Wcnf) Inpatient Case Payment Rates - Effective 1/1/2021 - 12/31/2021 (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11

NYS DEPARTMENT OF HEALTH SCHEDULE OF WORKERS' COMPENSATION / NO FAULT (WCNF) INPATIENT CASE PAYMENT RATES - EFFECTIVE 1/1/2021 - 12/31/2021 (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11)

DISCHARGE STATEWIDE HIGH COST CAPITAL RATE - PER CAPITAL RATE - RATE PRICE ISAF CC's IME %'s DME RATE DISCH PER DIEM ALC WCNF SURCHARGES CAPITAL PER DISCHARGE PLUS NON- *Informational COMPARABLES: DISCHARGE Only* AMBULANCE, SCHOOL WCNF WCNF CASE PAYMENT STATEWIDE INSTITUTION- HIGH COST INDIRECT DIRECT OF NURSING, TEACHING PUBLIC ADDITIONAL RATE BASE PRICE SPECIFIC CHARGE MEDICAL MEDICAL ELECTION AMENDMENT GOODS PUBLIC (EXCLUDING PHL (EXCLUDING ADJUSTMENT CONVERTOR EDUCATION EDUCATION PHYS & MINIMUM WAGE CAPITAL PER ALC PRICE POOL GOODS POOL § 2807-c(33)) PHL § 2807-c(33)) FACTOR (ISAF) (2019) (IME) % (DME) ADD-ON ADD-ONS DIEM PER DAY SURCHARGE SURCHARGE

OPCERT HOSPITAL NAME **(PER DISCH)** **(PER DAY**) 1623001 ADIRONDACK MEDICAL CENTER $6,937.93 $8,274.22 0.8385 0.433529 0.00% $0.00 $521.61 $147.72 $213.08 9.63% 28.27% 0101000 ALBANY MEDICAL CTR HOSP $8,081.57 $8,274.22 0.8250 0.296103 18.39% $1,259.43 $1,048.25 $192.13 $213.08 9.63% 28.27% 0101000 ALBANY MEDICAL CTR SO CLINICAL $8,081.57 $8,274.22 0.8250 0.296103 18.39% $1,259.43 $1,048.25 $192.13 $213.08 9.63% 28.27% 4102002 ALBANY MEMORIAL HOSP $6,593.73 $8,274.22 0.7969 0.424000 0.00% $0.00 $633.24 $107.85 $213.08 9.63% 28.27% 0701000 ARNOT OGDEN MEDICAL CTR $7,023.80 $8,274.22 0.7898 0.391577 7.48% $392.79 $593.38 $130.28 $213.08 9.63% 28.27% 0701000 ARNOT OGDEN - ST JOSEPHS HOSP / ELMIRA $7,023.80 $8,274.22 0.7898 0.391577 7.48% $392.79 $593.38 $130.28 $213.08 9.63% 28.27% 0501000 AUBURN COMMUNITY HOSPITAL $6,878.36 $8,274.22 0.8313 0.430421 0.00% $0.00 $200.40 $53.39 $213.08 9.63% 28.27% 3801000 AURELIA OSBORN FOX MEM HOSP $5,963.23 $8,274.22 0.7207 0.573073 0.00% $0.00 $298.38 $68.07 $213.08 9.63% 28.27% 7002001 BELLEVUE HOSPITAL CENTER $11,676.90 $8,274.22 1.0718 0.600166 31.67% $2,764.24 $2,677.84 $215.20 $289.71 9.63% 28.27% 1427000 BERTRAND CHAFFEE HOSPITAL $5,529.66 $8,274.22 0.6683 0.757808 0.00% $0.00 $255.28 $78.47 $213.08 9.63% 28.27% 3535001 BON SECOURS COMMUNITY HOSP $7,941.60 $8,274.22 0.9598 0.182572 0.00% $0.00 $975.78 $275.15 $289.71 9.63% 28.27% 7000001 BRONXCARE HOSPITAL CENTER $10,921.16 $8,274.22 1.0420 0.867440 26.67% $3,586.54 $524.86 $80.95 $289.71 9.63% 28.27% 7001002 BROOKDALE HOSPITAL MED CTR $10,716.16 $8,274.22 1.0269 0.503636 26.12% $1,625.05 $302.68 $59.61 $289.71 9.63% 28.27% 7001002 BROOKDALE HOSPITAL - INTERFAITH MEDICAL CENTER $10,486.91 $8,274.22 0.9309 0.336155 36.15% $2,274.06 $658.74 $111.28 $289.71 9.63% 28.27% 7001002 BROOKDALE HOSPITAL - KINGSBROOK JEWISH MED CTR $10,553.72 $8,274.22 1.0897 0.305240 17.05% $1,557.28 $0.00 $0.00 $289.71 9.63% 28.27% 7001003 BROOKLYN HOSPITAL CENTER $10,948.71 $8,274.22 1.0260 0.219430 28.97% $1,479.98 $787.46 $169.07 $289.71 9.63% 28.27% 0601000 BROOKS-TLC HOSPITAL SYSTEM $6,177.53 $8,274.22 0.7466 0.607536 0.00% $0.00 $286.59 $79.56 $213.08 9.63% 28.27% 4102004 BURDETT CARE CENTER $6,693.02 $8,274.22 0.8089 0.531061 0.00% $0.00 $0.00 $0.00 $213.08 9.63% 28.27% 4429000 CANTON-POTSDAM HOSPITAL $7,149.75 $8,274.22 0.8641 0.475229 0.00% $0.00 $310.55 $76.93 $213.08 9.63% 28.27% 5263000 CATSKILL REGIONAL MED CTR $7,766.18 $8,274.22 0.9386 0.272515 0.00% $0.00 $267.74 $66.65 $213.08 9.63% 28.27% 5401001 CAYUGA MEDICAL CENTER AT ITHACA $7,136.52 $8,274.22 0.8625 0.680338 0.00% $0.00 $380.34 $120.11 $213.08 9.63% 28.27% 0824000 CHENANGO MEMORIAL HOSPITAL $7,081.08 $8,274.22 0.8558 0.353335 0.00% $0.00 $209.93 $71.76 $213.08 9.63% 28.27% 4401000 CLAXTON-HEPBURN MED CTR $6,390.18 $8,274.22 0.7723 0.604771 0.00% $0.00 $474.05 $84.05 $213.08 9.63% 28.27% 3421000 CLIFTON SPRINGS HOSPITAL $5,330.25 $8,274.22 0.6442 0.357102 0.00% $0.00 $552.10 $125.44 $213.08 9.63% 28.27% 1001000 COLUMBIA MEMORIAL HOSPITAL $6,763.35 $8,274.22 0.8174 0.423282 0.00% $0.00 $446.88 $82.70 $213.08 9.63% 28.27% 7001009 CONEY ISLAND HOSPITAL $9,958.15 $8,274.22 1.0449 0.456979 15.18% $1,802.59 $3,026.78 $209.54 $289.71 9.63% 28.27% 5001000 CORNING HOSPITAL $6,987.58 $8,274.22 0.8445 0.375127 0.00% $0.00 $575.67 $180.66 $213.08 9.63% 28.27% 3301008 CROUSE HOSPITAL $7,660.79 $8,274.22 0.8930 0.498059 3.68% $147.17 $549.53 $84.11 $213.08 9.63% 28.27% 3101000 EASTERN NIAGARA HOSPITAL $6,721.15 $8,274.22 0.8123 0.419611 0.00% $0.00 $694.96 $150.60 $213.08 9.63% 28.27% 4601001 ELLIS HOSPITAL $7,024.52 $8,274.22 0.8070 0.277809 5.20% $137.23 $502.09 $95.58 $213.08 9.63% 28.27% 7003000 ELMHURST HOSPITAL CTR $10,953.15 $8,274.22 1.0855 0.464722 21.95% $1,216.08 $2,448.57 $190.60 $289.71 9.63% 28.27% 1401005 ERIE COUNTY MEDICAL CENTER $9,429.88 $8,274.22 0.9450 0.586222 20.60% $913.81 $958.43 $157.61 $213.08 9.63% 28.27% 3429000 F F THOMPSON HOSPITAL $5,946.68 $8,274.22 0.7187 0.463190 0.00% $0.00 $553.69 $125.75 $213.08 9.63% 28.27% 3202003 FAXTON-ST LUKES HEALTHCARE $7,254.31 $8,274.22 0.8654 0.305894 1.31% $11.24 $341.16 $73.12 $213.08 9.63% 28.27% 7003001 FLUSHING HOSPITAL MED CTR $9,613.25 $8,274.22 0.9877 0.584731 17.63% $1,406.95 $722.82 $75.07 $289.71 9.63% 28.27% 3402000 GENEVA GENERAL HOSPITAL $6,058.38 $8,274.22 0.7322 0.447055 0.00% $0.00 $767.49 $122.15 $213.08 9.63% 28.27% 2901000 GLEN COVE HOSPITAL $9,837.37 $8,274.22 1.0978 0.251058 8.30% $180.84 $1,096.09 $232.95 $289.71 9.63% 28.27% 5601000 GLENS FALLS HOSPITAL $6,485.33 $8,274.22 0.7838 0.305013 0.00% $0.00 $530.45 $132.25 $213.08 9.63% 28.27% 4329000 GOOD SAMARITAN / SUFFERN $8,624.22 $8,274.22 1.0423 0.152905 0.00% $0.00 $742.90 $199.85 $289.71 9.63% 28.27% 5154001 GOOD SAMARITAN HOSP MED CTR $8,797.03 $8,274.22 1.0031 0.202490 5.99% $222.16 $653.56 $140.05 $289.71 9.63% 28.27%

1 of 7 NYS DEPARTMENT OF HEALTH SCHEDULE OF WORKERS' COMPENSATION / NO FAULT (WCNF) INPATIENT CASE PAYMENT RATES - EFFECTIVE 1/1/2021 - 12/31/2021 (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11)

OPCERT HOSPITAL NAME **(PER DISCH)** **(PER DAY**) 1101000 GUTHRIE CORTLAND REGIONAL MED CTR $6,474.58 $8,274.22 0.7825 0.516389 0.00% $0.00 $259.33 $80.30 $213.08 9.63% 28.27% 7002009 HARLEM HOSPITAL CENTER $11,326.28 $8,274.22 1.0435 0.766118 31.18% $1,924.22 $5,067.95 $502.26 $289.71 9.63% 28.27% 5501000 HEALTHALLIANCE HOSP BROADWAY CAMPUS $7,367.70 $8,274.22 0.8512 0.164130 4.61% $292.71 $218.78 $51.93 $213.08 9.63% 28.27% 5501000 HEALTHALLIANCE HOSP MARYS AVE CAMPUS $7,367.70 $8,274.22 0.8512 0.164130 4.61% $292.71 $218.78 $51.93 $213.08 9.63% 28.27% 2701001 HIGHLAND HOSPITAL $7,830.28 $8,274.22 0.8445 0.464549 12.06% $365.71 $474.06 $108.24 $213.08 9.63% 28.27% 7002012 HOSPITAL FOR SPECIAL SURGERY $11,005.76 $8,274.22 1.1628 0.394987 14.39% $1,652.58 $2,739.67 $895.89 $289.71 9.63% 28.27% 5153000 HUNTINGTON HOSPITAL $9,311.23 $8,274.22 1.1024 0.260795 2.08% $117.91 $860.96 $212.91 $289.71 9.63% 28.27% 5022000 IRA DAVENPORT MEMORIAL HOSP $5,714.18 $8,274.22 0.6906 0.696766 0.00% $0.00 $1,077.10 $218.69 $213.08 9.63% 28.27% 7000002 JACOBI MEDICAL CENTER $11,690.95 $8,274.22 1.0650 0.592159 32.67% $3,141.38 $3,932.01 $175.81 $289.71 9.63% 28.27% 7003003 JAMAICA HOSPITAL MED CTR $10,770.89 $8,274.22 1.0987 0.504026 18.48% $1,520.77 $806.75 $63.11 $289.71 9.63% 28.27% 1401002 JOHN R. OISHEI CHILDRENS HOSPITAL $9,995.39 $8,274.22 0.9445 0.384712 27.90% $797.48 $1,471.83 $319.46 $213.08 9.63% 28.27% 5149000 JOHN T MATHER MEMORIAL HOSP $9,691.48 $8,274.22 1.0060 0.250937 16.43% $1,477.67 $674.93 $131.48 $289.71 9.63% 28.27% 0228000 JONES MEMORIAL HOSPITAL $5,910.28 $8,274.22 0.7143 0.400724 0.00% $0.00 $200.14 $48.10 $213.08 9.63% 28.27% 1401014 KALEIDA HEALTH $8,789.35 $8,274.22 0.9465 0.374025 12.23% $527.26 $881.37 $175.77 $213.08 9.63% 28.27% 1401014 KALEIDA HEALTH (MILLARD) $8,789.35 $8,274.22 0.9465 0.374025 12.23% $527.26 $881.37 $175.77 $213.08 9.63% 28.27% 1404000 KENMORE MERCY HOSPITAL $7,388.05 $8,274.22 0.8929 0.422852 0.00% $0.00 $612.93 $158.69 $213.08 9.63% 28.27% 7001016 KINGS COUNTY HOSPITAL CENTER $12,738.52 $8,274.22 1.1388 0.716528 35.19% $3,132.50 $2,692.54 $295.13 $289.71 9.63% 28.27% 7002017 LENOX HILL HOSPITAL $11,216.06 $8,274.22 1.1352 0.236866 19.41% $927.09 $2,153.23 $333.74 $289.71 9.63% 28.27% 7000008 LINCOLN MEDICAL & MENTAL HEALTH CTR $11,809.01 $8,274.22 1.0822 0.649616 31.88% $1,266.61 $3,077.48 $220.47 $289.71 9.63% 28.27% 5123000 LONG ISLAND COMMUNITY HOSPITAL $8,789.79 $8,274.22 1.0250 0.182531 3.64% $177.30 $519.11 $80.25 $289.71 9.63% 28.27% 7003004 LONG ISLAND JEWISH MED CTR $10,857.54 $8,274.22 1.1053 0.180448 18.72% $937.47 $985.41 $213.48 $289.71 9.63% 28.27% 7003004 LONG ISLAND JEWISH FOREST HILLS HOSPITAL $10,857.54 $8,274.22 1.1053 0.180448 18.72% $937.47 $985.41 $213.48 $289.71 9.63% 28.27% 7003004 LONG ISLAND JEWISH VALLEY STREAM HOSPITAL $10,857.54 $8,274.22 1.1053 0.180448 18.72% $937.47 $985.41 $213.48 $289.71 9.63% 28.27% 7001020 MAIMONIDES MEDICAL CENTER $12,363.48 $8,274.22 1.1890 0.256964 25.67% $1,481.63 $1,287.57 $237.45 $289.71 9.63% 28.27% 3824000 MARY IMOGENE BASSETT HOSP $7,544.00 $8,274.22 0.8075 0.496273 12.91% $534.84 $643.49 $158.83 $213.08 9.63% 28.27% 4402001 MASSENA HOSPITAL INC $7,049.64 $8,274.22 0.8520 0.773378 0.00% $0.00 $408.89 $118.91 $213.08 9.63% 28.27% 1401008 MERCY HOSPITAL OF BUFFALO $7,786.88 $8,274.22 0.9177 0.428124 2.55% $338.01 $737.20 $161.75 $213.08 9.63% 28.27% 2909000 MERCY MEDICAL CENTER $8,004.14 $8,274.22 0.9662 0.233859 0.12% $34.57 $618.44 $138.87 $289.71 9.63% 28.27% 7002021 METROPOLITAN HOSPITAL CENTER $11,893.95 $8,274.22 1.0733 0.902015 33.93% $1,566.26 $1,640.34 $331.97 $289.71 9.63% 28.27% 5957001 MID-HUDSON VALLEY DIV OF WESTCHESTER MED CTR $10,282.60 $8,274.22 1.0571 0.179907 17.56% $2,636.82 $2,679.01 $335.76 $289.71 9.63% 28.27% 7000006 MONTEFIORE MEDICAL CENTER $11,786.03 $8,274.22 1.0871 0.191600 31.03% $3,438.48 $1,334.33 $236.91 $289.71 9.63% 28.27% 5903001 MONTEFIORE MOUNT VERNON HOSP $8,819.25 $8,274.22 0.9206 0.312121 15.78% $927.13 $613.34 $158.48 $289.71 9.63% 28.27% 5904001 MONTEFIORE NEW ROCHELLE HOSP $9,426.77 $8,274.22 1.0165 0.331521 12.08% $859.44 $1,264.74 $209.20 $289.71 9.63% 28.27% 7002002 MOUNT SINAI BETH ISRAEL $11,370.16 $8,274.22 1.0810 0.240042 27.12% $1,908.53 $1,773.28 $315.35 $289.71 9.63% 28.27% 7001041 MOUNT SINAI BROOKLYN $9,019.73 $8,274.22 1.0901 0.141139 0.00% $0.00 $613.27 $89.95 $289.71 9.63% 28.27% 7002024 MOUNT SINAI HOSPITAL $11,334.55 $8,274.22 1.0755 0.246801 27.37% $1,966.20 $1,156.62 $168.22 $289.71 9.63% 28.27% 7002024 MOUNT SINAI HOSPITAL OF QUEENS $11,334.55 $8,274.22 1.0755 0.246801 27.37% $1,966.20 $1,156.62 $168.22 $289.71 9.63% 28.27% 7002032 MOUNT SINAI MORNINGSIDE $11,647.75 $8,274.22 1.1108 0.252068 26.73% $1,829.69 $1,488.51 $292.76 $289.71 9.63% 28.27% 3121001 MOUNT ST MARYS HOSPITAL AND HEALTH CTR $7,076.94 $8,274.22 0.8553 0.682940 0.00% $0.00 $646.47 $145.90 $213.08 9.63% 28.27% 2950002 NASSAU UNIV MED CTR $11,657.96 $8,274.22 1.1296 0.329983 24.73% $2,224.17 $410.30 $66.46 $289.71 9.63% 28.27% 2 of 7 NYS DEPARTMENT OF HEALTH SCHEDULE OF WORKERS' COMPENSATION / NO FAULT (WCNF) INPATIENT CASE PAYMENT RATES - EFFECTIVE 1/1/2021 - 12/31/2021 (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11)

OPCERT HOSPITAL NAME **(PER DISCH)** **(PER DAY**) 1701000 NATHAN LITTAUER HOSPITAL $6,421.62 $8,274.22 0.7761 0.377708 0.00% $0.00 $566.06 $175.69 $213.08 9.63% 28.27% 7002026 NEW YORK EYE AND EAR INFIRMARY OF MOUNT SINAI $11,219.93 $8,274.22 0.9978 0.216278 35.90% $225.02 $2,795.34 $1,191.45 $289.71 9.63% 28.27% 5901000 NEWYORK-PRESBYTERIAN HUDSON VALLEY HOSP $8,089.71 $8,274.22 0.9777 0.291043 0.00% $0.00 $854.53 $216.77 $289.71 9.63% 28.27% 5820000 NEWARK-WAYNE COMMUNITY HOSP $6,232.97 $8,274.22 0.7533 0.376052 0.00% $0.00 $294.70 $81.39 $213.08 9.63% 28.27% 3102000 NIAGARA FALLS MEMORIAL MED CTR $7,016.54 $8,274.22 0.8000 0.598101 6.00% $428.06 $499.28 $107.35 $213.08 9.63% 28.27% 2527000 NICHOLAS H NOYES MEMORIAL HOSPITAL $5,597.51 $8,274.22 0.6765 0.433386 0.00% $0.00 $310.98 $81.86 $213.08 9.63% 28.27% 7000024 NORTH CENTRAL BRONX HOSPITAL $10,598.39 $8,274.22 1.1180 0.651934 14.57% $1,919.16 $3,232.28 $248.97 $289.71 9.63% 28.27% 2951001 NORTH SHORE UNIVERSITY HOSP $10,868.92 $8,274.22 1.1289 0.193724 16.36% $843.42 $2,139.76 $262.82 $289.71 9.63% 28.27% 1327000 NORTHERN DUTCHESS HOSPITAL $8,026.82 $8,274.22 0.9701 0.420104 0.00% $0.00 $405.35 $113.07 $289.71 9.63% 28.27% 5920000 NORTHERN WESTCHESTER HOSP $8,452.12 $8,274.22 1.0215 0.407558 0.00% $0.00 $997.22 $289.69 $289.71 9.63% 28.27% 7001008 NY COMMUNITY HOSP OF BROOKLYN $9,566.11 $8,274.22 1.1386 0.459129 1.54% $148.64 $361.13 $68.42 $289.71 9.63% 28.27% 7003010 NEWYORK-PRESBYTERIAN/QUEENS $10,519.49 $8,274.22 1.0996 0.258763 15.62% $1,210.77 $695.30 $134.32 $289.71 9.63% 28.27% 7001021 NEWYORK-PRESBYTERIAN BROOKLYN METHODIST HOSP $10,522.70 $8,274.22 1.0669 0.291993 19.20% $1,180.96 $455.14 $92.19 $289.71 9.63% 28.27% 7002054 NEW YORK-PRESBYTERIAN HOSPITAL $12,219.33 $8,274.22 1.1654 0.266709 26.72% $2,371.04 $2,647.26 $419.31 $289.71 9.63% 28.27% 7002054 NY PRESBYTERIAN HOSPITAL (ALLEN) $12,219.33 $8,274.22 1.1654 0.266709 26.72% $2,371.04 $2,647.26 $419.31 $289.71 9.63% 28.27% 7002054 NY PRESBYTERIAN HOSPITAL (PRESBY) $12,219.33 $8,274.22 1.1654 0.266709 26.72% $2,371.04 $2,647.26 $419.31 $289.71 9.63% 28.27% 7002054 NY PRESBYTERIAN HOSPITAL/LOWER MANHATTAN HOSP $12,219.33 $8,274.22 1.1654 0.266709 26.72% $2,371.04 $2,647.26 $419.31 $289.71 9.63% 28.27% 7002054 NEW YORK-PRESBYTERIAN LAWRENCE HOSP $12,219.33 $8,274.22 1.1654 0.266709 26.72% $2,371.04 $2,647.26 $419.31 $289.71 9.63% 28.27% 4324000 MONTEFIORE NYACK HOSPITAL $8,116.18 $8,274.22 0.9809 0.218410 0.00% $0.00 $312.61 $68.51 $289.71 9.63% 28.27% 7002053 NYU LANGONE HOSPITALS $11,360.25 $8,274.22 1.0589 0.226182 29.66% $1,734.35 $2,975.94 $651.26 $289.71 9.63% 28.27% 7002053 NYU LANGONE ORTHOPEDIC HOSPITAL $11,360.25 $8,274.22 1.0589 0.226182 29.66% $1,734.35 $2,975.94 $651.26 $289.71 9.63% 28.27% 7002053 NYU LANGONE-BROOKLYN $11,360.25 $8,274.22 1.0589 0.226182 29.66% $1,734.35 $2,975.94 $651.26 $289.71 9.63% 28.27% 7002053 NYU WINTHROP HOSPITAL $11,360.25 $8,274.22 1.0589 0.226182 29.66% $1,734.35 $2,975.94 $651.26 $289.71 9.63% 28.27% 0401001 OLEAN GENERAL HOSPITAL $6,475.34 $8,274.22 0.7740 0.430533 1.11% $23.85 $289.00 $65.82 $213.08 9.63% 28.27% 2601001 ONEIDA HEALTH HOSPITAL $6,280.13 $8,274.22 0.7590 0.505785 0.00% $0.00 $365.90 $98.06 $213.08 9.63% 28.27% 3523000 GARNET HEALTH MEDICAL CTR $9,309.91 $8,274.22 1.0189 0.273537 10.43% $633.63 $839.08 $192.67 $289.71 9.63% 28.27% 3702000 OSWEGO HOSPITAL $5,991.36 $8,274.22 0.7241 0.535036 0.00% $0.00 $528.27 $155.56 $213.08 9.63% 28.27% 0301001 OUR LADY OF LOURDES MEMORIAL HOSP $6,703.92 $8,274.22 0.7835 0.393221 3.41% $31.69 $490.34 $122.58 $213.08 9.63% 28.27% 5155000 PECONIC BAY MED CTR $9,137.18 $8,274.22 1.0061 0.241077 9.76% $526.25 $586.83 $147.57 $289.71 9.63% 28.27% 5932000 PHELPS HOSPITAL $9,060.06 $8,274.22 1.0165 0.336401 7.72% $992.85 $1,397.78 $335.92 $289.71 9.63% 28.27% 2952005 PLAINVIEW HOSPITAL $9,922.71 $8,274.22 1.0918 0.291411 9.84% $853.11 $726.35 $155.24 $289.71 9.63% 28.27% 3950000 PUTNAM HOSPITAL $8,486.87 $8,274.22 1.0257 0.439243 0.00% $0.00 $680.18 $199.37 $289.71 9.63% 28.27% 7003007 QUEENS HOSPITAL CENTER $10,896.61 $8,274.22 1.1119 0.446847 18.44% $1,376.44 $2,809.61 $270.59 $289.71 9.63% 28.27% 7004010 RICHMOND UNIV MED CTR $9,440.41 $8,274.22 0.9692 0.356857 17.72% $1,155.98 $1,005.21 $122.14 $289.71 9.63% 28.27% 2701003 ROCHESTER GENERAL HOSPITAL $7,101.80 $8,274.22 0.7812 0.348994 9.87% $488.64 $1,199.54 $230.64 $213.08 9.63% 28.27% 3201002 ROME MEMORIAL HOSPITAL $6,724.46 $8,274.22 0.8127 0.399815 0.00% $0.00 $232.64 $44.89 $213.08 9.63% 28.27% 4102002 SAMARITAN HOSPITAL $6,593.73 $8,274.22 0.7969 0.424000 0.00% $0.00 $633.24 $107.85 $213.08 9.63% 28.27% 2201000 SAMARITAN MEDICAL CENTER $7,257.74 $8,274.22 0.8502 0.430041 3.17% $116.31 $737.59 $183.27 $213.08 9.63% 28.27% 4501000 SARATOGA HOSPITAL $6,734.39 $8,274.22 0.8139 0.237610 0.00% $0.00 $503.28 $112.90 $213.08 9.63% 28.27% 7000014 SBH HEALTH SYSTEM $11,729.28 $8,274.22 1.0478 0.362052 35.29% $1,936.53 $725.71 $142.83 $289.71 9.63% 28.27% 3 of 7 NYS DEPARTMENT OF HEALTH SCHEDULE OF WORKERS' COMPENSATION / NO FAULT (WCNF) INPATIENT CASE PAYMENT RATES - EFFECTIVE 1/1/2021 - 12/31/2021 (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11)

OPCERT HOSPITAL NAME **(PER DISCH)** **(PER DAY**) 1401013 SISTERS OF CHARITY HOSPITAL $7,710.13 $8,274.22 0.8766 0.436459 6.30% $314.73 $495.29 $116.01 $213.08 9.63% 28.27% 2950001 MOUNT SINAI SOUTH NASSAU $8,705.80 $8,274.22 0.9848 0.152142 6.84% $267.83 $897.29 $190.24 $289.71 9.63% 28.27% 5154000 SOUTH SHORE UNIVERSITY HOSP $9,579.66 $8,274.22 1.1018 0.225087 5.08% $415.58 $1,323.09 $314.41 $289.71 9.63% 28.27% 3529000 ST ANTHONY COMMUNITY HOSP $7,939.94 $8,274.22 0.9596 0.175370 0.00% $0.00 $641.32 $202.35 $289.71 9.63% 28.27% 5157003 ST CATHERINE OF SIENA HOSP $8,660.63 $8,274.22 1.0467 0.208550 0.00% $0.00 $505.18 $110.45 $289.71 9.63% 28.27% 5149001 ST CHARLES HOSPITAL $8,217.86 $8,274.22 0.9818 0.227482 1.16% $41.67 $455.95 $114.20 $289.71 9.63% 28.27% 3202002 ST ELIZABETH MEDICAL CENTER $7,111.25 $8,274.22 0.8095 0.286798 6.17% $407.70 $794.24 $100.02 $213.08 9.63% 28.27% 2953000 ST FRANCIS HOSP $8,547.15 $8,274.22 1.0301 0.177325 0.28% $5.99 $648.18 $132.64 $289.71 9.63% 28.27% 5002001 ST JAMES HOSPITAL $6,037.70 $8,274.22 0.7297 0.601919 0.00% $0.00 $1,134.43 $300.98 $213.08 9.63% 28.27% 7001024 ST JOHNS EPISCOPAL SO SHORE $10,583.38 $8,274.22 0.9985 0.312690 28.10% $1,218.30 $614.92 $103.54 $289.71 9.63% 28.27% 5907001 ST JOHNS RIVERSIDE HOSPITAL $8,684.36 $8,274.22 0.9910 0.291677 5.91% $299.07 $584.52 $66.92 $289.71 9.63% 28.27% 2952006 ST JOSEPH HOSPITAL $8,334.72 $8,274.22 1.0052 0.213232 0.21% $13.13 $532.66 $117.88 $289.71 9.63% 28.27% 3301003 ST JOSEPHS HOSP HLTH CTR $7,491.98 $8,274.22 0.8585 0.357449 5.47% $90.06 $848.87 $231.09 $213.08 9.63% 28.27% 5907002 ST JOSEPHS MEDICAL CENTER $8,637.60 $8,274.22 0.9217 0.505048 13.26% $444.06 $914.97 $173.49 $289.71 9.63% 28.27% 3522000 ST LUKES CORNWALL HOSPITAL $8,204.72 $8,274.22 0.9916 0.231466 0.00% $0.00 $496.55 $118.83 $289.71 9.63% 28.27% 2801001 ST MARYS HEALTHCARE $6,208.15 $8,274.22 0.7503 0.379047 0.00% $0.00 $190.87 $48.41 $213.08 9.63% 28.27% 0101004 ST PETERS HOSPITAL $6,930.03 $8,274.22 0.8208 0.290714 2.04% $87.88 $341.05 $81.44 $213.08 9.63% 28.27% 7004003 STATEN ISLAND UNIV HOSP $10,266.47 $8,274.22 1.0279 0.271005 20.71% $1,201.58 $879.93 $153.93 $289.71 9.63% 28.27% 5151001 STONY BROOK UNIVERSITY HOSPITAL $10,481.64 $8,274.22 1.0202 0.309879 24.17% $2,011.84 $1,495.18 $198.20 $289.71 9.63% 28.27% 5151001 STONY BROOK SOUTHAMPTON HOSPITAL $10,481.64 $8,274.22 1.0202 0.309879 24.17% $2,011.84 $1,495.18 $198.20 $289.71 9.63% 28.27% 5151001 \TONY BROOK EASTERN LONG ISLAND HOSPITAL $10,481.64 $8,274.22 1.0202 0.309879 24.17% $2,011.84 $1,495.18 $198.20 $289.71 9.63% 28.27% 2701005 STRONG MEMORIAL HOSPITAL $9,415.72 $8,274.22 0.8724 0.426075 30.44% $1,522.51 $1,007.75 $149.38 $213.08 9.63% 28.27% 2754001 THE UNITY HOSPITAL OF ROCHESTER $6,507.71 $8,274.22 0.7356 0.409849 6.92% $341.97 $704.24 $145.46 $213.08 9.63% 28.27% 0303001 UNITED HEALTH SERVICES HOSPITALS INC $7,383.25 $8,274.22 0.8286 0.419651 7.69% $339.35 $226.87 $44.37 $213.08 9.63% 28.27% 1801000 UNITED MEMORIAL MED CTR $6,810.18 $8,274.22 0.7940 0.386131 3.66% $75.06 $372.57 $120.74 $213.08 9.63% 28.27% 3301007 UNIV HOSP SUNY HLTH SCI CTR $9,546.16 $8,274.22 0.9373 0.251981 23.09% $1,027.32 $918.66 $191.65 $213.08 9.63% 28.27% 0901001 UNIV OF VERMONT HLTH-CHAMPLAIN VALLEY PHYS $7,269.73 $8,274.22 0.8786 0.347636 0.00% $0.00 $578.78 $120.27 $213.08 9.63% 28.27% 1624000 UNIV OF VERMONT HLTH-ALICE HYDE MEDICAL CENTER $6,575.52 $8,274.22 0.7947 0.530665 0.00% $0.00 $159.27 $41.20 $213.08 9.63% 28.27% 7001037 UNIVERSITY HOSPITAL OF BROOKLYN $11,399.92 $8,274.22 1.0399 0.669096 32.49% $5,143.79 $1,439.97 $230.20 $289.71 9.63% 28.27% 3301007 UPSTATE UNIV HOSPITAL AT COMM GEN $9,546.16 $8,274.22 0.9373 0.251981 23.09% $1,027.32 $918.66 $191.65 $213.08 9.63% 28.27% 1302001 VASSAR BROTHERS MED CTR $8,351.17 $8,274.22 1.0093 0.342098 0.00% $0.00 $514.80 $114.06 $289.71 9.63% 28.27% 5957001 WESTCHESTER MEDICAL CENTER $10,282.60 $8,274.22 1.0571 0.179907 17.56% $2,636.82 $2,679.01 $335.76 $289.71 9.63% 28.27% 0632000 WESTFIELD MEMORIAL HOSPITAL $6,083.21 $8,274.22 0.7352 0.000000 0.00% $0.00 $1,211.54 $364.55 $213.08 9.63% 28.27% 5902001 WHITE PLAINS HOSPITAL $8,430.60 $8,274.22 1.0189 0.239716 0.00% $0.00 $777.28 $187.98 $289.71 9.63% 28.27% 0602001 UPMC CHAUTAUQUA AT WCA $5,632.26 $8,274.22 0.6807 0.461295 0.00% $0.00 $314.75 $62.25 $213.08 9.63% 28.27% 7001045 WOODHULL MEDICAL & MENTAL HEALTH CTR $10,525.00 $8,274.22 1.0484 0.658941 21.33% $2,825.86 $5,733.16 $246.44 $289.71 9.63% 28.27% 7001035 WYCKOFF HEIGHTS MED CTR $10,249.18 $8,274.22 1.0200 0.405555 21.44% $1,440.19 $1,024.95 $138.14 $289.71 9.63% 28.27% 6027000 WYOMING CO COMMUNITY HOSP $6,623.51 $8,274.22 0.8005 0.839155 0.00% $0.00 $409.93 $97.93 $213.08 9.63% 28.27%

4 of 7 NYS DEPARTMENT OF HEALTH SCHEDULE OF WORKERS' COMPENSATION / NO FAULT (WCNF) INPATIENT EXEMPT UNIT RATES - EFFECTIVE 1/1/2021 - 12/31/2021 (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17)

SPECIALTY HOSPITAL PSYCHIATRIC PSYCHIATRIC-DD CHEMICAL DEPENDENCY REHAB CRITICAL ACCESS HOSPITAL MEDICAL REHABILITATION DETOX WCNF SURCHARGES

SPECIALTY SPECIALTY ACUTE, LONG- ACUTE, LONG- DETOX - DETOX - WCNF WCNF TERM CARE AND TERM CARE AND PSYCHIATRIC PSYCHIATRIC CHEMICAL CHEMICAL CRITICAL CRITICAL MEDICALLY MEDICALLY PUBLIC ADDITIONAL CHILDREN'S CHILDREN'S PSYCHIATRIC NON- ADULT DUAL DEPENDENCY DEPENDENCY ACCESS ACCESS MEDICAL MEDICAL MANAGED SUPERVISED GOODS PUBLIC HOSPITAL HOSPITAL OPERATING OPERATING PSYCHIATRIC PSYCHIATRIC DIAGNOSIS REHAB REHAB HOSPITAL HOSPITAL REHAB REHAB ALC WITHDRAWAL WITHDRAWAL POOL GOODS POOL BILLING RATE ALC PER DIEM BILLING RATE BILLING RATE ECT PAYMENT ALC PER DIEM BILLING RATE BILLING RATE ALC PER DIEM BILLING RATE ALC PER DIEM BILLING RATE PER DIEM BILLING RATE BILLING RATE SURCHARGE SURCHARGE

OPCERT HOSPITAL NAME 1623001 ADIRONDACK MEDICAL CENTER $0.00 $0.00 $919.68 $36.46 $231.32 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 0101000 ALBANY MEDICAL CTR HOSP $0.00 $0.00 $788.64 $82.91 $244.16 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $1,244.02 $210.58 Published Separately 9.63% 28.27% 0101000 ALBANY MEDICAL CTR SO CLINICAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 0101003 ALBANY MEMORIAL HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 0701000 ARNOT OGDEN MEDICAL CTR $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 0701000 ARNOT OGDEN - ST JOSEPHS HOSP / ELMIRA $0.00 $0.00 $829.97 $245.01 $208.75 $210.58 $0.00 $558.56 $210.58 $0.00 $0.00 $1,389.13 $210.58 Published Separately 9.63% 28.27% 0501000 AUBURN COMMUNITY HOSPITAL $0.00 $0.00 $963.25 $41.19 $242.28 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 3801000 AURELIA OSBORN FOX MEM HOSP $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 7002001 BELLEVUE HOSPITAL CENTER $0.00 $0.00 $844.35 $243.59 $287.55 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $1,440.02 $286.32 Published Separately 9.63% 28.27% 1427000 BERTRAND CHAFFEE HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 5957000 BLYTHEDALE CHILDRENS HOSP $2,073.12 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 3535001 BON SECOURS COMMUNITY HOSP $0.00 $0.00 $757.05 $85.54 $257.82 $210.58 $0.00 $696.72 $210.58 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 7000001 BRONXCARE HOSPITAL CTR $0.00 $0.00 $878.59 $279.83 $299.21 $286.32 $0.00 $805.33 $286.32 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 7001002 BROOKDALE HOSPITAL MED CTR $0.00 $0.00 $864.40 $133.65 $294.38 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 7001002 BROOKDALE HOSPITAL - INTERFAITH MEDICAL CENTER $0.00 $0.00 $869.51 $53.18 $296.12 $286.32 $0.00 $613.46 $286.32 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 7001002 BROOKDALE HOSPITAL - KINGSBROOK JEWISH MED CTR $0.00 $0.00 $947.40 $272.48 $322.64 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $1,466.91 $286.32 Published Separately 9.63% 28.27% 7001003 BROOKLYN HOSPITAL CENTER $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1,647.60 $286.32 Published Separately 9.63% 28.27% 0601000 BROOKS-TLC HOSPITAL SYSTEM INC $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 7000011 CALVARY HOSPITAL $1,297.05 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 4429000 CANTON-POTSDAM HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $496.31 $210.58 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 2238700 CARTHAGE AREA HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2,545.53 $210.58 $0.00 $0.00 Published Separately 9.63% 28.27% 5263000 CATSKILL REGIONAL MED CTR $0.00 $0.00 $1,022.13 $46.15 $257.09 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 5401001 CAYUGA MEDICAL CENTER AT ITHACA $0.00 $0.00 $984.48 $53.06 $247.62 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $1,200.59 $210.58 Published Separately 9.63% 28.27% 0824000 CHENANGO MEMORIAL HOSP $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 4401000 CLAXTON-HEPBURN MED CTR $0.00 $0.00 $859.35 $30.81 $216.15 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 3421000 CLIFTON SPRINGS HOSPITAL $0.00 $0.00 $776.23 $35.31 $195.24 $210.58 $0.00 $360.31 $210.58 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 4458701 CLIFTON-FINE HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4,044.91 $210.58 $0.00 $0.00 Published Separately 9.63% 28.27% 4720700 COBLESKILL REGIONAL HOSP $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2,396.61 $210.58 $0.00 $0.00 Published Separately 9.63% 28.27% 1001000 COLUMBIA MEMORIAL HOSPITAL $0.00 $0.00 $916.67 $24.86 $230.56 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 2625700 COMMUNITY MEMORIAL HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2,710.08 $210.58 $0.00 $0.00 Published Separately 9.63% 28.27% 7001009 CONEY ISLAND HOSPITAL $0.00 $0.00 $834.20 $207.16 $284.09 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $1,849.10 $286.32 Published Separately 9.63% 28.27% 5001000 CORNING HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 3301008 CROUSE HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $498.26 $210.58 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 0226700 CUBA MEMORIAL HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5,426.65 $210.58 $0.00 $0.00 Published Separately 9.63% 28.27% 1229700 DELAWARE VALLEY HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1,313.44 $210.58 $1,313.44 $210.58 $0.00 $0.00 Published Separately 9.63% 28.27% 3101000 EASTERN NIAGARA HOSPITAL $0.00 $0.00 $733.64 $0.00 $227.13 $210.58 $0.00 $416.29 $210.58 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 5526700 ELLENVILLE REGIONAL HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2,215.31 $210.58 $0.00 $0.00 Published Separately 9.63% 28.27% 4601001 ELLIS HOSPITAL $0.00 $0.00 $762.50 $54.20 $236.07 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 7003000 ELMHURST HOSPITAL CTR $0.00 $0.00 $888.08 $442.48 $302.44 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $1,786.22 $286.32 Published Separately 9.63% 28.27% 1401005 ERIE COUNTY MEDICAL CENTER $0.00 $0.00 $836.66 $116.15 $259.03 $210.58 $0.00 $369.25 $210.58 $0.00 $0.00 $1,269.53 $210.58 Published Separately 9.63% 28.27% 3429000 F F THOMPSON HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 3202003 FAXTON-ST LUKES HEALTHCARE $0.00 $0.00 $928.17 $26.39 $233.45 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $1,225.99 $210.58 Published Separately 9.63% 28.27% 7003001 FLUSHING HOSPITAL $0.00 $0.00 $852.51 $219.30 $290.33 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 3523000 GARNET HLTH MED CTR $0.00 $0.00 $821.65 $192.09 $279.82 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $1,305.72 $210.58 Published Separately 9.63% 28.27% 5263700 GARNET HLTH MED CTR-CATSKILLS-G HERMANN SITE $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2,918.38 $210.58 $0.00 $0.00 Published Separately 9.63% 28.27% 3402000 GENEVA GENERAL HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 2901000 GLEN COVE HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1,329.88 $286.32 Published Separately 9.63% 28.27% 5601000 GLENS FALLS HOSPITAL $0.00 $0.00 $910.30 $80.14 $228.96 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 4329000 GOOD SAMARITAN / SUFFERN $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $764.53 $286.32 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 5154001 GOOD SAMARITAN HOSP MED CTR $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 4423701 GOUVERNEUR HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2,232.26 $210.58 $0.00 $0.00 Published Separately 9.63% 28.27% 1101000 GUTHRIE CORTLAND REGIONAL MED CTR $0.00 $0.00 $897.11 $32.66 $225.64 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 7002009 HARLEM HOSPITAL CENTER $0.00 $0.00 $867.12 $456.11 $295.30 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 5501000 HEALTHALLIANCE HOSP MARYS AVE CAMPUS $0.00 $0.00 $974.87 $0.00 $245.20 $210.58 $0.00 $373.75 $210.58 $0.00 $0.00 $1,133.53 $210.58 Published Separately 9.63% 28.27% 4322000 HELEN HAYES HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1,553.26 $286.32 Published Separately 9.63% 28.27% 7002050 HENRY J CARTER SPECIALTY HOSPITAL $1,207.51 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 2701001 HIGHLAND HOSP OF ROCHESTER $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 7002012 HOSPITAL FOR SPECIAL SURGERY $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 5153000 HUNTINGTON HOSPITAL $0.00 $0.00 $872.98 $119.03 $297.30 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 5022000 IRA DAVENPORT MEMORIAL HOSP $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 7000002 JACOBI MEDICAL CENTER $0.00 $0.00 $915.31 $212.06 $311.71 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $1,678.16 $286.32 Published Separately 9.63% 28.27% 7003003 JAMAICA HOSPITAL $0.00 $0.00 $927.52 $285.28 $315.87 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $1,551.87 $286.32 Published Separately 9.63% 28.27% 1401002 JOHN R. OISHEI CHILDRENS HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27%

Page 5 of 7 NYS DEPARTMENT OF HEALTH SCHEDULE OF WORKERS' COMPENSATION / NO FAULT (WCNF) INPATIENT EXEMPT UNIT RATES - EFFECTIVE 1/1/2021 - 12/31/2021 (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17)

SPECIALTY HOSPITAL PSYCHIATRIC PSYCHIATRIC-DD CHEMICAL DEPENDENCY REHAB CRITICAL ACCESS HOSPITAL MEDICAL REHABILITATION DETOX WCNF SURCHARGES

OPCERT HOSPITAL NAME 5149000 JOHN T MATHER MEMORIAL HOSP $0.00 $0.00 $848.72 $60.68 $289.04 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 0228000 JONES MEMORIAL HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 1401014 KALEIDA HEALTH $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1,064.64 $210.58 Published Separately 9.63% 28.27% 1404000 KENMORE MERCY HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $872.24 $210.58 Published Separately 9.63% 28.27% 7001016 KINGS COUNTY HOSPITAL CENTER $0.00 $0.00 $837.08 $472.89 $285.07 $286.32 $1,529.66 $0.00 $0.00 $0.00 $0.00 $1,929.25 $286.32 Published Separately 9.63% 28.27% 7002017 LENOX HILL HOSPITAL $0.00 $0.00 $858.70 $434.44 $292.44 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 2424700 LEWIS COUNTY GENERAL HOSP $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2,828.65 $210.58 $0.00 $0.00 Published Separately 9.63% 28.27% 7000008 LINCOLN MEDICAL & MENTAL HEALTH CTR $0.00 $0.00 $851.61 $393.18 $290.02 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 2129700 LITTLE FALLS HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1,862.70 $210.58 $0.00 $0.00 Published Separately 9.63% 28.27% 5123000 LONG ISLAND COMMUNITY HOSPITAL $0.00 $0.00 $840.22 $77.86 $286.14 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 7003004 LONG ISLAND JEWISH $0.00 $0.00 $897.90 $219.15 $305.78 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 7003004 LONG ISLAND JEWISH VALLEY STREAM HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 7001020 MAIMONIDES MEDICAL CENTER $0.00 $0.00 $982.22 $116.95 $334.50 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 1226701 MARGARETVILLE HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2,325.39 $210.58 $0.00 $0.00 Published Separately 9.63% 28.27% 3824000 MARY IMOGENE BASSETT HOSP $0.00 $0.00 $842.15 $54.72 $211.82 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 4402001 MASSENA HOSPITAL INC $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 3622700 MEDINA MEMORIAL HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2,097.64 $210.58 $919.29 $210.58 Published Separately 9.63% 28.27% 7002020 MEMORIAL HOSP FOR CANCER $3,853.27 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 1401008 MERCY HOSPITAL OF BUFFALO $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1,164.42 $210.58 Published Separately 9.63% 28.27% 2909000 MERCY MEDICAL CENTER $0.00 $0.00 $838.90 $47.12 $285.69 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $1,087.89 $286.32 Published Separately 9.63% 28.27% 7002021 METROPOLITAN HOSPITAL CENTER $0.00 $0.00 $842.53 $417.09 $286.93 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $1,432.81 $286.32 Published Separately 9.63% 28.27% 5957001 MID-HUDSON VALLEY DIV OF WESTCHESTER MED CTR $0.00 $0.00 $712.90 $106.94 $242.78 $210.58 $0.00 $402.69 $210.58 $0.00 $0.00 $1,433.60 $210.58 Published Separately 9.63% 28.27% 2701006 MONROE COMMUNITY HOSPITAL $2,588.96 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 7000006 MONTEFIORE MEDICAL CENTER $0.00 $0.00 $926.53 $767.53 $315.53 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $2,275.41 $286.32 Published Separately 9.63% 28.27% 5903001 MONTEFIORE MOUNT VERNON HOSP $0.00 $0.00 $870.50 $13.74 $296.46 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 5904001 MONTEFIORE NEW ROCHELLE HOSP $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 4324000 MONTEFIORE NYACK HOSPITAL $0.00 $0.00 $804.49 $35.77 $273.98 $286.32 $0.00 $534.93 $286.32 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 7002002 MOUNT SINAI BETH ISRAEL $0.00 $0.00 $932.72 $387.47 $317.64 $286.32 $0.00 $823.13 $286.32 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 7001041 MOUNT SINAI BROOKLYN $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 7002024 MOUNT SINAI HOSP OF QUEENS $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 7002024 MOUNT SINAI HOSPITAL $0.00 $0.00 $924.63 $216.31 $314.89 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $1,684.89 $286.32 Published Separately 9.63% 28.27% 7002032 MOUNT SINAI MORNINGSIDE $0.00 $0.00 $1,005.08 $252.47 $342.29 $286.32 $0.00 $763.35 $286.32 $0.00 $0.00 $1,715.67 $286.32 Published Separately 9.63% 28.27% 3121001 MOUNT ST MARYS HOSPITAL AND HEALTH CTR $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $429.50 $210.58 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 2950002 NASSAU UNIV MED CTR $0.00 $0.00 $934.37 $57.51 $318.20 $286.32 $0.00 $750.60 $286.32 $0.00 $0.00 $1,505.06 $286.32 Published Separately 9.63% 28.27% 1701000 NATHAN LITTAUER HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 7002026 NEW YORK EYE AND EAR INFIRMARY OF MOUNT SINAI $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 7002054 NEW YORK-PRESBYTERIAN HOSPITAL $0.00 $0.00 $922.81 $305.66 $314.27 $286.32 $0.00 $908.79 $286.32 $0.00 $0.00 $1,933.19 $286.32 Published Separately 9.63% 28.27% 5901000 NEW YORK-PRESBYTERIAN HUDSON VALLEY HOSP $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 5820000 NEWARK-WAYNE COMMUNITY HOSP $0.00 $0.00 $864.05 $88.47 $217.33 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 7001021 NEWYORK-PRESBYTERIAN BROOKLYN METHODIST HOSP $0.00 $0.00 $881.48 $587.18 $300.19 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $1,077.42 $286.32 Published Separately 9.63% 28.27% 7003010 NEWYORK-PRESBYTERIAN/QUEENS $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 3102000 NIAGARA FALLS MEMORIAL MED CTR $0.00 $0.00 $705.05 $109.58 $218.28 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 2527000 NICHOLAS H NOYES MEMORIAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 7000024 NORTH CENTRAL BRONX HOSPITAL $0.00 $0.00 $941.30 $215.20 $320.56 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 2951001 NORTH SHORE UNIVERSITY HOSP $0.00 $0.00 $958.54 $816.60 $326.44 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 1327000 NORTHERN DUTCHESS HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1,438.72 $210.58 Published Separately 9.63% 28.27% 5920000 NORTHERN WESTCHESTER HOSP $0.00 $0.00 $834.69 $209.83 $284.26 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 7001008 NY COMMUNITY HOSP OF BROOKLYN $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 7002053 NYU LANGONE HOSPITALS $0.00 $0.00 $882.96 $703.08 $300.70 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $1,854.30 $286.32 Published Separately 9.63% 28.27% 7002053 NYU LANGONE-BROOKLYN $0.00 $0.00 $839.31 $305.37 $285.83 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $1,169.62 $286.32 Published Separately 9.63% 28.27% 7002053 NYU WINTHROP HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 1254700 O'CONNOR HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2,830.72 $210.58 $0.00 $0.00 Published Separately 9.63% 28.27% 0401001 OLEAN GENERAL HOSPITAL $0.00 $0.00 $858.12 $25.13 $215.84 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 2601001 ONEIDA HEALTHCARE $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 3702000 OSWEGO HOSPITAL $0.00 $0.00 $919.35 $28.79 $231.23 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 0301001 OUR LADY OF LOURDES MEMORIAL HOSP $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 5155000 PECONIC BAY MED CTR $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 5932000 PHELPS HOSPITAL $0.00 $0.00 $825.12 $156.76 $281.00 $286.32 $0.00 $752.95 $286.32 $0.00 $0.00 $1,705.53 $286.32 Published Separately 9.63% 28.27% 2952005 PLAINVIEW HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 3950000 PUTNAM HOSPITAL CENTER $0.00 $0.00 $846.33 $37.38 $288.22 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 7003007 QUEENS HOSPITAL CENTER $0.00 $0.00 $940.47 $409.74 $320.28 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 7004010 RICHMOND UNIV MED CTR $0.00 $0.00 $824.95 $42.98 $280.94 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 2221700 RIVER HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2,955.86 $210.58 $0.00 $0.00 Published Separately 9.63% 28.27%

Page 6 of 7 NYS DEPARTMENT OF HEALTH SCHEDULE OF WORKERS' COMPENSATION / NO FAULT (WCNF) INPATIENT EXEMPT UNIT RATES - EFFECTIVE 1/1/2021 - 12/31/2021 (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17)

SPECIALTY HOSPITAL PSYCHIATRIC PSYCHIATRIC-DD CHEMICAL DEPENDENCY REHAB CRITICAL ACCESS HOSPITAL MEDICAL REHABILITATION DETOX WCNF SURCHARGES

OPCERT HOSPITAL NAME 2701003 ROCHESTER GENERAL HOSPITAL $0.00 $0.00 $770.67 $172.28 $238.60 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $1,184.84 $210.58 Published Separately 9.63% 28.27% 7002031 ROCKEFELLER UNIVERSITY $2,752.58 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 3201002 ROME MEMORIAL HOSPITAL $0.00 $0.00 $861.03 $11.80 $216.57 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 1401010 ROSWELL PARK CANCER INSTITUTE $3,162.43 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 4102002 SAMARITAN HOSPITAL $0.00 $0.00 $721.66 $44.98 $223.42 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 4102002 SAMARITAN HOSPITAL - ST MARY'S CAMPUS $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.83 $210.58 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 2201000 SAMARITAN MEDICAL CENTER $0.00 $0.00 $943.37 $88.28 $237.28 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $1,370.39 $210.58 Published Separately 9.63% 28.27% 4501000 SARATOGA HOSPITAL $0.00 $0.00 $755.33 $43.09 $233.85 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 7000014 SBH HEALTH SYSTEM $0.00 $0.00 $847.15 $101.05 $288.50 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 4823700 SCHUYLER HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1,845.24 $210.58 $0.00 $0.00 Published Separately 9.63% 28.27% 1401013 SISTERS OF CHARITY HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 6120700 SOLDIERS AND SAILORS MEM HOSP $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2,098.90 $210.58 $0.00 $0.00 Published Separately 9.63% 28.27% 2950001 SOUTH NASSAU COMMUNITIES $0.00 $0.00 $794.76 $120.00 $270.66 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 5154000 SOUTHSIDE HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 3529000 ST ANTHONY COMMUNITY HOSP $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 5157003 ST CATHERINE OF SIENA HOSP $0.00 $0.00 $872.89 $59.35 $297.27 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 5149001 ST CHARLES HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $330.30 $286.32 $0.00 $0.00 $985.17 $286.32 Published Separately 9.63% 28.27% 3202002 ST ELIZABETH MEDICAL CENTER $0.00 $0.00 $937.45 $33.08 $235.79 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 2953000 ST FRANCIS HOSP $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 5002001 ST JAMES HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 7001024 ST JOHNS EPISCOPAL SO SHORE $0.00 $0.00 $984.95 $183.94 $335.43 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 5907001 ST JOHNS RIVERSIDE HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $569.34 $286.32 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 2952006 ST JOSEPH HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 3301003 ST JOSEPHS HOSP HLTH CTR $0.00 $0.00 $801.98 $173.58 $248.29 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 5907002 ST JOSEPHS MEDICAL CENTER $0.00 $0.00 $845.34 $89.76 $287.88 $286.32 $0.00 $456.35 $286.32 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 3522000 ST LUKES CORNWALL HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 2801001 ST MARYS HEALTHCARE $0.00 $0.00 $844.16 $14.53 $212.32 $210.58 $0.00 $487.29 $210.58 $0.00 $0.00 $1,284.22 $210.58 Published Separately 9.63% 28.27% 0101004 ST PETERS HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $488.40 $210.58 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 7004003 STATEN ISLAND UNIV HOSP $0.00 $0.00 $839.81 $320.94 $286.00 $286.32 $0.00 $1,047.37 $286.32 $0.00 $0.00 $1,883.13 $286.32 Published Separately 9.63% 28.27% 5151001 STONY BROOK UNIVERSITY HOSPITAL $0.00 $0.00 $846.33 $317.69 $288.22 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 5151001 STONY BROOK EASTERN LONG ISLAND HOSPITAL $0.00 $0.00 $817.20 $180.43 $278.30 $286.32 $0.00 $789.41 $286.32 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 5151001 STONY BROOK SOUTHAMPTON HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 2701005 STRONG MEMORIAL HOSPITAL $0.00 $0.00 $816.51 $103.02 $252.79 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $1,403.07 $210.58 Published Separately 9.63% 28.27% 4601004 SUNNYVIEW HOSP AND REHAB $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1,179.96 $210.58 Published Separately 9.63% 28.27% 2754001 THE UNITY HOSPITAL OF ROCHESTER $0.00 $0.00 $703.60 $47.33 $217.83 $210.58 $0.00 $437.68 $210.58 $0.00 $0.00 $1,307.84 $210.58 Published Separately 9.63% 28.27% 0303001 UNITED HEALTH SERVICES HOSPITALS INC $0.00 $0.00 $770.03 $19.26 $238.40 $210.58 $0.00 $503.39 $210.58 $0.00 $0.00 $1,229.26 $210.58 Published Separately 9.63% 28.27% 1801000 UNITED MEMORIAL MED CTR $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $418.68 $210.58 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 3301007 UNIV HOSP SUNY HLTH SCI CTR $0.00 $0.00 $833.57 $199.48 $258.07 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $1,517.59 $210.58 Published Separately 9.63% 28.27% 1624000 UNIV OF VERMONT HLTH - ALICE HYDE MEDICAL CENTER $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 0901001 UNIV OF VERMONT HLTH - CHAMPLAIN VALLEY PHYS $0.00 $0.00 $938.79 $49.52 $236.12 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 1552701 UNIV OF VERMONT HLTH - ELIZABETHTOWN COMM HOSP $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2,520.16 $210.58 $0.00 $0.00 Published Separately 9.63% 28.27% 7001037 UNIVERSITY HOSPITAL OF BROOKLYN $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2,447.40 $286.32 Published Separately 9.63% 28.27% 0602001 UPMC CHAUTAUQUA AT WCA $0.00 $0.00 $828.52 $13.78 $208.39 $210.58 $0.00 $407.61 $210.58 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 3301007 UPSTATE UNIV HOSPITAL AT COMM GEN $0.00 $0.00 $840.83 $50.89 $260.32 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $1,161.45 $210.58 Published Separately 9.63% 28.27% 1302001 VASSAR BROTHERS MED CTR $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 5957001 WESTCHESTER MEDICAL CENTER $0.00 $0.00 $940.06 $228.89 $320.14 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $1,856.21 $286.32 Published Separately 9.63% 28.27% 0632000 WESTFIELD MEMORIAL HOSP $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 5902001 WHITE PLAINS HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 5902002 WINIFRED MASTERSON BURKE REHAB HOSPITAL $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1,407.50 $286.32 Published Separately 9.63% 28.27% 7001045 WOODHULL MEDICAL & MENTAL HEALTH CTR $0.00 $0.00 $839.56 $180.65 $285.92 $286.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 7001035 WYCKOFF HEIGHTS MED CTR $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27% 6027000 WYOMING CO COMMUNITY HOSP $0.00 $0.00 $866.84 $33.96 $218.03 $210.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Published Separately 9.63% 28.27%

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