Allegiance‐Provided Out‐of‐Network Air Summary

Potential Total Balance Bill at Billed / Member Medicare 250% of Medicare Air Ambulance Provider Flights Total Billed Allowed Medicare Allowed 2016 LLC 1$ 29,600 $ 6,959 $ 12,202 425% NORTHWEST MEDSTAR 1$ 27,411 $ 5,845 $ 12,799 469% REACH LLC 3$ 132,605 $ 23,934 $ 72,769 554% SANFORD MEDICAL CENTER 1$ 16,631 $ 7,120 $ ‐ 234% TOTAL 6$ 206,247 $ 43,858 $ 97,771

2015 DALLAS AERO SALES LLC 1$ 7,500 $ 4,511 $ ‐ 166% EAGLEMED LLC 3$ 100,850 $ 28,750 $ 28,974 351% LIFE FLIGHT NETWORK LLC 13$ 528,773 $ 107,392 $ 260,292 492% NE MT STAT AIR AMBULANCE 2$ 38,807 $ 13,183 $ 5,850 294% NORTHWEST MEDSTAR 19$ 553,274 $ 137,269 $ 210,101 403% REACH AIR MEDICAL SERVICES LLC 11$ 386,466 $ 78,081 $ 191,263 495% ROCKY MOUNTAIN HOLDINGS 2$ 104,326 $ 15,712 $ 65,046 664% SANFORD MEDICAL CENTER 2$ 32,473 $ 14,309 $ ‐ 227% ST ANTHONY HOSP CENTRAL 1$ 66,866 $ 10,527 $ 40,548 635% SUMMIT AMBULANCE 4$ 141,210 $ 29,549 $ 67,337 478% VALLEY MED FLIGHT 2$ 106,667 $ 15,461 $ 68,014 690% TOTAL 60$ 2,067,213 $ 454,746 $ 937,426

2014 AIRLIFT NORTHWEST 3$ 191,958 $ 32,877 $ 109,766 584% LIFE FLIGHT NETWORK LLC 4$ 127,742 $ 31,169 $ 49,819 410% MAYO CLINIC MEDICAL TRANSPORT 1$ 25,030 $ 16,087 $ ‐ 156% NE MT STAT AIR AMBULANCE 9$ 170,186 $ 64,547 $ 24,621 264% NORTHWEST MEDSTAR 13$ 418,064 $ 92,450 $ 186,940 452% SUMMIT AMBULANCE 14$ 573,449 $ 110,371 $ 297,521 520% VALLEY MED FLIGHT 6$ 308,860 $ 44,711 $ 197,082 691% TOTAL 50$ 1,815,290 $ 392,213 $ 865,748

2013 AIRLIFT NORTHWEST 6$ 319,312 $ 62,284 $ 163,602 513% GUARDIAN FLIGHT 1$ 31,375 $ 6,585 $ 14,913 476% NE MT STAT AIR AMBULANCE 15$ 159,098 $ 112,036 $ ‐ 142% NORTHWEST MEDSTAR 2$ 73,550 $ 16,334 $ 32,716 450% SUMMIT AMBULANCE 2$ 38,412 $ 14,698 $ 1,668 261% VALLEY MED FLIGHT 9$ 162,875 $ 65,277 $ 29,915 250% TOTAL 35$ 784,623 $ 277,214 $ 242,813 Potential Total Balance Bill at Billed / Member Medicare 250% of Medicare Air Ambulance Provider Flights Total Billed Allowed Medicare Allowed 2012 AIRLIFT NORTHWEST 7$ 304,658 $ 65,811 $ 140,132 463% AMERICAN AEROVAC INC 2$ 26,474 $ 19,465 $ ‐ 136% DVA CENTRAL PLAINS CPAC 1$ 39,332 $ 9,343 $ 15,976 421% GUARDIAN FLIGHT 1$ 29,190 $ 6,297 $ 13,447 464% INTERMOUNTAIN LIFE FLIGHT 2$ 26,965 $ 13,077 $ ‐ 206% NE MT STAT AIR AMBULANCE 10$ 99,963 $ 72,391 $ ‐ 138% NORTHWEST MEDSTAR 3$ 106,063 $ 22,877 $ 48,869 464% ROCKY MOUNTAIN HOLDINGS 2$ 76,903 $ 17,373 $ 33,472 443% SUMMIT AMBULANCE 3$ 66,690 $ 29,803 $ ‐ 224% TRAVELAIRE SERVICE INC 1$ 9,250 $ 10,184 $ ‐ 91% VALLEY MED FLIGHT 2$ 29,492 $ 16,023 $ ‐ 184% TOTAL 34$ 814,980 $ 282,644 $ 251,897

2011 ADVANCED AIR AMBULANCE CORP 1$ 8,750 $ 4,163 $ ‐ 210% AIRLIFT NORTHWEST 5$ 196,412 $ 46,622 $ 79,858 421% EXEC AIR MONTANA INC 1$ 7,208 $ 5,497 $ ‐ 131% INTERMOUNTAIN LIFE FLIGHT 2$ 46,566 $ 18,912 $ ‐ 246% MEDICAL AIR RESCUE COMPANY 1$ 12,313 $ 7,322 $ ‐ 168% MONTANA VAMC 1$ 27,562 $ 7,552 $ 8,682 365% NE MT STAT AIR AMBULANCE 13$ 126,313 $ 92,976 $ ‐ 136% NORTHWEST MEDSTAR 6$ 145,747 $ 39,254 $ 47,611 371% ROCKY MOUNTAIN HOLDINGS 4$ 115,320 $ 28,863 $ 43,162 400% ST ANTHONY HOSP CENTRAL 2$ 54,108 $ 20,659 $ 17,567 262% TOTAL 36$ 740,299 $ 271,820 $ 196,880

2010 AIRLIFT NORTHWEST 5$ 206,689 $ 51,541 $ 77,835 401% BISMARCK AIR MEDICAL LLC 2$ 15,674 $ 12,982 $ ‐ 121% INTERMOUNTAIN LIFE FLIGHT 1$ 20,578 $ 8,962 $ ‐ 230% LIFE FLIGHT NETWORK LLC 1$ 9,800 $ 4,106 $ ‐ 239% NE MT STAT AIR AMBULANCE 10$ 86,416 $ 65,530 $ ‐ 132% NORTHWEST MEDSTAR 1$ 21,976 $ 7,303 $ 3,720 301% OMNIFLIGHT IDAHO 1$ 55,667 $ 7,528 $ 36,846 739% TOTAL 21$ 416,800 $ 157,952 $ 118,401