck B PT Ste 3 Bountiful UT. 84010 Layton UT. 84041 Performance West Physical Layton UT. 84041 p 801.662.4949 p 801.825.8091 Therapy p 801.497.0800 473 W Bourne Cir Hospital Affiliation *Granger, Keegan M PT Ste 1 Jolley, Curtis B PT - Primary Childrens Hospital Primary Childrens Rehab Farmington UT. 84025 Performance West Physical 201 W Layton Pkwy 3rd Fl p 801.451.5985 Therapy Easthope, Janae PT Layton UT. 84041 1551 Renaissance Towne Dr Wasatch Peak Physical p 801.543.6630 Hubble, Angela M PT Ste 350 Therapy Wasatch Peak Physical Bountiful UT. 84010 754 Wind Mill Ln Primary Childrens Hospital Therapy p 801.295.3553 Kaysville UT. 84037 280 N Main St 1492 W Antelope Dr p 801.931.9481 Bountiful UT. 84010 Ste 100 Jones, Cole H DPT p 801.662.4949 Layton UT. 84041 Performance West Physical Flinders, Mark A PT p 801.825.8091 Therapy Mountain Land Hospital Affiliation 1266 S Legend Hills Dr Rehabilitation Inc - Primary Childrens Hospital Hunsaker, Nikelle DPT Ste B2 1477 N 2000 W Hand and Orthopedic Clearfield UT. 84015 Ste A Gubler, Jason C DPT Rehabilitation Specialists p 801.776.6000 Clinton UT. 84015 Ogden Clinic - Cope Family 596 W 750 S p 801.773.4191 Medicine Ste 210 Judd, Robyn M DPT 185 S 400 E Bountiful UT. 84010 Wasatch Therapy Inc Fluhrer, Erin DPT Ste 100 p 801.298.2533 1916 N 700 W Mountain Land Bountiful UT. 84010 Ste 240 Rehabilitation Inc p 801.397.6200 Ita aehau, Melissa A DPT Layton UT. 84041 1188 Sportsplex Dr Wasatch Therapy Inc p 801.784.7373 Ste 101 Hadley, Steven C DPT 1916 N 700 W Kaysville UT. 84037 Mountain Land Ste 240 Kerbs, Alan J PT p 801.547.1155 Rehabilitation Inc Layton UT. 84041 Layton Physical Therapy 3024 W 300 N p 801.784.7373 and Sports Medicine Inc Gauderman, Kimberly J MPT Ste A 1868 N 1200 W Ability Innovations Clearfield UT. 84015 42 N 650 W Ste A 365 W 1550 N p 801.825.7500 Farmington UT. 84025 Layton UT. 84041 Layton UT. 84041 p 801.447.9627 p 801.728.4624 p 801.618.7903

87 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Khong, Taryn PT McCluskey, James R PT *Newby, Olivia J DPT Powers, Clayton D PT University of Utah Health University of Utah Health Primary Childrens Rehab University of Utah Health 165 N University Ave 165 N University Ave 201 W Layton Pkwy 3rd Fl 165 N University Ave Farmington UT. 84025 Farmington UT. 84025 Layton UT. 84041 Farmington UT. 84025 p 801.213.3200 p 801.213.3200 p 801.543.6630 p 801.213.3200

Kosturik, Andrew B PT McGeorge, Gillian M DPT 280 N Main St Hospital Affiliation University of Utah Health Wasatch Therapy Inc Bountiful UT. 84010 - University of Utah Hospital 165 N University Ave 1916 N 700 W p 801.662.4949 Farmington UT. 84025 Ste 240 *Quintana, Lisa M DPT p 801.213.3200 Layton UT. 84041 Hospital Affiliation Primary Childrens Hospital p 801.784.7373 - Primary Childrens Hospital 280 N Main St Hospital Affiliation Bountiful UT. 84010 - University of Utah Hospital Meads, David PT Norman, Haley N DPT p 801.662.4949 Aspen Ridge Physical Ability Innovations Lanenga, Amber L PT Therapy 365 W 1550 N Reid, Kim W PT University of Utah Health 2121 N 1700 W Ste H Performance West Physical 165 N University Ave Ste A Layton UT. 84041 Therapy Farmington UT. 84025 Layton UT. 84041 p 801.618.7903 185 S 400 E p 801.213.3200 p 801.773.1350 Ste 102 Olsen, Tyler J PT Bountiful UT. 84010 Hospital Affiliation *Milam, Kimberly B PT Wasatch Peak Physical p 801.797.9105 - University of Utah Hospital Primary Childrens Rehab Therapy 201 W Layton Pkwy 3rd Fl 1692 N 2475 W Reid, Nanette F PT *Lee, Kayla M DPT Layton UT. 84041 Clinton UT. 84015 Reid Physical Therapy Primary Childrens Rehab p 801.543.6630 p 801.776.4923 103 W 1450 N 201 W Layton Pkwy 3rd Fl Centerville UT. 84014 Layton UT. 84041 Money, Katelyn M PT Parker, Bryce S DPT p 801.554.3572 p 801.543.6630 University of Utah Health Layton Physical Therapy 165 N University Ave and Sports Medicine Inc Reynolds-Call, Tamara K 280 N Main St Farmington UT. 84025 1868 N 1200 W MPT Bountiful UT. 84010 p 801.213.3200 Ste A WorkAbility Centers p 801.662.4949 Layton UT. 84041 1689 E 1400 S Hospital Affiliation p 801.728.4624 Ste 120 Leschke, Kurt A PT - University of Utah Hospital Clearfield UT. 84015 Mountain Land Pennock, Brian H PT p 801.525.0007 Rehabilitation Inc Montague, Brett C PT Mountain Land 2950 N Church St University of Utah Health Rehabilitation Inc Ross, Kimberly M OT Ste 102 165 N University Ave 1188 Sportsplex Dr University of Utah Health Layton UT. 84040 Farmington UT. 84025 Ste 101 165 N University Ave p 801.547.9462 p 801.213.3200 Kaysville UT. 84037 Farmington UT. 84025 p 801.547.1155 p 801.213.3200 Lewis, J Brad PT Hospital Affiliation Hofmann Arthritis - University of Utah Hospital *Permenter, Taylor DPT Saenz, Erik DPT Institute Primary Childrens Rehab University of Utah Health 1492 W Antelope Dr Morris, Adam D PT 201 W Layton Pkwy 3rd Fl 165 N University Ave Ste 110 Restoration Physical Layton UT. 84041 Farmington UT. 84025 Layton UT. 84041 Therapy LLC p 801.543.6630 p 801.213.3200 p 801.355.6468 47 E Crestwood Rd Ste 2B 280 N Main St Sauter, Kendall C PT Lund, Rebekah E DPT Kaysville UT. 84037 Bountiful UT. 84010 University of Utah Health Mountain Land p 801.444.3440 p 801.662.4949 165 N University Ave Rehabilitation Inc Farmington UT. 84025 1188 Sportsplex Dr Moss, Megan DPT Hospital Affiliation p 801.213.3200 Ste 101 Performance West Physical - Primary Childrens Hospital Kaysville UT. 84037 Therapy Schade, Kristin M DPT p 801.547.1155 1551 Renaissance Towne Dr Perry, Ryan S DPT Mountain Land Ste 350 Mountain Land Rehabilitation Inc Martinez, Gregory S DPT Bountiful UT. 84010 Rehabilitation Inc 1477 N 2000 W Hand and Orthopedic p 801.295.3553 74 E 500 S Ste A Rehabilitation Specialists Ste 104 Clearfield UT. 84015 596 W 750 S Muhn, Peter H PT Bountiful UT. 84010 p 801.773.4191 Ste 210 University Of Utah Health p 801.292.5011 Bountiful UT. 84010 165 N University Ave p 801.298.2533 Farmington UT. 84025 p 801.213.3200

Hospital Affiliation - University of Utah Hospital 88 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Schiltz, Adam PT Sparks, Lindsi PT *Turner, Sean C DPT Wixom, Steven M PT University of Utah Health Wasatch Peak Physical Intermountain Rehab Agency University of Utah Health 165 N University Ave Therapy 280 N Main St 165 N University Ave Farmington UT. 84025 1492 W Antelope Dr Bountiful UT. 84010 Farmington UT. 84025 p 801.213.3200 Ste 100 p 801.294.1155 p 801.213.3200 Layton UT. 84041 Hospital Affiliation p 801.825.8091 Urban, Kenlee DPT Wright, Jessica L PT - University of Utah Hospital Reid Physical Therapy Wasatch Peak Physical Story, Mitchell S DPT 103 W 1450 N Therapy Schoenfeld, Chalise C PT Mountain Land Centerville UT. 84014 601 N Banbury Cir University of Utah Health Rehabilitation Inc p 801.554.3572 North Salt Lake UT. 84054 165 N University Ave 1188 Sportsplex Dr p 801.299.8715 Farmington UT. 84025 Ste 101 *Usher, Allison DPT p 801.213.3200 Kaysville UT. 84037 Primary Childrens Rehab Young, Carson M DPT p 801.547.1155 201 W Layton Pkwy 3rd Fl Aspen Ridge Physical Hospital Affiliation Layton UT. 84041 Therapy - University of Utah Hospital Stotts, Paige OTR p 801.543.6630 2121 N 1700 W University of Utah Health Ste A Schroeder, Gregory P DPT 165 N University Ave 280 N Main St Layton UT. 84041 Back@Work Physical Therapy Farmington UT. 84025 Bountiful UT. 84010 p 801.773.1350 772 E 700 S p 801.213.3200 p 801.662.4949 Ste 3 *Young, Elizabeth A PT Clearfield UT. 84015 Sueoka, Stephanie S PT Hospital Affiliation Primary Childrens Rehab p 801.217.3755 University of Utah Health - Primary Childrens Hospital 201 W Layton Pkwy 3rd Fl 165 N University Ave Layton UT. 84041 Sedgwick, Daniel J DPT Farmington UT. 84025 Vaughan, Clark PT p 801.543.6630 Mountain Land p 801.213.3200 University of Utah Health Rehabilitation Inc 165 N University Ave Plastic Surgery 3024 W 300 N Hospital Affiliation Farmington UT. 84025 Cheng, Christine A MD Ste A - University of Utah Hospital p 801.213.3200 415 Medical Dr Clearfield UT. 84015 Ste C101 p 801.825.7500 Swenson, Lennie M PT Hospital Affiliation Bountiful UT. 84010 University of Utah Health - University of Utah Hospital p 801.298.9774 *Sherman, Jessica E DPT 165 N University Ave Primary Childrens Rehab Farmington UT. 84025 Vendela, Tiffany R PT Hospital Affiliation 201 W Layton Pkwy 3rd Fl p 801.213.3200 Mountain Land - Lakeview Hospital Layton UT. 84041 Rehabilitation Inc - Salt Lake Regional Medical p 801.543.6630 Hospital Affiliation 2950 N Church St Center - University of Utah Hospital Ste 102 280 N Main St Layton UT. 84040 Goodwin, Isak A MD Bountiful UT. 84010 Thompson, Amanda DPT p 801.547.9462 University of Utah Health p 801.662.4949 Performance West Physical 165 N University Ave Therapy *Warner, Kelly D PT Farmington UT. 84025 Skinner, Lee A DPT 1551 Renaissance Towne Dr Primary Childrens Rehab p 801.213.3200 University of Utah Health Ste 350 201 W Layton Pkwy 3rd Fl 165 N University Ave Bountiful UT. 84010 Layton UT. 84041 Hospital Affiliation Farmington UT. 84025 p 801.295.3553 p 801.543.6630 - University of Utah Hospital p 801.213.3200 *Tischler, Dana F DPT Wiegand, Jennifer M PT Griner, Devan MD Hospital Affiliation Primary Childrens Rehab University of Utah Health Peak Plastic Surgery - University of Utah Hospital 201 W Layton Pkwy 165 N University Ave 975 N Main St Layton UT. 84041 Farmington UT. 84025 Ste 3A Sondrup, Stuart C DPT p 801.543.6630 p 801.213.3200 Layton UT. 84041 Performance West Physical p 801.702.9191 Therapy 280 N Main St Hospital Affiliation 1551 Renaissance Towne Dr Bountiful UT. 84010 - University of Utah Hospital Henstrom, Douglas K MD Ste 350 p 801.662.4949 Utah Facial Plastics Bountiful UT. 84010 Wilks, James M PT 2255 N 1700 W 205 p 801.295.3553 Toone, Matthew V DPT University of Utah Health Layton UT. 84041 Rhodes Physical Therapy 165 N University Ave p 801.776.2220 Sorensen, Richard T PT Inc Farmington UT. 84025 University of Utah Health 722 Shepard Ln p 801.213.3200 Hospital Affiliation 165 N University Ave Ste 105 - Davis Hospital Farmington UT. 84025 Farmington UT. 84025 Hospital Affiliation p 801.213.3200 p 801.447.9339 - University of Utah Hospital

Hospital Affiliation - University of Utah Hospital 89 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Kjar, J Gregory MD Campbell, Jason D DPM Graff, David M DPM Premier Plastic Surgery Wasatch Foot & Ankle Foot & Ankle Specialists Seegmiller, Richard G DPM Group of Utah Institute of Utah Utah Podiatry Group PC 1551 S Renaissance Towne 473 W Bourne Cir 596 W 750 S 440 Medical Dr Dr Ste 2 Ste 200 Ste 1-U Ste 360 Farmington UT. 84025 Bountiful UT. 84010 Bountiful UT. 84010 Bountiful UT. 84010 p 801.451.7500 p 801.292.4425 p 801.292.5070 p 801.295.9105 Hospital Affiliation Gulso, Gregory J DPM Hospital Affiliation Hospital Affiliation - Davis Hospital Gulso Podiatry - Davis Hospital - Lakeview Hospital - Ogden Regional Medical 415 S Medical Dr - Lakeview Hospital - Davis Hospital Center Ste C200 - Salt Lake Regional Medical Bountiful UT. 84010 Center Kwok, Alvin C MD Church, Robert A DPM p 801.294.8266 University of Utah Health Wasatch Foot And Ankle 1660 W Antelope Dr 165 N University Ave Specialists Hospital Affiliation Ste 110 Farmington UT. 84025 440 Medical Dr - Lakeview Hospital Layton UT. 84041 p 801.213.3200 Ste 2 p 801.825.4709 Bountiful UT. 84010 Murrah, Chantel B DPM Hospital Affiliation p 801.298.1160 Wasatch Foot & Ankle 440 Medical Dr - University of Utah Hospital Institute Ste 1-U Hospital Affiliation 473 W Bourne Cir Bountiful UT. 84010 Sellers, Daniel S MD - Lakeview Hospital Ste 2 p 801.292.5070 620 Medical Dr - St Marks Hospital Farmington UT. 84025 Ste 310 p 801.451.7500 Walker, Kevin G DPM Bountiful UT. 84010 Flitton, Todd B DPM Ogden Clinic p 801.295.6554 Tanner Memorial Clinic Hospital Affiliation 537 N Kays Dr 380 N 400 W - Ogden Regional Medical Kaysville UT. 84037 Yates, York J MD Kaysville UT. 84037 Center p 385.238.3850 Tanner Memorial Clinic p 801.773.4840 2121 N 1700 W Potter, Brooks H DPM Hospital Affiliation Layton UT. 84041 Hospital Affiliation Tanner Memorial Clinic - Ogden Regional Medical p 801.773.4840 - Davis Hospital 2121 N 1700 W Center Layton UT. 84041 Hospital Affiliation Foot & Ankle Specialists p 801.773.4840 Warby, David H DPM - Davis Hospital of Utah Utah Podiatric Physicians 596 W 750 S Hospital Affiliation and Surgeons Group Podiatry Ste 200 - Davis Hospital 2950 N Church St Anderson, Ryan K DPM Bountiful UT. 84010 Ste 303 Utah Podiatric Physicians p 801.566.7297 Richman, Brian H DPM Layton UT. 84040 and Surgeons Group 1660 W Antelope Dr p 801.544.9441 596 W 750 S Frost, Colby H DPM Ste 110 Ste 200 Wasatch Foot & Ankle Layton UT. 84041 Hospital Affiliation Bountiful UT. 84010 Institute p 801.825.4709 - Ogden Regional Medical p 801.292.4425 473 W Bourne Cir Center Ste 2 Hospital Affiliation - Davis Hospital Hospital Affiliation Farmington UT. 84025 - Davis Hospital - Lakeview Hospital p 801.451.7500 - Logan Regional Hospital Wasatch Foot & Ankle - Lakeview Hospital Institute Anselmo, Derek DPM Hospital Affiliation 473 W Bourne Cir Foot & Ankle Specialists - Davis Hospital Rushton, Ryan T DPM Ste 2 of Utah - Ogden Regional Medical University of Utah Health Farmington UT. 84025 596 W 750 S Center 165 N University Ave p 801.451.7500 Ste 200 Farmington UT. 84025 Bountiful UT. 84010 Gaertner-Crison, Gretel K p 801.213.8841 Woolley, Mark E DPM p 801.292.4425 DPM Wasatch Foot & Ankle Crison Foot Care PLLC Hospital Affiliation Institute Bruse, Jason DPM 3024 W 300 N St C - Salt Lake Regional Medical 473 W Bourne Cir Ogden Clinic - Davis West Point UT. 84015 Center Ste 2 Family Physicians p 385.393.8224 - University of Utah Hospital Farmington UT. 84025 3225 W Gordon Ave p 801.451.7500 Ste 1 Hospital Affiliation Seagle, Bryan L DPM Layton UT. 84041 - Davis Hospital Utah Podiatric Physicians Hospital Affiliation p 801.475.3000 - Jordan Valley Medical and Surgeons Group - Ogden Regional Medical Center 596 W 750 S Center Hospital Affiliation Ste 200 - Ogden Regional Medical Bountiful UT. 84010 Center p 801.292.4425 - Lakeview Hospital Hospital Affiliation - Lakeview Hospital 90 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider.- Lone Peak Hospital 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Psychiatry Gaines, Matthew M DO Javellana, Carmela md Sugden, Steven G MD Barusch, Nathaniel MD MountainStar Behavioral Neurobehavioral Center for University of Utah Health Cedar Psychiatry Health Growth 291 S 200 W 2950 N Church St 630 Medical Dr 415 S Medical Dr Farmington UT. 84025 Ste 101 Bountiful UT. 84010 Ste A101 p 801.213.3200 Layton UT. 84040 p 801.299.2200 Bountiful UT. 84010 p 801.369.8989 p 801.683.1062 Hospital Affiliation Gethin-Jones, Thomas L - University of Utah Hospital Hospital Affiliation University Of Utah Health 415 S Medical Dr - Mountain View Hospital 291 S 200 W Ste D101 Thatcher, Benjamin T DO (UT) Farmington UT. 84025 Bountiful UT. 84010 Valley Behavioral Health - Utah Valley Hospital p 801.213.3200 p 801.683.1062 1785 E 1450 S Ste 300 Birnkrant, Jonathan D MD Hospital Affiliation Johnson, Clark MD Clearfield UT. 84015 University of Utah Health - University of Utah Hospital Adult Behavioral Health p 888.949.4864 291 S 200 W Unit Davis - IP Farmington UT. 84025 Gibbs, Paula K MD 1600 W Antelope Dr Van Leeuwen, Benjamin MD p 801.213.3200 University of Utah Health Layton UT. 84041 Tanner Memorial Clinic 165 N University Ave p 801.350.4253 2121 N 1700 W Hospital Affiliation Farmington UT. 84025 Layton UT. 84041 - University of Utah Hospital p 801.581.7951 Hospital Affiliation p 801.773.4840 - Davis Hospital Bonebrake, Kathleen M MD Hospital Affiliation Hospital Affiliation University Of Utah Health - University of Utah Hospital Lewis, Gina - Davis Hospital 291 S 200 W Adult Behavioral Health Farmington UT. 84025 Godecke, Kelly Unit Davis - IP Wark, Heather MD p 801.213.3200 University Of Utah Health 1600 W Antelope Dr Davis Behavioral Health 291 S 200 W Layton UT. 84041 Unit - Layton Hospital Affiliation Farmington UT. 84025 p 801.350.4253 1600 W Antelope Dr - University of Utah Hospital p 801.213.3200 Layton UT. 84041 Marcum, James M MD p 801.807.1000 Dwyer, Luke M MD Hospital Affiliation Cedar Psychiatry University Of Utah Health - University of Utah Hospital 2950 N Church St Psychology 291 S 200 W Ste 101 Applewhite, Kimberly C Farmington UT. 84025 Harrop, Elizabeth A APRN Layton UT. 84040 PsyD p 801.213.3200 Ascendant Behavioral p 801.369.8989 University of Utah Health Health 291 S 200 W Hospital Affiliation 1133 N Main Merrill, Jordan W MD Farmington UT. 84025 - University of Utah Hospital Ste 128 University of Utah Health p 801.213.3200 Layton UT. 84041 291 S 200 W Freeman, Brenner L MD p 801.872.5516 Farmington UT. 84025 Hospital Affiliation University of Utah Health p 801.213.3200 - University of Utah Hospital 165 N University Ave Alliant Behavioral Health Farmington UT. 84025 of Utah LLC Moulton, David L MD Bullock, Emily Y PSYD p 801.581.7951 255 N Adamswood Rd University of Utah Health Bullock Psychological Layton UT. 84040 291 S 200 W Services University Of Utah Health p 385.888.9040 Farmington UT. 84025 240 N East Promontory 291 S 200 W p 801.213.3200 Ste 200 Farmington UT. 84025 Hoff, Troy C DO,PhD Farmington UT. 84025 p 801.213.3200 University of Utah Health Hospital Affiliation p 801.844.1615 291 S 200 W - University of Utah Hospital Hospital Affiliation Farmington UT. 84025 Cardinal, Jennifer R PhD, - University of Utah Hospital p 801.213.3200 Robison, Reid J MD BCBA Cedar Psychiatry Neurobehavioral Center for Freimer, Martin MD Hospital Affiliation 2950 N Church St Growth University of Utah Health - University of Utah Hospital Ste 101 327 W Gordon Ave 291 S 200 W Layton UT. 84040 Ste 2 Farmington UT. 84025 Imus, Austin B DO p 801.369.8989 Layton UT. 84041 p 801.213.3200 Austin B Imus DO p 801.683.1062 1433 N 1075 W Hospital Affiliation Hospital Affiliation Ste 120 - Mountain View Hospital 415 S Medical Dr - Salt Lake Regional Medical Farmington UT. 84025 (UT) Ste A101 Center p 801.923.8044 - Utah Valley Hospital Bountiful UT. 84010 - University of Utah Hospital p 801.683.1062

91 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 415 S Medical Dr Jones, Lisa PhD Newbold, David PhD Taylor, Trevor D PSYD Ste D101 Lisa Jones, PhD David Newbold & Associates Tanner Memorial Clinic Bountiful UT. 84010 1433 N 1075 W 370 S 500 E 1477 N 2000 W p 801.683.1062 Ste 120 Ste 180 Clearfield UT. 84015 Farmington UT. 84025 Clearfield UT. 84015 p 801.773.4840 Corgiat, Mark D PhD p 385.399.3696 p 801.776.1954 1916 N 700 W 2121 N 1700 W Ste 190 Kay, Steven J PSYD Perovich, John D PhD Layton UT. 84041 Layton UT. 84041 Kay Psychological & Center for Growth and p 801.773.4840 p 801.820.6169 Consulting PC Potential 1601 N Hill Field Rd 1785 E 1450 S Wasatch Psychological DeBerard, Michael S PhD Layton UT. 84041 Ste 250 Services Advanced Spine and Pain p 801.776.1303 Clearfield UT. 84015 240 N East Promontory Specialists p 801.773.0535 Ste 200 1600 W Antelope Dr Kay, Theresa S PhD Farmington UT. 84025 Layton UT. 84041 Kay Psychological & Perry, Jill PSYD p 801.590.0525 p 801.299.6824 Consulting PC Bullock Psychological 1601 N Hill Field Rd Services Wilkes, Ryan W PSYD Docherty, Anna R PhD Layton UT. 84041 240 N East Promontory Wasatch Psychological University of Utah Health p 801.776.1303 Ste 200 Services 291 S 200 W Farmington UT. 84025 240 N East Promontory Farmington UT. 84025 Mansour, Emma PhD p 801.923.1366 Ste 200 p 801.213.3200 Life Matters: Counseling Farmington UT. 84025 and Psychological Services Waves of Change Counseling p 801.590.0525 Hospital Affiliation 1433 N 1075 W 375 N Main St - University of Utah Hospital Ste 120 Ste 202 Pulmonology Farmington UT. 84025 Kaysville UT. 84037 Hammond, Gregory D MD Edgington, Carl PhD p 801.483.2447 p 385.231.1500 Lakeview Intermal Medicine ABS Kids and Surgery 2940 Church St Medina-Salvatore, Nicole Rogers, Kate Phd 520 E Medical Dr Ste 204 PSYD The OCD And Anxiety Ste 200 Layton UT. 84040 Neurobehavioral Center for Treatment Center Bountiful UT. 84010 p 801.935.4946 Growth 1459 N Main St p 801.294.9338 327 W Gordon Ave Ste 100 Empey, Dallas PhD Ste 2 Bountiful UT. 84010 Hospital Affiliation 240 N East Promontory Layton UT. 84041 p 801.298.2000 - Lakeview Hospital Ste 200 p 801.683.1062 Farmington UT. 84025 Russell Stamp, Mindy M Majoskey, Ashley M PA p 801.644.9244 415 S Medical Dr PhD MountainStar Cardiology St Ste A101 Neurobehavioral Center for Marks Evans, Lyndsey M PhD Bountiful UT. 84010 Growth 1407 N 2000 W Neurobehavioral Center for p 801.683.1062 327 W Gordon Ave Ste B Growth Ste 2 Clearfield UT. 84015 327 W Gordon Ave Neurobehavioral Center For Layton UT. 84041 p 801.773.3191 Ste 2 Growth p 801.683.1062 Layton UT. 84041 415 S Medical Dr Hospital Affiliation p 801.683.1062 Ste D101 415 S Medical Dr - St Marks Hospital Bountiful UT. 84010 Ste D101 415 S Medical Dr p 801.683.1062 Bountiful UT. 84010 Sadler, William T MD Ste A101 p 801.683.1062 415 Medical Dr Bountiful UT. 84010 Morris, Josh Phd Ste C202 p 801.683.1062 University Of Utah Health Schwebach, Adam PhD Bountiful UT. 84010 291 S 200 W NeuroPsychology of Utah p 801.295.8523 415 S Medical Dr Farmington UT. 84025 275 N 300 W Ste D101 p 801.213.3200 Ste 404 Hospital Affiliation Bountiful UT. 84010 Kaysville UT. 84037 - Lakeview Hospital p 801.683.1062 Hospital Affiliation p 801.614.5866 - University of Utah Hospital Scholand, Mary B MD Hatch, J S PsyD Sharifan, Tara PSYD University of Utah Health University of Utah Health Mower, Richard K PhD Busy Bee Pediatrics 165 N University Ave 291 S 200 W Richard King Mower 520 E Medical Dr Farmington UT. 84025 Farmington UT. 84025 505 S Main St Ste 301 p 801.213.3200 p 801.213.3200 Bountiful UT. 84010 Bountiful UT. 84010 p 801.292.6101 p 801.292.1464 Hospital Affiliation Hospital Affiliation - University of Utah Hospital - University of Utah Hospital

92 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Radiation Oncology Richards, Ray S MD Reproductive Endocrinology Kunkel, Gary A MD Fisher, Brandon J DO Gamma West Cancer Services Blauer, Keith University of Utah Health Gamma West Cancer Services 2132 N 1700 W Reproductive Care Center 165 N University Ave 2132 N 1700 W Ste B101 1725 E 1450 S Farmington UT. 84025 Layton UT. 84041 Layton UT. 84041 Ste 300 p 801.581.7724 p 801.807.7777 p 801.807.7777 Clearfield UT. 84015 p 801.784.5484 Hospital Affiliation Hospital Affiliation Hospital Affiliation - University of Utah Hospital - Ogden Regional Medical - St George Regional Hospital Kozola Maas, Kristi Ann Center MD Stromquist, Don L MD - St Marks Hospital Radiology Reproductive Care Center University of Utah Health - Davis Hospital Holmes, Stephanie M MD 1725 E 1450 S 165 N University Ave - Timpanogos Regional Hospital University of Utah Health Ste 300 Farmington UT. 84025 201 W Layton Pkwy Clearfield UT. 84015 p 801.213.3200 Hansen, Roger S MD Ste 3B p 801.784.5484 Gamma West Cancer Services Layton UT. 84041 Hospital Affiliation 2132 N 1700 W p 801.662.5600 Hospital Affiliation - University of Utah Hospital Ste B101 - Davis Hospital Layton UT. 84041 Hospital Affiliation Skilled Nursing Facility p 801.807.7777 - University of Utah Hospital Peterson, C Matthew MD Avalon Care Center - University Of Utah Health Bountiful Hospital Affiliation Jensen, Paul R MD 165 N University Ave 523 N Main St - Ogden Regional Medical Tanner Memorial Clinic Farmington UT. 84025 Bountiful UT. 84010 Center 2121 N 1700 W p 801.213.2995 p 801.951.2273 - Davis Hospital Layton UT. 84041 - Salt Lake Regional Medical p 801.773.4840 Hospital Affiliation Rocky Mountain Care - Center - University of Utah Hospital Clearfield - St Marks Hospital Hospital Affiliation 1481 E 1450 S - Ogden Regional Medical Reproductive Care Center Clearfield UT. 84015 Harris, Robert A MD Center 1725 E 1450 S p 801.397.4300 Gamma West Cancer Services - Brigham City Community Ste 300 2132 N 1700 W Hospital Clearfield UT. 84015 Life Care Center of Ste B101 - Lakeview Hospital p 801.784.5484 Bountiful Layton UT. 84041 - Lone Peak Hospital 460 W 2600 S p 801.807.7777 UUHC Centerville Clinic Bountiful UT. 84010 Kennard, Richard F MD 26 S Main St p 801.295.3135 Hospital Affiliation Tanner Memorial Clinic Centerville UT. 84014 - Ogden Regional Medical Mon-Fri 5pm-8pm Sat p 801.693.7900 North Canyon Center 9am-3pm 350 S 400 E - Davis Hospital 2121 N 1700 W Residential Treatment Facility Bountiful UT. 84010 - St Marks Hospital Layton UT. 84041 Cold Creek Behavioral p 801.397.4700 - Timpanogos Regional Hospital p 801.773.4840 Health 521 N Sportsplex Dr South Davis Specialty Care Hayes, John K MD Lee, Steven B MD Kaysville UT. 84037 481 S 400 E Gamma West Cancer Services Tanner Memorial Clinic p 801.593.6777 Ste 200 2132 N 1700 W 2121 N 1700 W Bountiful UT. 84010 Ste B101 Layton UT. 84041 Rheumatology p 801.295.2361 Layton UT. 84041 p 801.773.4840 Breviu, Brian A MD p 801.807.7777 University of Utah Health Sleep Disorders Center Hospital Affiliation 165 N University Ave Precision Diagnostic Hospital Affiliation - Lakeview Hospital Farmington UT. 84025 Services - St Marks Hospital - St Marks Hospital p 801.581.7724 2307 N Hill Field Rd - Salt Lake Regional Medical - Brigham City Community Ste 102 Center Hospital Hospital Affiliation Layton UT. 84041 - Davis Hospital - Lone Peak Hospital - University of Utah Hospital p 801.266.0399 - Timpanogos Regional Hospital Open Imaging - Layton Hoggan, Ryan MD Sleep Medicine Reilly, Mark W MD 2071 N Layton Tanner Memorial Clinic Chua, Milton M MD Gamma West Cancer Services Ste 100 2121 N 1700 W University of Utah Health 2132 N 1700 W Layton UT. 84041 Layton UT. 84041 165 N University Ave Ste B101 p 801.825.4040 p 801.773.4840 Farmington UT. 84025 Layton UT. 84041 p 801.213.3200 p 801.807.7777 Hospital Affiliation Hospital Affiliation - University of Utah Hospital - St Marks Hospital - Salt Lake Regional Medical Center - Jordan Valley Medical Center - Davis Hospital 93 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Hammond, Gregory D MD Wasatch Pediatrics - Elliott, Hannah LCSW Harmon, Jordan LCSW Lakeview Intermal Medicine Bountiful (Grow Up Great) University of Utah Health Cedar Psychiatry and Surgery 620 E Medical Dr 165 N University Ave 2950 N Church St 520 E Medical Dr Ste 100 Farmington UT. 84025 Ste 101 Ste 200 Bountiful UT. 84010 p 801.213.8841 Layton UT. 84040 Bountiful UT. 84010 p 801.295.2888 p 801.369.8989 p 801.294.9338 Ewanowski, Julia LCSW Buchanan, Rachal University of Utah Health Hospital Affiliation Hospital Affiliation University Of Utah Health 165 N University Ave - Mountain View Hospital - Lakeview Hospital 165 N University Ave Farmington UT. 84025 (UT) Farmington UT. 84025 p 801.213.3200 - Utah Valley Hospital Precision Diagnostic p 801.213.3200 Services 26 S Main St Hernandez, Kelsey A LCSW 2307 N Hill Field Rd Hospital Affiliation Centerville UT. 84014 The OCD And Anxiety Ste 102 - University of Utah Hospital p 801.693.7900 Treatment Center Layton UT. 84041 1459 N Main St p 801.266.0399 Capel, Adam B LCSW Hospital Affiliation Ste 100 Wellsprings Clinic - University of Utah Hospital Bountiful UT. 84010 Tucker, Brady J MD 425 Medical Dr p 801.298.2000 Tanner Memorial Clinic Ste 109 Falk, Joshua S LCSW 2121 N 1700 W Bountiful UT. 84010 University of Utah Health Kelsey A Hernandez CMHC Layton UT. 84041 p 801.641.8569 165 N University Ave 2317 N Hill Field Rd p 801.773.4840 Farmington UT. 84025 Ste 103 Champlin, Timothy M CSW p 801.213.3200 Layton UT. 84041 Social Worker Valley Behavioral Health p 801.896.7559 Alexander, Karolee LCSW 1785 E 1450 S 26 S Main St Center for Growth and Ste 380 Centerville UT. 84014 Herrera, Bryce LCSW Potential Clearfield UT. 84015 p 801.693.7900 University of Utah Health 1785 E 1450 S p 888.949.4864 26 S Main St Ste 250 Francis, Gina D LCSW Centerville UT. 84014 Clearfield UT. 84015 Cook, Ann G LCSW Francis Counseling Center p 801.693.7900 p 801.773.0535 University of Utah Health 82 E Antelope Dr 165 N University Ave Layton UT. 84041 Hospital Affiliation Anson, Marc L LCSW Farmington UT. 84025 p 801.298.2000 - University of Utah Hospital Anson Family Counseling p 801.213.3200 LLC Gloshen, Tonya S LCSW Hess, Leeanne M LCSW 1141 W 3090 S 26 S Main St Serenity Counseling University of Utah Health Syracuse UT. 84075 Centerville UT. 84014 Services 291 S 200 W p 385.439.1926 p 801.693.7900 890 N Heritage Park Blvd Farmington UT. 84025 Ste 104 p 801.213.3200 Bargar, Sarah A LCSW Hospital Affiliation Layton UT. 84041 Grandview Family - University of Utah Hospital p 801.556.8080 Hospital Affiliation Counseling - University of Utah Hospital 1576 S 500 W Daich, Nathan G LCSW Hakes, Chris C LCSW Ste 202 Aspire Counseling Aspen Ridge Counseling Higgins, Michael P LCSW Bountiful UT. 84010 2317 N Hill Field Rd 585 W 500 S University of Utah Health p 801.406.9002 Ste 103 Ste 200 165 N University Ave Layton UT. 84041 Bountiful UT. 84010 Farmington UT. 84025 Bradford, Lisa LCSW p 435.225.6520 p 801.990.4300 p 801.213.8841 Resilient Solutions Inc 1355 N Main St Dorsey Lamoreaux, Alina Hales, Mark T LCSW 26 S Main St Ste 1 LCSW 735 S 1750 W Centerville UT. 84014 Bountiful UT. 84010 The OCD And Anxiety Syracuse UT. 84075 p 801.693.7900 p 801.259.3883 Treatment Center p 801.389.2112 1459 N Main St Howick, Brennan P CSW Braun, Daniel S LCSW Ste 100 Hampton, Kathryn M LCSW Valley Behavioral Health Wasatch Pediatrics - Bountiful UT. 84010 725 N 300 E 1785 E 1450 S Farmington p 801.298.2000 Bountiful UT. 84010 Ste 300 491 W Bourne Cir p 801.698.6079 Clearfield UT. 84015 Farmington Fields Bldg 1 Eldredge, David G LCSW p 888.949.4864 Farmington UT. 84025 University of Utah Health Harding, Stephanie LCSW p 801.939.9111 165 N University Ave Comprehensive Hughes, Kathryn M LCSW Farmington UT. 84025 Psychological Services Grandview Family p 801.213.8841 2950 Church St Counseling Ste 101A 1576 S 500 W Hospital Affiliation Layton UT. 84040 Ste 202 - Primary Childrens Hospital p 801.483.1600 Bountiful UT. 84010 p 801.406.9002 94 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Jackson, Amanda LCSW 26 S Main St Maestas, Rio CSW Morrell-Hughes, Barbara Cedar Psychiatry Centerville UT. 84014 The OCD And Anxiety LCSW 2950 N Church St p 801.693.7900 Treatment Center 327 W Gordon Ave Ste 101 1459 N Main St Ste 2 Layton UT. 84040 Hospital Affiliation Ste 100 Layton UT. 84041 p 801.369.8989 - University of Utah Hospital Bountiful UT. 84010 p 801.726.1388 p 801.298.2000 Jackson, Melanie LCSW Lamb, Joseph LCSW Morrision, James R LCSW Resilient Solutions Inc University of Utah Health Manwaring, Todd LCSW Valley Behavioral Health 1355 N Main St 165 N University Ave The OCD And Anxiety 1785 E 1450 S Ste 1 Farmington UT. 84025 Treatment Center Ste 380 Bountiful UT. 84010 p 801.213.3200 1459 N Main St Clearfield UT. 84015 p 801.721.1013 Ste 100 p 888.949.4864 26 S Main St Bountiful UT. 84010 Jensen, Jill CSW Centerville UT. 84014 p 801.298.2000 Mullaney, Edward LCSW The OCD And Anxiety p 801.693.7900 University of Utah Health Treatment Center Margolis, Amber LCSW 165 N University Ave 1459 N Main St Hospital Affiliation University of Utah Health Farmington UT. 84025 Ste 100 - University of Utah Hospital 165 N University Ave p 801.213.8841 Bountiful UT. 84010 Farmington UT. 84025 p 801.298.2000 Lancaster, Steven LCSW p 801.213.3200 26 S Main St Solstone Counseling Centerville UT. 84014 Jensen, Tyson LCSW 1353 N 1075 W 26 S Main St p 801.693.7900 Aspen Ridge Counseling Ste 204 Centerville UT. 84014 585 W 500 S Farmington UT. 84025 p 801.693.7900 Negrette, Michael A LMFT Ste 200 p 385.280.2384 NCS Bountiful UT. 84010 McFadden, Molly Q LCSW 475 N 300 W p 801.990.4300 University of Utah Health University of Utah Health Ste 14 291 S 200 W 26 S Main St Kaysville UT. 84037 Johnson, Lisa LCSW Farmington UT. 84025 Centerville UT. 84014 p 801.390.3210 Lisa D.S. Johnson, LLC p 801.213.3200 p 801.693.7900 2317 N Hill Field Rd Nelson, Michelle M LCSW Ste 103 Leggitt, Valerie LCSW McFarland, Maryanne LCSW University of Utah Health Layton UT. 84041 Aspen Ridge Counseling LeafCrest Counseling 165 N University Ave p 801.388.2219 585 W 500 S 506 S Main Farmington UT. 84025 Ste 200 Ste 100 p 801.213.3200 Jones, Heather C LCSW Bountiful UT. 84010 Bountiful UT. 84010 University of Utah Health p 801.990.4300 p 801.510.6864 26 S Main St 291 S 200 W Centerville UT. 84014 Farmington UT. 84025 Lopez, Marta LCSW Milligan, Margaret LCSW p 801.693.7900 p 801.213.3200 University of Utah Health Wasatch Pediatrics - 165 N University Ave Farmington Hospital Affiliation Hospital Affiliation Farmington UT. 84025 491 W Bourne Cir - University of Utah Hospital - University of Utah Hospital p 801.213.3200 Farmington Fields Bldg 1 Farmington UT. 84025 Newberry, Diana L LCSW Jones, Lachelle LCSW 26 S Main St p 801.939.9111 Heritage Counseling, PLLC Wasatch Pediatrics - Centerville UT. 84014 1747 Heritage Ln Farmington p 801.693.7900 Wasatch Pediatrics - Ste B103 491 W Bourne Cir Bountiful (Grow Up Great) Syracuse UT. 84075 Farmington Fields Bldg 1 Hospital Affiliation 620 E Medical Dr p 801.525.6975 Farmington UT. 84025 - University of Utah Hospital Ste 100 p 801.939.9111 Bountiful UT. 84010 Nielsen, F Ann LCSW Loveland, Matthew T LCSW p 801.295.2888 Ann Nielsen, MSW, LCSW Wasatch Pediatrics - New Directions Counseling 1433 N 1075 W Bountiful (Grow Up Great) 31 W Ctr St Milne, Wade O LCSW Ste 120 620 E Medical Dr Kaysville UT. 84037 University of Utah Health Farmington UT. 84025 Ste 100 p 801.660.5557 291 S 200 W p 801.520.0073 Bountiful UT. 84010 Farmington UT. 84025 p 801.295.2888 Mack, Kimberly LCSW p 801.213.3200 Nielsen, Natalie A LCSW Ascendant Behavioral Tranquility of Mind Keshavarz, Yasaman LCSW Health Hospital Affiliation 2363 N Hill Field Rd University of Utah Health 1133 N Main - St George Regional Hospital Ste 6 165 N University Ave Ste 128 Layton UT. 84041 Farmington UT. 84025 Layton UT. 84041 p 801.928.8973 p 801.213.3200 p 801.872.5516

95 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. OReilly, Laree C MSW Plummer, Kristine LCSW Steed, Lisa M LCSW Vezie, Linda LCSW Neurobehavioral Center for Resilient Solutions Inc Resilient Solutions Inc University of Utah Health Growth 1355 N Main St 1355 N Main St 165 N University Ave 327 W Gordon Ave Ste 1 Ste 1 Farmington UT. 84025 Ste 2 Bountiful UT. 84010 Bountiful UT. 84010 p 801.213.8841 Layton UT. 84041 p 801.336.6363 p 801.259.3883 p 801.683.1062 26 S Main St Porschatis, Amber M LCSW Tellesbo, Sarah M LCSW Centerville UT. 84014 415 S Medical Dr University of Utah Health Cedar Psychiatry p 801.693.7900 Ste D101 165 N University Ave 2950 N Church St Bountiful UT. 84010 Farmington UT. 84025 Ste 101 Wall, Ainsley C MSW p 801.683.1062 p 801.213.3200 Layton UT. 84040 Aspire Counseling and p 801.369.8989 Consulting Ossip, Elizabeth LCSW 26 S Main St 2317 N Hill Field Rd Stepstone Connect Centerville UT. 84014 Tenney, Joseph T LCSW Ste 103 837 S 500 W p 801.693.7900 Valley Behavioral Health Layton UT. 84041 Ste 102 1785 E 1450 S p 801.814.1074 Bountiful UT. 84010 Robertson, Russell LCSW Ste 300 p 801.888.3843 Reflections Counseling Clearfield UT. 84015 Watson, Sandy K LCSW 2317 N Hill Field Rd p 888.949.4864 466 N Main St Painter, Lindsey CSW Ste 103 Ste 201C The OCD And Anxiety Layton UT. 84041 Thompson, Victoria LCSW Clearfield UT. 84015 Treatment Center p 801.690.0951 Tanner Memorial Clinic p 801.776.6906 1459 N Main St 1477 N 2000 W Ste 100 Salais Roden, Teresa S Clearfield UT. 84015 Whitlock, Megan J LCSW Bountiful UT. 84010 LCSW p 801.773.4840 University of Utah Health p 801.298.2000 Salais Counseling 26 S Main St 2363 N Hill Field Rd Torres-George, Christian Centerville UT. 84014 Paredes-Mora, Rocio F Ste 6 P LCSW p 801.693.7900 LCSW Layton UT. 84041 University of Utah Health RPM Counseling Services p 801.525.4645 165 N University Ave Hospital Affiliation 845 S Main St Farmington UT. 84025 - University of Utah Hospital Ste C-5 Sathiyanathan, Nisha p 801.213.8841 Bountiful UT. 84010 LCSW Willard, Holly LCSW p 801.554.2554 The OCD And Anxiety 26 S Main St Grandview Family Treatment Center Centerville UT. 84014 Counseling Parker, Cindie LCSW 1459 N Main St p 801.693.7900 1576 S 500 W 236 W 1400 N Ste 100 Ste 202 Bountiful UT. 84010 Bountiful UT. 84010 Hospital Affiliation Bountiful UT. 84010 p 801.309.8170 p 801.298.2000 - University of Utah Hospital p 801.406.9002

Paul, Derai LCSW Scott, Dennis M LCSW Tucker, Richard L LCSW Williamson, Jessica CSW DP Counseling 1454 N Hillfield Rd Tucker Counseling The OCD And Anxiety 2363 N Hill Field Rd Ste 1 1436 Legend Hills Dr Treatment Center Ste 7 Layton UT. 84041 Ste 333 1459 N Main St Layton UT. 84041 p 801.593.6000 Clearfield UT. 84015 Ste 100 p 801.589.1822 p 801.644.7129 Bountiful UT. 84010 Sill, Lynne LCSW p 801.298.2000 Peterson, Paul J LCSW The OCD And Anxiety Uckerman, Clifton R LCSW The OCD And Anxiety Treatment Center Ascendant Behavioral Wise, Kirt D LCSW Treatment Center 1459 N Main St Health New Directions Counseling 1459 N Main St Ste 100 1133 N Main Services Ste 100 Bountiful UT. 84010 Ste 128 31 W Ctr St Bountiful UT. 84010 p 801.298.2000 Layton UT. 84041 Kaysville UT. 84037 p 801.298.2000 p 801.872.5516 p 801.660.5557 Skinner, Ageuda LCSW Phillips, Rebecca A LCSW 447 N 300 W Valdez, Danielle LCSW Wood, Felicia LCSW University of Utah Health Ste 6 University of Utah Health Aspen Ridge Counseling 26 S Main St Kaysville UT. 84037 26 S Main St 585 W 500 S Centerville UT. 84014 p 801.828.5189 Centerville UT. 84014 Ste 200 p 801.693.7900 p 801.693.7900 Bountiful UT. 84010 Smith, Deanna LCSW p 801.990.4300 Hospital Affiliation The OCD And Anxiety Hospital Affiliation - University of Utah Hospital Treatment Center - University of Utah Hospital 1459 N Main St Ste 100 Bountiful UT. 84010 p 801.298.2000 96 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Woodard, Jeness L LCSW Harker, Lyssandra SLP 280 N Main St Davis Orthopedics and University of Utah Health Tanner Memorial Clinic Bountiful UT. 84010 Sports Medicine 165 N University Ave 2121 N 1700 W p 801.662.4949 2132 N 1700 W Farmington UT. 84025 Layton UT. 84041 Ste 230 p 801.213.3200 p 801.773.4840 Siciliano, Anna CCC-SLP Layton UT. 84041 Tanner Memorial Clinic p 801.773.3900 26 S Main St Hospital Affiliation 2121 N 1700 W Centerville UT. 84014 - Davis Hospital Layton UT. 84041 Hospital Affiliation p 801.693.7900 p 801.773.4840 - Davis Hospital *Hirte, Kimberly SLP Speech Therapy Primary Childrens Rehab Hospital Affiliation Martindale, Brett W MD Brinkmeyer, Ashley R SLP 280 N Main St - Davis Hospital Ogden Clinic - Davis Ability Innovations Bountiful UT. 84010 Family Physicians 365 W 1550 N p 801.662.4949 Smith, Mekell J SLP 3225 W Gordon Ave Layton UT. 84041 Ability Innovations Ste 1 p 801.618.7903 Keate, Megan SLP 365 W 1550 N Layton UT. 84041 Tanner Memorial Clinic Ste H p 801.475.3000 Buchanan, Brooke C SLP 2121 N 1700 W Layton UT. 84041 Ability Innovations Layton UT. 84041 p 801.618.7903 Ogden Clinic 365 W 1550 N p 801.773.4840 537 N Kays Dr Ste H *Taylor, Christopher SLP Kaysville UT. 84037 Layton UT. 84041 *Maughan, Page SLP Primary Childrens Rehab p 801.475.3500 p 801.618.7903 Primary Childrens Rehab 201 W Layton Pkwy 3rd Fl 201 W Layton Pkwy 3rd Fl Layton UT. 84041 991 W Shepard Ln *Chachas, Christine SLP Layton UT. 84041 p 801.543.6630 Ste 200 Primary Childrens Rehab p 801.543.6630 Farmington UT. 84025 201 W Layton Pkwy 3rd Fl 280 N Main St p 801.397.6080 Layton UT. 84041 280 N Main St Bountiful UT. 84010 p 801.543.6630 Bountiful UT. 84010 p 801.662.4949 Thomas, Bruce E MD p 801.662.4949 Mountain View Orthopaedics 280 N Main St Hospital Affiliation & Sports Medicine Bountiful UT. 84010 Mays, Elizabeth SLP - Primary Childrens Hospital 1477 N 2000 W p 801.662.4949 Ability Innovations Ste B 365 W 1550 N Walker, Megan C SLP Clinton UT. 84015 *Christensen, Hailee A SLP Ste H Ogden Clinic - Mountain p 801.475.5683 Primary Childrens Rehab Layton UT. 84041 West ENT 280 N Main St p 801.618.7903 1551 S Renaissance Towne University of Utah Health Bountiful UT. 84010 Dr 165 N University Ave p 801.662.4949 *Muller, Kacee M SLP Ste 310 Farmington UT. 84025 Primary Childrens Rehab Bountiful UT. 84010 p 801.213.3200 *Fintak, Emily A SLP 201 W Layton Pkwy 3rd Fl p 801.295.5581 Primary Childrens Hospital Layton UT. 84041 Hospital Affiliation 280 N Main St p 801.543.6630 2255 N 1700 W - Ogden Regional Medical Bountiful UT. 84010 Ste 200 Center p 801.662.4949 280 N Main St Layton UT. 84041 Bountiful UT. 84010 p 801.776.2180 Thurston, McKennan J MD Gudim, Katherine SLP p 801.662.4949 Tanner Memorial Clinic Ability Innovations Sports Medicine 1750 E 3100 N 365 W 1550 N Nelson, Breanna R SLP Anderson, Laura M MD Layton UT. 84040 Ste H Neurobehavioral Center for University of Utah Health p 801.773.4840 Layton UT. 84041 Growth 165 N University Ave p 801.618.7903 327 W Gordon Ave Farmington UT. 84025 2121 N 1700 W Ste 2 p 801.213.8841 Layton UT. 84041 *Guttenplan, Michelle D Layton UT. 84041 p 801.773.4840 *SLP p 801.683.1062 Hospital Affiliation Primary Childrens Rehab - University of Utah Hospital Hospital Affiliation 201 W Layton Pkwy 3rd Fl 415 S Medical Dr - Davis Hospital Layton UT. 84041 Ste D101 DeMordaunt, Dallin L p 801.543.6630 Bountiful UT. 84010 Davis Orthopedics and Watson, Brent T MD p 801.683.1062 Sports Medicine - Clinton Davis Orthopedics And 280 N Main St 1407 N 2000 W Sports Medicine - Clinton Bountiful UT. 84010 *Park, Christine M SLP Ste F 1407 N 2000 W p 801.662.4949 Primary Childrens Rehab Clinton UT. 84015 Ste F 201 W Layton Pkwy 3rd Fl p 801.773.3902 Clinton UT. 84015 Hospital Affiliation Layton UT. 84041 p 801.773.3902 - University of Utah Hospital p 801.543.6630

97 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Davis Orthopedics CareNow Urgent Care Hotaling, James M MD Stevenson, Bradford J MD 2132 N 1700 W 1512 Renaissance Town Dr University of Utah Health Ogden Clinic Ste 230 Ste 100 165 N University Ave 201 W Layton Pkwy Layton UT. 84041 Bountiful UT. 84010 Farmington UT. 84025 Ste 420 p 801.773.3900 p 801.295.6483 p 801.213.3200 Layton UT. 84041 p 801.475.3000 Hospital Affiliation Ward, Raymond P MD Hospital Affiliation - Davis Hospital Ogden Clinic - Cope Family - University of Utah Hospital Hospital Affiliation - Ogden Regional Medical Medicine - Davis Hospital Center 185 S 400 E Johnson, Gary B MD Ste 100 Weekend Vasectomy Clinic Stevenson, Scott M MD Yenna, Zachary MD Bountiful UT. 84010 1551 S Renaissance Towne Tanner Memorial Clinic Davis Orthopedics & Sports p 801.397.6200 Dr 2121 N 1700 W Medicine - Clinton Ste 370 Layton UT. 84041 1407 N 2000 W Hospital Affiliation Bountiful UT. 84010 p 801.773.4840 Ste F - Lakeview Hospital p 844.764.7733 Clinton UT. 84015 Hospital Affiliation p 801.773.3902 Wee Care Pediatrics, 24 Hospital Affiliation - Davis Hospital hrs a day 7 days a week - Salt Lake Regional Medical Davis Orthopedics & Sports (Appts Preferred) Center Summers, Stephen J MD Medicine 2084 N 1700 W - Jordan Valley Medical University of Utah Health 2132 N 1700 W Ste A Center West Valley Campus 165 N University Ave Ste 230 Layton UT. 84041 - Lakeview Hospital Farmington UT. 84025 Layton UT. 84041 p 801.773.8644 p 801.213.3200 p 801.773.3900 ONeil, Brock B MD Urogynecology University of Utah Health Hospital Affiliation Substance Abuse Facility Norton, Peggy A MD 165 N University Ave - University of Utah Hospital Cold Creek Behavioral University of Utah Health Farmington UT. 84025 Health 165 N University Ave p 801.213.3200 Wayment, Robert D MD 521 N Sportsplex Dr Farmington UT. 84025 Ogden Clinic Kaysville UT. 84037 p 801.587.1950 Hospital Affiliation 201 W Layton Pkwy p 801.593.6777 - University of Utah Hospital Ste 420 Hospital Affiliation Layton UT. 84041 Urgent Care - University of Utah Hospital Parkinson, Justin P MD p 801.475.3000 Medallus Medical Layton Granger Medical Clinic M-Sun 9am-7pm Urology Specialists Hospital Affiliation 1550 N Main St Foot, Laura M MD 1551 S Renaissance Town - Ogden Regional Medical Ste E Tanner Memorial Clinic Dr Center Layton UT. 84041 2121 N 1700 W Ste 370 - Davis Hospital p 801.614.9030 Layton UT. 84041 Bountiful UT. 84010 - Brigham City Community p 801.773.4840 p 801.797.9033 Hospital MountainStar Layton Family Medicine - Urgent Care Hospital Affiliation Weekend Vasectomy Clinic Vascular Surgery 2950 N Church St - Davis Hospital 1551 S Renaissance Towne Griffin, Claire L MD Ste 200 - Ogden Regional Medical Dr University of Utah Health Layton UT. 84040 Center Ste 370 165 N University Ave p 801.771.7700 - Salt Lake Regional Medical Bountiful UT. 84010 Farmington UT. 84025 Center p 844.764.7733 p 801.213.3200 Tanner Memorial Clinic Mon-Fri 5pm-8pm Sat Gross, Kelli X MD Hospital Affiliation Hospital Affiliation 9am-3pm University of Utah Health - Jordan Valley Medical - University of Utah Hospital 2038 W 1900 S 165 N University Ave Center Syracuse UT. 84075 Farmington UT. 84025 - Lakeview Hospital Oberg, Jon C MD p 801.773.4840 p 801.213.3200 - Jordan Valley Medical Tanner Memorial Clinic Center West Valley Campus 2121 N 1700 W 2121 N 1700 W Hospital Affiliation - Salt Lake Regional Medical Layton UT. 84041 Layton UT. 84041 - University of Utah Hospital Center p 801.773.4840 p 801.773.4840 Henderson, David J MD Reynolds, James R MD Hospital Affiliation 380 N 400 W Lakeview Urology and Tanner Memorial Clinic - Davis Hospital Kaysville UT. 84037 General Surgery 2121 N 1700 W - Lakeview Hospital p 801.773.4840 620 E Medical Dr Layton UT. 84041 Ste 300 p 801.773.4840 Bountiful UT. 84010 p 801.298.3247 Hospital Affiliation - Davis Hospital Hospital Affiliation - Ogden Regional Medical - Lakeview Hospital Center - Davis Hospital - Salt Lake Regional Medical Center 98 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Wound Care Hwang, Chun MD Edgepark Pacific Medical Inc Barney, Douglas P MD Revere Health Phone Number Only Phone Number Only Hyperbaric and Wound Care 250 W 300 N 2nd Fl p 800.321.0591 p 800.726.9180 Center Roosevelt UT. 84066 2132 N 1700 W p 801.377.4623 Roche Insulin Delivery RespirTech Ste 100 Systems Inc Phone Number Only Layton UT. 84041 Hospital Affiliation Phone Number Only p 800.793.1261 p 801.807.7900 - Timpanogos Regional Hospital p 800.280.7801 Roche Insulin Delivery Hospital Affiliation Weaver, Aaron N MD US MED LLC Systems Inc - Davis Hospital Revere Health Phone Number Only Phone Number Only 250 W 300 N p 800.787.6331 p 800.280.7801 Johnson, Sherman B MD Ste 203 AccuHeal Wound Care Roosevelt UT. 84066 United States Medical Smith Nephew Inc (Muscle 747 Sheringham Ct p 801.437.4366 Supply Stimulators) Farmington UT. 84025 Phone Number Only Phone Number Only p 801.964.2008 Hospital Affiliation p 877.840.8218 p 800.821.5700 - Timpanogos Regional Hospital Duchesne County - Mountain View Hospital Durable Medical Equipment US MED LLC (UT) Alpine Home Medical Phone Number Only Audiology Phone Number Only p 800.787.6331 Fox, C B CCC-A Counseling p 800.686.7993 Audiology Associates of Child, Grant LPC Uintah Basin Medical Holladay Northeastern Counseling CCS Medical Center - Durable Medical 57 N 100 E Center Phone Number Only Equipment Ste 2 285 W 800 S p 800.726.9811 26 W 200 N Roosevelt UT. 84066 Roosevelt UT. 84066 Ste 78-15 p 800.244.9001 p 435.725.6300 Care Rehab and Orthopedic Roosevelt UT. 84066 Products (Muscle p 435.722.2418 Fox, Damon B CCC-A Clover, Daniel LMFT Stimulators) Audiology Associates of Northeastern Utah Medical Phone Number Only United States Medical Holladay Group p 800.487.9644 Supply 57 N 100 E 210 W 300 N Phone Number Only Ste 2 Roosevelt UT. 84066 DJO Global p 877.840.8218 Roosevelt UT. 84066 p 435.247.4279 Phone Number Only p 800.244.9001 p 800.336.6569 Ear Nose And Throat Danley, Rochelle L LPC Catten, Michael MD Breast Pumps Northeastern Counseling Dynasplint Systems Inc Northeastern Utah Medical Alpine Home Medical Center Phone Number Only Group Phone Number Only 285 W 800 S p 800.638.6771 210 W 300 N p 800.686.7993 Roosevelt UT. 84066 Ste 75-3 p 435.725.6300 EBI LLC (Bone Stimulators) Roosevelt UT. 84066 Edgepark Phone Number Only p 435.722.6144 Phone Number Only Dermatology p 800.526.2579 p 800.321.0591 Blake, John MD Hospital Affiliation Northeastern Utah Medical Edgepark - Uintah Basin Medical Cardiac Monitoring Group Phone Number Only Center Remote Cardiac Services 210 W 300 N p 800.321.0591 - Ashley Valley Regional Phone Number Only Ste 201 Medical Center p 800.367.0300 Roosevelt UT. 84066 Empi Inc (Neuromuscular p 435.725.2030 Stimulator) Whiting, Phillip MD eCardio Diagnostics Phone Number Only Northeastern Utah Medical Phone Number Only Hospital Affiliation p 800.328.2536 Group p 888.400.3522 - Uintah Basin Medical 210 W 300 N Center KCI USA Inc (Wound Vac Roosevelt UT. 84066 Cardiology - Ashley Valley Regional Only) p 435.722.6143 Carter, Melvin E MD Medical Center Phone Number Only Revere Health p 800.275.4524 Family Practice 250 W 300 N Diabetic Supplies Dodenbier, Cindie MD Ste 203 CCS Medical Orthofix Inc (Bone Growth C & B Family Practice Roosevelt UT. 84066 Phone Number Only Stimulators Physicians 4601 N 16750 W p 801.437.4366 p 800.726.9811 Only) Altonah UT. 84002 Phone Number Only p 801.725.6872 Hospital Affiliation p 800.535.4492 - Timpanogos Regional Hospital - Mountain View Hospital (UT)

99 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Graham, Gary F MD Wells, John S MD Syndergaard, Clayton S DO Internal Medicine Northeastern Utah Medical Northeastern Utah Medical Northeastern Utah Medical Garcia, Joseph MD Group Group Group Northeastern Utah Medical 210 W 300 N 210 W 300 N 210 W 300 N Group Ste 201 Ste 75-3 Ste 75-12 210 W 300 N Roosevelt UT. 84066 Roosevelt UT. 84066 Roosevelt UT. 84066 Roosevelt UT. 84066 p 435.725.2030 p 435.722.3971 p 435.722.4652 p 435.722.4691

Hospital Affiliation Hospital Affiliation Hospital Affiliation Uinta Basin Medical Center - Uintah Basin Medical - Uintah Basin Medical - Uintah Basin Medical 250 W 300 N Center Center Center Roosevelt UT. 84066 p 435.722.4691 Larsen, Brett PA Wheeler, Jeffrey L DO Williams, Ben D MD Northeastern Utah Medical Northeastern Utah Medical Northeastern Utah Medical Hospital Affiliation Group Group Group - Uintah Basin Medical 210 W 300 N 210 W 300 N 210 W 300 N Center Ste 75-3 Ste 75-3 Ste 75-12 Roosevelt UT. 84066 Roosevelt UT. 84066 Roosevelt UT. 84066 Qureshi, Shakaib MD p 435.722.4541 p 435.722.3971 p 435.722.4652 Northeastern Utah Medical Group Hospital Affiliation Hospital Affiliation Hospital Affiliation 210 W 300 N - Uintah Basin Medical - Uintah Basin Medical - Uintah Basin Medical Roosevelt UT. 84066 Center Center Center p 435.722.4691

*Lewis, Linda APRN White, Gary B MD Hematology And Oncology Hospital Affiliation Primary Childrens Hospital Northeastern Utah Medical Lewis, Mark A MD - Uintah Basin Medical 136 N 500 W Group Northeastern Utah Medical Center Roosevelt UT. 84066 210 W 300 N Group p 435.722.4843 Ste 75-3 210 W 300 N Smith, Kent E MD Roosevelt UT. 84066 Roosevelt UT. 84066 Northeastern Utah Medical Hospital Affiliation p 435.722.6143 p 435.722.6143 Group - University of Utah Hospital 210 W 300 N Hospital Affiliation Wilcox, Ryan E MD Ste 75-3 McKee, Darwin PA - Uintah Basin Medical Northeastern Utah Medical Roosevelt UT. 84066 Northeastern Utah Medical Center Group p 435.725.2072 Group 210 W 300 N 50 E 200 S General Surgery Roosevelt UT. 84066 250 W 300 N Duchesne UT. 84021 Baum, Kerry MD p 435.722.6143 Roosevelt UT. 84066 p 435.738.2426 Northeastern Utah Medical p 435.722.4691 Group Hospital Affiliation Morrill, L L DO 210 W 300 N - St George Regional Hospital Hospital Affiliation Northeastern Utah Medical Roosevelt UT. 84066 - Cedar City Hospital - Uintah Basin Medical Group p 435.722.6143 Center 210 W 300 N Hospice Ste 201 Lewis, Dennis M MD Rocky Mountain Hospice Staker, Gregory MD Roosevelt UT. 84066 Unitah Basin Medical 590 E 100 N Northeastern Utah Medical p 434.722.6130 Center Ste 3 Group 250 W 300 N Mountain Home UT. 84051 210 W 300 N Hospital Affiliation Roosevelt UT. 84066 p 435.637.0665 Ste 75-3 - Uintah Basin Medical p 435.781.2161 Roosevelt UT. 84066 Center Uintah Basin Medical p 435.725.2000 Hospital Affiliation Center - Hospice Teem, Lori NP - Ashley Valley Regional 250 W 200 N Hospital Affiliation Teem Family Clinic Medical Center Roosevelt UT. 84066 - Uintah Basin Medical 51 E 800 N p 435.722.4691 Center Duchesne UT. 84021 Gynecology p 435.738.8336 Nolte, John MD Hospital Laboratory Northeastern Utah Medical Uintah Basin Medical Dominion Diagnostics Hospital Affiliation Group Center Phone Number Only - Uintah Basin Medical 205 W 300 N 250 W 300 N p 877.734.9600 Center Roosevelt UT. 84066 Ste 75-2 p 435.722.6104 Roosevelt UT. 84066 LabCorp of America p 435.722.4691 Holdings Hospital Affiliation Phone Number Only - Uintah Basin Medical p 888.522.2677 Center

100 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Mental Health Optometry *Stacie, Mecham W APRN Bennett, Patricia S LCSW Syndergaard, Clayton S DO Kowallis, Scott H OD Primary Childrens Hospital Northeastern Counseling Northeastern Utah Medical Roosevelt Vision Clinic 136 N 500 W Center Group 165 W 200 N Roosevelt UT. 84066 285 W 800 S 210 W 300 N Roosevelt UT. 84066 p 435.722.4843 Roosevelt UT. 84066 Ste 75-12 p 435.722.2981 p 435.725.6300 Roosevelt UT. 84066 Hospital Affiliation p 435.722.4652 Wilson, Jon P OD - Primary Childrens Hospital Child, Grant LPC Roosevelt Vision Clinic Northeastern Counseling Hospital Affiliation 165 W 200 N Staker, Gregory MD Center - Uintah Basin Medical Roosevelt UT. 84066 Northeastern Utah Medical 285 W 800 S Center p 435.722.2981 Group Roosevelt UT. 84066 210 W 300 N p 435.725.6300 Williams, Ben D MD Orthopedic Surgery Ste 75-3 Northeastern Utah Medical Hansen, Mark MD Roosevelt UT. 84066 Clover, Daniel LMFT Group Northeastern Utah Medical p 435.725.2000 Northeastern Utah Medical 210 W 300 N Group Group Ste 75-12 250 W 300 N Hospital Affiliation 210 W 300 N Roosevelt UT. 84066 Roosevelt UT. 84066 - Uintah Basin Medical Roosevelt UT. 84066 p 435.722.4652 p 435.722.4541 Center p 435.247.4279 Hospital Affiliation Hospital Affiliation Physical Medicine And Rehabilitation Danley, Rochelle L LPC - Uintah Basin Medical - Uintah Basin Medical White, James MD Northeastern Counseling Center Center Northeastern Utah Medical Center Group 285 W 800 S Occupational Therapy Olsen, Gordon S DO 210 W 300 N Roosevelt UT. 84066 Concentra Medical Centers Northeastern Utah Medical Ste 75-3 p 435.725.6300 2390 Redwood Rd Group Roosevelt UT. 84066 West Valley City UT. 84419 250 W 300 N p 435.781.2030 Miller, Melody A LCSW p 888.997.2669 Roosevelt UT. 84066 Northeastern Counseling p 435.722.4541 Hospital Affiliation Center Oncology - Uintah Basin Medical 285 W 800 S Haslem, Derrick S MD Pain Management Center Roosevelt UT. 84066 Northeastern Utah Medical Dodenbier, Cindie MD - Ashley Valley Regional p 435.725.6300 Group C & B Family Practice Medical Center 210 W 300 N 4601 N 16750 W Nephrology Roosevelt UT. 84066 Altonah UT. 84002 Physical Therapy Barager, William E DO p 435.722.4691 p 801.725.6872 Concentra Medical Centers Revere Health 2390 Redwood Rd 250 W 300 N 2nd Fl Hospital Affiliation Pediatrics West Valley City UT. 84419 Roosevelt UT. 84066 - St George Regional Hospital Beales, Jason MD p 888.997.2669 p 435.722.6143 - Cedar City Hospital Northeastern Utah Medical Group Kulland, Jerry D PT Hospital Affiliation Van Meter, Margaret E MD 210 W 300 N Ashley Creek Physical - Timpanogos Regional Hospital Northeastern Utah Medical Ste 75-3 Therapy - Mountain View Hospital Group Roosevelt UT. 84066 175 W 200 N (UT) 210 W 300 N p 435.725.2000 Roosevelt UT. 84066 Roosevelt UT. 84066 p 435.722.3177 Neurology p 435.722.6143 Hospital Affiliation Buchanan, Thomas M MD - Uintah Basin Medical Seeley, Michael J DPT Unitah Basin Medical Ophthalmology Center Ashley Creek Physical Center Powell, Shane K MD Therapy 250 W 300 N Northeastern Utah Medical *Carver, Jeanlee F APRN 175 W 200 N Roosevelt UT. 84066 Group Primary Childrens Hospital Roosevelt UT. 84066 p 435.781.8464 210 W 300 N 136 N 500 W p 435.722.3177 Ste 75-3 Roosevelt UT. 84066 Hospital Affiliation Roosevelt UT. 84066 p 435.722.4843 Podiatry - Ashley Valley Regional p 435.722.4541 Gardner, Brian K DPM Medical Center Hospital Affiliation Northeastern Utah Medical - Castleview Hospital Hospital Affiliation - Primary Childrens Hospital Group - Uintah Basin Medical - Lakeview Hospital 210 W 300 N Obstetrics And Gynecology Center - Ogden Regional Medical Ste 75-3 Nolte, John MD Center Roosevelt UT. 84066 Northeastern Utah Medical p 435.722.4652 Group 205 W 300 N Hospital Affiliation Roosevelt UT. 84066 - Uintah Basin Medical p 435.722.6104 Center

Hospital Affiliation - Uintah Basin Medical 101 *The PPO AgreementCenter with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Rheumatology 90 W Main St KCI USA Inc (Wound Vac Olsen, Ingrid PA Qureshi, Shakaib MD Castle Dale UT. 84513 Only) Castleview Hospital Northeastern Utah Medical p 801.373.4366 Phone Number Only 90 W Main St Group p 800.275.4524 Castle Dale UT. 84513 210 W 300 N Hospital Affiliation p 435.381.2305 Roosevelt UT. 84066 - Timpanogos Regional Hospital Orthofix Inc (Bone Growth p 435.722.4691 Stimulators Physicians Sermon, Gabriel J PA Diabetic Supplies Only) Castleview Hospital Hospital Affiliation CCS Medical Phone Number Only 90 W Main St - Uintah Basin Medical Phone Number Only p 800.535.4492 Castle Dale UT. 84513 Center p 800.726.9811 p 435.381.2305 Pacific Medical Inc Social Worker Edgepark Phone Number Only Home Health Agency Bennett, Patricia S LCSW Phone Number Only p 800.726.9180 CNS Community Nursing Northeastern Counseling p 800.321.0591 Services Center RespirTech Phone Number Only 285 W 800 S Roche Insulin Delivery Phone Number Only Castle Dale UT. 84513 Roosevelt UT. 84066 Systems Inc p 800.793.1261 p 877.613.8887 p 435.725.6300 Phone Number Only p 800.280.7801 Roche Insulin Delivery Hospice Miller, Melody A LCSW Systems Inc CNS Community Nursing Northeastern Counseling US MED LLC Phone Number Only Services Center Phone Number Only p 800.280.7801 Phone Number Only 285 W 800 S p 800.787.6331 Castle Dale UT. 84513 Roosevelt UT. 84066 Smith Nephew Inc (Muscle p 877.613.8887 p 435.725.6300 United States Medical Stimulators) Supply Phone Number Only Internal Medicine Urology Phone Number Only p 800.821.5700 Allen, Glori M MD Snihurowych, Walter M MD p 877.840.8218 Green River Medical Center Northeastern Utah Medical US MED LLC 385 W Main Group Durable Medical Equipment Phone Number Only Green River UT. 84525 210 W 300 N Alpine Home Medical p 800.787.6331 p 435.564.3434 Ste 75-3 Phone Number Only Roosevelt UT. 84066 p 800.686.7993 United States Medical Hospital Affiliation p 435.722.4541 Supply - Castleview Hospital CCS Medical Phone Number Only Hospital Affiliation Phone Number Only p 877.840.8218 Laboratory - Castleview Hospital p 800.726.9811 Dominion Diagnostics - Uintah Basin Medical Family Practice Phone Number Only Center Care Rehab and Orthopedic Donaldson, Richard J DO p 877.734.9600 Products (Muscle Castleview Hospital Emery County Stimulators) 90 W Main St LabCorp of America Phone Number Only Castle Dale UT. 84513 Holdings Breast Pumps p 800.487.9644 p 435.381.2305 Phone Number Only Alpine Home Medical p 888.522.2677 Phone Number Only DJO Global Hospital Affiliation p 800.686.7993 Phone Number Only - Castleview Hospital Mental Health p 800.336.6569 - Mountain View Hospital Fauver, Jonathon M LCSW Edgepark (UT) Innerworks Counseling and Phone Number Only Dynasplint Systems Inc Consulting p 800.321.0591 Phone Number Only Lauridsen, Clinton D DO 365 N Center p 800.638.6771 Castleview Hospital Castle Dale UT. 84513 Cardiac Monitoring 90 W Main St p 435.820.1596 Remote Cardiac Services EBI LLC (Bone Stimulators) Castle Dale UT. 84513 Phone Number Only Phone Number Only p 435.381.2305 Occupational Therapy p 800.367.0300 p 800.526.2579 Concentra Medical Centers Hospital Affiliation 2390 Redwood Rd eCardio Diagnostics Edgepark - Castleview Hospital West Valley City UT. 84419 Phone Number Only Phone Number Only p 888.997.2669 p 888.400.3522 p 800.321.0591 Morris, Lowell PA Emery Medical Center Optometry Cardiology Empi Inc (Neuromuscular 90 W Main St Tuttle, Steven O OD Hwang, Chun MD Stimulator) Castle Dale UT. 84513 Castle Valley Eyecare Revere Health Phone Number Only p 435.381.2305 190 E Main St 367 N Main St p 800.328.2536 Castle Dale UT. 84513 Huntington UT. 84528 p 435.381.2040 p 801.373.4366

102 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Physical Medicine And Rehabilitation Skilled Nursing Facility Southwest WCHC / Mental DJO Global Johnson, Dalen L NP Emery County Care and Health Phone Number Only Castleview Hospital Rehabilitation Center 75 N 200 E p 800.336.6569 90 W Main St 455 W Mill Rd Panguitch UT. 84759 Castle Dale UT. 84513 Ferron UT. 84523 p 435.676.2443 Dynasplint Systems Inc p 435.381.2305 p 435.384.2301 Phone Number Only Hospital Affiliation p 800.638.6771 Physical Therapy Social Worker - Garfield Memorial Hospital Concentra Medical Centers Fauver, Jonathon M LCSW EBI LLC (Bone Stimulators) 2390 Redwood Rd Innerworks Counseling and Dermatology Phone Number Only West Valley City UT. 84419 Consulting Adams, Benjamin E DO p 800.526.2579 p 888.997.2669 365 N Center Cedar Dermatology Castle Dale UT. 84513 200 N 400 E Edgepark Gagon, Michael MPT p 435.820.1596 Panguitch UT. 84759 Phone Number Only ProRehab Physical Therapy p 435.586.6440 p 800.321.0591 355 E 175 S Garfield County Green River UT. 84525 Hospital Affiliation Empi Inc (Neuromuscular p 435.613.1500 Breast Pumps - Cedar City Hospital Stimulator) Alpine Home Medical Phone Number Only Labrum, Scott R MPT Phone Number Only Diabetic Supplies p 800.328.2536 ProRehab Physical Therapy p 800.686.7993 CCS Medical 150 E Main Phone Number Only KCI USA Inc (Wound Vac Castle Dale UT. 84513 Edgepark p 800.726.9811 Only) p 435.381.5100 Phone Number Only Phone Number Only p 800.321.0591 Edgepark p 800.275.4524 Player, Kirk R DPT Phone Number Only ProRehab Physical Therapy Cardiac Monitoring p 800.321.0591 Orthofix Inc (Bone Growth 150 E Main Remote Cardiac Services Stimulators Physicians Castle Dale UT. 84513 Phone Number Only Roche Insulin Delivery Only) p 435.381.5100 p 800.367.0300 Systems Inc Phone Number Only Phone Number Only p 800.535.4492 Podiatry eCardio Diagnostics p 800.280.7801 Dicks, Adam DPM Phone Number Only Pacific Medical Inc Ellsworth Foot and Ankle p 888.400.3522 US MED LLC Phone Number Only Clinic Phone Number Only p 800.726.9180 367 N Main Certified Nurse Midwife p 800.787.6331 Huntington UT. 84528 Brown, DeAnn CNM RespirTech p 801.253.6886 Wayne Community Health United States Medical Phone Number Only Center - Kazan Memorial Supply p 800.793.1261 Hospital Affiliation Clinic Phone Number Only - Castleview Hospital 570 E Moqui Ln p 877.840.8218 Roche Insulin Delivery Escalante UT. 84726 Systems Inc Griffeth, Brian J DPM p 435.425.3744 Durable Medical Equipment Phone Number Only Turnquest Retreat Inc Advantage Medical Supply p 800.280.7801 Beehive Homes Counseling 551 E Center St 15 W 100 N Draper, Theron LCSW Panguitch UT. 84759 Smith Nephew Inc (Muscle Elmo UT. 84521 Wayne Community Health p 435.690.0572 Stimulators) p 435.653.2555 Center - Kazan Memorial Phone Number Only Clinic Alpine Home Medical p 800.821.5700 Emery Medical Center 570 E Moqui Ln Phone Number Only 30 N 100 W Escalante UT. 84726 p 800.686.7993 US MED LLC Castle Dale UT. 84513 p 435.826.4374 Phone Number Only p 435.381.2305 CCS Medical p 800.787.6331 Southwest WCHC / Mental Phone Number Only Emery County Care & Health p 800.726.9811 United States Medical Rehabilitation 75 N 200 E Supply 455 W Mill Rd Panguitch UT. 84759 Care Rehab and Orthopedic Phone Number Only Ferron UT. 84523 p 435.676.2443 Products (Muscle p 877.840.8218 p 435.381.2301 Stimulators) Peyton, R Michael LMFT Phone Number Only Family Practice Emery Medical Center Ivan W Kazan Memorial p 800.487.9644 Birch, Richard DO 90 W Main St Clinic Garfield Memorial Clinic Castle Dale UT. 84513 570 E Moqui Ln 200 N 400 E p 435.381.2305 Escalante UT. 84726 Panguitch UT. 84759 p 435.826.4374 p 435.676.8842 Hospital Affiliation - Castleview Hospital

103 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Bryce Valley Clinic Pope, David M MD Mental Health Optometry 25 S Redrock Dr Ivan W Kazan Memorial Barusch, Nathaniel MD Drake, Eric OD Cannonville UT. 84718 Clinic Ivan W Kazan Memorial Red Rock Eye Care p 435.679.8545 570 E Moqui Ln Clinic 415 E Center St Escalante UT. 84726 570 E Moqui Ln Panguitch UT. 84759 Ivan W Kazan Memorial p 435.826.4374 Escalante UT. 84726 p 435.676.8646 Clinic p 435.826.4374 570 E Moqui Ln Southwest WCHC / Mental Gooch, Paul R OD Escalante UT. 84726 Health Southwest WCHC / Mental Red Rock Eye Care p 435.826.4374 75 N 200 E Health 415 E Center St Panguitch UT. 84759 75 N 200 E Panguitch UT. 84759 Southwest WCHC / Mental p 435.676.2443 Panguitch UT. 84759 p 435.676.8646 Health p 435.676.2443 75 N 200 E Hospital Affiliation Pace, David J OD Panguitch UT. 84759 - Sevier Valley Hospital Hospital Affiliation Southern Utah Vision Care p 435.676.2443 - Mountain View Hospital 415 E Center St Roberts, Becky S FNP (UT) Panguitch UT. 84759 Hospital Affiliation Garfield Memorial Clinic - Utah Valley Hospital p 435.676.8646 - Garfield Memorial Hospital 200 N 400 E Panguitch UT. 84759 Draper, Theron LCSW Robison, Ryan E OD Chappell, Leland J MD p 435.676.8842 Wayne Community Health Red Rock Eye Care Wayne Community Health Center - Kazan Memorial 415 E Center St Center - Kazan Memorial Bryce Valley Clinic Clinic Panguitch UT. 84759 Clinic 25 S Redrock Dr 570 E Moqui Ln p 435.676.8646 570 E Moqui Ln Cannonville UT. 84718 Escalante UT. 84726 Escalante UT. 84726 p 435.679.8545 p 435.826.4374 Orthopedic Surgery p 435.425.3744 *Allen, Lex S MD Hospital Affiliation Southwest WCHC / Mental Southern Utah Ortho Sports Southwest WCHC / Mental - Garfield Memorial Hospital Health Med-Garfield Health 75 N 200 E 200 N 400 E 75 N 200 E Snedeger, Zachary PA Panguitch UT. 84759 Panguitch UT. 84759 Panguitch UT. 84759 Wayne Community Health p 435.676.2443 p 435.586.6962 p 435.676.2443 Center - Kazan Memorial Clinic Peyton, R Michael LMFT Hospital Affiliation Hospital Affiliation 570 E Moqui Ln Ivan W Kazan Memorial - Cedar City Hospital - Sevier Valley Hospital Escalante UT. 84726 Clinic - Kane County Hospital p 435.425.3744 570 E Moqui Ln Pain Management Escalante UT. 84726 Robinson, Cole MD Mooney, Todd MD Hospital p 435.826.4374 Ivan W Kazan Memorial Garfield Memorial Clinic Garfield Memorial Hospital Clinic 200 N 400 E 200 N 400 E Southwest WCHC / Mental 570 E Moqui Ln Panguitch UT. 84759 Panguitch UT. 84759 Health Escalante UT. 84726 p 435.676.8842 p 435.676.8842 75 N 200 E p 435.826.4374 Panguitch UT. 84759 Bryce Valley Clinic Internal Medicine p 435.676.2443 Southwest WCHC / Mental 25 S Redrock Dr Assiago, Marcellus S MD Health Cannonville UT. 84718 University of Utah Health Hospital Affiliation 75 N 200 E p 435.679.8545 224 N 400 E - Garfield Memorial Hospital Panguitch UT. 84759 Panguitch UT. 84759 p 435.676.2443 Ivan W Kazan Memorial p 435.586.8827 Nephrology Clinic Assiago, Marcellus S MD Physical Medicine And Rehabilitation 570 E Moqui Ln Hospital Affiliation University of Utah Health Robinson, Cole MD Escalante UT. 84726 - University of Utah Hospital 224 N 400 E Ivan W Kazan Memorial p 435.826.4374 - Davis Hospital Panguitch UT. 84759 Clinic p 435.586.8827 570 E Moqui Ln Southwest WCHC / Mental Laboratory Escalante UT. 84726 Health Dominion Diagnostics Hospital Affiliation p 435.826.4374 75 N 200 E Phone Number Only - University of Utah Hospital Panguitch UT. 84759 p 877.734.9600 - Davis Hospital Southwest WCHC / Mental p 435.676.2443 Health LabCorp of America Occupational Therapy 75 N 200 E Hospital Affiliation Holdings Concentra Medical Centers Panguitch UT. 84759 - Garfield Memorial Hospital Phone Number Only 2390 Redwood Rd p 435.676.2443 p 888.522.2677 West Valley City UT. 84419 p 888.997.2669 Hospital Affiliation - Sevier Valley Hospital

104 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Physical Therapy Sports Medicine DJO Global LabCorp of America Barney, Matthew PT *Southern Utah Ortho Sports Phone Number Only Holdings Ivan W Kazan Memorial *Med Garfield p 800.336.6569 Phone Number Only Clinic 200 N 400 E p 888.522.2677 570 E Moqui Ln Panguitch UT. 84759 Dynasplint Systems Inc Escalante UT. 84726 p 435.586.6962 Phone Number Only Occupational Therapy p 435.826.4374 p 800.638.6771 Concentra Medical Centers Gila County 2390 Redwood Rd Southwest WCHC / Mental EBI LLC (Bone Stimulators) West Valley City UT. 84419 Health Breast Pumps Phone Number Only p 888.997.2669 75 N 200 E Alpine Home Medical p 800.526.2579 Panguitch UT. 84759 Phone Number Only Physical Therapy p 435.676.2443 p 800.686.7993 Edgepark Concentra Medical Centers Phone Number Only 2390 Redwood Rd Concentra Medical Centers Edgepark p 800.321.0591 West Valley City UT. 84419 2390 Redwood Rd Phone Number Only p 888.997.2669 West Valley City UT. 84419 p 800.321.0591 Empi Inc (Neuromuscular p 888.997.2669 Stimulator) Grand County Cardiac Monitoring Phone Number Only Cottam, Chad R DPT Remote Cardiac Services p 800.328.2536 Breast Pumps Wayne Community Health Phone Number Only Alpine Home Medical Center - Kazan Memorial p 800.367.0300 KCI USA Inc (Wound Vac Phone Number Only Clinic Only) p 800.686.7993 570 E Moqui Ln eCardio Diagnostics Phone Number Only Escalante UT. 84726 Phone Number Only p 800.275.4524 Edgepark p 435.425.3744 p 888.400.3522 Phone Number Only Orthofix Inc (Bone Growth p 800.321.0591 Southwest WCHC / Mental Diabetic Supplies Stimulators Physicians Health CCS Medical Only) Cardiac Monitoring 75 N 200 E Phone Number Only Phone Number Only Remote Cardiac Services Panguitch UT. 84759 p 800.726.9811 p 800.535.4492 Phone Number Only p 435.676.2443 p 800.367.0300 Edgepark Pacific Medical Inc Gubler, John W DPT Phone Number Only Phone Number Only eCardio Diagnostics Ivan W Kazan Memorial p 800.321.0591 p 800.726.9180 Phone Number Only Clinic p 888.400.3522 570 E Moqui Ln Roche Insulin Delivery RespirTech Escalante UT. 84726 Systems Inc Phone Number Only Counseling p 435.826.4374 Phone Number Only p 800.793.1261 Anderson, Nancy B LPC p 800.280.7801 50 E Ctr St Southwest WCHC / Mental Roche Insulin Delivery Ste 8 Health US MED LLC Systems Inc Moab UT. 84532 75 N 200 E Phone Number Only Phone Number Only p 970.708.0078 Panguitch UT. 84759 p 800.787.6331 p 800.280.7801 p 435.676.2443 Rath, Antje CMHC United States Medical Smith Nephew Inc (Muscle Moab Regional Hosptial Psychiatry Supply Stimulators) 450 W Williams Way Barusch, Nathaniel MD Phone Number Only Phone Number Only Moab UT. 84532 Ivan W Kazan Memorial p 877.840.8218 p 800.821.5700 p 435.719.3500 Clinic 570 E Moqui Ln Durable Medical Equipment US MED LLC Moab Regional Medical Escalante UT. 84726 Alpine Home Medical Phone Number Only Clinic p 435.826.4374 Phone Number Only p 800.787.6331 476 W Williams Way p 800.686.7993 Moab UT. 84532 Southwest WCHC / Mental United States Medical p 435.719.5500 Health CCS Medical Supply 75 N 200 E Phone Number Only Phone Number Only Dermatology Panguitch UT. 84759 p 800.726.9811 p 877.840.8218 Bowen, Anneli R MD p 435.676.2443 University of Utah Health Care Rehab and Orthopedic Laboratory 450 Williams Way Hospital Affiliation Products (Muscle Dominion Diagnostics Moab UT. 84532 - Mountain View Hospital Stimulators) Phone Number Only p 801.581.2955 (UT) Phone Number Only p 877.734.9600 - Utah Valley Hospital p 800.487.9644 Hospital Affiliation - University of Utah Hospital

105 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Hull, Christopher M MD Durable Medical Equipment US MED LLC Moab Regional Family University of Utah Health Alpine Home Medical Phone Number Only Medical Clinic 450 Williams Way Phone Number Only p 800.787.6331 476 W Williams Way Moab UT. 84532 p 800.686.7993 Moab UT. 84532 p 801.581.2955 United States Medical p 435.719.3508 CCS Medical Supply Laggis, Caroline MD Phone Number Only Phone Number Only Hospital Affiliation University Of Utah Health p 800.726.9811 p 877.840.8218 - Moab Regional Hospital 450 Williams Way Moab UT. 84532 Care Rehab and Orthopedic Family Practice Westfall, Desiree L PA-C p 801.581.2955 Products (Muscle Andrew, Ray A MD Moab Family Medicine Stimulators) 2700 S Hwy 191 476 W Williams Way Hospital Affiliation Phone Number Only Ste 2 Ste A - University of Utah Hospital p 800.487.9644 Moab UT. 84532 Moab UT. 84532 p 435.259.4466 p 435.259.7121 Mathis, Jason G MD DJO Global University of Utah Health Phone Number Only Cole, Dylan DO Wibby, Christine APRN 450 Williams Way p 800.336.6569 Moab Family Medicine Moab Regional Hosptial Moab UT. 84532 476 W Williams Way 450 W Williams Way p 801.581.2955 Dynasplint Systems Inc Ste A Moab UT. 84532 Phone Number Only Moab UT. 84532 p 435.719.3500 Hospital Affiliation p 800.638.6771 p 435.259.7121 - University of Utah Hospital Moab Regional Medical EBI LLC (Bone Stimulators) Hospital Affiliation Clinic Odell, Richard H MD Phone Number Only - Moab Regional Hospital 476 W Williams Way 2700 S US-191 p 800.526.2579 Moab UT. 84532 Ste 2 Garling, Adam PA-C p 435.719.5500 Moab UT. 84532 Edgepark 2700 S US-191 p 801.272.4219 Phone Number Only Ste 2 Williams, Katherine K MD p 800.321.0591 Moab UT. 84532 Moab Family Medicine Hospital Affiliation p 801.272.4219 476 W Williams Way - St Marks Hospital Empi Inc (Neuromuscular Ste A Stimulator) Heaton, Julia S MD Moab UT. 84532 Tinklepaugh, Adam J MD Phone Number Only Moab Regional Hosptial p 435.259.7121 University of Utah Health p 800.328.2536 450 W Williams Way 450 Williams Way Moab UT. 84532 Hospital Affiliation Moab UT. 84532 KCI USA Inc (Wound Vac p 435.719.3500 - Moab Regional Hospital p 801.581.2955 Only) Phone Number Only Moab Regional Medical Williams, Kenneth L MD Hospital Affiliation p 800.275.4524 Clinic Moab Family Medicine - University of Utah Hospital 476 W Williams Way 476 W Williams Way Orthofix Inc (Bone Growth Moab UT. 84532 Ste A Diabetic Supplies Stimulators Physicians p 435.719.5500 Moab UT. 84532 CCS Medical Only) p 435.259.7121 Phone Number Only Phone Number Only Maher Young, Eve M PA p 800.726.9811 p 800.535.4492 Moab Family Medicine Hospital Affiliation 476 W Williams Way - Moab Regional Hospital Edgepark Pacific Medical Inc Ste A Phone Number Only Phone Number Only Moab UT. 84532 General Surgery p 800.321.0591 p 800.726.9180 p 435.259.7121 Brandau, Kim M MD Moab Regional Hospital Roche Insulin Delivery RespirTech Munger, Jonas S MD 450 W Williams Way Systems Inc Phone Number Only Moab Family Medicine Moab UT. 84532 Phone Number Only p 800.793.1261 476 W Williams Way p 435.719.3500 p 800.280.7801 Ste A Roche Insulin Delivery Moab UT. 84532 476 W Williams Way US MED LLC Systems Inc p 435.259.7121 Moab UT. 84532 Phone Number Only Phone Number Only p 435.719.5500 p 800.787.6331 p 800.280.7801 Hospital Affiliation - Moab Regional Hospital Vasquez, Juan C MD United States Medical Smith Nephew Inc (Muscle Moab Specialty Clinic Supply Stimulators) Sanders, John M DO 476 W Williams Way Phone Number Only Phone Number Only Moab Regional Hospital Moab UT. 84532 p 877.840.8218 p 800.821.5700 450 W Williams Way p 435.719.5550 Moab UT. 84532 p 435.719.3508 Hospital Affiliation - Moab Regional Hospital

106 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Home Health Agency Concentra Medical Centers Stevens, Peter M MD Hugentobler, Nicholas L CNS Community Nursing 2390 Redwood Rd University of Utah Health DPM Services West Valley City UT. 84419 450 Williams Way Rio Grande Foot & Ankle 1030 S Bowling Alley Ln p 888.997.2669 Moab UT. 84532 Specialists Moab UT. 84532 p 801.587.2255 476 W Williams Way p 866.220.1712 Ophthalmology Ste B Byers, Timothy MD Hospital Affiliation Moab UT. 84532 Hospice 471 S Main - University of Utah Hospital p 970.259.3154 CNS Community Nursing Moab UT. 84532 Services p 435.259.9411 Pain Management 476 W Williams Way 1030 S Bowling Alley Ln Beecher, Russell O DO Ste B Moab UT. 84532 Hospital Affiliation Eastern Utah Physical Moab UT. 84532 p 866.220.1712 - Castleview Hospital Medicine & Pain Center p 970.259.3154 450 Williams Way Hospital Lord, Ron K MD Moab UT. 84532 Sekulic, Selina DPM Moab Regional Hospital Retina Associates of p 435.613.7246 Rio Grande Foot & Ankle 450 W Williams Way Southern Utah Specialists Moab UT. 84532 570 W 400 N Hospital Affiliation 476 W Williams Way p 435.719.3500 Moab UT. 84532 - Castleview Hospital Ste B p 435.216.7032 Moab UT. 84532 Imaging Center Physical Therapy p 970.259.3154 Utah Imaging Associates Optometry Concentra Medical Centers 450 W Williams Way Hackney, Todd A OD 2390 Redwood Rd Tovey, Micah D DPM Moab UT. 84532 471 S Main West Valley City UT. 84419 Rio Grande Foot & Ankle p 435.259.7191 Ste 7 p 888.997.2669 Specialists Moab UT. 84532 476 W Williams Way Laboratory p 435.259.9441 Indergard, Cynthia J PT Ste B Dominion Diagnostics Mountain Land Moab UT. 84532 Phone Number Only Orthopedic Surgery Rehabilitation Inc p 970.259.3154 p 877.734.9600 Hofmann, Aaron A MD 450 W Williams Way Hofmann Arthritis Moab UT. 84532 Iron County LabCorp of America Institute p 435.259.3600 Holdings 450 W Williams Way Aba Therapy Phone Number Only Moab UT. 84532 Lewis, James A MPT Adolphson, Lillian p 888.522.2677 p 801.355.6468 Mountain Land BCBA-D Rehabilitation Inc Utah Behavior Services Mental Health Hospital Affiliation 450 W Williams Way 1870 N Main St Anderson, Nancy B LPC - University of Utah Hospital Moab UT. 84532 Ste 206 50 E Ctr St - Davis Hospital p 435.259.3600 Cedar City UT. 84721 Ste 8 - Lone Peak Hospital p 801.255.5131 Moab UT. 84532 - Salt Lake Regional Medical Shepherd, Kelly E DPT p 970.708.0078 Center Mountain Land Aleman, Arianna BCBA Rehabilitation Inc Utah Behavior Services Rath, Antje CMHC McQueen, Jordan R PA-C 450 W Williams Way 1870 N Main St Moab Regional Hosptial Hofmann Arthritis Moab UT. 84532 Ste 206 450 W Williams Way Institute p 435.259.3600 Cedar City UT. 84721 Moab UT. 84532 450 W Williams Way p 801.255.5131 p 435.719.3500 Moab UT. 84532 Podiatry p 801.355.6468 Griffeth, Brian J DPM Christianson, Grete BCBA Moab Regional Medical Moab Regional Hospital Utah Behavior Services Clinic Hospital Affiliation 450 W Williams Way 1870 N Main St 476 W Williams Way - Salt Lake Regional Medical Moab UT. 84532 Ste 206 Moab UT. 84532 Center p 435.719.5550 Cedar City UT. 84721 p 435.719.5500 - Davis Hospital p 801.255.5131 - Lone Peak Hospital Allen Memorial Hospital Occupational Therapy 719 W 400 N Chrysalis Utah Buschmann, Michelle A OT Meininger, Alexander MD Moab UT. 84532 660 N Airport Rd Mountain Land Moab Regional Hosptial p 435.259.7191 Cedar City UT. 84721 Rehabilitation Inc 450 W Williams Way p 801.655.4950 450 W Williams Way Moab UT. 84532 Hospital Affiliation Moab UT. 84532 p 435.719.3508 - Castleview Hospital Corey, Spencer BCBA p 435.259.3600 Utah Behavior Services Hospital Affiliation 1870 N Main St - Moab Regional Hospital Ste 206 Cedar City UT. 84721 p 801.255.5131

107 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Deceuster, Rachael BCBA Kennedy, Anne BCBA McGuire, Amy BCBA Smith, Erica BCBA Utah Behavior Services Utah Behavior Services Utah Behavior Services Utah Behavior Services 1870 N Main St 1870 N Main St 1870 N Main St 1870 N Main St Ste 206 Ste 206 Ste 206 Ste 206 Cedar City UT. 84721 Cedar City UT. 84721 Cedar City UT. 84721 Cedar City UT. 84721 p 801.255.5131 p 801.255.5131 p 801.255.5131 p 801.255.5131

Fujiwara, Mina BCBA Knudson, Mani BCBA Metzger, Debbie BCBA Smith, Saige LPC Utah Behavior Services Utah Behavior Services Utah Behavior Services Utah Behavior Services 1870 N Main St 1870 N Main St 1870 N Main St 1870 N Main St Ste 206 Ste 206 Ste 206 Ste 206 Cedar City UT. 84721 Cedar City UT. 84721 Cedar City UT. 84721 Cedar City UT. 84721 p 801.255.5131 p 801.255.5131 p 801.255.5131 p 801.255.5131

Green, Rachal BCBA,LCSW Kulow, Kacylia BCBA Nadalsky, Michelle Snow, Lauren BCBA Utah Behavior Services Utah Behavior Services BCBA,SSW Utah Behavior Services 1870 N Main St 1870 N Main St Utah Behavior Services 1870 N Main St Ste 206 Ste 206 1870 N Main St Ste 206 Cedar City UT. 84721 Cedar City UT. 84721 Ste 206 Cedar City UT. 84721 p 801.255.5131 p 801.255.5131 Cedar City UT. 84721 p 801.255.5131 p 801.255.5131 Gressmen, Casey BCBA Lambertsen, Hope BCBA Stevens, Nicole Utah Behavior Services Utah Behavior Services Oblad, Cicily BCBA BCBA,LMFT 1870 N Main St 1870 N Main St Utah Behavior Services Utah Behavior Services Ste 206 Ste 206 1870 N Main St 1870 N Main St Cedar City UT. 84721 Cedar City UT. 84721 Ste 206 Ste 206 p 801.255.5131 p 801.255.5131 Cedar City UT. 84721 Cedar City UT. 84721 p 801.255.5131 p 801.255.5131 Hanks, Julie BCBA Lee, Jennifer BCBA Utah Behavior Services Utah Behavior Services Renda, Cheyenne R PhD Sumrall, Ashley BCBA 1870 N Main St 1870 N Main St Utah Behavior Services Chrysalis Utah Ste 206 Ste 206 1870 N Main St 660 N Airport Rd Cedar City UT. 84721 Cedar City UT. 84721 Ste 206 Cedar City UT. 84721 p 801.255.5131 p 801.255.5131 Cedar City UT. 84721 p 801.655.4950 p 801.255.5131 Hoffmann, Audrey PhD Lopez, Kitrina BCBA Turner, Eric BCBA Utah Behavior Services Utah Behavior Services Rhodes, Tiffany BCBA Utah Behavior Services 1870 N Main St 1870 N Main St Utah Behavior Services 1870 N Main St Ste 206 Ste 206 1870 N Main St Ste 206 Cedar City UT. 84721 Cedar City UT. 84721 Ste 206 Cedar City UT. 84721 p 801.255.5131 p 801.255.5131 Cedar City UT. 84721 p 801.255.5131 p 801.255.5131 Hunt, Chelseigh BCBA Lowe, Kori BCBA 1870 N Main St Utah Behavior Services Utah Behavior Services Rockwell, Rene BCBA Ste 206 1870 N Main St 1870 N Main St Utah Behavior Services Cedar City UT. 84721 Ste 206 Ste 206 1870 N Main St p 801.255.5131 Cedar City UT. 84721 Cedar City UT. 84721 Ste 206 p 801.255.5131 p 801.255.5131 Cedar City UT. 84721 Whatcott, Natalie p 801.255.5131 BCBA,SSW Jensen, Julia P BCBA Madsen, Sara BCBA Utah Behavior Services Utah Behavior Services Utah Behavior Services Sagendorf, Emily BCBA 1870 N Main St 1870 N Main St 1870 N Main St Utah Behavior Services Ste 206 Ste 206 Ste 206 1870 N Main St Cedar City UT. 84721 Cedar City UT. 84721 Cedar City UT. 84721 Ste 206 p 801.255.5131 p 801.255.5131 p 801.255.5131 Cedar City UT. 84721 p 801.255.5131 Wills, Brooke BCBA Keller, Rebecca BCBA Maxwell, Kendra BCBA Utah Behavior Services Utah Behavior Services Utah Behavior Services Sanders, Sarah BCBA 1870 N Main St 1870 N Main St 1870 N Main St Utah Behavior Services Ste 206 Ste 206 Ste 206 1870 N Main St Cedar City UT. 84721 Cedar City UT. 84721 Cedar City UT. 84721 Ste 206 p 801.255.5131 p 801.255.5131 p 801.255.5131 Cedar City UT. 84721 p 801.255.5131

108 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Wilson, Megan BCBA eCardio Diagnostics Jones, Jamison C MD *Owan, Theophilus E MD Utah Behavior Services Phone Number Only Revere Health Cedar City Hospital 1870 N Main St p 888.400.3522 1320 N Main St 1303 N Main St Ste 206 Cedar City UT. 84720 Cedar City UT. 84720 Cedar City UT. 84721 Cardiology p 435.251.2900 p 435.868.5000 p 801.255.5131 Advanced Vein and Vascular of Southern Utah 1811 W Royal Hunte Dr Hospital Affiliation Woodall, Clifford BCBA 1251 Northfield Rd Ste 2 - St George Regional Hospital Utah Behavior Services Ste 102 Cedar City UT. 84720 - University of Utah Hospital 1870 N Main St Cedar City UT. 84721 p 435.251.2900 Ste 206 p 435.383.5770 *Pulsipher, Mark W MD Cedar City UT. 84721 1870 N Main St Southwest Cardiology-Cedar p 801.255.5131 1811 W Royal Hunte Dr Ste 201 City Ste 1 Cedar City UT. 84721 110 W 1325 N Wulfenstein, Lee BCBA Cedar City UT. 84720 p 435.251.2900 Ste 100 Utah Behavior Services p 435.586.1131 Cedar City UT. 84721 1870 N Main St Hospital Affiliation p 435.251.2500 Ste 206 *Atwood, Melony C MD - St George Regional Hospital Cedar City UT. 84721 Cedar City Heart Clinic Hospital Affiliation p 801.255.5131 1303 N Main St Kim, Christopher Y MD - St George Regional Hospital Ste H Advanced Vein and Vascular Yang, Danielle BCBA Cedar City UT. 84720 of Southern Utah *Van Woerkom, Ryan MD Utah Behavior Services p 435.868.5500 1251 Northfield Rd Southwest Cardiology-Cedar 1870 N Main St Ste 102 City Ste 206 Hospital Affiliation Cedar City UT. 84721 110 W 1325 N Cedar City UT. 84721 - Cedar City Hospital p 435.383.5770 Ste 100 p 801.255.5131 Cedar City UT. 84721 *Brizolara, Alberto A MD 1811 W Royal Hunte Dr p 435.251.2500 Ambulatory Surgery Center Southwest Cardiology-Cedar Ste 1 Cedar Surgical Associates City Cedar City UT. 84720 *Williams, Zachary R MD (Limited Services) 110 W 1325 N p 435.586.1131 Cedar City Hospital 1811 W Royal Hunte Dr Ste 100 1303 N Main St Ste 3 Cedar City UT. 84721 Hospital Affiliation Cedar City UT. 84720 Cedar City UT. 84720 p 435.251.2500 - Davis Hospital p 435.868.5000 p 435.586.3402 - Lakeview Hospital Hospital Affiliation - Ogden Regional Medical Hospital Affiliation Audiology - St George Regional Hospital Center - St George Regional Hospital Luekenga, Richard L AUD - Salt Lake Regional Medical Dixie Hearing and Balance George, Zachary H MD Center *Willis, Carrie A MD Center Revere Health Cedar City Hospital 1251 N Northfield Rd 1870 N Main St Laffely, Nicholas H MD 1303 N Main St Ste 202 Ste 201 Revere Health Cedar City UT. 84720 Cedar City UT. 84720 Cedar City UT. 84721 1320 N Main St p 435.868.5000 p 435.688.8991 p 435.251.2900 Cedar City UT. 84720 p 435.251.2900 Hospital Affiliation Maxwell, Eric AUD *Jensen, Ralph E MD - St George Regional Hospital 1870 N Main St Southwest Cardiology-Cedar 1870 N Main St Ste 202 City Ste 201 Certified Nurse Midwife Cedar City UT. 84720 110 W 1325 N Cedar City UT. 84721 Jensen, Josi K CNM p 435.867.0714 Ste 100 p 435.251.2900 1303 N Main St Cedar City UT. 84721 Ste E Breast Pumps p 435.251.2500 *Orme, Geoffrey J DO Cedar City UT. 84721 Alpine Home Medical Southwest Cardiology-Cedar p 435.865.9222 Phone Number Only Cedar City Hospital City p 800.686.7993 1303 N Main St 110 W 1325 N Chiropractic Cedar City UT. 84720 Ste 100 Emmett, Ryan L DC Edgepark p 435.868.5000 Cedar City UT. 84721 Cedar Ridge Family Phone Number Only p 435.251.2500 Medicine p 800.321.0591 Hospital Affiliation 110 W 1325 N - St George Regional Hospital Hospital Affiliation Ste 200 Cardiac Monitoring - Cedar City Hospital - Cedar City Hospital Cedar City UT. 84721 Remote Cardiac Services - St George Regional Hospital p 435.586.7676 Phone Number Only p 800.367.0300

109 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Sheldon, Dean F DC 1760 N Main St Nielson, Amy CMHC Tinajero, Sealtiel DO 96 N Main St Ste 103 Peace Balance & Joy Cedar Dermatology Ste 103 Cedar City UT. 84721 Consulting 116 W 1325 N Cedar City UT. 84720 p 435.586.7676 2069 N Main St Ste 250 p 435.867.8986 Ste 101 Cedar City UT. 84721 Horton, Darlene LPC Cedar City UT. 84721 p 435.586.6440 Counseling Darlene Horton CMHC, ASUDC p 435.267.4212 Acevedo, Carlos ACMHC 1800 W Royal Hunte Dr Diabetic Supplies Utah Behavior Services Ste 4 2069 N Main St CCS Medical 1870 N Main St Cedar City UT. 84720 Ste 101 Phone Number Only Ste 206 p 435.867.6471 Cedar City UT. 84721 p 800.726.9811 Cedar City UT. 84721 p 435.267.4212 p 801.255.5131 Peace Balance & Joy Edgepark Consulting 476 E Midvalley Rd Phone Number Only Archuleta, Jason LCSW 476 E Midvalley Rd Cedar City UT. 84721 p 800.321.0591 Utah Behavior Services Cedar City UT. 84721 p 435.267.4212 1870 N Main St p 435.267.4212 Roche Insulin Delivery Ste 206 Reiser, Matthew L PhD Systems Inc Cedar City UT. 84721 Huntsman, Dan J CMHC Matthew L Reiser PhD Phone Number Only p 801.255.5131 Dan J Huntsman CMHC 136 W Center St p 800.280.7801 1760 N Main St Cedar City UT. 84720 Black, Jed CMHC Ste 104-B p 801.870.9052 US MED LLC Utah Behavior Services Cedar City UT. 84721 Phone Number Only 1870 N Main St p 435.559.3473 Salsberry, Maria CSW p 800.787.6331 Ste 206 Utah Behavior Services Cedar City UT. 84721 Johnson, Helen B LPC 1870 N Main St United States Medical p 801.255.5131 1156 S Bentley Blvd Ste 206 Supply Ste 2B Cedar City UT. 84721 Phone Number Only Center for Couples & Cedar City UT. 84720 p 801.255.5131 p 877.840.8218 Families p 435.590.4411 1760 N Main St Sorensen, Scott LCSW Dialysis Center Ste 105 King, Kelsey LCSW Scott R Sorensen LCSW Iron Mission Dialysis Cedar City UT. 84720 Utah Behavior Services 351 W Ctr St Center p 435.688.1111 1870 N Main St Cedar City UT. 84720 1277 Northfield Rd Ste 206 p 435.586.1938 Cedar City UT. 84720 Dalton, Merilee CMHC Cedar City UT. 84721 p 435.867.8175 Center for Couples & p 801.255.5131 Stasiuk, John A LMFT Families Utah Behavior Services Dietician 1760 N Main St Lofthouse, Chelsea ACMHC 1870 N Main St Speener, Melinda S RD Ste 105 Utah Behavior Services Ste 206 University of Utah Health Cedar City UT. 84720 1870 N Main St Cedar City UT. 84721 1277 Northfield Rd p 435.688.1111 Ste 206 p 801.255.5131 Cedar City UT. 84721 Cedar City UT. 84721 p 435.867.8175 Goss, Angela CSW p 801.255.5131 Townsend, Natalie CMHC Utah Behavior Services Natalie P Townsend CMHC Hospital Affiliation 1870 N Main St Lovelace, Scott LCMHC 965 S Main St - University of Utah Hospital Ste 206 Utah Behavior Services Ste 5 Cedar City UT. 84721 1870 N Main St Cedar City UT. 84720 Durable Medical Equipment p 801.255.5131 Ste 206 p 435.592.4150 Alpine Home Medical Cedar City UT. 84721 Phone Number Only Haley, Natalie R MC p 801.255.5131 Dermatology p 800.686.7993 1156 S Bentley Blvd Adams, Benjamin E DO Ste 2A Morrow, Ruth Ann CMHC Cedar Dermatology Apria Healthcare LLC Cedar City UT. 84720 Natalie P Townsend CMHC 166 W 1325 N 987 N Main St p 435.691.2802 965 S Main St Ste 250 Ste 5 Ste 5 Cedar City UT. 84721 Cedar City UT. 84721 Hinton, Jen L CMHC Cedar City UT. 84720 p 435.586.6440 p 435.586.0379 Cedar Ridge Family p 435.592.4150 Medicine Hospital Affiliation CCS Medical 110 W 1325 N 965 S Main St - Cedar City Hospital Phone Number Only Ste 200 Ste 5 p 800.726.9811 Cedar City UT. 84721 Cedar City UT. 84720 Colbert, Rand L MD p 435.586.7676 p 435.592.4150 Cedar Dermatology 166 W 1325 N Ste 250 Cedar City UT. 84721 p 435.586.6440

Hospital Affiliation - Cedar City Hospital 110 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Care Rehab and Orthopedic Pacific Medical Inc Cedar City Hospital *Corry, Jacob DO Products (Muscle Phone Number Only 1303 N Main St Valley View Family Stimulators) p 800.726.9180 Cedar City UT. 84720 Practice Phone Number Only p 435.868.5000 1333 N Main St p 800.487.9644 RespirTech Cedar City UT. 84721 Phone Number Only Hospital Affiliation p 435.868.5500 DJO Global p 800.793.1261 - Cedar City Hospital Phone Number Only Hospital Affiliation p 800.336.6569 Roche Insulin Delivery Family Practice - Cedar City Hospital Systems Inc Allen, Daniel J DO Dynasplint Systems Inc Phone Number Only Cedar City Paiute Medical *Corry, Mark W MD Phone Number Only p 800.280.7801 Clinic Valley View Family p 800.638.6771 440 N Paiute Dr Practice Smith Nephew Inc (Muscle Cedar City UT. 84721 1333 N Main St EBI LLC (Bone Stimulators) Stimulators) p 435.867.1520 Cedar City UT. 84721 Phone Number Only Phone Number Only p 435.868.5500 p 800.526.2579 p 800.821.5700 Hospital Affiliation - West Valley Medical Center Hospital Affiliation Edgepark US MED LLC - Cedar City Hospital Phone Number Only Phone Number Only Bulloch, Michael DO p 800.321.0591 p 800.787.6331 Cedar Ridge Family Cox, Jamie MD Medicine Cedar Valley Medical Empi Inc (Neuromuscular United States Medical 110 W 1325 N Clinic Stimulator) Supply Ste 200 2002 N Main St Phone Number Only Phone Number Only Cedar City UT. 84721 Ste 3 p 800.328.2536 p 877.840.8218 p 435.586.7676 Cedar City UT. 84721 p 435.867.1960 *Intermountain Homecare Ear Nose And Throat 1760 N Main St *Medical Equipment and Pearson, Robert D MD Ste 106-B Gardner, Ellen F MD *Supply Cedar City 1251 N Northfield Rd Cedar City UT. 84721 Ellen F Gardner MD 1333 N Main St Ste 200 p 435.586.7676 200 S 4200 W Ste 102 Cedar City UT. 84721 Parowan UT. 84761 Cedar City UT. 84720 p 435.867.8719 Hospital Affiliation p 435.477.0133 p 435.868.5851 - Cedar City Hospital Hospital Affiliation Hospital Affiliation Utah Prosthetics & - Cedar City Hospital *Bunker, Clint O DO - Cedar City Hospital Orthotics Cedar City Clinic 2202 N Main Electrophysiology 1303 N Main St *Gray, Jarid D MD Ste 102 *Burkart, Thomas A MD Ste 3C Cedar City Hospital Cedar City UT. 84721 Southwest Cardiology-Cedar Cedar City UT. 84720 1303 N Main St p 435.383.9000 City p 435.868.5500 Cedar City UT. 84721 110 W 1325 N p 435.586.7676 KCI USA Inc (Wound Vac Ste 100 Hospital Affiliation Only) Cedar City UT. 84721 - Cedar City Hospital Hospital Affiliation Phone Number Only p 435.251.2500 - Cedar City Hospital p 800.275.4524 Cedar Ridge Family Hospital Affiliation Medicine *Haycock, Kimberly D PA-C Kolob Oxygen & Medical - Cedar City Hospital 100 W 1325 N Cedar City Hospital Equipment Ste 200 Physicians 620 W Industrial Rd Cooley, Ryan L MD Cedar City UT. 84721 1303 N Main St Ste 13 Revere Health p 435.586.7676 Cedar City UT. 84720 Cedar City UT. 84720 1870 N Main St p 435.868.5000 p 435.586.1212 Ste 201 1760 N Main St Cedar City UT. 84721 Ste 103 *Heaton, Sarah PA-C Lincare p 435.383.9009 Cedar City UT. 84721 Cedar City Clinic 2002 N Main St p 435.586.7676 1303 N Main St Ste 2 *Tate, Charles W MD Ste 3-C Cedar City UT. 84721 Southwest Cardiology-Cedar Christensen, Samuel DO Cedar City UT. 84720 p 435.586.0106 City Family Healthcare p 435.868.5500 110 W 1325 N 74 W Harding Ave Orthofix Inc (Bone Growth Ste 100 Cedar City UT. 84720 Johnson, Brian C MD Stimulators Physicians Cedar City UT. 84721 p 435.865.1387 Cedar Ridge Family Only) p 435.251.2500 Medicine Phone Number Only Hospital Affiliation 100 W 1325 N p 800.535.4492 - St George Regional Hospital Ste 200 Cedar City UT. 84721 p 435.586.7676

111 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Johnson, Nicole PA Oakden, R W MD *Speakman, Mori S MD Day, Trevor J DO Cedar Ridge Family Parowan Medical Clinic Cedar City Clinic Utah Surgical Associates Medicine 450 E Clinic Way 1303 N Main St 166 W 1325 N 110 W 1325 N Parowan UT. 84761 Ste 3C Ste 200 Ste 200 p 435.477.3344 Cedar City UT. 84720 Cedar City UT. 84721 Cedar City UT. 84721 p 435.868.5500 p 801.374.9625 p 435.586.7676 Hospital Affiliation - Beaver Valley Hospital Cedar City Hospital Hospital Affiliation 1760 N Main St - Milford Valley Hospital Physicians - Cedar City Hospital Ste 106-B 1303 N Main St - St George Regional Hospital Cedar City UT. 84721 Polson, Drew MD Cedar City UT. 84720 p 435.586.7676 Cedar Ridge Family p 435.868.5000 Munford, Michael I MD Medicine 1251 N Field Rd Newman, Steven R MD 110 W 1325 N Stirling, Todd A PA Ste 202 Cedar Ridge Family Ste 200 Advanced Pain Management Cedar City UT. 84721 Medicine Cedar City UT. 84721 110 W 1325 N p 435.807.0300 110 W 1325 N p 435.586.7676 Ste 175 Ste 200 Cedar City UT. 84721 Advanced Vein and Vascular Cedar City UT. 84721 1760 N Main St p 435.656.0029 of Southern Utah p 435.586.7676 Ste 106-B 1251 Northfield Rd Cedar City UT. 84721 Wilcken, Julie PA Ste 102 Cedar City Hospital p 435.586.7676 Cedar Ridge Family Cedar City UT. 84721 1303 N Main St Medicine p 435.383.5770 Cedar City UT. 84720 Hospital Affiliation 110 W 1325 N p 435.868.5000 - Cedar City Hospital Ste 200 1811 W Royal Hunte Dr Cedar City UT. 84721 Ste 1 Cedar City Hospitalists Premier Pediatrics p 435.586.7676 Cedar City UT. 84720 1303 N Main St 1251 N Northfield Rd p 435.586.1131 Cedar City UT. 84721 Ste 301 1760 N Main St p 435.868.5567 Cedar City UT. 84720 Ste 106B Hospital Affiliation p 435.865.7227 Cedar City UT. 84721 - Cedar City Hospital Cedar Ridge Family p 435.586.7676 Medicine Robbins, Brett E FNP Gynecology 1760 N Main St Cedar Valley Medical *Worth, Victor R DO *Bilanzich, Travis J DO Ste 106-B Clinic Canyon View Cedar City Clinic Cedar City UT. 84721 2002 N Main St 15 E 400 N 1303 N Main St p 435.586.7676 Ste 3 Parowan UT. 84761 Ste 3C Cedar City UT. 84721 p 435.477.3317 Cedar City UT. 84720 Cedar City Paiute Medical p 435.867.1960 p 435.868.5500 Clinic Hospital Affiliation 440 N Paiute Dr Hospital Affiliation - Cedar City Hospital Hospital Affiliation Cedar City UT. 84721 - Cedar City Hospital - Cedar City Hospital p 435.867.1520 General Surgery Smith, Rhett R MD Benedict, Amy J APRN *Gatherum, Daren O DO Hospital Affiliation Parowan Medical Clinic Revere Health Cedar City Clinic - Cedar City Hospital 450 E Clinic Way 1320 N Main St 1303 N Main St Parowan UT. 84761 Cedar City UT. 84720 Ste 3C North, Jason K DO p 435.477.3344 p 435.251.2900 Cedar City UT. 84720 Cedar Ridge Family p 435.868.5500 Medicine Hospital Affiliation 1811 W Royal Hunte Dr 110 W 1325 N - Bear River Valley Hospital Ste 2 Hospital Affiliation Ste 200 Cedar City UT. 84720 - Cedar City Hospital Cedar City UT. 84721 Smith, Roger H MD p 435.251.2900 p 435.586.7676 Parowan Medical Clinic Heath, Terence A MD 450 E Clinic Way Black, Cameron T MD The Cedar City Institute Cedar City Hospital Parowan UT. 84761 Utah Surgical Associates of Womens Health 1303 N Main St p 435.477.3344 166 W 1325 N 110 W 1325 N Cedar City UT. 84721 Ste 200 Ste 300 p 435.586.7676 Hospital Affiliation Cedar City UT. 84721 Cedar City UT. 84720 - Beaver Valley Hospital p 801.374.9625 p 435.865.9500 Cedar Ridge Family - Milford Valley Hospital Medicine Hospital Affiliation Hospital Affiliation 1760 N Main St - Cedar City Hospital - Cedar City Hospital Ste 106-B - St George Regional Hospital Cedar City UT. 84721 p 435.586.7676

Hospital Affiliation - Cedar City Hospital 112 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Sanders, Stephen M MD *Wilcox, Ryan E MD 1811 W Royal Hunte Dr *Gilbert, M H MD The Cedar City Institute Southwest Regional Ste 1 Southwest Regional of Womens Health Cancer-Cedar City Cedar City UT. 84720 Cancer-Cedar City 110 W 1325 N 1303 N Main St p 435.586.1131 1303 N Main St Ste 300 Cedar City UT. 84720 Cedar City UT. 84720 Cedar City UT. 84720 p 435.868.5690 Assiago, Marcellus S MD p 435.868.5690 p 435.865.9500 University of Utah Health Hospital Affiliation 1277 Northfield Rd Hospital Affiliation Hospital Affiliation - St George Regional Hospital Cedar City UT. 84721 - St George Regional Hospital - Cedar City Hospital - Cedar City Hospital p 435.867.8175 Kim, Christopher Y MD Hematology And Oncology Hematology 1303 N Main St Advanced Vein and Vascular *Gilbert, M H MD Lundell, Ryan MD Cedar City UT. 84721 of Southern Utah Southwest Regional Pathology Services p 435.868.5000 1251 Northfield Rd Cancer-Cedar City 595 S 75 E Ste 102 1303 N Main St Cedar City UT. 84720 Hospital Affiliation Cedar City UT. 84721 Cedar City UT. 84720 p 435.251.2202 - University of Utah Hospital p 435.383.5770 p 435.868.5690 - Davis Hospital Home Health Agency 1811 W Royal Hunte Dr Hospital Affiliation Horizon Home Health *Brant, Jamie L MD Ste 1 - St George Regional Hospital 2069 N Main St Southwest Regional Cedar City UT. 84720 Ste 106 Cancer-Cedar City p 435.586.1131 *Lin, Karen Y MD Cedar City UT. 84721 1303 N Main St Southwest Regional p 435.865.7481 Cedar City UT. 84720 Hospital Affiliation Cancer-Cedar City p 435.868.5690 - Davis Hospital 1303 N Main St *Intermountain Homecare - Lakeview Hospital Cedar City UT. 84720 *Home Health Cedar City Hospital Affiliation - Ogden Regional Medical p 435.868.5690 1333 N Main St - University of Utah Hospital Center Ste 102 - Salt Lake Regional Medical Hospital Affiliation Cedar City UT. 84721 Eppich, Irel S MD Center - St George Regional Hospital p 435.868.5852 University of Utah Health 1277 Northfield Rd Raj Krishnamurthy, Vidya *Reese, Zachary L MD Hospice Cedar City UT. 84721 M MD Southwest Regional *Intermountain Homecare p 435.867.8175 University of Utah Health Cancer-Cedar City *Hospice Cedar City 1277 Northfield Rd 1303 N Main St 1333 N Main St Hospital Affiliation Cedar City UT. 84721 Cedar City UT. 84720 Ste 102 - University of Utah Hospital p 435.867.8175 p 435.868.5690 Cedar City UT. 84720 - Mountain View Hospital p 435.868.5852 (UT) Hospital Affiliation Hospital Affiliation - Timpanogos Regional Hospital - University of Utah Hospital - St George Regional Hospital Hospital - Cedar City Hospital *Cedar City Hospital Gandhi, Zahabia T MD Roy, Abinash C MD 1303 N Main St Advanced Pulmonary, Sleep University of Utah Health Te, Joseph D MD Cedar City UT. 84720 Disorders and Internal 1277 Northfield Rd Revere Health p 435.586.6587 Medicine Cedar City UT. 84721 110 W 1350 N 110 W 1325 N p 435.586.8827 Ste 100 Hyperbaric Medicine Ste 175 Cedar City UT. 84720 *Cascio, Michael J MD Cedar City UT. 84721 1303 N Main St p 435.628.9298 Cedar City Wound Clinic p 435.688.7770 Cedar City UT. 84721 1333 N Main St p 435.868.5000 Hospital Affiliation Ste 3 Hospital Affiliation - St George Regional Hospital Cedar City UT. 84721 - St George Regional Hospital Hospital Affiliation p 435.868.5656 - St George Regional Hospital *Tudor, Brian P MD *Garrett, Todd M MD - University of Utah Hospital Southwest Regional Hospital Affiliation Cedar City Clinic Cancer-Cedar City - St George Regional Hospital 1303 N Main St *Smith, Philip E MD 1303 N Main St - Cedar City Hospital Ste 3-C Cedar City Clinic Cedar City UT. 84720 Cedar City UT. 84720 1303 N Main St p 435.868.5690 Internal Medicine p 435.868.5500 Ste 3C Advanced Vein and Vascular Cedar City UT. 84720 Hospital Affiliation of Southern Utah 1303 N Main St p 435.868.5500 - St George Regional Hospital 1251 Northfield Rd Ste 3C - Cedar City Hospital Ste 102 Cedar City UT. 84720 Hospital Affiliation Cedar City UT. 84721 p 435.868.5500 - Cedar City Hospital p 435.383.5770

113 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Interventional Cardiology Arballo, Jennifer CSW Corey, Spencer BCBA Green, Rachal BCBA,LCSW Kim, Christopher Y MD Utah Behavior Services Utah Behavior Services Utah Behavior Services Advanced Vein and Vascular 1870 N Main St 1870 N Main St 1870 N Main St of Southern Utah Ste 206 Ste 206 Ste 206 1251 Northfield Rd Cedar City UT. 84721 Cedar City UT. 84721 Cedar City UT. 84721 Ste 102 p 801.255.5131 p 801.255.5131 p 801.255.5131 Cedar City UT. 84721 p 435.383.5770 Archuleta, Jason LCSW Dalton, Merilee CMHC Gressmen, Casey BCBA Utah Behavior Services Center for Couples & Utah Behavior Services 1811 W Royal Hunte Dr 1870 N Main St Families 1870 N Main St Ste 1 Ste 206 1760 N Main St Ste 206 Cedar City UT. 84720 Cedar City UT. 84721 Ste 105 Cedar City UT. 84721 p 435.586.1131 p 801.255.5131 Cedar City UT. 84720 p 801.255.5131 p 435.688.1111 Hospital Affiliation Birch, Kelly LCSW Haley, Natalie R MC - Davis Hospital Utah Behavior Services Deceuster, Rachael BCBA 1156 S Bentley Blvd - Lakeview Hospital 1870 N Main St Utah Behavior Services Ste 2A - Ogden Regional Medical Ste 206 1870 N Main St Cedar City UT. 84720 Center Cedar City UT. 84721 Ste 206 p 435.691.2802 - Salt Lake Regional Medical p 801.255.5131 Cedar City UT. 84721 Center p 801.255.5131 Hinton, Jen L CMHC Black, Jed CMHC Cedar Ridge Family Laboratory Utah Behavior Services Donovan, Andrea LCSW Medicine Dominion Diagnostics 1870 N Main St Natalie P Townsend CMHC 110 W 1325 N Phone Number Only Ste 206 965 S Main St Ste 200 p 877.734.9600 Cedar City UT. 84721 Cedar City UT. 84720 Cedar City UT. 84721 p 801.255.5131 p 435.586.4966 p 435.586.7676 LabCorp of America Holdings Bunting, Catherine CSW Drabeck, Sharon E LCSW 1760 N Main St Phone Number Only Utah Behavior Services Sharon E Drabeck LCSW Ste 103 p 888.522.2677 1870 N Main St 1760 N Main St Cedar City UT. 84721 Ste 206 Ste 209 p 435.586.7676 Mental Health Cedar City UT. 84721 Cedar City UT. 84721 Abbey Road Counseling p 801.255.5131 p 702.306.8438 Hoffmann, Audrey PhD Services Utah Behavior Services 415 N Main St Center for Couples & Einfeldt, Keith T LCSW 1870 N Main St Ste 104 Families 115 N Main Ste 206 Cedar City UT. 84721 1760 N Main St Ste 204 Cedar City UT. 84721 p 435.586.9521 Ste 105 Cedar City UT. 84720 p 801.255.5131 Cedar City UT. 84720 p 435.865.1188 Acevedo, Carlos ACMHC p 435.688.1111 Holmes, Alisha MSW Utah Behavior Services Fujiwara, Mina BCBA Utah Behavior Services 1870 N Main St Cho, Jaeyong MSW Utah Behavior Services 1870 N Main St Ste 206 Utah Behavior Services 1870 N Main St Ste 206 Cedar City UT. 84721 1870 N Main St Ste 206 Cedar City UT. 84721 p 801.255.5131 Ste 206 Cedar City UT. 84721 p 801.255.5131 Cedar City UT. 84721 p 801.255.5131 Adolphson, Lillian p 801.255.5131 Horton, Darlene LPC BCBA-D Goddard, Tyler C LCSW Darlene Horton CMHC, ASUDC Utah Behavior Services Christianson, Grete BCBA Cambridge Counseling 1800 W Royal Hunte Dr 1870 N Main St Utah Behavior Services Center Inc Ste 4 Ste 206 1870 N Main St 337 S Main Cedar City UT. 84720 Cedar City UT. 84721 Ste 206 Ste 110 p 435.867.6471 p 801.255.5131 Cedar City UT. 84721 Cedar City UT. 84720 p 801.255.5131 p 435.225.2422 Peace Balance & Joy Aleman, Arianna BCBA Consulting Utah Behavior Services Chrysalis Utah Goss, Angela CSW 476 E Midvalley Rd 1870 N Main St 660 N Airport Rd Utah Behavior Services Cedar City UT. 84721 Ste 206 Cedar City UT. 84721 1870 N Main St p 435.267.4212 Cedar City UT. 84721 p 801.655.4950 Ste 206 p 801.255.5131 Cedar City UT. 84721 Hunt, Chelseigh BCBA Coburn, Alison MSW p 801.255.5131 Utah Behavior Services Utah Behavior Services 1870 N Main St 1870 N Main St Ste 206 Ste 206 Cedar City UT. 84721 Cedar City UT. 84721 p 801.255.5131 p 801.255.5131

114 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Huntsman, Dan J CMHC Lambertsen, Hope BCBA McGill, Katie MSW Nielson, Amy CMHC Dan J Huntsman CMHC Utah Behavior Services Utah Behavior Services Peace Balance & Joy 1760 N Main St 1870 N Main St 1870 N Main St Consulting Ste 104-B Ste 206 Ste 206 2069 N Main St Cedar City UT. 84721 Cedar City UT. 84721 Cedar City UT. 84721 Ste 101 p 435.559.3473 p 801.255.5131 p 801.255.5131 Cedar City UT. 84721 p 435.267.4212 Jensen, Julia P BCBA Lee, Jennifer BCBA McGuire, Amy BCBA Utah Behavior Services Utah Behavior Services Utah Behavior Services Oblad, Cicily BCBA 1870 N Main St 1870 N Main St 1870 N Main St Utah Behavior Services Ste 206 Ste 206 Ste 206 1870 N Main St Cedar City UT. 84721 Cedar City UT. 84721 Cedar City UT. 84721 Ste 206 p 801.255.5131 p 801.255.5131 p 801.255.5131 Cedar City UT. 84721 p 801.255.5131 Johnson, Helen B LPC Lofthouse, Chelsea ACMHC Metzger, Debbie BCBA 1156 S Bentley Blvd Utah Behavior Services Utah Behavior Services Peace Balance & Joy Ste 2B 1870 N Main St 1870 N Main St Consulting Cedar City UT. 84720 Ste 206 Ste 206 2069 N Main St p 435.590.4411 Cedar City UT. 84721 Cedar City UT. 84721 Ste 101 p 801.255.5131 p 801.255.5131 Cedar City UT. 84721 Johnston, Harmony MSW p 435.267.4212 Utah Behavior Services Lopez, Kitrina BCBA Morrow, Ruth Ann CMHC 1870 N Main St Utah Behavior Services Natalie P Townsend CMHC 476 E Midvalley Rd Ste 206 1870 N Main St 965 S Main St Cedar City UT. 84721 Cedar City UT. 84721 Ste 206 Ste 5 p 435.267.4212 p 801.255.5131 Cedar City UT. 84721 Cedar City UT. 84720 p 801.255.5131 p 435.592.4150 Phillips, Allison Keller, Rebecca BCBA LCSW,BCBA Utah Behavior Services Lovelace, Scott LCMHC Moss, Melissa M LCSW Utah Behavior Services 1870 N Main St Utah Behavior Services Melissa M Moss LCSW 1870 N Main St Ste 206 1870 N Main St 88 E Fiddlers Canyon Rd Ste 206 Cedar City UT. 84721 Ste 206 Ste 127 Cedar City UT. 84721 p 801.255.5131 Cedar City UT. 84721 Cedar City UT. 84721 p 801.255.5131 p 801.255.5131 p 435.760.0753 Kennedy, Anne BCBA Powell, Clark Randy LCSW Utah Behavior Services Lowe, Kori BCBA Nadalsky, Michelle Utah Behavior Services 1870 N Main St Utah Behavior Services BCBA,SSW 1870 N Main St Ste 206 1870 N Main St Utah Behavior Services Ste 206 Cedar City UT. 84721 Ste 206 1870 N Main St Cedar City UT. 84721 p 801.255.5131 Cedar City UT. 84721 Ste 206 p 801.255.5131 p 801.255.5131 Cedar City UT. 84721 King, Kelsey LCSW p 801.255.5131 Reeves, Linda G LCSW Utah Behavior Services Luna, Janette M LCSW Linda G Reeves LCSW 1870 N Main St Utah Behavior Services Natalie P Townsend CMHC 1156 S Bentley Blvd Ste 206 1870 N Main St 965 S Main St Ste 2D Cedar City UT. 84721 Ste 206 Ste 5 Cedar City UT. 84720 p 801.255.5131 Cedar City UT. 84721 Cedar City UT. 84720 p 435.559.0518 p 801.255.5131 p 435.592.4150 Knudson, Mani BCBA Reiser, Matthew L PhD Utah Behavior Services Madsen, Sara BCBA Neff, Michal A CSW,SUDC Matthew L Reiser PhD 1870 N Main St Utah Behavior Services Utah Behavior Services 136 W Center St Ste 206 1870 N Main St 1870 N Main St Cedar City UT. 84720 Cedar City UT. 84721 Ste 206 Ste 206 p 801.870.9052 p 801.255.5131 Cedar City UT. 84721 Cedar City UT. 84721 p 801.255.5131 p 801.255.5131 Renda, Cheyenne R PhD Kulow, Kacylia BCBA Utah Behavior Services Utah Behavior Services Maxwell, Kendra BCBA Nielsen, Stephanie MSW 1870 N Main St 1870 N Main St Utah Behavior Services Utah Behavior Services Ste 206 Ste 206 1870 N Main St 1870 N Main St Cedar City UT. 84721 Cedar City UT. 84721 Ste 206 Ste 206 p 801.255.5131 p 801.255.5131 Cedar City UT. 84721 Cedar City UT. 84721 p 801.255.5131 p 801.255.5131 Roche, Miriam MSW Utah Behavior Services 1870 N Main St Ste 206 Cedar City UT. 84721 p 801.255.5131

115 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Rockwell, Rene BCBA Smith, Saige LPC Tuft, Diane LCSW Yang, Danielle BCBA Utah Behavior Services Utah Behavior Services Peace Balance & Joy Utah Behavior Services 1870 N Main St 1870 N Main St Consulting 1870 N Main St Ste 206 Ste 206 2069 N Main St Ste 206 Cedar City UT. 84721 Cedar City UT. 84721 Ste 101 Cedar City UT. 84721 p 801.255.5131 p 801.255.5131 Cedar City UT. 84721 p 801.255.5131 p 435.267.4212 Sagendorf, Emily BCBA Snow, Lauren BCBA Nephrology Utah Behavior Services Utah Behavior Services Turner, Eric BCBA Assiago, Marcellus S MD 1870 N Main St 1870 N Main St Utah Behavior Services University of Utah Health Ste 206 Ste 206 1870 N Main St 1277 Northfield Rd Cedar City UT. 84721 Cedar City UT. 84721 Ste 206 Cedar City UT. 84721 p 801.255.5131 p 801.255.5131 Cedar City UT. 84721 p 435.867.8175 p 801.255.5131 Salsberry, Maria CSW Sorensen, Scott LCSW 1303 N Main St Utah Behavior Services Scott R Sorensen LCSW 1870 N Main St Cedar City UT. 84721 1870 N Main St 351 W Ctr St Ste 206 p 435.868.5000 Ste 206 Cedar City UT. 84720 Cedar City UT. 84721 Cedar City UT. 84721 p 435.586.1938 p 801.255.5131 Hospital Affiliation p 801.255.5131 - University of Utah Hospital Stasiuk, John A LMFT Ward, Cori APRN - Davis Hospital Sanders, Sarah BCBA Utah Behavior Services Utah Behavior Services Utah Behavior Services 1870 N Main St 1870 N Main St Bjordahl, Terrence S MD 1870 N Main St Ste 206 Ste 206 University of Utah Health Ste 206 Cedar City UT. 84721 Cedar City UT. 84721 1277 Northfield Rd Cedar City UT. 84721 p 801.255.5131 p 801.255.5131 Cedar City UT. 84721 p 801.255.5131 p 435.867.8175 Stevens, Nicole Whatcott, Natalie Shumway, Brett PSYD BCBA,LMFT BCBA,SSW Hospital Affiliation Utah Behavior Services Utah Behavior Services Utah Behavior Services - St Marks Hospital 1870 N Main St 1870 N Main St 1870 N Main St Ste 206 Ste 206 Ste 206 Boateng, Yaw A MD Cedar City UT. 84721 Cedar City UT. 84721 Cedar City UT. 84721 University of Utah Health p 801.255.5131 p 801.255.5131 p 801.255.5131 1277 Northfield Rd Cedar City UT. 84721 Siebert, Tatum LCPC Suarez, Alex LCSW Wills, Brooke BCBA p 435.867.8175 Utah Behavior Services Utah Behavior Services Utah Behavior Services 1870 N Main St 1870 N Main St 1870 N Main St 1303 N Main St Ste 206 Ste 206 Ste 206 Cedar City UT. 84721 Cedar City UT. 84721 Cedar City UT. 84721 Cedar City UT. 84721 p 435.868.5000 p 801.255.5131 p 801.255.5131 p 801.255.5131 Hospital Affiliation Skousen, Thomas MSW Sumrall, Ashley BCBA Wilson, Megan BCBA - University of Utah Hospital Utah Behavior Services Chrysalis Utah Utah Behavior Services 1870 N Main St 660 N Airport Rd 1870 N Main St Eppich, Irel S MD Ste 206 Cedar City UT. 84721 Ste 206 University of Utah Health Cedar City UT. 84721 p 801.655.4950 Cedar City UT. 84721 1277 Northfield Rd p 801.255.5131 p 801.255.5131 Cedar City UT. 84721 Thomas, Joni D LCSW p 435.867.8175 Slater, Courtney MSW Brighter Future Counseling Woodall, Clifford BCBA Utah Behavior Services 66 W Harding Ave Utah Behavior Services Hospital Affiliation 1870 N Main St Ste C3 1870 N Main St - University of Utah Hospital Ste 206 Cedar City UT. 84720 Ste 206 - Mountain View Hospital Cedar City UT. 84721 p 435.592.0366 Cedar City UT. 84721 (UT) p 801.255.5131 p 801.255.5131 - Timpanogos Regional Hospital Townsend, Natalie CMHC Smith, Erica BCBA Natalie P Townsend CMHC Wulfenstein, Lee BCBA Kakani, Siddhartha MD Utah Behavior Services 965 S Main St Utah Behavior Services University of Utah Health 1870 N Main St Ste 5 1870 N Main St 1277 Northfield Rd Ste 206 Cedar City UT. 84720 Ste 206 Cedar City UT. 84721 Cedar City UT. 84721 p 435.592.4150 Cedar City UT. 84721 p 435.867.8175 p 801.255.5131 p 801.255.5131 Hospital Affiliation - University of Utah Hospital

116 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Leon-Forero, Carlos A MD Southern Utah Kidney & Sanders, Stephen M MD *Voorhies, Benjamin N MD Southern Utah Kidney & Hypertension Center The Cedar City Institute Southwest Regional Hypertension Center 1320 N Main St of Womens Health Cancer-Cedar City 1320 N Main St Ste 103 110 W 1325 N 1303 N Main St Ste 103 Cedar City UT. 84721 Ste 300 Cedar City UT. 84720 Cedar City UT. 84721 p 435.586.1276 Cedar City UT. 84720 p 435.868.5690 p 435.586.1276 p 435.865.9500 Neurology Hospital Affiliation Hospital Affiliation *Bradbury, Matthew DO Hospital Affiliation - University of Utah Hospital - St George Regional Hospital Cedar City Clinic - Cedar City Hospital - Cedar City Hospital 1303 N Main St Ophthalmology Ste 3C Occupational Therapy Anderson, Chad W MD Mercado, Carlos A MD Cedar City UT. 84720 Concentra Medical Centers Mountain Eye Institute Southern Utah Kidney & p 435.868.5500 2390 Redwood Rd 1811 W Royal Hunte Dr Hypertension Center West Valley City UT. 84419 Ste 1 1320 N Main St Hospital Affiliation p 888.997.2669 Cedar City UT. 84720 Ste 103 - Baylor Scott & White p 435.586.1131 Cedar City UT. 84721 Medical Center - Temple *Haycock, Kimberly D PA-C p 435.586.1276 Cedar City Hospital Hospital Affiliation *Sanderson, Alan B MD Physicians - Cedar City Hospital Hospital Affiliation Cedar City Clinic 1303 N Main St - Kane County Hospital - St George Regional Hospital 1303 N Main St Cedar City UT. 84720 - Beaver Valley Hospital Ste 3C p 435.868.5000 Duncan, Clinton J MD - Cedar City Hospital Cedar City UT. 84720 Mountain Eye Institute p 435.868.5500 *Moe, Lorraine G OT 1811 W Royal Hunte Dr Patcha, Kishore MD Cedar City Hospital Ste 1 University of Utah Health Neurosurgery 1303 N Main St Cedar City UT. 84720 1277 Northfield Rd *Bate, Berkeley G MD Cedar City UT. 84720 p 435.586.1131 Cedar City UT. 84721 Southern Utah Neuro-Cedar p 435.868.5000 p 435.586.8827 1303 N Main St Goff, Mitchell J MD Cedar City UT. 84720 Oncology Rocky Mountain Retina Patchett, Andrew M DO p 435.868.5055 *Nadauld, Lincoln MD Consultants Southern Utah Kidney & Southwest Regional 1811 W Royal Hunte Dr Hypertension Center Hospital Affiliation Cancer-Cedar City Cedar City UT. 84720 1320 N Main St - St George Regional Hospital 1303 N Main St p 888.496.4400 Ste 103 Cedar City UT. 84720 Cedar City UT. 84721 Obstetrics And Gynecology p 435.868.5690 Hospital Affiliation p 435.586.1276 *Bilanzich, Travis J DO - St Marks Hospital Cedar City Clinic Hospital Affiliation Hospital Affiliation 1303 N Main St - St George Regional Hospital Mountain Eye Institute - Cedar City Hospital Ste 3C 1811 W Royal Hunte Dr - St George Regional Hospital Cedar City UT. 84720 *Rhodes, Terence MD Ste 1 p 435.868.5500 Southwest Regional Cedar City UT. 84720 Romney, Pace G MD Cancer-Cedar City p 435.586.1131 University of Utah Health Hospital Affiliation 1303 N Main St 1277 Northfield Rd - Cedar City Hospital Cedar City UT. 84720 Stringham, Jack D MD Cedar City UT. 84721 p 435.868.5690 Rocky Mountain Retina p 435.867.8175 *Gatherum, Daren O DO Consultants Cedar City Clinic Hospital Affiliation 1811 W Royal Hunt Dr Hospital Affiliation 1303 N Main St - St George Regional Hospital Cedar City UT. 84720 - University of Utah Hospital Ste 3C p 888.496.4400 Cedar City UT. 84720 *Tudor, Brian P MD Roy, Abinash C MD p 435.868.5500 Southwest Regional Optometry University of Utah Health Cancer-Cedar City Albrecht, William S OD 1277 Northfield Rd Hospital Affiliation 1303 N Main St Southern Utah Vision Care Cedar City UT. 84721 - Cedar City Hospital Cedar City UT. 84720 1251 N Northfield Rd p 435.586.8827 p 435.868.5690 Ste 215 Heath, Terence A MD Cedar City UT. 84721 1303 N Main St The Cedar City Institute Hospital Affiliation p 435.865.9899 Cedar City UT. 84721 of Womens Health - St George Regional Hospital p 435.868.5000 110 W 1325 N - Cedar City Hospital Cedar City Paiute Medical Ste 300 Clinic Hospital Affiliation Cedar City UT. 84720 440 N Paiute Dr - St George Regional Hospital p 435.865.9500 Cedar City UT. 84721 - University of Utah Hospital p 435.867.1520 Hospital Affiliation - Cedar City Hospital

117 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Brown, Loy D OD Orthopedic Surgery Orthotics And Prosthetics *Southern Utah Neuro-Cedar Southern Utah Vision Care *Allen, Lex S MD Utah Prosthetics & 1303 N Main St 1251 N Northfield Rd Southern Utah Ortho Sports Orthotics Cedar City UT. 84720 Ste 215 Med 2202 N Main p 435.251.6800 Cedar City UT. 84721 166 W 1325 N Ste 102 p 435.865.9899 Ste 150 Cedar City UT. 84721 Workman, Ryan K DO Cedar City UT. 84721 p 435.383.9000 Desert Pain Specialists 51 E 400 N p 435.586.6962 1760 N Main St Ste 4A Pain Management Ste 220 Cedar City UT. 84720 Hospital Affiliation Christensen, Bryt MD Cedar City UT. 84721 p 435.586.0700 - Cedar City Hospital Vista Neurology p 435.238.7000 Specialists Christian, Rory J OD Butterfield, Ted DPM 1303 N Main St Hospital Affiliation Mountain Eye Institute Foot and Ankle Institute Cedar City UT. 84720 - St George Regional Hospital 1811 W Royal Hunte Dr 1811 W Royal Hunte Dr p 435.586.2229 Ste 1 Ste 2 Palliative Care Cedar City UT. 84720 Cedar City UT. 84720 Hospital Affiliation *Brant, Jamie L MD p 435.586.1131 p 435.586.2225 - St George Regional Hospital Southwest Regional Cancer-Cedar City Hospital Affiliation Hospital Affiliation Frieden, Derek L MD 1303 N Main St - Cedar City Hospital - St George Regional Hospital Vista Neurology Cedar City UT. 84720 Specialists p 435.868.5690 Higbee, Lance D OD Clark, Randy MD 1303 N Main St Southern Utah Vision Care Revere Health Cedar City UT. 84721 Hospital Affiliation 1251 N Northfield Rd 1335 N Northfield Rd p 435.656.2424 - University of Utah Hospital Ste 215 Ste 200 Cedar City UT. 84721 Cedar City UT. 84720 Hospital Affiliation Pediatrics p 435.865.9899 p 435.628.9393 - St George Regional Hospital Burrows, Brian N MD Color Country Pediatrics Jackson, Russell B OD Hospital Affiliation Hillstead, Alan P MD 55 E Canyon Commercial Jackson Eye Care - St George Regional Hospital Vista Neurology Ave 51 E 400 N Specialists Cedar City UT. 84721 Ste 4A Jones, Daniel L MD 1303 N Main St p 435.865.0218 Cedar City UT. 84721 Daniel L Jones MD PA Cedar City UT. 84720 p 435.586.1500 1335 Northfield Rd p 435.586.2229 Hospital Affiliation Ste 200 - Cedar City Hospital Pace, David J OD Cedar City UT. 84721 Hospital Affiliation Southern Utah Vision Care p 435.586.1003 - St George Regional Hospital Dowse, Robert K MD 1251 N Northfield Rd Premier Pediatrics Ste 215 Hospital Affiliation Muir, Casey MD 1251 N Northfield Rd Cedar City UT. 84721 - Cedar City Hospital Vista Neurology Ste 301 p 435.865.9899 Specialists Cedar City UT. 84720 *Nakken, Robert E MD 1303 N Main St p 435.865.7227 1251 N Northfield Rd Southern Utah Ortho Sports Cedar City UT. 84720 Ste 215 Med p 435.586.2229 Hospital Affiliation Cedar City UT. 84721 166 W 1325 N - Cedar City Hospital p 435.865.9899 Ste 150 Obray, Jon B MD Cedar City UT. 84721 Vista Neurology Miller, Gia D MD Taggart, Steven C OD p 435.586.6962 Specialists Color Country Pediatrics Steven C Taggart OD 1303 N Main St 55 E Canyon Commercial 1330 S Providence Ctr Dr Hospital Affiliation Cedar City UT. 84721 Ave Cedar City UT. 84720 - Cedar City Hospital p 435.656.2424 Cedar City UT. 84721 p 435.865.2809 p 435.865.0218 *Stouffer, Mark H MD Hospital Affiliation Wallace, Shaune K OD Southern Utah Neuro-Cedar - St George Regional Hospital Hospital Affiliation Advanced Family Vision 1303 N Main St - Cedar City Hospital Center Cedar City UT. 84720 Obray, Rick W MD 1760 N Main St p 435.868.5055 Vista Neurology Nielson, Craig S DO Ste 103 Specialists Color Country Pediatrics Cedar City UT. 84721 Hospital Affiliation 1303 N Main St 55 E Canyon Commercial p 435.867.0644 - St George Regional Hospital Cedar City UT. 84721 Ave p 435.656.2424 Cedar City UT. 84721 p 435.865.0218 Hospital Affiliation - St George Regional Hospital Hospital Affiliation - Cedar City Hospital

118 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Parker, Scott B APRN Hermansen, Jonathan J DPT Utah Podiatry Group PC Radiation Oncology Color Country Pediatrics Color Country Physical 1251 Northfield Rd *Ashton, Spencer N MD 2002 N Main St Therapy Ste 103 Valley View Radiation Ste 3 450 E Clinic Way Cedar City UT. 84721 Oncology Cedar City UT. 84721 Ste B p 801.825.4709 1303 N Main St p 435.865.0218 Parowan UT. 84761 Cedar City UT. 84721 p 435.477.0095 Webb, Brad S DPM p 435.688.4175 Physical Therapy Advanced Foot & Ankle Applegate, Evan J DPT Lunt, Kregg PT 1811 W Royal Hunte Dr Hospital Affiliation Color Country Physical Southern Utah Physical and Ste 2 - Cedar City Hospital Therapy Rehabilitation Cedar City UT. 84720 450 E Clinic Way 1335 N Northfield Rd p 435.586.2225 *Barney, Brandon M MD Ste B Cedar City UT. 84721 Cedar City Radiation Parowan UT. 84761 p 435.865.1902 Foot and Ankle Institute Oncology p 435.477.0095 1811 W Royal Hunte Dr 1333 N Main St Mendenhall, Adam L PT Cedar City UT. 84720 Cedar City UT. 84721 Brinkerhoff, G Tyler PT Southern Utah Physical and p 435.586.2225 p 435.688.4175 Southern Utah Physical and Rehabilitation Rehabilitation 166 W 1325 N Hospital Affiliation *Evans, Jaden D MD 166 W 1325 N Ste 100 - Cedar City Hospital Cedar City Radiation Ste 100 Cedar City UT. 84721 Oncology Cedar City UT. 84721 p 435.586.0064 Psychiatry 1333 N Main St p 435.586.0064 *Bradbury, Matthew DO Cedar City UT. 84721 Podiatry Cedar City Clinic p 435.688.4175 Concentra Medical Centers Advanced Foot & Ankle 1303 N Main St 2390 Redwood Rd 1811 W Royal Hunte Dr Ste 3C *Grant, Jonathan D MD West Valley City UT. 84419 Ste 2 Cedar City UT. 84720 Valley View Radiation p 888.997.2669 Cedar City UT. 84720 p 435.868.5500 Oncology p 435.586.2225 1303 N Main St Englestead, Brady PT Hospital Affiliation Cedar City UT. 84721 Southern Utah Physical and Butterfield, Ted DPM - Baylor Scott & White p 435.688.4175 Rehabilitation Foot and Ankle Institute Medical Center - Temple 166 W 1325 N 1811 W Royal Hunte Dr Radiology Ste 100 Ste 2 Ward, Cori APRN *Davis, John A MD Cedar City UT. 84721 Cedar City UT. 84720 Utah Behavior Services Cedar City Hospital p 435.586.0064 p 435.586.2225 1870 N Main St 1303 N Main St Ste 206 Cedar City UT. 84720 Forsyth, Randy PT Hospital Affiliation Cedar City UT. 84721 p 435.868.5000 Southern Utah Physical and - St George Regional Hospital p 801.255.5131 Rehabilitation Hospital Affiliation 1335 N Northfield Rd Clark, Gary W DPM Psychology - St George Regional Hospital Ste 300 166 W 1325 N Shumway, Brett PSYD Cedar City UT. 84721 Ste 300 Utah Behavior Services *Davis, Steven B MD p 435.865.1902 Cedar City UT. 84721 1870 N Main St Cedar City Hospital p 435.867.8521 Ste 206 1303 N Main St 166 W 1325 N Cedar City UT. 84721 Cedar City UT. 84720 Ste 100 450 E Clinic Way p 801.255.5131 p 435.868.5000 Cedar City UT. 84721 Parawan UT. 84761 p 435.586.0064 p 435.867.8521 Siebert, Tatum LCPC Hospital Affiliation Utah Behavior Services - St George Regional Hospital Forsyth, Tori B PT Hospital Affiliation 1870 N Main St Southern Utah Physical and - Cedar City Hospital Ste 206 Sleep Medicine Rehabilitation Cedar City UT. 84721 Saifee, Mustafa T MD 1335 N Northfield Rd Myers, Victor K DPM p 801.255.5131 Advanced Pulmonary, Sleep Ste 300 Foot and Ankle Institute Disorders and Internal Cedar City UT. 84721 1811 W Royal Hunte Dr Pulmonology Medicine p 435.865.1902 Ste 2 Saifee, Mustafa T MD 110 W 1325 N Cedar City UT. 84720 Advanced Pulmonary, Sleep Ste 175 166 W 1325 N p 435.586.2225 Disorders and Internal Cedar City UT. 84721 Ste 100 Medicine p 435.688.7770 Cedar City UT. 84721 Reber, Leon K DPM 110 W 1325 N p 435.586.0064 Foot and Ankle Institute Ste 175 Hospital Affiliation 1811 W Royal Hunte Dr Cedar City UT. 84721 - St George Regional Hospital Ste 2 p 435.688.7770 Cedar City UT. 84720 p 435.586.2225 Hospital Affiliation - St George Regional Hospital Hospital Affiliation - St George Regional Hospital - Cedar City Hospital 119 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Social Worker Holmes, Alisha MSW Powell, Clark Randy LCSW *Southern Utah Ortho Sports Arballo, Jennifer CSW Utah Behavior Services Utah Behavior Services *Med Utah Behavior Services 1870 N Main St 1870 N Main St 166 W 1325 N 1870 N Main St Ste 206 Ste 206 Ste 150 Ste 206 Cedar City UT. 84721 Cedar City UT. 84721 Cedar City UT. 84721 Cedar City UT. 84721 p 801.255.5131 p 801.255.5131 p 435.586.6962 p 801.255.5131 Johnston, Harmony MSW Reeves, Linda G LCSW Urgent Care Birch, Kelly LCSW Utah Behavior Services Linda G Reeves LCSW *Cedar City InstaCare M-F Utah Behavior Services 1870 N Main St 1156 S Bentley Blvd *9am-5pm 1870 N Main St Ste 206 Ste 2D 962 S Sage Dr Ste 206 Cedar City UT. 84721 Cedar City UT. 84720 Cedar City UT. 84720 Cedar City UT. 84721 p 801.255.5131 p 435.559.0518 p 435.865.3440 p 801.255.5131 *Keate, Joseph L LCSW Roche, Miriam MSW Urology Bunting, Catherine CSW Valley View Family Utah Behavior Services *Adams, David M MD Utah Behavior Services Medicine 1870 N Main St Southern Utah Surgical 1870 N Main St 1333 N Main St Ste 206 Associates Ste 206 Cedar City UT. 84721 Cedar City UT. 84721 166 W 1325 N Cedar City UT. 84721 p 435.868.5500 p 801.255.5131 Ste 350 p 801.255.5131 Cedar City UT. 84720 Hospital Affiliation Skousen, Thomas MSW p 435.586.8192 Cho, Jaeyong MSW - Cedar City Hospital Utah Behavior Services Utah Behavior Services 1870 N Main St Hospital Affiliation 1870 N Main St Luna, Janette M LCSW Ste 206 - St George Regional Hospital Ste 206 Utah Behavior Services Cedar City UT. 84721 - Cedar City Hospital Cedar City UT. 84721 1870 N Main St p 801.255.5131 p 801.255.5131 Ste 206 *Whiting, Bryant M MD Cedar City UT. 84721 Slater, Courtney MSW Southern Utah Surgical Coburn, Alison MSW p 801.255.5131 Utah Behavior Services Associates Utah Behavior Services 1870 N Main St 166 W 1325 N 1870 N Main St McGill, Katie MSW Ste 206 Ste 350 Ste 206 Utah Behavior Services Cedar City UT. 84721 Cedar City UT. 84720 Cedar City UT. 84721 1870 N Main St p 801.255.5131 p 435.586.8192 p 801.255.5131 Ste 206 Cedar City UT. 84721 Suarez, Alex LCSW Hospital Affiliation Donovan, Andrea LCSW p 801.255.5131 Utah Behavior Services - St George Regional Hospital Natalie P Townsend CMHC 1870 N Main St - Cedar City Hospital 965 S Main St Moss, Melissa M LCSW Ste 206 Cedar City UT. 84720 Melissa M Moss LCSW Cedar City UT. 84721 Vascular Surgery p 435.586.4966 88 E Fiddlers Canyon Rd p 801.255.5131 *Olsen, Arne M MD Ste 127 Cedar City Heart Clinic Drabeck, Sharon E LCSW Cedar City UT. 84721 Thomas, Joni D LCSW 1303 N Main St Sharon E Drabeck LCSW p 435.760.0753 Brighter Future Counseling Ste H 1760 N Main St 66 W Harding Ave Cedar City UT. 84720 Ste 209 Neff, Michal A CSW,SUDC Ste C3 p 435.868.5500 Cedar City UT. 84721 Utah Behavior Services Cedar City UT. 84720 p 702.306.8438 1870 N Main St p 435.592.0366 Hospital Affiliation Ste 206 - St George Regional Hospital Einfeldt, Keith T LCSW Cedar City UT. 84721 Tuft, Diane LCSW - St George Regional Hospital 115 N Main p 801.255.5131 Peace Balance & Joy Ste 204 Consulting *Wirthlin, Douglas J MD Cedar City UT. 84720 Nielsen, Stephanie MSW 2069 N Main St Cedar City Heart Clinic p 435.865.1188 Utah Behavior Services Ste 101 1303 N Main St 1870 N Main St Cedar City UT. 84721 Cedar City UT. 84720 Goddard, Tyler C LCSW Ste 206 p 435.267.4212 p 435.868.5500 Cambridge Counseling Cedar City UT. 84721 Center Inc p 801.255.5131 Sports Medicine Jefferson County 337 S Main Allen, Daniel J DO Ste 110 Phillips, Allison Cedar City Paiute Medical Breast Pumps Cedar City UT. 84720 LCSW,BCBA Clinic Alpine Home Medical p 435.225.2422 Utah Behavior Services 440 N Paiute Dr Phone Number Only 1870 N Main St Cedar City UT. 84721 p 800.686.7993 Ste 206 p 435.867.1520 Cedar City UT. 84721 p 801.255.5131 Hospital Affiliation - West Valley Medical Center

120 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Edgepark Edgepark Physical Therapy Diabetic Supplies Phone Number Only Phone Number Only Concentra Medical Centers CCS Medical p 800.321.0591 p 800.321.0591 2390 Redwood Rd Phone Number Only West Valley City UT. 84419 p 800.726.9811 Cardiac Monitoring Empi Inc (Neuromuscular p 888.997.2669 Remote Cardiac Services Stimulator) Edgepark Phone Number Only Phone Number Only Juab County Phone Number Only p 800.367.0300 p 800.328.2536 p 800.321.0591 Audiology eCardio Diagnostics KCI USA Inc (Wound Vac Thomas, Curtis AUD Roche Insulin Delivery Phone Number Only Only) Peak ENT Associates Systems Inc p 888.400.3522 Phone Number Only 48 W 1500 N Phone Number Only p 800.275.4524 Nephi UT. 84648 p 800.280.7801 Diabetic Supplies p 801.357.7499 CCS Medical Orthofix Inc (Bone Growth US MED LLC Phone Number Only Stimulators Physicians Breast Pumps Phone Number Only p 800.726.9811 Only) Alpine Home Medical p 800.787.6331 Phone Number Only Phone Number Only Edgepark p 800.535.4492 p 800.686.7993 United States Medical Phone Number Only Supply p 800.321.0591 Pacific Medical Inc Edgepark Phone Number Only Phone Number Only Phone Number Only p 877.840.8218 Roche Insulin Delivery p 800.726.9180 p 800.321.0591 Systems Inc Durable Medical Equipment Phone Number Only RespirTech Cardiac Monitoring Alpine Home Medical p 800.280.7801 Phone Number Only Remote Cardiac Services Phone Number Only p 800.793.1261 Phone Number Only p 800.686.7993 US MED LLC p 800.367.0300 Phone Number Only Roche Insulin Delivery CCS Medical p 800.787.6331 Systems Inc eCardio Diagnostics Phone Number Only Phone Number Only Phone Number Only p 800.726.9811 United States Medical p 800.280.7801 p 888.400.3522 Supply Care Rehab and Orthopedic Phone Number Only Smith Nephew Inc (Muscle Cardiology Products (Muscle p 877.840.8218 Stimulators) Allen, Marvin R MD Stimulators) Phone Number Only Revere Health Phone Number Only Durable Medical Equipment p 800.821.5700 48 W 1500 N p 800.487.9644 Alpine Home Medical Nephi UT. 84648 Phone Number Only US MED LLC p 801.343.4366 DJO Global p 800.686.7993 Phone Number Only Phone Number Only p 800.787.6331 Hospital Affiliation p 800.336.6569 CCS Medical - Timpanogos Regional Hospital Phone Number Only United States Medical - Mountain View Hospital Dynasplint Systems Inc p 800.726.9811 Supply (UT) Phone Number Only Phone Number Only - Gunnison Valley Hospital p 800.638.6771 Care Rehab and Orthopedic p 877.840.8218 Products (Muscle Chiropractic EBI LLC (Bone Stimulators) Stimulators) Laboratory Bradford, Brandon D DC Phone Number Only Phone Number Only Dominion Diagnostics Nephi Chiropractic p 800.526.2579 p 800.487.9644 Phone Number Only 45 N Main St p 877.734.9600 Nephi UT. 84648 Edgepark DJO Global p 435.623.7400 Phone Number Only Phone Number Only LabCorp of America p 800.321.0591 p 800.336.6569 Holdings Counseling Phone Number Only Horton, Dwayne M LMFT Empi Inc (Neuromuscular Dynasplint Systems Inc p 888.522.2677 Nephi Medical Clinic Stimulator) Phone Number Only 48 W 1500 N Phone Number Only p 800.638.6771 Occupational Therapy Nephi UT. 84648 p 800.328.2536 Concentra Medical Centers p 435.623.3200 EBI LLC (Bone Stimulators) 2390 Redwood Rd KCI USA Inc (Wound Vac Phone Number Only West Valley City UT. 84419 Dermatology Only) p 800.526.2579 p 888.997.2669 Eyre, Michael P DO Phone Number Only Aspen Dermatology p 800.275.4524 48 W 1500 N Nephi UT. 84648 p 801.794.1490

Hospital Affiliation - Mountain View Hospital (UT) - Gunnison Valley Hospital 121 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Orthofix Inc (Bone Growth Gasser, Brian D APRN Rasmussen, Grant J MD Hospital Stimulators Physicians Nephi Medical Clinic Nephi Medical Clinic Central Valley Medical Only) 48 W 1500 N 48 W 1500 N Center Phone Number Only Nephi UT. 84648 Nephi UT. 84648 48 W 1500 N p 800.535.4492 p 435.623.3200 p 435.623.0775 Nephi UT. 84648 p 435.623.3000 Pacific Medical Inc Hospital Affiliation Hospital Affiliation Phone Number Only - Utah Valley Hospital - Central Valley Medical Laboratory p 800.726.9180 Center Dominion Diagnostics Jones, Marc F DO Phone Number Only RespirTech Nephi Medical Clinic Rosenbeck, James F DO p 877.734.9600 Phone Number Only 48 W 1500 N Nephi Medical Clinic p 800.793.1261 Nephi UT. 84648 48 W 1500 N LabCorp of America p 435.623.3200 Nephi UT. 84648 Holdings Roche Insulin Delivery p 435.623.3200 Phone Number Only Systems Inc Hospital Affiliation p 888.522.2677 Phone Number Only - Central Valley Medical Hospital Affiliation p 800.280.7801 Center - Central Valley Medical Mental Health Center Horton, Dwayne M LMFT Smith Nephew Inc (Muscle Mangelson, Christie L Nephi Medical Clinic Stimulators) APRN Standring, Jason R DO 48 W 1500 N Phone Number Only Nephi Medical Clinic Nephi Medical Clinic Nephi UT. 84648 p 800.821.5700 48 W 1500 N 48 W 1500 N p 435.623.3200 Nephi UT. 84648 Nephi UT. 84648 US MED LLC p 435.623.3200 p 435.623.3200 Porter, Corinna PhD Phone Number Only 643 N Main St p 800.787.6331 Hospital Affiliation Taylor, Jerald B DO Nephi UT. 84648 - Central Valley Medical Nephi Medical Clinic p 435.671.0367 United States Medical Center 48 W 1500 N Supply Nephi UT. 84648 Obstetrics And Gynecology Phone Number Only Neilsen, Jason D MD p 435.623.3200 Skinner, Reed J MD p 877.840.8218 Nephi Medical Clinic Nephi Medical Clinic 48 W 1500 N Hospital Affiliation 48 W 1500 N Ear Nose And Throat Nephi UT. 84648 - Central Valley Medical Nephi UT. 84648 Beus, Kirt S MD p 435.623.3200 Center p 435.623.3200 Peak ENT Associates 48 W 1500 N Oveson, Mark C MD Ward, Robertson D MD Occupational Therapy Nephi UT. 84648 Nephi Medical Clinic Nephi Medical Clinic Concentra Medical Centers p 435.637.8000 48 W 1500 N 48 W 1500 N 2390 Redwood Rd Nephi UT. 84648 Nephi UT. 84648 West Valley City UT. 84419 Hospital Affiliation p 435.623.3200 p 435.623.3200 p 888.997.2669 - Timpanogos Regional Hospital - Central Valley Medical Hospital Affiliation General Surgery Optometry Center - Central Valley Medical Anderson, Richard E MD Cope, James A OD Center 48 W 1500 N Nebo Vision Clinic Family Practice Nephi UT. 84648 48 S Main St Alsup Jr, Daniel D MD Pikus, Jared J MD p 435.843.9964 Nephi UT. 84648 Nephi Medical Clinic Nephi Medical Clinic p 435.623.2100 48 W 1500 N 48 W 1500 N Hospital Affiliation Nephi UT. 84648 Nephi UT. 84648 - Central Valley Medical Orthopedic Surgery p 435.623.3200 p 435.623.3200 Center Holman, Joel E MD - Gunnison Valley Hospital Nephi Medical Clinic Besendorfer, James M MD Poff, Emily S MD 48 W 1500 N Nephi Medical Clinic Nephi Medical Clinic Gynecology Nephi UT. 84648 48 W 1500 N 48 W 1500 N Skinner, Reed J MD p 435.623.3200 Nephi UT. 84648 Nephi UT. 84648 Nephi Medical Clinic p 435.623.0775 p 435.623.3211 48 W 1500 N Hospital Affiliation Nephi UT. 84648 - Central Valley Medical Hospital Affiliation Hospital Affiliation p 435.623.3200 Center - Central Valley Medical - Central Valley Medical Center Center Hand Surgery Karrasch, Chris K MD Holman, Joel E MD Nephi Medical Clinic Nephi Medical Clinic 48 W 1500 N 48 W 1500 N Nephi UT. 84648 Nephi UT. 84648 p 435.623.3200 p 435.623.3200

Hospital Affiliation - Central Valley Medical Center 122 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Pediatrics Kane County Diabetic Supplies KCI USA Inc (Wound Vac Duval, Gordon W DO CCS Medical Only) Nephi Medical Clinic Breast Pumps Phone Number Only Phone Number Only 48 W 1500 N Alpine Home Medical p 800.726.9811 p 800.275.4524 Nephi UT. 84648 Phone Number Only p 435.623.3200 p 800.686.7993 Edgepark Orthofix Inc (Bone Growth Phone Number Only Stimulators Physicians Physical Medicine And Rehabilitation Edgepark p 800.321.0591 Only) *Benfield, Jonathan A DO Phone Number Only Phone Number Only Utah Valley Pain p 800.321.0591 Roche Insulin Delivery p 800.535.4492 Management-Nephi Systems Inc 48 W 1500 N Cardiac Monitoring Phone Number Only Pacific Medical Inc Nephi UT. 84648 Remote Cardiac Services p 800.280.7801 Phone Number Only p 801.235.7246 Phone Number Only p 800.726.9180 p 800.367.0300 US MED LLC Hospital Affiliation Phone Number Only RespirTech - Baptist Medical Center eCardio Diagnostics p 800.787.6331 Phone Number Only Phone Number Only p 800.793.1261 Physical Therapy p 888.400.3522 United States Medical Concentra Medical Centers Supply Roche Insulin Delivery 2390 Redwood Rd Cardiology Phone Number Only Systems Inc West Valley City UT. 84419 Barton, Deborah NP p 877.840.8218 Phone Number Only p 888.997.2669 Revere Health p 800.280.7801 355 N Main St Durable Medical Equipment Podiatry Kanab UT. 84741 Advantage Medical Supply Smith Nephew Inc (Muscle Clegg, Jared T DPM p 435.251.2900 670 S Hwy 89 Stimulators) Utah Podiatry Group PC Ste A Phone Number Only 48 W 1500 N Hospital Affiliation Kanab UT. 84741 p 800.821.5700 Nephi UT. 84648 - St George Regional Hospital p 435.644.8600 p 801.373.2499 US MED LLC Jones, Jamison C MD Alpine Home Medical Phone Number Only Hospital Affiliation Revere Health Phone Number Only p 800.787.6331 - Central Valley Medical 355 N Main St p 800.686.7993 Center Kanab UT. 84741 United States Medical p 435.251.2900 CCS Medical Supply 48 W 1500 N Phone Number Only Phone Number Only Nephi UT. 84648 Hospital Affiliation p 800.726.9811 p 877.840.8218 p 435.623.3200 - St George Regional Hospital Care Rehab and Orthopedic Family Practice Psychology Chiropractic Products (Muscle Bowman, Jonathan C MD Porter, Corinna PhD Linton, Loral G DC Stimulators) Revere Health 643 N Main St Dr Loral G Linton DC PC Phone Number Only 355 N Main St Nephi UT. 84648 662 S Hwy 89 p 800.487.9644 Kanab UT. 84741 p 435.671.0367 Ste A p 435.644.4100 Kanab UT. 84741 DJO Global Skilled Nursing Facility p 435.644.5296 Phone Number Only Hospital Affiliation Heritage Hills Rehab & p 800.336.6569 - Kane County Hospital Care Center Counseling 1100 N 400 E Center for Couples & Dynasplint Systems Inc Hollingshead, Bryson H DO Nephi UT. 84648 Families Phone Number Only Revere Health p 435.623.1721 387 S 100 E Unit 2B p 800.638.6771 355 N Main St Kanab UT. 84741 Kanab UT. 84741 Speech Therapy p 435.688.1111 EBI LLC (Bone Stimulators) p 435.644.4100 Thomas, Curtis AUD Phone Number Only Peak ENT Associates Dermatology p 800.526.2579 Palmer, Joanne M NP 48 W 1500 N Adams, Benjamin E DO Valley Medical Clinic Nephi UT. 84648 Cedar Dermatology Edgepark 425 E State St p 801.357.7499 460 E 300 S Phone Number Only Orderville UT. 84758 Ste 4 p 800.321.0591 p 435.648.2775 Sports Medicine Kanab UT. 84741 Neilsen, Jason D MD p 435.586.6440 Empi Inc (Neuromuscular Hospital Affiliation Nephi Medical Clinic Stimulator) - Kane County Hospital 48 W 1500 N Hospital Affiliation Phone Number Only Nephi UT. 84648 - Cedar City Hospital p 800.328.2536 p 435.623.3200

123 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Root, Eric J DO Nephrology Quarnberg, Jana J OT Podiatry Revere Health Assiago, Marcellus S MD Mountain Land Stewart, Jeffrey L DPM 355 N Main St University of Utah Health Rehabilitation Inc Utah Podiatric Physicians Kanab UT. 84741 355 N Main St 355 N Main St and Surgeons Group p 435.644.4100 Kanab UT. 84741 Kanab UT. 84741 76 E 100 S p 435.586.8827 p 435.644.4199 Kanab UT. 84741 Hospital p 435.634.9225 Kane County Hospital Hospital Affiliation Optometry 355 N Main St - University of Utah Hospital Allan, Stuart K OD Hospital Affiliation Kanab UT. 84741 - Davis Hospital Kane County Eye Care, Inc. - St George Regional Hospital p 435.644.5811 75 E 200 S - Kane County Hospital Boateng, Yaw A MD Ste 1 Internal Medicine University of Utah Health Kanab UT. 84741 Millard County Assiago, Marcellus S MD 355 N Main St p 435.644.5717 University of Utah Health Kanab UT. 84741 Breast Pumps 355 N Main St p 435.586.8827 Orthopedic Surgery Alpine Home Medical Kanab UT. 84741 Anderson, Michael B MD Phone Number Only p 435.586.8827 Hospital Affiliation Revere Health p 800.686.7993 - University of Utah Hospital 355 N Main St Hospital Affiliation Kanab UT. 84741 Edgepark - University of Utah Hospital Eppich, Irel S MD p 435.251.2900 Phone Number Only - Davis Hospital University of Utah Health p 800.321.0591 355 N Main St Hospital Affiliation Eppich, Irel S MD Kanab UT. 84741 - St George Regional Hospital Cardiac Monitoring University of Utah Health p 435.867.8175 - Kane County Hospital Remote Cardiac Services 355 N Main St Phone Number Only Kanab UT. 84741 Hospital Affiliation Parry, Scott A MD p 800.367.0300 p 435.867.8175 - University of Utah Hospital Revere Health - Mountain View Hospital 355 N Main St eCardio Diagnostics Hospital Affiliation (UT) Kanab UT. 84741 Phone Number Only - University of Utah Hospital - Timpanogos Regional Hospital p 435.251.2900 p 888.400.3522 - Mountain View Hospital (UT) Kakani, Siddhartha MD Hospital Affiliation Cardiology - Timpanogos Regional Hospital University of Utah Health - St George Regional Hospital *Weaver, Aaron N MD 355 N Main St - Kane County Hospital Delta Community Hospital Foster, Christine K MD Kanab UT. 84741 126 White Sage Ave Revere Health p 435.867.8175 Prince, Edward J MD Delta UT. 84624 355 N Main St Revere Health p 435.864.5591 Kanab UT. 84741 Hospital Affiliation 355 N Main St p 435.644.4100 - University of Utah Hospital Kanab UT. 84741 Fillmore Community p 435.251.2900 Hospital Roy, Abinash C MD Roy, Abinash C MD 674 S Hwy 99 University of Utah Health University of Utah Health Hospital Affiliation Fillmore UT. 84631 355 N Main St 355 N Main St - St George Regional Hospital p 435.743.5591 Kanab UT. 84741 Kanab UT. 84741 - Kane County Hospital p 435.586.8827 p 435.586.8827 Hospital Affiliation Physical Therapy - Timpanogos Regional Hospital Hospital Affiliation Hospital Affiliation Concentra Medical Centers - Mountain View Hospital - St George Regional Hospital - St George Regional Hospital 2390 Redwood Rd (UT) - University of Utah Hospital - University of Utah Hospital West Valley City UT. 84419 p 888.997.2669 Chiropractic Laboratory Obstetrics And Gynecology Hughes, Rendon J DC Dominion Diagnostics Bowman, Jonathan C MD Stubbs, Brandon DPT Delta Chiropractic Center Phone Number Only Revere Health Mountain Land 58 E Main St p 877.734.9600 355 N Main St Rehabilitation Inc Ste 1 Kanab UT. 84741 355 N Main St Delta UT. 84624 LabCorp of America p 435.644.4100 Kanab UT. 84741 p 435.864.1833 Holdings p 435.644.4199 Phone Number Only Hospital Affiliation Counseling p 888.522.2677 - Kane County Hospital Wright, Taran DPT Anderson, Gary L LPC Mountain Land 520 E Topaz Blvd Mental Health Occupational Therapy Rehabilitation Inc Ste 208 Center for Couples & Concentra Medical Centers 355 N Main St Delta UT. 84624 Families 2390 Redwood Rd Kanab UT. 84741 p 435.864.7072 387 S 100 E Unit 2B West Valley City UT. 84419 p 435.644.4199 Kanab UT. 84741 p 888.997.2669 p 435.688.1111

124 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Center for Couples & Durable Medical Equipment Smith Nephew Inc (Muscle *Brown, Wayne O MD Families Alpine Home Medical Stimulators) Fillmore Clinic 111 E Main St Phone Number Only Phone Number Only 700 S Hwy 99 Delta UT. 84624 p 800.686.7993 p 800.821.5700 Ste 3 p 435.688.1111 Fillmore UT. 84631 CCS Medical US MED LLC p 435.743.5555 Thomas, Thurmon E LMFT Phone Number Only Phone Number Only Center for Couples & p 800.726.9811 p 800.787.6331 Canyon View Orthopedics Families Delta 111 E Main St Care Rehab and Orthopedic United States Medical 95 S White Sage Ave Delta UT. 84624 Products (Muscle Supply Ste C p 435.688.1111 Stimulators) Phone Number Only Delta UT. 84624 Phone Number Only p 877.840.8218 p 801.798.7301 Dermatology p 800.487.9644 Adams, Benjamin E DO Ear Nose And Throat *Davie, Daniel MD Cedar Dermatology DJO Global *Kemp, Edgar N DO Delta Community Hospital 126 S White Sage Ave Phone Number Only White Sage Family Medicine 126 White Sage Ave Delta UT. 84624 p 800.336.6569 130 White Sage Ave Delta UT. 84624 p 435.586.6440 Delta UT. 84624 p 435.864.5591 Dynasplint Systems Inc p 435.864.2708 700 S Hwy 99 Phone Number Only Fillmore Community Fillmore UT. 84631 p 800.638.6771 Fillmore Clinic Hospital p 435.586.6440 700 S Hwy 99 674 S Hwy 99 EBI LLC (Bone Stimulators) Ste 3 Fillmore UT. 84631 Hospital Affiliation Phone Number Only Fillmore UT. 84631 p 435.743.5591 - Cedar City Hospital p 800.526.2579 p 435.743.5555 *Dekker, Joshua A DO Colbert, Rand L MD Edgepark Hospital Affiliation Delta Community Hospital Cedar Dermatology Phone Number Only - Delta Community Hospital 126 White Sage Ave 126 S White Sage Ave p 800.321.0591 - Fillmore Community Hospital Delta UT. 84624 Delta UT. 84624 - Sanpete Valley Hospital p 435.864.5591 p 435.864.5113 Empi Inc (Neuromuscular - Sevier Valley Hospital Stimulator) White Sage Family Practice 700 S Hwy 99 Phone Number Only Family Practice 130 White Sage Ave Fillmore UT. 84631 p 800.328.2536 Allen, Daniel J DO Delta UT. 84624 p 435.743.5555 Kanosh Paiute Medical p 435.864.2708 KCI USA Inc (Wound Vac Clinic Hospital Affiliation Only) 157 N Reservation Dr Hospital Affiliation - Cedar City Hospital Phone Number Only Kanosh UT. 84637 - Delta Community Hospital p 800.275.4524 p 435.759.2610 Diabetic Supplies *Evans, Matthew MD CCS Medical Orthofix Inc (Bone Growth Hospital Affiliation Delta Community Hospital Phone Number Only Stimulators Physicians - West Valley Medical Center 126 White Sage Ave p 800.726.9811 Only) Delta UT. 84624 Phone Number Only *Bailey, Jacob D MD p 435.864.5591 Edgepark p 800.535.4492 White Sage Family Medicine Phone Number Only 130 White Sage Ave Fillmore Community p 800.321.0591 Pacific Medical Inc Delta UT. 84624 Hospital Phone Number Only p 435.864.2708 674 S Hwy 99 Roche Insulin Delivery p 800.726.9180 Fillmore UT. 84631 Systems Inc Hospital Affiliation p 435.743.5591 Phone Number Only RespirTech - Delta Community Hospital p 800.280.7801 Phone Number Only Gray, Jarid D MD p 800.793.1261 *Bassett, Jonathan MD Kanosh Paiute Medical US MED LLC Fillmore Community Clinic Phone Number Only Roche Insulin Delivery Hospital Physicians 157 N Reservation Dr p 800.787.6331 Systems Inc 674 S Hwy 99 Kanosh UT. 84637 Phone Number Only Fillmore UT. 84631 p 435.759.2610 United States Medical p 800.280.7801 p 435.743.5591 Supply Hospital Affiliation Phone Number Only Service Drug Fillmore Clinic - Cedar City Hospital p 877.840.8218 215 W Main St 700 S Hwy 99 Delta UT. 84624 Ste 3 p 435.864.2545 Fillmore UT. 84631 p 435.743.5555

Hospital Affiliation - Fillmore Community Hospital 125 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Grose, Craig M MD *Spencer, Jesse N MD Mental Health Ophthalmology Revere Health Delta Community Hospital Anderson, Gary L LPC Lohner, W S MD 770 S Hwy 99 126 White Sage Ave 520 E Topaz Blvd Excel Eye Center of Delta Fillmore UT. 84631 Delta UT. 84624 Ste 208 140 White Sage Ave p 435.253.8000 p 435.864.5591 Delta UT. 84624 Delta UT. 84624 p 435.864.7072 p 435.864.3333 *Huber, Brian NP Fillmore Community Delta Community Hospital Hospital Center for Couples & Excel Eye Center of Physicians 674 S Hwy 99 Families Fillmore 126 White Sage Ave Fillmore UT. 84631 111 E Main St 700 S Hwy 99 Delta UT. 84624 p 435.743.5591 Delta UT. 84624 Fillmore UT. 84631 p 435.864.5591 p 435.688.1111 p 435.743.5555 General Surgery Hospital Affiliation *Gilbert, Preston M DO *Holbrook, Garry R LCSW Hospital Affiliation - Delta Community Hospital White Sage Family Medicine White Sage Family Medicine - Central Valley Medical 130 White Sage Ave 130 White Sage Ave Center *Scoville, Spencer L DO Delta UT. 84624 Delta UT. 84624 - Mountain View Hospital Fillmore Community p 435.864.2708 p 435.864.2708 (UT) Hospital 674 S Hwy 99 Fillmore Clinic Fillmore Clinic Optometry Fillmore UT. 84631 700 S Hwy 99 700 S Hwy 99 Albrecht, William S OD p 435.743.5591 Ste 3 Ste 3 Kanosh Paiute Medical Fillmore UT. 84631 Fillmore UT. 84631 Clinic *Seiler, Chad W MD p 435.743.5555 p 435.743.5555 157 N Reservation Dr Fillmore Clinic Kanosh UT. 84637 700 S Hwy 99 Hospital Affiliation *Orton, Jana L LCSW p 435.759.2610 Ste 3 - Sevier Valley Hospital White Sage Family Medicine Fillmore UT. 84631 130 White Sage Ave Cope, James A OD p 435.743.5555 Home Health Agency Delta UT. 84624 Nebo Vision Clinic *Intermountain Homecare p 435.864.2708 360 E Main *Shamo, Steven W MD *Home Health Fillmore Ste A1 Delta Community Hospital 25 N Main St Fillmore Clinic Delta UT. 84624 126 White Sage Ave Fillmore UT. 84631 700 S Hwy 99 p 435.623.2100 Delta UT. 84624 p 435.743.5430 Ste 3 p 435.864.5591 Fillmore UT. 84631 Jackson, Russell B OD Hospice p 435.743.5555 Jackson Eye Care Revere Health *Intermountain Homecare 210 S 100 W 140 White Sage Ave *Hospice Fillmore *Sorenson, Russell D PhD Fillmore UT. 84631 Delta UT. 84624 25 N Main St White Sage Family Medicine p 435.743.6572 p 435.864.3333 Fillmore UT. 84631 130 White Sage Ave p 435.743.5430 Delta UT. 84624 Orthopedic Surgery Hospital Affiliation p 435.864.2708 *Evensen, Christopher S DO - Delta Community Hospital Hospital Fillmore Clinic *Delta Community Hospital Fillmore Clinic 700 S Hwy 99 Smith, Alan R MD 126 S White Sage Ave 700 S Hwy 99 Ste 3 Revere Health Delta UT. 84624 Ste 3 Fillmore UT. 84631 140 White Sage Ave p 435.864.5591 Fillmore UT. 84631 p 435.743.5555 Delta UT. 84624 p 435.743.5555 p 435.864.3333 *Fillmore Community Hospital Affiliation *Hospital Thomas, Thurmon E LMFT - Sanpete Valley Hospital Hospital Affiliation 674 S Hwy 99 Center for Couples & - Delta Community Hospital Fillmore UT. 84631 Families Taylor, John R MD p 435.743.5591 111 E Main St Revere Health *Smith, Daniel C MD Delta UT. 84624 770 S Hwy 99 Delta Community Hospital Laboratory p 435.688.1111 Fillmore UT. 84631 126 White Sage Ave Dominion Diagnostics p 435.253.8000 Delta UT. 84624 Phone Number Only Occupational Therapy p 435.864.5591 p 877.734.9600 Concentra Medical Centers Physical Therapy 2390 Redwood Rd Concentra Medical Centers Hospital Affiliation LabCorp of America West Valley City UT. 84419 2390 Redwood Rd - Sevier Valley Hospital Holdings p 888.997.2669 West Valley City UT. 84419 - Garfield Memorial Hospital Phone Number Only p 888.997.2669 p 888.522.2677

126 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Podiatry Fillmore Clinic Diabetic Supplies Orthofix Inc (Bone Growth Jaramillo, David H DPM 700 S Hwy 99 CCS Medical Stimulators Physicians Precision Foot and Ankle Ste 3 Phone Number Only Only) Specialists Fillmore UT. 84631 p 800.726.9811 Phone Number Only 770 S Hwy 99 p 435.743.5555 p 800.535.4492 Fillmore UT. 84631 Edgepark p 801.377.5649 Sports Medicine Phone Number Only Pacific Medical Inc Allen, Daniel J DO p 800.321.0591 Phone Number Only 95 White Sage Ave Kanosh Paiute Medical p 800.726.9180 Fillmore UT. 84631 Clinic Roche Insulin Delivery p 801.377.5649 157 N Reservation Dr Systems Inc RespirTech Kanosh UT. 84637 Phone Number Only Phone Number Only Hospital Affiliation p 435.759.2610 p 800.280.7801 p 800.793.1261 - Timpanogos Regional Hospital Hospital Affiliation US MED LLC Roche Insulin Delivery Jaramillo, Todd MD - West Valley Medical Center Phone Number Only Systems Inc Precision Foot and Ankle p 800.787.6331 Phone Number Only Specialists Urology p 800.280.7801 770 S Hwy 99 *Crouch, Ronald H MD United States Medical Fillmore UT. 84631 Delta Community Hospital Supply Smith Nephew Inc (Muscle p 801.377.5649 126 White Sage Ave Phone Number Only Stimulators) Delta UT. 84624 p 877.840.8218 Phone Number Only 95 White Sage Ave p 435.864.5591 p 800.821.5700 Fillmore UT. 84631 Durable Medical Equipment p 801.377.5649 Fillmore Community Alpine Home Medical US MED LLC Hospital Phone Number Only Phone Number Only Psychology 674 S Hwy 99 p 800.686.7993 p 800.787.6331 *Sorenson, Russell D PhD Fillmore UT. 84631 White Sage Family Medicine p 435.743.5591 CCS Medical United States Medical 130 White Sage Ave Phone Number Only Supply Delta UT. 84624 Hospital Affiliation p 800.726.9811 Phone Number Only p 435.864.2708 - Cedar City Hospital p 877.840.8218 - St George Regional Hospital Care Rehab and Orthopedic Fillmore Clinic Products (Muscle Family Practice 700 S Hwy 99 Morgan County Stimulators) Bybee, Alan N PA Ste 3 Phone Number Only Morgan Health Center Fillmore UT. 84631 Breast Pumps p 800.487.9644 166 N State St p 435.743.5555 Alpine Home Medical Morgan UT. 84050 Phone Number Only DJO Global p 801.829.3426 Skilled Nursing Facility p 800.686.7993 Phone Number Only Millard County Care and p 800.336.6569 Craner, Adam C FNP-C Rehabilitation Edgepark Mountain Star Medical 150 S White Sage Ave Phone Number Only Dynasplint Systems Inc Group Delta UT. 84624 p 800.321.0591 Phone Number Only 166 N State St p 435.864.2944 p 800.638.6771 Morgan UT. 84050 Cardiac Monitoring p 801.829.3426 Social Worker Remote Cardiac Services EBI LLC (Bone Stimulators) *Holbrook, Garry R LCSW Phone Number Only Phone Number Only Hospital Affiliation White Sage Family Medicine p 800.367.0300 p 800.526.2579 - Ogden Regional Medical 130 White Sage Ave Center Delta UT. 84624 eCardio Diagnostics Edgepark p 435.864.2708 Phone Number Only Phone Number Only Elkins, Keith W MD p 888.400.3522 p 800.321.0591 Morgan Health Center Fillmore Clinic 166 N State St 700 S Hwy 99 Dermatology Empi Inc (Neuromuscular Morgan UT. 84050 Ste 3 Odell, Richard H MD Stimulator) p 801.829.3426 Fillmore UT. 84631 103 Commercial St Phone Number Only p 435.743.5555 Morgan UT. 84050 p 800.328.2536 Garling, Adam PA-C p 801.272.4219 103 Commercial St *Orton, Jana L LCSW KCI USA Inc (Wound Vac Morgan UT. 84050 White Sage Family Medicine Hospital Affiliation Only) p 801.272.4219 130 White Sage Ave - St Marks Hospital Phone Number Only Delta UT. 84624 p 800.275.4524 p 435.864.2708

127 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Gynecology Occupational Therapy Cardiac Monitoring Empi Inc (Neuromuscular Rockenfield, Terra L PA Concentra Medical Centers Remote Cardiac Services Stimulator) Morgan Clinic 2390 Redwood Rd Phone Number Only Phone Number Only 166 N State St West Valley City UT. 84419 p 800.367.0300 p 800.328.2536 Ste 120 p 888.997.2669 Morgan UT. 84050 eCardio Diagnostics KCI USA Inc (Wound Vac p 801.829.3426 Optometry Phone Number Only Only) Reed, Paul E OD p 888.400.3522 Phone Number Only Home Health Agency Morgan EyeCare p 800.275.4524 CNS Community Nursing 139 N State St Bldg C-6 Diabetic Supplies Services Morgan UT. 84050 CCS Medical Orthofix Inc (Bone Growth Phone Number Only p 801.731.5558 Phone Number Only Stimulators Physicians Croydon UT. 84018 p 800.726.9811 Only) p 801.476.0088 Physical Therapy Phone Number Only Clyde, Willis PT Edgepark p 800.535.4492 Hospice Morgan Physical Therapy Phone Number Only CNS Community Nursing and Fitness Center p 800.321.0591 Pacific Medical Inc Services 129 N Commercial St Phone Number Only Phone Number Only Morgan UT. 84050 Roche Insulin Delivery p 800.726.9180 Croydon UT. 84018 p 801.845.1403 Systems Inc p 801.476.0088 Phone Number Only RespirTech Concentra Medical Centers p 800.280.7801 Phone Number Only Internal Medicine 2390 Redwood Rd p 800.793.1261 Craner, Adam C FNP-C West Valley City UT. 84419 US MED LLC Mountain Star Medical p 888.997.2669 Phone Number Only Roche Insulin Delivery Group p 800.787.6331 Systems Inc 166 N State St Goodrich, Daniel DPT Phone Number Only Morgan UT. 84050 Morgan Physical Therapy United States Medical p 800.280.7801 p 801.829.3426 and Fitness Center Inc Supply 129 N Commercial St Phone Number Only Smith Nephew Inc (Muscle Hospital Affiliation Morgan UT. 84050 p 877.840.8218 Stimulators) - Ogden Regional Medical p 801.845.1403 Phone Number Only Center Durable Medical Equipment p 800.821.5700 Hansen, Bradley DPT Alpine Home Medical Mohr, Robert R MD Physical Therapy And Phone Number Only US MED LLC Morgan Health Center Sports Medicine p 800.686.7993 Phone Number Only 166 N State St 4100 W Old Hwy Rd p 800.787.6331 Morgan UT. 84050 Mountain Green UT. 84050 CCS Medical p 801.829.3426 p 801.773.4624 Phone Number Only United States Medical p 800.726.9811 Supply Hospital Affiliation Kerbs, Alan J PT Phone Number Only - Ogden Regional Medical Physical Therapy and Care Rehab and Orthopedic p 877.840.8218 Center Sports Medicine Products (Muscle 4100 W Old Hwy Rd Stimulators) Family Practice Laboratory Morgan UT. 84050 Phone Number Only Birch, Richard DO Dominion Diagnostics p 801.773.4624 p 800.487.9644 Circleville Clinic Phone Number Only 145 W Main p 877.734.9600 Parker, Bryce S DPT DJO Global Circleville UT. 84723 Physical Therapy and Phone Number Only p 435.577.2958 LabCorp of America Sports Medicine p 800.336.6569 Holdings 4100 W Old Hwy Rd Hospital Affiliation Phone Number Only Morgan UT. 84050 Dynasplint Systems Inc - Garfield Memorial Hospital p 888.522.2677 p 801.773.4624 Phone Number Only p 800.638.6771 Mooney, Todd MD Obstetrics And Gynecology Piute County Circleville Clinic Rockenfield, Terra L PA EBI LLC (Bone Stimulators) 145 W Main Morgan Clinic Breast Pumps Phone Number Only Circleville UT. 84723 166 N State St Alpine Home Medical p 800.526.2579 p 435.577.2958 Ste 120 Phone Number Only Morgan UT. 84050 p 800.686.7993 Edgepark Hospital Affiliation p 801.829.3426 Phone Number Only - Garfield Memorial Hospital Edgepark p 800.321.0591 Phone Number Only p 800.321.0591

128 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Roberts, Becky S FNP US MED LLC Roche Insulin Delivery Martin, Colby PA Circleville Clinic Phone Number Only Systems Inc Bear Lake Community Health 145 W Main p 800.787.6331 Phone Number Only Center Circleville UT. 84723 p 800.280.7801 325 W Logan Hwy p 435.577.2958 United States Medical Garden City UT. 84028 Supply Smith Nephew Inc (Muscle p 435.946.3660 Hospital Affiliation Phone Number Only Stimulators) - Garfield Memorial Hospital p 877.840.8218 Phone Number Only Redmond, Tiffany M PA-C p 800.821.5700 Bear Lake Community Health Laboratory Durable Medical Equipment Center Dominion Diagnostics Alpine Home Medical US MED LLC 325 W Logan Hwy Phone Number Only Phone Number Only Phone Number Only Garden City UT. 84028 p 877.734.9600 p 800.686.7993 p 800.787.6331 p 435.946.3660

LabCorp of America CCS Medical United States Medical Robertson, Glenn l MD Holdings Phone Number Only Supply Bear Lake Community Health Phone Number Only p 800.726.9811 Phone Number Only Center p 888.522.2677 p 877.840.8218 325 W Logan Hwy Care Rehab and Orthopedic Garden City UT. 84028 Occupational Therapy Products (Muscle Family Practice p 435.946.3660 Concentra Medical Centers Stimulators) Adams, Michael D MD 2390 Redwood Rd Phone Number Only Bear Lake Community Health Skates, Andrea L APRN West Valley City UT. 84419 p 800.487.9644 Center Bear Lake Community Health p 888.997.2669 325 W Logan Hwy Center DJO Global Garden City UT. 84028 325 W Logan Hwy Physical Therapy Phone Number Only p 435.946.3660 Garden City UT. 84028 Concentra Medical Centers p 800.336.6569 p 435.946.3660 2390 Redwood Rd Hospital Affiliation West Valley City UT. 84419 Dynasplint Systems Inc - Evanston Regional Hospital Swensen, Eric N DO p 888.997.2669 Phone Number Only Bear Lake Community Health p 800.638.6771 Ballingham, David J PA Center Rich County Bear Lake Community Health 325 W Logan Hwy EBI LLC (Bone Stimulators) Center Garden City UT. 84028 Breast Pumps Phone Number Only 325 W Logan Hwy p 435.755.6061 Alpine Home Medical p 800.526.2579 Garden City UT. 84028 Phone Number Only p 435.946.3660 Hospital Affiliation p 800.686.7993 Edgepark - Evanston Regional Hospital Phone Number Only Boyer, Ben FNP Edgepark p 800.321.0591 Bear Lake Community Health Gynecology Phone Number Only Center Wells, Janelle M MD p 800.321.0591 Empi Inc (Neuromuscular 325 W Logan Hwy Bear Lake Community Health Stimulator) Garden City UT. 84028 Center Cardiac Monitoring Phone Number Only p 435.946.3660 325 W Logan Hwy Remote Cardiac Services p 800.328.2536 Garden City UT. 84028 Phone Number Only Buys, Kristin PA p 435.946.3660 p 800.367.0300 KCI USA Inc (Wound Vac Bear Lake Community Health Only) Center Hospital Affiliation eCardio Diagnostics Phone Number Only 325 W Logan Hwy - Logan Regional Hospital Phone Number Only p 800.275.4524 Garden City UT. 84028 p 888.400.3522 p 435.946.3660 Home Health Agency Orthofix Inc (Bone Growth CNS Community Nursing Diabetic Supplies Stimulators Physicians Carr, Ryan PA Services CCS Medical Only) Bear Lake Community Health Phone Number Only Phone Number Only Phone Number Only Center Garden City UT. 84028 p 800.726.9811 p 800.535.4492 325 W Logan Hwy p 800.501.0014 Garden City UT. 84028 Edgepark Pacific Medical Inc p 435.946.3660 Hospice Phone Number Only Phone Number Only CNS Community Nursing p 800.321.0591 p 800.726.9180 Hobbs, Sydnie M APRN Services Bear Lake Community Health Phone Number Only Roche Insulin Delivery RespirTech Center Garden City UT. 84028 Systems Inc Phone Number Only 325 W Logan Hwy p 800.501.0014 Phone Number Only p 800.793.1261 Garden City UT. 84028 p 800.280.7801 p 435.946.3660

129 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Laboratory Social Worker Baird, Jessica BCaBA Buchanan, Sarah C BCBA Dominion Diagnostics McCarthy, Mary A LCSW ABS Kids Valley Behavioral Health Phone Number Only Bear Lake Community Health 515 S 700 E 6232 S 900 E p 877.734.9600 Center Ste 2A Salt Lake City UT. 84121 325 W Logan Hwy Salt Lake City UT. 84102 p 888.949.4864 LabCorp of America Garden City UT. 84028 p 801.935.4171 Holdings p 435.946.3660 780 S Guardsman Way Phone Number Only Baylis, Allison BCBA Salt Lake City UT. 84108 p 888.522.2677 Urgent Care ABS Kids p 888.949.4864 Bear Lake Community Health 515 S 700 E Mental Health Center M-F 9am-6pm Ste 2A Burton, Brianna BCBA McCarthy, Mary A LCSW 325 W Logan Hwy Salt Lake City UT. 84102 ABS Kids Bear Lake Community Health Garden City UT. 84028 p 801.935.4171 515 S 700 E Center p 435.946.3660 Ste 2A 325 W Logan Hwy 6910 S Highland Dr Salt Lake City UT. 84102 Garden City UT. 84028 Salt Lake County Ste 1 p 801.935.4171 p 435.946.3660 Cottonwood Heights UT. 84121 Aba Therapy p 801.935.4946 Burton, Shelby BCBA Wilkinson, Thomas A PSYD Adolphson, Lillian ABS Kids Bear Lake Community Health BCBA-D Blanco, Stephanie BCBA 6910 S Highland Dr Center Utah Behavior Services ABS Kids Ste 1 325 W Logan Hwy 5558 S 1900 W 515 S 700 E Cottonwood Heights UT. 84121 Garden City UT. 84028 Ste B Ste 2A p 801.935.4946 p 435.946.3660 Salt Lake City UT. 84129 Salt Lake City UT. 84102 p 801.255.5131 p 801.935.4171 Butler, Erin BCBA Obstetrics And Gynecology Neurobehavioral Center for Wells, Janelle M MD 6013 S Redwood Rd 6910 S Highland Dr Growth Bear Lake Community Health Salt Lake City UT. 84123 Ste 1 370 E South Temple Center p 801.255.5131 Salt Lake City UT. 84121 Ste 175 325 W Logan Hwy p 801.935.4946 Salt Lake City UT. 84111 Garden City UT. 84028 Advanced Behavior Analysis p 801.683.1062 p 435.946.3660 1441 E Fort Union Blvd Bodily, Madison BCBA Salt Lake City UT. 84121 ABS Kids Cahoon, Stephanie BCBA Hospital Affiliation p 385.695.2203 515 S 700 E ABS Kids - Logan Regional Hospital Ste 2A 515 S 700 E Aleman, Arianna BCBA Salt Lake City UT. 84102 Ste 2A Occupational Therapy Utah Behavior Services p 801.935.4171 Salt Lake City UT. 84102 Concentra Medical Centers 5558 S 1900 W p 801.935.4171 2390 Redwood Rd Ste B 6910 S Highland Dr West Valley City UT. 84419 Salt Lake City UT. 84129 Ste 1 6910 S Highland Dr p 888.997.2669 p 801.255.5131 Cottonwood Heights UT. 84121 Ste 1 p 801.935.4946 Salt Lake City UT. 84121 Physical Therapy 6013 S Redwood Rd p 801.935.4171 Concentra Medical Centers Salt Lake City UT. 84123 Bouchelle, Elizabeth 2390 Redwood Rd p 801.255.5131 BCBA Call, Amy BCBA West Valley City UT. 84419 ABS Kids Utah Behavior Services p 888.997.2669 Allen, Julie BCBA 6910 S Highland Dr 6013 S Redwood Rd ABS Kids Ste 1 Salt Lake City UT. 84123 Jarman, Kam E PT 6910 S Highland Dr Cottonwood Heights UT. 84121 p 801.255.5131 Bear Lake Physical Therapy Ste 1 p 801.935.4946 35 N Main Cottonwood Heights UT. 84121 Cardinal, Jennifer R PhD, Randolph UT. 84064 p 801.935.4946 Bray, Kristl BCBA BCBA p 435.793.7000 ABS Kids Neurobehavioral Center for Allred, Jentrie BCBA 515 S 700 E Growth 95 W 50 S ABS Kids Ste 2A 370 E South Temple Garden City UT. 84028 515 S 700 E Salt Lake City UT. 84102 Ste 175 p 435.946.2777 Ste 2A p 801.935.4171 Salt Lake City UT. 84111 Salt Lake City UT. 84102 p 801.683.1062 Psychology p 801.935.4171 6910 S Highland Dr Wilkinson, Thomas A PSYD Ste 1 Chamberlain, Jordan BCBA Bear Lake Community Health 515 S 700 E Cottonwood Heights UT. 84121 Advanced Behavior Analysis Center Ste 2A p 801.935.4946 1441 E Fort Union Blvd 325 W Logan Hwy Salt Lake City UT. 84102 Salt Lake City UT. 84121 Garden City UT. 84028 p 801.935.4171 p 385.695.2203 p 435.946.3660

130 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Christianson, Grete BCBA De La Torre, Sandra BCBA 6910 S Highland Dr Garrett-Baker, Amanda Utah Behavior Services ABS Kids Ste 1 BCBA 5558 S 1900 W 515 S 700 E Salt Lake City UT. 84121 ABS Kids Ste B Ste 2A p 801.935.4946 515 S 700 E Salt Lake City UT. 84129 Salt Lake City UT. 84102 Ste 2A p 801.255.5131 p 801.935.4171 Dufek, Brandi BCBA Salt Lake City UT. 84102 ABS Kids p 801.935.4171 6013 S Redwood Rd Deceuster, Rachael BCBA 515 S 700 E Salt Lake City UT. 84123 Utah Behavior Services Ste 2A 6910 S Highland Dr p 801.255.5131 5558 S 1900 W Salt Lake City UT. 84102 Ste 1 Ste B p 801.935.4171 Cottonwood Heights UT. 84121 Chrysalis Utah Salt Lake City UT. 84129 p 801.935.4946 448 E Winchester St p 801.255.5131 6910 S Highland Dr Ste 200 Ste 1 Gibson, Crystal BCBA Salt Lake City UT. 84107 6013 S Redwood Rd Cottonwood Heights UT. 84121 ABS Kids p 801.655.4950 Salt Lake City UT. 84123 p 801.935.4946 515 S 700 E p 801.255.5131 Ste 2A Corey, Spencer BCBA Fackrell, Lachere BCBA Salt Lake City UT. 84102 Utah Behavior Services Devlin, Charissa BCBA ABS Kids p 801.935.4171 5558 S 1900 W ABS Kids 515 S 700 E Ste B 515 S 700 E Ste 2A 6910 S Highland Dr Salt Lake City UT. 84129 Ste 2A Salt Lake City UT. 84102 Ste 1 p 801.255.5131 Salt Lake City UT. 84102 p 801.935.4171 Cottonwood Heights UT. 84121 p 801.935.4171 p 801.935.4946 6013 S Redwood Rd Fox, Bryanna BCBA Salt Lake City UT. 84123 6910 S Highland Dr ABS Kids Goldberg, Annie BCBA p 801.255.5131 Ste 1 515 S 700 E ABS Kids Cottonwood Heights UT. 84121 Ste 2A 515 S 700 E Corry, Bradley BCBA p 801.935.4946 Salt Lake City UT. 84102 Ste 2A ABS Kids p 801.935.4171 Salt Lake City UT. 84102 515 S 700 E Dillon, Heather BCBA p 801.935.4946 Ste 2A Advanced Behavior Analysis 6910 S Highland Dr Salt Lake City UT. 84102 1441 E Fort Union Blvd Ste 1 6910 S Highland Dr p 801.935.4171 Salt Lake City UT. 84121 Cottonwood Heights UT. 84121 Ste 1 p 385.695.2203 p 801.935.4946 Cottonwood Heights UT. 84121 6910 S Highland Dr p 801.935.4946 Ste 1 Dobson, Nicole BCBA Fujiwara, Mina BCBA Cottonwood Heights UT. 84121 ABS Kids Utah Behavior Services Green, Courtney BCBA p 801.935.4946 515 S 700 E 5558 S 1900 W ABS Kids Ste 2A Ste B 515 S 700 E Cummings, Tara BCBA Salt Lake City UT. 84102 Salt Lake City UT. 84129 Ste 2A ABS Kids p 801.935.4171 p 801.255.5131 Salt Lake City UT. 84102 515 S 700 E p 801.935.4171 Ste 2A 6910 S Highland Dr 6013 S Redwood Rd Salt Lake City UT. 84102 Ste 1 Salt Lake City UT. 84123 6910 S Highland Dr p 801.935.4171 Cottonwood Heights UT. 84121 p 801.255.5131 Ste 1 p 801.935.4946 Cottonwood Heights UT. 84121 6910 S Highland Dr Garlock, John T BCBA p 801.935.4946 Ste 1 Downer, Tilly BCaBA ABS Kids Cottonwood Heights UT. 84121 ABS Kids 515 S 700 E Green, Rachal BCBA,LCSW p 801.935.4946 515 S 700 E Ste 2A Utah Behavior Services Ste 2A Salt Lake City UT. 84102 5558 S 1900 W Davis, Heather S BCBA Salt Lake City UT. 84102 p 801.935.4171 Ste B Valley Behavioral Health p 801.935.4171 Salt Lake City UT. 84129 6232 S 900 E 6910 S Highland Dr p 801.255.5131 Salt Lake City UT. 84121 Drennen, Melissa BCBA Ste 1 p 888.949.4864 ABS Kids Cottonwood Heights UT. 84121 6013 S Redwood Rd 515 S 700 E p 801.935.4946 Salt Lake City UT. 84123 780 S Guardsman Way Ste 2a p 801.255.5131 Salt Lake City UT. 84108 Salt Lake City UT. 84102 Utah Autism Academy p 888.949.4864 p 801.935.4171 7434 S State St Gressmen, Casey BCBA Midvale UT. 84047 Utah Behavior Services p 801.456.9955 5558 S 1900 W Ste B Salt Lake City UT. 84129 p 801.255.5131

131 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 6013 S Redwood Rd Hayes, Christa J BCBA 6013 S Redwood Rd 6013 S Redwood Rd Salt Lake City UT. 84123 ABS Kids Salt Lake City UT. 84123 Salt Lake City UT. 84123 p 801.255.5131 515 S 700 E p 801.255.5131 p 801.255.5131 Ste 2A Guerrieri, Joseph BCBA Salt Lake City UT. 84102 Hooton, Amy BCBA Jensen, Melissa BCBA ABS Kids p 801.935.4171 ABS Kids ABS Kids 515 S 700 E 515 S 700 E 515 S 700 E Ste 2A 6910 S Highland Dr Ste 2A Ste 2A Salt Lake City UT. 84102 Ste 1 Salt Lake City UT. 84102 Salt Lake City UT. 84102 p 801.935.4171 Cottonwood Heights UT. 84121 p 801.935.4171 p 801.935.4171 p 801.935.4946 6910 S Highland Dr 6910 S Highland Dr 6910 S Highland Dr Ste 1 Heath, Nicholas BCBA Ste 1 Ste 1 Salt Lake City UT. 84121 ABS Kids Cottonwood Heights UT. 84121 Cottonwood Heights UT. 84121 p 801.935.4171 515 S 700 E p 801.935.4946 p 801.935.4946 Ste 2A Guinn, Devin BCBA Salt Lake City UT. 84102 Hunt, Chelseigh BCBA Jenson, Hillary BCBA ABS Kids p 801.935.4171 Utah Behavior Services Chrysalis Utah 515 S 700 E 5558 S 1900 W 448 E Winchester St Ste 2A 6910 S Highland Dr Ste B Ste 200 Salt Lake City UT. 84102 Ste 1 Salt Lake City UT. 84129 Salt Lake City UT. 84107 p 801.935.4171 Salt Lake City UT. 84121 p 801.255.5131 p 801.655.4950 p 801.935.4171 Hadnagy-Roch, Alexis 6013 S Redwood Rd Johnson, Veronica BCBA BCBA Henshaw, Brandon J BCBA Salt Lake City UT. 84123 ABS Kids ABS Kids Neurobehavioral Center for p 801.255.5131 515 S 700 E 515 S 700 E Growth Ste 2A Ste 2A 370 E South Temple Hutton, Ann P NP Salt Lake City UT. 84102 Salt Lake City UT. 84102 Ste 175 University of Utah Health p 801.935.4171 p 801.935.4171 Salt Lake City UT. 84111 1578 W 1700 S p 801.683.1062 Salt Lake City UT. 84104 6910 S Highland Dr 6910 S Highland Dr p 801.581.4014 Ste 1 Ste 1 Hicks, Kenneth BCBA Salt Lake City UT. 84121 Cottonwood Heights UT. 84121 ABS Kids 50 N Medical Dr p 801.935.4946 p 801.935.4946 515 S 700 E Salt Lake City UT. 84132 Ste 2A p 801.581.4014 Jones, Lisa BCBA Hanks, Julie BCBA Salt Lake City UT. 84102 ABS Kids Utah Behavior Services p 801.935.4171 5126 W Daybreak Pkwy 515 S 700 E 5558 S 1900 W South Jordan UT. 84009 Ste 2A Ste B Hodgkin, Cameron BCBA p 801.213.4500 Salt Lake City UT. 84102 Salt Lake City UT. 84129 ABS Kids p 801.935.4171 p 801.255.5131 6910 S Highland Dr Hospital Affiliation Ste 1 - University of Utah Hospital 6910 S Highland Dr 6013 S Redwood Rd Cottonwood Heights UT. 84121 Ste 1 Salt Lake City UT. 84123 p 801.935.4946 Jacobsen, Maren BCBA Cottonwood Heights UT. 84121 p 801.255.5131 ABS Kids p 801.935.4946 Hoffman, Lindsey BCBA 515 S 700 E Harris, Kaitlyn BCBA ABS Kids Ste 2A Jones, Tonya BCBA ABS Kids 515 S 700 E Salt Lake City UT. 84102 ABS Kids 515 S 700 E Ste 2A p 801.935.4171 515 S 700 E Ste 2A Salt Lake City UT. 84102 Ste 2A Salt Lake City UT. 84102 p 801.935.4171 6910 S Highland Dr Salt Lake City UT. 84102 p 801.935.4171 Ste 1 p 801.935.4171 6910 S Highland Dr Salt Lake City UT. 84121 6910 S Highland Dr Ste 1 p 801.935.4171 Keller, Rebecca BCBA Ste 1 Cottonwood Heights UT. 84121 Utah Behavior Services Cottonwood Heights UT. 84121 p 801.935.4946 Jensen, Julia P BCBA 5558 S 1900 W p 801.935.4946 Utah Behavior Services Ste B Hoffmann, Audrey PhD 5558 S 1900 W Salt Lake City UT. 84129 Hawkins, Jeffrey BCBA Utah Behavior Services Ste B p 801.255.5131 ABS Kids 5558 S 1900 W Salt Lake City UT. 84129 6910 S Highland Dr Ste B p 801.255.5131 6013 S Redwood Rd Ste 1 Salt Lake City UT. 84129 Salt Lake City UT. 84123 Cottonwood Heights UT. 84121 p 801.255.5131 p 801.255.5131 p 801.935.4946

132 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Kennedy, Anne BCBA Kulow, Kacylia BCBA Lowe, Kori BCBA 6910 S Highland Dr Utah Behavior Services Utah Behavior Services Utah Behavior Services Ste 1 5558 S 1900 W 5558 S 1900 W 5558 S 1900 W Salt Lake City UT. 84121 Ste B Ste B Ste B p 801.935.4171 Salt Lake City UT. 84129 Salt Lake City UT. 84129 Salt Lake City UT. 84129 p 801.255.5131 p 801.255.5131 p 801.255.5131 Maxwell, Kendra BCBA Utah Behavior Services 6013 S Redwood Rd 6013 S Redwood Rd 6013 S Redwood Rd 5558 S 1900 W Salt Lake City UT. 84123 Salt Lake City UT. 84123 Salt Lake City UT. 84123 Ste B p 801.255.5131 p 801.255.5131 p 801.255.5131 Taylorsville UT. 84118 p 801.255.5131 Kennedy, Courtney BCBA Lambertsen, Hope BCBA Madsen, Sara BCBA ABS Kids Utah Behavior Services ABS Kids 6013 S Redwood Rd 515 S 700 E 5558 S 1900 W 515 S 700 E Taylorsville UT. 84123 Ste 2A Ste B Ste 2A p 801.255.5131 Salt Lake City UT. 84102 Salt Lake City UT. 84129 Salt Lake City UT. 84102 p 801.935.4171 p 801.255.5131 p 801.935.4171 McGuire, Amy BCBA Utah Behavior Services 6910 S Highland Dr 6013 S Redwood Rd Utah Behavior Services 5558 S 1900 W Ste 1 Salt Lake City UT. 84123 5558 S 1900 W Ste B Cottonwood Heights UT. 84121 p 801.255.5131 Ste B Salt Lake City UT. 84129 p 801.935.4946 Salt Lake City UT. 84129 p 801.255.5131 Lee, Jennifer BCBA p 801.255.5131 Kingston, Joshua BCBA Utah Behavior Services 6013 S Redwood Rd ABS Kids 5558 S 1900 W 6013 S Redwood Rd Salt Lake City UT. 84123 515 S 700 E Ste B Salt Lake City UT. 84123 p 801.255.5131 Ste 2A Salt Lake City UT. 84129 p 801.255.5131 Salt Lake City UT. 84102 p 801.255.5131 Meier, Heather BCBA p 801.935.4171 ABS Kids ABS Kids 6013 S Redwood Rd 6910 S Highland Dr 515 S 700 E 6910 S Highland Dr Salt Lake City UT. 84123 Ste 1 Ste 2A Ste 1 p 801.255.5131 Cottonwood Heights UT. 84121 Salt Lake City UT. 84102 Salt Lake City UT. 84121 p 801.935.4946 p 801.935.4171 p 801.935.4171 Lentchner, Kari BCBA ABS Kids Makowski, Alexandra BCBA 6910 S Highland Dr Knudson, Mani BCBA 515 S 700 E ABS Kids Ste 1 Utah Behavior Services Ste 2A 515 S 700 E Cottonwood Heights UT. 84121 5558 S 1900 W Salt Lake City UT. 84102 Ste 2A p 801.935.4946 Ste B p 801.935.4171 Salt Lake City UT. 84102 Salt Lake City UT. 84129 p 801.935.4171 Mendoza, Emily BCaBA p 801.255.5131 Lopes, Erika BCBA ABS Kids ABS Kids 6910 S Highland Dr 6910 S Highland Dr 6013 S Redwood Rd 515 S 700 E Ste 1 Ste 1 Salt Lake City UT. 84123 Ste 2A Cottonwood Heights UT. 84121 Cottonwood Heights UT. 84121 p 801.255.5131 Salt Lake City UT. 84102 p 801.935.4946 p 801.935.4946 p 801.935.4171 Kooyman, Malorey BCBA Malone, Sara BCBA Metzger, Debbie BCBA ABS Kids 6910 S Highland Dr ABS Kids Utah Behavior Services 515 S 700 E Ste 1 515 S 700 E 5558 S 1900 W Ste 2A Cottonwood Heights UT. 84121 Ste 2A Ste B Salt Lake City UT. 84102 p 801.935.4946 Salt Lake City UT. 84102 Taylorsville UT. 84118 p 801.935.4171 p 801.935.4171 p 801.255.5131 Lopez, Kitrina BCBA 6910 S Highland Dr Utah Behavior Services 6910 S Highland Dr 6013 S Redwood Rd Ste 1 5558 S 1900 W Ste 1 Taylorsville UT. 84123 Salt Lake City UT. 84121 Ste B Cottonwood Heights UT. 84121 p 801.255.5131 p 801.935.4946 Salt Lake City UT. 84129 p 801.935.4946 p 801.255.5131 Moosman, Julie BCBA Kramer, Andrea BCBA Mattingly, Mary BCBA ABS Kids ABS Kids 6013 S Redwood Rd ABS Kids 515 S 700 E 6910 S Highland Dr Salt Lake City UT. 84123 515 S 700 E Ste 2A Ste 1 p 801.255.5131 Ste 2A Salt Lake City UT. 84102 Cottonwood Heights UT. 84121 Salt Lake City UT. 84102 p 801.935.4171 p 801.935.4946 p 801.935.4171

133 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 6910 S Highland Dr Nicols, Jenissa BCBA 6910 S Highland Dr Plautz, Hailey C BCBA Ste 1 ABS Kids Ste 1 Neurobehavioral Center For Cottonwood Heights UT. 84121 515 S 700 E Cottonwood Heights UT. 84121 Growth p 801.935.4946 Ste 2A p 801.935.4946 370 E S Temple Salt Lake City UT. 84102 Ste 175 Morris, Tracee BCBA p 801.935.4171 Ossmen, Caitlin BCBA Salt Lake City UT. 84111 ABS Kids ABS Kids p 801.683.1062 515 S 700 E 6910 S Highland Dr 515 S 700 E Ste 2A Ste 1 Ste 2A Probert, Brittany BCBA Salt Lake City UT. 84102 Cottonwood Heights UT. 84121 Salt Lake City UT. 84102 Advanced Behavior Analysis p 801.935.4171 p 801.935.4946 p 801.935.4171 1441 E Fort Union Blvd Salt Lake City UT. 84121 6910 S Highland Dr Northup, Kathryn BCBA 6910 S Highland Dr p 385.695.2203 Ste 1 ABS Kids Ste 1 Cottonwood Heights UT. 84121 515 S 700 E Cottonwood Heights UT. 84121 Rasmussen, Jake BCBA p 801.935.4946 Ste 2A p 801.935.4946 ABS Kids Salt Lake City UT. 84102 515 S 700 E Murphy, H Nicole BCBA p 801.935.4171 Ossmen, Jordan BCBA Ste 2A ABS Kids ABS Kids Salt Lake City UT. 84102 515 S 700 E OQuinn, Casey L BCBA 515 S 700 E p 801.935.4171 Ste 2A Neurobehavioral Center for Ste 2A Salt Lake City UT. 84102 Growth Salt Lake City UT. 84102 Renda, Cheyenne R PhD p 801.935.4171 370 E South Temple p 801.935.4171 Utah Behavior Services Ste 175 5558 S 1900 W 6910 S Highland Dr Salt Lake City UT. 84111 6910 S Highland Dr Ste B Ste 1 p 801.683.1062 Ste 1 Salt Lake City UT. 84129 Salt Lake City UT. 84121 Cottonwood Heights UT. 84121 p 801.255.5131 p 801.935.4171 Oblad, Cicily BCBA p 801.935.4946 Utah Behavior Services 6013 S Redwood Rd Nadalsky, Michelle 5558 S 1900 W Parsons, Rita M BCBA Salt Lake City UT. 84123 BCBA,SSW Ste B ABS Kids p 801.255.5131 Utah Behavior Services Salt Lake City UT. 84129 515 S 700 E 5558 S 1900 W p 801.255.5131 Ste 2A Rhodes, Tiffany BCBA Ste B Salt Lake City UT. 84102 Utah Behavior Services Salt Lake City UT. 84129 6013 S Redwood Rd p 801.935.4171 5558 S 1900 W p 801.255.5131 Salt Lake City UT. 84123 Ste B p 801.255.5131 6910 S Highland Dr Salt Lake City UT. 84129 6013 S Redwood Rd Ste 1 p 801.255.5131 Salt Lake City UT. 84123 Ochoa, Rafael BCBA Cottonwood Heights UT. 84121 p 801.255.5131 Valley Behavioral Health p 801.935.4946 6013 S Redwood Rd 6232 S 900 E Salt Lake City UT. 84123 Navas, Barbara BCBA Salt Lake City UT. 84121 Pehrson, Heather BCBA p 801.255.5131 ABS Kids p 888.949.4864 ABS Kids 515 S 700 E 515 S 700 E Ringger, Brett BCBA Ste 2A 780 S Guardsman Way Ste 2A ABS Kids Salt Lake City UT. 84102 Salt Lake City UT. 84108 Salt Lake City UT. 84102 6910 S Highland Dr p 801.935.4946 p 888.949.4864 p 801.935.4171 Ste 1 Cottonwood Heights UT. 84121 6910 S Highland Dr Ogden, Stephanie BCBA Peterson, Kristyn BCBA p 801.935.4946 Ste 1 ABS Kids ABS Kids Cottonwood Heights UT. 84121 515 S 700 E 515 S 700 E Robinson, Jerianne BCBA p 801.935.4946 Ste 2A Ste 2A ABS Kids Salt Lake City UT. 84102 Salt Lake City UT. 84102 515 S 700 E Newman, Felicia BCBA p 801.935.4171 p 801.935.4171 Ste 2A ABS Kids Salt Lake City UT. 84102 515 S 700 E Ortiz-Perez, Marco BCBA 6910 S Highland Dr p 801.935.4171 Ste 2A ABS Kids Ste 1 Salt Lake City UT. 84102 515 S 700 E Salt Lake City UT. 84121 6910 S Highland Dr p 801.935.4171 Ste 2A p 801.935.4171 Ste 1 Salt Lake City UT. 84102 Cottonwood Heights UT. 84121 6910 S Highland Dr p 801.935.4171 Pickering, Jaclyn BCBA p 801.935.4946 Ste 1 Neurobehavioral Center for Cottonwood Heights UT. 84121 Growth p 801.935.4946 370 E South Temple Ste 175 Salt Lake City UT. 84111 p 801.683.1062

134 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Robles, Richard BCBA 6910 S Highland Dr 6910 S Highland Dr 6910 S Highland Dr ABS Kids Ste 1 Ste 1 Ste 1 515 S 700 E Cottonwood Heights UT. 84121 Cottonwood Heights UT. 84121 Cottonwood Heights UT. 84121 Ste 2A p 801.935.4946 p 801.935.4946 p 801.935.4946 Salt Lake City UT. 84102 p 801.935.4171 Saalfield, Andrew BCBA Schumacher, Marissa BCBA Skibitsky, Jeffrey BCBA ABS Kids ABS Kids ABS Kids 6910 S Highland Dr 515 S 700 E 515 S 700 E 515 S 700 E Ste 1 Ste 2A Ste 2A Ste 2A Cottonwood Heights UT. 84121 Salt Lake City UT. 84102 Salt Lake City UT. 84102 Salt Lake City UT. 84102 p 801.935.4946 p 801.935.4171 p 801.935.4171 p 801.935.4171

Rockwell, Rene BCBA Sagendorf, Emily BCBA 6910 S Highland Dr 6910 S Highland Dr Utah Behavior Services Utah Behavior Services Ste 1 Ste 1 5558 S 1900 W 5558 S 1900 W Salt Lake City UT. 84121 Cottonwood Heights UT. 84121 Ste B Ste B p 801.935.4946 p 801.935.4946 Salt Lake City UT. 84129 Salt Lake City UT. 84129 p 801.255.5131 p 801.255.5131 Selis, Emma BCBA Slack, Micah BCBA ABS Kids ABS Kids 6013 S Redwood Rd 6013 S Redwood Rd 515 S 700 E 515 S 700 E Salt Lake City UT. 84123 Salt Lake City UT. 84123 Ste 2A Ste 2A p 801.255.5131 p 801.255.5131 Salt Lake City UT. 84102 Salt Lake City UT. 84102 p 801.935.4171 p 801.935.4171 Rogers, Jennifer PSYD Sanders, Sarah BCBA ABS Kids Utah Behavior Services 6910 S Highland Dr Smith, Ashlin BCBA 515 S 700 E 5558 S 1900 W Ste 1 ABS Kids Ste 2A Ste B Salt Lake City UT. 84121 515 S 700 E Salt Lake City UT. 84102 Salt Lake City UT. 84129 p 801.935.4946 Ste 2A p 801.935.4171 p 801.255.5131 Salt Lake City UT. 84102 Shields, Haley B BCBA p 801.935.4171 6910 S Highland Dr 6013 S Redwood Rd ABS Kids Ste 1 Salt Lake City UT. 84123 515 S 700 E 6910 S Highland Dr Salt Lake City UT. 84121 p 801.255.5131 Ste 2A Ste 1 p 801.935.4171 Salt Lake City UT. 84102 Cottonwood Heights UT. 84121 Sands, Allison BCBA p 801.935.4171 p 801.935.4946 Rosado, Leah BCBA ABS Kids ABS Kids 515 S 700 E 6910 S Highland Dr Smith, Erica BCBA 515 S 700 E Ste 2A Ste 1 Utah Behavior Services Ste 2A Salt Lake City UT. 84102 Cottonwood Heights UT. 84121 5558 S 1900 W Salt Lake City UT. 84102 p 801.935.4171 p 801.935.4946 Ste B p 801.935.4171 Salt Lake City UT. 84129 6910 S Highland Dr Shumway, Luisa BCBA p 801.255.5131 6910 S Highland Dr Ste 1 ABS Kids Ste 1 Cottonwood Heights UT. 84121 515 S 700 E 6013 S Redwood Rd Cottonwood Heights UT. 84121 p 801.935.4946 Ste 2A Salt Lake City UT. 84123 p 801.935.4946 Salt Lake City UT. 84102 p 801.255.5131 Schifano, Brytni BCBA p 801.935.4171 Roskelley, Hannah BCBA ABS Kids Smith, Hannah BCBA ABS Kids 515 S 700 E Simancas (Monago), ABS Kids 515 S 700 E Ste 2A Letisia A BCBA 515 S 700 E Ste 2A Salt Lake City UT. 84102 ABS Kids Ste 2A Salt Lake City UT. 84102 p 801.935.4171 515 S 700 E Salt Lake City UT. 84102 p 801.935.4171 Ste 2A p 801.935.4171 6910 S Highland Dr Salt Lake City UT. 84102 6910 S Highland Dr Ste 1 p 801.935.4171 6910 S Highland Dr Ste 1 Cottonwood Heights UT. 84121 Ste 1 Cottonwood Heights UT. 84121 p 801.935.4946 6910 S Highland Dr Cottonwood Heights UT. 84121 p 801.935.4946 Ste 1 p 801.935.4946 Schuknecht, Kelly BCBA Cottonwood Heights UT. 84121 Roth, Natalie PhD ABS Kids p 801.935.4946 Smith, Krista BCBA ABS Kids 515 S 700 E ABS Kids 515 S 700 E Ste 2A Sivertson, Savannah BCBA 515 S 700 E Ste 2A Salt Lake City UT. 84102 ABS Kids Ste 2A Salt Lake City UT. 84102 p 801.935.4171 515 S 700 E Salt Lake City UT. 84102 p 801.935.4171 Ste 2A p 801.935.4171 Salt Lake City UT. 84102 p 801.935.4171

135 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 6910 S Highland Dr Stevenson, Victoria A 6910 S Highland Dr 6013 S Redwood Rd Ste 1 BCBA Ste 1 Taylorsville UT. 84123 Salt Lake City UT. 84121 ABS Kids Cottonwood Heights UT. 84121 p 801.255.5131 p 801.935.4946 515 S 700 E p 801.935.4946 Ste 2A Wilson, Megan BCBA Smith, Rayl BCBA Salt Lake City UT. 84102 Utah Behavior Services Utah Behavior Services ABS Kids p 801.935.4171 5558 S 1900 W 5558 S 1900 W 515 S 700 E Ste B Ste B Ste 2A 6910 S Highland Dr Salt Lake City UT. 84129 Salt Lake City UT. 84129 Salt Lake City UT. 84102 Ste 1 p 801.255.5131 p 801.255.5131 p 801.935.4171 Cottonwood Heights UT. 84121 p 801.935.4946 6013 S Redwood Rd 6013 S Redwood Rd Smith, Saige LPC Salt Lake City UT. 84123 Salt Lake City UT. 84123 Utah Behavior Services Stotts, Jonas BCBA p 801.255.5131 p 801.255.5131 5558 S 1900 W ABS Kids Ste B 6910 S Highland Dr Wagner, Brenna BCBA Winslow, Tatum BCBA Salt Lake City UT. 84129 Ste 1 ABS Kids ABS Kids p 801.255.5131 Cottonwood Heights UT. 84121 515 S 700 E 6910 S Highland Dr p 801.935.4946 Ste 2A Ste 1 6013 S Redwood Rd Salt Lake City UT. 84102 Cottonwood Heights UT. 84121 Salt Lake City UT. 84123 Tabara, Jackqueline BCBA p 801.935.4171 p 801.935.4946 p 801.255.5131 ABS Kids 515 S 700 E Western, Shasta BCBA Woodall, Clifford BCBA Snow, Lauren BCBA Ste 2A ABS Kids Utah Behavior Services Utah Behavior Services Salt Lake City UT. 84102 515 S 700 E 5558 S 1900 W 5558 S 1900 W p 801.935.4946 Ste 2A Ste B Ste B Salt Lake City UT. 84102 Salt Lake City UT. 84129 Taylorsville UT. 84118 6910 S Highland Dr p 801.935.4171 p 801.255.5131 p 801.255.5131 Ste 1 Salt Lake City UT. 84121 6910 S Highland Dr 6013 S Redwood Rd 6013 S Redwood Rd p 801.935.4171 Ste 1 Salt Lake City UT. 84123 Taylorsville UT. 84123 Cottonwood Heights UT. 84121 p 801.255.5131 p 801.255.5131 Taylor, Mark BCBA p 801.935.4946 ABS Kids Wulfenstein, Lee BCBA Sorenson, Cassie BCBA 515 S 700 E Weston, Sophia BCBA Utah Behavior Services ABS Kids Ste 2A ABS Kids 5558 S 1900 W 515 S 700 E Salt Lake City UT. 84102 515 S 700 E Ste B Ste 2A p 801.935.4171 Ste 2A Salt Lake City UT. 84129 Salt Lake City UT. 84102 Salt Lake City UT. 84102 p 801.255.5131 p 801.935.4171 Thomas, Jonathon (JT) p 801.935.4171 BCBA 6013 S Redwood Rd 6910 S Highland Dr ABS Kids 6910 S Highland Dr Salt Lake City UT. 84123 Ste 1 515 S 700 E Ste 1 p 801.255.5131 Cottonwood Heights UT. 84121 Ste 2A Salt Lake City UT. 84121 p 801.935.4946 Salt Lake City UT. 84102 p 801.935.4171 Yang, Danielle BCBA p 801.935.4171 Utah Behavior Services Stephens, Kaylie BCBA Whatcott, Natalie 5558 S 1900 W ABS Kids 6910 S Highland Dr BCBA,SSW Ste B 6910 S Highland Dr Ste 1 Utah Behavior Services Salt Lake City UT. 84129 Ste 1 Cottonwood Heights UT. 84121 5558 S 1900 W p 801.255.5131 Cottonwood Heights UT. 84121 p 801.935.4946 Ste B p 801.935.4946 Salt Lake City UT. 84129 6013 S Redwood Rd Thompson, Chelsea BCBA p 801.255.5131 Salt Lake City UT. 84123 Stevens, Nicole ABS Kids p 801.255.5131 BCBA,LMFT 515 S 700 E 6013 S Redwood Rd Utah Behavior Services Ste 2A Salt Lake City UT. 84123 Yarger, Jesse BCBA 5558 S 1900 W Salt Lake City UT. 84102 p 801.255.5131 Neurobehavioral Center for Ste B p 801.935.4171 Growth Salt Lake City UT. 84129 Wills, Brooke BCBA 370 E South Temple p 801.255.5131 Thurgood, Brook BCBA Utah Behavior Services Ste 175 ABS Kids 5558 S 1900 W Salt Lake City UT. 84111 6013 S Redwood Rd 515 S 700 E Ste B p 801.683.1062 Salt Lake City UT. 84123 Ste 2A Taylorsville UT. 84118 p 801.255.5131 Salt Lake City UT. 84102 p 801.255.5131 p 801.935.4171

136 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Young, Jeanelle BCBA 24 S 1100 E - Jordan Valley Medical 81 N Mario Capecchi Dr ABS Kids Ste 305 Center West Valley Campus Salt Lake City UT. 84113 515 S 700 E Salt Lake City UT. 84102 p 801.213.3599 Ste 2A p 385.290.1289 Hill, Gina NP Salt Lake City UT. 84102 Wasatch Allergy and Asthma Hospital Affiliation p 801.935.4171 Hospital Affiliation 13348 S Market Ctr Dr - University of Utah Hospital - Salt Lake Regional Medical Ste 220 6910 S Highland Dr Center Riverton UT. 84065 Olsen, Jonathan A DO Ste 1 p 385.290.1289 Granger Medical Cottonwood Heights UT. 84121 Firszt, Rafael MD Specialists p 801.935.4946 Tanner Memorial Clinic 24 S 1100 E 11724 S State St 5296 S Commerce Dr Ste 305 Draper UT. 84020 Acupuncture Salt Lake City UT. 84107 Salt Lake City UT. 84102 p 801.576.2050 Budhathoki, Annie LAc p 801.773.4840 p 385.290.1289 University of Utah Health 3181 W 9000 S 50 N Medical Dr Hospital Affiliation Kobernick, Aaron K MD West Jordan UT. 84088 Salt Lake City UT. 84132 - University of Utah Hospital University of Utah Health p 801.569.5600 p 801.581.2121 243 E 6100 S Galbraith, Brianne M Murray UT. 84107 999 E Murray Holladay Rd Hospital Affiliation FNP-C p 801.581.2955 Ste 207 - University of Utah Hospital Wasatch Allergy and Asthma Holladay UT. 84117 13348 S Market Ctr Dr 3730 W 4700 S p 801.268.2584 Allergy And Immunology Ste 220 Taylorsville UT. 84129 Allergy Associates of Utah Riverton UT. 84065 p 801.581.2955 Sarin, Tara MD 3855 W 7800 S p 385.831.1861 Allergy Associates of Utah Ste 225 3773 W 12600 S 3855 W 7800 S West Jordan UT. 84088 24 S 1100 E Riverton UT. 84065 Ste 225 p 801.263.8700 Ste 305 p 801.581.2955 West Jordan UT. 84088 Salt Lake City UT. 84102 p 801.263.8700 6095 S Fashion Blvd p 385.290.1289 50 N Medical Dr Clinic 28 Ste 100 Salt Lake City UT. 84132 6095 S Fashion Blvd Salt Lake City UT. 84107 Gleich, Gerald J MD p 801.581.2955 Ste 100 p 801.263.8700 University Health Care Salt Lake City UT. 84107 1525 W 2100 S 5126 W Daybreak Pkwy p 801.263.8700 Bohnsack, John F MD Salt Lake City UT. 84119 South Jordan UT. 84009 University of Utah Health p 801.213.9900 p 801.213.4500 Hospital Affiliation 100 N Mario Capecchi Dr - St Marks Hospital Salt Lake City UT. 84113 University of Utah Health 81 N Mario Capecchi Dr - Primary Childrens Hospital p 801.213.3599 243 E 6100 S Salt Lake City UT. 84113 - Jordan Valley Medical Salt Lake City UT. 84107 p 801.213.3599 Center 81 N Mario Capecchi Dr p 801.581.2955 - Jordan Valley Medical Salt Lake City UT. 84113 Hospital Affiliation Center West Valley Campus p 801.213.3599 50 N Medical Dr Clinic 28 - University of Utah Hospital Salt Lake City UT. 84132 Shum, Mili MD Broadbent, Jan B MD p 801.581.2955 Newman, Erik MD University of Utah Health Granger Medical University Of Utah Health 1280 E Stringham Ave Specialists University Health Care 100 N Mario Capecchi Dr Salt Lake City UT. 84106 5323 S Woodrow St 7495 S State St Salt Lake City UT. 84113 p 801.581.2955 Ste 201 Midvale UT. 84047 p 801.581.2955 Salt Lake City UT. 84107 p 801.213.9400 243 E 6100 S p 385.722.9140 1280 E Stringham Ave Salt Lake City UT. 84107 Gourley, David S MD Salt Lake City UT. 84106 p 801.581.2955 Hospital Affiliation Gourley Allergy & Asthma p 801.581.2955 - Primary Childrens Hospital 6065 S Fashion Blvd 81 N Mario Capecchi Dr Ste 255 243 E 6100 S Salt Lake City UT. 84113 Chenworth, Eric C DO Murray UT. 84107 Murray UT. 84107 p 801.213.3599 Wasatch Allergy and Asthma p 801.266.4115 p 801.581.2955 13348 S Market Ctr Dr Smith, Andrew MD Ste 220 Hospital Affiliation 50 N Medical Dr Clinic Allergy Associates of Utah Riverton UT. 84065 - St Marks Hospital E12 3855 W 7800 S p 385.831.1861 Salt Lake City UT. 84132 Ste 225 Harris, Duane J MD p 801.581.2955 West Jordan UT. 84088 Intermountain Allergy and p 801.263.8700 Asthma Draper 12422 S 450 E Ste C Draper UT. 84020 p 801.553.1900

Hospital Affiliation - Jordan Valley Medical 137 *The PPO Agreement with this provider is expressly betweenCenter the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 6095 S Fashion Blvd Utah Surgery Center *Bunker, Michelle AUD 3845 W 4700 S Ste 100 3715 W 4100 S Primary Childrens Hospital Taylorsville UT. 84129 Salt Lake City UT. 84107 West Valley City UT. 84120 100 N Mario Capecchi Dr p 801.840.4360 p 801.263.8700 p 801.957.0200 Salt Lake City UT. 84113 p 801.662.4980 Hospital Affiliation Hospital Affiliation Audiology - Primary Childrens Hospital - St Marks Hospital *Anthony, Meghan M AUD 3773 W 12600 S - Primary Childrens Hospital Primary Childrens Hospital Riverton UT. 84065 Fox, C B CCC-A - Jordan Valley Medical 100 N Mario Capecchi Dr p 801.285.1285 Audiology Associates of Center Salt Lake City UT. 84113 Holladay - Jordan Valley Medical p 801.662.4980 Calderwood, Jill F Aud 1377 E 3900 S Center West Valley Campus University of Utah Health Ste 201 3773 W 12600 S 417 S Wakara Way Salt Lake City UT. 84124 University of Utah Riverton UT. 84065 Ste 1112 p 801.272.1232 Hospital Clinical p 801.285.1285 Salt Lake City UT. 84108 Immunology Division p 801.581.3506 Fox, Damon B CCC-A 50 N Medical Dr Arceneaux, Denise AUD Audiology Associates of Salt Lake City UT. 84132 ENT Specialists Hospital Affiliation Holladay p 801.585.2031 74 E 11800 S - University of Utah Hospital 1377 E 3900 S Ste 360 Ste 201 Hospital Affiliation Draper UT. 84020 Choules, Coralee AUD Salt Lake City UT. 84124 - University of Utah Hospital p 801.260.3687 University Of Utah Health p 801.272.1232 50 N Medical Dr Wasatch Allergy And Asthma Barwick, Niki L AUD Salt Lake City UT. 84132 *Hayden, Angela J AUD 13348 S Market Ctr Dr Mountain West Ear Nose and p 801.581.7514 Primary Childrens Rehab Ste 220 Throat 100 N Mario Capecchi Dr Riverton UT. 84065 114 E 12450 S 5126 W Daybreak Pkwy Salt Lake City UT. 84113 p 385.831.1861 Ste 206 South Jordan UT. 84009 p 801.662.4980 Draper UT. 84020 p 801.581.7514 24 S 1100 E p 801.576.5930 Hospital Affiliation Ste 305 Hospital Affiliation - Primary Childrens Hospital Salt Lake City UT. 84102 University of Utah Health - University of Utah Hospital - Primary Childrens Hospital p 385.290.1289 50 N Medical Dr Salt Lake City UT. 84132 Cronin, Pamela J AUD Hayes, Fiona M Aud Ambulatory Surgery Center p 801.581.2121 South Valley Ear Nose And University of Utah Health Family Surgical Suite Throat 50 N Medical Dr (Oral Surgery Only) 5126 W Daybreak Pkwy 13348 S Market Ctr Dr Salt Lake City UT. 84132 151 E 5600 S South Jordan UT. 84009 Ste 210 p 801.581.7514 Ste 104 p 801.581.7514 Riverton UT. 84065 Salt Lake City UT. 84107 p 801.566.8304 5126 W Daybreak Pkwy p 801.495.1064 Bergen, Tad AUD South Jordan UT. 84009 My Hearing Centers 3584 W 9000 S p 801.581.7514 8822 S Redwood Rd 124 S 400 E Ste 311 Ste C113 Ste 360 West Jordan UT. 84088 Hospital Affiliation West Jordan UT. 84088 Salt Lake City UT. 84111 p 801.566.8304 - University of Utah Hospital p 801.495.1064 p 801.590.3140 Curtis, Christopher L AUD Hendriksen, Nathan E AUD St Marks Outpatient *Black, Pamella AUD Rocky Mountain Hearing and University of Utah Health Surgery Center Primary Childrens Rehab Balance 50 N Medical Dr 1250 E 3900 S 3845 W 4700 S 5872 S 900 E Salt Lake City UT. 84132 Ste 100 Taylorsville UT. 84129 Ste 175 p 801.581.7514 Salt Lake City UT. 84124 p 801.840.4360 Salt Lake City UT. 84121 p 801.262.0358 p 801.268.3277 Hodge, Karyn AUD Hospital Affiliation Mountain West Hearing Synergies Surgery Center - Primary Childrens Hospital *Despain, Natalie AUD Center LP dba Mt Olympus Surgery Primary Childrens Rehab 777 E 4500 S Center Boman, Tel S AUD 100 N Mario Capecchi Dr Ste 110 348 E 4500 S Mountain West Ear Nose and Salt Lake City UT. 84113 Salt Lake City UT. 84107 Salt Lake City UT. 84115 Throat p 801.662.4980 p 801.268.6497 p 801.685.6400 114 E 12450 S Ste 206 3741 W 12600 S Horn, Mary L Aud Lone Peak Surgery Center Draper UT. 84020 Ste 100 University of Utah Health 96 E Kimballs Ln p 801.576.5930 Riverton UT. 84065 50 N Medical Dr Ste 100 p 801.571.3081 Salt Lake City UT. 84132 Draper UT. 84020 p 801.581.7514 p 801.233.9300

138 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 5126 W Daybreak Pkwy Lobdell, Anne M AUD 8017 Royal Ln 3845 W 4700 S South Jordan UT. 84009 University of Utah Health Sandy UT. 84093 Taylorsville UT. 84129 p 801.581.7514 417 S Wakara Way p 801.652.9854 p 801.840.4360 Ste 1112 Hospital Affiliation Salt Lake City UT. 84108 Page, Andrea S AUD ENT Specialists - University of Utah Hospital p 801.581.3506 University Of Utah Health 4000 S 700 E 50 N Medical Dr Ste 10 Howell, Justin Y AUD Hospital Affiliation Salt Lake City UT. 84132 Salt Lake City UT. 84107 University of Utah Health - University of Utah Hospital p 801.581.7514 p 801.268.4141 417 S Wakara Way Ste 1112 Lodzins, David H 5126 W Daybreak Pkwy Primary Childrens Rehab Salt Lake City UT. 84108 ENT Specialists South Jordan UT. 84009 5770 S Fashion Blvd Bldg p 801.581.3506 4000 S 700 E p 801.581.7514 5 Ste 10 Ste 210 Hospital Affiliation Salt Lake City UT. 84107 Hospital Affiliation Murray UT. 84107 - University of Utah Hospital p 801.268.4141 - University of Utah Hospital p 801.314.5220

Jackson, Adrienne B AUD Lund, E Jolene AUD Pay, Amanda AUD ENT Specialists University of Utah Health University Of Utah Health Mountain West Ear Nose and 8846 S Redwood Rd 50 N Medical Dr 50 N Medical Dr Throat Ste E-121 Salt Lake City UT. 84132 Salt Lake City UT. 84132 114 E 12450 S West Jordan UT. 84088 p 801.581.2121 p 801.581.7514 Ste 206 p 801.268.4141 Draper UT. 84020 Johnson, Kathryn M AuD 5126 W Daybreak Pkwy p 801.576.5930 *Stone, Caitlin R AUD University of Utah Health South Jordan UT. 84009 Primary Childrens Rehab 50 N Medical Dr p 801.581.7514 Rocky Mountain Hearing and 100 N Mario Capecchi Dr Salt Lake City UT. 84132 Balance Salt Lake City UT. 84113 p 801.581.7514 Hospital Affiliation 1255 E 3900 S p 801.662.4980 - University of Utah Hospital Ste 106 C 5126 W Daybreak Pkwy Salt Lake City UT. 84124 3741 W 12600 S South Jordan UT. 84009 Lytle, Mary E AUD p 801.268.3277 Ste 100 p 801.581.7514 University of Utah Health Riverton UT. 84065 417 S Wakara Way 5872 S 900 E p 801.571.3081 Hospital Affiliation Ste 1112 Ste 175 - University of Utah Hospital Salt Lake City UT. 84108 Salt Lake City UT. 84121 3845 W 4700 S p 801.581.3506 p 801.268.3277 Taylorsville UT. 84129 *Layton, Ranae L AUD p 801.840.4360 Primary Childrens Hospital Hospital Affiliation Snow, Stacey C AUD 100 N Mario Capecchi Dr - University of Utah Hospital ENT Specialists Stone, Katie S AUD Salt Lake City UT. 84113 5770 S 250 E University of Utah Health p 801.662.4980 *Moncrief, Laura R AUD Ste 415 50 N Medical Dr Primary Childrens Rehab Salt Lake City UT. 84107 Salt Lake City UT. 84132 3773 W 12600 S 100 N Mario Capecchi Dr p 801.513.3223 p 801.581.7514 Riverton UT. 84065 Salt Lake City UT. 84113 p 801.285.1285 p 801.662.4980 Hospital Affiliation 5126 W Daybreak Pkwy - Davis Hospital South Jordan UT. 84009 3845 W 4700 S 3741 W 12600 S - Jordan Valley Medical p 801.581.7514 Taylorsville UT. 84129 Ste 100 Center p 801.840.4360 Riverton UT. 84065 - Lone Peak Hospital Hospital Affiliation p 801.571.3081 - Mountain View Hospital - University of Utah Hospital Leroy, Molly M AUD (UT) Utah Hearing and Balance 3845 W 4700 S Storey, Karyn AUD 1588 E 3300 S Taylorsville UT. 84129 *Sorensen, Tyler D AUD Rocky Mountain Hearing and Salt Lake City UT. 84106 p 801.840.4360 Primary Childrens Rehab Balance p 801.485.5534 100 N Mario Capecchi Dr 5872 S 900 E 5770 S Fashion Blvd Bldg Salt Lake City UT. 84113 Ste 175 756 E 12200 S 5 p 801.662.4980 Salt Lake City UT. 84121 Draper UT. 84020 Ste 210 p 801.268.3277 p 801.495.4800 Murray UT. 84107 3741 W 12600 S p 801.314.5220 Ste 100 *Tonkovich, Kathryn AUD 8806 S Redwood Rd Riverton UT. 84065 Primary Childrens Hospital Ste 103 Osborne, Christine S AUD p 801.571.3081 100 N Mario Capecchi Dr West Jordan UT. 84088 Rocky Mountain Hearing and Salt Lake City UT. 84113 p 801.495.4800 Balance p 801.662.4980 1255 E 3900 S Hospital Affiliation Ste 106 C - Mountain West Medical Salt Lake City UT. 84124 Center p 801.268.3277 139 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Tubaugh, Lindsey AUD Richards, Christina G MD Biggs, Jason PA Catino, Anna B MD Primary Childrens Bariatric Medicine Medallus Medical University of Utah Health Rehab/Audiology Institute 3451 S 5600 W 1950 Cir of Hope Dr 3773 W 12600 S 1046 E 100 S Ste F Salt Lake City UT. 84112 Riverton UT. 84065 Salt Lake City UT. 84102 West Valley City UT. 84120 p 801.585.0303 p 801.285.1285 p 801.746.2885 p 801.957.0900 50 N Medical Dr Primary Childrens Rehab Hospital Affiliation Bray, Bruce E MD Salt Lake City UT. 84132 3845 W 4700 S - Salt Lake Regional Medical University of Utah Health p 801.585.7676 Taylorsville UT. 84129 Center 1950 Cir of Hope Dr p 801.840.4360 - St Marks Hospital Salt Lake City UT. 84112 5126 W Daybreak Pkwy p 801.585.0303 South Jordan UT. 84009 Hospital Affiliation Breast Pumps p 801.213.4500 - Primary Childrens Hospital Alpine Home Medical 50 N Medical Dr 4030 S State St Salt Lake City UT. 84132 University Of Utah Health Udy, Mitchell R AUD Salt Lake City UT. 84107 p 801.585.7676 85 N Medical Dr University of Utah Health p 800.686.7993 Salt Lake City UT. 84112 50 N Medical Dr 5126 W Daybreak Pkwy p 801.585.7676 Salt Lake City UT. 84132 Phone Number Only South Jordan UT. 84009 p 801.581.7514 p 800.686.7993 p 801.213.4500 Hospital Affiliation - University of Utah Hospital 5126 W Daybreak Pkwy Edgepark University Of Utah Health South Jordan UT. 84009 Phone Number Only 85 N Medical Dr Chang, Lowell MD p 801.581.7514 p 800.321.0591 Salt Lake City UT. 84112 University of Utah Health p 801.585.7676 50 N Medical Dr Hospital Affiliation Cardiac Monitoring Salt Lake City UT. 84132 - University of Utah Hospital Remote Cardiac Services Hospital Affiliation p 801.585.7676 Phone Number Only - University of Utah Hospital Young, Alan AUD p 800.367.0300 Hospital Affiliation Granger Medical Clinic Brinton, Eliot A MD - University of Utah Hospital 2965 W 3500 S eCardio Diagnostics Intermountain Lipid Center West Valley City UT. 84119 Phone Number Only 421 Wakara Way Chaudhuri, Dipayan p 801.965.3600 p 888.400.3522 Ste 121 MD,PhD Salt Lake City UT. 84108 University of Utah Health Salt Lake Hearing Zone Cardiology p 801.583.8852 1950 Cir of Hope Dr 5642 S 900 E Abraham, Anu E MD Salt Lake City UT. 84112 Salt Lake City UT. 84121 University of Utah Health Brown, Ronald E MD p 801.585.0303 p 801.713.0101 50 N Medical Dr South Lincoln Medical Salt Lake City UT. 84132 Clinic 50 N Medical Dr Bariatric Surgery p 801.585.0434 1160 E 3900 S Salt Lake City UT. 84132 Beck, Catherine MD Ste 1000 p 801.585.7676 Specialty Surgery of Utah Hospital Affiliation Salt Lake City UT. 84124 Riverton - University of Utah Hospital p 801.262.1771 University Of Utah Health 13348 S Market Ctr Dr 85 N Medical Dr Ste 210 Allred, Clint W MD Granger Medical Clinic Salt Lake City UT. 84112 Riverton UT. 84065 University of Utah Health 2965 W 3500 S p 801.585.7676 p 801.601.4423 1950 Cir of Hope Dr West Valley City UT. 84119 Salt Lake City UT. 84112 p 801.965.3600 Hospital Affiliation Specialty Surgery of Utah p 801.585.0303 - University of Utah Hospital West Jordan Hospital Affiliation 3584 W 9000 S 50 N Medical Dr - St Marks Hospital Crouch, Jessica S PA Ste 304 Salt Lake City UT. 84132 University of Utah Health West Jordan UT. 84088 p 801.585.7676 Bunch, T MD 1280 E Stringham Ave p 801.601.4423 University Of Utah Health Salt Lake City UT. 84106 5126 W Daybreak Pkwy 85 N Medical Dr p 801.581.2000 Hospital Affiliation South Jordan UT. 84009 Salt Lake City UT. 84112 - Jordan Valley Medical p 801.213.4500 p 801.585.3229 1525 W 2100 S Center Salt Lake City UT. 84119 University Of Utah Health Hospital Affiliation p 801.213.8841 Cottam, Daniel R MD 85 N Medical Dr - Salt Lake Regional Medical Bariatric Medicine Salt Lake City UT. 84112 Center 3730 W 4700 S Institute p 801.585.7676 - St Marks Hospital West Valley City UT. 84129 1046 E 100 S p 801.213.9200 Salt Lake City UT. 84102 Hospital Affiliation p 801.746.2885 - University of Utah Hospital

Hospital Affiliation - Salt Lake Regional Medical Center 140 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 50 N Medical Dr 50 N Medical Dr Fang, James C MD Hacking, Scott B MD Salt Lake City UT. 84132 Salt Lake City UT. 84132 University of Utah Health Heart Center at St Marks p 801.585.7676 p 801.585.0434 1950 Cir of Hope Dr Hospital Salt Lake City UT. 84112 1160 E 3900 S 5126 W Daybreak Pkwy University Of Utah Health p 801.585.7676 Ste 2000 Ste 600 85 N Medical Dr Salt Lake City UT. 84124 South Jordan UT. 84009 Salt Lake City UT. 84112 50 N Medical Dr p 801.266.3418 p 801.213.4500 p 801.585.7676 Salt Lake City UT. 84132 p 801.585.0434 3540 S 4000 W 7495 S State St Hospital Affiliation Ste 340 Midvale UT. 84047 - University of Utah Hospital 5126 W Daybreak Pkwy West Valley City UT. 84120 p 801.213.9400 South Jordan UT. 84009 p 801.676.3776 Edwards, Thomas S MD p 801.585.7676 Hospital Affiliation Heart Center at St Marks MountainStar Cardiology St - University of Utah Hospital Hospital University Of Utah Health Marks 1160 E 3900 S 85 N Medical Dr 3584 W 9000 S Day, John D MD Ste 2000 Salt Lake City UT. 84112 Ste 209 Mountainstar Cardiology St Salt Lake City UT. 84124 p 801.585.7676 West Jordan UT. 84088 Marks p 801.266.3418 p 801.676.3776 1160 E 3900 S Hospital Affiliation Ste 2000 MountainStar Cardiology St - University of Utah Hospital 74 E Kimball Ln Salt Lake City UT. 84124 Marks Ste 260 p 801.266.3418 74 E Kimball Ln Forstall, Peter G MD Draper UT. 84020 Ste 260 Northern Utah p 801.571.6100 74 Kimballs Ln Draper UT. 84020 Cardiovascular Associates Ste 330 p 801.571.6100 1160 E 3900 S Hospital Affiliation Draper UT. 84020 Ste 2000 - St Marks Hospital p 801.266.3418 8846 S Redwood Rd Salt Lake City UT. 84124 - Lone Peak Hospital Ste E-121 p 801.226.3418 - Timpanogos Regional Hospital Hospital Affiliation West Jordan UT. 84088 - Salt Lake Regional Medical p 801.676.3776 Hospital Affiliation Hains, Jared B PA-C Center - Ogden Regional Medical Copperview Medical Center Hospital Affiliation Center 2556 W 9800 S Domanski, Damian J MD - Lone Peak Hospital - Brigham City Community Ste 101 MountainStar Cardiology St Hospital South Jordan UT. 84095 Marks Elhaddi, Adam M MD - Davis Hospital p 801.567.9780 1160 E 3900 S Steward Cardiology - Cache Valley Hospital Ste 2000 Associates - West Valley Hospital Affiliation Salt Lake City UT. 84124 3336 S Pioneer Pkwy Freedman, Roger A MD - Salt Lake Regional Medical p 801.266.3418 Ste 203 University of Utah Health Center West Valley City UT. 84120 100 N Mario Capecchi Dr Douglas, Wendy S APRN p 801.748.0113 Salt Lake City UT. 84113 Ibrahim, Majd MD University of Utah Health p 801.662.1000 University of Utah Health 50 N Medical Dr Heart and Lung Institute 1950 Cir of Hope Dr Salt Lake City UT. 84132 of Utah 50 N Medical Dr Salt Lake City UT. 84112 p 801.581.6709 3570 W 9000 S Salt Lake City UT. 84132 p 801.585.0303 Ste 110 p 801.585.3229 515 E 100 S West Jordan UT. 84088 5126 W Daybreak Pkwy Ste 350 p 801.263.2370 Hospital Affiliation South Jordan UT. 84009 Salt Lake City UT. 84102 - University of Utah Hospital p 801.213.4500 p 801.581.3981 3584 W 9000 S Ste 209 Gilbert, Edward M MD University Of Utah Health Downey, Laura K PA West Jordan UT. 84088 University of Utah Health 85 N Medical Dr University of Utah Health p 801.263.2370 1950 Cir of Hope Dr Salt Lake City UT. 84112 590 S Wakara Way Salt Lake City UT. 84112 p 801.585.7676 Salt Lake City UT. 84108 5979 S Fashion Blvd p 801.585.7676 p 801.587.7109 Murray UT. 84107 Hospital Affiliation p 801.263.2370 50 N Medical Dr - University of Utah Hospital Hospital Affiliation Salt Lake City UT. 84132 - University of Utah Hospital 82 S 1100 E p 801.585.0434 Internal Med-Cardiology Ste 200 Advanced Heart Drakos, Stavros G MD Salt Lake City UT. 84102 University Of Utah Health Failure-Department of University of Utah Health p 801.263.2370 85 N Medical Dr University of Utah 1950 Cir of Hope Dr Salt Lake City UT. 84112 50 N Medical Dr Salt Lake City UT. 84112 Hospital Affiliation p 801.585.7676 Salt Lake City UT. 84132 p 801.585.7676 - Jordan Valley Medical p 801.585.0434 Center Hospital Affiliation - Salt Lake Regional Medical - University of Utah Hospital Center 141 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Internal 50 N Medical Dr Center 3584 W 9000 S Med-Interventional Salt Lake City UT. 84132 Ste 209 Cardiology Department of p 801.585.0434 Konesavanh, Soutsada N PA West Jordan UT. 84088 University of Utah University of Utah Health p 801.263.2370 50 N Medical Dr University Of Utah Health 1280 E Stringham Ave Salt Lake City UT. 84132 85 N Medical Dr Salt Lake City UT. 84106 5979 S Fashion Blvd p 801.585.0434 Salt Lake City UT. 84112 p 801.581.2000 Murray UT. 84107 p 801.585.7676 p 801.263.2370 Jensen, Peter E MD 1525 W 2100 S Utah Vein Specialists Hospital Affiliation Salt Lake City UT. 84119 Hospital Affiliation 7410 S Creek Rd - University of Utah Hospital p 801.213.8841 - Jordan Valley Medical Ste 104 Center Sandy UT. 84093 Kenwood, Bruce R DO 50 N Medical Dr - Salt Lake Regional Medical p 801.501.8346 Steward Cardiology Salt Lake City UT. 84132 Center Associates - West Jordan p 801.585.0434 - Castleview Hospital Jetter, Tawni L APRN 3570 W 9000 S University of Utah Health Ste 110 5126 W Daybreak Pkwy Miller, Stephen L MD 1525 W 2100 S West Jordan UT. 84088 Ste 600 5292 College Dr Salt Lake City UT. 84119 p 801.265.1200 South Jordan UT. 84009 Ste 201 p 801.213.8841 p 801.213.4500 Salt Lake City UT. 84123 Heart and Lung Institute p 801.281.4278 3730 W 4700 S of Utah 7495 S State St West Valley City UT. 84129 3584 W 9000 S Midvale UT. 84047 Morshedzadeh, Jack H MD p 801.213.9200 Ste 209 p 801.213.9400 University of Utah Health West Jordan UT. 84088 1525 W 2100 S 5126 W Daybreak Pkwy p 801.263.2370 Hospital Affiliation Salt Lake City UT. 84119 Ste 600 - University of Utah Hospital p 801.213.9990 South Jordan UT. 84009 5979 S Fashion Blvd p 801.213.4500 Murray UT. 84107 Kutchera, William A MD 1950 Cir of Hope Dr p 801.263.2370 University of Utah Health Salt Lake City UT. 84112 7495 S State St 1950 Cir of Hope Dr p 801.585.0303 Midvale UT. 84047 Steward Cardiology Salt Lake City UT. 84112 p 801.213.9400 Associates p 801.585.0303 5126 W Daybreak Pkwy 82 S 1100 E South Jordan UT. 84009 Johnson, Kira D PA Ste 200 50 N Medical Dr p 801.213.4500 University of Utah Health Salt Lake City UT. 84102 Salt Lake City UT. 84132 50 N Medical Dr p 801.263.2370 p 801.585.7676 University Of Utah Health Salt Lake City UT. 84132 85 N Medical Dr p 801.585.3229 Hospital Affiliation Hospital Affiliation Salt Lake City UT. 84112 - Jordan Valley Medical - University of Utah Hospital p 801.585.7676 5126 W Daybreak Pkwy Center South Jordan UT. 84009 - Salt Lake Regional Medical Lambert, Linda M APRN Hospital Affiliation p 801.585.3229 Center University of Utah Health - University of Utah Hospital 100 N Mario Capecchi Dr Karwande, Shreekanth MD Khor, Lillian L MD Salt Lake City UT. 84113 Muhlestein, Joseph B MD MountainStar University of Utah Health p 801.662.5566 University of Utah Health Cardiovascular Surgery 1950 Cir of Hope Dr 50 N Medical Dr 1160 E 3900 S Salt Lake City UT. 84112 81 N Mario Capecchi Dr Salt Lake City UT. 84132 Ste 3500 p 801.585.0303 Salt Lake City UT. 84113 p 801.585.7676 Salt Lake City UT. 84124 p 801.662.5566 p 801.743.4750 University Of Utah Health Hospital Affiliation 85 N Medical Dr Massinople, David S MD - University of Utah Hospital Hospital Affiliation Salt Lake City UT. 84112 Steward Cardiology - St Marks Hospital p 801.585.7676 Associates - West Valley Nativi Nicolau, Jose N MD - Ogden Regional Medical 3336 S Pioneer Pkwy University of Utah Health Center Hospital Affiliation Ste 203 1950 Cir of Hope Dr - Timpanogos Regional Hospital - University of Utah Hospital West Valley City UT. 84120 Salt Lake City UT. 84112 - Lakeview Hospital p 801.748.0113 p 801.585.7676 Kim, Christopher Y MD Kemeyou, Line MD Advanced Vein and Vascular Heart and Lung Institute 50 N Medical Dr University of Utah Health of Salt Lake City of Utah Salt Lake City UT. 84132 1950 Cir of Hope Dr 6321 S Redwood Rd 3570 W 9000 S p 801.585.0434 Salt Lake City UT. 84112 Ste 102 Ste 110 p 801.585.7676 Salt Lake City UT. 84123 West Jordan UT. 84088 p 385.388.8003 p 801.263.2370

Hospital Affiliation - Davis Hospital - Lakeview Hospital - Ogden Regional Medical Center 142 *The PPO Agreement with this provider is expressly between- Salt Lake the Third Regional Party Administrator Medical and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. University Of Utah Health 5126 W Daybreak Pkwy University Of Utah Health 50 N Medical Dr 85 N Medical Dr South Jordan UT. 84009 85 N Medical Dr Salt Lake City UT. 84132 Salt Lake City UT. 84112 p 801.213.4500 Salt Lake City UT. 84112 p 801.585.0434 p 801.585.7676 p 801.585.7676 University Of Utah Health University Of Utah Health Hospital Affiliation 85 N Medical Dr Sharp, Sally D MD 85 N Medical Dr - University of Utah Hospital Salt Lake City UT. 84112 Heart Center at St Marks Salt Lake City UT. 84112 p 801.585.7676 Hospital p 801.585.7676 Nielson, Kenneth G MD 1160 E 3900 S Heart Center at St Marks Hospital Affiliation Ste 2000 Hospital Affiliation Hospital - University of Utah Hospital Salt Lake City UT. 84124 - University of Utah Hospital 1160 E 3900 S p 801.266.3418 Ste 2000 Savage, Julie E APRN Stringham, James C MD Salt Lake City UT. 84124 University of Utah Health 3540 S 4000 W Multispecialty Partners p 801.266.3418 50 N Medical Dr Ste 340 24 S 1100 E Salt Lake City UT. 84132 West Valley City UT. 84120 Ste 304 3540 S 4000 W p 801.585.7676 p 801.676.3776 Salt Lake City UT. 84102 Ste 340 p 801.746.4440 West Valley City UT. 84120 Hospital Affiliation MountainStar Cardiology St p 801.676.3776 - University of Utah Hospital Marks Heart and Lung Institute 3584 W 9000 S of Utah MountainStar Cardiology St Selzman, Craig H MD Ste 209 3336 S 4155 W Marks University of Utah Health West Jordan UT. 84088 Ste 203 3584 W 9000 S 50 N Medical Dr p 801.676.3776 Salt Lake City UT. 84120 Ste 209 Salt Lake City UT. 84132 p 801.263.2370 West Jordan UT. 84088 p 801.581.5311 3725 W 4100 S p 801.676.3776 Salt Lake City UT. 84119 3570 W 9000 S Hospital Affiliation p 801.676.3776 Ste 110 3725 W 4100 S - University of Utah Hospital West Jordan UT. 84088 Salt Lake City UT. 84119 74 E Kimball Ln p 801.263.2370 p 801.676.3776 Shah, Rashmee MD Ste 260 University of Utah Health Draper UT. 84020 5979 S Fashion Blvd Hospital Affiliation 1950 Cir of Hope Dr p 801.571.6100 Murray UT. 84107 - St Marks Hospital Salt Lake City UT. 84112 p 801.263.2370 - Lone Peak Hospital p 801.585.0303 Hospital Affiliation - Timpanogos Regional Hospital - St Marks Hospital Multispecialty Partners 50 N Medical Dr - Lone Peak Hospital 82 S 1000 E Ranjan, Ravi MD Salt Lake City UT. 84132 - Timpanogos Regional Hospital Ste 103 University of Utah Health p 801.585.7676 Salt Lake City UT. 84102 50 N Medical Dr Smith, Brigham R MD p 801.746.4440 Salt Lake City UT. 84132 5126 W Daybreak Pkwy University of Utah Health p 801.585.3229 South Jordan UT. 84009 50 N Medical Dr Heart and Lung Institute p 801.213.4500 Salt Lake City UT. 84132 of Utah Hospital Affiliation p 801.585.0434 82 S 1100 E - University of Utah Hospital University Of Utah Health Ste 200 85 N Medical Dr Hospital Affiliation Salt Lake City UT. 84102 Rokeach, Steven A MD Salt Lake City UT. 84112 - University of Utah Hospital p 801.299.7155 Steward Medical Group p 801.585.7676 Cardiology Sontum, Nathan C PA Hospital Affiliation 3655 S 8400 W Hospital Affiliation University of Utah Health - Salt Lake Regional Medical Ste 240 - University of Utah Hospital 50 N Medical Dr Center Magna UT. 84044 Salt Lake City UT. 84132 - Davis Hospital p 801.290.7154 Sharma, Pawan K MD p 801.581.5311 - Jordan Valley Medical University of Utah Health Center Hospital Affiliation 1950 Cir of Hope Dr Hospital Affiliation - St Marks Hospital Salt Lake City UT. 84112 - University of Utah Hospital Symkoviak, Gary P MD - Lone Peak Hospital p 801.585.0303 Intermountain Heart Center Stehlik, Josef MD 5292 College Dr Ryan, John J MD 50 N Medical Dr University of Utah Health Ste 201 University of Utah Health Salt Lake City UT. 84132 1950 Cir of Hope Dr Salt Lake City UT. 84123 1950 Cir of Hope Dr p 801.585.7676 Salt Lake City UT. 84112 p 801.281.4278 Salt Lake City UT. 84112 p 801.585.7676 p 801.585.0303

143 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Szwajkun, Konstantyn Y MD University Of Utah Health 1950 Cir of Hope Dr University Of Utah Health Heart and Lung Institute 85 N Medical Dr Salt Lake City UT. 84112 85 N Medical Dr of Utah Salt Lake City UT. 84112 p 801.585.0303 Salt Lake City UT. 84112 3336 S 4155 W p 801.585.7676 p 801.585.7676 Ste 203 University Of Utah Health Salt Lake City UT. 84120 Hospital Affiliation 85 N Medical Dr Hospital Affiliation p 801.263.2370 - University of Utah Hospital Salt Lake City UT. 84112 - Primary Childrens Hospital p 801.585.7676 - University of Utah Hospital 3570 W 9000 S UUHC Redwood Health Center Ste 110 1525 W 2100 S Hospital Affiliation Wilson, Brent D MD West Jordan UT. 84088 Salt Lake City UT. 84119 - University of Utah Hospital University of Utah Health p 801.263.2370 p 801.213.9900 1138 E Wilmington Ave Wall, Travis S MD Salt Lake City UT. 84106 3584 W 9000 S UUHC South Jordan Health University of Utah Health p 801.581.2000 Ste 209 Center 50 N Medical Dr West Jordan UT. 84088 5126 W Daybreak Pkwy Salt Lake City UT. 84132 1525 W 2100 S p 801.263.2370 South Jordan UT. 84095 p 801.585.3229 Salt Lake City UT. 84119 p 801.213.4500 p 801.213.9990 5979 S Fashion Blvd Hospital Affiliation Murray UT. 84107 UUHC Redwood Health Center - University of Utah Hospital 1950 Cir of Hope Dr p 801.263.2370 1525 W 2100 S Salt Lake City UT. 84112 Salt Lake City UT. 84119 Welt, Frederick G MD p 801.585.0303 82 S 1100 E p 801.213.9900 University of Utah Health Ste 200 50 N Medical Dr 5126 W Daybreak Pkwy Salt Lake City UT. 84102 U-U Cardiology Division Salt Lake City UT. 84132 South Jordan UT. 84009 p 801.263.2370 50 N Medical Dr p 801.585.0434 p 801.213.4500 Salt Lake City UT. 84132 Hospital Affiliation p 801.585.7676 5126 W Daybreak Pkwy University Of Utah Health - Jordan Valley Medical South Jordan UT. 84009 85 N Medical Dr Center UUHC South Jordan Health p 801.585.7676 Salt Lake City UT. 84112 - Salt Lake Regional Medical Center p 801.585.7676 Center 5126 W Daybreak Pkwy Hospital Affiliation South Jordan UT. 84095 - University of Utah Hospital Hospital Affiliation Tandar, Anwar MD p 801.213.4500 - University of Utah Hospital University of Utah Health Wever Pinzon, Omar MD 50 N Medical Dr University of Utah University of Utah Health Yaganti, Vamsee M MD Salt Lake City UT. 84132 Cardiothoracic Surgeons 1950 Cir of Hope Dr Heart Center at St Marks p 801.585.0434 50 N Medical Dr Salt Lake City UT. 84112 Hospital Salt Lake City UT. 84132 p 801.585.7676 1160 E 3900 S Hospital Affiliation p 801.581.5311 Ste 2000 - University of Utah Hospital 30 N 1900 E Salt Lake City UT. 84124 *Wahl, Jessica K OT Salt Lake City UT. 84132 p 801.266.3418 Thorne, J Kent MD Primary Childrens Rehab p 801.585.7676 MountainStar 100 N Mario Capecchi Dr 3540 S 4000 W Cardiovascular Surgery Salt Lake City UT. 84113 University Of Utah Health Ste 340 1160 E 3900 S p 801.662.4980 85 N Medical Dr West Valley City UT. 84120 Ste 2000 & 3500 Salt Lake City UT. 84112 p 801.676.3776 Salt Lake City UT. 84124 Waldron, Jill APRN p 801.585.7676 p 801.743.4765 University of Utah Health Yan-Che Lui, Charles MD 1950 Cir of Hope Dr Whitehead, Kevin J MD University of Utah Health Hospital Affiliation Salt Lake City UT. 84112 University of Utah Health 50 N Medical Dr - St Marks Hospital p 801.585.7676 100 N Mario Capecchi Dr Salt Lake City UT. 84132 - Ogden Regional Medical Salt Lake City UT. 84113 p 801.585.0434 Center 50 N Medical Dr p 801.662.1000 - Timpanogos Regional Hospital Salt Lake City UT. 84132 Hospital Affiliation p 801.585.0434 1950 Cir of Hope Dr - University of Utah Hospital Tuday, Eric C MD Salt Lake City UT. 84112 University of Utah Health Hospital Affiliation p 801.585.0303 Zebrack, James S MD 1950 Cir of Hope Dr - University of Utah Hospital Mountainstar Cardiology Salt Lake City UT. 84112 50 N Medical Dr St. Marks, LLC p 801.585.0303 Walker, Jr, Jerry D MD Salt Lake City UT. 84132 1160 E 3900 S University of Utah Health p 801.585.7676 Ste 2000 1525 W 2100 S Salt Lake City UT. 84124 Salt Lake City UT. 84119 p 801.266.3418 p 801.213.9990

144 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Heart Center at St Marks Cardiothoracic Surgery Primary Childrens Hospital 81 N Mario Capecchi Dr Hospital Eckhauser, Aaron W MD Physicians Salt Lake City UT. 84113 3540 S 4000 W University of Utah Health 81 N Mario Capecchi Dr p 801.662.5566 Ste 340 100 N Mario Capecchi Dr Salt Lake City UT. 84113 West Valley City UT. 84120 Salt Lake City UT. 84113 p 801.662.1000 Hospital Affiliation p 801.676.3776 p 801.662.5566 - University of Utah Hospital Hospital Affiliation MountainStar Cardiology St PCH Esophageal Airway - - University of Utah Hospital Stringham, James C MD Marks Riverton Multispecialty Partners 3584 W 9000 S 3741 W 12600 S Husain, S Adil MD 24 S 1100 E Ste 209 Riverton UT. 84065 University of Utah Health Ste 304 West Jordan UT. 84088 p 801.662.1644 100 N Mario Capecchi Dr Salt Lake City UT. 84102 p 801.676.3776 Salt Lake City UT. 84113 p 801.746.4440 University of Utah Health p 801.662.5566 3725 W 4100 S 50 N Medical Dr Heart and Lung Institute Salt Lake City UT. 84119 Salt Lake City UT. 84132 PCH Esophageal Airway - of Utah p 801.676.3776 p 801.581.5311 Riverton 3336 S 4155 W 3741 W 12600 S Ste 203 Hospital Affiliation Primary Childrens Hospital Riverton UT. 84065 Salt Lake City UT. 84120 - St Marks Hospital Physicians p 801.662.1644 p 801.263.2370 - Lone Peak Hospital 81 N Mario Capecchi Dr - Timpanogos Regional Hospital Salt Lake City UT. 84113 University of Utah Health 3570 W 9000 S p 801.662.1000 50 N Medical Dr Ste 110 Zink, Robert F MD Salt Lake City UT. 84132 West Jordan UT. 84088 MountainStar Hospital Affiliation p 801.581.5311 p 801.263.2370 Cardiovascular Surgery - University of Utah Hospital 1160 E 3900 S Primary Childrens Hospital 5979 S Fashion Blvd Ste 2000 & 3500 Glotzbach, Jason P MD Physicians Murray UT. 84107 Salt Lake City UT. 84124 University of Utah Health 81 N Mario Capecchi Dr p 801.263.2370 p 801.266.3418 100 N Mario Capecchi Dr Salt Lake City UT. 84113 Salt Lake City UT. 84113 p 801.662.1000 Multispecialty Partners Zubair, Imran MD p 801.662.5566 82 S 1000 E Salt Lake Regional Medical Hospital Affiliation Ste 103 Center - Behavioral Health 1950 Cir of Hope Dr - University of Utah Hospital Salt Lake City UT. 84102 1050 E South Temple Salt Lake City UT. 84112 p 801.746.4440 Salt Lake City UT. 84102 p 801.585.0100 Karwande, Shreekanth MD p 801.350.4715 MountainStar Heart and Lung Institute 50 N Medical Dr Cardiovascular Surgery of Utah Jordan Valley Medical Salt Lake City UT. 84132 1160 E 3900 S 82 S 1100 E Center - West Valley p 801.581.5311 Ste 3500 Ste 200 Campus Inpatient BH Unit Salt Lake City UT. 84124 Salt Lake City UT. 84102 3460 S 4155 W 81 N Mario Capecchi Dr p 801.743.4750 p 801.299.7155 West Valley City UT. 84120 Salt Lake City UT. 84113 p 801.964.3559 p 801.662.5566 Hospital Affiliation Hospital Affiliation - St Marks Hospital - Salt Lake Regional Medical Jordan Valley Medical Hospital Affiliation - Ogden Regional Medical Center Center - University of Utah Hospital Center - Davis Hospital 3580 W 9000 S - Timpanogos Regional Hospital - Jordan Valley Medical West Jordan UT. 84088 Griffiths, Eric R MD - Lakeview Hospital Center p 801.601.4423 University of Utah Health 100 N Mario Capecchi Dr Sharma, Vikas Varghese, Thomas K MD Steward Cardiology Salt Lake City UT. 84113 University of Utah Health University of Utah Health Associates - Salt Lake p 801.662.5566 100 N Mario Capecchi Dr 1950 Cir of Hope Dr City Salt Lake City UT. 84113 Salt Lake City UT. 84112 82 S 1100 E PCH Esophageal Airway - p 801.662.5566 p 801.585.0100 Ste 200 Riverton Salt Lake City UT. 84102 3741 W 12600 S 1950 Cir of Hope Dr 50 N Medical Dr p 801.263.2370 Riverton UT. 84065 Salt Lake City UT. 84112 Salt Lake City UT. 84132 p 801.662.1644 p 801.585.0100 p 801.581.5311 Hospital Affiliation - Salt Lake Regional Medical University of Utah Health 50 N Medical Dr 5126 W Daybreak Pkwy Center 50 N Medical Dr Salt Lake City UT. 84132 South Jordan UT. 84009 Salt Lake City UT. 84132 p 801.581.5311 p 801.581.5311 p 801.581.5311 Hospital Affiliation - University of Utah Hospital

145 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Zink, Robert F MD Barnard, Peter S CNM 74 Kimballs Ln 7495 S State St MountainStar St Marks Obstetrics and Ste 330 Midvale UT. 84047 Cardiovascular Surgery Gynecology Associates Draper UT. 84020 p 801.581.4014 1160 E 3900 S 1140 E 3900 S p 801.523.3053 Ste 2000 & 3500 Ste 400 Hospital Affiliation Salt Lake City UT. 84124 Salt Lake City UT. 84124 St Marks Gynecology and - University of Utah Hospital p 801.266.3418 p 801.268.6811 Oncology Care 96 E Kimballs Ln College of Nursing, Cardiovascular Surgery OBGYN Associates Ste 202 University of Utah Hunter, Curtis T MD 1151 E 3900 S Draper UT. 84020 4535 S 5600 W MountainStar Ste B 299 p 801.523.3053 Salt Lake City UT. 84120 Cardiovascular Surgery Salt Lake City UT. 84124 p 801.963.7335 1160 E 3900 S p 801.268.6811 Hospital Affiliation Ste 3500 - St Marks Hospital UUHC South Jordan Health Salt Lake City UT. 84124 Hospital Affiliation - Lone Peak Hospital Center p 801.743.4765 - St Marks Hospital - University of Utah Hospital 5126 W Daybreak Pkwy - Lone Peak Hospital South Jordan UT. 84095 Husain, S Adil MD Cohen, Susanna R CNM p 801.213.4500 University of Utah Health Barnes, Lisa E CNM University of Utah Health 100 N Mario Capecchi Dr University of Utah Health 1280 E Stringham Ave UUHC Madsen Health Center Salt Lake City UT. 84113 3690 S Main St Salt Lake City UT. 84106 555 S Foothill Blvd p 801.662.5566 Salt Lake City UT. 84115 p 801.581.4014 Ste 301 p 385.468.3950 Salt Lake City UT. 84112 PCH Esophageal Airway - 3690 S Main St p 801.581.8000 Riverton 50 N Medical Dr Salt Lake City UT. 84115 3741 W 12600 S Salt Lake City UT. 84132 p 385.468.3950 College of Nursing - Riverton UT. 84065 p 801.581.4014 Downtown Womens Clinic p 801.662.1644 50 N Medical Dr 82 S 1100 E 5126 W Daybreak Pkwy Salt Lake City UT. 84132 Ste 204 University of Utah Health South Jordan UT. 84009 p 801.581.4014 Salt Lake City UT. 84102 50 N Medical Dr p 801.213.4500 p 801.581.4014 Salt Lake City UT. 84132 5126 W Daybreak Pkwy p 801.581.5311 555 Foothill Dr South Jordan UT. 84009 Hospital Affiliation Salt Lake City UT. 84112 p 801.213.4500 - University of Utah Hospital Primary Childrens Hospital p 801.581.4014 Physicians 555 Foothill Dr Dearden, Vivian CNM 81 N Mario Capecchi Dr 7495 S State St Salt Lake City UT. 84112 Rocky Mountain Womans Salt Lake City UT. 84113 Midvale UT. 84047 p 801.581.4014 Health Center - Salt Lake p 801.662.1000 p 801.581.4014 City 7495 S State St 82 S 1100 E Hospital Affiliation Hospital Affiliation Midvale UT. 84047 Ste 305 - University of Utah Hospital - University of Utah Hospital p 801.581.4014 Salt Lake City UT. 84102 p 801.214.7651 Kagawa, Hiroshi MD Blair, Teresa CNM Hospital Affiliation University Of Utah Health Exodus Healthcare Network - University of Utah Hospital Hospital Affiliation 100 N Mario Capecchi Dr 3336 S Pioneer Pkwy - Davis Hospital Salt Lake City UT. 84113 Ste 201 Cole, Erin J CNM p 801.662.5566 West Valley City UT. 84120 University of Utah Health Dunipace, Caitlin E CNM p 801.250.9638 3690 S Main St University of Utah Health 50 N Medical Dr Salt Lake City UT. 84115 50 N Medical Dr Salt Lake City UT. 84132 3665 S 8400 W p 801.581.4014 Salt Lake City UT. 84132 p 801.581.5311 Ste 110 p 801.587.9500 Magna UT. 84044 50 N Medical Dr Hospital Affiliation p 801.250.9638 Salt Lake City UT. 84132 Hospital Affiliation - University of Utah Hospital p 801.581.4014 - University of Utah Hospital Blair, Veronica C CNM Certified Nurse Midwife OB/Gyn Associates LC 5126 W Daybreak Pkwy Ellis, Jessica A CNM Anderson, Laura CNM 1151 E 3900 S South Jordan UT. 84009 University of Utah Health University of Utah Health Ste B-299 p 801.581.4014 3690 S Main St 50 N Medical Dr Salt Lake City UT. 84124 Salt Lake City UT. 84115 Salt Lake City UT. 84132 p 801.268.6811 555 Foothill Dr p 801.581.4014 p 801.587.9500 Salt Lake City UT. 84112 p 801.581.4014 Hospital Affiliation - University of Utah Hospital

146 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 50 N Medical Dr Hayes, Emily H CNM Loveridge, Danica D CNM Nelson, Amy B CNM Salt Lake City UT. 84132 University of Utah Health University of Utah Health University of Utah Health p 801.581.4014 3690 S Main St 3690 S Main St 3690 S Main St Salt Lake City UT. 84115 Salt Lake City UT. 84115 Salt Lake City UT. 84115 5126 W Daybreak Pkwy p 385.468.3950 p 385.468.3950 p 385.468.3950 South Jordan UT. 84009 p 801.581.4014 50 N Medical Dr Hospital Affiliation 50 N Medical Dr Salt Lake City UT. 84132 - University of Utah Hospital Salt Lake City UT. 84132 555 Foothill Dr p 801.581.4014 p 801.581.4014 Salt Lake City UT. 84112 Miller, Kathleen G CNM p 801.581.4014 5126 W Daybreak Pkwy St Marks Obstetrics and 5126 W Daybreak Pkwy South Jordan UT. 84009 Gynecology Associates South Jordan UT. 84009 7495 S State St p 801.213.4500 1140 E 3900 S p 801.213.4500 Midvale UT. 84047 Ste 400 p 801.581.4014 555 Foothill Dr Salt Lake City UT. 84124 Hospital Affiliation Salt Lake City UT. 84112 p 801.268.6811 - University of Utah Hospital Hospital Affiliation p 801.581.8995 - University of Utah Hospital Hospital Affiliation Nelson, Patience CNM Hospital Affiliation - St Marks Hospital Exodus Healthcare Network Elmore, Christina CNM - University of Utah Hospital 3665 S 8400 W University of Utah Health Miller, Paige E CNM Ste 110 3690 S Main St Heubusch, Diane D CNM University of Utah Health Magna UT. 84044 Salt Lake City UT. 84115 Western GYN & OB Clinic 1280 E Stringham Ave p 801.250.9638 p 385.468.3950 12600 S 3723 W Salt Lake City UT. 84106 Ste 350 p 801.581.4014 Nichols, Kristi L CNM 50 N Medical Dr Riverton UT. 84065 University of Utah Health Salt Lake City UT. 84132 p 801.285.4900 3690 S Main St 1525 W 2100 S p 801.581.4014 Salt Lake City UT. 84115 Salt Lake City UT. 84119 Hospital Affiliation p 801.581.4014 p 801.213.8841 5126 W Daybreak Pkwy - Jordan Valley Medical South Jordan UT. 84009 Center 50 N Medical Dr 3730 W 4700 S p 801.213.4500 Salt Lake City UT. 84132 West Valley City UT. 84129 Jensen, Jennifer p 801.581.4014 p 801.213.9200 555 Foothill Dr Riverton Healthcare for Salt Lake City UT. 84112 Women 5126 W Daybreak Pkwy 7495 S State St p 801.581.4014 3409 W 12600 S South Jordan UT. 84009 Midvale UT. 84047 Ste 110 p 801.581.4014 p 801.213.9400 7495 S State St Riverton UT. 84065 Midvale UT. 84047 p 801.302.5777 555 Foothill Dr Hospital Affiliation p 801.581.4014 Salt Lake City UT. 84112 - University of Utah Hospital Jones, Julie CNM p 801.581.4014 Hospital Affiliation Riverton Healthcare for O Neal, A V CNM - University of Utah Hospital Women 7495 S State St University of Utah Health 3409 W 12600 S Midvale UT. 84047 50 N Medical Dr Grubb, Michelle CNM Ste 110 p 801.581.4014 Salt Lake City UT. 84132 St Marks Gynecology and Riverton UT. 84065 p 801.587.9500 Oncology Care p 801.302.5777 Hospital Affiliation 96 E Kimballs Ln - University of Utah Hospital Paegle, Rita A CNM Ste 202 Hospital Affiliation University of Utah Health Draper UT. 84020 - Jordan Valley Medical Montiel, Amanda S CNM 50 N Medical Dr p 801.523.3053 Center 24 S 1100 E Salt Lake City UT. 84132 Ste 209 p 801.213.2995 Hospital Affiliation King, Julie CNM Salt Lake City UT. 84102 - Lone Peak Hospital University of Utah Health p 801.908.0930 555 Foothill Dr - St Marks Hospital 3690 S Main St Salt Lake City UT. 84112 Salt Lake City UT. 84115 Hospital Affiliation p 801.581.8995 Harward, Marnae CNM p 385.468.3950 - Salt Lake Regional Medical St Marks Obstetrics and Center Hospital Affiliation Gynecology Associates 50 N Medical Dr - University of Utah Hospital 1140 E 3900 S Salt Lake City UT. 84132 Naval, Carlie CNM Ste 400 p 801.581.4014 University of Utah Health Richardson, Jill CNM Salt Lake City UT. 84124 50 N Medical Dr University of Utah Health p 801.268.6811 Hospital Affiliation Salt Lake City UT. 84132 50 N Medical Dr - University of Utah Hospital p 801.587.9500 Salt Lake City UT. 84132 Hospital Affiliation p 801.581.4014 - St Marks Hospital Hospital Affiliation - University of Utah Hospital 147 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Rizk, Abigail CNM Swanson, Trece B CNM St Marks Obstetrics & Zeer, Jennifer CNM University of Utah Health University of Utah Health Gynecology Associates University of Utah Health 3690 S Main St 50 N Medical Dr 1140 E 3900 S 50 N Medical Dr Salt Lake City UT. 84115 Salt Lake City UT. 84132 Ste 400 Salt Lake City UT. 84132 p 385.468.3950 p 801.581.4014 Salt Lake City UT. 84124 p 801.587.9500 p 801.268.6811 Roberts, Leissa A CNM 555 Foothill Dr Hospital Affiliation University of Utah Health Salt Lake City UT. 84112 Whiting, Christina M CNM - University of Utah Hospital 1280 E Stringham Ave p 801.581.8425 University of Utah Health Salt Lake City UT. 84106 3690 S Main St duBois Hollander, Emily p 801.581.4014 Hospital Affiliation Salt Lake City UT. 84115 CNM - University of Utah Hospital p 801.581.4014 University of Utah Health 3690 S Main St 3690 S Main St Salt Lake City UT. 84115 Thacker, Paula G CNM 5126 W Daybreak Pkwy Salt Lake City UT. 84115 p 385.468.3950 Hidden Valley Family South Jordan UT. 84009 p 385.468.3950 Medicine p 801.581.4014 Hospital Affiliation 121765 S 1000 E 50 N Medical Dr - University of Utah Hospital Ste 4 555 Foothill Dr Salt Lake City UT. 84132 Draper UT. 84020 Salt Lake City UT. 84112 p 801.581.4014 Roundy, Marci C CNM p 801.572.3750 p 801.581.4014 Exodus Healthcare Network 5126 W Daybreak Pkwy 3336 S Pioneer Pkwy Riverton Healthcare for 7495 S State St South Jordan UT. 84009 Ste 201 Women Midvale UT. 84047 p 801.213.4500 Salt Lake City UT. 84120 3409 W 12600 S p 801.581.4014 p 801.250.9638 Ste 110 555 Foothill Dr Riverton UT. 84065 Hospital Affiliation Salt Lake City UT. 84112 3665 S 8400 W p 801.302.5777 - University of Utah Hospital p 801.585.2111 Ste 110 Magna UT. 84044 Hospital Affiliation Whitney, Sandra E CNM 7495 S State St p 801.250.9638 - Jordan Valley Medical University of Utah Health Midvale UT. 84047 Center 50 N Medical Dr p 801.581.4014 Scott, Heather CNM Salt Lake City UT. 84132 Rocky Mountain Womans Thomas, Celeste R CNM p 801.213.2995 Hospital Affiliation Health Center - Salt Lake University of Utah Health - University of Utah Hospital City 3690 S Main St Hospital Affiliation 82 S 1100 E Salt Lake City UT. 84115 - University of Utah Hospital Chiropractic Ste 305 p 385.468.3950 Adams, Alan J DC Salt Lake City UT. 84102 Yale, Jocelyn S CNM Jordan Oaks Chiropractic p 801.214.7651 Hospital Affiliation University of Utah Health 7555 S Ctr View Ct - University of Utah Hospital 1280 E Stringham Ave Ste 102 Smithers, Jacqueline M Salt Lake City UT. 84106 West Jordan UT. 84084 CNM Trauscht-Van Horn, p 801.581.4014 p 801.568.9222 Womens Health Services Jennifer J MD 6440 Wasatch Blvd University of Utah Health 3690 S Main St Allen, Stephanie DC Ste 270 50 N Medical Dr Salt Lake City UT. 84115 Alta Vista Chiropractic Salt Lake City UT. 84121 Salt Lake City UT. 84132 p 385.468.3950 1781 W 9000 S p 801.942.5814 p 801.213.2995 West Jordan UT. 84088 50 N Medical Dr p 801.562.5600 7084 S 2300 E 5126 W Daybreak Pkwy Salt Lake City UT. 84132 Ste 110 South Jordan UT. 84009 p 801.581.4014 Asay, Scott DC Salt Lake City UT. 84121 p 801.213.4500 Apollo Health Centers p 801.942.5814 5126 W Daybreak Pkwy 5525 S 900 E Hospital Affiliation South Jordan UT. 84009 Ste 310 Hospital Affiliation - University of Utah Hospital p 801.213.4500 Salt Lake City UT. 84117 - Mountain West Medical p 801.685.2862 Center Waters, Kira M CNM 555 Foothill Dr Monarch Womens Cancer Salt Lake City UT. 84112 Awerkamp, Blaine A DC Stuck, Kimberly CNM Center p 801.585.2111 Awerkamp Chiropractic PC St Marks Gynecology and 1140 E 3900 S 8394 S 700 E Oncology Care Ste 340 7495 S State St Sandy UT. 84070 96 E Kimballs Ln Salt Lake City UT. 84124 Midvale UT. 84047 p 801.562.0135 Ste 202 p 801.743.4730 p 801.581.4014 Draper UT. 84020 p 801.523.3053 Hospital Affiliation - University of Utah Hospital

148 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Berlin, Daniel DC 912 W Baxter Dr Monson, Danny DC Colon And Rectal Surgery Berlin Chiropractic Inc Ste 130 Monson Chiropractic Bossart, Peter W MD 4360 S Redwood Rd South Jordan UT. 84095 3378 W 3500 S 324 10th Ave Ste 3 p 385.308.4355 Salt Lake City UT. 84119 Ste 280 Salt Lake City UT. 84123 p 801.966.5200 Salt Lake City UT. 84103 p 801.963.8750 Kaier, Jeremy DC p 801.408.5930 Aspen Falls Spinal Care Mousley, Jordan D DC Canada, Angela DC Center Elite Chiropractic and Hospital Affiliation Canada Chiropractic 912 W Baxter Dr Performance Center - Salt Lake Regional Medical 1473 S 600 E Ste 130 6717 S 900 E Center Salt Lake City UT. 84105 South Jordan UT. 84095 Ste 101 - St Marks Hospital p 801.487.1010 p 385.308.4355 Midvale UT. 84047 p 801.432.7511 Clark, Jill E MD Castillon, Travis DC Lane, Michael DC 1250 E 3900 S Apollo Health Centers Downtown Chiropractic and Olsen, John K DC Ste 320 5525 S 900 E Message Therapy Mountain Valley Wellness Salt Lake City UT. 84124 Ste 310 261 E 300 S 392 E 12300 S p 801.263.1621 Salt Lake City UT. 84117 Ste 310 Draper UT. 84020 p 801.685.2862 Salt Lake City UT. 84111 p 801.849.1029 Hospital Affiliation p 801.322.3067 - St Marks Hospital Corbaley, John DC Peterson, Brad N DC - Lakeview Hospital Aspen Falls Spinal Care Layton, Monte J DC Southwest Chiropractic Inc Center Elite Chiropractic and 10358 S 1700 W Crume, Abby N DO 370 E S Temple Performance Center South Jordan UT. 84095 Abby N Crume DO Ste 100 6717 S 900 E p 801.254.9400 1250 E 3900 S Salt Lake City UT. 84111 Ste 101 Ste 320 p 801.363.0060 Midvale UT. 84047 Rawlings, Lance S DC Salt Lake City UT. 84124 p 801.432.7511 Rawlings Chiropractic p 801.263.1621 Ewell, Brian H DC Services Corp 2964 W 4700 S LeSueur, Carl G DC 891 E 9400 S Hospital Affiliation Ste 102 Corner Canyon Chiropractic Sandy UT. 84094 - St Marks Hospital Salt Lake City UT. 84129 12176 S 1000 E p 801.569.8181 - Lakeview Hospital p 801.966.9100 Ste 10 - Lone Peak Hospital Draper UT. 84020 Rowell, James R DC Glaser, Crystal M DC p 801.553.9691 Capstone Chiropractic LLC Huang, Lyen C MD Alta Vista Chiropractic 2200 E 4500 S University of Utah Health 1781 W 9000 S Lorenc, Caleb J DC Ste 110 1950 Cir of Hope Dr West Jordan UT. 84088 Integrated Wellness South Salt Lake City UT. 84117 Salt Lake City UT. 84112 p 801.562.5600 Jordan p 801.272.8500 p 801.587.7000 10376 S Jordan Gateway Green, Ralph K DC South Jordan UT. 84095 Taylor, Zachary D DC 50 N Medical Dr Green Chiropractic Clinic p 801.816.0332 Aspen Falls Spinal Care Salt Lake City UT. 84132 2048 W 5400 S Center p 801.581.7738 Salt Lake City UT. 84129 Martin, Terry DC 370 E S Temple p 801.968.5400 Terry H Martin DC Ste 100 Hospital Affiliation 1951 W 4700 S Salt Lake City UT. 84111 - University of Utah Hospital Harbrecht, Chris J DC Ste 1 p 801.363.0060 Elite Chiropractic and Salt Lake City UT. 84129 Hughes, J Preston MD Performance Center p 801.969.8197 Thomas, Brian DC 1250 E 3900 S 6717 S 900 E Willow Creek Chiropractic Ste 320 Ste 101 Molina, Paul DC 8170 S Highland Dr Salt Lake City UT. 84124 Midvale UT. 84047 Canada Chiropractic Ste E2 p 801.266.1409 p 801.432.7511 1473 S 600 E Sandy UT. 84093 Salt Lake City UT. 84105 p 801.942.4999 Melvin, Joseph C MD Harward, Russell DC p 801.487.1010 1250 E 3900 S Harward Chiropractic Ward, Gannon O DC Ste 320 11616 S State St Molis, Gregory C DC Mountain Valley Wellness Salt Lake City UT. 84124 Ste 1502 Able Chiropractic Clinic 392 E 12300 S p 801.263.1621 Draper UT. 84020 3378 W 3500 S Draper UT. 84020 p 801.571.2200 Salt Lake City UT. 84119 p 801.849.1029 Hospital Affiliation p 801.966.0342 - St Marks Hospital Hedstrom, Dustin J DC Wimmer, Jeremy P DC - Lone Peak Hospital Aspen Falls Spinal Care Jeremy P Wimmer Center Chiropractic LLC 370 E S Temple 6717 S 900 E Ste 100 Ste 101 Salt Lake City UT. 84111 Midvale UT. 84047 p 801.363.0060 p 801.432.7511 149 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Murday, Michelle E MD Addiction and Anderson, Julie LCMHC Barakat, Jamal A LPC 1250 E 3900 S Psychological Services Sage Family Counseling Valley Behavioral Health Ste 320 6065 S Fashion Blvd 13552 S 110 W 1020 S Main St Salt Lake City UT. 84124 Ste 140 Ste 204 Ste 100 p 801.263.1621 Salt Lake City UT. 84107 Draper UT. 84020 Salt Lake City UT. 84101 p 801.268.2558 p 801.432.0883 p 888.949.4864 Hospital Affiliation - St Marks Hospital Akers, Erin CMHC Anderson, Sarah MSW 1020 S Main St - Lone Peak Hospital Aspen Ridge Counseling Early Life Child Ste 300 2711 S 8500 W Psychology & Education Salt Lake City UT. 84101 Peche, William J MD Magna UT. 84044 Center p 888.949.4864 University of Utah Health p 801.990.4300 10757 S River Front Pkwy 50 N Medical Dr Ste 275 3809 W 6200 S Salt Lake City UT. 84132 Alder, Andrew CMHC South Jordan UT. 84095 Salt Lake City UT. 84129 p 801.581.7738 Summit Community p 385.900.4020 p 888.949.4864 Counseling Hospital Affiliation 5689 S Redwood Rd 12397 S 300 E Barker, Autumn LCMHC - University of Utah Hospital Ste 27 Ste 100 The OCD And Anxiety Salt Lake City UT. 84123 Draper UT. 84020 Treatment Center Pickron, T B MD p 801.266.2485 p 385.900.4020 11260 S River Height Dr University of Utah Health South Jordan UT. 84095 1950 Cir of Hope Dr 5991 S Redwood Rd Anderson, Susan CMHC p 801.298.2000 Salt Lake City UT. 84112 Salt Lake City UT. 84123 Child and Family p 801.587.7000 p 801.266.2485 Empowerment Services Barnhurst, Mark LCMHC 1578 W 1700 S Inner Peace Conseling of 30 N 1900 E Rm 3B115 Allred, David D LMFT Ste 200 Utah Salt Lake City UT. 84132 2900 S State St Salt Lake City UT. 84104 11618 S State St p 801.581.7124 Ste 101 p 801.972.2711 Ste 1604 Salt Lake City UT. 84115 Draper UT. 84020 50 N Medical Dr p 385.275.6311 Andreason, Jacob R CMHC p 385.202.5645 Salt Lake City UT. 84132 Blue Theory Counseling p 801.581.7738 7370 S Creek Rd 10808 S River Front Pkwy Sundance Behavioral Ste 204 Ste 308 Resources Hospital Affiliation Sandy UT. 84093 South Jordan UT. 84095 845 E 4800 S - University of Utah Hospital p 385.275.6311 p 801.984.6728 Ste 200 Salt Lake City UT. 84107 Counseling Allred, Debbi CMHC Andrews, Ashley J LCMHC p 801.264.9522 Acevedo, Carlos ACMHC Neurobehavioral Center for Valley Behavioral Health Utah Behavior Services Growth 1020 S Main St Bear Creek Counseling 5558 S 1900 W 370 E South Temple Ste 100 1227 W 9000 S Ste B Ste 175 Salt Lake City UT. 84101 Ste H Salt Lake City UT. 84129 Salt Lake City UT. 84111 p 888.949.4864 West Jordan UT. 84084 p 801.255.5131 p 801.683.1062 p 385.274.7119 Apodaca, Kathleen E 6013 S Redwood Rd Collective Recovery Center Christian Counseling Bell, Naomia M CMHC Salt Lake City UT. 84123 8029 S 700 E Centers of Utah Military & Veteran p 801.255.5131 Sandy UT. 84070 525 E 4500 S Counseling Center p 385.557.2183 Ste F-125 140 W 2100 S Adams, Bonnie J LMFT Salt Lake City UT. 84107 Ste 244 Valley Behavioral Health Andersen, Adriane CMHC p 801.268.1564 Salt Lake City UT. 84115 2948 S Redwood Rd University of Utah Health p 385.231.8387 West Valley City UT. 84119 501 S Chipeta Way Archuleta, Jason LCSW p 888.949.4864 Salt Lake City UT. 84108 Utah Behavior Services Bennett Murphy, Laura p 801.585.1575 5558 S 1900 W PhD 3809 W 6200 S Ste B University of Utah Health Salt Lake City UT. 84129 Anderson, Barbara CMHC Taylorsville UT. 84118 100 N Mario Capecchi Dr p 888.949.4864 Jordan West Family p 801.255.5131 Salt Lake City UT. 84113 Counseling p 801.313.7711 4460 S Highland Dr 9263 Redwood Rd Bldg 8 6013 S Redwood Rd Ste 100 West Jordan UT. 84088 Taylorsville UT. 84123 50 N Medical Dr Salt Lake City UT. 84124 p 801.566.0749 p 801.255.5131 Salt Lake City UT. 84132 p 888.949.4864 p 801.581.2205

150 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Primary Childrens Hospital 6013 S Redwood Rd Burr, Hayley A CMHC Clayton, Frank G LPC Physicians Salt Lake City UT. 84123 Valley Behavioral Health Salt Lake Mental Health 81 N Mario Capecchi Dr p 801.255.5131 1020 S Main St 2290 E 4500 S Salt Lake City UT. 84113 Ste 100 Ste 270 p 801.662.1000 Borges de Martinez, Ana Salt Lake City UT. 84101 Salt Lake City UT. 84117 LMFT p 888.949.4864 p 877.476.6338 Benson, Peter H LMFT Empowering Relief Sage Family Counseling Counseling Butler, April A CMHC *Colte, Paul D PSYD 13552 S 110 W 5814 S 900 E Valley Behavioral Health Primary Childrens Hospital Ste 204 Salt Lake City UT. 84121 1141 E 3900 S 100 N Mario Capecchi Dr Draper UT. 84020 p 385.800.3272 Ste A250 Salt Lake City UT. 84113 p 801.432.0883 Salt Lake City UT. 84124 p 801.662.1000 Multicultural Counseling p 888.949.4864 Bergvall, Phoebe CMHC Center Cornell, Diana CMHC Ascendant Behavioral 7625 S 3200 W Caleron, Chrstina CMHC Jordan West Family Health Ste 2 Ascendant Behavioral Counseling 5383 S 900 E West Jordan UT. 84084 Health 9263 Redwood Rd Bldg 8 Ste 103 p 801.915.0359 5383 S 900 E Ste B Salt Lake City UT. 84117 Ste 103 West Jordan UT. 84088 p 801.872.5516 Boyle, Jeremy LMFT Salt Lake City UT. 84117 p 801.566.0749 Jeremy Boyle LMFT p 801.872.5516 Best, Lanette R CMHC 9055 S 1300 E Cox, Patricia CMHC Valley Behavioral Health Ste 12 Carter, Scott M LPC Bear Creek Counseling 12427 S Pasture Rd Sandy UT. 84092 Salt City Counseling & 1227 W 9000 S Ste 104 p 801.657.5312 Consultation Ste H Riverton UT. 84096 12465 S Fort St West Jordan UT. 84084 p 888.949.4864 Bradley, Jessica L CMHC Ste 250 p 385.274.7119 Valley Behavioral Health Draper UT. 84020 4460 S Highland Dr 12427 S Pasture Rd p 385.202.4174 Cunningham, Jeanna CMHC Ste 100 Ste 104 Valley Behavioral Health Salt Lake City UT. 84124 Herriman UT. 84096 Valley Behavioral Health 12427 S Pasture Rd p 888.949.4864 p 888.949.4864 195 W 7200 S Ste 104 Midvale UT. 84047 Herriman UT. 84096 Beyers, Stephen LPC 4460 S Highland Dr p 888.949.4864 p 888.949.4864 9192 S 300 W Ste 100 Ste 19 Salt Lake City UT. 84124 Cherry, Brian C CMHC 4460 S Highland Dr Sandy UT. 84070 p 888.949.4864 Summit Community Ste 100 p 801.554.3191 Counseling Salt Lake City UT. 84124 Brown, Jacob G CMHC 5689 S Redwood Rd p 888.949.4864 Bezzant, Christopher LPC Valley Behavioral Health Ste 27 Comprehensive 1020 S Main St Salt Lake City UT. 84123 Daniels, Marianne CMHC Psychological Services Ste 100 p 801.266.2485 Cedar Psychiatry 1208 E 3300 S Salt Lake City UT. 84101 1208 E 3300 S Salt Lake City UT. 84106 p 888.949.4864 5991 S Redwood Rd Salt Lake City UT. 84106 p 801.483.1600 Salt Lake City UT. 84123 p 801.369.8989 Bryan, Damon LMFT p 801.266.2485 Biesinger, Josh P LMFT 1291 W Atherton Dr 154 E Myrtle Ave 5667 S Redwood Rd Salt Lake City UT. 84123 Chipman, Lani LMFT Ste 204 Ste 5B p 970.403.2458 Summit Community Murray UT. 84107 Taylorsville UT. 84123 Counseling p 801.369.8989 p 801.755.8799 Buck, Timothy C CMHC 5689 S Redwood Rd Ascendant Behavioral Ste 27 Ascendant Behavioral Bills, Shawn LMFT Health Salt Lake City UT. 84123 Health Jordan West Family 5383 S 900 E p 801.266.2485 5383 S 900 E Counseling Ste 103 Ste 103 9263 Redwood Rd Bldg 8 Salt Lake City UT. 84117 5991 S Redwood Rd Salt Lake City UT. 84117 Ste B p 801.872.5516 Salt Lake City UT. 84123 p 801.872.5516 West Jordan UT. 84088 p 801.266.2485 p 801.523.5206 Bunker, Brandon CMHC Cedar Psychiatry Aspen Ridge Counseling Christy, Cheryl L ACMHC 721 E 12200 S Black, Jed CMHC 2711 S 8500 W Valley Behavioral Health Draper UT. 84020 Utah Behavior Services Magna UT. 84044 2948 S Redwood Rd p 801.369.8989 5558 S 1900 W p 801.990.4300 West Valley City UT. 84119 Ste B p 888.949.4864 Salt Lake City UT. 84129 p 801.255.5131

151 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Danner, Barbara A CMHC Doubek, Anne CMHC Elkins, Meghan LMFT Fahlberg, Cory LMFT Aspen Ridge Counseling Valley Behavioral Health Summit Community Ascendant Behavioral 1561 W 7000 S 195 W 7200 S Counseling Health Ste 200 Midvale UT. 84047 5689 S Redwood Rd 5383 S 900 E West Jordan UT. 84084 p 888.949.4864 Ste 27 Ste 103 p 801.990.4300 Salt Lake City UT. 84123 Salt Lake City UT. 84117 Ascendant Behavioral p 801.266.2485 p 801.872.5516 Imagine Counseling Health Services 5383 S 900 E Ellis, John LMFT Fairbourn, Jennifer LMFT 5663 S Redwood Rd Ste 103 Cedar Psychiatry Cottonwood Creek Ste 2 Salt Lake City UT. 84117 1208 E 3300 S Counseling Salt Lake City UT. 84123 p 801.872.5516 Salt Lake City UT. 84106 7321 S State St p 385.495.2705 p 801.369.8989 Ste A Doulis, Anastasia E LPC Midvale UT. 84047 Dastrup, Karen L LMFT Life Stone Group LLC 154 E Myrtle Ave p 801.878.4327 Valley Behavioral Health 613 E Fort Union Blvd Ste 204 12427 S Pasture Rd Ste 104 Murray UT. 84107 Faler, Pamela K Ste 104 Midvale UT. 84047 p 801.369.8989 2382 E Summerspring Ln Riverton UT. 84096 p 801.980.7222 Salt Lake City UT. 84124 p 888.949.4864 721 E 12200 S p 801.273.7480 Dow, Reed CMHC Draper UT. 84020 4460 S Highland Dr Ascendant Behavioral p 801.369.8989 Farnsworth, Jarom ACMHC Ste 300 Health Valley Behavioral Health Salt Lake City UT. 84124 5383 S 900 E Embrace Counseling 1020 S Main St p 888.949.4864 Ste 103 7478 S Campus View Dr Ste 100 Salt Lake City UT. 84117 Ste 100 Salt Lake City UT. 84101 Davis, Amy O LPC p 801.872.5516 West Jordan UT. 84084 p 888.949.4864 Comprehensive p 801.441.2239 Psychological Services Sage Family Counseling Fast, Danielle CMHC 1208 E 3300 S 13552 S 110 W England, Kimberly CMHC Milestone Integrative Salt Lake City UT. 84106 Ste 204 Ascendant Behavioral Healing p 801.483.1600 Draper UT. 84020 Health 4578 S Highland Dr p 801.432.0883 5383 S 900 E Ste 320 Dawson-Lovess, S Collette Ste 103 Salt Lake City UT. 84117 CSW Duersch, Allison E LMFT Salt Lake City UT. 84117 p 801.505.9137 The Green House for Growth South Point Counseling p 801.872.5516 & Learning 1206 W S Jordan Pkwy Feller, Amy CMHC 1325 W S Jordan Pkwy Ste D England, Leon C LCSW Lotus Center Inc Ste 102 South Jordan UT. 84095 England Counseling 4376 S 700 E South Jordan UT. 84095 p 801.302.3801 Services Ste 200 p 801.208.8838 166 E 5900 S Salt Lake City UT. 84107 Durfey, Roger LMFT Ste B108 p 385.272.4292 DeBirk, Karen M LPC The OCD And Anxiety Salt Lake City UT. 84107 Mindful Living Counseling Treatment Center p 801.290.2471 Collective Recovery Center 9055 S 1300 E 11260 S River Height Dr 8029 S 700 E Sandy UT. 84094 South Jordan UT. 84095 Ete, Lani LPC Sandy UT. 84070 p 801.784.1415 p 801.298.2000 Professional Counsleing p 385.557.2183 Services Dickson, Jennifer N LCSW Ascendant Behavioral 3940 W 4100 S Fordham, Bruce K CMHC Valley Behavioral Health Health West Valley City UT. 84120 Valley Behavioral Health 1141 E 3900 S 5383 S 900 E p 801.706.4026 12427 S Pasture Rd Ste A-170 Ste 103 Ste 104 Salt Lake City UT. 84124 Salt Lake City UT. 84117 Evans, Cheryl D LPC Riverton UT. 84096 p 888.949.4864 p 801.872.5516 Valley Behavioral Health p 888.949.4864 1141 E 3900 S Disher, Lauren LMFT Earle, Jason CMHC Ste A220 4460 S Highland Dr Collective Recovery Center Aspen Ridge Counseling Salt Lake City UT. 84124 Ste 100 8029 S 700 E 3509 W 4700 S p 888.949.4864 Salt Lake City UT. 84124 Sandy UT. 84070 Salt Lake City UT. 84129 p 888.949.4864 p 385.557.2183 p 801.990.4300 Evans, Emily CMHC Jordan West Family Francom, Austin P APRN Dixon, Randal LMHC Eckerselll, William CMHC Counseling Summitt Clinical Services Ascendant Behavioral Ascendant Behavioral 9263 Redwood Rd Bldg 8 1151 E 3900 S Health Health West Jordan UT. 84088 Ste B-299 5383 S 900 E 5383 S 900 E p 801.566.0749 Salt Lake City UT. 84124 Ste 103 Ste 103 p 801.263.0717 Salt Lake City UT. 84117 Salt Lake City UT. 84117 p 801.872.5516 p 801.872.5516 152 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Summit Primary Care & Gardiner, Katherine LPC Gibson, Jacob PhD,LMFT Goss, Angela CSW Clinical Services The Childrens Center The Green House for Growth Utah Behavior Services 1561 W 7000 S 5242 S 4820 W & Learning 5558 S 1900 W Ste 200 Salt Lake City UT. 84118 1325 W S Jordan Pkwy Ste B West Jordan UT. 84084 p 801.966.4251 Ste 102 Taylorsville UT. 84118 p 801.263.0717 South Jordan UT. 84095 p 801.255.5131 Gardner, Noelle K LPC p 801.208.8838 Francom, Mark NP Riley Individual Family 6013 S Redwood Rd Summit Primary Care & and Marriage Counseling Gileno, Zaneta M LCSW Taylorsville UT. 84123 Clinical Services 873 Baxter Dr Bear Creek Counseling p 801.255.5131 1561 W 7000 S South Jordan UT. 84095 1227 W 9000 S Ste 200 p 801.657.0163 Ste H Gouveia, Joseph R LCMHC West Jordan UT. 84084 West Jordan UT. 84084 Valley Behavioral Health p 801.263.0717 Garduno, Crystal N LPC p 385.274.7119 2948 S Redwood Rd Psychiatric & Behavioral West Valley City UT. 84119 Frantz, Mayreann CMHC Solutions Gillespie, Amy LCSW p 888.949.4864 Turning Point Centers 1522 S 1100 E Life Stone Counseling 4141 South Highland Dr Salt Lake City UT. 84105 Center Grow, Taffy Jo (TJ) LPC Ste 202 p 801.467.1200 613 E Fort Union Blvd Holistic Elements Salt Lake City UT. 84124 Ste 104 835 E 4800 S p 801.576.0745 Garner, Timothy B LMFT Midvale UT. 84047 Ste 220 Valley Behavioral Health p 801.984.1717 Salt Lake City UT. 84107 8375 S 700 E 1141 E 3900 S p 801.262.5418 Sandy UT. 84070 Ste A220 Gjording, Angela LCMHC p 801.576.0745 Salt Lake City UT. 84124 Valley Behavioral Health Gudmundsson, Fridrik R p 888.949.4864 1228 E 900 S LCSW Franz, Megan A CMHC Salt Lake City UT. 84105 Valley Behavioral Health Sundance Behavioral Garvin, Bradley K CMHC p 888.949.4864 780 S Guardsman Way Resources Jordan West Family Salt Lake City UT. 84108 845 E 4800 S Counseling Glaitti, Stephanie A p 888.949.4864 Ste 200 9263 Redwood Rd Bldg 8 LCMHC Salt Lake City UT. 84107 West Jordan UT. 84088 The OCD And Anxiety Gulick, Regina CMHC p 801.264.9522 p 801.566.0749 Treatment Center Aspen Ridge Counseling 11260 S River Height Dr 411 W 7200 S Freitag, Malinda LCMHC Gedeon, Iberty LPC South Jordan UT. 84095 Ste 304 The Childrens Center Jordan West Family p 801.298.2000 Midvale UT. 84047 5242 S 4820 W Counseling p 801.990.4300 Salt Lake City UT. 84118 9263 Redwood Rd Bldg 8 Godwin, Susan M NP p 801.966.4251 Ste B Mountain Paths Counseling Gunsolley, Corey LCSW West Jordan UT. 84088 7069 S Highland Dr Aspen Ridge Counseling Froerer, Jared D LPC p 801.566.0749 Ste 100 Unit 6 2880 W 4700 S Froerer Counseling Salt Lake City UT. 84121 Ste G-1 Services Geisel, Allison CMHC p 801.214.1565 Salt Lake City UT. 84129 11075 S State St Valley Behavioral Health p 801.990.4300 Ste 35 1020 S Main St Golden, Tracy H CMHC Sandy UT. 84070 Ste 100 Compass Counseling and Hackett, Linda R LPC p 801.501.8444 Salt Lake City UT. 84101 Consulting Comprehensive p 888.949.4864 4000 S 700 E Psychological Services 1561 W 7000 S Ste 9 1208 E 3300 S Ste 200 Gezon, Amy CMHC Salt Lake City UT. 84107 Salt Lake City UT. 84106 West Jordan UT. 84084 Summit Community p 801.639.9544 p 801.843.1600 p 801.501.8444 Counseling 5689 S Redwood Rd Goldstein, Terri E LCMHC 3725 W 4100 S Hospital Affiliation Ste 27 Insights Counseling West Valley City UT. 84119 - Mountain West Medical Salt Lake City UT. 84123 9192 S 300 W p 801.965.3759 Center p 801.266.2485 Ste 31 Sandy UT. 84070 Haga, Sydney LCMHC Fullmer, Burton LPC 5991 S Redwood Rd p 801.979.0610 Aspen Ridge Counseling Alpine Center for Personal Salt Lake City UT. 84123 1561 W 7000 S Growth p 801.266.2485 Gordon-White, Janice G Ste 200 5689 S Redwood Rd CMHC West Jordan UT. 84084 Ste 30 Gibb, Amanda CMHC Valley Behavioral Health p 801.990.4300 Salt Lake City UT. 84123 The OCD And Anxiety 1020 S Main St p 801.268.1715 Treatment Center Ste 300 11260 S River Height Dr Salt Lake City UT. 84101 South Jordan UT. 84095 p 888.949.4864 p 801.298.2000

153 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Hales, Christopher S CMHC Harrison, Shannon 4460 S Highland Dr 5383 S 900 E Valley Behavioral Health The OCD And Anxiety Ste 300 Ste 103 550 W 700 S Treatment Center Salt Lake City UT. 84124 Salt Lake City UT. 84117 Salt Lake City UT. 84101 11260 S River Height Dr p 888.949.4864 p 801.872.5516 p 888.949.4864 South Jordan UT. 84095 p 801.298.2000 Hobby, Esperanza A LMFT Ingle, Howard G LPC Halvorson, Isabelle T LPC Valley Behavioral Health Comprehensive Matt Larson Psychotherapy Haymond, David C CMHC 12427 S Pasture Rd Psychological Services and Associates Valley Behavioral Health Ste 104 3725 W 4100 S 1226 A S Jordan Pkwy 1020 S Main St Riverton UT. 84096 West Valley City UT. 84119 South Jordan UT. 84095 Ste 300 p 888.949.4864 p 801.965.3759 p 801.671.7612 Salt Lake City UT. 84101 p 888.949.4864 4460 S Highland Dr Insights Counseling Hamilton, Qrystel LCMHC Ste 100 9192 S 300 W Valley Behavioral Health Heline, Branden H LMFT Salt Lake City UT. 84124 Ste 317A 1141 E 3900 S Sage Family Counseling p 888.949.4864 Sandy UT. 84070 Ste A170 13552 S 110 W p 801.979.0612 Salt Lake City UT. 84124 Ste 204 Holbrook, Julie K LMFT p 888.949.4864 Draper UT. 84020 South Point Counseling 9192 S 300 W p 801.432.0883 1206 W S Jordan Pkwy Ste 31 University Of Utah Health Ste D Sandy UT. 84070 525 E 100 S Hernandez, Cindy C LPC South Jordan UT. 84095 p 801.979.0610 Ste 5000 Comprehensive p 801.302.3801 Salt Lake City UT. 84102 Psychological Services Institute of Change p 801.585.1212 1208 E 3300 S Holzer, April LMFT 11190 S 958 E Salt Lake City UT. 84106 Matt Larson Psychotherapy Sandy UT. 84094 Hancock, Charrisse R p 801.483.1600 and Associates p 801.571.4565 The Utah House 1226 W 10600 S Bldg A 1370 S West Temple Aspire Psychological South Jordan UT. 84095 Jacobson, Sheila CSW Salt Lake City UT. 84115 885 W Baxter Dr p 801.521.0699 Aspen Ridge Counseling p 801.678.3317 South Jordan UT. 84095 11075 S State St p 385.202.6113 24 S 600 E Ste 35 Embrace Counseling Ste 6 Sandy UT. 84070 7478 S Campus View Dr Hernandez, June Lee CMHC Salt Lake City UT. 84102 p 801.501.8444 Ste 100 Valley Behavioral Health p 801.521.0699 West Jordan UT. 84084 12427 S Pasture Rd Jardine-Tucker, Julie Ann p 801.441.2239 Ste 104 Hughes, Beth LMFT LCMHC Riverton UT. 84096 3320 S Old Millbrook Cir Insights Counseling Hancock, Lacey LMHC p 888.949.4864 Salt Lake City UT. 84115 9192 S 300 W Valley Behavioral Health p 801.266.7435 Ste 317A 12427 S Pasture Rd 4460 S Highland Dr Sandy UT. 84070 Ste 104 Ste 100 Huhnke, Leah K LMFT p 801.979.0612 Riverton UT. 84096 Salt Lake City UT. 84124 Summit Community p 888.949.4864 p 888.949.4864 Counseling 9192 S 300 W 5689 S Redwood Rd Ste 31 4460 S Highland Dr Hicks, Robert CMHC Ste 27 Sandy UT. 84070 Ste 100 On Call Doc Salt Lake City UT. 84123 p 801.979.0610 Salt Lake City UT. 84124 10437 S Jordan Gateway p 801.266.2485 p 888.949.4864 South Jordan UT. 84095 Jensen, David W LPC p 801.610.9159 5991 S Redwood Rd Riley Individual Family Life Stone Counseling Salt Lake City UT. 84123 and Marriage Counseling Center Higley, Aaron J CMHC p 801.266.2485 873 Baxter Dr 613 E Fort Union Blvd Valley Behavioral Health South Jordan UT. 84095 Ste 104 1020 S Main St Hurzeler, Kimberly CMHC p 801.657.0163 Midvale UT. 84047 Ste 200 Alpine Center for Personal p 801.984.1717 Salt Lake City UT. 84101 Growth Jensen, Tara L LPC p 888.949.4864 5689 S Redwood Rd Sundance Behavioral Hardman, Jesse R CMHC Ste 30 Resources Valley Behavioral Health Hinkle, Angela L LMFT Salt Lake City UT. 84123 845 E 4800 S 1020 S Main St Valley Behavioral Health p 801.268.1715 Ste 200 Ste 100 12427 S Pasture Rd Salt Lake City UT. 84107 Salt Lake City UT. 84101 Ste 104 Hutchinson, Mark p 801.264.9522 p 888.949.4864 Herriman UT. 84096 Ascendant Behavioral p 888.949.4864 Health 4179 Riverboat Rd Ste 220 Salt Lake City UT. 84123 p 801.872.5516 154 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Johnson-Waddell, Delsa PCH RESIDENTIAL TRMNT-ADOLLake, Lorri CMHC Jordan Valley Internal LPC 5770 S 1500 W MInd Body & Spirit Medicine Summit Community Taylorsville UT. 84123 Counseling 3570 W 9000 S Counseling p 801.313.7940 5801 S Fashion Blvd Ste 100 5689 S Redwood Rd Ste 200 West Jordan UT. 84088 Ste 27 Kimberlin-Flanders, Salt Lake City UT. 84107 p 801.569.2384 Salt Lake City UT. 84123 Cynthia LPC p 801.920.3490 p 801.266.2485 Sundance Behavioral Adult Behavioral Health Resources Lange, Christopher CMHC JVMC-WVC - OP 5991 S Redwood Rd 845 E 4800 S Valley Behavioral Health 4052 W Pioneer Pkwy Salt Lake City UT. 84123 Ste 200 1020 S Main St Ste 105 p 801.266.2485 Murray UT. 84107 Ste 100 Salt Lake City UT. 84120 p 801.264.9522 Salt Lake City UT. 84101 p 801.554.3420 Jones, Kristin LPC p 888.949.4864 684 E Vine St King, Kelsey LCSW Hospital Affiliation Ste 4A Utah Behavior Services Larrabee, Angelique R - Mountain West Medical Murray UT. 84107 5558 S 1900 W CMHC Center p 801.380.3846 Ste B Valley Behavioral Health Taylorsville UT. 84118 12427 S Pasture Rd Lemmon, Kristie APRN Judson, Ryan CMHC p 801.255.5131 Ste 104 Journeys Mental Health Ascendant Behavioral Riverton UT. 84096 Services Health 6013 S Redwood Rd p 888.949.4864 9253 S Redwood Rd 5383 S 900 E Taylorsville UT. 84123 Ste B Ste 103 p 801.255.5131 4460 S Highland Dr West Jordan UT. 84088 Salt Lake City UT. 84117 Ste 100 p 801.568.2898 p 801.872.5516 *Kingston, Merrill D PhD Salt Lake City UT. 84124 Primary Childrens Hospital p 888.949.4864 Levstek Caplin, Deirdre A Jurgela, Alycia LPC 5770 S 1500 W PhD The Utah House Taylorsville UT. 84123 Larsen, Danette CMHC University of Utah Health 1370 S West Temple p 801.313.7770 Life Stone Counseling 100 N Mario Capecchi Dr Salt Lake City UT. 84115 Center Salt Lake City UT. 84113 p 801.678.3317 Hospital Affiliation 613 E Fort Union Blvd p 801.313.7711 - Primary Childrens Hospital Ste 104 Kaloudis, Kathleen M CMHC Midvale UT. 84047 50 N Medical Dr 9190 S Highland Dr Kirschner, Rebecca CMHC p 801.984.1717 Salt Lake City UT. 84132 Ste 210 Valley Behavioral Health p 801.581.2205 Salt Lake City UT. 84124 12427 S Pasture Rd Larsen, Melissa L CMHC p 801.201.7050 Ste 104 Valley Behavioral Health 81 N Mario Capecchi Dr Riverton UT. 84096 12427 S Pasture Rd Salt Lake City UT. 84113 Kane, Christy P p 888.949.4864 Ste 104 p 801.213.3599 Comprehensive Riverton UT. 84096 Psychological Services 4460 S Highland Dr p 888.949.4864 Linda, Linda M ACMHC 1208 E 3300 S Ste 100 Valley Behavioral Health Salt Lake City UT. 84106 Salt Lake City UT. 84124 4460 S Highland Dr 2948 S Redwood Rd p 801.483.1600 p 888.949.4864 Ste 100 West Valley City UT. 84119 Salt Lake City UT. 84124 p 888.949.4864 Kasteler, Nicki C CMHC Kirschner, Richard D CMHC p 888.949.4864 Valley Behavioral Health Valley Behavioral Health Lineback, Holly H LPC 1141 E 3900 S 4460 S Highland Dr Laws, Rebecca B CMHC North Star Counseling Ste A170 Ste 100 Valley Behavioral Health 1104 Ashton Ave Salt Lake City UT. 84124 Salt Lake City UT. 84124 1020 S Main St Ste 103 p 888.949.4864 p 888.949.4864 Ste 100 Salt Lake City UT. 84106 Salt Lake City UT. 84101 p 801.436.6796 3809 W 6200 S Kistler, Romeo LPC p 888.949.4864 Taylorsville UT. 84129 11075 S State St Litchfield, Aubrey LPC p 888.949.4864 Ste 35 Le, Phuong LCSW Valley Behavioral Health Sandy UT. 84070 Adult Behavioral Health - 3809 W 6200 S PCH Residential Home p 801.717.7176 South Bangerter Salt Lake City UT. 84129 5770 S 1500 W Bldg C 13348 S Market Ctr Dr p 888.949.4864 Taylorsville UT. 84123 Kronmiller, Kalli CMHC Ste 220 p 801.313.7954 Valley Behavioral Health Riverton UT. 84065 Livingston, Derek CMHC 195 W 7200 S p 801.964.3111 Aspen Ridge Counseling Midvale UT. 84047 11075 S State St p 888.949.4864 Ste 33 Sandy UT. 84070 p 801.501.8444

155 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Lofthouse, Chelsea ACMHC Macfarlane, JeNae CMHC May, Katherine M LCSW 4460 S Highland Dr Utah Behavior Services Next Level Recovery Compass Counseling and Ste 100 5558 S 1900 W 6771 S 900 E Consulting Salt Lake City UT. 84124 Ste B Midvale UT. 84047 4000 S 700 E p 888.949.4864 Salt Lake City UT. 84129 p 801.386.9799 Ste 9 p 801.255.5131 Salt Lake City UT. 84107 Mcguinness, D P CMHC Madsen, Curtis R CMHC p 801.639.9544 Valley Behavioral Health 6013 S Redwood Rd Valley Behavioral Health 2472 S 300 E Salt Lake City UT. 84123 1020 S Main St McConnell, Scott CMHC Salt Lake City UT. 84115 p 801.255.5131 Ste 100 The Green House for Growth p 888.949.4864 Salt Lake City UT. 84101 & Learning Lovelace, Scott LCMHC p 888.949.4864 1325 W S Jordan Pkwy Michaels, Gary CMHC Utah Behavior Services Ste 102 Jordan West Family 5558 S 1900 W Madsen, Denise CMHC South Jordan UT. 84095 Counseling Ste B Jordan West Family p 801.208.8838 9263 Redwood Rd Bldg 8 Salt Lake City UT. 84129 Counseling Ste B p 801.255.5131 9263 Redwood Rd Bldg 8 McCoy, Margaret APRN West Jordan UT. 84088 West Jordan UT. 84088 Sundance Behavioral p 801.566.0749 6013 S Redwood Rd p 801.566.0749 Resources Salt Lake City UT. 84123 845 E 4800 S Miller, Robert LPC p 801.255.5131 Malmberg, Jan M LPC Ste 200 Ascendant Behavioral 7321 S State St Salt Lake City UT. 84107 Health Lowry, Michael R MD Ste A&B p 801.264.9522 5383 S 900 E University of Utah Health Midvale UT. 84047 Ste 103 1280 E Stringham Ave p 801.859.3523 McDonald, Jenna CSW Salt Lake City UT. 84117 Salt Lake City UT. 84106 Summit Community p 801.872.5516 p 801.581.7951 Maloof, Paula L LCSW Counseling Paula L Maloof LCSW Inc 5689 S Redwood Rd Mitchell, Loren CMHC 1950 Cir of Hope Dr 1399 S 700 E Ste 27 Sundance Behavioral Salt Lake City UT. 84112 Ste 17 Salt Lake City UT. 84123 Resources p 801.583.2500 Salt Lake City UT. 84105 p 801.266.2485 845 E 4800 S p 801.485.7441 Ste 200 50 N Medical Dr 5991 S Redwood Rd Murray UT. 84107 Salt Lake City UT. 84132 March, John T CMHC Salt Lake City UT. 84123 p 801.264.9522 p 801.585.1575 Valley Behavioral Health p 801.266.2485 1020 S Main St Mitchell, Merikay CMHC 501 S Chipeta Way Ste 100 McDonald, Tyler CMHC Merikay Mitchell LLC Salt Lake City UT. 84108 Salt Lake City UT. 84101 Valley Behavioral Health 2225 E Murray Holladay Rd p 801.587.3287 p 888.949.4864 280 E 600 S Ste 108 Salt Lake City UT. 84111 Salt Lake City UT. 84117 Lowry, Suzanne CMHC 1020 S Main St p 888.949.4864 p 385.313.0571 South Point Counseling Ste 300 1206 W S Jordan Pkwy Salt Lake City UT. 84101 McNaught, Jennifer A LPC Ascendant Behavioral Ste D p 888.949.4864 9980 S 300 W Health South Jordan UT. 84095 Ste 200 5383 S 900 E p 801.302.3801 195 W 7200 S Sandy UT. 84070 Ste 103 Midvale UT. 84047 p 801.706.9272 Salt Lake City UT. 84117 Lublin, Kristine Louise p 888.949.4864 p 801.872.5516 LPC McStotts, Kelli CMHC Valley Behavioral Health 550 W 700 S Summit Community Morphet, Cari Y CMHC 1141 E 3900 S Salt Lake City UT. 84101 Counseling Caring Journey Counseling Ste A250 p 888.949.4864 5689 S Redwood Rd 151 E 6100 S Salt Lake City UT. 84124 Ste 27 Ste 315 p 888.949.4864 Martin, Ann LPC Salt Lake City UT. 84123 Salt Lake City UT. 84107 Comprehensive p 801.266.2485 p 801.747.1754 3809 W 6200 S Psychological Services Taylorsville UT. 84129 1208 E 3300 S 5991 S Redwood Rd Morstein, Jodi APRN p 888.949.4864 Salt Lake City UT. 84106 Salt Lake City UT. 84123 University of Utah Health p 801.483.1600 p 801.266.2485 1578 W 1700 S Lund, Lori LMFT Salt Lake City UT. 84104 Ascendant Behavioral Mathis, Nicholas CMHC Mccune, Tara J CMHC p 801.581.4014 Health Neurobehavioral Center For Valley Behavioral Health 5383 S 900 E Growth 12427 S Pasture Rd Ste 103 370 E S Temple Ste 104 Salt Lake City UT. 84117 Ste 175 Riverton UT. 84096 p 801.872.5516 Salt Lake City UT. 84111 p 888.949.4864 p 801.683.1062

156 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 50 N Medical Dr Nuttall, Marie LPC Prescott, Ashley LCMHC Redd, Karen CMHC Salt Lake City UT. 84132 Ascendant Behavioral Aspen Ridge Counseling Center for Anxiety & PTSD p 801.581.4014 Health 2711 S 8500 W 1174 E Graystone Way 5383 S 900 E Magna UT. 84044 Ste 111 5126 W Daybreak Pkwy Ste 103 p 801.990.4300 Salt Lake City UT. 84106 South Jordan UT. 84009 Salt Lake City UT. 84117 p 801.856.3142 p 801.213.4500 p 801.872.5516 Price, Donald A LMFT Millbrook Counseling 4609 S 2300 E PCH Residential Home Osborne, Jane LPC 2118 E 3900 S Ste 107 5770 S 1500 W Bldg C Comprehensive Ste 100 Salt Lake City UT. 84124 Taylorsville UT. 84123 Psychological Services Salt Lake City UT. 84124 p 801.856.3142 p 801.313.7954 1208 E 3300 S p 801.277.3620 Salt Lake City UT. 84106 Rich, Stacey Primary Childrens Hospital p 801.483.1600 Proctor, Lyndsey D LCSW Mountain Paths Counseling 5770 S 1500 W Serenity Recovery and 7069 S Highland Dr Taylorsville UT. 84123 Oxborrow, Jennifer L LCSW Wellness Ste 100 p 801.313.7770 Lotus Center Inc 12447 S Crossing Dr Salt Lake City UT. 84121 4376 S 700 E Ste 13 p 801.214.1565 Hospital Affiliation Ste 200 Herriman UT. 84096 - University of Utah Hospital Salt Lake City UT. 84107 p 801.984.0184 Ridge, Brook CMHC p 385.272.4292 University Of Utah Health Moss, Terri LMFT Quinlan, Katherine B CMHC 501 S Chipeta Way Ascendant Behavioral Packer, Candice CSW Valley Behavioral Health Salt Lake City UT. 84108 Health The Green House for Growth 1141 E 3900 S p 801.583.2500 5383 S 900 E & Learning Ste A250 Ste 103 1325 W S Jordan Pkwy Salt Lake City UT. 84124 Hospital Affiliation Salt Lake City UT. 84117 Ste 102 p 888.949.4864 - University of Utah Hospital p 801.872.5516 South Jordan UT. 84095 p 801.208.8838 Ramos, Irma E LCMHC Ringold, Patricia LPC Moyes, Michelle CMHC Multicultural Counseling Ascendant Behavioral Valley Behavioral Health Pallos, Petra LPC Center Health 3809 W 6200 S Ascendant Behavioral 7625 S 3200 W 5383 S 900 E Taylorsville UT. 84129 Health Ste 2 Ste 103 p 888.949.4864 5383 S 900 E West Jordan UT. 84084 Salt Lake City UT. 84117 Ste 103 p 801.915.0359 p 801.872.5516 Multicultural Counseling Salt Lake City UT. 84117 Center p 801.872.5516 Ramos, Rachel MSW,CSW Rogers, Christina M LSUDC 7625 S 3200 W Summit Community Valley Behavioral Health Ste 2 Potts, Justin PSYD Counseling 3809 W 6200 S West Jordan UT. 84084 Summit Community 5689 S Redwood Rd Taylorsville UT. 84129 p 801.915.0359 Counseling Ste 27 p 888.949.4864 4991 S Commerce Dr Salt Lake City UT. 84123 Murdock, Brian B LPC Salt Lake City UT. 84117 p 801.266.2485 Russell, Laura CMHC Redwood Therapy Group p 801.266.2485 Comprehensive 8541 S Redwood Rd 5991 S Redwood Rd Psychological Services Ste C 5689 S Redwood Rd Salt Lake City UT. 84123 1208 E 3300 S West Jordan UT. 84088 Ste 27 p 801.266.2485 Salt Lake City UT. 84106 p 801.878.4220 Salt Lake City UT. 84123 p 801.483.1600 p 801.266.2485 Ranks, Georgann LPC Nielsen, Mandy J CMHC Ascendant Behavioral Russett, Ebbie I CMHC Mountain Paths Counseling Pratt, Nancy CMHC Health Valley Behavioral Health 7069 S Highland Dr Valley Behavioral Health 5383 S 900 E 12427 S Pasture Rd Ste 100 Unit 6 1141 E 3900 S Ste 103 Ste 104 Salt Lake City UT. 84121 Ste A170 Salt Lake City UT. 84117 Herriman UT. 84096 p 801.214.1565 Salt Lake City UT. 84124 p 801.872.5516 p 888.949.4864 p 888.949.4864 Niwa, Kathleen S CMHC Rathofer, David LMFT 4460 S Highland Dr Valley Behavioral Health The Childrens Center Jordan West Family Ste 100 195 W 7200 S 350 S 400 E Counseling Salt Lake City UT. 84124 Midvale UT. 84047 Salt Lake City UT. 84111 9263 Redwood Rd Bldg 8 p 888.949.4864 p 888.949.4864 p 801.582.5534 Ste B West Jordan UT. 84088 Sainsbury, Stacy LMFT p 801.523.5206 The Childrens Center 350 S 400 E Salt Lake City UT. 84111 p 801.582.5534

157 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 5242 S 4820 W Sellers, Jamie L LPC Skon, L Evelyn E LMFT 5991 S Redwood Rd Salt Lake City UT. 84118 The Childrens Center Family Counseling Center Salt Lake City UT. 84123 p 801.966.4251 5242 S 4820 W 650 E 4500 S p 801.266.2485 Salt Lake City UT. 84118 Ste 300 Salsberry, Maria CSW p 801.966.4251 Murray UT. 84107 925 E Executive Park Dr Utah Behavior Services p 801.261.3500 Ste B 5558 S 1900 W Seng, Alexandra L ACMHC Salt Lake City UT. 84107 Ste B Valley Behavioral Health Smith, Cielle LCMHC p 801.580.3837 Taylorsville UT. 84118 1020 S Main St Aspen Ridge Counseling p 801.255.5131 Ste 100 411 W 7200 S Sommers, Jania LCSW Salt Lake City UT. 84101 Ste 304 223 S 700 E 6013 S Redwood Rd p 888.949.4864 Midvale UT. 84047 Salt Lake City UT. 84102 Taylorsville UT. 84123 p 801.990.4300 p 385.282.8065 p 801.255.5131 3809 W 6200 S Taylorsville UT. 84129 Smith, Deanna LCSW South Point Counseling Scheffres, Jonathon B LPC p 888.949.4864 Center for Growth 1206 W S Jordan Pkwy 311 S 900 E 5411 S Vine St Ste D Ste 101A Serenity Recovery and Ste 6 South Jordan UT. 84095 Salt Lake City UT. 84102 Wellness Salt Lake City UT. 84107 p 801.302.3801 p 801.633.3908 12447 S Crossing Dr p 435.625.1717 Ste 13 The Utah House *Schindler, Sheryl CMHC Herriman UT. 84096 Smith, Tamatha CMHC 1370 S West Temple PCH CHILD PSYCH-OP p 801.984.0184 Summit Community Salt Lake City UT. 84115 5770 S 1500 W Counseling p 801.678.3317 TAYLORSVILLE UT. 84123 Sessions, Janet R LMFT 5689 S Redwood Rd p 801.313.7770 Janet R Sessions LMFT Ste 27 Stambaugh, Leigh Ann 4055 S 700 E Salt Lake City UT. 84123 CMHC Hospital Affiliation Ste 102 p 801.266.2485 Ascendant Behavioral - Primary Childrens Hospital Salt Lake City UT. 84105 Health p 385.743.1064 5991 S Redwood Rd 5383 S 900 E Schuler, Rebekah L CMHC Salt Lake City UT. 84123 Ste 103 The Utah House New Pathways Recovery and p 801.266.2485 Salt Lake City UT. 84117 1370 S West Temple Wellness p 801.872.5516 Salt Lake City UT. 84115 435 W 400 S Smolka, Mindy CMHC p 801.678.3317 Ste 101 Compass Counseling and Stark, Robert CMHC Salt Lake City UT. 84101 Consulting Valley Behavioral Health Sears, Wayne R CMHC p 801.722.5602 4000 S 700 E 1020 S Main St Life Stone Counseling Ste 9 Ste 200 Center Shields, Andrea LMFT Salt Lake City UT. 84107 Salt Lake City UT. 84101 613 E Fort Union Blvd 4516 S 700 E p 801.639.9544 p 888.949.4864 Ste 104 Ste 180 Midvale UT. 84047 Salt Lake City UT. 84107 Snow, Marie LPC Stasiuk, John A LMFT p 801.984.1717 p 801.824.2862 Jordan West Family Valley Behavioral Health Counseling 2948 S Redwood Rd Seashore, Karl E LPC Simpson, Clifford CMHC 9263 B Redwood Rd West Valley City UT. 84119 4190 S Highland Dr Summit Community West Jordan UT. 84088 p 888.949.4864 Ste 211 Counseling p 801.566.0749 Salt Lake City UT. 84124 5689 S Redwood Rd Utah Behavior Services p 801.272.0613 Ste 27 Snyder, Melissa LCSW 5558 S 1900 W Salt Lake City UT. 84123 Crystal Counseling Ste B Hospital Affiliation p 801.266.2485 151 E 5600 S Salt Lake City UT. 84129 - Mountain West Medical Ste 208 p 801.255.5131 Center 5991 S Redwood Rd Salt Lake City UT. 84107 Salt Lake City UT. 84123 p 801.633.5173 6013 S Redwood Rd Seiler, Edward A CMHC p 801.266.2485 Salt Lake City UT. 84123 Valley Behavioral Health Solomon, Kimberly A LCSW p 801.255.5131 12427 S Pasture Rd *Sinclair, Andrea CMHC Summit Community Ste 104 PCH CHILD PSYCH-OP Counseling Steans, Tammy LPC Herriman UT. 84096 5770 S 1500 W 5689 S Redwood Rd Psychiatric & Behavioral p 888.949.4864 Taylorsville UT. 84123 Ste 27 Solutions p 801.313.7770 Salt Lake City UT. 84123 1522 S 1100 E 4460 S Highland Dr p 801.266.2485 Salt Lake City UT. 84105 Ste 300 Hospital Affiliation p 801.467.1200 Salt Lake City UT. 84124 - Primary Childrens Hospital p 888.949.4864

158 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Stephenson, Sue A CMHC Collective Recovery Center Vicario, Matthew J LPC Walker, David R CMHC Ascendant Behavioral 8029 S 700 E 5691 S Redwood Rd Valley Behavioral Health Health Sandy UT. 84070 Ste 15 12427 S Pasture Rd 5383 S 900 E p 385.557.2183 Salt Lake City UT. 84123 Ste 104 Ste 103 p 801.946.2323 Riverton UT. 84096 Salt Lake City UT. 84117 Tucker, Dennis A LCSW p 888.949.4864 p 801.872.5516 Insights Counseling 8728 S 120 E 9192 S 300 W Sandy UT. 84070 4460 S Highland Dr Stout, Julie A LMFT Ste 317A p 801.946.2323 Ste 100 5667 S Redwood Rd Unit 5B Sandy UT. 84070 Salt Lake City UT. 84124 Taylorsville UT. 84123 p 801.979.0612 Visker, James K ANP p 888.949.4864 p 801.699.4149 White Tree Medical 9192 S 300 W Consultants LLC Walls, Sharon LMFT Summit Primary Care & Ste 31 10437 S Jordan Gateway Ascendant Behavioral Clinical Services Sandy UT. 84070 South Jordan UT. 84095 Health 1561 W 7000 S p 801.979.0610 p 385.535.6996 5383 S 900 E Ste 200 Ste 103 West Jordan UT. 84084 Turner, Meredith CSW Volkman, Sage CMHC Salt Lake City UT. 84117 p 801.263.0717 The Utah House Sage Wellness and p 801.872.5516 1370 S West Temple Counseling Szykula, Gail T LPC Salt Lake City UT. 84115 12884 S Frontrunner Blvd Wasatch Psychological Advanced Behavioral Care p 801.678.3317 Ste 140 Services 1545 E 3300 S Draper UT. 84020 1060 E 100 S Salt Lake City UT. 84106 Utah Autism Academy p 844.724.3935 Ste 100 p 801.478.2780 7434 S State St Salt Lake City UT. 84102 Midvale UT. 84047 Vonk, Vivian L CMHC p 801.590.0525 Talmadge, Tierney LCMHC p 801.456.9955 Early Life Child Next Level Recovery Psychology & Education Waugaman, Laura CMHC 6771 S 900 E Valley Behavioral Health Center Summit Community Midvale UT. 84047 Phone Number Only 10757 S River Front Pkwy Counseling p 801.386.9799 Salt Lake City UT. 84121 Ste 275 5689 S Redwood Rd p 888.949.4864 South Jordan UT. 84095 Ste 27 Thompson, Michael S LMFT p 385.900.4020 Salt Lake City UT. 84123 Valley Behavioral Health VandeMerwe, Leslie A CMHC p 801.266.2485 12427 S Pasture Rd Jordan West Family 12397 S 300 E Ste 104 Counseling Ste 100 5991 S Redwood Rd Herriman UT. 84096 9263 Redwood Rd Bldg 8 Draper UT. 84020 Salt Lake City UT. 84123 p 888.949.4864 Ste B p 385.900.4020 p 801.266.2485 West Jordan UT. 84088 4460 S Highland Dr p 801.523.5206 Ascendant Behavioral Webster, Peggy CMHC Ste 100 Health Ascendant Behavioral Salt Lake City UT. 84124 Vanengelenhoven, Jennifer 5383 S 900 E Health p 888.949.4864 LMFT Ste 103 5383 S 900 E Valley Behavioral Health Salt Lake City UT. 84117 Ste 103 *Thorn, Brian L PhD 4460 S Highland Dr p 801.872.5516 Salt Lake City UT. 84117 Primary Childrens Hospital Ste 100 p 801.872.5516 81 N Mario Capecchi Dr Salt Lake City UT. 84124 Wadleigh, Thomas LPC Salt Lake City UT. 84113 p 888.949.4864 Healing Vistas, LLC Weeks, Deanna p 801.662.3606 151 E 5600 S The OCD And Anxiety Varco, Tammy L CMHC Ste 302 Treatment Center Todd, Jessica J CMHC Valley Behavioral Health Salt Lake City UT. 84107 11260 S River Height Dr Neurobehavioral Center for 1020 S Main St p 801.865.6122 South Jordan UT. 84095 Growth Ste 100 p 801.298.2000 370 E South Temple Salt Lake City UT. 84101 Waite, Laura LMFT Ste 175 p 888.949.4864 The OCD And Anxiety Whitaker, David H PSYD Salt Lake City UT. 84111 Treatment Center David H Whitaker PsyD CMHC p 801.683.1062 Jordan West Family 11260 S River Height Dr 825 E 4800 S Counseling South Jordan UT. 84095 Ste 250C Tracy, Robin CMHC 9263 Redwood Rd Bldg 8 p 801.298.2000 Salt Lake City UT. 84107 Aspen Ridge Counseling West Jordan UT. 84088 p 801.657.5883 2880 W 4700 S p 801.566.0749 Waite, N John Evan CMHC Ste G-1 Jordan West Family 9001 S 3200 W Salt Lake City UT. 84129 Counseling West Jordan UT. 84088 p 801.990.4300 9263 Redwood Rd Bldg 8 p 801.657.5883 Ste B West Jordan UT. 84088 p 801.566.0749

159 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Wilson, Dodiann R CMHC Ybarra, Corylyn L CMHC 7495 S State St 7495 S State St SunDance Behavioral Valley Behavioral Health Midvale UT. 84047 Midvale UT. 84047 Resources 12427 S Pasture Rd p 801.213.9530 p 801.213.9530 845 E 4800 S Ste 104 Ste 200 Riverton UT. 84096 Hospital Affiliation Bingham, Tab P DDS Salt Lake City UT. 84107 p 888.949.4864 - University of Utah Hospital University of Utah Health p 801.264.9522 3690 S Main St 4460 S Highland Dr Aoki, Alan DDS Salt Lake City UT. 84115 Winward, Karen LPC Ste 100 Community Health Centers p 801.587.2525 Valley Behavioral Health Salt Lake City UT. 84124 610 S 200 E 12427 S Pasture Rd p 888.949.4864 Ste B 50 N Medical Dr Clinic 7 Ste 104 Salt Lake City UT. 84111 Salt Lake City UT. 84132 Riverton UT. 84096 Yeaman, Candice CMHC p 801.235.9835 p 801.581.2220 p 888.949.4864 Early Life Child Psychology & Education Aste, Leonard R DDS 530 S Wakara Way Wirthlin, Lora LCMHC Center University of Utah Health Salt Lake City UT. 84108 Aspen Ridge Counseling 12397 S 300 E 3690 S Main St p 801.587.6453 2880 W 4700 S Ste 100 Salt Lake City UT. 84115 Ste G-1 Draper UT. 84020 p 801.587.2525 7495 S State St Salt Lake City UT. 84129 p 385.900.4020 Midvale UT. 84047 p 801.990.4300 50 N Medical Dr Clinic 7 p 801.213.9530 Zeuschner, Jennifer CMHC Salt Lake City UT. 84132 Woodard, Jeness L LCSW Early Life Child p 801.581.2220 Hospital Affiliation University of Utah Health Psychology & Education - University of Utah Hospital 1280 E Stringham Ave Center 530 S Wakara Way Salt Lake City UT. 84106 10757 E River Front Pkwy Salt Lake City UT. 84108 Binns, Ralph DDS p 801.581.2000 Ste 275 p 801.587.6453 University of Utah Health South Jordan UT. 84095 3690 S Main St 1525 W 2100 S p 385.900.4020 7495 S State St Salt Lake City UT. 84115 Salt Lake City UT. 84119 Midvale UT. 84047 p 801.587.2525 p 801.213.9900 12397 S 300 E p 801.213.9530 Ste 100 50 N Medical Dr Clinic 7 3730 W 4700 S Draper UT. 84020 Hospital Affiliation Salt Lake City UT. 84132 Taylorsville UT. 84129 p 385.900.4020 - University of Utah Hospital p 801.581.2220 p 801.213.9200 Zimmerman, Rita M CMHC Bekker, James H DMD 530 S Wakara Way 5126 W Daybreak Pkwy Neurobehavioral Center for University of Utah Health Salt Lake City UT. 84108 Ste 600 Growth 1078 S 300 E p 801.587.6453 South Jordan UT. 84009 370 E South Temple Salt Lake City UT. 84111 p 801.213.4500 Ste 175 p 801.578.8180 7495 S State St Salt Lake City UT. 84111 Midvale UT. 84047 555 Foothill Dr p 801.683.1062 50 N Medical Dr Clinic 7 p 801.213.9530 Ste 301 Salt Lake City UT. 84132 Salt Lake City UT. 84112 da Silva, Laura CMHC p 801.581.2220 Boseman, Jody D DDS p 801.581.8000 Lighthouse Counseling University of Utah Health Services 530 S Wakara Way 50 N Medical Dr Clinic 7 7495 S State St 3409 W 12600 S Salt Lake City UT. 84108 Salt Lake City UT. 84132 Midvale UT. 84047 Ste 110 p 801.587.6453 p 801.581.2220 p 801.213.9400 Riverton UT. 84065 p 385.237.4943 7495 S State St 530 S Wakara Way Woolf, Paul L LPC Midvale UT. 84047 Salt Lake City UT. 84108 Summit Community Dentist p 801.213.9530 p 801.587.6453 Counseling Adams, David R DDS 5689 S Redwood Rd University of Utah Health Beyeler, Greg DDS 7495 S State St Ste 27 50 N Medical Dr Clinic 7 University of Utah Health Midvale UT. 84047 Salt Lake City UT. 84123 Salt Lake City UT. 84132 50 N Medical Dr Clinic 7 p 801.213.9530 p 801.266.2485 p 801.581.2220 Salt Lake City UT. 84132 p 801.581.2220 Hospital Affiliation 5991 S Redwood Rd 530 S Wakara Way - University of Utah Hospital Salt Lake City UT. 84123 Salt Lake City UT. 84108 530 S Wakara Way p 801.266.2485 p 801.587.6453 Salt Lake City UT. 84108 Boseman, John J DDS p 801.587.6453 University of Utah Health 50 N Medical Dr Clinic 7 Salt Lake City UT. 84132 p 801.581.2220

160 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 530 S Wakara Way 50 N Medical Dr Clinic 7 7495 S State St 7495 S State St Salt Lake City UT. 84108 Salt Lake City UT. 84132 Midvale UT. 84047 Midvale UT. 84047 p 801.587.6453 p 801.581.2220 p 801.213.9530 p 801.213.9530

7495 S State St 530 S Wakara Way Chandler, Nathan DDS Collman, Marc DDS Midvale UT. 84047 Salt Lake City UT. 84108 University of Utah Dental University of Utah Health p 801.213.9530 p 801.587.6453 Services 50 N Medical Dr Clinic 7 3690 S Main St Salt Lake City UT. 84132 Hospital Affiliation 7495 S State St Salt Lake City UT. 84115 p 801.581.2220 - University of Utah Hospital Midvale UT. 84047 p 801.587.2525 p 801.213.9530 530 S Wakara Way Bowen, Ronald DDS 50 N Medical Dr Clinic 7 Salt Lake City UT. 84108 University Of Utah Health Cahoon, Kevin DDS Salt Lake City UT. 84132 p 801.587.6453 1078 S 300 E University Of Utah Health p 801.581.2220 Salt Lake City UT. 84111 1078 S 300 E 7495 S State St p 801.578.8180 Salt Lake City UT. 84111 530 S Wakara Way Midvale UT. 84047 p 801.578.8180 Salt Lake City UT. 84108 p 801.213.9530 3491 W Wights Fort Rd 133 p 801.587.6453 West Jordan UT. 84088 3690 S Main St Cook, Justin DDS p 801.957.7522 Salt Lake City UT. 84115 7495 S State St University of Utah Dental p 801.587.2525 Midvale UT. 84047 Services 3690 S Main St p 801.213.9530 1078 S 300 E Salt Lake City UT. 84115 50 N Medical Dr Clinic 7 Salt Lake City UT. 84111 p 801.587.2525 Salt Lake City UT. 84132 Christensen, Mark L DDS p 801.578.8180 p 801.581.2220 University Of Utah Health 50 N Medical Dr Clinic 7 1078 S 300 E 3690 S Main St Salt Lake City UT. 84132 530 S Wakara Way Salt Lake City UT. 84111 Salt Lake City UT. 84115 p 801.581.2220 Salt Lake City UT. 84108 p 801.578.8180 p 801.587.2525 p 801.587.6453 530 S Wakara Way 3491 W Wights Fort Rd 133 50 N Medical Dr Clinic 7 Salt Lake City UT. 84108 Call, Nathan D DDS West Jordan UT. 84088 Salt Lake City UT. 84132 p 801.587.6453 University of Utah Dental p 801.957.7522 p 801.581.2220 Services 7495 S State St 1078 S 300 E 3690 S Main St 530 S Wakara Way Midvale UT. 84047 Salt Lake City UT. 84111 Salt Lake City UT. 84115 Salt Lake City UT. 84108 p 801.213.9530 p 801.578.8180 p 801.587.2525 p 801.587.6453

Broadbent, Jeffrey DMD 3690 S Main St 50 N Medical Dr Clinic 7 7495 S State St University of Utah Dental Salt Lake City UT. 84115 Salt Lake City UT. 84132 Midvale UT. 84047 Services p 801.587.2525 p 801.581.2220 p 801.213.9530 3690 S Main St Salt Lake City UT. 84115 50 N Medical Dr Clinic 7 530 S Wakara Way Denny, John M DDS p 801.587.2525 Salt Lake City UT. 84132 Salt Lake City UT. 84108 University of Utah Health p 801.581.2220 p 801.587.6453 50 N Medical Dr Clinic 7 50 N Medical Dr Clinic 7 Salt Lake City UT. 84132 Salt Lake City UT. 84132 530 S Wakara Way 7495 S State St p 801.581.2220 p 801.581.2220 Salt Lake City UT. 84108 Midvale UT. 84047 p 801.587.6453 p 801.213.9530 530 S Wakara Way 530 S Wakara Way Salt Lake City UT. 84108 Salt Lake City UT. 84108 7495 S State St Hospital Affiliation p 801.587.6453 p 801.587.6453 Midvale UT. 84047 - University of Utah Hospital p 801.213.9530 7495 S State St 7495 S State St Cold, Scott DDS Midvale UT. 84047 Midvale UT. 84047 Canfield, Steven M DDS University of Utah Health p 801.213.9530 p 801.213.9530 University of Utah Health 50 N Medical Dr Clinic 7 50 N Medical Dr Clinic 7 Salt Lake City UT. 84132 Hospital Affiliation Bullock, Jeri DMD Salt Lake City UT. 84132 p 801.581.2220 - University of Utah Hospital University of Utah Health p 801.581.2220 3690 S Main St 530 S Wakara Way Dickson, R Scott DDS Salt Lake City UT. 84115 530 S Wakara Way Salt Lake City UT. 84108 University of Utah Health p 801.587.2525 Salt Lake City UT. 84108 p 801.587.6453 50 N Medical Dr Clinic 7 p 801.587.6453 Salt Lake City UT. 84132 p 801.581.2220

161 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 530 S Wakara Way 530 S Wakara Way Iverson, Jeffrey A DMD 530 S Wakara Way Salt Lake City UT. 84108 Salt Lake City UT. 84108 University of Utah Health Salt Lake City UT. 84108 p 801.587.6453 p 801.587.6453 50 N Medical Dr Clinic 7 p 801.587.6453 Salt Lake City UT. 84132 7495 S State St 7495 S State St p 801.581.2220 7495 S State St Midvale UT. 84047 Midvale UT. 84047 Midvale UT. 84047 p 801.213.9530 p 801.213.9530 530 S Wakara Way p 801.213.9530 Salt Lake City UT. 84108 Durham, Mark R DMD Hospital Affiliation p 801.587.6453 Johnston, Thomas C DDS University of Utah Health - University of Utah Hospital University of Utah Health 50 N Medical Dr Clinic 7 7495 S State St 1078 S 300 E Salt Lake City UT. 84132 Ferrell, D T DDS Midvale UT. 84047 Salt Lake City UT. 84111 p 801.581.2220 University of Utah Health p 801.213.9530 p 801.578.8180 50 N Medical Dr Clinic 7 530 S Wakara Way Salt Lake City UT. 84132 Hospital Affiliation 3690 S Main St Salt Lake City UT. 84108 p 801.581.2220 - University of Utah Hospital Salt Lake City UT. 84115 p 801.587.6453 p 801.587.2525 530 S Wakara Way Jessop, Jaleena A DDS 7495 S State St Salt Lake City UT. 84108 University of Utah Health 50 N Medical Dr Clinic 7 Midvale UT. 84047 p 801.587.6453 50 N Medical Dr Clinic 7 Salt Lake City UT. 84132 p 801.213.9530 Salt Lake City UT. 84132 p 801.581.2220 7495 S State St p 801.581.2220 Hospital Affiliation Midvale UT. 84047 530 S Wakara Way - University of Utah Hospital p 801.213.9530 530 S Wakara Way Salt Lake City UT. 84108 Salt Lake City UT. 84108 p 801.587.6453 Egbert, Nicholas DDS Hospital Affiliation p 801.587.6453 University of Utah Health - University of Utah Hospital 7495 S State St 50 N Medical Dr Clinic 7 7495 S State St Midvale UT. 84047 Salt Lake City UT. 84132 Fessenden, Tami DDS Midvale UT. 84047 p 801.213.9530 p 801.581.2220 University of Utah Dental p 801.213.9530 Services Hospital Affiliation 530 S Wakara Way 3690 S Main St Hospital Affiliation - University of Utah Hospital Salt Lake City UT. 84108 Salt Lake City UT. 84115 - University of Utah Hospital p 801.587.6453 p 801.587.2525 Jones, Ryan DMD Johnson, David G DDS Community Health Centers 7495 S State St 50 N Medical Dr Clinic 7 University of Utah Health 1388 S Navajo St Midvale UT. 84047 Salt Lake City UT. 84132 1078 S 300 E Ste C p 801.213.9530 p 801.581.2220 Salt Lake City UT. 84111 Salt Lake City UT. 84104 p 801.578.8180 p 801.955.2360 Erickson, Lea W DDS 530 S Wakara Way University of Utah Health Salt Lake City UT. 84108 3690 S Main St 610 S 200 E 50 N Medical Dr Clinic 7 p 801.587.6453 Salt Lake City UT. 84115 Ste B Salt Lake City UT. 84132 p 801.587.2525 Salt Lake City UT. 84111 p 801.581.2220 7495 S State St p 801.235.9835 Midvale UT. 84047 50 N Medical Dr Clinic 7 530 S Wakara Way p 801.213.9530 Salt Lake City UT. 84132 Keddington, Ramah J DDS Salt Lake City UT. 84108 p 801.581.2220 University of Utah Health p 801.587.6453 Gerritsen, John A DDS 50 N Medical Dr Clinic 7 University of Utah Health 530 S Wakara Way Salt Lake City UT. 84132 7495 S State St 50 N Medical Dr Clinic 7 Salt Lake City UT. 84108 p 801.581.2220 Midvale UT. 84047 Salt Lake City UT. 84132 p 801.587.6453 p 801.213.9530 p 801.581.2220 530 S Wakara Way 7495 S State St Salt Lake City UT. 84108 Hospital Affiliation 530 S Wakara Way Midvale UT. 84047 p 801.587.6453 - University of Utah Hospital Salt Lake City UT. 84108 p 801.213.9530 p 801.587.6453 7495 S State St Evans, Lee C DMD Johnson, Randall DDS Midvale UT. 84047 University of Utah Health 7495 S State St University of Utah Health p 801.213.9530 50 N Medical Dr Clinic 7 Midvale UT. 84047 50 N Medical Dr Clinic 7 Salt Lake City UT. 84132 p 801.213.9530 Salt Lake City UT. 84132 Hospital Affiliation p 801.581.2220 p 801.581.2220 - University of Utah Hospital Hospital Affiliation - University of Utah Hospital

162 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Knudson, Peter C DDS 220 W 7200 S Linton, Dale R DDS Matsuura, Grant K DDS University of Utah Health Ste A University of Utah Health University of Utah Health 50 N Medical Dr Clinic 7 Midvale UT. 84047 50 N Medical Dr Clinic 7 3690 S Main St Salt Lake City UT. 84132 p 801.566.5494 Salt Lake City UT. 84132 Salt Lake City UT. 84115 p 801.581.2220 p 801.581.2220 p 801.587.2525 4535 S 5600 W 530 S Wakara Way West Valley City UT. 84120 530 S Wakara Way 50 N Medical Dr Clinic 7 Salt Lake City UT. 84108 p 801.676.4405 Salt Lake City UT. 84108 Salt Lake City UT. 84132 p 801.587.6453 p 801.587.6453 p 801.581.2220 4745 S 3200 W 7495 S State St Salt Lake City UT. 84129 7495 S State St 530 S Wakara Way Midvale UT. 84047 p 801.964.6214 Midvale UT. 84047 Salt Lake City UT. 84108 p 801.213.9530 p 801.213.9530 p 801.587.6453 610 S 200 E Hospital Affiliation Ste B Hospital Affiliation 7495 S State St - University of Utah Hospital Salt Lake City UT. 84111 - University of Utah Hospital Midvale UT. 84047 p 801.235.9835 p 801.213.9530 Larsen, Steven S DDS Lowder, Gary W DDS University of Utah Health Hospital Affiliation University of Utah Health Hospital Affiliation 50 N Medical Dr Clinic 7 - University of Utah Hospital 50 N Medical Dr Clinic 7 - University of Utah Hospital Salt Lake City UT. 84132 Salt Lake City UT. 84132 p 801.581.2220 Liddell, Thomas R DDS p 801.581.2220 Morris, Rosana T DDS University of Utah Health University of Utah Dental 530 S Wakara Way 50 N Medical Dr Clinic 7 530 S Wakara Way Services Salt Lake City UT. 84108 Salt Lake City UT. 84132 Salt Lake City UT. 84108 3690 S Main St p 801.587.6453 p 801.581.2220 p 801.587.6453 Salt Lake City UT. 84115 p 801.587.2525 7495 S State St 530 S Wakara Way 7495 S State St Midvale UT. 84047 Salt Lake City UT. 84108 Midvale UT. 84047 50 N Medical Dr Clinic 7 p 801.213.9530 p 801.587.6453 p 801.213.9530 Salt Lake City UT. 84132 p 801.581.2220 Hospital Affiliation 7495 S State St Hospital Affiliation - University of Utah Hospital Midvale UT. 84047 - University of Utah Hospital 530 S Wakara Way p 801.213.9530 Salt Lake City UT. 84108 Larson, William R DDS Mangelson, Mark L DDS p 801.587.6453 University of Utah Health Hospital Affiliation University of Utah Health 50 N Medical Dr Clinic 7 - University of Utah Hospital 50 N Medical Dr Clinic 7 7495 S State St Salt Lake City UT. 84132 Salt Lake City UT. 84132 Midvale UT. 84047 p 801.581.2220 Lieberman, Jay E DMD p 801.581.2220 p 801.213.9530 University of Utah Health 530 S Wakara Way 3690 S Main St 530 S Wakara Way Hospital Affiliation Salt Lake City UT. 84108 Salt Lake City UT. 84115 Salt Lake City UT. 84108 - University of Utah Hospital p 801.587.6453 p 801.587.2525 p 801.587.6453 Nicol, Kimberly H DMD 7495 S State St 50 N Medical Dr Clinic 7 7495 S State St University of Utah Dental Midvale UT. 84047 Salt Lake City UT. 84132 Midvale UT. 84047 Services p 801.213.9530 p 801.581.2220 p 801.213.9530 3690 S Main St Salt Lake City UT. 84115 Hospital Affiliation 530 S Wakara Way Hospital Affiliation p 801.587.2525 - University of Utah Hospital Salt Lake City UT. 84108 - University of Utah Hospital p 801.587.6453 50 N Medical Dr Clinic 7 Lauritzen, Christopher S Martinez, Richard DDS Salt Lake City UT. 84132 DDS 7495 S State St University of Utah Health p 801.581.2220 Community Health Centers Midvale UT. 84047 50 N Medical Dr Clinic 7 1365 W 1000 N p 801.213.9530 Salt Lake City UT. 84132 530 S Wakara Way Salt Lake City UT. 84116 p 801.581.2220 Salt Lake City UT. 84108 p 801.328.5756 Hospital Affiliation p 801.587.6453 - University of Utah Hospital 530 S Wakara Way 1388 S Navajo St Salt Lake City UT. 84108 7495 S State St Salt Lake City UT. 84104 Link, Devin DDS p 801.587.6453 Midvale UT. 84047 p 801.955.2360 Community Health Centers p 801.213.9530 1365 W 1000 N 7495 S State St Salt Lake City UT. 84116 Midvale UT. 84047 Hospital Affiliation p 801.328.5756 p 801.213.9530 - University of Utah Hospital

163 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Okano, David K DDS 7495 S State St University of Utah Dental Segura, Thomas R DDS University of Utah Health Midvale UT. 84047 Services University of Utah Health 50 N Medical Dr Clinic 7 p 801.213.9530 7495 S State St 3491 W Wights Fort Rd 133 Salt Lake City UT. 84132 Midvale UT. 84047 West Jordan UT. 84088 p 801.581.2220 Proctor, Craig R DDS p 801.213.9530 p 801.957.7522 University of Utah Health 530 S Wakara Way 50 N Medical Dr Clinic 7 Rich, John DDS 3690 S Main St Salt Lake City UT. 84108 Salt Lake City UT. 84132 University of Utah Dental Salt Lake City UT. 84115 p 801.587.6453 p 801.581.2220 Services p 801.587.2525 3690 S Main St 7495 S State St 530 S Wakara Way Salt Lake City UT. 84115 50 N Medical Dr Clinic 7 Midvale UT. 84047 Salt Lake City UT. 84108 p 801.587.2525 Salt Lake City UT. 84132 p 801.213.9530 p 801.587.6453 p 801.581.2220 50 N Medical Dr Clinic 7 Hospital Affiliation 7495 S State St Salt Lake City UT. 84132 530 S Wakara Way - University of Utah Hospital Midvale UT. 84047 p 801.581.2220 Salt Lake City UT. 84108 p 801.213.9530 p 801.587.6453 Okubo, Miranda DDS 530 S Wakara Way University of Utah Dental Rackham, Laurin G DMD Salt Lake City UT. 84108 7495 S State St Services University of Utah Health p 801.587.6453 Midvale UT. 84047 3690 S Main St 1078 S 300 E p 801.213.9530 Salt Lake City UT. 84115 Salt Lake City UT. 84111 7495 S State St p 801.587.2525 p 801.578.8180 Midvale UT. 84047 Hospital Affiliation p 801.213.9530 - University of Utah Hospital 50 N Medical Dr Clinic 7 3690 S Main St Salt Lake City UT. 84132 Salt Lake City UT. 84115 Richards, Robert S DDS Sergakis, William DDS p 801.581.2220 p 801.587.2525 University of Utah Health University of Utah Health 50 N Medical Dr Clinic 7 3690 S Main St 530 S Wakara Way 50 N Medical Dr Clinic 7 Salt Lake City UT. 84132 Salt Lake City UT. 84115 Salt Lake City UT. 84108 Salt Lake City UT. 84132 p 801.581.2220 p 801.587.2525 p 801.587.6453 p 801.581.2220 530 S Wakara Way 50 N Medical Dr Clinic 7 7495 S State St 530 S Wakara Way Salt Lake City UT. 84108 Salt Lake City UT. 84132 Midvale UT. 84047 Salt Lake City UT. 84108 p 801.587.6453 p 801.581.2220 p 801.213.9530 p 801.587.6453 7495 S State St 530 S Wakara Way Olson, Andrew C DDS 7495 S State St Midvale UT. 84047 Salt Lake City UT. 84108 University of Utah Health Midvale UT. 84047 p 801.213.9530 p 801.587.6453 50 N Medical Dr Clinic 7 p 801.213.9530 Salt Lake City UT. 84132 Hospital Affiliation 7495 S State St p 801.581.2220 Hospital Affiliation - University of Utah Hospital Midvale UT. 84047 - University of Utah Hospital p 801.213.9530 530 S Wakara Way Rogers, Marcy DDS Salt Lake City UT. 84108 Ramsdell, Christopher Community Health Centers Sharp, Holly D DDS p 801.587.6453 DDS 1388 S Navajo St University of Utah Health University of Utah Dental Ste C 1078 S 300 E 7495 S State St Services Salt Lake City UT. 84104 Salt Lake City UT. 84111 Midvale UT. 84047 3690 S Main St p 801.955.2360 p 801.578.8180 p 801.213.9530 Salt Lake City UT. 84115 p 801.587.2525 Rounds, Norman K DDS 3690 S Main St Hospital Affiliation University of Utah Health Salt Lake City UT. 84115 - University of Utah Hospital 50 N Medical Dr Clinic 7 50 N Medical Dr Clinic 7 p 801.587.2525 Salt Lake City UT. 84132 Salt Lake City UT. 84132 Pollock, Hal DDS p 801.581.2220 p 801.581.2220 50 N Medical Dr Clinic 7 University of Utah Health Salt Lake City UT. 84132 50 N Medical Dr Clinic 7 530 S Wakara Way 530 S Wakara Way p 801.581.2220 Salt Lake City UT. 84132 Salt Lake City UT. 84108 Salt Lake City UT. 84108 p 801.581.2220 p 801.587.6453 p 801.587.6453 530 S Wakara Way Salt Lake City UT. 84108 530 S Wakara Way Community Health Centers 7495 S State St p 801.587.6453 Salt Lake City UT. 84108 610 S 200 E Midvale UT. 84047 p 801.587.6453 Ste B p 801.213.9530 7495 S State St Salt Lake City UT. 84111 Midvale UT. 84047 p 801.235.9835 Hospital Affiliation p 801.213.9530 - University of Utah Hospital

164 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Shaw, Ronald K DDS 7495 S State St Stutznegger, Conrad W DDS Theurer, Jared M DDS University of Utah Health Midvale UT. 84047 University of Utah Health University of Utah Health 50 N Medical Dr Clinic 7 p 801.213.9530 1078 S 300 E 50 N Medical Dr Clinic 7 Salt Lake City UT. 84132 Salt Lake City UT. 84111 Salt Lake City UT. 84132 p 801.581.2220 Sorensen, Thomas C DDS p 801.578.8180 p 801.581.2220 University of Utah Health 530 S Wakara Way 1078 S 300 E 50 N Medical Dr Clinic 7 530 S Wakara Way Salt Lake City UT. 84108 Salt Lake City UT. 84111 Salt Lake City UT. 84132 Salt Lake City UT. 84108 p 801.587.6453 p 801.578.8180 p 801.581.2220 p 801.587.6453

7495 S State St 3690 S Main St 530 S Wakara Way 7495 S State St Midvale UT. 84047 Salt Lake City UT. 84115 Salt Lake City UT. 84108 Midvale UT. 84047 p 801.213.9530 p 801.587.2525 p 801.587.6453 p 801.213.9530

Hospital Affiliation 50 N Medical Dr Clinic 7 7495 S State St Hospital Affiliation - University of Utah Hospital Salt Lake City UT. 84132 Midvale UT. 84047 - University of Utah Hospital p 801.581.2220 p 801.213.9530 Smith, Michael G DDS Thomas, Allan S DMD University of Utah Health 530 S Wakara Way Hospital Affiliation University of Utah Health 1078 S 300 E Salt Lake City UT. 84108 - University of Utah Hospital 50 N Medical Dr Clinic 7 Salt Lake City UT. 84111 p 801.587.6453 Salt Lake City UT. 84132 p 801.578.8180 Swilling, Stacey E DDS p 801.581.2220 7495 S State St University of Utah Dental 3491 W Wights Fort Rd 133 Midvale UT. 84047 Services 530 S Wakara Way West Jordan UT. 84088 p 801.213.9530 1078 S 300 E Salt Lake City UT. 84108 p 801.957.7522 Salt Lake City UT. 84111 p 801.587.6453 Hospital Affiliation p 801.578.8180 3690 S Main St - University of Utah Hospital 7495 S State St Salt Lake City UT. 84115 3491 W Wights Fort Rd 133 Midvale UT. 84047 p 801.587.2525 Stark, Cory M DDS West Jordan UT. 84088 p 801.213.9530 University of Utah Health p 801.957.7522 50 N Medical Dr Clinic 7 50 N Medical Dr Clinic 7 Hospital Affiliation Salt Lake City UT. 84132 Salt Lake City UT. 84132 3690 S Main St - University of Utah Hospital p 801.581.2220 p 801.581.2220 Salt Lake City UT. 84115 p 801.587.2525 Thorell, Kenneth R DDS 530 S Wakara Way 530 S Wakara Way University of Utah Health Salt Lake City UT. 84108 Salt Lake City UT. 84108 50 N Medical Dr Clinic 7 3690 S Main St p 801.587.6453 p 801.587.6453 Salt Lake City UT. 84132 Salt Lake City UT. 84115 p 801.581.2220 p 801.587.2525 7495 S State St 7495 S State St Midvale UT. 84047 Midvale UT. 84047 530 S Wakara Way 50 N Medical Dr Clinic 7 p 801.213.9530 p 801.213.9530 Salt Lake City UT. 84108 Salt Lake City UT. 84132 p 801.587.6453 p 801.581.2220 Hospital Affiliation Hospital Affiliation - University of Utah Hospital - University of Utah Hospital 7495 S State St 530 S Wakara Way Midvale UT. 84047 Salt Lake City UT. 84108 Smith, Ronald T DDS Starley, John DDS p 801.213.9530 p 801.587.6453 University Of Utah Health University of Utah Dental 1078 S 300 E Services Hospital Affiliation 7495 S State St Salt Lake City UT. 84111 3690 S Main St - University of Utah Hospital Midvale UT. 84047 p 801.578.8180 Salt Lake City UT. 84115 p 801.213.9530 p 801.587.2525 Taylor, Mark R DDS 3690 S Main St University of Utah Health Hospital Affiliation Salt Lake City UT. 84115 50 N Medical Dr Clinic 7 50 N Medical Dr Clinic 7 - University of Utah Hospital p 801.587.2525 Salt Lake City UT. 84132 Salt Lake City UT. 84132 p 801.581.2220 p 801.581.2220 Thorup, David P DMD 50 N Medical Dr Clinic 7 University of Utah Health Salt Lake City UT. 84132 530 S Wakara Way 530 S Wakara Way 1078 S 300 E p 801.581.2220 Salt Lake City UT. 84108 Salt Lake City UT. 84108 Salt Lake City UT. 84111 p 801.587.6453 p 801.587.6453 p 801.578.8180 530 S Wakara Way Salt Lake City UT. 84108 7495 S State St 7495 S State St 3690 S Main St p 801.587.6453 Midvale UT. 84047 Midvale UT. 84047 Salt Lake City UT. 84115 p 801.213.9530 p 801.213.9530 p 801.587.2525

Hospital Affiliation - University of Utah Hospital

165 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 50 N Medical Dr Clinic 7 500 S Chipeta Way 530 S Wakara Way Dermatology Salt Lake City UT. 84132 Salt Lake City UT. 84108 Salt Lake City UT. 84108 Bahr, Brooks A MD p 801.581.2220 p 801.583.2787 p 801.587.6453 University of Utah Health 243 E 6100 S 530 S Wakara Way 530 S Wakara Way 7495 S State St Murray UT. 84107 Salt Lake City UT. 84108 Salt Lake City UT. 84108 Midvale UT. 84047 p 801.581.2955 p 801.587.6453 p 801.587.6453 p 801.213.9530 Hospital Affiliation 7495 S State St 7495 S State St Hospital Affiliation - University of Utah Hospital Midvale UT. 84047 Midvale UT. 84047 - University of Utah Hospital p 801.213.9530 p 801.213.9530 Bertoch, Spencer MD Wangsgard, Richard DMD University Of Utah Health Timothy, Robert J DDS Hospital Affiliation University Of Utah Health 243 E 6100 S University of Utah Dental - University of Utah Hospital 1078 S 300 E Murray UT. 84107 Services Salt Lake City UT. 84111 p 801.581.2955 3690 S Main St Varela, Alberto E DDS p 801.578.8180 Salt Lake City UT. 84115 University of Utah Health 50 N Medical Dr Clinic p 801.587.2525 1078 S 300 E 3690 S Main St E12 Salt Lake City UT. 84111 Salt Lake City UT. 84115 Salt Lake City UT. 84132 50 N Medical Dr Clinic 7 p 801.578.8180 p 801.587.2525 p 801.581.2955 Salt Lake City UT. 84132 p 801.581.2220 3690 S Main St 50 N Medical Dr Clinic 7 Hospital Affiliation Salt Lake City UT. 84115 Salt Lake City UT. 84132 - University of Utah Hospital 530 S Wakara Way p 801.587.2525 p 801.581.2220 Salt Lake City UT. 84108 Bowen, Anneli R MD p 801.587.6453 50 N Medical Dr Clinic 7 7495 S State St University of Utah Health Salt Lake City UT. 84132 Midvale UT. 84047 243 E 6100 S 7495 S State St p 801.581.2220 p 801.213.9530 Murray UT. 84107 Midvale UT. 84047 p 801.581.2955 p 801.213.9530 530 S Wakara Way Watts, Bart T DDS Salt Lake City UT. 84108 University of Utah Health 50 N Medical Dr Clinic 28 Hospital Affiliation p 801.587.6453 50 N Medical Dr Clinic 7 Salt Lake City UT. 84132 - University of Utah Hospital Salt Lake City UT. 84132 p 801.581.2955 7495 S State St p 801.581.2220 Tolboe, Donald G DDS Midvale UT. 84047 Hospital Affiliation University of Utah Health p 801.213.9530 530 S Wakara Way - University of Utah Hospital 50 N Medical Dr Clinic 7 Salt Lake City UT. 84108 Salt Lake City UT. 84132 Hospital Affiliation p 801.587.6453 Bradley, R Ralph MD p 801.581.2220 - University of Utah Hospital 166 E 5900 S 7495 S State St Ste B 111 530 S Wakara Way Wade, Spencer DDS Midvale UT. 84047 Salt Lake City UT. 84107 Salt Lake City UT. 84108 University of Utah Health p 801.213.9530 p 801.268.9672 p 801.587.6453 3690 S Main St Salt Lake City UT. 84115 Hospital Affiliation Brimhall, Angela K DO 7495 S State St p 801.587.2525 - University of Utah Hospital Woseth Dermatology Midvale UT. 84047 1548 E 4500 S p 801.213.9530 50 N Medical Dr Clinic 7 Williamson, James M DMD Ste 202 Salt Lake City UT. 84132 University of Utah Health Salt Lake City UT. 84117 Hospital Affiliation p 801.581.2220 50 N Medical Dr Clinic 7 p 801.266.8841 - University of Utah Hospital Salt Lake City UT. 84132 530 S Wakara Way p 801.581.2220 Hospital Affiliation Trump, Bryan G DDS Salt Lake City UT. 84108 - St Marks Hospital University of Utah Health p 801.587.6453 530 S Wakara Way 417 S Wakara Way Salt Lake City UT. 84108 Callis, Kristina P MD Salt Lake City UT. 84108 7495 S State St p 801.587.6453 University of Utah Health p 801.581.2955 Midvale UT. 84047 243 E 6100 S p 801.213.9530 7495 S State St Murray UT. 84107 50 N Medical Dr Clinic 7 Midvale UT. 84047 p 801.581.2955 Salt Lake City UT. 84132 Wall, Charles C DDS p 801.213.9530 p 801.581.2220 University of Utah Health 50 N Medical Dr Clinic 28 50 N Medical Dr Clinic 7 Hospital Affiliation Salt Lake City UT. 84132 50 N Medical Dr Clinic Salt Lake City UT. 84132 - University of Utah Hospital p 801.581.2955 E13 p 801.581.2220 Salt Lake City UT. 84132 p 801.581.2955

166 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Cipriano, Sarah E MD Curtis, Julia A MD 243 E 6100 S Grossman, Douglas MD,PhD University of Utah Health University of Utah Health Murray UT. 84107 University of Utah Health 100 N Mario Capecchi Dr 1950 Cir of Hope Dr p 801.581.2955 1950 Cir of Hope Dr Salt Lake City UT. 84113 Ste 2400 Ste 2400 p 801.581.2955 Salt Lake City UT. 84112 50 N Medical Dr Clinic 28 Salt Lake City UT. 84112 p 801.581.2955 Salt Lake City UT. 84132 p 801.585.0303 243 E 6100 S p 801.581.2955 Murray UT. 84107 243 E 6100 S Hadjicharalambous, Elena p 801.581.2955 Murray UT. 84107 Ellis, Laurie J NP M DO p 801.581.2955 1548 E 4500 S Woseth Dermatology 3773 W 12600 S Ste 202 1548 E 4500 S Riverton UT. 84065 3730 W 4700 S Salt Lake City UT. 84114 Ste 202 p 801.581.2955 Taylorsville UT. 84129 p 801.266.8841 Salt Lake City UT. 84117 p 801.581.2955 p 801.266.8841 50 N Medical Dr Clinic 28 Flint, Ivan D MD Salt Lake City UT. 84132 50 N Medical Dr Clinic 28 1250 E 3900 S 4060 W Daybreak Pkwy p 801.581.2955 Salt Lake City UT. 84132 Ste 450 Ste 200 p 801.581.2955 Salt Lake City UT. 84124 South Jordan UT. 84009 81 N Mario Capecchi Dr p 801.262.3600 p 801.266.8841 Salt Lake City UT. 84113 5126 W Daybreak Pkwy p 801.213.3599 South Jordan UT. 84009 Hospital Affiliation Hansen, C David MD p 801.213.4500 - St Marks Hospital University of Utah Health Hospital Affiliation - Mountain West Medical 243 E 6100 S - University of Utah Hospital Hospital Affiliation Center Murray UT. 84107 - University of Utah Hospital p 801.581.2955 Clarke, Jennie T MD Florell, Scott R MD University of Utah Health Donigan, Jessica M MD University of Utah Health Hansen, Christopher B MD 243 E 6100 S University of Utah Health 50 N Medical Dr Clinic 28 University of Utah Health Murray UT. 84107 1950 Cir of Hope Dr Salt Lake City UT. 84132 1950 Cir of Hope Dr p 801.581.2955 Ste 2400 p 801.581.2955 Ste 2400 Salt Lake City UT. 84112 Salt Lake City UT. 84112 50 N Medical Dr Clinic 28 p 801.585.2955 Hospital Affiliation p 801.585.0303 Salt Lake City UT. 84132 - University of Utah Hospital p 801.581.2955 50 N Medical Dr Clinic 28 243 E 6100 S Salt Lake City UT. 84132 Forsha, Douglass W MD Murray UT. 84107 Hospital Affiliation p 801.581.2955 Jordan Valley Dermatology p 801.581.2955 - University of Utah Hospital 3570 W 9000 S Duffy, Keith L MD Ste 220 50 N Medical Dr Clinic 28 Clifford, Rebekah MD University of Utah Health West Jordan UT. 84088 Salt Lake City UT. 84132 Granger Medical 1950 Cir of Hope Dr p 801.569.1456 p 801.581.2955 Specialists Ste 2400 1160 E 3900 S Salt Lake City UT. 84112 Hospital Affiliation Harrison, Paul E MD Ste 1000 p 801.585.0303 - Jordan Valley Medical Clearskin Dermatology & Salt Lake City UT. 84124 Center Surgery p 801.262.1771 243 E 6100 S 10011 Centennial Pkwy Murray UT. 84107 Gleich, Gerald J MD Ste 200 11724 S State St p 801.581.2955 University Health Care Sandy UT. 84070 Draper UT. 84020 1525 W 2100 S p 801.255.7546 p 801.576.2050 50 N Medical Dr Clinic 28 Salt Lake City UT. 84119 Salt Lake City UT. 84132 p 801.213.9900 Hospital Affiliation 348 E 4500 S p 801.581.2955 - St Marks Hospital Ste 200 University of Utah Health Salt Lake City UT. 84107 5126 W Daybreak Pkwy 243 E 6100 S Hawkes, Jason E MD p 801.262.9800 South Jordan UT. 84009 Salt Lake City UT. 84107 University of Utah Health p 801.213.4500 p 801.581.2955 243 E 6100 S Curtis, Amy V MD Murray UT. 84107 Dermatology and Aesthetics Hospital Affiliation 50 N Medical Dr Clinic 28 p 801.581.2955 Center of Utah - University of Utah Hospital Salt Lake City UT. 84132 3592 W 9000 S p 801.581.2955 Hospital Affiliation Ste 210 Eliason, Mark J MD - University of Utah Hospital West Jordan UT. 84088 University of Utah Health University Health Care p 801.298.3802 1280 E Stringham Ave 7495 S State St Hinckley, Michael R MD Salt Lake City UT. 84106 Midvale UT. 84047 602 E Fort Union Blvd p 801.581.2955 p 801.213.9400 Floor 2 Midvale UT. 84047 p 801.313.1010

167 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Granger Medical Jensen, Joseph D MD 50 N Medical Dr Clinic 28 Lewis, Bethany K MD Specialists 7396 S Union Park Ave Salt Lake City UT. 84132 University of Utah Health 9001 S 3200 W Ste 201 p 801.581.2955 243 E 6100 S Ste 2 Midvale UT. 84047 Murray UT. 84107 West Jordan UT. 84088 p 801.567.1400 5126 W Daybreak Pkwy p 801.581.2955 p 801.965.2799 South Jordan UT. 84009 Hospital Affiliation p 801.213.4500 3730 W 4700 S Hospital Affiliation - St Marks Hospital Taylorsville UT. 84129 - Jordan Valley Medical Hospital Affiliation p 801.581.2955 Center West Valley Campus Johnson, Luke S MD - University of Utah Hospital - Jordan Valley Medical University of Utah Health 50 N Medical Dr Clinic 28 Center 243 E 6100 S Laggis, Caroline MD Salt Lake City UT. 84132 Murray UT. 84107 University Of Utah Health p 801.581.2955 Horsley, Rolfe P MD p 801.581.2955 50 N Medical Dr Clinic 6040 Fashion Blvd E13 Hospital Affiliation Ste 203 3773 W 12600 S Salt Lake City UT. 84132 - University of Utah Hospital Murray UT. 84107 Riverton UT. 84065 p 801.581.2955 p 801.266.2353 p 801.581.2955 Madigan, Lauren M MD 50 N Medical Dr University of Utah Health Hull, Christopher M MD 81 N Mario Capecchi Dr Salt Lake City UT. 84132 50 N Medical Dr Clinic 28 University of Utah Health Salt Lake City UT. 84113 p 801.662.1603 Salt Lake City UT. 84132 100 N Mario Capecchi Dr p 801.213.3599 p 801.581.2955 Salt Lake City UT. 84113 Hospital Affiliation p 801.581.2955 Hospital Affiliation - University of Utah Hospital Hospital Affiliation - University of Utah Hospital - University of Utah Hospital 243 E 6100 S Leachman, Sancy A MD,PhD Murray UT. 84107 Klein, Stephanie Z MD University of Utah Health Mathis, Jason G MD p 801.581.2955 University of Utah Health 100 N Mario Capecchi Dr University of Utah Health 243 E 6100 S Salt Lake City UT. 84113 1280 E Stringham Ave 50 N Medical Dr Clinic 28 Murray UT. 84107 p 801.662.1603 Salt Lake City UT. 84106 Salt Lake City UT. 84132 p 801.581.2955 p 801.581.2000 p 801.581.2955 1950 Cir of Hope Dr 50 N Medical Dr Clinic 28 Ste 2400 1525 W 2100 S Hyde, Mark A PA Salt Lake City UT. 84132 Salt Lake City UT. 84112 West Valley City UT. 84119 University of Utah Health p 801.581.2955 p 801.585.0303 p 801.213.9900 1950 Cir of Hope Dr Ste 2400 Hospital Affiliation 243 E 6100 S 3730 W 4700 S Salt Lake City UT. 84112 - University of Utah Hospital Murray UT. 84107 Salt Lake City UT. 84129 p 801.585.0303 p 801.581.2955 p 801.213.9200 Krueger, Gerald G MD 50 N Medical Dr Clinic 28 University of Utah Health 3730 W 4700 S 50 N Medical Dr Clinic Salt Lake City UT. 84132 243 E 6100 S Taylorsville UT. 84129 E12 p 801.581.2955 Murray UT. 84107 p 801.581.2955 Salt Lake City UT. 84132 p 801.581.2955 p 801.581.2955 Dermatology and Aesthetics 50 N Medical Dr Clinic 28 Center of Utah 50 N Medical Dr Clinic 28 Salt Lake City UT. 84132 5126 W Daybreak Pkwy 3592 W 9000 S Salt Lake City UT. 84132 p 801.581.2955 Ste 600 Ste 210 p 801.581.2955 South Jordan UT. 84009 West Jordan UT. 84088 5126 W Daybreak Pkwy p 801.213.4500 p 801.298.3802 Kuechle, Melanie K MD South Jordan UT. 84009 University of Utah Health p 801.213.4500 7495 S State St Jensen, Jesse D DO 1950 Cir of Hope Dr Midvale UT. 84047 West Valley Dermatology Ste 2400 Leiferman, Kristin M MD p 801.213.9400 3465 S Pioneer Pkwy Salt Lake City UT. 84112 University of Utah Health Ste 1 p 801.585.0303 243 E 6100 S Hospital Affiliation West Valley City UT. 84120 Murray UT. 84107 - University of Utah Hospital p 801.966.1403 243 E 6100 S p 801.581.2955 Murray UT. 84107 Matis, Wendy L MD Hospital Affiliation p 801.581.2955 50 N Medical Dr Clinic 28 Matis Dermatology - Jordan Valley Medical Salt Lake City UT. 84132 710 E 200 S Center West Valley Campus 3730 W 4700 S p 801.581.2955 Ste 1B Taylorsville UT. 84129 Salt Lake City UT. 84102 p 801.581.2955 Hospital Affiliation p 801.521.0100 - University of Utah Hospital

168 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Maughan, Cory B DO Odell, Richard H MD Secrest, Aaron M MD Sotiriou, Michael C MD Dermatology and Aesthetics 1345 E 3900 S University of Utah Health Salt Lake Dermatology and Center of Utah Ste 110 243 E 6100 S Aesthetics 3592 W 9000 S Salt Lake City UT. 84124 Murray UT. 84107 250 E 300 S Ste 210 p 801.272.4219 p 801.581.2955 Ste 120 West Jordan UT. 84088 Salt Lake City UT. 84111 p 801.298.3802 Hospital Affiliation 3730 W 4700 S p 801.521.5630 - St Marks Hospital Taylorsville UT. 84129 Hospital Affiliation p 801.581.2955 Summers, Erika M MD - Logan Regional Hospital Orme, Robert L MD University of Utah Health - Cache Valley Hospital 11760 S 700 E 50 N Medical Dr Clinic 28 243 E 6100 S Ste 210 Salt Lake City UT. 84132 Murray UT. 84107 Meyer, Laurence J MD,PhD Draper UT. 84020 p 801.581.2955 p 801.581.2955 University of Utah Health p 801.572.8043 50 N Medical Dr Clinic 28 5126 W Daybreak Pkwy 50 N Medical Dr Clinic 28 Salt Lake City UT. 84132 Petersen, Marta J MD South Jordan UT. 84009 Salt Lake City UT. 84132 p 801.581.2955 University of Utah Health p 801.213.4500 p 801.581.2955 243 E 6100 S Millican, Eric A MD Murray UT. 84107 Hospital Affiliation Hospital Affiliation University of Utah Health p 801.581.2955 - University of Utah Hospital - University of Utah Hospital 1950 Cir of Hope Dr Ste 2400 50 N Medical Dr Clinic 28 Smart, David R MD Swinyer, Leonard J MD Salt Lake City UT. 84112 Salt Lake City UT. 84132 University of Utah Health 1548 E 4500 S p 801.581.2955 p 801.581.2955 100 N Mario Capecchi Dr Ste 202 Salt Lake City UT. 84113 Salt Lake City UT. 84114 243 E 6100 S Powell, Douglas L MD p 801.662.1603 p 801.266.8841 Murray UT. 84107 University of Utah Health p 801.581.2955 243 E 6100 S 1950 Cir of Hope Dr Hospital Affiliation Murray UT. 84107 Ste 2400 - St Marks Hospital 50 N Medical Dr Clinic 28 p 801.581.2955 Salt Lake City UT. 84112 Salt Lake City UT. 84132 p 801.585.0303 Swinyer, Michael R PA p 801.581.2955 3730 W 4700 S 1548 E 4500 S Taylorsville UT. 84129 243 E 6100 S Ste 202 5126 W Daybreak Pkwy p 801.581.2955 Murray UT. 84107 Salt Lake City UT. 84114 South Jordan UT. 84009 p 801.581.2955 p 801.266.8841 p 801.213.4500 50 N Medical Dr Clinic 28 Salt Lake City UT. 84132 3730 W 4700 S Hospital Affiliation Hospital Affiliation p 801.581.2955 Taylorsville UT. 84129 - St Marks Hospital - University of Utah Hospital p 801.581.2955 5126 W Daybreak Pkwy Thulin, Justin F MD Moss, Richard L MD South Jordan UT. 84009 50 N Medical Dr Clinic 28 1151 E 3900 S University of Utah Health p 801.213.4500 Salt Lake City UT. 84132 Ste B259 50 N Medical Dr Clinic 28 p 801.581.2955 Salt Lake City UT. 84124 Salt Lake City UT. 84132 Rhoads, Jamie Lynn W MD p 801.266.7325 p 801.581.2955 University of Utah Health 5126 W Daybreak Pkwy 243 E 6100 S South Jordan UT. 84009 Hospital Affiliation 5126 W Daybreak Pkwy Murray UT. 84107 p 801.213.4500 - St Marks Hospital South Jordan UT. 84009 p 801.581.2955 p 801.213.4500 Hospital Affiliation Tinklepaugh, Adam J MD 50 N Medical Dr Clinic 28 - University of Utah Hospital University of Utah Health Neville, Christopher A PA Salt Lake City UT. 84132 1950 Cir of Hope Dr University of Utah Health p 801.581.2955 Sontheimer, Richard D MD Ste 2400 1280 E Stringham Ave University of Utah Health Salt Lake City UT. 84112 Salt Lake City UT. 84106 5126 W Daybreak Pkwy 243 E 6100 S p 801.581.2955 p 801.581.2955 South Jordan UT. 84009 Murray UT. 84107 p 801.213.4500 p 801.581.2955 243 E 6100 S 243 E 6100 S Murray UT. 84107 Murray UT. 84107 Hospital Affiliation 50 N Medical Dr Clinic 28 p 801.581.2955 p 801.581.2955 - University of Utah Hospital Salt Lake City UT. 84132 p 801.581.2955 50 N Medical Dr Clinic 28 5126 W Daybreak Pkwy Salt Lake Dermatology and Salt Lake City UT. 84132 South Jordan UT. 84009 Aesthetics Sotiriou, Leo MD p 801.581.2955 p 801.213.4500 250 E 300 S 250 E 300 S Ste 120 Ste 330 Hospital Affiliation Salt Lake City UT. 84111 Salt Lake City UT. 84111 - Mountain West Medical p 801.521.5630 p 801.521.5630 Center Hospital Affiliation - Salt Lake Regional Medical Center 169 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 5126 W Daybreak Pkwy 81 N Mario Capecchi Dr 50 N Medical Dr Clinic 28 Diabetic Supplies South Jordan UT. 84009 Salt Lake City UT. 84113 Salt Lake City UT. 84132 CCS Medical p 801.581.2955 p 801.213.3599 p 801.581.2955 Phone Number Only p 800.726.9811 Hospital Affiliation Walker, Jennifer PA-C 5126 W Daybreak Pkwy - University of Utah Hospital Dermatology and Aesthetics South Jordan UT. 84009 Edgepark Center of Utah p 801.213.4500 Phone Number Only Topham, E Barry MD 3592 W 9000 S p 800.321.0591 Holladay Dermatology Ste 210 University Of Utah Health Clinic West Jordan UT. 84088 85 N Medical Dr Roche Insulin Delivery 1775 E 4500 S p 801.298.3802 Salt Lake City UT. 84112 Systems Inc Salt Lake City UT. 84117 p 801.581.2955 Phone Number Only p 801.272.4408 Williams, Brian J MD p 800.280.7801 602 E Fort Union Blvd 2nd Hospital Affiliation Tristani-Firouzi, Payam Fl - University of Utah Hospital US MED LLC MD Midvale UT. 84047 Phone Number Only University Of Utah Health p 801.313.1010 deShazo, Rosemary A MD p 800.787.6331 1950 Cir of Hope Dr University of Utah Health Ste 2400 Hospital Affiliation 243 E 6100 S United States Medical Salt Lake City UT. 84112 - St Marks Hospital Murray UT. 84107 Supply p 801.581.2955 p 801.581.2955 Phone Number Only Woseth, Douglas M MD p 877.840.8218 243 E 6100 S Woseth Dermatology 3730 W 4700 S Murray UT. 84107 1548 E 4500 S Taylorsville UT. 84129 Dialysis Center p 801.581.2955 Ste 202 p 801.581.2955 Kolff Dialysis Center Salt Lake City UT. 84114 85 Medical Dr 50 N Medical Dr Clinic p 801.266.8841 50 N Medical Dr Clinic 28 Salt Lake City UT. 84112 E13 Salt Lake City UT. 84132 p 801.581.8578 Salt Lake City UT. 84132 Hospital Affiliation p 801.581.2955 p 801.581.2955 - St Marks Hospital South Valley Dialysis 5126 W Daybreak Pkwy Center 50 N Medical Dr Yates, Breton MD South Jordan UT. 84009 8750 Sandy Pkwy Salt Lake City UT. 84132 Woseth Dermatology p 801.213.4500 Sandy UT. 84070 p 801.662.1603 1548 E 4500 S p 801.233.8745 Ste 202 Hospital Affiliation University Health Care Salt Lake City UT. 84117 - University of Utah Hospital University of Utah 50 N Medical Dr p 801.266.8841 Dialysis - Physicians Salt Lake City UT. 84132 Diabetic Education 85 N Medical Dr p 801.581.2955 Zone, John J MD *Badger, Christine M RN Ste E201 University of Utah Health Primary Childrens Hospital Salt Lake City UT. 84112 UUHC South Jordan Health 100 N Mario Capecchi Dr 81 N Mario Capecchi Dr p 801.581.8578 Center Salt Lake City UT. 84113 Salt Lake City UT. 84113 5126 W Daybreak Pkwy p 801.581.2955 p 801.662.1000 University of Utah South Jordan UT. 84095 Dialysis Program West p 801.213.4500 243 E 6100 S *Ballesteros, Maria R RD Valley Murray UT. 84107 Primary Childrens Hospital 3854 W 5400 S Vanderhooft, Sheryll L MD p 801.581.2955 81 N Mario Capecchi Dr Taylorsville UT. 84118 University of Utah Health Salt Lake City UT. 84113 p 801.581.8578 100 N Mario Capecchi Dr 50 N Medical Dr Clinic 28 p 801.662.1000 Salt Lake City UT. 84113 Salt Lake City UT. 84132 Dietician p 801.581.2955 p 801.581.2955 Burr, Robert E MD *Braae, Margaret A RD Wasatch Endocrinology and Primary Childrens Hospital 243 E 6100 S 5126 W Daybreak Pkwy Diabetes Specialists 81 N Mario Capecchi Dr Murray UT. 84107 South Jordan UT. 84009 1035 W Bellwood Ln Salt Lake City UT. 84113 p 801.581.2955 p 801.213.4500 Ste 160 p 801.662.1000 Salt Lake City UT. 84123 3773 W 12600 S Zussman, Jamie MD p 801.746.0776 Day, Barbara RD Riverton UT. 84065 University of Utah Health University of Utah Health p 801.581.2955 243 E 6100 S Hospital Affiliation 3854 W 5400 S Murray UT. 84107 - Salt Lake Regional Medical Taylorsville UT. 84129 50 N Medical Dr Clinic 28 p 801.581.2955 Center p 801.969.6801 Salt Lake City UT. 84132 p 801.581.2955

170 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 423 S Wakara Way Matheny Lehmitz, Teresa 50 N Medical Dr Phone Number Only Ste 200 Specialty Surgery of Utah Salt Lake City UT. 84132 p 800.686.7993 Salt Lake City UT. 84108 @ West Jordan p 801.581.6709 p 801.581.3981 3584 W 9000 S Apria Healthcare LLC Ste 304 515 E 100 S 6952 High Tech Dr 515 E 100 S West Jordan UT. 84088 Ste 350 Ste A Ste 350 p 801.601.4423 Salt Lake City UT. 84102 Midvale UT. 84047 Salt Lake City UT. 84102 p 801.581.3981 p 801.261.5100 p 801.581.3981 Endocrinology of Utah - Diabetes Center Hospital Affiliation CCS Medical Hospital Affiliation 3590 W 9000 S - University of Utah Hospital Phone Number Only - University of Utah Hospital Ste 240 p 800.726.9811 West Jordan UT. 84088 *Susan, Fitzgerald RD DeLapp, Edith A RD p 801.508.3140 Primary Childrens Hospital CNS Respiratory Services - University of Utah Health 100 N Mario Capecchi Dr West Jordan 423 S Wakara Way Reeder, Amy F RD Salt Lake City UT. 84113 3685 W 6200 S Ste 200 University of Utah Health p 801.662.1000 West Jordan UT. 84084 Salt Lake City UT. 84108 555 Foothill Dr p 801.973.0900 p 801.581.3981 Ste 301 Hospital Affiliation Salt Lake City UT. 84112 - Primary Childrens Hospital Care Rehab and Orthopedic 515 E 100 S p 801.581.8000 Products (Muscle Ste 350 Thompson, Sharee RD Stimulators) Salt Lake City UT. 84102 Hospital Affiliation University Of Utah Health Phone Number Only p 801.581.3981 - University of Utah Hospital 555 Foothill Dr p 800.487.9644 Ste 301 Hospital Affiliation Roberts, Sarah RD Salt Lake City UT. 84112 Carols Personal Mastectomy - University of Utah Hospital University Of Utah Health p 801.581.8000 Boutique 100 N Mario Capecchi Dr 3165 S Main St *Hardy, Sherrie I RD Salt Lake City UT. 84113 Ware, Suzanne O RD Salt Lake City UT. 84115 Primary Childrens Hospital p 801.213.3599 University of Utah Health p 801.483.1262 100 N Mario Capecchi Dr 423 S Wakara Way Salt Lake City UT. 84113 50 N Medical Dr Clinic 1 Ste 200 Center for Prosthetics Inc p 801.662.1675 Salt Lake City UT. 84132 Salt Lake City UT. 84108 2290 E 4500 S p 801.213.3599 p 801.581.3981 Ste 160 81 N Mario Capecchi Dr Salt Lake City UT. 84117 Salt Lake City UT. 84113 81 N Mario Capecchi Dr 515 E 100 S p 801.364.0083 p 801.662.1675 Salt Lake City UT. 84113 Ste 350 p 801.213.3599 Salt Lake City UT. 84102 DJO Global Haupt, Wendy W RD p 801.581.3981 Phone Number Only Granger Medical Clinic Hospital Affiliation p 800.336.6569 12391 S 4000 W - University of Utah Hospital Wirtz, Mary RD Riverton UT. 84065 Total Health and Fitness Dynasplint Systems Inc p 801.302.1700 Snyder, Anna B RD 767 E 12300 S Phone Number Only University of Utah Health Draper UT. 84020 p 800.638.6771 2965 W 3500 S 423 S Wakara Way p 801.572.8050 West Valley City UT. 84119 Ste 200 EBI LLC (Bone Stimulators) p 801.965.3600 Salt Lake City UT. 84108 Zou, Sarah N RD Phone Number Only p 801.581.3981 University of Utah Health p 800.526.2579 Landsman, Roxanne M RD 1280 E Stringham Ave University of Utah Health 515 E 100 S Salt Lake City UT. 84106 Edgepark 615 S Arapeen Dr Ste 350 p 801.581.2000 Phone Number Only Ste 100 Salt Lake City UT. 84102 p 800.321.0591 Salt Lake City UT. 84108 p 801.581.3981 Durable Medical Equipment p 801.581.7246 Advantage Medical Supply Empi Inc (Neuromuscular Hospital Affiliation 15 W Louise Ave Stimulator) Hospital Affiliation - University of Utah Hospital Salt Lake City UT. 84115 Phone Number Only - University of Utah Hospital p 435.757.6366 p 800.328.2536 Speener, Melinda S RD Martinez Gascoigne, University of Utah Health Alpine Home Medical Eye Prosthetics of Utah Denise M RD 423 S Wakara Way 4030 S State St 7400 Union Park Ave University of Utah Health Ste 200 Salt Lake City UT. 84107 Ste 102 555 Foothill Dr Salt Lake City UT. 84108 p 800.686.7993 Midvale UT. 84047 Ste 301 p 801.581.3981 p 801.942.1600 Salt Lake City UT. 84112 p 801.581.8000

Hospital Affiliation - University of Utah Hospital 171 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Fit Well Magic Rest Medical-SLC Smith Nephew Inc (Muscle 3584 W 9000 S Prosthetics/Orthotics 3450 S Main St Stimulators) Ste 311 50 S 900 E Salt Lake City UT. 84115 Phone Number Only West Jordan UT. 84088 Ste 1 p 801.281.8688 p 800.821.5700 p 801.566.8304 Salt Lake City UT. 84102 p 801.364.3100 Medicor Stone Mountain Surgical Hospital Affiliation 2469 Fort Union Blvd 6905 S 1300 E - Jordan Valley Medical 7575 S 900 E Ste 105 Ste 161 Center Midvale UT. 84047 Salt Lake City UT. 84121 Midvale UT. 84047 p 801.364.3100 p 801.942.5543 p 801.571.2295 Ballingham, TeeMarie CCC-A Hanger Prosthetics and Aamco Medical US MED LLC University of Utah Health Orthotics Inc 10520 S 700 E Phone Number Only 50 N Medical Dr 5292 College Dr Ste 209 p 800.787.6331 Salt Lake City UT. 84132 Ste 103 Sandy UT. 84070 p 801.581.7514 Salt Lake City UT. 84123 p 866.293.3218 United States Medical p 801.266.7768 Supply 5126 W Daybreak Pkwy Medway Medical Phone Number Only South Jordan UT. 84009 Hanger Clinic 1837 S 4130 W Unit B p 877.840.8218 p 801.581.7514 887 E Vine St Salt Lake City UT. 84104 Salt Lake City UT. 84107 p 435.755.9600 Utah Medical Products Hospital Affiliation p 801.293.8777 7043 S 300 W - University of Utah Hospital National DME Midvale UT. 84047 2785 E 3300 S 7757 S Allen St p 866.754.9789 Bennett, John R MD Salt Lake City UT. 84109 West Jordan UT. 84084 Ear, Nose & Throat Center p 801.467.5483 p 801.262.3236 Rotech of Utah 6973 S 300 W 1255 E 3900 S JQ Medical Supply National Seating and Midvale UT. 84047 Ste 301 6910 Highland Dr Mobility p 801.563.0202 Salt Lake City UT. 84124 Ste 4 6553 S Cottonwood St p 801.328.2522 Salt Lake City UT. 84121 Murray UT. 84107 Ear Nose And Throat p 801.942.8582 p 801.281.6601 Allak, Amir MD 22 S 900 E South Valley Ear Nose And Salt Lake City UT. 84102 Jenco Prosthetics and Orthofix Inc (Bone Growth Throat p 801.328.2522 Orthotics Stimulators Physicians 11348 S Market Ctr Dr 7026 S Commerce Park Dr Only) Ste 210 756 E 12200 S Ste 2 Phone Number Only Riverton UT. 84065 Draper UT. 84020 Midvale UT. 84047 p 800.535.4492 p 801.566.8304 p 801.328.2522 p 801.566.5795 Pacific Medical Inc 3584 W 9000 S Hospital Affiliation KCI USA Inc (Wound Vac Phone Number Only Ste 311 - Salt Lake Regional Medical Only) p 800.726.9180 West Jordan UT. 84088 Center 1761 S 900 W p 801.566.8304 Salt Lake City UT. 84104 Peak Prosthetic Design Buchmann, Luke O MD p 800.275.4524 1751 W Alexander St Alt, Jeremiah A MD University of Utah Health Ste 20 University of Utah Health 1950 Cir of Hope Dr Phone Number Only West Valley City UT. 84119 100 N Mario Capecchi Dr Salt Lake City UT. 84112 p 800.275.4524 p 801.972.5270 Salt Lake City UT. 84113 p 801.585.6387 p 801.213.3599 Lincare Precision Health Services 50 N Medical Dr 1735 S Redwood Rd 4885 S 900 E 5126 W Daybreak Pkwy Salt Lake City UT. 84132 Ste 130 Ste 107 South Jordan UT. 84009 p 801.581.7514 Salt Lake City UT. 84104 Salt Lake City UT. 84117 p 801.581.7514 p 801.487.0202 p 801.266.0399 Hospital Affiliation Hospital Affiliation - University of Utah Hospital Frontier LImited Leaseing RespirTech - University of Utah Hospital Partnership Phone Number Only Butler, John E MD 3685 W 6200 S p 800.793.1261 Anderson, Peter C MD Ear, Nose & Throat Center Ste A South Valley Ear Nose And of Utah Salt Lake City UT. 84129 Roche Insulin Delivery Throat 22 S 900 E p 801.973.0900 Systems Inc 13348 S Market Ctr Dr Salt Lake City UT. 84102 Phone Number Only Ste 210 p 801.328.2522 p 800.280.7801 Riverton UT. 84065 p 801.566.8304

172 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 4063 W 12600 S Crofts, Alicia K CCC-A 50 N Medical Dr Gilbert, Ryan MD Herriman UT. 84096 University of Utah Health Salt Lake City UT. 84132 South Valley Ear Nose And p 801.328.2522 50 N Medical Dr p 801.581.7514 Throat Salt Lake City UT. 84132 3584 W 9000 S Hospital Affiliation p 801.581.7514 5121 S Cottonwood St Ste 311 - St Marks Hospital Murray UT. 84107 West Jordan UT. 84088 - Lone Peak Hospital 5126 W Daybreak Pkwy p 801.581.7514 p 801.566.8304 South Jordan UT. 84009 Cannon, Richard B MD p 801.581.7514 Hospital Affiliation 4651 W 13400 S University of Utah Health - University of Utah Hospital Ste 120 100 N Mario Capecchi Dr Hospital Affiliation Herriman UT. 84096 Salt Lake City UT. 84113 - University of Utah Hospital Ear, Nose & Throat Center p 801.566.8304 p 801.213.3599 of Utah Dahl, Matthew E MD 1255 E 3900 S Hospital Affiliation 1950 Cir of Hope Dr Ear, Nose & Throat Center Ste 301 - Jordan Valley Medical Salt Lake City UT. 84112 of Utah Salt Lake City UT. 84124 Center p 801.585.0100 22 S 900 E p 801.328.2522 Salt Lake City UT. 84102 Gill, Amarbir S MD 50 N Medical Dr p 801.328.2522 22 S 900 E University Of Utah Health Salt Lake City UT. 84132 Salt Lake City UT. 84102 100 N Mario Capecchi Dr p 801.581.7514 4063 W 12600 S p 801.328.2522 Salt Lake City UT. 84113 Herriman UT. 84096 p 801.213.3599 5121 S Cottonwood St p 801.328.2522 4063 W 12600 S Murray UT. 84107 Herriman UT. 84096 1950 Cir of Hope Dr p 801.581.7514 756 E 12200 S p 801.328.2522 Salt Lake City UT. 84112 Draper UT. 84020 p 801.585.0100 8th Ave & C St p 801.328.2522 756 E 12200 S Salt Lake City UT. 84143 Draper UT. 84020 50 N Medical Dr p 801.581.7514 Hospital Affiliation p 801.328.2522 Salt Lake City UT. 84132 - Salt Lake Regional Medical p 801.581.7514 Hospital Affiliation Center Error, Marc E MD - University of Utah Hospital - Lone Peak Hospital University of Utah Health 5121 S Cottonwood St 1950 Cir of Hope Dr Murray UT. 84107 Cerrati, Eric W MD Dahlstrom, Lisa CCC-A Salt Lake City UT. 84112 p 801.581.7514 University of Utah Health University of Utah Health p 801.585.0100 100 N Mario Capecchi Dr 50 N Medical Dr 5126 W Daybreak Pkwy Salt Lake City UT. 84113 Salt Lake City UT. 84132 50 N Medical Dr South Jordan UT. 84009 p 801.213.3599 p 801.581.7514 Salt Lake City UT. 84132 p 801.213.4500 p 801.581.7514 1950 Cir of Hope Dr 5126 W Daybreak Pkwy 8th Ave & C St Salt Lake City UT. 84112 South Jordan UT. 84009 5126 W Daybreak Pkwy Salt Lake City UT. 84143 p 801.585.0100 p 801.581.7514 South Jordan UT. 84009 p 801.581.7514 p 801.581.7514 50 N Medical Dr Hospital Affiliation Hospital Affiliation Salt Lake City UT. 84132 - University of Utah Hospital Hospital Affiliation - University of Utah Hospital p 801.581.7514 - University of Utah Hospital Diaz, Jason A MD Goeller, Kristin G PA-C 5121 S Cottonwood St Ear, Nose & Throat Center Gale, Derrick C MD ENT Specialists Murray UT. 84107 of Utah Ear, Nose & Throat Center 5770 S 250 E p 801.581.7514 4063 W 12600 S of Utah Ste 415 Herriman UT. 84096 1355 E 3900 S Salt Lake City UT. 84107 5126 W Daybreak Pkwy p 801.328.2522 Ste 301 p 801.268.2822 South Jordan UT. 84009 Salt Lake City UT. 84124 p 801.213.4500 Drejet, Sarah M MD p 801.328.2522 Gordon, Steven A MD University Of Utah Health University Of Utah Health 8th Ave & C St 100 N Mario Capecchi Dr 4063 W 12600 S 100 N Mario Capecchi Dr Salt Lake City UT. 84143 Salt Lake City UT. 84113 Herriman UT. 84096 Salt Lake City UT. 84113 p 801.581.7514 p 801.213.3599 p 801.328.2522 p 801.213.3599

Hospital Affiliation 1950 Cir of Hope Dr Hospital Affiliation 1950 Cir of Hope Dr - University of Utah Hospital Salt Lake City UT. 84112 - Salt Lake Regional Medical Salt Lake City UT. 84112 p 801.585.0100 Center p 801.585.0100

173 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 50 N Medical Dr 3584 W 9000 S Hunter, Robert G MD 74 E 11800 S Salt Lake City UT. 84132 Ste 311 South Valley Ear Nose And Ste 360 p 801.581.7514 West Jordan UT. 84088 Throat Draper UT. 84020 p 801.566.8304 5169 S Cottonwood St p 801.260.3687 5121 S Cottonwood St Ste 310 Murray UT. 84107 Gurgel, Richard K MD Murray UT. 84107 Jones, Alan C DO p 801.581.7514 University of Utah Health p 801.507.3444 Alan Jones DO PLLC 100 N Mario Capecchi Dr 3336 S Pioneer Pkwy 5770 S 250 E Salt Lake City UT. 84113 Hospital Affiliation Ste 202 A Ste 170 p 801.213.3599 - St Marks Hospital West Valley City UT. 84120 Salt Lake City UT. 84107 - Jordan Valley Medical p 435.833.9600 p 801.581.7514 University Of Utah Health Center 1950 Cir of Hope Dr - Lone Peak Hospital Exodus Healthcare Network Hospital Affiliation Salt Lake City UT. 84112 3336 S Pioneer Pkwy - University of Utah Hospital p 801.585.0100 Jepsen, Matthew C MD Salt Lake City UT. 84120 Ear, Nose & Throat Center p 801.250.9638 Grimmer, Johannes F MD University of Utah Health of Utah University of Utah Health 50 N Medical Dr 1255 E 3900 S 3665 S 8400 W 100 N Mario Capecchi Dr Salt Lake City UT. 84132 Ste 301 Ste 110 Salt Lake City UT. 84113 p 801.581.7514 Salt Lake City UT. 84124 Magna UT. 84044 p 801.213.3599 p 801.328.2522 p 801.250.9638 5770 S 250 E 3773 W 12600 S Ste 170 22 S 900 E Alan Jones DO PLLC Riverton UT. 84065 Salt Lake City UT. 84107 Salt Lake City UT. 84102 8400 W 3665 S p 801.285.1285 p 801.581.7514 p 801.328.2522 Ste 260 Magna UT. 84044 50 N Medical Dr Hospital Affiliation 756 E 12200 S p 801.912.8270 Salt Lake City UT. 84132 - University of Utah Hospital Draper UT. 84020 p 801.581.7514 p 801.328.2522 Hospital Affiliation Hatch, Jonathan L MD - Mountain West Medical Hospital Affiliation South Valley Ear Nose and Hospital Affiliation Center - Primary Childrens Hospital Throat - Salt Lake Regional Medical - Jordan Valley Medical - University of Utah Hospital 3584 W 9000 S Center Center West Valley Campus Ste 311 - Jordan Valley Medical Gull, Justin D MD West Jordan UT. 84088 Center Larson, Stephen R MD ENT Specialists p 801.566.8304 - Lone Peak Hospital Ear, Nose & Throat Center 4000 S 700 E of Utah Ste 10 5169 S Cottonwood St Johnson, Jennifer H PA-C 1255 E 3900 S Salt Lake City UT. 84107 Salt Lake City UT. 84107 South Valley Ear Nose And Ste 301 p 801.268.4141 p 801.566.8304 Throat Salt Lake City UT. 84124 13348 S Market Ctr Dr p 801.328.2522 5770 S 250 E Hill, Justin D MD Ste 210 Ste 415 Ear, Nose & Throat Center Riverton UT. 84065 22 S 900 E Salt Lake City UT. 84107 of Utah p 801.566.8304 Salt Lake City UT. 84102 p 801.268.2822 756 E 12200 S p 801.328.2522 Draper UT. 84020 3584 W 9000 S 74 E 11800 S p 801.328.2522 Ste 311 Leonard, Ryan W DO Ste 360 West Jordan UT. 84088 Granger Medical Draper UT. 84020 Hunt, Jason P MD p 801.566.8304 Specialists p 801.260.3687 University of Utah Health 2965 W 3500 S 100 N Mario Capecchi Dr Hospital Affiliation West Valley City UT. 84119 8846 S Redwood Rd Salt Lake City UT. 84113 - Jordan Valley Medical p 801.965.3600 Ste E-121 p 801.213.3599 Center West Jordan UT. 84088 Major, Michael S MD p 801.268.4141 1950 Cir of Hope Dr ENT Specialists Revere Health Salt Lake City UT. 84112 4000 S 700 E 1407 N 2000 W Hospital Affiliation p 801.585.0100 Ste 10 Ste C - St Marks Hospital Salt Lake City UT. 84107 Salt Lake City UT. 84105 50 N Medical Dr p 801.268.4141 p 801.866.0170 Gunnell, Vance K AUD Salt Lake City UT. 84132 South Valley Ear Nose And p 801.581.7514 5770 S 250 E Hospital Affiliation Throat Ste 415 - Brigham City Community 13348 S Market Ctr Dr Hospital Affiliation Salt Lake City UT. 84107 Hospital Ste 210 - University of Utah Hospital p 801.268.2822 - Ogden Regional Medical Riverton UT. 84065 Center p 801.566.8304

174 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. McRae, Bryan R MD 756 E 12200 S Nelson, Adam A PA-C Palmer, David K MD University of Utah Health Draper UT. 84020 South Valley Ear Nose And ENT Specialists 100 N Mario Capecchi Dr p 801.328.2522 Throat 4000 S 700 E Salt Lake City UT. 84113 13348 S Market Ctr Dr Ste 10 p 801.213.3599 Hospital Affiliation Ste 210 Salt Lake City UT. 84107 - Primary Childrens Hospital Riverton UT. 84065 p 801.268.4141 50 N Medical Dr - Lone Peak Hospital p 801.566.8304 Salt Lake City UT. 84132 - Salt Lake Regional Medical 74 E 11800 S p 801.581.7514 Center 3584 W 9000 S Ste 360 Ste 311 Draper UT. 84020 5126 W Daybreak Pkwy Mobley, Steven R MD West Jordan UT. 84088 p 801.260.3687 South Jordan UT. 84009 Mobley MD Facial Plastic p 801.566.8304 p 801.581.7514 and Reconstructive Surgery 8846 S Redwood Rd 1200 E 3900 S Nelson, Natalie R PA-C Ste E-121 Hospital Affiliation Salt Lake City UT. 84124 Ear, Nose & Throat Center West Jordan UT. 84088 - University of Utah Hospital p 801.449.9990 of Utah p 801.268.4141 756 E 12200 S Meads, Garner B MD 3715 W 4100 S Draper UT. 84020 Hospital Affiliation South Valley Ear Nose And Ste 100 p 801.328.2522 - Mountain West Medical Throat Salt Lake City UT. 84120 Center 13348 S Market Ctr Dr p 801.449.9990 Oakley, Gretchen M MD - St Marks Hospital Ste 210 University of Utah Health Riverton UT. 84065 5292 College Dr 100 N Mario Capecchi Dr Park, Albert H MD p 801.566.8304 Ste 303 Salt Lake City UT. 84113 University of Utah Health Taylorsville UT. 84123 p 801.213.3599 100 N Mario Capecchi Dr 3584 W 9000 S p 801.449.9990 Salt Lake City UT. 84113 Ste 311 1950 Cir of Hope Dr p 801.213.3599 West Jordan UT. 84088 8th Ave C St Salt Lake City UT. 84112 p 801.566.8304 Salt Lake City UT. 84143 p 801.585.0100 3773 W 12600 S p 801.449.9990 Riverton UT. 84065 Hospital Affiliation 50 N Medical Dr p 801.285.1285 - Jordan Valley Medical Hospital Affiliation Salt Lake City UT. 84132 Center - University of Utah Hospital p 801.581.7514 50 N Medical Dr - Lone Peak Hospital Salt Lake City UT. 84132 Meier, Jeremy D MD - St Marks Hospital 5121 S Cottonwood St p 801.581.7514 University of Utah Health Murray UT. 84107 100 N Mario Capecchi Dr Monroe, Marcus M MD p 801.581.7514 Hospital Affiliation Salt Lake City UT. 84113 University of Utah Health - University of Utah Hospital p 801.213.3599 1950 Cir of Hope Dr 5126 W Daybreak Pkwy Salt Lake City UT. 84112 South Jordan UT. 84009 Patel, Neil S MD PCH Esophageal Airway - p 801.585.0100 p 801.213.4500 University Of Utah Health Riverton 100 N Mario Capecchi Dr 3741 W 12600 S 50 N Medical Dr 65 S Mario Capecchi Dr Salt Lake City UT. 84113 Riverton UT. 84065 Salt Lake City UT. 84132 Salt Lake City UT. 84132 p 801.213.3599 p 801.662.1644 p 801.581.7514 p 801.581.7514 1950 Cir of Hope Dr University of Utah Health Hospital Affiliation 8th Ave & C St Salt Lake City UT. 84112 3773 W 12600 S - University of Utah Hospital Salt Lake City UT. 84143 p 801.585.0100 Riverton UT. 84065 p 801.581.7514 p 801.285.1285 *Muntz, Harlan R MD 50 N Medical Dr Primary Childrens Hospital Hospital Affiliation Salt Lake City UT. 84132 Primary Childrens Hospital 100 N Mario Capecchi Dr - University of Utah Hospital p 801.581.7514 81 N Mario Capecchi Dr Salt Lake City UT. 84113 Salt Lake City UT. 84113 p 801.662.2100 Orb, Quinn T MD 5121 S Cottonwood St p 801.662.2100 University Of Utah Health Murray UT. 84107 81 N Mario Capecchi Dr 100 N Mario Capecchi Dr p 801.581.7514 Hospital Affiliation Salt Lake City UT. 84113 Salt Lake City UT. 84113 - Primary Childrens Hospital p 801.662.2100 p 801.213.3599 5770 S 250 E Ste 170 Miller, Steven K MD Hospital Affiliation 3773 W 12600 S Salt Lake City UT. 84107 Ear, Nose & Throat Center - Primary Childrens Hospital Riverton UT. 84065 p 801.581.7514 of Utah - University of Utah Hospital p 801.285.1285 22 S 900 E Salt Lake City UT. 84102 Hospital Affiliation p 801.328.2522 - University of Utah Hospital

175 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 8th Ave & C St 756 E 12200 S 3773 W 12600 S 756 E 12200 S Salt Lake City UT. 84143 Draper UT. 84020 Riverton UT. 84065 Draper UT. 84020 p 801.581.7514 p 801.328.2522 p 801.285.1285 p 801.328.2522

Hospital Affiliation Hospital Affiliation 440 D St Hospital Affiliation - University of Utah Hospital - St Marks Hospital Salt Lake City UT. 84103 - Salt Lake Regional Medical - Lone Peak Hospital p 801.581.8915 Center Peterson, Brian R MD - Salt Lake Regional Medical - Lone Peak Hospital South Valley Ear Nose And Center 50 N Medical Dr Throat Salt Lake City UT. 84132 Taylor, Steven R MD 13348 S Market Ctr Dr Shelton, Clough MD p 801.581.7514 Ear, Nose & Throat Center Ste 210 University of Utah Health of Utah Riverton UT. 84065 100 N Mario Capecchi Dr 729 S Arapeen Dr 4063 W 12600 S p 801.566.8304 Salt Lake City UT. 84113 Salt Lake City UT. 84108 Herriman UT. 84096 p 801.213.3599 p 801.581.7514 p 801.328.2522 3584 W 9000 S Ste 311 50 N Medical Dr Primary Childrens Hospital Ventura, Peter G MD West Jordan UT. 84088 Salt Lake City UT. 84132 Physicians ENT Surgical Associates p 801.566.8304 p 801.581.7514 81 N Mario Capecchi Dr 8400 W 3665 S Salt Lake City UT. 84113 Ste 260 Hospital Affiliation 5121 S Cottonwood St p 801.662.1000 Magna UT. 84044 - Jordan Valley Medical Murray UT. 84107 p 801.912.8270 Center p 801.581.7514 Hospital Affiliation - Primary Childrens Hospital Hospital Affiliation Prussin, Aaron J MD 5770 S 250 E - University of Utah Hospital - Mountain West Medical University of Utah Health Ste 170 Center 100 N Mario Capecchi Dr Salt Lake City UT. 84107 South Valley Ear Nose and Salt Lake City UT. 84113 p 801.581.7514 Throat Ward, Preston D MD p 801.213.3599 3584 W 9000 S Ward MD, LLC 8th Ave & C St Ste 311 6322 S 3000 E 50 N Medical Dr Salt Lake City UT. 84143 West Jordan UT. 84088 Ste 170 Salt Lake City UT. 84132 p 801.581.7514 p 801.566.8304 Salt Lake City UT. 84121 p 801.581.7514 p 801.513.3223 Hospital Affiliation 5169 S Cottonwood St Hospital Affiliation - University of Utah Hospital Salt Lake City UT. 84107 Hospital Affiliation - University of Utah Hospital p 801.566.8304 - University of Utah Hospital *Skirko, Jonathan R MD Schiffer, Breanne L MD Primary Childrens Hospital Swenson, Randal W MD Wilson, Kevin MD University Of Utah Health 100 N Mario Capecchi Dr ENT Specialists ENT Specialists 100 N Mario Capecchi Dr Salt Lake City UT. 84113 4000 S 700 E 4000 S 700 E Salt Lake City UT. 84113 p 801.662.2100 Ste 10 Ste 10 p 801.213.3599 Salt Lake City UT. 84107 Salt Lake City UT. 84107 Hospital Affiliation p 801.268.4141 p 801.268.4141 1950 Cir of Hope Dr - Primary Childrens Hospital Salt Lake City UT. 84112 74 E 11800 S 74 E 11800 S p 801.585.0100 Slattery, Eric L MD Ste 360 Ste 360 Ear, Nose & Throat Center Draper UT. 84020 Draper UT. 84020 440 D St of Utah p 801.260.3687 p 801.260.3687 Salt Lake City UT. 84103 22 S 900 E p 801.581.8915 Salt Lake City UT. 84102 Hospital Affiliation 8846 S Redwood Rd p 801.328.2522 - St Marks Hospital Ste E-121 50 N Medical Dr West Jordan UT. 84088 Salt Lake City UT. 84132 4063 W 12600 S Tagge, Bryan C MD p 801.268.4141 p 801.581.7514 Herriman UT. 84096 Ear, Nose & Throat Center p 801.328.2522 of Utah Hospital Affiliation Hospital Affiliation 1255 E 3900 S - University of Utah Hospital - University of Utah Hospital 756 E 12200 S Ste 301 Draper UT. 84020 Salt Lake City UT. 84124 Electrophysiology Sharma, Pramod K MD p 801.328.2522 p 801.328.2522 Day, John D MD Ear, Nose & Throat Center Mountainstar Cardiology St of Utah Smith, Marshall E MD 22 S 900 E Marks 22 S 900 E University of Utah Health Salt Lake City UT. 84102 1160 E 3900 S Salt Lake City UT. 84102 100 N Mario Capecchi Dr p 801.328.2522 Ste 2000 p 801.328.2522 Salt Lake City UT. 84113 Salt Lake City UT. 84124 p 801.213.3599 p 801.266.3418

176 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 74 Kimballs Ln 615 S Arapeen Dr Couldwell, Marie F MD Gamble, David NP Ste 330 Ste 100 Granger Medical Clinic Utah Endocrinology Draper UT. 84020 Salt Lake City UT. 84108 2965 W 3500 S Associates PLLC p 801.266.3418 p 801.581.7761 West Valley City UT. 84119 470 E 3900 S p 801.965.3600 Ste 200 Hospital Affiliation University Of Utah Health Salt Lake City UT. 84107 - Salt Lake Regional Medical 85 N Medical Dr Hospital Affiliation p 801.747.2800 Center Salt Lake City UT. 84112 - University of Utah Hospital p 801.581.7763 - Primary Childrens Hospital Graham, Timothy E MD Forstall, Peter G MD Diabetes & Endocrine Northern Utah Hospital Affiliation Craven, James P MD Treatment Specialists Cardiovascular Associates - University of Utah Hospital University Of Utah Health 7410 S Creek Rd 1160 E 3900 S 175 N Medical Dr Ste 100 Ste 2000 Ahmad, Shahzad MD Salt Lake City UT. 84132 Sandy UT. 84093 Salt Lake City UT. 84124 Endocrinology Center of p 801.585.7575 p 801.816.1010 p 801.226.3418 Utah 4465 S 900 E 85 N Medical Dr Hospital Affiliation Hospital Affiliation Ste 200 Salt Lake City UT. 84112 - University of Utah Hospital - Ogden Regional Medical Salt Lake City UT. 84124 p 801.581.7763 Center p 801.871.8366 Grotzke, Marissa P MD - Brigham City Community Falahati-Nini, Alireza University of Utah Health Hospital Hospital Affiliation MD 1950 Cir of Hope Dr - Davis Hospital - Timpanogos Regional Hospital Utah Endocrinology Salt Lake City UT. 84112 - Cache Valley Hospital - Lone Peak Hospital Associates PLLC p 801.581.7763 470 E 3900 S Navaravong, Leenhapong Aljammal, Jules MD Ste 200 50 N Medical Dr (Leen) MD JC Aljammal, PLLC Salt Lake City UT. 84107 Salt Lake City UT. 84132 University of Utah Health 4465 S 900 E p 801.747.2800 p 801.581.7763 1950 Cir Of Hope Dr Ste 200 Salt Lake City UT. 84112 Salt Lake City UT. 84124 Hospital Affiliation 615 S Arapeen Dr p 801.585.3229 p 801.572.3433 - St Marks Hospital Ste 100 - Lone Peak Hospital Salt Lake City UT. 84108 50 N Medical Dr Hospital Affiliation p 801.581.7761 Salt Lake City UT. 84132 - Mountain Point Medical Ferrone, Joyce C NP p 801.585.3229 Center Wasatch Endocrinology and University Of Utah Health - Utah Valley Hospital Diabetes Specialists 85 N Medical Dr University Of Utah Health 1035 W Bellwood Ln Salt Lake City UT. 84112 85 N Medical Dr Brady, Bruce R MD Ste 160 p 801.581.7763 Salt Lake City UT. 84112 Utah Endocrinology Salt Lake City UT. 84123 p 801.585.3229 Associates PLLC p 801.746.0776 Hospital Affiliation 470 E 3900 S - University of Utah Hospital Hospital Affiliation Ste 200 Fisher, Simon J MD - University of Utah Hospital Salt Lake City UT. 84107 University of Utah Health Grua, James R MD p 801.747.2800 1950 Cir of Hope Dr Granger Medical Steinberg, Benjamin A MD Salt Lake City UT. 84112 Specialists University of Utah Health Hospital Affiliation p 801.581.7763 2965 W 3500 S 50 N Medical Dr - St Marks Hospital West Valley City UT. 84119 Salt Lake City UT. 84132 50 N Medical Dr p 801.965.3600 p 801.585.3229 Brinton, Eliot A MD Salt Lake City UT. 84132 Intermountain Lipid Center p 801.581.7763 Hospital Affiliation Hospital Affiliation 421 Wakara Way - St George Regional Hospital - University of Utah Hospital Ste 121 615 S Arapeen Dr Salt Lake City UT. 84108 Ste 100 Knecht, Thomas MD Endocrinology p 801.583.8852 Salt Lake City UT. 84108 Wasatch Endocrinology and Abraham, Devaprabu MD p 801.581.7761 Diabetes Specialists University of Utah Health Burr, Robert E MD 1035 W Bellwood Ln 1950 Cir of Hope Dr Wasatch Endocrinology and University Of Utah Health Ste 160 Salt Lake City UT. 84112 Diabetes Specialists 85 N Medical Dr Salt Lake City UT. 84123 p 801.581.7763 1035 W Bellwood Ln Salt Lake City UT. 84112 p 801.746.0776 Ste 160 p 801.581.7763 50 N Medical Dr Salt Lake City UT. 84123 Padilla, Miriam Salt Lake City UT. 84132 p 801.746.0776 Hospital Affiliation Specialty Surgery of Utah p 801.581.7763 - University of Utah Hospital - West Valley Hospital Affiliation 3336 S 4155 W - Salt Lake Regional Medical Ste 306 Center West Valley City UT. 84120 p 801.964.3855

177 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Specialty Surgery Of Utah Endocrinology of Utah @ 50 N Medical Dr U-U Endocrinology Division - West Valley West Jordan Salt Lake City UT. 84132 615 Arapeen Dr 3336 S Pioneer Pkwy 3590 W 9000 S p 801.581.7763 Salt Lake City UT. 84108 Ste 306 Ste 240 p 801.581.7763 West Valley City UT. 84120 West Jordan UT. 84088 615 S Arapeen Dr p 801.208.6367 p 801.508.3140 Ste 100 Wahl, Matthew P MD Salt Lake City UT. 84108 University of Utah Health Endocrinology of Utah @ Schlegel, Amnon MD,PhD p 801.581.7761 1280 E Stringham Ave West Jordan University of Utah Health Salt Lake City UT. 84106 3590 W 9000 S 1950 Cir of Hope Dr University Of Utah Health p 801.581.7763 Ste 240 Salt Lake City UT. 84112 85 N Medical Dr West Jordan UT. 84088 p 801.581.7763 Salt Lake City UT. 84112 1950 Cir of Hope Dr p 801.508.3140 p 801.581.7763 Salt Lake City UT. 84112 50 N Medical Dr p 801.581.7763 Perkins, Kelly A PA Salt Lake City UT. 84132 Hospital Affiliation Utah Endocrinology p 801.581.7763 - University of Utah Hospital 50 N Medical Dr Associates PLLC Salt Lake City UT. 84132 470 E 3900 S 615 S Arapeen Dr Simonetti, Juliana MD p 801.581.7763 Ste 200 Ste 100 University of Utah Health Salt Lake City UT. 84107 Salt Lake City UT. 84108 615 S Arapeen Dr 615 S Arapeen Dr p 801.747.2800 p 801.581.7761 Ste 100 Ste 100 Salt Lake City UT. 84108 Salt Lake City UT. 84108 Rayner, Hansel M PA University Of Utah Health p 801.581.7761 p 801.581.7761 Mt Timpanogas Fertility & 85 N Medical Dr Endocrinology Salt Lake City UT. 84112 Staskus, Gitana MD University Of Utah Health 1561 W 7000 S p 801.581.7763 University of Utah Health 85 N Medical Dr Ste 201 1950 Cir of Hope Dr Salt Lake City UT. 84112 West Jordan UT. 84084 Hospital Affiliation Salt Lake City UT. 84112 p 801.581.7763 p 801.938.9627 - University of Utah Hospital p 801.581.7763 Hospital Affiliation Reddy, Deepika S MD Sharma, Anu MD 50 N Medical Dr - University of Utah Hospital University of Utah Health University of Utah Health Salt Lake City UT. 84132 1950 Cir of Hope Dr 1950 Cir of Hope Dr p 801.581.7763 Welt, Corrine K MD Salt Lake City UT. 84112 Salt Lake City UT. 84112 University of Utah Health p 801.581.7763 p 801.581.7763 615 S Arapeen Dr 1950 Cir of Hope Dr Ste 100 Salt Lake City UT. 84112 50 N Medical Dr 50 N Medical Dr Salt Lake City UT. 84108 p 801.581.7763 Salt Lake City UT. 84132 Salt Lake City UT. 84132 p 801.581.7761 p 801.581.7763 p 801.581.7763 50 N Medical Dr University Of Utah Health Salt Lake City UT. 84132 615 S Arapeen Dr 615 S Arapeen Dr 85 N Medical Dr p 801.581.7763 Ste 100 Ste 100 Salt Lake City UT. 84112 Salt Lake City UT. 84108 Salt Lake City UT. 84108 p 801.581.7763 615 S Arapeen Dr p 801.581.7761 p 801.581.7761 Ste 100 Hospital Affiliation Salt Lake City UT. 84108 University Of Utah Health University Of Utah Health - University of Utah Hospital p 801.581.7761 85 N Medical Dr 85 N Medical Dr Salt Lake City UT. 84112 Salt Lake City UT. 84112 Tobery, Ted MD University Of Utah Health p 801.581.7763 p 801.581.7763 Salt Lake Multi Specialty 85 N Medical Dr 82 S 1100 E Salt Lake City UT. 84112 Hospital Affiliation Hospital Affiliation Ste 103 p 801.581.7763 - University of Utah Hospital - University of Utah Hospital Salt Lake City UT. 84102 p 801.505.5370 Hospital Affiliation Rios, Marvin MD Simmons, Debra L MD - University of Utah Hospital Specialty Surgery of Utah University of Utah Health Hospital Affiliation - West Valley City 175 N Medical Dr E - Salt Lake Regional Medical Wilkerson, Jaclynn F NP 3336 S 4155 W Salt Lake City UT. 84132 Center Utah Endocrinology Ste 306 p 801.585.7575 Associates PLLC West Valley City UT. 84120 UUHC South Jordan Health 470 E 3900 S p 801.964.3855 1950 Cir of Hope Dr Center Ste 200 Salt Lake City UT. 84112 5126 W Daybreak Pkwy Salt Lake City UT. 84107 Jordan Valley Medical p 801.581.7763 South Jordan UT. 84095 p 801.747.2800 Center p 801.213.4500 3580 W 9000 S Ste 110 West Jordan UT. 84088 p 801.263.2370

178 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Endodontist 530 S Wakara Way Allen, Juanita APRN Alvarado, Gerica MD Elggren, Richard DMD Salt Lake City UT. 84108 Exodus Healthcare Network Community Health Centers University of Utah Health p 801.587.6453 3336 S Pioneer Pkwy 1365 W 1000 N 50 N Medical Dr Clinic 7 Ste 201 Salt Lake City UT. 84116 Salt Lake City UT. 84132 7495 S State St Salt Lake City UT. 84120 p 801.328.5756 p 801.581.2220 Midvale UT. 84047 p 801.250.9638 p 801.213.9530 American Wellness & Rehab 530 S Wakara Way 3665 S 8400 W 677 W 5300 S Salt Lake City UT. 84108 Endoscopy Center Ste 110 Murray UT. 84123 p 801.587.6453 Mountain West Endoscopy Magna UT. 84044 p 801.327.8700 Center p 801.250.9638 7495 S State St 6360 S 3000 E Andersen, Dana A MD Midvale UT. 84047 Ste 320 Hospital Affiliation Granger Medical Clinic p 801.213.9530 Salt Lake City UT. 84121 - Jordan Valley Medical 2751 W 9000 S p 801.944.3166 Center West Valley Campus West Jordan UT. 84088 Gibby, Stuart G DDS p 801.352.5900 University of Utah Health Wasatch Endoscopy Center Allen, Richard E MD 3690 S Main St 1220 E 3900 S Palliative Specialty Group 3181 W 9000 S Salt Lake City UT. 84115 Ste 1B 1106 E 6600 S West Jordan UT. 84088 p 801.587.2525 Salt Lake City UT. 84124 Salt Lake City UT. 84121 p 801.569.5600 p 801.281.3657 p 801.930.5266 50 N Medical Dr Clinic 7 Hospital Affiliation Salt Lake City UT. 84132 Family Practice St Marks Family Medicine - Jordan Valley Medical p 801.581.2220 Abarca, Sergio MD 1250 E 3900 S Center Mountain West Psychiatry Ste 260 530 S Wakara Way 3688 W 2100 S Salt Lake City UT. 84124 Anderson, Holly M MD Salt Lake City UT. 84108 West Valley City UT. 84120 p 801.265.2000 Foothill Family Clinic p 801.587.6453 p 435.830.0554 13953 S Bangerter Pkwy Hospital Affiliation Draper UT. 84020 7495 S State St Hospital Affiliation - St Marks Hospital p 385.900.4090 Midvale UT. 84047 - Mountain West Medical - Jordan Valley Medical p 801.213.9530 Center Center 2295 Foothill Dr Salt Lake City UT. 84109 Hospital Affiliation Abbey, Rebecca MD Allred, Don P DO p 801.486.3021 - University of Utah Hospital University of Utah Health Riverton Family Health 3730 W 4700 S Center 6360 S 3000 E Groneman, Brian S DDS Taylorsville UT. 84129 1756 W Park Ave Ste 100 University of Utah Dental p 801.213.9200 Riverton UT. 84065 Salt Lake City UT. 84121 Services p 801.254.0309 p 801.365.1032 3690 S Main St Hospital Affiliation Salt Lake City UT. 84115 - University of Utah Hospital Hospital Affiliation Anderson, Jess NP p 801.587.2525 - Jordan Valley Medical University of Utah Health Ala, Shirley PA-C Center 1950 Cir of Hope Dr 50 N Medical Dr Clinic 7 Senior Behavioral Health Salt Lake City UT. 84112 Salt Lake City UT. 84132 SLC - IP Allred, Matthew O p 801.585.7676 p 801.581.2220 1050 E S Temple 2nd Fl CORE @ West Jordan Salt Lake City UT. 84102 3584 W 9000 S 50 N Medical Dr 530 S Wakara Way p 801.350.4777 Ste 405 Salt Lake City UT. 84132 Salt Lake City UT. 84108 West Jordan UT. 84088 p 801.585.0434 p 801.587.6453 Allan, Jolelene FNP p 801.568.3480 Sunrise Family Practice Arbogast, Richard MD 7495 S State St 8785 Jordan Valley Way Alston, Emily APRN Odyssey House of Utah Midvale UT. 84047 Ste 100 University of Utah Health 350 E 2100 S p 801.213.9530 West Jordan UT. 84088 175 N Medical Dr E Salt Lake City UT. 84115 p 385.645.7474 Salt Lake City UT. 84132 p 801.428.3241 Hospital Affiliation p 801.585.7575 - University of Utah Hospital Allen, Brandon R MD 3944 S 400 E Granger Medical Clinic 50 N Medical Dr Salt Lake City UT. 84107 Rudd, Mitchell DDS 3181 W 9000 S Salt Lake City UT. 84132 p 801.428.3241 University of Utah Health West Jordan UT. 84088 p 801.585.7575 50 N Medical Dr Clinic 7 p 801.569.5600 880 E 3375 S Salt Lake City UT. 84132 Hospital Affiliation Salt Lake City UT. 84106 p 801.581.2220 Hospital Affiliation - University of Utah Hospital p 801.428.3241 - Jordan Valley Medical Center Hospital Affiliation - St Marks Hospital

179 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Arbon, Brett NP 6360 S 3000 E Beazer, Blake R MD Blackburn, Benjamin W PA Rocky Mountain Care Clinic Ste 100 Salson Clinics Medallus Medical 1820 S 4088 W Salt Lake City UT. 84121 1745 W 7800 S 3451 S 5600 W Salt Lake City UT. 84104 p 801.365.1032 West Jordan UT. 84088 Ste F p 801.975.7799 p 801.666.8640 West Valley City UT. 84120 Hospital Affiliation p 801.957.0900 Hospital Affiliation - Primary Childrens Hospital Hospital Affiliation - Mountain West Medical - Salt Lake Regional Medical - Mountain West Medical 7998 S 1300 E Center Center Center Sandy UT. 84092 p 801.255.2000 Archibald, Randall PA Backman, Richard L MD Becker, Brenna APRN St Marks Primary Care at University of Utah Health University of Utah Health Boam, W Derek MD West Valley 3690 S Main St 50 N Medical Dr Granger Medical Clinic 3540 S 4000 W Salt Lake City UT. 84115 Salt Lake City UT. 84132 11724 S State St Ste 340 p 801.213.4500 p 801.213.2995 Draper UT. 84020 West Valley City UT. 84120 p 801.576.2000 p 801.969.0200 555 Foothill Dr 5126 W Daybreak Pkwy Ste 301 South Jordan UT. 84009 12391 S 4000 W Armstrong, Crystal M MD Salt Lake City UT. 84112 p 801.213.4500 Riverton UT. 84065 University of Utah Health p 801.581.8000 p 801.302.1700 3730 W 4700 S 675 S Arapeen Dr West Valley City UT. 84129 Hospital Affiliation Salt Lake City UT. 84108 Hospital Affiliation p 801.213.9200 - University of Utah Hospital p 801.581.3834 - Jordan Valley Medical Center Hospital Affiliation Baiden, Erica N MD Hospital Affiliation - University of Utah Hospital Granger Medical Clinic - University of Utah Hospital Bockoven, Kurt M APRN 2965 W 3500 S Jordan Meadows Medical Atkin, Joseph S MD West Valley City UT. 84119 Berneike, John A MD Center Foothill Family Clinic p 801.965.3600 St Marks Family Medicine 3354 W 7800 S 13953 S Bangerter Pkwy 1250 E 3900 S West Jordan UT. 84088 Draper UT. 84020 Granger Medical Clinic Ste 260 p 801.282.2677 p 801.365.1032 West Jordan Salt Lake City UT. 84124 3181 W 9000 S p 801.265.2000 3534 S 6000 W 6360 S 3000 E West Jordan UT. 84088 West Valley City UT. 84128 Ste 100 p 801.569.5600 Hospital Affiliation p 801.282.2677 Salt Lake City UT. 84121 - St Marks Hospital p 801.365.1032 Hospital Affiliation Bowen, Matthew C DO - Jordan Valley Medical Bickel, Laura APRN Alpine Center Medical Hospital Affiliation Center West Valley Campus University of Utah Health Services - Salt Lake Regional Medical - Jordan Valley Medical 1950 Cir of Hope Dr 5689 S Redwood Rd Center Center Salt Lake City UT. 84112 Ste 30 - Salt Lake Regional Medical p 801.585.2626 Salt Lake City UT. 84123 Aune, David L MD Center p 801.268.1715 Aune Family Medicine Hospital Affiliation 164 E 5900 S Mountain States Counseling - University of Utah Hospital Hospital Affiliation Ste A 108 Center - Ashley Valley Regional Salt Lake City UT. 84107 5635 S Waterbury Way Biggs, Jeremy J MD Medical Center p 385.347.5935 Ste C202 University of Utah Health Salt Lake City UT. 84121 5126 W Daybreak Pkwy Bradley, Paula E PA Hospital Affiliation p 801.278.0200 Ste 600 University of Utah Health - Jordan Valley Medical South Jordan UT. 84009 1525 W 2100 S Center West Valley Campus Barrett, John W MD p 801.213.4500 Salt Lake City UT. 84119 - Jordan Valley Medical University of Utah Health p 801.213.8841 Center 1138 E Wilmington Ave Hospital Affiliation Salt Lake City UT. 84106 - University of Utah Hospital 5126 W Daybreak Pkwy Azarcon, Jose DO p 801.581.2000 Ste 600 Foothill Family Clinic Black, Luce PA South Jordan UT. 84009 13953 S Bangerter Pkwy 1525 W 2100 S University of Utah Health p 801.213.4500 Draper UT. 84020 Salt Lake City UT. 84119 1525 W 2100 S p 385.900.4090 p 801.213.8841 Salt Lake City UT. 84119 Hospital Affiliation p 801.213.8841 - University of Utah Hospital 2295 Foothill Dr Hospital Affiliation Salt Lake City UT. 84109 - University of Utah Hospital Hospital Affiliation p 801.486.3021 - University of Utah Hospital

180 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Brockbank, David J NP-C Caldwell, Katharine L MD Chen, Michael K MD 3534 S 6000 W Exodus Healthcare Network Exodus Healthcare Network University of Utah Health West Valley City UT. 84128 3336 S Pioneer Pkwy 3336 S Pioneer Pkwy 5126 W Daybreak Pkwy p 801.969.6264 Ste 201 Ste 201 Ste 600 Salt Lake City UT. 84120 West Valley City UT. 84120 South Jordan UT. 84009 Hospital Affiliation p 801.250.9638 p 801.250.9638 p 801.213.4500 - Jordan Valley Medical Center West Valley Campus 3336 S Pioneer Pkwy 3665 S 8400 W Hospital Affiliation - Jordan Valley Medical Salt Lake City UT. 84120 Ste 110 - University of Utah Hospital Center p 801.250.9638 Magna UT. 84044 p 801.250.9638 Cheng, Melissa MD Claris Health 3665 S 8400 W University of Utah Health 2730 E 3300 S Ste 110 Hospital Affiliation 1525 W 2100 S Salt Lake City UT. 84109 Magna UT. 84044 - University of Utah Hospital Salt Lake City UT. 84119 p 801.487.0896 p 801.250.9638 p 801.213.8841 Campbell, Amy L FNP Clark, Alexander P DO Brown, Wesley R MD Medallus Medical Hospital Affiliation Foothill Family Clinic Jordan Valley Dermatology 10433 S Redwood Rd - University of Utah Hospital 13953 S Bangerter Pkwy 3570 W 9000 S South Jordan UT. 84095 Draper UT. 84020 Ste 220 p 801.545.0600 Christensen, Peter L MD p 385.900.4090 West Jordan UT. 84088 Granger Medical Clinic p 801.569.1456 1126 E 12300 S 2751 W 9000 S 2295 Foothill Dr Draper UT. 84020 West Jordan UT. 84088 Salt Lake City UT. 84109 Hospital Affiliation p 801.545.0600 p 801.352.5900 p 801.486.3021 - Jordan Valley Medical Center Physician Homecare 3181 W 9000 S 6360 S 3000 E 1385 W 2200 S West Jordan UT. 84088 Ste 100 Brunetti, Ross MD Ste 202 p 801.569.5600 Salt Lake City UT. 84121 Foothill Family Clinic West Valley City UT. 84119 p 801.365.1032 13953 S Bangerter Pkwy p 801.682.4461 3968 W Crossing Dr Draper UT. 84020 Ste 100 Hospital Affiliation p 385.900.4090 Cardoza, Kristy L NP Riverton UT. 84065 - Salt Lake Regional Medical Exodus Healthcare Network p 801.302.1700 Center 2295 Foothill Dr 3336 S Pioneer Pkwy Salt Lake City UT. 84109 West Valley City UT. 84120 Hospital Affiliation Coates, Catherine APRN p 801.486.3021 p 801.250.9638 - Jordan Valley Medical Olympus Clinic Center 4624 S Holladay Blvd Hospital Affiliation 3665 S 8400 W Salt Lake City UT. 84117 - Salt Lake Regional Medical Ste 110 Christensen, Shane MD p 801.277.2682 Center Magna UT. 84044 Foothill Family Clinic p 801.250.9638 13953 S Bangerter Pkwy Cobb, Nadia M PA Burt, Rebecca APRN Draper UT. 84020 University of Utah Health University of Utah Health Chan, Kamun DO p 385.900.4090 1138 E Wilmington Ave 1280 E Stringham Ave Granger Medical Clinic Salt Lake City UT. 84106 Salt Lake City UT. 84106 12391 S 4000 W 6360 S 3000 E p 801.581.2000 p 801.581.2000 Riverton UT. 84065 Ste 100 p 801.302.1700 Salt Lake City UT. 84121 1280 E Stringham Ave 1525 W 2100 S p 801.365.1032 Salt Lake City UT. 84106 Salt Lake City UT. 84119 2965 W 3500 S p 801.581.2000 p 801.213.9900 West Valley City UT. 84119 Hospital Affiliation p 801.965.3600 - Salt Lake Regional Medical 555 Foothill Dr 3730 W 4700 S Center Ste 301 West Valley City UT. 84129 3181 W 9000 S - St Marks Hospital Salt Lake City UT. 84112 p 801.213.9200 West Jordan UT. 84088 p 801.581.8000 p 801.569.5600 Christensen, Thomas R MD 5126 W Daybreak Pkwy On Call Doc Hospital Affiliation Ste 600 Chapman, Diane APRN 10437 S Jordan Gateway - University of Utah Hospital South Jordan UT. 84009 St Marks Family Medicine South Jordan UT. 84095 p 801.213.4500 1250 E 3900 S p 801.610.9159 Cobble, Michael E MD Ste 260 Canyons Medical Center 7495 S State St Salt Lake City UT. 84124 Civish, Frederic M MD 9355 S 1300 E Midvale UT. 84047 p 801.265.2000 Jordan Meadows Medical Sandy UT. 84094 p 801.213.9400 Center p 801.572.1616 3354 W 7800 S Hospital Affiliation West Jordan UT. 84088 - University of Utah Hospital p 801.282.2677

181 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Cochella, Susan E MD 4535 S 5600 W 85 N Medical Dr Dame, John MD University of Utah Health West Valley City UT. 84120 Salt Lake City UT. 84112 St Marks Family Medicine 1138 E Wilmington Ave p 801.676.4405 p 801.581.7818 1250 E 3900 S Salt Lake City UT. 84106 Ste 260 p 801.581.2000 4745 S 3200 W Hospital Affiliation Salt Lake City UT. 84124 Salt Lake City UT. 84118 - University of Utah Hospital p 801.265.2000 1280 E Stringham Ave p 801.964.6214 Salt Lake City UT. 84106 Cox, Gina MD Midtown Community Health p 801.581.2000 610 S 200 E Foothill Family Clinic Centers Ste B 13953 S Bangerter Pkwy 2253 S State St Hospital Affiliation Salt Lake City UT. 84111 Draper UT. 84020 Salt Lake City UT. 84115 - Salt Lake Regional Medical p 801.539.8617 p 385.900.4090 p 801.486.0911 Center - University of Utah Hospital Conner, Thomas K MD 6360 S 3000 E Hospital Affiliation Foothill Family Clinic Ste 100 - St Marks Hospital Coleman, Stephen MD 13953 S Bangerter Pkwy Salt Lake City UT. 84121 Foothill Family Clinic Draper UT. 84020 p 801.365.1032 Day, Julie S MD 13953 S Bangerter Pkwy p 385.900.4090 University of Utah Health Draper UT. 84020 Hospital Affiliation 1525 W 2100 S p 385.900.4090 6360 S 3000 E - Salt Lake Regional Medical Salt Lake City UT. 84119 Ste 100 Center p 801.213.8841 6360 S 3000 E Salt Lake City UT. 84121 - St Marks Hospital Ste 100 p 801.365.1032 295 S Chipeta Way Salt Lake City UT. 84121 Cross, Zoe K MD Ste 248 p 801.365.1032 Hospital Affiliation St Marks Family Medicine Salt Lake City UT. 84108 - Salt Lake Regional Medical 1250 E 3900 S p 801.213.3777 Hospital Affiliation Center Ste 260 - Salt Lake Regional Medical Salt Lake City UT. 84124 50 N Medical Dr Center Cormier, Sarah J NP p 801.265.2000 Salt Lake City UT. 84132 Neurosci and p 801.581.2121 Collett, Camille MD Rehabilitation Specialists Curran, Marilyn L MD St Marks Family Medicine @ SLC Community Health Centers 7495 S State St 1250 E 3900 S 82 S 1100 E 610 S 200 E Midvale UT. 84047 Ste 260 Ste 103 Ste B p 801.213.9400 Salt Lake City UT. 84124 Salt Lake City UT. 84102 Salt Lake City UT. 84111 p 801.265.2000 p 801.505.5370 p 801.539.8617 Hospital Affiliation - University of Utah Hospital Hospital Affiliation Cosgrave, Michael L DO Hospital Affiliation - St Marks Hospital Medallus Medical - University of Utah Hospital Day, Stefani MD - Salt Lake Regional Medical 10433 S Redwood Rd Community Health Centers Center South Jordan UT. 84095 Curran, Rebecca L MD 610 S 200 E p 801.501.0500 University of Utah Health Ste B Collins, Elizabeth N FNP 1138 E Wilmington Ave Salt Lake City UT. 84111 Phase II Center for Womens Coursey, Jeffrey M PA Salt Lake City UT. 84106 p 801.539.8617 Health Community Health Centers p 801.581.2000 348 E 4500 S 610 S 200 E Hospital Affiliation Ste 200 Ste B 555 Foothill Dr - Primary Childrens Hospital Murray UT. 84107 Salt Lake City UT. 84111 Ste 301 p 801.262.9800 p 801.539.8617 Salt Lake City UT. 84112 Daynes, Randall P MD p 801.581.8000 Holladay Family Practice Community Health Centers Cox, China G MD 999 Murray Holladay Rd 1365 W 1000 N University Of Utah Health Hospital Affiliation Ste 207 Salt Lake City UT. 84116 1950 Cir of Hope Dr - University of Utah Hospital Salt Lake City UT. 84117 p 801.328.5756 Salt Lake City UT. 84112 p 801.268.2584 p 801.585.0100 Cutlip, Cheryle MD 1388 S Navajo St Granger Medical Clinic De La Garza, Amy Salt Lake City UT. 84104 50 N Medical Dr 2965 W 3500 S Heron Medical p 801.955.2360 Salt Lake City UT. 84132 West Valley City UT. 84119 77 S 700 E p 801.581.7818 p 801.965.3600 Ste 220 220 W 7200 S Salt Lake City UT. 84102 Ste A 501 S Chipeta Way Hospital Affiliation p 801.532.2570 Midvale UT. 84047 Salt Lake City UT. 84108 - Jordan Valley Medical p 801.566.5494 p 801.583.2500 Center - Jordan Valley Medical Center West Valley Campus

182 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Decker, Jocelyn J NP Ding, Mary APRN Dunn, Amanda J PA-C Ely, Brian M DO Exodus Healthcare Network University of Utah Health ENT Specialists University of Utah Health 3336 S Pioneer Pkwy 1280 E Stringham Ave 4000 S 700 E 5126 W Daybreak Pkwy Ste 201 Salt Lake City UT. 84106 Ste 10 Ste 600 Salt Lake City UT. 84120 p 801.581.7724 Salt Lake City UT. 84107 South Jordan UT. 84009 p 801.250.9638 p 801.268.4141 p 801.213.4500 50 N Medical Dr 3665 S 8400 W Salt Lake City UT. 84132 5770 S 250 E Hospital Affiliation Ste 110 p 801.581.4333 Ste 415 - University of Utah Hospital Ste 110 Salt Lake City UT. 84107 Magna UT. 84044 5126 W Daybreak Pkwy p 801.268.2822 Engelbert Fenton, Michael p 801.250.9638 South Jordan UT. 84009 D PA p 801.581.4333 74 E 11800 S Gourley Allergy & Asthma Depew, Craig MD Ste 360 6065 S Fashion Blvd Granger Medical Clinic - Hospital Affiliation Draper UT. 84020 Ste 255 Urgent Care - University of Utah Hospital p 801.260.3687 Salt Lake City UT. 84107 11724 S State St p 801.266.4115 Draper UT. 84020 Dinh, An T MD Dunn, Jessica APRN p 801.576.2050 South Valley Primary Care Palliative Specialty Group Epperson, Sally NP 13348 S Market Ctr Dr 1106 E 6600 S Olympus Clinic Granger Medical Clinic Ste 210 Salt Lake City UT. 84121 4624 S Holladay Blvd 12391 S 4000 W Riverton UT. 84065 p 801.930.5266 Salt Lake City UT. 84117 Riverton UT. 84065 p 801.987.7500 p 801.277.2682 p 801.302.1700 Durtschi, Ronald D MD St Marks Millcreek Primary Western Hills Medical Epstein, Angela PA 2965 W 3500 S Care Clinic - West Valley Medallus Medical West Valley City UT. 84119 4465 S 900 E 3336 S 4155 W 10433 S Redwood Rd p 801.965.3600 Ste 200 Ste 204 South Jordan UT. 84095 Salt Lake City UT. 84124 West Valley City UT. 84120 p 801.501.0500 3181 W 9000 S p 801.266.2777 p 801.912.9710 West Jordan UT. 84088 7998 S 1300 E p 801.569.5600 Steward Primary Care - Hospital Affiliation Sandy UT. 84092 Murray - Davis Hospital p 801.255.2000 Hospital Affiliation 5980 S Fashion Blvd - Jordan Valley Medical Murray UT. 84107 Eborn, Shana K MD Exodus Healthcare Network Center West Valley Campus p 385.351.6778 Foothill Family Clinic 3336 S Pioneer Pkwy 13953 S Bangerter Pkwy West Valley City UT. 84120 Devenport, Stephen B MD MountainStar Medical Draper UT. 84020 p 801.250.9638 Granger Medical Clinic Group-St. Marks Hospital p 385.900.4090 12391 S 4000 W 74 Kimballs Ln 3665 S 8400 W Riverton UT. 84096 Ste 260 2295 Foothill Dr Ste 110 p 801.302.1700 Draper UT. 84020 Salt Lake City UT. 84109 Magna UT. 84044 p 801.545.8480 p 801.486.3021 p 801.250.9638 2751 W 9000 S West Jordan UT. 84088 Hospital Affiliation Hospital Affiliation Farnworth, Zachary DO p 801.352.5900 - St Marks Hospital - Salt Lake Regional Medical Exodus Healthcare Network - Mountain West Medical Center 3336 S Pioneer Pkwy 3968 W Crossing Dr Center Ste 201 Ste 100 Edwards, Susan MD West Valley City UT. 84120 Riverton UT. 84065 Doucette, Cassidy APRN Foothill Family Clinic p 801.250.9638 p 801.302.1700 University of Utah Health 6360 S 3000 E 1950 Cir of Hope Dr Ste 100 3665 S 8400 W Hospital Affiliation Salt Lake City UT. 84112 Salt Lake City UT. 84121 Ste 110 - Jordan Valley Medical p 801.585.0100 p 801.365.1032 Magna UT. 84044 Center p 801.250.9638 - Jordan Valley Medical Hospital Affiliation Hospital Affiliation Center West Valley Campus - University of Utah Hospital - Salt Lake Regional Medical Farrell, Michael J DO Center University of Utah Health Dietlein, John MD Drage, Brian G MD 50 N Medical Dr Physician Homecare Highland Family Practice Elrod, Amanda L PA Salt Lake City UT. 84132 1385 W 2200 S 4460 S Highland Dr University of Utah Health p 801.581.2628 Ste 202 Ste 400 3690 S Main St West Valley City UT. 84119 Salt Lake City UT. 84124 Salt Lake City UT. 84115 p 801.682.4461 p 801.272.4111 p 801.587.2525

Hospital Affiliation - St Marks Hospital - Moab Regional Hospital 183 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. University Of Utah Health Fixmer, Jared M MD Fuller, Gene R MD Gellner, Cynthia L MD 85 N Medical Dr University of Utah Health Holladay Family Practice University of Utah Health Salt Lake City UT. 84112 1525 W 2100 S 999 Murray Holladay Rd 3730 W 4700 S p 801.581.2628 Salt Lake City UT. 84119 Ste 207 West Valley City UT. 84129 p 801.213.8841 Salt Lake City UT. 84117 p 801.213.9200 Hospital Affiliation p 801.268.2584 - University of Utah Hospital Hospital Affiliation Hospital Affiliation - University of Utah Hospital Hospital Affiliation - Jordan Valley Medical Farrell, Timothy W MD - St Marks Hospital Center University of Utah Health Flinders, Ann M FNP - St Marks Hospital 1525 W 2100 S Exodus Healthcare Network Furness, Todd W DO - University of Utah Hospital Salt Lake City UT. 84119 3336 S Pioneer Pkwy MountainStar Medical Group p 801.213.8841 Ste 201 74 Kimballs Ln Gontrum, David M MD West Valley City UT. 84120 Ste 260 Community Health Centers 50 N Medical Dr p 801.250.9638 Draper UT. 84020 4745 S 3200 W Salt Lake City UT. 84132 p 801.545.8480 Salt Lake City UT. 84129 p 801.581.2628 3665 S 8400 W p 801.964.6214 Ste 110 Hospital Affiliation 555 Foothill Dr Magna UT. 84044 - St Marks Hospital Hospital Affiliation Salt Lake City UT. 84112 p 801.250.9638 - Lone Peak Hospital - University of Utah Hospital p 801.581.2628 - Primary Childrens Hospital Fonua, Siosi O APRN Gamble, Christopher J MD 700 Foothill Blvd Odyssey House - Martindale Olympus Clinic Goossen, Rachel MD Salt Lake City UT. 84113 Medical Clinic 4624 S Holladay Blvd University of Utah Health p 801.581.2628 743 E 300 S Salt Lake City UT. 84117 1280 E Stringham Ave Salt Lake City UT. 84102 p 801.277.2682 Salt Lake City UT. 84106 University Of Utah Health p 801.428.3241 p 801.581.2000 85 N Medical Dr Hospital Affiliation Salt Lake City UT. 84112 Frame, Kara A MD - St Marks Hospital Gourde, Theresa D MD p 801.581.2628 University of Utah Health South Valley Primary Care 555 Foothill Dr Garcia, Maria V APRN 13348 S Market Ctr Dr Hospital Affiliation Ste 301 Midvalley Health Clinic Ste 210 - University of Utah Hospital Salt Lake City UT. 84112 8446 S Harrison St Riverton UT. 84065 p 801.581.8000 Midvale UT. 84047 p 801.987.7500 Fette, Gabriel N MD p 801.417.0131 University Of Utah Health Hospital Affiliation Jordan Valley Internal 85 N Medical Dr - University of Utah Hospital Garling, Adam PA-C Medicine Salt Lake City UT. 84112 1345 E 3900 S 3570 W 9000 S p 801.581.7818 Fredman, Zachary MD Ste 110 Ste 100 University Of Utah Health Salt Lake City UT. 84124 West Jordan UT. 84088 Hospital Affiliation 1280 E Stringham Ave p 801.272.4219 p 801.569.2384 - University of Utah Health Salt Lake City UT. 84106 Craig H Neilsen Rehabilitation Hospitalp 801.581.2000 Garrison, Andrew W MD Hospital Affiliation Community Health Centers - Jordan Valley Medical Fillmore, Randall R MD 555 Foothill Dr 610 S 200 E Center Granger Medical Clinic Ste 301 Ste B 2751 W 9000 S Salt Lake City UT. 84112 Salt Lake City UT. 84111 Grazulis, Diana MD West Jordan UT. 84088 p 801.581.8000 p 801.539.8617 Foothill Family Clinic p 801.352.5900 13953 S Bangerter Pkwy MountainStar Medical Group Hospital Affiliation Draper UT. 84020 3181 W 9000 S 74 Kimballs Ln - University of Utah Hospital p 385.900.4090 West Jordan UT. 84088 Ste 260 - Salt Lake Regional Medical p 801.569.5600 Draper UT. 84020 Center 6360 S 3000 E p 801.545.8480 Ste 100 Hospital Affiliation Gay, Christopher A MD Salt Lake City UT. 84121 - Jordan Valley Medical Hospital Affiliation Evolutionary Healthcare p 801.365.1032 Center - University of Utah Hospital 461 E 200 S Ste 100 Hospital Affiliation Fisher, Mahana S MD Freedom Healthcare Salt Lake City UT. 84111 - Salt Lake Regional Medical Physician Homecare 8899 S 700 E p 801.519.2461 Center 1385 W 2200 S Ste 250 Ste 202 Sandy UT. 84070 Hospital Affiliation Greenberg, Johanna E PA West Valley City UT. 84119 p 801.987.8800 - Salt Lake Regional Medical University of Utah Health p 801.682.4461 Center 1138 E Wilmington Ave Salt Lake City UT. 84106 Hospital Affiliation p 801.581.2000 - Blue Mountain Hospital - St George Regional Hospital 184 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 1212 E Wilmington Ave Hall, Ashley E DO Western Hills Medical Hegmann, Kurt T MD Salt Lake City UT. 84106 Stewart Primary Care Clinic University of Utah Health p 801.213.4500 127 E Main St 3336 S 4155 W 1525 W 2100 S Magna UT. 84044 Ste 204 Salt Lake City UT. 84119 1280 E Stringham Ave p 801.766.9802 West Valley City UT. 84120 p 801.213.8841 Salt Lake City UT. 84106 p 801.912.9700 p 801.581.2000 Exodus Healthcare Network 50 N Medical Dr 3336 S Pioneer Pkwy Harold, Emily J MD Salt Lake City UT. 84132 Hospital Affiliation Ste 201 University of Utah Health p 801.581.2121 - University of Utah Hospital West Valley City UT. 84120 1525 W 2100 S p 801.250.9638 Salt Lake City UT. 84119 Hospital Affiliation Greenwood, Jessica L MD p 801.213.9900 - University of Utah Hospital University of Utah Health Jordan Valley Medical 555 Foothill Dr Center 290 S 1850 E Henich, Casey MD Salt Lake City UT. 84112 3580 W 9000 S Salt Lake City UT. 84112 Granger Medical Clinic p 801.581.8000 West Jordan UT. 84088 p 801.587.7109 11724 S State St p 801.601.4423 Draper UT. 84020 Hospital Affiliation 580 S Guardsman Way p 801.576.2050 - Salt Lake Regional Medical Exodus Healthcare Network Salt Lake City UT. 84112 Center 3665 S 8400 W p 801.587.7109 2965 W 3500 S - University of Utah Hospital Ste 110 West Valley City UT. 84119 Magna UT. 84044 590 S Wakara Way p 801.965.3600 Greenwood, Lyle J DO p 801.250.9638 Salt Lake City UT. 84108 Midvalley Health Clinic p 801.587.7109 Hospital Affiliation 8446 S Harrison St Hamp, Dennis R DO - Jordan Valley Medical Midvale UT. 84047 Jordan Valley Family Hospital Affiliation Center p 801.417.0131 Health - University of Utah Hospital - Jordan Valley Medical 3895 W 7800 S Center West Valley Campus Gregory, Tony S PA Ste 100 Hastings, Katherine M MD Midvalley Health Clinic West Jordan UT. 84088 University of Utah Health Henry, Dan C MD 8446 S Harrison St p 801.280.7774 555 Foothill Dr Foothill Family Clinic Midvale UT. 84047 Ste 301 13953 S Bangerter Pkwy p 801.417.0131 Hospital Affiliation Salt Lake City UT. 84112 Draper UT. 84020 - Jordan Valley Medical p 801.581.8000 p 385.900.4090 Grogan, Margaret E NP Center Granger Medical Clinic Hospital Affiliation 2295 Foothill Dr 1160 E 3900 S Hanson, Nicholas G MD - University of Utah Hospital Salt Lake City UT. 84109 Ste 1000 Alpine Medical Group p 801.486.3021 Salt Lake City UT. 84124 24 S 1100 E Hayes, Lara A MD p 801.262.1771 Ste 310 University Of Utah Health Hospital Affiliation Salt Lake City UT. 84102 85 N Medical Dr - Salt Lake Regional Medical Grover, Eric R DO p 801.478.0010 Salt Lake City UT. 84112 Center Granger Medical Clinic p 801.581.7818 3181 W 9000 S Hospital Affiliation Hermansen, Layne A DO West Jordan UT. 84088 - Castleview Hospital Hospital Affiliation My Family Doctor p 801.569.5600 - University of Utah Health 877 E 12300 S Hardenbrook, Spencer J MD Craig H Neilsen Rehabilitation HospitalSte 201 Guitarrari, Carolina Hidden Valley Family Draper UT. 84020 APRN Medicine Haynes, Lara APRN p 801.542.7111 Community Health Centers 121765 S 1000 E University of Utah Health 1365 W 1000 N Ste 4 590 S Wakara Way Hospital Affiliation Salt Lake City UT. 84116 Draper UT. 84020 Salt Lake City UT. 84108 - Jordan Valley Medical p 801.328.5756 p 801.572.3750 p 801.587.7111 Center

Gundersen, Shaun T PA Hospital Affiliation Hospital Affiliation Hidden Valley Family St Marks Millcreek Primary - St Marks Hospital - University of Utah Hospital Medicine Care 121765 S 1000 E 348 E 4500 S Harmon, Steven J DO Heath, Steven W MD Ste 4 Ste 300 South Valley Primary Care Olympus Clinic Draper UT. 84020 Salt Lake City UT. 84107 13348 S Market Ctr Dr 4624 S Holladay Blvd p 801.572.3750 p 801.266.2777 Ste 210 Salt Lake City UT. 84117 Riverton UT. 84065 p 801.277.2682 Highland Family Practice p 801.987.7500 4460 S Highland Dr Hospital Affiliation Salt Lake City UT. 84124 - St Marks Hospital p 801.272.4111

185 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Hill, Daniel W NP Sandy Ridge Family Jack, David B MD 12391 S 4000 W Jordan Valley Family Medicine Lone Peak Family Medicine Riverton UT. 84065 Health 9350 S 150 E 11760 S 700 E p 801.302.1700 3895 W 7800 S Ste 150 Ste 111 Ste 100 Sandy UT. 84070 Draper UT. 84020 2965 W 3500 S West Jordan UT. 84088 p 801.608.3160 p 801.996.4384 West Valley City UT. 84119 p 801.280.7774 p 801.965.3600 Hospital Affiliation Hospital Affiliation Hill, Lisa MD - Jordan Valley Medical - St Marks Hospital Granger Medical Clinic The Health Spot Center West Valley Campus - Lone Peak Hospital West Jordan 10011 Centennial Pkwy 3181 W 9000 S Ste 350 Hope Family Medical Center Jackson, Andrea FNP-C West Jordan UT. 84088 Sandy UT. 84070 1345 E 3900 S Valley Behavioral Health p 801.569.5600 p 801.566.5350 Ste 204 1020 S Main St Salt Lake City UT. 84124 Ste 100 Hospital Affiliation Hill, Robert C MD p 385.275.4673 Salt Lake City UT. 84101 - Jordan Valley Medical Olympus Clinic p 888.949.4864 Center West Valley Campus 4624 S Holladay Blvd Horwood, Keith MD Salt Lake City UT. 84117 Community Health Centers South Valley Primary Care Jackson, Grant MD p 801.277.2682 4745 S 3200 W 13348 S Market Ctr Dr Olympus Clinic Salt Lake City UT. 84129 Ste 210 4624 S Holladay Blvd Hospital Affiliation p 801.964.6214 Riverton UT. 84065 Ste 100 - St Marks Hospital p 801.987.7500 Salt Lake City UT. 84117 Hospital Affiliation p 801.277.2682 Hogan, Kathleen NP - Primary Childrens Hospital Jordan Valley Internal Health Clinics of Utah Medicine Jackson, Heather A MD 168 N 1950 W Hougaard, Joni W MD 3570 W 9000 S Foothill Family Clinic Ste 201 MountainStar Jordan Family Ste 100 13953 S Bangerter Pkwy Salt Lake City UT. 84116 Health West Jordan UT. 84088 Draper UT. 84020 p 801.715.3500 8846 S Redwood Rd p 801.569.2384 p 385.900.4090 Ste E-121 Holladay Family Practice West Jordan UT. 84088 Taylorsville Urgent Care 2295 Foothill Dr 999 Murray Holladay Rd p 801.569.1999 5360 S 2700 W Salt Lake City UT. 84109 Ste 207 Taylorsville UT. 84129 p 801.486.3021 Salt Lake City UT. 84117 Hospital Affiliation p 801.840.2020 p 801.268.2584 - St Marks Hospital 6360 S 3000 E - Jordan Valley Medical Sandy Ridge Family Ste 100 Holman, Anna J MD Center Medicine Salt Lake City UT. 84121 University Of Utah Health 9350 S 150 E p 801.365.1032 1280 E Stringham Ave Howland, Philip M APRN Ste 150 Salt Lake City UT. 84106 University of Utah Health Sandy UT. 84070 Hospital Affiliation p 801.581.2000 50 N Medical Dr p 801.569.2384 - St Marks Hospital Salt Lake City UT. 84132 - Salt Lake Regional Medical Hospital Affiliation p 801.581.2292 Jackson, Caleb NP Center - University of Utah Hospital MountainStar Medical Group Hospital Affiliation Neurosurgery Jacobs-Peterson, LuAnn Hooda, Pragati MD - University of Utah Hospital 1220 E 3900 S APRN Exodus Healthcare Network Ste 1F Kevin Parzych, MD LLC 3336 S Pioneer Pkwy Huber, Jared S MD Salt Lake City UT. 84124 1151 E 3900 S Ste 201 University Of Utah Health p 801.262.5711 Ste B299 Salt Lake City UT. 84120 85 N Medical Dr Salt Lake City UT. 84124 p 801.250.9638 Salt Lake City UT. 84112 1220 E 3900 S p 801.892.0135 p 801.581.7818 Ste 4A 3665 S 8400 W Salt Lake City UT. 84124 Wasatch Allergy and Asthma Ste 110 Hospital Affiliation p 208.230.7611 13348 S Market Ctr Dr Magna UT. 84044 - University of Utah Health Ste 220 p 801.250.9638 Craig H Neilsen Rehabilitation Hospital74 E Kimballs Ln Riverton UT. 84065 Ste 330 p 385.290.1289 Steward Medical Group Hughes, Matthew A MD Draper UT. 84020 Primary Care Murray University of Utah Health p 801.262.5711 24 S 1100 E 5980 S Fashion Blvd 1525 W 2100 S Ste 305 Salt Lake City UT. 84107 Salt Lake City UT. 84119 Jackson, Easton D MD Salt Lake City UT. 84102 p 801.281.2668 p 801.213.8841 Granger Medical Clinic p 385.290.1289 11724 S State St Hospital Affiliation Draper UT. 84020 Hospital Affiliation - University of Utah Hospital p 801.576.2050 - Mountain West Medical Center

186 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Jarvi, Albert O MD Johnson, Mark D MD 7495 S State St MountainStar Jordan Family Alpine Medical Group 6321 S Redwood Rd Midvale UT. 84047 Health 24 S 1100 E Taylorsville UT. 84123 p 801.213.9400 8846 S Redwood Rd Ste 310 p 801.265.2212 Ste E-121 Salt Lake City UT. 84102 Hospital Affiliation West Jordan UT. 84088 p 801.478.0010 Johnson, Matthew B MD - University of Utah Hospital p 801.569.1999 University of Utah Health Jenkins, Darren B DO 1280 E Stringham Ave Jones, Michael D MD Jorgensen, Jesse A PA Health First Family Salt Lake City UT. 84106 Jordan River Family Health University of Utah Health Medicine p 801.581.2000 1868 W 9800 S 1138 E Wilmington Ave 6933 S 1300 W Ste 100 Salt Lake City UT. 84106 West Jordan UT. 84084 1525 W 2100 S South Jordan UT. 84095 p 801.581.2000 p 801.542.8080 Salt Lake City UT. 84119 p 801.433.2873 p 801.213.8841 3730 W 4700 S Hospital Affiliation Hospital Affiliation West Valley City UT. 84129 - Jordan Valley Medical 3730 W 4700 S - Jordan Valley Medical p 801.213.9200 Center West Valley City UT. 84129 Center p 801.213.9200 555 Foothill Dr Jensen, Tate PA Jones, Susanne F NP Ste 600 Community Health Centers 5126 W Daybreak Pkwy Exodus Healthcare Network Salt Lake City UT. 84112 4745 S 3200 W Ste 600 3336 S Pioneer Pkwy p 801.581.8000 Taylorsville UT. 84118 South Jordan UT. 84009 Ste 201 p 801.964.6214 p 801.213.4500 Salt Lake City UT. 84120 555 Foothill Dr p 801.250.9638 Salt Lake City UT. 84112 Hospital Affiliation 7495 S State St p 801.581.8000 - Jordan Valley Medical Midvale UT. 84047 3665 S 8400 W Center West Valley Campus p 801.213.9400 Ste 110 7495 S State St Magna UT. 84044 Midvale UT. 84047 Jenson, Rebecca APRN Hospital Affiliation p 801.250.9638 p 801.213.9400 Riverton Family Health - University of Utah Hospital Center Jones, Thomas PA Hospital Affiliation 1756 W Park Ave Johnson, Troy S PA-C University of Utah Health - University of Utah Hospital Riverton UT. 84065 Granger Medical Clinic 1525 W 2100 S p 801.254.0309 9001 S 3200 W Salt Lake City UT. 84119 Julien, Katie A MD Ste 3 p 801.213.8841 1868 W 9800 S Hospital Affiliation West Jordan UT. 84088 Ste 100 - Jordan Valley Medical p 801.569.5520 Hospital Affiliation South Jordan UT. 84095 Center - University of Utah Hospital p 801.433.2873 Jonat, Alana M MD Jerman, Douglas B PA Community Health Centers Jones, Wesley DO Hospital Affiliation Granger Medical Clinic 1365 W 1000 N Medallus Medical - Jordan Valley Medical 12391 S 4000 W Salt Lake City UT. 84116 7998 S 1300 E Center Riverton UT. 84065 p 801.328.5756 Sandy UT. 84094 p 801.302.1700 p 801.255.2000 Kammel, Julia M MD Hospital Affiliation Salt Lake Regional Medical 2965 W 3500 S - Primary Childrens Hospital Jordan Meadows Medical Center - Behavioral Health West Valley City UT. 84119 Center Unit p 801.965.3600 Jones, Kyle B MD 3354 W 7800 S 1050 E S Temple University of Utah Health West Jordan UT. 84088 Salt Lake City UT. 84102 Hospital Affiliation 1138 E Wilmington Ave p 801.282.2677 p 801.350.4255 - Jordan Valley Medical Salt Lake City UT. 84106 Center West Valley Campus p 801.581.2000 Jordan Valley Family Medallus Medical - Riverton Childrens Unit Health 6322 S 300 E Operated by Primary Childrens Medical1525 WCenter 2100 S 3570 W 9000 S Ste 140 Salt Lake City UT. 84119 Ste 100 Salt Lake City UT. 84121 Johnson, Laura A MD p 801.213.8841 West Jordan UT. 84088 p 801.912.8210 University of Utah Health p 801.569.1999 5126 W Daybreak Pkwy 3730 W 4700 S Comprehensive Orthopedic & Ste 600 West Valley City UT. 84129 Jorgensen, Brittany S NP Sports Medicine - SLC South Jordan UT. 84009 p 801.213.9200 Lone Peak Family Health 82 S 1100 E p 801.213.4500 74 Kimballs Ln Ste 303 5126 W Daybreak Pkwy Ste 260 Salt Lake City UT. 84102 Hospital Affiliation Ste 600 Draper UT. 84020 p 801.533.2002 - University of Utah Hospital South Jordan UT. 84009 p 801.572.0311 p 801.213.4500 Hospital Affiliation - University of Utah Hospital - Salt Lake Regional Medical Center 187 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Kimball, Erin PA Kirby, Karl A MD 4535 S 5600 W 1525 W 2100 S South Jordan Family St Marks Family Medicine West Valley City UT. 84120 Salt Lake City UT. 84119 Medicine 1250 E 3900 S p 801.676.4405 p 801.213.8841 10623 S Redwood Rd Ste 260 Ste 101 Salt Lake City UT. 84124 4745 S 3200 W 7495 S State St South Jordan UT. 84095 p 801.265.2000 Salt Lake City UT. 84129 Midvale UT. 84047 p 801.302.0899 p 801.964.6214 p 801.213.9400 Hospital Affiliation Lone Peak Family Medicine - St Marks Hospital 610 S 200 E Hospital Affiliation 11760 S 700 E Ste B - Salt Lake Regional Medical Ste 111 Knox, Jordan M MD Salt Lake City UT. 84111 Center Draper UT. 84020 University of Utah Health p 801.235.9835 - University of Utah Hospital p 801.576.8855 1138 E Wilmington Ave Salt Lake City UT. 84106 Larkin, Brian DO Levine, Rebecca J MD St Marks Primary Care at p 801.581.2000 Medallus Medical Jordan River Family West Valley 10433 S Redwood Rd Medicine 3540 S 4000 W 1280 E Stringham Ave South Jordan UT. 84095 1868 W 9800 S Ste 340 Salt Lake City UT. 84106 p 801.501.0500 South Jordan UT. 84095 West Valley City UT. 84120 p 801.581.2000 p 801.569.9133 p 801.969.0200 Larsen, David C MD 555 Foothill Dr Holladay Family Practice Hospital Affiliation St Marks Millcreek Primary Ste 301 999 Murray Holladay Rd - Jordan Valley Medical Care Salt Lake City UT. 84112 Ste 207 Center 4465 S 900 E p 801.581.8000 Salt Lake City UT. 84117 Ste 200 p 801.268.2584 *Lewis, Linda APRN Salt Lake City UT. 84124 Hospital Affiliation Primary Childrens Hospital p 801.266.2777 - University of Utah Hospital Hospital Affiliation 3773 W 12600 S - St Marks Hospital Riverton UT. 84065 74 Kimballs Ln Kowalski, Jedediah APRN p 801.285.1285 Ste 260 University of Utah Health Larsen, Steve W APRN Draper UT. 84020 5126 W Daybreak Pkwy Jordan Meadows Medical 81 N Mario Capecchi Dr p 801.572.0311 Ste 600 Center Salt Lake City UT. 84113 South Jordan UT. 84009 3354 W 7800 S p 801.662.3606 Alta Internal Medicine p 801.213.4500 West Jordan UT. 84088 74 Kimballs Ln p 801.282.2677 8282 S 2200 W Ste 300 Hospital Affiliation West Jordan UT. 84088 Draper UT. 84020 - University of Utah Hospital 3534 S 6000 W p 385.468.4580 p 801.572.0311 West Valley City UT. 84128 Kunkel, Courtney APRN p 801.969.6264 Hospital Affiliation MountainStar Jordan Family University of Utah Health - University of Utah Hospital Health 1950 Cir of Hope Dr Larson, Kirt W NP 8846 S Redwood Rd Salt Lake City UT. 84112 Step Mountain Medical Lewis, Randal J MD Ste E-121 p 801.585.0100 13352 S 5600 W Adult Care Clinic - West Jordan UT. 84088 Herriman UT. 84096 Chateau Brickyard p 801.569.1999 50 N Medical Dr p 801.446.8760 3080 S 1300 E Salt Lake City UT. 84132 Salt Lake City UT. 84106 King, Bari M FNP p 801.581.7553 Lee, Suzanne E MD p 801.466.9999 MountainStar Jordan Family Exodus Healthcare Network Health Hospital Affiliation 3665 S 8400 W Adult Care Clinic 8846 S Redwood Rd - University of Utah Hospital Ste 110 3920 S 1100 E Ste E-121 Ste 110 Ste 310 West Jordan UT. 84088 Lakin, Bobbi MD Magna UT. 84044 Salt Lake City UT. 84124 p 801.569.1999 Community Health Centers p 801.250.9638 p 801.308.8400 1365 W 1000 N Kiraly, Bernadette O MD Salt Lake City UT. 84116 Hospital Affiliation Hospital Affiliation University of Utah Health p 801.328.5756 - Jordan Valley Medical - Jordan Valley Medical 1138 E Wilmington Ave Center West Valley Campus Center West Valley Campus Salt Lake City UT. 84106 1388 S Navajo St p 801.581.2000 Salt Lake City UT. 84104 Leiser, Jennifer P MD Lewis, Wesley MD p 801.955.2360 University of Utah Health Foothill Family Clinic Hospital Affiliation 1138 E Wilmington Ave 13953 S Bangerter Pkwy - Salt Lake Regional Medical 220 W 7200 S Salt Lake City UT. 84106 Draper UT. 84020 Center Ste A p 801.581.2000 p 385.900.4090 - University of Utah Hospital Midvale UT. 84047 p 801.566.5494

188 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 6360 S 3000 E Longe, Jamie MD Mandujano, Martha P PA 3665 S 8400 W Ste 100 Foothill Family Clinic University of Utah Health Ste 110 Salt Lake City UT. 84121 13953 S Bangerter Pkwy 1525 W 2100 S Magna UT. 84044 p 801.365.1032 Draper UT. 84020 Salt Lake City UT. 84119 p 801.250.9638 p 385.900.4090 p 801.213.9900 Hospital Affiliation Maw, Laura C APRN - Salt Lake Regional Medical 6360 S 3000 E Marchand, Kolleen PA-C Ascendant Behavioral Center Ste 100 Jordan Landing Clinic Health Salt Lake City UT. 84121 3895 W 7800 S 5383 S 900 E Li, Marlana M MD p 801.365.1032 Ste 100 Ste 103 University of Utah Health West Jordan UT. 84088 Salt Lake City UT. 84117 555 Foothill Dr Hospital Affiliation p 801.280.7774 p 801.872.5516 Ste 301 - Primary Childrens Hospital Salt Lake City UT. 84112 - Salt Lake Regional Medical Masteller, Malcolm C MD McFarland, Cameron APRN p 801.581.8000 Center University of Utah Health Olympus Clinic 1280 E Stringham Ave 4624 S Holladay Blvd Hospital Affiliation Lowe, Spencer N FNP Salt Lake City UT. 84106 Salt Lake City UT. 84117 - University of Utah Hospital Utah Endocrinology p 801.581.2000 p 801.277.2682 Associates PLLC Lin, Kenneth W MD 470 E 3900 S 1525 W 2100 S Mcadams, Erin E MD University Of Utah Health Ste 200 Salt Lake City UT. 84119 University of Utah Health 1280 E Stringham Ave Salt Lake City UT. 84107 p 801.213.8841 1138 E Wilmington Ave Salt Lake City UT. 84106 p 801.747.2800 Salt Lake City UT. 84106 p 801.581.2000 Hospital Affiliation p 801.581.2000 Lucey, Ronda NP - University of Utah Hospital Hospital Affiliation Phase II Center for Womens 555 Foothill Dr - University of Utah Hospital Health Matich, Andrea J MD Ste 301 348 E 4500 S MountainStar Specialty Salt Lake City UT. 84112 Linsler, Rosemarie NP Ste 200 Services p 801.581.8000 St Marks Family Medicine Murray UT. 84107 1160 E 3900 S 1250 E 3900 S p 801.262.9800 Ste 5000 Hospital Affiliation Ste 260 Salt Lake City UT. 84124 - University of Utah Hospital Salt Lake City UT. 84124 Macey, Wendy PA p 801.262.8486 p 801.265.2000 University of Utah Health Melville, Brian T DO 1525 W 2100 S Center of Orthopedic & Exodus Healthcare Network Liu, Betty MD Salt Lake City UT. 84119 Rehabilitation Excellence 3336 S Pioneer Pkwy Community Health Centers p 801.213.8841 3580 W 9000 S Ste 201 220 W 7200 S Ste 405 & 209 West Valley City UT. 84120 Ste A 7495 S State St West Jordan UT. 84088 p 801.250.9638 Midvale UT. 84047 Midvale UT. 84047 p 801.568.3480 p 801.566.5494 p 801.213.9400 3665 S 8400 W MountainStar General Ste 110 Lobsiger, Jacqueline Hospital Affiliation Surgery Magna UT. 84044 APRN - University of Utah Hospital 74 E Kimballs Ln p 801.250.9638 Granger Medical Clinic Ste 330 1160 E 3900 S Machado-Lovon, Sariah Draper UT. 84020 Turning Point Centers Ste 1000 Medallus Medical p 801.576.2300 8375 S 700 E Salt Lake City UT. 84124 10433 S Redwood Rd Sandy UT. 84070 p 801.262.1771 South Jordan UT. 84095 96 E Kimballs Ln p 801.576.0745 p 801.501.0500 Ste 207 Locke, Amy B MD West Jordan UT. 84088 Midtown South Salt Lake University of Utah Health Macintyre, James G MD p 801.576.2300 Community Health Center 1138 E Wilmington Ave Center of Orthopedic & 2253 S State St Salt Lake City UT. 84106 Rehabilitation Excellence Hospital Affiliation Salt Lake City UT. 84115 p 801.581.2000 - West Jordan - Jordan Valley Medical p 801.625.3700 3584 W 9000 S Center 555 Foothill Dr Ste 405 Miles, Jeffrey G MD Ste 301 West Jordan UT. 84088 Mauric, John M DO Granger Medical Clinic Salt Lake City UT. 84112 p 801.568.3480 Exodus Healthcare Network 1160 E 3900 S p 801.581.8000 3336 S Pioneer Pkwy Ste 1000 Hospital Affiliation Ste 201 Salt Lake City UT. 84124 555 Foothill Dr - Jordan Valley Medical West Valley City UT. 84120 p 801.262.1771 Salt Lake City UT. 84112 Center p 801.250.9638 p 801.581.8000

Hospital Affiliation - University of Utah Hospital

189 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 11724 S State St Mooney, Jennifer PA Granger Medical Clinic 999 Murray Holladay Rd Draper UT. 84020 Medallus Medical 999 Murray Holladay Rd Ste 207 p 801.576.2050 3451 S 5600 W Ste 207 Salt Lake City UT. 84117 Ste F Salt Lake City UT. 84117 p 801.268.2584 12391 S 4000 W West Valley City UT. 84120 p 801.268.2584 Riverton UT. 84065 p 801.957.0900 Hospital Affiliation p 801.302.1700 Hospital Affiliation - St Marks Hospital Moore, David A MD - St Marks Hospital 2965 W 3500 S 1002 E S Temple Nguyen, Anh T MD West Valley City UT. 84119 Ste 508 Muse, Derek D MD 1819 W 3500 S p 801.965.3600 Salt Lake City UT. 84102 Highland Family Practice Ste 1 C p 801.531.8634 4460 S Highland Dr West Valley City UT. 84119 Granger Medical Clinic Ste 400 p 801.975.9707 West Jordan Hospital Affiliation Salt Lake City UT. 84124 3181 W 9000 S - Salt Lake Regional Medical p 801.272.4111 Hospital Affiliation West Jordan UT. 84088 Center - Jordan Valley Medical p 801.569.5600 Hospital Affiliation Center Moreland, Jay C MD - St Marks Hospital - Jordan Valley Medical Hospital Affiliation Community Health Centers Center West Valley Campus - Jordan Valley Medical 220 W 7200 S Nelson, David C DO Center West Valley Campus Ste A Granger Medical Clinic Nordin, Jarah M FNP Midvale UT. 84047 2965 W 3500 S Exodus Healthcare Network Moczygemba, Roger MD p 801.566.5494 West Valley City UT. 84119 3336 S Pioneer Pkwy Medallus Medical p 801.965.3600 Ste 201 10433 S Redwood Rd Hospital Affiliation West Valley City UT. 84120 South Jordan UT. 84095 - Salt Lake Regional Medical Hospital Affiliation p 801.250.9638 p 801.501.0500 Center - Jordan Valley Medical - Davis Hospital Center 3665 S 8400 W Moffat, Andrew DO - Jordan Valley Medical Ste 110 Hyperbaric and Wound Care Morgan, Max G MD Center West Valley Campus Magna UT. 84044 Center at Jordan Valley Medallus Medical p 801.250.9638 Medical Center 13348 S Market Ctr Dr Nelson, Jeanette C PA-C 3590 W 9000 S Ste 100 Endurance Orthopedics and Odyssey House - Martindale Ste 105 Riverton UT. 84065 Sports Medicine - Salt Medical Clinic West Jordan UT. 84088 p 901.844.1600 Lake City East 743 E 300 S p 801.601.2322 2645 E Parleys Way Salt Lake City UT. 84102 Morris, Ray MD Ste 500 p 801.428.3500 Hospital Affiliation Benita Medical Salt Lake City UT. 84109 - Jordan Valley Medical 3465 Pioneer Pkwy p 801.424.5042 Oliver, Steve A MD Center Ste 2 Granger Medical Clinic - Salt Lake Regional Medical West Valley City UT. 84120 Hospital Affiliation 11724 S State St Center p 801.963.7636 - Salt Lake Regional Medical Draper UT. 84020 Center p 801.576.2050 Monroy, Carissa MD Hospital Affiliation Midtown Community Health - Jordan Valley Medical Nelson, Jeffery S DO 2965 W 3500 S Centers Center Freedom Healthcare West Valley City UT. 84119 2253 S State St - Jordan Valley Medical 8899 S 700 E p 801.965.3600 Salt Lake City UT. 84115 Center West Valley Campus Ste 250 p 801.486.0911 Sandy UT. 84070 Granger Medical Clinic Mountain West Psychiatry p 801.613.2711 West Jordan Hospital Affiliation 3688 W 2100 S 3181 W 9000 S - St Marks Hospital West Valley City UT. 84120 Nelson, Joseph DO West Jordan UT. 84088 p 435.830.0554 Granger Medical Clinic p 801.569.5600 Monson, Nicholas DO 1160 E 3900 S University of Utah Health MountainStar Jordan Family Ste 1000 Hospital Affiliation 590 S Wakara Way Health Salt Lake City UT. 84124 - Jordan Valley Medical Salt Lake City UT. 84108 8846 S Redwood Rd p 801.262.1771 Center West Valley Campus p 801.587.7109 Ste E-121 - Jordan Valley Medical West Jordan UT. 84088 Hospital Affiliation Center University Of Utah Health p 801.569.1999 - St Marks Hospital 9385 Snowbird Ctr Dr *Olson, Christopher NP Sandy UT. 84092 Munt, Katherine W MD Nelson, Todd R MD Murray Vascular and Vein p 801.646.4800 Olympus Clinic Granger Medical Clinic 5323 S Woodrow St 4624 S Holladay Blvd 11724 S State St Ste 101 Hospital Affiliation Salt Lake City UT. 84117 Draper UT. 84020 Murray UT. 84107 - Davis Hospital p 801.277.2682 p 801.576.2050 p 801.261.8346

Hospital Affiliation - Davis Hospital 190 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. On Call Doc Overton, Eric S Paulsen, Brooke APRN 24 S 1100 E 10437 S Jordan Gateway Medallus Medical University of Utah Health Ste 305 South Jordan UT. 84095 6322 S 300 E 1525 W 2100 S Salt Lake City UT. 84102 p 801.877.0705 Ste 140 Salt Lake City UT. 84119 p 385.290.1289 Salt Lake City UT. 84121 p 801.213.9900 Oneida, Maria A MD p 801.912.8210 Petzold, Tricia MD West Jordan Medical Center Hospital Affiliation University Of Utah Health 3570 W 9000 S Owen, David G MD - University of Utah Hospital 9385 Snowbird Ctr Dr Ste 200 University of Utah Health Sandy UT. 84092 West Jordan UT. 84088 1525 W 2100 S Peiffer, Andy MD p 801.646.4800 p 801.566.9211 Salt Lake City UT. 84119 University of Utah Health p 801.213.8841 1280 E Stringham Ave Phillips, Alexandria S Hospital Affiliation Salt Lake City UT. 84106 FNP - Jordan Valley Medical 5126 W Daybreak Pkwy p 801.581.2000 Amazing Medical Associates Center Ste 600 835 E 4800 S South Jordan UT. 84009 Peterson, James T MD Ste 110 Oquendo, Valerie PA p 801.213.4500 Foothill Family Clinic Salt Lake City UT. 84107 Granger Medical Clinic 13953 S Bangerter Pkwy p 801.716.7008 1160 E 3900 S Hospital Affiliation Draper UT. 84020 Ste 1000 - University of Utah Hospital p 385.900.4090 Phillips, Andrew L MD Salt Lake City UT. 84124 University of Utah Health p 801.262.1771 Paisley, Theodore S MD 2295 Foothill Dr 1525 W 2100 S University of Utah Health Salt Lake City UT. 84109 Salt Lake City UT. 84119 12391 S 4000 W 1138 E Wilmington Ave p 801.486.3021 p 801.213.8841 Riverton UT. 84065 Salt Lake City UT. 84106 p 801.302.1700 p 801.581.2000 Hospital Affiliation 5126 W Daybreak Pkwy - Primary Childrens Hospital Ste 600 2965 W 3500 S 1280 E Stringham Ave - Salt Lake Regional Medical South Jordan UT. 84009 West Valley City UT. 84119 Salt Lake City UT. 84106 Center p 801.213.4500 p 801.965.3600 p 801.581.8000 Peterson, Mark W DO Hospital Affiliation 3181 W 9000 S 555 Foothill Dr Exodus Healthcare Network - University of Utah Hospital West Jordan UT. 84088 Ste 301 3665 S 8400 W p 801.569.5600 Salt Lake City UT. 84112 Ste 110 Piacitelli, Annliza MD p 801.581.8000 Magna UT. 84044 Annliza Piacitelli, MD Ortiz-Pacheco, Clarivette p 801.250.9638 1868 W 9800 S MD 555 Foothill Dr Ste 100 University of Utah Health Salt Lake City UT. 84112 Heiden Orthopedics South Jordan UT. 84095 1138 E Wilmington Ave p 801.581.8000 6360 S 3000 E p 801.433.2873 Salt Lake City UT. 84106 Ste 210 p 801.581.2000 University Of Utah Health Salt Lake City UT. 84121 Piper, Jaclyn J APRN 9385 Snowbird Ctr Dr p 435.615.8822 Palliative Specialty Group 1525 W 2100 S Sandy UT. 84092 1106 E 6600 S Salt Lake City UT. 84119 p 801.646.4800 Medallus Medical Salt Lake City UT. 84121 p 801.213.8841 7998 S 1300 E p 801.930.5266 Hospital Affiliation Sandy UT. 84092 555 Foothill Dr - Salt Lake Regional Medical p 801.255.2000 University of Utah Health Ste 301 Center 1950 Cir of Hope Dr Salt Lake City UT. 84112 - University of Utah Hospital Hospital Affiliation Salt Lake City UT. 84112 p 801.581.8000 - Jordan Valley Medical p 801.585.0100 Palmer, Michelle L Center West Valley Campus Hospital Affiliation University of Utah Health - Jordan Valley Medical 5126 W Daybreak Pkwy - University of Utah Hospital 3730 W 4700 S Center South Jordan UT. 84009 West Valley City UT. 84129 p 801.213.4246 Osborn, Carol MD p 801.213.9200 Peterson, Sean MD Evolutionary Healthcare Foothill Family Clinic Pippitt, Karly A MD 461 E 200 S Hospital Affiliation 13953 S Bangerter Pkwy University of Utah Health Ste 100 - Jordan Valley Medical Draper UT. 84020 1138 E Wilmington Ave Salt Lake City UT. 84111 Center p 385.900.4090 Salt Lake City UT. 84106 p 801.519.2461 - University of Utah Hospital p 801.581.2000 Peterson, Tia B NP-C Hospital Affiliation Panisi, Uaisele F PA Wasatch Allergy and Asthma 50 N Medical Dr - Salt Lake Regional Medical University of Utah Health 13348 S Market Ctr Dr Salt Lake City UT. 84132 Center 3690 S Main St Ste 220 p 801.585.6387 Salt Lake City UT. 84115 Riverton UT. 84065 p 801.213.4500 p 385.290.1289 Hospital Affiliation - Salt Lake Regional Medical Center - University of Utah Hospital 191 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Pohl, Susan D MD 3730 W 4700 S 3665 S 8400 W 999 Murray Holladay Rd University of Utah Health West Valley City UT. 84129 Ste 110 Ste 207 1525 W 2100 S p 801.213.9200 Ste 110 Salt Lake City UT. 84117 Salt Lake City UT. 84119 Magna UT. 84044 p 801.268.2584 p 801.213.8841 5126 W Daybreak Pkwy p 801.250.9638 Ste 600 Robins, Scott DO 3730 W 4700 S South Jordan UT. 84009 Hospital Affiliation South Valley Primary Care Taylorsville UT. 84129 p 801.213.4500 - Jordan Valley Medical 13348 S Market Ctr Dr p 801.213.9200 Center West Valley Campus Ste 210 7495 S State St Riverton UT. 84065 5126 W Daybreak Pkwy Midvale UT. 84047 Rassner, Leslie H MD p 801.987.7500 Ste 600 p 801.213.9400 St Marks Family Medicine South Jordan UT. 84009 1250 E 3900 S Hyperbaric and Wound Care p 801.213.4500 Hospital Affiliation Ste 260 Center at Jordan Valley - University of Utah Hospital Salt Lake City UT. 84124 Medical Center 555 Foothill Dr p 801.265.2000 3590 W 9000 S Ste 301 Probst, Jared B MD Ste 105 Salt Lake City UT. 84112 Olympus Clinic Hospital Affiliation West Jordan UT. 84088 p 801.581.8000 4624 S Holladay Blvd - St Marks Hospital p 801.601.2322 Salt Lake City UT. 84117 - Salt Lake Regional Medical 7495 S State St p 801.277.2682 Center Sandy Ridge Family Midvale UT. 84047 Medicine p 801.213.9400 Hospital Affiliation Reese, Betsy DO 9350 S 150 E - St Marks Hospital MountainStar Medical Group Ste 150 Hospital Affiliation 74 Kimballs Ln Sandy UT. 84070 - University of Utah Hospital Pugh, Brenten C MD Ste 300 p 801.569.2384 Jordan Landing Clinic Draper UT. 84020 Potter, Vernon D MD 3895 W 7800 S p 801.545.8480 Hospital Affiliation Summit View Medical Ste 100 - Jordan Valley Medical 9829 S 1300 E West Jordan UT. 84088 Reinhardt, Evan DO Center Ste 101 p 801.280.7774 Onsite Care Clinic Sandy UT. 84094 1600 W Merit Pkwy Rodier, Hugo E MD p 801.576.8988 Hospital Affiliation South Jordan UT. 84095 Pioneer Comprehensive - Jordan Valley Medical p 801.316.3900 Medical Hospital Affiliation Center 12433 S Fort St - St Marks Hospital Rhudy, Jackson M MD Draper UT. 84020 Quinton, Magdalena MD Rocky Mountain Care Clinic p 801.576.1086 Powers, Frank J MD University of Utah Health 4088 W 1820 S Community Health Centers 1525 W 2100 S Salt Lake City UT. 84104 Rodriguez, Jose E MD 4745 S 3200 W Salt Lake City UT. 84119 p 801.975.7799 University of Utah Health Salt Lake City UT. 84129 p 801.213.9900 1138 E Wilmington Ave p 801.964.6214 Robbins, James S DO Salt Lake City UT. 84106 Rabin, Mara L MD Exodus Healthcare Network p 801.581.2000 Hospital Affiliation Alpine Medical Group 3336 S Pioneer Pkwy - Primary Childrens Hospital 24 S 1100 E Ste 201 1525 W 2100 S Ste 310 Salt Lake City UT. 84120 Salt Lake City UT. 84119 Prater, Susan E MD Salt Lake City UT. 84102 p 801.250.9638 p 801.213.8841 Granger Medical Clinic p 801.478.0010 11724 S State St 3665 S 8400 W 555 Foothill Dr Draper UT. 84020 Rasmussen, Brian C MD Ste 110 Salt Lake City UT. 84112 p 801.576.2050 Holladay Family Practice Magna UT. 84044 p 801.581.8000 999 Murray Holladay Rd p 801.250.9638 Hospital Affiliation Ste 207 Hospital Affiliation - Jordan Valley Medical Salt Lake City UT. 84117 Hospital Affiliation - University of Utah Hospital Center p 801.268.2584 - Jordan Valley Medical - Lone Peak Hospital Center Rohrer, Jacqueline MD Rasmussen, Carol F FNP - Jordan Valley Medical Foothill Family Clinic Prince, Victoria L MD,PhD Exodus Healthcare Network Center West Valley Campus 13953 S Bangerter Pkwy University of Utah Health 3336 S Pioneer Pkwy Draper UT. 84020 1525 W 2100 S Ste 201 Roberts, Jordan R MD p 385.900.4090 Salt Lake City UT. 84119 Salt Lake City UT. 84120 Granger Medical Clinic p 801.213.9900 p 801.250.9638 11724 S State St 2295 Foothill Dr Draper UT. 84020 Salt Lake City UT. 84109 p 801.576.2050 p 801.486.3021

192 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 6360 S 3000 E Salari, Ali DO 8375 S 700 E Shaw, Dana M NP Ste 100 University of Utah Health Sandy UT. 84070 Olympus Clinic Salt Lake City UT. 84121 5126 W Daybreak Pkwy p 801.576.0745 4624 S Holladay Blvd p 801.365.1032 Ste 600 Salt Lake City UT. 84117 South Jordan UT. 84009 Lone Peak Family Medicine p 801.277.2682 Hospital Affiliation p 801.213.4500 9829 S 1300 E - St Marks Hospital Ste 101 Shen, Katherine A MD - Salt Lake Regional Medical Hospital Affiliation Sandy UT. 84094 Community Health Centers Center - University of Utah Hospital p 801.576.8855 4745 S 3200 W Salt Lake City UT. 84118 Romo, Kristen MD Sampson, Joshua MD Schauers, Todd N PA-C p 801.964.6214 Olympus Clinic University of Utah Health Jordan Valley Family 4624 S Holladay Blvd 1138 E Wilmington Ave Health Hospital Affiliation Salt Lake City UT. 84117 Salt Lake City UT. 84106 3570 W 9000 S - Primary Childrens Hospital p 801.277.2682 p 801.581.2000 Ste 100 West Jordan UT. 84088 Sheridan, Scott D MD Rosenfield, Micah G MD 555 Foothill Dr p 801.569.1999 Granger Medical Clinic Granger Medical Clinic Ste 301 11724 S State St 2965 W 3500 S Salt Lake City UT. 84112 MountainStar Jordan Family Draper UT. 84020 West Valley City UT. 84119 p 801.581.8000 Health p 801.576.2050 p 801.965.3600 8846 S Redwood Rd Hospital Affiliation Ste E-121 12391 S 4000 W Granger Medical Clinic - University of Utah Hospital West Jordan UT. 84088 Riverton UT. 84065 West Jordan p 801.569.1999 p 801.302.1700 3181 W 9000 S Sanderson, Michael J MD West Jordan UT. 84088 Granger Medical Clinic Schleenbaker, Bradley MD 2965 W 3500 S p 801.569.5600 3181 W 9000 S Community Health Centers West Valley City UT. 84119 West Jordan UT. 84088 4535 S 5600 W p 801.965.3600 Hospital Affiliation p 801.569.5600 West Valley City UT. 84120 - Jordan Valley Medical p 801.676.4405 Hospital Affiliation Center West Valley Campus 3725 W 4100 S - Jordan Valley Medical Salt Lake City UT. 84120 Schmidt, Joshua MD Center Rowley, Marcella (Marcy) p 801.965.3479 Prestige Mens Health - Jordan Valley Medical B FNP (Hormone Therapy Center West Valley Campus New Horizon Medical Care Hospital Affiliation Treatment) 1420 W 12600 S - Jordan Valley Medical 997 E 3900 S Sims, Bonnie J PA Ste 102 Center Ste 203 Granger Medical Clinic Riverton UT. 84065 Salt Lake City UT. 84124 11724 S State St p 801.254.4600 Sanyer, Osman N MD p 801.477.5327 Draper UT. 84020 University of Utah Health p 801.576.2000 Hospital Affiliation 555 Foothill Dr Schulof, Stacy APRN - Jordan Valley Medical Ste 301 University of Utah Health 12391 S 4000 W Center Salt Lake City UT. 84112 50 N Medical Dr Riverton UT. 84065 p 801.581.8000 Salt Lake City UT. 84132 p 801.302.1700 Royer, Lindsay FNP p 801.581.7818 Exodus Healthcare Network Hospital Affiliation Granger Medical Clinic 3336 S Pioneer Pkwy - Salt Lake Regional Medical Hospital Affiliation West Jordan Ste 201 Center - University of Utah Hospital 3181 W 9000 S West Valley City UT. 84120 - University of Utah Hospital West Jordan UT. 84088 p 801.250.9638 Scott, Sarah MD p 801.569.5600 *Saunders, Hilary F NP Foothill Family Clinic 3665 S 8400 W Primary Childrens Hospital 6360 S 3000 E Granger Medical Clinic Ste 110 100 N Mario Capecchi Dr Ste 100 3725 W 4100 S Magna UT. 84044 Salt Lake City UT. 84113 Salt Lake City UT. 84121 Salt Lake City UT. 84120 p 801.250.9638 p 801.662.1619 p 801.365.1032 p 801.965.3608

*Rymer, Karen R APRN Hospital Affiliation Severn, Ernest DO Sittler, Susan J NP Primary Childrens Hospital - University of Utah Hospital Riverton Family Health Community Health Centers 81 N Mario Capecchi Dr Center 4745 S 3200 W Salt Lake City UT. 84113 Schaat, Timothy J MD 1756 W Park Ave Salt Lake City UT. 84118 p 801.662.3606 Turning Point Centers Riverton UT. 84065 p 801.964.6214 4141 South Highland Dr p 801.254.0309 Hospital Affiliation Ste 202 - Primary Childrens Hospital Salt Lake City UT. 84124 Hospital Affiliation p 801.576.0745 - Jordan Valley Medical Center

193 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Skalka, David NP 50 N Medical Dr Speakman, Robert L MD St Marks Family Medicine Senior Behavioral Health Salt Lake City UT. 84132 University of Utah Health 1250 E 3900 S SLC - IP p 801.581.2205 1280 E Stringham Ave Ste 260 1050 E S Temple 2nd Fl Salt Lake City UT. 84106 Salt Lake City UT. 84124 Salt Lake City UT. 84102 Smith, Michelle L NP p 801.581.2000 p 801.265.2000 p 801.350.4111 Step Mountain Medical 13352 S 5600 W 1525 W 2100 S Stallings, Scott M MD Adult Behavioral Health Herriman UT. 84096 Salt Lake City UT. 84119 University of Utah Health JVMC-WVC - IP p 801.446.8760 p 801.213.8841 1525 W 2100 S 3460 S 4155 W 5th Fl Salt Lake City UT. 84119 West Valley City UT. 84120 Sojourner, Heather D MD Hospital Affiliation p 801.213.8841 p 801.964.3111 Jordan River Family Health - University of Utah Hospital 1868 W 9800 S Hospital Affiliation Senior Behavioral Health Ste 100 Spencer, Michelle NP - Ogden Regional Medical SLC - OP South Jordan UT. 84095 University of Utah Health Center 82 S 1100 E p 801.433.2873 1525 W 2100 S Ste 404 Salt Lake City UT. 84119 Stanford, Joseph B MD Salt Lake City UT. 84102 Hospital Affiliation p 801.213.8841 University of Utah Health p 801.350.4777 - Jordan Valley Medical 5126 W Daybreak Pkwy Center 5126 W Daybreak Pkwy Ste 600 Slack, Adelaide R MD Ste 600 South Jordan UT. 84009 Community Health Centers Sorweid, Michelle R DO South Jordan UT. 84009 p 801.213.4500 1388 S Navajo St University of Utah Health p 801.213.4500 Salt Lake City UT. 84104 1212 E Wilmington Ave Hospital Affiliation p 801.955.2360 Salt Lake City UT. 84106 7495 S State St - University of Utah Hospital p 801.581.2628 Midvale UT. 84047 Hospital Affiliation p 801.213.9400 Stillings, Hannah MD - University of Utah Hospital 2363 S Foothill Dr Community Health Centers Salt Lake City UT. 84109 Hospital Affiliation 1365 W 1000 N Slack, Caryn M MD p 801.581.2628 - University of Utah Hospital Salt Lake City UT. 84116 Community Health Centers p 801.328.5750 4535 S 5600 W 30 N 1900 E Spencer, Steven J MD West Valley City UT. 84120 Salt Lake City UT. 84132 Exodus Healthcare Network Hospital Affiliation p 801.676.4405 p 801.585.7676 3336 S Pioneer Pkwy - Primary Childrens Hospital Ste 201 - University of Utah Hospital Hospital Affiliation 50 N Medical Dr Salt Lake City UT. 84120 - Jordan Valley Medical Salt Lake City UT. 84132 p 801.250.9638 Stipelman, Carole H MD Center p 801.581.2628 University of Utah Health 3665 S 8400 W 100 N Mario Capecchi Dr Smith, Andrea J PT 555 Foothill Dr Ste 110 Salt Lake City UT. 84113 University of Utah Health Salt Lake City UT. 84112 Magna UT. 84044 p 801.662.1000 1525 W 2100 S p 801.581.2628 p 801.250.9638 Salt Lake City UT. 84119 50 N Medical Dr p 801.213.9907 700 Foothill Blvd Hospital Affiliation Salt Lake City UT. 84132 Salt Lake City UT. 84113 - Jordan Valley Medical p 801.581.2205 50 N Medical Dr p 801.581.2628 Center West Valley Campus Salt Lake City UT. 84132 Hospital Affiliation p 801.581.2121 729 S Arapeen Dr Spiess, Saskia MD - University of Utah Hospital Salt Lake City UT. 84108 Community Health Centers 7495 S State St p 801.581.2628 1365 W 1000 N Stoddard, Breony PA Midvale UT. 84047 Salt Lake City UT. 84116 Lone Peak Family Medicine p 801.213.8840 University Of Utah Health p 801.328.5756 11760 S 700 E 85 N Medical Dr Ste 111 Hospital Affiliation Salt Lake City UT. 84112 University Of Utah Health Draper UT. 84020 - University of Utah Hospital p 801.581.2628 1525 W 2100 S p 801.996.4384 South Salt Lake UT. 84119 Smith, Elizabeth R MD Hospital Affiliation p 801.213.8841 74 Kimballs Ln University of Utah Health - University of Utah Hospital Ste 260 100 N Mario Capecchi Dr 555 Foothill Dr Draper UT. 84020 Salt Lake City UT. 84113 Southwick, Martha F NP Ste 301 p 801.545.8480 p 801.662.1000 Southwick Integrative Salt Lake City UT. 84112 Healing p 801.581.8000 Stoesser, Kirsten L MD 8541 S Redwood Rd University of Utah Health Ste C-2 Hospital Affiliation 1138 E Wilmington Ave West Jordan UT. 84088 - Salt Lake Regional Medical Salt Lake City UT. 84106 p 801.432.7712 Center p 801.581.2000

Hospital Affiliation - Salt Lake Regional Medical Center - University of Utah Hospital194 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Stoker, Bradley L DO University of Utah Health 1525 W 2100 S Tran, Tan D MD UPRI Murray 7495 S State St Salt Lake City UT. 84119 3336 S Pioneer Pkwy 32 W Winchester St Midvale UT. 84047 p 801.213.8841 Ste 302 Ste 200 p 801.213.9400 West Valley City UT. 84120 Salt Lake City UT. 84107 7495 S State St p 801.964.8726 p 801.327.9336 Hospital Affiliation Midvale UT. 84047 - Jordan Valley Medical p 801.213.9400 Hospital Affiliation Hospital Affiliation Center - Jordan Valley Medical - University of Utah Hospital - University of Utah Hospital Hospital Affiliation Center West Valley Campus - University of Utah Hospital Stone, Gregory A DO Talebreza, Shaida MD Tubbs, Kennon C MD Exodus Healthcare Network University of Utah Health Thomas, Stephanie C MD Granger Medical Clinic 3336 S Pioneer Pkwy 50 N Medical Dr Medallus Medical 1160 E 3900 S Ste 201 Salt Lake City UT. 84132 1126 E 12300 S Ste 1000 West Valley City UT. 84120 p 801.581.2628 Draper UT. 84020 Salt Lake City UT. 84124 p 801.250.9638 p 801.545.0600 p 801.262.1771 Tangaro, Rachel A MD 3665 S 8400 W St. Marks Millcreek Hospital Affiliation 11724 S State St Ste 110 Primary Care - Logan Regional Hospital Draper UT. 84020 Magna UT. 84044 348 E 4500 S - Franklin County Medical p 801.576.2050 p 801.250.9638 Ste 300 Center Salt Lake City UT. 84107 12391 S 4000 W Storz, Benjamin N MD p 801.266.2777 Thompson, Daniel O MD Riverton UT. 84065 Jordan River Family Health Riverton Family Health p 801.302.1700 1868 W 9800 S Lone Peak Family Health Center Ste 100 74 Kimballs Ln 1756 W Park Ave 2965 W 3500 S South Jordan UT. 84095 Ste 260 Riverton UT. 84065 West Valley City UT. 84119 p 801.433.2873 Draper UT. 84020 p 801.254.0309 p 801.965.3600 p 801.572.0311 Hospital Affiliation Hospital Affiliation 3181 W 9000 S - Jordan Valley Medical Tanner, Carol S PA-C - Jordan Valley Medical West Jordan UT. 84088 Center Cedar Psychiatry Center p 801.569.5600 1288 E 3300 S Stubler, Geraldine Jody Salt Lake City UT. 84106 Thompson, Kim T APRN Tufts, Gillian G FNP APRN p 801.369.8989 Valley Behavioral Health Community Health Centers Hope Family Medical Center 2948 S Redwood Rd 1365 W 1000 N 1345 E 3900 S 721 E 12200 S West Valley City UT. 84119 Salt Lake City UT. 84116 Ste 204 Draper UT. 84020 p 888.949.4864 p 801.328.5750 Salt Lake City UT. 84124 p 801.369.8989 p 385.275.4673 Tillotson, Shadrick W MD Turner, Bryan MD Taylor, Jack MD Cedar Psychiatry American Wellness & Rehab Sullivan, Erika A MD Foothill Family Clinic 1208 E 3300 S 677 W 5300 S University of Utah Health 13953 S Bangerter Pkwy Salt Lake City UT. 84106 Salt Lake City UT. 84123 1138 E Wilmington Ave Draper UT. 84020 p 801.369.8989 p 801.327.8700 Salt Lake City UT. 84106 p 385.900.4090 p 801.581.2000 Tingey, Spencer D DO Turok, David K MD 2295 Foothill Dr University of Utah Health University of Utah Health Hospital Affiliation Salt Lake City UT. 84109 3730 W 4700 S 50 N Medical Dr - University of Utah Hospital p 801.486.3021 Taylorsville UT. 84129 Salt Lake City UT. 84132 p 801.213.9200 p 801.213.2995 Syddall, Tracy R PA-C Hospital Affiliation University of Utah Health - Salt Lake Regional Medical Hospital Affiliation Hospital Affiliation 1138 E Wilmington Ave Center - University of Utah Hospital - University of Utah Hospital Salt Lake City UT. 84106 p 801.581.2000 The Health Spot Toone, Keira E NP Tyler, Emily A PA 10011 Centennial Pkwy Exodus Healthcare Network The Bone Health Center 3730 W 4700 S Ste 350 3336 S Pioneer Pkwy 3584 W 9000 S West Valley City UT. 84129 Sandy UT. 84070 Ste 201 Ste 209 p 801.213.9200 p 801.566.5350 Salt Lake City UT. 84120 West Jordan UT. 84088 p 801.250.9638 p 801.568.3480 University Of Utah Health Thomas, Kelly L DO 50 N Medical Dr University of Utah Health 3665 S 8400 W UUHC Sugar House Health Salt Lake City UT. 84132 1280 E Stringham Ave Ste 110 Center p 801.581.2121 Salt Lake City UT. 84106 Magna UT. 84044 1138 E Wilmington Ave p 801.581.2000 p 801.250.9638 Salt Lake City UT. 84106 p 801.581.2000

195 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. UUHC Redwood Health Center 3730 W 4700 S 555 Foothill Dr 50 N Medical Dr 1525 W 2100 S Taylorsville UT. 84129 Salt Lake City UT. 84112 Salt Lake City UT. 84132 Salt Lake City UT. 84119 p 801.213.9200 p 801.581.8000 p 801.213.4500 p 801.213.9900 Hospital Affiliation Wall, Jon T MD Hospital Affiliation UUHC South Jordan Health - Salt Lake Regional Medical Olympus Clinic - Salt Lake Regional Medical Center Center 4624 S Holladay Blvd Center 5126 W Daybreak Pkwy - University of Utah Hospital Salt Lake City UT. 84117 South Jordan UT. 84095 p 801.277.2682 Western, Lisa L FNP-C p 801.213.4500 Velasqes, Gustavo MD St Marks Millcreek Primary Adult Care Clinic Walsman Leiva, Gabriela Care UUHC Madsen Health Center 3920 S 1100 E MD 4465 S 900 E 555 S Foothill Blvd Ste 310 Community Health Centers Ste 200 Ste 301 Salt Lake City UT. 84124 4745 S 3200 W Salt Lake City UT. 84124 Salt Lake City UT. 84112 p 801.308.8400 Salt Lake City UT. 84129 p 801.266.2777 p 801.581.8000 p 801.964.6214 Villalobos, Miguel A MD MountainStar Medical Group UUHC Redwood Health Center Western Hills Medical Warren, Steven MD 74 Kimballs Ln 1525 W 2100 S Clinic - CHN ADOL and Adult Care Clinic Ste 260 Salt Lake City UT. 84119 Adults 3920 S 1100 E Draper UT. 84020 p 801.213.9900 3336 S 4155 W Ste 310 p 801.545.8480 Ste 204 Salt Lake City UT. 84124 UUHC Westridge Health West Valley City UT. 84120 p 801.308.8400 White, Charles D MD Center p 801.912.9700 University of Utah Health 3730 W 4700 S Watson, Randall L MD 1138 E Wilmington Ave Taylorsville UT. 84118 Vogeler, Douglas M MD Southwest Family Medicine Salt Lake City UT. 84106 p 801.213.9200 Douglas Vogeler MD PC 1575 W 7000 S p 801.581.2000 8706 S 700 E West Jordan UT. 84084 UUHC South Jordan Health Ste 203 p 801.569.9113 1525 W 2100 S Center Sandy UT. 84094 Salt Lake City UT. 84119 5126 W Daybreak Pkwy p 801.572.0443 Western Hills Medical p 801.213.8841 South Jordan UT. 84095 Clinic p 801.213.4500 Hospital Affiliation 3336 S 4155 W 3730 W 4700 S - St Marks Hospital Ste 204 West Valley City UT. 84129 UUHC Greenwood Health West Valley City UT. 84120 p 801.213.9200 Center Vroman, Stacy T PA p 801.912.9700 7495 S State St University Of Utah Health 5126 W Daybreak Pkwy Midvale UT. 84047 50 N Medical Dr Hospital Affiliation Ste 600 p 801.213.9400 Salt Lake City UT. 84132 - Jordan Valley Medical South Jordan UT. 84009 p 801.581.2121 Center p 801.213.4500 UPRI Murray 32 W Winchester St University of Utah Health Watts, Bradley M DO 7495 S State St Ste 200 5126 W Daybreak Pkwy St Marks Millcreek Primary Midvale UT. 84047 Salt Lake City UT. 84107 Ste 600 Care p 801.213.9400 p 801.327.9336 South Jordan UT. 84009 348 E 4500 S p 801.213.4500 Ste 300 Hospital Affiliation ValleyFit Clinic Salt Lake City UT. 84107 - University of Utah Hospital 4460 S Highland Dr 7495 S State St p 801.266.2777 Ste 300 Midvale UT. 84047 Whittaker, Thomas C MD Salt Lake City UT. 84124 p 801.213.9400 Webb, Susan R NP Community Health Centers p 801.273.6300 Phase II Center for Womens 610 S 200 E Vukelic, Brian M MD Health Ste B Van Hala, Sonja MD University of Utah Health 348 E 4500 S Salt Lake City UT. 84111 University of Utah Health 1138 E Wilmington Ave Ste 200 p 801.539.8617 1138 E Wilmington Ave Salt Lake City UT. 84106 Murray UT. 84107 Salt Lake City UT. 84106 p 801.581.2000 p 801.262.9800 Wilkinson, Jessica MD p 801.581.2000 Foothill Family Clinic 555 Foothill Dr Weir, Peter T MD 13953 S Bangerter Pkwy 1280 E Stringham Ave Ste 301 University of Utah Health Draper UT. 84020 Salt Lake City UT. 84106 Salt Lake City UT. 84112 2830 S Redwood Rd p 385.900.4090 p 801.581.2000 p 801.581.8000 Ste C West Valley City UT. 84119 2295 Foothill Dr p 801.213.4500 Salt Lake City UT. 84109 p 801.486.3021

196 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 6360 S 3000 E 12391 S 4000 W Wood, Stephen MD 3665 S 8400 W Ste 100 Riverton UT. 84096 Foothill Family Clinic Ste 110 Salt Lake City UT. 84121 p 801.302.1700 13953 S Bangerter Pkwy Magna UT. 84044 p 801.365.1032 Draper UT. 84020 p 801.250.9638 2965 W 3500 S p 385.900.4090 Willardson, Crissi L PA West Valley City UT. 84119 Hospital Affiliation Jordan Valley Family p 801.965.3600 6360 S 3000 E - Jordan Valley Medical Health Ste 100 Center West Valley Campus 3895 W 7800 S 3181 W 9000 S Salt Lake City UT. 84121 Ste 100 West Jordan UT. 84088 p 801.365.1032 Young, Timothy P MD West Jordan UT. 84088 p 801.569.5600 Onsite Care Clinic p 801.280.7774 Hospital Affiliation 1407 W North Temple Wilson, Preston J DO - Primary Childrens Hospital Salt Lake City UT. 84116 Onsite Care Clinic Lone Peak Family Medicine - Salt Lake Regional Medical p 801.441.1002 560 S 300 E 11760 S 700 E Center Ste 275 Ste 111 Apollo Health Centers Salt Lake City UT. 84111 Draper UT. 84020 Yanguez, Katie FNP 5525 S 900 E p 801.441.1002 p 801.576.8855 Community Health Centers Ste 310 4535 S 5600 W Salt Lake City UT. 84117 Williams, Dorothy L MD MountainStar Medical Group West Valley City UT. 84120 p 801.685.2862 Foothill Family Clinic 74 Kimballs Ln p 801.676.4405 2295 Foothill Dr Ste 260 Hospital Affiliation Salt Lake City UT. 84109 Draper UT. 84020 Yanke, Lindsey MD - St Marks Hospital p 801.486.3021 p 801.545.8480 Community Health Centers 1365 W 1000 N Zehnder, Brian K MD Williams, Robert D MD MountainStar Jordan Family Salt Lake City UT. 84116 Exodus Healthcare Network Granger Medical Clinic Health p 801.328.5756 3336 S Pioneer Pkwy 11724 S State St 8846 S Redwood Rd Ste 201 Draper UT. 84020 Ste E-121 Yaroshchuk, Larisa B MD Salt Lake City UT. 84120 p 801.576.2050 West Jordan UT. 84088 University of Utah Health p 801.250.9638 p 801.569.1999 7495 S State St Parkway Family Practice Midvale UT. 84047 3665 S 8400 W 1288 W 12700 S Wirth, Amanda J MD p 801.213.9400 Ste 110 Riverton UT. 84065 Highland Family Practice Ste 110 p 801.253.0291 4460 S Highland Dr Hospital Affiliation Magna UT. 84044 Ste 400 - University of Utah Hospital p 801.250.9638 Hospital Affiliation Salt Lake City UT. 84124 - Jordan Valley Medical p 801.272.4111 Young, Daniel T DO Hospital Affiliation Center Alta Internal Medicine - Jordan Valley Medical - Mountain West Medical Hospital Affiliation 74 Kimballs Ln Center West Valley Campus Center - St Marks Hospital Ste 300 Draper UT. 84020 Zimmer, Stephanie NP Williams, Tanya M MD Witbeck, Teddy MD p 801.572.0311 Freedom Healthcare University Of Utah Health Foothill Family Clinic 6298 S 900 E 240 Morris Ave 13953 S Bangerter Pkwy Young, Diane NP Cottonwood Heights UT. 84121 Ste 400 Draper UT. 84020 New Horizon Medical Care p 801.679.2537 Salt Lake City UT. 84115 p 385.900.4090 1420 W 12600 S p 801.585.3828 Ste 102 Gastroenterology 6360 S 3000 E Riverton UT. 84065 Barnett, Robert K MD Hospital Affiliation Ste 100 p 801.254.4600 Granite Peaks - University of Utah Hospital Salt Lake City UT. 84121 Gastroenterology p 801.365.1032 Young Health & Wellness 1393 E Sego Lily Dr Williamson, Diantha A MD 3018 E 3300 S Sandy UT. 84092 Granger Medical Clinic Hospital Affiliation Salt Lake City UT. 84109 p 801.619.9000 1160 E 3900 S - Primary Childrens Hospital p 801.815.2967 Ste 1000 - Salt Lake Regional Medical Hospital Affiliation Salt Lake City UT. 84124 Center Hospital Affiliation - Jordan Valley Medical p 801.262.1771 - Jordan Valley Medical Center Wood, James S MD Center - Lone Peak Hospital 11724 S State St 4815 Center St Draper UT. 84020 Salt Lake City UT. 84107 Young, Shane S MD Batista, Oscar A MD p 801.576.2050 p 801.262.2443 Exodus Healthcare Network Utah Gastroenterology 3336 S Pioneer Pkwy 6360 S 3000 E Hospital Affiliation Ste 201 Ste 310 - Salt Lake Regional Medical West Valley City UT. 84120 Salt Lake City UT. 84121 Center p 801.250.9638 p 801.944.3144

Hospital Affiliation - Lakeview Hospital 197 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Bielefeldt, Klaus MD,PhD 13953 S Bangerter Pkwy Doxey, Brett W MD 5126 W Daybreak Pkwy University of Utah Health Draper UT. 84020 Utah Gastroenterology South Jordan UT. 84009 50 N Medical Dr p 801.727.4280 12391 S 4000 W p 801.213.9797 Salt Lake City UT. 84132 Herriman UT. 84096 p 801.213.9797 6360 S 3000 E p 801.727.4280 University Of Utah Health Ste 310 85 N Medical Dr Hospital Affiliation Salt Lake City UT. 84121 13953 S Bangerter Pkwy Salt Lake City UT. 84112 - University of Utah Hospital p 801.944.3144 Draper UT. 84020 p 801.213.9797 p 801.727.4280 Boschert, Mark E MD Byrne, Kathryn R MD Hospital Affiliation Utah Gastroenterology University of Utah Health 6360 S 3000 E - University of Utah Hospital 6360 S 3000 E 1525 W 2100 S Ste 310 Ste 310 Salt Lake City UT. 84119 SLC UT. 84121 Frech, Edward J MD Salt Lake City UT. 84121 p 801.213.8841 p 801.944.3144 Utah Gastroenterology p 801.944.3144 6360 S 3000 E 50 N Medical Dr Hospital Affiliation Ste 310 Hospital Affiliation Salt Lake City UT. 84132 - Lakeview Hospital SLC UT. 84121 - Lakeview Hospital p 801.213.9797 - Lone Peak Hospital p 801.944.3144 - St Marks Hospital University Of Utah Health Fang, John C MD Hospital Affiliation Bown, James W MD 85 N Medical Dr University of Utah Health - Lakeview Hospital Utah Gastroenterology Salt Lake City UT. 84112 1950 Cir of Hope Dr - St Marks Hospital 6360 S 3000 E p 801.213.9797 Salt Lake City UT. 84112 Ste 310 p 801.581.7802 Gawron, Andrew J MD SLC UT. 84121 Hospital Affiliation University of Utah Health p 801.944.3144 - University of Utah Hospital 50 N Medical Dr 50 N Medical Dr Salt Lake City UT. 84132 Salt Lake City UT. 84132 Hospital Affiliation Canale, Christopher C MD p 801.213.9797 p 801.213.9797 - St George Regional Hospital Utah Gastroenterology 6360 S 3000 E University Of Utah Health University Of Utah Health Box, Terry D MD Ste 310 85 N Medical Dr 85 N Medical Dr University of Utah Health SLC UT. 84121 Salt Lake City UT. 84112 Salt Lake City UT. 84112 50 N Medical Dr p 801.944.3144 p 801.213.9797 p 801.213.9797 Salt Lake City UT. 84132 p 801.213.9797 Hospital Affiliation Hospital Affiliation Hospital Affiliation - Lakeview Hospital - University of Utah Hospital - University of Utah Hospital Hospital Affiliation - University of Utah Hospital Craig, Richard M MD Fenton, Peter C MD Gessel, Luke M MD University of Utah Health Utah Gastroenterology University Of Utah Health Boynton, Kathleen K MD 1525 W 2100 S 12391 S 4000 W 85 N Medical Dr University of Utah Health Salt Lake City UT. 84119 Herriman UT. 84096 Salt Lake City UT. 84112 50 N Medical Dr p 801.213.8841 p 801.727.4280 p 801.213.9797 Salt Lake City UT. 84132 p 801.213.9797 50 N Medical Dr 13953 S Bangerter Pkwy Hospital Affiliation Salt Lake City UT. 84132 Draper UT. 84020 - University of Utah Hospital Hospital Affiliation p 801.213.9797 p 801.727.4280 - University of Utah Hospital Granite Peaks Hospital Affiliation 6360 S 3000 E Gastroenterology Bridge, Robert S MD - University of Utah Hospital Ste 310 1393 E Sego Lily Dr Utah Gastroenterology Salt Lake City UT. 84121 Sandy UT. 84092 1187 E 3900 S Cutler, Christopher S MD p 801.944.3144 p 801.619.9000 Salt Lake City UT. 84124 Granite Peaks p 801.263.3041 Gastroenterology Hospital Affiliation Harmston, Gordon E MD 1393 E Sego Lily Dr - Lakeview Hospital Utah Gastroenterology 12391 S 4000 W Sandy UT. 84092 6360 S 3000 E Riverton UT. 84096 p 801.619.9000 Flynn, Ann D MD Ste 310 p 801.727.4280 University of Utah Health Salt Lake City UT. 84121 Hospital Affiliation 1950 Cir of Hope Dr p 801.944.3144 1250 E 3900 S - Lone Peak Hospital Salt Lake City UT. 84112 Ste 360 p 801.581.7802 Hospital Affiliation Salt Lake City UT. 84124 Desautels, Steven G MD - Lakeview Hospital p 801.263.3041 Granite Peaks 50 N Medical Dr - St Marks Hospital Gastroenterology Salt Lake City UT. 84132 1393 E Sego Lily Dr p 801.213.9797 Sandy UT. 84092 p 801.619.9000

Hospital Affiliation - Lone Peak Hospital 198 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Heiner, Andrew M MD 50 N Medical Dr Kashani, Amir MD 13953 S Bangerter Pkwy Granite Peaks Salt Lake City UT. 84132 University of Utah Health Draper UT. 84020 Gastroenterology p 801.213.9797 1280 E Stringham Ave p 801.727.4280 1393 E Sego Lily Dr Salt Lake City UT. 84106 Sandy UT. 84092 University Of Utah Health p 801.213.9797 6360 S 3000 E p 801.619.9000 85 N Medical Dr Ste 310 Salt Lake City UT. 84112 University Of Utah Health Salt Lake City UT. 84124 Hospital Affiliation p 801.213.9797 85 N Medical Dr p 801.944.3144 - Lone Peak Hospital Salt Lake City UT. 84112 Hospital Affiliation p 801.213.9797 Hospital Affiliation Hilbig, Clarke A MD - University of Utah Hospital - St Marks Hospital Specialty Surgery of Utah Kottarathil, Thomas J MD - Lone Peak Hospital @ Riverton Jones, Robert G MD University of Utah Health 13348 S Market Ctr Dr Utah Gastroenterology 1525 W 2100 S Moore, David R MD Ste 210 6360 S 3000 E Salt Lake City UT. 84119 Utah Gastroenterology Riverton UT. 84065 Ste 310 p 801.213.8841 12391 S 4000 W p 801.601.4423 SLC UT. 84121 Herriman UT. 84096 p 801.944.3144 Hospital Affiliation p 801.727.4280 Jordan Valley - University of Utah Hospital Gastroenterology Hospital Affiliation 13953 S Bangerter Pkwy 3590 W 9000 S - Lakeview Hospital Krishnamurthy, Chaya MD Draper UT. 84020 Ste 120 - St Marks Hospital Utah Gastroenterology p 801.727.4280 West Jordan UT. 84088 12391 S 4000 W p 385.351.6735 Kanth, Priyanka MD Herriman UT. 84096 6360 S 3000 E University of Utah Health p 801.727.4280 Ste 310 Hixson, Lee J MD 1525 W 2100 S SLC UT. 84121 Utah Gastroenterology Salt Lake City UT. 84119 1250 E 3900 S p 801.944.3144 6360 S 3000 E p 801.213.8841 Ste 360 Ste 310 Salt Lake City UT. 84124 Hospital Affiliation Salt Lake City UT. 84121 1950 Cir of Hope Dr p 801.263.3041 - Lakeview Hospital p 801.944.3144 Salt Lake City UT. 84112 p 801.581.7802 13953 S Bangerter Pkwy Morris, John D MD Hospital Affiliation Draper UT. 84020 University of Utah Health - St George Regional Hospital 50 N Medical Dr p 801.727.4280 1950 Cir of Hope Dr Salt Lake City UT. 84132 Salt Lake City UT. 84112 Inadomi, John M MD p 801.213.9797 6360 S 3000 E p 801.581.7802 University Of Utah Health Ste 310 1950 Cir of Hope Dr University Of Utah Health Salt Lake City UT. 84124 University Of Utah Health Salt Lake City UT. 84112 85 N Medical Dr p 801.944.3144 85 N Medical Dr p 801.581.7802 Salt Lake City UT. 84112 Salt Lake City UT. 84112 p 801.213.9797 Hospital Affiliation p 801.213.9797 50 N Medical Dr - St Marks Hospital Salt Lake City UT. 84132 Hospital Affiliation - Lone Peak Hospital Hospital Affiliation p 801.213.9797 - University of Utah Hospital - Lakeview Hospital - University of Utah Hospital

Hospital Affiliation Karnam, Umaprasanna S MD Marschner, Marguerite M ORourke, Mary K PA-C - University of Utah Hospital Gut Whisperer PA-C University of Utah Health 1543 W 12600 S Granite Peaks 50 N Medical Dr Jensen, Mark A DO Ste 102 Gastroenterology Salt Lake City UT. 84132 Granite Peaks Riverton UT. 84065 1393 E Sego Lily Dr p 801.581.7674 Gastroenterology p 801.563.5121 Sandy UT. 84092 1393 E Sego Lily Dr p 801.619.9000 Hospital Affiliation Sandy UT. 84092 2295 S Foothill Dr - University of Utah Hospital p 801.619.9000 Salt Lake City UT. 84109 Maxwell, Christopher MD p 801.563.5121 Utah Gastroenterology Oakes, Alison E MD Hospital Affiliation 1187 E 3900 S Granger Medical - Lone Peak Hospital Hospital Affiliation Salt Lake City UT. 84124 Specialists - Salt Lake Regional Medical p 801.263.3041 2965 W 3500 S Johnson, Jessica B MD Center West Valley City UT. 84119 University of Utah Health - Jordan Valley Medical 1250 E 3900 S p 801.965.3600 1280 E Stringham Ave Center Ste 360 Salt Lake City UT. 84106 Salt Lake City UT. 84124 348 E 4500 S p 801.213.9797 p 801.263.3041 Ste 200 Salt Lake City UT. 84107 p 801.262.9800

199 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Oelsner, David H MD Peterson, Kathryn A MD Silon, Bryan R MD Stewart, James M MD Granger Medical University of Utah Health University of Utah Health Granite Peaks Specialists 243 E 6100 S 1950 Cir of Hope Dr Gastroenterology 2965 W 3500 S Murray UT. 84107 Salt Lake City UT. 84112 1393 E Sego Lily Dr West Valley City UT. 84119 p 801.585.3937 p 801.581.7802 Sandy UT. 84092 p 801.965.3600 p 801.619.9000 50 N Medical Dr 50 N Medical Dr Hospital Affiliation Salt Lake City UT. 84132 Salt Lake City UT. 84132 Hospital Affiliation - Jordan Valley Medical p 801.213.9797 p 801.213.9797 - Lone Peak Hospital Center - Jordan Valley Medical University Of Utah Health University Of Utah Health Suzuki, Takayuki MD Center West Valley Campus 85 N Medical Dr 85 N Medical Dr University of Utah Health - Mountain West Medical Salt Lake City UT. 84112 Salt Lake City UT. 84112 1525 W 2100 S Center p 801.213.9797 p 801.213.9797 Salt Lake City UT. 84119 p 801.213.8841 Parbhu, Sheeva K MD Hospital Affiliation Hospital Affiliation University Of Utah Health - University of Utah Hospital - University of Utah Hospital 1950 Cir of Hope Dr 1280 E Stringham Ave Salt Lake City UT. 84112 Salt Lake City UT. 84106 Radwin, Martin I MD Smith, Kent MD p 801.581.7802 p 801.213.9797 Exodus Healthcare Network Gut Whisperer 3336 S Pioneer Pkwy 1543 W 12600 S 50 N Medical Dr 1950 Cir of Hope Dr Ste 201 Ste 102 Salt Lake City UT. 84132 Salt Lake City UT. 84112 West Valley City UT. 84120 Riverton UT. 84065 p 801.213.9797 p 801.581.7802 p 801.250.9638 p 801.563.5121 Hospital Affiliation 50 N Medical Dr 3665 S 8400 W 2295 S Foothill Dr - University of Utah Hospital Salt Lake City UT. 84132 Ste 110 Salt Lake City UT. 84109 p 801.213.9797 Magna UT. 84044 p 801.563.5121 Thomason, I R MD p 801.250.9638 University of Utah Health 5126 W Daybreak Pkwy Sossenheimer, Michael J 1525 W 2100 S South Jordan UT. 84009 Hospital Affiliation MD Salt Lake City UT. 84119 p 801.213.9797 - Jordan Valley Medical University of Utah Health p 801.213.8841 Center West Valley Campus 1950 Cir of Hope Dr Hospital Affiliation Salt Lake City UT. 84112 50 N Medical Dr - University of Utah Hospital Rodriguez Zarate, Eduardo p 801.581.7802 Salt Lake City UT. 84132 A MD p 801.213.9797 Pedersen, Peder J MD University of Utah Health 50 N Medical Dr Utah Gastroenterology 1950 Cir of Hope Dr Salt Lake City UT. 84132 Hospital Affiliation 1187 E 3900 S Salt Lake City UT. 84112 p 801.213.9797 - University of Utah Hospital Salt Lake City UT. 84124 p 801.213.9797 p 801.263.3041 Hospital Affiliation Trowbridge, David B MD 50 N Medical Dr - Jordan Valley Medical Utah Gastroenterology 1250 E 3900 S Salt Lake City UT. 84132 Center 1187 E 3900 S Ste 360 p 801.213.9797 Salt Lake City UT. 84124 Salt Lake City UT. 84124 Steenblik, Matthew H MD p 801.263.3041 p 801.263.3041 Hospital Affiliation University of Utah Health - University of Utah Hospital 1280 E Stringham Ave 1250 E 3900 S 13953 S Bangerter Pkwy Salt Lake City UT. 84106 Ste 360 Draper UT. 84020 Schmidt, John D MD p 801.213.9797 Salt Lake City UT. 84124 p 801.727.4280 Granite Peaks p 801.263.3041 Gastroenterology 1950 Cir of Hope Dr 6360 S 3000 E 1393 E Sego Lily Dr Salt Lake City UT. 84112 6360 S 3000 E Ste 310 Sandy UT. 84092 p 801.581.7802 Ste 310 Salt Lake City UT. 84124 p 801.619.9000 Salt Lake City UT. 84124 p 801.944.3144 50 N Medical Dr p 801.944.3144 Hospital Affiliation Salt Lake City UT. 84132 Hospital Affiliation - Lone Peak Hospital p 801.213.9797 Hospital Affiliation - St Marks Hospital - St Marks Hospital - Lone Peak Hospital Siddoway, Roger L MD 5126 W Daybreak Pkwy - Lone Peak Hospital - Salt Lake Regional Medical Utah Gastroenterology South Jordan UT. 84009 - Salt Lake Regional Medical Center 6360 S 3000 E p 801.213.9797 Center Ste 310 SLC UT. 84121 Hospital Affiliation p 801.944.3144 - University of Utah Hospital

Hospital Affiliation - St George Regional Hospital

200 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Tuteja, Ashok K MD Weaver, Christine M PA-C Atherton, Justin DO University of Utah Health University of Utah Health Granite Peaks Specialty Surgery of Utah 3773 W 12600 S 1525 W 2100 S Gastroenterology @ West Valley Riverton UT. 84065 Salt Lake City UT. 84119 1393 E Sego Lily Dr 3336 S 4155 W p 801.285.1285 p 801.213.8841 Sandy UT. 84092 Ste 306 p 801.619.9000 West Valley City UT. 84120 50 N Medical Dr 50 N Medical Dr p 801.964.3855 Salt Lake City UT. 84132 Salt Lake City UT. 84132 Weaver, Michael MD p 801.581.2121 p 801.213.9797 Granite Peaks Exodus Healthcare Network Gastroenterology 3336 S Pioneer Pkwy Primary Childrens Hospital Hospital Affiliation 1393 E Sego Lily Dr Ste 201 Physicians - University of Utah Hospital Sandy UT. 84092 Magna UT. 84044 81 N Mario Capecchi Dr p 801.619.9000 p 801.250.9638 Salt Lake City UT. 84113 UUHC Redwood Health Center p 801.662.1000 1525 W 2100 S Hospital Affiliation 3665 S 8400 W Salt Lake City UT. 84119 - Lone Peak Hospital Ste 110 Beck, Catherine MD p 801.213.9900 Magna UT. 84044 Specialty Surgery of Utah Wills, Jason C MD p 801.250.9638 Riverton UUHC South Jordan Health Utah Gastroenterology 13348 S Market Ctr Dr Center 1187 E 3900 S Specialty Surgery of Utah Ste 210 5126 W Daybreak Pkwy Salt Lake City UT. 84124 @ Salt Lake City Riverton UT. 84065 South Jordan UT. 84095 p 801.263.3041 82 S 1100 E p 801.601.4423 p 801.213.4500 Ste 103 12391 S 4000 W Salt Lake City UT. 84102 Specialty Surgery of Utah Valentine, John F MD Herriman UT. 84096 p 801.384.4640 West Jordan University of Utah Health p 801.727.4280 3584 W 9000 S 1280 E Stringham Ave Hospital Affiliation Ste 304 Salt Lake City UT. 84106 1250 E 3900 S - Jordan Valley Medical West Jordan UT. 84088 p 801.213.9797 Ste 360 Center West Valley Campus p 801.601.4423 Salt Lake City UT. 84124 - Salt Lake Regional Medical 50 N Medical Dr p 801.263.3041 Center Hospital Affiliation Salt Lake City UT. 84132 - Jordan Valley Medical p 801.213.9797 13953 S Bangerter Pkwy Bailey, Molly PA-C Center Draper UT. 84020 University of Utah Health 5126 W Daybreak Pkwy p 801.727.4280 50 N Medical Dr Berkholder, Cristina South Jordan UT. 84009 Salt Lake City UT. 84132 PA-C p 801.213.9797 6360 S 3000 E p 801.581.7738 University of Utah Health Ste 310 1950 Cir of Hope Dr University Of Utah Health Salt Lake City UT. 84124 Hospital Affiliation Salt Lake City UT. 84112 85 N Medical Dr p 801.944.3144 - University of Utah Hospital p 801.587.7000 Salt Lake City UT. 84112 p 801.213.9797 Hospital Affiliation Barker, Rodney J MD 50 N Medical Dr - St Marks Hospital University of Utah Health Salt Lake City UT. 84132 Hospital Affiliation - Lone Peak Hospital 50 N Medical Dr p 801.581.7738 - University of Utah Hospital Salt Lake City UT. 84132 General Surgery p 801.581.7738 81 N Mario Capecchi Dr Walker, Michael J MD *Alonso, Diane MD Salt Lake City UT. 84113 University of Utah Health PCH Liver Transplant - 5126 W Daybreak Pkwy p 801.662.2950 1950 Cir of Hope Dr Eccles South Jordan UT. 84009 Salt Lake City UT. 84112 81 N Mario Capecchi Dr p 801.213.4500 Hospital Affiliation p 801.581.7802 Salt Lake City UT. 84113 - University of Utah Hospital p 801.662.2940 Hospital Affiliation 50 N Medical Dr - University of Utah Hospital Bossart, Peter W MD Salt Lake City UT. 84132 Ansari, Safdar A MD 324 10th Ave p 801.213.9797 University of Utah Health Barnhart, Douglas C MD Ste 280 175 N Medical Dr E University of Utah Health Salt Lake City UT. 84103 5126 W Daybreak Pkwy Salt Lake City UT. 84132 100 N Mario Capecchi Dr p 801.408.5930 South Jordan UT. 84009 p 801.585.7575 Salt Lake City UT. 84113 p 801.213.9797 p 801.662.2950 Hospital Affiliation 50 N Medical Dr - Salt Lake Regional Medical University Of Utah Health Salt Lake City UT. 84132 PCH Esophageal Airway - Center 85 N Medical Dr p 801.585.6387 Riverton - St Marks Hospital Salt Lake City UT. 84112 3741 W 12600 S p 801.213.9797 Hospital Affiliation Riverton UT. 84065 - University of Utah Hospital p 801.662.1644 Hospital Affiliation - Davis Hospital - University of Utah Hospital

201 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Brownson, Kirstyn MD 4000 S 700 E Cottam, Daniel R MD Steward Surgical Oncology University of Utah Health Ste 9 Bariatric Medicine Specialists 1280 E Stringham Ave Salt Lake City UT. 84107 Institute 3592 W 9000 S Salt Lake City UT. 84106 p 801.262.3564 1046 E 100 S Ste 210 p 801.581.7738 Salt Lake City UT. 84102 West Jordan UT. 84088 MountainStar Specialty p 801.746.2885 p 801.208.6376 Carbine, Stacie A PA Services University of Utah Health 74 E Kimballs Ln Hospital Affiliation Eakin, Jeffery L MD 50 N Medical Dr Ste 330 - Salt Lake Regional Medical Specialty Surgery Of Utah Salt Lake City UT. 84132 Draper UT. 84020 Center - West Valley p 801.581.7818 p 801.262.3564 3336 S Pioneer Pkwy Cox, Jordy MD Ste 306 Hospital Affiliation MountainStar General Heart and Lung Institute West Valley City UT. 84120 - University of Utah Hospital Surgery of Utah p 801.208.6367 96 E Kimballs Ln 3336 S 4155 W Cavin, Ian R DO Ste 203 Ste 203 Specialty Surgery of Utah Granger Medical West Jordan UT. 84088 Salt Lake City UT. 84120 West Jordan Specialists p 801.568.3480 p 801.263.2370 3584 W 9000 S 11724 S State St Ste 304 Draper UT. 84020 96 E Kimballs Ln 3570 W 9000 S West Jordan UT. 84088 p 801.576.2050 Ste 207 Ste 110 p 801.601.4423 West Jordan UT. 84088 West Jordan UT. 84088 4252 S Highland Dr p 801.576.2300 p 801.263.2370 Hospital Affiliation Ste 200 - Jordan Valley Medical Salt Lake City UT. 84124 Hospital Affiliation 5979 S Fashion Blvd Center West Valley Campus p 801.993.1800 - St Marks Hospital Murray UT. 84107 - Lone Peak Hospital p 801.263.2370 Enniss, Toby M MD Hospital Affiliation - Salt Lake Regional Medical University of Utah Health - St Marks Hospital Center 82 S 1100 E 50 N Medical Dr - Lone Peak Hospital Ste 200 Salt Lake City UT. 84132 Chen, Jennwood MD Salt Lake City UT. 84102 p 801.581.7738 Chachas, Angelo G MD University Of Utah Health p 801.263.2370 MountainStar General 1280 E Stringham Ave Hospital Affiliation Surgery Salt Lake City UT. 84106 Davis, Charles R MD - University of Utah Hospital 1160 E 3900 S p 801.581.2431 Granger Medical Ste 4000 Specialists Ewanowski, Kathleen PA-C Salt Lake City UT. 84124 50 N Medical Dr 11724 S State St University of Utah Health p 801.281.1565 Salt Lake City UT. 84132 Draper UT. 84020 50 N Medical Dr p 801.585.1618 p 801.576.2050 Salt Lake City UT. 84132 1160 E 3900 S p 801.581.7738 Ste 4050 Hospital Affiliation 4252 S Highland Dr Salt Lake City UT. 84124 - University of Utah Hospital Ste 200 Hospital Affiliation p 801.281.1565 Salt Lake City UT. 84124 - University of Utah Hospital Coe, Charity O PA p 801.993.1800 MountainStar Specialty University of Utah Health Finlayson, Samuel MD Services 50 N Medical Dr Hospital Affiliation University of Utah Health 1160 E 3900 S Salt Lake City UT. 84132 - St Marks Hospital 50 N Medical Dr Ste 5000 p 801.581.7738 - Lone Peak Hospital Salt Lake City UT. 84132 Salt Lake City UT. 84124 p 801.581.7738 p 801.262.8486 Hospital Affiliation Digney, Bradley L - University of Utah Hospital Specialty Surgery of Utah Hospital Affiliation MountainStar General @ Riverton - University of Utah Hospital Surgery Cohan, Jessica N MD 13348 S Market Ctr Dr 1250 E 3900 S University of Utah Health Ste 210 Fleming, Irma D MD Ste 460 50 N Medical Dr Riverton UT. 84065 University of Utah Health Salt Lake City UT. 84124 Salt Lake City UT. 84132 p 801.601.4423 50 N Medical Dr p 801.262.3654 p 801.581.7738 Salt Lake City UT. 84132 Specialty Surgery of Utah p 801.581.7738 24 S 1100 E Hospital Affiliation @ West Jordan Ste 302 - University of Utah Hospital 3584 W 9000 S Hospital Affiliation Salt Lake City UT. 84102 Ste 304 - University of Utah Hospital p 801.478.0010 Colonna, Alexander L MD West Jordan UT. 84088 University of Utah Health p 801.601.4423 50 N Medical Dr Salt Lake City UT. 84132 p 801.581.7738

Hospital Affiliation - University of Utah Hospital 202 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Fu, Kathy Y APRN Hollingsed, Timothy C MD Jost, Denise L APRN Lambert, Laura A MD University of Utah Health Granger Medical Clinic University of Utah Health University of Utah Health 50 N Medical Dr 2965 W 3500 S 100 N Mario Capecchi Dr 1950 Cir of Hope Dr Salt Lake City UT. 84132 West Valley City UT. 84119 Salt Lake City UT. 84113 Salt Lake City UT. 84112 p 801.587.7109 p 801.965.3600 p 801.662.2950 p 801.587.7000

590 S Wakara Way Hospital Affiliation 1950 Cir of Hope Dr 50 N Medical Dr Salt Lake City UT. 84108 - Jordan Valley Medical Salt Lake City UT. 84112 Salt Lake City UT. 84132 p 801.587.7109 Center West Valley Campus p 801.585.7676 p 801.581.7738

Hospital Affiliation Hughes, J Preston MD 50 N Medical Dr Hospital Affiliation - University of Utah Hospital 1250 E 3900 S Salt Lake City UT. 84132 - University of Utah Hospital Ste 320 p 801.581.7738 Glasgow, Robert E MD Salt Lake City UT. 84124 Le, Dinhkim MD University of Utah Health p 801.266.1409 Hospital Affiliation Foothill Family Clinic - 50 N Medical Dr - University of Utah Hospital Draper Salt Lake City UT. 84132 Hyngstrom, John R MD 13953 S Bangerter Pkwy p 801.581.7738 University of Utah Health Kim, Benjamin MD Draper UT. 84020 1950 Cir of Hope Dr Utah Cancer Institute p 801.208.6375 Hospital Affiliation Salt Lake City UT. 84112 1220 E 3900 S - University of Utah Hospital p 801.587.7000 Ste 4F Foothill Family Clinic - Salt Lake City UT. 84124 North Office Grudziak, Joanna MD University Of Utah Health p 801.268.8223 2295 S Foothill Dr University Of Utah Health 50 N Medical Dr Salt Lake City UT. 84109 50 N Medical Dr Salt Lake City UT. 84132 Hospital Affiliation p 801.208.6375 Salt Lake City UT. 84132 p 801.585.1618 - St Marks Hospital p 801.585.1618 - Lone Peak Hospital Physician Group of Utah Hospital Affiliation 4624 S Holladay Blvd Hospital Affiliation - University of Utah Hospital Kim, Rebecca Y MD Ste 201 - University of Utah Hospital University Of Utah Health Salt Lake City UT. 84117 Ibele, Anna MD 1280 E Stringham Ave p 801.384.4640 Gunter, Staci L PA-C University of Utah Health Salt Lake City UT. 84106 University of Utah Health 1280 E Stringham Ave p 801.581.2431 Foothill Family Clinic - 175 N Medical Dr E Salt Lake City UT. 84106 Cottonwood Salt Lake City UT. 84132 p 801.581.7738 1950 Cir of Hope Dr 6360 S 3000 E p 801.585.7575 Salt Lake City UT. 84112 Ste 100 50 N Medical Dr p 801.587.8808 Salt Lake City UT. 84121 Hospital Affiliation Salt Lake City UT. 84132 p 801.208.6375 - University of Utah Hospital p 801.581.7738 50 N Medical Dr Salt Lake City UT. 84132 Specialty Surgery of Utah Hansen, Darrin F MD 5126 W Daybreak Pkwy p 801.585.1618 @ Salt Lake City General Surgery & Utah South Jordan UT. 84009 82 S 1100 E Lap-Band p 801.213.4500 Hospital Affiliation Ste 103 96 E Kimballs Ln Bldg 3 - University of Utah Hospital Salt Lake City UT. 84102 Ste 409 Hospital Affiliation p 801.384.4640 Draper UT. 84020 - University of Utah Hospital Kryskow, Mark A DO p 801.523.6177 University Of Utah Health Hospital Affiliation James, Kevin APRN 50 N Medical Dr - Jordan Valley Medical Hospital Affiliation University of Utah Health Salt Lake City UT. 84132 Center - St Marks Hospital 50 N Medical Dr p 801.585.1618 - Lone Peak Hospital Salt Lake City UT. 84132 Leckman, Scott A MD p 801.581.7738 Hospital Affiliation 1220 E 3900 S Hobson, Gregory DO - University of Utah Hospital Ste 3G University Of Utah Health Hospital Affiliation Salt Lake City UT. 84124 100 N Mario Capecchi Dr - University of Utah Hospital Kuhn, Bradley D MD p 801.268.4924 Salt Lake City UT. 84113 University of Utah Health p 801.662.1700 Jayaraman, Sudha P MD 50 N Medical Dr Hospital Affiliation University Of Utah Health Salt Lake City UT. 84132 - St Marks Hospital 50 N Medical Dr 50 N Medical Dr p 801.581.7738 Salt Lake City UT. 84132 Salt Lake City UT. 84132 Lewis, Giavonni M MD p 801.581.7719 p 801.585.1618 Hospital Affiliation University Of Utah Health - University of Utah Hospital 1950 Cir of Hope Dr Hospital Affiliation Hospital Affiliation Salt Lake City UT. 84112 - University of Utah Hospital - University of Utah Hospital p 801.585.1618

203 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. University of Utah Health Matsen, Cindy MD 50 N Medical Dr Nunez, Jade M MD 50 N Medical Dr University of Utah Health Salt Lake City UT. 84132 University of Utah Health Salt Lake City UT. 84132 50 N Medical Dr p 801.662.1700 50 N Medical Dr p 801.581.2121 Salt Lake City UT. 84132 Salt Lake City UT. 84132 p 801.581.7738 Hospital Affiliation p 801.581.7738 Hospital Affiliation - University of Utah Hospital - University of Utah Hospital Hospital Affiliation Hospital Affiliation - University of Utah Hospital Mulvihill, Sean J MD - University of Utah Hospital Lloyd, Erika C MD University Of Utah Health Lloyd Surgical Associates McCrum, Marta L MD 1950 Cir of Hope Dr OBrien, Julie L APRN 1434 E 4500 S University of Utah Health Salt Lake City UT. 84112 University of Utah Health Ste 200 50 N Medical Dr p 801.587.8808 50 N Medical Dr Salt Lake City UT. 84117 Salt Lake City UT. 84132 Salt Lake City UT. 84132 p 801.263.8511 p 801.581.7738 University of Utah Health p 801.581.7738 50 N Medical Dr Hospital Affiliation Hospital Affiliation Salt Lake City UT. 84132 Hospital Affiliation - St Marks Hospital - University of Utah Hospital p 801.581.7738 - University of Utah Hospital

Lombardo, Sarah R MD McKinlay, Rodrick D MD Hospital Affiliation Peche, William J MD University Of Utah Health Rocky Mountain Associated - University of Utah Hospital University of Utah Health 1950 Cir of Hope Dr Physicians 50 N Medical Dr Salt Lake City UT. 84112 1160 E 3900 S Natwick, Raylene MD Salt Lake City UT. 84132 p 801.585.1618 Ste 4100 Jordan Valley Medical p 801.581.7738 Salt Lake City UT. 84124 Center 50 N Medical Dr p 801.268.3800 3580 W 9000 S Hospital Affiliation Salt Lake City UT. 84132 West Jordan UT. 84088 - University of Utah Hospital p 801.585.1618 Hospital Affiliation p 801.561.8888 - St Marks Hospital Porretta, Jane M MD Hospital Affiliation Specialty Surgery of Utah University of Utah Health - University of Utah Hospital Mintz, Steven J MD West Jordan 1950 Cir of Hope Dr 24 S 1100 E 3584 W 9000 S Salt Lake City UT. 84112 Lund, David J PA-C Ste 302 Ste 304 p 801.587.7000 University of Utah Health Salt Lake City UT. 84102 West Jordan UT. 84088 100 N Mario Capecchi Dr p 801.350.8110 p 801.568.3480 50 N Medical Dr Salt Lake City UT. 84113 Salt Lake City UT. 84132 p 801.662.2950 Alpine Medical Group Jordan Valley Cancer p 801.581.7738 24 S 1100 E Center 1950 Cir of Hope Dr Ste 310 3592 W 9000 S 5126 W Daybreak Pkwy Salt Lake City UT. 84112 Salt Lake City UT. 84102 Ste 210 South Jordan UT. 84009 p 801.585.7676 p 801.478.0010 West Jordan UT. 84088 p 801.213.4500 p 801.208.1050 50 N Medical Dr Hospital Affiliation Hospital Affiliation Salt Lake City UT. 84132 - Salt Lake Regional Medical Hospital Affiliation - Jordan Valley Medical p 801.581.2082 Center - Jordan Valley Medical Center Center - University of Utah Hospital Hospital Affiliation Morrow, Ellen H MD - University of Utah Hospital University of Utah Health Nelson, Edward W MD Preciado, Alfonso MD 50 N Medical Dr University of Utah Health MountainStar General Martin, Luke A MD Salt Lake City UT. 84132 81 N Mario Capecchi Dr Surgery University Of Utah Health p 801.581.7738 Salt Lake City UT. 84113 1160 E 3900 S 1280 E Stringham Ave p 801.662.2950 Ste 4000 Salt Lake City UT. 84106 Hospital Affiliation Salt Lake City UT. 84124 p 801.581.2431 - University of Utah Hospital Hospital Affiliation p 801.281.1565 - University of Utah Hospital 1950 Cir of Hope Dr Mulcock, Marie K PA-C MountainStar Specialty Salt Lake City UT. 84112 University of Utah Health Nirula, Raminder MD Services p 801.587.8808 1280 E Stringham Ave University of Utah Health 1160 E 3900 S Salt Lake City UT. 84106 50 N Medical Dr Ste 4050 50 N Medical Dr p 801.581.7719 Salt Lake City UT. 84132 Salt Lake City UT. 84124 Salt Lake City UT. 84132 p 801.581.7738 p 801.281.1565 p 801.585.1618 1950 Cir of Hope Dr Salt Lake City UT. 84112 Hospital Affiliation 1160 E 3900 S Hospital Affiliation p 801.585.0100 - University of Utah Hospital Ste 5000 - University of Utah Hospital - Mountain West Medical Salt Lake City UT. 84124 - Mountain West Medical Center p 801.262.8486 Center

204 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. MountainStar General Rofaiel, George MD 50 N Medical Dr University Of Utah Health Surgery University of Utah Health Salt Lake City UT. 84132 50 N Medical Dr 1250 E 3900 S 1950 Cir of Hope Dr p 801.581.7738 Salt Lake City UT. 84132 Ste 460 Salt Lake City UT. 84112 p 801.581.2121 Salt Lake City UT. 84124 p 801.587.7000 81 N Mario Capecchi Dr p 801.262.3654 Salt Lake City UT. 84113 University of Utah Health 50 N Medical Dr p 801.662.2950 7495 S State St 4000 S 700 E Salt Lake City UT. 84132 Midvale UT. 84047 Ste 9 p 801.581.7738 Hospital Affiliation p 801.213.9400 Murray UT. 84107 - University of Utah Hospital p 801.262.3564 81 N Mario Capecchi Dr Hospital Affiliation Salt Lake City UT. 84113 Simper, Steven C MD - Jordan Valley Medical MountainStar Specialty p 801.662.2950 Rocky Mountain Associated Center Services Physicians - University of Utah Hospital 74 E Kimballs Ln Rosenthal, Regina E MD 1160 E 3900 S Ste 330 University of Utah Health Ste 4100 Tam, Sophia MD Draper UT. 84020 50 N Medical Dr Salt Lake City UT. 84124 University Of Utah Health p 801.262.3564 Salt Lake City UT. 84132 p 801.268.3800 50 N Medical Dr p 801.581.7738 Salt Lake City UT. 84132 MountainStar General Hospital Affiliation p 801.585.1618 Surgery Hospital Affiliation - St Marks Hospital 74 Kimballs Ln - Salt Lake Regional Medical Hospital Affiliation Ste 210 Center Smith, Sherman C MD - University of Utah Hospital Draper UT. 84020 - University of Utah Hospital Rocky Mountain Associated p 801.566.3062 Physicians Thompson, Callie M MD Savarise, Mark T MD 1160 E 3900 S University Of Utah Health 96 E Kimballs Ln University of Utah Health Ste 4100 1950 Cir of Hope Dr Ste 207 50 N Medical Dr Salt Lake City UT. 84124 Salt Lake City UT. 84112 West Jordan UT. 84088 Salt Lake City UT. 84132 p 801.268.3800 p 801.587.8808 p 801.576.2300 p 801.581.7738 South, Samuel D MD 50 N Medical Dr Hospital Affiliation 5126 W Daybreak Pkwy University Of Utah Health Salt Lake City UT. 84132 - Jordan Valley Medical South Jordan UT. 84009 1950 Cir of Hope Dr p 801.585.1618 Center p 801.213.4500 Salt Lake City UT. 84112 - Lone Peak Hospital p 801.585.1618 Hospital Affiliation - St Marks Hospital Hospital Affiliation - University of Utah Hospital - University of Utah Hospital 50 N Medical Dr Reynolds, Jennifer PA-C Salt Lake City UT. 84132 Trotter, Lee D DO University of Utah Health Scaife, Courtney L MD p 801.585.1618 Pediatrix Medical Group 50 N Medical Dr University of Utah Health 11925 S State St Salt Lake City UT. 84132 50 N Medical Dr Hospital Affiliation Draper UT. 84020 p 801.581.7738 Salt Lake City UT. 84132 - University of Utah Hospital p 801.545.8000 p 801.581.7738 Hospital Affiliation Stringham, John MD Hospital Affiliation - University of Utah Hospital Hospital Affiliation University of Utah Health - Mountain Point Medical - University of Utah Hospital 1950 Cir of Hope Dr Center Richards, Christina G MD Salt Lake City UT. 84112 - Timpanogos Regional Hospital Bariatric Medicine Serpico, Victoria J APRN p 801.585.0100 Institute University of Utah Health Vargo, Daniel J MD 1046 E 100 S 50 N Medical Dr 50 N Medical Dr University of Utah Health Salt Lake City UT. 84102 Salt Lake City UT. 84132 Salt Lake City UT. 84132 50 N Medical Dr p 801.746.2885 p 801.581.7738 p 801.581.5311 Salt Lake City UT. 84132 p 801.581.7738 Hospital Affiliation Hospital Affiliation Syddall, Tracy R PA-C - Salt Lake Regional Medical - University of Utah Hospital University of Utah Health Hospital Affiliation Center 1138 E Wilmington Ave - University of Utah Hospital - St Marks Hospital Silva, Kathryn PA-C Salt Lake City UT. 84106 University of Utah Health p 801.581.2000 Volckmann, Eric T MD *Rodriguez-Davalos, Manuel 1950 Cir of Hope Dr University of Utah Health *I MD Salt Lake City UT. 84112 3730 W 4700 S 50 N Medical Dr PCH Liver Transplant - p 801.587.7000 West Valley City UT. 84129 Salt Lake City UT. 84132 Eccles p 801.213.9200 p 801.581.7738 81 N Mario Capecchi Dr Salt Lake City UT. 84113 Hospital Affiliation p 801.662.2940 - University of Utah Hospital

Hospital Affiliation - Primary Childrens Hospital 205 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Young, Jason B MD Koptiuch, Cathryn 81 N Mario Capecchi Dr Wong, Kristen GC University of Utah Health University of Utah Health Salt Lake City UT. 84113 University Of Utah Health 50 N Medical Dr 50 N Medical Dr p 801.213.3599 100 N Mario Capecchi Dr Salt Lake City UT. 84132 Salt Lake City UT. 84132 Salt Lake City UT. 84113 p 801.581.7738 p 801.581.2121 Hospital Affiliation p 801.213.3599 - University of Utah Hospital Hospital Affiliation Hospital Affiliation 3773 W 12600 S - University of Utah Hospital - University of Utah Hospital Palumbos, Janice C Riverton UT. 84065 University of Utah Health p 801.213.3599 Genetic Counseling Mathiesen, Amber M 100 N Mario Capecchi Dr Dent, Karin M University of Utah Health Salt Lake City UT. 84113 50 N Medical Dr University of Utah Health 50 N Medical Dr p 801.213.3599 Salt Lake City UT. 84132 100 N Mario Capecchi Dr Salt Lake City UT. 84132 p 801.213.3599 Salt Lake City UT. 84113 p 801.581.8425 3773 W 12600 S p 801.213.3599 Riverton UT. 84065 81 N Mario Capecchi Dr Hospital Affiliation p 801.213.3599 Salt Lake City UT. 84113 3773 W 12600 S - University of Utah Hospital p 801.213.3599 Riverton UT. 84065 81 N Mario Capecchi Dr p 801.213.3599 May, Caitlyn MD Salt Lake City UT. 84113 Hospital Affiliation University of Utah Health p 801.213.3599 - University of Utah Hospital 81 N Mario Capecchi Dr 1280 E Stringham Ave Salt Lake City UT. 84113 Salt Lake City UT. 84106 Hospital Affiliation Geriatrics p 801.213.3599 p 801.581.8425 - University of Utah Hospital Abueg, Florentino MD University of Utah Health Hospital Affiliation *Meyers, Lindsay L Rutz, Audrey M MD 50 N Medical Dr - University of Utah Hospital Primary Childrens Hospital University of Utah Health Salt Lake City UT. 84132 100 N Mario Capecchi Dr 100 N Mario Capecchi Dr p 801.581.2628 Elias, Abdallah F MD Salt Lake City UT. 84113 Salt Lake City UT. 84113 University Of Utah Health p 801.662.1000 p 801.213.3599 5126 W Daybreak Pkwy 100 N Mario Capecchi Dr South Jordan UT. 84009 Salt Lake City UT. 84113 Hospital Affiliation 3773 W 12600 S p 801.581.2628 p 801.213.3599 - Primary Childrens Hospital Riverton UT. 84065 p 801.213.3599 555 Foothill Dr 3773 W 12600 S Naumer, Anne Salt Lake City UT. 84112 Riverton UT. 84065 University of Utah Health 81 N Mario Capecchi Dr p 801.581.2628 p 801.213.3599 1950 Cir of Hope Dr Salt Lake City UT. 84113 Salt Lake City UT. 84112 p 801.213.3599 700 Foothill Blvd 81 N Mario Capecchi Dr p 801.587.7000 Salt Lake City UT. 84113 Salt Lake City UT. 84113 Hospital Affiliation p 801.581.2628 p 801.213.3599 50 N Medical Dr - University of Utah Hospital Salt Lake City UT. 84132 Anderson, Katherine A MD Hospital Affiliation p 801.581.2121 Sawyer, Briana L University Of Utah Health - University of Utah Hospital University of Utah Health 555 Foothill Dr Hospital Affiliation 100 N Mario Capecchi Dr Salt Lake City UT. 84112 Flores Daboub, Josue A MD - University of Utah Hospital Salt Lake City UT. 84113 p 801.581.2628 University of Utah Health p 801.581.2352 100 N Mario Capecchi Dr Newcomb, Tara M MD 700 Foothill Blvd Salt Lake City UT. 84113 University of Utah Health 3773 W 12600 S Salt Lake City UT. 84113 p 801.213.3599 50 N Medical Dr Riverton UT. 84065 p 801.581.2628 Salt Lake City UT. 84132 p 801.662.5400 81 N Mario Capecchi Dr p 801.585.6387 Hospital Affiliation Salt Lake City UT. 84113 Hospital Affiliation - University of Utah Hospital p 801.213.3599 Hospital Affiliation - University of Utah Hospital - University of Utah Hospital Baraldi, Carole A MD Hospital Affiliation Spoth, Emily J GC University of Utah Health - University of Utah Hospital Palmquist, Rachel N MD University Of Utah Health 1212 E Wilmington Ave University of Utah Health 175 N Medical Dr E Salt Lake City UT. 84106 Grbelja, Ivana GC 100 N Mario Capecchi Dr Salt Lake City UT. 84132 p 801.581.2628 University of Utah Health Salt Lake City UT. 84113 p 801.585.7575 50 N Medical Dr p 801.213.3599 50 N Medical Dr Salt Lake City UT. 84132 729 S Arapeen Dr Salt Lake City UT. 84132 p 801.585.7676 3773 W 12600 S Salt Lake City UT. 84108 p 801.581.2628 Riverton UT. 84065 p 801.585.6387 Hospital Affiliation p 801.213.3599 - University of Utah Hospital Hospital Affiliation - University of Utah Hospital

206 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 555 Foothill Dr DeWeese, Kip NP 700 Foothill Blvd Nebeker, Jonathan MD Salt Lake City UT. 84112 University of Utah Health Salt Lake City UT. 84113 University of Utah Health p 801.581.2628 50 N Medical Dr p 801.581.2628 50 N Medical Dr Salt Lake City UT. 84132 Salt Lake City UT. 84132 700 Foothill Blvd p 801.581.2628 University Of Utah Health p 801.581.2628 Salt Lake City UT. 84113 85 N Medical Dr p 801.581.2628 555 Foothill Dr Salt Lake City UT. 84112 Hospital Affiliation Salt Lake City UT. 84112 p 801.581.2628 - University of Utah Hospital 76 S 500 E p 801.581.2628 Salt Lake City UT. 84102 Hospital Affiliation Puckett, Megan M MD p 801.581.2628 700 Foothill Blvd - Salt Lake Regional Medical University Of Utah Health Salt Lake City UT. 84113 Center 1212 E Wilmington Ave University Of Utah Health p 801.581.2628 Salt Lake City UT. 84106 85 N Medical Dr Gupta, Sumati V MD p 801.581.2628 Salt Lake City UT. 84112 Hospital Affiliation University of Utah Health p 801.581.2628 - Salt Lake Regional Medical 1950 Cir of Hope Dr 50 N Medical Dr Center Salt Lake City UT. 84112 Salt Lake City UT. 84132 Hospital Affiliation - University of Utah Hospital p 801.585.0100 p 801.581.2628 - Salt Lake Regional Medical Center Dietlein, John MD University Of Utah Health 555 Foothill Dr - University of Utah Hospital Physician Homecare 85 N Medical Dr Salt Lake City UT. 84112 1385 W 2200 S Salt Lake City UT. 84112 p 801.581.2628 Beattie, Miriam D NP Ste 202 p 801.585.0100 University of Utah Health West Valley City UT. 84119 700 Foothill Blvd 50 N Medical Dr p 801.682.4461 Hospital Affiliation Salt Lake City UT. 84113 Salt Lake City UT. 84132 - University of Utah Hospital p 801.581.2628 p 801.581.2628 Farrell, Timothy W MD University of Utah Health Hueftle, Kristin M MD 76 S 500 E 555 Foothill Dr 1525 W 2100 S University of Utah Health Salt Lake City UT. 84102 Salt Lake City UT. 84112 Salt Lake City UT. 84119 50 N Medical Dr p 801.581.2628 p 801.581.2628 p 801.213.8841 Salt Lake City UT. 84132 p 801.581.2628 85 N Medical Dr 700 Foothill Blvd 50 N Medical Dr Salt Lake City UT. 84112 Salt Lake City UT. 84113 Salt Lake City UT. 84132 555 Foothill Dr p 801.581.2628 p 801.581.2628 p 801.581.2628 Salt Lake City UT. 84112 p 801.581.2628 Hospital Affiliation Hospital Affiliation 555 Foothill Dr - University of Utah Hospital - University of Utah Hospital Salt Lake City UT. 84112 700 Foothill Blvd p 801.581.2628 Salt Lake City UT. 84113 Rahimi, Danesh MD Brening, Nicholas R MD p 801.581.2628 St Marks Senior Health University of Utah Health 700 Foothill Blvd Center 555 Foothill Dr Salt Lake City UT. 84113 University Of Utah Health 1160 E 3900 S Salt Lake City UT. 84112 p 801.581.2628 85 N Medical Dr Ste G100 p 801.581.2628 Salt Lake City UT. 84112 Salt Lake City UT. 84124 University Of Utah Health p 801.581.2628 p 801.268.7479 University Of Utah Health 85 N Medical Dr 85 N Medical Dr Salt Lake City UT. 84112 Hospital Affiliation 1160 E 3900 S Salt Lake City UT. 84112 p 801.581.2628 - University of Utah Hospital Ste G200 p 801.581.2628 Salt Lake City UT. 84124 Hospital Affiliation Lane, Keith J MD p 801.268.7766 Hospital Affiliation - University of Utah Hospital Internal Medicine of Salt - University of Utah Hospital Lake Parley's Canyon 1200 E 3900 S Gottlieb, Frederick MD 2645 E Parleys Way Ste 3B Browning, Kelsee APRN University of Utah Health Ste 200 Salt Lake City UT. 84124 University of Utah Health 50 N Medical Dr Salt Lake City UT. 84109 p 801.268.7111 50 N Medical Dr Salt Lake City UT. 84132 p 801.384.4700 Salt Lake City UT. 84132 p 801.581.2628 St Marks Interventional p 801.585.7676 Hospital Affiliation Pain Clinic 555 Foothill Dr - Salt Lake Regional Medical 1220 E 3900 S Hospital Affiliation Salt Lake City UT. 84112 Center Ste 3-B - University of Utah Hospital p 801.581.2628 Salt Lake City UT. 84124 Meyer, Laurence J MD,PhD p 801.268.7725 University of Utah Health 50 N Medical Dr Clinic 28 Salt Lake City UT. 84132 p 801.581.2955

207 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. St Marks Senior Health 700 Foothill Blvd Dood, Robert MD Jolles, Christopher J MD Center Salt Lake City UT. 84113 University of Utah Health 12391 S 4000 W 1275 E Ft Union Blvd p 801.581.2628 1280 E Stringham Ave Ste 208 Ste 150 Salt Lake City UT. 84106 Riverton UT. 84065 Cottonwood Heights UT. 84047 University Of Utah Health p 801.213.2995 p 801.302.5360 p 801.268.7766 85 N Medical Dr Salt Lake City UT. 84112 University Of Utah Health Hospital Affiliation Hospital Affiliation p 801.581.2628 1950 Cir of Hope Dr - Jordan Valley Medical - St Marks Hospital Salt Lake City UT. 84112 Center Hospital Affiliation p 801.213.2995 Rupper, Randall W MD - University of Utah Hospital Maurer, Kathryn A MD University of Utah Health 370 E 9th Ave University of Utah Health 50 N Medical Dr Wood, James S MD Salt Lake City UT. 84103 1950 Cir of Hope Dr Salt Lake City UT. 84132 4815 Center St p 801.213.2995 Salt Lake City UT. 84112 p 801.581.2628 Salt Lake City UT. 84107 p 801.213.2995 p 801.262.2443 Hospital Affiliation Hospital Affiliation - University of Utah Hospital 324 E 10th Ave - University of Utah Hospital Hospital Affiliation Salt Lake City UT. 84103 - Salt Lake Regional Medical Harris, Katherine L MD p 801.587.2809 Schlisman, Alison MD Center University of Utah Health University of Utah Health 1950 Cir of Hope Dr 50 N Medical Dr 50 N Medical Dr Gynecologic Oncology Salt Lake City UT. 84112 Salt Lake City UT. 84132 Salt Lake City UT. 84132 Apte, Sachin MD p 801.213.2995 p 801.213.2995 p 801.581.2628 University Of Utah Health 1950 Cir of Hope Dr 324 E 10th Ave 5063 S Cottonwood St 555 Foothill Dr Salt Lake City UT. 84112 Salt Lake City UT. 84103 Ste 450 Salt Lake City UT. 84112 p 801.213.2995 p 801.587.2809 Murray UT. 84107 p 801.581.2628 p 801.213.2995 Hospital Affiliation 370 E 9th Ave 700 Foothill Blvd - University of Utah Hospital Salt Lake City UT. 84103 8th Ave & C St Salt Lake City UT. 84113 p 801.213.2746 Salt Lake City UT. 84143 p 801.581.2628 Brackmann, Melissa K p 801.408.1100 University Of Utah Health 50 N Medical Dr University Of Utah Health 1950 Cir of Hope Dr Salt Lake City UT. 84132 Hospital Affiliation 85 N Medical Dr Salt Lake City UT. 84112 p 801.213.2995 - University of Utah Hospital Salt Lake City UT. 84112 p 801.213.2995 p 801.581.2628 5063 S Cottonwood St Soisson, Andrew P MD 5063 S Cottonwood St Ste 450 University of Utah Health Hospital Affiliation Ste 450 Murray UT. 84107 1950 Cir of Hope Dr - Salt Lake Regional Medical Murray UT. 84107 p 801.213.2995 Salt Lake City UT. 84112 Center p 801.213.2995 p 801.213.2995 Hunn, Jessica R MD Skibitsky, Megan D MD Hospital Affiliation Valley Obstetrics & 50 N Medical Dr University of Utah Health - University of Utah Hospital Gynecology Salt Lake City UT. 84132 50 N Medical Dr 1140 E 3900 S p 801.213.2995 Salt Lake City UT. 84132 Dodson, Mark K MD Ste 300 p 801.581.2628 University of Utah Health Salt Lake City UT. 84124 Hospital Affiliation 324 E 10th Ave p 385.347.5450 - University of Utah Hospital 555 Foothill Dr Salt Lake City UT. 84103 Salt Lake City UT. 84112 p 801.587.2809 1250 E 3900 S University of Utah Dept of p 801.581.2628 Ste 200 Obgyn Gynecologic Oncology 370 E 9th Ave Salt Lake City Ut. 84124 50 N Medical Dr Supiano, Mark A MD Salt Lake City UT. 84103 p 385.347.5450 Salt Lake City UT. 84132 University of Utah Health p 801.236.7803 p 801.581.2719 50 N Medical Dr Hospital Affiliation Salt Lake City UT. 84132 50 N Medical Dr - St Marks Hospital Webb, Joel C MD p 801.581.2628 Salt Lake City UT. 84132 - Lone Peak Hospital Valley Obstetrics & p 801.213.2995 - Mountain View Hospital Gynecology 555 Foothill Dr (UT) 1250 E 3900 S Salt Lake City UT. 84112 8th Ave & C St - Ogden Region Medical Ste 200 p 801.581.2628 Salt Lake City UT. 84143 Center Salt Lake City UT. 84124 p 801.408.1100 p 801.756.9635

Hospital Affiliation Hospital Affiliation - University of Utah Hospital - St Marks Hospital - Utah Valley Hospital

208 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Zempolich, Karen A MD Anders, Suphithaya MD RMWHC @ Salt Lake City Burgett, Alton D MD St Marks Gynecology Western GYN & OB Clinic 82 S 1100 E Granger Medical Oncology Care 12600 S 3723 W Ste 305 Specialists 1140 E 3900 S Ste 350 Salt Lake City UT. 84102 12391 S 4000 W Ste 340 Riverton UT. 84065 p 801.214.7650 Riverton UT. 84096 Salt Lake City UT. 84124 p 801.285.4900 p 801.302.1700 p 801.743.4730 Barton, Scott R MD Hospital Affiliation Obstetrix Medical Group of 3181 W 9000 S 4465 S 900 E - Jordan Valley Medical Utah West Jordan UT. 84088 Ste 224 and 275 Center 1200 S 3900 S p 801.569.5600 Salt Lake City UT. 84124 Salt Lake City UT. 84124 p 801.743.4730 Archer, Sandra V MD p 801.743.4700 Hospital Affiliation Mt Timpanogas Fertility & - Jordan Valley Medical Hospital Affiliation Endocrinology Hospital Affiliation Center - St Marks Hospital 1561 W 7000 S - St Marks Hospital - Jordan Valley Medical - Ogden Regional Medical Ste 201 Center West Valley Campus Center West Jordan UT. 84084 Bechek, Frances MD p 801.938.9627 South Valley Womens Health Chavez, Javier Eduardo Gynecology 3570 W 9000 S MD Adams, Lan Le MD Barney, Mitchell F MD Ste 210 Granger Medical Obstetrix Medical Group Of South Valley Womens West Jordan UT. 84088 Specialists Utah Imaging p 801.569.2626 12391 S 4000 W 1200 E 3900 S 3570 W 9000 S Riverton UT. 84096 Salt Lake City UT. 84124 Ste 130 Hospital Affiliation p 801.302.1700 p 801.268.7111 West Jordan UT. 84088 - Jordan Valley Medical p 801.569.2626 Center 3181 W 9000 S Al-khudairi, Amanda APRN West Jordan UT. 84088 University of Utah Health South Valley Womens Health Benson, Ashley E MD p 801.569.5600 50 N Medical Dr 3570 W 9000 S University of Utah Health Salt Lake City UT. 84132 Ste 210 3690 S Main St Cleveland, Amanda M MD p 801.587.9500 West Jordan UT. 84088 Salt Lake City UT. 84115 Jordan River Womens Health p 801.569.2626 p 385.468.4000 13348 S Market Ctr Dr Hospital Affiliation Ste 200 - University of Utah Hospital Hospital Affiliation 50 N Medical Dr Riverton UT. 84065 - Jordan Valley Medical Salt Lake City UT. 84132 p 385.887.7199 Allen, Peggy R CNM Center p 801.581.8425 University of Utah Health 3584 W 9000 S 3690 S Main St Barney, Spencer P MD 5121 S Cottonwood St Ste 206 Salt Lake City UT. 84115 Old Farm OB/GYN Murray UT. 84107 West Jordan UT. 84088 p 385.468.3950 3970 S 700 E p 801.213.2995 p 801.561.2227 Ste 14 50 N Medical Dr Murray UT. 84107 Hospital Affiliation Colby, Spencer N MD Salt Lake City UT. 84132 p 801.261.3605 - University of Utah Hospital Jordan River Womens Health p 801.581.4014 3584 W 9000 S Hospital Affiliation Boudreaux-Nippert, Denise Ste 206 5126 W Daybreak Pkwy - St Marks Hospital J MD West Jordan UT. 84088 South Jordan UT. 84009 Jordan River Womens Health p 801.561.2227 p 801.213.4500 Barton, Christopher D MD 3584 W 9000 S Obstetrix Medical Group of Ste 206 Hospital Affiliation Hospital Affiliation Utah West Jordan UT. 84088 - Jordan Valley Medical - University of Utah Hospital 1200 S 3900 S p 801.561.2227 Center Salt Lake City UT. 84124 Allred, Shani APRN p 801.743.4700 Hospital Affiliation Daniels, Jonathan P MD South Valley Womens Health - Jordan Valley Medical Rocky Mountain Womens 3570 W 9000 S Mount Olympus OB/GYN Center Health Care Salt Lake City Ste 210 1220 E 3900 S 82 S 1100 E West Jordan UT. 84088 Ste 3E Brown, Bryant J MD Ste 305 p 801.569.2626 Salt Lake City UT. 84124 Old Farm OBGYN Salt Lake City UT. 84102 p 801.685.7188 3970 S 700 E p 801.214.7650 Hospital Affiliation Ste 14 - Salt Lake Regional Medical RMWHC @ Olympus Clinic Murray UT. 84107 Hospital Affiliation Center 4624 S Holladay Blvd p 801.261.3605 - Jordan Valley Medical - University of Utah Hospital Ste 201 Center West Valley Campus Salt Lake City UT. 84117 Hospital Affiliation - Salt Lake Regional Medical p 385.234.4785 - St Marks Hospital Center

209 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Debbink, Michelle L MD Primary Childrens Hospital Gerard, Claudia G CNM South Valley Womens Health University of Utah Health Physicians University of Utah Health 3570 W 9000 S 50 N Medical Dr 81 N Mario Capecchi Dr 3690 S Main St Ste 210 Salt Lake City UT. 84132 Salt Lake City UT. 84113 Salt Lake City UT. 84115 West Jordan UT. 84088 p 801.213.2995 p 801.662.1000 p 385.468.3950 p 801.569.2626

5121 S Cottonwood St Hospital Affiliation 50 N Medical Dr Hospital Affiliation Ste 100 - University of Utah Hospital Salt Lake City UT. 84132 - Jordan Valley Medical Murray UT. 84107 p 801.581.4014 Center p 801.581.7746 England, Edwin R MD Granger Medical 5126 W Daybreak Pkwy Hayes, Katherine G MD 5126 W Daybreak Pkwy Specialists South Jordan UT. 84009 University Of Utah Health South Jordan UT. 84009 12391 S 4000 W p 801.213.4500 100 N Mario Capecchi Dr p 801.213.2995 Riverton UT. 84096 Salt Lake City UT. 84113 p 801.302.1700 555 Foothill Dr p 801.213.2995 Hospital Affiliation Salt Lake City UT. 84112 - University of Utah Hospital Epstein, Scott F DO p 801.585.2111 50 N Medical Dr Jordan River Womens Health Salt Lake City UT. 84132 Densley, Chadwick M DO 3584 W 9000 S 7495 S State St p 801.213.2995 Western GYN & OB Clinic Ste 206 Midvale UT. 84047 12842 S 3600 W West Jordan UT. 84088 p 801.581.4014 Hospital Affiliation Ste 200 p 801.561.2227 - University of Utah Hospital Riverton UT. 84065 Hospital Affiliation p 801.285.4800 Hospital Affiliation - University of Utah Hospital Henderson, Stephanie D MD - Jordan Valley Medical Granger Medical Dildy, Gary A MD Center Gibson, Keri L MD Specialists Obstetrix Medical Group of University of Utah Health 348 E 4500 S Utah Faircloth, Erica A MD 1525 W 2100 S Ste 200 1140 E 3900 S Old Farm OBGYN/ Salt Lake City UT. 84119 Salt Lake City UT. 84107 Ste 390 3970 S 700 E p 801.213.8841 p 801.262.9800 Salt Lake City UT. 84124 Ste 14 p 801.743.4700 Murray UT. 84107 50 N Medical Dr Heuser, Cara C MD p 801.261.3605 Salt Lake City UT. 84132 University of Utah Health 11925 S State St p 801.213.2995 50 N Medical Dr Draper UT. 84020 Hospital Affiliation Salt Lake City UT. 84132 p 801.545.8000 - St Marks Hospital 7495 S State St p 801.587.9500 Midvale UT. 84047 1200 S 3900 S Falk, Jeanne M MD p 801.213.9400 Hospital Affiliation Salt Lake City UT. 84124 Salt Lake Regional Medical - University of Utah Hospital p 801.268.7111 Center - Behavioral Health Hospital Affiliation Unit - University of Utah Hospital Hinson, Joanne S MD Edmunds, Sean F MD 1050 E S Temple 24 S 1100 E St Marks Obstetrics and Salt Lake City UT. 84102 Goodenough, Lynda PA Ste 210 Gynecology Associates p 801.350.4255 Salt Lake Womens Center Salt Lake City UT. 84102 1140 E 3900 S 10011 Centennial Pkwy p 801.364.4030 Ste 400 Obstetrix Medical Group of Ste 350 Salt Lake City UT. 84124 Utah Sandy UT. 84070 Alpine Medical Group p 801.268.6811 1200 E 3900 S p 801.561.3922 24 S 1100 E Salt Lake City UT. 84124 Ste 310 850 E 300 S p 801.268.7111 Graul, Elizabeth S MD Salt Lake City UT. 84102 Ste 1 Phase II Center for Womens p 801.478.0010 Salt Lake City UT. 84102 Rocky Mountain Womans Health p 801.322.1214 Health Center - Salt Lake 348 E 4500 S Rocky Mountain Womans City Ste 200 Health Center - Salt Lake Hospital Affiliation 82 S 1100 E Murray UT. 84107 City - St Marks Hospital Ste 305 p 801.262.9800 82 S 1100 E Salt Lake City UT. 84102 Ste 305 Eller, Alexandra G MD p 801.214.7651 Hospital Affiliation Salt Lake City UT. 84102 University of Utah Health - St Marks Hospital p 801.214.7651 50 N Medical Dr Ferguson, Daniel R MD Salt Lake City UT. 84132 RMWHC @ Salt Lake City Hansen, Scott E MD Hospital Affiliation p 801.213.2995 82 S 1100 E South Valley Womens - Salt Lake Regional Medical Ste 305 Imaging Center Salt Lake City UT. 84102 3570 W 9000 S p 801.214.7650 Ste 130 West Jordan UT. 84088 Hospital Affiliation p 801.569.2626 - Salt Lake Regional Medical Center 210 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Horvath, Susan T MD Jarrett, Arlen K MD Kaiser, Jennifer E MD Luikenaar, Rixt A MD Monarch Womens Cancer South Valley Womens University of Utah Health Rebirth OB/GYN Center Imaging 50 N Medical Dr 2180 E 4500 S 1140 E 3900 S 3570 W 9000 S Salt Lake City UT. 84132 Ste 265 Ste 340 Ste 130 p 801.213.2995 Salt Lake City UT. 84117 Salt Lake City UT. 84124 West Jordan UT. 84088 p 801.272.3909 p 801.743.4730 p 801.569.2626 5121 S Cottonwood St Ste 100 Hospital Affiliation St Marks Obstetrics and South Valley Womens Health Murray UT. 84107 - St Marks Hospital Gynecology Associates 3570 W 9000 S p 801.581.7746 1140 E 3900 S Ste 210 Mainwaring, Robin G MD Ste 400 West Jordan UT. 84088 Hospital Affiliation Granger Medical Salt Lake City UT. 84124 p 801.569.2626 - University of Utah Hospital Specialists p 801.268.6811 348 E 4500 S Hospital Affiliation Kinghorn, Jennifer C MD Ste 200 Hospital Affiliation - Jordan Valley Medical St Marks Obstetrics and Salt Lake City UT. 84107 - St Marks Hospital Center Gynecology Associates p 801.262.9800 1140 E 3900 S Hurst, Barbara MD Johnson, Jason L MD Ste 400 Hospital Affiliation Phase II Center for Womens St Marks Obstetrics and Salt Lake City UT. 84124 - St Marks Hospital Health Gynecology Associates p 801.268.6811 348 E 4500 S 1140 E 3900 S Matthews, David J DO Ste 200 Ste 400 Langer, Kathleen M MD Western GYN & OB Clinic Murray UT. 84107 Salt Lake City UT. 84124 South Valley Womens 12600 S 3723 W p 801.262.9800 p 801.268.6811 Imaging Ste 350 3570 W 9000 S Riverton UT. 84065 Wasatch Infusion Obstetrics and Gynecology Ste 130 p 801.285.4800 348 E 4500 S Clinic West Jordan UT. 84088 Ste 220 850 E 300 S p 801.569.2626 Hospital Affiliation Salt Lake City UT. 84107 Ste 1 - Riverton Childrens Unit p 801.577.7055 Salt Lake City UT. 84102 South Valley Womens Health Operated by Primary Childrens Medical Center p 801.322.1214 3570 W 9000 S - Jordan Valley Medical Hospital Affiliation Ste 210 Center - St Marks Hospital Hospital Affiliation West Jordan UT. 84088 - St Marks Hospital p 801.569.2626 Metz, Torri MD Hutchison, Christopher University of Utah Health MD Johnstone, Erica B MD Hospital Affiliation 5121 S Cottonwood St Granger Medical University of Utah Health - Jordan Valley Medical Ste 100 Specialists 50 N Medical Dr Center Murray UT. 84107 12391 S 4000 W Salt Lake City UT. 84132 p 801.581.7746 Riverton UT. 84096 p 801.213.2995 Lash, Stephen D MD p 801.302.1700 Rocky Mountain Womens 5121 S Cottonwood St 5126 W Daybreak Pkwy Health Center at West Murray UT. 84107 3181 W 9000 S South Jordan UT. 84009 Valley Campus p 801.213.2995 West Jordan UT. 84088 p 801.213.4500 3336 S Pioneer Pkwy p 801.569.5600 Ste 301 Moran, Linh A MD 675 S Arapeen Dr Salt Lake City UT. 84120 St Marks Obstetrics and Hospital Affiliation Salt Lake City UT. 84108 p 801.964.3865 Gynecology Associates - Jordan Valley Medical p 801.581.3834 1140 E 3900 S Center West Valley Campus Hospital Affiliation Ste 400 - Jordan Valley Medical Hospital Affiliation - Jordan Valley Medical Salt Lake City UT. 84124 Center - University of Utah Hospital Center p 801.268.6811 - Lone Peak Hospital - Jordan Valley Medical Judd, Angela MD Center West Valley Campus Moreland, Kimberly S MD Janke, Lindsay L PA-C Western GYN & OB Clinic - Salt Lake Regional Medical South Valley Womens Monarch Womens Cancer 3723 W 12600 S Center Imaging Center Ste 350 3570 W 9000 S 1140 E 3900 S Riverton UT. 84065 Later, Robert W MD Ste 130 Ste 340 p 801.285.4800 Granger Medical West Jordan UT. 84088 Salt Lake City UT. 84124 Specialists p 801.569.2626 p 801.743.4730 Hospital Affiliation 9600 S 1300 E - Jordan Valley Medical Ste 220 South Valley Womens Health Center Sandy UT. 84094 3570 W 9000 S p 801.571.0009 Ste 210 West Jordan UT. 84088 p 801.569.2626

Hospital Affiliation - Jordan Valley Medical Center 211 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Nacy, Emily A MD 7495 S State St 5126 W Daybreak Pkwy Royer, Pamela MD University of Utah Health Midvale UT. 84047 Ste 600 Community Health Centers 1525 W 2100 S p 801.213.9400 South Jordan UT. 84009 610 S 200 E Salt Lake City UT. 84119 p 801.213.4500 Ste B p 801.213.8841 Hospital Affiliation Salt Lake City UT. 84111 - St Marks Hospital 5126 W Daybreak Pkwy p 801.539.8617 7495 S State St South Jordan UT. 84009 Midvale UT. 84047 Obstetrix Medical Group of p 801.213.4500 Saunders, Mark T MD p 801.213.9400 Utah UPRI Taylorsville 1140 E 3900 S 7495 S State St 1972 W 5400 S Hospital Affiliation Ste 390 Midvale UT. 84047 Ste 100 - University of Utah Hospital Salt Lake City UT. 84124 p 801.213.9400 Salt Lake City UT. 84129 p 801.743.4713 p 801.878.7880 Naisbitt, Jed P MD Hospital Affiliation Circle of Life Womens Planned Parenthood - Jordan Valley Medical UPRI Murray Center Association of Utah Center 32 W Winchester St 12523 S Creek Meadow Rd 1091 W S Jordan Pkwy - St Marks Hospital Ste 200 Ste 105 Ste 100 - University of Utah Hospital Salt Lake City UT. 84107 Riverton UT. 84065 South Jordan UT. 84095 p 801.327.9336 p 801.337.5800 p 801.254.2052 Rinne, Kirsti APRN University of Utah Health Sharp, Howard T MD Hospital Affiliation 160 S 10th E 1280 E Stringham Ave University of Utah Health - Ogden Regional Medical Ste 120 Salt Lake City UT. 84106 555 Foothill Dr Center Salt Lake City UT. 84102 p 801.581.4014 Salt Lake City UT. 84112 - Davis Hospital p 801.322.5571 p 801.581.8995 3690 S Main St Nielson, Eric C MD 1906 W 3600 S Salt Lake City UT. 84115 Hospital Affiliation Obstetrix Medical Group of West Valley City UT. 84119 p 385.468.3950 - University of Utah Hospital Utah p 801.973.9675 1200 S 3900 S 50 N Medical Dr Shifrar, Jacolin A APRN Salt Lake City UT. 84124 654 S 900 E Salt Lake City UT. 84132 Granger Medical p 801.268.7111 Salt Lake City UT. 84102 p 801.213.2995 Specialists p 801.532.1586 348 E 4500 S Hospital Affiliation Hospital Affiliation Ste 200 - St Marks Hospital Quinn, Jeffrey D MD - University of Utah Hospital Salt Lake City UT. 84107 Western GYN & OB Clinic p 801.262.9800 Orr, Rochelle DO 12600 S 3723 W Roberts, Audrey J MD St Marks Gynecology and Ste 350 Rocky Mountain Womens Skolnick, Sara MD Oncology Care Riverton UT. 84065 Health Center at West Exodus Healthcare Network 96 E Kimballs Ln p 801.285.4900 Valley Campus 3665 S 8400 W Ste 202 3336 S Pioneer Pkwy Ste 110 Draper UT. 84020 Hospital Affiliation Ste 301 Magna UT. 84044 p 801.523.3053 - Riverton Childrens Unit West Valley City UT. 84120 p 801.250.9638 Operated by Primary Childrens Medicalp 801.964.3865 Center Hospital Affiliation - Jordan Valley Medical Hospital Affiliation - Lone Peak Hospital Center Jordan Valley Medical - Jordan Valley Medical - St Marks Hospital Center West Valley Campus Center West Valley Campus Rappleye, Alan T MD Inpatient BH Unit Ostler, Leslie A MD Old Farm OBGYN 3460 S 4155 W Sloan, Carrie L MD Obstetrix Medical Group of 3970 S 700 E West Valley City UT. 84120 OBGYN Associates Utah Ste 14 p 801.964.3559 74 Kimballs Ln 1200 S 3900 S Murray UT. 84107 Ste 330 Salt Lake City UT. 84124 p 801.261.3605 Hospital Affiliation Draper UT. 84020 p 801.743.4700 - Ogden Regional Medical p 801.523.3053 Hospital Affiliation Center University of Utah Health - St Marks Hospital Lone Peak OBGYN 1525 W 2100 S Roth, James T MD 8846 S Redwood Rd Salt Lake City UT. 84119 Reynolds, Brandon L DO Old Farm OBGYN Ste E121 p 801.213.8841 University of Utah Health 3970 S 700 E West Jordan UT. 84088 50 N Medical Dr Ste 14 p 801.569.1999 50 N Medical Dr Salt Lake City UT. 84132 Murray UT. 84107 Salt Lake City UT. 84132 p 801.213.2995 p 801.261.3605 St Marks Gynecology and p 801.213.2995 Oncology Care Hospital Affiliation 96 E Kimballs Ln - St Marks Hospital Ste 202 Draper UT. 84020 p 801.523.3053

Hospital Affiliation - St Marks Hospital - Lone Peak Hospital 212 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Smid, Marcela MD Steele, Max M MD RMWHC @ Salt Lake City Verrilli, Lauren E MD University of Utah Health 370 9th Ave 82 S 1100 E University of Utah Health 50 N Medical Dr Ste 101 Ste 305 675 S Arapeen Dr Salt Lake City UT. 84132 Salt Lake City UT. 84103 Salt Lake City UT. 84102 Salt Lake City UT. 84108 p 801.213.2995 p 801.408.2999 p 801.214.7650 p 801.581.3834

5126 W Daybreak Pkwy Hospital Affiliation Theilen, Lauren H MD Hospital Affiliation South Jordan UT. 84009 - Salt Lake Regional Medical University of Utah Health - University of Utah Hospital p 801.581.8425 Center 50 N Medical Dr Salt Lake City UT. 84132 Voss, Stephen C MD Hospital Affiliation Stewart, Gayle MD p 801.213.2995 Obstetrics and Gynecology - University of Utah Hospital Rocky Mountain Womens Clinic Health Center at West 5121 S Cottonwood St 850 E 300 S Smith, Andrea N MD Valley Campus Murray UT. 84107 Ste 1 University of Utah Health 3336 S Pioneer Pkwy p 801.213.2995 Salt Lake City UT. 84102 50 N Medical Dr Ste 301 p 801.322.1214 Salt Lake City UT. 84132 Salt Lake City UT. 84120 Hospital Affiliation p 801.213.2995 p 801.964.3865 - University of Utah Hospital Hospital Affiliation - Salt Lake Regional Medical Rocky Mountain Womens Hospital Affiliation Townson, Walter MD Center Center - Jordan Valley Medical University of Utah Health - St Marks Hospital 5980 S Fashion Blvd Center 3730 W 4700 S Salt Lake City UT. 84107 - Jordan Valley Medical Taylorsville UT. 84129 Ward, Katherine W APRN p 801.281.2658 Center West Valley Campus p 801.213.9200 University of Utah Health - Salt Lake Regional Medical 3690 S Main St 82 S 1100 E Center 50 N Medical Dr Salt Lake City UT. 84115 Ste 305 Salt Lake City UT. 84132 p 385.468.3950 Salt Lake City UT. 84102 Summers, Paul R MD p 801.213.2995 p 801.214.7650 University of Utah Health Hospital Affiliation 370 E 9th Ave 7495 S State St - University of Utah Hospital Hospital Affiliation Salt Lake City UT. 84103 Midvale UT. 84047 - Salt Lake Regional Medical p 801.213.2746 p 801.213.9400 Warner, William B MD Center Granger Medical - University of Utah Hospital 50 N Medical Dr Hospital Affiliation Specialists Salt Lake City UT. 84132 - St Marks Hospital 12391 S 4000 W Smith, Layne A MD p 801.213.2995 - University of Utah Hospital Riverton UT. 84096 Granger Medical p 801.302.1700 Specialists 555 Foothill Dr Twede, Michael L MD 11724 S State St Salt Lake City UT. 84112 Granger Medical Hospital Affiliation Draper UT. 84020 p 801.581.8995 Specialists - Lone Peak Hospital p 801.576.2050 11724 S State St Hospital Affiliation Draper UT. 84020 Watts, Daren A MD Hospital Affiliation - University of Utah Hospital p 801.576.2050 St Marks Obstetrics and - Jordan Valley Medical Gynecology Associates Center Tanner, Gregory C MD Hospital Affiliation 1140 E 3900 S - Jordan Valley Medical 9600 S 1300 E - Lone Peak Hospital Ste 400 Center West Valley Campus Ste 305 - Jordan Valley Medical Salt Lake City UT. 84124 - Lone Peak Hospital Sandy UT. 84094 Center p 801.268.6811 p 801.572.5808 - Jordan Valley Medical Son, Shannon L MD Center West Valley Campus Hospital Affiliation University of Utah Health Hospital Affiliation - St Marks Hospital 50 N Medical Dr - Jordan Valley Medical Twelves, Tricia MD Salt Lake City UT. 84132 Center Granger Medical Webb, Susan R NP p 801.581.8425 - Jordan Valley Medical Specialists Phase II Center for Womens Center West Valley Campus 12391 S 4000 W Health 5121 S Cottonwood St Riverton UT. 84096 348 E 4500 S Murray UT. 84107 Tappin, Dyanne p 801.302.1700 Ste 200 p 801.213.2995 RMWHC @ Olympus Clinic Murray UT. 84107 4624 S Holladay Blvd Hospital Affiliation p 801.262.9800 Hospital Affiliation Ste 201 - Jordan Valley Medical - University of Utah Hospital Salt Lake City UT. 84117 Center Williams, Anneli PA-C p 385.234.4785 - North Canyon Medical St Marks Obstetrics and Center Gynecology Associates 1140 E 3900 S Ste 400 Salt Lake City UT. 84124 p 801.268.6811

Hospital Affiliation - St Marks Hospital 213 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Wilson, Matthew S MD 590 S Wakara Way Agarwal, Neeraj MD Chandramouli, Nitin B MD Granger Medical Clinic Salt Lake City UT. 84108 University of Utah Health Utah Cancer Specialists 12391 S 4000 W p 801.587.7109 1950 Cir of Hope Dr 3838 S 700 E Riverton UT. 84065 Salt Lake City UT. 84112 Ste 100 p 801.302.1700 Hospital Affiliation p 801.585.0100 Salt Lake City UT. 84106 - University of Utah Hospital p 801.269.0231 Granger Medical University Of Utah Health Specialists Ozaki, Susan S OT 85 N Medical Dr Hospital Affiliation 12391 S 4000 W Hand and Orthopedic Salt Lake City UT. 84112 - Mountain West Medical Herriman UT. 84096 Rehabilitation Specialists p 801.585.0100 Center p 801.302.1700 5151 S 900 E - St Marks Hospital Ste 100 Hospital Affiliation - Lakeview Hospital 3181 W 9000 S Murray UT. 84117 - University of Utah Hospital - Davis Hospital West Jordan UT. 84088 p 801.261.3321 p 801.569.5600 Batten, Julia A APRN Colonna, Sarah V MD Stockburger, Christopher University of Utah Health University of Utah Health Hospital Affiliation L MD 1950 Cir of Hope Dr 1950 Cir of Hope Dr - Jordan Valley Medical University of Utah Health Salt Lake City UT. 84112 Salt Lake City UT. 84112 Center 590 S Wakara Way p 801.585.0100 p 801.585.0100 - Lone Peak Hospital Salt Lake City UT. 84108 p 801.587.7109 Hospital Affiliation University Of Utah Health Wolfson, Robert N MD - University of Utah Hospital 85 N Medical Dr Obstetrix Medical Group of Hospital Affiliation Salt Lake City UT. 84112 Utah - University of Utah Hospital Buys, Saundra S MD p 801.585.0100 1140 E 3900 S University of Utah Health Ste 390 Wilkinson, John T MD 1280 E Stringham Ave Hospital Affiliation Salt Lake City UT. 84124 University of Utah Health Salt Lake City UT. 84106 - University of Utah Hospital p 801.743.4700 5126 W Daybreak Pkwy p 801.585.0100 South Jordan UT. 84009 Couriel, Daniel R MD Yamashiro, Vernon K MD p 801.581.8425 1950 Cir of Hope Dr University of Utah Health OBGYN Associates Salt Lake City UT. 84112 1950 Cir of Hope Dr 1151 E 3900 S 590 S Wakara Way p 801.585.0100 Salt Lake City UT. 84112 Ste B 299 Salt Lake City UT. 84108 p 801.585.2626 Salt Lake City UT. 84124 p 801.587.7109 University Of Utah Health p 801.268.6811 85 N Medical Dr Hospital Affiliation Hospital Affiliation Salt Lake City UT. 84112 - University of Utah Hospital Hospital Affiliation - University of Utah Hospital p 801.585.0100 - St Marks Hospital Esplin, Brandt L MD Health Department Hospital Affiliation Revere Health Hand Surgery Hegmann, Kurt T MD - University of Utah Hospital 96 E Kimballs Ln Burrows, J D MD University of Utah Health Ste 305 CORE West Valley 1525 W 2100 S Call, Justin A MD Draper UT. 84020 3336 S 4155 W Salt Lake City UT. 84119 Utah Cancer Specialists p 801.374.2367 Ste 102 p 801.213.8841 3592 W 9000 S West Valley City UT. 84120 Ste 200 Florou, Vaia MD p 801.964.3925 50 N Medical Dr West Jordan UT. 84088 University Of Utah Health Salt Lake City UT. 84132 p 801.562.8732 85 N Medical Dr Hospital Affiliation p 801.581.2121 Salt Lake City UT. 84112 - Jordan Valley Medical Hospital Affiliation p 801.585.0100 Center West Valley Campus Hospital Affiliation - St Marks Hospital - Mountain West Medical - University of Utah Hospital - Lakeview Hospital Hospital Affiliation Center - Davis Hospital - University of Utah Health Hematology And Oncology - Jordan Valley Medical Craig H Neilsen Rehabilitation Hospital Chidester, Jeremy R MD Abou-Ismail, Mouhamed Center Premier Plastic Surgery Yazan MD Frame, Richard N MD Group of Utah University Of Utah Health Chalmers, Anna W MD Utah Cancer Specialists 11762 S State St 1950 Cir of Hope Dr University of Utah Health 3592 W 9000 S Ste 333 Salt Lake City UT. 84112 1950 Cir of Hope Dr Ste 200 Draper UT. 84020 p 801.585.3229 Salt Lake City UT. 84112 West Jordan UT. 84088 p 801.839.5557 p 801.585.0100 p 801.562.8732 50 N Medical Dr Hutchinson, Douglas T MD Salt Lake City UT. 84132 University Of Utah Health Hospital Affiliation University of Utah Health p 801.585.3229 85 N Medical Dr - Salt Lake Regional Medical 100 N Mario Capecchi Dr Salt Lake City UT. 84112 Center Salt Lake City UT. 84113 Hospital Affiliation p 801.585.0100 - Davis Hospital p 801.662.5600 - University of Utah Hospital - Jordan Valley Medical Hospital Affiliation Center - University of Utah Hospital - Lakeview Hospital 214 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Garrido Laguna, Ignacio Halwani, Ahmad S MD Huntsman Cancer Institute Matsuoka, Yuko APRN MD University of Utah Health 1950 Circle of Hope University of Utah Health University of Utah Health 1950 Cir of Hope Dr Salt Lake City UT. 84112 50 N Medical Dr 1950 Cir of Hope Dr Salt Lake City UT. 84112 p 801.585.0100 Salt Lake City UT. 84132 Salt Lake City UT. 84112 p 801.585.2626 p 801.585.6387 p 801.585.0100 Hospital Affiliation Hospital Affiliation - University of Utah Hospital Hospital Affiliation University Of Utah Health - University of Utah Hospital - University of Utah Hospital 85 N Medical Dr Kannapel, Esther L APRN Salt Lake City UT. 84112 Havard, Robert MD University of Utah Health Maughan, Benjamin L MD p 801.585.0100 Utah Cancer Specialists 1950 Cir of Hope Dr University of Utah Health 1121 E 3900 S Salt Lake City UT. 84112 1950 Cir of Hope Dr Hospital Affiliation Ste C240 p 801.585.0100 Salt Lake City UT. 84112 - University of Utah Hospital Salt Lake City UT. 84124 p 801.585.0100 p 801.266.0878 Hospital Affiliation Gilcrease, Glynn W MD - University of Utah Hospital University Of Utah Health University of Utah Health 3838 S 700 E 85 N Medical Dr 1950 Cir of Hope Dr Ste 100 Kendall, Stephan MD Salt Lake City UT. 84112 Salt Lake City UT. 84112 Salt Lake City UT. 84106 Utah Cancer Specialists p 801.585.0100 p 801.585.0100 p 801.269.0231 5131 S Cottonwood St Ste L-2 Hospital Affiliation University Of Utah Health 5131 S Cottonwood St Murray UT. 84107 - University of Utah Hospital 85 N Medical Dr Ste L-2 p 801.263.3416 Salt Lake City UT. 84112 Murray UT. 84107 McClune, Brian L DO p 801.585.0100 p 801.263.3416 Hospital Affiliation University of Utah Health - St Marks Hospital 1950 Cir of Hope Dr Hospital Affiliation Hospital Affiliation - Davis Hospital Salt Lake City UT. 84112 - University of Utah Hospital - Jordan Valley Medical - Jordan Valley Medical p 801.585.2626 Center Center Godara, Amandeep MD - Lakeview Hospital Hospital Affiliation University Of Utah Health Henry, Norah L MD - University of Utah Hospital 1950 Cir of Hope Dr University of Utah Health Kovacsovics, Tibor J MD Salt Lake City UT. 84112 1950 Cir of Hope Dr University of Utah Health McGee-Conder, Rosemary p 801.585.2626 Salt Lake City UT. 84112 1950 Cir of Hope Dr APRN p 801.585.0100 Salt Lake City UT. 84112 University of Utah Health Hospital Affiliation p 801.585.2626 1950 Cir of Hope Dr - University of Utah Hospital Hospital Affiliation Salt Lake City UT. 84112 - University of Utah Hospital Hospital Affiliation p 801.585.0100 Gregg, Xylina T MD - University of Utah Hospital Utah Cancer Specialists Hu-Lieskovan, Siwen MD Hospital Affiliation 3838 S 700 E University of Utah Health Lee, Catherine J MD - University of Utah Hospital Ste 100 1950 Cir of Hope Dr University of Utah Health Salt Lake City UT. 84106 Salt Lake City UT. 84112 1950 Cir of Hope Dr Mueggenborg, Brenda S PNP p 801.269.0231 p 801.585.0100 Salt Lake City UT. 84112 University of Utah Health p 801.585.2626 100 N Mario Capecchi Dr Hospital Affiliation University Of Utah Health Salt Lake City UT. 84113 - St Marks Hospital 85 N Medical Dr Hospital Affiliation p 801.662.4700 - Davis Hospital Salt Lake City UT. 84112 - University of Utah Hospital - Jordan Valley Medical p 801.585.0100 Hospital Affiliation Center West Valley Campus Lewis, Mark A MD - University of Utah Hospital - Lakeview Hospital Hospital Affiliation Intermountain Medical - University of Utah Hospital Oncology Nibley, William E MD Grossmann, Kenneth F MD 5171 S Cottonwood St Utah Cancer Specialists University of Utah Health Hu, Boyu MD Ste 610 5131 S Cottonwood St 1950 Cir of Hope Dr University of Utah Health Salt Lake City UT. 84107 Ste L-2 Salt Lake City UT. 84112 1950 Cir of Hope Dr p 801.507.3900 Murray UT. 84107 p 801.585.0100 Salt Lake City UT. 84112 p 901.263.3416 p 801.585.3229 Lim, Ming Y MD University Of Utah Health University of Utah Health Hospital Affiliation 85 N Medical Dr Hospital Affiliation 1950 Cir of Hope Dr - St Marks Hospital Salt Lake City UT. 84112 - University of Utah Hospital Salt Lake City UT. 84112 - Lakeview Hospital p 801.585.0100 p 801.585.3229 - Ashley Valley Regional Medical Center Hospital Affiliation Hospital Affiliation - Davis Hospital - University of Utah Hospital - University of Utah Hospital

215 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Nuttall, Marc T MD Prchal, Josef T MD Shortridge, James MD Stephens, Deborah M DO Revere Health University of Utah Health Utah Cancer Specialists University of Utah Health 96 E Kimballs Ln 1950 Cir of Hope Dr 2965 W 3900 S L4 1950 Cir of Hope Dr Ste 305 Salt Lake City UT. 84112 West Valley City UT. 84119 Salt Lake City UT. 84112 Draper UT. 84020 p 801.585.0100 p 801.590.9900 p 801.585.3229 p 801.655.5670 Hospital Affiliation 3838 S 700 E Hospital Affiliation Hospital Affiliation - University of Utah Hospital Ste 100 - University of Utah Hospital - Mountain View Hospital Salt Lake City UT. 84106 (UT) Prystas, Elizabeth M MD p 801.269.0231 Swami, Umang MD - Castleview Hospital Wasatch Hematology and University of Utah Health - Lone Peak Hospital Oncology Associates PC 5131 S Cottonwood St 1280 E Stringham Ave - Timpanogos Regional Hospital 324 10th Ave Ste L-2 Salt Lake City UT. 84106 Ste 274 Salt Lake City UT. 84107 p 801.585.0100 Ormsby, Wayne MD Salt Lake City UT. 84103 p 801.263.3416 Utah Cancer Specialists p 801.408.5757 1950 Cir of Hope Dr 389 S 900 E Hospital Affiliation Salt Lake City UT. 84112 Ste 100 Hospital Affiliation - Salt Lake Regional Medical p 801.585.0100 Salt Lake City UT. 84102 - Salt Lake Regional Medical Center p 385.282.2125 Center - Davis Hospital 5126 W Daybreak Pkwy - University of Utah Hospital South Jordan UT. 84009 Hospital Affiliation Soares, Heloisa P MD p 801.585.0100 - Davis Hospital Radojcic, Vedran MD University of Utah Health University of Utah Health 1950 Cir of Hope Dr University Of Utah Health Osman, Afaf E MD 1950 Cir of Hope Dr Salt Lake City UT. 84112 85 N Medical Dr University Of Utah Health Salt Lake City UT. 84112 p 801.585.0100 Salt Lake City UT. 84112 1950 Cir of Hope Dr p 801.585.2626 p 801.585.0100 Salt Lake City UT. 84112 University Of Utah Health p 801.585.3229 Hospital Affiliation 85 N Medical Dr Hospital Affiliation - University of Utah Hospital Salt Lake City UT. 84112 - University of Utah Hospital 50 N Medical Dr p 801.585.0100 Salt Lake City UT. 84132 Samuelson, Scott J MD Tantravahi, Srinivas K MD p 801.585.3229 Utah Cancer Specialists Hospital Affiliation University of Utah Health 389 S 900 E - University of Utah Hospital 1280 E Stringham Ave Hospital Affiliation Ste 100 Salt Lake City UT. 84106 - University of Utah Hospital Salt Lake City UT. 84102 Solomon, Benjamin L MD p 801.585.3229 p 385.282.2125 University of Utah Health Parker, Charles J MD 1280 E Stringham Ave 1950 Cir of Hope Dr University of Utah Health Hospital Affiliation Salt Lake City UT. 84106 Salt Lake City UT. 84112 1950 Cir of Hope Dr - Jordan Valley Medical p 801.585.0100 p 801.585.0100 Salt Lake City UT. 84112 Center p 801.585.0100 - Davis Hospital 1950 Cir of Hope Dr Hospital Affiliation - Lakeview Hospital Salt Lake City UT. 84112 - University of Utah Hospital Hospital Affiliation - Salt Lake Regional Medical p 801.585.0100 - University of Utah Hospital Center Tashi, Tsewang MD 5126 W Daybreak Pkwy University of Utah Health Patel, Sagar S MD Sborov, Douglas W MD South Jordan UT. 84009 1950 Cir of Hope Dr University of Utah Health University of Utah Health p 801.585.0100 Salt Lake City UT. 84112 1950 Cir of Hope Dr 1950 Cir of Hope Dr p 801.585.2626 Salt Lake City UT. 84112 Salt Lake City UT. 84112 University Of Utah Health p 801.585.2626 p 801.585.2626 85 N Medical Dr 5126 W Daybreak Pkwy Salt Lake City UT. 84112 South Jordan UT. 84009 Patel, Shiven B MD Hospital Affiliation p 801.585.0100 p 801.213.4500 University of Utah Health - University of Utah Hospital 1950 Cir of Hope Dr Hospital Affiliation Hospital Affiliation Salt Lake City UT. 84112 Shah, Harsh R DO - University of Utah Hospital - University of Utah Hospital p 801.585.0100 University of Utah Health 1950 Cir of Hope Dr Southers, Emily I APRN Thomson, Nicholas MD University Of Utah Health Salt Lake City UT. 84112 University of Utah Health Revere Health 85 N Medical Dr p 801.585.3229 1950 Cir of Hope Dr 96 E Kimballs Ln Salt Lake City UT. 84112 Salt Lake City UT. 84112 Ste 305 p 801.585.0100 Shami, Paul J MD p 801.585.0100 Draper UT. 84020 University of Utah Health p 801.655.5670 Hospital Affiliation 1950 Cir of Hope Dr Hospital Affiliation - University of Utah Hospital Salt Lake City UT. 84112 - University of Utah Hospital p 801.585.2626

Hospital Affiliation - University of Utah Hospital 216 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Vaklavas, Christos MD University Of Utah Health Parker, Charles J MD 1950 Cir of Hope Dr University Of Utah Health 85 N Medical Dr University of Utah Health Salt Lake City UT. 84112 85 N Medical Dr Salt Lake City UT. 84112 1950 Cir of Hope Dr p 801.213.9797 Salt Lake City UT. 84112 p 801.585.0100 Salt Lake City UT. 84112 p 801.585.0100 p 801.585.0100 50 N Medical Dr Hospital Affiliation Salt Lake City UT. 84132 Hospital Affiliation - University of Utah Hospital Hospital Affiliation p 801.213.9797 - University of Utah Health - University of Utah Hospital Craig H Neilsen Rehabilitation HospitalWhisenant, Johnathan R MD Hospital Affiliation Utah Cancer Specialists Patel, Ami B MD - University of Utah Hospital Venniyil Radhakrishnan, 389 S 900 E University of Utah Health Sabarinath MD Ste 100 1950 Cir of Hope Dr Home Health Agency University of Utah Health Salt Lake City UT. 84102 Salt Lake City UT. 84112 A Step Forward Home Health 1950 Cir of Hope Dr p 385.347.5500 p 801.585.3229 and Hospice Salt Lake City UT. 84112 5284 S Commerce Dr p 801.585.3229 5131 S Cottonwood St Hospital Affiliation Ste C-124 Ste L-2 - University of Utah Hospital Murray UT. 84107 5126 W Daybreak Pkwy Murray UT. 84107 p 801.562.8564 South Jordan UT. 84009 p 801.263.3416 Hepatology p 801.213.4500 Aguilar, Maria T MD Amazing Medical Associates Hospital Affiliation University Of Utah Health 835 E 4800 S Hospital Affiliation - Ashley Valley Regional 1280 E Stringham Ave Ste 110 - University of Utah Hospital Medical Center Salt Lake City UT. 84106 Salt Lake City UT. 84107 p 801.213.9797 p 801.716.7008 Ward, John H MD Hematology University of Utah Health Deininger, Michael W MD 50 N Medical Dr Applegate Homecare and 1950 Cir of Hope Dr University of Utah Health Salt Lake City UT. 84132 Hospice Salt Lake City UT. 84112 1950 Cir of Hope Dr p 801.213.9797 5251 S Green St p 801.585.0100 Salt Lake City UT. 84112 Ste 150 p 801.585.0100 Hospital Affiliation Salt Lake City UT. 84123 University Of Utah Health - University of Utah Hospital p 801.261.3023 85 N Medical Dr Hospital Affiliation Salt Lake City UT. 84112 - University of Utah Hospital Chandna, Shaun DO Aspire Home Health p 801.585.0100 University of Utah Health 1020 Atherton Dr George, Tracy I MD 1280 E Stringham Ave Ste 220 Hospital Affiliation University of Utah Health Salt Lake City UT. 84106 Salt Lake City UT. 84123 - University of Utah Hospital 1950 Cir of Hope Dr p 801.213.9797 p 801.292.0296 Salt Lake City UT. 84112 Warner, David MD p 801.585.0100 50 N Medical Dr Brio Home Health Utah Cancer Specialists Salt Lake City UT. 84132 11762 S State St 3838 S 700 E 50 N Medical Dr p 801.213.9797 Ste 350 Ste 100 Salt Lake City UT. 84132 Draper UT. 84020 Salt Lake City UT. 84106 p 801.581.2507 Hospital Affiliation p 801.649.5566 p 801.269.0231 - University of Utah Hospital 500 S Chipeta Way CNS Community Nursing 389 S 900 E Salt Lake City UT. 84108 Gallegos Orozco, Juan F Services Ste 100 p 801.583.2787 MD 2820 S Redwood Rd Salt Lake City UT. 84102 University of Utah Health West Valley City UT. 84119 p 385.347.5500 Hospital Affiliation 1950 Cir of Hope Dr p 801.233.6100 - University of Utah Hospital Salt Lake City UT. 84112 5131 S Cottonwood St p 801.213.9797 Rehab Without Walls Ste L-2 Kerrigan, Kathleen C DO 4548 S Atherton Dr Ste260 Salt Lake City UT. 84107 University Of Utah Health 50 N Medical Dr Salt Lake City UT. 84107 p 801.263.3416 1280 E Stringham Ave Salt Lake City UT. 84132 p 855.741.0060 Salt Lake City UT. 84106 p 801.213.9797 Hospital Affiliation p 801.585.0100 Harmony Home Health and - Salt Lake Regional Medical Hospital Affiliation Hospice Center 1950 Cir of Hope Dr - University of Utah Hospital 5650 S Green St Salt Lake City UT. 84112 Salt Lake City UT. 84123 Werner, Theresa L MD p 801.585.0100 Pham, Tuan A MD p 877.463.3322 University of Utah Health University of Utah Health 1950 Cir of Hope Dr Hospital Affiliation 1280 E Stringham Ave Hearts for Hospice Salt Lake City UT. 84112 - University of Utah Hospital Salt Lake City UT. 84106 141 E 5600 S p 801.585.0100 p 801.213.9797 Salt Lake City UT. 84107 p 801.521.9200

217 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Horizon Home Health CNS Community Nursing 3580 W 9000 S Open Imaging - Redwood 2835 E 3300 S Services West Jordan UT. 84088 6243 S Redwood Rd Salt Lake City UT. 84109 2820 S Redwood Rd p 801.561.8888 Ste 130 p 801.293.8700 West Valley City UT. 84119 Salt Lake City UT. 84123 p 801.233.6100 Lone Peak Hospital p 801.288.9671 Hospice Alliance 11925 S State St 1245 E Brickyard Rd Harmony Home Health and Draper UT. 84020 South Valley Womens Ste 350 Hospice p 801.545.8000 Imaging Salt Lake City UT. 84106 5650 S Green St 3570 W 9000 S p 801.463.7200 Salt Lake City UT. 84123 *Primary Childrens Hospital Ste 130 p 877.463.3322 100 N Mario Capecchi Dr West Jordan UT. 84088 Lighten Home Health and Salt Lake City UT. 84113 p 801.569.2626 Hospice Hearts for Hospice p 801.662.1000 8160 S Highland Dr 141 E 5600 S South Valley Womens Health Ste A-1 Salt Lake City UT. 84107 Salt Lake Regional Medical 3570 W 9000 S Sandy UT. 84093 p 801.521.9200 Center Ste 210 p 801.327.2295 1050 E S Temple West Jordan UT. 84088 Horizon Hospice Salt Lake City UT. 84102 p 801.569.2626 Pinnacle Home Health Inc Specialists p 801.350.4111 2040 E Murray Holladay Rd 2835 W 3300 S St Marks Imaging West Ste 205 Salt Lake City UT. 84109 Shriners Hospitals for Valley Holladay UT. 84117 p 801.294.8600 Children 3715 W 4100 S p 801.274.0299 1275 Fairfax Rd West Valley City UT. 84120 Hospice Alliance Salt Lake City UT. 84103 p 801.924.0029 Valeo Home Health & 1245 E Brickyard Rd p 801.536.3714 Hospice Ste 350 St Marks Imaging Millcreek 1376 E 3300 S Salt Lake City UT. 84106 St Marks Hospital 3738 S 900 E Salt Lake City UT. 84106 p 801.463.7200 1200 E 3900 S Salt Lake City UT. 84106 p 801.639.0020 Salt Lake City UT. 84124 p 801.313.1955 Lifepath Hospice p 801.268.7111 Hospice 3838 S 700 E Wasatch Imaging A Step Forward Home Health Ste 210 University Health Care 9844 S 1300 E and Hospice Salt Lake City UT. 84106 Huntsman Cancer Hospital Ste 175 5284 S Commerce Dr p 801.293.0444 1950 Circle of Hope Dr Sandy UT. 84094 Ste C-124 Salt Lake City UT. 84132 p 801.576.1290 Murray UT. 84107 Lighten Home Health and p 801.587.7000 p 801.562.8564 Hospice West Valley Imaging 8160 S Highland Dr University of Utah 3715 W 4100 S Alpine Hospice Inc Ste A-1 Hospital Ste 150 990 W Bellwood Ln Sandy UT. 84093 50 N Medical Dr West Valley City UT. 84120 Salt Lake City UT. 84123 p 801.327.2295 Salt Lake City UT. 84132 p 801.924.0029 p 801.747.5500 p 801.581.2121 Valeo Home Health & Infectious Disease Applegate Homecare and Hospice Craig H Neilsen Amber, Ina J MD Hospice 1376 E 3300 S Rehabilitation Hospital 1151 E 3900 S 5251 S Green St Salt Lake City UT. 84106 85 N Medical Dr Ste B-275 Ste 150 p 801.639.0020 Salt Lake City UT. 84112 Salt Lake City UT. 84124 Salt Lake City UT. 84123 p 801.587.3422 p 801.268.6830 p 801.261.3023 Hospital Huntsman Cancer Institute Imaging Center Alpine Medical Group Aspire Home Health 1950 Circle of Hope Mountain Medical Physician 24 S 1100 E 1020 Atherton Dr Salt Lake City UT. 84112 Specialists Radiology Ste 310 Ste 220 p 801.585.0100 5323 S Woodrow St Salt Lake City UT. 84102 Salt Lake City UT. 84123 Ste 100 p 801.478.0010 p 801.292.0296 Hospital Affiliation Murray UT. 84123 - University of Utah Hospital p 801.713.0600 Hospital Affiliation Brio Hospice - St Marks Hospital 11762 S State St Jordan Valley Medical Open Imaging - East Side - Lone Peak Hospital Ste 350 Center 3702 S State St - Lakeview Hospital Draper UT. 84020 3460 Pioneer Pkwy Ste 111 p 801.649.5566 West Valley City UT. 84120 Salt Lake City UT. 84115 Carey, Adrienne L MD p 801.964.3100 p 801.288.9671 University of Utah Health 50 N Medical Dr Salt Lake City UT. 84132 p 801.585.2031

218 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. University Of Utah Health Hanson, Kimberly E MD Leung, Daniel T MD University of Utah Health 85 N Medical Dr University of Utah Health University of Utah Health 50 N Medical Dr Salt Lake City UT. 84112 1950 Cir Of Hope Dr 50 N Medical Dr Salt Lake City UT. 84132 p 801.585.2031 Salt Lake City UT. 84112 Salt Lake City UT. 84132 p 801.585.2031 p 801.585.2031 p 801.585.2031 Hospital Affiliation Hospital Affiliation - University of Utah Hospital 50 N Medical Dr University Of Utah Health - St Marks Hospital Salt Lake City UT. 84132 85 N Medical Dr - Lakeview Hospital Cariello, Paloma F MD p 801.585.2031 Salt Lake City UT. 84112 - Lone Peak Hospital University of Utah Health p 801.585.2031 - Salt Lake Regional Medical 1950 Cir of Hope Dr University Of Utah Health Center Salt Lake City UT. 84112 85 N Medical Dr Hospital Affiliation p 801.585.2031 Salt Lake City UT. 84112 - University of Utah Hospital Pavia, Andrew T MD p 801.585.2031 University of Utah Health 50 N Medical Dr Lewis, Julia E DO 50 N Medical Dr Salt Lake City UT. 84132 Hospital Affiliation University Of Utah Health Salt Lake City UT. 84132 p 801.585.2031 - University of Utah Hospital 50 N Medical Dr p 801.585.2031 Salt Lake City UT. 84132 University Of Utah Health Imlay, Hannah N MD p 801.585.2031 81 N Mario Capecchi Dr 85 N Medical Dr University Of Utah Health Salt Lake City UT. 84113 Salt Lake City UT. 84112 85 N Medical Dr Hospital Affiliation p 801.213.3599 p 801.585.2031 Salt Lake City UT. 84112 - University of Utah Hospital p 801.585.2031 Pupaibool, Jakrapun MD Hospital Affiliation Mayer, Jeanmarie MD University of Utah Health - University of Utah Hospital Hospital Affiliation University of Utah Health 50 N Medical Dr - University of Utah Health 50 N Medical Dr Salt Lake City UT. 84132 Certain, Laura K MD Craig H Neilsen Rehabilitation HospitalSalt Lake City UT. 84132 p 801.585.2031 University of Utah Health p 801.585.2031 50 N Medical Dr Johnson, Jessica M MD University Of Utah Health Salt Lake City UT. 84132 University Of Utah Health Hospital Affiliation 85 N Medical Dr p 801.585.2031 50 N Medical Dr - University of Utah Hospital Salt Lake City UT. 84112 Salt Lake City UT. 84132 p 801.585.2031 590 S Wakara Way p 801.585.2031 Melendez Lecca, Dante P Salt Lake City UT. 84108 MD Hospital Affiliation p 801.585.2031 5126 W Daybreak Pkwy University Of Utah Health - University of Utah Hospital South Jordan UT. 84009 50 N Medical Dr University Of Utah Health p 801.585.2031 Salt Lake City UT. 84132 Rosado Santos, Harry MD 85 N Medical Dr p 801.585.2031 University of Utah Health Salt Lake City UT. 84112 Hospital Affiliation 50 N Medical Dr p 801.585.2031 - University of Utah Hospital Hospital Affiliation Salt Lake City UT. 84132 - University of Utah Hospital p 801.585.2031 Gomez Alvarez, Carlos A Jones, Makoto M MD MD University of Utah Health Odrobina, Robert B MD University Of Utah Health University of Utah Health 50 N Medical Dr University of Utah Health 85 N Medical Dr 1950 Cir Of Hope Dr Salt Lake City UT. 84132 1950 Cir Of Hope Dr Salt Lake City UT. 84112 Salt Lake City UT. 84112 p 801.585.2031 Salt Lake City UT. 84112 p 801.585.2031 p 801.585.2031 p 801.585.2031 Hospital Affiliation Hospital Affiliation 50 N Medical Dr - University of Utah Hospital 50 N Medical Dr - University of Utah Hospital Salt Lake City UT. 84132 Salt Lake City UT. 84132 p 801.585.2031 Kriesel, John D MD p 801.585.2031 Rubin, Michael A MD University of Utah Health University of Utah Health University Of Utah Health 1950 Cir Of Hope Dr University Of Utah Health 50 N Medical Dr 85 N Medical Dr Salt Lake City UT. 84112 85 N Medical Dr Salt Lake City UT. 84132 Salt Lake City UT. 84112 p 801.585.2031 Salt Lake City UT. 84112 p 801.585.2031 p 801.585.2031 p 801.585.2031 50 N Medical Dr Hospital Affiliation Hospital Affiliation Salt Lake City UT. 84132 Hospital Affiliation - University of Utah Hospital - University of Utah Hospital p 801.585.2031 - University of Utah Hospital Spivak, Adam M MD Granger, Donald L MD University Of Utah Health Oliver, Mark R MD University of Utah Health University of Utah Health 85 N Medical Dr Utah Physicians Care 1525 W 2100 S 50 N Medical Dr Salt Lake City UT. 84112 Center Salt Lake City UT. 84119 Salt Lake City UT. 84132 p 801.585.2031 1160 E 3900 S p 801.213.8841 p 801.585.2031 Ste 1200 Hospital Affiliation Salt Lake City UT. 84124 Hospital Affiliation - University of Utah Hospital p 801.261.9651 - University of Utah Hospital 219 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 50 N Medical Dr University of Utah Health Allred, Clint W MD 50 N Medical Dr Salt Lake City UT. 84132 50 N Medical Dr University of Utah Health Salt Lake City UT. 84132 p 801.585.2031 Salt Lake City UT. 84132 1950 Cir of Hope Dr p 801.581.7818 p 801.213.9797 Salt Lake City UT. 84112 University Of Utah Health p 801.585.0303 501 S Chipeta Way 85 N Medical Dr Hospital Affiliation Salt Lake City UT. 84108 Salt Lake City UT. 84112 - St Marks Hospital 50 N Medical Dr p 801.583.2500 p 801.585.2031 - Lone Peak Hospital Salt Lake City UT. 84132 - Lakeview Hospital p 801.585.7676 85 N Medical Dr Hospital Affiliation - Salt Lake Regional Medical Salt Lake City UT. 84112 - University of Utah Hospital Center 5126 W Daybreak Pkwy p 801.581.7818 South Jordan UT. 84009 Spivak, Emily R MD Infusion Agency p 801.213.4500 Hospital Affiliation University of Utah Health Coram Specialty Infusion - University of Utah Health 50 N Medical Dr Services University Of Utah Health Craig H Neilsen Rehabilitation Hospital Salt Lake City UT. 84132 1149 W 2240 S 85 N Medical Dr p 801.585.2031 Ste A Salt Lake City UT. 84112 Archer, Cynthia MD Salt Lake City UT. 84119 p 801.585.7676 Steward Medical Group University Of Utah Health p 800.755.9710 Primary Care Murray 85 N Medical Dr Hospital Affiliation 5980 S Fashion Blvd Salt Lake City UT. 84112 120 W Vine St - University of Utah Hospital Salt Lake City UT. 84107 p 801.585.2031 Ste 140 p 801.281.2658 Salt Lake City UT. 84107 Anand, Sanjiv MD Hospital Affiliation p 800.755.9710 Nephrology Associates of Aslami, Stephen S MD - University of Utah Hospital Utah Utah Physicians Care Wasatch Infusion 12511 S Creek Meadow Rd Center Swaminathan, Sankar MD 348 E 4500 S Ste 111 1160 E 3900 S University of Utah Health Ste 220 Riverton UT. 84065 Ste 1200 50 N Medical Dr Salt Lake City UT. 84107 p 801.288.2634 Salt Lake City UT. 84124 Salt Lake City UT. 84132 p 801.577.7055 p 801.261.9651 p 801.585.2031 3702 S State St Internal Medicine Ste 107 Hospital Affiliation University Of Utah Health Abueg, Florentino MD Salt Lake City UT. 84115 - St Marks Hospital 85 N Medical Dr University of Utah Health p 801.288.2634 Salt Lake City UT. 84112 50 N Medical Dr Assiago, Marcellus S MD p 801.585.2031 Salt Lake City UT. 84132 3823 W 9000 S University of Utah Health p 801.581.2628 West Jordan UT. 84088 50 N Medical Dr Hospital Affiliation p 801.288.2634 Salt Lake City UT. 84132 - University of Utah Hospital 5126 W Daybreak Pkwy p 801.581.6709 South Jordan UT. 84009 4101 W Pioneer Pkwy Tanvir, Fawad MD p 801.581.2628 Ste 103 515 E 100 S Alpine Medical Group West Valley City UT. 84120 Ste 350 24 S 1100 E 555 Foothill Dr p 801.288.2634 Salt Lake City UT. 84102 Ste 310 Salt Lake City UT. 84112 p 801.581.3981 Salt Lake City UT. 84102 p 801.581.2628 Hospital Affiliation p 801.478.0010 - Salt Lake Regional Medical Hospital Affiliation 700 Foothill Blvd Center - University of Utah Hospital Hospital Affiliation Salt Lake City UT. 84113 - Jordan Valley Medical - Davis Hospital - Ogden Regional Medical p 801.581.2628 Center Center - St Marks Hospital Babbel, Danielle M MD - Davis Hospital Advanced Vein and Vascular University of Utah Health - Lakeview Hospital of Salt Lake City Anderson, Richard L MD 1950 Cir of Hope Dr - Lone Peak Hospital 6321 S Redwood Rd University of Utah Health Salt Lake City UT. 84112 Ste 102 7495 S State St p 801.585.0100 Trachtenberg, Joel D MD Salt Lake City UT. 84123 Midvale UT. 84047 Utah Physicians Care p 385.388.8003 p 801.213.9400 University Of Utah Health Center 85 N Medical Dr 1160 E 3900 S Ahn, Yong H MD Hospital Affiliation Salt Lake City UT. 84112 Ste 1200 Alpine Medical Group - University of Utah Hospital p 801.581.7818 Salt Lake City UT. 84124 24 S 1100 E p 801.261.9651 Ste 310 Anton, Marja E MD Hospital Affiliation Salt Lake City UT. 84102 University Of Utah Health - University of Utah Hospital p 801.478.0010 1950 Cir of Hope Dr Salt Lake City UT. 84112 Hospital Affiliation p 801.585.0100 - Salt Lake Regional Medical Center

220 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Balch, Heather M MD 50 N Medical Dr Boynton, Kathleen K MD Bray, Bruce E MD University of Utah Health Salt Lake City UT. 84132 University of Utah Health University of Utah Health 1950 Cir of Hope Dr p 801.581.6709 50 N Medical Dr 1950 Cir of Hope Dr Salt Lake City UT. 84112 Salt Lake City UT. 84132 Salt Lake City UT. 84112 p 801.585.0100 515 E 100 S p 801.213.9797 p 801.585.0303 Ste 350 50 N Medical Dr Salt Lake City UT. 84102 Hospital Affiliation 50 N Medical Dr Salt Lake City UT. 84132 p 801.581.3981 - University of Utah Hospital Salt Lake City UT. 84132 p 801.662.1000 p 801.585.7676 University Of Utah Health Brann, William M MD 501 S Chipeta Way 85 N Medical Dr Steward Cardiology 5126 W Daybreak Pkwy Salt Lake City UT. 84108 Salt Lake City UT. 84112 Associates - West Valley South Jordan UT. 84009 p 801.583.2500 p 801.581.6709 3336 S Pioneer Pkwy p 801.213.4500 Ste 203 University Of Utah Health Hospital Affiliation West Valley City UT. 84120 University Of Utah Health 85 N Medical Dr - University of Utah Hospital p 801.748.0113 85 N Medical Dr Salt Lake City UT. 84112 Salt Lake City UT. 84112 p 801.581.7818 Behunin, Andrew C DO Steward Cardiology p 801.585.7676 MountainStar Cardiology St Associates - West Jordan Hospital Affiliation Marks 3570 W 9000 S Hospital Affiliation - University of Utah Hospital 1160 E 3900 S Ste 110 - University of Utah Hospital Ste 2000 West Jordan UT. 84088 Barklow, Jeff A MD Salt Lake City UT. 84124 p 801.265.1200 Breding, David J MD Nephrology Associates of p 801.266.3418 9844 S 1300 E Utah Heart and Lung Institute Ste 335 12511 S Creek Meadow Rd Bhatt, Margi MD of Utah Sandy UT. 84094 Ste 111 Utah Physicians Care 3584 W 9000 S p 801.571.8517 Riverton UT. 84065 Center Ste 209 p 801.288.2634 1160 E 3900 S West Jordan UT. 84088 Hospital Affiliation Salt Lake City UT. 84124 p 801.263.2370 - St Marks Hospital 3702 S State St p 801.261.9651 Ste 107 5979 S Fashion Blvd Brunker, Cherie P MD Salt Lake City UT. 84115 Hospital Affiliation Murray UT. 84107 University of Utah Health p 801.288.2634 - St Marks Hospital p 801.263.2370 50 N Medical Dr Salt Lake City UT. 84132 3823 W 9000 S Bigelow, Barclay F MD Steward Cardiology p 801.581.2628 West Jordan UT. 84088 Jordan Valley Internal Associates p 801.288.2634 Medicine 82 S 1100 E Hospital Affiliation 3570 W 9000 S Ste 200 - University of Utah Hospital 4101 W Pioneer Pkwy Ste 100 Salt Lake City UT. 84104 Ste 103 West Jordan UT. 84088 p 801.263.2370 Bulaj, Zaneta J MD West Valley City UT. 84120 p 801.903.5620 Granger Medical Clinic p 801.288.2634 Hospital Affiliation 1160 E 3900 S 880 E 9400 S - Jordan Valley Medical Ste 1000 Hospital Affiliation Ste 105 Center Salt Lake City UT. 84124 - St Marks Hospital Sandy UT. 84094 - Salt Lake Regional Medical p 801.262.1771 - Jordan Valley Medical p 801.571.7494 Center Center West Valley Campus - Evanston Regional Hospital Hospital Affiliation - Salt Lake Regional Medical Boltax, Jonathan P MD - Castleview Hospital - St Marks Hospital Center University of Utah Health 50 N Medical Dr Brant, Jamie L MD Canga-Siao, Cynthia MD Barman, Thomas F MD Salt Lake City UT. 84132 University of Utah Health MountainStar Medical Group Granger Medical Clinic p 801.581.7806 1950 Cir of Hope Dr 74 Kimballs Ln 1160 E 3900 S Salt Lake City UT. 84112 Ste 300 Ste 1000 5126 W Daybreak Pkwy p 801.585.0100 Draper UT. 84020 Salt Lake City UT. 84124 South Jordan UT. 84009 p 801.572.0311 p 801.262.1771 p 801.581.7806 50 N Medical Dr Salt Lake City UT. 84132 Hospital Affiliation Hospital Affiliation Hospital Affiliation p 801.581.7818 - University of Utah Hospital - St Marks Hospital - University of Utah Hospital 5126 W Daybreak Pkwy Casull, Kathryn MD Beddhu, Srinivasan MD Box, Terry D MD South Jordan UT. 84009 Granger Medical Clinic University of Utah Health University of Utah Health p 801.213.4246 1140 E 3900 S 423 S Wakara Way 50 N Medical Dr Ste 300 Ste 200 Salt Lake City UT. 84132 Hospital Affiliation Salt Lake City UT. 84124 Salt Lake City UT. 84108 p 801.213.9797 - University of Utah Hospital p 801.268.8222 p 801.581.3981 Hospital Affiliation - University of Utah Hospital 221 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 2965 W 3500 S Chua, Milton M MD Conroy, Margaret B MD Devaney, Jeffrey S APRN West Valley City UT. 84119 University of Utah Health University of Utah Health Center for Orthopedic and p 801.965.3600 375 S Chipeta Way 50 N Medical Dr Rehabilitation Excellence Salt Lake City UT. 84108 Salt Lake City UT. 84132 3584 W 9000 S Medical Associates of Salt p 801.581.2016 p 801.581.7818 Ste 405 Lake West Jordan UT. 84088 508 E S Temple 50 N Medical Dr 555 Foothill Dr p 801.568.3480 Ste 300 Salt Lake City UT. 84132 Salt Lake City UT. 84112 Salt Lake City UT. 84102 p 801.581.7818 p 801.581.7790 Hospital Affiliation p 801.521.4500 - Jordan Valley Medical Hospital Affiliation Hospital Affiliation Center Hospital Affiliation - University of Utah Hospital - University of Utah Hospital - Jordan Valley Medical Dickson, Landon E MD Center West Valley Campus Ciarkowski, Claire E MD Couldwell, Marie F MD Nephrology Associates of University of Utah Health Granger Medical Clinic Utah Chadha, Amandeep MD 1950 Cir of Hope Dr 2965 W 3500 S 12511 S Creek Meadow Rd Alpine Medical Group Salt Lake City UT. 84112 West Valley City UT. 84119 Ste 111 24 S 1100 E p 801.585.0100 p 801.965.3600 Riverton UT. 84065 Ste 310 p 801.288.2634 Salt Lake City UT. 84102 50 N Medical Dr Hospital Affiliation p 801.478.0010 Salt Lake City UT. 84132 - University of Utah Hospital 3702 S State St p 801.581.7818 - Primary Childrens Hospital Ste 107 Hospital Affiliation Salt Lake City UT. 84115 - Davis Hospital 501 S Chipeta Way Craig, Richard M MD p 801.288.2634 Salt Lake City UT. 84108 University of Utah Health Chamberlain, James J MD p 801.583.2500 1525 W 2100 S 3823 W 9000 S Utah Physicians Care Salt Lake City UT. 84119 West Jordan UT. 84088 Center University Of Utah Health p 801.213.8841 p 801.288.2634 1160 E 3900 S 85 N Medical Dr Salt Lake City UT. 84124 Salt Lake City UT. 84112 50 N Medical Dr 4101 W Pioneer Pkwy p 801.261.9651 p 801.581.7818 Salt Lake City UT. 84132 Ste 103 p 801.213.9797 West Valley City UT. 84120 Hospital Affiliation Hospital Affiliation p 801.288.2634 - St Marks Hospital - University of Utah Hospital Hospital Affiliation - University of Utah Hospital Hospital Affiliation Chavez, Marcus B PA Coleby, Craig A MD - Salt Lake Regional Medical University of Utah Health Granger Medical Clinic Day, John D MD Center 1950 Cir of Hope Dr 11724 S State St Mountainstar Cardiology St - Jordan Valley Medical Salt Lake City UT. 84112 Draper UT. 84020 Marks Center p 801.585.0100 p 801.576.2000 1160 E 3900 S - St Marks Hospital Ste 2000 50 N Medical Dr 12391 S 4000 W Salt Lake City UT. 84124 U-U Division of Nephrology Salt Lake City UT. 84132 Riverton UT. 84065 p 801.266.3418 50 N Medical Dr p 801.587.7109 p 801.302.1700 Salt Lake City UT. 84132 74 Kimballs Ln p 801.581.6709 Cheung, Alfred K MD Hospital Affiliation Ste 330 University of Utah Health - Riverton Childrens Unit Draper UT. 84020 UUHC South Jordan Health 423 S Wakara Way Operated by Primary Childrens Medicalp 801.266.3418 Center Center Ste 200 - Jordan Valley Medical 5126 W Daybreak Pkwy Salt Lake City UT. 84108 Center Hospital Affiliation South Jordan UT. 84095 p 801.581.3981 - Lone Peak Hospital - Salt Lake Regional Medical p 801.213.4500 Center 50 N Medical Dr Como, Natalie M MD Doane, John A MD Salt Lake City UT. 84132 University of Utah Health Delucchi, Danielle M MD University of Utah Health p 801.581.6709 1950 Cir of Hope Dr University Of Utah Health 50 N Medical Dr Salt Lake City UT. 84112 50 N Medical Dr Salt Lake City UT. 84132 515 E 100 S p 801.585.0100 Salt Lake City UT. 84132 p 801.581.7818 Ste 350 p 801.581.7818 Salt Lake City UT. 84102 University Of Utah Health Hospital Affiliation p 801.581.3981 85 N Medical Dr Hospital Affiliation - University of Utah Hospital Salt Lake City UT. 84112 - University of Utah Hospital University Of Utah Health p 801.581.7818 Domanski, Damian J MD 85 N Medical Dr MountainStar Cardiology St Salt Lake City UT. 84112 Hospital Affiliation Marks p 801.581.6709 - University of Utah Hospital 1160 E 3900 S Ste 2000 Hospital Affiliation Salt Lake City UT. 84124 - University of Utah Hospital p 801.266.3418 222 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Doose, Molly MD Fang, John C MD Gleich, Gerald J MD 3702 S State St University of Utah Health University of Utah Health University Health Care Ste 107 1280 E Stringham Ave 1950 Cir of Hope Dr 1525 W 2100 S Salt Lake City UT. 84115 Salt Lake City UT. 84106 Salt Lake City UT. 84112 Salt Lake City UT. 84119 p 801.288.2634 p 801.581.7818 p 801.581.7802 p 801.213.9900 3823 W 9000 S Dunson, William A MD 50 N Medical Dr University of Utah Health West Jordan UT. 84088 University of Utah Health Salt Lake City UT. 84132 243 E 6100 S p 801.288.2634 1950 Cir of Hope Dr p 801.213.9797 Salt Lake City UT. 84107 Salt Lake City UT. 84112 p 801.581.2955 4101 W Pioneer Pkwy p 801.585.0100 University Of Utah Health Ste 103 85 N Medical Dr 50 N Medical Dr Clinic 28 West Valley City UT. 84120 Hospital Affiliation Salt Lake City UT. 84112 Salt Lake City UT. 84132 p 801.288.2634 - University of Utah Hospital p 801.213.9797 p 801.581.2955 Hospital Affiliation Eleazer, G P MD Hospital Affiliation University Health Care - St Marks Hospital University of Utah Health - University of Utah Hospital 7495 S State St - Jordan Valley Medical 50 N Medical Dr Midvale UT. 84047 Center West Valley Campus Salt Lake City UT. 84132 Farrukh, Hanadi M MD p 801.213.9400 - Salt Lake Regional Medical p 801.581.2628 University of Utah Health Center 50 N Medical Dr Gohari, Mina MD Hospital Affiliation Salt Lake City UT. 84132 St Marks Senior Health Gourde, Theresa D MD - University of Utah Hospital p 801.581.7818 Center South Valley Primary Care 1160 E 3900 S 13348 S Market Ctr Dr Engelen, Megan J 555 Foothill Dr Ste G200 Ste 210 Salt Lake Senior Clinic - Salt Lake City UT. 84112 Salt Lake City UT. 84124 Riverton UT. 84065 Salt Lake City p 801.581.7790 p 801.268.7766 p 801.987.7500 82 S 1100 E Ste 204 Hospital Affiliation St Marks Interventional Jordan Valley Internal Salt Lake City UT. 84102 - University of Utah Hospital Pain Clinic Medicine p 801.350.4753 1220 E 3900 S 3570 W 9000 S Freeman, Andrew L MD Ste 3-B Ste 100 Internal Medicine of Salt University of Utah Health Salt Lake City UT. 84124 West Jordan UT. 84088 Lake - Central 1280 E Stringham Ave p 801.268.7725 p 801.569.2384 82 S 1100 E Salt Lake City UT. 84106 Ste 403 p 801.587.7109 St Marks Senior Health Hospital Affiliation Salt Lake City UT. 84102 Center - Jordan Valley Medical p 801.350.4602 1950 Cir of Hope Dr 1275 E Ft Union Blvd Center Salt Lake City UT. 84112 Ste 150 Hospital Affiliation p 801.581.7806 Cottonwood Heights UT. 84047 Graves, Kencee K MD - Salt Lake Regional Medical p 801.268.7766 University of Utah Health Center 50 N Medical Dr 50 N Medical Dr Salt Lake City UT. 84132 Hospital Affiliation Salt Lake City UT. 84132 Eppich, Irel S MD p 801.581.2121 - St Marks Hospital p 801.581.7818 University of Utah Health 50 N Medical Dr Gandolfi, Roy J MD Gonzales, Gloria R MD University Of Utah Health Salt Lake City UT. 84132 Granger Medical Clinic Granger Medical Clinic 85 N Medical Dr p 801.581.6709 2965 W 3500 S 2965 W 3500 S Salt Lake City UT. 84112 West Valley City UT. 84119 West Valley City UT. 84119 p 801.581.7818 5126 W Daybreak Pkwy p 801.965.3600 p 801.965.3600 South Jordan UT. 84009 Hospital Affiliation p 801.213.4500 Hospital Affiliation Hospital Affiliation - University of Utah Hospital - Jordan Valley Medical - Jordan Valley Medical 515 E 100 S Center Center Grossmann, Kenneth F MD Ste 350 - Jordan Valley Medical - Jordan Valley Medical University of Utah Health Salt Lake City UT. 84102 Center West Valley Campus Center West Valley Campus 1950 Cir of Hope Dr p 801.581.3981 Salt Lake City UT. 84112 Gerstenberger, John P MD Gopinath, Arasu MD p 801.585.0100 Hospital Affiliation University Of Utah Health Nephrology Associates of - University of Utah Hospital 85 N Medical Dr Utah University Of Utah Health - Mountain View Hospital Salt Lake City UT. 84112 12511 S Creek Meadow Rd 85 N Medical Dr (UT) p 801.581.7818 Ste 111 Salt Lake City UT. 84112 - Timpanogos Regional Hospital Riverton UT. 84065 p 801.585.0100 Hospital Affiliation p 801.288.2634 - University of Utah Hospital Hospital Affiliation - University of Utah Hospital

223 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Grotzke, Marissa P MD Guthula, Raga MD Hanlon, Beth C MD 590 S Wakara Way University of Utah Health Copperview Medical Center Alpine Medical Group Salt Lake City UT. 84108 1950 Cir of Hope Dr 3556 W 9800 S 24 S 1100 E p 801.587.7109 Salt Lake City UT. 84112 Ste 101 Ste 310 p 801.581.7763 South Jordan UT. 84095 Salt Lake City UT. 84102 Hospital Affiliation p 801.567.9780 p 801.478.0010 - University of Utah Hospital 50 N Medical Dr Salt Lake City UT. 84132 Hospital Affiliation Hospital Affiliation Hatton, Nathan D MD p 801.581.7763 - Jordan Valley Medical - Salt Lake Regional Medical University of Utah Health Center Center 50 N Medical Dr 615 S Arapeen Dr Salt Lake City UT. 84132 Ste 100 Habib, Arsalan N MD Hansen, Brandon PA-C p 801.581.7806 Salt Lake City UT. 84108 University of Utah Health Granger Medical Clinic p 801.581.7761 1000 S Main St 11724 S State St Hospital Affiliation Ste 105 Draper UT. 84020 - University of Utah Hospital University Of Utah Health Salt Lake City UT. 84101 p 801.576.2000 85 N Medical Dr p 801.408.1400 Hawkins, Grant MD Salt Lake City UT. 84112 12391 S 4000 W Jordan Valley Internal p 801.581.7763 1250 E 3900 S Riverton UT. 84065 Medicine Ste 410 p 801.302.1700 3570 W 9000 S Hospital Affiliation Salt Lake City UT. 84124 Ste 100 - University of Utah Hospital p 801.281.5996 Hansen, Matthew C MD West Jordan UT. 84088 Olympus Clinic Mon-Fri p 801.569.2384 Grua, James R MD 1250 E 3900 S 5am - 8pm & Sat 8am - Granger Medical Salt Lake City UT. 84124 1:30pm Herold, Richard J MD Specialists p 801.268.7111 4624 S Holladay Blvd St Marks Senior Health 2965 W 3500 S Ste 100 Center West Valley City UT. 84119 423 S Wakara Way Salt Lake City UT. 84117 1160 E 3900 S p 801.965.3600 Ste 200 p 801.277.2682 Ste G100 Salt Lake City UT. 84108 Salt Lake City UT. 84124 Hospital Affiliation p 801.581.3981 Hospital Affiliation p 801.268.7479 - St George Regional Hospital - St Marks Hospital 50 N Medical Dr 1160 E 3900 S Gubler, David B MD Salt Lake City UT. 84132 Hanson, Kimberly E MD Ste G200 Utah Physicians Care p 801.581.6709 University of Utah Health Salt Lake City UT. 84124 Center 1950 Cir Of Hope Dr p 801.268.7766 1160 E 3900 S 5121 S Cottonwood St Salt Lake City UT. 84112 Ste 1200 Murray UT. 84107 p 801.585.2031 St Marks Interventional Salt Lake City UT. 84124 p 801.507.7000 Pain Clinic p 801.261.9651 50 N Medical Dr 1220 E 3900 S 5126 W Daybreak Pkwy Salt Lake City UT. 84132 Ste 3-B Hospital Affiliation South Jordan UT. 84009 p 801.585.2031 Salt Lake City UT. 84124 - St Marks Hospital p 801.213.4500 p 801.268.7725 - Lone Peak Hospital University Of Utah Health 515 E 100 S 85 N Medical Dr Hospital Affiliation Gupta, Sumati V MD Ste 350 Salt Lake City UT. 84112 - Mountain West Medical University of Utah Health Salt Lake City UT. 84102 p 801.585.2031 Center 1950 Cir of Hope Dr p 801.581.3981 - St Marks Hospital Salt Lake City UT. 84112 Hospital Affiliation p 801.585.0100 University Of Utah Health - University of Utah Hospital Hess, Rachel MD 85 N Medical Dr University of Utah Health University Of Utah Health Salt Lake City UT. 84112 Harold, Emily J MD 50 N Medical Dr 85 N Medical Dr p 801.581.6709 University of Utah Health Salt Lake City UT. 84132 Salt Lake City UT. 84112 1525 W 2100 S p 801.581.7818 p 801.585.0100 University of Utah Health Salt Lake City UT. 84119 8th Ave & C St p 801.213.9900 555 Foothill Dr Hospital Affiliation Salt Lake City UT. 84143 Salt Lake City UT. 84112 - University of Utah Hospital p 801.408.1100 290 S 1850 E p 801.581.7790 Salt Lake City UT. 84112 Guthrie, Ellen H MD Hospital Affiliation p 801.587.7109 Hospital Affiliation University Of Utah Health - St Marks Hospital - University of Utah Hospital 9385 Snowbird Ctr Dr - University of Utah Hospital 580 S Guardsman Way Sandy UT. 84092 Salt Lake City UT. 84112 p 801.646.4800 p 801.587.7109

Hospital Affiliation - University of Utah Hospital

224 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Hightower, Maia MD University Of Utah Health Iqbal, Ronak MD 50 N Medical Dr University of Utah Health 85 N Medical Dr Granger Medical Clinic Salt Lake City UT. 84132 50 N Medical Dr Salt Lake City UT. 84112 2965 W 3500 S p 801.581.7818 Salt Lake City UT. 84132 p 801.581.7818 West Valley City UT. 84119 p 801.581.7818 p 801.965.3600 501 S Chipeta Way Hospital Affiliation Salt Lake City UT. 84108 Hilbig, Clarke A MD - University of Utah Hospital Hospital Affiliation p 801.583.2500 Specialty Surgery of Utah - Jordan Valley Medical @ Riverton Huber, Jared S MD Center University Of Utah Health 13348 S Market Ctr Dr University Of Utah Health - Jordan Valley Medical 85 N Medical Dr Ste 210 85 N Medical Dr Center West Valley Campus Salt Lake City UT. 84112 Riverton UT. 84065 Salt Lake City UT. 84112 p 801.581.7818 p 801.601.4423 p 801.581.7818 Isenberg, Philip N MD University of Utah Health Hospital Affiliation Jordan Valley Hospital Affiliation 7495 S State St - University of Utah Hospital Gastroenterology - University of Utah Health Midvale UT. 84047 3590 W 9000 S Craig H Neilsen Rehabilitation Hospitalp 801.213.9400 Jimenez, Manuel MD Ste 120 Heart and Lung Institute West Jordan UT. 84088 Indahyung, Ruth M MD Hospital Affiliation of Utah p 385.351.6735 Nephrology Associates of - Jordan Valley Medical 3336 S 4155 W Utah Center Ste 203 Hollingsworth, Martin A 12511 S Creek Meadow Rd - St Marks Hospital Salt Lake City UT. 84120 MD Ste 111 - University of Utah Hospital p 801.263.2370 Copperview Medical Center Riverton UT. 84065 3556 W 9800 S p 801.288.2634 Jansen, Kevin MD 3570 W 9000 S Ste 101 Nephrology Associates of Ste 110 South Jordan UT. 84095 3702 S State St Utah West Jordan UT. 84088 p 801.567.9780 Ste 107 12511 S Creek Meadow Rd p 801.263.2370 Salt Lake City UT. 84115 Ste 111 Hospital Affiliation p 801.288.2634 Riverton UT. 84065 5979 S Fashion Blvd - Jordan Valley Medical p 801.288.2634 Murray UT. 84107 Center 3823 W 9000 S p 801.263.2370 - Lone Peak Hospital West Jordan UT. 84088 3702 S State St p 801.288.2634 Ste 107 82 S 1100 E Holmstrom, Scott T MD Salt Lake City UT. 84115 Ste 200 University of Utah Health 4101 W Pioneer Pkwy p 801.288.2634 Salt Lake City UT. 84102 1950 Cir of Hope Dr Ste 103 p 801.263.2370 Salt Lake City UT. 84112 West Valley City UT. 84120 3823 W 9000 S p 801.585.0100 p 801.288.2634 West Jordan UT. 84088 Johnson, Kevin B MD p 801.288.2634 Jordan Valley Internal 50 N Medical Dr Hospital Affiliation Medicine Salt Lake City UT. 84132 - St Marks Hospital 4101 W Pioneer Pkwy 3570 W 9000 S p 801.581.7818 - Jordan Valley Medical Ste 103 Ste 100 Center West Valley City UT. 84120 West Jordan UT. 84088 501 S Chipeta Way - Salt Lake Regional Medical p 801.288.2634 p 801.569.2384 Salt Lake City UT. 84108 Center p 801.583.2500 Hospital Affiliation Hospital Affiliation Internal Med Hepatology - St Marks Hospital - Jordan Valley Medical University Of Utah Health Department of University - Jordan Valley Medical Center 85 N Medical Dr of Utah Center West Valley Campus Salt Lake City UT. 84112 50 N Medical Dr - Salt Lake Regional Medical Johnson, Stacy A MD p 801.581.7818 Salt Lake City UT. 84132 Center University of Utah Health p 801.585.0434 50 N Medical Dr Hospital Affiliation Jefferds, Ann MD Salt Lake City UT. 84132 - University of Utah Hospital Internal Olympus Clinic p 801.581.7818 Med-Interventional 4624 S Holladay Blvd Horton, Devin J MD Cardiology Department of Ste 100 501 S Chipeta Way University of Utah Health University of Utah Salt Lake City UT. 84117 Salt Lake City UT. 84108 50 N Medical Dr 50 N Medical Dr p 801.277.2682 p 801.583.2500 Salt Lake City UT. 84132 Salt Lake City UT. 84132 p 801.581.7818 p 801.585.0434 Jenkins, Stephen L MD University Of Utah Health University of Utah Health 85 N Medical Dr 1950 Cir of Hope Dr Salt Lake City UT. 84112 Salt Lake City UT. 84112 p 801.581.7818 p 801.585.0100 Hospital Affiliation - University of Utah Hospital

225 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Kaplan, David A MD Kemeyou, Line MD Kim, Christopher Y MD Krishnamurthy, Chaya MD University of Utah Health University of Utah Health Advanced Vein and Vascular Utah Gastroenterology 50 N Medical Dr 1950 Cir of Hope Dr of Salt Lake City 12391 S 4000 W Salt Lake City UT. 84132 Salt Lake City UT. 84112 6321 S Redwood Rd Herriman UT. 84096 p 801.581.7818 p 801.585.7676 Ste 102 p 801.727.4280 Salt Lake City UT. 84123 555 Foothill Dr 50 N Medical Dr p 385.388.8003 1250 E 3900 S Salt Lake City UT. 84112 Salt Lake City UT. 84132 Ste 360 p 801.581.7790 p 801.585.0434 Hospital Affiliation Salt Lake City UT. 84124 - Davis Hospital p 801.263.3041 Hospital Affiliation University Of Utah Health - Lakeview Hospital - University of Utah Hospital 85 N Medical Dr - Ogden Regional Medical 13953 S Bangerter Pkwy Salt Lake City UT. 84112 Center Draper UT. 84020 Kaput, Katie DO p 801.585.7676 - Salt Lake Regional Medical p 801.727.4280 University of Utah Health Center 1280 E Stringham Ave Hospital Affiliation 6360 S 3000 E Salt Lake City UT. 84106 - University of Utah Hospital Kithas, Philip A MD Ste 310 p 801.581.7763 University of Utah Health Salt Lake City UT. 84124 Khan, Sohail MD 50 N Medical Dr p 801.944.3144 University Of Utah Health Heart Center at St Marks Salt Lake City UT. 84132 85 N Medical Dr Hospital p 801.581.2628 Hospital Affiliation Salt Lake City UT. 84112 1160 E 3900 S - St Marks Hospital p 801.581.7763 Ste 2000 555 Foothill Dr - Lone Peak Hospital Salt Lake City UT. 84124 Salt Lake City UT. 84112 - Lakeview Hospital Karnam, Umaprasanna S MD p 801.266.3418 p 801.581.2628 Gut Whisperer Kroencke, Rachel D MD 1543 W 12600 S MountainStar Cardiology St 700 Foothill Blvd University of Utah Health Ste 102 Marks Salt Lake City UT. 84113 555 Foothill Dr Riverton UT. 84065 3584 W 9000 S p 801.581.2628 Salt Lake City UT. 84112 p 801.563.5121 Ste 209 p 801.581.7790 West Jordan UT. 84088 University Of Utah Health 2295 S Foothill Dr p 801.676.3776 85 N Medical Dr Hospital Affiliation Salt Lake City UT. 84109 Salt Lake City UT. 84112 - University of Utah Hospital p 801.563.5121 American Heart and p 801.581.2628 Vascular Institute Kundra, Hena MD Hospital Affiliation 5292 College Dr Hospital Affiliation University of Utah Health - Salt Lake Regional Medical Ste 201 - University of Utah Hospital 5126 W Daybreak Pkwy Center Salt Lake City UT. 84123 Ste 600 - Jordan Valley Medical p 801.556.7745 Koening, Curry L MD South Jordan UT. 84009 Center University of Utah Health p 801.213.4500 5801 S Fashion Blvd 50 N Medical Dr Kaur, Manpreet MD Ste 120 Salt Lake City UT. 84132 Hospital Affiliation MountainStar Medical Group Salt Lake City UT. 84107 p 801.581.4333 - University of Utah Hospital 74 Kimballs Ln p 801.556.7745 Ste 300 University Of Utah Health Kuo, David MD Draper UT. 84020 MountainStar Cardiology St 85 N Medical Dr Utah Physicians Care p 801.572.0311 Marks Salt Lake City UT. 84112 Center 74 E Kimball Ln p 801.581.7724 1160 E 3900 S Keenan, Lynn M MD Ste 260 Ste 1200 University of Utah Health Draper UT. 84020 Hospital Affiliation Salt Lake City UT. 84124 1950 Cir of Hope Dr p 801.571.6100 - University of Utah Hospital p 801.261.9651 Salt Lake City UT. 84112 p 801.581.7806 Hospital Affiliation Kotwal, Pinky MD Hospital Affiliation - Wyoming Medical Center Granger Medical Clinic - St Marks Hospital 50 N Medical Dr 11724 S State St Salt Lake City UT. 84132 Kim-Butterfield, Yoon MD Draper UT. 84020 LaBrin, Joshua E MD p 801.581.2121 University Of Utah Health p 801.576.2050 University of Utah Health 1525 W 2100 S 50 N Medical Dr Hospital Affiliation Salt Lake City UT. 84119 Hospital Affiliation Salt Lake City UT. 84132 - University of Utah Hospital p 801.213.9900 - Jordan Valley Medical p 801.581.7818 Center Keihanian, Mana MD Hospital Affiliation - Jordan Valley Medical University Of Utah Health MountainStar Cardiology St - University of Utah Hospital Center West Valley Campus 85 N Medical Dr Marks Salt Lake City UT. 84112 1160 E 3900 S p 801.581.7818 Ste 2000 Salt Lake City UT. 84124 Hospital Affiliation p 801.266.3418 - University of Utah Hospital 226 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. LaPolla, Ann E MD 4101 W Pioneer Pkwy Lundberg, Max S MD University Of Utah Health Cottonwood Medical Clinic Ste 103 Granger Medical 85 N Medical Dr 6671 S Redwood Rd West Valley City UT. 84120 Specialists Salt Lake City UT. 84112 Ste 110 p 801.288.2634 11333 S 1000 E p 801.581.7818 West Jordan UT. 84084 Ste 100 p 801.281.5775 Hospital Affiliation Sandy UT. 84094 Hospital Affiliation - St Marks Hospital p 801.571.4100 - University of Utah Hospital Lamb, Sara M MD - Jordan Valley Medical University of Utah Health Center West Valley Campus Lunt, Margaret S MD Martinez-Ross, Juan M MD 50 N Medical Dr - Salt Lake Regional Medical Utah Physicians Care Granger Medical Clinic Salt Lake City UT. 84132 Center Center 1160 E 3900 S p 801.581.7818 1160 E 3900 S Ste 1000 Lawlor, Cynthia MD Ste 1200 Salt Lake City UT. 84124 Primary Childrens Spina St Marks Senior Health Salt Lake City UT. 84124 p 801.262.1771 Bifida Center p 801.261.9651 81 N Mario Capecchi Dr 1160 E 3900 S Martinez, Mark L MD Salt Lake City UT. 84113 Ste G100 Hospital Affiliation Silver Peaks Rehab p 801.662.1675 Salt Lake City UT. 84124 - St Marks Hospital 3540 S Main St p 801.268.7766 Salt Lake City UT. 84115 Hospital Affiliation Luras, John C MD p 801.997.9500 - University of Utah Hospital 1160 E 3900 S Salt Lake Senior Clinic - Ste G200 Salt Lake City ValleyFit Clinic Lane, Keith J MD Salt Lake City UT. 84124 82 S 1100 E 4460 S Highland Dr Internal Medicine of Salt p 801.268.7766 Ste 204 Ste 300 Lake Parley's Canyon Salt Lake City UT. 84102 Salt Lake City UT. 84124 2645 E Parleys Way St Marks Interventional p 801.350.4753 p 801.273.6300 Ste 200 Pain Clinic Salt Lake City UT. 84109 1220 E 3900 S Hospital Affiliation Hospital Affiliation p 801.384.4700 Ste 3-B - Salt Lake Regional Medical - Salt Lake Regional Medical Salt Lake City UT. 84124 Center Center Hospital Affiliation p 801.268.7725 - St Marks Hospital - Salt Lake Regional Medical Lynch, Keisa M APRN - Timpanogos Regional Hospital Center St Marks Senior Health University of Utah Health - Mountain View Hospital Center 50 N Medical Dr (UT) Lappe, Katherine L MD 1275 E Ft Union Blvd Salt Lake City UT. 84132 University of Utah Health Ste 150 p 801.213.9797 McLaughlin, Nancy L MD 50 N Medical Dr Cottonwood Heights UT. 84047 University of Utah Health Salt Lake City UT. 84132 p 801.268.7766 Hospital Affiliation 50 N Medical Dr p 801.581.7818 - University of Utah Hospital Salt Lake City UT. 84132 Hospital Affiliation p 801.581.7818 University Of Utah Health - St Marks Hospital Malik, Sonia A MD 85 N Medical Dr University Of Utah Health Medical Associates of Salt Salt Lake City UT. 84112 Litton, Gregory J MD 5126 W Daybreak Pkwy Lake p 801.581.7818 Utah Cancer Specialists South Jordan UT. 84009 508 E S Temple 5131 S Cottonwood St p 801.213.4500 Ste 300 Hospital Affiliation Ste L-2 Salt Lake City UT. 84102 - University of Utah Hospital Murray UT. 84107 Hospital Affiliation p 801.521.4500 p 801.263.3416 - University of Utah Hospital Lau, Sey M MD University of Utah Health Nephrology Associates of Hospital Affiliation Marr, Joshua M MD 555 Foothill Dr Utah - St Marks Hospital University of Utah Health Salt Lake City UT. 84112 12511 S Creek Meadow Rd - Lakeview Hospital 1950 Cir of Hope Dr p 801.581.7790 Ste 111 - Jordan Valley Medical Salt Lake City UT. 84112 Riverton UT. 84065 Center p 801.585.0100 Hospital Affiliation p 801.288.2634 - Salt Lake Regional Medical - Salt Lake Regional Medical Center 50 N Medical Dr Center 3702 S State St Salt Lake City UT. 84132 Ste 107 Liu, Zhenhao MD p 801.581.7818 Memon, Kashif A MD Salt Lake City UT. 84115 Granger Medical Salt Lake Regional Medical p 801.288.2634 Specialists 501 S Chipeta Way Associates 11333 S 1000 E Salt Lake City UT. 84108 24 S 1100 E 3823 W 9000 S Ste 100 p 801.583.2500 Ste 304 West Jordan UT. 84088 Sandy UT. 84094 Salt Lake City UT. 84102 p 801.288.2634 p 801.571.4100 p 801.521.4500

227 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Jordan Valley Internal Moore, Rebecca H MD 5126 W Daybreak Pkwy Musci, Anthony G Medicine St Marks Senior Health South Jordan UT. 84009 Onsite Care Clinic 3570 W 9000 S Center p 801.213.4500 230 S 500 E Ste 100 1160 E 3900 S Ste 510 West Jordan UT. 84088 Ste G200 University Of Utah Health Salt Lake City UT. 84102 p 801.569.2384 Salt Lake City UT. 84124 85 N Medical Dr p 801.320.5660 p 801.268.7766 Salt Lake City UT. 84112 Hospital Affiliation p 801.585.7676 560 S 300 E - Jordan Valley Medical St Marks Interventional Ste 275 Center Pain Clinic Hospital Affiliation Salt Lake City UT. 84111 - Salt Lake Regional Medical 1220 E 3900 S - University of Utah Hospital p 801.441.1002 Center Ste 3-B - Davis Hospital Salt Lake City UT. 84124 Muhlestein, Joseph B MD Hospital Affiliation p 801.268.7725 University of Utah Health - Salt Lake Regional Medical Mihalopoulos, Nicole L MD 50 N Medical Dr Center University of Utah Health St Marks Senior Health Salt Lake City UT. 84132 81 N Mario Capecchi Dr Center p 801.585.7676 Nalabothu, Poorna L MD Salt Lake City UT. 84113 1275 E Ft Union Blvd Heart Center at St Marks p 801.213.3599 Ste 150 Hospital Affiliation Hospital Cottonwood Heights UT. 84047 - University of Utah Hospital 1160 E 3900 S Hospital Affiliation p 801.268.7766 Ste 2000 - University of Utah Hospital Mulligan, Matthew J MD Salt Lake City UT. 84124 Hospital Affiliation University of Utah Health p 801.266.3418 Miller, Brien R MD - St Marks Hospital 1280 E Stringham Ave Utah Gastroenterology Salt Lake City UT. 84106 Nannapaneni, Nischala MD 6360 S 3000 E Morris, Donald R MD p 801.581.7818 Heart Center at St Marks Ste 310 Nephrology Associates of Hospital Salt Lake City UT. 84121 Utah Hospital Affiliation 1160 E 3900 S p 801.944.3144 12511 S Creek Meadow Rd - University of Utah Hospital Ste 2000 Ste 111 Salt Lake City UT. 84124 Miller, Karla L MD Riverton UT. 84065 Murnin, Kelly P MD p 801.266.3418 University of Utah Health p 801.288.2634 University of Utah Health 50 N Medical Dr 1525 W 2100 S Nelson, Bryan MD Salt Lake City UT. 84132 3702 S State St Salt Lake City UT. 84119 Foothill Family Clinic p 801.581.4333 Ste 107 p 801.213.8841 13953 S Bangerter Pkwy Salt Lake City UT. 84115 Draper UT. 84020 615 S Arapeen Dr p 801.288.2634 Hospital Affiliation p 385.900.4090 Ste 100 - University of Utah Hospital Salt Lake City UT. 84108 3823 W 9000 S 6360 S 3000 E p 801.581.7724 West Jordan UT. 84088 Murphy, Ryan D MD Ste 100 p 801.288.2634 University of Utah Health Salt Lake City UT. 84121 University Of Utah Health 1950 Cir of Hope Dr p 801.365.1032 85 N Medical Dr 4101 W Pioneer Pkwy Salt Lake City UT. 84112 Salt Lake City UT. 84112 Ste 103 p 801.585.0100 Hospital Affiliation p 801.581.7724 West Valley City UT. 84120 - Primary Childrens Hospital p 801.288.2634 50 N Medical Dr - Salt Lake Regional Medical Hospital Affiliation Salt Lake City UT. 84132 Center - University of Utah Hospital Hospital Affiliation p 801.581.7818 - St Marks Hospital Nord, John W MD Miller, Thomas L MD - Jordan Valley Medical 501 S Chipeta Way University of Utah Health University of Utah Health Center West Valley Campus Salt Lake City UT. 84108 50 N Medical Dr 50 N Medical Dr - Salt Lake Regional Medical p 801.583.2500 Salt Lake City UT. 84132 Salt Lake City UT. 84132 Center p 801.581.7818 p 801.581.7818 University Of Utah Health Morshedzadeh, Jack H MD 85 N Medical Dr University Of Utah Health Hospital Affiliation University of Utah Health Salt Lake City UT. 84112 85 N Medical Dr - University of Utah Hospital 1525 W 2100 S p 801.581.7818 Salt Lake City UT. 84112 Salt Lake City UT. 84119 p 801.581.7818 Mir-Kasimov, Mir-Mustafa p 801.213.9990 Hospital Affiliation MD - University of Utah Hospital Hospital Affiliation University of Utah Health 1950 Cir of Hope Dr - University of Utah Hospital 50 N Medical Dr Salt Lake City UT. 84112 Murray, Michelle MD Salt Lake City UT. 84132 p 801.585.0303 Copperview Medical Center p 801.581.7806 3556 W 9800 S Ste 101 Hospital Affiliation South Jordan UT. 84095 - University of Utah Hospital p 801.567.9780

Hospital Affiliation - Jordan Valley Medical Center 228 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Norris, Jennifer L MD Oberg, Christine E MD Patterson, Paige A MD Pilgram, Paul E MD Granger Medical Clinic University of Utah Health University of Utah Health The Practice of Medicine 1160 E 3900 S 50 N Medical Dr 1950 Cir of Hope Dr 1561 W 7000 S Ste 1000 Salt Lake City UT. 84132 Salt Lake City UT. 84112 Ste 200 Salt Lake City UT. 84124 p 801.581.7818 p 801.585.0100 West Jordan UT. 84084 p 801.262.1771 p 801.562.5300 University Of Utah Health 2830 S Redwood Rd Hospital Affiliation 85 N Medical Dr Ste C Hospital Affiliation - St Marks Hospital Salt Lake City UT. 84112 West Valley City UT. 84119 - Jordan Valley Medical p 801.581.7818 p 801.213.4500 Center Norton, Sarah E MD University Of Utah Health Hospital Affiliation 50 N Medical Dr Powell, Amy P MD 1950 Cir of Hope Dr - University of Utah Hospital Salt Lake City UT. 84132 University of Utah Health Salt Lake City UT. 84112 p 801.581.7818 290 S 1850 E p 801.585.0100 Oelsner, David H MD Salt Lake City UT. 84112 Granger Medical 555 Foothill Dr p 801.587.7109 50 N Medical Dr Specialists Salt Lake City UT. 84112 Salt Lake City UT. 84132 2965 W 3500 S p 801.581.7818 580 S Guardsman Way p 801.581.7818 West Valley City UT. 84119 Salt Lake City UT. 84112 p 801.965.3600 University Of Utah Health p 801.587.7109 501 S Chipeta Way 85 N Medical Dr Salt Lake City UT. 84108 Hospital Affiliation Salt Lake City UT. 84112 590 S Wakara Way p 801.583.2500 - Jordan Valley Medical p 801.581.7818 Salt Lake City UT. 84108 Center p 801.587.7109 85 N Medical Dr - Jordan Valley Medical Hospital Affiliation Salt Lake City UT. 84112 Center West Valley Campus - University of Utah Hospital University Of Utah Health p 801.581.7818 - Mountain West Medical 9385 Snowbird Ctr Dr Center Peacock, Penny J MD Sandy UT. 84092 Hospital Affiliation Parleys Primary Care p 801.646.4800 - University of Utah Hospital Oliver, Mark R MD Clinic Utah Physicians Care 2645 E Parleys Way Hospital Affiliation Novak, Kirsten MD Center Ste 200 - University of Utah Hospital Silverton Group 1160 E 3900 S Salt Lake City UT. 84109 4252 Birkhill Blvd Ste 1200 p 801.384.4730 Pua, Roland MD Salt Lake City UT. 84107 Salt Lake City UT. 84124 Claris Health p 385.425.0050 p 801.261.9651 Steward Medical Group 2730 E 3300 S Primary Care Murray Salt Lake City UT. 84109 ValleyFit Clinic University of Utah Health 5980 S Fashion Blvd p 801.487.0896 4460 S Highland Dr 50 N Medical Dr Salt Lake City UT. 84107 Ste 300 Salt Lake City UT. 84132 p 801.281.2668 Puckett, Megan M MD Salt Lake City UT. 84124 p 801.585.2031 University Of Utah Health p 801.273.6300 Hospital Affiliation 1212 E Wilmington Ave Hospital Affiliation - Park City Hospital Salt Lake City UT. 84106 Silverton Group - St Marks Hospital - University of Utah Hospital p 801.581.2628 5097 S 900 E - Lakeview Hospital Ste 100 - Lone Peak Hospital Pena Ayala, Esteban MD 50 N Medical Dr Salt Lake City UT. 84117 - Salt Lake Regional Medical University of Utah Health Salt Lake City UT. 84132 p 801.576.1455 Center 1950 Cir of Hope Dr p 801.581.2628 Salt Lake City UT. 84112 Nuttall, Marc T MD Osborn, James D MD p 801.585.2626 555 Foothill Dr Revere Health University of Utah Health Salt Lake City UT. 84112 96 E Kimballs Ln 1950 Cir of Hope Dr Hospital Affiliation p 801.581.2628 Ste 305 Salt Lake City UT. 84112 - University of Utah Hospital Draper UT. 84020 p 801.585.2626 700 Foothill Blvd p 801.655.5670 Penrod, Michael J MD Salt Lake City UT. 84113 Hospital Affiliation University of Utah Health p 801.581.2628 Hospital Affiliation - University of Utah Hospital 50 N Medical Dr - Mountain View Hospital Salt Lake City UT. 84132 76 S 500 E (UT) Ozbolt, Julia A MD p 801.581.7818 Salt Lake City UT. 84102 - Castleview Hospital University of Utah Health p 801.581.2628 - Lone Peak Hospital 1525 W 2100 S Hospital Affiliation - Timpanogos Regional Hospital Salt Lake City UT. 84119 - University of Utah Hospital 85 N Medical Dr p 801.213.8841 Salt Lake City UT. 84112 p 801.581.2628 Hospital Affiliation - Jordan Valley Medical Hospital Affiliation Center - University of Utah Hospital - St Marks Hospital - University of Utah Hospital 229 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Pulgiano, Angelo MD Rahimi, Danesh MD 50 N Medical Dr Rupper, Randall W MD University of Utah Health St Marks Senior Health Salt Lake City UT. 84132 University of Utah Health 5126 W Daybreak Pkwy Center p 801.581.7818 50 N Medical Dr Ste 600 1160 E 3900 S Salt Lake City UT. 84132 South Jordan UT. 84009 Ste G100 University Of Utah Health p 801.581.2628 p 801.213.4500 Salt Lake City UT. 84124 85 N Medical Dr p 801.268.7479 Salt Lake City UT. 84112 Hospital Affiliation Hospital Affiliation p 801.581.7818 - University of Utah Hospital - University of Utah Hospital 1160 E 3900 S Ste G200 Hospital Affiliation Saidi, Abdul F MD Puri, Sonam MD Salt Lake City UT. 84124 - University of Utah Hospital Heart and Lung Institute University Of Utah Health p 801.268.7766 of Utah 85 N Medical Dr Richards, Bradley D PA-C 3336 S 4155 W Salt Lake City UT. 84112 1200 E 3900 S Granger Medical Clinic Ste 203 p 801.585.0100 Ste 3B 12391 S 4000 W Salt Lake City UT. 84120 Salt Lake City UT. 84124 Riverton UT. 84065 p 801.263.2370 Hospital Affiliation p 801.268.7111 p 801.302.1700 - University of Utah Health 3570 W 9000 S Craig H Neilsen Rehabilitation HospitalSt Marks Interventional Rizzardi, Barbara E MD Ste 110 Pain Clinic 8706 S 700 E West Jordan UT. 84088 Qazi, Mohammed F MD 1220 E 3900 S Ste 203 p 801.263.2370 University Of Utah Health Ste 3-B Sandy UT. 84070 7495 S State St Salt Lake City UT. 84124 p 801.576.8333 5979 S Fashion Blvd Midvale UT. 84047 p 801.268.7725 Murray UT. 84107 p 801.213.9400 Roberts, Philip L MD p 801.263.2370 St Marks Senior Health MountainStar Medical Group Hospital Affiliation Center 74 Kimballs Ln 82 S 1100 E - University of Utah Hospital 1275 E Ft Union Blvd Ste 260 Ste 200 Ste 150 Draper UT. 84020 Salt Lake City UT. 84102 Raaum, Sonja E MD Cottonwood Heights UT. 84047 p 801.545.8480 p 801.263.2370 University of Utah Health p 801.268.7766 1950 Cir of Hope Dr 74 Kimballs Ln Hospital Affiliation Salt Lake City UT. 84112 Hospital Affiliation Ste 300 - Jordan Valley Medical p 801.585.0100 - St Marks Hospital Draper UT. 84020 Center West Valley Campus p 801.572.0311 50 N Medical Dr Raj Krishnamurthy, Vidya Samuelson, Scott J MD Salt Lake City UT. 84132 M MD Hospital Affiliation Utah Cancer Specialists p 801.581.7818 University of Utah Health - St Marks Hospital 389 S 900 E 50 N Medical Dr - Jordan Valley Medical Ste 100 501 S Chipeta Way Salt Lake City UT. 84132 Center Salt Lake City UT. 84102 Salt Lake City UT. 84108 p 801.581.6709 - Lone Peak Hospital p 385.282.2125 p 801.583.2500 Hospital Affiliation Rondina, Matthew T MD Hospital Affiliation University Of Utah Health - University of Utah Hospital University of Utah Health - Jordan Valley Medical 85 N Medical Dr 50 N Medical Dr Center Salt Lake City UT. 84112 Raman, Sanjeev M Salt Lake City UT. 84132 - Davis Hospital p 801.581.7818 University of Utah Health p 801.581.7818 - Lakeview Hospital 50 N Medical Dr - Salt Lake Regional Medical Hospital Affiliation Salt Lake City UT. 84132 Hospital Affiliation Center - University of Utah Hospital p 801.581.7806 - University of Utah Hospital Sanders, Natalie A DO Ragle, Nathan J MD 5126 W Daybreak Pkwy Roy, Abinash C MD University of Utah Health University of Utah Health South Jordan UT. 84009 University of Utah Health 2363 S Foothill Dr 50 N Medical Dr p 801.581.7806 50 N Medical Dr Salt Lake City UT. 84109 Salt Lake City UT. 84132 Salt Lake City UT. 84132 p 801.581.2628 p 801.581.7818 Hospital Affiliation p 801.581.6709 - University of Utah Hospital 50 N Medical Dr 555 Foothill Dr 515 E 100 S Salt Lake City UT. 84132 Salt Lake City UT. 84112 Reddy, Santosh P MD Ste 350 p 801.581.2628 p 801.581.7790 University of Utah Health Salt Lake City UT. 84102 1950 Cir of Hope Dr p 801.581.3981 555 Foothill Dr Hospital Affiliation Salt Lake City UT. 84112 Salt Lake City UT. 84112 - University of Utah Hospital p 801.585.0100 Hospital Affiliation p 801.581.2628 - St George Regional Hospital - University of Utah Hospital

230 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:47 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 76 S 500 E Shakeri, Mehrnoosh MD Sossenheimer, Michael J 50 N Medical Dr Salt Lake City UT. 84102 University of Utah Health MD Salt Lake City UT. 84132 p 801.581.2628 1525 W 2100 S University of Utah Health p 801.581.7763 Salt Lake City UT. 84119 1950 Cir of Hope Dr University Of Utah Health p 801.213.8841 Salt Lake City UT. 84112 5126 W Daybreak Pkwy 85 N Medical Dr p 801.581.7802 South Jordan UT. 84009 Salt Lake City UT. 84112 7495 S State St p 801.213.4500 p 801.581.2628 Midvale UT. 84047 50 N Medical Dr p 801.213.9400 Salt Lake City UT. 84132 615 S Arapeen Dr Hospital Affiliation p 801.213.9797 Ste 100 - University of Utah Hospital Hospital Affiliation Salt Lake City UT. 84108 - University of Utah Hospital Hospital Affiliation p 801.581.7761 Schaecher, Kenneth L MD - Jordan Valley Medical Granger Medical Clinic Shami, Paul J MD Center University Of Utah Health 2965 W 3500 S University of Utah Health 85 N Medical Dr West Valley City UT. 84119 1950 Cir of Hope Dr Srinivasan, Bharani MD Salt Lake City UT. 84112 p 801.965.3600 Salt Lake City UT. 84112 Granger Medical Clinic p 801.581.7763 p 801.585.2626 1160 E 3900 S Hospital Affiliation Ste 1000 Hospital Affiliation - Jordan Valley Medical Hospital Affiliation Salt Lake City UT. 84124 - University of Utah Hospital Center - University of Utah Hospital p 801.262.1771 - Jordan Valley Medical Szczesny, Lorraine B MD Center West Valley Campus Sheffield, Clinton R MD Hospital Affiliation University of Utah Health University of Utah Health - St Marks Hospital 50 N Medical Dr Scheidell, Renee MD 3730 W 4700 S Salt Lake City UT. 84132 Draper Family Practice West Valley City UT. 84129 Stehlik, Josef MD p 801.581.7818 12272 S 800 E p 801.213.9200 University of Utah Health Ste A 1950 Cir of Hope Dr Medical Associates of Salt Draper UT. 84020 Hospital Affiliation Salt Lake City UT. 84112 Lake p 801.523.1300 - University of Utah Hospital p 801.585.7676 508 E S Temple Ste 300 Schlisman, Alison MD Shum, Mili MD 50 N Medical Dr Salt Lake City UT. 84102 University of Utah Health University of Utah Health Salt Lake City UT. 84132 p 801.521.4500 50 N Medical Dr 1280 E Stringham Ave p 801.585.0434 Salt Lake City UT. 84132 Salt Lake City UT. 84106 Hospital Affiliation p 801.581.2628 p 801.581.2955 University Of Utah Health - Salt Lake Regional Medical 85 N Medical Dr Center 555 Foothill Dr 243 E 6100 S Salt Lake City UT. 84112 Salt Lake City UT. 84112 Salt Lake City UT. 84107 p 801.585.7676 Szwajkun, Konstantyn Y MD p 801.581.2628 p 801.581.2955 Heart and Lung Institute Hospital Affiliation of Utah 700 Foothill Blvd 81 N Mario Capecchi Dr - University of Utah Hospital 3336 S 4155 W Salt Lake City UT. 84113 Salt Lake City UT. 84113 Ste 203 p 801.581.2628 p 801.213.3599 Stults, Barry M MD Salt Lake City UT. 84120 University of Utah Health p 801.263.2370 University Of Utah Health Silverton Group 50 N Medical Dr 85 N Medical Dr 4252 Birkhill Blvd Salt Lake City UT. 84132 3570 W 9000 S Salt Lake City UT. 84112 Salt Lake City UT. 84107 p 801.581.7818 Ste 110 p 801.581.2628 p 385.425.0050 West Jordan UT. 84088 555 Foothill Dr p 801.263.2370 Hospital Affiliation Slatkin, Sara G MD Salt Lake City UT. 84112 - Salt Lake Regional Medical Copperview Medical Center p 801.581.7790 3584 W 9000 S Center 2556 W 9800 S Ste 209 Ste 101 Hospital Affiliation West Jordan UT. 84088 Shah, Sheetal R MD South Jordan UT. 84095 - University of Utah Hospital p 801.263.2370 Granger Medical Clinic p 801.567.9780 11724 S State St Sundaresh, Vishnu MD 5979 S Fashion Blvd Draper UT. 84020 Sofarelli, Theresa A PA-C University of Utah Health Murray UT. 84107 p 801.965.3600 University of Utah Health 1950 Cir of Hope Dr p 801.263.2370 50 N Medical Dr Salt Lake City UT. 84112 3181 W 9000 S Salt Lake City UT. 84132 p 801.581.7763 82 S 1100 E West Jordan UT. 84088 p 801.585.2031 Ste 200 p 801.569.5600 Salt Lake City UT. 84102 p 801.263.2370 Hospital Affiliation - Jordan Valley Medical Hospital Affiliation Center - Jordan Valley Medical - St Marks Hospital Center - Jordan Valley Medical - Salt Lake Regional Medical Center West Valley Campus Center 231 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Tanner, Rebecca P UUHC Redwood Health Center 50 N Medical Dr Jordan Valley Internal Titen, Jamie DO 1525 W 2100 S Salt Lake City UT. 84132 Medicine Salt Lake Internal Salt Lake City UT. 84119 p 801.581.7818 3570 W 9000 S Medicine Clinic p 801.213.9900 Ste 100 82 S 1100 E 501 S Chipeta Way West Jordan UT. 84088 Ste 403 UUHC South Jordan Health Salt Lake City UT. 84108 p 801.569.2384 Salt Lake City UT. 84102 Center p 801.583.2500 p 801.384.4730 5126 W Daybreak Pkwy Hospital Affiliation South Jordan UT. 84095 85 N Medical Dr - Jordan Valley Medical Topham, Robert B MD p 801.213.4500 Salt Lake City UT. 84112 Center Holladay Dermatology p 801.581.7818 Clinic UUHC Madsen Health Center Tanvir, Fawad MD 1775 E 4500 S 555 S Foothill Blvd Hospital Affiliation Alpine Medical Group Salt Lake City UT. 84117 Ste 301 - University of Utah Hospital 24 S 1100 E p 801.272.4408 Salt Lake City UT. 84112 Ste 310 p 801.581.8000 Vinik, Russell G MD Salt Lake City UT. 84102 Trachtenberg, Joel D MD University of Utah Health p 801.478.0010 Utah Physicians Care UUHC Redwood Health Center 50 N Medical Dr Center 1525 W 2100 S Salt Lake City UT. 84132 Hospital Affiliation 1160 E 3900 S Salt Lake City UT. 84119 p 801.581.7818 - Ogden Regional Medical Ste 1200 p 801.213.9900 Center Salt Lake City UT. 84124 University Of Utah Health - Davis Hospital p 801.261.9651 UUHC South Jordan Health 85 N Medical Dr - Lakeview Hospital Center Salt Lake City UT. 84112 - Lone Peak Hospital University of Utah Health 5126 W Daybreak Pkwy p 801.581.7818 50 N Medical Dr South Jordan UT. 84095 Tettelbach, William MD Salt Lake City UT. 84132 p 801.213.4500 Hospital Affiliation Silverton Group p 801.213.9797 - University of Utah Hospital 4252 Birkhill Blvd UUHC Redwood Health Center Salt Lake City UT. 84107 Hospital Affiliation 1525 W 2100 S Vogt, Jennifer E MD p 385.425.0050 - St Marks Hospital Salt Lake City UT. 84119 University of Utah Health - Lone Peak Hospital p 801.213.9900 3730 W 4700 S Tien, Dave MD - Lakeview Hospital West Valley City UT. 84129 Nephrology Associates of - Salt Lake Regional Medical UUHC Westridge Health p 801.213.9200 Utah Center Center 12511 S Creek Meadow Rd 3730 W 4700 S Hospital Affiliation Ste 111 Tschetter, Kevin W MD Taylorsville UT. 84118 - University of Utah Hospital Riverton UT. 84065 Alta Internal Medicine p 801.213.9200 p 801.288.2634 74 Kimballs Ln Wanner, Nathan A MD Ste 300 UUHC South Jordan Health University of Utah Health 3702 S State St Draper UT. 84020 Center 50 N Medical Dr Ste 107 p 801.572.0311 5126 W Daybreak Pkwy Salt Lake City UT. 84132 Salt Lake City UT. 84115 South Jordan UT. 84095 p 801.581.7818 p 801.288.2634 Hospital Affiliation p 801.213.4500 - St Marks Hospital University Of Utah Health 3823 W 9000 S - Lone Peak Hospital UUHC Greenwood Health 85 N Medical Dr West Jordan UT. 84088 Center Salt Lake City UT. 84112 p 801.288.2634 Tuan, Jenny C MD 7495 S State St p 801.581.7818 University of Utah Health Midvale UT. 84047 4101 W Pioneer Pkwy 50 N Medical Dr p 801.213.9400 Hospital Affiliation Ste 103 Salt Lake City UT. 84132 - University of Utah Hospital West Valley City UT. 84120 p 801.581.7818 U of U Palliative Care p 801.288.2634 50 N Medical Dr Wikstrom, Sara W MD University Of Utah Health Salt Lake City UT. 84132 University of Utah Health Hospital Affiliation 85 N Medical Dr p 801.581.2121 1950 Cir of Hope Dr - St Marks Hospital Salt Lake City UT. 84112 Salt Lake City UT. 84112 - Jordan Valley Medical p 801.581.7818 Hospital Affiliation p 801.585.0100 Center West Valley Campus - University of Utah Hospital - Salt Lake Regional Medical Hospital Affiliation University Of Utah Health Center - University of Utah Hospital Vaughn, Valerie M MD 85 N Medical Dr University Of Utah Health Salt Lake City UT. 84112 Tipton, Mary D MD UUHC Sugar House Health 1950 Cir of Hope Dr p 801.581.7818 Copperview Medical Center Center Salt Lake City UT. 84112 3556 W 9800 S 1138 E Wilmington Ave p 801.585.0100 Hospital Affiliation Ste 101 Salt Lake City UT. 84106 - University of Utah Hospital South Jordan UT. 84095 p 801.581.2000 p 801.567.9780

Hospital Affiliation - Jordan Valley Medical Center 232 *The PPO- Lone Agreement Peak Hospitalwith this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Wilson, Brent D MD 3540 S 4000 W 5979 S Fashion Blvd Sunkara, Nirmal T MD University of Utah Health Ste 340 Murray UT. 84107 Steward Cardiology 1138 E Wilmington Ave West Valley City UT. 84120 p 801.263.2370 Associates - West Valley Salt Lake City UT. 84106 p 801.676.3776 3336 S Pioneer Pkwy p 801.581.2000 82 S 1100 E Ste 203 Yan-Che Lui, Charles MD Ste 200 West Valley City UT. 84120 1525 W 2100 S University of Utah Health Salt Lake City UT. 84102 p 801.748.0113 Salt Lake City UT. 84119 50 N Medical Dr p 801.263.2370 p 801.213.9990 Salt Lake City UT. 84132 Heart and Lung Institute p 801.585.0434 Jones, Tara L MD of Utah 1950 Cir of Hope Dr University Of Utah Health 3570 W 9000 S Salt Lake City UT. 84112 Hospital Affiliation 50 N Medical Dr Ste 110 p 801.585.0303 - University of Utah Hospital Salt Lake City UT. 84132 West Jordan UT. 84088 p 801.585.7676 p 801.263.2370 5126 W Daybreak Pkwy Yarrish, Daniel MD South Jordan UT. 84009 Granger Medical Clinic Hospital Affiliation University of Utah Health p 801.213.4500 1160 E 3900 S - University of Utah Hospital 50 N Medical Dr Ste 1000 Salt Lake City UT. 84132 University Of Utah Health Salt Lake City UT. 84124 Khan, Sohail MD p 801.585.0434 85 N Medical Dr p 801.262.1771 Heart Center at St Marks Salt Lake City UT. 84112 Hospital Heart and Lung Institute p 801.585.7676 Hospital Affiliation 1160 E 3900 S of Utah - St Marks Hospital Ste 2000 5979 S Fashion Blvd Hospital Affiliation - Lone Peak Hospital Salt Lake City UT. 84124 Murray UT. 84107 - University of Utah Hospital p 801.266.3418 p 801.263.2370 Yen, Chi Gang MD Wilson, Kathleen B MD MountainStar Cardiology St MountainStar Cardiology St 82 S 1100 E Utah Physicians Care Marks Marks Ste 200 Center 1160 E 3900 S 3584 W 9000 S Salt Lake City UT. 84102 1160 E 3900 S Ste 2000 Ste 209 p 801.263.2370 Ste 1200 Salt Lake City UT. 84124 West Jordan UT. 84088 Salt Lake City UT. 84124 p 801.266.3418 p 801.676.3776 Hospital Affiliation p 801.261.9651 - University of Utah Hospital Zackrison, David R MD American Heart and Hospital Affiliation Jordan Valley Internal Vascular Institute Yaganti, Vamsee M MD - St Marks Hospital Medicine 5292 College Dr Heart Center at St Marks 3570 W 9000 S Ste 201 Hospital Win, Sonny MD Ste 100 Salt Lake City UT. 84123 1160 E 3900 S University of Utah Health West Jordan UT. 84088 p 801.556.7745 Ste 2000 1950 Cir of Hope Dr p 801.569.2384 Salt Lake City UT. 84124 Salt Lake City UT. 84112 5801 S Fashion Blvd p 801.266.3418 p 801.585.0100 Hospital Affiliation Ste 120 - Jordan Valley Medical Salt Lake City UT. 84107 3540 S 4000 W 50 N Medical Dr Center p 801.556.7745 Ste 340 Salt Lake City UT. 84132 West Valley City UT. 84120 p 801.581.7818 Interventional Cardiology MountainStar Cardiology St p 801.676.3776 Advanced Vein and Vascular Marks 501 S Chipeta Way of Salt Lake City 74 E Kimball Ln Yen, Chi Gang MD Salt Lake City UT. 84108 6321 S Redwood Rd Ste 260 MountainStar Cardiology St p 801.583.2500 Ste 102 Draper UT. 84020 Marks Salt Lake City UT. 84123 p 801.571.6100 1160 E 3900 S University Of Utah Health p 385.388.8003 Ste 2000 85 N Medical Dr Hospital Affiliation Salt Lake City UT. 84124 Salt Lake City UT. 84112 Bekwelem, Wobo MD - Wyoming Medical Center p 801.266.3418 p 801.581.7818 Steward Cardiology Associates - West Valley Kim, Christopher Y MD Laboratory Hospital Affiliation 3336 S Pioneer Pkwy Advanced Vein and Vascular Beechtree Diagnostics - University of Utah Hospital Ste 203 of Salt Lake City 12351 S Gateway Park Pl West Valley City UT. 84120 6321 S Redwood Rd Ste D-700 Yaganti, Vamsee M MD p 801.748.0113 Ste 102 Draper UT. 84020 Heart Center at St Marks Salt Lake City UT. 84123 p 844.869.5227 Hospital Heart and Lung Institute p 385.388.8003 1160 E 3900 S of Utah Ste 2000 3570 W 9000 S Hospital Affiliation Salt Lake City UT. 84124 Ste 110 - Davis Hospital p 801.266.3418 West Jordan UT. 84088 - Lakeview Hospital p 801.263.2370 - Ogden Regional Medical Center - Salt Lake Regional Medical Center 233 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Dominion Diagnostics 424 E 12300 S 5121 S Cottonwood St Carpenter, Jeanette R MD Phone Number Only Draper UT. 84020 Murray UT. 84107 Obstetrix Medical Group of p 877.734.9600 p 801.571.6161 p 801.213.2995 Utah 1140 E 3900 S Dynacare Northwest Inc Long Term Acute Care Facility Hospital Affiliation Ste 390 857 E 200 S KPC Promise Hospital of - University of Utah Hospital Salt Lake City UT. 84124 Ste 103 Salt Lake - Memorial Hospital of p 801.743.4700 Salt Lake City UT. 84102 4252 Birkhill Blvd Sweetwater County p 801.264.9675 Salt Lake City UT. 84107 Hospital Affiliation p 801.408.7100 Bobrowski, Renee A MD - Lone Peak Hospital LabCorp Draw Station Obstetrix Medical Group Of - Timpanogos Regional Hospital 1060 E 100 S Maternal And Fetal Medicine Utah - Ogden Regional Medical Ste L-7 Andres, Robert L MD 1200 E 3900 S Center Salt Lake City UT. 84102 University of Utah Health Salt Lake City UT. 84124 - Cache Valley Hospital p 801.355.8559 50 N Medical Dr p 801.268.7111 Salt Lake City UT. 84132 Clark, Erin A MD 1151 E 3900 S p 801.213.2995 Hospital Affiliation University of Utah Health Ste B165 - Saint Alphonsus Regional 50 N Medical Dr Salt Lake City UT. 84124 Hospital Affiliation Medical Center Salt Lake City UT. 84132 p 801.281.9803 - University of Utah Hospital p 801.213.2995 Branch, D W MD 12176 S 1000 E Balderston, Keith D MD University of Utah Health 5121 S Cottonwood St Draper UT. 84020 Obstetrix Medical Group of 50 N Medical Dr Murray UT. 84107 p 801.495.9514 Utah Salt Lake City UT. 84132 p 801.213.2995 1140 E 3900 S p 801.587.9500 1250 E 3900 S Ste 390 5126 W Daybreak Pkwy Ste 302 Salt Lake City UT. 84124 Hospital Affiliation South Jordan UT. 84009 Salt Lake City UT. 84124 p 801.743.4700 - University of Utah Hospital p 801.581.8425 p 801.264.9675 11800 S State St *Byrne, Janice L MD Hospital Affiliation 5199 Green St Draper UT. 84020 Primary Childrens Hospital - Davis Hospital Salt Lake City UT. 84123 p 801.545.8100 Physicians - University of Utah Hospital p 801.288.9000 100 N Mario Capecchi Dr 11925 S State St Salt Lake City UT. 84113 Daniels, Marianne CMHC LabCorp of America Draper UT. 84020 p 801.662.1000 Cedar Psychiatry Holdings p 801.545.8000 1208 E 3300 S Phone Number Only University of Utah Health Salt Lake City UT. 84106 p 888.522.2677 1200 E 3900 S 50 N Medical Dr p 801.369.8989 Salt Lake City UT. 84124 Salt Lake City UT. 84132 MSCL at St Marks Womens p 801.268.7111 p 801.581.8425 154 E Myrtle Ave Pavilion Ste 204 1140 E 3900 S Ball, Robert H MD 7495 S State St Murray UT. 84107 Ste 320 Obstetrix Medical Group of Midvale UT. 84047 p 801.369.8989 Salt Lake City UT. 84124 Utah p 801.213.9400 p 801.262.1709 1140 E 3900 S Ascendant Behavioral Ste 390 Primary Childrens Hospital Health Internal Medicine at St Salt Lake City UT. 84124 Physicians 5383 S 900 E Marks p 801.743.4700 81 N Mario Capecchi Dr Ste 103 1160 E 3900 S Salt Lake City UT. 84113 Salt Lake City UT. 84117 Ste 1200 Hospital Affiliation p 801.662.1000 p 801.872.5516 Salt Lake City UT. 84124 - St Marks Hospital p 801.261.6300 - Ogden Regional Medical Hospital Affiliation Cedar Psychiatry Center - University of Utah Hospital 721 E 12200 S MSCL at Lone Peak - Lone Peak Hospital Draper UT. 84020 74 E Kimball Ln - Timpanogos Regional Hospital Campbell, Heather D MD p 801.369.8989 Ste 250 University of Utah Health Draper UT. 84020 Blue, Nathan R MD 50 N Medical Dr Davidson, Jessica M MD p 801.523.5044 University of Utah Health Salt Lake City UT. 84132 University of Utah Health 5121 S Cottonwood St p 801.213.2995 100 N Mario Capecchi Dr Quest Diagnostics Ste 100 Salt Lake City UT. 84113 348 E 4500 S Murray UT. 84107 Hospital Affiliation p 801.662.4100 Ste 210 p 801.581.7746 - University of Utah Hospital Murray UT. 84107 p 801.262.5222

234 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 50 N Medical Dr 5121 S Cottonwood St Paegle, Rita A CNM Richardson, Jill CNM Center Salt Lake City UT. 84132 Ste 100 University of Utah Health University of Utah Health - Lone Peak Hospital p 801.581.2121 Murray UT. 84107 50 N Medical Dr 50 N Medical Dr - Timpanogos Regional Hospital p 801.581.7746 Salt Lake City UT. 84132 Salt Lake City UT. 84132 5121 S Cottonwood St p 801.213.2995 p 801.581.4014 Murray UT. 84107 Hospital Affiliation p 801.507.7000 - University of Utah Hospital 555 Foothill Dr Hospital Affiliation Salt Lake City UT. 84112 - University of Utah Hospital Hospital Affiliation Esplin, M S MD p 801.581.8995 - University of Utah Hospital University of Utah Health Rose, Susan M MD 50 N Medical Dr Hospital Affiliation University of Utah Health Dildy, Gary A MD Salt Lake City UT. 84132 - University of Utah Hospital 50 N Medical Dr Obstetrix Medical Group of p 801.587.9500 Salt Lake City UT. 84132 Utah Page, Jessica M MD p 801.213.2995 1140 E 3900 S Hospital Affiliation University of Utah Health Ste 390 - University of Utah Hospital 50 N Medical Dr Hospital Affiliation Salt Lake City UT. 84124 Salt Lake City UT. 84132 - University of Utah Hospital p 801.743.4700 Gainer, Julie A DO p 801.213.2995 University of Utah Health Sharshiner, Margarita Y 11925 S State St 50 N Medical Dr 5121 S Cottonwood St MD Draper UT. 84020 Salt Lake City UT. 84132 Ste 100 Obstetrix Medical Group of p 801.545.8000 p 801.581.8425 Murray UT. 84107 Utah p 801.581.7746 1140 E 3900 S 1200 S 3900 S Holmgren, Calla M MD Salt Lake City UT. 84124 Salt Lake City UT. 84124 University of Utah Health 5121 S Cottonwood St p 801.743.4700 p 801.268.7111 50 N Medical Dr Murray UT. 84107 Salt Lake City UT. 84132 p 801.213.2995 11925 S State St Dizon-Townson, Donna S MD p 801.587.9500 Draper UT. 84020 University of Utah Health Hospital Affiliation p 801.545.8000 50 N Medical Dr 5121 S Cottonwood St - University of Utah Hospital Salt Lake City UT. 84132 Murray UT. 84107 1200 E 3900 S p 801.213.2995 p 801.213.2995 Porter, Troy F MD Salt Lake City UT. 84124 University of Utah Health p 801.268.7111 Hospital Affiliation Hospital Affiliation 50 N Medical Dr - University of Utah Hospital - University of Utah Hospital Salt Lake City UT. 84132 Silver, Robert M MD p 801.587.9500 University of Utah Health Draper, Michael L MD Jacobson, Sig-Linda MD 50 N Medical Dr South Valley Womens Obstetrix Medical Group of Hospital Affiliation Salt Lake City UT. 84132 Imaging Utah - University of Utah Hospital p 801.587.9500 3570 W 9000 S 1140 E 3900 S Ste 130 Ste 390 Reed, Shelly J APRN 5121 S Cottonwood St West Jordan UT. 84088 Salt Lake City UT. 84124 University of Utah Health Murray UT. 84107 p 801.569.2626 p 801.743.4700 50 N Medical Dr p 801.213.2995 Salt Lake City UT. 84132 University of Utah Health Korenberg, Julie R MD p 801.587.9500 Hospital Affiliation 50 N Medical Dr University of Utah Health - University of Utah Hospital Salt Lake City UT. 84132 100 N Mario Capecchi Dr Hospital Affiliation - Davis Hospital p 801.587.9500 Salt Lake City UT. 84113 - University of Utah Hospital p 801.213.3599 Smid, Marcela MD 5126 W Daybreak Pkwy Richards, Douglas S MD University of Utah Health South Jordan UT. 84009 50 N Medical Dr University of Utah Health 50 N Medical Dr p 801.581.8425 Salt Lake City UT. 84132 50 N Medical Dr Salt Lake City UT. 84132 p 801.585.6387 Salt Lake City UT. 84132 p 801.213.2995 Hospital Affiliation p 801.587.9500 - University of Utah Hospital 729 S Arapeen Dr 5126 W Daybreak Pkwy - Davis Hospital Salt Lake City UT. 84108 Primary Childrens Hospital South Jordan UT. 84009 - Jordan Valley Medical p 801.585.6387 Physicians p 801.581.8425 Center 81 N Mario Capecchi Dr - Salt Lake Regional Medical 81 N Mario Capecchi Dr Salt Lake City UT. 84113 Hospital Affiliation Center Salt Lake City UT. 84113 p 801.662.1000 - University of Utah Hospital p 801.213.3599 Einerson, Brett D MD Hospital Affiliation Spencer, Andrew H MD University of Utah Health - University of Utah Hospital Obstetrix Medical Group of 50 N Medical Dr Utah PC Salt Lake City UT. 84132 1140 E 3900 S p 801.581.7647 Ste 390 Salt Lake City UT. 84124 p 801.743.4700

Hospital Affiliation - St Marks Hospital 235 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. -10/01/2021 Ogden Regional05:46:48 Medical **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Sullivan, Amy E MD Medical Genetics Clinical Consultants -Not Mental Health University of Utah Health Gunsolley, Corey LCSW all services covered, Accardi-Ravid, Michelle 50 N Medical Dr Aspen Ridge Counseling please contact your Phd Salt Lake City UT. 84132 2880 W 4700 S administrator University Of Utah Health p 801.213.2995 Ste G-1 8541 S Redwood Rd Bld A 30 N 1900 E Rm 1B620 Salt Lake City UT. 84129 West Jordan UT. 84088 Salt Lake City UT. 84132 Hospital Affiliation p 801.990.4300 p 801.233.8670 p 801.581.6228 - Davis Hospital - Salt Lake Regional Medical Manning, Linsay K LCSW Cold Creek Behavioral Hospital Affiliation Center Lotus Center Inc Health - University of Utah Hospital - University of Utah Hospital 4376 S 700 E 8155 Brighton Loop Rd Ste 200 Salt Lake City UT. 84121 Acevedo, Carlos ACMHC Thomas, James W MD Salt Lake City UT. 84107 p 801.593.6777 Utah Behavior Services University of Utah Health p 385.272.4292 5558 S 1900 W 100 N Mario Capecchi Dr Copper Sage Recovery Ste B Salt Lake City UT. 84113 Mental Health Facility 14014 S 2200 W Salt Lake City UT. 84129 p 801.662.4100 A/D Psychotherapy & Bluffdale UT. 84065 p 801.255.5131 Clinical Consulting -Not p 801.455.4167 50 N Medical Dr all services covered, 6013 S Redwood Rd Salt Lake City UT. 84132 please contact your Highland Ridge Hospital Salt Lake City UT. 84123 p 801.581.2121 administrator -Not all services covered, p 801.255.5131 9662 S 700 E please contact your 5121 S Cottonwood St Sandy UT. 84070 administrator Adams, Amber Mae LCSW Murray UT. 84107 p 801.233.8577 7309 S 180 W Centered Approach p 801.507.7000 Midvale UT. 84047 Counseling Alpine Center for Personal p 801.569.2153 4190 S Highland Dr Hospital Affiliation Growth -Not all services Ste 220 - University of Utah Hospital covered, please contact Lighthouse Recovery Center Salt Lake City UT. 84124 your administrator -Not all services covered, p 385.282.3349 Torr, Carrie B MD 5689 S Redwood Rd please contact your University of Utah Health Ste 30 administrator Adams, David B PhD 100 N Mario Capecchi Dr Salt Lake City UT. 84123 7602 S Main St South Valley Associates Salt Lake City UT. 84113 p 801.268.1715 Midvale UT. 84047 6925 S Union Park Ctr p 801.662.4100 p 801.631.7122 Ste 490 Recovery Ways - Chatham Midvale UT. 84047 50 N Medical Dr Place -Not all services Odyssey House of Utah p 801.566.2622 Salt Lake City UT. 84132 covered, please contact 350 E 2100 S p 801.581.2121 your administrator Salt Lake City UT. 84115 Adams, Josh M SSW 385 W 4800 S p 801.428.3241 Valley Behavioral Health 5121 S Cottonwood St Salt Lake City UT. 84123 1020 S Main St Murray UT. 84107 p 801.506.7701 *Primary Childrens Wasatch Ste 218 p 801.507.7000 *Canyons Behavioral Health Salt Lake City UT. 84101 Recovery Ways - Brunswick *Campus p 888.949.4864 Hospital Affiliation Place -Not all services 5770 S 1500 W - University of Utah Hospital covered, please contact Salt Lake City UT. 84123 Adams, Kathy LCSW your administrator p 801.313.7770 Ascendant Behavioral University of Utah Dept of 4848 S Commerce Health OB/GYN Salt Lake City UT. 84107 The Utah House 5383 S 900 E 50 N Medical Dr p 801.326.5180 1370 S West Temple Ste 103 Salt Lake City UT. 84132 Salt Lake City UT. 84115 Salt Lake City UT. 84117 p 801.581.7647 Recovery Ways - Mountain p 801.678.3317 p 801.872.5516 View -Not all services Whitecar, Paul W MD covered, please contact University Health Care Addiction and Obstetrix Medical Group of your administrator Neuropsych Inst -Not all Psychological Services Utah 4883 S Box Elder St services covered, please 6065 S Fashion Blvd 1200 S 3900 S Salt Lake City UT. 84107 contact your administrator Ste 140 Salt Lake City UT. 84124 p 801.293.6100 501 Chipeta Way Salt Lake City UT. 84107 p 801.268.7111 Salt Lake City UT. 84108 p 801.268.2558 Recovery Ways - Copper p 801.585.1575 Whitney, Sandra E CNM Hills -Not all services Adolphson, Lillian University of Utah Health covered, please contact Youth Care -Not all BCBA-D 50 N Medical Dr your administrator services covered, please Utah Behavior Services Salt Lake City UT. 84132 5288 Allendale Dr contact your administrator 5558 S 1900 W p 801.213.2995 Salt Lake City UT. 84123 12595 S Minuteman Dr Ste B p 801.487.0955 Draper UT. 84020 Salt Lake City UT. 84129 Hospital Affiliation p 801.572.6989 p 801.255.5131 - University of Utah Hospital

236 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 6013 S Redwood Rd Allred, Courtney R LCSW Andersen, Meghan C LCSW Andes, Jared C MSW Salt Lake City UT. 84123 Peaceful Solutions Valley Behavioral Health Valley Behavioral Health p 801.255.5131 1399 S 700 E 780 S Guardsman Way 1141 E 3900 S Ste 5 Salt Lake City UT. 84108 Ste A170 Aguayo, Patricia MD Salt Lake City UT. 84105 p 888.949.4864 Salt Lake City UT. 84124 University of Utah Health p 801.651.3907 p 888.949.4864 50 N Medical Dr Anderson, Barbara CMHC Salt Lake City UT. 84132 Hospital Affiliation Jordan West Family South Summit Pediatrics p 801.581.7951 - University of Utah Hospital Counseling 267 E Traversepoint Dr 9263 Redwood Rd Bldg 8 Draper UT. 84020 501 S Chipeta Way Allred, David D LMFT West Jordan UT. 84088 p 801.553.8300 Salt Lake City UT. 84108 2900 S State St p 801.566.0749 p 801.585.1575 Ste 101 Andreason, Jacob R CMHC Salt Lake City UT. 84115 Anderson, Julie LCMHC Blue Theory Counseling Hospital Affiliation p 385.275.6311 Sage Family Counseling 10808 S River Front Pkwy - University of Utah Hospital 13552 S 110 W Ste 308 7370 S Creek Rd Ste 204 South Jordan UT. 84095 Akers, Erin CMHC Ste 204 Draper UT. 84020 p 801.984.6728 Aspen Ridge Counseling Sandy UT. 84093 p 801.432.0883 2711 S 8500 W p 385.275.6311 Andrews, Ashley J LCMHC Magna UT. 84044 Anderson, Perrine APRN Valley Behavioral Health p 801.990.4300 Allred, Debbi CMHC Senior Outpatient 1020 S Main St Neurobehavioral Center for Behavioral Health Ste 100 Albertsen, Elizabeth PhD Growth 82 S 1100 E Salt Lake City UT. 84101 Valley Behavioral Health 370 E South Temple Ste 404 p 888.949.4864 1141 E 3900 S Ste 175 Salt Lake City UT. 84102 Ste A250 Salt Lake City UT. 84111 p 801.350.4777 Apodaca, Kathleen E Salt Lake City UT. 84124 p 801.683.1062 Christian Counseling p 888.949.4864 Hospital Affiliation Centers of Utah Collective Recovery Center - Salt Lake Regional Medical 525 E 4500 S 3809 W 6200 S 8029 S 700 E Center Ste F-125 Salt Lake City UT. 84129 Sandy UT. 84070 Salt Lake City UT. 84107 p 888.949.4864 p 385.557.2183 Anderson, Sarah MSW p 801.268.1564 Early Life Child 443 S 600 E Allred, Jentrie BCBA Psychology & Education Applewhite, Kimberly C Salt Lake City UT. 84102 ABS Kids Center PsyD p 888.949.4864 515 S 700 E 10757 S River Front Pkwy University of Utah Health Ste 2A Ste 275 1138 E Wilmington Ave Alder, Andrew CMHC Salt Lake City UT. 84102 South Jordan UT. 84095 Salt Lake City UT. 84106 Summit Community p 801.935.4171 p 385.900.4020 p 801.213.8845 Counseling 5689 S Redwood Rd 515 S 700 E 12397 S 300 E 1280 E Stringham Ave Ste 27 Ste 2A Ste 100 Salt Lake City UT. 84106 Salt Lake City UT. 84123 Salt Lake City UT. 84102 Draper UT. 84020 p 801.581.7951 p 801.266.2485 p 801.935.4171 p 385.900.4020 154 E Myrtle Ave 5991 S Redwood Rd Andersen, Adriane CMHC Anderson, Sumer D NP Salt Lake City UT. 84107 Salt Lake City UT. 84123 University of Utah Health Anderson Wellness Group p 801.581.2628 p 801.266.2485 501 S Chipeta Way 9533 S 700 E Salt Lake City UT. 84108 Ste 203 1950 Cir of Hope Dr Aleman, Arianna BCBA p 801.585.1575 Sandy UT. 84070 Salt Lake City UT. 84112 Utah Behavior Services p 801.676.9452 p 801.583.2500 5558 S 1900 W Andersen, Claire MD Ste B The Childrens Center Anderson, Susan CMHC 50 N Medical Dr Salt Lake City UT. 84129 350 S 400 E Child and Family Salt Lake City UT. 84132 p 801.255.5131 Salt Lake City UT. 84111 Empowerment Services p 801.585.1575 p 801.582.5534 1578 W 1700 S 6013 S Redwood Rd Ste 200 501 S Chipeta Way Salt Lake City UT. 84123 5242 S 4820 W Salt Lake City UT. 84104 Salt Lake City UT. 84108 p 801.255.5131 Salt Lake City UT. 84118 p 801.972.2711 p 801.585.1575 p 801.966.4251 Allen, Julie BCBA Anderson, Tracy B LCSW Hospital Affiliation ABS Kids Alpine Center for Personal - University of Utah Hospital 6910 S Highland Dr Growth Ste 1 5689 S Redwood Rd Cottonwood Heights UT. 84121 Ste 30 p 801.935.4946 Salt Lake City UT. 84123 p 801.268.1715 237 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Arballo, Jennifer CSW 501 S Chipeta Way Bagley, Heather M SSW 3809 W 6200 S Utah Behavior Services Salt Lake City UT. 84108 Valley Behavioral Health Salt Lake City UT. 84129 5558 S 1900 W p 801.587.3287 4460 S Highland Dr p 888.949.4864 Ste B Ste 100 Salt Lake City UT. 84129 5126 W Daybreak Pkwy Salt Lake City UT. 84124 Barker, Autumn LCMHC p 801.255.5131 South Jordan UT. 84009 p 888.949.4864 The OCD And Anxiety p 801.213.4500 Treatment Center 6013 S Redwood Rd Baird, Jessica BCaBA 11260 S River Height Dr Salt Lake City UT. 84123 Aslami, Amie MD ABS Kids South Jordan UT. 84095 p 801.255.5131 Comprehensive 515 S 700 E p 801.298.2000 Psychological Services Ste 2A Archuleta, Jason LCSW 1208 E 3300 S Salt Lake City UT. 84102 *Barnes, Matthew M LCSW Utah Behavior Services Salt Lake City UT. 84106 p 801.935.4171 PCH Residential Home 5558 S 1900 W p 801.483.1600 5770 S 1500 W Bldg C Ste B Ballard, Diana E LCSW Salt Lake City UT. 84123 Taylorsville UT. 84118 3725 W 4100 S River Oak Counseling p 801.313.7954 p 801.255.5131 West Valley City UT. 84120 3980 S 700 E p 801.483.1600 Ste 22 PCH Residential Trmnt - 6013 S Redwood Rd Salt Lake City UT. 84107 ADOL Taylorsville UT. 84123 Asper, William LCSW p 801.833.1291 5770 S 1500 W p 801.255.5131 Valley Behavioral Health Salt Lake City UT. 84123 1020 S Main St Compass Counseling and p 801.313.7940 Armstrong, Aaron N SSW Ste 100 Consulting Valley Behavioral Health Salt Lake City UT. 84101 4000 S 700 E Barney, Geralyn LCSW 1020 S Main St p 888.949.4864 Ste 9 Valley Behavioral Health Ste 100 Salt Lake City UT. 84107 1141 E 3900 S Salt Lake City UT. 84101 3610 S 1000 W p 801.639.9544 Ste A170 p 888.949.4864 West Valley City UT. 84119 Salt Lake City UT. 84124 p 888.949.4864 Ballou, Carol A PhD p 888.949.4864 Armstrong, Chelsea J LCSW University of Utah Health South Point Counseling Au Duong, Lan SSW 50 N Medical Dr 195 W 7200 S 1206 W S Jordan Pkwy Valley Behavioral Health Salt Lake City UT. 84132 Midvale UT. 84047 Ste D 2948 S Redwood Rd p 801.581.7951 p 888.949.4864 South Jordan UT. 84095 West Valley City UT. 84119 p 801.302.3801 p 888.949.4864 Banfill, Amanda LCSW Barnhurst, Mark LCMHC Ascendant Behavioral Inner Peace Conseling of Ascendant Behavioral Bach-Whitehead, Trudy Health Utah Health LCSW 5383 S 900 E 11618 S State St 4179 Riverboat Rd Sundance Behavioral Ste 103 Ste 1604 Ste 220 Resources Salt Lake City UT. 84117 Draper UT. 84020 Salt Lake City UT. 84123 845 E 4800 S p 801.872.5516 p 385.202.5645 p 801.872.5516 Ste 200 Murray UT. 84107 Banks, Duane R MD Sundance Behavioral 5383 S 900 E p 801.264.9522 Sundance Behavioral Resources Ste 103 Resources 845 E 4800 S Salt Lake City UT. 84117 Baggett, Nicholas APRN 845 E 4800 S Ste 200 p 801.502.3913 Cedar Psychiatry Ste 200 Salt Lake City UT. 84107 154 E Myrtle Ave Murray UT. 84107 p 801.264.9522 Ashworth, James C MD Ste 204 p 801.264.9522 University of Utah Health Salt Lake City UT. 84107 Baron, Kelly G PhD 1280 E Stringham Ave p 801.369.8989 Barakat, Jamal A LPC University of Utah Health Salt Lake City UT. 84106 Valley Behavioral Health 375 S Chipeta Way p 801.581.7951 University of Utah Health 1020 S Main St Ste A200 50 N Medical Dr Ste 100 Salt Lake City UT. 84108 1950 Cir of Hope Dr Salt Lake City UT. 84132 Salt Lake City UT. 84101 p 801.581.2016 Salt Lake City UT. 84112 p 801.581.4014 p 888.949.4864 p 801.583.2500 Barrett, Rebecca B SSW 5126 W Daybreak Pkwy 1020 S Main St Valley Behavioral Health 50 N Medical Dr South Jordan UT. 84009 Ste 300 1020 S Main St Salt Lake City UT. 84132 p 801.213.4500 Salt Lake City UT. 84101 Ste 100 p 801.585.1575 p 888.949.4864 Salt Lake City UT. 84101 Cedar Psychiatry p 888.949.4864 721 E 12200 S Draper UT. 84020 p 801.369.8989

Hospital Affiliation - University of Utah Hospital 238 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 550 W 700 S Baylis, Allison BCBA 4460 S Highland Dr Beth, Beth J RN Salt Lake City UT. 84101 ABS Kids Ste 100 Valley Behavioral Health p 888.949.4864 515 S 700 E Salt Lake City UT. 84124 1020 S Main St Ste 2A p 888.949.4864 Ste 100 Barrus, Matthew D LCSW Salt Lake City UT. 84102 Salt Lake City UT. 84101 Valley Behavioral Health p 801.935.4171 Benard, Brinlee K LCSW p 888.949.4864 12427 S Pasture Rd Valley Behavioral Health Ste 104 6910 S Highland Dr 195 W 7200 S 3809 W 6200 S Riverton UT. 84096 Ste 1 Midvale UT. 84047 Taylorsville UT. 84129 p 888.949.4864 Cottonwood Heights UT. 84121 p 888.949.4864 p 888.949.4864 p 801.935.4946 Barson, Joshua T CSW Bennett Murphy, Laura 443 S 600 E Valley Behavioral Health Bear Creek Counseling PhD Salt Lake City UT. 84102 3809 W 6200 S 1227 W 9000 S University of Utah Health p 888.949.4864 Taylorsville UT. 84129 Ste H 100 N Mario Capecchi Dr p 888.949.4864 West Jordan UT. 84084 Salt Lake City UT. 84113 6856 S 700 E p 385.274.7119 p 801.313.7711 Midvale UT. 84047 Bartel, Roxanne L MD p 888.949.4864 University of Utah Health Beckstead, A L PhD 50 N Medical Dr 1280 E Stringham Ave Aspen Grove Counseling Salt Lake City UT. 84132 Beyers, Perriann LCSW Salt Lake City UT. 84106 1433 S 1100 E p 801.581.2205 9192 S 300 W p 801.581.7951 Salt Lake City UT. 84105 Ste 19 p 801.581.0422 Primary Childrens Hospital Sandy UT. 84070 1950 Cir of Hope Dr Physicians p 801.558.7054 Salt Lake City UT. 84112 Beckstrom, Andrea W APRN 81 N Mario Capecchi Dr p 801.583.2500 Valley Behavioral Health Salt Lake City UT. 84113 Beyers, Stephen LPC 1141 E 3900 S p 801.662.1000 9192 S 300 W 50 N Medical Dr Ste A250 Ste 19 Salt Lake City UT. 84132 Salt Lake City UT. 84124 Bennett, Kathleen LCSW Sandy UT. 84070 p 801.585.1575 p 888.949.4864 Life Stone Counseling p 801.554.3191 Center 501 S Chipeta Way 280 E 600 S 613 E Fort Union Blvd Bezzant, Christopher LPC Salt Lake City UT. 84108 Salt Lake City UT. 84111 Ste 104 Comprehensive p 801.587.3287 p 888.949.4864 Midvale UT. 84047 Psychological Services p 801.984.1717 1208 E 3300 S Barusch, Nathaniel MD 3610 S 1000 W Salt Lake City UT. 84106 Cedar Psychiatry West Valley City UT. 84119 Benson, Peter H LMFT p 801.483.1600 1208 E 3300 S p 888.949.4864 Sage Family Counseling Salt Lake City UT. 84106 13552 S 110 W Biesinger, Josh P LMFT p 801.369.8989 Bell, Naomia M CMHC Ste 204 5667 S Redwood Rd Military & Veteran Draper UT. 84020 Ste 5B Lotus Center Inc Counseling Center p 801.432.0883 Taylorsville UT. 84123 4376 S 700 E 140 W 2100 S p 801.755.8799 Ste 200 Ste 244 Bergvall, Phoebe CMHC Salt Lake City UT. 84107 Salt Lake City UT. 84115 Ascendant Behavioral Bilder, Deborah A MD p 385.272.4292 p 385.231.8387 Health University of Utah Health 5383 S 900 E 1280 E Stringham Ave Cedar Psychiatry Belnap, Barbara LCSW Ste 103 Salt Lake City UT. 84106 721 E 12200 S 5630 Waterbury Way Salt Lake City UT. 84117 p 801.581.7951 Draper UT. 84020 Ste 104B p 801.872.5516 p 801.369.8989 Salt Lake City UT. 84121 1950 Cir of Hope Dr p 801.272.8818 Best, Lanette R CMHC Salt Lake City UT. 84112 Hospital Affiliation Valley Behavioral Health p 801.583.2500 - Mountain View Hospital Belnap, Jeffrey D LCSW 12427 S Pasture Rd (UT) Center for Counseling Ste 104 50 N Medical Dr - Utah Valley Hospital Excellence Riverton UT. 84096 Salt Lake City UT. 84132 940 E South Union Ave p 888.949.4864 p 801.585.1575 Batchelor, Marcia LCSW Midvale UT. 84047 White Tree Medical p 385.202.3778 4460 S Highland Dr 501 S Chipeta Way Consultants LLC Ste 100 Salt Lake City UT. 84108 10437 S Jordan Gateway Belnap, Lorrie M LCSW Salt Lake City UT. 84124 p 801.587.3287 South Jordan UT. 84095 Valley Behavioral Health p 888.949.4864 p 385.535.6996 12427 S Pasture Rd Hospital Affiliation Ste 104 - University of Utah Hospital Riverton UT. 84096 p 888.949.4864

239 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Bills, Shawn LMFT 6910 S Highland Dr Multicultural Counseling Bradley, Jessica L CMHC Jordan West Family Ste 1 Center Valley Behavioral Health Counseling Salt Lake City UT. 84121 7625 S 3200 W 12427 S Pasture Rd 9263 Redwood Rd Bldg 8 p 801.935.4946 Ste 2 Ste 104 Ste B West Jordan UT. 84084 Herriman UT. 84096 West Jordan UT. 84088 Blood, Cybele LCSW p 801.915.0359 p 888.949.4864 p 801.523.5206 Ascendant Behavioral Health Botts, Elizabeth L MD 4460 S Highland Dr Birch, Kelly LCSW 5383 S 900 E University of Utah Health Ste 100 Utah Behavior Services Ste 103 1280 E Stringham Ave Salt Lake City UT. 84124 5558 S 1900 W Salt Lake City UT. 84117 Salt Lake City UT. 84106 p 888.949.4864 Ste B p 801.872.5516 p 801.581.7951 Salt Lake City UT. 84118 Brandt, Paul S LCSW p 801.255.5131 Bodily, Madison BCBA 1950 Cir of Hope Dr Grow in Love ABS Kids Salt Lake City UT. 84112 8160 S Highland Dr 6013 S Redwood Rd 515 S 700 E p 801.583.2500 Sandy UT. 84093 Salt Lake City UT. 84123 Ste 2A p 801.944.0944 p 801.255.5131 Salt Lake City UT. 84102 50 N Medical Dr p 801.935.4171 Salt Lake City UT. 84132 Braun, Daniel S LCSW Birch, Robert D DO p 801.585.1575 Wasatch Pediatrics - 501 Chipeta Way 6910 S Highland Dr Willow Creek Ste 1214 Ste 1 501 S Chipeta Way 7138 S 2000 E Salt Lake City UT. 84108 Cottonwood Heights UT. 84121 Salt Lake City UT. 84108 Ste 106 p 801.585.1575 p 801.935.4946 p 801.587.3287 Salt Lake City UT. 84121 p 801.942.1800 Hospital Affiliation Boel, David M APRN Hospital Affiliation - University of Utah Hospital Valley Behavioral Health - University of Utah Hospital Bray, Kristl BCBA 1020 S Main St ABS Kids Birnkrant, Jonathan D MD Ste 100 Bouchelle, Elizabeth 515 S 700 E University of Utah Health Salt Lake City UT. 84101 BCBA Ste 2A 50 N Medical Dr p 888.949.4864 ABS Kids Salt Lake City UT. 84102 Salt Lake City UT. 84132 6910 S Highland Dr p 801.935.4171 p 801.585.1575 Bolte, Lauren CSW Ste 1 Valley Behavioral Health Cottonwood Heights UT. 84121 6910 S Highland Dr 501 S Chipeta Way 1228 S 900 E p 801.935.4946 Ste 1 Salt Lake City UT. 84108 Salt Lake City UT. 84105 Cottonwood Heights UT. 84121 p 801.587.3287 p 888.949.4864 Bowen, Corinne CSW p 801.935.4946 Valley Behavioral Health Hospital Affiliation Bonebrake, Kathleen M MD 2948 S Redwood Rd Breakaway Recovery Center - University of Utah Hospital University Of Utah Health West Valley City UT. 84119 Murray 50 N Medical Dr p 888.949.4864 5296 S Commerce Dr Black, Jed CMHC Salt Lake City UT. 84132 Ste 204 Utah Behavior Services p 801.585.1575 Bowman, Chelsea LCSW Salt Lake City UT. 84107 5558 S 1900 W The Green House for Growth p 801.904.3242 Ste B 501 S Chipeta Way & Learning Salt Lake City UT. 84129 Salt Lake City UT. 84108 1325 W S Jordan Pkwy Brewer, Stanley DO p 801.255.5131 p 801.585.1575 Ste 102 University of Utah Health South Jordan UT. 84095 100 N Mario Capecchi Dr 6013 S Redwood Rd 525 E 100 S p 801.208.8838 Salt Lake City UT. 84113 Salt Lake City UT. 84123 Ste 5000 p 801.313.7711 p 801.255.5131 Salt Lake City UT. 84102 Boykin, Sarah A SSW p 801.585.1212 Valley Behavioral Health Hospital Affiliation Blair, Sarah MSW 195 W 7200 S - Primary Childrens Hospital The Green House for Growth Hospital Affiliation Midvale UT. 84047 & Learning - University of Utah Hospital p 888.949.4864 Brock, Brandy SSW 1325 W S Jordan Pkwy Valley Behavioral Health Ste 102 Borges de Martinez, Ana Aspen Ridge Counseling 550 W 700 S South Jordan UT. 84095 LMFT 2711 S 8500 W Salt Lake City UT. 84101 p 801.208.8838 Empowering Relief Magna UT. 84044 p 888.949.4864 Counseling p 801.990.4300 Blanco, Stephanie BCBA 5814 S 900 E Brockbank, Laura B PhD ABS Kids Salt Lake City UT. 84121 Boyle, Jeremy LMFT Laura B Brockbank PHD 515 S 700 E p 385.800.3272 Jeremy Boyle LMFT 1399 S 700 E Ste 2A 9055 S 1300 E Ste 7 Salt Lake City UT. 84102 Ste 12 Salt Lake City UT. 84105 p 801.935.4171 Sandy UT. 84092 p 801.483.3068 p 801.657.5312 Hospital Affiliation - University of Utah Hospital 240 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Brooks, Denise E LCSW Buchanan, Sarah C BCBA Burke, Renee PhD 501 S Chipeta Way Valley Behavioral Health Valley Behavioral Health University Of Utah Health Salt Lake City UT. 84108 12427 S Pasture Rd 6232 S 900 E 1280 E Stringham Ave p 801.587.3287 Ste 104 Salt Lake City UT. 84121 Salt Lake City UT. 84106 Riverton UT. 84096 p 888.949.4864 p 801.581.7951 Bustamante, Jamie S PhD p 888.949.4864 Senior Behavioral Health 780 S Guardsman Way 154 E Myrtle Ave SLC - OP 4460 S Highland Dr Salt Lake City UT. 84108 Salt Lake City UT. 84107 82 S 1100 E Ste 100 p 888.949.4864 p 801.581.2628 Ste 404 Salt Lake City UT. 84124 Salt Lake City UT. 84102 p 888.949.4864 Buck, Timothy C CMHC 1950 Cir of Hope Dr p 801.350.4777 Ascendant Behavioral Salt Lake City UT. 84112 Brown, Jacob G CMHC Health p 801.583.2500 Butler, April A CMHC Valley Behavioral Health 5383 S 900 E Valley Behavioral Health 1020 S Main St Ste 103 50 N Medical Dr 1141 E 3900 S Ste 100 Salt Lake City UT. 84117 Salt Lake City UT. 84132 Ste A250 Salt Lake City UT. 84101 p 801.872.5516 p 801.581.7951 Salt Lake City UT. 84124 p 888.949.4864 p 888.949.4864 Buehner, Paul W CSW University of Utah Health Brown, Laura P LCSW Sundance Behavioral 501 S Chipeta Way Butler, Erin BCBA 885 Baxter Dr Resources Salt Lake City UT. 84108 Neurobehavioral Center for South Jordan UT. 84095 845 E 4800 S p 801.583.2500 Growth p 801.997.0939 Ste 200 370 E South Temple Salt Lake City UT. 84107 University Of Utah Health Ste 175 Brown, Rebecca A LCSW p 801.264.9522 51 W 3900 S Salt Lake City UT. 84111 Valley Behavioral Health Salt Lake City UT. 84107 p 801.683.1062 443 S 600 E Buerger, Natalie K PhD p 801.587.2370 Salt Lake City UT. 84102 University of Utah Health Butters, Robert P LCSW p 888.949.4864 50 N Medical Dr Burnham, T L PhD Life Matters Counseling & Salt Lake City UT. 84132 Jordan West Family Health Center *Bruce, Alysha LCSW p 801.581.7951 Counseling 2225 E Murray-Holladay Rd PCH RESIDENTIAL HOME 9263 Redwood Rd Bldg 8 Ste 112 5770 S 1500 W Bldg C Hospital Affiliation Ste B Salt Lake City UT. 84117 Salt Lake City UT. 84113 - University of Utah Hospital West Jordan UT. 84088 p 801.313.0555 p 801.313.7954 p 801.566.0749 Buie, Jerry LCSW 3336 S Pioneer Pkwy PCH CHILD PSYCH-OP Pride Counseling Inc Burr, Hayley A CMHC Ste 201 5770 S 1500 W 20 E Graystone Way Valley Behavioral Health West Valley City UT. 84120 Taylorsville UT. 84123 Ste 20E 1020 S Main St p 801.313.0555 p 801.313.7770 Salt Lake City UT. 84106 Ste 100 p 801.595.0666 Salt Lake City UT. 84101 Cahoon, Stephanie BCBA Hospital Affiliation p 888.949.4864 ABS Kids - Primary Childrens Hospital Bunker, Brandon CMHC 515 S 700 E Aspen Ridge Counseling Burton, Brianna BCBA Ste 2A Brunisholz, Sylvia J LCSW 2711 S 8500 W ABS Kids Salt Lake City UT. 84102 Valley Behavioral Health Magna UT. 84044 515 S 700 E p 801.935.4171 1020 S Main St p 801.990.4300 Ste 2A Ste 100 Salt Lake City UT. 84102 6910 S Highland Dr Salt Lake City UT. 84101 Bunting, Catherine CSW p 801.935.4171 Ste 1 p 888.949.4864 Utah Behavior Services Salt Lake City UT. 84121 5558 S 1900 W Burton, Shelby BCBA p 801.935.4171 Bryan, Damon LMFT Ste B ABS Kids 1291 W Atherton Dr Salt Lake City UT. 84129 6910 S Highland Dr Cain, Julie A SSW Salt Lake City UT. 84123 p 801.255.5131 Ste 1 Valley Behavioral Health p 970.403.2458 Cottonwood Heights UT. 84121 1141 E 3900 S 6013 S Redwood Rd p 801.935.4946 Ste A250 Bryant, Aaron LCSW Salt Lake City UT. 84123 Salt Lake City UT. 84124 Collective Recovery Center p 801.255.5131 Bushnell, Lowry A MD p 888.949.4864 8029 S 700 E University of Utah Health Sandy UT. 84070 Burgin, Sally S LCSW 1280 E Stringham Ave Caleron, Chrstina CMHC p 385.557.2183 24 South 600 E Salt Lake City UT. 84106 Ascendant Behavioral Ste 4 p 801.581.7951 Health Salt Lake City UT. 84102 5383 S 900 E p 801.537.5008 Ste 103 Salt Lake City UT. 84117 p 801.872.5516

241 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Calkins, Chad O LCSW Carlson, Paul J MD Cavin, Christopher LCSW 501 S Chipeta Way Valley Behavioral Health University of Utah Health Valley Behavioral Health Salt Lake City UT. 84108 12427 S Pasture Rd 1280 E Stringham Ave 12427 S Pasture Rd p 801.587.3287 Ste 104 Salt Lake City UT. 84106 Ste 104 Riverton UT. 84096 p 801.581.7951 Riverton UT. 84096 Hospital Affiliation p 888.949.4864 p 888.949.4864 - University of Utah Hospital 1950 Cir of Hope Dr 2948 S Redwood Rd Salt Lake City UT. 84112 4460 S Highland Dr Chavez, Johanna LCSW West Valley City UT. 84119 p 801.583.2500 Ste 100 Community Health Centers p 888.949.4864 Salt Lake City UT. 84124 1365 W 1000 N 50 N Medical Dr p 888.949.4864 Salt Lake City UT. 84116 4460 S Highland Dr Salt Lake City UT. 84132 p 801.328.5750 Ste 100 p 801.585.1575 Caya, Stephanie G LCSW Salt Lake City UT. 84124 Compass Counseling and 1388 S Navajo St p 888.949.4864 501 S Chipeta Way Consulting Ste C Salt Lake City UT. 84108 4000 S 700 E Salt Lake City UT. 84104 Call, Amy BCBA p 801.587.3287 Ste 9 p 801.955.2360 Utah Behavior Services Salt Lake City UT. 84107 6013 S Redwood Rd Carr, Alexa CSW p 801.639.9544 220 W 7200 S Salt Lake City UT. 84123 Valley Behavioral Health Ste A p 801.255.5131 2948 S Redwood Rd Cetrola, Gabriela V LCSW Midvale UT. 84047 West Valley City UT. 84119 Community Health Centers p 801.566.5494 Callister, Catherine p 888.949.4864 1365 W 1000 N LCSW Salt Lake City UT. 84116 324 10th Ave The Utah House Carr, Jeff LCSW p 801.328.5756 Ste 249 1370 S West Temple Comprehensive Salt Lake City UT. 84103 Salt Lake City UT. 84115 Psychological Services Chace, Gisella C LCSW p 801.539.8617 p 801.678.3317 1208 E 3300 S Valley Behavioral Health Salt Lake City UT. 84106 2948 S Redwood Rd 4535 S 5600 W Campolucci, Nicole LCSW p 801.483.1600 West Valley City UT. 84119 West Valley City UT. 84120 Valley Behavioral Health p 888.949.4864 p 801.676.4405 2948 S Redwood Rd Carranza, Veronica LCSW West Valley City UT. 84119 Valley Behavioral Health Chacon, Tana L SSW 4745 S 3200 W p 888.949.4864 195 W 7200 S Valley Behavioral Health Salt Lake City UT. 84129 Midvale UT. 84047 195 W 7200 S p 801.964.6214 Cannon, Karen L LCSW p 888.949.4864 Midvale UT. 84047 Family Counseling Center p 888.949.4864 Cheek-O'donnell, Nicholas 650 E 4500 S 3444 W 4400 S LCSW Ste 300 West Valley City UT. 84119 Chamberlain, Jordan BCBA University Of Utah Health Salt Lake City UT. 84107 p 888.949.4864 Advanced Behavior Analysis 1950 Cir of Hope Dr p 801.261.3500 1441 E Fort Union Blvd Salt Lake City UT. 84112 Carter, Scott M LPC Salt Lake City UT. 84121 p 801.587.7000 Carbone, Paul S MD Salt City Counseling & p 385.695.2203 University of Utah Health Consultation Hospital Affiliation 100 N Mario Capecchi Dr 12465 S Fort St Champlin, Timothy M CSW - University of Utah Hospital Salt Lake City UT. 84113 Ste 250 Valley Behavioral Health p 801.587.2255 Draper UT. 84020 2948 S Redwood Rd Cheney, Heidi H LCSW p 385.202.4174 West Valley City UT. 84119 Ascendant Behavioral 50 N Medical Dr p 888.949.4864 Health Salt Lake City UT. 84132 Valley Behavioral Health 5383 S 900 E p 801.581.2205 195 W 7200 S 4460 S Highland Dr Ste 103 Midvale UT. 84047 Ste 100 Salt Lake City UT. 84117 81 N Mario Capecchi Dr p 888.949.4864 Salt Lake City UT. 84124 p 801.872.5516 Salt Lake City UT. 84113 p 888.949.4864 p 801.213.3599 Castleton, Donna E LCSW Cherry, Brian C CMHC Donna E Castleton LCSW Chan, Benjamin R MD Summit Community Cardinal, Jennifer R PhD, 3468 Brockbank Dr University of Utah Health Counseling BCBA Salt Lake City UT. 84124 1280 E Stringham Ave 5689 S Redwood Rd Neurobehavioral Center for p 801.859.6608 Salt Lake City UT. 84106 Ste 27 Growth p 801.581.7951 Salt Lake City UT. 84123 370 E South Temple Casto, LeAnn LCSW p 801.266.2485 Ste 175 Family Counseling Center 50 N Medical Dr Salt Lake City UT. 84111 650 E 4500 S Salt Lake City UT. 84132 p 801.683.1062 Ste 300 p 801.585.1575 Salt Lake City UT. 84107 p 801.261.3500

242 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 5991 S Redwood Rd 6013 S Redwood Rd Nexus Pain Care 3725 W 4100 S Salt Lake City UT. 84123 Salt Lake City UT. 84123 1575 W 7000 S West Valley City UT. 84120 p 801.266.2485 p 801.255.5131 West Jordan UT. 84084 p 801.965.3600 p 801.833.6569 Chidester, Alan R LCSW Christy, Cheryl L ACMHC Hospital Affiliation Valley Behavioral Health Valley Behavioral Health Coburn, Alison MSW - Riverton Childrens Unit 1141 E 3900 S 2948 S Redwood Rd Utah Behavior Services Operated by Primary Childrens Medical Center Ste A250 West Valley City UT. 84119 5558 S 1900 W Salt Lake City UT. 84124 p 888.949.4864 Ste B Conover, Thomas G MD p 888.949.4864 Salt Lake City UT. 84118 University of Utah Health Christy, Monica D PhD p 801.255.5131 1280 E Stringham Ave 3809 W 6200 S Monica D Christy PhD, PC Salt Lake City UT. 84106 Salt Lake City UT. 84129 5383 S 900 E 6013 S Redwood Rd p 801.581.7951 p 888.949.4864 Ste 290 Salt Lake City UT. 84123 Salt Lake City UT. 84117 p 801.255.5131 50 N Medical Dr Chipman, Lani LMFT p 801.263.3335 Salt Lake City UT. 84132 Summit Community Coleman, Laurie A LCSW p 801.585.1575 Counseling Chrysalis Utah University of Utah Health 5689 S Redwood Rd 448 E Winchester St 1950 Cir of Hope Dr 501 S Chipeta Way Ste 27 Ste 200 Salt Lake City UT. 84112 Salt Lake City UT. 84108 Salt Lake City UT. 84123 Salt Lake City UT. 84107 p 801.587.7000 p 801.587.3287 p 801.266.2485 p 801.655.4950 50 N Medical Dr Cook, Barbra JoAnn LCSW 5991 S Redwood Rd Cipro, Laura A APRN Salt Lake City UT. 84132 University of Utah Health Salt Lake City UT. 84123 Sundance Behavioral p 801.581.2121 501 S Chipeta Way p 801.266.2485 Resources Salt Lake City UT. 84108 845 E 4800 S 5126 W Daybreak Pkwy p 801.585.1575 Cho, Jaeyong MSW Ste 200 South Jordan UT. 84009 Utah Behavior Services Salt Lake City UT. 84107 p 801.213.4500 51 W 3900 S 5558 S 1900 W p 801.264.9522 Salt Lake City UT. 84107 Ste B Hospital Affiliation p 801.585.1575 Salt Lake City UT. 84129 Hospital Affiliation - University of Utah Hospital p 801.255.5131 - Primary Childrens Hospital Hospital Affiliation Collins, Patrick M SSW - University of Utah Hospital 6013 S Redwood Rd Clark, Claire H PhD Valley Behavioral Health Salt Lake City UT. 84123 150 S 600 E 195 W 7200 S Cook, Melissa C RN p 801.255.5131 Ste 8-B Midvale UT. 84047 Valley Behavioral Health Salt Lake City UT. 84102 p 888.949.4864 4460 S Highland Dr Choudhary, Ibrahim CSW p 801.259.8325 Ste 300 Collective Recovery Center *Colte, Paul D PSYD Salt Lake City UT. 84124 8029 S 700 E Clayton, Frank G LPC Primary Childrens Hospital p 888.949.4864 Sandy UT. 84070 Salt Lake Mental Health 100 N Mario Capecchi Dr p 385.557.2183 2290 E 4500 S Salt Lake City UT. 84113 Cooke, Mckay L SSW Ste 270 p 801.662.1000 Valley Behavioral Health Christensen, Deborah A Salt Lake City UT. 84117 1850 S 2500 E PhD p 877.476.6338 Condon, Jennifer LCSW Salt Lake City UT. 84108 Corner Canyon Counseling Child & Family Empowerment p 888.949.4864 and Psychologist Services Clews, Kelsey PSYD Services 248 E 13800 S Wasatch Pediatrics - 1578 W 1700 S Corey, Spencer BCBA Ste 4 Draper Ste 200 Utah Behavior Services Draper UT. 84020 114 E 12450 S Salt Lake City UT. 84104 5558 S 1900 W p 801.335.6349 Ste 100 p 801.972.2711 Ste B Draper UT. 84020 Salt Lake City UT. 84129 Christensen, Kjarsten D p 801.523.3001 Connelly, Julia PhD p 801.255.5131 LCSW The Autism Clinic Mountain Paths Counseling Cloyd, James H PhD 1537 S Main St 6013 S Redwood Rd 7069 S Highland Dr Alta Pain Physicians Salt Lake City UT. 84115 Salt Lake City UT. 84123 Ste 100 Unit 6 11333 S 1000 E p 801.699.3133 p 801.255.5131 Salt Lake City UT. 84121 Ste 102 p 801.214.1565 Sandy UT. 84094 Connolly, Michael S MD Cornell, Diana CMHC p 801.462.2205 Granger Medical Clinic Jordan West Family Christianson, Grete BCBA 11724 S State St Counseling Utah Behavior Services Draper UT. 84020 9263 Redwood Rd Bldg 8 5558 S 1900 W p 801.576.2050 Ste B Ste B West Jordan UT. 84088 Salt Lake City UT. 84129 p 801.566.0749 p 801.255.5131

243 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Correa, Araceli CSW Cox, Patricia CMHC 50 N Medical Dr Danner, Barbara A CMHC Valley Behavioral Health Bear Creek Counseling Salt Lake City UT. 84132 Aspen Ridge Counseling 1020 S Main St 1227 W 9000 S p 801.581.2205 1561 W 7000 S Ste 100 Ste H Ste 200 Salt Lake City UT. 84101 West Jordan UT. 84084 81 N Mario Capecchi Dr West Jordan UT. 84084 p 888.949.4864 p 385.274.7119 Salt Lake City UT. 84113 p 801.990.4300 p 801.587.2255 2948 S Redwood Rd Cross, Hannah LCSW Imagine Counseling West Valley City UT. 84119 Cedar Psychiatry Hospital Affiliation Services p 888.949.4864 154 E Myrtle Ave - University of Utah Hospital 5663 S Redwood Rd Ste 204 Ste 2 Corry, Bradley BCBA Murray UT. 84107 Curtis, Heather MD Salt Lake City UT. 84123 ABS Kids p 801.369.8989 JVMC-WVC Behavioral Health p 385.495.2705 515 S 700 E - IP Ste 2A 721 E 12200 S 3460 S Pioneer Pkwy Dario, Joel S NP Salt Lake City UT. 84102 Draper UT. 84020 West Valley City UT. 84120 Valley Behavioral Health p 801.935.4171 p 801.369.8989 p 801.964.3575 4460 S Highland Dr Ste 100 6910 S Highland Dr Cumberledge, Frances Curtis, Leslie J LCSW Salt Lake City UT. 84124 Ste 1 LCSW Valley Behavioral Health p 888.949.4864 Cottonwood Heights UT. 84121 Ascendant Behavioral 4460 S Highland Dr p 801.935.4946 Health Ste 100 Dastrup, Karen L LMFT 4179 Riverboat Rd Salt Lake City UT. 84124 Valley Behavioral Health Cottrell, Stacie MSW Ste 220 p 888.949.4864 12427 S Pasture Rd Ascendant Behavioral Salt Lake City UT. 84123 Ste 104 Health p 801.872.5516 Czajkowski, Laura PhD Riverton UT. 84096 4179 Riverboat Rd University of Utah Health p 888.949.4864 Ste 220 5383 S 900 E 1280 E Stringham Ave Salt Lake City UT. 84123 Ste 103 Salt Lake City UT. 84106 4460 S Highland Dr p 801.872.5516 Salt Lake City UT. 84117 p 801.581.7951 Ste 300 p 801.872.5516 Salt Lake City UT. 84124 5383 S 900 E 1950 Cir of Hope Dr p 888.949.4864 Ste 103 Cummings, Tara BCBA Salt Lake City UT. 84112 Salt Lake City UT. 84117 ABS Kids p 801.583.2500 Dattilo, Wilbur R MD p 801.872.5516 515 S 700 E University of Utah Health Ste 2A 50 N Medical Dr 1280 E Stringham Ave Courtney, Robert J PhD Salt Lake City UT. 84102 Salt Lake City UT. 84132 Salt Lake City UT. 84106 University of Utah Health p 801.935.4171 p 801.581.2121 p 801.581.7951 1280 E Stringham Ave Salt Lake City UT. 84106 6910 S Highland Dr 501 S Chipeta Way 501 S Chipeta Way p 801.581.6228 Ste 1 Salt Lake City UT. 84108 Salt Lake City UT. 84108 Cottonwood Heights UT. 84121 p 801.583.2500 p 801.587.3287 University Of Utah Health p 801.935.4946 85 N Medical Dr Dahmen, Alexander LCSW Hospital Affiliation Salt Lake City UT. 84112 Cunningham, Jeanna CMHC Summit Community - University of Utah Hospital p 801.581.6228 Valley Behavioral Health Counseling 12427 S Pasture Rd 5689 S Redwood Rd Davidson, Kayleen S LCSW Hospital Affiliation Ste 104 Ste 27 Compass Counseling and - University of Utah Hospital Herriman UT. 84096 Salt Lake City UT. 84123 Consulting p 888.949.4864 p 801.266.2485 4000 S 700 E Covington, Misty LCSW Ste 9 Sage Family Counseling 4460 S Highland Dr 5991 S Redwood Rd Salt Lake City UT. 84107 13552 S 110 W Ste 100 Salt Lake City UT. 84123 p 801.639.9544 Ste 204 Salt Lake City UT. 84124 p 801.266.2485 Draper UT. 84020 p 888.949.4864 Davis, Amy O LPC p 801.432.0883 Dalanhese, Roselene S Comprehensive Cunningham, Sean D PhD LCSW Psychological Services Cox, Jamie M APRN University of Utah Health South Point Counseling 1208 E 3300 S Valley Behavioral Health 100 N Mario Capecchi Dr 1206 W S Jordan Pkwy Salt Lake City UT. 84106 2472 S 300 E Salt Lake City UT. 84113 Ste D p 801.483.1600 Salt Lake City UT. 84115 p 801.587.2255 South Jordan UT. 84095 p 888.949.4864 p 801.302.3801 Davis, Heather S BCBA Valley Behavioral Health 6232 S 900 E Salt Lake City UT. 84121 p 888.949.4864

244 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 780 S Guardsman Way DeVaud, Aline LCSW 501 S Chipeta Way Dillon, Heather BCBA Salt Lake City UT. 84108 Comprehensive Salt Lake City UT. 84108 Advanced Behavior Analysis p 888.949.4864 Psychological Services p 801.587.3287 1441 E Fort Union Blvd 1208 E 3300 S Salt Lake City UT. 84121 Davis, Myles Q LCSW Salt Lake City UT. 84106 Hospital Affiliation p 385.695.2203 Empowering Relief p 801.483.1600 - University of Utah Hospital Counseling Disher, Lauren LMFT 5814 S 900 E Debenham, Rachael CSW Derbidge, Christina M PhD Collective Recovery Center Salt Lake City UT. 84121 Ascendant Behavioral University of Utah Health 8029 S 700 E p 385.800.3272 Health 30 N 1900 E Rm 1B620 Sandy UT. 84070 4179 Riverboat Rd Salt Lake City UT. 84132 p 385.557.2183 Davis, Robin LCSW Ste 220 p 801.581.6228 Robin L Davis LLC Salt Lake City UT. 84123 Dixon, Randal LMHC 1208 E 3300 S p 801.872.5516 Hospital Affiliation Ascendant Behavioral Salt Lake City UT. 84106 - University of Utah Hospital Health p 801.483.1600 5383 S 900 E 5383 S 900 E Ste 103 Desjardins, Michael C Ste 103 923 E Executive Park Dr Salt Lake City UT. 84117 APRN Salt Lake City UT. 84117 Ste E p 801.872.5516 Alpine Center for Personal p 801.872.5516 Salt Lake City UT. 84117 Growth p 801.349.9063 Deceuster, Rachael BCBA 5689 S Redwood Rd Dobson, Nicole BCBA Utah Behavior Services Ste 30 ABS Kids Davis, Ronda M LCSW 5558 S 1900 W Salt Lake City UT. 84123 515 S 700 E Healing Feathers Ste B p 801.268.1715 Ste 2A 4578 S Highland Dr Salt Lake City UT. 84129 Salt Lake City UT. 84102 Ste 350 p 801.255.5131 Devlin, Charissa BCBA p 801.935.4171 Salt Lake City UT. 84117 ABS Kids p 801.906.8520 6013 S Redwood Rd 515 S 700 E 6910 S Highland Dr Salt Lake City UT. 84123 Ste 2A Ste 1 Holistic Elements p 801.255.5131 Salt Lake City UT. 84102 Cottonwood Heights UT. 84121 835 E 4800 S p 801.935.4171 p 801.935.4946 Ste 220 Deily, Jacquiline LCSW Salt Lake City UT. 84107 Ascendant Behavioral 6910 S Highland Dr Docherty, Anna R PhD p 801.262.5418 Health Ste 1 University of Utah Health 5383 S 900 E Cottonwood Heights UT. 84121 1280 E Stringham Ave Dawson-Lovess, S Collette Ste 103 p 801.935.4946 Salt Lake City UT. 84106 CSW Salt Lake City UT. 84117 p 801.581.7951 The Green House for Growth p 801.872.5516 Diamond, Allie D LCSW & Learning Ascendant Behavioral 50 N Medical Dr 1325 W S Jordan Pkwy Delewski, Richard LCSW Health Salt Lake City UT. 84132 Ste 102 University Of Utah Health 5383 S 900 E p 801.581.7951 South Jordan UT. 84095 501 S Chipeta Way Ste 103 p 801.208.8838 Salt Lake City UT. 84108 Salt Lake City UT. 84117 501 S Chipeta Way p 801.587.2500 p 801.872.5516 Salt Lake City UT. 84108 Daybell-Topham, Jamie p 801.583.2500 LCSW Hospital Affiliation Dickman, Thomas LCSW Centered Approach - University of Utah Hospital Family Counseling Center University Of Utah Health Counseling 650 E 4500 S 525 E 100 S 4190 S Highland Dr Delgadillo, Cindy J LCSW Ste 300 Ste 5000 Ste 220 Valley Behavioral Health Murray UT. 84107 Salt Lake City UT. 84102 Salt Lake City UT. 84124 4460 S Highland Dr p 801.261.3500 p 801.585.1212 p 385.282.3349 Ste 100 Salt Lake City UT. 84124 Dickson, Jennifer N LCSW Hospital Affiliation De La Torre, Sandra BCBA p 888.949.4864 Valley Behavioral Health - University of Utah Hospital ABS Kids 1141 E 3900 S 515 S 700 E *Deming, Annie M PhD Ste A-170 Domeier, Bridget LCSW Ste 2A Primary Childrens Hospital Salt Lake City UT. 84124 Peaceful Solutions Salt Lake City UT. 84102 5770 S 1500 W p 888.949.4864 1399 S 700 E p 801.935.4171 Taylorsville UT. 84123 Ste 5 p 801.313.7770 Didier, Drue B LCSW Salt Lake City UT. 84105 DeBirk, Karen M LPC Compass Counseling and p 801.651.3907 Mindful Living Counseling Dentino, Stamatios G MD Consulting 9055 S 1300 E University of Utah Health 4000 S 700 E Hospital Affiliation Sandy UT. 84094 1280 E Stringham Ave Ste 9 - University of Utah Hospital p 801.784.1415 Salt Lake City UT. 84106 Salt Lake City UT. 84107 p 801.581.7951 p 801.639.9544

245 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Donnelly, Stephanie L PhD Dowse, Brenda J LCSW Duncan, Susan L SSW Edgington, Carl PhD University of Utah Health Lotus Center Inc Valley Behavioral Health ABS Kids 50 N Medical Dr 4376 S 700 E 1141 E 3900 S 515 S 700 E Salt Lake City UT. 84132 Ste 200 Ste A250 Ste 2A p 801.581.7951 Salt Lake City UT. 84107 Salt Lake City UT. 84124 Salt Lake City UT. 84102 p 385.272.4292 p 888.949.4864 p 801.935.4171 501 S Chipeta Way Salt Lake City UT. 84108 Empowering Relief Durfey, Roger LMFT 6910 S Highland Dr p 801.585.1575 Counseling The OCD And Anxiety Ste 1 5814 S 900 E Treatment Center Salt Lake City UT. 84121 51 W 3900 S Salt Lake City UT. 84121 11260 S River Height Dr p 801.935.4171 Salt Lake City UT. 84102 p 385.800.3272 South Jordan UT. 84095 p 801.585.1212 p 801.298.2000 Edwards, Alisa LCSW Sage Family Counseling Valley Behavioral Health Hospital Affiliation 13552 S 110 W Ascendant Behavioral 3809 W 6200 S - University of Utah Hospital Ste 204 Health Taylorsville UT. 84129 Draper UT. 84020 5383 S 900 E p 888.949.4864 Doubek, Anne CMHC p 801.432.0883 Ste 103 Valley Behavioral Health Salt Lake City UT. 84117 Edwards, Steven D LCSW 195 W 7200 S Drennen, Melissa BCBA p 801.872.5516 University Of Utah Health Midvale UT. 84047 ABS Kids 50 N Medical Dr Rm AC210 p 888.949.4864 515 S 700 E Durrant, Laura LCSW Salt Lake City UT. 84132 Ste 2a Ascendant Behavioral p 801.213.8841 Ascendant Behavioral Salt Lake City UT. 84102 Health Health p 801.935.4171 4179 Riverboat Rd Collective Recovery Center 5383 S 900 E Ste 220 8029 S 700 E Ste 103 6910 S Highland Dr Salt Lake City UT. 84123 Sandy UT. 84070 Salt Lake City UT. 84117 Ste 1 p 801.872.5516 p 385.557.2183 p 801.872.5516 Salt Lake City UT. 84121 p 801.935.4946 Heartfelt Healing Egbert, Andrea LCSW Doulis, Anastasia E LPC 4885 S 900 E Wasatch Pediatrics - Life Stone Group LLC Duersch, Allison E LMFT Ste 110C Draper 613 E Fort Union Blvd South Point Counseling Salt Lake City UT. 84117 114 E 12450 S Ste 104 1206 W S Jordan Pkwy p 801.366.4469 Ste 100 Midvale UT. 84047 Ste D Draper UT. 84020 p 801.980.7222 South Jordan UT. 84095 Ascendant Behavioral p 801.523.3001 p 801.302.3801 Health Dover, Adam M SSW 5383 S 900 E PCH CHILD PSYCH-OP Valley Behavioral Health Dufek, Brandi BCBA Ste 103 5770 S 1500 W 1141 E 3900 S ABS Kids Salt Lake City UT. 84117 Taylorsville UT. 84123 Ste A250 515 S 700 E p 801.872.5516 p 801.313.7770 Salt Lake City UT. 84124 Ste 2A p 888.949.4864 Salt Lake City UT. 84102 Dusoe, Michael E LCSW Hospital Affiliation p 801.935.4171 A/D Psychotherapy & - Primary Childrens Hospital 4460 S Highland Dr Clinical Consulting -Not Ste 300 6910 S Highland Dr all services covered, Egbert, Phil CSW Salt Lake City UT. 84124 Ste 1 please contact your Next Level Recovery p 888.949.4864 Cottonwood Heights UT. 84121 administrator 6771 S 900 E p 801.935.4946 9662 S 700 E Midvale UT. 84047 Dow, Reed CMHC Sandy UT. 84070 p 801.386.9799 Ascendant Behavioral Duff, Kevin M PhD p 801.233.8577 Health University of Utah Health Eisenman, Erika LCSW 5383 S 900 E 50 N Medical Dr Earle, Jason CMHC Aspen Ridge Counseling Ste 103 Salt Lake City UT. 84132 Aspen Ridge Counseling 2880 W 4700 S Salt Lake City UT. 84117 p 801.585.6387 3509 W 4700 S Ste G-1 p 801.872.5516 Salt Lake City UT. 84129 Salt Lake City UT. 84129 Hospital Affiliation p 801.990.4300 p 801.990.4300 Downer, Tilly BCaBA - University of Utah Hospital ABS Kids Eckerselll, William CMHC Ekenstam, Nadia LCSW 515 S 700 E Duffy, Claire E PA-C Ascendant Behavioral Valley Behavioral Health Ste 2A University of Utah Health Health 1141 E 3900 S Salt Lake City UT. 84102 175 N Medical Dr E 5383 S 900 E Ste A170 p 801.935.4171 Salt Lake City UT. 84132 Ste 103 Salt Lake City UT. 84124 p 801.585.7575 Salt Lake City UT. 84117 p 888.949.4864 p 801.872.5516 Hospital Affiliation - University of Utah Hospital

246 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Primary Childrens Safe and Elkins, Meghan LMFT Enniss, Timothy S LCSW Fackrell, Lachere BCBA Healthy Families Summit Community Comprehensive ABS Kids 81 N Mario Capecchi Dr Counseling Psychological Services 515 S 700 E Salt Lake City UT. 84113 5689 S Redwood Rd 1208 E 3300 S Ste 2A p 801.662.3606 Ste 27 Salt Lake City UT. 84106 Salt Lake City UT. 84102 Salt Lake City UT. 84123 p 801.483.1600 p 801.935.4171 Eldredge, David G LCSW p 801.266.2485 University of Utah Health 3725 W 4100 S Fahlberg, Cory LMFT 1525 W 2100 S Ellis, John LMFT West Valley City UT. 84119 Ascendant Behavioral Salt Lake City UT. 84119 Cedar Psychiatry p 801.965.3759 Health p 801.213.8841 1208 E 3300 S 5383 S 900 E Salt Lake City UT. 84106 Escalanti, Laurian LCSW Ste 103 3730 W 4700 S p 801.369.8989 Compass Counseling and Salt Lake City UT. 84117 West Valley City UT. 84129 Consulting p 801.872.5516 p 801.213.9200 154 E Myrtle Ave 4000 S 700 E Ste 204 Ste 9 Fairbourn, Jennifer LMFT 5126 W Daybreak Pkwy Murray UT. 84107 Salt Lake City UT. 84107 Cottonwood Creek South Jordan UT. 84009 p 801.369.8989 p 801.639.9544 Counseling p 801.213.4500 7321 S State St 721 E 12200 S Arura Ste A 7495 S State St Draper UT. 84020 702 E South Temple Midvale UT. 84047 Midvale UT. 84047 p 801.369.8989 Ste B-40 p 801.878.4327 p 801.213.9400 Salt Lake City UT. 84102 Embrace Counseling p 801.613.7049 Fairclough, Cassandra Hospital Affiliation 7478 S Campus View Dr LCSW - Primary Childrens Hospital Ste 100 Eschler, Carrie J LCSW Jordan West Family West Jordan UT. 84084 Valley Behavioral Health Counseling Eliason, Benjamin A p 801.441.2239 550 W 700 S 9263 Redwood Rd Bldg 8 Adult Behavioral Health Salt Lake City UT. 84101 Ste B JVMC-WVC - IP Embree, Lindsay M PhD p 888.949.4864 West Jordan UT. 84088 3460 S 4155 W 5th Fl University of Utah Health p 801.566.0749 West Valley City UT. 84120 175 N Medical Dr E Ete, Lani LPC p 801.964.3111 Salt Lake City UT. 84132 Professional Counsleing Faizi, Sajid MD p 801.585.7575 Services White Tree Medical Adult Behavioral Health 3940 W 4100 S Consultants LLC JVMC-WVC - OP 50 N Medical Dr West Valley City UT. 84120 10437 S Jordan Gateway 4052 W Pioneer Pkwy Salt Lake City UT. 84132 p 801.706.4026 South Jordan UT. 84095 Ste 105 p 801.585.6387 p 385.535.6996 West Valley City UT. 84120 Evans, Cheryl D LPC p 801.554.3420 729 S Arapeen Dr Valley Behavioral Health Hospital Affiliation Salt Lake City UT. 84108 1141 E 3900 S - Davis Hospital *Elish, Katie F PhD p 801.585.6387 Ste A220 - Jordan Valley Medical PCH RESIDENTIAL HOME Salt Lake City UT. 84124 Center West Valley Campus 5770 S 1500 W Bldg C Hospital Affiliation p 888.949.4864 - Salt Lake Regional Medical Taylorsville UT. 84123 - University of Utah Hospital Center p 801.313.7954 Evans, Emily CMHC England, Kimberly CMHC Jordan West Family Faler, Pamela K PCH PSYCHIATRY Ascendant Behavioral Counseling 2382 E Summerspring Ln 5770 S 1500 W Health 9263 Redwood Rd Bldg 8 Salt Lake City UT. 84124 Taylorsville UT. 84123 5383 S 900 E West Jordan UT. 84088 p 801.273.7480 p 801.313.7770 Ste 103 p 801.566.0749 Salt Lake City UT. 84117 Farnsworth, Jarom ACMHC Hospital Affiliation p 801.872.5516 Evans, Lyndsey M PhD Valley Behavioral Health - Primary Childrens Hospital Neurobehavioral Center for 1020 S Main St England, Leon C LCSW Growth Ste 100 Elkins, Laurie LCSW England Counseling 370 E South Temple Salt Lake City UT. 84101 Ascendant Behavioral Services Ste 175 p 888.949.4864 Health 166 E 5900 S Salt Lake City UT. 84111 5383 S 900 E Ste B108 p 801.683.1062 Fast, Danielle CMHC Ste 103 Salt Lake City UT. 84107 Milestone Integrative Salt Lake City UT. 84117 p 801.290.2471 Ewell, Esther LCSW Healing p 801.872.5516 Valley Behavioral Health 4578 S Highland Dr 195 W 7200 S Ste 320 Midvale UT. 84047 Salt Lake City UT. 84117 p 888.949.4864 p 801.505.9137

247 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Faumuina, Jannah Lee K Flattes, Valerie J APRN Foster, Thomas M LCSW 8375 S 700 E LCSW AD Psychotherapy Interface Psychological Sandy UT. 84070 Valley Behavioral Health 8465 S 700 E 2180 E 4500 S p 801.576.0745 1020 S Main St Sandy UT. 84070 Ste 245 Ste 100 p 801.233.8577 Salt Lake City UT. 84117 Franz, Megan A CMHC Salt Lake City UT. 84101 p 801.328.8817 Sundance Behavioral p 888.949.4864 Florez, Monica LCSW Resources Monica Florez Fowers, Heidi M SSW 845 E 4800 S Fawcett, Alexandra F CSW 2180 E 4500 S Valley Behavioral Health Ste 200 Valley Behavioral Health Ste 150 1141 E 3900 S Salt Lake City UT. 84107 3809 W 6200 S Salt Lake City UT. 84117 Ste A250 p 801.264.9522 Taylorsville UT. 84129 p 801.828.8905 Salt Lake City UT. 84124 p 888.949.4864 p 888.949.4864 Freeman, Brenner L MD Fordham, Bruce K CMHC University of Utah Health Fehlberg, Amy L PhD Valley Behavioral Health 4460 S Highland Dr 1280 E Stringham Ave 1060 E 100 S 12427 S Pasture Rd Ste 300 Salt Lake City UT. 84106 Ste 100 Ste 104 Salt Lake City UT. 84124 p 801.581.7951 Salt Lake City UT. 84102 Riverton UT. 84096 p 888.949.4864 p 435.901.0759 p 888.949.4864 3730 W 4700 S Fox, Bryanna BCBA Salt Lake City UT. 84129 Feldman, Kristina J Phd 4460 S Highland Dr ABS Kids p 801.581.7951 University of Utah Health Ste 100 515 S 700 E 50 N Medical Dr Salt Lake City UT. 84124 Ste 2A University Of Utah Health Salt Lake City UT. 84132 p 888.949.4864 Salt Lake City UT. 84102 50 N Medical Dr p 801.581.7951 p 801.935.4171 Salt Lake City UT. 84132 Fortenberry, Katherine T p 801.581.7951 501 S Chipeta Way PhD 6910 S Highland Dr Salt Lake City UT. 84132 University of Utah Health Ste 1 501 S Chipeta Way p 801.585.1575 1138 E Wilmington Ave Cottonwood Heights UT. 84121 Salt Lake City UT. 84108 Salt Lake City UT. 84106 p 801.935.4946 p 801.585.1575 Hospital Affiliation p 801.581.2000 - University of Utah Hospital Francom, Austin P APRN 51 W 3900 S 1280 E Stringham Ave Summitt Clinical Services Salt Lake City UT. 84107 Feller, Amy CMHC Salt Lake City UT. 84106 1151 E 3900 S p 801.587.2370 Lotus Center Inc p 801.581.2000 Ste B-299 4376 S 700 E Salt Lake City UT. 84124 University of Utah Health Ste 200 1525 W 2100 S p 801.263.0717 5126 W Daybreak Pkwy Salt Lake City UT. 84107 Salt Lake City UT. 84119 South Jordan UT. 84009 p 385.272.4292 p 801.213.8841 Summit Primary Care & p 801.581.7951 Clinical Services Collective Recovery Center 50 N Medical Dr 1561 W 7000 S University Of Utah Health 8029 S 700 E Salt Lake City UT. 84132 Ste 200 525 E 100 S Sandy UT. 84070 p 801.581.2121 West Jordan UT. 84084 Ste 5000 p 385.557.2183 p 801.263.0717 Salt Lake City UT. 84102 555 Foothill Dr p 801.585.1212 Ferris, Barbara LCSW Ste 301 Francom, Mark NP Family Counseling Center Salt Lake City UT. 84112 Summit Primary Care & University of Utah Health 650 E 4500 S p 801.581.8000 Clinical Services 555 Foothill Dr Ste 300 1561 W 7000 S Salt Lake City UT. 84112 Murray UT. 84107 555 Foothill Dr Ste 200 p 801.581.7951 p 801.261.3500 Salt Lake City UT. 84112 West Jordan UT. 84084 p 801.581.8000 p 801.263.0717 7495 S State St Fidler, Scott W PhD Midvale UT. 84047 Scott W Fidler, PsyD Hospital Affiliation Francone, Stacey M LCSW p 801.581.7951 12176 S 1000 E - University of Utah Hospital 262 E 3900 S Ste 8-F Ste 125 Hospital Affiliation Draper UT. 84020 Fosmo, Chelsee F RN Salt Lake City UT. 84107 - University of Utah Hospital p 801.619.3569 Valley Behavioral Health p 801.209.8690 550 W 700 S Freimer, Martin MD Flaspehler, Carol LCSW Salt Lake City UT. 84101 Frantz, Mayreann CMHC University of Utah Health South Point Counseling p 888.949.4864 Turning Point Centers 1280 E Stringham Ave 1206 W S Jordan Pkwy 4141 South Highland Dr Salt Lake City UT. 84106 Ste D Ste 202 p 801.581.7951 South Jordan UT. 84095 Salt Lake City UT. 84124 p 801.302.3801 p 801.576.0745

248 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 154 E Myrtle Ave 1561 W 7000 S Gant, Ralph W PhD Garlock, John T BCBA Salt Lake City UT. 84107 Ste 200 5525 S 900 E Sports Mall ABS Kids p 801.581.2628 West Jordan UT. 84084 Plaza II, 515 S 700 E p 801.501.8444 Ste 102 Ste 2A 1950 Cir of Hope Dr Salt Lake City UT. 84117 Salt Lake City UT. 84102 Salt Lake City UT. 84112 Hospital Affiliation p 801.262.3700 p 801.935.4171 p 801.583.2500 - Mountain West Medical Center Garcia Leavitt, Elizabeth 6910 S Highland Dr 50 N Medical Dr R LCSW Ste 1 Salt Lake City UT. 84132 Frost, Robert B PhD University of Utah Health Cottonwood Heights UT. 84121 p 801.585.1575 University of Utah Health 50 N Medical Dr p 801.935.4946 175 N Medical Dr E Salt Lake City UT. 84132 501 S Chipeta Way Salt Lake City UT. 84132 p 801.581.2121 Utah Autism Academy Salt Lake City UT. 84108 p 801.585.7575 7434 S State St p 801.587.3287 University Of Utah Health Midvale UT. 84047 50 N Medical Dr 555 Foothill Dr p 801.456.9955 729 S Arapeen Dr Salt Lake City UT. 84132 Salt Lake City UT. 84112 Salt Lake City UT. 84108 p 801.585.6387 p 801.581.2628 Garner, Timothy B LMFT p 801.585.6387 Valley Behavioral Health 729 S Arapeen Dr University of Utah Health 1141 E 3900 S Hospital Affiliation Salt Lake City UT. 84108 729 S Arapeen Dr Ste A220 - Salt Lake Regional Medical p 801.585.6387 Salt Lake City UT. 84108 Salt Lake City UT. 84124 Center p 801.585.6387 p 888.949.4864 - University of Utah Hospital Hospital Affiliation - University of Utah Hospital Hospital Affiliation Garrett-Baker, Amanda Freitag, Malinda LCMHC - University of Utah Hospital BCBA The Childrens Center Fujiwara, Mina BCBA ABS Kids 5242 S 4820 W Utah Behavior Services Gardiner, Jane G APRN 515 S 700 E Salt Lake City UT. 84118 5558 S 1900 W Ascendant Behavioral Ste 2A p 801.966.4251 Ste B Health Salt Lake City UT. 84102 Salt Lake City UT. 84129 5383 S 900 E p 801.935.4171 *Freund Begley, Kelli p 801.255.5131 Ste 103 *APRN Salt Lake City UT. 84117 6910 S Highland Dr PCH RESIDENTIAL TRMNT-ADOL 6013 S Redwood Rd p 801.872.5516 Ste 1 5770 S 1500 W Salt Lake City UT. 84123 Cottonwood Heights UT. 84121 Taylorsville UT. 84123 p 801.255.5131 Gardiner, Katherine LPC p 801.935.4946 p 801.313.7940 The Childrens Center Fuller, Kayleen M PhD 5242 S 4820 W Garrett, Kelly D PhD Hospital Affiliation Calm Mind Inc Salt Lake City UT. 84118 Rocky Mountain Multiple - Primary Childrens Hospital 8706 S 700 E p 801.966.4251 Sclerosis Clinic Ste 103 370 E 9th Ave Frey, Cristie L LCSW Sandy UT. 84070 Gardner, Noelle K LPC Ste 106 Sundance Behavioral p 801.652.2720 Riley Individual Family Salt Lake City UT. 84103 Resources and Marriage Counseling p 801.408.5700 845 E 4800 S Fullmer, Burton LPC 873 Baxter Dr Ste 200 Alpine Center for Personal South Jordan UT. 84095 Garvin, Bradley K CMHC Salt Lake City UT. 84107 Growth p 801.657.0163 Jordan West Family p 801.264.9522 5689 S Redwood Rd Counseling Ste 30 Garduno, Crystal N LPC 9263 Redwood Rd Bldg 8 Froerer, Baylee E SSW Salt Lake City UT. 84123 Psychiatric & Behavioral West Jordan UT. 84088 Valley Behavioral Health p 801.268.1715 Solutions p 801.566.0749 1141 E 3900 S 1522 S 1100 E Ste A-250 Furse, Daniel D LCSW Salt Lake City UT. 84105 Garza Solis, Karem G LCSW Salt Lake City UT. 84124 Valley Behavioral Health p 801.467.1200 Valley Behavioral Health p 888.949.4864 1020 S Main St 12427 S Pasture Rd Ste 100 Garland, Eric L LCSW Ste 104 Froerer, Jared D LPC Salt Lake City UT. 84101 University of Utah Health Herriman UT. 84096 Froerer Counseling p 888.949.4864 1950 Cir of Hope Dr p 888.949.4864 Services Salt Lake City UT. 84112 11075 S State St Galloway, Teresa LCSW p 801.587.7000 4460 S Highland Dr Ste 35 Sundance Behavioral Ste 100 Sandy UT. 84070 Resources 50 N Medical Dr Salt Lake City UT. 84124 p 801.501.8444 845 E 4800 S Salt Lake City UT. 84132 p 888.949.4864 Ste 200 p 801.581.2121 Salt Lake City UT. 84107 p 801.264.9522 Hospital Affiliation - University of Utah Hospital

249 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Gauchay, Lisa LCSW Gibbs, Paula K MD Primary Childrens Hospital Goldman, Sarah PhD University of Utah Health University of Utah Health 5770 S 1500 W Summit Community 50 N Medical Dr 1280 E Stringham Ave Taylorsville UT. 84123 Counseling Salt Lake City UT. 84132 Salt Lake City UT. 84106 p 801.313.7770 5689 S Redwood Rd p 801.581.2121 p 801.581.7951 Ste 27 81 N Mario Capecchi Dr Salt Lake City UT. 84123 Hospital Affiliation 1950 Cir of Hope Dr Salt Lake City UT. 84113 p 801.266.2485 - University of Utah Hospital Salt Lake City UT. 84112 p 801.662.5592 p 801.583.2500 5991 S Redwood Rd Gaugh, Amy LCSW Hospital Affiliation Salt Lake City UT. 84123 The Childrens Center 50 N Medical Dr - Primary Childrens Hospital p 801.266.2485 5242 S 4820 W Salt Lake City UT. 84132 Salt Lake City UT. 84118 p 801.585.1575 Gillespie, Amy LCSW Goldstein, Marvin LCSW p 801.966.4251 Life Stone Counseling Clinical Consultants 501 S Chipeta Way Center 7601 S Redwood Rd Bldg E Gedeon, Iberty LPC Salt Lake City UT. 84108 613 E Fort Union Blvd West Jordan UT. 84084 Jordan West Family p 801.587.3287 Ste 104 p 801.233.8670 Counseling Midvale UT. 84047 9263 Redwood Rd Bldg 8 555 Foothill Dr p 801.984.1717 Goldstein, Sam PhD Ste B Salt Lake City UT. 84112 230 S 500 E West Jordan UT. 84088 p 801.581.7951 Gillespie, Bonnie L SSW Ste 100 p 801.566.0749 Valley Behavioral Health Salt Lake City UT. 84102 7495 S State St 4460 S Highland Dr p 801.532.1484 Geisel, Allison CMHC Midvale UT. 84047 Ste 300 Valley Behavioral Health p 801.581.7951 Salt Lake City UT. 84124 Goldstein, Terri E LCMHC 1020 S Main St p 888.949.4864 Insights Counseling Ste 100 Hospital Affiliation 9192 S 300 W Salt Lake City UT. 84101 - University of Utah Hospital Gjording, Angela LCMHC Ste 31 p 888.949.4864 Valley Behavioral Health Sandy UT. 84070 Gibson, Crystal BCBA 1228 E 900 S p 801.979.0610 George, Margaret LCSW ABS Kids Salt Lake City UT. 84105 Ascendant Behavioral 515 S 700 E p 888.949.4864 Golub, Lateisha L LCSW Health Ste 2A Compass Counseling and 5383 S 900 E Salt Lake City UT. 84102 Glaitti, Stephanie A Consulting Ste 103 p 801.935.4171 LCMHC 4000 S 700 E Salt Lake City UT. 84117 The OCD And Anxiety Ste 9 p 801.872.5516 6910 S Highland Dr Treatment Center Salt Lake City UT. 84107 Ste 1 11260 S River Height Dr p 801.639.9544 Gerritsen, James CSW Cottonwood Heights UT. 84121 South Jordan UT. 84095 Valley Behavioral Health p 801.935.4946 p 801.298.2000 Gomes, Andrea LCSW 2948 S Redwood Rd University Of Utah Health West Valley City UT. 84119 Gibson, Jacob PhD,LMFT Godwin, Susan M NP 501 S Chipeta Way p 888.949.4864 The Green House for Growth Mountain Paths Counseling Salt Lake City UT. 84108 & Learning 7069 S Highland Dr p 801.587.2500 Gezon, Amy CMHC 1325 W S Jordan Pkwy Ste 100 Unit 6 Summit Community Ste 102 Salt Lake City UT. 84121 Hospital Affiliation Counseling South Jordan UT. 84095 p 801.214.1565 - University of Utah Hospital 5689 S Redwood Rd p 801.208.8838 Ste 27 Goldberg, Annie BCBA Gonzalez, Yvette S LCSW Salt Lake City UT. 84123 Gileno, Zaneta M LCSW ABS Kids Lotus Center Inc p 801.266.2485 Bear Creek Counseling 515 S 700 E 348 E 4500 S 1227 W 9000 S Ste 2A Ste 360 5991 S Redwood Rd Ste H Salt Lake City UT. 84102 Salt Lake City UT. 84107 Salt Lake City UT. 84123 West Jordan UT. 84084 p 801.935.4946 p 385.272.4292 p 801.266.2485 p 385.274.7119 6910 S Highland Dr Gonzalz, Amanda J MSW Gibb, Amanda CMHC Giles, Lisa E MD Ste 1 Empowering Relief The OCD And Anxiety University of Utah Health Cottonwood Heights UT. 84121 Counseling Treatment Center 100 N Mario Capecchi Dr p 801.935.4946 5814 S 900 E 11260 S River Height Dr Salt Lake City UT. 84113 Salt Lake City UT. 84121 South Jordan UT. 84095 p 801.313.7711 Golden, Tracy H CMHC p 385.800.3272 p 801.298.2000 Compass Counseling and Consulting 4000 S 700 E Ste 9 Salt Lake City UT. 84107 p 801.639.9544

250 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Goodman, Julie A LCSW Gray, Douglas D MD Green, Rachal BCBA,LCSW Guerrieri, Joseph BCBA Valley Behavioral Health University of Utah Health Utah Behavior Services ABS Kids 1020 S Main St 1138 E Wilmington Ave 5558 S 1900 W 515 S 700 E Ste 218 Salt Lake City UT. 84106 Ste B Ste 2A Salt Lake City UT. 84101 p 801.213.8845 Salt Lake City UT. 84129 Salt Lake City UT. 84102 p 888.949.4864 p 801.255.5131 p 801.935.4171 1280 E Stringham Ave 4460 S Highland Dr Salt Lake City UT. 84106 6013 S Redwood Rd 6910 S Highland Dr Ste 100 p 801.581.7951 Salt Lake City UT. 84123 Ste 1 Salt Lake City UT. 84124 p 801.255.5131 Salt Lake City UT. 84121 p 888.949.4864 50 N Medical Dr p 801.935.4171 Salt Lake City UT. 84132 Greenwood, Nick C MD Gooley, Patrick J LCSW p 801.585.1575 Breakaway Recovery Center Guinn, Devin BCBA Life Matters Counseling & Murray ABS Kids Health Center 501 S Chipeta Way 5296 S Commerce Dr 515 S 700 E 2225 E Murray-Holladay Rd Salt Lake City UT. 84108 Ste 204 Ste 2A Ste 112 p 801.587.3287 Salt Lake City UT. 84107 Salt Lake City UT. 84102 Salt Lake City UT. 84117 p 801.904.3242 p 801.935.4171 p 801.313.0555 Hospital Affiliation - University of Utah Hospital Next Level Recovery Gulick, Regina CMHC 3336 S Pioneer Pkwy 6771 S 900 E Aspen Ridge Counseling Ste 201 Graziadei, Kelly A PA-C Midvale UT. 84047 411 W 7200 S West Valley City UT. 84120 University of Utah Health p 801.386.9799 Ste 304 p 801.313.0555 501 S Chipeta Way Midvale UT. 84047 Salt Lake City UT. 84108 Gressmen, Casey BCBA p 801.990.4300 Gordon-White, Janice G p 801.585.1575 Utah Behavior Services CMHC 5558 S 1900 W Gurrister, Linda LCSW Valley Behavioral Health 51 W 3900 S Ste B 4190 S Highland Dr 1020 S Main St Salt Lake City UT. 84107 Salt Lake City UT. 84129 Ste 210 Ste 300 p 801.585.1575 p 801.255.5131 Salt Lake City UT. 84124 Salt Lake City UT. 84101 p 801.278.8492 p 888.949.4864 Hospital Affiliation 6013 S Redwood Rd - University of Utah Hospital Salt Lake City UT. 84123 Gutierrez, Jose D LCSW Goss, Angela CSW p 801.255.5131 Valley Behavioral Health Utah Behavior Services Green, Courtney BCBA 1020 S Main St 5558 S 1900 W ABS Kids *Griffiths, Amanda D LCSW Ste 100 Ste B 515 S 700 E PCH Residential Home Salt Lake City UT. 84101 Taylorsville UT. 84118 Ste 2A 5770 S 1500 W Bldg C p 888.949.4864 p 801.255.5131 Salt Lake City UT. 84102 Salt Lake City UT. 84123 p 801.935.4171 p 801.313.7954 1141 E 3900 S 6013 S Redwood Rd Ste A250 Taylorsville UT. 84123 6910 S Highland Dr PCH Residential Trmnt - Salt Lake City UT. 84124 p 801.255.5131 Ste 1 ADOL p 888.949.4864 Cottonwood Heights UT. 84121 5770 S 1500 W Gouveia, Joseph R LCMHC p 801.935.4946 Salt Lake City UT. 84123 Guzman, Anthony LCSW Valley Behavioral Health p 801.313.7940 Lotus Center Inc 2948 S Redwood Rd Green, E Guerry LCSW 4376 S 700 E West Valley City UT. 84119 The Green House for Growth Grow, Taffy Jo (TJ) LPC Ste 200 p 888.949.4864 & Learning Holistic Elements Salt Lake City UT. 84107 1325 W S Jordan Pkwy 835 E 4800 S p 385.272.4292 *Grant, Ryan LCSW Ste 102 Ste 220 Primary Childrens Hospital South Jordan UT. 84095 Salt Lake City UT. 84107 *Haase, Lyssa PsyD 100 N Mario Capecchi Dr p 801.208.8838 p 801.262.5418 PCH PSYCHIATRY Salt Lake City UT. 84113 5770 S 1500 W p 801.662.1000 Green, Elsebeth Guardian Transportation Taylorsville UT. 84123 The Green House for Growth 4476 Century Dr p 801.313.7770 3773 W 12600 S & Learning Ste D Riverton UT. 84065 1325 W S Jordan Pkwy Salt Lake City UT. 84123 Hackett, Linda R LPC p 801.662.3606 Ste 102 p 385.212.2002 Comprehensive South Jordan UT. 84095 Psychological Services 81 N Mario Capecchi Dr p 801.785.1169 Gudmundsson, Fridrik R 1208 E 3300 S Salt Lake City UT. 84113 LCSW Salt Lake City UT. 84106 p 801.662.3606 Valley Behavioral Health p 801.843.1600 780 S Guardsman Way Salt Lake City UT. 84108 p 888.949.4864

251 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 3725 W 4100 S Hale, Jessica LCSW Hallett, C B PhD Embrace Counseling West Valley City UT. 84119 Valley Behavioral Health Center for Human Potential 7478 S Campus View Dr p 801.965.3759 12427 S Pasture Rd 265 E 100 S Ste 100 Ste 104 Ste 250 West Jordan UT. 84084 Hadnagy-Roch, Alexis Riverton UT. 84096 Salt Lake City UT. 84111 p 801.441.2239 BCBA p 888.949.4864 p 801.483.2447 ABS Kids Hancock, Lacey LMHC 515 S 700 E 4460 S Highland Dr Hallisey, Jenny T CSW Valley Behavioral Health Ste 2A Ste 100 Valley Behavioral Health 12427 S Pasture Rd Salt Lake City UT. 84102 Salt Lake City UT. 84124 1020 S Main St Ste 104 p 801.935.4171 p 888.949.4864 Ste 100 Riverton UT. 84096 Salt Lake City UT. 84101 p 888.949.4864 6910 S Highland Dr *Hale, Jonathan C LCSW p 888.949.4864 Ste 1 PCH Residential Home 4460 S Highland Dr Cottonwood Heights UT. 84121 5770 S 1500 W Bldg C Halvorson, Isabelle T LPC Ste 100 p 801.935.4946 Salt Lake City UT. 84123 Matt Larson Psychotherapy Salt Lake City UT. 84124 p 801.313.7954 and Associates p 888.949.4864 Haga, Sydney LCMHC 1226 A S Jordan Pkwy Aspen Ridge Counseling PCH Residential Trmnt - South Jordan UT. 84095 Life Stone Counseling 1561 W 7000 S ADOL p 801.671.7612 Center Ste 200 5770 S 1500 W 613 E Fort Union Blvd West Jordan UT. 84084 Salt Lake City UT. 84123 Hamilton, Qrystel LCMHC Ste 104 p 801.990.4300 p 801.313.7940 Valley Behavioral Health Midvale UT. 84047 1141 E 3900 S p 801.984.1717 Haggerty, Erin APRN Hales, Christopher S CMHC Ste A170 Senior Behavioral Health Valley Behavioral Health Salt Lake City UT. 84124 Hansen, Samuel J LCSW (SLC - IP) 550 W 700 S p 888.949.4864 Valley Behavioral Health 1050 E S Temple 2nd Fl Salt Lake City UT. 84101 1020 S Main St Salt Lake City UT. 84102 p 888.949.4864 University Of Utah Health Ste 300 p 801.350.4111 525 E 100 S Salt Lake City UT. 84101 Hales, Jason A LCSW Ste 5000 p 888.949.4864 Hospital Affiliation Hales Counseling Center Salt Lake City UT. 84102 - Salt Lake Regional Medical 8817 S Redwood Rd p 801.585.1212 Hanson, Laura LCSW Center Ste D Valley Behavioral Health West Jordan UT. 84088 Hammers, Dustin B PhD 195 W 7200 S Hakes, Chris C LCSW p 801.783.9265 University of Utah Health Midvale UT. 84047 Aspen Ridge Counseling 50 N Medical Dr p 888.949.4864 11075 S State St Hall, Abigail SSW Salt Lake City UT. 84132 Ste 35 Valley Behavioral Health p 801.581.2121 2948 S Redwood Rd Sandy UT. 84070 2948 S Redwood Rd West Valley City UT. 84119 p 801.501.8444 West Valley City UT. 84119 Hospital Affiliation p 888.949.4864 p 888.949.4864 - University of Utah Hospital 1561 W 7000 S Hanson, Nancy C LCSW Ste 200 4460 S Highland Dr Hamp, Breeann B LCSW 8160 S Highland Dr West Jordan UT. 84084 Ste 220 Life Matters Counseling & Ste 204 p 801.990.4300 Salt Lake City UT. 84124 Health Center Sandy UT. 84093 p 888.949.4864 2225 E Murray-Holladay Rd p 801.942.4444 2711 S 8500 W Ste 112 Magna UT. 84044 Hall, Aliah LCSW Salt Lake City UT. 84117 Hardesty Van Ginkel, p 801.990.4300 Kindling p 801.313.0555 Ashlee B MD 3980 S 700 E University of Utah Health 2880 W 4700 S Ste 22 3336 S Pioneer Pkwy 1280 E Stringham Ave Ste G-1 Salt Lake City UT. 84107 Ste 201 Salt Lake City UT. 84106 Salt Lake City UT. 84129 p 385.743.2728 West Valley City UT. 84120 p 801.581.7951 p 801.990.4300 p 801.313.0555 Compass Counseling and 50 N Medical Dr 411 W 7200 S Consulting Hancock, Charrisse R Salt Lake City UT. 84132 Ste 304 4000 S 700 E The Utah House p 801.581.7951 Midvale UT. 84047 Ste 9 1370 S West Temple p 801.990.4300 Salt Lake City UT. 84107 Salt Lake City UT. 84115 501 S Chipeta Way p 801.639.9544 p 801.678.3317 Salt Lake City UT. 84108 C Hakes LLC p 801.587.3287 8537 W 2700 S Ste C Hospital Affiliation Magna UT. 84044 - University of Utah Hospital p 801.503.8937

252 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Harding, Shannon N APRN 6910 S Highland Dr Hawkins, Jeffrey BCBA Sundance Behavioral Valley Behavioral Health Ste 1 ABS Kids Resources 1020 S Main St Cottonwood Heights UT. 84121 6910 S Highland Dr 845 E 4800 S Ste 100 p 801.935.4946 Ste 1 Ste 200 Salt Lake City UT. 84101 Cottonwood Heights UT. 84121 Murray UT. 84107 p 888.949.4864 *Harris, Natalie LCSW p 801.935.4946 p 801.264.9522 Primary Childrens Hospital 2948 S Redwood Rd 5770 S 1500 W Hayes, Christa J BCBA Hospital Affiliation West Valley City UT. 84119 Taylorsville UT. 84123 ABS Kids - Mountain West Medical p 888.949.4864 p 801.313.7770 515 S 700 E Center Ste 2A Harding, Stephanie LCSW Hospital Affiliation Salt Lake City UT. 84102 Heline, Branden H LMFT Comprehensive - Primary Childrens Hospital p 801.935.4171 Sage Family Counseling Psychological Services 13552 S 110 W 1208 E 3300 S Harris, Ted A PhD 6910 S Highland Dr Ste 204 Salt Lake City UT. 84106 Center for Family Ste 1 Draper UT. 84020 p 801.483.1600 Evaluation and Treatment Cottonwood Heights UT. 84121 p 801.432.0883 Inc p 801.935.4946 Hardman, Jesse R CMHC 5691 S Redwood Rd Henderson, Amy LCSW Valley Behavioral Health Ste 16A Hayes, Loran PhD University of Utah Health 1020 S Main St Taylorsville UT. 84123 Wasatch Pediatrics - 65 S Mario Capecchi Dr Ste 100 p 801.265.3895 Draper Salt Lake City UT. 84132 Salt Lake City UT. 84101 114 E 12450 S p 801.581.2121 p 888.949.4864 Harrison, Bryan C LCSW Ste 100 Jordan West Family Draper UT. 84020 Hospital Affiliation Hardy III, James PA-C Counseling p 801.523.3001 - University of Utah Hospital Comprehensive 9263 Redwood Rd Bldg 8 Psychological Services Ste B Haymond, David C CMHC Hendrix, Kelsey R RN 1208 E 3300 S West Jordan UT. 84088 Valley Behavioral Health Valley Behavioral Health Salt Lake City UT. 84106 p 801.566.0749 1020 S Main St 1020 S Main St p 801.264.6000 Ste 300 Ste 100 Harrison, Shannon Salt Lake City UT. 84101 Salt Lake City UT. 84101 Harmon, Jordan LCSW The OCD And Anxiety p 888.949.4864 p 888.949.4864 Cedar Psychiatry Treatment Center 1208 E 3300 S 11260 S River Height Dr Hazen, Shawn L LCSW Hendrix, Megan L LCSW Salt Lake City UT. 84106 South Jordan UT. 84095 Lotus Center Inc Valley Behavioral Health p 801.369.8989 p 801.298.2000 4376 S 700 E 1141 E 3900 S Ste 200 Ste A160 721 E 12200 S Harrop, Elizabeth A APRN Salt Lake City UT. 84107 Salt Lake City UT. 84124 Draper UT. 84020 Ascendant Behavioral p 385.272.4292 p 888.949.4864 p 801.369.8989 Health 5383 S 900 E Heath, Nicholas BCBA 195 W 7200 S Hospital Affiliation Ste 103 ABS Kids Midvale UT. 84047 - Mountain View Hospital Salt Lake City UT. 84117 515 S 700 E p 888.949.4864 (UT) p 801.872.5516 Ste 2A - Utah Valley Hospital Salt Lake City UT. 84102 Heninger, Carolyn LCSW Hasselfeld, Kimberly L RN p 801.935.4171 Sundance Behavioral Harris, Debra Jill J Valley Behavioral Health Resources Senior Behavioral Health 1785 E 1450 S 6910 S Highland Dr 845 E 4800 S SLC - OP Ste 370 Ste 1 Ste 200 82 S 1100 E Salt Lake City UT. 84124 Salt Lake City UT. 84121 Murray UT. 84107 Ste 404 p 888.949.4864 p 801.935.4171 p 801.264.9522 Salt Lake City UT. 84102 p 801.350.4777 Havertz, Stephen S LCSW Hejazi, Jamal MD Hennefer, Kenneth L LCSW Valley Behavioral Health Odyssey House of Utah Counseling & Education Harris, Kaitlyn BCBA 3809 W 6200 S 350 E 2100 S Associates ABS Kids Taylorsville UT. 84129 Salt Lake City UT. 84115 7321 S State St 515 S 700 E p 888.949.4864 p 801.428.3241 Ste A-B Ste 2A Midvale UT. 84047 Salt Lake City UT. 84102 4460 S Highland Dr Clinical Consultants p 801.352.2844 p 801.935.4171 Ste 100 7601 S Redwood Rd Bldg E Salt Lake City UT. 84124 West Jordan UT. 84084 Henry, Suzanne L LCSW p 888.949.4864 p 801.223.8670 University Of Utah Health 240 Morris Ave Ste 400 Salt Lake City UT. 84115 p 801.585.1212

Hospital Affiliation - University of Utah Hospital253 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Henshaw, Brandon J BCBA 50 N Medical Dr 7495 S State St Ascendant Behavioral Neurobehavioral Center for Salt Lake City UT. 84132 Midvale UT. 84047 Health Growth p 801.585.1575 p 801.213.9400 5383 S 900 E 370 E South Temple Ste 103 Ste 175 501 S Chipeta Way Higley, Aaron J CMHC Salt Lake City UT. 84117 Salt Lake City UT. 84111 Salt Lake City UT. 84108 Valley Behavioral Health p 801.872.5516 p 801.683.1062 p 801.587.3287 1020 S Main St Ste 200 Hobby, Esperanza A LMFT Hereth, Jacob L SSW Hospital Affiliation Salt Lake City UT. 84101 Valley Behavioral Health Valley Behavioral Health - University of Utah Hospital p 888.949.4864 12427 S Pasture Rd 4460 S Highland Dr Ste 104 Ste 300 Hickok, Angela LCSW Hill, Diane PhD Riverton UT. 84096 Salt Lake City UT. 84124 Jordan West Family Diane Hill PHD p 888.949.4864 p 888.949.4864 Counseling 4505 S Wasatch Blvd 9263 Redwood Rd Bldg 8 Ste 360 4460 S Highland Dr Hernandez, Cindy C LPC West Jordan UT. 84088 Salt Lake City UT. 84124 Ste 100 Comprehensive p 801.566.0749 p 801.440.2430 Salt Lake City UT. 84124 Psychological Services p 888.949.4864 1208 E 3300 S Hicks, Kenneth BCBA Hill, Kayleen M LCSW Salt Lake City UT. 84106 ABS Kids Jordan West Family Hodgkin, Cameron BCBA p 801.483.1600 515 S 700 E Counseling ABS Kids Ste 2A 9263 Redwood Rd Bldg 8 6910 S Highland Dr Aspire Psychological Salt Lake City UT. 84102 West Jordan UT. 84088 Ste 1 885 W Baxter Dr p 801.935.4171 p 801.566.0749 Cottonwood Heights UT. 84121 South Jordan UT. 84095 p 801.935.4946 p 385.202.6113 Hicks, Robert CMHC Hill, Nichole LCSW On Call Doc 1399 S 700 E Hoff, Troy C DO,PhD Hernandez, June Lee CMHC 10437 S Jordan Gateway Ste 15E University of Utah Health Valley Behavioral Health South Jordan UT. 84095 Salt Lake City UT. 84105 50 N Medical Dr 12427 S Pasture Rd p 801.610.9159 p 801.362.9665 Salt Lake City UT. 84132 Ste 104 p 801.585.1575 Riverton UT. 84096 Higgins, Michael P LCSW University of Utah Health p 888.949.4864 University of Utah Health 1525 W 2100 S 501 S Chipeta Way 1280 E Stringham Ave Salt Lake City UT. 84119 Salt Lake City UT. 84108 4460 S Highland Dr Salt Lake City UT. 84106 p 801.213.8841 p 801.587.3287 Ste 100 p 801.213.8841 Salt Lake City UT. 84124 Hospital Affiliation Hospital Affiliation p 888.949.4864 1525 W 2100 S - University of Utah Hospital - University of Utah Hospital Salt Lake City UT. 84119 Herndon, Natalie C PhD p 801.213.8841 Hill, Scott LCSW Hoffman, Lindsey BCBA Natalie C Herndon PHD CMHC University of Utah Health ABS Kids 9071 S 1300 W 3730 W 4700 S 50 N Medical Dr 515 S 700 E Ste 100 Taylorsville UT. 84129 Salt Lake City UT. 84132 Ste 2A West Jordan UT. 84088 p 801.213.9200 p 801.581.7951 Salt Lake City UT. 84102 p 801.657.3330 p 801.935.4171 5126 W Daybreak Pkwy 501 S Chipeta Way Hesse, Lucille LCSW Ste 600 Salt Lake City UT. 84108 6910 S Highland Dr 1399 S 700 E South Jordan UT. 84009 p 801.585.1575 Ste 1 Ste 8 p 801.213.4500 Cottonwood Heights UT. 84121 Salt Lake City UT. 84105 Hospital Affiliation p 801.935.4946 p 801.485.1271 5126 W Daybreak Pkwy - University of Utah Hospital South Jordan UT. 84009 Hoffmann, Audrey PhD Hesse, Toni M MD p 801.213.4500 Hilton, Gail C LCSW Utah Behavior Services University of Utah Health Valley Behavioral Health 5558 S 1900 W 1280 E Stringham Ave 555 Foothill Dr 12427 S Pasture Rd Ste B Salt Lake City UT. 84106 Ste 301 Ste 104 Salt Lake City UT. 84129 p 801.581.7951 Salt Lake City UT. 84112 Riverton UT. 84096 p 801.255.5131 p 801.581.8000 p 888.949.4864 1950 Cir of Hope Dr 6013 S Redwood Rd Salt Lake City UT. 84112 555 Foothill Dr 4460 S Highland Dr Salt Lake City UT. 84123 p 801.583.2500 Salt Lake City UT. 84112 Ste 100 p 801.255.5131 p 801.581.8000 Salt Lake City UT. 84124 p 888.949.4864

254 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Holbrook, Jocelyn E LCSW 6910 S Highland Dr Howick, Brennan P CSW 1950 Cir of Hope Dr 5796 S 900 E Ste 1 Valley Behavioral Health Salt Lake City UT. 84112 Ste 206 Cottonwood Heights UT. 84121 4460 S Highland Dr p 801.583.2500 Salt Lake City UT. 84121 p 801.935.4946 Ste 100 p 801.879.0252 Salt Lake City UT. 84124 50 N Medical Dr Hough, Amanda LCSW p 888.949.4864 Salt Lake City UT. 84132 Holbrook, Julie K LMFT Comprehensive p 801.585.1575 South Point Counseling Psychological Services Howlett, Sarah T LCSW 1206 W S Jordan Pkwy 1208 E 3300 S Valley Behavioral Health 501 S Chipeta Way Ste D Salt Lake City UT. 84106 4460 S Highland Dr Salt Lake City UT. 84108 South Jordan UT. 84095 p 801.264.6000 Ste 100 p 801.587.3287 p 801.302.3801 Salt Lake City UT. 84124 Hourmanesh, Najmeh PhD p 888.949.4864 Hurzeler, Kimberly CMHC Hollenbeck, Susan E LCSW Therapy For Kids Alpine Center for Personal Comprehensive 160 S 1000 E Howsley, Jessica Z MD Growth Psychological Services Ste 330 University of Utah Health 5689 S Redwood Rd 1208 E 3300 S Salt Lake City UT. 84102 50 N Medical Dr Ste 30 Salt Lake City UT. 84106 p 801.441.8943 Salt Lake City UT. 84132 Salt Lake City UT. 84123 p 801.483.1600 p 801.585.1575 p 801.268.1715 Houston, Ryan F PhD 3725 W 4100 S Comprehensive 501 S Chipeta Way *Hutchinson, Cassandra L West Valley City UT. 84119 Psychological Services Salt Lake City UT. 84108 *LCSW p 801.965.3759 1208 E 3300 S p 801.587.3287 PCH RESIDENTIAL HOME Salt Lake City UT. 84106 5770 S 1500 W Bldg C Holloway, Tifani J LCSW p 801.483.1600 Hospital Affiliation Taylorsville UT. 84123 Valley Behavioral Health - University of Utah Hospital p 801.313.7954 1020 S Main St 3725 W 4100 S Ste 100 West Valley City UT. 84119 Hughes, Beth LMFT PCH RESIDENTIAL TRMNT-ADOL Salt Lake City UT. 84101 p 801.965.3759 3320 S Old Millbrook Cir 5770 S 1500 W p 888.949.4864 Salt Lake City UT. 84115 Taylorsville UT. 84123 Howell, Elizabeth F MD p 801.266.7435 p 801.313.7940 Holmes, Alisha MSW University of Utah Health Utah Behavior Services 1280 E Stringham Ave Huhnke, Leah K LMFT PCH NEUROPSYCHOLOGY 5558 S 1900 W Salt Lake City UT. 84106 Summit Community 81 N Mario Capecchi Dr Ste B p 801.581.7951 Counseling Salt Lake City UT. 84113 Salt Lake City UT. 84129 5689 S Redwood Rd p 801.662.5592 p 801.255.5131 50 N Medical Dr Ste 27 Salt Lake City UT. 84132 Salt Lake City UT. 84123 Hospital Affiliation 6013 S Redwood Rd p 801.585.1575 p 801.266.2485 - Primary Childrens Hospital Salt Lake City UT. 84123 p 801.255.5131 501 S Chipeta Way 5991 S Redwood Rd Hutchinson, Mark Salt Lake City UT. 84108 Salt Lake City UT. 84123 Ascendant Behavioral Holyoak, Sarah CSW p 801.587.3287 p 801.266.2485 Health Valley Behavioral Health 4179 Riverboat Rd 2948 S Redwood Rd Hospital Affiliation Hungary, Katrina D SSW Ste 220 West Valley City UT. 84119 - University of Utah Hospital Valley Behavioral Health Salt Lake City UT. 84123 p 888.949.4864 280 E 600 S p 801.872.5516 Howell, Justin LCSW Salt Lake City UT. 84111 Holzer, April LMFT Wasatch Pediatrics - p 888.949.4864 5383 S 900 E Matt Larson Psychotherapy Willow Creek Ste 103 and Associates 7138 S 2000 E Hunt, Chelseigh BCBA Salt Lake City UT. 84117 1226 W 10600 S Bldg A Ste 106 Utah Behavior Services p 801.872.5516 South Jordan UT. 84095 Salt Lake City UT. 84121 5558 S 1900 W p 801.521.0699 p 801.942.1800 Ste B Hutchinson, Sheridan SSW Salt Lake City UT. 84129 Valley Behavioral Health 24 S 600 E Howes, Scott M LCSW p 801.255.5131 1020 S Main St Ste 6 Wasatch Spring Counseling Ste 100 Salt Lake City UT. 84102 2936 Highland Dr 6013 S Redwood Rd Salt Lake City UT. 84101 p 801.521.0699 Ste 100 Salt Lake City UT. 84123 p 888.949.4864 Salt Lake City UT. 84106 p 801.255.5131 Hooton, Amy BCBA p 801.540.4452 Ingle, Howard G LPC ABS Kids Hunziker, Jason MD Comprehensive 515 S 700 E University of Utah Health Psychological Services Ste 2A 1280 E Stringham Ave 3725 W 4100 S Salt Lake City UT. 84102 Salt Lake City UT. 84106 West Valley City UT. 84119 p 801.935.4171 p 801.581.7951 p 801.965.3759

255 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Insights Counseling Jacobs, Victoria FNP Jarvis, Julio C LCSW Jensen, Paula G LPN 9192 S 300 W Valley Behavioral Health University of Utah Health Valley Behavioral Health Ste 317A 1020 S Main St 1525 W 2100 S 1141 E 3900 S Sandy UT. 84070 Ste 100 Salt Lake City UT. 84119 Ste A250 p 801.979.0612 Salt Lake City UT. 84101 p 801.213.8841 Salt Lake City UT. 84124 p 888.949.4864 p 888.949.4864 9192 S 300 W 5126 W Daybreak Pkwy Ste 31 2948 S Redwood Rd South Jordan UT. 84009 Jensen, Tara L LPC Sandy UT. 84070 West Valley City UT. 84119 p 801.213.4500 Sundance Behavioral p 801.979.0610 p 888.949.4864 Resources Hospital Affiliation 845 E 4800 S Institute of Change 3809 W 6200 S - University of Utah Hospital Ste 200 11190 S 958 E Salt Lake City UT. 84129 Salt Lake City UT. 84107 Sandy UT. 84094 p 888.949.4864 Jennings, Karl E LCSW p 801.264.9522 p 801.571.4565 Compass Counseling and 4460 S Highland Dr Consulting Jensen, Tyson LCSW Jackson, Amanda LCSW Ste 220 4000 S 700 E Aspen Ridge Counseling Cedar Psychiatry Salt Lake City UT. 84124 Ste 9 2711 S 8500 W 1208 E 3300 S p 888.949.4864 Salt Lake City UT. 84107 Magna UT. 84044 Salt Lake City UT. 84106 p 801.639.9544 p 801.990.4300 p 801.369.8989 Jacobsen, Maren BCBA ABS Kids Jensen, David W LPC Lighthouse Counseling 154 E Myrtle Ave 515 S 700 E Riley Individual Family Services Ste 204 Ste 2A and Marriage Counseling 3405 W 12600 S Murray UT. 84107 Salt Lake City UT. 84102 873 Baxter Dr Ste 110 p 801.369.8989 p 801.935.4171 South Jordan UT. 84095 Riverton UT. 84065 p 801.657.0163 p 385.237.4943 721 E 12200 S 6910 S Highland Dr Draper UT. 84020 Ste 1 Jensen, Julia P BCBA Jenson, Hillary BCBA p 801.369.8989 Salt Lake City UT. 84121 Utah Behavior Services Chrysalis Utah p 801.935.4171 5558 S 1900 W 448 E Winchester St Jackson, Andrea FNP-C Ste B Ste 200 Valley Behavioral Health Jacobson, Sheila CSW Salt Lake City UT. 84129 Salt Lake City UT. 84107 1020 S Main St Aspen Ridge Counseling p 801.255.5131 p 801.655.4950 Ste 100 11075 S State St Salt Lake City UT. 84101 Ste 35 6013 S Redwood Rd Jeppson, Holly C LCSW p 888.949.4864 Sandy UT. 84070 Salt Lake City UT. 84123 Holly C Jeppson LCSW p 801.501.8444 p 801.255.5131 8545 S Redwood Rd Unit B South Valley Primary Care West Jordan UT. 84084 13348 S Market Ctr Dr Jacquez, Jacob E LCSW Jensen, Karen E LCSW p 801.748.2192 Ste 210 Empowering Relief University Of Utah Health Riverton UT. 84065 Counseling 1950 Cir of Hope Dr Jerome, Peggy A APRN p 801.987.7500 5814 S 900 E Salt Lake City UT. 84112 Lotus Center Inc Salt Lake City UT. 84121 p 801.587.7000 4376 S 700 E Jordan Valley Internal p 385.800.3272 Ste 200 Medicine Hospital Affiliation Salt Lake City UT. 84107 3570 W 9000 S Jardine-Tucker, Julie Ann - University of Utah Hospital p 385.272.4292 Ste 100 LCMHC West Jordan UT. 84088 Insights Counseling Jensen, Melissa BCBA Jewell, Jessica PhD p 801.569.2384 9192 S 300 W ABS Kids University of Utah Health Ste 317A 515 S 700 E 50 N Medical Dr Taylorsville Urgent Care Sandy UT. 84070 Ste 2A Salt Lake City UT. 84132 5360 S 2700 W p 801.979.0612 Salt Lake City UT. 84102 p 801.581.7951 Taylorsville UT. 84129 p 801.935.4171 p 801.840.2020 9192 S 300 W Hospital Affiliation Ste 31 6910 S Highland Dr - University of Utah Hospital Sandy Ridge Family Sandy UT. 84070 Ste 1 Medicine p 801.979.0610 Cottonwood Heights UT. 84121 Johnson-Waddell, Delsa 9350 S 150 E p 801.935.4946 LPC Ste 150 Jarman, Mary LCSW Summit Community Sandy UT. 84070 Comprehensive Counseling *Jensen, Michael B LCSW Counseling p 801.569.2384 Solutions PCH CHILD PSYCH-OP 5689 S Redwood Rd 885 Baxter Dr 5770 S 1500 W Ste 27 South Jordan UT. 84095 Taylorsville UT. 84123 Salt Lake City UT. 84123 p 801.671.1020 p 801.313.7770 p 801.266.2485

256 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 5991 S Redwood Rd Johnson, Sharon LCSW Jones, Kristin LPC Kane, Christy P Salt Lake City UT. 84123 Valley Behavioral Health 684 E Vine St Comprehensive p 801.266.2485 1141 E 3900 S Ste 4A Psychological Services Ste A250 Murray UT. 84107 1208 E 3300 S Johnson, Charles J LCSW Salt Lake City UT. 84124 p 801.380.3846 Salt Lake City UT. 84106 Lotus Center Inc p 888.949.4864 p 801.483.1600 4376 S 700 E Jones, Lisa BCBA Ste 200 12427 S Pasture Rd ABS Kids Kasteler, Nicki C CMHC Salt Lake City UT. 84107 Ste 104 515 S 700 E Valley Behavioral Health p 385.272.4292 Riverton UT. 84096 Ste 2A 1141 E 3900 S p 888.949.4864 Salt Lake City UT. 84102 Ste A170 Johnson, Clark MD p 801.935.4171 Salt Lake City UT. 84124 Senior Behavioral Health 4460 S Highland Dr p 888.949.4864 SLC - IP Ste 100 6910 S Highland Dr 1050 E S Temple 2nd Fl Salt Lake City UT. 84124 Ste 1 3809 W 6200 S Salt Lake City UT. 84102 p 888.949.4864 Cottonwood Heights UT. 84121 Taylorsville UT. 84129 p 801.350.4111 p 801.935.4946 p 888.949.4864 6856 S 700 E Adult Behavioral Health Midvale UT. 84047 Jones, Ondulyn RN PCH Residential Home JVMC-WVC - IP p 888.949.4864 Valley Behavioral Health 5770 S 1500 W Bldg C 3460 S 4155 W 5th Fl 1020 S Main St Taylorsville UT. 84123 West Valley City UT. 84120 Johnson, Tod LCSW Ste 300 p 801.313.7954 p 801.964.3111 Jordan West Family Salt Lake City UT. 84101 Counseling p 888.949.4864 PCH RESIDENTIAL TRMNT-ADOL 560 S 300 E 9263 Redwood Rd Bldg 8 5770 S 1500 W Ste 155 Ste B Jones, Tonya BCBA Taylorsville UT. 84123 Salt Lake City UT. 84111 West Jordan UT. 84088 ABS Kids p 801.313.7940 p 801.350.4111 p 801.566.0749 515 S 700 E Ste 2A Kastner, William R LCSW Senior Behavioral Health Johnson, Veronica BCBA Salt Lake City UT. 84102 South Point Counseling SLC - OP ABS Kids p 801.935.4171 1206 W S Jordan Pkwy 82 S 1100 E 515 S 700 E Ste D Ste 404 Ste 2A Jordan West Family South Jordan UT. 84095 Salt Lake City UT. 84102 Salt Lake City UT. 84102 Counseling p 801.302.3801 p 801.350.4777 p 801.935.4171 9263 Redwood Rd Bldg 8 West Jordan UT. 84088 Keen, Annalise S MD Hospital Affiliation 6910 S Highland Dr p 801.566.0749 University of Utah Health - Davis Hospital Ste 1 1280 E Stringham Ave Salt Lake City UT. 84121 Judson, Ryan CMHC Salt Lake City UT. 84106 Johnson, Glen E MD p 801.935.4946 Ascendant Behavioral p 801.581.7951 3940 W 4100 S Health Salt Lake City UT. 84120 Johnston, Harmony MSW 5383 S 900 E 501 S Chipeta Way p 801.966.3700 Utah Behavior Services Ste 103 Salt Lake City UT. 84108 5558 S 1900 W Salt Lake City UT. 84117 p 801.587.3287 Johnson, James G LCSW Ste B p 801.872.5516 Valley Behavioral Health Salt Lake City UT. 84129 Hospital Affiliation 12427 S Pasture Rd p 801.255.5131 Jurgela, Alycia LPC - University of Utah Hospital Ste 104 The Utah House Herriman UT. 84096 6013 S Redwood Rd 1370 S West Temple Keene, Susan LCSW p 888.949.4864 Salt Lake City UT. 84123 Salt Lake City UT. 84115 Valley Behavioral Health p 801.255.5131 p 801.678.3317 1020 S Main St 4460 S Highland Dr Ste 100 Ste 100 Johnston, Mark MD Kair, Kathryn M PhD Salt Lake City UT. 84101 Salt Lake City UT. 84124 Ascendant Behavioral 8160 S Highland Dr p 888.949.4864 p 888.949.4864 Health Ste 111 5383 S 900 E Sandy UT. 84093 Keeshin, Brooks R MD Johnson, Sara Jane LCSW Ste 103 p 801.792.4129 University of Utah Health The Childrens Center Salt Lake City UT. 84117 100 N Mario Capecchi Dr 350 S 400 E p 801.872.5516 Kaloudis, Kathleen M CMHC Salt Lake City UT. 84113 Salt Lake City UT. 84111 9190 S Highland Dr p 801.662.1000 p 801.582.5534 Jones, Georgia A LCSW Ste 210 4190 S Highland Dr Salt Lake City UT. 84124 Primary Childrens Hospital Ste 208 p 801.201.7050 3773 W 12600 S Salt Lake City UT. 84124 Riverton UT. 84065 p 801.467.6136 p 801.285.1285

257 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. University of Utah Health Kennedy, Anne BCBA King, Kelsey LCSW Kistler, Romeo LPC 50 N Medical Dr Utah Behavior Services Utah Behavior Services 11075 S State St Salt Lake City UT. 84132 5558 S 1900 W 5558 S 1900 W Ste 35 p 801.581.2205 Ste B Ste B Sandy UT. 84070 Salt Lake City UT. 84129 Taylorsville UT. 84118 p 801.717.7176 Primary Childrens Hospital p 801.255.5131 p 801.255.5131 81 N Mario Capecchi Dr Kivlovitz, Joshua LCSW Salt Lake City UT. 84113 6013 S Redwood Rd 6013 S Redwood Rd Valley Behavioral Health p 801.662.3606 Salt Lake City UT. 84123 Taylorsville UT. 84123 2948 S Redwood Rd p 801.255.5131 p 801.255.5131 West Valley City UT. 84119 8282 S 2200 W p 888.949.4864 West Jordan UT. 84088 Kennedy, Courtney BCBA Kingston, Joshua BCBA p 385.468.4580 ABS Kids ABS Kids Klein, Nanci C PhD 515 S 700 E 515 S 700 E UIPT Hospital Affiliation Ste 2A Ste 2A 265 E 100 S - Primary Childrens Hospital Salt Lake City UT. 84102 Salt Lake City UT. 84102 Ste 275 p 801.935.4171 p 801.935.4171 Salt Lake City UT. 84111 Kelen, Joyce A LCSW p 801.350.0116 Joyce Kelen Counseling and 6910 S Highland Dr 6910 S Highland Dr Consulting Ste 1 Ste 1 Kleinschmit, Kristi K MD 265 E 100 S Cottonwood Heights UT. 84121 Salt Lake City UT. 84121 University of Utah Health Ste 275 p 801.935.4946 p 801.935.4171 1138 E Wilmington Ave Salt Lake City UT. 84111 Salt Lake City UT. 84106 p 801.537.7523 Kennedy, Emily A SSW *Kingston, Merrill D PhD p 801.213.8845 Valley Behavioral Health Primary Childrens Hospital Keller, Rebecca BCBA 2472 S 300 E 5770 S 1500 W 1280 E Stringham Ave Utah Behavior Services Salt Lake City UT. 84115 Taylorsville UT. 84123 Salt Lake City UT. 84106 5558 S 1900 W p 888.949.4864 p 801.313.7770 p 801.581.7951 Ste B Salt Lake City UT. 84129 Ketchoyian, Jennifer Hospital Affiliation 50 N Medical Dr p 801.255.5131 LCSW - Primary Childrens Hospital Salt Lake City UT. 84132 Valley Behavioral Health p 801.585.1575 6013 S Redwood Rd 195 W 7200 S Kious, Brent M MD,PhD Salt Lake City UT. 84123 Midvale UT. 84047 University of Utah Health 501 S Chipeta Way p 801.255.5131 p 888.949.4864 1280 E Stringham Ave Salt Lake City UT. 84108 Salt Lake City UT. 84106 p 801.587.3287 Kemmochi, Tomohiro PSYD Kilpatrick, Lorraine S p 801.581.7951 University of Utah Health LCSW Wasatch Pediatrics - 50 N Medical Dr 6925 S Union Park Ctr 50 N Medical Dr Willow Creek Salt Lake City UT. 84132 Ste 500 Salt Lake City UT. 84132 7138 S 2000 E p 801.581.7951 Midvale UT. 84047 p 801.585.6387 Ste 106 p 801.566.2622 Salt Lake City UT. 84121 Hospital Affiliation 501 S Chipeta Way p 801.942.1800 - University of Utah Hospital Kim, Joseph U Phd Salt Lake City UT. 84108 University of Utah Health p 801.587.3287 Knaus, Erin R SSW Kendrick, Ernest J MD 50 N Medical Dr Valley Behavioral Health University of Utah Health Salt Lake City UT. 84132 Hospital Affiliation 1141 E 3900 S 1280 E Stringham Ave p 801.581.7951 - University of Utah Hospital Ste A250 Salt Lake City UT. 84106 Salt Lake City UT. 84124 p 801.581.7951 501 S Chipeta Way Kirschner, Rebecca CMHC p 888.949.4864 Salt Lake City UT. 84132 Valley Behavioral Health 1950 Cir of Hope Dr p 801.585.1575 12427 S Pasture Rd *Knight, Carin LCSW Salt Lake City UT. 84112 Ste 104 PCH Residential Home p 801.583.2500 Kimberlin-Flanders, Riverton UT. 84096 5770 S 1500 W Bldg C Cynthia LPC p 888.949.4864 Taylorsville UT. 84123 50 N Medical Dr Sundance Behavioral p 801.313.7954 Salt Lake City UT. 84132 Resources 4460 S Highland Dr p 801.581.7951 845 E 4800 S Ste 100 PCH Child Psych OP Ste 200 Salt Lake City UT. 84124 5770 S 1500 W 501 S Chipeta Way Murray UT. 84107 p 888.949.4864 Taylorsville UT. 84123 Salt Lake City UT. 84108 p 801.264.9522 p 801.313.7770 p 801.587.3287 Kirschner, Richard D CMHC Valley Behavioral Health Hospital Affiliation Hospital Affiliation 4460 S Highland Dr - Primary Childrens Hospital - University of Utah Hospital Ste 100 Salt Lake City UT. 84124 p 888.949.4864

258 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Knorr, James PhD 50 N Medical Dr Lake, Lorri CMHC 4460 S Highland Dr Summit Community Salt Lake City UT. 84132 MInd Body & Spirit Ste 100 Counseling p 801.585.1575 Counseling Salt Lake City UT. 84124 5689 S Redwood Rd 5801 S Fashion Blvd p 888.949.4864 Ste 27 501 S Chipeta Way Ste 200 Salt Lake City UT. 84123 Salt Lake City UT. 84108 Salt Lake City UT. 84107 Larsen, Danette CMHC p 801.266.2485 p 801.587.3287 p 801.920.3490 Life Stone Counseling Center 5991 S Redwood Rd Kooyman, Malorey BCBA Lakey, Kathleen F LCSW 613 E Fort Union Blvd Salt Lake City UT. 84123 ABS Kids Kathleen Fitzwilliam Lakey Ste 104 p 801.266.2485 515 S 700 E LLC Midvale UT. 84047 Ste 2A 275 E S Temple p 801.984.1717 Utah Neuropsychology Salt Lake City UT. 84102 Ste 101 Services p 801.935.4171 Salt Lake City UT. 84111 Larsen, Melissa L CMHC 7069 S Highland Dr p 385.218.8266 Valley Behavioral Health Ste 5 6910 S Highland Dr 12427 S Pasture Rd Salt Lake City UT. 84121 Ste 1 Lambert, Ruthann CSW Ste 104 p 801.441.0786 Salt Lake City UT. 84121 Valley Behavioral Health Riverton UT. 84096 p 801.935.4946 1020 S Main St p 888.949.4864 Knudson, Mani BCBA Ste 100 Utah Behavior Services Kraemer, Jennifer L LCSW Salt Lake City UT. 84101 4460 S Highland Dr 5558 S 1900 W Centered Approach p 888.949.4864 Ste 100 Ste B Counseling Salt Lake City UT. 84124 Salt Lake City UT. 84129 4190 S Highland Dr Lambert, Valerie K LCSW p 888.949.4864 p 801.255.5131 Ste 200 1060 E 1st S Salt Lake City UT. 84124 Ste 202 Larsen, Stephanie B LCSW 6013 S Redwood Rd p 385.282.3349 Salt Lake City UT. 84102 Valley Behavioral Health Salt Lake City UT. 84123 p 801.533.5632 1141 E 3900 S p 801.255.5131 Kramer, Andrea BCBA Ste A250 ABS Kids Lambertsen, Hope BCBA Salt Lake City UT. 84124 Kocherhans, Jeff C PhD 6910 S Highland Dr Utah Behavior Services p 888.949.4864 Comprehensive Ste 1 5558 S 1900 W Psychological Services Cottonwood Heights UT. 84121 Ste B Larson, Matt G LCSW 1208 E 3300 S p 801.935.4946 Salt Lake City UT. 84129 Matt Larson Psychotherapy Salt Lake City UT. 84106 p 801.255.5131 & Associates p 801.483.1600 Kravitz, Kent C LCSW 1226 W S Jordan Pkwy Bldg Valley Behavioral Health 6013 S Redwood Rd A Kohler, Shawn J MD 1020 S Main St Salt Lake City UT. 84123 South Jordan UT. 84095 University of Utah Health Ste 100 p 801.255.5131 p 801.599.6396 154 E Myrtle Ave Salt Lake City UT. 84101 Salt Lake City UT. 84107 p 888.949.4864 Lang, Emily CSW 24 S 600 E p 801.581.2628 Valley Behavioral Health Ste 6 Kronmiller, Kalli CMHC 1020 S Main St Salt Lake City UT. 84102 50 N Medical Dr Valley Behavioral Health Ste 100 p 801.599.6396 Salt Lake City UT. 84132 195 W 7200 S Salt Lake City UT. 84101 p 801.585.1575 Midvale UT. 84047 p 888.949.4864 Laskowski, Thomas M LCSW p 888.949.4864 Thomas M Laskowski, LCSW 501 S Chipeta Way 2948 S Redwood Rd 1174 E Graystone Way Salt Lake City UT. 84108 Kulow, Kacylia BCBA West Valley City UT. 84119 Ste 6 p 801.585.1575 Utah Behavior Services p 888.949.4864 Salt Lake City UT. 84106 5558 S 1900 W p 801.696.5538 51 W 3900 S Ste B Lange, Christopher CMHC Salt Lake City UT. 84107 Salt Lake City UT. 84129 Valley Behavioral Health 3108 E 3300 S p 801.585.1575 p 801.255.5131 1020 S Main St Salt Lake City UT. 84109 Ste 100 p 801.656.5538 Hospital Affiliation 6013 S Redwood Rd Salt Lake City UT. 84101 - University of Utah Hospital Salt Lake City UT. 84123 p 888.949.4864 Lasley, Linda K LCSW p 801.255.5131 Valley Behavioral Health Kondo, Douglas G MD Larrabee, Angelique R 1020 S Main St University of Utah Health Kweon, Sanghee APRN CMHC Ste 100 1280 E Stringham Ave Valley Behavioral Health Valley Behavioral Health Salt Lake City UT. 84101 Salt Lake City UT. 84106 2948 S Redwood Rd 12427 S Pasture Rd p 888.949.4864 p 801.581.7951 West Valley City UT. 84119 Ste 104 p 888.949.4864 Riverton UT. 84096 p 888.949.4864

259 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 12427 S Pasture Rd Lee, Jennifer BCBA Levstek Caplin, Deirdre A Lieu, Nancy LCSW Ste 104 Utah Behavior Services PhD Centered Approach Riverton UT. 84096 5558 S 1900 W University of Utah Health Counseling p 888.949.4864 Ste B 100 N Mario Capecchi Dr 4190 S Highland Dr Salt Lake City UT. 84129 Salt Lake City UT. 84113 Ste 220 4460 S Highland Dr p 801.255.5131 p 801.313.7711 Salt Lake City UT. 84124 Ste 100 p 385.282.3349 Salt Lake City UT. 84124 6013 S Redwood Rd 50 N Medical Dr p 888.949.4864 Salt Lake City UT. 84123 Salt Lake City UT. 84132 Lin, Anne G MD p 801.255.5131 p 801.581.2205 University of Utah Health Lawrence, Melanie A LCSW 1280 E Stringham Ave Valley Behavioral Health Leggitt, Valerie LCSW 81 N Mario Capecchi Dr Salt Lake City UT. 84106 3809 W 6200 S Aspen Ridge Counseling Salt Lake City UT. 84113 p 801.581.7951 Salt Lake City UT. 84129 11075 S State St p 801.213.3599 p 888.949.4864 Ste 35 50 N Medical Dr Sandy UT. 84070 Levy, Elizabeth PhD Salt Lake City UT. 84132 4460 S Highland Dr p 801.501.8444 Valley Behavioral Health p 801.585.1575 Ste 100 195 W 7200 S Salt Lake City UT. 84124 1561 W 7000 S Midvale UT. 84047 501 S Chipeta Way p 888.949.4864 Ste 200 p 888.949.4864 Salt Lake City UT. 84108 West Jordan UT. 84084 p 801.587.3287 Laws, Rebecca B CMHC p 801.990.4300 Lewis, Benjamin R MD Valley Behavioral Health University of Utah Health Hospital Affiliation 1020 S Main St 2711 S 8500 W 1280 E Stringham Ave - University of Utah Hospital Ste 100 Magna UT. 84044 Salt Lake City UT. 84106 Salt Lake City UT. 84101 p 801.990.4300 p 801.581.7951 Linda, Linda M ACMHC p 888.949.4864 Valley Behavioral Health 2880 W 4700 S 50 N Medical Dr 2948 S Redwood Rd LeCluyse, Christina LCSW Ste G-1 Salt Lake City UT. 84132 West Valley City UT. 84119 Child and Family Salt Lake City UT. 84129 p 801.585.1575 p 888.949.4864 Empowerment Services p 801.990.4300 1578 W 1700 S 501 S Chipeta Way Lindsey, Kendra LCSW Ste 200 411 W 7200 S Salt Lake City UT. 84108 Adult Behavioral Health Salt Lake City UT. 84104 Ste 304 p 801.587.3287 JVMC-WVC - OP p 801.972.2711 Midvale UT. 84047 4052 W Pioneer Pkwy p 801.990.4300 Hospital Affiliation Ste 105 Le, Phuong LCSW - University of Utah Hospital West Valley City UT. 84120 Adult Behavioral Health - Lehman, Mary E LCSW p 801.554.3420 South Bangerter Mary Eileen Lehman, LCSW Lewis, Gina 13348 S Market Ctr Dr 4055 S 700 E Senior Behavioral Health Lindstrom, Shanna LCSW Ste 220 Ste 102 SLC - IP Ascendant Behavioral Riverton UT. 84065 Salt Lake City UT. 84107 1050 E S Temple 2nd Fl Health p 801.964.3111 p 801.201.7661 Salt Lake City UT. 84102 5383 S 900 E p 801.350.4111 Ste 103 Jordan Valley Internal Lemmon, Kristie APRN Salt Lake City UT. 84117 Medicine Journeys Mental Health Adult Behavioral Health p 801.872.5516 3570 W 9000 S Services JVMC-WVC - IP Ste 100 9253 S Redwood Rd 3460 S 4155 W 5th Fl Lineback, Holly H LPC West Jordan UT. 84088 Ste B West Valley City UT. 84120 North Star Counseling p 801.569.2384 West Jordan UT. 84088 p 801.964.3111 1104 Ashton Ave p 801.568.2898 Ste 103 Adult Behavioral Health Lewis, Neva P LCSW Salt Lake City UT. 84106 JVMC-WVC - OP Lentchner, Kari BCBA Valley Behavioral Health p 801.436.6796 4052 W Pioneer Pkwy ABS Kids 1020 S Main St Ste 105 515 S 700 E Ste 200 Lines, Robin MD Salt Lake City UT. 84120 Ste 2A Salt Lake City UT. 84101 Adult Behavioral Health p 801.554.3420 Salt Lake City UT. 84102 p 888.949.4864 (JVMC-WVC - IP) p 801.935.4171 3460 S 4155 W 5th Fl Hospital Affiliation Leybas, Ryan L LCSW West Valley City UT. 84120 - Mountain West Medical Leon, Kameron R SSW SLC Mental Health p 801.964.3111 Center Valley Behavioral Health 1174 E Graystone Way 2472 S 300 E Ste 6 Hospital Affiliation Salt Lake City UT. 84115 Salt Lake City UT. 84106 - Jordan Valley Medical p 888.949.4864 p 801.277.2129 Center West Valley Campus

260 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Linnell, Randy S LCSW Granger Medical Clinic 3730 W 4700 S 1950 Cir of Hope Dr Intermountain Center for 12391 S 4000 W Taylorsville UT. 84129 Salt Lake City UT. 84112 Cognitive Therapy Riverton UT. 84065 p 801.213.9200 p 801.583.2500 111 E 5600 S p 801.302.1700 Ste 300 5126 W Daybreak Pkwy 50 N Medical Dr Murray UT. 84107 Granger Medical Ste 600 Salt Lake City UT. 84132 p 801.859.9238 Specialists South Jordan UT. 84009 p 801.585.1575 12391 S 4000 W p 801.213.4500 Litchfield, Aubrey LPC Riverton UT. 84096 501 S Chipeta Way Valley Behavioral Health p 801.302.1700 5126 W Daybreak Pkwy Salt Lake City UT. 84108 3809 W 6200 S South Jordan UT. 84009 p 801.587.3287 Salt Lake City UT. 84129 2965 W 3500 S p 801.213.4500 p 888.949.4864 West Valley City UT. 84119 Lowry, Suzanne CMHC p 801.965.3600 555 Foothill Dr South Point Counseling Little, Matthew A RN Ste 301 1206 W S Jordan Pkwy Valley Behavioral Health 3181 W 9000 S Salt Lake City UT. 84112 Ste D 1141 E 3900 S West Jordan UT. 84088 p 801.581.8000 South Jordan UT. 84095 Ste A250 p 801.569.5600 p 801.302.3801 Salt Lake City UT. 84124 555 Foothill Dr p 888.949.4864 999 E Murray Holladay Rd Salt Lake City UT. 84112 Lublin, Kristine Louise Ste 207 p 801.581.8000 LPC Livingston, Derek CMHC Holladay UT. 84117 Valley Behavioral Health Aspen Ridge Counseling p 801.268.2584 7495 S State St 1141 E 3900 S 11075 S State St Midvale UT. 84047 Ste A250 Ste 33 Granger Medical Clinic p 801.213.9400 Salt Lake City UT. 84124 Sandy UT. 84070 999 Murray Holladay Rd p 888.949.4864 p 801.501.8444 Ste 207 Hospital Affiliation Salt Lake City UT. 84117 - University of Utah Hospital 3809 W 6200 S Lloyd, Kendall LCSW p 801.268.2584 Taylorsville UT. 84129 Wasatch Pediatrics - Lovelace, Scott LCMHC p 888.949.4864 Willow Creek Lopes, Erika BCBA Utah Behavior Services 7138 S 2000 E ABS Kids 5558 S 1900 W Luker, Brenda A LCSW Ste 106 515 S 700 E Ste B Comprehensive Salt Lake City UT. 84121 Ste 2A Salt Lake City UT. 84129 Psychological Services p 801.942.1800 Salt Lake City UT. 84102 p 801.255.5131 1208 E 3300 S p 801.935.4171 Salt Lake City UT. 84106 Lofthouse, Chelsea ACMHC 6013 S Redwood Rd p 801.483.1600 Utah Behavior Services 6910 S Highland Dr Salt Lake City UT. 84123 5558 S 1900 W Ste 1 p 801.255.5131 3725 W 4100 S Ste B Cottonwood Heights UT. 84121 West Valley City UT. 84119 Salt Lake City UT. 84129 p 801.935.4946 Lowe, Kori BCBA p 801.965.3759 p 801.255.5131 Utah Behavior Services Lopez, Kitrina BCBA 5558 S 1900 W Luna, Janette M LCSW 6013 S Redwood Rd Utah Behavior Services Ste B Utah Behavior Services Salt Lake City UT. 84123 5558 S 1900 W Salt Lake City UT. 84129 5558 S 1900 W p 801.255.5131 Ste B p 801.255.5131 Ste B Salt Lake City UT. 84129 Salt Lake City UT. 84129 Longshaw, Alexandra E SSW p 801.255.5131 6013 S Redwood Rd p 801.255.5131 Valley Behavioral Health Salt Lake City UT. 84123 195 W 7200 S 6013 S Redwood Rd p 801.255.5131 6013 S Redwood Rd Midvale UT. 84047 Salt Lake City UT. 84123 Salt Lake City UT. 84123 p 888.949.4864 p 801.255.5131 Lowe, Tiffany L LCSW p 801.255.5131 Valley Behavioral Health Looye, Michelle D LCSW Lopez, Marta LCSW 2948 S Redwood Rd Clinical Consultants Granger Medical University of Utah Health West Valley City UT. 84119 7601 S Redwood Rd Bldg E Specialists 1280 E Stringham Ave p 888.949.4864 West Jordan UT. 84084 1160 E 3900 S Salt Lake City UT. 84106 p 801.233.8670 Ste 1000 p 801.213.8841 Lowry, Michael R MD Salt Lake City UT. 84124 University of Utah Health Lund, Lori LMFT p 801.262.1771 1525 W 2100 S 1280 E Stringham Ave Ascendant Behavioral Salt Lake City UT. 84119 Salt Lake City UT. 84106 Health 11724 S State St p 801.213.9900 p 801.581.7951 5383 S 900 E Draper UT. 84020 Ste 103 p 801.576.2050 Salt Lake City UT. 84117 p 801.872.5516

261 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Lund, Stacy L LCSW Madsen, Annette LPN Mai, Trinh LCSW Malouf, John PhD Valley Behavioral Health Valley Behavioral Health University Of Utah Health Valley Behavioral Health 1020 S Main St 1020 S Main St 615 S Arapeen Dr 12427 S Pasture Rd Ste 218 Ste 100 Ste 100 Ste 104 Salt Lake City UT. 84101 Salt Lake City UT. 84101 Salt Lake City UT. 84108 Riverton UT. 84096 p 888.949.4864 p 888.949.4864 p 801.581.7761 p 888.949.4864

Lundahl, Brad W PhD Madsen, Curtis R CMHC Hospital Affiliation 4460 S Highland Dr Compass Counseling and Valley Behavioral Health - University of Utah Hospital Ste 100 Consulting 1020 S Main St Salt Lake City UT. 84124 4000 S 700 E Ste 100 Makowski, Alexandra BCBA p 888.949.4864 Ste 9 Salt Lake City UT. 84101 ABS Kids Salt Lake City UT. 84107 p 888.949.4864 515 S 700 E Hospital Affiliation p 801.639.9544 Ste 2A - University of Utah Hospital Madsen, Denise CMHC Salt Lake City UT. 84102 Lundberg, Kelly J PhD Jordan West Family p 801.935.4171 Manning, Taylor C LCSW University of Utah Health Counseling Compass Counseling and 1280 E Stringham Ave 9263 Redwood Rd Bldg 8 6910 S Highland Dr Consulting Salt Lake City UT. 84106 West Jordan UT. 84088 Ste 1 4000 S 700 E p 801.581.7951 p 801.566.0749 Cottonwood Heights UT. 84121 Ste 9 p 801.935.4946 Salt Lake City UT. 84107 1950 Cir of Hope Dr Madsen, Julie LCSW p 801.639.9544 Salt Lake City UT. 84112 Herriman Counseling Malm, Karen W PhD p 801.583.2500 Services Summit Community Manov, Ludmil K MD 4831 W Copper Oaks Dr Counseling 1387 S 1100 E 50 N Medical Dr Herriman UT. 84096 5689 S Redwood Rd Salt Lake City UT. 84105 Salt Lake City UT. 84132 p 801.520.5724 Ste 27 p 801.463.4963 p 801.581.7951 Salt Lake City UT. 84123 5627 W 13100 St p 801.266.2485 Mansour, Emma PhD Lyon, McCall PhD Herriman UT. 84096 Life Matters: Counseling The Childrens Center p 801.520.5724 5991 S Redwood Rd and Psychological Services 350 S 400 E Salt Lake City UT. 84123 265 E 100 S Salt Lake City UT. 84111 Madsen, Kevin LCSW p 801.266.2485 Ste 250 p 801.582.5534 Ascendant Behavioral Salt Lake City UT. 84111 Health Malmberg, Jan M LPC p 801.483.2447 5242 S 4820 W 5383 S 900 E 7321 S State St Salt Lake City UT. 84118 Ste 103 Ste A&B March, John T CMHC p 801.966.4251 Salt Lake City UT. 84117 Midvale UT. 84047 Valley Behavioral Health p 801.872.5516 p 801.859.3523 1020 S Main St MacDougall, Mindy LCSW Ste 100 124 S 400 E Madsen, Sara BCBA Malmstrom, Lynette M LCSW Salt Lake City UT. 84101 Ste 301 ABS Kids 522 E 2100 S p 888.949.4864 Salt Lake City UT. 84111 515 S 700 E Salt Lake City UT. 84106 p 801.322.3923 Ste 2A p 801.486.4444 1020 S Main St Salt Lake City UT. 84102 Ste 300 Macfarlane, J R LCSW p 801.935.4171 Malone, Sara BCBA Salt Lake City UT. 84101 Interface Psychological ABS Kids p 888.949.4864 Services Utah Behavior Services 515 S 700 E 2180 E 4500 S 5558 S 1900 W Ste 2A 195 W 7200 S Ste 245 Ste B Salt Lake City UT. 84102 Midvale UT. 84047 Salt Lake City UT. 84117 Salt Lake City UT. 84129 p 801.935.4171 p 888.949.4864 p 801.328.8817 p 801.255.5131 6910 S Highland Dr 550 W 700 S Macfarlane, JeNae CMHC 6013 S Redwood Rd Ste 1 Salt Lake City UT. 84101 Next Level Recovery Salt Lake City UT. 84123 Cottonwood Heights UT. 84121 p 888.949.4864 6771 S 900 E p 801.255.5131 p 801.935.4946 Midvale UT. 84047 Marchant, Jennifer LCSW p 801.386.9799 ABS Kids Maloof, Paula L LCSW Jennifer Marchant LCSW 6910 S Highland Dr Paula L Maloof LCSW Inc 3627 W 13100 St Macfarlane, Lindsey A Ste 1 1399 S 700 E Herriman UT. 84096 LCSW Cottonwood Heights UT. 84121 Ste 17 p 801.520.5724 Valley Behavioral Health p 801.935.4946 Salt Lake City UT. 84105 4460 S Highland Dr p 801.485.7441 Ste 100 Salt Lake City UT. 84124 p 888.949.4864

262 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Marcum, James M MD 4745 S 3200 W May, Katherine M LCSW 5991 S Redwood Rd Cedar Psychiatry Salt Lake City UT. 84129 Compass Counseling and Salt Lake City UT. 84123 1208 E 3300 S p 801.964.6214 Consulting p 801.266.2485 Salt Lake City UT. 84106 4000 S 700 E p 801.369.8989 Martini, Richard D MD Ste 9 McDonald, Tyler CMHC University of Utah Health Salt Lake City UT. 84107 Valley Behavioral Health 721 E 12200 S 100 N Mario Capecchi Dr p 801.639.9544 280 E 600 S Draper UT. 84020 Salt Lake City UT. 84113 Salt Lake City UT. 84111 p 801.369.8989 p 801.313.7711 McCarthey, Rachele M MD p 888.949.4864 University of Utah Health Margolis, Amber LCSW Primary Childrens Hospital 1280 E Stringham Ave McFadden, Molly Q LCSW University of Utah Health 5770 S 1500 W Salt Lake City UT. 84106 Kaizen Center for Mental 1280 E Stringham Ave Taylorsville UT. 84123 p 801.581.7951 Health Salt Lake City UT. 84106 p 801.313.7770 1398 E Luck Ln p 801.581.2000 50 N Medical Dr Salt Lake City UT. 84106 81 N Mario Capecchi Dr Salt Lake City UT. 84132 p 801.416.0862 1525 W 2100 S Salt Lake City UT. 84113 p 801.585.1575 Salt Lake City UT. 84119 p 801.662.5592 University of Utah Health p 801.213.9900 501 S Chipeta Way 1525 W 2100 S Hospital Affiliation Salt Lake City UT. 84108 Salt Lake City UT. 84119 3730 W 4700 S - Primary Childrens Hospital p 801.587.3287 p 801.213.8841 Taylorsville UT. 84129 p 801.213.9200 Mathewson, Julie LCSW Hospital Affiliation 3730 W 4700 S Next Level Recovery - University of Utah Hospital Taylorsville UT. 84129 5126 W Daybreak Pkwy 6771 S 900 E p 801.213.9200 Ste 600 Midvale UT. 84047 McConnell, Scott CMHC South Jordan UT. 84009 p 801.386.9799 The Green House for Growth 5126 W Daybreak Pkwy p 801.213.4500 & Learning South Jordan UT. 84009 Mathis, Nicholas CMHC 1325 W S Jordan Pkwy p 801.213.4500 555 Foothill Dr Neurobehavioral Center For Ste 102 Ste 301 Growth South Jordan UT. 84095 7495 S State St Salt Lake City UT. 84112 370 E S Temple p 801.208.8838 Midvale UT. 84047 p 801.581.8000 Ste 175 p 801.213.9400 Salt Lake City UT. 84111 McCormick, Sarah H PhD 7495 S State St p 801.683.1062 University of Utah Health McGarrity, Larissa A PhD Midvale UT. 84047 1138 E Wilmington Ave University of Utah Health p 801.213.9400 Mattingly, Mary BCBA Salt Lake City UT. 84106 30 N 1900 E Rm 1B620 ABS Kids p 801.213.8845 Salt Lake City UT. 84132 Marriott, Caroline A LCSW 515 S 700 E p 801.581.6228 Compass Counseling and Ste 2A 1280 E Stringham Ave Consulting Salt Lake City UT. 84102 Salt Lake City UT. 84106 Hospital Affiliation 4000 S 700 E p 801.935.4171 p 801.213.8841 - University of Utah Hospital Ste 9 Salt Lake City UT. 84107 6910 S Highland Dr 555 Foothill Dr McGill, Katie MSW p 801.639.9544 Ste 1 Salt Lake City UT. 84112 Utah Behavior Services Salt Lake City UT. 84121 p 801.581.8000 5558 S 1900 W Martin, Ann LPC p 801.935.4171 Ste B Comprehensive Hospital Affiliation Salt Lake City UT. 84129 Psychological Services Maxwell, Kendra BCBA - University of Utah Hospital p 801.255.5131 1208 E 3300 S Utah Behavior Services Salt Lake City UT. 84106 5558 S 1900 W McCoy, Margaret APRN 6013 S Redwood Rd p 801.483.1600 Ste B Sundance Behavioral Salt Lake City UT. 84123 Taylorsville UT. 84118 Resources p 801.255.5131 Martineau, Karl T DO p 801.255.5131 845 E 4800 S MountainStar Behavioral Ste 200 McGuire, Amy BCBA Health 6013 S Redwood Rd Salt Lake City UT. 84107 Utah Behavior Services 1200 E 3900 S Taylorsville UT. 84123 p 801.264.9522 5558 S 1900 W Salt Lake City UT. 84124 p 801.255.5131 Ste B p 801.268.7111 McDonald, Jenna CSW Salt Lake City UT. 84129 Maxwell, Miranda L CSW Summit Community p 801.255.5131 Martinez, Mayra CSW Valley Behavioral Health Counseling Community Health Centers 280 E 600 S 5689 S Redwood Rd 6013 S Redwood Rd 220 W 7200 S Salt Lake City UT. 84111 Ste 27 Salt Lake City UT. 84123 Ste A p 888.949.4864 Salt Lake City UT. 84123 p 801.255.5131 Midvale UT. 84047 p 801.266.2485 p 801.566.5494

263 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. McIntosh, J M MD 4460 S Highland Dr *Meek, Matthew R MD 50 N Medical Dr University of Utah Health Ste 100 PCH RESIDENTIAL TRMNT-ADOL Salt Lake City UT. 84132 501 S Chipeta Way Salt Lake City UT. 84124 5770 S 1500 W p 801.585.6387 Salt Lake City UT. 84108 p 888.949.4864 Taylorsville UT. 84123 p 801.583.2500 p 801.313.7940 729 S Arapeen Dr Mcglade, Erin C Phd Salt Lake City UT. 84108 Hospital Affiliation University of Utah Health Hospital Affiliation p 801.585.6387 - University of Utah Hospital 50 N Medical Dr - Primary Childrens Hospital Salt Lake City UT. 84132 Hospital Affiliation McLaren, Kirsty LCSW p 801.581.7951 Meier, Heather BCBA - University of Utah Hospital Next Level Recovery ABS Kids 6771 S 900 E 501 S Chipeta Way 515 S 700 E Merrill, Jordan W MD Midvale UT. 84047 Salt Lake City UT. 84132 Ste 2A University of Utah Health p 801.386.9799 p 801.585.1575 Salt Lake City UT. 84102 Department of Psychiatry p 801.935.4171 50 N Medical Dr McMaster, James H LCSW Hospital Affiliation Salt Lake City UT. 84132 James H McMaster LCSW - University of Utah Hospital 6910 S Highland Dr p 801.581.7951 8545 S Redwood Rd Unit B Ste 1 West Jordan UT. 84084 Mcguinness, D P CMHC Cottonwood Heights UT. 84121 University of Utah Health p 801.455.8159 Valley Behavioral Health p 801.935.4946 UNI Chipeta Outpatient 2472 S 300 E Clinic - Adult McMaster, Triona LCSW Salt Lake City UT. 84115 Melling, Nicole Y APRN 501 S Chipeta Way Life Stone Center p 888.949.4864 Valley Behavioral Health Salt Lake City UT. 84108 7300 S 300 W 2948 S Redwood Rd p 801.585.1575 Ste 101 Mclaughlin Wilking, West Valley City UT. 84119 Midvale UT. 84047 Heather LCSW p 888.949.4864 University of Utah Health p 801.984.1717 Valley Behavioral Health 525 E 100 S 2948 S Redwood Rd 3809 W 6200 S Ste 5000 McNaught, Jennifer A LPC West Valley City UT. 84119 Salt Lake City UT. 84129 Salt Lake City UT. 84102 9980 S 300 W p 888.949.4864 p 888.949.4864 p 801.585.1212 Ste 200 Sandy UT. 84070 Meade, Gerard (Jerry) J Melton, Jeri L APRN Meservy, James B LCSW p 801.706.9272 LCSW Valley Behavioral Health Clinical Consultants Lifeline Christian 2948 S Redwood Rd 7601 S Redwood Rd Bldg E McPherson-Cutler, Amanda Counseling Center West Valley City UT. 84119 West Jordan UT. 84084 L LMSW 4131 W 8200 S p 888.949.4864 p 801.233.8670 7105 S Highland Dr West Jordan UT. 84088 Ste 202 p 801.280.8111 *Mendenhall, Keeley J LCSW Messick, Daniel L LCSW Salt Lake City UT. 84121 Primary Childrens Valley Behavioral Health p 208.918.1199 Measom, Michael O MD Behavioral Health 4460 S Highland Dr Center for Human Potential 5770 S 1500 W Ste 100 McQuade, Shannon M LCSW 265 E 100 S Salt Lake City UT. 84123 Salt Lake City UT. 84124 Real Caring Integrative Ste 250 p 801.265.3412 p 888.949.4864 Therapy Salt Lake City UT. 84111 1151 E 3900 S p 801.483.2447 Mendoza, Emily BCaBA Metos, Athena LCSW Ste B199 Parkview Bldg B ABS Kids 24 S 600 E Salt Lake City UT. 84124 Hospital Affiliation 6910 S Highland Dr Ste 2 p 801.853.8744 - University of Utah Hospital Ste 1 Salt Lake City UT. 84102 Cottonwood Heights UT. 84121 p 801.413.3901 McStotts, Kelli CMHC Mecham, Shelli F LCSW p 801.935.4946 Summit Community Valley Behavioral Health Metzger, Debbie BCBA Counseling 12427 S Pasture Rd Merkley, Patricia L LCSW Utah Behavior Services 5689 S Redwood Rd Ste 104 Ascendant Behavioral 5558 S 1900 W Ste 27 Riverton UT. 84096 Health Ste B Salt Lake City UT. 84123 p 888.949.4864 5383 S 900 E Taylorsville UT. 84118 p 801.266.2485 Ste 103 p 801.255.5131 4460 S Highland Dr Salt Lake City UT. 84117 5991 S Redwood Rd Ste 100 p 801.872.5516 6013 S Redwood Rd Salt Lake City UT. 84123 Salt Lake City UT. 84124 Taylorsville UT. 84123 p 801.266.2485 p 888.949.4864 Merkley, Tricia Phd p 801.255.5131 University Of Utah Health Mccune, Tara J CMHC Medina-Salvatore, Nicole 175 N Medical Dr E Michaels, Gary CMHC Valley Behavioral Health PSYD Salt Lake City UT. 84132 Jordan West Family 12427 S Pasture Rd Neurobehavioral Center For p 801.585.7575 Counseling Ste 104 Growth 9263 Redwood Rd Bldg 8 Riverton UT. 84096 370 E South Temple Ste B p 888.949.4864 Ste 175 West Jordan UT. 84088 Salt Lake City UT. 84111 p 801.566.0749 p 801.683.1062 264 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Mickens, Melody Phd Miller, Robert LPC Moench, Matthew L MD 6910 S Highland Dr University of Utah Health Ascendant Behavioral University of Utah Health Ste 1 1280 E Stringham Ave Health 1280 E Stringham Ave Cottonwood Heights UT. 84121 Salt Lake City UT. 84106 5383 S 900 E Salt Lake City UT. 84106 p 801.935.4946 p 801.581.6228 Ste 103 p 801.581.7951 Salt Lake City UT. 84117 Moretti, Paolo M MD 30 N 1900 E Rm 1B620 p 801.872.5516 501 S Chipeta Way University of Utah Health Salt Lake City UT. 84132 Salt Lake City UT. 84108 175 N Medical Dr E p 801.581.6228 Milne, Wade O LCSW p 801.587.3287 Salt Lake City UT. 84132 University of Utah Health p 801.585.7575 Hospital Affiliation 501 S Chipeta Way Hospital Affiliation - University of Utah Hospital Salt Lake City UT. 84108 - University of Utah Hospital 50 N Medical Dr p 801.585.1575 Salt Lake City UT. 84132 Mickey, Brian J MD,PhD Mohlman, Laura LCSW p 801.585.6387 University of Utah Health Hospital Affiliation Alpine Center for Personal 1280 E Stringham Ave - St George Regional Hospital Growth 729 S Arapeen Dr Salt Lake City UT. 84106 5689 S Redwood Rd Salt Lake City UT. 84108 p 801.581.7951 Miranda, Michelle PhD Ste 30 p 801.585.6387 University of Utah Health Salt Lake City UT. 84123 1950 Cir of Hope Dr 175 N Medical Dr E p 801.268.1715 Hospital Affiliation Salt Lake City UT. 84112 Salt Lake City UT. 84132 - University of Utah Hospital p 801.583.2500 p 801.585.7575 Monson, Marette LCSW Center for Counseling Morgan, Ryan W MSW 50 N Medical Dr 50 N Medical Dr Excellence Integrum Psychotherapy Salt Lake City UT. 84132 Salt Lake City UT. 84132 2180 E 4500 S 1174 E Graystone Way p 801.585.1575 p 801.585.6387 Ste 105 Ste 6 Salt Lake City UT. 84117 Salt Lake City UT. 84106 501 S Chipeta Way 729 S Arapeen Dr p 801.980.1343 p 801.682.1715 Salt Lake City UT. 84108 Salt Lake City UT. 84108 p 801.587.3287 p 801.585.6387 Montoya Duran, Maria SSW Morgan, Spencer G LCSW Valley Behavioral Health Jordan West Family Hospital Affiliation Mitchell, Jennifer PhD 1141 E 3900 S Counseling - University of Utah Hospital The Childrens Center Ste A250 9263 B Redwood Rd 350 S 400 E Salt Lake City UT. 84124 West Jordan UT. 84088 Midgley, Lydia LCSW Salt Lake City UT. 84111 p 888.949.4864 p 801.566.0749 Helping Hands Counseling p 801.582.5534 1108 W S Jordan Pkwy Moody, Jessica M LCSW Morimoto, Sarah S PsyD Ste B Mitchell, Loren CMHC Life Matters Counseling & University of Utah Health South Jordan UT. 84095 Sundance Behavioral Health Center 50 N Medical Dr p 801.755.5531 Resources 2225 E Murray-Holladt Rd Salt Lake City UT. 84132 845 E 4800 S Ste 112 p 801.581.7951 Miles, Michael B SSW Ste 200 Salt Lake City UT. 84117 Valley Behavioral Health Murray UT. 84107 p 801.313.0555 525 E 100 S 1141 E 3900 S p 801.264.9522 Ste 5000 Ste A160 3336 S Pioneer Pkwy Salt Lake City UT. 84102 Salt Lake City UT. 84124 Mitchell, Merikay CMHC Ste 201 p 801.585.1212 p 888.949.4864 Merikay Mitchell LLC West Valley City UT. 84120 2225 E Murray Holladay Rd p 801.313.0555 Morphet, Cari Y CMHC Miller, Leslee LCSW Ste 108 Caring Journey Counseling Sugarhouse Counseling Salt Lake City UT. 84117 Moon, Emilee SSW 151 E 6100 S Center p 385.313.0571 Valley Behavioral Health Ste 315 1415 E 2100 S 4460 S Highland Dr Salt Lake City UT. 84107 Salt Lake City UT. 84105 Ascendant Behavioral Ste 100 p 801.747.1754 p 801.558.1460 Health Salt Lake City UT. 84124 5383 S 900 E p 888.949.4864 Morris, Josh Phd Miller, Maria M CSW Ste 103 University Of Utah Health Valley Behavioral Health Salt Lake City UT. 84117 Moosman, Julie BCBA 1280 E Stringham Ave 1020 S Main St p 801.872.5516 ABS Kids Salt Lake City UT. 84106 Ste 300 515 S 700 E p 801.581.7951 Salt Lake City UT. 84101 Mockli, Cherie LCSW Ste 2A p 888.949.4864 Compass Counseling and Salt Lake City UT. 84102 154 E Myrtle Ave Consulting p 801.935.4171 Salt Lake City UT. 84107 4000 S 700 E p 801.581.2628 Ste 9 Salt Lake City UT. 84107 p 801.639.9544

265 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 1950 Cir of Hope Dr 5126 W Daybreak Pkwy 3730 W 4700 S 50 N Medical Dr Salt Lake City UT. 84112 South Jordan UT. 84009 Taylorsville UT. 84129 Salt Lake City UT. 84132 p 801.583.2500 p 801.213.4500 p 801.213.9200 p 801.585.1575

50 N Medical Dr PCH Residential Home 5126 W Daybreak Pkwy 501 S Chipeta Way Salt Lake City UT. 84132 5770 S 1500 W Bldg C Ste 600 Salt Lake City UT. 84108 p 801.581.7951 Taylorsville UT. 84123 South Jordan UT. 84009 p 801.587.3287 p 801.313.7954 p 801.213.4500 501 S Chipeta Way Hospital Affiliation Salt Lake City UT. 84108 Primary Childrens Hospital 5126 W Daybreak Pkwy - University of Utah Hospital p 801.583.2500 5770 S 1500 W South Jordan UT. 84009 Taylorsville UT. 84123 p 801.213.4500 Musso, Alison PhD 525 E 100 S p 801.313.7770 Sundance Behavioral Ste 5000 555 Foothill Dr Resources Salt Lake City UT. 84102 Hospital Affiliation Ste 301 845 E 4800 S p 801.585.1212 - University of Utah Hospital Salt Lake City UT. 84112 Ste 200 p 801.581.8000 Murray UT. 84107 Hospital Affiliation Moss, Terri LMFT p 801.264.9522 - University of Utah Hospital Ascendant Behavioral 555 Foothill Dr Health Salt Lake City UT. 84112 Nadalsky, Michelle Morris, Justin E LCSW 5383 S 900 E p 801.581.8000 BCBA,SSW Valley Behavioral Health Ste 103 Utah Behavior Services 6856 S 700 E Salt Lake City UT. 84117 7495 S State St 5558 S 1900 W Midvale UT. 84047 p 801.872.5516 Midvale UT. 84047 Ste B p 888.949.4864 p 801.213.9400 Salt Lake City UT. 84129 Moulton, David L MD p 801.255.5131 Morris, Maria A SSW University of Utah Health Multicultural Counseling Valley Behavioral Health 50 N Medical Dr Center 6013 S Redwood Rd 1020 S Main St Salt Lake City UT. 84132 7625 S 3200 W Salt Lake City UT. 84123 Ste 218 p 801.581.7951 Ste 2 p 801.255.5131 Salt Lake City UT. 84101 West Jordan UT. 84084 p 888.949.4864 Hospital Affiliation p 801.915.0359 Navas, Barbara BCBA - University of Utah Hospital ABS Kids Morris, Tracee BCBA Murdock, Brian B LPC 515 S 700 E ABS Kids Moulton, Emily Phd Redwood Therapy Group Ste 2A 515 S 700 E University of Utah Health 8541 S Redwood Rd Salt Lake City UT. 84102 Ste 2A 81 N Mario Capecchi Dr Ste C p 801.935.4946 Salt Lake City UT. 84102 Salt Lake City UT. 84113 West Jordan UT. 84088 p 801.935.4171 p 801.587.2255 p 801.878.4220 6910 S Highland Dr Ste 1 6910 S Highland Dr Hospital Affiliation Murphy, H Nicole BCBA Cottonwood Heights UT. 84121 Ste 1 - University of Utah Hospital ABS Kids p 801.935.4946 Cottonwood Heights UT. 84121 515 S 700 E p 801.935.4946 Mower, Richard K PhD Ste 2A Neff, Michal A CSW,SUDC Richard King Mower Salt Lake City UT. 84102 Utah Behavior Services Morse, Leigh Ann LCSW 336 E 900 S p 801.935.4171 5558 S 1900 W Compass Counseling and Salt Lake City UT. 84111 Ste B Consulting p 801.292.6101 6910 S Highland Dr Salt Lake City UT. 84129 4000 S 700 E Ste 1 p 801.255.5131 Ste 9 Moyes, Michelle CMHC Salt Lake City UT. 84121 Salt Lake City UT. 84107 Valley Behavioral Health p 801.935.4171 6013 S Redwood Rd p 801.639.9544 3809 W 6200 S Salt Lake City UT. 84123 Taylorsville UT. 84129 Murray, Brad L MD p 801.255.5131 Morstein, Jodi APRN p 888.949.4864 University of Utah Health University of Utah Health 1280 E Stringham Ave Neilson, Tamera L LCSW 1578 W 1700 S Mullaney, Edward LCSW Salt Lake City UT. 84106 Inner Peace Conseling of Salt Lake City UT. 84104 University of Utah Health p 801.581.7951 Utah p 801.581.4014 1280 E Stringham Ave 11618 S State St Salt Lake City UT. 84106 1950 Cir of Hope Dr Ste 1604 50 N Medical Dr p 801.213.8841 Salt Lake City UT. 84112 Draper UT. 84020 Salt Lake City UT. 84132 p 801.583.2500 p 385.202.5645 p 801.581.4014 1525 W 2100 S Salt Lake City UT. 84119 p 801.213.9900

266 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Nelford, Kalani LCSW Nettleton, Ashley CSW 6910 S Highland Dr Northway, Justin A LCSW Compass Counseling and Valley Behavioral Health Ste 1 Valley Behavioral Health Consulting 195 W 7200 S Salt Lake City UT. 84121 2948 S Redwood Rd 4000 S 700 E Midvale UT. 84047 p 801.935.4946 West Valley City UT. 84119 Ste 9 p 888.949.4864 p 888.949.4864 Salt Lake City UT. 84107 Nicols, Jenissa BCBA p 801.639.9544 Neuman, Mark D MD ABS Kids Nosanchuk, Melvin F PhD Comprehensive 515 S 700 E 1646 Kensington Ave Nelson, Michelle M LCSW Psychological Services Ste 2A Salt Lake City UT. 84105 University of Utah Health 1208 E 3300 S Salt Lake City UT. 84102 p 801.467.4875 1280 E Stringham Ave Salt Lake City UT. 84106 p 801.935.4171 Salt Lake City UT. 84106 p 801.483.1600 Nuttall, Marie LPC p 801.213.8841 6910 S Highland Dr Ascendant Behavioral 3725 W 4100 S Ste 1 Health 1525 W 2100 S West Valley City UT. 84120 Cottonwood Heights UT. 84121 5383 S 900 E Salt Lake City UT. 84119 p 801.483.1600 p 801.935.4946 Ste 103 p 801.213.9900 Salt Lake City UT. 84117 Newbold, Emily K LCSW Nielsen, Benjamin LCSW p 801.872.5516 3730 W 4700 S South Point Counseling Compass Counseling and Taylorsville UT. 84129 1206 W S Jordan Pkwy Consulting ODonohoe, Jennifer G MD p 801.213.9200 Ste D 4000 S 700 E University of Utah Health South Jordan UT. 84095 Ste 9 1280 E Stringham Ave 5126 W Daybreak Pkwy p 801.302.3801 Salt Lake City UT. 84107 Salt Lake City UT. 84106 Ste 600 p 801.639.9544 p 801.581.7951 South Jordan UT. 84009 Newman, Felicia BCBA p 801.213.4500 ABS Kids Nielsen, Mandy J CMHC 1950 Cir of Hope Dr 515 S 700 E Mountain Paths Counseling Salt Lake City UT. 84112 5126 W Daybreak Pkwy Ste 2A 7069 S Highland Dr p 801.583.2500 South Jordan UT. 84009 Salt Lake City UT. 84102 Ste 100 Unit 6 p 801.213.4500 p 801.935.4171 Salt Lake City UT. 84121 50 N Medical Dr p 801.214.1565 Salt Lake City UT. 84132 555 Foothill Dr 6910 S Highland Dr p 801.585.1575 Ste 301 Ste 1 Nielsen, Stephanie MSW Salt Lake City UT. 84112 Cottonwood Heights UT. 84121 Utah Behavior Services 501 S Chipeta Way p 801.581.8000 p 801.935.4946 5558 S 1900 W Salt Lake City UT. 84108 Ste B p 801.587.3287 555 Foothill Dr Next Level Recovery Salt Lake City UT. 84129 Salt Lake City UT. 84112 6771 S 900 E p 801.255.5131 Hospital Affiliation p 801.581.8000 Midvale UT. 84047 - University of Utah Hospital p 801.386.9799 6013 S Redwood Rd 7495 S State St Salt Lake City UT. 84123 OQuinn, Casey L BCBA Midvale UT. 84047 Ngu, Le Q PhD p 801.255.5131 Neurobehavioral Center for p 801.213.9400 5801 S Fashion Blvd Growth Ste 200 Niwa, Kathleen S CMHC 370 E South Temple Hospital Affiliation Salt Lake City UT. 84107 Valley Behavioral Health Ste 175 - University of Utah Hospital p 801.875.2128 195 W 7200 S Salt Lake City UT. 84111 Midvale UT. 84047 p 801.683.1062 Nelson, Ryan S LCSW Nickolaisen, Steven MD p 888.949.4864 13531 Lovers Ln Comprehensive OReilly, Laree C MSW Riverton UT. 84065 Psychological Services Nixon, Allison SSW Neurobehavioral Center for p 801.706.1818 1208 E 3300 S Valley Behavioral Health Growth Salt Lake City UT. 84106 2948 S Redwood Rd 370 E South Temple Valley Behavioral Health p 801.483.1600 West Valley City UT. 84119 Ste 175 195 W 7200 S p 888.949.4864 Salt Lake City UT. 84111 Midvale UT. 84047 Nicksic Springer, Taryn K p 801.683.1062 p 888.949.4864 PhD Northup, Kathryn BCBA ABS Kids ABS Kids Oblad, Cicily BCBA Nelson, Sunny LCSW 515 S 700 E 515 S 700 E Utah Behavior Services New Pathways Recovery and Ste 2A Ste 2A 5558 S 1900 W Wellness Salt Lake City UT. 84102 Salt Lake City UT. 84102 Ste B 435 W 400 S p 801.935.4171 p 801.935.4171 Salt Lake City UT. 84129 Ste 101 p 801.255.5131 Salt Lake City UT. 84101 p 801.722.5602

267 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 6013 S Redwood Rd Osborne, Jane LPC 51 W 3900 S 6910 S Highland Dr Salt Lake City UT. 84123 Comprehensive Salt Lake City UT. 84107 Ste 1 p 801.255.5131 Psychological Services p 801.585.1575 Cottonwood Heights UT. 84121 1208 E 3300 S p 801.935.4946 Ochoa, Rafael BCBA Salt Lake City UT. 84106 Hospital Affiliation Valley Behavioral Health p 801.483.1600 - University of Utah Hospital Payne, Aubree LCSW 6232 S 900 E Lotus Center Inc Salt Lake City UT. 84121 Ossmen, Caitlin BCBA *Pagoaga, Ted M LCSW 4376 S 700 E p 888.949.4864 ABS Kids PCH CHILD PSYCH-OP Ste 200 515 S 700 E 5770 S 1500 W Salt Lake City UT. 84107 780 S Guardsman Way Ste 2A Taylorsville UT. 84123 p 385.272.4292 Salt Lake City UT. 84108 Salt Lake City UT. 84102 p 801.313.7770 p 888.949.4864 p 801.935.4171 Pearce, Brett PSYD Hospital Affiliation Valley Behavioral Health Ogden, Stephanie BCBA 6910 S Highland Dr - Primary Childrens Hospital 3809 W 6200 S ABS Kids Ste 1 Salt Lake City UT. 84129 515 S 700 E Cottonwood Heights UT. 84121 Pallos, Petra LPC p 888.949.4864 Ste 2A p 801.935.4946 Ascendant Behavioral Salt Lake City UT. 84102 Health 4460 S Highland Dr p 801.935.4171 Ossmen, Jordan BCBA 5383 S 900 E Ste 100 ABS Kids Ste 103 Salt Lake City UT. 84124 Okifuji, Akiko PhD 515 S 700 E Salt Lake City UT. 84117 p 888.949.4864 University of Utah Health Ste 2A p 801.872.5516 50 N Medical Dr Salt Lake City UT. 84102 Pehrson, Heather BCBA Salt Lake City UT. 84132 p 801.935.4171 Palmer, Stephen D LCSW ABS Kids p 801.581.2121 Valley Behavioral Health 515 S 700 E 6910 S Highland Dr 4460 S Highland Dr Ste 2A 615 S Arapeen Dr Ste 1 Ste 100 Salt Lake City UT. 84102 Ste 100 Cottonwood Heights UT. 84121 Salt Lake City UT. 84124 p 801.935.4171 Salt Lake City UT. 84108 p 801.935.4946 p 888.949.4864 p 801.581.7246 Pehrson, Samantha LCSW Owen, Betty J LCSW Paredes-Mora, Rocio F Life Matters Counseling & *Ontiveros, Daniel A LCSW Jordan West Family LCSW Health Center PCH Neuropsychology Counseling RPM Counseling Services 3336 S Pioneer Pkwy 81 N Mario Capecchi Dr 9263 B Redwood Rd 3441 S Decker Lake Dr Ste 201 Salt Lake City UT. 84113 West Jordan UT. 84088 Ste 108 West Valley City UT. 84120 p 801.662.5592 p 801.566.0749 West Valley City UT. 84119 p 801.313.0555 p 801.554.2554 Ord, Lisa M LCSW Oxborrow, Jennifer L LCSW Perez, Erin P LCSW University of Utah Health Lotus Center Inc Parker, James E PA-C Valley Behavioral Health 65 S Mario Capecchi Dr 4376 S 700 E Comprehensive 12427 S Pasture Rd Salt Lake City UT. 84132 Ste 200 Psychological Services Ste 104 p 801.581.2352 Salt Lake City UT. 84107 1208 E 3300 S Riverton UT. 84096 p 385.272.4292 Salt Lake City UT. 84106 p 888.949.4864 Hospital Affiliation p 801.483.1600 - University of Utah Hospital Packer, Candice CSW 4460 S Highland Dr The Green House for Growth Parnell, Kathrine J LCSW Ste 100 Ortega, Catherine PA & Learning Valley Behavioral Health Salt Lake City UT. 84124 Comprehensive 1325 W S Jordan Pkwy 1141 E 3900 S p 888.949.4864 Psychological Services Ste 102 Ste A250 1208 E 3300 S South Jordan UT. 84095 Salt Lake City UT. 84124 Perkes, Melyssa L CSW Salt Lake City UT. 84106 p 801.208.8838 p 888.949.4864 Valley Behavioral Health p 801.264.6000 1020 S Main St Pagel, Kristen L MD Parsons, Alison P PSYD Ste 300 Ortiz-Perez, Marco BCBA University of Utah Health 2040 E Murray Holladay Rd Salt Lake City UT. 84101 ABS Kids 50 N Medical Dr Ste 222 p 888.949.4864 515 S 700 E Salt Lake City UT. 84132 Salt Lake City UT. 84124 Ste 2A p 801.585.1575 p 801.803.1091 1141 E 3900 S Salt Lake City UT. 84102 Ste A250 p 801.935.4171 501 S Chipeta Way Parsons, Rita M BCBA Salt Lake City UT. 84124 Salt Lake City UT. 84108 ABS Kids p 888.949.4864 6910 S Highland Dr p 801.585.1575 515 S 700 E Ste 1 Ste 2A Cottonwood Heights UT. 84121 Salt Lake City UT. 84102 p 801.935.4946 p 801.935.4171

268 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Petersen, Anthony M MD Phillips, Marci R LCSW Plumb, Taylor R PSYD Poulos, Jennifer LCSW A New Direction Recovery & Valley Behavioral Health Valley Behavioral Health Valley Behavioral Health Wellness 1020 S Main St 195 W 7200 S 3809 W 6200 S 8686 S 1300 E Ste 300 Midvale UT. 84047 Taylorsville UT. 84129 Sandy UT. 84094 Salt Lake City UT. 84101 p 888.949.4864 p 888.949.4864 p 801.709.0748 p 888.949.4864 Pohl, Richard L MD 4460 S Highland Dr Hospital Affiliation 550 W 700 S Sundance Behavioral Ste 100 - Lakeview Hospital Salt Lake City UT. 84101 Resources Salt Lake City UT. 84124 p 888.949.4864 845 E 4800 S p 888.949.4864 Petersen, Jodi LCSW Ste 200 Ascendant Behavioral Pickering, Jaclyn BCBA Salt Lake City UT. 84107 Powell, Clark Randy LCSW Health Neurobehavioral Center for p 801.264.9522 Utah Behavior Services 5383 S 900 E Growth 5558 S 1900 W Ste 103 370 E South Temple Poltoratzsky, Valerie Ste B Salt Lake City UT. 84117 Ste 175 LCSW Taylorsville UT. 84118 p 801.872.5516 Salt Lake City UT. 84111 1355 S 1100 E p 801.255.5131 p 801.683.1062 Salt Lake City UT. 84105 Peterson, Kristyn BCBA p 801.913.7394 6013 S Redwood Rd ABS Kids Pierce, Ricky W SSW Taylorsville UT. 84123 515 S 700 E Valley Behavioral Health Porschatis, Amber M LCSW p 801.255.5131 Ste 2A 1141 E 3900 S University of Utah Health Salt Lake City UT. 84102 Ste A250 1280 E Stringham Ave Powell, Jared N LCSW p 801.935.4171 Salt Lake City UT. 84124 Salt Lake City UT. 84106 Comprehensive p 888.949.4864 p 801.213.8841 Psychological Services 6910 S Highland Dr 1208 E 3300 S Ste 1 Pierson, Matthew D MD 1525 W 2100 S Salt Lake City UT. 84106 Salt Lake City UT. 84121 University of Utah Health Salt Lake City UT. 84119 p 801.483.1600 p 801.935.4171 1280 E Stringham Ave p 801.213.9900 Salt Lake City UT. 84106 Powell, Samantha LCSW *Peterson, Penny LCSW p 801.581.7951 3730 W 4700 S University Of Utah Health PCH CHILD PSYCH-OP Taylorsville UT. 84129 1950 Cir of Hope Dr 5770 S 1500 W 1950 Cir of Hope Dr p 801.213.9200 Salt Lake City UT. 84112 Taylorsville UT. 84123 Salt Lake City UT. 84112 p 801.587.7000 p 801.313.7770 p 801.583.2500 5126 W Daybreak Pkwy Ste 600 Hospital Affiliation Pham, Duy MD 50 N Medical Dr South Jordan UT. 84009 - University of Utah Hospital University of Utah Health Salt Lake City UT. 84132 p 801.213.4500 1280 E Stringham Ave p 801.585.1575 Pramann, Robert F PhD Salt Lake City UT. 84106 555 Foothill Dr Christian Counseling p 801.581.7951 501 S Chipeta Way Ste 301 Centers of Utah Salt Lake City UT. 84108 Salt Lake City UT. 84112 525 E 4500 S 501 S Chipeta Way p 801.587.3287 p 801.581.8000 Ste F-125 Salt Lake City UT. 84108 Salt Lake City UT. 84107 p 801.587.3287 Hospital Affiliation 7495 S State St p 801.268.1564 - University of Utah Hospital Midvale UT. 84047 Phelps, Ariane A SSW p 801.213.9400 Pratt, Nancy CMHC Valley Behavioral Health Pitcher, Shane MSW Valley Behavioral Health 1020 S Main St Odyssey House of Utah Porter, Mickayla A SSW 1141 E 3900 S Ste 100 344 E 100 S Valley Behavioral Health Ste A170 Salt Lake City UT. 84101 Ste 301 195 W 7200 S Salt Lake City UT. 84124 p 888.949.4864 Salt Lake City UT. 84111 Midvale UT. 84047 p 888.949.4864 p 801.322.3222 p 888.949.4864 Phillips, Allison The Childrens Center LCSW,BCBA Plastow, Anisa L SSW Potts, Justin PSYD 350 S 400 E Utah Behavior Services Valley Behavioral Health Summit Community Salt Lake City UT. 84111 5558 S 1900 W 1141 E 3900 S Counseling p 801.582.5534 Ste B Ste A250 4991 S Commerce Dr Salt Lake City UT. 84129 Salt Lake City UT. 84124 Salt Lake City UT. 84117 Prescott, Ashley LCMHC p 801.255.5131 p 888.949.4864 p 801.266.2485 Aspen Ridge Counseling 2711 S 8500 W 6013 S Redwood Rd Plautz, Hailey C BCBA 5689 S Redwood Rd Magna UT. 84044 Salt Lake City UT. 84123 Neurobehavioral Center For Ste 27 p 801.990.4300 p 801.255.5131 Growth Salt Lake City UT. 84123 370 E S Temple p 801.266.2485 Ste 175 Salt Lake City UT. 84111 p 801.683.1062 269 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Price, Donald A LMFT *Radford, Preston J LCSW Rathofer, David LMFT Reimherr, Kathleen R LCSW Millbrook Counseling PCH Neuropsychology Jordan West Family Psychiatric & Behavioral 2118 E 3900 S 81 N Mario Cappecchi Dr Counseling Solutions Ste 100 Salt Lake City UT. 84113 9263 Redwood Rd Bldg 8 1522 S 1100 E Salt Lake City UT. 84124 p 801.662.5592 Ste B Salt Lake City UT. 84105 p 801.277.3620 West Jordan UT. 84088 p 801.467.1200 Rael, Julie L LCSW p 801.523.5206 Price, Linda M PhD Valley Behavioral Health Renda, Cheyenne R PhD Millbrook Counseling 1020 S Main St Ratliff, Jeremy APRN Utah Behavior Services 2118 E 3900 S Ste 100 Valley Behavioral Health 5558 S 1900 W Ste 100 Salt Lake City UT. 84101 12427 S Pasture Rd Ste B Salt Lake City UT. 84124 p 888.949.4864 Ste 104 Salt Lake City UT. 84129 p 801.277.3620 Riverton UT. 84096 p 801.255.5131 1141 E 3900 S p 888.949.4864 Probert, Brittany BCBA Ste A250 6013 S Redwood Rd Advanced Behavior Analysis Salt Lake City UT. 84124 4460 S Highland Dr Salt Lake City UT. 84123 1441 E Fort Union Blvd p 888.949.4864 Ste 100 p 801.255.5131 Salt Lake City UT. 84121 Salt Lake City UT. 84124 p 385.695.2203 2948 S Redwood Rd p 888.949.4864 Reyes, Carla J PhD West Valley City UT. 84119 A Childs Place Proctor, Lyndsey D LCSW p 888.949.4864 Ratto, Joann M RN 4568 S Highland Dr Serenity Recovery and Valley Behavioral Health Ste 100 Wellness Rahimi, Donna SSW 1141 E 3900 S Salt Lake City UT. 84117 12447 S Crossing Dr Valley Behavioral Health Ste A250 p 801.232.5363 Ste 13 1141 E 3900 S Salt Lake City UT. 84124 Herriman UT. 84096 Ste A250 p 888.949.4864 Ricci, Jeanette M LCSW p 801.984.0184 Salt Lake City UT. 84124 Valley Behavioral Health p 888.949.4864 4460 S Highland Dr 12427 S Pasture Rd Prutch, Julie A SSW Ste 100 Ste 104 Valley Behavioral Health Ramos, Irma E LCMHC Salt Lake City UT. 84124 Riverton UT. 84096 1141 E 3900 S Multicultural Counseling p 888.949.4864 p 888.949.4864 Ste A250 Center Salt Lake City UT. 84124 7625 S 3200 W Redd, Karen CMHC Rice, Allan LCSW p 888.949.4864 Ste 2 Center for Anxiety & PTSD Valley Behavioral Health West Jordan UT. 84084 1174 E Graystone Way 1020 S Main St Psalto, Taylor J SSW p 801.915.0359 Ste 111 Ste 300 Valley Behavioral Health Salt Lake City UT. 84106 Salt Lake City UT. 84101 1020 S Main St Ramos, Rachel MSW,CSW p 801.856.3142 p 888.949.4864 Ste 100 Summit Community Salt Lake City UT. 84101 Counseling 4609 S 2300 E *Rich, Christopher C MD p 888.949.4864 5689 S Redwood Rd Ste 107 Primary Childrens Hospital Ste 27 Salt Lake City UT. 84124 5770 S 1500 W 1020 S Main St Salt Lake City UT. 84123 p 801.856.3142 Taylorsville UT. 84123 Ste 300 p 801.266.2485 p 801.313.7770 Salt Lake City UT. 84101 Reid, T Michael MD p 888.949.4864 5991 S Redwood Rd Sundance Behavioral 81 N Mario Capecchi Dr Salt Lake City UT. 84123 Resources Salt Lake City UT. 84113 Purdy, Tyler LCSW p 801.266.2485 845 E 4800 S p 801.662.5592 The Green House for Growth Ste 200 & Learning Ranks, Georgann LPC Murray UT. 84107 Hospital Affiliation 1325 W S Jordan Pkwy Ascendant Behavioral p 801.264.9522 - Primary Childrens Hospital Ste 102 Health South Jordan UT. 84095 5383 S 900 E Hospital Affiliation Rich, Stacey p 801.208.8838 Ste 103 - Mountain West Medical Mountain Paths Counseling Salt Lake City UT. 84117 Center 7069 S Highland Dr Quinlan, Katherine B CMHC p 801.872.5516 Ste 100 Valley Behavioral Health Reimherr, Frederick W MD Salt Lake City UT. 84121 1141 E 3900 S Rasmussen, Jake BCBA Psychiatric & Behavioral p 801.214.1565 Ste A250 ABS Kids Solutions Salt Lake City UT. 84124 515 S 700 E 1522 S 1100 E Richards, R L PhD p 888.949.4864 Ste 2A Salt Lake City UT. 84105 12481 S Fort St Salt Lake City UT. 84102 p 801.467.1200 Draper UT. 84020 p 801.935.4171 p 801.938.9025

270 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Ridge, Brook CMHC Rippon, Callie M LCSW 154 E Myrtle Ave 6013 S Redwood Rd University Of Utah Health Valley Behavioral Health Ste 204 Salt Lake City UT. 84123 501 S Chipeta Way 1020 S Main St Murray UT. 84107 p 801.255.5131 Salt Lake City UT. 84108 Ste 218 p 801.369.8989 p 801.583.2500 Salt Lake City UT. 84101 Rodeback, David LCSW p 888.949.4864 721 E 12200 S Utah Cancer Specialists Hospital Affiliation Draper UT. 84020 1121 E 3900 S - University of Utah Hospital Rith, Kendrick PhD p 801.369.8989 Ste C240 ABS Kids Salt Lake City UT. 84124 *Riekhof, Jeffrey D LCSW 6910 S Highland Dr Hospital Affiliation p 801.266.0878 Primary Childrens Hospital Ste 1 - Mountain View Hospital 5770 S 1500 W Salt Lake City UT. 84121 (UT) 3838 S 700 E Taylorsville UT. 84123 p 801.935.4171 - Utah Valley Hospital Ste 100 p 801.313.7940 Salt Lake City UT. 84106 Roberts, Diana J SSW Robles, Richard BCBA p 801.269.0231 Riley, Frederick R LCSW Valley Behavioral Health ABS Kids Riley Individual Family 1850 S 2500 E 515 S 700 E Rodgers, Kenneth C PhD and Marriage Counseling Salt Lake City UT. 84108 Ste 2A 8160 S Highland Dr 873 Baxter Dr p 888.949.4864 Salt Lake City UT. 84102 Ste 102 South Jordan UT. 84095 p 801.935.4171 Sandy UT. 84093 p 801.657.0163 4460 S Highland Dr p 801.943.3319 Ste 300 6910 S Highland Dr Riley, Katrina LCSW Salt Lake City UT. 84124 Ste 1 Rogers, Christina M LSUDC Life Matters Counseling & p 888.949.4864 Cottonwood Heights UT. 84121 Valley Behavioral Health Health Center p 801.935.4946 3809 W 6200 S 2225 E Murray-Holladay Rd Robinson, Jerianne BCBA Taylorsville UT. 84129 Ste 112 ABS Kids *Robnett, Jessica M PSYD p 888.949.4864 Salt Lake City UT. 84117 515 S 700 E PCH Gender Management And p 801.313.0555 Ste 2A Support Rogers, Jennifer PSYD Salt Lake City UT. 84102 81 N Mario Capecchi Dr ABS Kids 3336 S Pioneer Pkwy p 801.935.4171 Salt Lake City UT. 84113 515 S 700 E Ste 201 p 801.662.1600 Ste 2A West Valley City UT. 84120 6910 S Highland Dr Salt Lake City UT. 84102 p 801.313.0555 Ste 1 Hospital Affiliation p 801.935.4171 Cottonwood Heights UT. 84121 - University of Utah Hospital Rindflesh, Mark A MD p 801.935.4946 6910 S Highland Dr University of Utah Health Roche, Miriam MSW Ste 1 1280 E Stringham Ave Robinson, Kristin E PhD Utah Behavior Services Salt Lake City UT. 84121 Salt Lake City UT. 84106 Kristin E Robinson PHD 5558 S 1900 W p 801.935.4171 p 801.581.7951 8184 S Highland Dr Ste B Ste C8 Salt Lake City UT. 84129 Rojas, Eileen LCSW 50 N Medical Dr Sandy UT. 84093 p 801.255.5131 Compass Counseling and Salt Lake City UT. 84132 p 801.944.1666 Consulting p 801.585.1575 6013 S Redwood Rd 4000 S 700 E Robinson, Nichole R LCSW Salt Lake City UT. 84123 Ste 9 501 S Chipeta Way University Of Utah Health p 801.255.5131 Salt Lake City UT. 84107 Salt Lake City UT. 84108 1950 Cir of Hope Dr p 801.639.9544 p 801.587.3287 Salt Lake City UT. 84112 Roche, Vaughan S LCSW p 801.587.7000 Sundance Behavioral Romero, Jerry B LCSW Ringger, Brett BCBA Resources Valley Behavioral Health ABS Kids Hospital Affiliation 845 E 4800 S 1020 S Main St 6910 S Highland Dr - University of Utah Hospital Ste 200 Ste 100 Ste 1 Salt Lake City UT. 84107 Salt Lake City UT. 84101 Cottonwood Heights UT. 84121 Robinson, Sapphire M MSW p 801.264.9522 p 888.949.4864 p 801.935.4946 The Childrens Center 350 S 400 E Rockwell, Rene BCBA Romesser, Jennifer M PSYD Ringold, Patricia LPC Salt Lake City UT. 84111 Utah Behavior Services Valley Behavioral Health Ascendant Behavioral p 801.582.5534 5558 S 1900 W 1141 E 3900 S Health Ste B Ste A250 5383 S 900 E Robison, Reid J MD Salt Lake City UT. 84129 Salt Lake City UT. 84124 Ste 103 Cedar Psychiatry p 801.255.5131 p 888.949.4864 Salt Lake City UT. 84117 1208 E 3300 S p 801.872.5516 Salt Lake City UT. 84106 p 801.369.8989

271 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Rosado, Leah BCBA Russell, Laura CMHC Sainsbury, Stacy LMFT Scheffres, Jonathon B LPC ABS Kids Comprehensive The Childrens Center 311 S 900 E 515 S 700 E Psychological Services 350 S 400 E Ste 101A Ste 2A 1208 E 3300 S Salt Lake City UT. 84111 Salt Lake City UT. 84102 Salt Lake City UT. 84102 Salt Lake City UT. 84106 p 801.582.5534 p 801.633.3908 p 801.935.4171 p 801.483.1600 5242 S 4820 W Schiers, Cindy Jo PhD 6910 S Highland Dr Russett, Ebbie I CMHC Salt Lake City UT. 84118 Corner Canyon Counseling Ste 1 Valley Behavioral Health p 801.966.4251 and Psychologist Services Cottonwood Heights UT. 84121 12427 S Pasture Rd 248 E 13800 S p 801.935.4946 Ste 104 Salsberry, Maria CSW Ste 4 Herriman UT. 84096 Utah Behavior Services Draper UT. 84020 Roskelley, Hannah BCBA p 888.949.4864 5558 S 1900 W p 801.816.1801 ABS Kids Ste B 515 S 700 E 4460 S Highland Dr Taylorsville UT. 84118 Schifano, Brytni BCBA Ste 2A Ste 100 p 801.255.5131 ABS Kids Salt Lake City UT. 84102 Salt Lake City UT. 84124 515 S 700 E p 801.935.4171 p 888.949.4864 6013 S Redwood Rd Ste 2A Taylorsville UT. 84123 Salt Lake City UT. 84102 6910 S Highland Dr SAMUDRA, KALYANI MD p 801.255.5131 p 801.935.4171 Ste 1 University of Utah Health Cottonwood Heights UT. 84121 1280 E Stringham Ave Sandack, Margaret LCSW 6910 S Highland Dr p 801.935.4946 Salt Lake City UT. 84106 The Childrens Center Ste 1 p 801.581.7951 350 S 400 E Cottonwood Heights UT. 84121 Roth, Natalie PhD Salt Lake City UT. 84111 p 801.935.4946 ABS Kids 50 N Medical Dr p 801.582.5534 515 S 700 E Salt Lake City UT. 84132 *Schindler, Sheryl CMHC Ste 2A p 801.585.1575 Sanders, Michael R RN PCH CHILD PSYCH-OP Salt Lake City UT. 84102 Valley Behavioral Health 5770 S 1500 W p 801.935.4171 501 S Chipeta Way 1141 E 3900 S TAYLORSVILLE UT. 84123 Salt Lake City UT. 84108 Ste A250 p 801.313.7770 6910 S Highland Dr p 801.587.3287 Salt Lake City UT. 84124 Ste 1 p 888.949.4864 Hospital Affiliation Cottonwood Heights UT. 84121 Saalfield, Andrew BCBA - Primary Childrens Hospital p 801.935.4946 ABS Kids Sanders, Sarah BCBA 515 S 700 E Utah Behavior Services Schmelzer, Alina LCSW Rushforth, Jedediah S Ste 2A 5558 S 1900 W Ascendant Behavioral LCSW Salt Lake City UT. 84102 Ste B Health The OCD And Anxiety p 801.935.4171 Salt Lake City UT. 84129 5383 S 900 E Treatment Center p 801.255.5131 Ste 103 11260 S River Height Dr Saari, Lorraine LCSW Salt Lake City UT. 84117 South Jordan UT. 84095 Aspen Ridge Counseling 6013 S Redwood Rd p 801.872.5516 p 801.298.2000 1561 W 7000 S Salt Lake City UT. 84123 Ste 200 p 801.255.5131 Schmidt, Matthew G APRN PCH Residential Home West Jordan UT. 84084 Valley Behavioral Health 5770 S 1500 W Bldg C p 801.990.4300 Sands, Allison BCBA 1020 S Main St Salt Lake City UT. 84123 ABS Kids Ste 100 p 801.313.7954 Sabin, Maxine M RN 515 S 700 E Salt Lake City UT. 84101 Valley Behavioral Health Ste 2A p 888.949.4864 PCH Residential Trmnt - 1020 S Main St Salt Lake City UT. 84102 ADOL Ste 100 p 801.935.4171 Schuknecht, Kelly BCBA 5770 S 1500 W Salt Lake City UT. 84101 ABS Kids Salt Lake City UT. 84123 p 888.949.4864 6910 S Highland Dr 515 S 700 E p 801.313.7940 Ste 1 Ste 2A Sagendorf, Emily BCBA Cottonwood Heights UT. 84121 Salt Lake City UT. 84102 Russell Stamp, Mindy M Utah Behavior Services p 801.935.4946 p 801.935.4171 PhD 5558 S 1900 W Neurobehavioral Center for Ste B Sarhadi, Marissa D APRN 6910 S Highland Dr Growth Salt Lake City UT. 84129 Compass Counseling and Ste 1 370 E South Temple p 801.255.5131 Consulting Cottonwood Heights UT. 84121 Ste 175 4000 S 700 E p 801.935.4946 Salt Lake City UT. 84111 6013 S Redwood Rd Ste 9 p 801.683.1062 Salt Lake City UT. 84123 Salt Lake City UT. 84107 p 801.255.5131 p 801.639.9544

272 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Schuler, Rebekah L CMHC Seiler, Edward A CMHC Sessions, Janet R LMFT Shumway, Brett PSYD The Utah House Valley Behavioral Health Janet R Sessions LMFT Utah Behavior Services 1370 S West Temple 12427 S Pasture Rd 4055 S 700 E 5558 S 1900 W Salt Lake City UT. 84115 Ste 104 Ste 102 Ste B p 801.678.3317 Herriman UT. 84096 Salt Lake City UT. 84105 Taylorsville UT. 84118 p 888.949.4864 p 385.743.1064 p 801.255.5131 Schumacher, Marissa BCBA ABS Kids 4460 S Highland Dr New Pathways Recovery and 6013 S Redwood Rd 515 S 700 E Ste 300 Wellness Taylorsville UT. 84123 Ste 2A Salt Lake City UT. 84124 435 W 400 S p 801.255.5131 Salt Lake City UT. 84102 p 888.949.4864 Ste 101 p 801.935.4171 Salt Lake City UT. 84101 Shumway, Luisa BCBA Selis, Emma BCBA p 801.722.5602 ABS Kids 6910 S Highland Dr ABS Kids 515 S 700 E Ste 1 515 S 700 E Sharifan, Tara PSYD Ste 2A Salt Lake City UT. 84121 Ste 2A Comprehensive Salt Lake City UT. 84102 p 801.935.4946 Salt Lake City UT. 84102 Psychological Services p 801.935.4171 p 801.935.4171 1208 E 3300 S Schwebach, Derek LCSW Salt Lake City UT. 84106 Siebert, Tatum LCPC Family Counseling Center 6910 S Highland Dr p 801.483.1600 Comprehensive 650 E 4500 S Ste 1 Psychological Services Ste 300 Salt Lake City UT. 84121 *Shepard, Lindsay LCSW 1208 E 3300 S Murray UT. 84107 p 801.935.4946 Primary Childrens Safe & Salt Lake City UT. 84106 p 801.261.3500 Healthy Families p 801.483.1600 Sellers, Jamie L LPC 81 N Mario Capecchi Dr *Schwei, Mark G MD The Childrens Center Salt Lake City UT. 84113 Utah Behavior Services Primary Childrens Hospital 5242 S 4820 W p 801.662.3606 5558 S 1900 W 5770 S 1500 W Salt Lake City UT. 84118 Ste B Taylorsville UT. 84123 p 801.966.4251 Shields, Andrea LMFT Salt Lake City UT. 84129 p 801.313.7770 4516 S 700 E p 801.255.5131 Seng, Alexandra L ACMHC Ste 180 Hospital Affiliation Valley Behavioral Health Salt Lake City UT. 84107 6013 S Redwood Rd - Primary Childrens Hospital 1020 S Main St p 801.824.2862 Salt Lake City UT. 84123 Ste 100 p 801.255.5131 Scoville, Barbara A LCSW Salt Lake City UT. 84101 Shields, Haley B BCBA Mountain States Counseling p 888.949.4864 ABS Kids Silva, Emily A LCSW Center 515 S 700 E Valley Behavioral Health 5635 S Waterbury Way 3809 W 6200 S Ste 2A 3809 W 6200 S Ste C202 Taylorsville UT. 84129 Salt Lake City UT. 84102 Taylorsville UT. 84129 Salt Lake City UT. 84121 p 888.949.4864 p 801.935.4171 p 888.949.4864 p 801.278.0200 Serenity Recovery and 6910 S Highland Dr Silvester, Elizabeth Sears, Wayne R CMHC Wellness Ste 1 LCSW Life Stone Counseling 12447 S Crossing Dr Cottonwood Heights UT. 84121 University Of Utah Health Center Ste 13 p 801.935.4946 1280 E Stringham Ave 613 E Fort Union Blvd Herriman UT. 84096 Salt Lake City UT. 84106 Ste 104 p 801.984.0184 Shober, Lupita LCSW p 801.581.2000 Midvale UT. 84047 Multicultural Counseling p 801.984.1717 *Sergent, Natalie PSYD Center Hospital Affiliation PCH Residential Home 7625 S 3200 W - University of Utah Hospital Seashore, Karl E LPC 5770 S 1500 W Bldg C Ste 2 4190 S Highland Dr Taylorsville UT. 84123 West Jordan UT. 84084 Simancas (Monago), Ste 211 p 801.313.7954 p 801.915.0359 Letisia A BCBA Salt Lake City UT. 84124 ABS Kids p 801.272.0613 PCH CHILD PSYCHOP *Shotwell, Heather L LCSW 515 S 700 E 5770 S 1500 W Primary Childrens Hospital Ste 2A Hospital Affiliation Taylorsville UT. 84123 5770 S 1500 W Salt Lake City UT. 84102 - Mountain West Medical p 801.313.7770 Taylorsville UT. 84123 p 801.935.4171 Center p 801.313.7770 Hospital Affiliation 6910 S Highland Dr Seavey, Allison M LCSW - Primary Childrens Hospital Hospital Affiliation Ste 1 St Marks Family Medicine - Primary Childrens Hospital Cottonwood Heights UT. 84121 1250 E 3900 S p 801.935.4946 Ste 260 Salt Lake City UT. 84124 p 801.265.2000

273 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Simons, Kristina LCSW 6910 S Highland Dr Smith, Ashlin BCBA 6910 S Highland Dr Jordan West Family Ste 1 ABS Kids Ste 1 Counseling Cottonwood Heights UT. 84121 515 S 700 E Salt Lake City UT. 84121 9263 Redwood Rd Bldg 8 p 801.935.4946 Ste 2A p 801.935.4946 West Jordan UT. 84088 Salt Lake City UT. 84102 p 801.566.0749 Skinner, Ageuda LCSW p 801.935.4171 Smith, Rayl BCBA 1399 S 700 E ABS Kids Simpson, Clifford CMHC Ste 12-C 6910 S Highland Dr 515 S 700 E Summit Community Salt Lake City UT. 84105 Ste 1 Ste 2A Counseling p 801.828.5189 Cottonwood Heights UT. 84121 Salt Lake City UT. 84102 5689 S Redwood Rd p 801.935.4946 p 801.935.4171 Ste 27 Skon, L Evelyn E LMFT Salt Lake City UT. 84123 Family Counseling Center Smith, Cielle LCMHC Smith, Saige LPC p 801.266.2485 650 E 4500 S Aspen Ridge Counseling Utah Behavior Services Ste 300 411 W 7200 S 5558 S 1900 W 5991 S Redwood Rd Murray UT. 84107 Ste 304 Ste B Salt Lake City UT. 84123 p 801.261.3500 Midvale UT. 84047 Salt Lake City UT. 84129 p 801.266.2485 p 801.990.4300 p 801.255.5131 Skousen, Thomas MSW Simpson, David E LCSW Utah Behavior Services Smith, Deanna LCSW 6013 S Redwood Rd Mountain States Counseling 5558 S 1900 W Center for Growth Salt Lake City UT. 84123 Center Ste B 5411 S Vine St p 801.255.5131 5635 S Waterbury Way Salt Lake City UT. 84129 Ste 6 Ste C202 p 801.255.5131 Salt Lake City UT. 84107 Smith, Tamatha CMHC Salt Lake City UT. 84121 p 435.625.1717 Summit Community p 801.278.0200 6013 S Redwood Rd Counseling Salt Lake City UT. 84123 Smith, Erica BCBA 5689 S Redwood Rd Simpson, Robert I MD p 801.255.5131 Utah Behavior Services Ste 27 1377 E 3900 S 5558 S 1900 W Salt Lake City UT. 84123 Salt Lake City UT. 84124 Slack, Micah BCBA Ste B p 801.266.2485 p 801.852.9440 ABS Kids Salt Lake City UT. 84129 515 S 700 E p 801.255.5131 5991 S Redwood Rd *Sinclair, Andrea CMHC Ste 2A Salt Lake City UT. 84123 PCH CHILD PSYCH-OP Salt Lake City UT. 84102 6013 S Redwood Rd p 801.266.2485 5770 S 1500 W p 801.935.4171 Salt Lake City UT. 84123 Taylorsville UT. 84123 p 801.255.5131 Smolka, Mindy CMHC p 801.313.7770 Slater, Courtney MSW Compass Counseling and Utah Behavior Services Smith, Hannah BCBA Consulting Hospital Affiliation 5558 S 1900 W ABS Kids 4000 S 700 E - Primary Childrens Hospital Ste B 515 S 700 E Ste 9 Salt Lake City UT. 84129 Ste 2A Salt Lake City UT. 84107 Sivertson, Savannah BCBA p 801.255.5131 Salt Lake City UT. 84102 p 801.639.9544 ABS Kids p 801.935.4171 515 S 700 E 6013 S Redwood Rd Snow, Lauren BCBA Ste 2A Salt Lake City UT. 84123 6910 S Highland Dr Utah Behavior Services Salt Lake City UT. 84102 p 801.255.5131 Ste 1 5558 S 1900 W p 801.935.4171 Cottonwood Heights UT. 84121 Ste B Smith, Amy MD p 801.935.4946 Taylorsville UT. 84118 6910 S Highland Dr University of Utah Health p 801.255.5131 Ste 1 1280 E Stringham Ave Smith, Julien T PhD Cottonwood Heights UT. 84121 Salt Lake City UT. 84106 Wasatch Pediatric 6013 S Redwood Rd p 801.935.4946 p 801.581.7951 Neuropsychology Taylorsville UT. 84123 231 E 400 S p 801.255.5131 Skedros, Maria LCSW 50 N Medical Dr Ste 335 Maria K Skedros LCSW Salt Lake City UT. 84132 Salt Lake City UT. 84111 Snow, Marie LPC 3980 S 700 E p 801.585.1575 p 801.363.1189 Jordan West Family Ste 22 Counseling Salt Lake City UT. 84107 501 S Chipeta Way Smith, Krista BCBA 9263 B Redwood Rd p 801.230.3244 Salt Lake City UT. 84108 ABS Kids West Jordan UT. 84088 p 801.587.3287 515 S 700 E p 801.566.0749 Skibitsky, Jeffrey BCBA Ste 2A ABS Kids Hospital Affiliation Salt Lake City UT. 84102 Snyder, Melissa LCSW 515 S 700 E - University of Utah Hospital p 801.935.4171 Crystal Counseling Ste 2A 151 E 5600 S Salt Lake City UT. 84102 Ste 208 p 801.935.4171 Salt Lake City UT. 84107 p 801.633.5173

274 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Solomon, Kimberly A LCSW 613 E Fort Union Blvd Staub, Velvet LCSW Stevens, Ashley L PhD Summit Community Ste 104 Velvet Counseling University of Utah Health Counseling Midvale UT. 84047 123 E 8720 S 81 N Mario Capecchi Dr 5689 S Redwood Rd p 801.984.1717 Sandy UT. 84070 Salt Lake City UT. 84113 Ste 27 p 801.709.9089 p 801.587.2255 Salt Lake City UT. 84123 Speiser, Page LCSW p 801.266.2485 Page Speiser LCSW Steans, Tammy LPC Hospital Affiliation 275 E S Temple Psychiatric & Behavioral - University of Utah Hospital 5991 S Redwood Rd Ste 101 Solutions Salt Lake City UT. 84123 Salt Lake City UT. 84111 1522 S 1100 E Stevens, Melena LCSW p 801.266.2485 p 801.531.7389 Salt Lake City UT. 84105 Jordan West Family p 801.467.1200 Counseling 925 E Executive Park Dr Spencer, Melissa J APRN 9263 Redwood Rd Bldg 8 Ste B Valley Behavioral Health Steele, Isaac D APRN West Jordan UT. 84088 Salt Lake City UT. 84107 1020 S Main St Valley Behavioral Health p 801.566.0749 p 801.580.3837 Ste 100 12427 S Pasture Rd Salt Lake City UT. 84101 Ste 104 Stevens, Nicole Solzbacher, Daniela MD p 888.949.4864 Riverton UT. 84096 BCBA,LMFT University of Utah Health p 888.949.4864 Utah Behavior Services 1280 E Stringham Ave Springer, Amy E LCSW 5558 S 1900 W Salt Lake City UT. 84106 Valley Behavioral Health Steinmann, Mary E MD Ste B p 801.581.7951 3809 W 6200 S University of Utah Health Salt Lake City UT. 84129 Salt Lake City UT. 84129 1950 Cir of Hope Dr p 801.255.5131 501 S Chipeta Way p 888.949.4864 Salt Lake City UT. 84112 Salt Lake City UT. 84108 p 801.583.2500 6013 S Redwood Rd p 801.587.3287 Stambaugh, Leigh Ann Salt Lake City UT. 84123 CMHC 50 N Medical Dr p 801.255.5131 Hospital Affiliation Ascendant Behavioral Salt Lake City UT. 84132 - University of Utah Hospital Health p 801.581.7951 Stevens, Paul T MD 5383 S 900 E University of Utah Health Sommers, Jania LCSW Ste 103 501 S Chipeta Way 1280 E Stringham Ave 223 S 700 E Salt Lake City UT. 84117 Salt Lake City UT. 84108 Salt Lake City UT. 84106 Salt Lake City UT. 84102 p 801.872.5516 p 801.587.3287 p 801.581.7951 p 385.282.8065 Stander, Eric C CSW Hospital Affiliation 50 N Medical Dr Sorenson, Cassie BCBA Valley Behavioral Health - University of Utah Hospital Salt Lake City UT. 84132 ABS Kids 2948 S Redwood Rd p 801.581.7951 515 S 700 E West Valley City UT. 84119 Stephens, Kaylie BCBA Ste 2A p 888.949.4864 ABS Kids 501 S Chipeta Way Salt Lake City UT. 84102 6910 S Highland Dr Salt Lake City UT. 84108 p 801.935.4171 Stark, Robert CMHC Ste 1 p 801.587.3287 Valley Behavioral Health Cottonwood Heights UT. 84121 6910 S Highland Dr 1020 S Main St p 801.935.4946 Hospital Affiliation Ste 1 Ste 200 - University of Utah Hospital Cottonwood Heights UT. 84121 Salt Lake City UT. 84101 Stephens, Travis R CSW p 801.935.4946 p 888.949.4864 Valley Behavioral Health Stevenson, Victoria A 12427 S Pasture Rd BCBA South Point Counseling Stasiuk, John A LMFT Ste 104 ABS Kids 1206 W S Jordan Pkwy Valley Behavioral Health Riverton UT. 84096 515 S 700 E Ste D 2948 S Redwood Rd p 888.949.4864 Ste 2A South Jordan UT. 84095 West Valley City UT. 84119 Salt Lake City UT. 84102 p 801.302.3801 p 888.949.4864 4460 S Highland Dr p 801.935.4171 Ste 100 Souza, Sarah M CSW Utah Behavior Services Salt Lake City UT. 84124 6910 S Highland Dr Valley Behavioral Health 5558 S 1900 W p 888.949.4864 Ste 1 2948 S Redwood Rd Ste B Cottonwood Heights UT. 84121 West Valley City UT. 84119 Salt Lake City UT. 84129 Stephenson, Sue A CMHC p 801.935.4946 p 888.949.4864 p 801.255.5131 Ascendant Behavioral Health Stewart, Mitzy APRN Sovinsky, Lisa M LCSW 6013 S Redwood Rd 5383 S 900 E Ascendant Behavioral Life Stone Counseling Salt Lake City UT. 84123 Ste 103 Health Center p 801.255.5131 Salt Lake City UT. 84117 5383 S 900 E 4190 S Highland Dr p 801.872.5516 Ste 103 Ste 208 Salt Lake City UT. 84117 Salt Lake City UT. 84124 p 801.872.5516 p 385.352.3101

275 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Stivers, Lauren M LCSW 3809 W 6200 S Sutherland, Debbie A LCSW Taholo, Leilani LCSW Life Matters Counseling & Taylorsville UT. 84129 Valley Behavioral Health Child and Family Health Center p 888.949.4864 12427 S Pasture Rd Empowerment Services 3336 S Pioneer Pkwy Ste 104 1578 W 1700 S Ste 201 Suarez, Alex LCSW Riverton UT. 84096 Ste 200 West Valley City UT. 84120 Utah Behavior Services p 888.949.4864 Salt Lake City UT. 84104 p 801.313.0555 5558 S 1900 W p 801.972.2711 Ste B 4460 S Highland Dr Stoddard, Nancy L LCSW Salt Lake City UT. 84129 Ste 100 Talbert, Kristina L PSYD Nancy L Stoddard, LCSW p 801.255.5131 Salt Lake City UT. 84124 South Point Counseling 4527 S 2300 E p 888.949.4864 1206 W S Jordan Pkwy Ste 206 6013 S Redwood Rd Ste D Salt Lake City UT. 84117 Salt Lake City UT. 84123 Swan, David M LCSW South Jordan UT. 84095 p 801.859.2194 p 801.255.5131 University Of Utah Health p 801.302.3801 501 S Chipeta Way Stoddart, Jeremy R MD Sugden, Steven G MD Salt Lake City UT. 84108 Talmadge, Tierney LCMHC University of Utah Health University of Utah Health p 801.585.1575 Next Level Recovery 375 S Chipeta Way 50 N Medical Dr 6771 S 900 E Salt Lake City UT. 84108 Salt Lake City UT. 84132 Hospital Affiliation Midvale UT. 84047 p 801.581.2016 p 801.585.1575 - University of Utah Hospital p 801.386.9799

Stotts, Jonas BCBA 501 S Chipeta Way Swapp, Lisa LCSW Taroian, Sevon LCSW ABS Kids Salt Lake City UT. 84108 Decision Point Counseling The OCD And Anxiety 6910 S Highland Dr p 801.587.3287 9710 S 700 E Treatment Center Ste 1 Ste 205 11260 S River Height Dr Cottonwood Heights UT. 84121 Hospital Affiliation Sandy UT. 84070 South Jordan UT. 84095 p 801.935.4946 - University of Utah Hospital p 385.630.0336 p 801.298.2000

Stout, Aaron LCSW Suh, Eun H LCSW Sykes, Eliot B LCSW Tate, David F PhD The OCD And Anxiety Valley Behavioral Health Lotus Center Inc University of Utah Health Treatment Center 1020 S Main St 4376 S 700 E 175 N Medical Dr E 11260 S River Height Dr Ste 100 Ste 200 Salt Lake City UT. 84132 South Jordan UT. 84095 Salt Lake City UT. 84101 Salt Lake City UT. 84107 p 801.585.7575 p 801.298.2000 p 888.949.4864 p 385.272.4292 50 N Medical Dr Stout, Julie A LMFT Suh, Irene LCSW Szykula, Gail T LPC Salt Lake City UT. 84132 5667 S Redwood Rd Unit 5B South Summit Pediatrics Advanced Behavioral Care p 801.585.6387 Taylorsville UT. 84123 267 E Traverse Point Dr 1545 E 3300 S p 801.699.4149 Draper UT. 84020 Salt Lake City UT. 84106 729 S Arapeen Dr p 801.553.8300 p 801.478.2780 Salt Lake City UT. 84108 Stout, Kelly L PhD p 801.585.6387 University of Utah Health Summit Primary Care & Szykula, Steven A PhD 81 N Mario Capecchi Dr Clinical Services Comprehensive Taylor, Mark BCBA Salt Lake City UT. 84113 1561 W 7000 S Psychological Services ABS Kids p 801.587.2255 Ste 200 1208 E 3300 S 515 S 700 E West Jordan UT. 84084 Salt Lake City UT. 84106 Ste 2A Hospital Affiliation p 801.263.0717 p 801.483.1600 Salt Lake City UT. 84102 - University of Utah Hospital p 801.935.4171 Supiano, Katherine P LCSW 3725 W 4100 S Strachan, Robert K PhD University of Utah Health West Valley City UT. 84119 Tea, Elizabeth C LCSW Valley Behavioral Health 1578 W 1700 S p 801.965.3759 Valley Behavioral Health 1020 S Main St Salt Lake City UT. 84104 195 W 7200 S Ste 200 p 801.581.4014 Tabara, Jackqueline BCBA Midvale UT. 84047 Salt Lake City UT. 84101 ABS Kids p 888.949.4864 p 888.949.4864 50 N Medical Dr 515 S 700 E Salt Lake City UT. 84132 Ste 2A Tellesbo, Sarah M LCSW Stroh, Shane L RN p 801.213.2995 Salt Lake City UT. 84102 Cedar Psychiatry Valley Behavioral Health p 801.935.4946 1208 E 3300 S 1141 E 3900 S 5126 W Daybreak Pkwy Salt Lake City UT. 84106 Ste A170 South Jordan UT. 84009 6910 S Highland Dr p 801.369.8989 Salt Lake City UT. 84124 p 801.213.4500 Ste 1 p 888.949.4864 Salt Lake City UT. 84121 Valley Behavioral Health Hospital Affiliation p 801.935.4171 2948 S Redwood Rd - University of Utah Hospital West Valley City UT. 84119 p 888.949.4864

276 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Cedar Psychiatry Thielking, Paul D MD 12397 S 300 E Tidwell, Brant A SSW 721 E 12200 S University of Utah Health Ste 100 Valley Behavioral Health Draper UT. 84020 1280 E Stringham Ave Draper UT. 84020 195 W 7200 S p 801.369.8989 Salt Lake City UT. 84106 p 385.900.4020 Midvale UT. 84047 p 801.581.7951 p 888.949.4864 Tenney, Joseph T LCSW Thompson, Michael S LMFT Valley Behavioral Health Cedar Psychiatry Valley Behavioral Health Tillman, Daniel C SSW 12427 S Pasture Rd 154 E Myrtle Ave 12427 S Pasture Rd Valley Behavioral Health Ste 104 Ste 204 Ste 104 2472 S 300 E Riverton UT. 84096 Murray UT. 84107 Herriman UT. 84096 Salt Lake City UT. 84115 p 888.949.4864 p 801.369.8989 p 888.949.4864 p 888.949.4864

4460 S Highland Dr University of Utah Health 4460 S Highland Dr Timmins, Joseph M LCSW Ste 100 1950 Cir of Hope Dr Ste 100 Draper Family Therapy Salt Lake City UT. 84124 Salt Lake City UT. 84112 Salt Lake City UT. 84124 12176 S 1000 E p 888.949.4864 p 801.583.2500 p 888.949.4864 Ste 8C Draper UT. 84020 Thatcher, Benjamin T DO 50 N Medical Dr Thompson, Paula A CSW p 801.987.3222 Valley Behavioral Health Salt Lake City UT. 84132 Valley Behavioral Health 1020 S Main St p 801.585.1575 1141 E 3900 S Timpson, Melissa LCSW Ste 100 Ste A170 University Of Utah Health Salt Lake City UT. 84101 501 S Chipeta Way Salt Lake City UT. 84124 1950 Cir of Hope Dr p 888.949.4864 Salt Lake City UT. 84108 p 888.949.4864 Salt Lake City UT. 84112 p 801.587.3287 p 801.587.7000 12427 S Pasture Rd *Thorn, Brian L PhD Ste 104 Cedar Psychiatry Primary Childrens Hospital Hospital Affiliation Riverton UT. 84096 721 E 12200 S 81 N Mario Capecchi Dr - University of Utah Hospital p 888.949.4864 Draper UT. 84020 Salt Lake City UT. 84113 p 801.369.8989 p 801.662.3606 Tingey, Jenise D LCSW 4460 S Highland Dr Valley Behavioral Health Ste 100 Hospital Affiliation Thorn, Kirk B PhD 12427 S Pasture Rd Salt Lake City UT. 84124 - University of Utah Hospital Willow Creek Psychological Ste 104 p 888.949.4864 Service Inc Riverton UT. 84096 Thomas, Jonathon (JT) 1111 E Draper Pkwy p 888.949.4864 Thatcher, John W MD BCBA Ste 102 JVMC - WVC Behavioral ABS Kids Draper UT. 84020 4460 S Highland Dr Health - IP 515 S 700 E p 385.269.0333 Ste 100 3460 S Pioneer Pkwy Ste 2A Salt Lake City UT. 84124 West Valley City UT. 84120 Salt Lake City UT. 84102 Thueson, Jeremy E MD p 888.949.4864 p 801.964.3575 p 801.935.4171 University of Utah Health 1280 E Stringham Ave Tippins, Maurice P LPN Thayer, Stephen PhD 6910 S Highland Dr Salt Lake City UT. 84106 Valley Behavioral Health Cedar Psychiatry Ste 1 p 801.581.7951 3809 W 6200 S 154 E Myrtle Ave Cottonwood Heights UT. 84121 Salt Lake City UT. 84129 Ste 204 p 801.935.4946 501 S Chipeta Way p 888.949.4864 Murray UT. 84107 Salt Lake City UT. 84108 p 801.369.8989 Thompson, Chelsea BCBA p 801.587.3287 Tipton, Lauren LCSW ABS Kids Comprehensive 721 E 12200 S 515 S 700 E Hospital Affiliation Psychological Services Draper UT. 84020 Ste 2A - University of Utah Hospital 1208 E 3300 S p 801.369.8989 Salt Lake City UT. 84102 Salt Lake City UT. 84106 p 801.935.4171 Thurgood, Brook BCBA p 801.483.1600 The Green House for Growth ABS Kids & Learning Thompson, Frances L PSYD 515 S 700 E Todd, Jessica J CMHC 1325 W S Jordan Pkwy Early Life Child Ste 2A Neurobehavioral Center for Ste 102 Psychology & Education Salt Lake City UT. 84102 Growth South Jordan UT. 84095 Center p 801.935.4171 370 E South Temple p 801.208.8838 10757 E River Front Pkwy Ste 175 Ste 275 6910 S Highland Dr Salt Lake City UT. 84111 The OCD and Anxiety South Jordan UT. 84095 Ste 1 p 801.683.1062 Treatment Center p 385.900.4020 Cottonwood Heights UT. 84121 11260 River Heights Dr p 801.935.4946 Toth, Michele MD South Jordan UT. 84095 Jordan Valley Medical p 801.298.2000 Center West Valley Campus Inpatient BH Unit 3460 S 4155 W West Valley City UT. 84120 p 801.964.3559

Hospital Affiliation - Jordan Valley Medical 277 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021Center 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Tracy, Robin CMHC 501 S Chipeta Way University of Utah Valles, Rene J MD Aspen Ridge Counseling Salt Lake City UT. 84108 Pediatric Adolescent Valley Behavioral Health 2880 W 4700 S p 801.585.1575 Professional Services 1141 E 3900 S Ste G-1 501 Chipeta Way Ste A170 Salt Lake City UT. 84129 51 W 3900 S Salt Lake City UT. 84108 Salt Lake City UT. 84124 p 801.990.4300 Salt Lake City UT. 84107 p 801.585.1575 p 888.949.4864 p 801.585.1575 Collective Recovery Center Pediatric UNI-OutReach Hospital Affiliation 8029 S 700 E Hospital Affiliation Services - Jordan Valley Medical Sandy UT. 84070 - University of Utah Hospital 650 S Komas Dr Center West Valley Campus p 385.557.2183 Salt Lake City UT. 84108 Tuttle, Jenny Jo LCSW p 801.585.1212 Phone Number Only Tucker, Dennis A LCSW Jenny Jo Tuttle LCSW Salt Lake City UT. 84121 Insights Counseling 4190 S Highland Dr Universtiy of Utah Health p 888.949.4864 9192 S 300 W Ste 108 Care Girls Transition Ste 317A Salt Lake City UT. 84124 Center VandeMerwe, Leslie A CMHC Sandy UT. 84070 p 801.214.1582 51 W 3900 S Jordan West Family p 801.979.0612 Salt Lake City UT. 84107 Counseling Twu, Jesse p 801.583.2500 9263 Redwood Rd Bldg 8 9192 S 300 W Senior Behavioral Health Ste B Ste 31 SLC - IP Urry, Kristin K LCSW West Jordan UT. 84088 Sandy UT. 84070 1050 E S Temple 2nd Fl 1399 S 700 E p 801.523.5206 p 801.979.0610 Salt Lake City UT. 84102 Ste 15 p 801.350.4111 Salt Lake City UT. 84105 Vanderstappen, Amber Tuckett, Deborah SSW p 801.882.1262 LCSW Valley Behavioral Health Adult Behavioral Health Terrain Therapy 195 W 7200 S JVMC-WVC - IP Utah Autism Academy 2627 E Parleys Way Midvale UT. 84047 3460 S 4155 W 5th Fl 7434 S State St Salt Lake City UT. 84109 p 888.949.4864 West Valley City UT. 84120 Midvale UT. 84047 p 801.808.9235 p 801.964.3111 p 801.456.9955 3444 W 4400 S Vanengelenhoven, Jennifer West Valley City UT. 84119 Hospital Affiliation Utah Behavior Services LMFT p 888.949.4864 - Davis Hospital 5558 S 1900 W Valley Behavioral Health Ste B 4460 S Highland Dr Turner, Blake CSW Uckerman, Clifton R LCSW Salt Lake City UT. 84129 Ste 100 Community Health Centers Ascendant Behavioral p 801.255.5131 Salt Lake City UT. 84124 1365 W 1000 N Health p 888.949.4864 Salt Lake City UT. 84116 4179 Riverboat Rd 6013 S Redwood Rd p 801.328.5750 Ste 220 Salt Lake City UT. 84123 Varco, Tammy L CMHC Salt Lake City UT. 84123 p 801.255.5131 Valley Behavioral Health 4745 S 3200 W p 801.872.5516 1020 S Main St Salt Lake City UT. 84129 Valdez, Danielle LCSW Ste 100 p 801.964.6214 5383 S 900 E University of Utah Health Salt Lake City UT. 84101 Ste 103 1525 W 2100 S p 888.949.4864 Turner, Donna E PhD Salt Lake City UT. 84117 Salt Lake City UT. 84119 Valley Behavioral Health p 801.872.5516 p 801.213.8841 Jordan West Family 4460 S Highland Dr Counseling Ste 100 Underwood, Rocky C PhD 3730 W 4700 S 9263 Redwood Rd Bldg 8 Salt Lake City UT. 84124 Intermountain Taylorsville UT. 84129 West Jordan UT. 84088 p 888.949.4864 Psychological Services p 801.213.9200 p 801.566.0749 12401 S 450 E Bldg D-2 Turner, Meredith CSW Draper UT. 84020 5126 W Daybreak Pkwy Vezie, Linda LCSW The Utah House p 801.440.8501 South Jordan UT. 84009 University of Utah Health 1370 S West Temple p 801.213.4500 1280 E Stringham Ave Salt Lake City UT. 84115 Ungricht, Misty T LCSW Salt Lake City UT. 84106 p 801.678.3317 Valley Behavioral Health 7495 S State St p 801.213.8841 3809 W 6200 S Midvale UT. 84047 Turnidge Halvorson, Taylorsville UT. 84129 p 801.213.9400 1525 W 2100 S Nicole R PhD p 888.949.4864 Salt Lake City UT. 84119 University of Utah Health Hospital Affiliation p 801.213.9900 50 N Medical Dr Pediatric Behavioral - University of Utah Hospital Salt Lake City UT. 84132 Health 3730 W 4700 S p 801.585.1575 100 Mario Cappechi Dr Taylorsville UT. 84129 Salt Lake City UT. 84113 p 801.213.9200 p 801.662.1000

278 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 5126 W Daybreak Pkwy Visker, James K ANP 12397 S 300 E Waite, Laura LMFT Ste 600 White Tree Medical Ste 100 The OCD And Anxiety South Jordan UT. 84009 Consultants LLC Draper UT. 84020 Treatment Center p 801.213.4500 10437 S Jordan Gateway p 385.900.4020 11260 S River Height Dr South Jordan UT. 84095 South Jordan UT. 84095 5126 W Daybreak Pkwy p 385.535.6996 Ascendant Behavioral p 801.298.2000 South Jordan UT. 84009 Health p 801.213.4500 Vo, Michelle L MD 5383 S 900 E Waite, N John Evan CMHC University of Utah Health Ste 103 Jordan West Family 555 Foothill Dr 1280 E Stringham Ave Salt Lake City UT. 84117 Counseling Ste 301 Salt Lake City UT. 84106 p 801.872.5516 9263 Redwood Rd Bldg 8 Salt Lake City UT. 84112 p 801.581.7951 Ste B p 801.581.8000 Voss, Michael J MD West Jordan UT. 84088 1950 Cir of Hope Dr University of Utah Health p 801.566.0749 555 Foothill Dr Salt Lake City UT. 84112 1950 Cir of Hope Dr Salt Lake City UT. 84112 p 801.583.2500 Salt Lake City UT. 84112 Walker, Alison BCBA p 801.581.8000 p 801.583.2500 Utah Autism Academy 50 N Medical Dr 7434 S State St 7495 S State St Salt Lake City UT. 84132 50 N Medical Dr Midvale UT. 84047 Midvale UT. 84047 p 801.585.1575 Salt Lake City UT. 84132 p 801.456.9955 p 801.213.9400 p 801.581.7951 501 S Chipeta Way Walker, David R CMHC Vicario, Matthew J LPC Salt Lake City UT. 84108 501 S Chipeta Way Valley Behavioral Health 5691 S Redwood Rd p 801.587.3287 Salt Lake City UT. 84108 12427 S Pasture Rd Ste 15 p 801.587.3287 Ste 104 Salt Lake City UT. 84123 Hospital Affiliation Riverton UT. 84096 p 801.946.2323 - University of Utah Hospital Hospital Affiliation p 888.949.4864 - University of Utah Hospital 8728 S 120 E Voigt, Jonathan LCSW 4460 S Highland Dr Sandy UT. 84070 Valley Behavioral Health Vyfvinkel, Michael J SSW Ste 100 p 801.946.2323 1141 E 3900 S Valley Behavioral Health Salt Lake City UT. 84124 Ste A250 1141 E 3900 S p 888.949.4864 Villalobos, Michele E Phd Salt Lake City UT. 84124 Ste A250 University of Utah Health p 888.949.4864 Salt Lake City UT. 84124 Walls, Sharon LMFT 81 N Mario Capecchi Dr p 888.949.4864 Ascendant Behavioral Salt Lake City UT. 84113 12427 S Pasture Rd Health p 801.587.2255 Ste 104 Waddell, Kathryn J PhD 5383 S 900 E Riverton UT. 84096 Salt Lake Regional Medical Ste 103 Hospital Affiliation p 888.949.4864 Center - BH Unit Salt Lake City UT. 84117 - University of Utah Hospital 1050 E S Temple p 801.872.5516 4460 S Highland Dr Salt Lake City UT. 84102 Vincent, Alecia N SSW Ste 100 p 801.350.4715 Walter, Samuel Grey LCSW Valley Behavioral Health Salt Lake City UT. 84124 Compass Counseling and 1141 E 3900 S p 888.949.4864 Wadleigh, Thomas LPC Consulting Ste A250 Healing Vistas, LLC 4000 S 700 E Salt Lake City UT. 84124 Volkman, Sage CMHC 151 E 5600 S Ste 9 p 888.949.4864 Sage Wellness and Ste 302 Salt Lake City UT. 84107 Counseling Salt Lake City UT. 84107 p 801.639.9544 Vinegra, Christopher J MD 12884 S Frontrunner Blvd p 801.865.6122 Senior Behavioral Health - Ste 140 Ward, Cori APRN Inpatient Draper UT. 84020 Wagner, Brenna BCBA Utah Behavior Services 1050 E S Temple 2nd Fl p 844.724.3935 ABS Kids 5558 S 1900 W Salt Lake City UT. 84102 515 S 700 E Ste B p 801.350.4111 Vonk, Vivian L CMHC Ste 2A Salt Lake City UT. 84129 Early Life Child Salt Lake City UT. 84102 p 801.255.5131 Jordan Valley Outpatient Psychology & Education p 801.935.4171 Behavioral Health - West Center 6013 S Redwood Rd Valley 10757 S River Front Pkwy Wagner, Dorothy A SSW Salt Lake City UT. 84123 4052 W Pioneer Pkwy Ste 275 Valley Behavioral Health p 801.255.5131 Ste 105 South Jordan UT. 84095 1141 E 3900 S West Valley City UT. 84120 p 385.900.4020 Ste A250 *Ward, Melanie M LCSW p 801.964.3752 Salt Lake City UT. 84124 PCH CHILD PSYCH-OP p 888.949.4864 5770 S 1500 W Hospital Affiliation TAYLORSVILLE UT. 84123 - St Marks Hospital p 801.313.7770 - Salt Lake Regional Medical Center Hospital Affiliation - Primary Childrens Hospital 279 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Wark, Heather MD Weeks, Howard R MD Weisenbach, Sara L PhD Whitaker, David H PSYD Salt Lake Regional Medical University of Utah Health University of Utah Health David H Whitaker PsyD CMHC Center - BH Unit 1280 E Stringham Ave 50 N Medical Dr 825 E 4800 S 1050 E S Temple Salt Lake City UT. 84106 Salt Lake City UT. 84132 Ste 250C Salt Lake City UT. 84102 p 801.581.7951 p 801.581.7951 Salt Lake City UT. 84107 p 801.350.4715 p 801.657.5883 501 S Chipeta Way 501 S Chipeta Way Adult Behavioral Health Salt Lake City UT. 84108 Salt Lake City UT. 84108 9001 S 3200 W JVMC-WVC - OP p 801.587.3287 p 801.583.2500 West Jordan UT. 84088 4052 W Pioneer Pkwy p 801.657.5883 Ste 105 Weir, Rachel A MD Hospital Affiliation West Valley City UT. 84120 University of Utah Health - University of Utah Hospital White Tree Medical p 801.964.3111 1280 E Stringham Ave Consultants LLC Salt Lake City UT. 84106 Western, Shasta BCBA 10437 S Jordan Gateway Warr, Adriane N SSW p 801.581.7951 ABS Kids South Jordan UT. 84095 Valley Behavioral Health 515 S 700 E p 385.535.6996 1141 E 3900 S 1525 W 2100 S Ste 2A Ste A250 Salt Lake City UT. 84119 Salt Lake City UT. 84102 White, Laura PhD Salt Lake City UT. 84124 p 801.213.8841 p 801.935.4171 University of Utah Health p 888.949.4864 50 N Medical Dr 50 N Medical Dr 6910 S Highland Dr Salt Lake City UT. 84132 Wasatch Psychological Salt Lake City UT. 84132 Ste 1 p 801.581.7951 Services p 801.585.1575 Cottonwood Heights UT. 84121 1060 E 100 S p 801.935.4946 Hospital Affiliation Ste 100 501 S Chipeta Way - University of Utah Hospital Salt Lake City UT. 84102 Salt Lake City UT. 84108 Weston, Sophia BCBA p 801.590.0525 p 801.587.3287 ABS Kids White, Melinda CSW 515 S 700 E Valley Behavioral Health Waugaman, Laura CMHC Hospital Affiliation Ste 2A 1141 E 3900 S Summit Community - University of Utah Hospital Salt Lake City UT. 84102 Ste A250 Counseling p 801.935.4171 Salt Lake City UT. 84124 5689 S Redwood Rd Weisbender, Christopher P p 888.949.4864 Ste 27 CSW 6910 S Highland Dr Salt Lake City UT. 84123 Valley Behavioral Health Ste 1 White, Mollie M RN p 801.266.2485 1141 E 3900 S Salt Lake City UT. 84121 Valley Behavioral Health Ste A250 p 801.935.4171 3809 W 6200 S 5991 S Redwood Rd Salt Lake City UT. 84124 Taylorsville UT. 84129 Salt Lake City UT. 84123 p 888.949.4864 Weymann, Timothy J LCSW p 888.949.4864 p 801.266.2485 Compass Counseling and 3809 W 6200 S Consulting Whitehead, Dex LCSW Weaver, Nancy L LPN Taylorsville UT. 84129 4000 S 700 E Sundance Behavioral Valley Behavioral Health p 888.949.4864 Ste 9 Resources 1141 E 3900 S Salt Lake City UT. 84107 845 E 4800 S Ste A250 Weischedel, Bradley D p 801.639.9544 Ste 200 Salt Lake City UT. 84124 LCSW Murray UT. 84107 p 888.949.4864 Centered Approach Whatcott, Natalie p 801.264.9522 Counseling BCBA,SSW Webster, Peggy CMHC 4190 S Highland Dr Utah Behavior Services Whitlock, Megan J LCSW Ascendant Behavioral Ste 220 5558 S 1900 W University of Utah Health Health Salt Lake City UT. 84124 Ste B 1138 E Wilmington Ave 5383 S 900 E p 385.282.3349 Salt Lake City UT. 84129 Salt Lake City UT. 84106 Ste 103 p 801.255.5131 p 801.213.8845 Salt Lake City UT. 84117 Weischedel, Kamile MD p 801.872.5516 University of Utah Health 6013 S Redwood Rd 1280 E Stringham Ave 1280 E Stringham Ave Salt Lake City UT. 84123 Salt Lake City UT. 84106 Weeks, Deanna Salt Lake City UT. 84106 p 801.255.5131 p 801.213.8841 The OCD And Anxiety p 801.581.7951 Treatment Center Whipps, Paige CSW 555 Foothill Dr 11260 S River Height Dr 501 S Chipeta Way Peaceful Solutions Salt Lake City UT. 84112 South Jordan UT. 84095 Salt Lake City UT. 84108 Counseling, LLC p 801.581.8000 p 801.298.2000 p 801.587.3287 1399 S 700 E Ste 5 Hospital Affiliation Hospital Affiliation Salt Lake City UT. 84105 - University of Utah Hospital - University of Utah Hospital p 801.651.3907

280 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Wickersham, Michael C 6013 S Redwood Rd Winslow, Tatum BCBA 411 W 7200 S LCSW Taylorsville UT. 84123 ABS Kids Ste 304 Kaizen Center for Mental p 801.255.5131 6910 S Highland Dr Midvale UT. 84047 Health Ste 1 p 801.990.4300 4055 S 700 E Wilson Barlow, Lindsay D Cottonwood Heights UT. 84121 Ste 103 PhD p 801.935.4946 Woodall, Clifford BCBA Salt Lake City UT. 84107 University of Utah Health Utah Behavior Services p 801.712.1790 50 N Medical Dr Winward, Karen LPC 5558 S 1900 W Salt Lake City UT. 84132 Valley Behavioral Health Ste B Wiese, Julie MD p 801.581.7951 12427 S Pasture Rd Salt Lake City UT. 84129 Sundance Behavioral Ste 104 p 801.255.5131 Resources Hospital Affiliation Riverton UT. 84096 845 E 4800 S - University of Utah Hospital p 888.949.4864 6013 S Redwood Rd Ste 200 Salt Lake City UT. 84123 Murray UT. 84107 Wilson, Amy L MD Wirthlin, Lora LCMHC p 801.255.5131 p 801.264.9522 University of Utah Health Aspen Ridge Counseling 1280 E Stringham Ave 2880 W 4700 S Woodard, Jeness L LCSW Wiggins, Celeste M CSW Salt Lake City UT. 84106 Ste G-1 University of Utah Health Ascendant Behavioral p 801.581.7951 Salt Lake City UT. 84129 1280 E Stringham Ave Health p 801.990.4300 Salt Lake City UT. 84106 5383 S 900 E 1950 Cir of Hope Dr p 801.581.2000 Ste 103 Salt Lake City UT. 84112 Wisco, Monica LCSW Salt Lake City UT. 84117 p 801.583.2500 Life Stone Counseling 1525 W 2100 S p 801.872.5516 Center Salt Lake City UT. 84119 50 N Medical Dr 613 E Fort Union Blvd p 801.213.9900 Wilde, Craig H CSW Salt Lake City UT. 84132 Ste 104 Valley Behavioral Health p 801.585.1575 Midvale UT. 84047 3730 W 4700 S 1020 S Main St p 801.984.1717 Taylorsville UT. 84129 Ste 100 501 S Chipeta Way p 801.213.9200 Salt Lake City UT. 84101 Salt Lake City UT. 84108 Wolf, Marcella F LCSW p 888.949.4864 p 801.587.3287 Valley Behavioral Health 5126 W Daybreak Pkwy 1020 S Main St Ste 600 Wilde, Hannah K LCSW Hospital Affiliation Ste 100 South Jordan UT. 84009 Life Matters Counseling & - University of Utah Hospital Salt Lake City UT. 84101 p 801.213.4500 Health Center p 888.949.4864 2225 E Murray-Holladay Rd Wilson, Courtney CSW 555 Foothill Dr Ste 112 Valley Behavioral Health 1141 E 3900 S Ste 301 Salt Lake City UT. 84117 1141 E 3900 S Ste A250 Salt Lake City UT. 84112 p 801.313.0555 Ste A170 Salt Lake City UT. 84124 p 801.581.8000 Salt Lake City UT. 84124 p 888.949.4864 3336 S Pioneer Pkwy p 888.949.4864 7495 S State St Ste 201 2948 S Redwood Rd Midvale UT. 84047 West Valley City UT. 84120 Wilson, Dodiann R CMHC West Valley City UT. 84119 p 801.213.9400 p 801.313.0555 SunDance Behavioral p 888.949.4864 Resources Woods, Kamille D SSW Wilkerson, Tristyn PSYD 845 E 4800 S Wood, Felicia LCSW Valley Behavioral Health 230 S 500 E Ste 200 Aspen Ridge Counseling 1141 E 3900 S Ste 100 Salt Lake City UT. 84107 11075 S State St Ste A250 Salt Lake City UT. 84102 p 801.264.9522 Ste 35 Salt Lake City UT. 84124 p 801.532.1484 Sandy UT. 84070 p 888.949.4864 Wilson, Megan BCBA p 801.501.8444 Wilkes, Ryan W PSYD Utah Behavior Services Woolf, Paul L LPC Wasatch Psychological 5558 S 1900 W 1561 W 7000 S Summit Community Services Ste B Ste 200 Counseling 1060 E 100 S Salt Lake City UT. 84129 West Jordan UT. 84084 5689 S Redwood Rd Ste 100 p 801.255.5131 p 801.990.4300 Ste 27 Salt Lake City UT. 84102 Salt Lake City UT. 84123 p 801.590.0525 6013 S Redwood Rd 2711 S 8500 W p 801.266.2485 Salt Lake City UT. 84123 Magna UT. 84044 Wills, Brooke BCBA p 801.255.5131 p 801.990.4300 5991 S Redwood Rd Utah Behavior Services Salt Lake City UT. 84123 5558 S 1900 W Winn, Julie H LCSW 2880 W 4700 S p 801.266.2485 Ste B Valley Behavioral Health Ste G-1 Taylorsville UT. 84118 195 W 7200 S Salt Lake City UT. 84129 p 801.255.5131 Midvale UT. 84047 p 801.990.4300 p 888.949.4864

281 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Wright, Ashley M CSW 4460 S Highland Dr Zendejas, Viridiana LCSW de la Torre, J Manuel Valley Behavioral Health Ste 100 Multicultural Counseling LCSW 1141 E 3900 S Salt Lake City UT. 84124 Center 1579 W 600 S Ste A170 p 888.949.4864 7625 S 3200 W Salt Lake City UT. 84104 Salt Lake City UT. 84124 Ste 2 p 801.973.0655 p 888.949.4864 Yeaman, Candice CMHC West Jordan UT. 84084 Early Life Child p 801.915.0359 Neonatology Wulfenstein, Lee BCBA Psychology & Education Andres, Robert L MD Utah Behavior Services Center Zeuschner, Jennifer CMHC University of Utah Health 5558 S 1900 W 12397 S 300 E Early Life Child 50 N Medical Dr Ste B Ste 100 Psychology & Education Salt Lake City UT. 84132 Salt Lake City UT. 84129 Draper UT. 84020 Center p 801.213.2995 p 801.255.5131 p 385.900.4020 10757 E River Front Pkwy Ste 275 Hospital Affiliation 6013 S Redwood Rd Young, Jeanelle BCBA South Jordan UT. 84095 - University of Utah Hospital Salt Lake City UT. 84123 ABS Kids p 385.900.4020 p 801.255.5131 515 S 700 E *Byrne, Janice L MD Ste 2A 12397 S 300 E Primary Childrens Hospital Wyner, Gayle LCSW Salt Lake City UT. 84102 Ste 100 Physicians 10815 S 700 E p 801.935.4171 Draper UT. 84020 100 N Mario Capecchi Dr Sandy UT. 84070 p 385.900.4020 Salt Lake City UT. 84113 p 801.867.3472 6910 S Highland Dr p 801.662.1000 Ste 1 Zimmerman, Karyl J CSW Yang, Danielle BCBA Cottonwood Heights UT. 84121 Valley Behavioral Health University of Utah Health Utah Behavior Services p 801.935.4946 1141 E 3900 S 50 N Medical Dr 5558 S 1900 W Ste A250 Salt Lake City UT. 84132 Ste B Youngstrom, Glen LCSW Salt Lake City UT. 84124 p 801.581.8425 Salt Lake City UT. 84129 Aspen Ridge Counseling p 888.949.4864 p 801.255.5131 2880 W 4700 S 7495 S State St Ste G-1 Zimmerman, Rita M CMHC Midvale UT. 84047 6013 S Redwood Rd Salt Lake City UT. 84129 Neurobehavioral Center for p 801.213.9400 Salt Lake City UT. 84123 p 801.990.4300 Growth p 801.255.5131 370 E South Temple Primary Childrens Hospital Yurgelun-Todd, Deborah A Ste 175 Physicians Yarger, Jesse BCBA PhD Salt Lake City UT. 84111 81 N Mario Capecchi Dr Neurobehavioral Center for University of Utah Health p 801.683.1062 Salt Lake City UT. 84113 Growth 1280 E Stringham Ave p 801.662.1000 370 E South Temple Salt Lake City UT. 84106 Zubieta, Jon Kar MD Ste 175 p 801.581.7951 University of Utah Health Hospital Affiliation Salt Lake City UT. 84111 1950 Cir of Hope Dr - University of Utah Hospital p 801.683.1062 1950 Cir of Hope Dr Salt Lake City UT. 84112 Salt Lake City UT. 84112 p 801.583.2500 Carr, Nicholas R DO Yau, Joseph K MD p 801.583.2500 University Of Utah Health Ascendant Behavioral 50 N Medical Dr 100 N Mario Capecchi Dr Health 50 N Medical Dr Salt Lake City UT. 84132 Salt Lake City UT. 84113 5383 S 900 E Salt Lake City UT. 84132 p 801.581.7951 p 801.662.4100 Ste 103 p 801.581.7951 Salt Lake City UT. 84117 501 S Chipeta Way 50 N Medical Dr p 801.872.5516 Zabka, Hannah M LCSW Salt Lake City UT. 84108 Salt Lake City UT. 84132 Lotus Center Inc p 801.587.3287 p 801.581.2121 Hospital Affiliation 4376 S 700 E - University of Utah Hospital Ste 200 Hospital Affiliation 5121 S Cottonwood St Salt Lake City UT. 84107 - University of Utah Hospital Murray UT. 84107 Yazzie, Danet J LCSW p 385.272.4292 p 801.507.7000 Valley Behavioral Health Zuehlke, Angela M LCSW 1020 S Main St Zarbock, Micheala CSW Jordan West Family Hospital Affiliation Ste 300 Valley Behavioral Health Counseling - University of Utah Hospital Salt Lake City UT. 84101 2948 S Redwood Rd 9263 Redwood Rd Bldg 8 p 888.949.4864 West Valley City UT. 84119 West Jordan UT. 84088 Chan, Belinda MD p 888.949.4864 p 801.566.0749 University of Utah Health Ybarra, Corylyn L CMHC 100 N Mario Capecchi Dr Valley Behavioral Health Zehnder, Jean D MD da Silva, Laura CMHC Salt Lake City UT. 84113 12427 S Pasture Rd Exodus Healthcare Network Lighthouse Counseling p 801.662.4100 Ste 104 3336 S Pioneer Pkwy Services Riverton UT. 84096 Ste 201 3409 W 12600 S p 888.949.4864 Salt Lake City UT. 84120 Ste 110 p 801.250.9638 Riverton UT. 84065 p 385.237.4943 Hospital Affiliation - University of Utah Hospital 282 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 50 N Medical Dr Fung, Camille M MD 3460 S Pioneer Pkwy 5121 S Cottonwood St Salt Lake City UT. 84132 University of Utah Health West Valley City UT. 84120 Murray UT. 84107 p 801.581.2121 100 N Mario Capecchi Dr p 801.964.3100 p 801.507.7000 Salt Lake City UT. 84113 5121 S Cottonwood St p 801.662.4100 Hospital Affiliation Hospital Affiliation Murray UT. 84107 - St Marks Hospital - Primary Childrens Hospital p 801.507.7000 50 N Medical Dr - Lone Peak Hospital Salt Lake City UT. 84132 - Jordan Valley Medical Miner, Lonnie J MD Hospital Affiliation p 801.581.2121 Center University of Utah Health - Primary Childrens Hospital 100 N Mario Capecchi Dr Gerday, Erick B MD Ling, Con Y MD Salt Lake City UT. 84113 Christensen, Robert D MD University of Utah Health University of Utah Health p 801.662.4100 University of Utah Health 100 N Mario Capecchi Dr 100 N Mario Capecchi Dr 50 N Medical Dr Salt Lake City UT. 84113 Salt Lake City UT. 84113 50 N Medical Dr Salt Lake City UT. 84132 p 801.662.4100 p 801.662.4100 Salt Lake City UT. 84132 p 801.581.2121 p 801.581.2121 50 N Medical Dr 50 N Medical Dr Davidson, Jessica M MD Salt Lake City UT. 84132 Salt Lake City UT. 84132 5121 S Cottonwood St University of Utah Health p 801.581.2121 p 801.581.2121 Salt Lake City UT. 84107 100 N Mario Capecchi Dr p 801.507.7000 Salt Lake City UT. 84113 5121 S Cottonwood St 5121 S Cottonwood St p 801.662.4100 Murray UT. 84107 Salt Lake City UT. 84107 Murphy, Jennifer L MD p 801.507.7000 p 801.507.7000 Pediatrix Medical Group 50 N Medical Dr 11925 S State St Salt Lake City UT. 84132 Hospital Affiliation Hospital Affiliation Draper UT. 84020 p 801.581.2121 - St George Regional Hospital - University of Utah Hospital p 801.545.8000

5121 S Cottonwood St Grubb, Peter H MD Liu, Ellen MD 1200 E 3900 S Murray UT. 84107 University of Utah Health Pediatrix Medical Group Salt Lake City UT. 84124 p 801.507.7000 100 N Mario Capecchi Dr 1200 E 3900 S p 801.268.7111 Salt Lake City UT. 84113 Salt Lake City UT. 84124 Hospital Affiliation p 801.662.4100 p 801.268.7111 3460 S Pioneer Pkwy - University of Utah Hospital West Valley City UT. 84120 50 N Medical Dr Hospital Affiliation p 801.964.3100 Douglass, Matthew S DO Salt Lake City UT. 84132 - St Marks Hospital University Of Utah Health p 801.581.2121 - Lone Peak Hospital 3580 W 9000 S 50 N Medical Dr - Jordan Valley Medical West Jordan UT. 84088 Salt Lake City UT. 84132 5121 S Cottonwood St Center p 801.561.8888 p 801.581.2121 Murray UT. 84107 p 801.507.7000 Malone Jenkins, Sabrina R O Brien, Elizabeth A MD 5121 S Cottonwood St MD University of Utah Health Murray UT. 84107 Hospital Affiliation University of Utah Health 100 N Mario Capecchi Dr p 801.507.7000 - University of Utah Hospital 100 N Mario Capecchi Dr Salt Lake City UT. 84113 Salt Lake City UT. 84113 p 801.662.4100 Hospital Affiliation Judkins, Allison J MD p 801.662.4100 - University of Utah Hospital University of Utah Health 50 N Medical Dr 100 N Mario Capecchi Dr 50 N Medical Dr Salt Lake City UT. 84132 Fike, Candice D MD Salt Lake City UT. 84113 Salt Lake City UT. 84132 p 801.581.2121 University of Utah Health p 801.662.4100 p 801.581.2121 100 N Mario Capecchi Dr 5121 S Cottonwood St Salt Lake City UT. 84113 50 N Medical Dr 5121 S Cottonwood St Salt Lake City UT. 84107 p 801.662.4100 Salt Lake City UT. 84132 Murray UT. 84107 p 801.507.7000 p 801.581.2121 p 801.507.7000 50 N Medical Dr Smith, Robin S MD Salt Lake City UT. 84132 5121 S Cottonwood St Mankouski, Anastasiya MD Pediatrix Medical Group p 801.581.2121 Murray UT. 84107 University of Utah Health 1200 E 3900 S p 801.507.7000 100 N Mario Capecchi Dr Salt Lake City UT. 84124 5121 S Cottonwood St Salt Lake City UT. 84113 p 801.268.7111 Murray UT. 84107 Hospital Affiliation p 801.662.4100 p 801.507.7000 - Primary Childrens Hospital Hospital Affiliation 50 N Medical Dr - St Marks Hospital Hospital Affiliation LaPine, Timothy R MD Salt Lake City UT. 84132 - Lone Peak Hospital - University of Utah Hospital Pediatrix Medical Group p 801.581.2121 - Jordan Valley Medical 1200 E 3900 S Center Salt Lake City UT. 84124 p 801.268.7111

283 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Stiers, Justin L MD 81 N Mario Capecchi Dr 1200 E 3900 S University Of Utah Health Pediatrix Medical Group Salt Lake City UT. 84113 Salt Lake City UT. 84124 85 N Medical Dr 1200 E 3900 S p 801.213.3599 p 801.268.7111 Salt Lake City UT. 84112 Salt Lake City UT. 84124 p 801.581.6709 p 801.268.7111 Yang, Michelle J MD 3460 S Pioneer Pkwy University Of Utah Health West Valley City UT. 84120 Al Rabadi, Laith F MD Hospital Affiliation 100 N Mario Capecchi Dr p 801.964.3100 University of Utah Health - St Marks Hospital Salt Lake City UT. 84113 423 S Wakara Way - Lone Peak Hospital p 801.662.4100 3580 W 9000 S Ste 200 - Jordan Valley Medical West Jordan UT. 84088 Salt Lake City UT. 84108 Center 50 N Medical Dr p 801.561.8888 p 801.581.3981 Salt Lake City UT. 84132 Thomas, James W MD p 801.581.2121 University of Utah Health 50 N Medical Dr University of Utah Health 50 N Medical Dr Salt Lake City UT. 84132 100 N Mario Capecchi Dr 5121 S Cottonwood St Salt Lake City UT. 84132 p 801.581.6709 Salt Lake City UT. 84113 Murray UT. 84107 p 801.581.2121 p 801.662.4100 p 801.507.7000 515 E 100 S 5121 S Cottonwood St Ste 350 50 N Medical Dr Hospital Affiliation Salt Lake City UT. 84107 Salt Lake City UT. 84102 Salt Lake City UT. 84132 - University of Utah Hospital p 801.507.7000 p 801.581.3981 p 801.581.2121 Yoder, Bradley A MD Hospital Affiliation University Of Utah Health 5121 S Cottonwood St University of Utah Health - University of Utah Hospital 85 N Medical Dr Murray UT. 84107 100 N Mario Capecchi Dr Salt Lake City UT. 84112 p 801.507.7000 Salt Lake City UT. 84113 Nephrology p 801.581.6709 p 801.662.4100 Abraham, Josephine D MD Hospital Affiliation University of Utah Health Hospital Affiliation - University of Utah Hospital 50 N Medical Dr 1950 Cir of Hope Dr - University of Utah Hospital Salt Lake City UT. 84132 Salt Lake City UT. 84112 - Davis Hospital Torr, Carrie B MD p 801.581.2121 p 801.587.7000 University of Utah Health Anand, Sanjiv MD 100 N Mario Capecchi Dr 5121 S Cottonwood St 423 S Wakara Way Nephrology Associates of Salt Lake City UT. 84113 Salt Lake City UT. 84107 Ste 200 Utah p 801.662.4100 p 801.507.7000 Salt Lake City UT. 84108 12511 S Creek Meadow Rd p 801.581.3981 Ste 111 50 N Medical Dr Primary Childrens Hospital Riverton UT. 84065 Salt Lake City UT. 84132 Physicians 50 N Medical Dr p 801.288.2634 p 801.581.2121 81 N Mario Capecchi Dr Salt Lake City UT. 84132 Salt Lake City UT. 84113 p 801.581.6709 3702 S State St 5121 S Cottonwood St p 801.662.1000 Ste 107 Murray UT. 84107 515 E 100 S Salt Lake City UT. 84115 p 801.507.7000 Yost, Christian C MD Ste 350 p 801.288.2634 University of Utah Health Salt Lake City UT. 84102 Hospital Affiliation 100 N Mario Capecchi Dr p 801.581.3981 3823 W 9000 S - University of Utah Hospital Salt Lake City UT. 84113 West Jordan UT. 84088 p 801.662.4100 University Of Utah Health p 801.288.2634 Viskochil, David H MD,PhD 85 N Medical Dr University of Utah Health 50 N Medical Dr Salt Lake City UT. 84112 4101 W Pioneer Pkwy 100 N Mario Capecchi Dr Salt Lake City UT. 84132 p 801.581.6709 Ste 103 Salt Lake City UT. 84113 p 801.581.2121 West Valley City UT. 84120 p 801.213.3599 Hospital Affiliation p 801.288.2634 5121 S Cottonwood St - University of Utah Hospital 1275 E Fairfax Rd Salt Lake City UT. 84107 Hospital Affiliation Salt Lake City UT. 84103 p 801.507.7000 Agarwal, Adhish K MD - Salt Lake Regional Medical p 801.587.2255 University of Utah Health Center Zinkhan, Erin K MD 1950 Cir of Hope Dr - Jordan Valley Medical 3773 W 12600 S University of Utah Health Salt Lake City UT. 84112 Center Riverton UT. 84065 100 N Mario Capecchi Dr p 801.587.7000 - St Marks Hospital p 801.213.3599 Salt Lake City UT. 84113 p 801.662.4100 50 N Medical Dr Assiago, Marcellus S MD 50 N Medical Dr Clinic 1 Salt Lake City UT. 84132 University of Utah Health Salt Lake City UT. 84132 Pediatrix Medical Group p 801.581.6709 50 N Medical Dr p 801.213.3599 11925 S State St Salt Lake City UT. 84132 Draper UT. 84020 p 801.581.6709 p 801.545.8000

284 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 515 E 100 S Bjordahl, Terrence S MD Boseman, Jerald MD 3823 W 9000 S Ste 350 University of Utah Health Nephrology Associates of West Jordan UT. 84088 Salt Lake City UT. 84102 1250 E 3900 S Utah p 801.288.2634 p 801.581.3981 Ste 410 3702 S State St Salt Lake City UT. 84124 Ste 107 4101 W Pioneer Pkwy Hospital Affiliation p 801.281.5996 Salt Lake City UT. 84115 Ste 103 - University of Utah Hospital p 801.288.2634 West Valley City UT. 84120 - Davis Hospital 1250 E 3900 S p 801.288.2634 Salt Lake City UT. 84124 Cheung, Alfred K MD Barklow, Jeff A MD p 801.268.7111 University of Utah Health Dickson, Landon E MD Nephrology Associates of 423 S Wakara Way Nephrology Associates of Utah 3854 W 5400 S Ste 200 Utah 12511 S Creek Meadow Rd Taylorsville UT. 84129 Salt Lake City UT. 84108 12511 S Creek Meadow Rd Ste 111 p 801.969.6801 p 801.581.3981 Ste 111 Riverton UT. 84065 Riverton UT. 84065 p 801.288.2634 423 S Wakara Way 50 N Medical Dr p 801.288.2634 Ste 200 Salt Lake City UT. 84132 3702 S State St Salt Lake City UT. 84108 p 801.581.6709 3702 S State St Ste 107 p 801.581.3981 Ste 107 Salt Lake City UT. 84115 515 E 100 S Salt Lake City UT. 84115 p 801.288.2634 50 N Medical Dr Ste 350 p 801.288.2634 Salt Lake City UT. 84132 Salt Lake City UT. 84102 3823 W 9000 S p 801.581.6709 p 801.581.3981 3823 W 9000 S West Jordan UT. 84088 West Jordan UT. 84088 p 801.288.2634 5121 S Cottonwood St University Of Utah Health p 801.288.2634 Murray UT. 84107 85 N Medical Dr 4101 W Pioneer Pkwy p 801.507.7000 Salt Lake City UT. 84112 4101 W Pioneer Pkwy Ste 103 p 801.581.6709 Ste 103 West Valley City UT. 84120 515 E 100 S West Valley City UT. 84120 p 801.288.2634 Ste 350 Hospital Affiliation p 801.288.2634 Salt Lake City UT. 84102 - University of Utah Hospital Hospital Affiliation p 801.581.3981 Hospital Affiliation - St Marks Hospital Cho, Monique E MD - Salt Lake Regional Medical - Jordan Valley Medical 74 W Vine St University of Utah Health Center Center West Valley Campus Murray UT. 84107 423 S Wakara Way - Jordan Valley Medical - Salt Lake Regional Medical p 801.507.9000 Ste 200 Center Center Salt Lake City UT. 84108 - St Marks Hospital University Of Utah Health p 801.581.3981 Beddhu, Srinivasan MD 85 N Medical Dr U-U Division of Nephrology University of Utah Health Salt Lake City UT. 84112 50 N Medical Dr 50 N Medical Dr 423 S Wakara Way p 801.581.6709 Salt Lake City UT. 84132 Salt Lake City UT. 84132 Ste 200 p 801.581.6709 p 801.581.6709 Salt Lake City UT. 84108 University of Utah Health p 801.581.3981 8th Ave & C St 515 E 100 S UUHC South Jordan Health Salt Lake City UT. 84143 Ste 350 Center 50 N Medical Dr p 801.408.1100 Salt Lake City UT. 84102 5126 W Daybreak Pkwy Salt Lake City UT. 84132 p 801.581.3981 South Jordan UT. 84095 p 801.581.6709 Hospital Affiliation p 801.213.4500 - St Marks Hospital Hospital Affiliation 515 E 100 S - University of Utah Hospital Eppich, Irel S MD Ste 350 Boateng, Yaw A MD University of Utah Health Salt Lake City UT. 84102 University of Utah Health Dantis Tan, Minerva NP 50 N Medical Dr p 801.581.3981 423 S Wakara Way Nephrology Associates of Salt Lake City UT. 84132 Ste 200 Utah p 801.581.6709 University Of Utah Health Salt Lake City UT. 84108 12511 S Creek Meadow Rd 85 N Medical Dr p 801.581.3981 Ste 111 5126 W Daybreak Pkwy Salt Lake City UT. 84112 Riverton UT. 84065 South Jordan UT. 84009 p 801.581.6709 50 N Medical Dr p 801.288.2634 p 801.213.4500 Salt Lake City UT. 84132 Hospital Affiliation p 801.581.6709 3702 S State St 515 E 100 S - University of Utah Hospital Ste 107 Ste 350 515 E 100 S Salt Lake City UT. 84115 Salt Lake City UT. 84102 Ste 350 p 801.288.2634 p 801.581.3981 Salt Lake City UT. 84102 p 801.581.3981 Hospital Affiliation - University of Utah Hospital Hospital Affiliation - Mountain View Hospital - University of Utah Hospital (UT) - Timpanogos Regional Hospital 285 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Ghani, Nasimul MD Gregory, Martin C MD,PhD University Of Utah Health Jansen, Kevin MD University of Utah Health University of Utah Health 85 N Medical Dr Nephrology Associates of 50 N Medical Dr 1950 Cir of Hope Dr Salt Lake City UT. 84112 Utah Salt Lake City UT. 84132 Salt Lake City UT. 84112 p 801.581.6709 12511 S Creek Meadow Rd p 801.581.6709 p 801.587.7000 Ste 111 University of Utah Health Riverton UT. 84065 Hospital Affiliation 423 S Wakara Way 8th Ave & C St p 801.288.2634 - University of Utah Hospital Ste 200 Salt Lake City UT. 84143 Salt Lake City UT. 84108 p 801.408.1100 3702 S State St Gilligan, Sarah E MD p 801.581.3981 Ste 107 University Of Utah Health Hospital Affiliation Salt Lake City UT. 84115 1950 Cir of Hope Dr 50 N Medical Dr - St Marks Hospital p 801.288.2634 Salt Lake City UT. 84112 Salt Lake City UT. 84132 - University of Utah Hospital p 801.587.7000 p 801.581.6709 3823 W 9000 S Hall, Isaac E MD West Jordan UT. 84088 423 S Wakara Way 515 E 100 S University of Utah Health p 801.288.2634 Ste 200 Ste 350 50 N Medical Dr Salt Lake City UT. 84108 Salt Lake City UT. 84102 Salt Lake City UT. 84132 4101 W Pioneer Pkwy p 801.581.3981 p 801.581.3981 p 801.581.6709 Ste 103 West Valley City UT. 84120 50 N Medical Dr University Of Utah Health University Of Utah Health p 801.288.2634 Salt Lake City UT. 84132 85 N Medical Dr 85 N Medical Dr p 801.581.6709 Salt Lake City UT. 84112 Salt Lake City UT. 84112 Hospital Affiliation p 801.581.6709 p 801.581.6709 - St Marks Hospital 5126 W Daybreak Pkwy - Jordan Valley Medical South Jordan UT. 84009 Hospital Affiliation Hospital Affiliation Center West Valley Campus p 801.213.4500 - University of Utah Hospital - University of Utah Hospital - Salt Lake Regional Medical Center 85 N Medical Dr Habib, Arsalan N MD Horowitz, Bruce L MD Salt Lake City UT. 84112 University of Utah Health University of Utah Health Kakani, Siddhartha MD p 801.581.6709 1000 S Main St 50 N Medical Dr University of Utah Health Ste 105 Salt Lake City UT. 84132 50 N Medical Dr Hospital Affiliation Salt Lake City UT. 84101 p 801.581.6709 Salt Lake City UT. 84132 - University of Utah Hospital p 801.408.1400 p 801.581.6709 515 E 100 S Gopinath, Arasu MD 1250 E 3900 S Ste 350 5126 W Daybreak Pkwy Nephrology Associates of Ste 410 Salt Lake City UT. 84102 South Jordan UT. 84009 Utah Salt Lake City UT. 84124 p 801.581.3981 p 801.213.4500 12511 S Creek Meadow Rd p 801.281.5996 Ste 111 Hospital Affiliation 515 E 100 S Riverton UT. 84065 1250 E 3900 S - University of Utah Hospital Ste 350 p 801.288.2634 Salt Lake City UT. 84124 - Davis Hospital Salt Lake City UT. 84102 p 801.268.7111 p 801.581.3981 3702 S State St Indahyung, Ruth M MD Ste 107 423 S Wakara Way Nephrology Associates of Hospital Affiliation Salt Lake City UT. 84115 Ste 200 Utah - University of Utah Hospital p 801.288.2634 Salt Lake City UT. 84108 12511 S Creek Meadow Rd p 801.581.3981 Ste 111 Lau, Sey M MD 3823 W 9000 S Riverton UT. 84065 Nephrology Associates of West Jordan UT. 84088 50 N Medical Dr p 801.288.2634 Utah p 801.288.2634 Salt Lake City UT. 84132 12511 S Creek Meadow Rd p 801.581.6709 3702 S State St Ste 111 4101 W Pioneer Pkwy Ste 107 Riverton UT. 84065 Ste 103 5121 S Cottonwood St Salt Lake City UT. 84115 p 801.288.2634 West Valley City UT. 84120 Murray UT. 84107 p 801.288.2634 p 801.288.2634 p 801.507.7000 3702 S State St 3823 W 9000 S Ste 107 Hospital Affiliation 5126 W Daybreak Pkwy West Jordan UT. 84088 Salt Lake City UT. 84115 - St Marks Hospital South Jordan UT. 84009 p 801.288.2634 p 801.288.2634 - Jordan Valley Medical p 801.213.4500 Center West Valley Campus 4101 W Pioneer Pkwy 3823 W 9000 S - Salt Lake Regional Medical 515 E 100 S Ste 103 West Jordan UT. 84088 Center Ste 350 West Valley City UT. 84120 p 801.288.2634 Salt Lake City UT. 84102 p 801.288.2634 p 801.581.3981 Hospital Affiliation - St Marks Hospital - Jordan Valley Medical Center - Salt Lake Regional Medical Center 286 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 4101 W Pioneer Pkwy Morris, Donald R MD 5126 W Daybreak Pkwy Ramkumar, Nirupama MD Ste 103 Nephrology Associates of South Jordan UT. 84009 University of Utah Health West Valley City UT. 84120 Utah p 801.213.4500 423 S Wakara Way p 801.288.2634 12511 S Creek Meadow Rd Ste 200 Ste 111 515 E 100 S Salt Lake City UT. 84108 Hospital Affiliation Riverton UT. 84065 Ste 350 p 801.581.3981 - St Marks Hospital p 801.288.2634 Salt Lake City UT. 84102 - Jordan Valley Medical p 801.581.3981 50 N Medical Dr Center West Valley Campus 3702 S State St Salt Lake City UT. 84132 - Salt Lake Regional Medical Ste 107 74 W Vine St p 801.581.6709 Center Salt Lake City UT. 84115 Murray UT. 84107 p 801.288.2634 p 801.507.9000 515 E 100 S Lavasani, Tooran APRN Ste 350 University of Utah Health 3823 W 9000 S 8th Ave & C St Salt Lake City UT. 84102 423 S Wakara Way West Jordan UT. 84088 Salt Lake City UT. 84143 p 801.581.3981 Ste 200 p 801.288.2634 p 801.408.1100 Salt Lake City UT. 84108 University Of Utah Health p 801.581.3981 4101 W Pioneer Pkwy Hospital Affiliation 85 N Medical Dr Ste 103 - University of Utah Hospital Salt Lake City UT. 84112 50 N Medical Dr West Valley City UT. 84120 p 801.581.6709 Salt Lake City UT. 84132 p 801.288.2634 Ohri, Ritika p 801.581.6709 University Of Utah Health Hospital Affiliation Hospital Affiliation 1950 Cir of Hope Dr - University of Utah Hospital 515 E 100 S - St Marks Hospital Salt Lake City UT. 84112 Ste 350 - Jordan Valley Medical p 801.587.7000 Rodan, Aylin R MD Salt Lake City UT. 84102 Center West Valley Campus University of Utah Health p 801.581.3981 - Salt Lake Regional Medical 50 N Medical Dr 50 N Medical Dr Center Salt Lake City UT. 84132 Salt Lake City UT. 84132 Hospital Affiliation p 801.581.6709 p 801.581.6709 - University of Utah Hospital Nelson, Andrea M MD University of Utah Health 85 N Medical Dr University Of Utah Health Molnar, Miklos Z MD 1000 S Main St Salt Lake City UT. 84112 85 N Medical Dr University Of Utah Health Ste 105 p 801.581.6709 Salt Lake City UT. 84112 50 N Medical Dr Salt Lake City UT. 84101 p 801.581.6709 Salt Lake City UT. 84132 p 801.408.1400 Hospital Affiliation p 801.581.6709 - University of Utah Hospital Hospital Affiliation 1250 E 3900 S - University of Utah Hospital 85 N Medical Dr Ste 410 Patcha, Kishore MD Salt Lake City UT. 84112 Salt Lake City UT. 84124 University Of Utah Health Romney, Pace G MD p 801.581.6709 p 801.281.5996 50 N Medical Dr University of Utah Health Salt Lake City UT. 84132 50 N Medical Dr Hospital Affiliation 1250 E 3900 S p 801.581.6709 Salt Lake City UT. 84132 - University of Utah Hospital Salt Lake City UT. 84124 p 801.581.6709 p 801.268.7111 Raghavan, Divya MD Moore, Rebecca H MD University Of Utah Health Hospital Affiliation St Marks Senior Health 3854 W 5400 S 1950 Cir of Hope Dr - University of Utah Hospital Center Taylorsville UT. 84129 Salt Lake City UT. 84112 1160 E 3900 S p 801.969.6801 p 801.587.7000 Roy, Abinash C MD Ste G200 University of Utah Health Salt Lake City UT. 84124 423 S Wakara Way University of Utah Health 50 N Medical Dr p 801.268.7766 Ste 200 50 N Medical Dr Salt Lake City UT. 84132 Salt Lake City UT. 84108 Salt Lake City UT. 84132 p 801.581.6709 St Marks Interventional p 801.581.3981 p 801.581.6709 Pain Clinic 515 E 100 S 1220 E 3900 S 50 N Medical Dr University Of Utah Health Ste 350 Ste 3-B Salt Lake City UT. 84132 85 N Medical Dr Salt Lake City UT. 84102 Salt Lake City UT. 84124 p 801.581.6709 Salt Lake City UT. 84112 p 801.581.3981 p 801.268.7725 p 801.581.6709 5121 S Cottonwood St Hospital Affiliation St Marks Senior Health Murray UT. 84107 Hospital Affiliation - St George Regional Hospital Center p 801.507.7000 - University of Utah Hospital - University of Utah Hospital 1275 E Ft Union Blvd Ste 150 Cottonwood Heights UT. 84047 p 801.268.7766

Hospital Affiliation - St Marks Hospital 287 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Salameh, Hasan MD 3702 S State St 5126 W Daybreak Pkwy University Of Utah Health Nephrology Associates of Ste 107 South Jordan UT. 84009 85 N Medical Dr Utah Salt Lake City UT. 84115 p 801.213.4500 Salt Lake City UT. 84112 3702 S State St p 801.288.2634 p 801.581.6709 Ste 107 515 E 100 S Salt Lake City UT. 84115 3823 W 9000 S Ste 350 University of Utah Health p 801.288.2634 West Jordan UT. 84088 Salt Lake City UT. 84102 8th Ave & C St p 801.288.2634 p 801.581.3981 Salt Lake City UT. 84143 Shah, Sheetal R MD p 801.408.1100 Granger Medical Clinic 4101 W Pioneer Pkwy University Of Utah Health 11724 S State St Ste 103 85 N Medical Dr Hospital Affiliation Draper UT. 84020 West Valley City UT. 84120 Salt Lake City UT. 84112 - University of Utah Hospital p 801.965.3600 p 801.288.2634 p 801.581.6709 Neurology 3181 W 9000 S Hospital Affiliation University of Utah Health Abbatemarco, Justin R MD West Jordan UT. 84088 - St Marks Hospital 8th Ave & C St University Of Utah Health p 801.569.5600 - Jordan Valley Medical Salt Lake City UT. 84143 175 N Medical Dr E Center West Valley Campus p 801.408.1100 Salt Lake City UT. 84132 Hospital Affiliation - Salt Lake Regional Medical p 801.585.7575 - Jordan Valley Medical Center Hospital Affiliation Center - University of Utah Hospital 50 N Medical Dr - St Marks Hospital Westenfelder, Christof Salt Lake City UT. 84132 - Jordan Valley Medical MD Zaman, Tahir A MD p 801.585.6387 Center West Valley Campus University of Utah Health University of Utah Health 1950 Cir of Hope Dr 1000 S Main St 729 S Arapeen Dr Shihab, Fuad MD Salt Lake City UT. 84112 Ste 105 Salt Lake City UT. 84108 University of Utah Health p 801.587.7000 Salt Lake City UT. 84101 p 801.585.6387 50 N Medical Dr p 801.408.1400 Salt Lake City UT. 84132 50 N Medical Dr Hospital Affiliation p 801.581.6709 Salt Lake City UT. 84132 1250 E 3900 S - University of Utah Hospital p 801.581.6709 Ste 410 University Of Utah Health Salt Lake City UT. 84124 Al-Sadat, Ahmad N MD 85 N Medical Dr University Of Utah Health p 801.281.5996 RMWHC @ Olympus Clinic Salt Lake City UT. 84112 85 N Medical Dr 4624 S Holladay Blvd p 801.581.6709 Salt Lake City UT. 84112 1250 E 3900 S Ste 201 p 801.581.6709 Salt Lake City UT. 84124 Salt Lake City UT. 84117 Hospital Affiliation p 801.268.7111 p 801.505.5370 - University of Utah Hospital Hospital Affiliation - University of Utah Hospital 3854 W 5400 S Neurosci and Smith, Trevor R MD Taylorsville UT. 84129 Rehabilitation Specialists University of Utah Health Yenchek, Robert H MD p 801.969.6801 @ SLC 423 S Wakara Way University of Utah Health 82 S 1100 E Ste 200 1250 E 3900 S 423 S Wakara Way Ste 103 Salt Lake City UT. 84108 Ste 410 Ste 200 Salt Lake City UT. 84102 p 801.581.3981 Salt Lake City UT. 84124 Salt Lake City UT. 84108 p 801.505.5370 p 801.281.5996 p 801.581.3981 50 N Medical Dr Hospital Affiliation Salt Lake City UT. 84132 1250 E 3900 S 50 N Medical Dr - Davis Hospital p 801.581.6709 Salt Lake City UT. 84124 Salt Lake City UT. 84132 p 801.268.7111 p 801.581.6709 Allred, Juliann W MD 515 E 100 S University of Utah Health Ste 350 423 S Wakara Way 5126 W Daybreak Pkwy 175 N Medical Dr E Salt Lake City UT. 84102 Ste 200 South Jordan UT. 84009 Salt Lake City UT. 84132 p 801.581.3981 Salt Lake City UT. 84108 p 801.213.4500 p 801.585.7575 p 801.581.3981 Hospital Affiliation 515 E 100 S 50 N Medical Dr - University of Utah Hospital 50 N Medical Dr Ste 350 Salt Lake City UT. 84132 Salt Lake City UT. 84132 Salt Lake City UT. 84102 p 801.585.6387 Tien, Dave MD p 801.581.6709 p 801.581.3981 Nephrology Associates of 5126 W Daybreak Pkwy Utah 5121 S Cottonwood St 74 W Vine St South Jordan UT. 84009 12511 S Creek Meadow Rd Murray UT. 84107 Murray UT. 84107 p 801.585.0434 Ste 111 p 801.507.7000 p 801.507.9000 Riverton UT. 84065 p 801.288.2634

288 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 729 S Arapeen Dr Bartell, Jared W MD CarePoint Inpatient Blue Davidson, Christian J MD Salt Lake City UT. 84108 University of Utah Health Sky Neurology Utah, PLLC University of Utah Health p 801.585.6387 175 N Medical Dr E 1200 E 3900 S 1950 Cir of Hope Dr Salt Lake City UT. 84132 Salt Lake City UT. 84124 Salt Lake City UT. 84112 Hospital Affiliation p 801.585.7575 p 801.268.7111 p 801.585.0100 - University of Utah Hospital 50 N Medical Dr Chauhan, Muhammad A MD 50 N Medical Dr Arain, Amir M MD Salt Lake City UT. 84132 University of Utah Health Salt Lake City UT. 84132 University of Utah Health p 801.585.6387 175 N Medical Dr E p 801.581.2507 175 N Medical Dr E Salt Lake City UT. 84132 Salt Lake City UT. 84132 729 S Arapeen Dr p 801.585.7575 500 S Chipeta Way p 801.585.7575 Salt Lake City UT. 84108 Salt Lake City UT. 84108 p 801.585.6387 729 S Arapeen Dr p 801.583.2787 50 N Medical Dr Salt Lake City UT. 84108 Salt Lake City UT. 84132 Hospital Affiliation p 801.585.7575 Hospital Affiliation p 801.585.6387 - University of Utah Hospital - University of Utah Hospital Hospital Affiliation 729 S Arapeen Dr Black, Evan G MD - University of Utah Hospital DeWitt, Lucy D MD Salt Lake City UT. 84108 5323 S Woodrow St University of Utah Health p 801.585.7575 Ste 201 Chung, Lee S MD 175 N Medical Dr E Salt Lake City UT. 84107 University of Utah Health Salt Lake City UT. 84132 Hospital Affiliation p 801.261.4711 175 N Medical Dr E p 801.585.7575 - University of Utah Hospital Salt Lake City UT. 84132 Hospital Affiliation p 801.585.7575 50 N Medical Dr Bacharach, Rae E DO - St Marks Hospital Salt Lake City UT. 84132 University of Utah Health - Lakeview Hospital 50 N Medical Dr p 801.585.6387 175 N Medical Dr E - Lone Peak Hospital Salt Lake City UT. 84132 Salt Lake City UT. 84132 p 801.585.6387 Hospital Affiliation p 801.585.7575 Brennan, Kevin C MD - Ashley Valley Regional University of Utah Health 729 S Arapeen Dr Medical Center 50 N Medical Dr 50 N Medical Dr Salt Lake City UT. 84108 - Castleview Hospital Salt Lake City UT. 84132 Salt Lake City UT. 84132 p 801.585.6387 - Davis Hospital p 801.585.6387 p 801.585.6387 - Jordan Valley Medical Hospital Affiliation Center 729 S Arapeen Dr Hospital Affiliation - University of Utah Hospital Salt Lake City UT. 84108 - University of Utah Hospital - Davis Hospital Dept of Neurology School p 801.585.7575 of Medicine U of U Bromberg, Mark B MD,PhD Clardy, Stacey L MD 50 N Medical Dr Hospital Affiliation University of Utah Health University of Utah Health Salt Lake City UT. 84132 - University of Utah Hospital 175 N Medical Dr E 50 N Medical Dr p 801.585.6387 Salt Lake City UT. 84132 Salt Lake City UT. 84132 Baggaley, Susan K APRN p 801.585.7575 p 801.585.6387 UUHC South Jordan Health University of Utah Health Center 50 N Medical Dr 50 N Medical Dr 729 S Arapeen Dr 5126 W Daybreak Pkwy Salt Lake City UT. 84132 Salt Lake City UT. 84132 Salt Lake City UT. 84108 South Jordan UT. 84095 p 801.585.6387 p 801.585.6387 p 801.585.6387 p 801.213.4500

Bale, James F MD Hospital Affiliation Hospital Affiliation Digre, Kathleen B MD University Of Utah Health - University of Utah Hospital - University of Utah Hospital University of Utah Health 81 N Mario Capecchi Dr 175 N Medical Dr E Salt Lake City UT. 84113 Candee, Meghan S MD Cortez, Melissa M DO Salt Lake City UT. 84132 p 801.213.3599 University of Utah Health University of Utah Health p 801.585.7575 100 N Mario Capecchi Dr 175 N Medical Dr E Hospital Affiliation Salt Lake City UT. 84113 Salt Lake City UT. 84132 50 N Medical Dr - Primary Childrens Hospital p 801.213.3599 p 801.585.7575 Salt Lake City UT. 84132 p 801.581.2121 Banks, Diana D MD 3773 W 12600 S 50 N Medical Dr 5323 S Woodrow St Riverton UT. 84065 Salt Lake City UT. 84132 65 S Mario Capecchi Dr Ste 201 p 801.587.7575 p 801.585.6387 Salt Lake City UT. 84132 Salt Lake City UT. 84107 p 801.581.2352 p 801.261.4711 81 N Mario Capecchi Dr 729 S Arapeen Dr Salt Lake City UT. 84113 Salt Lake City UT. 84108 729 S Arapeen Dr Hospital Affiliation p 801.587.7575 p 801.585.6387 Salt Lake City UT. 84108 - St Marks Hospital p 801.585.6387 - Lakeview Hospital Hospital Affiliation Hospital Affiliation - Lone Peak Hospital - University of Utah Hospital - University of Utah Hospital Hospital Affiliation - University of Utah Hospital

289 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Duff, Kevin M PhD 729 S Arapeen Dr Hannon, Peter M MD 50 N Medical Dr University of Utah Health Salt Lake City UT. 84108 University of Utah Health Salt Lake City UT. 84132 50 N Medical Dr p 801.585.7575 175 N Medical Dr E p 801.585.6387 Salt Lake City UT. 84132 Salt Lake City UT. 84132 p 801.585.6387 Hospital Affiliation p 801.585.7575 729 S Arapeen Dr - University of Utah Hospital Salt Lake City UT. 84108 Hospital Affiliation 50 N Medical Dr p 801.585.6387 - University of Utah Hospital Gibson, Summer B MD Salt Lake City UT. 84132 University of Utah Health p 801.585.6387 Hospital Affiliation Faust, Barbara NP 175 N Medical Dr E - University of Utah Hospital University of Utah Health Salt Lake City UT. 84132 Hospital Affiliation 81 N Mario Capecchi Dr p 801.585.7575 - University of Utah Hospital Juster Switlyk, Kelsey R Salt Lake City UT. 84113 - Davis Hospital MD p 801.587.2255 Hospital Affiliation University of Utah Health - University of Utah Hospital Houts, Thomas D MD 175 N Medical Dr E Filloux, Francis M MD Wasatch Neurological Salt Lake City UT. 84132 University of Utah Health Goldstein, Eric D MD Clinic p 801.585.7575 3773 W 12600 S University of Utah Health 6040 Fashion Blvd Riverton UT. 84065 175 N Medical Dr E Ste 201 1950 Cir of Hope Dr p 801.587.7575 Salt Lake City UT. 84132 Murray UT. 84107 Salt Lake City UT. 84112 p 801.581.2121 p 801.268.1888 p 801.585.6387 50 N Medical Dr Salt Lake City UT. 84132 50 N Medical Dr Hospital Affiliation 50 N Medical Dr p 801.213.3599 Salt Lake City UT. 84132 - St Marks Hospital Salt Lake City UT. 84132 p 801.585.7575 - Lakeview Hospital p 801.585.6387 81 N Mario Capecchi Dr - Lone Peak Hospital Salt Lake City UT. 84113 729 S Arapeen Dr 729 S Arapeen Dr p 801.587.7575 Salt Lake City UT. 84108 Hoversten, Knut-Kjell E Salt Lake City UT. 84108 p 801.585.7575 MD p 801.585.6387 Hospital Affiliation University Of Utah Health - Primary Childrens Hospital Hospital Affiliation 175 N Medical Dr E Hospital Affiliation - University of Utah Hospital Salt Lake City UT. 84132 - University of Utah Hospital Foster, Norman L MD p 801.585.7575 University of Utah Health Grantz, Matthew Kadish, Robert MD 50 N Medical Dr Neuroscience & 50 N Medical Dr University of Utah Health Salt Lake City UT. 84132 Rehabilitation Specialists Salt Lake City UT. 84132 175 N Medical Dr E p 801.585.6387 - West Jordan p 801.585.6387 Salt Lake City UT. 84132 3590 W 9000 S p 801.585.7575 Hospital Affiliation Ste 240 729 S Arapeen Dr - University of Utah Hospital West Jordan UT. 84088 Salt Lake City UT. 84108 50 N Medical Dr p 801.352.8373 p 801.585.6387 Salt Lake City UT. 84132 Futrell, Nancy N MD p 801.585.6387 Intermountain Stroke Hospital Affiliation Hospital Affiliation Center - Jordan Valley Medical - University of Utah Hospital 729 S Arapeen Dr 7930 Majestic Ridge Dr Center Salt Lake City UT. 84108 Salt Lake City UT. 84121 James, Mary E MD p 801.585.6387 p 801.263.0611 Greenlee, John E MD Neuroscience & University of Utah Health Rehabilitation Specialists Hospital Affiliation Hospital Affiliation 50 N Medical Dr - SLC - University of Utah Hospital - Jordan Valley Medical Salt Lake City UT. 84132 82 S 1100 E Center p 801.585.6387 Ste 103 Klein, Julia M FNP - Jordan Valley Medical Salt Lake City UT. 84102 University of Utah Health Center West Valley Campus Hospital Affiliation p 801.505.5370 50 N Medical Dr - University of Utah Hospital Salt Lake City UT. 84132 Galli, Jonathan R MD Hospital Affiliation p 801.585.6387 University of Utah Health Groves, Jeffrey MD - Salt Lake Regional Medical 175 N Medical Dr E Revere Health Center 729 S Arapeen Dr Salt Lake City UT. 84132 96 E Kimballs Ln Salt Lake City UT. 84108 p 801.585.7575 Ste 307 Johnson, Brian L MD p 801.585.6387 Draper UT. 84020 University Of Utah Health 50 N Medical Dr p 801.260.3286 175 N Medical Dr E Hospital Affiliation Salt Lake City UT. 84132 Salt Lake City UT. 84132 - University of Utah Hospital p 801.585.6387 Hospital Affiliation p 801.585.7575 - Timpanogos Regional Hospital - Lone Peak Hospital

290 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Ledyard, Holly K LCSW 50 N Medical Dr 50 N Medical Dr Peters, Angela Y MD University of Utah Health Salt Lake City UT. 84132 Salt Lake City UT. 84132 University of Utah Health 175 N Medical Dr E p 801.585.6387 p 801.585.6387 175 N Medical Dr E Salt Lake City UT. 84132 Salt Lake City UT. 84132 p 801.585.7575 729 S Arapeen Dr 729 S Arapeen Dr p 801.585.7575 Salt Lake City UT. 84108 Salt Lake City UT. 84108 Hospital Affiliation p 801.585.6387 p 801.585.6387 50 N Medical Dr - Ashley Valley Regional Salt Lake City UT. 84132 Medical Center Hospital Affiliation Hospital Affiliation p 801.585.6387 - Castleview Hospital - University of Utah Hospital - University of Utah Hospital - Jordan Valley Medical - Davis Hospital 729 S Arapeen Dr Center Murray, Ronald S MD Salt Lake City UT. 84108 - University of Utah Hospital Rocky Mountain Multiple Nicholson, Patrick D MD p 801.585.6387 Sclerosis Clinic University of Utah Health Lyden, Stephanie M MD 370 E 9th Ave 50 N Medical Dr Hospital Affiliation University of Utah Health Ste 106 Salt Lake City UT. 84132 - University of Utah Hospital 175 N Medical Dr E Salt Lake City UT. 84103 p 801.585.6387 - Davis Hospital Salt Lake City UT. 84132 p 801.408.5700 p 801.585.7575 Hospital Affiliation Peterson, David S MD Nelson, Alex J MD - University of Utah Hospital 1151 E 3900 S 50 N Medical Dr Interventional Spine & Ste B240 Salt Lake City UT. 84132 Pain Management Onofrei, Ligia V MD Salt Lake City UT. 84124 p 801.585.7575 5121 S Cottonwood St University of Utah Health p 801.281.1788 Murray UT. 84107 175 N Medical Dr E 729 S Arapeen Dr p 435.753.1600 Salt Lake City UT. 84132 Hospital Affiliation Salt Lake City UT. 84108 p 801.585.7575 - St Marks Hospital p 801.585.7575 5801 S Fashion Blvd - Lone Peak Hospital Ste 180 & 120 729 S Arapeen Dr - Mountain View Hospital Hospital Affiliation Salt Lake City UT. 84107 Salt Lake City UT. 84108 (UT) - University of Utah Hospital p 801.262.7246 p 801.585.6387 Poon, Jason T MD Majersik, Jennifer J MD Hospital Affiliation Hospital Affiliation University Of Utah Health University of Utah Health - Lakeview Hospital - University of Utah Hospital 175 N Medical Dr E 175 N Medical Dr E - Timpanogos Regional Hospital Salt Lake City UT. 84132 Salt Lake City UT. 84132 Ozudogru, Seniha N MD p 801.585.7575 p 801.585.7575 Nelson, Gary R MD University of Utah Health University of Utah Health 175 N Medical Dr E 50 N Medical Dr 50 N Medical Dr 81 N Mario Capecchi Dr Salt Lake City UT. 84132 Salt Lake City UT. 84132 Salt Lake City UT. 84132 Salt Lake City UT. 84113 p 801.585.7575 p 801.585.6387 p 801.585.6387 p 801.587.7575 50 N Medical Dr 729 S Arapeen Dr Hospital Affiliation Hospital Affiliation Salt Lake City UT. 84132 Salt Lake City UT. 84108 - Ashley Valley Regional - University of Utah Hospital p 801.585.6387 p 801.585.6387 Medical Center - Castleview Hospital Nelson, Kellie L MD 729 S Arapeen Dr Hospital Affiliation - Davis Hospital University Of Utah Health Salt Lake City UT. 84108 - University of Utah Hospital - Jordan Valley Medical 175 N Medical Dr E p 801.585.6387 Center Salt Lake City UT. 84132 Pulst, Stefan M MD p 801.585.7575 Hospital Affiliation University of Utah Health Morita, Denise M MD - University of Utah Hospital 50 N Medical Dr Granger Medical Clinic 50 N Medical Dr Salt Lake City UT. 84132 11724 S State St Salt Lake City UT. 84132 Paz Soldan, M M MD p 801.585.6387 Draper UT. 84020 p 801.585.6387 University of Utah Health p 801.576.2050 175 N Medical Dr E Hospital Affiliation 729 S Arapeen Dr Salt Lake City UT. 84132 - University of Utah Hospital Hospital Affiliation Salt Lake City UT. 84108 p 801.585.7575 - Jordan Valley Medical p 801.585.6387 Reddy, Vivek K MD Center 50 N Medical Dr University of Utah Health Hospital Affiliation Salt Lake City UT. 84132 175 N Medical Dr E Moser, Clark A MD - University of Utah Hospital p 801.585.6387 Salt Lake City UT. 84132 University of Utah Health p 801.585.7575 175 N Medical Dr E Newman, Blake J MD 729 S Arapeen Dr Salt Lake City UT. 84132 University of Utah Health Salt Lake City UT. 84108 p 801.585.7575 175 N Medical Dr E p 801.585.6387 Salt Lake City UT. 84132 p 801.585.7575 Hospital Affiliation - University of Utah Hospital

291 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 50 N Medical Dr 50 N Medical Dr Rose, John W MD Singleton, John R MD Salt Lake City UT. 84132 Salt Lake City UT. 84132 University of Utah Health University of Utah Health p 801.585.6387 p 801.585.6387 50 N Medical Dr 175 N Medical Dr E Salt Lake City UT. 84132 Salt Lake City UT. 84132 Hospital Affiliation Hospital Affiliation p 801.585.6387 p 801.585.7575 - University of Utah Hospital - Ashley Valley Regional Medical Center 729 S Arapeen Dr 50 N Medical Dr Reichert, Walter H MD - Castleview Hospital Salt Lake City UT. 84108 Salt Lake City UT. 84132 University of Utah Health - Davis Hospital p 801.585.6387 p 801.585.6387 175 N Medical Dr E - Jordan Valley Medical Salt Lake City UT. 84132 Center Hospital Affiliation Hospital Affiliation p 801.585.7575 - University of Utah Hospital - University of Utah Hospital Riaz, Awais MD 50 N Medical Dr University of Utah Health Serafini, Ruggero MD Slota, Katarzyna A MD Salt Lake City UT. 84132 50 N Medical Dr University of Utah Health University Of Utah Health p 801.585.6387 Salt Lake City UT. 84132 175 N Medical Dr E 1280 E Stringham Ave p 801.585.6387 Salt Lake City UT. 84132 Salt Lake City UT. 84106 729 S Arapeen Dr p 801.585.7575 p 801.581.7818 Salt Lake City UT. 84108 Hospital Affiliation p 801.585.6387 - University of Utah Hospital 50 N Medical Dr 175 N Medical Dr E - Davis Hospital Salt Lake City UT. 84132 Salt Lake City UT. 84132 Neurosci and p 801.585.6387 p 801.585.7575 Rehabilitation Specialists Richards, Sindhu V MD @ SLC University of Utah Health 729 S Arapeen Dr 375 S Chipeta Way 82 S 1100 E 175 N Medical Dr E Salt Lake City UT. 84108 Salt Lake City UT. 84108 Ste 103 Salt Lake City UT. 84132 p 801.585.6387 p 801.581.2016 Salt Lake City UT. 84102 p 801.585.7575 p 801.505.5370 Hospital Affiliation 50 N Medical Dr 50 N Medical Dr - University of Utah Hospital Salt Lake City UT. 84132 Hospital Affiliation Salt Lake City UT. 84132 - Davis Hospital p 801.585.6387 - Jordan Valley Medical p 801.585.6387 Center Shoari, Mohammad MD 729 S Arapeen Dr - Jordan Valley Medical 729 S Arapeen Dr Neuroscience & Salt Lake City UT. 84108 Center West Valley Campus Salt Lake City UT. 84108 Rehabilitation Specialists p 801.585.6387 p 801.585.6387 - West Valley Reiser, Rebecca H MD 3336 S Pioneer Pkwy Hospital Affiliation Neuroscience & Hospital Affiliation Ste 102 - University of Utah Hospital Rehabilitation Specialists - University of Utah Hospital Salt Lake City UT. 84120 - West Jordan p 801.964.3925 Smith, Tammy L MD 3590 W 9000 S Robbins, Zoe APRN University of Utah Health Ste 240 Adult Behavioral Health Neuroscience & 175 N Medical Dr E West Jordan UT. 84088 4052 W Pioneer Pkwy Rehabilitation Specialists Salt Lake City UT. 84132 p 801.352.8373 Ste 105 - West Jordan p 801.585.7575 Salt Lake City UT. 84120 3590 W 9000 S Neuroscience & p 801.554.3420 Ste 240 50 N Medical Dr Rehabilitation Specialists West Jordan UT. 84088 Salt Lake City UT. 84132 - Magna Rodenbeck, Stefanie MD p 801.352.8373 p 801.585.6387 3665 S 8400 W University Of Utah Health Ste 260 175 N Medical Dr E Neuroscience & 729 S Arapeen Dr Magna UT. 84044 Salt Lake City UT. 84132 Rehabilitation Specialists Salt Lake City UT. 84108 p 801.505.5370 p 801.585.7575 - SLC p 801.585.6387 82 S 1100 E Hospital Affiliation 50 N Medical Dr Ste 103 Hospital Affiliation - Jordan Valley Medical Salt Lake City UT. 84132 Salt Lake City UT. 84102 - University of Utah Hospital Center p 801.585.6387 p 801.505.5370 Steffens, John D MD Renner, David R MD 729 S Arapeen Dr Hospital Affiliation University of Utah Health University of Utah Health Salt Lake City UT. 84108 - Salt Lake Regional Medical 50 N Medical Dr 175 N Medical Dr E p 801.585.6387 Center Salt Lake City UT. 84132 Salt Lake City UT. 84132 - Jordan Valley Medical p 801.585.6387 p 801.585.7575 Hospital Affiliation Center - University of Utah Hospital 729 S Arapeen Dr Salt Lake City UT. 84108 p 801.585.6387

Hospital Affiliation - University of Utah Hospital

292 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Tekiela, Piotr MD 65 S Mario Capecchi Dr Zinkhan, George M MD 50 N Medical Dr University Of Utah Health Salt Lake City UT. 84132 University of Utah Health Salt Lake City UT. 84132 175 N Medical Dr E p 801.581.2352 50 N Medical Dr p 801.585.6387 Salt Lake City UT. 84132 Salt Lake City UT. 84132 p 801.585.7575 Hospital Affiliation p 801.585.6387 729 S Arapeen Dr - University of Utah Hospital Salt Lake City UT. 84108 50 N Medical Dr 5126 W Daybreak Pkwy p 801.585.6387 Salt Lake City UT. 84132 West, Timothy MD South Jordan UT. 84009 p 801.585.6387 Rocky Mountain Multiple p 801.585.0434 Hospital Affiliation Sclerosis Clinic - University of Utah Hospital 729 S Arapeen Dr 370 E 9th Ave 729 S Arapeen Dr Salt Lake City UT. 84108 Ste 106 Salt Lake City UT. 84108 *Fulton, John PhD p 801.585.6387 Salt Lake City UT. 84103 p 801.585.6387 Primary Childrens Spina p 801.408.5700 Bifida Hospital Affiliation Hospital Affiliation 81 N Mario Capecchi Dr - University of Utah Hospital Williams, Dorothy L MD - University of Utah Hospital Salt Lake City UT. 84113 Foothill Family Clinic p 801.662.1675 Teynor, Steven V LCSW 2295 Foothill Dr Zorn, Meghan S PA Teynor Physicians Group, Salt Lake City UT. 84109 University of Utah Health Primary Childrens Hospital PLLC p 801.486.3021 50 N Medical Dr Neuropsychology 2290 E 4500 S Salt Lake City UT. 84132 81 N Mario Cappecchi Dr Ste 215 Wold, Jana MD p 801.585.6387 Salt Lake City UT. 84113 Salt Lake City UT. 84117 University of Utah Health p 801.662.5592 p 801.534.1360 175 N Medical Dr E 729 S Arapeen Dr Salt Lake City UT. 84132 Salt Lake City UT. 84108 Hospital Affiliation Thomas, Maya MD p 801.585.7575 p 801.585.6387 - Primary Childrens Hospital Intermountain Epilepsy & Sleep Center 50 N Medical Dr Hospital Affiliation Kitchen Andren, Katherine 5323 S Woodrow St Salt Lake City UT. 84132 - University of Utah Hospital A Phd Ste 203 p 801.585.6387 University of Utah Health Salt Lake City UT. 84107 deHavenon, Adam H MD 1138 E Wilmington Ave p 801.266.5559 Hospital Affiliation University of Utah Health Salt Lake City UT. 84106 - Ashley Valley Regional 175 N Medical Dr E p 801.581.6228 Thulin, Perla C MD Medical Center Salt Lake City UT. 84132 University of Utah Health - Castleview Hospital p 801.585.7575 1280 E Stringham Ave 50 N Medical Dr - Davis Hospital Salt Lake City UT. 84106 Salt Lake City UT. 84132 - Jordan Valley Medical Hospital Affiliation p 801.581.6228 p 801.585.6387 Center - University of Utah Hospital - Davis Hospital 30 N 1900 E Rm 1B620 Hospital Affiliation Zielinski, Brandon A Salt Lake City UT. 84132 - University of Utah Hospital MD,PhD Neuropsychology p 801.581.6228 University of Utah Health Buckley, Celestia H PSYD Van Orman, Colin B MD 3773 W 12600 S University of Utah Health 50 N Medical Dr University Of Utah Health Riverton UT. 84065 100 N Mario Capecchi Dr Salt Lake City UT. 84132 81 N Mario Capecchi Dr p 801.587.7575 Salt Lake City UT. 84113 p 801.581.2267 Salt Lake City UT. 84113 p 801.313.7711 p 801.213.3599 81 N Mario Capecchi Dr 729 S Arapeen Dr Salt Lake City UT. 84113 50 N Medical Dr Salt Lake City UT. 84108 Hospital Affiliation p 801.587.7575 Salt Lake City UT. 84132 p 801.585.6387 - Primary Childrens Hospital p 801.581.2205 - Davis Hospital Hospital Affiliation Hospital Affiliation - University of Utah Hospital Primary Childrens Hospital - University of Utah Hospital VickRoy, Joseph W MD 81 N Mario Capecchi Dr 1200 E 3900 S Zimmerman, Susan M MD Salt Lake City UT. 84113 Knorr, James PhD Salt Lake City UT. 84124 Granger Medical p 801.662.5592 Summit Community p 801.293.6800 Specialists Counseling 2965 W 3500 S Hospital Affiliation 5689 S Redwood Rd Hospital Affiliation West Valley City UT. 84119 - Primary Childrens Hospital Ste 27 - St Marks Hospital p 801.965.3600 Salt Lake City UT. 84123 Embree, Lindsay M PhD p 801.266.2485 Warner, Judith E MD Hospital Affiliation University of Utah Health University of Utah Health - St Marks Hospital 175 N Medical Dr E 5991 S Redwood Rd 50 N Medical Dr Salt Lake City UT. 84132 Salt Lake City UT. 84123 Salt Lake City UT. 84132 p 801.585.7575 p 801.266.2485 p 801.581.2121

293 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Utah Neuropsychology 5126 W Daybreak Pkwy 1525 W 2100 S Jensen, Randy L MD Services South Jordan UT. 84009 Salt Lake City UT. 84119 University of Utah Health 7069 S Highland Dr p 801.213.5081 p 801.213.8841 100 N Mario Capecchi Dr Ste 5 Salt Lake City UT. 84113 Salt Lake City UT. 84121 Hospital Affiliation 175 N Medical Dr E p 801.662.5340 p 801.441.0786 - University of Utah Hospital Salt Lake City UT. 84132 p 801.585.7575 175 N Medical Dr E Konopacki, Kelly L Phd Biswas, Arundhati MD Salt Lake City UT. 84132 University of Utah Health University of Utah Health 1950 Cir of Hope Dr p 801.585.7575 240 Morris Ave 175 N Medical Dr E Salt Lake City UT. 84112 Ste 400 Salt Lake City UT. 84132 p 801.585.7575 8th Ave & C St Salt Lake City UT. 84115 p 801.585.7575 Salt Lake City UT. 84143 p 801.585.1212 50 N Medical Dr p 801.408.1100 Hospital Affiliation Salt Lake City UT. 84132 50 N Medical Dr - University of Utah Hospital p 801.581.6909 Hospital Affiliation Salt Lake City UT. 84132 - University of Utah Hospital p 801.581.7951 Chavez, Juneyoung L MD Hospital Affiliation University of Utah Health - University of Utah Hospital Johnson, Andrew C PA 501 S Chipeta Way 175 N Medical Dr E University of Utah Health Salt Lake City UT. 84132 Salt Lake City UT. 84132 Fredrickson, Vance L MD 1950 Cir of Hope Dr p 801.585.1575 p 801.585.7575 University Of Utah Health Salt Lake City UT. 84112 100 N Mario Capecchi Dr p 801.585.0100 Hospital Affiliation Hospital Affiliation Salt Lake City UT. 84113 - University of Utah Hospital - University of Utah Hospital p 801.662.5340 50 N Medical Dr - Davis Hospital Salt Lake City UT. 84132 Merkley, Tricia Phd 175 N Medical Dr E p 801.581.5311 University Of Utah Health Couldwell, William T Salt Lake City UT. 84132 175 N Medical Dr E MD,PhD p 801.585.7575 Kendall, Richard W DO Salt Lake City UT. 84132 University of Utah Health University of Utah Health p 801.585.7575 100 N Mario Capecchi Dr 50 N Medical Dr 50 N Medical Dr Salt Lake City UT. 84113 Salt Lake City UT. 84132 Salt Lake City UT. 84132 50 N Medical Dr p 801.662.5340 p 801.585.7575 p 801.581.2267 Salt Lake City UT. 84132 p 801.585.6387 175 N Medical Dr E Hospital Affiliation 590 S Wakara Way Salt Lake City UT. 84132 - University of Utah Hospital Salt Lake City UT. 84108 729 S Arapeen Dr p 801.585.7575 p 801.587.7109 Salt Lake City UT. 84108 Garber, Sarah T MD p 801.585.6387 1950 Cir of Hope Dr University of Utah Health Hospital Affiliation Salt Lake City UT. 84112 175 N Medical Dr E - Salt Lake Regional Medical Hospital Affiliation p 801.585.7575 Salt Lake City UT. 84132 Center - University of Utah Hospital p 801.585.7575 - University of Utah Hospital 8th Ave & C St Miranda, Michelle PhD Salt Lake City UT. 84143 50 N Medical Dr Kestle, John R MD University of Utah Health p 801.408.1100 Salt Lake City UT. 84132 University of Utah Health 175 N Medical Dr E p 801.581.6909 100 N Mario Capecchi Dr Salt Lake City UT. 84132 Hospital Affiliation Salt Lake City UT. 84113 p 801.585.7575 - University of Utah Hospital Grandhi, Ramesh MD p 801.662.5340 University of Utah Health 50 N Medical Dr Cushing, Holly K PA 100 N Mario Capecchi Dr Primary Childrens Hospital Salt Lake City UT. 84132 Neurosurgical Associates Salt Lake City UT. 84113 81 N Mario Capecchi Dr p 801.585.6387 LLC p 801.662.5340 Salt Lake City UT. 84113 5171 Cottonwood St p 801.662.1675 729 S Arapeen Dr Ste 950 175 N Medical Dr E Salt Lake City UT. 84108 Salt Lake City UT. 84107 Salt Lake City UT. 84132 Hospital Affiliation p 801.585.6387 p 801.507.9555 p 801.585.7575 - Primary Childrens Hospital - University of Utah Hospital Neurosurgery Dailey, Andrew T MD Hospital Affiliation Bisson, Erica F MD University of Utah Health - University of Utah Hospital Kilburg, Craig J MD University of Utah Health 100 N Mario Capecchi Dr University Of Utah Health 175 N Medical Dr E Salt Lake City UT. 84113 House, Paul A MD 100 N Mario Capecchi Dr Salt Lake City UT. 84132 p 801.662.5340 Neurosurgical Associates Salt Lake City UT. 84113 p 801.585.7575 LLC p 801.662.5340 5171 Cottonwood St Ste 950 Salt Lake City UT. 84107 p 801.507.9555

Hospital Affiliation - University of Utah Hospital 294 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 175 N Medical Dr E Neuroscience & Min, W David MD Reichman, Mark V MD Salt Lake City UT. 84132 Rehabilitation Specialists Neuroscience & Neurosurgical Associates p 801.585.7575 - Salt Lake City Rehabilitation Specialists LLC 82 S 1100 E - SLC 5171 Cottonwood St 50 N Medical Dr Ste 103 82 S 1100 E Ste 950 Salt Lake City UT. 84132 Salt Lake City UT. 84102 Ste 103 Murray UT. 84107 p 801.581.6909 p 801.984.6657 Salt Lake City UT. 84102 p 801.507.9555 p 801.505.5370 Hospital Affiliation Hospital Affiliation Hospital Affiliation - University of Utah Hospital - Davis Hospital Hospital Affiliation - Jordan Valley Medical - Salt Lake Regional Medical Center Kotter, David J APRN Mahan, Mark A MD Center - St Marks Hospital Neurosurgical Associates University of Utah Health - Jordan Valley Medical LLC 100 N Mario Capecchi Dr Center Rich, Charles C MD 900 Round Valley Dr Salt Lake City UT. 84113 Neurosurgical Associates Ste 100 p 801.662.5340 Nathan, David J MD LLC Murray UT. 84107 Neuroscience & 5171 Cottonwood St p 801.507.9555 175 N Medical Dr E Rehabilitation Specialists Ste 950 Salt Lake City UT. 84132 - SLC Murray UT. 84107 Hospital Affiliation p 801.585.7575 82 S 1100 E p 801.507.9555 - Jordan Valley Medical Ste 103 Center 5126 W Daybreak Pkwy Salt Lake City UT. 84102 Hospital Affiliation - St Marks Hospital South Jordan UT. 84009 p 801.505.5370 - Park City Hospital p 801.213.5081 Kura, Bhavani MD Hospital Affiliation Rolston, John D MD,PhD University Of Utah Health Hospital Affiliation - Salt Lake Regional Medical University of Utah Health 175 N Medical Dr E - University of Utah Hospital Center 175 N Medical Dr E Salt Lake City UT. 84132 - Jordan Valley Medical Salt Lake City UT. 84132 p 801.585.7575 Margetts, Jeffrey C MD Center p 801.585.7575 1250 E 3900 S 50 N Medical Dr Ste 200 Passey, Lori E APRN 50 N Medical Dr Salt Lake City UT. 84132 Salt Lake City UT. 84124 Neurosurgical Associates Salt Lake City UT. 84132 p 801.585.7575 p 801.264.9521 LLC p 801.585.7575 5171 Cottonwood St Hospital Affiliation Maughan, Peter H MD Ste 950 Hospital Affiliation - University of Utah Hospital Neurosurgical Associates Murray UT. 84107 - University of Utah Hospital LLC p 801.507.9555 Levitt, Jodie K MD 5171 Cottonwood St Schmidt, Richard H MD,PhD Salt Lake Regional Ste 950 Hospital Affiliation University of Utah Health Physican Murray UT. 84107 - St Marks Hospital 175 N Medical Dr E 1060 E 100 S p 801.507.9555 Salt Lake City UT. 84132 Ste 101 Pingree, James C MD p 801.585.7575 Salt Lake City UT. 84102 Hospital Affiliation St Marks Hospital p 801.598.1041 - St Marks Hospital Comprehensive Spine Center Hospital Affiliation - Jordan Valley Medical 1220 E 3900 S - University of Utah Hospital Salt Lake Regional Center Ste 1-F Neurosurgery Salt Lake City UT. 84124 Taussky, Philipp MD 82 S 1100 E Mazur, Marcus D MD p 801.262.5711 University of Utah Health Ste 303 University of Utah Health 100 N Mario Capecchi Dr Salt Lake City UT. 84102 175 N Medical Dr E Wasatch Neurosurgery Salt Lake City UT. 84113 p 801.363.2473 Salt Lake City UT. 84132 1220 E 3900 S p 801.662.5340 p 801.585.7575 Ste 4E Hospital Affiliation Salt Lake City UT. 84124 175 N Medical Dr E - Salt Lake Regional Medical Hospital Affiliation p 801.261.8507 Salt Lake City UT. 84132 Center - University of Utah Hospital p 801.585.7575 MountainStar Medical Group MacDonald, Joel D MD Medical Neuroscience Neurosurgery Hospital Affiliation Jordan Valley Neuroscience 50 N Medical Dr 74 E Kimballs Ln - University of Utah Hospital & Rehabilitation Salt Lake City UT. 84132 Ste 330 - Davis Hospital Specialists p 801.581.6909 Draper UT. 84020 3590 W 9000 S p 801.262.5711 Teja, Sandeep S MD Ste 240 Mendez, Joe S MD Wasatch Neurosurgery and West Jordan UT. 84088 University of Utah Health Hospital Affiliation Spine Assoc at St Marks p 801.352.8459 175 N Medical Dr E - St Marks Hospital 1220 E 3900 S Salt Lake City UT. 84132 Ste 1F p 801.585.7575 Salt Lake City UT. 84124 p 801.262.5711 Hospital Affiliation - University of Utah Hospital 295 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 1220 E 3900 S 1950 Cir of Hope Dr 5126 W Daybreak Pkwy Barney, Spencer P MD Ste 4A Salt Lake City UT. 84112 South Jordan UT. 84009 Old Farm OB/GYN Salt Lake City UT. 84124 p 801.585.0100 p 801.213.4500 3970 S 700 E p 801.261.8507 Ste 14 50 N Medical Dr Hospital Affiliation Murray UT. 84107 MountainStar Medical Group Salt Lake City UT. 84132 - University of Utah Hospital p 801.261.3605 Neurosurgery p 801.581.7514 74 E Kimballs Ln Allred, Shani APRN Hospital Affiliation Ste 330 5121 S Cottonwood St South Valley Womens Health - St Marks Hospital Draper UT. 84020 Murray UT. 84107 3570 W 9000 S p 801.262.5711 p 801.581.7514 Ste 210 Barton, Christopher D MD West Jordan UT. 84088 Obstetrix Medical Group of Hospital Affiliation 5770 S 250 E p 801.569.2626 Utah - St Marks Hospital Ste 170 1200 S 3900 S Salt Lake City UT. 84107 Hospital Affiliation Salt Lake City UT. 84124 Tippets, Richard H MD p 801.581.7514 - Salt Lake Regional Medical p 801.743.4700 Neurosurgical Associates Center LLC 8th Ave & C St - University of Utah Hospital Mount Olympus OB/GYN 5171 Cottonwood St Salt Lake City UT. 84143 1220 E 3900 S Ste 950 p 801.581.7514 Anders, Suphithaya MD Ste 3E Murray UT. 84107 Western GYN & OB Clinic Salt Lake City UT. 84124 p 801.507.9555 Hospital Affiliation 12600 S 3723 W p 801.685.7188 - University of Utah Hospital Ste 350 Hospital Affiliation Riverton UT. 84065 RMWHC @ Olympus Clinic - St Marks Hospital Obstetrics And Gynecology p 801.285.4900 4624 S Holladay Blvd Adams, Lan Le MD Ste 201 UUHC South Jordan Health Obstetrix Medical Group Of Hospital Affiliation Salt Lake City UT. 84117 Center Utah - Jordan Valley Medical p 385.234.4785 5126 W Daybreak Pkwy 1200 E 3900 S Center South Jordan UT. 84095 Salt Lake City UT. 84124 RMWHC @ Salt Lake City p 801.213.4500 p 801.268.7111 Andres, Robert L MD 82 S 1100 E University of Utah Health Ste 305 Yoon, Nam K MD Adelman, Marisa R MD 50 N Medical Dr Salt Lake City UT. 84102 Neurosurgical Associates University of Utah Health Salt Lake City UT. 84132 p 801.214.7650 LLC 1950 Cir of Hope Dr p 801.213.2995 5171 Cottonwood St Salt Lake City UT. 84112 Barton, Scott R MD Ste 950 p 801.213.2995 Hospital Affiliation Obstetrix Medical Group of Salt Lake City UT. 84107 - University of Utah Hospital Utah p 801.507.9555 50 N Medical Dr 1200 S 3900 S Salt Lake City UT. 84132 Archer, Sandra V MD Salt Lake City UT. 84124 Hospital Affiliation p 801.213.2995 Mt Timpanogas Fertility & p 801.743.4700 - St Marks Hospital Endocrinology Hospital Affiliation 1561 W 7000 S Hospital Affiliation Zorn, Meghan S PA - University of Utah Hospital Ste 201 - St Marks Hospital University of Utah Health West Jordan UT. 84084 50 N Medical Dr Al-khudairi, Amanda APRN p 801.938.9627 Bechek, Frances MD Salt Lake City UT. 84132 University of Utah Health South Valley Womens Health p 801.585.6387 50 N Medical Dr Barney, Mitchell F MD 3570 W 9000 S Salt Lake City UT. 84132 South Valley Womens Ste 210 729 S Arapeen Dr p 801.587.9500 Imaging West Jordan UT. 84088 Salt Lake City UT. 84108 3570 W 9000 S p 801.569.2626 p 801.585.6387 Hospital Affiliation Ste 130 - University of Utah Hospital West Jordan UT. 84088 Hospital Affiliation Hospital Affiliation p 801.569.2626 - Jordan Valley Medical - University of Utah Hospital Allen, Peggy R CNM Center University of Utah Health South Valley Womens Health Neurotology 3690 S Main St 3570 W 9000 S Benson, Ashley E MD Patel, Neil S MD Salt Lake City UT. 84115 Ste 210 University of Utah Health University Of Utah Health p 385.468.3950 West Jordan UT. 84088 3690 S Main St 100 N Mario Capecchi Dr p 801.569.2626 Salt Lake City UT. 84115 Salt Lake City UT. 84113 50 N Medical Dr p 385.468.4000 p 801.213.3599 Salt Lake City UT. 84132 Hospital Affiliation p 801.581.4014 - Jordan Valley Medical Center

296 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 50 N Medical Dr 3181 W 9000 S 50 N Medical Dr College of Nursing, Salt Lake City UT. 84132 West Jordan UT. 84088 Salt Lake City UT. 84132 University of Utah p 801.581.8425 p 801.569.5600 p 801.213.2995 4535 S 5600 W Salt Lake City UT. 84120 5121 S Cottonwood St Hospital Affiliation Rocky Mountain Womans p 801.963.7335 Murray UT. 84107 - Jordan Valley Medical Health Center - Salt Lake p 801.213.2995 Center City UUHC South Jordan Health - Jordan Valley Medical 82 S 1100 E Center Hospital Affiliation Center West Valley Campus Ste 305 5126 W Daybreak Pkwy - University of Utah Hospital Salt Lake City UT. 84102 South Jordan UT. 84095 *Byrne, Janice L MD p 801.214.7651 p 801.213.4500 Blue, Nathan R MD Primary Childrens Hospital University of Utah Health Physicians Hospital Affiliation UUHC Madsen Health Center 5121 S Cottonwood St 100 N Mario Capecchi Dr - Salt Lake Regional Medical 555 S Foothill Blvd Ste 100 Salt Lake City UT. 84113 Center Ste 301 Murray UT. 84107 p 801.662.1000 Salt Lake City UT. 84112 p 801.581.7746 Christensen, Shane MD p 801.581.8000 University of Utah Health Foothill Family Clinic 5121 S Cottonwood St 50 N Medical Dr 13953 S Bangerter Pkwy College of Nursing - Murray UT. 84107 Salt Lake City UT. 84132 Draper UT. 84020 Downtown Womens Clinic p 801.213.2995 p 801.581.8425 p 385.900.4090 82 S 1100 E Ste 204 Hospital Affiliation 7495 S State St 6360 S 3000 E Salt Lake City UT. 84102 - University of Utah Hospital Midvale UT. 84047 Ste 100 p 801.581.4014 - Memorial Hospital of p 801.213.9400 Salt Lake City UT. 84121 Sweetwater County p 801.365.1032 Hospital Affiliation Primary Childrens Hospital - University of Utah Hospital Boudreaux-Nippert, Denise Physicians Hospital Affiliation J MD 81 N Mario Capecchi Dr - Salt Lake Regional Medical Cross, Zoe K MD Jordan River Womens Health Salt Lake City UT. 84113 Center St Marks Family Medicine 3584 W 9000 S p 801.662.1000 - St Marks Hospital 1250 E 3900 S Ste 206 Ste 260 West Jordan UT. 84088 Hospital Affiliation Clement, Amelia C MD Salt Lake City UT. 84124 p 801.561.2227 - University of Utah Hospital University Of Utah Health p 801.265.2000 50 N Medical Dr Hospital Affiliation Campbell, Heather D MD Salt Lake City UT. 84132 Dalton, Susan E MD - Jordan Valley Medical University of Utah Health p 801.213.2995 University Of Utah Health Center 50 N Medical Dr 50 N Medical Dr Salt Lake City UT. 84132 Hospital Affiliation Salt Lake City UT. 84132 Branch, D W MD p 801.213.2995 - University of Utah Hospital p 801.213.2995 University of Utah Health 50 N Medical Dr Hospital Affiliation Cleveland, Amanda M MD Hospital Affiliation Salt Lake City UT. 84132 - University of Utah Hospital Jordan River Womens Health - University of Utah Hospital p 801.587.9500 13348 S Market Ctr Dr Chavez, Javier Eduardo Ste 200 Daniels, Jonathan P MD Hospital Affiliation MD Riverton UT. 84065 Rocky Mountain Womens - University of Utah Hospital Granger Medical p 385.887.7199 Health Care Salt Lake City Specialists 82 S 1100 E Brown, Bryant J MD 12391 S 4000 W 3584 W 9000 S Ste 305 Old Farm OBGYN Riverton UT. 84096 Ste 206 Salt Lake City UT. 84102 3970 S 700 E p 801.302.1700 West Jordan UT. 84088 p 801.214.7650 Ste 14 p 801.561.2227 Murray UT. 84107 3181 W 9000 S Hospital Affiliation p 801.261.3605 West Jordan UT. 84088 Colby, Spencer N MD - Jordan Valley Medical p 801.569.5600 Jordan River Womens Health Center West Valley Campus Hospital Affiliation 3584 W 9000 S - Salt Lake Regional Medical - St Marks Hospital Chelu, Laura MD Ste 206 Center University of Utah Health West Jordan UT. 84088 Burgett, Alton D MD 1525 W 2100 S p 801.561.2227 Debbink, Michelle L MD Granger Medical Salt Lake City UT. 84119 University of Utah Health Specialists p 801.213.8841 Hospital Affiliation 50 N Medical Dr 12391 S 4000 W - Jordan Valley Medical Salt Lake City UT. 84132 Riverton UT. 84096 Center p 801.213.2995 p 801.302.1700

297 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 5121 S Cottonwood St Draper, Michael L MD Eggebroten, Jennifer MD Falk, Jeanne M MD Ste 100 South Valley Womens University of Utah Health Salt Lake Regional Medical Murray UT. 84107 Imaging 3730 W 4700 S Center - Behavioral Health p 801.581.7746 3570 W 9000 S Taylorsville UT. 84129 Unit Ste 130 p 801.213.9200 1050 E S Temple 5126 W Daybreak Pkwy West Jordan UT. 84088 Salt Lake City UT. 84102 South Jordan UT. 84009 p 801.569.2626 50 N Medical Dr p 801.350.4255 p 801.213.2995 Salt Lake City UT. 84132 University of Utah Health p 801.213.2995 Obstetrix Medical Group of Hospital Affiliation 50 N Medical Dr Utah - University of Utah Hospital Salt Lake City UT. 84132 7495 S State St 1200 E 3900 S p 801.587.9500 Midvale UT. 84047 Salt Lake City UT. 84124 Densley, Chadwick M DO p 801.213.9400 p 801.268.7111 Western GYN & OB Clinic 5126 W Daybreak Pkwy 12842 S 3600 W South Jordan UT. 84009 Hospital Affiliation Rocky Mountain Womans Ste 200 p 801.581.8425 - Salt Lake Regional Medical Health Center - Salt Lake Riverton UT. 84065 Center City p 801.285.4800 Hospital Affiliation 82 S 1100 E - University of Utah Hospital Eller, Alexandra G MD Ste 305 Dildy, Gary A MD - Davis Hospital University of Utah Health Salt Lake City UT. 84102 Obstetrix Medical Group of - Jordan Valley Medical 50 N Medical Dr p 801.214.7651 Utah Center Salt Lake City UT. 84132 1140 E 3900 S - Salt Lake Regional Medical p 801.213.2995 Feige, Jennifer MD Ste 390 Center University of Utah Health Salt Lake City UT. 84124 Primary Childrens Hospital 1525 W 2100 S p 801.743.4700 Eborn, Shana K MD Physicians Salt Lake City UT. 84119 Foothill Family Clinic 81 N Mario Capecchi Dr p 801.213.8841 11925 S State St 13953 S Bangerter Pkwy Salt Lake City UT. 84113 Draper UT. 84020 Draper UT. 84020 p 801.662.1000 50 N Medical Dr p 801.545.8000 p 385.900.4090 Salt Lake City UT. 84132 Hospital Affiliation p 801.213.2995 1200 S 3900 S 2295 Foothill Dr - University of Utah Hospital Salt Lake City UT. 84124 Salt Lake City UT. 84109 Hospital Affiliation p 801.268.7111 p 801.486.3021 England, Edwin R MD - Salt Lake Regional Medical Granger Medical Center Dizon-Townson, Donna S MD Hospital Affiliation Specialists University of Utah Health - Salt Lake Regional Medical 12391 S 4000 W Ferguson, Daniel R MD 50 N Medical Dr Center Riverton UT. 84096 RMWHC @ Salt Lake City Salt Lake City UT. 84132 p 801.302.1700 82 S 1100 E p 801.213.2995 Eddy, Janet MD Ste 305 Western GYN & OB Clinic Epstein, Scott F DO Salt Lake City UT. 84102 Hospital Affiliation 3723 W 12600 S Jordan River Womens Health p 801.214.7650 - University of Utah Hospital Ste 350 3584 W 9000 S Riverton UT. 84065 Ste 206 Hospital Affiliation Dodson, Mark K MD p 801.285.4800 West Jordan UT. 84088 - Salt Lake Regional Medical University of Utah Health p 801.561.2227 Center 324 E 10th Ave Edmunds, Sean F MD Salt Lake City UT. 84103 St Marks Obstetrics and Hospital Affiliation Gawron, Lori M MD p 801.587.2809 Gynecology Associates - Jordan Valley Medical University of Utah Health 1140 E 3900 S Center 50 N Medical Dr 370 E 9th Ave Ste 400 Salt Lake City UT. 84132 Salt Lake City UT. 84103 Salt Lake City UT. 84124 Esplin, M S MD p 801.213.2995 p 801.236.7803 p 801.268.6811 University of Utah Health 50 N Medical Dr 555 Foothill Dr 50 N Medical Dr 850 E 300 S Salt Lake City UT. 84132 Salt Lake City UT. 84112 Salt Lake City UT. 84132 Ste 1 p 801.587.9500 p 801.581.8995 p 801.213.2995 Salt Lake City UT. 84102 p 801.322.1214 Hospital Affiliation Hospital Affiliation 8th Ave & C St - University of Utah Hospital - University of Utah Hospital Salt Lake City UT. 84143 Hospital Affiliation p 801.408.1100 - St Marks Hospital Faircloth, Erica A MD Gerard, Claudia G CNM Old Farm OBGYN/ University of Utah Health Hospital Affiliation 3970 S 700 E 3690 S Main St - University of Utah Hospital Ste 14 Salt Lake City UT. 84115 Murray UT. 84107 p 385.468.3950 p 801.261.3605

Hospital Affiliation - St Marks Hospital 298 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 50 N Medical Dr Hansen, Scott E MD Rocky Mountain Womans Jarrett, Arlen K MD Salt Lake City UT. 84132 South Valley Womens Health Center - Salt Lake South Valley Womens p 801.581.4014 Imaging City Imaging 3570 W 9000 S 82 S 1100 E 3570 W 9000 S 5126 W Daybreak Pkwy Ste 130 Ste 305 Ste 130 South Jordan UT. 84009 West Jordan UT. 84088 Salt Lake City UT. 84102 West Jordan UT. 84088 p 801.213.4500 p 801.569.2626 p 801.214.7651 p 801.569.2626

555 Foothill Dr South Valley Womens Health Hospital Affiliation South Valley Womens Health Salt Lake City UT. 84112 3570 W 9000 S - Salt Lake Regional Medical 3570 W 9000 S p 801.585.2111 Ste 210 Center Ste 210 West Jordan UT. 84088 West Jordan UT. 84088 7495 S State St p 801.569.2626 Horvath, Susan T MD p 801.569.2626 Midvale UT. 84047 Monarch Womens Cancer p 801.581.4014 Hospital Affiliation Center Hospital Affiliation - Jordan Valley Medical 1140 E 3900 S - Jordan Valley Medical Hospital Affiliation Center Ste 340 Center - University of Utah Hospital Salt Lake City UT. 84124 Harker, Melani MD p 801.743.4730 Jensen, Kevin S MD Gibson, Keri L MD University of Utah Health Monarch Womens Cancer University of Utah Health 3730 W 4700 S St Marks Obstetrics and Center 1525 W 2100 S Taylorsville UT. 84129 Gynecology Associates 8845 S Redwood Rd Salt Lake City UT. 84119 p 801.213.9200 1140 E 3900 S Ste E-121 p 801.213.8841 Ste 400 West Jordan UT. 84088 50 N Medical Dr Salt Lake City UT. 84124 p 801.569.1999 50 N Medical Dr Salt Lake City UT. 84132 p 801.268.6811 Salt Lake City UT. 84132 p 801.213.2995 Johnson, Jason L MD p 801.213.2995 Hospital Affiliation St Marks Obstetrics and 555 Foothill Dr - St Marks Hospital Gynecology Associates 7495 S State St Salt Lake City UT. 84112 1140 E 3900 S Midvale UT. 84047 p 801.581.8995 Humphreys, Meredith A MD Ste 400 p 801.213.9400 University Of Utah Health Salt Lake City UT. 84124 Hospital Affiliation 675 S Arapeen Dr p 801.268.6811 Hospital Affiliation - Salt Lake Regional Medical Salt Lake City UT. 84108 - University of Utah Hospital Center p 801.213.2995 Obstetrics and Gynecology Clinic Goodenough, Lynda PA Heuser, Cara C MD Hospital Affiliation 850 E 300 S Salt Lake Womens Center University of Utah Health - University of Utah Hospital Ste 1 10011 Centennial Pkwy 50 N Medical Dr Salt Lake City UT. 84102 Ste 350 Salt Lake City UT. 84132 Hutchison, Christopher p 801.322.1214 Sandy UT. 84070 p 801.587.9500 MD p 801.561.3922 Granger Medical Hospital Affiliation Hospital Affiliation Specialists - St Marks Hospital Hammad, Ibrahim A MD - University of Utah Hospital 12391 S 4000 W University of Utah Health Riverton UT. 84096 Johnstone, Erica B MD 3690 S Main St Hill, Audra MD p 801.302.1700 University of Utah Health Salt Lake City UT. 84115 University of Utah Health 50 N Medical Dr p 385.468.4000 50 N Medical Dr 3181 W 9000 S Salt Lake City UT. 84132 Salt Lake City UT. 84132 West Jordan UT. 84088 p 801.213.2995 50 N Medical Dr p 801.587.1950 p 801.569.5600 Salt Lake City UT. 84132 5126 W Daybreak Pkwy p 801.213.2995 Hospital Affiliation Hospital Affiliation South Jordan UT. 84009 - University of Utah Hospital - Jordan Valley Medical p 801.213.4500 5121 S Cottonwood St Center West Valley Campus Ste 100 Hinson, Joanne S MD - Jordan Valley Medical 675 S Arapeen Dr Murray UT. 84107 24 S 1100 E Center Salt Lake City UT. 84108 p 801.581.7746 Ste 210 - Lone Peak Hospital p 801.581.3834 Salt Lake City UT. 84102 5121 S Cottonwood St p 801.364.4030 Janke, Lindsay L PA-C Hospital Affiliation Murray UT. 84107 Monarch Womens Cancer - University of Utah Hospital p 801.213.2995 Alpine Medical Group Center 24 S 1100 E 1140 E 3900 S Judd, Angela MD Hospital Affiliation Ste 310 Ste 340 Western GYN & OB Clinic - University of Utah Hospital Salt Lake City UT. 84102 Salt Lake City UT. 84124 3723 W 12600 S p 801.478.0010 p 801.743.4730 Ste 350 Riverton UT. 84065 p 801.285.4800

Hospital Affiliation - Jordan Valley Medical Center 299 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Kaiser, Jennifer E MD Lash, Stephen D MD Maclean, Courtney C MD Moreland, Kimberly S MD University of Utah Health Rocky Mountain Womens University of Utah Health South Valley Womens 50 N Medical Dr Health Center at West 50 N Medical Dr Imaging Salt Lake City UT. 84132 Valley Campus Salt Lake City UT. 84132 3570 W 9000 S p 801.213.2995 3336 S Pioneer Pkwy p 801.213.2995 Ste 130 Ste 301 West Jordan UT. 84088 5121 S Cottonwood St Salt Lake City UT. 84120 555 Foothill Dr p 801.569.2626 Ste 100 p 801.964.3865 Salt Lake City UT. 84112 Murray UT. 84107 p 801.581.8995 South Valley Womens Health p 801.581.7746 Hospital Affiliation 3570 W 9000 S - Jordan Valley Medical 7495 S State St Ste 210 Hospital Affiliation Center Midvale UT. 84047 West Jordan UT. 84088 - University of Utah Hospital - Jordan Valley Medical p 801.213.9400 p 801.569.2626 Center West Valley Campus Katz, Felicia R MD - Salt Lake Regional Medical Hospital Affiliation Hospital Affiliation University of Utah Health Center - University of Utah Hospital - Jordan Valley Medical 1525 W 2100 S Center Salt Lake City UT. 84119 Later, Robert W MD Matthews, David J DO p 801.213.8841 Granger Medical Western GYN & OB Clinic Moyle, Kimberly A MD Specialists 12600 S 3723 W University Of Utah Health 50 N Medical Dr 9600 S 1300 E Ste 350 50 N Medical Dr Salt Lake City UT. 84132 Ste 220 Riverton UT. 84065 Salt Lake City UT. 84132 p 801.213.2995 Sandy UT. 84094 p 801.285.4800 p 801.587.9500 p 801.571.0009 Rocky Mountain Womans Hospital Affiliation Hospital Affiliation Health Center - Salt Lake Lawrence, Lindsay DO - Riverton Childrens Unit - University of Utah Hospital City Rocky Mountain Womens Operated by Primary Childrens Medical Center 82 S 1100 E Health Center at West - Jordan Valley Medical Nacy, Emily A MD Ste 305 Valley Campus Center University of Utah Health Salt Lake City UT. 84102 3336 S Pioneer Pkwy 1525 W 2100 S p 801.214.7651 Ste 301 Metz, Torri MD Salt Lake City UT. 84119 West Valley City UT. 84120 University of Utah Health p 801.213.8841 Hospital Affiliation p 801.964.3865 5121 S Cottonwood St - Salt Lake Regional Medical Ste 100 7495 S State St Center Jordan Valley Medical Murray UT. 84107 Midvale UT. 84047 Center p 801.581.7746 p 801.213.9400 Kinghorn, Jennifer C MD 3580 W 9000 S St Marks Obstetrics and West Jordan UT. 84088 5121 S Cottonwood St Hospital Affiliation Gynecology Associates p 801.601.4423 Murray UT. 84107 - University of Utah Hospital 1140 E 3900 S p 801.213.2995 Ste 400 Hospital Affiliation Naisbitt, Jed P MD Salt Lake City UT. 84124 - Jordan Valley Medical Monson, Martha MD Circle of Life Womens p 801.268.6811 Center University of Utah Health Center 50 N Medical Dr 12523 S Creek Meadow Rd Langer, Kathleen M MD Lilja, Kristen MD Salt Lake City UT. 84132 Ste 105 South Valley Womens Rocky Mountain Womens p 801.581.7647 Riverton UT. 84065 Imaging Center p 801.337.5800 3570 W 9000 S 5980 S Fashion Blvd 5121 S Cottonwood St Ste 130 Salt Lake City UT. 84107 Ste 100 Hospital Affiliation West Jordan UT. 84088 p 801.281.2658 Murray UT. 84107 - Ogden Regional Medical p 801.569.2626 p 801.581.7746 Center Rocky Mountain Womens - Davis Hospital South Valley Womens Health Health Center 5121 S Cottonwood St 3570 W 9000 S 82 S 1100 E Murray UT. 84107 Nielson, Eric C MD Ste 210 Ste 305 p 801.213.2995 Obstetrix Medical Group of West Jordan UT. 84088 Salt Lake City UT. 84102 Utah p 801.569.2626 p 801.214.7650 Hospital Affiliation 1200 S 3900 S - University of Utah Hospital Salt Lake City UT. 84124 Hospital Affiliation Luikenaar, Rixt A MD p 801.268.7111 - Jordan Valley Medical Rebirth OB/GYN Moran, Linh A MD Center 2180 E 4500 S St Marks Obstetrics and Hospital Affiliation Ste 265 Gynecology Associates - St Marks Hospital Salt Lake City UT. 84117 1140 E 3900 S p 801.272.3909 Ste 400 Salt Lake City UT. 84124 Hospital Affiliation p 801.268.6811 - St Marks Hospital

300 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Orr, Rochelle DO Porter, Christie DO 7495 S State St Rose, Susan M MD St Marks Gynecology and South Valley Womens Health Midvale UT. 84047 University of Utah Health Oncology Care 3570 W 9000 S p 801.213.9400 50 N Medical Dr 96 E Kimballs Ln Ste 210 Salt Lake City UT. 84132 Ste 202 West Jordan UT. 84088 Hospital Affiliation p 801.213.2995 Draper UT. 84020 p 801.569.2626 - Jordan Valley Medical p 801.523.3053 Center Hospital Affiliation Hospital Affiliation - St Marks Hospital - University of Utah Hospital Hospital Affiliation - Lone Peak Hospital - University of Utah Hospital - Lone Peak Hospital Roth, James T MD - St Marks Hospital Porter, Troy F MD Rinne, Kirsti APRN Old Farm OBGYN University of Utah Health University of Utah Health 3970 S 700 E Ostler, Leslie A MD 50 N Medical Dr 1280 E Stringham Ave Ste 14 Obstetrix Medical Group of Salt Lake City UT. 84132 Salt Lake City UT. 84106 Murray UT. 84107 Utah p 801.587.9500 p 801.581.4014 p 801.261.3605 1200 S 3900 S Salt Lake City UT. 84124 Hospital Affiliation 3690 S Main St Hospital Affiliation p 801.743.4700 - University of Utah Hospital Salt Lake City UT. 84115 - St Marks Hospital p 385.468.3950 University of Utah Health Quinn, Jeffrey D MD Royer, Pamela MD 1525 W 2100 S Western GYN & OB Clinic 50 N Medical Dr Community Health Centers Salt Lake City UT. 84119 12600 S 3723 W Salt Lake City UT. 84132 610 S 200 E p 801.213.8841 Ste 350 p 801.213.2995 Ste B Riverton UT. 84065 Salt Lake City UT. 84111 50 N Medical Dr p 801.285.4900 Hospital Affiliation p 801.539.8617 Salt Lake City UT. 84132 - University of Utah Hospital p 801.213.2995 Hospital Affiliation Saunders, Mark T MD - Riverton Childrens Unit Roberts, Audrey J MD UPRI Taylorsville 7495 S State St Operated by Primary Childrens RockyMedical Mountain Center Womens 1972 W 5400 S Midvale UT. 84047 - Jordan Valley Medical Health Center at West Ste 100 p 801.213.9400 Center Valley Campus Salt Lake City UT. 84129 3336 S Pioneer Pkwy p 801.878.7880 Hospital Affiliation Rappleye, Alan T MD Ste 301 - St Marks Hospital Old Farm OBGYN West Valley City UT. 84120 UPRI Murray 3970 S 700 E p 801.964.3865 32 W Winchester St Obstetrix Medical Group of Ste 14 Ste 200 Utah Murray UT. 84107 Jordan Valley Medical Salt Lake City UT. 84107 1140 E 3900 S p 801.261.3605 Center West Valley Campus p 801.327.9336 Ste 390 Inpatient BH Unit Salt Lake City UT. 84124 Hospital Affiliation 3460 S 4155 W Sharp, Howard T MD p 801.743.4713 - St Marks Hospital West Valley City UT. 84120 University of Utah Health p 801.964.3559 555 Foothill Dr Planned Parenthood Reproductive Care Center Salt Lake City UT. 84112 Association of Utah 10150 S Petunia Way Hospital Affiliation p 801.581.8995 1091 W S Jordan Pkwy Sandy UT. 84092 - Ogden Regional Medical Ste 100 p 801.878.8888 Center Hospital Affiliation South Jordan UT. 84095 - University of Utah Hospital p 801.254.2052 Reynolds, Brandon L DO Rohrer, Jacqueline MD University of Utah Health Foothill Family Clinic Sharshiner, Margarita Y 160 S 10th E 50 N Medical Dr 13953 S Bangerter Pkwy MD Ste 120 Salt Lake City UT. 84132 Draper UT. 84020 Obstetrix Medical Group of Salt Lake City UT. 84102 p 801.213.2995 p 385.900.4090 Utah p 801.322.5571 1140 E 3900 S 5126 W Daybreak Pkwy 2295 Foothill Dr Salt Lake City UT. 84124 1906 W 3600 S Ste 600 Salt Lake City UT. 84109 p 801.743.4700 West Valley City UT. 84119 South Jordan UT. 84009 p 801.486.3021 p 801.973.9675 p 801.213.4500 11925 S State St 6360 S 3000 E Draper UT. 84020 654 S 900 E 5126 W Daybreak Pkwy Ste 100 p 801.545.8000 Salt Lake City UT. 84102 South Jordan UT. 84009 Salt Lake City UT. 84121 p 801.532.1586 p 801.213.4500 p 801.365.1032 1200 E 3900 S Salt Lake City UT. 84124 Hospital Affiliation p 801.268.7111 - St Marks Hospital - Salt Lake Regional Medical Center

301 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Shifrar, Jacolin A APRN 5126 W Daybreak Pkwy 5121 S Cottonwood St Summers, Paul R MD Granger Medical South Jordan UT. 84009 Murray UT. 84107 University of Utah Health Specialists p 801.581.8425 p 801.213.2995 370 E 9th Ave 348 E 4500 S Salt Lake City UT. 84103 Ste 200 Hospital Affiliation Hospital Affiliation p 801.213.2746 Salt Lake City UT. 84107 - University of Utah Hospital - University of Utah Hospital p 801.262.9800 50 N Medical Dr Smith, Andrea N MD Steele, Max M MD Salt Lake City UT. 84132 Silver, Robert M MD University of Utah Health 370 9th Ave p 801.213.2995 University of Utah Health 50 N Medical Dr Ste 101 50 N Medical Dr Salt Lake City UT. 84132 Salt Lake City UT. 84103 555 Foothill Dr Salt Lake City UT. 84132 p 801.213.2995 p 801.408.2999 Salt Lake City UT. 84112 p 801.587.9500 p 801.581.8995 Rocky Mountain Womens Hospital Affiliation 5121 S Cottonwood St Center - Salt Lake Regional Medical Hospital Affiliation Murray UT. 84107 5980 S Fashion Blvd Center - University of Utah Hospital p 801.213.2995 Salt Lake City UT. 84107 p 801.281.2658 Steffen, Jenna M MD Tanner, Gregory C MD Hospital Affiliation University of Utah Health 9600 S 1300 E - University of Utah Hospital 82 S 1100 E 1525 W 2100 S Ste 305 - Davis Hospital Ste 305 Salt Lake City UT. 84119 Sandy UT. 84094 Salt Lake City UT. 84102 p 801.213.8841 p 801.572.5808 Skolnick, Sara MD p 801.214.7650 Exodus Healthcare Network 50 N Medical Dr Hospital Affiliation 3665 S 8400 W Hospital Affiliation Salt Lake City UT. 84132 - Jordan Valley Medical Ste 110 - Salt Lake Regional Medical p 801.213.2995 Center Magna UT. 84044 Center - Jordan Valley Medical p 801.250.9638 - University of Utah Hospital 555 Foothill Dr Center West Valley Campus Salt Lake City UT. 84112 Hospital Affiliation Smith, Layne A MD p 801.581.8995 Tappin, Dyanne - Jordan Valley Medical Granger Medical RMWHC @ Olympus Clinic Center West Valley Campus Specialists Hospital Affiliation 4624 S Holladay Blvd 11724 S State St - Salt Lake Regional Medical Ste 201 Sloan, Carrie L MD Draper UT. 84020 Center Salt Lake City UT. 84117 OBGYN Associates p 801.576.2050 p 385.234.4785 74 Kimballs Ln Stewart, Gayle MD Ste 330 Hospital Affiliation Rocky Mountain Womens RMWHC @ Salt Lake City Draper UT. 84020 - Jordan Valley Medical Health Center at West 82 S 1100 E p 801.523.3053 Center Valley Campus Ste 305 - Jordan Valley Medical 3336 S Pioneer Pkwy Salt Lake City UT. 84102 Lone Peak OBGYN Center West Valley Campus Ste 301 p 801.214.7650 8846 S Redwood Rd - Lone Peak Hospital Salt Lake City UT. 84120 Ste E121 p 801.964.3865 Theilen, Lauren H MD West Jordan UT. 84088 Soisson, Andrew P MD University of Utah Health p 801.569.1999 University of Utah Health Hospital Affiliation 50 N Medical Dr 1950 Cir of Hope Dr - Jordan Valley Medical Salt Lake City UT. 84132 St Marks Gynecology and Salt Lake City UT. 84112 Center p 801.213.2995 Oncology Care p 801.213.2995 - Jordan Valley Medical 96 E Kimballs Ln Center West Valley Campus 5121 S Cottonwood St Ste 202 50 N Medical Dr - Salt Lake Regional Medical Murray UT. 84107 Draper UT. 84020 Salt Lake City UT. 84132 Center p 801.213.2995 p 801.523.3053 p 801.213.2995 Sullivan, Amy E MD Hospital Affiliation Hospital Affiliation Hospital Affiliation University of Utah Health - University of Utah Hospital - St Marks Hospital - University of Utah Hospital 50 N Medical Dr - Lone Peak Hospital Salt Lake City UT. 84132 Townson, Walter MD Son, Shannon L MD p 801.213.2995 University of Utah Health Smid, Marcela MD University of Utah Health 3730 W 4700 S University of Utah Health 50 N Medical Dr Hospital Affiliation Taylorsville UT. 84129 50 N Medical Dr Salt Lake City UT. 84132 - Davis Hospital p 801.213.9200 Salt Lake City UT. 84132 p 801.581.8425 - Salt Lake Regional Medical p 801.213.2995 Center 50 N Medical Dr - University of Utah Hospital Salt Lake City UT. 84132 p 801.213.2995

302 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 7495 S State St University of Utah Dept of 7495 S State St 3181 W 9000 S Midvale UT. 84047 Obgyn Gynecologic Oncology Midvale UT. 84047 West Jordan UT. 84088 p 801.213.9400 50 N Medical Dr p 801.213.9400 p 801.569.5600 Salt Lake City UT. 84132 Hospital Affiliation p 801.581.2719 Hospital Affiliation Hospital Affiliation - St Marks Hospital - University of Utah Hospital - Jordan Valley Medical - University of Utah Hospital University of Utah OB Center Diagnostic Center Watts, Daren A MD - Lone Peak Hospital Trauscht-Van Horn, 30 N 1900 E St Marks Obstetrics and Jennifer J MD Salt Lake City UT. 84132 Gynecology Associates Wolfson, Robert N MD University of Utah Health p 801.581.7647 1140 E 3900 S Obstetrix Medical Group of 50 N Medical Dr Ste 400 Utah Salt Lake City UT. 84132 Verrilli, Lauren E MD Salt Lake City UT. 84124 1140 E 3900 S p 801.213.2995 University of Utah Health p 801.268.6811 Ste 390 675 S Arapeen Dr Salt Lake City UT. 84124 5126 W Daybreak Pkwy Salt Lake City UT. 84108 Hospital Affiliation p 801.743.4700 South Jordan UT. 84009 p 801.581.3834 - St Marks Hospital p 801.213.4500 Wray, Adam T DO Hospital Affiliation Webb, Joel C MD Western GYN & OB Clinic Hospital Affiliation - University of Utah Hospital Valley Obstetrics & 12842 S 3600 W - University of Utah Hospital Gynecology Ste 200 Voss, Stephen C MD 1250 E 3900 S Riverton UT. 84065 Turok, David K MD Obstetrics and Gynecology Ste 200 p 801.285.4800 University of Utah Health Clinic Salt Lake City UT. 84124 50 N Medical Dr 850 E 300 S p 801.756.9635 Yamashiro, Vernon K MD Salt Lake City UT. 84132 Ste 1 OBGYN Associates p 801.213.2995 Salt Lake City UT. 84102 Hospital Affiliation 1151 E 3900 S p 801.322.1214 - St Marks Hospital Ste B 299 Hospital Affiliation - Utah Valley Hospital Salt Lake City UT. 84124 - University of Utah Hospital Hospital Affiliation p 801.268.6811 - Salt Lake Regional Medical Weber, Tiffany K MD Twede, Michael L MD Center University of Utah Health Hospital Affiliation Granger Medical - St Marks Hospital 50 N Medical Dr - St Marks Hospital Specialists Salt Lake City UT. 84132 11724 S State St Ward, Katherine W APRN p 801.213.2995 Zempolich, Karen A MD Draper UT. 84020 University of Utah Health St Marks Gynecology p 801.576.2050 3690 S Main St 555 Foothill Dr Oncology Care Salt Lake City UT. 84115 Salt Lake City UT. 84112 1140 E 3900 S Hospital Affiliation p 385.468.3950 p 801.581.8995 Ste 340 - Lone Peak Hospital Salt Lake City UT. 84124 - Jordan Valley Medical Hospital Affiliation Hospital Affiliation p 801.743.4730 Center - University of Utah Hospital - University of Utah Hospital - Jordan Valley Medical 4465 S 900 E Center West Valley Campus Warner, William B MD Williams, Anneli PA-C Ste 224 and 275 Granger Medical St Marks Obstetrics and Salt Lake City UT. 84124 Twelves, Tricia MD Specialists Gynecology Associates p 801.743.4730 Granger Medical 12391 S 4000 W 1140 E 3900 S Specialists Riverton UT. 84096 Ste 400 Hospital Affiliation 12391 S 4000 W p 801.302.1700 Salt Lake City UT. 84124 - St Marks Hospital Riverton UT. 84096 p 801.268.6811 - Ogden Regional Medical p 801.302.1700 Hospital Affiliation Center - Lone Peak Hospital Hospital Affiliation Hospital Affiliation - St Marks Hospital Occupational Medicine - Jordan Valley Medical Watson, Abby J MD Ashton, Heather OT Center University of Utah Health Wilson, Matthew S MD University of Utah Health - North Canyon Medical 50 N Medical Dr Granger Medical Clinic 1950 Cir of Hope Dr Center Salt Lake City UT. 84132 12391 S 4000 W Salt Lake City UT. 84112 p 801.213.2995 Riverton UT. 84065 p 801.587.7000 University of Utah Dept of p 801.302.1700 OB/GYN 555 Foothill Dr Hospital Affiliation 50 N Medical Dr Salt Lake City UT. 84112 Granger Medical - University of Utah Hospital Salt Lake City UT. 84132 p 801.581.8995 Specialists p 801.581.7647 12391 S 4000 W Herriman UT. 84096 p 801.302.1700

303 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Yoon, Sarang K DO 5770 S Fashion Blvd Bldg 85 N Medical Dr Buch, Lauren N OT University of Utah Health 5 Salt Lake City UT. 84112 Neuroworx 1525 W 2100 S Ste 210 p 801.581.2121 90 W Albion Village Way Salt Lake City UT. 84119 Murray UT. 84107 Sandy UT. 84070 p 801.213.9900 p 801.314.5220 Hospital Affiliation p 801.619.3670 - University of Utah Health 5126 W Daybreak Pkwy Hospital Affiliation Craig H Neilsen Rehabilitation HospitalBullard, Alissa D OT Ste 600 - Primary Childrens Hospital University Of Utah Health South Jordan UT. 84009 *Bracken, Andrew T OT 85 N Medical Dr p 801.213.4500 Anderson, Sarah OT Primary Childrens Hospital Salt Lake City UT. 84112 University of Utah Health 100 N Mario Capecchi Dr p 801.581.2121 Hospital Affiliation 1950 Cir of Hope Dr Salt Lake City UT. 84113 - University of Utah Hospital Salt Lake City UT. 84112 p 801.662.4980 Hospital Affiliation p 801.587.7000 - University of Utah Health Occupational Therapy Brown, Tanita OT Craig H Neilsen Rehabilitation Hospital Ahlswede, Sharon OT 5126 W Daybreak Pkwy University of Utah Health Hand and Orthopedic South Jordan UT. 84009 1138 E Wilmington Ave Burman-Newby, Sara OT Rehabilitation Specialists p 801.213.4500 Salt Lake City UT. 84106 University of Utah Health 5151 S 900 E p 801.581.8881 5126 W Daybreak Pkwy Ste 100 590 S Wakara Way South Jordan UT. 84009 Salt Lake City UT. 84117 Salt Lake City UT. 84108 1280 E Stringham Ave p 801.213.4500 p 801.261.3321 p 801.581.2121 Salt Lake City UT. 84106 p 801.581.2000 590 S Wakara Way Aldana, Shea University Of Utah Health Salt Lake City UT. 84108 University Of Utah Health 50 N Medical Dr Hospital Affiliation p 801.581.2121 50 N Medical Dr Salt Lake City UT. 84132 - University of Utah Hospital Salt Lake City UT. 84132 p 801.581.2121 Hospital Affiliation p 801.581.2121 *Browning, Stacey B OT - University of Utah Hospital Hospital Affiliation Primary Childrens Rehab 85 N Medical Dr - University of Utah Hospital 100 N Mario Capecchi Dr Byars, Gabe L OT Salt Lake City UT. 84112 Salt Lake City UT. 84113 University of Utah Health p 801.587.3422 Arnold, Paul A OT p 801.662.4980 1950 Cir of Hope Dr University of Utah Health Salt Lake City UT. 84112 Hospital Affiliation 50 N Medical Dr 3741 W 12600 S p 801.587.7000 - University of Utah Hospital Salt Lake City UT. 84132 Ste 100 p 801.581.2121 Riverton UT. 84065 50 N Medical Dr Allen, Ashkii C OT p 801.571.3081 Salt Lake City UT. 84132 University of Utah Health Hospital Affiliation p 801.581.2121 50 N Medical Dr - University of Utah Hospital 3845 W 4700 S Salt Lake City UT. 84132 Taylorsville UT. 84129 University Of Utah Health p 801.581.2121 Ascher, Danielle OT p 801.840.4360 85 N Medical Dr University of Utah Health Salt Lake City UT. 84112 University Of Utah Health 50 N Medical Dr *Bubb, Nellie OT p 801.581.2121 85 N Medical Dr Salt Lake City UT. 84132 Primary Childrens Rehab Salt Lake City UT. 84112 p 801.581.2121 100 N Mario Capecchi Dr Byrnes, Kyle OT p 801.581.2121 Salt Lake City UT. 84113 Neuroworx Banks, Todd R OT p 801.662.4980 90 W Albion Village Way Hospital Affiliation Mountain Land Sandy UT. 84070 - University of Utah Hospital Rehabilitation Inc 3741 W 12600 S p 801.619.3670 1227 W 9000 S Ste 100 *Altemus, Clara L OT Ste F Riverton UT. 84065 Call, Abby OT Primary Childrens Rehab West Jordan UT. 84088 p 801.571.3081 University Of Utah Health 100 N Mario Capecchi Dr p 801.282.2200 85 N Medical Dr Salt Lake City UT. 84113 3845 W 4700 S Salt Lake City UT. 84112 p 801.662.4980 Berry, Meghan OT Taylorsville UT. 84129 p 801.581.2121 University of Utah Health p 801.840.4360 3741 W 12600 S 1950 Cir of Hope Dr Hospital Affiliation Ste 100 Salt Lake City UT. 84112 5770 S Fashion Blvd Bldg - University of Utah Hospital Riverton UT. 84065 p 801.587.7000 5 p 801.571.3081 Ste 210 Cardell, Elizabeth M OTR University Of Utah Health Murray UT. 84107 University of Utah Health 3845 W 4700 S 50 N Medical Dr p 801.314.5220 417 S Wakara Way Taylorsville UT. 84129 Salt Lake City UT. 84132 Ste 1410 p 801.840.4360 p 801.581.2121 Salt Lake City UT. 84108 p 801.585.6837

304 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Cayias, Thomas G OT Doulis, Andriana S OT Follis, Elizabeth A OT *Golley, Theresa A OT University of Utah Health University of Utah Health University of Utah Health Primary Childrens Hospital 50 N Medical Dr 100 N Mario Capecchi Dr 1950 Cir of Hope Dr 3845 W 4700 S Salt Lake City UT. 84132 Salt Lake City UT. 84113 Salt Lake City UT. 84112 Taylorsville UT. 84129 p 801.581.2121 p 801.587.2255 p 801.587.7000 p 801.840.4360

University Of Utah Health 81 N Mario Capecchi Dr Hospital Affiliation Gray, Sarah OT 85 N Medical Dr Salt Lake City UT. 84113 - University of Utah Hospital University of Utah Health Salt Lake City UT. 84112 p 801.587.2255 417 S Wakara Way p 801.581.2121 *Fong, Jennifer OT Ste 1410 *Duffin, Valerie J OT Primary Childrens Rehab Salt Lake City UT. 84108 Hospital Affiliation Primary Childrens Hospital 100 N Mario Capecchi Dr p 801.585.6837 - University of Utah Hospital 100 N Mario Capecchi Dr Salt Lake City UT. 84113 Salt Lake City UT. 84113 p 801.662.4980 Hospital Affiliation Concentra Medical Centers p 801.662.4980 - University of Utah Hospital 12422 S 450 E 3741 W 12600 S Draper UT. 84020 3773 W 12600 S Ste 100 *Greshik-Swan, Jacqueline p 888.997.2669 Riverton UT. 84065 Riverton UT. 84065 *OT p 801.285.1285 p 801.571.3081 Primary Childrens Hospital 1735 S Redwood Rd 81 N Mario Capecchi Dr Ste 115 3845 W 4700 S 3845 W 4700 S Salt Lake City UT. 84113 Salt Lake City UT. 84104 Taylorsville UT. 84129 Taylorsville UT. 84129 p 801.662.1675 p 888.997.2669 p 801.840.4360 p 801.840.4360 Hager, Susan J OT 2390 Redwood Rd Hospital Affiliation Hospital Affiliation University of Utah Health West Valley City UT. 84419 - Primary Childrens Hospital - Primary Childrens Hospital 50 N Medical Dr p 888.997.2669 Salt Lake City UT. 84132 Echeverria, Dominic J OT French, Kristen M OT p 801.581.2121 385 W 9000 S University of Utah Health University of Utah Health Sandy UT. 84070 50 N Medical Dr 50 N Medical Dr Hospital Affiliation p 888.997.2669 Salt Lake City UT. 84132 Salt Lake City UT. 84132 - University of Utah Hospital p 801.581.2121 p 801.581.2121 *Coyle, Taelor K OT Hample, Shalyn K OT Primary Childrens Rehab Hospital Affiliation Hospital Affiliation University of Utah Health 100 N Mario Capecchi Dr - University of Utah Hospital - University of Utah Hospital 1950 Cir of Hope Dr Salt Lake City UT. 84113 Salt Lake City UT. 84112 p 801.662.4980 Einerson, Jackie OT Gardner, James D OT p 801.587.7000 University of Utah Health University of Utah Health 3773 W 12600 S 50 N Medical Dr 1138 E Wilmington Ave Hospital Affiliation Riverton UT. 84065 Salt Lake City UT. 84132 Salt Lake City UT. 84106 - University of Utah Hospital p 801.285.1285 p 801.581.2121 p 801.581.2221 Handley, Paige OT 3845 W 4700 S University Of Utah Health 50 N Medical Dr University of Utah Health Taylorsville UT. 84129 85 N Medical Dr Salt Lake City UT. 84132 1138 E Wilmington Ave p 801.840.4360 Salt Lake City UT. 84112 p 801.581.2121 Salt Lake City UT. 84106 p 801.581.2121 p 801.581.2000 Hospital Affiliation University Of Utah Health - Primary Childrens Hospital Hospital Affiliation 85 N Medical Dr 1280 E Stringham Ave - University of Utah Hospital Salt Lake City UT. 84112 Salt Lake City UT. 84106 DeTemple, Kathrine M OT p 801.581.2121 p 801.581.2000 University of Utah Health *Falck, Mckenzie D OT 50 N Medical Dr Primary Childrens Rehab Hospital Affiliation Harris, Alison L OT Salt Lake City UT. 84132 100 N Mario Capecchi Dr - University of Utah Hospital University of Utah Health p 801.581.2121 Salt Lake City UT. 84113 50 N Medical Dr p 801.662.4980 Goerke, Drew R OT Salt Lake City UT. 84132 5126 W Daybreak Pkwy University of Utah Health p 801.581.2121 South Jordan UT. 84009 3741 W 12600 S 50 N Medical Dr p 801.213.4500 Ste 100 Salt Lake City UT. 84132 University Of Utah Health Riverton UT. 84065 p 801.581.2121 85 N Medical Dr 590 S Wakara Way p 801.571.3081 Salt Lake City UT. 84112 Salt Lake City UT. 84108 Hospital Affiliation p 801.581.2121 p 801.581.2121 3845 W 4700 S - University of Utah Hospital Taylorsville UT. 84129 Hospital Affiliation Hospital Affiliation p 801.840.4360 - University of Utah Hospital - University of Utah Hospital

305 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Henderson, Jarrett W OT Jones, Derek OT 3845 W 4700 S *Little, Robyn C OT University Of Utah Health University of Utah Health Taylorsville UT. 84129 Primary Childrens Rehab 50 N Medical Dr 50 N Medical Dr p 801.840.4360 100 N Mario Capecchi Dr Salt Lake City UT. 84132 Salt Lake City UT. 84132 Salt Lake City UT. 84113 p 801.581.2121 p 801.581.2121 5770 S Fashion Blvd Bldg p 801.662.4980 5 Hospital Affiliation University Of Utah Health Ste 210 Hospital Affiliation - University of Utah Hospital 85 N Medical Dr Murray UT. 84107 - Primary Childrens Hospital Salt Lake City UT. 84112 p 801.314.5220 Hieb, Julie A OT p 801.587.3422 Liveris, Casey OT University of Utah Health Hospital Affiliation University of Utah Health 50 N Medical Dr Kahn, Jessica OT - Primary Childrens Hospital 50 N Medical Dr Salt Lake City UT. 84132 University of Utah Health Salt Lake City UT. 84132 p 801.581.2121 417 S Wakara Way Langille, Devyn J OT p 801.581.2121 Ste 1410 University of Utah Health Hospital Affiliation Salt Lake City UT. 84108 50 N Medical Dr University Of Utah Health - University of Utah Hospital p 801.585.6837 Salt Lake City UT. 84132 85 N Medical Dr p 801.581.2121 Salt Lake City UT. 84112 Holmes, Vanessa OT *Keenan, Denise D OT p 801.581.2121 University Of Utah Health Intermountain Rehab Agency University Of Utah Health 1280 E Stringham Ave 324 10Th Ave 85 N Medical Dr Hospital Affiliation Salt Lake City UT. 84106 Ste 100 Salt Lake City UT. 84112 - University of Utah Hospital p 801.581.2000 Salt Lake City UT. 84103 p 801.581.2121 p 801.408.5735 Lucio, Jose X OT Hospital Affiliation Hospital Affiliation University of Utah Health - University of Utah Hospital 3845 W 4700 S - University of Utah Hospital 50 N Medical Dr Taylorsville UT. 84129 Salt Lake City UT. 84132 Hughes, Matthew A MD p 801.840.2191 Larsen, Derek H OT p 801.581.2121 University of Utah Health University Of Utah Health 1525 W 2100 S Keizer, Lana OT 50 N Medical Dr Hospital Affiliation Salt Lake City UT. 84119 University of Utah Health Salt Lake City UT. 84132 - University of Utah Hospital p 801.213.8841 50 N Medical Dr p 801.581.2121 Salt Lake City UT. 84132 Mackay-Clark, Deanna OT Hospital Affiliation p 801.581.2121 Hospital Affiliation Mountain Land - University of Utah Hospital - University of Utah Hospital Rehabilitation Inc 5126 W Daybreak Pkwy 1227 W 9000 S Hunt, Hilary L OT South Jordan UT. 84009 Lee, Eun Jin B OT Ste F University Of Utah Health p 801.213.4500 Hand and Orthopedic West Jordan UT. 84088 417 S Wakara Way Rehabilitation Specialists p 801.282.2200 Ste 1410 590 S Wakara Way 702 E South Temple Salt Lake City UT. 84108 Salt Lake City UT. 84108 Ste 102 Manwill, Joel M OT p 801.585.6837 p 801.581.2121 Salt Lake City UT. 84102 ABS Kids p 801.328.8535 515 S 700 E Hospital Affiliation Kovacik, Lauren A OT Ste 2A - University of Utah Hospital University of Utah Health Leslie, Leslye A OT Salt Lake City UT. 84102 50 N Medical Dr University of Utah Health p 801.935.4171 Irvin, Amy K OT Salt Lake City UT. 84132 50 N Medical Dr University Of Utah Health p 801.581.2121 Salt Lake City UT. 84132 6910 S Highland Dr 240 Morris Ave p 801.581.2121 Ste 1 Ste 400 Hospital Affiliation Salt Lake City UT. 84121 Salt Lake City UT. 84115 - University of Utah Hospital 590 S Wakara Way p 801.935.4171 p 801.585.3828 Salt Lake City UT. 84108 *Kunkel, Mary K OT p 801.581.2121 McCune, Kathryn A OT ABS Kids Primary Childrens Rehab University of Utah Health 515 S 700 E 100 N Mario Capecchi Dr Hospital Affiliation 50 N Medical Dr Ste 2A Salt Lake City UT. 84113 - University of Utah Hospital Salt Lake City UT. 84132 Salt Lake City UT. 84102 p 801.662.4980 p 801.581.2121 p 801.935.4171 *Lichtenberg, Elise OT 3741 W 12600 S Primary Childrens Rehab Hospital Affiliation *Jesewitz, Brittany OT Ste 100 100 N Mario Capecchi Dr - University of Utah Hospital Primary Childrens Rehab Riverton UT. 84065 Salt Lake City UT. 84113 100 N Mario Capecchi Dr p 801.571.3081 p 801.662.4980 *McQueen, Patrice OT Salt Lake City UT. 84113 Primary Childrens Rehab p 801.662.4980 Hospital Affiliation 100 N Mario Capecchi Dr - Primary Childrens Hospital Salt Lake City UT. 84113 Hospital Affiliation p 801.662.4980 - University of Utah Hospital

306 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 3741 W 12600 S Nielson-Jones, Kristen V Pratt, Christine T OT 3741 W 12600 S Ste 100 OT University of Utah Health Ste 100 Riverton UT. 84065 Rocky Mountain Therapy 50 N Medical Dr Riverton UT. 84065 p 801.571.3081 Services Salt Lake City UT. 84132 p 801.571.3081 3540 S 4000 W p 801.581.2121 3845 W 4700 S Ste 340 3845 W 4700 S Taylorsville UT. 84129 West Valley City UT. 84120 *Pratt, Seth OT Taylorsville UT. 84129 p 801.840.4360 p 801.417.5017 Primary Childrens Rehab p 801.840.4360 100 N Mario Capecchi Dr 5770 S Fashion Blvd Bldg Ostler, Benjamin OT Salt Lake City UT. 84113 5770 S Fashion Blvd Bldg 5 University of Utah Health p 801.662.4980 5 Ste 210 1138 E Wilmington Ave Ste 210 Murray UT. 84107 Salt Lake City UT. 84106 3741 W 12600 S Murray UT. 84107 p 801.314.5220 p 801.581.2221 Ste 100 p 801.314.5220 Riverton UT. 84065 Mcfarland, Roxie OT 50 N Medical Dr p 801.571.3081 *Rosello, Amy J OT University Of Utah Health Salt Lake City UT. 84132 Primary Childrens Hospital 50 N Medical Dr p 801.581.2121 3845 W 4700 S 3845 W 4700 S Salt Lake City UT. 84132 Taylorsville UT. 84129 Taylorsville UT. 84129 p 801.581.2121 University Of Utah Health p 801.840.4360 p 801.840.4360 85 N Medical Dr Hospital Affiliation Salt Lake City UT. 84112 Hospital Affiliation Rosello, Marc A OT - University of Utah Hospital p 801.581.2121 - Logan Regional Hospital University of Utah Health 1138 E Wilmington Ave Mitchell, Kasey D OTR Hospital Affiliation Ramos, Alicia OT Salt Lake City UT. 84106 University of Utah Health - University of Utah Hospital University of Utah Health p 801.581.2221 417 S Wakara Way 50 N Medical Dr Ste 1410 Ozaki, Susan S OT Salt Lake City UT. 84132 1280 E Stringham Ave Salt Lake City UT. 84108 Hand and Orthopedic p 801.581.2121 Salt Lake City UT. 84106 p 801.585.6837 Rehabilitation Specialists p 801.581.2000 5151 S 900 E Hospital Affiliation 65 S Mario Capecchi Dr Ste 100 - University of Utah Hospital Hospital Affiliation Salt Lake City UT. 84132 Murray UT. 84117 - University of Utah Hospital p 801.581.2352 p 801.261.3321 Reopelle, Chelsea OT University of Utah Health Ross, Kimberly M OT Nagata, Nicole K OT Partin, Katherine E OT 50 N Medical Dr University of Utah Health Neuroworx University of Utah Health Salt Lake City UT. 84132 2645 E Parleys Way 90 W Albion Village Way 50 N Medical Dr p 801.581.2121 Salt Lake City UT. 84109 Sandy UT. 84070 Salt Lake City UT. 84132 p 801.587.7109 p 801.619.3670 p 801.581.2121 University Of Utah Health 85 N Medical Dr 5126 W Daybreak Pkwy Hospital Affiliation University Of Utah Health Salt Lake City UT. 84112 South Jordan UT. 84009 - University of Utah Hospital 85 N Medical Dr p 801.581.2121 p 801.213.4500 Salt Lake City UT. 84112 Ng, Jenny OT p 801.581.2121 Hospital Affiliation 590 S Wakara Way University Of Utah Health - University of Utah Hospital Salt Lake City UT. 84108 50 N Medical Dr Hospital Affiliation p 801.581.2121 Salt Lake City UT. 84132 - University of Utah Hospital Riche, Thomas N OT p 801.581.2121 University of Utah Health Roth, Rhonda L OTR *Peterson, Emily R OT 50 N Medical Dr University of Utah Health Hospital Affiliation Primary Childrens Hospital Salt Lake City UT. 84132 417 S Wakara Way - University of Utah Hospital 3845 W 4700 S p 801.581.2121 Ste 1410 Taylorsville UT. 84129 Salt Lake City UT. 84108 Nieland, Kasey L OT p 801.840.4360 University Of Utah Health p 801.585.6837 University Of Utah Health 85 N Medical Dr 50 N Medical Dr Porter, Adam G OT Salt Lake City UT. 84112 Rozmus, Margaret E OT Salt Lake City UT. 84132 University of Utah Health p 801.581.2121 University of Utah Health p 801.581.2121 50 N Medical Dr 50 N Medical Dr Salt Lake City UT. 84132 *Robinson, Auston OT Salt Lake City UT. 84132 Hospital Affiliation p 801.581.2121 Primary Childrens Rehab p 801.581.2121 - University of Utah Hospital 100 N Mario Capecchi Dr Hospital Affiliation Salt Lake City UT. 84113 Hospital Affiliation - University of Utah Hospital p 801.662.4980 - University of Utah Hospital

307 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Samantha, Duff OT Seckinger, Leanne R OT 1280 E Stringham Ave 3845 W 4700 S Primary Childrens Rehab University of Utah Health Salt Lake City UT. 84106 Taylorsville UT. 84129 5770 S Fashion Blvd Bldg 1950 Cir of Hope Dr p 801.581.2000 p 801.840.4360 5 Salt Lake City UT. 84112 Ste 210 p 801.587.7000 Smith, Alicia B OT 5770 S Fashion Blvd Bldg Murray UT. 84107 University Of Utah Health 5 p 801.314.5220 Hospital Affiliation 50 N Medical Dr Ste 210 - University of Utah Hospital Salt Lake City UT. 84132 Murray UT. 84107 Hospital Affiliation p 801.581.2121 p 801.314.5220 - Primary Childrens Hospital Sell, Katherine OT University Of Utah Health Hospital Affiliation Hospital Affiliation Sanders, Chad R OT 85 N Medical Dr - University of Utah Hospital - Primary Childrens Hospital University of Utah Health Salt Lake City UT. 84112 50 N Medical Dr p 801.581.2121 Smith, Jessica E OT Sosa, Emily E OT Salt Lake City UT. 84132 University of Utah Health University Of Utah Health p 801.581.2121 Hospital Affiliation 1950 Cir of Hope Dr 50 N Medical Dr - University of Utah Hospital Salt Lake City UT. 84112 Salt Lake City UT. 84132 Schafer, Courtney L OTR/L p 801.587.7000 p 801.581.2121 ABS Kids Sette, Rachel X OT 515 S 700 E University Of Utah Health University Of Utah Health Hospital Affiliation Ste 2A 50 N Medical Dr 50 N Medical Dr - University of Utah Hospital Salt Lake City UT. 84102 Salt Lake City UT. 84132 Salt Lake City UT. 84132 p 801.935.4171 p 801.581.2121 p 801.581.2121 Squire, Aubrianne OT University of Utah Health Schneider, Marilyn A OT Hospital Affiliation 85 N Medical Dr 417 S Wakara Way University of Utah Health - University of Utah Hospital Salt Lake City UT. 84112 Ste 1410 240 Morris Ave p 801.581.2121 Salt Lake City UT. 84108 Ste 400 *Shackelford, Rachel p 801.585.6837 Salt Lake City UT. 84115 *MOT,OTR/L Hospital Affiliation p 801.585.3828 Primary Childrens Rehab - University of Utah Health Hospital Affiliation 3741 W 12600 S Craig H Neilsen Rehabilitation Hospital- University of Utah Hospital 417 S Wakara Way Ste 100 Ste 1410 Riverton UT. 84065 *Smith, Katrina OT *Stauffer, Deborah A OT Salt Lake City UT. 84108 p 801.571.3081 Primary Childrens Rehab Primary Childrens Rehab p 801.585.6837 100 N Mario Capecchi Dr 100 N Mario Capecchi Dr 3845 W 4700 S Salt Lake City UT. 84113 Salt Lake City UT. 84113 Hospital Affiliation Taylorsville UT. 84129 p 801.662.4980 p 801.662.4980 - University of Utah Hospital p 801.840.4360 3741 W 12600 S 3741 W 12600 S Schutz, Bridget M OT 5770 S Fashion Blvd Bldg Ste 100 Ste 100 University of Utah Health 5 Riverton UT. 84065 Riverton UT. 84065 50 N Medical Dr Ste 210 p 801.571.3081 p 801.571.3081 Salt Lake City UT. 84132 Murray UT. 84107 p 801.581.2121 p 801.314.5220 3845 W 4700 S 3845 W 4700 S Taylorsville UT. 84129 Taylorsville UT. 84129 Hospital Affiliation *Sharp, Derek OT p 801.840.4360 p 801.840.4360 - University of Utah Hospital Primary Childrens Rehab 5770 S Fashion Blvd Bldg 5770 S Fashion Blvd Bldg Hospital Affiliation Scott, David S OT 5 5 - Primary Childrens Hospital University of Utah Health Ste 210 Ste 210 50 N Medical Dr Murray UT. 84107 Murray UT. 84107 Stratton, Jacob PT Salt Lake City UT. 84132 p 801.314.5220 p 801.314.5220 Rocky Mountain Therapy p 801.581.2121 Services Hospital Affiliation *Smith, Sarah OT 1950 E 7000 S Hospital Affiliation - Primary Childrens Hospital Primary Childrens Rehab Cottonwood Heights UT. 84121 - University of Utah Hospital 100 N Mario Capecchi Dr p 801.943.1041 Skoczylas, Gabriela OT Salt Lake City UT. 84113 Scott, Neil F OT University of Utah Health p 801.662.4980 Sudbury, Dallin S OT University of Utah Health 1138 E Wilmington Ave University of Utah Health 50 N Medical Dr Salt Lake City UT. 84106 3741 W 12600 S 50 N Medical Dr Salt Lake City UT. 84132 p 801.581.2221 Ste 100 Salt Lake City UT. 84132 p 801.581.2121 Riverton UT. 84065 p 801.581.2121 p 801.571.3081 Hospital Affiliation Hospital Affiliation - University of Utah Hospital - University of Utah Hospital

308 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Sullivan, Kristen OT Unck, Jennifer A OT Walther, Stacy L OT Zamias, Jessica L OT Primary Childrens Hospital University of Utah Health University Of Utah Health University Of Utah Health 100 N Mario Capecchi Dr 50 N Medical Dr 50 N Medical Dr 50 N Medical Dr Salt Lake City UT. 84113 Salt Lake City UT. 84132 Salt Lake City UT. 84132 Salt Lake City UT. 84132 p 801.662.4980 p 801.581.2121 p 801.581.2121 p 801.581.2121

Swan, Rachel C OT Hospital Affiliation Hospital Affiliation Hospital Affiliation University of Utah Health - University of Utah Hospital - University of Utah Hospital - University of Utah Hospital 417 S Wakara Way Ste 1410 Vannoy, Kirsty A OT Warner, Matthew T DPT Oculoplastic Surgery Salt Lake City UT. 84108 University Of Utah Health Advanced Motion Physical Anderson, Richard L MD p 801.585.6837 50 N Medical Dr Therapy Oculoplastic Surgery Salt Lake City UT. 84132 3665 S 8400 W 1002 E S Temple University Of Utah Health p 801.581.2121 Ste 210 Ste 308 85 N Medical Dr Magna UT. 84044 Salt Lake City UT. 84102 Salt Lake City UT. 84112 Hospital Affiliation p 801.250.6733 p 801.363.3355 p 801.581.2121 - University of Utah Hospital Wedekind, Nikolai H OT Hospital Affiliation Hospital Affiliation Vik, Kelsi J OT University of Utah Health - Salt Lake Regional Medical - University of Utah Hospital University of Utah Health 50 N Medical Dr Center 50 N Medical Dr Salt Lake City UT. 84132 Swinyard, Shauna L OT Salt Lake City UT. 84132 p 801.581.2121 McCann, John D MD University of Utah Health p 801.581.2121 The Eye Institute of Utah 50 N Medical Dr University Of Utah Health 755 E 3900 S Salt Lake City UT. 84132 University Of Utah Health 85 N Medical Dr Murray UT. 84107 p 801.581.2121 85 N Medical Dr Salt Lake City UT. 84112 p 801.226.2283 Salt Lake City UT. 84112 p 801.581.2121 University Of Utah Health p 801.581.2121 Center For Facial 85 N Medical Dr Hospital Affiliation Appearance Salt Lake City UT. 84112 Hospital Affiliation - University of Utah Hospital 9350 S 150 E p 801.581.2121 - University of Utah Hospital Ste 400 West, Tiffany A OTR Sandy UT. 84070 Hospital Affiliation Walker, Kaysen OT Registered Physical p 801.997.9999 - University of Utah Hospital University Of Utah Health Therapists Inc 50 N Medical Dr 74 E Kimball Ln Hospital Affiliation *Thompson, Robyn M OT Salt Lake City UT. 84132 Ste 200 - Salt Lake Regional Medical Primary Childrens Rehab p 801.581.2121 Draper UT. 84020 Center 3741 W 12600 S p 801.432.2070 Ste 100 Hospital Affiliation Oberg, Thomas MD Riverton UT. 84065 - University of Utah Hospital Williams, Lindsay M OT Oculoplastic Surgery p 801.571.3081 University of Utah Health 1002 E S Temple *Walker, Kristin D OT 50 N Medical Dr Ste 308 5770 S Fashion Blvd Bldg Primary Childrens Rehab Salt Lake City UT. 84132 Salt Lake City UT. 84102 5 100 N Mario Capecchi Dr p 801.581.2121 p 801.363.3356 Ste 210 Salt Lake City UT. 84113 Murray UT. 84107 p 801.662.4980 Hospital Affiliation Hospital Affiliation p 801.314.5220 - University of Utah Hospital - Salt Lake Regional Medical 3741 W 12600 S Center Hospital Affiliation Ste 100 Wogamon, Andrea M OT - Primary Childrens Hospital Riverton UT. 84065 University of Utah Health Patel, Bhupendra C MD p 801.571.3081 1950 Cir of Hope Dr University of Utah Health Thomson, Sarah OT Salt Lake City UT. 84112 100 N Mario Capecchi Dr University Of Utah Health 3845 W 4700 S p 801.587.7000 Salt Lake City UT. 84113 50 N Medical Dr Taylorsville UT. 84129 p 801.581.2352 Salt Lake City UT. 84132 p 801.840.4360 Hospital Affiliation p 801.581.2121 - University of Utah Hospital The Salt Lake Eye 5770 S Fashion Blvd Bldg Associates Hospital Affiliation 5 Wood, Eric M MD 1025 E 3300 S - University of Utah Hospital Ste 210 University Of Utah Health Ste B Murray UT. 84107 9385 Snowbird Ctr Dr Salt Lake City UT. 84106 Tippin, Krista L OT p 801.314.5220 Sandy UT. 84092 p 801.281.2020 University of Utah Health p 801.646.4800 50 N Medical Dr Salt Lake City UT. 84132 p 801.581.2121

309 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. St Marks Hospital Chittoria, Namita MD 1950 Cir of Hope Dr Nibley, William E MD - Salt Lake Regional Medical 1200 E 3900 S University Of Utah Health Salt Lake City UT. 84112 Utah Cancer Specialists Center Salt Lake City UT. 84107 85 N Medical Dr p 801.585.0100 5131 S Cottonwood St p 801.773.0690 Salt Lake City UT. 84112 Ste L-2 p 801.585.0100 Hospital Affiliation Murray UT. 84107 University of Utah Health - University of Utah Hospital p 901.263.3416 243 E 6100 S Hospital Affiliation Murray UT. 84107 - University of Utah Hospital Kinsey, Conan G MD Hospital Affiliation p 801.585.3937 University of Utah Health - St Marks Hospital Frame, Richard N MD 1950 Cir of Hope Dr - Lakeview Hospital 65 S Mario Capecchi Dr Utah Cancer Specialists Salt Lake City UT. 84112 - Ashley Valley Regional Salt Lake City UT. 84132 3592 W 9000 S p 801.585.0100 Medical Center p 801.581.2352 Ste 200 - Davis Hospital West Jordan UT. 84088 University Of Utah Health LDS Hospital (Avenues p 801.562.8732 85 N Medical Dr Pingree, James C MD Surgical Center) Salt Lake City UT. 84112 St Marks Hospital 8th Ave C St Hospital Affiliation p 801.585.0100 Comprehensive Spine Center Salt Lake City UT. 84132 - Salt Lake Regional Medical 1220 E 3900 S p 801.224.6767 Center Hospital Affiliation Ste 1-F - Davis Hospital - University of Utah Hospital Salt Lake City UT. 84124 Hospital Affiliation - Jordan Valley Medical p 801.262.5711 - University of Utah Hospital Center Kohli, Manish MD - Davis Hospital - Lakeview Hospital University Of Utah Health Wasatch Neurosurgery - St Marks Hospital 1950 Cir of Hope Dr 1220 E 3900 S Grossmann, Kenneth F MD Salt Lake City UT. 84112 Ste 4E Oncology University of Utah Health p 801.585.0100 Salt Lake City UT. 84124 Agarwal, Neeraj MD 1950 Cir of Hope Dr p 801.261.8507 University of Utah Health Salt Lake City UT. 84112 85 N Medical Dr 1950 Cir of Hope Dr p 801.585.0100 Salt Lake City UT. 84112 MountainStar Medical Group Salt Lake City UT. 84112 p 801.585.0100 Neurosurgery p 801.585.0100 University Of Utah Health 74 E Kimballs Ln 85 N Medical Dr Litton, Gregory J MD Ste 330 University Of Utah Health Salt Lake City UT. 84112 Utah Cancer Specialists Draper UT. 84020 85 N Medical Dr p 801.585.0100 5131 S Cottonwood St p 801.262.5711 Salt Lake City UT. 84112 Ste L-2 p 801.585.0100 Hospital Affiliation Murray UT. 84107 Hospital Affiliation - University of Utah Hospital p 801.263.3416 - St Marks Hospital Hospital Affiliation - University of Utah Hospital Jeter, Joanne M Hospital Affiliation Prchal, Josef T MD University Of Utah Health - St Marks Hospital University of Utah Health Akerley, Wallace L MD 1280 E Stringham Ave - Lakeview Hospital 1950 Cir of Hope Dr University of Utah Health Salt Lake City UT. 84106 - Jordan Valley Medical Salt Lake City UT. 84112 1950 Cir of Hope Dr p 801.585.0100 Center p 801.585.0100 Salt Lake City UT. 84112 - Salt Lake Regional Medical p 801.585.0100 1950 Cir of Hope Dr Center Hospital Affiliation Salt Lake City UT. 84112 - University of Utah Hospital University Of Utah Health p 801.585.0100 McGee-Conder, Rosemary 85 N Medical Dr APRN Prystas, Elizabeth M MD Salt Lake City UT. 84112 Hospital Affiliation University of Utah Health Wasatch Hematology and p 801.585.0100 - University of Utah Hospital 1950 Cir of Hope Dr Oncology Associates PC Salt Lake City UT. 84112 324 10th Ave Hospital Affiliation Kannapel, Esther L APRN p 801.585.0100 Ste 274 - University of Utah Hospital University of Utah Health Salt Lake City UT. 84103 1950 Cir of Hope Dr Hospital Affiliation p 801.408.5757 Chandramouli, Nitin B MD Salt Lake City UT. 84112 - University of Utah Hospital Utah Cancer Specialists p 801.585.0100 Hospital Affiliation 3838 S 700 E Neilsen, Courtnee D PA - Salt Lake Regional Medical Ste 100 Hospital Affiliation University of Utah Health Center Salt Lake City UT. 84106 - University of Utah Hospital 50 N Medical Dr - University of Utah Hospital p 801.269.0231 Salt Lake City UT. 84132 Kerrigan, Kathleen C DO p 801.581.2121 Samuelson, Scott J MD Hospital Affiliation University Of Utah Health Utah Cancer Specialists - Mountain West Medical 1280 E Stringham Ave Hospital Affiliation 389 S 900 E Center Salt Lake City UT. 84106 - University of Utah Hospital Ste 100 - St Marks Hospital p 801.585.0100 Salt Lake City UT. 84102 - Lakeview Hospital p 385.282.2125 - Davis Hospital Hospital Affiliation - Jordan Valley Medical Center - Davis Hospital 310 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. -10/01/2021 Lakeview 05:46:48 Hospital **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Stephenson, William T MD Werner, Theresa L MD Anderson, Bradley J MD Bernstein, Paul S MD,PhD Utah Cancer Specialists University of Utah Health Utah Eye Centers University of Utah Health 1121 E 3900 S 1950 Cir of Hope Dr 1025 E 3300 S 100 N Mario Capecchi Dr Ste C240 Salt Lake City UT. 84112 Ste B Salt Lake City UT. 84113 Salt Lake City UT. 84124 p 801.585.0100 Salt Lake City UT. 84106 p 801.581.2352 p 801.266.0878 p 801.476.0494 University Of Utah Health 243 E 6100 S 333 S 900 E 85 N Medical Dr 324 10th Ave Murray UT. 84107 Salt Lake City UT. 84102 Salt Lake City UT. 84112 Ste 260 p 801.585.3937 p 801.933.6070 p 801.585.0100 Salt Lake City UT. 84103 p 801.408.3937 50 N Medical Dr 5770 S 250 E Hospital Affiliation Salt Lake City UT. 84132 Ste 135 - University of Utah Hospital Anderson, Richard L MD p 801.581.2121 Murray UT. 84107 Oculoplastic Surgery p 801.263.3416 Whisenant, Johnathan R MD 1002 E S Temple 65 S Mario Capecchi Dr Utah Cancer Specialists Ste 308 Salt Lake City UT. 84132 Van Meter, Margaret E MD 389 S 900 E Salt Lake City UT. 84102 p 801.581.2352 Intermountain Medical Ste 100 p 801.363.3355 Oncology Salt Lake City UT. 84102 Hospital Affiliation 5171 S Cottonwood St p 385.347.5500 Hospital Affiliation - University of Utah Hospital Ste 610 - Salt Lake Regional Medical Salt Lake City UT. 84107 5131 S Cottonwood St Center Beson, James L DO p 801.507.3900 Ste L-2 University of Utah Health Murray UT. 84107 Barlow, William R MD 243 E 6100 S Voorhies, Benjamin N MD p 801.263.3416 University of Utah Health Murray UT. 84107 University of Utah Health 243 E 6100 S p 801.585.3937 1950 Cir of Hope Dr Hospital Affiliation Murray UT. 84107 Salt Lake City UT. 84112 - Ashley Valley Regional p 801.585.3937 50 N Medical Dr p 801.585.0100 Medical Center Salt Lake City UT. 84132 50 N Medical Dr p 801.581.2121 5126 W Daybreak Pkwy Ophthalmology Salt Lake City UT. 84132 South Jordan UT. 84009 Alder, John B MD p 801.581.2121 65 S Mario Capecchi Dr p 801.585.0100 Cottonwood Ophthalmology Salt Lake City UT. 84132 Assoc 5126 W Daybreak Pkwy p 801.581.2352 Hospital Affiliation 6412 S 900 E South Jordan UT. 84009 - University of Utah Hospital Ste 101 p 801.213.4500 Hospital Affiliation Murray UT. 84121 - University of Utah Hospital Ward, John H MD p 801.262.3344 65 S Mario Capecchi Dr University of Utah Health Salt Lake City UT. 84132 Bradley, Michael J MD 1950 Cir of Hope Dr Alldredge Jr, O Claron p 801.581.2352 Hoopes Vision Correction Salt Lake City UT. 84112 MD Center p 801.585.0100 Hoopes Vision Correction Hospital Affiliation 11820 S State St Center - University of Utah Hospital Ste 200 University Of Utah Health 11820 S State St Draper UT. 84020 85 N Medical Dr Ste 200 Benator, Rachel S MD p 801.568.0200 Salt Lake City UT. 84112 Draper UT. 84020 Olympus Eye Associates p 801.585.0100 p 801.568.0200 1025 E 3300 S Hospital Affiliation Ste B - St Marks Hospital Hospital Affiliation Alldredge, Claron D MD Salt Lake City UT. 84106 - University of Utah Hospital Utah Eye Centers p 801.261.0726 Bretz, Kristin O MD 1025 E 3300 S The Eye Institute of Utah Wei, Mei MD Ste B 6065 S Fashion Blvd 755 E 3900 S University of Utah Health Salt Lake City UT. 84106 Ste 125 Salt Lake City UT. 84107 1280 E Stringham Ave p 801.476.0494 Salt Lake City UT. 84107 p 801.845.0759 Salt Lake City UT. 84106 p 801.261.0726 p 801.585.0100 440 D St Hospital Affiliation Ste 210 Bernhisel, Ashlie A MD - University of Utah Hospital 1950 Cir of Hope Dr Salt Lake City UT. 84103 University Of Utah Health Salt Lake City UT. 84112 p 801.408.3705 65 S Mario Capecchi Dr Brinton, Eric P MD p 801.585.0100 Salt Lake City UT. 84132 Retina Associates of Utah Hospital Affiliation p 801.581.2352 5169 S Cottonwood St University Of Utah Health - Ogden Regional Medical Ste 630 85 N Medical Dr Center Hospital Affiliation Salt Lake City UT. 84107 Salt Lake City UT. 84112 - Davis Hospital - University of Utah Hospital p 801.312.2020 p 801.585.0100

Hospital Affiliation - University of Utah Hospital 311 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Brinton, Gregory S MD Charlton, Kevin H MD Coombs, Peter G MD Daynes, Todd E MD Retina Associates of Utah Rocky Mountain Eye Care Utah Eye Centers 324 10th Ave 5169 S Cottonwood St Bldg 4400 S 700 E 1025 E 3300 S Ste 260 B Ste 100 Ste B Salt Lake City UT. 84103 Ste 630 Murray UT. 84107 Salt Lake City UT. 84106 p 801.408.2020 Murray UT. 84107 p 801.264.4450 p 801.476.0494 p 801.312.2020 Hospital Affiliation 5069 W 13400 S Hospital Affiliation - Lakeview Hospital Hospital Affiliation Ste 400 - Ogden Regional Medical - St Marks Hospital - St Marks Hospital Herriman UT. 84096 Center - Mountain West Medical - Davis Hospital p 801.264.4450 Center Corey, Richard P MD Brockbank, David T MD Hospital Affiliation Retina & Vitreous Surgeons Digre, Kathleen B MD Olympus Eye Associates - St Marks Hospital of Utah University of Utah Health 1025 E 3300 S 11820 S State St 175 N Medical Dr E Ste B Chaya, Craig J MD Ste 320 Salt Lake City UT. 84132 Salt Lake City UT. 84106 University of Utah Health Draper UT. 84020 p 801.585.7575 p 801.261.0726 100 N Mario Capecchi Dr p 801.357.7704 Salt Lake City UT. 84113 50 N Medical Dr 5872 S 900 E p 801.581.2352 5171 Cottonwood St Salt Lake City UT. 84132 Ste 100 Ste 700 p 801.581.2121 Salt Lake City UT. 84121 1525 W 2100 S Murray UT. 84107 p 801.261.0726 Salt Lake City UT. 84119 p 801.892.8200 65 S Mario Capecchi Dr p 801.213.8841 Salt Lake City UT. 84132 6065 S Fashion Blvd Hospital Affiliation p 801.581.2352 Ste 125 243 E 6100 S - St Marks Hospital Murray UT. 84107 Murray UT. 84107 - Timpanogos Regional Hospital 729 S Arapeen Dr p 801.261.0726 p 801.585.3937 - Jordan Valley Medical Salt Lake City UT. 84108 Center p 801.585.6387 Hospital Affiliation 50 N Medical Dr - St Marks Hospital Salt Lake City UT. 84132 Crum, Alison V MD Hospital Affiliation p 801.581.2121 University of Utah Health - University of Utah Hospital Buckner, Benjamin MD 100 N Mario Capecchi Dr Hoopes Vision Correction 65 S Mario Capecchi Dr Salt Lake City UT. 84113 Dodds, David MD Center Salt Lake City UT. 84132 p 801.581.2352 Salt Lake Eye Associates 11820 S State St p 801.581.2352 1025 E 3300 S Ste 200 243 E 6100 S Ste B Draper UT. 84020 Hospital Affiliation Murray UT. 84107 Salt Lake City UT. 84106 p 801.568.0200 - University of Utah Hospital p 801.585.3937 p 801.281.2020

Burrow, Michael K MD Chortkoff, Susan MD 50 N Medical Dr Olympus Eye Associates Rocky Mountain Eye Care University of Utah Health Salt Lake City UT. 84132 5872 S 900 E 4400 S 700 E 243 E 6100 S p 801.581.2121 Ste 100 Ste 100 Murray UT. 84107 Salt Lake City UT. 84121 Salt Lake City UT. 84107 p 801.585.3937 65 S Mario Capecchi Dr p 801.261.0726 p 801.264.4450 Salt Lake City UT. 84132 50 N Medical Dr p 801.581.2352 6065 S Fashion Blvd Carver, John A MD Salt Lake City UT. 84132 Ste 125 Retina & Vitreous Surgeons p 801.581.2121 Hospital Affiliation Salt Lake City UT. 84107 of Utah - University of Utah Hospital p 801.261.0726 11820 S State St 65 S Mario Capecchi Dr Ste 320 Salt Lake City UT. 84132 Davis, Brian R MD Hospital Affiliation Draper UT. 84020 p 801.581.2352 Davis Vision Center - St Marks Hospital p 801.357.7704 Associates PLLC Hospital Affiliation 11649 S 4000 W Dries, David C MD 5171 Cottonwood St - University of Utah Hospital Ste 200 University of Utah Health Ste 700 South Jordan UT. 84009 100 N Mario Capecchi Dr Murray UT. 84107 Christiansen, Gregory A p 801.253.3080 Salt Lake City UT. 84113 p 801.892.8200 MD p 801.581.2352 Clarus Vision Hospital Affiliation Hospital Affiliation 6344 S 900 E - Jordan Valley Medical 50 N Medical Dr - St Marks Hospital Salt Lake City UT. 84121 Center Salt Lake City UT. 84132 - Timpanogos Regional Hospital p 801.892.8222 p 801.581.2121 - Jordan Valley Medical Center Hospital Affiliation - St Marks Hospital

312 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 65 S Mario Capecchi Dr Goff, Mitchell J MD 65 S Mario Capecchi Dr 243 E 6100 S Salt Lake City UT. 84132 Rocky Mountain Retina Salt Lake City UT. 84132 Murray UT. 84107 p 801.581.2352 Consultants p 801.581.2352 p 801.585.3937 4400 S 700 E Hospital Affiliation Ste 200 Hospital Affiliation 50 N Medical Dr - University of Utah Hospital Salt Lake City UT. 84107 - University of Utah Hospital Salt Lake City UT. 84132 p 801.264.4444 p 801.581.2121 Eftekhari, Kian MD Harris, Matheson A MD Ear, Nose & Throat Center Hospital Affiliation Utah Oculoplasty 65 S Mario Capecchi Dr of Utah - St Marks Hospital Consultants Salt Lake City UT. 84132 22 S 900 E 4400 S 700 E p 801.581.2352 Salt Lake City UT. 84102 Gudgel, Brett M MD Ste 130 p 801.328.2522 University Of Utah Health Murray UT. 84107 Hospital Affiliation 243 E 6100 S p 801.264.4420 - University of Utah Hospital Hospital Affiliation Murray UT. 84107 - Salt Lake Regional Medical p 801.585.3937 University of Utah Health Howard, James G MD Center 65 S Mario Capecchi Dr Retina Associates of Utah 65 S Mario Capecchi Dr Salt Lake City UT. 84132 5169 S Cottonwood St Faber, David W MD Salt Lake City UT. 84132 p 801.581.2352 Ste 630 Rocky Mountain Retina p 801.581.2352 Murray UT. 84107 Consultants Hospital Affiliation p 801.312.2020 4400 S 700 E Hospital Affiliation - Lone Peak Hospital Ste 200 - University of Utah Hospital - University of Utah Hospital Hospital Affiliation Salt Lake City UT. 84107 - St Marks Hospital p 801.264.4444 Hansen, Brock C MD Hartnett, Mary E MD - Davis Hospital Utah Eye Centers University of Utah Health Hospital Affiliation 1025 E 3300 S 100 N Mario Capecchi Dr Hu, Wen F MD - St Marks Hospital Ste B Salt Lake City UT. 84113 University Of Utah Health Salt Lake City UT. 84106 p 801.581.2352 243 E 6100 S Fassio, John B MD p 801.476.0494 Murray UT. 84107 Stacy R SMith MD PC 50 N Medical Dr p 801.585.3937 1548 E 4500 S Hospital Affiliation Salt Lake City UT. 84132 Ste 105 - Ogden Regional Medical p 801.581.2121 65 S Mario Capecchi Dr Salt Lake City UT. 84117 Center Salt Lake City UT. 84132 p 801.424.3090 65 S Mario Capecchi Dr p 801.581.2352 Hansen, Eric D MD Salt Lake City UT. 84132 Mountain Valley Eye University of Utah Health p 801.581.2352 Hospital Affiliation Institute 100 N Mario Capecchi Dr - University of Utah Hospital 4568 S Highland Dr Salt Lake City UT. 84113 Hospital Affiliation Ste 160 p 801.581.2352 - University of Utah Hospital Hurlbut-Miller, Peter MD Salt Lake City UT. 84117 Rocky Mountain Retina p 801.424.3090 243 E 6100 S Hoopes Jr, Phillip C MD Consultants Murray UT. 84107 Hoopes Vision Correction 4400 S 700 E Hospital Affiliation p 801.585.3937 Center Ste 200 - Evanston Regional Hospital 11820 S State St Salt Lake City UT. 84107 50 N Medical Dr Ste 200 p 801.264.4444 Fleckenstein, Monika MD Salt Lake City UT. 84132 Draper UT. 84020 University Of Utah Health p 801.581.2121 p 801.568.0200 Hospital Affiliation 243 E 6100 S - St Marks Hospital Murray UT. 84107 65 S Mario Capecchi Dr Hoopes Sr, Phillip C MD p 801.585.3937 Salt Lake City UT. 84132 Hoopes Vision Correction Isom, Ryan F MD p 801.581.2352 Center Retina & Vitreous Surgeons University of Utah Health 11820 S State St of Utah 65 S Mario Capecchi Dr Hospital Affiliation Ste 200 11820 S State St Salt Lake City UT. 84132 - University of Utah Hospital Draper UT. 84020 Ste 320 p 801.581.2352 p 801.568.0200 Draper UT. 84020 Harrie, Roger P MD p 801.357.7704 Gee, Christopher J MD University of Utah Health Horn, Rachael S MD Salt Lake Retina 50 N Medical Dr University of Utah Health 5171 Cottonwood St 3855 W 7800 S Salt Lake City UT. 84132 100 N Mario Capecchi Dr Ste 700 Ste 100 p 801.581.2121 Salt Lake City UT. 84113 Murray UT. 84107 West Jordan UT. 84088 p 801.581.2352 p 801.892.8200 p 801.260.0034 Hospital Affiliation Hospital Affiliation - St Marks Hospital - St Marks Hospital

313 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Jackson, Alan E MD Knudsen, Victoria M MD 243 E 6100 S Mifflin, Mark D MD Cottonwood Eye & Laser Retina Associates of Utah Murray UT. 84107 University of Utah Health Clinic 5169 S Cottonwood St p 801.585.3937 243 E 6100 S 201 E 5900 S Ste 630 Murray UT. 84107 Ste 101 Murray UT. 84107 50 N Medical Dr p 801.585.3937 Murray UT. 84107 p 801.312.2020 Salt Lake City UT. 84132 p 801.268.6600 p 801.581.2121 65 S Mario Capecchi Dr Hospital Affiliation Salt Lake City UT. 84132 Hospital Affiliation - St Marks Hospital 65 S Mario Capecchi Dr p 801.581.2352 - St Marks Hospital - Davis Hospital Salt Lake City UT. 84132 p 801.581.2352 Hospital Affiliation Jardine, Griffin J MD Kwun, Robert MD - University of Utah Hospital University of Utah Health Retina Associates of Utah Hospital Affiliation 100 N Mario Capecchi Dr 5169 S Cottonwood St - University of Utah Hospital Miller, Corey A MD Salt Lake City UT. 84113 Ste 630 1485 E 3900 S p 801.581.2352 Murray UT. 84107 Mamalis, Nick MD Ste 103 p 801.312.2020 University of Utah Health Salt Lake City UT. 84124 3773 W 12600 S 1525 W 2100 S p 801.277.1087 Riverton UT. 84065 Hospital Affiliation Salt Lake City UT. 84119 p 801.285.1460 - St Marks Hospital p 801.213.8841 Hospital Affiliation - Davis Hospital - St Marks Hospital 50 N Medical Dr 243 E 6100 S - Salt Lake Regional Medical Salt Lake City UT. 84132 Larochelle, Marissa MD Murray UT. 84107 Center p 801.581.2121 University of Utah Health p 801.585.3937 100 N Mario Capecchi Dr Moshirfar, Majid MD 65 S Mario Capecchi Dr Salt Lake City UT. 84113 50 N Medical Dr Hoopes Vision Correction Salt Lake City UT. 84132 p 801.581.2352 Salt Lake City UT. 84132 Center p 801.581.2352 p 801.581.2121 11820 S State St 243 E 6100 S Ste 200 Hospital Affiliation Murray UT. 84107 65 S Mario Capecchi Dr Draper UT. 84020 - University of Utah Hospital p 801.585.3937 Salt Lake City UT. 84132 p 801.568.0200 p 801.581.2352 Jeppsen, Paul MD 50 N Medical Dr Hospital Affiliation Rocky Mountain Eye Care Salt Lake City UT. 84132 Hospital Affiliation - University of Utah Hospital 4400 S 700 E p 801.581.2121 - University of Utah Hospital - St Marks Hospital Ste 100 Murray UT. 84107 65 S Mario Capecchi Dr McCann, John D MD Nakatsuka, Austin S MD p 801.264.4450 Salt Lake City UT. 84132 The Eye Institute of Utah University of Utah Health p 801.581.2352 755 E 3900 S 100 N Mario Capecchi Dr 5069 W 13400 S Murray UT. 84107 Salt Lake City UT. 84113 Ste 400 Hospital Affiliation p 801.226.2283 p 801.581.2352 Herriman UT. 84096 - University of Utah Hospital p 801.264.4450 Center For Facial 243 E 6100 S Le, Hong-Gam T MD Appearance Murray UT. 84107 Hospital Affiliation University Of Utah Health 9350 S 150 E p 801.585.3937 - St Marks Hospital 243 E 6100 S Ste 400 Murray UT. 84107 Sandy UT. 84070 65 S Mario Capecchi Dr Katz, Bradley J MD,PhD p 801.585.3937 p 801.997.9999 Salt Lake City UT. 84132 University of Utah Health p 801.581.2352 50 N Medical Dr 65 S Mario Capecchi Dr Hospital Affiliation Salt Lake City UT. 84132 Salt Lake City UT. 84132 - Salt Lake Regional Medical Hospital Affiliation p 801.581.2121 p 801.581.2352 Center - University of Utah Hospital

65 S Mario Capecchi Dr Hospital Affiliation Mehr, Douglas S MD Oberg, Thomas MD Salt Lake City UT. 84132 - University of Utah Hospital Granger Medical Clinic Oculoplastic Surgery p 801.581.2352 2965 W 3500 S 1002 E S Temple Lin, Amy MD West Valley City UT. 84119 Ste 308 Hospital Affiliation University of Utah Health p 801.965.3600 Salt Lake City UT. 84102 - University of Utah Hospital 1525 W 2100 S p 801.363.3356 Salt Lake City UT. 84119 Salt Lake Retina Katzman, Howard A MD p 801.213.8841 3855 W 7800 S Hospital Affiliation 1485 E 3900 S Ste 100 - Salt Lake Regional Medical Ste 104 West Jordan UT. 84088 Center Salt Lake City UT. 84124 p 801.260.0034 p 801.424.3937 Hospital Affiliation Hospital Affiliation - St Marks Hospital - St Marks Hospital 314 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Olson, Randall J MD St Marks Hospital Poll, Jed T MD 50 N Medical Dr University of Utah Health 1200 E 3900 S Eye Foundation of Utah Salt Lake City UT. 84132 50 N Medical Dr Salt Lake City UT. 84107 201 E 5900 S p 801.585.6387 Salt Lake City UT. 84132 p 801.773.0690 Ste 201 p 801.581.2121 Murray UT. 84107 65 S Mario Capecchi Dr University of Utah Health p 801.268.6408 Salt Lake City UT. 84132 65 S Mario Capecchi Dr 243 E 6100 S p 801.581.2352 Salt Lake City UT. 84132 Murray UT. 84107 Hospital Affiliation p 801.581.2352 p 801.585.3937 - Lakeview Hospital 729 S Arapeen Dr - Ogden Regional Medical Salt Lake City UT. 84108 Hospital Affiliation 65 S Mario Capecchi Dr Center p 801.585.7575 - University of Utah Hospital Salt Lake City UT. 84132 p 801.581.2352 Redfern, Amanda J MD Hospital Affiliation Owen, Leah MD,PhD University Of Utah Health - University of Utah Hospital University of Utah Health LDS Hospital (Avenues 243 E 6100 S 100 N Mario Capecchi Dr Surgical Center) Murray UT. 84107 Shakoor, Akbar MD Salt Lake City UT. 84113 8th Ave C St p 801.585.3937 University of Utah Health p 801.581.2352 Salt Lake City UT. 84132 100 N Mario Capecchi Dr p 801.224.6767 65 S Mario Capecchi Dr Salt Lake City UT. 84113 3773 W 12600 S Salt Lake City UT. 84132 p 801.581.2352 Riverton UT. 84065 Hospital Affiliation p 801.581.2352 p 801.285.1460 - University of Utah Hospital 243 E 6100 S - Davis Hospital Hospital Affiliation Murray UT. 84107 50 N Medical Dr - St Marks Hospital - University of Utah Hospital p 801.585.3937 Salt Lake City UT. 84132 p 801.581.2121 Petersen, David B MD Rocky Mountain Eye Care 50 N Medical Dr Rocky Mountain Eye Care 4400 S 700 E Salt Lake City UT. 84132 65 S Mario Capecchi Dr 4400 S 700 E Ste 100 p 801.581.2121 Salt Lake City UT. 84132 Ste 100 Salt Lake City UT. 84107 p 801.581.2352 Murray UT. 84107 p 801.264.4450 65 S Mario Capecchi Dr p 801.264.4450 Salt Lake City UT. 84132 Hospital Affiliation Ronquillo, Cecinio C MD p 801.581.2352 - University of Utah Hospital 5069 W 13400 S University of Utah Health Ste 400 243 E 6100 S Hospital Affiliation Parker, Jared W MD Herriman UT. 84096 Murray UT. 84107 - University of Utah Hospital Ungricht Eye Associates p 801.264.4450 p 801.585.3937 5770 S 250 E Simonett, Joseph M MD Ste 410 Pettey, Jeff H MD 65 S Mario Capecchi Dr University Of Utah Health Salt lake City UT. 84107 University of Utah Health Salt Lake City UT. 84132 243 E 6100 S p 801.314.4420 50 N Medical Dr p 801.581.2352 Murray UT. 84107 Salt Lake City UT. 84132 p 801.585.3937 Hospital Affiliation p 801.581.2121 Hospital Affiliation - St Marks Hospital - University of Utah Hospital 65 S Mario Capecchi Dr 65 S Mario Capecchi Dr Salt Lake City UT. 84132 Passi, Samuel F MD Salt Lake City UT. 84132 Schmitz-Valckenberg, Marc p 801.581.2352 The Eye Institute of Utah p 801.581.2352 S MD 755 E 3900 S University Of Utah Health Hospital Affiliation Salt Lake City UT. 84107 Hospital Affiliation 50 N Medical Dr - University of Utah Hospital p 801.850.0195 - University of Utah Hospital Salt Lake City UT. 84132 p 801.581.2121 Simpson, Rachel G MD Patel, Bhupendra C MD Pingree, Michael F MD University of Utah Health University of Utah Health 3465 Pioneer Pkwy Seay, Meagan D DO 100 N Mario Capecchi Dr 100 N Mario Capecchi Dr Ste 5 University of Utah Health Salt Lake City UT. 84113 Salt Lake City UT. 84113 West Valley City UT. 84120 100 N Mario Capecchi Dr p 801.581.2352 p 801.581.2352 p 801.966.0081 Salt Lake City UT. 84113 p 801.581.2352 1525 W 2100 S The Salt Lake Eye Hospital Affiliation Salt Lake City UT. 84119 Associates - Jordan Valley Medical 175 N Medical Dr E p 801.213.8841 1025 E 3300 S Center Salt Lake City UT. 84132 Ste B - Jordan Valley Medical p 801.585.7575 243 E 6100 S Salt Lake City UT. 84106 Center West Valley Campus Murray UT. 84107 p 801.281.2020 243 E 6100 S p 801.585.3937 Salt Lake City UT. 84107 p 801.585.3937

315 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 50 N Medical Dr Stoddard, William W MD 65 S Mario Capecchi Dr Vincent, Bryan H OD Salt Lake City UT. 84132 University Of Utah Health Salt Lake City UT. 84132 University of Utah Health p 801.581.2121 243 E 6100 S p 801.581.2352 243 E 6100 S Murray UT. 84107 Murray UT. 84107 65 S Mario Capecchi Dr p 801.585.3937 Hospital Affiliation p 801.585.3937 Salt Lake City UT. 84132 - University of Utah Hospital p 801.581.2352 65 S Mario Capecchi Dr 50 N Medical Dr Salt Lake City UT. 84132 Teske, Michael P MD Salt Lake City UT. 84132 Hospital Affiliation p 801.581.2352 Eye Foundation of Utah p 801.581.2121 - University of Utah Hospital 201 E 5900 S Hospital Affiliation Ste 201 65 S Mario Capecchi Dr Sinclair, Stephen H MD - University of Utah Hospital Salt Lake City UT. 84107 Salt Lake City UT. 84132 University of Utah Health p 801.268.6408 p 801.581.2352 243 E 6100 S Stringham, Jack D MD Murray UT. 84107 Retina & Vitreous Surgeons University of Utah Health Vitale, Albert T MD p 801.585.3937 of Utah 243 E 6100 S University of Utah Health 11820 S State St Murray UT. 84107 100 N Mario Capecchi Dr 65 S Mario Capecchi Dr Ste 320 p 801.585.3937 Salt Lake City UT. 84113 Salt Lake City UT. 84132 Draper UT. 84020 p 801.581.2352 p 801.581.2352 p 801.237.3200 50 N Medical Dr Salt Lake City UT. 84132 50 N Medical Dr Smith, Robert E MD 5171 Cottonwood St p 801.581.2121 Salt Lake City UT. 84132 Granger Medical Clinic Ste 700 p 801.581.2121 2965 W 3500 S Salt Lake City UT. 84107 65 S Mario Capecchi Dr West Valley City UT. 84119 p 801.892.8200 Salt Lake City UT. 84132 65 S Mario Capecchi Dr p 801.965.3600 p 801.581.2352 Salt Lake City UT. 84132 Swartz, Mano MD p 801.581.2352 West Valley Eye Care Retina Associates of Utah The Eye Institute of Utah 3725 W 4100 S 5169 S Cottonwood St 755 E 3900 S Hospital Affiliation West Valley City UT. 84120 Ste 630 Murray UT. 84107 - University of Utah Hospital p 801.965.3636 Murray UT. 84107 p 801.850.0195 p 801.312.2020 Wapner, Francis J MD Hospital Affiliation Hospital Affiliation Advanced Eye Care - Jordan Valley Medical Sykes, Scott O MD - University of Utah Hospital 1250 E 3900 S Center West Valley Campus Eye Foundation of Utah Ste 310 201 E 5900 S Ungricht, Albert L MD Salt Lake City UT. 84124 Smith, Stacy R MD Ste 201 Ungricht Eye Associates p 801.263.2020 Stacy R Smith MD PC Salt Lake City UT. 84107 5770 S 250 E 1548 E 4500 S p 801.268.6408 Ste 410 3556 W 9800 S Ste 105 Salt Lake City UT. 84107 Ste 104 Salt Lake City UT. 84117 Hospital Affiliation p 801.314.4420 South Jordan UT. 84095 p 801.424.3090 - Ogden Regional Medical p 801.676.2020 Center Hospital Affiliation Hospital Affiliation - St Marks Hospital Hospital Affiliation - St Marks Hospital Tabin, Jean MD - St Marks Hospital University of Utah Health UUHC Redwood Health Center Stagg, Brian C MD 50 N Medical Dr 1525 W 2100 S Warner, Judith E MD University of Utah Health Salt Lake City UT. 84132 Salt Lake City UT. 84119 University of Utah Health 100 N Mario Capecchi Dr p 801.581.2121 p 801.213.9900 50 N Medical Dr Salt Lake City UT. 84113 Salt Lake City UT. 84132 p 801.581.2352 65 S Mario Capecchi Dr UUHC South Jordan Health p 801.581.2121 Salt Lake City UT. 84132 Center 243 E 6100 S p 801.581.2352 5126 W Daybreak Pkwy 65 S Mario Capecchi Dr Murray UT. 84107 South Jordan UT. 84095 Salt Lake City UT. 84132 p 801.585.3937 Taylor, Kim Y MD p 801.213.4500 p 801.581.2352 University of Utah Health 5126 W Daybreak Pkwy 243 E 6100 S John A Moran Eye Center Hospital Affiliation South Jordan UT. 84009 Murray UT. 84107 65 Mario Capecchi Dr - University of Utah Hospital p 801.213.4500 p 801.585.3937 Salt Lake City UT. 84132 p 801.581.2352 Weber, Charles H MD 65 S Mario Capecchi Dr 50 N Medical Dr The Eye Institute of Utah Salt Lake City UT. 84132 Salt Lake City UT. 84132 Vegunta, Sravanthi MD 755 E 3900 S p 801.581.2352 p 801.581.2121 University Of Utah Health Murray UT. 84107 65 S Mario Capecchi Dr p 801.850.0195 Hospital Affiliation Salt Lake City UT. 84132 - University of Utah Hospital p 801.581.2352 Hospital Affiliation - University of Utah Hospital Hospital Affiliation - University of Utah Hospital 316 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Weinlander, Eric J MD 65 S Mario Capecchi Dr 50 N Medical Dr Bateman, Camron J OD University Of Utah Health Salt Lake City UT. 84132 Salt Lake City UT. 84132 Wasatch Vision Clinic 243 E 6100 S p 801.581.2352 p 801.581.2121 849 E 400 S Murray UT. 84107 Salt Lake City UT. 84102 p 801.585.3937 Hospital Affiliation 65 S Mario Capecchi Dr p 801.328.2020 - University of Utah Hospital Salt Lake City UT. 84132 65 S Mario Capecchi Dr p 801.581.2352 Beagley, Shawn D OD Salt Lake City UT. 84132 Wolsey, Darcy H MD Mountain West Eyecare p 801.581.2352 The Eye Institute of Utah Hospital Affiliation 3747 S 2700 W 755 E 3900 S - University of Utah Hospital Salt Lake City UT. 84119 Hospital Affiliation Murray UT. 84107 p 801.996.9019 - University of Utah Hospital p 801.850.0195 Zavodni, Zachary MD The Eye Institute of Utah Berner, Terry H OD Wilcox, Michael B MD Wong, Gilbert C MD 755 E 3900 S Berner Eye Clinic Utah Eye Centers Canyon Eye Center Salt Lake City UT. 84107 250 E Broadway 1025 E 3300 S 3895 W 7800 S p 801.850.0195 Salt Lake City UT. 84111 Ste B Ste 202 p 801.322.0467 Salt Lake City UT. 84106 West Jordan UT. 84088 Optometry p 801.476.0494 p 801.948.4442 Abraham, James M OD Bogus, William J OD Advantage Eye Care 2319 Highland Dr Eye Foundation of Utah Hospital Affiliation 7677 S Maple St Salt Lake City UT. 84106 201 E 5900 S - Jordan Valley Medical Midvale UT. 84047 p 801.485.1371 Ste 201 Center p 801.288.0882 Salt Lake City UT. 84107 Broadhead, Jeffrey L OD p 801.268.6408 Young, Marielle MD Abundo, Roland E OD Progressive Eyecare University of Utah Health Abundo Eye Care 3556 W 9800 S Hospital Affiliation 100 N Mario Capecchi Dr 579 E Fort Union Blvd Ste 104 - Lakeview Hospital Salt Lake City UT. 84113 Midvale UT. 84047 South Jordan UT. 84095 - Ogden Regional Medical p 801.581.2352 p 801.255.8500 p 801.676.2020 Center 3773 W 12600 S Anderson, Stuart I OD Brockbank, Stephen R OD Williams, Lloyd B MD Riverton UT. 84065 34 S 500 E Olympus Eye Associates Standard Optical p 801.285.1460 Ste 201 1025 E 3300 S 11514 S 4000 W Bldg H Salt Lake City UT. 84102 Ste B Ste 103 50 N Medical Dr p 801.262.2020 Salt Lake City UT. 84106 Salt Lake City UT. 84009 Salt Lake City UT. 84132 p 801.261.0726 p 801.727.8711 p 801.581.2121 6095 S Fashion Blvd Ste 110 Image Eyes Optical 2124 S Highland Dr 65 S Mario Capecchi Dr Murray UT. 84107 222 S Main St Salt Lake City UT. 84106 Salt Lake City UT. 84132 p 801.262.2020 Ste 110 p 801.487.4138 p 801.581.2352 Salt Lake City UT. 84101 Avila, Michele R OD p 801.456.2020 4878 S Highland Dr Hospital Affiliation Hoopes Vision Correction Salt Lake City UT. 84121 - University of Utah Hospital Center Olympus Eye Associates p 801.272.8861 11820 S State St 5872 S 900 E Zabriskie, Norman A MD Ste 200 Ste 100 Hospital Affiliation University of Utah Health Draper UT. 84020 Salt Lake City UT. 84121 - St Marks Hospital 50 N Medical Dr p 801.568.0200 p 801.261.0726 Salt Lake City UT. 84132 Winward, Kirk E MD p 801.581.2121 Barlow, Ryan T OD 6065 S Fashion Blvd Retina Associates of Utah Salt Lake City Eye Care Ste 125 5169 S Cottonwood St 65 S Mario Capecchi Dr 1818 S 300 W Inside Salt Lake City UT. 84107 Ste 630 Salt Lake City UT. 84132 Costco p 801.261.0726 Murray UT. 84107 p 801.581.2352 Salt Lake City UT. 84115 p 801.312.2020 p 801.485.9757 Brown, Michael D OD Hospital Affiliation Mountain West Eyecare Hospital Affiliation - University of Utah Hospital Barney, Weston T OD 2727 W 3500 S - St Marks Hospital Hoopes Vision Correction West Valley City UT. 84119 - Davis Hospital Zaugg, Brian E MD Center p 801.968.6772 University of Utah Health 11820 S State St Wirostko, Barbara MD 243 E 6100 S Ste 200 Bruderer, Paul C OD University of Utah Health Murray UT. 84107 Draper UT. 84020 West Valley Vision Source 50 N Medical Dr p 801.585.3937 p 801.568.0200 2782 S 5600 W Salt Lake City UT. 84132 Ste 101 p 801.581.2121 Salt Lake City UT. 84120 p 801.969.9999

317 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Buresh, Karri A OD 50 N Medical Dr Fellows, Bradley V OD 3754 W 5400 S Berner Eye Clinic Salt Lake City UT. 84132 Draper Vision Care Center Salt Lake City UT. 84129 250 E Broadway p 801.581.2121 12256 S 900 E p 801.964.9911 Salt Lake City UT. 84111 Ste 401 p 801.322.0467 5126 W Daybreak Pkwy Draper UT. 84020 Graham, Jessica P OD South Jordan UT. 84009 p 801.619.9494 Valley View Vision Carter, Randy B OD p 801.213.4500 4019 W 12600 S The Eye Institute of Utah Sandy Vision Care Center Ste 110 755 E 3900 S Craven, Ashley OD 9035 S 1300 E Riverton UT. 84096 Murray UT. 84107 InVision Eye Health Ste 100 p 801.302.9482 p 801.850.0195 10835 S 700 E Sandy UT. 84094 Sandy UT. 84070 p 801.566.4119 Gubler, Boyd K OD Catt, William C OD p 801.495.2020 Eye Physicians of Utah Standard Optical Findlay, Mathew G OD 3601 S 2700 W 11514 S 4000 W Bldg H Cutler, Craig J OD Murray Vision Center West Valley City UT. 84119 Ste 103 Wasatch Vision Clinic 126 E 4800 S p 801.889.8420 Salt Lake City UT. 84009 849 E 400 S Salt Lake City UT. 84107 p 801.727.8711 Salt Lake City UT. 84102 p 801.262.2411 7453 Plaza Ctr Dr p 801.328.2020 West Jordan UT. 84088 1901 W Parkway Blvd Galehdari, Nazanin OD p 801.889.8420 West Valley City UT. 84119 Dahl, Brandon J OD EyeMax Eye Care p 801.972.0203 University of Utah Health 166 E 5900 S Hadlock, Brent L OD 3730 W 4700 S Ste B-103 Standard Optical 2124 S Highland Dr West Valley City UT. 84129 Salt Lake City UT. 84107 11514 S 4000 W Bldg H Salt Lake City UT. 84106 p 801.213.9200 p 801.268.3937 Ste 103 p 801.487.4138 Salt Lake City UT. 84009 65 S Mario Capecchi Dr Gayer, Thomas E OD p 801.727.8711 Clark, Kim OD Salt Lake City UT. 84132 Ungricht Eye Associates Standard Optical p 801.581.2352 5770 S 250 E 1901 W Pkwy Blvd 11514 S 4000 W Bldg H Ste 410 Salt Lake City UT. 84119 Ste 103 Davies, Jarrod E OD Salt Lake City UT. 84107 p 801.972.0203 Salt Lake City UT. 84009 Utah Vision Development p 801.314.4420 p 801.727.8711 3590 W 9000 S 2124 S Highland Dr Ste 315 Gibbons, Tim OD Salt Lake City UT. 84106 1656 W 9000 S West Jordan UT. 84088 University of Utah Health p 801.487.4138 West Jordan UT. 84088 p 801.810.1060 1525 W 2100 S p 801.255.5454 Salt Lake City UT. 84119 5289 S State St Drennan, Kirk B OD p 801.213.8841 Murray UT. 84107 Cole, Michael W OD Hoopes Vision Correction p 801.506.1111 Standard Optical Center 3730 W 4700 S 11514 S 4000 W Bldg H 11820 S State St Taylorsville UT. 84129 Hardy, Dale F OD Ste 103 Ste 200 p 801.213.9200 10372 S Redwood Rd Salt Lake City UT. 84009 Draper UT. 84020 South Jordan UT. 84095 p 801.727.8711 p 801.568.0200 50 N Medical Dr p 801.253.1374 Salt Lake City UT. 84132 2124 S Highland Dr Dutson, Thomas P OD p 801.581.2121 Helman, Andrew OD Salt Lake City UT. 84106 Hoopes Vision Correction Standard Optical p 801.487.4138 Center Gilliland, Rodney N OD 11514 S 4000 W Bldg H 11820 S State St Standard Optical Ste 103 Conklin, Michael OD Ste 200 11514 S 4000 W Bldg H Salt Lake City UT. 84009 Standard Optical Draper UT. 84020 Ste 103 p 801.727.8711 1656 W 9000 S p 801.568.0200 Salt Lake City UT. 84009 West Jordan UT. 84088 p 801.727.8711 1656 W 9000 S p 801.255.5454 Ellison, John N OD West Jordan UT. 84088 Standard Optical 1901 Pkwy Blvd p 801.255.5454 5289 S State St 11514 S 4000 W Bldg H West Valley City UT. 84119 Salt Lake City UT. 84107 Ste 103 p 801.972.0203 1901 W Pkwy Blvd p 801.506.1111 Salt Lake City UT. 84009 West Valley City UT. 84119 p 801.727.8711 2124 S Highland Dr p 801.972.0203 Corry, Robert OD Salt Lake City UT. 84106 University of Utah Health 2124 S Highland Dr p 801.487.4138 2124 S Highland Dr 1525 W 2100 S Salt Lake City UT. 84106 Salt Lake City UT. 84106 Salt Lake City UT. 84119 p 801.487.4138 p 801.487.4138 p 801.213.8841

318 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 2190 Highland Dr Kimball, Jory T OD Lewis, Stephen C OD McKay, Mark A OD Salt Lake City UT. 84106 Sugarhouse Vision Clinic Standard Optical University of Utah Health p 801.487.4138 2178 S 900 E 11514 S 4000 W Bldg H 1525 W 2100 S Ste 4 Ste 103 Salt Lake City UT. 84119 3754 W 5400 S Salt Lake City UT. 84106 Salt Lake City UT. 84009 p 801.213.8841 Salt Lake City UT. 84118 p 801.484.2020 p 801.727.8711 p 801.964.9911 3730 W 4700 S Healthy Eyes for Life 2124 S Highland Dr Taylorsville UT. 84129 5289 S State St 8806 S Redwood Rd Salt Lake City UT. 84106 p 801.213.9200 Salt Lake City UT. 84107 Ste 101 p 801.487.4138 p 801.506.1111 West Jordan UT. 84088 50 N Medical Dr p 801.578.2020 Linn, Steven H OD Salt Lake City UT. 84132 Hepworth, Kurt P OD Hoopes Vision Correction p 801.581.2121 Davis Vision Center Kimball, Todd E OD Center Associates PLLC Sugarhouse Vision Clinic 11820 S State St 65 S Mario Capecchi Dr 11649 S 4000 W 2178 S 900 E Ste 200 Salt Lake City UT. 84132 Ste 200 Ste 4 Draper UT. 84020 p 801.581.2352 South Jordan UT. 84009 Salt Lake City UT. 84106 p 801.568.0200 p 801.253.3080 p 801.484.2020 McKell, James D OD Lundquist, Stephen OD Standard Optical Taylor Optical Kinney, Charles H OD Standard Optical 1656 W 9000 S 6556 S Big Cottonwood Standard Optical 5289 S State St West Jordan UT. 84088 Canyon Rd 11514 S 4000 W Bldg H Salt Lake City UT. 84107 p 801.255.5454 Ste 400 Ste 103 p 801.506.1111 Salt Lake City UT. 84121 Salt Lake City UT. 84009 McKell, Mark M OD p 801.278.0438 p 801.727.8711 Mackay, Jason H OD Salt Lake City Eye Care Hidden Valley Eye Care & 1818 S 300 W Inside Hospital Affiliation Knowles, Duane C OD Framed Optical Costco - Jordan Valley Medical Standard Optical 1147 E Draper Pkwy Salt Lake City UT. 84115 Center 11514 S 4000 W Bldg H Draper UT. 84020 p 801.485.9757 Ste 103 p 801.619.9555 Hill, Angela D OD Salt Lake City UT. 84009 Meek, Robert H OD Eyecare Associates p 801.727.8711 Marty, Michael S OD Jordan Vision Clinic 7400 Union Park Ave Standard Optical 9237 Redwood Rd Ste 202 1901 W Pkwy Blvd 11514 S 4000 W Bldg H Ste 5A Midvale UT. 84047 Salt Lake City UT. 84119 Ste 103 West Jordan UT. 84088 p 801.569.3698 p 801.972.0203 Salt Lake City UT. 84009 p 801.561.2020 p 801.727.8711 Hill, Kris A OD 2124 S Highland Dr Melton, Timothy OD Eyecare Associates Salt Lake City UT. 84106 1656 W 9000 S Hoopes Vision Correction 7400 Union Park Ave p 801.487.4138 West Jordan UT. 84088 Center Ste 202 p 801.255.5454 11820 S State St Midvale UT. 84047 5289 S State St Ste 200 p 801.569.3698 Murray UT. 84107 1901 W Pkwy Blvd Draper UT. 84020 p 801.506.1111 Salt Lake City UT. 84119 p 801.408.3705 Howells, Daniel C OD p 801.972.0203 Cornerstone Vision Center Larsen, Shaun D OD Meyer, David A OD 5069 W 13400 S 3665 S 8400 W 2124 S Highland Dr University of Utah Health Ste 400 Ste 100 Salt Lake City UT. 84106 100 N Mario Capecchi Dr Herriman UT. 84096 Magna UT. 84044 p 801.487.4138 Salt Lake City UT. 84113 p 801.254.7575 p 801.250.5745 p 801.581.2352 834 E 9400 S Hulet, Paul OD Leishman, Benjamin H OD Sandy UT. 84094 Standard Optical Family Focused Eyecare Lumina Vision p 801.572.9280 11514 S 4000 W Bldg H 5528 W 13400 S 1025 E 11400 S Ste 103 Herriman UT. 84096 Ste 104 Masihdas, David K OD Salt Lake City UT. 84009 p 801.302.3080 Sandy UT. 84094 150 S 1000 E p 801.727.8711 p 385.202.3937 Ste 100 Keller, Robert W OD Salt Lake City UT. 84102 1901 W Pkwy Blvd 2535 S State St Granger Medical Clinic p 801.363.2851 Salt Lake City UT. 84119 Salt Lake City UT. 84115 2965 W 3500 S p 801.972.0203 p 801.466.5611 West Valley City UT. 84119 McIntosh, Renee A OD p 801.965.3600 Hoopes Vision Correction Center 11820 S State St Ste 200 Draper UT. 84020 p 801.568.0200 319 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 2124 S Highland Dr Mortensen, Spencer D OD Peterson, Walter OD Rocky Mountain Eye Care Salt Lake City UT. 84106 University of Utah Health Standard Optical 4400 S 700 E p 801.487.4138 3730 W 4700 S 11514 S 4000 W Bldg H Ste 100 West Valley City UT. 84129 Ste 103 Salt Lake City UT. 84107 University of Utah Health p 801.213.9200 Salt Lake City UT. 84009 p 801.264.4450 243 E 6100 S p 801.727.8711 Murray UT. 84107 462 E 100 S Roden, Robert OD p 801.585.3937 Salt Lake City UT. 84111 1901 W Pkwy Blvd Standard Optical p 801.532.5176 Salt Lake City UT. 84119 11514 S 4000 W Bldg H 50 N Medical Dr p 801.972.0203 Ste 103 Salt Lake City UT. 84132 50 N Medical Dr South Jordan UT. 84009 p 801.581.2121 Salt Lake City UT. 84132 2124 S Highland Dr p 801.727.8711 p 801.581.2121 Salt Lake City UT. 84106 Clarus Vision Clinic p 801.487.4138 1901 W Pkwy Blvd 6412 S 900 E Mountain West Eyecare West Valley City UT. 84119 Ste 101 2727 W 3500 S Pettey, Dix H OD p 801.886.2020 Salt Lake City UT. 84121 West Valley City UT. 84119 University of Utah Health p 801.892.8222 p 801.968.6772 243 E 6100 S Sargent, Steven B OD Murray UT. 84107 InVision Eye Health University of Utah Health Nelson, Jared W OD p 801.585.3937 10835 S 700 E 65 S Mario Capecchi Dr Mountain West Eyecare Sandy UT. 84070 Salt Lake City UT. 84132 2727 W 3500 S 50 N Medical Dr p 801.495.2020 p 801.581.2352 West Valley City UT. 84119 Salt Lake City UT. 84132 p 801.968.6772 p 801.581.2121 Schubach, Colleen OD Standard Optical University of Utah Health 834 E 9400 S Ng, Pamela OD 65 S Mario Capecchi Dr 50 N Medical Dr Sandy UT. 84094 Rocky Mountain Eye Care Salt Lake City UT. 84132 Salt Lake City UT. 84132 p 801.572.9280 4400 S 700 E p 801.581.2352 p 801.581.2121 Ste 100 Millet, Curtis W OD Salt Lake City UT. 84107 Hospital Affiliation Simmons, Jeffrey MD Standard Optical p 801.264.4450 - University of Utah Hospital Standard Optical 11514 S 4000 W Bldg H 11514 S 4000 W Bldg H Ste 103 Okelberry, Kerry Poulter, William C OD Ste 103 Salt Lake City UT. 84009 Redwood Vision Center Vision Source at Jordan South Jordan UT. 84009 p 801.727.8711 6705 Redwood Rd Landing p 801.727.8711 West Jordan UT. 84084 7555 Ctr View Ct 2124 S Highland Dr p 801.268.0866 Ste 101 1901 W Pkwy Blvd Salt Lake City UT. 84106 West Jordan UT. 84084 West Valley City UT. 84119 p 801.487.4138 Parker, Clifford OD p 801.566.5683 p 801.886.2020 Standard Optical 4878 S Highland Dr 5289 S State St Purdy, Russell OD 5474 W Daybreak Pkwy Holladay UT. 84121 Salt Lake City UT. 84107 Standard Optical Ste G-3 p 801.272.8861 p 801.506.1111 11514 S 4000 W Bldg H South Jordan UT. 84009 Ste 103 p 801.923.3935 Mitchell, Mike K OD Parkinson, David M OD Salt Lake City UT. 84009 Cottonwood Eye & Laser Hoopes Vision Correction p 801.727.8711 Smith, Craig M OD Clinic Center University of Utah Health 201 E 5900 S 11820 S State St 1901 W Pkwy Blvd 243 E 6100 S Ste 101 Ste 200 Salt Lake City UT. 84119 Murray UT. 84107 Murray UT. 84107 Draper UT. 84020 p 801.972.0203 p 801.585.3937 p 801.268.6600 p 801.568.0200 2124 S Highland Dr 50 N Medical Dr Morgan, Alan OD Peirce, Sherman H OD Salt Lake City UT. 84106 Salt Lake City UT. 84132 University of Utah Health South Hills Family Eye p 801.487.4138 p 801.581.2121 50 N Medical Dr Care Salt Lake City UT. 84132 12357 S 450 E Rice, Dallin W OD Smith, Golden OD p 801.581.2121 Ste 2 Hidden Valley Eye Care Standard Optical Draper UT. 84020 1147 E Draper Pkwy 1901 W Pkwy Blvd Mortensen, Ryan J OD p 801.572.9804 Draper UT. 84020 West Valley City UT. 84119 The District Vision Care p 801.619.9555 p 801.886.2020 11506 S District Dr Peterson, Michael S OD Ste 400 Visionology Rice, R B OD Snow, Christopher OD South Jordan UT. 84095 177 W 12300 S Hidden Valley Eye Care InVision Eye Health p 801.495.4833 Ste 111 1147 E Draper Pkwy 10835 S 700 E Draper UT. 84020 Draper UT. 84020 Sandy UT. 84070 p 801.679.9177 p 801.619.9555 p 801.495.2020

320 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Standard Optical Mon-Fri UUHC Westridge Health Wooldridge, Robert P OD 7495 S State St 9am-7pm Sat 8am-5pm Center Eye Foundation of Utah Midvale UT. 84047 11514 S 4000 W Bldg H 3730 W 4700 S 201 E 5900 S p 801.213.9530 Ste 103 Taylorsville UT. 84118 Ste 201 South Jordan UT. 84009 p 801.213.9200 Salt Lake City UT. 84107 Hospital Affiliation p 801.727.8711 p 801.268.6408 - Ogden Regional Medical UUHC South Jordan Health Center 1656 W 9000 S Center Young, Roger OD - St Marks Hospital West Jordan UT. 84088 5126 W Daybreak Pkwy 3465 Pioneer Pkwy p 801.255.5454 South Jordan UT. 84095 Ste 4 Cannon, Grant DDS p 801.213.4500 West Valley City UT. 84120 University Of Utah Health 2124 S Highland Dr p 801.966.0081 1078 S 300 E Salt Lake City UT. 84106 UUHC Greenwood Health Salt Lake City UT. 84111 p 801.487.4138 Center Oral Surgery Center p 801.578.8180 7495 S State St Family Surgical Suite 3754 W 5400 S Midvale UT. 84047 (Oral Surgery Only) 3491 W Wights Fort Rd 133 Taylorsville UT. 84129 p 801.213.9400 151 E 5600 S West Jordan UT. 84088 p 801.964.9911 Ste 104 p 801.957.7522 VanLeeuwen, Craig W OD Salt Lake City UT. 84107 4878 S Highland Dr Ungricht Eye Associates p 801.495.1064 3690 S Main St Creekside Plaza 5770 S 250 E Salt Lake City UT. 84115 Holladay UT. 84121 Ste 410 8822 S Redwood Rd p 801.587.2525 p 801.272.8861 Salt Lake City UT. 84107 Ste C113 p 801.314.4420 West Jordan UT. 84088 University of Utah Health 5289 S State St p 801.495.1064 50 N Medical Dr Clinic 7 Murray UT. 84107 Vincent, Bryan H OD Salt Lake City UT. 84132 p 801.506.1111 University of Utah Health Oral And Maxillofacial Surgery p 801.581.2220 243 E 6100 S Adams, Nathan DMD 834 E 9400 S Murray UT. 84107 Oral & Facial 530 S Wakara Way Sandy UT. 84094 p 801.585.3937 Reconstructive Surgeons of Salt Lake City UT. 84108 p 801.572.9280 UT p 801.587.6453 50 N Medical Dr 3920 S 1100 E Stromness, Lynn D OD Salt Lake City UT. 84132 Ste 150 7495 S State St Canyon Eye Specialists p 801.581.2121 Salt Lake City UT. 84124 Midvale UT. 84047 1434 E 9400 S p 801.262.7447 p 801.213.9530 Ste 104 65 S Mario Capecchi Dr Sandy UT. 84093 Salt Lake City UT. 84132 University of Utah Health University Of Utah Health p 801.576.1145 p 801.581.2352 50 N Medical Dr Clinic 7 85 N Medical Dr Salt Lake City UT. 84132 Salt Lake City UT. 84112 Jordan Vision Clinic West, Michael L OD p 801.581.2220 p 801.581.7724 9237 Redwood Rd Eye Care Solutions Ste 5A 9565 S 700 E 530 S Wakara Way Egbert, Cameron J DDS West Jordan UT. 84088 Ste 101 Salt Lake City UT. 84108 6360 S 3000 E p 801.561.2020 Sandy UT. 84070 p 801.587.6453 Ste 305 p 801.572.3937 Salt Lake City UT. 84121 Eye Care Solutions 7495 S State St p 801.899.9737 9565 S 700 E Whetten, Ivan MD Midvale UT. 84047 Ste 101 Standard Optical p 801.213.9530 Hospital Affiliation Sandy UT. 84070 11514 S 4000 W Bldg H - Mountain View Hospital p 801.572.3937 Ste 103 Hospital Affiliation (UT) South Jordan UT. 84009 - St Marks Hospital - Lone Peak Hospital Torghele, Cheryl A OD p 801.727.8711 - St Marks Hospital Wasatch Vision Clinic Austin, Blaine DDS 849 E 400 S 1656 W 9000 S University of Utah Health Flint, Robert L DMD,MD Salt Lake City UT. 84102 West Jordan UT. 84088 50 N Medical Dr Clinic 7 Flint Oral & Facial p 801.328.2020 p 801.255.5454 Salt Lake City UT. 84132 Surgery p 801.581.2220 114 E 12450 S UUHC Redwood Health Center White, Brenden R OD Ste 104 1525 W 2100 S InVision Eye Health 530 S Wakara Way Draper UT. 84020 Salt Lake City UT. 84119 10835 S 700 E Salt Lake City UT. 84108 p 801.576.5910 p 801.213.9900 Sandy UT. 84070 p 801.587.6453 p 801.572.3937 4970 S 900 E Ste C Salt Lake City UT. 84117 p 801.263.3309

321 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Fullmer, Joseph DMD Hopkin, Dustin J DDS Smoot, David J DDS MountainStar General Utah Oral and Facial 2180 E 4500 S Smoot Center Surgery Surgeons Ste 285 2651 W S Jordan Pkwy 74 E Kimballs Ln 114 E 12450 S Salt Lake City UT. 84117 Ste 102 Ste 330 Ste 104 p 801.277.3942 South Jordan UT. 84095 Draper UT. 84020 Draper UT. 84020 p 801.253.4352 p 801.568.5972 p 801.576.5910 Hospital Affiliation - St Marks Hospital 6095 S Fashion Blvd 96 E Kimballs Ln 4970 S 900 E - Ogden Regional Medical Ste 120 Ste 207 Ste C Center Murray UT. 84107 West Jordan UT. 84088 Salt Lake City UT. 84117 p 801.264.8504 p 801.576.2300 p 801.263.3309 Nielsen, Erik DDS University Of Utah Health Hospital Affiliation Anderson, Lucas A PA Utah Oral & Facial 1078 S 300 E - Salt Lake Regional Medical University of Utah Health Surgeons Salt Lake City UT. 84111 Center 590 S Wakara Way 6268 S 900 E p 801.578.8180 Salt Lake City UT. 84108 Ste 100 Stosich, Alvin J DDS,MD p 801.587.7109 Salt Lake City UT. 84121 3690 S Main St Flint & Steel Surgical p 801.566.5117 Salt Lake City UT. 84115 114 E 12450 S Aoki, Stephen K MD p 801.587.2525 Ste 104 University of Utah Health Gladwell, Michael DMD Draper UT. 84020 100 N Mario Capecchi Dr Oral & Facial 50 N Medical Dr Clinic 7 p 801.566.5117 Salt Lake City UT. 84113 Reconstructive Surgeons of Salt Lake City UT. 84132 p 801.662.5600 UT p 801.581.2220 4970 S 900 E 3920 S 1100 E Ste C 290 S 1850 E Ste 150 530 S Wakara Way Salt Lake City UT. 84117 Salt Lake City UT. 84112 Salt Lake City UT. 84124 Salt Lake City UT. 84108 p 801.566.5117 p 801.587.7109 p 801.262.7447 p 801.587.6453 Utah Oral & Facial 580 S Guardsman Way University of Utah Health 7495 S State St Surgeons Salt Lake City UT. 84112 50 N Medical Dr Clinic 7 Midvale UT. 84047 6268 S 900 E p 801.587.7109 Salt Lake City UT. 84132 p 801.213.9530 Ste 100 p 801.581.2220 Salt Lake City UT. 84121 590 S Wakara Way Hospital Affiliation p 801.566.5117 Salt Lake City UT. 84108 530 S Wakara Way - University of Utah Hospital p 801.587.7109 Salt Lake City UT. 84108 Hospital Affiliation p 801.587.6453 Rahn, Andrew R DDS - St Marks Hospital Hospital Affiliation University of Utah Health - Lone Peak Hospital - University of Utah Hospital 7495 S State St 3690 S Main St Midvale UT. 84047 Salt Lake City UT. 84115 Orthopedic Surgery Bakshi, Neil K MD p 801.213.9530 p 801.587.2525 Amundsen, Spencer H University Of Utah Health MountainStar Specialty 590 S Wakara Way Hospital Affiliation 50 N Medical Dr Clinic 7 Services Salt Lake City UT. 84108 - St Marks Hospital Salt Lake City UT. 84132 1160 E 3900 S p 801.587.7109 p 801.581.2220 Ste 5000 Halpern, Leslie R DDS,MD Salt Lake City UT. 84124 Hospital Affiliation University of Utah Health 530 S Wakara Way p 801.262.8486 - University of Utah Hospital 50 N Medical Dr Clinic 7 Salt Lake City UT. 84108 Salt Lake City UT. 84132 p 801.587.6453 CORE @ South Bangerter Barnes, Patrick A PA-C p 801.581.2220 Health Center MountainStar Specialty 7495 S State St 13348 S Market Ctr Dr Services 530 S Wakara Way Midvale UT. 84047 Ste 120 1160 E 3900 S Salt Lake City UT. 84108 p 801.213.9530 Riverton UT. 84065 Ste 5000 p 801.587.6453 p 385.887.7100 Salt Lake City UT. 84124 Roberts, Greg A DDS p 801.262.8486 7495 S State St 622 E 4500 S CORE @ West Valley Midvale UT. 84047 Ste 202 3336 S 4155 W 74 E Kimballs Ln p 801.213.9530 Salt Lake City UT. 84107 Ste 102 Ste 330 p 801.266.3578 West Valley City UT. 84120 Draper UT. 84020 Hospital Affiliation p 801.964.3925 p 801.262.3564 - University of Utah Hospital Hospital Affiliation - Ogden Regional Medical CORE @ West Jordan MountainStar General Center 3584 W 9000 S Surgery Ste 405 96 E Kimballs Ln West Jordan UT. 84088 Ste 207 p 801.568.3480 West Jordan UT. 84088 p 801.568.5972

Hospital Affiliation - Jordan Valley Medical Center 322 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Beals, Timothy C MD Bonner, Bryant MD MountainStar General Burks, Robert T MD University of Utah Health Hofmann Arthritis Surgery University of Utah Health 590 S Wakara Way Institute 96 E Kimballs Ln 290 S 1850 E Salt Lake City UT. 84108 24 S 1100 E Ste 207 Salt Lake City UT. 84112 p 801.587.7109 Ste 101 & 105 West Jordan UT. 84088 p 801.587.7109 Salt Lake City UT. 84102 p 801.568.5972 Hospital Affiliation p 801.355.6468 580 S Guardsman Way - University of Utah Hospital Hospital Affiliation Salt Lake City UT. 84112 Hospital Affiliation - Salt Lake Regional Medical p 801.587.7109 Beck, Charles L MD - Lone Peak Hospital Center MountainStar Specialty - Salt Lake Regional Medical 590 S Wakara Way Services Center Brodke, Darrel S MD Salt Lake City UT. 84108 1160 E 3900 S University of Utah Health p 801.587.7109 Ste 5000 Bourne, Michael H MD 100 N Mario Capecchi Dr Salt Lake City UT. 84124 MountainStar Specialty Salt Lake City UT. 84113 Hospital Affiliation p 801.262.8486 Services p 801.662.5600 - University of Utah Hospital 1160 E 3900 S Center of Orthopedic & Ste 4050 590 S Wakara Way Burrows, J D MD Rehabilitation Excellence Salt Lake City UT. 84124 Salt Lake City UT. 84108 CORE West Valley 3584 W 9000 S p 801.281.1565 p 801.587.7109 3336 S 4155 W Ste 405 Ste 102 West Jordan UT. 84088 1160 E 3900 S Hospital Affiliation West Valley City UT. 84120 p 801.568.3480 Ste 5000 - University of Utah Hospital p 801.964.3925 Salt Lake City UT. 84124 MountainStar General p 801.262.8486 Brothers, Alexander T MD Hospital Affiliation Surgery University of Utah Health - Jordan Valley Medical 74 E Kimballs Ln 74 E Kimballs Ln 590 S Wakara Way Center West Valley Campus Ste 330 Ste 330 Salt Lake City UT. 84108 - Mountain West Medical Draper UT. 84020 Draper UT. 84020 p 801.587.7109 Center p 801.568.5972 p 801.262.8486 Hospital Affiliation Carpenter, Scott L PA 96 E Kimballs Ln 96 E Kimballs Ln - University of Utah Hospital Granger Medical Clinic Ste 207 Ste 207 2965 W 3500 S West Jordan UT. 84088 West Jordan UT. 84088 Bruderer, Scott E PA West Valley City UT. 84119 p 801.576.2300 p 801.576.2300 MountainStar Specialty p 801.965.3600 Services Hospital Affiliation Hospital Affiliation 1160 E 3900 S Hospital Affiliation - Jordan Valley Medical - St Marks Hospital Ste 5000 - Mountain West Medical Center - Lone Peak Hospital Salt Lake City UT. 84124 Center - Salt Lake Regional Medical p 801.262.8486 - Lakeview Hospital Center Bourne, Robert B MD MountainStar General CORE West Jordan Carroll, Kristen L MD Bellaire, Laura L MD Surgery 3584 W 9000 S University of Utah Health University of Utah Health 1160 E 3900 S Ste 405 100 N Mario Capecchi Dr 590 S Wakara Way Ste 4050 West Jordan UT. 84088 Salt Lake City UT. 84113 Salt Lake City UT. 84108 Salt Lake City UT. 84124 p 801.568.3480 p 801.662.5600 p 801.587.7109 p 801.281.1156 MountainStar General Hospital Affiliation Hospital Affiliation Salt Lake Orthopaedic Surgery - University of Utah Hospital - University of Utah Hospital Clinic 74 E Kimballs Ln 1160 E 3900 S Ste 300 Chalmers, Peter N MD Belton, Matthew D MD Ste 5000 Draper UT. 84020 University of Utah Health University Of Utah Health Salt Lake City UT. 84124 p 801.568.5972 100 N Mario Capecchi Dr 100 N Mario Capecchi Dr p 801.262.8486 Salt Lake City UT. 84113 Salt Lake City UT. 84113 74 E Kimballs Ln p 801.662.5600 p 801.662.5600 MountainStar Specialty Ste 330 Services Draper UT. 84020 5126 W Daybreak Pkwy 590 S Wakara Way 74 E Kimballs Ln p 801.568.5972 South Jordan UT. 84009 Salt Lake City UT. 84108 Ste 330 p 801.213.4500 p 801.587.7109 Draper UT. 84020 Hospital Affiliation p 801.262.3564 - Mountain West Medical 590 S Wakara Way Hospital Affiliation Center Salt Lake City UT. 84108 - University of Utah Hospital p 801.587.7109

Hospital Affiliation - University of Utah Hospital

323 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Christie, Matthew C MD 6322 S 3000 E Dean, Anna E PA Feria-Arias, Enrique MD University Of Utah Health Ste 140 University of Utah Health MountainStar Specialty 590 S Wakara Way Salt Lake City UT. 84121 590 S Wakara Way Services Salt Lake City UT. 84108 p 801.733.9924 Salt Lake City UT. 84108 1160 E 3900 S p 801.587.7109 p 801.587.7109 Ste 5000 Hospital Affiliation Salt Lake City UT. 84124 Hospital Affiliation - St Marks Hospital Hospital Affiliation p 801.261.7479 - University of Utah Hospital - Lone Peak Hospital - Park City Hospital - University of Utah Hospital Heiden Orthopedics Cooley, Vernon J MD Curtis, David E MD 6360 S 3000 E Rosenberg Cooley Metcalf Salt Lake Orthopaedic Dukas, Alex G MD Ste 210 5848 S Fashion Blvd Clinic University of Utah Health Salt Lake City UT. 84121 Salt Lake City UT. 84107 1160 E 3900 S 590 S Wakara Way p 435.615.8822 p 801.743.4500 Ste 5000 Salt Lake City UT. 84108 Salt Lake City UT. 84124 p 801.587.7109 Hospital Affiliation Hospital Affiliation p 801.262.8486 - Timpanogos Regional Hospital - Park City Hospital Hospital Affiliation - Lone Peak Hospital - Heber Valley Hospital Utah Orthopaedic - University of Utah Hospital - St Marks Hospital Associates Cooper, Andrew D MD 1250 E 3900 S Erickson, Jill A PA Fine, Alexandra PA-C Salt Lake Regional Ste 440 University of Utah Health Medallus Medical Solitude Ski Clinic Salt Lake City UT. 84124 5848 S Fashion Blvd 3461 S 5600 W 12000 Big Cottonwood p 801.261.2232 Murray UT. 84107 Ste F Canyon Rd p 801.587.7028 West Valley City UT. 84120 Salt Lake City UT. 84121 Steward Orthopedics And p 801.957.0900 p 801.536.5712 Sports Medicine - West 590 S Wakara Way Jordan Salt Lake City UT. 84108 Fossen, Kathleen PA-C Comprehensive Orthopedics 3584 W 9000 S p 801.587.7109 University of Utah Health and Sports Medicine Salt Ste 405 590 S Wakara Way Lake City Central West Jordan UT. 84088 Hospital Affiliation Salt Lake City UT. 84108 82 S 1100 E p 801.568.3482 - University of Utah Hospital p 801.587.7109 Ste 303 Salt Lake City UT. 84102 Steward Orthopedic and Evans, Bruce G MD Fukushima, Brian W MD p 801.533.2002 Sports Medicine Salt Lake Orthopaedic Utah Orthopaedic 6322 S 3000 E Clinic Specialists Comprehensive Orthopedics Ste 140 1160 E 3900 S 5323 S Woodrow St and Sports Medicine Sandy Salt Lake City UT. 84121 Ste 5000 Ste 200 9350 S 150 E p 801.733.9924 Salt Lake City UT. 84124 Murray UT. 84107 Ste 460 p 801.262.8486 p 801.747.1020 Sandy UT. 84070 Hospital Affiliation p 801.533.2002 - St Marks Hospital Steward Orthopedic and Hospital Affiliation - Lone Peak Hospital Sports Medicine - St Marks Hospital Hospital Affiliation - Salt Lake Regional Medical 3584 W 9000 S - Salt Lake Regional Medical - Salt Lake Regional Medical Center Ste 405 Center Center West Jordan UT. 84088 Davidson Orthopedics p 801.568.3480 Gibbs, Daniel B MD Curtis, Benjamin D MD 6360 S 3000 E Heiden Orthopedics Salt Lake Orthopaedic Ste 200 6322 S 3000 E 6360 S 3000 E Clinic Salt Lake City UT. 84121 Ste 140 Ste 210 1160 E 3900 S p 801.797.8000 Salt Lake City UT. 84121 Salt Lake City UT. 84121 Ste 5000 p 801.733.9924 p 435.615.8822 Salt Lake City UT. 84124 Davidson, Philip A MD p 801.262.8486 Davidson Orthopedics Hospital Affiliation Hospital Affiliation 6360 S 3000 E - St Marks Hospital - St Marks Hospital Utah Orthopaedic Ste 200 - Lone Peak Hospital - Lone Peak Hospital Associates Salt Lake City UT. 84121 1250 E 3900 S p 801.797.8000 Felix, Brent A MD Gililland, Jeremy M MD Ste 440 Salt Lake Orthopaedic University of Utah Health Salt Lake City UT. 84124 Hospital Affiliation Clinic 590 S Wakara Way p 801.261.2232 - Salt Lake Regional Medical 1160 E 3900 S Salt Lake City UT. 84108 Center Ste 5000 p 801.587.7109 Steward Orthopedic and - Park City Hospital Salt Lake City UT. 84124 Sports Medicine p 801.262.8486 Hospital Affiliation 3584 W 9000 S - University of Utah Hospital Ste 405 Hospital Affiliation West Jordan UT. 84088 - Brigham City Community p 801.568.3480 Hospital - St Marks Hospital - Logan Regional Hospital - Jordan Valley Medical Center West Valley Campus 324 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Golden, Michael L MD 590 S Wakara Way Harris, Leslie J MD Hendrickson, Nathan R MD University Of Utah Health Salt Lake City UT. 84108 Advanced Orthopedic and University of Utah Health 590 S Wakara Way p 801.587.7109 Sports Medicine 5126 W Daybreak Pkwy Salt Lake City UT. 84108 3584 W 9000 S South Jordan UT. 84009 p 801.587.7109 Hospital Affiliation Ste 405 p 801.581.7514 - University of Utah Hospital West Jordan UT. 84088 Hospital Affiliation p 801.568.3480 University Of Utah Health - University of Utah Hospital Gunter, Karen A PA 590 S Wakara Way Davidson Orthopedics Hospital Affiliation Salt Lake City UT. 84108 Gordon, Anthony S MD 6360 S 3000 E - Jordan Valley Medical p 801.587.7109 Granger Medical Ste 200 Center Specialists Salt Lake City UT. 84121 Hospital Affiliation 96 E Kimballs Ln p 801.797.8000 Hawes, Justin P MD - University of Utah Hospital Ste 304 Utah Orthopaedic Draper UT. 84020 Gupta, Andrew S MD Specialists Hennessey, Theresa A MD p 801.571.9433 University of Utah Health 5323 S Woodrow St University of Utah Health 590 S Wakara Way Ste 200 100 N Mario Capecchi Dr 9844 S 1300 E Salt Lake City UT. 84108 Murray UT. 84107 Salt Lake City UT. 84113 Ste 100 p 801.587.7109 p 801.747.1020 p 801.662.5600 Sandy UT. 84094 p 801.571.9433 Hospital Affiliation Hospital Affiliation 3773 W 12600 S - University of Utah Hospital - St Marks Hospital Riverton UT. 84065 Hospital Affiliation p 801.285.1440 - Lone Peak Hospital Haile, Nathan B MD Heflin, John MD University of Utah Health University of Utah Health Higgins, Thomas F MD Greis, Patrick E MD 590 S Wakara Way 100 N Mario Capecchi Dr University of Utah Health University of Utah Health Salt Lake City UT. 84108 Salt Lake City UT. 84113 100 N Mario Capecchi Dr 290 S 1850 E p 801.587.7109 p 801.587.2255 Salt Lake City UT. 84113 Salt Lake City UT. 84112 p 801.662.5600 p 801.587.7109 Hospital Affiliation 3773 W 12600 S - University of Utah Hospital Riverton UT. 84065 590 S Wakara Way 580 S Guardsman Way p 801.285.1440 Salt Lake City UT. 84108 Salt Lake City UT. 84112 Haller, Justin M MD p 801.587.7109 p 801.587.7109 University of Utah Health Primary Childrens Spina 100 N Mario Capecchi Dr Bifida Hospital Affiliation 590 S Wakara Way Salt Lake City UT. 84113 81 N Mario Capecchi Dr - University of Utah Hospital Salt Lake City UT. 84108 p 801.662.5600 Salt Lake City UT. 84113 p 801.587.7109 p 801.662.1675 Hofmann, Aaron A MD 590 S Wakara Way Precision Joint Surgery Hospital Affiliation Salt Lake City UT. 84108 Heiden Orthopedics Center - University of Utah Hospital p 801.587.7109 6360 S 3000 E 1046 E 100 S Ste 210 Ste B Groebs, Allen R MD Hospital Affiliation Salt Lake City UT. 84121 Salt Lake City UT. 84102 Utah Orthopaedic - University of Utah Hospital p 435.615.8822 p 801.355.6468 Specialists 5323 S Woodrow St Hansen, Benjamin J MD Heiden, Eric MD Hofmann Arthritis Ste 200 Salt Lake Orthopaedic Heiden Orthopedics Institute Murray UT. 84107 Clinic 6360 S 3000 E 11613 S State St p 801.747.1020 1160 E 3900 S Ste 210 Draper UT. 84020 Ste 5000 Salt Lake City UT. 84121 p 801.355.6468 Hospital Affiliation Salt Lake City UT. 84124 p 435.615.8822 - St Marks Hospital p 801.262.8486 24 S 1100 E - Salt Lake Regional Medical Hospital Affiliation Ste 101 & 105 Center Harlow, Amy J MD - Park City Hospital Salt Lake City UT. 84102 University of Utah Health p 801.355.6468 Groundland, John S MD 590 S Wakara Way Heiden, Karen D MD University of Utah Health Salt Lake City UT. 84108 Heiden Orthopedics Hospital Affiliation 100 N Mario Capecchi Dr p 801.587.7109 6360 S 3000 E - University of Utah Hospital Salt Lake City UT. 84113 Ste 210 - Davis Hospital p 801.662.5600 Hospital Affiliation Salt Lake City UT. 84121 - Lone Peak Hospital - University of Utah Hospital p 435.615.8822 - Salt Lake Regional Medical 1950 Cir of Hope Dr Center Salt Lake City UT. 84112 Hospital Affiliation p 801.585.0303 - Park City Hospital

325 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Holmes, Stephanie M MD Comp Ortho and Sports MountainStar Specialty 3773 W 12600 S University of Utah Health Medicine @ Sandy Services Riverton UT. 84065 100 N Mario Capecchi Dr 9350 S 150 E 74 E Kimballs Ln p 801.285.1440 Salt Lake City UT. 84113 Ste 460 Ste 330 p 801.662.5600 Sandy UT. 84070 Draper UT. 84020 590 S Wakara Way p 801.858.3715 p 801.262.3564 Salt Lake City UT. 84108 3773 W 12600 S p 801.587.7109 Riverton UT. 84065 Hospital Affiliation MountainStar General p 801.285.1440 - Davis Hospital Surgery Hospital Affiliation 96 E Kimballs Ln - University of Utah Hospital Hospital Affiliation Huntsman, Kade T MD Ste 207 - University of Utah Hospital MountainStar Specialty West Jordan UT. 84088 Kazmers, Nikolas H MD Services p 801.568.5972 University of Utah Health Howe, David J MD 1160 E 3900 S 100 N Mario Capecchi Dr Comprehensive Orthopedic Ste 4050 Hospital Affiliation Salt Lake City UT. 84113 and Sports Medicine - Salt Salt Lake City UT. 84124 - Lone Peak Hospital p 801.662.5600 Lake City p 801.281.1565 - St Marks Hospital 82 S 1100 E 590 S Wakara Way Ste 303 Salt Lake Orthopaedic Jacobsen, Jacoby D Salt Lake City UT. 84108 Salt Lake City UT. 84102 Clinic University Of Utah Health p 801.587.7109 p 801.533.2002 1160 E 3900 S 100 N Mario Capecchi Dr Ste 5000 Salt Lake City UT. 84113 Hospital Affiliation Comprehensive Orthopedic Salt Lake City UT. 84124 p 801.662.5600 - University of Utah Hospital and Sports Medicine - p 801.262.8486 Sandy 3773 W 12600 S Kelly, Mick P MD 9350 S 150 E MountainStar Specialty Riverton UT. 84065 University Of Utah Health Ste 460 Services p 801.285.1440 590 S Wakara Way Sandy UT. 84070 74 E Kimballs Ln Salt Lake City UT. 84108 p 801.858.3715 Ste 330 Hospital Affiliation p 801.587.7109 Draper UT. 84020 - University of Utah Hospital Hospital Affiliation p 801.262.3564 - Primary Childrens Hospital Hospital Affiliation - Salt Lake Regional Medical - University of Utah Hospital Center Hospital Affiliation Jarrett, Ross M PA - St Marks Hospital - St Marks Hospital C.O.R.E - West Valley Khachatryan, Armen MD - Lone Peak Hospital 3336 S Pioneer Pkwy C.O.R.E - South Bangerter Hubbard, James C MD Ste 102 Health Center University Of Utah Health Hutchinson, Douglas T MD Salt Lake City UT. 84120 13348 S Market Ctr Dr 100 N Mario Capecchi Dr University of Utah Health p 801.964.3925 Ste 120 Salt Lake City UT. 84113 100 N Mario Capecchi Dr Riverton UT. 84065 p 801.662.5600 Salt Lake City UT. 84113 Center of Orthopedic & p 385.887.7100 p 801.662.5600 Rehabilitation Excellence 590 S Wakara Way - West Jordan Center Of Orthopedic And Salt Lake City UT. 84108 590 S Wakara Way 3584 W 9000 S Rehabilitation Excellence p 801.587.7109 Salt Lake City UT. 84108 Ste 405 3584 W 9000 S p 801.587.7109 West Jordan UT. 84088 Ste 209 Hospital Affiliation p 801.568.3480 West Jordan UT. 84088 - University of Utah Hospital Hospital Affiliation p 801.208.6358 - University of Utah Hospital Hospital Affiliation Hunter, Joshua MD - Jordan Valley Medical Center of Orthopedic & Steward Orthopedics & Jackson, Jeffrey D MD Center West Valley Campus Rehabilitation Excellence Sports Medicine MountainStar General - Mountain West Medical - West Jordan 3584 W 9000 S Surgery Center 3584 W 9000 S Ste 405 1160 E 3900 S Ste 405 West Jordan UT. 84088 Ste 4050 Johnson, Troy S PA-C West Jordan UT. 84088 p 801.568.3480 Salt Lake City UT. 84124 Granger Medical Clinic p 801.568.3480 p 801.281.1565 9001 S 3200 W Comp Ortho and Sports Ste 3 Hospital Affiliation Medicine @ SLC Central Salt Lake Orthopaedic West Jordan UT. 84088 - Jordan Valley Medical 82 S 1100 E Clinic p 801.569.5520 Center Ste 303 1160 E 3900 S Salt Lake City UT. 84102 Ste 5000 Jones, Kevin B MD Kimball, Gordon R MD p 801.533.2002 Salt Lake City UT. 84124 University of Utah Health 9844 S 1300 E p 801.262.8486 100 N Mario Capecchi Dr Ste 275 Salt Lake City UT. 84113 Sandy UT. 84094 p 801.662.5600 p 801.571.7061

Hospital Affiliation - Lone Peak Hospital 326 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. King, Connor A MD Law, Jesua DO Machen, Michael S MD Magee, Trevor H MD University Of Utah Health Hofmann Arthritis University of Utah Health Steward Orthopedics & 590 S Wakara Way Institute 100 N Mario Capecchi Dr Sports Medicine Salt Lake City UT. 84108 11613 S State St Salt Lake City UT. 84113 3584 W 9000 S p 801.587.7109 Draper UT. 84020 p 801.662.5600 Ste 405 p 801.355.6468 West Jordan UT. 84088 Hospital Affiliation 3773 W 12600 S p 801.568.3480 - University of Utah Hospital 24 S 1100 E Riverton UT. 84065 Ste 101 p 801.285.1440 Comp Ortho and Sports Klatt, Joshua W MD Salt Lake City UT. 84102 Medicine @ SLC Central University of Utah Health p 801.355.6468 Hospital Affiliation 82 S 1100 E 100 N Mario Capecchi Dr - University of Utah Hospital Ste 303 Salt Lake City UT. 84113 Lawrence, Brandon D MD Salt Lake City UT. 84102 p 801.662.5600 University of Utah Health Macintyre, James G MD p 801.533.2002 100 N Mario Capecchi Dr Center of Orthopedic & 1950 Cir of Hope Dr Salt Lake City UT. 84113 Rehabilitation Excellence Comp Ortho and Sports Salt Lake City UT. 84112 p 801.662.5600 - West Jordan Medicine @ Sandy p 801.585.0303 3584 W 9000 S 9350 S 150 E 590 S Wakara Way Ste 405 Ste 460 50 N Medical Dr Salt Lake City UT. 84108 West Jordan UT. 84088 Sandy UT. 84070 Salt Lake City UT. 84132 p 801.587.7109 p 801.568.3480 p 801.533.2002 p 801.587.7109 Hospital Affiliation Hospital Affiliation Hospital Affiliation 590 S Wakara Way - University of Utah Hospital - Jordan Valley Medical - Salt Lake Regional Medical Salt Lake City UT. 84108 Center Center p 801.587.7109 Livermore, Andrew T MD University of Utah Health Mackey, Richard B MD Mangiapani, Daniel 81 N Mario Capecchi Dr 590 S Wakara Way MountainStar Specialty Hofmann Arthritis Salt Lake City UT. 84113 Salt Lake City UT. 84108 Services Institute p 801.662.5600 p 801.587.7109 1160 E 3900 S 11613 S State St Ste 5000 Draper UT. 84020 Klatt, Richard S PA-C Hospital Affiliation Salt Lake City UT. 84124 p 801.355.6468 Rosenberg Cooley Metcalf - University of Utah Hospital p 801.262.8486 5848 S Fashion Blvd 24 S 1100 E Salt Lake City UT. 84107 Lualemaga, Laurie M PA Center of Orthopedic and Ste 101 & 105 p 801.743.4500 Alta View Sports Medicine Rehabilitation Excellence Salt Lake City UT. 84102 Center - West Jordan p 801.355.6468 Labelle, Mark W MD 9844 S 1300 E 3584 W 9000 S University Of Utah Health Ste 100 Ste 405 Steward Orthopedics & 590 S Wakara Way Sandy UT. 84094 West Jordan UT. 84088 Sports Medicine Salt Lake City UT. 84108 p 801.571.9433 p 801.568.3480 3584 W 9000 S p 801.587.7109 Ste 405 Hospital Affiliation MountainStar General West Jordan UT. 84088 Hospital Affiliation - Mountain View Hospital Surgery p 801.568.3480 - University of Utah Hospital (UT) 74 E Kimballs Ln - Timpanogos Regional Hospital Ste 300 Hospital Affiliation Laird, Naomi R PA Draper UT. 84020 - Davis Hospital University of Utah Health Maak, Travis G MD p 801.568.5972 590 S Wakara Way University of Utah Health Mariani, E M MD Salt Lake City UT. 84108 100 N Mario Capecchi Dr 74 E Kimballs Ln MountainStar Specialty p 801.587.7109 Salt Lake City UT. 84113 Ste 330 Services p 801.662.5600 Draper UT. 84020 1160 E 3900 S Hospital Affiliation p 801.576.2300 Ste 4050 - University of Utah Hospital 50 N Medical Dr Salt Lake City UT. 84124 Salt Lake City UT. 84132 96 E Kimballs Ln p 801.281.1565 Larcom, Peter G MD p 801.581.2121 Ste 207 Utah Orthopaedic West Jordan UT. 84088 Salt Lake Orthopaedic Specialists 5126 W Daybreak Pkwy p 801.576.2300 Clinic 5323 S Woodrow St South Jordan UT. 84009 1160 E 3900 S Ste 200 p 801.213.4500 Hospital Affiliation Ste 5000 Murray UT. 84107 - Jordan Valley Medical Salt Lake City UT. 84124 p 801.747.1020 590 S Wakara Way Center p 801.262.8486 Salt Lake City UT. 84108 - Salt Lake Regional Medical Hospital Affiliation p 801.587.7109 Center - St Marks Hospital - University of Utah Hospital - Salt Lake Regional Medical Hospital Affiliation Center - University of Utah Hospital

327 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. MountainStar Specialty 96 E Kimballs Ln Metcalf, Michael H MD Muir, Traske M MD Services Ste 207 Rosenberg Cooley Metcalf C.O.R.E - South Bangerter 74 E Kimballs Ln West Jordan UT. 84088 5848 S Fashion Blvd Health Center Ste 330 p 801.576.2300 Salt Lake City UT. 84107 13348 S Market Ctr Dr Draper UT. 84020 p 801.743.4500 Ste 120 p 801.262.3564 Hospital Affiliation Riverton UT. 84065 - Jordan Valley Medical Hospital Affiliation p 385.887.7100 Hospital Affiliation Center - Heber Valley Hospital - St Marks Hospital CORE West Jordan - Lone Peak Hospital McQueen, Craig H MD Mihlfeith, Catherine M 3584 W 9000 S Salt Lake Spine and Ortho PA-C Ste 405 Marshall, Stuart C MD 1160 E 3900 S University of Utah Health West Jordan UT. 84088 Center of Orthopedic & Ste 4050 1525 W 2100 S p 801.568.3480 Rehabilitation Excellence Salt Lake City UT. 84124 Salt Lake City UT. 84119 - West Jordan p 801.262.8486 p 801.213.8841 MountainStar General 3584 W 9000 S Surgery Ste 405 Salt Lake Orthopaedic 50 N Medical Dr 74 E Kimballs Ln West Jordan UT. 84088 Clinic Salt Lake City UT. 84132 Ste 330 p 801.568.3480 1160 E 3900 S p 801.581.5311 Draper UT. 84020 Ste 5000 p 801.568.5972 Hospital Affiliation Salt Lake City UT. 84124 5126 W Daybreak Pkwy - Jordan Valley Medical p 801.262.8486 Ste 600 96 E Kimballs Ln Center South Jordan UT. 84009 Ste 207 Utah Orthopaedic Assoc p 801.213.4500 West Jordan UT. 84088 Martin, Christopher H MD 1250 E 3900 S p 801.568.5972 Salt Lake Orthopaedic Ste 440 7495 S State St Clinic Salt Lake City UT. 84124 Midvale UT. 84047 Hospital Affiliation 1160 E 3900 S p 801.261.2232 p 801.213.9400 - Jordan Valley Medical Ste 5000 Center Salt Lake City UT. 84124 Hospital Affiliation Hospital Affiliation p 801.262.8486 - St Marks Hospital - University of Utah Hospital Nelson, Russell L MD Utah Bone & Joint Center MountainStar Specialty McQueen, Jordan R PA-C Miller, Tony L PA 5323 S Woodrow St Services Hofmann Arthritis MountainStar General Ste 202 74 E Kimballs Ln Institute Surgery Murray UT. 84107 Ste 330 11613 S State St 1160 E 3900 S p 801.713.0606 Draper UT. 84020 Draper UT. 84020 Ste 4050 p 801.262.3564 p 801.355.6468 Salt Lake City UT. 84124 5323 S Woodrow St p 801.281.1565 Murray UT. 84107 Hospital Affiliation 24 S 1100 E p 801.713.0606 - St Marks Hospital Ste 101 & 105 Salt Lake Orthopaedic Salt Lake City UT. 84102 Clinic Hospital Affiliation Matich, Andrea J MD p 801.355.6468 1160 E 3900 S - St Marks Hospital MountainStar Specialty Ste 5000 Services Hospital Affiliation Salt Lake City UT. 84124 Nickisch, Florian MD 1160 E 3900 S - Salt Lake Regional Medical p 801.262.8486 University of Utah Health Ste 5000 Center 1525 W 2100 S Salt Lake City UT. 84124 - Davis Hospital MountainStar Specialty Salt Lake City UT. 84119 p 801.262.8486 - Lone Peak Hospital Services p 801.213.8841 74 E Kimballs Ln Center of Orthopedic & Meadows, James R MD Ste 330 590 S Wakara Way Rehabilitation Excellence Granger Medical Draper UT. 84020 Salt Lake City UT. 84108 3580 W 9000 S Specialists p 801.262.3564 p 801.587.7109 Ste 405 & 209 96 E Kimballs Ln West Jordan UT. 84088 Ste 304 MountainStar General Hospital Affiliation p 801.568.3480 Draper UT. 84020 Surgery - University of Utah Hospital p 801.571.9433 96 E Kimballs Ln MountainStar General Ste 207 Nikolaus, Oliver B MD Surgery 9844 S 1300 E West Jordan UT. 84088 MountainStar General 74 E Kimballs Ln Ste 100 p 801.576.2300 Surgery Ste 330 Sandy UT. 84094 1160 E 3900 S Draper UT. 84020 p 801.571.9433 Hospital Affiliation Ste 4050 p 801.576.2300 - St Marks Hospital Salt Lake City UT. 84124 Hospital Affiliation p 801.281.1565 - Lone Peak Hospital - St Marks Hospital

328 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Salt Lake Orthopaedic Park, Howard Y MD Pierce, Matthew J PA-C Richards, Dan DO Clinic University Of Utah Health Alta View Sports Medicine Granger Medical Clinic 1160 E 3900 S 590 S Wakara Way Center 12391 S 4000 W Ste 5000 Salt Lake City UT. 84108 9844 S 1300 E Riverton UT. 84065 Salt Lake City UT. 84124 p 801.587.7109 Ste 100 p 801.302.1700 p 801.262.8486 Sandy UT. 84094 Hospital Affiliation p 801.571.9433 2965 W 3500 S MountainStar Specialty - University of Utah Hospital West Valley City UT. 84119 Services Porretta, Jane M MD p 801.965.3600 74 E Kimballs Ln Pearmain, Steven B PA University of Utah Health Ste 330 Rosenberg Cooley Metcalf 1950 Cir of Hope Dr Hospital Affiliation Draper UT. 84020 5848 S Fashion Blvd Salt Lake City UT. 84112 - Jordan Valley Medical p 801.262.3564 Salt Lake City UT. 84107 p 801.587.7000 Center West Valley Campus p 435.655.6600 - Riverton Childrens Unit MountainStar General 50 N Medical Dr Operated by Primary Childrens Medical Center Surgery Hospital Affiliation Salt Lake City UT. 84132 - Mountain West Medical 96 E Kimballs Ln - Park City Hospital p 801.581.7738 Center Ste 207 West Jordan UT. 84088 Pelt, Christopher E MD 5126 W Daybreak Pkwy Roper, Stephen G PA p 801.568.5972 University of Utah Health South Jordan UT. 84009 Salt Lake Orthopaedic 5848 S Fashion Blvd p 801.213.4500 Clinic Nixon, Devon C MD Murray UT. 84107 1160 E 3900 S University of Utah Health p 801.587.7028 Hospital Affiliation Ste 5000 590 S Wakara Way - Jordan Valley Medical Salt Lake City UT. 84124 Salt Lake City UT. 84108 590 S Wakara Way Center p 801.262.8486 p 801.587.7109 Salt Lake City UT. 84108 - University of Utah Hospital p 801.587.7109 Rosen, Mark A MD Hospital Affiliation Powell, Amy P MD 2295 Foothill Dr - University of Utah Hospital Hospital Affiliation University of Utah Health Salt Lake City UT. 84107 - University of Utah Hospital 290 S 1850 E p 801.269.1333 Noda, Grace A PA Salt Lake City UT. 84112 University of Utah Health Peters, Christopher L MD p 801.587.7109 5911 Fashion Blvd 1950 Cir of Hope Dr University of Utah Health Ste 100 Salt Lake City UT. 84112 5848 S Fashion Blvd 580 S Guardsman Way Salt Lake City UT. 84107 p 801.585.0100 Murray UT. 84107 Salt Lake City UT. 84112 p 801.269.1333 p 801.587.7028 p 801.587.7109 Hospital Affiliation Hospital Affiliation - University of Utah Hospital 590 S Wakara Way 590 S Wakara Way - Jordan Valley Medical Salt Lake City UT. 84108 Salt Lake City UT. 84108 Center West Valley Campus Novak, Peter J MD p 801.587.7109 p 801.587.7109 MountainStar General Rosenberg, Thomas D MD Surgery Hospital Affiliation University Of Utah Health Rosenberg Cooley Metcalf 1160 E 3900 S - University of Utah Hospital 9385 Snowbird Ctr Dr 5848 S Fashion Blvd Ste 4050 Sandy UT. 84092 Salt Lake City UT. 84107 Salt Lake City UT. 84124 Petron, David J MD p 801.646.4800 p 801.743.4500 p 801.281.1565 University of Utah Health 290 S 1850 E Hospital Affiliation Hospital Affiliation Salt Lake Orthopaedic Salt Lake City UT. 84112 - University of Utah Hospital - Heber Valley Hospital Clinic p 801.587.7109 1160 E 3900 S Raskind, John R MD Rothberg, David L MD Ste 5000 580 S Guardsman Way University of Utah Health University of Utah Health Salt Lake City UT. 84124 Salt Lake City UT. 84112 5126 W Daybreak Pkwy 100 N Mario Capecchi Dr p 801.262.8486 p 801.587.7109 South Jordan UT. 84009 Salt Lake City UT. 84113 p 801.213.4500 p 801.662.5600 MountainStar Specialty 590 S Wakara Way Services Salt Lake City UT. 84108 590 S Wakara Way 590 S Wakara Way 74 E Kimballs Ln p 801.587.7109 Salt Lake City UT. 84108 Salt Lake City UT. 84108 Ste 330 p 801.587.7109 p 801.587.7109 Draper UT. 84020 University Of Utah Health p 801.262.3564 9385 Snowbird Ctr Dr Hospital Affiliation Hospital Affiliation Sandy UT. 84092 - University of Utah Hospital - University of Utah Hospital Hospital Affiliation p 801.646.4800 - St Marks Hospital Hospital Affiliation - University of Utah Hospital

329 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Saltzman, Charles L MD Serpico, Robert A PA 590 S Wakara Way 590 S Wakara Way University of Utah Health University of Utah Health Salt Lake City UT. 84108 Salt Lake City UT. 84108 100 N Mario Capecchi Dr 1950 Cir of Hope Dr p 801.587.7100 p 801.587.7109 Salt Lake City UT. 84113 Salt Lake City UT. 84112 p 801.662.5600 p 801.585.0303 Hospital Affiliation Primary Childrens Hospital - University of Utah Hospital 81 N Mario Capecchi Dr 590 S Wakara Way 590 S Wakara Way Salt Lake City UT. 84113 Salt Lake City UT. 84108 Salt Lake City UT. 84108 Spina, Nicholas T MD p 801.662.1675 p 801.587.7109 p 801.587.7109 University of Utah Health 100 N Mario Capecchi Dr Hospital Affiliation Hospital Affiliation Hospital Affiliation Salt Lake City UT. 84113 - Primary Childrens Hospital - University of Utah Hospital - University of Utah Hospital p 801.662.5600 Sumner, Benjamin R PA-C Sanjuan, Angielyn M DO Sessions, Wade M MD 590 S Wakara Way Alta View Sports Medicine University Of Utah Health Center of Orthopedic & Salt Lake City UT. 84108 Center 590 S Wakara Way Rehabilitation Excellence p 801.587.7109 9844 S 1300 E Salt Lake City UT. 84108 - West Jordan Ste 100 p 801.587.7109 3584 W 9000 S Hospital Affiliation Sandy UT. 84094 Ste 405 - University of Utah Hospital p 801.571.9433 Hospital Affiliation West Jordan UT. 84088 - University of Utah Hospital p 801.568.3480 Stefl Jr, David P PA Sybrowsky, Christian L MD MountainStar Specialty Granger Medical Schmidt, Donald A MD Hospital Affiliation Services Specialists 9844 S 1300 E - Jordan Valley Medical 1160 E 3900 S 96 E Kimballs Ln Ste 275 Center Ste 5000 Ste 304 Sandy UT. 84094 Salt Lake City UT. 84124 Draper UT. 84020 p 801.571.7061 Silvero, Peter p 801.262.8486 p 801.571.9433 C.O.R.E - West Valley Scholl, Mark D MD 3336 S Pioneer Pkwy 74 E Kimballs Ln 9844 S 1300 E Endurance Orthopedics and Ste 102 Ste 330 Ste 100 Sports Medicine - SLC East Salt Lake City UT. 84120 Draper UT. 84020 Sandy UT. 84094 2645 E Parleys Way p 801.964.3925 p 801.262.3564 p 801.571.9433 Ste 500 Salt Lake City UT. 84109 Hospital Affiliation Hospital Affiliation Hospital Affiliation p 801.424.5042 - Jordan Valley Medical - Lakeview Hospital - St Marks Hospital Center West Valley Campus - Lone Peak Hospital Steward Orthopedics & - Mountain West Medical Stevens, Peter M MD Sports Medicine Center University of Utah Health Tashjian, Robert Z MD 3584 W 9000 S 100 N Mario Capecchi Dr University of Utah Health Ste 405 Skedros, John G MD Salt Lake City UT. 84113 590 S Wakara Way West Jordan UT. 84088 Utah Bone & Joint Center p 801.587.2255 Salt Lake City UT. 84108 p 801.568.3480 5323 S Woodrow St p 801.587.7109 Ste 202 590 S Wakara Way Hospital Affiliation Murray UT. 84107 Salt Lake City UT. 84108 Hospital Affiliation - Salt Lake Regional Medical p 801.713.0606 p 801.587.7109 - University of Utah Hospital Center Hospital Affiliation 81 N Mario Capecchi Dr Thomas, Bruce E MD Schuenman, Spencer F DO - St Marks Hospital Salt Lake City UT. 84113 University of Utah Health Jordan Valley Medical p 801.662.5600 590 S Wakara Way Center - West Valley Sonnenberg, John D MD Salt Lake City UT. 84108 Campus South Valley OrthoMed Hospital Affiliation p 801.587.7109 3460 S 4155 W 10623 S Redwood Rd - University of Utah Hospital Salt Lake City UT. 84120 Ste 101 Hospital Affiliation p 801.964.3100 South Jordan UT. 84095 Stotts, Alan K MD - Ogden Regional Medical p 801.566.4242 University of Utah Health Center Jordan Valley Medical 100 N Mario Capecchi Dr Center 10623 S Redwood Rd Salt Lake City UT. 84113 Tobert, Daniel G MD 3580 W 9000 S Ste 101 p 801.587.2255 University of Utah Health West Jordan UT. 84088 South Jordan UT. 84095 590 S Wakara Way p 801.601.4423 p 801.566.4242 3773 W 12600 S Salt Lake City UT. 84108 Riverton UT. 84065 p 801.587.7109 Hospital Affiliation Spiker, William R MD p 801.285.1440 - Mountain Point Medical University of Utah Health Hospital Affiliation Center 100 N Mario Capecchi Dr - University of Utah Hospital Salt Lake City UT. 84113 p 801.662.5600

330 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Toth, Robert C PA 590 S Wakara Way Williams, Benjamin MD Orthotics And Prosthetics University of Utah Health Salt Lake City UT. 84108 Steward Orthopedics & Center for Prosthetics Inc 590 S Wakara Way p 801.587.7109 Sports Medicine 2290 E 4500 S Salt Lake City UT. 84108 3584 W 9000 S Ste 160 p 801.587.7109 Hospital Affiliation Ste 405 Salt Lake City UT. 84117 - University of Utah Hospital West Jordan UT. 84088 p 801.364.0083 Hospital Affiliation p 801.568.3480 - University of Utah Hospital Vanderhooft, J E MD Eye Prosthetics of Utah Salt Lake Orthopaedic Comprehensive Orthopedics 7400 Union Park Ave Townsley, Robert W PA-C Clinic and Sports Medicine Ste 102 MountainStar Specialty 1160 E 3900 S 82 S 1100 E Midvale UT. 84047 Services Ste 5000 Ste 303 p 801.942.1600 1160 E 3900 S Salt Lake City UT. 84124 Salt Lake City UT. 84102 Ste 5000 p 801.262.8486 p 801.533.2002 Fit Well Salt Lake City UT. 84124 Prosthetics/Orthotics p 801.262.8486 Hospital Affiliation 9350 S 150 E 50 S 900 E - St Marks Hospital Ste 460 Ste 1 Center of Orthopedic & Sandy UT. 84070 Salt Lake City UT. 84102 Rehabilitation Excellence Walker, Dean N MD p 801.533.2002 p 801.364.3100 - West Jordan Granger Medical Clinic 3584 W 9000 S 2965 W 3500 S Hospital Affiliation 7575 S 900 E Ste 405 West Valley City UT. 84119 - Lone Peak Hospital Midvale UT. 84047 West Jordan UT. 84088 p 801.965.3600 - Salt Lake Regional Medical p 801.364.3100 p 801.568.3480 Center Hospital Affiliation - St Marks Hospital Hanger Prosthetics and MountainStar General - Jordan Valley Medical Orthotics Inc Surgery Center West Valley Campus Winterton, Paul W MD 5292 College Dr 74 Kimballs Ln - Jordan Valley Medical 96 E Kimballs Ln Ste 103 Ste 330 Center Ste 407 Salt Lake City UT. 84123 Draper UT. 84020 - Mountain West Medical Draper UT. 84020 p 801.266.7768 p 801.568.5972 Center p 801.561.3101 - St Marks Hospital Hanger Clinic 96 E Kimballs Ln Hospital Affiliation 887 E Vine St Ste 207 Wang, Angela A MD - Lone Peak Hospital Salt Lake City UT. 84107 West Jordan UT. 84088 University of Utah Health - St Marks Hospital p 801.293.8777 p 801.576.2300 100 N Mario Capecchi Dr Salt Lake City UT. 84113 Woiczik, Marcella R MD 2785 E 3300 S Hospital Affiliation p 801.662.5600 University of Utah Health Salt Lake City UT. 84109 - Jordan Valley Medical 100 N Mario Capecchi Dr p 801.467.5483 Center 590 S Wakara Way Salt Lake City UT. 84113 Salt Lake City UT. 84108 p 801.662.5600 Peak Prosthetic Design Tranter, Devin DPM p 801.587.7109 1751 W Alexander St Jordan Valley Neuroscience Yadhati, Akshay G MD Ste 20 & Rehabilitation Hospital Affiliation University of Utah Health West Valley City UT. 84119 Specialists - University of Utah Hospital 590 S Wakara Way p 801.972.5270 3590 W 9000 S Salt Lake City UT. 84108 Ste 240 Werner, Whitney M PA p 801.587.7109 Jenco Prosthetics and West Jordan UT. 84088 Salt Lake Orthopaedic Orthotics p 801.352.8459 Clinic Hospital Affiliation 7026 S Commerce Park Dr 1160 E 3900 S - University of Utah Hospital Ste 2 Tyser, Andrew R MD Ste 5000 Midvale UT. 84047 University of Utah Health Salt Lake City UT. 84124 Zipnick, Richard MD p 801.566.5795 100 N Mario Capecchi Dr p 801.262.8486 Utah Orthopaedic Salt Lake City UT. 84113 Associates Mobility Prosthetics p 801.662.5600 Hospital Affiliation 1250 E 3900 S 480 E Winchester St - Logan Regional Hospital Ste 440 Ste 275 3773 W 12600 S Salt Lake City UT. 84124 Salt Lake City UT. 84107 Riverton UT. 84065 Wey, Aaron J MD p 801.261.2232 p 801.997.1367 p 801.285.1440 University Of Utah Health 590 S Wakara Way Heiden Orthopedics Outpatient Rehabilitation Clinic 5126 W Daybreak Pkwy Salt Lake City UT. 84108 6360 S 3000 E Rocky Mountain Care - South Jordan UT. 84009 p 801.587.7109 Ste 210 Hunter Hollow p 801.213.4500 Salt Lake City UT. 84121 4090 W Pioneer Pkwy Hospital Affiliation p 435.615.8822 West Valley City UT. 84120 - University of Utah Hospital p 801.397.4400 Hospital Affiliation - St Marks Hospital - Salt Lake Regional Medical Center 331 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Pain Management Davis, Craig W MD UPRI Murray Garg, Vikas MD Adult Care Clinic Granger Medical Clinic 32 W Winchester St Interventional Spine & 3920 S 1100 E 3725 W 4100 S Ste 200 Pain Management Ste 310 Salt Lake City UT. 84120 Salt Lake City UT. 84107 11800 S State St Salt Lake City UT. 84124 p 801.965.3634 p 801.327.9336 Ste 350 p 801.308.8400 Draper UT. 84020 9001 S 3200 W Earl, Brett J MD p 801.261.1391 Advanced Spine & Pain Ste 3 Integrated Functional 11760 S 700 E West Jordan UT. 84088 Medicine 11925 S State St Ste 112 p 801.569.5520 7138 S Highland Dr Draper UT. 84020 Draper UT. 84020 Salt Lake City UT. 84121 p 000.000.0000 p 801.572.1186 Hospital Affiliation p 801.725.4245 - Jordan Valley Medical 13953 S Bangerter Pkwy Basta, Susan V APRN Center West Valley Campus Engelen, Robert DO Draper UT. 84020 University of Utah Health - Mountain West Medical CORE @ West Valley p 801.262.7246 615 S Arapeen Dr Center 3336 S 4155 W Ste 100 Ste 102 2295 S Foothill Dr Salt Lake City UT. 84108 Despain, Devin DO West Valley City UT. 84120 Salt Lake City UT. 84109 p 801.581.7246 Interventional Spine & p 801.568.3480 p 801.486.3021 Pain Management Brogan, Shane E MD 11800 S State St Neurosci and 4624 S Holladay Blvd University of Utah Health Ste 350 Rehabilitation Specialists Salt Lake City UT. 84117 615 S Arapeen Dr Draper UT. 84020 @ West Jordan p 801.262.7246 Ste 100 p 801.261.1391 3590 W 9000 S Salt Lake City UT. 84108 Ste 240 5801 S Fashion Blvd p 801.581.7246 11925 S State St West Jordan UT. 84088 Ste 120 Draper UT. 84020 p 801.505.5370 Salt Lake City UT. 84107 Byrd, David D MD p 801.454.8000 p 801.261.1391 Alta Pain Physicians Neurosci and 11333 S 1000 E 13953 S Bangerter Pkwy Rehabilitation Specialists 6053 S Fashion Square Dr Ste 102 Draper UT. 84020 @ SLC Ste 100 Sandy UT. 84094 p 801.262.7246 82 S 1100 E Salt Lake City UT. 84107 p 801.462.2205 Ste 103 p 801.262.0098 2295 S Foothill Dr Salt Lake City UT. 84102 Hospital Affiliation Salt Lake City UT. 84109 p 801.505.5370 6360 S 3000 E - St Marks Hospital p 801.486.3021 Ste 100 Comprehensive Orthopedics Salt Lake City UT. 84121 Byrne, Ashleigh MD 4624 S Holladay Blvd & Sports Medicine p 801.262.7246 Granger Medical Clinic Salt Lake City UT. 84117 82 S 1100 E 9001 S 3200 W p 801.262.7246 Ste 303 6671 S Redwood Rd Ste 3 Salt Lake City UT. 84102 Ste 110 West Jordan UT. 84088 5801 S Fashion Blvd p 801.505.5370 West Jordan UT. 84084 p 801.569.5520 Ste 120 p 801.262.7246 Murray UT. 84107 9350 S 150 E Hospital Affiliation p 801.261.1391 Ste 460 Hospital Affiliation - Jordan Valley Medical Sandy UT. 84070 - Lone Peak Hospital Center 6053 S Fashion Square Dr p 801.533.2002 - Evanston Regional Hospital Ste 100 - Brigham City Community Clawson, Terri H PA Murray UT. 84107 Fine, Perry G MD Hospital Alta Pain Physicians p 801.262.0098 University of Utah Health 11333 S 1000 E 615 S Arapeen Dr Glines, Richard L MD Ste 102 6671 S Redwood Rd Ste 100 St Marks Interventional Sandy UT. 84094 Ste 110 Salt Lake City UT. 84108 Pain Clinic p 801.462.2205 West Jordan UT. 84084 p 801.581.7246 1160 E 3900 S p 801.262.7246 Ste G100 Dahl, Corey B PA Fonua, Siosi O APRN Salt Lake City UT. 84124 Omega Interventional Pain Drubin, Brittany J NP Odyssey House - Martindale p 801.268.7766 3838 S 700 E UPRI Taylorsville Medical Clinic Ste 300A 1972 W 5400 S 743 E 300 S 1220 E 3900 S Salt Lake City UT. 84106 Ste 100 Salt Lake City UT. 84102 Ste 3-B p 801.261.4988 Salt Lake City UT. 84129 p 801.428.3241 Salt Lake City UT. 84124 p 801.878.7880 p 801.268.7725

332 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 1250 E 3900 S Granger Medical Clinic 1220 E 3900 S 5801 S Fashion Blvd Ste 30 5323 S Woodrow St Ste 3B Ste 180 & 120 Salt Lake City UT. 84124 Ste 203 Salt Lake City UT. 84124 Salt Lake City UT. 84107 p 801.268.7725 Salt Lake City UT. 84107 p 801.268.7725 p 801.262.7246 p 385.722.9140 St Marks Interventional 1250 E 3900 S Hospital Affiliation Pain Center Hardy, Darryl APRN Ste 30 - Lakeview Hospital 74 Kimballs Ln UPRI Taylorsville Salt Lake City UT. 84124 - Timpanogos Regional Hospital Ste 230 1972 W 5400 S p 801.268.7725 Draper UT. 84020 Ste 100 Pulley, Steven C MD p 801.268.7248 Salt Lake City UT. 84129 Mathis, Jared PA Omega Interventional Pain p 801.327.9336 Granger Medical Clinic 3838 S 700 E Hospital Affiliation 9001 S 3200 W Ste 300 - St Marks Hospital UPRI Murray Ste 3 Salt Lake City UT. 84106 - Lone Peak Hospital 32 W Winchester St West Jordan UT. 84088 p 801.261.4988 - Davis Hospital Ste 200 p 801.569.5520 Salt Lake City UT. 84107 Hospital Affiliation Grose, Kendall DO p 801.327.9336 Matsumura, Kyle S MD - Salt Lake Regional Medical Neuroscience & Utah Pain Specialists Center Rehabilitation Specialists Harmer, Kyle PA-C 6750 S Highland Dr - West Valley Granger Medical Clinic Ste 100 Rosenthal, Richard MD 3336 S Pioneer Pkwy 9001 S 3200 W Salt Lake City UT. 84121 Nexus Pain Care Ste 102 Ste 3 p 801.685.7246 1575 W 7000 S West Valley City UT. 84120 West Jordan UT. 84088 West Jordan UT. 84084 p 801.964.3925 p 801.569.5520 Hospital Affiliation p 801.833.6569 - St Marks Hospital Jordan Valley Neuroscience Jessop, Jacob E DO Hospital Affiliation and Rehabilitation University of Utah Health Minori, Joshua J DO - Timpanogos Regional Hospital Specialists 615 S Arapeen Dr Interventional Spine & - Mountain View Hospital 3590 W 9000 S Ste 100 Pain Management (UT) Ste 240 Salt Lake City UT. 84108 5801 S Fashion Blvd West Jordan UT. 84088 p 801.581.7246 Ste 120 Saunders, Mark T MD p 801.352.8373 Salt Lake City UT. 84107 UPRI Taylorsville Hospital Affiliation p 801.262.7246 1972 W 5400 S Summit Medical Pain and - Mountain West Medical Ste 100 Spine Center 6671 S Redwood Rd Salt Lake City UT. 84129 4465 S 900 E Ste 110 p 801.878.7880 Ste 275 Joyal, Jeremy J MD West Jordan UT. 84084 Salt Lake City UT. 84124 Advanced Spine & Pain p 801.262.7246 UPRI Murray p 801.266.2440 11760 S 700 E 32 W Winchester St Ste 112 Hospital Affiliation Ste 200 Hospital Affiliation Draper UT. 84020 - Timpanogos Regional Hospital Salt Lake City UT. 84107 - Jordan Valley Medical p 801.572.1186 - Utah Valley Hospital p 801.327.9336 Center - Utah Valley Hospital Hospital Affiliation Nakken, Jason J DO Shah, Rajiv R MD - Jordan Valley Medical Nexus Pain Care Utah Pain Specialists Hadfield, Scott PA-C Center 4465 S 900 E 6750 S Highland Dr Granger Medical Clinic - Timpanogos Regional Hospital Ste 275 Ste 100 24 S 1100 E - Utah Valley Hospital Salt Lake City UT. 84124 Salt Lake City UT. 84121 Ste 105 p 801.833.6569 p 801.685.7246 Salt Lake City UT. 84102 Khan, Qamar R DO p 801.531.9453 Wasatch Pain Solutions Natkin, Erik DO Hospital Affiliation 661 W 10600 S Pain Management - Salt Lake Regional Medical 2965 W 3500 S South Jordan UT. 84095 Professionals Center West Valley City UT. 84119 p 801.302.2690 4541 S 700 E p 801.965.3600 Ste 100 Sharma, Gitanjali APRN Hospital Affiliation Salt Lake City UT. 84107 Adult Care Clinic Omega Interventional Pain - Jordan Valley Medical p 801.713.1560 3920 S 1100 E 3838 S 700 E Center Ste 310 Ste 300A - Lone Peak Hospital Nelson, Alex J MD Salt Lake City UT. 84124 Salt Lake City UT. 84117 Interventional Spine & p 801.308.8400 p 801.261.4988 Luo, Jie MD Pain Management St Marks Interventional 5121 S Cottonwood St Pain Clinic Murray UT. 84107 1160 E 3900 S p 435.753.1600 Ste G100 Salt Lake City UT. 84124 p 801.268.7479 333 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Sivertsen, Erik P PA Warren, Steven MD 50 N Medical Dr University of Utah Health University of Utah Health Adult Care Clinic Salt Lake City UT. 84132 81 N Mario Capecchi Dr 1950 Cir of Hope Dr 3920 S 1100 E p 801.581.7818 Salt Lake City UT. 84113 Salt Lake City UT. 84112 Ste 310 p 801.662.3770 p 801.585.0100 Salt Lake City UT. 84124 5126 W Daybreak Pkwy p 801.308.8400 South Jordan UT. 84009 Hospital Affiliation 50 N Medical Dr p 801.213.4246 - Primary Childrens Hospital Salt Lake City UT. 84132 Webb, Rachel PA-C p 801.581.5311 Omega Interventional Pain Hospital Affiliation Patterson, Paige A MD 3838 S 700 E - University of Utah Hospital University of Utah Health Slade, Travis D MD Ste B 1950 Cir of Hope Dr Intermountain Pain Salt Lake City UT. 84106 Chamberlain, Bruce H MD Salt Lake City UT. 84112 Solutions p 801.261.4988 Utah Cancer Specialists p 801.585.0100 6575 S Redwood Rd 3838 S 700 E Ste 201 Weinstein, Sharon M MD Ste 100 2830 S Redwood Rd Salt Lake City UT. 84123 University of Utah Health Salt Lake City UT. 84106 Ste C p 801.262.9600 100 N Mario Capecchi Dr p 801.269.0231 West Valley City UT. 84119 Salt Lake City UT. 84113 p 801.213.4500 Hospital Affiliation p 801.581.7172 5131 S Cottonwood St - Ogden Regional Medical Ste L-2 50 N Medical Dr Center 1950 Cir of Hope Dr Salt Lake City UT. 84107 Salt Lake City UT. 84132 Salt Lake City UT. 84112 p 801.263.3416 p 801.581.7818 Utah Pain Specialists p 801.585.0157 6750 S Highland Dr Gradick, Kathryn E MD 555 Foothill Dr Ste 100 615 S Arapeen Dr University Of Utah Health Salt Lake City UT. 84112 Salt Lake City UT. 84121 Ste 100 100 N Mario Capecchi Dr p 801.581.7818 p 801.685.7246 Salt Lake City UT. 84108 Salt Lake City UT. 84113 p 801.581.7246 p 801.662.3770 University Of Utah Health Steinberg, David P MD 85 N Medical Dr University Of Utah Health Wittleder, Fredrick PA 50 N Medical Dr Salt Lake City UT. 84112 50 N Medical Dr Summit Medical Pain and Salt Lake City UT. 84132 p 801.581.7818 Salt Lake City UT. 84132 Spine p 801.662.3770 p 801.581.2267 4465 S 900 E Hospital Affiliation Ste 275 81 N Mario Capecchi Dr - University of Utah Hospital 85 N Medical Dr Salt Lake City UT. 84124 Salt Lake City UT. 84113 Salt Lake City UT. 84112 p 801.266.2440 p 801.662.3770 Wanner, Nathan A MD p 801.581.2267 University of Utah Health Palliative Care Hospital Affiliation 50 N Medical Dr Hospital Affiliation Beck, Anna C MD - University of Utah Hospital Salt Lake City UT. 84132 - University of Utah Hospital University of Utah Health p 801.581.7818 1950 Cir of Hope Dr Graves, Kencee K MD Stephens, Billi PA Salt Lake City UT. 84112 University of Utah Health University Of Utah Health University of Utah Health p 801.585.0100 50 N Medical Dr 85 N Medical Dr 50 N Medical Dr Salt Lake City UT. 84132 Salt Lake City UT. 84112 Salt Lake City UT. 84132 5126 W Daybreak Pkwy p 801.581.7818 p 801.581.7818 p 801.581.7951 South Jordan UT. 84009 p 801.585.0100 University Of Utah Health Hospital Affiliation 501 S Chipeta Way 85 N Medical Dr - University of Utah Hospital Salt Lake City UT. 84108 University Of Utah Health Salt Lake City UT. 84112 p 801.587.3287 85 N Medical Dr p 801.581.7818 Wei, Jen Yu DO Salt Lake City UT. 84112 University of Utah Health Summit Medical Pain and p 801.585.0100 Hospital Affiliation 50 N Medical Dr Spine - University of Utah Hospital Salt Lake City UT. 84132 4465 S 900 E Hospital Affiliation p 801.581.7818 Ste 275 - University of Utah Hospital Moore, Dominic A MD Salt Lake City UT. 84124 University of Utah Health University Of Utah Health p 801.266.2440 Brant, Jamie L MD 100 N Mario Capecchi Dr 85 N Medical Dr University of Utah Health Salt Lake City UT. 84113 Salt Lake City UT. 84112 UPRI Murray 1950 Cir of Hope Dr p 801.662.3770 p 801.581.7818 32 W Winchester St Salt Lake City UT. 84112 Ste 200 p 801.585.0100 University Of Utah Health Hospital Affiliation Salt Lake City UT. 84107 50 N Medical Dr - University of Utah Hospital p 801.327.9336 Salt Lake City UT. 84132 p 801.662.3770

334 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Pediatric Allergy And Immunology Pediatric Cardiology *Cabrera, Antonio G MD Cox, Daniel A DO Allergy Associates of Utah Asaki, Sarah Y MD Primary Childrens University of Utah Health 3855 W 7800 S University of Utah Health Cardiology 3773 W 12600 S Ste 225 100 N Mario Capecchi Dr 100 N Mario Capecchi Dr Riverton UT. 84065 West Jordan UT. 84088 Salt Lake City UT. 84113 Ste 1500 p 801.213.3599 p 801.263.8700 p 801.662.5400 Salt Lake City UT. 84113 p 801.662.3900 50 N Medical Dr 6095 S Fashion Blvd 3773 W 12600 S Salt Lake City UT. 84132 Ste 100 Riverton UT. 84065 81 N Mario Capecchi Dr p 801.662.5400 Salt Lake City UT. 84107 p 801.662.5400 Salt Lake City UT. 84113 p 801.263.8700 p 801.662.1000 5121 S Cottonwood St 501 S Chipeta Way Murray UT. 84107 Duffey, Hannah MD Salt Lake City UT. 84108 Clark, Edward B MD p 801.507.4000 University of Utah Health p 801.662.5400 University of Utah Health 1280 E Stringham Ave 100 N Mario Capecchi Dr 5171 S Cottonwood St Salt Lake City UT. 84106 81 N Mario Capecchi Dr Salt Lake City UT. 84113 Murray UT. 84107 p 801.662.1603 Salt Lake City UT. 84113 p 801.662.1000 p 801.507.4000 p 801.213.3599 243 E 6100 S Colquitt, John MD 81 N Mario Capecchi Dr Salt Lake City UT. 84107 Binka, Edem K MD University Of Utah Health Salt Lake City UT. 84113 p 801.581.2955 University Of Utah Health 100 N Mario Capecchi Dr p 801.213.3599 100 N Mario Capecchi Dr Salt Lake City UT. 84113 81 N Mario Capecchi Dr Salt Lake City UT. 84113 p 801.213.3599 Hospital Affiliation Salt Lake City UT. 84113 p 801.213.3599 - Primary Childrens Hospital p 801.213.3599 3773 W 12600 S 3773 W 12600 S Riverton UT. 84065 Day, Ronald W MD Hospital Affiliation Riverton UT. 84065 p 801.662.5400 University of Utah Health - Primary Childrens Hospital p 801.662.5400 3773 W 12600 S 50 N Medical Dr Riverton UT. 84065 Hill, Harry MD 50 N Medical Dr Salt Lake City UT. 84132 p 801.662.5400 University of Utah Health Salt Lake City UT. 84132 p 801.662.5400 81 N Mario Capecchi Dr p 801.662.5400 50 N Medical Dr Salt Lake City UT. 84113 81 N Mario Capecchi Dr Salt Lake City UT. 84132 p 801.213.3599 81 N Mario Capecchi Dr Salt Lake City UT. 84113 p 801.662.5400 Salt Lake City UT. 84113 p 801.213.3599 Hospital Affiliation p 801.213.3599 81 N Mario Capecchi Dr - University of Utah Hospital Cowley, Collin G MD Salt Lake City UT. 84113 Hospital Affiliation Pediatrix Medical Group p 801.213.3599 Inman, Christi J MD - University of Utah Hospital 100 N Mario Capecchi Dr University of Utah Health Salt Lake City UT. 84113 Etheridge, Susan P MD 100 N Mario Capecchi Dr *Boucek, Dana M MD p 801.662.1000 University of Utah Health Salt Lake City UT. 84113 Primary Childrens 100 N Mario Capecchi Dr p 801.213.3599 Cardiology 11925 S State St Salt Lake City UT. 84113 100 N Mario Capecchi Dr Draper UT. 84020 p 801.662.5400 3773 W 12600 S Ste 1500 p 801.545.8000 Riverton UT. 84065 Salt Lake City UT. 84113 3773 W 12600 S p 801.213.3599 p 801.662.3900 1200 E 3900 S Riverton UT. 84065 Salt Lake City UT. 84124 p 801.662.5400 81 N Mario Capecchi Dr University of Utah Health p 801.268.7111 Salt Lake City UT. 84113 3773 W 12600 S 50 N Medical Dr p 801.213.3599 Riverton UT. 84065 3460 S Pioneer Pkwy Salt Lake City UT. 84132 p 801.662.5400 West Valley City UT. 84120 p 801.585.7676 Viera-Hutchins, Loida MD p 801.964.3100 Tanner Memorial Clinic 50 N Medical Dr 501 S Chipeta Way 5296 S Commerce Dr Salt Lake City UT. 84132 3580 W 9000 S Salt Lake City UT. 84108 Salt Lake City UT. 84107 p 801.662.5400 West Jordan UT. 84088 p 801.662.5400 p 801.773.4840 p 801.561.8888 5121 S Cottonwood St 81 N Mario Capecchi Dr Hospital Affiliation Murray UT. 84107 3741 W 12600 S Salt Lake City UT. 84113 - Primary Childrens Hospital p 801.507.2050 Riverton UT. 84065 p 801.213.3599 p 801.285.4000 Pediatric Behavioral Health 81 N Mario Capecchi Dr Freedman, Roger A MD Hamilton, Ryan W LCSW Salt Lake City UT. 84113 Hospital Affiliation University of Utah Health University of Utah Health p 801.213.3599 - Ogden Regional Medical 100 N Mario Capecchi Dr 51 W 3900 S Center Salt Lake City UT. 84113 Salt Lake City UT. 84107 Hospital Affiliation p 801.662.1000 p 801.585.1575 - Primary Childrens Hospital

335 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 50 N Medical Dr 81 N Mario Capecchi Dr Mart, Christopher R MD *Menon, Shaji C MD Salt Lake City UT. 84132 Salt Lake City UT. 84113 University of Utah Health Primary Childrens Hospital p 801.585.3229 p 801.213.3599 3773 W 12600 S 100 N Mario Capecchi Dr Riverton UT. 84065 Ste 1500 Hospital Affiliation Hospital Affiliation p 801.662.5400 Salt Lake City UT. 84113 - University of Utah Hospital - University of Utah Hospital p 801.662.3900 50 N Medical Dr *Gray, Robert G MD *Lal, Ashwin K MD Salt Lake City UT. 84132 University of Utah Health Primary Childrens Hospital Primary Childrens Hospital p 801.662.5400 3773 W 12600 S 100 N Mario Capecchi Dr 100 N Mario Capecchi Dr Riverton UT. 84065 Ste 1500 Ste 1500 81 N Mario Capecchi Dr p 801.662.5400 Salt Lake City UT. 84113 Salt Lake City UT. 84113 Salt Lake City UT. 84113 p 801.662.3900 p 801.662.3900 p 801.213.3599 50 N Medical Dr Salt Lake City UT. 84132 University of Utah Health University of Utah Health Hospital Affiliation p 801.662.3770 3773 W 12600 S 3773 W 12600 S - Primary Childrens Hospital Riverton UT. 84065 Riverton UT. 84065 - Ogden Regional Medical 81 N Mario Capecchi Dr p 801.285.4000 p 801.662.5400 Center Salt Lake City UT. 84113 p 801.213.3599 50 N Medical Dr 50 N Medical Dr *Martin, Mary H MD Salt Lake City UT. 84132 Salt Lake City UT. 84132 Primary Childrens Hospital Hospital Affiliation p 801.662.5400 p 801.662.5400 100 N Mario Capecchi Dr - Primary Childrens Hospital Ste 1500 - Ogden Regional Medical 5121 S Cottonwood St 81 N Mario Capecchi Dr Salt Lake City UT. 84113 Center Murray UT. 84107 Salt Lake City UT. 84113 p 801.662.3900 p 801.507.2050 p 801.213.3599 Miller, Thomas A DO University of Utah Health University of Utah Health 81 N Mario Capecchi Dr Hospital Affiliation 3773 W 12600 S 100 N Mario Capecchi Dr Salt Lake City UT. 84113 - Primary Childrens Hospital Riverton UT. 84065 Salt Lake City UT. 84113 p 801.213.3599 p 801.662.5400 p 801.587.2255 Lindsay, Ian M MD *Hoffman, James L MD University of Utah Health 50 N Medical Dr 50 N Medical Dr Primary Childrens Hospital 3773 W 12600 S Salt Lake City UT. 84132 Salt Lake City UT. 84132 100 N Mario Capecchi Dr Riverton UT. 84065 p 801.662.5400 p 801.662.5400 Ste 1500 p 801.662.5400 Salt Lake City UT. 84113 81 N Mario Capecchi Dr 81 N Mario Capecchi Dr p 801.662.3900 50 N Medical Dr Salt Lake City UT. 84113 Salt Lake City UT. 84113 Salt Lake City UT. 84132 p 801.213.3599 p 801.213.3599 University of Utah Health p 801.662.5400 100 N Mario Capecchi Dr *May, Lindsay J MD Hospital Affiliation Salt Lake City UT. 84113 5121 S Cottonwood St Primary Childrens Hospital - Lone Peak Hospital p 801.662.5400 Murray UT. 84107 100 N Mario Capecchi Dr p 801.507.2050 Ste 1500 Minich, Lois L MD 81 N Mario Capecchi Dr Salt Lake City UT. 84113 University of Utah Health Salt Lake City UT. 84113 81 N Mario Capecchi Dr p 801.662.3900 3773 W 12600 S p 801.213.3599 Salt Lake City UT. 84113 Riverton UT. 84065 p 801.213.3599 University of Utah Health p 801.662.5400 Hospital Affiliation 3773 W 12600 S - Timpanogos Regional Hospital Hospital Affiliation Riverton UT. 84065 50 N Medical Dr - Primary Childrens Hospital p 801.662.5400 Salt Lake City UT. 84132 Hogan, Whitnee MD p 801.662.5400 University Of Utah Health Magdo, Heidi S DO 50 N Medical Dr 100 N Mario Capecchi Dr University of Utah Health Salt Lake City UT. 84132 81 N Mario Capecchi Dr Salt Lake City UT. 84113 3773 W 12600 S p 801.662.5400 Salt Lake City UT. 84113 p 801.213.3599 Riverton UT. 84065 p 801.213.3599 p 801.662.5400 81 N Mario Capecchi Dr 3773 W 12600 S Salt Lake City UT. 84113 Hospital Affiliation Riverton UT. 84065 50 N Medical Dr p 801.213.3599 - Ogden Regional Medical p 801.662.5400 Salt Lake City UT. 84132 Center p 801.662.5400 Hospital Affiliation 50 N Medical Dr - Primary Childrens Hospital *Molina, Kimberly M MD Salt Lake City UT. 84132 81 N Mario Capecchi Dr Primary Childrens Hospital p 801.662.5400 Salt Lake City UT. 84113 100 N Mario Capecchi Dr p 801.213.3599 Ste 1500 Salt Lake City UT. 84113 Hospital Affiliation p 801.662.3900 - Primary Childrens Hospital

336 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 100 N Mario Capecchi Dr 5121 S Cottonwood St *Su, Jason T DO *Ware, Adam L MD Salt Lake City UT. 84113 Salt Lake City UT. 84107 Primary Childrens Hospital Primary Childrens Hospital p 801.662.5419 p 801.662.5400 81 N Mario Capecchi Dr Physicians Salt Lake City UT. 84113 100 N Mario Capecchi Dr University of Utah Health 81 N Mario Capecchi Dr p 801.662.1000 Salt Lake City UT. 84113 3773 W 12600 S Salt Lake City UT. 84113 p 801.662.1000 Riverton UT. 84065 p 801.213.3599 Hospital Affiliation p 801.662.5400 - Ogden Regional Medical University of Utah Health Hospital Affiliation Center 3773 W 12600 S 50 N Medical Dr - Primary Childrens Hospital Riverton UT. 84065 Salt Lake City UT. 84132 - Lone Peak Hospital Tani, Lloyd Y MD p 801.662.5400 p 801.662.5400 University of Utah Health *Pinto, Nelangi M MD 50 N Medical Dr 50 N Medical Dr 81 N Mario Capecchi Dr Primary Childrens Hospital Salt Lake City UT. 84132 Salt Lake City UT. 84132 Salt Lake City UT. 84113 100 N Mario Capecchi Dr p 801.662.5400 p 801.662.5400 p 801.213.3599 Ste 1500 Salt Lake City UT. 84113 81 N Mario Capecchi Dr 81 N Mario Capecchi Dr Hospital Affiliation p 801.662.3900 Salt Lake City UT. 84113 Salt Lake City UT. 84113 - Ogden Regional Medical p 801.213.3599 p 801.213.3599 Center University of Utah Health 3773 W 12600 S Hospital Affiliation Weyhrauch, Derek L MD Niu, Mary C MD Riverton UT. 84065 - Primary Childrens Hospital University Of Utah Health University of Utah Health p 801.662.5400 - Ogden Regional Medical 100 N Mario Capecchi Dr 100 N Mario Capecchi Dr Center Salt Lake City UT. 84113 Salt Lake City UT. 84113 50 N Medical Dr p 801.213.3599 p 801.662.5400 Salt Lake City UT. 84132 *Tristani-Firouzi, Martin p 801.662.5400 *J MD 3773 W 12600 S 3773 W 12600 S Primary Childrens Hospital Riverton UT. 84065 Riverton UT. 84065 81 N Mario Capecchi Dr 100 N Mario Capecchi Dr p 801.662.5400 p 801.285.4000 Salt Lake City UT. 84113 Ste 1500 p 801.213.3599 Salt Lake City UT. 84113 Hospital Affiliation 501 S Chipeta Way p 801.662.3900 - University of Utah Hospital Salt Lake City UT. 84108 Hospital Affiliation p 801.662.5400 - Primary Childrens Hospital University of Utah Health *Williams, Richard V MD - Ogden Regional Medical 50 N Medical Dr Primary Childrens Hospital 81 N Mario Capecchi Dr Center Salt Lake City UT. 84132 100 N Mario Capecchi Dr Salt Lake City UT. 84113 p 801.662.5400 Ste 1500 p 801.213.3599 *Ploutz, Michelle S MD Salt Lake City UT. 84113 Primary Childrens 81 N Mario Capecchi Dr p 801.662.3900 Hospital Affiliation Cardiology Salt Lake City UT. 84113 - Primary Childrens Hospital 100 N Mario Capecchi Dr p 801.213.3599 University of Utah Health - Primary Childrens Hospital Ste 1500 3773 W 12600 S Salt Lake City UT. 84113 Hospital Affiliation Riverton UT. 84065 *Pilcher, Thomas A MD p 801.662.3900 - Primary Childrens Hospital p 801.662.5400 Primary Childrens Hospital 100 N Mario Capecchi Dr 81 N Mario Capecchi Dr *Truong, Dongngan MD 50 N Medical Dr Ste 1500 Salt Lake City UT. 84113 Primary Childrens Hospital Salt Lake City UT. 84132 Salt Lake City UT. 84113 p 801.662.1000 100 N Mario Capecchi Dr p 801.662.5400 p 801.662.3900 Ste 1500 Hospital Affiliation Salt Lake City UT. 84113 81 N Mario Capecchi Dr University of Utah Health - Primary Childrens Hospital p 801.662.3900 Salt Lake City UT. 84113 100 N Mario Capecchi Dr p 801.213.3599 Salt Lake City UT. 84113 Ralston, Charles W MD University of Utah Health p 801.662.5400 Wasatch Pediatrics - 3773 W 12600 S Hospital Affiliation Cottonwood Riverton UT. 84065 - Ogden Regional Medical 3773 W 12600 S 5770 S 250 E p 801.662.5400 Center Riverton UT. 84065 Ste 290 - St Marks Hospital p 801.662.5400 Murray UT. 84107 50 N Medical Dr p 801.747.8700 Salt Lake City UT. 84132 Pediatric Cardiothoracic Surgery 501 S Chipeta Way p 801.662.5400 Eckhauser, Aaron W MD Salt Lake City UT. 84108 Hospital Affiliation University of Utah Health p 801.662.5400 - St Marks Hospital 81 N Mario Capecchi Dr 100 N Mario Capecchi Dr - Jordan Valley Medical Salt Lake City UT. 84113 Salt Lake City UT. 84113 Center p 801.213.3599 p 801.662.5566

Hospital Affiliation - Lone Peak Hospital

337 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. PCH Esophageal Airway - Krakovitz, Paul MD Pediatric Endocrinology University of Utah Health Riverton University of Utah Health Al Hamad, Dania MD 81 N Mario Capecchi Dr 3741 W 12600 S 100 N Mario Capecchi Dr University of Utah Health Salt Lake City UT. 84113 Riverton UT. 84065 Salt Lake City UT. 84113 3773 W 12600 S p 801.213.3599 p 801.662.1644 p 801.213.3599 Riverton UT. 84065 p 801.285.4000 Hospital Affiliation University of Utah Health Hospital Affiliation - Primary Childrens Hospital 50 N Medical Dr - University of Utah Hospital 81 N Mario Capecchi Dr Salt Lake City UT. 84132 Salt Lake City UT. 84113 Murray, Mary A MD p 801.581.5311 Lee, Janet W MD p 801.213.3599 University of Utah Health University of Utah Health 100 N Mario Capecchi Dr Primary Childrens Hospital 100 N Mario Capecchi Dr Hospital Affiliation Salt Lake City UT. 84113 Physicians Salt Lake City UT. 84113 - Primary Childrens Hospital p 801.587.3922 81 N Mario Capecchi Dr p 801.213.3599 Salt Lake City UT. 84113 Clements, Scott A MD Primary Childrens Hospital p 801.662.1000 3773 W 12600 S University of Utah Health 3773 W 12600 S Riverton UT. 84065 100 N Mario Capecchi Dr Riverton UT. 84065 Hospital Affiliation p 801.285.1285 Salt Lake City UT. 84113 p 801.662.1000 - University of Utah Hospital p 801.587.3922 Hospital Affiliation University of Utah Health Pediatric Dermatology - Primary Childrens Hospital Primary Childrens Hospital 81 N Mario Capecchi Dr U-U Pediatric Dermatology 3773 W 12600 S Salt Lake City UT. 84113 100 N Mario Capecchi Dr Orlandi, Richard R MD Riverton UT. 84065 p 801.213.3599 Salt Lake City UT. 84113 University of Utah Health p 801.662.1000 p 801.662.1603 50 N Medical Dr Hospital Affiliation Salt Lake City UT. 84132 University of Utah Health - University of Utah Hospital Vanderhooft, Sheryll L MD p 801.581.7514 81 N Mario Capecchi Dr University of Utah Health Salt Lake City UT. 84113 *Raleigh, Zoe T MD 100 N Mario Capecchi Dr 5126 W Daybreak Pkwy p 801.213.3599 Primary Childrens Diabetes Salt Lake City UT. 84113 South Jordan UT. 84009 81 N Mario Capecchi Dr p 801.581.2955 p 801.581.7514 Hospital Affiliation Salt Lake City UT. 84113 - University of Utah Hospital p 801.662.1000 243 E 6100 S 8th Ave & C St Murray UT. 84107 Salt Lake City UT. 84143 Foster, Carol M MD Hospital Affiliation p 801.581.2955 p 801.581.8915 University of Utah Health - Primary Childrens Hospital 100 N Mario Capecchi Dr 3773 W 12600 S Hospital Affiliation Salt Lake City UT. 84113 Raman, Vandana S MD Riverton UT. 84065 - University of Utah Hospital p 801.587.3922 University of Utah Health p 801.581.2955 100 N Mario Capecchi Dr Shelton, Clough MD 3773 W 12600 S Salt Lake City UT. 84113 50 N Medical Dr Clinic 28 University of Utah Health Riverton UT. 84065 p 801.587.3922 Salt Lake City UT. 84132 100 N Mario Capecchi Dr p 801.285.4000 p 801.581.2955 Salt Lake City UT. 84113 3773 W 12600 S p 801.213.3599 81 N Mario Capecchi Dr Riverton UT. 84065 81 N Mario Capecchi Dr Salt Lake City UT. 84113 p 801.285.4000 Salt Lake City UT. 84113 50 N Medical Dr p 801.213.3599 p 801.213.3599 Salt Lake City UT. 84132 81 N Mario Capecchi Dr p 801.581.7514 Hospital Affiliation Salt Lake City UT. 84113 Pediatric Ear Nose And Throat - University of Utah Hospital p 801.213.3599 Kelly, Steven M MD 5121 S Cottonwood St University of Utah Health Murray UT. 84107 Hamaker, Mark MD Hospital Affiliation 100 N Mario Capecchi Dr p 801.581.7514 University of Utah Health - University of Utah Hospital Salt Lake City UT. 84113 100 N Mario Capecchi Dr p 801.213.3599 5770 S 250 E Salt Lake City UT. 84113 Smego, Allison MD Ste 170 p 801.587.3922 University of Utah Health 3773 W 12600 S Salt Lake City UT. 84107 100 N Mario Capecchi Dr Riverton UT. 84065 p 801.581.7514 Primary Childrens Hospital Salt Lake City UT. 84113 p 801.285.1285 3773 W 12600 S p 801.587.3922 8th Ave & C St Riverton UT. 84065 Hospital Affiliation Salt Lake City UT. 84143 p 801.662.1000 81 N Mario Capecchi Dr - Primary Childrens Hospital p 801.581.7514 Salt Lake City UT. 84113 615 Arapeen Dr p 801.213.3599 Hospital Affiliation Ste 100 - University of Utah Hospital Salt Lake City UT. 84108 Hospital Affiliation p 801.662.1000 - Primary Childrens Hospital

338 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Swinyard, Mike T MD University of Utah Health Kavan, Marianne A MD *Patel, Raza A MD Mountain Vista Medicine 3773 W 12600 S University of Utah Health PCH Esophageal Airway - 1258 W S Jordan Pkwy Riverton UT. 84065 100 N Mario Capecchi Dr Riverton Ste 103 p 801.662.2900 Salt Lake City UT. 84113 3741 W 12600 S South Jordan UT. 84095 p 801.213.3599 Riverton UT. 84065 p 801.838.9090 50 N Medical Dr p 801.662.1644 Salt Lake City UT. 84132 3773 W 12600 S Hospital Affiliation p 801.581.8416 Riverton UT. 84065 University of Utah Health - Primary Childrens Hospital p 801.662.2900 81 N Mario Capecchi Dr 81 N Mario Capecchi Dr Salt Lake City UT. 84113 Timme, Kathleen H MD Salt Lake City UT. 84113 81 N Mario Capecchi Dr p 801.213.3599 University of Utah Health p 801.213.3599 Salt Lake City UT. 84113 3773 W 12600 S p 801.213.3599 Hospital Affiliation Riverton UT. 84065 Hospital Affiliation - Primary Childrens Hospital p 801.285.4000 - Primary Childrens Hospital Hospital Affiliation - Primary Childrens Hospital Pohl, John F MD 81 N Mario Capecchi Dr Guthery, Stephen L MD University of Utah Health Salt Lake City UT. 84113 University of Utah Health Mizell, Louis L MD 3773 W 12600 S p 801.213.3599 100 N Mario Capecchi Dr Pediatrix Medical Group Riverton UT. 84065 Salt Lake City UT. 84113 11800 S State St p 801.662.2900 Hospital Affiliation p 801.213.3599 Draper UT. 84020 - Primary Childrens Hospital p 801.545.8100 81 N Mario Capecchi Dr 3773 W 12600 S Salt Lake City UT. 84113 Pediatric Gastroenterology Riverton UT. 84065 11925 S State St p 801.213.3599 Book, Linda S MD p 801.662.2900 Draper UT. 84020 University of Utah Health p 801.545.8000 Robson, Jacob O MD 100 N Mario Capecchi Dr 81 N Mario Capecchi Dr University of Utah Health Salt Lake City UT. 84113 Salt Lake City UT. 84113 Cottonwood Pediatric 3773 W 12600 S p 801.213.3599 p 801.213.3599 Gastroenterology Riverton UT. 84065 5770 S 250 E p 801.662.2900 3773 W 12600 S Hospital Affiliation Ste 330 Riverton UT. 84065 - Primary Childrens Hospital Murray UT. 84107 50 N Medical Dr p 801.662.2900 p 801.314.4455 Salt Lake City UT. 84132 Jackson, William D MD p 801.581.8416 81 N Mario Capecchi Dr University of Utah Health Pediatrix Medical Group Salt Lake City UT. 84113 3773 W 12600 S 74 Kimballs Ln 81 N Mario Capecchi Dr p 801.213.3599 Riverton UT. 84065 Ste 330 Salt Lake City UT. 84113 p 801.662.2900 Draper UT. 84020 p 801.213.3599 Deneau, Mark R MD p 801.545.8363 University of Utah Health 81 N Mario Capecchi Dr Tuft, Blaine A DO 100 N Mario Capecchi Dr Salt Lake City UT. 84113 96 E Kimballs Ln University of Utah Health Salt Lake City UT. 84113 p 801.213.3599 Ste 100 100 N Mario Capecchi Dr p 801.213.3599 Draper UT. 84020 Salt Lake City UT. 84113 Hospital Affiliation p 801.233.9300 p 801.213.3599 3773 W 12600 S - Primary Childrens Hospital Riverton UT. 84065 Hospital Affiliation 81 N Mario Capecchi Dr p 801.662.2900 Jaramillo Castrillon, - Primary Childrens Hospital Salt Lake City UT. 84113 Catalina M MD - Lone Peak Hospital p 801.213.3599 81 N Mario Capecchi Dr University of Utah Health - Timpanogos Regional Hospital Salt Lake City UT. 84113 100 N Mario Capecchi Dr Hospital Affiliation p 801.213.3599 Salt Lake City UT. 84113 O Gorman, Molly A MD - Primary Childrens Hospital p 801.213.3599 University of Utah Health Hospital Affiliation 3773 W 12600 S Wheeler, Justin C MD - Primary Childrens Hospital 3773 W 12600 S Riverton UT. 84065 University of Utah Health Riverton UT. 84065 p 801.662.2900 100 N Mario Capecchi Dr *Ermarth, Anna K MD p 801.662.2900 Salt Lake City UT. 84113 PCH Esophageal Airway - 81 N Mario Capecchi Dr p 801.213.3599 Riverton 50 N Medical Dr Salt Lake City UT. 84113 3741 W 12600 S Salt Lake City UT. 84132 p 801.213.3599 3773 W 12600 S Riverton UT. 84065 p 801.581.8416 Riverton UT. 84065 p 801.662.1644 Hospital Affiliation p 801.662.2900 81 N Mario Capecchi Dr - Primary Childrens Hospital Salt Lake City UT. 84113 p 801.213.3599

Hospital Affiliation - University of Utah Hospital

339 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 50 N Medical Dr 1950 Cir of Hope Dr 1950 Cir of Hope Dr 1950 Cir of Hope Dr Salt Lake City UT. 84132 Salt Lake City UT. 84112 Salt Lake City UT. 84112 Salt Lake City UT. 84112 p 801.581.8416 p 801.587.4745 p 801.587.4745 p 801.587.4745

81 N Mario Capecchi Dr 50 N Medical Dr 50 N Medical Dr 50 N Medical Dr Salt Lake City UT. 84113 Salt Lake City UT. 84132 Salt Lake City UT. 84132 Salt Lake City UT. 84132 p 801.213.3599 p 801.662.4700 p 801.662.4700 p 801.662.4700

Pediatric Hematology And Oncology Hospital Affiliation Hospital Affiliation Schiffman, Joshua D MD Barnette, Phillip E MD - Primary Childrens Hospital - Primary Childrens Hospital University of Utah Health University of Utah Health 100 N Mario Capecchi Dr 100 N Mario Capecchi Dr Heneghan, Mallorie B MD Mueggenborg, Brenda S PNP Salt Lake City UT. 84113 Salt Lake City UT. 84113 University Of Utah Health University of Utah Health p 801.662.4700 p 801.662.4700 100 N Mario Capecchi Dr 100 N Mario Capecchi Dr Salt Lake City UT. 84113 Salt Lake City UT. 84113 1950 Cir of Hope Dr Boyer, Michael W MD p 801.662.4700 p 801.662.4700 Salt Lake City UT. 84112 University of Utah Health p 801.587.4745 100 N Mario Capecchi Dr 1950 Cir of Hope Dr Hospital Affiliation Salt Lake City UT. 84113 Salt Lake City UT. 84112 - University of Utah Hospital Whipple, Nicholas S MD p 801.662.4700 p 801.587.4745 University of Utah Health Nibley, William E MD 100 N Mario Capecchi Dr Hospital Affiliation 50 N Medical Dr Utah Cancer Specialists Salt Lake City UT. 84113 - University of Utah Hospital Salt Lake City UT. 84132 5131 S Cottonwood St p 801.662.4700 p 801.662.4700 Ste L-2 Bruggers, Carol S MD Murray UT. 84107 Hospital Affiliation University of Utah Health Hospital Affiliation p 901.263.3416 - University of Utah Hospital 100 N Mario Capecchi Dr - University of Utah Hospital Salt Lake City UT. 84113 Hospital Affiliation *Yaish, Hassan M MD p 801.662.4700 Huntsman Cancer Institute - St Marks Hospital Primary Childrens Hospital 1950 Circle of Hope - Lakeview Hospital 100 N Mario Capecchi Dr Dietz, Matthew S DO Salt Lake City UT. 84112 - Ashley Valley Regional Salt Lake City UT. 84113 University Of Utah Health p 801.585.0100 Medical Center p 801.662.1000 100 N Mario Capecchi Dr - Davis Hospital Salt Lake City UT. 84113 Hospital Affiliation Pediatric Hepatology p 801.662.4700 - University of Utah Hospital Parker, Kellee N DO Jensen, Michael K MD University Of Utah Health University of Utah Health 1950 Cir of Hope Dr Lemons, Richard S MD,PhD 100 N Mario Capecchi Dr 100 N Mario Capecchi Dr Salt Lake City UT. 84112 University of Utah Health Salt Lake City UT. 84113 Salt Lake City UT. 84113 p 801.587.4745 100 N Mario Capecchi Dr p 801.662.4700 p 801.213.3599 Salt Lake City UT. 84113 50 N Medical Dr p 801.662.4700 1950 Cir of Hope Dr 3773 W 12600 S Salt Lake City UT. 84132 Salt Lake City UT. 84112 Riverton UT. 84065 p 801.662.4700 Maese, Luke D DO p 801.587.4745 p 801.662.2900 University of Utah Health Hospital Affiliation 100 N Mario Capecchi Dr 50 N Medical Dr 81 N Mario Capecchi Dr - University of Utah Hospital Salt Lake City UT. 84113 Salt Lake City UT. 84132 Salt Lake City UT. 84113 p 801.662.4700 p 801.662.4700 p 801.213.3599 Fair, Douglas B MD University of Utah Health 1950 Cir of Hope Dr University of Utah Health Hospital Affiliation 81 N Mario Capecchi Dr Salt Lake City UT. 84112 81 N Mario Capecchi Dr - Primary Childrens Hospital Salt Lake City UT. 84113 p 801.587.4745 Salt Lake City UT. 84113 p 801.213.3599 p 801.213.3599 Pediatric Infectious Disease 50 N Medical Dr Ampofo, Kwabena K MD Hospital Affiliation Salt Lake City UT. 84132 Hospital Affiliation University of Utah Health - Primary Childrens Hospital p 801.662.4700 - University of Utah Hospital 81 N Mario Capecchi Dr Salt Lake City UT. 84113 Harris, Andrew MD Hospital Affiliation Rayes, Ahmad MD p 801.213.3599 University of Utah Health - Primary Childrens Hospital University Of Utah Health 100 N Mario Capecchi Dr 100 N Mario Capecchi Dr Hospital Affiliation Salt Lake City UT. 84113 Meznarich, Jessica A MD Salt Lake City UT. 84113 - Primary Childrens Hospital p 801.662.4700 University of Utah Health p 801.662.4700 100 N Mario Capecchi Dr Blaschke-Bonkowsky, Anne Salt Lake City UT. 84113 J MD,PhD p 801.662.4700 University of Utah Health 81 N Mario Capecchi Dr Salt Lake City UT. 84113 p 801.213.3599

340 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Doby, Elizabeth H MD Miner, Lonnie J MD 50 N Medical Dr 50 N Medical Dr Primary Childrens Hospital University of Utah Health Salt Lake City UT. 84132 Salt Lake City UT. 84132 100 N Mario Capecchi Dr 100 N Mario Capecchi Dr p 801.581.6709 p 801.213.3599 Salt Lake City UT. 84113 Salt Lake City UT. 84113 p 801.662.1000 p 801.662.4100 515 E 100 S 81 N Mario Capecchi Dr Ste 350 Salt Lake City UT. 84113 University of Utah Health 50 N Medical Dr Salt Lake City UT. 84102 p 801.213.3599 81 N Mario Capecchi Dr Salt Lake City UT. 84132 p 801.581.3981 Salt Lake City UT. 84113 p 801.581.2121 Hospital Affiliation p 801.213.3599 University Of Utah Health - Primary Childrens Hospital 5121 S Cottonwood St 85 N Medical Dr Hersh, Adam L MD Salt Lake City UT. 84107 Salt Lake City UT. 84112 *Seamon, Meredith L MD University of Utah Health p 801.507.7000 p 801.581.6709 Primary Childrens Hospital 81 N Mario Capecchi Dr 100 N Mario Capecchi Dr Salt Lake City UT. 84113 *Osguthorpe, Russell J MD Hospital Affiliation Salt Lake City UT. 84113 p 801.213.3599 Primary Childrens Hospital - University of Utah Hospital p 801.662.1675 100 N Mario Capecchi Dr Hospital Affiliation Salt Lake City UT. 84113 *Grinsell, Matthew M MD University of Utah Health - Primary Childrens Hospital p 801.662.1000 Primary Childrens Spina 3773 W 12600 S Bifida Riverton UT. 84065 Keeshin, Susan MD University of Utah Health 100 N Mario Capecchi Dr p 801.525.7676 University of Utah Health 81 N Mario Capecchi Dr Salt Lake City UT. 84113 1525 W 2100 S Salt Lake City UT. 84113 p 801.662.1675 81 N Mario Capecchi Dr Salt Lake City UT. 84119 p 801.213.3599 Salt Lake City UT. 84113 p 801.213.8841 University of Utah Health p 801.213.3599 Hospital Affiliation 3773 W 12600 S 50 N Medical Dr - Primary Childrens Hospital Riverton UT. 84065 Hospital Affiliation Salt Lake City UT. 84132 p 801.525.7676 - Primary Childrens Hospital p 801.585.2031 Pavia, Andrew T MD University of Utah Health 81 N Mario Capecchi Dr *Sherbotie, Joseph R MD 81 N Mario Capecchi Dr 50 N Medical Dr Salt Lake City UT. 84113 Primary Childrens Hospital Salt Lake City UT. 84113 Salt Lake City UT. 84132 p 801.213.3599 100 N Mario Capecchi Dr p 801.213.3599 p 801.585.2031 Salt Lake City UT. 84113 Hospital Affiliation p 801.662.1000 Hospital Affiliation 81 N Mario Capecchi Dr - University of Utah Hospital - Primary Childrens Hospital Salt Lake City UT. 84113 University of Utah Health p 801.213.3599 *Nelson, Raoul D MD 3773 W 12600 S Lake, Jason G MD Primary Childrens Hospital Riverton UT. 84065 University Of Utah Health Thorell, Emily A MD 100 N Mario Capecchi Dr p 801.525.7676 100 N Mario Capecchi Dr University of Utah Health Salt Lake City UT. 84113 Salt Lake City UT. 84113 81 N Mario Capecchi Dr p 801.662.1000 423 S Wakara Way p 801.213.3599 Salt Lake City UT. 84113 Ste 200 p 801.213.3599 University of Utah Health Salt Lake City UT. 84108 81 N Mario Capecchi Dr 3773 W 12600 S p 801.581.3981 Salt Lake City UT. 84113 Pediatric Nephrology Riverton UT. 84065 p 801.213.3599 Afify, Zeinab A MD p 801.525.7676 515 E 100 S University of Utah Health Ste 350 Hospital Affiliation 100 N Mario Capecchi Dr 81 N Mario Capecchi Dr Salt Lake City UT. 84102 - University of Utah Hospital Salt Lake City UT. 84113 Salt Lake City UT. 84113 p 801.581.3981 p 801.662.4700 p 801.213.3599 Mehra, Sonia MD 81 N Mario Capecchi Dr University of Utah Health Hospital Affiliation Hospital Affiliation Salt Lake City UT. 84113 100 N Mario Capecchi Dr - Primary Childrens Hospital - University of Utah Hospital p 801.213.3599 Salt Lake City UT. 84113 p 801.213.3599 Gregory, Martin C MD,PhD Peterson, Caitlin G DO Hospital Affiliation University of Utah Health University of Utah Health - University of Utah Hospital 50 N Medical Dr 1950 Cir of Hope Dr 100 N Mario Capecchi Dr Salt Lake City UT. 84132 Salt Lake City UT. 84112 Salt Lake City UT. 84113 Pediatric Neurology p 801.585.2031 p 801.587.7000 p 801.213.3599 Benedict, Susan L MD University of Utah Health 81 N Mario Capecchi Dr 423 S Wakara Way 3773 W 12600 S 3773 W 12600 S Salt Lake City UT. 84113 Ste 200 Riverton UT. 84065 Riverton UT. 84065 p 801.213.3599 Salt Lake City UT. 84108 p 801.525.7676 p 801.587.7575 p 801.581.3981 Hospital Affiliation - Primary Childrens Hospital

341 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 81 N Mario Capecchi Dr 3773 W 12600 S 81 N Mario Capecchi Dr Cheshier, Samuel H MD,PhD Salt Lake City UT. 84113 Riverton UT. 84065 Salt Lake City UT. 84113 University of Utah Health p 801.587.7575 p 801.213.3599 p 801.587.7575 100 N Mario Capecchi Dr Salt Lake City UT. 84113 Bonkowsky, Joshua L 50 N Medical Dr Hospital Affiliation p 801.662.5340 MD,PhD Salt Lake City UT. 84132 - Primary Childrens Hospital University of Utah Health p 801.213.3599 175 N Medical Dr E 81 N Mario Capecchi Dr Teynor Physicians Group, Salt Lake City UT. 84132 Salt Lake City UT. 84113 81 N Mario Capecchi Dr PLLC p 801.585.7575 p 801.587.7575 Salt Lake City UT. 84113 2290 E 4500 S p 801.213.3599 Ste 215 Primary Childrens Spina Butterfield, Russell J MD Salt Lake City UT. 84117 Bifida University of Utah Health Hospital Affiliation p 801.534.1360 81 N Mario Capecchi Dr 175 N Medical Dr E - University of Utah Hospital Salt Lake City UT. 84113 Salt Lake City UT. 84132 Wilson, Carey A MD p 801.662.1675 p 801.585.7575 Morita, Denise M MD University of Utah Health Granger Medical Clinic 100 N Mario Capecchi Dr Hospital Affiliation 81 N Mario Capecchi Dr 11724 S State St Salt Lake City UT. 84113 - University of Utah Hospital Salt Lake City UT. 84113 Draper UT. 84020 p 801.213.3599 p 801.587.7575 p 801.576.2050 Couldwell, William T 81 N Mario Capecchi Dr MD,PhD Hospital Affiliation Hospital Affiliation Salt Lake City UT. 84113 University of Utah Health - University of Utah Hospital - Jordan Valley Medical p 801.213.3599 100 N Mario Capecchi Dr Center Salt Lake City UT. 84113 Espinoza, Audie C MD Hospital Affiliation p 801.662.5340 University Of Utah Health Nelson, Clint R MD - University of Utah Hospital 100 N Mario Capecchi Dr University of Utah Health 175 N Medical Dr E Salt Lake City UT. 84113 100 N Mario Capecchi Dr Pediatric Neurosurgery Salt Lake City UT. 84132 p 801.213.3599 Salt Lake City UT. 84113 Bollo, Robert J MD p 801.585.7575 p 801.587.2255 University of Utah Health 3773 W 12600 S 100 N Mario Capecchi Dr 1950 Cir of Hope Dr Riverton UT. 84065 81 N Mario Capecchi Dr Salt Lake City UT. 84113 Salt Lake City UT. 84112 p 801.213.3599 Salt Lake City UT. 84113 p 801.662.5340 p 801.585.7575 p 801.587.7575 50 N Medical Dr Primary Childrens Hospital 8th Ave & C St Salt Lake City UT. 84132 Hospital Affiliation 81 N Mario Capecchi Dr Salt Lake City UT. 84143 p 801.213.3599 - Primary Childrens Hospital Salt Lake City UT. 84113 p 801.408.1100 p 801.662.1675 81 N Mario Capecchi Dr Ostrander, Betsy MD Hospital Affiliation Salt Lake City UT. 84113 University of Utah Health Hospital Affiliation - University of Utah Hospital p 801.213.3599 100 N Mario Capecchi Dr - University of Utah Hospital Salt Lake City UT. 84113 Pediatric Ophthalmology Hospital Affiliation p 801.587.2255 Bragg, Taryn L MD Bullard, Michael L MD - University of Utah Hospital University Of Utah Health Utah Eye Centers 3773 W 12600 S 100 N Mario Capecchi Dr 1025 E 3300 S *Kerr, Lynne M MD Riverton UT. 84065 Salt Lake City UT. 84113 Ste B Primary Childrens Hospital p 801.587.7575 p 801.662.5340 Salt Lake City UT. 84106 100 N Mario Capecchi Dr p 801.476.0494 Salt Lake City UT. 84113 81 N Mario Capecchi Dr Hospital Affiliation p 801.662.1000 Salt Lake City UT. 84113 - University of Utah Hospital 440 D St p 801.587.7575 Ste 210 University of Utah Health Brockmeyer, Douglas L MD Salt Lake City UT. 84103 81 N Mario Capecchi Dr Sweney, Matthew T MD University of Utah Health p 801.408.3705 Salt Lake City UT. 84113 University of Utah Health 100 N Mario Capecchi Dr p 801.587.7575 3773 W 12600 S Salt Lake City UT. 84113 Hospital Affiliation Riverton UT. 84065 p 801.662.5340 - Lakeview Hospital Hospital Affiliation p 801.587.7575 - Ogden Regional Medical - Primary Childrens Hospital 175 N Medical Dr E Center 50 N Medical Dr Salt Lake City UT. 84132 Manberg, Stephanie M DO Salt Lake City UT. 84132 p 801.585.7575 Charlton, Kevin H MD University Of Utah Health p 801.213.3599 Rocky Mountain Eye Care 100 N Mario Capecchi Dr Primary Childrens Hospital 4400 S 700 E Salt Lake City UT. 84113 81 N Mario Capecchi Dr Ste 100 p 801.213.3599 Salt Lake City UT. 84113 Murray UT. 84107 p 801.662.1675 p 801.264.4450

Hospital Affiliation - Primary Childrens Hospital - University of Utah Hospital 342 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 5069 W 13400 S 243 E 6100 S 50 N Medical Dr 590 S Wakara Way Ste 400 Murray UT. 84107 Salt Lake City UT. 84132 Salt Lake City UT. 84108 Herriman UT. 84096 p 801.585.3937 p 801.585.6387 p 801.587.7109 p 801.264.4450 3773 W 12600 S 65 S Mario Capecchi Dr Hospital Affiliation Hospital Affiliation Riverton UT. 84065 Salt Lake City UT. 84132 - University of Utah Hospital - St Marks Hospital p 801.213.4500 p 801.581.2352 Higgins, Thomas F MD Dries, David C MD 50 N Medical Dr 729 S Arapeen Dr University of Utah Health University of Utah Health Salt Lake City UT. 84132 Salt Lake City UT. 84108 100 N Mario Capecchi Dr 100 N Mario Capecchi Dr p 801.581.2121 p 801.585.7575 Salt Lake City UT. 84113 Salt Lake City UT. 84113 p 801.662.5600 p 801.581.2352 5126 W Daybreak Pkwy Hospital Affiliation South Jordan UT. 84009 - University of Utah Hospital 590 S Wakara Way 50 N Medical Dr p 801.213.4500 Salt Lake City UT. 84108 Salt Lake City UT. 84132 Stagg, Brian C MD p 801.587.7109 p 801.581.2121 65 S Mario Capecchi Dr University of Utah Health Salt Lake City UT. 84132 100 N Mario Capecchi Dr Hospital Affiliation 65 S Mario Capecchi Dr p 801.581.2352 Salt Lake City UT. 84113 - University of Utah Hospital Salt Lake City UT. 84132 p 801.581.2352 p 801.581.2352 Nakatsuka, Austin S MD Holmes, Stephanie M MD University of Utah Health 243 E 6100 S University of Utah Health Hospital Affiliation 100 N Mario Capecchi Dr Murray UT. 84107 100 N Mario Capecchi Dr - University of Utah Hospital Salt Lake City UT. 84113 p 801.585.3937 Salt Lake City UT. 84113 p 801.581.2352 p 801.662.5600 Hoffman, Robert O MD 5126 W Daybreak Pkwy University of Utah Health 243 E 6100 S South Jordan UT. 84009 3773 W 12600 S 100 N Mario Capecchi Dr Murray UT. 84107 p 801.213.4500 Riverton UT. 84065 Salt Lake City UT. 84113 p 801.585.3937 p 801.285.1440 p 801.581.2352 65 S Mario Capecchi Dr 65 S Mario Capecchi Dr Salt Lake City UT. 84132 Hospital Affiliation 50 N Medical Dr Salt Lake City UT. 84132 p 801.581.2352 - University of Utah Hospital Salt Lake City UT. 84132 p 801.581.2352 p 801.581.2121 Hospital Affiliation Hutchinson, Douglas T MD Hospital Affiliation - University of Utah Hospital University of Utah Health 65 S Mario Capecchi Dr - University of Utah Hospital 100 N Mario Capecchi Dr Salt Lake City UT. 84132 Vitale, Albert T MD Salt Lake City UT. 84113 p 801.581.2352 Petersen, David B MD University of Utah Health p 801.662.5600 Rocky Mountain Eye Care 100 N Mario Capecchi Dr Hospital Affiliation 4400 S 700 E Salt Lake City UT. 84113 590 S Wakara Way - University of Utah Hospital Ste 100 p 801.581.2352 Salt Lake City UT. 84108 Murray UT. 84107 p 801.587.7109 Jeppsen, Paul MD p 801.264.4450 50 N Medical Dr Rocky Mountain Eye Care Salt Lake City UT. 84132 Hospital Affiliation 4400 S 700 E 5069 W 13400 S p 801.581.2121 - University of Utah Hospital Ste 100 Ste 400 Murray UT. 84107 Herriman UT. 84096 65 S Mario Capecchi Dr Kraiss, Larry W MD p 801.264.4450 p 801.264.4450 Salt Lake City UT. 84132 University of Utah Health p 801.581.2352 100 N Mario Capecchi Dr 5069 W 13400 S Seay, Meagan D DO Salt Lake City UT. 84113 Ste 400 University of Utah Health Hospital Affiliation p 801.662.2950 Herriman UT. 84096 100 N Mario Capecchi Dr - University of Utah Hospital p 801.264.4450 Salt Lake City UT. 84113 1950 Cir of Hope Dr p 801.581.2352 Pediatric Optometry Salt Lake City UT. 84112 Hospital Affiliation Hulet, Paul OD p 801.585.7676 - St Marks Hospital 175 N Medical Dr E Family Focused Eyecare Salt Lake City UT. 84132 5528 W 13400 S Hospital Affiliation Marx, Douglas P MD p 801.585.7575 Herriman UT. 84096 - University of Utah Hospital University of Utah Health p 801.302.3080 100 N Mario Capecchi Dr 243 E 6100 S Makarewich, Christopher A Salt Lake City UT. 84113 Salt Lake City UT. 84107 Pediatric Orthopedic Surgery MD p 801.581.2352 p 801.585.3937 Brodke, Darrel S MD University of Utah Health University of Utah Health 100 N Mario Capecchi Dr 100 N Mario Capecchi Dr Salt Lake City UT. 84113 Salt Lake City UT. 84113 p 801.662.5600 p 801.662.5600

343 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 3773 W 12600 S Whitehead, Kevin J MD 501 S Chipeta Way Dwyer, Luke M MD Riverton UT. 84065 University of Utah Health Salt Lake City UT. 84108 University Of Utah Health p 801.285.1440 100 N Mario Capecchi Dr p 801.587.3287 50 N Medical Dr Salt Lake City UT. 84113 Salt Lake City UT. 84132 81 N Mario Capecchi Dr p 801.662.1000 5126 W Daybreak Pkwy p 801.581.7951 Salt Lake City UT. 84113 South Jordan UT. 84009 p 801.662.5600 1950 Cir of Hope Dr p 801.213.4500 501 S Chipeta Way Salt Lake City UT. 84112 Salt Lake City UT. 84108 Hospital Affiliation p 801.585.0303 Burris, Mary K MD p 801.585.1575 - University of Utah Hospital University of Utah Health 50 N Medical Dr 1280 E Stringham Ave 51 W 3900 S McClure, Philip K MD Salt Lake City UT. 84132 Salt Lake City UT. 84106 Salt Lake City UT. 84107 University of Utah Health p 801.585.7676 p 801.581.7951 p 801.587.2370 100 N Mario Capecchi Dr Salt Lake City UT. 84113 University Of Utah Health 1950 Cir of Hope Dr 525 E 100 S p 801.662.5600 85 N Medical Dr Salt Lake City UT. 84112 Ste 5000 Salt Lake City UT. 84112 p 801.583.2500 Salt Lake City UT. 84102 590 S Wakara Way p 801.585.7676 p 801.585.1212 Salt Lake City UT. 84108 50 N Medical Dr p 801.587.7109 Hospital Affiliation Salt Lake City UT. 84132 Hospital Affiliation - Primary Childrens Hospital p 801.585.1575 - University of Utah Hospital Hospital Affiliation - University of Utah Hospital - University of Utah Hospital 501 S Chipeta Way Francis, Kristin C MD Winter, Sarah L MD Salt Lake City UT. 84108 University of Utah Health Sarfati, Mark R MD University of Utah Health p 801.587.3287 1280 E Stringham Ave University of Utah Health 100 N Mario Capecchi Dr Salt Lake City UT. 84106 100 N Mario Capecchi Dr Salt Lake City UT. 84113 Hospital Affiliation p 801.581.7951 Salt Lake City UT. 84113 p 801.587.2255 - University of Utah Hospital p 801.662.2950 1950 Cir of Hope Dr 50 N Medical Dr Chan, Benjamin R MD Salt Lake City UT. 84112 1950 Cir of Hope Dr Salt Lake City UT. 84132 University of Utah Health p 801.583.2500 Salt Lake City UT. 84112 p 801.581.2205 1280 E Stringham Ave p 801.585.7676 Salt Lake City UT. 84106 50 N Medical Dr 81 N Mario Capecchi Dr p 801.581.7951 Salt Lake City UT. 84132 Hospital Affiliation Salt Lake City UT. 84113 p 801.585.1575 - University of Utah Hospital p 801.587.2255 50 N Medical Dr Salt Lake City UT. 84132 501 S Chipeta Way Smith, John T MD Pediatric Psychiatry p 801.585.1575 Salt Lake City UT. 84108 University of Utah Health Aguayo, Patricia MD p 801.587.3287 100 N Mario Capecchi Dr University of Utah Health 501 S Chipeta Way Salt Lake City UT. 84113 50 N Medical Dr Salt Lake City UT. 84108 Hospital Affiliation p 801.587.2255 Salt Lake City UT. 84132 p 801.587.3287 - University of Utah Hospital p 801.581.7951 3773 W 12600 S Hospital Affiliation Gilley Hensley, Laura B Riverton UT. 84065 501 S Chipeta Way - University of Utah Hospital MD p 801.285.1440 Salt Lake City UT. 84108 University of Utah Health p 801.585.1575 Conover, Thomas G MD 1280 E Stringham Ave Primary Childrens Hospital University of Utah Health Salt Lake City UT. 84106 81 N Mario Capecchi Dr Hospital Affiliation 1280 E Stringham Ave p 801.581.7951 Salt Lake City UT. 84113 - University of Utah Hospital Salt Lake City UT. 84106 p 801.662.1675 p 801.581.7951 1950 Cir of Hope Dr Ashworth, James C MD Salt Lake City UT. 84112 Wang, Angela A MD University of Utah Health 50 N Medical Dr p 801.583.2500 University of Utah Health 1280 E Stringham Ave Salt Lake City UT. 84132 100 N Mario Capecchi Dr Salt Lake City UT. 84106 p 801.585.1575 50 N Medical Dr Salt Lake City UT. 84113 p 801.581.7951 Salt Lake City UT. 84132 p 801.662.5600 501 S Chipeta Way p 801.585.1575 1950 Cir of Hope Dr Salt Lake City UT. 84108 590 S Wakara Way Salt Lake City UT. 84112 p 801.587.3287 501 S Chipeta Way Salt Lake City UT. 84108 p 801.583.2500 Salt Lake City UT. 84108 p 801.587.7109 *Deming, Annie M PhD p 801.587.3287 50 N Medical Dr Primary Childrens Hospital Hospital Affiliation Salt Lake City UT. 84132 5770 S 1500 W Hospital Affiliation - University of Utah Hospital p 801.585.1575 Taylorsville UT. 84123 - University of Utah Hospital p 801.313.7770

344 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Gray, Douglas D MD 501 S Chipeta Way 50 N Medical Dr Pagel, Kristen L MD University of Utah Health Salt Lake City UT. 84108 Salt Lake City UT. 84132 University of Utah Health 1138 E Wilmington Ave p 801.587.3287 p 801.585.1575 50 N Medical Dr Salt Lake City UT. 84106 Salt Lake City UT. 84132 p 801.213.8845 Hospital Affiliation 501 S Chipeta Way p 801.585.1575 - University of Utah Hospital Salt Lake City UT. 84108 1280 E Stringham Ave p 801.587.3287 501 S Chipeta Way Salt Lake City UT. 84106 Keeshin, Brooks R MD Salt Lake City UT. 84108 p 801.581.7951 University of Utah Health Lin, Anne G MD p 801.585.1575 100 N Mario Capecchi Dr University of Utah Health 50 N Medical Dr Salt Lake City UT. 84113 1280 E Stringham Ave 51 W 3900 S Salt Lake City UT. 84132 p 801.662.1000 Salt Lake City UT. 84106 Salt Lake City UT. 84107 p 801.585.1575 p 801.581.7951 p 801.585.1575 Primary Childrens Hospital 501 S Chipeta Way 3773 W 12600 S 50 N Medical Dr Hospital Affiliation Salt Lake City UT. 84108 Riverton UT. 84065 Salt Lake City UT. 84132 - University of Utah Hospital p 801.587.3287 p 801.285.1285 p 801.585.1575 Thompson, Frances L PSYD Hospital Affiliation University of Utah Health 501 S Chipeta Way Early Life Child - University of Utah Hospital 50 N Medical Dr Salt Lake City UT. 84108 Psychology & Education Salt Lake City UT. 84132 p 801.587.3287 Center Hardesty Van Ginkel, p 801.581.2205 10757 E River Front Pkwy Ashlee B MD Hospital Affiliation Ste 275 University of Utah Health Primary Childrens Hospital - University of Utah Hospital South Jordan UT. 84095 1280 E Stringham Ave 81 N Mario Capecchi Dr p 385.900.4020 Salt Lake City UT. 84106 Salt Lake City UT. 84113 Martini, Richard D MD p 801.581.7951 p 801.662.3606 University of Utah Health 12397 S 300 E 100 N Mario Capecchi Dr Ste 100 50 N Medical Dr 8282 S 2200 W Salt Lake City UT. 84113 Draper UT. 84020 Salt Lake City UT. 84132 West Jordan UT. 84088 p 801.313.7711 p 385.900.4020 p 801.581.7951 p 385.468.4580 Primary Childrens Hospital Weeks, Howard R MD 501 S Chipeta Way Hospital Affiliation 5770 S 1500 W University of Utah Health Salt Lake City UT. 84108 - Primary Childrens Hospital Taylorsville UT. 84123 1280 E Stringham Ave p 801.587.3287 p 801.313.7770 Salt Lake City UT. 84106 Kohler, Shawn J MD p 801.581.7951 Hospital Affiliation University of Utah Health 81 N Mario Capecchi Dr - University of Utah Hospital 154 E Myrtle Ave Salt Lake City UT. 84113 501 S Chipeta Way Salt Lake City UT. 84107 p 801.662.5592 Salt Lake City UT. 84108 Hesse, Toni M MD p 801.581.2628 p 801.587.3287 University of Utah Health Hospital Affiliation 1280 E Stringham Ave 50 N Medical Dr - Primary Childrens Hospital Weir, Rachel A MD Salt Lake City UT. 84106 Salt Lake City UT. 84132 University of Utah Health p 801.581.7951 p 801.585.1575 McCarthey, Rachele M MD 1280 E Stringham Ave University of Utah Health Salt Lake City UT. 84106 1950 Cir of Hope Dr 501 S Chipeta Way 1280 E Stringham Ave p 801.581.7951 Salt Lake City UT. 84112 Salt Lake City UT. 84108 Salt Lake City UT. 84106 p 801.583.2500 p 801.585.1575 p 801.581.7951 1525 W 2100 S Salt Lake City UT. 84119 50 N Medical Dr 51 W 3900 S 50 N Medical Dr p 801.213.8841 Salt Lake City UT. 84132 Salt Lake City UT. 84107 Salt Lake City UT. 84132 p 801.585.1575 p 801.585.1575 p 801.585.1575 50 N Medical Dr Salt Lake City UT. 84132 501 S Chipeta Way Hospital Affiliation 501 S Chipeta Way p 801.585.1575 Salt Lake City UT. 84108 - University of Utah Hospital Salt Lake City UT. 84108 p 801.587.3287 p 801.587.3287 501 S Chipeta Way Kondo, Douglas G MD Salt Lake City UT. 84108 Hospital Affiliation University of Utah Health Hospital Affiliation p 801.587.3287 - University of Utah Hospital 1280 E Stringham Ave - University of Utah Hospital Salt Lake City UT. 84106 Hospital Affiliation Keen, Annalise S MD p 801.581.7951 *Meek, Matthew R MD - University of Utah Hospital University of Utah Health PCH RESIDENTIAL TRMNT-ADOL 1280 E Stringham Ave 5770 S 1500 W Salt Lake City UT. 84106 Taylorsville UT. 84123 p 801.581.7951 p 801.313.7940

Hospital Affiliation - Primary Childrens Hospital 345 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Pediatric Pulmonology Pediatric Sleep Inman, Christi J MD 81 N Mario Capecchi Dr *Asfour, Fadi Y MD Medicine-Department of University of Utah Health Salt Lake City UT. 84113 PCH Esophageal Airway - University of Utah 100 N Mario Capecchi Dr p 801.213.3599 Riverton 100 N Mario Capecchi Dr Salt Lake City UT. 84113 3741 W 12600 S Salt Lake City UT. 84113 p 801.213.3599 Hospital Affiliation Riverton UT. 84065 p 743.134.268 - Primary Childrens Hospital p 801.662.1644 3773 W 12600 S Pediatric Rehabilitation Riverton UT. 84065 Pediatric Surgery University of Utah Health Darro, Natalie H DO p 801.213.3599 Barnhart, Douglas C MD 81 N Mario Capecchi Dr University Of Utah Health University of Utah Health Salt Lake City UT. 84113 100 N Mario Capecchi Dr 81 N Mario Capecchi Dr 100 N Mario Capecchi Dr p 801.213.3599 Salt Lake City UT. 84113 Salt Lake City UT. 84113 Salt Lake City UT. 84113 p 801.662.1000 p 801.213.3599 p 801.662.2950 Hospital Affiliation - Primary Childrens Hospital 13747 S Redwood Rd James, Karen E MD PCH Esophageal Airway - Riverton UT. 84065 University of Utah Health Riverton Lai, Khanh V MD p 801.662.1000 100 N Mario Capecchi Dr 3741 W 12600 S University of Utah Health Salt Lake City UT. 84113 Riverton UT. 84065 81 N Mario Capecchi Dr 81 N Mario Capecchi Dr p 801.213.3599 p 801.662.1644 Salt Lake City UT. 84113 Salt Lake City UT. 84113 p 801.213.3599 p 801.213.3599 3773 W 12600 S University of Utah Health Riverton UT. 84065 3773 W 12600 S Hospital Affiliation *Flavin, Marisa H MD p 801.213.3359 Riverton UT. 84065 - Primary Childrens Hospital Primary Childrens Hospital p 801.285.1285 Physicians 81 N Mario Capecchi Dr *McGinley, Brian M MD 3773 W 12600 S Salt Lake City UT. 84113 50 N Medical Dr PCH Esophageal Airway - Riverton UT. 84065 p 801.213.3599 Salt Lake City UT. 84132 Riverton p 801.285.1285 p 801.581.2121 3741 W 12600 S Hospital Affiliation Riverton UT. 84065 81 N Mario Capecchi Dr - Primary Childrens Hospital Primary Childrens Hospital p 801.662.1644 Salt Lake City UT. 84113 Physicians p 801.662.1000 Overbury, Rebecca S MD 81 N Mario Capecchi Dr University of Utah Health University of Utah Health Salt Lake City UT. 84113 81 N Mario Capecchi Dr Hospital Affiliation 3773 W 12600 S p 801.662.1000 Salt Lake City UT. 84113 - Primary Childrens Hospital Riverton UT. 84065 p 801.213.3599 p 801.213.3599 Bucher, Brian T MD Pediatric Rheumatology University of Utah Health Pfeffer, Kathleen D MD Bohnsack, John F MD 50 N Medical Dr 100 N Mario Capecchi Dr Utah Sleep Specialists University of Utah Health Salt Lake City UT. 84132 Salt Lake City UT. 84113 9103 S 1300 W 100 N Mario Capecchi Dr p 801.581.7724 p 801.662.2950 Ste 103 Salt Lake City UT. 84113 West Jordan UT. 84088 p 801.213.3599 81 N Mario Capecchi Dr 3773 W 12600 S p 801.432.8690 Salt Lake City UT. 84113 Riverton UT. 84065 81 N Mario Capecchi Dr p 801.213.3599 p 801.285.1285 Hospital Affiliation Salt Lake City UT. 84113 - Salt Lake Regional Medical p 801.213.3599 University Of Utah Health 50 N Medical Dr Center 85 N Medical Dr Salt Lake City UT. 84132 Hersh, Aimee O MD Salt Lake City UT. 84112 p 801.581.2121 Safi, Khalid MD University of Utah Health p 801.581.7724 University of Utah Health 100 N Mario Capecchi Dr 81 N Mario Capecchi Dr 81 N Mario Capecchi Dr Salt Lake City UT. 84113 Hospital Affiliation Salt Lake City UT. 84113 Salt Lake City UT. 84113 p 801.213.3599 - Primary Childrens Hospital p 801.213.3599 p 801.213.3599 3773 W 12600 S Stern, Sara M MD Hospital Affiliation Hospital Affiliation Riverton UT. 84065 University of Utah Health - Primary Childrens Hospital - Primary Childrens Hospital p 801.213.3359 100 N Mario Capecchi Dr Salt Lake City UT. 84113 Fenton, Stephen J Uchida, Derek A MD 81 N Mario Capecchi Dr p 801.213.3599 University of Utah Health University of Utah Health Salt Lake City UT. 84113 100 N Mario Capecchi Dr 81 N Mario Capecchi Dr p 801.213.3599 3773 W 12600 S Salt Lake City UT. 84113 Salt Lake City UT. 84113 Riverton UT. 84065 p 801.662.2950 p 801.213.3599 Hospital Affiliation p 801.213.3359 - Primary Childrens Hospital

346 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 3773 W 12600 S PCH Esophageal Airway - Wynne, Elisabeth K MD 3773 W 12600 S Riverton UT. 84065 Riverton University of Utah Health Ste 300 p 801.285.1285 3741 W 12600 S 100 N Mario Capecchi Dr Riverton UT. 84065 Riverton UT. 84065 Salt Lake City UT. 84113 p 801.581.2121 50 N Medical Dr p 801.662.1644 p 801.662.2950 Salt Lake City UT. 84132 Hospital Affiliation p 801.581.2121 University of Utah Health 50 N Medical Dr - Primary Childrens Hospital 3773 W 12600 S Salt Lake City UT. 84132 81 N Mario Capecchi Dr Riverton UT. 84065 p 801.581.2121 Wallis, Michaelo C MD Salt Lake City UT. 84113 p 801.285.1285 University of Utah Health p 801.213.3599 81 N Mario Capecchi Dr 100 N Mario Capecchi Dr 50 N Medical Dr Salt Lake City UT. 84113 Salt Lake City UT. 84113 Kastenberg, Zachary J MD Salt Lake City UT. 84132 p 801.213.3599 p 801.662.5555 University of Utah Health p 801.581.2121 100 N Mario Capecchi Dr Hospital Affiliation 3773 W 12600 S Salt Lake City UT. 84113 Primary Childrens Hospital - Primary Childrens Hospital Ste 300 p 801.662.2950 Physicians Riverton UT. 84065 81 N Mario Capecchi Dr Pediatric Urology p 801.581.2121 50 N Medical Dr Salt Lake City UT. 84113 Cartwright, Patrick C MD Salt Lake City UT. 84132 p 801.662.1000 University of Utah Health 81 N Mario Capecchi Dr p 801.581.2121 100 N Mario Capecchi Dr Salt Lake City UT. 84113 Hospital Affiliation Salt Lake City UT. 84113 p 801.662.5555 Hospital Affiliation - Primary Childrens Hospital p 801.662.5555 - University of Utah Hospital Pediatrics Short, Scott S MD 3773 W 12600 S Aizad, Tazeem A MD Meyers, Rebecka L MD University of Utah Health Ste 300 1561 W 7000 S University of Utah Health 100 N Mario Capecchi Dr Riverton UT. 84065 Ste 202 100 N Mario Capecchi Dr Salt Lake City UT. 84113 p 801.581.2121 West Jordan UT. 84084 Salt Lake City UT. 84113 p 801.662.2950 p 801.569.8344 p 801.662.2950 Primary Childrens Hospital 3773 W 12600 S 81 N Mario Capecchi Dr Hospital Affiliation 3773 W 12600 S Riverton UT. 84065 Salt Lake City UT. 84113 - Jordan Valley Medical Riverton UT. 84065 p 801.285.1285 p 801.662.1675 Center p 801.285.1285 50 N Medical Dr Hospital Affiliation Alexander, Molly L MD 50 N Medical Dr Salt Lake City UT. 84132 - University of Utah Hospital University Of Utah Health Salt Lake City UT. 84132 p 801.581.2121 100 N Mario Capecchi Dr p 801.581.2121 Jacobson, Deborah MD Salt Lake City UT. 84113 81 N Mario Capecchi Dr University of Utah Health p 801.662.1234 Russell, Kathryn W MD Salt Lake City UT. 84113 100 N Mario Capecchi Dr University of Utah Health p 801.213.3599 Salt Lake City UT. 84113 Hospital Affiliation 100 N Mario Capecchi Dr p 801.662.5555 - University of Utah Hospital Salt Lake City UT. 84113 Hospital Affiliation p 801.662.2950 - University of Utah Hospital 3773 W 12600 S Alvey, Justin C MD Ste 300 University of Utah Health 3773 W 12600 S Skarda, David E MD Riverton UT. 84065 100 N Mario Capecchi Dr Riverton UT. 84065 University of Utah Health p 801.581.2121 Salt Lake City UT. 84113 p 801.285.1285 100 N Mario Capecchi Dr p 801.662.1000 Salt Lake City UT. 84113 Matta, Rano MD 50 N Medical Dr p 801.662.2950 University Of Utah Health 50 N Medical Dr Salt Lake City UT. 84132 100 N Mario Capecchi Dr Salt Lake City UT. 84132 p 801.581.2121 50 N Medical Dr Salt Lake City UT. 84113 p 801.581.2205 Salt Lake City UT. 84132 p 801.662.5555 81 N Mario Capecchi Dr p 801.581.2121 81 N Mario Capecchi Dr Salt Lake City UT. 84113 Hospital Affiliation Salt Lake City UT. 84113 p 801.213.3599 Vargo, Daniel J MD - University of Utah Hospital p 801.213.3599 University of Utah Health Hospital Affiliation 50 N Medical Dr Schaeffer, Anthony J MD Andrews, Curtis MD - University of Utah Hospital Salt Lake City UT. 84132 University of Utah Health Copperview Medical Center p 801.581.7738 100 N Mario Capecchi Dr 3556 W 9800 S Scaife, Eric R MD Salt Lake City UT. 84113 Ste 101 University of Utah Health Hospital Affiliation p 801.662.5555 South Jordan UT. 84095 100 N Mario Capecchi Dr - University of Utah Hospital p 801.567.9780 Salt Lake City UT. 84113 p 801.662.2950 Hospital Affiliation - Jordan Valley Medical Center - Lone Peak Hospital 347 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Baese, Philip L MD 81 N Mario Capecchi Dr 81 N Mario Capecchi Dr Brown, Laura L MD University of Utah Health Salt Lake City UT. 84113 Salt Lake City UT. 84113 University of Utah Health 1280 E Stringham Ave p 801.662.3770 p 801.213.3599 100 N Mario Capecchi Dr Salt Lake City UT. 84106 Salt Lake City UT. 84113 p 801.581.7951 Bilder, Deborah A MD Bragg, Taryn L MD p 801.662.1000 University of Utah Health University Of Utah Health 1950 Cir of Hope Dr 1280 E Stringham Ave 100 N Mario Capecchi Dr 50 N Medical Dr Salt Lake City UT. 84112 Salt Lake City UT. 84106 Salt Lake City UT. 84113 Salt Lake City UT. 84132 p 801.583.2500 p 801.581.7951 p 801.662.5340 p 801.581.2205

50 N Medical Dr 1950 Cir of Hope Dr Hospital Affiliation Hospital Affiliation Salt Lake City UT. 84132 Salt Lake City UT. 84112 - University of Utah Hospital - Primary Childrens Hospital p 801.581.7951 p 801.583.2500 Brasher, Craig A MD Brownstein, Ellie MD 501 S Chipeta Way 50 N Medical Dr Granger Medical Clinic University of Utah Health Salt Lake City UT. 84108 Salt Lake City UT. 84132 2965 W 3500 S 7495 S State St p 801.587.3287 p 801.585.1575 West Valley City UT. 84119 Midvale UT. 84047 p 801.965.3600 p 801.213.9400 Hospital Affiliation 501 S Chipeta Way - University of Utah Hospital Salt Lake City UT. 84108 3181 W 9000 S Hospital Affiliation p 801.587.3287 West Jordan UT. 84088 - Jordan Valley Medical Barrett, Mark B MD p 801.569.5600 Center Wasatch Pediatrics - Hospital Affiliation - St Marks Hospital Cottonwood - University of Utah Hospital Hospital Affiliation - University of Utah Hospital 5770 S 250 E - Jordan Valley Medical Ste 290 Borgenicht, Louis MD Center Buchanan, Brian J MD Murray UT. 84107 Sunnyside Pediatrics - Jordan Valley Medical Wasatch Pediatrics - p 801.747.8700 24 S 1100 E Center West Valley Campus Southpoint Ste 301 - St Marks Hospital 9071 S 1300 W Hospital Affiliation Salt Lake City UT. 84102 Ste 301 - Primary Childrens Hospital p 801.521.2640 Brinton, Jennifer N MD West Jordan UT. 84088 - St Marks Hospital University Of Utah Health p 801.565.1162 Hospital Affiliation 13747 S Redwood Rd Behunin, Katie DO - Salt Lake Regional Medical Riverton UT. 84065 Hospital Affiliation South Summit Pediatrics Center p 801.662.1000 - St Marks Hospital 267 E Traverse Point Dr - Jordan Valley Medical Draper UT. 84020 Bosworth, Darin G MD University of Utah Health Center p 801.553.8300 Wasatch Pediatrics - 81 N Mario Capecchi Dr Southpoint Salt Lake City UT. 84113 Buchi, Karen F MD Bexfield, Nathan A MD 9071 S 1300 W p 801.213.3599 University of Utah Health University of Utah Health Ste 301 100 N Mario Capecchi Dr 5126 W Daybreak Pkwy West Jordan UT. 84088 Broadbent, Kenneth R MD Salt Lake City UT. 84113 Ste 600 p 801.565.1162 Wasatch Pediatrics - St p 801.662.1000 South Jordan UT. 84009 Marks p 801.213.4500 Hospital Affiliation 1140 E 3900 S Primary Childrens Diabetes - St Marks Hospital Ste 360 3773 W 12600 S Hospital Affiliation - Jordan Valley Medical Salt Lake City UT. 84124 Riverton UT. 84065 - University of Utah Hospital Center p 801.264.8686 p 801.662.1000

Bierer, Ryann MD Botto, Lorenzo D MD Hospital Affiliation University of Utah Health University of Utah Health University of Utah Health - St Marks Hospital 50 N Medical Dr 100 N Mario Capecchi Dr 100 N Mario Capecchi Dr Salt Lake City UT. 84132 Salt Lake City UT. 84113 Salt Lake City UT. 84113 Brogli, Julia C MD p 801.581.2205 p 801.662.4100 p 801.213.3599 Wasatch Pediatrics - Cottonwood Primary Childrens Hospital 50 N Medical Dr 1275 E Fairfax Rd 5770 S 250 E Physicians Salt Lake City UT. 84132 Salt Lake City UT. 84103 Ste 290 81 N Mario Capecchi Dr p 801.581.2121 p 801.587.2255 Murray UT. 84107 Salt Lake City UT. 84113 p 801.747.8700 p 801.662.1000 5121 S Cottonwood St 50 N Medical Dr Clinic 1 Salt Lake City UT. 84107 Salt Lake City UT. 84132 Hospital Affiliation Butterfield, Russell J MD p 801.507.7000 p 801.213.3599 - Primary Childrens Hospital University of Utah Health - St Marks Hospital 175 N Medical Dr E Salt Lake City UT. 84132 p 801.585.7575

348 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 81 N Mario Capecchi Dr Carey, John C MD 3773 W 12600 S Coleby, Craig A MD Salt Lake City UT. 84113 University of Utah Health Ste 300 Granger Medical Clinic p 801.587.7575 100 N Mario Capecchi Dr Riverton UT. 84065 11724 S State St Salt Lake City UT. 84113 p 801.581.2121 Draper UT. 84020 Hospital Affiliation p 801.213.3599 p 801.576.2000 - University of Utah Hospital 50 N Medical Dr 1275 E Fairfax Rd Salt Lake City UT. 84132 12391 S 4000 W Byas, Kamisha A MD Salt Lake City UT. 84103 p 801.213.2700 Riverton UT. 84065 University Of Utah Health p 801.587.2255 p 801.302.1700 100 N Mario Capecchi Dr Hospital Affiliation Salt Lake City UT. 84113 50 N Medical Dr Clinic 1 - University of Utah Hospital Hospital Affiliation p 801.662.1234 Salt Lake City UT. 84132 - Riverton Childrens Unit p 801.213.3599 Chamberlain, Michelle A Operated by Primary Childrens Medical Center Hospital Affiliation MD - Jordan Valley Medical - University of Utah Hospital 81 N Mario Capecchi Dr Wasatch Pediatrics - Center Salt Lake City UT. 84113 Willow Creek - Lone Peak Hospital Campbell, Kristine A MD p 801.213.3599 7138 S 2000 E University of Utah Health Ste 106 Coor, Cynthia L MD 100 N Mario Capecchi Dr Carmack, Cynthia L MD Salt Lake City UT. 84121 The Health Spot Salt Lake City UT. 84113 Comfort Care Pediatrics p 801.942.1800 10011 Centennial Pkwy p 801.662.1000 495 E 4500 S Ste 350 Ste 200 Hospital Affiliation Sandy UT. 84070 3690 S Main St Salt Lake City UT. 84107 - St Marks Hospital p 801.566.5350 Salt Lake City UT. 84132 p 801.595.8844 p 801.464.8929 Chapman, Dale L MD Cornwall, Kylie MD Hospital Affiliation Wasatch Pediatrics - Wasatch Pediatrics - Primary Childrens Hospital - St Marks Hospital Cottonwood Cottonwood 3773 W 12600 S 5770 S 250 E 5770 S 250 E Riverton UT. 84065 Carpenter, Kyleen C MD Ste 290 Ste 290 p 801.285.1285 South Summit Pediatrics Murray UT. 84107 Salt Lake City UT. 84107 267 E Traverse Point Dr p 801.747.8700 p 801.747.8700 University of Utah Health Draper UT. 84020 50 N Medical Dr p 801.553.8300 Hospital Affiliation Hospital Affiliation Salt Lake City UT. 84132 - St Marks Hospital - Primary Childrens Hospital p 801.581.2205 Hospital Affiliation - Jordan Valley Medical - St Marks Hospital - Lone Peak Hospital Center Primary Childrens Hospital Cox, Jennifer A MD 81 N Mario Capecchi Dr *Carver, Jeanlee F APRN Clayton, Daniel B MD Sunnyside Pediatrics Salt Lake City UT. 84113 Primary Childrens Hospital Families First Pediatrics 24 S 1100 E p 801.662.3606 3773 W 12600 S 1320 W S Jordan Pkwy Ste 301 Riverton UT. 84065 South Jordan UT. 84095 Salt Lake City UT. 84102 8282 S 2200 W p 801.662.3606 p 801.254.9700 p 801.521.2640 West Jordan UT. 84088 p 385.468.4580 81 N Mario Capecchi Dr 4651 W 13400 S Hospital Affiliation Salt Lake City UT. 84113 Ste 100 - Primary Childrens Hospital Hospital Affiliation p 801.662.3606 Herriman UT. 84096 - Salt Lake Regional Medical - University of Utah Hospital p 801.987.8541 Center 8282 S 2200 W Carbone, Paul S MD West Jordan UT. 84088 Hospital Affiliation Cox, Matthew N MD University of Utah Health p 385.468.4580 - Jordan Valley Medical Families First Pediatrics 100 N Mario Capecchi Dr Center 1320 W S Jordan Pkwy Salt Lake City UT. 84113 Hospital Affiliation South Jordan UT. 84095 p 801.587.2255 - Primary Childrens Hospital Cline, Jeffrey W MD p 801.254.9700 - Lakeview Hospital University of Utah Health 50 N Medical Dr - Ogden Regional Medical 7495 S State St 4651 W 13400 S Salt Lake City UT. 84132 Center Midvale UT. 84047 Ste 100 p 801.581.2205 p 801.213.9400 Herriman UT. 84096 Cervantez, DeeAnn APRN p 801.987.8541 81 N Mario Capecchi Dr University of Utah Health Hospital Affiliation Salt Lake City UT. 84113 100 N Mario Capecchi Dr - Jordan Valley Medical Hospital Affiliation p 801.213.3599 Salt Lake City UT. 84113 Center - Jordan Valley Medical p 801.662.5555 - St Marks Hospital Center - University of Utah Hospital

349 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Crowell, Kody R MD 3690 S Main St 3773 W 12600 S 4651 W 13400 S Families First Pediatrics Salt Lake City UT. 84115 Riverton UT. 84065 Ste 100 1320 W S Jordan Pkwy p 801.464.8929 p 801.213.3599 Herriman UT. 84096 South Jordan UT. 84095 p 801.987.8541 p 801.254.9700 50 N Medical Dr 81 N Mario Capecchi Dr Salt Lake City UT. 84132 Salt Lake City UT. 84113 Faust, Barbara NP 4651 W 13400 S p 801.581.2205 p 801.213.3599 University of Utah Health Ste 100 81 N Mario Capecchi Dr Herriman UT. 84096 81 N Mario Capecchi Dr Hospital Affiliation Salt Lake City UT. 84113 p 801.987.8541 Salt Lake City UT. 84113 - University of Utah Hospital p 801.587.2255 p 801.213.3599 Hospital Affiliation Ellis, Michael MD Feindt, Karla A MD - Jordan Valley Medical Hospital Affiliation Wasatch Pediatrics - Wasatch Pediatrics - Center - University of Utah Hospital Southpoint Draper 9071 S 1300 W 114 E 12450 S Dangerfield, Shane C MD Diaz Ochu, Margarita MD Ste 301 Ste 100 University of Utah Health University of Utah Health West Jordan UT. 84088 Draper UT. 84020 100 N Mario Capecchi Dr 100 N Mario Capecchi Dr p 801.565.1162 p 801.523.3001 Salt Lake City UT. 84113 Salt Lake City UT. 84113 p 801.662.1000 p 801.662.1000 Hospital Affiliation Hospital Affiliation - Primary Childrens Hospital - Lone Peak Hospital 81 N Mario Capecchi Dr 50 N Medical Dr - St Marks Hospital Salt Lake City UT. 84113 Salt Lake City UT. 84132 *Feola, G G MD p 801.213.3599 p 801.581.2205 Ellzey, Allison R MD Intermountain Pediatric University of Utah Health Imaging Davis, Carly MD Hospital Affiliation 100 N Mario Capecchi Dr 100 Mario Capecchi Dr Granger Medical Clinic - Primary Childrens Hospital Salt Lake City UT. 84113 Salt Lake City UT. 84113 12391 S 4000 W p 801.587.2255 p 801.487.0451 Riverton UT. 84065 Donnelly, Ryan T MD p 801.302.1700 Wasatch Pediatrics - University Of Utah Health Intermountain Pediatric Willow Creek 81 N Mario Capecchi Dr Imaging Riverton 1250 E 3900 S 7138 S 2000 E Salt Lake City UT. 84113 3741 W 12600 S Ste 250 Ste 106 p 801.587.2255 Riverton UT. 84065 Salt Lake City UT. 84124 Salt Lake City UT. 84121 p 801.487.0451 p 801.268.6283 p 801.942.1800 Hospital Affiliation - University of Utah Hospital Firszt, Rafael MD 3725 W 4100 S Hospital Affiliation Tanner Memorial Clinic Salt Lake City UT. 84120 - St Marks Hospital Evers, Reed MD 5296 S Commerce Dr p 801.965.3600 Granger Medical Clinic Salt Lake City UT. 84107 Douglass, Matthew S DO 2965 W 3500 S p 801.773.4840 Hospital Affiliation University Of Utah Health West Valley City UT. 84119 - Jordan Valley Medical 50 N Medical Dr p 801.965.3600 Hospital Affiliation Center Salt Lake City UT. 84132 - University of Utah Hospital - Lone Peak Hospital p 801.581.2121 Eyre, Alyson MD - Mountain West Medical Granger Medical Clinic Flynn, Michael C MD Center 5121 S Cottonwood St 2965 W 3500 S University of Utah Health Murray UT. 84107 West Valley City UT. 84119 1525 W 2100 S DeLaO, Angela MD p 801.507.7000 p 801.965.3600 Salt Lake City UT. 84119 Wasatch Pediatrics - St p 801.213.8841 Marks Hospital Affiliation 3181 W 9000 S 1140 E 3900 S - University of Utah Hospital West Jordan UT. 84088 3730 W 4700 S Ste 360 p 801.569.5600 Salt Lake City UT. 84129 Salt Lake City UT. 84124 Eisenberg, Jonathan MD p 801.213.9200 p 801.264.8686 University Of Utah Health Hospital Affiliation 100 N Mario Capecchi Dr - Jordan Valley Medical Hospital Affiliation Hospital Affiliation Salt Lake City UT. 84113 Center - Jordan Valley Medical - Primary Childrens Hospital p 801.662.1234 - Jordan Valley Medical Center - St Marks Hospital Center West Valley Campus - St Marks Hospital Hospital Affiliation - St Marks Hospital - University of Utah Hospital Dell, Adam W MD - University of Utah Hospital University of Utah Health Families First Pediatrics Fox, Rita K MD 100 N Mario Capecchi Dr Elias, Abdallah F MD 1320 W S Jordan Pkwy Comfort Care Pediatrics Salt Lake City UT. 84113 University Of Utah Health South Jordan UT. 84095 495 E 4500 S p 801.662.1000 100 N Mario Capecchi Dr p 801.254.9700 Ste 200 Salt Lake City UT. 84113 Salt Lake City UT. 84107 p 801.213.3599 p 801.595.8844

Hospital Affiliation - St Marks Hospital 350 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Franchek-Roa, Kathleen M Center Hayes, Katherine G MD Hobson, Winifred L MD MD University Of Utah Health University of Utah Health University of Utah Health Greenberg, Richard A MD 100 N Mario Capecchi Dr 100 N Mario Capecchi Dr 100 N Mario Capecchi Dr South Summit Pediatrics Salt Lake City UT. 84113 Salt Lake City UT. 84113 Salt Lake City UT. 84113 267 E Traverse Point Dr p 801.213.2995 p 801.662.1000 p 801.662.1000 Draper UT. 84020 p 801.553.8300 50 N Medical Dr 50 N Medical Dr 50 N Medical Dr Salt Lake City UT. 84132 Salt Lake City UT. 84132 Salt Lake City UT. 84132 Hospital Affiliation p 801.213.2995 p 801.581.2205 p 801.581.2205 - Primary Childrens Hospital - Riverton Childrens Unit Hospital Affiliation Holbrook, Suzanne T MD Frick, Glen S MD Operated by Primary Childrens Medical- University Center of Utah Hospital Sunnyside Pediatrics Comfort Care Pediatrics - Jordan Valley Medical 24 S 1100 E 495 E 4500 S Center Heise, Amber S MD Ste 301 Ste 200 - Lone Peak Hospital Community Health Centers Salt Lake City UT. 84102 Salt Lake City UT. 84107 4745 S 3200 W p 801.521.2640 p 801.595.8844 Griffin, Katherine NP Salt Lake City UT. 84129 Granger Medical Clinic p 801.964.6214 Hospital Affiliation Hospital Affiliation 2965 W 3500 S - Salt Lake Regional Medical - St Lukes Wood River Medical West Valley City UT. 84119 Hemond, Joni A MD Center Center p 801.965.3600 University of Utah Health 100 N Mario Capecchi Dr Hornyik, Galina R MD Garcia, Kathy S MD Hansen, Kimberly MD Salt Lake City UT. 84113 Wasatch Pediatrics - Copperview Medical Center Wasatch Pediatrics - p 801.662.1000 Draper 3556 W 9800 S Draper 114 E 12450 S Ste 101 114 E 12450 S 3690 S Main St Ste 100 South Jordan UT. 84095 Ste 100 Salt Lake City UT. 84132 Draper UT. 84020 p 801.567.9780 Draper UT. 84020 p 801.464.8929 p 801.523.3001 p 801.523.3001 Hospital Affiliation 50 N Medical Dr Hospital Affiliation - Jordan Valley Medical Hospital Affiliation Salt Lake City UT. 84132 - Lone Peak Hospital Center - Lone Peak Hospital p 801.581.2205 - Lone Peak Hospital Hull, Maggie S MD Harousseau, Mark MD Herman, Bruce E MD Community Health Centers Garvin, Daniel MD University Of Utah Health University of Utah Health 4745 S 3200 W University of Utah Health 100 N Mario Capecchi Dr 100 N Mario Capecchi Dr Taylorsville UT. 84118 5126 W Daybreak Pkwy Salt Lake City UT. 84113 Salt Lake City UT. 84113 p 801.964.6214 Ste 600 p 801.662.3645 p 801.662.1000 South Jordan UT. 84009 Hospital Affiliation p 801.213.4500 3450 S 900 W 50 N Medical Dr - Primary Childrens Hospital Salt Lake City UT. 84119 Salt Lake City UT. 84132 Giardino, Angelo P MD p 801.261.2060 p 801.581.2205 Hurley, David C MD University of Utah Health Wasatch Pediatrics - 100 N Mario Capecchi Dr 3723 W 12600 S Hospital Affiliation Cottonwood Salt Lake City UT. 84113 Riverton UT. 84065 - Primary Childrens Hospital 5770 S 250 E p 801.662.1000 p 801.285.4000 - University of Utah Hospital Ste 290 Murray UT. 84107 Goldman Luthy, Jennifer A 51 W 3900 S Hiatt, Virginia L NP p 801.747.8700 MD Salt Lake City UT. 84107 Sunnyside Pediatrics University of Utah Health p 801.662.1000 24 S 1100 E Hospital Affiliation 100 N Mario Capecchi Dr Ste 301 - St Marks Hospital Salt Lake City UT. 84113 Hospital Affiliation Salt Lake City UT. 84102 - Jordan Valley Medical p 801.662.1000 - University of Utah Hospital p 801.521.2640 Center

50 N Medical Dr Harris, Chris J PA-C Hospital Affiliation Inman, Christi J MD Salt Lake City UT. 84132 University of Utah Health - Primary Childrens Hospital University of Utah Health p 801.581.2205 100 N Mario Capecchi Dr - Salt Lake Regional Medical 100 N Mario Capecchi Dr Salt Lake City UT. 84113 Center Salt Lake City UT. 84113 Hospital Affiliation p 801.662.5600 p 801.213.3599 - University of Utah Hospital Hightower, Robert R MD 3773 W 12600 S Murray Pediatrics 3773 W 12600 S Goodwin, Leslie MD Riverton UT. 84065 164 E 5900 S Riverton UT. 84065 Wasatch Pediatrics - p 801.285.1440 Ste A112 p 801.213.3599 Southpoint Murray UT. 84107 9071 S 1300 W p 801.262.2673 Ste 301 West Jordan UT. 84088 Hospital Affiliation p 801.565.1162 - St Marks Hospital

Hospital Affiliation - St Marks Hospital 351 *The PPO- Jordan Agreement Valley with Medical this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 81 N Mario Capecchi Dr Johnson, Sara E MD Kincaid, Rebecca MD Kramer, Bradley DO Salt Lake City UT. 84113 Wasatch Pediatrics - Wasatch Pediatrics - Wasatch Pediatrics - St p 801.213.3599 Draper Cottonwood Marks 114 E 12450 S 5770 S 250 E 1140 E 3900 S *Intermountain Pediatric Ste 100 Ste 290 Ste 360 *Imaging Draper UT. 84020 Salt Lake City UT. 84107 Salt Lake City UT. 84124 100 Mario Capecchi Dr p 801.523.3001 p 801.747.8700 p 801.264.8686 Salt Lake City UT. 84113 p 801.487.0451 Comfort Care Pediatrics Kingston, Joseph L DO Hospital Affiliation 495 E 4500 S Health First Family - St Marks Hospital *Intermountain Pediatric Ste 200 Medicine - Primary Childrens Hospital *Imaging Riverton Salt Lake City UT. 84107 1561 W 7000 S 3741 W 12600 S p 801.595.8844 Ste 200 LaMere, Richard G MD Riverton UT. 84065 West Jordan UT. 84088 University of Utah Health p 801.487.0451 Hospital Affiliation p 801.397.8707 1138 E Wilmington Ave - St Marks Hospital Salt Lake City UT. 84106 Isenberg, Philip N MD - Primary Childrens Hospital Hospital Affiliation p 801.581.2000 University of Utah Health - Lone Peak Hospital 7495 S State St Jolma, Catherine D MD - Jordan Valley Medical 1525 W 2100 S Midvale UT. 84047 Wasatch Pediatrics - St Center Salt Lake City UT. 84119 p 801.213.9400 Marks p 801.213.8841 1140 E 3900 S Kleinschmit, Kristi K MD Hospital Affiliation Ste 360 University of Utah Health Hospital Affiliation - Jordan Valley Medical Salt Lake City UT. 84124 1138 E Wilmington Ave - University of Utah Hospital Center p 801.264.8686 Salt Lake City UT. 84106 - St Marks Hospital p 801.213.8845 LaPine, Timothy R MD - University of Utah Hospital Hospital Affiliation Pediatrix Medical Group - St Marks Hospital 1280 E Stringham Ave 1200 E 3900 S Jackson, Jeffrey B MD Salt Lake City UT. 84106 Salt Lake City UT. 84124 Southwest Childrens Clinic Jones, Jake MD p 801.581.7951 p 801.268.7111 8822 S Redwood Rd Wasatch Pediatrics - Ste C-211 Cottonwood 50 N Medical Dr 3460 S Pioneer Pkwy West Jordan UT. 84088 5770 S 250 E Salt Lake City UT. 84132 West Valley City UT. 84120 p 801.563.1975 Ste 290 p 801.585.1575 p 801.964.3100 Salt Lake City UT. 84107 Hospital Affiliation p 801.747.8700 501 S Chipeta Way Hospital Affiliation - Jordan Valley Medical Salt Lake City UT. 84108 - St Marks Hospital Center Hospital Affiliation p 801.587.3287 - Lone Peak Hospital - Primary Childrens Hospital - St Marks Hospital - Jordan Valley Medical - Lone Peak Hospital - Primary Childrens Hospital Wasatch Pediatrics - Center Willow Creek Johnson, Catherine B APRN Kagen, Zainab N MD 7138 S 2000 E Lamb, Sara M MD South Summit Pediatrics University of Utah Health Ste 106 University of Utah Health 267 E Traverse Point Dr 100 N Mario Capecchi Dr Salt Lake City UT. 84121 50 N Medical Dr Draper UT. 84020 Salt Lake City UT. 84113 p 801.942.1800 Salt Lake City UT. 84132 p 801.553.8300 p 801.662.3645 p 801.581.7818 Korenberg, Julie R MD Hospital Affiliation 1280 E Stringham Ave University of Utah Health Primary Childrens Spina - Lone Peak Hospital Salt Lake City UT. 84106 100 N Mario Capecchi Dr Bifida p 801.662.1000 Salt Lake City UT. 84113 81 N Mario Capecchi Dr Johnson, Michael R MD p 801.213.3599 Salt Lake City UT. 84113 Families First Pediatrics 50 N Medical Dr p 801.662.1675 1320 W S Jordan Pkwy Salt Lake City UT. 84132 50 N Medical Dr South Jordan UT. 84095 p 801.581.2205 Salt Lake City UT. 84132 Hospital Affiliation p 801.254.9700 p 801.585.6387 - University of Utah Hospital Hospital Affiliation 4651 W 13400 S - University of Utah Hospital 729 S Arapeen Dr Lash, Kevin B MD Ste 100 Salt Lake City UT. 84108 Wasatch Pediatrics - Herriman UT. 84096 Kelly, Colin K MD p 801.585.6387 Southpoint p 801.987.8541 1250 E 3900 S 9071 S 1300 W Ste 250 81 N Mario Capecchi Dr Ste 301 Hospital Affiliation Salt Lake City UT. 84125 Salt Lake City UT. 84113 West Jordan UT. 84088 - Jordan Valley Medical p 801.268.6283 p 801.213.3599 p 801.565.1162 Center Hospital Affiliation - St Marks Hospital - Jordan Valley Medical Center 352 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Le, Trung M MD Longo, Nicola MD,PhD - Lone Peak Hospital 1280 E Stringham Ave Foothill Family Clinic University of Utah Health Salt Lake City UT. 84106 13953 S Bangerter Pkwy 100 N Mario Capecchi Dr McElligott, Kathleen M MD p 801.662.1000 Draper UT. 84020 Salt Lake City UT. 84113 Comfort Care Pediatrics p 385.900.4090 p 801.213.3599 4546 S 815 W 13747 S Redwood Rd Ste 204 Riverton UT. 84065 2295 Foothill Dr 1275 E Fairfax Rd Taylorsville UT. 84123 p 801.662.1000 Salt Lake City UT. 84109 Salt Lake City UT. 84103 p 801.595.8844 p 801.486.3021 p 801.587.2255 University Of Utah Health Wasatch Pediatrics - 3450 S 900 W Hospital Affiliation 50 N Medical Dr Clinic 1 Cottonwood West Valley City UT. 84119 - Jordan Valley Medical Salt Lake City UT. 84132 5770 S 250 E p 801.261.2060 Center p 801.213.3599 Ste 290 Murray UT. 84107 3690 S Main St Lei, Paul S MD 81 N Mario Capecchi Dr p 801.747.8700 Salt Lake City UT. 84115 South Summit Pediatrics Salt Lake City UT. 84113 p 801.464.8929 267 E Traverse Point Dr p 801.213.3599 Hospital Affiliation Draper UT. 84020 - University of Utah Hospital University of Utah Health p 801.553.8300 Lynch, Steven M MD - St Marks Hospital 50 N Medical Dr Wasatch Pediatrics - Salt Lake City UT. 84132 Hospital Affiliation Willow Creek McNaught, Teresa NP p 801.662.1000 - Lone Peak Hospital 7138 S 2000 E Wasatch Pediatrics - - Jordan Valley Medical Ste 106 Southpoint University Of Utah Health Center Salt Lake City UT. 84121 9071 S 1300 W 51 W 3900 S - Mountain Point Medical p 801.942.1800 Ste 301 Salt Lake City UT. 84107 Center West Jordan UT. 84088 p 801.662.1000 Hospital Affiliation p 801.565.1162 Liu, Diane MD - St Marks Hospital University of Utah Health University of Utah Health Mccrate, Sara M MD 81 N Mario Capecchi Dr 100 N Mario Capecchi Dr Marriott, Woodrow C MD University Of Utah Health Salt Lake City UT. 84113 Salt Lake City UT. 84113 Rose Creek Pediatrics 100 N Mario Capecchi Dr p 801.213.3599 p 801.662.1000 4121 W 13400 S Unit B Salt Lake City UT. 84113 Herriman UT. 84096 p 801.662.1234 Hospital Affiliation 50 N Medical Dr p 801.446.0102 - University of Utah Hospital Salt Lake City UT. 84132 Hospital Affiliation p 801.581.2205 Mashkuri, Pari MD - University of Utah Hospital Moresco, Benjamin L MD Southwest Childrens Clinic University Of Utah Health Hospital Affiliation 8822 S Redwood Rd Memmott, Jim C MD 100 N Mario Capecchi Dr - Primary Childrens Hospital Ste C-211 Wasatch Pediatrics - Salt Lake City UT. 84113 West Jordan UT. 84088 Willow Creek p 801.662.3645 *Lloyd, Michael B MD p 801.563.1975 7138 S 2000 E Primary Childrens Hospital Ste 106 3723 W 12600 S 100 N Mario Capecchi Dr Hospital Affiliation Salt Lake City UT. 84121 Riverton UT. 84065 Salt Lake City UT. 84113 - Jordan Valley Medical p 801.942.1800 p 801.285.4000 p 801.662.1000 Center - Primary Childrens Hospital Hospital Affiliation 50 N Medical Dr University of Utah Health - Lone Peak Hospital - St Marks Hospital Salt Lake City UT. 84132 3773 W 12600 S p 801.662.3770 Riverton UT. 84065 *Maves, Constance K MD Montes, Molly L MD p 801.587.7575 Intermountain Pediatric Southwest Childrens Clinic University of Utah Health Imaging 8822 S Redwood Rd 81 N Mario Capecchi Dr 81 N Mario Capecchi Dr 100 Mario Capecchi Dr Ste C-211 Salt Lake City UT. 84113 Salt Lake City UT. 84113 Salt Lake City UT. 84113 West Jordan UT. 84088 p 801.662.3770 p 801.587.7575 p 801.487.0451 p 801.563.1975 Hospital Affiliation Hospital Affiliation Intermountain Pediatric Hospital Affiliation - University of Utah Hospital - Primary Childrens Hospital Imaging Riverton - Jordan Valley Medical 3741 W 12600 S Center Muniyappa, Bhanu MD Lofgren, David N MD Riverton UT. 84065 - Primary Childrens Hospital University of Utah Health 1434 E 9400 S p 801.487.0451 - Lone Peak Hospital 100 N Mario Capecchi Dr Ste 100 Salt Lake City UT. 84113 Sandy UT. 84093 Maxwell, Joshua B MD Moore, Melissa A MD p 801.662.3645 p 801.572.9369 Southwest Childrens Clinic University of Utah Health 8822 S Redwood Rd 100 N Mario Capecchi Dr Ste C-211 Salt Lake City UT. 84113 West Jordan UT. 84088 p 801.662.1000 p 801.563.1975

Hospital Affiliation - Jordan Valley Medical Center 353 *The PPO Agreement with this provider is expressly between- Primary the ChildrensThird Party AdministratorHospital and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 3690 S Main St 3450 S 900 W Nguyen, Quang Tuyen T MD Omura, Terry H MD Salt Lake City UT. 84115 Salt Lake City UT. 84119 University of Utah Health Wasatch Pediatrics - p 801.464.8929 p 801.261.2060 100 N Mario Capecchi Dr Cottonwood Salt Lake City UT. 84113 5770 S 250 E 50 N Medical Dr 3660 S West Temple p 801.587.2255 Ste 290 Salt Lake City UT. 84132 Salt Lake City UT. 84115 Murray UT. 84107 p 801.581.2205 p 801.587.2525 1280 E Stringham Ave p 801.747.8700 Salt Lake City UT. 84106 Hospital Affiliation 3690 S Main St p 801.662.1000 Hospital Affiliation - University of Utah Hospital Salt Lake City UT. 84115 - St Marks Hospital p 801.464.8929 50 N Medical Dr - Jordan Valley Medical Murphy, Nancy A MD Salt Lake City UT. 84132 Center University of Utah Health 3723 W 12600 S p 801.581.2205 100 N Mario Capecchi Dr Riverton UT. 84065 Orchard, Anna G MD Salt Lake City UT. 84113 p 801.285.4000 81 N Mario Capecchi Dr Murray Pediatrics p 801.662.1000 Salt Lake City UT. 84113 164 E 5900 S 50 N Medical Dr p 801.213.3599 Ste A112 University Of Utah Health Salt Lake City UT. 84132 Murray UT. 84107 13747 S Redwood Rd p 801.581.2205 Hospital Affiliation p 801.262.2673 Riverton UT. 84065 - Primary Childrens Hospital p 801.662.1000 51 W 3900 S Hospital Affiliation Salt Lake City UT. 84107 Nielson, Amanda MD - Primary Childrens Hospital University of Utah Health p 801.662.1000 Wasatch Pediatrics - - St Marks Hospital 81 N Mario Capecchi Dr Cottonwood Salt Lake City UT. 84113 Hospital Affiliation 5770 S 250 E Ormsby, Sarah A MD p 801.213.3599 - University of Utah Hospital Ste 290 Wasatch Pediatrics - St Salt Lake City UT. 84107 Marks Murray, Kathryn M MD Nemeyer, Ronald MD p 801.747.8700 1140 E 3900 S University of Utah Health South Summit Pediatrics Ste 360 50 N Medical Dr 267 E Traverse Point Dr Hospital Affiliation Salt Lake City UT. 84124 Salt Lake City UT. 84132 Draper UT. 84020 - Primary Childrens Hospital p 801.264.8686 p 801.581.2205 p 801.553.8300 - St Marks Hospital Hospital Affiliation Hospital Affiliation Hospital Affiliation O Connor, Meghan M MD - St Marks Hospital - University of Utah Hospital - Lone Peak Hospital University of Utah Health 100 N Mario Capecchi Dr Ostergaard, Steve FNP Nelson, Bryan MD Newman, Erik MD Salt Lake City UT. 84113 Wasatch Pediatrics - Foothill Family Clinic University Of Utah Health p 801.662.1000 Southpoint 13953 S Bangerter Pkwy 100 N Mario Capecchi Dr 9071 S 1300 W Draper UT. 84020 Salt Lake City UT. 84113 1280 E Stringham Ave Ste 301 p 385.900.4090 p 801.581.2955 Salt Lake City UT. 84106 West Jordan UT. 84088 p 801.662.1000 p 801.565.1162 6360 S 3000 E 1280 E Stringham Ave Ste 100 Salt Lake City UT. 84106 50 N Medical Dr Owens, Cynthia S MD Salt Lake City UT. 84121 p 801.581.2955 Salt Lake City UT. 84132 Wasatch Pediatrics - St p 801.365.1032 p 801.581.2205 Marks 243 E 6100 S 1140 E 3900 S Hospital Affiliation Murray UT. 84107 OMara, Kathleen A MD Ste 360 - Primary Childrens Hospital p 801.581.2955 Wasatch Pediatrics - Salt Lake City UT. 84124 - Salt Lake Regional Medical Willow Creek p 801.264.8686 Center 50 N Medical Dr Clinic 7138 S 2000 E E12 Ste 106 Hospital Affiliation Nelson, Melanie MD Salt Lake City UT. 84132 Salt Lake City UT. 84121 - St Marks Hospital University Of Utah Health p 801.581.2955 p 801.942.1800 100 N Mario Capecchi Dr Ozbolt, Julia A MD Salt Lake City UT. 84113 81 N Mario Capecchi Dr Hospital Affiliation University of Utah Health p 801.662.1234 Salt Lake City UT. 84113 - St Marks Hospital 1525 W 2100 S p 801.213.3599 Salt Lake City UT. 84119 1280 E Stringham Ave Okubo, David MD p 801.213.8841 Salt Lake City UT. 84106 Hospital Affiliation 1995 W 9000 S p 801.662.1000 - University of Utah Hospital West Jordan UT. 84088 Hospital Affiliation p 801.566.9888 - Jordan Valley Medical Center Hospital Affiliation - St Marks Hospital - Jordan Valley Medical - University of Utah Hospital Center

354 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Packer, Alissa A MD 3181 W 9000 S 81 N Mario Capecchi Dr Wasatch Pediatrics - Wasatch Pediatrics - West Jordan UT. 84088 Salt Lake City UT. 84113 Southpoint Southpoint p 801.569.5600 p 801.213.3599 9071 S 1300 W 9071 S 1300 W Ste 301 Ste 301 348 E 4500 S *Primary Childrens Hospital West Jordan UT. 84088 West Jordan UT. 84088 Ste 200 *Specialty Clinics p 801.565.1162 p 801.565.1162 Salt Lake City UT. 84107 100 Mario Capecchi Dr p 801.262.9800 Salt Lake City UT. 84132 Rollins, Michael D MD Hospital Affiliation University of Utah Health - St Marks Hospital 5801 S Fashion Blvd Rahaniotis, Valerie L MD 100 N Mario Capecchi Dr - Jordan Valley Medical Ste 280 Southwest Childrens Clinic Salt Lake City UT. 84113 Center Murray UT. 84107 8822 S Redwood Rd p 801.662.2950 p 801.260.5864 Ste C-211 *Paula, Peterson NP West Jordan UT. 84088 University Of Utah Health Primary Childrens Hospital 7181 S Campus View Dr p 801.563.1975 3773 W 12600 S 100 N Mario Capecchi Dr West Jordan UT. 84084 Riverton UT. 84065 Salt Lake City UT. 84113 p 801.965.3600 Hospital Affiliation p 801.285.1285 p 801.662.1000 - Jordan Valley Medical Hospital Affiliation Center University of Utah Health Primary Childrens Spina - St Marks Hospital - Primary Childrens Hospital 50 N Medical Dr Bifida - Lone Peak Hospital Salt Lake City UT. 84132 81 N Mario Capecchi Dr Petersen, Sarah C p 801.581.2121 Salt Lake City UT. 84113 University of Utah Health Ralston, Charles W MD p 801.662.1675 5126 W Daybreak Pkwy Wasatch Pediatrics - 81 N Mario Capecchi Dr Ste 600 Cottonwood Salt Lake City UT. 84113 Hospital Affiliation South Jordan UT. 84009 5770 S 250 E p 801.213.3599 - Primary Childrens Hospital p 801.213.4500 Ste 290 Murray UT. 84107 Rose Creek Pediatrics Peacock, Penny J MD Hospital Affiliation p 801.747.8700 4121 W 13400 S Unit B Parleys Primary Care - Jordan Valley Medical Herriman UT. 84096 Clinic Center Hospital Affiliation p 801.446.0102 2645 E Parleys Way - St Marks Hospital - St Marks Hospital Ste 200 - University of Utah Hospital - Jordan Valley Medical Roundy, Lindsi M MD Salt Lake City UT. 84109 Center Families First Pediatrics p 801.384.4730 Peterson, Mitchell MD 1320 W S Jordan Pkwy Families First Pediatrics Ramsey, Keith P DO South Jordan UT. 84095 Steward Medical Group 1320 W S Jordan Pkwy 8822 S Redwood Rd p 801.254.9700 Primary Care Murray South Jordan UT. 84095 Ste S103 5980 S Fashion Blvd p 801.254.9700 West Jordan UT. 84088 4651 W 13400 S Salt Lake City UT. 84107 p 801.253.2273 Ste 100 p 801.281.2668 4651 W 13400 S Herriman UT. 84096 Ste 100 Hospital Affiliation p 801.987.8541 Hospital Affiliation Herriman UT. 84096 - Jordan Valley Medical - Park City Hospital p 801.987.8541 Center Sandvig, Jenifer L MD - University of Utah Hospital Wasatch Pediatrics - St Phillips, Sandra A MD Rayes, Ahmad MD Marks Pennington, Mary J MD Sunnyside Pediatrics University Of Utah Health 1140 E 3900 S Granger Medical 24 S 1100 E 100 N Mario Capecchi Dr Ste 360 Specialists Ste 301 Salt Lake City UT. 84113 Salt Lake City UT. 84124 11724 S State St Salt Lake City UT. 84102 p 801.662.4700 p 801.264.8686 Draper UT. 84020 p 801.521.2640 p 801.576.2050 1950 Cir of Hope Dr Hospital Affiliation Hospital Affiliation Salt Lake City UT. 84112 - St Marks Hospital 12391 S 4000 W - Salt Lake Regional Medical p 801.587.4745 Riverton UT. 84096 Center Sawicki, Jonathan G MD p 801.302.1700 50 N Medical Dr University Of Utah Health Pohl, John F MD Salt Lake City UT. 84132 1950 Cir of Hope Dr 1880 S 1045 W University of Utah Health p 801.662.4700 Salt Lake City UT. 84112 Salt Lake City UT. 84104 3773 W 12600 S p 801.585.0100 p 801.290.3406 Riverton UT. 84065 Ridge, Nathanael W PhD p 801.662.2900 Wasatch Pediatrics - 50 N Medical Dr Clinic 2965 W 3500 S Cottonwood E12 West Valley City UT. 84119 5770 S 250 E Salt Lake City UT. 84132 p 801.965.3600 Ste 290 p 801.581.7818 Murray UT. 84107 p 801.747.8700

355 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 501 S Chipeta Way Solomon, Margaret H MD Stampfl, Daniel R MD Salt Lake City UT. 84108 Shayota, Brian MD University of Utah Health Wasatch Pediatrics - p 801.583.2500 University Of Utah Health 1525 W 2100 S Draper 100 N Mario Capecchi Dr Salt Lake City UT. 84119 114 E 12450 S 85 N Medical Dr Salt Lake City UT. 84113 p 801.213.8841 Ste 100 Salt Lake City UT. 84112 p 801.213.3599 Draper UT. 84020 p 801.581.7818 Hospital Affiliation p 801.523.3001 3773 W 12600 S - Jordan Valley Medical Schiffman, Joshua D MD Riverton UT. 84065 Center Hospital Affiliation University of Utah Health p 801.213.3599 - St Marks Hospital - Lone Peak Hospital 100 N Mario Capecchi Dr - University of Utah Hospital Salt Lake City UT. 84113 50 N Medical Dr Clinic 1 Steele, Julie S FNP p 801.662.4700 Salt Lake City UT. 84132 Sorenson, Carly DO University of Utah Health p 801.213.3599 Wasatch Pediatrics - 100 N Mario Capecchi Dr 1950 Cir of Hope Dr Willow Creek Salt Lake City UT. 84113 Salt Lake City UT. 84112 University of Utah Health 7138 S 2000 E p 801.662.1000 p 801.587.4745 81 N Mario Capecchi Dr Ste 106 Salt Lake City UT. 84113 Salt Lake City UT. 84121 3450 S 900 W Schlichter, Gary W MD p 801.213.3599 p 801.942.1800 Salt Lake City UT. 84119 Murray Pediatrics p 801.261.2060 164 E 5900 S Hospital Affiliation Southerland, Andrea FNP Ste A112 - University of Utah Hospital New Horizon Medical Care 3690 S Main St Murray UT. 84107 1273 W 12600 S Salt Lake City UT. 84132 p 801.262.2673 Siddiqi, Faizi A MD Ste 402 p 801.464.8929 University of Utah Health Riverton UT. 84065 Hospital Affiliation 100 N Mario Capecchi Dr p 801.254.4600 50 N Medical Dr - St Marks Hospital Salt Lake City UT. 84113 Salt Lake City UT. 84132 - Salt Lake Regional Medical p 801.662.1700 Southwest Childrens Clinic p 801.581.2205 Center 8822 S Redwood Rd 50 N Medical Dr Ste C-211 Stipelman, Carole H MD Schriewer, Sharon K MD Salt Lake City UT. 84132 West Jordan UT. 84088 University of Utah Health Sunnyside Pediatrics p 801.581.7719 p 801.563.1975 100 N Mario Capecchi Dr 24 S 1100 E Salt Lake City UT. 84113 Ste 301 81 N Mario Capecchi Dr Spackman, Jared P PA p 801.662.1000 Salt Lake City UT. 84102 Salt Lake City UT. 84113 University of Utah Health p 801.521.2640 p 801.213.3599 3690 S Main St 50 N Medical Dr Salt Lake City UT. 84115 Salt Lake City UT. 84132 Hospital Affiliation Hospital Affiliation p 801.213.4500 p 801.581.2205 - Primary Childrens Hospital - University of Utah Hospital - Salt Lake Regional Medical 50 N Medical Dr Hospital Affiliation Center Sizakoti, Kirti MD Salt Lake City UT. 84132 - University of Utah Hospital Southwest Childrens Clinic p 801.581.2292 Shakib, Julie DO 8822 S Redwood Rd Stowers, Kimberly B MD University of Utah Health Ste C-211 Hospital Affiliation University Of Utah Health 100 N Mario Capecchi Dr West Jordan UT. 84088 - Jordan Valley Medical 1280 E Stringham Ave Salt Lake City UT. 84113 p 801.563.1975 Center Salt Lake City UT. 84106 p 801.662.1000 p 801.662.1000 Hospital Affiliation Srinivas, Ganga L MD 50 N Medical Dr - Jordan Valley Medical University of Utah Health 3690 S Main St Salt Lake City UT. 84132 Center 100 N Mario Capecchi Dr Salt Lake City UT. 84115 p 801.581.2205 - Primary Childrens Hospital Salt Lake City UT. 84113 p 801.464.8929 - Lone Peak Hospital p 801.662.1000 Shakula, John R MD 50 N Medical Dr 9720 S 1300 E Smith, Elizabeth R MD 50 N Medical Dr Salt Lake City UT. 84132 Ste W120 University of Utah Health Salt Lake City UT. 84132 p 801.581.2205 Sandy UT. 84094 100 N Mario Capecchi Dr p 801.581.2205 p 801.571.0423 Salt Lake City UT. 84113 Hospital Affiliation p 801.662.1000 Hospital Affiliation - University of Utah Hospital Hospital Affiliation - Primary Childrens Hospital - Primary Childrens Hospital 50 N Medical Dr Swensen, Paul H MD Salt Lake City UT. 84132 *Srivastava, Rajendu MD Sunnyside Pediatrics Shapiro, Mary E MD p 801.581.2205 Primary Childrens Hospital 24 S 1100 E University of Utah Health 100 N Mario Capecchi Dr Ste 301 3730 W 4700 S Salt Lake City UT. 84113 Salt Lake City UT. 84102 West Valley City UT. 84129 p 801.662.1000 p 801.521.2640 p 801.213.9200 Hospital Affiliation Hospital Affiliation - Salt Lake Regional Medical - Jordan Valley Medical Center Center - St Marks Hospital 356 *The PPO- University Agreement of with Utah this Hospital provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Swinton, Cameron H MD Vogt, Jennifer E MD 50 N Medical Dr Pediatrix Medical Group Pediatric Sleep University of Utah Health Salt Lake City UT. 84132 1200 E 3900 S Medicine-Department of 3730 W 4700 S p 801.581.2205 Salt Lake City UT. 84124 University of Utah West Valley City UT. 84129 p 801.268.7111 100 N Mario Capecchi Dr p 801.213.9200 Hospital Affiliation Salt Lake City UT. 84113 - University of Utah Hospital Hospital Affiliation p 743.134.268 Hospital Affiliation - St Marks Hospital - University of Utah Hospital Whittemore, Kerry E MD - Lone Peak Hospital Vala, Aarti MD University of Utah Health - Jordan Valley Medical University of Utah Health Wasatch Pediatrics - 1525 W 2100 S Center 100 N Mario Capecchi Dr Draper Salt Lake City UT. 84119 Salt Lake City UT. 84113 114 E 12450 S p 801.213.8841 Terashima, Robert S MD p 801.662.1000 Ste 100 8925 S 2700 W Draper UT. 84020 5126 W Daybreak Pkwy West Jordan UT. 84088 1280 E Stringham Ave p 801.523.3001 Ste 600 p 801.566.6200 Salt Lake City UT. 84106 South Jordan UT. 84009 p 801.662.1000 Wasatch Pediatrics - St p 801.213.4500 Hospital Affiliation Marks - Jordan Valley Medical Verma, Anupam R MD 1140 E 3900 S 7495 S State St Center University of Utah Health Ste 360 Midvale UT. 84047 - Jordan Valley Medical 100 N Mario Capecchi Dr Salt Lake City UT. 84124 p 801.213.9400 Center West Valley Campus Salt Lake City UT. 84113 p 801.264.8686 p 801.662.4700 Hospital Affiliation Thomas, Mary W NP Wasatch Pediatrics - - University of Utah Hospital Wasatch Pediatrics - Viskochil, David H MD,PhD Cottonwood Southpoint University of Utah Health 5770 S 250 E Wilkerson, Julie I MD 9071 S 1300 W 100 N Mario Capecchi Dr Ste 290 Granger Medical Clinic Ste 301 Salt Lake City UT. 84113 Salt Lake City UT. 84107 2965 W 3500 S West Jordan UT. 84088 p 801.213.3599 p 801.747.8700 West Valley City UT. 84119 p 801.565.1162 p 801.965.3600 1275 E Fairfax Rd Wasatch Pediatrics - Thomas, Tiffany A MD Salt Lake City UT. 84103 Willow Creek 3181 W 9000 S Families First Pediatrics p 801.587.2255 7138 S 2000 E West Jordan UT. 84088 1320 W S Jordan Pkwy Ste 106 p 801.569.5600 South Jordan UT. 84095 3773 W 12600 S Salt Lake City UT. 84121 p 801.254.9700 Riverton UT. 84065 p 801.942.1800 Hospital Affiliation p 801.213.3599 - Jordan Valley Medical 4651 W 13400 S Wasatch Pediatrics - Center Ste 100 50 N Medical Dr Clinic 1 Southpoint - Jordan Valley Medical Herriman UT. 84096 Salt Lake City UT. 84132 9071 S 1300 W Center West Valley Campus p 801.987.8541 p 801.213.3599 Ste 301 - St Marks Hospital West Jordan UT. 84088 Hospital Affiliation 81 N Mario Capecchi Dr p 801.565.1162 Winter, Sarah L MD - Jordan Valley Medical Salt Lake City UT. 84113 University of Utah Health Center p 801.213.3599 Waterhouse, Lulu MD 100 N Mario Capecchi Dr Wasatch Pediatrics - Salt Lake City UT. 84113 Thomsen, William C MD Vlam, Sheri L NP Willow Creek p 801.587.2255 University of Utah Health Families First Pediatrics 7138 S 2000 E 100 N Mario Capecchi Dr 1320 W S Jordan Pkwy Ste 106 50 N Medical Dr Salt Lake City UT. 84113 South Jordan UT. 84095 Salt Lake City UT. 84121 Salt Lake City UT. 84132 p 801.662.4700 p 801.254.9700 p 801.942.1800 p 801.581.2205

Hospital Affiliation South Summit Pediatrics Hospital Affiliation 81 N Mario Capecchi Dr - Primary Childrens Hospital 267 E Traverse Point Dr - Primary Childrens Hospital Salt Lake City UT. 84113 Draper UT. 84020 - St Marks Hospital p 801.587.2255 Thorell, Emily A MD p 801.553.8300 University of Utah Health Watson, Kira C MD Wirkus, Paul E MD 81 N Mario Capecchi Dr Families First Pediatrics University Of Utah Health Wasatch Pediatrics - Salt Lake City UT. 84113 4651 W 13400 S 1280 E Stringham Ave Cottonwood p 801.213.3599 Ste 100 Salt Lake City UT. 84106 5770 S 250 E Herriman UT. 84096 p 801.581.7818 Ste 290 Tipton, Mary D MD p 801.987.8541 Murray UT. 84107 Copperview Medical Center p 801.747.8700 3556 W 9800 S Ste 101 Hospital Affiliation South Jordan UT. 84095 - Primary Childrens Hospital p 801.567.9780 - Jordan Valley Medical Center Hospital Affiliation - St Marks Hospital - Jordan Valley Medical Center 357 *The PPO- Lone Agreement Peak Hospitalwith this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Witt, Mark T MD 50 N Medical Dr Clinic 5 Pediatrix Medical Group Periodontist Families First Pediatrics Salt Lake City UT. 84132 11925 S State St McKeown, Sean B DDS 1320 W S Jordan Pkwy p 801.662.3930 Draper UT. 84020 University of Utah Health South Jordan UT. 84095 p 801.545.8000 3690 S Main St p 801.254.9700 Primary Childrens Hospital Salt Lake City UT. 84115 81 N Mario Capecchi Dr 1200 E 3900 S p 801.587.2525 4651 W 13400 S Salt Lake City UT. 84113 Salt Lake City UT. 84124 Ste 100 p 801.662.2100 p 801.268.7111 50 N Medical Dr Clinic 7 Herriman UT. 84096 Salt Lake City UT. 84132 p 801.987.8541 Hospital Affiliation 3460 S Pioneer Pkwy p 801.581.2220 - University of Utah Hospital West Valley City UT. 84120 Hospital Affiliation p 801.964.3100 530 S Wakara Way - Park City Hospital Yang, Cheryl MD Salt Lake City UT. 84108 - Primary Childrens Hospital University Of Utah Health 3580 W 9000 S p 801.587.6453 100 N Mario Capecchi Dr West Jordan UT. 84088 Wong, Adrianna Salt Lake City UT. 84113 p 801.561.8888 7495 S State St University Of Utah Health p 801.662.1234 Midvale UT. 84047 100 N Mario Capecchi Dr University of Utah Health p 801.213.9530 Salt Lake City UT. 84113 Hospital Affiliation 50 N Medical Dr p 801.662.1234 - University of Utah Hospital Salt Lake City UT. 84132 Hospital Affiliation p 801.581.2121 - University of Utah Hospital Hospital Affiliation Yanke, Peter MD - University of Utah Hospital University of Utah Health 5121 S Cottonwood St Thunell, Daniel DMD 3773 W 12600 S Salt Lake City UT. 84107 University of Utah Health Wonnacott, Monica C MD Riverton UT. 84065 p 801.507.7000 50 N Medical Dr Clinic 7 Granger Medical Clinic p 801.285.1801 Salt Lake City UT. 84132 11724 S State St Hospital Affiliation p 801.581.2220 Draper UT. 84020 Hospital Affiliation - University of Utah Hospital p 801.576.2000 - Primary Childrens Hospital 530 S Wakara Way Zobell, Sarah T APRN Salt Lake City UT. 84108 12391 S 4000 W Yost, Christian C MD University of Utah Health p 801.587.6453 Riverton UT. 84065 University of Utah Health 100 N Mario Capecchi Dr p 801.302.1700 100 N Mario Capecchi Dr Salt Lake City UT. 84113 7495 S State St Salt Lake City UT. 84113 p 801.662.2950 Midvale UT. 84047 3725 W 4100 S p 801.662.4100 p 801.213.9530 West Valley City UT. 84120 81 N Mario Capecchi Dr p 801.965.3600 50 N Medical Dr Salt Lake City UT. 84113 Physical Medicine And Rehabilitation Salt Lake City UT. 84132 p 801.213.3599 Adelman, Scott MD 3968 W Crossing Dr p 801.581.2121 The Smart Clinic Ste 100 Pedodontist 96 E Kimballs Ln Riverton UT. 84065 5121 S Cottonwood St Taylor, Colleen DMD Ste 408 p 801.302.1700 Salt Lake City UT. 84107 University of Utah Health Draper UT. 84020 p 801.507.7000 1078 S 300 E p 801.676.7627 Hospital Affiliation Salt Lake City UT. 84111 - Lone Peak Hospital Zarbock, Zachary R MD p 801.578.8180 Albright, Austin L MD - Jordan Valley Medical Families First Pediatrics Davidson Orthopedics Center 1320 W S Jordan Pkwy 3690 S Main St 6360 S 3000 E South Jordan UT. 84095 Salt Lake City UT. 84115 Ste 200 Woods, Rachel J MD p 801.254.9700 p 801.587.2525 Salt Lake City UT. 84121 Wasatch Pediatrics - p 801.797.8000 Draper 4651 W 13400 S 50 N Medical Dr Clinic 7 114 E 12450 S Ste 100 Salt Lake City UT. 84132 Balbierz, Janet M MD Ste 100 Herriman UT. 84096 p 801.581.2220 166 E 5900 S Draper UT. 84020 p 801.987.8541 Ste B106 p 801.523.3001 530 S Wakara Way Murray UT. 84107 Hospital Affiliation Salt Lake City UT. 84108 p 801.743.6444 Hospital Affiliation - Jordan Valley Medical p 801.587.6453 - Lone Peak Hospital Center Hospital Affiliation 7495 S State St - St Marks Hospital Yamashiro, Duane K DDS Zinkhan, Erin K MD Midvale UT. 84047 University of Utah Health University of Utah Health p 801.213.9530 Ballard, D J PT 100 N Mario Capecchi Dr 100 N Mario Capecchi Dr University of Utah Health Salt Lake City UT. 84113 Salt Lake City UT. 84113 520 S Wakara Way p 801.662.1700 p 801.662.4100 Ste 120 Salt Lake City UT. 84108 p 801.587.9161

Hospital Affiliation - University of Utah Hospital 358 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Burnham, Taylor DO Salt Lake Orthopaedic Djurich, Milan DO 85 N Medical Dr University Of Utah Health Clinic Encompass Rehabilitation Salt Lake City UT. 84112 5126 W Daybreak Pkwy 1160 E 3900 S Hospital p 801.581.2267 South Jordan UT. 84009 Ste 5000 8074 S 1300 E p 801.581.2267 Salt Lake City UT. 84124 Sandy UT. 84094 Hospital Affiliation p 801.262.8486 p 801.565.6500 - University of Utah Hospital 590 S Wakara Way Salt Lake City UT. 84108 Hospital Affiliation Hospital Affiliation Giovanniello, Michael T p 801.587.7111 - St Marks Hospital - Jordan Valley Medical MD Center The Smart Clinic Hospital Affiliation Davis, Alan M MD,PhD 96 E Kimballs Ln - University of Utah Hospital University of Utah Health Duncan, Christopher C MD Ste 408 1950 Cir Of Hope Dr University Of Utah Health Draper UT. 84020 Chen, Michael M DO Salt Lake City UT. 84112 50 N Medical Dr p 801.676.7627 Alta Pain Physicians p 801.581.2267 Salt Lake City UT. 84132 11333 S 1000 E p 801.581.2267 Hospital Affiliation Ste 102 University Of Utah Health - Lone Peak Hospital Sandy UT. 84094 50 N Medical Dr 85 N Medical Dr p 801.462.2205 Salt Lake City UT. 84132 Salt Lake City UT. 84112 Grange, Timothy S MD p 801.581.2267 p 801.581.2267 4052 W Pioneer Pkwy Clark, Jayne E MD Ste 208 1414 E 4500 S 85 N Medical Dr Hospital Affiliation West Valley City UT. 84120 Ste 2 Salt Lake City UT. 84112 - University of Utah Hospital p 801.955.1232 Salt Lake City UT. 84117 p 801.581.2267 p 801.272.6972 Dunn, Ryan DO Alpine Center Medical Hospital Affiliation University Of Utah Health Services Conger, Aaron DO - Salt Lake Regional Medical 5126 W Daybreak Pkwy 5689 S Redwood Rd University of Utah Health Center South Jordan UT. 84009 Ste 30 590 S Wakara Way - University of Utah Hospital p 801.581.2267 Salt Lake City UT. 84123 Salt Lake City UT. 84108 p 801.268.1715 p 801.587.7111 DeMordaunt, Dallin L 590 S Wakara Way Davis Orthopedics and Salt Lake City UT. 84108 Hospital Affiliation Hospital Affiliation Sports Medicine p 801.587.7111 - Jordan Valley Medical - University of Utah Hospital 3336 S 4155 W Center Ste 102 Hospital Affiliation - Jordan Valley Medical Cushman, Daniel M MD West Valley City UT. 84120 - University of Utah Hospital Center West Valley Campus University of Utah Health p 801.964.3925 100 N Mario Capecchi Dr Edgley, Steven MD *Green, Michael M DO Salt Lake City UT. 84113 Medallus Medical University Of Utah Health Primary Childrens Hospital p 801.213.3599 7998 S 1300 E 50 N Medical Dr 100 N Mario Capecchi Dr Sandy UT. 84092 Salt Lake City UT. 84132 Salt Lake City UT. 84113 50 N Medical Dr p 801.255.2000 p 801.581.2267 p 801.662.1000 Salt Lake City UT. 84132 p 801.581.2267 Hospital Affiliation 85 N Medical Dr University of Utah Health - Davis Hospital Salt Lake City UT. 84112 3773 W 12600 S 590 S Wakara Way p 801.581.2267 Riverton UT. 84065 Salt Lake City UT. 84108 Deans, Wesley MD p 801.213.3599 p 801.587.7111 Jordan Valley Medical Hospital Affiliation Center - Suite 240 - Salt Lake Regional Medical University Of Utah Health 81 N Mario Capecchi Dr 3490 W 9000 S Center 50 N Medical Dr Salt Lake City UT. 84113 Ste 240 - University of Utah Hospital Salt Lake City UT. 84132 p 801.213.3599 West Jordan UT. 84088 p 801.581.2267 p 801.964.3000 Egbert, Jacob R DO University Of Utah Health 8074 S 1300 E University of Utah Health 9385 Snowbird Ctr Dr Jordan Valley Neuroscience Sandy UT. 84094 81 N Mario Capecchi Dr Sandy UT. 84092 & Rehabilitation p 801.561.3400 Salt Lake City UT. 84113 p 801.646.4800 Specialists p 801.213.3599 3590 W 9000 S Flis, Alexandra E MD Hospital Affiliation Ste 240 University Of Utah Health University Of Utah Health - University of Utah Hospital West Jordan UT. 84088 50 N Medical Dr 85 N Medical Dr p 801.505.5370 Salt Lake City UT. 84132 Salt Lake City UT. 84112 Dall, Joel T MD p 801.581.2267 p 801.581.2267 Salt Lake Spine and Ortho 1160 E 3900 S Hospital Affiliation Ste 4050 - University of Utah Hospital Salt Lake City UT. 84124 p 801.262.8486

359 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Grose, Kendall DO Hayes, Heather A PT 590 S Wakara Way 1951 W 4700 S Neuroscience & University of Utah Health Salt Lake City UT. 84108 Ste 2 Rehabilitation Specialists 520 S Wakara Way p 801.587.7109 Salt Lake City UT. 84129 - West Valley Ste 120 p 801.356.6100 3336 S Pioneer Pkwy Salt Lake City UT. 84108 Hospital Affiliation Ste 102 p 801.587.9161 - Salt Lake Regional Medical Hospital Affiliation West Valley City UT. 84120 Center - Timpanogos Regional Hospital p 801.964.3925 Hospital Affiliation - University of Utah Hospital - University of Utah Hospital Mann, Kilby S MD Jordan Valley Neuroscience Khan, Qamar R DO University of Utah Health and Rehabilitation Henrie, Arlan M DO Wasatch Pain Solutions 100 N Mario Capecchi Dr Specialists University of Utah Health 661 W 10600 S Salt Lake City UT. 84113 3590 W 9000 S 50 N Medical Dr South Jordan UT. 84095 p 801.662.1000 Ste 240 Salt Lake City UT. 84132 p 801.302.2690 West Jordan UT. 84088 p 801.581.2267 3773 W 12600 S p 801.352.8373 Hospital Affiliation Riverton UT. 84065 5126 W Daybreak Pkwy - Jordan Valley Medical p 801.213.3599 Summit Medical Pain and South Jordan UT. 84009 Center Spine p 213.213.4500 - Lone Peak Hospital 81 N Mario Capecchi Dr 4465 S 900 E Salt Lake City UT. 84113 Ste 275 590 S Wakara Way Knorpp, Scott W MD p 801.213.3599 Salt Lake City UT. 84124 Salt Lake City UT. 84108 Utah Physical Medicine & p 801.266.2440 p 801.587.7111 Rehabilitation Hospital Affiliation 488 E Winchester St - Primary Childrens Hospital Hospital Affiliation University Of Utah Health Ste 160 - Jordan Valley Medical 9385 Snowbird Ctr Dr Salt Lake City UT. 84107 McCormick, Zachary L MD Center Sandy UT. 84092 p 801.532.8540 University of Utah Health - Utah Valley Hospital p 801.646.4800 5126 W Daybreak Pkwy Koniuch, Michael M DO South Jordan UT. 84009 Hansen, Colby R MD Hospital Affiliation Encompass Rehabilitation p 801.581.2267 University Of Utah Health - Salt Lake Regional Medical Hospital 50 N Medical Dr Center 8074 S 1300 E 590 S Wakara Way Salt Lake City UT. 84132 - University of Utah Hospital Sandy UT. 84094 Salt Lake City UT. 84108 p 801.581.2267 p 801.565.6500 p 801.587.7111 Ingraham, Benjamin DO University of Utah Health University Of Utah Health Krull, Angela M MD Hospital Affiliation 590 S Wakara Way 50 N Medical Dr The Smart Clinic - University of Utah Hospital Salt Lake City UT. 84108 Salt Lake City UT. 84132 96 E Kimballs Ln p 801.587.7111 p 801.581.2267 Ste 408 Merrill, Anina MD Draper UT. 84020 HealthSouth Rehabilitation 81 N Mario Capecchi Dr 85 N Medical Dr p 801.676.7627 Hospital Salt Lake City UT. 84113 Salt Lake City UT. 84112 8074 S 1300 E p 801.213.3599 p 801.581.2267 Hospital Affiliation Sandy UT. 84094 - Lone Peak Hospital p 801.565.6500 University Of Utah Health Hospital Affiliation 85 N Medical Dr - University of Utah Health Lee, Venessa A MD Michalik, Adam DO Salt Lake City UT. 84112 Craig H Neilsen Rehabilitation HospitalUniversity Of Utah Health University Of Utah Health p 801.581.2267 50 N Medical Dr 5126 W Daybreak Pkwy Jensen, Benjamin T MD Salt Lake City UT. 84132 South Jordan UT. 84009 Hospital Affiliation University of Utah Health p 801.581.2267 p 801.581.2267 - Primary Childrens Hospital 50 N Medical Dr - University of Utah Hospital Salt Lake City UT. 84132 85 N Medical Dr 590 S Wakara Way - Salt Lake Regional Medical p 801.581.2267 Salt Lake City UT. 84112 Salt Lake City UT. 84108 Center p 801.581.2267 p 801.587.7111 Hospital Affiliation Hansen, Pamela A MD - University of Utah Hospital Hospital Affiliation Hospital Affiliation University of Utah Health - University of Utah Hospital - University of Utah Hospital 1950 Cir of Hope Dr Kendall, Richard W DO Salt Lake City UT. 84112 University of Utah Health Li, Tao MD Minori, Joshua J DO p 801.581.2267 50 N Medical Dr Nexus Pain Care Interventional Spine & Salt Lake City UT. 84132 1575 W 7000 S Pain Management 50 N Medical Dr p 801.581.2267 West Jordan UT. 84084 5801 S Fashion Blvd Salt Lake City UT. 84132 p 801.833.6569 Ste 120 p 801.581.2267 Salt Lake City UT. 84107 p 801.262.7246 Hospital Affiliation - Salt Lake Regional Medical Center - University of Utah Hospital 360 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 6671 S Redwood Rd 3773 W 12600 S 590 S Wakara Way Willick, Stuart E MD Ste 110 Riverton UT. 84065 Salt Lake City UT. 84108 University of Utah Health West Jordan UT. 84084 p 801.213.3599 p 801.587.7111 50 N Medical Dr p 801.262.7246 Salt Lake City UT. 84132 University Of Utah Health Hospital Affiliation p 801.581.2267 Hospital Affiliation 50 N Medical Dr - University of Utah Hospital - Timpanogos Regional Hospital Salt Lake City UT. 84132 590 S Wakara Way - Utah Valley Hospital p 801.581.2267 Sederberg, Mark DO Salt Lake City UT. 84108 University Of Utah Health p 801.587.7111 Newton, Bruce Y MD University of Utah Health 5126 W Daybreak Pkwy Salt Lake Spine and Ortho 81 N Mario Capecchi Dr South Jordan UT. 84009 University Of Utah Health 1160 E 3900 S Salt Lake City UT. 84113 p 801.581.2267 9385 Snowbird Ctr Dr Ste 4050 p 801.213.3599 Sandy UT. 84092 Salt Lake City UT. 84124 590 S Wakara Way p 801.646.4800 p 801.262.8486 University Of Utah Health Salt Lake City UT. 84108 85 N Medical Dr p 801.587.7111 Hospital Affiliation Salt Lake Orthopaedic Salt Lake City UT. 84112 - Salt Lake Regional Medical Clinic p 801.581.2267 Hospital Affiliation Center 1160 E 3900 S - University of Utah Hospital - University of Utah Hospital Ste 5000 Hospital Affiliation Salt Lake City UT. 84124 - Primary Childrens Hospital Shepherd, Douglas T MD Wilson, Rebecca R DO p 801.262.8486 - University of Utah Hospital Ogden Clinic University of Utah Health 441 S Redwood Rd 50 N Medical Dr Hospital Affiliation Randle, Jeffrey G MD Salt Lake City UT. 84104 Salt Lake City UT. 84132 - St Marks Hospital Salt Lake Spine and Ortho p 801.475.3500 p 801.581.2267 1160 E 3900 S Nickisch, Florian MD Ste 4050 Hospital Affiliation Hospital Affiliation University of Utah Health Salt Lake City UT. 84124 - Ogden Regional Medical - University of Utah Hospital 1525 W 2100 S p 801.262.8486 Center Salt Lake City UT. 84119 Physical Therapy p 801.213.8841 Salt Lake Orthopaedic Speed, John MD Aberton, Laura J PT Clinic University Of Utah Health Salt Lake Orthopaedic 590 S Wakara Way 1160 E 3900 S 50 N Medical Dr Clinic Salt Lake City UT. 84108 Ste 5000 Salt Lake City UT. 84132 1160 E 3900 S p 801.587.7109 Salt Lake City UT. 84124 p 801.581.2267 Ste 5000 p 801.262.8486 Salt Lake City UT. 84124 Hospital Affiliation 85 N Medical Dr p 801.262.8486 - University of Utah Hospital Hospital Affiliation Salt Lake City UT. 84112 - St Marks Hospital p 801.581.2267 Aberton, Mark J PT Novich-Welter, Lorraine C Salt Lake Orthopaedic MD Rosenbluth, Jeffrey P MD Hospital Affiliation Clinic University of Utah Health University Of Utah Health - Salt Lake Regional Medical 1160 E 3900 S 175 N Medical Dr E 50 N Medical Dr Center Ste 5000 Salt Lake City UT. 84132 Salt Lake City UT. 84132 - University of Utah Hospital Salt Lake City UT. 84124 p 801.585.7575 p 801.581.2267 p 801.262.8486 U of U Rehabilitation & 50 N Medical Dr 85 N Medical Dr Wellness Program *Adamavich, Crystal L DPT Salt Lake City UT. 84132 Salt Lake City UT. 84112 520 Wakara Way Primary Childrens Rehab p 801.585.6387 p 801.581.2267 Salt Lake City UT. 84108 3741 W 12600 S p 801.756.7200 Ste 100 729 S Arapeen Dr Hospital Affiliation Riverton UT. 84065 Salt Lake City UT. 84108 - Salt Lake Regional Medical U-U Rehabilitation p 801.571.3081 p 801.585.6387 Center Medicine - University of Utah Hospital 50 N Medical Dr 3845 W 4700 S Hospital Affiliation Salt Lake City UT. 84132 Taylorsville UT. 84129 - Logan Regional Hospital Ross, Brendon S DO p 801.581.2268 p 801.840.4360 - Franklin County Medical University of Utah Health Center 50 N Medical Dr UUHC South Jordan Health Ahern, Naquita G PT Salt Lake City UT. 84132 Center University Of Utah Health Oki, Allison MD p 801.581.2267 5126 W Daybreak Pkwy 85 N Medical Dr University of Utah Health South Jordan UT. 84095 Salt Lake City UT. 84112 100 N Mario Capecchi Dr 5126 W Daybreak Pkwy p 801.213.4500 p 801.581.2121 Salt Lake City UT. 84113 South Jordan UT. 84009 p 801.213.3599 p 801.581.2267 Hospital Affiliation - University of Utah Hospital

361 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Ahlswede, Sharon OT Baker, Greg J PT Bay, Brian W DPT 3845 W 4700 S Hand and Orthopedic Registered Physical Mountain Land Taylorsville UT. 84129 Rehabilitation Specialists Therapists Rehabilitation Inc p 801.840.4360 5151 S 900 E 1577 W 7000 S 4624 S Holladay Blvd Ste 100 Ste 100 Holladay UT. 84117 Benvegnu, Rachel R PT Salt Lake City UT. 84117 West Jordan UT. 84084 p 801.277.1028 University Of Utah Health p 801.261.3321 p 801.566.6301 50 N Medical Dr Beck, Carol A DPT Salt Lake City UT. 84132 Anderson, Casey PT Ballato, Mariella PT Registered Physical p 801.581.2121 University Of Utah Health University of Utah Health Therapists Inc 1950 Cir of Hope Dr 50 N Medical Dr 12391 S 4000 W Hospital Affiliation Salt Lake City UT. 84112 Salt Lake City UT. 84132 Ste 210 - University of Utah Hospital p 801.587.7000 p 801.581.2121 Herriman UT. 84096 p 801.446.0990 Berke, Matthew PT Anderson, Mark D MSPT Hospital Affiliation University of Utah Health Mountain Land - University of Utah Hospital Behjani, N Scott PT 3730 W 4700 S Rehabilitation Inc University of Utah Health Taylorsville UT. 84129 1153 E 3900 S Banks, Todd R OT 50 N Medical Dr p 801.213.9200 Salt Lake City UT. 84124 Mountain Land Salt Lake City UT. 84132 p 801.262.6331 Rehabilitation Inc p 801.581.2121 5126 W Daybreak Pkwy 1227 W 9000 S Ste 600 Anyan, Walter R PT Ste F 590 S Wakara Way South Jordan UT. 84009 University of Utah Health West Jordan UT. 84088 Salt Lake City UT. 84108 p 801.213.4500 50 N Medical Dr p 801.282.2200 p 801.581.2121 Salt Lake City UT. 84132 5126 W Daybreak Pkwy p 801.581.2121 Barck, Lynn L PT Hospital Affiliation South Jordan UT. 84009 University of Utah Health - University of Utah Hospital p 801.213.4500 Hospital Affiliation 615 S Arapeen Dr - University of Utah Hospital Ste 100 Bellendir, Trina R PT 590 S Wakara Way Salt Lake City UT. 84108 University of Utah Health Salt Lake City UT. 84108 Applegate, Bruce R PT p 801.581.7246 50 N Medical Dr p 801.581.2121 Registered Physical Salt Lake City UT. 84132 Therapists Inc Hospital Affiliation p 801.581.2121 Hospital Affiliation 12391 S 4000 W - University of Utah Hospital - University of Utah Hospital Ste 210 590 S Wakara Way Herriman UT. 84096 Barker, Michelle A PT Salt Lake City UT. 84108 Bigham, Abigail p 801.446.0990 University Of Utah Health p 801.581.2121 University Of Utah Health 50 N Medical Dr 590 S Wakara Way Atherton, Monica PT Salt Lake City UT. 84132 Hospital Affiliation Salt Lake City UT. 84108 Eccles Health Wellness & p 801.581.2121 - University of Utah Hospital p 801.581.2121 Athletic Center 1840 S 1300 E Hospital Affiliation Benson, Doug W PT Hospital Affiliation Salt Lake City UT. 84105 - University of Utah Hospital University of Utah Health - University of Utah Hospital p 801.832.2860 50 N Medical Dr Barlow, Lauren DPT Salt Lake City UT. 84132 Black Bain, Kristen PT Ayala, Lauren N DPT University Of Utah Health p 801.581.2121 University of Utah Health University of Utah Health 590 S Wakara Way 1138 E Wilmington Ave 100 N Mario Capecchi Dr Salt Lake City UT. 84108 University Of Utah Health Salt Lake City UT. 84106 Salt Lake City UT. 84113 p 801.581.2121 85 N Medical Dr p 801.581.2221 p 801.587.2255 Salt Lake City UT. 84112 *Barnes, Lisa E PT p 801.581.2121 Hospital Affiliation 81 N Mario Capecchi Dr Primary Childrens Hospital - University of Utah Hospital Salt Lake City UT. 84113 100 N Mario Capecchi Dr *Bentley, Bradford Scott S p 801.587.2255 Salt Lake City UT. 84113 *PT Black, Jan R MSPT p 801.662.4980 Primary Childrens Rehab Neuroworx Hospital Affiliation 100 N Mario Capecchi Dr 90 W Albion Village Way - University of Utah Hospital Bass, Melissa L DPT Salt Lake City UT. 84113 Sandy UT. 84070 University of Utah Health p 801.662.4980 p 801.619.3670 Baird, Lisa PT 1950 Cir of Hope Dr University of Utah Health Salt Lake City UT. 84112 3741 W 12600 S Blake, Bevan PT 50 N Medical Dr p 801.587.7000 Ste 100 In Motion Physical Therapy Salt Lake City UT. 84132 Riverton UT. 84065 370 E S Temple p 801.581.2121 Hospital Affiliation p 801.571.3081 Ste 250 - University of Utah Hospital Salt Lake City UT. 84111 Hospital Affiliation p 801.512.2656 - University of Utah Hospital

362 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 6900 S 900 E Brandon, Zoe Y PT Brown, Kristi PT CNS Eccles Physical Ste 100 University of Utah Health Eccles Health Wellness & Therapy Midvale UT. 84047 1950 Cir of Hope Dr Athletic Center 2830 S Redwood Rd p 801.890.6626 Salt Lake City UT. 84112 1840 S 1300 E West Valley City UT. 84119 p 801.587.7000 Salt Lake City UT. 84105 p 801.639.5454 Blumenthal, Katherine A p 801.832.2860 PT 50 N Medical Dr Cagle, Leslie C DPT University of Utah Health Salt Lake City UT. 84132 Sports Med Utah Physical University Of Utah Health 590 S Wakara Way p 801.581.2121 Therapy 590 S Wakara Way Salt Lake City UT. 84108 9350 S 150 E Salt Lake City UT. 84108 p 801.581.2121 University Of Utah Health Ste 460 p 801.581.2121 85 N Medical Dr Sandy UT. 84070 Hospital Affiliation Salt Lake City UT. 84112 p 801.323.9546 Call, Christopher D PT - University of Utah Hospital p 801.581.2121 University Of Utah Health Brown, Todd E PT 50 N Medical Dr Boden, Erinlee DPT Brenkmann, Charlene R DPT Rocky Mountain Therapy Salt Lake City UT. 84132 Utah Physical Therapy University of Utah Health Services p 801.581.2121 Specialists 50 N Medical Dr 3540 S 4000 W 9001 S 3200 W Salt Lake City UT. 84132 Ste 340 85 N Medical Dr Ste 1 p 801.581.2121 West Valley City UT. 84120 Salt Lake City UT. 84112 West Jordan UT. 84088 p 801.417.5017 p 801.587.3422 p 801.561.1061 590 S Wakara Way Salt Lake City UT. 84108 Rocky Mountain Therapy Neuroworx *Bognar, Lindsay PT p 801.581.2121 Services West Jordan 90 W Albion Village Way Primary Childrens Rehab 8822 S Redwood Rd Sandy UT. 84070 100 N Mario Capecchi Dr Hospital Affiliation Ste E122 p 801.619.3670 Salt Lake City UT. 84113 - University of Utah Hospital West Jordan UT. 84088 p 801.662.4980 p 801.566.7080 Hospital Affiliation Brenkmann, Joshua R PT - University of Utah Hospital 3741 W 12600 S University Of Utah Health Buckley, Emma DPT Ste 100 2645 E Parleys Way Neuroworx Cantor, Mark M CCC-SLP Riverton UT. 84065 Salt Lake City UT. 84109 90 W Albion Village Way University of Utah Health p 801.571.3081 p 435.645.9095 Sandy UT. 84070 417 S Wakara Way p 801.619.3670 Ste 1112 3845 W 4700 S 590 S Wakara Way Salt Lake City UT. 84108 Taylorsville UT. 84129 Salt Lake City UT. 84108 Bulanon, Millard E PT p 801.581.3506 p 801.840.4360 p 801.581.2121 University of Utah Health 50 N Medical Dr Capobianchi, Michael DPT 5770 S Fashion Blvd Bldg Hospital Affiliation Salt Lake City UT. 84132 Advanced Motion Physical 5 - University of Utah Hospital p 801.581.2121 Therapy Ste 210 3665 S 8400 W Murray UT. 84107 Brooks, Carly DPT Hospital Affiliation Ste 210 p 801.314.5220 University of Utah Health - University of Utah Hospital Magna UT. 84044 2645 E Parleys Way p 801.250.6733 Hospital Affiliation Salt Lake City UT. 84109 Burr, Casie E PT - Primary Childrens Hospital p 435.645.9095 University of Utah Health Carlson, Jessica PT 1950 Cir of Hope Dr University of Utah Health Bois, Pierre PT 3730 W 4700 S Salt Lake City UT. 84112 50 N Medical Dr Salt Lake Orthopaedic Taylorsville UT. 84129 p 801.587.7000 Salt Lake City UT. 84132 Clinic p 801.213.9200 p 801.581.2121 1160 E 3900 S University Of Utah Health Ste 5000 5126 W Daybreak Pkwy 50 N Medical Dr Carson, Randy J PT Salt Lake City UT. 84124 Ste 600 Salt Lake City UT. 84132 University of Utah Health p 801.262.8486 South Jordan UT. 84009 p 801.581.2121 50 N Medical Dr p 801.213.4500 Salt Lake City UT. 84132 Bradford, Misha PT 85 N Medical Dr p 801.581.2121 University of Utah Health 590 S Wakara Way Salt Lake City UT. 84112 50 N Medical Dr Salt Lake City UT. 84108 p 801.587.3422 University Of Utah Health Salt Lake City UT. 84132 p 801.581.2121 85 N Medical Dr p 801.581.2121 Hospital Affiliation Salt Lake City UT. 84112 Hospital Affiliation - University of Utah Hospital p 801.581.2121 590 S Wakara Way - Primary Childrens Hospital Salt Lake City UT. 84108 Hospital Affiliation p 801.581.2121 - University of Utah Hospital

Hospital Affiliation - University of Utah Hospital

363 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Carter, David S PT University Of Utah Health Cooper, Carrie A DPT Cummings, Bret DPT University of Utah Health 85 N Medical Dr University of Utah Health Registered Physical 50 N Medical Dr Salt Lake City UT. 84112 50 N Medical Dr Therapists Inc Salt Lake City UT. 84132 p 801.581.2121 Salt Lake City UT. 84132 13348 S Market Ctr Dr p 801.581.2121 p 801.581.2121 Ste 130 Hospital Affiliation Riverton UT. 84065 590 S Wakara Way - University of Utah Hospital 590 S Wakara Way p 801.302.8866 Salt Lake City UT. 84108 Salt Lake City UT. 84108 p 801.581.2121 Clark, Jillian S PT p 801.581.2121 Czop, Joseph F PT University of Utah Health University of Utah Health Hospital Affiliation 50 N Medical Dr Hospital Affiliation 50 N Medical Dr - University of Utah Hospital Salt Lake City UT. 84132 - University of Utah Hospital Salt Lake City UT. 84132 p 801.581.2121 p 801.581.2121 Carter, Matthew R DPT Corwin, Andrea E DPT Neuroworx Hospital Affiliation Hand and Orthopedic Hospital Affiliation 90 W Albion Village Way - University of Utah Hospital Rehabilitation Specialists - University of Utah Hospital Sandy UT. 84070 11762 S State St p 801.619.3670 Clark, Spencer PT,DPT Ste 120 Dangerfield, Tamara A PT Adult Care Clinic Draper UT. 84020 University of Utah Health Carter, Taylor R PT 3920 S 1100 E p 801.501.8359 50 N Medical Dr University of Utah Health Ste 310 Salt Lake City UT. 84132 50 N Medical Dr Salt Lake City UT. 84124 5151 S 900 E p 801.581.2121 Salt Lake City UT. 84132 p 801.308.8400 Ste 100 p 801.581.2121 Salt Lake City UT. 84117 615 S Arapeen Dr Cohee, Kimberley P PT p 801.261.3321 Ste 100 Hospital Affiliation University of Utah Health Salt Lake City UT. 84108 - University of Utah Hospital 50 N Medical Dr Couce, Logan J p 801.581.7246 Salt Lake City UT. 84132 University Of Utah Health Cerrone, Cristina R DPT p 801.581.2121 590 S Wakara Way Hospital Affiliation Registered Physical Salt Lake City UT. 84108 - University of Utah Hospital Therapists 590 S Wakara Way p 801.581.2121 74 E Kimball Ln Salt Lake City UT. 84108 Daub, Graham Ste 200 p 801.581.2121 Hospital Affiliation University Of Utah Health Draper UT. 84020 - University of Utah Hospital 590 S Wakara Way p 801.432.2070 Hospital Affiliation Salt Lake City UT. 84108 - University of Utah Hospital *Crandall, Rachel G PT p 801.581.2121 Cervantez, Robert D PT Primary Childrens Rehab University of Utah Health Concentra Medical Centers 3741 W 12600 S Hospital Affiliation 2645 E Parleys Way 12422 S 450 E Ste 100 - University of Utah Hospital Salt Lake City UT. 84109 Draper UT. 84020 Riverton UT. 84065 p 801.587.7109 p 888.997.2669 p 801.571.3081 Dawson Tandy, Samantha DPT 590 S Wakara Way 1735 S Redwood Rd Crandall, Steven PT Hand and Orthopedic Salt Lake City UT. 84108 Ste 115 Hand and Orthopedic Rehabilitation Specialists p 801.587.7109 Salt Lake City UT. 84104 Rehabilitation Specialists 5151 S 900 E p 888.997.2669 5151 S 900 E Ste 100 Child, Bryan F PT Ste 100 Salt Lake City UT. 84117 Precision EMG PLLC 2390 Redwood Rd Murray UT. 84117 p 801.261.3321 6360 S 3000 E West Valley City UT. 84419 p 801.261.3321 Ste 210 p 888.997.2669 702 E South Temple Salt Lake City UT. 84121 *Crawford, Megan R PT Ste 102 p 801.725.2380 385 W 9000 S Primary Childrens Rehab Salt Lake City UT. 84102 Sandy UT. 84070 100 N Mario Capecchi Dr p 801.328.8535 Christensen, Spencer E p 888.997.2669 Salt Lake City UT. 84113 DPT p 801.662.4980 *De La Torre Alva, Linda M University Of Utah Health Cook, Benajmin A PT *DPT 5126 W Daybreak Pkwy University Of Utah Health Cuison, Ambrose J PT Primary Childrens Rehab South Jordan UT. 84009 50 N Medical Dr University of Utah Health 100 N Mario Capecchi Dr p 801.213.4500 Salt Lake City UT. 84132 50 N Medical Dr Salt Lake City UT. 84113 p 801.581.2121 Salt Lake City UT. 84132 p 801.662.4980 Clark, Eleisha I DPT p 801.581.2121 University of Utah Health Cook, William PT 3741 W 12600 S 50 N Medical Dr University Of Utah Health Hospital Affiliation Ste 100 Salt Lake City UT. 84132 50 N Medical Dr - University of Utah Hospital Riverton UT. 84065 p 801.581.2121 Salt Lake City UT. 84132 p 801.571.3081 p 801.581.2121

Hospital Affiliation - University of Utah Hospital 364 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 3845 W 4700 S Dickinson, Erica PT Ellis, Abigail C PT Fankhauser, Nathan R PT Taylorsville UT. 84129 University of Utah Health University of Utah Health University of Utah Health p 801.840.4360 1950 Cir of Hope Dr 1950 Cir of Hope Dr 1138 E Wilmington Ave Salt Lake City UT. 84112 Salt Lake City UT. 84112 Salt Lake City UT. 84106 Hospital Affiliation p 801.587.7000 p 801.587.7000 p 801.581.2221 - Primary Childrens Hospital Hospital Affiliation University Of Utah Health 50 N Medical Dr DeCaria, Stefanie A PT - University of Utah Hospital 85 N Medical Dr Salt Lake City UT. 84132 University of Utah Health Salt Lake City UT. 84112 p 801.581.2121 50 N Medical Dr Doar, Grayson DPT p 801.581.2121 Salt Lake City UT. 84132 University of Utah Health University Of Utah Health p 801.581.2121 520 S Wakara Way Hospital Affiliation 85 N Medical Dr Ste 120 - University of Utah Hospital Salt Lake City UT. 84112 Hospital Affiliation Salt Lake City UT. 84108 p 801.581.2121 - University of Utah Hospital p 801.587.9161 Ellis, Tyler K DPT Mountain Land Hospital Affiliation DeGrendele, Libby R PT Hospital Affiliation Rehabilitation Inc - University of Utah Hospital University of Utah Health - University of Utah Hospital 885 E 9400 S 50 N Medical Dr Sandy UT. 84094 Farnsworth, Cheryl A MPT Salt Lake City UT. 84132 Dougher, Robert L DPT p 801.562.0066 Cutting Edge Physical p 801.581.2121 Advanced Motion Physical Therapy Therapy Elmer, John R DPT 308 E 4500 S University Of Utah Health 14572 S 790 W Rocky Mountain Therapy Ste 280 85 N Medical Dr Ste B Services West Jordan LLC Murray UT. 84107 Salt Lake City UT. 84112 Bluffdale UT. 84065 8822 S Redwood Rd p 801.685.9212 p 801.581.2121 p 801.571.3030 Ste E 122 West Jordan UT. 84088 Farrell, Anna C PT Hospital Affiliation 3665 S 8400 W p 801.566.7080 University Of Utah Health - University of Utah Hospital Ste 210 50 N Medical Dr Magna UT. 84044 *Emerson, Mary L PT Salt Lake City UT. 84132 Demory, Alyssa A PT p 801.250.6733 Primary Childrens Hospital p 801.581.2121 University of Utah Health 3845 W 4700 S 50 N Medical Dr Dowling, Nathan E PT Taylorsville UT. 84129 Hospital Affiliation Salt Lake City UT. 84132 University of Utah Health p 801.840.4360 - University of Utah Hospital p 801.581.2121 50 N Medical Dr Salt Lake City UT. 84132 Esplin, Jared F PT Fast, Andrew PT Hospital Affiliation p 801.581.2121 University of Utah Health Mountain Land - University of Utah Hospital 1525 W 2100 S Rehabilitation 590 S Wakara Way Salt Lake City UT. 84119 1153 E 3900 S Depola, Michael T DPT Salt Lake City UT. 84108 p 801.213.9907 Salt Lake City UT. 84124 Registered Physical p 801.581.2121 p 801.262.6331 Therapists 50 N Medical Dr 9844 S 1300 E Hospital Affiliation Salt Lake City UT. 84132 Fechter, Brett J DPT Ste 200 - University of Utah Hospital p 801.581.2121 University of Utah Health Sandy UT. 84094 1950 Cir of Hope Dr p 801.572.0690 Dummer, Danica R DPT Fagin, Stephanie L PT Salt Lake City UT. 84112 University of Utah Health University of Utah Health p 801.587.7000 Di Francesco, Cynthia A 50 N Medical Dr 2645 E Parleys Way DPT Salt Lake City UT. 84132 Salt Lake City UT. 84109 50 N Medical Dr University of Utah Health p 801.581.2121 p 801.587.7109 Salt Lake City UT. 84132 590 S Wakara Way p 801.581.2121 Salt Lake City UT. 84108 University Of Utah Health 50 N Medical Dr p 801.581.2121 85 N Medical Dr Salt Lake City UT. 84132 Hospital Affiliation Salt Lake City UT. 84112 p 801.581.2121 - University of Utah Hospital University Of Utah Health p 801.581.2121 85 N Medical Dr 590 S Wakara Way Felix, Travis D DPT Salt Lake City UT. 84112 Hospital Affiliation Salt Lake City UT. 84108 Apollo Health Centers p 801.581.2121 - University of Utah Hospital p 801.587.7109 5525 S 900 E Ste 310 Hospital Affiliation Dyer, David M PT Falck, Caleb Z PT Salt Lake City UT. 84117 - University of Utah Hospital Salt Lake Orthopaedic University Of Utah Health p 801.685.2862 Clinic 50 N Medical Dr 1160 E 3900 S Salt Lake City UT. 84132 Ste 5000 p 801.581.2121 Salt Lake City UT. 84124 p 801.262.8486 Hospital Affiliation - University of Utah Hospital

365 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Fillmore, Sadie A DPT Frederick, Monica A PT Gerace, Laila PT *Granger, Keegan M PT University of Utah Health University of Utah Health University Of Utah Health Primary Childrens Hospital 50 N Medical Dr 1950 Cir of Hope Dr 85 N Medical Dr 3773 W 12600 S Salt Lake City UT. 84132 Salt Lake City UT. 84112 Salt Lake City UT. 84112 Riverton UT. 84065 p 801.581.2121 p 801.587.7000 p 801.581.2121 p 801.285.1285

Fink, Barbara P PT 50 N Medical Dr Hospital Affiliation 3845 W 4700 S University of Utah Health Salt Lake City UT. 84132 - University of Utah Hospital Taylorsville UT. 84129 50 N Medical Dr p 801.581.2121 p 801.840.4360 Salt Lake City UT. 84132 Geurts, Gerald H PT p 801.581.2121 Hospital Affiliation Rocky Mountain Therapy Hospital Affiliation - University of Utah Hospital Services North - Primary Childrens Hospital 590 S Wakara Way 2965 W 3500 S Salt Lake City UT. 84108 Fuhriman, Joshua D PT Ste 1 Gray, Camaeron A PT p 801.581.2121 University of Utah Health West Valley City UT. 84119 University of Utah Health 230 S 1850 E p 801.679.0123 1950 Cir of Hope Dr Hospital Affiliation Salt Lake City UT. 84112 Salt Lake City UT. 84112 - University of Utah Hospital p 801.587.7109 Glad, Jaclyn PT p 801.587.7000 University of Utah Health Fisher, Kelley 580 S Guardsman Way 1138 E Wilmington Ave Hospital Affiliation University Of Utah Health Salt Lake City UT. 84112 Salt Lake City UT. 84106 - University of Utah Hospital 50 N Medical Dr p 801.587.7109 p 801.581.2000 Salt Lake City UT. 84132 Griffin, Ryan PT p 801.581.2121 590 S Wakara Way 1525 W 2100 S University Of Utah Health Salt Lake City UT. 84108 Salt Lake City UT. 84119 2645 E Parleys Way Hospital Affiliation p 801.581.2121 p 801.213.9907 Salt Lake City UT. 84109 - University of Utah Hospital p 435.645.9095 Fuhriman, Ryan R MSPT 2645 E Parleys Way Fletcher, Joel PT Hand and Orthopedic Salt Lake City UT. 84109 590 S Wakara Way University of Utah Health Rehabilitation Specialists p 435.645.9095 Salt Lake City UT. 84108 50 N Medical Dr 5151 S 900 E p 801.581.2121 Salt Lake City UT. 84132 Ste 100 3730 W 4700 S p 801.581.2121 Murray UT. 84117 Taylorsville UT. 84129 Gubler, Matthew M DPT p 801.261.3321 p 801.213.9200 Hand and Orthopedic Hospital Affiliation Rehabilitation Specialists - University of Utah Hospital Fullmer, Jared H DPT 5126 W Daybreak Pkwy 5151 S 900 E Registered Physical South Jordan UT. 84009 Ste 100 Foerster, Daniel R DPT Therapists p 801.213.4500 Murray UT. 84117 Mountain Land 5316 S Woodrow St p 801.261.3321 Rehabilitation Inc Ste 100 590 S Wakara Way 1153 E 3900 S Salt Lake City UT. 84107 Salt Lake City UT. 84108 Hale, Natalie R PT Salt Lake City UT. 84124 p 801.261.9255 p 801.581.2121 University of Utah Health p 801.262.6331 50 N Medical Dr Furze, Derek D PT 7495 S State St Salt Lake City UT. 84132 Forsberg, Laurie E PT University of Utah Health Midvale UT. 84047 p 801.581.2121 University of Utah Health 50 N Medical Dr p 801.213.8840 50 N Medical Dr Salt Lake City UT. 84132 University Of Utah Health Salt Lake City UT. 84132 p 801.581.2121 Hospital Affiliation 85 N Medical Dr p 801.581.2121 - University of Utah Hospital Salt Lake City UT. 84112 University Of Utah Health p 801.581.2121 Hospital Affiliation 85 N Medical Dr Goudelock, Bruce T PT - University of Utah Hospital Salt Lake City UT. 84112 University of Utah Health Hospital Affiliation p 801.581.2121 50 N Medical Dr - University of Utah Hospital Foulks, Matthew N PT Salt Lake City UT. 84132 University of Utah Health Hospital Affiliation p 801.581.2121 Hall, Jason D DPT 50 N Medical Dr - University of Utah Hospital Beyond Limits Physical Salt Lake City UT. 84132 Hospital Affiliation Therapy p 801.581.2121 Gaillard, Jeramie PT - University of Utah Hospital 13358 S 5600 W University of Utah Health Herriman UT. 84096 Hospital Affiliation 50 N Medical Dr Grady, Meredith L PT p 801.789.7332 - University of Utah Hospital Salt Lake City UT. 84132 University Of Utah Health p 801.581.2121 50 N Medical Dr Hall, Joshua N Salt Lake City UT. 84132 Eccles Health Wellness & Hospital Affiliation p 801.581.2121 Athletic Center - University of Utah Hospital 1840 S 1300 E Hospital Affiliation Salt Lake City UT. 84105 - University of Utah Hospital p 801.832.3671

366 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Hamilton, Alice DPT 50 N Medical Dr Hopkins, Ronda L PT Jarvis, Eon PT Mountain Land Salt Lake City UT. 84132 University of Utah Health University of Utah Health Rehabilitation Inc p 801.581.2121 50 N Medical Dr 50 N Medical Dr 2295 S Foothill Dr Salt Lake City UT. 84132 Salt Lake City UT. 84132 Ste 1 590 S Wakara Way p 801.581.2121 p 801.581.2121 Salt Lake City UT. 84109 Salt Lake City UT. 84108 p 801.486.7542 p 801.581.2121 Ivie, Amber L PT 590 S Wakara Way University of Utah Health Salt Lake City UT. 84108 Hansen, Matthew DPT 7495 S State St 50 N Medical Dr p 801.581.2121 Neuroworx Midvale UT. 84047 Salt Lake City UT. 84132 90 W Albion Village Way p 801.213.8840 p 801.581.2121 Hospital Affiliation Sandy UT. 84070 - University of Utah Hospital p 801.619.3670 Hospital Affiliation Jabez, Melody A DPT - University of Utah Hospital University of Utah Health Jensen, Bradley C PT Hansen, Tyler M PT 3730 W 4700 S University of Utah Health In Motion Physical Therapy Henry, Timothy A PT Taylorsville UT. 84129 1138 E Wilmington Ave 370 E S Temple University of Utah Health p 801.213.9200 Salt Lake City UT. 84106 Ste 250 50 N Medical Dr p 801.581.2221 Salt Lake City UT. 84111 Salt Lake City UT. 84132 50 N Medical Dr p 801.512.2656 p 801.581.2121 Salt Lake City UT. 84132 50 N Medical Dr p 801.581.2121 Salt Lake City UT. 84132 6900 S 900 E 590 S Wakara Way p 801.581.2121 Ste 100 Salt Lake City UT. 84108 590 S Wakara Way Midvale UT. 84047 p 801.581.2121 Salt Lake City UT. 84108 Hospital Affiliation p 801.890.6626 p 801.581.2121 - University of Utah Hospital *Hensiek, Renee A DPT Hanson, Wesley B DPT Primary Childrens Rehab Hospital Affiliation *Jensen, Holly M DPT Registered Physical 100 N Mario Capecchi Dr - University of Utah Hospital Primary Childrens Hospital Therapists Inc Salt Lake City UT. 84113 100 N Mario Capecchi Dr 1577 W 7000 S p 801.662.4980 Jackson, Steven DPT Salt Lake City UT. 84113 Ste 100 Registered Physical p 801.662.4980 West Jordan UT. 84084 3741 W 12600 S Therapists p 801.566.6301 Ste 100 9844 S 1300 E 3845 W 4700 S Riverton UT. 84065 Ste 200 Taylorsville UT. 84129 Harden, Anne L PT p 801.571.3081 Sandy UT. 84094 p 801.840.4360 University Of Utah Health p 801.572.0690 50 N Medical Dr 3845 W 4700 S *Jessup, Jesse C PT Salt Lake City UT. 84132 Taylorsville UT. 84129 Jackson, Summer D DPT Primary Childrens Rehab p 801.581.2121 p 801.840.4360 University of Utah Health 100 N Mario Capecchi Dr 1950 Cir of Hope Dr Salt Lake City UT. 84113 Hospital Affiliation 5770 S Fashion Blvd Bldg Salt Lake City UT. 84112 p 801.662.4980 - University of Utah Hospital 5 p 801.587.7000 Ste 210 3741 W 12600 S Harrison, James DPT Murray UT. 84107 Hospital Affiliation Ste 100 Mountain View Physical p 801.314.5220 - University of Utah Hospital Riverton UT. 84065 Therapy and Rehabilitation p 801.571.3081 6770 S 900 E Hospital Affiliation *Jain, Ranu PT Ste 100 - Primary Childrens Hospital Intermountain Rehab Agency 3845 W 4700 S Midvale UT. 84047 1685 W 2200 S Taylorsville UT. 84129 p 801.996.3626 Hirai, Stanford K PT Salt Lake City UT. 84119 p 801.840.4360 Registered Physical p 801.975.1027 Harward, Joshua MPT Therapists 5770 S Fashion Blvd Bldg Registered Physical 9844 S 1300 E Janeway, Caitlin R PT 5 Therapists Ste 200 University Of Utah Health Ste 210 74 E Kimball Ln Sandy UT. 84094 50 N Medical Dr Murray UT. 84107 Ste 200 p 801.572.0690 Salt Lake City UT. 84132 p 801.314.5220 Draper UT. 84020 p 801.581.2121 p 801.432.2070 Holland, Joshua PT Johncock, Sarah H DPT University Of Utah Health Hospital Affiliation Mountain Land Helmer, Amber Rose F PT 50 N Medical Dr - University of Utah Hospital Rehabilitation Inc University of Utah Health Salt Lake City UT. 84132 885 E 9400 S 1525 W 2100 S p 801.581.2121 Jansen, Anika K DPT Sandy UT. 84094 Salt Lake City UT. 84119 Rocky Mountain Therapy p 801.562.0066 p 801.213.9907 Hospital Affiliation Services North - University of Utah Hospital 2965 W 3500 S Ste 1 West Valley City UT. 84119 p 801.679.0123 367 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Johnson, Emma E DPT Kilbourne, Katharine H PT 590 S Wakara Way 290 S 1850 E University of Utah Health University of Utah Health Salt Lake City UT. 84108 Salt Lake City UT. 84112 50 N Medical Dr 1138 E Wilmington Ave p 801.581.2121 p 801.587.7109 Salt Lake City UT. 84132 Salt Lake City UT. 84106 p 801.581.2121 p 801.581.2221 Hospital Affiliation 580 S Guardsman Way - University of Utah Hospital Salt Lake City UT. 84112 Hospital Affiliation Hospital Affiliation p 801.587.7109 - University of Utah Hospital - University of Utah Hospital Kosturik, Andrew B PT University of Utah Health 590 S Wakara Way Johnson, Jacquelyn I DPT Kimball, Jennifer L PT 1138 E Wilmington Ave Salt Lake City UT. 84108 University of Utah Health University of Utah Health Salt Lake City UT. 84106 p 801.581.2121 50 N Medical Dr 2645 E Parleys Way p 801.581.8881 Salt Lake City UT. 84132 Salt Lake City UT. 84109 Hospital Affiliation p 801.581.2121 p 435.645.9095 1525 W 2100 S - University of Utah Hospital Salt Lake City UT. 84119 Hospital Affiliation 590 S Wakara Way p 801.213.9907 Kunzer, Elizabeth - University of Utah Hospital Salt Lake City UT. 84108 University of Utah Health p 801.581.2121 2645 E Parleys Way 50 N Medical Dr Johnson, Kathryn A DPT Salt Lake City UT. 84109 Salt Lake City UT. 84132 University of Utah Health Hospital Affiliation p 801.587.7109 p 801.581.2121 1138 E Wilmington Ave - University of Utah Hospital Salt Lake City UT. 84106 3730 W 4700 S LaJom, Jeanne PT p 801.581.2221 Kinzinger, Jonathan H PT Taylorsville UT. 84129 Registered Physical University of Utah Health p 801.213.9200 Therapists 2645 E Parleys Way 50 N Medical Dr 1868 W 9800 S Salt Lake City UT. 84109 Salt Lake City UT. 84132 50 N Medical Dr Ste 200 p 435.645.9095 p 801.581.2121 Salt Lake City UT. 84132 South Jordan UT. 84095 p 801.581.2121 p 801.676.2210 590 S Wakara Way University Of Utah Health Salt Lake City UT. 84108 85 N Medical Dr 5126 W Daybreak Pkwy LaMarche, Laura A PT p 801.581.2121 Salt Lake City UT. 84112 South Jordan UT. 84009 University of Utah Health p 801.581.2121 p 801.213.4500 50 N Medical Dr Hospital Affiliation Salt Lake City UT. 84132 - University of Utah Hospital Hospital Affiliation 590 S Wakara Way p 801.581.2121 - University of Utah Hospital Salt Lake City UT. 84108 Jurosevic, Bojan DPT p 801.581.2121 590 S Wakara Way Zenith Physical Therapy Klemetson, Bradley DPT Salt Lake City UT. 84108 PLLC Rocky Mountain Therapy 7495 S State St p 801.581.2121 7940 S 1300 E Services West Jordan LLC Midvale UT. 84047 Sandy UT. 84094 8822 S Redwood Rd p 801.213.8840 Hospital Affiliation p 801.386.6722 Ste E 122 - University of Utah Hospital West Jordan UT. 84088 Hospital Affiliation Khong, Taryn PT p 801.566.7080 - University of Utah Hospital Ladsten, Tanner C PT University of Utah Health University Of Utah Health 1525 W 2100 S Kljajic, Naida PT Koszarek, Shannon L PT 50 N Medical Dr Salt Lake City UT. 84119 University of Utah Health University of Utah Health Salt Lake City UT. 84132 p 801.213.9907 1950 Cir of Hope Dr 50 N Medical Dr p 801.581.2121 Salt Lake City UT. 84112 Salt Lake City UT. 84132 50 N Medical Dr p 801.587.7000 p 801.581.2121 Hospital Affiliation Salt Lake City UT. 84132 - University of Utah Hospital p 801.581.2121 Kohler, Kevin PT University Of Utah Health University of Utah Health 85 N Medical Dr Lane, Elizabeth F DPT 5126 W Daybreak Pkwy 50 N Medical Dr Salt Lake City UT. 84112 University of Utah Health South Jordan UT. 84009 Salt Lake City UT. 84132 p 801.581.2121 50 N Medical Dr p 801.213.4500 p 801.581.2121 Salt Lake City UT. 84132 Hospital Affiliation p 801.581.2121 590 S Wakara Way Hospital Affiliation - University of Utah Hospital Salt Lake City UT. 84108 - University of Utah Hospital 590 S Wakara Way p 801.581.2121 Kudrna, Tyson PT Salt Lake City UT. 84108 Kohring, Elizabeth A DPT University Of Utah Health p 801.581.2121 7495 S State St University of Utah Health 230 S 1850 E Midvale UT. 84047 50 N Medical Dr Salt Lake City UT. 84112 Hospital Affiliation p 801.213.8840 Salt Lake City UT. 84132 p 801.587.7109 - University of Utah Hospital p 801.581.2121

368 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Lane, Heidi L PT Latimer, Noall H PT Lieu, Kevin PT Lopez Lennon, Cielita L Primary Childrens Hospital Noall H Latimer RPT Inc Eccles Health Wellness & PT 100 N Mario Capecchi Dr 3441 S 8400 W Athletic Center University of Utah Health Salt Lake City UT. 84113 Ste F 1840 S 1300 E 520 S Wakara Way p 801.662.4980 Magna UT. 84044 Salt Lake City UT. 84105 Ste 120 p 801.250.9107 p 801.832.2860 Salt Lake City UT. 84108 Lanenga, Amber L PT p 801.587.9161 University of Utah Health *Lee, Kayla M DPT D1 Sports Training Therapy 50 N Medical Dr Primary Childrens Rehab 7111 S Bingham Junction Lovell, Dallen DPT Salt Lake City UT. 84132 3741 W 12600 S Blvd Balanced Body Physical p 801.581.2121 Ste 100 Midvale UT. 84047 Therapy Riverton UT. 84065 p 801.350.4483 4465 S 900 E 5126 W Daybreak Pkwy p 801.571.3081 Ste 250 South Jordan UT. 84009 Lim, Alexander K PT Salt Lake City UT. 84124 p 801.213.4500 3845 W 4700 S University Of Utah Health p 801.293.8888 Taylorsville UT. 84129 50 N Medical Dr 590 S Wakara Way p 801.840.4360 Salt Lake City UT. 84132 Lowry, Aaron J DPT Salt Lake City UT. 84108 p 801.581.2121 University of Utah Health p 801.581.2121 Primary Childrens Rehab 50 N Medical Dr TOSH Hospital Affiliation Salt Lake City UT. 84132 Hospital Affiliation 5770 S Fashion Blvd Bldg - University of Utah Hospital p 801.581.2121 - University of Utah Hospital 5 Ste 210 Limmer, Margaret PT University Of Utah Health Lapray, Christopher R DPT Murray UT. 84107 University of Utah Health 85 N Medical Dr Mountain Land p 801.314.5220 590 S Wakara Way Salt Lake City UT. 84112 Rehabilitation Inc Salt Lake City UT. 84108 p 801.581.2121 1227 W 9000 S Lege, Stephen M DPT p 801.581.2121 Ste F Utah Physical Therapy Ludlow, Monica L PT West Jordan UT. 84088 Specialists Hospital Affiliation University of Utah Health p 801.282.2200 9001 S 3200 W - University of Utah Hospital 50 N Medical Dr Ste 1 Salt Lake City UT. 84132 Larson, Dave S PT West Jordan UT. 84088 Lindsay, Allison S PT p 801.581.2121 University of Utah Health p 801.561.1061 University Of Utah Health 50 N Medical Dr 50 N Medical Dr 590 S Wakara Way Salt Lake City UT. 84132 Leininger, Michael P PT Salt Lake City UT. 84132 Salt Lake City UT. 84108 p 801.581.2121 University of Utah Health p 801.581.2121 p 801.581.2121 50 N Medical Dr 590 S Wakara Way Salt Lake City UT. 84132 Hospital Affiliation Hospital Affiliation Salt Lake City UT. 84108 p 801.581.2121 - University of Utah Hospital - University of Utah Hospital p 801.581.2121 Hospital Affiliation Lobb, Jason D MSPT Ludwig, B J MPT Hospital Affiliation - University of Utah Hospital Mountain Land Rocky Mountain Therapy - University of Utah Hospital Rehabilitation Services North Lesueur, Robert B DPT 370 E South Temple 2965 W 3500 S Larson, Justin J PT Beyond Limits Physical Ste 150 Ste 1 University Of Utah Health Therapy Salt Lake City UT. 84111 West Valley City UT. 84119 50 N Medical Dr 13358 S 5600 W p 801.521.9222 p 801.679.0123 Salt Lake City UT. 84132 Herriman UT. 84096 p 801.581.2121 p 801.302.7232 Lohse, Bryan D PT Ludwig, Keith J MPT University of Utah Health Rocky Mountain Therapy Hospital Affiliation Lewis, J Brad PT 50 N Medical Dr Services North - University of Utah Hospital Hofmann Arthritis Salt Lake City UT. 84132 2965 W 3500 S Institute p 801.581.2121 Ste 1 Laser, Natalie L PT 11613 S State St West Valley City UT. 84119 University Of Utah Health Draper UT. 84020 Hospital Affiliation p 801.679.0123 50 N Medical Dr p 801.355.6468 - University of Utah Hospital Salt Lake City UT. 84132 Lund, Morgan A DPT p 801.581.2121 24 S 1100 E Long, Jaclyn T DPT Registered Physical Ste 101 &105 Rocky Mountain Therapy Therapists Hospital Affiliation Salt Lake City UT. 84102 Services 74 E Kimball Ln - University of Utah Hospital p 801.355.6468 3540 S 4000 W Ste 200 Ste 340 Draper UT. 84020 West Valley City UT. 84120 p 801.432.2070 p 801.417.5017

369 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Lund, Robert W DPT 1525 W 2100 S *McNulty, Dawn A PT *Milam, Kimberly B PT FYZICAL Spine Orthopedic West Valley City UT. 84119 Primary Childrens Hospital Primary Childrens Rehab Sports Therapy and Balance p 801.213.9907 100 N Mario Capecchi Dr 3845 W 4700 S Center Salt Lake City UT. 84113 Taylorsville UT. 84129 6717 S 900 E 2645 E Parleys Way p 801.662.4980 p 801.840.4360 Midvale UT. 84047 Salt Lake City UT. 84109 p 801.649.4690 p 801.587.7109 Mcatee, Daniel DPT Miller, Brent L MPT Community Health Centers Registered Physical Lundy, Cynthia J PT 50 N Medical Dr 1365 W 1000 N Therapists Inc University of Utah Health Salt Lake City UT. 84132 Salt Lake City UT. 84116 12391 S 4000 W 50 N Medical Dr p 801.581.2121 p 801.328.5756 Ste 210 Salt Lake City UT. 84132 Herriman UT. 84096 p 801.581.2121 5126 W Daybreak Pkwy Mcgrath, Maureen H PT p 801.446.0990 South Jordan UT. 84009 University of Utah Health Hospital Affiliation p 801.213.4500 615 S Arapeen Dr Miller, Byron C PT - University of Utah Hospital Ste 100 University of Utah Health 590 S Wakara Way Salt Lake City UT. 84108 1280 E Stringham Ave Magel, John S DPT Salt Lake City UT. 84108 p 801.581.7246 Salt Lake City UT. 84106 University of Utah Health p 801.581.2121 p 801.581.2000 50 N Medical Dr Mehler, Mandy C PT Salt Lake City UT. 84132 7495 S State St Mountain Land 2645 E Parleys Way p 801.581.2121 Midvale UT. 84047 Rehabilitation Inc Salt Lake City UT. 84109 p 801.213.8840 370 E South Temple p 435.645.9095 Hospital Affiliation Ste 150 - University of Utah Hospital McCulloch, Sarah DPT Salt Lake City UT. 84111 590 S Wakara Way University of Utah Health p 801.521.9222 Salt Lake City UT. 84108 *Malik, Lauren M PT 1950 Cir of Hope Dr p 801.581.2121 Primary Childrens Rehab Salt Lake City UT. 84112 Meier, Charles W PT 100 N Mario Capecchi Dr p 801.587.7000 Meier and Marsh Hospital Affiliation Salt Lake City UT. 84113 Professional Therapies - University of Utah Hospital p 801.662.4980 50 N Medical Dr 4785 W 4100 S Salt Lake City UT. 84132 West Valley City UT. 84120 Miller, Caitlin PT Primary Childrens Hospital p 801.581.2121 p 801.955.0500 University of Utah Health 3845 W 4700 S 590 S Wakara Way Taylorsville UT. 84129 Hospital Affiliation Meier, Whitney A PT Salt Lake City UT. 84108 p 801.840.4360 - University of Utah Hospital University of Utah Health p 801.581.2121 50 N Medical Dr Mann, Janna DPT McGarvey, Daniel Salt Lake City UT. 84132 Miller, Jason L PT University of Utah Health Eccles Health Wellness & p 801.581.2121 University of Utah Health 2645 E Parleys Way Athletic Center 50 N Medical Dr Salt Lake City UT. 84109 1840 S 1300 E 590 S Wakara Way Salt Lake City UT. 84132 p 801.587.7109 Salt Lake City UT. 84105 Salt Lake City UT. 84108 p 801.581.2121 p 801.832.3671 p 801.581.2121 590 S Wakara Way 5126 W Daybreak Pkwy Salt Lake City UT. 84108 McIntyre, Melissa M DPT Hospital Affiliation South Jordan UT. 84009 p 801.587.7109 University of Utah Health - University of Utah Hospital p 801.213.4500 50 N Medical Dr Mathews, Michael J DPT Salt Lake City UT. 84132 Michaels, Caitlin M PT Hospital Affiliation Registered Physical p 801.581.2121 University Of Utah Health - University of Utah Hospital Therapists 50 N Medical Dr 6360 S 3000 E Hospital Affiliation Salt Lake City UT. 84132 Mills, Daniel MPT Ste 125 - University of Utah Hospital p 801.581.2121 Performance Rehab Clinic Salt Lake City UT. 84121 7827 S Highland Dr p 385.900.5094 *McKinnon, Candace PT Hospital Affiliation Cottonwood Heights UT. 84121 Primary Childrens Rehab - University of Utah Hospital p 801.938.9234 Mayer, Lloyd L PT 100 N Mario Capecchi Dr University of Utah Health Salt Lake City UT. 84113 Michalko, Bradley S DPT Misejka, Kristen L PT 590 S Wakara Way p 801.662.4980 Rocky Mountain Therapy University of Utah Health Salt Lake City UT. 84108 Services LLC 50 N Medical Dr p 801.581.2121 Hospital Affiliation 441 S Redwood Rd Salt Lake City UT. 84132 - Primary Childrens Hospital Salt Lake City UT. 84104 p 801.581.2121 McCluskey, James R PT p 801.975.1403 University of Utah Health Hospital Affiliation 1138 E Wilmington Ave - University of Utah Hospital Salt Lake City UT. 84106 p 801.581.2000

370 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Money, Katelyn M PT Mortensen, Kelly C PT Navarro, Juan F DPT ONeill, Jacqueline DPT University of Utah Health University of Utah Health Registered Physical University of Utah Health 1138 E Wilmington Ave 1525 W 2100 S Therapists Inc 1280 E Stringham Ave Salt Lake City UT. 84106 Salt Lake City UT. 84119 1577 W 7000 S Salt Lake City UT. 84106 p 801.581.2000 p 801.213.8841 Ste 100 p 801.581.2000 West Jordan UT. 84084 1525 W 2100 S Hospital Affiliation p 801.566.6301 Oakes, Paisley H DPT Salt Lake City UT. 84119 - University of Utah Hospital In Motion Physical Therapy p 801.213.9907 Nelson, Ashley DPT 370 E S Temple Moss, David C PT University of Utah Health Ste 250 2645 E Parleys Way Hand and Orthopedic 50 N Medical Dr Salt Lake City UT. 84111 Salt Lake City UT. 84109 Rehabilitation Specialists Salt Lake City UT. 84132 p 801.512.2656 p 435.645.9095 702 E S Temple p 801.213.2995 Ste 102 6900 S 900 E 3730 W 4700 S Salt Lake City UT. 84102 *Newby, Olivia J DPT Ste 100 Taylorsville UT. 84129 p 801.328.8535 Primary Childrens Rehab Midvale UT. 84047 p 801.213.9200 100 N Mario Capecchi Dr p 801.890.6626 Muhn, Peter H PT Salt Lake City UT. 84113 5126 W Daybreak Pkwy University Of Utah Health p 801.662.4980 Odell, Nathan E DPT South Jordan UT. 84009 50 N Medical Dr Registered Physical p 801.213.4500 Salt Lake City UT. 84132 3741 W 12600 S Therapists Inc p 801.581.2121 Ste 100 1868 W 9800 S 590 S Wakara Way Riverton UT. 84065 Ste 200 Salt Lake City UT. 84108 5126 W Daybreak Pkwy p 801.571.3081 South Jordan UT. 84095 p 801.581.2121 South Jordan UT. 84009 p 801.676.2210 p 801.213.4500 3845 W 4700 S 7495 S State St Taylorsville UT. 84129 Olivier, Genevieve N PT Midvale UT. 84047 Hospital Affiliation p 801.840.4360 University of Utah Health p 801.213.8840 - University of Utah Hospital 520 S Wakara Way 5770 S Fashion Blvd Bldg Ste 120 Hospital Affiliation Mullin, Brooke OT 5 Salt Lake City UT. 84108 - University of Utah Hospital University of Utah Health Ste 210 p 801.587.9161 1138 E Wilmington Ave Murray UT. 84107 Montague, Brett C PT Salt Lake City UT. 84106 p 801.314.5220 Hospital Affiliation University of Utah Health p 801.581.2221 - University of Utah Hospital 5126 W Daybreak Pkwy Hospital Affiliation South Jordan UT. 84009 50 N Medical Dr - Primary Childrens Hospital Olsen, Miranda DPT p 801.213.4500 Salt Lake City UT. 84132 Mountain Land p 801.581.2121 Newlin, Eileen C PT Rehabilitation Inc 590 S Wakara Way University of Utah Health 2295 S Foothill Dr Salt Lake City UT. 84108 University Of Utah Health 1950 Cir of Hope Dr Ste 1 p 801.581.2121 85 N Medical Dr Salt Lake City UT. 84112 Salt Lake City UT. 84109 Salt Lake City UT. 84112 p 801.587.7000 p 801.486.7542 7495 S State St p 801.581.2121 Midvale UT. 84047 Hospital Affiliation Olsen, Tasha H DPT p 801.213.8840 Murdock, McKay B PT - University of Utah Hospital University of Utah Health Hand And Orthopedic 50 N Medical Dr Hospital Affiliation Rehabilitation Specialists Norris, Trac PT Salt Lake City UT. 84132 - University of Utah Hospital 5151 S 900 E University of Utah Health p 801.581.2121 Ste 100 230 S 1850 E Moran, Marissa L DPT Murray UT. 84117 Salt Lake City UT. 84112 590 S Wakara Way Neuroworx p 801.261.3321 p 801.587.7109 Salt Lake City UT. 84108 90 W Albion Village Way p 801.581.2121 Sandy UT. 84070 Myers, Chantel M DPT 590 S Wakara Way p 801.619.3670 Registered Physical Salt Lake City UT. 84108 Hospital Affiliation Therapists p 801.581.2121 - University of Utah Hospital Morita Nagai, Patricia 13348 S Market Center Dr PT Ste 130 Hospital Affiliation Orr, John M DPT University of Utah Health Riverton UT. 84065 - University of Utah Hospital Orr Training and Therapy 590 S Wakara Way p 801.302.8866 Services Salt Lake City UT. 84108 Norwood, Drew R MPT 1098 W S Jordan Pkwy p 801.581.2121 Myshrall, Janet M PT Registered Physical Ste 101 Mountain Land Therapists South Jordan UT. 84095 Rehabilitation Inc 1868 W 9800 S p 801.254.5800 2295 S Foothill Dr Ste 200 Ste 1 South Jordan UT. 84095 Salt Lake City UT. 84109 p 801.676.2210 p 801.486.7542 371 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Orr, Mitchell PT *Permenter, Taylor DPT 50 N Medical Dr 5126 W Daybreak Pkwy University Of Utah Health Primary Childrens Rehab Salt Lake City UT. 84132 South Jordan UT. 84009 50 N Medical Dr 100 N Mario Capecchi Dr p 801.581.2121 p 801.213.4500 Salt Lake City UT. 84132 Salt Lake City UT. 84113 p 801.581.2121 p 801.662.4980 5126 W Daybreak Pkwy 590 S Wakara Way South Jordan UT. 84009 Salt Lake City UT. 84108 Hospital Affiliation 3741 W 12600 S p 801.213.4500 p 801.581.2121 - University of Utah Hospital Ste 100 Riverton UT. 84065 590 S Wakara Way Hospital Affiliation Pack, Brodie J PT p 801.571.3081 Salt Lake City UT. 84108 - University of Utah Hospital Impackt Physical Therapy p 801.581.2121 And Sports Recovery 3845 W 4700 S *Reinhart, Megan K PT 11531 S District Dr Taylorsville UT. 84129 7495 S State St Primary Childrens Rehab Ste 1200 p 801.840.4360 Midvale UT. 84047 100 N Mario Capecchi Dr South Jordan UT. 84095 p 801.213.8840 Salt Lake City UT. 84113 p 801.260.3100 5770 S Fashion Blvd Bldg p 801.662.4980 5 Hospital Affiliation Palmer, Rebecca M PT Ste 210 - University of Utah Hospital Primary Childrens Hospital University of Utah Health Murray UT. 84107 3845 W 4700 S 590 S Wakara Way p 801.314.5220 Preitz, Rachael A DPT Taylorsville UT. 84129 Salt Lake City UT. 84108 Balanced Body Physical p 801.840.4360 p 801.581.2121 Hospital Affiliation Therapy LLC - Primary Childrens Hospital 4465 S 900 E Rhodes, Jonathon P PT Parkin, Craig S PT Ste 250 Rhodes Physical Therapy University of Utah Health Perry, Daphne A PT Salt Lake City UT. 84124 51 S Main St 50 N Medical Dr University of Utah Health p 801.293.8888 Ste 308 Salt Lake City UT. 84132 50 N Medical Dr Salt Lake City UT. 84111 p 801.581.2121 Salt Lake City UT. 84132 Probert, Erin N PT p 801.447.9339 p 801.581.2121 University of Utah Health Hospital Affiliation 50 N Medical Dr Riddle, Andrew S PT - University of Utah Hospital Hospital Affiliation Salt Lake City UT. 84132 University of Utah Health - University of Utah Hospital p 801.581.2121 50 N Medical Dr Pasdera, Nicole DPT Salt Lake City UT. 84132 Neuroworx Peterson, Mitchell 5126 W Daybreak Pkwy p 801.581.2121 90 W Albion Village Way Eccles Health Wellness & South Jordan UT. 84009 Sandy UT. 84070 Athletic Center p 801.213.4500 University Of Utah Health p 801.619.3670 1840 S 1300 E 85 N Medical Dr Salt Lake City UT. 84105 Hospital Affiliation Salt Lake City UT. 84112 Pearce, Melissa L MPT p 801.832.3671 - University of Utah Hospital p 801.581.2121 Mountain Land Rehabilitation Inc Sports Med Utah Physical Rauk, Reva P PT Hospital Affiliation 5872 S 900 E Therapy University of Utah Health - University of Utah Hospital Ste 150 7111 S Bingham Junction 520 S Wakara Way Salt Lake City UT. 84121 Blvd Ste 120 Riley, Seth M DPT p 801.747.3889 Midvale UT. 84047 Salt Lake City UT. 84108 Hand and Orthopedic p 385.887.8860 p 801.587.9161 Rehabilitation Specialists Pelo, Ryan M DPT 11762 S State St University of Utah Health 9350 S 150 E Hospital Affiliation Ste 120 1138 E Wilmington Ave Ste 460 - University of Utah Hospital Draper UT. 84020 Salt Lake City UT. 84106 Sandy UT. 84070 p 801.501.8359 p 801.581.2221 p 801.748.1861 Reano, Steven H PT StepUp Physical Therapy Rindlisbacher, Ryan D DPT 1280 E Stringham Ave Porter, Patrick DPT 8789 S Redwood Rd Mountain Land Salt Lake City UT. 84106 Mountain Land Ste 100 Rehabilitation Inc p 801.581.2000 Rehabilitation Inc West Jordan UT. 84088 5872 S 900 E 12197 S Draper Gate Dr p 801.981.5977 Ste 150 Hospital Affiliation Ste B Salt Lake City UT. 84121 - University of Utah Hospital Draper UT. 84020 Reich, Todd D PT p 801.747.3889 p 801.523.3415 University of Utah Health Pendley, Chase J DPT 50 N Medical Dr Rios, Michelle G PT Registered Physical Powers, Clayton D PT Salt Lake City UT. 84132 University Of Utah Health Therapists Inc University of Utah Health p 801.581.2121 50 N Medical Dr 1868 W 9800 S 1525 W 2100 S Salt Lake City UT. 84132 Ste 200 Salt Lake City UT. 84119 p 801.581.2121 South Jordan UT. 84095 p 801.213.9907 p 801.676.2210 Hospital Affiliation - University of Utah Hospital

372 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Rittmanic, Ashlyn S DPT 5126 W Daybreak Pkwy 590 S Wakara Way Sauter, Kendall C PT Neuroworx South Jordan UT. 84009 Salt Lake City UT. 84108 University of Utah Health 90 W Albion Village Way p 801.213.4500 p 801.587.7109 2645 E Parleys Way Sandy UT. 84070 Salt Lake City UT. 84109 p 801.619.3670 590 S Wakara Way Hospital Affiliation p 435.645.9095 Salt Lake City UT. 84108 - University of Utah Hospital Rivas, Laura M PT p 801.581.2121 3730 W 4700 S University of Utah Health Saenz, Erik DPT Taylorsville UT. 84129 50 N Medical Dr Ruekert, Kristin PT University of Utah Health p 801.213.9200 Salt Lake City UT. 84132 University of Utah Health 1138 E Wilmington Ave p 801.581.2121 1950 Cir of Hope Dr Salt Lake City UT. 84106 50 N Medical Dr Salt Lake City UT. 84112 p 801.581.2000 Salt Lake City UT. 84132 Hospital Affiliation p 801.587.7000 p 801.581.2121 - University of Utah Hospital 1525 W 2100 S 50 N Medical Dr Salt Lake City UT. 84119 5126 W Daybreak Pkwy Robbins, Steven E PT Salt Lake City UT. 84132 p 801.213.9907 South Jordan UT. 84009 FYZICAL Therapy and p 801.581.2121 p 801.213.4500 Balance Centers - Draper 2645 E Parleys Way 12198 S State St University Of Utah Health Salt Lake City UT. 84109 590 S Wakara Way Ste 3 85 N Medical Dr p 801.587.7109 Salt Lake City UT. 84108 Draper UT. 84020 Salt Lake City UT. 84112 p 801.581.2121 p 801.571.6600 p 801.581.2121 50 N Medical Dr Salt Lake City UT. 84132 Savarise, Yvonne C DPT Robertson, Tracie H PT Rushton, Ryan J PT p 801.581.2121 University of Utah Health University of Utah Health University of Utah Health 2645 E Parleys Way 50 N Medical Dr 1950 Cir of Hope Dr 5126 W Daybreak Pkwy Salt Lake City UT. 84109 Salt Lake City UT. 84132 Salt Lake City UT. 84112 South Jordan UT. 84009 p 801.587.7109 p 801.581.2121 p 801.587.7000 p 801.213.4500 Schiltz, Adam PT Hospital Affiliation 50 N Medical Dr 590 S Wakara Way University of Utah Health - University of Utah Hospital Salt Lake City UT. 84132 Salt Lake City UT. 84108 1138 E Wilmington Ave p 801.581.2121 p 801.581.2121 Salt Lake City UT. 84106 Rodriguez, Brian DPT p 801.581.2000 Utah Physical Therapy Hospital Affiliation 7495 S State St Specialists - University of Utah Hospital Midvale UT. 84047 1525 W 2100 S 9001 S 3200 W p 801.213.8840 Salt Lake City UT. 84119 Ste 1 Ryan, Lauren A DPT p 801.213.9907 West Jordan UT. 84088 University of Utah Health Salazar, Sarah DPT p 801.561.1061 50 N Medical Dr Mountain Land 2645 E Parleys Way Salt Lake City UT. 84132 Rehabilitation Inc Salt Lake City UT. 84109 Romanowska, Katarzyna p 801.581.2121 5872 S 900 E p 435.645.9095 DPT Ste 150 Beyond Limits Physical Hospital Affiliation Salt Lake City UT. 84121 3730 W 4700 S Therapy - University of Utah Hospital p 801.747.3889 Taylorsville UT. 84129 13358 S 5600 W p 801.213.9200 Herriman UT. 84096 Ryle, Hailey J DPT Sanderson, Madison DPT p 801.302.7232 Mountain Land Mountain Land 5126 W Daybreak Pkwy Rehabilitation Inc Rehabilitation Inc South Jordan UT. 84009 Roper, Keith L DPT 1227 W 9000 S 2295 S Foothill Dr p 801.213.4500 University of Utah Health Ste F Ste 1 590 S Wakara Way West Jordan UT. 84088 Salt Lake City UT. 84109 590 S Wakara Way Salt Lake City UT. 84108 p 801.282.2200 p 801.486.7542 Salt Lake City UT. 84108 p 801.581.2121 p 801.581.2121 Sabey, Brian J PT Sandwick, Suzanne PT Hospital Affiliation Salt Lake Orthopaedic University of Utah Health Hospital Affiliation - University of Utah Hospital Clinic 1138 E Wilmington Ave - University of Utah Hospital 1160 E 3900 S Salt Lake City UT. 84106 Ross, Kimberly M OT Ste 5000 p 801.581.2221 Schiltz, Kelsi PT University of Utah Health Salt Lake City UT. 84124 University of Utah Health 2645 E Parleys Way p 801.262.8486 1280 E Stringham Ave 1138 E Wilmington Ave Salt Lake City UT. 84109 Salt Lake City UT. 84106 Salt Lake City UT. 84106 p 801.587.7109 Sadoff, Zachary A PT p 801.581.2000 p 801.581.2221 University of Utah Health 2645 E Parleys Way Hospital Affiliation Hospital Affiliation Salt Lake City UT. 84109 - University of Utah Hospital - University of Utah Hospital p 801.587.7109

373 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Schoenfeld, Chalise C PT Shelly, Daniel H DPT 3665 S 8400 W Smith, Jared H DPT University of Utah Health University of Utah Health Ste 210 Mountain Land 50 N Medical Dr 50 N Medical Dr Magna UT. 84044 Rehabilitation Inc Salt Lake City UT. 84132 Salt Lake City UT. 84132 p 801.250.6733 1153 E 3900 S p 801.581.2121 p 801.581.2121 Salt Lake City UT. 84124 Sinner, Ryan T PT p 801.262.6331 Hospital Affiliation University Of Utah Health University of Utah Health - University of Utah Hospital 85 N Medical Dr 1138 E Wilmington Ave Smith, Michael J DPT Salt Lake City UT. 84112 Salt Lake City UT. 84106 Registered Physical Scholl, Linda V PT p 801.581.2121 p 801.581.2221 Therapists Inc University of Utah Health 74 E Kimball Ln 50 N Medical Dr Hospital Affiliation 1280 E Stringham Ave Ste 200 Salt Lake City UT. 84132 - University of Utah Hospital Salt Lake City UT. 84106 Draper UT. 84020 p 801.581.2121 p 801.581.2000 p 801.432.2070 Shepherd, Collin K 590 S Wakara Way University of Utah Health Hospital Affiliation Snell, Casey PT Salt Lake City UT. 84108 1138 E Wilmington Ave - University of Utah Hospital Sports Med Utah Physical p 801.581.2121 Salt Lake City UT. 84106 Therapy p 801.581.2221 Skinner, Lee A DPT 9350 S 150 E Hospital Affiliation University of Utah Health Ste 460 - University of Utah Hospital *Sherman, Jessica E DPT 50 N Medical Dr Sandy UT. 84070 Primary Childrens Rehab Salt Lake City UT. 84132 p 801.323.9546 Schulz, Shaun S MSPT 3741 W 12600 S p 801.581.2121 Beyond Limits Phyiscal Ste 100 Sorensen, Richard T PT Therapy Riverton UT. 84065 590 S Wakara Way University of Utah Health 13358 S 5600 W p 801.571.3081 Salt Lake City UT. 84108 1525 W 2100 S Herriman UT. 84096 p 801.581.2121 Salt Lake City UT. 84119 p 801.302.7232 3845 W 4700 S p 801.213.9907 Taylorsville UT. 84129 Hospital Affiliation Schwartz, Todd DPT p 801.840.4360 - University of Utah Hospital 50 N Medical Dr Hand and Orthopedic Salt Lake City UT. 84132 Rehabilitation Specialists Primary Childrens Rehab Slaugh, James PT p 801.581.2121 5151 S 900 E TOSH University Of Utah Health Ste 100 5770 S Fashion Blvd Bldg 50 N Medical Dr 5126 W Daybreak Pkwy Murray UT. 84117 5 Salt Lake City UT. 84132 South Jordan UT. 84009 p 801.261.3321 Ste 210 p 801.581.2121 p 801.213.4500 Murray UT. 84107 Seay, Seth W PT p 801.314.5220 Hospital Affiliation 590 S Wakara Way University of Utah Health - University of Utah Hospital Salt Lake City UT. 84108 1950 Cir of Hope Dr Shingleton, Robert W DPT p 801.581.2121 Salt Lake City UT. 84112 University of Utah Health Smith, Andrea J PT p 801.587.7000 50 N Medical Dr University of Utah Health Hospital Affiliation Salt Lake City UT. 84132 1525 W 2100 S - University of Utah Hospital Hospital Affiliation p 801.581.2121 Salt Lake City UT. 84119 - University of Utah Hospital p 801.213.9907 Splan, Madison E DPT Hospital Affiliation Mountain Land Shegrud, Kyle A DPT - University of Utah Hospital 50 N Medical Dr Rehabilitation Inc ENT Specialists Salt Lake City UT. 84132 5872 S 900 E 5770 S 250 E Shober, Linda R DPT p 801.581.2121 Ste 150 Ste 415 Mountain Land Salt Lake City UT. 84121 Salt Lake City UT. 84107 Rehabilitation Inc 7495 S State St p 801.747.3889 p 801.268.2822 2532 S 5600 W Midvale UT. 84047 West Valley City UT. 84120 p 801.213.8840 *Stam, Katherine J DPT Shell, Lloyd PT p 801.415.6882 Primary Childrens Hospital University of Utah Health Hospital Affiliation 100 N Mario Capecchi Dr 50 N Medical Dr Simon, Andrew DPT - University of Utah Hospital Salt Lake City UT. 84113 Salt Lake City UT. 84132 Advanced Motion Physical p 801.662.4980 p 801.581.2121 Therapy Smith, Emily S PT 14572 S 790 W University of Utah Health Stephens, Emily M PT Hospital Affiliation Ste B 590 S Wakara Way University of Utah Health - University of Utah Hospital Riverton UT. 84065 Salt Lake City UT. 84108 1950 Cir of Hope Dr p 801.571.3030 p 801.581.2121 Salt Lake City UT. 84112 p 801.587.7000 Hospital Affiliation - University of Utah Hospital

374 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 50 N Medical Dr Street, Katharine OT Tansock, Katelyn DPT Thoreson, Shane J DPT Salt Lake City UT. 84132 University of Utah Health University of Utah Health University of Utah Health p 801.581.2121 81 N Mario Capecchi Dr 50 N Medical Dr 590 S Wakara Way Salt Lake City UT. 84113 Salt Lake City UT. 84132 Salt Lake City UT. 84108 University Of Utah Health p 801.587.2255 p 801.581.2121 p 801.581.2121 85 N Medical Dr Salt Lake City UT. 84112 Sueoka, Stephanie S PT Hospital Affiliation Hospital Affiliation p 801.581.2121 University of Utah Health - University of Utah Hospital - University of Utah Hospital 50 N Medical Dr Hospital Affiliation Salt Lake City UT. 84132 Taylor, David L PT Timpson, Davis DPT - University of Utah Hospital p 801.581.2121 University of Utah Health Registered Physical 50 N Medical Dr Therapists Stewart, Brianna K DPT 5126 W Daybreak Pkwy Salt Lake City UT. 84132 6360 S 3000 E Hand and Orthopedic South Jordan UT. 84009 p 801.581.2121 Ste 125 Rehabilitation Specialists p 801.213.4500 Cottonwood Heights UT. 84121 5151 S 900 E 590 S Wakara Way p 385.900.5094 Ste 100 590 S Wakara Way Salt Lake City UT. 84108 Salt Lake City UT. 84117 Salt Lake City UT. 84108 p 801.581.2121 *Tischler, Dana F DPT p 801.261.3321 p 801.581.2121 Primary Childrens Rehab Hospital Affiliation 100 N Mario Capecchi Dr Stocking, Alison N DPT Hospital Affiliation - University of Utah Hospital Salt Lake City UT. 84113 University of Utah Health - University of Utah Hospital p 801.662.4980 50 N Medical Dr Tazoi, Jordan E PT Salt Lake City UT. 84132 Sweetser, Erin L DPT University of Utah Health 3741 W 12600 S p 801.581.2121 University of Utah Health 50 N Medical Dr Ste 100 1950 Cir of Hope Dr Salt Lake City UT. 84132 Riverton UT. 84065 590 S Wakara Way Salt Lake City UT. 84112 p 801.581.2121 p 801.571.3081 Salt Lake City UT. 84108 p 801.587.7000 p 801.581.2121 590 S Wakara Way 3845 W 4700 S Hospital Affiliation Salt Lake City UT. 84108 Taylorsville UT. 84129 Hospital Affiliation - University of Utah Hospital p 801.581.2121 p 801.840.4360 - University of Utah Hospital Swenson, Lennie M PT Hospital Affiliation 5770 S Fashion Blvd Bldg Stotts, Paige OTR University of Utah Health - University of Utah Hospital 5 University of Utah Health 1138 E Wilmington Ave Ste 210 50 N Medical Dr Salt Lake City UT. 84106 Thackeray, Anne PT Murray UT. 84107 Salt Lake City UT. 84132 p 801.581.2000 University of Utah Health p 801.314.5220 p 801.581.2121 50 N Medical Dr 1525 W 2100 S Salt Lake City UT. 84132 Tobler, Michael E DPT 5126 W Daybreak Pkwy Salt Lake City UT. 84119 p 801.581.2121 Registered Physical South Jordan UT. 84009 p 801.213.9907 Therapists p 801.213.4500 Hospital Affiliation 6360 S 3000 E 3730 W 4700 S - University of Utah Hospital Ste 125 590 S Wakara Way Taylorsville UT. 84129 Salt Lake City UT. 84121 Salt Lake City UT. 84108 p 801.213.9200 *Thomas, Deborah S DPT p 385.900.5094 p 801.581.2121 Primary Childrens Rehab 5126 W Daybreak Pkwy 100 N Mario Capecchi Dr Tolley, Jesse DPT Stratton, Jacob PT South Jordan UT. 84009 Salt Lake City UT. 84113 Cutting Edge Physical Rocky Mountain Therapy p 801.213.4500 p 801.662.4980 Therapy LLC Services 308 E 4500 S 1950 E 7000 S 520 S Wakara Way Hospital Affiliation Ste 280 Cottonwood Heights UT. 84121 Ste 120 - Primary Childrens Hospital Murray UT. 84107 p 801.943.1041 Salt Lake City UT. 84108 p 801.685.9212 p 801.587.9161 Thompson, Spencer Straup, Alexandria DPT University of Utah Health Treanor, Kristen M PT Registered Physical 590 S Wakara Way 1138 E Wilmington Ave Wasatch Peak Physical Therapists Salt Lake City UT. 84108 Salt Lake City UT. 84106 Therapy 1868 W 9800 S p 801.581.2121 p 801.581.2221 1542 E 3150 S Ste 200 Salt Lake City UT. 84106 South Jordan UT. 84095 7495 S State St 1280 E Stringham Ave p 801.485.0684 p 801.676.2210 Midvale UT. 84047 Salt Lake City UT. 84106 p 801.213.8840 p 801.581.2000 Trela, Patricia A DPT University of Utah Health Hospital Affiliation 50 N Medical Dr - University of Utah Hospital Salt Lake City UT. 84132 p 801.581.2121

375 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 590 S Wakara Way Turner, Joshua PT 3845 W 4700 S 590 S Wakara Way Salt Lake City UT. 84108 University of Utah Health Taylorsville UT. 84129 Salt Lake City UT. 84108 p 801.581.2121 615 S Arapeen Dr p 801.840.4360 p 801.581.2121 Ste 100 Hospital Affiliation Salt Lake City UT. 84108 5770 S Fashion Blvd Bldg Warner, Matthew T DPT - University of Utah Hospital p 801.581.7246 5 Advanced Motion Physical Ste 210 Therapy Tripp, Paul S DPT Hospital Affiliation Murray UT. 84107 3665 S 8400 W In Motion Physical Therapy - University of Utah Hospital p 801.314.5220 Ste 210 370 E S Temple Magna UT. 84044 Ste 250 *Turner, Sean C DPT Hospital Affiliation p 801.250.6733 Salt Lake City UT. 84111 Intermountain Rehab Agency - Primary Childrens Hospital p 801.512.2656 12473 S Minuteman Dr Warner, Scott B DPT Draper UT. 84020 Vandersteen, Paul C DPT Mountain Land 370 E South Temple p 801.495.7950 University of Utah Health Rehabilitation Inc Ste 250 50 N Medical Dr 2532 S 5600 W Salt Lake City UT. 84111 1685 W 2200 S Salt Lake City UT. 84132 West Valley City UT. 84120 p 801.512.2656 Salt Lake City UT. 84119 p 801.581.2121 p 801.415.6882 p 801.975.1027 6900 S 900 E Hospital Affiliation Weber, Zachary K DPT Ste 100 2000 S 900 E - University of Utah Hospital Mountain Land Midvale UT. 84047 Salt Lake City UT. 84105 Rehabilitation Inc p 801.890.6626 p 801.464.7888 Vaughan, Clark PT 12197 S Draper Gate Dr University of Utah Health Ste B Tucker, Kara K DPT 2655 W 9000 S 3730 W 4700 S Draper UT. 84020 University of Utah Health West Jordan UT. 84088 Taylorsville UT. 84129 p 801.523.3415 1138 E Wilmington Ave p 801.256.6430 p 801.213.9200 Salt Lake City UT. 84106 Wehrli, Jared PT p 801.581.2221 324 10Th Ave 5126 W Daybreak Pkwy University of Utah Health Ste 100 South Jordan UT. 84009 50 N Medical Dr Hospital Affiliation Salt Lake City UT. 84103 p 801.213.4500 Salt Lake City UT. 84132 - University of Utah Hospital p 801.408.5735 p 801.581.2121 590 S Wakara Way Turcuato, Jay E DPT 3845 W 4700 S Salt Lake City UT. 84108 5126 W Daybreak Pkwy Hand and Orthopedic Taylorsville UT. 84129 p 801.581.2121 South Jordan UT. 84009 Rehabilitation Specialists p 801.840.2191 p 801.213.4500 11762 S State St Hospital Affiliation Ste 120 389 S 900 E - University of Utah Hospital 7495 S State St Draper UT. 84020 Salt Lake City UT. 84102 Midvale UT. 84047 p 801.501.8359 p 385.282.2575 Verhaaren, Steven R PT p 801.213.8840 Registered Physical Turcuato, Kacie N PT 5541 W 13400 S Therapists White, Henry M PT University of Utah Health Riverton UT. 84096 9844 S 1300 E Rhodes Physical Therapy 3730 W 4700 S p 801.871.4770 Ste 200 51 S Main St Taylorsville UT. 84129 Sandy UT. 84094 Ste 308 p 801.213.9200 6272 S Highland Dr p 801.572.0690 Salt Lake City UT. 84111 Ste 203 p 801.447.9339 590 S Wakara Way Murray UT. 84121 Ward, Preston R DPT Salt Lake City UT. 84108 p 801.871.6350 University of Utah Health Wiegand, Jennifer M PT p 801.581.2121 590 S Wakara Way University of Utah Health Turner, Stacey N Salt Lake City UT. 84108 1138 E Wilmington Ave Hospital Affiliation University Of Utah Health p 801.581.2121 Salt Lake City UT. 84106 - University of Utah Hospital 85 N Medical Dr p 801.581.2000 Salt Lake City UT. 84112 Hospital Affiliation Turner, Channing DPT p 801.581.2121 - University of Utah Hospital 1525 W 2100 S Cutting Edge Physical Salt Lake City UT. 84119 Therapy *Usher, Allison DPT Waring, Jacqueline PT p 801.213.9907 308 E 4500 S Primary Childrens Rehab University of Utah Health Ste 280 3741 W 12600 S 50 N Medical Dr 2645 E Parleys Way Salt Lake City UT. 84107 Ste 100 Salt Lake City UT. 84132 Salt Lake City UT. 84109 p 801.685.9212 Riverton UT. 84065 p 801.581.2121 p 435.645.9095 p 801.571.3081

376 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 3730 W 4700 S 7495 S State St University of Utah Health Young, Christine W PT Taylorsville UT. 84129 Midvale UT. 84047 50 N Medical Dr University of Utah Health p 801.213.9200 p 801.213.8840 Salt Lake City UT. 84132 50 N Medical Dr p 801.581.2121 Salt Lake City UT. 84132 5126 W Daybreak Pkwy Hospital Affiliation p 801.581.2121 South Jordan UT. 84009 - University of Utah Hospital Primary Childrens Hospital p 801.213.4500 81 N Mario Capecchi Dr Hospital Affiliation Williams, Jason G DPT Salt Lake City UT. 84113 - University of Utah Hospital 590 S Wakara Way Mountain Land p 801.662.1675 Salt Lake City UT. 84108 Rehabilitation Inc Zarate, Juan P DPT p 801.581.2121 370 E South Temple Wortley, James M PT Registered Physical Ste 150 Rocky Mountain Therapy Therapists Inc 7495 S State St Salt Lake City UT. 84111 Services LLC 1577 W 7000 S Midvale UT. 84047 p 801.521.9222 441 S Redwood Rd Ste 100 p 801.213.8840 Salt Lake City UT. 84104 West Jordan UT. 84084 Williams, Molly K DPT p 801.975.1403 p 801.566.6301 Hospital Affiliation Cancer Rehabilitation - University of Utah Hospital Centers Wortley, Paul G PT Plastic Surgery 11333 S 1000 E Rocky Mountain Therapy Agarwal, Cori A MD Wike, Brian L DPT Ste 101 B Services University of Utah Health Registered Physical Sandy UT. 84094 1950 E 7000 S 100 N Mario Capecchi Dr Therapists p 801.456.9898 Cottonwood Heights UT. 84121 Salt Lake City UT. 84113 5316 S Woodrow St p 801.943.1041 p 801.662.1700 Ste 100 Wilson, Amelia A DPT Salt Lake City UT. 84107 University of Utah Health Wortley, Richard D PT 1950 Cir of Hope Dr p 801.261.9255 50 N Medical Dr Rocky Mountain Therapy Salt Lake City UT. 84112 Salt Lake City UT. 84132 Services North p 801.585.0100 Wilkinson, N N PT p 801.581.2121 2965 W 3500 S University of Utah Health Ste 1 50 N Medical Dr 50 N Medical Dr Hospital Affiliation West Valley City UT. 84119 Salt Lake City UT. 84132 Salt Lake City UT. 84132 - University of Utah Hospital p 801.679.0123 p 801.662.1700 p 801.581.2121 Wixom, Steven M PT Rocky Mountain Therapy 5126 W Daybreak Pkwy Hospital Affiliation University of Utah Health Services LLC South Jordan UT. 84009 - University of Utah Hospital 5126 W Daybreak Pkwy 441 S Redwood Rd p 801.213.5200 South Jordan UT. 84009 Salt Lake City UT. 84104 Wilks, James M PT p 801.213.4500 p 801.975.1403 Hospital Affiliation University of Utah Health - University of Utah Hospital 1138 E Wilmington Ave 590 S Wakara Way Rocky Mountain Therapy Salt Lake City UT. 84106 Salt Lake City UT. 84108 Services West Jordan LLC Agarwal, Jayant P MD p 801.581.2000 p 801.581.2121 8822 S Redwood Rd University of Utah Health Ste E122 100 N Mario Capecchi Dr 1525 W 2100 S Wolfe, Alex R PT West Jordan UT. 84088 Salt Lake City UT. 84113 Salt Lake City UT. 84119 University of Utah Health p 801.566.7080 p 801.662.1700 p 801.213.9907 590 S Wakara Way Salt Lake City UT. 84108 Yarborough, Allison G PT 1950 Cir of Hope Dr 2645 E Parleys Way p 801.581.2121 University Of Utah Health Salt Lake City UT. 84112 Salt Lake City UT. 84109 5126 W Daybreak Pkwy p 801.585.0100 p 435.645.9095 Hospital Affiliation South Jordan UT. 84009 - University of Utah Hospital p 801.213.4500 50 N Medical Dr 3730 W 4700 S Salt Lake City UT. 84132 Taylorsville UT. 84129 Woolf, Kathryn L PT 590 S Wakara Way p 801.581.7719 p 801.213.9200 University of Utah Health Salt Lake City UT. 84108 50 N Medical Dr p 801.581.2121 Hospital Affiliation 5126 W Daybreak Pkwy Salt Lake City UT. 84132 - University of Utah Hospital South Jordan UT. 84009 p 801.581.2121 Hospital Affiliation p 801.213.4500 - University of Utah Hospital Allred, Bryce MD Hospital Affiliation 3584 W 9000 S 590 S Wakara Way - University of Utah Hospital Yolken, Haley A DPT Ste 400 Salt Lake City UT. 84108 University of Utah Health West Jordan UT. 84088 p 801.581.2121 *Workman, Michael J PT 50 N Medical Dr p 801.569.2456 Primary Childrens Hospital Salt Lake City UT. 84132 100 N Mario Capecchi Dr p 801.581.2121 Hospital Affiliation Salt Lake City UT. 84113 - Jordan Valley Medical p 801.662.1675 Hospital Affiliation Center - University of Utah Hospital - Salt Lake Regional Medical Center

377 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Bennett, John R MD 50 N Medical Dr Griner, Devan MD Kelly, Christopher P MD Ear, Nose & Throat Center Salt Lake City UT. 84132 Peak Plastic Surgery Revivology of Utah p 801.581.7719 3570 W 9000 S 11464 S Pkwy Plz 1255 E 3900 S Ste 140 Ste 300 Ste 301 5126 W Daybreak Pkwy West Jordan UT. 84088 South Jordan UT. 84095 Salt Lake City UT. 84124 South Jordan UT. 84009 p 801.601.2268 p 801.987.8653 p 801.328.2522 p 801.213.5200 Haupt, R S MD Kwok, Alvin C MD 22 S 900 E 8th Ave & C St 5292 College Dr University of Utah Health Salt Lake City UT. 84102 Salt Lake City UT. 84143 Ste 302 100 N Mario Capecchi Dr p 801.328.2522 p 801.581.8915 Murray UT. 84123 Salt Lake City UT. 84113 p 801.293.8100 p 801.662.1700 756 E 12200 S Hospital Affiliation Draper UT. 84020 - Jordan Valley Medical Hospital Affiliation 1280 E Stringham Ave p 801.328.2522 Center - Salt Lake Regional Medical Salt Lake City UT. 84106 - University of Utah Hospital Center p 801.662.1700 Hospital Affiliation - Jordan Valley Medical - Salt Lake Regional Medical Fairbanks, Grant A MD Center West Valley Campus 1950 Cir of Hope Dr Center Fairbanks Plastic Surgery Salt Lake City UT. 84112 1151 E 3900 S Henstrom, Douglas K MD p 801.585.0100 Chen, June S MD Ste B110 Utah Facial Plastics 7240 S Highland Dr Salt Lake City UT. 84124 114 E 12450 S 206 50 N Medical Dr Ste 175 p 801.268.8838 Draper UT. 84020 Salt Lake City UT. 84132 Salt Lake City UT. 84121 p 801.776.2220 p 801.662.1700 p 801.943.0401 Hospital Affiliation - St Marks Hospital Hospital Affiliation Hospital Affiliation Hospital Affiliation - Lone Peak Hospital - Davis Hospital - University of Utah Hospital - St Marks Hospital - Lakeview Hospital Hobson, Gregory DO Mendenhall, Shaun D MD Cheng, Christine A MD Gociman, Barbu R MD University Of Utah Health University of Utah Health 1002 E S Temple University of Utah Health 100 N Mario Capecchi Dr 100 N Mario Capecchi Dr Ste 202 100 N Mario Capecchi Dr Salt Lake City UT. 84113 Salt Lake City UT. 84113 Salt Lake City UT. 84102 Salt Lake City UT. 84113 p 801.662.1700 p 801.662.1700 p 801.298.9774 p 801.662.1700 50 N Medical Dr 1950 Cir of Hope Dr Hospital Affiliation 1950 Cir of Hope Dr Salt Lake City UT. 84132 Salt Lake City UT. 84112 - Lakeview Hospital Salt Lake City UT. 84112 p 801.581.7719 p 801.585.0100 - Salt Lake Regional Medical p 801.585.0100 Center Hospital Affiliation 50 N Medical Dr 50 N Medical Dr - University of Utah Hospital Salt Lake City UT. 84132 Chick, Leland R MD Salt Lake City UT. 84132 p 801.662.1700 Premier Plastic Surgery p 801.662.1700 Johns, Dana N MD Group of Utah University of Utah Health 5126 W Daybreak Pkwy 24 S 1100 E 81 N Mario Capecchi Dr 100 N Mario Capecchi Dr South Jordan UT. 84009 Ste 302 Salt Lake City UT. 84113 Salt Lake City UT. 84113 p 801.213.5200 Salt Lake City UT. 84102 p 801.213.3599 p 801.662.1700 p 801.322.1188 Hospital Affiliation Hospital Affiliation 1950 Cir of Hope Dr - University of Utah Hospital Hospital Affiliation - University of Utah Hospital Salt Lake City UT. 84112 - Salt Lake Regional Medical p 801.585.0100 Mobley, Steven R MD Center Goodwin, Isak A MD Mobley MD Facial Plastic - St Marks Hospital University of Utah Health 50 N Medical Dr and Reconstructive Surgery 1950 Cir of Hope Dr Salt Lake City UT. 84132 1200 E 3900 S Chidester, Jeremy R MD Salt Lake City UT. 84112 p 801.662.1700 Salt Lake City UT. 84124 Premier Plastic Surgery p 801.585.0100 p 801.449.9990 Group of Utah 5126 W Daybreak Pkwy 11762 S State St 50 N Medical Dr South Jordan UT. 84009 3715 W 4100 S Ste 333 Salt Lake City UT. 84132 p 801.213.5200 Ste 100 Draper UT. 84020 p 801.662.1700 Salt Lake City UT. 84120 p 801.839.5557 Primary Childrens Cleft p 801.449.9990 Hospital Affiliation 81 N Mario Capecchi Dr Crombie, Courtney H MD - University of Utah Hospital Salt Lake City UT. 84113 5292 College Dr University of Utah Health p 801.662.2100 Ste 303 100 N Mario Capecchi Dr Taylorsville UT. 84123 Salt Lake City UT. 84113 Hospital Affiliation p 801.449.9990 p 801.662.1700 - University of Utah Hospital

378 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 8th Ave C St 50 N Medical Dr UUHC South Jordan Health Jordan Valley Medical Salt Lake City UT. 84143 Salt Lake City UT. 84132 Center Center p 801.449.9990 p 801.662.1700 5126 W Daybreak Pkwy 3580 W 9000 S South Jordan UT. 84095 West Jordan UT. 84088 Hospital Affiliation 81 N Mario Capecchi Dr p 801.213.4500 p 801.601.4423 - University of Utah Hospital Salt Lake City UT. 84113 - Lone Peak Hospital p 801.213.3599 Ward MD, LLC Steward Orthopedic and - St Marks Hospital 6322 S 3000 E Sports Medicine Hospital Affiliation Ste 170 6322 S 3000 E Motoki, David S MD - University of Utah Hospital Salt Lake City UT. 84121 Ste 140 Premier Plastic Surgery p 801.513.3223 Salt Lake City UT. 84121 Group of Utah Schmelzer, Rodney E MD p 801.733.9924 11762 S State St Plastic Surgery Associates Ward, Preston D MD Ste 220 100 N Medical Dr Ward MD, LLC Hospital Affiliation Draper UT. 84020 Salt Lake City UT. 84113 6322 S 3000 E - Jordan Valley Medical p 801.571.2020 p 801.743.0700 Ste 170 Center Salt Lake City UT. 84121 Pannucci, Christopher J 5089 S 900 E p 801.513.3223 Anderson, Mikol R DPM MD Ste 100 1250 E 3900 S University of Utah Health Salt Lake City UT. 84117 Hospital Affiliation Ste 420 100 N Mario Capecchi Dr p 801.743.0700 - University of Utah Hospital Salt Lake City UT. 84124 Salt Lake City UT. 84113 p 801.269.9939 p 801.662.1700 Hospital Affiliation Warnock, Steven H MD - Primary Childrens Hospital Premier Plastic Surgery Hospital Affiliation 1950 Cir of Hope Dr - Ogden Regional Medical Group of Utah - St Marks Hospital Salt Lake City UT. 84112 Center 11762 S State St - Lone Peak Hospital p 801.585.0100 - Salt Lake Regional Medical Draper UT. 84020 Center p 801.571.2020 Anderson, Ryan K DPM 50 N Medical Dr - St Marks Hospital Foot & Ankle Specialists Salt Lake City UT. 84132 Hospital Affiliation of Utah p 801.662.1700 Self, J M MD - Jordan Valley Medical 909 E 9400 S 11762 S State St Center West Valley Campus Ste B Hospital Affiliation Ste 260 Sandy UT. 84094 - University of Utah Hospital Draper UT. 84020 Podiatry p 801.566.7297 p 801.266.3671 Anderson, Gregory S DPM Premier Plastic Surgery Salt Lake Orthopaedic Hospital Affiliation Group of Utah Hospital Affiliation Clinic - Lakeview Hospital 11762 S State St - St Marks Hospital 1160 E 3900 S Draper UT. 84020 - Lone Peak Hospital Ste 5000 Anselmo, Derek DPM p 801.571.2020 Salt Lake City UT. 84124 Foot & Ankle Specialists Tuncer, Fatma B MD p 801.262.8486 of Utah Rioux-Forker, Dana MD University Of Utah Health 909 E 9400 S University Of Utah Health 100 N Mario Capecchi Dr Steward Orthopedic and Ste B 100 N Mario Capecchi Dr Salt Lake City UT. 84113 Sports Medicine Sandy UT. 84094 Salt Lake City UT. 84113 p 801.662.1700 6322 S 3000 E p 801.566.7297 p 801.662.1700 Ste 140 1280 E Stringham Ave Salt Lake City UT. 84121 Auger, Elizabeth E DPM 1280 E Stringham Ave Salt Lake City UT. 84106 p 801.733.9924 1561 W 7000 S Salt Lake City UT. 84106 p 801.662.1700 Ste 200 p 801.662.1700 Hospital Affiliation West Jordan UT. 84084 1950 Cir of Hope Dr - St Marks Hospital p 801.619.2170 50 N Medical Dr Salt Lake City UT. 84112 Salt Lake City UT. 84132 p 801.585.0100 Anderson, Jeremy S DPM 4460 S Highland Dr p 801.581.7719 Salt Lake Regional Medical Ste 400 50 N Medical Dr Center Salt Lake City UT. 84124 Hospital Affiliation Salt Lake City UT. 84132 1050 E S Temple p 801.619.2170 - University of Utah Hospital p 801.581.7719 Salt Lake City UT. 84102 p 801.350.4715 9355 S 1300 E Rockwell, William B MD Hospital Affiliation Sandy UT. 84094 University of Utah Health - University of Utah Hospital Jordan Valley Medical p 801.619.2170 100 N Mario Capecchi Dr Center West Valley Campus Salt Lake City UT. 84113 University of Utah Plastic 3460 S 4155 W Hospital Affiliation p 801.662.1700 Surgery Associates West Valley City UT. 84120 - St Marks Hospital 50 N Medical Dr p 801.964.3100 Salt Lake City UT. 84132 p 801.581.7719

379 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Banks, Justin DPM Clark, Scott A DPM Eddy, Thomas V DPM Goebel, Christiaan H DPM Exodus Healthcare Network Utah Podiatry Group PC Rocky Mountain Foot and Utah Podiatric Physicians 3336 S Pioneer Pkwy 24 S 1100 E Ankle and Surgeons Group Ste 201 Ste 210 11800 S State St 101 E Fort Union Blvd West Valley City UT. 84120 Salt Lake City UT. 84102 Ste 350 Ste B p 801.250.9638 p 801.505.5277 Draper UT. 84020 Midvale UT. 84047 p 801.261.1391 p 801.561.1011 3665 S 8400 W 8822 S Redwood Rd Ste 110 Ste E121 5801 S Fashion Blvd 4578 S Highland Dr Magna UT. 84044 West Jordan UT. 84088 Ste 120 Ste 380 p 801.250.9638 p 801.505.5277 Salt Lake City UT. 84107 Salt Lake City UT. 84117 p 801.261.1391 p 801.274.9060 Brklacich, Braden DPM Hospital Affiliation Ellsworth Foot and Ankle - Salt Lake Regional Medical Hospital Affiliation Hospital Affiliation Clinic Center - Lone Peak Hospital - St Marks Hospital 12523 S Creek Meadow Rd - St Marks Hospital Ste 105 Daniels, Paul N DPM - Jordan Valley Medical Graff, David M DPM Riverton UT. 84065 1449 E 3300 S Center Foot & Ankle Specialists p 801.253.6886 Salt Lake City UT. 84106 of Utah p 801.483.1015 Ellsworth Foot and Ankle 909 E 9400 S Brown, H Ronald DPM Clinic Ste B 4370 S Redwood Rd Hospital Affiliation 12523 S Creek Meadow Rd Sandy UT. 84094 Salt Lake City UT. 84123 - Jordan Valley Medical Ste 105 p 801.566.7297 p 801.967.3338 Center West Valley Campus Riverton UT. 84065 p 801.253.6886 Groberg, Darren F DPM Hospital Affiliation Davis, Nathan W DPM Salt Lake Podiatry Center - St Marks Hospital 154 Myrtle Ave 4019 W 12600 S 144 S 700 E - Jordan Valley Medical Ste 201 Ste 120 Salt Lake City UT. 84102 Center West Valley Campus Murray UT. 84107 Herriman UT. 84096 p 801.532.1822 p 801.743.2909 p 801.253.6886 Burleigh, William H DPM Hospital Affiliation Granger Medical Clinic Hospital Affiliation 4578 S Highland Dr - St Marks Hospital 2965 W 3500 S - St Marks Hospital Ste 380 West Valley City UT. 84119 - Jordan Valley Medical Salt Lake City UT. 84117 Hall, Daphne M NP p 801.965.3600 Center West Valley Campus p 801.253.6886 Ellsworth Foot and Ankle Clinic Hospital Affiliation Decker, Kathryn Ellsworth, Ryan S DPM 4019 W 12600 S - Jordan Valley Medical Ellsworth Foot and Ankle Ellsworth Foot and Ankle Ste 120 Center Clinic Clinic Herriman UT. 84096 - Jordan Valley Medical 12523 S Creek Meadow Rd 12523 S Creek Meadow Rd p 801.253.6886 Center West Valley Campus Ste 105 Ste 105 Riverton UT. 84065 Riverton UT. 84065 4578 S Highland Dr Call, Donald R DPM p 801.253.6886 p 801.253.6886 Ste 380 1325 W S Jordan Pkwy Salt Lake City UT. 84117 Ste 105 4019 W 12600 S 4019 W 12600 S p 801.253.6886 South Jordan UT. 84095 Ste 120 Ste 120 p 801.254.3123 Herriman UT. 84096 Herriman UT. 84096 Halladay, Kim A DPM p 801.253.6886 p 801.253.6886 Foot & Ankle Specialists Campbell, Craig J DPM of Utah SouthWest Foot Clinic 4578 S Highland Dr 4578 S Highland Dr 909 E 9400 S 5255 S 4015 W Ste 380 Ste 380 Ste B Ste 140 Salt Lake City UT. 84117 Salt Lake City UT. 84117 Sandy UT. 84094 Kearns UT. 84118 p 801.253.6886 p 801.253.6886 p 801.566.7297 p 801.969.1434 Dickerson, Jason B DPM Hospital Affiliation Hospital Affiliation Hospital Affiliation Heiden Orthopedics - Jordan Valley Medical - Mountain West Medical - Jordan Valley Medical 6360 S 3000 E Center Center Center Ste 210 - Timpanogos Regional Hospital Salt Lake City UT. 84121 Foot & Ankle Specialists Clark, Francis J DPM p 435.615.8822 of Utah Hamblin, Kelly L DPM 3584 W 9000 S 909 E 9400 S Granger Medical Ste 301 Hospital Affiliation Ste B Specialists West Jordan UT. 84088 - Lone Peak Hospital Sandy UT. 84094 12391 S 4000 W p 801.255.8633 - St Marks Hospital p 801.566.7297 Riverton UT. 84096 p 801.302.1700 Hospital Affiliation - St Marks Hospital - Lone Peak Hospital - Jordan Valley Medical Center 380 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 3181 W 9000 S Rocky Mountain Foot and Moritz, Mark E DPM 5126 W Daybreak Pkwy West Jordan UT. 84088 Ankle Salt Lake Podiatry Ste 600 p 801.569.5600 11800 S State St 1250 E 3900 S South Jordan UT. 84009 Murray UT. 84020 Ste 420 p 801.213.4500 Hospital Affiliation p 801.261.1391 Salt Lake City UT. 84124 - Jordan Valley Medical p 801.269.9939 7495 S State St Center 5801 S Fashion Blvd Midvale UT. 84047 - Jordan Valley Medical Ste 120 Hospital Affiliation p 801.213.9400 Center West Valley Campus Salt Lake City UT. 84107 - St Marks Hospital - Lone Peak Hospital p 801.261.1391 Hospital Affiliation Packard, Weston MD - Salt Lake Regional Medical Hansen, Daniel D DPM Larsen, Clark C DPM Utah Podiatric Physicians Center Rocky Mountain Foot and Rocky Mountain Foot and And Surgeons Group - University of Utah Hospital Ankle Ankle 1561 W 7000 S 11800 S State St 11800 S State St Ste 100 Schiffgen, S T DPM Ste 350 Murray UT. 84020 West Jordan UT. 84084 9690 S 1300 E Draper UT. 84020 p 801.261.1391 p 801.569.2696 Ste 120 p 801.261.1391 Sandy UT. 84094 5801 S Fashion Blvd 4578 S Highland Dr p 801.501.4335 5801 S Fashion Blvd Ste 120 Ste 380 Ste 120 Salt Lake City UT. 84107 Salt Lake City UT. 84117 Seagle, Bryan L DPM Salt Lake City UT. 84107 p 801.261.1391 p 801.274.9060 Foot & Ankle Specialists p 801.261.1391 of Utah Hospital Affiliation Phillips, Stanley J DPM 909 E 9400 S Harper, Spence D DPM - St Marks Hospital 9690 S 1300 E Ste B Dr Spence D Harper - Lone Peak Hospital Ste 120 Sandy UT. 84094 999 Murray Holladay Rd Sandy UT. 84094 p 801.566.7297 Ste 102 Larsen, Clint P DPM p 801.501.4335 Salt Lake City UT. 84117 Utah Podiatric Physicians Hospital Affiliation p 801.274.9062 and Surgeons Group Hospital Affiliation - Lakeview Hospital 11800 S State St - Timpanogos Regional Hospital - Lone Peak Hospital Hospital Affiliation Ste 350 - Heber Valley Hospital Draper UT. 84020 Poulson, Hayden DPM Seegmiller, David C DPM - St Marks Hospital p 801.261.1391 Steward Orthopedic and Utah Podiatry Group PC - Salt Lake Regional Medical Sports Medicine 82 S 1100 E Center Hospital Affiliation 6322 S 3000 E Ste 301 - Jordan Valley Medical Ste 140 Salt Lake City UT. 84102 Jaramillo, Todd MD Center Salt Lake City UT. 84121 p 801.505.5277 Ellsworth Foot and Ankle p 801.733.9924 Clinic McKenzie II, David G DPM 8822 S Redwood Rd 4578 S Highland Dr Foot & Ankle Specialists Preece, Daniel L DPM Ste E-121 Ste 380 of Utah Salt Lake Podiatry Center West Jordan UT. 84088 Salt Lake City UT. 84118 909 E 9400 S 144 S 700 E p 801.505.5277 p 801.253.6886 Ste B Salt Lake City UT. 84102 Sandy UT. 84094 p 801.532.1822 Hospital Affiliation Jones, Richard L DPM p 801.566.7297 - St Marks Hospital Steward Orthopedic & Hospital Affiliation - Jordan Valley Medical Sports Medicine Hospital Affiliation - St Marks Hospital Center 6322 S 3000 E - Central Valley Medical - Salt Lake Regional Medical Ste 140 Center Royall, Steven P DPM Center Salt Lake City UT. 84121 Summit Foot and Ankle p 801.733.9924 McManama, Craig A DPM 5450 S Green St Seegmiller, Richard G DPM West Valley Foot & Ankle Ste B Utah Podiatry Group PC Hospital Affiliation 3465 S Pioneer Pkwy Salt Lake City UT. 84123 24 S 1100 E - Jordan Valley Medical Ste 3 p 801.784.1111 Ste 210 Center Salt Lake City UT. 84120 Salt Lake City UT. 84102 p 801.966.3556 Hospital Affiliation p 801.505.5277 Kitterman, Ryan T DPM - Salt Lake Regional Medical Utah Podiatry Group PC Hospital Affiliation Center 8822 S Redwood Rd 2159 S 700 E - Jordan Valley Medical Ste E121 Ste 150 Center Rushton, Ryan T DPM West Jordan UT. 84088 Salt Lake City UT. 84106 - Jordan Valley Medical University of Utah Health p 801.505.5277 p 801.466.1333 Center West Valley Campus 1525 W 2100 S - Mountain West Medical Salt Lake City UT. 84119 Hospital Affiliation Hospital Affiliation Center p 801.213.8841 - Davis Hospital - St Marks Hospital - Lakeview Hospital - Salt Lake Regional Medical - Salt Lake Regional Medical Center Center 381 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Shelton, Scott S DPM 82 S 1100 E Arbogast, Richard MD 1950 Cir of Hope Dr Alpine Foot and Ankle Ste 301 Odyssey House of Utah Salt Lake City UT. 84112 1434 E 9400 S Salt Lake City UT. 84102 350 E 2100 S p 801.583.2500 Ste 203 p 801.505.5277 Salt Lake City UT. 84115 Sandy UT. 84093 p 801.428.3241 50 N Medical Dr p 801.571.7911 8822 S Redwood Rd Salt Lake City UT. 84132 Ste E121 3944 S 400 E p 801.585.1575 Hospital Affiliation West Jordan UT. 84088 Salt Lake City UT. 84107 - Lone Peak Hospital p 801.285.7060 p 801.428.3241 501 S Chipeta Way Salt Lake City UT. 84108 Smith, Stanton M DPM 999 Murray Holladay Rd 880 E 3375 S p 801.587.3287 K2 Foot and Ankle Ste 102 Salt Lake City UT. 84106 5770 S 250 E Salt Lake City UT. 84117 p 801.428.3241 Barusch, Nathaniel MD Ste 415 p 801.274.9062 Cedar Psychiatry Murray UT. 84107 Hospital Affiliation 1208 E 3300 S p 801.314.5400 Williams, Trevor R DPM - St Marks Hospital Salt Lake City UT. 84106 Foot and Ankle Specialists p 801.369.8989 Hospital Affiliation 1561 W 7000 S Aslami, Amie MD - St Marks Hospital Ste 100 Comprehensive Lotus Center Inc - Lone Peak Hospital West Jordan UT. 84084 Psychological Services 4376 S 700 E p 801.569.2696 1208 E 3300 S Ste 200 Southerland Jr, Charles C Salt Lake City UT. 84106 Salt Lake City UT. 84107 DPM Hospital Affiliation p 801.483.1600 p 385.272.4292 Utah Podiatry Group PC - Jordan Valley Medical 8822 S Redwood Rd Center 3725 W 4100 S Cedar Psychiatry Ste E-121 West Valley City UT. 84120 721 E 12200 S West Jordan UT. 84088 Wright, Taylor DPM p 801.483.1600 Draper UT. 84020 p 801.505.5277 Taylor G Wright PC p 801.369.8989 740 E 3900 S Baggett, Nicholas APRN Thomas, Benjamin A DPM Ste 108 Cedar Psychiatry Hospital Affiliation Foothill Family Clinic Salt Lake City UT. 84107 154 E Myrtle Ave - Mountain View Hospital 13953 S Bangerter Pkwy p 801.266.3113 Ste 204 (UT) Draper UT. 84020 Salt Lake City UT. 84107 - Utah Valley Hospital p 385.900.4090 Hospital Affiliation p 801.369.8989 - St Marks Hospital Beckstrom, Andrea W APRN 2295 Foothill Dr - Lone Peak Hospital University of Utah Health Valley Behavioral Health Salt Lake City UT. 84109 50 N Medical Dr 1141 E 3900 S p 801.486.3021 Young, J Randal DPM Salt Lake City UT. 84132 Ste A250 3336 S Pioneer Pkwy p 801.581.4014 Salt Lake City UT. 84124 Tronstein, Elizabeth DPM Ste 302 p 888.949.4864 Utah Podiatry Group PC West Valley City UT. 84120 5126 W Daybreak Pkwy 24 S 1100 E p 801.417.5386 South Jordan UT. 84009 280 E 600 S Ste 210 p 801.213.4500 Salt Lake City UT. 84111 Salt Lake City UT. 84102 4370 S Redwood Rd p 888.949.4864 p 801.505.5277 Salt Lake City UT. 84123 Cedar Psychiatry p 801.967.3338 721 E 12200 S 3610 S 1000 W 8822 S Redwood Rd Draper UT. 84020 West Valley City UT. 84119 Ste E121 Hospital Affiliation p 801.369.8989 p 888.949.4864 West Jordan UT. 84088 - Jordan Valley Medical p 801.285.7060 Center West Valley Campus Hospital Affiliation Bilder, Deborah A MD - University of Utah Hospital University of Utah Health Utah Podiatric Physicians Psychiatry 1280 E Stringham Ave and Surgeons Group Andersen, Claire MD Banks, Duane R MD Salt Lake City UT. 84106 1434 E 9400 S The Childrens Center Sundance Behavioral p 801.581.7951 Ste 203 350 S 400 E Resources Sandy UT. 84093 Salt Lake City UT. 84111 845 E 4800 S 1950 Cir of Hope Dr p 801.571.7911 p 801.582.5534 Ste 200 Salt Lake City UT. 84112 Murray UT. 84107 p 801.583.2500 Utah Podiatry Group PC 5242 S 4820 W p 801.264.9522 2159 S 700 E Salt Lake City UT. 84118 50 N Medical Dr Ste 150 p 801.966.4251 Bartel, Roxanne L MD Salt Lake City UT. 84132 Salt Lake City UT. 84106 University of Utah Health p 801.585.1575 p 801.466.1333 1280 E Stringham Ave Salt Lake City UT. 84106 p 801.581.7951

382 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 501 S Chipeta Way 50 N Medical Dr 50 N Medical Dr 50 N Medical Dr Salt Lake City UT. 84108 Salt Lake City UT. 84132 Salt Lake City UT. 84132 Salt Lake City UT. 84132 p 801.587.3287 p 801.585.1575 p 801.585.1575 p 801.581.2121

Hospital Affiliation 501 S Chipeta Way 501 S Chipeta Way 501 S Chipeta Way - University of Utah Hospital Salt Lake City UT. 84108 Salt Lake City UT. 84108 Salt Lake City UT. 84108 p 801.587.3287 p 801.587.3287 p 801.583.2500 Birch, Robert D DO 501 Chipeta Way Hospital Affiliation Hospital Affiliation Dattilo, Wilbur R MD Ste 1214 - University of Utah Hospital - University of Utah Hospital University of Utah Health Salt Lake City UT. 84108 1280 E Stringham Ave p 801.585.1575 Brewer, Stanley DO Cipro, Laura A APRN Salt Lake City UT. 84106 University of Utah Health Sundance Behavioral p 801.581.7951 Hospital Affiliation 100 N Mario Capecchi Dr Resources - University of Utah Hospital Salt Lake City UT. 84113 845 E 4800 S 501 S Chipeta Way p 801.313.7711 Ste 200 Salt Lake City UT. 84108 Birnkrant, Jonathan D MD Salt Lake City UT. 84107 p 801.587.3287 University of Utah Health Hospital Affiliation p 801.264.9522 50 N Medical Dr - Primary Childrens Hospital Hospital Affiliation Salt Lake City UT. 84132 Hospital Affiliation - University of Utah Hospital p 801.585.1575 Bushnell, Lowry A MD - Primary Childrens Hospital University of Utah Health *Deming, Annie M PhD 501 S Chipeta Way 1280 E Stringham Ave Connolly, Michael S MD Primary Childrens Hospital Salt Lake City UT. 84108 Salt Lake City UT. 84106 Granger Medical Clinic 5770 S 1500 W p 801.587.3287 p 801.581.7951 11724 S State St Taylorsville UT. 84123 Draper UT. 84020 p 801.313.7770 Hospital Affiliation 501 S Chipeta Way p 801.576.2050 - University of Utah Hospital Salt Lake City UT. 84108 Dentino, Stamatios G MD p 801.587.3287 3725 W 4100 S University of Utah Health Boel, David M APRN West Valley City UT. 84120 1280 E Stringham Ave Valley Behavioral Health Bustamante, Jamie S PhD p 801.965.3600 Salt Lake City UT. 84106 1020 S Main St Senior Behavioral Health p 801.581.7951 Ste 100 SLC - OP Hospital Affiliation Salt Lake City UT. 84101 82 S 1100 E - Riverton Childrens Unit 501 S Chipeta Way p 888.949.4864 Ste 404 Operated by Primary Childrens MedicalSalt Lake Center City UT. 84108 Salt Lake City UT. 84102 p 801.587.3287 Bonebrake, Kathleen M MD p 801.350.4777 Cross, Hannah LCSW University Of Utah Health Cedar Psychiatry Hospital Affiliation 50 N Medical Dr Carlson, Paul J MD 154 E Myrtle Ave - University of Utah Hospital Salt Lake City UT. 84132 University of Utah Health Ste 204 p 801.585.1575 1280 E Stringham Ave Murray UT. 84107 Desjardins, Michael C Salt Lake City UT. 84106 p 801.369.8989 APRN 501 S Chipeta Way p 801.581.7951 Alpine Center for Personal Salt Lake City UT. 84108 721 E 12200 S Growth p 801.585.1575 1950 Cir of Hope Dr Draper UT. 84020 5689 S Redwood Rd Salt Lake City UT. 84112 p 801.369.8989 Ste 30 525 E 100 S p 801.583.2500 Salt Lake City UT. 84123 Ste 5000 Curtis, Heather MD p 801.268.1715 Salt Lake City UT. 84102 50 N Medical Dr JVMC-WVC Behavioral Health p 801.585.1212 Salt Lake City UT. 84132 - IP Dwyer, Luke M MD p 801.585.1575 3460 S Pioneer Pkwy University Of Utah Health Hospital Affiliation West Valley City UT. 84120 50 N Medical Dr - University of Utah Hospital 501 S Chipeta Way p 801.964.3575 Salt Lake City UT. 84132 Salt Lake City UT. 84108 p 801.581.7951 Botts, Elizabeth L MD p 801.587.3287 Czajkowski, Laura PhD University of Utah Health University of Utah Health 501 S Chipeta Way 1280 E Stringham Ave Chan, Benjamin R MD 1280 E Stringham Ave Salt Lake City UT. 84108 Salt Lake City UT. 84106 University of Utah Health Salt Lake City UT. 84106 p 801.585.1575 p 801.581.7951 1280 E Stringham Ave p 801.581.7951 Salt Lake City UT. 84106 51 W 3900 S 1950 Cir of Hope Dr p 801.581.7951 1950 Cir of Hope Dr Salt Lake City UT. 84107 Salt Lake City UT. 84112 Salt Lake City UT. 84112 p 801.587.2370 p 801.583.2500 p 801.583.2500

383 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 525 E 100 S Freeman, Brenner L MD 501 S Chipeta Way 7495 S State St Ste 5000 University of Utah Health Salt Lake City UT. 84108 Midvale UT. 84047 Salt Lake City UT. 84102 1280 E Stringham Ave p 801.587.3287 p 801.581.7951 p 801.585.1212 Salt Lake City UT. 84106 p 801.581.7951 729 S Arapeen Dr Hospital Affiliation Hospital Affiliation Salt Lake City UT. 84108 - University of Utah Hospital - University of Utah Hospital 3730 W 4700 S p 801.585.6387 Salt Lake City UT. 84129 Giles, Lisa E MD Eliason, Benjamin A p 801.581.7951 Hospital Affiliation University of Utah Health Adult Behavioral Health - Salt Lake Regional Medical 100 N Mario Capecchi Dr JVMC-WVC - IP University Of Utah Health Center Salt Lake City UT. 84113 3460 S 4155 W 5th Fl 50 N Medical Dr - University of Utah Hospital p 801.313.7711 West Valley City UT. 84120 Salt Lake City UT. 84132 p 801.964.3111 p 801.581.7951 *Freund Begley, Kelli Primary Childrens Hospital *APRN 5770 S 1500 W Adult Behavioral Health 501 S Chipeta Way PCH RESIDENTIAL TRMNT-ADOL Taylorsville UT. 84123 JVMC-WVC - OP Salt Lake City UT. 84108 5770 S 1500 W p 801.313.7770 4052 W Pioneer Pkwy p 801.585.1575 Taylorsville UT. 84123 Ste 105 p 801.313.7940 81 N Mario Capecchi Dr West Valley City UT. 84120 51 W 3900 S Salt Lake City UT. 84113 p 801.554.3420 Salt Lake City UT. 84107 Hospital Affiliation p 801.662.5592 p 801.587.2370 - Primary Childrens Hospital Faizi, Sajid MD Hospital Affiliation White Tree Medical University of Utah Health Gethin-Jones, Thomas L - Primary Childrens Hospital Consultants LLC 5126 W Daybreak Pkwy University Of Utah Health 10437 S Jordan Gateway South Jordan UT. 84009 50 N Medical Dr Gilley Hensley, Laura B South Jordan UT. 84095 p 801.581.7951 Salt Lake City UT. 84132 MD p 385.535.6996 p 801.581.7951 University of Utah Health University Of Utah Health 1280 E Stringham Ave Hospital Affiliation 525 E 100 S 501 S Chipeta Way Salt Lake City UT. 84106 - Davis Hospital Ste 5000 Salt Lake City UT. 84108 p 801.581.7951 - Jordan Valley Medical Salt Lake City UT. 84102 p 801.583.2500 Center West Valley Campus p 801.585.1212 1950 Cir of Hope Dr - Salt Lake Regional Medical 525 E 100 S Salt Lake City UT. 84112 Center University of Utah Health Ste 5000 p 801.583.2500 555 Foothill Dr Salt Lake City UT. 84102 Faust, Barbara NP Salt Lake City UT. 84112 p 801.585.1212 50 N Medical Dr University of Utah Health p 801.581.7951 Salt Lake City UT. 84132 81 N Mario Capecchi Dr Hospital Affiliation p 801.585.1575 Salt Lake City UT. 84113 7495 S State St - University of Utah Hospital p 801.587.2255 Midvale UT. 84047 501 S Chipeta Way p 801.581.7951 Gibbs, Paula K MD Salt Lake City UT. 84108 Francis, Kristin C MD University of Utah Health p 801.587.3287 University of Utah Health Hospital Affiliation 1280 E Stringham Ave 1280 E Stringham Ave - University of Utah Hospital Salt Lake City UT. 84106 Hospital Affiliation Salt Lake City UT. 84106 p 801.581.7951 - University of Utah Hospital p 801.581.7951 Freimer, Martin MD University of Utah Health 1950 Cir of Hope Dr Godecke, Kelly 1950 Cir of Hope Dr 1280 E Stringham Ave Salt Lake City UT. 84112 University Of Utah Health Salt Lake City UT. 84112 Salt Lake City UT. 84106 p 801.583.2500 50 N Medical Dr p 801.583.2500 p 801.581.7951 Salt Lake City UT. 84132 50 N Medical Dr p 801.585.1575 50 N Medical Dr 154 E Myrtle Ave Salt Lake City UT. 84132 Salt Lake City UT. 84132 Salt Lake City UT. 84107 p 801.585.1575 501 S Chipeta Way p 801.585.1575 p 801.581.2628 Salt Lake City UT. 84108 501 S Chipeta Way p 801.583.2500 501 S Chipeta Way 1950 Cir of Hope Dr Salt Lake City UT. 84108 Salt Lake City UT. 84108 Salt Lake City UT. 84112 p 801.587.3287 525 E 100 S p 801.587.3287 p 801.583.2500 Ste 5000 555 Foothill Dr Salt Lake City UT. 84102 Hospital Affiliation 50 N Medical Dr Salt Lake City UT. 84112 p 801.585.1212 - University of Utah Hospital Salt Lake City UT. 84132 p 801.581.7951 p 801.585.1575 Hospital Affiliation - University of Utah Hospital

384 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Godwin, Susan M NP Hejazi, Jamal MD Jerome, Peggy A APRN 501 S Chipeta Way Mountain Paths Counseling Odyssey House of Utah Lotus Center Inc Salt Lake City UT. 84108 7069 S Highland Dr 350 E 2100 S 4376 S 700 E p 801.587.3287 Ste 100 Unit 6 Salt Lake City UT. 84115 Ste 200 Salt Lake City UT. 84121 p 801.428.3241 Salt Lake City UT. 84107 Hospital Affiliation p 801.214.1565 p 385.272.4292 - University of Utah Hospital Clinical Consultants Gray, Douglas D MD 7601 S Redwood Rd Bldg E Johnson, Clark MD Kious, Brent M MD,PhD University of Utah Health West Jordan UT. 84084 Senior Behavioral Health University of Utah Health 1138 E Wilmington Ave p 801.223.8670 SLC - IP 1280 E Stringham Ave Salt Lake City UT. 84106 1050 E S Temple 2nd Fl Salt Lake City UT. 84106 p 801.213.8845 Sundance Behavioral Salt Lake City UT. 84102 p 801.581.7951 Resources p 801.350.4111 1280 E Stringham Ave 845 E 4800 S 50 N Medical Dr Salt Lake City UT. 84106 Ste 200 Adult Behavioral Health Salt Lake City UT. 84132 p 801.581.7951 Murray UT. 84107 JVMC-WVC - IP p 801.585.6387 p 801.264.9522 3460 S 4155 W 5th Fl 50 N Medical Dr West Valley City UT. 84120 501 S Chipeta Way Salt Lake City UT. 84132 Hospital Affiliation p 801.964.3111 Salt Lake City UT. 84108 p 801.585.1575 - Mountain West Medical p 801.587.3287 Center 560 S 300 E 501 S Chipeta Way Ste 155 Hospital Affiliation Salt Lake City UT. 84108 Hoff, Troy C DO,PhD Salt Lake City UT. 84111 - University of Utah Hospital p 801.587.3287 University of Utah Health p 801.350.4111 50 N Medical Dr Kleinschmit, Kristi K MD Hospital Affiliation Salt Lake City UT. 84132 Senior Behavioral Health University of Utah Health - University of Utah Hospital p 801.585.1575 SLC - OP 1138 E Wilmington Ave 82 S 1100 E Salt Lake City UT. 84106 Harding, Shannon N APRN 501 S Chipeta Way Ste 404 p 801.213.8845 Valley Behavioral Health Salt Lake City UT. 84108 Salt Lake City UT. 84102 1020 S Main St p 801.587.3287 p 801.350.4777 1280 E Stringham Ave Ste 100 Salt Lake City UT. 84106 Salt Lake City UT. 84101 Hospital Affiliation Hospital Affiliation p 801.581.7951 p 888.949.4864 - University of Utah Hospital - Davis Hospital 50 N Medical Dr 2948 S Redwood Rd Howell, Elizabeth F MD Johnson, Glen E MD Salt Lake City UT. 84132 West Valley City UT. 84119 University of Utah Health 3940 W 4100 S p 801.585.1575 p 888.949.4864 1280 E Stringham Ave Salt Lake City UT. 84120 Salt Lake City UT. 84106 p 801.966.3700 501 S Chipeta Way Hardy III, James PA-C p 801.581.7951 Salt Lake City UT. 84108 Comprehensive Johnston, Mark MD p 801.587.3287 Psychological Services 50 N Medical Dr Ascendant Behavioral 1208 E 3300 S Salt Lake City UT. 84132 Health Wasatch Pediatrics - Salt Lake City UT. 84106 p 801.585.1575 5383 S 900 E Willow Creek p 801.264.6000 Ste 103 7138 S 2000 E 501 S Chipeta Way Salt Lake City UT. 84117 Ste 106 Harris, Debra Jill J Salt Lake City UT. 84108 p 801.872.5516 Salt Lake City UT. 84121 Senior Behavioral Health p 801.587.3287 p 801.942.1800 SLC - OP Kendrick, Ernest J MD 82 S 1100 E Hospital Affiliation University of Utah Health Kondo, Douglas G MD Ste 404 - University of Utah Hospital 1280 E Stringham Ave University of Utah Health Salt Lake City UT. 84102 Salt Lake City UT. 84106 1280 E Stringham Ave p 801.350.4777 Howsley, Jessica Z MD p 801.581.7951 Salt Lake City UT. 84106 University of Utah Health p 801.581.7951 Harrop, Elizabeth A APRN 50 N Medical Dr 1950 Cir of Hope Dr Ascendant Behavioral Salt Lake City UT. 84132 Salt Lake City UT. 84112 50 N Medical Dr Health p 801.585.1575 p 801.583.2500 Salt Lake City UT. 84132 5383 S 900 E p 801.585.1575 Ste 103 501 S Chipeta Way 50 N Medical Dr Salt Lake City UT. 84117 Salt Lake City UT. 84108 Salt Lake City UT. 84132 501 S Chipeta Way p 801.872.5516 p 801.587.3287 p 801.581.7951 Salt Lake City UT. 84108 p 801.587.3287 Hospital Affiliation - University of Utah Hospital

385 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:48 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Lewis, Benjamin R MD Marcum, James M MD University of Utah Health Murray, Brad L MD University of Utah Health Cedar Psychiatry 525 E 100 S University of Utah Health 1280 E Stringham Ave 1208 E 3300 S Ste 5000 1280 E Stringham Ave Salt Lake City UT. 84106 Salt Lake City UT. 84106 Salt Lake City UT. 84102 Salt Lake City UT. 84106 p 801.581.7951 p 801.369.8989 p 801.585.1212 p 801.581.7951

50 N Medical Dr 721 E 12200 S Mickey, Brian J MD,PhD 1950 Cir of Hope Dr Salt Lake City UT. 84132 Draper UT. 84020 University of Utah Health Salt Lake City UT. 84112 p 801.585.1575 p 801.369.8989 1280 E Stringham Ave p 801.583.2500 Salt Lake City UT. 84106 501 S Chipeta Way Martineau, Karl T DO p 801.581.7951 50 N Medical Dr Salt Lake City UT. 84108 MountainStar Behavioral Salt Lake City UT. 84132 p 801.587.3287 Health 1950 Cir of Hope Dr p 801.585.1575 1200 E 3900 S Salt Lake City UT. 84112 Hospital Affiliation Salt Lake City UT. 84124 p 801.583.2500 501 S Chipeta Way - University of Utah Hospital p 801.268.7111 Salt Lake City UT. 84108 50 N Medical Dr p 801.587.3287 Lewis, Gina McCarthey, Rachele M MD Salt Lake City UT. 84132 Senior Behavioral Health University of Utah Health p 801.585.1575 Hospital Affiliation SLC - IP 1280 E Stringham Ave - University of Utah Hospital 1050 E S Temple 2nd Fl Salt Lake City UT. 84106 501 S Chipeta Way Salt Lake City UT. 84102 p 801.581.7951 Salt Lake City UT. 84108 Neuman, Mark D MD p 801.350.4111 p 801.587.3287 Comprehensive 50 N Medical Dr Psychological Services Adult Behavioral Health Salt Lake City UT. 84132 Hospital Affiliation 1208 E 3300 S JVMC-WVC - IP p 801.585.1575 - University of Utah Hospital Salt Lake City UT. 84106 3460 S 4155 W 5th Fl p 801.483.1600 West Valley City UT. 84120 501 S Chipeta Way Moench, Matthew L MD p 801.964.3111 Salt Lake City UT. 84108 University of Utah Health 3725 W 4100 S p 801.587.3287 1280 E Stringham Ave West Valley City UT. 84120 Lin, Anne G MD Salt Lake City UT. 84106 p 801.483.1600 University of Utah Health Hospital Affiliation p 801.581.7951 1280 E Stringham Ave - University of Utah Hospital ODonohoe, Jennifer G MD Salt Lake City UT. 84106 501 S Chipeta Way University of Utah Health p 801.581.7951 McIntosh, J M MD Salt Lake City UT. 84108 1280 E Stringham Ave University of Utah Health p 801.587.3287 Salt Lake City UT. 84106 50 N Medical Dr 501 S Chipeta Way p 801.581.7951 Salt Lake City UT. 84132 Salt Lake City UT. 84108 Hospital Affiliation p 801.585.1575 p 801.583.2500 - University of Utah Hospital 1950 Cir of Hope Dr Salt Lake City UT. 84112 501 S Chipeta Way Hospital Affiliation Moretti, Paolo M MD p 801.583.2500 Salt Lake City UT. 84108 - University of Utah Hospital University of Utah Health p 801.587.3287 175 N Medical Dr E 50 N Medical Dr Measom, Michael O MD Salt Lake City UT. 84132 Salt Lake City UT. 84132 Hospital Affiliation Center for Human Potential p 801.585.7575 p 801.585.1575 - University of Utah Hospital 265 E 100 S Ste 250 50 N Medical Dr 501 S Chipeta Way Lines, Robin MD Salt Lake City UT. 84111 Salt Lake City UT. 84132 Salt Lake City UT. 84108 Adult Behavioral Health p 801.483.2447 p 801.585.6387 p 801.587.3287 (JVMC-WVC - IP) 3460 S 4155 W 5th Fl Hospital Affiliation 729 S Arapeen Dr Hospital Affiliation West Valley City UT. 84120 - University of Utah Hospital Salt Lake City UT. 84108 - University of Utah Hospital p 801.964.3111 p 801.585.6387 Merrill, Jordan W MD Ortega, Catherine PA Hospital Affiliation University of Utah Health Hospital Affiliation Comprehensive - Jordan Valley Medical Department of Psychiatry - University of Utah Hospital Psychological Services Center West Valley Campus 50 N Medical Dr 1208 E 3300 S Salt Lake City UT. 84132 Moulton, David L MD Salt Lake City UT. 84106 Manov, Ludmil K MD p 801.581.7951 University of Utah Health p 801.264.6000 1387 S 1100 E 50 N Medical Dr Salt Lake City UT. 84105 University of Utah Health Salt Lake City UT. 84132 Parker, James E PA-C p 801.463.4963 UNI Chipeta Outpatient p 801.581.7951 Comprehensive Clinic - Adult Psychological Services 501 S Chipeta Way Hospital Affiliation 1208 E 3300 S Salt Lake City UT. 84108 - University of Utah Hospital Salt Lake City UT. 84106 p 801.585.1575 p 801.483.1600

386 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Petersen, Anthony M MD *Rich, Christopher C MD *Schwei, Mark G MD Stevens, Paul T MD A New Direction Recovery & Primary Childrens Hospital Primary Childrens Hospital University of Utah Health Wellness 5770 S 1500 W 5770 S 1500 W 1280 E Stringham Ave 8686 S 1300 E Taylorsville UT. 84123 Taylorsville UT. 84123 Salt Lake City UT. 84106 Sandy UT. 84094 p 801.313.7770 p 801.313.7770 p 801.581.7951 p 801.709.0748 81 N Mario Capecchi Dr Hospital Affiliation 50 N Medical Dr Hospital Affiliation Salt Lake City UT. 84113 - Primary Childrens Hospital Salt Lake City UT. 84132 - Lakeview Hospital p 801.662.5592 p 801.581.7951 Smith, Amy MD Pham, Duy MD Hospital Affiliation University of Utah Health 501 S Chipeta Way University of Utah Health - Primary Childrens Hospital 1280 E Stringham Ave Salt Lake City UT. 84108 1280 E Stringham Ave Salt Lake City UT. 84106 p 801.587.3287 Salt Lake City UT. 84106 Rindflesh, Mark A MD p 801.581.7951 p 801.581.7951 University of Utah Health Hospital Affiliation 1280 E Stringham Ave 50 N Medical Dr - University of Utah Hospital 501 S Chipeta Way Salt Lake City UT. 84106 Salt Lake City UT. 84132 Salt Lake City UT. 84108 p 801.581.7951 p 801.585.1575 Stoddart, Jeremy R MD p 801.587.3287 University of Utah Health 50 N Medical Dr 501 S Chipeta Way 375 S Chipeta Way Pierson, Matthew D MD Salt Lake City UT. 84132 Salt Lake City UT. 84108 Salt Lake City UT. 84108 University of Utah Health p 801.585.1575 p 801.587.3287 p 801.581.2016 1280 E Stringham Ave Salt Lake City UT. 84106 501 S Chipeta Way Hospital Affiliation Sugden, Steven G MD p 801.581.7951 Salt Lake City UT. 84108 - University of Utah Hospital University of Utah Health p 801.587.3287 50 N Medical Dr 1950 Cir of Hope Dr Solzbacher, Daniela MD Salt Lake City UT. 84132 Salt Lake City UT. 84112 Robison, Reid J MD University of Utah Health p 801.585.1575 p 801.583.2500 Cedar Psychiatry 1280 E Stringham Ave 1208 E 3300 S Salt Lake City UT. 84106 501 S Chipeta Way 50 N Medical Dr Salt Lake City UT. 84106 p 801.581.7951 Salt Lake City UT. 84108 Salt Lake City UT. 84132 p 801.369.8989 p 801.587.3287 p 801.585.1575 501 S Chipeta Way 154 E Myrtle Ave Salt Lake City UT. 84108 Hospital Affiliation 501 S Chipeta Way Ste 204 p 801.587.3287 - University of Utah Hospital Salt Lake City UT. 84108 Murray UT. 84107 p 801.587.3287 p 801.369.8989 Hospital Affiliation Teynor, Steven V LCSW - University of Utah Hospital Teynor Physicians Group, Hospital Affiliation 721 E 12200 S PLLC - University of Utah Hospital Draper UT. 84020 Spencer, Melissa J APRN 2290 E 4500 S p 801.369.8989 Valley Behavioral Health Ste 215 Pohl, Richard L MD 1020 S Main St Salt Lake City UT. 84117 Sundance Behavioral Hospital Affiliation Ste 100 p 801.534.1360 Resources - Mountain View Hospital Salt Lake City UT. 84101 845 E 4800 S (UT) p 888.949.4864 Thatcher, Benjamin T DO Ste 200 - Utah Valley Hospital Valley Behavioral Health Salt Lake City UT. 84107 Steinmann, Mary E MD 1020 S Main St p 801.264.9522 SAMUDRA, KALYANI MD University of Utah Health Ste 100 University of Utah Health 1950 Cir of Hope Dr Salt Lake City UT. 84101 Reid, T Michael MD 1280 E Stringham Ave Salt Lake City UT. 84112 p 888.949.4864 Sundance Behavioral Salt Lake City UT. 84106 p 801.583.2500 Resources p 801.581.7951 12427 S Pasture Rd 845 E 4800 S 50 N Medical Dr Ste 104 Ste 200 50 N Medical Dr Salt Lake City UT. 84132 Riverton UT. 84096 Murray UT. 84107 Salt Lake City UT. 84132 p 801.581.7951 p 888.949.4864 p 801.264.9522 p 801.585.1575 501 S Chipeta Way 4460 S Highland Dr Hospital Affiliation 501 S Chipeta Way Salt Lake City UT. 84108 Ste 100 - Mountain West Medical Salt Lake City UT. 84108 p 801.587.3287 Salt Lake City UT. 84124 Center p 801.587.3287 p 888.949.4864 Hospital Affiliation Reimherr, Frederick W MD Sarhadi, Marissa D APRN - University of Utah Hospital Thatcher, John W MD Psychiatric & Behavioral Compass Counseling and JVMC - WVC Behavioral Solutions Consulting Health - IP 1522 S 1100 E 4000 S 700 E 3460 S Pioneer Pkwy Salt Lake City UT. 84105 Ste 9 West Valley City UT. 84120 p 801.467.1200 Salt Lake City UT. 84107 p 801.964.3575 p 801.639.9544 387 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Thayer, Stephen PhD Toth, Michele MD Vo, Michelle L MD Weir, Rachel A MD Cedar Psychiatry Jordan Valley Medical University of Utah Health University of Utah Health 154 E Myrtle Ave Center West Valley Campus 1280 E Stringham Ave 1280 E Stringham Ave Ste 204 Inpatient BH Unit Salt Lake City UT. 84106 Salt Lake City UT. 84106 Murray UT. 84107 3460 S 4155 W p 801.581.7951 p 801.581.7951 p 801.369.8989 West Valley City UT. 84120 p 801.964.3559 1950 Cir of Hope Dr 1525 W 2100 S 721 E 12200 S Salt Lake City UT. 84112 Salt Lake City UT. 84119 Draper UT. 84020 Hospital Affiliation p 801.583.2500 p 801.213.8841 p 801.369.8989 - Jordan Valley Medical Center 50 N Medical Dr 50 N Medical Dr Thielking, Paul D MD Salt Lake City UT. 84132 Salt Lake City UT. 84132 University of Utah Health Universtiy of Utah Health p 801.585.1575 p 801.585.1575 1280 E Stringham Ave Care Girls Transition Salt Lake City UT. 84106 Center 501 S Chipeta Way 501 S Chipeta Way p 801.581.7951 51 W 3900 S Salt Lake City UT. 84108 Salt Lake City UT. 84108 Salt Lake City UT. 84107 p 801.587.3287 p 801.587.3287 Cedar Psychiatry p 801.583.2500 154 E Myrtle Ave Hospital Affiliation Hospital Affiliation Ste 204 Valles, Rene J MD - University of Utah Hospital - University of Utah Hospital Murray UT. 84107 Valley Behavioral Health p 801.369.8989 1141 E 3900 S Voss, Michael J MD Weischedel, Kamile MD Ste A170 University of Utah Health University of Utah Health University of Utah Health Salt Lake City UT. 84124 1950 Cir of Hope Dr 1280 E Stringham Ave 1950 Cir of Hope Dr p 888.949.4864 Salt Lake City UT. 84112 Salt Lake City UT. 84106 Salt Lake City UT. 84112 p 801.583.2500 p 801.581.7951 p 801.583.2500 Hospital Affiliation - Jordan Valley Medical 50 N Medical Dr 501 S Chipeta Way 50 N Medical Dr Center West Valley Campus Salt Lake City UT. 84132 Salt Lake City UT. 84108 Salt Lake City UT. 84132 p 801.581.7951 p 801.587.3287 p 801.585.1575 Vejerla, Keerthi P MD University of Utah Health 501 S Chipeta Way Hospital Affiliation 501 S Chipeta Way 50 N Medical Dr Salt Lake City UT. 84108 - University of Utah Hospital Salt Lake City UT. 84108 Salt Lake City UT. 84132 p 801.587.3287 p 801.587.3287 p 801.581.7951 West, Timothy MD Hospital Affiliation Rocky Mountain Multiple Cedar Psychiatry 501 S Chipeta Way - University of Utah Hospital Sclerosis Clinic 721 E 12200 S Salt Lake City UT. 84132 370 E 9th Ave Draper UT. 84020 p 801.585.1575 Ward, Cori APRN Ste 106 p 801.369.8989 Utah Behavior Services Salt Lake City UT. 84103 Hospital Affiliation 5558 S 1900 W p 801.408.5700 Hospital Affiliation - University of Utah Hospital Ste B - University of Utah Hospital Salt Lake City UT. 84129 Wiese, Julie MD Vinegra, Christopher J MD p 801.255.5131 Sundance Behavioral Thrasher, Marie APRN Senior Behavioral Health - Resources University of Utah Health Inpatient 6013 S Redwood Rd 845 E 4800 S 50 N Medical Dr 1050 E S Temple 2nd Fl Salt Lake City UT. 84123 Ste 200 Salt Lake City UT. 84132 Salt Lake City UT. 84102 p 801.255.5131 Murray UT. 84107 p 801.581.4014 p 801.350.4111 p 801.264.9522 Wark, Heather MD 5126 W Daybreak Pkwy Jordan Valley Outpatient Salt Lake Regional Medical Wilson, Amy L MD South Jordan UT. 84009 Behavioral Health - West Center - BH Unit University of Utah Health p 801.213.4500 Valley 1050 E S Temple 1280 E Stringham Ave 4052 W Pioneer Pkwy Salt Lake City UT. 84102 Salt Lake City UT. 84106 Thueson, Jeremy E MD Ste 105 p 801.350.4715 p 801.581.7951 University of Utah Health West Valley City UT. 84120 1280 E Stringham Ave p 801.964.3752 Adult Behavioral Health 1950 Cir of Hope Dr Salt Lake City UT. 84106 JVMC-WVC - OP Salt Lake City UT. 84112 p 801.581.7951 Hospital Affiliation 4052 W Pioneer Pkwy p 801.583.2500 - St Marks Hospital Ste 105 501 S Chipeta Way - Salt Lake Regional Medical West Valley City UT. 84120 50 N Medical Dr Salt Lake City UT. 84108 Center p 801.964.3111 Salt Lake City UT. 84132 p 801.587.3287 p 801.585.1575

Hospital Affiliation - University of Utah Hospital

388 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 501 S Chipeta Way Addiction and Beckstead, A L PhD Christensen, Deborah A Salt Lake City UT. 84108 Psychological Services Aspen Grove Counseling PhD p 801.587.3287 6065 S Fashion Blvd 1433 S 1100 E Corner Canyon Counseling Ste 140 Salt Lake City UT. 84105 and Psychologist Services Hospital Affiliation Salt Lake City UT. 84107 p 801.581.0422 248 E 13800 S - University of Utah Hospital p 801.268.2558 Ste 4 Brockbank, Laura B PhD Draper UT. 84020 Yau, Joseph K MD Albertsen, Elizabeth PhD Laura B Brockbank PHD p 801.335.6349 Ascendant Behavioral Valley Behavioral Health 1399 S 700 E Health 1141 E 3900 S Ste 7 Christy, Monica D PhD 5383 S 900 E Ste A250 Salt Lake City UT. 84105 Monica D Christy PhD, PC Ste 103 Salt Lake City UT. 84124 p 801.483.3068 5383 S 900 E Salt Lake City UT. 84117 p 888.949.4864 Ste 290 p 801.872.5516 Hospital Affiliation Salt Lake City UT. 84117 3809 W 6200 S - University of Utah Hospital p 801.263.3335 Hospital Affiliation Salt Lake City UT. 84129 - University of Utah Hospital p 888.949.4864 Buerger, Natalie K PhD Clark, Claire H PhD University of Utah Health 150 S 600 E Zehnder, Jean D MD 443 S 600 E 50 N Medical Dr Ste 8-B Exodus Healthcare Network Salt Lake City UT. 84102 Salt Lake City UT. 84132 Salt Lake City UT. 84102 3336 S Pioneer Pkwy p 888.949.4864 p 801.581.7951 p 801.259.8325 Ste 201 Salt Lake City UT. 84120 Applewhite, Kimberly C Hospital Affiliation Clews, Kelsey PSYD p 801.250.9638 PsyD - University of Utah Hospital Wasatch Pediatrics - University of Utah Health Draper Hospital Affiliation 1138 E Wilmington Ave Burke, Renee PhD 114 E 12450 S - University of Utah Hospital Salt Lake City UT. 84106 University Of Utah Health Ste 100 p 801.213.8845 1280 E Stringham Ave Draper UT. 84020 Zubieta, Jon Kar MD Salt Lake City UT. 84106 p 801.523.3001 University of Utah Health 1280 E Stringham Ave p 801.581.7951 1950 Cir of Hope Dr Salt Lake City UT. 84106 Cloyd, James H PhD Salt Lake City UT. 84112 p 801.581.7951 154 E Myrtle Ave Alta Pain Physicians p 801.583.2500 Salt Lake City UT. 84107 11333 S 1000 E 154 E Myrtle Ave p 801.581.2628 Ste 102 50 N Medical Dr Salt Lake City UT. 84107 Sandy UT. 84094 Salt Lake City UT. 84132 p 801.581.2628 1950 Cir of Hope Dr p 801.462.2205 p 801.581.7951 Salt Lake City UT. 84112 1950 Cir of Hope Dr p 801.583.2500 Nexus Pain Care 501 S Chipeta Way Salt Lake City UT. 84112 1575 W 7000 S Salt Lake City UT. 84108 p 801.583.2500 50 N Medical Dr West Jordan UT. 84084 p 801.587.3287 Salt Lake City UT. 84132 p 801.833.6569 50 N Medical Dr p 801.581.7951 Hospital Affiliation Salt Lake City UT. 84132 Connelly, Julia PhD - University of Utah Hospital p 801.585.1575 University of Utah Health The Autism Clinic 501 S Chipeta Way 1537 S Main St Psychology 501 S Chipeta Way Salt Lake City UT. 84108 Salt Lake City UT. 84115 Accardi-Ravid, Michelle Salt Lake City UT. 84108 p 801.583.2500 p 801.699.3133 Phd p 801.585.1575 University Of Utah Health University Of Utah Health Courtney, Robert J PhD 30 N 1900 E Rm 1B620 Hospital Affiliation 51 W 3900 S University of Utah Health Salt Lake City UT. 84132 - University of Utah Hospital Salt Lake City UT. 84107 1280 E Stringham Ave p 801.581.6228 p 801.587.2370 Salt Lake City UT. 84106 Ballou, Carol A PhD p 801.581.6228 Hospital Affiliation University of Utah Health Burnham, T L PhD - University of Utah Hospital 50 N Medical Dr Jordan West Family University Of Utah Health Salt Lake City UT. 84132 Counseling 85 N Medical Dr Adams, David B PhD p 801.581.7951 9263 Redwood Rd Bldg 8 Salt Lake City UT. 84112 South Valley Associates Ste B p 801.581.6228 6925 S Union Park Ctr Baron, Kelly G PhD West Jordan UT. 84088 Ste 490 University of Utah Health p 801.566.0749 Hospital Affiliation Midvale UT. 84047 375 S Chipeta Way - University of Utah Hospital p 801.566.2622 Ste A200 Cardinal, Jennifer R PhD, Salt Lake City UT. 84108 BCBA p 801.581.2016 Neurobehavioral Center for Growth 370 E South Temple Ste 175 Salt Lake City UT. 84111 p 801.683.1062 389 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Cunningham, Sean D PhD Dryjski, Mona L Phd Feldman, Kristina J Phd Fuller, Kayleen M PhD University of Utah Health University of Utah Health University of Utah Health Calm Mind Inc 100 N Mario Capecchi Dr 1280 E Stringham Ave 50 N Medical Dr 8706 S 700 E Salt Lake City UT. 84113 Salt Lake City UT. 84106 Salt Lake City UT. 84132 Ste 103 p 801.587.2255 p 801.581.7951 p 801.581.7951 Sandy UT. 84070 p 801.652.2720 50 N Medical Dr Hospital Affiliation 501 S Chipeta Way Salt Lake City UT. 84132 - University of Utah Hospital Salt Lake City UT. 84132 Gant, Ralph W PhD p 801.581.2205 p 801.585.1575 5525 S 900 E Sports Mall Duff, Kevin M PhD Plaza II, 81 N Mario Capecchi Dr University of Utah Health Hospital Affiliation Ste 102 Salt Lake City UT. 84113 50 N Medical Dr - University of Utah Hospital Salt Lake City UT. 84117 p 801.587.2255 Salt Lake City UT. 84132 p 801.262.3700 p 801.585.6387 Fidler, Scott W PhD Hospital Affiliation Scott W Fidler, PsyD Garrett, Kelly D PhD - University of Utah Hospital Hospital Affiliation 12176 S 1000 E Rocky Mountain Multiple - University of Utah Hospital Ste 8-F Sclerosis Clinic Derbidge, Christina M PhD Draper UT. 84020 370 E 9th Ave University of Utah Health Edgington, Carl PhD p 801.619.3569 Ste 106 30 N 1900 E Rm 1B620 ABS Kids Salt Lake City UT. 84103 Salt Lake City UT. 84132 515 S 700 E Fortenberry, Katherine T p 801.408.5700 p 801.581.6228 Ste 2A PhD Salt Lake City UT. 84102 University of Utah Health Goldman, Sarah PhD Hospital Affiliation p 801.935.4171 1138 E Wilmington Ave Summit Community - University of Utah Hospital Salt Lake City UT. 84106 Counseling 6910 S Highland Dr p 801.581.2000 5689 S Redwood Rd Docherty, Anna R PhD Ste 1 Ste 27 University of Utah Health Salt Lake City UT. 84121 1280 E Stringham Ave Salt Lake City UT. 84123 1280 E Stringham Ave p 801.935.4171 Salt Lake City UT. 84106 p 801.266.2485 Salt Lake City UT. 84106 p 801.581.2000 p 801.581.7951 *Elish, Katie F PhD 5991 S Redwood Rd PCH RESIDENTIAL HOME 1525 W 2100 S Salt Lake City UT. 84123 50 N Medical Dr 5770 S 1500 W Bldg C Salt Lake City UT. 84119 p 801.266.2485 Salt Lake City UT. 84132 Taylorsville UT. 84123 p 801.213.8841 p 801.581.7951 p 801.313.7954 Goldstein, Sam PhD 50 N Medical Dr 230 S 500 E 501 S Chipeta Way PCH PSYCHIATRY Salt Lake City UT. 84132 Ste 100 Salt Lake City UT. 84108 5770 S 1500 W p 801.581.2121 Salt Lake City UT. 84102 p 801.583.2500 Taylorsville UT. 84123 p 801.532.1484 p 801.313.7770 555 Foothill Dr University Of Utah Health Ste 301 *Haase, Lyssa PsyD 525 E 100 S Hospital Affiliation Salt Lake City UT. 84112 PCH PSYCHIATRY Ste 5000 - Primary Childrens Hospital p 801.581.8000 5770 S 1500 W Salt Lake City UT. 84102 Taylorsville UT. 84123 p 801.585.1212 Evans, Lyndsey M PhD 555 Foothill Dr p 801.313.7770 Neurobehavioral Center for Salt Lake City UT. 84112 Hospital Affiliation Growth p 801.581.8000 Hallett, C B PhD - University of Utah Hospital 370 E South Temple Center for Human Potential Ste 175 Hospital Affiliation 265 E 100 S Donnelly, Stephanie L PhD Salt Lake City UT. 84111 - University of Utah Hospital Ste 250 University of Utah Health p 801.683.1062 Salt Lake City UT. 84111 50 N Medical Dr Frost, Robert B PhD p 801.483.2447 Salt Lake City UT. 84132 Farrar, Jessica D Phd University of Utah Health p 801.581.7951 University of Utah Health 175 N Medical Dr E Hammers, Dustin B PhD 1280 E Stringham Ave Salt Lake City UT. 84132 University of Utah Health 501 S Chipeta Way Salt Lake City UT. 84106 p 801.585.7575 50 N Medical Dr Salt Lake City UT. 84108 p 801.581.7951 Salt Lake City UT. 84132 p 801.585.1575 50 N Medical Dr p 801.581.2121 Hospital Affiliation Salt Lake City UT. 84132 51 W 3900 S - University of Utah Hospital p 801.585.6387 Hospital Affiliation Salt Lake City UT. 84102 - University of Utah Hospital p 801.585.1212 Fehlberg, Amy L PhD 729 S Arapeen Dr 1060 E 100 S Salt Lake City UT. 84108 Hospital Affiliation Ste 100 p 801.585.6387 - University of Utah Hospital Salt Lake City UT. 84102 p 435.901.0759 Hospital Affiliation - University of Utah Hospital

390 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Harris, Ted A PhD Kemmochi, Tomohiro PSYD Lyon, McCall PhD McGarrity, Larissa A PhD Center for Family University of Utah Health The Childrens Center University of Utah Health Evaluation and Treatment 50 N Medical Dr 350 S 400 E 30 N 1900 E Rm 1B620 Inc Salt Lake City UT. 84132 Salt Lake City UT. 84111 Salt Lake City UT. 84132 5691 S Redwood Rd p 801.581.7951 p 801.582.5534 p 801.581.6228 Ste 16A Taylorsville UT. 84123 Hospital Affiliation 5242 S 4820 W Hospital Affiliation p 801.265.3895 - University of Utah Hospital Salt Lake City UT. 84118 - University of Utah Hospital p 801.966.4251 Hayes, Loran PhD Kim, Joseph U Phd Mcglade, Erin C Phd Wasatch Pediatrics - University of Utah Health Malm, Karen W PhD University of Utah Health Draper 50 N Medical Dr Summit Community 50 N Medical Dr 114 E 12450 S Salt Lake City UT. 84132 Counseling Salt Lake City UT. 84132 Ste 100 p 801.581.7951 5689 S Redwood Rd p 801.581.7951 Draper UT. 84020 Ste 27 p 801.523.3001 501 S Chipeta Way Salt Lake City UT. 84123 501 S Chipeta Way Salt Lake City UT. 84132 p 801.266.2485 Salt Lake City UT. 84132 Herndon, Natalie C PhD p 801.585.1575 p 801.585.1575 Natalie C Herndon PHD CMHC 5991 S Redwood Rd 9071 S 1300 W Klein, Nanci C PhD Salt Lake City UT. 84123 Hospital Affiliation Ste 100 UIPT p 801.266.2485 - University of Utah Hospital West Jordan UT. 84088 265 E 100 S p 801.657.3330 Ste 275 Malouf, John PhD Medina-Salvatore, Nicole Salt Lake City UT. 84111 Valley Behavioral Health PSYD Hill, Diane PhD p 801.350.0116 12427 S Pasture Rd Neurobehavioral Center For Diane Hill PHD Ste 104 Growth 4505 S Wasatch Blvd Knorr, James PhD Riverton UT. 84096 370 E South Temple Ste 360 Summit Community p 888.949.4864 Ste 175 Salt Lake City UT. 84124 Counseling Salt Lake City UT. 84111 p 801.440.2430 5689 S Redwood Rd 4460 S Highland Dr p 801.683.1062 Ste 27 Ste 100 Hourmanesh, Najmeh PhD Salt Lake City UT. 84123 Salt Lake City UT. 84124 Mickens, Melody Phd Therapy For Kids p 801.266.2485 p 888.949.4864 University of Utah Health 160 S 1000 E 1280 E Stringham Ave Ste 330 5991 S Redwood Rd Hospital Affiliation Salt Lake City UT. 84106 Salt Lake City UT. 84102 Salt Lake City UT. 84123 - University of Utah Hospital p 801.581.6228 p 801.441.8943 p 801.266.2485 Mansour, Emma PhD 30 N 1900 E Rm 1B620 Houston, Ryan F PhD Utah Neuropsychology Life Matters: Counseling Salt Lake City UT. 84132 Comprehensive Services and Psychological Services p 801.581.6228 Psychological Services 7069 S Highland Dr 265 E 100 S 1208 E 3300 S Ste 5 Ste 250 Hospital Affiliation Salt Lake City UT. 84106 Salt Lake City UT. 84121 Salt Lake City UT. 84111 - University of Utah Hospital p 801.483.1600 p 801.441.0786 p 801.483.2447 Mitchell, Jennifer PhD 3725 W 4100 S Kocherhans, Jeff C PhD McCormick, Sarah H PhD The Childrens Center West Valley City UT. 84119 Comprehensive University of Utah Health 350 S 400 E p 801.965.3759 Psychological Services 1138 E Wilmington Ave Salt Lake City UT. 84111 1208 E 3300 S Salt Lake City UT. 84106 p 801.582.5534 Jewell, Jessica PhD Salt Lake City UT. 84106 p 801.213.8845 University of Utah Health p 801.483.1600 Morimoto, Sarah S PsyD 50 N Medical Dr 1280 E Stringham Ave University of Utah Health Salt Lake City UT. 84132 Levy, Elizabeth PhD Salt Lake City UT. 84106 50 N Medical Dr p 801.581.7951 Valley Behavioral Health p 801.213.8841 Salt Lake City UT. 84132 195 W 7200 S p 801.581.7951 Hospital Affiliation Midvale UT. 84047 555 Foothill Dr - University of Utah Hospital p 888.949.4864 Salt Lake City UT. 84112 525 E 100 S p 801.581.8000 Ste 5000 Kair, Kathryn M PhD Lundahl, Brad W PhD Salt Lake City UT. 84102 8160 S Highland Dr Compass Counseling and Hospital Affiliation p 801.585.1212 Ste 111 Consulting - University of Utah Hospital Sandy UT. 84093 4000 S 700 E Morris, Josh Phd p 801.792.4129 Ste 9 University Of Utah Health Salt Lake City UT. 84107 1280 E Stringham Ave p 801.639.9544 Salt Lake City UT. 84106 p 801.581.7951

391 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 154 E Myrtle Ave 6910 S Highland Dr Reyes, Carla J PhD *Sergent, Natalie PSYD Salt Lake City UT. 84107 Ste 1 A Childs Place PCH Residential Home p 801.581.2628 Salt Lake City UT. 84121 4568 S Highland Dr 5770 S 1500 W Bldg C p 801.935.4946 Ste 100 Taylorsville UT. 84123 1950 Cir of Hope Dr Salt Lake City UT. 84117 p 801.313.7954 Salt Lake City UT. 84112 Nosanchuk, Melvin F PhD p 801.232.5363 p 801.583.2500 1646 Kensington Ave PCH CHILD PSYCHOP Salt Lake City UT. 84105 Richards, R L PhD 5770 S 1500 W 50 N Medical Dr p 801.467.4875 12481 S Fort St Taylorsville UT. 84123 Salt Lake City UT. 84132 Draper UT. 84020 p 801.313.7770 p 801.581.7951 Okifuji, Akiko PhD p 801.938.9025 University of Utah Health Hospital Affiliation 501 S Chipeta Way 50 N Medical Dr Rith, Kendrick PhD - Primary Childrens Hospital Salt Lake City UT. 84108 Salt Lake City UT. 84132 ABS Kids p 801.583.2500 p 801.581.2121 6910 S Highland Dr Sharifan, Tara PSYD Ste 1 Comprehensive 525 E 100 S 615 S Arapeen Dr Salt Lake City UT. 84121 Psychological Services Ste 5000 Ste 100 p 801.935.4171 1208 E 3300 S Salt Lake City UT. 84102 Salt Lake City UT. 84108 Salt Lake City UT. 84106 p 801.585.1212 p 801.581.7246 Robinson, Kristin E PhD p 801.483.1600 Kristin E Robinson PHD Hospital Affiliation Parsons, Alison P PSYD 8184 S Highland Dr Shumway, Brett PSYD - University of Utah Hospital 2040 E Murray Holladay Rd Ste C8 Utah Behavior Services Ste 222 Sandy UT. 84093 5558 S 1900 W Moulton, Emily Phd Salt Lake City UT. 84124 p 801.944.1666 Ste B University of Utah Health p 801.803.1091 Taylorsville UT. 84118 81 N Mario Capecchi Dr *Robnett, Jessica M PSYD p 801.255.5131 Salt Lake City UT. 84113 Pearce, Brett PSYD PCH Gender Management And p 801.587.2255 Valley Behavioral Health Support 6013 S Redwood Rd 3809 W 6200 S 81 N Mario Capecchi Dr Taylorsville UT. 84123 Hospital Affiliation Salt Lake City UT. 84129 Salt Lake City UT. 84113 p 801.255.5131 - University of Utah Hospital p 888.949.4864 p 801.662.1600 Siebert, Tatum LCPC Mower, Richard K PhD 4460 S Highland Dr Hospital Affiliation Comprehensive Richard King Mower Ste 100 - University of Utah Hospital Psychological Services 336 E 900 S Salt Lake City UT. 84124 1208 E 3300 S Salt Lake City UT. 84111 p 888.949.4864 Rodgers, Kenneth C PhD Salt Lake City UT. 84106 p 801.292.6101 8160 S Highland Dr p 801.483.1600 Petersen, Jodi LCSW Ste 102 Musso, Alison PhD Ascendant Behavioral Sandy UT. 84093 Utah Behavior Services Sundance Behavioral Health p 801.943.3319 5558 S 1900 W Resources 5383 S 900 E Ste B 845 E 4800 S Ste 103 Romesser, Jennifer M PSYD Salt Lake City UT. 84129 Ste 200 Salt Lake City UT. 84117 Valley Behavioral Health p 801.255.5131 Murray UT. 84107 p 801.872.5516 1141 E 3900 S p 801.264.9522 Ste A250 6013 S Redwood Rd Plumb, Taylor R PSYD Salt Lake City UT. 84124 Salt Lake City UT. 84123 Ngu, Le Q PhD Valley Behavioral Health p 888.949.4864 p 801.255.5131 5801 S Fashion Blvd 195 W 7200 S Ste 200 Midvale UT. 84047 Russell Stamp, Mindy M Smith, Julien T PhD Salt Lake City UT. 84107 p 888.949.4864 PhD Wasatch Pediatric p 801.875.2128 Neurobehavioral Center for Neuropsychology Pramann, Robert F PhD Growth 231 E 400 S Nickolaisen, Steven MD Christian Counseling 370 E South Temple Ste 335 Comprehensive Centers of Utah Ste 175 Salt Lake City UT. 84111 Psychological Services 525 E 4500 S Salt Lake City UT. 84111 p 801.363.1189 1208 E 3300 S Ste F-125 p 801.683.1062 Salt Lake City UT. 84106 Salt Lake City UT. 84107 Stevens, Ashley L PhD p 801.483.1600 p 801.268.1564 Schiers, Cindy Jo PhD University of Utah Health Corner Canyon Counseling 81 N Mario Capecchi Dr Nicksic Springer, Taryn K Price, Linda M PhD and Psychologist Services Salt Lake City UT. 84113 PhD Millbrook Counseling 248 E 13800 S p 801.587.2255 ABS Kids 2118 E 3900 S Ste 4 515 S 700 E Ste 100 Draper UT. 84020 Hospital Affiliation Ste 2A Salt Lake City UT. 84124 p 801.816.1801 - University of Utah Hospital Salt Lake City UT. 84102 p 801.277.3620 p 801.935.4171

392 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Stewart, Mitzy APRN Turner, Donna E PhD Weisenbach, Sara L PhD 1950 Cir of Hope Dr Ascendant Behavioral Valley Behavioral Health University of Utah Health Salt Lake City UT. 84112 Health 4460 S Highland Dr 50 N Medical Dr p 801.583.2500 5383 S 900 E Ste 100 Salt Lake City UT. 84132 Ste 103 Salt Lake City UT. 84124 p 801.581.7951 50 N Medical Dr Salt Lake City UT. 84117 p 888.949.4864 Salt Lake City UT. 84132 p 801.872.5516 501 S Chipeta Way p 801.581.7951 Turnidge Halvorson, Salt Lake City UT. 84108 Stout, Kelly L PhD Nicole R PhD p 801.583.2500 Pulmonology University of Utah Health University of Utah Health Aberegg, Scott K MD 81 N Mario Capecchi Dr 50 N Medical Dr Hospital Affiliation University of Utah Health Salt Lake City UT. 84113 Salt Lake City UT. 84132 - University of Utah Hospital 50 N Medical Dr p 801.587.2255 p 801.585.1575 Salt Lake City UT. 84132 Whitaker, David H PSYD p 801.581.7806 Hospital Affiliation 501 S Chipeta Way David H Whitaker PsyD CMHC - University of Utah Hospital Salt Lake City UT. 84108 825 E 4800 S Hospital Affiliation p 801.585.1575 Ste 250C - Jordan Valley Medical Strachan, Robert K PhD Salt Lake City UT. 84107 Center Valley Behavioral Health 51 W 3900 S p 801.657.5883 1020 S Main St Salt Lake City UT. 84107 Ansari, Sikander Ste 200 p 801.585.1575 9001 S 3200 W University of Utah Health Salt Lake City UT. 84101 West Jordan UT. 84088 1950 Cir of Hope Dr p 888.949.4864 Hospital Affiliation p 801.657.5883 Salt Lake City UT. 84112 - University of Utah Hospital p 801.585.0100 Szykula, Steven A PhD White, Laura PhD Comprehensive Underwood, Rocky C PhD University of Utah Health 50 N Medical Dr Psychological Services Intermountain 50 N Medical Dr Salt Lake City UT. 84132 1208 E 3300 S Psychological Services Salt Lake City UT. 84132 p 801.581.7806 Salt Lake City UT. 84106 12401 S 450 E Bldg D-2 p 801.581.7951 p 801.483.1600 Draper UT. 84020 Beck, Emily M MD p 801.440.8501 Hospital Affiliation University of Utah Health 3725 W 4100 S - University of Utah Hospital 1950 Cir of Hope Dr West Valley City UT. 84119 Valley Behavioral Health Salt Lake City UT. 84112 p 801.965.3759 Phone Number Only Wilkerson, Tristyn PSYD p 801.585.0100 Salt Lake City UT. 84121 230 S 500 E Talbert, Kristina L PSYD p 888.949.4864 Ste 100 50 N Medical Dr South Point Counseling Salt Lake City UT. 84102 Salt Lake City UT. 84132 1206 W S Jordan Pkwy Vanderveen, John Phd p 801.532.1484 p 801.581.7806 Ste D University of Utah Health South Jordan UT. 84095 615 S Arapeen Dr Wilkes, Ryan W PSYD Hospital Affiliation p 801.302.3801 Ste 100 Wasatch Psychological - University of Utah Hospital Salt Lake City UT. 84108 Services Tate, David F PhD p 801.581.7246 1060 E 100 S Bird, Garrett R MD University of Utah Health Ste 100 Heart and Lung Institute 175 N Medical Dr E Villalobos, Michele E Phd Salt Lake City UT. 84102 of Utah Salt Lake City UT. 84132 University of Utah Health p 801.590.0525 3336 S 4155 W p 801.585.7575 81 N Mario Capecchi Dr Ste 203 Salt Lake City UT. 84113 Wilson Barlow, Lindsay D Salt Lake City UT. 84120 50 N Medical Dr p 801.587.2255 PhD p 801.263.2370 Salt Lake City UT. 84132 University of Utah Health p 801.585.6387 Hospital Affiliation 50 N Medical Dr 3570 W 9000 S - University of Utah Hospital Salt Lake City UT. 84132 Ste 110 729 S Arapeen Dr p 801.581.7951 West Jordan UT. 84088 Salt Lake City UT. 84108 Waddell, Kathryn J PhD p 801.263.2370 p 801.585.6387 Salt Lake Regional Medical Hospital Affiliation Center - BH Unit - University of Utah Hospital Steward Pulmonary Critical Thorn, Kirk B PhD 1050 E S Temple Care And Sleep Medicine - Willow Creek Psychological Salt Lake City UT. 84102 Yurgelun-Todd, Deborah A West Jordan Service Inc p 801.350.4715 PhD 3584 W 9000 S 1111 E Draper Pkwy University of Utah Health Ste 401 Ste 102 Wasatch Psychological 1280 E Stringham Ave West Jordan UT. 84088 Draper UT. 84020 Services Salt Lake City UT. 84106 p 801.263.2370 p 385.269.0333 1060 E 100 S p 801.581.7951 Ste 100 Salt Lake City UT. 84102 p 801.590.0525

393 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Heart and Lung Institute Heart and Lung Institute Chowdhary, Sandeep L MD Edwards, Anthony MD of Utah of Utah Granger Medical Clinic Jordan Valley Medical 5979 S Fashion Blvd 3336 S 4155 W 3181 W 9000 S Center West Valley Campus Murray UT. 84107 Ste 203 West Jordan UT. 84088 Inpatient BH Unit p 801.263.2370 Salt Lake City UT. 84120 p 801.569.5600 3460 S 4155 W p 801.263.2370 West Valley City UT. 84120 82 S 1100 E Heart and Lung Institute p 801.964.3100 Ste 200 3570 W 9000 S of Utah Salt Lake City UT. 84102 Ste 110 3460 S Pioneer Pkwy Heart and Lung Institute p 801.263.2370 West Jordan UT. 84088 Salt Lake City UT. 84120 of Utah p 801.263.2370 p 801.263.2370 3580 W 9000 S Sleep and Breathe Ste 110 Specialists University of Utah Health 3580 W 9000 S West Jordan UT. 84088 8785 Jordan Valley Way 50 N Medical Dr Ste 110 p 801.263.2370 Ste 2-A Salt Lake City UT. 84132 West Jordan UT. 84088 West Jordan UT. 84088 p 801.581.7806 p 801.263.2370 Jordan Valley Medical p 801.935.8180 Center Heart and Lung Institute Hospital Affiliation 3580 W 9000 S Hospital Affiliation of Utah - Jordan Valley Medical West Jordan UT. 84088 - Jordan Valley Medical 5979 S Fashion Blvd Center p 801.601.4423 Center West Valley Campus Murray UT. 84107 - Lone Peak Hospital - Jordan Valley Medical p 801.263.2370 Steward Pulmonary Critical Center Dienhart, David G MD Care and Sleep Medicine 82 S 1100 E Granger Medical 3584 W 9000 S Brown, Jeanette P MD Ste 200 Specialists Ste 401 University of Utah Health Salt Lake City UT. 84102 5801 S Fashion Blvd West Jordan UT. 84088 1950 Cir of Hope Dr p 801.263.2370 Ste 280 p 801.568.3480 Salt Lake City UT. 84112 Murray UT. 84107 p 801.581.7806 Hospital Affiliation p 801.260.5864 Hospital Affiliation - Mountain West Medical - Jordan Valley Medical 50 N Medical Dr Center Hospital Affiliation Center Salt Lake City UT. 84132 - Salt Lake Regional Medical - Jordan Valley Medical p 801.581.2121 Center Center Farney, Robert V - University of Utah Hospital - Lone Peak Hospital University of Utah Health University Of Utah Health 375 S Chipeta Way 85 N Medical Dr Chowdhary, Rasheel A MD Dupont, Gregory P MD Ste A200 Salt Lake City UT. 84112 Heart and Lung Institute Heart and Lung Institute Salt Lake City UT. 84108 p 801.581.7806 of Utah of Utah p 801.581.2016 3570 W 9000 S 3336 S 4155 W Hospital Affiliation Ste 110 Ste 203 50 N Medical Dr - University of Utah Hospital West Jordan UT. 84088 Salt Lake City UT. 84120 Salt Lake City UT. 84132 p 801.263.2370 p 801.263.2370 p 801.581.7806 Cahill, Barbara C MD University of Utah Health Steward Pulmonary Critical 3570 W 9000 S Farrukh, Imad S MD 50 N Medical Dr Care and Sleep Medicine Ste 110 Utah Lung Center Salt Lake City UT. 84132 3584 W 9000 S West Jordan UT. 84088 3584 W 9000 S p 801.581.7806 Ste 401 p 801.263.2370 Ste 201 West Jordan UT. 84088 West Jordan UT. 84088 Hospital Affiliation p 801.568.3480 5979 S Fashion Blvd p 801.562.5864 - University of Utah Hospital Murray UT. 84107 Heart and Lung Institute p 801.263.2370 Hospital Affiliation Carveth, Holly J MD of Utah - Jordan Valley Medical University of Utah Health 5980 S Fashion Blvd 82 S 1100 E Center 50 N Medical Dr Murray UT. 84107 Ste 200 Salt Lake City UT. 84132 p 801.263.2370 Salt Lake City UT. 84102 Francis, Kurt F MD p 801.581.7806 p 801.263.2370 MountainStar Cardiology St Hospital Affiliation Marks Hospital Affiliation - Salt Lake Regional Medical Utah Sleep Specialists 1160 E 3900 S - University of Utah Hospital Center 9103 S 1300 W Ste 2000 - Jordan Valley Medical West Jordan UT. 84088 Salt Lake City UT. 84124 Chakravarthy, Srinivas Center p 801.432.8690 p 801.266.3418 MD University of Utah Health Hospital Affiliation 100 N Mario Capecchi Dr - Jordan Valley Medical Salt Lake City UT. 84113 Center p 801.581.7806 - Salt Lake Regional Medical Center

394 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Pulmonary Internal Harris, Estelle S MD 3570 W 9000 S 1950 Cir of Hope Dr Medicine University of Utah Health Ste 110 Salt Lake City UT. 84112 1220 E 3900 S 1950 Cir of Hope Dr West Jordan UT. 84088 p 801.581.7806 Ste 2 C Salt Lake City UT. 84112 p 801.263.2370 Salt Lake City UT. 84124 p 801.581.7806 University of Utah Health p 801.263.2482 Steward Pulmonary Critical 375 S Chipeta Way 50 N Medical Dr Care and Sleep Medicine Salt Lake City UT. 84108 Hospital Affiliation Salt Lake City UT. 84132 3584 W 9000 S p 801.581.2016 - St Marks Hospital p 801.581.7806 Ste 401 - Lone Peak Hospital West Jordan UT. 84088 University Of Utah Health Hospital Affiliation p 801.568.3480 50 N Medical Dr Given, Michael MD - University of Utah Hospital Salt Lake City UT. 84132 Heart and Lung Institute Heart and Lung Institute p 801.581.2121 of Utah Hatton, Nathan D MD of Utah 3336 S 4155 W University of Utah Health 5979 S Fashion Blvd Hospital Affiliation Ste 203 50 N Medical Dr Murray UT. 84107 - University of Utah Hospital Salt Lake City UT. 84120 Salt Lake City UT. 84132 p 801.263.2370 p 801.263.2370 p 801.581.7806 Liou, Theodore G MD 5980 S Fashion Blvd University of Utah Health 3570 W 9000 S Hospital Affiliation Murray UT. 84107 50 N Medical Dr Ste 110 - University of Utah Hospital p 801.263.2370 Salt Lake City UT. 84132 West Jordan UT. 84088 p 801.581.7806 p 801.263.2370 Hoidal, John R MD 82 S 1100 E University of Utah Health Ste 200 Hospital Affiliation 5979 S Fashion Blvd 50 N Medical Dr Salt Lake City UT. 84102 - University of Utah Hospital Murray UT. 84107 Salt Lake City UT. 84132 p 801.263.2370 p 801.263.2370 p 801.581.7806 Majoskey, Ashley M PA Hospital Affiliation MountainStar Cardiology St 82 S 1100 E Hospital Affiliation - St Marks Hospital Marks Ste 200 - University of Utah Hospital - Jordan Valley Medical 1160 E 3900 S Salt Lake City UT. 84102 Center West Valley Campus Ste 2000 p 801.263.2370 Jefferds, Ann MD - Lakeview Hospital Salt Lake City UT. 84124 Olympus Clinic - Salt Lake Regional Medical p 801.266.3418 Hammond, Gregory D MD 4624 S Holladay Blvd Center Steward Cardiology Ste 100 5405 S 500 E Associates - West Valley Salt Lake City UT. 84117 Kristen, Ameel MD Ste 202 3336 S Pioneer Pkwy p 801.277.2682 University of Utah Health Salt Lake City UT. 84124 Ste 203 100 N Mario Capecchi Dr p 801.475.1928 West Valley City UT. 84120 Kanner, Richard E MD Salt Lake City UT. 84113 p 801.748.0113 University of Utah Health p 801.213.3599 Mountainstar Cardiology St 1950 Cir of Hope Dr Marks Heart and Lung Institute Salt Lake City UT. 84112 Kurrus, Jeffrey A MD 74 Kimballs Ln of Utah p 801.585.0100 Pulmonary Internal Ste 330 3570 W 9000 S Medicine Draper UT. 84020 Ste 110 50 N Medical Dr 1220 E 3900 S p 801.266.3418 West Jordan UT. 84088 Salt Lake City UT. 84132 Ste 2 C p 801.263.2370 p 801.581.7806 Salt Lake City UT. 84124 Hospital Affiliation p 801.263.2482 - St Marks Hospital Steward Pulmonary Critical 5126 W Daybreak Pkwy Care and Sleep Medicine South Jordan UT. 84009 Hospital Affiliation Markewitz, Boaz A MD 3584 W 9000 S p 801.581.7806 - St Marks Hospital University of Utah Health Ste 401 1950 Cir of Hope Dr West Jordan UT. 84088 Hospital Affiliation Leclair, Laurie W MD Salt Lake City UT. 84112 p 801.568.3480 - University of Utah Hospital University of Utah Health p 801.585.0100 50 N Medical Dr Heart and Lung Institute Klein, David MD Salt Lake City UT. 84132 375 S Chipeta Way of Utah Heart and Lung Institute p 801.581.7806 Ste A200 5979 S Fashion Blvd of Utah Salt Lake City UT. 84108 Murray UT. 84107 3336 S 4155 W Hospital Affiliation p 801.581.2016 p 801.263.2370 Ste 203 - University of Utah Hospital Salt Lake City UT. 84120 50 N Medical Dr 82 S 1100 E p 801.263.2370 Lee, Janet J MD Salt Lake City UT. 84132 Ste 200 University Of Utah Health p 801.581.7806 Salt Lake City UT. 84102 1280 E Stringham Ave p 801.263.2370 Salt Lake City UT. 84106 p 801.581.7806 Hospital Affiliation - Lakeview Hospital 395 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 5126 W Daybreak Pkwy Peng, Wei MD Raman, Sanjeev M 3570 W 9000 S South Jordan UT. 84009 WH-BM Consultant University of Utah Health Ste 110 p 801.581.7806 1046 E 100 S 50 N Medical Dr West Jordan UT. 84088 Salt Lake City UT. 84102 Salt Lake City UT. 84132 p 801.263.2370 Hospital Affiliation p 801.869.7110 p 801.581.7806 - University of Utah Hospital 5979 S Fashion Blvd Heart and Lung Institute 5126 W Daybreak Pkwy Murray UT. 84107 Martinez, Mark L MD of Utah South Jordan UT. 84009 p 801.263.2370 Silver Peaks Rehab 1050 E S Temple p 801.581.7806 3540 S Main St Salt Lake City UT. 84102 Multispecialty Partners Salt Lake City UT. 84115 p 801.263.2370 Hospital Affiliation 82 S 1000 E p 801.997.9500 - University of Utah Hospital Ste 103 WH-BM Consultant Salt Lake City UT. 84102 ValleyFit Clinic 1060 E 100 S Ryujin, Daren T PA p 801.746.4440 4460 S Highland Dr Ste L10 University of Utah Health Ste 300 Salt Lake City UT. 84102 375 S Chipeta Way Heart and Lung Institute Salt Lake City UT. 84124 p 801.328.1260 Ste A200 of Utah p 801.273.6300 Salt Lake City UT. 84108 82 S 1100 E Alpine Medical Group p 801.581.2016 Ste 200 Hospital Affiliation 24 S 1100 E Salt Lake City UT. 84102 - Salt Lake Regional Medical Ste 310 50 N Medical Dr p 801.299.7155 Center Salt Lake City UT. 84102 Salt Lake City UT. 84132 - St Marks Hospital p 801.478.0010 p 801.581.7806 Hospital Affiliation - Timpanogos Regional Hospital - Salt Lake Regional Medical - Mountain View Hospital Heart and Lung Institute Hospital Affiliation Center (UT) of Utah - University of Utah Hospital - Davis Hospital 3460 S Pioneer Pkwy - Jordan Valley Medical Mir-Kasimov, Mir-Mustafa Salt Lake City UT. 84120 Samuelson, Wayne M MD Center MD p 801.263.2370 University of Utah Health University of Utah Health 50 N Medical Dr Stults, Barry M MD 50 N Medical Dr 3580 W 9000 S Salt Lake City UT. 84132 University of Utah Health Salt Lake City UT. 84132 Ste 110 p 801.581.7806 50 N Medical Dr p 801.581.7806 West Jordan UT. 84088 Salt Lake City UT. 84132 p 801.263.2370 Hospital Affiliation p 801.581.7818 Hospital Affiliation - University of Utah Hospital - University of Utah Hospital Steward Pulmonary Critical 555 Foothill Dr Care And Sleep Medicine - Scholand, Mary B MD Salt Lake City UT. 84112 Nelson, Patricia L MD West Jordan University of Utah Health p 801.581.7790 Granger Medical 3584 W 9000 S 50 N Medical Dr Specialists Ste 401 Salt Lake City UT. 84132 Hospital Affiliation 5801 S Fashion Blvd West Jordan UT. 84088 p 801.581.7806 - University of Utah Hospital Ste 280 p 801.265.1200 Murray UT. 84107 5126 W Daybreak Pkwy Sundar, Krishna M MD p 801.260.5864 Hospital Affiliation South Jordan UT. 84009 University of Utah Health - Salt Lake Regional Medical p 801.581.7806 375 S Chipeta Way Hospital Affiliation Center Ste A200 - Lone Peak Hospital - Jordan Valley Medical Hospital Affiliation Salt Lake City UT. 84108 - Jordan Valley Medical Center - University of Utah Hospital p 801.581.2016 Center - Mountain West Medical Center Stringham, James C MD 50 N Medical Dr Paine, Robert MD Multispecialty Partners Salt Lake City UT. 84132 University of Utah Health Radin, Gregory T MD 24 S 1100 E p 801.581.7806 50 N Medical Dr University of Utah Health Ste 304 Salt Lake City UT. 84132 1950 Cir of Hope Dr Salt Lake City UT. 84102 Hospital Affiliation p 801.581.7806 Salt Lake City UT. 84112 p 801.746.4440 - University of Utah Hospital p 801.581.7806 Hospital Affiliation Heart and Lung Institute U-U Pulmonary Division - University of Utah Hospital 50 N Medical Dr of Utah 50 N Medical Dr Salt Lake City UT. 84132 3336 S 4155 W Salt Lake City UT. 84132 Pandita, Sunny MD p 801.581.2121 Ste 203 p 801.581.7806 Granger Medical Salt Lake City UT. 84120 Specialists 5126 W Daybreak Pkwy p 801.263.2370 UUHC South Jordan Health 5801 S Fashion Blvd South Jordan UT. 84009 Center Ste 280 p 801.581.7806 5126 W Daybreak Pkwy Murray UT. 84107 South Jordan UT. 84095 p 801.260.5864 Hospital Affiliation p 801.213.4500 - University of Utah Hospital Hospital Affiliation - Jordan Valley Medical Center - Lone Peak Hospital 396 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Willis, Alika M APRN Gaffney, David K MD,PhD Johnson, Skyler B MD Shrieve, Dennis C MD,PhD University of Utah Health University of Utah Health University of Utah Health University of Utah Health 50 N Medical Dr 1950 Cir of Hope Dr 1950 Cir of Hope Dr 1950 Cir of Hope Dr Salt Lake City UT. 84132 Salt Lake City UT. 84112 Salt Lake City UT. 84112 Salt Lake City UT. 84112 p 801.581.7806 p 801.581.8793 p 801.581.8793 p 801.581.8793

5126 W Daybreak Pkwy Hospital Affiliation Hospital Affiliation Hospital Affiliation South Jordan UT. 84009 - University of Utah Hospital - University of Utah Hospital - University of Utah Hospital p 801.581.7806 Hansen, Roger S MD Kokeny, Kristine MD Skidmore, Thomas B MD Hospital Affiliation Gamma West Brachytherapy University of Utah Health Gamma West Cancer Services - University of Utah Hospital 1050 E S Temple 1950 Cir of Hope Dr 1050 E S Temple Salt Lake City UT. 84102 Salt Lake City UT. 84112 Salt Lake City UT. 84102 Zinger, Alan PA p 801.350.8400 p 801.581.8793 p 801.350.8400 University of Utah Health 50 N Medical Dr Hospital Affiliation Hospital Affiliation 1250 E 3900 S Salt Lake City UT. 84132 - Ogden Regional Medical - University of Utah Hospital Ste B-10 p 801.581.7806 Center Salt Lake City UT. 84124 - Davis Hospital Lee, Robert J MD p 801.456.8401 Hospital Affiliation - Salt Lake Regional Medical Utah Cancer Specialists - University of Utah Hospital Center 3838 S 700 E Hospital Affiliation - St Marks Hospital Ste 100 - Timpanogos Regional Hospital Radiation Oncology Salt Lake City UT. 84106 - Salt Lake Regional Medical Avizonis, Vilija MD Harris, Robert A MD p 801.269.0231 Center Utah Cancer Specialists Gamma West Brachytherapy - St Marks Hospital 3838 S 700 E 1050 E S Temple Hospital Affiliation - Davis Hospital Ste 100 Salt Lake City UT. 84102 - St Marks Hospital Salt Lake City UT. 84106 p 801.350.8400 - Jordan Valley Medical Suneja, Gita MD p 801.269.0231 Center University of Utah Health Hospital Affiliation - Lone Peak Hospital 1280 E Stringham Ave Hospital Affiliation - Ogden Regional Medical Salt Lake City UT. 84106 - St Marks Hospital Center Poppe, Matthew M MD p 801.581.2396 - Davis Hospital University of Utah Health Bair, Ryan J MD - St Marks Hospital 1950 Cir of Hope Dr 1950 Cir of Hope Dr Gamma West Cancer Services - Timpanogos Regional Hospital Salt Lake City UT. 84112 Salt Lake City UT. 84112 3592 W 9000 S p 801.581.8793 p 801.581.2396 Ste 100 Hayes, John K MD West Jordan UT. 84088 Gamma West Cancer Services Hospital Affiliation Tao, Randa MD p 801.601.2260 1050 E S Temple - University of Utah Hospital University of Utah Health Salt Lake City UT. 84102 1950 Cir of Hope Dr Boothe, Dustin MD p 801.350.8400 Reilly, Mark W MD Salt Lake City UT. 84112 Utah Cancer Specialists Gamma West Brachytherapy p 801.581.8793 3838 S 700 E 1250 E 3900 S 1050 E S Temple Ste 100 Ste B-10 Salt Lake City UT. 84102 Hospital Affiliation Salt Lake City UT. 84106 Salt Lake City UT. 84124 p 801.350.8400 - University of Utah Hospital p 801.269.0231 p 801.456.8401 Hospital Affiliation Tward, Jonathan D MD Burt, Lindsay M MD Hospital Affiliation - St Marks Hospital University of Utah Health University of Utah Health - St Marks Hospital - Salt Lake Regional Medical 1950 Cir of Hope Dr 1950 Cir of Hope Dr - Salt Lake Regional Medical Center Salt Lake City UT. 84112 Salt Lake City UT. 84112 Center - Jordan Valley Medical p 801.581.8793 p 801.581.8793 - Davis Hospital Center - Timpanogos Regional Hospital - Davis Hospital Hospital Affiliation Hospital Affiliation - University of Utah Hospital - University of Utah Hospital Hitchcock, Ying J MD Rogers, Charles L MD University of Utah Health Gamma West Cancer Services Radiology Cannon, Donald M MD 1280 E Stringham Ave 1200 E 3900 S Abbott, Mark F MD University of Utah Health Salt Lake City UT. 84106 Salt Lake City UT. 84102 Utah Imaging Associates 1950 Cir of Hope Dr p 801.581.2396 p 801.456.8401 1200 E 3900 S Salt Lake City UT. 84112 Salt Lake City UT. 84124 p 801.581.8793 1950 Cir of Hope Dr 3592 W 9000 S p 801.268.2111 Salt Lake City UT. 84112 Ste 100 p 801.581.8793 West Jordan UT. 84088 p 801.601.2260 Hospital Affiliation - University of Utah Hospital

397 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Andolsek, William DO Chalian, Hamid MD *Fuentes, Jaun D MD *Jacobs, John M MD Intermountain Pediatric University Of Utah Health Murray Vascular and Vein Murray Vascular and Vein Imaging 9385 Snowbird Ctr Dr 5323 S Woodrow St 5323 S Woodrow St 100 Mario Capecchi Dr Sandy UT. 84092 Ste 101 Ste 101 Salt Lake City UT. 84113 p 801.646.4800 Murray UT. 84107 Murray UT. 84107 p 801.487.0451 p 801.261.8346 p 801.261.8346 Chin, Brian M MD Intermountain Pediatric University of Utah Health Hospital Affiliation Hospital Affiliation Imaging Riverton 50 N Medical Dr - Cassia Regional Hospital - Cassia Regional Hospital 3741 W 12600 S Salt Lake City UT. 84132 - Davis Hospital Riverton UT. 84065 p 801.581.7553 Gilfeather, Maryellyn MD p 801.487.0451 University of Utah Health *Jepperson, Maria A MD Damme, Nikolas M MD 1950 Cir of Hope Dr Murray Vascular and Vein *Arnold, Ryan MD University Of Utah Health Salt Lake City UT. 84112 5323 S Woodrow St Intermountain Pediatric 9385 Snowbird Ctr Dr p 801.585.0100 Ste 101 Imaging Sandy UT. 84092 Murray UT. 84107 100 Mario Capecchi Dr p 801.646.4800 Hospital Affiliation p 801.261.8346 Salt Lake City UT. 84113 - Lakeview Hospital p 801.487.0451 Hospital Affiliation - St Marks Hospital Hospital Affiliation - University of Utah Hospital - Brigham City Community - Cassia Regional Hospital Intermountain Pediatric Hospital - Davis Hospital Imaging Riverton *Dansie, David MD - Lone Peak Hospital 3741 W 12600 S Intermountain Pediatric *Johnson, Emily MD Riverton UT. 84065 Imaging *Harker, Colleen P MD Vascular and Vein - Murray p 801.487.0451 100 Mario Capecchi Dr Murray Vascular and Vein 5323 S Woodrow St Salt Lake City UT. 84113 5323 S Woodrow St Ste 101 *Baskin, Henry MD p 801.487.0451 Ste 101 Murray UT. 84107 Intermountain Pediatric Murray UT. 84107 p 801.313.7500 Imaging Intermountain Pediatric p 801.261.8346 100 Mario Capecchi Dr Imaging Riverton Hospital Affiliation Salt Lake City UT. 84113 3741 W 12600 S Hospital Affiliation - Intermountain Medical p 801.487.0451 Riverton UT. 84065 - Cassia Regional Hospital Center p 801.487.0451 - Davis Hospital Intermountain Pediatric Kobes, Patrick H DO Imaging Riverton Dunn, Dell P MD *Hoeg, Karin MD University of Utah Health 3741 W 12600 S University Of Utah Health Intermountain Pediatric 1950 Cir of Hope Dr Riverton UT. 84065 9385 Snowbird Ctr Dr Imaging Salt Lake City UT. 84112 p 801.487.0451 Sandy UT. 84092 100 Mario Capecchi Dr p 801.585.0100 p 801.646.4800 Salt Lake City UT. 84113 *Blatter, Duane D MD p 801.487.0451 50 N Medical Dr Murray Vascular and Vein Hospital Affiliation Salt Lake City UT. 84132 5323 S Woodrow St - University of Utah Hospital Intermountain Pediatric p 801.581.7553 Ste 101 Imaging Riverton Murray UT. 84107 Duong, Phuong-Anh T MD 3741 W 12600 S 590 S Wakara Way p 801.261.8346 University Of Utah Health Riverton UT. 84065 Salt Lake City UT. 84108 9385 Snowbird Ctr Dr p 801.487.0451 p 801.587.7109 Hospital Affiliation Sandy UT. 84092 - Cassia Regional Hospital p 801.646.4800 Hoffman, John M MD Hospital Affiliation - Davis Hospital University Of Utah Health - University of Utah Hospital Hospital Affiliation 9385 Snowbird Ctr Dr *Bress, Aaron L DO - University of Utah Hospital Sandy UT. 84092 *Kringlen, Mark W MD Vascular and Vein - Murray p 801.646.4800 Murray Vascular and Vein 5323 S Woodrow St *Feola, G G MD 5323 S Woodrow St Ste 101 Intermountain Pediatric Holmes, Stephanie M MD Ste 101 Murray UT. 84107 Imaging University of Utah Health Murray UT. 84107 p 801.313.7500 100 Mario Capecchi Dr 100 N Mario Capecchi Dr p 801.261.8346 Salt Lake City UT. 84113 Salt Lake City UT. 84113 Brown, Richard K MD p 801.487.0451 p 801.662.5600 Hospital Affiliation University Of Utah Health - Cassia Regional Hospital 9385 Snowbird Ctr Dr Intermountain Pediatric 3773 W 12600 S - Davis Hospital Sandy UT. 84092 Imaging Riverton Riverton UT. 84065 p 801.646.4800 3741 W 12600 S p 801.285.1440 Lloyd, Shane MD Riverton UT. 84065 University of Utah Health Hospital Affiliation p 801.487.0451 Hospital Affiliation 1280 E Stringham Ave - University of Utah Hospital - University of Utah Hospital Salt Lake City UT. 84106 p 801.581.2396

398 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 1950 Cir of Hope Dr *Pisani, David E MD Wiggins III, Richard H MD 5063 S Cottonwood St Salt Lake City UT. 84112 Murray Vascular and Vein University of Utah Health Ste 450 p 801.581.8793 5323 S Woodrow St 1525 W 2100 S Murray UT. 84107 Ste 101 Salt Lake City UT. 84119 p 801.507.1950 Hospital Affiliation Murray UT. 84107 p 801.213.8841 - University of Utah Hospital p 801.261.8346 675 S Arapeen Dr Hospital Affiliation Salt Lake City UT. 84108 Martin, Gregory B MD Hospital Affiliation - University of Utah Hospital p 801.581.3834 Utah Imaging Associates - Cassia Regional Hospital 1200 E 3900 S - Davis Hospital *Winters, William D MD Hospital Affiliation Salt Lake City UT. 84124 Intermountain Pediatric - University of Utah Hospital p 801.268.7111 *Prince, Jeffrey S MD Imaging Intermountain Pediatric 100 Mario Capecchi Dr Link, Megan H MD *McKenzie, Travis T DO Imaging Salt Lake City UT. 84113 University of Utah Health Vascular and Vein - Murray 100 Mario Capecchi Dr p 801.487.0451 50 N Medical Dr 5323 S Woodrow St Salt Lake City UT. 84113 Salt Lake City UT. 84132 Ste 101 p 801.487.0451 Intermountain Pediatric p 801.213.2995 Murray UT. 84107 Imaging Riverton p 801.313.7500 Intermountain Pediatric 3741 W 12600 S 675 S Arapeen Dr Imaging Riverton Riverton UT. 84065 Ste 205 Hospital Affiliation 3741 W 12600 S p 801.487.0451 Salt Lake City UT. 84108 - Intermountain Medical Riverton UT. 84065 p 801.581.3834 Center p 801.487.0451 Zollinger, Lauren V MD Utah Imaging Associates 675 S Arapeen Dr Minoshima, Satoshi *Rampton, John W MD 1200 E 3900 S Salt Lake City UT. 84108 MD,PhD Intermountain Pediatric Salt Lake City UT. 84124 p 801.581.3834 University Of Utah Health Imaging p 801.268.7111 9385 Snowbird Ctr Dr 100 Mario Capecchi Dr Hospital Affiliation Sandy UT. 84092 Salt Lake City UT. 84113 Rehabilitation Hospital - University of Utah Hospital p 801.646.4800 p 801.487.0451 Encompass Health Rehabilitation Hospital of Peterson, C Matthew MD Hospital Affiliation Intermountain Pediatric Utah University of Utah Health - University of Utah Hospital Imaging Riverton 8074 S 1300 E 26 S Main St 3741 W 12600 S Sandy UT. 84094 Centerville UT. 84104 *Moore, Kevin R MD Riverton UT. 84065 p 801.561.3400 p 801.693.7900 Intermountain Pediatric p 801.487.0451 Imaging University Health Neilsen 50 N Medical Dr 100 Mario Capecchi Dr *Schloesser, Peter MD Rehabilitation Hospital Salt Lake City UT. 84132 Salt Lake City UT. 84113 Murray Vascular and Vein 85 N Medical Dr p 801.213.2995 p 801.487.0451 5323 S Woodrow St Salt Lake City UT. 84132 Ste 101 p 801.581.2267 5126 W Daybreak Pkwy Intermountain Pediatric Murray UT. 84107 South Jordan UT. 84009 Imaging Riverton p 801.261.8346 Reproductive Endocrinology p 801.213.4500 3741 W 12600 S Kozola Maas, Kristi Ann Riverton UT. 84065 Hospital Affiliation MD 675 S Arapeen Dr p 801.487.0451 - Cassia Regional Hospital Reproductive Care Center Salt Lake City UT. 84108 - Davis Hospital 10150 S Petunia Way p 801.581.3834 Morton, Kathryn A MD Sandy UT. 84092 University Of Utah Health South Valley Womens p 801.878.8888 Hospital Affiliation 9385 Snowbird Ctr Dr Imaging - University of Utah Hospital Sandy UT. 84092 3570 W 9000 S Hospital Affiliation p 801.646.4800 Ste 130 - Davis Hospital Reproductive Care Center West Jordan UT. 84088 10150 S Petunia Way Mountain Medical Physician p 801.569.2626 Letourneau, Joseph M MD Sandy UT. 84092 Specialists Radiology University of Utah Health p 801.878.8888 5323 S Woodrow St South Valley Womens Health 100 N Mario Capecchi Dr Ste 100 3570 W 9000 S Salt Lake City UT. 84113 UUHC South Jordan Health Murray UT. 84123 Ste 210 p 801.213.2995 Center p 801.713.0600 West Jordan UT. 84088 5126 W Daybreak Pkwy p 801.569.2626 50 N Medical Dr South Jordan UT. 84095 Olpin, Jeffrey D MD Salt Lake City UT. 84132 p 801.213.4500 University of Utah Health West Valley Imaging p 801.213.2995 7495 S State St 3715 W 4100 S Midvale UT. 84047 Ste 150 p 801.213.9400 West Valley City UT. 84120 p 801.924.0029

399 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Residential Treatment Facility 8375 S 700 E Gupta, Pankhuri MD Liu, Zhenhao MD BRC Outpatient LLC Sandy UT. 84070 Rheumatology At Salt Lake Granger Medical 4905 S 900 E p 801.576.0745 Regional Specialists Salt Lake City UT. 84117 82 S 1100 E 11333 S 1000 E p 801.905.1352 Rheumatology Ste 403 Ste 100 Anderson, Steven J MD Salt Lake City UT. 84102 Sandy UT. 84094 Brighton House LLC 1151 E 3900 S p 801.350.4753 p 801.571.4100 2945 E Robidoux Rd Ste 275 Sandy UT. 84093 Salt Lake City UT. 84124 Jackson, Christopher G MD Lundberg, Max S MD p 385.557.4318 p 801.262.2452 University of Utah Health Granger Medical 50 N Medical Dr Specialists Recovery Ways - Chatham Battistone, Michael J MD Salt Lake City UT. 84132 11333 S 1000 E Place -Not all services University of Utah Health p 801.581.4333 Ste 100 covered, please contact 50 N Medical Dr Sandy UT. 84094 your administrator Salt Lake City UT. 84132 University Of Utah Health p 801.571.4100 385 W 4800 S p 801.581.4333 85 N Medical Dr Salt Lake City UT. 84123 Salt Lake City UT. 84112 McMillan, Sean E MD p 801.506.7701 University Of Utah Health p 801.581.7724 University of Utah Health 85 N Medical Dr 1280 E Stringham Ave Recovery Ways - Brunswick Salt Lake City UT. 84112 Hospital Affiliation Salt Lake City UT. 84106 Place -Not all services p 801.581.7724 - University of Utah Hospital p 801.581.7724 covered, please contact your administrator Hospital Affiliation Koening, Curry L MD 50 N Medical Dr 4848 S Commerce - University of Utah Hospital University of Utah Health Salt Lake City UT. 84132 Salt Lake City UT. 84107 50 N Medical Dr p 801.581.4333 p 801.326.5180 Braaten, Tawnie J MD Salt Lake City UT. 84132 University Of Utah Health p 801.581.4333 5126 W Daybreak Pkwy Recovery Ways - Mountain 85 N Medical Dr South Jordan UT. 84009 View -Not all services Salt Lake City UT. 84112 University Of Utah Health p 801.581.7724 covered, please contact p 801.581.7724 85 N Medical Dr your administrator Salt Lake City UT. 84112 University Of Utah Health 4883 S Box Elder St Breviu, Brian A MD p 801.581.7724 85 N Medical Dr Salt Lake City UT. 84107 University of Utah Health Salt Lake City UT. 84112 p 801.293.6100 50 N Medical Dr Hospital Affiliation p 801.581.7724 Salt Lake City UT. 84132 - University of Utah Hospital Recovery Ways - Copper p 801.581.7724 Hospital Affiliation Hills -Not all services Kunkel, Gary A MD - University of Utah Hospital covered, please contact University Of Utah Health University of Utah Health your administrator 85 N Medical Dr 50 N Medical Dr Miller, Karla L MD 5288 Allendale Dr Salt Lake City UT. 84112 Salt Lake City UT. 84132 University of Utah Health Salt Lake City UT. 84123 p 801.581.7724 p 801.581.4333 50 N Medical Dr p 801.487.0955 Salt Lake City UT. 84132 Hospital Affiliation University Of Utah Health p 801.581.4333 Cold Creek Behavioral - University of Utah Hospital 85 N Medical Dr Health Salt Lake City UT. 84112 615 S Arapeen Dr 8155 Brighton Loop Rd Frech, Tracy M MD p 801.581.7724 Ste 100 Salt Lake City UT. 84121 University of Utah Health Salt Lake City UT. 84108 p 801.593.6777 50 N Medical Dr Hospital Affiliation p 801.581.7724 Salt Lake City UT. 84132 - University of Utah Hospital Liberty Addiction Recovery p 801.581.4333 University Of Utah Health Centers Lebiedz Odrobina, Dorota 85 N Medical Dr 15257 S Scenic Crest Cir University Of Utah Health J MD Salt Lake City UT. 84112 South Jordan UT. 84095 85 N Medical Dr University of Utah Health p 801.581.7724 p 801.997.9183 Salt Lake City UT. 84112 50 N Medical Dr p 801.581.7724 Salt Lake City UT. 84132 Hospital Affiliation Turning Point Centers p 801.581.4333 - University of Utah Hospital 2945 E Turning Point Cir Hospital Affiliation Sandy UT. 84092 - University of Utah Hospital 5126 W Daybreak Pkwy Penmetsa, Gopi K MD p 801.576.0745 South Jordan UT. 84009 University of Utah Health Gremillion, Richard B MD p 801.581.4333 50 N Medical Dr 2961 E Turning Point Cir Granger Medical Salt Lake City UT. 84132 Sandy UT. 84092 Specialists Hospital Affiliation p 801.581.4333 p 801.576.0745 11333 S 1000 E - University of Utah Hospital Ste 100 Sandy UT. 84094 p 801.571.4100

400 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. University Of Utah Health 5126 W Daybreak Pkwy Avalon West Health and Life Care Center of Salt 85 N Medical Dr South Jordan UT. 84009 Rehab Lake City Salt Lake City UT. 84112 p 801.581.7724 6246 S Redwood Rd 1201 E 4500 S p 801.581.7724 Salt Lake City UT. 84123 Salt Lake City UT. 84117 85 N Medical Dr p 801.969.1420 p 801.261.3664 Hospital Affiliation Salt Lake City UT. 84112 - University of Utah Hospital p 801.581.7724 Draper Rehabilitation and Highland Care Center Care Center 4285 S Highland Dr Register, Kyle A MD Hospital Affiliation 12702 S Fort St Salt Lake City UT. 84124 University of Utah Health - University of Utah Hospital Draper UT. 84020 p 801.278.2839 1280 E Stringham Ave p 801.571.2704 Salt Lake City UT. 84106 Stromquist, Don L MD Spring Creek Healthcare p 801.581.7724 University of Utah Health City Creek Post Acute 4600 S Highland Dr 50 N Medical Dr 165 S 1000 E Salt Lake City UT. 84117 50 N Medical Dr Salt Lake City UT. 84132 Salt Lake City UT. 84102 p 801.272.1892 Salt Lake City UT. 84132 p 801.581.4333 p 801.322.5521 p 801.581.4333 Deseret Care Center University Of Utah Health Rocky Mountain Care - 950 E 3300 S 5126 W Daybreak Pkwy 85 N Medical Dr Riverton Salt Lake City UT. 84106 South Jordan UT. 84009 Salt Lake City UT. 84112 3419 W 12600 S p 801.486.5121 p 801.581.4333 p 801.581.7724 Riverton UT. 84065 p 801.693.3900 Aspen Park Rehabilitation University Of Utah Health Hospital Affiliation 1430 E 4500 S 85 N Medical Dr - University of Utah Hospital Copper Ridge Health Care Salt Lake City UT. 84117 Salt Lake City UT. 84112 3706 W 9000 S p 801.272.8000 p 801.581.7724 Thomas, Julie K MD West Jordan UT. 84088 University of Utah Health p 801.280.2273 Utah State Veterans Hospital Affiliation 50 N Medical Dr Nursing Home - University of Utah Hospital Salt Lake City UT. 84132 Paramount Health and 700 Foothill Blvd p 801.581.4333 Rehabilitation Salt Lake City UT. 84113 Sawitzke, Allen D MD 4035 S 500 E p 801.584.1900 University of Utah Health University Of Utah Health Salt Lake City UT. 84107 50 N Medical Dr 85 N Medical Dr p 801.262.9181 Willow Wood Care Center Salt Lake City UT. 84132 Salt Lake City UT. 84112 1205 E 4725 S p 801.581.4333 p 801.581.7724 Rocky Mountain Care - Salt Lake City UT. 84117 Hunter Hollow p 801.262.2908 University Of Utah Health Hospital Affiliation 4090 W Pioneer Pkwy 85 N Medical Dr - University of Utah Hospital West Valley City UT. 84120 Woodland Park Salt Lake City UT. 84112 p 801.397.4400 Rehabilitation and Care p 801.581.7724 Walsh, Jessica A MD Center University of Utah Health St Joseph Villa 3855 S 700 E Hospital Affiliation 50 N Medical Dr 451 E Bishop Federal Ln Salt Lake City UT. 84106 - University of Utah Hospital Salt Lake City UT. 84132 Salt Lake City UT. 84115 p 801.268.4766 p 801.581.4333 p 801.487.7557 Shaskey, David J MD Sleep Disorders Center Millcreek Rheumatology University Of Utah Health Holladay Healthcare Center Avastra Sleep Diagnostics 1121 E 3900 S 85 N Medical Dr 4782 S Holladay Blvd 613 E Fort Union Blvd Ste 125 Salt Lake City UT. 84112 Salt Lake City UT. 84117 Ste A102 Salt Lake City UT. 84124 p 801.581.7724 p 801.277.7002 Midvale UT. 84047 p 801.262.0116 p 801.523.7533 Hospital Affiliation Rocky Mountain Care - Hospital Affiliation - University of Utah Hospital Cottage on Vine Chowdhary, Sandeep L MD - University of Utah Hospital 835 E Vine St Granger Medical Clinic Skilled Nursing Facility Salt Lake City UT. 84107 3181 W 9000 S Stever, Jacob R MD Amazing Medical Associates p 801.693.3800 West Jordan UT. 84088 University Of Utah Health 835 E 4800 S p 801.569.5600 1280 E Stringham Ave Ste 110 Canyon Rim Care Center Salt Lake City UT. 84106 Salt Lake City UT. 84107 2730 E 3300 S Heart and Lung Institute p 801.581.7724 p 801.716.7008 Salt Lake City UT. 84109 of Utah p 801.487.0896 3460 S Pioneer Pkwy 50 N Medical Dr Avalon Valley Salt Lake City UT. 84120 Salt Lake City UT. 84132 Rehabilitation Center Encompass Health p 801.263.2370 p 801.581.7724 2472 S 300 E Rehabilitation Hospital of Salt Lake City UT. 84115 Utah p 801.466.2211 8074 S 1300 E Sandy UT. 84094 p 801.561.3400

401 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 3580 W 9000 S 82 S 1100 E Utah Sleep Specialists Hollingshaus, Scott M MD Ste 110 Ste 200 9103 S 1300 W University of Utah Health West Jordan UT. 84088 Salt Lake City UT. 84102 West Jordan UT. 84088 375 S Chipeta Way p 801.263.2370 p 801.263.2370 p 801.432.8690 Salt Lake City UT. 84108 p 801.581.2016 Hospital Affiliation Sleep and Breathe Hospital Affiliation - Jordan Valley Medical Specialists - Jordan Valley Medical 50 N Medical Dr Center 8785 Jordan Valley Way Center Salt Lake City UT. 84132 - Lone Peak Hospital Ste 2-A - Salt Lake Regional Medical p 801.581.7818 West Jordan UT. 84088 Center Precision Diagnostic p 801.935.8180 5126 W Daybreak Pkwy Services Farney, Robert V South Jordan UT. 84009 4885 S 900 E Hospital Affiliation University of Utah Health p 801.213.4500 Ste 107 - Jordan Valley Medical 375 S Chipeta Way Salt Lake City UT. 84117 Center West Valley Campus Ste A200 Hospital Affiliation p 801.266.0399 - Jordan Valley Medical Salt Lake City UT. 84108 - University of Utah Hospital Center p 801.581.2016 5242 S College Dr Lee, Janet J MD Ste 206 Chua, Milton M MD 50 N Medical Dr University Of Utah Health Salt Lake City UT. 84123 University of Utah Health Salt Lake City UT. 84132 1280 E Stringham Ave p 801.266.0399 375 S Chipeta Way p 801.581.7806 Salt Lake City UT. 84106 Salt Lake City UT. 84108 p 801.581.7806 613 E Fort Union Blvd p 801.581.2016 Farrukh, Imad S MD Ste A-102 Utah Lung Center 1950 Cir of Hope Dr Midvale UT. 84047 50 N Medical Dr 3584 W 9000 S Salt Lake City UT. 84112 p 801.523.7533 Salt Lake City UT. 84132 Ste 201 p 801.581.7806 p 801.581.7818 West Jordan UT. 84088 Sleep Institue Medical p 801.562.5864 University of Utah Health Clinic Hospital Affiliation 375 S Chipeta Way 8819 S Redwood Rd - University of Utah Hospital Hospital Affiliation Salt Lake City UT. 84108 West Jordan UT. 84088 - Jordan Valley Medical p 801.581.2016 p 801.593.9576 Dienhart, David G MD Center Granger Medical University Of Utah Health Sleep Medicine Specialists Hammond, Gregory D MD 50 N Medical Dr Avastra Sleep Diagnostics 5801 S Fashion Blvd Steward Cardiology Salt Lake City UT. 84132 613 E Fort Union Blvd Ste 280 Associates - West Valley p 801.581.2121 Ste A102 Murray UT. 84107 3336 S Pioneer Pkwy Midvale UT. 84047 p 801.260.5864 Ste 203 Hospital Affiliation p 801.523.7533 West Valley City UT. 84120 - University of Utah Hospital Hospital Affiliation p 801.748.0113 Bird, Garrett R MD - Jordan Valley Medical Martinez-Ferrate, Rodolfo Heart and Lung Institute Center Heart and Lung Institute MD of Utah - Lone Peak Hospital of Utah Sleep Alternatives Salt 3336 S 4155 W 3570 W 9000 S Lake Ste 203 Dupont, Gregory P MD Ste 110 1226 W S Jordan Pkwy Salt Lake City UT. 84120 Heart and Lung Institute West Jordan UT. 84088 Ste B101 p 801.263.2370 of Utah p 801.263.2370 South Jordan UT. 84095 3336 S 4155 W p 801.302.8172 3570 W 9000 S Ste 203 Steward Pulmonary Critical Ste 110 Salt Lake City UT. 84120 Care and Sleep Medicine Diabetes Health Management West Jordan UT. 84088 p 801.263.2370 3584 W 9000 S 1226 W S Jordan Pkwy p 801.263.2370 Ste 401 Ste C 3570 W 9000 S West Jordan UT. 84088 South Jordan UT. 84095 Steward Pulmonary Critical Ste 110 p 801.568.3480 p 801.651.4283 Care And Sleep Medicine - West Jordan UT. 84088 West Jordan p 801.263.2370 Heart and Lung Institute Hospital Affiliation 3584 W 9000 S of Utah - Jordan Valley Medical Ste 401 5979 S Fashion Blvd 5979 S Fashion Blvd Center West Valley Campus West Jordan UT. 84088 Murray UT. 84107 Murray UT. 84107 p 801.263.2370 p 801.263.2370 p 801.263.2370 *McGinley, Brian M MD PCH Esophageal Airway - Heart and Lung Institute 82 S 1100 E 82 S 1100 E Riverton of Utah Ste 200 Ste 200 3741 W 12600 S 5979 S Fashion Blvd Salt Lake City UT. 84102 Salt Lake City UT. 84102 Riverton UT. 84065 Murray UT. 84107 p 801.263.2370 p 801.263.2370 p 801.662.1644 p 801.263.2370 Hospital Affiliation - Lakeview Hospital 402 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. University of Utah Health Pediatric Sleep South Summit Pediatrics Ballard, Diana E LCSW 81 N Mario Capecchi Dr Medicine-Department of 267 E Traversepoint Dr River Oak Counseling Salt Lake City UT. 84113 University of Utah Draper UT. 84020 3980 S 700 E p 801.213.3599 100 N Mario Capecchi Dr p 801.553.8300 Ste 22 Salt Lake City UT. 84113 Salt Lake City UT. 84107 Nelson, Patricia L MD p 743.134.268 Arballo, Jennifer CSW p 801.833.1291 Granger Medical Utah Behavior Services Specialists Social Worker 5558 S 1900 W Compass Counseling and 5801 S Fashion Blvd Adams, Amber Mae LCSW Ste B Consulting Ste 280 Centered Approach Salt Lake City UT. 84129 4000 S 700 E Murray UT. 84107 Counseling p 801.255.5131 Ste 9 p 801.260.5864 4190 S Highland Dr Salt Lake City UT. 84107 Ste 220 6013 S Redwood Rd p 801.639.9544 Hospital Affiliation Salt Lake City UT. 84124 Salt Lake City UT. 84123 - Lone Peak Hospital p 385.282.3349 p 801.255.5131 Banfill, Amanda LCSW - Jordan Valley Medical Ascendant Behavioral Center Adams, Josh M SSW Armstrong, Aaron N SSW Health Valley Behavioral Health Valley Behavioral Health 5383 S 900 E Pandita, Sunny MD 1020 S Main St 1020 S Main St Ste 103 Granger Medical Ste 218 Ste 100 Salt Lake City UT. 84117 Specialists Salt Lake City UT. 84101 Salt Lake City UT. 84101 p 801.872.5516 5801 S Fashion Blvd p 888.949.4864 p 888.949.4864 Ste 280 *Barnes, Matthew M LCSW Murray UT. 84107 Adams, Kathy LCSW Armstrong, Chelsea J LCSW PCH Residential Home p 801.260.5864 Ascendant Behavioral South Point Counseling 5770 S 1500 W Bldg C Health 1206 W S Jordan Pkwy Salt Lake City UT. 84123 Hospital Affiliation 5383 S 900 E Ste D p 801.313.7954 - Jordan Valley Medical Ste 103 South Jordan UT. 84095 Center Salt Lake City UT. 84117 p 801.302.3801 PCH Residential Trmnt - - Lone Peak Hospital p 801.872.5516 ADOL Asper, William LCSW 5770 S 1500 W Precision Diagnostic Allred, Courtney R LCSW Valley Behavioral Health Salt Lake City UT. 84123 Services Peaceful Solutions 1020 S Main St p 801.313.7940 4885 S 900 E 1399 S 700 E Ste 100 Ste 107 Ste 5 Salt Lake City UT. 84101 Barney, Geralyn LCSW Salt Lake City UT. 84117 Salt Lake City UT. 84105 p 888.949.4864 Valley Behavioral Health p 801.266.0399 p 801.651.3907 1141 E 3900 S 3610 S 1000 W Ste A170 5242 S College Dr Hospital Affiliation West Valley City UT. 84119 Salt Lake City UT. 84124 Ste 206 - University of Utah Hospital p 888.949.4864 p 888.949.4864 Salt Lake City UT. 84123 p 801.266.0399 Andersen, Meghan C LCSW Au Duong, Lan SSW 195 W 7200 S Valley Behavioral Health Valley Behavioral Health Midvale UT. 84047 613 E Fort Union Blvd 780 S Guardsman Way 2948 S Redwood Rd p 888.949.4864 Ste A-102 Salt Lake City UT. 84108 West Valley City UT. 84119 Midvale UT. 84047 p 888.949.4864 p 888.949.4864 Barrett, Rebecca B SSW p 801.523.7533 Valley Behavioral Health Anderson, Tracy B LCSW Bach-Whitehead, Trudy 1020 S Main St Sleep Institue Medical Alpine Center for Personal LCSW Ste 100 Clinic Growth Sundance Behavioral Salt Lake City UT. 84101 8819 S Redwood Rd 5689 S Redwood Rd Resources p 888.949.4864 West Jordan UT. 84088 Ste 30 845 E 4800 S p 801.593.9576 Salt Lake City UT. 84123 Ste 200 550 W 700 S p 801.268.1715 Murray UT. 84107 Salt Lake City UT. 84101 Sundar, Krishna M MD p 801.264.9522 p 888.949.4864 University of Utah Health Andes, Jared C MSW 375 S Chipeta Way Valley Behavioral Health Bagley, Heather M SSW Barrus, Matthew D LCSW Ste A200 1141 E 3900 S Valley Behavioral Health Valley Behavioral Health Salt Lake City UT. 84108 Ste A170 4460 S Highland Dr 12427 S Pasture Rd p 801.581.2016 Salt Lake City UT. 84124 Ste 100 Ste 104 p 888.949.4864 Salt Lake City UT. 84124 Riverton UT. 84096 50 N Medical Dr p 888.949.4864 p 888.949.4864 Salt Lake City UT. 84132 p 801.581.7806

Hospital Affiliation - University of Utah Hospital

403 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Barson, Joshua T CSW 6013 S Redwood Rd Brock, Brandy SSW Buie, Jerry LCSW Valley Behavioral Health Salt Lake City UT. 84123 Valley Behavioral Health Pride Counseling Inc 3809 W 6200 S p 801.255.5131 550 W 700 S 20 E Graystone Way Taylorsville UT. 84129 Salt Lake City UT. 84101 Ste 20E p 888.949.4864 Blair, Sarah MSW p 888.949.4864 Salt Lake City UT. 84106 The Green House for Growth p 801.595.0666 Batchelor, Marcia LCSW & Learning Brooks, Denise E LCSW White Tree Medical 1325 W S Jordan Pkwy Valley Behavioral Health Bunting, Catherine CSW Consultants LLC Ste 102 12427 S Pasture Rd Utah Behavior Services 10437 S Jordan Gateway South Jordan UT. 84095 Ste 104 5558 S 1900 W South Jordan UT. 84095 p 801.208.8838 Riverton UT. 84096 Ste B p 385.535.6996 p 888.949.4864 Salt Lake City UT. 84129 Blood, Cybele LCSW p 801.255.5131 Belnap, Barbara LCSW Ascendant Behavioral 4460 S Highland Dr 5630 Waterbury Way Health Ste 100 6013 S Redwood Rd Ste 104B 5383 S 900 E Salt Lake City UT. 84124 Salt Lake City UT. 84123 Salt Lake City UT. 84121 Ste 103 p 888.949.4864 p 801.255.5131 p 801.272.8818 Salt Lake City UT. 84117 p 801.872.5516 Brown, Laura P LCSW Burgin, Sally S LCSW Belnap, Jeffrey D LCSW 885 Baxter Dr 24 South 600 E Center for Counseling Bolte, Lauren CSW South Jordan UT. 84095 Ste 4 Excellence Valley Behavioral Health p 801.997.0939 Salt Lake City UT. 84102 940 E South Union Ave 1228 S 900 E p 801.537.5008 Midvale UT. 84047 Salt Lake City UT. 84105 Brown, Rebecca A LCSW p 385.202.3778 p 888.949.4864 Valley Behavioral Health Butters, Robert P LCSW 443 S 600 E Life Matters Counseling & Belnap, Lorrie M LCSW Bowen, Corinne CSW Salt Lake City UT. 84102 Health Center Valley Behavioral Health Valley Behavioral Health p 888.949.4864 2225 E Murray-Holladay Rd 12427 S Pasture Rd 2948 S Redwood Rd Ste 112 Ste 104 West Valley City UT. 84119 *Bruce, Alysha LCSW Salt Lake City UT. 84117 Riverton UT. 84096 p 888.949.4864 PCH RESIDENTIAL HOME p 801.313.0555 p 888.949.4864 5770 S 1500 W Bldg C Bowman, Chelsea LCSW Salt Lake City UT. 84113 3336 S Pioneer Pkwy 4460 S Highland Dr The Green House for Growth p 801.313.7954 Ste 201 Ste 100 & Learning West Valley City UT. 84120 Salt Lake City UT. 84124 1325 W S Jordan Pkwy PCH CHILD PSYCH-OP p 801.313.0555 p 888.949.4864 Ste 102 5770 S 1500 W South Jordan UT. 84095 Taylorsville UT. 84123 Cain, Julie A SSW Benard, Brinlee K LCSW p 801.208.8838 p 801.313.7770 Valley Behavioral Health Valley Behavioral Health 1141 E 3900 S 195 W 7200 S Boykin, Sarah A SSW Hospital Affiliation Ste A250 Midvale UT. 84047 Valley Behavioral Health - Primary Childrens Hospital Salt Lake City UT. 84124 p 888.949.4864 195 W 7200 S p 888.949.4864 Midvale UT. 84047 Brunisholz, Sylvia J LCSW Bennett, Kathleen LCSW p 888.949.4864 Valley Behavioral Health Calkins, Chad O LCSW Life Stone Counseling 1020 S Main St Valley Behavioral Health Center Aspen Ridge Counseling Ste 100 12427 S Pasture Rd 613 E Fort Union Blvd 2711 S 8500 W Salt Lake City UT. 84101 Ste 104 Ste 104 Magna UT. 84044 p 888.949.4864 Riverton UT. 84096 Midvale UT. 84047 p 801.990.4300 p 888.949.4864 p 801.984.1717 Bryant, Aaron LCSW Brandt, Paul S LCSW Collective Recovery Center 2948 S Redwood Rd Beyers, Perriann LCSW Grow in Love 8029 S 700 E West Valley City UT. 84119 9192 S 300 W 8160 S Highland Dr Sandy UT. 84070 p 888.949.4864 Ste 19 Sandy UT. 84093 p 385.557.2183 Sandy UT. 84070 p 801.944.0944 4460 S Highland Dr p 801.558.7054 Buehner, Paul W CSW Ste 100 Braun, Daniel S LCSW Sundance Behavioral Salt Lake City UT. 84124 Birch, Kelly LCSW Wasatch Pediatrics - Resources p 888.949.4864 Utah Behavior Services Willow Creek 845 E 4800 S 5558 S 1900 W 7138 S 2000 E Ste 200 Callister, Catherine Ste B Ste 106 Salt Lake City UT. 84107 LCSW Salt Lake City UT. 84118 Salt Lake City UT. 84121 p 801.264.9522 The Utah House p 801.255.5131 p 801.942.1800 1370 S West Temple Salt Lake City UT. 84115 p 801.678.3317

404 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Campolucci, Nicole LCSW Cetrola, Gabriela V LCSW Cheney, Heidi H LCSW 5126 W Daybreak Pkwy Valley Behavioral Health Community Health Centers Ascendant Behavioral South Jordan UT. 84009 2948 S Redwood Rd 1365 W 1000 N Health p 801.213.4500 West Valley City UT. 84119 Salt Lake City UT. 84116 5383 S 900 E p 888.949.4864 p 801.328.5756 Ste 103 Hospital Affiliation Salt Lake City UT. 84117 - University of Utah Hospital Cannon, Karen L LCSW Chace, Gisella C LCSW p 801.872.5516 Family Counseling Center Valley Behavioral Health Collins, Patrick M SSW 650 E 4500 S 2948 S Redwood Rd Chidester, Alan R LCSW Valley Behavioral Health Ste 300 West Valley City UT. 84119 Valley Behavioral Health 195 W 7200 S Salt Lake City UT. 84107 p 888.949.4864 1141 E 3900 S Midvale UT. 84047 p 801.261.3500 Ste A250 p 888.949.4864 Chacon, Tana L SSW Salt Lake City UT. 84124 Carr, Alexa CSW Valley Behavioral Health p 888.949.4864 Condon, Jennifer LCSW Valley Behavioral Health 195 W 7200 S Child & Family Empowerment 2948 S Redwood Rd Midvale UT. 84047 3809 W 6200 S Services West Valley City UT. 84119 p 888.949.4864 Salt Lake City UT. 84129 1578 W 1700 S p 888.949.4864 p 888.949.4864 Ste 200 Champlin, Timothy M CSW Salt Lake City UT. 84104 Carr, Jeff LCSW Valley Behavioral Health Cho, Jaeyong MSW p 801.972.2711 Comprehensive 2948 S Redwood Rd Utah Behavior Services Psychological Services West Valley City UT. 84119 5558 S 1900 W Cook, Ann G LCSW 1208 E 3300 S p 888.949.4864 Ste B University of Utah Health Salt Lake City UT. 84106 Salt Lake City UT. 84129 1138 E Wilmington Ave p 801.483.1600 4460 S Highland Dr p 801.255.5131 Salt Lake City UT. 84106 Ste 100 p 801.213.8845 Carranza, Veronica LCSW Salt Lake City UT. 84124 6013 S Redwood Rd Valley Behavioral Health p 888.949.4864 Salt Lake City UT. 84123 1280 E Stringham Ave 195 W 7200 S p 801.255.5131 Salt Lake City UT. 84106 Midvale UT. 84047 Chavez, Johanna LCSW p 801.581.2000 p 888.949.4864 Community Health Centers Choudhary, Ibrahim CSW 1365 W 1000 N Collective Recovery Center 1525 W 2100 S 3444 W 4400 S Salt Lake City UT. 84116 8029 S 700 E Salt Lake City UT. 84119 West Valley City UT. 84119 p 801.328.5750 Sandy UT. 84070 p 801.213.9900 p 888.949.4864 p 385.557.2183 1388 S Navajo St 3730 W 4700 S Castleton, Donna E LCSW Ste C Christensen, Kjarsten D Taylorsville UT. 84129 Donna E Castleton LCSW Salt Lake City UT. 84104 LCSW p 801.213.9200 3468 Brockbank Dr p 801.955.2360 Mountain Paths Counseling Salt Lake City UT. 84124 7069 S Highland Dr 5126 W Daybreak Pkwy p 801.859.6608 220 W 7200 S Ste 100 Unit 6 Ste 600 Ste A Salt Lake City UT. 84121 South Jordan UT. 84009 Casto, LeAnn LCSW Midvale UT. 84047 p 801.214.1565 p 801.213.4500 Family Counseling Center p 801.566.5494 650 E 4500 S Coburn, Alison MSW 555 Foothill Dr Ste 300 324 10th Ave Utah Behavior Services Ste 301 Salt Lake City UT. 84107 Ste 249 5558 S 1900 W Salt Lake City UT. 84112 p 801.261.3500 Salt Lake City UT. 84103 Ste B p 801.581.8000 p 801.539.8617 Salt Lake City UT. 84118 Cavin, Christopher LCSW p 801.255.5131 555 Foothill Dr Valley Behavioral Health 4535 S 5600 W Salt Lake City UT. 84112 12427 S Pasture Rd West Valley City UT. 84120 6013 S Redwood Rd p 801.581.8000 Ste 104 p 801.676.4405 Salt Lake City UT. 84123 Riverton UT. 84096 p 801.255.5131 7495 S State St p 888.949.4864 4745 S 3200 W Midvale UT. 84047 Salt Lake City UT. 84129 Coleman, Laurie A LCSW p 801.213.9400 4460 S Highland Dr p 801.964.6214 University of Utah Health Ste 100 1950 Cir of Hope Dr Hospital Affiliation Salt Lake City UT. 84124 Cheek-O'donnell, Nicholas Salt Lake City UT. 84112 - University of Utah Hospital p 888.949.4864 LCSW p 801.587.7000 University Of Utah Health Cook, Barbra JoAnn LCSW Caya, Stephanie G LCSW 1950 Cir of Hope Dr 50 N Medical Dr University of Utah Health Compass Counseling and Salt Lake City UT. 84112 Salt Lake City UT. 84132 501 S Chipeta Way Consulting p 801.587.7000 p 801.581.2121 Salt Lake City UT. 84108 4000 S 700 E p 801.585.1575 Ste 9 Hospital Affiliation Salt Lake City UT. 84107 - University of Utah Hospital p 801.639.9544 405 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 51 W 3900 S Dahmen, Alexander LCSW Daybell-Topham, Jamie Didier, Drue B LCSW Salt Lake City UT. 84107 Summit Community LCSW Compass Counseling and p 801.585.1575 Counseling Centered Approach Consulting 5689 S Redwood Rd Counseling 4000 S 700 E Hospital Affiliation Ste 27 4190 S Highland Dr Ste 9 - University of Utah Hospital Salt Lake City UT. 84123 Ste 220 Salt Lake City UT. 84107 p 801.266.2485 Salt Lake City UT. 84124 p 801.639.9544 Cooke, Mckay L SSW p 385.282.3349 Valley Behavioral Health 5991 S Redwood Rd Domeier, Bridget LCSW 1850 S 2500 E Salt Lake City UT. 84123 DeVaud, Aline LCSW Peaceful Solutions Salt Lake City UT. 84108 p 801.266.2485 Comprehensive 1399 S 700 E p 888.949.4864 Psychological Services Ste 5 Dalanhese, Roselene S 1208 E 3300 S Salt Lake City UT. 84105 Correa, Araceli CSW LCSW Salt Lake City UT. 84106 p 801.651.3907 Valley Behavioral Health South Point Counseling p 801.483.1600 1020 S Main St 1206 W S Jordan Pkwy Hospital Affiliation Ste 100 Ste D Debenham, Rachael CSW - University of Utah Hospital Salt Lake City UT. 84101 South Jordan UT. 84095 Ascendant Behavioral p 888.949.4864 p 801.302.3801 Health Dover, Adam M SSW 4179 Riverboat Rd Valley Behavioral Health 2948 S Redwood Rd Dalrymple, Penny LCSW Ste 220 1141 E 3900 S West Valley City UT. 84119 Penny P Dalrymple Salt Lake City UT. 84123 Ste A250 p 888.949.4864 124 S 400 E p 801.872.5516 Salt Lake City UT. 84124 Ste 301 p 888.949.4864 Cottrell, Stacie MSW Salt Lake City UT. 84111 5383 S 900 E Ascendant Behavioral p 801.359.1114 Ste 103 4460 S Highland Dr Health Salt Lake City UT. 84117 Ste 300 4179 Riverboat Rd Davidson, Kayleen S LCSW p 801.872.5516 Salt Lake City UT. 84124 Ste 220 Compass Counseling and p 888.949.4864 Salt Lake City UT. 84123 Consulting Deily, Jacquiline LCSW p 801.872.5516 4000 S 700 E Ascendant Behavioral Dowse, Brenda J LCSW Ste 9 Health Lotus Center Inc 5383 S 900 E Salt Lake City UT. 84107 5383 S 900 E 4376 S 700 E Ste 103 p 801.639.9544 Ste 103 Ste 200 Salt Lake City UT. 84117 Salt Lake City UT. 84117 Salt Lake City UT. 84107 p 801.872.5516 Davis, Myles Q LCSW p 801.872.5516 p 385.272.4292 Empowering Relief Covington, Misty LCSW Counseling Delewski, Richard LCSW Empowering Relief Sage Family Counseling 5814 S 900 E University Of Utah Health Counseling 13552 S 110 W Salt Lake City UT. 84121 501 S Chipeta Way 5814 S 900 E Ste 204 p 385.800.3272 Salt Lake City UT. 84108 Salt Lake City UT. 84121 Draper UT. 84020 p 801.587.2500 p 385.800.3272 p 801.432.0883 Davis, Robin LCSW Robin L Davis LLC Hospital Affiliation Duncan, Susan L SSW Cumberledge, Frances 1208 E 3300 S - University of Utah Hospital Valley Behavioral Health LCSW Salt Lake City UT. 84106 1141 E 3900 S Ascendant Behavioral p 801.483.1600 Delgadillo, Cindy J LCSW Ste A250 Health Valley Behavioral Health Salt Lake City UT. 84124 4179 Riverboat Rd 923 E Executive Park Dr 4460 S Highland Dr p 888.949.4864 Ste 220 Ste E Ste 100 Salt Lake City UT. 84123 Salt Lake City UT. 84117 Salt Lake City UT. 84124 Durrant, Laura LCSW p 801.872.5516 p 801.349.9063 p 888.949.4864 Ascendant Behavioral Health 5383 S 900 E Davis, Ronda M LCSW Diamond, Allie D LCSW 4179 Riverboat Rd Ste 103 Healing Feathers Ascendant Behavioral Ste 220 Salt Lake City UT. 84117 4578 S Highland Dr Health Salt Lake City UT. 84123 p 801.872.5516 Ste 350 5383 S 900 E p 801.872.5516 Salt Lake City UT. 84117 Ste 103 Curtis, Leslie J LCSW p 801.906.8520 Salt Lake City UT. 84117 Heartfelt Healing Valley Behavioral Health p 801.872.5516 4885 S 900 E 4460 S Highland Dr Holistic Elements Ste 110C Ste 100 835 E 4800 S Dickman, Thomas LCSW Salt Lake City UT. 84117 Salt Lake City UT. 84124 Ste 220 Family Counseling Center p 801.366.4469 p 888.949.4864 Salt Lake City UT. 84107 650 E 4500 S p 801.262.5418 Ste 300 Murray UT. 84107 p 801.261.3500

406 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Ascendant Behavioral Eisenman, Erika LCSW Arura Falk, Joshua S LCSW Health Aspen Ridge Counseling 702 E South Temple University of Utah Health 5383 S 900 E 2880 W 4700 S Ste B-40 1280 E Stringham Ave Ste 103 Ste G-1 Salt Lake City UT. 84102 Salt Lake City UT. 84106 Salt Lake City UT. 84117 Salt Lake City UT. 84129 p 801.613.7049 p 801.213.8841 p 801.872.5516 p 801.990.4300 Eschler, Carrie J LCSW 1525 W 2100 S Dusoe, Michael E LCSW Ekenstam, Nadia LCSW Valley Behavioral Health Salt Lake City UT. 84119 A/D Psychotherapy & Valley Behavioral Health 550 W 700 S p 801.213.8841 Clinical Consulting -Not 1141 E 3900 S Salt Lake City UT. 84101 all services covered, Ste A170 p 888.949.4864 3730 W 4700 S please contact your Salt Lake City UT. 84124 Taylorsville UT. 84129 administrator p 888.949.4864 Ewanowski, Julia LCSW p 801.213.9200 9662 S 700 E University of Utah Health Sandy UT. 84070 Primary Childrens Safe and 1138 E Wilmington Ave 5126 W Daybreak Pkwy p 801.233.8577 Healthy Families Salt Lake City UT. 84106 Ste 600 81 N Mario Capecchi Dr p 801.213.8845 South Jordan UT. 84009 Ebling, Richard LCSW Salt Lake City UT. 84113 p 801.213.4500 University Of Utah Health p 801.662.3606 1280 E Stringham Ave 501 S Chipeta Way Salt Lake City UT. 84106 5126 W Daybreak Pkwy Salt Lake City UT. 84108 Eldredge, David G LCSW p 801.581.2000 South Jordan UT. 84009 p 801.587.2500 University of Utah Health p 801.213.4500 1525 W 2100 S 1525 W 2100 S Hospital Affiliation Salt Lake City UT. 84119 Salt Lake City UT. 84119 555 Foothill Dr - University of Utah Hospital p 801.213.8841 p 801.213.9900 Ste 301 Salt Lake City UT. 84112 Edwards, Alisa LCSW 3730 W 4700 S 3730 W 4700 S p 801.581.8000 Valley Behavioral Health West Valley City UT. 84129 Taylorsville UT. 84129 3809 W 6200 S p 801.213.9200 p 801.213.9200 555 Foothill Dr Taylorsville UT. 84129 Salt Lake City UT. 84112 p 888.949.4864 5126 W Daybreak Pkwy 5126 W Daybreak Pkwy p 801.581.8000 South Jordan UT. 84009 Ste 600 Edwards, Steven D LCSW p 801.213.4500 South Jordan UT. 84009 7495 S State St University Of Utah Health p 801.213.4500 Midvale UT. 84047 50 N Medical Dr Rm AC210 7495 S State St p 801.213.9400 Salt Lake City UT. 84132 Midvale UT. 84047 555 Foothill Dr p 801.213.8841 p 801.213.9400 Ste 301 Faumuina, Jannah Lee K Salt Lake City UT. 84112 LCSW Collective Recovery Center Hospital Affiliation p 801.581.8000 Valley Behavioral Health 8029 S 700 E - Primary Childrens Hospital 1020 S Main St Sandy UT. 84070 555 Foothill Dr Ste 100 p 385.557.2183 Elkins, Laurie LCSW Salt Lake City UT. 84112 Salt Lake City UT. 84101 Ascendant Behavioral p 801.581.8000 p 888.949.4864 Egbert, Andrea LCSW Health Wasatch Pediatrics - 5383 S 900 E 7495 S State St Fawcett, Alexandra F CSW Draper Ste 103 Midvale UT. 84047 Valley Behavioral Health 114 E 12450 S Salt Lake City UT. 84117 p 801.213.9400 3809 W 6200 S Ste 100 p 801.872.5516 Taylorsville UT. 84129 Draper UT. 84020 Hospital Affiliation p 888.949.4864 p 801.523.3001 Enniss, Timothy S LCSW - University of Utah Hospital Comprehensive Ferris, Barbara LCSW PCH CHILD PSYCH-OP Psychological Services Ewell, Esther LCSW Family Counseling Center 5770 S 1500 W 1208 E 3300 S Valley Behavioral Health 650 E 4500 S Taylorsville UT. 84123 Salt Lake City UT. 84106 195 W 7200 S Ste 300 p 801.313.7770 p 801.483.1600 Midvale UT. 84047 Murray UT. 84107 p 888.949.4864 p 801.261.3500 Hospital Affiliation 3725 W 4100 S - Primary Childrens Hospital West Valley City UT. 84119 Fairclough, Cassandra Flaspehler, Carol LCSW p 801.965.3759 LCSW South Point Counseling Egbert, Phil CSW Jordan West Family 1206 W S Jordan Pkwy Next Level Recovery Escalanti, Laurian LCSW Counseling Ste D 6771 S 900 E Compass Counseling and 9263 Redwood Rd Bldg 8 South Jordan UT. 84095 Midvale UT. 84047 Consulting Ste B p 801.302.3801 p 801.386.9799 4000 S 700 E West Jordan UT. 84088 Ste 9 p 801.566.0749 Salt Lake City UT. 84107 p 801.639.9544

407 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Florez, Monica LCSW Garcia Leavitt, Elizabeth Gerritsen, James CSW Goodman, Julie A LCSW Monica Florez R LCSW Valley Behavioral Health Valley Behavioral Health 2180 E 4500 S University of Utah Health 2948 S Redwood Rd 1020 S Main St Ste 150 50 N Medical Dr West Valley City UT. 84119 Ste 218 Salt Lake City UT. 84117 Salt Lake City UT. 84132 p 888.949.4864 Salt Lake City UT. 84101 p 801.828.8905 p 801.581.2121 p 888.949.4864 Gileno, Zaneta M LCSW Foster, Thomas M LCSW University Of Utah Health Bear Creek Counseling 4460 S Highland Dr Interface Psychological 555 Foothill Dr 1227 W 9000 S Ste 100 2180 E 4500 S Salt Lake City UT. 84112 Ste H Salt Lake City UT. 84124 Ste 245 p 801.581.2628 West Jordan UT. 84084 p 888.949.4864 Salt Lake City UT. 84117 p 385.274.7119 p 801.328.8817 University of Utah Health Gooley, Patrick J LCSW 729 S Arapeen Dr Gillespie, Amy LCSW Life Matters Counseling & Fowers, Heidi M SSW Salt Lake City UT. 84108 Life Stone Counseling Health Center Valley Behavioral Health p 801.585.6387 Center 2225 E Murray-Holladay Rd 1141 E 3900 S 613 E Fort Union Blvd Ste 112 Ste A250 Hospital Affiliation Ste 104 Salt Lake City UT. 84117 Salt Lake City UT. 84124 - University of Utah Hospital Midvale UT. 84047 p 801.313.0555 p 888.949.4864 p 801.984.1717 Garland, Eric L LCSW 3336 S Pioneer Pkwy 4460 S Highland Dr University of Utah Health Gillespie, Bonnie L SSW Ste 201 Ste 300 1950 Cir of Hope Dr Valley Behavioral Health West Valley City UT. 84120 Salt Lake City UT. 84124 Salt Lake City UT. 84112 4460 S Highland Dr p 801.313.0555 p 888.949.4864 p 801.587.7000 Ste 300 Salt Lake City UT. 84124 Gould, Caron L CSW Francone, Stacey M LCSW 50 N Medical Dr p 888.949.4864 Valley Behavioral Health 262 E 3900 S Salt Lake City UT. 84132 2948 S Redwood Rd Ste 125 p 801.581.2121 Goldstein, Marvin LCSW West Valley City UT. 84119 Salt Lake City UT. 84107 Clinical Consultants p 888.949.4864 p 801.209.8690 Hospital Affiliation 7601 S Redwood Rd Bldg E - University of Utah Hospital West Jordan UT. 84084 *Grant, Ryan LCSW Frey, Cristie L LCSW p 801.233.8670 Primary Childrens Hospital Sundance Behavioral Garza Solis, Karem G LCSW 100 N Mario Capecchi Dr Resources Valley Behavioral Health Golub, Lateisha L LCSW Salt Lake City UT. 84113 845 E 4800 S 12427 S Pasture Rd Compass Counseling and p 801.662.1000 Ste 200 Ste 104 Consulting Salt Lake City UT. 84107 Herriman UT. 84096 4000 S 700 E 3773 W 12600 S p 801.264.9522 p 888.949.4864 Ste 9 Riverton UT. 84065 Salt Lake City UT. 84107 p 801.662.3606 Froerer, Baylee E SSW 4460 S Highland Dr p 801.639.9544 Valley Behavioral Health Ste 100 81 N Mario Capecchi Dr 1141 E 3900 S Salt Lake City UT. 84124 Gomes, Andrea LCSW Salt Lake City UT. 84113 Ste A-250 p 888.949.4864 University Of Utah Health p 801.662.3606 Salt Lake City UT. 84124 501 S Chipeta Way p 888.949.4864 Gauchay, Lisa LCSW Salt Lake City UT. 84108 Green, E Guerry LCSW University of Utah Health p 801.587.2500 The Green House for Growth Furse, Daniel D LCSW 50 N Medical Dr & Learning Valley Behavioral Health Salt Lake City UT. 84132 Hospital Affiliation 1325 W S Jordan Pkwy 1020 S Main St p 801.581.2121 - University of Utah Hospital Ste 102 Ste 100 South Jordan UT. 84095 Salt Lake City UT. 84101 Hospital Affiliation Gonzalez, Yvette S LCSW p 801.208.8838 p 888.949.4864 - University of Utah Hospital Lotus Center Inc 348 E 4500 S Green, Elsebeth Galloway, Teresa LCSW Gaugh, Amy LCSW Ste 360 The Green House for Growth Sundance Behavioral The Childrens Center Salt Lake City UT. 84107 & Learning Resources 5242 S 4820 W p 385.272.4292 1325 W S Jordan Pkwy 845 E 4800 S Salt Lake City UT. 84118 Ste 102 Ste 200 p 801.966.4251 Gonzalz, Amanda J MSW South Jordan UT. 84095 Salt Lake City UT. 84107 Empowering Relief p 801.785.1169 p 801.264.9522 George, Margaret LCSW Counseling Ascendant Behavioral 5814 S 900 E *Griffiths, Amanda D LCSW Health Salt Lake City UT. 84121 PCH Residential Home 5383 S 900 E p 385.800.3272 5770 S 1500 W Bldg C Ste 103 Salt Lake City UT. 84123 Salt Lake City UT. 84117 p 801.313.7954 p 801.872.5516

408 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. PCH Residential Trmnt - Hale, Jessica LCSW Hamilton, Ryan W LCSW *Harris, Natalie LCSW ADOL Valley Behavioral Health University of Utah Health Primary Childrens Hospital 5770 S 1500 W 12427 S Pasture Rd 51 W 3900 S 5770 S 1500 W Salt Lake City UT. 84123 Ste 104 Salt Lake City UT. 84107 Taylorsville UT. 84123 p 801.313.7940 Riverton UT. 84096 p 801.585.1575 p 801.313.7770 p 888.949.4864 Gurrister, Linda LCSW Hamp, Breeann B LCSW Hospital Affiliation 4190 S Highland Dr 4460 S Highland Dr Life Matters Counseling & - Primary Childrens Hospital Ste 210 Ste 100 Health Center Salt Lake City UT. 84124 Salt Lake City UT. 84124 2225 E Murray-Holladay Rd Harrison, Bryan C LCSW p 801.278.8492 p 888.949.4864 Ste 112 Jordan West Family Salt Lake City UT. 84117 Counseling Gutierrez, Jose D LCSW *Hale, Jonathan C LCSW p 801.313.0555 9263 Redwood Rd Bldg 8 Valley Behavioral Health PCH Residential Home Ste B 1020 S Main St 5770 S 1500 W Bldg C 3336 S Pioneer Pkwy West Jordan UT. 84088 Ste 100 Salt Lake City UT. 84123 Ste 201 p 801.566.0749 Salt Lake City UT. 84101 p 801.313.7954 West Valley City UT. 84120 p 888.949.4864 p 801.313.0555 Havertz, Stephen S LCSW PCH Residential Trmnt - Valley Behavioral Health 1141 E 3900 S ADOL Hansen, Samuel J LCSW 3809 W 6200 S Ste A250 5770 S 1500 W Valley Behavioral Health Taylorsville UT. 84129 Salt Lake City UT. 84124 Salt Lake City UT. 84123 1020 S Main St p 888.949.4864 p 888.949.4864 p 801.313.7940 Ste 300 Salt Lake City UT. 84101 4460 S Highland Dr Guzman, Anthony LCSW Hales, Jason A LCSW p 888.949.4864 Ste 100 Lotus Center Inc Hales Counseling Center Salt Lake City UT. 84124 4376 S 700 E 8817 S Redwood Rd Hanson, Laura LCSW p 888.949.4864 Ste 200 Ste D Valley Behavioral Health Salt Lake City UT. 84107 West Jordan UT. 84088 195 W 7200 S Hazen, Shawn L LCSW p 385.272.4292 p 801.783.9265 Midvale UT. 84047 Lotus Center Inc p 888.949.4864 4376 S 700 E Hakes, Chris C LCSW Hall, Abigail SSW Ste 200 Aspen Ridge Counseling Valley Behavioral Health 2948 S Redwood Rd Salt Lake City UT. 84107 11075 S State St 2948 S Redwood Rd West Valley City UT. 84119 p 385.272.4292 Ste 35 West Valley City UT. 84119 p 888.949.4864 Sandy UT. 84070 p 888.949.4864 Henderson, Amy LCSW p 801.501.8444 Hanson, Nancy C LCSW University of Utah Health 4460 S Highland Dr 8160 S Highland Dr 65 S Mario Capecchi Dr 1561 W 7000 S Ste 220 Ste 204 Salt Lake City UT. 84132 Ste 200 Salt Lake City UT. 84124 Sandy UT. 84093 p 801.581.2121 West Jordan UT. 84084 p 888.949.4864 p 801.942.4444 p 801.990.4300 Hospital Affiliation Hall, Aliah LCSW Harding, Stephanie LCSW - University of Utah Hospital 2711 S 8500 W Kindling Comprehensive Magna UT. 84044 3980 S 700 E Psychological Services Hendrix, Megan L LCSW p 801.990.4300 Ste 22 1208 E 3300 S Valley Behavioral Health Salt Lake City UT. 84107 Salt Lake City UT. 84106 1141 E 3900 S 2880 W 4700 S p 385.743.2728 p 801.483.1600 Ste A160 Ste G-1 Salt Lake City UT. 84124 Salt Lake City UT. 84129 Compass Counseling and Harmon, Jordan LCSW p 888.949.4864 p 801.990.4300 Consulting Cedar Psychiatry 4000 S 700 E 1208 E 3300 S 195 W 7200 S 411 W 7200 S Ste 9 Salt Lake City UT. 84106 Midvale UT. 84047 Ste 304 Salt Lake City UT. 84107 p 801.369.8989 p 888.949.4864 Midvale UT. 84047 p 801.639.9544 p 801.990.4300 721 E 12200 S Heninger, Carolyn LCSW Hallisey, Jenny T CSW Draper UT. 84020 Sundance Behavioral C Hakes LLC Valley Behavioral Health p 801.369.8989 Resources 8537 W 2700 S 1020 S Main St 845 E 4800 S Ste C Ste 100 Hospital Affiliation Ste 200 Magna UT. 84044 Salt Lake City UT. 84101 - Mountain View Hospital Murray UT. 84107 p 801.503.8937 p 888.949.4864 (UT) p 801.264.9522 - Utah Valley Hospital

409 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Hennefer, Kenneth L LCSW 3730 W 4700 S 4460 S Highland Dr Hough, Amanda LCSW Counseling & Education Taylorsville UT. 84129 Ste 100 Comprehensive Associates p 801.213.9200 Salt Lake City UT. 84124 Psychological Services 7321 S State St p 888.949.4864 1208 E 3300 S Ste A-B 5126 W Daybreak Pkwy Salt Lake City UT. 84106 Midvale UT. 84047 Ste 600 Ascendant Behavioral p 801.264.6000 p 801.352.2844 South Jordan UT. 84009 Health p 801.213.4500 5383 S 900 E Howell, Justin LCSW Henry, Suzanne L LCSW Ste 103 Wasatch Pediatrics - University Of Utah Health 5126 W Daybreak Pkwy Salt Lake City UT. 84117 Willow Creek 240 Morris Ave South Jordan UT. 84009 p 801.872.5516 7138 S 2000 E Ste 400 p 801.213.4500 Ste 106 Salt Lake City UT. 84115 Holbrook, Jocelyn E LCSW Salt Lake City UT. 84121 p 801.585.1212 555 Foothill Dr 5796 S 900 E p 801.942.1800 Ste 301 Ste 206 Hospital Affiliation Salt Lake City UT. 84112 Salt Lake City UT. 84121 Howes, Scott M LCSW - University of Utah Hospital p 801.581.8000 p 801.879.0252 Wasatch Spring Counseling 2936 Highland Dr Hereth, Jacob L SSW 555 Foothill Dr Hollenbeck, Susan E LCSW Ste 100 Valley Behavioral Health Salt Lake City UT. 84112 Comprehensive Salt Lake City UT. 84106 4460 S Highland Dr p 801.581.8000 Psychological Services p 801.540.4452 Ste 300 1208 E 3300 S Salt Lake City UT. 84124 7495 S State St Salt Lake City UT. 84106 Howick, Brennan P CSW p 888.949.4864 Midvale UT. 84047 p 801.483.1600 Valley Behavioral Health p 801.213.9400 4460 S Highland Dr Herrera, Bryce LCSW 3725 W 4100 S Ste 100 University of Utah Health Hill, Kayleen M LCSW West Valley City UT. 84119 Salt Lake City UT. 84124 1138 E Wilmington Ave Jordan West Family p 801.965.3759 p 888.949.4864 Salt Lake City UT. 84106 Counseling p 801.213.8845 9263 Redwood Rd Bldg 8 Holloway, Tifani J LCSW Howlett, Sarah T LCSW West Jordan UT. 84088 Valley Behavioral Health Valley Behavioral Health 1280 E Stringham Ave p 801.566.0749 1020 S Main St 4460 S Highland Dr Salt Lake City UT. 84106 Ste 100 Ste 100 p 801.213.8841 Hill, Nichole LCSW Salt Lake City UT. 84101 Salt Lake City UT. 84124 1399 S 700 E p 888.949.4864 p 888.949.4864 555 Foothill Dr Ste 15E Salt Lake City UT. 84112 Salt Lake City UT. 84105 Holmes, Alisha MSW Hulet, Lindsey CSW p 801.581.8000 p 801.362.9665 Utah Behavior Services Valley Behavioral Health 5558 S 1900 W 2948 S Redwood Rd Hospital Affiliation University of Utah Health Ste B West Valley City UT. 84119 - University of Utah Hospital 1525 W 2100 S Salt Lake City UT. 84129 p 888.949.4864 Salt Lake City UT. 84119 p 801.255.5131 Hesse, Lucille LCSW p 801.213.8841 Hungary, Katrina D SSW 1399 S 700 E 6013 S Redwood Rd Valley Behavioral Health Ste 8 Hospital Affiliation Salt Lake City UT. 84123 280 E 600 S Salt Lake City UT. 84105 - University of Utah Hospital p 801.255.5131 Salt Lake City UT. 84111 p 801.485.1271 p 888.949.4864 Hill, Scott LCSW Holyoak, Sarah CSW Hickok, Angela LCSW University of Utah Health Valley Behavioral Health *Hutchinson, Cassandra L Jordan West Family 50 N Medical Dr 2948 S Redwood Rd *LCSW Counseling Salt Lake City UT. 84132 West Valley City UT. 84119 PCH RESIDENTIAL HOME 9263 Redwood Rd Bldg 8 p 801.581.7951 p 888.949.4864 5770 S 1500 W Bldg C West Jordan UT. 84088 Taylorsville UT. 84123 p 801.566.0749 501 S Chipeta Way Horyna, Amy p 801.313.7954 Salt Lake City UT. 84108 University Of Utah Health Higgins, Michael P LCSW p 801.585.1575 1950 Cir of Hope Dr PCH RESIDENTIAL TRMNT-ADOL University of Utah Health Salt Lake City UT. 84112 5770 S 1500 W 1280 E Stringham Ave Hospital Affiliation p 801.587.7000 Taylorsville UT. 84123 Salt Lake City UT. 84106 - University of Utah Hospital p 801.313.7940 p 801.213.8841 Hospital Affiliation Hilton, Gail C LCSW - University of Utah Hospital PCH NEUROPSYCHOLOGY 1525 W 2100 S Valley Behavioral Health 81 N Mario Capecchi Dr Salt Lake City UT. 84119 12427 S Pasture Rd Salt Lake City UT. 84113 p 801.213.8841 Ste 104 p 801.662.5592 Riverton UT. 84096 p 888.949.4864 Hospital Affiliation - Primary Childrens Hospital

410 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Hutchinson, Sheridan SSW *Jensen, Michael B LCSW 4460 S Highland Dr Keshavarz, Yasaman LCSW Valley Behavioral Health PCH CHILD PSYCH-OP Ste 100 University of Utah Health 1020 S Main St 5770 S 1500 W Salt Lake City UT. 84124 1138 E Wilmington Ave Ste 100 Taylorsville UT. 84123 p 888.949.4864 Salt Lake City UT. 84106 Salt Lake City UT. 84101 p 801.313.7770 p 801.213.8845 p 888.949.4864 6856 S 700 E Jensen, Tyson LCSW Midvale UT. 84047 1280 E Stringham Ave Jackson, Amanda LCSW Aspen Ridge Counseling p 888.949.4864 Salt Lake City UT. 84106 Cedar Psychiatry 2711 S 8500 W p 801.581.2000 1208 E 3300 S Magna UT. 84044 Johnson, Tod LCSW Salt Lake City UT. 84106 p 801.990.4300 Jordan West Family 1525 W 2100 S p 801.369.8989 Counseling Salt Lake City UT. 84119 Lighthouse Counseling 9263 Redwood Rd Bldg 8 p 801.213.9900 154 E Myrtle Ave Services Ste B Ste 204 3405 W 12600 S West Jordan UT. 84088 3730 W 4700 S Murray UT. 84107 Ste 110 p 801.566.0749 Taylorsville UT. 84129 p 801.369.8989 Riverton UT. 84065 p 801.213.9200 p 385.237.4943 Johnston, Harmony MSW 721 E 12200 S Utah Behavior Services 5126 W Daybreak Pkwy Draper UT. 84020 Jeppson, Holly C LCSW 5558 S 1900 W Ste 600 p 801.369.8989 Holly C Jeppson LCSW Ste B South Jordan UT. 84009 8545 S Redwood Rd Unit B Salt Lake City UT. 84129 p 801.213.4500 Jacquez, Jacob E LCSW West Jordan UT. 84084 p 801.255.5131 Empowering Relief p 801.748.2192 555 Foothill Dr Counseling 6013 S Redwood Rd Ste 301 5814 S 900 E Johnson, Charles J LCSW Salt Lake City UT. 84123 Salt Lake City UT. 84112 Salt Lake City UT. 84121 Lotus Center Inc p 801.255.5131 p 801.581.8000 p 385.800.3272 4376 S 700 E Ste 200 Jones, Georgia A LCSW 555 Foothill Dr Jarman, Mary LCSW Salt Lake City UT. 84107 4190 S Highland Dr Salt Lake City UT. 84112 Comprehensive Counseling p 385.272.4292 Ste 208 p 801.581.8000 Solutions Salt Lake City UT. 84124 885 Baxter Dr Johnson, James G LCSW p 801.467.6136 7495 S State St South Jordan UT. 84095 Valley Behavioral Health Midvale UT. 84047 p 801.671.1020 12427 S Pasture Rd Kastner, William R LCSW p 801.213.9400 Ste 104 South Point Counseling Jarvis, Julio C LCSW Herriman UT. 84096 1206 W S Jordan Pkwy Hospital Affiliation University of Utah Health p 888.949.4864 Ste D - University of Utah Hospital 1525 W 2100 S South Jordan UT. 84095 Salt Lake City UT. 84119 4460 S Highland Dr p 801.302.3801 Ketchoyian, Jennifer p 801.213.8841 Ste 100 LCSW Salt Lake City UT. 84124 Keene, Susan LCSW Valley Behavioral Health 5126 W Daybreak Pkwy p 888.949.4864 Valley Behavioral Health 195 W 7200 S South Jordan UT. 84009 1020 S Main St Midvale UT. 84047 p 801.213.4500 Johnson, Sara Jane LCSW Ste 100 p 888.949.4864 The Childrens Center Salt Lake City UT. 84101 Hospital Affiliation 350 S 400 E p 888.949.4864 Kilpatrick, Lorraine S - University of Utah Hospital Salt Lake City UT. 84111 LCSW p 801.582.5534 Kelen, Joyce A LCSW 6925 S Union Park Ctr Jennings, Karl E LCSW Joyce Kelen Counseling and Ste 500 Compass Counseling and Johnson, Sharon LCSW Consulting Midvale UT. 84047 Consulting Valley Behavioral Health 265 E 100 S p 801.566.2622 4000 S 700 E 1141 E 3900 S Ste 275 Ste 9 Ste A250 Salt Lake City UT. 84111 Kivlovitz, Joshua LCSW Salt Lake City UT. 84107 Salt Lake City UT. 84124 p 801.537.7523 Valley Behavioral Health p 801.639.9544 p 888.949.4864 2948 S Redwood Rd Kennedy, Emily A SSW West Valley City UT. 84119 Jensen, Karen E LCSW 12427 S Pasture Rd Valley Behavioral Health p 888.949.4864 University Of Utah Health Ste 104 2472 S 300 E 1950 Cir of Hope Dr Riverton UT. 84096 Salt Lake City UT. 84115 Knaus, Erin R SSW Salt Lake City UT. 84112 p 888.949.4864 p 888.949.4864 Valley Behavioral Health p 801.587.7000 1141 E 3900 S Ste A250 Hospital Affiliation Salt Lake City UT. 84124 - University of Utah Hospital p 888.949.4864

411 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Knight, Carin LCSW 5126 W Daybreak Pkwy Laskowski, Thomas M LCSW 2880 W 4700 S PCH Residential Home South Jordan UT. 84009 Thomas M Laskowski, LCSW Ste G-1 5770 S 1500 W Bldg C p 801.213.4500 1174 E Graystone Way Salt Lake City UT. 84129 Taylorsville UT. 84123 Ste 6 p 801.990.4300 p 801.313.7954 555 Foothill Dr Salt Lake City UT. 84106 Ste 301 p 801.696.5538 411 W 7200 S PCH Child Psych OP Salt Lake City UT. 84112 Ste 304 5770 S 1500 W p 801.581.8000 3108 E 3300 S Midvale UT. 84047 Taylorsville UT. 84123 Salt Lake City UT. 84109 p 801.990.4300 p 801.313.7770 555 Foothill Dr p 801.656.5538 Salt Lake City UT. 84112 Lehman, Mary E LCSW Hospital Affiliation p 801.581.8000 Lasley, Linda K LCSW Mary Eileen Lehman, LCSW - Primary Childrens Hospital Valley Behavioral Health 4055 S 700 E 7495 S State St 1020 S Main St Ste 102 Kraemer, Jennifer L LCSW Midvale UT. 84047 Ste 100 Salt Lake City UT. 84107 Centered Approach p 801.213.9400 Salt Lake City UT. 84101 p 801.201.7661 Counseling p 888.949.4864 4190 S Highland Dr Hospital Affiliation Leon, Kameron R SSW Ste 200 - University of Utah Hospital 12427 S Pasture Rd Valley Behavioral Health Salt Lake City UT. 84124 Ste 104 2472 S 300 E p 385.282.3349 Lambert, Ruthann CSW Riverton UT. 84096 Salt Lake City UT. 84115 Valley Behavioral Health p 888.949.4864 p 888.949.4864 Kravitz, Kent C LCSW 1020 S Main St Valley Behavioral Health Ste 100 4460 S Highland Dr Lewis, Neva P LCSW 1020 S Main St Salt Lake City UT. 84101 Ste 100 Valley Behavioral Health Ste 100 p 888.949.4864 Salt Lake City UT. 84124 1020 S Main St Salt Lake City UT. 84101 p 888.949.4864 Ste 200 p 888.949.4864 Lambert, Valerie K LCSW Salt Lake City UT. 84101 1060 E 1st S Lawrence, Melanie A LCSW p 888.949.4864 Lakey, Kathleen F LCSW Ste 202 Valley Behavioral Health Kathleen Fitzwilliam Lakey Salt Lake City UT. 84102 3809 W 6200 S Leybas, Ryan L LCSW LLC p 801.533.5632 Salt Lake City UT. 84129 SLC Mental Health 275 E S Temple p 888.949.4864 1174 E Graystone Way Ste 101 Lang, Emily CSW Ste 6 Salt Lake City UT. 84111 Valley Behavioral Health 4460 S Highland Dr Salt Lake City UT. 84106 p 385.218.8266 1020 S Main St Ste 100 p 801.277.2129 Ste 100 Salt Lake City UT. 84124 Lamb, Joseph LCSW Salt Lake City UT. 84101 p 888.949.4864 Lieu, Nancy LCSW University of Utah Health p 888.949.4864 Centered Approach 1280 E Stringham Ave LeCluyse, Christina LCSW Counseling Salt Lake City UT. 84106 2948 S Redwood Rd Child and Family 4190 S Highland Dr p 801.213.8841 West Valley City UT. 84119 Empowerment Services Ste 220 p 888.949.4864 1578 W 1700 S Salt Lake City UT. 84124 1525 W 2100 S Ste 200 p 385.282.3349 Salt Lake City UT. 84119 Larsen, Stephanie B LCSW Salt Lake City UT. 84104 p 801.213.8841 Valley Behavioral Health p 801.972.2711 Lindsey, Kendra LCSW 1141 E 3900 S Adult Behavioral Health 3730 W 4700 S Ste A250 Leggitt, Valerie LCSW JVMC-WVC - OP Taylorsville UT. 84129 Salt Lake City UT. 84124 Aspen Ridge Counseling 4052 W Pioneer Pkwy p 801.213.9200 p 888.949.4864 11075 S State St Ste 105 Ste 35 West Valley City UT. 84120 University Of Utah Health Larson, Matt G LCSW Sandy UT. 84070 p 801.554.3420 501 S Chipeta Way Matt Larson Psychotherapy p 801.501.8444 Salt Lake City UT. 84108 & Associates Lindstrom, Shanna LCSW p 801.587.2500 1226 W S Jordan Pkwy Bldg 1561 W 7000 S Ascendant Behavioral A Ste 200 Health University of Utah Health South Jordan UT. 84095 West Jordan UT. 84084 5383 S 900 E 5126 W Daybreak Pkwy p 801.599.6396 p 801.990.4300 Ste 103 Ste 600 Salt Lake City UT. 84117 South Jordan UT. 84009 24 S 600 E 2711 S 8500 W p 801.872.5516 p 801.213.4500 Ste 6 Magna UT. 84044 Salt Lake City UT. 84102 p 801.990.4300 Linnell, Randy S LCSW p 801.599.6396 Intermountain Center for Cognitive Therapy 111 E 5600 S Ste 300 Murray UT. 84107 p 801.859.9238 412 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Lloyd, Kendall LCSW 1525 W 2100 S Lund, Stacy L LCSW Manning, Linsay K LCSW Wasatch Pediatrics - Salt Lake City UT. 84119 Valley Behavioral Health Lotus Center Inc Willow Creek p 801.213.9900 1020 S Main St 4376 S 700 E 7138 S 2000 E Ste 218 Ste 200 Ste 106 3730 W 4700 S Salt Lake City UT. 84101 Salt Lake City UT. 84107 Salt Lake City UT. 84121 Taylorsville UT. 84129 p 888.949.4864 p 385.272.4292 p 801.942.1800 p 801.213.9200 MacDougall, Mindy LCSW Manning, Taylor C LCSW Longshaw, Alexandra E SSW 5126 W Daybreak Pkwy 124 S 400 E Compass Counseling and Valley Behavioral Health Ste 600 Ste 301 Consulting 195 W 7200 S South Jordan UT. 84009 Salt Lake City UT. 84111 4000 S 700 E Midvale UT. 84047 p 801.213.4500 p 801.322.3923 Ste 9 p 888.949.4864 Salt Lake City UT. 84107 5126 W Daybreak Pkwy Macfarlane, J R LCSW p 801.639.9544 Looye, Michelle D LCSW South Jordan UT. 84009 Interface Psychological Granger Medical p 801.213.4500 Services Marchant, Jennifer LCSW Specialists 2180 E 4500 S Jennifer Marchant LCSW 1160 E 3900 S 555 Foothill Dr Ste 245 3627 W 13100 St Ste 1000 Ste 301 Salt Lake City UT. 84117 Herriman UT. 84096 Salt Lake City UT. 84124 Salt Lake City UT. 84112 p 801.328.8817 p 801.520.5724 p 801.262.1771 p 801.581.8000 Macfarlane, Lindsey A Margolis, Amber LCSW 11724 S State St 555 Foothill Dr LCSW University of Utah Health Draper UT. 84020 Salt Lake City UT. 84112 Valley Behavioral Health 1280 E Stringham Ave p 801.576.2050 p 801.581.8000 4460 S Highland Dr Salt Lake City UT. 84106 Ste 100 p 801.581.2000 Granger Medical Clinic 7495 S State St Salt Lake City UT. 84124 12391 S 4000 W Midvale UT. 84047 p 888.949.4864 1525 W 2100 S Riverton UT. 84065 p 801.213.9400 Salt Lake City UT. 84119 p 801.302.1700 Madsen, Julie LCSW p 801.213.9900 Hospital Affiliation Herriman Counseling Granger Medical - University of Utah Hospital Services 3730 W 4700 S Specialists 4831 W Copper Oaks Dr Taylorsville UT. 84129 12391 S 4000 W Lowe, Tiffany L LCSW Herriman UT. 84096 p 801.213.9200 Riverton UT. 84096 Valley Behavioral Health p 801.520.5724 p 801.302.1700 2948 S Redwood Rd 5126 W Daybreak Pkwy West Valley City UT. 84119 5627 W 13100 St Ste 600 2965 W 3500 S p 888.949.4864 Herriman UT. 84096 South Jordan UT. 84009 West Valley City UT. 84119 p 801.520.5724 p 801.213.4500 p 801.965.3600 Luker, Brenda A LCSW Comprehensive Madsen, Kevin LCSW 555 Foothill Dr 3181 W 9000 S Psychological Services Ascendant Behavioral Ste 301 West Jordan UT. 84088 1208 E 3300 S Health Salt Lake City UT. 84112 p 801.569.5600 Salt Lake City UT. 84106 5383 S 900 E p 801.581.8000 p 801.483.1600 Ste 103 999 E Murray Holladay Rd Salt Lake City UT. 84117 7495 S State St Ste 207 3725 W 4100 S p 801.872.5516 Midvale UT. 84047 Holladay UT. 84117 West Valley City UT. 84119 p 801.213.9400 p 801.268.2584 p 801.965.3759 Mai, Trinh LCSW University Of Utah Health Marriott, Caroline A LCSW Granger Medical Clinic Luna, Janette M LCSW 615 S Arapeen Dr Compass Counseling and 999 Murray Holladay Rd Utah Behavior Services Ste 100 Consulting Ste 207 5558 S 1900 W Salt Lake City UT. 84108 4000 S 700 E Salt Lake City UT. 84117 Ste B p 801.581.7761 Ste 9 p 801.268.2584 Salt Lake City UT. 84129 Salt Lake City UT. 84107 p 801.255.5131 Hospital Affiliation p 801.639.9544 Lopez, Marta LCSW - University of Utah Hospital University of Utah Health 6013 S Redwood Rd Martinez, Mayra CSW 1280 E Stringham Ave Salt Lake City UT. 84123 Malmstrom, Lynette M LCSW Community Health Centers Salt Lake City UT. 84106 p 801.255.5131 522 E 2100 S 220 W 7200 S p 801.213.8841 Salt Lake City UT. 84106 Ste A Clinical Consultants p 801.486.4444 Midvale UT. 84047 7601 S Redwood Rd Bldg E p 801.566.5494 West Jordan UT. 84084 p 801.233.8670

413 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 4745 S 3200 W McMaster, James H LCSW Merkley, Patricia L LCSW Mockli, Cherie LCSW Salt Lake City UT. 84129 James H McMaster LCSW Ascendant Behavioral Compass Counseling and p 801.964.6214 8545 S Redwood Rd Unit B Health Consulting West Jordan UT. 84084 5383 S 900 E 4000 S 700 E Mathewson, Julie LCSW p 801.455.8159 Ste 103 Ste 9 Next Level Recovery Salt Lake City UT. 84117 Salt Lake City UT. 84107 6771 S 900 E McMaster, Triona LCSW p 801.872.5516 p 801.639.9544 Midvale UT. 84047 Life Stone Center p 801.386.9799 7300 S 300 W Meservy, James B LCSW Mohlman, Laura LCSW Ste 101 Clinical Consultants Alpine Center for Personal Mauchley, Melissa LCSW Midvale UT. 84047 7601 S Redwood Rd Bldg E Growth University Of Utah Health p 801.984.1717 West Jordan UT. 84084 5689 S Redwood Rd 729 S Arapeen Dr p 801.233.8670 Ste 30 Salt Lake City UT. 84108 McPherson-Cutler, Amanda Salt Lake City UT. 84123 p 801.585.6387 L LMSW Messick, Daniel L LCSW p 801.268.1715 7105 S Highland Dr Valley Behavioral Health Hospital Affiliation Ste 202 4460 S Highland Dr Monson, Marette LCSW - University of Utah Hospital Salt Lake City UT. 84121 Ste 100 Center for Counseling p 208.918.1199 Salt Lake City UT. 84124 Excellence Maxwell, Miranda L CSW p 888.949.4864 2180 E 4500 S Valley Behavioral Health McQuade, Shannon M LCSW Ste 105 280 E 600 S Real Caring Integrative Metos, Athena LCSW Salt Lake City UT. 84117 Salt Lake City UT. 84111 Therapy 24 S 600 E p 801.980.1343 p 888.949.4864 1151 E 3900 S Ste 2 Ste B199 Parkview Bldg B Salt Lake City UT. 84102 Montoya Duran, Maria SSW McFadden, Molly Q LCSW Salt Lake City UT. 84124 p 801.413.3901 Valley Behavioral Health Kaizen Center for Mental p 801.853.8744 1141 E 3900 S Health Midgley, Lydia LCSW Ste A250 1398 E Luck Ln Mclaughlin Wilking, Helping Hands Counseling Salt Lake City UT. 84124 Salt Lake City UT. 84106 Heather LCSW 1108 W S Jordan Pkwy p 888.949.4864 p 801.416.0862 Valley Behavioral Health Ste B 2948 S Redwood Rd South Jordan UT. 84095 Moody, Jessica M LCSW University of Utah Health West Valley City UT. 84119 p 801.755.5531 Life Matters Counseling & 1525 W 2100 S p 888.949.4864 Health Center Salt Lake City UT. 84119 Miles, Michael B SSW 2225 E Murray-Holladt Rd p 801.213.8841 Meade, Gerard (Jerry) J Valley Behavioral Health Ste 112 LCSW 1141 E 3900 S Salt Lake City UT. 84117 3730 W 4700 S Lifeline Christian Ste A160 p 801.313.0555 Taylorsville UT. 84129 Counseling Center Salt Lake City UT. 84124 p 801.213.9200 4131 W 8200 S p 888.949.4864 3336 S Pioneer Pkwy West Jordan UT. 84088 Ste 201 5126 W Daybreak Pkwy p 801.280.8111 Miller, Leslee LCSW West Valley City UT. 84120 South Jordan UT. 84009 Sugarhouse Counseling p 801.313.0555 p 801.213.4500 Mecham, Shelli F LCSW Center Valley Behavioral Health 1415 E 2100 S Moon, Emilee SSW 7495 S State St 12427 S Pasture Rd Salt Lake City UT. 84105 Valley Behavioral Health Midvale UT. 84047 Ste 104 p 801.558.1460 4460 S Highland Dr p 801.213.9400 Riverton UT. 84096 Ste 100 p 888.949.4864 Miller, Maria M CSW Salt Lake City UT. 84124 McGill, Katie MSW Valley Behavioral Health p 888.949.4864 Utah Behavior Services 4460 S Highland Dr 1020 S Main St 5558 S 1900 W Ste 100 Ste 300 Morgan, Ryan W MSW Ste B Salt Lake City UT. 84124 Salt Lake City UT. 84101 Integrum Psychotherapy Salt Lake City UT. 84129 p 888.949.4864 p 888.949.4864 1174 E Graystone Way p 801.255.5131 Ste 6 *Mendenhall, Keeley J LCSW Milne, Wade O LCSW Salt Lake City UT. 84106 6013 S Redwood Rd Primary Childrens University of Utah Health p 801.682.1715 Salt Lake City UT. 84123 Behavioral Health 501 S Chipeta Way p 801.255.5131 5770 S 1500 W Salt Lake City UT. 84108 Morgan, Spencer G LCSW Salt Lake City UT. 84123 p 801.585.1575 Jordan West Family McLaren, Kirsty LCSW p 801.265.3412 Counseling Next Level Recovery Hospital Affiliation 9263 B Redwood Rd 6771 S 900 E - St George Regional Hospital West Jordan UT. 84088 Midvale UT. 84047 p 801.566.0749 p 801.386.9799

414 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Morris, Justin E LCSW Neff, Michal A CSW,SUDC Nelson, Ryan S LCSW OReilly, Laree C MSW Valley Behavioral Health Utah Behavior Services 13531 Lovers Ln Neurobehavioral Center for 6856 S 700 E 5558 S 1900 W Riverton UT. 84065 Growth Midvale UT. 84047 Ste B p 801.706.1818 370 E South Temple p 888.949.4864 Salt Lake City UT. 84129 Ste 175 p 801.255.5131 Valley Behavioral Health Salt Lake City UT. 84111 Morris, Maria A SSW 195 W 7200 S p 801.683.1062 Valley Behavioral Health 6013 S Redwood Rd Midvale UT. 84047 1020 S Main St Salt Lake City UT. 84123 p 888.949.4864 *Ontiveros, Daniel A LCSW Ste 218 p 801.255.5131 PCH Neuropsychology Salt Lake City UT. 84101 Nelson, Sunny LCSW 81 N Mario Capecchi Dr p 888.949.4864 Neilson, Tamera L LCSW New Pathways Recovery and Salt Lake City UT. 84113 Inner Peace Conseling of Wellness p 801.662.5592 Morrision, James R LCSW Utah 435 W 400 S Valley Behavioral Health 11618 S State St Ste 101 Ord, Lisa M LCSW 1141 E 3900 S Ste 1604 Salt Lake City UT. 84101 University of Utah Health Ste A160 Draper UT. 84020 p 801.722.5602 65 S Mario Capecchi Dr Salt Lake City UT. 84124 p 385.202.5645 Salt Lake City UT. 84132 p 888.949.4864 Nettleton, Ashley CSW p 801.581.2352 Nelford, Kalani LCSW Valley Behavioral Health Morse, Leigh Ann LCSW Compass Counseling and 195 W 7200 S Hospital Affiliation Compass Counseling and Consulting Midvale UT. 84047 - University of Utah Hospital Consulting 4000 S 700 E p 888.949.4864 4000 S 700 E Ste 9 Owen, Betty J LCSW Ste 9 Salt Lake City UT. 84107 Newbold, Emily K LCSW Jordan West Family Salt Lake City UT. 84107 p 801.639.9544 South Point Counseling Counseling p 801.639.9544 1206 W S Jordan Pkwy 9263 B Redwood Rd Nelson, Michelle M LCSW Ste D West Jordan UT. 84088 Mullaney, Edward LCSW University of Utah Health South Jordan UT. 84095 p 801.566.0749 University of Utah Health 1280 E Stringham Ave p 801.302.3801 1280 E Stringham Ave Salt Lake City UT. 84106 Oxborrow, Jennifer L LCSW Salt Lake City UT. 84106 p 801.213.8841 Nielsen, Benjamin LCSW Lotus Center Inc p 801.213.8841 Compass Counseling and 4376 S 700 E 1525 W 2100 S Consulting Ste 200 1525 W 2100 S Salt Lake City UT. 84119 4000 S 700 E Salt Lake City UT. 84107 Salt Lake City UT. 84119 p 801.213.9900 Ste 9 p 385.272.4292 p 801.213.9900 Salt Lake City UT. 84107 3730 W 4700 S p 801.639.9544 *Pagoaga, Ted M LCSW 3730 W 4700 S Taylorsville UT. 84129 PCH CHILD PSYCH-OP Taylorsville UT. 84129 p 801.213.9200 Nielsen, Stephanie MSW 5770 S 1500 W p 801.213.9200 Utah Behavior Services Taylorsville UT. 84123 5126 W Daybreak Pkwy 5558 S 1900 W p 801.313.7770 5126 W Daybreak Pkwy Ste 600 Ste B Ste 600 South Jordan UT. 84009 Salt Lake City UT. 84129 Hospital Affiliation South Jordan UT. 84009 p 801.213.4500 p 801.255.5131 - Primary Childrens Hospital p 801.213.4500 5126 W Daybreak Pkwy 6013 S Redwood Rd Palmer, Stephen D LCSW 5126 W Daybreak Pkwy South Jordan UT. 84009 Salt Lake City UT. 84123 Valley Behavioral Health South Jordan UT. 84009 p 801.213.4500 p 801.255.5131 4460 S Highland Dr p 801.213.4500 Ste 100 555 Foothill Dr Nixon, Allison SSW Salt Lake City UT. 84124 555 Foothill Dr Ste 301 Valley Behavioral Health p 888.949.4864 Ste 301 Salt Lake City UT. 84112 2948 S Redwood Rd Salt Lake City UT. 84112 p 801.581.8000 West Valley City UT. 84119 Paredes-Mora, Rocio F p 801.581.8000 p 888.949.4864 LCSW 555 Foothill Dr RPM Counseling Services 555 Foothill Dr Salt Lake City UT. 84112 Northway, Justin A LCSW 3441 S Decker Lake Dr Salt Lake City UT. 84112 p 801.581.8000 Valley Behavioral Health Ste 108 p 801.581.8000 2948 S Redwood Rd West Valley City UT. 84119 7495 S State St West Valley City UT. 84119 p 801.554.2554 7495 S State St Midvale UT. 84047 p 888.949.4864 Midvale UT. 84047 p 801.213.9400 Parnell, Kathrine J LCSW p 801.213.9400 Valley Behavioral Health Hospital Affiliation 1141 E 3900 S - University of Utah Hospital Ste A250 Salt Lake City UT. 84124 p 888.949.4864

415 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Payne, Aubree LCSW Phillips, Marci R LCSW 3730 W 4700 S Proctor, Lyndsey D LCSW Lotus Center Inc Valley Behavioral Health Taylorsville UT. 84129 Serenity Recovery and 4376 S 700 E 1020 S Main St p 801.213.9200 Wellness Ste 200 Ste 300 12447 S Crossing Dr Salt Lake City UT. 84107 Salt Lake City UT. 84101 5126 W Daybreak Pkwy Ste 13 p 385.272.4292 p 888.949.4864 Ste 600 Herriman UT. 84096 South Jordan UT. 84009 p 801.984.0184 Pehrson, Samantha LCSW 550 W 700 S p 801.213.4500 Life Matters Counseling & Salt Lake City UT. 84101 Prutch, Julie A SSW Health Center p 888.949.4864 555 Foothill Dr Valley Behavioral Health 3336 S Pioneer Pkwy Ste 301 1141 E 3900 S Ste 201 Phillips, Rebecca A LCSW Salt Lake City UT. 84112 Ste A250 West Valley City UT. 84120 University of Utah Health p 801.581.8000 Salt Lake City UT. 84124 p 801.313.0555 1138 E Wilmington Ave p 888.949.4864 Salt Lake City UT. 84106 7495 S State St Perez, Erin P LCSW p 801.213.8845 Midvale UT. 84047 Psalto, Taylor J SSW Valley Behavioral Health p 801.213.9400 Valley Behavioral Health 12427 S Pasture Rd 1280 E Stringham Ave 1020 S Main St Ste 104 Salt Lake City UT. 84106 Porter, Mickayla A SSW Ste 100 Riverton UT. 84096 p 801.213.8841 Valley Behavioral Health Salt Lake City UT. 84101 p 888.949.4864 195 W 7200 S p 888.949.4864 555 Foothill Dr Midvale UT. 84047 4460 S Highland Dr Salt Lake City UT. 84112 p 888.949.4864 1020 S Main St Ste 100 p 801.581.8000 Ste 300 Salt Lake City UT. 84124 Poulos, Jennifer LCSW Salt Lake City UT. 84101 p 888.949.4864 Hospital Affiliation Valley Behavioral Health p 888.949.4864 - University of Utah Hospital 3809 W 6200 S Perkes, Melyssa L CSW Taylorsville UT. 84129 Purdy, Tyler LCSW Valley Behavioral Health Pierce, Ricky W SSW p 888.949.4864 The Green House for Growth 1020 S Main St Valley Behavioral Health & Learning Ste 300 1141 E 3900 S 4460 S Highland Dr 1325 W S Jordan Pkwy Salt Lake City UT. 84101 Ste A250 Ste 100 Ste 102 p 888.949.4864 Salt Lake City UT. 84124 Salt Lake City UT. 84124 South Jordan UT. 84095 p 888.949.4864 p 888.949.4864 p 801.208.8838 1141 E 3900 S Ste A250 Pitcher, Shane MSW Powell, Clark Randy LCSW *Pyzikiewicz, Jenisabel S Salt Lake City UT. 84124 Odyssey House of Utah Utah Behavior Services *LCSW p 888.949.4864 344 E 100 S 5558 S 1900 W PCH Residential Home Ste 301 Ste B 5770 S 1500 W Bldg C *Peterson, Penny LCSW Salt Lake City UT. 84111 Taylorsville UT. 84118 Taylorsville UT. 84123 PCH CHILD PSYCH-OP p 801.322.3222 p 801.255.5131 p 801.313.7954 5770 S 1500 W Taylorsville UT. 84123 Plastow, Anisa L SSW 6013 S Redwood Rd PCH CHild PSYCH-OP p 801.313.7770 Valley Behavioral Health Taylorsville UT. 84123 5770 S 1500 W 1141 E 3900 S p 801.255.5131 Taylorsville UT. 84123 Phelps, Ariane A SSW Ste A250 p 801.313.7770 Valley Behavioral Health Salt Lake City UT. 84124 Powell, Jared N LCSW 1020 S Main St p 888.949.4864 Comprehensive PCH Neuropsychology Ste 100 Psychological Services 81 N Mario Capecchi Dr Salt Lake City UT. 84101 Poltoratzsky, Valerie 1208 E 3300 S Salt Lake City UT. 84113 p 888.949.4864 LCSW Salt Lake City UT. 84106 p 801.662.5592 1355 S 1100 E p 801.483.1600 Phillips, Allison Salt Lake City UT. 84105 Hospital Affiliation LCSW,BCBA p 801.913.7394 Powell, Samantha LCSW - Primary Childrens Hospital Utah Behavior Services University Of Utah Health 5558 S 1900 W Porschatis, Amber M LCSW 1950 Cir of Hope Dr *Radford, Preston J LCSW Ste B University of Utah Health Salt Lake City UT. 84112 PCH Neuropsychology Salt Lake City UT. 84129 1280 E Stringham Ave p 801.587.7000 81 N Mario Cappecchi Dr p 801.255.5131 Salt Lake City UT. 84106 Salt Lake City UT. 84113 p 801.213.8841 Hospital Affiliation p 801.662.5592 6013 S Redwood Rd - University of Utah Hospital Salt Lake City UT. 84123 1525 W 2100 S Rael, Julie L LCSW p 801.255.5131 Salt Lake City UT. 84119 Valley Behavioral Health p 801.213.9900 1020 S Main St Ste 100 Salt Lake City UT. 84101 p 888.949.4864

416 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 1141 E 3900 S Rippon, Callie M LCSW Rojas, Eileen LCSW Scoville, Barbara A LCSW Ste A250 Valley Behavioral Health Compass Counseling and Mountain States Counseling Salt Lake City UT. 84124 1020 S Main St Consulting Center p 888.949.4864 Ste 218 4000 S 700 E 5635 S Waterbury Way Salt Lake City UT. 84101 Ste 9 Ste C202 2948 S Redwood Rd p 888.949.4864 Salt Lake City UT. 84107 Salt Lake City UT. 84121 West Valley City UT. 84119 p 801.639.9544 p 801.278.0200 p 888.949.4864 Roberts, Diana J SSW Valley Behavioral Health Romero, Jerry B LCSW Seavey, Allison M LCSW Rahimi, Donna SSW 1850 S 2500 E Valley Behavioral Health St Marks Family Medicine Valley Behavioral Health Salt Lake City UT. 84108 1020 S Main St 1250 E 3900 S 1141 E 3900 S p 888.949.4864 Ste 100 Ste 260 Ste A250 Salt Lake City UT. 84101 Salt Lake City UT. 84124 Salt Lake City UT. 84124 4460 S Highland Dr p 888.949.4864 p 801.265.2000 p 888.949.4864 Ste 300 Salt Lake City UT. 84124 Rushforth, Jedediah S *Shepard, Lindsay LCSW Reimherr, Kathleen R LCSW p 888.949.4864 LCSW Primary Childrens Safe & Psychiatric & Behavioral The OCD And Anxiety Healthy Families Solutions Robinson, Nichole R LCSW Treatment Center 81 N Mario Capecchi Dr 1522 S 1100 E University Of Utah Health 11260 S River Height Dr Salt Lake City UT. 84113 Salt Lake City UT. 84105 1950 Cir of Hope Dr South Jordan UT. 84095 p 801.662.3606 p 801.467.1200 Salt Lake City UT. 84112 p 801.298.2000 p 801.587.7000 Shober, Lupita LCSW Ricci, Jeanette M LCSW PCH Residential Home Multicultural Counseling Valley Behavioral Health Hospital Affiliation 5770 S 1500 W Bldg C Center 12427 S Pasture Rd - University of Utah Hospital Salt Lake City UT. 84123 7625 S 3200 W Ste 104 p 801.313.7954 Ste 2 Riverton UT. 84096 Robinson, Sapphire M MSW West Jordan UT. 84084 p 888.949.4864 The Childrens Center PCH Residential Trmnt - p 801.915.0359 350 S 400 E ADOL Rice, Allan LCSW Salt Lake City UT. 84111 5770 S 1500 W *Shotwell, Heather L LCSW Valley Behavioral Health p 801.582.5534 Salt Lake City UT. 84123 Primary Childrens Hospital 1020 S Main St p 801.313.7940 5770 S 1500 W Ste 300 Roche, Miriam MSW Taylorsville UT. 84123 Salt Lake City UT. 84101 Utah Behavior Services Saari, Lorraine LCSW p 801.313.7770 p 888.949.4864 5558 S 1900 W Aspen Ridge Counseling Ste B 1561 W 7000 S Hospital Affiliation *Riekhof, Jeffrey D LCSW Salt Lake City UT. 84129 Ste 200 - Primary Childrens Hospital Primary Childrens Hospital p 801.255.5131 West Jordan UT. 84084 5770 S 1500 W p 801.990.4300 Silva, Emily A LCSW Taylorsville UT. 84123 6013 S Redwood Rd Valley Behavioral Health p 801.313.7940 Salt Lake City UT. 84123 Sandack, Margaret LCSW 3809 W 6200 S p 801.255.5131 The Childrens Center Taylorsville UT. 84129 Riley, Frederick R LCSW 350 S 400 E p 888.949.4864 Riley Individual Family Roche, Vaughan S LCSW Salt Lake City UT. 84111 and Marriage Counseling Sundance Behavioral p 801.582.5534 Silvester, Elizabeth 873 Baxter Dr Resources LCSW South Jordan UT. 84095 845 E 4800 S Schmelzer, Alina LCSW University Of Utah Health p 801.657.0163 Ste 200 Ascendant Behavioral 1280 E Stringham Ave Salt Lake City UT. 84107 Health Salt Lake City UT. 84106 Riley, Katrina LCSW p 801.264.9522 5383 S 900 E p 801.581.2000 Life Matters Counseling & Ste 103 Health Center Rodeback, David LCSW Salt Lake City UT. 84117 Hospital Affiliation 2225 E Murray-Holladay Rd Utah Cancer Specialists p 801.872.5516 - University of Utah Hospital Ste 112 1121 E 3900 S Salt Lake City UT. 84117 Ste C240 Schwebach, Derek LCSW Simons, Kristina LCSW p 801.313.0555 Salt Lake City UT. 84124 Family Counseling Center Jordan West Family p 801.266.0878 650 E 4500 S Counseling 3336 S Pioneer Pkwy Ste 300 9263 Redwood Rd Bldg 8 Ste 201 3838 S 700 E Murray UT. 84107 West Jordan UT. 84088 West Valley City UT. 84120 Ste 100 p 801.261.3500 p 801.566.0749 p 801.313.0555 Salt Lake City UT. 84106 p 801.269.0231

417 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Simpson, David E LCSW Sovinsky, Lisa M LCSW Stoddard, Nancy L LCSW Sykes, Eliot B LCSW Mountain States Counseling Life Stone Counseling Nancy L Stoddard, LCSW Lotus Center Inc Center Center 4527 S 2300 E 4376 S 700 E 5635 S Waterbury Way 4190 S Highland Dr Ste 206 Ste 200 Ste C202 Ste 208 Salt Lake City UT. 84117 Salt Lake City UT. 84107 Salt Lake City UT. 84121 Salt Lake City UT. 84124 p 801.859.2194 p 385.272.4292 p 801.278.0200 p 385.352.3101 Stout, Aaron LCSW Taholo, Leilani LCSW Skedros, Maria LCSW 613 E Fort Union Blvd The OCD And Anxiety Child and Family Maria K Skedros LCSW Ste 104 Treatment Center Empowerment Services 3980 S 700 E Midvale UT. 84047 11260 S River Height Dr 1578 W 1700 S Ste 22 p 801.984.1717 South Jordan UT. 84095 Ste 200 Salt Lake City UT. 84107 p 801.298.2000 Salt Lake City UT. 84104 p 801.230.3244 Speiser, Page LCSW p 801.972.2711 Page Speiser LCSW Suarez, Alex LCSW Skinner, Ageuda LCSW 275 E S Temple Utah Behavior Services Taroian, Sevon LCSW 1399 S 700 E Ste 101 5558 S 1900 W The OCD And Anxiety Ste 12-C Salt Lake City UT. 84111 Ste B Treatment Center Salt Lake City UT. 84105 p 801.531.7389 Salt Lake City UT. 84129 11260 S River Height Dr p 801.828.5189 p 801.255.5131 South Jordan UT. 84095 Springer, Amy E LCSW p 801.298.2000 Skousen, Thomas MSW Valley Behavioral Health 6013 S Redwood Rd Utah Behavior Services 3809 W 6200 S Salt Lake City UT. 84123 Tea, Elizabeth C LCSW 5558 S 1900 W Salt Lake City UT. 84129 p 801.255.5131 Valley Behavioral Health Ste B p 888.949.4864 195 W 7200 S Salt Lake City UT. 84129 Suh, Eun H LCSW Midvale UT. 84047 p 801.255.5131 Stander, Eric C CSW Valley Behavioral Health p 888.949.4864 Valley Behavioral Health 1020 S Main St 6013 S Redwood Rd 2948 S Redwood Rd Ste 100 Tellesbo, Sarah M LCSW Salt Lake City UT. 84123 West Valley City UT. 84119 Salt Lake City UT. 84101 Cedar Psychiatry p 801.255.5131 p 888.949.4864 p 888.949.4864 1208 E 3300 S Salt Lake City UT. 84106 Slater, Courtney MSW Staub, Velvet LCSW Suh, Irene LCSW p 801.369.8989 Utah Behavior Services Velvet Counseling South Summit Pediatrics 5558 S 1900 W 123 E 8720 S 267 E Traverse Point Dr Valley Behavioral Health Ste B Sandy UT. 84070 Draper UT. 84020 2948 S Redwood Rd Salt Lake City UT. 84129 p 801.709.9089 p 801.553.8300 West Valley City UT. 84119 p 801.255.5131 p 888.949.4864 Stephens, Travis R CSW Sutherland, Debbie A LCSW 6013 S Redwood Rd Valley Behavioral Health Valley Behavioral Health Cedar Psychiatry Salt Lake City UT. 84123 12427 S Pasture Rd 12427 S Pasture Rd 721 E 12200 S p 801.255.5131 Ste 104 Ste 104 Draper UT. 84020 Riverton UT. 84096 Riverton UT. 84096 p 801.369.8989 Smith, Deanna LCSW p 888.949.4864 p 888.949.4864 Center for Growth Tenney, Joseph T LCSW 5411 S Vine St 4460 S Highland Dr 4460 S Highland Dr Valley Behavioral Health Ste 6 Ste 100 Ste 100 12427 S Pasture Rd Salt Lake City UT. 84107 Salt Lake City UT. 84124 Salt Lake City UT. 84124 Ste 104 p 435.625.1717 p 888.949.4864 p 888.949.4864 Riverton UT. 84096 p 888.949.4864 Snyder, Melissa LCSW Stevens, Melena LCSW Swan, David M LCSW Crystal Counseling Jordan West Family University Of Utah Health 4460 S Highland Dr 151 E 5600 S Counseling 501 S Chipeta Way Ste 100 Ste 208 9263 Redwood Rd Bldg 8 Salt Lake City UT. 84108 Salt Lake City UT. 84124 Salt Lake City UT. 84107 West Jordan UT. 84088 p 801.585.1575 p 888.949.4864 p 801.633.5173 p 801.566.0749 Hospital Affiliation Thompson, Paula A CSW Souza, Sarah M CSW Stivers, Lauren M LCSW - University of Utah Hospital Valley Behavioral Health Valley Behavioral Health Life Matters Counseling & 1141 E 3900 S 2948 S Redwood Rd Health Center Swapp, Lisa LCSW Ste A170 West Valley City UT. 84119 3336 S Pioneer Pkwy Decision Point Counseling Salt Lake City UT. 84124 p 888.949.4864 Ste 201 9710 S 700 E p 888.949.4864 West Valley City UT. 84120 Ste 205 p 801.313.0555 Sandy UT. 84070 p 385.630.0336

418 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Tidwell, Brant A SSW 5126 W Daybreak Pkwy Urry, Kristin K LCSW 555 Foothill Dr Valley Behavioral Health Ste 600 1399 S 700 E Salt Lake City UT. 84112 195 W 7200 S South Jordan UT. 84009 Ste 15 p 801.581.8000 Midvale UT. 84047 p 801.213.4500 Salt Lake City UT. 84105 p 888.949.4864 p 801.882.1262 7495 S State St 555 Foothill Dr Midvale UT. 84047 Tillman, Daniel C SSW Ste 301 Valdez, Danielle LCSW p 801.213.9400 Valley Behavioral Health Salt Lake City UT. 84112 University of Utah Health 2472 S 300 E p 801.581.8000 1525 W 2100 S Vincent, Alecia N SSW Salt Lake City UT. 84115 Salt Lake City UT. 84119 Valley Behavioral Health p 888.949.4864 555 Foothill Dr p 801.213.8841 1141 E 3900 S Salt Lake City UT. 84112 Ste A250 Timmins, Joseph M LCSW p 801.581.8000 3730 W 4700 S Salt Lake City UT. 84124 Draper Family Therapy Taylorsville UT. 84129 p 888.949.4864 12176 S 1000 E 7495 S State St p 801.213.9200 Ste 8C Midvale UT. 84047 Voigt, Jonathan LCSW Draper UT. 84020 p 801.213.9400 5126 W Daybreak Pkwy Valley Behavioral Health p 801.987.3222 South Jordan UT. 84009 1141 E 3900 S Hospital Affiliation p 801.213.4500 Ste A250 Timpson, Melissa LCSW - University of Utah Hospital Salt Lake City UT. 84124 University Of Utah Health 7495 S State St p 888.949.4864 1950 Cir of Hope Dr Tuckett, Deborah SSW Midvale UT. 84047 Salt Lake City UT. 84112 Valley Behavioral Health p 801.213.9400 12427 S Pasture Rd p 801.587.7000 195 W 7200 S Ste 104 Midvale UT. 84047 Hospital Affiliation Riverton UT. 84096 Hospital Affiliation p 888.949.4864 - University of Utah Hospital p 888.949.4864 - University of Utah Hospital 3444 W 4400 S Vanderstappen, Amber 4460 S Highland Dr Tingey, Jenise D LCSW West Valley City UT. 84119 LCSW Ste 100 Valley Behavioral Health p 888.949.4864 Terrain Therapy Salt Lake City UT. 84124 12427 S Pasture Rd 2627 E Parleys Way p 888.949.4864 Ste 104 Turner, Blake CSW Salt Lake City UT. 84109 Riverton UT. 84096 Community Health Centers p 801.808.9235 Vyfvinkel, Michael J SSW p 888.949.4864 1365 W 1000 N Valley Behavioral Health Salt Lake City UT. 84116 Vezie, Linda LCSW 1141 E 3900 S 4460 S Highland Dr p 801.328.5750 University of Utah Health Ste A250 Ste 100 1280 E Stringham Ave Salt Lake City UT. 84124 Salt Lake City UT. 84124 4745 S 3200 W Salt Lake City UT. 84106 p 888.949.4864 p 888.949.4864 Salt Lake City UT. 84129 p 801.213.8841 p 801.964.6214 Wagner, Dorothy A SSW Tipton, Lauren LCSW 1525 W 2100 S Valley Behavioral Health Comprehensive Tuttle, Jenny Jo LCSW Salt Lake City UT. 84119 1141 E 3900 S Psychological Services Jenny Jo Tuttle LCSW p 801.213.9900 Ste A250 1208 E 3300 S 4190 S Highland Dr Salt Lake City UT. 84124 Salt Lake City UT. 84106 Ste 108 3730 W 4700 S p 888.949.4864 p 801.483.1600 Salt Lake City UT. 84124 Taylorsville UT. 84129 p 801.214.1582 p 801.213.9200 Walter, Samuel Grey LCSW Torres-George, Christian Compass Counseling and P LCSW Uckerman, Clifton R LCSW 5126 W Daybreak Pkwy Consulting University of Utah Health Ascendant Behavioral Ste 600 4000 S 700 E 1280 E Stringham Ave Health South Jordan UT. 84009 Ste 9 Salt Lake City UT. 84106 4179 Riverboat Rd p 801.213.4500 Salt Lake City UT. 84107 p 801.213.8841 Ste 220 p 801.639.9544 Salt Lake City UT. 84123 5126 W Daybreak Pkwy 1525 W 2100 S p 801.872.5516 South Jordan UT. 84009 *Ward, Melanie M LCSW Salt Lake City UT. 84119 p 801.213.4500 PCH CHILD PSYCH-OP p 801.213.9900 5383 S 900 E 5770 S 1500 W Ste 103 555 Foothill Dr TAYLORSVILLE UT. 84123 3730 W 4700 S Salt Lake City UT. 84117 Ste 301 p 801.313.7770 Taylorsville UT. 84129 p 801.872.5516 Salt Lake City UT. 84112 p 801.213.9200 p 801.581.8000 Hospital Affiliation Ungricht, Misty T LCSW - Primary Childrens Hospital Valley Behavioral Health 3809 W 6200 S Taylorsville UT. 84129 p 888.949.4864

419 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Warr, Adriane N SSW 1280 E Stringham Ave Wolf, Marcella F LCSW 7495 S State St Valley Behavioral Health Salt Lake City UT. 84106 Valley Behavioral Health Midvale UT. 84047 1141 E 3900 S p 801.213.8841 1020 S Main St p 801.213.9400 Ste A250 Ste 100 Salt Lake City UT. 84124 555 Foothill Dr Salt Lake City UT. 84101 Woods, Kamille D SSW p 888.949.4864 Salt Lake City UT. 84112 p 888.949.4864 Valley Behavioral Health p 801.581.8000 1141 E 3900 S Weisbender, Christopher P 1141 E 3900 S Ste A250 CSW Hospital Affiliation Ste A250 Salt Lake City UT. 84124 Valley Behavioral Health - University of Utah Hospital Salt Lake City UT. 84124 p 888.949.4864 1141 E 3900 S p 888.949.4864 Ste A250 Wickersham, Michael C Wright, Ashley M CSW Salt Lake City UT. 84124 LCSW 2948 S Redwood Rd Valley Behavioral Health p 888.949.4864 Kaizen Center for Mental West Valley City UT. 84119 1141 E 3900 S Health p 888.949.4864 Ste A170 3809 W 6200 S 4055 S 700 E Salt Lake City UT. 84124 Taylorsville UT. 84129 Ste 103 Wood, Felicia LCSW p 888.949.4864 p 888.949.4864 Salt Lake City UT. 84107 Aspen Ridge Counseling p 801.712.1790 11075 S State St Wyner, Gayle LCSW Weischedel, Bradley D Ste 35 10815 S 700 E LCSW Wiggins, Celeste M CSW Sandy UT. 84070 Sandy UT. 84070 Centered Approach Ascendant Behavioral p 801.501.8444 p 801.867.3472 Counseling Health 4190 S Highland Dr 5383 S 900 E 1561 W 7000 S Yazzie, Danet J LCSW Ste 220 Ste 103 Ste 200 Valley Behavioral Health Salt Lake City UT. 84124 Salt Lake City UT. 84117 West Jordan UT. 84084 1020 S Main St p 385.282.3349 p 801.872.5516 p 801.990.4300 Ste 300 Salt Lake City UT. 84101 Weymann, Timothy J LCSW Wilde, Craig H CSW 2711 S 8500 W p 888.949.4864 Compass Counseling and Valley Behavioral Health Magna UT. 84044 Consulting 1020 S Main St p 801.990.4300 Youngstrom, Glen LCSW 4000 S 700 E Ste 100 Aspen Ridge Counseling Ste 9 Salt Lake City UT. 84101 2880 W 4700 S 2880 W 4700 S Salt Lake City UT. 84107 p 888.949.4864 Ste G-1 Ste G-1 p 801.639.9544 Salt Lake City UT. 84129 Salt Lake City UT. 84129 Wilde, Hannah K LCSW p 801.990.4300 p 801.990.4300 Whipps, Paige CSW Life Matters Counseling & Peaceful Solutions Health Center 411 W 7200 S Zabka, Hannah M LCSW Counseling, LLC 2225 E Murray-Holladay Rd Ste 304 Lotus Center Inc 1399 S 700 E Ste 112 Midvale UT. 84047 4376 S 700 E Ste 5 Salt Lake City UT. 84117 p 801.990.4300 Ste 200 Salt Lake City UT. 84105 p 801.313.0555 Salt Lake City UT. 84107 p 801.651.3907 Woodard, Jeness L LCSW p 385.272.4292 3336 S Pioneer Pkwy University of Utah Health White, Melinda CSW Ste 201 1280 E Stringham Ave Zarbock, Micheala CSW Valley Behavioral Health West Valley City UT. 84120 Salt Lake City UT. 84106 Valley Behavioral Health 1141 E 3900 S p 801.313.0555 p 801.581.2000 2948 S Redwood Rd Ste A250 West Valley City UT. 84119 Salt Lake City UT. 84124 Wilson, Courtney CSW 1525 W 2100 S p 888.949.4864 p 888.949.4864 Valley Behavioral Health Salt Lake City UT. 84119 1141 E 3900 S p 801.213.9900 Zendejas, Viridiana LCSW Whitehead, Dex LCSW Ste A170 Multicultural Counseling Sundance Behavioral Salt Lake City UT. 84124 3730 W 4700 S Center Resources p 888.949.4864 Taylorsville UT. 84129 7625 S 3200 W 845 E 4800 S p 801.213.9200 Ste 2 Ste 200 Winn, Julie H LCSW West Jordan UT. 84084 Murray UT. 84107 Valley Behavioral Health 5126 W Daybreak Pkwy p 801.915.0359 p 801.264.9522 195 W 7200 S Ste 600 Midvale UT. 84047 South Jordan UT. 84009 Zimmerman, Karyl J CSW Whitlock, Megan J LCSW p 888.949.4864 p 801.213.4500 Valley Behavioral Health University of Utah Health 1141 E 3900 S 1138 E Wilmington Ave Wisco, Monica LCSW 555 Foothill Dr Ste A250 Salt Lake City UT. 84106 Life Stone Counseling Ste 301 Salt Lake City UT. 84124 p 801.213.8845 Center Salt Lake City UT. 84112 p 888.949.4864 613 E Fort Union Blvd p 801.581.8000 Ste 104 Midvale UT. 84047 p 801.984.1717 420 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Zuehlke, Angela M LCSW 85 N Medical Dr Corrigan, Colleen SLP Faust, Lauren G SLP Jordan West Family Salt Lake City UT. 84112 University Of Utah Health University of Utah Health Counseling p 801.587.3422 50 N Medical Dr 50 N Medical Dr 9263 Redwood Rd Bldg 8 Salt Lake City UT. 84132 Salt Lake City UT. 84132 West Jordan UT. 84088 Hospital Affiliation p 801.581.2121 p 801.581.2121 p 801.566.0749 - University of Utah Hospital 85 N Medical Dr Hospital Affiliation de la Torre, J Manuel Brown, Pardis A SLP Salt Lake City UT. 84112 - University of Utah Hospital LCSW University of Utah Health p 801.587.3422 1579 W 600 S 1950 Cir of Hope Dr Fisk, Elizabeth J DPT Salt Lake City UT. 84104 Salt Lake City UT. 84112 Hospital Affiliation University of Utah Health p 801.973.0655 p 801.587.7000 - University of Utah Hospital 50 N Medical Dr Salt Lake City UT. 84132 Speech Therapy Hospital Affiliation *Day, Janene SLP p 801.581.2121 Anderson, Patricia L SLP - University of Utah Hospital Primary Childrens Rehab Neuroworx 100 N Mario Capecchi Dr Foye, Mary D 90 W Albion Village Way Browning, Victoria E SLP Salt Lake City UT. 84113 University of Utah Health Sandy UT. 84070 Browning Speech Therapy p 801.662.4980 417 S Wakara Way p 801.619.3670 LLC Ste 1112 6558 W Candice View Cove University of Utah Health Salt Lake City UT. 84108 Barkmeier Kraemer, Julie Herriman UT. 84096 50 N Medical Dr p 801.581.3506 M SLP p 801.493.9690 Salt Lake City UT. 84132 University of Utah Health p 801.581.2121 Fue, Laurie D SLP 50 N Medical Dr Cantor, Mark M CCC-SLP University of Utah Health Salt Lake City UT. 84132 University of Utah Health Hospital Affiliation 417 S Wakara Way p 801.581.2121 417 S Wakara Way - Primary Childrens Hospital Ste 1112 Ste 1112 Salt Lake City UT. 84108 Hospital Affiliation Salt Lake City UT. 84108 *Dixon, Adria SLP p 801.581.3506 - University of Utah Hospital p 801.581.3506 Primary Childrens Rehab 100 N Mario Capecchi Dr Hospital Affiliation Bennett, Jared L SLP *Chachas, Christine SLP Salt Lake City UT. 84113 - University of Utah Hospital South Valley Speech and Primary Childrens Rehab p 801.662.4980 Language, LLC 100 N Mario Capecchi Dr Gabiola, Nicassia M SLP 1098 W 10550 S Salt Lake City UT. 84113 Hospital Affiliation University of Utah Health South Jordan UT. 84095 p 801.662.4980 - Primary Childrens Hospital 50 N Medical Dr p 801.253.1023 Salt Lake City UT. 84132 3741 W 12600 S Ellerston, Julia K SLP p 801.581.2121 Blades, Cheri D SLP Ste 100 University of Utah Health University of Utah Health Riverton UT. 84065 50 N Medical Dr University Of Utah Health 50 N Medical Dr p 801.571.3081 Salt Lake City UT. 84132 85 N Medical Dr Salt Lake City UT. 84132 p 801.581.2121 Salt Lake City UT. 84112 p 801.581.2121 3845 W 4700 S p 801.581.2121 Salt Lake City UT. 84129 Hospital Affiliation Hospital Affiliation p 801.840.4360 - University of Utah Hospital Hospital Affiliation - University of Utah Hospital - University of Utah Hospital Christensen, Tyler S SLP Erickson, Olivia L SLP Booz, Jaime SLP University Of Utah Health University of Utah Health Gallant, Sarah SLP University Of Utah Health 85 N Medical Dr 1138 E Wilmington Ave University of Utah Health 50 N Medical Dr Salt Lake City UT. 84112 Salt Lake City UT. 84106 417 S Wakara Way Salt Lake City UT. 84132 p 801.581.2121 p 801.581.2221 Ste 1112 p 801.581.2121 Salt Lake City UT. 84108 Hospital Affiliation 1280 E Stringham Ave p 801.581.3506 85 N Medical Dr - University of Utah Hospital Salt Lake City UT. 84106 Salt Lake City UT. 84112 p 801.581.2000 Hospital Affiliation p 801.581.2121 Cook-Mauszycki, Shannon - University of Utah Hospital SLP Hospital Affiliation Hospital Affiliation University Of Utah Health - University of Utah Hospital Gummersall, Dawn M SLP - University of Utah Health 417 S Wakara Way ABS Kids Craig H Neilsen Rehabilitation HospitalSte 1112 Estep, Jennifer A SLP 515 S 700 E Salt Lake City UT. 84108 University of Utah Health Ste 2A Bringhurst, Sara p 801.581.3506 50 N Medical Dr Salt Lake City UT. 84102 University Of Utah Health Salt Lake City UT. 84132 p 801.935.4171 50 N Medical Dr Hospital Affiliation p 801.581.2121 Salt Lake City UT. 84132 - University of Utah Hospital p 801.581.2121 Hospital Affiliation - University of Utah Hospital

421 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 6910 S Highland Dr Hales, Kimberly SLP *Landro, Diana L SLP 3741 W 12600 S Ste 1 University of Utah Health Primary Childrens Hospital Ste 100 Salt Lake City UT. 84121 417 S Wakara Way 3845 W 4700 S Riverton UT. 84065 p 801.935.4171 Ste 1112 Taylorsville UT. 84129 p 801.571.3081 Salt Lake City UT. 84108 p 801.840.4360 Gurrister, Maria p 801.581.3506 3845 W 4700 S Wasatch Speech and Lanza, Elizabeth L SLP Taylorsville UT. 84129 Language Center Hospital Affiliation University Of Utah Health p 801.840.4360 2120 E 3900 S - University of Utah Hospital 50 N Medical Dr Ste 200 Salt Lake City UT. 84132 5770 S Fashion Blvd Bldg Holladay UT. 84124 Hary, Elizabeth R SLP p 801.581.2121 5 p 801.308.0400 University of Utah Health Ste 210 729 S Arapeen Dr 729 S Arapeen Dr Murray UT. 84107 Gurrister, Tom Salt Lake City UT. 84108 Salt Lake City UT. 84108 p 801.314.5220 Wasatch Speech and p 801.581.2121 p 801.581.2121 Language Center Mendlow, Robyn SLP 2120 E 3900 S Hospital Affiliation 85 N Medical Dr University of Utah Health Ste 200 - University of Utah Hospital Salt Lake City UT. 84112 1950 Cir of Hope Dr Holladay UT. 84124 p 801.587.3422 Salt Lake City UT. 84112 p 801.308.0400 Heller, Amanda C SLP p 801.587.7000 University of Utah Health Hospital Affiliation *Guttenplan, Michelle D 50 N Medical Dr - University of Utah Hospital Hospital Affiliation *SLP Salt Lake City UT. 84132 - University of Utah Hospital Primary Childrens Rehab p 801.581.2121 Lidgard, Julia V 100 N Mario Capecchi Dr University of Utah Health Miller, Miranda SLP Salt Lake City UT. 84113 Hospital Affiliation 417 S Wakara Way University Of Utah Health p 801.662.4980 - University of Utah Hospital Ste 1112 50 N Medical Dr Salt Lake City UT. 84108 Salt Lake City UT. 84132 3741 W 12600 S *Hirte, Kimberly SLP p 801.581.3506 p 801.581.2121 Ste 100 Primary Childrens Rehab Riverton UT. 84065 100 N Mario Capecchi Dr Lyon, Tiffany SLP 85 N Medical Dr p 801.571.3081 Salt Lake City UT. 84113 University of Utah Health Salt Lake City UT. 84112 p 801.662.4980 729 S Arapeen Dr p 801.581.2121 3845 W 4700 S Salt Lake City UT. 84108 Taylorsville UT. 84129 3741 W 12600 S p 801.581.2121 Hospital Affiliation p 801.840.4360 Ste 100 - University of Utah Health Riverton UT. 84065 Hospital Affiliation Craig H Neilsen Rehabilitation Hospital 5770 S Fashion Blvd Bldg p 801.571.3081 - University of Utah Hospital 5 Milstead, Norma E SLP Ste 210 3845 W 4700 S Martin, Suzanne G SLP University of Utah Health Murray UT. 84107 Taylorsville UT. 84129 University Of Utah Health 50 N Medical Dr p 801.314.5220 p 801.840.4360 85 N Medical Dr Salt Lake City UT. 84132 Salt Lake City UT. 84112 p 801.581.2121 Hospital Affiliation Jensen, Brayden SLP p 801.581.2121 - University of Utah Hospital University of Utah Health Hospital Affiliation 1138 E Wilmington Ave Hospital Affiliation - University of Utah Hospital Haas, Ani R SLP Salt Lake City UT. 84106 - University of Utah Hospital University of Utah Health p 801.581.2000 *Muller, Kacee M SLP 1950 Cir of Hope Dr Mathy, Pamela A SLP Primary Childrens Rehab Salt Lake City UT. 84112 1280 E Stringham Ave University of Utah Health 100 N Mario Capecchi Dr p 801.587.7000 Salt Lake City UT. 84106 417 S Wakara Way Salt Lake City UT. 84113 p 801.581.2000 Ste 1112 p 801.662.4980 University Of Utah Health Salt Lake City UT. 84108 50 N Medical Dr University Of Utah Health p 801.581.3506 3741 W 12600 S Salt Lake City UT. 84132 85 N Medical Dr Ste 100 p 801.581.2121 Salt Lake City UT. 84112 Hospital Affiliation Riverton UT. 84065 p 801.581.2121 - University of Utah Hospital p 801.571.3081 85 N Medical Dr Salt Lake City UT. 84112 Ketchoyian, Alexandra *Maughan, Page SLP 3845 W 4700 S p 801.581.2121 SLP Primary Childrens Rehab Salt Lake City UT. 84129 University of Utah Health 100 N Mario Capecchi Dr p 801.840.4360 Hospital Affiliation 50 N Medical Dr Salt Lake City UT. 84113 - Primary Childrens Hospital Salt Lake City UT. 84132 p 801.662.4980 p 801.581.2121

422 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Naidu, Susan R AUD Regal, Hadley SLP *Taylor, Christopher SLP Sports Medicine University of Utah Health University of Utah Health Primary Childrens Rehab Albano, Joseph J MD 417 S Wakara Way 50 N Medical Dr 3845 W 4700 S Albano Clinic Ste 1112 Salt Lake City UT. 84132 Taylorsville UT. 84129 6360 S 3000 E Salt Lake City UT. 84108 p 801.581.2121 p 801.840.4360 Ste 210 p 801.581.3506 Salt Lake City UT. 84121 Hospital Affiliation 5770 S Fashion Blvd Bldg p 385.220.9009 Nelson, Breanna R SLP - University of Utah Hospital 5 Neurobehavioral Center for Ste 210 Hospital Affiliation Growth Reymer, Elena C SLP Murray UT. 84107 - Salt Lake Regional Medical 370 E South Temple University Of Utah Health p 801.314.5220 Center Ste 175 85 N Medical Dr Salt Lake City UT. 84111 Salt Lake City UT. 84112 Hospital Affiliation Anderson, Laura M MD p 801.683.1062 p 801.581.2121 - Primary Childrens Hospital University of Utah Health 1525 W 2100 S Olsen, Collin M SLP Hospital Affiliation U of U Communications & Salt Lake City UT. 84119 University Of Utah Health - University of Utah Hospital Disorders Speech & Hearing p 801.213.8841 85 N Medical Dr Clinic Salt Lake City UT. 84112 Schiedermayer, Benjamin F 417 Wakara Way 3730 W 4700 S p 801.581.2121 SLP Salt Lake City UT. 84108 West Valley City UT. 84129 University of Utah Health p 801.581.3506 p 801.213.9200 Hospital Affiliation 729 S Arapeen Dr - University of Utah Health Salt Lake City UT. 84108 Wadsworth, Jamie P SLP 5126 W Daybreak Pkwy Craig H Neilsen Rehabilitation Hospitalp 801.581.2121 University of Utah Health Ste 600 1950 Cir of Hope Dr South Jordan UT. 84009 *Park, Christine M SLP Hospital Affiliation Salt Lake City UT. 84112 p 801.213.4500 Primary Childrens Rehab - University of Utah Hospital p 801.587.7000 3741 W 12600 S 7495 S State St Ste 100 Schweitzer, Lisa A SLP Hospital Affiliation Midvale UT. 84047 Riverton UT. 84065 University of Utah Health - University of Utah Hospital p 801.213.9400 p 801.571.3081 1138 E Wilmington Ave Salt Lake City UT. 84106 Wheeler, Katrina H SLP Hospital Affiliation 3845 W 4700 S p 801.581.2221 University of Utah Health - University of Utah Hospital Taylorsville UT. 84129 100 N Mario Capecchi Dr p 801.840.4360 Hospital Affiliation Salt Lake City UT. 84113 Aoki, Stephen K MD - University of Utah Hospital p 801.587.2255 University of Utah Health 5770 S Fashion Blvd Bldg 100 N Mario Capecchi Dr 5 Silberman, Hilary J SLP 50 N Medical Dr Salt Lake City UT. 84113 Ste 210 University of Utah Health Salt Lake City UT. 84132 p 801.662.5600 Murray UT. 84107 417 S Wakara Way p 801.581.2205 p 801.314.5220 Ste 1112 290 S 1850 E Salt Lake City UT. 84108 81 N Mario Capecchi Dr Salt Lake City UT. 84112 Pierce, Jennifer L p 801.581.3506 Salt Lake City UT. 84113 p 801.587.7109 University of Utah Health p 801.587.2255 417 S Wakara Way Hospital Affiliation 580 S Guardsman Way Ste 1112 - University of Utah Hospital Hospital Affiliation Salt Lake City UT. 84112 Salt Lake City UT. 84108 - University of Utah Hospital p 801.587.7109 p 801.581.3506 Stevens, Maya E SLP University of Utah Health Wright, Miranda L SLP 590 S Wakara Way Hospital Affiliation 50 N Medical Dr University Of Utah Health Salt Lake City UT. 84108 - University of Utah Hospital Salt Lake City UT. 84132 50 N Medical Dr p 801.587.7109 p 801.581.2121 Salt Lake City UT. 84132 Price, Summer A SLP p 801.581.2121 Hospital Affiliation Ear, Nose & Throat Center Taggart, Michelle M SLP - University of Utah Hospital Of Utah University Of Utah Health 729 S Arapeen Dr 1255 E 3900 S 50 N Medical Dr Salt Lake City UT. 84108 Bourne, Robert B MD Ste 301 Salt Lake City UT. 84132 p 801.581.2121 MountainStar General Salt Lake City UT. 84124 p 801.581.2121 Surgery p 801.328.2522 85 N Medical Dr 1160 E 3900 S Hospital Affiliation Salt Lake City UT. 84112 Ste 4050 22 S 900 E - University of Utah Hospital p 801.587.3422 Salt Lake City UT. 84124 Salt Lake City UT. 84102 p 801.281.1156 p 801.328.2522 Hospital Affiliation - University of Utah Hospital

423 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Salt Lake Orthopaedic DeMordaunt, Dallin L Gunter, Karen A PA Comprehensive Orthopedics Clinic Davis Orthopedics and Davidson Orthopedics and Sports Medicine - SLC 1160 E 3900 S Sports Medicine 6360 S 3000 E Central Ste 5000 3336 S 4155 W Ste 200 82 S 1100 E Salt Lake City UT. 84124 Ste 102 Salt Lake City UT. 84121 Ste 303 p 801.262.8486 West Valley City UT. 84120 p 801.797.8000 Salt Lake City UT. 84102 p 801.964.3925 p 801.533.2002 MountainStar Specialty Heiden Orthopedics Services Medallus Medical 6360 S 3000 E Comprehensive Orthopedics 74 E Kimballs Ln 7998 S 1300 E Ste 210 and Sports Medicine - Ste 330 Sandy UT. 84092 Salt Lake City UT. 84121 Sandy Draper UT. 84020 p 801.255.2000 p 435.615.8822 9350 S 150 E p 801.262.3564 Ste 460 Hospital Affiliation Heiden, Eric MD Sandy UT. 84070 MountainStar General - Davis Hospital Heiden Orthopedics p 801.858.3715 Surgery 6360 S 3000 E 96 E Kimballs Ln Engelen, Robert DO Ste 210 Hospital Affiliation Ste 207 CORE @ West Valley Salt Lake City UT. 84121 - Salt Lake Regional Medical West Jordan UT. 84088 3336 S 4155 W p 435.615.8822 Center p 801.568.5972 Ste 102 West Valley City UT. 84120 Hospital Affiliation Lewis, Wesley MD Hospital Affiliation p 801.568.3480 - Park City Hospital Foothill Family Clinic - Salt Lake Regional Medical 13953 S Bangerter Pkwy Center Neurosci and Kammel, Julia M MD Draper UT. 84020 Rehabilitation Specialists Salt Lake Regional Medical p 385.900.4090 Coleby, Craig A MD @ West Jordan Center - Behavioral Health Granger Medical Clinic 3590 W 9000 S Unit 6360 S 3000 E 11724 S State St Ste 240 1050 E S Temple Ste 100 Draper UT. 84020 West Jordan UT. 84088 Salt Lake City UT. 84102 Salt Lake City UT. 84121 p 801.576.2000 p 801.505.5370 p 801.350.4255 p 801.365.1032

12391 S 4000 W Neurosci and Medallus Medical Hospital Affiliation Riverton UT. 84065 Rehabilitation Specialists 6322 S 300 E - Salt Lake Regional Medical p 801.302.1700 @ SLC Ste 140 Center 82 S 1100 E Salt Lake City UT. 84121 Hospital Affiliation Ste 103 p 801.912.8210 Longe, Jamie MD - Riverton Childrens Unit Salt Lake City UT. 84102 Foothill Family Clinic Operated by Primary Childrens Medicalp 801.505.5370 Center Comprehensive Orthopedic & 13953 S Bangerter Pkwy - Jordan Valley Medical Sports Medicine - SLC Draper UT. 84020 Center Comprehensive Orthopedics 82 S 1100 E p 385.900.4090 - Lone Peak Hospital & Sports Medicine Ste 303 82 S 1100 E Salt Lake City UT. 84102 6360 S 3000 E Cosgrave, Michael L DO Ste 303 p 801.533.2002 Ste 100 Medallus Medical Salt Lake City UT. 84102 Salt Lake City UT. 84121 10433 S Redwood Rd p 801.505.5370 Hospital Affiliation p 801.365.1032 South Jordan UT. 84095 - University of Utah Hospital p 801.501.0500 9350 S 150 E - Salt Lake Regional Medical Hospital Affiliation Ste 460 Center - Primary Childrens Hospital Davidson Orthopedics Sandy UT. 84070 - Salt Lake Regional Medical 6360 S 3000 E p 801.533.2002 Kirk, Stephen T MD Center Ste 200 Medallus Medical Salt Lake City UT. 84121 Fukushima, Brian W MD 13348 S Market Ctr Dr Macintyre, James G MD p 801.797.8000 Utah Orthopaedic Ste 100 Center of Orthopedic & Specialists Riverton UT. 84065 Rehabilitation Excellence Davidson, Philip A MD 5323 S Woodrow St p 901.844.1600 - West Jordan Davidson Orthopedics Ste 200 3584 W 9000 S 6360 S 3000 E Murray UT. 84107 Steward Orthopedics & Ste 405 Ste 200 p 801.747.1020 Sports Medicine West Jordan UT. 84088 Salt Lake City UT. 84121 3584 W 9000 S p 801.568.3480 p 801.797.8000 Hospital Affiliation Ste 405 - St Marks Hospital West Jordan UT. 84088 Hospital Affiliation Hospital Affiliation - Salt Lake Regional Medical p 801.568.3480 - Jordan Valley Medical - Salt Lake Regional Medical Center Center Center - Park City Hospital

424 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. McIntyre, James S MD Heiden Orthopedics Thomas, Bruce E MD University Health Care Granger Medical 6360 S 3000 E University of Utah Health Neuropsych Inst -Not all Specialists Ste 210 590 S Wakara Way services covered, please 1160 E 3900 S Salt Lake City UT. 84121 Salt Lake City UT. 84108 contact your administrator Ste 1000 p 435.615.8822 p 801.587.7109 501 Chipeta Way Salt Lake City UT. 84124 Salt Lake City UT. 84108 p 801.262.1771 Medallus Medical Hospital Affiliation p 801.585.1575 7998 S 1300 E - Ogden Regional Medical 96 E Kimballs Ln Sandy UT. 84092 Center Thoracic Surgery Ste 304 p 801.255.2000 Affleck, David G MD Draper UT. 84020 Substance Abuse Facility MountainStar p 801.571.9433 Hospital Affiliation Altium Health Cardiovascular Surgery - Jordan Valley Medical 7613 S Jordan Landing 1160 E 3900 S 9844 S 1300 E Center West Valley Campus Blvd Ste 3500 Ste 100 - Jordan Valley Medical Ste 200 Salt Lake City UT. 84124 Sandy UT. 84094 Center West Jordan UT. 84084 p 801.743.4750 p 801.571.9433 p 801.613.9843 Petron, David J MD Hospital Affiliation Hospital Affiliation University of Utah Health BRC Outpatient LLC - St Marks Hospital - St Marks Hospital 290 S 1850 E 4905 S 900 E - Lakeview Hospital - Lone Peak Hospital Salt Lake City UT. 84112 Salt Lake City UT. 84117 - Ogden Regional Medical p 801.587.7109 p 801.905.1352 Center Meadows, James R MD - Timpanogos Regional Hospital Granger Medical 580 S Guardsman Way Brighton House LLC Specialists Salt Lake City UT. 84112 2945 E Robidoux Rd Goodwin, Matthew L 96 E Kimballs Ln p 801.587.7109 Sandy UT. 84093 University Of Utah Health Ste 304 p 385.557.4318 50 N Medical Dr Draper UT. 84020 590 S Wakara Way Salt Lake City UT. 84132 p 801.571.9433 Salt Lake City UT. 84108 Cold Creek Behavioral p 801.581.5311 p 801.587.7109 Health 9844 S 1300 E 8155 Brighton Loop Rd Hospital Affiliation Ste 100 University Of Utah Health Salt Lake City UT. 84121 - University of Utah Hospital Sandy UT. 84094 9385 Snowbird Ctr Dr p 801.593.6777 p 801.571.9433 Sandy UT. 84092 Hunter, Curtis T MD p 801.646.4800 Collective Recovery Center MountainStar Hospital Affiliation 8029 S 700 E Cardiovascular Surgery - Lone Peak Hospital Hospital Affiliation Sandy UT. 84070 1160 E 3900 S - St Marks Hospital - University of Utah Hospital p 385.557.2183 Ste 3500 Salt Lake City UT. 84124 Ngatuvai, Tauaina J MD Pilgram, Paul E MD The Haven p 801.743.4765 Lihai Medical Clinic The Practice of Medicine 974 E S Temple 313 E 900 S 1561 W 7000 S Salt Lake City UT. 84102 Kagawa, Hiroshi MD Ste 102 Ste 200 p 801.533.0070 University Of Utah Health Salt Lake City UT. 84111 West Jordan UT. 84084 100 N Mario Capecchi Dr p 801.532.2265 p 801.562.5300 Highland Ridge Hospital Salt Lake City UT. 84113 -Not all services covered, p 801.662.5566 Hospital Affiliation Hospital Affiliation please contact your - Timpanogos Regional Hospital - Jordan Valley Medical administrator 50 N Medical Dr Center 7309 S 180 W Salt Lake City UT. 84132 Overton, Eric S Midvale UT. 84047 p 801.581.5311 Medallus Medical Scholl, Mark D MD p 801.569.2153 6322 S 300 E Endurance Orthopedics and Hospital Affiliation Ste 140 Sports Medicine - SLC East Turning Point Centers - University of Utah Hospital Salt Lake City UT. 84121 2645 E Parleys Way 2945 E Turning Point Cir p 801.912.8210 Ste 500 Sandy UT. 84092 Mitzman, Brian A MD Salt Lake City UT. 84109 p 801.576.0745 University Of Utah Health Peterson, Mark W DO p 801.424.5042 50 N Medical Dr Exodus Healthcare Network 2961 E Turning Point Cir Salt Lake City UT. 84132 3665 S 8400 W Steward Orthopedics & Sandy UT. 84092 p 801.581.5311 Ste 110 Sports Medicine p 801.576.0745 Magna UT. 84044 3584 W 9000 S Hospital Affiliation p 801.250.9638 Ste 405 8375 S 700 E - University of Utah Hospital West Jordan UT. 84088 Sandy UT. 84070 p 801.568.3480 p 801.576.0745

Hospital Affiliation - Salt Lake Regional Medical Center 425 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Pereira, Sara J MD Medallus Medical Draper MountainStar Urgent Care Caputo, Peter A MD University Of Utah Health Clinic M-Sun 8am-8pm at Jordan Family Health Granger Medical 100 N Mario Capecchi Dr 1126 E 12300 S 8846 S Redwood Rd Specialists Salt Lake City UT. 84113 Draper UT. 84020 Ste E121 4252 S Highland Dr p 801.662.5566 p 801.545.0600 West Jordan UT. 84088 Ste 200 p 801.569.1999 Salt Lake City UT. 84124 50 N Medical Dr Medallus Medical South p 801.993.1800 Salt Lake City UT. 84132 Bangerter Clinic M-Sat Olympus Clinic Mon-Fri p 801.581.5311 9am-8pm 5am - 8pm & Sat 8am - Hospital Affiliation 13348 S Market Ctr Dr 1:30pm - Jordan Valley Medical 81 N Mario Capecchi Dr Ste 100 4624 S Holladay Blvd Center Salt Lake City UT. 84113 Riverton UT. 84065 Salt Lake City UT. 84117 p 801.662.5566 p 801.255.2000 p 801.277.2682 Cheng, Philip J MD University of Utah Health Hospital Affiliation Medallus Medical West Rocky Mountain Care 1950 Cir of Hope Dr - University of Utah Hospital Valley Clinic M-Sun Clinic- Urgent Care M-F Salt Lake City UT. 84112 9am-10pm 8am-6pm p 801.587.4381 Schorlemmer, Gilbert R MD 3451 S 5600 W 1775 S 4130 W MountainStar Ste F Salt Lake City UT. 84104 50 N Medical Dr Cardiovascular Surgery West Valley City UT. 84120 p 801.975.7799 Salt Lake City UT. 84132 1160 E 3900 S p 801.957.0900 p 801.213.2700 Ste 2000 CareNow Urgent Care Salt Lake City UT. 84124 Medallus Medical Holladay 1950 E 7000 S Hospital Affiliation p 801.743.4750 Clinic M-Sun 9am-7pm Salt Lake City UT. 84121 - University of Utah Hospital 3934 S 2300 E p 801.943.3300 Hospital Affiliation Salt Lake City UT. 84124 Childs, Lane C MD - Lakeview Hospital p 801.849.8500 441 S Redwood Rd Western Urological Clinic - Mountain View Hospital Salt Lake City UT. 84104 4252 Highland Dr (UT) Medallus Medical Sandy p 801.973.2588 Ste 200 - Ogden Regional Medical Clinic M-Sun 9am-8pm Salt Lake City UT. 84124 Center 7998 S 1300 E 5911 S Fashion Blvd p 801.993.1800 - Timpanogos Regional Hospital Sandy UT. 84094 Salt Lake City UT. 84107 p 801.255.2000 p 801.295.6483 Granger Medical Thorne, J Kent MD Specialists MountainStar Copperview Medical Center 8822 S Redwood Rd 4252 S Highland Dr Cardiovascular Surgery Urgent Care (Appts West Jordan UT. 84088 Ste 200 1160 E 3900 S Preferred) M-F 8am-10pm p 801.256.0009 Salt Lake City UT. 84124 Ste 2000 & 3500 Sat-Sun 10am-8pm p 801.993.1800 Salt Lake City UT. 84124 3556 W 9800 S Urogynecology p 801.743.4765 South Jordan UT. 84095 Norton, Peggy A MD Hospital Affiliation p 801.567.9780 University of Utah Health - St Marks Hospital Hospital Affiliation 50 N Medical Dr - Lone Peak Hospital - St Marks Hospital Exodus Healthcare Network Salt Lake City UT. 84132 - Salt Lake Regional Medical - Ogden Regional Medical M-Sun 7am-10pm p 801.587.1950 Center Center 8211 W 3500 S - Timpanogos Regional Hospital Magna UT. 84044 5063 S Cottonwood St Clark, Stanley C MD p 801.250.9638 Ste 450 Granger Medical Zink, Robert F MD Murray UT. 84107 Specialists MountainStar Foothill Family Clinic p 801.587.1560 9600 S 1300 E Cardiovascular Surgery 13953 S Bangerter Pkwy Ste 240 1160 E 3900 S Draper UT. 84020 Hospital Affiliation Sandy UT. 84094 Ste 2000 & 3500 p 385.900.4090 - University of Utah Hospital p 801.571.5121 Salt Lake City UT. 84124 p 801.266.3418 Foothill Family Clinic M-F Urology 9690 S 1300 E 8am-9pm Sat-Sun 9am-12pm Brant, William O MD Ste 100 Urgent Care 2295 Foothill Dr Granger Medical Sandy UT. 84094 Medallus Medical South Salt Lake City UT. 84109 Specialists p 801.571.5121 Jordan Clinic M-Sun p 801.486.3021 24 S 1100 E 9am-8pm Ste 105 Hospital Affiliation 10433 S Redwood Rd 6360 S 3000 E Salt Lake City UT. 84102 - Jordan Valley Medical South Jordan UT. 84095 Salt Lake City UT. 84121 p 801.531.9453 Center p 801.501.0500 p 801.365.1032 - Lone Peak Hospital Hospital Affiliation - University of Utah Hospital - Jordan Valley Medical Center - Lakeview Hospital - Lone Peak Hospital 426 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Curry, Wallace M MD Gross, Kelli X MD Hotaling, James M MD Labasky, Richard F MD University of Utah Health University of Utah Health University of Utah Health 9600 S 1300 E 1280 E Stringham Ave 1950 Cir of Hope Dr 324 E 10th Ave Ste 303 Salt Lake City UT. 84106 Salt Lake City UT. 84112 Salt Lake City UT. 84103 Sandy UT. 84094 p 801.213.2700 p 801.587.4381 p 801.587.2809 p 801.501.5300

Dechet, Christopher B MD 50 N Medical Dr 50 N Medical Dr Hospital Affiliation University of Utah Health Salt Lake City UT. 84132 Salt Lake City UT. 84132 - St Marks Hospital 100 N Mario Capecchi Dr p 801.213.2700 p 801.581.7674 - Jordan Valley Medical Salt Lake City UT. 84113 Center p 801.662.5555 5126 W Daybreak Pkwy 5126 W Daybreak Pkwy - Lone Peak Hospital South Jordan UT. 84009 South Jordan UT. 84009 - Salt Lake Regional Medical 1950 Cir of Hope Dr p 801.213.4500 p 801.213.4500 Center Salt Lake City UT. 84112 p 801.587.4381 5296 S Commerce Dr 5296 S Commerce Dr Landau, Stewart T MD Ste 301 Ste 301 Granger Medical 50 N Medical Dr Salt Lake City UT. 84107 Salt Lake City UT. 84107 Specialists Salt Lake City UT. 84132 p 801.213.2700 p 801.213.2700 5323 S Woodrow St p 801.581.7674 Ste 203 675 S Arapeen Dr 675 S Arapeen Dr Salt Lake City UT. 84107 Hospital Affiliation Ste 205 Ste 205 p 801.266.8664 - University of Utah Hospital Salt Lake City UT. 84108 Salt Lake City UT. 84108 p 801.581.3834 p 801.581.3834 Hospital Affiliation Fisher, Peter C MD - Timpanogos Regional Hospital Western Urological Clinic Hospital Affiliation Hospital Affiliation 4252 Highland Dr - University of Utah Hospital - University of Utah Hospital Lau, Glen A MD Ste 200 University of Utah Health Salt Lake City UT. 84124 Hamilton, Blake D MD Johnson, Gary B MD 100 N Mario Capecchi Dr p 801.993.1800 University of Utah Health Weekend Vasectomy Clinic Salt Lake City UT. 84113 100 N Mario Capecchi Dr 1060 E 100 S p 801.662.5555 Granger Medical Salt Lake City UT. 84113 Ste 110 Specialists p 801.662.5555 Salt Lake City UT. 84102 3773 W 12600 S 4252 S Highland Dr p 844.764.7733 Ste 300 Ste 200 50 N Medical Dr Riverton UT. 84065 Salt Lake City UT. 84124 Salt Lake City UT. 84132 Middleton Urological Assoc p 801.581.2121 p 801.993.1800 p 801.581.7674 181 E 5600 S Ste 113 50 N Medical Dr 9600 S 1300 E 5126 W Daybreak Pkwy Murray UT. 84107 Salt Lake City UT. 84132 Ste 240 South Jordan UT. 84009 p 801.266.8664 p 801.213.2700 Sandy UT. 84094 p 801.213.4500 p 801.571.5121 Granger Medical Primary Childrens 675 S Arapeen Dr Specialists Colorectal Hospital Affiliation Ste 205 24 S 1100 E 81 N Mario Capecchi Dr - St Marks Hospital Salt Lake City UT. 84108 Ste 105 Salt Lake City UT. 84113 - Lone Peak Hospital p 801.581.3834 Salt Lake City UT. 84102 p 801.662.1619 p 801.531.9453 Gange, Steven N MD Hospital Affiliation Hospital Affiliation Western Urological Clinic - University of Utah Hospital 2965 W 3500 S - University of Utah Hospital 4252 Highland Dr West Valley City UT. 84119 Ste 200 Holyoak, Joshua D MD p 801.965.3600 Lenherr, Sara M MD Salt Lake City UT. 84124 Granger Medical University of Utah Health p 801.993.1800 Specialists Weekend Vasectomy Clinic 1280 E Stringham Ave 2965 W 3500 S 3584 W 9000 S Salt Lake City UT. 84106 Granger Medical West Valley City UT. 84119 Ste 401 p 801.213.2700 Specialists p 801.965.3600 West Jordan UT. 84088 4252 S Highland Dr p 844.764.7733 50 N Medical Dr Ste 200 3181 W 9000 S Salt Lake City UT. 84132 Salt Lake City UT. 84124 West Jordan UT. 84088 Hospital Affiliation p 801.581.7674 p 801.993.1800 p 801.569.5600 - Salt Lake Regional Medical Center 5126 W Daybreak Pkwy Hospital Affiliation Hopkins, Scott A MD - Jordan Valley Medical South Jordan UT. 84009 - St Marks Hospital Western Urological Clinic Center West Valley Campus p 801.213.4500 - Lone Peak Hospital 4252 Highland Dr - Lakeview Hospital Ste 200 Salt Lake City UT. 84124 p 801.993.1800

Hospital Affiliation - Salt Lake Regional Medical Center 427 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 85 N Medical Dr 50 N Medical Dr Patel, Darshan P MD Granger Medical Salt Lake City UT. 84112 Salt Lake City UT. 84132 University of Utah Health Specialists p 801.213.2700 p 801.581.7674 1950 Cir of Hope Dr 24 S 1100 E Salt Lake City UT. 84112 Ste 105 Hospital Affiliation Hospital Affiliation p 801.581.3834 Salt Lake City UT. 84102 - University of Utah Hospital - University of Utah Hospital p 801.531.9453 50 N Medical Dr Linton, Jeffrey D PA ONeil, Brock B MD Salt Lake City UT. 84132 5323 S Woodrow St University of Utah Health University of Utah Health p 801.581.3834 Ste 203 1950 Cir of Hope Dr 1950 Cir of Hope Dr Salt Lake City UT. 84107 Salt Lake City UT. 84112 Salt Lake City UT. 84112 Hospital Affiliation p 801.266.8664 p 801.587.4381 p 801.587.4381 - University of Utah Hospital Hospital Affiliation 50 N Medical Dr 50 N Medical Dr Sanchez, Alejandro MD - Salt Lake Regional Medical Salt Lake City UT. 84132 Salt Lake City UT. 84132 University of Utah Health Center p 801.581.7674 p 801.581.7674 1950 Cir of Hope Dr - Jordan Valley Medical Salt Lake City UT. 84112 Center Hospital Affiliation 5126 W Daybreak Pkwy p 801.587.4381 - St Marks Hospital - University of Utah Hospital South Jordan UT. 84009 p 801.213.4500 50 N Medical Dr Summers, Stephen J MD Mccormick, Benjamin J MD Salt Lake City UT. 84132 University of Utah Health University Of Utah Health Hospital Affiliation p 801.213.2700 1950 Cir of Hope Dr 1950 Cir of Hope Dr - University of Utah Hospital Salt Lake City UT. 84112 Salt Lake City UT. 84112 Hospital Affiliation p 801.587.4381 p 801.587.4381 Parkinson, Justin P MD - University of Utah Hospital Weekend Vasectomy Clinic 50 N Medical Dr 50 N Medical Dr 1060 E 100 S Smith, John P DO Salt Lake City UT. 84132 Salt Lake City UT. 84132 Ste 110 University of Utah Health p 801.581.7674 p 801.213.2700 Salt Lake City UT. 84102 50 N Medical Dr p 844.764.7733 Salt Lake City UT. 84132 5126 W Daybreak Pkwy Hospital Affiliation p 801.581.3834 South Jordan UT. 84009 - University of Utah Hospital Granger Medical p 801.213.4500 Specialists 5126 W Daybreak Pkwy Middleton, George W MD 2965 W 3500 S South Jordan UT. 84009 675 S Arapeen Dr Middleton Urological Assoc West Valley City UT. 84119 p 801.581.3834 Ste 205 181 E 5600 S p 801.965.3600 Salt Lake City UT. 84108 Ste 130 Hospital Affiliation p 801.581.3834 Murray UT. 84107 Weekend Vasectomy Clinic - University of Utah Hospital p 801.266.8664 3584 W 9000 S Hospital Affiliation Ste 401 Stephenson, Robert A MD - University of Utah Hospital Hospital Affiliation West Jordan UT. 84088 University of Utah Health - Salt Lake Regional Medical p 844.764.7733 50 N Medical Dr University Urology Center Salt Lake City UT. 84132 Associates Hospital Affiliation p 801.581.7674 50 N Medical Dr Morris, Targhee J MD - Jordan Valley Medical Salt Lake City UT. 84132 Utah Urology Center Hospital Affiliation p 801.587.4888 11760 S 700 E - Lakeview Hospital - Salt Lake Regional Medical Ste 210 - Jordan Valley Medical Center UUHC South Jordan Health Draper UT. 84020 Center West Valley Campus - University of Utah Hospital Center p 801.609.4476 - Salt Lake Regional Medical 5126 W Daybreak Pkwy Center Stout, Lisa MD South Jordan UT. 84095 Hospital Affiliation Middleton Urological p 801.213.4500 - Mountain View Hospital Pastuszak, Alexander W MD Associates (UT) University of Utah Health 1060 E 100 S Waterman, Bradley J MD - Timpanogos Regional Hospital 50 N Medical Dr Ste 110 Middleton Urological Assoc Salt Lake City UT. 84132 Salt Lake City UT. 84102 1060 E 100 S Myers, Jeremy B MD p 801.213.2700 p 801.531.9453 Ste 110 University of Utah Health Murray UT. 84107 100 N Mario Capecchi Dr 5126 W Daybreak Pkwy 181 E 5600 S p 801.266.8664 Salt Lake City UT. 84113 South Jordan UT. 84009 Ste 130 p 801.662.5555 p 801.213.4500 Murray UT. 84107 181 E 5600 S p 801.266.8664 Ste 130 Hospital Affiliation Murray UT. 84107 - University of Utah Hospital p 801.266.8664

428 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Granger Medical 1950 Cir of Hope Dr 1950 Cir of Hope Dr 1950 Cir of Hope Dr Specialists Salt Lake City UT. 84112 Salt Lake City UT. 84112 Salt Lake City UT. 84112 24 S 1100 E p 801.585.7676 p 801.585.7676 p 801.585.7676 Ste 105 Salt Lake City UT. 84102 Hospital Affiliation Hospital Affiliation 50 N Medical Dr p 801.531.9453 - University of Utah Hospital - University of Utah Hospital Salt Lake City UT. 84132 p 801.585.7676 2965 W 3500 S *Brownie, Evan R MD Jensen, Peter E MD West Valley City UT. 84119 Vascular and Vein - Murray Utah Vein Specialists Hospital Affiliation p 801.965.3600 5323 S Woodrow St 7410 S Creek Rd - University of Utah Hospital Ste 101 Ste 104 5323 S Woodrow St Murray UT. 84107 Sandy UT. 84093 *Murray Vascular and Vein Ste 203 p 801.313.7500 p 801.501.8346 5323 S Woodrow St Salt Lake City UT. 84107 Ste 101 p 801.266.8664 Hospital Affiliation Jost, Denise L APRN Salt Lake City UT. 84107 - Summit Physician Specialists University of Utah Health p 801.313.7500 Hospital Affiliation 100 N Mario Capecchi Dr - Salt Lake Regional Medical *Galt, Spencer W MD Salt Lake City UT. 84113 *Merrell, Steven W MD Center Murray Vascular and Vein p 801.662.2950 Murray Vascular and Vein - Jordan Valley Medical 5323 S Woodrow St 5323 S Woodrow St Center Ste 101 1950 Cir of Hope Dr Ste 101 - Mountain Point Medical Murray UT. 84107 Salt Lake City UT. 84112 Murray UT. 84107 Center p 801.261.8346 p 801.585.7676 p 801.261.8346

White, Heidi K PNP Hospital Affiliation 50 N Medical Dr Hospital Affiliation University of Utah Health - Ogden Regional Medical Salt Lake City UT. 84132 - Ogden Regional Medical 100 N Mario Capecchi Dr Center p 801.581.7738 Center Salt Lake City UT. 84113 - Jordan Valley Medical - Jordan Valley Medical p 801.662.5555 Center Hospital Affiliation Center - Salt Lake Regional Medical - University of Utah Hospital - Salt Lake Regional Medical 3773 W 12600 S Center Center Ste 300 Karwande, Shreekanth MD Riverton UT. 84065 Goodman, Greg R MD MountainStar Mitzman, Brian A MD p 801.285.1460 Mountain Medical Vascular Cardiovascular Surgery University Of Utah Health Specialists 1160 E 3900 S 50 N Medical Dr Vascular Surgery 5323 S Woodrow St Ste 3500 Salt Lake City UT. 84132 Affleck, David G MD Ste 101 Salt Lake City UT. 84124 p 801.581.5311 MountainStar Murray UT. 84107 p 801.743.4750 Cardiovascular Surgery p 801.713.1010 Hospital Affiliation 1160 E 3900 S Hospital Affiliation - University of Utah Hospital Ste 3500 Hospital Affiliation - St Marks Hospital Salt Lake City UT. 84124 - Jordan Valley Medical - Ogden Regional Medical Morasch, Mark D MD p 801.743.4750 Center Center MountainStar - Ogden Regional Medical - Timpanogos Regional Hospital Cardiovascular Surgery Hospital Affiliation Center - Lakeview Hospital 1160 E 3900 S - St Marks Hospital - Salt Lake Regional Medical Ste 3100 - Lakeview Hospital Center Kraiss, Larry W MD Salt Lake City UT. 84124 - Ogden Regional Medical University of Utah Health p 801.262.2806 Center Goodwin, Matthew L 100 N Mario Capecchi Dr - Timpanogos Regional Hospital University Of Utah Health Salt Lake City UT. 84113 Sarfati, Mark R MD 50 N Medical Dr p 801.662.2950 University of Utah Health Bech, Fritz R MD Salt Lake City UT. 84132 100 N Mario Capecchi Dr MountainStar p 801.581.5311 1950 Cir of Hope Dr Salt Lake City UT. 84113 Cardiovascular Surgery Salt Lake City UT. 84112 p 801.662.2950 1160 E 3900 S Hospital Affiliation p 801.585.7676 Ste 3100 - University of Utah Hospital 1950 Cir of Hope Dr Salt Lake City UT. 84124 Hospital Affiliation Salt Lake City UT. 84112 p 801.262.2806 Griffin, Claire L MD - University of Utah Hospital p 801.585.7676 University of Utah Health Brooke, Benjamin S MD 100 N Mario Capecchi Dr Lynch, Joanna PA Hospital Affiliation University of Utah Health Salt Lake City UT. 84113 University of Utah Health - University of Utah Hospital 100 N Mario Capecchi Dr p 801.662.2950 100 N Mario Capecchi Dr Salt Lake City UT. 84113 Salt Lake City UT. 84113 p 801.662.2950 p 801.662.2950

429 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Schorlemmer, Gilbert R MD Wilkinson, Craig W MD Cardiac Monitoring Black, Sterling P DC MountainStar Heart and Lung Institute Remote Cardiac Services Blanding Family Cardiovascular Surgery of Utah Phone Number Only Chiropractic 1160 E 3900 S 3336 S 4155 W p 800.367.0300 910 S 300 W Ste 2000 Ste 203 Blanding UT. 84511 Salt Lake City UT. 84124 Salt Lake City UT. 84120 eCardio Diagnostics p 435.678.3601 p 801.743.4750 p 801.263.2370 Phone Number Only p 888.400.3522 Maughan, Thomas R DC Hospital Affiliation 3570 W 9000 S Blue Mountain Chiropractic - Lakeview Hospital Ste 110 Cardiology PC - Mountain View Hospital West Jordan UT. 84088 Johnson, Kira D PA 225 S Main (UT) p 801.263.2370 University of Utah Health Monticello UT. 84535 - Ogden Regional Medical 910 S 300 W p 435.587.3255 Center 5979 S Fashion Blvd Blanding UT. 84511 - Timpanogos Regional Hospital Murray UT. 84107 p 801.585.3229 Counseling p 801.263.2370 Galloway, Charles J CMHC Smith, Brigitte MD Konesavanh, Soutsada N PA Monument Valley Community University of Utah Health 82 S 1100 E University of Utah Health Health Center 100 N Mario Capecchi Dr Ste 200 380 N 100 W 30 W Medical Dr Salt Lake City UT. 84113 Salt Lake City UT. 84102 Monticello UT. 84535 Monument Valley Ut. 84536 p 801.662.2950 p 801.263.2370 p 801.585.7676 p 435.727.3000

1950 Cir of Hope Dr Hospital Affiliation Hospital Affiliation Stubbs, Jessica LMFT Salt Lake City UT. 84112 - Jordan Valley Medical - University of Utah Hospital Montezuma Creek Community p 801.585.7676 Center Health Center - Salt Lake Regional Medical Kutchera, William A MD 1478 E Hwy 162 5126 W Daybreak Pkwy Center University of Utah Health Montezuma Creek Ut. 84534 South Jordan UT. 84009 380 N 100 W p 435.651.3700 p 801.213.4500 Wound Care Monticello UT. 84535 Boyle, Bret R DO p 435.587.5054 Dermatology Hospital Affiliation Physician Wound Care Klein, Stephanie Z MD - University of Utah Hospital Specialists of Utah Hospital Affiliation Blanding Family Practice 1220 E 3900 S - University of Utah Hospital Community Health Center Thorne, J Kent MD Ste 3A 910 S 300 W MountainStar Salt Lake City UT. 84124 Ranjan, Ravi MD Blanding UT. 84511 Cardiovascular Surgery p 801.590.9064 University of Utah Health p 435.678.3601 1160 E 3900 S 910 S 300 W Ste 2000 & 3500 Hospital Affiliation Blanding UT. 84511 Hospital Affiliation Salt Lake City UT. 84124 - St Marks Hospital p 801.585.3229 - University of Utah Hospital p 801.743.4765 Hyperbaric Medicine Hospital Affiliation Diabetic Supplies Hospital Affiliation Physicians - University of Utah Hospital CCS Medical - St Marks Hospital 540 Arapeen Dr Phone Number Only - Ogden Regional Medical Salt Lake City UT. 84108 Ryan, John J MD p 800.726.9811 Center p 801.582.4268 University of Utah Health - Timpanogos Regional Hospital 910 S 300 W Edgepark Salt Lake Wound Care Blanding UT. 84511 Phone Number Only University of Utah 3949 S 700 E p 435.678.3601 p 800.321.0591 Vascular Surgeons Ste 180 50 N Medical Dr Salt Lake City UT. 84107 Hospital Affiliation Roche Insulin Delivery Salt Lake City UT. 84132 p 801.288.2273 - University of Utah Hospital Systems Inc p 801.581.5311 Phone Number Only San Juan County Tandar, Anwar MD p 800.280.7801 *Whitten, Matthew G MD University of Utah Health Murray Vascular and Vein Breast Pumps 910 S 300 W US MED LLC 5323 S Woodrow St Alpine Home Medical Blanding UT. 84511 Phone Number Only Ste 101 Phone Number Only p 801.585.7676 p 800.787.6331 Murray UT. 84107 p 800.686.7993 p 801.261.8346 Hospital Affiliation United States Medical Edgepark - University of Utah Hospital Supply Hospital Affiliation Phone Number Only Phone Number Only - Cassia Regional Hospital p 800.321.0591 Chiropractic p 877.840.8218 - Jordan Valley Medical Black, Lewis A DC Center Montezuma Creek Community - Ogden Regional Medical Health Center Center 1478 E Hwy 162 Montezuma Creek Ut. 84534 p 435.651.3700 430 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Durable Medical Equipment Smith Nephew Inc (Muscle Jeppesen, Kelly M MD Nielson, Michael DO Petersen Medical Stimulators) San Juan Clinic San Juan Clinic 154 S Main Phone Number Only 380 W 100 N 380 W 100 N Blanding UT. 84511 p 800.821.5700 Ste A Ste A p 435.678.2250 Monticello UT. 84535 Monticello UT. 84535 US MED LLC p 435.587.5051 p 435.587.5054 Alpine Home Medical Phone Number Only Phone Number Only p 800.787.6331 Blanding Medical Clinic San Juan Hospital ER p 800.686.7993 804 N 400 W Physician United States Medical Blanding UT. 84511 380 W 100 N CCS Medical Supply p 435.678.2254 Monticello UT. 84535 Phone Number Only Phone Number Only p 435.587.2116 p 800.726.9811 p 877.840.8218 Hospital Affiliation - San Juan Hospital Blanding Clinic Care Rehab and Orthopedic Family Practice 804 N 400 W Products (Muscle Crofts, Douglas Z DO Jones, Lloyd V MD Blanding UT. 84511 Stimulators) San Juan Clinic Monument Valley Community p 435.678.2254 Phone Number Only 380 W 100 N Health Center p 800.487.9644 Monticello UT. 84535 30 W Medical Dr Richey, Tanya FNP p 435.587.5054 Monument Valley UT. 84536 San Juan Hospital DJO Global p 435.727.3000 380 W 100 N Phone Number Only Blanding Clinic Monticello UT. 84535 p 800.336.6569 804 N 400 W Hospital Affiliation p 435.587.5054 Blanding UT. 84511 - Blue Mountain Hospital Dynasplint Systems Inc p 435.678.2254 Blanding Clinic Phone Number Only Key, Wendell G MD 804 N 400 W p 800.638.6771 Hospital Affiliation Montezuma Creek Community Blanding UT. 84511 - San Juan Hospital Health Center p 435.678.2254 EBI LLC (Bone Stimulators) 1478 E Hwy 262 Phone Number Only Cuskelly, William MD Montezuma Creek UT. 84534 Smith, Douglas R p 800.526.2579 Montezuma Creek Community p 435.651.3700 San Juan Clinic Health Center 380 W 100 N Edgepark 1478 E Hwy 262 Monument Valley Community Ste A Phone Number Only Montezuma Creek UT. 84534 Health Center Monticello UT. 84535 p 800.321.0591 p 435.651.3700 30 W Medical Dr p 435.587.5054 Monument Valley UT. 84536 Empi Inc (Neuromuscular Fairley, Kimberly MD p 435.727.3000 Smith, Phillip MD Stimulator) Montezuma Creek Community Monument Valley Community Phone Number Only Health Center Blanding Family Practice Health Center p 800.328.2536 1478 E Hwy 262 Community Health Center 30 W Medical Dr Montezuma Creek UT. 84534 802 S 200 W Monument Valley UT. 84536 KCI USA Inc (Wound Vac p 435.651.3700 Blanding UT. 84511 p 435.727.3000 Only) p 435.678.0710 Phone Number Only Freestone, Blen PA Sparks, Jane M FNP p 800.275.4524 San Juan Clinic Hospital Affiliation San Juan Clinic 380 W 100 N - Blue Mountain Hospital 380 W 100 N Orthofix Inc (Bone Growth Monticello UT. 84535 Ste A Stimulators Physicians p 435.587.5054 McCullough, Casey K MD Monticello UT. 84535 Only) Blanding Family Practice p 435.587.5054 Phone Number Only Haney, Peter C FNP Community Health Center p 800.535.4492 Blanding Medical Clinic 802 S 200 W Spencer, Patricia MD 804 N 400 W Blanding Ut. 84511 Blanding Family Practice Pacific Medical Inc Blanding UT. 84511 p 435.678.0710 Community Health Center Phone Number Only p 435.678.2254 802 S 200 W p 800.726.9180 Nielson, Joshua DO Blanding UT. 84511 Harrington, Catherine MD Blanding Family Practice p 435.678.0710 RespirTech San Juan Clinic Community Health Center Phone Number Only 380 W 100 N 802 S 200 W General Surgery p 800.793.1261 Monticello UT. 84535 Blanding UT. 84511 La Giglia, Mario D DO p 435.587.5054 p 435.678.0710 San Juan Clinic Roche Insulin Delivery 380 W 100 N Systems Inc Blanding Medical Clinic Hospital Affiliation Ste A Phone Number Only 804 N 400 W - Blue Mountain Hospital Monticello UT. 84535 p 800.280.7801 Blanding UT. 84511 p 435.587.5054 p 435.678.2254

Hospital Affiliation - San Juan Hospital 431 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 735 S 200 W Heck, Ryan L LCSW Blanding Family Practice Wyman, Edwin M MD Ste 3 San Juan Counseling Community Health Center San Juan Clinic Blanding UT. 84511 356 S Main St 802 S 200 W 380 W 100 N p 435.678.2254 Blanding UT. 84511 Blanding UT. 84511 Monticello UT. 84535 p 435.678.2992 p 435.678.0710 p 435.587.5054 Vasquez, Juan C MD San Juan Clinic Hendy, Richard LCSW Stubbs, Jessica LMFT Hospital Affiliation 380 W 100 N Montezuma Creek Community Montezuma Creek Community - San Juan Hospital STE A Health Center Health Center Monticello UT. 84535 1478 E Hwy 262 1478 E Hwy 162 Physical Therapy p 435.587.5054 Montezuma Creek UT. 84534 Montezuma Creek Ut. 84534 Concentra Medical Centers p 435.651.3700 p 435.651.3700 2390 Redwood Rd Hospital Affiliation West Valley City UT. 84419 - Moab Regional Hospital Hiatt, Stephen H APRN Occupational Therapy p 888.997.2669 San Juan Counseling Concentra Medical Centers Home Health Agency 356 S Main St 2390 Redwood Rd Goodrich, Paul R DPT Rocky Mountain Home Care Blanding UT. 84511 West Valley City UT. 84419 Montezuma Creek Community 792 S Main St p 435.678.2992 p 888.997.2669 Health Center Blanding UT. 84511 1478 E Hwy 262 p 801.693.2300 Hospital Affiliation Schriber, Elynn M OT Montezuma Creek UT. 84534 - Mountain View Hospital Precision Rehabilitation p 435.651.3700 Hospice (UT) PC Rocky Mountain Home Care 364 W 100 N Precision Rehabilitation 792 S Main St Lyman, Mark E LCSW Monticello UT. 84535 PC Blanding UT. 84511 Lyman Counseling p 435.587.1162 364 W 100 N p 801.693.2300 457 W Ctr Monticello UT. 84535 Blanding UT. 84511 802 S 200 W p 435.587.1162 Rocky Mountain Hospice p 435.678.2617 Blanding UT. 84511 792 S Main St p 435.678.3869 802 S 200 W Blanding UT. 84511 Maryboy, Roselyn LCSW Blanding UT. 84511 p 435.678.3266 Montezuma Creek Community Ophthalmology p 435.678.3869 Health Center Byers, Timothy MD Hospital 1478 E Hwy 262 San Juan Vision Clinic Jeppson, Matthew P DPT Blue Mountain Hospital Montezuma Creek UT. 84534 46 N Main St Montezuma Creek Community 802 S 200 W p 435.651.3700 Blanding UT. 84511 Health Center Blanding UT. 84511 p 435.678.2324 1478 E Hwy 162 p 435.678.3993 Blanding Family Practice Montezuma Creek Ut. 84534 Community Health Center 802 S 200 W p 435.651.3700 San Juan Hospital 802 S 200 W Blanding UT. 84511 380 W 100 N Blanding UT. 84511 p 435.678.3993 Precision Rehabilitation Monticello UT. 84535 p 435.678.0710 PC p 435.587.2116 Hospital Affiliation 364 W 100 N Olsen, Nicolette CMHC - Castleview Hospital Monticello UT. 84535 Laboratory Blanding Family Practice p 435.587.1162 Dominion Diagnostics Community Health Center Optometry Phone Number Only 802 S 200 W Kirk, Ronald D OD 802 S 200 W p 877.734.9600 Blanding UT. 84511 Blanding Family Vision Blanding UT. 84511 p 435.678.0710 Clinic p 435.678.3869 LabCorp of America 46 N Main St Holdings Piotrowski, Deirdre LCSW Blanding UT. 84511 Kartchner, David DPT Phone Number Only Montezuma Creek Community p 435.678.0590 Montezuma Creek Community p 888.522.2677 Health Center Health Center 1478 E Hwy 262 Orthopedic Surgery 1478 E Hwy 162 Mental Health Montezuma Creek UT. 84534 Stevens, Peter M MD Montezuma Creek UT. 84534 Eskee, Pfawnn LCSW p 435.651.3700 University of Utah Health p 435.651.3700 Montezuma Creek Community 735 S 200 W Health Center Monument Valley Community Ste 2 Monument Valley Community 1478 E Hwy 262 Health Center Blanding UT. 84511 Health Center Montezuma Creek UT. 84534 30 W Medical Dr p 801.587.2255 30 W Medical Dr p 435.651.3700 Monument Valley UT. 84536 Monument Valley UT. 84536 p 435.727.3000 Hospital Affiliation p 435.727.3000 Galloway, Charles J CMHC - University of Utah Hospital Monument Valley Community Health Center 30 W Medical Dr Monument Valley Ut. 84536 p 435.727.3000

432 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Precision Rehabilitation Blanding Family Practice Monument Valley Community Care Rehab and Orthopedic PC Community Health Center Health Center Products (Muscle 364 W 100 N 802 S 200 W 30 W Medical Dr Stimulators) Monticello UT. 84535 Blanding UT. 84511 Monument Valley UT. 84536 Phone Number Only p 435.587.1162 p 435.678.0710 p 435.727.3000 p 800.487.9644

802 S 200 W Hospital Affiliation Blanding Family Practice DJO Global Blanding UT. 84511 - Southwest Memorial Hospital Community Health Center Phone Number Only p 435.678.3869 802 S 200 W p 800.336.6569 Hugentobler, Nicholas L Blanding UT. 84511 Ward, Alan PT DPM p 435.678.0710 Dynasplint Systems Inc Montezuma Creek Community San Juan Hospital ER Phone Number Only Health Center Physician Sandoval County p 800.638.6771 1478 E Hwy 262 380 W 100 N Montezuma Creek UT. 84534 Monticello UT. 84535 Breast Pumps EBI LLC (Bone Stimulators) p 435.651.3700 p 435.587.2116 Alpine Home Medical Phone Number Only Phone Number Only p 800.526.2579 Precision Rehabilitation Social Worker p 800.686.7993 PC Eskee, Pfawnn LCSW Edgepark 364 W 100 N Montezuma Creek Community Edgepark Phone Number Only Monticello UT. 84535 Health Center Phone Number Only p 800.321.0591 p 435.587.1162 1478 E Hwy 262 p 800.321.0591 Montezuma Creek UT. 84534 Empi Inc (Neuromuscular 802 S 200 W p 435.651.3700 Cardiac Monitoring Stimulator) Blanding UT. 84511 Remote Cardiac Services Phone Number Only p 435.678.3869 Heck, Ryan L LCSW Phone Number Only p 800.328.2536 San Juan Counseling p 800.367.0300 Ward, Richard T MSPT 356 S Main St KCI USA Inc (Wound Vac Montezuma Creek Community Blanding UT. 84511 eCardio Diagnostics Only) Health Center p 435.678.2992 Phone Number Only Phone Number Only 1478 E Hwy 262 p 888.400.3522 p 800.275.4524 Montezuma Creek UT. 84534 Hendy, Richard LCSW p 435.651.3700 Montezuma Creek Community Diabetic Supplies Orthofix Inc (Bone Growth Health Center CCS Medical Stimulators Physicians Precision Rehabilitation 1478 E Hwy 262 Phone Number Only Only) PC Montezuma Creek UT. 84534 p 800.726.9811 Phone Number Only 364 W 100 N p 435.651.3700 p 800.535.4492 Monticello UT. 84535 Edgepark p 435.587.1162 Lyman, Mark E LCSW Phone Number Only Pacific Medical Inc Lyman Counseling p 800.321.0591 Phone Number Only 802 S 200 W 457 W Ctr p 800.726.9180 Blanding UT. 84511 Blanding UT. 84511 Roche Insulin Delivery p 435.678.3869 p 435.678.2617 Systems Inc RespirTech Phone Number Only Phone Number Only Podiatry Maryboy, Roselyn LCSW p 800.280.7801 p 800.793.1261 Carelock, Benjamin DPM Montezuma Creek Community Montezuma Creek Community Health Center US MED LLC Roche Insulin Delivery Health Center 1478 E Hwy 262 Phone Number Only Systems Inc 1478 E Hwy 262 Montezuma Creek UT. 84534 p 800.787.6331 Phone Number Only Montezuma Creek UT. 84534 p 435.651.3700 p 800.280.7801 p 435.651.3700 United States Medical Blanding Family Practice Supply Smith Nephew Inc (Muscle Cook, Terry R DPM Community Health Center Phone Number Only Stimulators) Montezuma Creek Community 802 S 200 W p 877.840.8218 Phone Number Only Health Center Blanding UT. 84511 p 800.821.5700 1478 E Hwy 262 p 435.678.0710 Durable Medical Equipment Montezuma Creek UT. 84534 Alpine Home Medical US MED LLC p 435.651.3700 Piotrowski, Deirdre LCSW Phone Number Only Phone Number Only Montezuma Creek Community p 800.686.7993 p 800.787.6331 Monument Valley Community Health Center Health Center 1478 E Hwy 262 CCS Medical United States Medical 30 W Medical Dr Montezuma Creek UT. 84534 Phone Number Only Supply Monument Valley UT. 84536 p 435.651.3700 p 800.726.9811 Phone Number Only p 435.727.3000 p 877.840.8218

433 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Laboratory Cardiology Eyre, Michael P DO Durable Medical Equipment Dominion Diagnostics Allen, Marvin R MD Aspen Dermatology Alpine Home Medical Phone Number Only Revere Health 1100 S Medical Dr Phone Number Only p 877.734.9600 65 E 100 N Mount Pleasant UT. 84647 p 800.686.7993 Ste B p 801.794.1490 LabCorp of America Gunnison UT. 84634 CCS Medical Holdings p 801.373.7350 35 E Ctr St Phone Number Only Phone Number Only Gunnison UT. 84634 p 800.726.9811 p 888.522.2677 Hospital Affiliation p 801.794.1490 - Timpanogos Regional Hospital Care Rehab and Orthopedic Occupational Therapy - Mountain View Hospital Hospital Affiliation Products (Muscle Concentra Medical Centers (UT) - Mountain View Hospital Stimulators) 2390 Redwood Rd - Gunnison Valley Hospital (UT) Phone Number Only West Valley City UT. 84419 - Gunnison Valley Hospital p 800.487.9644 p 888.997.2669 *Weaver, Aaron N MD Sanpete Valley Hospital Peterson, Chad R DO DJO Global Physical Therapy 1100 S Medical Dr Aspen Dermatology Phone Number Only Concentra Medical Centers Mt Pleasant UT. 84647 1100 S Medical Dr p 800.336.6569 2390 Redwood Rd p 435.462.2441 Mount Pleasant UT. 84647 West Valley City UT. 84419 p 801.794.1490 Dynasplint Systems Inc p 888.997.2669 Hospital Affiliation Phone Number Only - Timpanogos Regional Hospital Hospital Affiliation p 800.638.6771 Sanpete County - Mountain View Hospital - Mountain View Hospital (UT) (UT) EBI LLC (Bone Stimulators) Audiology Phone Number Only Fox, C B CCC-A Chiropractic Diabetic Education p 800.526.2579 Audiology Associates of Howard, Charles A DC Mason, Drake S RN Holladay Charles A Howard Revere Health Edgepark 1100 S Medical Dr 435 S Main St 96 E Ctr St Phone Number Only Mount Pleasant UT. 84647 Ephraim UT. 84627 Gunnison UT. 84634 p 800.321.0591 p 800.244.9001 p 435.283.4069 p 801.377.4623 Empi Inc (Neuromuscular Fox, Damon B CCC-A Counseling Diabetic Supplies Stimulator) Audiology Associates of Blair, Michael E LMFT CCS Medical Phone Number Only Holladay Blair Counseling Services Phone Number Only p 800.328.2536 1100 S Medical Dr 4615 S 2940 W p 800.726.9811 Mount Pleasant UT. 84647 Sterling UT. 84665 *Intermountain Homecare p 800.244.9001 p 435.703.0756 Edgepark *Medical Equipment and Phone Number Only *Supply Mt Pleasant Thomas, Curtis AUD Greene, Jared LPC p 800.321.0591 130 W Main Peak ENT Associates Jared Green LPC Mt Pleasant UT. 84647 1100 S Medical Dr 50 S Main Roche Insulin Delivery p 435.462.3431 Mount Pleasant UT. 84647 Ste 21 Systems Inc p 801.357.7499 Manti UT. 84642 Phone Number Only KCI USA Inc (Wound Vac p 435.851.9126 p 800.280.7801 Only) Breast Pumps Phone Number Only Alpine Home Medical Dentist US MED LLC p 800.275.4524 Phone Number Only Aste, Leonard R DDS Phone Number Only p 800.686.7993 University of Utah Health p 800.787.6331 Lincare 93 S Main St 728 N 50 E Edgepark Manti UT. 84642 United States Medical Ephraim UT. 84627 Phone Number Only p 435.835.4881 Supply p 435.283.0091 p 800.321.0591 Phone Number Only Hospital Affiliation p 877.840.8218 Orthofix Inc (Bone Growth Cardiac Monitoring - University of Utah Hospital Stimulators Physicians Remote Cardiac Services Dietician Only) Phone Number Only Dermatology *Baugh, Melissa A RD Phone Number Only p 800.367.0300 Adams, Benjamin E DO Sanpete Valley Hospital p 800.535.4492 Cedar Dermatology 1100 S Medical Dr eCardio Diagnostics 43 E 450 N Mt Pleasant UT. 84647 Pacific Medical Inc Phone Number Only Ephraim UT. 84627 p 435.462.2441 Phone Number Only p 888.400.3522 p 435.586.6440 p 800.726.9180 Hospital Affiliation Hospital Affiliation - Sanpete Valley Hospital - Cedar City Hospital

434 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. RespirTech Moroni Clinic *Frischknecht, Michael S Judy, Cary J DO Phone Number Only 51 E Main St *MD Revere Health p 800.793.1261 Moroni UT. 84646 Sanpete Hospitalist 95 E Ctr St p 435.436.5250 1100 S Medical Dr Gunnison UT. 84634 Roche Insulin Delivery Mount Pleasant UT. 84647 p 435.528.7227 Systems Inc Ephraim Clinic p 435.462.4169 Phone Number Only 525 N Main St Hospital Affiliation p 800.280.7801 Ephraim UT. 84627 Manti Family Clinic - Gunnison Valley Hospital p 435.283.4076 159 N Main St Smith Nephew Inc (Muscle Manti UT. 84642 Miller, Lauren L FNP Stimulators) Hospital Affiliation p 435.835.3344 Main Street Clinic Phone Number Only - Sanpete Valley Hospital 46 N Main St p 800.821.5700 Hospital Affiliation Manti UT. 84642 Beck, Kimberly E MD - Sanpete Valley Hospital p 435.835.6000 US MED LLC 76 E Ctr Phone Number Only Gunnison UT. 84634 Inouye, Dwight H MD Hospital Affiliation p 800.787.6331 p 435.528.7935 85 N 100 E - Gunnison Valley Hospital Gunnison UT. 84634 United States Medical Hospital Affiliation p 435.528.7202 *Patterson, Rebekah A NP Supply - Gunnison Valley Hospital Primary Childrens Hospital Phone Number Only Hospital Affiliation 167 E 100 S p 877.840.8218 Blackham, Brady C DO - Gunnison Valley Hospital Ephraim UT. 84627 Revere Health p 435.283.3120 Ear Nose And Throat 95 E Ctr St *Jackson, Eileen K MD Ence, Bradford K MD Gunnison UT. 84634 Sanpete Hospitalist Hospital Affiliation Revere Health p 435.528.7227 1100 S Medical Dr - Primary Childrens Hospital 65 E 100 N Mount Pleasant UT. 84647 Gunnison UT. 84634 Hospital Affiliation p 435.462.4169 Poff, Emily S MD p 801.354.8225 - Gunnison Valley Hospital Fountain Green Medical Moroni Clinic Clinic Hospital Affiliation *Christensen, Kyle J PA 51 E Main St 275 W 300 S - Mountain View Hospital Sevier Valley Specialty Moroni UT. 84646 Fountain Green UT. 84632 (UT) Clinic-Gunnison-Orthopedics p 435.436.5250 p 435.445.3301 - Gunnison Valley Hospital 65 E 100 N - Timpanogos Regional Hospital Gunnison UT. 84634 Hospital Affiliation Hospital Affiliation p 435.893.0800 - Sanpete Valley Hospital - Central Valley Medical Family Practice Center *Allison, Camille H MD *Christensen, Tristy L MD Jensen, Adam DO Sanpete Valley Hospital Sanpete Hospitalist Revere Health Rasch, Leslie K APRN 1100 S Medical Dr 1100 S Medical Dr 65 E 100 N Fountain Green Medical Mt Pleasant UT. 84647 Mount Pleasant UT. 84647 Gunnison UT. 84634 Clinic p 435.462.2441 p 435.462.4169 p 435.528.2130 275 W 300 S Fountain Green UT. 84632 Hospital Affiliation Ephraim Clinic Hospital Affiliation p 435.445.3301 - Sanpete Valley Hospital 525 N Main St - Gunnison Valley Hospital Ephraim UT. 84627 Hospital Affiliation Alsup Jr, Daniel D MD p 435.283.4076 *Johnson, Brett A DO - Central Valley Medical Fountain Green Medical Mt Pleasant Clinic Center Clinic Hospital Affiliation 1100 S Medical Dr - St George Regional Hospital 275 W 300 S - Sanpete Valley Hospital Mt Pleasant UT. 84647 Fountain Green UT. 84632 p 435.462.3471 Rosenbeck, James F DO p 435.623.3200 *Cole, Gary M DO Fountain Green Medical Sanpete Hospitalist Ephraim Clinic Clinic *Armstrong, Robert D MD 1100 S Medical Dr 525 N Main St 275 W 300 S Mt Pleasant Clinic Mount Pleasant UT. 84647 Ephraim UT. 84627 Fountain Green UT. 84632 1100 S Medical Dr p 435.462.4169 p 435.283.4076 p 435.445.3301 Mount Pleasant UT. 84647 p 435.462.3471 Hospital Affiliation Hospital Affiliation Hospital Affiliation - Sanpete Valley Hospital - Sanpete Valley Hospital - Central Valley Medical Manti Family Clinic Center 159 N Main St Day, Allen M MD Jones, Marc F DO Manti UT. 84642 Revere Health Fountain Green Medical *Spencer, Jesse N MD p 435.835.3344 1075 S Hwy 89 Clinic Sanpete Valley Hospital Mount Pleasant UT. 84647 275 W 300 S 1100 S Medical Dr p 435.462.2044 Fountain Green UT. 84632 Mt Pleasant UT. 84647 p 435.445.3301 p 435.462.2441 Hospital Affiliation - Sanpete Valley Hospital Hospital Affiliation - Central Valley Medical Center 435 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Walker, Scott J DO LabCorp of America Sunray Family Counseling Orthopedic Surgery Scott J Warner DO Holdings 45 W 700 S Christensen, Kevin D MD 65 E 100 N Phone Number Only Ephraim UT. 84627 Revere Health Gunnison UT. 84634 p 888.522.2677 p 435.283.4690 65 E 100 N p 435.000.0000 Gunnison UT. 84634 Mental Health Occupational Therapy p 801.373.7350 Hospital Affiliation Allen, Rachel LCSW Concentra Medical Centers - Gunnison Valley Hospital Sunray Family Counseling 2390 Redwood Rd *Evensen, Christopher S DO 45 W 700 S West Valley City UT. 84419 Sanpete Valley Hospital General Surgery Ephraim UT. 84627 p 888.997.2669 1100 S Medical Dr *Krzymowski, David K MD p 435.283.4690 Mt Pleasant UT. 84647 Sanpete Valley Hospital Ophthalmology p 435.462.2441 Physicians Blair, Michael E LMFT Kirk, Kevin MD 1100 S Medical Dr Blair Counseling Services Central Utah Eye Sevier Valley Specialty Mt Pleasant UT. 84647 4615 S 2940 W 1125 S Blackhawk Blvd Clinic-Gunnison-Orthopedics p 435.462.2441 Sterling UT. 84665 Mount Pleasant UT. 84647 65 E 100 N p 435.703.0756 p 435.287.0563 Gunnison UT. 84634 Manti Family Clinic p 435.893.0800 159 N Main St Brown, Steven D PhD Hospital Affiliation Manti UT. 84642 63 S Main - Sevier Valley Hospital Hospital Affiliation p 435.835.3344 Ste 1 - Sanpete Valley Hospital - Sanpete Valley Hospital Ephraim UT. 84627 - Gunnison Valley Hospital Moroni Clinic p 435.283.5559 *Robinson, Ben C 51 E Main St Lohner, W S MD Sevier Valley Specialty Moroni UT. 84646 Greene, Jared LPC Excel Eye Center of Mount Clinic-Gunnison-Orthopedics p 435.436.5250 Jared Green LPC Pleasant 65 E 100 N 50 S Main 1100 S Medical Dr Gunnison UT. 84634 Ephraim Clinic Ste 21 Mount Pleasant UT. 84647 p 435.893.0800 525 N Main St Manti UT. 84642 p 435.462.2441 Ephraim UT. 84627 p 435.851.9126 Hospital Affiliation p 435.283.4076 Hospital Affiliation - Cedar City Hospital *Holbrook, Garry R LCSW - Central Valley Medical - Sanpete Valley Hospital Hospital Affiliation Mt Pleasant Clinic Center - Uintah Basin Medical 1100 S Medical Dr - Mountain View Hospital Taylor, John R MD Center Mt Pleasant UT. 84647 (UT) Revere Health p 435.462.3471 65 E 100 N Home Health Agency Parsons, Matthew R MD Ste A *Intermountain Homecare Manti Family Clinic Excel Eye Center of Mount Gunnison UT. 84634 *Home Health Mt Pleasant 159 N Main St Pleasant p 801.373.7350 130 W Main Manti UT. 84642 1100 S Medical Dr Mt Pleasant UT. 84647 p 435.835.3344 Mount Pleasant UT. 84647 Wallentine, Jeffrey M MD p 435.462.3431 p 435.462.2441 Revere Health Moroni Clinic 1100 S Medical Dr Hospice 51 E Main St Excel Eye Center of Mount Pleasant UT. 84647 *Intermountain Homecare Moroni UT. 84646 Gunnison p 801.373.7350 *Hospice Mt Pleasant p 435.436.5250 79 E Ctr St 130 W Main Gunnison UT. 84634 Hospital Affiliation Mt Pleasant UT. 84647 Ephraim Clinic p 435.528.2187 - Mountain View Hospital p 435.462.3431 525 N Main St (UT) Ephraim UT. 84627 Hospital Affiliation - Gunnison Valley Hospital Hospital p 435.283.4076 - Central Valley Medical - Timpanogos Regional Hospital Gunnison Valley Hospital Center 64 E 100 N Holbrook Therapeutic - Gunnison Valley Hospital Pain Management Gunnison UT. 84634 Services *Frieden, Derek L MD p 435.528.7246 550 N 200 E Optometry Sanpete Valley Hospital Moroni UT. 84646 Cummings, Darin R OD 1100 S Medical Dr *Sanpete Valley Hospital p 435.626.9652 Eye Center of Ephraim Mt Pleasant UT. 84647 1100 S Medical Dr 43 E 450 N p 435.462.2441 Mount Pleasant UT. 84647 Jensen, Michael D LCSW Ephraim UT. 84627 p 435.462.2441 New Beginnings Family p 435.283.5555 Hospital Affiliation Counseling Inc - St George Regional Hospital Laboratory 50 S Main Robison, Jacob M OD Dominion Diagnostics Ste 25 Eye Center of Ephraim Phone Number Only Manti UT. 84642 43 E 450 N p 877.734.9600 p 435.528.7048 Ephraim UT. 84627 p 435.283.5555

436 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Obray, Jon B MD Concentra Medical Centers *Holbrook, Garry R LCSW Corey, Spencer BCBA Sanpete Valley Hospital 2390 Redwood Rd Mt Pleasant Clinic Utah Behavior Services 1100 S Medical Dr West Valley City UT. 84419 1100 S Medical Dr 60 E 100 N Mt Pleasant UT. 84647 p 888.997.2669 Mt Pleasant UT. 84647 Ste 2 p 435.462.2441 p 435.462.3471 Richfield UT. 84701 Overly, Dallas C MPT p 801.255.5131 Hospital Affiliation Therapy West, PC Manti Family Clinic - St George Regional Hospital 13 E Center St 159 N Main St Deceuster, Rachael BCBA Gunnison UT. 84634 Manti UT. 84642 Utah Behavior Services *Obray, Rick W MD p 435.528.7575 p 435.835.3344 60 E 100 N Sanpete Valley Hospital Ste 2 1100 S Medical Dr Rasmussen, Brent M DPT Moroni Clinic Richfield UT. 84701 Mt Pleasant UT. 84647 Sanpete Valley Physical 51 E Main St p 801.255.5131 p 435.462.2441 Therapy Moroni UT. 84646 112 N Main St p 435.436.5250 Hanks, Julie BCBA Hospital Affiliation Ephraim UT. 84627 Utah Behavior Services - St George Regional Hospital p 435.283.5662 Ephraim Clinic 60 E 100 N 525 N Main St Ste 2 Robinson, Cole MD Plastic Surgery Ephraim UT. 84627 Richfield UT. 84701 Vista Neurology Kelly, Christopher P MD p 435.283.4076 p 801.255.5131 Specialists Revivology 1125 S Blackhawk Blvd 64 E 100 N Holbrook Therapeutic Hoffmann, Audrey PhD Mount Pleasant UT. 84647 Gunnison UT. 84634 Services Utah Behavior Services p 435.986.7156 p 435.528.7246 550 N 200 E 60 E 100 N Moroni UT. 84646 Ste 2 Hospital Affiliation Podiatry p 435.626.9652 Richfield UT. 84701 - Sevier Valley Hospital Jolley, Tyler V DPM p 801.255.5131 Elite Ankle & Foot Jensen, Michael D LCSW Pediatrics 1075 S Hwy 89 New Beginnings Family Hunt, Chelseigh BCBA *Carver, Jeanlee F APRN Mount Pleasant UT. 84647 Counseling Inc Utah Behavior Services Primary Childrens Hospital p 435.462.3668 50 S Main 60 E 100 N 167 E 100 S Ste 25 Ste 2 Ephraim UT. 84627 Sanpete Valley Hospital Manti UT. 84642 Richfield UT. 84701 p 435.283.3120 1100 S Medical Dr p 435.528.7048 p 801.255.5131 Mt Pleasant UT. 84647 Hospital Affiliation p 435.462.2441 Speech Therapy Jensen, Julia P BCBA - Primary Childrens Hospital Thomas, Curtis AUD Utah Behavior Services - Lakeview Hospital Hospital Affiliation Peak ENT Associates 60 E 100 N - Ogden Regional Medical - Sanpete Valley Hospital 1100 S Medical Dr Ste 2 Center Mount Pleasant UT. 84647 Richfield UT. 84701 Waite, Jason D DPM p 801.357.7499 p 801.255.5131 Physical Medicine And Rehabilitation Arches Family Foot Care Robinson, Cole MD 46 N Main St Urgent Care Kulow, Kacylia BCBA Vista Neurology Manti UT. 84642 Revere Health Mt Pleasant Utah Behavior Services Specialists p 435.528.2130 Medical Clinic M-Th 60 E 100 N 1125 S Blackhawk Blvd 9am-8pm F 9am-5pm Ste 2 Mount Pleasant UT. 84647 65 E 100 N 1075 S Hwy 89 Richfield UT. 84701 p 435.986.7156 Gunnison UT. 84634 Mount Pleasant UT. 84647 p 801.255.5131 p 435.528.2130 p 435.462.2044 Hospital Affiliation Lowe, Kori BCBA - Sevier Valley Hospital Hospital Affiliation Revere Health Gunnison Utah Behavior Services - Gunnison Valley Hospital Multi-Specialty Center 60 E 100 N Physical Therapy 65 E 100 N Ste 2 *Breau, Destiny L PT Psychology Gunnison UT. 84634 Richfield UT. 84701 Sanpete Valley Hospital Brown, Steven D PhD p 435.528.2130 p 801.255.5131 1100 S Medical Dr 63 S Main Mt Pleasant UT. 84647 Ste 1 Sevier County Renda, Cheyenne R PhD p 435.462.2441 Ephraim UT. 84627 Utah Behavior Services p 435.283.5559 Aba Therapy 60 E 100 N Hospital Affiliation Aleman, Arianna BCBA Ste 2 - Sanpete Valley Hospital Social Worker Utah Behavior Services Richfield UT. 84701 Allen, Rachel LCSW 60 E 100 N p 801.255.5131 Sunray Family Counseling Ste 2 45 W 700 S Richfield UT. 84701 Ephraim UT. 84627 p 801.255.5131 p 435.283.4690

437 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Rhodes, Tiffany BCBA Breast Pumps Chiropractic Lovelace, Scott LCMHC Utah Behavior Services Alpine Home Medical Ogden, Jon D DC Utah Behavior Services 60 E 100 N 43 S Main Ogden Chiropractic Clinic 60 E 100 N Ste 2 Richfield UT. 84701 3 S Main St Ste 2 Richfield UT. 84701 p 435.896.6474 Richfield UT. 84701 Richfield UT. 84701 p 801.255.5131 p 435.896.5300 p 801.255.5131 Phone Number Only Smith, Erica BCBA p 800.686.7993 Whittaker, C Bret DC Meacham, Kory L LPC Utah Behavior Services Whittaker Chiropractic Voyager Therapeutic 60 E 100 N Edgepark Center Inc Services Ste 2 Phone Number Only 458 S Main St 672 W 1000 S Richfield UT. 84701 p 800.321.0591 Richfield UT. 84701 Richfield UT. 84701 p 801.255.5131 p 435.896.5656 p 435.633.1701 Cardiac Monitoring Smith, Saige LPC Remote Cardiac Services Counseling Peyton, R Michael LMFT Utah Behavior Services Phone Number Only Acevedo, Carlos ACMHC Salina Family Medicine 60 E 100 N p 800.367.0300 Utah Behavior Services Clinic Ste 2 60 E 100 N 131 E Main Richfield UT. 84701 eCardio Diagnostics Ste 2 Ste 3 p 801.255.5131 Phone Number Only Richfield UT. 84701 Saline UT. 84654 p 888.400.3522 p 801.255.5131 p 435.529.2215 60 E 100 N Ste 2 Cardiology Black, Jed CMHC Hospital Affiliation Richfield UT. 84701 *Jensen, Ralph E MD Utah Behavior Services - Garfield Memorial Hospital p 801.255.5131 Sevier Valley Specialty 60 E 100 N Clinic Ste 2 Stasiuk, John A LMFT Wilson, Megan BCBA 1000 N Main St Richfield UT. 84701 Utah Behavior Services Utah Behavior Services Ste B p 801.255.5131 60 E 100 N 60 E 100 N Richfield UT. 84701 Ste 2 Ste 2 p 435.893.0800 Draper, Theron LCSW Richfield UT. 84701 Richfield UT. 84701 Salina Family Medicine p 801.255.5131 p 801.255.5131 Hospital Affiliation Clinic - St George Regional Hospital 131 E Main Dermatology Wulfenstein, Lee BCBA - Cedar City Hospital Ste 3 Adams, Benjamin E DO Utah Behavior Services Saline UT. 84654 Cedar Dermatology 60 E 100 N *Weaver, Aaron N MD p 435.529.2215 861 N Main St Ste 2 Sevier Valley Hospital Richfield UT. 84701 Richfield UT. 84701 1000 N Main St Essey, Daryl K CMHC p 435.586.6440 p 801.255.5131 Richfield UT. 84701 Health Balanced Counseling p 435.893.4100 164 N Main St Hospital Affiliation Yang, Danielle BCBA Richfield UT. 84701 - Cedar City Hospital Utah Behavior Services Hospital Affiliation p 435.633.5465 60 E 100 N - Timpanogos Regional Hospital Colbert, Rand L MD Ste 2 - Mountain View Hospital Garcia, Milo F LPC Cedar Dermatology Richfield UT. 84701 (UT) Behavioral Health 1000 N Main St p 801.255.5131 Associates of Utah Richfield UT. 84701 Certified Nurse Midwife 146 N Main p 435.893.0226 Ambulatory Surgery Center Dahlsrud, Sadie CNM Ste 29B Richfield Surgery Center Mountain Utah Family Richfield UT. 84701 Hospital Affiliation 860 N Main St Medicine p 435.896.5165 - Cedar City Hospital Ste A 879 N Main Richfield UT. 84701 Richfield UT. 84701 Greene, Jared LPC Tinajero, Sealtiel DO p 435.879.7612 p 435.896.9561 Jared Green LPC Central Utah Dermatology 180 N 100 E 166 W 1325 N Audiology Rasmussen, Dixie CNM Ste J Ste 250 *Fox, C B AUD Mountain Utah Family Richfield UT. 84701 Richfield UT. 84701 Sevier Valley Hospital Medicine p 435.851.9126 p 435.896.4298 1000 N Main St 879 N Main Richfield UT. 84701 Richfield UT. 84701 Lofthouse, Chelsea ACMHC 861 N Main p 435.893.4100 p 435.896.9561 Utah Behavior Services Richfield UT. 84701 60 E 100 N p 435.896.4298 Luekenga, Richard L AUD Hospital Affiliation Ste 2 Dixie Hearing and Balance - Sevier Valley Hospital Richfield UT. 84701 Center p 801.255.5131 145 N 100 E Richfield UT. 84701 p 435.688.8991

438 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Diabetic Education DJO Global US MED LLC *Christensen, Kyle J PA *Mason, Drake S RN Phone Number Only Phone Number Only Sevier Valley Orthopedics Sevier Valley Hospital p 800.336.6569 p 800.787.6331 1000 N Main St 1000 N Main St Ste B Richfield UT. 84701 Dynasplint Systems Inc United States Medical Richfield UT. 84701 p 435.893.4100 Phone Number Only Supply p 435.893.0800 p 800.638.6771 Phone Number Only Revere Health p 877.840.8218 *Curtis, Scott R MD 568 S Main St EBI LLC (Bone Stimulators) North Sevier Medical Monroe UT. 84754 Phone Number Only Ear Nose And Throat Clinic p 435.527.8866 p 800.526.2579 *Kemp, Edgar N DO 530 N 250 W Sevier Valley Specialty Salina UT. 84654 Diabetic Supplies Edgepark Clinic p 435.529.7411 CCS Medical Phone Number Only 1000 N Main St Phone Number Only p 800.321.0591 Ste B *Davie, Daniel MD p 800.726.9811 Richfield UT. 84701 Sevier Valley Hospital Empi Inc (Neuromuscular p 435.893.0800 1000 N Main St Edgepark Stimulator) Richfield UT. 84701 Phone Number Only Phone Number Only Hospital Affiliation p 435.893.4100 p 800.321.0591 p 800.328.2536 - Delta Community Hospital - Fillmore Community Hospital *Ferris, Tyler DO Roche Insulin Delivery *Intermountain Homecare - Sanpete Valley Hospital Sevier Valley Clinic Systems Inc *Medical Equipment and - Sevier Valley Hospital 1000 N Main St Phone Number Only *Supply Richfield Ste A p 800.280.7801 45 E 500 N Family Practice Richfield UT. 84701 Richfield UT. 84754 Anderson, Kevin K PA p 435.893.0580 US MED LLC p 435.896.5884 Mountain Utah Family Phone Number Only Medicine Hospital Affiliation p 800.787.6331 KCI USA Inc (Wound Vac 879 N Main - Sevier Valley Hospital Only) Richfield UT. 84701 United States Medical Phone Number Only p 435.896.9561 *Hilton, Bret D PA Supply p 800.275.4524 Sevier Valley Clinic Phone Number Only Birch, Richard DO 1000 N Main St p 877.840.8218 Lincare Salina Family Medicine Ste A 1030 S Hwy 118 Clinic Richfield UT. 84701 Dialysis Center Richfield UT. 84701 131 E Main p 435.893.0580 *Sevier Valley Dialysis p 435.893.8900 Ste 3 *Center Saline UT. 84654 Hospital Affiliation 1100 N Main St Orthofix Inc (Bone Growth p 435.529.2215 - Garfield Memorial Hospital Ste D Stimulators Physicians Richfield UT. 84701 Only) Hospital Affiliation Jensen, Adam DO p 435.893.0358 Phone Number Only - Garfield Memorial Hospital Revere Health p 800.535.4492 131 E Main St Durable Medical Equipment Blackham, Brady C DO Ste 3 Alpine Home Medical Pacific Medical Inc Revere Health Salina UT. 84654 43 S Main Phone Number Only 131 E Main St p 435.528.2130 Richfield UT. 84701 p 800.726.9180 Ste 3 p 435.896.6474 Salina UT. 84654 Hospital Affiliation RespirTech p 435.528.2130 - Gunnison Valley Hospital Phone Number Only Phone Number Only p 800.686.7993 p 800.793.1261 Hospital Affiliation *Jones, Steven J DO - Gunnison Valley Hospital Sevier Valley Clinic CCS Medical Roche Insulin Delivery 1000 N Main St Phone Number Only Systems Inc Chappell, Leland J MD Ste A p 800.726.9811 Phone Number Only Salina Family Medicine Richfield UT. 84701 p 800.280.7801 Clinic p 435.893.0580 Care Rehab and Orthopedic 131 E Main Products (Muscle Smith Nephew Inc (Muscle Ste 3 Hospital Affiliation Stimulators) Stimulators) Saline UT. 84654 - Sevier Valley Hospital Phone Number Only Phone Number Only p 435.529.2215 p 800.487.9644 p 800.821.5700 Mooney, Todd MD Hospital Affiliation Salina Family Medicine - Sevier Valley Hospital Clinic - Kane County Hospital 131 E Main Ste 3 Saline UT. 84654 p 435.529.2215

Hospital Affiliation - Garfield Memorial Hospital439 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Mountain Utah Family *Spencer, Jesse N MD *Parker, Jennifer L Aleman, Arianna BCBA Medicine Sevier Valley Clinic Sevier Valley Obstetrics Utah Behavior Services 879 N Main 1000 N Main St and Gynecology 60 E 100 N Richfield UT. 84701 Ste A 1000 N Main St Ste 2 p 435.896.9561 Richfield UT. 84701 Ste 2-C Richfield UT. 84701 p 435.893.0580 Richfield UT. 84701 p 801.255.5131 Patterson, Rebekah A NP p 435.893.0580 Mountain Utah Family Sevier Valley Hospital Arballo, Jennifer CSW Medicine 1000 N Main St Hospital Affiliation Utah Behavior Services 879 N Main Richfield UT. 84701 - Sevier Valley Hospital 60 E 100 N Richfield UT. 84701 p 435.893.4100 Ste 2 p 435.896.9561 Health Department Richfield UT. 84701 North Sevier Medical Central Utah Public Health p 801.255.5131 Hospital Affiliation Clinic 70 Westview Dr - Primary Childrens Hospital 530 N 250 W Richfield UT. 84701 Barusch, Nathaniel MD Salina UT. 84654 p 435.896.5451 Salina Family Medicine Pope, David M MD p 435.529.7411 Clinic Salina Family Medicine Home Health Agency 131 E Main Clinic *Stewart, James R DO *Intermountain Homecare Ste 3 131 E Main Sevier Valley Hospital *Home Health Richfield Saline UT. 84654 Ste 3 1000 N Main St 70 E 1000 N p 435.529.2215 Saline UT. 84654 Richfield UT. 84701 Ste B p 435.529.2215 p 435.893.4100 Richfield UT. 84701 Hospital Affiliation p 435.893.0371 - Mountain View Hospital Mountain Utah Family General Surgery (UT) Medicine *Allen, Brent J DO Hospice - Utah Valley Hospital 879 N Main Sevier Valley Specialty *Intermountain Homecare Richfield UT. 84701 Clinic *Hospice Richfield Black, Jed CMHC p 435.896.9561 1000 N Main St 70 E 1000 N Utah Behavior Services Ste B Ste B 60 E 100 N Hospital Affiliation Richfield UT. 84701 Richfield UT. 84701 Ste 2 - Sevier Valley Hospital p 435.893.0800 p 435.893.0371 Richfield UT. 84701 p 801.255.5131 Seely, Brett PA-C Sevier Valley Hospital Hospital Mountain Utah Family 1000 N Main St *Sevier Valley Hospital Bunting, Catherine CSW Medicine Richfield UT. 84701 1000 N Main St Utah Behavior Services 879 N Main p 435.893.4100 Richfield UT. 84701 60 E 100 N Richfield UT. 84701 p 435.893.4100 Ste 2 p 435.896.9561 *Gilbert, Preston M DO Richfield UT. 84701 Sevier Valley Specialty Internal Medicine p 801.255.5131 *Smith, Daniel C MD Clinic *Johnson, Jeffrey W MD Sevier Valley Clinic 1000 N Main St Sevier Valley Hospital Burr, Brandon M LCSW 1000 N Main St Ste B Physicians Rocky Mountain Behavioral Ste A Richfield UT. 84701 1000 N Main St Consultants Richfield UT. 84701 p 435.893.0800 Richfield UT. 84701 45 N State St p 435.893.0580 p 435.893.4100 Ste 3 Hospital Affiliation Salina UT. 84654 Sevier Valley Hospital - Sevier Valley Hospital Hospital Affiliation p 435.691.0206 1000 N Main St - Timpanogos Regional Hospital Richfield UT. 84701 Gynecology *Burrow, David N MD p 435.893.4100 *Bunot, Britney B DO Laboratory Sevier Valley Clinic Sevier Valley Obstetrics Dominion Diagnostics 1000 N Main St Hospital Affiliation and Gynecology Phone Number Only Ste A - Sevier Valley Hospital 1000 N Main St p 877.734.9600 Richfield UT. 84701 - Garfield Memorial Hospital Ste 2-C p 435.893.0580 Richfield UT. 84701 LabCorp of America *Speakman, Mori S MD p 435.893.0580 Holdings Hospital Affiliation Sevier Valley Hospital Phone Number Only - Park City Hospital Physicians Hospital Affiliation p 888.522.2677 1000 N Main St - Sevier Valley Hospital Cho, Jaeyong MSW Richfield UT. 84701 Mental Health Utah Behavior Services p 435.893.4100 *Jones, Eric R DO Acevedo, Carlos ACMHC 60 E 100 N Sevier Valley Obstetrics Utah Behavior Services Ste 2 And Gynecology 60 E 100 N Richfield UT. 84701 1000 N Main St Ste 2 p 801.255.5131 Ste 2-C Richfield UT. 84701 Richfield UT. 84701 p 801.255.5131 p 435.893.0580 440 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Corey, Spencer BCBA Jensen, Julia P BCBA Renda, Cheyenne R PhD 60 E 100 N Utah Behavior Services Utah Behavior Services Utah Behavior Services Ste 2 60 E 100 N 60 E 100 N 60 E 100 N Richfield UT. 84701 Ste 2 Ste 2 Ste 2 p 801.255.5131 Richfield UT. 84701 Richfield UT. 84701 Richfield UT. 84701 p 801.255.5131 p 801.255.5131 p 801.255.5131 Wilson, Megan BCBA Utah Behavior Services Deceuster, Rachael BCBA Johnston, Harmony MSW Roche, Miriam MSW 60 E 100 N Utah Behavior Services Utah Behavior Services Utah Behavior Services Ste 2 60 E 100 N 60 E 100 N 60 E 100 N Richfield UT. 84701 Ste 2 Ste 2 Ste 2 p 801.255.5131 Richfield UT. 84701 Richfield UT. 84701 Richfield UT. 84701 p 801.255.5131 p 801.255.5131 p 801.255.5131 Wulfenstein, Lee BCBA Utah Behavior Services Draper, Theron LCSW Kulow, Kacylia BCBA Siebert, Tatum LCPC 60 E 100 N Salina Family Medicine Utah Behavior Services Utah Behavior Services Ste 2 Clinic 60 E 100 N 60 E 100 N Richfield UT. 84701 131 E Main Ste 2 Ste 2 p 801.255.5131 Ste 3 Richfield UT. 84701 Richfield UT. 84701 Saline UT. 84654 p 801.255.5131 p 801.255.5131 Yang, Danielle BCBA p 435.529.2215 Utah Behavior Services Lofthouse, Chelsea ACMHC Skousen, Thomas MSW 60 E 100 N Essey, Daryl K CMHC Utah Behavior Services Utah Behavior Services Ste 2 Health Balanced Counseling 60 E 100 N 60 E 100 N Richfield UT. 84701 164 N Main St Ste 2 Ste 2 p 801.255.5131 Richfield UT. 84701 Richfield UT. 84701 Richfield UT. 84701 p 435.633.5465 p 801.255.5131 p 801.255.5131 Nephrology Boyack, Mark NP Garcia, Milo F LPC Lovelace, Scott LCMHC Slater, Courtney MSW Revere Health Behavioral Health Utah Behavior Services Utah Behavior Services 1000 N Main St Associates of Utah 60 E 100 N 60 E 100 N Ste C, 2nd Flr 146 N Main Ste 2 Ste 2 Richfield UT. 84701 Ste 29B Richfield UT. 84701 Richfield UT. 84701 p 801.377.4623 Richfield UT. 84701 p 801.255.5131 p 801.255.5131 p 435.896.5165 Hospital Affiliation Lowe, Kori BCBA Smith, Erica BCBA - Timpanogos Regional Hospital Greene, Jared LPC Utah Behavior Services Utah Behavior Services Jared Green LPC 60 E 100 N 60 E 100 N Freestone, Zachary T DO 180 N 100 E Ste 2 Ste 2 Revere Health Ste J Richfield UT. 84701 Richfield UT. 84701 1000 N Main St Richfield UT. 84701 p 801.255.5131 p 801.255.5131 Ste C, 2nd Flr p 435.851.9126 Richfield UT. 84701 Meacham, Kory L LPC Smith, Saige LPC p 801.377.4623 Hoffmann, Audrey PhD Voyager Therapeutic Utah Behavior Services Utah Behavior Services Services 60 E 100 N Hammond, Terry C MD 60 E 100 N 672 W 1000 S Ste 2 Revere Health Ste 2 Richfield UT. 84701 Richfield UT. 84701 1000 N Main St Richfield UT. 84701 p 435.633.1701 p 801.255.5131 Ste C, 2nd Flr p 801.255.5131 Richfield UT. 84701 Nielsen, Stephanie MSW Sorenson, Russell D PhD p 801.377.4623 Holmes, Alisha MSW Utah Behavior Services Mountain Utah Family Utah Behavior Services 60 E 100 N Medicine Hospital Affiliation 60 E 100 N Ste 2 879 N Main - Timpanogos Regional Hospital Ste 2 Richfield UT. 84701 Richfield UT. 84701 Richfield UT. 84701 p 801.255.5131 p 435.896.9561 Obstetrics And Gynecology p 801.255.5131 *Bunot, Britney B DO Peyton, R Michael LMFT Stasiuk, John A LMFT Sevier Valley Obstetrics Hunt, Chelseigh BCBA Salina Family Medicine Utah Behavior Services and Gynecology Utah Behavior Services Clinic 60 E 100 N 1000 N Main St 60 E 100 N 131 E Main Ste 2 Ste 2-C Ste 2 Ste 3 Richfield UT. 84701 Richfield UT. 84701 Richfield UT. 84701 Saline UT. 84654 p 801.255.5131 p 435.893.0580 p 801.255.5131 p 435.529.2215 Hospital Affiliation Hospital Affiliation - Sevier Valley Hospital - Garfield Memorial Hospital

441 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Jones, Eric R DO Graf, David M OD 860 N Main St 860 N Main St Sevier Valley Obstetrics Valley Vision Clinic Ste B Ste B And Gynecology 145 N 100 E Richfield UT. 84701 Richfield UT. 84701 1000 N Main St Richfield UT. 84701 p 435.986.7156 p 435.986.7156 Ste 2-C p 435.896.8142 Richfield UT. 84701 Hospital Affiliation Hospital Affiliation p 435.893.0580 Luekenga, Richard L OD - St George Regional Hospital - Sevier Valley Hospital Valley Vision Clinic *Parker, Jennifer L 145 N 100 E Hillstead, Alan P MD Pediatrics Sevier Valley Obstetrics Richfield UT. 84701 Vista Neurology *Carver, Jeanlee F APRN and Gynecology p 435.896.8142 Specialists Primary Childrens Hospital 1000 N Main St 860 N Main St 58 E 300 N Ste 2-C Yardley, Richard OD Ste B Ste C Richfield UT. 84701 Mountain View Vision Richfield UT. 84701 Richfield UT. 84701 p 435.893.0580 Center p 435.986.7156 p 435.896.5343 90 E Ctr St Hospital Affiliation Richfield UT. 84701 Hospital Affiliation Hospital Affiliation - Sevier Valley Hospital p 435.896.5671 - St George Regional Hospital - Primary Childrens Hospital - Lakeview Hospital Occupational Therapy Orthopedic Surgery Obray, Jon B MD - Ogden Regional Medical Concentra Medical Centers *Evensen, Christopher S DO Vista Neurology Center 2390 Redwood Rd Sevier Valley Orthopedics Specialists West Valley City UT. 84419 1000 N Main St 860 N Main St Physical Medicine And Rehabilitation p 888.997.2669 Ste B Ste A Robinson, Cole MD Richfield UT. 84701 Richfield UT. 84701 Salina Family Medicine *Stewart, James N OT p 435.893.0800 p 435.986.7156 Clinic Sevier Valley Hospital 131 E Main 1000 N Main St Hospital Affiliation 860 N Main St Ste 3 Richfield UT. 84701 - Sanpete Valley Hospital Ste B Saline UT. 84654 p 435.893.4100 Richfield UT. 84701 p 435.529.2215 *Robinson, Ben C p 435.986.7156 Hospital Affiliation Sevier Valley Orthopedics Vista Neurology - St George Regional Hospital 1000 N Main St Hospital Affiliation Specialists Ste B - St George Regional Hospital 860 N Main St Ophthalmology Cedar City UT. 84701 Ste A Kirk, Kevin MD p 435.893.0800 Obray, Rick W MD Richfield UT. 84701 Central Utah Eye Vista Neurology p 435.986.7156 41 S 100 E Hospital Affiliation Specialists Ste J - Cedar City Hospital 860 N Main St 860 N Main St Richfield UT. 84701 - Sanpete Valley Hospital Ste A Ste B p 435.287.0563 Richfield UT. 84701 Richfield UT. 84701 *Stouffer, Mark H MD p 435.986.7156 p 435.986.7156 Hospital Affiliation Sevier Valley Specialty - Sevier Valley Hospital Clinic 860 N Main St Hospital Affiliation - Sanpete Valley Hospital 1000 N Main St Ste B - Sevier Valley Hospital - Gunnison Valley Hospital Ste B Richfield UT. 84701 Richfield UT. 84701 p 435.986.7156 Physical Therapy Lord, Ron K MD p 435.893.0800 Barney, Matthew PT Retina Associates of Hospital Affiliation Salina Family Medicine Southern Utah Hospital Affiliation - St George Regional Hospital Clinic 460 N Main St - St George Regional Hospital 131 E Main Richfield UT. 84701 Robinson, Cole MD Ste 3 p 435.216.7032 Vakautakakala, Viliami H Salina Family Medicine Saline UT. 84654 DPM Clinic p 435.529.2215 Optometry Apex Foot & Ankle 131 E Main Albrecht, William S OD Institute Ste 3 Concentra Medical Centers Koosharem Paiute Medical 882 N Main St Saline UT. 84654 2390 Redwood Rd Clinic Ste 2 p 435.529.2215 West Valley City UT. 84419 826 N 100 E Richfield UT. 84701 p 888.997.2669 Richfield UT. 84701 p 435.287.2444 Vista Neurology p 435.893.0977 Specialists Cottam, Chad R DPT Pain Management 860 N Main St Salina Family Medicine Frieden, Derek L MD Ste A Clinic Vista Neurology Richfield UT. 84701 131 E Main Specialists p 435.986.7156 Ste 3 860 N Main St Salina UT. 84654 Ste A p 435.425.3744 Richfield UT. 84701 p 435.986.7156 442 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Gubler, John W DPT Radiology Holmes, Alisha MSW Snihurowych, Walter M MD Salina Family Medicine *Davis, John A MD Utah Behavior Services 70 E 1100 N Clinic Sevier Valley Hospital 60 E 100 N Richfield UT. 84701 131 E Main 1000 N Main St Ste 2 p 435.893.0225 Ste 3 Richfield UT. 84701 Richfield UT. 84701 Saline UT. 84654 p 435.893.4100 p 801.255.5131 Hospital Affiliation p 435.529.2215 - Castleview Hospital Hospital Affiliation Johnston, Harmony MSW - Uintah Basin Medical Podiatry - St George Regional Hospital Utah Behavior Services Center Utah Podiatry Group PC 60 E 100 N 390 N 100 W *Davis, Steven B MD Ste 2 Summit County Monroe UT. 84754 Sevier Valley Hospital Richfield UT. 84701 p 801.505.5277 1000 N Main St p 801.255.5131 Aba Therapy Richfield UT. 84701 Advanced Behavior Analysis Zobell, Blake O DPM p 435.893.4100 Nielsen, Stephanie MSW 1742 Teal Dr Mountain Utah Family Utah Behavior Services Park City UT. 84098 Medicine Hospital Affiliation 60 E 100 N p 385.695.2203 879 N Main - St George Regional Hospital Ste 2 Richfield UT. 84701 Richfield UT. 84701 Allergy And Immunology p 435.896.9561 *Orr, Tracy R MD p 801.255.5131 Hendershot, Richard W MD Sevier Valley Hospital Granger Medical Hospital Affiliation 1000 N Main St Roche, Miriam MSW Specialists - Sanpete Valley Hospital Richfield UT. 84701 Utah Behavior Services 8178 Gorgoza Pines Rd p 435.893.4100 60 E 100 N Ste 8H Psychiatry Ste 2 Park City UT. 84098 Barusch, Nathaniel MD Hospital Affiliation Richfield UT. 84701 p 801.747.7244 Salina Family Medicine - St George Regional Hospital p 801.255.5131 Clinic Hospital Affiliation 131 E Main Skilled Nursing Facility Skousen, Thomas MSW - Park City Hospital Ste 3 Richfield Care Center Utah Behavior Services Saline UT. 84654 163 E 1000 N 60 E 100 N Kobernick, Aaron K MD p 435.529.2215 Richfield UT. 84701 Ste 2 University of Utah Health p 435.896.8211 Richfield UT. 84701 1743 Redstone Ctr Dr Hospital Affiliation p 801.255.5131 Ste 115 - Mountain View Hospital Social Worker Park City UT. 84098 (UT) Arballo, Jennifer CSW Slater, Courtney MSW p 435.658.9200 - Utah Valley Hospital Utah Behavior Services Utah Behavior Services 60 E 100 N 60 E 100 N Hospital Affiliation *Burrow, David N MD Ste 2 Ste 2 - University of Utah Hospital Sevier Valley Clinic Richfield UT. 84701 Richfield UT. 84701 1000 N Main St p 801.255.5131 p 801.255.5131 Audiology Ste A Norman, Leanne M AUD Richfield UT. 84701 Bunting, Catherine CSW Urgent Care Utah Audiology and Hearing p 435.893.0580 Utah Behavior Services Revere Health Monroe 2041 Sidewinder Dr 60 E 100 N Family Medicine Ste 1 Hospital Affiliation Ste 2 568 S Main St Park City UT. 84060 - Park City Hospital Richfield UT. 84701 Monroe UT. 84754 p 435.655.8824 p 801.255.5131 p 435.527.8866 Psychology Hospital Affiliation Siebert, Tatum LCPC Burr, Brandon M LCSW Urology - University of Utah Hospital Utah Behavior Services Rocky Mountain Behavioral *Crouch, Ronald H MD 60 E 100 N Consultants Sevier Valley Specialty Breast Pumps Ste 2 45 N State St Clinic Alpine Home Medical Richfield UT. 84701 Ste 3 1000 N Main St Phone Number Only p 801.255.5131 Salina UT. 84654 Ste B p 800.686.7993 p 435.691.0206 Richfield UT. 84701 Sorenson, Russell D PhD p 435.893.0800 Edgepark Mountain Utah Family Cho, Jaeyong MSW Phone Number Only Medicine Utah Behavior Services Hospital Affiliation p 800.321.0591 879 N Main 60 E 100 N - Cedar City Hospital Richfield UT. 84701 Ste 2 - St George Regional Hospital Cardiac Monitoring p 435.896.9561 Richfield UT. 84701 Remote Cardiac Services p 801.255.5131 Phone Number Only p 800.367.0300

443 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. eCardio Diagnostics *Luna, Jaime D PA-C Wilson, Brent D MD Daniels, Marianne CMHC Phone Number Only Int Heart Cardiology-PKMC University of Utah Health Cedar Psychiatry p 888.400.3522 900 Round Valley 1743 Redstone Ctr Dr 1526 Ute Blvd Ste 200 Ste 115 Ste 106 Cardiology Park City UT. 84060 Park City UT. 84098 Park City UT. 84098 *Biggs, Jason PA p 801.507.3500 p 435.658.9200 p 801.369.8989 Int Heart Cardiology-PKMC 900 Round Valley *Mauro, Heather A APRN Hospital Affiliation Elgie, Brigette D LMFT Ste 200 Int Heart Cardiology-PKMC - University of Utah Hospital Counseling Center of Park Park City UT. 84060 900 Round Valley City p 801.507.3500 Ste 200 *Young, Daniel J APRN 1283 Deer Valley Dr Park City UT. 84060 Int Heart Cardiology-PKMC Park City UT. 84068 *Burke, J L MD p 801.507.3500 900 Round Valley p 303.981.9685 Int Heart Cardiology-PKMC Ste 200 900 Round Valley Dr *Meredith, Kent G MD Park City UT. 84060 Ellis, John LMFT Park City UT. 84060 Int Heart Cardiology-PKMC p 801.507.3500 Cedar Psychiatry p 801.507.3500 900 Round Valley Dr 1526 Ute Blvd Park City UT. 84060 Chiropractic Ste 106 Catino, Anna B MD p 801.507.3500 Lundstrom, Chad A DC Park City UT. 84098 University of Utah Health Lundstrom Chiropractic p 801.369.8989 1743 Redstone Ctr Dr *Miner, Edward C MD 1790 Sun Peak Dr Ste 115 Int Heart Cardiology-PKMC Ste A201 Footer, Jeremy D LCSW Park City UT. 84098 900 Round Valley Dr Park City UT. 84098 UNI Park City Outpatient p 435.658.9200 Park City UT. 84060 p 435.649.4424 Clinic - Adult p 801.507.3500 1820 Sidewinder Dr Hospital Affiliation Counseling Ste 100 - University of Utah Hospital *Orford, James L MD Bennett, Marlo LMFT Park City UT. 84060 Int Heart Cardiology-PKMC Marlo Bennett, LMFT p 801.585.1212 Crouch, Jessica S PA 900 Round Valley Dr 1901 Prospector Ave University of Utah Health Park City UT. 84060 Ste 22 University of Utah Health 1743 Redstone Ctr Dr p 801.507.3500 Park City UT. 84060 1820 Sidewinder Dr Ste 115 p 435.901.3218 Park City UT. 84060 Park City UT. 84098 *Senapati, Alpana DO p 801.585.1212 p 435.658.9200 Int Heart Cardiology-PKMC Bingham, Amy A LCMHC 900 Round Valley Dr University Of Utah Health Franz, Megan A CMHC Hospital Affiliation Ste 200 1820 Sidewinder Dr University Of Utah Health - University of Utah Hospital Park City UT. 84060 Ste 100 110 N Main St p 801.507.3500 Park City UT. 84060 Kamas UT. 84036 *Dhar, Ritesh MD p 801.585.1212 p 801.585.1212 Int Heart Cardiology-PKMC Hospital Affiliation 900 Round Valley Dr - Heber Valley Hospital 1820 Sidewinder Dr 1820 Sidewinder Dr Park City UT. 84060 - Park City Hospital Park City UT. 84060 Ste 100 p 801.507.3500 p 801.585.1212 Park City UT. 84060 Shah, Rashmee MD p 801.585.1212 Fang, James C MD University of Utah Health Bingham, Tamara LCMHC University of Utah Health 1743 Redstone Ctr Dr Counseling Center of Park 1820 Sidewinder Dr 1743 Redstone Ctr Dr Ste 115 City Park City UT. 84060 Ste 115 Park City UT. 84098 1283 Deer Valley Dr p 801.585.1212 Park City UT. 84098 p 435.658.9200 Park City UT. 84068 p 801.585.7676 p 303.981.9685 85 N 50 E Hospital Affiliation Coalville UT. 84017 Hospital Affiliation - University of Utah Hospital CG Mental Health p 801.585.1212 - University of Utah Hospital 2700 Homestead Rd UUHC Redstone Center Ste 210-A Harter, Leah M LPC *Hu, Peter T MD 1743 W Redstone Ctr Park City UT. 84098 Counseling Center of Park Int Heart Cardiology-PKMC Park City UT. 84098 p 307.254.1818 City 900 Round Valley Dr p 435.658.9200 1283 Deer Valley Dr Ste 200 3100 W Pinebrook Rd Park City UT. 84068 Park City UT. 84060 *Walsh, Kevin J MD Ste 1250-B p 303.981.9685 p 801.507.3500 Int Heart Cardiology-PKMC Park City UT. 84098 900 Round Valley Dr p 307.254.1818 Howell, Karlina K LMFT *LaPine, Armond M MD Park City UT. 84060 Karlina K Howell LMFT Int Heart Cardiology-PKMC p 801.507.3500 700 Bitner Rd 900 Round Valley Dr Ste 145 Park City UT. 84060 Park City UT. 84098 p 801.507.3500 p 435.565.1019

444 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. University Of Utah Health Winterton, Julia L CMHC Leachman, Sancy A MD,PhD Stankiewicz, Kelly MD 1820 Sidewinder Dr Counseling Center of Park University of Utah Health The Dermatology House Ste 100 City 1743 Redstone Ctr Dr 1526 Ute Blvd Park City UT. 84060 1283 Deer Valley Dr Ste 115 Ste 104 p 801.585.1212 Park City UT. 84068 Park City UT. 84098 Park City UT. 84098 p 435.671.6552 p 435.658.9200 p 435.602.1918 1820 Sidewinder Dr Park City UT. 84060 Woodard, Jeness L LCSW Lewis, Bethany K MD Hospital Affiliation p 801.585.1212 University of Utah Health University of Utah Health - Park City Hospital 1743 Redstone Ctr Dr 1743 Redstone Ctr Dr CG Mental Health Ste 115 Ste 115 Summers, Erika M MD 3100 W Pinebrook Rd Park City UT. 84098 Park City UT. 84098 University of Utah Health Ste 1250-B p 435.658.9200 p 435.658.9200 1743 Redstone Ctr Dr Park City UT. 84098 Ste 115 p 307.254.1818 Dermatology Hospital Affiliation Park City UT. 84098 Callis, Kristina P MD - University of Utah Hospital p 435.658.9200 Nelson, Roxi LCSW University of Utah Health 3100 Pinebrook Rd 1743 Redstone Ctr Dr Mathis, Jason G MD Hospital Affiliation Ste 2250 Ste 115 University of Utah Health - University of Utah Hospital Park City UT. 84098 Park City UT. 84098 1743 Redstone Ctr Dr p 435.615.7600 p 435.658.9200 Ste 115 The Dermatology House Park City UT. 84098 1526 Ute Blvd Page, Allison J NP Clarke, Jennie T MD p 435.658.9200 Ste 104 Trailtalk University of Utah Health Park City UT. 84098 1750 Sun Peak Dr 1743 Redstone Ctr Dr Hospital Affiliation p 435.602.1918 Ste 175 Ste 115 - University of Utah Hospital Park City UT. 84098 Park City UT. 84098 UUHC Redstone Center p 435.513.2715 p 435.658.9200 Petersen, Marta J MD 1743 W Redstone Ctr University of Utah Health Park City UT. 84098 Paletta, Caroline S LPC Hospital Affiliation 1743 Redstone Ctr Dr p 435.658.9200 Pathways of Healing LLC - University of Utah Hospital Ste 115 50 Shadow Ridge Pl Park City UT. 84098 deShazo, Rosemary A MD Park City UT. 84060 Curtis, Julia A MD p 435.658.9200 University of Utah Health p 435.659.0761 University of Utah Health 1743 Redstone Ctr Dr 1743 Redstone Ctr Dr Rhoads, Jamie Lynn W MD Ste 115 Peay, T Roger PhD Ste 115 University of Utah Health Park City UT. 84098 T Roger Peay Therapy Park City UT. 84098 1743 Redstone Ctr Dr p 435.658.9200 10-B Pinebrook Rd p 435.658.9200 Ste 115 Park City UT. 84098 Park City UT. 84098 Hospital Affiliation p 801.893.9687 Hospital Affiliation p 435.658.9200 - University of Utah Hospital - University of Utah Hospital Rehn, Phyllis A LPC Hospital Affiliation Diabetic Supplies Counseling Center of Park Duffy, Keith L MD - University of Utah Hospital CCS Medical City University of Utah Health Phone Number Only 1283 Deer Valley Dr 1743 Redstone Ctr Dr Secrest, Aaron M MD p 800.726.9811 Park City UT. 84068 Ste 115 University of Utah Health p 303.981.9685 Park City UT. 84098 1743 Redstone Ctr Dr Edgepark p 435.658.9200 Ste 115 Phone Number Only Sutton, Nancy M LMFT Park City UT. 84098 p 800.321.0591 Harmony Family Therapy Hospital Affiliation p 435.658.9200 2720 Homestead Rd - University of Utah Hospital Roche Insulin Delivery Ste 19 Hospital Affiliation Systems Inc Park City UT. 84098 *Gardner, Kevin H DO - University of Utah Hospital Phone Number Only p 435.513.5708 Park City Specialty p 800.280.7801 900 Round Valley Dr Smart, David R MD Tan, Margaret LPC Ste 200 University of Utah Health US MED LLC 1760 Prospector Ave 2nd Park City UT. 84060 1743 Redstone Ctr Dr Phone Number Only Floor p 435.658.7400 Ste 115 p 800.787.6331 Park City UT. 84060 Park City UT. 84098 p 435.513.4799 Kuechle, Melanie K MD p 435.658.9200 United States Medical University of Utah Health Supply Valley Behavioral Health 1743 Redstone Ctr Dr Hospital Affiliation Phone Number Only Phone Number Only Ste 115 - University of Utah Hospital p 877.840.8218 Park City UT. 84098 Park City UT. 84098 p 888.949.4864 p 435.658.9200

Hospital Affiliation - University of Utah Hospital 445 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Durable Medical Equipment US MED LLC Family Practice *Darling, Heather A APRN Alpine Home Medical Phone Number Only Allen, D W MD Park City Hospital Phone Number Only p 800.787.6331 Coalville Health Center 900 Round Valley Dr p 800.686.7993 142 S 50 E Park City UT. 84060 United States Medical Coalville UT. 84017 p 435.658.7880 CCS Medical Supply p 435.336.4403 Phone Number Only Phone Number Only *Dolan, Julie A MD p 800.726.9811 p 877.840.8218 Kamas Health Center Mountain Family Health 228 W 200 S 2720 Home Stead Rd Care Rehab and Orthopedic Ear Nose And Throat Ste B Ste 100 Products (Muscle Bennett, John R MD Kamas UT. 84036 Park City UT. 84098 Stimulators) Ear, Nose & Throat Center p 435.783.4385 p 435.940.9400 Phone Number Only of Utah p 800.487.9644 1820 Sidewinder Dr Hospital Affiliation Hospital Affiliation Ste 110 - Salt Lake Regional Medical - Primary Childrens Hospital DJO Global Park City UT. 84060 Center Phone Number Only p 435.649.4106 *Downing, Phillip K PA-C p 800.336.6569 Anderson, Lisa M MD Int Heart Cardiology-PKMC Hospital Affiliation MountainStar Medical Group 900 Round Valley Dynasplint Systems Inc - Salt Lake Regional Medical 1600 Snow Creek Dr Ste 200 Phone Number Only Center Park City UT. 84060 Park City UT. 84060 p 800.638.6771 p 435.655.0555 p 801.507.3500 Butler, John E MD EBI LLC (Bone Stimulators) Ear, Nose & Throat Center Hospital Affiliation Park City Vaccines at Snow Phone Number Only of Utah - Salt Lake Regional Medical Creek p 800.526.2579 1820 Sidewinder Dr Center 1600 Snow Creek Dr Ste 110 Park City UT. 84060 Edgepark Park City UT. 84060 Barrett, John W MD p 435.604.0250 Phone Number Only p 435.649.4106 University of Utah Health p 800.321.0591 1743 Redstone Ctr Dr Farrell, Michael J DO Hospital Affiliation Ste 115 University of Utah Health Empi Inc (Neuromuscular - St Marks Hospital Park City UT. 84098 1743 Redstone Ctr Dr Stimulator) - Lone Peak Hospital p 435.658.9200 Ste 115 Phone Number Only Park City UT. 84098 p 800.328.2536 1820 Sidewinder Dr Hospital Affiliation p 435.658.9200 Ste 110 - University of Utah Hospital KCI USA Inc (Wound Vac Park City UT. 84060 Hospital Affiliation Only) p 435.649.4106 Berman, Joseph H MD - University of Utah Hospital Phone Number Only University of Utah Health p 800.275.4524 Miller, Steven K MD 1743 Redstone Ctr Dr *Ferrell, Donna L APRN Ear, Nose & Throat Center Ste 115 Park City Sleep Disorders Orthofix Inc (Bone Growth of Utah Park City UT. 84098 Clinic Stimulators Physicians 1820 Sidewinder Dr p 435.658.9200 900 Round Valley Dr Only) Ste 110 Ste 200 Phone Number Only Park City UT. 84060 Hospital Affiliation Park City UT. 84060 p 800.535.4492 p 435.649.4106 - Salt Lake Regional Medical p 435.658.6621 Center Pacific Medical Inc Hospital Affiliation - University of Utah Hospital *Haberman, Paula L MD Phone Number Only - Primary Childrens Hospital Park City Clinic-Round p 800.726.9180 - Lone Peak Hospital Borrelli, Tillie M DNP Valley - Salt Lake Regional Medical Coalville Health Center 750 Round Valley Dr RespirTech Center 142 S 50 E Park City UT. 84060 Phone Number Only Coalville UT. 84017 p 435.649.7680 p 800.793.1261 Tagge, Bryan C MD p 435.336.4403 Ear, Nose & Throat Center Harper, Jason M DO Roche Insulin Delivery of Utah Kamas Health Center Gregory Iverson Family Systems Inc 1820 Sidewinder Dr 228 W 200 S Medicine Phone Number Only Ste 110 Kamas UT. 84036 142 S 50 E p 800.280.7801 Park City UT. 84060 p 435.783.4385 Coalville UT. 84017 p 435.649.4106 p 435.336.4403 Smith Nephew Inc (Muscle Burt, Rebecca APRN Stimulators) Hospital Affiliation University of Utah Health 228 W 200 S Phone Number Only - Salt Lake Regional Medical 1743 Redstone Ctr Dr Kamas UT. 84036 p 800.821.5700 Center Ste 115 p 435.783.4385 - Lone Peak Hospital Park City UT. 84098 p 435.658.9200

Hospital Affiliation - University of Utah Hospital 446 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Iverson, Gregory D DO *Moyes, Rebecca T APRN *Rassner, Leslie H MD Thomas, Kelly L DO Coalville Health Center Park City Sleep Disorders Canyons Village Medical University of Utah Health 142 S 50 E Clinic Clinic 1743 Redstone Ctr Dr Coalville UT. 84017 900 Round Valley Dr 3850 Canyons Resort Dr Ste 115 p 435.336.4403 Ste 200 Park City UT. 84098 Park City UT. 84098 Park City UT. 84060 p 435.615.2235 p 435.658.9200 Kamas Health Center p 435.658.6621 228 W 200 S Hospital Affiliation Hospital Affiliation Kamas UT. 84036 Park City Family Health - St Marks Hospital - University of Utah Hospital p 435.783.4385 Center - Salt Lake Regional Medical 1665 Bonanza Dr Center *Tullis, David T MD Hospital Affiliation Park City UT. 84060 Park City Hospital - Park City Hospital p 435.649.7640 *Rowles, Eva L APRN 900 Round Valley Dr Park City Specialty Park City UT. 84060 Johnson, Troy S PA-C Peterson, Mark W DO 900 Round Valley Dr p 435.658.7000 Rosenberg Cooley Metcalf Heiden Orthopedics Ste 200 900 Round Valley Dr 2200 Park Ave Bldg D Park City UT. 84060 Hospital Affiliation Ste 100 Ste 100 p 435.658.7400 - Heber Valley Hospital Park City UT. 84060 Park City UT. 84060 p 435.655.6600 p 435.615.8822 *Rush, Brian J MD UUHC Redstone Center Mountain Family Health 1743 W Redstone Ctr Jones, Kyle B MD Hospital Affiliation 2720 Home Stead Rd Park City UT. 84098 University of Utah Health - Jordan Valley Medical Ste 100 p 435.658.9200 1743 Redstone Ctr Dr Center West Valley Campus Park City UT. 84098 Ste 115 - Jordan Valley Medical p 435.940.9400 Van Leuven, Sandra L MD Park City UT. 84098 Center University of Utah Health p 435.658.9200 Hospital Affiliation 1743 Redstone Ctr Dr *Petzold, Tricia MD - Park City Hospital Ste 115 Hospital Affiliation Park City Hospital Park City UT. 84098 - University of Utah Hospital 900 Round Valley Dr *Saturnino, Lisa M MD p 435.658.9200 Park City UT. 84060 Park City Clinic-Round Jorgensen, Jesse A PA p 435.658.7000 Valley 1790 Sun Peak Dr University of Utah Health 750 Round Valley Dr Ste A101 1743 Redstone Ctr Dr Pidwell, William B MD Park City UT. 84060 Park City UT. 84098 Ste 115 Rosenberg Cooley Metcalf p 435.649.7680 p 435.645.0800 Park City UT. 84098 900 Round Valley Dr p 435.658.9200 Ste 100 Park City Hospital Hospital Affiliation Park City UT. 84060 900 Round Valley Dr - Park City Hospital Hospital Affiliation p 435.655.6600 Park City UT. 84060 - University of Utah Hospital - University of Utah Hospital p 435.658.7000 Hospital Affiliation *Veghte, Mary W MD *Madeo, Jared APRN - Salt Lake Regional Medical Hospital Affiliation Park City Clinic-Round Int Heart Cardiology-PKMC Center - Salt Lake Regional Medical Valley 900 Round Valley Center 750 Round Valley Dr Ste 200 Pohl, Susan D MD Park City UT. 84060 Park City UT. 84060 University of Utah Health Speakman, Robert L MD p 435.649.7680 p 801.507.3500 1743 Redstone Ctr Dr University of Utah Health Ste 115 1743 Redstone Ctr Dr Hospital Affiliation Hospital Affiliation Park City UT. 84098 Ste 115 - Park City Hospital - Park City Hospital p 435.658.9200 Park City UT. 84098 p 435.658.9200 Vroman, Stacy T PA *Morrison, Charles R MD Hospital Affiliation University of Utah Health Park City Clinic-Round - University of Utah Hospital Hospital Affiliation 1743 Redstone Ctr Dr Valley - University of Utah Hospital Ste 115 750 Round Valley Dr Prince, Victoria L MD,PhD Park City UT. 84098 Park City UT. 84060 University of Utah Health Syddall, Tracy R PA-C p 435.658.9200 p 435.649.7680 1743 Redstone Ctr Dr University of Utah Health Ste 115 1743 Redstone Ctr Dr White, Charles D MD Hospital Affiliation Park City UT. 84098 Ste 115 University of Utah Health - Salt Lake Regional Medical p 435.658.9200 Park City UT. 84098 1743 Redstone Ctr Dr Center p 435.658.9200 Ste 115 Hospital Affiliation Park City UT. 84098 - University of Utah Hospital Hospital Affiliation p 435.658.9200 - Jordan Valley Medical Center Hospital Affiliation - University of Utah Hospital - University of Utah Hospital

447 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Winn, Robert T MD General Surgery Singer, Stephanie DO Internal Medicine Park City Clinic-Round *Adams, Danielle MD Park City Gynecology *Beller, Klarissa N MD Valley Park City Specialty 1441 W Ute Blvd Park City Clinic-Round 750 Round Valley Dr 900 Round Valley Dr Ste 160 Valley Park City UT. 84060 Ste 200 Park City UT. 84098 750 Round Valley Dr p 435.649.7680 Park City UT. 84060 p 435.214.5335 Ste 201 p 435.658.7400 Park City UT. 84060 Hospital Affiliation Hospital Affiliation p 435.649.7680 - Park City Hospital Park City Hospital - St Marks Hospital 900 Round Valley Dr - Salt Lake Regional Medical Craig, Richard M MD *Woodward, Kelly H DO Park City UT. 84060 Center University of Utah Health PKMC Live Well Center- p 435.658.7000 1743 Redstone Ctr Dr Park City Health Department Ste 115 900 Round Valley Dr Hospital Affiliation Summit County Health Park City UT. 84098 Park City UT. 84060 - Heber Valley Hospital Department p 435.658.9200 p 435.658.7880 - Park City Hospital 110 N Main Kamas UT. 84036 Hospital Affiliation Hospital Affiliation Syddall, Tracy R PA-C p 435.333.1500 - University of Utah Hospital - Park City Hospital University of Utah Health 1743 Redstone Ctr Dr 650 Round Valley Dr *Gundersen, Nancy E MD Free Standing Emergency Center Ste 115 Park City UT. 84060 Park City Sleep Disorders Snow Creek Emergency & Park City UT. 84098 p 435.333.1500 Clinic Medical Center p 435.658.9200 900 Round Valley Dr 1600 Snow Creek Dr 85 N 50 E Ste 200 Park City UT. 84060 Hospital Affiliation Park City UT. 84060 Park City UT. 84060 p 435.655.0055 - Jordan Valley Medical p 435.336.3234 p 435.658.6621 Center Gastroenterology - University of Utah Hospital Home Health Agency Hendershot, Richard W MD Craig, Richard M MD Applegate Homecare and Granger Medical University of Utah Health Gynecology Hospice Specialists 1743 Redstone Ctr Dr *Clark, C Jeremy DO 750 Round Valley Dr 8178 Gorgoza Pines Rd Ste 115 Park City Specialty Ste 204 Ste 8H Park City UT. 84098 900 Round Valley Dr Park City UT. 84060 Park City UT. 84098 p 435.658.9200 Ste 200 p 435.647.3765 p 801.747.7244 Park City UT. 84060 Hospital Affiliation p 435.658.7400 CNS Community Nursing Hospital Affiliation - University of Utah Hospital Services - Park City Hospital Hospital Affiliation Phone Number Only *Feurer, Matthew E MD - Park City Hospital Kamas UT. 84036 Karnam, Umaprasanna S MD Park City Specialty p 800.486.2186 Gut Whisperer 900 Round Valley Dr *Homewood, Virginia J MD 900 Round Valley Dr Ste 200 Park City Specialty Pinnacle Home Health Inc Ste 120 Park City UT. 84060 900 Round Valley Dr Phone Number Only Zip Park City UT. 84060 p 435.658.7400 Ste 200 84098 p 435.776.3499 Park City UT. 84060 p 801.274.0299 Hospital Affiliation p 435.658.7400 Hospital Affiliation - Park City Hospital Hospice - Salt Lake Regional Medical Hospital Affiliation Applegate Homecare and Center Karnam, Umaprasanna S MD - Jordan Valley Medical Hospice - Jordan Valley Medical Gut Whisperer Center West Valley Campus 750 Round Valley Dr Center 900 Round Valley Dr Ste 204 Ste 120 *Paas, John T MD Park City UT. 84060 Odell, Timothy W MD Park City UT. 84060 Park City Specialty p 435.647.3765 University of Utah Health p 435.776.3499 900 Round Valley Dr 1743 Redstone Ctr Dr Ste 200 CNS Community Nursing Ste 115 Hospital Affiliation Park City UT. 84060 Services Park City UT. 84098 - Salt Lake Regional Medical p 435.658.7400 Phone Number Only p 435.658.9200 Center Kamas UT. 84036 - Jordan Valley Medical Planned Parenthood p 800.486.2186 Hospital Affiliation Center Association of Utah - University of Utah Hospital 1670 Bonanza Dr Hospital Smith, Kent MD Park City UT. 84068 *Park City Hospital Parsons, Mary H MD Gut Whisperer p 435.649.5989 900 Round Valley Dr University of Utah Health 900 Round Valley Dr Park City UT. 84060 1743 Redstone Ctr Dr Ste 120 p 435.658.7000 Ste 115 Park City UT. 84060 Park City UT. 84098 p 435.776.3499 p 435.658.9200

Hospital Affiliation - University of Utah Hospital448 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Pestotnik, Michael L MD UUHC Redstone Center Braun, Daniel S LCSW Cross, Hannah LCSW University of Utah Health 1743 W Redstone Ctr Wasatch Pediatrics - Cedar Psychiatry 1743 Redstone Ctr Dr Park City UT. 84098 Summit 1526 Ute Blvd Ste 115 p 435.658.9200 750 Round Valley Dr Ste 106 Park City UT. 84098 Ste 102 Park City UT. 84098 p 435.658.9200 Mental Health Park City UT. 84060 p 801.369.8989 Allred, Courtney R LCSW p 435.655.0926 Hospital Affiliation Peaceful Solutions Eldredge, David G LCSW - University of Utah Hospital 2700 Homestead Rd Buehner, Paul W CSW University of Utah Health Ste 151 UNI Park City Outpatient 1743 Redstone Ctr Dr Scott, Kim E MD Park City UT. 84098 Clinic - Adult Ste 115 1790 Sun Peak Dr p 801.651.3907 1820 Sidewinder Dr Park City UT. 84098 Ste A101 Ste 100 p 435.658.9200 Park City UT. 84098 Hospital Affiliation Park City UT. 84060 p 435.645.0800 - University of Utah Hospital p 801.585.1212 Hospital Affiliation - Primary Childrens Hospital Hospital Affiliation Beiler, Lorita L LCSW UNI Summit Clinic - Child - Park City Hospital University Of Utah Health 1820 Sidewinder Dr Elgie, Brigette D LMFT 110 N Main St Park City UT. 84060 Counseling Center of Park UUHC Redstone Center Kamas UT. 84036 p 801.585.1212 City 1743 W Redstone Ctr p 801.585.1212 1283 Deer Valley Dr Park City UT. 84098 *Burrow, David N MD Park City UT. 84068 p 435.658.9200 1820 Sidewinder Dr Sevier Valley Clinic p 303.981.9685 Ste 100 2720 Homestead Rd Wilson, Brent D MD Park City UT. 84060 Ste 100 Ellis, John LMFT University of Utah Health p 801.585.1212 Park City UT. 84098 Cedar Psychiatry 1743 Redstone Ctr Dr p 435.940.9400 1526 Ute Blvd Ste 115 1820 Sidewinder Dr Ste 106 Park City UT. 84098 Park City UT. 84060 Park City Psychiatry and Park City UT. 84098 p 435.658.9200 p 801.585.1212 Counseling p 801.369.8989 750 Round Valley Dr Hospital Affiliation 85 N 50 E Ste 101 Embree, Lindsay M PhD - University of Utah Hospital Coalville UT. 84017 Park City UT. 84060 University of Utah Health p 801.585.1212 p 435.200.6890 1743 Redstone Ctr Dr Laboratory Park City UT. 84098 Dominion Diagnostics Bennett, Marlo LMFT Park City Clinic-Round p 801.585.6387 Phone Number Only Marlo Bennett, LMFT Valley p 877.734.9600 1901 Prospector Ave 750 Round Valley Dr Hospital Affiliation Ste 22 Park City UT. 84060 - University of Utah Hospital LabCorp of America Park City UT. 84060 p 435.649.7680 Holdings p 435.901.3218 Evangelista, Manuel N Phone Number Only Hospital Affiliation LCSW p 888.522.2677 Bingham, Amy A LCMHC - Park City Hospital Valley Behavioral Health University Of Utah Health 1753 Sidewinder Dr Long Term Acute Care Facility 1820 Sidewinder Dr CG Mental Health Park City UT. 84060 *Hester, Cory NP Ste 100 2700 Homestead Rd p 888.949.4864 Int Heart Cardiology-PKMC Park City UT. 84060 Ste 210-A 900 Round Valley p 801.585.1212 Park City UT. 84098 Fehlberg, Amy L PhD Ste 200 p 307.254.1818 1790 Sun Peak Dr Park City UT. 84060 1820 Sidewinder Dr Ste B105 p 801.507.3500 Park City UT. 84060 3100 W Pinebrook Rd Park City UT. 84098 p 801.585.1212 Ste 1250-B p 435.901.0759 Hospital Affiliation Park City UT. 84098 - Park City Hospital Bingham, Tamara LCMHC p 307.254.1818 Footer, Jeremy D LCSW Counseling Center of Park UNI Park City Outpatient Maternal And Fetal Medicine City Cain, Season LCSW Clinic - Adult Daniels, Marianne CMHC 1283 Deer Valley Dr 3040 Homestead Rd 1820 Sidewinder Dr Cedar Psychiatry Park City UT. 84068 Park City UT. 84098 Ste 100 1526 Ute Blvd p 303.981.9685 p 310.351.6158 Park City UT. 84060 Ste 106 p 801.585.1212 Park City UT. 84098 Bradish, Nancy LCSW Camp, Claire PSYD p 801.369.8989 1700 Park Ave Counseling Center of Park University of Utah Health Park City UT. 84068 City 1820 Sidewinder Dr p 435.649.2430 1283 Deer Valley Dr Park City UT. 84060 Park City UT. 84068 p 801.585.1212 p 303.981.9685

449 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Franz, Megan A CMHC Harmon, Kevin C LCSW CG Mental Health Nelson, Roxi LCSW University Of Utah Health Valley Behavioral Health 3100 W Pinebrook Rd 3100 Pinebrook Rd 110 N Main St 1753 Sidewinder Dr Ste 1250-B Ste 2250 Kamas UT. 84036 Park City UT. 84060 Park City UT. 84098 Park City UT. 84098 p 801.585.1212 p 888.949.4864 p 307.254.1818 p 435.615.7600

1820 Sidewinder Dr Harter, Leah M LPC Jackson, Amanda LCSW Page, Allison J NP Ste 100 Counseling Center of Park Cedar Psychiatry Trailtalk Park City UT. 84060 City 1526 Ute Blvd 1750 Sun Peak Dr p 801.585.1212 1283 Deer Valley Dr Ste 106 Ste 175 Park City UT. 84068 Park City UT. 84098 Park City UT. 84098 1820 Sidewinder Dr p 303.981.9685 p 801.369.8989 p 435.513.2715 Park City UT. 84060 p 801.585.1212 Higgins, Michael P LCSW Kleinschmit, Kristi K MD Paletta, Caroline S LPC University of Utah Health Wasatch Pediatrics - Pathways of Healing LLC 85 N 50 E 1743 Redstone Ctr Dr Summit 50 Shadow Ridge Pl Coalville UT. 84017 Ste 115 750 Round Valley Dr Park City UT. 84060 p 801.585.1212 Park City UT. 84098 Ste 102 p 435.659.0761 p 435.658.9200 Park City UT. 84060 Freeman, Brenner L MD p 435.655.0926 *Park City Psychiatry and University of Utah Health Hill, Scott F PhD *Counseling 1743 Redstone Ctr Dr Counseling Center of Park Lopez, Marta LCSW 750 Round Valley Dr Park City UT. 84098 City University of Utah Health Park City UT. 84060 p 801.581.7951 1283 Deer Valley Dr 1743 Redstone Ctr Dr p 435.200.6890 Park City UT. 84068 Ste 115 University Of Utah Health p 303.981.9685 Park City UT. 84098 Peay, T Roger PhD 1820 Sidewinder Dr p 435.658.9200 T Roger Peay Therapy Ste 100 Hough, Amanda LCSW 10-B Pinebrook Rd Park City UT. 84060 University Of Utah Health Hospital Affiliation Park City UT. 84098 p 801.585.1212 1820 Sidewinder Dr - University of Utah Hospital p 801.893.9687 Ste 100 Hospital Affiliation Park City UT. 84060 Margolis, Amber LCSW Peters, Donn W PSYD - University of Utah Hospital p 801.585.1212 University of Utah Health Park City Psychotherapy 1743 Redstone Ctr Dr 2720 Homestead Rd Frey, Cristie L LCSW 1820 Sidewinder Dr Ste 115 Ste 30 University of Utah Health Park City UT. 84060 Park City UT. 84098 Park City UT. 84098 1820 Sidewinder Dr p 801.585.1212 p 435.658.9200 p 435.649.6838 Ste 100 Park City UT. 84060 Hove, Scott D LCSW Merkley, Tricia Phd Porschatis, Amber M LCSW p 801.585.1212 CG Mental Health University Of Utah Health University of Utah Health 3100 W Pinebrook Rd 1743 Redstone Ctr Dr 1743 Redstone Ctr Dr 1820 Sidewinder Dr Ste 1250-B Park City UT. 84098 Ste 115 Park City UT. 84060 Park City UT. 84098 p 801.585.6387 Park City UT. 84098 p 801.585.1212 p 307.254.1818 p 435.658.9200 Hospital Affiliation Gauger, Christopher D Howell, Karlina K LMFT - University of Utah Hospital Rehn, Phyllis A LPC LCSW Karlina K Howell LMFT Counseling Center of Park CG Mental Health 700 Bitner Rd Miranda, Michelle PhD City 2700 Homestead Rd Ste 145 University of Utah Health 1283 Deer Valley Dr Ste 210-A Park City UT. 84098 1743 Redstone Ctr Dr Park City UT. 84068 Park City UT. 84098 p 435.565.1019 Ste 115 p 303.981.9685 p 307.254.1818 Park City UT. 84098 University Of Utah Health p 801.585.6387 Robison, Reid J MD Gibbs, Paula K MD 1820 Sidewinder Dr Cedar Psychiatry University of Utah Health Ste 100 Mullaney, Edward LCSW 1526 Ute Blvd 1743 Redstone Ctr Dr Park City UT. 84060 University of Utah Health Ste 106 Ste 115 p 801.585.1212 1743 Redstone Ctr Dr Park City UT. 84098 Park City UT. 84098 Ste 115 p 801.369.8989 p 801.581.7951 1820 Sidewinder Dr Park City UT. 84098 Park City UT. 84060 p 435.658.9200 Hospital Affiliation Hospital Affiliation p 801.585.1212 - Mountain View Hospital - University of Utah Hospital Nelson, Michelle M LCSW (UT) University of Utah Health - Utah Valley Hospital 1743 Redstone Ctr Dr Ste 115 Park City UT. 84098 p 435.658.9200

Hospital Affiliation - University of Utah Hospital 450 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Smart, Christine A LCSW Whipps, Paige CSW Gibson, Summer B MD Kotter, David J APRN Mountain Family Health Peaceful Solutions University of Utah Health Neurosurgical Associates 2720 Homestead Rd Counseling, LLC 1743 Redstone Ctr Dr LLC Ste 100 2700 Homestead Rd Ste 115 5171 Cottonwood St Park City UT. 84098 Ste 151 Park City UT. 84098 Ste 950 p 435.940.9400 Park City UT. 84098 p 435.658.9200 Park City UT. 84060 p 801.651.3907 p 801.507.9555 Park City Clinic-Round Hospital Affiliation Valley Wilkison, Pamela C PhD - University of Utah Hospital Hospital Affiliation 750 Round Valley Dr Pamela C Wilkison PhD - Jordan Valley Medical Park City UT. 84060 2700 Homestead Rd Singleton, John R MD Center p 435.649.7680 Ste 40 University of Utah Health - St Marks Hospital Park City UT. 84098 1743 Redstone Ctr Dr Sutton, Nancy M LMFT p 435.901.4307 Ste 115 Passey, Lori E APRN Harmony Family Therapy Park City UT. 84098 Neurosurgical Associates 2720 Homestead Rd Winterton, Julia L CMHC p 435.658.9200 LLC Ste 19 Counseling Center of Park 900 Round Valley Dr Park City UT. 84098 City Hospital Affiliation Ste 100 p 435.513.5708 1283 Deer Valley Dr - University of Utah Hospital Park City UT. 84060 Park City UT. 84068 p 801.507.9555 Tan, Margaret LPC p 435.671.6552 *Walker, Kevin A MD 1760 Prospector Ave 2nd Park City Sleep Disorders Hospital Affiliation Floor Woodard, Jeness L LCSW Clinic - St Marks Hospital Park City UT. 84060 University of Utah Health 750 Round Valley Dr p 435.513.4799 1743 Redstone Ctr Dr Ste 101A Rich, Charles C MD Ste 115 Park City UT. 84060 Neurosurgical Associates Tate, David F PhD Park City UT. 84098 p 435.658.6621 LLC University Of Utah Health p 435.658.9200 900 Round Valley Dr 1743 Redstone Ctr Dr Neuropsychology Ste 100 Park City UT. 84098 Nephrology Embree, Lindsay M PhD Park City UT. 84060 p 801.585.6387 Bjordahl, Terrence S MD University of Utah Health p 801.507.9555 University of Utah Health 1743 Redstone Ctr Dr Taylor, John R PhD 1743 Redstone Ctr Dr Park City UT. 84098 Hospital Affiliation 136 Heber Ave Ste 115 p 801.585.6387 - Park City Hospital Ste 204 Park City UT. 84098 Park City UT. 84068 p 435.658.9262 Hospital Affiliation Yonemura, Kenneth S MD p 435.647.2911 - University of Utah Hospital NeuroSpine Institute Hospital Affiliation 1820 Sidewinder Dr Thayer, Stephen PhD - St Marks Hospital Merkley, Tricia Phd Ste 100 Cedar Psychiatry University Of Utah Health Park City UT. 84060 1526 Ute Blvd Neurology 1743 Redstone Ctr Dr p 435.200.1196 Ste 106 Bromberg, Mark B MD,PhD Park City UT. 84098 Park City UT. 84098 University of Utah Health p 801.585.6387 Hospital Affiliation p 801.369.8989 1743 Redstone Ctr Dr - Lakeview Hospital Ste 115 Hospital Affiliation Valley Behavioral Health Park City UT. 84098 - University of Utah Hospital Obstetrics And Gynecology Phone Number Only p 435.658.9200 *Clark, C Jeremy DO Park City UT. 84098 Miranda, Michelle PhD Park City Specialty p 888.949.4864 Hospital Affiliation University of Utah Health 900 Round Valley Dr - University of Utah Hospital 1743 Redstone Ctr Dr Ste 200 Vezie, Linda LCSW Ste 115 Park City UT. 84060 University of Utah Health Chebeleu, Lia Ana MD Park City UT. 84098 p 435.658.7400 1743 Redstone Ctr Dr Vista Neurology p 801.585.6387 Ste 115 Specialists Hospital Affiliation Park City UT. 84098 1122 Center Dr Neurosurgery - Park City Hospital p 435.658.9200 Ste D-350 Dailey, Andrew T MD Park City UT. 84098 University of Utah Health *Homewood, Virginia J MD Walter, Samuel Grey LCSW p 435.714.7277 1743 Redstone Ctr Dr Park City Specialty Insight Psychotherapy Ste 115 900 Round Valley Dr 1912 Sidewinder Dr Hospital Affiliation Park City UT. 84098 Ste 200 Ste 201 - St Marks Hospital p 435.658.9200 Park City UT. 84060 Park City UT. 84060 p 435.658.7400 p 435.850.1484 Hospital Affiliation - University of Utah Hospital Hospital Affiliation - Jordan Valley Medical Center West Valley Campus

451 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Nisimblat Bodnar, Tania P DeTemple, Kathrine M OT Fassio, John B MD Poulter, William C OD *MD University of Utah Health Mountain Valley Eye Vision Source at Jordan Park City Specialty 1850 Sidewinder Dr Institute Landing 900 Round Valley Dr Park City UT. 84060 2700 W Homestead Rd 6584 N Creekside Ln Ste 200 p 435.645.9095 Ste 30 Ste 150 Park City UT. 84060 Park City UT. 84098 Park City UT. 84098 p 435.658.7400 Hospital Affiliation p 435.658.3090 p 435.649.5200 - University of Utah Hospital Hospital Affiliation Hospital Affiliation Robertson, Jill L OD - Park City Hospital Keizer, Lana OT - Evanston Regional Hospital Mountain Valley Eye University of Utah Health Institute *Paas, John T MD 1850 Sidewinder Dr Larochelle, Marissa MD 2700 W Homestead Rd Park City Specialty Park City UT. 84060 University of Utah Health Ste 30 900 Round Valley Dr p 435.645.9095 1743 Redstone Ctr Dr Park City UT. 84098 Ste 200 Ste 115 p 435.615.0435 Park City UT. 84060 *Labree-Berg, Michele OT Park City UT. 84098 p 435.658.7400 Park City Hospital p 435.658.9200 Schubach, Colleen OD 900 Round Valley Dr University of Utah Health Planned Parenthood Park City UT. 84060 Hospital Affiliation 1743 Redstone Ctr Dr Association of Utah p 435.658.7000 - University of Utah Hospital Ste 115 1670 Bonanza Dr Park City UT. 84098 Park City UT. 84068 *Papi-Baker, Kathleen M OT Pettey, Jeff H MD p 435.658.9200 p 435.649.5989 Park City Hospital University of Utah Health 900 Round Valley Dr 1743 Redstone Ctr Dr UUHC Redstone Center Singer, Stephanie DO Park City UT. 84060 Ste 115 1743 W Redstone Ctr Park City Gynecology p 435.658.7000 Park City UT. 84098 Park City UT. 84098 1441 W Ute Blvd p 435.658.9200 p 435.658.9200 Ste 160 Ross, Kimberly M OT Park City UT. 84098 University of Utah Health Hospital Affiliation Orthopedic Surgery p 435.214.5335 1850 Sidewinder Dr - University of Utah Hospital Avery, Andrew H PA-C Park City UT. 84060 Rosenberg Cooley Metcalf Hospital Affiliation p 801.587.7109 Smith, Stacy R MD 900 Round Valley Dr - St Marks Hospital Mountain Valley Eye Ste 100 - Salt Lake Regional Medical Thompson, Robyn M OT Institute Park City UT. 84060 Center Roots Pediatric Therapy 2700 W Homestead Rd p 435.655.6600 4554 Forestdale Dr Unit Ste 30 UUHC Redstone Center E26 Park City UT. 84098 Hospital Affiliation 1743 W Redstone Ctr Park City UT. 84098 p 435.658.3090 - Park City Hospital Park City UT. 84098 p 435.400.4064 p 435.658.9200 Hospital Affiliation Beals, Timothy C MD Hospital Affiliation - St Marks Hospital Rosenberg Cooley Metcalf Weber, Tiffany K MD - Primary Childrens Hospital 900 Round Valley Dr University of Utah Health Wirostko, Barbara MD Ste 100 1743 Redstone Ctr Dr *Tiley, Donna M OT University of Utah Health Park City UT. 84060 Ste 115 Park City Hospital 1743 Redstone Ctr Dr p 435.655.6600 Park City UT. 84098 900 Round Valley Dr Ste 115 p 435.658.9200 Park City UT. 84060 Park City UT. 84098 Hospital Affiliation p 435.658.7000 p 435.658.9200 - University of Utah Hospital Hospital Affiliation - University of Utah Hospital *Williams, Megan B OT Hospital Affiliation Cooley, Vernon J MD Park City Hospital - University of Utah Hospital Rosenberg Cooley Metcalf Occupational Therapy 900 Round Valley Dr 900 Round Valley Dr Burman-Newby, Sara OT Park City UT. 84060 Optometry Ste 100 University of Utah Health p 435.658.7000 Coyle, Ryan OD Park City UT. 84060 1850 Sidewinder Dr University Of Utah Health p 435.655.6600 Park City UT. 84060 Ophthalmology 1743 Redstone Ctr Dr p 435.645.9095 Barlow, William R MD Ste 115 Hospital Affiliation University of Utah Health Park City UT. 84098 - Park City Hospital Hospital Affiliation 1743 Redstone Ctr Dr p 435.658.9200 - Heber Valley Hospital - University of Utah Hospital Ste 115 Park City UT. 84098 Hospital Affiliation Cooper, Andrew D MD Concentra Medical Centers p 435.658.9200 - University of Utah Hospital Comprehensive Orthopedics 2390 Redwood Rd & Sports Medicine Park West Valley City UT. 84419 Hospital Affiliation City p 888.997.2669 - University of Utah Hospital 2200 N Park Ave D100 Park City UT. 84060 p 801.533.2002

Hospital Affiliation - Salt Lake Regional Medical Center 452 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Davidson Orthopedics Gunter, Karen A PA Lind, Charles C MD Rosenberg, Thomas D MD 1122 Center Dr Davidson Orthopedics Rosenberg Cooley Metcalf Rosenberg Cooley Metcalf Ste D-350 1122 Center Dr 900 Round Valley Dr 900 Round Valley Dr Park City UT. 84098 Ste D-350 Ste 100 Ste 100 p 801.797.8000 Park City UT. 84098 Park City UT. 84060 Park City UT. 84060 p 801.797.8000 p 435.655.6600 p 435.655.6600 Davidson, Philip A MD Davidson Orthopedics Hatch, Mark D MD Hospital Affiliation Hospital Affiliation 1122 Center Dr Rosenberg Cooley Metcalf - Park City Hospital - Heber Valley Hospital Ste D-350 900 Round Valley Dr Park City UT. 84098 Ste 100 Magee, Trevor H MD Zipnick, Richard MD p 801.797.8000 Park City UT. 84060 Comprehensive Orthopedics Heiden Orthopedics p 435.655.6600 & Sports Medicine - Park 2200 Park Ave Bldg D Hospital Affiliation City Ste 100 - Salt Lake Regional Medical Heiden Orthopedics 2200 Park Ave Park City UT. 84060 Center 2200 Park Ave Bldg D Ste D100 p 435.615.8822 - Park City Hospital Ste 100 Park City UT. 84060 Park City UT. 84060 p 801.323.9546 Hospital Affiliation Davis, Garrett C MD p 435.615.8822 - St Marks Hospital Rosenberg Cooley Metcalf Hospital Affiliation - Salt Lake Regional Medical 900 Round Valley Dr Heiden, Eric MD - Salt Lake Regional Medical Center Ste 100 Heiden Orthopedics Center Park City UT. 84060 2200 Park Ave Bldg D Pain Management p 435.655.6600 Ste 100 Metcalf, Michael H MD *Baker, Elizabeth PhD Park City UT. 84060 Rosenberg Cooley Metcalf Park City Specialty Hospital Affiliation p 435.615.8822 900 Round Valley Dr 900 Round Valley Dr - Park City Hospital Ste 100 Ste 200 Hospital Affiliation Park City UT. 84060 Park City UT. 84060 Dean, Anna E PA - Park City Hospital p 435.655.6600 p 435.658.7400 Rosenberg Cooley Metcalf 900 Round Valley Dr Heiden, Karen D MD Hospital Affiliation Byrne, Ashleigh MD Ste 100 Heiden Orthopedics - Heber Valley Hospital Granger Medical Park City Park City UT. 84060 2200 Park Ave Bldg D 1600 Snow Creek Dr p 435.655.6600 Ste 100 Olson, Patrick R MD Ste B Park City UT. 84060 Rosenberg Cooley Metcalf Park City UT. 84060 Hospital Affiliation p 435.615.8822 900 Round Valley Dr p 801.352.5900 - Park City Hospital Ste 100 - University of Utah Hospital Hospital Affiliation Park City UT. 84060 Hospital Affiliation - Park City Hospital p 435.655.6600 - Jordan Valley Medical Dupaix, Charles F PA-C Center Rosenberg Cooley Metcalf Johnson, Troy S PA-C Hospital Affiliation 900 Round Valley Dr Rosenberg Cooley Metcalf - Park City Hospital *Chesley, Garrett G PhD Ste 100 900 Round Valley Dr Park City Specialty Park City UT. 84060 Ste 100 Pearmain, Steven B PA 900 Round Valley Dr p 435.655.6600 Park City UT. 84060 Rosenberg Cooley Metcalf Ste 200 p 435.655.6600 900 Round Valley Dr Park City UT. 84060 Fine, Alexandra PA-C Ste 100 p 435.658.7400 Rosenberg Cooley Metcalf Klatt, Richard S PA-C Park City UT. 84060 900 Round Valley Dr Rosenberg Cooley Metcalf p 435.655.6600 Despain, Devin DO Ste 100 900 Round Valley Dr Interventional Spine & Park City UT. 84060 Ste 100 Hospital Affiliation Pain Management p 435.655.6600 Park City UT. 84060 - Park City Hospital 900 Round Valley Dr p 435.655.6600 Ste 120 Gibbs, Daniel B MD Ray, Christine H PA-C Park City UT. 84060 Heiden Orthopedics Lawrence, Brandon D MD Rosenberg Cooley Metcalf p 801.262.7246 2200 Park Ave Bldg D University of Utah Health 900 Round Valley Dr Ste 100 1743 Redstone Ctr Dr Ste 100 Freeman, Eric MD Park City UT. 84060 Ste 115 Park City UT. 84060 Vista Neurology p 435.615.8822 Park City UT. 84098 p 435.655.6600 Specialists p 435.658.9200 1122 Center Dr Hospital Affiliation Remington, Travis M PA-C Ste D-350 - St Marks Hospital Hospital Affiliation Rosenberg Cooley Metcalf Park City UT. 84098 - Lone Peak Hospital - University of Utah Hospital 900 Round Valley Dr p 435.714.7277 Ste 100 Park City UT. 84060 p 435.655.6600

Hospital Affiliation - Park City Hospital 453 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Frieden, Derek L MD Obray, Jon B MD Pediatrics Ostler, Kathy M MD Vista Neurology Vista Neurology Delgado, Alison MD Wasatch Pediatrics - Specialists Specialists Wasatch Pediatrics - Summit 1122 Center Dr 1122 Center Dr Summit 750 Round Valley Dr Ste D-350 Ste D-350 750 Round Valley Dr Ste 102 Park City UT. 84098 Park City UT. 84098 Ste 102 Park City UT. 84060 p 435.714.7277 p 435.714.7277 Park City UT. 84060 p 435.655.0926 p 435.655.0926 Hospital Affiliation Hospital Affiliation Hospital Affiliation - St George Regional Hospital - St George Regional Hospital Hospital Affiliation - Primary Childrens Hospital - Primary Childrens Hospital Garg, Vikas MD Obray, Rick W MD Parson, Karyn MD Interventional Spine & Vista Neurology Gallagher Pediatrics Park Wasatch Pediatrics - Pain Management Specialists City Summit 900 Round Valley Dr 1122 Center Dr 1154 Center Dr 750 Round Valley Dr Ste 120 Ste D-350 Ste D240 Ste 102 Park City UT. 84060 Park City UT. 84098 Park City UT. 84098 Park City UT. 84060 p 801.262.7246 p 435.656.2424 p 435.602.0187 p 435.655.0926

Hospital Affiliation Hospital Affiliation Gallagher, Eileen MD Hospital Affiliation - Lone Peak Hospital - St George Regional Hospital Gallagher Pediatrics Park - Primary Childrens Hospital - Evanston Regional Hospital City - Park City Hospital - Brigham City Community Talbott, Andrew P MD 1154 Center Dr Hospital Vista Neurology Ste D240 Roots Pediatric Therapy Specialists Park City UT. 84098 4554 N Forestdale Dr Hoelzer, Bryan MD 1122 Center Dr p 435.602.0187 Ste E-26 Vista Neurology Ste D-350 Park City UT. 84098 Specialists Park City UT. 84098 Hospital Affiliation p 907.744.3978 1122 Center Dr p 435.714.7277 - Park City Hospital Ste D-350 Schaffer, Monica M MD Park City UT. 84098 Pediatric Cardiology Kleinschmit, Kristi K MD Wasatch Pediatrics - p 435.714.7277 Su, Jason T DO Wasatch Pediatrics - Summit Peak Pediatric Specialists Summit 750 Round Valley Dr Minori, Joshua J DO 750 Round Valley Dr 750 Round Valley Dr Ste 102 Interventional Spine & Ste 102 Ste 102 Park City UT. 84060 Pain Management Park City UT. 84060 Park City UT. 84060 p 435.655.0926 900 Round Valley Dr p 385.477.6800 p 435.655.0926 Ste 120 Hospital Affiliation Park City UT. 84060 Hospital Affiliation LaMere, Richard G MD - Primary Childrens Hospital p 801.262.7246 - Ogden Regional Medical University of Utah Health Center 1743 Redstone Ctr Dr Terry, Lena S MD Park City Specialty Ste 115 Wasatch Pediatrics - 900 Round Valley Dr Pediatric Neurosurgery Park City UT. 84098 Summit Ste 200 Yonemura, Kenneth S MD p 435.658.9200 750 Round Valley Dr Park City UT. 84060 NeuroSpine Institute Ste 102 p 435.658.7400 1820 Sidewinder Dr Hospital Affiliation Park City UT. 84060 Ste 100 - University of Utah Hospital p 435.655.0926 Hospital Affiliation Park City UT. 84060 - Timpanogos Regional Hospital p 435.200.1196 Lavender, Katherine R MD Hospital Affiliation - Utah Valley Hospital Wasatch Pediatrics - - Primary Childrens Hospital Hospital Affiliation Summit Mosley, Joseph J DO - Lakeview Hospital 750 Round Valley Dr 750 Round Valley Dr Vista Neurology Ste 102 Ste 102 Specialists Pediatric Ophthalmology Park City UT. 84060 Park City UT. 84060 1122 Center Dr Marx, Douglas P MD p 435.655.0926 p 435.655.0926 Ste D-350 University of Utah Health Park City UT. 84098 1743 Redstone Ctr Dr Hospital Affiliation Webster, Leslie W MD p 435.714.7277 Ste 115 - Primary Childrens Hospital Wasatch Pediatrics - Park City UT. 84098 Summit Hospital Affiliation p 435.658.9200 Mailey, Katherine MD 750 Round Valley Dr - Timpanogos Regional Hospital Wasatch Pediatrics - Ste 102 - Utah Valley Hospital Pediatric Psychiatry Summit Park City UT. 84060 Dwyer, Luke M MD 750 Round Valley Dr p 435.655.0926 University Of Utah Health Ste 102 1820 Sidewinder Dr Park City UT. 84060 Hospital Affiliation Ste 100 p 435.655.0926 - Primary Childrens Hospital Park City UT. 84060 p 801.585.1212 Hospital Affiliation - Primary Childrens Hospital Hospital Affiliation - Park City Hospital - University of Utah Hospital 454 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Winn, Robert T MD Physical Therapy Concentra Medical Centers Ivie, Dan S MPT Park City Clinic-Round Adams, Shaun B MSPT 2390 Redwood Rd Wasatch Physical Therapy Valley MountainTop Physical West Valley City UT. 84419 and Sports Medicine at 750 Round Valley Dr Therapy and Wellness p 888.997.2669 Park City Park City UT. 84060 Center Inc 597 Pkwy Dr Unit C p 435.649.7680 1794 Olympic Pkwy *Cooke, Jessica DPT Park City UT. 84098 Ste 140 Physical Therapy p 435.649.7335 Hospital Affiliation Park City UT. 84098 900 Round Valley Dr - Park City Hospital p 435.575.0345 Park City UT. 84060 Johnson, Kathryn A DPT p 435.658.7000 University of Utah Health Witt, Mark T MD *Beaver, Kristina C DPT 1850 Sidewinder Dr Wasatch Pediatrics - Physical Therapy *DeFord, Heather J PT Park City UT. 84060 Summit 900 Round Valley Dr Park City Hospital p 435.645.9095 750 Round Valley Dr Park City UT. 84060 900 Round Valley Dr Ste 102 p 435.658.7000 Park City UT. 84060 Hospital Affiliation Park City UT. 84060 p 435.658.7000 - University of Utah Hospital p 435.655.0926 Bochnowski, Kathleen S PT MountainTop Physical Emerson, Mary L PT Judd, Brandon DPT Hospital Affiliation Therapy and Wellness Roots Pediatric Therapy Wasatch Physical Therapy - Park City Hospital Center Inc LLC and Sports Medicine at - Primary Childrens Hospital 1794 Olympic Pkwy 4554 Forestdale Dr Unit Park City Ste 140 E26 597 Pkwy Dr Unit C Physical Medicine And Rehabilitation Park City UT. 84098 Park City UT. 84098 Park City UT. 84098 Albright, Austin L MD p 435.575.0345 p 435.400.4064 p 435.649.7335 Davidson Orthopedics 1122 Center Dr *Brady, Casey J DPT Fagin, Stephanie L PT *Kase, Barbara J PT Ste D-350 Park City Hospital University of Utah Health Park City Hospital Park City UT. 84098 900 Round Valley Dr 1850 Sidewinder Dr 900 Round Valley Dr p 801.797.8000 Park City UT. 84060 Park City UT. 84060 Park City UT. 84060 p 435.658.7000 p 801.587.7109 p 435.658.7000 Minori, Joshua J DO Interventional Spine & Brenkmann, Joshua R PT Glad, Jaclyn PT Kimball, Jennifer L PT Pain Management University Of Utah Health University of Utah Health University of Utah Health 900 Round Valley Dr 1850 Sidewinder Dr 1850 Sidewinder Dr 1850 Sidewinder Dr Ste 120 Park City UT. 84060 Park City UT. 84060 Park City UT. 84060 Park City UT. 84060 p 435.645.9095 p 435.645.9095 p 435.645.9095 p 801.262.7246 Hospital Affiliation Hospital Affiliation Hospital Affiliation Park City Specialty - University of Utah Hospital - University of Utah Hospital - University of Utah Hospital 900 Round Valley Dr Ste 200 Brooks, Carly DPT Griffin, Ryan PT Kosturik, Andrew B PT Park City UT. 84060 University of Utah Health University Of Utah Health University of Utah Health p 435.658.7400 1850 Sidewinder Dr 1850 Sidewinder Dr 1850 Sidewinder Dr Park City UT. 84060 Park City UT. 84060 Park City UT. 84060 Hospital Affiliation p 435.645.9095 p 435.645.9095 p 801.587.7109 - Timpanogos Regional Hospital - Utah Valley Hospital Hospital Affiliation Hall, Preston B DPT Hospital Affiliation - Primary Childrens Hospital MountainTop Physical - University of Utah Hospital *Taubin, Rhonda G MD Therapy and Wellness Park City Specialty *Butts, Erin R PT Center Inc Krammen, Matthew DPT 900 Round Valley Dr Park City Hospital 1794 Olympic Pkwy Wasatch Physical Therapy Ste 200 900 Round Valley Dr Ste 140 and Sports Medicine at Park City UT. 84060 Park City UT. 84060 Park City UT. 84098 Park City p 435.658.7400 p 435.658.7000 p 435.575.0345 597 Pkwy Dr Unit C Park City UT. 84098 Hospital Affiliation Cervantez, Robert D PT *Hatch, S M PT p 435.649.7335 - Park City Hospital University of Utah Health Park City Hospital 1850 Sidewinder Dr 900 Round Valley Dr Lanenga, Amber L PT Willick, Stuart E MD Park City UT. 84060 Park City UT. 84060 University of Utah Health University of Utah Health p 801.587.7109 p 435.658.7000 1850 Sidewinder Dr 1743 Redstone Ctr Dr Park City UT. 84060 Ste 115 Child, Bryan F PT Horner, Byron H MSPT p 435.645.9095 Park City UT. 84098 Precision EMG PLLC Summit Physical Therapy p 435.658.9262 2200 Park Ave Bldg D 228 W State Rd 248 Hospital Affiliation Ste 100 Kamas UT. 84036 - University of Utah Hospital Hospital Affiliation Park City UT. 84060 p 435.783.2659 - Salt Lake Regional Medical p 801.725.2380 Center - University of Utah Hospital 455 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Law, Mason W PT Sadoff, Zachary A PT *Tiley, Donna M OT Griner, Devan MD Park City Hospital University of Utah Health Park City Hospital Peak Plastic Surgery 900 Round Valley Dr 1850 Sidewinder Dr 900 Round Valley Dr 1441 Ute Blvd Park City UT. 84060 Park City UT. 84060 Park City UT. 84060 Ste 220 p 435.658.7000 p 801.587.7109 p 435.658.7000 Park City UT. 84098 p 435.647.5911 Maki, Jennifer DPT Hospital Affiliation Voss, Ryan T DPT Wasatch Physical Therapy - University of Utah Hospital MountainTop Physical Guilfoyle, Gregg MD and Sports Medicine at Therapy and Wellness Peak Plastic Surgery Park City Saenz, Erik DPT Center Inc 1441 Ute Blvd 597 Pkwy Dr Unit C University of Utah Health 1794 Olympic Pkwy Ste 220 Park City UT. 84098 1850 Sidewinder Dr Ste 140 Park City UT. 84098 p 435.649.7335 Park City UT. 84060 Park City UT. 84098 p 801.702.9191 p 801.587.7109 p 435.575.0345 Mann, Janna DPT Teasley, David G MD University of Utah Health Sauter, Kendall C PT Wade, Rodney E MPT Teasley Plastic Surgery 1850 Sidewinder Dr University of Utah Health Toole and Associates 1441 W Ute Blvd Park City UT. 84060 1850 Sidewinder Dr Physical Therapy and Ste 220 p 801.587.7109 Park City UT. 84060 Wellness Park City UT. 84098 p 435.645.9095 142 S 50 E p 435.647.5911 McCluskey, James R PT Coalville UT. 84017 University of Utah Health Savarise, Yvonne C DPT p 435.336.9355 Hospital Affiliation 1850 Sidewinder Dr University of Utah Health - Park City Hospital Park City UT. 84060 1850 Sidewinder Dr Wiegand, Jennifer M PT p 801.587.7109 Park City UT. 84060 University of Utah Health Podiatry p 435.645.9095 1850 Sidewinder Dr Harper, Spence D DPM McCooey, Stacy DPT Park City UT. 84060 Dr Spence D Harper MountainTop Physical Schiltz, Adam PT p 435.645.9095 1122 Center Dr Therapy and Wellness University of Utah Health Ste D-350 Center Inc 1850 Sidewinder Dr Hospital Affiliation Park City UT. 84098 1794 Olympic Pkwy Park City UT. 84060 - University of Utah Hospital p 801.274.9062 Ste 140 p 435.645.9095 Park City UT. 84098 Wilks, James M PT Hospital Affiliation p 435.575.0345 Hospital Affiliation University of Utah Health - Heber Valley Hospital - University of Utah Hospital 1850 Sidewinder Dr - St Marks Hospital Miller, Byron C PT Park City UT. 84060 - Salt Lake Regional Medical University of Utah Health Smith, Michelle N DPT p 435.645.9095 Center 1850 Sidewinder Dr MountainTop Physical Park City UT. 84060 Therapy and Wellness Hospital Affiliation Jaramillo, David H DPM p 435.645.9095 Center Inc - University of Utah Hospital Precision Foot and Ankle 1794 Olympic Pkwy Specialists Hospital Affiliation Ste 140 Wixom, Steven M PT 1678 Bonanza Dr - University of Utah Hospital Park City UT. 84098 University of Utah Health Park City UT. 84060 p 435.575.0345 1850 Sidewinder Dr p 801.377.5649 Money, Katelyn M PT Park City UT. 84060 University of Utah Health Stotts, Paige OTR p 435.645.9095 Hospital Affiliation 1850 Sidewinder Dr University of Utah Health - Timpanogos Regional Hospital Park City UT. 84060 1850 Sidewinder Dr *Ziaks, Lauren J DPT p 435.645.9095 Park City UT. 84060 Park City Hospital Jaramillo, Todd MD p 435.645.9095 900 Round Valley Dr Precision Foot and Ankle Hospital Affiliation Park City UT. 84060 Specialists - University of Utah Hospital Sueoka, Stephanie S PT p 435.658.7000 1678 Bonanza Dr University of Utah Health Park City UT. 84060 *Randell, Matthew E DPT 1850 Sidewinder Dr Plastic Surgery p 801.377.5649 Park City Medical Center Park City UT. 84060 Bennett, John R MD Physical Therapy p 435.645.9095 Ear, Nose & Throat Center Lister, Douglas S DPM 900 Round Valley Dr of Utah 2720 Homestead Rd Park City UT. 84060 Hospital Affiliation 1820 Sidewinder Dr Ste 50 p 435.658.7000 - University of Utah Hospital Ste 110 Park City UT. 84098 Park City UT. 84060 p 435.604.0449 Ross, Kimberly M OT *Telian, Molly DPT p 435.649.4106 University of Utah Health Physical Therapy Hospital Affiliation 1850 Sidewinder Dr 900 Round Valley Dr Hospital Affiliation - Heber Valley Hospital Park City UT. 84060 Park City UT. 84060 - Salt Lake Regional Medical p 801.587.7109 p 435.658.7000 Center

Hospital Affiliation - Heber Valley Hospital 456 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. McPhie, Jared D DPM University Of Utah Health Fehlberg, Amy L PhD Reproductive Endocrinology Utah Podiatry Group PC 1820 Sidewinder Dr 1790 Sun Peak Dr UUHC Redstone Center 900 Round Valley Dr Ste 100 Ste B105 1743 W Redstone Ctr Ste 120 Park City UT. 84060 Park City UT. 84098 Park City UT. 84098 Park City UT. 84060 p 801.585.1212 p 435.901.0759 p 435.658.9200 p 801.373.2499 Hospital Affiliation Hill, Scott F PhD Sleep Disorders Center Hospital Affiliation - University of Utah Hospital Counseling Center of Park *Park City Sleep Disorders - St Marks Hospital City *Clinic - Evanston Regional Hospital Gibbs, Paula K MD 1283 Deer Valley Dr 900 Round Valley Dr - Timpanogos Regional Hospital University of Utah Health Park City UT. 84068 Ste 200 1743 Redstone Ctr Dr p 303.981.9685 Park City UT. 84060 750 Round Valley Dr Ste 115 p 435.658.6621 Ste 101-A Park City UT. 84098 Peters, Donn W PSYD Park City UT. 84060 p 801.581.7951 Park City Psychotherapy Sleep Medicine p 801.274.9062 2720 Homestead Rd *King, Ann R MD Hospital Affiliation Ste 30 Park City Sleep Disorders Psychiatry - University of Utah Hospital Park City UT. 84098 Clinic *Burrow, David N MD p 435.649.6838 900 Round Valley Dr Sevier Valley Clinic Kleinschmit, Kristi K MD Ste 200 2720 Homestead Rd Wasatch Pediatrics - Tate, David F PhD Park City UT. 84060 Ste 100 Summit University Of Utah Health p 435.658.6621 Park City UT. 84098 750 Round Valley Dr 1743 Redstone Ctr Dr p 435.940.9400 Ste 102 Park City UT. 84098 Hospital Affiliation Park City UT. 84060 p 801.585.6387 - Park City Hospital Park City Psychiatry and p 435.655.0926 - Heber Valley Hospital Counseling Taylor, John R PhD 750 Round Valley Dr *Mitchell, Joshua M MD 136 Heber Ave *Mazzola, Robert L MD Ste 101 Park City Clinic-Round Ste 204 Park City Sleep Disorders Park City UT. 84060 Valley Park City UT. 84068 Clinic p 435.200.6890 750 Round Valley Dr p 435.647.2911 750 Round Valley Dr Park City UT. 84060 Ste 101A Park City Clinic-Round p 435.649.7680 Valley Behavioral Health Park City UT. 84060 Valley Phone Number Only p 435.658.6621 750 Round Valley Dr Hospital Affiliation Park City UT. 84098 Park City UT. 84060 - Park City Hospital p 888.949.4864 900 Round Valley Dr p 435.649.7680 Ste 200 Robison, Reid J MD Wilkison, Pamela C PhD Park City UT. 84060 Hospital Affiliation Cedar Psychiatry Pamela C Wilkison PhD p 435.658.6621 - Park City Hospital 1526 Ute Blvd 2700 Homestead Rd Ste 106 Ste 40 *Walker, Kevin A MD Cross, Hannah LCSW Park City UT. 84098 Park City UT. 84098 Park City Sleep Disorders Cedar Psychiatry p 801.369.8989 p 435.901.4307 Clinic 1526 Ute Blvd 750 Round Valley Dr Ste 106 Hospital Affiliation Pulmonology Ste 101A Park City UT. 84098 - Mountain View Hospital *Cloward, Tom V Park City UT. 84060 p 801.369.8989 (UT) Park City Sleep Disorders p 435.658.6621 - Utah Valley Hospital Clinic Dwyer, Luke M MD 750 Round Valley Dr Social Worker University Of Utah Health Thayer, Stephen PhD Ste 101A Allred, Courtney R LCSW 1820 Sidewinder Dr Cedar Psychiatry Park City UT. 84060 Peaceful Solutions Ste 100 1526 Ute Blvd p 435.658.6621 2700 Homestead Rd Park City UT. 84060 Ste 106 Ste 151 p 801.585.1212 Park City UT. 84098 Hospital Affiliation Park City UT. 84098 p 801.369.8989 - Sevier Valley Hospital p 801.651.3907 Hospital Affiliation - University of Utah Hospital Psychology *Mazzola, Robert L MD Hospital Affiliation Camp, Claire PSYD Park City Sleep Disorders - University of Utah Hospital Freeman, Brenner L MD Counseling Center of Park Clinic University of Utah Health City 750 Round Valley Dr Beiler, Lorita L LCSW 1743 Redstone Ctr Dr 1283 Deer Valley Dr Ste 101A University Of Utah Health Park City UT. 84098 Park City UT. 84068 Park City UT. 84060 110 N Main St p 801.581.7951 p 303.981.9685 p 435.658.6621 Kamas UT. 84036 p 801.585.1212

457 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 1820 Sidewinder Dr Evangelista, Manuel N 1820 Sidewinder Dr Nelson, Michelle M LCSW Ste 100 LCSW Park City UT. 84060 University of Utah Health Park City UT. 84060 Valley Behavioral Health p 801.585.1212 1743 Redstone Ctr Dr p 801.585.1212 1753 Sidewinder Dr Ste 115 Park City UT. 84060 Hove, Scott D LCSW Park City UT. 84098 1820 Sidewinder Dr p 888.949.4864 CG Mental Health p 435.658.9200 Park City UT. 84060 3100 W Pinebrook Rd p 801.585.1212 Ewanowski, Julia LCSW Ste 1250-B Hospital Affiliation University of Utah Health Park City UT. 84098 - University of Utah Hospital 85 N 50 E 1743 Redstone Ctr Dr p 307.254.1818 Coalville UT. 84017 Ste 115 Nelson, Roxi LCSW p 801.585.1212 Park City UT. 84098 Jackson, Amanda LCSW 3100 Pinebrook Rd p 435.658.9200 Cedar Psychiatry Ste 2250 Bradish, Nancy LCSW 1526 Ute Blvd Park City UT. 84098 1700 Park Ave Hospital Affiliation Ste 106 p 435.615.7600 Park City UT. 84068 - University of Utah Hospital Park City UT. 84098 p 435.649.2430 p 801.369.8989 Porschatis, Amber M LCSW Falk, Joshua S LCSW University of Utah Health Braun, Daniel S LCSW University of Utah Health Keshavarz, Yasaman LCSW 1743 Redstone Ctr Dr Wasatch Pediatrics - 1743 Redstone Ctr Dr University of Utah Health Ste 115 Summit Ste 115 1743 Redstone Ctr Dr Park City UT. 84098 750 Round Valley Dr Park City UT. 84098 Ste 115 p 435.658.9200 Ste 102 p 435.658.9200 Park City UT. 84098 Park City UT. 84060 p 435.658.9200 Torres-George, Christian p 435.655.0926 Frey, Cristie L LCSW P LCSW University of Utah Health Hospital Affiliation University of Utah Health Buehner, Paul W CSW 1820 Sidewinder Dr - University of Utah Hospital 1743 Redstone Ctr Dr UNI Park City Outpatient Ste 100 Ste 115 Clinic - Adult Park City UT. 84060 Lamb, Joseph LCSW Park City UT. 84098 1820 Sidewinder Dr p 801.585.1212 University of Utah Health p 435.658.9200 Ste 100 1743 Redstone Ctr Dr Park City UT. 84060 1820 Sidewinder Dr Ste 115 Hospital Affiliation p 801.585.1212 Park City UT. 84060 Park City UT. 84098 - University of Utah Hospital p 801.585.1212 p 435.658.9200 UNI Summit Clinic - Child Vezie, Linda LCSW 1820 Sidewinder Dr Gauger, Christopher D Hospital Affiliation University of Utah Health Park City UT. 84060 LCSW - University of Utah Hospital 1743 Redstone Ctr Dr p 801.585.1212 CG Mental Health Ste 115 2700 Homestead Rd Lopez, Marta LCSW Park City UT. 84098 Cain, Season LCSW Ste 210-A University of Utah Health p 435.658.9200 3040 Homestead Rd Park City UT. 84098 1743 Redstone Ctr Dr Park City UT. 84098 p 307.254.1818 Ste 115 Walter, Samuel Grey LCSW p 310.351.6158 Park City UT. 84098 Insight Psychotherapy Harmon, Kevin C LCSW p 435.658.9200 1912 Sidewinder Dr Cook, Ann G LCSW Valley Behavioral Health Ste 201 University of Utah Health 1753 Sidewinder Dr Hospital Affiliation Park City UT. 84060 1743 Redstone Ctr Dr Park City UT. 84060 - University of Utah Hospital p 435.850.1484 Ste 115 p 888.949.4864 Park City UT. 84098 Margolis, Amber LCSW Whipps, Paige CSW p 435.658.9200 Higgins, Michael P LCSW University of Utah Health Peaceful Solutions University of Utah Health 1743 Redstone Ctr Dr Counseling, LLC Hospital Affiliation 1743 Redstone Ctr Dr Ste 115 2700 Homestead Rd - University of Utah Hospital Ste 115 Park City UT. 84098 Ste 151 Park City UT. 84098 p 435.658.9200 Park City UT. 84098 Eldredge, David G LCSW p 435.658.9200 p 801.651.3907 University of Utah Health Mullaney, Edward LCSW 1743 Redstone Ctr Dr Hough, Amanda LCSW University of Utah Health Woodard, Jeness L LCSW Ste 115 University Of Utah Health 1743 Redstone Ctr Dr University of Utah Health Park City UT. 84098 1820 Sidewinder Dr Ste 115 1743 Redstone Ctr Dr p 435.658.9200 Ste 100 Park City UT. 84098 Ste 115 Park City UT. 84060 p 435.658.9200 Park City UT. 84098 Hospital Affiliation p 801.585.1212 p 435.658.9200 - Primary Childrens Hospital

458 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Speech Therapy *Massimo, Testa MD Tooele County Breast Pumps Levy, Elizabeth P SLP Park City Hospital Alpine Home Medical Roots Pediatric Therapy 900 Round Valley Dr Aba Therapy Phone Number Only LLC Park City UT. 84060 Parish, Erin M BCBA p 800.686.7993 4554 Forestdale Dr Unit p 435.658.7880 iBehave Therapy Group E26 272 N Broadway Edgepark Park City UT. 84098 Peterson, Mark W DO Ste 101 Phone Number Only p 435.400.4064 Heiden Orthopedics Tooele UT. 84074 p 800.321.0591 2200 Park Ave Bldg D p 801.771.0273 Stone, D Kamaile SLP Ste 100 Cardiac Monitoring Peak Plastic Surgury Park City UT. 84060 Allergy And Immunology Remote Cardiac Services 1441 Ute Blvd p 435.615.8822 Gleich, Gerald J MD Phone Number Only Ste 220 University of Utah Health p 800.367.0300 Park City UT. 84098 Hospital Affiliation 7495 S State St p 435.647.5911 - Jordan Valley Medical Midvale UT. 84071 eCardio Diagnostics Center West Valley Campus p 801.213.9400 Phone Number Only Sports Medicine - Jordan Valley Medical p 888.400.3522 Davidson Orthopedics Center Hendershot, Richard W MD 1122 Center Dr Granger Medical Cardiology Ste D-350 Urgent Care Specialists Crouch, Jessica S PA Park City UT. 84098 *Canyons Village Medical 2326 N 400 E Bldg C University of Utah Health p 801.797.8000 *Clinic Ste 203 220 Millpond 3850 Canyons Resort Dr Tooele UT. 84074 Ste 100 Davidson, Philip A MD Park City UT. 84098 p 435.843.4406 Stansbury Park UT. 84074 Davidson Orthopedics p 435.645.4130 p 435.843.3000 1122 Center Dr Hospital Affiliation Ste D-350 *Park City InstaCare - Park City Hospital Hospital Affiliation Park City UT. 84098 1750 Sidewinder Dr - University of Utah Hospital p 801.797.8000 Park City UT. 84060 Kobernick, Aaron K MD p 435.649.7640 University of Utah Health Sharma, Pawan K MD Hospital Affiliation 220 Millpond University of Utah Health - Salt Lake Regional Medical *Park City Mountain Medical Ste 100 220 Millpond Center *Clinic Stansbury Park UT. 84074 Ste 100 - Park City Hospital 1493 Lowell Ave p 435.843.3000 Stansbury Park UT. 84074 Park City UT. 84060 p 435.843.3000 Gunter, Karen A PA p 435.645.6020 7495 S State St Davidson Orthopedics Midvale UT. 84071 UUHC Stansbury Health 1122 Center Dr Snow Creek Emergency & p 801.213.9400 Center Ste D-350 Medical Center - Urgent 220 Millpond Rd Park City UT. 84098 Care Hospital Affiliation Ste 100 p 801.797.8000 1600 Snow Creek Dr - University of Utah Hospital Tooele UT. 84074 Park City UT. 84060 p 435.843.3000 *Hansen, Scott F MD p 435.655.0055 Ambulatory Surgery Center Park City Hospital Northpointe Surgical Zubair, Imran MD 900 Round Valley Dr Stat MD Center Steward Cardiology Park City UT. 84060 1784 W Uinta Way 2326 N 400 E Bldg C, Associates - Salt Lake p 435.658.7880 Ste E-2 Ste 100 City Park City UT. 84098 Tooele UT. 84074 2326 N 400 E Hospital Affiliation p 435.604.0160 p 435.843.0180 Ste 201 - Park City Hospital Tooele UT. 84074 Urology Audiology p 801.263.2370 Heiden Orthopedics Myers, Jeremy B MD Leroy, Molly M AUD 2200 Park Ave Bldg D University of Utah Health Utah Hearing and Balance Hospital Affiliation Ste 100 1743 Redstone Ctr Dr 453 N Main - Salt Lake Regional Medical Park City UT. 84060 Ste 115 Tooele UT. 84074 Center p 435.615.8822 Park City UT. 84098 p 801.495.4800 p 435.658.9200 Certified Nurse Midwife Heiden, Eric MD Hospital Affiliation Smithers, Jacqueline M Heiden Orthopedics Hospital Affiliation - Mountain West Medical CNM 2200 Park Ave Bldg D - University of Utah Hospital Center Womens Health Services Ste 100 391 N Aria Blvd Park City UT. 84060 *Stern, Joshua M MD Sorensen, Tyler D AUD Ste A p 435.615.8822 Park City Specialty ENT Specialists Wendover UT. 84083 900 Round Valley Dr 491 N Main St p 801.733.0555 Hospital Affiliation Ste 200 Tooele UT. 84074 - Park City Hospital Park City UT. 84060 p 435.882.6448 Hospital Affiliation p 435.658.7400 - Mountain West Medical Center Hospital Affiliation - Park City Hospital 459 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Chiropractic Gillen, Shawna LCMHC Phone Number Only Kuechle, Melanie K MD McPhie, John T DC Healing Heart Center for Tooele UT. 84074 University of Utah Health Tooele Valley Spine Center Meaningful Change p 888.949.4864 220 Millpond 1244 N Main St 300 S Main St Ste 100 Ste 100 Tooele UT. 84074 Weight, Marci N LPC Stansbury Park UT. 84074 Tooele UT. 84074 p 435.243.7174 Transitions Counseling p 435.843.3000 p 435.833.9200 185 N Main St Hanson, Ashley A CMHC Ste 701 7495 S State St Porter, Kip DC Valley Behavioral Health Tooele UT. 84074 Midvale UT. 84071 Porter Family Chiropractic 100 S 1000 W p 435.882.7928 p 801.213.9400 275 S Main St Tooele UT. 84074 Tooele UT. 84074 p 888.949.4864 Woodard, Jeness L LCSW Hospital Affiliation p 435.833.0977 University of Utah Health - University of Utah Hospital Landgren, Morgan CSW 220 Millpond Thompson, Glenn H DC Aspen Ridge Counseling Ste 100 Leachman, Sancy A MD,PhD Tooele Valley Spine Center 50 N Main St Stansbury Park UT. 84074 University of Utah Health 1244 N Main St Tooele UT. 84074 p 435.843.3000 220 Millpond Ste 100 p 801.990.4300 Ste 100 Tooele UT. 84074 Dermatology Stansbury Park UT. 84074 p 435.833.9200 Le, Phuong LCSW Bowen, Anneli R MD p 435.843.3000 Adult Behavioral Health - University of Utah Health Counseling Tooele 220 Millpond 7495 S State St Akers, Erin CMHC 2326 N 400 E Ste 100 Midvale UT. 84071 Aspen Ridge Counseling Ste C200 Stansbury Park UT. 84074 p 801.213.9400 50 N Main St Tooele UT. 84074 p 435.843.3000 Tooele UT. 84074 p 801.964.3111 Lewis, Bethany K MD p 801.990.4300 Hospital Affiliation University of Utah Health Hospital Affiliation - University of Utah Hospital 220 Millpond Andrews, Ashley J LCMHC - Mountain West Medical Ste 100 Valley Behavioral Health Center Curtis, Julia A MD Stansbury Park UT. 84074 100 S 1000 W University of Utah Health p 435.843.3000 Tooele UT. 84074 Rios, Veronica CMHC 220 Millpond p 888.949.4864 Aspen Ridge Counseling Ste 100 Hospital Affiliation 50 N Main St Stansbury Park UT. 84074 - University of Utah Hospital Butler, Rita CMHC Tooele UT. 84074 p 435.843.3000 Aspen Ridge Counseling p 801.990.4300 Neville, Christopher A PA 50 N Main St 7495 S State St University of Utah Health Tooele UT. 84074 Rodriguez Diaz, Berta A Midvale UT. 84071 220 Millpond p 801.990.4300 LCMHC p 801.213.9400 Ste 100 Valley Behavioral Health Stansbury Park UT. 84074 Chacon, Shauna R CMHC 100 S 1000 W Hospital Affiliation p 801.581.2955 C Hakes LLC Tooele UT. 84074 - University of Utah Hospital 50 N Main St p 888.949.4864 Hospital Affiliation Tooele UT. 84074 Flint, Ivan D MD - Mountain West Medical p 435.850.8723 Seashore, Karl E LPC 1929 N Aaron Dr Center 50 N Main St Ste I Francom, Austin P APRN Tooele UT. 84074 Tooele UT. 84074 Peterson, Michael W DO C Hakes LLC p 801.272.0613 p 801.262.3600 Springville Dermatology & 50 N Main St Diagnostics Tooele UT. 84074 Hospital Affiliation Hospital Affiliation 196 E 2000 N p 435.850.8723 - Mountain West Medical - St Marks Hospital Ste 106 Center - Mountain West Medical Tooele UT. 84074 Froerer, Jared D LPC Center p 801.704.7001 Aspen Ridge Counseling Shelton, M Jim 11075 S State St Deseret Peak Counseling Gleich, Gerald J MD Hospital Affiliation Ste 35 185 N Main St University of Utah Health - Mountain View Hospital Sandy UT. 84074 Ste 701 7495 S State St (UT) p 801.990.4300 Tooele UT. 84074 Midvale UT. 84071 - Mountain West Medical p 435.224.4390 p 801.213.9400 Center C Hakes LLC 50 N Main St Smaellie, Kimberli E CMHC Jensen, Jesse D DO Rhoads, Jamie Lynn W MD Tooele UT. 84074 Valley Behavioral Health West Valley Dermatology University of Utah Health p 801.990.4300 100 S 1000 W 2376 N 400 E 220 Millpond Tooele UT. 84074 Ste 202 Ste 100 Hospital Affiliation p 888.949.4864 Tooele UT. 84074 Stansbury Park UT. 84074 - Mountain West Medical p 801.966.1403 p 435.843.3000 Center Hospital Affiliation Hospital Affiliation - Jordan Valley Medical - University of Utah Hospital Center West Valley Campus 460 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Secrest, Aaron M MD US MED LLC Orthofix Inc (Bone Growth Knight, Jesse C MD University of Utah Health Phone Number Only Stimulators Physicians ENT Surgical Associates 220 Millpond p 800.787.6331 Only) 2376 N 400 E Ste 100 Phone Number Only Ste 202 Stansbury Park UT. 84074 United States Medical p 800.535.4492 Tooele UT. 84074 p 435.843.3000 Supply p 435.833.9600 Phone Number Only Pacific Medical Inc 7495 S State St p 877.840.8218 Phone Number Only Hospital Affiliation Midvale UT. 84071 p 800.726.9180 - Mountain West Medical p 801.213.9400 Durable Medical Equipment Center Alpine Home Medical RespirTech Hospital Affiliation Phone Number Only Phone Number Only Palmer, David K MD - University of Utah Hospital p 800.686.7993 p 800.793.1261 ENT Specialists 491 N Main St Smart, David R MD Apria Healthcare LLC Roche Insulin Delivery Tooele UT. 84074 University of Utah Health 36 N Main St Systems Inc p 435.882.6448 220 Millpond Ste 4 Phone Number Only Ste 100 Tooele UT. 84074 p 800.280.7801 Hospital Affiliation Stansbury Park UT. 84074 p 435.882.4334 - Mountain West Medical p 435.843.3000 Smith Nephew Inc (Muscle Center CCS Medical Stimulators) - St Marks Hospital 7495 S State St Phone Number Only Phone Number Only Midvale UT. 84071 p 800.726.9811 p 800.821.5700 Ventura, Peter G MD p 801.213.9400 ENT Surgical Associates Care Rehab and Orthopedic US MED LLC 2376 N 400 E Hospital Affiliation Products (Muscle Phone Number Only Ste 202 - University of Utah Hospital Stimulators) p 800.787.6331 Tooele UT. 84074 Phone Number Only p 435.833.9600 UUHC Stansbury Health p 800.487.9644 United States Medical Center Supply Hospital Affiliation 220 Millpond Rd DJO Global Phone Number Only - Mountain West Medical Ste 100 Phone Number Only p 877.840.8218 Center Tooele UT. 84074 p 800.336.6569 p 435.843.3000 Ear Nose And Throat Electrophysiology Dependable Oxygen Company Error, Marc E MD Navaravong, Leenhapong deShazo, Rosemary A MD 63 E 1280 N University of Utah Health (Leen) MD University of Utah Health Tooele UT. 84074 220 Millpond University of Utah Health 220 Millpond p 435.882.0055 Ste 100 220 Millpond Ste 100 Stansbury Park UT. 84074 Ste 100 Stansbury Park UT. 84074 Dynasplint Systems Inc p 435.843.3000 Stansbury Park UT. 84074 p 435.843.3000 Phone Number Only p 801.585.3229 p 800.638.6771 Hospital Affiliation 7495 S State St - University of Utah Hospital Hospital Affiliation Midvale UT. 84071 EBI LLC (Bone Stimulators) - University of Utah Hospital p 801.213.9400 Phone Number Only Jones, Alan C DO p 800.526.2579 Alan Jones DO PLLC Family Practice Hospital Affiliation 2321 N 400 E Abarca, Sergio MD - University of Utah Hospital Edgepark Ste 200 Mountain West Family Phone Number Only Tooele UT. 84074 Practice Diabetic Supplies p 800.321.0591 p 435.833.9600 2356 N 400 E CCS Medical Ste 201 Phone Number Only Empi Inc (Neuromuscular 2376 N 400 E Tooele UT. 84074 p 800.726.9811 Stimulator) Ste 202 p 435.882.2350 Phone Number Only Tooele UT. 84074 Edgepark p 800.328.2536 p 435.833.9600 Hospital Affiliation Phone Number Only - Mountain West Medical p 800.321.0591 KCI USA Inc (Wound Vac Hospital Affiliation Center Only) - Mountain West Medical Roche Insulin Delivery Phone Number Only Center Aldridge, Rebekah PA Systems Inc p 800.275.4524 - Jordan Valley Medical Grantsville Medical Clinic Phone Number Only Center West Valley Campus 822 E Main St p 800.280.7801 Lincare Ste 7 1198 N Main St Grantsville UT. 84029 Tooele UT. 84074 p 435.884.3578 p 435.843.4373 Hospital Affiliation - Mountain West Medical Center 461 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Atkin, Jonathan D PA-C Choate, Melinda PA Greenberg, Johanna E PA Jarvis, Chad S PA University of Utah Health Mountain West Family University of Utah Health Tooele Orthopaedics & 220 Millpond Practice 220 Millpond Sports Medicine Ste 100 2356 N 400 E Ste 100 Specialists Stansbury Park UT. 84074 Ste 201 Stansbury Park UT. 84074 2321 N 400 E p 435.843.3000 Tooele UT. 84074 p 435.843.3000 Ste 300 p 435.882.2350 Tooele UT. 84074 Mountain West Family Hospital Affiliation p 435.833.9180 Practice Hospital Affiliation - University of Utah Hospital 2356 N 400 E - Mountain West Medical Mountain West Family Ste 201 Center Gundersen, Shaun T PA Practice Tooele UT. 84074 Bonneville Family Practice 2356 N 400 E p 435.882.2350 Cox, China G MD 134 W 1180 N Ste 201 Tooele Clinic Corp Ste 5 Tooele UT. 84074 Hospital Affiliation 2055 N Main St Tooele UT. 84074 p 435.882.2350 - Mountain West Medical Tooele UT. 84074 p 435.248.0333 Center p 435.843.3600 Hospital Affiliation Holt, Charles E DO - Mountain West Medical Barrett, John W MD Hospital Affiliation 280 N Main St Center University of Utah Health - University of Utah Hospital Tooele UT. 84074 220 Millpond p 435.882.8610 Jorgensen, Jesse A PA Ste 100 Davis, Russel NP University of Utah Health Stansbury Park UT. 84074 Stansbury Springs Health Hospital Affiliation 220 Millpond p 435.843.3000 Care - Mountain West Medical Ste 100 576 E Hwy 138 Center Stansbury Park UT. 84074 Hospital Affiliation Ste 400 p 435.843.3000 - University of Utah Hospital Tooele UT. 84074 Huber, Jared S MD p 435.843.3647 Tooele Clinic Corp Hospital Affiliation Beazer, Blake R MD 2055 N Main St - University of Utah Hospital Mountain West Family Dustin, Curt R APRN Tooele UT. 84074 Practice Mountain View Health Care p 435.843.3600 Mountain West Family 1929 N Aaron Dr 196 E 2000 N Practice Ste I Ste 104 Hospital Affiliation 2356 N 400 E Tooele UT. 84074 Tooele UT. 84074 - University of Utah Health Ste 201 p 435.882.2350 p 435.882.1644 Craig H Neilsen Rehabilitation HospitalTooele UT. 84074 p 435.882.2350 2356 N 400 E Stansbury Springs Health Ingleby, Joshua S PA Ste 201 Care Mountain West Family Parker, Alma L MD Tooele UT. 84074 576 E Hwy 138 Practice Oquirrh Surgical Services p 435.882.2350 Ste 400 2356 N 400 E 196 E 2000 N Tooele UT. 84074 Ste 201 Ste 106 Hospital Affiliation p 435.843.4653 Tooele UT. 84074 Tooele UT. 84074 - Mountain West Medical p 435.882.2350 p 435.843.2634 Center Hospital Affiliation - Mountain West Medical Hospital Affiliation Hospital Affiliation Carter, Catherine MD Center - Mountain West Medical - Ashley Valley Regional Tooele Medical Group Center Medical Center Orthopedics & Sports Forbes, Carolyn MD - Mountain West Medical Medicine 2376 N 400 E Jacobs-Peterson, LuAnn Center 1929 N Aaron Dr Ste 102 APRN Ste L Tooele UT. 84074 Tooele Clinic Corp Reynolds, Brand P NP Tooele UT. 84074 p 435.843.1225 208 Main St Advanced Practice Medical p 435.843.3859 Tooele UT. 84074 Clinic Hospital Affiliation p 435.882.8610 491 N Main St Tooele Clinic Corp - Mountain West Medical Tooele UT. 84074 196 E 2000 N Center Cedar Creek Family Health p 435.843.8881 Tooele UT. 84074 Care p 435.843.5681 Green, Patrick N MD 453 N Main St Hospital Affiliation Bonneville Family Practice Ste A - Mountain West Medical Toole Clinic 134 W 1180 N Tooele UT. 84074 Center 576 E Hwy 138 Ste 5 p 435.843.5700 Ste 400 Tooele UT. 84074 Salari, Ali DO Tooele UT. 84074 p 435.248.0333 Hospital Affiliation University of Utah Health p 435.843.1342 - Mountain West Medical 220 Millpond Hospital Affiliation Center Ste 100 - St Marks Hospital Stansbury Park UT. 84074 - Mountain West Medical p 435.843.3000 Center Hospital Affiliation - University of Utah Hospital462 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Schultz, Edward R MD Vroman, Stacy T PA Nirula, Raminder MD Vered, Eldad MD Granger Medical Clinic University of Utah Health Tooele Clinic Corp Deseret Peak Womens Center 2326 N 400 E Bldg C, 220 Millpond 196 E 2000 N 2376 N 400 E Ste 203 Ste 100 Ste 109 Ste 204 Tooele UT. 84074 Stansbury Park UT. 84074 Tooele UT. 84074 Tooele UT. 84074 p 801.965.3600 p 435.843.3000 p 435.775.9973 p 435.882.1433

Seibert, Hilary S DO Yarrington, Jesse PA Hospital Affiliation Hospital Affiliation Bonneville Family Practice Mountain West Family - University of Utah Hospital - Mountain West Medical 134 W 1180 N Practice - Mountain West Medical Center Ste 5 2356 N 400 E Center - Memorial Hospital of Tooele UT. 84074 Ste 201 Sweetwater County p 435.248.0333 Tooele UT. 84074 Strindberg, Gail MD p 435.882.2350 General Surgery at Health Department Hospital Affiliation Northpointe Tooele County Health Dept - Jordan Valley Medical Gastroenterology 2376 N 400 E 151 N Main St Center Oelsner, David H MD Ste 205 Tooele UT. 84074 - Mountain West Medical Granger Medical Tooele UT. 84074 p 435.843.2300 Center Specialists p 435.882.8111 2326 N 400 E Bldg C Hematology And Oncology Shinkle, Debra S MD Ste 203 Hospital Affiliation Chandramouli, Nitin B MD University of Utah Health Tooele UT. 84074 - Mountain West Medical Utah Cancer Specialists 220 Millpond p 435.843.4406 Center 1244 N Main St Ste 100 Ste 101 Stansbury Park UT. 84074 Hospital Affiliation Syddall, Tracy R PA-C Tooele UT. 84074 p 435.843.3000 - Jordan Valley Medical University of Utah Health p 435.882.2365 Center 220 Millpond Hospital Affiliation - Jordan Valley Medical Ste 100 Hospital Affiliation - University of Utah Hospital Center West Valley Campus Stansbury Park UT. 84074 - Mountain West Medical - Mountain West Medical p 435.843.3000 Center Spector, Jay M MD Center - St Marks Hospital Oasis Family Medicine Hospital Affiliation - Lakeview Hospital 1929 N Aaron Dr General Surgery - Jordan Valley Medical - Davis Hospital Ste I Cashmore, Blaine J MD Center Tooele UT. 84074 Oquirrh Surgical Services - University of Utah Hospital Home Health Agency p 435.833.0229 196 E 2000 N CNS Community Nursing Ste 106 Geriatrics Services Hospital Affiliation Tooele UT. 84074 Skibitsky, Megan D MD 601 N Main St - Mountain West Medical p 435.228.0061 University of Utah Health Tooele UT. 84074 Center 220 Millpond p 866.882.3913 Hospital Affiliation Ste 100 Syddall, Tracy R PA-C - Mountain West Medical Tooele UT. 84074 Harmony Home Health and University of Utah Health Center p 801.581.2628 Hospice 220 Millpond 1929 N Aaron Dr Ste 100 General Surgery at Gynecology Ste H Stansbury Park UT. 84074 Northpointe Lazernick, Samara MD Tooele UT. 84074 p 435.843.3000 2376 N 400 E Wellsprings Womens Care p 877.463.3322 Ste 205 196 E 2000 N Hospital Affiliation Tooele UT. 84074 Ste 101 Pinnacle Home Health Inc - Jordan Valley Medical p 435.882.8111 Tooele UT. 84074 Phone Number Only Zip Center p 435.843.3678 84074 - University of Utah Hospital Martin, Luke A MD p 801.274.0299 Tooele Clinic Corp Hospital Affiliation UUHC Stansbury Health 196 E 2000 N - Mountain West Medical Hospice Center Ste 104 Center CNS Community Nursing 220 Millpond Rd Tooele UT. 84074 Services Ste 100 p 435.775.9973 Shutts Karjola, Megan M 601 N Main St Tooele UT. 84074 MD Tooele UT. 84074 p 435.843.3000 Hospital Affiliation Wellsprings Womens Care p 866.882.3913 - University of Utah Hospital 196 E 2000 N 220 Millpond Rd - Mountain West Medical Ste 101 Harmony Home Health and Ste 100 Center Tooele UT. 84074 Hospice Tooele UT. 84074 p 435.843.3678 1929 N Aaron Dr p 435.843.3000 Ste H Hospital Affiliation Tooele UT. 84074 - Mountain West Medical p 877.463.3322 Center

463 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Hospital Gleich, Gerald J MD Lau, Sey M MD Tien, Dave MD Mountain West Medical University of Utah Health Nephrology Associates of Nephrology Associates of Center 7495 S State St Utah Utah 2055 N Main Midvale UT. 84071 1244 N Main St 1244 N Main St Tooele UT. 84074 p 801.213.9400 Ste 101 Ste 101 p 435.843.3600 Tooele UT. 84074 Tooele UT. 84074 Gopinath, Arasu MD p 801.288.2634 p 801.288.2634 Imaging Center Nephrology Associates of Tooele Valley Imaging Utah Hospital Affiliation Hospital Affiliation 2356 N 400 E 1244 N Main St - St Marks Hospital - St Marks Hospital Ste 103 Ste 101 - Jordan Valley Medical - Jordan Valley Medical Tooele UT. 84074 Tooele UT. 84074 Center West Valley Campus Center West Valley Campus p 435.882.1674 p 801.288.2634 - Salt Lake Regional Medical - Salt Lake Regional Medical Center Center Internal Medicine Hospital Affiliation Anand, Sanjiv MD - St Marks Hospital Morris, Donald R MD Trudel, Ronald R MD Nephrology Associates of - Jordan Valley Medical Nephrology Associates of Tooele Clinic Corp Utah Center West Valley Campus Utah 1959 N Aaron Dr 1244 N Main St - Salt Lake Regional Medical 1244 N Main St Ste A Ste 101 Center Ste 101 Tooele UT. 84074 Tooele UT. 84074 Tooele UT. 84074 p 435.882.1644 p 801.288.2634 Hendershot, Richard W MD p 801.288.2634 Granger Medical Mountain West Medical Hospital Affiliation Specialists Hospital Affiliation Group Internal Medicine - Salt Lake Regional Medical 2326 N 400 E Bldg C - St Marks Hospital 196 E 2000 N Center Ste 203 - Jordan Valley Medical Ste 105 - Jordan Valley Medical Tooele UT. 84074 Center West Valley Campus Tooele UT. 84074 Center p 435.843.4406 - Salt Lake Regional Medical p 435.882.1644 - St Marks Hospital Center Hospital Affiliation Tooele Clinic Corp Anton, Marja E MD - Park City Hospital Oberg, Christine E MD 196 E 2000 N Tooele Clinic Corp Tooele Clinic Corp Ste 110 2055 N Main St Huber, Jared S MD 2055 N Main St Tooele UT. 84074 Tooele UT. 84074 Tooele Clinic Corp Tooele UT. 84074 p 435.882.1644 p 435.843.3600 2055 N Main St p 435.843.3600 Tooele UT. 84074 Hospital Affiliation Hospital Affiliation p 435.843.3600 Hospital Affiliation - Mountain West Medical - University of Utah Health - University of Utah Hospital Center Craig H Neilsen Rehabilitation HospitalHospital Affiliation - University of Utah Health Oelsner, David H MD UUHC Stansbury Health Barklow, Jeff A MD Craig H Neilsen Rehabilitation HospitalGranger Medical Center Nephrology Associates of Specialists 220 Millpond Rd Utah Indahyung, Ruth M MD 2326 N 400 E Bldg C Ste 100 1244 N Main St Nephrology Associates of Ste 203 Tooele UT. 84074 Ste 101 Utah Tooele UT. 84074 p 435.843.3000 Tooele UT. 84074 1244 N Main St p 435.843.4406 p 801.288.2634 Ste 101 220 Millpond Rd Tooele UT. 84074 Hospital Affiliation Ste 100 Hospital Affiliation p 801.288.2634 - Jordan Valley Medical Tooele UT. 84074 - St Marks Hospital Center p 435.843.3000 - Jordan Valley Medical Hospital Affiliation - Jordan Valley Medical Center West Valley Campus - St Marks Hospital Center West Valley Campus Interventional Cardiology - Salt Lake Regional Medical - Jordan Valley Medical - Mountain West Medical Bekwelem, Wobo MD Center Center Center Steward Cardiology - Salt Lake Regional Medical Associates - Tooele Dickson, Landon E MD Center Satter, Paul A MD 2326 N 400 E Nephrology Associates of Complete Care Clinic Ste 201 Utah Jansen, Kevin MD 15 N 100 E Tooele UT. 84074 1244 N Main St Nephrology Associates of Tooele UT. 84074 p 801.265.1200 Ste 101 Utah p 435.882.6618 Tooele UT. 84074 1244 N Main St Heart and Lung Institute p 801.288.2634 Ste 101 Hospital Affiliation of Utah Tooele UT. 84074 - Mountain West Medical 2326 N 400 E Hospital Affiliation p 801.288.2634 Center Ste 202 Bldg C - Salt Lake Regional Medical Tooele UT. 84074 Center Hospital Affiliation p 801.263.2370 - Jordan Valley Medical - St Marks Hospital Center - Jordan Valley Medical - St Marks Hospital Center West Valley Campus - Salt Lake Regional Medical Center 464 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Jones, Tara L MD Curtis, Leslie J LCSW C Hakes LLC Kenison, Evan T LCSW Tooele Clinic Corp Valley Behavioral Health 50 N Main St Sunset Counseling Services 196 E 2000 N 100 S 1000 W Tooele UT. 84074 2356 N 400 E Tooele UT. 84074 Tooele UT. 84074 p 801.990.4300 Ste 202 p 435.843.5681 p 888.949.4864 Tooele UT. 84074 Hospital Affiliation p 435.850.2547 Hospital Affiliation Debois, Sarah LCSW - Mountain West Medical - University of Utah Hospital Valley Behavioral Health Center Landgren, Morgan CSW 100 S 1000 W Aspen Ridge Counseling Laboratory Tooele UT. 84074 Gibbs, Paula K MD 50 N Main St Dominion Diagnostics p 888.949.4864 University of Utah Health Tooele UT. 84074 Phone Number Only 220 Millpond p 801.990.4300 p 877.734.9600 Hospital Affiliation Ste 100 - Mountain West Medical Tooele UT. 84074 Le, Phuong LCSW LabCorp Draw Station Center p 801.581.7951 Adult Behavioral Health - 2356 N 400 E Tooele Ste 204 Eldredge, Daniel LCSW Hospital Affiliation 2326 N 400 E Tooele UT. 84074 Juniper Family Counseling - University of Utah Hospital Ste C200 p 435.882.7106 66 W Vine St Unit 4 Tooele UT. 84074 Tooele UT. 84074 Gillen, Shawna LCMHC p 801.964.3111 LabCorp of America p 801.901.3460 Healing Heart Center for Holdings Meaningful Change Hospital Affiliation Phone Number Only Eldredge, David G LCSW 300 S Main St - Mountain West Medical p 888.522.2677 University of Utah Health Tooele UT. 84074 Center 220 Millpond p 435.243.7174 Mental Health Ste 100 Leggitt, Valerie LCSW Akers, Erin CMHC Stansbury Park UT. 84074 Hakes, Chris C LCSW Aspen Ridge Counseling Aspen Ridge Counseling p 435.843.3000 C Hakes LLC 50 N Main St 50 N Main St 50 N Main St Tooele UT. 84074 Tooele UT. 84074 Hospital Affiliation Tooele UT. 84074 p 801.990.4300 p 801.990.4300 - Primary Childrens Hospital p 435.850.8723 Looye, Michelle D LCSW Andrews, Ashley J LCMHC Evangelista, Manuel N Hales, Jason A LCSW Granger Medical Valley Behavioral Health LCSW Hales Counseling Center Specialists 100 S 1000 W Valley Behavioral Health 36 N Main 2326 N 400 E Bldg C Tooele UT. 84074 100 S 1000 W Ste 12 Ste 203 p 888.949.4864 Tooele UT. 84074 Tooele UT. 84074 Tooele UT. 84074 p 888.949.4864 p 435.243.5760 p 435.843.4406 Austin, Michael R LCSW Valley Behavioral Health Francom, Austin P APRN Hanson, Ashley A CMHC Lopez, Marta LCSW 100 S 1000 W C Hakes LLC Valley Behavioral Health University of Utah Health Tooele UT. 84074 50 N Main St 100 S 1000 W 220 Millpond p 888.949.4864 Tooele UT. 84074 Tooele UT. 84074 Ste 100 p 435.850.8723 p 888.949.4864 Stansbury Park UT. 84074 Barrus, Matthew D LCSW p 435.843.3000 Valley Behavioral Health Freeman, Brenner L MD Herrera, Nicole LCSW 100 S 1000 W University of Utah Health Valley Behavioral Health Hospital Affiliation Tooele UT. 84074 220 Millpond 100 S 1000 W - University of Utah Hospital p 888.949.4864 Ste 100 Tooele UT. 84074 Tooele UT. 84074 p 888.949.4864 Mack, Kathleen A APRN Butler, Rita CMHC p 801.581.7951 Valley Behavioral Health Aspen Ridge Counseling Higgins, Michael P LCSW 100 S 1000 W 50 N Main St Hospital Affiliation University of Utah Health Tooele UT. 84074 Tooele UT. 84074 - University of Utah Hospital 220 Millpond p 888.949.4864 p 801.990.4300 Ste 100 Froerer, Jared D LPC Stansbury Park UT. 84074 Mackay, Marjorie E CSW Chacon, Shauna R CMHC Aspen Ridge Counseling p 435.843.3000 Valley Behavioral Health C Hakes LLC 11075 S State St 100 S 1000 W 50 N Main St Ste 35 Juliann, Juliann LCSW Tooele UT. 84074 Tooele UT. 84074 Sandy UT. 84074 Valley Behavioral Health p 888.949.4864 p 435.850.8723 p 801.990.4300 100 S 1000 W Tooele UT. 84074 Margolis, Amber LCSW p 888.949.4864 University of Utah Health 220 Millpond Ste 100 Stansbury Park UT. 84074 p 435.843.3000

465 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Matuszewski, Fran APRN Rios, Veronica CMHC Valley Behavioral Health Bjordahl, Terrence S MD Valley Behavioral Health Aspen Ridge Counseling Phone Number Only University of Utah Health 100 S 1000 W 50 N Main St Tooele UT. 84074 196 E 2000 N Tooele UT. 84074 Tooele UT. 84074 p 888.949.4864 Ste 112 p 888.949.4864 p 801.990.4300 Tooele UT. 84074 Vezie, Linda LCSW p 801.408.1430 Hospital Affiliation Rodriguez Diaz, Berta A University of Utah Health - Mountain West Medical LCMHC 220 Millpond Hospital Affiliation Center Valley Behavioral Health Ste 100 - St Marks Hospital 100 S 1000 W Stansbury Park UT. 84074 McFadden, Molly Q LCSW Tooele UT. 84074 p 435.843.3000 Dantis Tan, Minerva NP University of Utah Health p 888.949.4864 Nephrology Associates of 220 Millpond Walters, John L LCSW Utah Ste 100 Seashore, Karl E LPC C Hakes LLC 1244 N Main St Stansbury Park UT. 84074 50 N Main St 50 N Main St Ste 101 p 435.843.3000 Tooele UT. 84074 Tooele UT. 84074 Tooele UT. 84074 p 801.272.0613 p 435.850.8723 p 801.288.2634 McWhorter, Patricia PhD 40 S Main St Hospital Affiliation Weight, Marci N LPC Dickson, Landon E MD Tooele UT. 84074 - Mountain West Medical Transitions Counseling Nephrology Associates of p 435.843.7060 Center 185 N Main St Utah Ste 701 1244 N Main St Mullaney, Edward LCSW Shelton, M Jim Tooele UT. 84074 Ste 101 University of Utah Health Deseret Peak Counseling p 435.882.7928 Tooele UT. 84074 220 Millpond 185 N Main St p 801.288.2634 Ste 100 Ste 701 Wood, Felicia LCSW Stansbury Park UT. 84074 Tooele UT. 84074 Aspen Ridge Counseling Hospital Affiliation p 435.843.3000 p 435.224.4390 50 N Main St - Salt Lake Regional Medical Tooele UT. 84074 Center Neff, Michal A CSW,SUDC Smaellie, Kimberli E CMHC p 801.990.4300 - Jordan Valley Medical Bonneville Family Practice Valley Behavioral Health Center 134 W 1180 N 100 S 1000 W Woodard, Jeness L LCSW - St Marks Hospital Ste 5 Tooele UT. 84074 University of Utah Health Tooele UT. 84074 p 888.949.4864 220 Millpond Gopinath, Arasu MD p 435.248.0333 Ste 100 Nephrology Associates of Starr, Trenton D LCSW Stansbury Park UT. 84074 Utah Nelson, Michelle M LCSW Valley Behavioral Health p 435.843.3000 1244 N Main St University of Utah Health 100 S 1000 W Ste 101 220 Millpond Tooele UT. 84074 Nephrology Tooele UT. 84074 Ste 100 p 888.949.4864 Anand, Sanjiv MD p 801.288.2634 Stansbury Park UT. 84074 Nephrology Associates of p 435.843.3000 Stone, Keri LCSW Utah Hospital Affiliation Aspen Ridge Counseling 1244 N Main St - St Marks Hospital Hospital Affiliation 50 N Main St Ste 101 - Jordan Valley Medical - University of Utah Hospital Tooele UT. 84074 Tooele UT. 84074 Center West Valley Campus p 801.990.4300 p 801.288.2634 - Salt Lake Regional Medical Palmer, Stephen D LCSW Center Valley Behavioral Health Swan, Melissa K SSW Hospital Affiliation 100 S 1000 W Valley Behavioral Health - Salt Lake Regional Medical Indahyung, Ruth M MD Tooele UT. 84074 100 S 1000 W Center Nephrology Associates of p 888.949.4864 Tooele UT. 84074 - Jordan Valley Medical Utah p 888.949.4864 Center 1244 N Main St Parry, Odbayar LCSW - St Marks Hospital Ste 101 Valley Behavioral Health Toles, Susan L LCSW Tooele UT. 84074 100 S 1000 W Valley Behavioral Health Barklow, Jeff A MD p 801.288.2634 Tooele UT. 84074 100 S 1000 W Nephrology Associates of p 888.949.4864 Tooele UT. 84074 Utah Hospital Affiliation p 888.949.4864 1244 N Main St - St Marks Hospital Porschatis, Amber M LCSW Ste 101 - Jordan Valley Medical University of Utah Health Valdez, Danielle LCSW Tooele UT. 84074 Center 220 Millpond University of Utah Health p 801.288.2634 - Salt Lake Regional Medical Ste 100 220 Millpond Center Stansbury Park UT. 84074 Ste 100 Hospital Affiliation p 435.843.3000 Stansbury Park UT. 84074 - St Marks Hospital p 435.843.3000 - Jordan Valley Medical Center West Valley Campus Hospital Affiliation - Salt Lake Regional Medical - University of Utah Hospital Center 466 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Jansen, Kevin MD Yenchek, Robert H MD Occupational Therapy Hill, Kris A OD Nephrology Associates of University of Utah Health Concentra Medical Centers Tooele Vision Center Utah 196 E 2000 N 2390 Redwood Rd 300 S Main St 1244 N Main St Ste 112 West Valley City UT. 84419 Tooele UT. 84074 Ste 101 Tooele UT. 84074 p 888.997.2669 p 435.882.3233 Tooele UT. 84074 p 801.408.1430 p 801.288.2634 Oncology Knowles, Duane C OD Hospital Affiliation Chandramouli, Nitin B MD Standard Optical Hospital Affiliation - University of Utah Hospital Utah Cancer Specialists 196 E 2000 N - St Marks Hospital 1244 N Main St Ste 101 - Jordan Valley Medical Zaman, Tahir A MD Ste 101 Tooele UT. 84074 Center West Valley Campus University of Utah Health Tooele UT. 84074 p 435.882.4815 - Salt Lake Regional Medical 196 E 2000 N p 435.882.2365 Center Ste 112 Morrill, David K OD Tooele UT. 84074 Hospital Affiliation Oquirrh Mountain Eye Care Lau, Sey M MD p 801.408.1430 - Mountain West Medical 1244 N Main St Nephrology Associates of Center Ste 200 Utah 220 Millpond - St Marks Hospital Tooele UT. 84074 1244 N Main St Ste 100 - Lakeview Hospital p 435.882.8439 Ste 101 Stansbury Park UT. 84074 - Davis Hospital Tooele UT. 84074 p 435.843.3000 Orgill, Ryan S OD p 801.288.2634 196 E 2000 N Spectrum Eye Care Hospital Affiliation Ste 107 225 E Main St Hospital Affiliation - University of Utah Hospital Tooele UT. 84074 Ste E - St Marks Hospital p 435.843.3619 Grantsville UT. 84029 - Jordan Valley Medical Obstetrics And Gynecology p 435.249.0530 Center West Valley Campus Aserlind, Meena M MD Ophthalmology - Salt Lake Regional Medical Wellsprings Womens Care Griffeth, Michael T MD Standard Optical Mon-Fri Center 196 E 2000 N Clear Vue 9am-6pm Sat 8am-4pm Ste 101 2376 N 400 E 966 N Main St Morris, Donald R MD Tooele UT. 84074 Ste 101 Tooele UT. 84074 Nephrology Associates of p 435.843.3678 Tooele UT. 84074 p 435.882.4815 Utah p 435.843.8333 1244 N Main St Lazernick, Samara MD UUHC Stansbury Health Ste 101 Wellsprings Womens Care Hospital Affiliation Center Tooele UT. 84074 196 E 2000 N - Mountain West Medical 220 Millpond Rd p 801.288.2634 Ste 101 Center Ste 100 Tooele UT. 84074 Tooele UT. 84074 Hospital Affiliation p 435.843.3678 Optometry p 435.843.3000 - St Marks Hospital Allen, Scott OD - Jordan Valley Medical Hospital Affiliation Wendover Eye Care Vega, Baltazar OD Center West Valley Campus - Mountain West Medical 393 N Aria Bld Standard Optical - Salt Lake Regional Medical Center Wendover UT. 84083 966 N Main St Center p 435.665.7923 Tooele UT. 84074 Shutts Karjola, Megan M p 435.882.4815 Nelson, Andrea M MD MD Clark, Kim OD University of Utah Health Wellsprings Womens Care Standard Optical Winder, Jed C OD 196 E 2000 N 196 E 2000 N 966 N Main St Tooele Vision Center Ste 112 Ste 101 Tooele UT. 84074 300 S Main St Tooele UT. 84074 Tooele UT. 84074 p 435.882.4815 Tooele UT. 84074 p 801.408.1430 p 435.843.3678 p 435.882.3233 Duclos, Lanny F OD Hospital Affiliation Hospital Affiliation Eye Health Professionals Orthopedic Surgery - University of Utah Hospital - Mountain West Medical 88 E 700 N Broadhead, Cassie PA Center Ste A Tooele Medical Group Tien, Dave MD Tooele UT. 84074 Orthopedics & Sports Nephrology Associates of Vered, Eldad MD p 435.882.6452 Medicine Utah Deseret Peak Womens Center 1929 N Aaron Dr 1244 N Main St 2376 N 400 E Gibbons, Tim OD Ste L Ste 101 Ste 204 University of Utah Health Tooele UT. 84074 Tooele UT. 84074 Tooele UT. 84074 220 Millpond p 435.843.3859 p 801.288.2634 p 435.882.1433 Ste 100 Stansbury Park UT. 84074 Hospital Affiliation Hospital Affiliation p 435.843.3000 - St Marks Hospital - Mountain West Medical - Jordan Valley Medical Center Center West Valley Campus - Memorial Hospital of - Salt Lake Regional Medical Sweetwater County Center 467 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Daynes, Jacob DO Relyea, Randall M DO Pain Management - Mountain West Medical Tooele Medical Group Tooele Orthopaedics & Byrne, Ashleigh MD Center Orthopedics & Sports Sports Medicine Granger Medical Clinic Medicine Specialists 2356 N 400 E Bldg C, Duval, Gordon W DO 1929 N Aaron Dr 2321 N 400 E Ste 203 Tooele Clinic Corp Ste L Ste 300 Tooele UT. 84074 196 E 2000 N Tooele UT. 84074 Tooele UT. 84074 p 801.352.5900 Ste 104 p 435.843.3859 p 435.833.9180 Tooele UT. 84074 Hospital Affiliation p 435.843.5681 Northpointe Surgical Richards, Dan DO - Jordan Valley Medical Center Granger Medical Clinic Center Gould, Jim J MD 2326 N 400 E 2356 N 400 E Bldg C, Bedtime Kids Care Ste 100 Ste 203 Davis, Craig W MD 2356 N 400 E Tooele UT. 84074 Tooele UT. 84074 Granger Medical Clinic Ste 202 p 435.843.0180 p 801.965.3600 2326 N 400 E Bldg C, Tooele UT. 84074 Ste 203 p 435.843.8380 Hospital Affiliation Hospital Affiliation Tooele UT. 84074 - Mountain West Medical - Jordan Valley Medical p 801.965.3634 Hospital Affiliation Center Center West Valley Campus - Mountain West Medical - Riverton Childrens Unit Hospital Affiliation Center Douglas, John A DO Operated by Primary Childrens Medical- Jordan Center Valley Medical Tooele Orthopaedics & - Mountain West Medical Center West Valley Campus Rich, Steven DO Sports Medicine Center - Mountain West Medical Wellsprings Pediatrics Specialists Center 196 E 2000 N 2321 N 400 E Silvero, Peter Ste 104 Ste 300 C.O.R.E - Tooele Harmer, Kyle PA-C Tooele UT. 84074 Tooele UT. 84074 2326 N 400 E Granger Medical Tooele p 435.882.9035 p 435.833.9180 Ste A203 2326 N 400 E Bldg C, Tooele UT. 84074 Ste 203 Tooele Clinic Corp Hospital Affiliation p 435.228.0190 Tooele UT. 84074 196 E 2000 N - Mountain West Medical p 801.965.3634 Tooele UT. 84074 Center Hospital Affiliation p 435.843.5681 - Lakeview Hospital - Jordan Valley Medical Mathis, Jared PA Center West Valley Campus Granger Medical Tooele Hospital Affiliation Feria-Arias, Enrique MD - Mountain West Medical 2326 N 400 E Bldg C, - Mountain West Medical Heiden Orthopedics Center Ste 203 Center 2356 N 400 E Bldg C Tooele UT. 84074 Ste 102 Snook, Gary D MD p 801.965.3634 Szalkowski Lehane, Tooele UT. 84074 Gary D Snook MD PC Veronica MD p 435.615.8822 2321 W Erda Way Palliative Care University of Utah Health Ste 300 Parker, Alma L MD 220 Millpond Hospital Affiliation Tooele UT. 84074 Oquirrh Surgical Services Ste 100 - Timpanogos Regional Hospital p 435.862.2371 196 E 2000 N Stansbury Park UT. 84074 - Lone Peak Hospital Ste 106 p 435.843.3000 - St Marks Hospital Hospital Affiliation Tooele UT. 84074 - Mountain West Medical p 435.843.2634 Hospital Affiliation Gibbs, Daniel B MD Center - University of Utah Hospital Heiden Orthopedics Hospital Affiliation 2326 N 400 E Bldg C Tooele Orthopaedics & - Ashley Valley Regional Physical Therapy Ste 102 Sports Medicine Medical Center Bohman, Kevin J DPT Tooele UT. 84074 Specialists - Mountain West Medical Meier and Marsh p 435.615.8822 2356 N 400 E Center Professional Therapies Ste 102 1197 N Main St Hospital Affiliation Tooele UT. 84074 Pediatrics Tooele UT. 84074 - St Marks Hospital p 435.833.9180 Crosbie, Rynthia NP p 435.882.3157 - Lone Peak Hospital Mountain West Pediatrics Walker, Dean N MD 2356 N 400 E Concentra Medical Centers 2326 N 400 E Bldg C Granger Medical Clinic Ste 202 2390 Redwood Rd Ste 102 2356 N 400 E Bldg C, Tooele UT. 84074 West Valley City UT. 84419 Tooele UT. 84074 Ste 203 p 435.843.8380 p 888.997.2669 p 435.615.8822 Tooele UT. 84074 p 801.965.3600 Davis, Carly MD Cragun, Robert B DPT Granger Medical Clinic Rocky Mountain Therapy Hospital Affiliation 2356 N 400 E Bldg C, Services - Jordan Valley Medical Ste 203 822 E Main St Center West Valley Campus Tooele UT. 84074 Grantsville UT. 84029 - Jordan Valley Medical p 801.352.5900 p 435.882.0324 Center - Mountain West Medical Hospital Affiliation Center - Jordan Valley Medical - St Marks Hospital Center 468 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider.- Lone Peak Hospital 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Dennis, Ronen DPT Podiatry Foot & Ankle Specialists Radiology Mountain Land Anselmo, Derek DPM of Utah Mann, Howard MD Rehabilitation Inc Foot & Ankle Specialists 2376 N 400 E University of Utah Health 29 S Main St of Utah Ste 204 220 Millpond Tooele UT. 84074 2376 N 400 E Tooele UT. 84074 Ste 100 p 435.843.7466 Ste 204 p 435.882.0711 Stansbury Park UT. 84074 Tooele UT. 84074 p 435.843.3000 Gubler, Adam D DPT p 435.882.0711 Hospital Affiliation Meier and Marsh - Central Valley Medical Skilled Nursing Facility Professional Therapies Dickerson, Jason B DPM Center Rocky Mountain Care - 168 E Main St Heiden Orthopedics Willow Springs Grantsville UT. 84029 2326 N 400 E Bldg C McManama, Craig A DPM 85 E 2000 N p 385.249.8101 Ste 102 West Valley Foot & Ankle Tooele UT. 84074 Tooele UT. 84074 225 Skyhawk Dr p 801.397.4200 2356 N 400 E p 435.615.8822 Wendover UT. 84083 Ste 101 p 801.966.3556 Social Worker Tooele UT. 84074 Hospital Affiliation Austin, Michael R LCSW p 435.843.1311 - Lone Peak Hospital Hospital Affiliation Valley Behavioral Health - St Marks Hospital - Jordan Valley Medical 100 S 1000 W Horrocks, James S PT Center Tooele UT. 84074 Mountain Land Foot & Ankle Specialists - Jordan Valley Medical p 888.949.4864 Rehabilitation Inc of Utah Center West Valley Campus 220 Millpond 2376 N 400 E - Mountain West Medical Barrus, Matthew D LCSW Ste 109 Ste 204 Center Valley Behavioral Health Stansbury UT. 84074 Tooele UT. 84074 100 S 1000 W p 435.882.4144 p 435.882.0711 The Foot LLC Tooele UT. 84074 491 N Main St p 888.949.4864 Johnson, Nylin J PT Halladay, Kim A DPM Tooele UT. 84074 Mountain Land Tooele Foot and Ankle p 801.503.4053 Cook, Ann G LCSW Rehabilitation Inc Clinic University of Utah Health 220 Millpond 2356 N 400 E Psychiatry 220 Millpond Ste 109 Ste 104 Freeman, Brenner L MD Ste 100 Tooele UT. 84074 Tooele UT. 84074 University of Utah Health Stansbury Park UT. 84074 p 801.882.4144 p 435.882.0711 220 Millpond p 435.843.3000 Ste 100 Marsh, Troy MPT Foot & Ankle Specialists Tooele UT. 84074 Hospital Affiliation Meier and Marsh of Utah p 801.581.7951 - University of Utah Hospital Professional Therapies 2376 N 400 E 168 E Main St Ste 204 Hospital Affiliation Curtis, Leslie J LCSW Grantsville UT. 84029 Tooele UT. 84074 - University of Utah Hospital Valley Behavioral Health p 385.249.8101 p 435.882.0711 100 S 1000 W Gibbs, Paula K MD Tooele UT. 84074 2356 N 400 E Hospital Affiliation University of Utah Health p 888.949.4864 Ste 101 - Mountain West Medical 220 Millpond Tooele UT. 84074 Center Ste 100 Debois, Sarah LCSW p 435.843.1311 - Timpanogos Regional Hospital Tooele UT. 84074 Valley Behavioral Health p 801.581.7951 100 S 1000 W Metters, Dylan S DPT Jones, Richard L DPM Tooele UT. 84074 Mountain Land The Foot LLC Hospital Affiliation p 888.949.4864 Rehabilitation Inc 491 N Main St - University of Utah Hospital 29 S Main St Tooele UT. 84074 Hospital Affiliation Tooele UT. 84074 p 801.503.4053 Psychology - Mountain West Medical p 435.843.7466 McWhorter, Patricia PhD Center Hospital Affiliation 40 S Main St Moorad, Danielle J DPT - Jordan Valley Medical Tooele UT. 84074 Eldredge, Daniel LCSW Mountain Land Center p 435.843.7060 Juniper Family Counseling Rehabilitation Inc 66 W Vine St Unit 4 29 S Main St McKenzie II, David G DPM Valley Behavioral Health Tooele UT. 84074 Tooele UT. 84074 Tooele Orthopaedics & Phone Number Only p 801.901.3460 p 435.843.7466 Sports Medicine Tooele UT. 84074 Specialists p 888.949.4864 Eldredge, David G LCSW Wortley, Richard D PT 1929 N Aaron Dr University of Utah Health Rocky Mountain Therapy Ste L 220 Millpond Services Tooele UT. 84074 Ste 100 822 E Main St p 435.833.9170 Stansbury Park UT. 84074 Grantsville UT. 84029 p 435.843.3000 p 435.882.0324 Hospital Affiliation - Primary Childrens Hospital 469 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Evangelista, Manuel N Keshavarz, Yasaman LCSW Mullaney, Edward LCSW Torres-George, Christian LCSW University of Utah Health University of Utah Health P LCSW Valley Behavioral Health 220 Millpond 220 Millpond University of Utah Health 100 S 1000 W Ste 100 Ste 100 220 Millpond Tooele UT. 84074 Stansbury Park UT. 84074 Stansbury Park UT. 84074 Ste 100 p 888.949.4864 p 435.843.3000 p 435.843.3000 Stansbury Park UT. 84074 p 435.843.3000 Ewanowski, Julia LCSW Hospital Affiliation Neff, Michal A CSW,SUDC University of Utah Health - University of Utah Hospital Bonneville Family Practice Hospital Affiliation 220 Millpond 134 W 1180 N - University of Utah Hospital Ste 100 Lamb, Joseph LCSW Ste 5 Stansbury Park UT. 84074 University of Utah Health Tooele UT. 84074 Valdez, Danielle LCSW p 435.843.3000 220 Millpond p 435.248.0333 University of Utah Health Ste 100 220 Millpond Hospital Affiliation Stansbury Park UT. 84074 Nelson, Michelle M LCSW Ste 100 - University of Utah Hospital p 435.843.3000 University of Utah Health Stansbury Park UT. 84074 220 Millpond p 435.843.3000 Falk, Joshua S LCSW Hospital Affiliation Ste 100 University of Utah Health - University of Utah Hospital Stansbury Park UT. 84074 Hospital Affiliation 220 Millpond p 435.843.3000 - University of Utah Hospital Ste 100 Leggitt, Valerie LCSW Stansbury Park UT. 84074 Aspen Ridge Counseling Hospital Affiliation Vezie, Linda LCSW p 435.843.3000 50 N Main St - University of Utah Hospital University of Utah Health Tooele UT. 84074 220 Millpond Hakes, Chris C LCSW p 801.990.4300 Palmer, Stephen D LCSW Ste 100 C Hakes LLC Valley Behavioral Health Stansbury Park UT. 84074 50 N Main St Looye, Michelle D LCSW 100 S 1000 W p 435.843.3000 Tooele UT. 84074 Granger Medical Tooele UT. 84074 p 435.850.8723 Specialists p 888.949.4864 Walters, John L LCSW 2326 N 400 E Bldg C C Hakes LLC Hales, Jason A LCSW Ste 203 Parry, Odbayar LCSW 50 N Main St Hales Counseling Center Tooele UT. 84074 Valley Behavioral Health Tooele UT. 84074 36 N Main p 435.843.4406 100 S 1000 W p 435.850.8723 Ste 12 Tooele UT. 84074 Tooele UT. 84074 Lopez, Marta LCSW p 888.949.4864 Wood, Felicia LCSW p 435.243.5760 University of Utah Health Aspen Ridge Counseling 220 Millpond Porschatis, Amber M LCSW 50 N Main St Herrera, Nicole LCSW Ste 100 University of Utah Health Tooele UT. 84074 Valley Behavioral Health Stansbury Park UT. 84074 220 Millpond p 801.990.4300 100 S 1000 W p 435.843.3000 Ste 100 Tooele UT. 84074 Stansbury Park UT. 84074 Woodard, Jeness L LCSW p 888.949.4864 Hospital Affiliation p 435.843.3000 University of Utah Health - University of Utah Hospital 220 Millpond Higgins, Michael P LCSW Starr, Trenton D LCSW Ste 100 University of Utah Health Mackay, Marjorie E CSW Valley Behavioral Health Stansbury Park UT. 84074 220 Millpond Valley Behavioral Health 100 S 1000 W p 435.843.3000 Ste 100 100 S 1000 W Tooele UT. 84074 Stansbury Park UT. 84074 Tooele UT. 84074 p 888.949.4864 Sports Medicine p 435.843.3000 p 888.949.4864 Heiden Orthopedics Stone, Keri LCSW 2326 N 400 E Bldg C Juliann, Juliann LCSW Margolis, Amber LCSW Aspen Ridge Counseling Ste 102 Valley Behavioral Health University of Utah Health 50 N Main St Tooele UT. 84074 100 S 1000 W 220 Millpond Tooele UT. 84074 p 435.615.8822 Tooele UT. 84074 Ste 100 p 801.990.4300 p 888.949.4864 Stansbury Park UT. 84074 Tooele Orthopaedics & p 435.843.3000 Swan, Melissa K SSW Sports Medicine Kenison, Evan T LCSW Valley Behavioral Health Specialists Sunset Counseling Services McFadden, Molly Q LCSW 100 S 1000 W 2356 N 400 E 2356 N 400 E University of Utah Health Tooele UT. 84074 Ste 102 Ste 202 220 Millpond p 888.949.4864 Tooele UT. 84074 Tooele UT. 84074 Ste 100 p 435.833.9180 p 435.850.2547 Stansbury Park UT. 84074 Toles, Susan L LCSW p 435.843.3000 Valley Behavioral Health 100 S 1000 W Tooele UT. 84074 p 888.949.4864

470 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Urgent Care eCardio Diagnostics Dermatology Edgepark Tooele Valley Urgent Care Phone Number Only Blake, John MD Phone Number Only M-Sun 9am-10pm p 888.400.3522 Northeastern Utah Medical p 800.321.0591 1244 N Main St Group Ste 201 Cardiology 582 N 1700 W Empi Inc (Neuromuscular Tooele UT. 84074 Johnson, Kira D PA Vernal UT. 84078 Stimulator) p 435.882.3968 University of Utah Health p 435.781.2511 Phone Number Only 475 N 500 W p 800.328.2536 Urology Vernal UT. 84078 Hospital Affiliation Hibbert, Daniel L MD p 801.585.3229 - Uintah Basin Medical KCI USA Inc (Wound Vac Tooele Urology Center Only) 2376 N 400 E Konesavanh, Soutsada N PA - Ashley Valley Regional Phone Number Only Ste 104 University of Utah Health Medical Center p 800.275.4524 Tooele UT. 84074 475 N 500 W p 435.882.0071 Vernal UT. 84078 Diabetic Supplies Orthofix Inc (Bone Growth p 801.585.7676 CCS Medical Stimulators Physicians Hospital Affiliation Phone Number Only Only) - Jordan Valley Medical Hospital Affiliation p 800.726.9811 Phone Number Only Center - University of Utah Hospital p 800.535.4492 - Mountain West Medical Edgepark Center Kutchera, William A MD Phone Number Only Pacific Medical Inc - Salt Lake Regional Medical University of Utah Health p 800.321.0591 Phone Number Only Center 475 N 500 W p 800.726.9180 Vernal UT. 84078 Roche Insulin Delivery Otto, Samuel J MD p 435.789.1165 Systems Inc RespirTech Samuel J Otto, MD Phone Number Only Phone Number Only 2376 N 400 E Hospital Affiliation p 800.280.7801 p 800.793.1261 Ste A-104 - University of Utah Hospital Tooele UT. 84074 US MED LLC Roche Insulin Delivery p 435.882.0071 Welt, Frederick G MD Phone Number Only Systems Inc University of Utah Health p 800.787.6331 Phone Number Only Uintah County 475 N 500 W p 800.280.7801 Vernal UT. 84078 United States Medical Audiology p 801.585.7676 Supply Smith Nephew Inc (Muscle Fox, C B CCC-A Phone Number Only Stimulators) Audiology Associates of Hospital Affiliation p 877.840.8218 Phone Number Only Holladay - University of Utah Hospital p 800.821.5700 38 E 100 N Durable Medical Equipment Vernal UT. 84078 Chiropractic Alpine Home Medical US MED LLC p 800.244.9001 Allan, Travis R DC Phone Number Only Phone Number Only Chirocenter Inc p 800.686.7993 p 800.787.6331 Fox, Damon B CCC-A 1781 W 1000 S Audiology Associates of Vernal UT. 84078 CCS Medical United States Medical Holladay p 435.781.6035 Phone Number Only Supply 38 E 100 N p 800.726.9811 Phone Number Only Vernal UT. 84078 Smuin, Bryan D DC p 877.840.8218 p 800.244.9001 Smuin Chiropractic Clinic Care Rehab and Orthopedic 319 W 100 S Products (Muscle Valley Home Medical Breast Pumps Ste B Stimulators) 395 S Vernal Ave Alpine Home Medical Vernal UT. 84078 Phone Number Only Vernal UT. 84078 Phone Number Only p 435.789.7290 p 800.487.9644 p 435.781.3011 p 800.686.7993 Counseling DJO Global Ear Nose And Throat Edgepark Child, Grant LPC Phone Number Only Catten, Michael MD Phone Number Only Northeastern Counseling p 800.336.6569 Northeastern Utah Medical p 800.321.0591 Center Group 1140 W 500 S Dynasplint Systems Inc 150 W 100 N Cardiac Monitoring Ste 9 Phone Number Only Ste 101 Remote Cardiac Services Vernal UT. 84078 p 800.638.6771 Vernal UT. 84078 Phone Number Only p 435.725.6300 p 435.789.4009 p 800.367.0300 EBI LLC (Bone Stimulators) Dentist Phone Number Only Hospital Affiliation Gilley, Drew DMD p 800.526.2579 - Uintah Basin Medical Mountainlands Community Center Health Center - Ashley Valley Regional 133 S 500 E Medical Center Ste 101 Vernal UT. 84078 p 435.247.1190 471 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Family Practice Garey, Michael MD Northeastern Utah Medical Gynecology Allen, Melinda B NP Ashley Regional Family Group Fleenor, Karen E MD Neurology of Eastern Utah Medicine 475 N 500 W Ashley Regional Womens 175 N 100 W 175 N 100 W Vernal UT. 84078 Health Ste S205-A Ste 205-C p 435.781.6634 150 W 100 N Vernal UT. 84078 Vernal UT. 84078 Ste GL02 p 435.781.8464 p 435.781.6300 Shurtliff, Shaun C DO Vernal UT. 84078 Ashley Valley Family p 435.789.3342 Anderson, Rodney S MD *Lewis, Linda APRN Practice Basin Clinic Primary Childrens Hospital 175 N 100 W Hospital Affiliation 379 N 500 W 167 S 200 E Ste 103 - St George Regional Hospital Ste 1A Vernal UT. 84078 Vernal UT. 84078 Vernal UT. 84078 p 435.781.0105 p 435.781.8899 Griffith, John L MD p 435.789.1165 150 W 100 N Hospital Affiliation Hospital Affiliation Ste S104 Northeastern Utah Medical - University of Utah Hospital - Ashley Valley Regional Vernal UT. 84078 Group Medical Center p 435.781.1099 379 N 500 W Mahler, Laura L FNP Vernal UT. 84078 Valley Family Clinic Woodward, Kirk J MD Hospital Affiliation p 435.789.1165 266 W 100 N Basin Clinic - Castleview Hospital Ste 6 379 N 500 W - Ashley Valley Regional Hospital Affiliation Vernal UT. 84078 Ste 1A Medical Center - Ashley Valley Regional p 435.789.0064 Vernal UT. 84078 Medical Center p 435.789.1165 Joyce, Eileen MD Olsen, Michael T MD Ashley Valley Physician Batty, Craig DO Basin Clinic Northeastern Utah Medical Practices Ashley Regional Family 379 N 500 W Group 150 W 100 N Medicine Ste 1A 379 N 500 W Ste GL-02 150 W 100 N Vernal UT. 84078 Vernal UT. 84078 Vernal UT. 84078 Ste 202 p 435.789.1165 p 435.789.1165 p 435.789.6962 Vernal UT. 84078 p 435.781.1200 Northeastern Utah Medical Hospital Affiliation Lewis, Henry MD Group - Uintah Basin Medical 150 W 100 N 510 S 500 W 379 N 500 W Center Ste S103 Vernal UT. 84078 Vernal UT. 84078 - Ashley Valley Regional Vernal UT. 84078 p 435.781.1200 p 435.789.1165 Medical Center p 435.781.1011

Bowen, Matthew C DO Hospital Affiliation General Surgery Hospital Affiliation Ashley Regional Family - Uintah Basin Medical Driggs, Xondra MD - Ashley Valley Regional Medicine Center Ashley VAlley Physician Medical Center 1680 W Hwy 40 - Ashley Valley Regional Practices Ste 202 Medical Center 150 W 100 N Health Department Vernal UT. 84078 Vernal UT. 84078 Tri County Health Dept p 431.781.1200 Parker, Alma L MD p 435.781.2161 133 S 500 E Ashley Regional Vernal UT. 84078 Hospital Affiliation Hospitalist Lewis, Dennis M MD p 435.247.1177 - Ashley Valley Regional 150 W 100 N Northeastern Utah General Medical Center Vernal UT. 84078 Surgery Hospital p 435.781.0757 150 W 100 N Suite 102 S Ashley Valley Regional Breitenbach, Karl MD Vernal UT. 84078 Medical Center Basin Clinic 175 N 100 W p 435.781.2161 150 W 100 N 379 N 500 W Ste 205C Vernal UT. 84078 Ste 1A Vernal UT. 84078 Hospital Affiliation p 435.789.3342 Vernal UT. 84078 p 435.781.6300 - Ashley Valley Regional p 435.789.1165 Medical Center Internal Medicine Hospital Affiliation Brann, William M MD Northeastern Utah Medical - Ashley Valley Regional Mathis, Trevor J MD Heart and Lung Institute Group Medical Center Northeastern Utah General of Utah 379 N 500 W - Mountain West Medical Surgery 175 N 100 W Vernal UT. 84078 Center 150 W 100 N Suite 102 S Ste 103 p 435.789.1165 Vernal UT. 84078 Vernal UT. 84078 Rimmasch, Alec FNP p 435.781.2161 p 801.263.2370 Hospital Affiliation WorkPoint Ashley Valley - Ashley Valley Regional 1680 W Hwy 40 Hospital Affiliation Medical Center Ste 202 - Ashley Valley Regional Vernal UT. 84078 Medical Center p 435.781.3053

472 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Steward Cardiology Muir, Garth MD Nephrology Occupational Therapy Associates - Vernal Ashley Regional Barager, William E DO Concentra Medical Centers 372 W Hwy 40 Hospitalist Revere Health 2390 Redwood Rd Vernal UT. 84078 150 W 100 N 379 N 500 W West Valley City UT. 84419 p 801.263.2370 Vernal UT. 84078 Ste 1B p 888.997.2669 p 435.789.3342 Vernal UT. 84078 Heart and Lung Institute p 801.377.5757 Ophthalmology of Utah Zang, Shulun MD Powell, Shane K MD 872 W Hwy 40 Ashley Regional Womens Hospital Affiliation Northeastern Utah Medical Vernal UT. 84078 Health - Timpanogos Regional Hospital Group p 801.263.2370 150 W 100 N - Mountain View Hospital 150 W 100 N Ste GL02 (UT) Ste 101 Hospital Affiliation Vernal UT. 84078 Vernal UT. 84078 - Jordan Valley Medical p 435.789.3342 Neurology p 435.781.2030 Center Buchanan, Thomas M MD - Salt Lake Regional Medical Laboratory Neurology of Eastern Utah Hospital Affiliation Center Dominion Diagnostics 175 N 100 W - Uintah Basin Medical - Evanston Regional Hospital Phone Number Only Ste S205-A Center - Castleview Hospital p 877.734.9600 Vernal UT. 84078 p 435.781.8464 Optometry Daniel, Sara D DO LabCorp of America Hunt, Adam R OD Ashley Regional Holdings Hospital Affiliation 1851 W Hwy 40 Hospitalist Phone Number Only - Ashley Valley Regional Vernal UT. 84078 150 W 100 N p 888.522.2677 Medical Center p 435.781.8601 Vernal UT. 84078 - Castleview Hospital p 435.781.0757 Mental Health Seitz, Gordon A OD Benson, Brad LCSW Obstetrics And Gynecology Seitz Eyecare Hospital Affiliation 290 W 100 S Fleenor, Karen E MD 185 N Vernal Ave - Ashley Valley Regional Vernal UT. 84078 Ashley Regional Womens Vernal UT. 84078 Medical Center p 435.621.6142 Health p 435.789.1552 150 W 100 N Kesler, Cameron DO Child, Grant LPC Ste GL02 Seitz, Neldon OD Ashley Regional Womens Northeastern Counseling Vernal UT. 84078 Seitz Eyecare Health Center p 435.789.3342 185 N Vernal Ave 150 W 100 N 1140 W 500 S Ste 3 Vernal UT. 84078 Ste 9 Hospital Affiliation Vernal UT. 84078 p 435.789.3342 Vernal UT. 84078 - St George Regional Hospital p 435.789.1552 p 435.725.6300 Larsen, Eugene D DO Griffith, John L MD Oral And Maxillofacial Surgery Ashley Regional Hall, Laura L LCSW 150 W 100 N Jessen, Gregory S DDS Hospitalist Laura Hall, LCSW Ste S104 40 W 100 N 150 W 100 N Progressive Therapy P. C. Vernal UT. 84078 Vernal UT. 84078 Vernal UT. 84078 266 W 100 N p 435.781.1099 p 800.860.6260 p 435.781.0757 Ste 1 Vernal UT. 84078 Hospital Affiliation Hospital Affiliation Hospital Affiliation p 435.219.9967 - Castleview Hospital - Ogden Regional Medical - Castleview Hospital - Ashley Valley Regional Center - Ashley Valley Regional Henry, Carolyn S LCSW Medical Center Medical Center Basin Family Clinic Orthopedic Surgery 388 W 100 N Joyce, Eileen MD Moore, Tyler MD Madsen, Ace MD Vernal UT. 84078 Ashley Valley Physician Ashley Regional 175 N 100 W p 435.781.8000 Practices Orthopedicis Ste 205B 150 W 100 N 150 W 100 N Vernal UT. 84078 Hospital Affiliation Ste GL-02 Ste S-201 p 435.789.6400 - Uintah Basin Medical Vernal UT. 84078 Vernal UT. 84078 Center p 435.789.6962 p 435.789.3342 Hospital Affiliation - Ashley Valley Regional Kamai-Kekela, Rhonda Lewis, Henry MD Stotts, Alan K MD Medical Center LCSW 150 W 100 N University of Utah Health Northeastern Counseling Ste S103 133 S 500 E Mendez, Omar MD Center Vernal UT. 84078 Vernal UT. 84078 Ashley Regional 1140 W 500 S p 435.781.1011 p 801.587.2255 Hospitalist Ste 9 150 W 100 N Vernal UT. 84078 Hospital Affiliation Hospital Affiliation Vernal UT. 84078 p 435.789.6300 - Ashley Valley Regional - Primary Childrens Hospital p 435.789.3342 Medical Center

473 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Young, Burk T MD Physical Medicine And Rehabilitation Hall, Laura L LCSW Affinity Behavior and 175 N 100 W White, James MD Laura Hall, LCSW Mental Health Services Ste 201 Northeastern Utah Medical Progressive Therapy P. C. 533 W State Rd Vernal UT. 84078 Group 266 W 100 N Ste 103 p 435.789.7845 175 N 100 W Ste 1 Pleasant Grove UT. 84062 Ste 102 Vernal UT. 84078 p 801.506.6695 Hospital Affiliation Vernal UT. 84078 p 435.219.9967 - Ashley Valley Regional p 435.789.4489 Aleman, Arianna BCBA Medical Center Henry, Carolyn S LCSW Utah Behavior Services Hospital Affiliation Basin Family Clinic 216 E Main St Palliative Care - Uintah Basin Medical 388 W 100 N Ste 4 Parker, Alma L MD Center Vernal UT. 84078 Lehi UT. 84043 Ashley Regional - Ashley Valley Regional p 435.781.8000 p 801.255.5131 Hospitalist Medical Center 150 W 100 N Hospital Affiliation Allen, Julie BCBA Vernal UT. 84078 Physical Therapy - Uintah Basin Medical ABS Kids p 435.781.0757 Concentra Medical Centers Center 1140 W 1130 S Bldg B 2390 Redwood Rd Orem UT. 84058 175 N 100 W West Valley City UT. 84419 Kamai-Kekela, Rhonda p 801.935.4946 Ste 205C p 888.997.2669 LCSW Vernal UT. 84078 Northeastern Counseling Allred, Jentrie BCBA p 435.781.6300 Kulland, Jerry D PT Center ABS Kids Ashley Creek Physical 1140 W 500 S 1140 W 1130 S Bldg B Hospital Affiliation Therapy Ste 9 Orem UT. 84058 - Ashley Valley Regional 595 N Vernal Ave Vernal UT. 84078 p 801.935.4171 Medical Center Vernal UT. 84078 p 435.789.6300 - Mountain West Medical p 435.789.0022 1140 W 1130 S Bldg B Center Urgent Care Orem UT. 84058 Seeley, Michael J DPT Vernal Urgent Care p 801.935.4171 Pediatrics Ashley Creek Physical 842 W Hwy 40 *Carver, Jeanlee F APRN Therapy Vernal UT. 84078 Angus, Troy BCBA Primary Childrens Hospital 595 N Vernal Ave p 435.789.6677 Affinity Behavior and 167 S 200 E Vernal UT. 84078 Mental Health Services Vernal UT. 84078 p 435.789.0022 Urology 533 W State Rd p 435.781.0105 Snihurowych, Walter M MD Ste 103 Stilson, Brad DPT Ashley Valley Medical Pleasant Grove UT. 84062 Hospital Affiliation Elite Rehab Physical Center p 801.506.6695 - Primary Childrens Hospital Therapy 151 W 200 N - Lakeview Hospital 425 S Vernal Ave Vernal UT. 84078 Ballif, Kendal BCBA - Ogden Regional Medical Vernal UT. 84078 p 435.789.3342 Kids On The Move Center p 435.781.1502 475 W 260 N Hospital Affiliation Orem UT. 84057 Pettit, Ethan C DO Podiatry - Castleview Hospital p 801.221.9930 Pettit Pediatrics Strange, Jeremy A DPM - Uintah Basin Medical 1360 W Hwy 40 Ashley Valley Foot and Center Barton, Rebecca BCBA Vernal UT. 84078 Ankle, Inc. Kids On The Move p 435.789.7337 365 W 50 N Utah County 475 W 260 N Ste W1 Orem UT. 84057 Dinosaurland Pediatrics Vernal UT. 84078 Aba Therapy p 801.221.9930 Group p 435.789.2062 Achieving Abilities 175 N 100 W 1392 W Turf Farm Way Baylis, Allison BCBA Ste 106 Hospital Affiliation Ste 1-153 ABS Kids Vernal UT. 84078 - Ashley Valley Regional Payson UT. 84651 1140 W 1130 S Bldg B p 435.789.9060 Medical Center p 801.935.5796 Orem UT. 84058 - Ashley Valley Regional p 801.935.4946 Hospital Affiliation Medical Center Adolphson, Lillian - Ashley Valley Regional BCBA-D Beus, Ben BCBA Medical Center Social Worker Utah Behavior Services Affinity Behavior and Benson, Brad LCSW 216 E Main St Mental Health Services *Stacie, Mecham W APRN 290 W 100 S Ste 4 533 W State Rd Primary Childrens Hospital Vernal UT. 84078 Lehi UT. 84043 Ste 103 167 S 200 E p 435.621.6142 p 801.255.5131 Pleasant Grove UT. 84062 Vernal UT. 84078 p 801.506.6695 p 435.781.0105

Hospital Affiliation - Primary Childrens Hospital

474 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Bodily, Madison BCBA Call, Stephanie P BCBA Corey, Spencer BCBA Fabian House ABS Kids Fabian House Utah Behavior Services 3118 N 1200 W 1140 W 1130 S Bldg B 3118 N 1200 W 216 E Main St Lehi UT. 84043 Orem UT. 84058 Lehi UT. 84043 Ste 4 p 801.917.0940 p 801.935.4946 p 801.917.0940 Lehi UT. 84043 p 801.255.5131 Fackrell, Lachere BCBA Bouchelle, Elizabeth Carpenter, Erica BCBA ABS Kids BCBA Affinity Behavior and Corry, Bradley BCBA 1140 W 1130 S Bldg B ABS Kids Mental Health Services ABS Kids Orem UT. 84058 1140 W 1130 S Bldg B 533 W State Rd 1140 W 1130 S Bldg B p 801.935.4171 Orem UT. 84058 Ste 103 Orem UT. 84058 p 801.935.4946 Pleasant Grove UT. 84062 p 801.935.4171 Fox, Bryanna BCBA p 801.506.6695 ABS Kids Brady, Noel BCBA Cummings, Tara BCBA 1140 W 1130 S Bldg B Affinity Behavior and Carpenter, Kristen C BCBA ABS Kids Orem UT. 84058 Mental Health Services Achieving Abilities 1140 W 1130 S Bldg B p 801.935.4946 533 W State Rd 1392 W Turf Farm Way Orem UT. 84058 Ste 103 Ste 1-153 p 801.935.4946 Fujiwara, Mina BCBA Pleasant Grove UT. 84062 Payson UT. 84651 Utah Behavior Services p 801.506.6695 p 801.935.5796 Davies, Celestial L BCBA 216 E Main St Kids On The Move Ste 4 Bray, Kristl BCBA Cheney, Ashley BCBA 475 W 260 N Lehi UT. 84043 ABS Kids Kids On The Move Orem UT. 84057 p 801.255.5131 1140 W 1130 S Bldg B 475 W 260 N p 801.221.9930 Orem UT. 84058 Orem UT. 84057 Garlock, John T BCBA p 801.935.4946 p 801.221.9930 DeCosta, Alycen F SLP ABS Kids The Whole Child Therapy 1140 W 1130 S Bldg B Burton, Shelby BCBA Christianson, Grete BCBA 1570 N Main St Orem UT. 84058 ABS Kids Utah Behavior Services Spanish Fork UT. 84660 p 801.935.4171 1140 W 1130 S Bldg B 216 E Main St p 801.210.9319 Orem UT. 84058 Ste 4 Utah Autism Academy p 801.935.4946 Lehi UT. 84043 727 S Main St 1875 S Geneva Rd p 801.255.5131 Spanish Fork UT. 84660 Orem UT. 84058 Burwell, Briana BCBA p 801.210.9319 p 801.437.0490 Affinity Behavior and Chrysalis Utah Mental Health Services 1443 W 800 N Deceuster, Rachael BCBA Garrett-Baker, Amanda 533 W State Rd Ste 103 Utah Behavior Services BCBA Ste 103 Orem UT. 84057 216 E Main St ABS Kids Pleasant Grove UT. 84062 p 801.655.4950 Ste 4 1140 W 1130 S Bldg B p 801.506.6695 Lehi UT. 84043 Orem UT. 84058 220 N 1200 E p 801.255.5131 p 801.935.4946 Buttars, Ashley A BCBA Ste 102 Achieving Abilities Lehi UT. 84043 Devlin, Charissa BCBA Gibson, Crystal BCBA 1392 W Turf Farm Way p 801.655.4950 ABS Kids ABS Kids Ste 1-153 1140 W 1130 S Bldg B 1140 W 1130 S Bldg B Payson UT. 84651 Chun, Tamra BCBA Orem UT. 84058 Orem UT. 84058 p 801.935.5796 Kids On The Move p 801.935.4946 p 801.935.4171 475 W 260 N Caceres-Loveless, Maria Orem UT. 84057 Dilworth, Leticia BCBA Glad, Bruce BCBA BCBA p 801.221.9930 Utah Autism Academy Affinity Behavior and Achieving Abilities 1875 S Geneva Rd Mental Health Services 1392 W Turf Farm Way Clark, Kathleen P BCBA Orem UT. 84058 533 W State Rd Ste 1-153 Kids Who Count p 801.437.0490 Ste 103 Payson UT. 84651 345 N State Rd 198 Pleasant Grove UT. 84062 p 801.935.5796 Salem UT. 84653 Dobson, Nicole BCBA p 801.506.6695 p 801.423.3000 ABS Kids Cahoon, Stephanie BCBA 1140 W 1130 S Bldg B Goldberg, Annie BCBA ABS Kids Collins, Shawnee BCBA-D Orem UT. 84058 ABS Kids 1140 W 1130 S Bldg B Chrysalis Utah p 801.935.4946 1140 W 1130 S Bldg B Orem UT. 84058 1443 W 800 N Orem UT. 84058 p 801.935.4946 Ste 103 Dufek, Brandi BCBA p 801.935.4946 Orem UT. 84057 ABS Kids p 801.655.4950 1140 W 1130 S Bldg B Orem UT. 84058 p 801.935.4946

475 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Green, Courtney BCBA Hayes, Christa J BCBA Jensen, Melissa BCBA Klinkefus, Nick BCBA ABS Kids ABS Kids ABS Kids ABS Kids 1140 W 1130 S Bldg B 1140 W 1130 S Bldg B 1140 W 1130 S Bldg B 1140 W 1130 S Bldg B Orem UT. 84058 Orem UT. 84058 Orem UT. 84058 Orem UT. 84058 p 801.935.4171 p 801.935.4946 p 801.935.4171 p 801.935.4946

Green, Rachal BCBA,LCSW Kids On The Move Jespersen, Marcella G Knudson, Mani BCBA Utah Behavior Services 475 W 260 N Kids On The Move Utah Behavior Services 216 E Main St Orem UT. 84057 475 W 260 N 216 E Main St Ste 4 p 801.221.9930 Orem UT. 84057 Ste 4 Lehi UT. 84043 p 801.221.9930 Lehi UT. 84043 p 801.255.5131 Heath, Nicholas BCBA p 801.255.5131 ABS Kids Jimenez, Virginia BCBA Gressmen, Casey BCBA 1140 W 1130 S Bldg B Affinity Behavior and Kramer, Andrea BCBA Utah Behavior Services Orem UT. 84058 Mental Health Services ABS Kids 216 E Main St p 801.935.4946 533 W State Rd 1140 W 1130 S Bldg B Ste 4 Ste 103 Orem UT. 84058 Lehi UT. 84043 Hodgkin, Cameron BCBA Pleasant Grove UT. 84062 p 801.935.4946 p 801.255.5131 ABS Kids p 801.506.6695 1140 W 1130 S Bldg B Kulow, Kacylia BCBA Guerrieri, Joseph BCBA Orem UT. 84058 Jones, Lisa BCBA Utah Behavior Services ABS Kids p 801.935.4946 ABS Kids 216 E Main St 1140 W 1130 S Bldg B 1140 W 1130 S Bldg B Ste 4 Orem UT. 84058 Hoffman, Lindsey BCBA Orem UT. 84058 Lehi UT. 84043 p 801.935.4946 ABS Kids p 801.935.4946 p 801.255.5131 1140 W 1130 S Bldg B Guinn, Devin BCBA Orem UT. 84058 Jones, Tonya BCBA Lambertsen, Hope BCBA ABS Kids p 801.935.4946 ABS Kids Utah Behavior Services 1140 W 1130 S Bldg B 1140 W 1130 S Bldg B 216 E Main St Orem UT. 84058 Hoffmann, Audrey PhD Orem UT. 84058 Ste 4 p 801.935.4171 Utah Behavior Services p 801.935.4171 Lehi UT. 84043 216 E Main St p 801.255.5131 Gutknecht, Kylie BCBA Ste 4 Keeler, Celeste LMFT Kids On The Move Lehi UT. 84043 Healings Steps Counseling Lee, Jennifer BCBA 475 W 260 N p 801.255.5131 111 E Main St Utah Behavior Services Orem UT. 84057 Ste L4 216 E Main St p 801.221.9930 Hooton, Amy BCBA Lehi UT. 84043 Ste 4 ABS Kids p 801.980.3676 Lehi UT. 84043 Hadnagy-Roch, Alexis 1140 W 1130 S Bldg B p 801.255.5131 BCBA Orem UT. 84058 Keller, Rebecca BCBA ABS Kids p 801.935.4946 Utah Behavior Services Lilino, Leslie L 1140 W 1130 S Bldg B 216 E Main St Kids On The Move Orem UT. 84058 Hunsaker, Kellie D BCBA Ste 4 475 W 260 N p 801.935.4946 Kids On The Move Lehi UT. 84043 Orem UT. 84057 475 W 260 N p 801.255.5131 p 801.221.9930 Hanks, Julie BCBA Orem UT. 84057 Utah Behavior Services p 801.221.9930 Kennedy, Anne BCBA Lopes, Erika BCBA 216 E Main St Utah Behavior Services ABS Kids Ste 4 Hunt, Chelseigh BCBA 216 E Main St 1140 W 1130 S Bldg B Lehi UT. 84043 Utah Behavior Services Ste 4 Orem UT. 84058 p 801.255.5131 216 E Main St Lehi UT. 84043 p 801.935.4171 Ste 4 p 801.255.5131 Harris, Kaitlyn BCBA Lehi UT. 84043 Lopez, Kitrina BCBA ABS Kids p 801.255.5131 Kennedy, Courtney BCBA Utah Behavior Services 1140 W 1130 S Bldg B ABS Kids 216 E Main St Orem UT. 84058 Jacobsen, Maren BCBA 1140 W 1130 S Bldg B Ste 4 p 801.935.4171 ABS Kids Orem UT. 84058 Lehi UT. 84043 1140 W 1130 S Bldg B p 801.935.4946 p 801.255.5131 Hawkins, Jeffrey BCBA Orem UT. 84058 ABS Kids p 801.935.4946 Kids On The Move Lowe, Kori BCBA 1140 W 1130 S Bldg B 475 W 260 N Utah Behavior Services Orem UT. 84058 Jensen, Julia P BCBA Orem UT. 84057 216 E Main St p 801.935.4946 Utah Behavior Services p 801.221.9930 Ste 4 216 E Main St Lehi UT. 84043 Ste 4 p 801.255.5131 Lehi UT. 84043 p 801.255.5131

476 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Lyon, Nathan BCBA McGuire, Amy BCBA Navas, Barbara BCBA Kids Who Count Kids Who Count Utah Behavior Services ABS Kids 345 N State Rd 198 345 N State Rd 198 216 E Main St 1140 W 1130 S Bldg B Salem UT. 84653 Salem UT. 84653 Ste 4 Orem UT. 84058 p 801.423.3000 p 801.423.3000 Lehi UT. 84043 p 801.935.4946 p 801.255.5131 Pehrson, Heather BCBA Madsen, Sara BCBA Nelson, Michael D BCBA ABS Kids ABS Kids Meier, Heather BCBA @Preferred Family Clinic 1140 W 1130 S Bldg B 1140 W 1130 S Bldg B ABS Kids 1355 N Univeristy Ave Orem UT. 84058 Orem UT. 84058 1140 W 1130 S Bldg B Ste 200 p 801.935.4171 p 801.935.4171 Orem UT. 84058 Provo UT. 84604 p 801.935.4946 p 801.221.0223 Pollock, Clinton BCBA Utah Behavior Services Chrysalis Utah 216 E Main St Mendoza, Emily BCaBA Newman, Felicia BCBA 220 N 1200 E Ste 4 ABS Kids ABS Kids Ste 102 Lehi UT. 84043 1140 W 1130 S Bldg B 1140 W 1130 S Bldg B Lehi UT. 84043 p 801.255.5131 Orem UT. 84058 Orem UT. 84058 p 801.655.4950 p 801.935.4946 p 801.935.4946 Kids Who Count Randall, Cameron E BCBA 345 N State Rd 198 Metzger, Debbie BCBA Nicols, Jenissa BCBA Kids On The Move Salem UT. 84653 Utah Behavior Services ABS Kids 475 W 260 N p 801.423.3000 216 E Main St 1140 W 1130 S Bldg B Orem UT. 84057 Ste 4 Orem UT. 84058 p 801.221.9930 Maher, Jaclyn BCBA Lehi UT. 84043 p 801.935.4171 Kids On The Move p 801.255.5131 Rasmussen, Jake BCBA 475 W 260 N Utah Autism Academy ABS Kids Orem UT. 84057 Mitchell, Courtney E 1875 S Geneva Rd 1140 W 1130 S Bldg B p 801.221.9930 Kids On The Move Orem UT. 84058 Orem UT. 84058 475 W 260 N p 801.437.0490 p 801.935.4171 Makowski, Alexandra BCBA Orem UT. 84057 ABS Kids p 801.221.9930 Oblad, Cicily BCBA The Whole Child Therapy 1140 W 1130 S Bldg B Utah Behavior Services 727 S Main St Orem UT. 84058 Moosman, Julie BCBA 216 E Main St Spanish Fork UT. 84660 p 801.935.4946 ABS Kids Ste 4 p 801.210.9319 1140 W 1130 S Bldg B Lehi UT. 84043 Malone, Sara BCBA Orem UT. 84058 p 801.255.5131 Renda, Cheyenne R PhD ABS Kids p 801.935.4171 Utah Behavior Services 1140 W 1130 S Bldg B Ortiz-Perez, Marco BCBA 216 E Main St Orem UT. 84058 Morris, Tracee BCBA ABS Kids Ste 4 p 801.935.4946 ABS Kids 1140 W 1130 S Bldg B Lehi UT. 84043 1140 W 1130 S Bldg B Orem UT. 84058 p 801.255.5131 Manwill, Andrea BCBA Orem UT. 84058 p 801.935.4946 Kids On The Move p 801.935.4171 Rhodes, Tiffany BCBA 475 W 260 N Ossmen, Caitlin BCBA Utah Behavior Services Orem UT. 84057 Moseng, Megan ABS Kids 216 E Main St p 801.221.9930 Utah Autism Academy 1140 W 1130 S Bldg B Ste 4 1875 S Geneva Rd Orem UT. 84058 Lehi UT. 84043 Mattingly, Mary BCBA Orem UT. 84058 p 801.935.4171 p 801.255.5131 ABS Kids p 801.437.0490 1140 W 1130 S Bldg B Ossmen, Jordan BCBA Ringger, Brett BCBA Orem UT. 84058 Murphy, H Nicole BCBA ABS Kids ABS Kids p 801.935.4946 ABS Kids 1140 W 1130 S Bldg B 1140 W 1130 S Bldg B 1140 W 1130 S Bldg B Orem UT. 84058 Orem UT. 84058 Maughan, Sari BCBA Orem UT. 84058 p 801.935.4171 p 801.935.4946 Affinity Behavior and p 801.935.4946 Mental Health Services Parsons, Rita M BCBA Robles, Richard BCBA 533 W State Rd Nadalsky, Michelle ABS Kids ABS Kids Ste 103 BCBA,SSW 1140 W 1130 S Bldg B 1140 W 1130 S Bldg B Pleasant Grove UT. 84062 Utah Behavior Services Orem UT. 84058 Orem UT. 84058 p 801.506.6695 216 E Main St p 801.935.4946 p 801.935.4946 Ste 4 Maxwell, Kendra BCBA Lehi UT. 84043 Peabody, Deanna L OT Rockwell, Rene BCBA Utah Behavior Services p 801.255.5131 The Whole Child Therapy Utah Behavior Services 216 E Main St 1570 N Main St 216 E Main St Ste 4 Spanish Fork UT. 84660 Ste 4 Lehi UT. 84043 p 801.210.9319 Lehi UT. 84043 p 801.255.5131 p 801.255.5131

477 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Rogers, Jennifer PSYD Simmons, Stacey LCSW Sorenson, Cassie BCBA Turner, Meghan BCBA ABS Kids The Whole Child Therapy ABS Kids ABS Kids 1140 W 1130 S Bldg B 727 S Main St 1140 W 1130 S Bldg B 1140 W 1130 S Bldg B Orem UT. 84058 Spanish Fork UT. 84660 Orem UT. 84058 Orem UT. 84058 p 801.935.4946 p 801.210.9319 p 801.935.4946 p 801.935.4946

Roll, Ashley A Sivertson, Savannah BCBA Stevens, Nicole Unick, Timothie BCBA Kids On The Move ABS Kids BCBA,LMFT Affinity Behavior and 475 W 260 N 1140 W 1130 S Bldg B Utah Behavior Services Mental Health Services Orem UT. 84057 Orem UT. 84058 216 E Main St 533 W State Rd p 801.221.9930 p 801.935.4946 Ste 4 Ste 103 Lehi UT. 84043 Pleasant Grove UT. 84062 Rosado, Leah BCBA Skibitsky, Jeffrey BCBA p 801.255.5131 p 801.506.6695 ABS Kids ABS Kids 1140 W 1130 S Bldg B 1140 W 1130 S Bldg B Stevenson, Victoria A Utah Behavior Services Orem UT. 84058 Orem UT. 84058 BCBA 216 E Main St p 801.935.4171 p 801.935.4946 ABS Kids Ste 4 1140 W 1130 S Bldg B Lehi UT. 84043 Roskelley, Hannah BCBA Slack, Micah BCBA Orem UT. 84058 p 801.255.5131 ABS Kids ABS Kids p 801.935.4171 1140 W 1130 S Bldg B 1140 W 1130 S Bldg B Western, Shasta BCBA Orem UT. 84058 Orem UT. 84058 Stotts, Jonas BCBA ABS Kids p 801.935.4946 p 801.935.4171 ABS Kids 1140 W 1130 S Bldg B 1140 W 1130 S Bldg B Orem UT. 84058 Roth, Natalie PhD Smith, Ashlin BCBA Orem UT. 84058 p 801.935.4171 ABS Kids ABS Kids p 801.935.4946 1140 W 1130 S Bldg B 1140 W 1130 S Bldg B Weston, Sophia BCBA Orem UT. 84058 Orem UT. 84058 Tabara, Jackqueline BCBA ABS Kids p 801.935.4946 p 801.935.4946 ABS Kids 1140 W 1130 S Bldg B 1140 W 1130 S Bldg B Orem UT. 84058 Sagendorf, Emily BCBA Affinity Behavior and Orem UT. 84058 p 801.935.4946 Utah Behavior Services Mental Health Services p 801.935.4946 216 E Main St 533 W State Rd Whatcott, Natalie Ste 4 Ste 103 Taylor, Amanda BCBA BCBA,SSW Lehi UT. 84043 Pleasant Grove UT. 84062 ABS Kids Utah Behavior Services p 801.255.5131 p 801.506.6695 1140 W 1130 S Bldg B 216 E Main St Orem UT. 84058 Ste 4 Sanders, Sarah BCBA Smith, Erica BCBA p 801.935.4946 Lehi UT. 84043 Utah Behavior Services Utah Behavior Services p 801.255.5131 216 E Main St 216 E Main St Thomas, Jonathon (JT) Ste 4 Ste 4 BCBA Wight, Gregory BCBA Lehi UT. 84043 Lehi UT. 84043 ABS Kids Achieving Abilities p 801.255.5131 p 801.255.5131 1140 W 1130 S Bldg B 1392 W Turf Farm Way Orem UT. 84058 Ste 1-153 Schuknecht, Kelly BCBA Smith, Hannah BCBA p 801.935.4946 Payson UT. 84651 ABS Kids ABS Kids p 801.935.5796 1140 W 1130 S Bldg B 1140 W 1130 S Bldg B Thomas, Ruth A CMHC Orem UT. 84058 Orem UT. 84058 Eagle Mountain Counseling Wills, Brooke BCBA p 801.935.4946 p 801.935.4171 3726 E Campus Dr Utah Behavior Services Ste H 216 E Main St Shields, Haley B BCBA Smith, Saige LPC Eagle Mountain UT. 84005 Ste 4 ABS Kids Utah Behavior Services p 801.784.7780 Lehi UT. 84043 1140 W 1130 S Bldg B 216 E Main St p 801.255.5131 Orem UT. 84058 Ste 4 Thompson, Chelsea BCBA p 801.935.4946 Lehi UT. 84043 ABS Kids Wilson, Megan BCBA p 801.255.5131 1140 W 1130 S Bldg B Utah Behavior Services Simancas (Monago), Orem UT. 84058 216 E Main St Letisia A BCBA Snow, Lauren BCBA p 801.935.4171 Ste 4 ABS Kids Utah Behavior Services Lehi UT. 84043 1140 W 1130 S Bldg B 216 E Main St Thurgood, Brook BCBA p 801.255.5131 Orem UT. 84058 Ste 4 ABS Kids p 801.935.4946 Lehi UT. 84043 1140 W 1130 S Bldg B Winslow, Tatum BCBA p 801.255.5131 Orem UT. 84058 ABS Kids p 801.935.4171 1140 W 1130 S Bldg B Orem UT. 84058 p 801.935.4946

478 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Woodall, Clifford BCBA 972 N 600 E Peak ENT Associates Fox, Damon B CCC-A Utah Behavior Services Spanish Fork UT. 84660 1055 N 300 W Audiology Associates of 216 E Main St p 801.226.3600 Ste 401 Holladay Ste 4 Provo UT. 84604 130 W Main Lehi UT. 84043 Hospital Affiliation p 801.357.7499 Ste E p 801.255.5131 - Timpanogos Regional Hospital Lehi UT. 84043 3000 N Triumph Blvd p 800.244.9001 Wulfenstein, Lee BCBA Kobernick, Aaron K MD Ste 260 Utah Behavior Services University of Utah Health Lehi UT. 84043 Garrett, Layne AUD 216 E Main St 145 W University Pkwy p 801.768.3500 Timpanogos Hearing and Ste 4 Orem UT. 84058 Balance Lehi UT. 84043 p 801.581.2955 Cordingley, Sarah AUD 321 E 300 N p 801.255.5131 Hearing And Balance American Fork UT. 84003 Hospital Affiliation Institute p 801.763.0724 Yang, Danielle BCBA - University of Utah Hospital 1055 N 300 W Utah Behavior Services Ste 211 Ireland, Adam S AUD 216 E Main St Matheson, Evan J MD Provo UT. 84604 Revere Health Wasatch Ste 4 Provo Allergy & Asthma p 801.852.9696 Otolaryngology Group Lehi UT. 84043 Clinic 2230 N University Ave p 801.255.5131 745 N 500 W Peak ENT Associates Ste 9-B Provo UT. 84601 1055 N 300 W Provo UT. 84604 Young, Jeanelle BCBA p 801.375.9292 Ste 401 p 801.375.3175 ABS Kids Provo UT. 84604 1140 W 1130 S Bldg B Hospital Affiliation p 801.357.7499 39 Professional Way Orem UT. 84058 - Timpanogos Regional Hospital Payson UT. 84651 p 801.935.4171 3000 N Triumph Blvd p 801.465.4805 Ambulatory Surgery Center Ste 260 Allergy And Immunology Central Utah Surgical Lehi UT. 84043 Norton, Shellie M AUD Altamirano, Hugo MD Center p 801.768.3500 Revere Health Provo Allergy & Asthma 1067 N 500 W 1175 E 50 S Clinic Provo UT. 84604 Dansie, Joseph E AUD Ste 221 745 N 500 W p 801.374.0354 Hearing and Balance American Fork UT. 84003 Provo UT. 84601 Institute p 801.418.0870 p 801.375.9292 Revere Health Surgery 1055 N 300 W Center Ste 211 700 W 800 N Hospital Affiliation 1175 E 50 S Provo UT. 84604 Ste 100 - Timpanogos Regional Hospital American Fork UT. 84003 p 801.852.9696 Orem UT. 84057 p 801.375.8858 p 801.465.4805 Burkhardt, Joshua G DO Peak ENT Associates Revere Health Riverwoods Surgery Center 1055 N 300 W Thomas, Curtis AUD 159 N 400 W 320 W River Park Dr Ste 401 Hearing and Balance Ste B-8 Ste 125 Provo UT. 84604 Institute Orem UT. 84057 Provo UT. 84604 p 801.357.7499 1055 N 300 W p 801.226.3600 p 801.437.4500 Ste 211 Forsey, Steven AUD Provo UT. 84604 555 W SR 164 N Audiology Hearing and Balance p 801.852.9696 Salem UT. 84653 Blair, Nancy AUD Institute p 801.226.3600 Revere Health 1055 N 300 W Peak ENT Associates 39 N Professional Way Ste 211 1055 N 300 W Gordon, Christopher L DO Ste 1 Provo UT. 84604 Ste 401 Christopher L Gardon, DO Payson UT. 84651 p 801.852.9696 Provo UT. 84604 LLC p 801.465.4805 p 801.357.7499 745 N 500 W Peak ENT Associates Provo UT. 84601 972 N 600 E 1055 N 300 W Turner, Jay D AUD p 801.375.9292 Spanish Fork UT. 84660 Ste 401 FYZICAL Spine Orthopedic p 801.465.4805 Provo UT. 84604 Sports Therapy and Balance Hospital Affiliation p 801.357.7499 Center - Utah Valley Hospital Bown, Brittany AUD 3303 N University Ave - Timpanogos Regional Hospital Hearing And Balance Fox, C B CCC-A Provo UT. 84604 Institute Audiology Associates of p 801.373.7438 Jacobs, Tammy MD 1055 N 300 W Holladay Revere Health Ste 211 130 W Main Willson, Kylie AUD 159 N 400 W Provo UT. 84604 Ste E Revere Health Ste B8 p 801.852.9696 Lehi UT. 84043 1175 E 50 S Orem UT. 84057 p 800.244.9001 Ste 211 p 801.224.5373 American Fork UT. 84003 p 801.418.0870

479 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Worthington, Douglas K Asay, Ronald W MD Wasatch Cardiovascular Hwang, Chun MD AUD MountainStar Utah County Services Revere Health Hearing and Balance Cardiology 3000 N Triumph Blvd 700 W 800 N Institute 325 W Center St Ste 330 Ste 100 1055 N 300 W Spanish Fork UT. 84660 Lehi UT. 84043 Orem UT. 84057 Ste 211 p 801.714.6412 p 801.463.7411 p 801.224.5373 Provo UT. 84604 p 801.852.9696 700 W 800 N Hospital Affiliation Hospital Affiliation Ste 444 - Mountain Point Medical - Timpanogos Regional Hospital Peak ENT Associates Orem UT. 84057 Center 1055 N 300 W p 801.714.6412 Karwande, Shreekanth MD Ste 401 Carter, Melvin E MD MountainStar Provo UT. 84604 Hospital Affiliation Revere Health Cardiovascular Surgery p 801.357.7499 - Timpanogos Regional Hospital 3000 N Triumph Blvd 700 W 800 N - Mountain View Hospital Ste 100 Ste 444 3000 N Triumph Blvd (UT) Lehi UT. 84043 Orem UT. 84057 Ste 260 p 801.373.4366 p 801.743.4750 Lehi UT. 84043 Bennett, Daniel N MD p 801.768.3500 Revere Health Hospital Affiliation Hospital Affiliation 1055 N 500 W - Timpanogos Regional Hospital - St Marks Hospital Young, Jared R AUD Ste 101 Bldg C - Mountain View Hospital - Ogden Regional Medical Young Hearing Provo UT. 84604 (UT) Center 528 N Main St p 801.763.3885 - Timpanogos Regional Hospital Springville UT. 84663 Cragun, David T MD - Lakeview Hospital p 801.489.7948 2183 W Main St Revere Health Ste A-107 97 S Professional Way Kim, Christopher Y MD Breast Pumps Lehi UT. 84043 Payson UT. 84651 Advanced Vein and Vascular Alpine Home Medical p 385.203.1215 p 801.373.4366 of Utah Valley 1481 N State St 320 W River Park Dr Provo UT. 84604 972 N 600 E Hospital Affiliation Ste 125 p 801.852.0077 Spanish Fork UT. 84660 - Mountain View Hospital Provo UT. 84604 p 820.137.3436 (UT) p 385.388.8003 Phone Number Only - Timpanogos Regional Hospital p 800.686.7993 Bingham, Scott E MD Hospital Affiliation Revere Health Creer, Analee APRN - Davis Hospital Edgepark 700 W 800 N MountainStar - Lakeview Hospital Phone Number Only Ste 230 Cardiovascular Surgery - Ogden Regional Medical p 800.321.0591 Orem UT. 84057 698 W 800 N Center p 801.429.0620 Ste 210 - Salt Lake Regional Medical Cardiac Monitoring Orem UT. 84057 Center Remote Cardiac Services 972 N 600 E p 801.714.6412 Phone Number Only Spanish Fork UT. 84660 Paulson, Toby DO p 800.367.0300 p 801.465.4896 Hospital Affiliation Revere Health - Timpanogos Regional Hospital 3000 N Triumph Blvd eCardio Diagnostics Hospital Affiliation Lehi UT. 84043 Phone Number Only - Timpanogos Regional Hospital Dahl, Charles F MD p 801.373.4366 p 888.400.3522 - Gunnison Valley Hospital Revere Health - Mountain View Hospital 700 W 800 N 700 W 800 N Cardiology (UT) Ste 230 Ste 230 Allen, Marvin R MD Orem UT. 84057 Orem UT. 84057 Revere Health Borchardt, Roger L MD p 801.429.0620 p 801.492.0620 700 W 80 N Heart and Lung Institute - Ste 230 Mountain Point Hospital Affiliation Perry, David E DO Orem UT. 84057 3000 N Triumph Blvd - Timpanogos Regional Hospital Revere Health p 801.492.2815 Ste 300 - Mountain View Hospital 700 W 800 N Lehi UT. 84043 (UT) Ste 230 700 W 800 N p 801.753.4700 Orem UT. 84057 Ste 230 Edwards, Thomas S MD p 801.373.4366 Orem UT. 84057 Heart & Lung Institute Of Wasatch Cardiovascular p 801.492.2815 Utah - Lehi Services 972 N 600 E 3000 N Triumph Blvd 3000 N Triumph Blvd Spanish Fork UT. 84660 Hospital Affiliation Ste 320 Ste 330 p 801.465.4896 - Timpanogos Regional Hospital Lehi UT. 84043 Lehi UT. 84043 - Mountain View Hospital p 801.753.4700 p 801.463.7411 (UT) - Gunnison Valley Hospital Hospital Affiliation - Lone Peak Hospital

480 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Thorne, J Kent MD Cardiovascular Surgery Guymon, Tiffani J CNM Lass, Stevie N CNM MountainStar Hunter, Curtis T MD Valley Obstetrics & Valley Obstetrics & Cardiovascular Surgery MountainStar Gynecology Gynecology 700 W 800 N Cardiovascular Surgery 527 W 400 N 1228 N Commerce Dr Ste 444 700 W 800 N Ste 4 Saratoga Springs Ut. 84045 Orem UT. 84057 Ste 444 Orem UT. 84057 p 801.756.1577 p 801.743.4750 Orem UT. 84057 p 801.404.5588 p 801.743.4750 1248 E 90 N Hospital Affiliation 585 N 500 W Ste 300 - St Marks Hospital Certified Nurse Midwife Provo UT. 84601 American Fork UT. 84003 - Ogden Regional Medical Christensen, Amanda J CNM p 801.404.5588 p 801.756.9635 Center Valley Obstetrics & - Timpanogos Regional Hospital Gynecology Hardy, Kathryn CNM 3000 N Triumph Blvd 1228 N Commerce Dr Valley Obstetrics & Lehi UT. 84043 UUHC Parkway Health Center Saratoga Springs Ut. 84045 Gynecology p 801.756.9635 145 W University Pkwy p 801.756.1577 1228 N Commerce Dr Orem UT. 84058 Saratoga Springs Ut. 84045 Lee, Diana J CNM p 801.234.8600 1248 E 90 N p 801.756.1577 Revere Health Ste 300 1886 W 800 N Wang, David C MD American Fork UT. 84003 1248 E 90N Pleasant Grove UT. 84062 Revere Health p 801.756.1577 Ste 300 p 801.756.5288 972 N 600 E American Fork Ut. 84003 Spanish Fork UT. 84660 3000 N Truimph Blvd p 801.756.1577 3000 N Triumph Blvd p 801.465.4896 Ste 210 Ste 100 Lehi Ut. 84043 3000 N Truimph Blvd Lehi UT. 84043 Hospital Affiliation p 801.756.1577 Ste 210 p 801.756.5288 - Timpanogos Regional Hospital Lehi Ut. 84043 Dhungel, Sweta CNM p 801.756.1577 3943 Pony Express Pkwy Weaver, Aaron N MD Valley Obstetrics & Ste 110-A Revere Health Gynecology Killebrew, Claudia CNM Eagle Mountain UT. 84005 3000 N Triumph Blvd 1248 E 90 N Valley Obstetrics & p 801.756.5288 Ste 100 Ste 300 Gynecology Lehi UT. 84043 American Fork UT. 84003 1228 N Commerce Dr Hospital Affiliation p 801.373.4366 p 801.756.1577 Saratoga Springs Ut. 84045 - Timpanogos Regional Hospital p 801.756.1577 700 W 800 N 3000 N Truimph Blvd Lindstrom, Becky CNM Ste 230 Ste 210 1248 E 90N Valley Obstetrics & Orem UT. 84057 Lehi UT. 84043 Ste 300 Gynecology p 801.429.0620 p 801.756.9635 American Fork Ut. 84003 1228 N Commerce Dr p 801.756.1577 Saratoga Springs UT. 84045 Hospital Affiliation Hospital Affiliation p 801.756.9635 - Timpanogos Regional Hospital - Mountain Point Medical 3000 N Truimph Blvd - Mountain View Hospital Center Ste 210 1248 E 90 N (UT) Lehi Ut. 84043 Ste 300 DiVall, Leslie CNM p 801.756.1577 American Fork UT. 84003 Zubair, Imran MD Mountainlands Community p 801.756.9635 Mountain Point Medical Health Center Krebs, Jennifer J CNM Center 589 S State St Valley Obstetrics & 3000 N Triumph Blvd 3000 N Triumph Blvd Provo UT. 84606 Gynecology Lehi UT. 84043 Lehi UT. 84043 p 801.429.2000 1228 N Commerce Dr p 801.756.9635 p 385.345.3000 Saratoga Springs Ut. 84045 Glifort, Virginia M CNM p 801.756.1577 Meidell, Emily CNM Hospital Affiliation Valley Obstetrics & Revere Health - Salt Lake Regional Medical Gynecology 1248 E 90 N 1886 W 800 N Center 1248 E 90 N Ste 300 Pleasant Grove UT. 84062 Ste 300 American Fork UT. 84003 p 801.756.5288 Cardiothoracic Surgery American Fork UT. 84003 p 801.756.1577 Karwande, Shreekanth MD p 801.756.9635 3943 Pony Express Pkwy MountainStar 3000 N Triumph Blvd Ste 110-A Cardiovascular Surgery 3000 N Triumph Blvd Lehi UT. 84043 Eagle Mountain UT. 84005 700 W 800 N Lehi UT. 84043 p 801.756.9635 p 801.756.5288 Ste 444 p 801.756.9635 Orem UT. 84057 p 801.743.4750

Hospital Affiliation - St Marks Hospital - Ogden Regional Medical Center - Timpanogos Regional Hospital - Lakeview Hospital 481 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Nackos, Tina CNM Wilson, Renee P CNM Addiction and Barrow, Alec D CMHC Valley Obstetrics & Valley Obstetrics & Psychological Services 1355 N University Ave Gynecology Gynecology 224 N Orem Blvd Ste 200 527 W 400 N 527 W 400 N Orem UT. 84057 Provo UT. 84604 Ste 4 Ste 4 p 801.222.0603 p 801.221.0223 Orem UT. 84057 Orem UT. 84057 p 801.404.5588 p 801.404.5588 81 N Ctr St Belliston, Nancy L LCSW American Fork UT. 84003 Deseret Counseling 585 N 500 W 585 N 500 W p 801.847.7272 1413 S 550 E Provo UT. 84601 Provo UT. 84601 Ste 106 p 801.374.1801 p 801.404.5588 826 N 100 E Orem UT. 84097 Ste 2-B p 801.360.3166 700 W 800 N 700 W 800 N Spanish Fork UT. 84660 Ste 200 Ste 200 p 801.794.2350 Bergvall, Phoebe CMHC Orem Ut. 84057 Orem UT. 84057 Ascendant Behavioral p 801.404.5588 p 801.756.9635 Alder, Andrew CMHC Health Summit Community 3051 W Maple Loop Dr Nelson, Erica C CNM Chiropractic Counseling Ste 210 Valley Obstetrics & Clark, Jerry S DC 1429 S 550 E Lehi UT. 84043 Gynecology Alpine Spinal Ste 260 p 801.872.5516 1228 N Commerce Dr Rehabilitation Orem UT. 84057 Saratoga Springs Ut. 84045 3325 N University Ave p 801.266.2485 Best, Lanette R CMHC p 801.756.1577 Ste 125 Valley Behavioral Health Provo UT. 84604 Archuleta, Jason LCSW 1875 S State St 1248 E 90 N p 801.374.2774 Utah Behavior Services Ste 1000 Ste 300 216 E Main St Orem UT. 84097 American Fork UT. 84003 Goodman, Kenneth M DC Ste 4 p 888.949.4864 p 801.756.1577 Goodman Chiropractic Lehi UT. 84043 85 E Crossroads Blvd p 801.255.5131 751 E 700 S 3000 N Triumph Blvd Saratoga Springs UT. 84045 Ste 102 Lehi UT. 84043 p 801.766.0507 Astorga, Polly A LMFT American Fork UT. 84003 p 801.756.9635 Polly Anne Astorga LMFT p 888.949.4864 McClean, Devin D DC 2940 W Maple Loop Dr Porter, Karlie CNM McClean Clinic Ste L02 Bischoff, Rodger D CMHC Valley Obstetrics & 385 N 500 W Lehi UT. 84043 Eagle Mountain Counseling Gynecology Provo UT. 84601 p 801.404.0604 3726 E Campus Dr 527 W 400 N p 801.373.1035 Ste H Ste 4 Atkin, Kayla LCSW Eagle Mountain UT. 84005 Orem UT. 84057 McClean, Matthew R DC Healings Steps Counseling p 801.642.4196 p 801.404.5588 McClean Clinic 111 E Main St 385 N 500 W Ste L4 Black, Jed CMHC 700 W 800 N Provo UT. 84601 Lehi UT. 84043 Utah Behavior Services Ste 200 p 801.373.1035 p 801.980.3676 216 E Main St Orem UT. 84057 Ste 4 p 801.404.5588 Rosquist, Bryon DC Atwood, Caidy LCMHC Lehi UT. 84043 405 S 100 E Healings Steps Counseling p 801.255.5131 Schlegelmilch, Sue CNM Ste 104 111 E Main St Valley Obstetrics & Pleasant Grove UT. 84062 Ste L4 Bradley, Jessica L CMHC Gynecology p 801.785.9411 Lehi UT. 84043 Valley Behavioral Health 527 W 400 N p 801.980.3676 1875 S State St Ste 4 Vanchiere, Charles M DC Ste 1000 Orem Ut. 84057 Alpine Spinal Ball, Jarom LMFT Orem UT. 84097 p 801.404.5588 Rehabilitation Utah Psychological p 888.949.4864 3325 N University Ave Associates 585 N 500 W Ste 125 3549 N University Ave 751 E 700 S Provo UT. 84601 Provo UT. 84604 Ste 200 Ste 102 p 801.374.1801 p 801.374.2774 Provo UT. 84604 American Fork UT. 84003 p 801.377.2014 p 888.949.4864 700 W 800 N Counseling Ste 200 Acevedo, Carlos ACMHC Barkdull, Matthew D LMFT Buck, Timothy C CMHC Orem Ut. 84057 Utah Behavior Services Paramount Counseling Ascendant Behavioral p 801.404.5588 216 E Main St Solutions Health Ste 4 1177 S 800 E 3051 W Maple Loop Dr Hospital Affiliation Lehi UT. 84043 Orem UT. 84097 Ste 210 - Timpanogos Regional Hospital p 801.255.5131 p 888.990.0320 Lehi UT. 84043 p 801.872.5516

482 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Caleron, Chrstina CMHC 751 E 700 S Eckerselll, William CMHC 751 E 700 S Ascendant Behavioral Ste 102 Ascendant Behavioral Ste 102 Health American Fork UT. 84003 Health American Fork UT. 84003 3051 W Maple Loop Dr p 888.949.4864 3051 W Maple Loop Dr p 888.949.4864 Ste 210 Ste 210 Lehi UT. 84043 Dastrup, Suzanne L LMFT Lehi UT. 84043 Francom, Aimee L p 801.502.3913 Linden Tree Therapy p 801.872.5516 Lifes Solutions Counseling 831 N 1420 E 309 N State St Clawson, Jason LCSW Orem UT. 84097 Ellis, John LMFT Orem UT. 84057 Affinity Guidance Services p 385.225.0464 Cedar Psychiatry p 801.404.3069 Inc 1788 N State St 1971 N State St Dawson-Lovess, S Collette Orem UT. 84663 Francom, Austin P APRN Provo UT. 84604 CSW p 801.369.8989 Envision Physician p 855.200.2471 The Green House for Growth Services & Learning 672 W 400 S 1345 W 1600 N Cunningham, Jeanna CMHC 135 W Center St Ste 201 Orem UT. 84057 Valley Behavioral Health Pleasant Grove UT. 84062 Springville UT. 84663 p 801.225.7971 1875 S State St p 801.785.1169 p 801.369.8989 Ste 1000 Gibson, Jacob PhD,LMFT Orem UT. 84097 Dixon, Randal LMHC Emmons, Dana LMFT The Green House for Growth p 888.949.4864 Ascendant Behavioral Health Plus Clinic & Learning Health 376 E 400 S 135 W Center St 751 E 700 S 3051 W Maple Loop Dr Springville UT. 84663 Pleasant Grove UT. 84062 Ste 102 Ste 210 p 801.491.9355 p 801.785.1169 American Fork UT. 84003 Lehi UT. 84043 p 888.949.4864 p 801.872.5516 61 W 3200 N Gillespie, Amy LCSW Lehi UT. 84043 Life Stone Counseling Dagley, Krystal C Dobbs, Sareta LPC p 385.352.0404 Center Ascendant Behavioral Ascendant Behavioral 150 S 400 E Health Health England, Kimberly CMHC American Fork UT. 84003 3051 W Maple Loop Dr 3051 W Maple Loop Dr Ascendant Behavioral p 801.980.7222 Ste 210 Ste 210 Health Lehi UT. 84043 Lehi UT. 84043 3051 W Maple Loop Dr Gonzalez, Rosanne LCSW p 801.502.3913 p 801.502.3913 Ste 210 Healings Steps Counseling Lehi UT. 84043 111 E Main St Daniels, Marianne CMHC Dommer, Martin L LMFT p 801.872.5516 Ste L4 Cedar Psychiatry Marriage & Family Therapy Lehi UT. 84043 1788 N State St Payson Fahlberg, Cory LMFT p 801.980.3676 Orem UT. 84663 766 E 100 N Ascendant Behavioral p 801.369.8989 Payson UT. 84651 Health Goss, Angela CSW p 801.885.1316 3051 W Maple Loop Dr Utah Behavior Services Ascendant Behavioral Ste 210 216 E Main St Health Doubek, Anne CMHC Lehi UT. 84043 Ste 4 3051 W Maple Loop Dr Ascendant Behavioral p 801.872.5516 Lehi UT. 84043 Ste 210 Health p 801.255.5131 Lehi UT. 84043 3051 W Maple Loop Dr Fenn, Danielle LMFT p 801.872.5516 Ste 210 Health Plus Clinic Gunnell, Ryan C LMFT Lehi UT. 84043 376 E 400 S Psychological Assessment Cedar Psychiatry p 801.872.5516 Springville UT. 84663 and Treatment Specialists 672 W 400 S p 801.491.9355 814 E Bamberger Dr Ste 201 Dow, Reed CMHC Ste A Springville UT. 84663 Ascendant Behavioral Fesler, Shaun CMHC American Fork UT. 84003 p 801.369.8989 Health Utah Psychological p 801.772.0202 3051 W Maple Loop Dr Associates Dasianu, Ashely C LMFT Ste 210 3549 N University Ave Halvorson, Isabelle T LPC Eagle Mountain Counseling Lehi UT. 84043 Ste 200 Matt Larson Psychotherapy 3726 E Campus Dr p 801.872.5516 Provo UT. 84604 and Associates Ste H p 801.377.2014 433 Glacier Lily Dr Eagle Mountain UT. 84005 Durfey, Roger LMFT Alpine UT. 84004 p 801.642.4196 Ascendant Behavioral Fordham, Bruce K CMHC p 801.671.7612 Health Valley Behavioral Health Dastrup, Karen L LMFT 3051 W Maple Loop Dr 1875 S State St Hancock, Lacey LMHC Valley Behavioral Health Ste 210 Ste 1000 Life Stone Counseling 1875 S State St Lehi UT. 84043 Orem UT. 84097 Center Ste 1000 p 801.872.5516 p 888.949.4864 150 S 400 E Orem UT. 84097 American Fork UT. 84003 p 888.949.4864 p 801.980.7222

483 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Valley Behavioral Health Hinkle, Angela L LMFT Kids On The Move Koller, Karolee LCSW 1875 S State St Valley Behavioral Health 475 W 260 N Affinity Guidance Services Ste 1000 1875 S State St Orem UT. 84057 Inc Orem UT. 84097 Ste 1000 p 801.221.9930 1971 N State St p 888.949.4864 Orem UT. 84097 Provo UT. 84604 p 888.949.4864 Killpack, Ruth M PhD p 855.200.2471 751 E 700 S Aspen Therapy Inc Ste 102 751 E 700 S 3707 N Canyon Rd Kronmiller, Kalli CMHC American Fork UT. 84003 Ste 102 Ste 8F Valley Behavioral Health p 888.949.4864 American Fork UT. 84003 Provo UT. 84604 1875 S State St p 888.949.4864 p 801.225.3111 Ste 100 Hansen, Allison LCSW Orem UT. 84097 Affinity Guidance Services Hobby, Esperanza A LMFT King, Kelsey LCSW p 888.949.4864 Inc Valley Behavioral Health Utah Behavior Services 1971 N State St 1875 S State St 216 E Main St Landvatter, Jared LCPC Provo UT. 84604 Ste 1000 Ste 4 Alpine Counseling Center p 855.200.2471 Orem UT. 84097 Lehi UT. 84043 475 W 50 N p 888.949.4864 p 801.255.5131 American Fork UT. 84003 Harper, Jessica L LPC p 801.756.3664 210 W 520 N 751 E 700 S Kirschner, Rebecca CMHC Orem UT. 84057 Ste 102 Valley Behavioral Health Larrabee, Angelique R p 801.224.1103 American Fork UT. 84003 1875 S State St CMHC p 888.949.4864 Ste 1000 Valley Behavioral Health Healings Steps Counseling Orem UT. 84097 1875 S State St 111 E Main St Holman, Jim LMFT p 888.949.4864 Ste 1000 Ste L4 Eagle Mountain Counseling Orem UT. 84097 Lehi UT. 84043 3726 E Campus Dr 751 E 700 S p 888.949.4864 p 801.980.3676 Ste H Ste 102 Eagle Mountain UT. 84005 American Fork UT. 84003 751 E 700 S Heer, Crystal A LPC p 801.642.4196 p 888.949.4864 Ste 102 Preferred Family Clinic American Fork UT. 84003 1355 N University Ave Horne, Christine CMHC RK General Consultants p 888.949.4864 Ste 200 Valley Behavioral Health 837 N 500 W Provo UT. 84604 751 E 700 S American Fork UT. 84003 Larsen, Danette CMHC p 801.221.0223 Ste 102 p 801.699.5362 Life Stone Counseling American Fork UT. 84003 Center Henrie, Patricia CMHC p 888.949.4864 Kirschner, Richard D CMHC 150 S 400 E Riverwoods Therapy Valley Behavioral Health American Fork UT. 84003 202 E 800 S Hutchinson, Mark 1875 S State St p 801.980.7222 Ste 104 Ascendant Behavioral Ste 100 Orem UT. 84058 Health Orem UT. 84097 Larsen, Melissa L CMHC p 801.787.9855 3051 W Maple Lp Dr p 888.949.4864 Valley Behavioral Health Ste 210 1875 S State St Hernandez, June Lee CMHC Lehi UT. 84043 751 E 700 S Ste 1000 Valley Behavioral Health p 801.502.3913 Ste 102 Orem UT. 84097 1875 S State St American Fork UT. 84003 p 888.949.4864 Ste 1000 Jacob, Alan R LPC p 888.949.4864 Orem UT. 84097 Preferred Family Clinic 751 E 700 S p 888.949.4864 1355 N University Ave RK General Consultants Ste 102 Ste 200 837 N 500 W American Fork UT. 84003 751 E 700 S Provo UT. 84604 American Fork UT. 84003 p 888.949.4864 Ste 102 p 801.221.0223 p 801.699.5362 American Fork UT. 84003 Lee, Susannah R LMFT p 888.949.4864 Judson, Ryan CMHC Klein, Leah R LPC Eagle Mountain Counseling Ascendant Behavioral Psychological Assessment 3726 E Campus Dr Hess, Brandi E LMFT Health and Treatment Specialists Ste H Eagle Mountain Counseling 3051 W Maple Loop Dr 814 E Bamberger Dr Eagle Mountain UT. 84005 3726 E Campus Dr Ste 210 Ste A p 801.789.7780 Ste H Lehi UT. 84043 American Fork UT. 84003 Eagle Mountain UT. 84005 p 801.872.5516 p 801.772.0202 Levstek Caplin, Deirdre A p 801.642.4196 PhD Keeler, Celeste LMFT Koh, Kyung-Ran CMHC University of Utah Health Healings Steps Counseling Ascendant Behavioral 151 S University Ave 111 E Main St Health Ste 1610 Ste L4 3051 W Maple Loop Dr Provo UT. 84601 Lehi UT. 84043 Ste 210 p 801.587.2255 p 801.980.3676 Lehi UT. 84043 p 801.502.3913 484 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Lewis, Brian ACMHC 135 W Center St Nuttall, Marie LPC Preston, Shara LCMHC Healings Steps Counseling Pleasant Grove UT. 84062 Ascendant Behavioral Healings Steps Counseling 111 E Main St p 801.785.1169 Health 111 E Main St Ste L4 3051 W Maple Loop Dr Ste L4 Lehi UT. 84043 McStotts, Kelli CMHC Ste 210 Lehi UT. 84043 p 801.980.3676 Summit Community Lehi UT. 84043 p 801.980.3676 Counseling p 801.872.5516 Lofthouse, Chelsea ACMHC 359 E 1200 S Proctor, Lyndsey D LCSW Utah Behavior Services Orem UT. 84058 Oka, Megan LMFT Serenity Recovery and 216 E Main St p 801.266.2485 Megan Oka LMFT Wellness Ste 4 602 Campus Dr 39 Professional Way Lehi UT. 84043 Mccune, Tara J CMHC Orem UT. 84058 Ste 2 p 801.255.5131 Valley Behavioral Health p 435.213.3062 Payson UT. 84651 751 E 700 S p 801.658.0098 Louw, Keith LMFT Ste 102 Packer, Candice CSW Peak Relational Counseling American Fork UT. 84003 The Green House for Growth RK General Consultants 1450 E 820 N p 888.949.4864 & Learning 837 N 500 W Orem UT. 84097 135 W Center St American Fork UT. 84003 p 801.472.8442 Miller, Robert LPC Pleasant Grove UT. 84062 p 801.699.5362 Ascendant Behavioral p 801.785.1169 Lovelace, Scott LCMHC Health Ranks, Georgann LPC Utah Behavior Services 3051 W Maple Loop Dr Pallos, Petra LPC Ascendant Behavioral 216 E Main St Ste 210 Ascendant Behavioral Health Ste 4 Lehi UT. 84043 Health 3051 W Maple Loop Dr Lehi UT. 84043 p 801.872.5516 3051 W Maple Loop Dr Ste 210 p 801.255.5131 Ste 210 Lehi UT. 84043 Mitchell, Merikay CMHC Lehi UT. 84043 p 801.872.5516 Lund, Lori LMFT Ascendant Behavioral p 801.872.5516 Ascendant Behavioral Health Rasmussen, Kipling S PhD Health 3051 W Maple Loop Dr Palmer-Merrill, Lauren K Affinity Guidance Services 3051 W Maple Loop Dr Ste 210 BCBA Inc Ste 210 Lehi UT. 84043 Kids On The Move 1971 N State St Lehi UT. 84043 p 801.872.5516 475 W 260 N Provo UT. 84604 p 801.502.3913 Orem UT. 84057 p 855.200.2471 Moleni, Fisi LCSW p 801.221.9930 Madsen, April LPC Affinity Guidance Services Utah Psychological Aspen Valley Counseling Inc Pauole, Allan K CMHC Associates 210 W 520 N 1971 N State St Revere Health 3549 N University Ave Orem UT. 84057 Provo UT. 84604 1055 N 500 W Bldg A Ste 200 p 801.224.1103 p 855.200.2471 Provo UT. 84604 Provo UT. 84604 p 801.812.5033 p 801.377.2014 McConnell, Scott CMHC Morris, Laura L LPC The Green House for Growth Preferred Family Clinic 700 W 800 N Reynolds, Susan M LPC & Learning 1355 N University Ave Ste 100 Susan Reynolds Counseling 135 W Center St Ste 200 Orem UT. 84057 3355 N University Ave Pleasant Grove UT. 84062 Provo UT. 84604 p 801.812.5033 Ste 250C p 801.785.1169 p 801.221.0223 Provo UT. 84604 Pearson, David LCSW p 801.427.9309 McDonald, Tyler CMHC Moss, Terri LMFT Affinity Guidance Services Valley Behavioral Health Ascendant Behavioral Inc Rich, Stacey 751 E 700 S Health 1971 N State St Ascendant Behavioral Ste 102 3051 W Maple Loop Dr Provo UT. 84604 Health American Fork UT. 84003 Ste 210 p 855.200.2471 3051 W Maple Loop Dr p 888.949.4864 Lehi UT. 84043 Ste 210 p 801.872.5516 Ponce, Timothy W LMFT Lehi UT. 84043 McMillan, Myrna LMFT ABC Family Counseling p 801.502.3913 The Green House for Growth Nelson, Angela LCSW 1149 W Center St & Learning Healings Steps Counseling Orem UT. 84057 Ringold, Patricia LPC 1220 N Main St 111 E Main St p 801.361.2237 Ascendant Behavioral Ste 5 Ste L4 Health Springville UT. 84663 Lehi UT. 84043 Potts, Justin PSYD 3051 W Maple Loop Dr p 801.210.7216 p 801.980.3676 Summit Community Ste 210 Counseling Lehi UT. 84043 359 E 1200 S p 801.872.5516 Orem UT. 84058 p 801.266.2485

485 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Robinson, Brian CMHC Smith, Jennifer LCSW Thomas, Ruth A CMHC Warenski, Bonnie CMHC Alpine Counseling Center Affinity Guidance Services Eagle Mountain Counseling Alpine Counseling Center 475 W 50 N Inc 3726 E Campus Dr 475 W 50 N American Fork UT. 84003 1971 N State St Ste H American Fork UT. 84003 p 801.756.3664 Provo UT. 84604 Eagle Mountain UT. 84005 p 801.756.3664 p 855.200.2471 p 801.784.7780 Rogers, Tirzah L CMHC Waugaman, Laura CMHC Eagle Mountain Counseling Smith, Melanie J LMFT Thompson, Michael S LMFT Summit Community 3726 E Campus Dr Art City Family Counseling Valley Behavioral Health Counseling Ste H 1453 N 440 W 1875 S State St 1429 S 550 E Eagle Mountain UT. 84005 Mapleton UT. 84664 Ste 1000 Ste 260 p 801.642.4196 p 801.615.0554 Orem UT. 84097 Orem UT. 84057 p 888.949.4864 p 801.266.2485 Russett, Ebbie I CMHC Snyder, Daniel LCSW Valley Behavioral Health Healings Steps Counseling 751 E 700 S Webster, Peggy CMHC 1875 S State St 111 E Main St Ste 102 Ascendant Behavioral Ste 100 Ste L4 American Fork UT. 84003 Health Orem UT. 84097 Lehi UT. 84043 p 888.949.4864 3051 W Maple Loop Dr p 888.949.4864 p 801.980.3676 Ste 210 Tripp, Richard C CMHC Lehi UT. 84043 751 E 700 S Stambaugh, Leigh Ann Ascend Mental Health p 801.502.3913 Ste 102 CMHC 308 N Cherry Ln American Fork UT. 84003 Ascendant Behavioral Santaquin UT. 84655 Wesson, Brenda CMHC p 888.949.4864 Health p 801.210.9449 14 N Main St 3051 W Maple Loop Dr Springville UT. 84663 Salsberry, Maria CSW Ste 210 Veas-Wall, Rodrigo PhD p 801.310.7478 Utah Behavior Services Lehi UT. 84043 Preferred Family Clinic 216 E Main St p 801.872.5516 1355 N University Ave White, Shannon LMFT Ste 4 Ste 200 Healings Steps Counseling Lehi UT. 84043 Stasiuk, John A LMFT Provo UT. 84604 111 E Main St p 801.255.5131 Utah Behavior Services p 801.221.0223 Ste L4 216 E Main St Lehi UT. 84043 Sears, Wayne R CMHC Ste 4 Vonk, Vivian L CMHC p 801.980.3676 Life Stone Counseling Lehi UT. 84043 Ascendant Behavioral Center p 801.255.5131 Health Williams, David O LPC 150 S 400 E 3051 W Maple Loop Dr Choosing Joy Wellness American Fork UT. 84003 Steinke, Alyssa LMFT Ste 210 Clinic p 801.980.7222 Aspen Valley Wellness Lehi UT. 84043 313 E 1200 S 210 W 520 N p 801.872.5516 Ste 101 Seiler, Edward A CMHC Orem UT. 84057 Orem UT. 84058 Valley Behavioral Health p 801.224.1103 Wagstaff, Doug T LPC p 801.960.5388 1875 S State St Alpine Counseling Center Ste 1000 Stephenson, Sue A CMHC 475 W 50 N Winward, Karen LPC Orem UT. 84097 Ascendant Behavioral American Fork UT. 84003 Valley Behavioral Health p 888.949.4864 Health p 801.756.3664 1875 S State St 3051 W Maple Loop Dr Ste 1000 751 E 700 S Ste 210 Walker, David R CMHC Orem UT. 84097 Ste 102 Lehi UT. 84043 Valley Behavioral Health p 888.949.4864 American Fork UT. 84003 p 801.872.5516 1875 S State St p 888.949.4864 Ste 1000 751 E 700 S Stevens, Odessa CMHC Orem UT. 84097 Ste 102 Serenity Recovery and The Green House for Growth p 888.949.4864 American Fork UT. 84003 Wellness & Learning p 888.949.4864 39 Professional Way 135 W Center St 751 E 700 S Ste 2 Pleasant Grove UT. 84062 Ste 102 Woodard, Jeness L LCSW Payson UT. 84651 p 801.785.1169 American Fork UT. 84003 University of Utah Health p 801.658.0098 p 888.949.4864 145 W University Pkwy Tew, Kyle LMFT Orem UT. 84058 Skelton, Andy H LPC Acadian Counseling Walls, Sharon LMFT p 801.234.8600 1355 N University Ave Services Ascendant Behavioral Ste 200 796 Pacific Dr Health Utah Psychological Provo UT. 84604 Ste A 3051 W Maple Loop Dr Associates p 801.221.0223 American Fork UT. 84003 Ste 210 3549 N University Ave p 801.642.2491 Lehi UT. 84043 Ste 200 p 801.872.5516 Provo UT. 84604 p 801.377.2014

486 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Woods, Kevin CMHC Curtis, Julia A MD 220 N 1200 E Moss, Richard L MD Mountain Ridge Behavioral University of Utah Health Ste 203 University of Utah Health Health Center 145 W University Pkwy Lehi UT. 84043 145 W University Pkwy 704 S 1600 W Orem UT. 84058 p 801.418.0920 Orem UT. 84058 Ste 104 p 801.581.2955 p 801.581.2955 Mapleton UT. 84664 555 W SR 164 N p 801.491.6394 Hospital Affiliation Salem UT. 84653 Myers, David J MD - University of Utah Hospital p 801.465.4896 Utah Valley Dermatology Ybarra, Corylyn L CMHC 24 W Sergeant Ct Dr Valley Behavioral Health Donaldson, Mark L MD Goodsell, Brent H DO Ste 1 1875 S State St Revere Health 162 S 1100 E Saratoga Springs UT. 84045 Ste 1000 1055 N 500 W American Fork UT. 84003 p 801.768.8800 Orem UT. 84097 Ste 111 p 801.756.9669 p 888.949.4864 Provo UT. 84604 680 E Main St p 801.374.8999 Hospital Affiliation Ste 201 751 E 700 S - Timpanogos Regional Hospital Lehi UT. 84043 Ste 102 220 N 1200 E p 801.768.8800 American Fork UT. 84003 Ste 203 Harris, Jordan R DO p 888.949.4864 Lehi UT. 84043 Utah Valley Dermatology Hospital Affiliation p 801.418.0920 24 W Sergeant Ct Dr - Timpanogos Regional Hospital Zeidner, Kristina LMFT Ste 1 5 E 400 N Hospital Affiliation Saratoga Springs UT. 84045 Myers, Kevin C DO Ste 100 - Timpanogos Regional Hospital p 801.768.8800 Utah Valley Dermatology Springville UT. 84663 - Mountain View Hospital 24 W Sergeant Ct Dr p 801.852.5566 (UT) Huber, Brad S MD Ste 1 Revere Health Saratoga Springs UT. 84045 Dentist Eyre, Michael P DO 1055 N 500 W p 801.768.8800 Condie, Jared DMD Aspen Dermatology Ste 111 Mountainlands Community 114 E 800 N Provo UT. 84604 680 E Main St Health Center Spanish Fork UT. 84660 p 801.354.8225 Ste 201 910 E 100 N p 801.794.1490 Lehi UT. 84043 Ste 155 220 N 1200 E p 801.768.8800 Payson UT. 84651 753 S 1040 W Ste 203 p 801.429.2000 Payson UT. 84651 Lehi UT. 84043 Parkinson, Richard W p 801.794.1490 p 801.418.0920 MD,PhD Ferrell, D T DDS 5314 N 250 W University of Utah Health Hospital Affiliation Hospital Affiliation Ste 220 10 E State St - Mountain View Hospital - Timpanogos Regional Hospital Provo UT. 84604 Lehi UT. 84043 (UT) p 801.225.8484 p 801.766.3700 - Gunnison Valley Hospital Jenson, Kraig K MD 1385 E 750 N Hospital Affiliation Hospital Affiliation Eyre, Russell W MD Orem UT. 84097 - Timpanogos Regional Hospital - University of Utah Hospital Eyre Dermatology Clinic p 801.224.5200 486 W 800 N Peterson, Aaron DO Norman, Jason DMD Ste 201 Kuechle, Melanie K MD Premier Family Medical Mountainlands Community Orem UT. 84057 University of Utah Health 226 N 1100 E Health Center p 801.431.0300 145 W University Pkwy Ste A 589 S State St Orem UT. 84058 American Fork UT. 84003 Provo UT. 84606 Hospital Affiliation p 801.581.2955 p 801.855.3840 p 801.429.2000 - Timpanogos Regional Hospital Hospital Affiliation 48 N 1100 Dermatology Eyre, Steven P MD - University of Utah Hospital Ste 100 Bradshaw, Brian R MD Eyre Dermatology Clinic American Fork UT. 84003 Revere Health 486 W 800 N Leachman, Sancy A MD,PhD p 801.642.2950 1055 N 500 W Ste 201 University of Utah Health Ste 111 Orem UT. 84057 145 W University Pkwy Peterson, Chad R DO Provo UT. 84604 p 801.431.0300 Orem UT. 84058 Aspen Dermatology p 801.374.8999 p 801.581.2955 114 E 800 N Hospital Affiliation Spanish Fork UT. 84660 220 N 1200 E - Timpanogos Regional Hospital Macdonald, James MD p 801.794.1490 Ste 203 Revere Health Lehi UT. 84043 Garza, Reed M MD 220 N 1200 E 753 S 1040 W p 801.418.0920 Revere Health Ste 203 Payson UT. 84651 1055 N 500 W Lehi UT. 84043 p 801.794.1490 Hospital Affiliation Ste 111 p 801.418.0920 - Timpanogos Regional Hospital Provo UT. 84604 p 801.374.8999 Hospital Affiliation - Timpanogos Regional Hospital 487 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 89 E SR 198 220 N 1200 E Dietician 1675 N Freedom Blvd Ste D Ste 203 Day, Barbara RD Ste 15 Salem UT. 84653 Lehi UT. 84043 University of Utah Health Provo UT. 84604 p 801.794.1490 p 801.418.0920 1159 E 200 N p 801.373.0167 Ste 150 Hospital Affiliation Utah Valley Dermatology American Fork UT. 84003 Hospital Affiliation - Mountain View Hospital 24 W Sergeant Ct Dr p 801.373.0167 - University of Utah Hospital (UT) Ste 1 Saratoga Springs UT. 84045 Hospital Affiliation Speener, Melinda S RD Peterson, Michael W DO p 801.768.8800 - University of Utah Hospital University of Utah Health Springville Dermatology & 1159 E 200 N Diagnostics 680 E Main St DeLapp, Edith A RD Ste 150 732 N Main St Ste 201 University of Utah Health American Fork UT. 84003 Springville UT. 84663 Lehi UT. 84043 1159 E 200 N p 801.373.0167 p 801.704.7001 p 801.768.8800 Ste 150 American Fork UT. 84003 Hospital Affiliation Hospital Affiliation deShazo, Rosemary A MD p 801.763.0652 - University of Utah Hospital - Mountain View Hospital University of Utah Health (UT) 145 W University Pkwy Hospital Affiliation Ware, Suzanne O RD - Mountain West Medical Orem UT. 84058 - University of Utah Hospital University of Utah Health Center p 801.581.2955 1159 E 200 N Erickson, Rachel J RD Ste 150 Secrest, Aaron M MD Hospital Affiliation Mountain Springs Family American Fork UT. 84003 University of Utah Health - University of Utah Hospital Medicine p 801.373.0167 145 W University Pkwy 468 S Main St Orem UT. 84058 Diabetic Supplies Spanish Fork UT. 84660 Durable Medical Equipment p 801.581.2955 CCS Medical p 801.504.6117 Petersen Medical Phone Number Only 1268 S 1380 W Hospital Affiliation p 800.726.9811 Galvez, Lorraine RD Orem UT. 84058 - University of Utah Hospital Premier Family Medical p 801.374.8101 Edgepark 275 W 200 N Contour Dermatology Phone Number Only Lindon UT. 84042 325 E University Pkwy 3200 W Clubhouse Dr p 800.321.0591 p 801.796.1333 Orem UT. 84058 Ste 100 p 801.374.8101 Lehi UT. 84043 Roche Insulin Delivery Kennedy, Megan M RD p 385.273.3376 Systems Inc Revere Health Alpine Home Medical Phone Number Only 1055 N 500 W Bldg A 1481 N State St Smart, David R MD p 800.280.7801 Provo UT. 84604 Provo UT. 84604 University of Utah Health p 801.812.5033 p 801.852.0077 145 W University Pkwy US MED LLC Orem UT. 84058 Phone Number Only 700 W 800 N Phone Number Only p 801.581.2955 p 800.787.6331 Ste 220 p 800.686.7993 Orem UT. 84057 Contour Dermatology United States Medical p 385.203.1250 Apria Healthcare LLC 3200 W Clubhouse Dr Supply 400 N Geneva Rd Ste 100 Phone Number Only Rich, Kelsey RD Ste F Lehi UT. 84043 p 877.840.8218 1384 W State Rd Unit 24 Lindon UT. 84042 p 385.273.3376 Pleasant Grove UT. 84062 p 801.785.1000 Dialysis Center p 801.842.7095 Hospital Affiliation American Fork Dialysis CCS Medical - University of Utah Hospital 120 N 1220 E Snyder, Anna B RD Phone Number Only Ste 14 University of Utah Health p 800.726.9811 Stone, Richard L MD American Fork UT. 84003 1159 E 200 N 1375 N University Ave p 801.581.8578 Ste 150 Care Rehab and Orthopedic Provo UT. 84604 American Fork UT. 84003 Products (Muscle p 801.377.4745 Payson Regional Dialysis p 801.373.0167 Stimulators) Office Phone Number Only Hospital Affiliation 15 S 1000 E 15 S 1000 E p 800.487.9644 - Timpanogos Regional Hospital Payson UT. 84651 Ste 50 p 801.465.2060 Payson UT. 84651 DJO Global Tristani-Firouzi, Payam p 801.465.2060 Phone Number Only MD Provo Dialysis Center p 800.336.6569 Revere Health 1675 N Freedom Blvd 1055 N 500 W Bldg C Provo UT. 84604 Ste 111 p 801.373.0167 Provo UT. 84604 p 801.374.8999

488 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Dynasplint Systems Inc Orthopedic Services of Beus, Kirt S MD Grover, Olivia NP Phone Number Only Utah Peak ENT Associates Peak ENT Associates p 800.638.6771 415 E 1550 N 1055 N 300 W 1055 N 300 W Orem UT. 84097 Ste 401 Ste 401 EBI LLC (Bone Stimulators) p 801.949.4943 Provo UT. 84604 Provo UT. 84604 Phone Number Only p 801.357.7499 p 801.357.7499 p 800.526.2579 Pacific Medical Inc Phone Number Only Hospital Affiliation Hamilton, Sanford T MD Edgepark p 800.726.9180 - Timpanogos Regional Hospital Revere Health Phone Number Only - Central Valley Medical 1175 E 50 S p 800.321.0591 Peak Prosthetic Design Center Ste 211 504 E 770 N American Fork UT. 84003 Empi Inc (Neuromuscular Orem UT. 84097 Coy, Jen NP p 801.465.4805 Stimulator) p 801.972.5270 Hearing and Balance Phone Number Only Institute 3000 N Triumph Blvd p 800.328.2536 RespirTech 1055 N 300 W Lehi UT. 84043 Phone Number Only Ste 211 p 801.429.8000 Hanger Prosthetics and p 800.793.1261 Provo UT. 84604 Orthotics Inc p 801.852.9696 Hospital Affiliation 1355 N University Ave Roche Insulin Delivery - Timpanogos Regional Hospital Ste 160 Systems Inc Peak ENT Associates Provo UT. 84604 Phone Number Only 1055 N 300 W Harvey, Jinil K NP p 801.356.1830 p 800.280.7801 Ste 401 Peak ENT Associates Provo UT. 84604 1055 N 300 W Intermountain Orthopedic Smith Nephew Inc (Muscle p 801.357.7499 Ste 401 Care Stimulators) Provo UT. 84604 471 E 1000 S Phone Number Only Hospital Affiliation p 801.357.7499 Ste E p 800.821.5700 - Timpanogos Regional Hospital Pleasant Grove UT. 84062 Hospital Affiliation p 801.376.9004 US MED LLC Darley, David S MD - Timpanogos Regional Hospital Phone Number Only Hearing and Balance KCI USA Inc (Wound Vac p 800.787.6331 Institute Heras, Heidi A MD Only) 1055 N 300 W 482 W 50 N Phone Number Only United States Medical Ste 211 Ste 14 p 800.275.4524 Supply Provo UT. 84604 American Fork UT. 84003 Phone Number Only p 801.852.9696 p 801.492.7662 Lincare p 877.840.8218 1442 W Business Park Dr Peak ENT Associates Johnson, Jennifer H PA-C Orem UT. 84057 Valley Home Medical 1055 N 300 W South Valley Ear Nose And p 801.224.3338 538 S Commerce St Ste 401 Throat Orem UT. 84058 Provo UT. 84604 24 W Sergeant Ct Dr Northwest Orthotics and p 801.225.9979 p 801.357.7499 Ste 102 Prosthetics Saratoga Springs UT. 84045 1675 N Freedom Blvd Ear Nose And Throat Hospital Affiliation p 801.566.8304 Ste 12C Anderson, Peter C MD - Timpanogos Regional Hospital Provo UT. 84604 South Valley Ear Nose And Hospital Affiliation p 801.377.3433 Throat Ence, Bradford K MD - Jordan Valley Medical 24 W Sergeant Ct Dr Revere Health Center 1988 W 930 N Ste 102 39 N Professional Way Ste C Saratoga Springs UT. 84045 Ste 1 Meads, Garner B MD Pleasant Grove UT. 84062 p 801.566.8304 Payson UT. 84651 South Valley Ear Nose And p 801.377.3433 p 801.465.4805 Throat Hospital Affiliation 24 W Sergeant Ct Dr 671 E Kirby Ln - Jordan Valley Medical 700 W 800 N Ste 102 Ste 103 Center Ste 400 Saratoga Springs UT. 84045 Spanish Fork UT. 84660 Orem UT. 84057 p 801.566.8304 p 801.377.3433 Anderson, Zachary V MD p 801.465.4805 Peak ENT Associates Hospital Affiliation Orthofix Inc (Bone Growth 1055 N 300 W 972 N 600 E - Jordan Valley Medical Stimulators Physicians Ste 401 Spanish Fork UT. 84660 Center Only) Provo UT. 84604 p 801.465.4896 Phone Number Only p 801.357.7499 *Meier, Jeremy D MD p 800.535.4492 Hospital Affiliation PCH Cleft Hospital Affiliation - Mountain View Hospital Palate/Craniofacial-Utah - Utah Valley Hospital (UT) Valley - Timpanogos Regional Hospital - Gunnison Valley Hospital 1157 N 300 W - Timpanogos Regional Hospital Provo UT. 84604 p 801.662.1630

Hospital Affiliation - Primary Childrens Hospital489 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Nelson, Adam A PA-C Peak Pediatric Specialists 700 W 800 N Gamble, David NP South Valley Ear Nose And 3000 N Triumph Blvd Ste 230 Utah Endocrinology Throat Ste 260 Orem UT. 84057 Associates PLLC 24 W Sergeant Ct Dr Lehi UT. 84043 p 801.224.5373 629 Quality Dr Ste 102 p 385.477.6800 Ste E Saratoga Springs UT. 84045 Endocrinology American Fork UT. 84003 p 801.566.8304 Hospital Affiliation Ahmad, Shahzad MD p 801.747.2800 - Primary Childrens Hospital Endocrinology Center of Peak ENT Associates Utah Morgan, Sharla E NP 1055 N 300 W Shipley, Scott G MD 3000 N Triumph Blvd Thyroid Institute of Utah Ste 401 Peak ENT Associates Ste 340 1055 N 300 W Provo UT. 84604 1055 N 300 W Lehi UT. 84043 Ste 303 p 801.357.7499 Ste 401 p 801.871.8366 Provo UT. 84604 Provo UT. 84604 p 801.356.1300 Peterson, Brian R MD p 801.357.7499 Hospital Affiliation South Valley Ear Nose And - Timpanogos Regional Hospital 3000 N Triumph Blvd Throat 3000 N Triumph Blvd - Lone Peak Hospital Ste 260 24 W Sergeant Ct Dr Ste 260 Lehi UT. 84043 Ste 102 Lehi UT. 84043 Aljammal, Jules MD p 801.768.3531 Saratoga Springs UT. 84045 p 801.768.3500 JC Aljammal, PLLC p 801.566.8304 3000 N Triumph Blvd Nizam, M S MD Hospital Affiliation Ste 340 Revere Health Hospital Affiliation - Timpanogos Regional Hospital Lehi UT. 84043 1055 N 500 W - Jordan Valley Medical - Mountain Point Medical p 801.572.3433 Ste 205 Bldg C Center Center Provo UT. 84604 Hospital Affiliation p 801.429.8095 Riddle, Seth A MD Stephenson, Ryan MD - Mountain Point Medical Peak ENT Associates Peak ENT Associates Center 1175 E 50 S 1055 N 300 W 1055 N 300 W - Utah Valley Hospital Ste 241 Ste 401 Ste 401 American Fork UT. 84003 Provo UT. 84604 Provo UT. 84604 Brady, Bruce R MD p 801.429.8008 p 801.357.7499 p 801.357.7499 Utah Endocrinology Associates PLLC Hospital Affiliation 3000 N Triumph Blvd 3000 N Triumph Blvd 629 Quality Dr - Timpanogos Regional Hospital Ste 260 Ste 260 Ste E Lehi UT. 84043 Lehi UT. 84043 American Fork UT. 84003 Perkins, Kelly A PA p 801.768.3500 p 801.768.3500 p 801.747.2800 Utah Endocrinology Associates PLLC Hospital Affiliation Vanhille, Derek MD Hospital Affiliation 629 E Quality Dr - Timpanogos Regional Hospital Revere Health - St Marks Hospital Ste 204 39 N Professional Way American Fork UT. 84003 Robins, Kipp MD Ste 1 Falahati-Nini, Alireza p 801.747.2800 Revere Health Payson UT. 84651 MD 2230 N University Ave p 801.465.4805 Utah Endocrinology Segkos, Konstantinos Ste 9-B Associates PLLC Thyroid Institute of Utah Provo UT. 84604 700 W 800 N 60 N North County Blvd 1055 N 300 W p 801.375.3175 Ste 100 American Fork UT. 84003 Ste 303 Orem UT. 84057 p 801.747.2800 Provo UT. 84604 2230 N University Pkwy p 801.465.4805 p 801.356.1300 Ste 9B Hospital Affiliation Provo UT. 84604 Electrophysiology - St Marks Hospital 3000 N Triumph Blvd p 801.375.3175 Luni, Faraz K MD - Lone Peak Hospital Ste 260 Revere Health Lehi UT. 84043 Hospital Affiliation 1055 N 500 W Frieze, Todd W MD p 801.768.3531 - Timpanogos Regional Hospital Ste 101 Thyroid Institute of Utah Provo UT. 84604 3000 N Triumph Blvd Wilkerson, Jaclynn F NP Schramm, Jordan C MD p 801.373.4366 Ste 260 Utah Endocrinology Peak ENT Associates Lehi UT. 84043 Associates PLLC 1055 N 300 W 1175 E 50 S p 801.768.3531 629 Quality Dr Ste 401 Ste 251 Ste E Provo UT. 84604 American Fork UT. 84003 Hospital Affiliation American Fork UT. 84003 p 801.357.7499 p 801.373.4366 - Mountain Point Medical p 801.747.2800 Center - Utah Valley Hospital

490 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Family Practice Spanish Fork Family Beazer, Blake R MD Bingham, Jared L MD Adams, Bryan K APRN Medicine Mountain West Family Canyon View Medical Group Utah Valley Urgent Care 24 N 100 E Practice 94 W Main 127 E Main St Spanish Fork UT. 84660 3435 E Pony Express Pkwy Santaquin UT. 84655 Ste E p 801.798.5359 Ste 140 p 801.754.3122 Lehi UT. 84043 Eagle Mountain UT. 84005 p 801.766.9822 Hospital Affiliation p 801.789.2444 Hospital Affiliation - Mountain View Hospital - Mountain View Hospital 960 W 800 N (UT) Hospital Affiliation (UT) Orem UT. 84057 - Evanston Regional Hospital - Mountain West Medical p 801.766.9822 Center Boehler, Jana R PA-C Baker, Troy R MD Mountain Springs Family Allred, Don P DO Premier Family Medical Beckstead, David J MD Medicine PLLC Zenith Family Health 226 N 1000 E Canyon View Medical Group 468 S Main St Center Ste A 336 W 100 S Spanish Fork UT. 84660 24 W Sergeant Ct Dr American Fork UT. 84003 Spanish Fork UT. 84660 p 801.504.6117 Ste 1 p 801.855.3840 p 801.798.7301 Saratoga Springs UT. 84045 Bott, Wesley S DO p 801.407.3048 3943 E Pony Express Pkwy Hospital Affiliation Canyon View Medical Group Ste 120 - Mountain View Hospital 15 S 1000 E Hospital Affiliation Eagle Mountain UT. 84005 (UT) Payson UT. 84651 - Jordan Valley Medical p 801.789.5566 - Franklin County Medical p 801.465.9480 Center Center Barkdull, Jill B MD Spanish Fork Clinic Alpine Pediatrics-Urgent Premier Family Medical Beckstead, Russell J DO 325 W Ctr Care M-F 6pm-10pm Sat 226 N 1100 E Mapleton Medical Clinic Spanish Fork UT. 84660 9am-5pm Ste A 1429 S 1600 W p 801.798.7301 1912 W 930 N American Fork UT. 84003 Mapleton UT. 84664 Pleasant Grove UT. 84062 p 801.855.3841 p 801.489.8464 Santaquin Medical Clinic p 801.492.1999 94 W Main 275 W 200 N Canyon View Medical Group Santaquin UT. 84655 Anderson, Esme P FNP Ste 100 5 E 400 N p 801.754.3122 Athena Womens Clinic Lindon UT. 84042 Springville UT. 84663 1407 N State St p 801.796.1333 p 801.489.8464 Hospital Affiliation Ste A - Mountain View Hospital Orem UT. 84057 830 N 2000 W Bench, Pahl MD (UT) p 801.225.5323 Pleasant Grove UT. 84062 Mountainlands Community p 801.756.3511 Health Center Brockbank, Roger D MD Anderson, Karen J FNP 589 S State St Premier Family Medical Alpine Clinic Barkdull, Thad J MD Provo UT. 84606 226 N 1100 E 1175 E 3200 N Premier Family Medical p 801.429.2000 Ste A Lehi UT. 84043 226 N 1100 E American Fork UT. 84003 p 801.407.3000 Ste A Berg, William P MD p 801.855.3841 American Fork UT. 84003 Revere Health Andrews, Sarah M MD p 801.855.3841 4095 E Pony Express Pkwy 275 W 200 N Valley Obstetrics & Ste 1 Lindon UT. 84042 Gynecology 275 W 200 N Eagle Mountain UT. 84005 p 801.796.1333 585 N 500 W Lindon UT. 84042 p 801.429.8037 Provo UT. 84601 p 801.796.1333 830 N 2000 W p 801.374.1801 Berry, Steven L MD Pleasant Grove UT. 84062 830 N 2000 W Revere Health p 801.756.3511 700 W 800 N Pleasant Grove UT. 84062 173 N 400 W Ste 200 p 801.756.3511 Ste C11 Hospital Affiliation Orem UT. 84057 Orem UT. 84057 - Timpanogos Regional Hospital p 801.374.1801 Hospital Affiliation p 801.802.7373 - Timpanogos Regional Hospital Cameron, Matthew P DO Hospital Affiliation Hospital Affiliation Canyon View Medical Group - Timpanogos Regional Hospital Barton, Karl J NP - Timpanogos Regional Hospital 336 W 100 S Express Med Family Care Spanish Fork UT. 84660 Archer, Frank J MD 415 N Main St Biggs, Jeremy J MD p 801.798.7301 Hillside Medical Clinic Spanish Fork UT. 84660 University of Utah Health 118 N Main St p 801.798.9715 145 W University Pkwy 94 W Main Salem UT. 84653 Orem UT. 84058 Santaquin UT. 84655 p 801.477.9007 Hospital Affiliation p 801.234.8600 p 801.754.3122 - Castleview Hospital Hospital Affiliation - University of Utah Hospital

491 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 5 E 400 N 830 N 2000 W Clark, Robert B MD Cripe, Gary E PA Springville UT. 84663 Pleasant Grove UT. 84062 Revere Health Cherry Tree Family p 801.489.8464 p 801.756.3511 555 W SR 164 N Practice Salem UT. 84653 155 N 400 W Mapleton Medical Clinic Hospital Affiliation p 801.465.4896 Ste B6 724 S 1600 W - Timpanogos Regional Hospital Orem UT. 84057 Ste 203 97 S Professional Way p 801.224.1300 Mapleton UT. 84664 Chipman, S B MD Ste 2 p 801.489.8464 Stone Creek Family Payson UT. 84651 Crop, Justin A DO Practice p 801.465.4896 Premier Family Medical Canyon View Womens Care 910 E 100 N 1159 E 200 N Provo Ste 105 Hospital Affiliation Ste 100 777 N 500 W Payson UT. 84651 - Mountain View Hospital American Fork UT. 84003 Ste 203 p 801.465.1555 (UT) p 801.796.1333 Provo UT. 84601 - Timpanogos Regional Hospital p 801.465.2559 Chriss, Shauna APRN 226 N 1100 E Alpine Clinic Corry, Elwood J MD Ste A Canyon View Medical Group 1175 E 3200 N Premier Family Medical American Fork UT. 84003 910 E 100 N Lehi UT. 84043 226 N 1100 E p 801.855.3840 Payson UT. 84651 p 801.407.3000 Ste A p 801.465.9480 American Fork UT. 84003 275 W 200 N Christensen, Thomas R MD p 801.855.3841 Lindon UT. 84042 Carn, Thomas R MD On Call Doc p 801.796.1333 Revere Health 125 E Main St 275 W 200 N 575 S State St Ste 135 Lindon UT. 84042 3000 N Triumph Blvd Orem UT. 84058 American Fork UT. 84003 p 801.796.1333 Ste 220 p 801.225.2926 p 801.610.9159 Lehi UT. 84043 830 N 2000 W p 801.756.3511 Hospital Affiliation Precision Medical Urgent Pleasant Grove UT. 84062 - Timpanogos Regional Hospital Care & Family Practice p 801.756.3511 680 E Main St 348 E State Rd Lehi UT. 84043 Cashman Thomas, Mary Pleasant Grove UT. 84062 Hospital Affiliation p 801.768.1699 Michelle NP p 801.375.2207 - Timpanogos Regional Hospital Envision Physician 76 E Commerce Dr Services 65 W 200 N Cosgrave, Michael L MD Ste 204 1345 W 1600 N Ste 7 Premier Family Medical Saratoga Springs UT. 84045 Orem UT. 84058 Spanish Fork UT. 84660 226 N 1100 E p 801.766.8427 p 801.225.7971 p 801.375.2207 Ste A American Fork UT. 84003 830 N 2000 W Chappell, Craig D DO 75 S 200 E p 801.855.3841 Pleasant Grove UT. 84062 In-2-It Medical Ste 202 p 801.756.3511 1888 W 800 N Provo UT. 84606 275 W 200 N Pleasant Grove UT. 84062 p 801.375.2207 Ste 100 Hospital Affiliation p 801.610.7321 Lindon UT. 84042 - Mountain Point Medical Claris Health p 801.796.1333 Center Hospital Affiliation 350 E 300 N - Timpanogos Regional Hospital American Fork UT. 84003 680 E Main St Crump, Kenneth L MD p 801.756.5293 Lehi UT. 84043 Crossroads Family Medicine Cherrington, Steven B DO p 801.768.1699 41 E 1140 N Premier Family Medical Clark, Matthew B MD Ste C 226 N 1100 E Revere Health 830 N 2000 W Saratoga Springs UT. 84045 Ste A 1886 W 800 N Pleasant Grove UT. 84062 p 801.766.2121 American Fork UT. 84003 Pleasant Grove UT. 84062 p 801.756.3511 p 801.855.3840 p 801.756.5288 Lakeview Family Medicine Hospital Affiliation 811 N 900 W 275 W 200 N 3000 N Triumph Blvd - Salt Lake Regional Medical Orem UT. 84057 Lindon UT. 84042 Ste 100 Center p 801.434.7600 p 801.796.1333 Lehi UT. 84043 p 801.756.5288 Craner, Adam C FNP-C Hospital Affiliation 680 E Main St Envision Physician - Timpanogos Regional Hospital Lehi UT. 84043 3943 Pony Express Pkwy Services p 801.768.1699 Ste 110-A 1345 W 1600 N Curtis, Michael MD Eagle Mountain UT. 84005 Orem UT. 84057 Premier Family Medical p 801.756.5288 p 801.225.7971 155 W 400 N Ste B6 Hospital Affiliation Hospital Affiliation Orem UT. 84057 - Timpanogos Regional Hospital - Ogden Regional Medical p 801.224.1300 Center 492 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 226 N 1100 E Egan, Daniel W MD 275 W 200 N Gasser, Brian D APRN Ste A Alpine Family Medicine Lindon UT. 84042 772 E 100 N American Fork UT. 84003 155 W Canyon Crest Rd p 801.796.1333 Ste 6 p 801.855.3840 Alpine UT. 84004 Payson UT. 84651 p 801.763.9851 3000 N Triumph Blvd p 801.465.7758 275 W 200 N Ste 220 Lindon UT. 84042 Envision Physician Lehi UT. 84043 Hospital Affiliation p 801.796.1333 Services p 801.753.4650 - Utah Valley Hospital 1345 W 2600 N 830 N 2000 W Orem UT. 84057 3943 E Pony Express Pkwy Grover, Bruce MD Pleasant Grove UT. 84062 p 801.225.7971 Ste 120 Mountainlands Community p 801.756.3511 Eagle Mountain UT. 84005 Health Center Farley-Jones, Dianne MD p 801.789.5566 589 S State St Hospital Affiliation Alpine Clinic Provo UT. 84606 - Timpanogos Regional Hospital 1175 E 3200 N 680 E Main St p 801.429.2000 Lehi UT. 84043 Lehi UT. 84043 Daniels, Elizabeth NP p 801.407.3000 p 801.768.1699 Hafen, David K MD Optimal Health Family Premier Family Medical Practice Hospital Affiliation 830 N 2000 W 226 N 1100 E 75 S 200 E - Timpanogos Regional Hospital Pleasant Grove UT. 84062 Ste A Ste 100 p 801.756.3511 American Fork UT. 84003 Provo UT. 84606 Fernandez, Salvador MD p 801.855.3841 p 801.877.5801 Mountainlands Community Frandsen, Tracy M MD Health Center Canyon View Medical Group 680 E Main St Day, Shelly A NP 589 S State St 325 W Ctr St Lehi UT. 84043 Cherry Tree Family Provo UT. 84606 Spanish Fork UT. 84660 p 801.768.1699 Practice p 801.429.2000 p 801.798.7301 155 N 400 W 830 N 2000 W Ste B6 Fjeldsted, Thomas H DO Hospital Affiliation Pleasant Grove UT. 84062 Orem UT. 84057 Blue Rock Medical Center - Mountain View Hospital p 801.756.3511 p 801.224.1300 3152 N University Ave (UT) Ste 220 Hospital Affiliation Donaldson, Richard J DO Provo UT. 84604 Frazier, Mark A MD - Timpanogos Regional Hospital Canyon View Medical Group p 801.375.2177 Express Med Family Care 336 W 100 S 1172 E 100 N Hafen, Mark DO Spanish Fork UT. 84660 Foster, Carla MD Ste 11 Premier Family Medical p 801.798.7301 Medallus Medical Payson UT. 84651 226 N 1100 E 476 N 900 W p 801.798.9700 Ste A 94 W Main Ste C American Fork UT. 84003 Santaquin UT. 84655 American Fork UT. 84003 Hospital Affiliation p 801.855.3841 p 801.754.3122 p 801.492.1611 - Castleview Hospital 680 E Main St Hospital Affiliation Frampton, Robert A MD Gale, Bradford A PA Lehi UT. 84043 - Castleview Hospital 24 N 100 E Alpine Pain Solutions of p 801.768.1699 - Mountain View Hospital Spanish Fork UT. 84660 Utah (UT) p 801.798.5359 3051 W Maple Loop Dr 830 N 2000 W Ste 125 Pleasant Grove UT. 84062 Doyle, Sean C DO Francis, William J DO Lehi UT. 84043 p 801.756.3511 Premier Family Medical Premier Family Medical p 801.766.6055 275 W 200 N 1159 E 200 N Hospital Affiliation Lindon UT. 84042 Ste 100 Hospital Affiliation - Timpanogos Regional Hospital p 801.796.1333 American Fork UT. 84003 - Jordan Valley Medical p 801.796.1333 Center Hammer, Jarrett DO 830 N 2000 W - Salt Lake Regional Medical Revere Health Pleasant Grove UT. 84062 155 W 400 N Center 555 W SR 164 N p 801.756.3511 Ste B6 Salem UT. 84653 Orem UT. 84057 Gardner, Stanley M MD p 801.465.4896 Hospital Affiliation p 801.224.1300 Alpine Clinic - Timpanogos Regional Hospital 1175 E 3200 N 972 N 600 E 226 N 1100 E Lehi UT. 84043 Spanish Fork UT. 84660 Durrans, Robert G MD Ste A p 801.407.3000 p 801.465.4896 Mountain Peaks Family American Fork UT. 84003 Practice p 801.855.3841 Hospital Affiliation 501 E 770 N - Mountain View Hospital Orem UT. 84097 (UT) p 801.724.9840

Hospital Affiliation - Timpanogos Regional Hospital 493 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Hansen, Orrin B NP Hogenson, Eric M MD 960 W 800 N Kennedy, Michael S MD Utah Valley Urgent Care Canyon View Medical Group Orem UT. 84057 Premier Family Medical 127 E Main St 325 W Ctr St p 801.766.9822 226 N 1100 E Ste E Spanish Fork UT. 84660 Ste A Lehi UT. 84043 p 801.798.7301 Hospital Affiliation American Fork UT. 84003 p 801.766.9822 - Mountain West Medical p 801.855.3841 Hospital Affiliation Center 960 W 800 N - Mountain View Hospital 275 W 200 N Orem UT. 84057 (UT) Johnson, Cheryl A MD Lindon UT. 84042 p 801.766.9822 Premier Family Medical p 801.796.1333 Hoggard, Timo J MD 226 N 1100 E Hardman, Joshua J DO Premier Family Medical Ste A 830 N 2000 W Premier Family Medical 226 N 1100 E American Fork UT. 84003 Pleasant Grove UT. 84062 226 N 1100 E Ste A p 801.855.3840 p 801.756.3511 Ste A American Fork UT. 84003 American Fork UT. 84003 p 801.855.3841 680 E Main St Hospital Affiliation p 801.756.3511 Lehi UT. 84043 - Timpanogos Regional Hospital 275 W 200 N p 801.768.1699 275 W 200 N Ste 100 Kerr, Jay D MD Lindon UT. 84042 Lindon UT. 84042 830 N 2000 W University of Utah Health p 801.796.1333 p 801.796.1333 Pleasant Grove UT. 84062 145 W University Pkwy p 801.756.3511 Orem UT. 84058 830 N 2000 W 830 N 2000 W p 801.234.8600 Pleasant Grove UT. 84062 Pleasant Grove UT. 84062 Hospital Affiliation p 801.756.3511 p 801.756.3511 - Timpanogos Regional Hospital Hospital Affiliation - University of Utah Hospital Hospital Affiliation Hospital Affiliation Jones, Justin E MD - Timpanogos Regional Hospital - Timpanogos Regional Hospital Revere Health Kimball, David V DO 1055 N 500 W Bldg A Revere Health Harline, Donald N MD Holmes, Richard J MD Provo UT. 84604 2183 W Main St Timpanogos Family Medicine Cotton Tree Medical p 801.812.5033 Ste A-107 423 N Orem Blvd 2230 N University Pkwy Lehi UT. 84043 Orem UT. 84057 Ste 1A 1175 E 50 S p 385.203.1215 p 801.426.8141 Provo UT. 84604 Ste 241 p 801.377.3413 American Fork UT. 84003 3000 N Triumph Blvd Hospital Affiliation p 801.812.5033 Lehi UT. 84043 - Timpanogos Regional Hospital Hospital Affiliation p 385.203.1215 - Timpanogos Regional Hospital 700 W 800 N Harrison, Heather DO Ste 220 Layton, Miles DO Revere Health Hunter, Judd D APRN Orem UT. 84057 Premier Family Medical 1055 N 500 W Utah Valley Urgent Care p 801.812.5033 1528 N Commerce Dr Ste A 127 E Main St Ste 204 Provo UT. 84604 Ste E Hospital Affiliation Saratoga Springs UT. 84045 p 801.429.8177 Lehi UT. 84043 - Timpanogos Regional Hospital p 801.766.8427 p 801.766.9822 Hospital Affiliation Jones, Steven L NP 155 W 400 N - Timpanogos Regional Hospital 960 W 800 N Alpine Clinic Ste B6 Orem UT. 84057 1175 E 3200 N Orem UT. 84057 Hartle, Aaron C FNP p 801.766.9822 Lehi UT. 84043 p 801.224.1300 Pace Clinic p 801.407.3000 405 S Main St In-2-It Medical 226 N 1100 E Springville UT. 84663 1888 W 800 N Jorgensen, Jesse A PA Ste A p 801.491.2238 Pleasant Grove UT. 84062 University of Utah Health American Fork UT. 84003 p 801.610.7321 145 W University Pkwy p 801.855.3840 Hawthorne, Shane M MD Orem UT. 84058 Premier Family Medical Jacobs-Peterson, LuAnn p 801.234.8600 275 W 200 N 155 W 400 N APRN Lindon UT. 84042 Ste B6 Utah Valley Urgent Care Hospital Affiliation p 801.796.1333 Orem UT. 84057 127 E Main St - University of Utah Hospital p 801.224.1300 Ste E 76 E Commerce Dr Lehi UT. 84043 Juchau, Jeffrey J MD Ste 204 707 E Mill Rd p 801.766.9822 Canyon View Medical Group Saratoga Springs UT. 84045 Ste 303 325 W Ctr St p 801.766.8427 Vineyard UT. 84059 Spanish Fork UT. 84660 p 801.224.1300 p 801.798.7301

Hospital Affiliation - Timpanogos Regional Hospital 494 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 830 N 2000 W Mackintosh, Rebecca NP McManus, Shawn P DO 585 N 500 W Pleasant Grove UT. 84062 Mountain Point Medical Premier Family Medical Provo UT. 84601 p 801.756.3511 Center - Wound Clinic 1528 N Commerce Dr p 801.374.1801 3000 N Triumph Blvd Ste 204 Lehnardt, Michael D MD Ste 330 Saratoga Springs UT. 84045 700 W 800 N Premier Family Medical Lehi UT. 84043 p 801.766.8427 Ste 200 226 N 1000 E p 385.345.3000 Orem Ut. 84057 Ste A 155 W 400 N p 801.374.1801 American Fork UT. 84003 Masteller, Malcolm C MD Ste B6 p 801.855.3841 University of Utah Health Orem UT. 84057 Money, Nolan B MD 145 W University Pkwy p 801.224.1300 Revere Health 275 W 200 N Orem UT. 84058 97 S Professional Way Lindon UT. 84042 p 801.234.8600 226 N 1000 E Ste 2 p 801.796.1333 Ste A Payson UT. 84651 Hospital Affiliation American Fork UT. 84003 p 801.465.4896 680 E Main St - University of Utah Hospital p 801.855.3840 Lehi UT. 84043 Hospital Affiliation p 801.768.1699 Maw, Laura C APRN 275 W 200 N - Mountain View Hospital Visiting Physician Lindon UT. 84042 (UT) 76 E Commerce Dr Services p 801.796.1333 Ste 204 278 W Ctr St Mountain West Family Saratoga Springs UT. 84045 Orem UT. 84057 76 E Commerce Dr Practice p 801.766.8427 p 801.559.7848 Ste 204 3435 E Pony Express Pkwy Saratoga Springs UT. 84045 Ste 140 830 N 2000 W Conti-Care p 801.766.8427 Eagle Mountain UT. 84005 Pleasant Grove UT. 84062 2874 Parkside Dr p 801.789.2444 p 801.756.3571 Lehi UT. 84043 830 N 2000 W p 801.361.6038 Pleasant Grove UT. 84062 Mountainlands Community Hospital Affiliation p 801.756.3511 Health Center - Timpanogos Regional Hospital Ascendant Behavioral 589 S State St Health Hospital Affiliation Provo UT. 84606 Life Tree 3051 W Maple Loop Dr - Timpanogos Regional Hospital p 801.429.2000 179 N 1200 E Ste 210 Ste 104 Lehi UT. 84043 McMaster, Ian B MD Mower, Douglas R MD Lehi UT. 84043 p 801.872.5516 Hobble Creek Medical Premier Family Medical p 801.501.6073 Clinic 226 N 1100 E McBride, Brayden T MD 672 W 400 S Ste A 251 W SR 198 Mapleton Medical Clinic Ste 101 American Fork UT. 84003 Ste 3 1429 S 1600 W Springville UT. 84663 p 801.855.3841 Salem UT. 84653 Mapleton UT. 84664 p 801.491.9883 p 801.501.6665 p 801.489.8464 275 W 200 N Hospital Affiliation Lindon UT. 84042 Lowe, Spencer N FNP Canyon View Medical Group - Mountain View Hospital p 801.796.1333 Utah Endocrinology 5 E 400 N (UT) Associates PLLC Springville UT. 84663 680 E Main St 629 Quality Dr p 801.489.8464 Messerly, Shelly P PA Lehi UT. 84043 Ste E Mountain Springs Family p 801.768.1699 American Fork UT. 84003 Hospital Affiliation Medicine PLLC p 801.747.2800 - Mountain View Hospital 468 S Main St 830 N 2000 W (UT) Spanish Fork UT. 84660 Pleasant Grove UT. 84062 MacArthur, Toran J MD p 801.504.6117 p 801.756.3511 Premier Family Medical McLay, Michael MD 226 N 1100 E Mapleton Medical Clinic Miconi-Correa, Lisa NP Hospital Affiliation Ste A 1429 S 1600 W Envision Physician - Timpanogos Regional Hospital American Fork UT. 84003 Mapleton UT. 84664 Services p 801.855.3840 p 801.489.8464 1345 W 1600 N Munn, Dana H DO Orem UT. 84057 Revere Health 680 E Main St Canyon View Medical Group p 801.225.7971 555 W SR 164 N Lehi UT. 84043 5 E 400 N Salem UT. 84653 p 801.768.1699 Springville UT. 84663 Miller, Stephanie APRN p 801.385.2031 p 801.489.8464 Valley Obstetrics & Hospital Affiliation Gynecology 97 S Professional Way - Timpanogos Regional Hospital Hospital Affiliation 527 W 400 N Ste 2 - Mountain View Hospital Ste 4 Payson UT. 84651 (UT) Orem UT. 84057 p 801.465.4896 p 801.404.5588

495 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 972 N 600 E Oldham, Jedidiah D DO Peterson, Mark W DO Potter, Tracy PA-C Spanish Fork UT. 84660 Revere Health Envision Physician Medallus Medical p 820.137.3436 97 S Professional Way Services 476 N 900 W Ste 2 1345 W 1600 N Ste C Murdock, Kenneth J MD Payson UT. 84651 Orem UT. 84057 American Fork UT. 84003 Premier Family Medical p 801.465.4896 p 801.225.7971 p 801.492.1611 226 N 1100 E Ste A 972 N 600 E Hospital Affiliation Premier Family Medical M-F American Fork UT. 84003 Spanish Fork UT. 84660 - Jordan Valley Medical 8am-9pm Sat 9am-9pm p 801.855.3841 p 801.465.4896 Center West Valley Campus 1159 E 200 N - Jordan Valley Medical Ste 100 275 W 200 N Optimal Health Family Center American Fork UT. 84003 Lindon UT. 84042 Practice p 801.796.1333 p 801.796.1333 75 S 200 E Peterson, Scott D MD Ste 100 Revere Health Premier Family Medical M-F 680 E Main St Provo UT. 84606 575 S State St 8Am-9Pm Sat 9Am-9Pm Lehi UT. 84043 p 801.877.5801 Orem UT. 84058 1528 N Commerce Dr p 801.768.1699 p 801.225.2926 Ste 204 Pace, Randall MD Saratoga Springs UT. 84045 830 N 2000 W Revere Health Hospital Affiliation p 801.766.8427 Pleasant Grove UT. 84062 173 N 400 W - Timpanogos Regional Hospital p 801.756.3511 Ste C11 Premier Family Medical M-F Orem UT. 84058 Pickett, Heather R DO 8:30am-9pm Sat 9am-9pm Hospital Affiliation p 801.802.7373 Thriver Health 155 W 400 N - Timpanogos Regional Hospital 360 S 1300 W Ste B6 Hospital Affiliation Pleasant Grove UT. 84062 Orem UT. 84057 Neilsen, Jason D MD - Timpanogos Regional Hospital p 385.440.1400 p 801.224.1300 Santaquin Medical Clinic - Gunnison Valley Hospital 210 E Main St Pikus, Jared J MD Premier Family Medical M-F Santaquin UT. 84655 Packer, Kraig L APRN Santaquin Medical Clinic 8am-9pm Sat 9am-9pm p 801.754.3600 Utah Valley Urgent Care 210 E Main St 226 N 1100 E 960 W 800 N Santaquin UT. 84655 Ste A Nordstrom, Bjorn A DO Orem UT. 84057 p 801.754.3600 American Fork UT. 84003 Premier Family Medical p 801.766.9822 p 801.855.3841 226 N 1100 E Poor, David D MD Ste A Hospital Affiliation Envision Physician 275 W 200 N American Fork UT. 84003 - Timpanogos Regional Hospital Services Ste 100 p 801.855.3841 1345 W 1600 N Lindon UT. 84042 Parajuli, Durga FNP Orem UT. 84058 p 801.796.1333 275 W 200 N Envision Physician p 801.225.7971 Lindon UT. 84042 Services 3000 N Triumph Blvd p 801.796.1333 1345 W 1600 N Hospital Affiliation Ste 220 Orem UT. 84058 - University of Utah Hospital Lehi UT. 84043 3943 E Pony Express Pkwy p 801.225.7971 p 801.796.1333 Ste 120 Porter, Stuart B DO Eagle Mountain UT. 84005 Pearce, Tami L NP ALX Family Health Premier Family Medical M-F p 801.789.5566 Mountain Springs Family 245 S 1060 W 8Am-9Pm Sat 9Am-9Pm Medicine PLLC Lindon UT. 84042 3943 E Pony Express Pkwy 707 E Mill Rd 468 S Main St p 385.306.1222 Ste 120 Ste 303 Spanish Fork UT. 84660 Eagle Mountain UT. 84005 Vineyard UT. 84059 p 801.504.6117 Integrative Medical p 801.789.5566 p 801.224.1300 Associates Penrod, Marc A MD 3650 N University Ave Premier Family Medical M-F 830 N 2000 W Mapleton Medical Clinic Ste 200 8am-9pm Sat 9am-9pm Pleasant Grove UT. 84062 1429 S 1600 W Provo UT. 84604 680 E Main St p 801.756.3511 Mapleton UT. 84664 p 801.375.7100 Lehi UT. 84043 p 801.489.8464 p 801.768.1699 Ogden, Lida J MD Hospital Affiliation University of Utah Health Canyon View Medical Group - Timpanogos Regional Hospital Premier Family Medical M-F 145 W University Pkwy 5 E 400 N - Mountain View Hospital 8Am-9Pm Sat 9Am-9Pm Orem UT. 84058 Springville UT. 84663 (UT) 707 E Mill Rd p 801.234.8600 p 801.489.8464 Ste 303 Vineyard UT. 84059 Hospital Affiliation p 801.224.1300 - Mountain View Hospital (UT)

496 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Premier Family Medical M-F Robins, Scott DO Sharp, Richard MD 830 N 2000 W 8am-9pm Sat 9am-9pm Utah Valley Urgent Care Dry Creek Medical Center Pleasant Grove UT. 84062 76 E Commerce Dr 127 E Main St 3300 N Running Creek Way p 801.756.3511 Ste 204 Ste E Bldg B Saratoga Springs UT. 84045 Lehi UT. 84043 Ste 100 Hospital Affiliation p 801.766.8427 p 801.766.9822 Lehi UT. 84043 - Timpanogos Regional Hospital p 801.766.4214 Premier Family Medical M-F Hospital Affiliation Stansfield-Duvall, Micah 8:30am-9pm Sat 9am-9pm - Jordan Valley Medical Hospital Affiliation T NP 830 N 2000 W Center - Timpanogos Regional Hospital Blue Rock Neurological Pleasant Grove UT. 84062 Center p 801.756.3511 Robinson, Aaron M DO Shumway, Jonathan DO 3152 N University Ave Grandview Family Medicine Revere Health Ste 220 Preston, William D MD 1900 N State St 555 W SR 164 N Provo UT. 84604 Cherry Tree Family Provo UT. 84604 Salem UT. 84653 p 801.229.1014 Practice p 801.373.2001 p 801.465.4896 155 N 400 W Blue Rock Medical Center Ste B6 Hospital Affiliation Slater, Ryan MD 3152 N University Ave Orem UT. 84057 - Timpanogos Regional Hospital Revere Health Provo UT. 84604 p 801.224.1300 1184 E 80 N p 801.375.2177 Robinson, Janice H FNP American Fork UT. 84003 Hospital Affiliation Lakeview Family Medicine p 801.763.3885 Starbuck, Aaron K MD - Timpanogos Regional Hospital 811 N 900 W Revere Health Orem UT. 84057 1305 N Commerce Dr 575 S State St Quick, Nichole A MD p 801.434.7600 Ste 120 Orem UT. 84058 Blue Rock Neurological Saratoga Springs UT. 84045 p 801.225.2926 Center Roney, Savanna PA p 801.753.7424 3152 N University Ave Health Plus Clinic Sundwall, Peter V MD Ste 220 376 E 400 S 700 W 800 N Alpine Family Medicine Provo UT. 84604 Springville UT. 84663 Ste 100 155 W Canyon Crest Rd p 801.229.1014 p 801.491.9355 Orem UT. 84057 Alpine UT. 84004 p 801.224.5373 p 801.763.9851 Blue Rock Medical Center 61 W 3200 N 3152 N University Ave Lehi UT. 84043 Smith, Garrett B DO Syddall, Tracy R PA-C Provo UT. 84604 p 385.352.0404 Premier Family Medical University of Utah Health p 801.375.2177 226 N 1100 E 145 W University Pkwy Salmon, Cheryl NP Ste A Orem UT. 84058 Rarick, Kevin PA Envision Physician American Fork UT. 84003 p 801.234.8600 Crossroads Canyon Family Services p 801.855.3841 Medicine 1345 W 1600 N Hospital Affiliation 1305 N Commerce Dr Orem UT. 84057 275 W 200 N - Jordan Valley Medical Ste 120 p 801.225.7971 Lindon UT. 84042 Center Saratoga Springs UT. 84043 p 801.796.1333 - University of Utah Hospital p 801.766.2121 Hospital Affiliation - Ogden Regional Medical 830 N 2000 W Takasaki, Roman Y MD Riggs, Brannick B MD Center Pleasant Grove UT. 84062 Canyon View Medical Group Thriver Health p 801.756.3511 325 W Ctr St 360 S 1300 W Savage, Shelly L MD Spanish Fork UT. 84660 Pleasant Grove UT. 84062 Grandview Family Medicine Hospital Affiliation p 801.798.7301 p 385.440.1400 1900 N State St - Timpanogos Regional Hospital Provo UT. 84604 94 W Main Blue Rock Medical Center p 801.373.2001 Smith, Scott L MD Santaquin UT. 84655 3152 N University Ave Premier Family Medical p 801.754.3122 Provo UT. 84604 Hospital Affiliation 226 N 1100 E p 801.375.2177 - Timpanogos Regional Hospital Ste A Hospital Affiliation American Fork UT. 84003 - Mountain View Hospital Roberts, Stanley D MD Severn, Ernest DO p 801.855.3841 (UT) HIllside Medical Clinic Riverton Family Health 118 N Main St Center 275 W 200 N Tanner, Carol S PA-C Ste B 24 W Sergeant Ct Dr Lindon UT. 84042 Cedar Psychiatry Salem UT. 84653 Ste 107 p 801.796.1333 1788 N State St p 801.477.9007 Saratoga Springs UT. 84045 Springville UT. 84663 p 801.407.3048 p 801.369.8989

Hospital Affiliation - Jordan Valley Medical Center

497 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Express Med Family Care Tomco, Abraham R MD 94 W Main Willis, Marshall F MD 415 N Main St Revere Health Santaquin UT. 84655 Premier Family Medical Spanish Fork UT. 84660 700 W 800 N p 801.754.3122 226 N 1100 E p 801.798.9715 Ste 220 Ste A Orem UT. 84057 Webb, Ann E FNP American Fork UT. 84003 Cedar Psychiatry p 801.354.8205 Mountain Springs Family p 801.855.3841 672 W 400 S Medicine PLLC Ste 201 Hospital Affiliation 468 S Main St 275 W 200 N Springville UT. 84663 - Timpanogos Regional Hospital Spanish Fork UT. 84660 Lindon UT. 84042 p 801.369.8989 p 801.504.6117 p 801.796.1333 UUHC Parkway Health Center Taylor, Connie D APRN 145 W University Pkwy Weenig, Karl N MD 830 N 2000 W Optimal Health Family Orem UT. 84058 Revere Health Pleasant Grove UT. 84062 Practice p 801.234.8600 1055 N 500 W p 801.756.3511 75 S 200 E Ste 121 Ste 100 Vest, Alyssa FNP Provo UT. 84604 Hospital Affiliation Provo UT. 84606 Optimal Health Family p 801.357.7350 - Timpanogos Regional Hospital p 801.877.5801 Practice 75 S 200 E 700 W 800 N Woodmansee, James MD Taylor, John S MD Ste 100 Ste 100 Cotton Tree Medical Mapleton Medical Clinic Provo UT. 84606 Orem UT. 84057 2230 N University Pkwy 1429 S 1600 W p 801.877.5801 p 801.224.5373 Ste 1A Mapleton UT. 84664 Provo UT. 84604 p 801.489.8464 Vincent, Anne APRN Hospital Affiliation p 801.377.3413 Promise Medical - Timpanogos Regional Hospital Canyon View Medical Group 861 N 980 W Hospital Affiliation 5 E 400 N Orem UT. 84057 Welch, Kerry D MD - Timpanogos Regional Hospital Springville UT. 84663 p 385.262.4135 Premier Family Medical p 801.489.8464 226 N 1100 E Woolman, Michael D MD Voss, William D DO Ste A Envision Physician Hospital Affiliation Health Plus Clinic American Fork UT. 84003 Services - Mountain View Hospital 376 E 400 S p 801.855.3841 1345 W 2600 N (UT) Springville UT. 84663 Orem UT. 84057 p 801.491.9355 3000 N Triumph Blvd p 801.225.7971 Thompson, Daniel O MD Ste 220 Riverton Family Health Hospital Affiliation Lehi UT. 84043 Hospital Affiliation Center - Mountain View Hospital p 801.753.4650 - Ogden Regional Medical 24 W Sergeant Ct Dr (UT) Center Ste 102 - Timpanogos Regional Hospital Hospital Affiliation Saratoga Springs UT. 84045 - Timpanogos Regional Hospital Gastroenterology p 801.407.3049 Walton, Matthew S DO Alsolaiman, Mohammad M MD Canyon View Medical Group White, Vernon MD Revere Health Hospital Affiliation 325 W Ctr St Mountainlands Community 1175 E 50 S - Jordan Valley Medical Spanish Fork UT. 84660 Health Center Ste 221 Center p 801.798.7301 589 S State St American Fork UT. 84003 Provo UT. 84606 p 801.772.0775 Thriver Health Hospital Affiliation p 801.429.2000 360 S 1300 W - Mountain View Hospital Hospital Affiliation Pleasant Grove UT. 84062 (UT) Willis, Kent DO - Timpanogos Regional Hospital p 385.440.1400 Premier Family Medical - Mountain View Hospital Wayment, Nadya P MD 226 N 1100 E (UT) Tillotson, Shadrick W MD Envision Physician Ste A Cedar Psychiatry Services American Fork UT. 84003 Bodily, Kurt O MD 1788 N State St 1345 W 2600 N p 801.855.3840 Revere Health Orem UT. 84663 Orem UT. 84057 1055 N 500 W p 801.369.8989 p 801.225.7971 275 W 200 N Ste 100 Bldg C Lindon UT. 84042 Provo UT. 84604 672 W 400 S Hospital Affiliation p 801.796.1333 p 801.374.1268 Ste 201 - Ogden Regional Medical Springville UT. 84663 Center 830 N 2000 W Hospital Affiliation p 801.369.8989 Pleasant Grove UT. 84062 - Timpanogos Regional Hospital Weatherspoon, Steven R DO p 801.756.3511 - Mountain View Hospital Canyon View Medical Group (UT) 336 W 100 S Spanish Fork UT. 84660 p 801.798.7301

498 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Dickinson, Brandon T MD 3300 N Running Creek Way General Surgery Francis, Karl M MD Revere Health Bldg B Baker, Matthew T MD Utah Surgical Associates 1055 N 500 W Bldg B Ste 100 Utah Surgical Associates 1000 E 15 S Ste 100 Lehi UT. 84043 1000 E 15 S Ste 350 Provo UT. 84604 p 801.772.0775 Ste 350 Payson UT. 84651 p 801.374.1268 Payson UT. 84651 p 801.465.5602 Hospital Affiliation p 801.465.5602 Dickinson, Thomas A MD - Mountain View Hospital 1248 E 90 N Revere Health (UT) 1248 E 90 N Ste 102 1055 N 500 W - Timpanogos Regional Hospital Ste 102 American Fork UT. 84003 Ste 100 Bld B American Fork UT. 84003 p 801.756.9132 Provo UT. 84604 Schmidt, John D MD p 801.756.9132 p 801.374.1268 Granite Peaks 3000 N Triumph Blvd Gastroenterology 3000 N Triumph Blvd Ste 250 Hospital Affiliation 2961 W Maple Loop Dr Ste 250 Lehi UT. 84043 - Timpanogos Regional Hospital Ste 220 Lehi UT. 84043 p 801.852.9480 - Mountain View Hospital Lehi UT. 84043 p 801.852.9480 (UT) p 801.619.9000 3550 N University Ave 3550 N University Ave Ste 250 Erdmann, Alan B MD Hospital Affiliation Ste 250 Provo UT. 84604 Revere Health - Lone Peak Hospital Provo UT. 84604 p 801.374.9625 1055 N 500 W p 801.374.9625 Ste 100 Stewart, James M MD Hospital Affiliation Provo UT. 84604 Granite Peaks Barnhart, Douglas C MD - Mountain View Hospital p 801.374.1268 Gastroenterology University of Utah Health (UT) 2961 W Maple Loop Dr 395 W Bulldog Blvd - Timpanogos Regional Hospital 555 W SR 164 N Ste 220 Ste 702 Salem UT. 84653 Lehi UT. 84043 Provo UT. 84604 Garry, David P MD p 801.374.1268 p 801.619.9000 p 801.662.2950 Utah Surgical Associates 1000 E 15 S 972 N 600 E Hospital Affiliation Cook, Craig S MD Ste 350 Spanish Fork UT. 84660 - Lone Peak Hospital Utah Surgical Associates Payson UT. 84651 p 801.374.1268 1000 E 15 S p 801.465.5602 Thorpe, Brett L MD Ste 350 Haslem, Bryce D MD Revere Health Payson UT. 84651 1055 N 300 W Revere Health 1055 N 500 W p 801.465.5602 Ste 101 1055 N 500 W Ste 100 Bldg B Provo UT. 84604 Ste 100 Bldg B Provo UT. 84604 1055 N 300 W p 801.852.3460 Provo UT. 84604 p 801.374.1268 Ste 101 p 801.374.1268 Provo UT. 84604 1248 E 90 N Hospital Affiliation p 801.852.3460 Ste 102 Hospital Affiliation - Timpanogos Regional Hospital American Fork UT. 84003 - Timpanogos Regional Hospital - Mountain View Hospital 1248 E 90 N p 801.756.9132 - Mountain View Hospital (UT) Ste 102 (UT) American Fork UT. 84003 3000 N Triumph Blvd Weaver, Christine M PA-C p 801.756.9132 Ste 250 Jensen, Mark A DO Granite Peaks Lehi UT. 84043 Granite Peaks Gastroenterology 3000 N Triumph Blvd p 801.852.9480 Gastroenterology 2961 W Maple Loop Dr Ste 250 2961 W Maple Lp Dr Ste 220 Lehi UT. 84043 3550 N University Ave Ste 220 Lehi UT. 84043 p 801.852.9480 Ste 250 Lehi UT. 84043 p 801.619.9000 Provo UT. 84604 p 801.619.9000 3550 N University Ave p 801.374.9625 Weaver, Michael MD Ste 250 Hospital Affiliation Granite Peaks Provo UT. 84604 Hospital Affiliation - Lone Peak Hospital Gastroenterology p 801.374.9625 - Timpanogos Regional Hospital 2961 W Maple Lp Dr - Mountain View Hospital Kawa, Chad B MD Ste 220 Hospital Affiliation (UT) Revere Health Lehi UT. 84043 - Timpanogos Regional Hospital 1175 E 50 S p 801.619.9000 - Mountain View Hospital Gill, Brian MD Ste 211 (UT) Utah Surgical Associates American Fork UT. 84003 Hospital Affiliation 1000 E 15 S p 801.418.0870 - Lone Peak Hospital Ste 350 Payson UT. 84651 p 801.465.5602

499 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 1055 N 300 W Jones, Joshua L MD Syddall, Tracy R PA-C 1248 E 90 N Ste 101 Utah Surgical Associates University of Utah Health Ste 102 Provo UT. 84604 1248 E 90 N 145 W University Pkwy American Fork UT. 84003 p 801.852.3460 Ste 102 Orem UT. 84058 p 801.756.9132 American Fork UT. 84003 p 801.234.8600 1248 E 90 N p 801.756.9132 3000 N Triumph Blvd Ste 102 Hospital Affiliation Ste 250 American Fork UT. 84003 3000 N Triumph Blvd - Jordan Valley Medical Lehi UT. 84043 p 801.756.9132 Ste 250 Center p 801.852.9480 Lehi UT. 84043 - University of Utah Hospital 3000 N Triumph Blvd p 801.852.9480 3550 N University Ave Ste 250 Tittensor, Jennifer J MD Ste 250 Lehi UT. 84043 Miller, D Anderson MD Utah Surgical Associates Provo UT. 84604 p 801.852.9480 Utah Surgical Associates 1248 E 90 N p 801.374.9625 1055 N 300 W Ste 102 3550 N University Ave Ste 101 American Fork UT. 84003 Hospital Affiliation Ste 250 Provo UT. 84604 p 801.756.9132 - Timpanogos Regional Hospital Provo UT. 84604 p 801.374.9625 - Mountain View Hospital p 801.374.9625 1248 E 90 N (UT) 3550 N University Ave Ste 103 Hospital Affiliation Ste 250 American Fork UT. 84003 Wennergren, John MD - Timpanogos Regional Hospital Provo UT. 84604 p 801.756.9132 Utah Surgical Associates - Mountain View Hospital p 801.374.9625 1000 E 15 S (UT) 3000 N Triumph Blvd Ste 350 Peterson, Lee M MD Ste 250 Payson UT. 84651 Guilfoyle, Cara Marie MD Utah Surgical Associates Lehi UT. 84043 p 801.465.5602 Neuroscience & 3550 N University Ave p 801.852.9480 Rehabilitation Specialists Ste 250 1248 E 90 N - Lehi Provo UT. 84604 Hospital Affiliation Ste 102 3000 N Triumph Blvd p 801.374.9625 - Timpanogos Regional Hospital American Fork UT. 84003 Ste 110 p 801.756.9132 Lehi UT. 84043 Hospital Affiliation Trotter, Lee D DO p 385.345.3555 - Timpanogos Regional Hospital Pediatrix Medical Group 3000 N Triumph Blvd - Mountain View Hospital 1000 E 100 N Ste 250 Mountain Point Medical (UT) Payson UT. 84651 Lehi UT. 84043 Center p 801.465.7000 p 801.852.9480 3000 N Triumph Blvd Rasmussen, R Richard MD Lehi UT. 84043 Utah Surgical Associates 700 W 800 N 3550 N University Ave p 385.345.3555 1000 E 15 S Ste 330 Ste 250 Ste 350 Orem UT. 84057 Provo UT. 84604 Hospital Affiliation Payson UT. 84651 p 801.714.6404 p 801.374.9625 - Mountain Point Medical p 801.465.5602 Center 750 W 800 N Hospital Affiliation 1055 N 300 W Orem UT. 84057 - Mountain View Hospital Hill, Bruce B MD Ste 101 p 801.714.6000 (UT) Utah Surgical Associates Provo UT. 84604 - Timpanogos Regional Hospital 1000 E 15 S p 801.374.9625 Hospital Affiliation Ste 350 - Mountain Point Medical Gynecologic Oncology Payson UT. 84651 1248 E 90 N Center Harris, Katherine L MD p 801.465.5602 Ste 102 - Timpanogos Regional Hospital University of Utah Health American Fork UT. 84003 1157 N 300 W 1248 E 90 N p 801.756.9132 Watts, David M MD Ste 301 Ste 102 Utah Surgical Associates Provo UT. 84604 American Fork UT. 84003 3000 N Triumph Blvd 1000 E 15 S p 801.213.2995 p 801.756.9132 Ste 250 Ste 350 Lehi UT. 84043 Payson UT. 84651 Hunn, Jessica R MD 3000 N Triumph Blvd p 801.852.9480 p 801.465.5602 Valley Obstetrics & Ste 250 Gynecology Lehi UT. 84043 3550 N University Ave 1055 N 300 W 3000 N Triumph Blvd p 801.852.9480 Ste 250 Ste 101 Ste 210 Provo UT. 84604 Provo UT. 84604 Lehi UT. 84043 3550 N University Ave p 801.374.9625 p 801.374.9625 p 385.347.5450 Ste 250 Provo UT. 84604 Hospital Affiliation p 801.374.9625 - Timpanogos Regional Hospital - Mountain View Hospital Hospital Affiliation (UT) - Mountain View Hospital - Mountain Point Medical (UT) Center - Timpanogos Regional Hospital 500 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 585 N 500 W 1248 E 90 N 1248 E 90N Burkinshaw, Sandra NP Provo UT. 84601 Ste 300 Ste 300 Valley Obstetrics & p 801.374.1801 American Fork UT. 84003 American Fork Ut. 84003 Gynecology p 801.756.9635 p 801.756.9635 1228 N Commerce Dr 700 W 800 N Saratoga Springs UT. 84045 Ste 200 3000 N Triumph Blvd 3000 N Triumph Blvd p 801.756.9635 Orem UT. 84057 Lehi UT. 84043 Lehi UT. 84043 p 801.756.9635 p 801.756.9635 p 801.756.9635 1248 E 90 N Ste 300 Hospital Affiliation Adams, Lan Le MD Hospital Affiliation American Fork UT. 84003 - St Marks Hospital Obstetrix Medical Group Of - Timpanogos Regional Hospital p 801.756.9635 - Lone Peak Hospital Utah - Mountain View Hospital 750 W 800 N Bennett, Donna S MD 3000 N Triumph Blvd (UT) Orem UT. 84057 Valley Obstetrics & Lehi UT. 84043 - Ogden Region Medical p 801.714.6000 Gynecology p 801.756.9635 Center 527 W 400 N Allen, Douglas DO Ste 4 Cloward, Tenille B MD Soisson, Andrew P MD Revere Health Orem Ut. 84057 Valley Obstetrics & University of Utah Health 1055 N 500 W p 801.374.1801 Gynecology 1157 N 300 W Ste 205 1228 N Commerce Dr Ste 301 Provo UT. 84604 585 N 500 W Saratoga Springs UT. 84045 Provo UT. 84604 p 801.373.7350 Provo UT. 84601 p 801.756.9635 p 801.213.2995 p 801.374.1801 1886 W 800 N 1248 E 90 N Hospital Affiliation Pleasant Grove UT. 84062 700 W 800 N Ste 300 - University of Utah Hospital p 801.756.5288 Ste 200 American Fork UT. 84003 Orem UT. 84057 p 801.756.9635 Webb, Joel C MD 3943 Pony Express Pkwy p 801.374.1801 Valley Obstetrics & Ste 110-A 3000 N Truimph Blvd Gynecology Eagle Mountain UT. 84005 Hospital Affiliation Ste 210 3000 N Triumph Blvd p 801.756.5288 - Timpanogos Regional Hospital Lehi Ut. 84043 Lehi UT. 84043 - Mountain View Hospital p 801.756.9635 p 801.756.9635 Hospital Affiliation (UT) - Timpanogos Regional Hospital Cowles, Steven D MD 585 N 500 W Broadbent, David H MD Valley Obstetrics & Provo UT. 84601 Anderson, Cameron D MD 1355 N University Ave Gynecology p 801.404.5588 South Valley OB/GYN Ste 130 585 N 500 W 39 S Professional Way Provo UT. 84604 Provo UT. 84601 700 W 800 N Ste 4 p 801.373.4649 p 801.374.1801 Ste 200 Payson UT. 84651 Orem UT. 84057 p 801.465.3201 Hospital Affiliation 700 W 800 N p 801.756.9635 - Timpanogos Regional Hospital Ste 200 Valley Obstetrics & Orem UT. 84057 Hospital Affiliation Gynecology Broberg, Jeffrey C MD p 801.374.1801 - St Marks Hospital 819 E Marketplace Dr 3rd Valley Obstetrics & - Utah Valley Hospital Fl Gynecology Dabling, Heather A MD Spanish Fork UT. 84660 527 W 400 N Valley Obstetrics & Zempolich, Karen A MD p 801.756.9635 Ste 4 Gynecology Timpanogos Womens Center Orem Ut. 84057 527 W 400 N 3401 N Ctr St Archer, Sandra V MD p 801.374.1801 Ste 4 Ste 150 Utah Center for Womens Orem Ut. 84057 Lehi UT. 84043 Healthcare 585 N 500 W p 801.374.1801 p 801.268.6811 3651 N 100 E Provo UT. 84601 Ste 375 p 801.374.1801 585 N 500 W Hospital Affiliation Provo UT. 84604 Provo UT. 84601 - St Marks Hospital p 435.843.2576 700 W 800 N p 801.374.1801 - Ogden Regional Medical Ste 200 Center Bean, Gregory H MD Orem UT. 84057 700 W 800 N Valley Obstetrics & p 801.434.4443 Ste 200 Gynecology Gynecology Orem Ut. 84057 Aagard, Robert MD 1228 N Commerce Dr Hospital Affiliation p 801.374.1801 Valley Obstetrics & Saratoga Springs Ut. 84045 - Timpanogos Regional Hospital Gynecology p 801.756.9635 Hospital Affiliation 1228 N Commerce Dr - Timpanogos Regional Hospital Saratoga Springs Ut. 84045 p 801.756.9635

501 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Dewey, Steven J MD Grover, Julie MD Jones, Evan B DO Larimer, Sophia NP Southwestern OBGYN Utah Valley Obstetrics & Valley Obstetrics & Valley Obstetrics & 39 Professional Way Gynecology Gynecology Gynecology Ste 3 1055 N 300 W 1228 N Commerce Dr 527 W 400 N Payson UT. 84651 Ste 110 Saratoga Springs Ut. 84045 Ste 4 p 801.465.9263 Provo UT. 84604 p 801.756.9635 Orem Ut. 84057 p 801.357.7377 p 801.374.1801 777 N 500 W 1248 E 90 N Ste 203 Hospital Affiliation Ste 300 585 N 500 W Provo UT. 84601 - Timpanogos Regional Hospital American Fork UT. 84003 Provo UT. 84601 p 801.375.8889 p 801.756.9635 p 801.374.1801 Harward, Kory A DO Southwestern OB/GYN Valley Obstetrics & 3000 N Triumph Blvd 700 W 800 N 777 N 500 W Gynecology Lehi UT. 84043 Ste 200 Ste 203 1900 N State St p 801.756.9635 Orem UT. 84057 Provo UT. 84604 Ste 103 p 801.434.4443 p 801.375.8889 Provo UT. 84604 700 W 800 N p 801.669.5758 Ste 200 McCarter, John D MD Hospital Affiliation Orem UT. 84057 Valley Obstetrics & - Mountain View Hospital 585 N 500 W p 801.756.9635 Gynecology (UT) Provo UT. 84601 1900 N State St - Timpanogos Regional Hospital p 801.669.5758 Hospital Affiliation Ste 103 - Timpanogos Regional Hospital Provo UT. 84604 Dildy, Gary A MD 700 W 800 N p 801.669.5758 Obstetrix Medical Group of Ste 200 Jorgensen, Christy NP Utah Orem UT. 84057 Valley Obstetrics & McSweeney, Heidi NP 700 W 800 N p 801.756.9635 Gynecology Valley Obstetrics & Ste 310 527 W 400 N Gynecology Orem UT. 84057 Hospital Affiliation Ste 4 527 W 400 N p 801.225.1937 - Timpanogos Regional Hospital Orem Ut. 84057 Ste 4 p 801.374.1801 Orem Ut. 84057 750 W 800 N Haskett, Sean G MD p 801.374.1801 Orem UT. 84057 Valley Obstetrics & Hospital Affiliation p 801.714.6000 Gynecology - Timpanogos Regional Hospital 585 N 500 W 1228 N Commerce Dr Provo Ut. 84601 Drewes, Peter G MD Saratoga Springs Ut. 84045 Judd, Thomas E MD p 801.374.1801 Valley Obstetrics & p 801.756.9635 University OB/GYN Gynecology 1355 N University Ave 700 W 800 N 527 W 400 N 1248 E 90 N Ste 110 Ste 200 Ste 4 Ste 300 Provo UT. 84604 Orem UT. 84057 Orem Ut. 84057 American Fork UT. 84003 p 801.374.5000 p 801.756.9635 p 801.374.1801 p 801.756.9635 Kinghorn, Jennifer C MD Hospital Affiliation 585 N 500 W 3000 N Triumph Blvd Timpanogos Womens Center - Timpanogos Regional Hospital Provo UT. 84601 Ste 210 3401 N Ctr St p 801.374.1801 Lehi UT. 84043 Ste 150 Melendez, Terry MD p 801.756.9635 Lehi UT. 84043 Valley Obstetrics & 700 W 800 N p 801.653.2757 Gynecology Ste 200 Jacob, Scott R MD 1228 N Commerce Dr Orem UT. 84057 Valley Obstetrics & Lamoreaux, James MD Saratoga Springs Ut. 84045 p 801.756.9635 Gynecology Valley Obstetrics & p 801.756.9635 527 W 400 N Gynecology Hospital Affiliation Ste 4 1228 N Commerce Dr 1248 E 90N - Timpanogos Regional Hospital Orem Ut. 84057 Saratoga Springs Ut. 84045 Ste 300 p 801.374.1801 p 801.756.9635 American Fork Ut. 84003 Gourley, George C DO p 801.756.9635 1055 N 300 W 585 N 500 W 1248 E 90N Ste 305 Provo UT. 84601 Ste 300 3000 N Triumph Blvd Provo UT. 84604 p 801.374.1801 American Fork Ut. 84003 Lehi UT. 84043 p 801.357.7190 p 801.756.9635 p 801.756.9635 700 W 800 N Hospital Affiliation Ste 200 3000 N Triumph Blvd Morris, Cassandra NP - Timpanogos Regional Hospital Orem UT. 84057 Lehi UT. 84043 Valley Obstetrics & p 801.434.4443 p 801.756.9635 Gynecology 1228 N Commerce Dr Hospital Affiliation Saratoga Springs Ut. 84045 - Timpanogos Regional Hospital p 801.756.9635

502 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 1248 E 90N Parker, Kelli NP 585 N 500 W Timpanogos Womens Center Ste 300 Valley Obstetrics & Provo UT. 84601 3401 N Center St American Fork Ut. 84003 Gynecology p 801.374.1801 Ste 150 p 801.756.9635 1228 N Commerce Dr Lehi UT. 84043 Saratoga Springs Ut. 84045 700 W 800 N p 801.653.2757 Morris, Jason K MD p 801.756.9635 Ste 200 Canyon View Medical Group Orem UT. 84057 Hospital Affiliation 15 S 1000 E 1248 E 90 N p 801.756.9635 - Timpanogos Regional Hospital Ste 125 Ste 300 Payson UT. 84651 American Fork UT. 84003 Skinner, Reed J MD Wolsey, Brian L MD p 801.465.2559 p 801.756.9635 Santaquin Medical Clinic Valley Obstetrics & 210 E Main St Gynecology 325 W Ctr St 3000 N Truimph Blvd Santaquin UT. 84655 527 W 400 N Spanish Fork UT. 84660 Ste 210 p 801.754.3600 Ste 4 p 801.798.7301 Lehi Ut. 84043 Orem Ut. 84057 p 801.756.9635 Spencer, Tiffany NP p 801.374.1801 Nance, Jeff D MD Valley Obstetrics & Valley Obstetrics & Pennington, David A MD Gynecology 585 N 500 W Gynecology Pennington Womens Center 1228 N Commerce Dr Provo UT. 84601 672 W 400 S Provo Saratoga Springs Ut. 84045 p 801.374.1801 Ste 100 3507 N University Ave p 801.756.9635 Springville UT. 84663 Ste 175 700 W 800 N p 801.489.0111 Provo UT. 84604 1248 E 90 N Ste 200 p 801.719.8395 Ste 300 Orem UT. 84057 Nance, Steven G MD American Fork UT. 84003 p 801.756.9635 Valley Obstetrics & Hospital Affiliation p 801.756.9635 Gynecology - Timpanogos Regional Hospital Hospital Affiliation 672 W 400 S 3000 N Triumph Blvd - Timpanogos Regional Hospital Ste 100 Planned Parenthood Lehi UT. 84043 Springville Ut. 84663 Association of Utah p 801.756.9635 Young, David B DO p 801.481.0111 1086 N 1200 W Revere Health Orem UT. 84057 41 E Commerce Dr 1886 W 800 N Hospital Affiliation p 801.226.5246 Ste 2 Pleasant Grove UT. 84062 - Mountain View Hospital Saratoga Springs UT. 84045 p 801.756.5288 (UT) 1842 S Columbia Ln p 801.756.9635 Orem UT. 84097 3943 Pony Express Pkwy Ollerton, Ryan C DO p 801.226.5246 700 W 800 N Ste 110-A Valley Obstetrics & Ste 200 Eagle Mountain UT. 84005 Gynecology Rees, Scott S DO Orem UT. 84057 p 801.756.5288 1228 N Commerce Dr Valley Obstetrics & p 801.756.9635 Saratoga Springs Ut. 84045 Gynecology Hospital Affiliation p 801.756.9635 527 W 400 N Thorpe, Jefforey R MD - Timpanogos Regional Hospital Ste 4 Valley Obstetrics & 1248 E 90N Orem Ut. 84057 Gynecology Hand Surgery Ste 300 p 801.374.1801 527 W 400 N Johnson, Curtis C MD American Fork Ut. 84003 Ste 4 Revere Health p 801.756.9635 585 N 500 W Orem Ut. 84057 1055 N 500 W Provo UT. 84601 p 801.374.1801 Ste 207 3000 N Triumph Blvd p 801.374.1801 Provo UT. 84604 Lehi UT. 84043 585 N 500 W p 801.373.7350 p 801.756.9635 700 W 800 N Provo UT. 84601 Ste 200 p 801.374.1801 1130 Smith Fieldhouse Hospital Affiliation Orem UT. 84057 Provo UT. 84602 - Timpanogos Regional Hospital p 801.756.9635 700 W 800 N p 801.373.7350 Ste 200 Orr, Rochelle DO Hospital Affiliation Orem UT. 84057 Hospital Affiliation Timpanogos Womens Center - Timpanogos Regional Hospital p 801.756.9635 - Timpanogos Regional Hospital 3401 N Ctr St - Mountain View Hospital Ste 150 Roberts, Sarah NP Hospital Affiliation (UT) Lehi UT. 84043 Valley Obstetrics & - Timpanogos Regional Hospital p 801.653.2757 Gynecology Health Department 527 W 400 N Wexler, Kristin E DO Utah County Health Hospital Affiliation Ste 4 Mountainstar Medical Group Department - Lone Peak Hospital Orem Ut. 84057 Timpanogos 151 S University Ave - St Marks Hospital p 801.374.1801 1020 S 1100 W Ste 1900 Ste B Provo UT. 84601 Lehi UT. 84043 p 801.851.7042 p 801.653.2757 503 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Hematology And Oncology Thomson, Nicholas MD Horizon Home Health Mountain View Hospital Chipman, Gregory MD Revere Health 11 E 200 N (UT) Utah Cancer Specialists 1055 N 500 W Bldg C Orem UT. 84057 1000 E 100 N 395 Bulldog Blvd Ste 202 p 801.226.1919 Payson UT. 84651 Ste 103 Provo UT. 84604 p 801.465.7000 Provo UT. 84604 p 801.374.2367 Hospice Alliance p 801.357.7200 495 E 770 N Timpanogos Regional 1152 E 200 N Orem UT. 84097 Hospital 48 N 1100 E American Fork UT. 84003 p 801.426.5480 750 W 800 N Ste B p 801.772.0698 Orem UT. 84057 American Fork UT. 84003 Pinnacle Home Health Inc p 801.714.6000 p 801.492.9934 1175 E 50 S Phone Number Only Zip Ste 171 84601 Imaging Center Hospital Affiliation American Fork UT. 84003 p 801.274.0299 Revere Health Provo - Jordan Valley Medical p 801.772.0698 Imaging Center Hospice 1055 N 500 W - Davis Hospital Wallentine, Steven L MD Alpine Hospice Inc Ste 112 - Lakeview Hospital Revere Health 1172 E 100 N Provo UT. 84604 - Salt Lake Regional Medical 1055 N 500 W Ste D p 801.812.4624 Center Ste 202 Payson UT. 84058 Provo UT. 84604 p 435.465.4401 Revere Health American Esplin, Brandt L MD p 801.374.2367 Fork Imaging Revere Health 259 S Orem Blvd 1175 E 50 S 1055 N 500 W Hospital Affiliation Orem UT. 84058 Ste 141 Ste 202 - Timpanogos Regional Hospital p 801.221.0669 American Fork UT. 84003 Provo UT. 84604 - Castleview Hospital p 801.812.4624 p 801.374.2367 - Lone Peak Hospital Applegate Homecare and - Mountain View Hospital Hospice Revere Health Radiology Nuttall, Marc T MD (UT) 54 E Main St 852 N 500 W Revere Health American Fork UT. 84003 Provo UT. 84604 1055 N 500 W Home Health Agency p 801.763.0101 p 801.812.4624 Ste 202 Applegate Homecare and Provo UT. 84604 Hospice CNS Community Nursing Riverwoods Advanced p 801.374.2367 54 E Main St Services Diagnostic Imaging Center American Fork UT. 84003 1841 N 1120 W 280 W River Park Dr 1152 E 200 N p 801.763.0101 Provo UT. 84604 Ste 100 American Fork UT. 84003 p 800.404.8138 Provo UT. 84604 p 801.772.0698 Total Knee and Hip p 801.229.1009 Rehabilitation Harmony Home Health and 1175 E 50 S 383 E 60 S Hospice 3152 N University Ave Ste 171 American Fork UT. 84003 1815 S State St Ste 100 American Fork UT. 84003 p 801.576.6417 Ste 120 Provo UT. 84604 p 801.772.0698 Orem UT. 84097 p 801.229.1009 CNS Community Nursing p 877.463.3322 Hospital Affiliation Services Internal Medicine - Mountain View Hospital 1841 N 1120 W Hearts for Hospice Advanced Vein and Vascular (UT) Provo UT. 84604 677 Quality Dr of Utah Valley - Castleview Hospital p 800.404.8138 Ste 201 320 W River Park Dr - Lone Peak Hospital American Fork UT. 84003 Ste 125 - Timpanogos Regional Hospital Harmony Home Health and p 801.772.0243 Provo UT. 84604 Hospice p 385.388.8003 Rich, Nathan T MD 1815 S State St Hospice Alliance Utah Cancer Specialists Ste 120 495 E 770 N Beddhu, Srinivasan MD 395 Bulldog Blvd Orem UT. 84097 Orem UT. 84097 University of Utah Health Ste 103 p 877.463.3322 p 801.426.5480 1159 E 200 N Provo UT. 84604 Ste 150 p 801.357.7200 Hearts for Hospice Hospital American Fork UT. 84003 677 Quality Dr Mountain Point Medical p 801.373.0167 Hospital Affiliation Ste 201 Center - St Marks Hospital American Fork UT. 84003 3000 N Triumph Blvd Hospital Affiliation - Lakeview Hospital p 801.772.0243 Lehi UT. 84043 - University of Utah Hospital - Davis Hospital p 385.345.3000 - Jordan Valley Medical Center West Valley Campus

504 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Brann, William M MD Curzon, Sean R DO Fonseca, Walstir H MD Kim, Christopher Y MD Heart & Lung Institute Of Revere Health Revere Health Advanced Vein and Vascular Utah - Mountain Point 700 W 800 N 700 W 800 N of Utah Valley Pulmonary Ste 400 Ste 400 320 W River Park Dr 3000 N Triumph Blvd Orem UT. 84057 Orem UT. 84057 Ste 125 Lehi UT. 84043 p 801.221.8811 p 801.221.8811 Provo UT. 84604 p 801.753.4700 p 385.388.8003 Hospital Affiliation Hospital Affiliation Hospital Affiliation - Timpanogos Regional Hospital - Timpanogos Regional Hospital Hospital Affiliation - Jordan Valley Medical - Mountain View Hospital - Davis Hospital Center Duros, Peter MD (UT) - Lakeview Hospital - Salt Lake Regional Medical Revere Health - Ogden Regional Medical Center 700 W 800 N Foster, Christine K MD Center - Evanston Regional Hospital Ste 400 Revere Health - Salt Lake Regional Medical - Castleview Hospital Orem UT. 84057 1055 N 500 W Center p 801.221.8811 Provo UT. 84604 Call, Matthew R DO p 801.374.2362 Ling, Yun MD Matthew R Call DO Hospital Affiliation Revere Health 771 W 450 S - Timpanogos Regional Hospital Frantz, David J MD 1175 E 50 S Springville UT. 84663 - Mountain View Hospital Revere Health Ste 241 p 801.226.0737 (UT) 1175 E 50 S American Fork UT. 84003 Ste 221 p 801.492.5999 Cheung, Alfred K MD Envision Physician American Fork UT. 84003 University of Utah Health Services p 801.772.0775 Hospital Affiliation 1159 E 200 N 1345 W 2600 N - Timpanogos Regional Hospital Ste 150 Orem UT. 84057 Hospital Affiliation American Fork UT. 84003 p 801.225.7971 - Timpanogos Regional Hospital Lunceford, Troy MD p 801.373.0167 - Mountain View Hospital Revere Health Eppich, Irel S MD (UT) 972 N 600 E Hospital Affiliation University of Utah Health Spanish Fork UT. 84660 - University of Utah Hospital 1000 E 100 N Habib, Arsalan N MD p 801.465.4896 Payson UT. 84651 University of Utah Health Clayson, Brett PA p 801.465.7000 1159 E 200 N Hospital Affiliation University of Utah Health Ste 150 - Mountain View Hospital 145 W University Pkwy 1034 N 500 W American Fork UT. 84003 (UT) Orem UT. 84058 Provo UT. 84604 p 801.373.0167 - Timpanogos Regional Hospital p 801.234.8600 p 801.357.7850 Hospital Affiliation Marshall, Kent G MD Hospital Affiliation 1159 E 200 N - St Marks Hospital Revere Health - University of Utah Hospital Ste 150 - University of Utah Hospital 700 W 800 N American Fork UT. 84003 Ste 400 Clements, Brian A DO p 801.373.0167 Huddleston, Jason DO Orem UT. 84057 Revere Health Revere Health p 801.221.8811 555 W SR 164 N 15 S 1000 E 1175 E 50 S Salem UT. 84653 Ste 50 Ste 241 Hospital Affiliation p 801.465.4813 Payson UT. 84651 American Fork UT. 84003 - Timpanogos Regional Hospital p 801.465.2060 p 801.492.5999 Corniea, Robert E MD Memon, Kashif A MD Revere Health 1675 N Freedom Blvd Hospital Affiliation Mountain Point Multi 1055 N 500 W Ste 15 - Timpanogos Regional Hospital Specialty Ste 212 Provo UT. 84604 3000 N Triumph Blvd Provo UT. 84604 p 801.373.0167 Johnson, Jeffrey W MD Ste 320 p 801.374.2362 Revere Health Lehi UT. 84043 170 N 1100 E 1055 N 500 W p 801.903.5620 Hospital Affiliation American Fork UT. 84003 Ste 212 - Timpanogos Regional Hospital p 801.855.3300 Provo UT. 84604 Hospital Affiliation p 801.374.2362 - Jordan Valley Medical Craner, Adam C FNP-C 306 River Bend Ln Center Envision Physician Provo UT. 84604 Hospital Affiliation - Salt Lake Regional Medical Services p 801.226.8880 - Timpanogos Regional Hospital Center 1345 W 1600 N - Davis Hospital Orem UT. 84057 750 W 800 N Johnson, Mark MD p 801.225.7971 Orem UT. 84057 Envision Physician p 801.714.6000 Services Hospital Affiliation 1345 W 1600 N - Ogden Regional Medical Hospital Affiliation Orem UT. 84057 Center - University of Utah Hospital p 801.225.7971 - Mountain View Hospital (UT) - Timpanogos Regional Hospital 505 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Miner, Joseph K MD Owens, Casey MD Staheli, John K MD Laboratory Health Clinics of Utah Revere Health Revere Health Dominion Diagnostics 150 E Ctr St 1175 E 50 S 1055 N 500 W Phone Number Only Ste 1100 Ste 251 Ste 212 p 877.734.9600 Provo UT. 84606 American Fork UT. 84003 Provo UT. 84604 p 801.374.7011 p 801.772.0775 p 801.374.2362 LabCorp Draw Station 269 E 400 S Nizam, M S MD 3000 N Triumph Blvd 3300 N Running Creek Way Ste 102 Revere Health Lehi UT. 84043 Bldg B Springville UT. 84663 1055 N 500 W p 801.772.0775 Ste 100 p 801.489.1006 Ste 205 Bldg C Lehi UT. 84043 Provo UT. 84604 Parkinson, Reed MD p 801.277.7378 LabCorp of America p 801.429.8095 Revere Health Holdings 1055 N 500 W 3650 N University Ave Phone Number Only 1175 E 50 S Ste 212 Ste 125 p 888.522.2677 Ste 241 Provo UT. 84604 Provo UT. 84604 American Fork UT. 84003 p 801.374.2362 p 801.227.7378 Long Term Acute Care Facility p 801.429.8008 Utah Valley Specialty Perry, David E DO Hospital Affiliation Hospital Hospital Affiliation Revere Health - Timpanogos Regional Hospital 306 W River Bend Ln - Timpanogos Regional Hospital 700 W 800 N Provo UT. 84604 Ste 230 Swenson, Bryce DO p 801.226.8880 Nobuhara, Lawrence K MD Orem UT. 84057 Revere Health Revere Health p 801.373.4366 1055 N 500 W Maternal And Fetal Medicine 1055 N 500 W Ste 212 Balderston, Keith D MD Ste 121 972 N 600 E Provo UT. 84604 Obstetrix Medical Group of Provo UT. 84604 Spanish Fork UT. 84660 p 801.374.2362 Utah p 801.373.7350 p 801.465.4896 700 W 800 N Hospital Affiliation Ste 310 Hospital Affiliation Raj Krishnamurthy, Vidya - Timpanogos Regional Hospital Orem UT. 84057 - Timpanogos Regional Hospital M MD p 801.225.1937 University of Utah Health Tucker, Stephen MD Nuttall, Marc T MD 1000 E 100 N Envision Physician 750 W 800 N Revere Health Payson UT. 84651 Services Orem UT. 84057 1055 N 500 W p 801.465.7000 1345 W 1600 N p 801.743.4700 Ste 202 Orem UT. 84058 Provo UT. 84604 1034 N 500 W p 801.225.7971 Daniels, Marianne CMHC p 801.374.2367 Provo UT. 84604 Cedar Psychiatry p 801.357.7850 UUHC Parkway Health Center 1788 N State St 1152 E 200 N 145 W University Pkwy Orem UT. 84663 American Fork UT. 84003 1675 N Freedom Blvd Orem UT. 84058 p 801.369.8989 p 801.772.0698 Ste 15 p 801.234.8600 Provo UT. 84604 Ascendant Behavioral 1175 E 50 S p 801.373.0167 Interventional Cardiology Health Ste 171 Advanced Vein and Vascular 3051 W Maple Loop Dr American Fork UT. 84003 170 N 1100 E of Utah Valley Ste 210 p 801.772.0698 American Fork UT. 84003 320 W River Park Dr Lehi UT. 84043 p 801.855.3300 Ste 125 p 801.872.5516 Hospital Affiliation Provo UT. 84604 - Mountain View Hospital 306 River Bend Ln p 385.388.8003 Cedar Psychiatry (UT) Provo UT. 84604 672 W 400 S - Castleview Hospital p 801.226.8880 Kim, Christopher Y MD Ste 201 - Lone Peak Hospital Advanced Vein and Vascular Springville UT. 84663 - Timpanogos Regional Hospital 750 W 800 N of Utah Valley p 801.369.8989 Orem UT. 84057 320 W River Park Dr Ogden, Jeffrey G MD p 801.714.6000 Ste 125 Dildy, Gary A MD 421 N Orem Blvd Provo UT. 84604 Obstetrix Medical Group of Orem UT. 84057 Hospital Affiliation p 385.388.8003 Utah p 801.764.0200 - University of Utah Hospital 700 W 800 N Hospital Affiliation Ste 310 Olsen, Richard K MD Roy, Abinash C MD - Davis Hospital Orem UT. 84057 Revere Health University of Utah Health - Lakeview Hospital p 801.225.1937 1055 N 500 W 1159 E 200 N - Ogden Regional Medical Ste 212 Ste 150 Center Provo UT. 84604 American Fork UT. 84003 - Salt Lake Regional Medical p 801.374.2362 p 801.373.0167 Center

Hospital Affiliation Hospital Affiliation - Timpanogos Regional Hospital - St George Regional Hospital - University of Utah Hospital 506 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 750 W 800 N Affinity Behavior and Andes, Jared C MSW Ball, Jarom LMFT Orem UT. 84057 Mental Health Services 475 W 260 N Utah Psychological p 801.714.6000 533 W State Rd Orem UT. 84057 Associates Ste 103 p 801.221.9930 3549 N University Ave Mental Health Facility Pleasant Grove UT. 84062 Ste 200 Affinity Guidance Services p 801.506.6695 Angus, Troy BCBA Provo UT. 84604 Inc Affinity Behavior and p 801.377.2014 1971 N State St Akalis, Jenivee LCSW Mental Health Services Provo UT. 84604 Healings Steps Counseling 533 W State Rd Ballif, Kendal BCBA p 435.830.6945 111 E Main St Ste 103 Kids On The Move Ste L4 Pleasant Grove UT. 84062 475 W 260 N Steps Recovery Center Lehi UT. 84043 p 801.506.6695 Orem UT. 84057 984 S 903 W p 801.980.3676 p 801.221.9930 Payson UT. 84651 Arballo, Jennifer CSW p 801.465.5111 Alder, Andrew CMHC Utah Behavior Services Banfill, Amanda LCSW Summit Community 216 E Main St Ascendant Behavioral Center for Change Counseling Ste 4 Health 1790 N State St 1429 S 550 E Lehi UT. 84043 3051 W Maple Loop Dr Orem UT. 84057 Ste 260 p 801.255.5131 Ste 210 p 801.224.8255 Orem UT. 84057 Lehi UT. 84043 p 801.266.2485 Archuleta, Jason LCSW p 801.872.5516 Mental Health Utah Behavior Services Acevedo, Carlos ACMHC Aleman, Arianna BCBA 216 E Main St Barkdull, Matthew D LMFT Utah Behavior Services Utah Behavior Services Ste 4 Paramount Counseling 216 E Main St 216 E Main St Lehi UT. 84043 Solutions Ste 4 Ste 4 p 801.255.5131 1177 S 800 E Lehi UT. 84043 Lehi UT. 84043 Orem UT. 84097 p 801.255.5131 p 801.255.5131 Ascendant Behavioral p 888.990.0320 Health Achieving Abilities Allen, Julie BCBA 3051 W Maple Loop Dr Barrow, Alec D CMHC 1392 W Turf Farm Way ABS Kids Ste 210 1355 N University Ave Ste 1-153 1140 W 1130 S Bldg B Lehi UT. 84043 Ste 200 Payson UT. 84651 Orem UT. 84058 p 801.502.3913 Provo UT. 84604 p 801.935.5796 p 801.935.4946 p 801.221.0223 Astorga, Polly A LMFT Adams, Kathy LCSW Allred, Jentrie BCBA Polly Anne Astorga LMFT Barton, Rebecca BCBA Ascendant Behavioral ABS Kids 2940 W Maple Loop Dr Kids On The Move Health 1140 W 1130 S Bldg B Ste L02 475 W 260 N 3051 W Maple Loop Dr Orem UT. 84058 Lehi UT. 84043 Orem UT. 84057 Ste 210 p 801.935.4171 p 801.404.0604 p 801.221.9930 Lehi UT. 84043 p 801.872.5516 1140 W 1130 S Bldg B Atkin, Kayla LCSW Barusch, Nathaniel MD Orem UT. 84058 Healings Steps Counseling Cedar Psychiatry Addiction and p 801.935.4171 111 E Main St 1788 N State St Psychological Services Ste L4 Orem UT. 84663 224 N Orem Blvd Andersen, Jason L DO Lehi UT. 84043 p 801.369.8989 Orem UT. 84057 Silver Creek Psychiatry p 801.980.3676 p 801.222.0603 1480 E 820 N 672 W 400 S Orem UT. 84097 Atwood, Caidy LCMHC Ste 201 81 N Ctr St p 801.919.5197 Healings Steps Counseling Springville UT. 84663 American Fork UT. 84003 111 E Main St p 801.369.8989 p 801.847.7272 Anderson, Rebecca CSW Ste L4 Eagle Mountain Counseling Lehi UT. 84043 Hospital Affiliation 826 N 100 E 3726 E Campus Dr p 801.980.3676 - Mountain View Hospital Ste 2-B Ste H (UT) Spanish Fork UT. 84660 Eagle Mountain UT. 84005 Baldwin, Ashleigh E LCSW - Utah Valley Hospital p 801.794.2350 p 801.642.4196 Valley Behavioral Health 1875 S State St Baylis, Allison BCBA Adolphson, Lillian Anderson, Victoria E PhD Ste 100 ABS Kids BCBA-D Alpine Counseling Center Orem UT. 84097 1140 W 1130 S Bldg B Utah Behavior Services 475 W 50 N p 888.949.4864 Orem UT. 84058 216 E Main St American Fork UT. 84003 p 801.935.4946 Ste 4 p 801.756.3664 Lehi UT. 84043 p 801.255.5131

507 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Beebe, Jesse R MSW Beus, Ben BCBA Blood, Cybele LCSW Bronson, Barbara J LCSW Ascendant Behavioral Affinity Behavior and Ascendant Behavioral Discovery Family Health Mental Health Services Health Counseling 3051 W Maple Loop Dr 533 W State Rd 3051 W Maple Loop Dr 244 W 520 N Ste 210 Ste 103 Ste 210 Orem UT. 84057 Lehi UT. 84043 Pleasant Grove UT. 84062 Lehi UT. 84043 p 801.636.7074 p 801.502.3913 p 801.506.6695 p 801.502.3913 Brooks, Denise E LCSW Belliston, Nancy L LCSW Binks, Paul G PhD Bodily, Madison BCBA Valley Behavioral Health Deseret Counseling Ascendant Behavioral ABS Kids 1875 S State St 1413 S 550 E Health 1140 W 1130 S Bldg B Ste 1000 Ste 106 3051 W Maple Loop Dr Orem UT. 84058 Orem UT. 84097 Orem UT. 84097 Ste 210 p 801.935.4946 p 888.949.4864 p 801.360.3166 Lehi UT. 84043 p 801.502.3913 Bouchelle, Elizabeth 751 E 700 S Belnap, Lorrie M LCSW BCBA Ste 102 Valley Behavioral Health Birch, Kelly LCSW ABS Kids American Fork UT. 84003 1875 S State St Utah Behavior Services 1140 W 1130 S Bldg B p 888.949.4864 Ste 1000 216 E Main St Orem UT. 84058 Orem UT. 84097 Ste 4 p 801.935.4946 Buck, Timothy C CMHC p 888.949.4864 Lehi UT. 84043 Ascendant Behavioral p 801.255.5131 Bowman, Chelsea LCSW Health 751 E 700 S The Green House for Growth 3051 W Maple Loop Dr Ste 102 Bircher, Del LCSW & Learning Ste 210 American Fork UT. 84003 Acadian Counseling 135 W Center St Lehi UT. 84043 p 888.949.4864 Services Pleasant Grove UT. 84062 p 801.872.5516 796 Pacific Dr p 801.785.1169 Bennett, Celeste LCSW Ste A Bunn II, William E DO Ascendant Behavioral American Fork UT. 84003 Bradley, Jessica L CMHC Intercare LLC Health p 801.642.2491 Valley Behavioral Health 1145 S 800 E 3051 W Maple Loop Dr 1875 S State St Ste 111 Ste 210 Bischoff, Rodger D CMHC Ste 1000 Orem UT. 84097 Lehi UT. 84043 Eagle Mountain Counseling Orem UT. 84097 p 801.704.5027 p 801.502.3913 3726 E Campus Dr p 888.949.4864 Ste H William Bunn DO Bennett, Kathleen LCSW Eagle Mountain UT. 84005 751 E 700 S 1750 N Wymount Terrace Dr Life Stone Counseling p 801.642.4196 Ste 102 Provo UT. 84604 Center American Fork UT. 84003 p 801.442.2773 150 S 400 E Black, Jed CMHC p 888.949.4864 American Fork UT. 84003 Utah Behavior Services Intercare LLC p 801.980.7222 216 E Main St Brady, Noel BCBA 2975 W Executive Pkwy Ste 4 Affinity Behavior and Ste 189 Bergvall, Phoebe CMHC Lehi UT. 84043 Mental Health Services Lehi UT. 84043 Ascendant Behavioral p 801.255.5131 533 W State Rd p 801.704.5027 Health Ste 103 3051 W Maple Loop Dr Blair, Sarah MSW Pleasant Grove UT. 84062 Hospital Affiliation Ste 210 The Green House for Growth p 801.506.6695 - Utah Valley Hospital Lehi UT. 84043 & Learning - Primary Childrens Hospital p 801.872.5516 135 W Center St Brandt, Darrin LCSW Pleasant Grove UT. 84062 Ascendant Behavioral Bunting, Catherine CSW Best, Lanette R CMHC p 801.785.1169 Health Utah Behavior Services Valley Behavioral Health 3051 W Maple Loop Dr 216 E Main St 1875 S State St Blanchard, Maria L LCSW Ste 210 Ste 4 Ste 1000 Jill Sabin Smart LCSW LLC Lehi UT. 84043 Lehi UT. 84043 Orem UT. 84097 315 S 100 E p 801.872.5516 p 801.255.5131 p 888.949.4864 Provo UT. 84606 p 801.358.4140 Bray, Kristl BCBA Burr, John LCSW 751 E 700 S ABS Kids 871 S Orem Blvd Ste 102 Blaylock, Rachel M LCSW 1140 W 1130 S Bldg B Orem UT. 84058 American Fork UT. 84003 Family Support & Treatment Orem UT. 84058 p 801.225.7805 p 888.949.4864 Center p 801.935.4946 1255 N 1200 W Burton, Shelby BCBA Orem UT. 84057 ABS Kids p 801.229.1181 1140 W 1130 S Bldg B Orem UT. 84058 p 801.935.4946

508 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Burwell, Briana BCBA 751 E 700 S Cheney, Heidi H LCSW Clement, Kellie M MSW Affinity Behavior and Ste 102 Ascendant Behavioral Ascendant Behavioral Mental Health Services American Fork UT. 84003 Health Health 533 W State Rd p 888.949.4864 3051 W Maple Loop Dr 3051 W Maple Loop Dr Ste 103 Ste 210 Ste 210 Pleasant Grove UT. 84062 Call, Stephanie P BCBA Lehi UT. 84043 Lehi UT. 84043 p 801.506.6695 Fabian House p 801.872.5516 p 801.502.3913 3118 N 1200 W Busch, Heidi J LCSW Lehi UT. 84043 Cho, Jaeyong MSW Cloyd, James H PhD Wasatch Mental Health p 801.917.0940 Utah Behavior Services Nexus Pain Care 1165 E 300 N 216 E Main St 3585 N University Ave Provo UT. 84606 Cannon, Jennifer A PhD Ste 4 Ste 150 p 801.377.1213 Child, Adolescent, and Lehi UT. 84043 Provo UT. 84604 Adult Treatment p 801.255.5131 p 801.356.6100 285 N 1250 E Specialists Payson UT. 84651 796 Pacific Dr Christianson, Grete BCBA Coburn, Alison MSW p 801.852.3805 Ste B Utah Behavior Services Utah Behavior Services American Fork UT. 84003 216 E Main St 216 E Main St 578 E 300 S p 801.756.1626 Ste 4 Ste 4 American Fork UT. 84003 Lehi UT. 84043 Lehi UT. 84043 p 801.763.5010 Carpenter, Erica BCBA p 801.255.5131 p 801.255.5131 Affinity Behavior and 750 N Freedom Blvd Mental Health Services Chrysalis Utah Collins, Shawnee BCBA-D Provo UT. 84601 533 W State Rd 1443 W 800 N Chrysalis Utah p 801.373.4760 Ste 103 Ste 103 1443 W 800 N Pleasant Grove UT. 84062 Orem UT. 84057 Ste 103 Buttars, Ashley A BCBA p 801.506.6695 p 801.655.4950 Orem UT. 84057 Achieving Abilities p 801.655.4950 1392 W Turf Farm Way Carpenter, Kristen C BCBA 220 N 1200 E Ste 1-153 Achieving Abilities Ste 102 Coombs, Amy LCSW Payson UT. 84651 1392 W Turf Farm Way Lehi UT. 84043 Alpine Pain Solutions of p 801.935.5796 Ste 1-153 p 801.655.4950 Utah Payson UT. 84651 3051 W Maple Loop Dr Caceres-Loveless, Maria p 801.935.5796 Chun, Tamra BCBA Ste 125 BCBA Kids On The Move Lehi UT. 84043 Achieving Abilities Carter, Mary A LCSW 475 W 260 N p 801.766.6055 1392 W Turf Farm Way 286 S 600 E Orem UT. 84057 Ste 1-153 Ste C p 801.221.9930 Corey, Spencer BCBA Payson UT. 84651 Provo UT. 84606 Utah Behavior Services p 801.935.5796 p 801.318.8634 Clark, Kathleen P BCBA 216 E Main St Kids Who Count Ste 4 Cahoon, Stephanie BCBA Childrens Justice Center 345 N State Rd 198 Lehi UT. 84043 ABS Kids 315 S 100 E Salem UT. 84653 p 801.255.5131 1140 W 1130 S Bldg B Provo UT. 84606 p 801.423.3000 Orem UT. 84058 p 801.318.8634 Corry, Bradley BCBA p 801.935.4946 Clawson, Jason LCSW ABS Kids Cavin, Christopher LCSW Affinity Guidance Services 1140 W 1130 S Bldg B Caleron, Chrstina CMHC Valley Behavioral Health Inc Orem UT. 84058 Ascendant Behavioral 1875 S State St 1971 N State St p 801.935.4171 Health Ste 1000 Provo UT. 84604 3051 W Maple Loop Dr Orem UT. 84097 p 855.200.2471 Cox, Michael LCSW Ste 210 p 888.949.4864 Veritas Mental Health Lehi UT. 84043 Clegg, Robert LCSW 825 N 1420 E p 801.502.3913 751 E 700 S Keystone Family Counseling Orem UT. 84097 Ste 102 1172 E 100 N p 801.376.7560 Calkins, Chad O LCSW American Fork UT. 84003 Ste 10 Valley Behavioral Health p 888.949.4864 Payson UT. 84651 Crawford, Herta A LCSW 1875 S State St p 801.380.9305 313 E 1200 S Ste 1000 Cheney, Ashley BCBA Ste 101 Orem UT. 84097 Kids On The Move 165 W Canyon Crest Rd Orem UT. 84058 p 888.949.4864 475 W 260 N Ste 210 & 240 p 801.310.0849 Orem UT. 84057 Alpine UT. 84004 p 801.221.9930 p 801.380.9305

509 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Creekpaum, Stephanie M Summit Community Deily, Jacquiline LCSW Doubek, Anne CMHC PSYD Counseling Ascendant Behavioral Ascendant Behavioral Kids On The Move 359 E 1200 S Health Health 475 W 260 N Orem UT. 84058 3051 W Maple Lp Dr 3051 W Maple Loop Dr Orem UT. 84057 p 801.266.2485 Ste 210 Ste 210 p 801.221.9930 Lehi UT. 84043 Lehi UT. 84043 Dasianu, Ashely C LMFT p 801.502.3913 p 801.872.5516 Cross, Hannah LCSW Eagle Mountain Counseling Cedar Psychiatry 3726 E Campus Dr Densley, Logan LCSW Dow, Reed CMHC 672 W 400 S Ste H Veritas Mental Health Ascendant Behavioral Ste 201 Eagle Mountain UT. 84005 825 N 1420 E Health Springville UT. 84663 p 801.642.4196 Orem UT. 84097 3051 W Maple Loop Dr p 801.369.8989 p 801.367.6544 Ste 210 Dastrup, Karen L LMFT Lehi UT. 84043 Cumberledge, Frances Valley Behavioral Health Devlin, Charissa BCBA p 801.872.5516 LCSW 1875 S State St ABS Kids Ascendant Behavioral Ste 1000 1140 W 1130 S Bldg B Dufek, Brandi BCBA Health Orem UT. 84097 Orem UT. 84058 ABS Kids 3051 W Maple Loop Dr p 888.949.4864 p 801.935.4946 1140 W 1130 S Bldg B Ste 210 Orem UT. 84058 Lehi UT. 84043 751 E 700 S Diamond, Allie D LCSW p 801.935.4946 p 801.502.3913 Ste 102 Ascendant Behavioral American Fork UT. 84003 Health Durfey, Roger LMFT Cummings, Tara BCBA p 888.949.4864 3051 W Maple Loop Dr Ascendant Behavioral ABS Kids Ste 210 Health 1140 W 1130 S Bldg B Dastrup, Suzanne L LMFT Lehi UT. 84043 3051 W Maple Loop Dr Orem UT. 84058 Linden Tree Therapy p 801.872.5516 Ste 210 p 801.935.4946 831 N 1420 E Lehi UT. 84043 Orem UT. 84097 Dilworth, Leticia BCBA p 801.872.5516 Cunningham, Jeanna CMHC p 385.225.0464 Utah Autism Academy Valley Behavioral Health 1875 S Geneva Rd Durrant, Laura LCSW 1875 S State St Davies, Celestial L BCBA Orem UT. 84058 Ascendant Behavioral Ste 1000 Kids On The Move p 801.437.0490 Health Orem UT. 84097 475 W 260 N 3051 W Maple Loop Dr p 888.949.4864 Orem UT. 84057 Dixon, Randal LMHC Ste 210 p 801.221.9930 Ascendant Behavioral Lehi UT. 84043 751 E 700 S Health p 801.872.5516 Ste 102 Davis, Sylvia R LCSW 3051 W Maple Loop Dr American Fork UT. 84003 Sylvia Rios Davis Ste 210 Dutson, Devin E LCSW p 888.949.4864 Counseling Lehi UT. 84043 1404 W State Rd 14 N Main St p 801.872.5516 Ste 205 Cunningham, Sean D PhD Springville UT. 84663 Pleasant Grove UT. 84062 University of Utah Health p 801.489.0124 Dobbs, Sareta LPC p 307.254.3407 151 S University Ave Ascendant Behavioral Ste 1610 Dawson-Lovess, S Collette Health Eckerselll, William CMHC Provo UT. 84601 CSW 3051 W Maple Loop Dr Ascendant Behavioral p 801.587.2255 The Green House for Growth Ste 210 Health & Learning Lehi UT. 84043 3051 W Maple Loop Dr Hospital Affiliation 135 W Center St p 801.502.3913 Ste 210 - University of Utah Hospital Pleasant Grove UT. 84062 Lehi UT. 84043 p 801.785.1169 Dobson, Nicole BCBA p 801.872.5516 Dagley, Krystal C ABS Kids Ascendant Behavioral Debenham, Rachael CSW 1140 W 1130 S Bldg B Edgington, Carl PhD Health Ascendant Behavioral Orem UT. 84058 ABS Kids 3051 W Maple Loop Dr Health p 801.935.4946 1140 W 1130 S Bldg B Ste 210 3051 W Maple Loop Dr Orem UT. 84058 Lehi UT. 84043 Ste 210 Dommer, Martin L LMFT p 801.935.4946 p 801.502.3913 Lehi UT. 84043 Marriage & Family Therapy p 801.872.5516 Payson Edmonds, Rita LCSW Dahmen, Alexander LCSW 766 E 100 N Aspen Therapy Valley Behavioral Health Deceuster, Rachael BCBA Payson UT. 84651 3707 N Canyon Rd 1875 S State St Utah Behavior Services p 801.885.1316 Ste 8F Ste 1000 216 E Main St Provo UT. 84604 Orem UT. 84097 Ste 4 p 801.225.3111 p 888.949.4864 Lehi UT. 84043 p 801.255.5131

510 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Eldredge, David G LCSW Fannin, Kerry L LCSW Freeman, Brenner L MD George, Margaret LCSW University of Utah Health Envision Physician University of Utah Health Ascendant Behavioral 145 W University Pkwy Services 145 W University Pkwy Health Orem UT. 84058 1345 W 2600 N Orem UT. 84058 3051 W Maple Loop Dr p 801.234.8600 Orem UT. 84057 p 801.581.7951 Ste 210 p 801.225.7971 Lehi UT. 84043 Hospital Affiliation Hospital Affiliation p 801.872.5516 - Primary Childrens Hospital Fenn, Danielle LMFT - University of Utah Hospital Health Plus Clinic Gibbs, Paula K MD Elkins, Laurie LCSW 376 E 400 S Fujiwara, Mina BCBA University of Utah Health Ascendant Behavioral Springville UT. 84663 Utah Behavior Services 145 W University Pkwy Health p 801.491.9355 216 E Main St Orem UT. 84058 3051 W Maple Loop Dr Ste 4 p 801.581.7951 Ste 210 Fesler, Shaun CMHC Lehi UT. 84043 Lehi UT. 84043 Utah Psychological p 801.255.5131 Hospital Affiliation p 801.872.5516 Associates - University of Utah Hospital 3549 N University Ave Gardiner, Jane G APRN Ellis, John LMFT Ste 200 Ascendant Behavioral Gibson, Crystal BCBA Cedar Psychiatry Provo UT. 84604 Health ABS Kids 1788 N State St p 801.377.2014 3051 W Maple Lp Dr 1140 W 1130 S Bldg B Orem UT. 84663 Ste 210 Orem UT. 84058 p 801.369.8989 Fordham, Bruce K CMHC Lehi UT. 84043 p 801.935.4171 Valley Behavioral Health p 801.502.3913 672 W 400 S 1875 S State St Gibson, Jacob PhD,LMFT Ste 201 Ste 1000 Garlock, John T BCBA The Green House for Growth Springville UT. 84663 Orem UT. 84097 ABS Kids & Learning p 801.369.8989 p 888.949.4864 1140 W 1130 S Bldg B 135 W Center St Orem UT. 84058 Pleasant Grove UT. 84062 Emmons, Dana LMFT 751 E 700 S p 801.935.4171 p 801.785.1169 Health Plus Clinic Ste 102 376 E 400 S American Fork UT. 84003 Utah Autism Academy Gilbert, Natalie LCSW Springville UT. 84663 p 888.949.4864 1875 S Geneva Rd Family Support & Treatment p 801.491.9355 Orem UT. 84058 Center Fox, Bryanna BCBA p 801.437.0490 1255 N 1200 W 61 W 3200 N ABS Kids Orem UT. 84057 Lehi UT. 84043 1140 W 1130 S Bldg B Garrett-Baker, Amanda p 801.229.1181 p 385.352.0404 Orem UT. 84058 BCBA p 801.935.4946 ABS Kids Gillespie, Amy LCSW England, Kimberly CMHC 1140 W 1130 S Bldg B Life Stone Counseling Ascendant Behavioral Francis, Wendy LCSW Orem UT. 84058 Center Health Ascendant Behavioral p 801.935.4946 150 S 400 E 3051 W Maple Loop Dr Health American Fork UT. 84003 Ste 210 3051 W Maple Loop Dr Garza Solis, Karem G LCSW p 801.980.7222 Lehi UT. 84043 Ste 210 Valley Behavioral Health p 801.872.5516 Lehi UT. 84043 1875 S State St Gillespie, Darren J LCSW p 801.502.3913 Ste 1000 Eagle Mountain Counseling Fabian House Orem UT. 84097 3726 E Campus Dr 3118 N 1200 W Francom, Aimee L p 888.949.4864 Ste H Lehi UT. 84043 Lifes Solutions Counseling Eagle Mountain UT. 84005 p 801.917.0940 309 N State St 751 E 700 S p 801.642.4196 Orem UT. 84057 Ste 102 Fackrell, Lachere BCBA p 801.404.3069 American Fork UT. 84003 Glad, Bruce BCBA ABS Kids p 888.949.4864 Affinity Behavior and 1140 W 1130 S Bldg B Francom, Austin P APRN Mental Health Services Orem UT. 84058 Envision Physician Gentry, Steven M PhD 533 W State Rd p 801.935.4171 Services Psychological Assessment & Ste 103 1345 W 1600 N Treatment Specialists Pleasant Grove UT. 84062 Fahlberg, Cory LMFT Orem UT. 84057 814 E Bamberger Dr p 801.506.6695 Ascendant Behavioral p 801.225.7971 Ste B Health American Fork UT. 84003 Goldberg, Annie BCBA 3051 W Maple Loop Dr Frazier, Kenneth D LCSW p 801.772.0202 ABS Kids Ste 210 Acadian Counseling 1140 W 1130 S Bldg B Lehi UT. 84043 Services Orem UT. 84058 p 801.872.5516 796 Pacific Dr p 801.935.4946 Ste A American Fork UT. 84003 p 801.642.2491

511 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Goldman, Sarah PhD Gunnell, Ryan C LMFT 385 N University Ave Harns, Jessica CSW Summit Community Psychological Assessment Ste 250 Healings Steps Counseling Counseling and Treatment Specialists Provo UT. 84604 111 E Main St 359 E 1200 S 814 E Bamberger Dr p 801.377.0088 Ste L4 Orem UT. 84058 Ste A Lehi UT. 84043 p 801.266.2485 American Fork UT. 84003 Hale, Jessica LCSW p 801.980.3676 p 801.772.0202 Valley Behavioral Health Gonzalez, Rosanne LCSW 1875 S State St Harper, Jessica L LPC Healings Steps Counseling Gutknecht, Kylie BCBA Ste 1000 210 W 520 N 111 E Main St Kids On The Move Orem UT. 84097 Orem UT. 84057 Ste L4 475 W 260 N p 888.949.4864 p 801.224.1103 Lehi UT. 84043 Orem UT. 84057 p 801.980.3676 p 801.221.9930 751 E 700 S Harper, Stuart D LCSW Ste 102 Family Support & Treatment Goss, Angela CSW Haderlie, Michael PhD American Fork UT. 84003 Center Utah Behavior Services Giles, Haderlie & p 888.949.4864 1255 N 1200 W 216 E Main St Associates Orem UT. 84057 Ste 4 233 S Pleasant Grove Blvd Halvorson, Isabelle T LPC p 801.229.1181 Lehi UT. 84043 Ste 203 Matt Larson Psychotherapy p 801.255.5131 Pleasant Grove UT. 84062 and Associates 315 S 100 E p 801.785.4622 433 Glacier Lily Dr Provo UT. 84606 Green, Courtney BCBA Alpine UT. 84004 p 801.229.1181 ABS Kids 330 E 400 S p 801.671.7612 1140 W 1130 S Bldg B Ste 3 Harris, Kaitlyn BCBA Orem UT. 84058 Springville UT. 84663 Hancock, Lacey LMHC ABS Kids p 801.935.4171 p 801.491.6394 Life Stone Counseling 1140 W 1130 S Bldg B Center Orem UT. 84058 Green, E Guerry LCSW Mountain Ridge Behavioral 150 S 400 E p 801.935.4171 The Green House for Growth Health Center American Fork UT. 84003 & Learning 704 S 1600 W p 801.980.7222 Harrop, Elizabeth A APRN 135 W Center St Mapleton UT. 84664 Ascendant Behavioral Pleasant Grove UT. 84062 p 801.491.6394 Valley Behavioral Health Health p 801.785.1169 1875 S State St 3051 W Maple Loop Dr Hadnagy-Roch, Alexis Ste 1000 Ste 210 Green, Elsebeth BCBA Orem UT. 84097 Lehi UT. 84043 The Green House for Growth ABS Kids p 888.949.4864 p 801.872.5516 & Learning 1140 W 1130 S Bldg B 135 W Center St Orem UT. 84058 751 E 700 S Hawkins, Jeffrey BCBA Pleasant Grove UT. 84062 p 801.935.4946 Ste 102 ABS Kids p 801.785.1169 American Fork UT. 84003 1140 W 1130 S Bldg B Haines, Marianne NP p 888.949.4864 Orem UT. 84058 Green, Rachal BCBA,LCSW Silver Creek Psychiatry p 801.935.4946 Utah Behavior Services 1480 E 820 N Hansen, Allison LCSW 216 E Main St Orem UT. 84097 Affinity Guidance Services Hayes, Christa J BCBA Ste 4 p 801.919.5197 Inc ABS Kids Lehi UT. 84043 1971 N State St 1140 W 1130 S Bldg B p 801.255.5131 Marianne, Haines, PLLC Provo UT. 84604 Orem UT. 84058 179 N 1200 E p 855.200.2471 p 801.935.4946 Gressmen, Casey BCBA Ste 104 Utah Behavior Services Lehi UT. 84043 Harmon, Jordan LCSW Kids On The Move 216 E Main St p 801.377.0088 Cedar Psychiatry 475 W 260 N Ste 4 1788 N State St Orem UT. 84057 Lehi UT. 84043 Aspen Health, LLC Orem UT. 84663 p 801.221.9930 p 801.255.5131 251 W State Rd 198 Salem p 801.369.8989 Salem UT. 84653 Healings Steps Counseling Guerrieri, Joseph BCBA p 801.377.0088 672 W 400 S 111 E Main St ABS Kids Ste 201 Ste L4 1140 W 1130 S Bldg B Marianne, Haines, PLLC Springville UT. 84663 Lehi UT. 84043 Orem UT. 84058 251 W State Rd 198 p 801.369.8989 p 801.980.3676 p 801.935.4946 Salem UT. 84653 p 801.377.0088 Hospital Affiliation Heath, Nicholas BCBA Guinn, Devin BCBA - Mountain View Hospital ABS Kids ABS Kids (UT) 1140 W 1130 S Bldg B 1140 W 1130 S Bldg B - Utah Valley Hospital Orem UT. 84058 Orem UT. 84058 p 801.935.4946 p 801.935.4171

512 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Heer, Crystal A LPC Valley Behavioral Health Life Tree Jackson, Aaron P PhD Preferred Family Clinic 751 E 700 S 179 N 1200 E 14 N Main St 1355 N University Ave Ste 102 Ste 104 Springville UT. 84663 Ste 200 American Fork UT. 84003 Lehi UT. 84043 p 801.422.8031 Provo UT. 84604 p 888.949.4864 p 801.501.6073 p 801.221.0223 Jackson, Amanda LCSW Hobby, Esperanza A LMFT 251 W SR 198 Cedar Psychiatry Heiner, Hanna M LCSW Valley Behavioral Health Ste 3 1788 N State St Veritas Mental Health 1875 S State St Salem UT. 84653 Orem UT. 84663 825 N 1420 E Ste 1000 p 801.501.6665 p 801.369.8989 Orem UT. 84097 Orem UT. 84097 p 307.707.5060 p 888.949.4864 Horne, Christine CMHC 672 W 400 S Valley Behavioral Health Ste 201 Henderson, Alicia PhD 751 E 700 S 751 E 700 S Springville UT. 84663 Preferred Family Clinic Ste 102 Ste 102 p 801.369.8989 1355 N University Ave American Fork UT. 84003 American Fork UT. 84003 Ste 200 p 888.949.4864 p 888.949.4864 Jacob, Alan R LPC Provo UT. 84604 Preferred Family Clinic p 801.221.0223 Hodgkin, Cameron BCBA Hughes, Lisa B LCSW 1355 N University Ave ABS Kids LBH Counseling Ste 200 Henrie, Patricia CMHC 1140 W 1130 S Bldg B 14 N Main St Provo UT. 84604 Riverwoods Therapy Orem UT. 84058 Springville UT. 84663 p 801.221.0223 202 E 800 S p 801.935.4946 p 801.489.0124 Ste 104 Jacobsen, Maren BCBA Orem UT. 84058 Hoffman, Lindsey BCBA Hunsaker, Kellie D BCBA ABS Kids p 801.787.9855 ABS Kids Kids On The Move 1140 W 1130 S Bldg B 1140 W 1130 S Bldg B 475 W 260 N Orem UT. 84058 Hernandez, June Lee CMHC Orem UT. 84058 Orem UT. 84057 p 801.935.4946 Valley Behavioral Health p 801.935.4946 p 801.221.9930 1875 S State St Jarreau-Wihongi, Lynn A Ste 1000 Hoffmann, Audrey PhD Hunt, Chelseigh BCBA LCSW Orem UT. 84097 Utah Behavior Services Utah Behavior Services Acadian Counseling p 888.949.4864 216 E Main St 216 E Main St Services Ste 4 Ste 4 796 Pacific Dr 751 E 700 S Lehi UT. 84043 Lehi UT. 84043 Ste A Ste 102 p 801.255.5131 p 801.255.5131 American Fork UT. 84003 American Fork UT. 84003 p 801.642.2491 p 888.949.4864 Holman, Jim LMFT Hutchinson, Mark Eagle Mountain Counseling Ascendant Behavioral Jensen, Julia P BCBA Hess, Brandi E LMFT 3726 E Campus Dr Health Utah Behavior Services Eagle Mountain Counseling Ste H 3051 W Maple Lp Dr 216 E Main St 3726 E Campus Dr Eagle Mountain UT. 84005 Ste 210 Ste 4 Ste H p 801.642.4196 Lehi UT. 84043 Lehi UT. 84043 Eagle Mountain UT. 84005 p 801.502.3913 p 801.255.5131 p 801.642.4196 Holmes, Alisha MSW Utah Behavior Services Hyde, Randall F PhD Jensen, Melissa BCBA Higgins, Michael P LCSW 216 E Main St Preferred Family Clinic ABS Kids University of Utah Health Ste 4 1355 N University Ave 1140 W 1130 S Bldg B 145 W University Pkwy Lehi UT. 84043 Ste 200 Orem UT. 84058 Orem UT. 84058 p 801.255.5131 Provo UT. 84604 p 801.935.4171 p 801.234.8600 p 801.221.0223 Hooton, Amy BCBA Jespersen, Marcella G Hilton, Gail C LCSW ABS Kids I Am Recovery Kids On The Move Valley Behavioral Health 1140 W 1130 S Bldg B 121 E State St 475 W 260 N 1875 S State St Orem UT. 84058 Lehi UT. 84043 Orem UT. 84057 Ste 1000 p 801.935.4946 p 801.407.9998 p 801.221.9930 Orem UT. 84097 p 888.949.4864 Hooton, Josh T APRN Ingalls, Lisa J LCSW Jimenez, Virginia BCBA Silver Creek Psychiatry Psychological Assessment & Affinity Behavior and Ascendant Behavioral 1480 E 820 N Treatment Specialists Mental Health Services Health Orem UT. 84097 814 E Bamberger Dr 533 W State Rd 3051 W Maple Loop Dr p 801.919.5197 Ste B Ste 103 Ste 210 American Fork UT. 84003 Pleasant Grove UT. 84062 Lehi UT. 84043 p 801.772.0202 p 801.506.6695 p 801.872.5516

513 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Johnson, Angela LCSW Judson, Ryan CMHC Kirschner, Richard D CMHC Kulow, Kacylia BCBA Acadian Counseling Ascendant Behavioral Valley Behavioral Health Utah Behavior Services Services Health 1875 S State St 216 E Main St 796 Pacific Dr 3051 W Maple Loop Dr Ste 100 Ste 4 Ste A Ste 210 Orem UT. 84097 Lehi UT. 84043 American Fork UT. 84003 Lehi UT. 84043 p 888.949.4864 p 801.255.5131 p 801.836.1151 p 801.872.5516 751 E 700 S Lambertsen, Hope BCBA Johnson, James G LCSW Keller, Rebecca BCBA Ste 102 Utah Behavior Services Valley Behavioral Health Utah Behavior Services American Fork UT. 84003 216 E Main St 1875 S State St 216 E Main St p 888.949.4864 Ste 4 Ste 1000 Ste 4 Lehi UT. 84043 Orem UT. 84097 Lehi UT. 84043 RK General Consultants p 801.255.5131 p 888.949.4864 p 801.255.5131 837 N 500 W American Fork UT. 84003 Landvatter, Jared LCPC Ascendant Behavioral Kennedy, Anne BCBA p 801.699.5362 Alpine Counseling Center Health Utah Behavior Services 475 W 50 N 3051 W Maple Loop Dr 216 E Main St Klein, Leah R LPC American Fork UT. 84003 Ste 210 Ste 4 Psychological Assessment p 801.756.3664 Lehi UT. 84043 Lehi UT. 84043 and Treatment Specialists p 801.502.3913 p 801.255.5131 814 E Bamberger Dr Larrabee, Angelique R Ste A CMHC Valley Behavioral Health Kennedy, Courtney BCBA American Fork UT. 84003 Valley Behavioral Health 751 E 700 S ABS Kids p 801.772.0202 1875 S State St Ste 102 1140 W 1130 S Bldg B Ste 1000 American Fork UT. 84003 Orem UT. 84058 Klinkefus, Nick BCBA Orem UT. 84097 p 888.949.4864 p 801.935.4946 ABS Kids p 888.949.4864 1140 W 1130 S Bldg B Johnson, Sharon LCSW Kids On The Move Orem UT. 84058 751 E 700 S Valley Behavioral Health 475 W 260 N p 801.935.4946 Ste 102 1875 S State St Orem UT. 84057 American Fork UT. 84003 Ste 1000 p 801.221.9930 Knudson, Mani BCBA p 888.949.4864 Orem UT. 84097 Utah Behavior Services p 888.949.4864 Killpack, Ruth M PhD 216 E Main St Larsen, Danette CMHC Aspen Therapy Inc Ste 4 Life Stone Counseling 751 E 700 S 3707 N Canyon Rd Lehi UT. 84043 Center Ste 102 Ste 8F p 801.255.5131 150 S 400 E American Fork UT. 84003 Provo UT. 84604 American Fork UT. 84003 p 888.949.4864 p 801.225.3111 Koh, Kyung-Ran CMHC p 801.980.7222 Ascendant Behavioral Johnston, Harmony MSW King, Kelsey LCSW Health Larsen, Melissa L CMHC Utah Behavior Services Utah Behavior Services 3051 W Maple Loop Dr Valley Behavioral Health 216 E Main St 216 E Main St Ste 210 1875 S State St Ste 4 Ste 4 Lehi UT. 84043 Ste 1000 Lehi UT. 84043 Lehi UT. 84043 p 801.502.3913 Orem UT. 84097 p 801.255.5131 p 801.255.5131 p 888.949.4864 Koller, Karolee LCSW Johnston, Mark MD Kirschner, Rebecca CMHC Affinity Guidance Services 751 E 700 S Ascendant Behavioral Valley Behavioral Health Inc Ste 102 Health 1875 S State St 1971 N State St American Fork UT. 84003 3051 W Maple Loop Dr Ste 1000 Provo UT. 84604 p 888.949.4864 Ste 210 Orem UT. 84097 p 855.200.2471 Lehi UT. 84043 p 888.949.4864 Lasley, Linda K LCSW p 801.872.5516 Kramer, Andrea BCBA Valley Behavioral Health 751 E 700 S ABS Kids 1875 S State St Jones, Lisa BCBA Ste 102 1140 W 1130 S Bldg B Ste 1000 ABS Kids American Fork UT. 84003 Orem UT. 84058 Orem UT. 84097 1140 W 1130 S Bldg B p 888.949.4864 p 801.935.4946 p 888.949.4864 Orem UT. 84058 p 801.935.4946 RK General Consultants Kronmiller, Kalli CMHC 751 E 700 S 837 N 500 W Valley Behavioral Health Ste 102 Jones, Tonya BCBA American Fork UT. 84003 1875 S State St American Fork UT. 84003 ABS Kids p 801.699.5362 Ste 100 p 888.949.4864 1140 W 1130 S Bldg B Orem UT. 84097 Orem UT. 84058 p 888.949.4864 p 801.935.4171

514 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Lee, Cindy L LCSW 285 N 1250 E Lopes, Erika BCBA Macfarlane, Lindsey A Hearthstone Counseling Payson UT. 84651 ABS Kids LCSW PLLC p 801.852.3805 1140 W 1130 S Bldg B Valley Behavioral Health 286 S 600 E Orem UT. 84058 1875 S State St Provo UT. 84606 578 E 300 S p 801.935.4171 Ste 1000 p 801.377.8222 American Fork UT. 84003 Orem UT. 84097 p 801.763.5010 Lopez, Kitrina BCBA p 888.949.4864 Lee, Jennifer BCBA Utah Behavior Services Utah Behavior Services 750 N Freedom Blvd 216 E Main St 751 E 700 S 216 E Main St Provo UT. 84601 Ste 4 Ste 102 Ste 4 p 801.373.4760 Lehi UT. 84043 American Fork UT. 84003 Lehi UT. 84043 p 801.255.5131 p 888.949.4864 p 801.255.5131 Lindstrom, Shanna LCSW Ascendant Behavioral Lopez, Marta LCSW Maciel, Diane G LCSW Lee, Susannah R LMFT Health University of Utah Health 265 N Main St Eagle Mountain Counseling 3051 W Maple Loop Dr 145 W University Pkwy Ste 100 3726 E Campus Dr Ste 210 Orem UT. 84058 Spanish Fork UT. 84660 Ste H Lehi UT. 84043 p 801.234.8600 p 801.358.4082 Eagle Mountain UT. 84005 p 801.872.5516 p 801.789.7780 Hospital Affiliation 315 S 100 E Linnell, Randy S LCSW - University of Utah Hospital Provo UT. 84606 Levstek Caplin, Deirdre A Institute for Cognitive p 801.358.4140 PhD Therapy Louw, Keith LMFT University of Utah Health 879 S Orem Blvd Peak Relational Counseling Madsen, April LPC 151 S University Ave Ste 1 1450 E 820 N Aspen Valley Counseling Ste 1610 Orem UT. 84058 Orem UT. 84097 210 W 520 N Provo UT. 84601 p 801.859.9238 p 801.472.8442 Orem UT. 84057 p 801.587.2255 p 801.224.1103 Little, Tamara A LCSW Lovelace, Scott LCMHC Lewis, Brian ACMHC Center for Growth & Utah Behavior Services Madsen, Sara BCBA Healings Steps Counseling Healing 216 E Main St ABS Kids 111 E Main St 101 E 200 S Ste 4 1140 W 1130 S Bldg B Ste L4 Springville UT. 84663 Lehi UT. 84043 Orem UT. 84058 Lehi UT. 84043 p 801.592.0885 p 801.255.5131 p 801.935.4171 p 801.980.3676 Livingstone, John D PhD Lowe, Kori BCBA Utah Behavior Services Life Tree Alpine Pediatrics Utah Behavior Services 216 E Main St 179 N 1200 E 1238 N Commerce Dr 216 E Main St Ste 4 Ste 104 Saratoga Springs UT. 84045 Ste 4 Lehi UT. 84043 Lehi UT. 84043 p 801.922.9222 Lehi UT. 84043 p 801.255.5131 p 801.501.6073 p 801.255.5131 1912 W 930 N Kids Who Count 251 W SR 198 Pleasant Grove UT. 84062 Luna, Janette M LCSW 345 N State Rd 198 Ste 3 p 801.492.1999 Utah Behavior Services Salem UT. 84653 Salem UT. 84653 216 E Main St p 801.423.3000 p 801.501.6665 3000 N Triumph Blvd Ste 4 Ste 240 Lehi UT. 84043 Maher, Jaclyn BCBA Lilino, Leslie L Lehi UT. 84043 p 801.255.5131 Kids On The Move Kids On The Move p 801.229.1000 475 W 260 N 475 W 260 N Lund, Lori LMFT Orem UT. 84057 Orem UT. 84057 3231 N 1120 E Ascendant Behavioral p 801.221.9930 p 801.221.9930 Lehi UT. 84043 Health p 801.768.2800 3051 W Maple Loop Dr Makowski, Alexandra BCBA Lilly, John P LCSW Ste 210 ABS Kids Sierra Counseling 848 N 980 W Lehi UT. 84043 1140 W 1130 S Bldg B Associates Orem UT. 84057 p 801.502.3913 Orem UT. 84058 286 S 600 E p 801.374.1999 p 801.935.4946 Ste C Lyon, Nathan BCBA Provo UT. 84606 Lofthouse, Chelsea ACMHC Kids Who Count Malone, Sara BCBA p 801.377.8222 Utah Behavior Services 345 N State Rd 198 ABS Kids 216 E Main St Salem UT. 84653 1140 W 1130 S Bldg B Limb, Joseph C LCSW Ste 4 p 801.423.3000 Orem UT. 84058 Wasatch Mental Health Lehi UT. 84043 p 801.935.4946 1165 E 300 N p 801.255.5131 Provo UT. 84606 p 801.377.1213

515 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Malouf, John PhD McConnell, Scott CMHC Mendoza, Emily BCaBA Mitchell, Susan LCSW Valley Behavioral Health The Green House for Growth ABS Kids Ascendant Behavioral 1875 S State St & Learning 1140 W 1130 S Bldg B Health Ste 1000 135 W Center St Orem UT. 84058 3051 W Maple Loop Dr Orem UT. 84097 Pleasant Grove UT. 84062 p 801.935.4946 Ste 210 p 888.949.4864 p 801.785.1169 Lehi UT. 84043 Meng, Ashley CSW p 801.502.3913 751 E 700 S McDonald, Tyler CMHC Healings Steps Counseling Ste 102 Valley Behavioral Health 111 E Main St Moleni, Fisi LCSW American Fork UT. 84003 751 E 700 S Ste L4 Affinity Guidance Services p 888.949.4864 Ste 102 Lehi UT. 84043 Inc American Fork UT. 84003 p 801.980.3676 1971 N State St Hospital Affiliation p 888.949.4864 Provo UT. 84604 - University of Utah Hospital Merkley, Patricia L LCSW p 855.200.2471 McFadden, Molly Q LCSW Ascendant Behavioral Manov, Ludmil K MD University of Utah Health Health Moosman, Julie BCBA 21 N 49 W 145 W University Pkwy 3051 W Maple Loop Dr ABS Kids American Fork UT. 84043 Orem UT. 84058 Ste 210 1140 W 1130 S Bldg B p 801.642.2396 p 801.234.8600 Lehi UT. 84043 Orem UT. 84058 p 801.872.5516 p 801.935.4171 Manwill, Andrea BCBA McGill, Katie MSW Kids On The Move Utah Behavior Services Metzger, Debbie BCBA Morrill, Jennifer A PhD 475 W 260 N 216 E Main St Utah Behavior Services Utah Psychological Orem UT. 84057 Ste 4 216 E Main St Associates p 801.221.9930 Lehi UT. 84043 Ste 4 3549 N University Ave p 801.255.5131 Lehi UT. 84043 Ste 200 Marcum, James M MD p 801.255.5131 Provo UT. 84604 Cedar Psychiatry McGuire, Amy BCBA p 801.377.2014 1788 N State St Utah Behavior Services Middleton, Susan G LCSW Orem UT. 84663 216 E Main St Preferred Family Clinic Morris, Laura L LPC p 801.369.8989 Ste 4 1355 N University Ave Preferred Family Clinic Lehi UT. 84043 Ste 200 1355 N University Ave 672 W 400 S p 801.255.5131 Provo UT. 84604 Ste 200 Ste 201 p 801.221.0223 Provo UT. 84604 Springville UT. 84663 McMillan, Myrna LMFT p 801.221.0223 p 801.369.8989 The Green House for Growth Miller, Kierea LMFT & Learning Acadian Counseling Morris, Tracee BCBA Margolis, Amber LCSW 1220 N Main St Services ABS Kids University of Utah Health Ste 5 796 Pacific Dr 1140 W 1130 S Bldg B 145 W University Pkwy Springville UT. 84663 Ste A Orem UT. 84058 Orem UT. 84058 p 801.210.7216 American Fork UT. 84003 p 801.935.4171 p 801.234.8600 p 801.225.6246 135 W Center St Moseng, Megan Mattingly, Mary BCBA Pleasant Grove UT. 84062 Miller, Robert LPC Utah Autism Academy ABS Kids p 801.785.1169 Ascendant Behavioral 1875 S Geneva Rd 1140 W 1130 S Bldg B Health Orem UT. 84058 Orem UT. 84058 McStotts, Kelli CMHC 3051 W Maple Loop Dr p 801.437.0490 p 801.935.4946 Summit Community Ste 210 Counseling Lehi UT. 84043 Moser, Terri L LMFT Maughan, Sari BCBA 359 E 1200 S p 801.872.5516 Heart of Peace Counseling Affinity Behavior and Orem UT. 84058 1441 N 1220 W Mental Health Services p 801.266.2485 Mitchell, Courtney E Orem UT. 84057 533 W State Rd Kids On The Move p 801.516.1198 Ste 103 Mccune, Tara J CMHC 475 W 260 N Pleasant Grove UT. 84062 Valley Behavioral Health Orem UT. 84057 Moss, Terri LMFT p 801.506.6695 751 E 700 S p 801.221.9930 Ascendant Behavioral Ste 102 Health Maxwell, Kendra BCBA American Fork UT. 84003 Mitchell, Merikay CMHC 3051 W Maple Loop Dr Utah Behavior Services p 888.949.4864 Ascendant Behavioral Ste 210 216 E Main St Health Lehi UT. 84043 Ste 4 Meier, Heather BCBA 3051 W Maple Loop Dr p 801.872.5516 Lehi UT. 84043 ABS Kids Ste 210 p 801.255.5131 1140 W 1130 S Bldg B Lehi UT. 84043 Orem UT. 84058 p 801.872.5516 p 801.935.4946

516 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Moulton, Emily Phd Nelson, Heather J LCSW Oblad, Cicily BCBA Parsons, Rita M BCBA University of Utah Health Heather Nelson, LCSW Utah Behavior Services ABS Kids 151 S University Ave 441 W Main 216 E Main St 1140 W 1130 S Bldg B Ste 1610 Ste B Ste 4 Orem UT. 84058 Provo UT. 84601 Lehi UT. 84043 Lehi UT. 84043 p 801.935.4946 p 801.587.2255 p 801.520.3160 p 801.255.5131 Paulson, David L MD Hospital Affiliation Nelson, Michael D BCBA Oka, Megan LMFT Alliance Behavioral - University of Utah Hospital @Preferred Family Clinic Megan Oka LMFT Psychiatry 1355 N Univeristy Ave 602 Campus Dr 361 E 1200 S Mullaney, Edward LCSW Ste 200 Orem UT. 84058 Ste 201 University of Utah Health Provo UT. 84604 p 435.213.3062 Orem UT. 84058 145 W University Pkwy p 801.221.0223 p 801.224.3014 Orem UT. 84058 Olsen, Lisa J APRN p 801.234.8600 Nelson, Michelle M LCSW Alliance Behavioral Pauole, Allan K CMHC University of Utah Health Psychiatry Revere Health Murphy, H Nicole BCBA 145 W University Pkwy 361 E 1200 S 1055 N 500 W Bldg A ABS Kids Orem UT. 84058 Ste 201 Provo UT. 84604 1140 W 1130 S Bldg B p 801.234.8600 Orem UT. 84058 p 801.812.5033 Orem UT. 84058 p 801.224.3014 p 801.935.4946 Hospital Affiliation 700 W 800 N - University of Utah Hospital Ortiz-Perez, Marco BCBA Ste 100 Murray, Kelli A MSW ABS Kids Orem UT. 84057 Utah Valley Family Support Newman, Felicia BCBA 1140 W 1130 S Bldg B p 801.812.5033 1255 N 1200 W ABS Kids Orem UT. 84058 Orem UT. 84057 1140 W 1130 S Bldg B p 801.935.4946 Pearson, David LCSW p 801.229.1181 Orem UT. 84058 Affinity Guidance Services p 801.935.4946 Ossmen, Caitlin BCBA Inc Nadalsky, Michelle ABS Kids 1971 N State St BCBA,SSW Nicols, Jenissa BCBA 1140 W 1130 S Bldg B Provo UT. 84604 Utah Behavior Services ABS Kids Orem UT. 84058 p 855.200.2471 216 E Main St 1140 W 1130 S Bldg B p 801.935.4171 Ste 4 Orem UT. 84058 Pehrson, Heather BCBA Lehi UT. 84043 p 801.935.4171 Ossmen, Jordan BCBA ABS Kids p 801.255.5131 ABS Kids 1140 W 1130 S Bldg B Utah Autism Academy 1140 W 1130 S Bldg B Orem UT. 84058 Navas, Barbara BCBA 1875 S Geneva Rd Orem UT. 84058 p 801.935.4171 ABS Kids Orem UT. 84058 p 801.935.4171 1140 W 1130 S Bldg B p 801.437.0490 Pennington, Randal S PSYD Orem UT. 84058 Pabst, Mackenzie MSW Spinal Interventions p 801.935.4946 Nielsen, Douglas L PhD Kids On The Move 230 N 1200 E Alpine Counseling Center 475 W 260 N Ste 201 Neff, Michal A CSW,SUDC 475 W 50 N Orem UT. 84057 Lehi UT. 84043 Utah Behavior Services American Fork UT. 84003 p 801.221.9930 p 801.852.9555 216 E Main St p 801.756.3664 Ste 4 Packer, Candice CSW 280 W River Park Dr Lehi UT. 84043 Nielsen, Stephanie MSW The Green House for Growth Ste 200 p 801.255.5131 Utah Behavior Services & Learning Provo UT. 84604 216 E Main St 135 W Center St p 801.223.4860 Neilson, Tamera L LCSW Ste 4 Pleasant Grove UT. 84062 Veritas Mental Health Lehi UT. 84043 p 801.785.1169 Perez, Erin P LCSW 825 N 1420 E p 801.255.5131 Valley Behavioral Health Orem UT. 84097 Pallos, Petra LPC 1875 S State St p 801.505.8745 Nuttall, Marie LPC Ascendant Behavioral Ste 1000 Ascendant Behavioral Health Orem UT. 84097 Nelson, Angela LCSW Health 3051 W Maple Loop Dr p 888.949.4864 Healings Steps Counseling 3051 W Maple Loop Dr Ste 210 111 E Main St Ste 210 Lehi UT. 84043 751 E 700 S Ste L4 Lehi UT. 84043 p 801.872.5516 Ste 102 Lehi UT. 84043 p 801.872.5516 American Fork UT. 84003 p 801.980.3676 Palmer-Merrill, Lauren K p 888.949.4864 OBanion, Joy A LCSW BCBA Family Support & Treatment Kids On The Move Center 475 W 260 N 1255 N 1200 W Orem UT. 84057 Orem UT. 84057 p 801.221.9930 p 801.229.1181

517 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Petersen, Jodi LCSW 135 W Center St Randall, Cameron E BCBA 751 E 700 S Ascendant Behavioral Pleasant Grove UT. 84062 Kids On The Move Ste 102 Health p 801.785.1169 475 W 260 N American Fork UT. 84003 3051 W Maple Loop Dr Orem UT. 84057 p 888.949.4864 Ste 210 Porter, Nathan MSW p 801.221.9930 Lehi UT. 84043 The Green House for Growth Rich, Stacey p 801.872.5516 & Learning Ranks, Georgann LPC Ascendant Behavioral 1220 N Main St Ascendant Behavioral Health Acadian Counseling Ste 5 Health 3051 W Maple Loop Dr Services Springville UT. 84663 3051 W Maple Loop Dr Ste 210 796 Pacific Dr p 801.210.7216 Ste 210 Lehi UT. 84043 Ste A Lehi UT. 84043 p 801.502.3913 American Fork UT. 84003 135 W Center St p 801.872.5516 p 801.225.6246 Pleasant Grove UT. 84062 Richards, R L PhD p 801.785.1169 Rasmussen, Jake BCBA 1432 E 850 S Peterson, Clint W APRN ABS Kids Provo UT. 84606 Wasatch Mental Health Potts, Justin PSYD 1140 W 1130 S Bldg B p 801.371.8784 1165 E 300 N Summit Community Orem UT. 84058 Provo UT. 84606 Counseling p 801.935.4171 Ringger, Brett BCBA p 801.377.1213 359 E 1200 S ABS Kids Orem UT. 84058 Rasmussen, Kipling S PhD 1140 W 1130 S Bldg B 285 N 1250 E p 801.266.2485 Affinity Guidance Services Orem UT. 84058 Payson UT. 84651 Inc p 801.935.4946 p 801.852.3805 Powell, Clark Randy LCSW 1971 N State St Utah Behavior Services Provo UT. 84604 Ringold, Patricia LPC 578 E 300 S 216 E Main St p 855.200.2471 Ascendant Behavioral American Fork UT. 84003 Ste 4 Health p 801.763.5010 Lehi UT. 84043 Utah Psychological 3051 W Maple Loop Dr p 801.255.5131 Associates Ste 210 750 N Freedom Blvd 3549 N University Ave Lehi UT. 84043 Provo UT. 84601 Preston, Shara LCMHC Ste 200 p 801.872.5516 p 801.373.4760 Healings Steps Counseling Provo UT. 84604 111 E Main St p 801.377.2014 Robinson, Brian CMHC Phillips, Allison Ste L4 Alpine Counseling Center LCSW,BCBA Lehi UT. 84043 Ratliff, Jeremy APRN 475 W 50 N Utah Behavior Services p 801.980.3676 Valley Behavioral Health American Fork UT. 84003 216 E Main St 1875 S State St p 801.756.3664 Ste 4 Proctor, Lyndsey D LCSW Ste 100 Lehi UT. 84043 Serenity Recovery and Orem UT. 84097 Robinson, Kerri F LCSW p 801.255.5131 Wellness p 888.949.4864 Family Support & Treatment 39 Professional Way Center Pollock, Clinton BCBA Ste 2 751 E 700 S 1255 N 1200 W Chrysalis Utah Payson UT. 84651 Ste 102 Orem UT. 84057 220 N 1200 E p 801.658.0098 American Fork UT. 84003 p 801.229.1181 Ste 102 p 888.949.4864 Lehi UT. 84043 Purdy, Tyler LCSW Robison, Reid J MD p 801.655.4950 The Green House for Growth Renda, Cheyenne R PhD Cedar Psychiatry & Learning Utah Behavior Services 1788 N State St Ponce, Timothy W LMFT 135 W Center St 216 E Main St Orem UT. 84663 ABC Family Counseling Pleasant Grove UT. 84062 Ste 4 p 801.369.8989 1149 W Center St p 801.785.1169 Lehi UT. 84043 Orem UT. 84057 p 801.255.5131 672 W 400 S p 801.361.2237 Putnam, Emily PhD Ste 201 Healings Steps Counseling Reynolds, Susan M LPC Springville UT. 84663 Porschatis, Amber M LCSW 111 E Main St Susan Reynolds Counseling p 801.369.8989 University of Utah Health Ste L4 3355 N University Ave 145 W University Pkwy Lehi UT. 84043 Ste 250C Hospital Affiliation Orem UT. 84058 p 801.980.3676 Provo UT. 84604 - Mountain View Hospital p 801.234.8600 p 801.427.9309 (UT) RK General Consultants - Utah Valley Hospital Porter, Jalynn MSW 837 N 500 W Ricci, Jeanette M LCSW The Green House for Growth American Fork UT. 84003 Valley Behavioral Health Robles, Richard BCBA & Learning p 801.699.5362 1875 S State St ABS Kids 1220 N Main St Ste 1000 1140 W 1130 S Bldg B Ste 5 Orem UT. 84097 Orem UT. 84058 Springville UT. 84663 p 888.949.4864 p 801.935.4946 p 801.210.7216

518 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Roche, Miriam MSW Sagendorf, Emily BCBA 751 E 700 S 3231 N 1120 E Utah Behavior Services Utah Behavior Services Ste 102 Lehi UT. 84043 216 E Main St 216 E Main St American Fork UT. 84003 p 801.768.2800 Ste 4 Ste 4 p 888.949.4864 Lehi UT. 84043 Lehi UT. 84043 77 E Commerce Dr p 801.255.5131 p 801.255.5131 Serenity Recovery and Saratoga Springs UT. 84045 Wellness p 801.922.9222 Rockwell, Rene BCBA Salsberry, Maria CSW 39 Professional Way Utah Behavior Services Utah Behavior Services Ste 2 848 N 980 W 216 E Main St 216 E Main St Payson UT. 84651 Orem UT. 84057 Ste 4 Ste 4 p 801.658.0098 p 801.374.1999 Lehi UT. 84043 Lehi UT. 84043 p 801.255.5131 p 801.255.5131 Sewell, Nathan PhD Simpson, Robert I MD Preferred Family Clinic 619 N 500 W Rogers, Jennifer PSYD Sanders, Sarah BCBA 1355 N University Ave Provo UT. 84601 ABS Kids Utah Behavior Services Provo UT. 84604 p 801.852.9440 1140 W 1130 S Bldg B 216 E Main St p 801.221.0223 Orem UT. 84058 Ste 4 Sivertson, Savannah BCBA p 801.935.4946 Lehi UT. 84043 Shields, Haley B BCBA ABS Kids p 801.255.5131 ABS Kids 1140 W 1130 S Bldg B Rogers, Tirzah L CMHC 1140 W 1130 S Bldg B Orem UT. 84058 Eagle Mountain Counseling Schiefelbein, Julieanne H Orem UT. 84058 p 801.935.4946 3726 E Campus Dr APRN p 801.935.4946 Ste H Wasatch Neonatal Skelton, Andy H LPC Eagle Mountain UT. 84005 730 W 800 N Shumway, Brett PSYD 1355 N University Ave p 801.642.4196 Ste 340-B Utah Behavior Services Ste 200 Orem UT. 84057 216 E Main St Provo UT. 84604 Roll, Ashley A p 801.655.5425 Ste 4 p 801.221.0223 Kids On The Move Lehi UT. 84043 475 W 260 N Hospital Affiliation p 801.255.5131 Skibitsky, Jeffrey BCBA Orem UT. 84057 - Salt Lake Regional Medical ABS Kids p 801.221.9930 Center Siebert, Tatum LCPC 1140 W 1130 S Bldg B - Timpanogos Regional Hospital Utah Behavior Services Orem UT. 84058 Rosado, Leah BCBA 216 E Main St p 801.935.4946 ABS Kids Schmelzer, Alina LCSW Ste 4 1140 W 1130 S Bldg B Ascendant Behavioral Lehi UT. 84043 Skousen, Thomas MSW Orem UT. 84058 Health p 801.255.5131 Utah Behavior Services p 801.935.4171 3051 W Maple Loop Dr 216 E Main St Ste 210 Simancas (Monago), Ste 4 Roskelley, Hannah BCBA Lehi UT. 84043 Letisia A BCBA Lehi UT. 84043 ABS Kids p 801.872.5516 ABS Kids p 801.255.5131 1140 W 1130 S Bldg B 1140 W 1130 S Bldg B Orem UT. 84058 Schuknecht, Kelly BCBA Orem UT. 84058 Slack, Micah BCBA p 801.935.4946 ABS Kids p 801.935.4946 ABS Kids 1140 W 1130 S Bldg B 1140 W 1130 S Bldg B Roth, Natalie PhD Orem UT. 84058 Simmons, Stacey LCSW Orem UT. 84058 ABS Kids p 801.935.4946 The Whole Child Therapy p 801.935.4171 1140 W 1130 S Bldg B 727 S Main St Orem UT. 84058 Sears, Wayne R CMHC Spanish Fork UT. 84660 Slater, Courtney MSW p 801.935.4946 Life Stone Counseling p 801.210.9319 Utah Behavior Services Center 216 E Main St Russett, Ebbie I CMHC 150 S 400 E Simpson, Julia B PhD Ste 4 Valley Behavioral Health American Fork UT. 84003 Alpine Pediatrics Lehi UT. 84043 1875 S State St p 801.980.7222 1912 W 930 N p 801.255.5131 Ste 100 Pleasant Grove UT. 84062 Orem UT. 84097 Seiler, Edward A CMHC p 801.492.1999 Smart, Jill S LCSW p 888.949.4864 Valley Behavioral Health 265 N Main St 1875 S State St 3000 N Triumph Blvd Ste 100 751 E 700 S Ste 1000 Ste 240 Spanish Fork UT. 84660 Ste 102 Orem UT. 84097 Lehi UT. 84043 p 801.358.4082 American Fork UT. 84003 p 888.949.4864 p 801.229.1000 p 888.949.4864 315 S 100 E Provo UT. 84606 p 801.358.4082

519 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Smith, Ashlin BCBA Sorenson, Cassie BCBA Stevens, Nicole 751 E 700 S ABS Kids ABS Kids BCBA,LMFT Ste 102 1140 W 1130 S Bldg B 1140 W 1130 S Bldg B Utah Behavior Services American Fork UT. 84003 Orem UT. 84058 Orem UT. 84058 216 E Main St p 888.949.4864 p 801.935.4946 p 801.935.4946 Ste 4 Lehi UT. 84043 Swenson, Matthew J MD Affinity Behavior and Stambaugh, Leigh Ann p 801.255.5131 Alpine Pediatrics Mental Health Services CMHC 1238 N Commerce Dr 533 W State Rd Ascendant Behavioral Stevens, Odessa CMHC Saratoga Springs UT. 84045 Ste 103 Health The Green House for Growth p 801.922.9222 Pleasant Grove UT. 84062 3051 W Maple Loop Dr & Learning p 801.506.6695 Ste 210 135 W Center St 1912 W 930 N Lehi UT. 84043 Pleasant Grove UT. 84062 Pleasant Grove UT. 84062 Smith, Erica BCBA p 801.872.5516 p 801.785.1169 p 801.492.1999 Utah Behavior Services 216 E Main St Stasiuk, John A LMFT Stevenson, Victoria A 3000 N Triumph Blvd Ste 4 Utah Behavior Services BCBA Ste 240 Lehi UT. 84043 216 E Main St ABS Kids Lehi UT. 84043 p 801.255.5131 Ste 4 1140 W 1130 S Bldg B p 801.229.1000 Lehi UT. 84043 Orem UT. 84058 Smith, Hannah BCBA p 801.255.5131 p 801.935.4171 3231 N 1120 E ABS Kids Lehi UT. 84043 1140 W 1130 S Bldg B Steele, Isaac D APRN Stewart, Mitzy APRN p 801.492.1999 Orem UT. 84058 Valley Behavioral Health Ascendant Behavioral p 801.935.4171 1875 S State St Health 848 N 980 W Ste 1000 3051 W Maple Loop Dr Orem UT. 84057 Smith, Jennifer LCSW Orem UT. 84097 Ste 210 p 801.374.1999 Affinity Guidance Services p 888.949.4864 Lehi UT. 84043 Inc p 801.502.3913 Hospital Affiliation 1971 N State St 751 E 700 S - Utah Valley Hospital Provo UT. 84604 Ste 102 Stoddard, Nancy L LCSW p 855.200.2471 American Fork UT. 84003 Nancy L Stoddard, LCSW Tabara, Jackqueline BCBA p 888.949.4864 286 S 600 E ABS Kids Smith, Mary L LCSW Ste C 1140 W 1130 S Bldg B Sycamore Counseling Center Steinke, Alyssa LMFT Provo UT. 84606 Orem UT. 84058 900 S State Rd Aspen Valley Wellness p 801.859.2194 p 801.935.4946 Orem UT. 84097 210 W 520 N p 801.224.3322 Orem UT. 84057 Stotts, Jonas BCBA Tate, David F PhD p 801.224.1103 ABS Kids David F Tate PhD Smith, Melanie J LMFT 1140 W 1130 S Bldg B 1055 N 300 W Art City Family Counseling Stephens, Travis R CSW Orem UT. 84058 Ste 410 1453 N 440 W Valley Behavioral Health p 801.935.4946 Provo UT. 84604 Mapleton UT. 84664 1875 S State St p 801.616.3675 p 801.615.0554 Ste 1000 Stout, Kelly L PhD Orem UT. 84097 University of Utah Health Taylor, Amanda BCBA Smith, Saige LPC p 888.949.4864 151 S University Ave ABS Kids Utah Behavior Services Ste 1610 1140 W 1130 S Bldg B 216 E Main St 751 E 700 S Provo UT. 84601 Orem UT. 84058 Ste 4 Ste 102 p 801.587.2255 p 801.935.4946 Lehi UT. 84043 American Fork UT. 84003 p 801.255.5131 p 888.949.4864 Hospital Affiliation Taylor, Patricia E PhD - University of Utah Hospital Child, Adolescent, and Snow, Lauren BCBA Stephenson, Sue A CMHC Adult Treatment Utah Behavior Services Ascendant Behavioral Suarez, Alex LCSW Specialists 216 E Main St Health Utah Behavior Services 796 Pacific Dr Ste 4 3051 W Maple Loop Dr 216 E Main St Ste B Lehi UT. 84043 Ste 210 Ste 4 American Fork UT. 84003 p 801.255.5131 Lehi UT. 84043 Lehi UT. 84043 p 801.756.1626 p 801.872.5516 p 801.255.5131 Snyder, Daniel LCSW Tellesbo, Sarah M LCSW Healings Steps Counseling Stevens, Ashley L PhD Sutherland, Debbie A LCSW Cedar Psychiatry 111 E Main St University of Utah Health Valley Behavioral Health 1788 N State St Ste L4 151 S University Ave 1875 S State St Orem UT. 84663 Lehi UT. 84043 Ste 1610 Ste 1000 p 801.369.8989 p 801.980.3676 Provo UT. 84601 Orem UT. 84097 p 801.587.2255 p 888.949.4864

Hospital Affiliation - University of Utah Hospital 520 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 672 W 400 S Thompson, Chelsea BCBA Unick, Timothie BCBA Vezie, Linda LCSW Ste 201 ABS Kids Affinity Behavior and University of Utah Health Springville UT. 84663 1140 W 1130 S Bldg B Mental Health Services 145 W University Pkwy p 801.369.8989 Orem UT. 84058 533 W State Rd Orem UT. 84058 p 801.935.4171 Ste 103 p 801.234.8600 Tenney, Joseph T LCSW Pleasant Grove UT. 84062 Valley Behavioral Health Thompson, Michael S LMFT p 801.506.6695 Villalobos, Michele E Phd 1875 S State St Valley Behavioral Health University of Utah Health Ste 1000 1875 S State St Utah Behavior Services 151 S University Ave Orem UT. 84097 Ste 1000 216 E Main St Ste 1610 p 888.949.4864 Orem UT. 84097 Ste 4 Provo UT. 84601 p 888.949.4864 Lehi UT. 84043 p 801.587.2255 751 E 700 S p 801.255.5131 Ste 102 751 E 700 S Hospital Affiliation American Fork UT. 84003 Ste 102 Utah Psychological - University of Utah Hospital p 888.949.4864 American Fork UT. 84003 Associates p 888.949.4864 ARNP 3549 N University Voigt, Jonathan LCSW Tew, Kyle LMFT Ave Valley Behavioral Health Acadian Counseling Thorn, Kirk B PhD Ste 200 1875 S State St Services Willow Creek Psychological Provo UT. 84604 Ste 100 796 Pacific Dr Service Inc p 801.377.2014 Orem UT. 84097 Ste A 376 E 400 S p 888.949.4864 American Fork UT. 84003 Springville UT. 84663 MA 3549 N University Ave p 801.642.2491 p 385.269.0333 Ste 200 751 E 700 S Provo UT. 84604 Ste 102 Thatcher, Benjamin T DO Thurgood, Brook BCBA p 801.377.2014 American Fork UT. 84003 Valley Behavioral Health ABS Kids p 888.949.4864 1875 S State St 1140 W 1130 S Bldg B MD 3549 N University Ave Ste 100 Orem UT. 84058 Ste 200 Vonk, Vivian L CMHC Orem UT. 84097 p 801.935.4171 Provo UT. 84604 Ascendant Behavioral p 888.949.4864 p 801.377.2014 Health Tingey, Jenise D LCSW 3051 W Maple Loop Dr 751 E 700 S Valley Behavioral Health PHD 3549 N University Ave Ste 210 Ste 102 1875 S State St Ste 200 Lehi UT. 84043 American Fork UT. 84003 Ste 1000 Provo UT. 84604 p 801.872.5516 p 888.949.4864 Orem UT. 84097 p 801.377.2014 p 888.949.4864 Wagstaff, Doug T LPC Thayer, Stephen PhD Valdez, Danielle LCSW Alpine Counseling Center Cedar Psychiatry 751 E 700 S University of Utah Health 475 W 50 N 672 W 400 S Ste 102 145 W University Pkwy American Fork UT. 84003 Ste 201 American Fork UT. 84003 Orem UT. 84058 p 801.756.3664 Springville UT. 84663 p 888.949.4864 p 801.234.8600 p 801.369.8989 Walker, David R CMHC Tripp, Richard C CMHC Hospital Affiliation Valley Behavioral Health The Green House for Growth Ascend Mental Health - University of Utah Hospital 1875 S State St & Learning 308 N Cherry Ln Ste 1000 1220 N Main St Santaquin UT. 84655 Vanderhoff, Laura CSW Orem UT. 84097 Ste 5 p 801.210.9449 Healings Steps Counseling p 888.949.4864 Springville UT. 84663 111 E Main St p 801.210.7216 Turner, Meghan BCBA Ste L4 751 E 700 S ABS Kids Lehi UT. 84043 Ste 102 135 W Center St 1140 W 1130 S Bldg B p 801.980.3676 American Fork UT. 84003 Pleasant Grove UT. 84062 Orem UT. 84058 p 888.949.4864 p 801.785.1169 p 801.935.4946 Vasquez, Jeanette P LCSW Ascendant Behavioral Walley, Susan LCSW Thomas, Jonathon (JT) Uckerman, Clifton R LCSW Health Utah Psychological BCBA Ascendant Behavioral 3051 W Maple Loop Dr Associates ABS Kids Health Ste 210 3549 N University Ave 1140 W 1130 S Bldg B 3051 W Maple Loop Dr Lehi UT. 84043 Ste 200 Orem UT. 84058 Ste 210 p 801.502.3913 Provo UT. 84604 p 801.935.4946 Lehi UT. 84043 p 801.377.2014 p 801.872.5516 Veas-Wall, Rodrigo PhD Preferred Family Clinic 1355 N University Ave Ste 200 Provo UT. 84604 p 801.221.0223

521 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Walls, Sharon LMFT Westover, Christopher D Winslow, Tatum BCBA Yau, Joseph K MD - Ogden Region Medical Ascendant Behavioral LCSW ABS Kids Ascendant Behavioral Center Health Revere Health 1140 W 1130 S Bldg B Health 3051 W Maple Loop Dr 1055 N 500 W Orem UT. 84058 3051 W Maple Loop Dr Ste 210 Ste 222, Bldg C p 801.935.4946 Ste 210 Lehi UT. 84043 Provo UT. 84604 Lehi UT. 84043 p 801.872.5516 p 801.377.5757 Winward, Karen LPC p 801.872.5516 Valley Behavioral Health Ward, Cori APRN 555 W SR 164 N 1875 S State St Hospital Affiliation Utah Behavior Services Salem UT. 84653 Ste 1000 - University of Utah Hospital 216 E Main St p 385.203.1285 Orem UT. 84097 Ste 4 p 888.949.4864 Ybarra, Corylyn L CMHC Lehi UT. 84043 Whatcott, Natalie Valley Behavioral Health p 801.255.5131 BCBA,SSW 751 E 700 S 1875 S State St Utah Behavior Services Ste 102 Ste 1000 Warenski, Bonnie CMHC 216 E Main St American Fork UT. 84003 Orem UT. 84097 Alpine Counseling Center Ste 4 p 888.949.4864 p 888.949.4864 475 W 50 N Lehi UT. 84043 American Fork UT. 84003 p 801.255.5131 Wisco, Monica LCSW 751 E 700 S p 801.756.3664 Life Stone Counseling Ste 102 White, Shannon LMFT Center American Fork UT. 84003 Waugaman, Laura CMHC Healings Steps Counseling 150 S 400 E p 888.949.4864 Summit Community 111 E Main St American Fork UT. 84003 Counseling Ste L4 p 801.980.7222 Young, Ellie L PhD 1429 S 550 E Lehi UT. 84043 14 N Main St Ste 260 p 801.980.3676 Woodall, Clifford BCBA Springville UT. 84663 Orem UT. 84057 Utah Behavior Services p 801.472.6294 p 801.266.2485 Wiggins, Celeste M CSW 216 E Main St Ascendant Behavioral Ste 4 Young, Jeanelle BCBA Webster, Peggy CMHC Health Lehi UT. 84043 ABS Kids Ascendant Behavioral 3051 W Maple Loop Dr p 801.255.5131 1140 W 1130 S Bldg B Health Ste 210 Orem UT. 84058 3051 W Maple Loop Dr Lehi UT. 84043 Woodard, Jeness L LCSW p 801.935.4171 Ste 210 p 801.502.3913 University of Utah Health Lehi UT. 84043 145 W University Pkwy Zeidner, Kristina LMFT p 801.502.3913 Wight, Gregory BCBA Orem UT. 84058 5 E 400 N Achieving Abilities p 801.234.8600 Ste 100 Weitzal, Robert A MD 1392 W Turf Farm Way Springville UT. 84663 Ascendant Behavioral Ste 1-153 Utah Psychological p 801.852.5566 Health Payson UT. 84651 Associates 3051 W Maple Loop Dr p 801.935.5796 3549 N University Ave Neonatology Ste 210 Ste 200 Allison, Dolla J NP Lehi UT. 84043 Williams, David O LPC Provo UT. 84604 Wasatch Neonatal p 801.502.3913 Choosing Joy Wellness p 801.377.2014 730 W 800 N Clinic Ste 340B Wesson, Brenda CMHC 313 E 1200 S Woods, Kevin CMHC Orem UT. 84057 14 N Main St Ste 101 Mountain Ridge Behavioral p 801.655.5425 Springville UT. 84663 Orem UT. 84058 Health Center p 801.310.7478 p 801.960.5388 704 S 1600 W Hospital Affiliation Ste 104 - Timpanogos Regional Hospital Western, Shasta BCBA Wills, Brooke BCBA Mapleton UT. 84664 ABS Kids Utah Behavior Services p 801.491.6394 Gronseth, Margrit L APRN 1140 W 1130 S Bldg B 216 E Main St Wasatch Neonatal LC Orem UT. 84058 Ste 4 Wulfenstein, Lee BCBA 730 W 800 N p 801.935.4171 Lehi UT. 84043 Utah Behavior Services Ste 340B p 801.255.5131 216 E Main St Orem UT. 84057 Weston, Sophia BCBA Ste 4 p 801.655.5425 ABS Kids Wilson, Megan BCBA Lehi UT. 84043 1140 W 1130 S Bldg B Utah Behavior Services p 801.255.5131 Hospital Affiliation Orem UT. 84058 216 E Main St - Timpanogos Regional Hospital p 801.935.4946 Ste 4 Yang, Danielle BCBA Lehi UT. 84043 Utah Behavior Services Jenkins, Alysha K NP p 801.255.5131 216 E Main St Wasatch Neonatal Ste 4 730 W 800 N Lehi UT. 84043 Ste 340-B p 801.255.5131 Orem UT. 84057 p 801.655.5425

Hospital Affiliation - Timpanogos Regional Hospital - Davis Hospital 522 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. -10/01/2021 Lakeview 05:46:49 Hospital **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Jenkins, Shannon L DO Beddhu, Srinivasan MD 1034 N 500 W Hammond, Terry C MD Wasatch Neonatal University of Utah Health Provo UT. 84604 Revere Health 730 W 800 N 1159 E 200 N p 801.357.7850 1175 E 50 S Ste 340B Ste 150 Ste 211 Orem UT. 84057 American Fork UT. 84003 1159 E 200 N American Fork UT. 84003 p 801.655.5425 p 801.373.0167 Ste 150 p 801.418.0870 American Fork UT. 84003 Latta, George MD Hospital Affiliation p 801.373.0167 Hospital Affiliation Pediatrix Medical Group - University of Utah Hospital - Timpanogos Regional Hospital 750 W 800 N 15 S 1000 E Orem UT. 84057 Bjordahl, Terrence S MD Ste 50 Kakani, Siddhartha MD p 801.714.6000 University of Utah Health Payson UT. 84651 University of Utah Health 1159 E 200 N p 801.465.2060 1000 E 100 N Latta, Teresa M APRN Ste 150 Payson UT. 84651 Wasatch Neonatal LC American Fork UT. 84003 1675 N Freedom Blvd p 801.465.7000 730 W 800 N p 801.373.0167 Ste 15 Ste 340-B Provo UT. 84604 1034 N 500 W Orem UT. 84057 Hospital Affiliation p 801.373.0167 Provo UT. 84604 p 801.655.5425 - St Marks Hospital p 801.357.7850 170 N 1100 E Hospital Affiliation Boateng, Yaw A MD American Fork UT. 84003 1159 E 200 N - Timpanogos Regional Hospital University of Utah Health p 801.855.3300 Ste 150 1159 E 200 N American Fork UT. 84003 Lawrence, Jonathan R MD Ste 150 306 River Bend Ln p 801.373.0167 Pediatrix Medical Group American Fork UT. 84003 Provo UT. 84604 750 W 800 N p 801.373.0167 p 801.226.8880 15 S 1000 E Orem UT. 84057 Ste 50 p 801.714.6000 Hospital Affiliation 750 W 800 N Payson UT. 84651 - University of Utah Hospital Orem UT. 84057 p 801.465.2060 ODonnell, Elizabeth MD p 801.714.6000 Pediatrix Medical Group Boyack, Mark NP 1675 N Freedom Blvd 750 W 800 N Revere Health Hospital Affiliation Ste 15 Orem UT. 84057 555 W SR 164 N - University of Utah Hospital Provo UT. 84604 p 801.714.6000 Salem UT. 84653 - Mountain View Hospital p 801.373.0167 p 801.812.5400 (UT) Patel, Shrena MD - Timpanogos Regional Hospital 170 N 1100 E Pediatrix Medical Group Hospital Affiliation American Fork UT. 84003 750 W 800 N - Timpanogos Regional Hospital Freestone, Zachary T DO p 801.855.3300 Orem UT. 84057 Revere Health p 801.714.6000 Cheung, Alfred K MD 1175 E 50 S 306 River Bend Ln University of Utah Health Ste 161 Provo UT. 84604 Hospital Affiliation 1159 E 200 N American Fork UT. 84003 p 801.226.8880 - Timpanogos Regional Hospital Ste 150 p 801.377.4623 American Fork UT. 84003 750 W 800 N Stern, Susan NP p 801.373.0167 3000 N Triumph Blvd Orem UT. 84057 Wasatch Neonatal Lehi UT. 84043 p 801.714.6000 730 W 800 N Hospital Affiliation p 801.429.8000 Ste 340-B - University of Utah Hospital Hospital Affiliation Orem UT. 84057 Gregory, Martin C MD,PhD - University of Utah Hospital p 801.655.5425 Cho, Monique E MD University of Utah Health University of Utah Health 1159 E 200 N Lavasani, Tooran APRN Hospital Affiliation 1159 E 200 N Ste 150 University of Utah Health - Timpanogos Regional Hospital Ste 150 American Fork UT. 84003 1159 E 200 N American Fork UT. 84003 p 801.373.0167 Ste 150 Nephrology p 801.373.0167 American Fork UT. 84003 Barager, William E DO Hospital Affiliation p 801.373.0167 Revere Health Hospital Affiliation - University of Utah Hospital 1055 N 500 W - University of Utah Hospital Hospital Affiliation Ste 222 Habib, Arsalan N MD - University of Utah Hospital Provo UT. 84604 Eppich, Irel S MD University of Utah Health p 801.377.4623 University of Utah Health 1159 E 200 N Lile, Kristen DO 1000 E 100 N Ste 150 Revere Health Hospital Affiliation Payson UT. 84651 American Fork UT. 84003 1055 N 500 W - Timpanogos Regional Hospital p 801.465.7000 p 801.373.0167 Ste 222 Bldg C - Mountain View Hospital Provo UT. 84604 (UT) Hospital Affiliation p 801.812.5033 - St Marks Hospital - University of Utah Hospital 523 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 555 W SR 164 N Neurology Reiser, Rebecca H MD Taher, Mohammad E MD Salem UT. 84653 Chebeleu, Lia Ana MD Neuroscience & Neurological Associates p 801.812.5400 Vista Neurology Rehabilitation Specialists 11 N 400 W Specialists - Lehi Payson UT. 84651 Nelson, Andrea M MD 15 S 1000 E 3000 N Triumph Blvd p 801.763.0901 University of Utah Health Ste 125 Ste 330 1159 E 200 N Payson UT. 84651 Lehi UT. 84043 212 S 1100 E Ste 150 p 385.336.1157 p 801.505.5370 American Fork UT. 84003 American Fork UT. 84003 p 801.763.0901 p 801.373.0167 24 W Sergeant Ct Dr Bldg Hospital Affiliation 1 - Jordan Valley Medical 3152 N University Ave Hospital Affiliation Saratoga Springs UT. 84045 Center Ste 220 - University of Utah Hospital p 385.336.1157 Provo UT. 84604 Reynolds, Christopher J p 801.763.0901 Ramkumar, Nirupama MD Vista Veurology MD University of Utah Health Specialists Neurological Associates 498 E 800 N 1159 E 200 N 320 W River Park Dr 11 N 400 W Ste 3-B Ste 150 Ste 215 Payson UT. 84651 Orem UT. 84097 American Fork UT. 84003 Provo UT. 84604 p 801.763.0901 p 801.763.0901 p 801.373.0167 p 385.203.0246 212 S 1100 E Hospital Affiliation Hospital Affiliation Vista Neurology American Fork UT. 84003 - Lone Peak Hospital - University of Utah Hospital Specialists p 801.763.0901 - Mountain View Hospital 336 W 100 S (UT) Romney, Pace G MD Spanish Fork UT. 84660 3152 N University Ave - Timpanogos Regional Hospital University of Utah Health p 385.203.0246 Ste 220 - Evanston Regional Hospital 1159 E 200 N Provo UT. 84604 Ste 150 Hospital Affiliation p 801.763.0901 Watkins, Joseph R MD American Fork UT. 84003 - St Marks Hospital Utah Neurological Clinic p 801.373.0167 498 E 800 N 1055 N 300 W Faust, Barbara NP Ste 3-B Ste 404 15 S 1000 E University of Utah Health Orem UT. 84097 Provo UT. 84604 Ste 50 151 S University Ave p 801.763.0901 p 801.357.7401 Payson UT. 84651 Ste 1610 p 801.373.0167 Provo UT. 84601 Hospital Affiliation Blue Rock Neurological p 801.587.2255 - Lone Peak Hospital Center 1675 N Freedom Blvd - Mountain View Hospital 3152 N University Ave Ste 15 Langford, Douglas R MD (UT) Ste 220 Provo UT. 84604 Revere Health - Evanston Regional Hospital Provo UT. 84604 p 801.373.0167 1055 N 500 W p 801.229.1014 Ste 212 Shoari, Mohammad MD 170 N 1100 E Provo UT. 84604 Mountain Multispecialty - Blue Rock Medical Center American Fork UT. 84003 p 801.374.2362 Lehi 3152 N University Ave p 801.855.3300 3000 N Triumph Blvd Provo UT. 84604 Hospital Affiliation Ste 110 p 801.375.2177 Hospital Affiliation - Timpanogos Regional Hospital Lehi UT. 84043 - University of Utah Hospital p 385.345.3554 Hospital Affiliation Nelson, Alex J MD - Timpanogos Regional Hospital Roy, Abinash C MD Interventional Spine & Neuroscience & University of Utah Health Pain Management Rehabilitation Specialists Neurosurgery 1159 E 200 N 3943 E Pony Express Pkwy - Lehi Brock, Andrea MD Ste 150 Eagle Mountain UT. 84005 3000 N Triumph Blvd Summit Brain and Spine American Fork UT. 84003 p 801.262.7246 Ste 330 3000 N Triumph Blvd p 801.373.0167 Lehi UT. 84043 Ste 110 Hospital Affiliation p 801.505.5370 Lehi UT. 84043 Hospital Affiliation - Lakeview Hospital p 385.345.3560 - St George Regional Hospital - Timpanogos Regional Hospital Hospital Affiliation - University of Utah Hospital - Salt Lake Regional Medical Edwards, John R MD Nguyen, Thu A MD Center Summit Brain and Spine Yenchek, Robert H MD Revere Health - Jordan Valley Medical 3000 N Triumph Blvd University of Utah Health 1175 E 50 S Center Ste 110 1159 E 200 N Ste 161 Lehi UT. 84043 Ste 150 American Fork UT. 84003 p 385.345.3560 American Fork UT. 84003 p 801.492.5992 p 801.373.0167 Hospital Affiliation Hospital Affiliation - Utah Valley Hospital Hospital Affiliation - Timpanogos Regional Hospital - Mountain Point Medical - University of Utah Hospital Center 524 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Farley, Chad W MD Summit Brain and Spine Arbabi, Kathryn M MD Blauer, Keith Rock Creek Neurosurgery 3000 N Triumph Blvd Valley Obstetrics & Reproductive Care Center 1248 E 90 N Ste 110 Gynecology 2345 W 450 S Ste 203 Lehi UT. 84043 527 W 400 N Ste 103 American Fork UT. 84003 p 385.345.3560 Ste 4 Pleasant Grove UT. 84062 p 801.609.9310 Orem UT. 84057 p 801.492.5959 UUHC Parkway Health Center p 801.404.5588 15 S 1000 E 145 W University Pkwy Broadbent, David H MD Ste 225 Orem UT. 84058 585 N 500 W 1355 N University Ave Payson UT. 84651 p 801.234.8600 Provo UT. 84601 Ste 130 p 801.609.9310 p 801.404.5588 Provo UT. 84604 Obstetrics And Gynecology p 801.373.4649 Hospital Affiliation Aagard, Robert MD 700 W 800 N - Timpanogos Regional Hospital Valley Obstetrics & Ste 200 Hospital Affiliation - Mountain View Hospital Gynecology Orem UT. 84057 - Timpanogos Regional Hospital (UT) 1228 N Commerce Dr p 801.756.9635 Saratoga Springs Ut. 84045 Broberg, Jeffrey C MD Gardner, Paul K MD p 801.756.9635 Hospital Affiliation Valley Obstetrics & Utah Neurological Clinic - Utah Valley Hospital Gynecology 1055 N 300 W 1248 E 90 N - Timpanogos Regional Hospital 527 W 400 N Ste 400 Ste 300 Ste 4 Provo UT. 84604 American Fork UT. 84003 Archer, Sandra V MD Orem Ut. 84057 p 801.357.7404 p 801.756.9635 Utah Center for Womens p 801.374.1801 Healthcare Hospital Affiliation 3000 N Triumph Blvd 3651 N 100 E 585 N 500 W - Timpanogos Regional Hospital Lehi UT. 84043 Ste 375 Provo UT. 84601 p 801.756.9635 Provo UT. 84604 p 801.374.1801 Gaufin, Lynn M MD p 435.843.2576 Utah Neurological Clinic Adams, Lan Le MD 700 W 800 N 1055 N 300 W Obstetrix Medical Group Of Bean, Gregory H MD Ste 200 Ste 400 Utah Valley Obstetrics & Orem UT. 84057 Provo UT. 84604 750 W 800 N Gynecology p 801.434.4443 p 801.357.7404 Orem UT. 84057 1228 N Commerce Dr p 801.714.6000 Saratoga Springs Ut. 84045 Hospital Affiliation Hospital Affiliation p 801.756.9635 - Timpanogos Regional Hospital - Timpanogos Regional Hospital Allen, Douglas DO Revere Health 1248 E 90N Burkinshaw, Sandra NP Reichman, Howard R MD 1055 N 500 W Ste 300 Valley Obstetrics & Utah Neurological Clinic Ste 205 American Fork Ut. 84003 Gynecology 1055 N 300 W Provo UT. 84604 p 801.756.9635 1228 N Commerce Dr Ste 400 p 801.373.7350 Saratoga Springs UT. 84045 Provo UT. 84604 3000 N Triumph Blvd p 801.756.9635 p 801.357.7404 1886 W 800 N Lehi UT. 84043 Pleasant Grove UT. 84062 p 801.756.9635 1248 E 90 N Hospital Affiliation p 801.756.5288 Ste 300 - Mountain Point Medical Hospital Affiliation American Fork UT. 84003 Center 3943 Pony Express Pkwy - Timpanogos Regional Hospital p 801.756.9635 Ste 110-A Smith, David M MD Eagle Mountain UT. 84005 Bennett, Donna S MD 3000 N Triumph Blvd Utah Neurological Clinic p 801.756.5288 Valley Obstetrics & Lehi UT. 84043 1055 N 300 W Gynecology p 801.756.9635 Ste 400 Hospital Affiliation 527 W 400 N Provo UT. 84604 - Timpanogos Regional Hospital Ste 4 Cloward, Tenille B MD p 801.357.7404 Orem Ut. 84057 Valley Obstetrics & Anderson, Cameron D MD p 801.374.1801 Gynecology 3000 N Triumph Blvd South Valley OB/GYN 1228 N Commerce Dr Ste 110 39 S Professional Way 585 N 500 W Saratoga Springs UT. 84045 Lehi UT. 84043 Ste 4 Provo UT. 84601 p 801.756.9635 p 801.357.7404 Payson UT. 84651 p 801.374.1801 p 801.465.3201 1248 E 90 N Hospital Affiliation 700 W 800 N Ste 300 - Utah Valley Hospital Valley Obstetrics & Ste 200 American Fork UT. 84003 - Mountain Point Medical Gynecology Orem UT. 84057 p 801.756.9635 Center 819 E Marketplace Dr 3rd p 801.374.1801 Fl Spanish Fork UT. 84660 Hospital Affiliation p 801.756.9635 - Timpanogos Regional Hospital - Mountain View Hospital (UT) 525 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 3000 N Truimph Blvd Dildy, Gary A MD 700 W 800 N 1248 E 90 N Ste 210 Obstetrix Medical Group of Ste 200 Ste 300 Lehi Ut. 84043 Utah Orem UT. 84057 American Fork UT. 84003 p 801.756.9635 700 W 800 N p 801.756.9635 p 801.756.9635 Ste 310 Conway, Deirdre A MD Orem UT. 84057 Hospital Affiliation 3000 N Triumph Blvd Utah Fertility Center p 801.225.1937 - Timpanogos Regional Hospital Lehi UT. 84043 1446 W Pleasant Grove p 801.756.9635 Blvd 750 W 800 N Haskett, Sean G MD Pleasant Grove UT. 84062 Orem UT. 84057 Valley Obstetrics & 700 W 800 N p 801.785.5100 p 801.714.6000 Gynecology Ste 200 1228 N Commerce Dr Orem UT. 84057 Cowles, Steven D MD Drewes, Peter G MD Saratoga Springs Ut. 84045 p 801.756.9635 Valley Obstetrics & Valley Obstetrics & p 801.756.9635 Gynecology Gynecology Hospital Affiliation 585 N 500 W 527 W 400 N 1248 E 90 N - Timpanogos Regional Hospital Provo UT. 84601 Ste 4 Ste 300 p 801.374.1801 Orem Ut. 84057 American Fork UT. 84003 Jorgensen, Christy NP p 801.374.1801 p 801.756.9635 Valley Obstetrics & 700 W 800 N Gynecology Ste 200 585 N 500 W 3000 N Triumph Blvd 527 W 400 N Orem UT. 84057 Provo UT. 84601 Ste 210 Ste 4 p 801.374.1801 p 801.374.1801 Lehi UT. 84043 Orem Ut. 84057 p 801.756.9635 p 801.374.1801 Dabling, Heather A MD 700 W 800 N Valley Obstetrics & Ste 200 Holmes, Richard J MD Hospital Affiliation Gynecology Orem UT. 84057 Cotton Tree Medical - Timpanogos Regional Hospital 527 W 400 N p 801.756.9635 2230 N University Pkwy Ste 4 Ste 1A Judd, Thomas E MD Orem Ut. 84057 Hospital Affiliation Provo UT. 84604 University OB/GYN p 801.374.1801 - Timpanogos Regional Hospital p 801.377.3413 1355 N University Ave Ste 110 585 N 500 W Gourley, George C DO Hospital Affiliation Provo UT. 84604 Provo UT. 84601 1055 N 300 W - Timpanogos Regional Hospital p 801.374.5000 p 801.374.1801 Ste 305 Provo UT. 84604 Jacob, Scott R MD Kinghorn, Jennifer C MD 700 W 800 N p 801.357.7190 Valley Obstetrics & Timpanogos Womens Center Ste 200 Gynecology 3401 N Ctr St Orem Ut. 84057 Hospital Affiliation 527 W 400 N Ste 150 p 801.374.1801 - Timpanogos Regional Hospital Ste 4 Lehi UT. 84043 Orem Ut. 84057 p 801.653.2757 Hospital Affiliation Grover, Julie MD p 801.374.1801 - Timpanogos Regional Hospital Utah Valley Obstetrics & Lamoreaux, James MD Gynecology 585 N 500 W Valley Obstetrics & Dewey, Steven J MD 1055 N 300 W Provo UT. 84601 Gynecology Southwestern OBGYN Ste 110 p 801.374.1801 1228 N Commerce Dr 39 Professional Way Provo UT. 84604 Saratoga Springs Ut. 84045 Ste 3 p 801.357.7377 700 W 800 N p 801.756.9635 Payson UT. 84651 Ste 200 p 801.465.9263 Hospital Affiliation Orem UT. 84057 1248 E 90N - Timpanogos Regional Hospital p 801.434.4443 Ste 300 777 N 500 W American Fork Ut. 84003 Ste 203 Harward, Kory A DO Hospital Affiliation p 801.756.9635 Provo UT. 84601 Valley Obstetrics & - Timpanogos Regional Hospital p 801.375.8889 Gynecology 3000 N Triumph Blvd 1900 N State St Jones, Evan B DO Lehi UT. 84043 Southwestern OB/GYN Ste 103 Valley Obstetrics & p 801.756.9635 777 N 500 W Provo UT. 84604 Gynecology Ste 203 p 801.669.5758 1228 N Commerce Dr Laraway, John D MD Provo UT. 84604 Saratoga Springs Ut. 84045 Canyon View Womens Care p 801.375.8889 585 N 500 W p 801.756.9635 15 S 1000 E Provo UT. 84601 Ste 125 Hospital Affiliation p 801.669.5758 Payson UT. 84651 - Mountain View Hospital p 801.465.2559 (UT) - Timpanogos Regional Hospital

526 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Larimer, Sophia NP 3000 N Triumph Blvd Ollerton, Ryan C DO 1842 S Columbia Ln Valley Obstetrics & Lehi UT. 84043 Valley Obstetrics & Orem UT. 84097 Gynecology p 801.756.9635 Gynecology p 801.226.5246 527 W 400 N 1228 N Commerce Dr Ste 4 Moore, Andrew K MD Saratoga Springs Ut. 84045 Rees, Scott S DO Orem Ut. 84057 Valley Obstetrics & p 801.756.9635 Valley Obstetrics & p 801.374.1801 Gynecology Gynecology 1900 N State St 1248 E 90N 527 W 400 N 585 N 500 W Ste 103 Ste 300 Ste 4 Provo UT. 84601 Provo UT. 84604 American Fork Ut. 84003 Orem Ut. 84057 p 801.374.1801 p 801.669.5758 p 801.756.9635 p 801.374.1801

700 W 800 N 585 N 500 W 3000 N Triumph Blvd 585 N 500 W Ste 200 Provo UT. 84601 Lehi UT. 84043 Provo UT. 84601 Orem UT. 84057 p 801.404.5588 p 801.756.9635 p 801.374.1801 p 801.434.4443 Hospital Affiliation Hospital Affiliation 700 W 800 N Madsen, Jenna DO - University of Utah Hospital - Timpanogos Regional Hospital Ste 200 Timpanogos Womens Center - Utah Valley Hospital Orem UT. 84057 3401 N Center St - Timpanogos Regional Hospital Orr, Rochelle DO p 801.756.9635 Ste 150 Timpanogos Womens Center Lehi UT. 84043 Morris, Cassandra NP 3401 N Ctr St Hospital Affiliation p 801.653.2757 Valley Obstetrics & Ste 150 - Timpanogos Regional Hospital Gynecology Lehi UT. 84043 McCarter, John D MD 1228 N Commerce Dr p 801.653.2757 Reproductive Care Center Valley Obstetrics & Saratoga Springs Ut. 84045 2345 W 450 S Gynecology p 801.756.9635 Hospital Affiliation Ste 103 1900 N State St - Lone Peak Hospital Pleasant Grove UT. 84062 Ste 103 1248 E 90N - St Marks Hospital p 801.492.5959 Provo UT. 84604 Ste 300 p 801.669.5758 American Fork Ut. 84003 Parker, Kelli NP Roberts, Sarah NP p 801.756.9635 Valley Obstetrics & Valley Obstetrics & McSweeney, Heidi NP Gynecology Gynecology Valley Obstetrics & Morris, Jason K MD 1228 N Commerce Dr 527 W 400 N Gynecology Canyon View Medical Group Saratoga Springs Ut. 84045 Ste 4 527 W 400 N 15 S 1000 E p 801.756.9635 Orem Ut. 84057 Ste 4 Ste 125 p 801.374.1801 Orem Ut. 84057 Payson UT. 84651 1248 E 90 N p 801.374.1801 p 801.465.2559 Ste 300 585 N 500 W American Fork UT. 84003 Provo UT. 84601 585 N 500 W 325 W Ctr St p 801.756.9635 p 801.374.1801 Provo Ut. 84601 Spanish Fork UT. 84660 p 801.374.1801 p 801.798.7301 3000 N Truimph Blvd 700 W 800 N Ste 210 Ste 200 700 W 800 N Nance, Jeff D MD Lehi Ut. 84043 Orem UT. 84057 Ste 200 Valley Obstetrics & p 801.756.9635 p 801.756.9635 Orem UT. 84057 Gynecology p 801.756.9635 672 W 400 S Pennington, David A MD Skinner, Reed J MD Ste 100 Pennington Womens Center Santaquin Medical Clinic Hospital Affiliation Springville UT. 84663 Provo 210 E Main St - Timpanogos Regional Hospital p 801.489.0111 3507 N University Ave Santaquin UT. 84655 Ste 175 p 801.754.3600 Melendez, Terry MD Nance, Steven G MD Provo UT. 84604 Valley Obstetrics & Valley Obstetrics & p 801.719.8395 Soisson, Andrew P MD Gynecology Gynecology University of Utah Health 1228 N Commerce Dr 672 W 400 S Hospital Affiliation 1157 N 300 W Saratoga Springs Ut. 84045 Ste 100 - Timpanogos Regional Hospital Ste 301 p 801.756.9635 Springville Ut. 84663 Provo UT. 84604 p 801.481.0111 Planned Parenthood p 801.213.2995 1248 E 90N Association of Utah Ste 300 Hospital Affiliation 1086 N 1200 W Hospital Affiliation American Fork Ut. 84003 - Mountain View Hospital Orem UT. 84057 - University of Utah Hospital p 801.756.9635 (UT) p 801.226.5246

527 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Spencer, Tiffany NP 585 N 500 W 700 W 800 N 601 N 1200 W Valley Obstetrics & Provo UT. 84601 Ste 200 Orem UT. 84057 Gynecology p 801.404.5588 Orem UT. 84057 p 888.997.2669 1228 N Commerce Dr p 801.756.9635 Saratoga Springs Ut. 84045 700 W 800 N Doulis, Andriana S OT p 801.756.9635 Ste 200 Hospital Affiliation University of Utah Health Orem UT. 84057 - Timpanogos Regional Hospital 151 S University Ave 1248 E 90 N p 801.756.9635 Ste 1610 Ste 300 Woodmansee, James MD Provo UT. 84601 American Fork UT. 84003 Hospital Affiliation Cotton Tree Medical p 801.587.2255 p 801.756.9635 - St Marks Hospital 2230 N University Pkwy - Utah Valley Hospital Ste 1A Giles, Sarah OT 3000 N Triumph Blvd Provo UT. 84604 Dry Creek Physical Therapy Lehi UT. 84043 Wendt, Luke DO p 801.377.3413 & Wellness p 801.756.9635 Revere Health 3000 N Triumph Blvd 1886 W 800 N Hospital Affiliation Ste 310 41 E Commerce Dr Pleasant Grove UT. 84062 - Timpanogos Regional Hospital Lehi UT. 84043 Ste 2 p 801.756.5288 p 801.766.4244 Saratoga Springs UT. 84045 Young, David B DO p 801.756.9635 3943 Pony Express Pkwy Revere Health Henrie, Jason OT Ste 110-A 1886 W 800 N Horizon Rehab 700 W 800 N Eagle Mountain UT. 84005 Pleasant Grove UT. 84062 11 E 200 N Ste 200 p 801.756.5288 p 801.756.5288 Ste 101 Orem UT. 84057 Orem UT. 84057 p 801.756.9635 Wexler, Kristin E DO 3943 Pony Express Pkwy p 801.374.1706 Mountainstar Medical Group Ste 110-A Starbuck, Aaron K MD Timpanogos Eagle Mountain UT. 84005 Manwill, Joel M OT Revere Health 1020 S 1100 W p 801.756.5288 ABS Kids 575 S State St Ste B 1140 W 1130 S Bldg B Orem UT. 84058 Lehi UT. 84043 Hospital Affiliation Orem UT. 84058 p 801.225.2926 p 801.653.2757 - Timpanogos Regional Hospital p 801.935.4171

Thorpe, Jefforey R MD Timpanogos Womens Center Zempolich, Karen A MD Nielson-Jones, Kristen V Valley Obstetrics & 3401 N Center St Timpanogos Womens Center OT Gynecology Ste 150 3401 N Ctr St Revere Health 527 W 400 N Lehi UT. 84043 Ste 150 1055 N 500 W Ste 4 p 801.653.2757 Lehi UT. 84043 Ste 122 Orem Ut. 84057 p 801.268.6811 Provo UT. 84604 p 801.374.1801 Hospital Affiliation p 801.375.4263 - Timpanogos Regional Hospital Hospital Affiliation 585 N 500 W - St Marks Hospital 555 W SR 164 N Provo UT. 84601 Wing, Adam MD - Ogden Regional Medical Salem UT. 84653 p 801.374.1801 Revere Health Center p 801.375.4263 1886 W 800 N 700 W 800 N Pleasant Grove UT. 84062 Occupational Therapy Peabody, Deanna L OT Ste 200 p 801.756.5288 Burditt, Emily OT The Whole Child Therapy Orem UT. 84057 The Whole Child Therapy 1570 N Main St p 801.756.9635 3943 Pony Express Pkwy 1570 N Main St Spanish Fork UT. 84660 Ste 110-A Spanish Fork UT. 84660 p 801.210.9319 Hospital Affiliation Eagle Mountain UT. 84005 p 801.210.9319 - Timpanogos Regional Hospital p 801.756.5288 Kids Who Count Carter, Heidi M OTR/L 345 N State Rd 198 Utah Fertility Center Wolsey, Brian L MD The Whole Child Therapy Salem UT. 84653 1446 W Pleasant Grove Valley Obstetrics & 727 S Main St p 801.423.3000 Blvd Gynecology Spanish Fork UT. 84660 Pleasant Grove UT. 84062 527 W 400 N p 801.210.9319 Wood, Eric M MD p 801.785.5100 Ste 4 University of Utah Health Orem Ut. 84057 Concentra Medical Centers 145 W University Pkwy Webb, Joel C MD p 801.374.1801 2390 Redwood Rd Orem UT. 84058 Valley Obstetrics & West Valley City UT. 84419 p 801.234.8600 Gynecology 585 N 500 W p 888.997.2669 3000 N Triumph Blvd Provo UT. 84601 Oculoplastic Surgery Lehi UT. 84043 p 801.374.1801 Call, Conley B MD p 801.756.9635 Avalon Oculoplastics 78 E 900 N Spanish Fork UT. 84660 p 801.794.4964

Hospital Affiliation - Mountain View Hospital (UT) 528 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. -10/01/2021 Castleview 05:46:49 Hospital **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Patel, Bhupendra C MD Brockbank, David T MD Gardiner, Jeffrey P MD Isom, Ryan F MD Cataract and Lasik Center Revere Health Utah Valley Eye Center Retina and Vitreous of Utah 1055 N 500 W 1055 N 300 W Surgeons of Utah 175 N 400 W Ste 212 Provo UT. 84604 1055 N 300 W Ste C-10 Provo UT. 84604 p 801.357.7373 Ste 210 Orem UT. 84057 p 801.375.6565 Provo UT. 84604 p 801.224.6767 Griffin, David R MD p 801.357.7705 1145 N 500 W Utah Eye Centers Hospital Affiliation Ste A-4 175 N 400 W Hospital Affiliation - University of Utah Hospital Payson UT. 84651 Ste C10 - St Marks Hospital - Davis Hospital p 801.375.6565 Orem UT. 84057 - St Marks Hospital p 801.476.0494 Knudsen, Victoria M MD Hospital Affiliation Retina Associates of Utah Oncology - St Marks Hospital 1972 W Grove Pkwy 1055 N 300 W Stephenson, William T MD Pleasant Grove UT. 84062 Ste 420 Utah Cancer Specialists Call, Conley B MD p 801.476.0494 Provo UT. 84604 395 Bulldog Blvd Avalon Oculoplastics p 801.357.7999 Ste 103 78 E 900 N Gunther, Jonathan B MD Provo UT. 84604 Spanish Fork UT. 84660 Excel Eye Center of Hospital Affiliation p 801.357.8200 p 801.794.4964 American Fork - St Marks Hospital 12 N 1100 E - Davis Hospital 1034 N 500 W Hospital Affiliation American Fork UT. 84003 Provo UT. 84604 - Mountain View Hospital p 801.756.9627 Kwun, Robert MD p 801.357.8200 (UT) Retina Associates of Utah - Castleview Hospital Excel Eye Center of Provo 1055 N 300 W Wallentine, Steven L MD 1735 N State St Ste 420 Revere Health Carver, John A MD Provo UT. 84604 Provo UT. 84604 1055 N 500 W Retina & Vitreous Surgeons p 801.374.1818 p 801.357.7999 Ste 202 of Utah Provo UT. 84604 1055 N 300 W Hospital Affiliation Hospital Affiliation p 801.374.2367 Ste 210 - Central Valley Medical - St Marks Hospital Provo UT. 84604 Center - Davis Hospital Hospital Affiliation p 801.357.7704 - Timpanogos Regional Hospital Henriksen, Bradley MD Lambert, Nathan MD - Castleview Hospital Hospital Affiliation Excel Eye Center of Excel Eye Center of - Lone Peak Hospital - St Marks Hospital Spanish Fork Saratoga Springs - Mountain View Hospital - Timpanogos Regional Hospital 325 W Center St 1305 N Commerce Dr (UT) - Jordan Valley Medical Ste 201 Ste 120 Center Spanish Fork UT. 84660 Saratoga Springs UT. 84045 Ophthalmology p 801.465.2575 p 801.379.2929 Anderson, Bradley J MD Cook, Loran Todd MD Utah Eye Centers Utah Valley Eye Center Excel Eye Center of Orem Excel Eye Center of Provo 1972 W Grove Pkwy 1055 N 300 W 820 N 980 W 1735 N State St Pleasant Grove UT. 84062 Ste 204 Orem UT. 84057 Provo UT. 84604 p 801.224.6767 Provo UT. 84604 p 801.465.2575 p 801.374.1818 p 801.357.7373 Brinton, Eric P MD Howard, James G MD Hospital Affiliation Retina Associates of Utah Corey, Richard P MD Retina Associates of Utah - Utah Valley Hospital 1055 N 300 W Retina & Vitreous Surgeons 1055 N 300 W - Mountain Point Medical Ste 420 of Utah Ste 420 Center Provo UT. 84604 1055 N 300 W Provo UT. 84604 p 801.357.7999 Ste 210 p 801.357.7999 Lloyd, Michael J MD Provo UT. 84604 Utah Valley Eye Center 3600 Ashton Blvd p 801.357.7704 Hospital Affiliation 1055 N 300 W Ste C - St Marks Hospital Ste 204 Lehi UT. 84043 Hospital Affiliation - Davis Hospital Provo UT. 84604 p 801.899.3030 - St Marks Hospital p 801.357.7373 - Timpanogos Regional Hospital Hunsaker, Jesse N MD Brinton, Gregory S MD - Jordan Valley Medical Excel Eye Center of Lohner, W S MD Retina Associates of Utah Center American Fork Excel Eye Center of Orem 1055 N 300 W 12 N 1100 E 1735 N State St Ste 420 Engen, Todd B MD American Fork UT. 84003 Provo UT. 84604 Provo UT. 84604 Excel Eye Center of Payson p 801.756.9627 p 801.379.2900 p 801.357.7999 1172 E 100 N Ste 4 Hospital Affiliation Hospital Affiliation Payson UT. 84651 - Central Valley Medical - St Marks Hospital p 801.379.2900 Center - Davis Hospital - Mountain View Hospital (UT) 529 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Monroe, Jamie M MD Parsons, Matthew R MD Excel Eye Center of Provo Excel Eye Center of Orem Cataract & Lasik Center of Excel Eye Center of Provo 1735 N State St 700 W 800 N Utah 1735 N State St Provo UT. 84604 Ste 160 175 N 400 W Provo UT. 84604 p 801.374.1818 Orem UT. 84057 Ste C10 p 801.374.1818 p 801.426.9700 Orem UT. 84057 Smalley, Aaron D MD p 800.437.3937 Hospital Affiliation Excel Eye Center of Lehi Hospital Affiliation - Central Valley Medical 220 N 1200 E - Timpanogos Regional Hospital Utah Eye Centers Center Ste 101 - Mountain View Hospital 1972 W Grove Pkwy - Gunnison Valley Hospital Lehi UT. 84043 (UT) Pleasant Grove UT. 84062 p 801.341.6200 p 801.224.6767 Patel, Bhupendra C MD Winward, Kirk E MD Cataract and Lasik Center Hospital Affiliation Retina Associates of Utah Hospital Affiliation of Utah - Central Valley Medical 1055 N 300 W - Castleview Hospital 175 N 400 W Center Ste 420 - Ashley Valley Regional Ste C-10 Provo UT. 84604 Medical Center Orem UT. 84057 Stringham, Jack D MD p 801.357.7999 p 801.224.6767 Retina & Vitreous Monson, Bryan K MD Suregions of Utah Hospital Affiliation Logan Eye Institute Hospital Affiliation 1055 N 300 W - St Marks Hospital 2230 N University Pkwy - University of Utah Hospital Ste 210 - Davis Hospital Ste 10A - Davis Hospital Provo UT. 84604 Provo UT. 84604 - St Marks Hospital p 801.357.7704 Young, Marielle MD p 435.752.2020 University of Utah Health Ricks, Christopher J MD Swartz, Mano MD 145 W University Pkwy Myers, Thomas D MD Excel Eye Center of Retina Associates of Utah Orem UT. 84058 280 W River Park Dr Saratoga Springs 1055 N 300 W p 801.234.8600 Ste 220 1305 N Commerce Dr Ste 420 Provo UT. 84604 Ste 120 Provo UT. 84604 Hospital Affiliation p 801.224.3565 Saratoga Springs UT. 84045 p 801.357.7999 - University of Utah Hospital p 801.379.2929 Nelson, Duane J MD Theurer, James G MD Optometry Utah Valley Eye Center Excel Eye Center of Excel Eye Center of Provo Abraham, James M OD 1055 N 300 W Spanish Fork 1735 N State St Advantage Eye Care Ste 204 325 W Center St Provo UT. 84604 542 S State St Provo UT. 84604 Ste 201 p 801.374.1818 Orem UT. 84058 p 801.357.7373 Spanish Fork UT. 84660 p 801.373.1711 p 801.465.2575 Vincent, Bryan H OD Noble, Larry MD University of Utah Health Anderson, Kenyon B OD 1055 N 300 W Ririe, Peter A MD 145 W University Pkwy Santaquin Family Vision Ste 204 Excel Eye Center of Orem UT. 84058 252 W Main St Provo UT. 84604 American Fork p 801.234.8600 Ste C p 801.357.7373 12 N 1100 E Santaquin UT. 84655 American Fork UT. 84003 Waite, Aaron N MD p 801.609.2020 3200 N Canyon Rd p 801.756.9627 Waite Vision Ste A 3333 N Digital Dr Barney, Tyler J OD Provo UT. 84604 Schmutz, Joseph S MD Ste 300 Eagle Vision p 801.375.2020 Excel Eye Center Lehi UT. 84043 3535 Ranches Pkwy 1172 E 100 N p 801.876.6000 Ste C Hospital Affiliation Payson UT. 84651 Eagle Mountain UT. 84005 - Utah Valley Hospital p 801.465.2575 Ward, Matthew S MD p 801.789.3937 280 W River Park Dr Olson, Paul F MD Hospital Affiliation Ste 220 Bird, Blaine F OD Utah Valley Eye Center - Timpanogos Regional Hospital Provo UT. 84604 Utah Valley Eye Center 1055 N 300 W - Mountain View Hospital p 801.224.3565 1055 N 300 W Ste 204 (UT) Ste 204 Provo UT. 84604 Wilkinson, Justin MD Provo UT. 84604 p 801.357.7373 Schmutz, Mason A MD Excel Eye Center of Provo p 801.357.7373 Excel Eye Center of 1735 N State St Hospital Affiliation Saratoga Springs Provo UT. 84604 Brockbank, Stephen R OD - Central Valley Medical 1305 N Commerce Dr p 801.374.1818 Insight Eye Care Center Ste 120 575 E University Pkwy Saratoga Springs UT. 84045 Ste M-211 p 801.379.2929 Orem UT. 84097 p 801.225.3920

530 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Campbell, Solomon R OD Davies, Jarrod E OD 5455 W 11000 N King, Aaron OD Complete Eye Care LLC Child and Family Eye Care Ste 101 Complete Eye Care LLC 742 N 530 E Center Highland UT. 84003 742 N 530 E Orem UT. 84097 908 N 2000 W p 801.756.9357 Orem UT. 84097 p 801.224.4799 Pleasant Grove UT. 84062 p 801.224.4799 p 801.492.6393 Gilliland, Rodney N OD Castleton, Keith J OD Standard Optical Kofoed, Lavar W OD Alpine Vision Center Dunn, Kristine A OD 1455 S State St The Eye Pros 11038 N Highland Blvd Utah Valley Eye Center Orem UT. 84057 366 E University Pkwy Ste 200 1055 N 300 W p 801.964.9911 Orem UT. 84058 American Fork UT. 84003 Ste 204 p 801.765.0048 p 801.756.7150 Provo UT. 84604 Gray, Robert F OD p 801.357.7373 Eyecare of Lehi Lewis, Stephen C OD 76 E Commerce Dr 785 E 200 S Standard Optical Ste 102 Duval, Devin A OD Ste 9 1200 Provo Towne Centre Saratoga Springs UT. 84045 Child & Family EyeCare Lehi UT. 84043 Ste 1060 p 801.768.1900 Center p 801.768.4100 Provo UT. 84601 320 W River Park Dr p 801.373.2254 Caywood, Traer G OD Ste 245 Haggard, Joe R OD Utah Valley Optometric Provo UT. 84604 Utah Valley Eye Center 1438 E Main St Physicians p 801.800.8508 1055 N 300 W Ste 4 1355 N University Ave Ste 204 Lehi UT. 84043 Ste 100 3507 N University Ave Provo UT. 84604 p 801.753.7999 Provo UT. 84604 Ste 225 p 801.357.7373 p 801.377.4333 Provo UT. 84604 1455 S State St p 801.800.8508 Hatch, William OD Orem UT. 84057 374 E 400 S Excel Eye Center of Orem p 801.802.7326 Ste 1 Edmunds, David O OD 700 W 800 N Springville UT. 84663 Utah Valley Eye Center Ste 160 Lewis, Todd J OD p 801.489.5111 1055 N 300 W Orem UT. 84057 Eye Clinic & Contact Lens Ste 204 p 801.426.9800 Center of Utah Valley Clark, Douglas R OD Provo UT. 84604 2230 N University Pkwy Douglas R Clark OD p 801.357.7373 Helman, Andrew OD Ste 10A 446 N State Rd 198 Standard Optical Provo UT. 84604 Salem UT. 84653 Edmunds, Franklin M OD 1200 Provo Towne Centre p 801.373.4550 p 801.504.6335 Utah Valley Eye Center Ste 1060 1055 N 300 W Provo UT. 84601 Loveless, Reese OD Codner, Bill G OD Ste 204 p 801.373.2254 Excel Eye Center of Provo Complete Eye Care LLC Provo UT. 84604 1735 N State St 209 N State St p 801.357.7373 1438 E Main St Provo UT. 84604 Orem UT. 84057 Ste 4 p 801.374.1818 p 801.224.4799 Esplin, David J OD Lehi UT. 84043 Esplin Eye Center p 801.753.7999 Excel Eye Center of Cooper, Jared L OD 59 S 400 W Spanish Fork American Fork Vision Spanish Fork UT. 84660 1455 S State St 325 W Center St Center p 801.794.3937 Orem UT. 84057 Ste 204 24 W Main St p 801.802.7326 Spanish Fork UT. 84660 American Fork UT. 84003 Freestone, Jared OD p 801.465.2575 p 801.756.7996 Alpine Vision Center Hooley, Lori K OD 11038 N Highland Blvd Clear View Vision Center McKell, James D OD Curtis, Mark E OD Ste 200 60 S 200 E Standard Optical Child & Family EyeCare American Fork UT. 84003 American Fork UT. 84003 1438 E Main St Center p 801.756.7150 p 801.756.4731 Ste 4 908 N 2000 W Lehi UT. 84043 Pleasant Grove UT. 84062 1528 N Commerce Dr Hooton, Kenneth E OD p 801.753.7999 p 801.492.6393 Ste 102 Clear View Vision Center Saratoga Springs UT. 84045 60 S 200 E Monson, Roland K OD Dahl, Brandon J OD p 801.768.1900 American Fork UT. 84003 Eye Clinic & Contact Lens University of Utah Health p 801.756.4731 Center of Utah Valley 145 W University Pkwy Fromm, Kevin J OD 2230 N University Pkwy Orem UT. 84058 Timpanogos Vision Center Jones, David I OD Ste 10A p 801.234.8600 238 E State Rd 57 E 1000 N Provo UT. 84604 Ste 4 Spanish Fork UT. 84660 p 801.373.4550 Pleasant Grove UT. 84062 p 801.798.5341 p 801.796.1054

531 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Morris, Dell C OD 1307 N Commerce Dr Smith, Andrew T OD 374 E 400 S Excel Eye Center of Provo Ste 100 Eye Clinic and Contact Ste 1 1735 N State St Saratoga Springs UT. 84045 Lens Center Springville UT. 84663 Provo UT. 84604 p 801.768.1900 2230 N University Pkwy p 801.489.5111 p 801.374.1818 Ste 10a 76 E Commerce Dr Provo UT. 84604 Oral And Maxillofacial Surgery Paxman, Paul A OD Ste 102 p 801.373.4550 Egbert, Cameron J DDS American Fork Vision Saratoga Springs UT. 84045 Summit Oral and Center p 801.768.1900 Standard Optical Mon-Wed Maxillofacial Surgery 24 W Main St and Fri 10am-9pm Thur and 642 E Kirby Ln American Fork UT. 84003 Rigtrup, Chad L OD Sat 9am-9pm Sun 12pm-6pm Ste 101 p 801.756.7996 1675 N 200 W 1200 Provo Towne Centre Spanish Fork UT. 84660 Ste 11A Ste 1060 p 801.798.9500 Pickering, Roger M OD Provo UT. 84604 Provo UT. 84601 Lehi Vision Care p 801.374.2227 p 801.373.2254 Hospital Affiliation 159 E Main St - Mountain View Hospital Ste F 262 E 400 S Standard Optical Mon-Fri (UT) Lehi UT. 84043 Springville UT. 84663 9am-7pm Sat 8am-5pm - Lone Peak Hospital p 801.766.1696 p 801.374.2227 1438 E Main St - St Marks Hospital Ste 4 Plothow, Phillip A OD Roberts, Neil J OD Lehi UT. 84043 Jenkins, Maurice DDS,MD 3651 N 100 E Eye Physicians of Utah p 801.753.7999 Riverwoods Oral and Ste 250 482 S Main St Maxillofacial Surgery Provo UT. 84604 Spanish Fork UT. 84660 1455 S State St 280 W River Park Dr p 801.373.3337 p 801.504.6448 Orem UT. 84057 Ste 360 p 801.226.3044 Provo UT. 84604 Potts, Bruce T OD CT Vision p 801.437.7701 Timpanogos Vision Center 648 E 800 S Stromness, Lynn D OD 238 E State Rd Orem UT. 84097 Standard Optical Hospital Affiliation Ste 4 p 801.541.1052 1438 E Main St - Mountain View Hospital Pleasant Grove UT. 84062 Ste 4 (UT) p 801.796.1054 Roden, Robert OD Lehi UT. 84043 - Timpanogos Regional Hospital Alpine Vision Center p 801.753.7999 5455 W 11000 N 1528 N Commerce Dr Viehweg, Tate L DMD Ste 101 Ste 102 UUHC Parkway Health Center Alpine Surgical Arts Highland UT. 84003 Saratoga Springs UT. 84045 145 W University Pkwy 3300 N Running Creek Way p 801.756.9357 p 801.768.1900 Orem UT. 84058 Bldg H 210 p 801.234.8600 Lehi UT. 84043 Price, Robin S OD 3435 N Ctr p 801.766.4834 Child and Family Eye Care Ste 1 Vincent, Bryan H OD Center Lehi UT. 84043 University of Utah Health Hospital Affiliation 908 N 2000 W p 800.756.7150 145 W University Pkwy - Lone Peak Hospital Pleasant Grove UT. 84062 Orem UT. 84058 p 801.492.6393 Rowley, Brian F OD p 801.234.8600 Orthopedic Surgery Apple Valley Vision Allen, Judd C MD Pugh, Ronald M OD 539 S 100 W Weaver, Steven J OD Advanced Physicians of 2696 N University Ave Payson UT. 84651 Alpine Vision Center Sports & Orthopedic Ste 100A p 801.465.0355 11038 N Highland Blvd Medicine Provo UT. 84604 Ste 300 3401 N Center St p 801.373.0440 Siddoway, Frank A OD American Fork UT. 84003 Ste 100 1675 N Freedom Blvd p 801.756.7150 Lehi UT. 84043 321 W Ctr St Ste 11 A p 801.753.7770 Spanish Fork UT. 84660 Provo UT. 84604 1307 N Commerce Dr p 801.798.7496 p 801.374.2227 Ste 100 3943 E Pony Express Pkwy Saratoga Springs UT. 84045 Ste 201 Reese, William C OD 262 E 400 S p 801.768.1900 Eagle Mountain UT. 84005 Alpine Vision Center Springville UT. 84663 p 801.753.7770 11038 N Highland Blvd p 801.374.2227 Winward, Rick W OD Ste 300 Utah Valley Optometric Hospital Affiliation American Fork UT. 84003 Simmons, Robert L OD Physicians - Mountain Point Medical p 801.756.7150 Excel Eye Center of 1355 N University Ave Center American Fork Ste 100 12 N 1100 E Provo UT. 84604 American Fork UT. 84003 p 801.377.4333 p 801.756.9627

532 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Bacon, Carl W MD 3000 N Triumph Blvd 1305 N Commerce Dr Hoopes, Daniel M MD Revere Health Ste 100 Ste 120 Revere Health 1055 N 500 W Lehi UT. 84043 Saratoga Springs UT. 84045 1055 N 500 W Ste 121 p 801.373.7350 p 801.753.7424 Ste 121 Bldg C Provo UT. 84604 Provo UT. 84604 p 801.373.7350 555 W SR 164 N 555 W SR 164 N p 801.373.7350 Salem UT. 84653 Salem UT. 84653 555 W SR 164 N p 801.373.7350 p 801.373.7350 1184 E 80 N Salem UT. 84653 American Fork UT. 84003 p 801.373.7350 700 W 800 N Hospital Affiliation p 801.373.7350 Ste 100 - Timpanogos Regional Hospital 700 W 800 N Orem UT. 84057 - Mountain View Hospital 1305 N Commerce Dr Ste 100 p 801.373.7350 (UT) Ste 120 Orem UT. 84057 - Lone Peak Hospital Saratoga Springs UT. 84045 p 801.224.5373 Hospital Affiliation p 801.373.7350 - Mountain View Hospital Gilbert, Todd M MD Hospital Affiliation (UT) Revere Health 680 E Main St - Timpanogos Regional Hospital - Timpanogos Regional Hospital 1055 N 500 W Bldg C Lehi UT. 84043 - Mountain View Hospital Ste 101 p 801.373.7350 (UT) Christensen, Kevin D MD Provo UT. 84604 Revere Health p 801.373.7350 700 W 800 N Barber, Collin C MD 1055 N 500 W Ste 100 Revere Health Ste 211 2183 W Main St Orem UT. 84057 1055 N 500 W Provo UT. 84604 Ste A-107 p 801.373.7350 Ste 121 p 801.357.7327 Lehi UT. 84043 Provo UT. 84604 p 385.203.1215 Hospital Affiliation p 801.373.7350 555 W SR 164 N - Mountain View Hospital Salem UT. 84653 555 W SR 164 N (UT) 2183 W Main St p 801.373.7350 Salem UT. 84653 - Lone Peak Hospital Ste A-107 p 801.373.7350 - Timpanogos Regional Hospital Lehi UT. 84043 700 W 800 N p 385.203.1215 Ste 100 700 W 800 N Jackson, Scott T MD Orem UT. 84057 Ste 100 Revere Health 3000 N Triumph Blvd p 801.224.5373 Orem UT. 84057 1055 N 500 W Lehi UT. 84043 p 801.465.4805 Ste 121 p 801.429.8000 Edwards, Gary MD Provo UT. 84604 Summit Brain and Spine Hicken, Gregory J MD p 801.373.7350 555 W SR 164 N 3000 N Triumph Blvd Grove Creek Surgical Salem UT. 84653 Ste 110 Center 700 W 800 N p 801.373.7350 Lehi UT. 84043 2168 W Grove Pkwy Ste 100 p 385.345.3560 Ste 101 Orem UT. 84057 700 W 800 N Provo UT. 84602 p 801.224.5373 Ste 100 Faux, Jonathan R MD p 801.772.5050 Orem UT. 84057 Revere Health Hospital Affiliation p 801.373.7350 1055 N 500 W Hospital Affiliation - Mountain View Hospital Ste 121 - Brigham City Community (UT) Barker, Jordan P MD Provo UT. 84604 Hospital - Timpanogos Regional Hospital Revere Health p 801.357.7350 - Franklin County Medical 1055 N 500 W Center Jacobsen, Jacoby D Ste 211 1130 Smith Fieldhouse - Cache Valley Hospital University Of Utah Health Provo UT. 84604 Provo UT. 84602 1157 N 300 W p 801.373.7350 p 801.373.7350 Hoffman, Michael MD Ste 302 Neuroscience & Provo UT. 84604 700 W 800 N Hospital Affiliation Rehabilitation Specialists p 801.357.4470 Ste 100 - Mountain View Hospital - Lehi Orem UT. 84057 (UT) 3000 N Triumph Blvd Hospital Affiliation p 801.224.5373 - Timpanogos Regional Hospital Ste 110 - University of Utah Hospital Lehi UT. 84043 - Primary Childrens Hospital Carlson, Michael MD Frazier, Matthew S DO p 385.345.3558 Revere Health Revere Health Johnson, Curtis C MD 1055 N 500 W 1055 N 500 W Mountain Point Multi Revere Health Ste 121 Ste 207 Specialty 1055 N 500 W Provo UT. 84604 Provo UT. 84604 3000 N Triumph Blvd Ste 207 p 801.373.7350 p 801.373.7350 Ste 330 Provo UT. 84604 Lehi UT. 84043 p 801.373.7350 p 801.789.2275

533 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 1130 Smith Fieldhouse Nielsen, Evan S MD 1305 N Commerce Dr Stock, Gordon H MD Provo UT. 84602 Revere Health Ste 120 Revere Health p 801.373.7350 1055 N 500 W Saratoga Springs UT. 84045 1184 E 80 N Ste 201 p 801.753.7424 American Fork UT. 84003 Hospital Affiliation Provo UT. 84604 p 801.763.3885 - Timpanogos Regional Hospital p 801.373.7350 555 W SR 164 N - Mountain View Hospital Salem UT. 84653 680 E Main St (UT) 555 W SR 164 N p 801.373.7350 Lehi UT. 84043 Salem UT. 84653 p 801.763.3885 Karrasch, Chris K MD p 801.373.7350 Hospital Affiliation Santaquin Medical Clinic - Lone Peak Hospital Hospital Affiliation 210 E Main St 700 W 800 N - Timpanogos Regional Hospital - Timpanogos Regional Hospital Santaquin UT. 84655 Ste 100 - Mountain View Hospital - Mountain View Hospital p 801.754.3600 Orem UT. 84057 (UT) (UT) p 801.373.7350 Kimball, Kirt M MD Ritchie, Paul K MD Stotts, Alan K MD Revere Health Hospital Affiliation Revere Health University of Utah Health 1055 N 500 W - Timpanogos Regional Hospital 1184 E 80 N 247 N 100 E Ste 121 - Mountain View Hospital American Fork UT. 84003 Orem UT. 84057 Provo UT. 84604 (UT) p 801.763.3885 p 801.587.2255 p 801.373.7350 Ogden, Benjamin W MD 1305 N Commerce Dr Hospital Affiliation 1130 Smith Fieldhouse Revere Health Ste 120 - Primary Childrens Hospital Provo UT. 84602 1055 N 500 W Saratoga Springs UT. 84045 p 801.373.7350 Ste 207 p 801.373.7350 Taylor, John R MD Provo UT. 84604 Revere Health 555 W SR 164 N p 801.375.4263 680 E Main St 2183 W Main St Salem UT. 84653 Lehi UT. 84043 Ste A-107 p 801.373.7350 3000 N Triumph Blvd p 801.763.3885 Lehi UT. 84043 Lehi UT. 84043 p 385.203.1215 700 W 800 N p 801.429.8000 Hospital Affiliation Ste 100 - Timpanogos Regional Hospital 3000 N Triumph Blvd Orem UT. 84057 700 W 800 N Ste 100 p 801.224.5373 Orem UT. 84057 Schuenman, Spencer F DO Lehi UT. 84043 p 801.375.4263 Premier Family Medical p 801.763.3885 Hospital Affiliation 226 N 1100 E - Timpanogos Regional Hospital Poulsen, Matthew R MD Ste A 700 W 800 N - Utah Valley Hospital Blue Rock Medical Center American Fork UT. 84003 Ste 100 3152 N University Ave p 801.855.3841 Orem UT. 84057 Larsen, Mitchell W MD Provo UT. 84604 p 801.373.7350 Revere Health p 801.375.2177 275 W 200 N 1055 N 500 W Lindon UT. 84042 Tranter, Devin DPM Ste 121 Hospital Affiliation p 801.796.1333 Mountain Point Multi Provo UT. 84604 - Timpanogos Regional Hospital Specialty - Lehi p 801.373.7350 - Lone Peak Hospital 3000 N Triumph Blvd 3000 N Triumph Blvd - Mountain View Hospital Ste 220 Ste 110 1130 Smith Fieldhouse (UT) Lehi UT. 84043 Lehi UT. 84043 Provo UT. 84602 - Jordan Valley Medical p 801.756.3511 p 801.789.4488 p 801.373.7350 Center Mountain Point Medical Mountain Point Foot And 700 W 800 N Relyea, Randall M DO Center Ankle - Eagle Mountain Ste 100 Tooele Orthopaedics & 3000 N Triumph Blvd 3943 E Pony Express Pkwy Orem UT. 84057 Sports Medicine Lehi UT. 84043 Ste 110 p 801.224.5373 Specialists p 385.345.3000 Lehi UT. 84043 3000 N Triumph Blvd p 801.789.2275 Hospital Affiliation Ste 340 Premier Family Medical - Mountain View Hospital Lehi UT. 84043 680 E Main St Vakautakakala, Viliami H (UT) p 435.833.9180 Lehi UT. 84043 DPM - Timpanogos Regional Hospital p 801.768.1699 Apex Foot & Ankle Richards, Ryan A MD Institute Machen, Michael S MD Revere Health Hospital Affiliation 15 S 1000 E University of Utah Health 1055 N 500 W - Mountain Point Medical Ste 125 1157 N 300 W Ste 207 Center Payson UT. 84651 Ste 302 Provo UT. 84604 p 435.287.2444 Provo UT. 84604 p 801.357.7350 p 801.357.4470

Hospital Affiliation - University of Utah Hospital 534 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Wallentine, Jeffrey M MD 671 E Kirby Ln 280 W River Park Dr Grose, Kendall DO Revere Health Ste 103 Ste 200 Neuroscience & 1055 N 500 W Spanish Fork UT. 84660 Provo UT. 84604 Rehabilitation Specialists Ste 121 p 801.377.3433 p 801.223.4860 - Lehi Provo UT. 84604 3000 N Triumph Blvd p 801.373.7350 Pain Management Hospital Affiliation Ste 330 Alpine Pain Solutions of - Mountain View Hospital Lehi UT. 84043 1130 Smith Fieldhouse Utah (UT) p 801.505.5370 Provo UT. 84602 3051 W Maple Loop Dr - Timpanogos Regional Hospital p 801.373.7350 Ste 125 Orem Community Hospital Lehi UT. 84043 Freeman, Eric MD 331 N 400 W 700 W 800 N p 801.860.0931 Vista Neurology Lehi UT. 84043 Ste 100 Specialists p 801.505.5370 Orem UT. 84057 Baker, Elizabeth PhD 15 S 1000 E p 801.224.5373 1453 N 1200 W Ste 125 Hospital Affiliation Orem UT. 84057 Payson UT. 84651 - Jordan Valley Medical Hospital Affiliation p 801.360.7379 p 385.336.1157 Center - Mountain View Hospital - Utah Valley Hospital (UT) Child, Gary L DO 24 W Sergeant Ct Dr Bldg - Gunnison Valley Hospital Alpine Pain Solutions of 1 Hoelzer, Bryan MD - Timpanogos Regional Hospital Utah Saratoga Springs UT. 84045 Vista Neurology 3051 W Maple Loop Dr p 385.336.1157 Specialists Wells, John T MD Ste 125 15 S 1000 E Revere Health Lehi UT. 84043 320 W River Park Dr Ste 125 1184 E 80 N p 801.860.0931 Ste 255 Payson UT. 84651 American Fork UT. 84003 Provo UT. 84604 p 385.336.1157 p 801.763.3885 Despain, Devin DO p 385.203.0246 Interventional Spine & 24 W Sergeant Ct Dr Bldg 680 W Main St Pain Management 336 W 100 S 1 Lehi UT. 84043 346 E State Rd Spanish Fork UT. 84660 Saratoga Springs UT. 84045 p 801.763.3885 Pleasant Grove UT. 84062 p 385.203.0246 p 385.336.1157 p 801.262.7246 Hospital Affiliation Frieden, Derek L MD 320 W River Park Dr - Timpanogos Regional Hospital 3943 E Pony Express Pkwy Vista Neurology Ste 255 Eagle Mountain UT. 84005 Specialists Provo UT. 84604 Orthotics And Prosthetics p 801.262.7246 320 W River Park Dr p 385.203.0246 Hanger Prosthetics and Ste 255 Orthotics Inc Donaldson, Ashley R MD Provo UT. 84604 336 W 100 S 1355 N University Ave Spinal Interventions p 385.203.0246 Spanish Fork UT. 84660 Ste 160 230 N 1200 E p 385.203.0246 Provo UT. 84604 Ste 201 Hospital Affiliation p 801.356.1830 Lehi UT. 84043 - St George Regional Hospital Kennington, Konrad S MD p 801.852.9555 Rock Creek Neurosurgery Northwest Orthotics and Garg, Vikas MD 1248 E 90 N Prosthetics 280 W River Park Dr Interventional Spine & Ste 203 1675 N Freedom Blvd Ste 200 Pain Management American Fork UT. 84003 Ste 12C Provo UT. 84604 346 E State Rd p 801.609.9310 Provo UT. 84604 p 801.223.4860 Pleasant Grove UT. 84062 p 801.377.3433 p 801.262.7246 15 S 1000 E Egan, Brent H FNP Ste 225 Peak Prosthetic Design Alpine Pain Solutions of 3943 E Pony Express Pkwy Payson UT. 84651 504 E 770 N Utah Eagle Mountain UT. 84005 p 801.609.9310 Orem UT. 84097 3051 W Maple Loop Dr p 801.262.7246 p 801.972.5270 Ste 125 Hospital Affiliation Lehi UT. 84043 Hospital Affiliation - University of Utah Hospital Northwest Orthotics and p 801.766.6055 - Lone Peak Hospital - Mountain View Hospital Prosthetics - Evanston Regional Hospital (UT) 1988 W 930 N Faber, Daniel R MD - Brigham City Community - Timpanogos Regional Hospital Ste C Spinal Interventions Hospital Pleasant Grove UT. 84062 230 N 1200 E Khan, Qamar R DO p 801.377.3433 Ste 201 Green, Brandon MD Wasatch Pain Solutions Lehi UT. 84043 Mountain Multispecialty - 1988 W 930 N p 801.852.9555 Lehi Ste A 3000 N Triumph Blvd Pleasant Grove UT. 84062 Ste 110 p 801.302.2690 Lehi UT. 84043 p 385.345.3554 Hospital Affiliation - Jordan Valley Medical Center - Lone Peak Hospital 535 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:49 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Layne, Travis PA-C Obray, Jon B MD 280 W River Park Dr Su, Jason T DO Nexus Pain Care Vista Neurology Ste 200 Peak Pediatric Specialists 3585 N University Ave Specialists Provo UT. 84604 1055 N 300 W Ste 150 320 W River Park Dr p 801.223.4860 Ste 311 Provo UT. 84604 Ste 255 Provo UT. 84604 p 801.356.6100 Provo UT. 84604 Stringham, J Riley MD p 385.477.6800 p 385.203.0246 Spinal Interventions Minori, Joshua J DO 230 N 1200 E 3000 N Triumph Blvd Interventional Spine & Hospital Affiliation Ste 201 Ste 260 Pain Management - St George Regional Hospital Lehi UT. 84043 Lehi UT. 84043 346 E State Rd p 801.852.9555 p 385.477.6800 Pleasant Grove UT. 84062 Obray, Rick W MD p 801.262.7246 Vista Neurology 280 W River Park Dr Hospital Affiliation Specialists Ste 200 - Ogden Regional Medical 3943 E Pony Express Pkwy 320 W River Park Dr Provo UT. 84604 Center Eagle Mountain UT. 84005 Ste 255 p 801.223.4860 p 801.262.7246 Provo UT. 84604 Pediatric Ear Nose And Throat p 385.203.0246 Hospital Affiliation *Kelly, Steven M MD Hospital Affiliation - Timpanogos Regional Hospital PCH Cleft - Timpanogos Regional Hospital Hospital Affiliation - Mountain View Hospital Palate/Craniofacial-Utah - Utah Valley Hospital - St George Regional Hospital (UT) Valley 1157 N 300 W Mosley, Joseph J DO Robinson, Cole MD Pediatric Cardiology Provo UT. 84604 Vista Neurology Vista Neurology Jou, Chuanchau J DO p 801.662.1630 Specialists Specialists Peak Pediatric Specialists 15 S 1000 E 320 W River Park Dr 1055 N 300 W Hospital Affiliation Ste 125 Ste 255 Ste 311 - Primary Childrens Hospital Payson UT. 84651 Provo UT. 84604 Provo UT. 84604 p 385.404.8300 p 385.203.0216 p 385.477.6800 Schramm, Jordan C MD Peak ENT Associates 24 W Sergeant Ct Dr Bldg Hospital Affiliation 3000 N Triumph Blvd 1055 N 300 W 1 - Sevier Valley Hospital Ste 260 Ste 401 Saratoga Springs UT. 84045 Lehi UT. 84043 Provo UT. 84604 p 385.336.1157 Rosenthal, Richard MD p 385.477.6800 p 801.357.7499 Nexus Pain Care 320 W River Park Dr 3585 N University Ave Hospital Affiliation Peak Pediatric Specialists Ste 215 Ste 150 - Utah Valley Hospital 3000 N Triumph Blvd Provo UT. 84604 Provo UT. 84604 - Timpanogos Regional Hospital Ste 260 p 385.203.0247 p 801.356.6100 Lehi UT. 84043 Menon, Shaji C MD p 385.477.6800 336 W 100 S Hospital Affiliation University Of Utah Health Spanish Fork UT. 84660 - Timpanogos Regional Hospital 1034 N 500 W Hospital Affiliation p 385.437.3724 - Mountain View Hospital Provo UT. 84604 - Primary Childrens Hospital (UT) p 801.662.3645 Hospital Affiliation Pediatric Gastroenterology - Timpanogos Regional Hospital Sanders, Matthew D MD Hospital Affiliation Mizell, Louis L MD - Utah Valley Hospital Spinal Interventions - Primary Childrens Hospital Pediatrix Medical Group 230 N 1200 E - Ogden Regional Medical 700 W 800 N Nakken, Jason J DO Ste 201 Center Ste 330 Nexus Pain Care Lehi UT. 84043 Orem UT. 84057 3585 N University Ave p 801.852.9555 Menon, Sharad P p 801.714.6404 Ste 150 Pediatrix Medical Group Provo UT. 84604 280 W River Park Dr 750 W 800 N 750 W 800 N p 801.356.6100 Ste 200 Orem UT. 84057 Orem UT. 84057 Provo UT. 84604 p 801.714.6000 p 801.716.0000 Nelson, Alex J MD p 801.223.4860 Interventional Spine & Hospital Affiliation Hospital Affiliation Pain Management Hospital Affiliation - Phoenix Childrens Hospital - Primary Childrens Hospital 3943 E Pony Express Pkwy - Mountain Point Medical - Lone Peak Hospital Eagle Mountain UT. 84005 Center Pinto, Nelangi M MD - Timpanogos Regional Hospital p 801.262.7246 University Of Utah Health 230 N 1200 E 1034 N 500 W Pediatric Nephrology Hospital Affiliation Ste 201 Provo UT. 84604 Gregory, Martin C MD,PhD - Lakeview Hospital Lehi UT. 84043 p 801.213.3599 University of Utah Health - Timpanogos Regional Hospital p 801.852.9555 1159 E 200 N Hospital Affiliation Ste 150 - Primary Childrens Hospital American Fork UT. 84003 - Ogden Regional Medical p 801.373.0167 Center Hospital Affiliation - University of Utah Hospital536 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Sherbotie, Joseph R MD Kastenberg, Zachary J MD Alba, Jesse A MD 1355 N University Ave University of Utah Health University of Utah Health Alpine Pediatrics Ste 210 1159 E 200 N 395 W Bulldog Blvd 848 N 980 W Provo UT. 84604 Ste 150 Ste 702 Orem UT. 84057 p 801.756.5609 American Fork UT. 84003 Provo UT. 84604 p 801.374.1999 p 801.373.0167 p 801.662.2950 Hospital Affiliation Hospital Affiliation - Timpanogos Regional Hospital Hospital Affiliation Hospital Affiliation - Timpanogos Regional Hospital - University of Utah Hospital - University of Utah Hospital - Mountain Point Medical Bailey, Ernest MD Center Utah Valley Pediatrics Pediatric Ophthalmology Russell, Kathryn W MD 716 W 800 N Yeates, Scott W MD University of Utah Health Allen, Matthew D DO Ste 300 Excel Eye Center of Orem 395 W Bulldog Blvd Utah Valley Pediatrics Orem UT. 84057 700 W 800 N Ste 702 41 E 1140 N p 801.224.0421 Ste 160 Provo UT. 84604 Ste B Orem UT. 84057 p 801.662.2950 Saratoga Springs UT. 84045 Hospital Affiliation p 801.426.9800 p 801.407.6500 - Timpanogos Regional Hospital Hospital Affiliation Hospital Affiliation - University of Utah Hospital Alpine Pediatrics Bartholomew, Jonathen DO - Timpanogos Regional Hospital 1238 N Commerce Dr Utah Valley Pediatrics - Central Valley Medical Scaife, Eric R MD Saratoga Springs UT. 84045 1355 N University Ave Center University of Utah Health p 801.922.9222 Ste 210 395 W Bulldog Blvd Provo UT. 84604 Pediatric Orthopedic Surgery Ste 702 1912 W 930 N p 801.374.8863 Smith, John T MD Provo UT. 84604 Pleasant Grove UT. 84062 University of Utah Health p 801.662.2950 p 801.492.1999 171 N 400 W 1157 N 300 W Ste C12 Ste 302 Hospital Affiliation Anderson, Bradley W MD Orem UT. 84057 Provo UT. 84604 - Primary Childrens Hospital Utah Valley Pediatrics p 801.224.4550 p 801.357.4470 1355 N University Ave Short, Scott S MD Ste 210 Hospital Affiliation Winter, Sarah L MD University of Utah Health Provo UT. 84604 - Timpanogos Regional Hospital University of Utah Health 395 W Bulldog Blvd p 801.373.8930 - Mountain View Hospital 151 S University Ave Ste 702 (UT) Ste 1610 Provo UT. 84604 Hospital Affiliation Provo UT. 84601 p 801.662.2950 - Timpanogos Regional Hospital Behrmann, Gary MD p 801.587.2255 1172 E 100 N Hospital Affiliation Anderson, Vickie NP Ste 2 Pediatric Surgery - University of Utah Hospital Utah Valley Pediatrics Payson UT. 84651 Barnhart, Douglas C MD 1159 E 200 N p 801.465.4877 University of Utah Health Skarda, David E MD Ste 200 395 W Bulldog Blvd University of Utah Health American Fork UT. 84003 Hospital Affiliation Ste 702 395 W Bulldog Blvd p 801.756.5209 - Timpanogos Regional Hospital Provo UT. 84604 Ste 702 - Mountain View Hospital p 801.662.2950 Provo UT. 84604 1355 N University Ave (UT) p 801.662.2950 Ste 210 Bucher, Brian T MD Provo UT. 84604 Bennett, John N MD University of Utah Health Pediatric Urology p 801.465.2800 Canyon View Medical Group 395 W Bulldog Blvd Schaeffer, Anthony J MD 325 W Ctr St Ste 702 University of Utah Health Arnold, Bradley C MD Spanish Fork UT. 84660 Provo UT. 84604 1134 N 500 W Alpine Pediatrics p 801.798.7301 p 801.662.2950 Ste 104 1912 W 930 N Provo UT. 84604 Pleasant Grove UT. 84062 Hospital Affiliation Hospital Affiliation p 801.581.7719 p 801.492.1999 - Mountain View Hospital - Primary Childrens Hospital (UT) Hospital Affiliation Hospital Affiliation Fenton, Stephen J - Primary Childrens Hospital - Timpanogos Regional Hospital Blad, Kent D FNP University of Utah Health Pediatric Care 395 W Bulldog Blvd Pediatrics Ashby, Sarah L MD 1675 N Freedom Blvd Ste 702 Adams, Ross M DO Utah Valley Pediatrics Ste 3 Provo UT. 84604 Utah Valley Pediatrics 1159 E 200 N Provo UT. 84604 p 801.662.2950 1355 N University Ave Ste 200 p 801.377.8000 Ste 210 American Fork UT. 84003 Provo UT. 84604 p 801.756.5209 Hospital Affiliation p 801.373.8930 - Timpanogos Regional Hospital

Hospital Affiliation - Timpanogos Regional Hospital 537 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Carter, Bryce E MD Cornish, Matthew J MD 1912 W 930 N Foster, Christopher C MD Alpine Pediatrics Utah Valley Pediatrics Pleasant Grove UT. 84062 Alpine Pediatrics 1238 N Commerce Dr 716 W 800 N p 801.492.1999 1238 N Commerce Dr Saratoga Springs UT. 84045 Ste 300 Saratoga Springs UT. 84045 p 801.922.9222 Orem UT. 84057 3000 N Triumph Blvd p 801.922.9222 p 801.224.0421 Ste 240 1912 W 930 N Lehi UT. 84043 Hospital Affiliation Pleasant Grove UT. 84062 Hospital Affiliation p 801.229.1000 - Timpanogos Regional Hospital p 801.492.1999 - Timpanogos Regional Hospital 3231 N 1120 E Fuller, Joshua D MD 3000 N Triumph Blvd Cox, Chad M MD Lehi UT. 84043 Pediatric Care Ste 240 Alpine Pediatrics p 801.768.2800 1675 N Freedom Blvd Lehi UT. 84043 1912 W 930 N Ste 3 p 801.229.1000 Pleasant Grove UT. 84062 848 N 980 W Provo UT. 84604 p 801.492.1999 Orem UT. 84057 p 801.377.8000 3231 N 1120 E p 801.374.1999 Lehi UT. 84043 Hospital Affiliation Hospital Affiliation p 801.768.2800 - Timpanogos Regional Hospital Edelman, Samuel B DO - Utah Valley Hospital Pediatrix Medical Group - Timpanogos Regional Hospital 848 N 980 W Coyner, Seth J OD 750 W 800 N Orem UT. 84057 Canyon View Womens Care Orem UT. 84057 Fullmer, Michael P DO p 801.374.1999 15 S 1000 E p 801.714.6000 Utah Valley Pediatrics Ste 125 15 S 1000 E Hospital Affiliation Payson UT. 84651 Edwards, William F MD Ste 200 - Timpanogos Regional Hospital p 801.465.2559 Alpine Pediatrics Payson UT. 84651 - Mountain Point Medical 1238 N Commerce Dr p 801.465.2800 Center Davenport, Derek J MD Saratoga Springs UT. 84045 - Utah Valley Hospital Revere Health p 801.922.9222 Hospital Affiliation 4095 E Pony Express Pkwy - Mountain View Hospital Chalom, Rene MD Ste 1 Hospital Affiliation (UT) Pediatrix Medical Group Eagle Mountain UT. 84005 - Timpanogos Regional Hospital 750 W 800 N p 801.429.8037 Glade, Gordon B MD Orem UT. 84057 Ellertson, Bryan MD Utah Valley Pediatrics p 801.714.6000 Devenport, David S MD Utah Valley Pediatrics 1159 E 200 N Hobble Creek Medical 1305 N Commerce Dr Ste 200 Chidester, Todd NP Clinic Ste 230 American Fork UT. 84003 Utah Valley Pediatrics 269 E 400 S Saratoga Springs UT. 84045 p 801.756.5209 1159 E 200 N Ste 2 p 801.407.6500 Ste 200 Springville UT. 84663 Gunther, Julia K MD American Fork UT. 84003 p 801.491.9883 1355 N University Ave Alpine Pediatrics p 801.756.5209 Ste 210 1238 N Commerce Dr Hospital Affiliation Provo UT. 84604 Saratoga Springs UT. 84045 1355 N Universtiy Ave - Mountain View Hospital p 801.373.8930 p 801.922.9222 Ste 210 (UT) Provo UT. 84604 Hospital Affiliation Hospital Affiliation p 801.374.8863 Devenport, Mark J MD - Davis Hospital - Timpanogos Regional Hospital Hobble Creek Medical - Ogden Region Medical - Mountain Point Medical Clayton, Matthew J DO Clinic Center Center Village Green Pediatrics 269 E 400 S PC Ste 2 Farnsworth, Richard Y MD Harousseau, Mark MD 1675 N Freedom Blvd Springville UT. 84663 Utah Valley Pediatrics University Of Utah Health Ste 9C p 801.491.9883 1355 N University Ave 1034 N 500 W Provo UT. 84604 Ste 210 Provo UT. 84604 p 801.377.4800 Hospital Affiliation Provo UT. 84604 p 801.662.3645 - Mountain View Hospital p 801.373.8930 Hospital Affiliation (UT) Hospital Affiliation - Timpanogos Regional Hospital Faust, Barbara NP - University of Utah Hospital Dickson, Michael A MD University of Utah Health Conner, Marsena E MD Alpine Pediatrics 151 S University Ave Harris, Chris J PA-C Utah Valley Pediatrics 1238 N Commerce Dr Ste 1610 University of Utah Health 1159 E 200 N Saratoga Springs UT. 84045 Provo UT. 84601 1157 N 300 W Ste 200 p 801.922.9222 p 801.587.2255 Ste 302 American Fork UT. 84003 Provo UT. 84604 p 801.756.5209 p 801.357.4470

Hospital Affiliation - Mountain Point Medical Center 538 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Hedges, Jonathan D MD 3231 N 1120 E 3000 N Triumph Blvd 15 S 1000 E Hobble Creek Medical Lehi UT. 84043 Ste 260 Ste 200 Clinic p 801.768.2800 Lehi UT. 84043 Payson UT. 84651 672 W 400 S p 385.477.6800 p 801.465.2800 Ste 101 848 N 980 W Springville UT. 84663 Orem UT. 84057 Hospital Affiliation Hospital Affiliation p 801.491.9883 p 801.374.1999 - Utah Valley Hospital - Mountain View Hospital - Timpanogos Regional Hospital (UT) Hendricks, Landon R MD Johnson, Joseph M MD Alpine Pediatrics 1675 N Freedom Blvd Kendall, Melissa MD Lee, Stephen MD 1238 N Commerce Dr Ste 9C Utah Valley Pediatrics Utah Valley Pediatrics Saratoga Springs UT. 84045 Provo UT. 84604 716 W 800 N 1159 E 200 N p 801.922.9222 p 801.377.4800 Ste 300 Ste 200 Orem UT. 84057 American Fork UT. 84003 1912 W 930 N Hospital Affiliation p 801.224.0421 p 801.756.5209 Pleasant Grove UT. 84062 - Timpanogos Regional Hospital p 801.492.1999 Hospital Affiliation Hospital Affiliation Jones, Eric W MD - Timpanogos Regional Hospital - Mountain Point Medical 3000 N Triumph Blvd Utah Valley Pediatrics Center Ste 240 15 S 1000 E Knorr, Brett K MD Lehi UT. 84043 Ste 200 Alpine Pediatrics Leifson, Scott L DO p 801.229.1000 Payson UT. 84651 3231 N 1120 E Utah Valley Pediatrics p 801.465.2800 Lehi UT. 84043 1355 N University Ave 3231 N 1120 E p 801.768.2800 Ste 210 Lehi UT. 84043 Hospital Affiliation Provo UT. 84604 p 801.768.2800 - Mountain View Hospital Hospital Affiliation p 801.374.8863 (UT) - Timpanogos Regional Hospital 848 N 980 W - Utah Valley Hospital - Mountain Point Medical 852 E Expwy Ln Orem UT. 84057 Center Spanish Fork UT. 84660 p 801.374.1999 Jones, Ronald C MD p 801.794.7947 Pediatric Care Later, Douglas J DO Hershkop, Joseph MD 1675 N Freedom Blvd Utah Valley Pediatrics Hospital Affiliation Utah Valley Pediatrics Ste 3 747 E 440 N - Mountain View Hospital 41 E 1140 N Provo UT. 84604 Ste A (UT) Ste B p 801.377.8000 Vineyard UT. 84059 Saratoga Springs UT. 84045 p 801.357.7883 MacEntee, Mary V MD p 801.407.6500 247 W 2230 N Pediatrix Medical Group Ste 202 Later, Richard W MD 750 W 800 N Jensen, Jeffrey L MD Provo UT. 84604 Utah Valley Pediatrics Orem UT. 84057 Utah Valley Pediatrics p 801.373.1275 747 E 440 N p 801.714.6000 1355 N University Ave Ste A Ste 210 Hospital Affiliation Vineyard UT. 84059 McArthur, Nathan R MD Provo UT. 84604 - Timpanogos Regional Hospital p 801.357.7883 Alpine Pediatrics p 801.373.8930 - Utah Valley Hospital 3000 N Triumph Blvd Hospital Affiliation Ste 240 Hospital Affiliation Jones, Tyson MD - Timpanogos Regional Hospital Lehi UT. 84043 - Timpanogos Regional Hospital Utah Valley Pediatrics p 801.229.1000 1159 E 200 N Lauret, Michael MD Johnson, David S MD Ste 200 Utah Valley Pediatrics Hospital Affiliation Alpine Pediatrics American Fork UT. 84003 1355 N University Ave - Mountain Point Medical 1238 N Commerce Dr p 801.756.5209 Ste 210 Center Saratoga Springs UT. 84045 Provo UT. 84604 - Timpanogos Regional Hospital p 801.922.9222 1355 N University Ave p 801.373.8930 Ste 210 McCune, Brian C MD 1912 W 930 N Provo UT. 84604 Hospital Affiliation Utah Valley Pediatrics Pleasant Grove UT. 84062 p 801.374.8863 - Timpanogos Regional Hospital 41 E 1140 N p 801.492.1999 Ste B Hospital Affiliation Lauritzen, Benjamin G MD Saratoga Springs UT. 84045 3000 N Triumph Blvd - Mountain Point Medical Utah Valley Pediatrics p 801.407.6500 Ste 240 Center 1355 N University Ave Lehi UT. 84043 Ste 210 Hospital Affiliation p 801.229.1000 Jou, Chuanchau J DO Provo UT. 84604 - Mountain Point Medical Peak Pediatric Specialists p 801.465.2800 Center 1055 N 300 W Ste 311 Provo UT. 84604 p 385.477.6800

539 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. McVey, Patrick T MD Moresco, Benjamin L MD Perry, Jacob H PA Spencer, Weston E MD Canyon View Womens Care University Of Utah Health Hobble Creek Medical Alpine Pediatrics 15 S 1000 E 1034 N 500 W Clinic 1912 W 930 N Ste 125 Provo UT. 84604 672 W 400 S Pleasant Grove UT. 84062 Payson UT. 84651 p 801.662.3645 Ste 101 p 801.492.1999 p 801.465.2559 Springville UT. 84663 Hospital Affiliation p 801.491.9883 Hospital Affiliation Canyon View Medical Group - University of Utah Hospital - Timpanogos Regional Hospital 325 W Ctr St Peterson, Jonathan P MD - Mountain Point Medical Spanish Fork UT. 84660 Mumford, Scott H MD Utah Valley Pediatrics Center p 801.798.7301 Utah Valley Pediatrics 1355 N University Ave 1159 E 200 N Ste 210 Swords, Darden MD Mccoy, Aaron W MD Ste 200 Provo UT. 84604 Alpine Pediatrics Utah Valley Pediatrics American Fork UT. 84003 p 801.374.8863 1912 W 930 N 1355 N University Ave p 801.756.5209 Pleasant Grove UT. 84062 Ste 210 852 E Expwy Ln p 801.492.1999 Provo UT. 84604 Napa, Balasubramanyan MD Spanish Fork UT. 84660 p 801.373.8930 Pediatrix Medical Group p 801.794.7947 Townsend, Stacey MD 750 W 800 N Hobble Creek Medical Hospital Affiliation Orem UT. 84057 Hospital Affiliation Clinic - Timpanogos Regional Hospital p 801.714.6000 - Mountain View Hospital 672 W 400 S - Primary Childrens Hospital (UT) Ste 101 Nelson, Melanie MD Springville UT. 84663 Miers, Cindy J MD University Of Utah Health Pollary, Rodney A MD p 801.491.9883 Alpine Pediatrics 1034 N 500 W Alpine Pediatrics 1238 N Commerce Dr Provo UT. 84604 1238 N Commerce Dr Hospital Affiliation Saratoga Springs UT. 84045 p 801.662.3645 Saratoga Springs UT. 84045 - Saint Alphonsus Medical p 801.922.9222 p 801.922.9222 Center - Nampa Hospital Affiliation 1912 W 930 N - University of Utah Hospital Hospital Affiliation Utah Valley Pediatrics Pleasant Grove UT. 84062 - Ashley Valley Regional 1055 N 300 W p 801.492.1999 Patel, Shrena MD Medical Center Ste 311 Pediatrix Medical Group Provo UT. 84604 3000 N Triumph Blvd 750 W 800 N Rollins, Michael D MD p 801.371.7883 Ste 240 Orem UT. 84057 University of Utah Health Lehi UT. 84043 p 801.714.6000 395 W Bulldog Blvd 1159 E 200 N p 801.229.1000 Ste 702 Ste 200 Hospital Affiliation Provo UT. 84604 American Fork UT. 84003 3231 N 1120 E - Timpanogos Regional Hospital p 801.662.2950 p 801.756.5609 Lehi UT. 84043 p 801.768.2800 Pavich, Greg M MD Rowan, Mark B MD 1355 N University Ave Alpine Pediatrics Alpine Pediatrics Ste 210 848 N 980 W 3000 N Triumph Blvd 1912 W 930 N Provo UT. 84604 Orem UT. 84057 Ste 240 Pleasant Grove UT. 84062 p 801.373.8930 p 801.374.1999 Lehi UT. 84043 p 801.492.1999 p 801.229.1000 171 N 400 W Miller, Garron E MD Hospital Affiliation Ste C12 Pediatrix Medical Group Hospital Affiliation - Timpanogos Regional Hospital Orem UT. 84057 1000 E 100 N - Timpanogos Regional Hospital - Mountain Point Medical p 801.224.4550 Payson UT. 84651 Center p 801.465.7000 Paxton, Richard D MD 716 W 800 N Canyon View Medical Group Simmons, Daniel MD Ste 300 Utah Valley Pediatrics 325 W Ctr St Utah Valley Pediatrics Orem UT. 84057 15 S 1000 E Spanish Fork UT. 84660 171 N 400 W p 801.224.0421 Ste 200 p 801.798.7301 Ste C12 Payson UT. 84651 Orem UT. 84057 Vargo, Beverly L MD p 801.465.2800 Hospital Affiliation p 801.224.4550 Alpine Pediatrics - Mountain View Hospital 3231 N 1120 E Hospital Affiliation (UT) Hospital Affiliation Lehi UT. 84043 - Mountain View Hospital - Timpanogos Regional Hospital p 801.768.2800 (UT) Pediatric Care 1675 N Freedom Blvd Smith, Michelle NP Hospital Affiliation Ste 3 Pediatric Care - Timpanogos Regional Hospital Provo UT. 84604 1675 N Freedom Blvd - Mountain Point Medical p 801.377.8000 Ste 3 Center Provo UT. 84604 p 801.377.8000

540 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Wallace, Danielle C MD Wynn, John R MD Grose, Kendall DO 3943 E Pony Express Pkwy Utah Valley Pediatrics Utah Valley Pediatrics Neuroscience & Eagle Mountain UT. 84005 15 S 1000 E 171 N 400 W Rehabilitation Specialists p 801.262.7246 Ste 200 Ste C12 - Lehi Payson UT. 84651 Orem UT. 84057 3000 N Triumph Blvd Hospital Affiliation p 801.465.2800 p 801.224.4550 Ste 330 - Timpanogos Regional Hospital Lehi UT. 84043 - Utah Valley Hospital Whiting, David Todd MD Hospital Affiliation p 801.505.5370 Alpine Pediatrics - Timpanogos Regional Hospital Randle, Jeffrey G MD 3231 N 1120 E Orem Community Hospital ALX Family Health Lehi UT. 84043 *Yamashiro, Duane K DDS 331 N 400 W 245 S 1060 W p 801.768.2800 PCH Cleft Lehi UT. 84043 Lindon UT. 84042 Palate/Craniofacial-Utah p 801.505.5370 p 385.306.1222 Hospital Affiliation Valley - Timpanogos Regional Hospital 1157 N 300 W Hospital Affiliation Hospital Affiliation - Mountain Point Medical Provo UT. 84604 - Jordan Valley Medical - St Marks Hospital Center p 801.662.1630 Center - Utah Valley Hospital Robinson, Cole MD Whiting, Michael D MD Hospital Affiliation Vista Neurology 48 N 1100 E - University of Utah Hospital Khan, Qamar R DO Specialists Ste C Wasatch Pain Solutions 320 W River Park Dr American Fork UT. 84003 Zollo, Kenneth A MD 1988 W 930 N Ste 255 p 801.492.4333 Pediatric Care Ste A Provo UT. 84604 1675 N Freedom Blvd Pleasant Grove UT. 84062 p 385.203.0216 Hospital Affiliation Ste 3 p 801.302.2690 - Timpanogos Regional Hospital Provo UT. 84604 Hospital Affiliation p 801.377.8000 Hospital Affiliation - Sevier Valley Hospital Wilcox, Ryan MD - Jordan Valley Medical Utah Valley Pediatrics Hospital Affiliation Center Speed, John MD 1159 E 200 N - Timpanogos Regional Hospital - Lone Peak Hospital University of Utah Health Ste 200 - Utah Valley Hospital 145 W University Pkwy American Fork UT. 84003 King, Stuart W MD Orem UT. 84058 p 801.756.5209 Physical Medicine And Rehabilitation Utah Physiatry Associates p 801.234.8600 Colledge, Alan L MD 839 E 1200 S 1355 N University Ave Revere Health Orem UT. 84097 Hospital Affiliation Ste 210 1055 N 500 W p 801.224.7100 - Salt Lake Regional Medical Provo UT. 84604 Ste 121 Center p 801.374.8863 Provo UT. 84604 King, Valton N DO - University of Utah Hospital p 801.373.7350 Utah Physiatry Associates Williams, Gerald A DO 839 E 1200 S UUHC Parkway Health Center Pediatrix Medical Group 555 W SR 164 N Orem UT. 84097 145 W University Pkwy 750 W 800 N Salem UT. 84653 p 801.224.0891 Orem UT. 84058 Orem UT. 84057 p 801.373.7350 p 801.234.8600 p 801.714.6000 Kinne, Robert MD 700 W 800 N Nexus Pain Care Physical Therapy Winter, Sarah L MD Ste 100 3585 N University Ave Adamson, Ace L DPT University of Utah Health Orem UT. 84057 Ste 150 Dry Creek Physical Therapy 151 S University Ave p 801.224.5373 Provo UT. 84604 & Wellness Ste 1610 p 801.356.6100 3000 N Triumph Blvd Provo UT. 84601 Hospital Affiliation Ste 310 p 801.587.2255 - Timpanogos Regional Hospital Li, Tao MD Lehi UT. 84043 Nexus Pain Care p 801.766.4244 Wynn, Gregory MD Crouch, Benjamin S DO 3585 N University Ave Utah Valley Pediatrics Revere Health Ste 150 Albrecht, Dane DPT 716 W 800 N 555 W SR 164 N Provo UT. 84604 FYZICAL Spine Orthopedic Ste 300 Salem UT. 84653 p 801.356.6100 Sports Therapy & Balance Orem UT. 84057 p 801.373.7350 Center p 801.224.0421 Hospital Affiliation 3303 N University Ave Hospital Affiliation - Timpanogos Regional Hospital Provo UT. 84604 Hospital Affiliation - Timpanogos Regional Hospital p 801.373.7438 - Timpanogos Regional Hospital - Mountain View Hospital Minori, Joshua J DO (UT) Interventional Spine & Anderson, James N PT Pain Management Revere Health 346 E State Rd 1055 N 500 W Pleasant Grove UT. 84062 Ste 122 p 801.262.7246 Provo UT. 84604 p 801.429.0610

541 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Anderson, Kyle C DPT 555 W SR 164 N Buchanan, Stephen J DPT Concentra Medical Centers Physical and Sports Salem UT. 84653 Dry Creek Physical Therapy 2390 Redwood Rd Therapy Services p 801.812.5400 and Wellness West Valley City UT. 84419 15 S 1000 E 3300 N Running Creek Way p 888.997.2669 Ste 25 Baldwin, Matthew D DPT Bldg B Payson UT. 84651 Back@Work Physical Therapy Ste 150 601 N 1200 W p 801.465.5610 280 River Park Dr Lehi UT. 84043 Orem UT. 84057 Ste 310 p 801.766.4244 p 888.997.2669 Anderson, Paul D MPT Provo UT. 84604 Alpine Physical Therapy p 385.401.5010 Budge, Edward H DPT Crampton, Jonathan PT 75 W Main St Ct Peak Physical Therapy and Horizon Rehab Ste 100 Blatter, Ian W PT Sports Medicine 11 E 200 N Alpine UT. 84004 Revere Health 77 S 400 W Ste 101 p 801.216.4298 1055 N 500 W Spanish Fork UT. 84660 Orem UT. 84057 Ste 122 p 801.798.1626 p 801.374.1706 Astle, David J PT Provo UT. 84604 Premier Family Medical p 801.429.0610 Bushnell, Matthew F DPT Critchfield, Cody D DPT 1159 E 200 N Orem Sports Medicine Beyond Limits Phyiscal Ste 100 555 W SR 164 N Center Therapy American Fork UT. 84003 Salem UT. 84653 252 N State St 3943 E Pony Express Pkwy p 801.642.2890 p 801.385.2031 Orem UT. 84057 Ste 220 p 801.226.0599 Eagle Mountain UT. 84005 275 W 200 N Bliss, Brandon PT p 801.789.7333 Ste 100 FYZICAL Spine Orthopedic Butler, David D DPT Lindon UT. 84042 Sports Therapy and Balance Align Therapy LLC Deorcher, Korey B DPT p 801.769.2642 Center 230 N 1200 E Align Therapy LLC 3303 N University Ave Ste 103 230 N 1200 E Austin, Todd W PT Provo UT. 84604 Lehi UT. 84043 Ste 103 Saratoga Physical Therapy p 801.373.7438 p 801.980.0860 Lehi UT. 84043 and Sports Medicine p 801.980.0860 18 W Sergeant Ct Dr FYZICAL Spine Orthopedic Carter, Karen L DPT Ste 101 Sports Therapy & Balance Professional Physical Dollar, Victor PT Saratoga Springs UT. 84045 Center Therapy and Sports Horizon Rehab p 801.766.0103 3401 N Ctr St Medicine 11 E 200 N Ste 200 1325 S 800 E Ste 101 Averett, Darren PT Lehi UT. 84043 Ste 215 Orem UT. 84057 Revere Health p 385.309.1951 Orem UT. 84097 p 801.374.1706 555 W 2000 N p 801.373.1053 Salem UT. 84653 Boulter, Tyler C DPT Gunnell, Jamie DPT p 801.429.0610 Saratoga Physical Therapy Carter, Reed W DPT Dry Creek Physical Therapy and Sports Medicine FYZICAL Spine Orthopedic & Wellness Ayala, Lauren N DPT 18 W Sergeant Ct Dr Sports Therapy and Balance 3000 N Triumph Blvd University of Utah Health Ste 101 Center Ste 310 151 S University Ave Saratoga Springs UT. 84045 3303 N University Ave Lehi UT. 84043 Ste 1610 p 801.766.0103 Provo UT. 84604 p 801.766.4244 Provo UT. 84601 p 801.373.7438 p 801.587.2255 Brinkerhoff, Jace DPT Haws, Eric A DPT Physical and Sports Christensen, Scott D DPT Human Performance Hospital Affiliation Therapy Services RX Rehab Institute - University of Utah Hospital 15 S 1000 E 5455 W 11000 N 1184 E 80 N Ste 25 Ste 107 American Fork UT. 84003 Back@Work Physical Therapy Payson UT. 84651 American Fork UT. 84003 p 801.756.7777 280 River Park Dr p 801.465.5610 p 385.498.3757 Ste 310 Hill, Von O MPT Provo UT. 84604 Brown, Justin G DPT Colyar, Casey J DPT Peak Physical Therapy and p 385.401.5010 Bushnell Physical Therapy Beyond Limits Physical Sports Medicine 524 W 300 N Therapy 77 S 400 W Bagley, Douglas K PT Ste 201 3943 E Pony Express Pkwy Spanish Fork UT. 84660 Revere Health Provo UT. 84601 Ste 220 p 801.798.1626 1055 N 500 W p 801.370.9981 Eagle Mountain UT. 84005 Ste 122 & 207 p 801.789.7333 Hobbs, Matthew J DPT Provo UT. 84604 Brown, Kimberli L DPT Registered Physical p 801.373.7350 Beyond Limits Physical Therapists Therapy 649 N Redwood Rd 3943 E Pony Express Pkwy Ste 115 Ste 220 Saratoga Springs UT. 84045 Eagle Mountain UT. 84005 p 801.302.1434 p 801.789.7333 542 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Horizon Rehab Jones, Bradley PT Dry Creek Physical Therapy Orrock, Steven J MPT 11 E 200 N Alpine Pain Solutions of & Wellness Professional Physical Ste 101 Utah 564 W 700 S Bldg B Therapy and Sports Orem UT. 84057 3051 W Maple Loop Dr Pleasant Grove UT. 84062 Medicine p 801.374.1706 Ste 125 p 801.766.2088 1325 S 800 E Lehi UT. 84043 Ste 215 Horrocks, Bradley D MPT p 801.766.6055 McKell, John MPT Orem UT. 84097 Mountain Land McKell Therapy Group PC p 801.373.1053 Rehabilitation Inc Knudsen, Howard A DPT 504 E 770 N 416 N State Rd 198 Howard A. Knudsen, PT, PC Orem UT. 84097 680 E Main St Salem UT. 84653 3000 N University Ave p 801.224.2177 Ste 101 p 801.423.8600 Ste 100 Lehi UT. 84043 Provo UT. 84604 Mendenhall, Wendell B MPT p 801.768.2723 94 W Main p 801.310.0851 Professional Physical Ste 1 Therapy and Sports Peterson, Mark H DPT Santaquin UT. 84655 Leavitt, Lisa M PT Medicine FYZICAL Spine Orthopedic p 801.754.5700 Dry Creek Physical Therapy 155 W Canyon Crest Rd Sports Therapy and Balance and Wellness Ste 100 Center Howe, Kara DPT 3300 N Running Creek Way Alpine UT. 84004 3303 N University Ave Dry Creek Physical Therapy Bldg B, p 801.756.7061 Provo UT. 84604 and Wellness Ste 150 p 801.373.7438 3300 N Running Creek Way Lehi UT. 84043 680 E Main St Bldg B p 801.766.4244 Ste 101 FYZICAL Spine Orthopedic Ste 150 Lehi UT. 84043 Sports Therapy & Balance Lehi UT. 84043 564 W 700 S Bldg B p 801.768.2723 Center p 801.766.4244 Pleasant Grove UT. 84062 360 S State St p 801.766.2088 Metz, Samuel T DPT Ste C110 Hudson, Farrah L PT Mountain Land Orem UT. 84058 Dry Creek Physical Therapy Lillywhite, Daniel R DPT Rehabilitation Inc p 801.850.9146 & Wellness Bushnell Physical Therapy 416 N State Rd 198 3000 N Triumph Blvd 524 W 300 N Salem UT. 84653 Pierce, Jonathan DPT Ste 310 Ste 201 p 801.423.8600 Registered Physical Lehi UT. 84043 Provo UT. 84601 Therapists p 801.766.4244 p 801.370.9981 Mitchell, Andrew K DPT 649 N Redwood Rd Mountain Land Ste 115 Hunt, Henry D DPT Littledike, Jason S MPT Rehabilitation Inc Saratoga Springs UT. 84045 Synergy Physical Therapy Peak Physical Therapy and 94 W Main p 801.302.1434 205 N Main St Sports Medicine Ste 1 Spanish Fork UT. 84660 77 S 400 W Santaquin UT. 84655 Redford, Breanna L DPT p 801.436.3110 Spanish Fork UT. 84660 p 801.754.5700 Beyond Limits Physical p 801.798.1626 Therapy Jacobsen, Jonathan V MPT Moore, Alex S PT 3943 E Pony Express Pkwy Professional Physical Mangum, Brad A PT Revere Health Ste 220 Therapy and Sports Revere Health 555 W 2000 N Eagle Mountain UT. 84005 Medicine 1055 N 500 W Salem UT. 84653 p 801.789.7333 680 E Main St Ste 207 p 385.203.1313 Ste 101 Provo UT. 84604 Robinson, Tyler B DPT Lehi UT. 84043 p 801.375.4263 Muncey, Kevin R PT FYZICAL Spine Orthopedic p 801.768.2723 Dry Creek Physical Therapy Sports Therapy And Balance 555 W SR 164 N & Wellness Center Jarrett, Matthew T DPT Salem UT. 84653 564 W 700 S Bldg B 3303 N University Ave Dry Creek Physical Therapy p 801.812.5400 Pleasant Grove UT. 84062 Provo UT. 84604 & Wellness p 801.766.2088 p 801.373.7438 3000 N Triumph Blvd McFarlane, Mallory L DPT Ste 310 Dry Creek Physical Therapy Natter, Sharla I DPT FYZICAL Spine Orthopedic Lehi UT. 84043 and Wellness Human Performance Sports Therapy & Balance p 801.766.4244 3300 N Running Creek Way Institute PC Center Bldg B 1184 E 80 N 360 S State St Jensen, Benjamin J DPT Ste 150 American Fork UT. 84003 Ste C110 Dry Creek Physical Therapy Lehi UT. 84043 p 801.756.7777 Orem UT. 84058 & Wellness p 801.766.4244 p 801.850.9146 3000 N Triumph Blvd Nielson, Riley T DPT Ste 310 FYZICAL Spine Orthopedic Lehi UT. 84043 Sports Therapy and Balance p 801.766.4244 Center 3303 N University Ave Provo UT. 84604 p 801.373.7438 543 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Rogers, Melody DPT Snow, Zachery T DPT Thorpe, Greg R MPT Jensen, Mark H MD Dry Creek Physical Therapy Orem Sports Medicine Physical and Sports Utah Surgical Associates & Wellness Center LLC Therapy Services 1248 E 90 N 3000 N Triumph Blvd 252 N State St 380 E 400 S Ste 102 Ste 310 Orem UT. 84057 Springville UT. 84663 American Fork UT. 84003 Lehi UT. 84043 p 801.226.0599 p 801.489.5669 p 801.756.9132 p 801.766.4244 Street, Katharine OT Wilson, Orion C DPT 1248 E 90 N Romanowska, Katarzyna University of Utah Health Bushnell Physical Therapy Ste 103 DPT 151 S University Ave 524 W 300 N American Fork UT. 84003 Beyond Limits Physical Ste 1610 Ste 201 p 801.756.9132 Therapy Provo UT. 84601 Provo UT. 84601 3943 E Pony Express Pkwy p 801.587.2255 p 801.370.9981 Hospital Affiliation Ste 220 - Timpanogos Regional Hospital Eagle Mountain UT. 84005 Sudweeks, Matthew P DPT Wright, Kirk L PT - Mountain View Hospital p 801.789.7333 Beyond Limits Physical Premier Family Medical (UT) Therapy 1159 E 200 N Sagers, Paul PT 3943 E Pony Express Pkwy Ste 100 Johns, Dana N MD Revere Health Ste 220 American Fork UT. 84003 University of Utah Health 1055 N 500 W Eagle Mountain UT. 84005 p 801.642.2890 1034 N 500 W Ste 122 p 801.789.7333 Provo UT. 84604 Provo UT. 84604 275 W 200 N p 801.662.1700 p 801.429.0610 Sumison, Jordan R DPT Ste 100 Physical and Sports Lindon UT. 84042 1157 N 300 W Horizon Rehab Therapy Services p 801.769.2642 Provo UT. 84604 11 E 200 N 380 E 400 S p 801.662.1700 Ste 101 Springville UT. 84663 Plastic Surgery Orem UT. 84057 p 801.489.5669 Bishop, Jon B MD Hospital Affiliation p 801.374.1706 700 W 800 N - University of Utah Hospital Sumsion, John R MSPT Ste 442 Saunders, Casey R DPT Human Performance Orem UT. 84057 Mecham, Elise MD Orem Sports Medicine Institute p 801.802.0120 Utah Surgical Associates Center 1184 E 80 N 1000 E 15 S 252 N State St American Fork UT. 84003 Hospital Affiliation Ste 350 Orem UT. 84057 p 801.756.7777 - Timpanogos Regional Hospital Payson UT. 84651 p 801.226.0599 p 801.465.5602 Sumsion, William MPT Deramo, Paul J MD Schroeder, Gregory P DPT Physical and Sports Utah Surgical Associates 1248 E 90 N Back@Work Physical Therapy Therapy Services 3000 N Triumph Blvd Ste 102 280 River Park Dr 684 W 800 N Ste 250 American Fork UT. 84003 Ste 310 Ste 110 Lehi UT. 84043 p 801.756.9132 Provo UT. 84604 Orem UT. 84057 p 801.852.9480 p 385.401.5010 p 801.224.2250 Hospital Affiliation 3550 N University Ave - Utah Valley Hospital Schultz, Craig A MSPT Taylor, Kimball DPT Ste 250 - Timpanogos Regional Hospital Physical and Sports FYZICAL Spine Orthopedic Provo UT. 84604 Therapy Services Sports Therapy and Balance p 801.374.9625 3000 N Triumph Blvd 684 W 800 N Center Ste 250 Ste 110 3303 N University Ave Griner, Devan MD Lehi UT. 84043 Orem UT. 84057 Provo UT. 84604 Peak Plastic Surgery p 801.852.9480 p 801.224.2250 p 801.373.7438 1055 N 300 W Ste 301 3550 N University Ave Scott, Matthew A DPT FYZICAL Spine Orthopedic Provo UT. 84604 Ste 250 Elevate Sports Medicine Sports Therapy & Balance p 801.702.9191 Provo UT. 84604 147 W 400 N Center p 801.374.9625 Orem UT. 84057 360 S State St Guilfoyle, Gregg MD p 801.221.9060 Ste C110 Peak Plastic Surgery Pledger, Charles MD Orem UT. 84058 1055 N 300 W Charles V Pledger MD Snow, Robert M DPT p 801.850.9146 Ste 301 3650 N University Ave Synergy Physical Therapy Provo UT. 84604 Ste 200 205 N Main St Taylor, Rogan L PT p 801.702.9191 Provo UT. 84604 Spanish Fork UT. 84660 FYZICAL Spine Orthopedic p 801.373.4300 p 801.436.3110 Sports Therapy and Balance Center 3303 N University Ave Provo UT. 84604 p 801.373.7438

544 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Sanderson, Mark C MD Clegg, Jared T DPM Jaramillo, David H DPM McPhie, Jared D DPM Revere Health Utah Podiatry Group PC Precision Foot and Ankle Utah Podiatry Group PC 1184 E 80 N 1973 N State St Specialists 1973 N State St American Fork UT. 84003 Provo UT. 84604 3355 N University Ave Provo UT. 84604 p 801.763.3885 p 801.373.2499 Ste 175 p 801.373.2499 Provo UT. 84604 Hospital Affiliation 3435 E Pony Express Pkwy p 801.377.5649 3435 E Pony Express Pkwy - Timpanogos Regional Hospital Ste 140 Ste 140 Eagle Mountain UT. 84005 Hospital Affiliation Eagle Mountain UT. 84005 Podiatry p 801.692.3868 - Timpanogos Regional Hospital p 801.692.3868 Beck, Thomas A DPM Central Utah Foot Clinic Hospital Affiliation Jaramillo, Todd MD Hospital Affiliation 150 W 800 N - Central Valley Medical Precision Foot and Ankle - St Marks Hospital Provo UT. 84601 Center Specialists - Evanston Regional Hospital p 801.375.5353 3355 N University Ave - Timpanogos Regional Hospital Dicks, Adam DPM Ste 175 Berry, Levi J DPM Ellsworth Foot and Ankle Provo UT. 84604 Nelson, Michael L DPM Canyon Foot and Ankle Clinic p 801.377.5649 65 W 200 N 478 S Main St 777 N 500 W Ste 1 Spanish Fork UT. 84660 Ste 103 Ellsworth Foot and Ankle Spanish Fork UT. 84660 p 801.609.3477 Provo UT. 84601 Clinic p 801.794.3856 p 801.253.6886 777 N 500 W Hospital Affiliation Ste 103 Hospital Affiliation - Mountain View Hospital Hospital Affiliation Provo UT. 84601 - Mountain View Hospital (UT) - Castleview Hospital p 801.253.6886 (UT) - Timpanogos Regional Hospital - Timpanogos Regional Hospital Garr, Randy DPM Jones, Richard L DPM Burnham, Brant M DPM Garr Foot and Ankle Steward Orthopedic & Ollerton, Matthew G DPM Brant Matthew Burnham DPM 1355 N University Ave Sports Medicine Foot and Ankle Clinic of 828 S 1040 W Provo UT. 84604 3000 N Triumph Blvd Utah Payson UT. 84651 p 801.374.3010 Lehi UT. 84043 5 E 400 N p 801.980.9444 p 385.345.3000 Springville UT. 84663 336 W 100 S p 801.491.3668 Hospital Affiliation Spanish Fork UT. 84660 Hospital Affiliation - Mountain View Hospital p 801.472.8544 - Jordan Valley Medical Hospital Affiliation (UT) Center - Timpanogos Regional Hospital Hospital Affiliation - Mountain View Hospital Christiansen, Wade A DPM - Timpanogos Regional Hospital Kitterman, Ryan T DPM (UT) Garr Foot and Ankle - Mountain Point Medical Utah Podiatry Group PC 1355 N University Ave Center 3435 E Pony Express Pkwy Patty, Daniel R DPM Ste 125 Ste 140 Foot and Ankle Clinic of Provo UT. 84604 Gibson, Brandt R DPM Eagle Mountain UT. 84005 Utah p 801.374.3010 36 N 1100 E p 801.692.3868 157 N 400 W Ste B Ste B7 Arches Foot and Ankle American Fork UT. 84003 Hospital Affiliation Orem UT. 84057 Clinic p 801.756.0765 - St Marks Hospital p 801.226.2421 179 N 1200 E - Salt Lake Regional Medical Ste 103 Hospital Affiliation Center Hospital Affiliation Lehi UT. 84043 - Timpanogos Regional Hospital - Timpanogos Regional Hospital p 801.766.9947 McKell, Scott R DPM Hoyal, James I DPM Foot and Ankle Clinic of Phillips, Stanley J DPM Hospital Affiliation 1798 N State St Utah Foot and Ankle Clinic of - Timpanogos Regional Hospital Orem UT. 84057 157 N 400 W Utah p 801.224.6464 Ste B7 1184 E 80 N Clark, Scott A DPM Orem UT. 84057 American Fork UT. 84003 Utah Podiatry Group PC Hospital Affiliation p 801.765.1718 p 801.763.3885 3435 E Pony Express Pkwy - Timpanogos Regional Hospital Ste 140 Hospital Affiliation 680 E Main St Eagle Mountain UT. 84005 Humpherys, Scott B DPM - Timpanogos Regional Hospital Ste 200 p 801.692.3868 1355 N University Ave - Mountain View Hospital Lehi UT. 84043 Provo UT. 84604 (UT) p 801.766.0606 Hospital Affiliation p 801.225.3095 - Salt Lake Regional Medical Hospital Affiliation Center - Timpanogos Regional Hospital

545 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Riley, Jesse E DPM Royall, Steven P DPM Southerland Jr, Charles C Bunn II, William E DO Summit Foot and Ankle Summit Foot and Ankle DPM Intercare LLC 41 N 400 W 3000 N Triumph Blvd Utah Podiatry Group PC 1145 S 800 E Ste A Lehi UT. 84043 1973 N State St Ste 111 Payson UT. 84651 p 801.784.1111 Provo UT. 84604 Orem UT. 84097 p 801.218.3338 p 801.373.2499 p 801.704.5027 Hospital Affiliation Rogers Foot and Ankle - Salt Lake Regional Medical Tronstein, Elizabeth DPM William Bunn DO Institute Center Utah Podiatry Group PC 1750 N Wymount Terrace Dr 1248 E 90 N 3435 E Pony Express Pkwy Provo UT. 84604 Ste 101 Savage, David T DPM Ste 140 p 801.442.2773 American Fork UT. 84003 Aspen Foot and Ankle Eagle Mountain UT. 84005 p 801.756.4200 1120 E 100 N p 801.692.3868 Intercare LLC Ste 2 2975 W Executive Pkwy 1305 N Commerce Dr Payson UT. 84651 Utah Podiatric Physicians Ste 189 Ste 120 p 801.465.1345 and Surgeons Group Lehi UT. 84043 Saratoga Springs UT. 84045 5455 W 11000 N p 801.704.5027 p 801.756.4200 875 E 100 N Ste 203 Ste 7 American Fork UT. 84003 Hospital Affiliation Rogers, Mark F DPM Payson UT. 84651 p 801.756.1800 - Utah Valley Hospital Rogers Foot and Ankle p 801.465.1345 - Primary Childrens Hospital Institute Utah Podiatry Group PC 1248 E 90 N Hospital Affiliation 1973 N State St Cross, Hannah LCSW Ste 101 - Mountain View Hospital Provo UT. 84604 Cedar Psychiatry American Fork UT. 84003 (UT) p 801.373.2499 672 W 400 S p 801.756.4200 - Gunnison Valley Hospital Ste 201 3435 E Pony Express Pkwy Springville UT. 84663 1305 N Commerce Dr Seegmiller, David C DPM Ste 140 p 801.369.8989 Ste 120 Utah Podiatry Group PC Eagle Mountain UT. 84005 Saratoga Springs UT. 84045 3435 E Pony Express Pkwy p 801.692.3868 Faust, Barbara NP p 801.756.4200 Ste 140 University of Utah Health Eagle Mountain UT. 84005 700 W 800 N 151 S University Ave Hospital Affiliation p 801.692.3868 Ste 330 Ste 1610 - Timpanogos Regional Hospital Orem UT. 84057 Provo UT. 84601 - Mountain View Hospital Hospital Affiliation p 801.426.3686 p 801.587.2255 (UT) - St Marks Hospital - Jordan Valley Medical Whiting, David T DPM Freeman, Brenner L MD Rogers, Scott DPM Center Wasatch Foot And Ankle University of Utah Health Rogers Foot and Ankle - Salt Lake Regional Medical Specialists 145 W University Pkwy Institute Center 780 W 800 N Orem UT. 84058 1248 E 90 N Ste 330 p 801.581.7951 Ste 101 Seegmiller, Richard G DPM Orem UT. 84057 American Fork UT. 84003 Utah Podiatry Group PC p 801.426.3686 Hospital Affiliation p 801.756.4200 3435 E Pony Express Pkwy - University of Utah Hospital Ste 140 Psychiatry 1305 N Commerce Dr Eagle Mountain UT. 84005 Andersen, Jason L DO Gibbs, Paula K MD Ste 120 p 801.692.3868 Silver Creek Psychiatry University of Utah Health Saratoga Springs UT. 84045 1480 E 820 N 145 W University Pkwy p 801.756.4200 Hospital Affiliation Orem UT. 84097 Orem UT. 84058 - Davis Hospital p 801.919.5197 p 801.581.7951 Hospital Affiliation - Lakeview Hospital - Timpanogos Regional Hospital - Salt Lake Regional Medical Barusch, Nathaniel MD Hospital Affiliation Center Cedar Psychiatry - University of Utah Hospital Rogers, Thomas G DPM 1788 N State St Central Utah Foot Clinic Shelton, Scott S DPM Orem UT. 84663 Harrop, Elizabeth A APRN 1248 E 90 N Alpine Foot and Ankle p 801.369.8989 Ascendant Behavioral Ste 101 5455 W 11000 N Health American Fork UT. 84003 Ste 203 672 W 400 S 3051 W Maple Loop Dr p 801.756.4200 American Fork UT. 84003 Ste 201 Ste 210 p 801.756.1800 Springville UT. 84663 Lehi UT. 84043 150 W 800 N p 801.369.8989 p 801.872.5516 Provo UT. 84601 Hospital Affiliation p 801.375.5353 - Lone Peak Hospital Hospital Affiliation - Mountain View Hospital Hospital Affiliation (UT) - Timpanogos Regional Hospital - Utah Valley Hospital - Mountain View Hospital (UT) - Salt Lake Regional Medical Center 546 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Hooton, Josh T APRN 285 N 1250 E 3231 N 1120 E 81 N Ctr St Silver Creek Psychiatry Payson UT. 84651 Lehi UT. 84043 American Fork UT. 84003 1480 E 820 N p 801.852.3805 p 801.492.1999 p 801.847.7272 Orem UT. 84097 p 801.919.5197 578 E 300 S 848 N 980 W 826 N 100 E American Fork UT. 84003 Orem UT. 84057 Ste 2-B Life Tree p 801.763.5010 p 801.374.1999 Spanish Fork UT. 84660 179 N 1200 E p 801.794.2350 Ste 104 750 N Freedom Blvd Hospital Affiliation Lehi UT. 84043 Provo UT. 84601 - Utah Valley Hospital Anderson, Victoria E PhD p 801.501.6073 p 801.373.4760 Alpine Counseling Center Thatcher, Benjamin T DO 475 W 50 N 251 W SR 198 Robison, Reid J MD Valley Behavioral Health American Fork UT. 84003 Ste 3 Cedar Psychiatry 1875 S State St p 801.756.3664 Salem UT. 84653 1788 N State St Ste 100 p 801.501.6665 Orem UT. 84663 Orem UT. 84097 Binks, Paul G PhD p 801.369.8989 p 888.949.4864 Ascendant Behavioral Johnston, Mark MD Health Ascendant Behavioral 672 W 400 S 751 E 700 S 3051 W Maple Loop Dr Health Ste 201 Ste 102 Ste 210 3051 W Maple Loop Dr Springville UT. 84663 American Fork UT. 84003 Lehi UT. 84043 Ste 210 p 801.369.8989 p 888.949.4864 p 801.502.3913 Lehi UT. 84043 p 801.872.5516 Hospital Affiliation Thayer, Stephen PhD Cannon, Jennifer A PhD - Mountain View Hospital Cedar Psychiatry Child, Adolescent, and Manov, Ludmil K MD (UT) 672 W 400 S Adult Treatment 21 N 49 W - Utah Valley Hospital Ste 201 Specialists American Fork UT. 84043 Springville UT. 84663 796 Pacific Dr p 801.642.2396 Simpson, Julia B PhD p 801.369.8989 Ste B Alpine Pediatrics American Fork UT. 84003 Marcum, James M MD 1912 W 930 N Ward, Cori APRN p 801.756.1626 Cedar Psychiatry Pleasant Grove UT. 84062 Utah Behavior Services 1788 N State St p 801.492.1999 216 E Main St Cloyd, James H PhD Orem UT. 84663 Ste 4 Nexus Pain Care p 801.369.8989 3000 N Triumph Blvd Lehi UT. 84043 3585 N University Ave Ste 240 p 801.255.5131 Ste 150 672 W 400 S Lehi UT. 84043 Provo UT. 84604 Ste 201 p 801.229.1000 Weitzal, Robert A MD p 801.356.6100 Springville UT. 84663 Ascendant Behavioral p 801.369.8989 3231 N 1120 E Health Creekpaum, Stephanie M Lehi UT. 84043 3051 W Maple Loop Dr PSYD Olsen, Lisa J APRN p 801.768.2800 Ste 210 Kids On The Move Alliance Behavioral Lehi UT. 84043 475 W 260 N Psychiatry 77 E Commerce Dr p 801.502.3913 Orem UT. 84057 361 E 1200 S Saratoga Springs UT. 84045 p 801.221.9930 Ste 201 p 801.922.9222 Yau, Joseph K MD Orem UT. 84058 Ascendant Behavioral Cunningham, Sean D PhD p 801.224.3014 848 N 980 W Health University of Utah Health Orem UT. 84057 3051 W Maple Loop Dr 151 S University Ave Paulson, David L MD p 801.374.1999 Ste 210 Ste 1610 Alliance Behavioral Lehi UT. 84043 Provo UT. 84601 Psychiatry Swenson, Matthew J MD p 801.872.5516 p 801.587.2255 361 E 1200 S Alpine Pediatrics Ste 201 1238 N Commerce Dr Hospital Affiliation Hospital Affiliation Orem UT. 84058 Saratoga Springs UT. 84045 - University of Utah Hospital - University of Utah Hospital p 801.224.3014 p 801.922.9222 Psychology Edgington, Carl PhD Peterson, Clint W APRN 1912 W 930 N Addiction and ABS Kids Wasatch Mental Health Pleasant Grove UT. 84062 Psychological Services 1140 W 1130 S Bldg B 1165 E 300 N p 801.492.1999 224 N Orem Blvd Orem UT. 84058 Provo UT. 84606 Orem UT. 84057 p 801.935.4946 p 801.377.1213 3000 N Triumph Blvd p 801.222.0603 Ste 240 Lehi UT. 84043 p 801.229.1000

547 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Gentry, Steven M PhD 3000 N Triumph Blvd 280 W River Park Dr Stewart, Mitzy APRN Psychological Assessment & Ste 240 Ste 200 Ascendant Behavioral Treatment Specialists Lehi UT. 84043 Provo UT. 84604 Health 814 E Bamberger Dr p 801.229.1000 p 801.223.4860 3051 W Maple Loop Dr Ste B Ste 210 American Fork UT. 84003 3231 N 1120 E Petersen, Jodi LCSW Lehi UT. 84043 p 801.772.0202 Lehi UT. 84043 Ascendant Behavioral p 801.502.3913 p 801.768.2800 Health Goldman, Sarah PhD 3051 W Maple Loop Dr Stout, Kelly L PhD Summit Community 848 N 980 W Ste 210 University of Utah Health Counseling Orem UT. 84057 Lehi UT. 84043 151 S University Ave 359 E 1200 S p 801.374.1999 p 801.872.5516 Ste 1610 Orem UT. 84058 Provo UT. 84601 p 801.266.2485 Malouf, John PhD Acadian Counseling p 801.587.2255 Valley Behavioral Health Services Haderlie, Michael PhD 1875 S State St 796 Pacific Dr Hospital Affiliation Giles, Haderlie & Ste 1000 Ste A - University of Utah Hospital Associates Orem UT. 84097 American Fork UT. 84003 233 S Pleasant Grove Blvd p 888.949.4864 p 801.225.6246 Tate, David F PhD Ste 203 David F Tate PhD Pleasant Grove UT. 84062 751 E 700 S Putnam, Emily PhD 1055 N 300 W p 801.785.4622 Ste 102 Healings Steps Counseling Ste 410 American Fork UT. 84003 111 E Main St Provo UT. 84604 330 E 400 S p 888.949.4864 Ste L4 p 801.616.3675 Ste 3 Lehi UT. 84043 Springville UT. 84663 Hospital Affiliation p 801.980.3676 Taylor, Patricia E PhD p 801.491.6394 - University of Utah Hospital Child, Adolescent, and Richards, R L PhD Adult Treatment Mountain Ridge Behavioral Miller, Kierea LMFT 1432 E 850 S Specialists Health Center Acadian Counseling Provo UT. 84606 796 Pacific Dr 704 S 1600 W Services p 801.371.8784 Ste B Mapleton UT. 84664 796 Pacific Dr American Fork UT. 84003 p 801.491.6394 Ste A Sewell, Nathan PhD p 801.756.1626 American Fork UT. 84003 Preferred Family Clinic Henderson, Alicia PhD p 801.225.6246 1355 N University Ave Thorn, Kirk B PhD Preferred Family Clinic Provo UT. 84604 Willow Creek Psychological 1355 N University Ave Morrill, Jennifer A PhD p 801.221.0223 Service Inc Ste 200 Utah Psychological 376 E 400 S Provo UT. 84604 Associates Shumway, Brett PSYD Springville UT. 84663 p 801.221.0223 3549 N University Ave Utah Behavior Services p 385.269.0333 Ste 200 216 E Main St Hyde, Randall F PhD Provo UT. 84604 Ste 4 Veas-Wall, Rodrigo PhD Preferred Family Clinic p 801.377.2014 Lehi UT. 84043 Preferred Family Clinic 1355 N University Ave p 801.255.5131 1355 N University Ave Ste 200 Moulton, Emily Phd Ste 200 Provo UT. 84604 University of Utah Health Siebert, Tatum LCPC Provo UT. 84604 p 801.221.0223 151 S University Ave Utah Behavior Services p 801.221.0223 Ste 1610 216 E Main St Jackson, Aaron P PhD Provo UT. 84601 Ste 4 Villalobos, Michele E Phd 14 N Main St p 801.587.2255 Lehi UT. 84043 University of Utah Health Springville UT. 84663 p 801.255.5131 151 S University Ave p 801.422.8031 Hospital Affiliation Ste 1610 - University of Utah Hospital Stevens, Ashley L PhD Provo UT. 84601 Livingstone, John D PhD University of Utah Health p 801.587.2255 Alpine Pediatrics Nielsen, Douglas L PhD 151 S University Ave 1238 N Commerce Dr Alpine Counseling Center Ste 1610 Hospital Affiliation Saratoga Springs UT. 84045 475 W 50 N Provo UT. 84601 - University of Utah Hospital p 801.922.9222 American Fork UT. 84003 p 801.587.2255 p 801.756.3664 Young, Ellie L PhD 1912 W 930 N Hospital Affiliation 14 N Main St Pleasant Grove UT. 84062 Pennington, Randal S PSYD - University of Utah Hospital Springville UT. 84663 p 801.492.1999 Spinal Interventions p 801.472.6294 230 N 1200 E Ste 201 Lehi UT. 84043 p 801.852.9555

548 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Pulmonology Hayes, John K MD 3000 N Triumph Blvd Revere Health Provo Al Shuquirat, Tala at MD Gamma West Cancer Services Ste 100 Imaging Revere Health 674 W 800 N Lehi UT. 84043 1055 N 500 W 1000 E 100 N Ste B10 p 385.345.3155 Ste 112 Payson UT. 84651 Orem UT. 84057 Provo UT. 84604 p 801.465.4813 p 801.852.0210 555 W 2000 N p 801.812.4624 Salem UT. 84653 1055 N 500 W Hospital Affiliation p 801.812.4624 Revere Health American Ste 205/212 - St Marks Hospital Fork Imaging Provo UT. 84604 - Salt Lake Regional Medical Gibby, Wendell A MD 1175 E 50 S p 801.357.7350 Center Blue Rock Neurological Ste 141 - Davis Hospital Center American Fork UT. 84003 Advanced Sleep Solutions - Timpanogos Regional Hospital 3152 N University Ave p 801.812.4624 1806 N 1120 W Ste 220 Provo UT. 84604 McAllister, Bruce C MD Provo UT. 84604 Revere Health Radiology p 801.418.9167 Revere Health p 801.229.1014 852 N 500 W 1055 N 500 W Provo UT. 84604 Hospital Affiliation Ste 102 Gledhill, Kent M MD p 801.812.4624 - Mountain View Hospital Provo UT. 84604 Revere Health (UT) p 801.374.2367 3000 N Triumph Blvd Riverwoods Advanced - Timpanogos Regional Hospital Lehi UT. 84043 Diagnostic Imaging Center Hospital Affiliation p 801.429.8000 280 W River Park Dr Nelson, Ashley D MD - Timpanogos Regional Hospital Ste 100 Heart & Lung Institute Of - Mountain View Hospital Hospital Affiliation Provo UT. 84604 Utah - Mountain Point (UT) - Timpanogos Regional Hospital p 801.229.1009 Pulmonary - Mountain View Hospital 3000 N Triumph Blvd Reilly, Mark W MD (UT) 3152 N University Ave Lehi UT. 84043 Gamma West Cancer Services Ste 100 p 801.753.4701 674 W 800 N Layton, Brent T MD Provo UT. 84604 Ste B10 Revere Health p 801.229.1009 Hospital Affiliation Orem UT. 84057 1055 N 500 W - Mountain Point Medical p 801.852.0210 Ste 112 Smith, Greg B MD Center Provo UT. 84604 Revere Health - Jordan Valley Medical Hospital Affiliation p 801.812.4624 1055 N 500 W Center - St Marks Hospital Ste 112 - Salt Lake Regional Medical 1175 E 50 S Provo UT. 84604 Radiation Oncology Center Ste 211 p 801.354.8215 *Grant, Jonathan D MD - Jordan Valley Medical American Fork UT. 84003 American Fork Radiation Center p 801.418.0870 3000 N Triumph Blvd Oncology - Davis Hospital Lehi UT. 84043 170 N 1100 E 3000 N Triumph Blvd p 801.429.8000 American Fork UT. 84003 Richards, Ray S MD Lehi UT. 84043 p 801.357.2480 Gamma West Cancer Services p 801.429.8000 Hospital Affiliation 674 W 800 N - Mountain View Hospital Hansen, Roger S MD Ste B10 Hospital Affiliation (UT) Gamma West Cancer Services Orem UT. 84057 - Mountain View Hospital - Timpanogos Regional Hospital 674 W 800 N p 801.852.0210 (UT) Orem UT. 84057 - Timpanogos Regional Hospital Utah Vascular Center p 801.852.0210 Hospital Affiliation 1055 N 300 W - St George Regional Hospital Patch, Gregory G MD Ste 205 Hospital Affiliation Utah Imaging Associates Provo UT. 84604 - Ogden Regional Medical Radiology 280 River Park Dr p 801.374.9100 Center Christianson, Kimball MD Ste 100 - Davis Hospital Revere Health Provo UT. 84604 Valadez, Scott D MD - Salt Lake Regional Medical 1055 N 500 W p 801.225.4515 Revere Health Center Ste 122 1055 N 500 W - St Marks Hospital Provo UT. 84604 Hospital Affiliation Ste 112 p 801.812.4624 - Lakeview Hospital Provo UT. 84604 Harris, Robert A MD - Brigham City Community p 801.812.4624 Gamma West Cancer Services 1175 E 50 S Hospital 674 W 800 N Ste 141 - Lone Peak Hospital 3000 N Triumph Blvd Ste B10 American Fork UT. 84003 - Ogden Region Medical Lehi UT. 84043 Orem UT. 84057 p 801.492.5996 Center p 801.429.8000 p 801.852.0210 Hospital Affiliation Hospital Affiliation - Mountain View Hospital - Ogden Regional Medical (UT) Center - Timpanogos Regional Hospital - Davis Hospital - St Marks Hospital - Timpanogos Regional Hospital 549 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Wright, Dalton H MD Reproductive Care Center Orem Rehabilitation and Utah Sleep Medicine Center Revere Health 2345 W 450 S Nursing Center 1055 N 300 W 1055 N 500 W Ste 103 575 E 1400 S Ste 402 Ste 112 Pleasant Grove UT. 84062 Orem UT. 84097 Provo UT. 84604 Provo UT. 84604 p 801.492.5959 p 801.225.4741 p 801.357.4858 p 801.354.8215 UUHC Parkway Health Center Central Utah Veterans Home Social Worker 3000 N Triumph Blvd 145 W University Pkwy 1551 N Main St Adams, Kathy LCSW Lehi UT. 84043 Orem UT. 84058 Payson UT. 84651 Ascendant Behavioral p 801.429.8000 p 801.234.8600 p 801.465.5400 Health 3051 W Maple Loop Dr Hospital Affiliation Utah Fertility Center Heritage Care Center Ste 210 - Mountain View Hospital 1446 W Pleasant Grove 350 E 300 N Lehi UT. 84043 (UT) Blvd American Fork UT. 84003 p 801.872.5516 - Timpanogos Regional Hospital Pleasant Grove UT. 84062 p 801.756.5293 p 801.785.5100 Akalis, Jenivee LCSW Reproductive Endocrinology Sleep Disorders Center Healings Steps Counseling Blauer, Keith Residential Treatment Facility Utah Sleep Medicine Center 111 E Main St Reproductive Care Center Provo Canyon School 1055 N 300 W Ste L4 2345 W 450 S 4501 N University Ave Ste 402 Lehi UT. 84043 Ste 103 Provo UT. 84604 Provo UT. 84604 p 801.980.3676 Pleasant Grove UT. 84062 p 801.227.2000 p 801.357.4858 p 801.492.5959 Anderson, Rebecca CSW 763 N 1650 W Sleep Medicine Eagle Mountain Counseling Conway, Deirdre A MD Springville UT. 84663 Martinez-Ferrate, Rodolfo 3726 E Campus Dr Utah Fertility Center p 801.227.2000 MD Ste H 1446 W Pleasant Grove Diabetes Health Management Eagle Mountain UT. 84005 Blvd Rheumatology 255 E 930 S p 801.642.4196 Pleasant Grove UT. 84062 Call, Matthew R DO Orem UT. 84058 p 801.785.5100 Matthew R Call DO p 801.691.0457 Andes, Jared C MSW 771 W 450 S 475 W 260 N Foulk, Russell A MD Springville UT. 84663 Hospital Affiliation Orem UT. 84057 Utah Fertility Center p 801.226.0737 - Jordan Valley Medical p 801.221.9930 1446 W Pleasant Grove Center West Valley Campus Blvd Call, Steven E MD Arballo, Jennifer CSW Pleasant Grove UT. 84062 771 W 450 S Reynolds, Christopher J Utah Behavior Services p 801.785.5100 Springville UT. 84663 MD 216 E Main St p 801.226.0737 Neurological Associates Ste 4 Gurtcheff, Shawn MD 11 N 400 W Lehi UT. 84043 Utah Fertility Center Darley, Michael D MD Payson UT. 84651 p 801.255.5131 1446 W Pleasant Grove Rheumatology Clinic of p 801.763.0901 Blvd Utah Baldwin, Ashleigh E LCSW Pleasant Grove UT. 84062 1055 N 300 W 212 S 1100 E Valley Behavioral Health p 801.785.5100 Ste 303 American Fork UT. 84003 1875 S State St Provo UT. 84604 p 801.763.0901 Ste 100 Kozola Maas, Kristi Ann p 801.852.9600 Orem UT. 84097 MD 3152 N University Ave p 888.949.4864 Reproductive Care Center 3000 N Triumph Blvd Ste 220 2345 W 450 S Ste 260 Provo UT. 84604 Banfill, Amanda LCSW Ste 103 Lehi UT. 84043 p 801.763.0901 Ascendant Behavioral Pleasant Grove UT. 84062 p 801.852.9600 Health p 801.492.5959 498 E 800 N 3051 W Maple Loop Dr Skilled Nursing Facility Ste 3-B Ste 210 Hospital Affiliation Provo Rehabilitation and Orem UT. 84097 Lehi UT. 84043 - Davis Hospital Nursing p 801.763.0901 p 801.872.5516 1001 N 500 W Parker, Jason D DO Provo UT. 84604 Hospital Affiliation Beebe, Jesse R MSW Utah Fertility Center p 801.377.9661 - Lone Peak Hospital Ascendant Behavioral 1446 W Pleasant Grove - Mountain View Hospital Health Blvd Pointe Meadows Health and (UT) 3051 W Maple Loop Dr Pleasant Grove UT. 84062 Rehabilitation - Evanston Regional Hospital Ste 210 p 801.785.5100 2750 N Digital Dr Lehi UT. 84043 Lehi UT. 84043 p 801.502.3913 p 385.374.5600

550 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Belliston, Nancy L LCSW Blaylock, Rachel M LCSW 285 N 1250 E Clegg, Robert LCSW Deseret Counseling Family Support & Treatment Payson UT. 84651 Keystone Family Counseling 1413 S 550 E Center p 801.852.3805 1172 E 100 N Ste 106 1255 N 1200 W Ste 10 Orem UT. 84097 Orem UT. 84057 578 E 300 S Payson UT. 84651 p 801.360.3166 p 801.229.1181 American Fork UT. 84003 p 801.380.9305 p 801.763.5010 Belnap, Lorrie M LCSW Blood, Cybele LCSW 165 W Canyon Crest Rd Valley Behavioral Health Ascendant Behavioral 750 N Freedom Blvd Ste 210 & 240 1875 S State St Health Provo UT. 84601 Alpine UT. 84004 Ste 1000 3051 W Maple Loop Dr p 801.373.4760 p 801.380.9305 Orem UT. 84097 Ste 210 p 888.949.4864 Lehi UT. 84043 Calkins, Chad O LCSW Clement, Kellie M MSW p 801.502.3913 Valley Behavioral Health Ascendant Behavioral 751 E 700 S 1875 S State St Health Ste 102 Bowman, Chelsea LCSW Ste 1000 3051 W Maple Loop Dr American Fork UT. 84003 The Green House for Growth Orem UT. 84097 Ste 210 p 888.949.4864 & Learning p 888.949.4864 Lehi UT. 84043 135 W Center St p 801.502.3913 Bennett, Celeste LCSW Pleasant Grove UT. 84062 751 E 700 S Ascendant Behavioral p 801.785.1169 Ste 102 Coburn, Alison MSW Health American Fork UT. 84003 Utah Behavior Services 3051 W Maple Loop Dr Brandt, Darrin LCSW p 888.949.4864 216 E Main St Ste 210 Ascendant Behavioral Ste 4 Lehi UT. 84043 Health Carter, Mary A LCSW Lehi UT. 84043 p 801.502.3913 3051 W Maple Loop Dr 286 S 600 E p 801.255.5131 Ste 210 Ste C Bennett, Kathleen LCSW Lehi UT. 84043 Provo UT. 84606 Cook, Ann G LCSW Life Stone Counseling p 801.872.5516 p 801.318.8634 University of Utah Health Center 145 W University Pkwy 150 S 400 E Bronson, Barbara J LCSW Childrens Justice Center Orem UT. 84058 American Fork UT. 84003 Discovery Family 315 S 100 E p 801.234.8600 p 801.980.7222 Counseling Provo UT. 84606 244 W 520 N p 801.318.8634 Hospital Affiliation Birch, Kelly LCSW Orem UT. 84057 - University of Utah Hospital Utah Behavior Services p 801.636.7074 Cavin, Christopher LCSW 216 E Main St Valley Behavioral Health Coombs, Amy LCSW Ste 4 Brooks, Denise E LCSW 1875 S State St Alpine Pain Solutions of Lehi UT. 84043 Valley Behavioral Health Ste 1000 Utah p 801.255.5131 1875 S State St Orem UT. 84097 3051 W Maple Loop Dr Ste 1000 p 888.949.4864 Ste 125 Bircher, Del LCSW Orem UT. 84097 Lehi UT. 84043 Acadian Counseling p 888.949.4864 751 E 700 S p 801.766.6055 Services Ste 102 796 Pacific Dr 751 E 700 S American Fork UT. 84003 Cox, Michael LCSW Ste A Ste 102 p 888.949.4864 Veritas Mental Health American Fork UT. 84003 American Fork UT. 84003 825 N 1420 E p 801.642.2491 p 888.949.4864 Cheney, Heidi H LCSW Orem UT. 84097 Ascendant Behavioral p 801.376.7560 Blair, Sarah MSW Bunting, Catherine CSW Health The Green House for Growth Utah Behavior Services 3051 W Maple Loop Dr Crawford, Herta A LCSW & Learning 216 E Main St Ste 210 313 E 1200 S 135 W Center St Ste 4 Lehi UT. 84043 Ste 101 Pleasant Grove UT. 84062 Lehi UT. 84043 p 801.872.5516 Orem UT. 84058 p 801.785.1169 p 801.255.5131 p 801.310.0849 Cho, Jaeyong MSW Blanchard, Maria L LCSW Burr, John LCSW Utah Behavior Services Cumberledge, Frances Jill Sabin Smart LCSW LLC 871 S Orem Blvd 216 E Main St LCSW 315 S 100 E Orem UT. 84058 Ste 4 Ascendant Behavioral Provo UT. 84606 p 801.225.7805 Lehi UT. 84043 Health p 801.358.4140 p 801.255.5131 3051 W Maple Loop Dr Busch, Heidi J LCSW Ste 210 Wasatch Mental Health Lehi UT. 84043 1165 E 300 N p 801.502.3913 Provo UT. 84606 p 801.377.1213

551 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Dahmen, Alexander LCSW Edmonds, Rita LCSW Garza Solis, Karem G LCSW 751 E 700 S Valley Behavioral Health Aspen Therapy Valley Behavioral Health Ste 102 1875 S State St 3707 N Canyon Rd 1875 S State St American Fork UT. 84003 Ste 1000 Ste 8F Ste 1000 p 888.949.4864 Orem UT. 84097 Provo UT. 84604 Orem UT. 84097 p 888.949.4864 p 801.225.3111 p 888.949.4864 Harmon, Jordan LCSW Cedar Psychiatry Summit Community Eldredge, David G LCSW 751 E 700 S 1788 N State St Counseling University of Utah Health Ste 102 Orem UT. 84663 359 E 1200 S 145 W University Pkwy American Fork UT. 84003 p 801.369.8989 Orem UT. 84058 Orem UT. 84058 p 888.949.4864 p 801.266.2485 p 801.234.8600 672 W 400 S George, Margaret LCSW Ste 201 Davis, Sylvia R LCSW Hospital Affiliation Ascendant Behavioral Springville UT. 84663 Sylvia Rios Davis - Primary Childrens Hospital Health p 801.369.8989 Counseling 3051 W Maple Loop Dr 14 N Main St Elkins, Laurie LCSW Ste 210 Hospital Affiliation Springville UT. 84663 Ascendant Behavioral Lehi UT. 84043 - Mountain View Hospital p 801.489.0124 Health p 801.872.5516 (UT) 3051 W Maple Loop Dr - Utah Valley Hospital Debenham, Rachael CSW Ste 210 Gilbert, Natalie LCSW Ascendant Behavioral Lehi UT. 84043 Family Support & Treatment Harns, Jessica CSW Health p 801.872.5516 Center Healings Steps Counseling 3051 W Maple Loop Dr 1255 N 1200 W 111 E Main St Ste 210 Ewanowski, Julia LCSW Orem UT. 84057 Ste L4 Lehi UT. 84043 University of Utah Health p 801.229.1181 Lehi UT. 84043 p 801.872.5516 145 W University Pkwy p 801.980.3676 Orem UT. 84058 Gillespie, Amy LCSW Deily, Jacquiline LCSW p 801.234.8600 Life Stone Counseling Harper, Stuart D LCSW Ascendant Behavioral Center Family Support & Treatment Health Hospital Affiliation 150 S 400 E Center 3051 W Maple Lp Dr - University of Utah Hospital American Fork UT. 84003 1255 N 1200 W Ste 210 p 801.980.7222 Orem UT. 84057 Lehi UT. 84043 Falk, Joshua S LCSW p 801.229.1181 p 801.502.3913 University of Utah Health Gillespie, Darren J LCSW 145 W University Pkwy Eagle Mountain Counseling 315 S 100 E Densley, Logan LCSW Orem UT. 84058 3726 E Campus Dr Provo UT. 84606 Veritas Mental Health p 801.234.8600 Ste H p 801.229.1181 825 N 1420 E Eagle Mountain UT. 84005 Orem UT. 84097 Fannin, Kerry L LCSW p 801.642.4196 Heiner, Hanna M LCSW p 801.367.6544 Envision Physician Veritas Mental Health Services Green, E Guerry LCSW 825 N 1420 E Diamond, Allie D LCSW 1345 W 2600 N The Green House for Growth Orem UT. 84097 Ascendant Behavioral Orem UT. 84057 & Learning p 307.707.5060 Health p 801.225.7971 135 W Center St 3051 W Maple Loop Dr Pleasant Grove UT. 84062 Higgins, Michael P LCSW Ste 210 Francis, Wendy LCSW p 801.785.1169 University of Utah Health Lehi UT. 84043 Ascendant Behavioral 145 W University Pkwy p 801.872.5516 Health Green, Elsebeth Orem UT. 84058 3051 W Maple Loop Dr The Green House for Growth p 801.234.8600 Durrant, Laura LCSW Ste 210 & Learning Ascendant Behavioral Lehi UT. 84043 135 W Center St Hilton, Gail C LCSW Health p 801.502.3913 Pleasant Grove UT. 84062 Valley Behavioral Health 3051 W Maple Loop Dr p 801.785.1169 1875 S State St Ste 210 Frazier, Kenneth D LCSW Ste 1000 Lehi UT. 84043 Acadian Counseling Hale, Jessica LCSW Orem UT. 84097 p 801.872.5516 Services Valley Behavioral Health p 888.949.4864 796 Pacific Dr 1875 S State St Dutson, Devin E LCSW Ste A Ste 1000 Ascendant Behavioral 1404 W State Rd American Fork UT. 84003 Orem UT. 84097 Health Ste 205 p 801.642.2491 p 888.949.4864 3051 W Maple Loop Dr Pleasant Grove UT. 84062 Ste 210 p 307.254.3407 Lehi UT. 84043 p 801.872.5516

552 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Valley Behavioral Health Ascendant Behavioral 751 E 700 S Luna, Janette M LCSW 751 E 700 S Health Ste 102 Utah Behavior Services Ste 102 3051 W Maple Loop Dr American Fork UT. 84003 216 E Main St American Fork UT. 84003 Ste 210 p 888.949.4864 Ste 4 p 888.949.4864 Lehi UT. 84043 Lehi UT. 84043 p 801.502.3913 Lee, Cindy L LCSW p 801.255.5131 Holmes, Alisha MSW Hearthstone Counseling Utah Behavior Services Valley Behavioral Health PLLC Macfarlane, Lindsey A 216 E Main St 751 E 700 S 286 S 600 E LCSW Ste 4 Ste 102 Provo UT. 84606 Valley Behavioral Health Lehi UT. 84043 American Fork UT. 84003 p 801.377.8222 1875 S State St p 801.255.5131 p 888.949.4864 Ste 1000 Lilly, John P LCSW Orem UT. 84097 Hughes, Lisa B LCSW Johnson, Sharon LCSW Sierra Counseling p 888.949.4864 LBH Counseling Valley Behavioral Health Associates 14 N Main St 1875 S State St 286 S 600 E 751 E 700 S Springville UT. 84663 Ste 1000 Ste C Ste 102 p 801.489.0124 Orem UT. 84097 Provo UT. 84606 American Fork UT. 84003 p 888.949.4864 p 801.377.8222 p 888.949.4864 Ingalls, Lisa J LCSW Psychological Assessment & 751 E 700 S Limb, Joseph C LCSW Maciel, Diane G LCSW Treatment Specialists Ste 102 Wasatch Mental Health 265 N Main St 814 E Bamberger Dr American Fork UT. 84003 1165 E 300 N Ste 100 Ste B p 888.949.4864 Provo UT. 84606 Spanish Fork UT. 84660 American Fork UT. 84003 p 801.377.1213 p 801.358.4082 p 801.772.0202 Johnston, Harmony MSW Utah Behavior Services 285 N 1250 E 315 S 100 E Jackson, Amanda LCSW 216 E Main St Payson UT. 84651 Provo UT. 84606 Cedar Psychiatry Ste 4 p 801.852.3805 p 801.358.4140 1788 N State St Lehi UT. 84043 Orem UT. 84663 p 801.255.5131 578 E 300 S Margolis, Amber LCSW p 801.369.8989 American Fork UT. 84003 University of Utah Health Keshavarz, Yasaman LCSW p 801.763.5010 145 W University Pkwy 672 W 400 S University of Utah Health Orem UT. 84058 Ste 201 145 W University Pkwy 750 N Freedom Blvd p 801.234.8600 Springville UT. 84663 Orem UT. 84058 Provo UT. 84601 p 801.369.8989 p 801.234.8600 p 801.373.4760 McFadden, Molly Q LCSW University of Utah Health Jarreau-Wihongi, Lynn A Hospital Affiliation Lindstrom, Shanna LCSW 145 W University Pkwy LCSW - University of Utah Hospital Ascendant Behavioral Orem UT. 84058 Acadian Counseling Health p 801.234.8600 Services Kroes, Dana CSW 3051 W Maple Loop Dr 796 Pacific Dr Healings Steps Counseling Ste 210 McGill, Katie MSW Ste A 111 E Main St Lehi UT. 84043 Utah Behavior Services American Fork UT. 84003 Ste L4 p 801.872.5516 216 E Main St p 801.642.2491 Lehi UT. 84043 Ste 4 p 801.980.3676 Linnell, Randy S LCSW Lehi UT. 84043 Johnson, Angela LCSW Institute for Cognitive p 801.255.5131 Acadian Counseling Lamb, Joseph LCSW Therapy Services University of Utah Health 879 S Orem Blvd Meng, Ashley CSW 796 Pacific Dr 145 W University Pkwy Ste 1 Healings Steps Counseling Ste A Orem UT. 84058 Orem UT. 84058 111 E Main St American Fork UT. 84003 p 801.234.8600 p 801.859.9238 Ste L4 p 801.836.1151 Lehi UT. 84043 Hospital Affiliation Little, Tamara A LCSW p 801.980.3676 Johnson, James G LCSW - University of Utah Hospital Center for Growth & Valley Behavioral Health Healing Merkley, Patricia L LCSW 1875 S State St Lasley, Linda K LCSW 101 E 200 S Ascendant Behavioral Ste 1000 Valley Behavioral Health Springville UT. 84663 Health Orem UT. 84097 1875 S State St p 801.592.0885 3051 W Maple Loop Dr p 888.949.4864 Ste 1000 Ste 210 Orem UT. 84097 Lopez, Marta LCSW Lehi UT. 84043 p 888.949.4864 University of Utah Health p 801.872.5516 145 W University Pkwy Orem UT. 84058 p 801.234.8600

Hospital Affiliation - University of Utah Hospital 553 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Middleton, Susan G LCSW Nielsen, Stephanie MSW 135 W Center St Skousen, Thomas MSW Preferred Family Clinic Utah Behavior Services Pleasant Grove UT. 84062 Utah Behavior Services 1355 N University Ave 216 E Main St p 801.785.1169 216 E Main St Ste 200 Ste 4 Ste 4 Provo UT. 84604 Lehi UT. 84043 Powell, Clark Randy LCSW Lehi UT. 84043 p 801.221.0223 p 801.255.5131 Utah Behavior Services p 801.255.5131 216 E Main St Mitchell, Susan LCSW OBanion, Joy A LCSW Ste 4 Slater, Courtney MSW Ascendant Behavioral Family Support & Treatment Lehi UT. 84043 Utah Behavior Services Health Center p 801.255.5131 216 E Main St 3051 W Maple Loop Dr 1255 N 1200 W Ste 4 Ste 210 Orem UT. 84057 Proctor, Lyndsey D LCSW Lehi UT. 84043 Lehi UT. 84043 p 801.229.1181 Serenity Recovery and p 801.255.5131 p 801.502.3913 Wellness Pabst, Mackenzie MSW 39 Professional Way Smart, Jill S LCSW Moser, Terri L LMFT Kids On The Move Ste 2 265 N Main St Heart of Peace Counseling 475 W 260 N Payson UT. 84651 Ste 100 1441 N 1220 W Orem UT. 84057 p 801.658.0098 Spanish Fork UT. 84660 Orem UT. 84057 p 801.221.9930 p 801.358.4082 p 801.516.1198 Purdy, Tyler LCSW Perez, Erin P LCSW The Green House for Growth 315 S 100 E Mullaney, Edward LCSW Valley Behavioral Health & Learning Provo UT. 84606 University of Utah Health 1875 S State St 135 W Center St p 801.358.4082 145 W University Pkwy Ste 1000 Pleasant Grove UT. 84062 Orem UT. 84058 Orem UT. 84097 p 801.785.1169 Smith, Mary L LCSW p 801.234.8600 p 888.949.4864 Sycamore Counseling Center Ricci, Jeanette M LCSW 900 S State Rd Murray, Kelli A MSW 751 E 700 S Valley Behavioral Health Orem UT. 84097 Utah Valley Family Support Ste 102 1875 S State St p 801.224.3322 1255 N 1200 W American Fork UT. 84003 Ste 1000 Orem UT. 84057 p 888.949.4864 Orem UT. 84097 Stephens, Travis R CSW p 801.229.1181 p 888.949.4864 Valley Behavioral Health Phillips, Allison 1875 S State St Neff, Michal A CSW,SUDC LCSW,BCBA 751 E 700 S Ste 1000 Utah Behavior Services Utah Behavior Services Ste 102 Orem UT. 84097 216 E Main St 216 E Main St American Fork UT. 84003 p 888.949.4864 Ste 4 Ste 4 p 888.949.4864 Lehi UT. 84043 Lehi UT. 84043 751 E 700 S p 801.255.5131 p 801.255.5131 Robinson, Kerri F LCSW Ste 102 Family Support & Treatment American Fork UT. 84003 Neilson, Tamera L LCSW Porschatis, Amber M LCSW Center p 888.949.4864 Veritas Mental Health University of Utah Health 1255 N 1200 W 825 N 1420 E 145 W University Pkwy Orem UT. 84057 Stoddard, Nancy L LCSW Orem UT. 84097 Orem UT. 84058 p 801.229.1181 Nancy L Stoddard, LCSW p 801.505.8745 p 801.234.8600 286 S 600 E Roche, Miriam MSW Ste C Nelson, Heather J LCSW Porter, Jalynn MSW Utah Behavior Services Provo UT. 84606 Heather Nelson, LCSW The Green House for Growth 216 E Main St p 801.859.2194 441 W Main & Learning Ste 4 Ste B 1220 N Main St Lehi UT. 84043 Suarez, Alex LCSW Lehi UT. 84043 Ste 5 p 801.255.5131 Utah Behavior Services p 801.520.3160 Springville UT. 84663 216 E Main St p 801.210.7216 Schmelzer, Alina LCSW Ste 4 Nelson, Michelle M LCSW Ascendant Behavioral Lehi UT. 84043 University of Utah Health 135 W Center St Health p 801.255.5131 145 W University Pkwy Pleasant Grove UT. 84062 3051 W Maple Loop Dr Orem UT. 84058 p 801.785.1169 Ste 210 Sutherland, Debbie A LCSW p 801.234.8600 Lehi UT. 84043 Valley Behavioral Health Porter, Nathan MSW p 801.872.5516 1875 S State St Hospital Affiliation The Green House for Growth Ste 1000 - University of Utah Hospital & Learning Simmons, Stacey LCSW Orem UT. 84097 1220 N Main St The Whole Child Therapy p 888.949.4864 Ste 5 727 S Main St Springville UT. 84663 Spanish Fork UT. 84660 p 801.210.7216 p 801.210.9319

554 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 751 E 700 S Vanderhoff, Laura CSW Wisco, Monica LCSW Mabey, Maren A SLP Ste 102 Healings Steps Counseling Life Stone Counseling Dry Creek Physical Therapy American Fork UT. 84003 111 E Main St Center and Wellness p 888.949.4864 Ste L4 150 S 400 E 3000 N Triumph Blvd Lehi UT. 84043 American Fork UT. 84003 Ste 310 Tellesbo, Sarah M LCSW p 801.980.3676 p 801.980.7222 Lehi UT. 84043 Cedar Psychiatry p 801.766.4244 1788 N State St Vasquez, Jeanette P LCSW Woodard, Jeness L LCSW Orem UT. 84663 Ascendant Behavioral University of Utah Health Mills, Kenna SLP p 801.369.8989 Health 145 W University Pkwy Dry Creek Physical Therapy 3051 W Maple Loop Dr Orem UT. 84058 & Wellness 672 W 400 S Ste 210 p 801.234.8600 3000 N Triumph Blvd Ste 201 Lehi UT. 84043 Ste 310 Springville UT. 84663 p 801.502.3913 Utah Psychological Lehi UT. 84043 p 801.369.8989 Associates p 801.766.2454 Vezie, Linda LCSW 3549 N University Ave Tenney, Joseph T LCSW University of Utah Health Ste 200 Mullins, Amy S SLP Valley Behavioral Health 145 W University Pkwy Provo UT. 84604 Dry Creek Physical Therapy 1875 S State St Orem UT. 84058 p 801.377.2014 and Wellness Ste 1000 p 801.234.8600 3000 N Triumph Blvd Orem UT. 84097 Speech Therapy Lehi UT. 84043 p 888.949.4864 Voigt, Jonathan LCSW Boucher, Kurtt R SLP p 801.766.2454 Valley Behavioral Health Physical and Sports 751 E 700 S 1875 S State St Therapy Services Stone, D Kamaile SLP Ste 102 Ste 100 15 S 1000 E Peak Plastic Surgury American Fork UT. 84003 Orem UT. 84097 Ste 25 1055 N 300 W p 888.949.4864 p 888.949.4864 Payson UT. 84651 Ste 301 p 801.465.5610 Provo UT. 84604 Tingey, Jenise D LCSW 751 E 700 S p 801.702.9191 Valley Behavioral Health Ste 102 684 W 800 N 1875 S State St American Fork UT. 84003 Ste 110 Thomas, Curtis AUD Ste 1000 p 888.949.4864 Orem UT. 84057 Hearing and Balance Orem UT. 84097 p 801.224.2250 Institute p 888.949.4864 Walley, Susan LCSW 1055 N 300 W Utah Psychological DeCosta, Alycen F SLP Ste 211 751 E 700 S Associates The Whole Child Therapy Provo UT. 84604 Ste 102 3549 N University Ave 1570 N Main St p 801.852.9696 American Fork UT. 84003 Ste 200 Spanish Fork UT. 84660 p 888.949.4864 Provo UT. 84604 p 801.210.9319 Peak ENT Associates p 801.377.2014 1055 N 300 W Torres-George, Christian 727 S Main St Ste 401 P LCSW Weaver, Patricia LCSW Spanish Fork UT. 84660 Provo UT. 84604 University of Utah Health Utah Psychological p 801.210.9319 p 801.357.7499 145 W University Pkwy Associates Orem UT. 84058 3549 N University Ave Gummersall, Dawn M SLP Wheeler, Katrina H SLP p 801.234.8600 Ste 200 ABS Kids University of Utah Health Provo UT. 84604 1140 W 1130 S Bldg B 151 S University Ave Hospital Affiliation p 801.377.2014 Orem UT. 84058 Ste 1610 - University of Utah Hospital p 801.935.4171 Provo UT. 84601 Westover, Christopher D p 801.587.2255 Uckerman, Clifton R LCSW LCSW Harrision, Emily SLP Ascendant Behavioral Revere Health Horizon Rehab Hospital Affiliation Health 1055 N 500 W 11 E 200 N - University of Utah Hospital 3051 W Maple Loop Dr Ste 222, Bldg C Ste 101 Ste 210 Provo UT. 84604 Orem UT. 84057 Sports Medicine Lehi UT. 84043 p 801.377.5757 p 801.374.1706 Anderson, Laura M MD p 801.872.5516 University of Utah Health 555 W SR 164 N Keske, Coolleen E SLP 145 W University Pkwy Valdez, Danielle LCSW Salem UT. 84653 Dry Creek Physical Therapy Orem UT. 84058 University of Utah Health p 385.203.1285 and Wellness p 801.234.8600 145 W University Pkwy 3000 N Triumph Blvd Orem UT. 84058 Wiggins, Celeste M CSW Ste 310 Hospital Affiliation p 801.234.8600 Ascendant Behavioral Lehi UT. 84043 - University of Utah Hospital Health p 801.766.2454 Hospital Affiliation 3051 W Maple Loop Dr - University of Utah Hospital Ste 210 Lehi UT. 84043 p 801.502.3913 555 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Brill, Jason MD Neilsen, Jason D MD Peterson, Mark W DO Thorne, J Kent MD Advanced Physicians of Santaquin Medical Clinic Envision Physician MountainStar Sports & Orthopedic 210 E Main St Services Cardiovascular Surgery Medicine Santaquin UT. 84655 1345 W 1600 N 700 W 800 N 3401 N Center St p 801.754.3600 Orem UT. 84057 Ste 444 Ste 100 p 801.225.7971 Orem UT. 84057 Lehi UT. 84043 Nelson, Cory D DO p 801.743.4750 p 801.753.7770 Advanced Physicians of Hospital Affiliation Sports & Orthopedic - Jordan Valley Medical Hospital Affiliation 3943 Pony Express Pkwy Medicine Center West Valley Campus - St Marks Hospital Ste 210 3401 N Center St - Jordan Valley Medical - Ogden Regional Medical Eagle Mountain UT. 84005 Ste 100 Center Center p 801.789.3030 Lehi UT. 84043 - Timpanogos Regional Hospital p 801.753.7770 Poulsen, Matthew R MD Hospital Affiliation Blue Rock Medical Center Urgent Care - Mountain Point Medical 3943 E Pony Express Pkwy 3152 N University Ave Medallus Medical American Center Ste 210 Provo UT. 84604 Fork Clinic M-Sun 9am-8pm Eagle Mountain UT. 84005 p 801.375.2177 476 N 900 W Chappell, Craig D DO p 801.789.3030 Ste C In-2-It Medical Hospital Affiliation American Fork UT. 84003 1888 W 800 N Ngatuvai, Tauaina J MD - Timpanogos Regional Hospital p 801.492.1611 Pleasant Grove UT. 84062 Premier Family Medical - Lone Peak Hospital p 801.610.7321 226 N 1100 E - Mountain View Hospital Canyon View Family Ste A (UT) Medicine M-F 8am-8pm Sat Hospital Affiliation American Fork UT. 84003 - Jordan Valley Medical 9am-5pm - Timpanogos Regional Hospital p 801.855.3840 Center 336 W 100 S Spanish Fork UT. 84660 Edwards, Christopher R DO Lihai Medical Clinic Substance Abuse Facility p 801.798.7301 In-2-It Medical 247 W 2230 N ARDU Recovery 1888 W 800 N Ste 202-B 1053 W 1020 S Canyon View Family Pleasant Grove UT. 84062 Provo UT. 84604 Provo UT. 84601 Medicine M-F 8am-8pm Sat p 801.610.7321 p 801.687.0511 p 801.823.6832 8am-2pm 5 E 400 N Hansen, Kellen T DO Premier Family Medical I Am Recovery Springville UT. 84663 Advanced Physicians of 275 W 200 N 121 E State St p 801.489.8464 Sports & Orthopedic Lindon UT. 84042 Lehi UT. 84043 Medicine p 801.796.1333 p 801.407.9998 Canyon View Family 3401 N Center St Medicine M-F 9am-8pm Sat Ste 100 680 E Main St Life Balance 9am-12pm Lehi UT. 84043 Lehi UT. 84043 1291 Expwy Ln 94 W Main p 801.753.7770 p 801.768.1699 Spanish Fork UT. 84660 Santaquin UT. 84655 p 801.367.0394 p 801.754.3122 3943 E Pony Express Pkwy 830 N 2000 W Ste 201 Pleasant Grove UT. 84062 Thoracic Surgery Revere Health Provo Main Eagle Mountain UT. 84005 p 801.756.3511 Hunter, Curtis T MD Campus Mon-Sun 8am-8pm p 801.753.7770 MountainStar 1055 N 500 W Bldg A Hospital Affiliation Cardiovascular Surgery Provo UT. 84604 In-2-It Medical - Timpanogos Regional Hospital 700 W 800 N p 801.812.5033 1888 W 800 N Ste 444 Pleasant Grove UT. 84062 Nielsen, Curtis A DO Orem UT. 84057 Revere Health Eagle p 801.610.7321 Advanced Physicians of p 801.743.4750 Mountain Clinic Mon-Sat Sports & Orthopedic 8am-8pm Kirk, Stephen T MD Medicine Schorlemmer, Gilbert R MD 4095 E Pony Express Pkwy Revere Health 3401 N Ctr St MountainStar Ste 101 700 W 800 N Ste 100 Cardiovascular Surgery Eagle Mountain UT. 84005 Ste 100 Lehi UT. 84043 700 W 800 N p 801.429.8037 Orem UT. 84057 p 801.753.7770 Ste 444 p 801.224.5373 Orem UT. 84057 Revere Health Salem 3943 E Pony Express Pkwy p 801.743.4750 Multi-Specialty Health Hospital Affiliation Ste 210 Center Mon-Sun 8am-8pm - Salt Lake Regional Medical Eagle Mountain UT. 84005 Hospital Affiliation 555 W SR 164 N Center p 801.789.3030 - Lakeview Hospital Salem UT. 84653 - Mountain View Hospital p 801.465.4896 Hospital Affiliation (UT) - Mountain Point Medical - Ogden Regional Medical Center Center - Timpanogos Regional Hospital

556 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Riverwoods Urgent Care 145 W University Pkwy 275 W 200 N Reynolds, Brandon P MD M-Sun 10am-10pm Orem UT. 84058 Ste 100 Urology Clinic of Utah 280 River Park Dr p 801.234.8600 Lindon UT. 84042 Valley Ste 120 p 801.609.4476 1159 E 200 N Provo UT. 84604 Hospital Affiliation Ste 300 p 801.229.2011 - University of Utah Hospital 336 W 100 S American Fork UT. 84003 Spanish Fork UT. 84660 p 801.756.7609 Riverwoods Interventional Henderson, Sean J DO p 801.609.4476 Center Granger Medical Hospital Affiliation 280 W River Park Dr Specialists 39 N Professional Way - Timpanogos Regional Hospital Ste 100 1159 E 200 N Ste 2 - Mountain Point Medical Provo UT. 84604 Ste 300 Payson UT. 84651 Center p 801.229.1009 American Fork UT. 84003 p 801.609.4476 p 801.756.7609 Savage, Joshua MD Urology 415 N Main St Male Fertility and Armstrong, Joseph M MD 3000 N Triumph Blvd Spanish Fork UT. 84660 Peyronies Clinic Revere Health Ste 340 p 801.609.4476 1443 W 800 N 1055 N 500 W Lehi UT. 84043 Ste 202 Ste 211 Bldg C p 801.756.7609 Hospital Affiliation Orem UT. 84057 Provo UT. 84604 - Mountain View Hospital p 801.655.0015 p 801.357.7327 Hotaling, James M MD (UT) University of Utah Health - Timpanogos Regional Hospital Trost, Landon MD 972 N 600 E 1446 W Pleasant Grove Male Fertility and Spanish Fork UT. 84660 Blvd Oldroyd, Ronald I MD Peyronies Clinic p 820.137.3436 Pleasant Grove UT. 84062 Urology Clinic of Utah 1443 W 800 N p 801.785.5100 Valley Ste 202 Cahoon, D V MD 1055 N 300 W Orem UT. 84057 Granger Medical 145 W University Pkwy Ste 316 p 801.655.0015 Specialists Orem UT. 84058 Provo UT. 84059 1159 E 200 N p 801.234.8600 p 801.357.7530 Hospital Affiliation Ste 300 - Utah Valley Hospital American Fork UT. 84003 Hospital Affiliation Pastuszak, Alexander W MD - Timpanogos Regional Hospital p 801.756.7609 - University of Utah Hospital University of Utah Health 1446 W Pleasant Grove Vascular Surgery 3000 N Triumph Blvd Landau, Stewart T MD Blvd Karwande, Shreekanth MD Ste 340 Urology Clinic of Utah Pleasant Grove UT. 84062 MountainStar Lehi UT. 84043 Valley p 801.785.5100 Cardiovascular Surgery p 801.756.7609 1055 N 300 W 700 W 800 N Ste 316 Hospital Affiliation Ste 444 Hospital Affiliation Provo UT. 84059 - University of Utah Hospital Orem UT. 84057 - Timpanogos Regional Hospital p 801.357.7530 p 801.743.4750 Patel, Darshan P MD Crowley, Jim D MD Granger Medical University Of Utah Health Hospital Affiliation Revere Health Specialists 1446 W Pleasant Grove - St Marks Hospital 1055 N 500 W 1159 E 200 N Blvd - Ogden Regional Medical Ste 211 Ste 300 Pleasant Grove UT. 84062 Center Provo UT. 84604 American Fork UT. 84003 p 801.581.3834 - Timpanogos Regional Hospital p 801.357.7327 p 801.756.7609 - Lakeview Hospital Hospital Affiliation 972 N 600 E 3000 N Triumph Blvd - University of Utah Hospital Schorlemmer, Gilbert R MD Spanish Fork UT. 84660 Ste 340 MountainStar p 801.465.4896 Lehi UT. 84043 Platt, McKay L MD Cardiovascular Surgery p 801.756.7609 Revere Health 700 W 800 N Hospital Affiliation 1055 N 500 W Ste 444 - Timpanogos Regional Hospital Hospital Affiliation Ste 211 Orem UT. 84057 - Mountain View Hospital - Timpanogos Regional Hospital Provo UT. 84604 p 801.743.4750 (UT) p 801.357.7327 Morris, Targhee J MD Hospital Affiliation Gross, Kelli X MD Utah Urology 972 N 600 E - Lakeview Hospital University of Utah Health 1055 N 500 W Spanish Fork UT. 84660 - Mountain View Hospital 1446 W Pleasant Grove Ste 211 p 801.465.4896 (UT) Blvd Provo UT. 84604 - Ogden Regional Medical Pleasant Grove UT. 84062 p 801.609.4476 Hospital Affiliation Center p 801.785.5100 - Timpanogos Regional Hospital - Timpanogos Regional Hospital - Mountain View Hospital (UT)

557 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Thorne, J Kent MD Heber Valley Hospital *Hwang, Chun MD Cherry, Brian C CMHC MountainStar Physicians Heber Valley Hospital Summit Community Cardiovascular Surgery 454 E Medical Way Physicians Counseling 700 W 800 N Heber City UT. 84032 454 E Medical Way 150 N Main St Ste 444 p 435.654.2500 Heber City UT. 84032 Ste 204 Orem UT. 84057 p 435.654.2500 Heber City UT. 84032 p 801.743.4750 Hospital Affiliation p 801.266.2485 - Timpanogos Regional Hospital Hospital Affiliation Hospital Affiliation - Gunnison Valley Hospital - Timpanogos Regional Hospital Chipman, Lani LMFT - St Marks Hospital - Mountain View Hospital Summit Community - Ogden Regional Medical (UT) *Mauro, Heather A APRN Counseling Center Int Heart Cardiology - 150 N Main St - Timpanogos Regional Hospital *Carter, Melvin E MD Heber Ste 204 Heber Valley Hospital 1485 S Hwy 40 Heber City UT. 84032 Wasatch County Physicians Ste D p 801.266.2485 454 E Medical Way Heber UT. 84032 Breast Pumps Heber City UT. 84032 p 801.507.3500 Gutierrez, Jodi CMHC Alpine Home Medical p 435.654.2500 Solstice Counseling & Phone Number Only *Senapati, Alpana DO Wellness PC p 800.686.7993 Hospital Affiliation Int Heart Cardiology - 722 W 100 S - Timpanogos Regional Hospital Heber Ste 1 Edgepark - Mountain View Hospital 1485 S Hwy 40 Heber City UT. 84032 Phone Number Only (UT) Ste D p 435.654.4037 p 800.321.0591 Heber City UT. 84032 *Cragun, David T MD p 801.507.3500 Huhnke, Leah K LMFT Cardiac Monitoring Heber Valley Hospital Summit Community Remote Cardiac Services Physicians Hospital Affiliation Counseling Phone Number Only 454 E Medical Way - Heber Valley Hospital 150 N Main St p 800.367.0300 Heber City UT. 84032 - Park City Hospital Ste 204 p 435.654.2500 Heber City UT. 84032 eCardio Diagnostics *Wang, David C MD p 801.266.2485 Phone Number Only Hospital Affiliation Heber Valley Hospital p 888.400.3522 - Mountain View Hospital Physicians McDonald, Jenna CSW (UT) 454 E Medical Way Summit Community Cardiology - Timpanogos Regional Hospital Heber City UT. 84032 Counseling *Allen, Marvin R MD p 435.654.2500 150 N Main St Heber Valley Hospital Dahl, Charles F MD Ste 204 Physicians Revere Health Hospital Affiliation Heber City UT. 84032 454 E Medical Way 1485 S Hwy 40 - Timpanogos Regional Hospital p 801.266.2485 Heber City UT. 84032 Ste F p 435.654.2500 Heber City UT. 84032 *Weaver, Aaron N MD McStotts, Kelli CMHC p 801.373.4366 Heber Valley Hospital Summit Community Hospital Affiliation Physicians Counseling - Timpanogos Regional Hospital Heber Valley Hospital 454 E Medical Way 150 N Main St - Mountain View Hospital Physicians Heber City UT. 84032 Ste 204 (UT) 454 E Medical Way p 435.654.2500 Heber City UT. 84032 - Gunnison Valley Hospital Heber City UT. 84032 p 801.266.2485 p 435.654.2500 Hospital Affiliation *Biggs, Jason PA - Timpanogos Regional Hospital Peay, T Roger PhD Int Heart Cardiology - Hospital Affiliation - Mountain View Hospital T Roger Peay Therapy Heber - Timpanogos Regional Hospital (UT) 150 N Main St 1485 S Hwy 40 - Mountain View Hospital Ste 204-2 Ste D (UT) Chiropractic Heber City UT. 84032 Heber UT. 84032 Frogley, Stephen DC p 801.376.8775 p 801.507.3500 *Hu, Peter T MD Wasatch Back Wellness Int Heart Cardiology - 758 W 100 S Potts, Justin PSYD Bingham, Scott E MD Heber Heber City UT. 84032 Summit Community Revere Health 1485 S Hwy 40 p 435.654.3032 Counseling 1485 S Hwy 40 Ste D 150 N Main St Ste F Heber City UT. 84032 Counseling Ste 204 Heber City UT. 84032 p 801.507.3500 Alder, Andrew CMHC Heber City UT. 84032 p 801.373.4366 Summit Community p 801.266.2485 Counseling 150 N Main St Ste 204 #6 Heber City UT. 84032 p 801.266.2485

558 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Power, Alicia M LMFT Dietician Pacific Medical Inc *Clark, Ann L MD Wasatch Community *Wade, Betty RD Phone Number Only Heber Valley Hospital Counseling Heber Valley Hospital p 800.726.9180 Physicians 150 N Main St Physicians 454 E Medical Way Ste 206 454 E Medical Way RespirTech Heber City UT. 84032 Heber City UT. 84032 Heber City UT. 84032 Phone Number Only p 435.654.2500 p 435.709.8849 p 435.654.2500 p 800.793.1261 *Cobabe, Maurine M MD Solomon, Kimberly A LCSW Durable Medical Equipment Roche Insulin Delivery Heber Valley Hospital Summit Community Alpine Home Medical Systems Inc Physicians Counseling Phone Number Only Phone Number Only 454 E Medical Way 150 N Main St p 800.686.7993 p 800.280.7801 Heber City UT. 84032 Ste 204 p 435.654.2500 Heber City UT. 84032 CCS Medical Smith Nephew Inc (Muscle p 801.266.2485 Phone Number Only Stimulators) *Downing, Phillip K PA-C p 800.726.9811 Phone Number Only Int Heart Cardiology - Dermatology p 800.821.5700 Heber *Gardner, Kevin H DO Care Rehab and Orthopedic 1485 S Hwy 40 Heber Valley Specialty Products (Muscle US MED LLC Ste D Clinic Stimulators) Phone Number Only Heber UT. 84032 380 E 1500 S Phone Number Only p 800.787.6331 p 801.507.3500 Ste 202 p 800.487.9644 Heber City UT. 84032 United States Medical *Drew, Lynsey J DO p 435.657.4600 DJO Global Supply Heber Valley Clinic Phone Number Only Phone Number Only 1473 S Hwy 40 Kern, Steven M MD p 800.336.6569 p 877.840.8218 Ste E Park City Dermatology Heber City UT. 84032 150 N Main St Dynasplint Systems Inc Family Practice p 435.657.4400 Ste 202 Phone Number Only *Baker, Shannon C MD Heber City UT. 84032 p 800.638.6771 Heber Valley Hospital *Duncan, Nicholas J MD p 435.654.5444 Physicians Heber Valley Hospital EBI LLC (Bone Stimulators) 454 E Medical Way Physicians Hospital Affiliation Phone Number Only Heber City UT. 84032 454 E Medical Way - Heber Valley Hospital p 800.526.2579 p 435.654.2500 Heber City UT. 84032 p 435.654.2500 Diabetic Supplies Edgepark *Berg, Tod L MD CCS Medical Phone Number Only Heber Valley Clinic *Faatz, Jill B MD Phone Number Only p 800.321.0591 1473 S Hwy 40 Heber Valley Clinic p 800.726.9811 Ste E 1473 S Hwy 40 Empi Inc (Neuromuscular Heber City UT. 84032 Ste E Edgepark Stimulator) p 435.657.4400 Heber City UT. 84032 Phone Number Only Phone Number Only p 435.657.4400 p 800.321.0591 p 800.328.2536 Heber Valley Hospital Physicians Heber Valley Hospital Roche Insulin Delivery *Intermountain Homecare 454 E Medical Way Physicians Systems Inc *Medical Equipment and Heber City UT. 84032 454 E Medical Way Phone Number Only *Supply Heber p 435.654.2500 Heber City UT. 84032 p 800.280.7801 175 N Main p 435.654.2500 Ste 104 Hospital Affiliation US MED LLC Heber City UT. 84032 - Heber Valley Hospital *Ferriter, Joseph P MD Phone Number Only p 435.657.4323 Heber Valley Hospital p 800.787.6331 Campbell, Cynthia L FNP Physicians KCI USA Inc (Wound Vac 728 W 100 S 454 E Medical Way United States Medical Only) Ste 1 Heber City UT. 84032 Supply Phone Number Only Heber City UT. 84032 p 435.654.2500 Phone Number Only p 800.275.4524 p 435.654.4192 p 877.840.8218 Hospital Affiliation Orthofix Inc (Bone Growth Chappell, Craig D DO - Salt Lake Regional Medical Dialysis Center Stimulators Physicians In-2-It Medical Center *Heber Valley Dialysis Only) 513 N Main St *Center Phone Number Only Heber City UT. 84032 *Galli, Vanessa M MD 380 E 1500 S p 800.535.4492 p 801.610.7321 Heber Valley Hospital Ste 101 Physicians Heber City UT. 84032 Hospital Affiliation 454 E Medical Way p 435.657.4680 - Timpanogos Regional Hospital Heber City UT. 84032 p 435.654.2500

559 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Giles, Virginia C NP *Madeo, Jared APRN Pitts, George D MD Heber Valley Clinic Heber Valley Clinic Int Heart Cardiology - Wasatch Medical Clinic 1473 S Hwy 40 1473 S Hwy 40 Heber 35 S 500 E Ste E Ste E 1485 S Hwy 40 Heber City UT. 84032 Heber City UT. 84032 Heber City UT. 84032 Ste D p 435.654.1501 p 435.657.4400 p 435.657.4400 Heber UT. 84032 p 801.507.3500 Heber Valley Hospital Heber Valley Hospital Hospital Affiliation Physicians Physicians - Heber Valley Hospital Hospital Affiliation 454 E Medical Way 454 E Medical Way - Park City Hospital Heber City UT. 84032 Heber City UT. 84032 Haderlie, Todd M MD p 435.654.2500 p 435.654.2500 1465 S Hwy 40 McDonald, Stanton B MD Heber City UT. 84032 Wasatch Medical Clinic Hospital Affiliation Hospital Affiliation p 435.654.1234 35 S 500 E - Heber Valley Hospital - Heber Valley Hospital Heber City UT. 84032 Hospital Affiliation p 435.654.1501 *Power, Renae L APRN *Timmons-Terry, Holly MD - Heber Valley Hospital Heber Valley Hospital Heber Valley Hospital Heber Valley Hospital Physicians Physicians *Hamula, Jason F MD Physicians 454 E Medical Way 454 E Medical Way Heber Valley Hospital 454 E Medical Way Heber City UT. 84032 Heber City UT. 84032 Physicians Heber City UT. 84032 p 435.654.2500 p 435.654.2500 454 E Medical Way p 435.654.2500 Heber City UT. 84032 Hospital Affiliation *Tullis, David T MD p 435.654.2500 Hospital Affiliation - Salt Lake Regional Medical Heber Valley Clinic - Heber Valley Hospital Center 1473 S Hwy 40 *Helms, Erin B MD Ste E Heber Valley Hospital *Mckellar, Nathan C DO *Pradhan, Saphu MD Heber City UT. 84032 Physicians Heber Valley Hospital Heber Valley Hospital p 435.657.4400 454 E Medical Way Physicians Physicians Heber City UT. 84032 454 E Medical Way 454 E Medical Way Heber Valley Hospital p 435.654.2500 Heber City UT. 84032 Heber City UT. 84032 Physicians p 435.654.2500 p 435.654.2500 454 E Medical Way *Howell, Jason MD Heber City UT. 84032 Heber Valley Clinic Moore, Judith S DO *Price, Mark A MD p 435.654.2500 1473 S Hwy 40 Diamond Springs Wellness Heber Valley Hospital Ste E Center Physicians Hospital Affiliation Heber City UT. 84032 210 E Main St 454 E Medical Way - Heber Valley Hospital p 435.657.4400 Midway UT. 84049 Heber City UT. 84032 p 435.657.1777 p 435.654.2500 *Turtle, Faryal M MD In-2-It Medical Heber Valley Hospital 513 N Main St Hospital Affiliation *Rowe, Megan B PA-C Physicians Heber City UT. 84032 - Heber Valley Hospital Heber Valley Hospital 454 E Medical Way p 801.610.7321 Physicians Heber City UT. 84032 *Noyes, Michael B MD 454 E Medical Way p 435.654.2500 *Leavitt, Peter S MD Heber Valley Hospital Heber City UT. 84032 Heber Valley Clinic Physicians p 435.654.2500 *Wight, Ryan D PA-C 1473 S Hwy 40 454 E Medical Way Heber Valley Hospital Ste E Heber City UT. 84032 *Spain, Chad A MD Physicians Heber City UT. 84032 p 435.654.2500 Heber Valley Hospital 454 E Medical Way p 435.657.4400 Physicians Heber City UT. 84032 *Parker, Jessica A FNP 454 E Medical Way p 435.654.2500 Hospital Affiliation Heber Valley Clinic Heber City UT. 84032 - Heber Valley Hospital 1473 S Hwy 40 p 435.654.2500 *Wood, Lauren W MD Heber City UT. 84032 Heber Valley Hospital *Lofgran, Brian C MD p 435.657.4400 *Stagg, Gordon N MD Physicians Heber Valley Clinic Heber Valley Hospital 454 E Medical Way 1473 S Hwy 40 Hospital Affiliation Physicians Heber City UT. 84032 Ste E - Heber Valley Hospital 454 E Medical Way p 435.654.2500 Heber City UT. 84032 Heber City UT. 84032 p 435.657.4400 Pidwell, William B MD p 435.654.2500 Gastroenterology Rosenberg Cooley Metcalf *Clark, Holly B MD Heber Valley Hospital 380 E 1500 S Tayler, Gregory P MD Heber Valley Specialty Physicians Ste 103 1469 S Hwy 40 Clinic 454 E Medical Way Heber City UT. 84032 Ste C 380 E 1500 S Heber City UT. 84032 p 435.655.6600 Heber City UT. 84032 Ste 202 p 435.654.2500 p 435.654.3535 Heber City UT. 84032 Hospital Affiliation p 435.657.4600 - Salt Lake Regional Medical Center Hospital Affiliation - St Marks Hospital - Salt Lake Regional Medical560 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021Center 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. General Surgery *Intermountain Homecare *Peterson, Michael C MD Chipman, Lani LMFT *OBrien, John G MD *Home Health Heber Heber Valley Hospital Summit Community Heber Valley Specialty 175 N Main Physicians Counseling Clinic Ste 103 454 E Medical Way 150 N Main St 380 E 1500 S Heber City UT. 84032 Heber City UT. 84032 Ste 204 Ste 202 p 435.657.4323 p 435.654.2500 Heber City UT. 84032 Heber City UT. 84032 p 801.266.2485 p 435.657.4600 Hospice Hospital Affiliation Alpine Hospice Inc - Mountain View Hospital Goldman, Sarah PhD Gynecology 135 S Main St (UT) Summit Community *Cook, Christopher D DO Ste 206 Counseling Heber Valley Clinic Heber City UT. 84032 *Scoresby, Travis PA 150 N Main St 1473 S Hwy 40 p 435.654.1464 Heber Valley Hospital Ste 204 Ste E Physicians Heber City UT. 84032 Heber City UT. 84032 Applegate Homecare and 454 E Medical Way p 801.266.2485 p 435.657.4400 Hospice Heber City UT. 84032 345 W 600 S p 435.654.2500 Gutierrez, Jodi CMHC Hospital Affiliation Ste 120 Solstice Counseling & - Heber Valley Hospital Heber City UT. 84032 Laboratory Wellness PC p 435.654.5983 Dominion Diagnostics 722 W 100 S *Hendrickson, Johanna Phone Number Only Ste 1 *PA-C CNS Community Nursing p 877.734.9600 Heber City UT. 84032 Heber Valley Specialty Services p 435.654.4037 Clinic Phone Number Only LabCorp of America 380 E 1500 S Wallsburg UT. 84082 Holdings Haines, Marianne NP Ste 202 p 800.404.8138 Phone Number Only Marianne, Haines, PLLC Heber City UT. 84032 p 888.522.2677 425 E 1200 S p 435.657.4600 Hospice Alliance Ste 3B 190 N Main Mental Health Facility Heber City UT. 84032 Hospital Affiliation Ste 203 Wasatch Crest Recovery p 801.377.0088 - St George Regional Hospital Heber City UT. 84032 425 Moulton Ln p 435.654.6634 Heber City UT. 84032 Huhnke, Leah K LMFT *Longenecker, Brandon S DO p 800.385.3507 Summit Community Heber Valley Clinic *Intermountain Homecare Counseling 1473 S Hwy 40 *Hospice Heber Mental Health 150 N Main St Ste E 175 N Main Alder, Andrew CMHC Ste 204 Heber City UT. 84032 Ste 103 Summit Community Heber City UT. 84032 p 435.657.4400 Heber City UT. 84032 Counseling p 801.266.2485 p 435.657.4323 150 N Main St Townsend, Duane E MD Ste 204 #6 McDonald, Jenna CSW 112 Ryans Ln Hospital Heber City UT. 84032 Summit Community Midway UT. 84049 *Heber Valley Hospital p 801.266.2485 Counseling p 435.657.2047 454 E Medical Way 150 N Main St Heber City UT. 84032 Anderton, Neil G LCSW Ste 204 Home Health Agency p 435.654.2500 Neil G Anderton Counseling Heber City UT. 84032 Applegate Homecare and 135 S Main St p 801.266.2485 Hospice Internal Medicine Ste 211 345 W 600 S *Allen, Eric K DO Heber City UT. 84032 McStotts, Kelli CMHC Ste 120 Heber Valley Hospital p 435.657.0660 Summit Community Heber City UT. 84032 Physicians Counseling p 435.654.5983 454 E Medical Way *Burrow, David N MD 150 N Main St Heber City UT. 84032 Heber Valley Clinic Ste 204 CNS Community Nursing p 435.654.2500 1473 S Hwy 40 Heber City UT. 84032 Services Ste E p 801.266.2485 Phone Number Only *Hendler, Nedda B MD Heber City UT. 84032 Wallsburg UT. 84082 Heber Valley Hospital p 435.657.4400 Miller, Shawn M PhD p 800.404.8138 Physicians Solstice Counseling & 454 E Medical Way Hospital Affiliation Wellness PC Hospice Alliance Heber City UT. 84032 - Park City Hospital 722 W 100 S 190 N Main p 435.654.2500 Ste 1 Ste 203 Cherry, Brian C CMHC Heber City UT. 84032 Heber City UT. 84032 *Hill-Garrett, Karen L MD Summit Community p 435.654.4037 p 435.654.6634 Heber Valley Hospital Counseling Physicians 150 N Main St 454 E Medical Way Ste 204 Heber City UT. 84032 Heber City UT. 84032 p 435.654.2500 p 801.266.2485

561 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Monson, Christian H PSYD Nelson, Andrea M MD Occupational Therapy Smith, Stacy R MD Solstice Counseling & University of Utah Health *Bernhard, Nichole L OT Mountain Valley Eye Wellness PC 380 E 1500 S Heber Valley Hospital Institute 722 W 100 S Ste 101 Physicians 1471 S Hwy 40 Ste 1 Heber City UT. 84032 454 E Medical Way Heber City UT. 84032 Heber City UT. 84032 p 435.657.4680 Heber City UT. 84032 p 435.654.3090 p 435.654.4037 p 435.654.2500 Hospital Affiliation Stacy R Smith MD PC Peay, T Roger PhD - University of Utah Hospital Hospital Affiliation 380 E 1500 S T Roger Peay Therapy - Heber Valley Hospital Ste 204 150 N Main St Yenchek, Robert H MD Heber City UT. 84032 Ste 204-2 University of Utah Health Concentra Medical Centers p 435.654.3090 Heber City UT. 84032 380 E 1500 S 2390 Redwood Rd p 801.376.8775 Ste 101 West Valley City UT. 84419 Hospital Affiliation Heber City UT. 84032 p 888.997.2669 - St Marks Hospital Porter, Corinna PhD p 435.657.4680 150 N Main St *Hines, Gordon L OT Optometry Ste 206 Hospital Affiliation Heber Valley Hospital Ackerson, John H OD Heber City UT. 84032 - University of Utah Hospital Physicians Ackerson Eyecare p 435.671.0367 454 E Medical Way 736 W 100 S Neurology Heber City UT. 84032 Heber City UT. 84032 Potts, Justin PSYD Chebeleu, Lia Ana MD p 435.654.2500 p 435.503.6363 Summit Community Vista Neurology Counseling Specialists Hospital Affiliation Goode, Tory J OD 150 N Main St 150 N Main St - Heber Valley Hospital Mountain View Family Ste 204 Ste 105 Eyecare Heber City UT. 84032 Heber City UT. 84032 *Tiley, Donna M OT 425 E 1200 S p 801.266.2485 p 435.714.7277 Heber Valley Specialty Ste 200 Clinic Heber City UT. 84032 Power, Alicia M LMFT Hospital Affiliation 380 E 1500 S p 435.657.1555 Wasatch Community - St Marks Hospital Ste 102 Counseling Heber City UT. 84032 Rounds, Bradley B OD 150 N Main St Obstetrics And Gynecology p 435.657.4690 37 E 100 N Ste 206 *Cook, Christopher D DO Heber City UT. 84032 Heber City UT. 84032 Heber Valley Clinic Ophthalmology p 435.654.1863 p 435.709.8849 1473 S Hwy 40 Fassio, John B MD Ste E Mountain Valley Eye Seitz, Cory OD *Smart, Christine A LCSW Heber City UT. 84032 Institute Seitz Vision Heber Valley Clinic p 435.657.4400 1471 S Hwy 40 37 E 100 N 1473 S Hwy 40 Heber City UT. 84032 Heber City UT. 84032 Ste E Hospital Affiliation p 435.654.3090 p 435.654.1863 Heber City UT. 84032 - Heber Valley Hospital p 435.657.4400 Stacy R SMith MD PC Orthopedic Surgery *Hendrickson, Johanna 380 E 1500 S Davis, Garrett C MD Solomon, Kimberly A LCSW *PA-C Ste 204 Rosenberg Cooley Metcalf Summit Community Heber Valley Specialty Heber City UT. 84032 380 E 1500 S Counseling Clinic p 435.654.3090 Ste 103 150 N Main St 380 E 1500 S Heber City UT. 84032 Ste 204 Ste 202 Hospital Affiliation p 435.655.6600 Heber City UT. 84032 Heber City UT. 84032 - Evanston Regional Hospital p 801.266.2485 p 435.657.4600 Hospital Affiliation *Gunther, Jonathan B MD - Park City Hospital Nephrology Hospital Affiliation Heber Valley Hospital Bjordahl, Terrence S MD - St George Regional Hospital Physicians Dupaix, Charles F PA-C University of Utah Health 454 E Medical Way Rosenberg Cooley Metcalf 380 E 1500 S *Longenecker, Brandon S DO Heber City UT. 84032 380 E 1500 S Ste 101 Heber Valley Clinic p 435.654.2500 Ste 103 Heber City UT. 84032 1473 S Hwy 40 Heber City UT. 84032 p 435.657.4680 Ste E Hospital Affiliation p 435.655.6600 Heber City UT. 84032 - Central Valley Medical Hospital Affiliation p 435.657.4400 Center Hatch, Mark D MD - St Marks Hospital Rosenberg Cooley Metcalf 380 E 1500 S Ste 103 Heber City UT. 84032 p 435.655.6600

562 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Olsen, Gordon S DO Obray, Jon B MD Physical Medicine And Rehabilitation *DeFord, Heather J PT 1485 S Hwy 40 Vista Neurology *Minori, Joshua J DO Heber Valley Hospital Ste D Specialists Heber Valley Clinic 380 E 1500 S Heber City UT. 84032 150 N Main St 454 E Medical Way Ste 102 p 435.654.6360 Ste 105 Heber City UT. 84032 Heber City UT. 84032 Heber City UT. 84032 p 435.657.4400 p 435.657.4690 Heber Valley Hospital p 435.714.7277 Physicians Hospital Affiliation Ferguson, Dayton K DPT 454 E Medical Way Hospital Affiliation - Timpanogos Regional Hospital Wasatch Physical Therapy Heber City UT. 84032 - St George Regional Hospital - Utah Valley Hospital And Sports Medicine p 435.654.2500 376 E Gateway Dr Obray, Rick W MD Physical Therapy Ste 101 Pain Management Vista Neurology Bluth, Alan W MPT Heber City UT. 84032 Freeman, Eric MD Specialists Fit Stop Physical Therapy p 435.654.4525 Vista Neurology 150 N Main St 345 W 600 S Specialists Ste 105 Ste 200 *Guyer, Katie E PT 150 N Main St Heber City UT. 84032 Heber City UT. 84032 Heber Valley Specialty Ste 105 p 435.714.7277 p 435.654.5607 Clinic Heber City UT. 84032 380 E 1500 S p 435.714.7277 Hospital Affiliation Bluth, Tobin DPT Ste 102 - St George Regional Hospital Fit Stop Physical Therapy Heber City UT. 84032 Frieden, Derek L MD 345 W 600 S p 435.657.4690 Vista Neurology Talbott, Andrew P MD Ste 200 Specialists Vista Neurology Heber City UT. 84032 Heber Valley Hospital 150 N Main St Specialists p 435.654.5607 Physicians Ste 105 150 N Main St 454 E Medical Way Heber City UT. 84032 Ste 105 Bluth, Tyler W MPT Heber City UT. 84032 p 435.714.7277 Heber City UT. 84032 Fit Stop Physical Therapy p 435.654.2500 p 435.714.7277 345 W 600 S Hospital Affiliation Ste 200 Ivie, Dan S MPT - St George Regional Hospital Pediatric Cardiology Heber City UT. 84032 Wasatch Physical Therapy *Pilcher, Thomas A MD p 435.654.5607 And Sports Medicine Hoelzer, Bryan MD Heber Valley Hospital 376 E Gateway Dr Vista Neurology Physicians *Brooks, Carly DPT Ste 101 Specialists 454 E Medical Way Heber Valley Hospital Heber City UT. 84032 150 N Main St Heber City UT. 84032 Physicians p 435.654.4525 Ste 105 p 435.654.2500 454 E Medical Way Heber City UT. 84032 Heber City UT. 84032 *Kase, Barbara J PT p 435.714.7277 Hospital Affiliation p 435.654.2500 Heber Valley Hospital - Primary Childrens Hospital Physicians *Minori, Joshua J DO - Lone Peak Hospital Hospital Affiliation 454 E Medical Way Heber Valley Clinic - Primary Childrens Hospital Heber City UT. 84032 454 E Medical Way Pediatrics p 435.654.2500 Heber City UT. 84032 Larson, David C MD Clark, Krista J PT p 435.657.4400 Heber Valley Pediatrics 210 E Main St *Murphy, Samuel V DPT 380 E 1500 S Ste 111 Heber Valley Hospital Hospital Affiliation Ste 201 Midway UT. 84049 Physicians - Timpanogos Regional Hospital Heber City UT. 84032 p 435.657.0123 454 E Medical Way - Utah Valley Hospital p 435.657.0101 Heber City UT. 84032 Clyde, Willis PT p 435.654.2500 Mosley, Joseph J DO Hospital Affiliation Heber Valley Physical Vista Neurology - Heber Valley Hospital Therapy and Fitness *Randell, Matthew E DPT Specialists 190 N Main St Heber Valley Hospital 150 N Main St *Tidwell, Tyson J MD Heber City UT. 84032 Physical Therapy Ste 105 Heber Valley Clinic p 435.654.0410 380 E 1500 S Heber City UT. 84032 1473 S Hwy 40 Ste 102 p 435.709.4202 Ste E Concentra Medical Centers Heber City UT. 84032 Heber City UT. 84032 2390 Redwood Rd p 435.657.4690 Hospital Affiliation p 435.657.4400 West Valley City UT. 84419 - Timpanogos Regional Hospital p 888.997.2669 *Telian, Molly DPT - Utah Valley Hospital Hospital Affiliation Physical Therapy - Heber Valley Hospital *Cooke, Jessica DPT 380 E 1500 S Heber Valley Hospital Ste 102 380 E 1500 S Heber City UT. 84032 Ste 102 p 435.657.4690 Heber City UT. 84032 p 435.657.4690 Hospital Affiliation - Heber Valley Hospital 563 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Tiley, Donna M OT Psychology 513 N Main St Corey, Spencer BCBA Heber Valley Specialty Goldman, Sarah PhD Heber City UT. 84032 Utah Behavior Services Clinic Summit Community p 801.610.7321 1067 E Tabernacle St 380 E 1500 S Counseling Ste 7 Ste 102 150 N Main St Substance Abuse Facility Saint George UT. 84770 Heber City UT. 84032 Ste 204 Aqua Recovery p 801.255.5131 p 435.657.4690 Heber City UT. 84032 100 N Johnson Mill Rd p 801.266.2485 Midway UT. 84049 Day, Paul Podiatry p 844.654.3700 Autism Therapy Services Harper, Spence D DPM Miller, Shawn M PhD 321 N Mall Dr Dr Spence D Harper Solstice Counseling & Wasatch Crest Recovery Saint George UT. 84790 190 N Main St Wellness PC 425 Moulton Ln p 435.313.4571 Heber City UT. 84032 722 W 100 S Heber City UT. 84032 p 435.657.0329 Ste 1 p 800.385.3507 Deceuster, Rachael BCBA Heber City UT. 84032 Utah Behavior Services Hospital Affiliation p 435.654.4037 Urgent Care 1067 E Tabernacle St - Heber Valley Hospital *Heber InstaCare Ste 7 - St Marks Hospital Monson, Christian H PSYD 484 E Medical Way Saint George UT. 84770 - Salt Lake Regional Medical Solstice Counseling & Heber City UT. 84032 p 801.255.5131 Center Wellness PC p 435.657.4500 722 W 100 S Fujiwara, Mina BCBA McPhie, Jared D DPM Ste 1 Washington County Utah Behavior Services Utah Podiatry Group PC Heber City UT. 84032 1067 E Tabernacle St 345 W 600 S p 435.654.4037 Aba Therapy Ste 7 Ste 408 Adolphson, Lillian St George UT. 84770 Heber City UT. 84032 Porter, Corinna PhD BCBA-D p 801.255.5131 p 801.373.2499 150 N Main St Utah Behavior Services Ste 206 1067 E Tabernacle St Green, Rachal BCBA,LCSW Hospital Affiliation Heber City UT. 84032 Ste 7 Utah Behavior Services - St Marks Hospital p 435.671.0367 St George UT. 84770 1067 E Tabernacle St - Evanston Regional Hospital p 801.255.5131 Ste 7 - Timpanogos Regional Hospital Residential Treatment Facility St George UT. 84770 Aqua Recovery Aleman, Arianna BCBA p 801.255.5131 Taylor, Ryan D DPM 100 N Johnson Mill Rd Utah Behavior Services Utah Podiatric Physicians Midway UT. 84049 1067 E Tabernacle St Gressmen, Casey BCBA and Surgeons Group p 844.654.3700 Ste 7 Utah Behavior Services 150 N Main St Saint George UT. 84770 1067 E Tabernacle St Ste 202 Wasatch Crest Recovery p 801.255.5131 Ste 7 Heber City UT. 84032 425 Moulton Ln St George UT. 84770 p 435.671.4726 Heber City UT. 84032 Bell, Brynn BCBA,LCSW p 801.255.5131 p 800.385.3507 Utah Behavior Services Hospital Affiliation 1067 E Tabernacle St Hanks, Julie BCBA - Heber Valley Hospital Skilled Nursing Facility Ste 7 Utah Behavior Services Rocky Mountain Care - The St George UT. 84770 1067 E Tabernacle St Utah Podiatry Group PC Lodge p 801.255.5131 Ste 7 190 N Main St 544 E 1220 S Saint George UT. 84770 Heber City UT. 84032 Heber City UT. 84032 Butterfield, Brittney p 801.255.5131 p 435.657.0329 p 435.654.5500 BCBA Chrysalis Utah Hoffmann, Audrey PhD 620 E Medical Dr Social Worker 230 N 1680 E Utah Behavior Services Ste 150 Anderton, Neil G LCSW Ste OP 1067 E Tabernacle St Heber City UT. 84032 Neil G Anderton Counseling Saint George UT. 84790 Ste 7 p 801.292.5070 135 S Main St p 801.655.4950 Saint George UT. 84770 Ste 211 p 801.255.5131 Psychiatry Heber City UT. 84032 Christianson, Grete BCBA *Burrow, David N MD p 435.657.0660 Utah Behavior Services Hunt, Chelseigh BCBA Heber Valley Clinic 1067 E Tabernacle St Utah Behavior Services 1473 S Hwy 40 Sports Medicine Ste 7 1067 E Tabernacle St Ste E Chappell, Craig D DO St George UT. 84770 Ste 7 Heber City UT. 84032 In-2-It Medical p 801.255.5131 Saint George UT. 84770 p 435.657.4400 513 N Main St p 801.255.5131 Heber City UT. 84032 Chrysalis Utah Hospital Affiliation p 801.610.7321 230 N 1680 E - Park City Hospital Ste OP Hospital Affiliation Saint George UT. 84790 - Timpanogos Regional Hospital p 801.655.4950

564 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Jensen, Julia P BCBA Lowe, Kori BCBA Rhodes, Tiffany BCBA Turner, Eric BCBA Utah Behavior Services Utah Behavior Services Utah Behavior Services Utah Behavior Services 1067 E Tabernacle St 1067 E Tabernacle St 1067 E Tabernacle St 1067 E Tabernacle St Ste 7 Ste 7 Ste 7 Ste 7 Saint George UT. 84770 Saint George UT. 84770 St George UT. 84770 Saint George UT. 84770 p 801.255.5131 p 801.255.5131 p 801.255.5131 p 801.255.5131

Keller, Rebecca BCBA Madsen, Sara BCBA Rockwell, Rene BCBA 1067 E Tabernacle St Utah Behavior Services Utah Behavior Services Utah Behavior Services Ste 7 1067 E Tabernacle St 1067 E Tabernacle St 1067 E Tabernacle St St George UT. 84770 Ste 7 Ste 7 Ste 7 p 801.255.5131 St George UT. 84770 St George UT. 84770 St George UT. 84770 p 801.255.5131 p 801.255.5131 p 801.255.5131 Whatcott, Natalie BCBA,SSW Kennedy, Anne BCBA Manwill, Andrea BCBA Rudd, Ryan LCSW Utah Behavior Services Utah Behavior Services Utah Autism Academy Crimson Counseling 1067 E Tabernacle St 1067 E Tabernacle St 1680 E 230 N Bldg A 249 E Tabernacle St Ste 7 Ste 7 Saint George UT. 84790 Ste 100 St George UT. 84770 St George UT. 84770 p 435.720.8876 Saint George UT. 84770 p 801.255.5131 p 801.255.5131 p 435.705.7574 Maxwell, Kendra BCBA Wills, Brooke BCBA Knudson, Mani BCBA Utah Behavior Services Sagendorf, Emily BCBA Utah Behavior Services Utah Behavior Services 1067 E Tabernacle St Utah Behavior Services 1067 E Tabernacle St 1067 E Tabernacle St Ste 7 1067 E Tabernacle St Ste 7 Ste 7 St George UT. 84770 Ste 7 St George UT. 84770 St George UT. 84770 p 801.255.5131 St George UT. 84770 p 801.255.5131 p 801.255.5131 p 801.255.5131 McGuire, Amy BCBA Wilson, Megan BCBA Kulow, Kacylia BCBA Utah Behavior Services Sanders, Sarah BCBA Utah Behavior Services Utah Behavior Services 1067 E Tabernacle St Utah Behavior Services 1067 E Tabernacle St 1067 E Tabernacle St Ste 7 1067 E Tabernacle St Ste 7 Ste 7 St George UT. 84770 Ste 7 Saint George UT. 84770 Saint George UT. 84770 p 801.255.5131 St George UT. 84770 p 801.255.5131 p 801.255.5131 p 801.255.5131 Metzger, Debbie BCBA Woodall, Clifford BCBA Lambertsen, Hope BCBA Utah Behavior Services Smith, Erica BCBA Utah Behavior Services Utah Behavior Services 1067 E Tabernacle St Utah Behavior Services 1067 E Tabernacle St 1067 E Tabernacle St Ste 7 1067 E Tabernacle St Ste 7 Ste 7 St George UT. 84770 Ste 7 St George UT. 84770 St George UT. 84770 p 801.255.5131 Saint George UT. 84770 p 801.255.5131 p 801.255.5131 p 801.255.5131 Nadalsky, Michelle Wulfenstein, Lee BCBA Larisch, Torrey BCBA BCBA,SSW Smith, Saige LPC Utah Behavior Services Chrysalis Utah Utah Behavior Services Utah Behavior Services 1067 E Tabernacle St 230 N 1680 E 1067 E Tabernacle St 1067 E Tabernacle St Ste 7 Ste OP Ste 7 Ste 7 Saint George UT. 84770 Saint George UT. 84790 St George UT. 84770 Saint George UT. 84770 p 801.255.5131 p 801.655.4950 p 801.255.5131 p 801.255.5131 Yang, Danielle BCBA Lee, Jennifer BCBA Oblad, Cicily BCBA Snow, Lauren BCBA Utah Behavior Services Utah Behavior Services Utah Behavior Services Utah Behavior Services 1067 E Tabernacle St 1067 E Tabernacle St 1067 E Tabernacle St 1067 E Tabernacle St Ste 7 Ste 7 Ste 7 Ste 7 Saint George UT. 84770 St George UT. 84770 St George UT. 84770 St George UT. 84770 p 801.255.5131 p 801.255.5131 p 801.255.5131 p 801.255.5131 Allergy And Immunology Lopez, Kitrina BCBA Renda, Cheyenne R PhD Stevens, Nicole Pinna, Kenneth R MD Utah Behavior Services Utah Behavior Services BCBA,LMFT Southwest Allergy & Asthma 1067 E Tabernacle St 1067 E Tabernacle St Utah Behavior Services Clinic Ste 7 Ste 7 1067 E Tabernacle St 515 S 300 E St George UT. 84770 Saint George UT. 84770 Ste 7 Ste 101 p 801.255.5131 p 801.255.5131 St George UT. 84770 St George UT. 84770 p 801.255.5131 p 435.688.1128

Hospital Affiliation - St George Regional Hospital

565 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Stevens, Mark E MD Lewis, Steven T AUD Barton, Deborah NP Hurst, Robert APRN Southwest Rheumatology Southern Utah Ear Nose & Revere Health St George Orthopedic Spine Associates Throat 1380 E Medical Ctr Dr 230 N 1680 E 577 S River Rd 617 E Riverside Dr Ste 4100 Ste I-1 St George UT. 84790 Ste 201 St George UT. 84790 St George UT. 84790 p 435.688.6262 Saint George UT. 84790 p 435.251.2900 p 435.652.6024 p 435.628.3334 Hospital Affiliation Hospital Affiliation *Jensen, Ralph E MD - St George Regional Hospital Luekenga, Richard L AUD - St George Regional Hospital Southwest Cardiology-St - Cedar City Hospital Dixie Hearing and Balance George Center Boorman, David C MD 1380 E Medical Ctr Dr Ambulatory Surgery Center 1054 E Riverside Dr Revere Health Ste 1500 Coral Desert Surgery Ste 201 2825 E Mall Dr St George UT. 84790 Center St George UT. 84790 St Geroge UT. 84790 p 435.251.2500 1490 E Foremaster Dr Bldg p 435.688.8991 p 435.251.2900 C St George Regional Saint George UT. 84790 Whittaker, Dane B AUD Hospital Affiliation Hospital p 435.674.5230 Southern Utah Ear Nose & - St George Regional Hospital 1380 E Medical Ctr Dr Throat St George UT. 84790 South Main Surgery Center 617 E Riverside Dr *Bowles, B J MD p 435.251.1000 (Podiatry Care Ste 201 Cardiovascular and Exclusively) Saint George UT. 84790 Thoracic Surgery - St Hospital Affiliation 754 S Main p 435.628.3334 George - St George Regional Hospital Ste 3 1380 E Medical Ctr Dr - Cedar City Hospital St George UT. 84770 Breast Pumps Ste 2600 p 435.628.2671 Alpine Home Medical St George UT. 84790 Jones, Jamison C MD 42 S River Rd p 435.251.2700 Revere Health St George Surgical Center Ste 10 1380 E Medical Ctr Dr (Pain Management and Saint George UT. 84790 Hospital Affiliation Ste 4100 Ophthalmology Services p 435.674.0080 - St George Regional Hospital St George UT. 84790 Only) p 435.251.2900 676 S Bluff St Phone Number Only *Brizolara, Alberto A MD St George UT. 84770 p 800.686.7993 Southwest Cardiology-St St George Regional p 435.673.8080 George Hospital Edgepark 1380 E Medical Ctr Dr 1380 E Medical Ctr Dr Zion Eye Institute Phone Number Only Ste 1500 St George UT. 84790 (Ophthalmology Services p 800.321.0591 St George UT. 84790 p 435.251.1000 Only) p 435.251.2500 1791 E 280 N Cardiac Monitoring Revere Health St George UT. 84790 Remote Cardiac Services St George Regional 2825 E Mall Dr p 435.656.2020 Phone Number Only Hospital St Geroge UT. 84790 p 800.367.0300 1380 E Medical Ctr Dr p 435.251.2900 Audiology St George UT. 84790 Forbes, Kimball B AUD eCardio Diagnostics p 435.251.1000 Hospital Affiliation Audiology and Hearing Care Phone Number Only - St George Regional Hospital of Southern Utah p 888.400.3522 Hospital Affiliation 617 E Riverside Dr - St George Regional Hospital Kim, Christopher Y MD Ste 102 Cardiology Advanced Vein and Vascular Saint George UT. 84790 Advanced Vein and Vascular *Eror, Alec T MD of Southern Utah p 435.688.8866 of Southern Utah Cardiovascular and 676 S Bluff St 676 S Bluff St Thoracic Surgery - St Ste 101 Garcia, Brittany AUD Ste 101 George Saint George UT. 84770 Southern Utah Ear Nose & Saint George UT. 84770 1380 E Medical Ctr Dr p 435.673.0095 Throat p 435.673.0095 Ste 2600 617 E Riverside Dr St George UT. 84790 Hospital Affiliation Ste 201 *Atwood, Melony C MD p 435.251.2700 - Davis Hospital Saint George UT. 84790 Southwest Cardiology-St - Lakeview Hospital p 435.628.3334 George George, Zachary H MD - Ogden Regional Medical 1380 E Medical Ctr Dr Revere Health Center Greer, Lance F AUD Ste 1500 2825 E Mall Dr - Salt Lake Regional Medical Audiology and Hearing Care St George UT. 84790 Saint George UT. 84790 Center of Southern Utah p 435.251.2500 p 435.628.9393 617 E Riverside Dr Ste 102 Hospital Affiliation Saint George UT. 84790 - Cedar City Hospital p 435.688.8866

566 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Laffely, Nicholas H MD *Van Woerkom, Ryan MD Margles, Ellen CNM Counseling Revere Health Southwest Cardiology-St St George OB/GYN Acevedo, Carlos ACMHC 1380 E Medical Ctr Dr George 295 S 1470 E Utah Behavior Services Ste 4100 1380 E Medical Ctr Dr Ste 300 1067 E Tabernacle St St George UT. 84790 Ste 1500 Saint George UT. 84790 Ste 7 p 435.251.2900 St George UT. 84790 p 435.647.0999 Saint George UT. 84770 p 435.251.2500 p 801.255.5131 St George Regional Chiropractic Hospital Physicians *Williams, Zachary R MD Carr, Joshua A DC Arbizu, Jamie CMHC 1380 E Medical Ctr Dr Southwest Cardiology-St Coral Canyon Chiropractic Core Compass Counseling St George UT. 84790 George 83 S 2600 4 S 2600 W p 435.251.1000 1380 E Medical Ctr Dr Ste 102 Ste 6 Ste 1500 Hurricane UT. 84737 Hurricane UT. 84737 Revere Health St George UT. 84790 p 435.635.7771 p 435.229.8405 2825 E Mall Dr p 435.251.2500 St Geroge UT. 84790 Davis, O Troy DC Archuleta, Jason LCSW p 435.251.2900 St George Regional Summit Chiropractic LLC Utah Behavior Services Hospital 321 N Mall Dr 1067 E Tabernacle St *Orme, Geoffrey J DO 1380 E Medical Ctr Dr Ste H-102 Ste 7 Southwest Cardiology-St St George UT. 84790 Saint George UT. 84790 St George UT. 84770 George p 435.251.1000 p 435.862.0125 p 801.255.5131 1380 E Medical Ctr Dr Ste 1500 Hospital Affiliation Elite Healthcare Southern Barlow, Tiffany LCSW St George UT. 84790 - St George Regional Hospital Utah Red Desert Counseling p 435.251.2500 FAC 568 W Telegraph Rd 230 N 1680 E Bldg 1 *Willis, Carrie A MD Washington UT. 84780 Ste 2 Hospital Affiliation Southwest Cardiology-St p 435.627.0231 Saint George UT. 84790 - Cedar City Hospital George p 801.906.1736 - St George Regional Hospital 1380 E Medical Ctr Dr Hardy, Brian N DC Ste 1500 Brian Neil Hardy Bess, Cleola CMHC *Owan, Theophilus E MD St George UT. 84790 75 S 100 E S & S Counseling Southwest Cardiology-St p 435.251.2500 Ste 1A 321 N Mall Dr George St George UT. 84770 Ste E102 1380 E Medical Ctr Dr St George Regional p 435.688.8830 Washington UT. 84780 Ste 1500 Hospital p 435.932.3672 St George UT. 84790 1380 E Medical Ctr Dr Hicken, Jeffrey L DC p 435.251.2500 St George UT. 84790 Elite Healthcare Southern Black, Jed CMHC p 435.251.1000 Utah Utah Behavior Services Cardiovascular and 568 W Telegraph Rd 1067 E Tabernacle St Thoracic Surgery - St Hospital Affiliation Washington UT. 84780 Ste 7 George - St George Regional Hospital p 435.627.0231 Saint George UT. 84770 1380 E Medical Ctr Dr p 801.255.5131 Ste 2600 *Woodbury, Kory U MD Hospital Affiliation St George UT. 84790 Cardiovascular and - Logan Regional Hospital Center for Couples & p 435.251.2700 Thoracic Surgery - St - Cache Valley Hospital Families George - Franklin County Medical 1173 S 250 W Bldg I Hospital Affiliation 1380 E Medical Ctr Dr Center Ste 208 - St George Regional Hospital Ste 2600 - Brigham City Community Saint George UT. 84770 - University of Utah Hospital St George UT. 84790 Hospital p 435.688.1111 p 435.251.2700 *Pulsipher, Mark W MD Jensen, Richard S DC 52 S 850 W Southwest Cardiology-St Hospital Affiliation Zion Health Management Ste 202B George - St George Regional Hospital Services Hurricane UT. 84737 1380 E Medical Ctr Dr 237 N Bluff St p 435.688.1111 Ste 1500 Certified Nurse Midwife Ste A St George UT. 84790 Fought, Theresa (Tina) M St George UT. 84770 Evolving Light Counseling p 435.251.2500 CNM p 435.674.2626 32 E 100 S St George OB/GYN Ste 202 St George Regional 295 S 1470 E Jepson, Russell DC Saint George UT. 84770 Hospital Ste 300 Vista Neurology p 435.628.8945 1380 E Medical Ctr Dr Saint George UT. 84790 Specialists St George UT. 84790 p 435.647.0999 301 N 200 E Fatkin, Kenneth LMFT p 435.251.1000 Ste 2-A Family Healthcare Hospital Affiliation Saint George UT. 84770 25 N 100 E Hospital Affiliation - Salt Lake Regional Medical p 435.688.7246 Ste 102 - St George Regional Hospital Center Saint George UT. 84770 - University of Utah Hospital p 435.986.2565

567 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Finke, Karen A LPC Lofthouse, Chelsea ACMHC Thomas, Thurmon E LMFT DeMille, Maurice DMD Karen A Finke CMHC Utah Behavior Services Center for Couples & University Of Utah Health 415 N State St 1067 E Tabernacle St Families 225 S 700 E Ste 201 Ste 7 1173 S 250 W Bldg I Saint George UT. 84770 Hurricane UT. 84737 Saint George UT. 84770 Ste 208 p 801.587.6453 p 406.570.2915 p 801.255.5131 Saint George UT. 84770 p 435.688.1111 Fessenden, Tami DDS Gibbons, Debra LMFT Lovelace, Scott LCMHC University of Utah Dental 321 N Mall Dr Bldg O, Utah Behavior Services 52 S 850 W Services Ste 101 1067 E Tabernacle St Ste 202B 225 S 700 E Saint George UT. 84790 Ste 7 Hurricane UT. 84737 Saint George UT. 84770 p 435.868.8376 Saint George UT. 84770 p 435.688.1111 p 801.587.6453 p 801.255.5131 Goss, Angela CSW Zolman, David LMFT Howard, Ryan DDS Utah Behavior Services Munk, Adam C LMFT Family Healthcare Family Healthcare 1067 E Tabernacle St Family Healthcare 25 N 100 E 25 N 100 E Ste 7 2408 E Riverside Dr Ste 102 Ste 102 St George UT. 84770 Saint George UT. 84790 Saint George UT. 84770 Saint George UT. 84770 p 801.255.5131 p 435.986.2565 p 435.986.2565 p 435.986.2565

Helquist, Linda M LMFT 25 N 100 E Dentist Johnson, David G DDS Alpine Counseling Group Ste 102 Bowen, Ronald DDS University of Utah Health 321 N Mall Dr Saint George UT. 84770 University Of Utah Health 225 S 700 E Ste 0-101 p 435.986.2565 225 S 700 E Saint George UT. 84770 Saint George UT. 84790 Saint George UT. 84770 p 801.587.6453 p 435.200.9413 Ogilvie, Shara M p 801.587.6453 Daybreak Family Therapy Johnson, Randall DDS Hinton, Angela CMHC 1173 S 250 W Butler, Colten DMD University of Utah Health Hinton Counseling Ste 203 Family Healthcare 225 S 700 E 230 N 1680 E Saint George UT. 84770 245 E 680 S Saint George UT. 84770 Ste I-2 p 435.668.4138 Cedar City UT. 84770 p 801.587.6453 Saint George UT. 84790 p 435.986.2565 p 435.767.1072 Parker, Brian L LMFT Johnston, Thomas C DDS New Beginnings 25 N 100 E University of Utah Health Jenkins, Nancy LPC 301 N 200 E Ste 102 225 S 700 E Nancy Jenkins LPC Ste 3-D St George UT. 84770 Saint George UT. 84770 321 N Mall Dr Saint George UT. 84770 p 435.986.2565 p 801.587.6453 Ste 201 Bldg B p 435.628.5505 Saint George UT. 84790 Cahoon, Kevin DDS Hospital Affiliation p 801.949.1323 Porter, Desiree L LPC University Of Utah Health - University of Utah Hospital Spring Creek Wellness 225 S 700 E Jones, David H LMFT 1990 N Park Grove Dr Saint George UT. 84770 Moore, Becky Sue DDS Red Mountain Counseling Washington UT. 84780 p 801.587.6453 University of Utah Dental and Education p 801.499.7869 Services 321 N MAll Dr Chandler, Nathan DDS 225 S 700 E Ste VW-103 Porter, Glen S ACMHC University of Utah Dental Saint George UT. 84770 Saint George UT. 84790 Transitions Therapy Services p 801.587.6453 p 435.767.1532 Associates 225 S 700 E 283 Auto Mall Dr Saint George UT. 84770 Okubo, Miranda DDS King, Kelsey LCSW Ste 4 p 801.587.6453 University of Utah Dental Utah Behavior Services Saint George UT. 84770 Services 1067 E Tabernacle St p 435.227.5052 Christensen, Mark L DDS 225 S 700 E Ste 7 University Of Utah Health Saint George UT. 84770 St George UT. 84770 Salsberry, Maria CSW 225 S 700 E p 801.587.6453 p 801.255.5131 Utah Behavior Services Saint George UT. 84770 1067 E Tabernacle St p 801.587.6453 Segura, Thomas R DDS Koford, Martin CMHC Ste 7 University of Utah Health Center for Couples & St George UT. 84770 Hospital Affiliation 225 S 700 E Families p 801.255.5131 - University of Utah Hospital Saint George UT. 84770 1173 S 250 W Bldg I p 801.587.6453 Ste 208 Stasiuk, John A LMFT Cook, Justin DDS Saint George UT. 84770 Utah Behavior Services University of Utah Dental Hospital Affiliation p 435.688.1111 1067 E Tabernacle St Services - University of Utah Hospital Ste 7 225 S 700 E Saint George UT. 84770 Saint George UT. 84770 p 801.255.5131 p 801.587.6453

568 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Sharp, Holly D DDS Cope, Austin R MD Smith, W Austin MD United States Medical University of Utah Health Riverside Medical Arts Southwest Skin & Cancer Supply 225 S 700 E 1068 E Riverside Dr 383 S 300 E Phone Number Only Saint George UT. 84770 Saint George UT. 84790 Saint George UT. 84770 p 877.840.8218 p 801.587.6453 p 435.628.6466 p 435.628.2826 Dialysis Center Smith, Michael G DDS Vivida Dermatology Smith, W Bret MD Dixie Dialysis Center University of Utah Health 1490 E Foremaster Dr Southwest Skin & Cancer 720 S River Rd 225 S 700 E Ste 260 383 S 300 E St George UT. 84791 Saint George UT. 84770 St George UT. 84790 Saint George UT. 84770 p 435.656.0857 p 801.587.6453 p 435.673.5373 p 435.628.2826 Hurricane Dialysis Center Hospital Affiliation Fife, Douglas MD Hospital Affiliation 48 S 2500 W - University of Utah Hospital Vivida Dermatology - St George Regional Hospital Ste 100 1490 E Foremaster Dr Hurricane UT. 84737 Smith, Ronald T DDS Ste 260 Riverside Medical Arts p 435.635.0399 University Of Utah Health St George UT. 84790 1068 E Riverside Dr 225 S 700 E p 435.673.5373 St George UT. 84790 Dietician Saint George UT. 84770 p 435.628.6466 Speener, Melinda S RD p 801.587.6453 Jacobsen, Greg R MD University of Utah Health Southwest Skin & Cancer Hospital Affiliation 48 S 2500 W Squires, Jeffrey W 383 S 300 E - St George Regional Hospital Ste 100 University Of Utah Health Saint George UT. 84770 Hurricane UT. 84737 225 S 700 E p 435.628.2826 Southwest Skin & Cancer p 435.635.0399 Saint George UT. 84770 383 S 300 E p 801.587.6453 Hospital Affiliation Saint George UT. 84770 720 S River Rd - St George Regional Hospital p 435.628.2826 Ste D1100 Hospital Affiliation Saint George UT. 84790 - University of Utah Hospital Jorgensen, Jeremiah M PA Trimble, Karl K MD p 435.656.0857 Vivida Dermatology Dixie Dermatology Thorup, David P DMD 1490 E Foremaster Dr 169 W 2710 S Cir Hospital Affiliation University of Utah Health Ste 260 Ste 107 - University of Utah Hospital 225 S 700 E St George UT. 84790 St George UT. 84790 Saint George UT. 84770 p 435.673.5373 p 435.674.3552 Durable Medical Equipment p 801.587.6453 Petersen Medical Hospital Affiliation Hospital Affiliation 2019 E Riverside Dr Valantine, Matthew DDS - Jordan Valley Medical - St George Regional Hospital Ste A-100 University Of Utah Health Center Saint George UT. 84790 225 S 700 E Tuttle, Marie S MD p 435.628.4949 Saint George UT. 84770 Larson, April A MD Tuttle Dermatology p 801.587.6453 Riverside Medical Arts 617 E Riverside Dr Advantage Medical Supply 1068 E Riverside Dr Ste 103 640 E 700 S Wangsgard, Richard DMD Saint George UT. 84790 Saint George UT. 84790 Ste 102 University Of Utah Health p 435.628.6466 p 435.218.7779 St George UT. 84770 225 S 700 E p 435.619.8003 Saint George UT. 84770 Vivida Dermatology Diabetic Supplies p 801.587.6453 1490 E Foremaster Dr CCS Medical Alpine Home Medical Ste 260 Phone Number Only 42 S River Rd Dermatology St George UT. 84790 p 800.726.9811 Ste 10 Berger, Robin MD p 435.673.5373 Saint George UT. 84790 640 E 700 S Edgepark p 435.674.0080 Ste 1 Southern Utah Plastic Phone Number Only St George UT. 84770 Surgery and Dermatology p 800.321.0591 Phone Number Only p 435.673.7546 652 S Medical Center Dr p 800.686.7993 Ste 300 Roche Insulin Delivery Hospital Affiliation St George UT. 84790 Systems Inc Apria Healthcare LLC - St George Regional Hospital p 435.251.3670 Phone Number Only 1509 S 270 E p 800.280.7801 St George UT. 84790 Carter, Benjamin G MD Hospital Affiliation p 435.628.5222 Riverside Medical Arts - St George Regional Hospital US MED LLC 1068 E Riverside Dr Phone Number Only CCS Medical St George UT. 84790 Peine, Steven D MD p 800.787.6331 Phone Number Only p 435.628.6466 Vivida Dermatology p 800.726.9811 1490 E Foremaster Dr Ste 260 St George UT. 84790 p 435.673.5373

569 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Care Rehab and Orthopedic Kolob Oxygen And Medical 617 E Riverside Dr *Muntz, Harlan R MD Products (Muscle Equipment Ste 201 Primary Childrens Hospital Stimulators) 677 N 3050 Saint George UT. 84790 736 S 900 E Phone Number Only Ste 210 p 435.628.3334 Ste 107 p 800.487.9644 Saint George UT. 84790 St George UT. 84790 p 435.673.6664 Hospital Affiliation p 435.251.2888 Carols Personal Mastectomy - St George Regional Hospital Boutique Lincare Hospital Affiliation 330 E 600 S 291 E 1400 S Doxey, George P MD - Primary Childrens Hospital Saint George UT. 84770 Ste 5 Southern Utah Ear Nose & - University of Utah Hospital p 801.483.1262 Saint George UT. 84790 Throat p 435.674.4477 617 E Riverside Dr Southern Utah Ear Nose & DJO Global Ste 201 Throat Phone Number Only Magic Rest Medical-St Saint George UT. 84790 617 E Riverside Dr p 800.336.6569 George p 435.628.3334 Ste 201 1316 S 400 E Saint George UT. 84790 Dynasplint Systems Inc St George UT. 84790 736 S 900 E p 435.628.3334 Phone Number Only p 435.674.5980 Ste 201 p 800.638.6771 St George UT. 84790 Vaughan, Andrew H MD Orthofix Inc (Bone Growth p 435.628.3342 Southern Utah Ear Nose & EBI LLC (Bone Stimulators) Stimulators Physicians Throat Phone Number Only Only) Hospital Affiliation 617 E Riverside Dr p 800.526.2579 Phone Number Only - St George Regional Hospital Ste 201 p 800.535.4492 Saint George UT. 84790 Edgepark Gardner, Kent E MD p 435.628.3334 Phone Number Only Pacific Medical Inc Southern Utah Ear Nose & p 800.321.0591 Phone Number Only Throat Hospital Affiliation p 800.726.9180 617 E Riverside Dr - St George Regional Hospital Empi Inc (Neuromuscular Ste 201 Stimulator) RespirTech Saint George UT. 84790 Wallin, Jordan L MD Phone Number Only Phone Number Only p 435.628.3334 Desert Bloom Plastic p 800.328.2536 p 800.793.1261 Surgery Hospital Affiliation 446 S Mall Dr Fit Well Roche Insulin Delivery - St George Regional Hospital Ste B-1 Prosthetics/Orthotics Systems Inc Saint George UT. 84790 720 S River Rd Phone Number Only Jacob, Joseph R MD p 435.627.8150 Ste A113 p 800.280.7801 Southern Utah Ear Nose & St George UT. 84790 Throat Electrophysiology p 800.854.5462 Smith Nephew Inc (Muscle 617 E Riverside Dr *Burkart, Thomas A MD Stimulators) Ste 201 Southwest Cardiology-St Hall, Phillip C DDS Phone Number Only St George UT. 84790 George Phillip C Hall DDS p 800.821.5700 p 435.628.3334 1380 E Medical Ctr Dr 382 S Bluff Ste 1500 Ste 200 Total Respiratory Care Hospital Affiliation St George UT. 84790 St George UT. 84770 1664 S Dixie Commons - St George Regional Hospital p 435.251.2500 p 435.656.1111 Ste H-111 St George UT. 84770 Lipsman, Rocky A MD Hospital Affiliation Hanger Clinic p 435.688.2089 Southern Utah Ear Nose & - Cedar City Hospital 923 S River Rd Throat Ste 100 US MED LLC 617 E Riverside Dr Cooley, Ryan L MD Saint George UT. 84790 Phone Number Only Ste 201 Revere Health p 435.673.6449 p 800.787.6331 Saint George UT. 84790 1380 E Medical Ctr Dr p 435.628.3334 Ste 4100 *Intermountain Homecare United States Medical Saint George UT. 84790 *Medical Equipment and Supply Hospital Affiliation p 435.251.2900 *Supply St George Phone Number Only - St George Regional Hospital 1424 E Foremaster Dr p 877.840.8218 2825 E Mall Dr Ste 130 *Meier, Jeremy D MD St Geroge UT. 84790 St George UT. 84790 Ear Nose And Throat Primary Childrens Hospital p 435.251.2900 p 435.251.2323 Chase, Steven P MD 736 S 900 E Southern Utah Ear Nose & Ste 107 *Tate, Charles W MD KCI USA Inc (Wound Vac Throat St George UT. 84790 Southwest Cardiology-St Only) 1490 E Foremaster Dr p 435.251.2888 George Phone Number Only Ste 350 1380 E Medical Ctr Dr p 800.275.4524 St George UT. 84790 Hospital Affiliation Ste 1500 p 435.628.3334 - Primary Childrens Hospital St George UT. 84790 p 435.251.2500

570 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. St George Regional Bigham, Thomas H DO Carter, Phillip R PA *Fisher, Jennifer H APRN Hospital Enterprise Valley Medical Hurricane Family Practice St George Sleep Disorders 1380 E Medical Ctr Dr Clinic 11 S Main St Center St George UT. 84790 223 S 200 E Hurricane UT. 84737 652 S Medical Ctr Dr p 435.251.1000 Enterprise UT. 84725 p 435.635.9444 Ste 310 p 435.878.2281 St George UT. 84790 Hospital Affiliation Chamberlain, Howard L MD p 435.251.3940 - Cedar City Hospital *Boyer, Mark C APRN Revere Health St George Regional 2825 E Mall Dr Hospital Affiliation Endocrinology Hospital St Geroge UT. 84790 - St George Regional Hospital Diabetes and Wound Care 1380 E Medical Ctr Dr p 435.673.6131 Clinic of St George St George UT. 84790 Fisher, Mahana S MD 1054 E Riverside Dr p 435.251.1000 736 S 900 E Diabetes and Wound Care Ste 201 Ste 203 Clinic of St George Saint George UT. 84770 Hospital Affiliation St George UT. 84790 1054 E Riverside Dr p 435.574.5123 - St George Regional Hospital p 435.673.6131 Ste 201 Saint George UT. 84790 Grua, James R MD *Cain, Larry A MD Hospital Affiliation p 435.574.5123 Granger Medical River Road Family Practice - St George Regional Hospital Specialists 577 S River Rd Family Healthcare 1308 E 900 S St George UT. 84790 Christensen, Samuel DO 25 N 100 E Ste C p 435.688.6100 Family Healthcare Ste 102 St George UT. 84790 25 N 100 E Saint George UT. 84770 p 801.408.5151 Hospital Affiliation Ste 102 p 435.986.2565 - St George Regional Hospital Saint George UT. 84770 Hospital Affiliation p 435.986.2565 Hospital Affiliation - St George Regional Hospital Callahan, Douglas D DO - Blue Mountain Hospital Callahan Clinic Hospital Affiliation - St George Regional Hospital *Moreno Daza, Monica P MD 1240 E 100 S - St George Regional Hospital St George Regional Ste 15A *Frei, Rhett DO Hospital St George UT. 84790 *Clark, Stephen E DO SGRH Live Well Center 1380 E Medical Ctr Dr p 435.656.5323 River Road Family Practice 652 S Medical Ctr Dr St George UT. 84790 577 S River Rd Ste LL20 p 435.251.1000 Hospital Affiliation St George UT. 84790 St George UT. 84790 - St George Regional Hospital p 435.688.6100 p 435.251.3793 Hospital Affiliation - St George Regional Hospital Callahan, Thomas D MD Hospital Affiliation *Golding, Brady J MD Callahan Clinic - St George Regional Hospital River Road Internal Family Practice 1240 E 100 S Medicine Abegglen, Joanne H APRN Ste 15A Desert Edge Medical 577 S River Rd Zion Pain Management St George UT. 84790 1664 S Dixie Dr St George UT. 84790 301 N 200 E p 435.656.5323 Ste D102 p 435.688.6200 Ste 2A Saint George UT. 84770 St George UT. 84770 Hospital Affiliation p 435.656.2995 Hospital Affiliation p 435.688.7246 - St George Regional Hospital - St George Regional Hospital Esplin, William F DO Hospital Affiliation Carter, Curtis MD Revere Health Graff, William T MD - Cedar City Hospital Revere Health 2825 E Mall Dr Enterprise Valley Medical 2825 E Mall Dr St Geroge UT. 84790 Clinic Allen, Daniel J DO St Geroge UT. 84790 p 435.673.6131 223 S 200 E Shivwits Paiute Medical p 435.673.6131 Enterprise UT. 84725 Clinic 736 S 900 E p 435.878.2281 6109 W 3700 N 736 S 900 E Ste 203 Ivins UT. 84738 Ste 203 Saint George UT. 84790 Hospital Affiliation p 435.688.8198 St George UT. 84790 p 435.673.6131 - St George Regional Hospital p 435.673.6131 Hospital Affiliation Hospital Affiliation *Grames, Chase A DO - West Valley Medical Center Hospital Affiliation - St George Regional Hospital Southwest Ortho and Sports - St George Regional Hospital Med-DSC Barton, Scott D MD *Etzler, Cynthia A APRN 225 S 700 E Revere Health Carter, Melvin R MD St George Regional St George UT. 84770 736 S 900 E Hurricane Family Practice Hospital p 435.251.3600 Ste 203 11 S Main St 1380 E Medical Ctr Dr St George UT. 84790 Hurricane UT. 84737 St George UT. 84790 p 435.673.6131 p 435.635.9444 p 435.251.2474

Hospital Affiliation Hospital Affiliation Hospital Affiliation - St George Regional Hospital - St George Regional Hospital - St George Regional Hospital 571 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Southwest Ortho and Sports *Koldyke, Brian NP Nilsson, Kody J MD Family Healthcare Med River Road Internal Desert Edge Medical 2408 E Riverside Dr 652 S Medical Center Dr Medicine 1664 S Dixie Dr Saint George UT. 84790 Ste 120 577 S River Rd Ste D102 p 435.986.2565 St George UT. 84790 St George UT. 84790 Saint George UT. 84770 p 435.628.4460 p 435.688.6200 p 435.656.2995 391 N 200 W Hurricane UT. 84737 Zion Orthopedics and Hospital Affiliation Noorda, Scott J DO p 435.635.9444 Sports Medicine - St George Regional Hospital Thriver Health 652 S Medical Center Dr - Utah Valley Hospital 640 E 700 E S *Spanos, Seth A MD Ste 400 Ste 201 River Road Family Practice Saint George UT. 84790 *Lloyd, Christina A NP Saint George UT. 84770 577 S River Rd p 435.251.2650 Southwest Cardiology-St p 435.627.3500 St George UT. 84790 George p 435.688.6100 *Hansen, Jay H MD 1380 E Medical Ctr Dr Ogden, Walter MD Sunset Family Practice Ste 1500 1404 W Sun River Pkwy Hospital Affiliation 1739 W Sunset Blvd Saint George UT. 84790 St George UT. 84790 - St George Regional Hospital St George UT. 84770 p 435.251.2500 p 435.635.9444 p 435.634.6000 Stirling, Todd A PA Lunt, Bryce C MD Page, Trevor DO Advanced Pain Management Hubbard, Jonathan P DO Revere Health Family Healthcare 620 S 400 E Revere Health 2825 E Mall Dr 245 E 680 S Ste 201 2825 E Mall Dr St Geroge UT. 84790 Cedar City UT. 84770 St George UT. 84770 St Geroge UT. 84790 p 435.673.6131 p 435.986.2565 p 435.656.0029 p 435.673.6131 736 S 500 E 25 N 100 E Stratford, Charles K MD 736 S 900 E Ste 203 Ste 102 Revere Health Ste 203 Saint George UT. 84790 St George UT. 84770 2825 E Mall Dr St George UT. 84790 p 435.673.6131 p 435.986.2565 St Geroge UT. 84790 p 435.673.6131 p 435.673.6131 *McIff, Matthew S MD Hospital Affiliation Hospital Affiliation Sunset Family Practice - St George Regional Hospital 736 S 900 E - St George Regional Hospital 1739 W Sunset Blvd Ste 203 St George UT. 84770 Pendleton, Gus C MD St George UT. 84790 Johnson, Charlotte B NP p 435.634.6000 Revere Health p 435.673.6131 Hildale Health Service 2825 E Mall Dr Center McMahon, K Tiffany APRN St Geroge UT. 84790 Hospital Affiliation 1065 N Hildale St Utah Surgical Associates p 435.673.6131 - St George Regional Hospital Hildale UT. 84784 1490 E Foremaster Dr p 435.874.2217 Ste 200 736 S 900 E *Thompson, Bradley S MD St George UT. 84790 Ste 203 River Road Family Practice Kirk, Shelly F FNP p 435.628.1641 St George UT. 84790 577 S River Rd Red Hills Wellness Center p 435.673.6131 St George UT. 84790 301 N 200 E Hospital Affiliation p 435.688.6100 Ste 2C - St George Regional Hospital Hospital Affiliation St George UT. 84770 - St George Regional Hospital Hospital Affiliation p 435.674.1700 *Millward, Christian S MD - St George Regional Hospital Southwest Ortho and Sports Radley, Karen M MD *Kline, Michael R MD Med 965 E 700 S Thriver Health St George Pulmonary Clinic 652 S Medical Center Dr Ste 300 640 E 700 E S 1380 E Medical Ctr Dr Ste 120 Saint George UT. 84790 Ste 201 Ste 2200 St George UT. 84790 p 435.673.4644 Saint George UT. 84770 St George UT. 84790 p 435.628.4460 p 435.627.3500 p 435.251.2600 Hospital Affiliation *Miner, Jared T MD - St George Regional Hospital Winger, Gregory L MD St George Pulmonary River Road Family Practice Revere Health Critical Care 577 S River Rd Riggs, Brannick B MD 2825 E Mall Dr 1380 E Medical Ctr Dr St George UT. 84790 Thriver Health St Geroge UT. 84790 St George UT. 84790 p 435.688.6100 640 E 700 E S p 435.673.6131 p 435.251.2600 Ste 201 *Moon, Sheldon B MD Saint George UT. 84770 736 S 500 E Hospital Affiliation Hurricane Valley Clinic p 435.627.3500 Ste 203 - St George Regional Hospital 75 N 2260 W Saint George UT. 84790 Hurricane UT. 84737 p 435.674.6065 p 435.635.6500

572 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Worwood, Danny K MD General Surgery Myers, Brad A MD *Mladucky, Janessa K GC Hurricane Valley Clinic Benedict, Amy J APRN Utah Surgical Associates St George Maternal Fetal 75 N 2260 W Revere Health 1490 E Foremaster Dr Medicine Hurricane UT. 84737 1380 E Medical Ctr Dr Ste 200 1380 E Medical Ctr Dr p 435.635.6500 Ste 4100 St George UT. 84790 Ste 1600 St George UT. 84790 p 435.628.1641 St George UT. 84790 Hospital Affiliation p 435.251.2900 p 435.688.4770 - St George Regional Hospital Hospital Affiliation Christensen, Autum APRN - St George Regional Hospital Geriatrics Gastroenterology Utah Surgical Associates *Gulbranson, Loren K MD *Ammar, Tarek MD 1490 E Foremaster Dr Speakman, James J MD River Road Internal Redrock Digestive Health Ste 200 Utah Surgical Associates Medicine 1380 E Medical Ctr Dr St George UT. 84790 1490 E Foremaster Dr 577 S River Rd Ste 4100 p 435.628.1641 Ste 200 St George UT. 84790 Saint George UT. 84790 St George UT. 84790 p 435.688.6200 p 435.251.3800 Hospital Affiliation p 435.628.1641 - St George Regional Hospital Hospital Affiliation Hospital Affiliation Hospital Affiliation - St George Regional Hospital - St George Regional Hospital Hanza, Ivo K NP - St George Regional Hospital - St George Regional Hospital Utah Surgical Associates Gynecologic Oncology 1490 E Foremaster Dr *Sutherland, John B MD Hunn, Jessica R MD Bown, James W MD Ste 200 St George Regional Valley Obstetrics & Utah Gastroenterology St George UT. 84790 Hospital Physicians Gynecology 368 E Riverside Dr p 435.628.1641 1380 E Medical Ctr Dr 515 S 300 E Ste A St George UT. 84790 Ste 206 St George UT. 84790 Hospital Affiliation p 435.251.1000 Saint George UT. 84770 p 435.673.1149 - St George Regional Hospital p 385.347.5450 Utah Surgical Associates Hospital Affiliation Jennings, Cameron S MD 1490 E Foremaster Dr Hospital Affiliation - St George Regional Hospital Utah Surgical Associates Ste 200 - St Marks Hospital 1490 E Foremaster Dr Saint George UT. 84790 - Lone Peak Hospital *Gunnerson, A C DO Ste 200 p 435.628.1641 - Mountain View Hospital Redrock Digestive Health Saint George UT. 84790 (UT) 1380 E Medical Ctr Dr p 435.628.1641 Hospital Affiliation - Ogden Region Medical Ste 4100 - Cedar City Hospital Center Saint George UT. 84790 Lewis, Ryan L DO p 435.251.3800 Utah Surgical Associates Watson, Gregory L DO Webb, Joel C MD 1490 E Foremaster Dr Utah Surgical Associates Valley Obstetrics & Hospital Affiliation Ste 200 1490 E Foremaster Dr Gynecology - Cedar City Hospital St George UT. 84790 Ste 200 295 S 1470 E p 435.628.1641 St George UT. 84790 Ste 200 Hixson, Lee J MD p 435.628.1641 Saint George UT. 84790 Utah Gastroenterology Hospital Affiliation p 435.628.1662 368 E Riverside Dr - St George Regional Hospital Hospital Affiliation Ste A - St George Regional Hospital Hospital Affiliation Saint George UT. 84790 Miller, John T MD - Kane County Hospital - St Marks Hospital p 435.673.1149 Utah Surgical Associates - Utah Valley Hospital 1490 E Foremaster Dr Wintch, Richard W MD Hospital Affiliation Ste 200 515 S 300 E Gynecology - St George Regional Hospital St George UT. 84790 Ste 102 Astle, Craig D MD p 435.628.1641 St George UT. 84770 Valley Obstetrics & Siddoway, Roger L MD p 435.628.4489 Gynecology Utah Gastroenterology Hospital Affiliation 515 S 300 E 368 E Riverside Dr - St George Regional Hospital Hospital Affiliation Ste 206 Ste A - St George Regional Hospital Saint George UT. 84770 St George UT. 84790 Munford, Michael I MD p 435.628.1662 p 435.673.1149 Advanced Vein and Vascular Genetic Counseling of Southern Utah *Arch, Ellen M MD Hospital Affiliation Hospital Affiliation 676 S Bluff St St George Regional - St George Regional Hospital - St George Regional Hospital Ste 101 Hospital Saint George UT. 84770 544 S 400 E Benham, Brady N MD *Snyder, Ethan PA p 435.673.0095 St George UT. 84770 Valley Obstetrics & St George Acute Rehab p 435.688.4000 Gynecology 544 S 400 E Hospital Affiliation 515 S 300 E St George UT. 84770 - Cedar City Hospital Ste 206 p 435.688.4700 Saint George UT. 84770 p 435.628.1662 Hospital Affiliation - St George Regional Hospital Hospital Affiliation - St George Regional Hospital573 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Brown, Coby T MD *Ellis, Diane E MD Lynn, Sean F MD Riverside Medical Arts Valley Obstetrics & St George High Risk OB Snow Canyon Womens Center 1068 E Riverside Dr Gynecology 544 S 400 E 965 E 700 S St George UT. 84790 515 S 300 E St George UT. 84770 Ste 105 p 435.628.6466 Ste 206 p 435.688.4770 Saint George UT. 84790 Saint George UT. 84770 p 435.218.7770 Hospital Affiliation p 435.628.1662 Hospital Affiliation - St George Regional Hospital - University of Utah Hospital Hospital Affiliation Hospital Affiliation - Saint Alphonsus Medical *Walker, Kathryn MD - St George Regional Hospital Hendrickson, Johanna Center - Nampa Womens Health Specialists PA-C 346 E 600 S Carter, Gayle M MD Valley Obstetrics & *Miller, Emma DO St George UT. 84770 Riverside Medical Arts Gynecology St George High Risk OB p 435.688.4600 1068 E Riverside Dr 515 S 300 E 1380 E Medical Ctr Dr St George UT. 84790 Ste 206 Ste 1600 St George High Risk OB p 435.628.6466 Saint George UT. 84770 St George UT. 84790 544 S 400 E p 435.628.1662 p 435.251.4170 St George UT. 84770 Hospital Affiliation p 435.688.4770 - St George Regional Hospital Hospital Affiliation Hospital Affiliation - St George Regional Hospital - Timpanogos Regional Hospital Welsh, Joy L MD *Chalmers, Robert W MD 1490 E Foremaster Dr Womens Health Specialists *Heuser, Cara C MD *Nichols, John M DO Ste 310 346 E 600 S St George Maternal And St George High Risk OB St George UT. 84790 St George UT. 84770 Fetal Medicine 544 S 400 E p 435.688.1922 p 435.688.4600 544 S 400 E St George UT. 84770 St George UT. 84770 p 435.688.4770 Hospital Affiliation St George High Risk OB p 435.688.4770 - St George Regional Hospital 544 S 400 E Hospital Affiliation St George UT. 84770 Hospital Affiliation - St George Regional Hospital Winward, Tracy W MD p 435.688.4770 - University of Utah Hospital - Jordan Valley Medical Valley Obstetrics & Center Gynecology Hospital Affiliation *Howey, Susan M MD 515 S 300 E - St George Regional Hospital St George High Risk OB *Ott, Richard W MD Ste 206 544 S 400 E Womens Health Specialists Saint George UT. 84770 *Chun Moon, Deborah M MD St George UT. 84770 346 E 600 S p 435.628.1662 St George Maternal And p 435.688.4770 St George UT. 84770 Fetal Medicine p 435.688.4600 Hospital Affiliation 544 S 400 E Kirk, Shelly F FNP - St George Regional Hospital St George UT. 84770 Red Hills Wellness Center Hospital Affiliation p 435.688.4770 301 N 200 E - St George Regional Hospital *Wong, Alice MD Ste 2C St George High Risk OB Hospital Affiliation St George UT. 84770 Planned Parenthood 544 S 400 E - St George Regional Hospital p 435.674.1700 Association of Utah St George UT. 84770 595 S Bluff St p 435.688.4770 Eggert, Joan V MD Kvarfordt, Tracy MD St George UT. 84770 Valley Obstetrics & St George OB/GYN p 435.674.9933 Hand Surgery Gynecology 295 S 1470 E Chase, Lawrence J MD 515 S 300 E Ste 300 Rogers, Jeffrey G MD Chase Plastic Surgery Ste 206 Saint George UT. 84790 Valley Obstetrics & 321 N Mall Dr Bldg N Saint George UT. 84770 p 435.647.0999 Gynecology St George UT. 84790 p 435.628.1662 515 S 300 E p 435.634.0358 515 S 300 E Ste 206 Hospital Affiliation Ste 205 Saint George UT. 84770 Hospital Affiliation - St George Regional Hospital St George UT. 84770 p 435.628.1662 - St George Regional Hospital p 435.674.0999 *Eller, Alexandra G MD Hospital Affiliation Hutchinson, Douglas T MD St George Maternal And Hospital Affiliation - St George Regional Hospital University of Utah Health Fetal Medicine - St George Regional Hospital 652 S Medical Ctr Dr 544 S 400 E Sorensen, Pamela J PA Saint George UT. 84790 St George UT. 84770 Lunt, Chad C MD Valley Obstetrics & p 435.251.2250 p 435.688.4770 St George OB/GYN Gynecology 295 S 1470 E 515 S 300 E Hospital Affiliation Hospital Affiliation Ste 300 Ste 206 - University of Utah Hospital - University of Utah Hospital Saint George UT. 84790 Saint George UT. 84770 p 435.647.0999 p 435.628.1662

Hospital Affiliation - St George Regional Hospital 574 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Slade, Dirk L MD *Motyckova, Gabriela MD 544 S 400 E Hospice Alliance Zion Orthopedics and BMT Leukemia Program SWR St George UT. 84770 965 E 700 S Sports Medicine 544 S 400 E p 435.251.2205 Ste 201 652 S Medical Center Dr St George UT. 84770 St George UT. 84790 Ste 400 p 435.688.4900 Home Health Agency p 435.656.2889 St George UT. 84790 Applegate Homecare and p 435.251.2650 *Reese, Zachary L MD Hospice *Intermountain Homecare Southwest Regional Cancer 1490 E Foremaster Dr *Hospice St George Hospital Affiliation Clinic Ste 340 1424 E Foremaster Dr - St George Regional Hospital 544 S 400 E St George UT. 84790 Ste 130 St George UT. 84770 p 435.628.1569 St George UT. 84790 Health Department p 435.688.4900 p 435.251.2367 Southwest Utah Public CNS Community Nursing Health Department Intermountain Cancer Services Rocky Mountain Home Care 620 S 400 E Center of St George 720 S River Rd 736 S 900 E Ste 400 600 S Medical Dr Ste E-101 Ste B-107 St George UT. 84770 Saint George UT. 84790 St George UT. 84790 Saint George UT. 84790 p 435.652.4078 p 435.251.4900 p 866.652.9077 p 801.693.2300

Hematology And Oncology Hospital Affiliation Horizon Home Health Rocky Mountain Hospice *Asch, Julie D MD - St George Regional Hospital 292 S 1470 E 736 S 900 E BMT Leukemia Program SWR - Cedar City Hospital Ste 101 Ste B-107 544 S 400 E Saint George UT. 84790 St George UT. 84790 St George UT. 84770 Te, Joseph D MD p 435.688.9202 p 435.673.6699 p 435.688.4900 Revere Health 2019 E Riverside Dr Hospice Alliance Hospital Hospital Affiliation Ste A200 965 E 700 S *St George Regional - Primary Childrens Hospital St George UT. 84790 Ste 201 *Hospital p 435.628.9298 St George UT. 84790 1380 E Medical Ctr Dr *Gilbert, M H MD p 435.656.2889 Saint George UT. 84790 Southwest Regional Cancer Hospital Affiliation p 435.251.1000 Clinic - St George Regional Hospital *Intermountain Homecare 544 S 400 E *Home Health St George Hyperbaric Medicine St George UT. 84770 *Tudor, Brian P MD 1424 E Foremaster Dr *Beckstrand, Devin MD p 435.688.4900 Southwest Regional Cancer Ste 130 St George Wound And Clinic St George UT. 84790 Hyperbaric Hospital Affiliation 544 S 400 E p 435.251.2367 544 S 400 E - St George Regional Hospital St George UT. 84770 St George UT. 84770 p 435.688.4900 Rocky Mountain Home Care p 435.688.4293 *Gouw, Launce MD 736 S 900 E BMT Leukemia Program SWR Hospital Affiliation Ste B-107 Hospital Affiliation 544 S 400 E - St George Regional Hospital Saint George UT. 84790 - St George Regional Hospital St George UT. 84770 - Cedar City Hospital p 801.693.2300 p 435.688.4900 *Cascio, Michael J MD *Wilcox, Ryan E MD Hospice St George Wound And *Konopa, Kelly L MD Southwest Regional Cancer Applegate Homecare and Hyperbaric BMT Leukemia Program SWR Clinic Hospice 544 S 400 E 544 S 400 E 544 S 400 E 1490 E Foremaster Dr St George UT. 84770 St George UT. 84770 St George UT. 84770 Ste 340 p 435.688.4293 p 435.688.4900 p 435.688.4900 St George UT. 84790 p 435.628.1569 Hospital Affiliation Lim, Ming Y MD Intermountain Cancer - St George Regional Hospital University of Utah Health Center CNS Community Nursing - Cedar City Hospital 1380 E Medical Ctr Dr 600 S Medical Dr Services Saint George UT. 84790 Saint George UT. 84790 720 S River Rd Eggert, Joan V MD p 801.213.3599 p 435.251.4900 Ste E-101 Valley Obstetrics & St George UT. 84790 Gynecology Hospital Affiliation Hospital Affiliation p 866.652.9077 515 S 300 E - University of Utah Hospital - St George Regional Hospital Ste 206 - Cedar City Hospital Horizon Hospice Saint George UT. 84770 *Lin, Karen Y MD Specialists p 435.628.1662 Southwest Regional Cancer Hematology 292 S 1470 E Clinic Lundell, Ryan MD Ste 101 Hospital Affiliation 544 S 400 E Pathology Services St George UT. 84790 - St George Regional Hospital St George UT. 84770 1380 E Medical Ctr Dr p 435.674.4744 p 435.688.4900 St George UT. 84790 p 435.251.2205 Hospital Affiliation - St George Regional Hospital 575 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Infectious Disease 736 S 500 E Gandhi, Zahabia T MD *Horani, Jamal MD *Horani, Jamal MD Ste 203 Advanced Pulmonary, Sleep St George Infectious St George Infectious Saint George UT. 84790 Disorders and Internal Disease Clinic Disease Clinic p 435.673.6131 Medicine 1380 E Medical Ctr Dr 1380 E Medical Ctr Dr 640 E 700 S Ste 2300 Ste 2300 Hospital Affiliation Ste 105 St George UT. 84790 St George UT. 84790 - Lone Peak Hospital St George UT. 84770 p 435.251.2620 p 435.251.2620 p 435.688.7770 Codiga, Michael A MD Hospital Affiliation Hospital Affiliation Pacific Medical Associates Hospital Affiliation - Jordan Valley Medical - Jordan Valley Medical 1380 E Medical Ctr Dr - St George Regional Hospital Center Center St George UT. 84790 p 435.251.1000 *Gardner, Blake I MD *Jones, Thomas K MD Infusion Agency St George Regional River Road Internal *Intermountain Homecare 321 N Mall Dr Hospital Medicine *Pharmacy Ste 102 1380 E Medical Ctr Dr 577 S River Rd 1380 E Medical Ctr Dr Saint George UT. 84790 St George UT. 84790 St George UT. 84790 St George UT. 84790 p 435.628.3651 p 435.251.1000 p 435.688.6200 p 435.251.2425 Hospital Affiliation *Gilbert, M H MD Hospital Affiliation Internal Medicine - St George Regional Hospital Southwest Regional Cancer - St George Regional Hospital Advanced Vein and Vascular Clinic of Southern Utah Dixie Primary Care 544 S 400 E Kim, Christopher Y MD 676 S Bluff St 292 S 1470 E St George UT. 84770 Advanced Vein and Vascular Ste 101 Ste 200 p 435.688.4900 of Southern Utah Saint George UT. 84770 Saint George UT. 84790 676 S Bluff St p 435.673.0095 p 435.688.0759 Hospital Affiliation Ste 101 - St George Regional Hospital Saint George UT. 84770 Assiago, Marcellus S MD *Ellis, Corey S DO p 435.673.0095 University of Utah Health River Road Internal *Gouw, Launce MD 1380 E Medical Ctr Dr Medicine BMT Leukemia Program SWR Hospital Affiliation Saint George UT. 84790 577 S River Rd 544 S 400 E - Davis Hospital p 435.251.1000 St George UT. 84790 St George UT. 84770 - Lakeview Hospital p 435.688.6200 p 435.688.4900 - Ogden Regional Medical 48 S 2500 W Center Ste 100 Hospital Affiliation Grua, James R MD - Salt Lake Regional Medical Hurricane UT. 84737 - St George Regional Hospital Granger Medical Center p 435.673.3556 Specialists Eppich, Irel S MD 1308 E 900 S *Kline, Michael R MD 720 S River Rd University of Utah Health Ste C St George Pulmonary Clinic Ste D1100 48 S 2500 W St George UT. 84790 1380 E Medical Ctr Dr Saint George UT. 84790 Ste 100 p 801.408.5151 Ste 2200 p 435.656.0857 Hurricane UT. 84737 St George UT. 84790 p 435.635.0399 Hospital Affiliation p 435.251.2600 Hospital Affiliation - St George Regional Hospital - University of Utah Hospital Hospital Affiliation St George Pulmonary - Davis Hospital - University of Utah Hospital *Haberle, Tyler H MD Critical Care - Mountain View Hospital River Road Internal 1380 E Medical Ctr Dr Baza, Jonathan DO (UT) Medicine St George UT. 84790 Dixie Primary Care - Timpanogos Regional Hospital 577 S River Rd p 435.251.2600 292 S 1470 E St George UT. 84790 Ste 200 Foster, Christine K MD p 435.688.6200 Hospital Affiliation Saint George UT. 84790 Revere Health - St George Regional Hospital p 435.688.0759 2825 E Mall Dr Hospital Affiliation Saint George UT. 84790 - St George Regional Hospital LaRowe, Judd L MD Hospital Affiliation p 801.374.2362 1664 S Dixie Dr - St George Regional Hospital *Hansen, Jason L MD Ste D-102 Frame, Joshua L DO River Road Internal St George UT. 84770 Bennett, Richard W MD Southwest Internal Medicine p 435.656.2995 Revere Health Medicine 577 S River Rd 2825 E Mall Dr 292 S 1470 E St George UT. 84790 Hospital Affiliation St Geroge UT. 84790 Ste 100 p 435.688.6200 - St George Regional Hospital p 435.673.6131 St George UT. 84790 p 435.628.9200 Hospital Affiliation - St George Regional Hospital Hospital Affiliation - St George Regional Hospital

576 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Madsen, Daniel B MD Raj Krishnamurthy, Vidya *Warner, Claude A MD Laboratory Southwest Internal M MD St George Regional Dominion Diagnostics Medicine University of Utah Health Hospital Phone Number Only 292 S 1470 E 1380 E Medical Ctr Dr 1380 E Medical Ctr Dr p 877.734.9600 Ste 100 Saint George UT. 84790 St George UT. 84790 St George UT. 84790 p 435.251.1000 p 435.251.1000 LabCorp Draw Station p 435.628.9200 1490 E Foremaster Dr Hospital Affiliation River Road Internal Ste 130 Hospital Affiliation - University of Utah Hospital Medicine St George UT. 84790 - St George Regional Hospital 577 S River Rd p 435.673.8266 Rencher, Tyler W DO St George UT. 84790 Miller, Brien R MD Dixie Primary Care p 435.688.6200 LabCorp of America Utah Gastroenterology 292 S 1470 E Holdings 368 E Riverside Dr Ste 200 Hospital Affiliation Phone Number Only Ste A Saint George UT. 84790 - St George Regional Hospital p 888.522.2677 Saint George UT. 84790 p 435.688.0759 p 435.673.1149 Woolley, Joseph H MD Maternal And Fetal Medicine Roy, Abinash C MD Southwest Internal *Andres, Robert L MD *Mitchell, Birgitta H MD University of Utah Health Medicine St George Maternal And BMT Leukemia Program SWR 1380 E Medical Ctr Dr 292 S 1470 E Fetal Medicine 544 S 400 E Saint George UT. 84790 Ste 100 544 S 400 E St George UT. 84770 p 435.251.1000 St George UT. 84790 St George UT. 84770 p 435.688.4900 p 435.628.9200 p 435.688.4770 720 S River Rd *Obray, Cathleen F MD Ste D1100 Hospital Affiliation Hospital Affiliation River Road Internal Saint George UT. 84790 - St George Regional Hospital - University of Utah Hospital Medicine p 435.656.0857 577 S River Rd Interventional Cardiology *Branch, D W MD St George UT. 84790 Hospital Affiliation *Gardner, Blake I MD St George Maternal And p 435.688.6200 - St George Regional Hospital Southwest Cardiology-St Fetal Medicine - University of Utah Hospital George 544 S 400 E Hospital Affiliation 1380 E Medical Ctr Dr St George UT. 84770 - St George Regional Hospital *Smith, Gordon L MD Ste 1500 p 435.688.4770 River Road Internal St George UT. 84790 Paradela, Grace MD Medicine p 435.251.2500 Hospital Affiliation Dixie Primary Care 577 S River Rd - University of Utah Hospital 292 S 1470 E St George UT. 84790 Cardiovascular and Ste 200 p 435.688.6200 Thoracic Surgery - St *Draper, Michael L MD Saint George UT. 84790 George St George Maternal And p 435.688.0759 Hospital Affiliation 1380 E Medical Ctr Dr Fetal Medicine - St George Regional Hospital Ste 2600 544 S 400 E Hospital Affiliation Saint George UT. 84790 St George UT. 84770 - St George Regional Hospital Staheli, John K MD p 435.251.2700 p 435.688.4770 Revere Health *Parkinson, J Scott DO 736 S 900 E Hospital Affiliation Hospital Affiliation St George Regional Ste 203 - St George Regional Hospital - University of Utah Hospital Hospital Saint George UT. 84790 - Davis Hospital 1380 E Medical Ctr Dr p 435.673.6131 Kim, Christopher Y MD - Jordan Valley Medical St George UT. 84790 Advanced Vein and Vascular Center p 435.251.2474 Hospital Affiliation of Southern Utah - Salt Lake Regional Medical - Timpanogos Regional Hospital 676 S Bluff St Center River Road Internal Ste 101 Medicine Wallin, Brett S MD Saint George UT. 84770 *Esplin, M S MD 577 S River Rd Desert Vista Internal p 435.673.0095 St George Maternal And St George UT. 84790 Medicine Fetal Medicine p 435.688.6200 368 E Riverside Dr Hospital Affiliation 544 S 400 E Ste 3B - Davis Hospital St George UT. 84770 Hospital Affiliation St George UT. 84790 - Lakeview Hospital p 435.688.4770 - St George Regional Hospital p 435.656.3324 - Ogden Regional Medical Center Hospital Affiliation Powell, John J PA-C Hospital Affiliation - Salt Lake Regional Medical - University of Utah Hospital Southwest Internal - St George Regional Hospital Center Medicine 292 S 1470 E Ste 100 St George UT. 84790 p 435.628.9200

Hospital Affiliation - St George Regional Hospital 577 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Hales, Kurt A MD Medical Genetics Barlow, Tiffany LCSW Butterfield, Brittney St George Maternal And Porter, Glen S ACMHC Red Desert Counseling BCBA Fetal Medicine Transitions Therapy 230 N 1680 E Bldg 1 Chrysalis Utah 544 S 400 E Associates Ste 2 230 N 1680 E St George UT. 84770 283 Auto Mall Dr Saint George UT. 84790 Ste OP p 435.688.4770 Ste 4 p 801.906.1736 Saint George UT. 84790 Saint George UT. 84770 p 801.655.4950 *Page, Jessica M MD p 435.227.5052 *Baumgarten, Victor A LCSW St George Maternal Fetal Int Psychiatry and Center for Couples & Medicine Mental Health Counseling-St George Families 1380 E Medical Ctr Dr Acevedo, Carlos ACMHC 320 E 600 S 1173 S 250 W Bldg I Ste 1600 Utah Behavior Services St George UT. 84770 Ste 208 St George UT. 84790 1067 E Tabernacle St p 435.688.4850 Saint George UT. 84770 p 435.688.4770 Ste 7 p 435.688.1111 Saint George UT. 84770 Beatty, Eva LCSW Hospital Affiliation p 801.255.5131 437 S Bluff St 52 S 850 W - University of Utah Hospital Ste 202 Ste 202B Adolphson, Lillian Saint George UT. 84770 Hurricane UT. 84737 *Porter, Troy F MD BCBA-D p 435.272.7974 p 435.688.1111 St George Maternal And Utah Behavior Services Fetal Medicine 1067 E Tabernacle St Bell, Brynn BCBA,LCSW Chamberlain, Cary LCSW 544 S 400 E Ste 7 Utah Behavior Services 1224 S River Rd St George UT. 84770 St George UT. 84770 1067 E Tabernacle St Ste B-230 p 435.688.4770 p 801.255.5131 Ste 7 St George UT. 84790 St George UT. 84770 p 435.632.0946 Hospital Affiliation Aleman, Arianna BCBA p 801.255.5131 - University of Utah Hospital Utah Behavior Services Child, Steve LCSW 1067 E Tabernacle St Bess, Cleola CMHC Center for Couples & *Richards, Douglas S MD Ste 7 S & S Counseling Families St George Maternal And Saint George UT. 84770 321 N Mall Dr 1173 S 250 W Bldg I Fetal Medicine p 801.255.5131 Ste E102 Ste 208 544 S 400 E Washington UT. 84780 Saint George UT. 84770 St George UT. 84770 Arballo, Jennifer CSW p 435.932.3672 p 435.688.1111 p 435.688.4770 Utah Behavior Services 1067 E Tabernacle St Birch, Kelly LCSW Cho, Jaeyong MSW Hospital Affiliation Ste 7 Utah Behavior Services Utah Behavior Services - University of Utah Hospital St George UT. 84770 1067 E Tabernacle St 1067 E Tabernacle St p 801.255.5131 Ste 7 Ste 7 *Silver, Robert M MD St George UT. 84770 Saint George UT. 84770 St George Maternal And Arbizu, Jamie CMHC p 801.255.5131 p 801.255.5131 Fetal Medicine Core Compass Counseling 544 S 400 E 4 S 2600 W Black, Jed CMHC Christiansen, Ryan J LCSW St George UT. 84770 Ste 6 Utah Behavior Services ABC Counseling Services p 435.688.4770 Hurricane UT. 84737 1067 E Tabernacle St 169 W 2710 S Cir p 435.229.8405 Ste 7 Ste 201-A Hospital Affiliation Saint George UT. 84770 St George UT. 84790 - University of Utah Hospital Archuleta, Jason LCSW p 801.255.5131 p 435.674.6650 - Davis Hospital Utah Behavior Services 1067 E Tabernacle St Bracken, Talaisha LCSW Christianson, Grete BCBA *Varner, Michael W MD Ste 7 Family Healthcare Utah Behavior Services St George Maternal And St George UT. 84770 245 E 680 S 1067 E Tabernacle St Fetal Medicine p 801.255.5131 Cedar City UT. 84770 Ste 7 544 S 400 E p 435.865.1387 St George UT. 84770 St George UT. 84770 Bacon, Jaime L LCSW p 801.255.5131 p 435.688.4770 321 N Mall Dr 25 N 100 E Ste I-201 Ste 102 Chrysalis Utah Hospital Affiliation St George UT. 84790 St George UT. 84770 230 N 1680 E - University of Utah Hospital p 435.652.2114 p 435.986.2565 Ste OP Saint George UT. 84790 *Whitecar, Paul W MD Hospital Affiliation Bunting, Catherine CSW p 801.655.4950 St George Maternal Fetal - St George Regional Hospital Utah Behavior Services Medicine 1067 E Tabernacle St Coburn, Alison MSW 1380 E Medical Ctr Dr Ste 7 Utah Behavior Services Ste N1600 Saint George UT. 84770 1067 E Tabernacle St St George UT. 84770 p 801.255.5131 Ste 7 p 435.688.4770 St George UT. 84770 p 801.255.5131

578 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Corey, Spencer BCBA Finke, Karen A LPC Behavioral Health Access *Johnson, Kevin R LCSW Utah Behavior Services Karen A Finke CMHC Center - SGRH SGRH Rehab Center 1067 E Tabernacle St 415 N State St 544 S 400 E 652 S Medical Ctr Dr Ste 7 Ste 201 St George UT. 84770 Ste LL10 Saint George UT. 84770 Hurricane UT. 84737 p 435.688.4290 St George UT. 84790 p 801.255.5131 p 406.570.2915 p 435.251.2250 *Hall, W C PhD Deceuster, Rachael BCBA Fujiwara, Mina BCBA Int Psychiatry and Johnston, Harmony MSW Utah Behavior Services Utah Behavior Services Counseling-St George Utah Behavior Services 1067 E Tabernacle St 1067 E Tabernacle St 292 S 1470 E 1067 E Tabernacle St Ste 7 Ste 7 St George UT. 84790 Ste 7 Saint George UT. 84770 St George UT. 84770 p 435.251.5900 Saint George UT. 84770 p 801.255.5131 p 801.255.5131 p 801.255.5131 River Road Internal *Edwards, Elisa A NP Gibbons, Debra LMFT Medicine Jones, David H LMFT St George Regional 321 N Mall Dr Bldg O, 577 S River Rd Red Mountain Counseling Hospital Physicians Ste 101 St George UT. 84790 and Education 1380 E Medical Ctr Dr Saint George UT. 84790 p 435.688.6200 321 N MAll Dr St George UT. 84790 p 435.868.8376 Ste VW-103 p 435.251.1000 Helquist, Linda M LMFT Saint George UT. 84790 Gomez, Carlos E LCSW Alpine Counseling Group p 435.767.1532 Hospital Affiliation Trauma Treatment & 321 N Mall Dr - St George Regional Hospital Counseling Ste 0-101 Keller, Rebecca BCBA 166 N 300 W Saint George UT. 84790 Utah Behavior Services Empey, Dallas PhD Ste 3 p 435.200.9413 1067 E Tabernacle St 905 N Talasi Way Saint George UT. 84770 Ste 7 Ivins UT. 84738 p 435.817.9026 Hinton, Angela CMHC St George UT. 84770 p 801.644.9244 Hinton Counseling p 801.255.5131 1664 S Dixie Dr 230 N 1680 E *Everett, Ethan R PSYD Ste E102 Ste I-2 Kennedy, Anne BCBA Int Psychiatry and Saint George UT. 84770 Saint George UT. 84790 Utah Behavior Services Counseling-St George p 435.817.9026 p 435.767.1072 1067 E Tabernacle St 320 E 600 S Ste 7 St George UT. 84770 Goss, Angela CSW Hoffmann, Audrey PhD St George UT. 84770 p 435.688.4850 Utah Behavior Services Utah Behavior Services p 801.255.5131 1067 E Tabernacle St 1067 E Tabernacle St Hurricane Valley Clinic Ste 7 Ste 7 King, Kelsey LCSW 75 N 2260 W St George UT. 84770 Saint George UT. 84770 Utah Behavior Services Hurricane UT. 84737 p 801.255.5131 p 801.255.5131 1067 E Tabernacle St p 435.635.6500 Ste 7 Green, Rachal BCBA,LCSW Holmes, Alisha MSW St George UT. 84770 Evolving Light Counseling Utah Behavior Services Utah Behavior Services p 801.255.5131 32 E 100 S 1067 E Tabernacle St 1067 E Tabernacle St Ste 202 Ste 7 Ste 7 Knudson, Mani BCBA Saint George UT. 84770 St George UT. 84770 Saint George UT. 84770 Utah Behavior Services p 435.628.8945 p 801.255.5131 p 801.255.5131 1067 E Tabernacle St Ste 7 *Farnsworth, Heather L NP Gressmen, Casey BCBA Hunt, Chelseigh BCBA St George UT. 84770 Sunset Family Practice Utah Behavior Services Utah Behavior Services p 801.255.5131 1739 W Sunset Blvd 1067 E Tabernacle St 1067 E Tabernacle St St George UT. 84770 Ste 7 Ste 7 Kockler, Timothy R PhD p 435.634.6000 St George UT. 84770 Saint George UT. 84770 Timothy Richard Kockler, p 801.255.5131 p 801.255.5131 LLC Hospital Affiliation 1224 S River Rd - St George Regional Hospital *Grimwood, Brian L DO Jenkins, Nancy LPC Ste B-221 Redrock Pediatrics Nancy Jenkins LPC St George UT. 84790 Fatkin, Kenneth LMFT 1380 E Medical Ctr Dr 321 N Mall Dr p 435.632.1445 Family Healthcare Ste 3100 Ste 201 Bldg B 25 N 100 E St George UT. 84790 Saint George UT. 84790 Koford, Martin CMHC Ste 102 p 435.251.2740 p 801.949.1323 Center for Couples & Saint George UT. 84770 Families p 435.986.2565 Int Psychiatry and Jensen, Julia P BCBA 1173 S 250 W Bldg I Counseling-St George Utah Behavior Services Ste 208 320 E 600 S 1067 E Tabernacle St Saint George UT. 84770 St George UT. 84770 Ste 7 p 435.688.1111 p 435.688.4850 Saint George UT. 84770 p 801.255.5131

579 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Kulow, Kacylia BCBA *Mackay, Matthew PhD Mendez, Ari LCSW Nielsen, Cantril MD Utah Behavior Services Int Psychiatry and Family Healthcare St George Children & 1067 E Tabernacle St Counseling-St George 25 N 100 E Family Psychiatric Center Ste 7 320 E 600 S Ste 102 230 N 1680 E Saint George UT. 84770 St George UT. 84770 St George UT. 84770 Ste H-1 p 801.255.5131 p 435.688.4850 p 435.986.2565 St George UT. 84790 p 435.652.1897 Lambertsen, Hope BCBA Madsen, Sara BCBA Ari Mendez LCSW Utah Behavior Services Utah Behavior Services 32 E 100 S Behavioral Health Access 1067 E Tabernacle St 1067 E Tabernacle St Ste 202 Center - SGRH Ste 7 Ste 7 Saint George UT. 84770 544 S 400 E St George UT. 84770 St George UT. 84770 p 435.668.4956 St George UT. 84770 p 801.255.5131 p 801.255.5131 p 435.688.4290 Family Healthcare Larisch, Torrey BCBA Manwill, Andrea BCBA 391 N 200 W Hospital Affiliation Chrysalis Utah Utah Autism Academy Hurricane UT. 84737 - St George Regional Hospital 230 N 1680 E 1680 E 230 N Bldg A p 435.986.2565 Ste OP Saint George UT. 84790 Nielsen, Stephanie MSW Saint George UT. 84790 p 435.720.8876 Metzger, Debbie BCBA Utah Behavior Services p 801.655.4950 Utah Behavior Services 1067 E Tabernacle St Marshall, Paige PhD 1067 E Tabernacle St Ste 7 Lee, Jennifer BCBA Red Sands Psychiatry Ste 7 Saint George UT. 84770 Utah Behavior Services 1031 S Bluff St St George UT. 84770 p 801.255.5131 1067 E Tabernacle St Saint George UT. 84770 p 801.255.5131 Ste 7 p 435.634.8848 Oblad, Cicily BCBA St George UT. 84770 Moody, Richard Y PhD Utah Behavior Services p 801.255.5131 630 S 400 E TurningLeaf Wellness 1067 E Tabernacle St Ste 103 Center Ste 7 Lofthouse, Chelsea ACMHC Saint George UT. 84770 1240 E 100 S Bldg 22 St George UT. 84770 Utah Behavior Services p 435.634.8848 Ste 121 p 801.255.5131 1067 E Tabernacle St St George UT. 84790 Ste 7 Martineau, Clint APRN p 435.652.1202 Ogilvie, Shara M Saint George UT. 84770 St George Children & Daybreak Family Therapy p 801.255.5131 Family Psychiatric Center Mortensen, Michael LCSW 1173 S 250 W 230 N 1680 E Family Healthcare Ste 203 Lopez, Kitrina BCBA Ste H1 25 N 100 E Saint George UT. 84770 Utah Behavior Services Saint George UT. 84790 Ste 102 p 435.668.4138 1067 E Tabernacle St p 435.652.1897 St George UT. 84770 Ste 7 p 435.986.2565 Parker, Brian L LMFT St George UT. 84770 Maxwell, Kendra BCBA New Beginnings p 801.255.5131 Utah Behavior Services Munk, Adam C LMFT 301 N 200 E 1067 E Tabernacle St Family Healthcare Ste 3-D Lovelace, Scott LCMHC Ste 7 2408 E Riverside Dr Saint George UT. 84770 Utah Behavior Services St George UT. 84770 Saint George UT. 84790 p 435.628.5505 1067 E Tabernacle St p 801.255.5131 p 435.986.2565 Ste 7 Phillips, Allison Saint George UT. 84770 McBride, Laurie SSW 25 N 100 E LCSW,BCBA p 801.255.5131 Evolving Light Counseling Ste 102 Utah Behavior Services 32 E 100 S Saint George UT. 84770 1067 E Tabernacle St Lowe, Kori BCBA Ste 202 p 435.986.2565 Ste 7 Utah Behavior Services Saint George UT. 84770 St George UT. 84770 1067 E Tabernacle St p 435.628.8945 Nadalsky, Michelle p 801.255.5131 Ste 7 BCBA,SSW Saint George UT. 84770 McGill, Katie MSW Utah Behavior Services Porter, Desiree L LPC p 801.255.5131 Utah Behavior Services 1067 E Tabernacle St Spring Creek Wellness 1067 E Tabernacle St Ste 7 1990 N Park Grove Dr Luna, Janette M LCSW Ste 7 St George UT. 84770 Washington UT. 84780 Utah Behavior Services St George UT. 84770 p 801.255.5131 p 801.499.7869 1067 E Tabernacle St p 801.255.5131 Ste 7 Neff, Michal A CSW,SUDC Powell, Clark Randy LCSW St George UT. 84770 McGuire, Amy BCBA Utah Behavior Services Utah Behavior Services p 801.255.5131 Utah Behavior Services 1067 E Tabernacle St 1067 E Tabernacle St 1067 E Tabernacle St Ste 7 Ste 7 Ste 7 St George UT. 84770 St George UT. 84770 St George UT. 84770 p 801.255.5131 p 801.255.5131 p 801.255.5131

580 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Rasmusen, Carl MD Rockwell, Rene BCBA Shinedling, Teresa C LCSW Stasiuk, John A LMFT Behavioral Health Access Utah Behavior Services Shinedling and Shinedling Utah Behavior Services Center - SGRH 1067 E Tabernacle St PLLC 1067 E Tabernacle St 544 S 400 E Ste 7 640 E 700 S Ste 7 St George UT. 84770 St George UT. 84770 Ste 201 Saint George UT. 84770 p 435.688.4290 p 801.255.5131 St George UT. 84770 p 801.255.5131 p 435.652.3775 Hospital Affiliation *Romer, Laura K MD Stevens, Nicole - Jordan Valley Medical Int Psychiatry and Shumway, Brett PSYD BCBA,LMFT Center West Valley Campus Counseling-St George Utah Behavior Services Utah Behavior Services 292 S 1470 E 1067 E Tabernacle St 1067 E Tabernacle St Red Sands Psychiatry St George UT. 84790 Ste 7 Ste 7 1031 S Bluff St p 435.251.5900 St George UT. 84770 St George UT. 84770 Saint George UT. 84770 p 801.255.5131 p 801.255.5131 p 435.634.8848 Behavioral Health Access Center - SGRH Siebert, Tatum LCPC Stoddard, Lisa M APRN 630 S 400 E 544 S 400 E Utah Behavior Services Desert Spring Behavioral Ste 103 St George UT. 84770 1067 E Tabernacle St Health Saint George UT. 84770 p 435.688.4290 Ste 7 640 E 700 S p 435.634.8848 Saint George UT. 84770 Ste 205-B Hospital Affiliation p 801.255.5131 Saint George UT. 84770 *Reinhardt, Gayla M LCSW - St George Regional Hospital p 435.703.9647 St George MFM High Risk OB Skousen, Thomas MSW 1380 E Medical Ctr Dr Rudd, Ryan LCSW Utah Behavior Services Suarez, Alex LCSW Ste 1600 Crimson Counseling 1067 E Tabernacle St Utah Behavior Services St George UT. 84790 249 E Tabernacle St Ste 7 1067 E Tabernacle St p 435.688.4770 Ste 100 Saint George UT. 84770 Ste 7 Saint George UT. 84770 p 801.255.5131 St George UT. 84770 Womens Health Specialists p 435.705.7574 p 801.255.5131 346 E 600 S Slater, Courtney MSW St George UT. 84770 Sagendorf, Emily BCBA Utah Behavior Services Tate, David B PhD p 435.688.4600 Utah Behavior Services 1067 E Tabernacle St St George Community 1067 E Tabernacle St Ste 7 Healing Arts Hospital Affiliation Ste 7 Saint George UT. 84770 113 E 200 N - St George Regional Hospital St George UT. 84770 p 801.255.5131 St George UT. 84770 p 801.255.5131 p 435.656.0506 Renda, Cheyenne R PhD Smith, Erica BCBA Utah Behavior Services Salsberry, Maria CSW Utah Behavior Services David B. Tate, PhD 1067 E Tabernacle St Utah Behavior Services 1067 E Tabernacle St 321 N Mall Dr Ste 7 1067 E Tabernacle St Ste 7 Ste I-201 Saint George UT. 84770 Ste 7 Saint George UT. 84770 Saint George UT. 84790 p 801.255.5131 St George UT. 84770 p 801.255.5131 p 435.656.0506 p 801.255.5131 Richards, Allen S LCSW Smith, Saige LPC Center for Stress St George Children & Sanchez, Rafael A CSW Utah Behavior Services Reduction Family Psychiatric Center Family Healthcare 1067 E Tabernacle St 920 W 437 S 230 N 1680 E 245 E 680 S Ste 7 Ste 202 Ste H1 Saint George UT. 84770 Saint George UT. 84770 St George UT. 84770 Saint George UT. 84790 p 435.986.2565 p 801.255.5131 p 435.656.0506 p 435.652.1897 25 N 100 E Snow, Lauren BCBA Thomas, Thurmon E LMFT Roberts, Jacob S NP Ste 102 Utah Behavior Services Center for Couples & St George Children & Saint George UT. 84770 1067 E Tabernacle St Families Family Psychiatric Center p 435.986.2565 Ste 7 1173 S 250 W Bldg I 230 N 1680 E St George UT. 84770 Ste 208 Ste H1 Sanders, Sarah BCBA p 801.255.5131 Saint George UT. 84770 Saint George UT. 84790 Utah Behavior Services p 435.688.1111 p 435.652.5909 1067 E Tabernacle St Stallings, Saskia A LCSW Ste 7 Saskia A Stallings LCSW 52 S 850 W Roche, Miriam MSW St George UT. 84770 321 N Mall Dr VW104 Ste 202B Utah Behavior Services p 801.255.5131 Saint George UT. 84790 Hurricane UT. 84737 1067 E Tabernacle St p 435.359.2433 p 435.688.1111 Ste 7 Saint George UT. 84770 p 801.255.5131

581 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Tolman, McKenzie CSW Yang, Danielle BCBA 48 S 2500 W Kakani, Siddhartha MD Family Healthcare Utah Behavior Services Ste 100 University of Utah Health 25 N 100 E 1067 E Tabernacle St Hurricane UT. 84737 48 S 2500 W Ste 102 Ste 7 p 435.673.3556 Ste 100 Saint George UT. 84770 Saint George UT. 84770 Hurricane UT. 84737 p 435.986.2565 p 801.255.5131 720 S River Rd p 435.635.0399 Ste D1100 Turner, Eric BCBA Young, William S Saint George UT. 84790 Hospital Affiliation Utah Behavior Services Premier Psychological p 435.656.0857 - University of Utah Hospital 1067 E Tabernacle St Counseling & Consulting Ste 7 230 N 1680 E Bldg T-2 Hospital Affiliation Lavasani, Tooran APRN Saint George UT. 84770 St George UT. 84790 - University of Utah Hospital University of Utah Health p 801.255.5131 p 435.865.9119 - Davis Hospital 720 S River Rd Ste D1100 1067 E Tabernacle St Zolman, David LMFT Bjordahl, Terrence S MD Saint George UT. 84790 Ste 7 Family Healthcare University of Utah Health p 435.656.0857 St George UT. 84770 25 N 100 E 48 S 2500 W p 801.255.5131 Ste 102 Ste 100 Hospital Affiliation Saint George UT. 84770 Hurricane UT. 84737 - University of Utah Hospital Ward, Cori APRN p 435.986.2565 p 435.635.0399 Utah Behavior Services Leon-Forero, Carlos A MD 1067 E Tabernacle St Neonatology Hospital Affiliation Southern Utah Kidney & Ste 7 *Andres, Robert L MD - St Marks Hospital Hypertension Center St George UT. 84770 St George Maternal And 624 S 1000 E p 801.255.5131 Fetal Medicine Boateng, Yaw A MD Ste 103 544 S 400 E University of Utah Health Saint George UT. 84790 Whatcott, Natalie St George UT. 84770 1380 E Medical Ctr Dr p 435.652.1135 BCBA,SSW p 435.688.4770 Saint George UT. 84790 Utah Behavior Services p 435.251.1000 Hospital Affiliation 1067 E Tabernacle St Hospital Affiliation - St George Regional Hospital Ste 7 - University of Utah Hospital 48 S 2500 W - Cedar City Hospital St George UT. 84770 Ste 100 p 801.255.5131 *Carroll, Patrick D MD Hurricane UT. 84737 Mercado, Carlos A MD St George Neonatology p 435.635.0399 Southern Utah Kidney & Wills, Brooke BCBA 1380 E Medical Ctr Dr Hypertension Center Utah Behavior Services Ste 1600 720 S River Rd 624 S 1000 E 1067 E Tabernacle St Saint George UT. 84770 Ste D1100 Ste 103 Ste 7 p 435.251.5200 Saint George UT. 84790 Saint George UT. 84790 St George UT. 84770 p 435.656.0857 p 435.652.1135 p 801.255.5131 St George Neonatology-Graduate Hospital Affiliation Hospital Affiliation Wilson, Megan BCBA 544 S 400 E - University of Utah Hospital - St George Regional Hospital Utah Behavior Services Saint George UT. 84770 - Beaver Valley Hospital 1067 E Tabernacle St p 435.251.5200 Eppich, Irel S MD - Cedar City Hospital Ste 7 University of Utah Health Saint George UT. 84770 Hospital Affiliation 48 S 2500 W Patchett, Andrew M DO p 801.255.5131 - St George Regional Hospital Ste 100 Southern Utah Kidney & Hurricane UT. 84737 Hypertension Center Woodall, Clifford BCBA *Ridout, R E MD p 435.635.0399 624 S 1000 E Utah Behavior Services St George Neonatology Ste 103 1067 E Tabernacle St 1380 E Medical Ctr Dr Hospital Affiliation Saint George UT. 84790 Ste 7 Ste 1600 - University of Utah Hospital p 435.652.1135 St George UT. 84770 St George UT. 84790 - Mountain View Hospital p 801.255.5131 p 435.251.5200 (UT) Hospital Affiliation - Timpanogos Regional Hospital - Cedar City Hospital Wulfenstein, Lee BCBA St George - St George Regional Hospital Utah Behavior Services Neonatology-Graduate Horowitz, Bruce L MD 1067 E Tabernacle St 544 S 400 E University of Utah Health Roy, Abinash C MD Ste 7 St George UT. 84770 1380 E Medical Ctr Dr University of Utah Health Saint George UT. 84770 p 435.251.5200 Saint George UT. 84790 1380 E Medical Ctr Dr p 801.255.5131 p 435.251.1000 Saint George UT. 84790 Nephrology p 435.251.1000 Assiago, Marcellus S MD Hospital Affiliation University of Utah Health - University of Utah Hospital 1380 E Medical Ctr Dr - Davis Hospital Saint George UT. 84790 p 435.251.1000

582 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 720 S River Rd Gibson, Summer B MD *Southwest Neurology Cole, Chad D MD Ste D1100 University of Utah Health *Associates Utah Neurosurgery Saint George UT. 84790 48 S 2500 W 652 S Medical Center Dr 1490 E Foremaster Dr p 435.656.0857 Ste 100 Ste 320 Ste 260 Hurricane UT. 84737 Saint George UT. 84790 St George UT. 84790 Hospital Affiliation p 801.585.7575 p 435.251.3950 p 435.688.7131 - St George Regional Hospital - University of Utah Hospital Hospital Affiliation *Tisel, Sarah M MD Hospital Affiliation - University of Utah Hospital Southwest Neurology - St George Regional Hospital Southern Utah Kidney & Associates - University of Utah Hospital Hypertension Center *Hoesch, Robert E MD 652 S Medical Center Dr 624 S 1000 E Southern Utah Ste 320 Garber, Sarah T MD Ste 103 Neurosciences Institute St George UT. 84790 Utah Neurosurgery Saint George UT. 84790 652 S Medical Center Dr p 435.251.3950 1490 E Foremaster Dr p 435.652.1135 Ste 420 Ste 260 St George UT. 84790 Hospital Affiliation Saint George UT. 84790 Neurology p 435.251.6800 - St George Regional Hospital p 435.688.7131 *Bradbury, Matthew DO Int Psychiatry & *Laroia Coon, Swati DO Desert Ridge Neurology *Manwaring, Jotham C MD Counseling-St George Southwest Neurology 295 S 1470 E Southern Utah 292 S 1470 E Associates Ste 301 Neurosciences Institute St George UT. 84790 652 S Medical Center Dr Saint George UT. 84790 652 S Medical Center Dr p 435.251.5900 Ste 320 p 435.775.2015 Ste 420 Saint George UT. 84790 St George UT. 84790 Hospital Affiliation p 435.251.3950 *Vine, Daniel B MD p 435.251.6800 - Baylor Scott & White St George Regional Medical Center - Temple Southern Utah Hospital Physicians Pingree, James C MD Neurosciences Institute 1380 E Medical Ctr Dr Coral Desert Spine Center Bromberg, Mark B MD,PhD 652 S Medical Center Dr St George UT. 84790 1490 E Foremaster Dr University of Utah Health Ste 420 p 435.251.1000 Ste 210 48 S 2500 W St George UT. 84790 St George UT. 84790 Ste 100 p 435.251.6800 Southwest Neurology p 435.656.8366 Hurricane UT. 84737 Associates p 801.585.6387 Hospital Affiliation 652 S Medical Center Dr Hospital Affiliation - Cedar City Hospital Ste 320 - St Marks Hospital 720 S River Rd St George UT. 84790 Ste D1100 *McDonald, Melissa MD p 435.251.3950 Sampson, Judith A APRN Saint George UT. 84790 Southwest Neurology Utah Neurosurgery p 801.585.7575 Associates Hospital Affiliation 1490 E Foremaster Dr 652 S Medical Center Dr - Davis Hospital Ste 260 Hospital Affiliation Ste 320 St George UT. 84790 - University of Utah Hospital St George UT. 84790 Neurosurgery p 435.688.7131 p 435.251.3950 *Bate, Berkeley G MD *De Saibro, Luciana MD Southern Utah Hospital Affiliation St George Regional Overall, Trenton L DO Neurosciences Institute - St George Regional Hospital Hospital Desert Ridge Neurology 652 S Medical Center Dr - University of Utah Hospital 1380 E Medical Ctr Dr 295 S 1470 E Ste 420 St George UT. 84790 Ste 301 St George UT. 84790 *Weaver, Kyle D MD p 435.251.1000 Saint George UT. 84790 p 435.251.6800 Southern Utah p 435.775.2015 Neurosciences Institute 577 S River Rd Hospital Affiliation 652 S Medical Ctr Dr St George UT. 84790 Hospital Affiliation - St George Regional Hospital Ste 420 p 435.688.6000 - St George Regional Hospital St George UT. 84790 - Cedar City Hospital *Bishop, Frank S MD p 435.251.6800 Southwest Neurology Southern Utah Associates Schlagel, Laura J MD Neurosciences Institute Obstetrics And Gynecology 652 S Medical Center Dr Red Rock Neurology 652 S Medical Ctr Dr *Andres, Robert L MD Ste 320 2019 E Riverside Dr Ste 420 St George Maternal And St George UT. 84790 Ste A-101 St George UT. 84790 Fetal Medicine p 435.251.3950 Saint George UT. 84790 p 435.251.6800 544 S 400 E p 435.673.5217 St George UT. 84770 Hospital Affiliation Hospital Affiliation p 435.688.4770 - St George Regional Hospital - St George Regional Hospital Hospital Affiliation - University of Utah Hospital

583 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Astle, Craig D MD *Chun Moon, Deborah M MD Hendrickson, Johanna Lynn, Sean F MD Valley Obstetrics & St George Maternal And PA-C Snow Canyon Womens Center Gynecology Fetal Medicine Valley Obstetrics & 965 E 700 S 515 S 300 E 544 S 400 E Gynecology Ste 105 Ste 206 St George UT. 84770 515 S 300 E Saint George UT. 84790 Saint George UT. 84770 p 435.688.4770 Ste 206 p 435.218.7770 p 435.628.1662 Saint George UT. 84770 Hospital Affiliation p 435.628.1662 Hospital Affiliation Hospital Affiliation - St George Regional Hospital - Saint Alphonsus Medical - St George Regional Hospital Hospital Affiliation Center - Nampa *Draper, Michael L MD - St George Regional Hospital Benham, Brady N MD St George Maternal And *Miller, Emma DO Valley Obstetrics & Fetal Medicine *Heuser, Cara C MD St George High Risk OB Gynecology 544 S 400 E St George Maternal And 1380 E Medical Ctr Dr 515 S 300 E St George UT. 84770 Fetal Medicine Ste 1600 Ste 206 p 435.688.4770 544 S 400 E St George UT. 84790 Saint George UT. 84770 St George UT. 84770 p 435.251.4170 p 435.628.1662 Hospital Affiliation p 435.688.4770 - University of Utah Hospital Hospital Affiliation Hospital Affiliation - Davis Hospital Hospital Affiliation - Timpanogos Regional Hospital - St George Regional Hospital - Jordan Valley Medical - University of Utah Hospital Center *Nichols, John M DO *Branch, D W MD - Salt Lake Regional Medical *Howey, Susan M MD St George High Risk OB St George Maternal And Center St George High Risk OB 544 S 400 E Fetal Medicine 544 S 400 E St George UT. 84770 544 S 400 E Eggert, Joan V MD St George UT. 84770 p 435.688.4770 St George UT. 84770 Valley Obstetrics & p 435.688.4770 p 435.688.4770 Gynecology Hospital Affiliation 515 S 300 E Kirk, Shelly F FNP - St George Regional Hospital Hospital Affiliation Ste 206 Red Hills Wellness Center - Jordan Valley Medical - University of Utah Hospital Saint George UT. 84770 301 N 200 E Center p 435.628.1662 Ste 2C Brown, Coby T MD St George UT. 84770 *Ott, Richard W MD Valley Obstetrics & Hospital Affiliation p 435.674.1700 Womens Health Specialists Gynecology - St George Regional Hospital 346 E 600 S 515 S 300 E Kvarfordt, Tracy MD St George UT. 84770 Ste 206 *Eller, Alexandra G MD St George OB/GYN p 435.688.4600 Saint George UT. 84770 St George Maternal And 295 S 1470 E p 435.628.1662 Fetal Medicine Ste 300 Hospital Affiliation 544 S 400 E Saint George UT. 84790 - St George Regional Hospital Hospital Affiliation St George UT. 84770 p 435.647.0999 - St George Regional Hospital p 435.688.4770 Planned Parenthood 515 S 300 E Association of Utah Carter, Gayle M MD Hospital Affiliation Ste 205 595 S Bluff St Riverside Medical Arts - University of Utah Hospital St George UT. 84770 St George UT. 84770 1068 E Riverside Dr p 435.674.0999 p 435.674.9933 St George UT. 84790 *Ellis, Diane E MD p 435.628.6466 St George High Risk OB Hospital Affiliation *Porter, Troy F MD 544 S 400 E - St George Regional Hospital St George Maternal And Hospital Affiliation St George UT. 84770 Fetal Medicine - St George Regional Hospital p 435.688.4770 Leavitt, Cameron DO 544 S 400 E Valley Obstetrics & St George UT. 84770 *Chalmers, Robert W MD Hospital Affiliation Gynecology p 435.688.4770 Womens Health Specialists - University of Utah Hospital 295 S 1470 E 346 E 600 S Ste 200 Hospital Affiliation St George UT. 84770 *Esplin, M S MD Saint George UT. 84790 - University of Utah Hospital p 435.688.4600 St George Maternal And p 435.628.1662 Fetal Medicine Rogers, Jeffrey G MD St George High Risk OB 544 S 400 E Hospital Affiliation Valley Obstetrics & 544 S 400 E St George UT. 84770 - St George Regional Hospital Gynecology St George UT. 84770 p 435.688.4770 515 S 300 E p 435.688.4770 Lunt, Chad C MD Ste 206 Hospital Affiliation St George OB/GYN Saint George UT. 84770 Hospital Affiliation - University of Utah Hospital 295 S 1470 E p 435.628.1662 - St George Regional Hospital Ste 300 Saint George UT. 84790 Hospital Affiliation p 435.647.0999 - St George Regional Hospital

Hospital Affiliation - St George Regional Hospital 584 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Silver, Robert M MD Winward, Tracy W MD *Gottfredson, Gary L OT *Williams, Nicholas OT St George Maternal And Valley Obstetrics & St George Regional SGRH Rehab Center Fetal Medicine Gynecology Hospital 652 S Medical Ctr Dr 544 S 400 E 515 S 300 E 652 S Medical Center Dr Ste LL10 St George UT. 84770 Ste 206 Ste LL10 St George UT. 84790 p 435.688.4770 Saint George UT. 84770 St George UT. 84790 p 435.251.2250 p 435.628.1662 p 435.251.2250 Hospital Affiliation Hospital Affiliation - University of Utah Hospital Hospital Affiliation *Moe, Lorraine G OT - St George Regional Hospital - Davis Hospital - St George Regional Hospital St George Regional Hospital Oculoplastic Surgery Sorensen, Pamela J PA *Wong, Alice MD 652 S Medical Center Dr Patel, Bhupendra C MD Valley Obstetrics & St George High Risk OB Ste LL10 St George Eye Center Gynecology 544 S 400 E St George UT. 84790 1054 E Riverside Dr 515 S 300 E St George UT. 84770 p 435.251.2250 Ste 201 Ste 206 p 435.688.4770 Saint George UT. 84790 Saint George UT. 84770 *Munson, Scott S OT p 435.656.4040 p 435.628.1662 Occupational Therapy St George Regional *Carpenter, Cody J OT Hospital 676 S Bluff St *Taylor, Bryan R MD SGRH Rehab Center 652 S Medical Center Dr Ste 208 St George MFM High Risk OB 652 S Medical Ctr Dr Ste LL10 St George UT. 84770 1380 E Medical Ctr Dr Ste LL10 St George UT. 84790 p 435.628.4507 Ste 1600 St George UT. 84790 p 435.251.2250 St George UT. 84790 p 435.251.2250 Hospital Affiliation p 435.688.4770 75 N 2260 W - University of Utah Hospital Concentra Medical Centers Hurricane UT. 84737 - Davis Hospital *Varner, Michael W MD 2390 Redwood Rd p 435.635.7227 - St Marks Hospital St George Maternal And West Valley City UT. 84419 Fetal Medicine p 888.997.2669 *Pereira, Christine M OT Oncology 544 S 400 E St George Regional *Asch, Julie D MD St George UT. 84770 Dower, Kimber Lee OT Hospital BMT Leukemia Program SWR p 435.688.4770 Riverside Rehabilitation 652 S Medical Center Dr 544 S 400 E 2044 S Mesa Palms Dr Ste LL10 St George UT. 84770 Hospital Affiliation St George UT. 84770 St George UT. 84790 p 435.688.4900 - University of Utah Hospital p 435.632.3423 p 435.251.2250 Hospital Affiliation *Walker, Kathryn MD *Durst, Lyndsey T OT *Richard, Winn A OT - Primary Childrens Hospital Womens Health Specialists St George Regional St George Regional 346 E 600 S Hospital Hospital *Gouw, Launce MD St George UT. 84770 652 S Medical Center Dr 652 S Medical Center Dr BMT Leukemia Program SWR p 435.688.4600 Ste LL10 Ste LL10 544 S 400 E St George UT. 84790 St George UT. 84790 St George UT. 84770 St George High Risk OB p 435.251.2250 p 435.251.2250 p 435.688.4900 544 S 400 E St George UT. 84770 Hospital Affiliation Hospital Affiliation *Haslem, Derrick S MD p 435.688.4770 - St George Regional Hospital - St George Regional Hospital Southwest Regional Cancer Clinic Webb, Joel C MD *Earl, Jacob D OT *Stewart, James N OT 544 S 400 E Valley Obstetrics & SGRH Rehab Center St George Regional St George UT. 84770 Gynecology 652 S Medical Ctr Dr Hospital p 435.688.4900 295 S 1470 E Ste LL10 1380 E Medical Ctr Dr Ste 200 St George UT. 84790 St George UT. 84790 Hospital Affiliation Saint George UT. 84790 p 435.251.2250 p 435.251.1000 - St George Regional Hospital p 435.628.1662 - Cedar City Hospital Hospital Affiliation 652 S Medical Center Dr Hospital Affiliation - St George Regional Hospital Ste LL10 *Hoda, Daanish MD - St Marks Hospital St George UT. 84790 BMT Leukemia Program SWR - Utah Valley Hospital *Edwards, Matthew G OT p 435.251.2250 544 S 400 E St George Regional St George UT. 84770 Weidman, Cassandra DO Hospital Hospital Affiliation p 435.688.4900 Valley Obstetrics & 652 S Medical Center Dr - St George Regional Hospital Gynecology Ste LL10 *Konopa, Kelly L MD 295 S 1470 E St George UT. 84790 BMT Leukemia Program SWR Ste 200 p 435.251.2250 544 S 400 E Saint George UT. 84790 St George UT. 84770 p 435.628.1662 p 435.688.4900

Hospital Affiliation - St George Regional Hospital 585 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Nadauld, Lincoln MD Behunin, Nicholas L MD Lewis, Mark M MD Richens, Sharon MD Southwest Regional Cancer St George Eye Center Dixie Ophthalmic Richens Eye Center Clinic 617 E Riverside Dr Specialists 161 W 200 N 544 S 400 E Ste 101 1791 E 280 N Ste 200 St George UT. 84770 Saint George UT. 84790 St George UT. 84790 St George UT. 84770 p 435.688.4900 p 435.628.4507 p 435.656.2020 p 435.652.4040

Hospital Affiliation Hospital Affiliation Hospital Affiliation Hospital Affiliation - St George Regional Hospital - St George Regional Hospital - St George Regional Hospital - St George Regional Hospital

*Ostronoff, Fabiana MD Carlson, Joshua MD *Lord, Ron K MD Slade, David S MD BMT Leukemia Program SWR Retina Associates of St George Neonatology St George Eye Center 544 S 400 E Southern Utah 1380 E Medical Ctr Dr 1054 E Riverside Dr St George UT. 84770 110 W 1325 N Ste 1600 Ste 201 p 435.688.4900 Ste 175 Saint George UT. 84790 Saint George UT. 84790 St George UT. 84790 p 435.251.5200 p 435.628.4507 Pingree, James C MD p 435.216.7032 Coral Desert Spine Center Retina Associates of Hospital Affiliation 1490 E Foremaster Dr 230 N 1680 E Bldg F Southern Utah - St George Regional Hospital Ste 210 Saint George UT. 84790 230 N 1680 E Bldg F St George UT. 84790 p 435.216.7032 Saint George UT. 84790 Tarbet, Kristin J MD p 435.656.8366 p 435.216.7032 558 E Riverside Dr Hospital Affiliation Ste 200 Hospital Affiliation - St George Regional Hospital St George St George UT. 84790 - St Marks Hospital Neonatology-Graduate p 435.652.9355 Edwards, Jayson D MD 544 S 400 E *Rhodes, Terence MD Dixie Ophthalmic St George UT. 84770 Optometry Southwest Regional Cancer Specialists p 435.251.5200 Albrecht, Kent S OD Clinic 1791 E 280 N Southern Utah Eyecare 544 S 400 E St George UT. 84790 May, Shawno E MD 10 Diagonal St St George UT. 84770 p 435.656.2020 Richens Eye Center Ste 101 p 435.688.4900 161 W 200 N St George UT. 84770 Hospital Affiliation Ste 200 p 435.673.3201 Hospital Affiliation - St George Regional Hospital Saint George UT. 84770 - St George Regional Hospital p 435.652.4040 Albrecht, William S OD Gibb, Reed T OD Shivwits Paiute Medical *Tudor, Brian P MD Richens Eye Center Hospital Affiliation Clinic Southwest Regional Cancer 161 W 200 N - St George Regional Hospital 6109 W 3700 N Clinic Ste 200 Ivins UT. 84738 544 S 400 E St George UT. 84770 Patel, Bhupendra C MD p 435.688.8198 St George UT. 84770 p 435.652.4040 St George Eye Center p 435.688.4900 1054 E Riverside Dr Ames, Derek B OD Hospital Affiliation Ste 201 Ames Eye Care Hospital Affiliation - St George Regional Hospital Saint George UT. 84790 2610 Pioneer Rd - St George Regional Hospital p 435.656.4040 St George UT. 84790 - Cedar City Hospital Goff, Mitchell J MD p 435.674.9770 Rocky Mountain Retina 676 S Bluff St *Voorhies, Benjamin N MD Consultants Ste 208 Andrus, Kyle D OD Southwest Regional Cancer 1791 E 280 N St George UT. 84770 Snow Canyon Eye Center Clinic St George UT. 84790 p 435.628.4507 1930 W Sunset Blvd 600 Medical Ctr Dr p 888.496.4400 Ste 106 St George UT. 84790 Hospital Affiliation St George UT. 84770 p 435.688.4900 Hospital Affiliation - University of Utah Hospital p 435.628.1112 - St Marks Hospital - Davis Hospital Hospital Affiliation - St Marks Hospital Croft, Brent L OD - University of Utah Hospital Hendrix, Jason W MD Dixie Eye Care St George Eye Center Reyes, Marcos MD 301 E Tabernacle St Ophthalmology 1054 E Riverside Dr Dixie Ophthalmic Ste 101 Ahee, Jason A MD Ste 201 Specialists St George UT. 84770 Dixie Ophthalmic Saint George UT. 84790 1791 E 280 N p 435.673.3558 Specialists p 435.628.4507 St George UT. 84790 1791 E 280 N p 435.656.2020 Croft, Michael OD St George UT. 84790 Hospital Affiliation Dixie Eye Care p 435.656.2020 - St George Regional Hospital Hospital Affiliation 301 E Tabernacle St - St George Regional Hospital Ste 101 Hospital Affiliation St George UT. 84770 - St George Regional Hospital p 435.673.3558

586 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Dorius, Michael C OD 749 S River Rd Terry, Joshua J OD Southwest Ortho and Sports 20 S 850 W St George UT. 84770 Joshua J Terry OD Med-HHC Ste 3 p 435.628.4464 617 E Riverside Dr 75 N 2260 W Hurricane UT. 84737 Ste 101 Hurricane UT. 84737 p 435.635.7766 Miller, Russell M OD Saint George UT. 84790 p 435.628.4460 Southern Utah Eyecare p 435.628.4507 Drake, Eric OD 10 Diagonal St Anderson, Michael B MD SouthWest Vision Ste 101 Thatcher, Jeffery J OD Revere Health 965 E 700 S St George UT. 84770 Red Cliffs Eye Care 11 S Main St Ste 100 p 435.673.3201 625 W Telegraph St Hurricane UT. 84737 St George UT. 84790 Washington UT. 84780 p 800.239.9393 p 435.673.5577 OBrien, Jenna OD p 435.986.3770 The Childrens Vision 1490 E Foremaster Dr Fife, Joseph OD Center The Childrens Vision Ste 150 Paradise Canyon Eye Care 1490 E Foremaster Dr Center St George UT. 84790 1449 N 1400 W Ste 120 1490 E Foremaster Dr p 435.628.9393 Ste 24 Saint George UT. 84790 Ste 120 Saint George UT. 84770 p 435.625.0804 Saint George UT. 84790 2825 E Mall Dr p 435.222.2011 p 435.625.0804 St Geroge UT. 84790 Standard Optical p 435.628.9393 Gooch, Paul R OD 250 N Red Cliffs Dr Wallace, Shaune K OD SouthWest Vision Saint George UT. 84790 Clear View Eye Care Hospital Affiliation 965 E 700 S p 435.674.2020 1100 Canyon View Dr - St George Regional Hospital Ste 100 Ste G - Kane County Hospital St George UT. 84790 Peterson, Walter OD Santa Clara UT. 84765 p 435.673.5577 Standard Optical p 435.674.3502 *Andruss, Robert J MD 250 N Red Cliffs Dr Zion Orthopedics and Graf, Jeffery D OD St George UT. 84790 Oral And Maxillofacial Surgery Sports Medicine 754 S Main p 435.674.2020 Cannon, Grant DDS 652 S Medical Center Dr Ste 6 University Of Utah Health Ste 400 St George UT. 84770 Ricks, Jeffry R OD 225 S 700 E St George UT. 84790 p 435.634.0420 Dixie Ophthalmic Saint George UT. 84770 p 435.251.2650 Specialists p 801.587.6453 Hauck, Jason W OD 1791 E 280 N Southwest Ortho and Sports Dixie Ophthalmic St George UT. 84790 Mizukawa, Matthew DMD Med-HHC Specialists p 435.628.2020 University Of Utah Health 75 N 2260 W 1791 E 280 N 225 S 700 E Hurricane UT. 84737 St George UT. 84790 Robison, Ryan E OD Saint George UT. 84770 p 435.628.4460 p 435.628.2020 SouthWest Vision p 801.587.6453 965 E 700 S Hospital Affiliation Hospital Affiliation Ste 100 Hospital Affiliation - St George Regional Hospital - St George Regional Hospital St George UT. 84790 - University of Utah Hospital p 435.673.5577 Burns, Keven S MD Helman, Andrew OD Nielsen, Erik DDS St George Orthopedic Spine Standard Optical Smith, Golden OD University Of Utah Health 617 E Riverside Dr 250 N Red Cliffs Dr Standard Optical 225 S 700 E Ste 302 Saint George UT. 84790 250 Red Cliffs Dr Saint George UT. 84770 Saint George UT. 84790 p 435.674.2020 Ste 7 p 801.587.6453 p 435.652.6024 Saint George UT. 84790 Hunt, Mark T OD p 801.886.2020 Hospital Affiliation Butterfield, Ted DPM St George Eye Center - University of Utah Hospital Foot and Ankle Institute 1054 E Riverside Dr Smith, Joseph A OD 754 S Main Ste 201 Stone Canyon Eye Care Rahn, Andrew R DDS Ste 3 Saint George UT. 84790 599 S Mall Dr Sp K1 University of Utah Health Saint George UT. 84770 p 435.628.4507 Saint George UT. 84790 225 S 700 E p 435.628.2671 p 435.359.2020 Saint George UT. 84770 Lofgran, Adam J OD p 801.587.6453 Hospital Affiliation Focus Eye Center Standard Optical Mon-Fri - St George Regional Hospital 250 W State St 10am-9pm Sat 8am-9pm Orthopedic Surgery Ste 1 250 N Red Cliffs Dr *Allred, Darin K DO *Butterfield, Warren L MD Hurricane UT. 84737 Ste 7 Southwest Ortho and Sports Southwest Ortho and Sports p 435.628.4464 St George UT. 84790 Med Med p 435.674.2020 652 S Medical Center Dr 652 S Medical Center Dr Ste 120 Ste 120 St George UT. 84790 St George UT. 84790 p 435.628.4460 p 435.628.4460

587 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Clark, Randy MD Hicken, Jeffrey L DC McPherson, Bruce A PA 736 S 900 E Revere Health Elite Healthcare Southern Coral Desert Orthopedics Ste 203 1490 E Foremaster Dr Utah 1490 E Foremaster Dr Saint George UT. 84790 Ste 150 568 W Telegraph Rd Ste 150 p 435.673.6131 St George UT. 84790 Washington UT. 84780 St George UT. 84790 p 435.628.9393 p 435.627.0231 p 435.628.9393 Hospital Affiliation - St George Regional Hospital 272 E Ctr St Hospital Affiliation Hospital Affiliation - Kane County Hospital Ivins UT. 84738 - Logan Regional Hospital - St George Regional Hospital p 435.628.9393 - Cache Valley Hospital *Ray, Christine H PA-C - Franklin County Medical OBrien, Aaron M MD Southwest Ortho & Sports 2825 E Mall Dr Center Revere Health Med St Geroge UT. 84790 - Brigham City Community 1490 E Foremaster Dr 652 S Medical Ctr Dr p 435.673.6131 Hospital Ste 150 Ste 120 St George UT. 84790 St George UT. 84790 Hospital Affiliation St George Orthopedic Spine p 435.628.9393 p 435.628.4460 - St George Regional Hospital 617 E Riverside Dr Ste 302 2825 E Mall Dr Stotts, Alan K MD *Eggers, Ryan M MD Saint George UT. 84790 St Geroge UT. 84790 University of Utah Health Southwest Ortho & Sports p 435.652.6024 p 435.628.9393 1380 E Medical Ctr Dr Med Ste N1200 652 S Medical Ctr Dr Hutchinson, Douglas T MD Hospital Affiliation St George UT. 84790 Ste 120 University of Utah Health - St George Regional Hospital p 801.587.2255 St George UT. 84790 652 S Medical Ctr Dr p 435.628.4460 Saint George UT. 84790 Parry, Scott A MD Hospital Affiliation p 435.251.2250 Revere Health - Primary Childrens Hospital Hospital Affiliation 1490 E Foremaster Dr - St George Regional Hospital Hospital Affiliation Ste 150 Stouffer, Mark H MD - University of Utah Hospital St George UT. 84790 St George Orthopedic Spine Elite Healthcare Southern p 435.628.9393 617 E Riverside Dr Utah *Jager, Zachary S MD Ste 302 FAC 568 W Telegraph Rd Zion Orthopedics & Sports 2825 E Mall Dr Saint George UT. 84790 Washington UT. 84780 Medicine St Geroge UT. 84790 p 435.652.6024 p 435.627.0231 652 S Medical Ctr Dr p 435.628.9393 Ste 400 Southern Utah Hansen, Stephen M MD St George UT. 84790 Hospital Affiliation Neurosciences Institute Advance Spine and Rehab p 435.251.2650 - St George Regional Hospital 652 S Medical Center Dr 619 S Bluff St - Kane County Hospital Ste 420 Ste 100 Tower 1 Hospital Affiliation St George UT. 84790 Saint George UT. 84770 - St George Regional Hospital Parry, Todd R MD p 435.251.6800 p 435.656.1116 Revere Health *Larsen, Nicholas J MD 1490 E Foremaster Dr Hospital Affiliation Heflin, John MD Southwest Ortho and Sports Ste 150 - St George Regional Hospital University of Utah Health Med St George UT. 84790 1380 E Medical Ctr Dr 652 S Medical Center Dr p 435.628.9393 Sutak, Alan K MD Ste N1200 Ste 120 Revere Health St George UT. 84790 St George UT. 84790 2825 E Mall Dr 1490 E Foremaster Dr p 801.587.2255 p 435.628.4460 St Geroge UT. 84790 Ste 150 p 435.628.9393 St George UT. 84790 Hicken, Gregory J MD *Leitze, Zachary R MD p 435.628.9393 Elite Healthcare Southern Southwest Ortho and Sports Hospital Affiliation Utah Med - St George Regional Hospital 2825 E Mall Dr 568 W Telegraph Rd 652 S Medical Center Dr St Geroge UT. 84790 Washington UT. 84780 Ste 120 Prince, Edward J MD p 435.628.9393 p 435.627.0231 St George UT. 84790 Revere Health p 435.628.4460 1490 E Foremaster Dr West, Kristoffer R MD Hospital Affiliation Ste 150 St George Orthopedic Spine - Brigham City Community Southwest Ortho and Sports St George UT. 84790 230 N 1680 E Hospital Med-HHC p 435.628.9393 Ste I-1 - Franklin County Medical 75 N 2260 W St George UT. 84790 Center Hurricane UT. 84737 2825 E Mall Dr p 435.652.6024 - Cache Valley Hospital p 435.628.4460 St Geroge UT. 84790 p 435.628.9393 Hospital Affiliation - St George Regional Hospital - St Marks Hospital

588 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Orthotics And Prosthetics 368 E Riverside Dr 652 S Medical Ctr Dr 301 N 200 E Fit Well Ste 3B Ste 400 Ste 2-A Prosthetics/Orthotics St George UT. 84790 Saint George UT. 84790 Saint George UT. 84770 720 S River Rd p 435.216.7000 p 435.656.2424 p 435.688.7246 Ste A113 St George UT. 84790 Hospital Affiliation Obray, Jon B MD 652 S Medical Ctr Dr p 800.854.5462 - St George Regional Hospital Vista Neurology Ste 110 Specialists Saint George UT. 84790 Hanger Clinic Frieden, Derek L MD 25 N 2000 W p 435.656.2424 923 S River Rd Vista Neurology Ste 8 Ste 100 Specialists Hurricane UT. 84737 652 S Medical Ctr Dr Saint George UT. 84790 301 N 200 E p 435.635.0174 Ste 400 p 435.673.6449 Ste 2-A Saint George UT. 84790 Saint George UT. 84770 301 N 200 E p 435.215.0252 Pain Management p 435.688.7246 Ste 2-A Abegglen, Joanne H APRN Saint George UT. 84770 *Southern Utah Zion Pain Management 652 S Medical Ctr Dr p 435.688.7246 *Neurosciences Institute 301 N 200 E Ste 110 652 S Medical Center Dr Ste 2A St George UT. 84790 652 S Medical Ctr Dr Ste 420 St George UT. 84770 p 435.656.2424 Ste 110 Saint George UT. 84790 p 435.688.7246 Saint George UT. 84790 p 435.251.3700 652 S Medical Ctr Dr p 435.656.2424 Hospital Affiliation Ste 400 Stott, Dale G MD - Cedar City Hospital Saint George UT. 84790 652 S Medical Ctr Dr Zion Pain Management p 435.215.0252 Ste 400 301 N 200 E Boeckle, Leigh R PA-C Saint George UT. 84790 Ste 2A Zion Pain Management Hospital Affiliation p 435.215.0252 St George UT. 84770 301 N 200 E - St George Regional Hospital p 435.688.7246 Ste 2A Hospital Affiliation Saint George UT. 84770 Mathews, Jeffrey MD - St George Regional Hospital Hospital Affiliation p 435.688.7246 Vista Neurology - St George Regional Hospital Specialists Obray, Rick W MD Christensen, Bryt MD 1490 E Foremaster Dr Vista Neurology Wells, Spencer G MD Vista Neurology Ste 220 Specialists Desert Pain Specialists Specialists Saint George UT. 84790 25 N 2000 W 1490 E Foremaster Dr 25 N 2000 W p 435.879.7610 Ste 8 Ste 220 Ste 8 Hurricane UT. 84737 St George UT. 84790 Hurricane UT. 84737 25 N 2000 W p 435.635.0174 p 435.216.7000 p 435.635.0174 Ste 8 Hurricane UT. 84737 301 N 200 E 368 E Riverside Dr 301 N 200 E p 435.635.0174 Ste 2-A Ste 3B Ste 2-A Saint George UT. 84770 St George UT. 84790 Saint George UT. 84770 652 S Medical Ctr Dr p 435.688.7246 p 435.216.7000 p 435.688.7246 Ste 110 St George UT. 84790 652 S Medical Ctr Dr Hospital Affiliation 652 S Medical Ctr Dr p 435.656.2424 Ste 110 - St George Regional Hospital Ste 110 Saint George UT. 84790 Saint George UT. 84790 Muir, Casey MD p 435.656.2424 Pediatric Cardiology p 435.656.2424 Vista Neurology Binka, Edem K MD Specialists 652 S Medical Ctr Dr University Of Utah Health 652 S Medical Ctr Dr 25 N 2000 W Ste 400 1380 E Medical Ctr Dr Ste 400 Ste 8 Saint George UT. 84790 St George UT. 84790 Saint George UT. 84790 Hurricane UT. 84737 p 435.215.0252 p 801.213.3599 p 435.215.0252 p 435.635.0174 Hospital Affiliation Hospital Affiliation Hospital Affiliation 301 N 200 E - St George Regional Hospital - University of Utah Hospital - St George Regional Hospital Ste 2-A Saint George UT. 84770 Oliver, Stacie L MD Colquitt, John MD Empey, J C MD p 435.688.7246 Vista Neurology University Of Utah Health Desert Pain Specialists Specialists 1380 E Medical Ctr Dr 1490 E Foremaster Dr 652 S Medical Ctr Dr 25 N 2000 W St George UT. 84790 Ste 220 Ste 110 Ste 8 p 801.213.3599 St George UT. 84790 Saint George UT. 84790 Hurricane UT. 84737 p 435.216.7000 p 435.656.2424 p 435.635.0174

589 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Etheridge, Susan P MD Murray, Mary A MD Pediatric Ophthalmology Behavioral Health Access University of Utah Health University of Utah Health Schliesser, Joshua A MD Center - SGRH 1380 E Medical Ctr Dr 1380 E Medical Ctr Dr Dixie Ophthalmic 544 S 400 E Saint George UT. 84790 St George UT. 84790 Specialists St George UT. 84770 p 801.213.3599 p 801.213.3599 1791 E 280 N p 435.688.4290 St George UT. 84790 *Hoffman, James L MD Primary Childrens Hospital p 435.656.2020 Pediatric Urology St George Regional 348 E 600 S Jacobson, Deborah MD Hospital St George UT. 84770 Hospital Affiliation University of Utah Health 544 S 400 E p 801.662.1000 - St George Regional Hospital 1380 E Medical Ctr Dr St George UT. 84770 Ste 4500 p 435.251.1914 Hospital Affiliation Pediatric Optometry St George UT. 84790 - University of Utah Hospital OBrien, Jenna OD p 801.662.5555 Hospital Affiliation The Childrens Vision - Timpanogos Regional Hospital *Raleigh, Zoe T MD Center Schaeffer, Anthony J MD Primary Childrens Diabetes 1490 E Foremaster Dr University of Utah Health Hogan, Whitnee MD 1380 E Medical Ctr Dr Ste 120 1380 E Medical Ctr Dr University Of Utah Health Ste N1200 Saint George UT. 84790 Ste 4500 1380 E Medical Ctr Dr St George UT. 84790 p 435.625.0804 St George UT. 84790 St George UT. 84790 p 801.662.1000 p 801.662.5555 p 801.213.3599 Standard Optical Hospital Affiliation 250 N Red Cliffs Dr 544 E 300 S Hospital Affiliation - Primary Childrens Hospital Saint George UT. 84790 Saint George UT. 84770 - University of Utah Hospital p 435.674.2020 p 435.688.4770 *Raman, Vandana S MD Lindsay, Ian M MD Primary Childrens Hospital The Childrens Vision Hospital Affiliation University of Utah Health 348 E 600 S Center - Primary Childrens Hospital 1380 E Medical Ctr Dr St George UT. 84770 1490 E Foremaster Dr St George UT. 84790 p 801.662.1000 Ste 120 Pediatrics p 801.213.3599 Saint George UT. 84790 *Andersen, Nisha D APRN Hospital Affiliation p 435.625.0804 Southern Utah Plastic Hospital Affiliation - University of Utah Hospital Surgery - Primary Childrens Hospital Pediatric Orthopedic Surgery 652 S Medical Center Dr *Timme, Kathleen H MD Hutchinson, Douglas T MD Ste 300 Ware, Adam L MD Primary Childrens Diabetes University of Utah Health St George UT. 84790 University of Utah Health 1380 E Medical Ctr Dr 652 S Medical Ctr Dr p 435.251.3670 1380 E Medical Ctr Dr Ste N-1200 Saint George UT. 84790 Saint George UT. 84790 St George UT. 84790 p 435.251.2250 Hospital Affiliation p 801.213.3599 p 801.662.1000 - St George Regional Hospital Hospital Affiliation Pediatric Endocrinology University of Utah Health - University of Utah Hospital *Bosshardt, Gary MD *Clements, Scott A MD 1380 E Medical Ctr Dr Sunset Family Practice Primary Childrens Hospital St George UT. 84790 Smith, John T MD 1739 W Sunset Blvd 348 E 600 S p 801.213.3599 University of Utah Health St George UT. 84770 St George UT. 84770 1380 E Medical Ctr Dr p 435.634.6000 p 801.662.1000 Hospital Affiliation Ste N1200 - Primary Childrens Hospital St George UT. 84790 Hospital Affiliation Hospital Affiliation p 801.587.2255 - St George Regional Hospital - University of Utah Hospital Pediatric Gastroenterology *Kaddu, Rajiv J MD Pediatric Psychiatry *Cannon, Daniel G MD *Foster, Carol M MD Redrock Pediatrics *Grimwood, Brian L DO Redrock Pediatrics Primary Childrens Hospital 1380 E Medical Ctr Dr Redrock Pediatrics 1380 E Medical Ctr Dr 348 E 600 S Ste 3100 1380 E Medical Ctr Dr Ste 3100 St George UT. 84770 St George UT. 84790 Ste 3100 St George UT. 84790 p 801.662.1000 p 435.251.2740 St George UT. 84790 p 435.251.2740 p 435.251.2740 Hospital Affiliation Hospital Affiliation Hospital Affiliation - University of Utah Hospital - St George Regional Hospital Int Psychiatry and - St George Regional Hospital Counseling-St George *Hamaker, Mark MD Pediatric Hematology And Oncology 320 E 600 S Dixie Pediatrics Primary Childrens Hospital *Asch, Julie D MD St George UT. 84770 1240 E 100 S 348 E 600 S BMT Leukemia Program SWR p 435.688.4850 Ste 14 St George UT. 84770 544 S 400 E St George UT. 84790 p 801.662.1000 St George UT. 84770 p 435.628.8232 p 435.688.4900 Hospital Affiliation - Primary Childrens Hospital Hospital Affiliation - Primary Childrens Hospital 590 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Holmes, Brendon J DO *McNally, Jeffrey M MD Woolley, Joseph H MD 1424 E Foremaster Dr Redrock Pediatrics St George Palliative Care Southwest Internal Ste 120 1380 E Medical Ctr Dr 1380 E Medical Ctr Dr Medicine St George UT. 84790 Ste 3100 St George UT. 84790 292 S 1470 E p 435.656.8800 St George UT. 84790 p 385.887.6277 Ste 100 p 435.251.2740 St George UT. 84790 2825 E Mall Dr *Merkley, Taylor R MD p 435.628.9200 St Geroge UT. 84790 Hurricane Valley Clinic Redrock Pediatrics p 435.251.2900 75 N 2260 W 1380 E Medical Ctr Dr Hospital Affiliation Hurricane UT. 84737 Ste 3100 - St George Regional Hospital Hospital Affiliation p 435.635.6500 St George UT. 84790 - St George Regional Hospital p 435.251.2740 Physical Medicine And Rehabilitation *Jocelyn, Amanda M APRN Irvin, Matthew C DO *Vroenen, Diane M DO Hurricane Valley Clinic Hospital Affiliation Revere Health Southern Utah 75 N 2260 W - St George Regional Hospital 1424 E Foremaster Dr Neurosciences Institute Hurricane UT. 84737 Ste 120 652 S Medical Center Dr p 435.635.6500 Nilson, Wendell T MD Saint George UT. 84790 Ste 420 Canyonland Pediatrics p 435.656.8800 St George UT. 84790 Hospital Affiliation 1240 E 100 S Bldg 14 p 435.251.6800 - St George Regional Hospital Upstairs 2825 E Mall Dr Saint George UT. 84790 St Geroge UT. 84790 Hospital Affiliation *Kaddu, Rajiv J MD p 435.634.0055 p 435.251.2900 - St George Regional Hospital Redrock Pediatrics 1380 E Medical Ctr Dr *Sepp, H MD *Moore, Rusty A DO Physical Therapy Ste 3100 Redrock Pediatrics St George Acute Rehab *Aguirre-Jensen, Teena M St George UT. 84790 1380 E Medical Ctr Dr 544 S 400 E *PT p 435.251.2740 Ste 3100 St George UT. 84770 SGRH Rehab Center St George UT. 84790 p 435.688.4700 652 S Medical Ctr Dr Hospital Affiliation p 435.251.2740 Ste LL10 - St George Regional Hospital Southern Utah St George UT. 84790 Sunset Family Practice Neurosciences Institute p 435.251.2250 *Larsen, Timothy C MD 1739 W Sunset Blvd 652 S Medical Center Dr Redrock Pediatrics St George UT. 84770 Ste 420 *Armstrong, Arndreke DPT 1380 E Medical Ctr Dr p 435.634.6000 St George UT. 84790 SGRH Rehab Center Ste 3100 p 435.251.6800 652 S Medical Ctr Dr St George UT. 84790 Hospital Affiliation Ste LL10 p 435.251.2740 - St George Regional Hospital Pinna, Charisma O MD St George UT. 84790 515 S 300 E p 435.251.2250 Hospital Affiliation *Siddiqi, Faizi A MD Ste 101 - St George Regional Hospital Primary Childrens Hospital St George UT. 84770 Banks, Wyatt D PT 736 S 900 E p 435.688.8413 Truman & Moore Therapy Leeflang, Johan N PA-C Ste 107 660 E Main St Bldg B Utah Surgical Associates St George UT. 84790 Hospital Affiliation Enterprise UT. 84725 1490 E Foremaster Dr p 435.251.2888 - St George Regional Hospital p 435.878.2722 Ste 200 St George UT. 84790 Hospital Affiliation Root, Bradley DO Bennett, Steven C MSPT p 435.628.1641 - University of Utah Hospital Revere Health Mountain Land 1424 E Foremaster Dr Rehabilitation Inc Hospital Affiliation Twiggs, Jerry D MD Ste 120 736 S 900 E - St George Regional Hospital Night Light Pediatrics St George UT. 84790 Ste 106 1240 E 100 S p 435.656.8800 Saint George UT. 84790 *Marsden, Michael C DO Ste 14 p 435.673.0191 Redrock Pediatrics St George UT. 84790 2825 E Mall Dr 1380 E Medical Ctr Dr p 435.628.8232 St Geroge UT. 84790 Blatter, Grant PT Ste 3100 p 435.251.2900 Revere Health St George UT. 84790 Hospital Affiliation 1424 E Foremaster Dr p 435.251.2740 - St George Regional Hospital Hospital Affiliation Ste 120 - St George Regional Hospital St George UT. 84790 Hospital Affiliation *Walker Jenkins, Adrianne p 435.656.8800 - St George Regional Hospital *R MD Root, Max MD Redrock Pediatrics Revere Health 1449 N 1400 W McMullin, Karl T NP 1380 E Medical Ctr Dr 1335 N Northfield Rd Ste 21 Dixie Pediatrics Ste 3100 Ste 300 St George UT. 84770 1240 E 100 S St George UT. 84790 Saint George UT. 84790 p 435.656.8800 Ste 14 p 435.251.2740 p 435.656.8800 St George UT. 84790 p 435.628.8232 Hospital Affiliation - St George Regional Hospital 591 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 2825 E Mall Dr *Droubay, Jonathan L PT Green, Katherine DPT Johnson, Benjamin J DPT St Geroge UT. 84790 St George Regional Fit Physical Therapy Fit Physical Therapy p 435.251.2900 Hospital 617 E Riverside Dr 1490 E Foremaster Dr 652 S Medical Center Dr Ste 303 Ste 110 *Brown, David C DPT Ste LL10 St George UT. 84790 St George UT. 84790 SGRH Rehab Center St George UT. 84790 p 435.673.4303 p 435.652.4455 652 S Medical Ctr Dr p 435.251.2250 Ste LL10 Gubler, Troy C MPT 2192 W 100 N St George UT. 84790 *Dumitru, Samantha PT Gublers Physical Therapy Hurricane UT. 84737 p 435.251.2250 St George Regional 83 S 2600 W p 435.767.0747 Hospital Ste 201 Hurricane Valley Clinic 652 S Medical Center Dr Hurricane UT. 84737 Johnson, Trevor S DPT Physical Therapy Ste LL10 p 435.635.9333 Mountain Land 75 N 2260 W St George UT. 84790 Rehabilitation Inc Hurricane UT. 84737 p 435.251.2250 Harper, Jason L DPT 272 E Center St p 435.635.6480 Fortify Physical Therapy Ste 103 *Esplin, Dave C PT 792 S 3000 E Ivins UT. 84738 Hospital Affiliation St George Regional St George UT. 84790 p 435.674.2115 - St George Regional Hospital Hospital p 208.431.0211 652 S Medical Center Dr 736 S 900 E Burbank, Tricia L DPT Ste LL10 Harward, Aaron A DPT Ste 106 Fit Physical Therapy St George UT. 84790 Fit Physical Therapy Saint George UT. 84790 617 E Riverside Dr p 435.251.2250 1490 E Foremaster Dr p 435.673.0191 Ste 303 Ste 110 St George UT. 84790 Farr, Tyler J DPT Saint George UT. 84790 Laird, Trenton DPT p 435.673.4303 Fit Physical Therapy p 435.652.4455 Fit Physical Therapy 1490 E Foremaster Dr 617 E Riverside Dr Burningham, Rulon D DPT Ste 110 1532 E 1450 S Ste 303 Mountain Land Saint George UT. 84790 St George UT. 84790 St George UT. 84790 Rehabilitation Inc p 435.652.4455 p 435.359.9200 p 435.673.4303 1404 W Sun River Pkwy Ste 100 *Farrer, Rhett P PT Harward, Roger J PT Larrabee, Christopher M Saint George UT. 84790 St George Regional Fit Physical Therapy DPT p 435.767.9094 Hospital 1490 E Foremaster Dr Fit Physical Therapy 652 S Medical Center Dr Ste 110 617 E Riverside Dr 272 E Center St Ste LL10 St George UT. 84790 Ste 303 Ste 103 St George UT. 84790 p 435.652.4455 St George UT. 84790 Ivins UT. 84738 p 435.251.2250 p 435.673.4303 p 435.674.2115 Hicken, Jeffrey L DC *Gary, Huntington R DPT Elite Healthcare Southern Majeskie, Amber DPT Burton, Tyler C DPT St George Regional Utah Fit Physical Therapy Fit Physical Therapy Hospital 568 W Telegraph Rd 617 E Riverside Dr 617 E Riverside Dr 652 S Medical Center Dr Washington UT. 84780 Ste 303 Ste 303 Ste LL10 p 435.627.0231 St George UT. 84790 St George UT. 84790 St George UT. 84790 p 435.673.4303 p 435.673.4303 p 435.251.2250 Hospital Affiliation - Logan Regional Hospital May, Trent C PT *Carey, Sean W PT Hospital Affiliation - Cache Valley Hospital Fit Physical Therapy St George Regional - St George Regional Hospital - Franklin County Medical 1040 W Utah Ave Hospital Center Hildale UT. 84784 652 S Medical Center Dr *Glazier, Steven K PT - Brigham City Community p 435.429.0019 Ste LL10 St George Regional Hospital St George UT. 84790 Hospital 1490 E Foremaster Dr p 435.251.2250 652 S Medical Center Dr *Hugunin, Jane A PT Ste 110 Ste LL10 St George Regional St George UT. 84790 75 N 2260 W St George UT. 84790 Hospital p 435.652.4455 Hurricane UT. 84737 p 435.251.2250 652 S Medical Center Dr p 435.635.7227 Ste LL10 *McCausland, W Luke PT *Gray, Ryan M DPT St George UT. 84790 St George Regional Concentra Medical Centers SGRH Rehab Center p 435.251.2250 Hospital 2390 Redwood Rd 652 S Medical Ctr Dr 652 S Medical Center Dr West Valley City UT. 84419 Ste LL10 Jensen, Curtis D DPT Ste LL10 p 888.997.2669 St George UT. 84790 House Call Physical St George UT. 84790 p 435.251.2250 Therapy LLC p 435.251.2250 3143 S 840 E Ste 327 Saint George UT. 84790 p 435.749.1852 592 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Mccombs, Benjiman R DPT *Smith, Tyler D DPT Peterson, Marcus L MD Magnesen, David T DPM Mountain Land SGRH Rehab Center Center for Advanced 676 S Bluff St Rehabilitation Inc 652 S Medical Ctr Dr Plastic Surgery Ste 205 736 S 900 E Ste LL10 676 S Bluff St St George UT. 84770 Ste 106 St George UT. 84790 Ste 207 p 435.628.5690 St George UT. 84790 p 435.251.2250 St George UT. 84770 p 435.673.0191 p 435.628.2895 Hospital Affiliation Physical Therapy - St George Regional Hospital *Mills, Mark A PT 75 N 2260 W Hospital Affiliation St George Regional Hurricane UT. 84737 - St George Regional Hospital Myers, Victor K DPM Hospital p 435.635.7227 Foot and Ankle Institute 652 S Medical Center Dr Wallin, Jordan L MD 52 S 850 W Ste LL10 Hospital Affiliation Desert Bloom Plastic Ste 101 St George UT. 84790 - St George Regional Hospital Surgery Hurricane UT. 84737 p 435.251.2250 446 S Mall Dr p 435.635.4609 *Sparks, Jonathan L PT Ste B-1 *Mongeon, Sheila A PT St George Regional Saint George UT. 84790 754 S Main Physical Therapy Hospital p 435.627.8150 Ste 3 75 N 2260 W 652 S Medical Center Dr St George UT. 84770 Hurricane UT. 84737 Ste LL10 Podiatry p 435.586.2225 p 435.635.7227 St George UT. 84790 Burton, Stephen K DPM p 435.251.2250 Foot and Ankle Institute Powell, Andrew B DPM Hospital Affiliation 1404 W Sun River Pkwy Foot and Ankle Institute - St George Regional Hospital *Taylor, Victoria R PT Ste 100 1404 W Sun River Pkwy St George Regional St George UT. 84770 Ste 100 Myers, Karen S PT Hospital p 435.628.2671 St George UT. 84770 Fit Physical Therapy 652 S Medical Center Dr p 435.628.2671 1490 E Foremaster Dr Ste LL10 754 S Main Ste 110 St George UT. 84790 Ste 3 52 S 850 W St George UT. 84790 p 435.251.2250 St George UT. 84770 Ste 101 p 435.652.4455 p 435.628.2671 Hurricane UT. 84737 Tomlinson, Stephen J PT p 435.635.4609 617 E Riverside Dr Revere Health Hospital Affiliation Ste 303 1424 E Foremaster Dr - St George Regional Hospital 754 S Main Saint George UT. 84790 Ste 120 Ste 3 p 435.767.0747 St George UT. 84790 Butterfield, Ted DPM St George UT. 84770 p 435.656.8800 Foot and Ankle Institute p 435.628.2671 *Ogilvie, Paul M PT 754 S Main St George Regional 1449 N 1400 W Ste 3 Hospital Affiliation Hospital Ste 21 Saint George UT. 84770 - St George Regional Hospital 652 S Medical Center Dr St George UT. 84770 p 435.628.2671 Ste LL10 p 435.656.8800 Reber, Keith R DPM St George UT. 84790 Hospital Affiliation Foot and Ankle Institute p 435.251.2250 2825 E Mall Dr - St George Regional Hospital 1404 W Sun River Pkwy St Geroge UT. 84790 Ste 100 *Perry, Tyler N PT p 435.251.2900 Cameron, Landon T DPM St George UT. 84770 SGRH Rehab Center Diabetes and Wound Care p 435.628.2671 652 S Medical Ctr Dr Plastic Surgery Clinic of St George Ste LL10 Chase, Lawrence J MD 1054 E Riverside Dr 754 S Main St George UT. 84790 Chase Plastic Surgery Ste 201 Ste 3 p 435.251.2250 321 N Mall Dr Bldg N Saint George UT. 84790 St George UT. 84770 St George UT. 84790 p 435.574.5123 p 435.628.2671 *Reynolds, Joshua L PT p 435.634.0358 St George Regional Coral Desert Foot & Ankle Hospital Affiliation Hospital Hospital Affiliation 1490 E Foremaster Dr - St George Regional Hospital 652 S Medical Center Dr - St George Regional Hospital Ste 250 Ste LL10 St George UT. 84770 Reber, Leon K DPM St George UT. 84790 *Klomp, Aaron O MD p 435.634.9225 Foot and Ankle Institute p 435.251.2250 Southern Utah Plastic 1404 W Sun River Pkwy Surgery and Dermatology Hospital Affiliation Ste 100 *Rincon, Daniel R DPT 652 S Medical Center Dr - St George Regional Hospital St George UT. 84770 SGRH Rehab Center Ste 300 p 435.628.2671 652 S Medical Ctr Dr St George UT. 84790 Ste LL10 p 435.251.3670 St George UT. 84790 p 435.251.2250 Hospital Affiliation - St George Regional Hospital Hospital Affiliation - St George Regional Hospital 593 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 272 E Ctr St 754 S Main Nielsen, Cantril MD Stoddard, Lisa M APRN Ste 101 Ste 3 St George Children & Desert Spring Behavioral Ivins UT. 84738 St George UT. 84770 Family Psychiatric Center Health p 435.656.4477 p 435.628.2671 230 N 1680 E 640 E 700 S Ste H-1 Ste 205-B 52 S 850 W Hospital Affiliation St George UT. 84790 Saint George UT. 84770 Ste 101 - St George Regional Hospital p 435.652.1897 p 435.703.9647 Hurricane UT. 84737 p 435.635.4609 Webb, Brad S DPM Behavioral Health Access Ward, Cori APRN Foot and Ankle Institute Center - SGRH Utah Behavior Services Foot And Ankle Institute 1404 W Sun River Pkwy 544 S 400 E 1067 E Tabernacle St 754 S Main Ste 100 St George UT. 84770 Ste 7 Ste 3 St George UT. 84770 p 435.688.4290 St George UT. 84770 St George UT. 84770 p 435.628.2671 p 801.255.5131 p 435.628.2671 Hospital Affiliation 754 S Main - St George Regional Hospital Psychology Hospital Affiliation Ste 3 Empey, Dallas PhD - St George Regional Hospital St George UT. 84770 *Rasmusen, Carl MD 905 N Talasi Way - Cedar City Hospital p 435.586.2225 Behavioral Health Access Ivins UT. 84738 Center - SGRH p 801.644.9244 Smith, Lary J DPM Hospital Affiliation 544 S 400 E Foot and Ankle Institute - Cedar City Hospital St George UT. 84770 *Everett, Ethan R PSYD 1404 W Sun River Pkwy p 435.688.4290 Int Psychiatry and Ste 100 Yates, D A DPM Counseling-St George St George UT. 84770 736 S 900 E Hospital Affiliation 320 E 600 S p 435.628.2671 Ste 101 - Jordan Valley Medical St George UT. 84770 St George UT. 84790 Center West Valley Campus p 435.688.4850 52 S 850 W p 435.674.7444 Ste 101 Red Sands Psychiatry Hurricane Valley Clinic Hurricane UT. 84737 Hospital Affiliation 1031 S Bluff St 75 N 2260 W p 435.635.4609 - St George Regional Hospital Saint George UT. 84770 Hurricane UT. 84737 p 435.634.8848 p 435.635.6500 754 S Main Psychiatry Ste 3 *Bradbury, Matthew DO 630 S 400 E *Hall, W C PhD St George UT. 84770 Int Psychiatry & Ste 103 Int Psychiatry and p 435.628.2671 Counseling-St George Saint George UT. 84770 Counseling-St George 292 S 1470 E p 435.634.8848 292 S 1470 E Hospital Affiliation St George UT. 84790 St George UT. 84790 - St George Regional Hospital p 435.251.5900 Roberts, Jacob S NP p 435.251.5900 St George Children & Stewart, Jeffrey L DPM Hospital Affiliation Family Psychiatric Center River Road Internal Diabetes and Wound Care - Baylor Scott & White 230 N 1680 E Medicine Clinic of St George Medical Center - Temple Ste H1 577 S River Rd 1054 E Riverside Dr Saint George UT. 84790 St George UT. 84790 Ste 201 Marshall, Paige PhD p 435.652.5909 p 435.688.6200 Saint George UT. 84790 Red Sands Psychiatry p 435.574.5123 1031 S Bluff St *Romer, Laura K MD Kockler, Timothy R PhD Saint George UT. 84770 Int Psychiatry and Timothy Richard Kockler, Coral Desert Foot & Ankle p 435.634.8848 Counseling-St George LLC 1490 E Foremaster Dr 292 S 1470 E 1224 S River Rd Ste 250 630 S 400 E St George UT. 84790 Ste B-221 St George UT. 84770 Ste 103 p 435.251.5900 St George UT. 84790 p 435.634.9225 Saint George UT. 84770 p 435.632.1445 p 435.634.8848 Behavioral Health Access Hospital Affiliation Center - SGRH *Mackay, Matthew PhD - St George Regional Hospital Martineau, Clint APRN 544 S 400 E Int Psychiatry and - Kane County Hospital St George Children & St George UT. 84770 Counseling-St George Family Psychiatric Center p 435.688.4290 320 E 600 S VanGils, Carl C DPM 230 N 1680 E St George UT. 84770 Foot and Ankle Institute Ste H1 Hospital Affiliation p 435.688.4850 1404 W Sun River Pkwy Saint George UT. 84790 - St George Regional Hospital Ste 100 p 435.652.1897 Moody, Richard Y PhD St George UT. 84770 TurningLeaf Wellness p 435.628.2671 Center 1240 E 100 S Bldg 22 Ste 121 St George UT. 84790 p 435.652.1202 594 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Shumway, Brett PSYD *Kline, Michael R MD Radiation Oncology Harris, Robert A MD Utah Behavior Services St George Pulmonary Clinic *Ashton, Spencer N MD Gamma West Cancer Services 1067 E Tabernacle St 1380 E Medical Ctr Dr St George Radiation 1308 E 900 S Ste 7 Ste 2200 Oncology Ste B St George UT. 84770 St George UT. 84790 544 S 400 E St George UT. 84790 p 801.255.5131 p 435.251.2600 St George UT. 84770 p 435.627.5327 p 435.688.4175 Siebert, Tatum LCPC St George Pulmonary Hospital Affiliation Utah Behavior Services Critical Care Hospital Affiliation - Ogden Regional Medical 1067 E Tabernacle St 1380 E Medical Ctr Dr - Cedar City Hospital Center Ste 7 St George UT. 84790 - Davis Hospital Saint George UT. 84770 p 435.251.2600 *Avizonis, Vilija MD - St Marks Hospital p 801.255.5131 St George Radiation - Timpanogos Regional Hospital Hospital Affiliation Oncology Tate, David B PhD - St George Regional Hospital 544 S 400 E Hayes, John K MD St George Community St George UT. 84770 Gamma West Cancer Services Healing Arts *Moon, Theodore H MD p 435.688.4175 1308 E 900 S 113 E 200 N St George Pulmonary Clinic Ste B St George UT. 84770 1380 E Medical Ctr Dr Hospital Affiliation St George UT. 84790 p 435.656.0506 Ste 2200 - St Marks Hospital p 435.627.5327 St George UT. 84790 David B. Tate, PhD p 435.251.2600 *Barney, Brandon M MD Hospital Affiliation 321 N Mall Dr St George Radiation - St Marks Hospital Ste I-201 St George Pulmonary Oncology - Salt Lake Regional Medical Saint George UT. 84790 Critical Care 600 S Medical Ctr Dr Center p 435.656.0506 1380 E Medical Ctr Dr St George UT. 84790 - Davis Hospital St George UT. 84790 p 435.688.4175 - Timpanogos Regional Hospital Center for Stress p 435.251.2600 Reduction Clarke, James W MD Reilly, Mark W MD 920 W 437 S Hospital Affiliation Gamma West Cancer Services Gamma West Cancer Services Ste 202 - St George Regional Hospital 1308 E 900 S 1308 E 900 S St George UT. 84770 Ste B Ste B p 435.656.0506 *Saifee, Mustafa T MD St George UT. 84790 St George UT. 84790 St George Pulmonary p 435.627.5327 p 435.627.5327 Young, William S Critical Care Premier Psychological 1380 E Medical Ctr Dr Hospital Affiliation Hospital Affiliation Counseling & Consulting St George UT. 84790 - Timpanogos Regional Hospital - St Marks Hospital 230 N 1680 E Bldg T-2 p 435.251.2600 - St Marks Hospital - Salt Lake Regional Medical St George UT. 84790 - Davis Hospital Center p 435.865.9119 Advanced Pulmonary, Sleep - Ogden Region Medical - Jordan Valley Medical Disorders and Internal Center Center Pulmonology Medicine - Davis Hospital *Callaway, Jonathan K MD 640 E 700 S *Evans, Jaden D MD St George Pulmonary Clinic Ste 105 St George Radiation Richards, Ray S MD 1380 E Medical Ctr Dr St George UT. 84770 Oncology Gamma West Cancer Services Ste 2200 p 435.688.7770 600 S Medical Ctr Dr 1308 E 900 S St George UT. 84790 St George UT. 84790 Ste B p 435.251.2600 Hospital Affiliation p 435.688.4175 St George UT. 84790 - St George Regional Hospital p 435.627.5327 Hospital Affiliation *Grant, Jonathan D MD - St George Regional Hospital *Strawter, Christopher H St George Radiation Hospital Affiliation *MD Oncology - St George Regional Hospital *Ferguson, Bryce L MD St George Pulmonary 544 S 400 E St George Pulmonary Clinic Critical Care St George UT. 84770 Radiology 1380 E Medical Ctr Dr 1380 E Medical Ctr Dr p 435.688.4175 Christianson, Kimball MD Ste 2200 St George UT. 84790 Revere Health St George UT. 84790 p 435.251.2600 Hansen, Roger S MD 1490 E Foremaster Dr Bldg p 435.251.2600 Gamma West Cancer Services C *Taub, Lewis D MD 1308 E 900 S St George UT. 84790 St George Pulmonary St George Pulmonary Ste B p 801.812.4624 Critical Care Critical Care St George UT. 84790 1380 E Medical Ctr Dr 1380 E Medical Ctr Dr p 435.627.5327 *Davis, John A MD St George UT. 84790 St George UT. 84790 St George Regional p 435.251.2600 p 435.251.2600 Hospital Affiliation Hospital - Ogden Regional Medical 1380 E Medical Ctr Dr Hospital Affiliation Center St George UT. 84790 - St George Regional Hospital - Davis Hospital p 435.251.1000 - Salt Lake Regional Medical Center Hospital Affiliation - St Marks Hospital - St George Regional Hospital595 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. *Davis, Steven B MD Rheumatology Advanced Pulmonary, Sleep Bracken, Talaisha LCSW St George Regional *Jensen, Paul T MD Disorders and Internal Family Healthcare Hospital Southwest Rheumatology Medicine 245 E 680 S 1380 E Medical Ctr Dr Associates 640 E 700 S Cedar City UT. 84770 St George UT. 84790 577 S River Rd Ste 105 p 435.865.1387 p 435.251.1000 Saint George UT. 84790 St George UT. 84770 p 435.688.6200 p 435.688.7770 25 N 100 E Hospital Affiliation Ste 102 - St George Regional Hospital Hospital Affiliation Hospital Affiliation St George UT. 84770 - St George Regional Hospital - St George Regional Hospital p 435.986.2565 Layton, Brent T MD Revere Health Kookootsedes, Gayle M MD *Watkins, Kirk G MD Bunting, Catherine CSW 1490 E Foremaster Dr Bldg Vista Neurology St George Sleep Disorders Utah Behavior Services C Specialists Center 1067 E Tabernacle St St George UT. 84790 1490 E Foremaster Dr 652 S Medical Ctr Dr Ste 7 p 435.812.4624 Ste 220 Ste 310 Saint George UT. 84770 Saint George UT. 84790 St George UT. 84790 p 801.255.5131 Hospital Affiliation p 435.879.7610 p 435.251.3940 - Mountain View Hospital Chamberlain, Cary LCSW (UT) *Southwest Rheumatology Hospital Affiliation 1224 S River Rd - Timpanogos Regional Hospital *Associates - St George Regional Hospital Ste B-230 577 S River Rd St George UT. 84790 Smith, Greg B MD Saint George UT. 84790 Social Worker p 435.632.0946 Revere Health p 435.688.6200 Arballo, Jennifer CSW 1490 E Foremaster Dr Bldg Utah Behavior Services Child, Steve LCSW C Skilled Nursing Facility 1067 E Tabernacle St Center for Couples & St George UT. 84790 St George Rehabilitation Ste 7 Families p 801.812.4624 1032 E 100 S St George UT. 84770 1173 S 250 W Bldg I Saint George UT. 84770 p 801.255.5131 Ste 208 Hospital Affiliation p 435.628.0488 Saint George UT. 84770 - Mountain View Hospital Bacon, Jaime L LCSW p 435.688.1111 (UT) Hurricane Health and 321 N Mall Dr - Timpanogos Regional Hospital Rehabilitation Ste I-201 Cho, Jaeyong MSW 416 N State St St George UT. 84790 Utah Behavior Services Valadez, Scott D MD Hurricane UT. 84737 p 435.652.2114 1067 E Tabernacle St Revere Health p 435.635.9833 Ste 7 1490 E Foremaster Dr Bldg Hospital Affiliation Saint George UT. 84770 C Coral Desert - St George Regional Hospital p 801.255.5131 St George UT. 84790 Rehabilitation p 801.812.4624 1490 E Foremaster Dr Barlow, Tiffany LCSW Christiansen, Ryan J LCSW St George UT. 84790 Red Desert Counseling ABC Counseling Services Hospital Affiliation p 435.674.5195 230 N 1680 E Bldg 1 169 W 2710 S Cir - Mountain View Hospital Ste 2 Ste 201-A (UT) Southern Utah Veterans Saint George UT. 84790 St George UT. 84790 - Timpanogos Regional Hospital Home p 801.906.1736 p 435.674.6650 160 N 200 E Wright, Dalton H MD Ivins UT. 84738 *Baumgarten, Victor A LCSW Coburn, Alison MSW Revere Health p 435.634.5220 Int Psychiatry and Utah Behavior Services 1490 E Foremaster Dr Bldg Counseling-St George 1067 E Tabernacle St C Sleep Medicine 320 E 600 S Ste 7 St George UT. 84790 *Hintze, Jonathan P MD St George UT. 84770 St George UT. 84770 p 801.812.4624 St George Sleep Disorders p 435.688.4850 p 801.255.5131 Center Hospital Affiliation 652 S Medical Ctr Dr Beatty, Eva LCSW Gomez, Carlos E LCSW - Mountain View Hospital Ste 310 437 S Bluff St Trauma Treatment & (UT) St George UT. 84790 Ste 202 Counseling - Timpanogos Regional Hospital p 435.251.3940 Saint George UT. 84770 166 N 300 W p 435.272.7974 Ste 3 Reproductive Endocrinology Hospital Affiliation Saint George UT. 84770 Peterson, C Matthew MD - St George Regional Hospital Birch, Kelly LCSW p 435.817.9026 University of Utah Health Utah Behavior Services 544 E 300 S *Saifee, Mustafa T MD 1067 E Tabernacle St 1664 S Dixie Dr Saint George UT. 84770 St George Pulmonary Ste 7 Ste E102 p 435.688.4770 Critical Care St George UT. 84770 Saint George UT. 84770 1380 E Medical Ctr Dr p 801.255.5131 p 435.817.9026 Hospital Affiliation St George UT. 84790 - University of Utah Hospital p 435.251.2600

596 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Holmes, Alisha MSW Mortensen, Michael LCSW Rudd, Ryan LCSW *Puntil-Sheltman, Jo SLP Utah Behavior Services Family Healthcare Crimson Counseling SGRH Rehab Center 1067 E Tabernacle St 25 N 100 E 249 E Tabernacle St 652 S Medical Ctr Dr Ste 7 Ste 102 Ste 100 Ste LL10 Saint George UT. 84770 St George UT. 84770 Saint George UT. 84770 St George UT. 84790 p 801.255.5131 p 435.986.2565 p 435.705.7574 p 435.251.2250

*Johnson, Kevin R LCSW Neff, Michal A CSW,SUDC Sanchez, Rafael A CSW Sports Medicine SGRH Rehab Center Utah Behavior Services Family Healthcare Allen, Daniel J DO 652 S Medical Ctr Dr 1067 E Tabernacle St 245 E 680 S Shivwits Paiute Medical Ste LL10 Ste 7 Saint George UT. 84770 Clinic St George UT. 84790 St George UT. 84770 p 435.986.2565 6109 W 3700 N p 435.251.2250 p 801.255.5131 Ivins UT. 84738 25 N 100 E p 435.688.8198 Johnston, Harmony MSW Nielsen, Stephanie MSW Ste 102 Utah Behavior Services Utah Behavior Services Saint George UT. 84770 Hospital Affiliation 1067 E Tabernacle St 1067 E Tabernacle St p 435.986.2565 - West Valley Medical Center Ste 7 Ste 7 Saint George UT. 84770 Saint George UT. 84770 Shinedling, Teresa C LCSW Kirk, Stephen T MD p 801.255.5131 p 801.255.5131 Shinedling and Shinedling Revere Health PLLC 1490 E Foremaster Dr *Koehn, Samantha LCSW Phillips, Allison 640 E 700 S Ste 150 St George Palliative Care LCSW,BCBA Ste 201 Saint George UT. 84790 1380 E Medical Ctr Dr Utah Behavior Services St George UT. 84770 p 435.628.9393 St George UT. 84790 1067 E Tabernacle St p 435.652.3775 p 385.887.6277 Ste 7 2825 E Mall Dr St George UT. 84770 Skousen, Thomas MSW St Geroge UT. 84790 Luna, Janette M LCSW p 801.255.5131 Utah Behavior Services p 435.628.9393 Utah Behavior Services 1067 E Tabernacle St 1067 E Tabernacle St Powell, Clark Randy LCSW Ste 7 Hospital Affiliation Ste 7 Utah Behavior Services Saint George UT. 84770 - Salt Lake Regional Medical St George UT. 84770 1067 E Tabernacle St p 801.255.5131 Center p 801.255.5131 Ste 7 St George UT. 84770 Slater, Courtney MSW *Millward, Christian S MD McBride, Laurie SSW p 801.255.5131 Utah Behavior Services Southwest Ortho and Sports Evolving Light Counseling 1067 E Tabernacle St Med 32 E 100 S *Reinhardt, Gayla M LCSW Ste 7 652 S Medical Center Dr Ste 202 St George MFM High Risk OB Saint George UT. 84770 Ste 120 Saint George UT. 84770 1380 E Medical Ctr Dr p 801.255.5131 St George UT. 84790 p 435.628.8945 Ste 1600 p 435.628.4460 St George UT. 84790 Stallings, Saskia A LCSW McGill, Katie MSW p 435.688.4770 Saskia A Stallings LCSW Urgent Care Utah Behavior Services 321 N Mall Dr VW104 *Hurricane Valley InstaCare 1067 E Tabernacle St Womens Health Specialists Saint George UT. 84790 *M-Sat 9am-9pm Ste 7 346 E 600 S p 435.359.2433 75 N 2260 W St George UT. 84770 St George UT. 84770 Hurricane UT. 84737 p 801.255.5131 p 435.688.4600 Suarez, Alex LCSW p 435.635.6550 Utah Behavior Services Mendez, Ari LCSW Hospital Affiliation 1067 E Tabernacle St Night Light Pediatrics Family Healthcare - St George Regional Hospital Ste 7 M-Sun 6pm-10pm 25 N 100 E St George UT. 84770 1240 E 100 S Ste 102 Richards, Allen S LCSW p 801.255.5131 Ste 14 St George UT. 84770 St George Children & St George UT. 84790 p 435.986.2565 Family Psychiatric Center Tolman, McKenzie CSW p 435.628.8232 230 N 1680 E Family Healthcare Ari Mendez LCSW Ste H1 25 N 100 E Revere Health St George 32 E 100 S Saint George UT. 84790 Ste 102 Clinic M-F 9am-7pm Sat Ste 202 p 435.652.1897 Saint George UT. 84770 9am-2pm Saint George UT. 84770 p 435.986.2565 736 S 900 E p 435.668.4956 Roche, Miriam MSW Ste 203 Utah Behavior Services Speech Therapy Saint George UT. 84790 Family Healthcare 1067 E Tabernacle St Jones, Jessica L SLP p 435.673.6131 391 N 200 W Ste 7 Riverside Rehabilitation Hurricane UT. 84737 Saint George UT. 84770 2044 S Mesa Palms Dr p 435.986.2565 p 801.255.5131 St George UT. 84770 p 435.632.3423

597 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Revere Health Washington *Whiting, Bryant M MD Edgepark US MED LLC Medical Clinic M-F 9am-5pm Southwest Urology Phone Number Only Phone Number Only 195 W Telegraph 1380 E Medical Ctr Dr p 800.321.0591 p 800.787.6331 Washington UT. 84780 Ste 2100 p 435.215.0600 St George UT. 84790 Cardiac Monitoring United States Medical p 435.251.3250 Remote Cardiac Services Supply *River Road InstaCare M-Sun Phone Number Only Phone Number Only *9am-9pm Hospital Affiliation p 800.367.0300 p 877.840.8218 577 S River Rd - St George Regional Hospital Saint George UT. 84790 - Cedar City Hospital eCardio Diagnostics Durable Medical Equipment p 435.688.6300 Phone Number Only Alpine Home Medical Vascular Surgery p 888.400.3522 Phone Number Only *Sunset InstaCare M-Sat *Hogan, Jessica L MD p 800.686.7993 *9am-9pm Vascular And Vein - St Certified Nurse Midwife 1739 W Sunset Blvd George Dahlsrud, Sadie CNM CCS Medical Saint George UT. 84770 1380 E Medical Ctr Dr Wayne Community Health Phone Number Only p 435.634.6000 Ste 4500 Center p 800.726.9811 St George UT. 84790 128 S 300 W Urology p 435.251.2501 Bicknell UT. 84715 Care Rehab and Orthopedic *Adams, David M MD p 435.425.3744 Products (Muscle Southwest Urology Hospital Affiliation Stimulators) 1380 E Medical Ctr Dr - St George Regional Hospital Rasmussen, Dixie CNM Phone Number Only Ste 2100 Wayne Community Health p 800.487.9644 St George UT. 84790 Huard, G Stedman MD Center p 435.251.3250 1490 E Foremaster Dr 128 S 300 W DJO Global Ste 310 Bicknell UT. 84715 Phone Number Only Hospital Affiliation St George UT. 84790 p 435.425.3744 p 800.336.6569 - St George Regional Hospital p 435.688.1922 - Cedar City Hospital Hospital Affiliation Dynasplint Systems Inc Hospital Affiliation - Sevier Valley Hospital Phone Number Only *Brinton, Thomas S MD - St George Regional Hospital p 800.638.6771 Southwest Urology Counseling 1380 E Medical Ctr Dr *Olsen, Arne M MD Draper, Theron LCSW EBI LLC (Bone Stimulators) Ste 2100 Vascular and Vein - St Wayne Community Health Phone Number Only St George UT. 84790 George Center p 800.526.2579 p 435.251.3250 1380 E Medical Ctr Dr 128 S 300 W Ste 4500 Bicknell UT. 84715 Edgepark Hospital Affiliation St George UT. 84790 p 435.425.3744 Phone Number Only - St George Regional Hospital p 435.251.2501 p 800.321.0591 - Cedar City Hospital Peyton, R Michael LMFT Hospital Affiliation Wayne Community Health Empi Inc (Neuromuscular Cope, Robert M MD - St George Regional Hospital Center Stimulator) St George Urology - St George Regional Hospital 128 S 300 W Phone Number Only 1490 E Foremaster Dr Bicknell UT. 84715 p 800.328.2536 Ste 300 *Wirthlin, Douglas J MD p 435.425.3744 St George UT. 84790 Vascular and Vein - St KCI USA Inc (Wound Vac p 435.688.2104 George Hospital Affiliation Only) 1380 E Medical Ctr Dr - Garfield Memorial Hospital Phone Number Only Hospital Affiliation Ste 4500 p 800.275.4524 - St George Regional Hospital St George UT. 84790 Diabetic Supplies p 435.251.2501 CCS Medical Orthofix Inc (Bone Growth Ellsworth, J B MD Phone Number Only Stimulators Physicians Urology Associates Wound Care p 800.726.9811 Only) 736 S 900 E Diabetes and Wound Care Phone Number Only Ste 108 Clinic of St George Edgepark p 800.535.4492 St George UT. 84790 1054 E Riverside Dr Phone Number Only p 435.628.3606 Ste 201 p 800.321.0591 Pacific Medical Inc Saint George UT. 84770 Phone Number Only Hospital Affiliation p 435.574.5123 Roche Insulin Delivery p 800.726.9180 - St George Regional Hospital Systems Inc Wayne County Phone Number Only RespirTech Taylor, Gregory S MD p 800.280.7801 Phone Number Only St George Urology Breast Pumps p 800.793.1261 1490 E Foremaster Dr Alpine Home Medical Ste 300 Phone Number Only St George UT. 84790 p 800.686.7993 p 435.688.2104

Hospital Affiliation - St George Regional Hospital 598 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Roche Insulin Delivery Snedeger, Zachary PA Peyton, R Michael LMFT Psychiatry Systems Inc Wayne Community Health Wayne Community Health Barusch, Nathaniel MD Phone Number Only Center Center Wayne Community Health p 800.280.7801 128 S 300 W 128 S 300 W Center Bicknell UT. 84715 Bicknell UT. 84715 128 S 300 W Smith Nephew Inc (Muscle p 435.425.3744 p 435.425.3744 Bicknell UT. 84715 Stimulators) p 435.425.3744 Phone Number Only Thurston, Shannon PA Hospital Affiliation p 800.821.5700 Wayne Community Health - Garfield Memorial Hospital Hospital Affiliation Center - Mountain View Hospital US MED LLC 128 S 300 W Occupational Therapy (UT) Phone Number Only Bicknell UT. 84715 Concentra Medical Centers - Utah Valley Hospital p 800.787.6331 p 435.425.3744 2390 Redwood Rd West Valley City UT. 84419 Weber County United States Medical Hospital Affiliation p 888.997.2669 Supply - Garfield Memorial Hospital Aba Therapy Phone Number Only Pain Management Adolphson, Lillian p 877.840.8218 30 S Hwy 95 Robinson, Cole MD BCBA-D Hanksville UT. 84734 Wayne Community Health Utah Behavior Services Family Practice p 435.542.3281 Center 5202 S Fwy Park Dr Birch, Richard DO 128 S 300 W Ogden UT. 84405 Wayne Community Health White, Ryan NP Bicknell UT. 84715 p 801.255.5131 Center Wayne Community Health p 435.425.3744 128 S 300 W Center Aleman, Arianna BCBA Bicknell UT. 84715 128 S 300 W Physical Medicine And Rehabilitation Utah Behavior Services p 435.425.3744 Bicknell UT. 84715 Robinson, Cole MD 5202 S Fwy Park Dr p 435.425.3744 Wayne Community Health Ogden UT. 84405 Hospital Affiliation Center p 801.255.5131 - Garfield Memorial Hospital Health Department 128 S 300 W Wayne Community Health Bicknell UT. 84715 Applied Behavior Chappell, Leland J MD Center p 435.425.3744 Connections Wayne Community Health 30 S Hwy 95 5160 Sunset Ln Center Hanksville UT. 84734 Hospital Affiliation Ogden UT. 84403 128 S 300 W p 435.542.3281 - Sevier Valley Hospital p 801.935.5796 Bicknell UT. 84715 p 435.425.3744 Laboratory Physical Therapy Butler, Erin BCBA Dominion Diagnostics Barney, Matthew PT Neurobehavioral Center For Hospital Affiliation Phone Number Only Wayne Community Health Growth - Sevier Valley Hospital p 877.734.9600 Center 1893 Skyline Dr - Kane County Hospital 128 S 300 W Ogden UT. 84403 LabCorp of America Bicknell UT. 84715 p 801.683.1062 *Christensen, Kyle J PA Holdings p 436.425.3744 Sevier Valley Phone Number Only 5974 Fashion Point Dr Specialty-Wayne-Orthopedics p 888.522.2677 Concentra Medical Centers Ste 100 130 S 300 W 2390 Redwood Rd Ogden UT. 84403 Bicknell UT. 84715 Mental Health West Valley City UT. 84419 p 801.683.1062 p 435.893.0800 Barusch, Nathaniel MD p 888.997.2669 Wayne Community Health 5974 Fashion Point Dr Mooney, Todd MD Center Cottam, Chad R DPT Ste 140 Wayne Community Health 128 S 300 W Wayne Community Health Ogden UT. 84403 Center Bicknell UT. 84715 Center p 801.683.1062 128 S 300 W p 435.425.3744 128 S 300 W Bicknell UT. 84715 Bicknell UT. 84715 Caceres-Loveless, Maria p 435.425.3744 Hospital Affiliation p 435.425.3744 BCBA - Mountain View Hospital Applied Behavior Hospital Affiliation (UT) Gubler, John W DPT Connections - Garfield Memorial Hospital - Utah Valley Hospital Wayne Community Health 5160 Sunset Ln Center Ogden UT. 84403 Pope, David M MD Draper, Theron LCSW 128 S 300 W p 801.935.5796 Wayne Community Health Wayne Community Health Bicknell UT. 84715 Center Center p 435.425.3744 Cardinal, Jennifer R PhD, 128 S 300 W 128 S 300 W BCBA Bicknell UT. 84715 Bicknell UT. 84715 Neurobehavioral Center For p 435.425.3744 p 435.425.3744 Growth 1893 Skyline Dr Hospital Affiliation Ogden UT. 84403 - Sevier Valley Hospital p 801.683.1062

599 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Neurobehavioral Center for Fujiwara, Mina BCBA Jensen, Julia P BCBA Maxwell, Kendra BCBA Growth Utah Behavior Services Utah Behavior Services Utah Behavior Services 5974 Fashion Point Dr 5202 S Freeway Park Dr 5202 S Fwy Park Dr 5202 S Fwy Park Dr Ste 100 Ogden UT. 84405 Ogden UT. 84405 Riverdale UT. 84405 Ogden UT. 84403 p 801.255.5131 p 801.255.5131 p 801.255.5131 p 801.683.1062 Goyal, Anu BCBA Johnson, William BCBA McGuire, Amy BCBA 5974 Fashion Point Dr Neurobehavioral Center For Applied Behavior Utah Behavior Services Ste 140 Growth Connections 5202 S Fwy Park Dr Ogden UT. 84403 1893 Skyline Dr 5160 Sunset Ln Ogden UT. 84405 p 801.683.1062 Ogden UT. 84403 Ogden UT. 84403 p 801.255.5131 p 801.683.1062 p 801.935.5796 Celauro, Melissa BCBA Meier, Heather BCBA Chrysalis Utah 5974 Fashion Point Dr Keller, Rebecca BCBA Applied Behavior 4933 S 1500 W Ste 100 Utah Behavior Services Connections Ste 210 Ogden UT. 84403 5202 S Fwy Park Dr 5160 Sunset Ln Ogden UT. 84405 p 801.683.1062 Ogden UT. 84405 Ogden UT. 84403 p 801.655.4950 p 801.255.5131 p 801.935.5796 Green, Rachal BCBA,LCSW Christianson, Grete BCBA Utah Behavior Services Kennedy, Anne BCBA Metzger, Debbie BCBA Utah Behavior Services 5202 S Fwy Park Dr Utah Behavior Services Utah Behavior Services 5202 S Fwy Park Dr Ogden UT. 84405 5202 S Fwy Park Dr 5202 S Fwy Park Dr Ogden UT. 84405 p 801.255.5131 Ogden UT. 84405 Riverdale UT. 84405 p 801.255.5131 p 801.255.5131 p 801.255.5131 Gressmen, Casey BCBA Chrysalis Utah Utah Behavior Services Knudson, Mani BCBA Nadalsky, Michelle 4933 S 1500 W 5202 S Freeway Park Dr Utah Behavior Services BCBA,SSW Ste 210 Ogden UT. 84405 5202 S Freeway Park Dr Utah Behavior Services Ogden UT. 84405 p 801.255.5131 Ogden UT. 84405 5202 S Fwy Park Dr p 801.655.4950 p 801.255.5131 Ogden UT. 84405 Hanks, Julie BCBA p 801.255.5131 Corey, Spencer BCBA Utah Behavior Services Kulow, Kacylia BCBA Utah Behavior Services 5202 S Fwy Park Dr Utah Behavior Services OQuinn, Casey L BCBA 5202 S Freeway Park Dr Ogden UT. 84405 5202 S Fwy Park Dr Neurobehavioral Center For Ogden UT. 84405 p 801.255.5131 Ogden UT. 84405 Growth p 801.255.5131 p 801.255.5131 1893 Skyline Dr Henshaw, Brandon J BCBA Ogden UT. 84403 Deceuster, Rachael BCBA Neurobehavioral Center For Lambertsen, Hope BCBA p 801.683.1062 Utah Behavior Services Growth Utah Behavior Services 5202 S Fwy Park Dr 1893 Skyline Dr 5202 S Fwy Park Dr 5974 Fashion Point Dr Ogden UT. 84405 Ogden UT. 84403 Ogden UT. 84405 Ste 100 p 801.255.5131 p 801.683.1062 p 801.255.5131 Ogden UT. 84403 p 801.683.1062 Dwyer, Molly M BCBA Neurobehavioral Center for Lee, Jennifer BCBA Neurobehavioral Center For Growth Utah Behavior Services 5974 Fashion Point Dr Growth 5974 Fashion Point Dr 5202 S Fwy Park Dr Ste 140 1893 Skyline Dr Ste 100 Ogden UT. 84405 Ogden UT. 84403 Ogden UT. 84403 Ogden UT. 84403 p 801.255.5131 p 801.683.1062 p 801.683.1062 p 801.683.1062 Lopez, Kitrina BCBA Oblad, Cicily BCBA 5974 Fashion Point Dr Hoffmann, Audrey PhD Utah Behavior Services Utah Behavior Services Ste 100 Utah Behavior Services 5202 S Fwy Park Dr 5202 S Fwy Park Dr Ogden UT. 84403 5202 S Fwy Park Dr Ogden UT. 84405 Ogden UT. 84405 p 801.683.1062 Ogden UT. 84405 p 801.255.5131 p 801.255.5131 p 801.255.5131 5974 Fashion Point Dr Lowe, Kori BCBA Paz, Corinna G BCBA Ste 140 Hunt, Chelseigh BCBA Utah Behavior Services Neurobehavioral Center for Ogden UT. 84403 Utah Behavior Services 5202 S Fwy Park Dr Growth p 801.683.1062 5202 S Fwy Park Dr Ogden UT. 84405 1893 Skyline Dr Ogden UT. 84405 p 801.255.5131 Ogden UT. 84403 Eddy, Alex BCBA p 801.255.5131 p 801.683.1062 Chrysalis Utah Madsen, Sara BCBA 4933 S 1500 W Utah Behavior Services Ste 210 5202 S Fwy Park Dr Ogden UT. 84405 Ogden UT. 84405 p 801.655.4950 p 801.255.5131

600 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 5974 Fashion Point Dr Smith, Saige LPC Yang, Danielle BCBA Ambulatory Surgery Center Ste 140 Utah Behavior Services Utah Behavior Services Mt Ogden Surgical Center Ogden UT. 84403 5202 S Fwy Park Dr 5202 S Freeway Park Dr 4364 Washington Blvd p 801.683.1062 Ogden UT. 84405 Ogden UT. 84405 Ogden UT. 84403 p 801.255.5131 p 801.255.5131 p 801.479.4470 Pickering, Jaclyn BCBA Neurobehavioral Center For Snow, Lauren BCBA Yarger, Jesse BCBA Audiology Growth Utah Behavior Services Neurobehavioral Center For Barwick, Niki L AUD 1893 Skyline Dr 5202 S Fwy Park Dr Growth Ogden Speech & Hearing Ogden UT. 84403 Riverdale UT. 84405 1893 Skyline Dr Center p 801.683.1062 p 801.255.5131 Ogden UT. 84403 978 Chambers St p 801.683.1062 Ste 1 5974 Fashion Point Dr Stevens, Nicole Ogden UT. 84403 Ste 100 BCBA,LMFT 5974 Fashion Point Dr p 801.399.5601 Ogden UT. 84403 Utah Behavior Services Ste 100 p 801.683.1062 5202 S Fwy Park Dr Ogden UT. 84403 Boman, Tel S AUD Ogden UT. 84405 p 801.683.1062 Ogden Speech & Hearing 5974 Fashion Point Dr p 801.255.5131 Center Ste 140 5974 Fashion Point Dr 978 Chambers St Ogden UT. 84403 Traeden, Heather BCBA Ste 140 Ste 1 p 801.683.1062 Neurobehavioral Center For Ogden UT. 84403 Ogden UT. 84403 Growth p 801.683.1062 p 801.399.5601 Plautz, Hailey C BCBA 1893 Skyline Dr Neurobehavioral Center For Ogden UT. 84403 Allergy And Immunology Braunberger, Kerry S AUD Growth p 801.683.1062 Anderson, Joseph R MD Eartech Audiology 5974 Fashion Point Dr IAA Ogden 2850 N 2000 W Ste 140 Utah Behavior Services 5929 S Fashion Point Farr West UT. 84404 Ogden UT. 84403 5202 S Freeway Park Dr Ste 101 p 801.399.9955 p 801.683.1062 Ogden UT. 84405 Ogden UT. 84403 p 801.255.5131 p 801.476.0052 917 Country Hills Dr Rae, Rebecca BCBA Ste 5 Utah Behavior Services Whatcott, Natalie Lyons, Vicki J MD Ogden UT. 84403 5202 S Fwy Park Dr BCBA,SSW Advanced Allergy & Asthma p 801.399.9955 Ogden UT. 84405 Utah Behavior Services 4403 Harrison Blvd p 801.255.5131 5202 S Fwy Park Dr Ste 4640 Brewer, Laurel C AUD Ogden UT. 84405 Ogden UT. 84403 Ogden Clinic - Renda, Cheyenne R PhD p 801.255.5131 p 801.387.4850 Professional Center North Utah Behavior Services 4650 Harrison Blvd 5202 S Fwy Park Dr Wills, Brooke BCBA 5929 Fashion Point Dr Ogden UT. 84403 Ogden UT. 84405 Utah Behavior Services Ste 101 p 801.475.3000 p 801.255.5131 5202 S Fwy Park Dr Ogden UT. 84403 Riverdale UT. 84405 p 801.387.4850 Christensen, Lisa K AUD Rhodes, Tiffany BCBA p 801.255.5131 5275 S Adams Ave Pkwy Utah Behavior Services Hospital Affiliation Ste B 5202 S Freeway Park Dr Wilson, Megan BCBA - Ogden Regional Medical Ogden UT. 84405 Ogden UT. 84405 Utah Behavior Services Center p 801.394.4399 p 801.255.5131 5202 S Fwy Park Dr Ogden UT. 84405 Sullivan, Timothy J MD Clawson, Terry D AUD Sagendorf, Emily BCBA p 801.255.5131 Advanced Allergy & Asthma Eartech Audiology Utah Behavior Services 4403 Harrison Blvd 2850 N 2000 W 5202 S Fwy Park Dr Woodall, Clifford BCBA Ste 4640 Farr West UT. 84404 Ogden UT. 84405 Utah Behavior Services Ogden UT. 84403 p 801.399.9955 p 801.255.5131 5202 S Fwy Park Dr p 801.387.4850 Ogden UT. 84405 Harward, Stephen B AUD Sanders, Sarah BCBA p 801.255.5131 5929 Fashion Point Dr Ogden Audiology Services Utah Behavior Services Ste 101 5349 S Adams Ave 5202 S Fwy Park Dr Wulfenstein, Lee BCBA Ogden UT. 84403 Ste C Ogden UT. 84405 Utah Behavior Services p 801.387.4850 Ogden UT. 84405 p 801.255.5131 5202 S Freeway Park Dr p 801.479.3346 Ogden UT. 84405 Hospital Affiliation Smith, Erica BCBA p 801.255.5131 - Ogden Regional Medical Kennington, Kody D AUD Utah Behavior Services Center Medical Hearing Clinic 5202 S Fwy Park Dr 1100 Country Hills Dr Ogden UT. 84405 Ste 200 p 801.255.5131 Ogden UT. 84403 p 801.399.5014

601 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Pay, Amanda AUD 5405 S 500 E 425 E 5350 S Fronk, Daniel MD Ogden Speech & Hearing Ste 204 Ste 405 Utah Cardiology Center Ogden UT. 84405 Ogden UT. 84405 5682 S 3500 W 978 Chambers St p 801.479.0184 p 801.479.7740 Ste 2A Ste 1 Roy UT. 84067 Ogden UT. 84403 Hospital Affiliation Hospital Affiliation p 801.776.0174 p 801.399.5601 - Ogden Regional Medical - Salt Lake Regional Medical Center Center Hospital Affiliation Turgoose, Aaron C AUD - Brigham City Community - Davis Hospital Lakeside Audiology Hospital Domanski, Damian J MD - Lakeview Hospital 3651 Wall Ave - Davis Hospital MountainStar Cardiology St Ste 1127 - Cache Valley Hospital Marks Hacking, Scott B MD Ogden UT. 84405 5405 S 500 E MountainStar Cardiology St p 801.612.0202 Asay, Ronald W MD Ste 202 Marks MountainStar Cardiology St Ogden UT. 84405 425 E 5350 S Breast Pumps Marks p 801.801.4751 Ste 400 Alpine Home Medical 425 E 5350 S Ogden UT. 84405 4669 Harrison Blvd Ste 400 Douglas, Wendy S APRN p 801.479.5642 Ogden UT. 84403 Ogden UT. 84405 University of Utah Health p 801.393.0015 p 801.479.5642 1151 Country Hills Dr 425 E 5350 S Ogden UT. 84403 Ste 405 Phone Number Only 425 E 5350 S p 801.581.8573 Ogden UT. 84405 p 800.686.7993 Ste 405 p 801.479.7740 Ogden UT. 84405 1920 W 250 N Edgepark p 801.479.7740 Ogden UT. 84404 Hospital Affiliation Phone Number Only p 801.731.4178 - St Marks Hospital p 800.321.0591 MountainStar Utah County - Lone Peak Hospital Cardiology 2715 N Hwy 89 - Timpanogos Regional Hospital Cardiac Monitoring 5405 S 500 E Pleasant View UT. 84404 Remote Cardiac Services Ste 202 p 801.737.9555 Karwande, Shreekanth MD Phone Number Only Ogden UT. 84405 MountainStar p 800.367.0300 p 801.475.1928 5575 S 500 E Cardiovascular Surgery Ogden UT. 84405 425 E 5350 S eCardio Diagnostics Hospital Affiliation p 801.479.0351 Ste 405 Phone Number Only - Timpanogos Regional Hospital Ogden UT. 84405 p 888.400.3522 - Mountain View Hospital Forstall, Peter G MD p 801.476.6900 (UT) MountainStar Cardiology St Cardiology Marks 5405 S 500 E Almony, Gregory T MD Creer, Analee APRN 425 E 5350 S Ste 100-B MountainStar Cardiology St MountainStar Ste 400 Ogden UT. 84405 Marks Cardiovascular Surgery Ogden UT. 84405 p 801.476.6900 425 E 5350 S 425 E 5350 S p 801.479.5642 Ste 400 Ste 405 Hospital Affiliation Ogden UT. 84405 Ogden UT. 84405 425 E 5350 S - St Marks Hospital p 801.479.5642 p 801.476.6900 Ste 405 - Ogden Regional Medical Ogden UT. 84405 Center 425 E 5350 S 5405 S 500 E p 801.479.7740 - Timpanogos Regional Hospital Ste 405 Ste 200 - Lakeview Hospital Ogden UT. 84405 Ogden UT. 84405 Northern Utah p 801.479.7740 p 801.476.6900 Cardiovascular Associates Khan, Muhammad MD 5405 S 500 E MountainStar Cardiology St Northern Utah Hospital Affiliation Ste 202 Marks Cardiovascular Associates - Timpanogos Regional Hospital Ogden UT. 84405 425 E 5350 S 5405 S 500 E p 801.479.0184 Ste 400 Ste 100B Day, John D MD Ogden UT. 84405 Ogden UT. 84405 MountainStar Cardiology St 5405 S 500 E p 801.479.5642 p 801.476.6900 Marks Ste 204 425 E 5350 S Ogden UT. 84405 425 E 5350 S 5405 S 500 E Ste 400 p 801.479.0184 Ste 405 Ste 202 Ogden UT. 84405 Ogden UT. 84405 Ogden UT. 84405 p 801.479.5642 Hospital Affiliation p 801.479.7740 p 801.475.1928 - Ogden Regional Medical Center - Brigham City Community Hospital - Davis Hospital - Cache Valley Hospital

602 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 434 E 5350 S 5405 S 500 E Zink, Robert F MD Cox, Guy T CNM Ste C Ste 204 MountainStar Ogden Nurse Midwives Ogden UT. 84405 Ogden UT. 84405 Cardiovascular Surgery 5285 S 400 E p 801.479.2244 p 801.479.0184 425 E 5350 S Ste B Ste 405 Ogden UT. 84405 5405 S 500 E Hospital Affiliation Ogden UT. 84405 p 801.476.7300 Ste 202 - Jordan Valley Medical p 801.476.6900 Ogden UT. 84405 Center Fawson, Sara L CNM p 801.475.1928 - Salt Lake Regional Medical Cardiothoracic Surgery Womens Health and Birth Center Karwande, Shreekanth MD Care Mohiuddin, Ishtiaque H MD MountainStar 1920 W 250 N MountainStar Cardiology St Thorne, J Kent MD Cardiovascular Surgery Ste 17 Marks MountainStar 425 E 5350 S Ogden UT. 84404 425 E 5350 S Cardiovascular Surgery Ste 405 p 801.689.3490 Ste 400 425 E 5350 S Ogden UT. 84405 Ogden UT. 84405 Ste 405 p 801.476.6900 Francis, Christina M CNM p 801.479.5642 Ogden UT. 84405 Ogden Nurse Midwives p 801.476.6900 5405 S 500 E 5285 S 400 E 425 E 5350 S Ste 100-B Ste B Ste 405 Hospital Affiliation Ogden UT. 84405 Ogden UT. 84405 Ogden UT. 84405 - St Marks Hospital p 801.476.6900 p 801.476.7300 p 801.479.7740 - Ogden Regional Medical Center Hospital Affiliation Hospital Affiliation Northern Utah - Timpanogos Regional Hospital - St Marks Hospital - Ogden Regional Medical Cardiovascular Associates - Ogden Regional Medical Center 5405 S 500 E Yaganti, Vamsee M MD Center - Davis Hospital Ste 100B MountainStar Cardiology St - Timpanogos Regional Hospital Ogden UT. 84405 Marks - Lakeview Hospital Knowles, Machel M CNM p 801.476.6900 425 E 5350 S Circle of Life Womens Ste 400 Zink, Robert F MD Center 5405 S 500 E Ogden UT. 84405 MountainStar 1525 E 6000 S Ste 202 p 801.479.5642 Cardiovascular Surgery Ogden UT. 84405 Ogden UT. 84405 425 E 5350 S p 801.337.5800 p 801.475.1928 425 E 5350 S Ste 405 Ste 405 Ogden UT. 84405 Hospital Affiliation 5405 S 500 E Ogden UT. 84405 p 801.476.6900 - Ogden Regional Medical Ste 204 p 801.479.7740 Center Ogden UT. 84405 Cardiovascular Surgery p 801.479.0184 Mountainstar Cardiology St Hunter, Curtis T MD Loffey, Kathleen CNM Marks MountainStar My Family Birth Center Nielson, Kenneth G MD 5405 S 500 E Cardiovascular Surgery 5319 S 500 E MountainStar Cardiology St Ste 202 425 E 5350 S Ste C Marks Ogden UT. 84405 Ste 405 Ogden UT. 84405 425 E 5350 S p 801.475.1928 Ogden UT. 84405 p 801.917.6104 Ste 400 p 801.476.6900 Ogden UT. 84405 Zebrack, James S MD Mark, Kathleen C CNM p 801.479.5642 MountainStar Cardiology St 5405 S 500 E Circle of Life Womens Marks Ste 100-B Center 425 E 5350 S 425 E 5350 S Ogden UT. 84405 1525 E 6000 S Ste 405 Ste 400 p 801.476.6900 Ogden UT. 84405 Ogden UT. 84405 Ogden UT. 84405 p 801.337.5800 p 801.479.7740 p 801.479.5642 Certified Nurse Midwife Carter-Gibbins, Stacie B Hospital Affiliation Hospital Affiliation 425 E 5350 S CNM - Ogden Regional Medical - St Marks Hospital Ste 405 Ogden Nurse Midwives Center - Lone Peak Hospital Ogden UT. 84405 5285 S 400 E - Davis Hospital - Timpanogos Regional Hospital p 801.479.7740 Ste B Ogden UT. 84405 McBride, Karen E CNM Szwajkun, Konstantyn Y MD 5405 S 500 E p 801.476.7300 Circle of Life Womens MountainStar Cardiology St Ste 202 Center Marks Ogden UT. 84405 Hospital Affiliation 1525 E 6000 S 425 E 5350 S p 801.475.1928 - Davis Hospital Ogden UT. 84405 Ste 400 p 801.337.5800 Ogden UT. 84405 Hospital Affiliation p 801.479.0184 - St Marks Hospital Hospital Affiliation - Lone Peak Hospital - Ogden Regional Medical - Timpanogos Regional Hospital Center - Davis Hospital 603 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Overson, Christy A CNM Wahlen, Russell S DC Andersen, Marcia CMHC Halliday, Blake T LMFT Brigham Center for Womens Utah Pain and Rehab Aloha Behavioral A1 Alliance Counseling Health 1276 S Wall Ave Consultants Services 1741 N 2000 W Ogden UT. 84404 811 N Harrisville Rd 5149 S 1500 W Ste 3 p 801.337.4000 Ogden UT. 84404 Ogden UT. 84405 Ogden UT. 84404 p 801.399.1818 p 801.475.0402 p 435.695.2273 Wheeler, Stephen M DC Health Solutions Apodaca, Kathleen E Hargrave, Dina S CMHC Hospital Affiliation Chiropractic LLC Christian Counseling Neurobehavioral Center for - Brigham City Community 1893 Skyline Dr Centers of Utah Growth Hospital Ste 204 575 23rd St 5974 Fashion Point Dr - Ogden Regional Medical Ogden UT. 84403 Ogden UT. 84401 Ste 140 Center p 801.621.1667 p 801.268.1564 Ogden UT. 84403 p 801.683.1062 Shupe, Loretta CNM Wooden, Wesley V DC Archuleta, Jason LCSW Vitality Generation & Health Solutions Utah Behavior Services Harward, Heather T LMFT Midwifery Chiropractic LLC 5202 S Fwy Park Dr A1 Alliance Counseling 5319 S 500 E 1893 Skyline Dr Riverdale UT. 84405 Services Ogden UT. 84405 Ste 204 p 801.255.5131 5149 S 1500 W p 801.516.0589 Ogden UT. 84403 Ogden UT. 84405 p 801.621.1667 Barker, Melinda C LMFT p 801.475.0402 Stuart, Mari R CNM Ataraxis Therapy Ogden Clinic - Grand View Colon And Rectal Surgery 3500 Harrison Blvd Herrin, Taylor C LMFT 3485 W 5200 S Foley, Craig R MD Ste 101 A1 Alliance Counseling Roy UT. 84067 4403 Harrison Blvd Ogden UT. 84403 Services p 801.475.3900 Ste 2855 p 801.564.4281 5149 S 1500 W Ogden UT. 84403 Ogden UT. 84405 Ogden Clinic - p 801.387.2550 Biesinger, Josh P LMFT p 801.475.0402 Professional Center North 1496 E 5600 S 4650 Harrison Blvd Hospital Affiliation Ste 4 Kaserman, Kristin Ogden UT. 84403 - Ogden Regional Medical Ogden UT. 84403 Aloha Behavioral p 801.475.3000 Center p 801.755.8799 Consultants 811 N Harrisville Rd Ogden Clinic - Womens Counseling Black, Jed CMHC Ogden UT. 84404 Center ORMC Acevedo, Carlos ACMHC Utah Behavior Services p 801.399.1818 5495 S 500 E Utah Behavior Services 5202 S Fwy Park Dr Ste 310 5202 S Freeway Park Dr Ogden UT. 84405 King, Kelsey LCSW Ogden UT. 84405 Ogden UT. 84405 p 801.255.5131 Utah Behavior Services p 801.475.3100 p 801.255.5131 5202 S Fwy Park Dr Bonella, Barrett LCSW Riverdale UT. 84405 Hospital Affiliation Allen, Dixie LPC Family Counseling Services p 801.255.5131 - Ogden Regional Medical Dixie Allen Therapy 3518 Washington Blvd Center 5105 S 1500 W Ogden UT. 84403 Lofthouse, Chelsea ACMHC Ogden UT. 84405 p 801.399.1600 Utah Behavior Services Chiropractic p 801.621.4000 5202 S Fwy Park Dr Bosley, Ryan B DC Cox, Patrick LPC Ogden UT. 84405 3500 Harrison Blvd Allred, Debbi CMHC Utah Behavior Services p 801.255.5131 Ste 200 Neurobehavioral Center For 5202 S Fwy Park Dr Ogden UT. 84403 Growth Ogden UT. 84405 Lovelace, Scott LCMHC p 801.627.2225 1893 Skyline Dr p 801.255.5131 Utah Behavior Services Ogden UT. 84403 5202 S Freeway Park Dr Davenport, Daniel B DC p 801.683.1062 Evans, Steve G CMHC Ogden UT. 84405 Utah Pain and Rehab 2909 Washington Blvd p 801.255.5131 1276 S Wall Ave 5974 Fashion Point Dr Ogden UT. 84401 Ogden UT. 84404 Ste 100 p 888.801.1556 Mathis, Nicholas CMHC p 801.337.4000 Ogden UT. 84403 Neurobehavioral Center For p 801.683.1062 Goss, Angela CSW Growth Skaggs, Daniel S DC Utah Behavior Services 5974 Fashion Point Dr Skaggs Chiropractic 5974 Fashion Point Dr 5202 S Fwy Park Dr Ste 140 2721 N Hwy 89 Ste 140 Riverdale UT. 84405 Ogden UT. 84403 Ste 100 Ogden UT. 84403 p 801.255.5131 p 801.683.1062 Ogden UT. 84404 p 801.683.1062 p 801.782.4454

604 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Melcher, Brian LCSW 5974 Fashion Point Dr Hadley, Jason C MD 434 E 350 S 2909 Washington Blvd Ste 100 Ogden Clinic - Grand View Ste D Ogden UT. 84401 Ogden UT. 84403 3485 W 5200 S Ogden UT. 84405 p 801.347.1778 p 801.683.1062 Roy UT. 84067 p 801.827.9100 p 801.779.9975 Orgill, Kristin MSW 5974 Fashion Point Dr Maughan, Julie A MD Aloha Behavioral Ste 140 Ogden Clinic - Wasatch Dermatology Consultants Ogden UT. 84403 Professional Center North 5734 S 1475 E 811 N Harrisville Rd p 801.683.1062 4650 Harrison Blvd Ste 300 Ogden UT. 84404 Ogden UT. 84403 Ogden UT. 84405 p 801.399.1818 VanHope, Lisa LMHC p 801.475.3000 p 801.475.5210 Red Cliff Counseling and Peters, Nicole CMHC Wellness Hospital Affiliation 6028 S Ridgeline Dr Wasatch Clarity Counseling 1186 E 4600 S - Lakeview Hospital Ste 200 549 25th St Ste 200 South Ogden UT. 84405 Ste 203 Ogden UT. 84403 Hadley, Michael L MD p 801.475.5210 Ogden UT. 84401 p 801.725.8431 Ogden Clinic - Grand View p 801.597.7673 3485 W 5200 S Peterson, Warren A DO Woolworth, Stephanie Roy UT. 84067 Wasatch Dermatology Pomeroy, Colby LMFT CMHC p 801.475.3900 5734 S 1475 E Colby D Pomeroy LMFT Aloha Behavioral Ste 300 5149 S 1500 W Consultants Ogden Clinic - Ogden UT. 84405 Ogden UT. 84405 811 N Harrisville Rd Professional Center North p 801.475.5210 p 801.475.0402 Ogden UT. 84404 4650 Harrison Blvd p 801.399.1818 Ogden UT. 84403 Ramirez, Lori K MD Reed, Robert J LPC p 801.479.4621 Ogden Clinic - Mountain Grace & Peace Christian Zimmerman, Rita M CMHC View Counseling Neurobehavioral Center For Hospital Affiliation 1100 W 2700 N 2909 Washington Blvd Growth - Lakeview Hospital Ogden UT. 84414 Ogden UT. 84401 1893 Skyline Dr p 801.475.3600 p 888.801.1556 Ogden UT. 84403 Hansen, Daniel J DO p 801.683.1062 Northern Utah Dermatology Ogden Clinic - Richter, Ryan C CMHC 6028 S Ridgeline Dr Professional Center North 2036 Lincoln Ave 5974 Fashion Point Dr Ste 102 4650 Harrison Blvd Ste 102-B Ste 100 South Ogden UT. 84405 Ogden UT. 84403 Ogden UT. 84403 Ogden UT. 84403 p 801.399.3324 p 801.475.3011 p 801.784.8720 p 801.683.1062 Hospital Affiliation Smith, Wayne E MD Salsberry, Maria CSW 5974 Fashion Point Dr - Ogden Regional Medical 5333 S Adams Ave Utah Behavior Services Ste 140 Center Ste C 5202 S Fwy Park Dr Ogden UT. 84403 Washington Terrace UT. 84405 Riverdale UT. 84405 p 801.683.1062 Heaton, Jared DO p 801.479.6200 p 801.255.5131 Rocky Mountain Dermatology Dermatology 1920 W 250 N Taintor, Adam R MD Smith, Charles R CMHC Allen, David M MD Ste 17 & 18 Intermountain Skin Cancer Grace and Peace Christian Intermountain Skin Cancer Ogden UT. 84404 and Aesthetics Center Counseling and Aesthetics Center p 801.827.9100 3860 Jackson Ave 2909 Washington Blvd 3860 Jackson Ave Ste 2 Ogden UT. 84401 Ste 2 5748 S Adams Ave Pkwy Ogden UT. 84403 p 888.801.1556 Ogden UT. 84403 Ste B p 801.627.0515 p 801.627.0515 Ogden UT. 84405 Stasiuk, John A LMFT p 801.827.9100 Tingey, Chad W MD Utah Behavior Services Hospital Affiliation Ogden Clinic - 5202 S Fwy Park Dr - Ogden Regional Medical Hospital Affiliation Professional Center North Ogden UT. 84405 Center - Lakeview Hospital 4650 Harrison Blvd p 801.255.5131 Ogden UT. 84403 Draper, Bradley MD MacDonald, Scott MD p 801.475.3000 Todd, Jessica J CMHC Wasatch Dermatology Rocky Mountain Dermatology Neurobehavioral Center For 5734 S 1475 E 1920 W 250 N Hospital Affiliation Growth Ste 300 Ste 17 & 18 - Ogden Regional Medical 1893 Skyline Dr Ogden UT. 84403 Ogden UT. 84404 Center Ogden UT. 84403 p 801.475.5210 p 801.827.9100 p 801.683.1062

605 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Urry, Larry E MD DeLapp, Edith A RD Empi Inc (Neuromuscular United States Medical 4403 Harrison Blvd University of Utah Health Stimulator) Supply Ste 2635 1151 Country Hills Dr Phone Number Only Phone Number Only Ogden UT. 84403 Ogden UT. 84403 p 800.328.2536 p 877.840.8218 p 801.387.3515 p 801.581.8573 Fit Well Western Medical Supplies Young, Robert P MD 5575 S 500 E Prosthetics/Orthotics 3293 Harrison Blvd Rocky Mountain Dermatology Ogden UT. 84405 3354 Harrison Blvd Ste 210 1920 W 250 N p 801.479.0351 Ste 3 Ogden UT. 84403 Ste 17 & 18 Ogden UT. 84403 p 877.937.8342 Ogden UT. 84404 Hospital Affiliation p 801.334.6000 p 801.827.9100 - University of Utah Hospital Ear Nose And Throat Hanger Clinic Anderson, Douglas K MD 434 E 350 S Durable Medical Equipment 3585 Harrison Blvd Ogden Clinic - Ste D Alpine Home Medical Ogden UT. 84403 Professional Center North Ogden UT. 84405 4669 Harrison Blvd p 801.392.5999 4650 Harrison Blvd p 801.827.9100 Ogden UT. 84403 Ogden UT. 84403 p 801.393.0015 1464 E Ridgeline Dr p 801.475.3000 Hospital Affiliation Ste 103 - Logan Regional Hospital Phone Number Only Ogden UT. 84405 Hospital Affiliation p 800.686.7993 p 801.392.5999 - Ogden Regional Medical Diabetic Supplies Center CCS Medical Apria Healthcare LLC KCI USA Inc (Wound Vac Phone Number Only 206 W 36th St Only) Barlow, Stewart E MD p 800.726.9811 Ogden UT. 84405 Phone Number Only 5275 S Adams Ave p 801.394.4000 p 800.275.4524 Ste B Edgepark Ogden UT. 84405 Phone Number Only CCS Medical National Seating and p 801.621.0350 p 800.321.0591 Phone Number Only Mobility p 800.726.9811 1805 W 2900 S Hospital Affiliation Roche Insulin Delivery Ste 3 - Ogden Regional Medical Systems Inc Care Rehab and Orthopedic Ogden UT. 84401 Center Phone Number Only Products (Muscle p 801.392.1010 - Davis Hospital p 800.280.7801 Stimulators) Phone Number Only Orthofix Inc (Bone Growth Bikhazi, Nadim B MD US MED LLC p 800.487.9644 Stimulators Physicians Ogden Clinic - Phone Number Only Only) Professional Center North p 800.787.6331 1140 36th St Phone Number Only 4650 Harrison Blvd Ste 165 p 800.535.4492 Ogden UT. 84403 United States Medical Ogden UT. 84403 p 801.475.3000 Supply p 801.392.0075 Pacific Medical Inc Phone Number Only Phone Number Only Hospital Affiliation p 877.840.8218 DJO Global p 800.726.9180 - Ogden Regional Medical Phone Number Only Center Dialysis Center p 800.336.6569 RespirTech Bonneville Dialysis Center Phone Number Only Bikhazi, Paul H MD 5575 S 500 E Debra Lynns Mastectomy p 800.793.1261 Ogden Clinic - Ogden UT. 84405 Specialties Professional Center North p 801.479.0351 1090 E 30th St Roche Insulin Delivery 4650 Harrison Blvd Ogden UT. 84403 Systems Inc Ogden UT. 84403 Mark Lindsay Dialysis p 801.393.2885 Phone Number Only p 801.475.3075 Center p 800.280.7801 1151 E Country Hills Dr Dynasplint Systems Inc Major, Michael S MD Ogden UT. 84403 Phone Number Only Smith Nephew Inc (Muscle Revere Health p 800.638.6771 Stimulators) 2850 N 2000 W Pleasant View Dialysis Phone Number Only Ste 201 Center EBI LLC (Bone Stimulators) p 800.821.5700 Ogden UT. 84404 2715 N Hwy 89 Phone Number Only p 801.465.4813 Ogden UT. 84414 p 800.526.2579 US MED LLC p 801.737.9555 Phone Number Only 5896 S Ridgeline Dr Edgepark p 800.787.6331 Ste B Dietician Phone Number Only Ogden UT. 84405 Bird, Kelsey M RD p 800.321.0591 p 801.866.0170 Ogden Clinic - Womens Center McKay Hospital Affiliation 4403 Harrison Blvd - Brigham City Community Ste 4650 Hospital Ogden UT. 84403 - Ogden Regional Medical p 801.475.3240 Center 606 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Owens, William I MD - Cache Valley Hospital Ballingham, David J PA South Ogden Center for Medical Hearing Clinic, Aloha Medical Services Family Medicine Inc. Whipple, Kevan DPT 811 N Harrisville Rd 5740 Crestwood Dr 1100 Country Hills Dr Precision EMG Ogden UT. 84404 Ogden UT. 84405 Ste 200 4650 Harrison Blvd p 801.399.1818 p 801.475.7966 Ogden UT. 84403 Ogden UT. 84403 p 801.399.5014 p 801.475.3010 Ballingham, Suzanne NP Bybee, Alan N PA Pediatric Care of Ogden Mountain Star Medical Hospital Affiliation Endocrinology 1740 E Combe Rd Group - Ogden Regional Medical Falahati-Nini, Alireza Ste 5 1741 N 2000 W Center MD Ogden UT. 84403 Ste 3 Utah Endocrinology p 801.621.1701 Ogden UT. 84404 Siddoway, John R MD Associates PLLC p 801.475.7966 Ogden Clinic - 5926 S Fashion Point Belfry, Carolyn MD Professional Center North Ste 120 Ogden Clinic - Mountain South Ogden Center for 4650 Harrison Blvd Ogden UT. 84403 View Family Medicine Ogden UT. 84403 p 801.747.2800 1100 W 2700 N 5740 Crestwood Dr p 801.475.3000 Ogden UT. 84414 Ogden UT. 84405 Hospital Affiliation p 801.475.3600 p 801.479.7771 Hospital Affiliation - St Marks Hospital - Ogden Regional Medical - Lone Peak Hospital Ogden Clinic - Chappell, Daniel H DO Center Professional Center North Ogden Clinic - Gamble, David NP 4650 Harrison Blvd Professional Center North Electrophysiology Utah Endocrinology Ogden UT. 84403 4650 Harrison Blvd Day, John D MD Associates PLLC p 801.479.4621 Ogden UT. 84403 MountainStar Cardiology St 5926 S Fashion Point p 801.475.3000 Marks Ste 120 Hospital Affiliation 425 E 5350 S Ogden UT. 84403 - Ogden Regional Medical Christiansen, Van G MD Ste 400 p 801.747.2800 Center Ogden Clinic - Mountain Ogden UT. 84405 View p 801.479.5642 Wilkerson, Jaclynn F NP Bledsoe, James A DO 1100 W 2700 N Utah Endocrinology South Ogden Center for Ogden UT. 84414 425 E 5350 S Associates PLLC Family Medicine p 801.475.3600 Ste 405 5926 S Fashion Point 5740 Crestwood Dr Ogden UT. 84405 Ste 120 Ogden UT. 84405 Ogden Clinic - p 801.479.7740 Ogden UT. 84403 p 801.479.7771 Professional Center North p 801.747.2800 4650 Harrison Blvd Hospital Affiliation Hospital Affiliation Ogden UT. 84403 - Salt Lake Regional Medical Endoscopy Center - Ogden Regional Medical p 801.475.3500 Center Ridgeline Endoscopy Center Center 6028 S Ridgeline Dr - Davis Hospital Hospital Affiliation Forstall, Peter G MD Ogden UT. 84405 - Ogden Regional Medical MountainStar Cardiology St p 801.475.4900 Breen Family Medicine Center Marks 5991 S 3500 W 425 E 5350 S Family Practice Ste 400 Clemens, Peter C DO Ste 400 Amann, Kelly R DO Roy UT. 84067 Paramount Medical Care Ogden UT. 84405 Ogden Clinic - Grand View p 801.845.4911 434 E 5350 S p 801.479.5642 3485 W 5200 S Ste B Roy UT. 84067 Brennan, Shannon A NP Ogden UT. 84405 425 E 5350 S p 801.475.3900 Circle of Life Womens p 801.475.7100 Ste 405 Center Ogden UT. 84405 Hospital Affiliation 1525 E 6000 S SanCuro Wound Care Systems p 801.479.7740 - Ogden Regional Medical Ogden UT. 84405 inc Center p 801.337.5800 434 E 5350 S Northern Utah Ogden UT. 84405 Cardiovascular Associates Anderson, Jeff W PA Bruce, Stephen J MD p 801.475.7100 5405 S 500 E Revere Health Ogden Clinic - Ste 202 5640 S 3500 W Professional Center North Hospital Affiliation Ogden UT. 84405 Roy UT. 84067 4650 Harrison Blvd - Ogden Regional Medical p 801.479.0184 p 801.773.2838 Ogden UT. 84403 Center p 801.475.3000 5405 S 500 E Baires, Enrique P MD Craner, Adam C FNP-C Ste 204 Ogden Clinic - Grand View Mountain Star Medical Ogden UT. 84405 3485 W 5200 S Group p 801.479.0184 Roy UT. 84067 1741 N 2000 W p 801.475.3900 Ste 3 Hospital Affiliation Ogden UT. 84404 - Ogden Regional Medical Hospital Affiliation p 801.475.7966 Center - Ogden Regional Medical - Brigham City Community Center Hospital 607 *The PPO- Davis Agreement Hospital with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 5405 S 500 E Freedom Healthcare Hess, Jessica L NP Manning, Shiloh D NP Ste 100 1893 E Skyline Dr Circle of Life Womens NowCare of Roy Ogden UT. 84405 Ste 204 Center 1937 W 5700 S p 801.475.7966 Ogden UT. 84403 1525 E 6000 S Roy UT. 84067 p 801.605.3801 Ogden UT. 84405 p 801.773.9380 Hospital Affiliation p 801.337.5800 - Ogden Regional Medical Graham, Stanley T MD NowCare of Ogden Center Midtown Community Health Horning, Ryan R PA-C 698 E 12th St Centers Wee Care Pediatrics Ogden UT. 84404 Creager, Joelle NP 2240 Adams Ave 5682 S 3500 W p 801.621.3466 University of Utah Health Ogden UT. 84401 Ste A 5957 Fashion Point Dr p 801.393.5355 Roy UT. 84067 Martindale, Brett W MD Ste 101 p 801.773.8644 Ogden Clinic - Ogden UT. 84403 Hospital Affiliation Professional Center North p 801.392.3720 - Ogden Regional Medical Hospital Affiliation 4650 Harrison Blvd Center - Mountain West Medical Ogden UT. 84403 Eggleston, Darek K DO Center p 801.475.3000 Ogden Clinic - Mountain Gregoire, Richard J MD View Midtown Community Health Housley, Mark D MD Ogden Clinic - 1100 W 2700 N Center Midtown Community Health Professional Center South Ogden UT. 84414 2240 Adams Ave Center 4700 Harrison Blvd p 801.475.3600 Ogden UT. 84401 2240 Adams Ave Ogden UT. 84403 p 801.393.5355 Ogden UT. 84401 p 801.475.3300 Elkins, Keith W MD p 801.393.5355 Mountain Star Medical Midtown Community Health Ogden Clinic Specialty Group Centers Hospital Affiliation Services 1741 N 2000 W 781 25th St - Ogden Regional Medical 6112 S 1550 E Ste 3 Ogden UT. 84401 Center Ogden UT. 84405 Ogden UT. 84404 p 801.622.1451 p 801.475.3800 p 801.475.7966 Judd, Deborah M FNP-C Hospital Affiliation Health Clinics of Utah Ogden Clinic - Canyon View Emerson, Haleigh MD - Ogden Regional Medical 2540 Washington Blvd 698 E 12th St Tanner Memorial Clinic Center Ste 122 Ogden UT. 84404 3443 W 5600 S Ogden UT. 84401 p 801.475.3700 Roy UT. 84067 Hagemeyer, Matthew MD p 801.626.3670 p 801.773.4840 Ogden Clinic CV Merrell, Stephen C MD 698 E 12th St Larsen, Benjamin MD Tanner Memorial Clinic Erickson, Dallin T DO Ogden UT. 84404 Tanner Memorial Clinic 3443 W 5600 S Ogden Clinic - p 801.475.3700 3443 W 5600 S Roy UT. 84067 Professional Center North Roy UT. 84067 p 801.773.4840 4650 Harrison Blvd Haun, Tiffanie A FNP p 801.773.4840 Ogden UT. 84403 Midtown Community Health Midtown Community Health p 801.475.3010 Center *Lewis, Linda APRN Center 2240 Adams Ave Primary Childrens Hospital 2240 Adams Ave Ogden Clinic - South Ogden Ogden UT. 84401 2408 Van Buren Ave Ogden UT. 84401 Family Medicine p 801.393.5355 Ogden UT. 84401 p 801.393.5355 5740 Crestwood Dr p 801.778.6261 Ogden UT. 84405 Hazelwood, Cynthia L NP Midtown Community Health p 801.479.7771 6781 N 2100 E Hospital Affiliation Center Weber Midtown Eden UT. 84310 - University of Utah Hospital Wellnes Clinic Flinders, Kurt T DO p 435.787.2000 237 26th St Tanner Memorial Clinic Lloyd, Jesse C NP Ogden UT. 84401 3443 W 5600 S Hemmersmeier, John M MD Outreach Medical Group p 801.625.3700 Roy UT. 84067 Ogden Clinic - 3385 W 2525 N p 801.773.4840 Professional Center North Ogden UT. 84404 Hope Community Health 4650 Harrison Blvd p 801.644.5121 Center Hospital Affiliation Ogden UT. 84403 269 W 33rd St - Davis Hospital p 801.475.3000 Lowe, Spencer N FNP Ogden UT. 84401 Utah Endocrinology p 801.393.5355 Fowers, Jody L APRN South Ogden Center for Associates PLLC Gynecology Specialists of Family Medicine 5926 S Fashion Point James Madison Elementary Utah 5740 Crestwood Dr Ste 120 Health Center 5495 S 500 E Ogden UT. 84405 Ogden UT. 84403 781 25th St Ste 320 p 801.475.7966 p 801.747.2800 Ogden UT. 84401 Ogden UT. 84405 p 801.393.5355 p 801.476.4200 Hospital Affiliation - Ogden Regional Medical Center 608 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Naylor, Susan (Marie) M Rifleman, Kurt E MD Stansfield-Duvall, Micah Ogden Clinic - South Ogden NP Midtown Community Health T NP Family Medicine Roots and Raices Center Now Care Clinic 5740 Crestwood Dr Functional Medicine 2240 Adams Ave 1937 W 5700 S Ogden UT. 84405 1452 E Ridgeline Dr Ogden UT. 84401 Roy UT. 84067 p 801.479.7771 Ste 5 p 801.393.5355 p 801.773.9380 Ogden UT. 84405 Woolf, Kurtis A MD p 435.919.7668 Hospital Affiliation 698 12th St Ogden Clinic - Grand View - Ogden Regional Medical Ogden UT. 84404 3485 W 5200 S Hospital Affiliation Center p 801.621.3466 Roy UT. 84067 - Davis Hospital p 801.475.3900 Rigby, Rohn C MD Stelter, Casey L MD Nelson, Joseph DO Ogden Clinic - Womens Outreach Medical Group Ogden Clinic - Canyon Medical Home Center Mckay 3385 W 2525 N Professional Center North 2265 Fillmore Ave 4403 Harrison Blvd Ogden UT. 84404 4650 Harrison Blvd Ogden UT. 84401 Ogden UT. 84403 p 801.644.5121 Ogden UT. 84403 p 801.403.8421 p 801.475.3240 p 801.475.3000 Hospital Affiliation Hospital Affiliation Ogden Clinic - - Davis Hospital Woolman, Michael D MD - St Marks Hospital Professional Center North Ogden Clinic - 4650 Harrison Blvd Thurston, McKennan J MD Professional Center North Obrien, Grace M DO Ogden UT. 84403 Tanner Memorial Clinic 4650 Harrison Blvd Ogden Clinic - Skyline p 801.475.3000 3443 W 5600 S Ogden UT. 84403 6112 S 1550 E Roy UT. 84067 p 801.475.3000 Ogden UT. 84405 Hospital Affiliation p 801.773.4840 p 801.475.3800 - Davis Hospital Ogden Clinic - South Ogden Hospital Affiliation Family Medicine Hospital Affiliation Schmitt, Ann MD - Davis Hospital 5740 Crestwood Dr - Ogden Regional Medical Revere Health Ogden UT. 84405 Center 2850 N 2000 W Weeks, Jonathan A MD p 801.475.3000 Ste 101 MountainStar Layton Family Ogden Clinic- Grand View Ogden UT. 84404 Medicine Hospital Affiliation 3485 W 5200 S p 801.528.5095 1741 N 2000 W - Ogden Regional Medical Roy UT. 84067 Ste 3 Center p 801.475.3900 Schmitz, J D MD Ogden UT. 84404 Ogden Clinic CV p 801.771.7799 Gastroenterology Ogden Clinic Urgent Care 698 E 12th St Gonzales, Chad M MD M-F 8am-8pm Sat-Sun Ogden UT. 84404 Hospital Affiliation 4403 Harrison Blvd 10am-8pm p 801.475.3700 - Ogden Regional Medical Ste 2855 4650 Harrison Blvd Center Ogden UT. 84403 Ogden UT. 84403 Hospital Affiliation - Davis Hospital p 801.387.2550 p 801.475.3800 - Ogden Regional Medical Center West, Renee MD Ogden Clinic - Mckay Dee Overdiek, Kirk R FNP Ogden Clinic - GI Wee Care Pediatrics Severance, Michael E PA Professional Center North 4403 Harrison Blvd 5682 S 3500 W MountainStar Ogden 4650 Harrison Blvd Ste 4410 Ste A Pediatrics Ogden UT. 84403 Ogden UT. 84403 Roy UT. 84067 5495 S 500 E p 801.479.4621 p 801.387.2550 p 801.773.8644 Ste 120 Ogden UT. 84405 Ogden Clinic - South Ogden 4403 Harrison Blvd Pace, Brad PA p 801.479.0174 Family Medicine Ste 4650 Wee Care Pediatrics 5740 Crestwood Dr Ogden UT. 84403 5682 S 3500 W Stallings, Scott M MD Ogden UT. 84405 p 801.475.3240 Ste A University of Utah Health p 801.479.7771 Roy UT. 84067 5957 Fashion Point Dr Hospital Affiliation p 801.773.8644 Ste 101 Hospital Affiliation - Ogden Regional Medical Ogden UT. 84403 - Ogden Regional Medical Center Hospital Affiliation p 801.392.3720 Center - Bear River Valley Hospital Poole, Jeffrey S MD - Davis Hospital Hospital Affiliation Winn, Darin MD Tanner Memorial Clinic - Ogden Regional Medical Ogden Clinic - 6028 S Ridgeline Dr Petersen, Darlene MD Center Professional Center North Ste 201 Revere Health 4650 Harrison Blvd Ogden UT. 84405 5640 S 3500 W Ogden UT. 84403 p 801.475.5400 Roy UT. 84067 p 801.475.3000 p 801.773.2838 Hospital Affiliation - Davis Hospital Hospital Affiliation - Ogden Regional Medical - Davis Hospital Center 609 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Porter, Steven A MD Ziegler, Robert H MD Grunander, Megan W MD Zempolich, Karen A MD 4403 Harrison Blvd Ogden Clinic - Ogden Clinic - St Marks Gynecology Ste 2855 Professional Center North Professional Center North Oncology Care Ogden UT. 84403 4650 Harrison Blvd 4650 Harrison Blvd 5405 S 500 E p 801.387.2550 Ogden UT. 84403 Ogden UT. 84403 Ste 200 p 801.475.3000 p 801.475.3000 Ogden UT. 84405 Hospital Affiliation p 801.743.4730 - Ogden Regional Medical Ogden Clinic - South Ogden Hospital Affiliation Center Family Medicine - Ogden Regional Medical Hospital Affiliation 5740 Crestwood Dr Center - St Marks Hospital Pugh, Brian W DO Ogden UT. 84405 - Ogden Regional Medical Tanner Memorial Clinic p 801.479.7771 Jordan, Edward A MD Center 6028 S Ridgeline Dr Ogden Clinic - Ste 201 Hospital Affiliation Professional Center North Gynecology Ogden UT. 84405 - Ogden Regional Medical 4650 Harrison Blvd Adams, Lan Le MD p 801.475.5400 Center Ogden UT. 84403 Obstetrix Medical Group Of p 801.475.3000 Utah Hospital Affiliation General Surgery 5475 S 500 E - Ogden Regional Medical Davis, Jan W APRN Ogden Clinic - Ogden UT. 84405 Center Utah Hematology Oncology Professional Center South p 801.479.2111 - Davis Hospital PC 4700 Harrison Blvd 5290 S 400 E Ogden UT. 84405 Bailey, Stanton A MD Redd, Matthew K DO Ogden UT. 84405 p 801.475.3000 Brigham Center for Womens Tanner Memorial Clinic p 801.476.1777 Health 6028 S Ridgeline Dr Hospital Affiliation 1741 N 2000 W Ste 201 Hospital Affiliation - Ogden Regional Medical Ste 3 Ogden UT. 84405 - Ogden Regional Medical Center Ogden UT. 84404 p 801.475.5400 Center - Lakeview Hospital p 435.695.2273

Hospital Affiliation Dunning, Kyle G MD Walker, Derrick DO Hospital Affiliation - Ogden Regional Medical Ogden Clinic - Brigham Center for Womens - Central Valley Medical Center Professional Center North Health Center - Davis Hospital 4650 Harrison Blvd 1741 N 2000 W - Gunnison Valley Hospital Ogden UT. 84403 Ste 3 Tadros, Caroline R MD p 801.475.3000 Ogden UT. 84404 Beverly, Steven M MD 4403 Harrison Blvd p 435.695.2273 Ogden Clinic - Womens Ste 2855 Hospital Affiliation Center Mckay Ogden UT. 84403 - Ogden Regional Medical 2850 N 2000 W 4403 Harrison Blvd p 801.387.2550 Center Ste 101 Ste 4650 Ogden UT. 84404 Ogden UT. 84403 Vandersteen, Joshua G DO Foley, Craig R MD p 435.695.2273 p 801.475.3240 Ogden Clinic - 4403 Harrison Blvd Professional Center North Ste 2855 Wride, Noah L MD Hospital Affiliation 4650 Harrison Blvd Ogden UT. 84403 Brigham Center for Womens - Ogden Regional Medical Ogden UT. 84403 p 801.387.2550 Health Center p 801.475.3000 1741 N 2000 W Hospital Affiliation Ste 3 Bierer, David R MD Ogden Clinic - - Ogden Regional Medical Ogden UT. 84404 Circle of Life Womens Professional Center South Center p 435.695.2273 Center 4700 Harrison Blvd 1525 E 6000 S Ogden UT. 84403 Garvey, Sheila G MD Gynecologic Oncology Ogden UT. 84405 p 801.475.3150 Ogden Clinic - Hunn, Jessica R MD p 801.337.5800 Professional Center North Valley Obstetrics & Ogden Clinic - South Ogden 4650 Harrison Blvd Gynecology Hospital Affiliation Family Medicine Ogden UT. 84403 5495 S 500 E - Ogden Regional Medical 5740 Crestwood Dr p 801.476.2353 Ste 310 Center Ogden UT. 84405 Ogden Ut. 84405 - Davis Hospital p 801.479.7771 Hospital Affiliation p 385.347.5450 - Ogden Regional Medical Brown, Jeffery B DO Hospital Affiliation Center Hospital Affiliation Circle of Life Womens - Davis Hospital - Lakeview Hospital - St Marks Hospital Center - Lone Peak Hospital 1525 E 6000 S - Mountain View Hospital Ste A (UT) Ogden UT. 84405 - Ogden Region Medical p 801.337.5800 Center

610 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Davis, Wesley B MD Housel, Darren W MD Naisbitt, Jed P MD Smithing, Larry O MD Circle of Life Womens Circle of Life Womens Circle of Life Womens Ogden Clinic - Center Center Center Professional Center North 1525 E 6000 S 1525 E 6000 S 1525 E 6000 S 4650 Harrison Blvd Ogden UT. 84405 Ogden UT. 84405 Ogden UT. 84405 Ogden UT. 84403 p 801.337.5800 p 801.337.5800 p 801.337.5800 p 801.475.3000

Hospital Affiliation Hospital Affiliation Hospital Affiliation Ogden Clinic - Womens - Ogden Regional Medical - Ogden Regional Medical - Ogden Regional Medical Center ORMC Center Center Center 5495 S 500 E - Davis Hospital - Davis Hospital - Davis Hospital Ste 310 Ogden UT. 84405 Dildy, Gary A MD Johansson, Julia W MD Palmer, Bryan MD p 801.475.3100 Obstetrix Medical Group of Circle of Life Womens Ogden Clinic - Womens Utah Center Center Mckay Hospital Affiliation 5475 S 500 E 1525 E 6000 S 4403 Harrison Blvd - Ogden Regional Medical Ogden UT. 84405 Ogden UT. 84405 Ste 4650 Center p 801.479.2111 p 801.337.5800 Ogden UT. 84403 p 801.475.3240 Vegh, Amber MD 5495 S 500 E Hospital Affiliation Ogden Clinic - Womens Ste 100 - Ogden Regional Medical Hospital Affiliation Center Mckay Ogden UT. 84405 Center - Ogden Regional Medical 4403 Harrison Blvd p 801.479.4266 - Davis Hospital Center Ste 4650 Ogden UT. 84403 Ferguson, Daniel R MD Lammi, Kirk A DO Planned Parenthood p 801.475.3240 Ogden Clinic - Mountain Ogden Clinic - Womens Association of Utah View Center Mckay 4387 Harrison Blvd Ogden Clinic - 1100 W 2700 N 4403 Harrison Blvd Ste D8 Professional Center North Ogden UT. 84414 Ste 4650 Ogden UT. 84403 4650 Harrison Blvd p 801.475.3600 Ogden UT. 84403 p 801.479.7721 Ogden UT. 84403 p 801.475.3240 p 801.475.3011 Ogden Clinic - Womens Rockenfield, Terra L PA Center ORMC Ogden Clinic - MountainStar Layton Family Hospital Affiliation 5495 S 500 E Professional Center North Medicine - Mercy Gilbert Medical Ste 310 4650 Harrison Blvd 1741 N 2000 W Center Ogden UT. 84405 Ogden UT. 84403 Ste 3 - Chandler Regional Medical p 801.475.3100 p 801.475.3240 Ogden UT. 84404 Center p 801.771.7799 Hospital Affiliation Hospital Affiliation Whitear, Amber D MD - Salt Lake Regional Medical - Ogden Regional Medical Gynecology Specialists of Ogden Clinic - Center Center Utah Professional Center North 5495 S 500 E 4650 Harrison Blvd Hartman, Albert R MD Larson, Alexander J MD Ste 320 Ogden UT. 84403 4403 Harrison Blvd Ogden Clinic - Ogden UT. 84405 p 801.475.3001 Ste 4625 Professional Center North p 801.476.4200 Ogden UT. 84403 4650 Harrison Blvd Ogden Clinic - Womens p 801.387.4800 Ogden UT. 84403 Rynearson, Scott A DO Center ORMC p 801.475.3100 Ogden Clinic - Grand View 5495 S 500 E Hospital Affiliation 3485 W 5200 S Ste 310 - Ogden Regional Medical Ogden Clinic - Womens Roy UT. 84067 Ogden UT. 84405 Center Center ORMC p 801.475.3900 p 801.475.3100 - Davis Hospital 5495 S 500 E Ste 310 Hospital Affiliation Hospital Affiliation Houpe, Robin MD Ogden UT. 84405 - Ogden Regional Medical - Ogden Regional Medical Circle of Life Womens p 801.475.3100 Center Center Center 1525 E 6000 S Hospital Affiliation Seale, Fred G MD Hand Surgery Ogden UT. 84405 - Ogden Regional Medical Ogden Clinic - Womens Barnett, Randall D MD p 801.337.5800 Center Center Mckay Alpine Plastic & 4403 Harrison Blvd Reconstructive Surgery Hospital Affiliation Murphy, Christopher MD Ste 4650 5405 S 500 E - Ogden Regional Medical Ogden Clinic - Womens Ogden UT. 84403 Ste 101 Center Center Mckay p 801.475.3240 Ogden UT. 84405 - Davis Hospital 4403 Harrison Blvd p 801.387.3900 Ste 4650 Hospital Affiliation Ogden UT. 84403 - Ogden Regional Medical Hospital Affiliation p 801.475.3240 Center - Ogden Regional Medical Center 611 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Larsen, Kenna MD Hansen, Vincent L MD Hearts for Hospice 2715 N Hwy 89 Utah Orthopaedics Utah Hematology Oncology 942 Chambers St Pleasant View UT. 84404 5782 Adams Ave Pkwy 4403 Harrison Blvd Ste 15 p 801.737.9555 Ogden UT. 84405 Ste 1685 Ogden UT. 84403 p 801.917.8000 Ogden UT. 84403 p 801.475.6222 4401 Harrison Blvd p 801.387.7150 Ogden UT. 84403 Hospital Affiliation Hospice Alliance p 801.387.2800 - Ogden Regional Medical Hospital Affiliation 1196 E 4800 S Center - Ogden Regional Medical Ste 200 5575 S 500 E - Davis Hospital Center Ogden UT. 84403 Ogden UT. 84405 - Davis Hospital p 801.476.4410 p 801.479.0351 Okawa, Allisyn MD Skyline Plastic and Hand Johnson, Harold M MD Hospice Care of Northern Hospital Affiliation Surgery Utah Hematology Oncology Utah - University of Utah Hospital 6112 S 1550 E 4403 Harrison Blvd 2721 N Hwy 89 - Davis Hospital Ste 102 Ste 1685 Ste 200 Ogden UT. 84405 Ogden UT. 84403 Pleasant View UT. 84414 Behunin, Andrew C DO p 801.689.3079 p 801.387.7150 p 801.689.3049 MountainStar Cardiology St Marks Hospital Affiliation 5290 S 400 E Hospital 425 E 5350 S - Ogden Regional Medical Ogden UT. 84405 Davis Hospital Weber Ste 400 Center p 801.476.1777 Campus Ogden UT. 84405 3451 W 5600 S p 801.479.5642 Richards, Brett E MD Hospital Affiliation Roy UT. 84067 Ogden Clinic - - Ogden Regional Medical p 801.896.5600 425 E 5350 S Professional Center North Center Ste 405 4650 Harrison Blvd - Davis Hospital Ogden Regional Medical Ogden UT. 84405 Ogden UT. 84403 Center p 801.479.7740 p 801.475.3000 Home Health Agency 5475 S 500 E Applegate Homecare and Ogden UT. 84405 Craner, Adam C FNP-C Ogden Clinic - Hospice p 801.479.2111 Mountain Star Medical Professional Center South 1492 E Ridgeline Dr Group 4700 Harrison Blvd Ste 1 Imaging Center 1741 N 2000 W Ogden UT. 84403 Ogden UT. 84405 Imaging Center North at Ste 3 p 801.475.3300 p 801.394.3250 Ogden Regional Medical Ogden UT. 84404 Center p 801.475.7966 Hospital Affiliation Hearts for Hospice 5322 S 400 E - Ogden Regional Medical 942 Chambers St Ogden UT. 84405 5405 S 500 E Center Ste 15 p 801.479.2450 Ste 100 Ogden UT. 84403 Ogden UT. 84405 Hematology And Oncology p 801.475.6222 Mountain Medical Physician p 801.475.7966 Davis, Jan W APRN Specialists Utah Hematology Oncology Hospice Alliance 1486 E Skyline Dr Hospital Affiliation PC 1196 E 4800 S Ogden UT. 84403 - Ogden Regional Medical 5290 S 400 E Ste 200 p 801.475.4558 Center Ogden UT. 84405 Ogden UT. 84403 p 801.476.1777 p 801.476.4410 Ogden Imaging Cueva, Carlos MD 5322 S 400 E Ogden Internal Medicine Hospital Affiliation Hospice Ogden UT. 84405 and Urology - Ogden Regional Medical Alpine Hospice Inc p 801.475.0800 5405 S 500 E Center 5478 S Adams Ave Pkwy Ste 203 Ste 1 Internal Medicine Ogden UT. 84405 Gray, Carl R MD Ogden UT. 84405 Assiago, Marcellus S MD p 801.475.8600 Utah Hematology Oncology p 801.392.8880 University of Utah Health 4403 Harrison Blvd 1151 Country Hills Dr Day, John D MD Ste 1685 Applegate Homecare and Ogden UT. 84403 MountainStar Cardiology St Ogden UT. 84403 Hospice p 801.581.8573 Marks p 801.387.7150 1492 E Ridgeline Dr 425 E 5350 S Ste 1 1920 W 250 N Ste 400 5290 S 400 E Ogden UT. 84405 Ogden UT. 84404 Ogden UT. 84405 Ogden UT. 84405 p 801.394.3250 p 801.731.4178 p 801.479.5642 p 801.476.1777

Hospital Affiliation - Ogden Regional Medical Center - Davis Hospital

612 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. 425 E 5350 S Keihanian, Mana MD Mohr, Robert R MD 434 E 5350 S Ste 405 MountainStar Cardiology St Mountain Star Medical Ste C Ogden UT. 84405 Marks Group Ogden UT. 84405 p 801.479.7740 425 E 5350 S 1741 N 2000 W p 801.479.2244 Ste 400 Ste 3 Hospital Affiliation Ogden UT. 84405 Ogden UT. 84404 Saeed, Musab MD - Salt Lake Regional Medical p 801.479.5642 p 801.475.7966 MountainStar Skin Cancer Center and Dermatology Center 425 E 5350 S 5405 S 500 E 5405 S 500 E DeRemer, Kathleen R MD Ste 405 Ste 100 Ste 202 MountainStar Skin Cancer Ogden UT. 84405 Ogden UT. 84405 Ogden UT. 84405 and Dermatology Center p 801.479.7740 p 801.475.7966 p 801.475.1928 5405 S 500 E Ste 202 Mountainstar Cardiology St MountainStar Primary Care Ogden Internal Medicine Ogden UT. 84405 Marks 5740 Crestwood Dr Ste100 and Urology LLC p 801.475.1928 5405 S 500 E Ogden UT. 84405 5405 S 500 E Ste 202 p 801.475.7966 Ste 203 Ogden Internal Medicine & Ogden UT. 84405 Ogden UT. 84405 Urology p 801.475.1928 Hospital Affiliation p 801.475.8600 5405 S 500 E - Ogden Regional Medical Ste 203 Lewis, Seth R MD Center Hospital Affiliation Ogden UT. 84405 Ogden Internal Medicine - Davis Hospital p 801.475.8600 425 E 5350 S Murray, Michelle MD Ste 335 University of Utah Health Szwajkun, Konstantyn Y MD Hospital Affiliation Ogden UT. 84405 5957 Fashion Point Dr MountainStar Cardiology St - Ogden Regional Medical p 801.475.5100 Ste 101 Marks Center Ogden UT. 84403 425 E 5350 S Hospital Affiliation p 801.475.5683 Ste 400 Domanski, Damian J MD - Ogden Regional Medical Ogden UT. 84405 MountainStar Cardiology St Center Hospital Affiliation p 801.479.0184 Marks - Mountain West Medical - Jordan Valley Medical 5405 S 500 E Center Center 5405 S 500 E Ste 202 Ste 204 Ogden UT. 84405 Mohiuddin, Ishtiaque H MD Nalabothu, Poorna L MD Ogden UT. 84405 p 801.801.4751 MountainStar Cardiology St MountainStar Cardiology St p 801.479.0184 Marks Marks Fronk, Daniel MD 425 E 5350 S 425 E 5350 S Hospital Affiliation Utah Cardiology Ste 400 Ste 400 - Jordan Valley Medical 5682 S 3500 W Ogden UT. 84405 Ogden UT. 84405 Center Ste 2A p 801.479.5642 p 801.479.5642 - Salt Lake Regional Medical Roy UT. 84067 Center p 801.776.0174 425 E 5350 S 425 E 5350 S Ste 405 Ste 405 Tadros, Caroline R MD Hospital Affiliation Ogden UT. 84405 Ogden UT. 84405 4403 Harrison Blvd - Davis Hospital p 801.479.7740 p 801.479.7740 Ste 2855 - Lakeview Hospital Ogden UT. 84403 Northern Utah Mountainstar Cardiology St p 801.387.2550 Herold, Richard J MD Cardiovascular Associates Marks 6028 S Ridgeline Dr 5405 S 500 E 5405 S 500 E Vandersteen, Joshua G DO Ste 204 Ste 100B Ste 202 Ogden Clinic - Ogden UT. 84405 Ogden UT. 84405 Ogden UT. 84405 Professional Center North p 801.475.8100 p 801.476.6900 p 801.475.1928 4650 Harrison Blvd Ogden UT. 84403 Hospital Affiliation 5405 S 500 E Nannapaneni, Nischala MD p 801.475.3000 - Mountain West Medical Ste 202 MountainStar Cardiology St Center Ogden UT. 84405 Marks Ogden Clinic - - St Marks Hospital p 801.475.1928 425 E 5350 S Professional Center South Ste 400 4700 Harrison Blvd Ivester, Charles T MD 5405 S 500 E Ogden UT. 84405 Ogden UT. 84403 Mountain States Pulmonary Ste 204 p 801.479.5642 p 801.475.3150 and Critical Care Ogden UT. 84405 5957 Fashion Point Dr p 801.479.0184 425 E 5350 S Ogden Clinic - South Ogden Ogden UT. 84403 Ste 405 Family Medicine p 385.492.4930 Ogden UT. 84405 5740 Crestwood Dr p 801.479.7740 Ogden UT. 84405 Hospital Affiliation p 801.479.7771 - Ogden Regional Medical Center Hospital Affiliation - Davis Hospital - Davis Hospital - Cache Valley Hospital 613 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Williams, Tyler R MD Yen, Chi Gang MD Dildy, Gary A MD 5974 Fashion Point Dr Tanner Memorial Clinic MountainStar Cardiology St Obstetrix Medical Group of Ste 100 3443 W 5600 S Marks Utah Ogden UT. 84403 Roy UT. 84067 425 E 5350 S 5475 S 500 E p 801.683.1062 p 801.773.4840 Ste 405 Ogden UT. 84405 Ogden UT. 84405 p 801.479.2111 5974 Fashion Point Dr Yaganti, Vamsee M MD p 801.479.7740 Ste 140 MountainStar Cardiology St 5495 S 500 E Ogden UT. 84403 Marks Mountainstar Cardiology St Ste 100 p 801.683.1062 425 E 5350 S Marks Ogden UT. 84405 Ste 400 5405 S 500 E p 801.479.4266 Andersen, Marcia CMHC Ogden UT. 84405 Ste 202 Aloha Behavioral p 801.479.5642 Ogden UT. 84405 Sharshiner, Margarita Y Consultants p 801.475.1928 MD 811 N Harrisville Rd 425 E 5350 S Obstetrix Medical Group of Ogden UT. 84404 Ste 405 Laboratory Utah p 801.399.1818 Ogden UT. 84405 Dominion Diagnostics 5475 S 500 E p 801.479.7740 Phone Number Only Ogden UT. 84405 Apodaca, Kathleen E p 877.734.9600 p 801.479.2111 Christian Counseling Mountainstar Cardiology St Centers of Utah Marks LabCorp Draw Station 5495 S 500 E 575 23rd St 5405 S 500 E 6028 S Ridgeline Dr Ogden UT. 84405 Ogden UT. 84401 Ste 202 Ste 203 p 801.479.4266 p 801.268.1564 Ogden UT. 84405 Ogden UT. 84405 p 801.475.1928 p 801.475.7195 Mental Health Facility Applied Behavior Aloha Medical Services Connections Yen, Chi Gang MD LabCorp of America 811 N Harrisville Rd 5160 Sunset Ln MountainStar Cardiology St Holdings Ogden UT. 84404 Ogden UT. 84403 Marks Phone Number Only p 801.399.1818 p 801.935.5796 425 E 5350 S p 888.522.2677 Ste 405 Mental Health Arballo, Jennifer CSW Ogden UT. 84405 MSCL at Ogden Hub Acevedo, Carlos ACMHC Utah Behavior Services p 801.479.7740 425 E 5350 S Utah Behavior Services 5202 S Freeway Park Dr Ste 160 5202 S Freeway Park Dr Ogden UT. 84405 Mountainstar Cardiology St Ogden UT. 84405 Ogden UT. 84405 p 801.255.5131 Marks p 801.337.5111 p 801.255.5131 5405 S 500 E Archuleta, Jason LCSW Ste 202 Maternal And Fetal Medicine Adolphson, Lillian Utah Behavior Services Ogden UT. 84405 Balderston, Keith D MD BCBA-D 5202 S Fwy Park Dr p 801.475.1928 Obstetrix Medical Group of Utah Behavior Services Riverdale UT. 84405 Utah 5202 S Fwy Park Dr p 801.255.5131 Interventional Cardiology 5475 S 500 E Ogden UT. 84405 Yaganti, Vamsee M MD Ogden UT. 84405 p 801.255.5131 Banks, Duane R MD MountainStar Cardiology St p 801.743.4700 Clinical Consultants Marks Aleman, Arianna BCBA 2661 Washington Blvd 425 E 5350 S 5495 S 500 E Utah Behavior Services Ste 102-B Ste 400 Ste 100 5202 S Fwy Park Dr Ogden UT. 84401 Ogden UT. 84405 Ogden UT. 84405 Ogden UT. 84405 p 801.621.8670 p 801.479.5642 p 801.743.4700 p 801.255.5131 Barker, Melinda C LMFT 425 E 5350 S Carpenter, Jeanette R MD Allen, Dixie LPC Ataraxis Therapy Ste 405 Obstetrix Medical Group of Dixie Allen Therapy 3500 Harrison Blvd Ogden UT. 84405 Utah 5105 S 1500 W Ste 101 p 801.479.7740 5495 S 500 E Ogden UT. 84405 Ogden UT. 84403 Ste 100 p 801.621.4000 p 801.564.4281 Mountainstar Cardiology St Ogden UT. 84405 Marks p 801.743.4700 Allred, Debbi CMHC Biesinger, Josh P LMFT 5405 S 500 E Neurobehavioral Center For 1496 E 5600 S Ste 202 Hospital Affiliation Growth Ste 4 Ogden UT. 84405 - Lone Peak Hospital 1893 Skyline Dr Ogden UT. 84403 p 801.475.1928 - Timpanogos Regional Hospital Ogden UT. 84403 p 801.755.8799 - Ogden Regional Medical p 801.683.1062 Center - Cache Valley Hospital

614 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Birch, Kelly LCSW Neurobehavioral Center for 5974 Fashion Point Dr Gardner, Alyson CSW Utah Behavior Services Growth Ste 100 Neurobehavioral Center For 5202 S Fwy Park Dr 5974 Fashion Point Dr Ogden UT. 84403 Growth Ogden UT. 84405 Ste 100 p 801.683.1062 5974 Fashion Point Dr p 801.255.5131 Ogden UT. 84403 Ste 100 p 801.683.1062 5974 Fashion Point Dr Ogden UT. 84403 Black, Jed CMHC Ste 140 p 801.683.1062 Utah Behavior Services 5974 Fashion Point Dr Ogden UT. 84403 5202 S Fwy Park Dr Ste 140 p 801.683.1062 5974 Fashion Point Dr Ogden UT. 84405 Ogden UT. 84403 Ste 140 p 801.255.5131 p 801.683.1062 Eddy, Alex BCBA Ogden UT. 84403 Chrysalis Utah p 801.683.1062 Bonella, Barrett LCSW Celauro, Melissa BCBA 4933 S 1500 W Family Counseling Services Chrysalis Utah Ste 210 Gilmore, Patrick D LCSW 3518 Washington Blvd 4933 S 1500 W Ogden UT. 84405 Ogden Center for Ogden UT. 84403 Ste 210 p 801.655.4950 Counseling p 801.399.1600 Ogden UT. 84405 4590 Harrison Blvd p 801.655.4950 Evans, Lyndsey M PhD Ste 200A Bunting, Catherine CSW Neurobehavioral Center For Ogden UT. 84405 Utah Behavior Services Cho, Jaeyong MSW Growth p 801.479.8286 5202 S Fwy Park Dr Utah Behavior Services 1893 Skyline Dr Ogden UT. 84405 5202 S Fwy Park Dr Ogden UT. 84403 Goebel, Austin G DO p 801.255.5131 Ogden UT. 84405 p 801.683.1062 Ogden Regional Behavioral p 801.255.5131 Health Butler, Erin BCBA 5974 Fashion Point Dr 5475 S 500 E Neurobehavioral Center For Christianson, Grete BCBA Ste 100 Ogden UT. 84405 Growth Utah Behavior Services Ogden UT. 84403 p 801.479.2111 1893 Skyline Dr 5202 S Fwy Park Dr p 801.683.1062 Ogden UT. 84403 Ogden UT. 84405 Goss, Angela CSW p 801.683.1062 p 801.255.5131 5974 Fashion Point Dr Utah Behavior Services Ste 140 5202 S Fwy Park Dr 5974 Fashion Point Dr Chrysalis Utah Ogden UT. 84403 Riverdale UT. 84405 Ste 100 4933 S 1500 W p 801.683.1062 p 801.255.5131 Ogden UT. 84403 Ste 210 p 801.683.1062 Ogden UT. 84405 Evans, Steve G CMHC Goyal, Anu BCBA p 801.655.4950 2909 Washington Blvd Neurobehavioral Center For 5974 Fashion Point Dr Ogden UT. 84401 Growth Ste 140 Coburn, Alison MSW p 888.801.1556 1893 Skyline Dr Ogden UT. 84403 Utah Behavior Services Ogden UT. 84403 p 801.683.1062 5202 S Fwy Park Dr Flessner, Karen L MSW p 801.683.1062 Ogden UT. 84405 Grace and Peace Christian Caceres-Loveless, Maria p 801.255.5131 Counseling 5974 Fashion Point Dr BCBA 2909 Washington Blvd Ste 100 Applied Behavior Corey, Spencer BCBA Ogden UT. 84401 Ogden UT. 84403 Connections Utah Behavior Services p 888.801.1556 p 801.683.1062 5160 Sunset Ln 5202 S Freeway Park Dr Ogden UT. 84403 Ogden UT. 84405 Franco, Christina D LCSW Green Josoff, Reena F p 801.935.5796 p 801.255.5131 Ogden Psychological LCSW Services Aloha Behavioral Carcelli, Lawrence A PhD Cox, Patrick LPC 1186 E 4600 Consultants Ogden Center for Utah Behavior Services Ste 440 811 N Harrisville Rd Counseling 5202 S Fwy Park Dr Ogden UT. 84403 Ogden UT. 84404 4699 Harrison Blvd Ogden UT. 84405 p 801.505.6545 p 801.399.1818 Ste 300 p 801.255.5131 Ogden UT. 84403 Fujiwara, Mina BCBA Green, Rachal BCBA,LCSW p 801.479.8286 Deceuster, Rachael BCBA Utah Behavior Services Utah Behavior Services Utah Behavior Services 5202 S Freeway Park Dr 5202 S Fwy Park Dr Cardinal, Jennifer R PhD, 5202 S Fwy Park Dr Ogden UT. 84405 Ogden UT. 84405 BCBA Ogden UT. 84405 p 801.255.5131 p 801.255.5131 Neurobehavioral Center For p 801.255.5131 Growth Gallegos, Melissa N LCSW Gressmen, Casey BCBA 1893 Skyline Dr Dwyer, Molly M BCBA Utah Pain and Rehab Utah Behavior Services Ogden UT. 84403 Neurobehavioral Center For 1276 S Wall Ave 5202 S Freeway Park Dr p 801.683.1062 Growth Ogden UT. 84404 Ogden UT. 84405 1893 Skyline Dr p 801.337.4000 p 801.255.5131 Ogden UT. 84403 p 801.683.1062

615 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Hadley, Nathan M LCSW Hoffmann, Audrey PhD Jones, Jennifer L LCSW Kulow, Kacylia BCBA Midtown Community Health Utah Behavior Services Healing Journey Utah Utah Behavior Services Center 5202 S Fwy Park Dr 221 25th St 5202 S Fwy Park Dr 2240 Adams Ave Ogden UT. 84405 Ogden UT. 84401 Ogden UT. 84405 Ogden UT. 84401 p 801.255.5131 p 801.613.2322 p 801.255.5131 p 801.393.5355 Holmes, Alisha MSW Kang, Catharina H PhD Lambertsen, Hope BCBA Halliday, Blake T LMFT Utah Behavior Services 1496 E 5600 S Utah Behavior Services A1 Alliance Counseling 5202 S Fwy Park Dr Ste 4 5202 S Fwy Park Dr Services Ogden UT. 84405 Ogden UT. 84403 Ogden UT. 84405 5149 S 1500 W p 801.255.5131 p 801.475.7139 p 801.255.5131 Ogden UT. 84405 p 801.475.0402 Howes, Scott M LCSW Kaserman, Kristin Lazar, Lynda NP Wasatch Spring Counseling Aloha Behavioral Aloha Medical Services Hargrave, Dina S CMHC 2748 Adam Ave Consultants 811 N Harrisville Rd Neurobehavioral Center for Ogden UT. 84403 811 N Harrisville Rd Ogden UT. 84404 Growth p 801.540.4452 Ogden UT. 84404 p 801.399.1818 5974 Fashion Point Dr p 801.399.1818 Ste 140 Hulphers, Brenda LCSW Lee, Jennifer BCBA Ogden UT. 84403 Family Counseling Services Keller, Rebecca BCBA Utah Behavior Services p 801.683.1062 3518 Washington Blvd Utah Behavior Services 5202 S Fwy Park Dr Ogden UT. 84403 5202 S Fwy Park Dr Ogden UT. 84405 Harmon, B S LCSW p 801.399.1600 Ogden UT. 84405 p 801.255.5131 A1 Alliance Counseling p 801.255.5131 Services Hunt, Chelseigh BCBA Lofthouse, Chelsea ACMHC 5149 S 1500 W Utah Behavior Services Kelstrom-Smith, Cheryl Utah Behavior Services Ogden UT. 84405 5202 S Fwy Park Dr LCSW 5202 S Fwy Park Dr p 801.475.0402 Ogden UT. 84405 A1 Alliance Counseling Ogden UT. 84405 p 801.255.5131 Services p 801.255.5131 Harward, Heather T LMFT 5149 S 1500 W A1 Alliance Counseling Innes, Brent W LCSW Ogden UT. 84405 Lopez, Kitrina BCBA Services Family Counseling Services p 801.475.0402 Utah Behavior Services 5149 S 1500 W 3518 Washington Blvd 5202 S Fwy Park Dr Ogden UT. 84405 Ogden UT. 84403 Kennedy, Anne BCBA Ogden UT. 84405 p 801.475.0402 p 801.399.1600 Utah Behavior Services p 801.255.5131 5202 S Fwy Park Dr Henshaw, Brandon J BCBA Javellana, Carmela md Ogden UT. 84405 Lovelace, Scott LCMHC Neurobehavioral Center For Neurobehavioral Center For p 801.255.5131 Utah Behavior Services Growth Growth 5202 S Freeway Park Dr 1893 Skyline Dr 1893 Skyline Dr King, Kelsey LCSW Ogden UT. 84405 Ogden UT. 84403 Ogden UT. 84403 Utah Behavior Services p 801.255.5131 p 801.683.1062 p 801.683.1062 5202 S Fwy Park Dr Riverdale UT. 84405 Lowe, Kori BCBA Neurobehavioral Center for Jensen, Julia P BCBA p 801.255.5131 Utah Behavior Services Growth Utah Behavior Services 5202 S Fwy Park Dr 5974 Fashion Point Dr 5202 S Fwy Park Dr Kluthe, John L PhD Ogden UT. 84405 Ste 100 Ogden UT. 84405 Ogden Center for p 801.255.5131 Ogden UT. 84403 p 801.255.5131 Counseling and Assessment p 801.683.1062 4590 Harrison Blvd Luna, Janette M LCSW Johnson, William BCBA Ste 200A Utah Behavior Services Herrin, Taylor C LMFT Applied Behavior Ogden UT. 84405 5202 S Freeway Park Dr A1 Alliance Counseling Connections p 801.479.8286 Ogden UT. 84405 Services 5160 Sunset Ln p 801.255.5131 5149 S 1500 W Ogden UT. 84403 Knopp, Julie LCSW Ogden UT. 84405 p 801.935.5796 Family Counseling Services Madsen, Sara BCBA p 801.475.0402 3518 Washington Blvd Utah Behavior Services Johnston, Harmony MSW Ogden UT. 84403 5202 S Fwy Park Dr Hexum, Julie MSW Utah Behavior Services p 801.399.1600 Ogden UT. 84405 Utah Behavior Services 5202 S Fwy Park Dr p 801.255.5131 5202 S Fwy Park Dr Ogden UT. 84405 Knudson, Mani BCBA Ogden UT. 84405 p 801.255.5131 Utah Behavior Services Mason, Patricia A LCSW p 801.255.5131 5202 S Freeway Park Dr Life Management Ogden UT. 84405 585 24th St p 801.255.5131 Ste 110 Ogden UT. 84401 p 801.394.4522

616 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Mathis, Nicholas CMHC Meier, Heather BCBA 5974 Fashion Point Dr Peters, Nicole CMHC Neurobehavioral Center For Applied Behavior Ste 100 Wasatch Clarity Counseling Growth Connections Ogden UT. 84403 549 25th St 5974 Fashion Point Dr 5160 Sunset Ln p 801.683.1062 Ste 203 Ste 140 Ogden UT. 84403 Ogden UT. 84401 Ogden UT. 84403 p 801.935.5796 5974 Fashion Point Dr p 801.597.7673 p 801.683.1062 Ste 140 Melcher, Brian LCSW Ogden UT. 84403 Petrovich, Brian PSYD Maxwell, Kendra BCBA 2909 Washington Blvd p 801.683.1062 Ogden Psychological Utah Behavior Services Ogden UT. 84401 Services 5202 S Fwy Park Dr p 801.347.1778 OReilly, Laree C MSW 1186 E 4600 Riverdale UT. 84405 Neurobehavioral Center For Ste 440 p 801.255.5131 Metzger, Debbie BCBA Growth Ogden UT. 84403 Utah Behavior Services 1893 Skyline Dr p 801.505.6545 Mayer, Gregory L PhD 5202 S Fwy Park Dr Ogden UT. 84403 OCCA Riverdale UT. 84405 p 801.683.1062 Phillips, Allison 4590 Harrison Blvd p 801.255.5131 LCSW,BCBA Ste 200A 5974 Fashion Point Dr Utah Behavior Services Ogden UT. 84403 Mitchell, Craig T LCSW Ste 100 5202 S Fwy Park Dr p 801.479.8286 Circle of Life Womens Ogden UT. 84403 Ogden UT. 84405 Center p 801.683.1062 p 801.255.5131 McFarland, Maryanne LCSW 1525 E 6000 S LeafCrest Counseling Ogden UT. 84405 5974 Fashion Point Dr Pickering, Jaclyn BCBA 1140 36th St p 801.337.5800 Ste 140 Neurobehavioral Center For Ste 275 Ogden UT. 84403 Growth Ogden UT. 84403 5922 S 2125 E p 801.683.1062 1893 Skyline Dr p 801.510.6864 Ogden UT. 84403 Ogden UT. 84403 p 801.337.5800 Oblad, Cicily BCBA p 801.683.1062 McGill, Katie MSW Utah Behavior Services Utah Behavior Services Montgomery, M Andrew 5202 S Fwy Park Dr 5974 Fashion Point Dr 5202 S Freeway Park Dr LCSW Ogden UT. 84405 Ste 100 Ogden UT. 84405 Aloha Behavioral p 801.255.5131 Ogden UT. 84403 p 801.255.5131 Consultants p 801.683.1062 811 N Harrisville Rd Oblock, Jessica M LCSW McGuire, Amy BCBA Ogden UT. 84404 Healing Journey Utah 5974 Fashion Point Dr Utah Behavior Services p 801.399.1818 221 25th St Ste 140 5202 S Fwy Park Dr Ogden UT. 84401 Ogden UT. 84403 Ogden UT. 84405 Nadalsky, Michelle p 801.613.2322 p 801.683.1062 p 801.255.5131 BCBA,SSW Utah Behavior Services Orgill, Kristin MSW Plautz, Hailey C BCBA Meccico, Carolie LCSW 5202 S Fwy Park Dr Aloha Behavioral Neurobehavioral Center For Meccico Therapeuctic Ogden UT. 84405 Consultants Growth Services Inc p 801.255.5131 811 N Harrisville Rd 5974 Fashion Point Dr 920 Chambers St Ogden UT. 84404 Ste 140 Ste 17 Neff, Michal A CSW,SUDC p 801.399.1818 Ogden UT. 84403 Ogden UT. 84403 Utah Behavior Services p 801.683.1062 p 801.528.5054 5202 S Freeway Park Dr Palau, Shawn M LCSW Ogden UT. 84405 Aloha Behavioral Pomeroy, Colby LMFT Medina-Salvatore, Nicole p 801.255.5131 Consultants Colby D Pomeroy LMFT PSYD 811 N Harrisville Rd 5149 S 1500 W Neurobehavioral Center For Nielsen, Stephanie MSW Ogden UT. 84404 Ogden UT. 84405 Growth Utah Behavior Services p 801.399.1818 p 801.475.0402 1893 Skyline Dr 5202 S Fwy Park Dr Ogden UT. 84403 Ogden UT. 84405 Paz, Corinna G BCBA Powell, Clark Randy LCSW p 801.683.1062 p 801.255.5131 Neurobehavioral Center for Utah Behavior Services Growth 5202 S Fwy Park Dr 5974 Fashion Point Dr OQuinn, Casey L BCBA 1893 Skyline Dr Riverdale UT. 84405 Ste 100 Neurobehavioral Center For Ogden UT. 84403 p 801.255.5131 Ogden UT. 84403 Growth p 801.683.1062 p 801.683.1062 1893 Skyline Dr Pramann, Robert F PhD Ogden UT. 84403 5974 Fashion Point Dr Christian Counseling 5974 Fashion Point Dr p 801.683.1062 Ste 140 Centers of Utah Ste 140 Ogden UT. 84403 575 23rd St Ogden UT. 84403 p 801.683.1062 Ogden UT. 84401 p 801.683.1062 p 801.268.1564

617 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Prantil, Joseph E LCSW 5974 Fashion Point Dr Snow, Lauren BCBA Tracy, Jaime LCSW Licensed Clinical Ste 140 Utah Behavior Services Aloha Behavioral Associates Ogden UT. 84403 5202 S Fwy Park Dr Consultants 3544 Lincoln Ave p 801.683.1062 Riverdale UT. 84405 811 N Harrisville Rd Ste 6 p 801.255.5131 Ogden UT. 84404 Ogden UT. 84401 Sagendorf, Emily BCBA p 801.399.1818 p 801.393.5010 Utah Behavior Services Stasiuk, John A LMFT 5202 S Fwy Park Dr Utah Behavior Services Traeden, Heather BCBA Rae, Rebecca BCBA Ogden UT. 84405 5202 S Fwy Park Dr Neurobehavioral Center For Utah Behavior Services p 801.255.5131 Ogden UT. 84405 Growth 5202 S Fwy Park Dr p 801.255.5131 1893 Skyline Dr Ogden UT. 84405 Salsberry, Maria CSW Ogden UT. 84403 p 801.255.5131 Utah Behavior Services Stevens, Mason LCSW p 801.683.1062 5202 S Fwy Park Dr Aloha Behavioral Reed, Robert J LPC Riverdale UT. 84405 Consultants Uno, Tab L LCSW Grace & Peace Christian p 801.255.5131 811 N Harrisville Rd Family Counseling Services Counseling Ogden UT. 84404 3518 Washington Blvd 2909 Washington Blvd Sanders, Sarah BCBA p 801.399.1818 Ogden UT. 84403 Ogden UT. 84401 Utah Behavior Services p 801.399.1600 p 888.801.1556 5202 S Fwy Park Dr Stevens, Nicole Ogden UT. 84405 BCBA,LMFT Utah Behavior Services Renda, Cheyenne R PhD p 801.255.5131 Utah Behavior Services 5202 S Freeway Park Dr Utah Behavior Services 5202 S Fwy Park Dr Ogden UT. 84405 5202 S Fwy Park Dr Shumway, Brett PSYD Ogden UT. 84405 p 801.255.5131 Ogden UT. 84405 Utah Behavior Services p 801.255.5131 p 801.255.5131 5202 S Fwy Park Dr VanHope, Lisa LMHC Riverdale UT. 84405 Suarez, Alex LCSW Red Cliff Counseling and Richter, Ryan C CMHC p 801.255.5131 Utah Behavior Services Wellness 2036 Lincoln Ave 5202 S Freeway Park Dr 1186 E 4600 S Ste 102-B Siebert, Tatum LCPC Ogden UT. 84405 Ste 200 Ogden UT. 84403 Utah Behavior Services p 801.255.5131 Ogden UT. 84403 p 801.784.8720 5202 S Fwy Park Dr p 801.725.8431 Ogden UT. 84405 Suggs, Trent K MD Ringgenberg, Alyssa CSW p 801.255.5131 Ogden Regional Behavioral Ward, Cori APRN Alyssa Ringgenberg CSW Health Utah Behavior Services 5149 S 1500 W Skousen, Thomas MSW 5475 S 500 E 5202 S Fwy Park Dr Ogden UT. 84405 Utah Behavior Services Ogden UT. 84405 Ogden UT. 84405 p 801.475.0402 5202 S Fwy Park Dr p 801.479.2111 p 801.255.5131 Ogden UT. 84405 Rippon, Kimberly LCSW p 801.255.5131 Taylor, Sheila D LCSW Watson, Steven L LCSW Kimberly Rippon LCSW & Sheila Taylor Associated Therapists Associates Slater, Courtney MSW 2389 N 2000 W 3670 Quincy Ave 3785 Harrison Blvd Utah Behavior Services Ogden UT. 84404 Ste 103 Ste 4 5202 S Fwy Park Dr p 385.312.0686 Ogden UT. 84403 Ogden UT. 84403 Ogden UT. 84405 p 801.479.9073 p 801.510.3637 p 801.255.5131 Todd, Jessica J CMHC Neurobehavioral Center For Webb, Cara MSW Roche, Miriam MSW Smith, Charles R CMHC Growth Aloha Behavioral Utah Behavior Services Grace and Peace Christian 1893 Skyline Dr Consultants 5202 S Fwy Park Dr Counseling Ogden UT. 84403 811 N Harrisville Rd Ogden UT. 84405 2909 Washington Blvd p 801.683.1062 Ogden UT. 84404 p 801.255.5131 Ogden UT. 84401 p 801.399.1818 p 888.801.1556 5974 Fashion Point Dr Russell Stamp, Mindy M Ste 100 Whatcott, Natalie PhD Smith, Erica BCBA Ogden UT. 84403 BCBA,SSW Neurobehavioral Center For Utah Behavior Services p 801.683.1062 Utah Behavior Services Growth 5202 S Fwy Park Dr 5202 S Fwy Park Dr 1893 Skyline Dr Ogden UT. 84405 5974 Fashion Point Dr Ogden UT. 84405 Ogden UT. 84403 p 801.255.5131 Ste 140 p 801.255.5131 p 801.683.1062 Ogden UT. 84403 Smith, Saige LPC p 801.683.1062 Wills, Brooke BCBA 5974 Fashion Point Dr Utah Behavior Services Utah Behavior Services Ste 100 5202 S Fwy Park Dr 5202 S Fwy Park Dr Ogden UT. 84403 Ogden UT. 84405 Riverdale UT. 84405 p 801.683.1062 p 801.255.5131 p 801.255.5131

618 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Wilson, Megan BCBA Neonatology McDonald, Ryan P MD Neurology Utah Behavior Services Cheatham, Robert W MD Kidney and Hypertension Hammond, Richard C DO 5202 S Fwy Park Dr Pediatrix Medical Group Institute of Utah PLLC Ogden Clinic - Ogden UT. 84405 5475 S 500 E 4780 Old Post Rd Professional Center North p 801.255.5131 Ogden UT. 84405 Ogden UT. 84403 4650 Harrison Blvd p 801.476.4280 p 801.476.3400 Ogden UT. 84403 Woodall, Clifford BCBA p 801.475.3200 Utah Behavior Services Nephrology Hospital Affiliation 5202 S Fwy Park Dr Assiago, Marcellus S MD - Davis Hospital Hospital Affiliation Ogden UT. 84405 University of Utah Health - Lakeview Hospital - Ogden Regional Medical p 801.255.5131 1151 Country Hills Dr - Ogden Regional Medical Center Ogden UT. 84403 Center Woolworth, Stephanie p 801.581.8573 Imani, Jahan MD CMHC Patcha, Kishore MD Intermountain Neurology Aloha Behavioral 1920 W 250 N University Of Utah Health Clinic Consultants Ogden UT. 84404 4403 Harrison Blvd 5315 S Adams Ave Pkwy 811 N Harrisville Rd p 801.731.4178 Ste 2635 Ste A and B Ogden UT. 84404 Ogden UT. 84403 Washington Terrace UT. 84405 p 801.399.1818 2715 N Hwy 89 p 801.387.2800 p 801.475.7707 Pleasant View UT. 84404 Wulfenstein, Lee BCBA p 801.737.9555 5475 S 500 E Hospital Affiliation Utah Behavior Services Ogden UT. 84405 - Ogden Regional Medical 5202 S Freeway Park Dr 4401 Harrison Blvd p 801.479.2111 Center Ogden UT. 84405 Ogden UT. 84403 p 801.255.5131 p 801.387.2800 5825 Harrison Blvd Integrated Pain Ogden UT. 84403 Consultants Yang, Danielle BCBA 5575 S 500 E p 801.475.5254 2850 N 2000 W Utah Behavior Services Ogden UT. 84405 Ste 203 5202 S Freeway Park Dr p 801.479.0351 Smith, Trevor R MD Ogden UT. 84404 Ogden UT. 84405 University of Utah Health p 801.689.3389 p 801.255.5131 Hospital Affiliation 1151 Country Hills Dr - University of Utah Hospital Ogden UT. 84403 Morita, Denise M MD Yarger, Jesse BCBA - Davis Hospital p 801.581.8573 Pediatrix Medical Group Neurobehavioral Center For 5475 S 500 E Growth Horowitz, Bruce L MD 1920 W 250 N Ogden UT. 84405 1893 Skyline Dr University of Utah Health Ogden UT. 84404 p 801.476.4280 Ogden UT. 84403 1151 Country Hills Dr p 801.731.4178 p 801.683.1062 Ogden UT. 84403 5495 S 500 E p 801.581.8573 2715 N Hwy 89 Ste 100 5974 Fashion Point Dr Pleasant View UT. 84404 Ogden UT. 84405 Ste 100 1920 W 250 N p 801.737.9555 p 801.479.4266 Ogden UT. 84403 Ogden UT. 84404 p 801.683.1062 p 801.731.4178 4401 Harrison Blvd Hospital Affiliation Ogden UT. 84403 - Jordan Valley Medical 5974 Fashion Point Dr 2715 N Hwy 89 p 801.387.2800 Center Ste 140 Pleasant View UT. 84404 Ogden UT. 84403 p 801.737.9555 5475 S 500 E Nelson, Alex J MD p 801.683.1062 Ogden UT. 84405 Interventional Spine & 4401 Harrison Blvd p 801.479.2111 Pain Management Zimmerman, Rita M CMHC Ogden UT. 84403 1276 S Wall Ave Neurobehavioral Center For p 801.581.6709 5575 S 500 E Ste 1 Growth Ogden UT. 84405 Ogden UT. 84404 1893 Skyline Dr 5475 S 500 E p 801.479.0351 p 801.262.7246 Ogden UT. 84403 Ogden UT. 84405 p 801.683.1062 p 801.479.2111 5825 Harrison Blvd Integrated Pain Ogden UT. 84403 Consultants 5974 Fashion Point Dr 5575 S 500 E p 801.475.5254 2850 N 2000 W Ste 100 Ogden UT. 84405 Ste 203 Ogden UT. 84403 p 801.479.0351 Hospital Affiliation Ogden UT. 84404 p 801.683.1062 - University of Utah Hospital p 801.689.3389 Hospital Affiliation 5974 Fashion Point Dr - University of Utah Hospital Yenchek, Robert H MD Hospital Affiliation Ste 140 - Davis Hospital University of Utah Health - Lakeview Hospital Ogden UT. 84403 1151 Country Hills Dr - Timpanogos Regional Hospital p 801.683.1062 Ogden UT. 84403 p 801.581.8573

Hospital Affiliation - University of Utah Hospital 619 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Piercey, Sydney C MD Obstetrics And Gynecology Dildy, Gary A MD Johansson, Julia W MD Ogden Clinic - Adams, Lan Le MD Obstetrix Medical Group of Circle of Life Womens Professional Center North Obstetrix Medical Group Of Utah Center 4650 Harrison Blvd Utah 5475 S 500 E 1525 E 6000 S Ogden UT. 84403 5475 S 500 E Ogden UT. 84405 Ogden UT. 84405 p 801.475.3204 Ogden UT. 84405 p 801.479.2111 p 801.337.5800 p 801.479.2111 Neurosurgery 5495 S 500 E Hospital Affiliation Aucoin, Jeffrey C MD Bailey, Stanton A MD Ste 100 - Ogden Regional Medical Ogden Clinic - Utah Spine Brigham Center for Womens Ogden UT. 84405 Center 4403 Harrison Blvd Health p 801.479.4266 - Davis Hospital Ste 1815 1741 N 2000 W Ogden UT. 84403 Ste 3 Ferguson, Daniel R MD Lammi, Kirk A DO p 801.732.5900 Ogden UT. 84404 Ogden Clinic - Mountain Ogden Clinic - Womens p 435.695.2273 View Center Mckay Bangerter, Kurt D MD 1100 W 2700 N 4403 Harrison Blvd Ogden Clinic - Utah Spine Hospital Affiliation Ogden UT. 84414 Ste 4650 4403 Harrison Blvd - Central Valley Medical p 801.475.3600 Ogden UT. 84403 Ste 1815 Center p 801.475.3240 Ogden UT. 84403 - Gunnison Valley Hospital Ogden Clinic - Womens p 801.732.5900 Center ORMC Ogden Clinic - Beverly, Steven M MD 5495 S 500 E Professional Center North Hospital Affiliation Ogden Clinic - Womens Ste 310 4650 Harrison Blvd - Ogden Regional Medical Center Mckay Ogden UT. 84405 Ogden UT. 84403 Center 4403 Harrison Blvd p 801.475.3100 p 801.475.3240 - Davis Hospital Ste 4650 Ogden UT. 84403 Hospital Affiliation Hospital Affiliation Smith, Bryson MD p 801.475.3240 - Salt Lake Regional Medical - Ogden Regional Medical Ogden Clinic - Utah Spine Center Center 4403 Harrison Blvd Hospital Affiliation Ste 1815 - Ogden Regional Medical Gordon, Carrie A MD Larson, Alexander J MD Ogden UT. 84403 Center Ogden Clinic - Ogden Clinic - p 801.732.5900 Professional Center North Professional Center North Bierer, David R MD 4650 Harrison Blvd 4650 Harrison Blvd Hospital Affiliation Circle of Life Womens Ogden UT. 84403 Ogden UT. 84403 - Ogden Regional Medical Center p 801.475.3000 p 801.475.3100 Center 1525 E 6000 S - Davis Hospital Ogden UT. 84405 Hartman, Albert R MD Ogden Clinic - Womens p 801.337.5800 4403 Harrison Blvd Center ORMC Welling, Blake G MD Ste 4625 5495 S 500 E Ogden Clinic - Utah Spine Hospital Affiliation Ogden UT. 84403 Ste 310 4403 Harrison Blvd - Ogden Regional Medical p 801.387.4800 Ogden UT. 84405 Ste 1815 Center p 801.475.3100 Ogden UT. 84403 - Davis Hospital Hospital Affiliation p 801.732.5900 - Ogden Regional Medical Hospital Affiliation Brown, Jeffery B DO Center - Ogden Regional Medical Hospital Affiliation Circle of Life Womens - Davis Hospital Center - Ogden Regional Medical Center Center 1525 E 6000 S Houpe, Robin MD Lee, Rhonda G PA Ste A Circle of Life Womens Health Clinics of Utah Winters, Dennis D MD Ogden UT. 84405 Center 2540 Washington Blvd Ogden Clinic - Utah Spine p 801.337.5800 1525 E 6000 S Ste 122 4403 Harrison Blvd Ogden UT. 84405 Ogden UT. 84401 Ste 1815 Davis, Wesley B MD p 801.337.5800 p 801.626.3670 Ogden UT. 84403 Circle of Life Womens p 801.732.5900 Center Hospital Affiliation Merrell, Stephen C MD 1525 E 6000 S - Ogden Regional Medical Tanner Memorial Clinic Ogden Clinic - Ogden UT. 84405 Center 3443 W 5600 S Professional Center North p 801.337.5800 - Davis Hospital Roy UT. 84067 4650 Harrison Blvd p 801.773.4840 Ogden UT. 84403 Hospital Affiliation Housel, Darren W MD p 801.475.3011 - Ogden Regional Medical Circle of Life Womens Murphy, Christopher MD Center Center Ogden Clinic - Womens Hospital Affiliation - Davis Hospital 1525 E 6000 S Center Mckay - Ogden Regional Medical Ogden UT. 84405 4403 Harrison Blvd Center p 801.337.5800 Ste 4650 Ogden UT. 84403 Hospital Affiliation p 801.475.3240 - Ogden Regional Medical Center - Davis Hospital 620 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Naisbitt, Jed P MD Sharshiner, Margarita Y Zempolich, Karen A MD Ogden Clinic - Skyline Circle of Life Womens MD St Marks Gynecology 6112 S 1550 E Center Obstetrix Medical Group of Oncology Care Ogden UT. 84405 1525 E 6000 S Utah 5405 S 500 E p 801.475.3800 Ogden UT. 84405 5475 S 500 E Ste 200 p 801.337.5800 Ogden UT. 84405 Ogden UT. 84405 Oncology p 801.479.2111 p 801.743.4730 Gray, Carl R MD Hospital Affiliation Utah Hematology Oncology - Ogden Regional Medical 5495 S 500 E Hospital Affiliation 4403 Harrison Blvd Center Ogden UT. 84405 - St Marks Hospital Ste 1685 - Davis Hospital p 801.479.4266 - Ogden Regional Medical Ogden UT. 84403 Center p 801.387.7150 Palmer, Bryan MD Smithing, Larry O MD Ogden Clinic - Womens Ogden Clinic - Occupational Medicine 5290 S 400 E Center Mckay Professional Center North Burst, Annette MD Ogden UT. 84405 4403 Harrison Blvd 4650 Harrison Blvd Brookstar Knee Clinic p 801.476.1777 Ste 4650 Ogden UT. 84403 3500 Harrison Blvd Ogden UT. 84403 p 801.475.3000 Ste 200 Hospital Affiliation p 801.475.3240 Ogden UT. 84403 - Ogden Regional Medical Ogden Clinic - Womens p 801.668.2010 Center Hospital Affiliation Center ORMC - Davis Hospital - Ogden Regional Medical 5495 S 500 E Occupational Therapy Center Ste 310 Concentra Medical Centers Ophthalmology Ogden UT. 84405 2390 Redwood Rd Alldredge, Claron D MD Planned Parenthood p 801.475.3100 West Valley City UT. 84419 Utah Eye Centers Association of Utah p 888.997.2669 4360 Washington Blvd 4387 Harrison Blvd Hospital Affiliation Ogden UT. 84403 Ste D8 - Ogden Regional Medical Davis, Charity S OT p 801.476.0494 Ogden UT. 84403 Center Utah Physical Therapy Inc p 801.479.7721 3476 W 4600 S Hospital Affiliation Vegh, Amber MD West Haven UT. 84401 - Ogden Regional Medical Rockenfield, Terra L PA Ogden Clinic - Womens p 801.689.0200 Center MountainStar Layton Family Center Mckay - Davis Hospital Medicine 4403 Harrison Blvd DeLong, Samuel OT 1741 N 2000 W Ste 4650 Summit Hand Therapy Armstrong, John D MD Ste 3 Ogden UT. 84403 2850 N 2000 W Utah Eye Centers Ogden UT. 84404 p 801.475.3240 Ste 107 4360 Washington Blvd p 801.771.7799 Ogden UT. 84404 Ogden UT. 84403 Ogden Clinic - p 801.773.2633 p 801.476.0494 Gynecology Specialists of Professional Center North Utah 4650 Harrison Blvd Gold, Nephi OT Ballif, Mark S MD 5495 S 500 E Ogden UT. 84403 Ogden Clinic - Utah Eye Centers Ste 320 p 801.475.3011 Professional Center South 4360 Washington Blvd Ogden UT. 84405 4700 Harrison Blvd Ogden UT. 84403 p 801.476.4200 Hospital Affiliation Ogden UT. 84403 p 801.476.0494 - Mercy Gilbert Medical p 801.475.3300 Rynearson, Scott A DO Center Hospital Affiliation Ogden Clinic - Grand View - Chandler Regional Medical Larson, Jacob K OT - Davis Hospital 3485 W 5200 S Center Summit Hand Therapy Roy UT. 84067 2850 N 2000 W Brodstein, David E MD p 801.475.3900 Whitear, Amber D MD Ste 107 Country Hills Eye Center Ogden Clinic - Ogden UT. 84404 875 Country Hills Dr Hospital Affiliation Professional Center North p 801.773.2633 Ogden UT. 84403 - Ogden Regional Medical 4650 Harrison Blvd p 801.399.1149 Center Ogden UT. 84403 Stanley, Sherman D OT p 801.475.3001 Ogden Clinic - Hospital Affiliation Seale, Fred G MD Professional Center North - Ogden Regional Medical Ogden Clinic - Womens Ogden Clinic - Womens 4650 Harrison Blvd Center Center Mckay Center ORMC Ogden UT. 84403 4403 Harrison Blvd 5495 S 500 E p 801.475.3870 Clayson, Fred E MD Ste 4650 Ste 310 4403 Harrison Blvd Ogden UT. 84403 Ogden UT. 84405 Ogden Clinic - Ste 3600 p 801.475.3240 p 801.475.3100 Professional Center South Ogden UT. 84403 4700 Harrison Blvd p 801.387.3550 Hospital Affiliation Hospital Affiliation Ogden UT. 84403 - Ogden Regional Medical - Ogden Regional Medical p 801.475.3870 Center Center

621 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Coombs, Peter G MD Rupp, Jason D MD Optometry Gibson, Roy R OD Utah Eye Centers Country Hills Eye Center Boster Vision The Eye Pros 4360 Washington Blvd 875 Country Hills Dr 4848 S 900 W 4115 S Riverdale Rd Ogden UT. 84403 Ogden UT. 84403 Ogden UT. 84405 Ste B p 801.476.0494 p 801.399.1149 p 385.333.4592 Ogden UT. 84405 p 801.872.2020 Hospital Affiliation Hospital Affiliation Boster, Jonathan J OD - Ogden Regional Medical - Ogden Regional Medical Boster Vision 4949 S 900 W Center Center 4848 S 900 W Riverdale UT. 84405 Ogden UT. 84405 p 801.621.0480 Dastrup, Benjamin T MD Swift, Jesse S MD p 385.333.4592 Country Hills Eye Center Country Hills Eye Center Helman, Andrew OD 875 Country Hills Dr 875 Country Hills Dr Clark, Michael C OD Standard Optical Ogden UT. 84403 Ogden UT. 84403 Brigham Eye Specialists 4283 Harrision Blvd p 801.399.1149 p 801.399.1149 2850 N 2000 W Ogden UT. 84403 Ste 202 p 801.479.5060 Hospital Affiliation Hospital Affiliation Ogden UT. 84404 - Ogden Regional Medical - Ogden Regional Medical p 801.731.6326 460 N 325 Center Center Ogden UT. 84404 Dygert, Lincoln J OD p 801.546.0255 Gunther, Jonathan B MD Sykes, Scott O MD Ogden Vision Center Country Hills Eye Center Utah Eye Centers 3475 Harrison Blvd 5421 S 1900 W 875 Country Hills Dr 4360 Washington Blvd Ogden UT. 84403 Roy UT. 84067 Ogden UT. 84403 Ogden UT. 84403 p 801.394.8885 p 801.825.9703 p 801.399.1149 p 801.476.0494 Edmunds, Franklin M OD Humpherys, Rich H OD Hospital Affiliation Hospital Affiliation Standard Optical Family Vision Care - Central Valley Medical - Ogden Regional Medical 4283 Harrision Blvd 1055 N Washington Blvd Center Center Ogden UT. 84403 Ogden UT. 84404 p 801.479.5060 p 801.394.5709 Hansen, Brock C MD Turner, Scott D MD Utah Eye Centers Farr West Eye Specialists 460 N 325 E Judkins, Michael M OD 4360 Washington Blvd 2850 N 2000 W Ogden UT. 84404 Promontory Family Vision Ogden UT. 84403 Ste 202 p 801.546.0255 5331 S Adams Ave p 801.476.0494 Ogden UT. 84404 Ste B p 801.731.6326 Ellison, John N OD Ogden UT. 84405 Hospital Affiliation Standard Optical p 801.479.7850 - Ogden Regional Medical Hospital Affiliation 5421 S 1900 W Center - Brigham City Community Roy UT. 84067 Knowles, Duane C OD Hospital p 801.825.9703 Standard Optical Lever, Jackson F MD - Ogden Regional Medical 4283 Harrision Blvd Country Hills Eye Center Center Farr, Devin B OD Ogden UT. 84403 875 Country Hills Dr Utah Eye Centers p 801.479.5060 Ogden UT. 84403 Wilcox, Michael B MD 4360 Washington Blvd p 801.399.1149 Utah Eye Centers Ogden UT. 84403 460 N 325 E 4360 Washington Blvd p 801.476.0494 Ogden UT. 84404 Poll, Jed T MD Ogden UT. 84403 p 801.827.9000 Utah Eye Centers p 801.476.0494 Farrell, Scott D OD 4360 Washington Blvd Utah Eye Centers 5421 S 19th W Ogden UT. 84403 Hospital Affiliation 4360 Washington Blvd Roy UT. 84067 p 801.476.0494 - Lakeview Hospital Ogden UT. 84403 p 801.825.9703 - Ogden Regional Medical p 801.476.0494 Hospital Affiliation Center Kofoed, Lavar W OD - Lakeview Hospital Fielden, Clark E OD The Eye Pros - Ogden Regional Medical Williams, Brice J MD 4403 Harrison Blvd 4115 S Riverdale Rd Center 4403 Harrison Blvd Ste 3600 Ste B Ste 3600 Ogden UT. 84403 Ogden UT. 84405 Richards, Bradley W MD Ogden UT. 84403 p 801.387.3550 p 801.872.2020 Country Hills Eye Center p 801.387.3550 875 Country Hills Dr Frost, James L OD Lewis, Stephen C OD Ogden UT. 84403 Hospital Affiliation Optical Associates Standard Optical p 801.399.1149 - Ogden Regional Medical 1196 30th St 4283 Harrision Blvd Center Ogden UT. 84403 Ogden UT. 84403 Hospital Affiliation p 801.399.9873 p 801.479.5060 - Ogden Regional Medical Center

622 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Linford, Keith W OD 460 N 325 E 3590 Harrison Blvd Ogden Clinic - Utah Eye Centers Ogden UT. 84404 Ste 2 Professional Center South 4360 Washington Blvd p 801.546.0255 Ogden UT. 84403 4700 Harrison Blvd Ogden UT. 84403 p 801.392.7176 Ogden UT. 84403 p 801.476.0494 Roberts, Joshua OD p 801.475.3301 Standard Optical Hospital Affiliation Mannen, Megan OD 4283 Harrision Blvd - Ogden Regional Medical Hospital Affiliation Country Hills Eye Center Ste 8 Center - Ogden Regional Medical 875 Country Hills Dr Ogden UT. 84403 - Lakeview Hospital Center Ogden UT. 84403 p 801.479.5060 p 801.399.1149 Chandler, Jason G DMD Bitner, Mathew F MD 460 N 325 E Oral & Maxillofacial Sumko-Bitner Orthopaedics Meyer, David A OD Ogden UT. 84404 Surgeons of Utah & Sports Medicine Clinic Standard Optical p 801.827.9000 2711 N Hwy 89 2850 N 2000 W 4283 Harrision Blvd Ogden UT. 84414 Ste 105 Ogden UT. 84403 Standard Optical Mon-Fri p 801.782.7175 Ogden UT. 84404 p 801.479.5060 9am-7pm Sat 8am-5pm p 801.732.1175 4283 Harrison Blvd Hospital Affiliation Millet, Curtis W OD Ste 8 - Ogden Regional Medical Hospital Affiliation Standard Optical Ogden UT. 84403 Center - Brigham City Community 4283 Harrision Blvd p 801.479.5060 - Lakeview Hospital Hospital Ogden UT. 84403 - Bear River Valley Hospital p 801.479.5060 460 N 325 E Jessen, Gregory S DDS Harrisville UT. 84404 1508 E Skyline Dr Byck, Dann C MD Myers, Rochelle A OD p 801.827.9000 Ste 800 Utah Orthopaedics Standard Optical Ogden UT. 84405 5782 Adams Ave Pkwy 460 N 325 E 5421 S 1900 W p 800.860.6260 Ogden UT. 84405 Ogden UT. 84404 Roy UT. 84067 p 801.917.8000 p 801.546.0255 p 801.825.9703 Hospital Affiliation - Ogden Regional Medical Hospital Affiliation Parker, Clifford OD Thompson, Dale E OD Center - Ogden Regional Medical Standard Optical Target Optical Center 4283 Harrision Blvd 1135 W Riverdale Rd McCormick, Adam DDS - Davis Hospital Ogden UT. 84403 Riverdale UT. 84405 Oral & Maxillofacial p 801.479.5060 p 801.393.9076 Surgeons of Utah Dee, Michael S MD 3590 Harrison Blvd Tanner Memorial Clinic Pessoa, Carlos OD Turner, Glen OD Ste 2 3443 W 5600 S Standard Optical The Eye Pros Ogden UT. 84403 Roy UT. 84067 4283 Harrision Blvd 4115 S Riverdale Rd p 801.392.7176 p 801.773.4840 Ste 8 Ste B Ogden UT. 84403 Ogden UT. 84405 Hospital Affiliation Hospital Affiliation p 801.479.5060 p 801.872.2020 - Ogden Regional Medical - Davis Hospital Center - Ogden Regional Medical Peterson, Scott D OD Wenom, Greg M OD - Lakeview Hospital Center Family Vision Clinic 5735 S Harrison Blvd 3988 Washington Blvd South Ogden UT. 84403 Roberts, Greg A DDS Hall, Michael J MD South Ogden UT. 84403 p 801.393.9440 5742 S 1475 E Ogden Clinic - p 801.621.2883 Ste 100 Professional Center North Whipple, Ian G OD Ogden UT. 84403 4650 Harrison Blvd Peterson, Walter OD Vision Source of Farr West p 801.479.9070 Ogden UT. 84403 Standard Optical 1741 N 2000 W p 801.475.3000 4283 Harrision Blvd Ste 7 Hospital Affiliation Ogden UT. 84403 Ogden UT. 84404 - Ogden Regional Medical Ogden Clinic - p 801.479.5060 p 801.731.5558 Center Professional Center South 4700 Harrison Blvd Pickett, Greg M OD Wilkins, Court R OD Orthopedic Surgery Ogden UT. 84403 Optical Associates Utah Eye Centers Baranko, Brent M MD p 801.475.3300 1196 30th St 4360 Washington Blvd Ogden Clinic - Ogden UT. 84403 Ogden UT. 84403 Professional Center North Hospital Affiliation p 801.399.9873 p 801.476.0494 4650 Harrison Blvd - Ogden Regional Medical Ogden UT. 84403 Center Purdy, Russell OD Oral And Maxillofacial Surgery p 801.475.3001 Standard Optical Broadbent, Michael DMD 4283 Harrision Blvd Oral & Maxillofacial Ogden UT. 84403 Surgeons of Utah p 801.479.5060 2711 N Hwy 89 Ste 200 Ogden UT. 84414 p 801.782.7175 623 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Higbee, Daniel D DO Park, Brandon D NP Sumko, Michael H DO Sumko-Bitner Orthopaedics Utah Orthopaedics Sumko & Bitner Orthopedic Houden, Timothy S MD & Sports Medicine Clinic 5782 Adams Ave Pkwy Clinic Ogden Clinic - Utah Spine 2850 N 2000 W Ogden UT. 84405 2850 N 2000 W 4403 Harrison Blvd Ste 105 p 801.917.8000 Ogden UT. 84404 Ste 1815 Ogden UT. 84404 p 801.732.1175 Ogden UT. 84403 p 801.732.1175 Hospital Affiliation p 801.732.5900 - Ogden Regional Medical Hospital Affiliation Hospital Affiliation Center - Brigham City Community Ogden Clinic - - Brigham City Community - Davis Hospital Hospital Professional Center North Hospital - Bear River Valley Hospital 4650 Harrison Blvd - Bear River Valley Hospital Richards, Brett E MD Ogden UT. 84403 Ogden Clinic - Thomas, Bruce E MD p 801.475.3011 Larsen, Kenna MD Professional Center North University of Utah Health Utah Orthopaedics 4650 Harrison Blvd 5957 Fashion Point Dr Hospital Affiliation 5782 Adams Ave Pkwy Ogden UT. 84403 Ste 101 - Davis Hospital Ogden UT. 84405 p 801.475.3000 Ogden UT. 84403 p 801.917.8000 p 801.475.5683 Integrated Pain Ogden Clinic - Consultants Hospital Affiliation Professional Center South Mountain View Orthopaedics 2850 N 2000 W - Ogden Regional Medical 4700 Harrison Blvd & Sports Medicine Ste 203 Center Ogden UT. 84403 5957 S Fashion Point Ogden UT. 84404 - Davis Hospital p 801.475.3300 Ogden UT. 84403 p 801.689.3389 p 801.475.5683 Mele, Tristan B DO Hospital Affiliation Nelson, Alex J MD MountainStar Cardiology St - Ogden Regional Medical Hospital Affiliation Interventional Spine & Marks Center - Ogden Regional Medical Pain Management 425 E 5350 S Center 1276 S Wall Ave Ste 400 Rocco, Jeffrey J MD Ste 1 Ogden UT. 84405 Utah Orthopaedics Orthotics And Prosthetics Ogden UT. 84404 p 801.479.5642 5782 Adams Ave Pkwy Fit Well p 801.262.7246 Ogden UT. 84405 Prosthetics/Orthotics 425 E 5350 S p 801.917.8000 3354 Harrison Blvd Integrated Pain Ste 405 Ste 3 Consultants Ogden UT. 84405 Hospital Affiliation Ogden UT. 84403 2850 N 2000 W p 801.479.7740 - Ogden Regional Medical p 801.334.6000 Ste 203 Center Ogden UT. 84404 5405 S 500 E Hanger Clinic p 801.689.3389 Ste 100B Sorensen, Jeffery T MD 3585 Harrison Blvd Ogden UT. 84405 Ogden Clinic - Ogden UT. 84403 Hospital Affiliation p 801.476.6900 Professional Center North p 801.392.5999 - Lakeview Hospital 4650 Harrison Blvd - Timpanogos Regional Hospital 5405 S 500 E Ogden UT. 84403 1464 E Ridgeline Dr Ste 202 p 801.475.3000 Ste 103 Shepherd, Joshua DO Ogden UT. 84405 Ogden UT. 84405 Avail Medical p 801.475.1928 Ogden Clinic - p 801.392.5999 5742 S 1475 E Professional Center South Ste 200 Mitchell, Chase MD 4700 Harrison Blvd 1140 36th St Ogden UT. 84403 Tanner Memorial Clinic Ogden UT. 84403 Ste 165 p 801.438.4438 3443 W 5600 S p 801.475.3300 Ogden UT. 84403 Roy UT. 84067 p 801.392.0075 Hospital Affiliation p 801.773.4840 Hospital Affiliation - Davis Hospital - Ogden Regional Medical Outpatient Rehabilitation Clinic Hospital Affiliation Center Action Recovery Group Simkins, April NP - Davis Hospital 1708 E 5550 S Utah Pain and Rehab Sumko, Daniel DO Ste 23 1276 S Wall Ave Mock, Brady K MD Tanner Memorial Clinic Ogden UT. 84403 Ogden UT. 84404 Ogden Clinic - 3443 W 5600 S p 801.475.4673 p 801.337.4000 Professional Center South Roy UT. 84067 4700 Harrison Blvd p 801.773.4840 Pain Management Slade, Travis D MD Ogden UT. 84403 Anden, Corey D MD Intermountain Pain p 801.457.3000 Hospital Affiliation Utah Spine Care Solutions - Davis Hospital 4403 Harrison Blvd 5333 S 500 E Ste 1815 Ste C Ogden UT. 84403 Ogden UT. 84405 p 801.387.6320 p 801.262.9600

Hospital Affiliation Hospital Affiliation - Ogden Regional Medical - Ogden Regional Medical Center Center - Brigham City Community 624 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider.Hospital 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Utah Pain and Rehab *Hamaker, Mark MD Pediatric Ophthalmology Boehm, Mindy M MD 1276 S Wall Ave Primary Childrens Hospital Bullard, Michael L MD Pediatrix Medical Group Ogden UT. 84404 4403 Harrison Blvd Utah Eye Centers 5475 S 500 E p 801.337.4000 Ste 3630 4360 Washington Blvd Ogden UT. 84405 Ogden UT. 84403 Ogden UT. 84403 p 801.476.4280 Vigil, Debra FNP p 801.387.7900 p 801.476.0494 Utah Pain and Rehab Hospital Affiliation 1276 S Wall Ave Hospital Affiliation Hospital Affiliation - Ogden Regional Medical Ogden UT. 84404 - Primary Childrens Hospital - Lakeview Hospital Center p 801.337.4000 - Ogden Regional Medical *Murray, Mary A MD Center Brown, Edward D MD Weston, Raul K MD Primary Childrens Hospital Ogden Clinic - Canyon Ridge Pain and 4403 Harrison Blvd Pediatrics Professional Center North Spine Ste 3630 Allred, John G DO 4650 Harrison Blvd 5957 S Fashion Point Dr Ogden UT. 84403 Ogden Clinic - Grand View Ogden UT. 84403 Ste 101 p 801.387.7900 3485 W 5200 S p 801.475.3000 Ogden UT. 84403 Roy UT. 84067 p 801.294.7246 Hospital Affiliation p 801.475.3900 Hospital Affiliation - University of Utah Hospital - Ogden Regional Medical Hospital Affiliation Hospital Affiliation Center - Lakeview Hospital *Raman, Vandana S MD - Ogden Regional Medical Primary Childrens Hospital Center Buchanan, Marcus P MD Whaley Pryor, Gigi NP 4403 Harrison Blvd Farr West Pediatrics Utah Pain and Rehab Ste 3630 Baranko, Anne G MD 2850 N 2000 W 1276 S Wall Ave Ogden UT. 84403 Pediatric Care Of Ogden Farr West UT. 84404 Ogden UT. 84404 p 801.387.7900 1740 E Combe Rd p 801.732.0780 p 801.337.4000 Ste 5 Hospital Affiliation Ogden UT. 84403 Hospital Affiliation Pediatric Cardiology - University of Utah Hospital p 801.621.1701 - Brigham City Community Cowley, Collin G MD Hospital Pediatrix Medical Group Pediatric Gastroenterology Hospital Affiliation 4401 Harrison Blvd Mizell, Louis L MD - Ogden Regional Medical *Carver, Jeanlee F APRN Ogden UT. 84403 Pediatrix Medical Group Center Primary Childrens Hospital p 801.387.2800 434 E 5350 S 2408 Van Buren Ave Ogden UT. 84405 Berger, Vicki L PA-C Ogden UT. 84401 5475 S 500 E p 801.479.2111 Wee Care Pediatrics p 801.778.6261 Ogden UT. 84405 5682 S 3500 W p 801.479.2111 5475 S 500 E Ste A Hospital Affiliation Ogden UT. 84405 Roy UT. 84067 - Primary Childrens Hospital 5495 S 500 E p 801.479.2111 p 801.773.8644 - Lakeview Hospital Ste 100 - Ogden Regional Medical Ogden UT. 84405 Hospital Affiliation Hospital Affiliation Center p 801.479.2111 - Primary Childrens Hospital - Davis Hospital - Lone Peak Hospital Castro, Jan M PA-C Hospital Affiliation - Timpanogos Regional Hospital Berry, Julie L MD Mountain Star Pediatrics - Ogden Regional Medical Pediatric Care Of Ogden 5495 S 500 E Center Pediatric Neurology 1740 E Combe Rd Ste 120 Morita, Denise M MD Ste 5 Ogden UT. 84405 Pediatric Endocrinology Pediatrix Medical Group Ogden UT. 84403 p 801.479.0174 *Clements, Scott A MD 5475 S 500 E p 801.621.1701 Primary Childrens Hospital Ogden UT. 84405 Cheatham, Robert W MD 4403 Harrison Blvd p 801.476.4280 Hospital Affiliation Pediatrix Medical Group Ste 3630 - Ogden Regional Medical 5475 S 500 E Ogden UT. 84403 5495 S 500 E Center Ogden UT. 84405 p 801.387.7900 Ste 100 p 801.476.4280 Ogden UT. 84405 Blanca, Haydee MD Hospital Affiliation p 801.479.4266 Midtown Community Health Church, Jason V MD - University of Utah Hospital Centers Ogden Clinic - Mountain Hospital Affiliation 5285 S 400 E View *Foster, Carol M MD - Jordan Valley Medical Ste A 1100 W 2700 N Primary Childrens Hospital Center Washington Terrace UT. 84405 Ogden UT. 84414 4403 Harrison Blvd p 801.393.5355 p 801.475.3000 Ste 3630 Ogden UT. 84403 Hospital Affiliation p 801.387.7900 - Ogden Regional Medical Center Hospital Affiliation - University of Utah Hospital 625 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Ogden Clinic - Hawkes, Cody J DO Ogden Clinic - *Stacie, Mecham W APRN Professional Center North Wee Care Pediatrics Professional Center North Primary Childrens Hospital 4650 Harrison Blvd 5682 S 3500 W 4650 Harrison Blvd 2408 Van Buren Ave Ogden UT. 84403 Ste A Ogden UT. 84403 Ogden UT. 84401 p 801.475.3000 Roy UT. 84067 p 801.475.3000 p 801.778.6261 p 801.773.8644 Hospital Affiliation Ogden Clinic CV Hospital Affiliation - Ogden Regional Medical Hospital Affiliation 698 E 12th St - Primary Childrens Hospital Center - Ogden Regional Medical Ogden UT. 84404 Center p 801.475.3700 Stevenson, Kenneth E MD Clark, Bradley J DO - Davis Hospital Mountain Star Pediatrics Ogden Clinic - Grand View Neumann, Daniel MD 174 N 2000 W 3485 W 5200 S Hoki, Robert S MD Wee Care Pediatrics Ste 3 Roy UT. 84067 Wee Care Pediatrics 5682 S 3500 W Ogden UT. 84404 p 801.475.3900 5682 S 3500 W Ste A p 801.479.0174 Ste A Roy UT. 84067 Ogden Clinic - Roy UT. 84067 p 801.773.8644 5495 S 500 E Professional Center North p 801.773.8644 Ste 120 4650 Harrison Blvd Nguyen, Amy L PA Ogden UT. 84405 Ogden UT. 84403 Hospital Affiliation Wee Care Pediatrics p 801.479.0174 p 801.475.3000 - Davis Hospital 5682 S 3500 W - Ogden Regional Medical Ste A Hospital Affiliation Clawson, Charlene G MD Center Roy UT. 84067 - Ogden Regional Medical Pediatric Care Of Ogden p 801.773.8644 Center 1740 E Combe Rd Husseman, Michael P MD Ste 5 Wee Care Pediatrics Nielsen, Robert J MD Torbeck, Jenna APRN Ogden UT. 84403 5682 S 3500 W Pediatric Care of Ogden Wee Care Pediatrics p 801.621.1701 Ste A 1740 E Combe Rd 5682 S 3500 W Roy UT. 84067 Ste 5 Ste A Hospital Affiliation p 801.773.8644 Ogden UT. 84403 Roy UT. 84067 - Ogden Regional Medical p 801.621.1701 p 801.773.8644 Center Hospital Affiliation - Davis Hospital Hospital Affiliation Watts, Donald F MD Fennell, James A MD - Ogden Regional Medical - Ogden Regional Medical Pediatric Care Of Ogden Wee Care Pediatrics Center Center 1740 E Combe Rd 5682 S 3500 W Ste 5 Ste A Lau, Isabel C MD Pruitt, Anthony G MD Ogden UT. 84403 Roy UT. 84067 MountainStar Ogden Wee Care Pediatrics p 801.621.1701 p 801.773.8644 Pediatrics 5682 S 3500 W 1741 N 200 W Ste A Wee Care Pediatrics, Mon - Hospital Affiliation Ste 3 Roy UT. 84067 Fri 8:00am - 8:00pm - Davis Hospital Ogden UT. 84404 p 801.773.8644 5682 S 3500 W - Ogden Regional Medical p 801.479.0174 Ste A Center Hospital Affiliation Roy UT. 84067 5495 S 500 E - Ogden Regional Medical p 801.773.8644 Gabrielsen, Alvin A MD Ste 120 Center Wee Care Pediatrics Ogden UT. 84405 - Davis Hospital West-Ellis, Karen APRN 5682 S 3500 W p 801.479.0174 Wee Care Pediatrics Ste A Sigg, Laurent C MD 5682 S 3500 W Roy UT. 84067 Hospital Affiliation Wee Care Pediatrics Ste A p 801.773.8644 - Ogden Regional Medical 5682 S 3500 W Roy UT. 84067 Center Ste A p 801.773.8644 Hospital Affiliation Roy UT. 84067 - Ogden Regional Medical Maxwell, Roderick D PA p 801.773.8644 Physical Medicine And Rehabilitation Center Wee Care Pediatrics Anden, Corey D MD - Davis Hospital 5682 S 3500 W Hospital Affiliation Utah Spine Care Ste A - Davis Hospital 4403 Harrison Blvd Gilsoul, Jennifer M MD Roy UT. 84067 - Ogden Regional Medical Ste 1815 Wee Care Pediatrics p 801.773.8644 Center Ogden UT. 84403 5682 S 3500 W p 801.387.6320 Ste A Naegle, Matthew S DO Silas, Peter E MD Roy UT. 84067 Ogden Clinic - Canyon View Wee Care Pediatrics Hospital Affiliation p 801.773.8644 1159 E 12th St 5682 S 3500 W - Ogden Regional Medical Ogden UT. 84404 Ste A Center Hospital Affiliation p 801.475.3700 Roy UT. 84067 - Brigham City Community - Davis Hospital p 801.773.8644 Hospital - Ogden Regional Medical Center Hospital Affiliation - Davis Hospital - Ogden Regional Medical Center 626 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Anderson, Sean D DO Bravo, Alexander J DPT Ogden Clinic - Hultquist, Jared J DPT Mountainstar Cardiology St The Clinic-Physical Professional Center South Utah Physical Therapy Inc Marks Therapy & Human 4700 Harrison Blvd 3476 W 4600 S 5405 S 500 E Performance, Inc. Ogden UT. 84403 Ogden UT. 84401 Ste 202 955 Chambers St p 801.475.7010 p 801.689.0200 Ogden UT. 84405 Ste 150 p 801.475.1928 Ogden UT. 84403 Greenhalgh, Jordan DPT Jackson, Brandi N DPT p 801.689.2495 Mountain Land Mountain Land Kokkonen, Jeremy J DO Rehabilitation Inc Rehabilitation Inc Utah Orthopaedics Child, Bryan F PT 349 12th St 2572 E South Weber Dr 5782 Adams Ave Pkwy Precision EMG PLLC Ogden UT. 84404 South Weber UT. 84405 Washington Terrace UT. 84405 5740 Crestwood Dr p 801.782.0300 p 801.479.7045 p 801.917.8000 Ogden UT. 84405 p 801.725.2380 Gubler, Jason C DPT Judd, Robyn M DPT Melville, Bradley R MD Ogden Clinic - Cope Family Wasatch Therapy Inc Ogden Clinic - Utah Spine Concentra Medical Centers Medicine 1967 W 5700 S 4403 Harrison Blvd 2390 Redwood Rd 1159 E 12th St Roy UT. 84067 Ste 1815 West Valley City UT. 84419 Ogden UT. 84404 p 801.774.8600 Ogden UT. 84403 p 888.997.2669 p 801.475.3700 p 801.732.5900 Kerbs, Alan J PT Cooper, Jacob PT Ogden Clinic - Grand View Physical Therapy and Hospital Affiliation Ogden Clinic - 3485 W 5200 S Sports Medicine - Ogden Regional Medical Professional Center North Roy UT. 84067 2369 N 400 E Center 4650 Harrison Blvd p 801.475.3900 Ogden UT. 84414 - Davis Hospital Ogden UT. 84403 p 801.728.4624 p 801.475.3090 Ogden Clinic CV Positional Release Therapy 698 E 12th St Landgren, Tyler DPT Institute Ogden Clinic - Ogden UT. 84404 Wasatch Therapy Inc 1702 E 5600 S Professional Center South p 801.475.3700 5360 S 1900 W Ogden UT. 84403 4700 Harrison Blvd Ste B3 p 801.689.2546 Ogden UT. 84403 Hanni, Kevin A DPT Roy UT. 84067 p 801.475.3870 Utah Physical Therapy Inc p 801.774.8600 Shepherd, Douglas T MD 3476 W 4600 S Ogden Clinic - Cox, Sheldon PT Ogden UT. 84401 Langford, Daniel P DPT Professional Center North Wasatch Peak Physical p 801.689.0200 Bridge Physical Therapy 4650 Harrison Blvd Therapy 6017 Fashion Point Dr Ogden UT. 84403 8025 S 2500 E Hansen, Bradley DPT South Ogden UT. 84403 p 801.475.3011 South Weber UT. 84405 Physical Therapy And p 801.317.1618 p 801.479.0162 Sports Medicine Hospital Affiliation 2369 N 400 E Lider, Camille DPT - Ogden Regional Medical Dahlberg, Chris H PT North Ogden UT. 84414 Utah Physical Therapy Inc Center Sports Medicine Clinic p 801.728.4624 3476 W 4600 S 2261 Kiesel Ave West Haven UT. 84401 Yubero, Francis X MD Ste 320 Hanson, Hugh J p 801.689.0200 Ogden Clinic Ogden UT. 84401 Wasatch Peak Physical 4403 Harrison Blvd p 801.621.8835 Therapy Lillywhite, Mitch L DPT Ste 1875 4253 S 950 W Wasatch Therapy Inc Ogden UT. 84403 Duft, Sherri MPT Riverdale UT. 84405 5360 S 1900 W p 801.732.5900 Sundance Physical Therapy p 801.755.3334 Ste B3 3870 Stadium Way Dept Roy UT. 84067 Utah Spine Care 2701 Ogden Speech & Hearing p 801.774.8600 4403 Harrison Blvd Ogden UT. 84408 Center Ste 1875 p 801.626.7712 978 Chambers St Norris, Trac PT Ogden UT. 84405 Ste 1 Mountain Land p 801.387.6320 Erickson, Randall W DPT Ogden UT. 84403 Rehabilitation Inc Wasatch Peak Physical p 801.399.5601 2572 E S Weber Dr 5782 Adams Ave Pkwy Therapy South Weber UT. 84405 Ogden UT. 84405 2983 S 4300 W Harris, Naomi PT p 801.479.7045 p 801.917.8000 Ogden UT. 84401 Ogden Clinic - p 801.773.2872 Professional Center South Hospital Affiliation Physical Therapy 4700 Harrison Blvd - University of Utah Hospital Adams, Carly N DPT Goff, Nathan S PT Ogden UT. 84403 Wasatch Therapy Inc Ogden Clinic - Grand View p 801.475.3870 5360 S 1900 W 3485 W 5200 S Ste B3 Roy UT. 84067 Roy UT. 84067 p 801.475.3900 p 801.774.8600

627 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Owen, Kaitlyn DPT Ogden Clinic - Ogden Clinic Fawson, Lorell B DPM Positional Release Therapy Professional Center South 5430 S 1900 W 3590 Harrison Blvd Institute 4700 Harrison Blvd Ste G1 Ste G1 1702 E 5600 S Ogden UT. 84403 Roy UT. 84067 Ogden UT. 84403 Ogden UT. 84403 p 801.475.3870 p 801.779.9975 p 801.627.2122 p 801.689.2546 Ogden Clinic - Skyline Plastic Surgery Frost, Colby H DPM Reid, Kim W PT 6112 S 1550 E Barnett, Randall D MD Wasatch Foot & Ankle Performance West Physical Ogden UT. 84405 Alpine Plastic & Institute Therapy p 801.475.3800 Reconstructive Surgery 955 Chambers St 2131 N 5500 E 5405 S 500 E Ste 200 Eden UT. 84310 Stoker, Jeremy D DPT Ste 101 Ogden UT. 84403 p 801.745.3200 Mountain Land Ogden UT. 84405 p 801.627.2122 Rehabilitation Inc p 801.387.3900 Roberts, Scott C DPT 2572 E South Weber Dr Hospital Affiliation Ogden Clinic - South Weber UT. 84405 Hospital Affiliation - Davis Hospital Professional Center South p 801.479.7045 - Ogden Regional Medical - Ogden Regional Medical 4700 Harrison Blvd Center Center Ogden UT. 84403 Stokes, Corbin J DPT p 801.475.3870 Mountain Land Okawa, Allisyn MD Glover, David B DPM Rehabilitation Inc Skyline Plastic and Hand Mountain View Foot and Rose, Jared A DPT 349 12th St Surgery Ankle Institute Performance West Physical Ogden UT. 84404 6112 S 1550 E 6112 S 1550 E Therapy p 801.782.0300 Ste 102 Ste 201 2131 N 5500 E Ogden UT. 84405 Ogden UT. 84405 Eden UT. 84310 Tenney, Chad MPT p 801.689.3079 p 801.475.5683 p 801.745.3200 Utah Physical Therapy Inc 3476 W 4600 S Hospital Affiliation Hospital Affiliation Shepherd, Douglas M MPT Ogden UT. 84401 - Ogden Regional Medical - Ogden Regional Medical ARC Physical Therapy p 801.689.0200 Center Center 1276 S Wall Ave - Davis Hospital Ogden UT. 84404 Underwood, Josh PT Podiatry p 801.781.0651 Positional Release Therapy Bruse, Jason DPM Murrah, Chantel B DPM Institute Ogden Clinic - 3590 Harrison Blvd Shepherd, Kevin L PT 1702 E 5600 S Professional Center North Ste G1 Mountain Land Ogden UT. 84403 4650 Harrison Blvd Ogden UT. 84403 Rehabilitation Inc p 801.689.2546 Ogden UT. 84403 p 801.627.2122 12197 S Draper Gate Dr p 801.475.3200 Ste B Whipple, Kevan DPT Wasatch Foot & Ankle Ogden UT. 84405 Precision EMG Ogden Clinic - Institute p 801.523.3415 4650 Harrison Blvd Professional Center South 955 Chambers St Ogden UT. 84403 4700 Harrison Blvd Ste 200 Sniteman, Clay MSPT p 801.475.3010 Ogden UT. 84403 Ogden UT. 84403 Sundance Physical Therapy p 801.475.3300 p 801.627.2122 Farr West Whitaker, Timothy DPT 2850 N 2000 W Bridge Physical Therapy Hospital Affiliation Hospital Affiliation Ste 204 6017 Fashion Point Dr - Ogden Regional Medical - Ogden Regional Medical Farr West UT. 84404 South Ogden UT. 84403 Center Center p 801.731.5421 p 801.317.1618 - Lakeview Hospital Oaks, Gary N DPM Sundance Physical Therapy Wood, Dorian M PT Burgon, Andrew H DPM Tanner Memorial Clinic 3870 Stadium Way Dept Ogden Clinic - Mountain Summit Foot and Ankle 3443 W 5600 S 2701 View 1761 N 2000 W Roy UT. 84067 Ogden UT. 84408 1100 W 2700 N Ogden UT. 84404 p 801.773.4840 p 801.626.7712 Ogden UT. 84414 p 801.564.1562 p 801.475.3600 Hospital Affiliation Stanley, Sherman D OT Campbell, Jason D DPM - Davis Hospital Ogden Clinic - Ogden Clinic - Wasatch Foot & Ankle - Ogden Regional Medical Professional Center North Professional Center South Institute Center 4650 Harrison Blvd 4700 Harrison Blvd 955 Chambers St Ogden UT. 84403 Ogden UT. 84403 Ste 200 Walker, Kevin G DPM p 801.475.3870 p 801.475.7010 Ogden UT. 84403 Ogden Clinic - p 801.627.2122 Professional Center South 4700 Harrison Blvd Hospital Affiliation Ogden UT. 84403 - Davis Hospital p 801.475.3300 - Ogden Regional Medical Center Hospital Affiliation - Ogden Regional Medical Center 628 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Wasatch Foot & Ankle Psychology Medina-Salvatore, Nicole Pulmonology - Salt Lake Regional Medical Institute Carcelli, Lawrence A PhD PSYD Anderson, Christopher K Center 955 Chambers St Ogden Center for Neurobehavioral Center For MD - St Marks Hospital Ste 200 Counseling Growth Mountain States Pulmonary Ogden UT. 84403 4699 Harrison Blvd 1893 Skyline Dr and Critical Care p 801.627.2122 Ste 300 Ogden UT. 84403 5957 Fashion Point Dr Ogden UT. 84403 p 801.683.1062 Ogden UT. 84403 Woolley, Mark E DPM p 801.479.8286 p 385.492.4930 The Foot and Ankle Health 5974 Fashion Point Dr Center Cardinal, Jennifer R PhD, Ste 100 Hospital Affiliation 6028 S Ridgeline Dr BCBA Ogden UT. 84403 - Ogden Regional Medical Ste 205 Neurobehavioral Center For p 801.683.1062 Center Ogden UT. 84405 Growth - Davis Hospital p 801.409.2100 1893 Skyline Dr 5974 Fashion Point Dr - Cache Valley Hospital Ogden UT. 84403 Ste 140 Wasatch Foot & Ankle p 801.683.1062 Ogden UT. 84403 Francis, Kurt F MD Institute p 801.683.1062 MountainStar Cardiology St 955 Chambers St Neurobehavioral Center for Marks Ste 200 Growth Petrovich, Brian PSYD 425 E 5350 S Ogden UT. 84403 5974 Fashion Point Dr Ogden Psychological Ste 400 p 801.627.2122 Ste 100 Services Ogden UT. 84405 Ogden UT. 84403 1186 E 4600 p 801.479.5642 Hospital Affiliation p 801.683.1062 Ste 440 - Ogden Regional Medical Ogden UT. 84403 425 E 5350 S Center 5974 Fashion Point Dr p 801.505.6545 Ste 405 Ste 140 Ogden UT. 84405 Psychiatry Ogden UT. 84403 Pramann, Robert F PhD p 801.479.7740 Banks, Duane R MD p 801.683.1062 Christian Counseling Clinical Consultants Centers of Utah Hospital Affiliation 2661 Washington Blvd Evans, Lyndsey M PhD 575 23rd St - St Marks Hospital Ste 102-B Neurobehavioral Center For Ogden UT. 84401 - Lone Peak Hospital Ogden UT. 84401 Growth p 801.268.1564 p 801.621.8670 1893 Skyline Dr Ivester, Charles T MD Ogden UT. 84403 Russell Stamp, Mindy M Mountain States Pulmonary Goebel, Austin G DO p 801.683.1062 PhD and Critical Care Ogden Regional Behavioral Neurobehavioral Center For 5957 Fashion Point Dr Health 5974 Fashion Point Dr Growth Ogden UT. 84403 5475 S 500 E Ste 100 1893 Skyline Dr p 385.492.4930 Ogden UT. 84405 Ogden UT. 84403 Ogden UT. 84403 p 801.479.2111 p 801.683.1062 p 801.683.1062 Hospital Affiliation - Ogden Regional Medical Javellana, Carmela md 5974 Fashion Point Dr 5974 Fashion Point Dr Center Neurobehavioral Center For Ste 140 Ste 100 - Davis Hospital Growth Ogden UT. 84403 Ogden UT. 84403 - Cache Valley Hospital 1893 Skyline Dr p 801.683.1062 p 801.683.1062 Ogden UT. 84403 Majoskey, Ashley M PA p 801.683.1062 Kang, Catharina H PhD 5974 Fashion Point Dr MountainStar Cardiology St 1496 E 5600 S Ste 140 Marks Lazar, Lynda NP Ste 4 Ogden UT. 84403 425 E 5350 S Aloha Medical Services Ogden UT. 84403 p 801.683.1062 Ste 400 811 N Harrisville Rd p 801.475.7139 Ogden UT. 84405 Ogden UT. 84404 Shumway, Brett PSYD p 801.479.5642 p 801.399.1818 Kluthe, John L PhD Utah Behavior Services Ogden Center for 5202 S Fwy Park Dr 425 E 5350 S Suggs, Trent K MD Counseling and Assessment Riverdale UT. 84405 Ste 405 Ogden Regional Behavioral 4590 Harrison Blvd p 801.255.5131 Ogden UT. 84405 Health Ste 200A p 801.479.7740 5475 S 500 E Ogden UT. 84405 Siebert, Tatum LCPC Ogden UT. 84405 p 801.479.8286 Utah Behavior Services Hospital Affiliation p 801.479.2111 5202 S Fwy Park Dr - St Marks Hospital Mayer, Gregory L PhD Ogden UT. 84405 Ward, Cori APRN OCCA p 801.255.5131 Radiation Oncology Utah Behavior Services 4590 Harrison Blvd Hansen, Roger S MD 5202 S Fwy Park Dr Ste 200A Gamma West Brachytherapy Ogden UT. 84405 Ogden UT. 84403 5475 S 500 E p 801.255.5131 p 801.479.8286 Ogden UT. 84405 p 801.479.2570

Hospital Affiliation - Ogden Regional Medical Center 629 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. -10/01/2021 Davis Hospital 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Harris, Robert A MD Residential Treatment Facility Birch, Kelly LCSW Gamma West Brachytherapy *Johnson, Emily MD Brighton Recovery Center Utah Behavior Services 5475 S 500 E Vascular and Vein - McKay 6000 S 1075 E 5202 S Fwy Park Dr Ogden UT. 84405 Dee Ogden UT. 84405 Ogden UT. 84405 p 801.479.2570 3903 Harrison Blvd p 801.479.7035 p 801.255.5131 Ste 100 Hospital Affiliation Ogden UT. 84403 Brighton Recovery Bunting, Catherine CSW - Ogden Regional Medical p 801.387.8900 Intensive Outpatient Utah Behavior Services Center 5677 S 1475 E 5202 S Fwy Park Dr - Davis Hospital Hospital Affiliation Ogden UT. 84403 Ogden UT. 84405 - St Marks Hospital - Intermountain Medical p 385.238.4119 p 801.255.5131 - Timpanogos Regional Hospital Center Skilled Nursing Facility Cho, Jaeyong MSW Hayes, John K MD Lance, Jason N MD Heritage Park Healthcare Utah Behavior Services Gamma West Cancer Services Ogden Clinic - and Rehabilitation 5202 S Fwy Park Dr 5475 S 500 E Professional Center North 2700 W 5600 S Ogden UT. 84405 Ogden UT. 84405 4650 Harrison Blvd Roy UT. 84067 p 801.255.5131 p 801.479.2570 Ogden UT. 84403 p 801.825.9731 p 801.475.3830 Coburn, Alison MSW Hospital Affiliation Mt Ogden Health and Utah Behavior Services - St Marks Hospital *McKenzie, Travis T DO Rehabilitation Center 5202 S Fwy Park Dr - Salt Lake Regional Medical Vascular And Vein - Mckay 375 E 5350 S Ogden UT. 84405 Center Dee Ogden UT. 84405 p 801.255.5131 - Davis Hospital 3903 Harrison Blvd p 801.479.5700 - Timpanogos Regional Hospital Ste 100 Flessner, Karen L MSW Ogden UT. 84403 Harrison Pointe Healthcare Grace and Peace Christian Reilly, Mark W MD p 801.387.8900 and Rehabilitation Counseling Gamma West Cancer Services 3430 Harrison Blvd 2909 Washington Blvd 5475 S 500 E Hospital Affiliation Ogden UT. 84403 Ogden UT. 84401 Ogden UT. 84405 - Intermountain Medical p 801.399.5609 p 888.801.1556 p 801.479.2570 Center George E Wahlen Ogden Franco, Christina D LCSW Hospital Affiliation Mountain Medical Physician Veterans Home Ogden Psychological - St Marks Hospital Specialists 1102 N 1200 W Services - Salt Lake Regional Medical 1486 E Skyline Dr Ogden UT. 84404 1186 E 4600 Center Ogden UT. 84403 p 801.334.4300 Ste 440 - Jordan Valley Medical p 801.475.4558 Ogden UT. 84403 Center Deseret Health and Rehab p 801.505.6545 - Davis Hospital *Webb, Michael S MD at Ogden McKay Dee Vascular and 524 E 800 N Gallegos, Melissa N LCSW Richards, Ray S MD Vein Ogden UT. 84404 Utah Pain and Rehab Gamma West Cancer Services 3903 Harrison Blvd p 801.782.3740 1276 S Wall Ave 5475 S 500 E Ste 100 Ogden UT. 84404 Ogden UT. 84405 Ogden UT. 84403 Wasatch Healthcare & p 801.337.4000 p 801.479.2570 p 801.387.8920 Rehabilitation 3430 Harrison Blvd Gardner, Alyson CSW Hospital Affiliation Hospital Affiliation Ogden UT. 84403 Neurobehavioral Center For - St George Regional Hospital - Cassia Regional Hospital p 801.399.5609 Growth - Davis Hospital 5974 Fashion Point Dr Radiology Sleep Medicine Ste 100 *Fuentes, Jaun D MD Ogden Imaging Hammond, Richard C DO Ogden UT. 84403 McKay Dee Vascular and 5322 S 400 E Ogden Clinic - p 801.683.1062 Vein Ogden UT. 84405 Professional Center North 3903 Harrison Blvd p 801.475.0800 4650 Harrison Blvd 5974 Fashion Point Dr Ste 100 Ogden UT. 84403 Ste 140 Ogden UT. 84403 Rehabilitation Hospital p 801.475.3200 Ogden UT. 84403 p 801.387.8920 Northern Utah p 801.683.1062 Rehabilitation Hospital Hospital Affiliation Hospital Affiliation 5825 Harrison Blvd - Ogden Regional Medical Gilmore, Patrick D LCSW - Cassia Regional Hospital Ogden UT. 84403 Center Ogden Center for p 801.475.5254 Counseling *Jepperson, Maria A MD Social Worker 4590 Harrison Blvd McKay Dee Vascular and Arballo, Jennifer CSW Ste 200A Vein Utah Behavior Services Ogden UT. 84405 3903 Harrison Blvd 5202 S Freeway Park Dr p 801.479.8286 Ste 100 Ogden UT. 84405 Ogden UT. 84403 p 801.255.5131 p 801.387.8920

Hospital Affiliation - Cassia Regional Hospital 630 *The PPO- Davis Agreement Hospital with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Green Josoff, Reena F Kelstrom-Smith, Cheryl Neff, Michal A CSW,SUDC Ringgenberg, Alyssa CSW LCSW LCSW Utah Behavior Services Alyssa Ringgenberg CSW Aloha Behavioral A1 Alliance Counseling 5202 S Freeway Park Dr 5149 S 1500 W Consultants Services Ogden UT. 84405 Ogden UT. 84405 811 N Harrisville Rd 5149 S 1500 W p 801.255.5131 p 801.475.0402 Ogden UT. 84404 Ogden UT. 84405 p 801.399.1818 p 801.475.0402 Nielsen, Stephanie MSW Rippon, Kimberly LCSW Utah Behavior Services Kimberly Rippon LCSW & Hadley, Nathan M LCSW Knopp, Julie LCSW 5202 S Fwy Park Dr Associates Midtown Community Health Family Counseling Services Ogden UT. 84405 3785 Harrison Blvd Center 3518 Washington Blvd p 801.255.5131 Ste 4 2240 Adams Ave Ogden UT. 84403 Ogden UT. 84403 Ogden UT. 84401 p 801.399.1600 OReilly, Laree C MSW p 801.510.3637 p 801.393.5355 Neurobehavioral Center For Luna, Janette M LCSW Growth Roche, Miriam MSW Harmon, B S LCSW Utah Behavior Services 1893 Skyline Dr Utah Behavior Services A1 Alliance Counseling 5202 S Freeway Park Dr Ogden UT. 84403 5202 S Fwy Park Dr Services Ogden UT. 84405 p 801.683.1062 Ogden UT. 84405 5149 S 1500 W p 801.255.5131 p 801.255.5131 Ogden UT. 84405 5974 Fashion Point Dr p 801.475.0402 Mason, Patricia A LCSW Ste 100 Skousen, Thomas MSW Life Management Ogden UT. 84403 Utah Behavior Services Hexum, Julie MSW 585 24th St p 801.683.1062 5202 S Fwy Park Dr Utah Behavior Services Ste 110 Ogden UT. 84405 5202 S Fwy Park Dr Ogden UT. 84401 5974 Fashion Point Dr p 801.255.5131 Ogden UT. 84405 p 801.394.4522 Ste 140 p 801.255.5131 Ogden UT. 84403 Slater, Courtney MSW McFarland, Maryanne LCSW p 801.683.1062 Utah Behavior Services Holmes, Alisha MSW LeafCrest Counseling 5202 S Fwy Park Dr Utah Behavior Services 1140 36th St Oblock, Jessica M LCSW Ogden UT. 84405 5202 S Fwy Park Dr Ste 275 Healing Journey Utah p 801.255.5131 Ogden UT. 84405 Ogden UT. 84403 221 25th St p 801.255.5131 p 801.510.6864 Ogden UT. 84401 Stevens, Mason LCSW p 801.613.2322 Aloha Behavioral Howes, Scott M LCSW McGill, Katie MSW Consultants Wasatch Spring Counseling Utah Behavior Services Palau, Shawn M LCSW 811 N Harrisville Rd 2748 Adam Ave 5202 S Freeway Park Dr Aloha Behavioral Ogden UT. 84404 Ogden UT. 84403 Ogden UT. 84405 Consultants p 801.399.1818 p 801.540.4452 p 801.255.5131 811 N Harrisville Rd Ogden UT. 84404 Suarez, Alex LCSW Hulphers, Brenda LCSW Meccico, Carolie LCSW p 801.399.1818 Utah Behavior Services Family Counseling Services Meccico Therapeuctic 5202 S Freeway Park Dr 3518 Washington Blvd Services Inc Phillips, Allison Ogden UT. 84405 Ogden UT. 84403 920 Chambers St LCSW,BCBA p 801.255.5131 p 801.399.1600 Ste 17 Utah Behavior Services Ogden UT. 84403 5202 S Fwy Park Dr Taylor, Sheila D LCSW Innes, Brent W LCSW p 801.528.5054 Ogden UT. 84405 Sheila Taylor Family Counseling Services p 801.255.5131 2389 N 2000 W 3518 Washington Blvd Mitchell, Craig T LCSW Ogden UT. 84404 Ogden UT. 84403 Circle of Life Womens Powell, Clark Randy LCSW p 385.312.0686 p 801.399.1600 Center Utah Behavior Services 1525 E 6000 S 5202 S Fwy Park Dr Tracy, Jaime LCSW Johnston, Harmony MSW Ogden UT. 84405 Riverdale UT. 84405 Aloha Behavioral Utah Behavior Services p 801.337.5800 p 801.255.5131 Consultants 5202 S Fwy Park Dr 811 N Harrisville Rd Ogden UT. 84405 5922 S 2125 E Prantil, Joseph E LCSW Ogden UT. 84404 p 801.255.5131 Ogden UT. 84403 Licensed Clinical p 801.399.1818 p 801.337.5800 Associates Jones, Jennifer L LCSW 3544 Lincoln Ave Uno, Tab L LCSW Healing Journey Utah Montgomery, M Andrew Ste 6 Family Counseling Services 221 25th St LCSW Ogden UT. 84401 3518 Washington Blvd Ogden UT. 84401 Aloha Behavioral p 801.393.5010 Ogden UT. 84403 p 801.613.2322 Consultants p 801.399.1600 811 N Harrisville Rd Ogden UT. 84404 p 801.399.1818

631 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Watson, Steven L LCSW Ogden Clinic - 5405 S 500 E Urgent Care Associated Therapists Professional Center South Ste 100B Ogden Clinic- Grand View 3670 Quincy Ave 4700 Harrison Blvd Ogden UT. 84405 3485 W 5200 S Ste 103 Ogden UT. 84403 p 801.476.6900 Roy UT. 84067 Ogden UT. 84403 p 801.475.3300 p 801.475.3900 p 801.479.9073 Hospital Affiliation Ogden Clinic Specialty - St Marks Hospital Ogden Clinic Urgent Care Webb, Cara MSW Services - Lakeview Hospital M-F 8am-8pm Sat-Sun Aloha Behavioral 6112 S 1550 E - Ogden Regional Medical 10am-8pm Consultants Ogden UT. 84405 Center 4650 Harrison Blvd 811 N Harrisville Rd p 801.475.3800 - Timpanogos Regional Hospital Ogden UT. 84403 Ogden UT. 84404 p 801.475.3800 p 801.399.1818 Ogden Clinic - Canyon View Hunter, Curtis T MD 698 E 12th St MountainStar Revere Health Rock Run Speech Therapy Ogden UT. 84404 Cardiovascular Surgery Family Medicine Hanson, Hugh J p 801.475.3700 425 E 5350 S 5640 S 3500 W Wasatch Peak Physical Ste 405 Roy UT. 84067 Therapy Thomas, Bruce E MD Ogden UT. 84405 p 801.773.2838 4253 S 950 W University of Utah Health p 801.476.6900 Riverdale UT. 84405 5957 Fashion Point Dr Urology p 801.755.3334 Ste 101 5405 S 500 E Campbell, Curtis M MD Ogden UT. 84403 Ste 100-B 4403 Harrison Blvd Ogden Speech & Hearing p 801.475.5683 Ogden UT. 84405 Ste 4400 Center p 801.476.6900 Ogden UT. 84403 978 Chambers St Mountain View Orthopaedics p 801.387.4550 Ste 1 & Sports Medicine Schorlemmer, Gilbert R MD Ogden UT. 84403 5957 S Fashion Point MountainStar Hospital Affiliation p 801.399.5601 Ogden UT. 84403 Cardiovascular Surgery - Ogden Regional Medical p 801.475.5683 425 E 5350 S Center Neider, Tristan A SLP Ste 405 Ogden Speech & Hearing Hospital Affiliation Ogden UT. 84405 Christensen, Tyler L MD Center - Ogden Regional Medical p 801.476.6900 Ogden Clinic - 978 Chambers St Center Professional Center South Ste 1 5405 S 500 E 4700 Harrison Blvd Ogden UT. 84403 Thurston, McKennan J MD Ste 100-B Ogden UT. 84403 p 801.399.5601 Tanner Memorial Clinic Ogden UT. 84405 p 801.457.3160 3443 W 5600 S p 801.476.6900 Nelson, Breanna R SLP Roy UT. 84067 Hospital Affiliation Neurobehavioral Center For p 801.773.4840 Hospital Affiliation - Ogden Regional Medical Growth - Lakeview Hospital Center 1893 Skyline Dr Hospital Affiliation - Mountain View Hospital - Davis Hospital Ogden UT. 84403 - Davis Hospital (UT) - Brigham City Community p 801.683.1062 - Ogden Regional Medical Hospital Substance Abuse Facility Center 5974 Fashion Point Dr Action Recovery Group - Timpanogos Regional Hospital Heaton, Brian W MD Ste 100 1708 E 5550 S 4403 Harrison Blvd Ogden UT. 84403 Ste 23 Thorne, J Kent MD Ste 4400 p 801.683.1062 Ogden UT. 84403 MountainStar Ogden UT. 84403 p 801.475.4673 Cardiovascular Surgery p 801.387.4550 5974 Fashion Point Dr 425 E 5350 S Ste 140 Brighton Recovery Center Ste 405 Hospital Affiliation Ogden UT. 84403 6000 S 1075 E Ogden UT. 84405 - Ogden Regional Medical p 801.683.1062 Ogden UT. 84405 p 801.476.6900 Center p 801.479.7035 - Davis Hospital Walker, Megan C SLP Hospital Affiliation Ogden Clinic - Thoracic Surgery - St Marks Hospital Morris, Targhee J MD Professional Center North Affleck, David G MD - Ogden Regional Medical Utah Urology 4650 Harrison Blvd MountainStar Center 1495 E Ridgeline Dr Ogden UT. 84403 Cardiovascular Surgery - Timpanogos Regional Hospital Ogden UT. 84405 p 801.475.3090 425 E 5350 S p 801.609.4476 Ste 405 Zink, Robert F MD Sports Medicine Ogden UT. 84405 MountainStar Hospital Affiliation Martindale, Brett W MD p 801.476.6900 Cardiovascular Surgery - Mountain View Hospital Ogden Clinic - 425 E 5350 S (UT) Professional Center North Ste 405 - Timpanogos Regional Hospital 4650 Harrison Blvd Ogden UT. 84405 Ogden UT. 84403 p 801.476.6900 p 801.475.3000 632 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks. Moulton, Scott DO *Akhtar, Faheem MD *McKay Dee Vascular and 5405 S 500 E Ogden Internal Medicine McKay Dee Vascular and *Vein Ste 100-B and Urology Vein 3903 Harrison Blvd Ogden UT. 84405 5405 S 500 E 3903 Harrison Blvd Ste 100 p 801.476.6900 Ste 203 Ste 100 Ogden UT. 84403 Ogden UT. 84405 Ogden UT. 84403 p 801.387.8920 Hospital Affiliation p 801.475.8600 p 801.387.8920 - Lakeview Hospital *Merrell, Steven W MD - Mountain View Hospital Hospital Affiliation Bech, Fritz R MD McKay Dee Vascular and (UT) - Ogden Regional Medical MountainStar Vein - Ogden Regional Medical Center Cardiovascular Surgery 3903 Harrison Blvd Center - Lakeview Hospital 425 E 5350 S Ste 100 - Timpanogos Regional Hospital Ste 405 Ogden UT. 84403 Stevenson, Bradford J MD Ogden UT. 84405 p 801.387.8920 Thorne, J Kent MD Ogden Clinic - p 801.476.6900 MountainStar Professional Center South Hospital Affiliation Cardiovascular Surgery 4700 Harrison Blvd 5405 S 500 E - Ogden Regional Medical 425 E 5350 S Ogden UT. 84403 Ste 100-B Center Ste 405 p 801.457.3300 Ogden UT. 84405 - Jordan Valley Medical Ogden UT. 84405 p 801.476.6900 Center p 801.476.6900 Hospital Affiliation - Salt Lake Regional Medical - Davis Hospital *Galt, Spencer W MD Center Hospital Affiliation McKay Dee Vascular and - St Marks Hospital Wayment, Robert D MD Vein Morasch, Mark D MD - Ogden Regional Medical Ogden Clinic - Womens 3903 Harrison Blvd MountainStar Center Center Mckay Ste 100 Cardiovascular Surgery - Timpanogos Regional Hospital 4403 Harrison Blvd Ogden UT. 84403 425 E 5350 S Ste 4650 p 801.387.8920 Ste 405 *Whitten, Matthew G MD Ogden UT. 84403 Ogden UT. 84405 McKay Dee Vascular and p 801.475.3240 Hospital Affiliation p 801.476.6900 Vein - Ogden Regional Medical 3903 Harrison Blvd Ogden Clinic - Center 5405 S 500 E Ste 100 Professional Center South - Jordan Valley Medical Ste 100-B Ogden UT. 84403 4700 Harrison Blvd Center Ogden UT. 84405 p 801.387.8920 Ogden UT. 84403 - Salt Lake Regional Medical p 801.476.6900 p 801.475.3160 Center Hospital Affiliation Nedeau, April E MD - Cassia Regional Hospital Hospital Affiliation Homsi, Amer M MD MountainStar Cardiology St - Jordan Valley Medical - Ogden Regional Medical MountainStar Cardiology St Marks Center Center Marks 425 E 5350 S - Ogden Regional Medical - Davis Hospital 5405 S 500 E Ste 400 Center - Brigham City Community Ste 202 Ogden UT. 84405 Hospital Ogden UT. 84405 p 801.479.5642 Wound Care p 801.801.4751 Clemens, Peter C DO Vascular Surgery 425 E 5350 S Paramount Medical Care Affleck, David G MD Karwande, Shreekanth MD Ste 405 434 E 5350 S MountainStar MountainStar Ogden UT. 84405 Ste B Cardiovascular Surgery Cardiovascular Surgery p 801.479.7740 Ogden UT. 84405 425 E 5350 S 425 E 5350 S p 801.475.7100 Ste 405 Ste 405 Northern Utah Ogden UT. 84405 Ogden UT. 84405 Cardiovascular Associates SanCuro Wound Care Systems p 801.476.6900 p 801.476.6900 5405 S 500 E inc Ste 100B 434 E 5350 S 5405 S 500 E 5405 S 500 E Ogden UT. 84405 Ogden UT. 84405 Ste 100B Ste 100-B p 801.476.6900 p 801.475.7100 Ogden UT. 84405 Ogden UT. 84405 p 801.476.6900 p 801.476.6900 Hospital Affiliation Hospital Affiliation - St Marks Hospital - Ogden Regional Medical Hospital Affiliation Hospital Affiliation Center - St Marks Hospital - St Marks Hospital Schorlemmer, Gilbert R MD - Lakeview Hospital - Ogden Regional Medical MountainStar - Ogden Regional Medical Center Cardiovascular Surgery Center - Timpanogos Regional Hospital 425 E 5350 S - Timpanogos Regional Hospital - Lakeview Hospital Ste 405 Ogden UT. 84405 p 801.476.6900

633 *The PPO Agreement with this provider is expressly between the Third Party Administrator and the Provider. 10/01/2021 05:46:50 **This facility may be used ONLY for specific specialty services. Members must obtain prior authorization from Payor before receiving services. All other services are available at participating hospitals with Wise Provider Networks.