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Florida Workers’ Compensation

Health Care Provider Reimbursement Manual

Rule 69L-7.020, F.A.C.

20165 Edition

Florida Workers’ Compensation Health Care Provider Reimbursement Manual

2016 Edition Effective Date: ___________

TABLE OF CONTENTS

CHAPTER 1 INTRODUCTION AND OVERVIEW .............................................. 6

Overview ----------------------------------------------------------------------------------------------------- 6

E-Alert System ---------------------------------------------------------------------------------------------- 6

How to Obtain or Purchase Manuals ------------------------------------------------------------------- 7

Characteristics of the Manual ---------------------------------------------------------------------------- 8

Identifying New Material --------------------------------------------------------------------------------- 9

Authorization ----------------------------------------------------------------------------------------------- 10

Health Care Provider Use of Codes, Descriptions and Modifiers -------------------------------- 12

Carrier Use of Codes, Descriptions, and References ------------------------------------------------ 12

General Reimbursement Information ----------------------------------------------------------------- 15

Co-Payments ----------------------------------------------------------------------------------------------- 15

Exceptions to Service Limitations ---------------------------------------------------------------------- 18

Disputing Reimbursement ------------------------------------------------------------------------------- 19

Classification of an Injured Worker’s Status -------------------------------------------------------- 20

CHAPTER 2 MEDICAL SERVICES ................................................................... 22

Anesthesia Services ---------------------------------------------------------------------------------------- 22

Biofeedback Services -------------------------------------------------------------------------------------- 27

Dental Services --------------------------------------------------------------------------------------------- 28

Electrodiagnostic Medicine ------------------------------------------------------------------------------ 29

Evaluation and Management Services ----------------------------------------------------------------- 30

Functional Capacity Evaluations (FCE) -------------------------------------------------------------- 31

Home Health Agency Services -------------------------------------------------------------------------- 32

Independent Medical Examinations ------------------------------------------------------------------- 33

Failure to Appear for IME ------------------------------------------------------------------------------ 34



Consensus Independent Medical Examination ------------------------------------------------------ 34

Medications ------------------------------------------------------------------------------------------------- 34

Medical Supplies and Home Medical Equipment --------------------------------------------------- 39

Ophthalmologic Services --------------------------------------------------------------------------------- 40

Permanent Impairment Ratings (PIR) ---------------------------------------------------------------- 40

Psychiatric and Psychological Services ---------------------------------------------------------------- 41

Radiology---------------------------------------------------------------------------------------------------- 43

Thermography --------------------------------------------------------------------------------------------- 44

Physical Medicine and Rehabilitation Services ------------------------------------------------------ 45

Acupuncture ------------------------------------------------------------------------------------------------ 51

Orthotics and Prosthetics -------------------------------------------------------------------------------- 52

Tests and Measurements --------------------------------------------------------------------------------- 53

Physical Reconditioning Services ----------------------------------------------------------------------- 54

Physical Reconditioning Program ---------------------------------------------------------------------- 55

Chapter 2 Medical Services, continued ---------------------------------------------------------------- 56

Surgical Services ------------------------------------------------------------------------------------------- 59

CHAPTER 3 MAXIMUM REIMBURSEMENT ALLOWANCES ........................ 68

CHAPTER 4 BILLING INSTRUCTIONS AND FORMS ................................... 410

Bill Submission/Filing and Reporting Requirements --------------------------------------------- 410

Form DFS-F5-DWC-9 (CMS-1500) ------------------------------------------------------------------ 412

Form DFS-F5-DWC-10--------------------------------------------------------------------------------- 414

APPENDIX A: WORKERS’ COMPENSATION UNIQUE PROCEDURE CODES .......................................................................................................................... 415

APPENDIX B OFFICIAL SOURCE FOR REFERENCES ............................... 416

APPENDIX C MEDICARE PAYMENT LOCALITIES (COUNTIES) ................ 419



APPENDIX D FORMS ..................................................................................... 420

APPENDIX E DEFINITIONS ............................................................................ 421



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Chapter 1 Introduction and Overview

Overview

Changes to the Manual Notification of approved changes to the Manual will be sent via the Division of Workers’ Compensation E-Alert system. An update can be an approved change, addition, or correction to the policies. Updates Reimbursement Manuals will be available under the ‘Reimbursement Manuals’ section on the DWC web site. It is important that health care providers (HCPs) and carriers read the updated material in the Manual. information. Both parties have a responsibility for performing specific duties when billing, reporting, or reimbursing medical services rendered to injured workers.

E-Alert System The Division of Workers’ Compensation has an electronic alert system to

notify subscribers of upcoming news impacting the Workers’ Compensation industry, dates of public meetings and workshops. To subscribe to the “E-Alerts”, please go to the DWC web site to register for our mailing list. Look for the box entitled “Register”. Once registered completed, you will shall receive E-Alerts whenever they are provided by the Division.

Explanation of the

Update Log The health care provider and carrier can use the update log to determine if

all the updates to the Manual have been received. Update No. is the year that the update was issued. Effective Date is the date that the update is effective.

Instructions File the Manual as instructed. You may wish to retain the prior Manual

for billing services prior to the effective date of this Manual or for comparing policy changes.

UPDATE NO. EFFECTIVE DATE 2015 TBD

http://www.myfloridacfo.com/Division/WC/




Chapter 1 Introduction and Overview, continued Overview, continued

Preface This Chapter introduces the format used for the Florida Workers’

Compensation Provider Reimbursement Manual and tells the reader how to use the Manual.

Background There are 3 types of Workers’ Compensation Manuals:

• Florida Workers’ Compensation Reimbursement Manual for

Ambulatory Surgical Centers, [ASC Manual], Rule 69L-7.100, Florida Administrative Code (F.A.C.);

• Florida Workers’ Compensation Health Care Provider Reimbursement Manual, [HCP RM],Rule 69L-7.020, F.A.C.; and

• Florida Workers’ Compensation Reimbursement Manual for Hospitals, [Hospital Manual], Rule 69L-7.501, F.A.C.

Other Applicable Rules

In addition to this Manual, the Florida Workers’ Compensation Health Care Provider Reimbursement Manual, Rule 69L-7.020, F.A.C., also recognizes the following resource:

1. The Workers’ Compensation Medical Reimbursement and Utilization Review, Rule Chapter 69L-7, F.A.C., and

2. Selected Materials Incorporated by Reference For Use In Workers’

Compensation, Rule Chapter 69L-8, F.A.C.

How to Obtain or Purchase Manuals

Thise effective Manual can be obtained free of charge on the DWC website, under the ‘Reimbursement Manuals’ section or Provider tab, then click on Reimbursement Manuals. The Manual may also be purchased in hard copy from the Department of Financial Services, Document Processing Section, at 200 East Gaines Street, Tallahassee, Florida 32399-0311.




Chapter 1 Introduction and Overview, continued

Characteristics of the Manual Format The format styles used in the Manual represent a concise and consistent

way of displaying complex, technical material. Information Block Information Blocks replace the traditional paragraph and may consist of

one or more paragraphs about a portion of a subject. Blocks are separated by horizontal lines. Each block is identified or named with a label.

Label Labels or names are located in the left margin of each information

block. The labels identify the content of the block in order to facilitate scanning and locating information quickly.

Note: Note: is used most frequently to refer the user to pertinent material

located elsewhere in the Manual, related Rules, specific statutory authority or to exceptions and limitations to a policy.

Update Log The first page of each Manual will contain an update log.

Every update will contain a new updated log page with the most recent update information added to the log. The health care provider can use the update log to determine if all updates to the current Manual have been received. Each update is designated by an “Update No.” and the “Effective Date”.

How Changes Are Updated

The Manual will be updated as needed. When a Manual is updated, the resulting new Manual will be replaced with a new effective date at the bottom of each page of the Manual.




Identifying New Material New Material will be identified by vertical lines. The following

information blocks give examples of how new labels, new information blocks, and new or changed material within an information block will be indicated.

New Label A new label for an existing information block will be indicated by a

vertical line to the left and right of the label only. New Label and New Information Block

A new label and a new information block will be identified by a vertical line to the left and right of the label and the information block.

New Material in an Existing Information Block

A paragraph within an existing information block that has new or changed material will be indicated by a vertical line to the left and right of the paragraph. Paragraph with new material will be indicated in this manner.

Existing material New material within a list of bullets will be indicated in this manner.



Chapter 1 Introduction and Overview, continued Administrative Purpose of the Manual

The administrative purpose of the Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 20165 Edition, is to furnish health care providers, as defined in subsections. 440.13(1), F.S., with general information, billing and reimbursement policies, and Maximum Reimbursement Allowances (MRAs) for covered services and procedures.

Authorization

Prior Authorization of Services

Health care providers and out-of-state providers must have authorization by the Workers’ Compensation carrier or a self-insured employer prior to: • Rendering initial care, remedial medical services; and pharmacy

services, or • Making a referral for the injured worker to facilities or other health

care providers. Note: Exceptions to prior authorization are: • Federal facilities; • Emergency room services and care, defined in section 395.002, F.S.;

or • A provider referral for emergency treatment resulting from

emergency services. Notification of Emergency Treatment

Any health care provider who renders emergency care must notify the carrier, in writing or by facsimile, by the close of the third business day after care has been rendered. If the emergency care results in admission to a health care facility, the health care provider must notify the carrier by telephone within 24 hours after initial treatment.



Chapter 1 Introduction and Overview, continued Carrier Responsibilities at Authorization

An carrier is responsible for meeting its obligations under this Rule regardless of any business arrangements with any service company/TPA, submitter or any entity acting on behalf of a carrier which medical bills are paid, adjusted and paid, disallowed, denied, or otherwise processed or submitted to the Division. At the time of authorization for medical service(s), a carrier must shall notify each health care provider, in writing, of additional form completion requirements or supporting documents that are necessary for reimbursement and provide the specific address for submitting a reimbursement request. At the time of authorization for medical service(s), a carrier must shall inform out-of-state health care providers of the specific reporting, billing and submission requirements of this Rule and provide the specific address for submitting a reimbursement request.

Fraud Statement A health care provider involved in the process of making a claim under the

Workers’ Compensation Program must shall provide his or her personal signature once per calendar year attesting that he or she has reviewed, understands, and acknowledges the following statement: “Any person who, knowingly and with intent to injure, defraud, or deceive any employer or worker, insurance company, or self-insured program, files a statement of medical bill containing any false or misleading information commits insurance fraud, punishable as provided in Sections 817.234, F.S.”




Health Care Provider Use of Codes, Descriptions and Modifiers

Physicians and other health care providers must shall use the codes and descriptions, modifiers, policies, definitions and instructions of the referenced CPT®, CDT®, HCPCS®, ICD-9®, ICD-10® or Florida Workers’ Compensation unique codes or other materials referenced in Chapter Rules 69L-8.071 and 69L-8.074, F.A.C. and:

• The Minnesota Department of Labor and Industry Disability Schedule, as adopted in Rule 69L-7.604, F.A.C.; • The Florida Impairment Rating Guide, as adopted in

Rule 69L-7.604, F.A.C.; • The 1996 Florida Uniform Permanent Impairment Rating

Schedule, as adopted in Rule 69L-7.604, F.A.C.; and • The American Medical Association’s Guide to the Evaluation of

Permanent Impairment, as adopted in Rule 69L-7.604, F.A.C The use of HCPCS® Level II codes is allowed only when there is not a more specific CPT® code available for use. All diagnosis codes must be reported at the highest level of specificity according to the ICD-9-CM® or the ICD-10-CM® valid number of digits, i.e., five (5) to seven (7) digits where notedion is made in the ICD-9-CM® or ICD-10-CM® manual. upon the federal implementation date of ICD-10-CM®. Both ICD-9 and ICD-10 codes may not be reported on the same claim form.

Carrier Use of Codes, Descriptions, and References

Carriers must shall use the codes and descriptions, modifiers, policies, definitions, and instructions of the referenced CPT®, CDT®, HCPCS®, ICD-9®, ICD-10 CM® upon the federal implementation date, or Florida Workers’ Compensation Unique Codes on the medical bill prior to making reimbursement decisions. In addition, where not inconsistent with instructions in this Manual, carriers may utilize the National Correct Coding Initiative (NCCI) edits in effect on the date(s) of service as part of the bill review process.



Chapter 1 Introduction and Overview, continued Notice of Privacy Practices

Every health care provider and other recognized health care practitioner will shall, except in emergency treatment situations, make a good faith effort to obtain a written acknowledgement of receipt of notice of privacy practices no later than the first day of providing medical services to a workers’ compensation insured patient. If not obtained, document its good faith efforts to obtain such acknowledgement and the reason why the acknowledgement was not obtained. In the event a patient, guardian, curator, or personal representative requests restriction(s) of the use or disclosure of identifiable health information that would prevent disclosure as necessary for treatment or payment for health care services, the provider or other recognized health care practitioner must shall notify the carrier immediately, if possible, or by close of business on the next regular business day.

Disclosure to Carriers Unless instructed otherwise, it is the responsibility of all health care

providers to furnish, without charge, the following documentation to the carrier:

1. A complete report of the patient’s symptoms, findings and plan of treatment pursuant to reporting requirements of the

DFS-F5-DWC-25; • An operative report when a surgical procedure is performed; • A narrative report when a consultation or an independent medical

examination is rendered; • Copies of medical records, when requested at the time of

authorization by the employer/carrier or designated entity, in order to determine the medical necessity of services that must be substantiated in more detail than previously disclosed;

• A copy of the DFS-F5-DWC-25 associated with the recommended or rendered care or treatment.

• Failure of the health care provider to forward information when requested by the carrier may result in the billed service being disallowed or denied payment until sufficient documentation is provided to render the necessary determination.

Moreover, a health care provider’s failure to release medical records or information upon a reasonable request or to release full and truthful medical reports of all of his or her findings will shall constitute a violation of Chapter 440, F.S., subject to penalties imposed by the Division.

http://www.fldfs.com/WC/provider/hcp-violations.html

http://www.fldfs.com/WC/provider/admin-penalties.html



Chapter 1 Introduction and Overview, continued Disclosure to Workers A health care provider, upon request, must shall furnish the injured worker,

injured worker’s attorney, the employer or carrier or its attorney, on demand, relevant portions of his or her office chart, records, and reports. The relevant portions sought must be related to the particular injury or illness for which compensation is sought.

Injured Worker’s Requests

A health care provider may charge an injured worker or their representatives no more than $0.50 per page for copies of written medical records. The relevant portions of the medical record sought must be related to the particular injury or illness for which compensation is sought. Payment must shall be made to a health care provider by the requesting party at the provider’s actual cost for x-rays, microfilm, or other non-written records.

Carrier’s Requests A health care provider, upon request, must shall provide a copy of the

injured worker’s medical records to a carrier or carrier’s representative or attorney. A health care provider, upon request, must shall furnish a carrier or the carrier’s attorney a copy of the injured worker’s medical chart, records and reports. A health care provider, upon request, must shall furnish the carrier or the carrier’s attorney, non-written medical records.

Division or Judge of Compensation Claims Requests

A health care provider, upon request, must shall provide medical records to the Division or a Judge of Compensation Claims without charge.




General Reimbursement Information Billing the Injured Worker

Health care providers must shall not bill the injured worker for services rendered for a compensable work-related injury except when it is to collect a co-payment fee or when apportioning out the percentage of need for the care attributable to a pre-existing condition.

Co-Payments A health care provider is entitled to collect a co-payment of $10.00 per

visit when providing medical services and care to an injured worker who has reached overall maximum medical improvement (MMI).

• Co-payments may only be collected for evaluation and management visits after the injured worker has received an assignment of MMI.

• The co-payment will shall not apply to emergency care or services provided to the worker; and

• The co-payment is not in addition to the maximum reimbursement allowance or fee agreement. The reimbursement amount otherwise payable by the carrier will shall be reduced by the amount of the

co-payment. Federal Facilities Federal facilities are exempt from the reimbursement provisions and

allowances in this Manual. An carrier must shall reimburse a federal facility its usual charge.

Florida Health Care Providers

Reimbursement will shall be made to a Florida health care provider after applying the appropriate reimbursement policies contained in this Manual. A carrier will shall reimburse a health care provider either the MRA in the appropriate reimbursement schedule or a mutually agreed upon contract price. Note: See Chapter 3 for MRAs and instructions on how to determine the correct MRA.



Chapter 1 Introduction and Overview, continued General Reimbursement Information, continued Out-of-State Providers Prior to the delivery of medical services, a carrier and health care provider

must agree upon the amounts of reimbursement for the services at the time of authorization; or If no agreement is made prior to the service being rendered, the carrier will shall reimburse the greater of either: 1. The MRA according to the out-of-state fee schedule provider for the

services provided; or 2. The MRA according to Chapter 3 Part A of this Manual. or under the

state Workers’ Compensation program in the state where the services are provided; whichever is greater.

Codes Paid by MRAs Reimbursement for procedure codes listed in this Manual with an MRA

will shall be at the maximum reimbursement allowance after the application of any reimbursement policies contained in this Manual. When the bBilled charges that are is less than the MRA, the reimbursement will shall be reimbursed the MRA amount in the Fee Schedule. Note: The only exception is when there is a clearly defined reimbursement amount between the health care provider and carrier provided in a contractual agreement.




General Reimbursement Information, continued Codes Paid By Report (BR)

Reimbursement will shall be determined by the carrier for procedure codes listed in the Fee Schedule as By Report (BR). Payment will shall be based on a provider’s documentation submitted to the carrier containing information on the complete description of the service or procedures actually performed, medical necessity, and cost of any additional supplies. At a minimum, reimbursement will shall be: • The Florida Workers’ Compensation MRA for clinically similar

procedure codes in the current fee schedule. The health care provider must shall submit the required documentation to the carrier when the following situations occur:

• The procedure code’s MRA is listed in the Fee Schedule as BR in Chapter 3 of this Manual; or

• There is a valid procedure code in the CPT® or the HCPCS® Level II Manual which corresponds to the date of service. The billed procedure code cannot be listed in this Manual.

Note: See Codes with No MRAs later in this Chapter.



Chapter 1 Introduction and Overview, continued General Reimbursement Information, continued Codes with No MRAs Carriers must shall have an established methodology for determining

reimbursement for procedure codes that have no established MRAs, unlisted procedure codes, and codes that are paid By Report. Carriers must shall utilize the expertise of peer review physicians for concurrent review, including the appropriateness and cost of the medical services reported; billing and coding issues; and determining reimbursement.

• Carriers will shall determine reimbursement by comparing the billed procedure code(s) with clinically similar procedure code(s) found in the appropriate CPT or HCPCS Manual ; and

• Carriers will shall make reimbursement decisions based on all of the provider’s documentation, the carriers medical bills, relative value data, services and supplies and peer physician recommendations; and

• Carriers will shall reimburse all work-related and medically necessary services provided in a documented medical or dental emergency.

This reimbursement methodology must also be available in response to any Petition for Reimbursement Dispute or upon request by the Division.

Reimbursement for Failed Appointments

Reimbursement is not made for failed appointments. Note: This exclusion does not apply to Independent Medical Examinations pursuant to paragraph s.440.13(5)(d), F.S. See Independent Medical Examination in Chapter 2.

Exceptions to Service Limitations

When a health care provider deems it medically necessary in the treatment of an injured worker’s particular individual’s injury or illness to furnish medical services that exceed the number of services in reimbursement policies in this Manual, a health care provider must:

• Submit documentation to the carrier substantiating the medical necessity for the request; and

• Receive specific written authorization from the carrier to render the requested additional services before they are provided.



Chapter 1 Introduction and Overview, continued General Reimbursement Information, continued

Services Unrelated to the Compensable Injury

Carriers will not reimburse hospital charges for services unrelated to the treatment or care of a compensable injury except when the treatment is required to stabilize or maintain the patient’s medical status in order to treat the patient’s compensable injury or condition. Carriers shall not reimburse health care providers or other recognized health care practitioners for services unrelated to the treatment or care of a compensable injury.

Disputing Reimbursement

The health care provider may elect to contest the disallowance or adjustment of payment under subsection 440.13(7), F.S. The election to contest the disallowance or adjustment of payment under subsection. 440.13(7), F.S. must be made by the health care provider within forty-five (45) calendar days of receipt of the Explanation of Bill Review (EOBR) or notice of disallowance or adjustment of payment.




Classification of an Injured Worker’s Status General Policies Providers are to utilize the Workers’ Compensation specific patient

classification levels when submitting the required treatment status on the DFS-F5-DWC-25 to the carrier.

Classification System The following best describes the patient classification levels are:

• Criteria based. • Comprised of descriptive categories to provide a means to promote

decision-making, accountability and responsible medical bill handling practices.

• Neither hierarchical nor severity indicators.

Purpose of Proper Patient Classification

Proper classification of the patient is intended to:

• Convey to carriers the complexity of services that may be required for optimal clinical management;

• Distinguish the overall critical differences among cases that influence the intensity, scope, and cost of services provided;

• Facilitate recognition of three varying clinical configurations that affect the medical treatment plan and treatment progress or other available benefits for an injured worker;

• Assist the carrier in decisions related to authorization of recommended treatment plans or treatment plan revisions;

• Ensure that on-going treatment plans and authorized reimbursable services are consistent with the high intensity, short duration treatment approach which focuses on specific clinical dysfunction before authorization is made to a provider.

• Enhance communication between the provider and the carrier to facilitate the authorization process for the provision of medically necessary care.



Chapter 1 Introduction and Overview, continued Classification of an Injured worker Status, continued Patient Classification Levels

Level I: Key issue – specific, well defined medical condition, with clear correlation between objective relevant findings and patient’s subjective complaints. Treatment correlates to specific findings. Level II: Key issue- regional or generalized de-conditioning (i.e., deficits in strength, flexibility, endurance, and motor control). Treatment includes physical reconditioning or functional restoration. Level III: Key issue – poor correlation between patient’s complaints and objective, relevant physical findings, both somatic and non-somatic clinical factors. Treatment includes interdisciplinary management and rehabilitation.



Chapter 2 Medical Services

Anesthesia Services Reimbursable Providers

Anesthesia services are reimbursed to anesthesiologists, certified registered nurse anesthetists (CRNAs) and anesthesia assistants (AAs) practicing within the scope of state licensure. A surgeon may also be reimbursed for anesthesia services performed during surgery.

Anesthesia Minutes

Anesthesia time begins when the provider starts to prepare the injured worker for anesthesia care in the operating room or in an equivalent area and stops when the provider is no longer in personal attendance, that is, when the injured worker may be safely placed under postoperative supervision. Note: Anesthesia time must shall be billed as the total number of minutes of anesthesia. For example, one (1) hour and fifteen (15) minutes of anesthesia must be billed as seventy-five (75) minutes of anesthesia.

Anesthesia Time Units

The minutes of anesthesia must be converted by the carrier into time units as follows:

1. For anesthesiologists, each ten (10) minutes of anesthesia time equals one (1) time unit and each minute over a time unit has a value of one-tenth (1/10) time unit.

2. For CRNAs or AAs, each fifteen (15) minutes of anesthesia time equals one (1) time unit and each minute over has a value of one-fifteenth (1/15) time unit.



Chapter 2 Medical Services, continued Anesthesia Services, continued Physical Status Modifiers

Anesthesia services will shall warrant additional reimbursement for units based upon the injured worker’s condition and the complexity of the anesthesia service provided. A physical status modifier will shall be determined by the provider (CRNA or anesthesiologist only) to rank the injured worker’s condition. Additional reimbursement will shall be based on the unit value for the specific physical status modifier, as assigned by the CPT® Manual. A physical status modifier is required for billing and reimbursement of anesthesia bills.

Physical Status Modifiers Unit Values P1 A normal healthy patient 0 P2 A patient with mild systemic disease 1 P3 A patient with severe systemic disease 2 P4 A patient with severe systemic disease that is a constant threat to life 3 P5 A moribund patient who is not expected to survive without the operation 4 P6 A declared brain dead patient whose organs are being removed for donor purposes 5



Chapter 2 Medical Services, continued Anesthesia Services, continued Difficult or Qualifying Circumstances

Anesthesia services, which are provided under particularly difficult circumstances, may warrant additional reimbursement for unit values based on unusual events. Listed below are the specific qualifying circumstances, as assigned by the CPT® Manual, that impact the anesthesia services provided. These procedure codes are not to be reported alone, but are reported as additional procedure codes. The listed unit value must be added to the base value units to calculate the reimbursement. List each of the following codes below the primary anesthesia procedure code on the billing form.

Code Unit Value 99100 Anesthesia for patient of extreme age,

under one year and over seventy 1 99116 Anesthesia complicated by utilization of

total body hypothermia 5 99135 Anesthesia complicated by utilization of

controlled hypothermia 5 99140 Anesthesia complicated by

emergency conditions (specify) 2 All others 0

Calculation of Anesthesia Reimbursement

Select the applicable anesthesia procedure code and note the base value from the fee schedule in Chapter 3, Part A, of this Manual. Determine the time units based on provider type. Determine any additional units that are justified by the physical status modifier and qualifying circumstances. Add the base value, time units, physical status modifier and any applicable qualifying circumstances to determine total anesthesia value. Multiply the total anesthesia value by the conversion factor of $29.49 to obtain the total anesthesia reimbursement.

Base Value (BV) Time Units (TM) Physical Status modifier units

+ Qualifying Circumstances Units = Total Anesthesia Units Total Anesthesia Units x $29.49 = $ Reimbursement



Chapter 2 Medical Services, continued Anesthesia Services, continued Procedures Listed as BV with No TM Units

Certain anesthesia services do not have a listed time value component. The reimbursement method for an anesthesia services that does not have time units associated with the anesthesia base value is as follows:

• Select the applicable anesthesia procedure code and base value from the schedule in Chapter 3, Part A of this Manual.

• Determine any additional units that are justified by the physical status modifiers or qualifying circumstances.

• Add the base value, physical status modifier and any applicable qualifying circumstances to determine total anesthesia value.

• Multiply the total anesthesia value by the conversion factor of $29.49 to obtain the total anesthesia reimbursement.

Base Value Physical Status Modifier units + Qualifying Status units = Total Anesthesia Units Total Anesthesia Units x $29.49 = $ Reimbursement Note: CRNAs and AAs reimbursement will shall be limited to 85% of the total anesthesia reimbursement allowance for an anesthesiologist for any procedure that has no TM units.



Chapter 2 Medical Services, continued Anesthesia Services, continued Medical Direction of CRNA/AA by Anesthesiologist

Reimbursement will shall only be made to the anesthesiologist for the direct supervision of anesthesia services which are provided by the anesthesiologist and billed under the name and license number of the physician. Reimbursement will shall be made to an anesthesiologist for providing medical direction, including pre-operative and post-operative evaluations or specific consultations to a CRNA/AA as previously identified by the specific protocol. Reimbursement for a CRNA/AA requiring medical direction by an anesthesiologist will shall be fifty percent (50%) of the anesthesia reimbursement allowance listed in Chapter 3, Part A or the agreed upon contract price. Reimbursement for medical direction by an anesthesiologist will shall be fifty percent (50%) of the anesthesia reimbursement allowance listed in Chapter 3, Part A of this Manual or the agreed upon contract price. Reimbursement will shall not be made to either the anesthesiologist or the CRNA/AA until the carrier has received and reviewed the medical bills and anesthesia reports from both providers. No additional reimbursement will shall be made for general supervisory services rendered by the anesthesiologist.

Special Billing Requirements for Anesthesia

All anesthesia services must be billed on Form DFS-F5-DWC-9. Anesthesia services must include the CPT® code and the “P” code (physical status modifier) which corresponds with the procedure performed in Field 24D.

1. Anesthesia providers must shall enter the date of service and the 5 digit qualifying circumstances code, which corresponds with the procedure performed, in Field 24D on the next line, if applicable.

2. Medical direction must shall be billed by the anesthesiologist by adding the HCPCS® Level II modifier QY to the anesthesia procedure code.

3. When medical direction is required, the CRNA or AA must shall bill by appending the HCPCS® Level II modifier QX to the anesthesia procedure code. The CRNA or AA must shall provide his or her Florida Department of Health (DOH) license number in Field 33b.

• When a Certified Registered Nurse Anesthetist provides anesthesia services, the CRNA must enter his/her Florida Department of Health (DOH) license number in Field 33b.

Note: See Chapter Rule 69L-7, F.A.C.



Chapter 2 Medical Services, continued Anesthesia Services, continued Anesthesia Performed by a Surgeon

When a surgeon provides regional or general anesthesia for a surgical procedure that he or she actually performs, modifier 47 is appended to the anesthesia procedure code to indicate that the operating surgeon performed the anesthesia. An operating surgeon cannot report time units in the calculation of anesthesia reimbursement request on the medical bill. Reimbursement will shall be for the base value (BV) multiplied by the anesthesia conversion factor only for the anesthesia service rendered. Base Value x $29.49 (anesthesia CF)= $ Reimbursement Note: See Chapter 3, Part A of this Manual for anesthesia Base Values.

Biofeedback Services Requirements for Reimbursement

Reimbursement for the collection and interpretation of biofeedback data digitally stored and downloaded will shall be included in the reimbursement to the provider for the basic biofeedback service. The written interpretation of the digitally stored biofeedback results must be signed and dated by the health care provider and maintained in the medical record.

Limitations to Biofeedback Services

Reimbursement for biofeedback training will shall be limited to twelve (12) visits per date of injury. Note: This biofeedback training limitation does not include individual psycho-physiological therapy incorporating biofeedback training by any modality with psychotherapy.



Chapter 2 Medical Services, continued

Dental Services Reimbursable Providers

All dental services must shall be authorized by a carrier before the services are rendered. A carrier will shall only reimburse a dentist or an oral surgeon for authorized services. Note: Emergency oral surgery does not require prior authorization. The carrier must shall be notified by the provider no later than the close of the third business day after emergency treatment.

Dental Codes and Descriptions

Dentists must shall use the dental guidelines, codes and descriptors from the CDT® or the D codes in the HCPCS® for dental procedures. Dental services are billed on Form DFS-F5-DWC-11.

Oral Surgery Oral Surgeons must shall use the CPT® guidelines, codes, descriptors and

modifiers for oral and maxillofacial surgical services. Oral surgery services are billed on the DFS-F5-DWC-9 medical bill form. Note: Oral Surgeons will shall refer to the label block “Billing and Reimbursement of Multiple Surgical Procedures” under Surgical Services in this Manual for information regarding reimbursement for multiple surgical procedures, as well as other surgical reimbursement guidelines.

Temporo-mandibular Joint (TMJ) Services

Dentists must shall bill using a combination of the dental guidelines, codes and descriptors from the CDT® manual and the D codes from the HCPCS® manual. • Dentists who provide TMJ services may use a combination of CPT® codes

and dental codes from the CDT® or HCPCS®. • Dentists will shall refer to the physical medicine section of this Manual for

information on physical medicine reimbursement policies.



Chapter 2 Medical Services, continued Dental Services, continued Reimbursement to Dentists and Oral Surgeons

Reimbursement to a dentist or oral surgeon for dental procedures or services will shall be the MRA or the agreed upon contract price. Note: See Chapter 3 for the MRAs for Dentists and Oral and Maxillofacial Surgeons in this Manual.

Electrodiagnostic Medicine Determining Medical Necessity

The referring physician must shall determine the medical necessity of an electromyography (EMG) or a nerve conduction study (NCS). Only a physician will shall determine the frequency of testing or the necessity of repeat testing.

Needle Electromyography (EMG)

Only a physician or a recognized practitioner specifically qualified by regulations in the state where the service is provided will shall be reimbursed for needle EMG testing. Reimbursement must shall include the testing, interpretation of the studies and a written report of the findings.

Reimbursement Policies for EMG

When the initial evaluation and management service and needle EMG testing are performed during the same visit, reimbursement will shall be made for both services. When a follow-up evaluation and management service and needle EMG testing are performed on the same day, reimbursement will shall be made to a physician for both services if the physician’s documentation validates the medical necessity for the follow-up evaluation and management service. When needle EMG testing is performed in a hospital or other facility, reimbursement will shall be made to a physician for an interpretation and report of the testing. Modifier 26 must be appended to the appropriate procedure code for reimbursement.



Chapter 2 Medical Services, continued Electrodiagnostic Medicine, continued Nerve Conduction Studies (NCS)

Only physicians or recognized practitioners specifically qualified by state regulations to perform Nerve Conduction Studies (NCS) will shall be reimbursed. A physician or a recognized practitioner specifically qualified by regulations in their state will shall determine the nerves to be tested based on specific clinical findings during the examination performed at the time of the study will shall be reimbursed if authorized by the carrier for an NCS.

Reimbursement Policies for NCS

When the initial evaluation and management service and the NCS are performed during the same visit, reimbursement will shall be made for both services. When a follow-up evaluation and management service and NCS are performed on the same day, reimbursement will shall be made for both services only if the physician’s documentation validates the medical necessity of the follow-up evaluation and management service subsequent to findings from the initial visit. A technologist under the direct supervision of the physician may perform a NCS. However, the services must be billed under the name and Florida Department of Health license number of the supervising physician or out-of-state license number. Reimbursement will shall include the testing, interpretation of the studies and a written report of the findings.

Evaluation and Management Services Office Visits A carrier will shall reimburse a physician for evaluation and management

services (new or established patient visits). A new patient means an injured worker who is new to the health care provider or an established patient with a new compensable injury or illness and a new date of accident. Note: Reimbursement is limited to one (1) visit per day at the level of care documented by the physician.



Chapter 2 Medical Services, continued Evaluation and Management Services, continued Consultations A consultation is a type of service provided by a physician whose opinion or

advice regarding evaluation or management of a specific problem is requested by another physician or other appropriate resource. A physician will shall be reimbursed for consultations, confirmatory consultations and follow-up consultation services. Reimbursement will shall include a review of all submitted medical records, paper and non-paper; an examination of the injured worker; and a written report.

Home Visit Services

A physician will shall be reimbursed for home visits when authorized by the carrier. A physician must shall bill with the appropriate evaluation and management procedure code for a home visit to bill the service.

Functional Capacity Evaluations (FCE) Reimbursement Criteria

All FCE protocols must shall be evidence-based. Test design and written interpretation must shall, at a minimum, focus on identifying associated functional loss, limitations or restrictions and the correlation to work-related clinical dysfunction (i.e., correlate impairment with disability). Reimbursement for an authorized FCE will shall be made at any time in the clinical continuum (see Patient Classification System in Chapter 1 of this Manual), as long as the evaluation protocol matches the scope and specificity of the clinical situation and referral question(s). Reimbursement will shall be made for the CPT® code 97750, specifically designated for use solely in reporting a FCE. The reimbursement for a FCE includes a written program plan and a written report. The provider must shall provide the results of the evaluation and recommendations to the injured worker, the carrier and the treating physician without additional charge. Reimbursement for an FCE will shall be made only when a physical therapist or occupational therapist is directly and actively involved with the testing protocol, although additional professional personnel may be involved as well. Note: Bill using CPT® code 97750.




Home Health Agency Services Definition Home Health Services are medically necessary services which can be

effectively and efficiently provided in the place of residence of an injured worker. Services include home health visits (nurses and home health aides), therapy services (speech therapy, physical therapy, occupational therapy), and authorized home medical equipment.

Home Health Visit Definition

A Home Health Visit is a face-to-face encounter between a registered nurse, licensed practical nurse, home health aide, or licensed therapist employed by a Home Health Agency and an injured worker at his or her place of residence. A Home Health Visit is not limited to a specific length of time, but is defined as an entry into the injured worker’s place of residence for the length of time needed to provide the medically necessary nursing, home health aide, or therapy service(s). An injured worker’s residence cannot be in a facility such as a hospital, a nursing facility, or a rehabilitation facility of any type.

General Policies A Home Health Agency must have a signed order outlining the Home Health

Plan of Care from the authorized, treating physician in order to obtain carrier authorization of home health services. The Home Health Plan of Care must be renewed every thirty (30) calendar days and submitted to the carrier for approval before further services may be authorized by the carrier.

Treating Physician The authorized treating physician is the doctor responsible for the management

and treatment of the injured worker’s compensable medical condition or the physician assigned by the Judge of Compensation Claims to treat the injured worker for the compensable condition. The treating physician cannot be a consulting physician unless there has been a complete transfer of care.

Authorization A Home Health Agency must shall obtain authorization from the carrier prior to

assigning any licensed health care employees to render services in an injured worker’s residence. A Home Health Agency is required to obtain a separate, written or electronic authorization from the carrier for any Home Medical Equipment needed. The carrier’s authorization to provide home health services does not authorize home medical equipment and supplies unless such authorization is expressly stated.



Chapter 2 Medical Services, continued Home Health Agency Services, continued Staff Skill Level A Home Health Agency must provide staff with the skill level designated and

appropriate for each service prescribed in the treating physician order and approved plan of care as authorized by the carrier.

Staff Substitutions If a staff absence occurs, the Home Health Agency is responsible for providing

and assuring that appropriate staff substitutions are made. Licensure or discipline of the staff substitutions must be equivalent to, or above, the discipline level as specified in the plan of care.

Reimbursement The carrier will shall reimburse the Home Health Agency at the reimbursement

amounts mutually agreed upon between the Home Health Agency and the carrier in a contract prior to the services being delivered in the home.

Billing for Home Health Agency Services

The Home Health Agency must bill on the Form DFS-F5-DWC-90 and include a copy of their contractual agreement with the billing form to the carrier for proper reimbursement. When a Home Health Agency is billing for authorized DME, on the Form DFS-F5-DWC-90, a copy of the treating physician’s original order for the DME item(s) must accompany the bill submitted to the carrier.

Independent Medical Examinations Requirements for Reimbursement

Reimbursement for an Independent Medical Examination (IME) shall include: • The review of applicable paper medical records; • The review of non-paper medical records; and • The examination of the injured worker with production of a written report.

Reimbursement for IME

A physician will shall be reimbursed by the party requesting the IME. IME services are reimbursed at either the MRA or a mutually agreed upon contract amount. Note: The only procedure code for billing an IME is the Workers’ Compensation Unique code 99456.




Failure to Appear for IME

If an injured worker fails to appear for an IME, scheduled by the employer or carrier, without good cause and failed to advise the physician at least 24 hours before the scheduled date for the examination that he or she will not appear, the physician may bill his or her cancellation or no-show fee to the carrier. Note: The physician must shall bill using the Workers’ Compensation unique code 99456 CN to indicate the injured worker failed to appear or the appointment was canceled without proper notice.

Consensus Independent Medical Examination Requirements for Reimbursement

Reimbursement for a Consensus Independent Medical Examination (CIME) must shall include:

1. The review of applicable paper and non-paper medical records; 2. An examination of the injured worker including determination of

Maximum Medical Improvement (MMI); 3. Assignment of a permanent impairment rating, as appropriate; and 4. A written report.

Reimbursement for CIME

Reimbursement for a CIME will shall be negotiated between the physician and the carrier prior to rendering the service. A physician will shall be reimbursed by the carrier for a CIME. Note: CIME service must shall be billed with the Workers’ Compensation Unique code 99457 for reimbursement.

Medications General Policies Medicinal drugs, commonly known as legend or prescription drugs, dispensed

to treat an injured worker must shall be ordered by a physician or other recognized health care practitioner and authorized by the carrier. Medicinal drugs are dispensed, stored and sold only by a pharmacist licensed under Chapter 465, F.S., or a licensed dispensing practitioner according to the provisions in sections. 465.0276, F.S.



Chapter 2 Medical Services, continued Medications, continued Codes and Descriptions for Medications

Physicians and other recognized practitioners must shall refer to the HCPCS® manual in effect for the date of service when reporting injection procedures, as well as immune globulin, or vaccine products. Providers must shall use the J codes in the HCPCS®Level II Manual, as adopted as part of in Chapter 69L-8, F.A.C., this Manual for reporting other injectable medications. If the specific medication is not listed in either of these references, the provider must shall bill the medication using the National Drug Code (NDC) number for reimbursement.

Reimbursement for Injectable Medications

Reimbursement for injectable medications will shall be made to a health care provider as follows:

• Reimbursement shall be made to a health care provider using CPT® or HCPCS® J codes for specific injectable medications and CPT® codes for the administration of injectable medications.

• Reimbursement will shall be at either the contract price or the listed MRA in the appropriate schedule.

• Reimbursement for an injection will shall include a local anesthetic, if necessary.

• Reimbursement for multiple medications administered from the same syringe will shall be:

At either the contract price or the listed MRA, in Chapter 3, Part A of this Manual for the first reported drug; and

At either the contract price or fifty percent (50%) of the listed MRA in the appropriate schedule for each additional drug. Each additional drug must shall be reported by appending modifier 51 to the HCPCS® or CPT® code.



Chapter 2 Medical Services, continued Medications, continued Reimbursement for Injectable Medications (continued)

Reimbursement to a physician for codes 90749 or J3490 will shall be twenty percent (20%) above the actual cost of the injectable medication based on submission of:

1. The name, strength and dosage of the medication, vaccine or toxoid; and 2. Documentation verifying the cost of the medication, vaccine or toxoid. 3. Applicable manufacturers Shipping and Handling will shall be reimbursed

at the actual cost on the invoice. Morphine via Infusion Pump

A special provision is allowed for identification of the loading dose of Morphine Sulfate administered via infusion pump. Providers must shall utilize an appropriate HCPCS® code if deemed by the practitioner to be the most appropriate coding option. Reimbursement will shall be twenty percent (20%) above the documented cost of the drug. Applicable manufacturer’s Shipping and Handling will shall be reimbursed at the actual cost on the invoice.

Dispensing Medications

The dispensing of medicinal drugs will shall be limited to a pharmacist or a licensed dispensing practitioner and billed under the NDC number. The reimbursement for prescription medications will shall be: Average Wholesale Price (AWP) + $4.18 = $ Reimbursement Note: see paragraph 440.13(12)(c), F.S. for the definition of Average Wholesale Price. For repackaged or relabeled prescription medications dispensed by a health care practitioner on or after date of service July 1, 2013, see paragraph 440.13(12)(c), F.S. to obtain the requirements for billing and reimbursement of repackaged prescription medications. Note: See Chapter 69L-7, F.A.C. for proper billing of repackaged or relabeled medications. Additionally, the pharmacist or dispensing practitioner shall bill for medication dispensing by using the Workers’ Compensation Unique code DSPNS.



Chapter 2 Medical Services, continued Medications, continued Compounded Drugs

Medicinal drugs may be compounded by a pharmacist or a physician when the drug formulation prescribed is not commercially available. Compounded drugs do not have a NDC number.

Reimbursement for Compounded Drugs

The provision and reimbursement of compounded drugs will shall be limited to a pharmacist or a physician and billed under the NDC number of each component that is used to make up the compounded drug. The provider must shall bill a professional fee for compounding by using the Workers’ Compensation Unique code COMPD. Reimbursement is the lesser of:

1. [AWP (of each component)] + $4.18 = Reimbursement; or 2. The amount the carrier has contracted for pursuant to

paragraph 440.13(12)(c), F.S. Note: Please refer to paragraph 440.13(12)(c), F.S. for the definition of AWP.

Unlisted Medications

Reimbursement for unlisted medications or medications with no MRA in Chapter 3 of this Manual, will shall be twenty percent (20%) above the actual cost of the medication based on the submission of documentation which includes:

• The name, strength, and dosage of the medication dispensed to the injured worker; and

• The invoice verifying the actual cost of the medication.



Chapter 2 Medical Services, continued Non-Reimbursable Drugs and Supplies

Reimbursement will shall not be made for oral vitamins, nutrient preparations or dietary supplements. Reimbursement will shall not be made for medical food pursuant to paragraph 440.13(3)(k), F.S.], as defined in 21 U.S.C s. 360ee (b) (3), unless the self-insured employer or the carrier in its sole discretion authorizes the provision of such food. Such authorization may be limited by frequency, type, dosage, and reimbursement amount of such food as part of a proposed written course of medical treatment.

Reimbursable Materials and Supplies

Reimbursement for supplies and materials not incidental to a service or a procedure will shall be reimbursed using the specific HCPCS® Level II supply codes.

Unlisted Supply Code

When a more specific code is not available for reimbursable supplies and materials, bill using the HCPCS® miscellaneous supply code A9999 and submit documentation with the following:

• A detailed description of the supply or material and the unique medical need for the injured worker; and

• A copy of the actual invoice to document the cost of the item billed including unit(s) of supply and unit pricing information. If needed, please circle the items on any invoice that are specific to the injured worker when submitting the medical bill.

Supplies and Materials Not Separately Reimbursed

Material and supplies which are necessary to perform a procedure or provide a service will shall be included in the reimbursement for the procedure or service and will shall not be reimbursed separately.

Reimbursement for Supplies

Reimbursement will shall be limited to twenty percent (20%) above the actual invoice cost of the supply(s) based on submission of the documentation that substantiates the provider’s cost.




Medical Supplies and Home Medical Equipment General Requirements

Medical supplies and home medical equipment must shall be prescribed by a physician and may be provided to an injured worker by a home medical equipment supplier through rental or purchase.

Authorization A home medical equipment supplier must shall obtain a specific written or

electronic authorization and a written payment agreement from the carrier prior to furnishing an injured worker with medical supplies or equipment.

Billing A home medical equipment supplier must shall provide the carrier with a copy

of the physician’s original order with the medical bill when requesting reimbursement. A home medical equipment supplier is required to bill on the Form DFS-F5-DWC-10 using HCPCS® codes. The home medical equipment supplier is not required to provide invoices with the bill to document the acquisition costs of supplies and equipment. Note: When no specific code is available to describe the item provided, bill using HCPCS® code A9999 unless specifically requested by the carrier at the time of authorization.

Reimbursement Reimbursement will shall be made by the carrier to a home medical equipment

supplier for rental or purchase of medical equipment and supplies ordered or prescribed by a physician or recognized practitioner according to the written payment agreement obtained at the time of authorization. • The carrier may rent the item from the supplier for the injured worker; or • The carrier may write a provision in the payment agreement that when the

amount received by the supplier from the rental payments equals the purchase price, the item will become the property of the carrier or injured worker; or

• The carrier may purchase the item from the supplier.



Chapter 2 Medical Services, continued Medical Supplies and Home Medical Equipment, continued Limitations for Supplies and DME

No reimbursement will shall be made for supplies or equipment that are automatically supplied or refilled by the supplier. All services and refilled supplies require explicit carrier authorization as a requirement for reimbursement.

Ophthalmologic Services General Reimbursement Requirements

Reimbursement for ophthalmologic services will shall be made for all medically necessary services. Authorization from the carrier is required unless the condition is an emergency situation.

Glasses, Contacts or Frames

Reimbursement will shall only be made for glasses, contact lens, or frames of comparable quality to the original when they are damaged, lost or required for treatment as a result of an injury or surgery to correct an injury.

Permanent Impairment Ratings (PIR) Providers Eligible for Reimbursement

Only a physician licensed by the Chapters listed in paragraphs. 440.13(3)(b), F.S. will shall be reimbursed by the carrier for addressing maximum medical improvement (MMI) and the assignment of a Permanent Impairment Rating (PIR ).

Reimbursement Components and PIR

Reimbursement will shall include an examination to include: 1.Evaluation of an injured worker’s condition to include the establishment of the MMI date and PI rating of zero (0) percent or greater; and 2.The systematic completion of the required reporting form, Form DFS-F5-DWC-25, and submission to the appropriate parties in accordance with s. 440.15(3), F.S.

• The Form DWC-25 does not replace physician notes or other medical records.

• The Form DWC-25 must shall be fully completed and must shall document the method(s) and guide used to assign a PI rating.

Reimbursement will shall not be made for an evaluation and management code on the same date of service as a PI rating. Note: The procedure code for billing a PI rating is the CPT® code 99455.




Psychiatric and Psychological Services Providers Eligible for Reimbursement

Reimbursement for psychiatric and psychological services will shall be made by the carrier to the following recognized practitioners to provide individual psychotherapy services within the scope of state licensure:

• Medical doctors; • Osteopathic physician; • Psychologists; • Mental health practitioners; • Other qualified health professionals.

Required Documentation

All psychiatric and psychotherapy procedure codes that are reimbursed based on face-to-face time with the injured worker patient must have a beginning and an ending time documented in the medical record.

Individual Psychotherapy Combined with Evaluation and Management Codes

Only a physician may be reimbursed for individual psychotherapy in combination with evaluation and management services provided by a physician at a therapy session. Documentation must support the services billed. A physician will shall not be reimbursed for an evaluation and management procedure code (99201-99499) on the same day that reimbursement is made for psychotherapy combined with evaluation and management services. Note: Refer to the CPT® for specific psychiatric procedure codes to identify the combined codes.

Multiple Psychotherapy Sessions on the Same Day

When more than one individual psychotherapy session is performed on the same day, only the session lasting the longest period of time will shall be reimbursed.



Chapter 2 Medical Services, continued Psychiatric and Psychological Service, continued Family Psychotherapy

Reimbursement for family psychotherapy, with or without the injured worker present, will shall be made if the documentation supports that the purpose is related to the treatment of the injured worker’s compensable injury. Reimbursement will shall not be made for psychiatric or psychological services provided directly to members of the injured worker’s family for support and assistance in adjusting to the injured worker’s condition.

Central Nervous System Testing

Central Nervous System (CNS) Assessment and Testing must shall be specifically authorized by the carrier.

Reimbursement of CNS Testing

Reimbursement will shall be made for CNS Assessment and Testing. Reimbursement includes:

• An assessment and administration of a test with interpretation and a written report;

• The amount of reimbursement for these services shall be determined from Tthe number of hours (units of service) reported by the provider to perform the assessment and testing;

• The procedure code used for billing shall indicatinge if the service is per hour or is all-inclusive.

Reimbursement will shall be the MRA in Chapter 3 of this Manual or the agreed upon contract price.

Behavioral Assessment Interventions

Reimbursement will shall be made for Health and Behavior Assessment and Intervention Services when authorized by the carrier.

Billing Providers must shall refer to the most specific Health and Behavior Assessment

and Intervention procedure codes when billing for health and behavioral interventions.




Radiology Reimbursable Services

Reimbursement will shall be made for radiology services including diagnostic radiology (diagnostic imaging), diagnostic ultrasound and nuclear medicine.

Components of Radiology Reimbursement

Radiology services consist of two components: the technical component and the professional component.

• Technical Component: modifier TC When the technical component only [the actual performance of the radiological test and the production of film(s)] is reported separately, the service is billed by adding the HCPCS® modifier TC to the procedure code when requesting payment.

• Professional Component: modifier 26 When the professional component (physician interpretation of radiological test results) is reported separately, the service is billed by adding the HCPCS® modifier 26 to the procedure code when requesting payment.

Global Services Global services may be reported when one practitioner provides both the

technical and the professional components of a radiological procedure or service. The unmodified 5 digit procedure code is used to identify a global service inclusive of the professional service and the technical component of providing that service.

Reimbursement Policies

Reimbursement will shall not be made for a professional component (modifier 26) billed in the following situations:

• A professional component billed by a physician for x-rays taken and interpreted by another physician and reviewed during an IME, CIME, medical visit or consultation.

• A professional component billed by a physician for reviewing x-rays during an emergency department or hospital visit when the x-rays were interpreted by the radiologist at the hospital.

• A professional component billed by a provider who is not the provider that reviewed, interpreted and signed the radiology report.



Chapter 2 Medical Services, continued Radiology, continued Independent Radiology Facilities

Reimbursement will shall be made to an independent radiology facility for the technical component of the service by appending the modifier TC to the five (5) digit procedure code. No reimbursement will shall be made for the professional component of a service to an independent radiology facility. Only a technical component may be reimbursed to an independent radiology facility. The professional component will be billed separately by the health care provider that interprets the radiology exam.

Thermography Requirements for Authorization

The carrier will shall not authorize a physician to perform thermography any earlier than forty-five (45) calendar days after the date of accident unless the documentation of medical necessity is submitted to the carrier along with the request for authorization.

Thermography Limitations

Reimbursement for thermography is limited to one (1) body area; either major or limited.

1. Major body areas. (The following areas include all views.) • Head; • Cervical spine and upper extremities; • Lumbosacral spine and lower extremities.

2. Limited body areas. (The following areas include all views.)

• Thoracic spine; • Any portion of a major area.



Chapter 2 Medical Services, continued Reimbursement Requirements

An authorization and a written reimbursement agreement must shall be obtained from the carrier for rental or purchase of a TENS unit prior to a physician or other recognized practitioner furnishing a TENS unit to the injured worker. Reimbursement will shall be twenty percent (20%) above the provider’s documented cost when the TENS unit is purchased. A copy of the provider’s invoice must shall be submitted with the bill to substantiate the provider’s cost.

Training Sessions for TENS

Reimbursement will shall be made to an authorized physician or other recognized practitioner for furnishing training to an injured worker on the application and use of a TENS unit. Note: Reimbursement is limited to four (4) training sessions per approved TENS unit.

Physical Medicine and Rehabilitation Services General Information

Physical medicine and rehabilitation services will shall be considered as covered treatment only when such care is given based on a physician referral or prescription and when the medical necessity for such services is clearly supported in the recognized practitioner’s evaluation and in the specific physical medicine plan of care.

Covered Services Carriers will shall reimburse authorized providers, as specified in this Manual,

for the following physical medicine and rehabilitation services provided to injured workers for a compensable injury/illness:

1. Modalities and therapeutic procedures applied to acute injuries to reduce symptoms, restore function, and return the injured worker to work.

2. Physical reconditioning focused on injuries requiring intensive physical reconditioning services to restore the injured worker to pre-injury level of physical health and function. The goal will shall be for the worker to return to a job and/or become physically reconditioned.

3. Interdisciplinary rehabilitation programs covering a variety of services that are coordinated, outcome focused and directed at the injured worker’s needs to increase the worker’s functioning or to return the worker to work.



Chapter 2 Medical Services Physical Medicine and Rehabilitation Services, continued Authorization of Services

All services must shall be authorized in writing by the carrier prior to initiation of services. Reimbursement will shall only be made for physical medicine, therapeutic procedures, modalities and rehabilitation services up to six (6) months after the date of accident, based on a signed order or referral from an authorized, treating physician.

Exceptions to Limitations

Exceptions may be made to the above limitation when the treating provider provides documented, objective, relevant medical findings that demonstrate the following:

1. The injured worker has a specifically defined, relevant clinical dysfunction, consistent with the patient classifications outlined in Chapter 1 of this Manual, that is reasonably expected to respond to the requested physical medicine modalities or procedures; and

2. The injured worker does not conform to either the Level II or Level III patient classifications based on specific documentation of the following: a. No systemic musculoskeletal deficit (strength, flexibility,

endurance, coordination) or substantive functional loss requiring an intensive physical reconditioning program;

b. No behavioral or psychological issues that present a substantive factor in the rehabilitation effort or outcome;

c. No significant vocational or return to work issues; and d. No significant disparity between the injured worker’s subjective

complaints, response to intervention, and other relevant clinical indicators when compared with documented, objective, relevant findings.

Note: See Classification of an Injured Worker Status in Chapter 1 of this Manual.



Chapter 2 Medical Services, continued Physical Medicine and Rehabilitation Services, continued Physical Medicine Plan of Care (DWC-25)

The requirement of medically necessary physical medicine services (i.e., modalities and therapeutic services, physical reconditioning, or interdisciplinary rehabilitation programs) must shall be documented on the Form DWC-25 submitted to the carrier by the physician and supported in the evaluation with a specific physical medicine plan of care, regardless of the location of where the services are rendered or if rendered by a physician or other recognized practitioner.

• If the carrier questions the appropriateness of the therapy listed in the plan of care, the carrier must shall contact the physician to obtain the rationale for the ordered therapy, prior to authorization.

• It will shall be the responsibility of the physician to provide the documentation of medical necessity for the therapy to the carrier in order to avoid unnecessary delays in obtaining authorization for treatment or in initiating therapy.

Service Limitations

Reimbursement for physical medicine services is limited to one visit per day, unless specifically authorized by the carrier.

Physical Medicine Initial Evaluation by a Therapist

• Reimbursement for an initial evaluation by a physician will shall be made as an evaluation and management service.

• Reimbursement for an initial evaluation by a therapist will shall be made when billed using procedure code 97001 or 97003.

• Separate reimbursement will shall not be made to a physician and to a physician-employed therapist for an evaluation by each on the same date of service.

• Reimbursement for an initial evaluation will shall include the evaluation and a plan of care or treatment.

Note: Documentation of the evaluation and preparation of a plan of care must shall be submitted to the carrier with the medical bill. At a minimum, the documentation must shall include:

1. The evaluation findings including any functional limitations; 2. The proposed therapy specifying the frequency and duration of

services; and 3. The anticipated degree of restoration of function with measurable

goals.



Chapter 2 Medical Services, continued Physical Medicine and Rehabilitation Services, continued Evaluation by an Athletic Trainer

a. Reimbursement for an initial evaluation, when performed by a physician, must shall be billed as an evaluation and management service.

b. Reimbursement for an initial evaluation by an athletic trainer will shall be made only after a referral from a physician and billed using procedure code 97005.

c. Separate reimbursement will shall not be made to a physician and to a physician-employed athletic trainer for an evaluation by each on the same date of service.

d. Reimbursement for an initial evaluation by an athletic trainer must shall include the evaluation and a plan of care or treatment.

Re-Evaluation by an Athletic Trainer

Reimbursement will shall be made for a re-evaluation by an athletic trainer, when ordered by a physician, and documented on the DWC-25 no more than once every four (4) weeks. Re-evaluations must shall be billed using procedure code 97006.

Revised Plan of Care

1. The physician must shall submit to the carrier a revised DWC-25 prepared by the physician to document the change in care or treatment, when appropriate.

2. An authorized treating physician CIME service must shall be billed with the Workers’ Compensation Unique code 99457 for reimbursement from the carrier. The physician performing the CIME has the responsibility for providing documentation of medical necessity for therapy modifications, if questioned by the carrier.



Chapter 2 Medical Services, continued Physical Medicine and Rehabilitation Services, continued Modalities and Therapeutic Procedures

Reimbursement to a physician or recognized practitioner will shall be made for the modalities and therapeutic procedures listed in the plan of care with the limitation that no more than four (4) units of service shall be reimbursed per visit.

• Codes 97010-97028 will shall each equal one (1) reimbursable unit of service. The performance of the supervised modality codes is not time-oriented and each code may only be reported once during the visit.

• Codes 97032-97542 will shall each equal one (1) reimbursable unit of service for each fifteen (15) minute increment of service performed.

• Code 97150 will shall be restricted to one (1) reimbursable unit of service per visit.

Manipulative Treatment

Reimbursement to a physician for a manipulative treatment will shall be limited to: 1. One (1) visit per day, 2. Two (2) body regions per visit.

Each of the following is one body region: a. The entire spine; b. Head; c. Two (2) upper extremities; d. Two (2) lower extremities; e. One (1) upper and one (1) lower extremity; f. Rib cage; g. Abdomen.

Spinal Manipulation by a Physician

The entire spine shall be reimbursed as one (1) region for Workers’ Compensation even though there are five spinal (5) regions:

a. Cervical; b. Thoracic; c. Lumbar; d. Sacral; and e. Pelvic.

Reimbursement will shall be made to a physician for spinal manipulation when billed using procedure code 97260.



Chapter 2 Medical Services, continued Physical Medicine and Rehabilitation Services, continued Manipulation of Extra-Spinal Regions

When manipulative treatment is performed by a physician on the:

a. Head region; b. Lower extremities; c. Upper extremities; d. One upper and one lower extremity; e. Rib cage and abdomen; and f. Viscera region.

Reimbursement will shall be made when the service is billed using procedure code 97261.

Osteopathic Manipulative Treatment (OMT)

Reimbursement for osteopathic manipulative treatment (OMT) to the two (2) body regions, spinal and extra-spinal, listed in this Chapter will shall be made for procedure codes 98926 and 98928, respectively.

• Reimbursement will shall be made for code 98926 when used to bill for a spinal manipulation. The spine will shall be reimbursed as one (1) region for Workers’ Compensation, although there are five (5) spinal regions (cervical; thoracic; lumbar; sacral; and pelvic).

• Reimbursement will shall be made for procedure code 98928 when used for manipulation to the head region; lower extremities; upper extremities; one upper and one lower extremity; rib cage and abdomen; and viscera region.

Chiropractic Manipulative Treatment (CMT)

Reimbursement for CMT to two (2) regions, spinal and extra-spinal, listed in this section will shall be made when billed with procedure codes 98941 and 98943, respectively. These manipulation procedure codes are specifically designated for chiropractic physicians.

Chiropractic Spinal Manipulations

Reimbursement will shall be made for procedure code 98941 when used to bill for a spinal manipulation. The spine shall be reimbursed as one (1) region for Workers’ Compensation, although there are five (5) spinal regions: cervical region (includes atlanto-occipital joint); thoracic region (includes costo-vertebral and costo-transverse joints); lumbar region; sacral region; and pelvic (sacroiliac joint) region.



Chapter 2 Medical Services, continued Physical Medicine and Rehabilitation Services, continued Chiropractic Extra-Spinal Manipulations

Reimbursement will shall be made for procedure code 98943, when used to bill for a manipulation to an extra-spinal region: head (including temporomandibular joint, excluding atlanto-occipital); lower extremities; upper extremities; rib cage (excluding costotransverse and costovertebral joints); and abdomen.

Acupuncture Providers Eligible for Reimbursement

Reimbursement for acupuncture will shall be made to a physician or a recognized practitioner specifically licensed by the Florida Department of Health to diagnose and treat with acupuncture.

Reimbursement Requirements

• Reimbursement for acupuncture or electro-acupuncture service is based on fifteen (15) minute increments of face-to-face contact with the patient during a session.

• Each treatment session consists of only one (1) initial fifteen minute (15 minute) increment.

• If additional time is required to be reported, use the appropriate add-on codes.

• Reinsertion of the acupuncture needle(s) is required for the use of acupuncture add-on codes.

Limitations • Reimbursement is limited to one visit per day.

• Only one (1) initial acupuncture treatment procedure code may be billed per injured worker per visit.

Note: A provider may not bill the initial acupuncture with electrical stimulation and without electrical stimulation for the same visit.




Orthotics and Prosthetics Reimbursement Policies

All prosthetic or orthotic devices must be prescribed by the treating physician. Reimbursement will shall only be made to a licensed orthotics, prosthetics, occupational therapist, or physical therapist for custom fabricated orthotic or prosthetic device(s) when they directly provide the service. If the licensed provider is employed by a Home Medical Equipment supplier, a Home Health Agency, or any other employer, the bill is submitted by the employing party. When billing, orthotics and prosthetics must be billed using HCPCS® Level II codes that specifically describe the device.

Reimbursement Prior written authorization by the carrier is a requirement for reimbursement of

fabricated orthotics and prosthetics. Reimbursement for orthotics and prosthetics will shall be By Report (BR).

Orthotic Fitter and Orthotic Fitter Assistant

Orthotic Fitters and orthotic fitter assistants may be reimbursed for services provided within the scope of their licensure that are prescribed by a licensed treating health care provider. These services must shall be billed on the DWC-9 claim form using HCPCS® Level II codes that specifically describe the service or supply provided. The DOH license number of the orthotic fitter or orthotic fitter assistant must be on the claim form in Field 33b. If the licensed provider is employed by a Home Medical Equipment supplier, Home Health Agency, or any other employer the bill is submitted by the employing party.




Tests and Measurements General Policies & Limitations

Reimbursement to a provider will shall be limited to one (1) visit by an injured worker per thirty (30) calendar days for tests and measurements to a selected body area or number of areas unless a different interval is outlined in the patient’s plan of care. A variation to the standard limitation for tests and measurements must be ordered by the treating physician and authorized by the carrier.

Billing Providers must shall bill using the Workers’ Compensation unique code 97752,

specifically designated for both the manual and automated testing. Reimbursement Reimbursement for tests and measurements must shall include a written report

of the testing results. Manual muscle testing procedure codes and range of motion procedure codes will shall not be reimbursed when reported separately with procedure code 97752. Reimbursement will shall be made for range of motion measurements.




Physical Reconditioning Services Providers Eligible for Reimbursement

Reimbursement for physical reconditioning services will shall only be made to an authorized occupational therapist, physical therapist, or athletic trainer.

Authorization Reimbursement will shall only be made for carrier authorized physical

reconditioning based on a signed order from the authorized treating physician. Physical reconditioning services must shall be authorized by the carrier prior to initiation and must shall not begin any earlier than thirty (30) calendar days after the injured worker’s date of accident.

Physical Reconditioning Assessment

Reimbursement for a physical reconditioning assessment and written report will shall be determined from the number of hours reported by the provider to perform the assessment and the listed MRA. Note: Reimbursement is limited to eight (8) hours.

• Reimbursement will shall be made for Workers’ Compensation Unique

codes 97850 and 97851, specifically designated for use in reporting a physical conditioning assessment.

• Reimbursement will shall be made for procedure code 97850 only when it is used to bill for the initial hour of a physical reconditioning assessment.

• Reimbursement will shall be made for procedure code 97851 only for each additional thirty (30) minutes of a physical reconditioning assessment subsequent to procedure code 97850.




Physical Reconditioning Program General Reimbursement Guidelines

Reimbursement for a physical reconditioning program will shall be paid based on the number of hours billed by the provider and the listed MRA. Note: Reimbursement will shall be limited to a program lasting no longer than sixty (60) hours during a six (6) week period, which includes a physical reconditioning assessment.

Billing Guidelines Reimbursement will shall be made for Workers’ Compensation Unique

procedure codes 97852 and 97853, specifically designated for use in reporting a physical reconditioning program.

• Reimbursement will shall be made for procedure code 97852 to bill the initial per hour session of physical reconditioning each day.

• Reimbursement will shall be made for procedure code 97853 when used to bill each additional thirty (30) minutes per session of physical reconditioning each day.

Multiple Therapies by the Same Provider

Reimbursement will shall be made for a physical reconditioning program when the services are provided alone, along with, or subsequent to modalities and procedures by the same authorized occupational therapist or physical therapist.

Limitations Reimbursement will shall be made to a therapist or athletic trainer for only one

(1) physical reconditioning program for an injured worker per date of accident, unless specifically authorized by the carrier for an exacerbation of the injury or surgical intervention, as documented by the treating physician. Note: Reimbursement for an extension of the program will shall be limited to reimbursement of an additional twenty (20) hours during a two (2) week period.



Chapter 2 Medical Services, continued Interdisciplinary Rehabilitation Programs

Authorization All services must shall be authorized prior to initiation of services. Reimbursement will shall only be made to a facility for carrier authorized interdisciplinary services based on a signed order from the authorized treating physician.

Exceptions to Policies

Approval beyond the policies provided in this section must be obtained from the carrier, in writing, prior to a health care provider furnishing the service. The unusual circumstances must be documented and forwarded by the health care provider to the carrier for review before an exception to the policies can be considered and a determination made by the carrier to authorize additional services.

CARF Accreditation Requirements

Reimbursement for Interdisciplinary Rehabilitation Programs will shall only be made to rehabilitation programs accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF), except for a facility operating pursuant to Chapter 395, F.S., as part of a hospital. Rehabilitation Program services must be provided through a CARF accredited Outpatient Medical Rehabilitation Program, Occupational Rehabilitation Program or Interdisciplinary Pain Rehabilitation Program.

Work Hardening Programs

Reimbursement for a work hardening program will shall be made to a facility for the duration of the recommended individualized program. Procedure codes 97545 and 97546 are specifically designated to use exclusively in reporting the services of a work hardening program as follows:

• Bill the initial two (2) hours of a work hardening program each day using procedure code 97545;

• Bill each additional hour of a work hardening program each day using procedure code 97546.



Chapter 2 Medical Services, continued Interdisciplinary Rehabilitation Programs, continued Pain Programs Reimbursement for an interdisciplinary pain management program will shall be

made to a facility for the recommended time indicated in the injured worker’s program plan.

Pain Program Components

The services provided must relate to the physical, psychological, social, functional and vocational goals of the worker’s program plan. Services billed must shall reflect these components in the documentation submitted to the carrier for reimbursement.

Reimbursement for Pain Programs

Reimbursement will shall be made for biofeedback; physical and rehabilitation medicine services; pharmacy services; psychological and psychiatric services and testing; musculoskeletal services tests and measurements; neuromuscular services tests and studies, and other medically necessary services during the course of the program.

Discharge from an Interdisciplinary Program

The facility’s program director must shall determine if the injured worker will shall be discharged from the work hardening or pain program before completion. If the injured worker has not completed the program and program director recommends discontinuance of the program, the director will shall provide discharge information to the injured worker, the carrier and the treating physician without charge.

Discharge Report Upon program completion, a report shall be sent by the facility’s program

director without charge to the treating physician and to the carrier with the final bill. The report will shall include:

• The injured worker’s current clinical status and plan for transition from the program; and

• Return to work recommendations. Functional Capacity Evaluation (FCE)

Reimbursement for an authorized FCE will shall be made at any time in the clinical continuum, as long as the evaluation protocol matches the scope and specificity of the clinical situation and referral question(s). Note: See Patient Classification System in Chapter 1 of this Manual



Chapter 2 Medical Services, continued Interdisciplinary Rehabilitation Programs, continued Requirements for FCE

All FCE protocols must be evidence-based. Test design and written interpretation must, at a minimum, focus on identifying associated functional loss, limitations or restrictions and the correlation to work-related clinical dysfunction (i.e. correlate impairment with disability). Note: Reimbursement will shall only be made when a physical therapist or occupational therapist is directly or actively involved with the testing protocol, although additional professional personnel may be involved as well.

Billing and Reimbursement for FCE

The provider must shall provide written results of the evaluation and recommendations to the injured worker, the carrier and the treating physician without additional charge. The reimbursement for FCE includes a written program plan and a written report. Note: The Workers’ Compensation unique procedure code 97750 is designated for billing a FCE using the DFS-F5-DWC-9 Form.




Surgical Services General Reimbursement Information

General reimbursement information from an authoritative resource is used to determine any limitations or reductions from the MRAs in Chapter 3. All procedure codes having indicators for multiple surgery pricing rules, bilateral surgery pricing rules, assistant at surgery, co-surgeon, team surgery and information are found in an authoritative resource, such as the National Physician Fee Schedule Relative Value File Resource-Based Relative Value File, copyrighted by the American Medical Association. The Relative Value File is available from the American Medical Association, 515 N. State Street, Chicago, IL 60610 or by calling 1-800-621-8335. These indicators will shall be used to determine reimbursement by the Division.

Global Surgical Package

Reimbursement for a surgical package (global reimbursement) will shall include the provision of certain services before and after surgery. Payment for these services will shall include:

• The immediate preoperative visit; • Local infiltration, metacarpal/metatarsal/digital block or topical

anesthesia; • The surgical procedure; • Immediate postoperative care, including dictating operative notes,

talking with the family and other physicians; • Writing orders; • Evaluating the patient in the post-anesthesia recovery area; • Typical postoperative follow-up care; and • The time period for routine follow-up care related to the surgical

procedure is listed in the Follow-Up Days (FUD) column in Chapter 3, Part B.

1. Reimbursement for a procedure code with a ZZZ designation for the global period will shall be the same as the other procedure code that is billed in conjunction with this “add-on” procedure code.

2. Reimbursement for a procedure code with a YYY designation in the global period will shall be set by the carrier.

Note: The maximum reimbursement allowance (MRA) to physicians for surgical procedures will shall be found in Chapter 3, Part B of this Manual.



Chapter 2 Medical Services, continued Surgical Services, continued Services Reimbursed in Addition to Global Package

Reimbursement will shall be made for other services in addition to the surgical package only in the following situations when:

• The preoperative visit is the initial visit made by the provider, when prolonged detention or evaluation is necessary to prepare an injured worker for surgery and when there is a need to establish the reason for a particular type of surgery;

• The preoperative visit is a consultation; • The preoperative services are not part of the usual preparation for the

particular surgical procedure; and • The services are to treat complications, exacerbations, recurrences or other

diseases and injuries. Documentation substantiating the medical necessity of the additional services rendered must shall be submitted with the medical bill.

Surgery Performed During Post-Op Period

Reimbursement for surgical services will shall be made when an additional surgery is performed during the postoperative period of another surgical procedure. Reimbursement for normal postoperative care must shall run concurrently and must shall be made according to the separate FUD periods listed in Chapter 3, Part B unless it is a procedure code with the YYY designation. For theses codes, the FUD period will shall be set by the carrier.

Assistant Surgeon Reimbursement for an assistant surgeon will shall be twenty-five percent (25%) of

the physician reimbursement listed in the MRAs in Chapter 3, Part B of this Manual. The services provided must shall be identified by appending the modifier 80 to the specific procedure code.



Chapter 2 Medical Services, continued Surgical Services, continued Non-Physician Surgical Assistants

Reimbursement will shall be made to a non-physician surgical assistant for surgical services. Non-physician surgical assistants include: physician assistants, advanced registered nurse practitioners and registered nurse first assistants.

Billing Requirements for Non-Physician Surgical Assistants

The surgical procedure code(s) must be appended with the HCPCS® Level II modifier AS to identify services rendered by a non-physician surgical assistant at surgery. Non-physician surgical assistants must follow the billing requirements in Chapter 69L-7, F.A.C. The non-physician surgical assistant must provide his or her Florida DOH license number in Field 33b on the DWC-9 medical bill form. Note: No reimbursement is made to non-physician surgical assistants employed by hospitals.

Reimbursement for Non-Physician Surgical Assistants

Reimbursement will shall be made for non-physician surgical assistants performing surgical services. Reimbursement will shall be seventy-five percent (75%) of twenty-five percent (25%) of the MRA listed in Chapter 3, Part B when the carrier has determined:

• The non-physician meets state licensure requirements and holds current Division Health Care Provider Certification, and

• Written authorization to the non-physician surgical assistant was provided by the carrier prior to the surgery or,

• During a medical emergency, a physician was not available to assist at surgery.

Procedure codes having indicators for multiple surgery pricing rules, bilateral surgery pricing rules, assistant at surgery, co-surgeon, team surgery and other information shall be utilized for determining reimbursement for all claims. These indicators will come from an authoritative resource, such as the National Physician Fee Schedule Relative Value File, Resource-Based Relative Value File, copyrighted by the American Medical Association. The Relative Value File is available from the American Medical Association, 515 N. State Street, Chicago, IL 60610 or by calling 1-800-621-8335. These indicators will shall be used to determine reimbursement by the Division.



Chapter 2 Medical Services, continued Surgical Services, continued Two Surgeons Distinct Parts

Reimbursements will shall be made to two (2) surgeons at the same operative session for performing distinct parts of a surgical procedure. The services provided must shall be identified by the same procedure code with modifier 62 appended.

Two Surgeons Separate Procedures

Reimbursement will shall be made to two surgeons for rendering separate surgical procedures during the same operative session. The services must shall be identified by billing different, unmodified procedure codes.

Reimbursement to each surgeon will shall be:

• The listed MRA in Chapter 3; Part B; or • The agreed upon contract price.

Note: Reimbursement will not be made to either surgeon until the carrier has received and reviewed each surgeon’s bill and individual operative reports.

Surgical Team Reimbursement for a surgical team will shall be made By Report (BR) to each team

member for each surgeon’s surgical service. Each team member must shall identify the specific procedure they provided by appending modifier 66 to the procedure code(s) billed. Note: Reimbursement will not be made until all surgical bills and individual operative reports are received and reviewed by the carrier.



Chapter 2 Medical Services, continued Surgical Services, continued Billing and Reimbursement for Multiple Surgical Procedures

Reimbursement will shall be made for all medically necessary surgical procedures when more than one (1) procedure is performed at a single operative session.

• Each procedure performed must shall be identified by use of the appropriate five-digit CPT® code and listed separately.

• The primary, or most significant procedure, must shall be reported first. • Each additional procedure code must shall be listed separately and

reported with a modifier 51. Reimbursement for the primary surgical procedure will shall be the MRA listed in Chapter 3, Part B of this Manual or the agreed upon contract price. Reimbursement for additional procedure(s) will shall be fifty percent (50%) of the listed MRA in Chapter 3, Part B of this Manual or the agreed upon contract price. Note: Designated add-on procedure codes, listed in the CPT® Manual are exempt from modifier 51 billing and the multiple surgery pricing reduction rules. Add-on procedure codes must shall not be billed with a modifier 51. Add-on procedure codes must shall be billed immediately following their primary procedure codes for proper identification and reimbursement. Note: If there is an agreed upon contract between the health care provider and the carrier, the contract establishes the reimbursement at a specified contract price.

Billing and Reimbursement for Procedures Listed as Bilateral

Bilateral procedures that are listed as “bilateral” in the CPT® description are exempt from modifier 50. Bill using the five digit procedure code only. Reimbursement will shall be:

• The MRA listed in Chapter 3, Part B in this Manual; or • The agreed upon contract price.



Chapter 2 Medical Services, continued Surgical Services, continued Billing and Reimbursement for Bilateral Procedures Not Listed as Bilateral

Procedures performed bilaterally that do not contain the word “bilateral” in CPT® require a modifier to identify they are performed bilaterally for proper reimbursement. Bill the five digit procedure code on one line only using modifier 50. Reimbursement for a bilateral procedure that does not include the word “bilateral” in the description will shall only be made when the payment policy indicators from an authoritative resource, such as the National Physician Fee Schedule Relative Value File, allows bilateral reimbursement. If the payment policy indicator allows bilateral reimbursement, the maximum reimbursement amount will shall be:

• One hundred and fifty percent (150%) of the MRA, unless otherwise stated in this Manual; or

• The agreed upon contract price.



Chapter 2 Medical Services, continued Surgical Services, continued Bilateral Procedures with Multiple Surgery

• Bill the first procedure code on the first line using no modifier 51;

• Bill additional procedure(s) using modifier 51 to indicate multiple procedures performed during the same operative session; and

• For the bilateral procedure(s), use modifier 50 in the first modifier position followed by modifier 51 in the second modifier position, where appropriate.

Note: Add-on procedure codes, listed in the CPT® Manual, are exempt from modifier 51 billing and from the multiple surgery pricing reduction rules. Add-on procedure codes must shall not be billed with a modifier 51.

Bilateral Procedures Performed Unilaterally Procedures

When a procedure is listed in the CPT® as a bilateral-procedure, but, it is performed only unilaterally, the procedure must shall be identified with a modifier 52. Reimbursement will shall be fifty percent (50%) of:

• The MRA listed in Chapter 3, Part B; or • The agreed upon contract amount for a bilateral procedure.

Terminated Procedures A bill submitted for reimbursement of a terminated surgery must include

documentation that specifies the following:

1. Reason for termination of surgery; 2. Services, reported by CPT® code, that were actually performed; 3. Services, reported by CPT® code, not performed that would have

been performed if surgery had not been terminated; 4. Supplies actually provided; 5. Supplies not provided that would have been provided if the surgery

had not been terminated; 6. Time actually spent by the health care provider in each stage, e.g.

pre-operative, operative, and post-operative; 7. Time that would have been spent in each of these stages if the

surgery had not been terminated; and 8. Modifier 53 must be added to the procedure codes to identify the

circumstances under which the services were terminated.



Chapter 2 Medical Services, continued Surgical Services, continued Reimbursement for Terminated Procedures

Terminated Procedures will shall be reimbursed as follows:

• No reimbursement will shall be made for a procedure that is terminated either for medical or non-medical reasons before the pre-operative procedures are initiated by staff.

• Reimbursement will shall be fifty percent (50%) of the amount allowed for the procedure(s), according to the policies in this Manual, if a procedure is terminated due to the onset of medical complications after the patient has been taken to the operating suite, but before anesthesia has been induced.

• Payment will shall be fifty percent (50%) of the amount allowed for the procedure(s), according to policies in this Manual, if a medical complication arises which causes the procedure to be terminated after induction of anesthesia.

Modifier 51 Exempt A procedure code that is “Modifier 51 Exempt” is a HCPCS or CPT® code

typically performed with another procedure. These procedure codes are summarized, but not completely identified, in the CPT codebook incorporated by reference in Rule 69L-8.074, F.A.C.

“Modifier 51 Exempt” procedure codes do not require modifier 51 in Field 24d on DFS-F5-DWC-9 Claim Form and are reimbursed at 100% of the Maximum Reimbursement Allowance (MRA).



THIS PAGE LEFT INTENTIONALLY BLANK


2015 Edition Effective Date: ____________

Chapter 3 Maximum Reimbursement Allowances General Instructions This chapter establishes the Maximum Reimbursement Allowances (MRAs)

for services and procedures performed by workers’ compensation providers of this manual and for out-of-state providers who have not contracted with the carrier for an alternate reimbursement.

Part A Part A establishes the Maximum Reimbursement Allowances (MRAs) for

services and procedures performed by workers’ compensation providers not specifically addressed in this Manual and for out-of-state providers who have not contracted with the carrier for an alternate reimbursement. Part A also includes the basic value (or base unit) on which reimbursement shall be calculated for all anesthesia services according to this Manual.

Part B Part B establishes the Maximum Reimbursement Allowances (MRAs) for

Florida physician providers of surgical procedures and services. Physician assistants and advanced registered nurse practitioners will shall be paid eighty-five percent (85%) of the physician’s MRA when these non-physician providers directly perform the surgical procedure or service.

Part C Part C establishes the Maximum Reimbursement Allowances (MRAs) for

Florida physicians, physical and occupational therapists, athletic trainers, audiologists, speech pathologists, and psychologist providers of non-surgical procedures and services. Physician assistants and advanced registered nurse practitioners will shall be paid eighty-five percent (85%) of the physician’s MRA when these non-physician providers directly perform a non-surgical procedure or service.

Part C also establishes the MRAs for independent clinical laboratories, freestanding imaging/x-ray centers, dietitians, nutritionists, nutrition counselors and clinical social workers.


Chapter 3 Maximum Reimbursement Allowances, continued To determine the MRA to which a provider is entitled under Part B or Part C:

Determining the MRA

A. Determine the county location of the provider according to the Medicare locality map in Appendix C.

B. Determine whether the procedure should be paid according to the non-facility MRA (services rendered in a provider’s office, urgent care center, diagnostic facility, nursing home, home health agency or home) or the facility MRA (services rendered in a hospital setting, ambulatory surgical center, skilled nursing facility, inpatient psychiatric facility, or comprehensive [Level III] outpatient rehabilitation facility).

C. Identify the specific CPT® code in the far left column of the matrix and the correct locality/non-facility or facility column across the top row.

D. Locate the point of intersection for the procedure code row and the appropriate non-facility or facility locality column on the reimbursement matrix.

E. Compare the amount allowed at the point of intersection on the matrix to the amount listed in the 2003 column.

F. Reimburse the provider the greater of the amount in the 2003 MRA column or the amount in the column at the point of intersection.

20165 Edition

Effective Date: __________

Chapter 3 Maximum Reimbursement Allowances, continued

PART A

SCHEDULE OF MAXIMUM REIMBURSEMENT

ALLOWANCES

Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2016 EditionRULE- 69L-7.020, F.A.C., Effective ___________

CPT only © 2015 American Medical Association. All Rights Reserved. PartA, 71

Anesthesia Anesthesia AnesthesiaCPT Code BV + TM CPT Code BV + TM CPT Code BV + TM

00100 5 + TM 00528 8 + TM 00842 4 + TM00102 6 + TM 00529 11 + TM 00844 7 + TM00103 5 + TM 00530 4 + TM 00846 8 + TM00104 4 + TM 00532 4 + TM 00848 8 + TM00120 5 + TM 00534 7 + TM 00851 6 + TM00124 4 + TM 00537 10 + TM 00860 6 + TM00126 4 + TM 00539 18 + TM 00862 7 + TM00140 5 + TM 00540 12 + TM 00864 8 + TM00142 4 + TM 00541 15 + TM 00865 7 + TM00144 6 + TM 00542 15 + TM 00866 10 + TM00145 6 + TM 00546 15 + TM 00868 10 + TM00147 6 + TM 00548 17 + TM 00870 5 + TM00148 4 + TM 00550 10 + TM 00872 7 + TM00160 5 + TM 00560 15 + TM 00873 5 + TM00162 7 + TM 00562 20 + TM 00880 15 + TM00164 4 + TM 00563 25 + TM 00882 10 + TM00170 5 + TM 00566 25 + TM 00902 5 + TM00172 6 + TM 00567 18 + TM 00904 7 + TM00174 6 + TM 00580 20 + TM 00906 4 + TM00176 7 + TM 00600 10 + TM 00908 6 + TM00190 5 + TM 00604 13 + TM 00910 3 + TM00192 7 + TM 00620 10 + TM 00912 5 + TM00210 11 + TM 00625 13 + TM 00914 5 + TM00211 10 + TM 00626 15 + TM 00916 5 + TM00212 5 + TM 00630 8 + TM 00918 5 + TM00214 9 + TM 00632 7 + TM 00920 3 + TM00215 9 + TM 00635 4 + TM 00921 3 + TM00216 15 + TM 00640 3 + TM 00922 6 + TM00218 13 + TM 00670 13 + TM 00924 4 + TM00220 10 + TM 00700 4 + TM 00926 4 + TM00222 6 + TM 00702 4 + TM 00928 6 + TM00300 5 + TM 00730 5 + TM 00930 4 + TM00320 6 + TM 00740 5 + TM 00932 4 + TM00322 3 + TM 00750 4 + TM 00934 6 + TM00350 10 + TM 00752 6 + TM 00936 8 + TM00352 5 + TM 00754 7 + TM 00938 4 + TM00400 3 + TM 00756 7 + TM 00940 3 + TM00402 5 + TM 00770 15 + TM 00942 4 + TM00404 5 + TM 00790 7 + TM 00944 6 + TM00406 13 + TM 00792 13 + TM 00948 4 + TM00410 4 + TM 00794 8 + TM 00950 5 + TM00450 5 + TM 00796 30 + TM 00952 4 + TM00454 3 + TM 00797 11 + TM 01112 5 + TM00470 6 + TM 00800 4 + TM 01120 6 + TM00472 10 + TM 00802 5 + TM 01130 3 + TM00474 13 + TM 00810 5 + TM 01140 15 + TM00500 15 + TM 00820 5 + TM 01150 10 + TM00520 6 + TM 00830 4 + TM 01160 4 + TM00522 4 + TM 00832 6 + TM 01170 8 + TM00524 4 + TM 00840 6 + TM 01173 12 + TM


CPT only © 2015 American Medical Association. All Rights Reserved. PartA, 72

Anesthesia Anesthesia AnesthesiaCPT Code BV + TM CPT Code BV + TM CPT Code BV + TM

01180 3 + TM 01630 5 + TM 01951 3 + TM01190 4 + TM 01634 9 + TM 01952 5 + TM01200 4 + TM 01636 15 + TM 01953 1 + TM01202 4 + TM 01638 10 + TM 01960 5 + TM01210 6 + TM 01650 6 + TM 01961 7 + TM01212 10 + TM 01652 10 + TM 01962 8 + TM01214 8 + TM 01654 8 + TM 01963 10 + TM01215 10 + TM 01656 10 + TM 01967 5 + TM01220 4 + TM 01670 4 + TM 01968 3 + TM01230 6 + TM 01680 3 + TM 01969 5 + TM01232 5 + TM 01682 4 + TM 01990 001234 8 + TM 01710 3 + TM 01991 3 + TM01250 4 + TM 01712 5 + TM 01992 5 + TM01260 3 + TM 01714 5 + TM 01996 301270 8 + TM 01716 5 + TM 01999 BR01272 4 + TM 01730 3 + TM01274 6 + TM 01732 3 + TM01320 4 + TM 01740 4 + TM01340 4 + TM 01742 5 + TM01360 5 + TM 01744 5 + TM01380 3 + TM 01756 6 + TM01382 3 + TM 01758 5 + TM01390 3 + TM 01760 7 + TM01392 4 + TM 01770 6 + TM01400 4 + TM 01772 6 + TM01402 7 + TM 01780 3 + TM01404 5 + TM 01782 4 + TM01420 3 + TM 01810 3 + TM01430 3 + TM 01820 3 + TM01432 6 + TM 01829 3 + TM01440 8 + TM 01830 3 + TM01442 8 + TM 01832 6 + TM01444 8 + TM 01840 6 + TM01462 3 + TM 01842 6 + TM01464 3 + TM 01844 6 + TM01470 3 + TM 01850 3 + TM01472 5 + TM 01852 4 + TM01474 5 + TM 01860 3 + TM01480 3 + TM 01916 5 + TM01482 4 + TM 01920 7 + TM01484 4 + TM 01922 7 + TM01486 7 + TM 01924 6 + TM01490 3 + TM 01925 8 + TM01500 8 + TM 01926 10 + TM01502 6 + TM 01930 5 + TM01520 3 + TM 01931 7 + TM01522 5 + TM 01932 7 + TM01610 5 + TM 01933 8 + TM01620 4 + TM 01935 5 + TM01622 4 + TM 01936 5 + TM


CPT only © 2015 American Medical Association. All Rights Reserved. Part A, 73

Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD10021 $90.00 0 11401 $114.00 10 11760 $131.00 1010022 $92.00 0 11402 $145.00 10 11762 $223.00 1010030 $791.00 0 11403 $178.00 10 11765 $65.00 1010035 $544.00 0 11404 $200.00 10 11770 $275.00 1010036 $473.00 ZZZ 11406 $246.00 10 11771 $496.00 9010040 $54.00 10 11420 $98.00 10 11772 $585.00 9010060 $53.00 10 11421 $92.00 10 11900 $33.00 010061 $133.00 10 11422 $157.00 10 11901 $37.00 010080 $65.00 10 11423 $163.00 10 11920 $147.00 010081 $203.00 10 11424 $221.00 10 11921 $172.00 010120 $53.00 10 11426 $303.00 10 11922 $40.00 ZZZ10121 $169.00 10 11440 $105.00 10 11950 $107.00 010140 $53.00 10 11441 $102.00 10 11951 $114.00 010160 $45.00 10 11442 $174.00 10 11952 $155.00 010180 $164.00 10 11443 $221.00 10 11954 $165.00 011000 $45.00 0 11444 $276.00 10 11960 $829.00 9011001 $27.00 ZZZ 11446 $344.00 10 11970 $632.00 9011004 $564.00 0 11450 $282.00 90 11971 $280.00 9011005 $768.00 0 11451 $366.00 90 11976 $123.00 011006 $710.00 0 11462 $264.00 90 12001 $84.00 011008 $289.00 ZZZ 11463 $351.00 90 12002 $98.00 011010 $348.00 10 11470 $320.00 90 12004 $122.00 011011 $432.00 0 11471 $391.00 90 12005 $165.00 011012 $597.00 0 11600 $148.00 10 12006 $203.00 011042 $88.00 0 11601 $180.00 10 12007 $339.00 011043 $210.00 0 11602 $199.00 10 12011 $98.00 011044 $283.00 0 11603 $226.00 10 12013 $141.00 011045 $43.00 ZZZ 11604 $249.00 10 12014 $165.00 011046 $75.00 ZZZ 11606 $315.00 10 12015 $207.00 011047 $127.00 ZZZ 11620 $150.00 10 12016 $268.00 011055 $26.00 0 11621 $191.00 10 12017 $316.00 011056 $35.00 0 11622 $223.00 10 12018 $515.00 011057 $39.00 0 11623 $259.00 10 12020 $211.00 1011100 $78.00 0 11624 $305.00 10 12021 $87.00 1011101 $41.00 ZZZ 11626 $373.00 10 12031 $93.00 1011200 $66.00 10 11640 $168.00 10 12032 $110.00 1011201 $26.00 ZZZ 11641 $227.00 10 12034 $148.00 1011300 $59.00 0 11642 $260.00 10 12035 $223.00 1011301 $80.00 0 11643 $305.00 10 12036 $356.00 1011302 $96.00 0 11644 $380.00 10 12037 $411.00 1011303 $119.00 0 11646 $494.00 10 12041 $116.00 1011305 $61.00 0 11719 $22.00 0 12042 $141.00 1011306 $86.00 0 11720 $32.00 0 12044 $176.00 1011307 $100.00 0 11721 $50.00 0 12045 $250.00 1011308 $125.00 0 11730 $62.00 0 12046 $341.00 1011310 $75.00 0 11732 $31.00 ZZZ 12047 $363.00 1011311 $95.00 0 11740 $41.00 0 12051 $126.00 1011312 $110.00 0 11750 $156.00 10 12052 $148.00 1011313 $144.00 0 11752 $234.00 10 12053 $223.00 1011400 $81.00 10 11755 $106.00 0 12054 $301.00 10



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD12055 $380.00 10 15157 $196.00 ZZZ 15793 $232.00 9012056 $487.00 10 15200 $644.00 90 15819 $780.00 9012057 $539.00 10 15201 $126.00 ZZZ 15820 $556.00 9013100 $178.00 10 15220 $687.00 90 15821 $607.00 9013101 $240.00 10 15221 $114.00 ZZZ 15822 $499.00 9013102 $89.00 ZZZ 15240 $763.00 90 15823 $718.00 9013120 $223.00 10 15241 $334.00 ZZZ 15824 BR 013121 $348.00 10 15260 $841.00 90 15825 BR 013122 $104.00 ZZZ 15261 $207.00 ZZZ 15826 BR 013131 $252.00 10 15271 $143.00 0 15828 BR 013132 $484.00 10 15272 $27.00 ZZZ 15829 BR 013133 $154.00 ZZZ 15273 $299.00 0 15830 $1,072.00 9013151 $375.00 10 15274 $70.00 ZZZ 15832 $926.00 9013152 $542.00 10 15275 $155.00 0 15833 $833.00 9013153 $169.00 ZZZ 15276 $35.00 ZZZ 15834 $837.00 9013160 $655.00 90 15277 $320.00 0 15835 $865.00 9014000 $512.00 90 15278 $83.00 ZZZ 15836 $721.00 9014001 $695.00 90 15570 $748.00 90 15837 $696.00 9014020 $590.00 90 15572 $721.00 90 15838 $600.00 9014021 $818.00 90 15574 $775.00 90 15839 $643.00 9014040 $701.00 90 15576 $457.00 90 15840 $1,187.00 9014041 $936.00 90 15600 $259.00 90 15841 $1,859.00 9014060 $766.00 90 15610 $320.00 90 15842 $3,099.00 9014061 $1,330.00 90 15620 $506.00 90 15845 $1,116.00 9014301 $1,088.00 90 15630 $362.00 90 15850 $63.00 014302 $228.00 ZZZ 15650 $427.00 90 15851 $40.00 014350 $734.00 90 15731 $990.00 90 15852 $35.00 015002 $351.00 0 15732 $1,465.00 90 15860 $151.00 015003 $77.00 ZZZ 15734 $1,557.00 90 15876 BR 015004 $407.00 0 15736 $1,862.00 90 15877 BR 015005 $127.00 ZZZ 15738 $1,415.00 90 15878 BR 015040 $258.00 0 15740 $913.00 90 15879 BR 015050 $349.00 90 15750 $1,064.00 90 15920 $571.00 9015100 $679.00 90 15756 $2,892.00 90 15922 $771.00 9015101 $146.00 ZZZ 15757 $2,892.00 90 15931 $638.00 9015110 $815.00 90 15758 $2,884.00 90 15933 $860.00 9015111 $129.00 ZZZ 15760 $810.00 90 15934 $1,064.00 9015115 $766.00 90 15770 $674.00 90 15935 $1,184.00 9015116 $167.00 ZZZ 15775 $327.00 0 15936 $1,032.00 9015120 $788.00 90 15776 $475.00 0 15937 $1,223.00 9015121 $235.00 ZZZ 15777 $219.00 ZZZ 15940 $318.00 9015130 $677.00 90 15780 $532.00 90 15941 $919.00 9015131 $105.00 ZZZ 15781 $420.00 90 15944 $954.00 9015135 $820.00 90 15782 $314.00 90 15945 $1,078.00 9015136 $98.00 ZZZ 15783 $340.00 90 15946 $1,737.00 9015150 $677.00 90 15786 $146.00 10 15950 $549.00 9015151 $136.00 ZZZ 15787 $27.00 ZZZ 15951 $872.00 9015152 $167.00 ZZZ 15788 $194.00 90 15952 $876.00 9015155 $678.00 90 15789 $360.00 90 15953 $1,013.00 9015156 $177.00 ZZZ 15792 $130.00 90 15956 $1,382.00 90



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD15958 $1,379.00 90 19083 $677.00 0 19369 $2,317.00 9015999 BR YYY 19084 $543.00 ZZZ 19370 $662.00 9016000 $53.00 0 19085 $1,025.00 0 19371 $788.00 9016020 $49.00 0 19086 $817.00 ZZZ 19380 $780.00 9016025 $67.00 0 19100 $117.00 0 19396 $231.00 016030 $153.00 0 19101 $338.00 10 19499 BR YYY16035 $341.00 0 19105 $1,878.00 0 20005 $267.00 1016036 $81.00 ZZZ 19110 $406.00 90 20100 $727.00 1017000 $60.00 10 19112 $354.00 90 20101 $261.00 1017003 $16.00 ZZZ 19120 $429.00 90 20102 $314.00 1017004 $233.00 10 19125 $468.00 90 20103 $405.00 1017106 $341.00 90 19126 $201.00 ZZZ 20150 $1,141.00 9017107 $648.00 90 19260 $1,101.00 90 20200 $134.00 017108 $1,015.00 90 19271 $1,561.00 90 20205 $243.00 017110 $55.00 10 19272 $1,674.00 90 20206 $119.00 017111 $83.00 10 19281 $246.00 0 20220 $128.00 017250 $27.00 0 19282 $171.00 ZZZ 20225 $215.00 017260 $96.00 10 19283 $279.00 0 20240 $279.00 017261 $117.00 10 19284 $205.00 ZZZ 20245 $364.00 1017262 $150.00 10 19285 $472.00 0 20250 $447.00 1017263 $172.00 10 19286 $396.00 ZZZ 20251 $511.00 1017264 $189.00 10 19287 $875.00 0 20500 $59.00 1017266 $225.00 10 19288 $696.00 ZZZ 20501 $60.00 017270 $125.00 10 19296 $4,903.00 0 20520 $75.00 1017271 $143.00 10 19297 $96.00 ZZZ 20525 $331.00 1017272 $170.00 10 19298 $1,841.00 0 20526 $64.00 017273 $195.00 10 19300 $482.00 90 20527 $84.00 017274 $240.00 10 19301 $367.00 90 20550 $40.00 017276 $281.00 10 19302 $780.00 90 20551 $62.00 017280 $123.00 10 19303 $788.00 90 20552 $62.00 017281 $165.00 10 19304 $487.00 90 20553 $62.00 017282 $194.00 10 19305 $964.00 90 20555 $301.00 017283 $239.00 10 19306 $1,003.00 90 20600 $41.00 017284 $282.00 10 19307 $1,008.00 90 20604 $73.00 017286 $373.00 10 19316 $954.00 90 20605 $48.00 017311 $629.00 0 19318 $1,313.00 90 20606 $81.00 017312 $380.00 ZZZ 19324 $440.00 90 20610 $49.00 017313 $575.00 0 19325 $656.00 90 20611 $93.00 017314 $352.00 ZZZ 19328 $457.00 90 20612 $56.00 017315 $74.00 ZZZ 19330 $569.00 90 20615 $94.00 1017340 $37.00 10 19340 $545.00 90 20650 $170.00 1017360 $96.00 10 19342 $963.00 90 20660 $320.00 017380 BR 0 19350 $853.00 90 20661 $476.00 9017999 BR YYY 19355 $755.00 90 20662 $559.00 9019000 $74.00 0 19357 $1,449.00 90 20663 $465.00 9019001 $40.00 ZZZ 19361 $1,667.00 90 20665 $105.00 1019020 $288.00 90 19364 $2,737.00 90 20670 $80.00 1019030 $98.00 0 19366 $1,676.00 90 20680 $332.00 9019081 $682.00 0 19367 $2,056.00 90 20690 $298.00 9019082 $551.00 ZZZ 19368 $2,444.00 90 20692 $516.00 90



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD20693 $477.00 90 21029 $700.00 90 21155 $2,640.00 9020694 $421.00 90 21030 $496.00 90 21159 $3,302.00 9020696 $1,156.00 90 21031 $310.00 90 21160 $3,500.00 9020697 $1,860.00 0 21032 $315.00 90 21172 $2,111.00 9020802 $3,363.00 90 21034 $1,140.00 90 21175 $2,604.00 9020805 $4,317.00 90 21040 $227.00 90 21179 $1,826.00 9020808 $5,324.00 90 21044 $957.00 90 21180 $2,035.00 9020816 $3,060.00 90 21045 $1,313.00 90 21181 $813.00 9020822 $2,511.00 90 21046 $899.00 90 21182 $2,570.00 9020824 $3,027.00 90 21047 $1,109.00 90 21183 $2,770.00 9020827 $3,920.00 90 21048 $925.00 90 21184 $3,150.00 9020838 $3,484.00 90 21049 $1,051.00 90 21188 $1,786.00 9020900 $454.00 0 21050 $1,026.00 90 21193 $1,331.00 9020902 $658.00 0 21060 $972.00 90 21194 $1,540.00 9020910 $338.00 90 21070 $679.00 90 21195 $1,360.00 9020912 $549.00 90 21073 $337.00 90 21196 $1,764.00 9020920 $460.00 90 21076 $1,192.00 10 21198 $1,268.00 9020922 $634.00 90 21077 $3,002.00 90 21199 $1,018.00 9020924 $583.00 90 21079 $2,086.00 90 21206 $1,112.00 9020926 $444.00 90 21080 $2,346.00 90 21208 $946.00 9020930 BR 0 21081 $2,138.00 90 21209 $576.00 9020931 $156.00 ZZZ 21082 $1,855.00 90 21210 $930.00 9020936 BR 0 21083 $1,802.00 90 21215 $970.00 9020937 $234.00 ZZZ 21084 $2,105.00 90 21230 $956.00 9020938 $257.00 ZZZ 21085 $801.00 10 21235 $707.00 9020950 $123.00 0 21086 $2,333.00 90 21240 $1,281.00 9020955 $3,332.00 90 21087 $2,217.00 90 21242 $1,207.00 9020956 $3,167.00 90 21088 BR 90 21243 $1,501.00 9020957 $3,074.00 90 21089 BR YYY 21244 $1,062.00 9020962 $3,122.00 90 21100 $297.00 90 21245 $1,038.00 9020969 $3,716.00 90 21110 $371.00 90 21246 $1,010.00 9020970 $3,650.00 90 21116 $207.00 0 21247 $2,003.00 9020972 $3,420.00 90 21120 $500.00 90 21248 $1,023.00 9020973 $3,821.00 90 21121 $651.00 90 21249 $1,525.00 9020974 $266.00 0 21122 $700.00 90 21255 $1,459.00 9020975 $334.00 0 21123 $903.00 90 21256 $1,470.00 9020979 $19.00 0 21125 $656.00 90 21260 $1,372.00 9020982 $4,231.00 0 21127 $909.00 90 21261 $2,347.00 9020983 $7,394.00 0 21137 $797.00 90 21263 $2,361.00 9020985 $140.00 ZZZ 21138 $960.00 90 21267 $1,539.00 9020999 BR YYY 21139 $1,168.00 90 21268 $1,946.00 9021010 $854.00 90 21141 $1,438.00 90 21270 $890.00 9021011 $349.00 90 21142 $1,527.00 90 21275 $963.00 9021012 $341.00 90 21143 $1,511.00 90 21280 $571.00 9021013 $521.00 90 21145 $1,513.00 90 21282 $360.00 9021014 $528.00 90 21146 $1,570.00 90 21295 $144.00 9021015 $520.00 90 21147 $1,639.00 90 21296 $384.00 9021016 $1,063.00 90 21150 $1,914.00 90 21299 BR YYY21025 $546.00 90 21151 $2,264.00 90 21310 $81.00 021026 $413.00 90 21154 $2,364.00 90 21315 $180.00 10



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD21320 $235.00 10 21485 $318.00 90 22102 $781.00 9021325 $348.00 90 21490 $865.00 90 22103 $198.00 ZZZ21330 $639.00 90 21495 $500.00 90 22110 $889.00 9021335 $852.00 90 21497 $372.00 90 22112 $1,090.00 9021336 $478.00 90 21499 BR YYY 22114 $1,062.00 9021337 $300.00 90 21501 $315.00 90 22116 $195.00 ZZZ21338 $550.00 90 21502 $612.00 90 22206 $2,153.00 9021339 $689.00 90 21510 $534.00 90 22207 $2,126.00 9021340 $907.00 90 21550 $165.00 10 22208 $545.00 ZZZ21343 $1,043.00 90 21552 $453.00 90 22210 $1,892.00 9021344 $1,450.00 90 21554 $744.00 90 22212 $1,668.00 9021345 $738.00 90 21555 $337.00 90 22214 $819.00 9021346 $917.00 90 21556 $431.00 90 22216 $492.00 ZZZ21347 $1,048.00 90 21557 $794.00 90 22220 $1,801.00 9021348 $1,286.00 90 21558 $1,380.00 90 22222 $1,604.00 9021355 $295.00 10 21600 $631.00 90 22224 $1,731.00 9021356 $372.00 10 21610 $828.00 90 22226 $488.00 ZZZ21360 $590.00 90 21615 $938.00 90 22305 $213.00 9021365 $1,239.00 90 21616 $1,042.00 90 22310 $272.00 9021366 $1,386.00 90 21620 $689.00 90 22315 $711.00 9021385 $810.00 90 21627 $686.00 90 22318 $1,755.00 9021386 $812.00 90 21630 $1,455.00 90 22319 $1,983.00 9021387 $958.00 90 21632 $1,514.00 90 22325 $1,407.00 9021390 $920.00 90 21685 $918.00 90 22326 $1,710.00 9021395 $1,384.00 90 21700 $576.00 90 22327 $1,660.00 9021400 $143.00 90 21705 $746.00 90 22328 $391.00 ZZZ21401 $313.00 90 21720 $523.00 90 22505 $174.00 1021406 $852.00 90 21725 $588.00 90 22510 $1,804.00 1021407 $736.00 90 21740 $1,387.00 90 22511 $1,786.00 1021408 $1,007.00 90 21742 BR 90 22512 $1,001.00 ZZZ21421 $528.00 90 21743 BR 90 22513 $7,471.00 1021422 $761.00 90 21750 $1,009.00 90 22514 $7,462.00 1021423 $890.00 90 21811 $634.00 0 22515 $4,518.00 ZZZ21431 $598.00 90 21812 $761.00 0 22526 $2,013.00 1021432 $744.00 90 21813 $992.00 0 22527 $1,637.00 ZZZ21433 $1,981.00 90 21820 $143.00 90 22532 $1,618.00 9021435 $1,404.00 90 21825 $810.00 90 22533 $1,509.00 9021436 $2,045.00 90 21899 BR YYY 22534 $381.00 ZZZ21440 $308.00 90 21920 $165.00 10 22548 $2,271.00 9021445 $533.00 90 21925 $371.00 90 22551 $1,759.00 9021450 $325.00 90 21930 $403.00 90 22552 $406.00 ZZZ21451 $498.00 90 21931 $478.00 90 22554 $1,727.00 9021452 $195.00 90 21932 $672.00 90 22556 $2,054.00 9021453 $902.00 90 21933 $749.00 90 22558 $1,907.00 9021454 $905.00 90 21935 $1,280.00 90 22585 $473.00 ZZZ21461 $769.00 90 21936 $1,442.00 90 22586 $1,926.00 9021462 $1,012.00 90 22010 $822.00 90 22590 $1,895.00 9021465 $923.00 90 22015 $815.00 90 22595 $1,960.00 9021470 $1,331.00 90 22100 $850.00 90 22600 $1,567.00 9021480 $82.00 0 22101 $862.00 90 22610 $1,494.00 90



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD22612 $1,861.00 90 23044 $708.00 90 23450 $1,210.00 9022614 $530.00 ZZZ 23065 $171.00 10 23455 $1,340.00 9022630 $1,201.00 90 23066 $302.00 90 23460 $1,364.00 9022632 $442.00 ZZZ 23071 $426.00 90 23462 $1,383.00 9022633 $1,894.00 90 23073 $705.00 90 23465 $1,398.00 9022634 $511.00 ZZZ 23075 $247.00 90 23466 $1,332.00 9022800 $1,960.00 90 23076 $613.00 90 23470 $1,540.00 9022802 $2,633.00 90 23077 $1,228.00 90 23472 $1,570.00 9022804 $2,951.00 90 23078 $1,476.00 90 23473 $1,672.00 9022808 $2,157.00 90 23100 $616.00 90 23474 $1,807.00 9022810 $2,356.00 90 23101 $583.00 90 23480 $926.00 9022812 $2,675.00 90 23105 $814.00 90 23485 $1,181.00 9022818 $2,701.00 90 23106 $581.00 90 23490 $1,038.00 9022819 $2,968.00 90 23107 $851.00 90 23491 $1,251.00 9022830 $1,176.00 90 23120 $645.00 90 23500 $148.00 9022840 $943.00 ZZZ 23125 $865.00 90 23505 $293.00 9022841 BR 0 23130 $722.00 90 23515 $688.00 9022842 $2,352.00 ZZZ 23140 $597.00 90 23520 $205.00 9022843 $1,028.00 ZZZ 23145 $889.00 90 23525 $320.00 9022844 $1,277.00 ZZZ 23146 $704.00 90 23530 $659.00 9022845 $1,853.00 ZZZ 23150 $755.00 90 23532 $713.00 9022846 $999.00 ZZZ 23155 $945.00 90 23540 $148.00 9022847 $1,077.00 ZZZ 23156 $794.00 90 23545 $148.00 9022848 $529.00 ZZZ 23170 $645.00 90 23550 $701.00 9022849 $2,235.00 90 23172 $638.00 90 23552 $753.00 9022850 $872.00 90 23174 $882.00 90 23570 $88.00 9022851 $600.00 ZZZ 23180 $566.00 90 23575 $306.00 9022852 $854.00 90 23182 $865.00 90 23585 $809.00 9022855 $1,193.00 90 23184 $962.00 90 23600 $318.00 9022856 $1,701.00 90 23190 $656.00 90 23605 $511.00 9022857 $1,386.00 90 23195 $902.00 90 23615 $900.00 9022858 $527.00 ZZZ 23200 $1,095.00 90 23616 $1,895.00 9022861 $2,262.00 90 23210 $1,095.00 90 23620 $286.00 9022862 $1,690.00 90 23220 $1,307.00 90 23625 $422.00 9022864 $2,035.00 90 23330 $59.00 10 23630 $712.00 9022865 $1,646.00 90 23333 $466.00 90 23650 $296.00 9022899 BR YYY 23334 $1,100.00 90 23655 $374.00 9022900 $446.00 90 23335 $1,312.00 90 23660 $712.00 9022901 $673.00 90 23350 $74.00 0 23665 $440.00 9022902 $436.00 90 23395 $1,366.00 90 23670 $759.00 9022903 $440.00 90 23397 $1,403.00 90 23675 $550.00 9022904 $1,069.00 90 23400 $1,196.00 90 23680 $1,064.00 9022905 $1,362.00 90 23405 $799.00 90 23700 $237.00 1022999 BR YYY 23406 $977.00 90 23800 $1,346.00 9023000 $447.00 90 23410 $1,119.00 90 23802 $1,368.00 9023020 $807.00 90 23412 $1,229.00 90 23900 $1,561.00 9023030 $323.00 10 23415 $622.00 90 23920 $1,300.00 9023031 $185.00 10 23420 $1,276.00 90 23921 $497.00 9023035 $861.00 90 23430 $884.00 90 23929 BR YYY23040 $898.00 90 23440 $906.00 90 23930 $71.00 10



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD23931 $62.00 10 24344 $971.00 90 24670 $263.00 9023935 $630.00 90 24345 $643.00 90 24675 $490.00 9024000 $550.00 90 24346 $971.00 90 24685 $819.00 9024006 $793.00 90 24357 $408.00 90 24800 $984.00 9024065 $166.00 10 24358 $478.00 90 24802 $1,181.00 9024066 $461.00 90 24359 $587.00 90 24900 $858.00 9024071 $413.00 90 24360 $1,125.00 90 24920 $851.00 9024073 $704.00 90 24361 $1,215.00 90 24925 $661.00 9024075 $349.00 90 24362 $1,269.00 90 24930 $928.00 9024076 $529.00 90 24363 $1,663.00 90 24931 $1,063.00 9024077 $1,058.00 90 24365 $747.00 90 24935 $1,327.00 9024079 $1,357.00 90 24366 $850.00 90 24940 BR 9024100 $467.00 90 24370 $1,581.00 90 24999 BR YYY24101 $591.00 90 24371 $1,826.00 90 25000 $381.00 9024102 $755.00 90 24400 $991.00 90 25001 $294.00 9024105 $360.00 90 24410 $1,319.00 90 25020 $594.00 9024110 $724.00 90 24420 $1,265.00 90 25023 $1,040.00 9024115 $898.00 90 24430 $1,209.00 90 25024 $683.00 9024116 $1,037.00 90 24435 $1,260.00 90 25025 $1,104.00 9024120 $595.00 90 24470 $774.00 90 25028 $417.00 9024125 $663.00 90 24495 $742.00 90 25031 $266.00 9024126 $731.00 90 24498 $1,076.00 90 25035 $794.00 9024130 $595.00 90 24500 $288.00 90 25040 $654.00 9024134 $966.00 90 24505 $574.00 90 25065 $164.00 1024136 $720.00 90 24515 $1,018.00 90 25066 $322.00 9024138 $697.00 90 24516 $1,029.00 90 25071 $432.00 9024140 $963.00 90 24530 $88.00 90 25073 $540.00 9024145 $592.00 90 24535 $671.00 90 25075 $352.00 9024147 $703.00 90 24538 $850.00 90 25076 $544.00 9024149 $1,224.00 90 24545 $946.00 90 25077 $957.00 9024150 $1,265.00 90 24546 $1,273.00 90 25078 $1,195.00 9024152 $829.00 90 24560 $266.00 90 25085 $562.00 9024155 $1,019.00 90 24565 $526.00 90 25100 $420.00 9024160 $533.00 90 24566 $705.00 90 25101 $492.00 9024164 $564.00 90 24575 $872.00 90 25105 $635.00 9024200 $58.00 10 24576 $295.00 90 25107 $600.00 9024201 $444.00 90 24577 $575.00 90 25109 $470.00 9024220 $89.00 0 24579 $964.00 90 25110 $403.00 9024300 $352.00 90 24582 $773.00 90 25111 $356.00 9024301 $869.00 90 24586 $1,314.00 90 25112 $441.00 9024305 $579.00 90 24587 $1,278.00 90 25115 $837.00 9024310 $511.00 90 24600 $360.00 90 25116 $807.00 9024320 $944.00 90 24605 $371.00 90 25118 $466.00 9024330 $845.00 90 24615 $836.00 90 25119 $653.00 9024331 $927.00 90 24620 $560.00 90 25120 $712.00 9024332 $487.00 90 24635 $1,329.00 90 25125 $803.00 9024340 $697.00 90 24650 $262.00 90 25126 $781.00 9024341 $702.00 90 24655 $436.00 90 25130 $502.00 9024342 $950.00 90 24665 $749.00 90 25135 $631.00 9024343 $643.00 90 24666 $905.00 90 25136 $546.00 90



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD25145 $713.00 90 25430 $638.00 90 25685 $887.00 9025150 $720.00 90 25431 $631.00 90 25690 $518.00 9025151 $771.00 90 25440 $931.00 90 25695 $520.00 9025170 $1,085.00 90 25441 $1,147.00 90 25800 $703.00 9025210 $561.00 90 25442 $936.00 90 25805 $1,078.00 9025215 $817.00 90 25443 $970.00 90 25810 $1,008.00 9025230 $531.00 90 25444 $1,031.00 90 25820 $2,276.00 9025240 $567.00 90 25445 $959.00 90 25825 $895.00 9025246 $72.00 0 25446 $1,542.00 90 25830 $991.00 9025248 $236.00 90 25447 $952.00 90 25900 $871.00 9025250 $616.00 90 25449 $395.00 90 25905 $900.00 9025251 $933.00 90 25450 $805.00 90 25907 $799.00 9025259 $348.00 90 25455 $899.00 90 25909 $849.00 9025260 $728.00 90 25490 $955.00 90 25915 $1,523.00 9025263 $809.00 90 25491 $1,006.00 90 25920 $771.00 9025265 $998.00 90 25492 $1,170.00 90 25922 $670.00 9025270 $549.00 90 25500 $200.00 90 25924 $768.00 9025272 $613.00 90 25505 $517.00 90 25927 $830.00 9025274 $887.00 90 25515 $800.00 90 25929 $645.00 9025275 $620.00 90 25520 $644.00 90 25931 $731.00 9025280 $670.00 90 25525 $1,097.00 90 25999 BR YYY25290 $436.00 90 25526 $1,293.00 90 26010 $59.00 1025295 $562.00 90 25530 $270.00 90 26011 $223.00 1025300 $592.00 90 25535 $516.00 90 26020 $484.00 9025301 $757.00 90 25545 $803.00 90 26025 $548.00 9025310 $865.00 90 25560 $276.00 90 26030 $655.00 9025312 $968.00 90 25565 $590.00 90 26034 $601.00 9025315 $1,004.00 90 25574 $804.00 90 26035 $741.00 9025316 $1,203.00 90 25575 $974.00 90 26037 $730.00 9025320 $834.00 90 25600 $312.00 90 26040 $367.00 9025332 $1,022.00 90 25605 $540.00 90 26045 $621.00 9025335 $1,166.00 90 25606 $643.00 90 26055 $343.00 9025337 $946.00 90 25607 $645.00 90 26060 $293.00 9025350 $913.00 90 25608 $739.00 90 26070 $440.00 9025355 $1,014.00 90 25609 $942.00 90 26075 $400.00 9025360 $468.00 90 25622 $148.00 90 26080 $382.00 9025365 $1,216.00 90 25624 $482.00 90 26100 $398.00 9025370 $1,214.00 90 25628 $716.00 90 26105 $481.00 9025375 $1,280.00 90 25630 $148.00 90 26110 $282.00 9025390 $1,043.00 90 25635 $458.00 90 26111 $423.00 9025391 $1,349.00 90 25645 $668.00 90 26113 $557.00 9025392 $1,294.00 90 25650 $185.00 90 26115 $344.00 9025393 $1,473.00 90 25651 $379.00 90 26116 $544.00 9025394 $723.00 90 25652 $560.00 90 26117 $806.00 9025400 $1,112.00 90 25660 $378.00 90 26118 $1,076.00 9025405 $1,388.00 90 25670 $731.00 90 26121 $833.00 9025415 $1,343.00 90 25671 $462.00 90 26123 $959.00 9025420 $1,554.00 90 25675 $404.00 90 26125 $342.00 ZZZ25425 $1,403.00 90 25676 $741.00 90 26130 $629.00 9025426 $1,401.00 90 25680 $471.00 90 26135 $668.00 90



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD26140 $678.00 90 26476 $543.00 90 26593 $587.00 9026145 $660.00 90 26477 $553.00 90 26596 $809.00 9026160 $319.00 90 26478 $608.00 90 26600 $133.00 9026170 $452.00 90 26479 $653.00 90 26605 $296.00 9026180 $444.00 90 26480 $808.00 90 26607 $334.00 9026185 $511.00 90 26483 $986.00 90 26608 $497.00 9026200 $598.00 90 26485 $891.00 90 26615 $521.00 9026205 $788.00 90 26489 $738.00 90 26641 $71.00 9026210 $543.00 90 26490 $496.00 90 26645 $371.00 9026215 $731.00 90 26492 $971.00 90 26650 $533.00 9026230 $624.00 90 26494 $946.00 90 26665 $693.00 9026235 $612.00 90 26496 $949.00 90 26670 $148.00 9026236 $444.00 90 26497 $946.00 90 26675 $501.00 9026250 $814.00 90 26498 $1,317.00 90 26676 $527.00 9026260 $758.00 90 26499 $934.00 90 26685 $592.00 9026262 $624.00 90 26500 $557.00 90 26686 $710.00 9026320 $414.00 90 26502 $715.00 90 26700 $88.00 9026340 $266.00 90 26508 $334.00 90 26705 $296.00 9026341 $99.00 10 26510 $564.00 90 26706 $469.00 9026350 $715.00 90 26516 $630.00 90 26715 $526.00 9026352 $855.00 90 26517 $890.00 90 26720 $96.00 9026356 $886.00 90 26518 $877.00 90 26725 $187.00 9026357 $932.00 90 26520 $583.00 90 26727 $187.00 9026358 $979.00 90 26525 $531.00 90 26735 $532.00 9026370 $832.00 90 26530 $708.00 90 26740 $148.00 9026372 $945.00 90 26531 $877.00 90 26742 $148.00 9026373 $904.00 90 26535 $546.00 90 26746 $548.00 9026390 $889.00 90 26536 $770.00 90 26750 $96.00 9026392 $1,123.00 90 26540 $726.00 90 26755 $133.00 9026410 $371.00 90 26541 $926.00 90 26756 $366.00 9026412 $737.00 90 26542 $716.00 90 26765 $398.00 9026415 $846.00 90 26545 $722.00 90 26770 $79.00 9026416 $1,093.00 90 26546 $918.00 90 26775 $275.00 9026418 $444.00 90 26548 $665.00 90 26776 $401.00 9026420 $741.00 90 26550 $1,861.00 90 26785 $408.00 9026426 $733.00 90 26551 $3,901.00 90 26820 $854.00 9026428 $790.00 90 26553 $3,868.00 90 26841 $756.00 9026432 $430.00 90 26554 $4,551.00 90 26842 $901.00 9026433 $371.00 90 26555 $1,567.00 90 26843 $800.00 9026434 $656.00 90 26556 $4,005.00 90 26844 $875.00 9026437 $491.00 90 26560 $576.00 90 26850 $704.00 9026440 $458.00 90 26561 $1,067.00 90 26852 $829.00 9026442 $548.00 90 26562 $1,017.00 90 26860 $542.00 9026445 $455.00 90 26565 $730.00 90 26861 $151.00 ZZZ26449 $738.00 90 26567 $622.00 90 26862 $747.00 9026450 $353.00 90 26568 $1,003.00 90 26863 $317.00 ZZZ26455 $364.00 90 26580 $1,585.00 90 26910 $747.00 9026460 $346.00 90 26587 $792.00 90 26951 $444.00 9026471 $592.00 90 26590 $1,609.00 90 26952 $608.00 9026474 $586.00 90 26591 $431.00 90 26989 BR YYY



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD26990 $592.00 90 27111 $1,099.00 90 27252 $520.00 9026991 $466.00 90 27120 $1,603.00 90 27253 $1,162.00 9026992 $1,146.00 90 27122 $1,406.00 90 27254 $1,478.00 9027000 $421.00 90 27125 $1,371.00 90 27256 $338.00 1027001 $550.00 90 27130 $1,853.00 90 27257 $455.00 1027003 $698.00 90 27132 $2,128.00 90 27258 $1,355.00 9027005 $738.00 90 27134 $2,576.00 90 27259 $1,803.00 9027006 $788.00 90 27137 $2,190.00 90 27265 $442.00 9027025 $896.00 90 27138 $2,025.00 90 27266 $614.00 9027027 $866.00 90 27140 $1,092.00 90 27267 $382.00 9027030 $1,148.00 90 27146 $1,432.00 90 27268 $470.00 9027033 $1,173.00 90 27147 $1,744.00 90 27269 $1,117.00 9027035 $1,413.00 90 27151 $1,732.00 90 27275 $220.00 1027036 $1,176.00 90 27156 $2,017.00 90 27279 $718.00 9027040 $196.00 10 27158 $1,588.00 90 27280 $1,179.00 9027041 $699.00 90 27161 $1,443.00 90 27282 $990.00 9027043 $476.00 90 27165 $1,572.00 90 27284 $1,435.00 9027045 $764.00 90 27170 $1,453.00 90 27286 $1,503.00 9027047 $535.00 90 27175 $491.00 90 27290 $2,073.00 9027048 $588.00 90 27176 $1,024.00 90 27295 $1,594.00 9027049 $1,162.00 90 27177 $1,257.00 90 27299 BR YYY27050 $449.00 90 27178 $1,020.00 90 27301 $193.00 9027052 $624.00 90 27179 $1,107.00 90 27303 $520.00 9027054 $843.00 90 27181 $1,206.00 90 27305 $555.00 9027057 $972.00 90 27185 $676.00 90 27306 $377.00 9027059 $1,849.00 90 27187 $1,280.00 90 27307 $503.00 9027060 $491.00 90 27193 $425.00 90 27310 $877.00 9027062 $499.00 90 27194 $740.00 90 27323 $211.00 1027065 $583.00 90 27200 $180.00 90 27324 $433.00 9027066 $931.00 90 27202 $776.00 90 27325 $476.00 9027067 $1,234.00 90 27215 $954.00 90 27326 $451.00 9027070 $1,040.00 90 27216 $1,085.00 90 27327 $400.00 9027071 $1,112.00 90 27217 $1,285.00 90 27328 $503.00 9027075 $1,485.00 90 27218 $1,570.00 90 27329 $1,249.00 9027076 $1,859.00 90 27220 $444.00 90 27330 $492.00 9027077 $1,976.00 90 27222 $973.00 90 27331 $585.00 9027078 $1,164.00 90 27226 $1,350.00 90 27332 $786.00 9027080 $568.00 90 27227 $1,967.00 90 27333 $719.00 9027086 $57.00 10 27228 $2,195.00 90 27334 $840.00 9027087 $555.00 90 27230 $491.00 90 27335 $959.00 9027090 $981.00 90 27232 $916.00 90 27337 $425.00 9027091 $1,482.00 90 27235 $1,128.00 90 27339 $765.00 9027093 $62.00 0 27236 $1,421.00 90 27340 $405.00 9027095 $121.00 0 27238 $504.00 90 27345 $565.00 9027096 $491.00 0 27240 $1,043.00 90 27347 $394.00 9027097 $795.00 90 27244 $1,426.00 90 27350 $786.00 9027098 $799.00 90 27245 $1,691.00 90 27355 $763.00 9027100 $987.00 90 27246 $459.00 90 27356 $882.00 9027105 $946.00 90 27248 $980.00 90 27357 $950.00 9027110 $1,174.00 90 27250 $535.00 0 27358 $394.00 ZZZ



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD27360 $977.00 90 27466 $1,441.00 90 27591 $1,182.00 9027364 $1,601.00 90 27468 $1,613.00 90 27592 $911.00 9027365 $1,421.00 90 27470 $1,501.00 90 27594 $600.00 9027370 $75.00 0 27472 $1,665.00 90 27596 $931.00 9027372 $371.00 90 27475 $782.00 90 27598 $976.00 9027380 $698.00 90 27477 $938.00 90 27599 BR YYY27381 $1,118.00 90 27479 $1,123.00 90 27600 $517.00 9027385 $753.00 90 27485 $797.00 90 27601 $516.00 9027386 $1,064.00 90 27486 $1,771.00 90 27602 $621.00 9027390 $506.00 90 27487 $2,352.00 90 27603 $412.00 9027391 $647.00 90 27488 $1,438.00 90 27604 $308.00 9027392 $834.00 90 27495 $1,477.00 90 27605 $236.00 1027393 $608.00 90 27496 $563.00 90 27606 $362.00 1027394 $748.00 90 27497 $652.00 90 27607 $608.00 9027395 $1,093.00 90 27498 $701.00 90 27610 $777.00 9027396 $742.00 90 27499 $782.00 90 27612 $701.00 9027397 $989.00 90 27500 $520.00 90 27613 $165.00 1027400 $832.00 90 27501 $659.00 90 27614 $327.00 9027403 $792.00 90 27502 $909.00 90 27615 $1,106.00 9027405 $842.00 90 27503 $911.00 90 27616 $1,297.00 9027407 $918.00 90 27506 $1,522.00 90 27618 $421.00 9027409 $1,212.00 90 27507 $1,297.00 90 27619 $730.00 9027412 $1,605.00 90 27508 $400.00 90 27620 $587.00 9027415 $1,340.00 90 27509 $649.00 90 27625 $796.00 9027416 $878.00 90 27510 $755.00 90 27626 $863.00 9027418 $1,596.00 90 27511 $1,281.00 90 27630 $430.00 9027420 $927.00 90 27513 $1,562.00 90 27632 $422.00 9027422 $930.00 90 27514 $1,508.00 90 27634 $697.00 9027424 $927.00 90 27516 $579.00 90 27635 $781.00 9027425 $639.00 90 27517 $820.00 90 27637 $921.00 9027427 $1,118.00 90 27519 $1,311.00 90 27638 $978.00 9027428 $1,266.00 90 27520 $266.00 90 27640 $1,122.00 9027429 $2,333.00 90 27524 $910.00 90 27641 $922.00 9027430 $884.00 90 27530 $408.00 90 27645 $1,302.00 9027435 $501.00 90 27532 $641.00 90 27646 $1,212.00 9027437 $819.00 90 27535 $1,075.00 90 27647 $1,044.00 9027438 $1,065.00 90 27536 $1,282.00 90 27648 $72.00 027440 $1,064.00 90 27538 $487.00 90 27650 $869.00 9027441 $1,006.00 90 27540 $1,106.00 90 27652 $935.00 9027442 $1,117.00 90 27550 $296.00 90 27654 $937.00 9027443 $1,037.00 90 27552 $619.00 90 27656 $458.00 9027445 $1,618.00 90 27556 $832.00 90 27658 $527.00 9027446 $1,764.00 90 27557 $1,479.00 90 27659 $725.00 9027447 $1,960.00 90 27558 $1,529.00 90 27664 $504.00 9027448 $1,060.00 90 27560 $88.00 90 27665 $618.00 9027450 $1,311.00 90 27562 $514.00 90 27675 $656.00 9027454 $1,524.00 90 27566 $1,047.00 90 27676 $762.00 9027455 $1,157.00 90 27570 $184.00 10 27680 $523.00 9027457 $1,209.00 90 27580 $1,644.00 90 27681 $634.00 9027465 $1,253.00 90 27590 $1,059.00 90 27685 $565.00 90



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD27686 $706.00 90 27818 $613.00 90 28055 $377.00 9027687 $589.00 90 27822 $1,201.00 90 28060 $495.00 9027690 $757.00 90 27823 $1,472.00 90 28062 $657.00 9027691 $889.00 90 27824 $384.00 90 28070 $476.00 9027692 $159.00 ZZZ 27825 $670.00 90 28072 $445.00 9027695 $658.00 90 27826 $1,080.00 90 28080 $392.00 9027696 $758.00 90 27827 $1,310.00 90 28086 $462.00 9027698 $881.00 90 27828 $1,823.00 90 28088 $414.00 9027700 $835.00 90 27829 $742.00 90 28090 $414.00 9027702 $1,278.00 90 27830 $412.00 90 28092 $330.00 9027703 $1,337.00 90 27831 $415.00 90 28100 $571.00 9027704 $683.00 90 27832 $617.00 90 28102 $700.00 9027705 $985.00 90 27840 $334.00 90 28103 $709.00 9027707 $484.00 90 27842 $373.00 90 28104 $491.00 9027709 $1,118.00 90 27846 $877.00 90 28106 $632.00 9027712 $1,227.00 90 27848 $1,224.00 90 28107 $517.00 9027715 $1,285.00 90 27860 $211.00 10 28108 $418.00 9027720 $1,147.00 90 27870 $1,269.00 90 28110 $421.00 9027722 $1,076.00 90 27871 $843.00 90 28111 $537.00 9027724 $1,402.00 90 27880 $1,015.00 90 28112 $457.00 9027725 $1,312.00 90 27881 $1,120.00 90 28113 $481.00 9027726 $823.00 90 27882 $854.00 90 28114 $890.00 9027727 $1,175.00 90 27884 $579.00 90 28116 $648.00 9027730 $647.00 90 27886 $835.00 90 28118 $568.00 9027732 $611.00 90 27888 $911.00 90 28119 $524.00 9027734 $766.00 90 27889 $879.00 90 28120 $601.00 9027740 $1,044.00 90 27892 $575.00 90 28122 $622.00 9027742 $1,045.00 90 27893 $574.00 90 28124 $480.00 9027745 $940.00 90 27894 $712.00 90 28126 $393.00 9027750 $319.00 90 27899 BR YYY 28130 $727.00 9027752 $614.00 90 28001 $185.00 10 28140 $533.00 9027756 $708.00 90 28002 $362.00 10 28150 $416.00 9027758 $1,115.00 90 28003 $520.00 90 28153 $400.00 9027759 $1,262.00 90 28005 $520.00 90 28160 $412.00 9027760 $223.00 90 28008 $296.00 90 28171 $789.00 9027762 $495.00 90 28010 $235.00 90 28173 $747.00 9027766 $759.00 90 28011 $340.00 90 28175 $571.00 9027767 $233.00 90 28020 $509.00 90 28190 $75.00 1027768 $361.00 90 28022 $422.00 90 28192 $326.00 9027769 $622.00 90 28024 $371.00 90 28193 $341.00 9027780 $244.00 90 28035 $532.00 90 28200 $478.00 9027781 $296.00 90 28039 $525.00 90 28202 $613.00 9027784 $643.00 90 28041 $473.00 90 28208 $406.00 9027786 $223.00 90 28043 $305.00 90 28210 $609.00 9027788 $422.00 90 28045 $456.00 90 28220 $435.00 9027792 $706.00 90 28046 $814.00 90 28222 $555.00 9027808 $332.00 90 28047 $1,056.00 90 28225 $345.00 9027810 $567.00 90 28050 $414.00 90 28226 $334.00 9027814 $972.00 90 28052 $402.00 90 28230 $380.00 9027816 $386.00 90 28054 $236.00 90 28232 $286.00 90



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD28234 $178.00 90 28445 $874.00 90 28805 $731.00 9028238 $695.00 90 28446 $1,075.00 90 28810 $543.00 9028240 $370.00 90 28450 $148.00 90 28820 $377.00 9028250 $535.00 90 28455 $321.00 90 28825 $339.00 9028260 $641.00 90 28456 $288.00 90 28890 $358.00 9028261 $881.00 90 28465 $533.00 90 28899 BR YYY28262 $1,363.00 90 28470 $178.00 90 29000 $247.00 028264 $912.00 90 28475 $296.00 90 29010 $271.00 028270 $266.00 90 28476 $364.00 90 29015 $289.00 028272 $336.00 90 28485 $521.00 90 29035 $213.00 028280 $426.00 90 28490 $80.00 90 29040 $260.00 028285 $463.00 90 28495 $133.00 90 29044 $260.00 028286 $441.00 90 28496 $261.00 90 29046 $286.00 028288 $452.00 90 28505 $399.00 90 29049 $45.00 028289 $458.00 90 28510 $75.00 90 29055 $180.00 028290 $557.00 90 28515 $115.00 90 29058 $110.00 028292 $666.00 90 28525 $345.00 90 29065 $88.00 028293 $845.00 90 28530 $120.00 90 29075 $72.00 028294 $797.00 90 28531 $243.00 90 29085 $59.00 028296 $832.00 90 28540 $145.00 90 29086 $54.00 028297 $838.00 90 28545 $208.00 90 29105 $59.00 028298 $755.00 90 28546 $325.00 90 29125 $45.00 028299 $829.00 90 28555 $592.00 90 29126 $53.00 028300 $845.00 90 28570 $189.00 90 29130 $26.00 028302 $930.00 90 28575 $308.00 90 29131 $53.00 028304 $776.00 90 28576 $382.00 90 29200 $29.00 028305 $1,030.00 90 28585 $742.00 90 29240 $45.00 028306 $530.00 90 28600 $144.00 90 29260 $26.00 028307 $614.00 90 28605 $287.00 90 29280 $29.00 028308 $516.00 90 28606 $487.00 90 29305 $223.00 028309 $955.00 90 28615 $621.00 90 29325 $260.00 028310 $505.00 90 28630 $145.00 10 29345 $126.00 028312 $469.00 90 28635 $189.00 10 29355 $133.00 028313 $436.00 90 28636 $318.00 10 29358 $241.00 028315 $462.00 90 28645 $434.00 90 29365 $101.00 028320 $833.00 90 28660 $106.00 10 29405 $96.00 028322 $667.00 90 28665 $172.00 10 29425 $101.00 028340 $649.00 90 28666 $309.00 10 29435 $133.00 028341 $753.00 90 28675 $348.00 90 29440 $22.00 028344 $414.00 90 28705 $1,353.00 90 29445 $214.00 028345 $557.00 90 28715 $1,179.00 90 29450 $84.00 028360 $1,197.00 90 28725 $1,015.00 90 29505 $75.00 028400 $266.00 90 28730 $945.00 90 29515 $59.00 028405 $473.00 90 28735 $961.00 90 29520 $22.00 028406 $616.00 90 28737 $873.00 90 29530 $55.00 028415 $1,354.00 90 28740 $690.00 90 29540 $41.00 028420 $1,619.00 90 28750 $690.00 90 29550 $37.00 028430 $110.00 90 28755 $466.00 90 29580 $39.00 028435 $371.00 90 28760 $654.00 90 29581 $62.00 028436 $463.00 90 28800 $731.00 90 29582 $71.00 0



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD29583 $44.00 0 29871 $631.00 90 30200 $68.00 029584 $71.00 0 29873 $489.00 90 30210 $75.00 1029700 $29.00 0 29874 $676.00 90 30220 $154.00 1029705 $26.00 0 29875 $639.00 90 30300 $45.00 1029710 $29.00 0 29876 $809.00 90 30310 $170.00 1029720 $29.00 0 29877 $852.00 90 30320 $419.00 9029730 $29.00 0 29879 $1,064.00 90 30400 $741.00 9029740 $37.00 0 29880 $1,169.00 90 30410 $1,173.00 9029750 $105.00 0 29881 $745.00 90 30420 $1,424.00 9029799 BR YYY 29882 $819.00 90 30430 $626.00 9029800 $557.00 90 29883 $1,235.00 90 30435 $1,005.00 9029804 $902.00 90 29884 $721.00 90 30450 $1,445.00 9029805 $360.00 90 29885 $832.00 90 30460 $857.00 9029806 $1,003.00 90 29886 $697.00 90 30462 $1,633.00 9029807 $976.00 90 29887 $949.00 90 30465 $803.00 9029819 $756.00 90 29888 $1,296.00 90 30520 $533.00 9029820 $718.00 90 29889 $1,255.00 90 30540 $643.00 9029821 $863.00 90 29891 $796.00 90 30545 $981.00 9029822 $749.00 90 29892 $835.00 90 30560 $104.00 1029823 $1,330.00 90 29893 $472.00 90 30580 $566.00 9029824 $611.00 90 29894 $690.00 90 30600 $466.00 9029825 $941.00 90 29895 $679.00 90 30620 $564.00 9029826 $980.00 ZZZ 29897 $704.00 90 30630 $624.00 9029827 $1,058.00 90 29898 $863.00 90 30801 $88.00 1029828 $830.00 90 29899 $973.00 90 30802 $172.00 1029830 $524.00 90 29900 $434.00 90 30901 $75.00 029834 $635.00 90 29901 $479.00 90 30903 $110.00 029835 $612.00 90 29902 $514.00 90 30905 $224.00 029836 $680.00 90 29904 $557.00 90 30906 $208.00 029837 $830.00 90 29905 $601.00 90 30915 $596.00 9029838 $931.00 90 29906 $633.00 90 30920 $862.00 9029840 $501.00 90 29907 $775.00 90 30930 $213.00 1029843 $580.00 90 29914 $1,036.00 90 30999 BR YYY29844 $612.00 90 29915 $1,057.00 90 31000 $81.00 1029845 $931.00 90 29916 $1,057.00 90 31002 $135.00 1029846 $976.00 90 29999 BR YYY 31020 $281.00 9029847 $1,277.00 90 30000 $96.00 10 31030 $531.00 9029848 $608.00 90 30020 $117.00 10 31032 $604.00 9029850 $752.00 90 30100 $86.00 0 31040 $772.00 9029851 $1,137.00 90 30110 $157.00 10 31050 $489.00 9029855 $1,007.00 90 30115 $360.00 90 31051 $654.00 9029856 $1,231.00 90 30117 $301.00 90 31070 $410.00 9029860 $658.00 90 30118 $819.00 90 31075 $839.00 9029861 $845.00 90 30120 $500.00 90 31080 $942.00 9029862 $907.00 90 30124 $243.00 90 31081 $1,089.00 9029863 $880.00 90 30125 $599.00 90 31084 $1,210.00 9029866 $1,046.00 90 30130 $275.00 90 31085 $1,281.00 9029867 $1,250.00 90 30140 $320.00 90 31086 $1,081.00 9029868 $1,694.00 90 30150 $790.00 90 31087 $1,075.00 9029870 $460.00 90 30160 $875.00 90 31090 $877.00 90



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD31200 $463.00 90 31525 $234.00 0 31633 $90.00 ZZZ31201 $716.00 90 31526 $222.00 0 31634 $1,886.00 031205 $851.00 90 31527 $262.00 0 31635 $298.00 031225 $1,683.00 90 31528 $202.00 0 31636 $241.00 031230 $1,908.00 90 31529 $217.00 0 31637 $86.00 ZZZ31231 $122.00 0 31530 $284.00 0 31638 $268.00 031233 $221.00 0 31531 $311.00 0 31640 $399.00 031235 $217.00 0 31535 $272.00 0 31641 $304.00 031237 $266.00 0 31536 $308.00 0 31643 $208.00 031238 $311.00 0 31540 $357.00 0 31645 $208.00 031239 $775.00 10 31541 $453.00 0 31646 $161.00 031240 $224.00 0 31545 $384.00 0 31647 $228.00 031254 $588.00 0 31546 $587.00 0 31648 $218.00 031255 $601.00 0 31560 $446.00 0 31649 $71.00 ZZZ31256 $292.00 0 31561 $509.00 0 31651 $82.00 ZZZ31267 $453.00 0 31570 $369.00 0 31652 $921.00 031276 $690.00 0 31571 $363.00 0 31653 $979.00 031287 $339.00 0 31575 $128.00 0 31654 $147.00 ZZZ31288 $396.00 0 31576 $186.00 0 31660 $218.00 031290 $1,462.00 10 31577 $230.00 0 31661 $230.00 031291 $1,551.00 10 31578 $264.00 0 31717 $138.00 031292 $1,235.00 10 31579 $219.00 0 31720 $89.00 031293 $1,346.00 10 31580 $1,213.00 90 31725 $103.00 031294 $1,587.00 10 31582 $1,881.00 90 31730 $199.00 031295 $2,104.00 0 31584 $1,616.00 90 31750 $1,088.00 9031296 $2,136.00 0 31587 $913.00 90 31755 $1,448.00 9031297 $2,101.00 0 31588 $1,206.00 90 31760 $1,648.00 9031299 BR YYY 31590 $691.00 90 31766 $2,315.00 9031300 $1,295.00 90 31595 $773.00 90 31770 $1,815.00 9031320 $508.00 90 31599 BR YYY 31775 $1,973.00 9031360 $1,630.00 90 31600 $306.00 0 31780 $1,577.00 9031365 $2,238.00 90 31603 $343.00 0 31781 $1,936.00 9031367 $1,913.00 90 31605 $297.00 0 31785 $1,320.00 9031368 $2,478.00 90 31610 $794.00 90 31786 $1,866.00 9031370 $1,891.00 90 31611 $614.00 90 31800 $628.00 9031375 $1,720.00 90 31612 $99.00 0 31805 $1,175.00 9031380 $1,782.00 90 31613 $384.00 90 31820 $458.00 9031382 $1,822.00 90 31614 $736.00 90 31825 $659.00 9031390 $2,513.00 90 31615 $213.00 0 31830 $460.00 9031395 $2,937.00 90 31622 $230.00 0 31899 BR YYY31400 $969.00 90 31623 $225.00 0 32035 $821.00 9031420 $969.00 90 31624 $217.00 0 32036 $908.00 9031500 $116.00 0 31625 $235.00 0 32096 $835.00 9031502 $74.00 0 31626 $450.00 0 32097 $836.00 9031505 $62.00 0 31627 $1,310.00 ZZZ 32098 $789.00 9031510 $145.00 0 31628 $269.00 0 32100 $1,120.00 9031511 $88.00 0 31629 $198.00 0 32110 $1,223.00 9031512 $197.00 0 31630 $308.00 0 32120 $1,077.00 9031513 $182.00 0 31631 $252.00 0 32124 $1,144.00 9031515 $160.00 0 31632 $73.00 ZZZ 32140 $1,284.00 90



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD32141 $1,267.00 90 32655 $1,213.00 90 33207 $753.00 9032150 $1,226.00 90 32656 $1,222.00 90 33208 $573.00 9032151 $1,231.00 90 32658 $1,142.00 90 33210 $204.00 032160 $842.00 90 32659 $1,141.00 90 33211 $210.00 032200 $1,132.00 90 32661 $1,165.00 90 33212 $511.00 9032215 $1,024.00 90 32662 $1,459.00 90 33213 $437.00 9032220 $1,680.00 90 32663 $1,636.00 90 33214 $532.00 9032225 $1,268.00 90 32664 $1,197.00 90 33215 $304.00 9032310 $1,221.00 90 32665 $1,360.00 90 33216 $402.00 9032320 $1,787.00 90 32666 $902.00 90 33217 $428.00 9032400 $129.00 0 32667 $164.00 ZZZ 33218 $488.00 9032405 $159.00 0 32668 $164.00 ZZZ 33220 $390.00 9032440 $1,837.00 90 32669 $1,395.00 90 33221 $379.00 9032442 $2,093.00 90 32670 $1,658.00 90 33222 $471.00 9032445 $2,093.00 90 32671 $1,847.00 90 33223 $585.00 9032480 $1,622.00 90 32672 $1,584.00 90 33224 $490.00 032482 $1,714.00 90 32673 $1,251.00 90 33225 $434.00 ZZZ32484 $1,771.00 90 32674 $224.00 ZZZ 33226 $472.00 032486 $1,974.00 90 32701 $229.00 0 33227 $359.00 9032488 $2,094.00 90 32800 $1,166.00 90 33228 $374.00 9032491 $1,784.00 90 32810 $1,085.00 90 33229 $393.00 9032501 $374.00 ZZZ 32815 $1,917.00 90 33230 $408.00 9032503 $1,875.00 90 32820 $1,848.00 90 33231 $421.00 9032504 $2,145.00 90 32851 $3,100.00 90 33233 $270.00 9032505 $964.00 90 32852 $3,339.00 90 33234 $598.00 9032506 $164.00 ZZZ 32853 $3,787.00 90 33235 $587.00 9032507 $164.00 ZZZ 32854 $4,038.00 90 33236 $933.00 9032540 $1,308.00 90 32900 $1,532.00 90 33237 $1,184.00 9032550 $821.00 0 32905 $1,661.00 90 33238 $1,235.00 9032551 $171.00 0 32906 $2,100.00 90 33240 $648.00 9032552 $196.00 10 32940 $1,555.00 90 33241 $301.00 9032553 $597.00 0 32960 $126.00 0 33243 $1,650.00 9032554 $201.00 0 32997 $312.00 0 33244 $1,081.00 9032555 $300.00 0 32998 $2,809.00 0 33249 $1,271.00 9032556 $542.00 0 32999 BR YYY 33250 $1,687.00 9032557 $578.00 0 33010 $124.00 0 33251 $2,071.00 9032560 $302.00 0 33011 $125.00 0 33254 $1,307.00 9032561 $97.00 0 33015 $555.00 90 33255 $1,573.00 9032562 $87.00 0 33020 $1,178.00 90 33256 $1,879.00 9032601 $456.00 0 33025 $1,165.00 90 33257 $565.00 ZZZ32604 $663.00 0 33030 $1,786.00 90 33258 $639.00 ZZZ32606 $637.00 0 33031 $1,816.00 90 33259 $839.00 ZZZ32607 $321.00 0 33050 $1,224.00 90 33261 $1,993.00 9032608 $394.00 0 33120 $2,358.00 90 33262 $394.00 9032609 $272.00 0 33130 $1,734.00 90 33263 $409.00 9032650 $957.00 90 33140 $1,571.00 90 33264 $427.00 9032651 $1,166.00 90 33141 $254.00 ZZZ 33265 $1,307.00 9032652 $1,615.00 90 33202 $749.00 90 33266 $1,789.00 9032653 $1,144.00 90 33203 $766.00 90 33270 $614.00 9032654 $1,096.00 90 33206 $642.00 90 33271 $517.00 90



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD33272 $364.00 90 33471 $1,929.00 90 33641 $1,981.00 9033273 $418.00 90 33474 $2,173.00 90 33645 $2,352.00 9033282 $470.00 90 33475 $2,666.00 90 33647 $2,732.00 9033284 $365.00 90 33476 $2,270.00 90 33660 $2,444.00 9033300 $1,576.00 90 33477 $1,345.00 0 33665 $2,700.00 9033305 $1,889.00 90 33478 $2,544.00 90 33670 $2,820.00 9033310 $1,577.00 90 33496 $2,595.00 90 33675 $2,085.00 9033315 $1,875.00 90 33500 $2,370.00 90 33676 $2,151.00 9033320 $1,485.00 90 33501 $1,546.00 90 33677 $2,236.00 9033321 $1,890.00 90 33502 $1,938.00 90 33681 $2,657.00 9033322 $1,935.00 90 33503 $1,983.00 90 33684 $2,740.00 9033330 $1,726.00 90 33504 $2,416.00 90 33688 $2,602.00 9033335 $2,336.00 90 33505 $2,423.00 90 33690 $1,884.00 9033361 $1,404.00 0 33506 $2,448.00 90 33692 $2,816.00 9033362 $1,535.00 0 33507 $1,809.00 90 33694 $2,856.00 9033363 $1,589.00 0 33508 $17.00 ZZZ 33697 $3,064.00 9033364 $1,671.00 0 33510 $2,354.00 90 33702 $2,549.00 9033365 $1,843.00 0 33511 $2,546.00 90 33710 $2,731.00 9033366 $1,995.00 0 33512 $2,732.00 90 33720 $2,508.00 9033367 $644.00 ZZZ 33513 $2,933.00 90 33722 $2,704.00 9033368 $780.00 ZZZ 33514 $3,197.00 90 33724 $1,491.00 9033369 $1,030.00 ZZZ 33516 $3,404.00 90 33726 $1,963.00 9033400 $2,401.00 90 33517 $219.00 ZZZ 33730 $2,785.00 9033401 $2,228.00 90 33518 $414.00 ZZZ 33732 $2,622.00 9033403 $2,369.00 90 33519 $607.00 ZZZ 33735 $2,036.00 9033404 $2,698.00 90 33521 $801.00 ZZZ 33736 $2,288.00 9033405 $2,745.00 90 33522 $994.00 ZZZ 33737 $1,977.00 9033406 $2,962.00 90 33523 $1,189.00 ZZZ 33750 $1,877.00 9033410 $2,637.00 90 33530 $521.00 ZZZ 33755 $1,831.00 9033411 $2,981.00 90 33533 $2,415.00 90 33762 $1,900.00 9033412 $3,213.00 90 33534 $2,654.00 90 33764 $1,895.00 9033413 $3,282.00 90 33535 $2,899.00 90 33766 $2,119.00 9033414 $2,904.00 90 33536 $3,143.00 90 33767 $2,173.00 9033415 $2,563.00 90 33542 $2,693.00 90 33768 $449.00 ZZZ33416 $2,684.00 90 33545 $3,250.00 90 33770 $2,954.00 9033417 $2,756.00 90 33548 $2,381.00 90 33771 $2,924.00 9033418 $1,871.00 90 33572 $340.00 ZZZ 33774 $2,681.00 9033419 $440.00 ZZZ 33600 $2,644.00 90 33775 $2,654.00 9033420 $1,796.00 90 33602 $2,556.00 90 33776 $2,844.00 9033422 $2,431.00 90 33606 $2,831.00 90 33777 $2,724.00 9033425 $2,509.00 90 33608 $2,940.00 90 33778 $3,199.00 9033426 $2,806.00 90 33610 $2,871.00 90 33779 $3,121.00 9033427 $3,026.00 90 33611 $2,985.00 90 33780 $3,232.00 9033430 $2,891.00 90 33612 $3,152.00 90 33781 $3,057.00 9033460 $2,215.00 90 33615 $3,051.00 90 33782 $3,439.00 9033463 $2,396.00 90 33617 $3,272.00 90 33783 $3,834.00 9033464 $2,547.00 90 33619 $3,678.00 90 33786 $2,970.00 9033465 $2,665.00 90 33620 $1,527.00 90 33788 $2,288.00 9033468 $2,952.00 90 33621 $914.00 90 33800 $1,546.00 9033470 $1,749.00 90 33622 $3,597.00 90 33802 $1,752.00 90



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD33803 $1,746.00 90 33964 $513.00 0 34804 $1,279.00 9033813 $1,935.00 90 33965 $194.00 0 34805 $1,243.00 9033814 $2,464.00 90 33966 $246.00 0 34806 $100.00 ZZZ33820 $1,619.00 90 33967 $258.00 0 34808 $220.00 ZZZ33822 $1,559.00 90 33968 $51.00 0 34812 $359.00 033824 $1,884.00 90 33969 $287.00 0 34813 $256.00 ZZZ33840 $2,029.00 90 33970 $576.00 0 34820 $519.00 033845 $2,129.00 90 33971 $578.00 90 34825 $694.00 9033851 $2,129.00 90 33973 $756.00 0 34826 $220.00 ZZZ33852 $2,311.00 90 33974 $1,095.00 90 34830 $1,803.00 9033853 $3,057.00 90 33975 $1,758.00 0 34831 $1,950.00 9033860 $3,044.00 90 33976 $2,056.00 0 34832 $1,950.00 9033863 $3,183.00 90 33977 $1,561.00 0 34833 $650.00 033864 $3,035.00 90 33978 $1,754.00 0 34834 $306.00 033870 $3,638.00 90 33979 $2,496.00 0 34900 $960.00 9033875 $2,876.00 90 33980 $3,212.00 0 35001 $1,564.00 9033877 $3,767.00 90 33981 $879.00 0 35002 $1,547.00 9033880 $1,866.00 90 33982 $2,052.00 0 35005 $1,268.00 9033881 $1,603.00 90 33983 $2,418.00 0 35011 $1,007.00 9033883 $1,187.00 90 33984 $298.00 0 35013 $1,376.00 9033884 $441.00 ZZZ 33985 $541.00 0 35021 $1,635.00 9033886 $1,025.00 90 33986 $554.00 0 35022 $1,686.00 9033889 $882.00 0 33987 $218.00 ZZZ 35045 $995.00 9033891 $1,126.00 0 33988 $812.00 0 35081 $2,175.00 9033910 $1,987.00 90 33989 $525.00 0 35082 $2,661.00 9033915 $1,588.00 90 33990 $454.00 0 35091 $2,634.00 9033916 $2,096.00 90 33991 $662.00 0 35092 $2,872.00 9033917 $2,345.00 90 33992 $215.00 0 35102 $2,346.00 9033920 $2,981.00 90 33993 $188.00 0 35103 $2,587.00 9033922 $2,227.00 90 33999 BR YYY 35111 $1,398.00 9033924 $421.00 ZZZ 34001 $1,012.00 90 35112 $1,351.00 9033925 $1,849.00 90 34051 $1,134.00 90 35121 $2,000.00 9033926 $2,499.00 90 34101 $800.00 90 35122 $2,382.00 9033935 $5,415.00 90 34111 $669.00 90 35131 $1,495.00 9033945 $3,813.00 90 34151 $1,288.00 90 35132 $1,742.00 9033946 $319.00 0 34201 $777.00 90 35141 $1,231.00 9033947 $353.00 0 34203 $949.00 90 35142 $1,339.00 9033948 $252.00 0 34401 $953.00 90 35151 $1,390.00 9033949 $245.00 0 34421 $779.00 90 35152 $1,229.00 9033951 $435.00 0 34451 $1,117.00 90 35180 $997.00 9033952 $449.00 0 34471 $685.00 90 35182 $1,345.00 9033953 $486.00 0 34490 $660.00 90 35184 $976.00 9033954 $502.00 0 34501 $910.00 90 35188 $1,048.00 9033955 $873.00 0 34502 $2,044.00 90 35189 $1,380.00 9033956 $875.00 0 34510 $1,108.00 90 35190 $1,018.00 9033957 $194.00 0 34520 $1,077.00 90 35201 $852.00 9033958 $191.00 0 34530 $1,368.00 90 35206 $835.00 9033959 $246.00 0 34800 $1,159.00 90 35207 $935.00 9033962 $249.00 0 34802 $1,279.00 90 35211 $1,833.00 9033963 $493.00 0 34803 $1,372.00 90 35216 $1,494.00 90



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD35221 $1,243.00 90 35518 $1,313.00 90 35665 $1,333.00 9035226 $841.00 90 35521 $1,393.00 90 35666 $1,686.00 9035231 $1,053.00 90 35522 $1,253.00 90 35671 $1,315.00 9035236 $947.00 90 35523 $1,237.00 90 35681 $751.00 ZZZ35241 $1,926.00 90 35525 $1,197.00 90 35682 $627.00 ZZZ35246 $1,701.00 90 35526 $1,527.00 90 35683 $702.00 ZZZ35251 $1,260.00 90 35531 $2,000.00 90 35685 $216.00 ZZZ35256 $1,568.00 90 35533 $1,716.00 90 35686 $178.00 ZZZ35261 $1,008.00 90 35535 $1,816.00 90 35691 $1,546.00 9035266 $921.00 90 35536 $1,888.00 90 35693 $1,140.00 9035271 $1,814.00 90 35537 $2,141.00 90 35694 $1,353.00 9035276 $1,541.00 90 35538 $2,391.00 90 35695 $1,351.00 9035281 $1,396.00 90 35539 $2,248.00 90 35697 $166.00 ZZZ35286 $1,036.00 90 35540 $2,505.00 90 35700 $264.00 ZZZ35301 $1,486.00 90 35556 $1,745.00 90 35701 $494.00 9035302 $1,109.00 90 35558 $1,219.00 90 35721 $500.00 9035303 $1,218.00 90 35560 $1,899.00 90 35741 $499.00 9035304 $1,267.00 90 35563 $1,115.00 90 35761 $532.00 9035305 $1,218.00 90 35565 $1,312.00 90 35800 $567.00 9035306 $456.00 ZZZ 35566 $2,161.00 90 35820 $951.00 9035311 $1,999.00 90 35570 $1,455.00 90 35840 $771.00 9035321 $1,031.00 90 35571 $1,612.00 90 35860 $496.00 9035331 $1,724.00 90 35572 $369.00 ZZZ 35870 $1,583.00 9035341 $1,908.00 90 35583 $1,843.00 90 35875 $827.00 9035351 $1,555.00 90 35585 $2,277.00 90 35876 $1,232.00 9035355 $1,336.00 90 35587 $1,698.00 90 35879 $1,163.00 9035361 $1,859.00 90 35600 $273.00 ZZZ 35881 $1,275.00 9035363 $2,006.00 90 35601 $1,495.00 90 35883 $1,247.00 9035371 $1,006.00 90 35606 $1,539.00 90 35884 $1,324.00 9035372 $1,085.00 90 35612 $1,349.00 90 35901 $709.00 9035390 $225.00 ZZZ 35616 $1,346.00 90 35903 $818.00 9035400 $224.00 ZZZ 35621 $1,265.00 90 35905 $1,343.00 9035450 $643.00 0 35623 $1,193.00 90 35907 $1,335.00 9035452 $518.00 0 35626 $1,921.00 90 36000 $46.00 035458 $804.00 0 35631 $1,891.00 90 36002 $181.00 035460 $430.00 0 35632 $1,725.00 90 36005 $68.00 035471 $626.00 0 35633 $1,926.00 90 36010 $136.00 035472 $388.00 0 35634 $1,688.00 90 36011 $194.00 035475 $569.00 0 35636 $1,656.00 90 36012 $186.00 035476 $338.00 0 35637 $1,704.00 90 36013 $141.00 035500 $423.00 ZZZ 35638 $1,731.00 90 36014 $159.00 035501 $1,569.00 90 35642 $1,298.00 90 36015 $186.00 035506 $1,641.00 90 35645 $1,304.00 90 36100 $176.00 035508 $1,564.00 90 35646 $2,105.00 90 36120 $120.00 035509 $1,529.00 90 35647 $1,555.00 90 36140 $106.00 035510 $1,316.00 90 35650 $1,236.00 90 36147 $853.00 035511 $1,256.00 90 35654 $1,603.00 90 36148 $265.00 ZZZ35512 $1,291.00 90 35656 $1,589.00 90 36160 $196.00 035515 $1,387.00 90 35661 $1,145.00 90 36200 $240.00 035516 $1,391.00 90 35663 $1,237.00 90 36215 $240.00 0



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD36216 $270.00 0 36566 $1,121.00 10 37183 $425.00 036217 $325.00 0 36569 $350.00 0 37184 $3,074.00 036218 $79.00 ZZZ 36571 $1,550.00 10 37185 $1,002.00 ZZZ36221 $1,132.00 0 36575 $172.00 0 37186 $2,076.00 ZZZ36222 $1,433.00 0 36576 $429.00 10 37187 $2,991.00 036223 $1,560.00 0 36578 $546.00 10 37188 $2,586.00 036224 $1,715.00 0 36580 $307.00 0 37191 $2,683.00 036225 $1,545.00 0 36581 $646.00 10 37192 $1,555.00 036226 $1,749.00 0 36582 $1,210.00 10 37193 $1,638.00 036227 $253.00 ZZZ 36583 $708.00 10 37195 $302.00 036228 $1,190.00 ZZZ 36584 $321.00 0 37197 $1,541.00 036245 $249.00 0 36585 $1,525.00 10 37200 $232.00 036246 $272.00 0 36589 $176.00 10 37211 $419.00 036247 $323.00 0 36590 $378.00 10 37212 $370.00 036248 $53.00 ZZZ 36591 $21.00 0 37213 $258.00 036251 $1,436.00 0 36592 $26.00 0 37214 $152.00 036252 $1,561.00 0 36593 $37.00 0 37215 $1,095.00 9036253 $2,307.00 0 36595 $880.00 0 37217 $1,164.00 9036254 $2,211.00 0 36596 $194.00 0 37218 $861.00 9036260 $749.00 90 36597 $167.00 0 37220 $3,236.00 036261 $388.00 90 36598 $130.00 0 37221 $4,750.00 036262 $297.00 90 36600 $24.00 0 37222 $911.00 ZZZ36299 BR YYY 36620 $64.00 0 37223 $2,638.00 ZZZ36410 $18.00 0 36625 $133.00 0 37224 $3,919.00 036415 BR 0 36640 $130.00 0 37225 $11,190.00 036416 BR 0 36680 $72.00 0 37226 $9,188.00 036425 $86.00 0 36800 $159.00 0 37227 $15,065.00 036430 $37.00 0 36810 $345.00 0 37228 $5,569.00 036455 $141.00 0 36815 $236.00 0 37229 $11,021.00 036468 BR 0 36818 $736.00 90 37230 $8,434.00 036470 $76.00 10 36819 $977.00 90 37231 $13,463.00 036471 $96.00 10 36820 $800.00 90 37232 $1,238.00 ZZZ36475 $2,216.00 0 36821 $721.00 90 37233 $1,486.00 ZZZ36476 $434.00 ZZZ 36823 $1,461.00 90 37234 $3,935.00 ZZZ36478 $2,041.00 0 36825 $867.00 90 37235 $4,017.00 ZZZ36479 $438.00 ZZZ 36830 $967.00 90 37236 $2,863.00 036481 $499.00 0 36831 $488.00 90 37237 $1,243.00 ZZZ36500 $159.00 0 36832 $810.00 90 37238 $4,186.00 036511 $92.00 0 36833 $780.00 90 37239 $2,081.00 ZZZ36512 $92.00 0 36835 $542.00 90 37241 $4,634.00 036513 $92.00 0 36838 $1,230.00 90 37242 $7,805.00 036514 $92.00 0 36860 $166.00 0 37243 $9,853.00 036515 $92.00 0 36861 $224.00 0 37244 $6,899.00 036516 $92.00 0 36870 $1,755.00 90 37252 $1,426.00 ZZZ36522 $305.00 0 37140 $1,666.00 90 37253 $222.00 ZZZ36556 $316.00 0 37145 $1,741.00 90 37500 $739.00 9036558 $703.00 10 37160 $1,681.00 90 37501 BR YYY36561 $1,333.00 10 37180 $1,769.00 90 37565 $364.00 9036563 $1,679.00 10 37181 $1,923.00 90 37600 $414.00 9036565 $1,073.00 10 37182 $914.00 0 37605 $521.00 90



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD37606 $563.00 90 38525 $369.00 90 40652 $436.00 9037607 $456.00 90 38530 $517.00 90 40654 $529.00 9037609 $278.00 10 38542 $507.00 90 40700 $1,009.00 9037615 $495.00 90 38550 $519.00 90 40701 $1,452.00 9037616 $1,128.00 90 38555 $1,115.00 90 40702 $1,030.00 9037617 $1,132.00 90 38562 $799.00 90 40720 $1,107.00 9037618 $514.00 90 38564 $831.00 90 40761 $1,202.00 9037619 $1,712.00 90 38570 $695.00 10 40799 BR YYY37650 $430.00 90 38571 $902.00 10 40800 $110.00 1037660 $789.00 90 38572 $1,049.00 10 40801 $208.00 1037700 $336.00 90 38589 BR YYY 40804 $105.00 1037718 $416.00 90 38700 $863.00 90 40805 $245.00 1037722 $495.00 90 38720 $1,328.00 90 40806 $38.00 037735 $847.00 90 38724 $1,366.00 90 40808 $100.00 1037760 $813.00 90 38740 $539.00 90 40810 $141.00 1037761 $577.00 90 38745 $770.00 90 40812 $202.00 1037765 $462.00 90 38746 $312.00 ZZZ 40814 $319.00 9037766 $561.00 90 38747 $337.00 ZZZ 40816 $336.00 9037780 $301.00 90 38760 $699.00 90 40818 $249.00 9037785 $270.00 90 38765 $1,283.00 90 40819 $208.00 9037788 $1,654.00 90 38770 $1,111.00 90 40820 $104.00 1037790 $690.00 90 38780 $1,357.00 90 40830 $140.00 1037799 BR YYY 38790 $158.00 0 40831 $213.00 1038100 $974.00 90 38792 $26.00 0 40840 $687.00 9038101 $982.00 90 38794 $298.00 90 40842 $684.00 9038102 $332.00 ZZZ 38900 $141.00 ZZZ 40843 $947.00 9038115 $1,020.00 90 38999 BR YYY 40844 $1,232.00 9038120 $1,138.00 90 39000 $664.00 90 40845 $1,593.00 9038129 BR YYY 39010 $1,148.00 90 40899 BR YYY38200 $180.00 0 39200 $1,249.00 90 41000 $119.00 1038205 $79.00 0 39220 $1,542.00 90 41005 $109.00 1038206 $79.00 0 39401 $324.00 0 41006 $237.00 9038220 $212.00 0 39402 $423.00 0 41007 $283.00 9038221 $228.00 0 39499 BR YYY 41008 $248.00 9038230 $265.00 0 39501 $1,083.00 90 41009 $319.00 9038232 $214.00 0 39503 $2,726.00 90 41010 $91.00 1038240 $128.00 0 39540 $1,133.00 90 41015 $267.00 9038241 $128.00 0 39541 $1,179.00 90 41016 $357.00 9038242 $90.00 0 39545 $1,102.00 90 41017 $300.00 9038243 $121.00 0 39560 $968.00 90 41018 $424.00 9038300 $104.00 10 39561 $1,328.00 90 41019 $444.00 038305 $375.00 90 39599 BR YYY 41100 $140.00 1038308 $425.00 90 40490 $108.00 0 41105 $136.00 1038380 $628.00 90 40500 $422.00 90 41108 $110.00 1038381 $1,087.00 90 40510 $469.00 90 41110 $159.00 1038382 $798.00 90 40520 $467.00 90 41112 $255.00 9038500 $234.00 10 40525 $714.00 90 41113 $301.00 9038505 $139.00 0 40527 $851.00 90 41114 $682.00 9038510 $349.00 10 40530 $501.00 90 41115 $176.00 1038520 $431.00 90 40650 $368.00 90 41116 $242.00 90



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD41120 $813.00 90 42225 $803.00 90 42836 $286.00 9041130 $937.00 90 42226 $848.00 90 42842 $729.00 9041135 $1,869.00 90 42227 $762.00 90 42844 $1,173.00 9041140 $2,005.00 90 42235 $631.00 90 42845 $1,958.00 9041145 $2,406.00 90 42260 $491.00 90 42860 $207.00 9041150 $1,897.00 90 42280 $148.00 10 42870 $427.00 9041153 $2,091.00 90 42281 $160.00 10 42890 $1,047.00 9041155 $2,448.00 90 42299 BR YYY 42892 $1,262.00 9041250 $168.00 10 42300 $165.00 10 42894 $1,825.00 9041251 $203.00 10 42305 $448.00 90 42900 $429.00 1041252 $294.00 10 42310 $145.00 10 42950 $745.00 9041500 $334.00 90 42320 $208.00 10 42953 $752.00 9041510 $313.00 90 42330 $184.00 10 42955 $561.00 9041512 $644.00 90 42335 $287.00 90 42960 $178.00 1041520 $255.00 90 42340 $411.00 90 42961 $406.00 9041530 $3,327.00 0 42400 $94.00 0 42962 $602.00 9041599 BR YYY 42405 $258.00 10 42970 $284.00 9041800 $107.00 10 42408 $377.00 90 42971 $472.00 9041805 $115.00 10 42409 $266.00 90 42972 $562.00 9041806 $217.00 10 42410 $746.00 90 42999 BR YYY41820 BR 0 42415 $1,364.00 90 43020 $696.00 9041821 BR 0 42420 $1,577.00 90 43030 $712.00 9041822 $237.00 10 42425 $1,097.00 90 43045 $1,574.00 9041823 $312.00 90 42426 $1,882.00 90 43100 $744.00 9041825 $144.00 10 42440 $634.00 90 43101 $1,248.00 9041826 $211.00 10 42450 $395.00 90 43107 $2,325.00 9041827 $322.00 90 42500 $407.00 90 43108 $2,664.00 9041828 $176.00 10 42505 $559.00 90 43112 $2,471.00 9041830 $156.00 10 42507 $522.00 90 43113 $2,755.00 9041850 BR 0 42509 $915.00 90 43116 $2,509.00 9041870 BR 0 42510 $711.00 90 43117 $2,469.00 9041872 $249.00 90 42550 $82.00 0 43118 $2,607.00 9041874 $193.00 90 42600 $445.00 90 43121 $2,350.00 9041899 BR YYY 42650 $67.00 0 43122 $2,287.00 9042000 $106.00 10 42660 $89.00 0 43123 $2,661.00 9042100 $122.00 10 42665 $238.00 90 43124 $2,242.00 9042104 $161.00 10 42699 BR YYY 43130 $1,020.00 9042106 $204.00 10 42700 $144.00 10 43135 $1,332.00 9042107 $409.00 90 42720 $270.00 10 43180 $573.00 9042120 $573.00 90 42725 $720.00 90 43191 $130.00 042140 $174.00 90 42800 $123.00 10 43192 $155.00 042145 $741.00 90 42804 $136.00 10 43193 $185.00 042160 $176.00 10 42806 $167.00 10 43194 $168.00 042180 $222.00 10 42808 $250.00 10 43195 $186.00 042182 $324.00 10 42809 $152.00 10 43196 $203.00 042200 $946.00 90 42810 $335.00 90 43197 $188.00 042205 $863.00 90 42815 $659.00 90 43198 $210.00 042210 $1,174.00 90 42821 $378.00 90 43200 $266.00 042215 $766.00 90 42826 $320.00 90 43201 $245.00 042220 $586.00 90 42831 $235.00 90 43202 $205.00 0



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD43204 $228.00 0 43274 $498.00 0 43502 $1,247.00 9043205 $207.00 0 43275 $411.00 0 43510 $680.00 9043206 $337.00 0 43276 $518.00 0 43520 $599.00 9043210 $444.00 0 43277 $413.00 0 43605 $686.00 9043211 $253.00 0 43278 $470.00 0 43610 $861.00 9043212 $200.00 0 43279 $1,319.00 90 43611 $1,001.00 9043213 $1,253.00 0 43280 $1,314.00 90 43620 $1,691.00 9043214 $203.00 0 43281 $1,577.00 90 43621 $1,718.00 9043215 $160.00 0 43282 $1,774.00 90 43622 $1,798.00 9043216 $149.00 0 43283 $161.00 ZZZ 43631 $1,445.00 9043217 $176.00 0 43289 BR YYY 43632 $1,443.00 9043220 $128.00 0 43300 $837.00 90 43633 $1,467.00 9043226 $142.00 0 43305 $1,428.00 90 43634 $1,786.00 9043227 $218.00 0 43310 $2,138.00 90 43635 $143.00 ZZZ43229 $739.00 0 43312 $2,331.00 90 43640 $1,119.00 9043231 $182.00 0 43313 $2,632.00 90 43641 $1,138.00 9043232 $252.00 0 43314 $2,891.00 90 43644 $1,598.00 9043233 $241.00 0 43320 $1,299.00 90 43645 $1,724.00 9043235 $239.00 0 43325 $1,261.00 90 43651 $716.00 9043236 $285.00 0 43327 $838.00 90 43652 $856.00 9043237 $219.00 0 43328 $1,193.00 90 43653 $617.00 9043238 $271.00 0 43330 $1,236.00 90 43659 BR YYY43239 $246.00 0 43331 $1,378.00 90 43752 $36.00 043240 $369.00 0 43332 $1,188.00 90 43753 $21.00 043241 $157.00 0 43333 $1,292.00 90 43754 $92.00 043242 $384.00 0 43334 $1,282.00 90 43755 $140.00 043243 $276.00 0 43335 $1,374.00 90 43756 $214.00 043244 $268.00 0 43336 $1,557.00 90 43757 $301.00 043245 $214.00 0 43337 $1,681.00 90 43760 $81.00 043246 $485.00 0 43338 $120.00 ZZZ 43761 $107.00 043247 $229.00 0 43340 $1,292.00 90 43770 $1,009.00 9043248 $191.00 0 43341 $1,351.00 90 43771 $1,162.00 9043249 $175.00 0 43351 $1,180.00 90 43772 $885.00 9043250 $194.00 0 43352 $1,028.00 90 43773 $1,162.00 9043251 $224.00 0 43360 $2,277.00 90 43774 $888.00 9043252 $376.00 0 43361 $2,596.00 90 43775 $1,146.00 9043253 $280.00 0 43400 $1,261.00 90 43800 $793.00 9043254 $291.00 0 43401 $1,299.00 90 43810 $846.00 9043255 $343.00 0 43405 $1,330.00 90 43820 $896.00 9043257 $305.00 0 43410 $946.00 90 43825 $1,128.00 9043259 $271.00 0 43415 $1,382.00 90 43830 $592.00 9043260 $349.00 0 43420 $854.00 90 43831 $593.00 9043261 $362.00 0 43425 $1,338.00 90 43832 $904.00 9043262 $447.00 0 43450 $91.00 0 43840 $893.00 9043263 $386.00 0 43453 $102.00 0 43843 $1,249.00 9043264 $522.00 0 43460 $203.00 0 43845 $1,738.00 9043265 $527.00 0 43496 BR 90 43846 $1,528.00 9043266 $241.00 0 43499 BR YYY 43847 $1,678.00 9043270 $737.00 0 43500 $649.00 90 43848 $1,795.00 9043273 $129.00 ZZZ 43501 $1,105.00 90 43850 $1,425.00 90



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD43855 $1,454.00 90 44204 $1,353.00 90 44403 $324.00 043860 $1,435.00 90 44205 $1,198.00 90 44404 $434.00 043865 $1,549.00 90 44206 $1,480.00 90 44405 $622.00 043870 $590.00 90 44207 $1,620.00 90 44406 $247.00 043880 $1,352.00 90 44208 $1,752.00 90 44407 $296.00 043886 $280.00 90 44210 $1,551.00 90 44408 $250.00 043887 $274.00 90 44211 $1,926.00 90 44500 $28.00 043888 $389.00 90 44212 $1,800.00 90 44602 $815.00 9043999 BR YYY 44213 $196.00 ZZZ 44603 $1,041.00 9044005 $1,171.00 90 44227 $1,536.00 90 44604 $1,027.00 9044010 $809.00 90 44238 BR YYY 44605 $1,132.00 9044015 $1,171.00 ZZZ 44300 $697.00 90 44615 $994.00 9044020 $891.00 90 44310 $950.00 90 44620 $741.00 9044021 $888.00 90 44312 $453.00 90 44625 $1,277.00 9044025 $905.00 90 44314 $892.00 90 44626 $1,581.00 9044050 $862.00 90 44316 $1,229.00 90 44640 $1,036.00 9044055 $957.00 90 44320 $1,029.00 90 44650 $1,076.00 9044100 $117.00 0 44322 $1,015.00 90 44660 $1,050.00 9044110 $784.00 90 44340 $397.00 90 44661 $1,326.00 9044111 $963.00 90 44345 $816.00 90 44680 $1,049.00 9044120 $1,078.00 90 44346 $923.00 90 44700 $1,115.00 9044121 $308.00 ZZZ 44360 $177.00 0 44701 $161.00 ZZZ44125 $1,135.00 90 44361 $195.00 0 44720 $268.00 044126 $1,951.00 90 44363 $213.00 0 44721 $393.00 044127 $2,243.00 90 44364 $255.00 0 44799 BR 044128 $242.00 ZZZ 44365 $226.00 0 44800 $791.00 9044130 $938.00 90 44366 $300.00 0 44820 $755.00 9044133 BR 0 44369 $308.00 0 44850 $708.00 9044136 BR 0 44370 $253.00 0 44899 BR YYY44139 $154.00 ZZZ 44372 $301.00 0 44900 $644.00 9044140 $1,350.00 90 44373 $238.00 0 44950 $643.00 9044141 $1,488.00 90 44376 $305.00 0 44955 $136.00 ZZZ44143 $1,536.00 90 44377 $320.00 0 44960 $790.00 9044144 $1,442.00 90 44378 $410.00 0 44970 $631.00 9044145 $1,678.00 90 44379 $396.00 0 44979 BR YYY44146 $1,840.00 90 44380 $91.00 0 45000 $329.00 9044147 $1,452.00 90 44381 $1,016.00 0 45005 $197.00 1044150 $1,661.00 90 44382 $110.00 0 45020 $364.00 9044151 $1,499.00 90 44384 $164.00 0 45100 $321.00 9044155 $1,892.00 90 44385 $219.00 0 45108 $419.00 9044156 $1,709.00 90 44386 $183.00 0 45110 $1,801.00 9044157 $1,952.00 90 44388 $326.00 0 45111 $1,270.00 9044158 $2,003.00 90 44388-53 $178.00 0 45112 $1,904.00 9044160 $1,236.00 90 44389 $301.00 0 45113 $1,885.00 9044180 $853.00 90 44390 $319.00 0 45114 $1,732.00 9044186 $600.00 90 44391 $376.00 0 45116 $1,485.00 9044187 $992.00 90 44392 $359.00 0 45119 $1,911.00 9044188 $1,088.00 90 44394 $395.00 0 45120 $1,845.00 9044202 $1,603.00 90 44401 $3,308.00 0 45121 $1,870.00 9044203 $235.00 ZZZ 44402 $282.00 0 45123 $1,126.00 90



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD45126 $2,444.00 90 45398 $744.00 0 46601 $140.00 045130 $1,041.00 90 45400 $1,058.00 90 46604 $92.00 045135 $1,354.00 90 45402 $1,435.00 90 46606 $66.00 045136 $1,526.00 90 45500 $584.00 90 46607 $195.00 045150 $475.00 90 45505 $510.00 90 46608 $115.00 045160 $949.00 90 45520 $46.00 0 46610 $114.00 045171 $615.00 90 45540 $1,009.00 90 46611 $149.00 045172 $835.00 90 45541 $888.00 90 46612 $196.00 045190 $623.00 90 45550 $1,350.00 90 46614 $169.00 045300 $75.00 0 45560 $618.00 90 46615 $202.00 045303 $72.00 0 45562 $915.00 90 46700 $585.00 9045305 $102.00 0 45563 $1,412.00 90 46706 $140.00 1045307 $172.00 0 45800 $1,050.00 90 46707 $473.00 9045308 $137.00 0 45805 $1,273.00 90 46710 $953.00 9045309 $174.00 0 45820 $1,066.00 90 46712 $1,999.00 9045315 $211.00 0 45825 $1,241.00 90 46715 $545.00 9045317 $209.00 0 45900 $120.00 10 46716 $906.00 9045320 $230.00 0 45905 $133.00 10 46730 $1,584.00 9045321 $154.00 0 45910 $163.00 10 46735 $1,881.00 9045327 $96.00 0 45915 $142.00 10 46740 $1,671.00 9045330 $87.00 0 45990 $105.00 0 46742 $2,236.00 9045331 $120.00 0 45999 BR YYY 46744 $2,412.00 9045332 $174.00 0 46020 $230.00 10 46746 $2,725.00 9045333 $176.00 0 46030 $94.00 10 46748 $2,933.00 9045334 $171.00 0 46040 $393.00 90 46750 $636.00 9045335 $144.00 0 46045 $312.00 90 46753 $511.00 9045337 $144.00 0 46050 $105.00 10 46754 $188.00 1045338 $212.00 0 46060 $482.00 90 46760 $846.00 9045340 $328.00 0 46080 $246.00 10 46761 $813.00 9045341 $153.00 0 46083 $98.00 10 46762 $731.00 9045342 $224.00 0 46200 $323.00 90 46900 $128.00 1045346 $3,167.00 0 46220 $118.00 10 46910 $144.00 1045347 $168.00 0 46221 $124.00 10 46916 $145.00 1045349 $214.00 0 46230 $198.00 10 46917 $228.00 1045350 $593.00 0 46250 $400.00 90 46922 $189.00 1045379 $415.00 0 46255 $501.00 90 46924 $297.00 1045380 $369.00 0 46257 $504.00 90 46930 $207.00 9045381 $388.00 0 46258 $539.00 90 46940 $165.00 1045382 $481.00 0 46260 $598.00 90 46942 $145.00 1045384 $415.00 0 46261 $655.00 90 46945 $199.00 9045385 $479.00 0 46262 $686.00 90 46946 $270.00 9045386 $739.00 0 46270 $328.00 90 46947 $328.00 9045388 $3,327.00 0 46275 $442.00 90 46999 BR YYY45389 $311.00 0 46280 $514.00 90 47000 $218.00 045390 $355.00 0 46285 $335.00 90 47001 $141.00 ZZZ45391 $283.00 0 46288 $521.00 90 47010 $788.00 9045392 $358.00 0 46320 $126.00 10 47015 $755.00 9045393 $271.00 0 46500 $109.00 10 47100 $550.00 9045395 $1,813.00 90 46505 $229.00 10 47120 $1,663.00 9045397 $1,969.00 90 46600 $38.00 0 47122 $2,512.00 90



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD47125 $2,293.00 90 47605 $935.00 90 48999 BR YYY47130 $2,482.00 90 47610 $1,164.00 90 49000 $862.00 9047135 $6,164.00 90 47612 $1,276.00 90 49002 $784.00 9047146 $337.00 0 47620 $1,295.00 90 49010 $915.00 9047147 $393.00 0 47700 $1,111.00 90 49020 $910.00 9047300 $778.00 90 47701 $1,913.00 90 49040 $763.00 9047350 $942.00 90 47711 $1,442.00 90 49060 $827.00 9047360 $1,305.00 90 47712 $1,793.00 90 49062 $892.00 9047361 $2,129.00 90 47715 $1,157.00 90 49082 $193.00 047362 $849.00 90 47720 $1,040.00 90 49083 $300.00 047370 $943.00 90 47721 $1,248.00 90 49084 $104.00 047371 $889.00 90 47740 $1,188.00 90 49180 $212.00 047379 BR YYY 47741 $1,425.00 90 49185 $1,012.00 047380 $1,107.00 90 47760 $1,568.00 90 49203 $1,049.00 9047381 $1,094.00 90 47765 $1,624.00 90 49204 $1,337.00 9047382 $660.00 10 47780 $1,635.00 90 49205 $1,530.00 9047383 $7,678.00 10 47785 $1,871.00 90 49215 $1,551.00 9047399 BR YYY 47800 $1,485.00 90 49220 $1,182.00 9047400 $1,435.00 90 47801 $906.00 90 49250 $622.00 9047420 $1,222.00 90 47802 $1,352.00 90 49255 $591.00 9047425 $1,275.00 90 47900 $1,331.00 90 49320 $415.00 1047460 $1,039.00 90 47999 BR YYY 49321 $443.00 1047480 $755.00 90 48000 $1,053.00 90 49322 $460.00 1047490 $467.00 10 48001 $1,305.00 90 49323 $712.00 9047531 $379.00 0 48020 $983.00 90 49324 $348.00 1047532 $835.00 0 48100 $779.00 90 49325 $374.00 1047533 $1,362.00 0 48102 $341.00 10 49326 $171.00 ZZZ47534 $1,678.00 0 48105 $2,505.00 90 49327 $133.00 ZZZ47535 $1,126.00 0 48120 $1,083.00 90 49329 BR YYY47536 $831.00 0 48140 $1,546.00 90 49400 $127.00 047537 $411.00 0 48145 $1,661.00 90 49402 $748.00 9047538 $4,584.00 0 48146 $1,830.00 90 49405 $886.00 047539 $5,009.00 0 48148 $1,149.00 90 49406 $886.00 047540 $5,208.00 0 48150 $3,101.00 90 49407 $749.00 047541 $1,202.00 0 48152 $2,888.00 90 49411 $537.00 047542 $526.00 ZZZ 48153 $3,099.00 90 49412 $83.00 ZZZ47543 $1,350.00 ZZZ 48154 $2,893.00 90 49418 $1,453.00 047544 $831.00 ZZZ 48155 $1,855.00 90 49419 $405.00 9047550 $209.00 ZZZ 48160 BR 0 49421 $452.00 047552 $364.00 0 48400 $100.00 ZZZ 49422 $468.00 1047553 $342.00 0 48500 $1,012.00 90 49423 $106.00 047554 $594.00 0 48510 $938.00 90 49424 $54.00 047555 $383.00 0 48520 $1,103.00 90 49425 $914.00 9047556 $425.00 0 48540 $1,350.00 90 49426 $725.00 9047562 $837.00 90 48545 $1,170.00 90 49427 $48.00 047563 $900.00 90 48547 $1,630.00 90 49428 $184.00 1047564 $1,069.00 90 48548 $1,460.00 90 49429 $522.00 1047570 $961.00 90 48552 $230.00 0 49435 $110.00 ZZZ47579 BR YYY 48554 $2,365.00 90 49436 $164.00 1047600 $868.00 90 48556 $1,117.00 90 49440 $1,113.00 10



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD49441 $1,319.00 10 50045 $1,137.00 90 50500 $1,471.00 9049442 $1,075.00 10 50060 $1,394.00 90 50520 $1,281.00 9049446 $1,100.00 0 50065 $1,514.00 90 50525 $1,644.00 9049450 $771.00 0 50070 $1,476.00 90 50526 $1,639.00 9049451 $817.00 0 50075 $1,839.00 90 50540 $1,468.00 9049452 $998.00 0 50080 $1,186.00 90 50541 $1,037.00 9049460 $818.00 0 50081 $1,635.00 90 50542 $1,093.00 9049465 $170.00 0 50100 $1,250.00 90 50543 $1,374.00 9049505 $510.00 90 50120 $1,180.00 90 50544 $1,428.00 9049507 $636.00 90 50125 $1,228.00 90 50545 $1,273.00 9049520 $631.00 90 50130 $1,301.00 90 50546 $1,325.00 9049521 $730.00 90 50135 $1,506.00 90 50547 $1,702.00 9049525 $584.00 90 50200 $151.00 0 50548 $1,555.00 9049540 $668.00 90 50205 $807.00 90 50549 BR YYY49550 $557.00 90 50220 $1,316.00 90 50551 $411.00 049553 $598.00 90 50225 $1,554.00 90 50553 $447.00 049555 $621.00 90 50230 $1,695.00 90 50555 $668.00 049557 $715.00 90 50234 $1,671.00 90 50557 $676.00 049560 $734.00 90 50236 $1,873.00 90 50561 $755.00 049561 $856.00 90 50240 $1,679.00 90 50562 $580.00 9049565 $754.00 90 50250 $1,157.00 90 50570 $549.00 049566 $881.00 90 50280 $1,170.00 90 50572 $728.00 049568 $339.00 ZZZ 50290 $1,080.00 90 50574 $762.00 049570 $411.00 90 50320 $1,680.00 90 50575 $991.00 049572 $491.00 90 50327 $214.00 0 50576 $801.00 049585 $444.00 90 50328 $187.00 0 50580 $726.00 049587 $501.00 90 50329 $179.00 0 50590 $980.00 9049590 $585.00 90 50340 $1,083.00 90 50592 $5,936.00 1049600 $774.00 90 50360 $2,475.00 90 50593 $4,692.00 1049605 $1,648.00 90 50365 $2,941.00 90 50600 $1,150.00 9049606 $1,416.00 90 50370 $1,128.00 90 50605 $1,054.00 9049610 $784.00 90 50380 $1,507.00 90 50606 $538.00 ZZZ49611 $770.00 90 50382 $1,594.00 0 50610 $1,209.00 9049650 $484.00 90 50384 $1,540.00 0 50620 $1,152.00 9049651 $621.00 90 50385 $1,326.00 0 50630 $1,170.00 9049652 $700.00 90 50386 $857.00 0 50650 $1,297.00 9049653 $874.00 90 50387 $772.00 0 50660 $1,426.00 9049654 $795.00 90 50389 $529.00 0 50684 $74.00 049655 $971.00 90 50390 $118.00 0 50686 $109.00 049656 $864.00 90 50391 $139.00 0 50688 $89.00 1049657 $1,240.00 90 50395 $203.00 0 50690 $85.00 049659 BR YYY 50396 $101.00 0 50693 $1,078.00 049900 $512.00 90 50400 $1,441.00 90 50694 $1,187.00 049904 $1,394.00 90 50405 $1,802.00 90 50695 $1,447.00 049905 $454.00 ZZZ 50430 $531.00 0 50700 $1,192.00 9049906 BR 90 50431 $165.00 0 50705 $1,735.00 ZZZ49999 BR YYY 50432 $860.00 0 50706 $778.00 ZZZ50010 $886.00 90 50433 $1,158.00 0 50715 $1,397.00 9050020 $1,084.00 90 50434 $916.00 0 50722 $1,211.00 9050040 $910.00 90 50435 $481.00 0 50725 $1,371.00 90



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD50727 $640.00 90 51525 $1,069.00 90 51785-26 $80.00 050728 $924.00 90 51530 $957.00 90 51785-TC $155.00 050740 $1,386.00 90 51535 $932.00 90 51792 $143.00 050750 $1,457.00 90 51550 $1,171.00 90 51792-26 $60.00 050760 $1,389.00 90 51555 $1,514.00 90 51792-TC $213.00 050770 $1,485.00 90 51565 $1,624.00 90 51797 $109.00 ZZZ50780 $1,391.00 90 51570 $1,762.00 90 51797-26 $84.00 ZZZ50782 $1,465.00 90 51575 $2,284.00 90 51797-TC $205.00 ZZZ50783 $1,515.00 90 51580 $2,252.00 90 51798 $20.00 050785 $1,548.00 90 51585 $2,601.00 90 51800 $1,294.00 9050800 $1,226.00 90 51590 $2,441.00 90 51820 $1,236.00 9050810 $1,527.00 90 51595 $2,900.00 90 51840 $858.00 9050815 $1,643.00 90 51596 $3,063.00 90 51841 $1,040.00 9050820 $1,729.00 90 51597 $2,914.00 90 51845 $843.00 9050825 $2,351.00 90 51600 $54.00 0 51860 $912.00 9050830 $2,292.00 90 51605 $83.00 0 51865 $1,150.00 9050840 $1,493.00 90 51610 $45.00 0 51880 $590.00 9050845 $1,513.00 90 51700 $29.00 0 51900 $1,050.00 9050860 $1,163.00 90 51701 $58.00 0 51920 $881.00 9050900 $1,043.00 90 51702 $92.00 0 51925 $1,167.00 9050920 $1,075.00 90 51703 $128.00 0 51940 $2,082.00 9050930 $1,380.00 90 51705 $37.00 0 51960 $1,848.00 9050940 $1,107.00 90 51710 $119.00 0 51980 $858.00 9050945 $1,096.00 90 51715 $322.00 0 51990 $850.00 9050947 $1,384.00 90 51720 $140.00 0 51992 $925.00 9050948 $1,265.00 90 51725 $116.00 0 52000 $190.00 050949 BR YYY 51725-26 $79.00 0 52001 $133.00 050951 $414.00 0 51725-TC $199.00 0 52005 $265.00 050953 $461.00 0 51726 $136.00 0 52007 $230.00 050955 $546.00 0 51726-26 $90.00 0 52010 $292.00 050957 $546.00 0 51726-TC $274.00 0 52204 $286.00 050961 $510.00 0 51727 $314.00 0 52214 $367.00 050970 $510.00 0 51727-26 $111.00 0 52224 $339.00 050972 $408.00 0 51727-TC $203.00 0 52234 $471.00 050974 $661.00 0 51728 $315.00 0 52235 $546.00 050976 $641.00 0 51728-26 $108.00 0 52240 $887.00 050980 $443.00 0 51728-TC $207.00 0 52250 $311.00 051020 $587.00 90 51729 $341.00 0 52260 $262.00 051030 $538.00 90 51729-26 $131.00 0 52265 $243.00 051040 $439.00 90 51729-TC $211.00 0 52270 $374.00 051045 $548.00 90 51736 $47.00 0 52275 $446.00 051050 $596.00 90 51736-26 $32.00 0 52276 $490.00 051060 $768.00 90 51736-TC $15.00 0 52277 $448.00 051065 $704.00 90 51741 $81.00 0 52281 $259.00 051080 $510.00 90 51741-26 $59.00 0 52282 $560.00 051100 $63.00 0 51741-TC $17.00 0 52283 $309.00 051101 $130.00 0 51784 $119.00 0 52285 $375.00 051102 $335.00 0 51784-26 $80.00 0 52287 $311.00 051500 $775.00 90 51784-TC $136.00 0 52290 $304.00 051520 $764.00 90 51785 $52.00 0 52300 $370.00 0



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD52301 $382.00 0 53240 $506.00 90 54100 $149.00 052305 $370.00 0 53250 $464.00 90 54105 $261.00 1052310 $348.00 0 53260 $240.00 10 54110 $775.00 9052315 $553.00 0 53265 $295.00 10 54111 $1,035.00 9052317 $772.00 0 53270 $226.00 10 54112 $1,210.00 9052318 $684.00 0 53275 $332.00 10 54115 $588.00 9052320 $369.00 0 53400 $929.00 90 54120 $777.00 9052325 $494.00 0 53405 $1,088.00 90 54125 $1,092.00 9052327 $369.00 0 53410 $1,151.00 90 54130 $1,532.00 9052330 $507.00 0 53415 $1,381.00 90 54135 $1,945.00 9052332 $451.00 0 53420 $1,088.00 90 54162 $220.00 1052334 $340.00 0 53425 $1,150.00 90 54163 $207.00 1052341 $317.00 0 53430 $1,116.00 90 54164 $182.00 1052342 $344.00 0 53431 $1,053.00 90 54200 $78.00 1052343 $380.00 0 53440 $1,057.00 90 54205 $633.00 9052344 $407.00 0 53442 $639.00 90 54220 $189.00 052345 $433.00 0 53444 $755.00 90 54230 $104.00 052346 $488.00 0 53445 $1,197.00 90 54231 $172.00 052351 $297.00 0 53446 $699.00 90 54235 $81.00 052352 $349.00 0 53447 $991.00 90 54240 $109.00 052353 $404.00 0 53448 $1,259.00 90 54240-26 $68.00 052354 $372.00 0 53449 $784.00 90 54240-TC $24.00 052355 $447.00 0 53450 $447.00 90 54250 $104.00 052356 $424.00 0 53460 $494.00 90 54250-26 $116.00 052400 $580.00 90 53500 $719.00 90 54250-TC $9.00 052402 $279.00 0 53502 $590.00 90 54300 $830.00 9052441 $1,258.00 0 53505 $586.00 90 54304 $988.00 9052442 $962.00 ZZZ 53510 $777.00 90 54308 $881.00 9052450 $602.00 90 53515 $987.00 90 54312 $1,067.00 9052500 $705.00 90 53520 $661.00 90 54316 $1,316.00 9052601 $1,021.00 90 53600 $37.00 0 54318 $900.00 9052630 $653.00 90 53601 $37.00 0 54322 $974.00 9052640 $573.00 90 53605 $81.00 0 54324 $1,260.00 9052647 $858.00 90 53620 $59.00 0 54326 $1,212.00 9052648 $957.00 90 53621 $45.00 0 54328 $1,201.00 9052649 $973.00 90 53660 $49.00 0 54332 $1,327.00 9052700 $517.00 90 53661 $50.00 0 54336 $1,672.00 9053000 $224.00 10 53665 $50.00 0 54340 $727.00 9053010 $336.00 90 53850 $741.00 90 54344 $1,360.00 9053020 $153.00 0 53852 $728.00 90 54348 $1,318.00 9053040 $460.00 90 53855 $770.00 0 54352 $1,820.00 9053060 $180.00 10 53860 $1,546.00 90 54360 $898.00 9053080 $567.00 90 53899 BR YYY 54380 $1,054.00 9053085 $836.00 90 54015 $348.00 10 54385 $1,217.00 9053200 $218.00 0 54050 $91.00 10 54390 $1,635.00 9053210 $904.00 90 54055 $106.00 10 54400 $784.00 9053215 $1,142.00 90 54056 $100.00 10 54401 $892.00 9053220 $546.00 90 54057 $149.00 10 54405 $1,294.00 9053230 $760.00 90 54060 $180.00 10 54406 $687.00 9053235 $607.00 90 54065 $281.00 10 54408 $724.00 90



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD54410 $856.00 90 55200 $310.00 90 56625 $735.00 9054411 $933.00 90 55250 $349.00 90 56630 $1,061.00 9054415 $510.00 90 55300 $167.00 0 56631 $1,400.00 9054416 $665.00 90 55400 $660.00 90 56632 $1,636.00 9054417 $819.00 90 55450 $391.00 10 56633 $1,350.00 9054420 $899.00 90 55500 $445.00 90 56634 $1,537.00 9054430 $799.00 90 55520 $446.00 90 56637 $1,806.00 9054435 $503.00 90 55530 $467.00 90 56640 $1,777.00 9054437 $701.00 90 55535 $496.00 90 56700 $227.00 1054438 $1,413.00 90 55540 $572.00 90 56740 $321.00 1054440 BR 90 55550 $486.00 90 56800 $310.00 1054450 $88.00 0 55559 BR YYY 56805 $1,349.00 9054500 $102.00 0 55600 $486.00 90 56810 $316.00 1054505 $259.00 10 55605 $609.00 90 56820 $119.00 054512 $519.00 90 55650 $853.00 90 56821 $154.00 054520 $445.00 90 55680 $426.00 90 57000 $237.00 1054522 $589.00 90 55700 $183.00 0 57010 $429.00 9054530 $683.00 90 55705 $368.00 10 57020 $118.00 054535 $922.00 90 55706 $373.00 10 57022 $179.00 1054550 $588.00 90 55720 $555.00 90 57023 $290.00 1054560 $842.00 90 55725 $670.00 90 57061 $124.00 1054600 $524.00 90 55801 $1,331.00 90 57065 $251.00 1054620 $373.00 10 55810 $1,711.00 90 57100 $90.00 054640 $594.00 90 55812 $1,989.00 90 57105 $132.00 1054650 $861.00 90 55815 $2,328.00 90 57106 $409.00 9054660 $401.00 90 55821 $1,153.00 90 57107 $1,467.00 9054670 $485.00 90 55831 $1,252.00 90 57109 $1,787.00 9054680 $948.00 90 55840 $1,705.00 90 57110 $1,015.00 9054690 $825.00 90 55842 $1,859.00 90 57111 $1,793.00 9054692 $850.00 90 55845 $2,222.00 90 57112 $1,907.00 9054699 BR YYY 55860 $1,012.00 90 57120 $612.00 9054700 $133.00 10 55862 $1,351.00 90 57130 $220.00 1054800 $257.00 0 55865 $1,890.00 90 57135 $231.00 1054830 $411.00 90 55866 $1,615.00 90 57150 $50.00 054840 $432.00 90 55870 $166.00 0 57155 $383.00 054860 $503.00 90 55873 $1,127.00 90 57156 $198.00 054861 $696.00 90 55875 $729.00 90 57160 $67.00 054865 $333.00 90 55876 $147.00 0 57170 $74.00 054900 $969.00 90 55899 BR YYY 57180 $124.00 1054901 $1,340.00 90 55920 $420.00 0 57200 $313.00 9055000 $109.00 0 56405 $131.00 10 57210 $395.00 9055040 $439.00 90 56420 $130.00 10 57220 $378.00 9055041 $634.00 90 56440 $271.00 10 57230 $442.00 9055060 $430.00 90 56441 $183.00 10 57240 $536.00 9055100 $156.00 10 56442 $45.00 0 57250 $485.00 9055110 $223.00 90 56501 $122.00 10 57260 $700.00 9055120 $350.00 90 56515 $200.00 10 57265 $902.00 9055150 $562.00 90 56605 $96.00 0 57267 $284.00 ZZZ55175 $426.00 90 56606 $49.00 ZZZ 57268 $577.00 9055180 $796.00 90 56620 $607.00 90 57270 $867.00 90



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD57280 $1,071.00 90 57700 $279.00 90 58552 $853.00 9057282 $734.00 90 57720 $328.00 90 58553 $1,096.00 9057283 $673.00 90 57800 $71.00 0 58554 $1,085.00 9057284 $950.00 90 58100 $74.00 0 58555 $261.00 057285 $607.00 90 58110 $53.00 ZZZ 58558 $340.00 057287 $685.00 90 58120 $297.00 10 58559 $436.00 057288 $1,009.00 90 58140 $1,010.00 90 58560 $482.00 057289 $879.00 90 58145 $677.00 90 58561 $677.00 057291 $622.00 90 58146 $1,089.00 90 58562 $339.00 057292 $925.00 90 58150 $1,110.00 90 58563 $450.00 057295 $485.00 90 58152 $1,159.00 90 58565 $2,189.00 9057296 $880.00 90 58180 $1,118.00 90 58570 $844.00 9057300 $653.00 90 58200 $1,562.00 90 58571 $922.00 9057305 $995.00 90 58210 $2,080.00 90 58572 $1,047.00 9057307 $997.00 90 58240 $2,898.00 90 58573 $1,178.00 9057308 $769.00 90 58260 $926.00 90 58578 BR YYY57310 $517.00 90 58262 $1,026.00 90 58579 BR YYY57311 $612.00 90 58263 $1,120.00 90 58600 $337.00 9057320 $693.00 90 58267 $1,133.00 90 58605 $298.00 9057330 $916.00 90 58270 $1,019.00 90 58611 $47.00 ZZZ57335 $963.00 90 58275 $1,121.00 90 58615 $319.00 1057400 $70.00 0 58280 $1,132.00 90 58660 $793.00 9057410 $57.00 0 58285 $1,360.00 90 58661 $804.00 1057415 $75.00 10 58290 $1,089.00 90 58662 $807.00 9057420 $124.00 0 58291 $1,197.00 90 58670 $450.00 9057421 $162.00 0 58292 $1,268.00 90 58671 $463.00 9057423 $848.00 90 58293 $1,318.00 90 58672 $872.00 9057425 $902.00 90 58294 $1,168.00 90 58673 $928.00 9057426 $879.00 90 58301 $71.00 0 58679 BR YYY57452 $96.00 0 58321 $81.00 0 58700 $544.00 9057454 $125.00 0 58322 $90.00 0 58720 $844.00 9057455 $149.00 0 58323 $24.00 0 58740 $508.00 9057456 $141.00 0 58340 $87.00 0 58750 $949.00 9057460 $223.00 0 58345 $335.00 10 58752 $893.00 9057461 $333.00 0 58346 $408.00 90 58760 $769.00 9057500 $89.00 0 58350 $103.00 10 58770 $763.00 9057505 $105.00 10 58353 $225.00 10 58800 $343.00 9057510 $140.00 10 58356 $531.00 10 58805 $509.00 9057511 $159.00 10 58400 $519.00 90 58820 $326.00 9057513 $191.00 10 58410 $752.00 90 58822 $603.00 9057520 $359.00 90 58520 $663.00 90 58825 $469.00 9057522 $319.00 90 58540 $923.00 90 58900 $489.00 9057530 $386.00 90 58541 $793.00 90 58920 $571.00 9057531 $2,036.00 90 58542 $877.00 90 58925 $820.00 9057540 $815.00 90 58543 $891.00 90 58940 $592.00 9057545 $700.00 90 58544 $965.00 90 58943 $1,368.00 9057550 $486.00 90 58545 $876.00 90 58950 $1,170.00 9057555 $774.00 90 58546 $1,104.00 90 58951 $1,703.00 9057556 $718.00 90 58548 $1,688.00 90 58952 $1,876.00 9057558 $120.00 10 58550 $1,038.00 90 58953 $1,839.00 90



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD58954 $1,999.00 90 59620 $1,293.00 0 61026 $138.00 058956 $1,329.00 90 59622 $1,397.00 0 61050 $106.00 058957 $1,365.00 90 59812 $343.00 90 61055 $143.00 058958 $1,511.00 90 59820 $389.00 90 61070 $67.00 058960 $1,174.00 90 59821 $398.00 90 61105 $503.00 9058999 BR YYY 59830 $496.00 90 61107 $863.00 059000 $123.00 0 59840 $331.00 10 61108 $959.00 9059001 $167.00 0 59841 $443.00 10 61120 $733.00 9059012 $267.00 0 59850 $449.00 90 61140 $1,389.00 9059015 $168.00 0 59851 $464.00 90 61150 $1,503.00 9059020 $85.00 0 59852 $642.00 90 61151 $795.00 9059020-26 $40.00 0 59855 $477.00 90 61154 $1,393.00 9059020-TC $23.00 0 59856 $577.00 90 61156 $1,473.00 9059025 $54.00 0 59857 $711.00 90 61210 $527.00 059025-26 $32.00 0 59866 $304.00 0 61215 $637.00 9059025-TC $10.00 0 59870 $348.00 90 61250 $888.00 9059030 $155.00 0 59871 $192.00 0 61253 $1,042.00 9059050 $71.00 0 59898 BR YYY 61304 $2,005.00 9059051 $47.00 0 59899 BR YYY 61305 $2,419.00 9059100 $633.00 90 60000 $114.00 10 61312 $2,187.00 9059120 $893.00 90 60100 $96.00 0 61313 $2,207.00 9059121 $768.00 90 60200 $744.00 90 61314 $2,200.00 9059130 $832.00 90 60210 $872.00 90 61315 $2,393.00 9059135 $1,083.00 90 60212 $1,170.00 90 61316 $88.00 ZZZ59136 $934.00 90 60220 $851.00 90 61320 $2,118.00 9059140 $461.00 90 60225 $1,107.00 90 61321 $2,310.00 9059150 $543.00 90 60240 $1,228.00 90 61322 $1,779.00 9059151 $690.00 90 60252 $1,427.00 90 61323 $1,842.00 9059160 $279.00 10 60254 $1,911.00 90 61330 $1,706.00 9059200 $79.00 0 60260 $1,022.00 90 61332 $2,307.00 9059300 $179.00 0 60270 $1,468.00 90 61333 $2,231.00 9059320 $196.00 0 60271 $1,210.00 90 61340 $1,584.00 9059325 $316.00 0 60280 $546.00 90 61343 $2,673.00 9059350 $375.00 0 60281 $670.00 90 61345 $2,259.00 9059400 $1,816.00 0 60300 $99.00 0 61450 $2,173.00 9059409 $1,019.00 0 60500 $1,232.00 90 61458 $2,433.00 9059410 $1,123.00 0 60502 $1,475.00 90 61460 $2,426.00 9059412 $141.00 0 60505 $1,631.00 90 61480 $1,922.00 9059414 $134.00 0 60512 $310.00 ZZZ 61500 $1,637.00 9059425 $414.00 0 60520 $1,405.00 90 61501 $1,353.00 9059426 $708.00 0 60521 $1,591.00 90 61510 $2,506.00 9059430 $140.00 0 60522 $1,820.00 90 61512 $2,981.00 9059510 $2,064.00 0 60540 $1,272.00 90 61514 $2,262.00 9059514 $1,199.00 0 60545 $1,505.00 90 61516 $2,253.00 9059515 $1,324.00 0 60600 $1,477.00 90 61517 $74.00 ZZZ59525 $591.00 ZZZ 60605 $1,624.00 90 61518 $3,163.00 9059610 $1,805.00 0 60650 $1,340.00 90 61519 $3,450.00 9059612 $1,113.00 0 60659 BR YYY 61520 $4,349.00 9059614 $1,208.00 0 60699 BR YYY 61521 $3,667.00 9059618 $2,035.00 0 61020 $150.00 0 61522 $2,415.00 90



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD61524 $2,484.00 90 61607 $2,961.00 90 61799 $308.00 ZZZ61526 $3,918.00 90 61608 $3,458.00 90 61800 $156.00 ZZZ61530 $3,611.00 90 61610 $2,354.00 ZZZ 61850 $1,090.00 9061531 $1,344.00 90 61611 $584.00 ZZZ 61860 $1,197.00 9061533 $1,712.00 90 61612 $2,219.00 ZZZ 61863 $1,231.00 9061534 $1,535.00 90 61613 $3,375.00 90 61864 $295.00 ZZZ61535 $958.00 90 61615 $2,576.00 90 61867 $1,863.00 9061536 $2,862.00 90 61616 $3,535.00 90 61868 $491.00 ZZZ61537 $1,714.00 90 61618 $1,389.00 90 61870 $616.00 9061538 $2,466.00 90 61619 $1,682.00 90 61880 $559.00 9061539 $2,660.00 90 61623 $540.00 0 61885 $262.00 9061540 $2,069.00 90 61624 $1,073.00 0 61886 $678.00 9061541 $2,363.00 90 61626 $877.00 0 61888 $331.00 1061543 $2,307.00 90 61630 $1,245.00 0 62000 $848.00 9061544 $2,271.00 90 61635 $1,362.00 0 62005 $1,282.00 9061545 $3,474.00 90 61640 $555.00 0 62010 $1,754.00 9061546 $2,695.00 90 61641 $195.00 ZZZ 62100 $1,962.00 9061548 $1,964.00 90 61642 $390.00 ZZZ 62115 $1,686.00 9061550 $1,141.00 90 61645 $809.00 0 62117 $2,211.00 9061552 $1,463.00 90 61650 $540.00 0 62120 $1,898.00 9061556 $1,760.00 90 61651 $229.00 ZZZ 62121 $1,822.00 9061557 $1,807.00 90 61680 $2,758.00 90 62140 $1,221.00 9061558 $2,085.00 90 61682 $4,798.00 90 62141 $1,955.00 9061559 $2,700.00 90 61684 $3,341.00 90 62142 $1,011.00 9061563 $2,175.00 90 61686 $5,012.00 90 62143 $1,096.00 9061564 $2,597.00 90 61690 $2,556.00 90 62145 $1,566.00 9061566 $2,048.00 90 61692 $4,007.00 90 62146 $1,327.00 9061567 $2,340.00 90 61697 $3,231.00 90 62147 $1,566.00 9061570 $1,975.00 90 61698 $3,103.00 90 62148 $120.00 ZZZ61571 $2,140.00 90 61700 $4,037.00 90 62160 $172.00 ZZZ61575 $2,992.00 90 61702 $4,019.00 90 62161 $1,229.00 9061576 $3,772.00 90 61703 $1,444.00 90 62162 $1,578.00 9061580 $2,383.00 90 61705 $3,043.00 90 62163 $999.00 9061581 $2,674.00 90 61708 $2,546.00 90 62164 $1,706.00 9061582 $2,557.00 90 61710 $2,129.00 90 62165 $1,336.00 9061583 $2,972.00 90 61711 $3,150.00 90 62180 $1,695.00 9061584 $2,830.00 90 61720 $1,558.00 90 62190 $1,034.00 9061585 $3,142.00 90 61735 $1,664.00 90 62192 $1,146.00 9061586 $2,097.00 90 61750 $1,521.00 90 62194 $239.00 1061590 $3,299.00 90 61751 $1,628.00 90 62200 $1,625.00 9061591 $3,491.00 90 61760 $1,670.00 90 62201 $1,200.00 9061592 $3,245.00 90 61770 $1,867.00 90 62220 $1,215.00 9061595 $2,350.00 90 61781 $240.00 ZZZ 62223 $1,199.00 9061596 $2,827.00 90 61782 $197.00 ZZZ 62225 $488.00 9061597 $3,046.00 90 61783 $241.00 ZZZ 62230 $935.00 9061598 $2,693.00 90 61790 $952.00 90 62252 $85.00 061600 $2,039.00 90 61791 $1,205.00 90 62252-26 $49.00 061601 $2,279.00 90 61796 $1,027.00 90 62252-TC $42.00 061605 $2,299.00 90 61797 $224.00 ZZZ 62256 $616.00 9061606 $3,178.00 90 61798 $1,404.00 90 62258 $1,308.00 90



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD62263 $426.00 10 63044 BR ZZZ 63271 $2,401.00 9062264 $593.00 10 63045 $1,647.00 90 63272 $2,206.00 9062267 $253.00 0 63046 $2,117.00 90 63273 $2,012.00 9062268 $285.00 0 63047 $1,907.00 90 63275 $2,166.00 9062269 $271.00 0 63048 $367.00 ZZZ 63276 $2,135.00 9062270 $109.00 0 63050 $1,411.00 90 63277 $1,905.00 9062272 $137.00 0 63051 $1,605.00 90 63278 $1,877.00 9062273 $130.00 0 63055 $2,029.00 90 63280 $2,529.00 9062280 $199.00 10 63056 $1,960.00 90 63281 $2,496.00 9062281 $186.00 10 63057 $421.00 ZZZ 63282 $2,305.00 9062282 $211.00 10 63064 $2,200.00 90 63283 $2,041.00 9062284 $196.00 0 63066 $263.00 ZZZ 63285 $2,934.00 9062287 $784.00 90 63075 $1,720.00 90 63286 $3,003.00 9062290 $235.00 0 63076 $383.00 ZZZ 63287 $3,012.00 9062291 $232.00 0 63077 $1,828.00 90 63290 $3,073.00 9062292 $1,064.00 90 63078 $261.00 ZZZ 63295 $319.00 ZZZ62294 $821.00 90 63081 $2,203.00 90 63300 $2,006.00 9062302 $246.00 0 63082 $391.00 ZZZ 63301 $2,209.00 9062303 $256.00 0 63085 $2,416.00 90 63302 $2,290.00 9062304 $244.00 0 63086 $282.00 ZZZ 63303 $2,357.00 9062305 $266.00 0 63087 $2,930.00 90 63304 $2,513.00 9062310 $200.00 0 63088 $381.00 ZZZ 63305 $2,574.00 9062311 $201.00 0 63090 $2,490.00 90 63306 $2,596.00 9062318 $208.00 0 63091 $249.00 ZZZ 63307 $2,522.00 9062319 $203.00 0 63101 $2,127.00 90 63308 $425.00 ZZZ62350 $488.00 10 63102 $2,127.00 90 63600 $797.00 9062351 $782.00 90 63103 $249.00 ZZZ 63610 $476.00 062355 $402.00 10 63170 $1,788.00 90 63615 $1,348.00 9062360 $195.00 10 63172 $1,672.00 90 63620 $1,133.00 9062361 $390.00 10 63173 $1,851.00 90 63621 $256.00 ZZZ62362 $517.00 10 63180 $1,486.00 90 63650 $819.00 1062365 $418.00 10 63182 $1,711.00 90 63655 $1,064.00 9062367 $39.00 0 63185 $1,347.00 90 63661 $584.00 1062368 $53.00 0 63190 $1,610.00 90 63662 $792.00 9062369 $121.00 0 63191 $1,444.00 90 63663 $811.00 1062370 $128.00 0 63194 $1,593.00 90 63664 $820.00 9063001 $1,882.00 90 63195 $1,603.00 90 63685 $615.00 1063003 $1,591.00 90 63196 $1,810.00 90 63688 $707.00 1063005 $1,390.00 90 63197 $1,725.00 90 63700 $1,340.00 9063011 $1,151.00 90 63198 $1,956.00 90 63702 $1,512.00 9063012 $1,568.00 90 63199 $2,258.00 90 63704 $1,708.00 9063015 $1,862.00 90 63200 $1,569.00 90 63706 $1,873.00 9063016 $1,788.00 90 63250 $3,182.00 90 63707 $1,041.00 9063017 $1,489.00 90 63251 $3,207.00 90 63709 $1,310.00 9063020 $1,395.00 90 63252 $3,319.00 90 63710 $1,165.00 9063030 $1,145.00 90 63265 $1,940.00 90 63740 $1,062.00 9063035 $280.00 ZZZ 63266 $2,053.00 90 63741 $741.00 9063040 $1,764.00 90 63267 $1,651.00 90 63744 $738.00 9063042 $1,620.00 90 63268 $1,469.00 90 63746 $529.00 9063043 BR ZZZ 63270 $2,197.00 90 64400 $78.00 0



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD64402 $75.00 0 64568 $628.00 90 64736 $388.00 9064405 $103.00 0 64569 $799.00 90 64738 $475.00 9064408 $120.00 0 64570 $709.00 90 64740 $461.00 9064410 $109.00 0 64575 $367.00 90 64742 $517.00 9064413 $128.00 0 64580 $343.00 90 64744 $798.00 9064415 $109.00 0 64581 $745.00 90 64746 $494.00 9064416 $159.00 0 64585 $37.00 10 64755 $1,042.00 9064417 $105.00 0 64590 $217.00 10 64760 $578.00 9064418 $108.00 0 64595 $153.00 10 64763 $561.00 9064420 $89.00 0 64600 $228.00 10 64766 $713.00 9064421 $128.00 0 64605 $319.00 10 64771 $632.00 9064425 $116.00 0 64610 $307.00 10 64772 $636.00 9064430 $130.00 0 64611 $114.00 10 64774 $392.00 9064435 $114.00 0 64612 $188.00 10 64776 $390.00 9064445 $68.00 0 64615 $146.00 10 64778 $249.00 ZZZ64446 $165.00 0 64616 $125.00 10 64782 $482.00 9064447 $77.00 0 64617 $193.00 10 64783 $298.00 ZZZ64448 $152.00 0 64620 $185.00 10 64784 $751.00 9064449 $152.00 0 64630 $202.00 10 64786 $1,281.00 9064450 $53.00 0 64632 $87.00 10 64787 $458.00 ZZZ64455 $49.00 0 64633 $441.00 10 64788 $381.00 9064461 $151.00 0 64634 $200.00 ZZZ 64790 $884.00 9064462 $86.00 ZZZ 64635 $435.00 10 64792 $1,148.00 9064463 $164.00 0 64636 $181.00 ZZZ 64795 $247.00 064479 $224.00 0 64640 $208.00 10 64802 $711.00 9064480 $194.00 ZZZ 64642 $142.00 0 64804 $1,202.00 9064483 $206.00 0 64643 $93.00 ZZZ 64809 $1,080.00 9064484 $183.00 ZZZ 64644 $162.00 0 64818 $845.00 9064486 $127.00 0 64645 $114.00 ZZZ 64820 $838.00 9064487 $156.00 0 64646 $152.00 0 64821 $609.00 9064488 $156.00 0 64647 $176.00 0 64822 $609.00 9064489 $218.00 0 64650 $62.00 0 64823 $703.00 9064490 $196.00 0 64653 $71.00 0 64831 $592.00 9064491 $96.00 ZZZ 64680 $180.00 10 64832 $171.00 ZZZ64492 $97.00 ZZZ 64681 $464.00 10 64834 $711.00 9064493 $177.00 0 64702 $383.00 90 64835 $834.00 9064494 $88.00 ZZZ 64704 $402.00 90 64836 $856.00 9064495 $89.00 ZZZ 64708 $562.00 90 64837 $480.00 ZZZ64505 $104.00 0 64712 $678.00 90 64840 $1,058.00 9064508 $99.00 0 64713 $867.00 90 64856 $1,063.00 9064510 $103.00 0 64714 $715.00 90 64857 $1,137.00 9064517 $188.00 0 64716 $523.00 90 64858 $1,313.00 9064520 $131.00 0 64718 $558.00 90 64859 $341.00 ZZZ64530 $135.00 0 64719 $446.00 90 64861 $1,524.00 9064550 $23.00 0 64721 $439.00 90 64862 $1,798.00 9064553 $137.00 10 64722 $411.00 90 64864 $970.00 9064555 $131.00 10 64726 $271.00 90 64865 $1,250.00 9064561 $801.00 10 64727 $261.00 ZZZ 64866 $1,238.00 9064565 $121.00 10 64732 $405.00 90 64868 $1,162.00 9064566 $121.00 0 64734 $432.00 90 64872 $155.00 ZZZ



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD64874 $230.00 ZZZ 65410 $142.00 0 66185 $769.00 9064876 $189.00 ZZZ 65420 $448.00 90 66220 $711.00 9064885 $1,382.00 90 65426 $534.00 90 66225 $1,006.00 9064886 $1,636.00 90 65430 $81.00 0 66250 $602.00 9064890 $1,112.00 90 65435 $88.00 0 66500 $359.00 9064891 $1,243.00 90 65436 $319.00 90 66505 $359.00 9064892 $1,177.00 90 65450 $52.00 90 66600 $825.00 9064893 $1,321.00 90 65600 $325.00 90 66605 $1,136.00 9064895 $1,500.00 90 65710 $1,124.00 90 66625 $543.00 9064896 $1,185.00 90 65730 $1,314.00 90 66630 $623.00 9064897 $1,419.00 90 65750 $1,381.00 90 66635 $595.00 9064898 $1,549.00 90 65755 $1,373.00 90 66680 $526.00 9064901 $865.00 ZZZ 65756 $1,201.00 90 66682 $627.00 9064902 $982.00 ZZZ 65770 $1,461.00 90 66700 $506.00 9064905 $1,059.00 90 65772 $449.00 90 66710 $513.00 9064907 $1,472.00 90 65775 $595.00 90 66711 $507.00 9064910 $645.00 90 65778 $1,389.00 0 66720 $506.00 9064911 $783.00 90 65779 $1,238.00 0 66740 $473.00 9064999 BR YYY 65780 $766.00 90 66761 $506.00 1065091 $678.00 90 65781 $1,169.00 90 66762 $433.00 9065093 $712.00 90 65782 $1,008.00 90 66770 $483.00 9065101 $726.00 90 65785 $2,144.00 90 66820 $433.00 9065103 $769.00 90 65800 $88.00 0 66821 $275.00 9065105 $846.00 90 65810 $516.00 90 66825 $753.00 9065110 $1,305.00 90 65815 $327.00 90 66830 $651.00 9065112 $1,386.00 90 65820 $813.00 90 66840 $707.00 9065114 $1,456.00 90 65850 $968.00 90 66850 $805.00 9065125 $312.00 90 65855 $441.00 10 66852 $878.00 9065130 $730.00 90 65860 $339.00 90 66920 $785.00 9065135 $678.00 90 65865 $540.00 90 66930 $906.00 9065140 $738.00 90 65870 $572.00 90 66940 $819.00 9065150 $652.00 90 65875 $597.00 90 66982 $846.00 9065155 $862.00 90 65880 $641.00 90 66983 $763.00 9065175 $654.00 90 65900 $945.00 90 66984 $898.00 9065205 $45.00 0 65920 $752.00 90 66985 $744.00 9065210 $53.00 0 65930 $700.00 90 66986 $1,038.00 9065220 $58.00 0 66020 $164.00 10 66990 $84.00 ZZZ65222 $62.00 0 66030 $160.00 10 66999 BR YYY65235 $627.00 90 66130 $631.00 90 67005 $639.00 9065260 $956.00 90 66150 $798.00 90 67010 $647.00 9065265 $1,104.00 90 66155 $795.00 90 67015 $637.00 9065270 $88.00 10 66160 $942.00 90 67025 $774.00 9065272 $223.00 90 66170 $1,089.00 90 67027 $1,089.00 9065273 $376.00 90 66172 $1,264.00 90 67028 $338.00 065275 $75.00 90 66174 $1,006.00 90 67030 $485.00 9065280 $711.00 90 66175 $1,140.00 90 67031 $402.00 9065285 $1,177.00 90 66179 $1,092.00 90 67036 $1,384.00 9065286 $692.00 90 66180 $1,313.00 90 67039 $1,490.00 9065290 $519.00 90 66183 $1,090.00 90 67040 $1,960.00 9065400 $603.00 90 66184 $796.00 90 67041 $1,065.00 90



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD67042 $1,218.00 90 67450 $1,300.00 90 67973 $1,126.00 9067043 $1,279.00 90 67500 $75.00 0 67974 $1,140.00 9067101 $767.00 90 67505 $109.00 0 67975 $681.00 9067105 $941.00 90 67515 $53.00 0 67999 BR YYY67107 $1,350.00 90 67550 $946.00 90 68020 $106.00 1067108 $1,878.00 90 67560 $936.00 90 68040 $75.00 067110 $1,040.00 90 67570 $1,148.00 90 68100 $137.00 067113 $1,405.00 90 67599 BR YYY 68110 $172.00 1067115 $496.00 90 67700 $87.00 10 68115 $248.00 1067120 $751.00 90 67710 $117.00 10 68130 $378.00 9067121 $962.00 90 67715 $102.00 10 68135 $146.00 1067141 $536.00 90 67800 $119.00 10 68200 $59.00 067145 $514.00 90 67801 $189.00 10 68320 $502.00 9067208 $655.00 90 67805 $208.00 10 68325 $672.00 9067210 $779.00 90 67808 $308.00 90 68326 $654.00 9067218 $1,217.00 90 67810 $133.00 0 68328 $741.00 9067220 $894.00 90 67820 $36.00 0 68330 $488.00 9067221 $325.00 0 67825 $130.00 10 68335 $636.00 9067225 $44.00 ZZZ 67830 $239.00 10 68340 $413.00 9067227 $652.00 10 67835 $500.00 90 68360 $449.00 9067228 $1,025.00 10 67840 $187.00 10 68362 $691.00 9067229 $926.00 90 67850 $143.00 10 68371 $363.00 1067250 $793.00 90 67875 $163.00 0 68399 BR YYY67255 $872.00 90 67880 $442.00 90 68400 $154.00 1067299 BR YYY 67882 $643.00 90 68420 $191.00 1067311 $616.00 90 67900 $487.00 90 68440 $96.00 1067312 $773.00 90 67901 $646.00 90 68500 $882.00 9067314 $688.00 90 67902 $650.00 90 68505 $921.00 9067316 $857.00 90 67903 $657.00 90 68510 $491.00 067318 $663.00 90 67904 $720.00 90 68520 $687.00 9067320 $602.00 ZZZ 67906 $633.00 90 68525 $340.00 067331 $560.00 ZZZ 67908 $550.00 90 68530 $379.00 1067332 $621.00 ZZZ 67909 $577.00 90 68540 $875.00 9067334 $447.00 ZZZ 67911 $517.00 90 68550 $1,107.00 9067335 $253.00 ZZZ 67912 $983.00 90 68700 $628.00 9067340 $559.00 ZZZ 67914 $487.00 90 68705 $176.00 1067343 $628.00 90 67915 $252.00 90 68720 $807.00 9067345 $275.00 10 67916 $675.00 90 68745 $704.00 9067346 $173.00 0 67917 $631.00 90 68750 $792.00 9067399 BR YYY 67921 $419.00 90 68760 $109.00 1067400 $960.00 90 67922 $243.00 90 68761 $130.00 1067405 $799.00 90 67923 $718.00 90 68770 $634.00 9067412 $976.00 90 67924 $605.00 90 68801 $202.00 1067413 $909.00 90 67930 $280.00 10 68810 $290.00 1067414 $1,023.00 90 67935 $520.00 90 68811 $191.00 1067415 $146.00 0 67938 $67.00 10 68815 $399.00 1067420 $1,729.00 90 67950 $584.00 90 68816 $592.00 1067430 $1,203.00 90 67961 $571.00 90 68840 $100.00 1067440 $1,257.00 90 67966 $645.00 90 68850 $76.00 067445 $1,269.00 90 67971 $875.00 90 68899 BR YYY



Surgery Surgery SurgeryCPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD69000 $52.00 10 69637 $1,370.00 90 G0364 $12.00 ZZZ69005 $175.00 10 69641 $1,154.00 90 G0412 $742.00 9069020 $109.00 10 69642 $1,519.00 90 G0413 $1,092.00 9069100 $85.00 0 69643 $1,389.00 90 G0414 $1,017.00 9069105 $87.00 0 69644 $1,529.00 90 G0415 $1,407.00 9069110 $294.00 90 69645 $1,479.00 90 G0429 $102.00 069120 $274.00 90 69646 $1,620.00 9069140 $722.00 90 69650 $879.00 9069145 $248.00 90 69660 $1,072.00 9069150 $1,111.00 90 69661 $1,412.00 9069155 $1,680.00 90 69662 $1,386.00 9069200 $53.00 0 69666 $887.00 9069205 $110.00 10 69667 $887.00 9069209 $13.00 0 69670 $988.00 9069210 $39.00 0 69676 $828.00 9069220 $78.00 0 69700 $702.00 9069222 $123.00 10 69710 BR 069300 $522.00 YYY 69711 $878.00 9069310 $937.00 90 69714 $961.00 9069320 $1,434.00 90 69715 $1,217.00 9069399 BR YYY 69717 $996.00 9069420 $117.00 10 69718 $1,232.00 9069421 $155.00 10 69720 $1,307.00 9069424 $84.00 0 69725 $1,922.00 9069433 $145.00 10 69740 $1,274.00 9069436 $182.00 10 69745 $1,447.00 9069440 $699.00 90 69799 BR YYY69450 $525.00 90 69801 $785.00 069501 $829.00 90 69805 $1,187.00 9069502 $1,118.00 90 69806 $1,123.00 9069505 $1,176.00 90 69820 $876.00 9069511 $1,221.00 90 69840 $869.00 9069530 $1,616.00 90 69905 $1,013.00 9069535 $2,824.00 90 69910 $1,228.00 9069540 $126.00 10 69915 $1,754.00 9069550 $998.00 90 69930 $1,498.00 9069552 $1,621.00 90 69949 BR YYY69554 $2,600.00 90 69950 $2,017.00 9069601 $1,195.00 90 69955 $2,185.00 9069602 $1,225.00 90 69960 $2,116.00 9069603 $1,264.00 90 69970 $2,306.00 9069604 $1,263.00 90 69979 BR YYY69605 $1,526.00 90 69990 $262.00 ZZZ69610 $41.00 10 G0127 $17.00 069620 $651.00 90 G0168 $75.00 069631 $985.00 90 G0247 $38.00 ZZZ69632 $1,166.00 90 G0289 $82.00 ZZZ69633 $1,110.00 90 G0341 $333.00 069635 $1,207.00 90 G0342 $622.00 9069636 $1,381.00 90 G0343 $1,026.00 90



Radiology Radiology RadiologyCPT Code MRA CPT Code MRA CPT Code MRA70010 $70.00 70240-TC $15.00 70450-26 $43.0070010-26 $19.00 70250 $35.00 70450-TC $176.0070010-TC $51.00 70250-26 $12.00 70460 $271.0070015 $58.00 70250-TC $22.00 70460-26 $58.0070015-26 $31.00 70260 $50.00 70460-TC $211.0070015-TC $27.00 70260-26 $17.00 70470 $332.0070030 $24.00 70260-TC $33.00 70470-26 $65.0070030-26 $10.00 70300 $15.00 70470-TC $264.0070030-TC $15.00 70300-26 $5.00 70480 $244.0070100 $29.00 70300-TC $10.00 70480-26 $65.0070100-26 $9.00 70310 $24.00 70480-TC $176.0070100-TC $19.00 70310-26 $8.00 70481 $284.0070110 $36.00 70310-TC $15.00 70481-26 $70.0070110-26 $12.00 70320 $40.00 70481-TC $211.0070110-TC $22.00 70320-26 $11.00 70482 $340.0070120 $32.00 70320-TC $29.00 70482-26 $74.0070120-26 $9.00 70328 $28.00 70482-TC $264.0070120-TC $22.00 70328-26 $10.00 70486 $236.0070130 $46.00 70328-TC $18.00 70486-26 $58.0070130-26 $17.00 70330 $43.00 70486-TC $176.0070130-TC $29.00 70330-26 $12.00 70487 $279.0070134 $45.00 70330-TC $31.00 70487-26 $66.0070134-26 $17.00 70332 $107.00 70487-TC $211.0070134-TC $28.00 70332-26 $27.00 70488 $339.0070140 $33.00 70332-TC $80.00 70488-26 $72.0070140-26 $9.00 70336 $497.00 70488-TC $264.0070140-TC $22.00 70336-26 $72.00 70490 $244.0070150 $42.00 70336-TC $419.00 70490-26 $65.0070150-26 $12.00 70350 $24.00 70490-TC $176.0070150-TC $29.00 70350-26 $10.00 70491 $284.0070160 $29.00 70350-TC $14.00 70491-26 $70.0070160-26 $8.00 70355 $32.00 70491-TC $211.0070160-TC $19.00 70355-26 $10.00 70492 $340.0070170 $52.00 70355-TC $21.00 70492-26 $74.0070170-26 $15.00 70360 $24.00 70492-TC $264.0070170-TC $37.00 70360-26 $8.00 70496 $366.0070190 $34.00 70360-TC $15.00 70496-26 $92.0070190-26 $10.00 70370 $65.00 70496-TC $270.0070190-TC $22.00 70370-26 $16.00 70498 $366.0070200 $43.00 70370-TC $48.00 70498-26 $92.0070200-26 $14.00 70371 $122.00 70498-TC $270.0070200-TC $29.00 70371-26 $43.00 70540 $482.0070210 $32.00 70371-TC $79.00 70540-26 $70.0070210-26 $8.00 70380 $34.00 70540-TC $413.0070210-TC $22.00 70380-26 $8.00 70542 $579.0070220 $42.00 70380-TC $24.00 70542-26 $82.0070220-26 $12.00 70390 $87.00 70542-TC $495.0070220-TC $29.00 70390-26 $19.00 70543 $1,029.0070240 $26.00 70390-TC $68.00 70543-26 $109.0070240-26 $9.00 70450 $221.00 70543-TC $916.00



Radiology Radiology RadiologyCPT Code MRA CPT Code MRA CPT Code MRA70544 $481.00 71020-TC $22.00 71550-26 $75.0070544-26 $61.00 71021 $41.00 71550-TC $415.0070544-TC $419.00 71021-26 $13.00 71551 $587.0070545 $481.00 71021-TC $28.00 71551-26 $88.0070545-26 $61.00 71022 $44.00 71551-TC $496.0070545-TC $419.00 71022-26 $16.00 71552 $1,029.0070546 $914.00 71022-TC $28.00 71552-26 $114.0070546-26 $92.00 71023 $49.00 71552-TC $911.0070546-TC $820.00 71023-26 $19.00 71555 $514.0070547 $481.00 71023-TC $29.00 71555-26 $92.0070547-26 $61.00 71030 $45.00 71555-TC $419.0070547-TC $419.00 71030-26 $16.00 72020 $22.0070548 $481.00 71030-TC $29.00 72020-26 $7.0070548-26 $61.00 71034 $79.00 72020-TC $15.0070548-TC $419.00 71034-26 $23.00 72040 $34.0070549 $914.00 71034-TC $54.00 72040-26 $11.0070549-26 $92.00 71035 $56.00 72040-TC $22.0070549-TC $820.00 71035-26 $19.00 72050 $49.0070551 $497.00 71035-TC $38.00 72050-26 $16.0070551-26 $76.00 71100 $33.00 72050-TC $33.0070551-TC $419.00 71100-26 $11.00 72052 $61.0070552 $596.00 71100-TC $21.00 72052-26 $18.0070552-26 $91.00 71101 $38.00 72052-TC $42.0070552-TC $502.00 71101-26 $13.00 72070 $36.0070553 $1,055.00 71101-TC $24.00 72070-26 $11.0070553-26 $120.00 71110 $43.00 72070-TC $24.0070553-TC $931.00 71110-26 $13.00 72072 $39.0070554 $618.00 71110-TC $29.00 72072-26 $11.0070554-26 $99.00 71111 $49.00 72072-TC $28.0070554-TC $520.00 71111-26 $16.00 72074 $45.0070555 BR 71111-TC $33.00 72074-26 $11.0070555-26 $118.00 71120 $35.00 72074-TC $34.0070555-TC BR 71120-26 $10.00 72080 $36.0070557 $392.00 71120-TC $24.00 72080-26 $11.0070557-26 $148.00 71130 $38.00 72080-TC $24.0070557-TC $349.00 71130-26 $11.00 72081 $39.0070558 $425.00 71130-TC $26.00 72081-26 $14.0070558-26 $164.00 71250 $282.00 72081-TC $25.0070558-TC $376.00 71250-26 $59.00 72082 $63.0070559 $548.00 71250-TC $220.00 72082-26 $16.0070559-26 $164.00 71260 $328.00 72082-TC $46.0070559-TC $499.00 71260-26 $63.00 72083 $68.0071010 $27.00 71260-TC $264.00 72083-26 $18.0071010-26 $9.00 71270 $402.00 72083-TC $50.0071010-TC $17.00 71270-26 $70.00 72084 $81.0071015 $30.00 71270-TC $330.00 72084-26 $21.0071015-26 $10.00 71275 $431.00 72084-TC $61.0071015-TC $19.00 71275-26 $100.00 72100 $36.0071020 $35.00 71275-TC $328.00 72100-26 $11.0071020-26 $11.00 71550 $490.00 72100-TC $24.00



Radiology Radiology RadiologyCPT Code MRA CPT Code MRA CPT Code MRA72110 $50.00 72148-TC $465.00 72202-26 $9.0072110-26 $16.00 72149 $597.00 72202-TC $22.0072110-TC $34.00 72149-26 $92.00 72220 $30.0072114 $64.00 72149-TC $502.00 72220-26 $8.0072114-26 $18.00 72156 $1,066.00 72220-TC $21.0072114-TC $44.00 72156-26 $131.00 72240 $132.0072120 $45.00 72156-TC $931.00 72240-26 $26.0072120-26 $11.00 72157 $1,066.00 72240-TC $106.0072120-TC $33.00 72157-26 $131.00 72255 $129.0072125 $282.00 72157-TC $931.00 72255-26 $28.0072125-26 $59.00 72158 $1,056.00 72255-TC $101.0072125-TC $220.00 72158-26 $121.00 72265 $132.0072126 $328.00 72158-TC $931.00 72265-26 $28.0072126-26 $62.00 72159 $563.00 72265-TC $104.0072126-TC $264.00 72159-26 $94.00 72270 $176.0072127 $397.00 72159-TC $465.00 72270-26 $39.0072127-26 $65.00 72170 $29.00 72270-TC $137.0072127-TC $330.00 72170-26 $8.00 72275 $112.0072128 $282.00 72170-TC $19.00 72275-26 $34.0072128-26 $59.00 72190 $35.00 72275-TC $78.0072128-TC $220.00 72190-26 $10.00 72285 $101.0072129 $328.00 72190-TC $24.00 72285-26 $15.0072129-26 $62.00 72191 $413.00 72285-TC $86.0072129-TC $264.00 72191-26 $94.00 72295 $107.0072130 $397.00 72191-TC $315.00 72295-26 $13.0072130-26 $65.00 72192 $278.00 72295-TC $94.0072130-TC $330.00 72192-26 $56.00 73000 $28.0072131 $282.00 72192-TC $220.00 73000-26 $8.0072131-26 $59.00 72193 $317.00 73000-TC $19.0072131-TC $220.00 72193-26 $59.00 73010 $29.0072132 $328.00 72193-TC $256.00 73010-26 $8.0072132-26 $62.00 72194 $380.00 73010-TC $19.0072132-TC $264.00 72194-26 $62.00 73020 $26.0072133 $391.00 72194-TC $317.00 73020-26 $7.0072133-26 $65.00 72195 $491.00 73020-TC $17.0072133-TC $323.00 72195-26 $74.00 73030 $31.0072141 $503.00 72195-TC $415.00 73030-26 $9.0072141-26 $82.00 72196 $526.00 73030-TC $21.0072141-TC $419.00 72196-26 $84.00 73040 $68.0072142 $604.00 72196-TC $442.00 73040-26 $17.0072142-26 $99.00 72197 $1,037.00 73040-TC $51.0072142-TC $502.00 72197-26 $114.00 73050 $35.0072146 $549.00 72197-TC $919.00 73050-26 $10.0072146-26 $82.00 72198 $517.00 73050-TC $24.0072146-TC $465.00 72198-26 $95.00 73060 $30.0072147 $603.00 72198-TC $419.00 73060-26 $8.0072147-26 $98.00 72200 $29.00 73060-TC $21.0072147-TC $502.00 72200-26 $9.00 73070 $27.0072148 $543.00 72200-TC $19.00 73070-26 $7.0072148-26 $76.00 72202 $33.00 73070-TC $19.00



Radiology Radiology RadiologyCPT Code MRA CPT Code MRA CPT Code MRA73080 $30.00 73221-TC $413.00 73580-26 $18.0073080-26 $8.00 73222 $579.00 73580-TC $66.0073080-TC $21.00 73222-26 $82.00 73590 $29.0073085 $74.00 73222-TC $495.00 73590-26 $8.0073085-26 $19.00 73223 $1,029.00 73590-TC $19.0073085-TC $55.00 73223-26 $109.00 73600 $27.0073090 $28.00 73223-TC $916.00 73600-26 $8.0073090-26 $8.00 73225 $513.00 73600-TC $18.0073090-TC $19.00 73225-26 $92.00 73610 $29.0073100 $27.00 73225-TC $419.00 73610-26 $8.0073100-26 $8.00 73501 $30.00 73610-TC $19.0073100-TC $18.00 73501-26 $10.00 73615 $72.0073110 $29.00 73501-TC $20.00 73615-26 $19.0073110-26 $8.00 73502 $42.00 73615-TC $53.0073110-TC $19.00 73502-26 $11.00 73620 $27.0073115 $54.00 73502-TC $30.00 73620-26 $8.0073115-26 $17.00 73503 $52.00 73620-TC $18.0073115-TC $37.00 73503-26 $15.00 73630 $29.0073120 $27.00 73503-TC $37.00 73630-26 $8.0073120-26 $8.00 73521 $40.00 73630-TC $19.0073120-TC $18.00 73521-26 $12.00 73650 $26.0073130 $29.00 73521-TC $28.00 73650-26 $8.0073130-26 $8.00 73522 $49.00 73650-TC $17.0073130-TC $19.00 73522-26 $15.00 73660 $22.0073140 $22.00 73522-TC $34.00 73660-26 $7.0073140-26 $7.00 73523 $57.00 73660-TC $15.0073140-TC $15.00 73523-26 $16.00 73700 $242.0073200 $242.00 73523-TC $40.00 73700-26 $56.0073200-26 $56.00 73525 $84.00 73700-TC $185.0073200-TC $185.00 73525-26 $21.00 73701 $282.0073201 $282.00 73525-TC $63.00 73701-26 $61.0073201-26 $59.00 73551 $28.00 73701-TC $220.0073201-TC $220.00 73551-26 $9.00 73702 $341.0073202 $342.00 73551-TC $19.00 73702-26 $62.0073202-26 $63.00 73552 $33.00 73702-TC $277.0073202-TC $277.00 73552-26 $10.00 73706 $379.0073206 $375.00 73552-TC $23.00 73706-26 $98.0073206-26 $94.00 73560 $29.00 73706-TC $277.0073206-TC $277.00 73560-26 $8.00 73718 $482.0073218 $482.00 73560-TC $19.00 73718-26 $68.0073218-26 $68.00 73562 $31.00 73718-TC $413.0073218-TC $413.00 73562-26 $9.00 73719 $579.0073219 $579.00 73562-TC $21.00 73719-26 $82.0073219-26 $82.00 73564 $35.00 73719-TC $495.0073219-TC $495.00 73564-26 $11.00 73720 $520.0073220 $520.00 73564-TC $22.00 73720-26 $78.0073220-26 $78.00 73565 $28.00 73720-TC $442.0073220-TC $442.00 73565-26 $8.00 73721 $482.0073221 $482.00 73565-TC $18.00 73721-26 $68.0073221-26 $68.00 73580 $84.00 73721-TC $413.00



Radiology Radiology RadiologyCPT Code MRA CPT Code MRA CPT Code MRA73722 $579.00 74182-TC $496.00 74261-26 $122.0073722-26 $82.00 74183 $1,037.00 74261-TC $126.0073722-TC $495.00 74183-26 $114.00 74262 $376.0073723 $1,029.00 74183-TC $919.00 74262-26 $127.0073723-26 $109.00 74185 $514.00 74262-TC $249.0073723-TC $916.00 74185-26 $92.00 74263 $757.0073725 $515.00 74185-TC $419.00 74263-26 $117.0073725-26 $92.00 74190 $73.00 74263-TC $639.0073725-TC $419.00 74190-26 $24.00 74270 $100.0074000 $29.00 74190-TC $49.00 74270-26 $35.0074000-26 $9.00 74210 $63.00 74270-TC $64.0074000-TC $19.00 74210-26 $18.00 74280 $136.0074010 $33.00 74210-TC $44.00 74280-26 $50.0074010-26 $11.00 74220 $68.00 74280-TC $84.0074010-TC $21.00 74220-26 $23.00 74283 $201.0074020 $37.00 74220-TC $44.00 74283-26 $103.0074020-26 $13.00 74230 $77.00 74283-TC $95.0074020-TC $22.00 74230-26 $27.00 74290 $44.0074022 $44.00 74230-TC $48.00 74290-26 $16.0074022-26 $16.00 74235 $160.00 74290-TC $28.0074022-TC $28.00 74235-26 $60.00 74300 $31.0074150 $274.00 74235-TC $100.00 74300-26 $19.0074150-26 $60.00 74240 $91.00 74300-TC $104.0074150-TC $211.00 74240-26 $35.00 74301 $107.0074160 $322.00 74240-TC $55.00 74301-26 $11.0074160-26 $65.00 74241 $91.00 74301-TC $104.0074160-TC $256.00 74241-26 $35.00 74328 $155.0074170 $390.00 74241-TC $56.00 74328-26 $35.0074170-26 $71.00 74245 $137.00 74328-TC $120.0074170-TC $317.00 74245-26 $46.00 74329 $155.0074174 $502.00 74245-TC $89.00 74329-26 $35.0074174-26 $112.00 74246 $97.00 74329-TC $120.0074174-TC $390.00 74246-26 $35.00 74330 $165.0074175 $418.00 74246-TC $61.00 74330-26 $45.0074175-26 $98.00 74247 $99.00 74330-TC $120.0074175-TC $315.00 74247-26 $35.00 74340 $121.0074176 $219.00 74247-TC $63.00 74340-26 $26.0074176-26 $89.00 74249 $144.00 74340-TC $95.0074176-TC $130.00 74249-26 $46.00 74355 $137.0074177 $327.00 74249-TC $96.00 74355-26 $38.0074177-26 $93.00 74250 $73.00 74355-TC $99.0074177-TC $235.00 74250-26 $23.00 74360 $145.0074178 $381.00 74250-TC $48.00 74360-26 $27.0074178-26 $102.00 74251 $85.00 74360-TC $118.0074178-TC $279.00 74251-26 $34.00 74363 $274.0074181 $498.00 74251-TC $48.00 74363-26 $44.0074181-26 $85.00 74260 $82.00 74363-TC $230.0074181-TC $415.00 74260-26 $25.00 74400 $89.0074182 $587.00 74260-TC $56.00 74400-26 $24.0074182-26 $88.00 74261 $248.00 74400-TC $63.00



Radiology Radiology RadiologyCPT Code MRA CPT Code MRA CPT Code MRA74410 $98.00 74775-TC $55.00 75710-26 $21.0074410-26 $24.00 75557 $462.00 75710-TC $173.0074410-TC $72.00 75557-26 $79.00 75716 $293.0074415 $105.00 75557-TC $344.00 75716-26 $35.0074415-26 $24.00 75559 $495.00 75716-TC $258.0074415-TC $79.00 75559-26 $99.00 75726 $530.0074420 $117.00 75559-TC $344.00 75726-26 $56.0074420-26 $18.00 75561 $656.00 75726-TC $474.0074420-TC $97.00 75561-26 $87.00 75731 $530.0074425 $68.00 75561-TC $525.00 75731-26 $56.0074425-26 $18.00 75563 $683.00 75731-TC $474.0074425-TC $50.00 75563-26 $101.00 75733 $540.0074430 $48.00 75563-TC $526.00 75733-26 $65.0074430-26 $14.00 75565 $56.00 75733-TC $475.0074430-TC $34.00 75565-26 $13.00 75736 $530.0074440 $62.00 75565-TC $44.00 75736-26 $56.0074440-26 $19.00 75571 $50.00 75736-TC $474.0074440-TC $43.00 75571-26 $28.00 75741 $540.0074445 $101.00 75571-TC $22.00 75741-26 $65.0074445-26 $57.00 75572 $291.00 75741-TC $475.0074445-TC $44.00 75572-26 $87.00 75743 $253.0074450 $60.00 75572-TC $204.00 75743-26 $37.0074450-26 $14.00 75573 $349.00 75743-TC $216.0074450-TC $46.00 75573-26 $126.00 75746 $530.0074455 $75.00 75573-TC $222.00 75746-26 $56.0074455-26 $16.00 75574 $341.00 75746-TC $474.0074455-TC $59.00 75574-26 $119.00 75756 $183.0074470 $74.00 75574-TC $222.00 75756-26 $20.0074470-26 $27.00 75600 $497.00 75756-TC $163.0074470-TC $47.00 75600-26 $25.00 75774 $80.0074485 $146.00 75600-TC $472.00 75774-26 $3.0074485-26 $27.00 75605 $183.00 75774-TC $77.0074485-TC $119.00 75605-26 $20.00 75791 $331.0074710 $57.00 75605-TC $163.00 75791-26 $83.0074710-26 $17.00 75625 $143.00 75791-TC $248.0074710-TC $39.00 75625-26 $15.00 75801 $245.0074712 $426.00 75625-TC $128.00 75801-26 $41.0074712-26 $154.00 75630 $239.00 75801-TC $204.0074712-TC $273.00 75630-26 $37.00 75803 $264.0074713 $233.00 75630-TC $202.00 75803-26 $58.0074713-26 $91.00 75635 $445.00 75803-TC $206.0074713-TC $142.00 75635-26 $75.00 75805 $271.0074740 $68.00 75635-TC $370.00 75805-26 $40.0074740-26 $19.00 75658 $540.00 75805-TC $231.0074740-TC $49.00 75658-26 $66.00 75807 $289.0074742 $150.00 75658-TC $474.00 75807-26 $58.0074742-26 $30.00 75705 $587.00 75807-TC $231.0074742-TC $120.00 75705-26 $109.00 75809 $54.0074775 $88.00 75705-TC $478.00 75809-26 $24.0074775-26 $32.00 75710 $194.00 75809-TC $30.00



Radiology Radiology RadiologyCPT Code MRA CPT Code MRA CPT Code MRA75810 $530.00 75891-TC $474.00 75970-26 $42.0075810-26 $56.00 75893 $499.00 75970-TC $433.0075810-TC $474.00 75893-26 $26.00 75978 $617.0075820 $72.00 75893-TC $473.00 75978-26 $26.0075820-26 $35.00 75894 $972.00 75978-TC $591.0075820-TC $37.00 75894-26 $65.00 75984 $110.0075822 $111.00 75894-TC $907.00 75984-26 $36.0075822-26 $54.00 75898 $124.00 75984-TC $74.0075822-TC $57.00 75898-26 $84.00 75989 $180.0075825 $194.00 75898-TC $39.00 75989-26 $59.0075825-26 $21.00 75901 $98.00 75989-TC $121.0075825-TC $173.00 75901-26 $23.00 76000 $58.0075827 $530.00 75901-TC $75.00 76000-26 $8.0075827-26 $56.00 75902 $93.00 76000-TC $48.0075827-TC $474.00 75902-26 $19.00 76001 $134.0075831 $54.00 75902-TC $74.00 76001-26 $34.0075831-26 $6.00 75952 BR 76001-TC $97.0075831-TC $48.00 75952-26 $254.00 76080 $67.0075833 $549.00 75952-TC BR 76080-26 $27.0075833-26 $74.00 75953 BR 76080-TC $40.0075833-TC $475.00 75953-26 $98.00 76098 $23.0075840 $531.00 75953-TC BR 76098-26 $8.0075840-26 $57.00 75954 BR 76098-TC $15.0075840-TC $474.00 75954-26 $132.00 76100 $77.0075842 $549.00 75954-TC BR 76100-26 $30.0075842-26 $73.00 75956 BR 76100-TC $46.0075842-TC $476.00 75956-26 $394.00 76101 $94.0075860 $531.00 75956-TC BR 76101-26 $36.0075860-26 $57.00 75957 BR 76101-TC $59.0075860-TC $474.00 75957-26 $338.00 76102 $95.0075870 $531.00 75957-TC BR 76102-26 $30.0075870-26 $57.00 75958 BR 76102-TC $65.0075870-TC $474.00 75958-26 $225.00 76120 $157.0075872 $530.00 75958-TC BR 76120-26 $56.0075872-26 $56.00 75959 BR 76120-TC $102.0075872-TC $474.00 75959-26 $197.00 76125 $49.0075880 $72.00 75959-TC BR 76125-26 $17.0075880-26 $35.00 75962 $618.00 76125-TC $33.0075880-TC $37.00 75962-26 $27.00 76140 $31.0075885 $546.00 75962-TC $591.00 76376 $144.0075885-26 $71.00 75964 $333.00 76376-26 $11.0075885-TC $475.00 75964-26 $18.00 76376-TC $133.0075887 $546.00 75964-TC $315.00 76377 $185.0075887-26 $71.00 75966 $659.00 76377-26 $43.0075887-TC $475.00 75966-26 $66.00 76377-TC $142.0075889 $530.00 75966-TC $593.00 76380 $182.0075889-26 $56.00 75968 $333.00 76380-26 $50.0075889-TC $474.00 75968-26 $18.00 76380-TC $131.0075891 $530.00 75968-TC $315.00 76390 $493.0075891-26 $56.00 75970 $475.00 76390-26 $71.00



Radiology Radiology RadiologyCPT Code MRA CPT Code MRA CPT Code MRA76390-TC $419.00 76642-26 $35.00 76817 $96.0076496 BR 76642-TC $55.00 76817-26 $39.0076496-26 BR 76700 $116.00 76817-TC $57.0076496-TC $79.00 76700-26 $42.00 76818 $105.0076497 BR 76700-TC $73.00 76818-26 $40.0076497-26 BR 76705 $84.00 76818-TC $60.0076497-TC $94.00 76705-26 $30.00 76819 $101.0076498 BR 76705-TC $53.00 76819-26 $40.0076498-26 BR 76770 $112.00 76819-TC $60.0076498-TC $280.00 76770-26 $38.00 76820 $93.0076499 BR 76770-TC $73.00 76820-26 $27.0076499-26 BR 76775 $84.00 76820-TC $66.0076499-TC BR 76775-26 $30.00 76821 $103.0076506 $88.00 76775-TC $53.00 76821-26 $38.0076506-26 $33.00 76776 $124.00 76821-TC $66.0076506-TC $53.00 76776-26 $36.00 76825 $160.0076510 $171.00 76776-TC $88.00 76825-26 $65.0076510-26 $86.00 76800 $112.00 76825-TC $73.0076510-TC $85.00 76800-26 $61.00 76826 $71.0076511 $96.00 76800-TC $54.00 76826-26 $46.0076511-26 $48.00 76801 $93.00 76826-TC $27.0076511-TC $48.00 76801-26 $51.00 76827 $97.0076512 $96.00 76801-TC $42.00 76827-26 $35.0076512-26 $36.00 76802 $73.00 76827-TC $65.0076512-TC $60.00 76802-26 $43.00 76828 $72.0076513 $96.00 76802-TC $30.00 76828-26 $29.0076513-26 $36.00 76805 $131.00 76828-TC $42.0076513-TC $60.00 76805-26 $51.00 76830 $93.0076514 $12.00 76805-TC $79.00 76830-26 $35.0076514-26 $10.00 76810 $252.00 76830-TC $57.0076514-TC $3.00 76810-26 $100.00 76831 $95.0076516 $99.00 76810-TC $151.00 76831-26 $37.0076516-26 $37.00 76811 $243.00 76831-TC $57.0076516-TC $63.00 76811-26 $100.00 76856 $93.0076519 $88.00 76811-TC $142.00 76856-26 $35.0076519-26 $31.00 76812 $145.00 76856-TC $57.0076519-TC $53.00 76812-26 $94.00 76857 $59.0076529 $86.00 76812-TC $51.00 76857-26 $19.0076529-26 $31.00 76813 $125.00 76857-TC $39.0076529-TC $53.00 76813-26 $55.00 76870 $90.0076536 $83.00 76813-TC $71.00 76870-26 $33.0076536-26 $31.00 76814 $83.00 76870-TC $57.0076536-TC $54.00 76814-26 $46.00 76872 $93.0076604 $78.00 76814-TC $37.00 76872-26 $36.0076604-26 $28.00 76815 $88.00 76872-TC $57.0076604-TC $48.00 76815-26 $33.00 76873 $151.0076641 $109.00 76815-TC $53.00 76873-26 $68.0076641-26 $37.00 76816 $72.00 76873-TC $80.0076641-TC $72.00 76816-26 $30.00 76881 $120.0076642 $90.00 76816-TC $41.00 76881-26 $32.00



Radiology Radiology RadiologyCPT Code MRA CPT Code MRA CPT Code MRA76881-TC $88.00 76999-26 BR 77058-26 $78.0076882 $36.00 76999-TC BR 77058-TC $726.0076882-26 $25.00 77001 $83.00 77059 $994.0076882-TC $11.00 77001-26 $18.00 77059-26 $78.0076930 $93.00 77001-TC $64.00 77059-TC $917.0076930-26 $34.00 77002 $75.00 77063 $56.0076930-TC $59.00 77002-26 $25.00 77063-26 $30.0076932 $93.00 77002-TC $50.00 77063-TC $25.0076932-26 $34.00 77003 $73.00 77071 $29.0076932-TC $59.00 77003-26 $27.00 77072 $22.0076936 $341.00 77003-TC $45.00 77072-26 $9.0076936-26 $102.00 77011 $309.00 77072-TC $14.0076936-TC $236.00 77011-26 $58.00 77073 $42.0076937 $34.00 77011-TC $251.00 77073-26 $13.0076937-26 $17.00 77012 $306.00 77073-TC $29.0076937-TC $18.00 77012-26 $55.00 77074 $64.0076940 $171.00 77012-TC $251.00 77074-26 $22.0076940-26 $104.00 77013-26 $191.00 77074-TC $42.0076940-TC $68.00 77013-TC $297.00 77075 $89.0076941 $128.00 77014 $135.00 77075-26 $26.0076941-26 $69.00 77014-26 $41.00 77075-TC $63.0076941-TC $59.00 77014-TC $94.00 77077 $54.0076942 $92.00 77021 $353.00 77077-26 $15.0076942-26 $24.00 77021-26 $73.00 77077-TC $39.0076942-TC $68.00 77021-TC $280.00 77078 $84.0076945 $93.00 77022 BR 77078-26 $12.0076945-26 $34.00 77022-26 $204.00 77078-TC $72.0076945-TC $59.00 77022-TC $280.00 77080 $83.0076946 $78.00 77051 $17.00 77080-26 $11.0076946-26 $19.00 77051-26 $3.00 77080-TC $72.0076946-TC $59.00 77051-TC $14.00 77081 $40.0076948 $77.00 77052 $17.00 77081-26 $11.0076948-26 $19.00 77052-26 $3.00 77081-TC $29.0076948-TC $58.00 77052-TC $14.00 77084 $356.0076965 $281.00 77053 $102.00 77084-26 $77.0076965-26 $84.00 77053-26 $17.00 77084-TC $280.0076965-TC $208.00 77053-TC $85.00 77085 $57.0076970 $60.00 77054 $126.00 77085-26 $16.0076970-26 $20.00 77054-26 $22.00 77085-TC $41.0076970-TC $39.00 77054-TC $104.00 77086 $36.0076975 $99.00 77055 $78.00 77086-26 $9.0076975-26 $41.00 77055-26 $33.00 77086-TC $27.0076975-TC $58.00 77055-TC $45.00 77261 $73.0076977 $34.00 77056 $97.00 77262 $110.0076977-26 $3.00 77056-26 $41.00 77263 $163.0076977-TC $31.00 77056-TC $56.00 77280 $166.0076998 BR 77057 $82.00 77280-26 $36.0076998-26 $61.00 77057-26 $33.00 77280-TC $130.0076998-TC $96.00 77057-TC $49.00 77285 $264.0076999 BR 77058 $804.00 77285-26 $53.00



Radiology Radiology RadiologyCPT Code MRA CPT Code MRA CPT Code MRA77285-TC $209.00 77338 $502.00 77761 $284.0077290 $325.00 77338-26 $223.00 77761-26 $188.0077290-26 $79.00 77338-TC $279.00 77761-TC $93.0077290-TC $243.00 77370 $130.00 77762 $427.0077293 $432.00 77371 $1,151.00 77762-26 $289.0077293-26 $104.00 77372 $874.00 77762-TC $135.0077293-TC $328.00 77373 $1,630.00 77763 $605.0077295 $1,287.00 77399 BR 77763-26 $435.0077295-26 $232.00 77399-26 BR 77763-TC $167.0077295-TC $1,046.00 77399-TC BR 77767 $227.0077299 BR 77401 $66.00 77767-26 $55.0077299-26 BR 77402 $66.00 77767-TC $172.0077299-TC BR 77407 $78.00 77768 $356.0077300 $87.00 77412 $87.00 77768-26 $73.0077300-26 $36.00 77417 $21.00 77768-TC $283.0077300-TC $52.00 77422 $70.00 77770 $324.0077301 $1,473.00 77423 $91.00 77770-26 $102.0077301-26 $415.00 77427 $166.00 77770-TC $222.0077301-TC $1,046.00 77431 $95.00 77771 $604.0077306 $151.00 77432 $417.00 77771-26 $199.0077306-26 $73.00 77435 $644.00 77771-TC $405.0077306-TC $78.00 77469 $313.00 77772 $922.0077307 $292.00 77470 $527.00 77772-26 $282.0077307-26 $151.00 77470-26 $106.00 77772-TC $640.0077307-TC $140.00 77470-TC $417.00 77778 $764.0077316 $191.00 77499 BR 77778-26 $568.0077316-26 $73.00 77499-26 BR 77778-TC $192.0077316-TC $117.00 77499-TC BR 77789 $74.0077317 $248.00 77520 BR 77789-26 $57.0077317-26 $96.00 77522 BR 77789-TC $16.0077317-TC $153.00 77523 BR 77790 $72.0077318 $358.00 77525 BR 77790-26 $53.0077318-26 $151.00 77600 $196.00 77790-TC $18.0077318-TC $207.00 77600-26 $80.00 77799 BR77321 $200.00 77600-TC $113.00 77799-26 BR77321-26 $48.00 77605 $263.00 77799-TC BR77321-TC $150.00 77605-26 $108.00 78012 $78.0077331 $64.00 77605-TC $151.00 78012-26 $9.0077331-26 $45.00 77610 $195.00 78012-TC $69.0077331-TC $18.00 77610-26 $79.00 78013 $198.0077332 $78.00 77610-TC $113.00 78013-26 $18.0077332-26 $27.00 77615 $262.00 78013-TC $179.0077332-TC $50.00 77615-26 $106.00 78014 $240.0077333 $115.00 77615-TC $151.00 78014-26 $25.0077333-26 $43.00 77620 $196.00 78014-TC $215.0077333-TC $70.00 77620-26 $80.00 78015 $132.0077334 $187.00 77620-TC $113.00 78015-26 $34.0077334-26 $63.00 77750 $299.00 78015-TC $96.0077334-TC $121.00 77750-26 $248.00 78016 $173.0077336 $111.00 77750-TC $49.00 78016-26 $42.00



Radiology Radiology RadiologyCPT Code MRA CPT Code MRA CPT Code MRA78016-TC $130.00 78135-26 $33.00 78232 $157.0078018 $248.00 78135-TC $182.00 78232-26 $23.0078018-26 $44.00 78140 $179.00 78232-TC $132.0078018-TC $202.00 78140-26 $31.00 78258 $146.0078020 $35.00 78140-TC $147.00 78258-26 $38.0078020-26 $30.00 78185 $110.00 78258-TC $108.0078020-TC $5.00 78185-26 $20.00 78261 $190.0078070 $112.00 78185-TC $88.00 78261-26 $36.0078070-26 $36.00 78190 $272.00 78261-TC $152.0078070-TC $68.00 78190-26 $57.00 78262 $195.0078071 $357.00 78190-TC $214.00 78262-26 $35.0078071-26 $59.00 78191 $307.00 78262-TC $159.0078071-TC $298.00 78191-26 $31.00 78264 $195.0078072 $446.00 78191-TC $274.00 78264-26 $40.0078072-26 $80.00 78195 $216.00 78264-TC $154.0078072-TC $366.00 78195-26 $49.00 78265 $381.0078075 $242.00 78195-TC $152.00 78265-26 $49.0078075-26 $38.00 78199 BR 78265-TC $332.0078075-TC $202.00 78199-26 BR 78266 $494.0078099 BR 78199-TC BR 78266-26 $54.0078099-26 BR 78201 $112.00 78266-TC $440.0078099-TC BR 78201-26 $22.00 78267 BR78102 $106.00 78201-TC $88.00 78268 BR78102-26 $28.00 78202 $135.00 78270 $68.0078102-TC $77.00 78202-26 $26.00 78270-26 $10.0078103 $158.00 78202-TC $108.00 78270-TC $58.0078103-26 $39.00 78205 $259.00 78271 $72.0078103-TC $118.00 78205-26 $36.00 78271-26 $10.0078104 $194.00 78205-TC $220.00 78271-TC $61.0078104-26 $41.00 78206 $265.00 78272 $100.0078104-TC $152.00 78206-26 $46.00 78272-26 $14.0078110 $45.00 78206-TC $214.00 78272-TC $87.0078110-26 $9.00 78215 $135.00 78278 $234.0078110-TC $35.00 78215-26 $24.00 78278-26 $50.0078111 $108.00 78215-TC $109.00 78278-TC $182.0078111-26 $11.00 78216 $160.00 78282 $230.0078111-TC $96.00 78216-26 $29.00 78282-26 $19.0078120 $78.00 78216-TC $130.00 78282-TC $224.0078120-26 $11.00 78226 $339.00 78290 $149.0078120-TC $65.00 78226-26 $37.00 78290-26 $35.0078121 $125.00 78226-TC $301.00 78290-TC $113.0078121-26 $16.00 78227 $418.00 78291 $161.0078121-TC $108.00 78227-26 $45.00 78291-26 $45.0078122 $196.00 78227-TC $373.00 78291-TC $114.0078122-26 $22.00 78230 $106.00 78299 BR78122-TC $171.00 78230-26 $23.00 78299-26 BR78130 $139.00 78230-TC $82.00 78299-TC BR78130-26 $32.00 78231 $146.00 78300 $125.0078130-TC $106.00 78231-26 $27.00 78300-26 $32.0078135 $216.00 78231-TC $118.00 78300-TC $93.00



Radiology Radiology RadiologyCPT Code MRA CPT Code MRA CPT Code MRA78305 $181.00 78459-26 $100.00 78598 $314.0078305-26 $42.00 78459-TC $731.00 78598-26 $42.0078305-TC $137.00 78466 $135.00 78598-TC $272.0078306 $205.00 78466-26 $36.00 78599 BR78306-26 $44.00 78466-TC $97.00 78599-26 BR78306-TC $159.00 78468 $180.00 78599-TC BR78315 $233.00 78468-26 $41.00 78600 $131.0078315-26 $52.00 78468-TC $137.00 78600-26 $22.0078315-TC $179.00 78469 $244.00 78600-TC $108.0078320 $276.00 78469-26 $47.00 78601 $154.0078320-26 $53.00 78469-TC $195.00 78601-26 $26.0078320-TC $220.00 78472 $259.00 78601-TC $126.0078350 $40.00 78472-26 $50.00 78605 $155.0078350-26 $11.00 78472-TC $206.00 78605-26 $27.0078350-TC $29.00 78473 $387.00 78605-TC $126.0078351 $23.00 78473-26 $75.00 78606 $221.0078399 BR 78473-TC $308.00 78606-26 $45.0078399-26 BR 78481 $248.00 78606-TC $177.0078399-TC BR 78481-26 $51.00 78607 $311.0078414 BR 78481-TC $195.00 78607-26 $64.0078414-26 $23.00 78483 $373.00 78607-TC $245.0078414-TC BR 78483-26 $77.00 78608 $876.0078428 $126.00 78483-TC $294.00 78608-26 $78.0078428-26 $41.00 78491 $756.00 78608-TC $855.0078428-TC $84.00 78491-26 $85.00 78609 $51.0078445 $97.00 78491-TC $731.00 78609-26 $78.0078445-26 $28.00 78492 $764.00 78609-TC BR78445-TC $69.00 78492-26 $100.00 78610 $74.0078451 $351.00 78492-TC $731.00 78610-26 $15.0078451-26 $68.00 78494 $324.00 78610-TC $59.0078451-TC $283.00 78494-26 $59.00 78630 $223.0078452 $486.00 78494-TC $262.00 78630-26 $35.0078452-26 $80.00 78496 $92.00 78630-TC $188.0078452-TC $407.00 78496-26 $24.00 78635 $129.0078453 $313.00 78496-TC $66.00 78635-26 $32.0078453-26 $51.00 78499 BR 78635-TC $95.0078453-TC $263.00 78499-26 BR 78645 $158.0078454 $446.00 78499-TC BR 78645-26 $29.0078454-26 $67.00 78579 $191.00 78645-TC $128.0078454-TC $379.00 78579-26 $24.00 78647 $268.0078456 $205.00 78579-TC $166.00 78647-26 $46.0078456-26 $49.00 78580 $167.00 78647-TC $220.0078456-TC $151.00 78580-26 $38.00 78650 $206.0078457 $140.00 78580-TC $128.00 78650-26 $31.0078457-26 $39.00 78582 $343.00 78650-TC $173.0078457-TC $99.00 78582-26 $53.00 78660 $107.0078458 $198.00 78582-TC $289.00 78660-26 $27.0078458-26 $46.00 78597 $206.00 78660-TC $79.0078458-TC $149.00 78597-26 $36.00 78699 BR78459 $755.00 78597-TC $171.00 78699-26 BR



Radiology Radiology RadiologyCPT Code MRA CPT Code MRA CPT Code MRA78699-TC BR 78805-26 $38.00 79445-TC $105.0078700 $137.00 78805-TC $126.00 79999 BR78700-26 $22.00 78806 $286.00 79999-26 BR78700-TC $113.00 78806-26 $44.00 79999-TC BR78701 $158.00 78806-TC $241.00 G0130 $34.0078701-26 $24.00 78807 $303.00 G0130-26 $10.0078701-TC $133.00 78807-26 $57.00 G0130-TC $24.0078707 $217.00 78807-TC $245.00 G0202 $120.0078707-26 $49.00 78808 $47.00 G0202-26 $32.0078707-TC $166.00 78811 $879.00 G0202-TC $88.0078708 $231.00 78811-26 $83.00 G0204 $136.0078708-26 $61.00 78811-TC $855.00 G0204-26 $40.0078708-TC $166.00 78812 $884.00 G0204-TC $96.0078709 $241.00 78812-26 $102.00 G0206 $109.0078709-26 $68.00 78812-TC $855.00 G0206-26 $32.0078709-TC $166.00 78813 $885.00 G0206-TC $77.0078710 $256.00 78813-26 $106.00 G0252-26 $78.0078710-26 $34.00 78813-TC $855.00 G0278 $13.0078710-TC $220.00 78814 $982.00 G0279 $56.0078725 $87.00 78814-26 $116.00 G0279-26 $30.0078725-26 $19.00 78814-TC $950.00 G0279-TC $25.0078725-TC $66.00 78815 $985.00 G0288 $201.0078730 $73.00 78815-26 $128.00 G0297 $255.0078730-26 $18.00 78815-TC $950.00 G0297-26 $52.0078730-TC $55.00 78816 $986.00 G0297-TC $203.0078740 $109.00 78816-26 $132.00 G0365 $164.0078740-26 $29.00 78816-TC $950.00 G0365-26 $12.0078740-TC $79.00 78999 BR G0365-TC $152.0078761 $157.00 78999-26 BR G0389 $104.0078761-26 $36.00 78999-TC BR G0389-26 $27.0078761-TC $119.00 79005 $199.00 G0389-TC $77.0078799 BR 79005-26 $94.00 G6001 $52.0078799-26 BR 79005-TC $105.00 G6001-26 $30.0078799-TC BR 79101 $207.00 G6001-TC $22.0078800 $162.00 79101-26 $103.00 G6002 $76.0078800-26 $34.00 79101-TC $105.00 G6002-26 $20.0078800-TC $126.00 79200 $203.00 G6002-TC $55.0078801 $199.00 79200-26 $102.00 G6003 $188.0078801-26 $40.00 79200-TC $97.00 G6004 $146.0078801-TC $158.00 79300 BR G6005 $145.0078802 $252.00 79300-26 $83.00 G6006 $145.0078802-26 $44.00 79300-TC BR G6007 $303.0078802-TC $207.00 79403 $287.00 G6008 $202.0078803 $303.00 79403-26 $121.00 G6009 $199.0078803-26 $56.00 79403-TC $165.00 G6010 $199.0078803-TC $245.00 79440 $204.00 G6011 $324.0078804 $227.00 79440-26 $104.00 G6012 $266.0078804-26 $55.00 79440-TC $97.00 G6013 $266.0078804-TC $171.00 79445 $232.00 G6014 $266.0078805 $166.00 79445-26 $127.00 G6015 $347.00



RadiologyCPT Code MRAG6016 $346.00Q0092 $14.00



Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA80048 $23.00 80170-TC $11.00 80400-26 $18.0080048-26 $4.00 80173 $33.00 80400-TC $36.0080048-TC $19.00 80173-26 $11.00 80402 $138.0080050 $45.00 80173-TC $22.00 80402-26 $42.0080050-26 $18.00 80176 $35.00 80402-TC $95.0080050-TC $26.00 80176-26 $11.00 80406 $138.0080051 $16.00 80176-TC $23.00 80406-26 $42.0080051-26 $6.00 80178 $17.00 80406-TC $95.0080051-TC $10.00 80178-26 $6.00 80408 $213.0080053 $29.00 80178-TC $11.00 80408-26 $77.0080053-26 $8.00 80184 $34.00 80408-TC $136.0080053-TC $21.00 80184-26 $10.00 80410 $166.0080055 $67.00 80184-TC $23.00 80410-26 $54.0080055-26 $21.00 80185 $36.00 80410-TC $110.0080055-TC $43.00 80185-26 $10.00 80412 $533.0080061 $31.00 80185-TC $25.00 80412-26 $176.0080061-26 $11.00 80186 $38.00 80412-TC $355.0080061-TC $19.00 80186-26 $11.00 80414 $88.0080069 $26.00 80186-TC $26.00 80414-26 $26.0080069-26 $6.00 80188 $35.00 80414-TC $59.0080069-TC $20.00 80188-26 $11.00 80415 $93.0080074 $107.00 80188-TC $23.00 80415-26 $28.0080074-26 $43.00 80190 $41.00 80415-TC $64.0080074-TC $64.00 80190-26 $13.00 80416 $256.0080076 $18.00 80190-TC $28.00 80416-26 $88.0080076-26 $7.00 80192 $44.00 80416-TC $166.0080076-TC $11.00 80192-26 $17.00 80417 $256.0080150 $40.00 80192-TC $26.00 80417-26 $88.0080150-26 $13.00 80194 $33.00 80417-TC $166.0080150-TC $26.00 80194-26 $10.00 80418 $934.0080156 $35.00 80194-TC $22.00 80418-26 $266.0080156-26 $11.00 80197 $34.00 80418-TC $666.0080156-TC $23.00 80197-26 $11.00 80420 $107.0080157 $22.00 80197-TC $22.00 80420-26 $33.0080157-26 $8.00 80198 $20.00 80420-TC $74.0080157-TC $14.00 80198-26 $5.00 80422 $62.0080158 $35.00 80198-TC $15.00 80422-26 $18.0080158-26 $12.00 80200 $24.00 80422-TC $43.0080158-TC $22.00 80200-26 $7.00 80424 $94.0080162 $13.00 80200-TC $16.00 80424-26 $26.0080162-26 $3.00 80201 $33.00 80424-TC $67.0080162-TC $9.00 80201-26 $11.00 80426 $232.0080164 $43.00 80201-TC $21.00 80426-26 $54.0080164-26 $14.00 80202 $42.00 80426-TC $176.0080164-TC $29.00 80202-26 $14.00 80428 $93.0080168 $43.00 80202-TC $28.00 80428-26 $19.0080168-26 $17.00 80299 BR 80428-TC $73.0080168-TC $25.00 80299-26 BR 80430 $99.0080170 $18.00 80299-TC BR 80430-26 $24.0080170-26 $6.00 80400 $54.00 80430-TC $74.00



Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA80432 $243.00 81025-TC $4.00 82105-26 $8.0080432-26 $56.00 81050 $33.00 82105-TC $18.0080432-TC $186.00 81050-26 $11.00 82106 $26.0080434 $161.00 81050-TC $21.00 82106-26 $8.0080434-26 $49.00 81099 BR 82106-TC $18.0080434-TC $110.00 81099-26 BR 82108 $45.0080435 $166.00 81099-TC BR 82108-26 $14.0080435-26 $49.00 82009 $10.00 82108-TC $32.0080435-TC $115.00 82009-26 $3.00 82120 $9.0080436 $119.00 82009-TC $6.00 82120-26 $3.0080436-26 $35.00 82010 $22.00 82120-TC $5.0080436-TC $85.00 82010-26 $7.00 82127 $33.0080438 $82.00 82010-TC $15.00 82127-26 $11.0080438-26 $24.00 82013 $24.00 82127-TC $22.0080438-TC $56.00 82013-26 $7.00 82128 $26.0080439 $176.00 82013-TC $17.00 82128-26 $6.0080439-26 $33.00 82024 $26.00 82128-TC $19.0080439-TC $144.00 82024-26 $7.00 82131 $57.0080500 $34.00 82024-TC $18.00 82131-26 $13.0080500-26 $34.00 82030 $43.00 82131-TC $44.0080500-TC BR 82030-26 $17.00 82135 $41.0080502 $72.00 82030-TC $25.00 82135-26 $13.0080502-26 $72.00 82040 $11.00 82135-TC $28.0080502-TC BR 82040-26 $3.00 82136 $38.0081000 $7.00 82040-TC $7.00 82136-26 $14.0081000-26 $3.00 82042 $12.00 82136-TC $23.0081000-TC $4.00 82042-26 $3.00 82139 $38.0081001 $7.00 82042-TC $8.00 82139-26 $14.0081001-26 $3.00 82043 $14.00 82139-TC $23.0081001-TC $4.00 82043-26 $4.00 82140 $40.0081002 $5.00 82043-TC $10.00 82140-26 $12.0081002-26 $3.00 82044 $12.00 82140-TC $28.0081002-TC $3.00 82044-26 $4.00 82143 $28.0081003 $5.00 82044-TC $9.00 82143-26 $8.0081003-26 $2.00 82075 $32.00 82143-TC $19.0081003-TC $3.00 82075-26 $10.00 82150 $16.0081005 $3.00 82075-TC $21.00 82150-26 $5.0081005-26 $1.00 82085 $24.00 82150-TC $11.0081005-TC $3.00 82085-26 $7.00 82154 $34.0081007 $5.00 82085-TC $17.00 82154-26 $13.0081007-26 $2.00 82088 $91.00 82154-TC $20.0081007-TC $4.00 82088-26 $28.00 82157 $57.0081015 $5.00 82088-TC $62.00 82157-26 $17.0081015-26 $3.00 82103 $21.00 82157-TC $40.0081015-TC $3.00 82103-26 $7.00 82160 $67.0081020 $8.00 82103-TC $14.00 82160-26 $21.0081020-26 $3.00 82104 $22.00 82160-TC $43.0081020-TC $5.00 82104-26 $7.00 82163 $42.0081025 $7.00 82104-TC $15.00 82163-26 $12.0081025-26 $4.00 82105 $26.00 82163-TC $31.00



Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA82164 $32.00 82306-TC $52.00 82382-26 $12.0082164-26 $10.00 82308 $62.00 82382-TC $25.0082164-TC $21.00 82308-26 $18.00 82383 $62.0082172 $33.00 82308-TC $43.00 82383-26 $18.0082172-26 $10.00 82310 $11.00 82383-TC $43.0082172-TC $22.00 82310-26 $3.00 82384 $62.0082175 $48.00 82310-TC $7.00 82384-26 $18.0082175-26 $15.00 82330 $37.00 82384-TC $43.0082175-TC $33.00 82330-26 $11.00 82387 $34.0082180 $25.00 82330-TC $25.00 82387-26 $10.0082180-26 $8.00 82331 $14.00 82387-TC $23.0082180-TC $17.00 82331-26 $4.00 82390 $24.0082190 $24.00 82331-TC $10.00 82390-26 $7.0082190-26 $8.00 82340 $13.00 82390-TC $17.0082190-TC $16.00 82340-26 $4.00 82397 $22.0082232 $43.00 82340-TC $8.00 82397-26 $7.0082232-26 $14.00 82355 $31.00 82397-TC $15.0082232-TC $29.00 82355-26 $10.00 82415 $28.0082239 $23.00 82355-TC $20.00 82415-26 $8.0082239-26 $8.00 82360 $31.00 82415-TC $19.0082239-TC $15.00 82360-26 $10.00 82435 $8.0082240 $49.00 82360-TC $20.00 82435-26 $2.0082240-26 $15.00 82365 $31.00 82435-TC $6.0082240-TC $34.00 82365-26 $8.00 82436 $14.0082247 $10.00 82365-TC $21.00 82436-26 $4.0082247-26 $3.00 82370 $22.00 82436-TC $10.0082247-TC $7.00 82370-26 $7.00 82438 $13.0082248 $10.00 82370-TC $15.00 82438-26 $4.0082248-26 $3.00 82373 $16.00 82438-TC $8.0082248-TC $7.00 82373-26 $5.00 82441 $16.0082252 $11.00 82373-TC $11.00 82441-26 $5.0082252-26 $3.00 82374 $10.00 82441-TC $11.0082252-TC $7.00 82374-26 $3.00 82465 $8.0082261 $38.00 82374-TC $6.00 82465-26 $2.0082261-26 $13.00 82375 $26.00 82465-TC $6.0082261-TC $24.00 82375-26 $7.00 82480 $23.0082270 $5.00 82375-TC $18.00 82480-26 $6.0082270-26 $2.00 82376 $11.00 82480-TC $17.0082270-TC $3.00 82376-26 $3.00 82482 $23.0082274 BR 82376-TC $7.00 82482-26 $7.0082274-26 BR 82378 $31.00 82482-TC $15.0082274-TC BR 82378-26 $8.00 82485 $37.0082286 $12.00 82378-TC $21.00 82485-26 $8.0082286-26 $3.00 82379 $38.00 82485-TC $28.0082286-TC $8.00 82379-26 $13.00 82495 $48.0082300 $48.00 82379-TC $24.00 82495-26 $16.0082300-26 $15.00 82380 $21.00 82495-TC $32.0082300-TC $33.00 82380-26 $6.00 82507 $55.0082306 $79.00 82380-TC $15.00 82507-26 $16.0082306-26 $25.00 82382 $38.00 82507-TC $39.00



Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA82523 $43.00 82600-TC $28.00 82677-26 $17.0082523-26 $17.00 82607 $38.00 82677-TC $35.0082523-TC $25.00 82607-26 $10.00 82679 $70.0082525 $34.00 82607-TC $27.00 82679-26 $20.0082525-26 $10.00 82608 $40.00 82679-TC $48.0082525-TC $23.00 82608-26 $13.00 82693 $23.0082528 $40.00 82608-TC $26.00 82693-26 $7.0082528-26 $13.00 82615 $17.00 82693-TC $16.0082528-TC $26.00 82615-26 $5.00 82696 $57.0082530 $38.00 82615-TC $12.00 82696-26 $19.0082530-26 $12.00 82626 $59.00 82696-TC $38.0082530-TC $25.00 82626-26 $19.00 82705 $14.0082533 $35.00 82626-TC $40.00 82705-26 $6.0082533-26 $10.00 82627 $37.00 82705-TC $9.0082533-TC $24.00 82627-26 $12.00 82710 $42.0082540 $10.00 82627-TC $24.00 82710-26 $13.0082540-26 $3.00 82633 $81.00 82710-TC $29.0082540-TC $6.00 82633-26 $23.00 82715 $33.0082542 $42.00 82633-TC $56.00 82715-26 $11.0082542-26 $13.00 82634 $81.00 82715-TC $21.0082542-TC $28.00 82634-26 $23.00 82725 $28.0082550 $16.00 82634-TC $56.00 82725-26 $8.0082550-26 $4.00 82638 $23.00 82725-TC $19.0082550-TC $12.00 82638-26 $7.00 82726 $42.0082552 $33.00 82638-TC $16.00 82726-26 $13.0082552-26 $10.00 82652 $89.00 82726-TC $28.0082552-TC $22.00 82652-26 $25.00 82728 $24.0082553 $16.00 82652-TC $62.00 82728-26 $7.0082553-26 $5.00 82657 $42.00 82728-TC $17.0082553-TC $11.00 82657-26 $13.00 82735 $36.0082554 $19.00 82657-TC $28.00 82735-26 $12.0082554-26 $6.00 82658 $42.00 82735-TC $23.0082554-TC $13.00 82658-26 $13.00 82746 $39.0082565 $13.00 82658-TC $28.00 82746-26 $13.0082565-26 $2.00 82664 $40.00 82746-TC $25.0082565-TC $11.00 82664-26 $13.00 82747 $29.0082570 $10.00 82664-TC $26.00 82747-26 $10.0082570-26 $2.00 82668 $45.00 82747-TC $19.0082570-TC $7.00 82668-26 $14.00 82757 $36.0082575 $25.00 82668-TC $32.00 82757-26 $11.0082575-26 $8.00 82670 $61.00 82757-TC $24.0082575-TC $17.00 82670-26 $18.00 82759 $38.0082585 $15.00 82670-TC $42.00 82759-26 $12.0082585-26 $3.00 82671 $61.00 82759-TC $25.0082585-TC $12.00 82671-26 $17.00 82760 $26.0082595 $31.00 82671-TC $43.00 82760-26 $8.0082595-26 $10.00 82672 $57.00 82760-TC $18.0082595-TC $21.00 82672-26 $16.00 82775 $47.0082600 $40.00 82672-TC $41.00 82775-26 $14.0082600-26 $12.00 82677 $52.00 82775-TC $33.00



Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA83070 $13.00 83527-TC $23.00 83721-26 $5.0083070-26 $4.00 83528 $43.00 83721-TC $11.0083070-TC $8.00 83528-26 $14.00 83727 $43.0083080 $38.00 83528-TC $29.00 83727-26 $14.0083080-26 $11.00 83540 $16.00 83727-TC $29.0083080-TC $26.00 83540-26 $3.00 83735 $15.0083088 $59.00 83540-TC $13.00 83735-26 $5.0083088-26 $18.00 83550 $20.00 83735-TC $10.0083088-TC $41.00 83550-26 $5.00 83775 $17.0083090 $38.00 83550-TC $15.00 83775-26 $5.0083090-26 $13.00 83570 $23.00 83775-TC $12.0083090-TC $25.00 83570-26 $7.00 83785 $58.0083150 $49.00 83570-TC $16.00 83785-26 $17.0083150-26 $16.00 83582 $34.00 83785-TC $41.0083150-TC $33.00 83582-26 $8.00 83789 $39.0083491 $37.00 83582-TC $24.00 83789-26 $13.0083491-26 $11.00 83586 $38.00 83789-TC $25.0083491-TC $25.00 83586-26 $13.00 83825 $34.0083497 $35.00 83586-TC $24.00 83825-26 $11.0083497-26 $11.00 83593 $59.00 83825-TC $22.0083497-TC $23.00 83593-26 $18.00 83835 $41.0083498 $62.00 83593-TC $41.00 83835-26 $12.0083498-26 $20.00 83605 $19.00 83835-TC $29.0083498-TC $41.00 83605-26 $6.00 83857 $26.0083499 $51.00 83605-TC $13.00 83857-26 $8.0083499-26 $15.00 83615 $16.00 83857-TC $18.0083499-TC $36.00 83615-26 $5.00 83864 $32.0083500 $69.00 83615-TC $11.00 83864-26 $8.0083500-26 $21.00 83625 $23.00 83864-TC $22.0083500-TC $45.00 83625-26 $6.00 83872 $13.0083505 $77.00 83625-TC $17.00 83872-26 $4.0083505-26 $21.00 83632 $42.00 83872-TC $8.0083505-TC $54.00 83632-26 $14.00 83873 $54.0083516 $26.00 83632-TC $28.00 83873-26 $18.0083516-26 $8.00 83655 $31.00 83873-TC $36.0083516-TC $18.00 83655-26 $8.00 83874 $25.0083518 $21.00 83655-TC $21.00 83874-26 $8.0083518-26 $7.00 83670 $18.00 83874-TC $17.0083518-TC $14.00 83670-26 $5.00 83880 BR83519 $21.00 83670-TC $13.00 83880-26 BR83519-26 $7.00 83690 $18.00 83880-TC BR83519-TC $14.00 83690-26 $6.00 83883 $11.0083520 $20.00 83690-TC $12.00 83883-26 $3.0083520-26 $6.00 83718 $16.00 83883-TC $7.0083520-TC $14.00 83718-26 $5.00 83885 $45.0083525 $31.00 83718-TC $11.00 83885-26 $14.0083525-26 $8.00 83719 $42.00 83885-TC $32.0083525-TC $21.00 83719-26 $14.00 83915 $31.0083527 $35.00 83719-TC $28.00 83915-26 $10.0083527-26 $11.00 83721 $16.00 83915-TC $20.00



Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA83916 $54.00 84066-TC $12.00 84135-26 $19.0083916-26 $18.00 84075 $12.00 84135-TC $38.0083916-TC $36.00 84075-26 $3.00 84138 $56.0083918 $41.00 84075-TC $8.00 84138-26 $18.0083918-26 $12.00 84078 $19.00 84138-TC $38.0083918-TC $29.00 84078-26 $5.00 84140 $41.0083919 $42.00 84078-TC $14.00 84140-26 $8.0083919-26 $12.00 84080 $36.00 84140-TC $33.0083919-TC $29.00 84080-26 $11.00 84143 $62.0083921 $37.00 84080-TC $24.00 84143-26 $20.0083921-26 $12.00 84081 $45.00 84143-TC $41.0083921-TC $25.00 84081-26 $15.00 84144 $38.0083930 $11.00 84081-TC $31.00 84144-26 $7.0083930-26 $3.00 84085 $15.00 84144-TC $31.0083930-TC $7.00 84085-26 $5.00 84146 $53.0083935 $17.00 84085-TC $10.00 84146-26 $17.0083935-26 $5.00 84087 $25.00 84146-TC $36.0083935-TC $12.00 84087-26 $7.00 84150 $69.0083937 $29.00 84087-TC $18.00 84150-26 $20.0083937-26 $10.00 84100 $11.00 84150-TC $47.0083937-TC $19.00 84100-26 $3.00 84152 $42.0083945 $32.00 84100-TC $7.00 84152-26 $14.0083945-26 $11.00 84105 $11.00 84152-TC $27.0083945-TC $20.00 84105-26 $3.00 84153 $33.0083950 BR 84105-TC $7.00 84153-26 $11.0083950-26 BR 84106 $10.00 84153-TC $21.0083950-TC BR 84106-26 $2.00 84154 $33.0083970 $94.00 84106-TC $7.00 84154-26 $11.0083970-26 $31.00 84110 $21.00 84154-TC $21.0083970-TC $62.00 84110-26 $6.00 84155 $12.0083986 $8.00 84110-TC $15.00 84155-26 $4.0083986-26 $3.00 84119 $21.00 84155-TC $7.0083986-TC $5.00 84119-26 $6.00 84160 $5.0083992 $40.00 84119-TC $15.00 84160-26 $2.0083992-26 $12.00 84120 $38.00 84160-TC $2.0083992-TC $28.00 84120-26 $11.00 84165 $24.0084030 $11.00 84120-TC $26.00 84165-26 $8.0084030-26 $3.00 84126 $71.00 84165-TC $16.0084030-TC $7.00 84126-26 $20.00 84166 BR84035 $12.00 84126-TC $49.00 84166-26 $20.0084035-26 $3.00 84132 $11.00 84166-TC BR84035-TC $8.00 84132-26 $3.00 84181 $29.0084060 $20.00 84132-TC $7.00 84181-26 $10.0084060-26 $6.00 84133 $11.00 84181-TC $19.0084060-TC $14.00 84133-26 $3.00 84182 $33.0084061 $14.00 84133-TC $7.00 84182-26 $11.0084061-26 $4.00 84134 $24.00 84182-TC $21.0084061-TC $10.00 84134-26 $7.00 84202 $39.0084066 $18.00 84134-TC $17.00 84202-26 $13.0084066-26 $6.00 84135 $57.00 84202-TC $25.00



Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA84203 $16.00 84285-TC $42.00 84430-26 $10.0084203-26 $5.00 84295 $10.00 84430-TC $20.0084203-TC $11.00 84295-26 $3.00 84432 $28.0084206 $32.00 84295-TC $6.00 84432-26 $8.0084206-26 $10.00 84300 $10.00 84432-TC $19.0084206-TC $21.00 84300-26 $3.00 84436 $14.0084207 $54.00 84300-TC $6.00 84436-26 $3.0084207-26 $16.00 84302 BR 84436-TC $11.0084207-TC $38.00 84302-26 BR 84437 $13.0084210 $24.00 84302-TC BR 84437-26 $4.0084210-26 $10.00 84305 $34.00 84437-TC $8.0084210-TC $15.00 84305-26 $11.00 84439 $16.0084220 $25.00 84305-TC $22.00 84439-26 $4.0084220-26 $8.00 84307 $26.00 84439-TC $12.0084220-TC $17.00 84307-26 $8.00 84442 $25.0084228 $32.00 84307-TC $18.00 84442-26 $6.0084228-26 $10.00 84311 $11.00 84442-TC $19.0084228-TC $21.00 84311-26 $3.00 84443 $32.0084233 $116.00 84311-TC $7.00 84443-26 $7.0084233-26 $35.00 84315 $5.00 84443-TC $23.0084233-TC $81.00 84315-26 $2.00 84445 $98.0084234 $116.00 84315-TC $3.00 84445-26 $29.0084234-26 $35.00 84375 $37.00 84445-TC $69.0084234-TC $81.00 84375-26 $11.00 84446 $35.0084235 $114.00 84375-TC $25.00 84446-26 $11.0084235-26 $34.00 84376 $10.00 84446-TC $23.0084235-TC $80.00 84376-26 $3.00 84449 $38.0084238 $97.00 84376-TC $7.00 84449-26 $13.0084238-26 $32.00 84377 $10.00 84449-TC $24.0084238-TC $65.00 84377-26 $3.00 84450 $11.0084244 $47.00 84377-TC $7.00 84450-26 $3.0084244-26 $15.00 84378 $25.00 84450-TC $7.0084244-TC $32.00 84378-26 $8.00 84460 $13.0084252 $47.00 84378-TC $17.00 84460-26 $4.0084252-26 $14.00 84379 $25.00 84460-TC $8.0084252-TC $33.00 84379-26 $8.00 84466 $22.0084255 $58.00 84379-TC $17.00 84466-26 $7.0084255-26 $17.00 84392 $8.00 84466-TC $15.0084255-TC $41.00 84392-26 $2.00 84478 $12.0084260 $54.00 84392-TC $6.00 84478-26 $3.0084260-26 $16.00 84402 $72.00 84478-TC $8.0084260-TC $38.00 84402-26 $21.00 84479 $15.0084270 $36.00 84402-TC $49.00 84479-26 $5.0084270-26 $11.00 84403 $67.00 84479-TC $10.0084270-TC $24.00 84403-26 $19.00 84480 $20.0084275 $37.00 84403-TC $45.00 84480-26 $6.0084275-26 $11.00 84425 $54.00 84480-TC $14.0084275-TC $25.00 84425-26 $17.00 84481 $33.0084285 $59.00 84425-TC $37.00 84481-26 $10.0084285-26 $17.00 84430 $31.00 84481-TC $22.00



Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA84482 $45.00 84583-TC $7.00 85007-26 $3.0084482-26 $15.00 84585 $36.00 85007-TC $4.0084482-TC $31.00 84585-26 $11.00 85008 $5.0084484 $21.00 84585-TC $24.00 85008-26 $2.0084484-26 $6.00 84586 $42.00 85008-TC $3.0084484-TC $15.00 84586-26 $14.00 85009 $8.0084485 $15.00 84586-TC $27.00 85009-26 $3.0084485-26 $4.00 84588 $73.00 85009-TC $5.0084485-TC $11.00 84588-26 $23.00 85013 $3.0084488 $15.00 84588-TC $47.00 85013-26 $1.0084488-26 $4.00 84590 $33.00 85013-TC $2.0084488-TC $11.00 84590-26 $11.00 85014 $4.0084490 $15.00 84590-TC $21.00 85014-26 $1.0084490-26 $4.00 84591 $26.00 85014-TC $3.0084490-TC $11.00 84591-26 $9.00 85018 $5.0084510 $26.00 84591-TC $18.00 85018-26 $2.0084510-26 $8.00 84597 $37.00 85018-TC $3.0084510-TC $18.00 84597-26 $11.00 85025 $20.0084512 $17.00 84597-TC $25.00 85025-26 $6.0084512-26 $5.00 84600 $43.00 85025-TC $14.0084512-TC $12.00 84600-26 $13.00 85027 $15.0084520 $12.00 84600-TC $31.00 85027-26 $5.0084520-26 $3.00 84620 $29.00 85027-TC $10.0084520-TC $8.00 84620-26 $8.00 85032 BR84525 $7.00 84620-TC $20.00 85032-26 BR84525-26 $2.00 84630 $26.00 85032-TC BR84525-TC $5.00 84630-26 $8.00 85041 $7.0084540 $13.00 84630-TC $18.00 85041-26 $3.0084540-26 $4.00 84681 $52.00 85041-TC $4.0084540-TC $8.00 84681-26 $17.00 85044 $10.0084545 $18.00 84681-TC $35.00 85044-26 $3.0084545-26 $5.00 84702 $38.00 85044-TC $6.0084545-TC $13.00 84702-26 $11.00 85045 $6.0084550 $12.00 84702-TC $26.00 85045-26 $2.0084550-26 $4.00 84703 $22.00 85045-TC $4.0084550-TC $7.00 84703-26 $6.00 85046 $13.0084560 $12.00 84703-TC $15.00 85046-26 $4.0084560-26 $3.00 84830 $17.00 85046-TC $9.0084560-TC $8.00 84830-26 $5.00 85048 $7.0084577 $34.00 84830-TC $12.00 85048-26 $3.0084577-26 $11.00 84999 BR 85048-TC $4.0084577-TC $22.00 84999-26 BR 85049 BR84578 $7.00 84999-TC BR 85049-26 BR84578-26 $2.00 85002 $10.00 85049-TC BR84578-TC $5.00 85002-26 $3.00 85060 $25.0084580 $17.00 85002-TC $6.00 85060-26 $7.0084580-26 $5.00 85004 BR 85060-TC $18.0084580-TC $12.00 85004-26 BR 85097 $59.0084583 $11.00 85004-TC BR 85097-26 $59.0084583-26 $3.00 85007 $6.00 85097-TC BR



Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA85130 $19.00 85291-TC $14.00 85366-26 $3.0085130-26 $6.00 85292 $51.00 85366-TC $10.0085130-TC $13.00 85292-26 $17.00 85370 $20.0085170 $7.00 85292-TC $34.00 85370-26 $5.0085170-26 $2.00 85293 $51.00 85370-TC $15.0085170-TC $5.00 85293-26 $17.00 85378 $13.0085175 $10.00 85293-TC $34.00 85378-26 $4.0085175-26 $3.00 85300 $35.00 85378-TC $8.0085175-TC $6.00 85300-26 $12.00 85379 $18.0085210 $31.00 85300-TC $23.00 85379-26 $6.0085210-26 $8.00 85301 $29.00 85379-TC $12.0085210-TC $21.00 85301-26 $10.00 85380 BR85220 $47.00 85301-TC $19.00 85380-26 BR85220-26 $15.00 85302 $33.00 85380-TC BR85220-TC $32.00 85302-26 $11.00 85384 $11.0085230 $47.00 85302-TC $21.00 85384-26 $3.0085230-26 $14.00 85303 $26.00 85384-TC $7.0085230-TC $33.00 85303-26 $8.00 85385 $16.0085240 $48.00 85303-TC $18.00 85385-26 $5.0085240-26 $15.00 85305 $21.00 85385-TC $11.0085240-TC $33.00 85305-26 $7.00 85390 $10.0085244 $49.00 85305-TC $14.00 85390-26 $2.0085244-26 $15.00 85306 $29.00 85390-TC $7.0085244-TC $34.00 85306-26 $10.00 85396 $22.0085245 $54.00 85306-TC $19.00 85400 $12.0085245-26 $18.00 85307 $35.00 85400-26 $3.0085245-TC $36.00 85307-26 $12.00 85400-TC $8.0085246 $54.00 85307-TC $23.00 85410 $12.0085246-26 $18.00 85335 $21.00 85410-26 $3.0085246-TC $36.00 85335-26 $7.00 85410-TC $8.0085247 $54.00 85335-TC $14.00 85415 $28.0085247-26 $18.00 85337 $19.00 85415-26 $10.0085247-TC $36.00 85337-26 $6.00 85415-TC $18.0085250 $49.00 85337-TC $13.00 85420 $16.0085250-26 $14.00 85345 $10.00 85420-26 $3.0085250-TC $35.00 85345-26 $2.00 85420-TC $13.0085260 $49.00 85345-TC $7.00 85421 $39.0085260-26 $14.00 85347 $8.00 85421-26 $12.0085260-TC $35.00 85347-26 $2.00 85421-TC $26.0085270 $49.00 85347-TC $6.00 85441 $7.0085270-26 $14.00 85348 $10.00 85441-26 $2.0085270-TC $35.00 85348-26 $3.00 85441-TC $5.0085280 $49.00 85348-TC $6.00 85445 $16.0085280-26 $14.00 85360 $16.00 85445-26 $5.0085280-TC $35.00 85360-26 $4.00 85445-TC $11.0085290 $44.00 85360-TC $12.00 85460 $15.0085290-26 $13.00 85362 $18.00 85460-26 $4.0085290-TC $32.00 85362-26 $7.00 85460-TC $11.0085291 $20.00 85362-TC $11.00 85461 $12.0085291-26 $6.00 85366 $13.00 85461-26 $3.00



Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA85461-TC $8.00 85635-26 $8.00 86023 $28.0085475 $15.00 85635-TC $18.00 86023-26 $10.0085475-26 $4.00 85651 $8.00 86023-TC $18.0085475-TC $11.00 85651-26 $2.00 86038 $22.0085520 $22.00 85651-TC $6.00 86038-26 $7.0085520-26 $6.00 85652 $8.00 86038-TC $15.0085520-TC $16.00 85652-26 $2.00 86039 $19.0085525 $20.00 85652-TC $6.00 86039-26 $6.0085525-26 $6.00 85660 $10.00 86039-TC $13.0085525-TC $14.00 85660-26 $3.00 86060 $13.0085530 $39.00 85660-TC $6.00 86060-26 $3.0085530-26 $12.00 85670 $13.00 86060-TC $10.0085530-TC $26.00 85670-26 $3.00 86063 $21.0085536 $14.00 85670-TC $10.00 86063-26 $6.0085536-26 $4.00 85675 $13.00 86063-TC $15.0085536-TC $10.00 85675-26 $4.00 86077 $91.0085540 $24.00 85675-TC $8.00 86077-26 $26.0085540-26 $7.00 85705 $13.00 86077-TC $64.0085540-TC $17.00 85705-26 $4.00 86078 $91.0085547 $23.00 85705-TC $8.00 86078-26 $26.0085547-26 $6.00 85730 $11.00 86078-TC $64.0085547-TC $17.00 85730-26 $3.00 86079 $79.0085549 $45.00 85730-TC $7.00 86079-26 $25.0085549-26 $15.00 85732 $17.00 86079-TC $52.0085549-TC $31.00 85732-26 $5.00 86140 $14.0085555 $17.00 85732-TC $12.00 86140-26 $4.0085555-26 $5.00 85810 $19.00 86140-TC $10.0085555-TC $12.00 85810-26 $4.00 86141 BR85557 $34.00 85810-TC $15.00 86141-26 BR85557-26 $10.00 85999 BR 86141-TC BR85557-TC $23.00 85999-26 BR 86146 $58.0085576 $21.00 85999-TC BR 86146-26 $19.0085576-26 $5.00 86000 $16.00 86146-TC $39.0085576-TC $16.00 86000-26 $5.00 86147 $53.0085597 $32.00 86000-TC $11.00 86147-26 $16.0085597-26 $10.00 86001 $12.00 86147-TC $36.0085597-TC $21.00 86001-26 $4.00 86148 $59.0085610 $6.00 86001-TC $8.00 86148-26 $21.0085610-26 $3.00 86003 $6.00 86148-TC $38.0085610-TC $4.00 86003-26 $2.00 86153-26 $35.0085611 $6.00 86003-TC $3.00 86155 $26.0085611-26 $2.00 86005 $11.00 86155-26 $8.0085611-TC $4.00 86005-26 $4.00 86155-TC $18.0085612 $22.00 86005-TC $6.00 86156 $11.0085612-26 $6.00 86021 $41.00 86156-26 $3.0085612-TC $16.00 86021-26 $12.00 86156-TC $7.0085613 $15.00 86021-TC $29.00 86157 $13.0085613-26 $4.00 86022 $57.00 86157-26 $4.0085613-TC $11.00 86022-26 $18.00 86157-TC $8.0085635 $26.00 86022-TC $39.00 86160 $21.00



Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA86160-26 $5.00 86304 $47.00 86337-TC $36.0086160-TC $16.00 86304-26 $15.00 86340 $39.0086161 $21.00 86304-TC $32.00 86340-26 $13.0086161-26 $5.00 86308 $8.00 86340-TC $25.0086161-TC $16.00 86308-26 $3.00 86341 $38.0086162 $54.00 86308-TC $5.00 86341-26 $13.0086162-26 $18.00 86309 $12.00 86341-TC $24.0086162-TC $36.00 86309-26 $3.00 86343 $33.0086171 $25.00 86309-TC $8.00 86343-26 $11.0086171-26 $7.00 86310 $19.00 86343-TC $21.0086171-TC $18.00 86310-26 $6.00 86344 $21.0086185 $19.00 86310-TC $13.00 86344-26 $7.0086185-26 $6.00 86316 $37.00 86344-TC $14.0086185-TC $13.00 86316-26 $11.00 86353 $102.0086215 $36.00 86316-TC $25.00 86353-26 $31.0086215-26 $12.00 86317 $31.00 86353-TC $72.0086215-TC $23.00 86317-26 $10.00 86359 $61.0086225 $36.00 86317-TC $20.00 86359-26 $19.0086225-26 $11.00 86318 $23.00 86359-TC $41.0086225-TC $24.00 86318-26 $10.00 86360 $99.0086226 $24.00 86318-TC $14.00 86360-26 $33.0086226-26 $8.00 86320 $49.00 86360-TC $67.0086226-TC $16.00 86320-26 $19.00 86361 $66.0086235 $33.00 86320-TC $29.00 86361-26 $21.0086235-26 $10.00 86325 $49.00 86361-TC $43.0086235-TC $22.00 86325-26 $16.00 86376 $35.0086243 $50.00 86325-TC $33.00 86376-26 $11.0086243-26 $15.00 86327 $62.00 86376-TC $23.0086243-TC $35.00 86327-26 $19.00 86378 $45.0086255 $25.00 86327-TC $42.00 86378-26 $15.0086255-26 $8.00 86329 $37.00 86378-TC $31.0086255-TC $17.00 86329-26 $12.00 86382 $45.0086256 $25.00 86329-TC $24.00 86382-26 $14.0086256-26 $8.00 86331 $22.00 86382-TC $32.0086256-TC $17.00 86331-26 $6.00 86384 $24.0086277 $41.00 86331-TC $15.00 86384-26 $8.0086277-26 $14.00 86332 $54.00 86384-TC $16.0086277-TC $26.00 86332-26 $18.00 86403 $18.0086280 $15.00 86332-TC $36.00 86403-26 $3.0086280-26 $3.00 86334 $65.00 86403-TC $14.0086280-TC $12.00 86334-26 $18.00 86406 $21.0086294 BR 86334-TC $45.00 86406-26 $5.0086294-26 BR 86335 BR 86406-TC $16.0086294-TC BR 86335-26 $20.00 86430 $13.0086300 $47.00 86335-TC BR 86430-26 $4.0086300-26 $15.00 86336 BR 86430-TC $8.0086300-TC $32.00 86336-26 BR 86431 $17.0086301 $47.00 86336-TC BR 86431-26 $6.0086301-26 $15.00 86337 $54.00 86431-TC $11.0086301-TC $32.00 86337-26 $18.00 86485 $13.00



Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA86485-26 $4.00 86619-TC $15.00 86663-26 $7.0086485-TC $8.00 86622 $16.00 86663-TC $14.0086486 $6.00 86622-26 $5.00 86664 $53.0086490 $17.00 86622-TC $11.00 86664-26 $17.0086490-26 $5.00 86625 $21.00 86664-TC $36.0086490-TC $12.00 86625-26 $6.00 86665 $29.0086510 $13.00 86625-TC $15.00 86665-26 $10.0086510-26 $4.00 86628 $20.00 86665-TC $19.0086510-TC $8.00 86628-26 $6.00 86666 $23.0086580 $13.00 86628-TC $14.00 86666-26 $8.0086580-26 $4.00 86631 $20.00 86666-TC $15.0086580-TC $8.00 86631-26 $6.00 86668 $17.0086590 $18.00 86631-TC $14.00 86668-26 $5.0086590-26 $6.00 86632 $20.00 86668-TC $12.0086590-TC $12.00 86632-26 $6.00 86671 $20.0086592 $8.00 86632-TC $14.00 86671-26 $6.0086592-26 $2.00 86635 $18.00 86671-TC $14.0086592-TC $6.00 86635-26 $5.00 86674 $23.0086593 $11.00 86635-TC $13.00 86674-26 $7.0086593-26 $3.00 86638 $20.00 86674-TC $16.0086593-TC $7.00 86638-26 $6.00 86677 $24.0086602 $17.00 86638-TC $14.00 86677-26 $8.0086602-26 $5.00 86641 $21.00 86677-TC $16.0086602-TC $12.00 86641-26 $7.00 86682 $21.0086603 $20.00 86641-TC $14.00 86682-26 $7.0086603-26 $6.00 86644 $22.00 86682-TC $14.0086603-TC $14.00 86644-26 $7.00 86684 $24.0086606 $24.00 86644-TC $15.00 86684-26 $8.0086606-26 $8.00 86645 $28.00 86684-TC $16.0086606-TC $16.00 86645-26 $10.00 86687 $22.0086609 $20.00 86645-TC $18.00 86687-26 $7.0086609-26 $6.00 86648 $24.00 86687-TC $16.0086609-TC $14.00 86648-26 $8.00 86688 $20.0086611 $23.00 86648-TC $16.00 86688-26 $7.0086611-26 $8.00 86651 $21.00 86688-TC $14.0086611-TC $15.00 86651-26 $7.00 86689 $25.0086612 $21.00 86651-TC $14.00 86689-26 $8.0086612-26 $6.00 86652 $21.00 86689-TC $17.0086612-TC $15.00 86652-26 $7.00 86692 $22.0086615 $21.00 86652-TC $14.00 86692-26 $7.0086615-26 $6.00 86653 $21.00 86692-TC $15.0086615-TC $15.00 86653-26 $7.00 86694 $22.0086617 $29.00 86653-TC $14.00 86694-26 $7.0086617-26 $10.00 86654 $21.00 86694-TC $15.0086617-TC $19.00 86654-26 $7.00 86695 $21.0086618 $26.00 86654-TC $14.00 86695-26 $7.0086618-26 $8.00 86658 $21.00 86695-TC $14.0086618-TC $18.00 86658-26 $7.00 86696 $44.0086619 $21.00 86658-TC $14.00 86696-26 $14.0086619-26 $6.00 86663 $21.00 86696-TC $30.00



Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA86821 $123.00 86910-TC $57.00 86975-26 $16.0086821-26 $36.00 86911 $19.00 86975-TC $37.0086821-TC $86.00 86911-26 $6.00 86976 $53.0086822 $96.00 86911-TC $13.00 86976-26 $16.0086822-26 $32.00 86920 $19.00 86976-TC $37.0086822-TC $64.00 86920-26 $3.00 86977 $53.0086849 BR 86920-TC $15.00 86977-26 $16.0086849-26 BR 86921 $23.00 86977-TC $37.0086849-TC BR 86921-26 $7.00 86978 $65.0086850 $10.00 86921-TC $16.00 86978-26 $19.0086850-26 $3.00 86922 $20.00 86978-TC $44.0086850-TC $6.00 86922-26 $6.00 86985 $35.0086860 $44.00 86922-TC $14.00 86985-26 $12.0086860-26 $15.00 86927 $21.00 86985-TC $23.0086860-TC $29.00 86927-26 $5.00 86999 BR86870 $17.00 86927-TC $16.00 86999-26 BR86870-26 $6.00 86930 $155.00 86999-TC BR86870-TC $11.00 86930-26 $45.00 87003 $40.0086880 $13.00 86930-TC $108.00 87003-26 $13.0086880-26 $4.00 86931 $155.00 87003-TC $26.0086880-TC $8.00 86931-26 $45.00 87015 $14.0086885 $15.00 86931-TC $108.00 87015-26 $5.0086885-26 $4.00 86932 $161.00 87015-TC $9.0086885-TC $11.00 86932-26 $48.00 87040 $18.0086886 $14.00 86932-TC $111.00 87040-26 $6.0086886-26 $4.00 86940 $18.00 87040-TC $12.0086886-TC $10.00 86940-26 $5.00 87045 $18.0086890 $67.00 86940-TC $13.00 87045-26 $6.0086890-26 $11.00 86941 $31.00 87045-TC $11.0086890-TC $54.00 86941-26 $8.00 87046 $5.0086891 $91.00 86941-TC $21.00 87046-26 $2.0086891-26 $26.00 86945 $35.00 87046-TC $3.0086891-TC $64.00 86945-26 $11.00 87070 $14.0086900 $10.00 86945-TC $23.00 87070-26 $4.0086900-26 $3.00 86950 $99.00 87070-TC $10.0086900-TC $6.00 86950-26 $29.00 87071 $11.0086901 $10.00 86950-TC $70.00 87071-26 $3.0086901-26 $3.00 86965 $25.00 87071-TC $8.0086901-TC $6.00 86965-26 $7.00 87073 $11.0086904 $19.00 86965-TC $18.00 87073-26 $3.0086904-26 $6.00 86970 $41.00 87073-TC $8.0086904-TC $13.00 86970-26 $12.00 87075 $18.0086905 $7.00 86970-TC $29.00 87075-26 $6.0086905-26 $1.00 86971 $20.00 87075-TC $12.0086905-TC $6.00 86971-26 $5.00 87076 $24.0086906 $11.00 86971-TC $15.00 87076-26 $8.0086906-26 $3.00 86972 $20.00 87076-TC $16.0086906-TC $7.00 86972-26 $6.00 87077 $16.0086910 $83.00 86972-TC $14.00 87077-26 $5.0086910-26 $24.00 86975 $53.00 87077-TC $11.00



Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA87081 $12.00 87149-TC $31.00 87197-26 $10.0087081-26 $3.00 87152 $12.00 87197-TC $19.0087081-TC $8.00 87152-26 $4.00 87205 $11.0087084 $23.00 87152-TC $8.00 87205-26 $3.0087084-26 $7.00 87158 $5.00 87205-TC $7.0087084-TC $16.00 87158-26 $1.00 87206 $15.0087086 $14.00 87158-TC $3.00 87206-26 $3.0087086-26 $3.00 87164 $24.00 87206-TC $12.0087086-TC $11.00 87164-26 $8.00 87207 $10.0087088 $18.00 87164-TC $16.00 87207-26 $3.0087088-26 $6.00 87166 $24.00 87207-TC $6.0087088-TC $12.00 87166-26 $7.00 87210 $8.0087101 $20.00 87166-TC $17.00 87210-26 $2.0087101-26 $6.00 87168 $10.00 87210-TC $6.0087101-TC $14.00 87168-26 $3.00 87220 $12.0087102 $20.00 87168-TC $7.00 87220-26 $4.0087102-26 $6.00 87169 $10.00 87220-TC $7.0087102-TC $14.00 87169-26 $3.00 87230 $35.0087103 $32.00 87169-TC $7.00 87230-26 $11.0087103-26 $11.00 87172 $10.00 87230-TC $23.0087103-TC $20.00 87172-26 $3.00 87250 $33.0087106 $25.00 87172-TC $7.00 87250-26 $13.0087106-26 $7.00 87176 $16.00 87250-TC $19.0087106-TC $18.00 87176-26 $5.00 87252 $44.0087107 $23.00 87176-TC $11.00 87252-26 $14.0087107-26 $8.00 87177 $18.00 87252-TC $31.0087107-TC $15.00 87177-26 $6.00 87253 $33.0087109 $26.00 87177-TC $12.00 87253-26 $10.0087109-26 $8.00 87181 $13.00 87253-TC $22.0087109-TC $18.00 87181-26 $3.00 87254 $11.0087110 $23.00 87181-TC $8.00 87254-26 $3.0087110-26 $7.00 87184 $13.00 87254-TC $8.0087110-TC $15.00 87184-26 $3.00 87255 BR87116 $15.00 87184-TC $10.00 87255-26 BR87116-26 $3.00 87185 $11.00 87255-TC BR87116-TC $11.00 87185-26 $3.00 87260 $26.0087118 $28.00 87185-TC $8.00 87260-26 $8.0087118-26 $9.00 87186 $16.00 87260-TC $18.0087118-TC $20.00 87186-26 $4.00 87265 $26.0087140 $24.00 87186-TC $12.00 87265-26 $8.0087140-26 $7.00 87187 $20.00 87265-TC $18.0087140-TC $17.00 87187-26 $3.00 87267 BR87143 $34.00 87187-TC $17.00 87267-26 BR87143-26 $11.00 87188 $18.00 87267-TC BR87143-TC $22.00 87188-26 $5.00 87270 $26.0087147 $26.00 87188-TC $13.00 87270-26 $8.0087147-26 $8.00 87190 $7.00 87270-TC $18.0087147-TC $18.00 87190-26 $2.00 87271 BR87149 $46.00 87190-TC $5.00 87271-26 BR87149-26 $15.00 87197 $29.00 87271-TC BR



Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA87592 $88.00 87901-TC $398.00 88106-26 $16.0087592-26 $28.00 87902 BR 88106-TC $38.0087592-TC $58.00 87902-26 BR 88108 $59.0087650 $42.00 87902-TC BR 88108-26 $47.0087650-26 $13.00 87903 $1,126.00 88108-TC $11.0087650-TC $28.00 87903-26 $371.00 88112 $121.0087651 $73.00 87903-TC $755.00 88112-26 $65.0087651-26 $23.00 87904 $59.00 88112-TC $56.0087651-TC $48.00 87904-26 $20.00 88120 $619.0087652 $86.00 87904-TC $39.00 88120-26 $59.0087652-26 $28.00 87999 BR 88120-TC $560.0087652-TC $56.00 87999-26 BR 88121 $535.0087797 $42.00 87999-TC BR 88121-26 $51.0087797-26 $13.00 88000 $445.00 88121-TC $484.0087797-TC $28.00 88000-26 $445.00 88125 $70.0087798 $73.00 88000-TC BR 88125-26 $20.0087798-26 $23.00 88005 $500.00 88125-TC $48.0087798-TC $48.00 88005-26 $500.00 88130 $25.0087799 $88.00 88005-TC BR 88130-26 $7.0087799-26 $28.00 88007 $556.00 88130-TC $18.0087799-TC $58.00 88007-26 $556.00 88140 $18.0087800 $46.00 88007-TC BR 88140-26 $5.0087800-26 $15.00 88020 $556.00 88140-TC $13.0087800-TC $31.00 88020-26 $556.00 88141 $33.0087801 $81.00 88020-TC BR 88141-26 BR87801-26 $26.00 88025 $610.00 88141-TC BR87801-TC $54.00 88025-26 $610.00 88142 $82.0087802 BR 88025-TC BR 88142-26 $21.0087802-26 BR 88027 $666.00 88142-TC $59.0087802-TC BR 88027-26 $666.00 88143 $94.0087803 BR 88027-TC BR 88143-26 $33.0087803-26 BR 88036 $477.00 88143-TC $59.0087803-TC BR 88036-26 $477.00 88147 $82.0087804 BR 88036-TC BR 88147-26 BR87804-26 BR 88037 $389.00 88147-TC $82.0087804-TC BR 88037-26 $389.00 88148 $104.0087810 $26.00 88037-TC BR 88148-26 $21.0087810-26 $8.00 88040 $1,445.00 88148-TC $82.0087810-TC $18.00 88040-26 $1,445.00 88150 $13.0087850 $26.00 88040-TC BR 88150-26 $3.0087850-26 $8.00 88045 BR 88150-TC $9.0087850-TC $18.00 88045-26 BR 88152 $46.0087880 $26.00 88045-TC BR 88152-26 $8.0087880-26 $8.00 88099 BR 88152-TC $38.0087880-TC $18.00 88099-26 BR 88153 $82.0087899 $26.00 88099-TC BR 88153-26 $21.0087899-26 $8.00 88104 $49.00 88153-TC $59.0087899-TC $18.00 88104-26 $37.00 88154 $104.0087901 $594.00 88104-TC $10.00 88154-26 $21.0087901-26 $196.00 88106 $54.00 88154-TC $82.00



Pathology & Laboratory Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA CPT Code MRA88155 $14.00 88233 $243.00 88323-TC $32.0088155-26 $3.00 88233-26 $73.00 88325 $54.0088155-TC $10.00 88233-TC $170.00 88325-26 $54.0088160 $45.00 88235 $256.00 88325-TC BR88160-26 $14.00 88235-26 $76.00 88329 $51.0088160-TC $24.00 88235-TC $177.00 88329-26 $51.0088161 $64.00 88240 $21.00 88329-TC BR88161-26 $19.00 88240-26 $6.00 88331 $102.0088161-TC $37.00 88240-TC $15.00 88331-26 $70.0088162 $77.00 88241 $21.00 88331-TC $33.0088162-26 $22.00 88241-26 $6.00 88332 $53.0088162-TC $53.00 88241-TC $15.00 88332-26 $36.0088164 $54.00 88300 $24.00 88332-TC $17.0088164-26 $21.00 88300-26 $19.00 88333 $89.0088164-TC $33.00 88300-TC $5.00 88333-26 $67.0088165 $72.00 88302 $53.00 88333-TC $22.0088165-26 $33.00 88302-26 $42.00 88334 $47.0088165-TC $38.00 88302-TC $11.00 88334-26 $33.0088166 $82.00 88304 $70.00 88334-TC $14.0088166-26 $21.00 88304-26 $54.00 88341 $90.0088166-TC $59.00 88304-TC $14.00 88341-26 $28.0088167 $87.00 88305 $108.00 88341-TC $62.0088167-26 $26.00 88305-26 $86.00 88342 $53.0088167-TC $59.00 88305-TC $21.00 88342-26 $36.0088172 $70.00 88307 $210.00 88342-TC $17.0088172-26 $54.00 88307-26 $168.00 88344 $174.0088172-TC $14.00 88307-TC $41.00 88344-26 $41.0088173 $95.00 88309 $322.00 88344-TC $133.0088173-26 $95.00 88309-26 $258.00 88346 $96.0088173-TC $26.00 88309-TC $64.00 88346-26 $66.0088174 BR 88311 $23.00 88346-TC $28.0088174-26 BR 88311-26 $19.00 88348 $191.0088174-TC BR 88311-TC $4.00 88348-26 $145.0088175 BR 88312 $23.00 88348-TC $44.0088175-26 BR 88312-26 $7.00 88350 $72.0088175-TC BR 88312-TC $16.00 88350-26 $29.0088177 $30.00 88313 $23.00 88350-TC $44.0088177-26 $22.00 88313-26 $7.00 88355 $108.0088177-TC $8.00 88313-TC $16.00 88355-26 $80.0088182 $88.00 88314 $21.00 88355-TC $26.0088182-26 $33.00 88314-26 $6.00 88356 $108.0088182-TC $54.00 88314-TC $15.00 88356-26 $80.0088184 $51.00 88319 $26.00 88356-TC $26.0088185 $25.00 88319-26 $13.00 88358 $108.0088187 $69.00 88319-TC $14.00 88358-26 $80.0088188 $86.00 88321 $43.00 88358-TC $26.0088189 $113.00 88321-26 $43.00 88360 $110.0088199 BR 88321-TC BR 88360-26 $62.0088199-26 BR 88323 $61.00 88360-TC $49.0088199-TC BR 88323-26 $61.00 88361 $139.00



Pathology & Laboratory Pathology & LaboratoryCPT Code MRA CPT Code MRA88361-26 $55.00 88388-26 $24.0088361-TC $84.00 88388-TC $9.0088362 $251.00 88399 BR88362-26 $119.00 88399-26 BR88362-TC $132.00 88399-TC BR88363 $22.00 89049 $190.0088364 $135.00 89050 $10.0088364-26 $35.00 89050-26 $3.0088364-TC $100.00 89050-TC $6.0088365 $24.00 89051 $13.0088365-26 $24.00 89051-26 $4.0088365-TC $68.00 89051-TC $8.0088366 $263.00 89055 BR88366-26 $65.00 89055-26 BR88366-TC $198.00 89055-TC BR88367 $210.00 89060 $13.0088367-26 $72.00 89060-26 $5.0088367-TC $138.00 89060-TC $8.0088368 $190.00 89125 $14.0088368-26 $78.00 89125-26 $4.0088368-TC $112.00 89125-TC $10.0088369 $108.00 89160 $6.0088369-26 $32.00 89160-26 $2.0088369-TC $77.00 89160-TC $4.0088371 $34.00 89190 $10.0088371-26 $10.00 89190-26 $3.0088371-TC $23.00 89190-TC $6.0088372 $38.00 89220 $17.0088372-26 $11.00 89230 $5.0088372-TC $26.00 G0124 $24.0088373 $75.00 G0141 $24.0088373-26 $21.00 G0416 $651.0088373-TC $54.00 G0416-26 $184.0088374 $346.00 G0416-TC $467.0088374-26 $46.00 G0452-26 $19.0088374-TC $300.00 G0455 $126.0088375 $20.0088377 $412.0088377-26 $67.0088377-TC $346.0088380 $159.0088380-26 $71.0088380-TC $88.0088381 $213.0088381-26 $54.0088381-TC $159.0088387 $36.0088387-26 $29.0088387-TC $6.0088388 $33.00



Medicine Medicine MedicineCPT Code MRA CPT Code MRA CPT Code MRA90460 $25.00 90959 $298.00 91111 $743.0090461 $13.00 90960 $287.00 91111-26 $53.0090471 $4.00 90961 $241.00 91111-TC $690.0090472 $4.00 90962 $186.00 91112 $1,083.0090473 $13.00 90963 $552.00 91112-26 $113.0090474 $9.00 90964 $481.00 91112-TC $969.0090632 BR 90965 $456.00 91117 $152.0090636 BR 90966 $241.00 91120 $457.0090675 BR 90967 $18.00 91120-26 $52.0090746 BR 90968 $15.00 91120-TC $405.0090749 BR 90969 $15.00 91122 $169.0090785 $14.00 90970 $8.00 91122-26 $122.0090791 $134.00 90997 $115.00 91122-TC $37.0090792 $144.00 90999 BR 91132 $156.0090832 $65.00 91010 $116.00 91132-26 $28.0090833 $66.00 91010-26 $76.00 91132-TC $127.0090834 $86.00 91010-TC $32.00 91133 $174.0090836 $84.00 91013 $24.00 91133-26 $34.0090837 $129.00 91013-26 $10.00 91133-TC $139.0090838 $111.00 91013-TC $14.00 91200 $32.0090839 $134.00 91020 $60.00 91200-26 $13.0090840 $64.00 91020-26 $49.00 91200-TC $19.0090845 $85.00 91020-TC $9.00 91299 BR90846 $93.00 91022 $227.00 91299-26 BR90847 $110.00 91022-26 $77.00 91299-TC BR90849 $32.00 91022-TC $150.00 92002 $63.0090853 $32.00 91030 $57.00 92004 $98.0090865 $143.00 91030-26 $47.00 92012 $53.0090870 $94.00 91030-TC $8.00 92014 $75.0090875 $74.00 91034 $240.00 92015 $34.0090876 $112.00 91034-26 $52.00 92018 $80.0090880 $112.00 91034-TC $188.00 92019 $70.0090882 $104.00 91035 $474.00 92020 $31.0090885 $49.00 91035-26 $84.00 92025 $29.0090887 $77.00 91035-TC $390.00 92025-26 $17.0090889 BR 91037 $152.00 92025-TC $13.0090899 BR 91037-26 $52.00 92060 $40.0090901 $46.00 91037-TC $100.00 92060-26 $32.0090911 $82.00 91038 $130.00 92060-TC $7.0090935 $76.00 91038-26 $59.00 92065 $34.0090937 $226.00 91038-TC $72.00 92065-26 $19.0090940 BR 91040 $463.00 92065-TC $6.0090945 $80.00 91040-26 $52.00 92071 $39.0090947 $125.00 91040-TC $411.00 92072 $140.0090951 $943.00 91065 $34.00 92081 $32.0090954 $818.00 91065-26 $23.00 92081-26 $19.0090955 $461.00 91065-TC $14.00 92081-TC $6.0090956 $321.00 91110 $928.00 92082 $48.0090957 $651.00 91110-26 $185.00 92082-26 $24.0090958 $440.00 91110-TC $743.00 92082-TC $9.00



Medicine Medicine MedicineCPT Code MRA CPT Code MRA CPT Code MRA92083 $59.00 92284-26 $151.00 92538 $21.0092083-26 $31.00 92284-TC $46.00 92538-26 $16.0092083-TC $14.00 92285 $26.00 92538-TC $5.0092100 $40.00 92285-26 $12.00 92540 $102.0092132 $36.00 92285-TC $6.00 92540-26 $81.0092132-26 $20.00 92286 $91.00 92540-TC $22.0092132-TC $16.00 92286-26 $53.00 92541 $37.0092133 $45.00 92286-TC $29.00 92541-26 $25.0092133-26 $29.00 92287 $99.00 92541-TC $9.0092133-TC $16.00 92287-26 $48.00 92542 $33.0092134 $46.00 92287-TC $77.00 92542-26 $20.0092134-26 $30.00 92310 $86.00 92542-TC $10.0092134-TC $16.00 92311 $78.00 92544 $26.0092136 $93.00 92312 $89.00 92544-26 $16.0092136-26 $29.00 92313 $70.00 92544-TC $8.0092136-TC $63.00 92314 $54.00 92545 $22.0092140 $38.00 92315 $44.00 92545-26 $14.0092145 $15.00 92316 $59.00 92545-TC $8.0092145-26 $9.00 92317 $39.00 92546 $29.0092145-TC $7.00 92325 $14.00 92546-26 $17.0092225 $45.00 92326 $44.00 92546-TC $9.0092226 $39.00 92340 $32.00 92547 $21.0092227 $14.00 92341 $43.00 92548 $92.0092228 $35.00 92342 $43.00 92548-26 $30.0092228-26 $22.00 92358 $24.00 92548-TC $59.0092228-TC $14.00 92370 $35.00 92550 $21.0092230 $58.00 92371 $18.00 92551 $17.0092235 $104.00 92499 BR 92552 $16.0092235-26 $46.00 92499-26 BR 92553 $24.0092235-TC $53.00 92499-TC BR 92555 $14.0092240 $132.00 92502 $101.00 92556 $21.0092240-26 $60.00 92504 $24.00 92557 $46.0092240-TC $67.00 92507 $40.00 92560 $23.0092250 $40.00 92508 $42.00 92561 $27.0092250-26 $24.00 92511 $81.00 92562 $15.0092250-TC $7.00 92512 $46.00 92563 $14.0092260 $20.00 92516 $36.00 92564 $17.0092265 $53.00 92520 $47.00 92565 $15.0092265-26 $37.00 92521 $114.00 92567 $20.0092265-TC $10.00 92522 $93.00 92568 $14.0092270 $64.00 92523 $193.00 92570 $33.0092270-26 $45.00 92524 $97.00 92571 $14.0092270-TC $19.00 92526 $48.00 92572 $3.0092275 $80.00 92531 $10.00 92575 $11.0092275-26 $56.00 92532 $14.00 92576 $17.0092275-TC $17.00 92533 $41.00 92577 $28.0092283 $24.00 92534 BR 92579 $28.0092283-26 $10.00 92537 $41.00 92582 $28.0092283-TC $5.00 92537-26 $32.00 92583 $34.0092284 $192.00 92537-TC $9.00 92584 $94.00



Medicine Medicine MedicineCPT Code MRA CPT Code MRA CPT Code MRA92585 $114.00 92960 $162.00 93261-26 $39.0092585-26 $52.00 92961 $239.00 93261-TC $22.0092585-TC $70.00 92970 $201.00 93268 $109.0092586 $70.00 92971 $100.00 93270 $46.0092587 $58.00 92973 $174.00 93271 $90.0092587-26 $8.00 92974 $197.00 93272 $28.0092587-TC $49.00 92975 $400.00 93278 $58.0092588 $78.00 92977 $302.00 93278-26 $24.0092588-26 $20.00 92978 $269.00 93278-TC $44.0092588-TC $57.00 92978-26 $95.00 93279 $50.0092590 $41.00 92978-TC $170.00 93279-26 $33.0092591 BR 92979 $163.00 93279-TC $17.0092592 BR 92979-26 $76.00 93280 $59.0092593 BR 92979-TC $86.00 93280-26 $39.0092594 BR 92986 $1,222.00 93280-TC $20.0092595 BR 92987 $1,271.00 93281 $68.0092596 $22.00 92990 $974.00 93281-26 $45.0092597 $96.00 92992 BR 93281-TC $23.0092603 $88.00 92993 BR 93282 $63.0092604 $60.00 92997 $765.00 93282-26 $43.0092605 $94.00 92998 $331.00 93282-TC $20.0092606 $84.00 93000 $26.00 93283 $82.0092607 $109.00 93005 $16.00 93283-26 $58.0092608 $22.00 93010 $12.00 93283-TC $24.0092609 $59.00 93015 $104.00 93284 $90.0092610 $42.00 93016 $25.00 93284-26 $63.0092611 $46.00 93017 $63.00 93284-TC $27.0092612 $173.00 93018 $54.00 93285 $42.0092613 $43.00 93024 $111.00 93285-26 $26.0092614 $134.00 93024-26 $71.00 93285-TC $16.0092615 $39.00 93024-TC $42.00 93286 $27.0092616 $183.00 93025 $277.00 93286-26 $15.0092617 $48.00 93025-26 $40.00 93286-TC $12.0092618 $34.00 93025-TC $299.00 93287 $36.0092620 $45.00 93040 $14.00 93287-26 $23.0092621 $12.00 93041 $31.00 93287-TC $13.0092625 $45.00 93042 $9.00 93288 $37.0092626 $86.00 93050 $18.00 93288-26 $21.0092627 $22.00 93050-26 $9.00 93288-TC $16.0092640 $53.00 93050-TC $9.00 93289 $66.0092700 BR 93224 $159.00 93289-26 $46.0092920 $561.00 93225 $46.00 93289-TC $19.0092924 $668.00 93226 $83.00 93290 $31.0092928 $623.00 93227 $50.00 93290-26 $21.0092933 $697.00 93228 $27.00 93290-TC $9.0092937 $623.00 93229 $669.00 93291 $36.0092941 $699.00 93260 $68.00 93291-26 $21.0092943 $699.00 93260-26 $45.00 93291-TC $15.0092950 $203.00 93260-TC $22.00 93292 $32.0092953 $35.00 93261 $61.00 93292-26 $21.00



Medicine Medicine MedicineCPT Code MRA CPT Code MRA CPT Code MRA93292-TC $11.00 93350 $216.00 93530 $872.0093293 $54.00 93350-26 $77.00 93530-26 $250.0093293-26 $16.00 93350-TC $66.00 93530-TC $634.0093293-TC $38.00 93351 $282.00 93531 $2,268.0093294 $34.00 93351-26 $86.00 93531-26 $467.0093295 $68.00 93351-TC $195.00 93531-TC $1,815.0093296 $26.00 93352 $34.00 93532 $2,317.0093297 $27.00 93355 $230.00 93532-26 $569.0093298 $27.00 93451 $790.00 93532-TC $1,766.0093303 $215.00 93451-26 $151.00 93533 $2,131.0093303-26 $70.00 93451-TC $638.00 93533-26 $352.0093303-TC $144.00 93452 $887.00 93533-TC $1,766.0093304 $114.00 93452-26 $265.00 93561 $59.0093304-26 $43.00 93452-TC $622.00 93561-26 $47.0093304-TC $73.00 93453 $1,149.00 93561-TC $20.0093306 $229.00 93453-26 $347.00 93562 $46.0093306-26 $64.00 93453-TC $801.00 93562-26 $33.0093306-TC $165.00 93454 $903.00 93562-TC $13.0093307 $196.00 93454-26 $267.00 93563 $57.0093307-26 $56.00 93454-TC $637.00 93564 $58.0093307-TC $144.00 93455 $1,052.00 93565 $44.0093308 $118.00 93455-26 $308.00 93566 $173.0093308-26 $46.00 93455-TC $744.00 93567 $142.0093308-TC $75.00 93456 $1,132.00 93568 $154.0093312 $322.00 93456-26 $341.00 93571 $270.0093312-26 $140.00 93456-TC $791.00 93571-26 $93.0093312-TC $182.00 93457 $1,280.00 93571-TC $170.0093313 $76.00 93457-26 $383.00 93572 $222.0093314 $212.00 93457-TC $897.00 93572-26 $74.0093314-26 $65.00 93458 $1,084.00 93572-TC $155.0093314-TC $144.00 93458-26 $326.00 93580 $974.0093315 $287.00 93458-TC $758.00 93581 $1,303.0093315-26 $144.00 93459 $1,197.00 93582 $697.0093315-TC $141.00 93459-26 $367.00 93583 $776.0093316 $78.00 93459-TC $830.00 93600 $198.0093317 $236.00 93460 $1,284.00 93600-26 $129.0093317-26 $95.00 93460-26 $408.00 93600-TC $73.0093317-TC $141.00 93460-TC $875.00 93602 $159.0093318 $412.00 93461 $1,468.00 93602-26 $119.0093318-26 $114.00 93461-26 $451.00 93602-TC $42.0093318-TC $384.00 93461-TC $1,018.00 93603 $187.0093320 $86.00 93462 $215.00 93603-26 $127.0093320-26 $30.00 93463 $109.00 93603-TC $63.0093320-TC $65.00 93464 $284.00 93609 $578.0093321 $50.00 93464-26 $99.00 93609-26 $481.0093321-26 $10.00 93464-TC $186.00 93609-TC $101.0093321-TC $42.00 93503 $187.00 93610 $214.0093325 $114.00 93505 $318.00 93610-26 $166.0093325-26 $4.00 93505-26 $248.00 93610-TC $52.0093325-TC $110.00 93505-TC $74.00 93612 $224.00



Medicine Medicine MedicineCPT Code MRA CPT Code MRA CPT Code MRA93612-26 $167.00 93657 $433.00 93893-TC $188.0093612-TC $61.00 93660 $162.00 93922 $60.0093613 $377.00 93660-26 $103.00 93922-26 $16.0093615 $62.00 93660-TC $61.00 93922-TC $44.0093615-26 $49.00 93662 BR 93923 $112.0093615-TC $12.00 93662-26 $158.00 93923-26 $28.0093616 $94.00 93662-TC BR 93923-TC $85.0093616-26 $82.00 93701 $36.00 93924 $122.0093616-TC $12.00 93701-26 $9.00 93924-26 $31.0093618 $399.00 93701-TC $27.00 93924-TC $92.0093618-26 $258.00 93702 $109.00 93925 $175.0093618-TC $148.00 93724 $411.00 93925-26 $31.0093619 $717.00 93724-26 $259.00 93925-TC $144.0093619-26 $444.00 93724-TC $148.00 93926 $117.0093619-TC $290.00 93740 $17.00 93926-26 $21.0093620 $358.00 93740-26 $12.00 93926-TC $96.0093620-26 $272.00 93740-TC $5.00 93930 $174.0093620-TC $91.00 93750 $55.00 93930-26 $26.0093621 BR 93770 NC 93930-TC $150.0093621-26 $769.00 93770-26 NC 93931 $118.0093621-TC BR 93770-TC NC 93931-26 $17.0093622 BR 93784 NC 93931-TC $101.0093622-26 $771.00 93786 NC 93965 $63.0093622-TC BR 93788 NC 93965-26 $26.0093623 BR 93790 NC 93965-TC $42.0093623-26 $167.00 93797 $17.00 93970 $189.0093623-TC BR 93798 $38.00 93970-26 $36.0093624 $333.00 93799 BR 93970-TC $154.0093624-26 $256.00 93799-26 BR 93971 $121.0093624-TC $74.00 93799-TC BR 93971-26 $23.0093631 $651.00 93880 $176.00 93971-TC $96.0093631-26 $420.00 93880-26 $31.00 93975 $277.0093631-TC $239.00 93880-TC $144.00 93975-26 $89.0093640 $467.00 93882 $117.00 93975-TC $181.0093640-26 $230.00 93882-26 $21.00 93976 $184.0093640-TC $269.00 93882-TC $95.00 93976-26 $59.0093641 $613.00 93886 $215.00 93976-TC $121.0093641-26 $360.00 93886-26 $50.00 93978 $177.0093641-TC $269.00 93886-TC $162.00 93978-26 $34.0093642 $549.00 93888 $142.00 93978-TC $143.0093642-26 $295.00 93888-26 $33.00 93979 $122.0093642-TC $269.00 93888-TC $109.00 93979-26 $23.0093644 $282.00 93890 $241.00 93979-TC $98.0093644-26 $176.00 93890-26 $55.00 93980 $183.0093644-TC $106.00 93890-TC $185.00 93980-26 $65.0093650 $639.00 93892 $256.00 93980-TC $105.0093653 $865.00 93892-26 $63.00 93981 $148.0093654 $1,152.00 93892-TC $193.00 93981-26 $25.0093655 $432.00 93893 $251.00 93981-TC $124.0093656 $1,153.00 93893-26 $63.00 93982 $10.00



Medicine Medicine MedicineCPT Code MRA CPT Code MRA CPT Code MRA93990 $110.00 94642 BR 95052 $9.0093990-26 $14.00 94644 $36.00 95056 $6.0093990-TC $96.00 94645 $14.00 95060 $13.0094002 $84.00 94660 $54.00 95065 $7.0094003 $61.00 94662 $38.00 95070 $82.0094004 $45.00 94664 $18.00 95071 $105.0094010 $30.00 94667 $23.00 95076 $117.0094010-26 $12.00 94668 $16.00 95079 $84.0094010-TC $16.00 94669 $35.00 95115 $10.0094014 $39.00 94680 $47.00 95117 $9.0094015 $14.00 94680-26 $23.00 95120 BR94016 $26.00 94680-TC $22.00 95125 BR94060 $57.00 94681 $60.00 95130 BR94060-26 $18.00 94681-26 $12.00 95131 BR94060-TC $36.00 94681-TC $43.00 95132 BR94070 $32.00 94690 $24.00 95133 BR94070-26 $11.00 94690-26 $4.00 95134 BR94070-TC $19.00 94690-TC $20.00 95144 $9.0094150 $8.00 94726 $53.00 95145 $17.0094150-26 $6.00 94726-26 $13.00 95146 $24.0094150-TC $3.00 94726-TC $41.00 95147 $33.0094200 $17.00 94727 $42.00 95148 $32.0094200-26 $7.00 94727-26 $13.00 95149 $36.0094200-TC $9.00 94727-TC $30.00 95165 $7.0094250 $12.00 94728 $40.00 95170 $13.0094250-26 $8.00 94728-26 $13.00 95180 $103.0094250-TC $5.00 94728-TC $28.00 95199 BR94375 $34.00 94729 $54.00 95250 $114.0094375-26 $16.00 94729-26 $9.00 95251 $28.0094375-TC $17.00 94729-TC $45.00 95803 $151.0094400 $40.00 94750 $37.00 95803-26 $44.0094400-26 $24.00 94750-26 $14.00 95803-TC $107.0094400-TC $14.00 94750-TC $21.00 95805 $334.0094450 $37.00 94760 $9.00 95805-26 $94.0094450-26 $20.00 94761 $20.00 95805-TC $237.0094450-TC $15.00 94762 $30.00 95806 $232.0094452 $52.00 94770 $21.00 95806-26 $109.0094452-26 $16.00 94770-26 $9.00 95806-TC $137.0094452-TC $36.00 94770-TC $12.00 95807 $367.0094453 $74.00 94799 BR 95807-26 $98.0094453-26 $20.00 94799-26 BR 95807-TC $256.0094453-TC $53.00 94799-TC BR 95808 $456.0094610 $63.00 95004 $3.00 95808-26 $149.0094620 $91.00 95012 $19.00 95808-TC $256.0094620-26 $38.00 95017 $8.00 95810 $521.0094620-TC $54.00 95018 $20.00 95810-26 $183.0094621 $122.00 95024 $3.00 95810-TC $256.0094621-26 $71.00 95027 $5.00 95811 $644.0094621-TC $52.00 95028 $8.00 95811-26 $196.0094640 $19.00 95044 $7.00 95811-TC $423.00



Medicine Medicine MedicineCPT Code MRA CPT Code MRA CPT Code MRA95812 $137.00 95867 $66.00 95911-TC $92.0095812-26 $58.00 95867-26 $43.00 95912 $266.0095812-TC $68.00 95867-TC $21.00 95912-26 $161.0095813 $177.00 95868 $96.00 95912-TC $105.0095813-26 $89.00 95868-26 $71.00 95913 $308.0095813-TC $68.00 95868-TC $26.00 95913-26 $191.0095816 $133.00 95869 $29.00 95913-TC $117.0095816-26 $54.00 95869-26 $21.00 95921 $61.0095816-TC $78.00 95869-TC $8.00 95921-26 $46.0095819 $115.00 95870 $29.00 95921-TC $14.0095819-26 $58.00 95870-26 $21.00 95922 $65.0095819-TC $56.00 95870-TC $8.00 95922-26 $50.0095822 $120.00 95872 $104.00 95922-TC $14.0095822-26 $58.00 95872-26 $81.00 95923 $105.0095822-TC $63.00 95872-TC $22.00 95923-26 $47.0095824 $51.00 95873 $29.00 95923-TC $57.0095824-26 $41.00 95873-26 $21.00 95924 $147.0095824-TC $10.00 95873-TC $8.00 95924-26 $90.0095827 $145.00 95874 $30.00 95924-TC $57.0095827-26 $59.00 95874-26 $21.00 95925 $94.0095827-TC $86.00 95874-TC $8.00 95925-26 $53.0095829 $328.00 95875 $43.00 95925-TC $41.0095829-26 $291.00 95875-26 $34.00 95926 $66.0095829-TC $6.00 95875-TC $7.00 95926-26 $34.0095830 $133.00 95885 $59.00 95926-TC $34.0095831 $26.00 95885-26 $19.00 95927 $67.0095832 $21.00 95885-TC $40.00 95927-26 $34.0095833 $34.00 95886 $92.00 95927-TC $34.0095834 $44.00 95886-26 $47.00 95928 $175.0095851 $18.00 95886-TC $45.00 95928-26 $84.0095852 $14.00 95887 $87.00 95928-TC $91.0095857 $40.00 95887-26 $38.00 95929 $182.0095860 $73.00 95887-TC $48.00 95929-26 $84.0095860-26 $53.00 95905 $68.00 95929-TC $98.0095860-TC $15.00 95905-26 $3.00 95930 $44.0095861 $113.00 95905-TC $66.00 95930-26 $25.0095861-26 $86.00 95907 $95.00 95930-TC $11.0095861-TC $28.00 95907-26 $54.00 95933 $62.0095863 $138.00 95907-TC $42.00 95933-26 $33.0095863-26 $102.00 95908 $117.00 95933-TC $30.0095863-TC $35.00 95908-26 $67.00 95937 $40.0095864 $177.00 95908-TC $51.00 95937-26 $31.0095864-26 $114.00 95909 $142.00 95937-TC $9.0095864-TC $67.00 95909-26 $80.00 95938 $339.0095865 $119.00 95909-TC $61.00 95938-26 $47.0095865-26 $92.00 95910 $186.00 95938-TC $292.0095865-TC $27.00 95910-26 $107.00 95939 $495.0095866 $80.00 95910-TC $79.00 95939-26 $122.0095866-26 $71.00 95911 $226.00 95939-TC $373.0095866-TC $9.00 95911-26 $134.00 95940 $33.00



Medicine Medicine MedicineCPT Code MRA CPT Code MRA CPT Code MRA95950 $265.00 95991 $84.00 96416 $186.0095950-26 $84.00 95992 $44.00 96417 $85.0095950-TC $177.00 95999 BR 96420 $46.0095951 $34.00 96000 $93.00 96422 $46.0095951-26 $14.00 96001 $111.00 96423 $17.0095951-TC $20.00 96002 $21.00 96425 $54.0095953 $411.00 96003 $20.00 96440 $156.0095953-26 $165.00 96004 $97.00 96446 $193.0095953-TC $240.00 96020 BR 96450 $134.0095954 $208.00 96020-26 $156.00 96521 $153.0095954-26 $134.00 96020-TC BR 96522 $111.0095954-TC $23.00 96101 $97.00 96523 $28.0095955 $130.00 96102 $44.00 96542 $126.0095955-26 $59.00 96103 $28.00 96549 BR95955-TC $74.00 96105 $68.00 96567 $62.0095956 $541.00 96110 $88.00 96570 $69.0095956-26 $166.00 96111 $68.00 96571 $38.0095956-TC $314.00 96116 $109.00 96900 $17.0095957 $171.00 96118 $130.00 96904 $70.0095957-26 $104.00 96119 $66.00 96910 $21.0095957-TC $64.00 96120 $48.00 96912 $24.0095958 $296.00 96125 $57.00 96913 $53.0095958-26 $230.00 96127 $5.00 96920 $152.0095958-TC $66.00 96150 $26.00 96921 $155.0095961 $216.00 96151 $25.00 96922 $214.0095961-26 $166.00 96152 $24.00 96999 BR95961-TC $48.00 96153 $6.00 97001 $62.0095962 $227.00 96154 $24.00 97002 $29.0095962-26 $176.00 96155 $22.00 97003 $62.0095962-TC $48.00 96360 $57.00 97004 $29.0095965 BR 96361 $15.00 97005 BR95965-26 $420.00 96365 $69.00 97006 BR95965-TC BR 96366 $19.00 97010 $10.0095966 BR 96367 $30.00 97012 $16.0095966-26 $210.00 96368 $20.00 97014 $14.0095966-TC BR 96369 $195.00 97016 $15.0095967 BR 96370 $15.00 97018 $10.0095967-26 $184.00 96371 $91.00 97022 $15.0095967-TC BR 96372 $25.00 97024 $10.0095970 $22.00 96373 $19.00 97026 $9.0095971 $39.00 96374 $56.00 97028 $10.0095972 $78.00 96375 $22.00 97032 $16.0095974 $155.00 96401 $53.00 97033 $16.0095975 $88.00 96402 $46.00 97034 $13.0095978 $213.00 96405 $57.00 97035 $11.0095979 $98.00 96406 $86.00 97036 $19.0095980 $27.00 96409 $122.00 97039 $15.0095981 $10.00 96411 $71.00 97110 $22.0095982 $22.00 96413 $173.00 97112 $23.0095990 $57.00 96415 $39.00 97113 $24.00



Medicine Medicine MedicineCPT Code MRA CPT Code MRA CPT Code MRA97116 $21.00 98962 $7.00 G0238 $13.0097124 $19.00 99000 $6.00 G0239 $11.0097139 $15.00 99001 $4.00 G0248 $168.0097140 $26.00 99002 $35.00 G0249 $124.0097150 $18.00 99026 BR G0250 $9.0097260 $23.00 99027 BR G0268 $43.0097261 $17.00 99070 BR G0270 $22.0097530 $22.00 99071 NC G0271 $13.0097532 $22.00 99075 See 440.13 G0277 $45.0097533 $24.00 99078 NC G0281 $10.0097535 $23.00 99082 BR G0283 $10.0097537 $23.00 99090 BR G0329 $7.0097542 $17.00 99172 BR G0403 $17.0097545 $83.00 99173 $3.00 G0404 $8.0097546 $41.00 99174 $8.00 G0405 $9.0097597 $49.00 99175 $53.00 G0422 $103.0097598 $62.00 99183 $123.00 G0423 $103.0097602 BR 99184 $232.00 G0424 $30.0097605 $34.00 99190 BR G0453 $33.0097606 $37.00 99191 BR G0454 $9.0097610 $121.00 99192 BR G0459 $49.0097750 BR 99195 $16.00 G0473 $13.0097752 $48.00 99199 NC G9157 $112.0097755 $35.00 G0101 $32.00 G9187 $48.0097760 $31.00 G0102 $18.00 P3001 $24.0097761 $28.00 G0104 $115.00 Q0035 $19.0097762 $26.00 G0105 $344.00 Q0035-26 $8.0097799 BR G0105-53 $115.00 Q0035-TC $11.0097802 $26.00 G0106 $165.00 Q0091 $37.0097803 $17.00 G0106-26 $46.0097804 $7.00 G0106-TC $119.0097810 $35.00 G0108 $24.0097811 $27.00 G0109 $14.0097813 $37.00 G0117 $40.0097814 $30.00 G0118 $27.0097850 $54.00 G0120 $179.0097851 $26.00 G0120-26 $46.0097852 $54.00 G0120-TC $132.0097853 $26.00 G0121 $344.0098925 NC G0121-53 $115.0098926 $32.00 G0122 $177.0098927 NC G0122-26 $45.0098928 $23.00 G0122-TC $132.0098929 NC G0128 $4.0098940 NC G0166 $138.0098941 $32.00 G0179 $41.0098942 NC G0180 $54.0098943 $23.00 G0181 $99.0098960 $19.00 G0182 $102.0098961 $9.00 G0237 $12.00



Evaluation & Management Evaluation & Management Evaluation & ManagementCPT Code MRA CPT Code MRA CPT Code MRA99201 $35.00 99309 $80.00 99457 BR99202 $58.00 99310 $100.00 99487 $52.0099203 $58.00 99315 $60.00 99489 $41.0099204 $84.00 99316 $77.00 99490 $41.0099205 $84.00 99318 $66.00 99495 $164.0099211 $19.00 99324 $59.00 99496 $232.0099212 $31.00 99325 $86.00 99497 $86.0099213 $40.00 99326 $125.00 99498 $75.0099214 $40.00 99327 $164.00 99499 BR99215 $65.00 99328 $203.00 99600 BR99217 $65.00 99334 $45.00 G0245 $58.0099218 $65.00 99335 $72.00 G0246 $34.0099219 $109.00 99336 $111.00 G0296 $29.0099220 $152.00 99337 $163.00 G0337 $62.0099221 $66.00 99339 $67.00 G0372 $13.0099222 $109.00 99340 $93.00 G0396 $29.0099223 $152.00 99341 $59.00 G0397 $56.0099224 $40.00 99342 $85.00 G0402 $165.0099225 $73.00 99343 $109.00 G0406 $39.0099226 $105.00 99344 $160.00 G0407 $72.0099231 $33.00 99345 $193.00 G0408 $104.0099232 $54.00 99347 $46.00 G0409 $16.0099233 $77.00 99348 $71.0099234 $129.00 99349 $107.0099235 $173.00 99350 $156.0099236 $213.00 99354 $106.0099238 $66.00 99355 $104.0099239 $88.00 99356 $87.0099241 $54.00 99357 $88.0099242 $88.00 99360 $47.0099243 $117.00 99363 $108.0099244 $163.00 99364 $38.0099245 $212.00 99366 $37.0099251 $54.00 99367 $48.0099252 $70.00 99368 $31.0099253 $96.00 99374 $75.0099254 $138.00 99375 $75.0099255 $190.00 99377 $75.0099281 $18.00 99378 $104.0099282 $28.00 99379 $75.0099283 $60.00 99380 $104.0099284 $94.00 99406 $12.0099285 $103.00 99407 $24.0099291 $192.00 99408 $29.0099292 $95.00 99409 $58.0099304 $66.00 99415 $9.0099305 $88.00 99416 $5.0099306 $108.00 99450 NC99307 $34.00 99455 $90.0099308 $56.00 99456 BR


CDT © 2015 American Dental Association. All rights reserved. Part A, 156

Dental Dental DentalD-Code MRA D-Code MRA D-Code MRAD0120 $17.00 D2335 $81.00 D2950 $81.00D0140 $13.00 D2390 $57.00 D2951 $20.00D0150 $20.00 D2391 $43.00 D2952 $79.00D0160 $36.00 D2392 $55.00 D2953 $133.00D0170 $18.00 D2393 $63.00 D2954 $102.00D0180 $20.00 D2394 $69.00 D2955 $81.00D0210 $40.00 D2410 $163.00 D2957 $71.00D0220 $10.00 D2420 $203.00 D2960 $121.00D0230 $5.00 D2430 $293.00 D2961 $204.00D0240 $12.00 D2510 $155.00 D2962 $294.00D0250 $20.00 D2520 $259.00 D2980 $83.00D0270 $7.00 D2530 $244.00 D2999 BRD0272 $12.00 D2542 $302.00 D3110 $25.00D0274 $20.00 D2543 $318.00 D3120 $20.00D0277 $18.00 D2544 $348.00 D3220 $61.00D0290 $36.00 D2610 $206.00 D3221 $81.00D0310 $50.00 D2620 $266.00 D3230 $70.00D0320 $204.00 D2630 $348.00 D3240 $75.00D0321 $64.00 D2642 $287.00 D3310 $206.00D0322 $105.00 D2643 $328.00 D3320 $204.00D0330 $29.00 D2644 $378.00 D3330 $287.00D0340 $40.00 D2650 $206.00 D3331 $102.00D0350 $10.00 D2651 $266.00 D3332 $110.00D0415 $34.00 D2652 $348.00 D3333 $53.00D0425 $25.00 D2662 $266.00 D3346 $225.00D0460 $13.00 D2663 $328.00 D3347 $274.00D0470 $24.00 D2664 $348.00 D3348 $337.00D0472 $30.00 D2710 $194.00 D3351 $102.00D0473 BR D2720 $410.00 D3352 $81.00D0474 BR D2721 $306.00 D3353 $163.00D0480 BR D2722 $348.00 D3410 $179.00D0502 $54.00 D2740 $410.00 D3421 $194.00D0999 BR D2750 $451.00 D3425 $206.00D1110 $29.00 D2751 $328.00 D3426 $77.00D1310 $23.00 D2752 $368.00 D3430 $55.00D1320 $48.00 D2780 $368.00 D3450 $102.00D1330 $13.00 D2781 $266.00 D3460 $318.00D1351 $21.00 D2782 $306.00 D3470 $204.00D1510 $81.00 D2783 $389.00 D3910 $50.00D1515 $121.00 D2790 $389.00 D3920 $102.00D1520 $102.00 D2791 $287.00 D3950 $61.00D1525 $143.00 D2792 $328.00 D3999 BRD1550 $14.00 D2799 $204.00 D4210 $114.00D2140 $38.00 D2910 $29.00 D4211 $50.00D2150 $44.00 D2920 $29.00 D4240 $223.00D2160 $54.00 D2930 $81.00 D4241 $63.00D2161 $67.00 D2931 $121.00 D4245 $265.00D2330 $40.00 D2932 $77.00 D4249 $208.00D2331 $61.00 D2933 $91.00 D4260 $328.00D2332 $66.00 D2940 $29.00 D4261 $164.00



Dental Dental DentalD-Code MRA D-Code MRA D-Code MRAD4263 $195.00 D5741 $102.00 D5988 $219.00D4264 $159.00 D5750 $132.00 D5999 BRD4265 $96.00 D5751 $163.00 D6010 $649.00D4266 $285.00 D5760 $100.00 D6040 $3,016.00D4267 $328.00 D5761 $163.00 D6050 $1,557.00D4268 $273.00 D5810 $244.00 D6055 $769.00D4270 $155.00 D5811 $244.00 D6056 $265.00D4273 $337.00 D5820 $194.00 D6057 $303.00D4274 $208.00 D5821 $204.00 D6058 $392.00D4275 $178.00 D5850 $46.00 D6059 $418.00D4276 $194.00 D5851 $50.00 D6060 $289.00D4320 $77.00 D5862 $181.00 D6061 $379.00D4321 $55.00 D5867 $36.00 D6062 $365.00D4341 $79.00 D5875 $100.00 D6063 $359.00D4342 $55.00 D5899 BR D6064 $377.00D4355 $50.00 D5911 $81.00 D6065 $513.00D4381 $69.00 D5912 $121.00 D6066 $513.00D4910 $40.00 D5913 $2,052.00 D6067 $513.00D4920 $27.00 D5914 $2,052.00 D6068 $365.00D4999 BR D5915 $2,770.00 D6069 $359.00D5110 $513.00 D5916 $2,874.00 D6070 $322.00D5120 $513.00 D5919 BR D6071 $326.00D5130 $563.00 D5922 $1,334.00 D6072 $365.00D5140 $563.00 D5923 $1,641.00 D6073 $346.00D5211 $256.00 D5924 BR D6074 $350.00D5212 $259.00 D5925 BR D6075 $414.00D5213 $614.00 D5926 $1,026.00 D6076 $402.00D5214 $614.00 D5927 $1,026.00 D6077 $447.00D5281 $279.00 D5928 $1,384.00 D6080 $71.00D5410 $27.00 D5929 BR D6090 $229.00D5411 $27.00 D5931 $656.00 D6095 $247.00D5421 $27.00 D5932 $1,539.00 D6100 $264.00D5422 $27.00 D5933 $306.00 D6199 BRD5510 $61.00 D5934 $1,539.00 D6210 $410.00D5520 $40.00 D5935 $1,539.00 D6211 $287.00D5610 $61.00 D5936 $563.00 D6212 $328.00D5620 $83.00 D5937 BR D6240 $451.00D5630 $22.00 D5951 $614.00 D6241 $368.00D5640 $53.00 D5953 $614.00 D6242 $410.00D5650 $61.00 D5954 BR D6245 $309.00D5660 $102.00 D5955 $1,334.00 D6250 $410.00D5670 $305.00 D5958 $780.00 D6251 $287.00D5671 $305.00 D5959 $244.00 D6252 $368.00D5710 $204.00 D5960 $163.00 D6253 $51.00D5711 $204.00 D5982 $167.00 D6545 $195.00D5720 $163.00 D5983 BR D6548 $281.00D5721 $163.00 D5984 BR D6600 $155.00D5730 $121.00 D5985 $574.00 D6601 $166.00D5731 $121.00 D5986 $61.00 D6602 $172.00D5740 $102.00 D5987 BR D6603 $203.00



Dental Dental DentalD-Code MRA D-Code MRA D-Code MRAD6604 $110.00 D7310 $85.00 D7850 $1,682.00D6605 $141.00 D7320 $108.00 D7852 $2,011.00D6606 $139.00 D7340 $195.00 D7854 $2,052.00D6607 $151.00 D7350 $410.00 D7856 BRD6608 $170.00 D7410 $102.00 D7858 $2,298.00D6609 $178.00 D7411 $100.00 D7860 $614.00D6610 $203.00 D7412 $139.00 D7865 $1,723.00D6611 $217.00 D7413 $205.00 D7870 $81.00D6612 $141.00 D7414 $180.00 D7871 BRD6613 $155.00 D7415 $291.00 D7872 $533.00D6614 $151.00 D7440 $161.00 D7873 $584.00D6615 $162.00 D7441 $247.00 D7874 $737.00D6720 $410.00 D7450 $139.00 D7875 $789.00D6721 $233.00 D7451 $179.00 D7876 $820.00D6722 $348.00 D7460 $137.00 D7877 $758.00D6740 $328.00 D7461 $195.00 D7880 $291.00D6750 $356.00 D7465 $71.00 D7899 BRD6751 $328.00 D7471 $174.00 D7910 $73.00D6752 $410.00 D7472 $143.00 D7911 $110.00D6780 $389.00 D7473 $147.00 D7912 $163.00D6781 $320.00 D7485 $162.00 D7920 $676.00D6782 $322.00 D7490 $2,545.00 D7940 $841.00D6783 $324.00 D7510 $54.00 D7941 $2,874.00D6790 $389.00 D7520 $121.00 D7943 $2,914.00D6791 $287.00 D7530 $85.00 D7944 $2,298.00D6792 $348.00 D7540 $121.00 D7945 $2,319.00D6793 $30.00 D7550 $143.00 D7946 $2,566.00D6920 $279.00 D7560 $266.00 D7947 $2,566.00D6930 $40.00 D7610 $1,189.00 D7948 $2,874.00D6940 $102.00 D7620 $984.00 D7949 $4,186.00D6950 $155.00 D7630 $1,354.00 D7950 $881.00D6980 $106.00 D7640 $820.00 D7955 $922.00D6999 BR D7650 $1,292.00 D7960 $121.00D7140 $45.00 D7660 $780.00 D7970 $137.00D7210 $70.00 D7670 $410.00 D7971 $67.00D7220 $111.00 D7671 $779.00 D7972 BRD7230 $139.00 D7680 $1,949.00 D7980 $169.00D7240 $147.00 D7710 $1,415.00 D7981 $820.00D7241 $204.00 D7720 $903.00 D7982 $306.00D7250 $81.00 D7730 $1,580.00 D7983 $244.00D7260 $244.00 D7740 $922.00 D7990 $340.00D7270 $147.00 D7750 $1,334.00 D7991 $820.00D7272 $204.00 D7760 $1,046.00 D7995 BRD7280 $121.00 D7770 $533.00 D7996 BRD7282 $41.00 D7771 $73.00 D7997 BRD7285 $106.00 D7780 $2,504.00 D7999 BRD7286 $81.00 D7810 $1,292.00 D8010 $451.00D7287 BR D7820 $110.00 D8020 $533.00D7290 $133.00 D7830 $186.00 D8030 $718.00D7291 $77.00 D7840 $1,764.00 D8040 $583.00



Dental DentalD-Code MRA D-Code MRAD8050 $676.00 D9972 $113.00D8060 $758.00 D9973 $40.00D8070 $1,867.00 D9974 $50.00D8080 $1,867.00 D9999 BRD8090 $1,949.00D8210 $155.00D8220 $179.00D8660 $73.00D8670 $54.00D8680 $171.00D8690 $71.00D8691 $67.00D8692 $104.00D8999 BRD9110 $40.00D9210 $14.00D9211 $14.00D9212 $13.00D9215 $7.00D9230 $18.00D9248 $91.00D9310 $41.00D9410 $61.00D9420 $46.00D9430 $23.00D9440 $41.00D9450 BRD9610 $20.00D9630 $10.00D9910 $21.00D9911 $21.00D9920 $32.00D9930 $34.00D9940 $204.00D9941 $58.00D9950 $114.00D9951 $46.00D9952 $163.00D9970 $83.00D9971 $55.00D9972 $113.00D9973 $40.00D9974 $50.00D9999 BRD9941 $58.00D9950 $114.00D9951 $46.00D9952 $163.00D9970 $83.00D9971 $55.00


HCPCS © 2016 Part A, 160

Injections Injections InjectionsJ-Code MRA J-Code MRA J-Code MRAJ0120 $12.00 J0702 $4.00 J1438 BRJ0130 BR J0710 $3.00 J1450 BRJ0190 $3.00 J0713 $8.00 J1455 $12.00J0200 BR J0715 $6.00 J1460 $2.00J0205 $38.00 J0720 $6.00 J1560 BRJ0207 BR J0725 $3.00 J1570 $36.00J0210 $7.00 J0735 BR J1580 $3.00J0215 BR J0740 BR J1590 BRJ0256 $101.00 J0743 $14.00 J1595 BRJ0280 $1.00 J0744 BR J1600 $10.00J0282 BR J0745 $1.00 J1610 $27.00J0285 BR J0760 $3.00 J1620 $69.00J0287 BR J0770 $32.00 J1626 BRJ0288 BR J0780 $3.00 J1630 $4.00J0289 BR J0800 $18.00 J1631 $28.00J0290 $2.00 J0850 $362.00 J1642 $1.00J0295 $7.00 J0895 $10.00 J1644 $1.00J0300 $2.00 J0945 $1.00 J1645 BRJ0330 $1.00 J1000 $3.00 J1650 $16.00J0350 $2,408.00 J1020 $1.00 J1652 BRJ0360 $6.00 J1030 $2.00 J1655 BRJ0380 $1.00 J1040 $3.00 J1670 $23.00J0390 $3.00 J1094 BR J1700 $1.00J0395 BR J1100 $1.00 J1710 $5.00J0456 BR J1110 $10.00 J1720 $4.00J0470 $11.00 J1120 $35.00 J1730 $94.00J0475 $201.00 J1160 $2.00 J1742 BRJ0476 BR J1165 $1.00 J1745 BRJ0500 $3.00 J1170 $1.00 J1750 BRJ0515 $3.00 J1180 $1.00 J1756 BRJ0520 $5.00 J1190 BR J1790 $4.00J0583 BR J1200 $1.00 J1800 $10.00J0585 $393.00 J1205 $9.00 J1810 $6.00J0587 BR J1212 $36.00 J1815 BRJ0592 BR J1230 $1.00 J1817 BRJ0595 BR J1240 $1.00 J1830 $76.00J0600 $6.00 J1245 $31.00 J1835 BRJ0610 $1.00 J1250 $49.00 J1840 $7.00J0620 $3.00 J1260 BR J1850 $4.00J0630 $21.00 J1270 BR J1885 $7.00J0636 BR J1320 $1.00 J1890 $11.00J0637 BR J1325 BR J1940 $1.00J0640 $22.00 J1327 BR J1950 $411.00J0670 BR J1330 $2.00 J1955 $37.00J0690 $3.00 J1335 BR J1956 BRJ0692 BR J1364 $6.00 J1960 $2.00J0694 $10.00 J1380 $1.00 J1980 $3.00J0696 $11.00 J1410 $33.00 J1990 $8.00J0697 $6.00 J1435 $1.00 J2001 BRJ0698 $11.00 J1436 $68.00 J2010 $2.00


HCPCS © 2016 Part A, 161

Injections Injections InjectionsJ-Code MRA J-Code MRA J-Code MRAJ2020 BR J2790 $36.00 J3490 BRJ2060 $12.00 J2792 BR J3590 BRJ2150 $3.00 J2795 BR J7030 $11.00J2175 $1.00 J2800 $3.00 J7040 $10.00J2180 $3.00 J2810 $3.00 J7042 $10.00J2185 BR J2820 $115.00 J7050 $10.00J2210 $3.00 J2910 $11.00 J7060 $10.00J2250 $2.00 J2916 BR J7070 $11.00J2260 $32.00 J2920 $5.00 J7100 $137.00J2270 $1.00 J2930 $13.00 J7110 $93.00J2280 BR J2940 BR J7120 $12.00J2300 $2.00 J2941 BR J7190 $241.00J2310 $3.00 J2950 $1.00 J7191 BRJ2320 $5.00 J2993 BR J7192 $316.00J2353 BR J2995 BR J7193 BRJ2354 BR J2997 BR J7194 $120.00J2355 BR J3000 $2.00 J7195 BRJ2360 $2.00 J3010 $2.00 J7197 $284.00J2370 $3.00 J3030 $34.00 J7198 BRJ2400 BR J3070 $4.00 J7199 BRJ2405 $6.00 J3105 $2.00 J7501 $98.00J2410 $3.00 J3230 $2.00 J7504 $282.00J2430 $189.00 J3240 $214.00 J7505 $576.00J2440 $2.00 J3250 $1.00 J7513 BRJ2460 $1.00 J3260 $7.00 J7516 BRJ2501 BR J3265 $2.00 J7599 BRJ2505 BR J3280 $5.00 J7194 $120.00J2510 $1.00 J3301 $1.00 J7195 BRJ2515 $1.00 J3302 $1.00 J7197 $284.00J2540 $1.00 J3303 $1.00 J7198 BRJ2543 BR J3305 $55.00 J7199 BRJ2545 $105.00 J3310 $5.00 J7501 $98.00J2550 $1.00 J3320 $16.00 J7504 $282.00J2560 $5.00 J3350 $72.00 J7505 $576.00J2590 $1.00 J3360 $1.00 J7513 BRJ2597 $20.00 J3364 $52.00 J7516 BRJ2650 $1.00 J3365 $433.00 J7599 BRJ2670 BR J3370 $9.00J2680 $16.00 J3400 $12.00J2690 $7.00 J3410 $1.00J2700 $2.00 J3411 BRJ2710 $1.00 J3415 BRJ2720 $1.00 J3420 $1.00J2725 $11.00 J3430 $2.00J2730 $29.00 J3465 BRJ2760 $29.00 J3470 $7.00J2765 $2.00 J3475 $1.00J2770 BR J3480 $1.00J2780 BR J3485 BRJ2783 BR J3486 BR

20165 Edition



PART B


ALLOWANCES

Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2016 EditionRULE- 69L-7.020, F.A.C., Effective __________

CPT only © 2015 American Medical Association. All rights reserved. Part B, 163

Surgery

CPT Code FUD 2003 MRA Locality 01/02 (Non-Facility MRA)

Locality 03 (Non-Facility MRA)


Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)


10021 0 $90.00 $174.00 $184.00 $191.00 $102.00 $107.00 $114.0010022 0 $92.00 $197.00 $209.00 $215.00 $95.00 $100.00 $105.0010030 0 -------- $1,084.00 $1,163.00 $1,193.00 $253.00 $271.00 $298.0010035 0 -------- $737.00 $787.00 $796.00 $127.00 $132.00 $139.0010036 ZZZ -------- $639.00 $683.00 $689.00 $64.00 $67.00 $70.0010040 10 $54.00 $144.00 $153.00 $160.00 $126.00 $134.00 $140.0010060 10 $53.00 $165.00 $174.00 $179.00 $138.00 $145.00 $150.0010061 10 $133.00 $292.00 $309.00 $321.00 $257.00 $271.00 $283.0010080 10 $65.00 $250.00 $267.00 $274.00 $147.00 $156.00 $163.0010081 10 $203.00 $377.00 $401.00 $415.00 $245.00 $259.00 $273.0010120 10 $53.00 $212.00 $225.00 $231.00 $147.00 $155.00 $161.0010121 10 $169.00 $387.00 $411.00 $427.00 $268.00 $284.00 $300.0010140 10 $53.00 $229.00 $243.00 $251.00 $169.00 $179.00 $187.0010160 10 $45.00 $183.00 $194.00 $201.00 $137.00 $145.00 $151.0010180 10 $164.00 $351.00 $376.00 $396.00 $260.00 $279.00 $298.0011000 0 $45.00 $76.00 $80.00 $82.00 $42.00 $43.00 $45.0011001 ZZZ $27.00 $30.00 $32.00 $33.00 $21.00 $22.00 $23.0011004 0 -------- $864.00 $919.00 $998.00 $864.00 $919.00 $998.0011005 0 -------- $1,178.00 $1,261.00 $1,387.00 $1,178.00 $1,261.00 $1,387.0011006 0 -------- $1,050.00 $1,117.00 $1,216.00 $1,050.00 $1,117.00 $1,216.0011008 ZZZ -------- $414.00 $444.00 $489.00 $414.00 $444.00 $489.0011010 10 $348.00 $695.00 $742.00 $773.00 $409.00 $435.00 $465.0011011 0 $432.00 $759.00 $812.00 $851.00 $442.00 $471.00 $510.0011012 0 $597.00 $1,017.00 $1,087.00 $1,144.00 $631.00 $674.00 $729.0011042 0 $88.00 $163.00 $173.00 $178.00 $89.00 $94.00 $99.0011043 0 $210.00 $325.00 $345.00 $361.00 $228.00 $240.00 $256.0011044 0 $283.00 $451.00 $479.00 $505.00 $340.00 $360.00 $386.0011045 ZZZ -------- $58.00 $62.00 $64.00 $38.00 $40.00 $43.0011046 ZZZ -------- $106.00 $113.00 $120.00 $83.00 $88.00 $95.0011047 ZZZ -------- $180.00 $192.00 $205.00 $148.00 $157.00 $170.0011055 0 $26.00 $66.00 $69.00 $70.00 $23.00 $24.00 $25.0011056 0 $35.00 $80.00 $85.00 $86.00 $33.00 $34.00 $35.0011057 0 $39.00 $91.00 $96.00 $98.00 $43.00 $44.00 $46.0011100 0 $78.00 $144.00 $153.00 $158.00 $71.00 $75.00 $79.0011101 ZZZ $41.00 $47.00 $49.00 $52.00 $37.00 $39.00 $41.0011200 10 $66.00 $123.00 $131.00 $136.00 $104.00 $110.00 $115.0011201 ZZZ $26.00 $27.00 $29.00 $30.00 $24.00 $26.00 $27.0011300 0 $59.00 $134.00 $143.00 $147.00 $51.00 $54.00 $57.0011301 0 $80.00 $167.00 $177.00 $182.00 $78.00 $82.00 $87.0011302 0 $96.00 $196.00 $209.00 $215.00 $92.00 $97.00 $103.0011303 0 $119.00 $217.00 $231.00 $239.00 $109.00 $115.00 $122.0011305 0 $61.00 $138.00 $146.00 $149.00 $57.00 $60.00 $62.0011306 0 $86.00 $169.00 $180.00 $185.00 $76.00 $79.00 $84.0011307 0 $100.00 $200.00 $213.00 $219.00 $97.00 $102.00 $108.0011308 0 $125.00 $210.00 $223.00 $228.00 $107.00 $112.00 $118.0011310 0 $75.00 $158.00 $168.00 $172.00 $69.00 $73.00 $77.0011311 0 $95.00 $157.00 $166.00 $173.00 $96.00 $101.00 $108.0011312 0 $110.00 $224.00 $238.00 $246.00 $114.00 $121.00 $128.0011313 0 $144.00 $260.00 $277.00 $287.00 $147.00 $155.00 $165.0011400 10 $81.00 $173.00 $184.00 $189.00 $114.00 $121.00 $127.00



Surgery







11401 10 $114.00 $209.00 $222.00 $230.00 $148.00 $157.00 $165.0011402 10 $145.00 $232.00 $247.00 $257.00 $164.00 $174.00 $183.0011403 10 $178.00 $271.00 $289.00 $301.00 $212.00 $226.00 $239.0011404 10 $200.00 $308.00 $329.00 $344.00 $235.00 $250.00 $266.0011406 10 $246.00 $448.00 $479.00 $507.00 $360.00 $385.00 $413.0011420 10 $98.00 $171.00 $181.00 $186.00 $116.00 $123.00 $128.0011421 10 $92.00 $220.00 $233.00 $242.00 $158.00 $167.00 $175.0011422 10 $157.00 $246.00 $262.00 $272.00 $194.00 $206.00 $216.0011423 10 $163.00 $285.00 $304.00 $317.00 $227.00 $241.00 $254.0011424 10 $221.00 $331.00 $352.00 $369.00 $260.00 $277.00 $293.0011426 10 $303.00 $477.00 $509.00 $538.00 $401.00 $427.00 $457.0011440 10 $105.00 $188.00 $200.00 $205.00 $146.00 $155.00 $160.0011441 10 $102.00 $236.00 $251.00 $260.00 $188.00 $200.00 $209.0011442 10 $174.00 $265.00 $282.00 $293.00 $209.00 $222.00 $233.0011443 10 $221.00 $317.00 $337.00 $353.00 $257.00 $273.00 $288.0011444 10 $276.00 $400.00 $425.00 $446.00 $329.00 $349.00 $370.0011446 10 $344.00 $557.00 $592.00 $623.00 $473.00 $502.00 $533.0011450 90 $282.00 $539.00 $577.00 $606.00 $367.00 $392.00 $420.0011451 90 $366.00 $689.00 $737.00 $775.00 $474.00 $507.00 $544.0011462 90 $264.00 $525.00 $562.00 $587.00 $349.00 $373.00 $398.0011463 90 $351.00 $696.00 $744.00 $781.00 $475.00 $507.00 $543.0011470 90 $320.00 $585.00 $626.00 $657.00 $409.00 $437.00 $467.0011471 90 $391.00 $723.00 $771.00 $807.00 $508.00 $541.00 $576.0011600 10 $148.00 $269.00 $286.00 $296.00 $171.00 $182.00 $191.0011601 10 $180.00 $321.00 $342.00 $354.00 $215.00 $228.00 $240.0011602 10 $199.00 $348.00 $371.00 $385.00 $236.00 $250.00 $264.0011603 10 $226.00 $400.00 $425.00 $443.00 $284.00 $301.00 $318.0011604 10 $249.00 $445.00 $474.00 $495.00 $313.00 $333.00 $353.0011606 10 $315.00 $642.00 $685.00 $721.00 $470.00 $500.00 $536.0011620 10 $150.00 $272.00 $290.00 $300.00 $174.00 $185.00 $195.0011621 10 $191.00 $323.00 $344.00 $357.00 $217.00 $230.00 $243.0011622 10 $223.00 $361.00 $384.00 $399.00 $249.00 $264.00 $278.0011623 10 $259.00 $426.00 $453.00 $473.00 $309.00 $328.00 $348.0011624 10 $305.00 $481.00 $512.00 $536.00 $351.00 $372.00 $396.0011626 10 $373.00 $582.00 $620.00 $653.00 $432.00 $460.00 $492.0011640 10 $168.00 $281.00 $299.00 $309.00 $180.00 $191.00 $201.0011641 10 $227.00 $335.00 $356.00 $370.00 $226.00 $240.00 $253.0011642 10 $260.00 $383.00 $408.00 $424.00 $268.00 $284.00 $300.0011643 10 $305.00 $453.00 $482.00 $504.00 $336.00 $356.00 $377.0011644 10 $380.00 $560.00 $596.00 $624.00 $416.00 $441.00 $469.0011646 10 $494.00 $736.00 $783.00 $824.00 $580.00 $615.00 $656.0011719 0 $22.00 $19.00 $20.00 $21.00 $11.00 $11.00 $12.0011720 0 $32.00 $45.00 $47.00 $48.00 $21.00 $22.00 $23.0011721 0 $50.00 $63.00 $66.00 $68.00 $36.00 $37.00 $39.0011730 0 $62.00 $138.00 $146.00 $149.00 $74.00 $76.00 $80.0011732 ZZZ $31.00 $50.00 $53.00 $54.00 $29.00 $30.00 $31.0011740 0 $41.00 $69.00 $73.00 $74.00 $46.00 $48.00 $50.0011750 10 $156.00 $251.00 $266.00 $271.00 $198.00 $209.00 $214.0011752 10 $234.00 $457.00 $484.00 $500.00 $376.00 $396.00 $413.0011755 0 $106.00 $186.00 $197.00 $201.00 $112.00 $117.00 $121.00



Surgery







11760 10 $131.00 $271.00 $288.00 $297.00 $168.00 $177.00 $185.0011762 10 $223.00 $393.00 $415.00 $426.00 $264.00 $276.00 $287.0011765 10 $65.00 $232.00 $245.00 $249.00 $133.00 $140.00 $143.0011770 10 $275.00 $395.00 $423.00 $446.00 $271.00 $290.00 $313.0011771 90 $496.00 $821.00 $880.00 $935.00 $637.00 $682.00 $736.0011772 90 $585.00 $996.00 $1,066.00 $1,132.00 $840.00 $899.00 $964.0011900 0 $33.00 $78.00 $83.00 $86.00 $46.00 $48.00 $51.0011901 0 $37.00 $99.00 $105.00 $109.00 $70.00 $74.00 $79.0011920 0 $147.00 $239.00 $255.00 $265.00 $165.00 $175.00 $185.0011921 0 $172.00 $280.00 $298.00 $311.00 $195.00 $207.00 $220.0011922 ZZZ $40.00 $86.00 $92.00 $95.00 $43.00 $46.00 $49.0011950 0 $107.00 $103.00 $109.00 $111.00 $73.00 $77.00 $79.0011951 0 $114.00 $139.00 $148.00 $156.00 $105.00 $112.00 $120.0011952 0 $155.00 $186.00 $198.00 $208.00 $142.00 $150.00 $159.0011954 0 $165.00 $224.00 $239.00 $251.00 $168.00 $178.00 $190.0011960 90 $829.00 $1,359.00 $1,446.00 $1,523.00 $1,359.00 $1,446.00 $1,523.0011970 90 $632.00 $880.00 $936.00 $991.00 $880.00 $936.00 $991.0011971 90 $280.00 $657.00 $701.00 $725.00 $455.00 $485.00 $508.0011976 0 $123.00 $202.00 $213.00 $222.00 $137.00 $143.00 $152.0012001 0 $84.00 $125.00 $133.00 $137.00 $65.00 $68.00 $72.0012002 0 $98.00 $153.00 $162.00 $168.00 $85.00 $90.00 $96.0012004 0 $122.00 $181.00 $192.00 $200.00 $107.00 $113.00 $120.0012005 0 $165.00 $229.00 $243.00 $254.00 $140.00 $147.00 $158.0012006 0 $203.00 $272.00 $288.00 $302.00 $172.00 $181.00 $195.0012007 0 $339.00 $319.00 $339.00 $357.00 $217.00 $230.00 $248.0012011 0 $98.00 $154.00 $163.00 $169.00 $81.00 $85.00 $91.0012013 0 $141.00 $161.00 $171.00 $178.00 $85.00 $90.00 $96.0012014 0 $165.00 $189.00 $200.00 $209.00 $110.00 $116.00 $124.0012015 0 $207.00 $229.00 $243.00 $254.00 $138.00 $146.00 $156.0012016 0 $268.00 $292.00 $310.00 $325.00 $189.00 $199.00 $215.0012017 0 $316.00 $228.00 $240.00 $260.00 $228.00 $240.00 $260.0012018 0 $515.00 $258.00 $272.00 $295.00 $258.00 $272.00 $295.0012020 10 $211.00 $411.00 $440.00 $462.00 $284.00 $303.00 $325.0012021 10 $87.00 $238.00 $254.00 $268.00 $205.00 $218.00 $231.0012031 10 $93.00 $332.00 $354.00 $366.00 $221.00 $234.00 $247.0012032 10 $110.00 $425.00 $452.00 $468.00 $281.00 $298.00 $314.0012034 10 $148.00 $439.00 $467.00 $487.00 $300.00 $319.00 $338.0012035 10 $223.00 $539.00 $575.00 $599.00 $350.00 $372.00 $396.0012036 10 $356.00 $598.00 $638.00 $669.00 $409.00 $435.00 $466.0012037 10 $411.00 $679.00 $724.00 $761.00 $479.00 $510.00 $546.0012041 10 $116.00 $332.00 $353.00 $366.00 $218.00 $231.00 $243.0012042 10 $141.00 $407.00 $433.00 $450.00 $290.00 $308.00 $324.0012044 10 $176.00 $504.00 $536.00 $556.00 $312.00 $330.00 $349.0012045 10 $250.00 $568.00 $605.00 $629.00 $392.00 $416.00 $440.0012046 10 $341.00 $680.00 $729.00 $769.00 $456.00 $489.00 $529.0012047 10 $363.00 $737.00 $788.00 $829.00 $506.00 $541.00 $581.0012051 10 $126.00 $363.00 $386.00 $401.00 $248.00 $263.00 $278.0012052 10 $148.00 $414.00 $441.00 $458.00 $295.00 $313.00 $330.0012053 10 $223.00 $485.00 $516.00 $536.00 $316.00 $335.00 $354.0012054 10 $301.00 $508.00 $540.00 $562.00 $324.00 $343.00 $364.00



Surgery







12055 10 $380.00 $660.00 $702.00 $731.00 $446.00 $472.00 $501.0012056 10 $487.00 $772.00 $822.00 $858.00 $549.00 $583.00 $618.0012057 10 $539.00 $801.00 $856.00 $902.00 $596.00 $635.00 $680.0013100 10 $178.00 $470.00 $500.00 $519.00 $300.00 $317.00 $336.0013101 10 $240.00 $556.00 $592.00 $614.00 $368.00 $390.00 $412.0013102 ZZZ $89.00 $172.00 $184.00 $193.00 $110.00 $117.00 $125.0013120 10 $223.00 $492.00 $524.00 $544.00 $343.00 $363.00 $383.0013121 10 $348.00 $601.00 $640.00 $664.00 $390.00 $413.00 $437.0013122 ZZZ $104.00 $189.00 $201.00 $211.00 $126.00 $134.00 $143.0013131 10 $252.00 $542.00 $577.00 $600.00 $364.00 $385.00 $408.0013132 10 $484.00 $672.00 $715.00 $744.00 $459.00 $486.00 $515.0013133 ZZZ $154.00 $255.00 $271.00 $284.00 $193.00 $204.00 $217.0013151 10 $375.00 $596.00 $634.00 $660.00 $419.00 $444.00 $470.0013152 10 $542.00 $717.00 $763.00 $796.00 $509.00 $539.00 $571.0013153 ZZZ $169.00 $277.00 $294.00 $309.00 $208.00 $221.00 $236.0013160 90 $655.00 $1,179.00 $1,255.00 $1,342.00 $1,179.00 $1,255.00 $1,342.0014000 90 $512.00 $882.00 $940.00 $985.00 $727.00 $774.00 $818.0014001 90 $695.00 $1,140.00 $1,215.00 $1,278.00 $950.00 $1,012.00 $1,074.0014020 90 $590.00 $987.00 $1,050.00 $1,097.00 $821.00 $872.00 $919.0014021 90 $818.00 $1,238.00 $1,316.00 $1,379.00 $1,041.00 $1,105.00 $1,167.0014040 90 $701.00 $1,082.00 $1,149.00 $1,202.00 $915.00 $970.00 $1,022.0014041 90 $936.00 $1,341.00 $1,425.00 $1,491.00 $1,128.00 $1,196.00 $1,261.0014060 90 $766.00 $1,106.00 $1,174.00 $1,229.00 $975.00 $1,033.00 $1,088.0014061 90 $1,330.00 $1,442.00 $1,532.00 $1,602.00 $1,207.00 $1,279.00 $1,349.0014301 90 -------- $1,538.00 $1,636.00 $1,719.00 $1,285.00 $1,364.00 $1,447.0014302 ZZZ -------- $327.00 $347.00 $373.00 $327.00 $347.00 $373.0014350 90 $734.00 $1,004.00 $1,056.00 $1,105.00 $1,004.00 $1,056.00 $1,105.0015002 0 -------- $494.00 $526.00 $552.00 $333.00 $354.00 $379.0015003 ZZZ -------- $108.00 $115.00 $121.00 $68.00 $72.00 $78.0015004 0 -------- $569.00 $603.00 $629.00 $395.00 $417.00 $442.0015005 ZZZ -------- $179.00 $191.00 $202.00 $135.00 $143.00 $155.0015040 0 -------- $361.00 $386.00 $402.00 $189.00 $201.00 $216.0015050 90 $349.00 $797.00 $848.00 $884.00 $641.00 $681.00 $716.0015100 90 $679.00 $1,230.00 $1,313.00 $1,389.00 $1,044.00 $1,113.00 $1,188.0015101 ZZZ $146.00 $264.00 $283.00 $297.00 $164.00 $176.00 $190.0015110 90 -------- $1,154.00 $1,225.00 $1,294.00 $1,016.00 $1,076.00 $1,145.0015111 ZZZ -------- $171.00 $183.00 $199.00 $156.00 $167.00 $183.0015115 90 -------- $1,182.00 $1,252.00 $1,318.00 $1,042.00 $1,102.00 $1,167.0015116 ZZZ -------- $227.00 $244.00 $267.00 $207.00 $222.00 $245.0015120 90 $788.00 $1,218.00 $1,296.00 $1,364.00 $1,018.00 $1,081.00 $1,149.0015121 ZZZ $235.00 $296.00 $317.00 $332.00 $195.00 $208.00 $223.0015130 90 -------- $963.00 $1,027.00 $1,084.00 $821.00 $875.00 $931.0015131 ZZZ -------- $145.00 $154.00 $164.00 $134.00 $142.00 $152.0015135 90 -------- $1,208.00 $1,280.00 $1,342.00 $1,069.00 $1,130.00 $1,193.0015136 ZZZ -------- $138.00 $146.00 $155.00 $130.00 $137.00 $147.0015150 90 -------- $1,019.00 $1,092.00 $1,180.00 $939.00 $1,007.00 $1,094.0015151 ZZZ -------- $181.00 $194.00 $212.00 $169.00 $181.00 $199.0015152 ZZZ -------- $223.00 $239.00 $261.00 $210.00 $225.00 $247.0015155 90 -------- $1,038.00 $1,098.00 $1,154.00 $965.00 $1,020.00 $1,076.0015156 ZZZ -------- $234.00 $250.00 $272.00 $223.00 $238.00 $260.00



Surgery







15157 ZZZ -------- $254.00 $268.00 $284.00 $238.00 $251.00 $268.0015200 90 $644.00 $1,184.00 $1,261.00 $1,325.00 $976.00 $1,038.00 $1,102.0015201 ZZZ $126.00 $209.00 $223.00 $233.00 $116.00 $123.00 $133.0015220 90 $687.00 $1,093.00 $1,164.00 $1,217.00 $890.00 $946.00 $999.0015221 ZZZ $114.00 $193.00 $206.00 $214.00 $105.00 $112.00 $120.0015240 90 $763.00 $1,328.00 $1,412.00 $1,480.00 $1,159.00 $1,231.00 $1,297.0015241 ZZZ $334.00 $262.00 $279.00 $291.00 $164.00 $174.00 $186.0015260 90 $841.00 $1,440.00 $1,528.00 $1,597.00 $1,243.00 $1,317.00 $1,385.0015261 ZZZ $207.00 $306.00 $326.00 $340.00 $206.00 $218.00 $232.0015271 0 -------- $199.00 $211.00 $219.00 $124.00 $131.00 $139.0015272 ZZZ -------- $39.00 $41.00 $43.00 $26.00 $27.00 $29.0015273 0 -------- $426.00 $454.00 $479.00 $299.00 $318.00 $343.0015274 ZZZ -------- $102.00 $109.00 $116.00 $69.00 $73.00 $80.0015275 0 -------- $210.00 $222.00 $229.00 $139.00 $145.00 $153.0015276 ZZZ -------- $49.00 $52.00 $54.00 $37.00 $38.00 $41.0015277 0 -------- $461.00 $490.00 $516.00 $332.00 $351.00 $377.0015278 ZZZ -------- $122.00 $130.00 $138.00 $85.00 $91.00 $98.0015570 90 $748.00 $1,304.00 $1,390.00 $1,465.00 $1,071.00 $1,140.00 $1,214.0015572 90 $721.00 $1,265.00 $1,347.00 $1,416.00 $1,082.00 $1,150.00 $1,219.0015574 90 $775.00 $1,304.00 $1,386.00 $1,455.00 $1,113.00 $1,182.00 $1,250.0015576 90 $457.00 $1,147.00 $1,218.00 $1,274.00 $971.00 $1,029.00 $1,084.0015600 90 $259.00 $449.00 $480.00 $494.00 $295.00 $314.00 $328.0015610 90 $320.00 $497.00 $530.00 $548.00 $345.00 $367.00 $385.0015620 90 $506.00 $618.00 $659.00 $683.00 $468.00 $498.00 $522.0015630 90 $362.00 $647.00 $689.00 $715.00 $498.00 $529.00 $555.0015650 90 $427.00 $711.00 $757.00 $788.00 $550.00 $585.00 $615.0015731 90 -------- $1,617.00 $1,716.00 $1,807.00 $1,464.00 $1,553.00 $1,642.0015732 90 $1,465.00 $1,837.00 $1,945.00 $2,035.00 $1,616.00 $1,709.00 $1,798.0015734 90 $1,557.00 $2,179.00 $2,325.00 $2,482.00 $1,937.00 $2,066.00 $2,222.0015736 90 $1,862.00 $1,904.00 $2,028.00 $2,151.00 $1,666.00 $1,773.00 $1,896.0015738 90 $1,415.00 $2,029.00 $2,161.00 $2,299.00 $1,806.00 $1,922.00 $2,060.0015740 90 $913.00 $1,452.00 $1,543.00 $1,616.00 $1,238.00 $1,313.00 $1,386.0015750 90 $1,064.00 $1,336.00 $1,420.00 $1,510.00 $1,336.00 $1,420.00 $1,510.0015756 90 $2,892.00 $3,408.00 $3,614.00 $3,854.00 $3,408.00 $3,614.00 $3,854.0015757 90 $2,892.00 $3,365.00 $3,564.00 $3,794.00 $3,365.00 $3,564.00 $3,794.0015758 90 $2,884.00 $3,371.00 $3,572.00 $3,806.00 $3,371.00 $3,572.00 $3,806.0015760 90 $810.00 $1,215.00 $1,290.00 $1,349.00 $1,026.00 $1,088.00 $1,146.0015770 90 $674.00 $972.00 $1,033.00 $1,092.00 $972.00 $1,033.00 $1,092.0015775 0 $327.00 $429.00 $455.00 $476.00 $326.00 $344.00 $365.0015776 0 $475.00 $706.00 $751.00 $788.00 $521.00 $553.00 $589.0015777 ZZZ -------- $316.00 $336.00 $363.00 $316.00 $336.00 $363.0015780 90 $532.00 $1,189.00 $1,262.00 $1,310.00 $912.00 $964.00 $1,011.0015781 90 $420.00 $784.00 $835.00 $870.00 $624.00 $664.00 $697.0015782 90 $314.00 $889.00 $948.00 $976.00 $636.00 $677.00 $704.0015783 90 $340.00 $658.00 $700.00 $727.00 $518.00 $550.00 $577.0015786 10 $146.00 $342.00 $363.00 $373.00 $196.00 $206.00 $216.0015787 ZZZ $27.00 $68.00 $72.00 $74.00 $25.00 $26.00 $28.0015788 90 $194.00 $638.00 $681.00 $695.00 $350.00 $372.00 $385.0015789 90 $360.00 $774.00 $825.00 $857.00 $595.00 $632.00 $664.0015792 90 $130.00 $614.00 $657.00 $671.00 $372.00 $397.00 $410.00



Surgery







15793 90 $232.00 $692.00 $737.00 $762.00 $525.00 $558.00 $582.0015819 90 $780.00 $1,066.00 $1,130.00 $1,195.00 $1,066.00 $1,130.00 $1,195.0015820 90 $556.00 $789.00 $832.00 $853.00 $715.00 $752.00 $774.0015821 90 $607.00 $852.00 $899.00 $926.00 $770.00 $810.00 $836.0015822 90 $499.00 $625.00 $661.00 $681.00 $552.00 $583.00 $602.0015823 90 $718.00 $851.00 $897.00 $920.00 $767.00 $806.00 $829.0015824 0 NC BR BR BR BR BR BR15825 0 NC BR BR BR BR BR BR15826 0 NC BR BR BR BR BR BR15828 0 NC BR BR BR BR BR BR15829 0 NC BR BR BR BR BR BR15830 90 -------- $1,711.00 $1,822.00 $1,947.00 $1,711.00 $1,822.00 $1,947.0015832 90 $926.00 $1,333.00 $1,418.00 $1,507.00 $1,333.00 $1,418.00 $1,507.0015833 90 $833.00 $1,249.00 $1,328.00 $1,410.00 $1,249.00 $1,328.00 $1,410.0015834 90 $837.00 $1,286.00 $1,367.00 $1,449.00 $1,286.00 $1,367.00 $1,449.0015835 90 $865.00 $1,349.00 $1,435.00 $1,526.00 $1,349.00 $1,435.00 $1,526.0015836 90 $721.00 $1,108.00 $1,181.00 $1,261.00 $1,108.00 $1,181.00 $1,261.0015837 90 $696.00 $1,159.00 $1,238.00 $1,314.00 $981.00 $1,046.00 $1,122.0015838 90 $600.00 $830.00 $879.00 $927.00 $830.00 $879.00 $927.0015839 90 $643.00 $1,266.00 $1,348.00 $1,421.00 $1,073.00 $1,141.00 $1,213.0015840 90 $1,187.00 $1,465.00 $1,550.00 $1,638.00 $1,465.00 $1,550.00 $1,638.0015841 90 $1,859.00 $2,371.00 $2,517.00 $2,692.00 $2,371.00 $2,517.00 $2,692.0015842 90 $3,099.00 $3,851.00 $4,089.00 $4,365.00 $3,851.00 $4,089.00 $4,365.0015845 90 $1,116.00 $1,437.00 $1,510.00 $1,566.00 $1,437.00 $1,510.00 $1,566.0015850 0 $63.00 $125.00 $133.00 $137.00 $61.00 $64.00 $68.0015851 0 $40.00 $138.00 $146.00 $150.00 $66.00 $69.00 $73.0015852 0 $35.00 $69.00 $73.00 $79.00 $69.00 $73.00 $79.0015860 0 $151.00 $164.00 $174.00 $188.00 $164.00 $174.00 $188.0015876 0 NC BR BR BR BR BR BR15877 0 NC BR BR BR BR BR BR15878 0 NC BR BR BR BR BR BR15879 0 NC BR BR BR BR BR BR15920 90 $571.00 $883.00 $944.00 $1,014.00 $883.00 $944.00 $1,014.0015922 90 $771.00 $1,128.00 $1,200.00 $1,270.00 $1,128.00 $1,200.00 $1,270.0015931 90 $638.00 $1,010.00 $1,081.00 $1,169.00 $1,010.00 $1,081.00 $1,169.0015933 90 $860.00 $1,238.00 $1,322.00 $1,418.00 $1,238.00 $1,322.00 $1,418.0015934 90 $1,064.00 $1,360.00 $1,453.00 $1,566.00 $1,360.00 $1,453.00 $1,566.0015935 90 $1,184.00 $1,599.00 $1,706.00 $1,831.00 $1,599.00 $1,706.00 $1,831.0015936 90 $1,032.00 $1,305.00 $1,392.00 $1,495.00 $1,305.00 $1,392.00 $1,495.0015937 90 $1,223.00 $1,510.00 $1,610.00 $1,725.00 $1,510.00 $1,610.00 $1,725.0015940 90 $318.00 $1,026.00 $1,096.00 $1,180.00 $1,026.00 $1,096.00 $1,180.0015941 90 $919.00 $1,308.00 $1,394.00 $1,489.00 $1,308.00 $1,394.00 $1,489.0015944 90 $954.00 $1,289.00 $1,374.00 $1,468.00 $1,289.00 $1,374.00 $1,468.0015945 90 $1,078.00 $1,421.00 $1,513.00 $1,616.00 $1,421.00 $1,513.00 $1,616.0015946 90 $1,737.00 $2,388.00 $2,542.00 $2,718.00 $2,388.00 $2,542.00 $2,718.0015950 90 $549.00 $863.00 $922.00 $990.00 $863.00 $922.00 $990.0015951 90 $872.00 $1,269.00 $1,349.00 $1,428.00 $1,269.00 $1,349.00 $1,428.0015952 90 $876.00 $1,298.00 $1,379.00 $1,462.00 $1,298.00 $1,379.00 $1,462.0015953 90 $1,013.00 $1,439.00 $1,530.00 $1,622.00 $1,439.00 $1,530.00 $1,622.0015956 90 $1,382.00 $1,683.00 $1,794.00 $1,921.00 $1,683.00 $1,794.00 $1,921.00



Surgery







15958 90 $1,379.00 $1,708.00 $1,819.00 $1,944.00 $1,708.00 $1,819.00 $1,944.0015999 YYY BR -------- -------- -------- -------- -------- --------16000 0 $53.00 $98.00 $103.00 $108.00 $67.00 $71.00 $75.0016020 0 $49.00 $114.00 $121.00 $125.00 $78.00 $82.00 $86.0016025 0 $67.00 $209.00 $222.00 $232.00 $161.00 $171.00 $181.0016030 0 $153.00 $264.00 $281.00 $294.00 $195.00 $207.00 $220.0016035 0 $341.00 $287.00 $302.00 $322.00 $287.00 $302.00 $322.0016036 ZZZ $81.00 $120.00 $127.00 $137.00 $120.00 $127.00 $137.0017000 10 $60.00 $94.00 $100.00 $103.00 $76.00 $81.00 $84.0017003 ZZZ $16.00 $8.00 $9.00 $9.00 $4.00 $4.00 $4.0017004 10 $233.00 $211.00 $224.00 $232.00 $144.00 $152.00 $160.0017106 90 $341.00 $482.00 $512.00 $533.00 $397.00 $420.00 $441.0017107 90 $648.00 $614.00 $652.00 $679.00 $500.00 $529.00 $556.0017108 90 $1,015.00 $909.00 $965.00 $1,011.00 $761.00 $807.00 $852.0017110 10 $55.00 $154.00 $164.00 $167.00 $99.00 $105.00 $108.0017111 10 $83.00 $183.00 $195.00 $200.00 $122.00 $129.00 $135.0017250 0 $27.00 $110.00 $117.00 $120.00 $53.00 $56.00 $59.0017260 10 $96.00 $133.00 $142.00 $147.00 $101.00 $107.00 $113.0017261 10 $117.00 $201.00 $214.00 $221.00 $132.00 $140.00 $147.0017262 10 $150.00 $246.00 $261.00 $271.00 $168.00 $178.00 $188.0017263 10 $172.00 $269.00 $286.00 $297.00 $187.00 $198.00 $209.0017264 10 $189.00 $288.00 $306.00 $318.00 $200.00 $211.00 $223.0017266 10 $225.00 $327.00 $348.00 $362.00 $234.00 $247.00 $261.0017270 10 $125.00 $211.00 $225.00 $233.00 $144.00 $152.00 $160.0017271 10 $143.00 $229.00 $243.00 $252.00 $160.00 $169.00 $178.0017272 10 $170.00 $262.00 $279.00 $290.00 $186.00 $197.00 $207.0017273 10 $195.00 $293.00 $311.00 $323.00 $209.00 $221.00 $233.0017274 10 $240.00 $346.00 $368.00 $383.00 $256.00 $271.00 $286.0017276 10 $281.00 $402.00 $427.00 $445.00 $308.00 $325.00 $344.0017280 10 $123.00 $197.00 $210.00 $217.00 $131.00 $139.00 $146.0017281 10 $165.00 $250.00 $266.00 $277.00 $180.00 $191.00 $201.0017282 10 $194.00 $288.00 $306.00 $319.00 $209.00 $221.00 $234.0017283 10 $239.00 $346.00 $367.00 $383.00 $261.00 $276.00 $292.0017284 10 $282.00 $396.00 $420.00 $438.00 $305.00 $322.00 $341.0017286 10 $373.00 $510.00 $541.00 $568.00 $410.00 $434.00 $460.0017311 0 -------- $930.00 $989.00 $1,028.00 $554.00 $586.00 $623.0017312 ZZZ -------- $545.00 $580.00 $601.00 $295.00 $312.00 $331.0017313 0 -------- $868.00 $924.00 $958.00 $497.00 $525.00 $559.0017314 ZZZ -------- $522.00 $556.00 $575.00 $273.00 $289.00 $307.0017315 ZZZ -------- $113.00 $120.00 $125.00 $78.00 $82.00 $87.0017340 10 $37.00 $73.00 $77.00 $81.00 $71.00 $74.00 $78.0017360 10 $96.00 $182.00 $193.00 $202.00 $142.00 $151.00 $159.0017380 0 NC BR BR BR BR BR BR17999 YYY BR -------- -------- -------- -------- -------- --------19000 0 $74.00 $158.00 $168.00 $173.00 $64.00 $68.00 $72.0019001 ZZZ $40.00 $39.00 $41.00 $43.00 $32.00 $34.00 $36.0019020 90 $288.00 $669.00 $717.00 $751.00 $445.00 $477.00 $511.0019030 0 $98.00 $231.00 $245.00 $251.00 $113.00 $118.00 $124.0019081 0 -------- $962.00 $1,026.00 $1,043.00 $249.00 $261.00 $277.0019082 ZZZ -------- $790.00 $845.00 $854.00 $125.00 $131.00 $138.00



Surgery







19083 0 -------- $929.00 $991.00 $1,006.00 $233.00 $244.00 $257.0019084 ZZZ -------- $760.00 $812.00 $821.00 $117.00 $122.00 $129.0019085 0 -------- $1,422.00 $1,519.00 $1,538.00 $274.00 $287.00 $302.0019086 ZZZ -------- $1,122.00 $1,200.00 $1,210.00 $135.00 $141.00 $148.0019100 0 $117.00 $214.00 $229.00 $241.00 $105.00 $112.00 $124.0019101 10 $338.00 $487.00 $522.00 $551.00 $326.00 $349.00 $379.0019105 0 -------- $2,937.00 $3,143.00 $3,167.00 $284.00 $297.00 $312.0019110 90 $406.00 $692.00 $742.00 $784.00 $500.00 $536.00 $578.0019112 90 $354.00 $648.00 $695.00 $732.00 $453.00 $486.00 $523.0019120 90 $429.00 $716.00 $768.00 $823.00 $609.00 $653.00 $708.0019125 90 $468.00 $795.00 $853.00 $917.00 $678.00 $728.00 $791.0019126 ZZZ $201.00 $244.00 $261.00 $289.00 $244.00 $261.00 $289.0019260 90 $1,101.00 $1,779.00 $1,907.00 $2,070.00 $1,779.00 $1,907.00 $2,070.0019271 90 $1,561.00 $2,396.00 $2,568.00 $2,772.00 $2,396.00 $2,568.00 $2,772.0019272 90 $1,674.00 $2,623.00 $2,810.00 $3,037.00 $2,623.00 $2,810.00 $3,037.0019281 0 -------- $334.00 $354.00 $362.00 $148.00 $154.00 $162.0019282 ZZZ -------- $233.00 $248.00 $252.00 $75.00 $78.00 $82.0019283 0 -------- $376.00 $399.00 $408.00 $150.00 $157.00 $165.0019284 ZZZ -------- $282.00 $301.00 $306.00 $76.00 $80.00 $84.0019285 0 -------- $710.00 $758.00 $767.00 $127.00 $132.00 $139.0019286 ZZZ -------- $621.00 $665.00 $670.00 $64.00 $67.00 $70.0019287 0 -------- $1,186.00 $1,267.00 $1,280.00 $190.00 $198.00 $208.0019288 ZZZ -------- $953.00 $1,019.00 $1,027.00 $95.00 $98.00 $103.0019296 0 -------- $5,420.00 $5,815.00 $5,864.00 $316.00 $338.00 $371.0019297 ZZZ -------- $143.00 $153.00 $169.00 $143.00 $153.00 $169.0019298 0 -------- $1,465.00 $1,562.00 $1,598.00 $481.00 $506.00 $539.0019300 90 -------- $750.00 $804.00 $852.00 $603.00 $646.00 $694.0019301 90 -------- $968.00 $1,039.00 $1,133.00 $968.00 $1,039.00 $1,133.0019302 90 -------- $1,335.00 $1,432.00 $1,564.00 $1,335.00 $1,432.00 $1,564.0019303 90 -------- $1,501.00 $1,610.00 $1,758.00 $1,501.00 $1,610.00 $1,758.0019304 90 -------- $844.00 $905.00 $978.00 $844.00 $905.00 $978.0019305 90 -------- $1,672.00 $1,793.00 $1,954.00 $1,672.00 $1,793.00 $1,954.0019306 90 -------- $1,778.00 $1,909.00 $2,081.00 $1,778.00 $1,909.00 $2,081.0019307 90 -------- $1,774.00 $1,903.00 $2,074.00 $1,774.00 $1,903.00 $2,074.0019316 90 $954.00 $1,121.00 $1,193.00 $1,273.00 $1,121.00 $1,193.00 $1,273.0019318 90 $1,313.00 $1,603.00 $1,703.00 $1,811.00 $1,603.00 $1,703.00 $1,811.0019324 90 $440.00 $720.00 $772.00 $836.00 $720.00 $772.00 $836.0019325 90 $656.00 $926.00 $984.00 $1,040.00 $926.00 $984.00 $1,040.0019328 90 $457.00 $717.00 $763.00 $809.00 $717.00 $763.00 $809.0019330 90 $569.00 $919.00 $978.00 $1,038.00 $919.00 $978.00 $1,038.0019340 90 $545.00 $1,456.00 $1,548.00 $1,644.00 $1,456.00 $1,548.00 $1,644.0019342 90 $963.00 $1,336.00 $1,420.00 $1,504.00 $1,336.00 $1,420.00 $1,504.0019350 90 $853.00 $1,175.00 $1,252.00 $1,315.00 $975.00 $1,037.00 $1,100.0019355 90 $755.00 $1,022.00 $1,097.00 $1,179.00 $847.00 $909.00 $991.0019357 90 $1,449.00 $2,170.00 $2,309.00 $2,436.00 $2,170.00 $2,309.00 $2,436.0019361 90 $1,667.00 $2,295.00 $2,438.00 $2,596.00 $2,295.00 $2,438.00 $2,596.0019364 90 $2,737.00 $4,028.00 $4,278.00 $4,566.00 $4,028.00 $4,278.00 $4,566.0019366 90 $1,676.00 $2,065.00 $2,198.00 $2,360.00 $2,065.00 $2,198.00 $2,360.0019367 90 $2,056.00 $2,611.00 $2,773.00 $2,954.00 $2,611.00 $2,773.00 $2,954.0019368 90 $2,444.00 $3,218.00 $3,417.00 $3,645.00 $3,218.00 $3,417.00 $3,645.00



Surgery







19369 90 $2,317.00 $2,991.00 $3,178.00 $3,395.00 $2,991.00 $3,178.00 $3,395.0019370 90 $662.00 $993.00 $1,056.00 $1,119.00 $993.00 $1,056.00 $1,119.0019371 90 $788.00 $1,136.00 $1,208.00 $1,281.00 $1,136.00 $1,208.00 $1,281.0019380 90 $780.00 $1,119.00 $1,190.00 $1,262.00 $1,119.00 $1,190.00 $1,262.0019396 0 $231.00 $390.00 $416.00 $430.00 $205.00 $217.00 $231.0019499 YYY BR -------- -------- -------- -------- -------- --------20005 10 $267.00 $442.00 $470.00 $493.00 $341.00 $361.00 $384.0020100 10 $727.00 $903.00 $964.00 $1,048.00 $903.00 $964.00 $1,048.0020101 10 $261.00 $636.00 $682.00 $713.00 $310.00 $332.00 $363.0020102 10 $314.00 $698.00 $748.00 $785.00 $380.00 $407.00 $443.0020103 10 $405.00 $825.00 $880.00 $918.00 $510.00 $542.00 $579.0020150 90 $1,141.00 $1,320.00 $1,397.00 $1,487.00 $1,320.00 $1,397.00 $1,487.0020200 0 $134.00 $293.00 $315.00 $330.00 $142.00 $153.00 $168.0020205 0 $243.00 $413.00 $444.00 $470.00 $233.00 $251.00 $276.0020206 0 $119.00 $327.00 $349.00 $354.00 $86.00 $90.00 $94.0020220 0 $128.00 $236.00 $250.00 $255.00 $106.00 $111.00 $115.0020225 0 $215.00 $728.00 $777.00 $786.00 $158.00 $166.00 $173.0020240 0 $279.00 $226.00 $239.00 $254.00 $226.00 $239.00 $254.0020245 10 $364.00 $763.00 $810.00 $869.00 $763.00 $810.00 $869.0020250 10 $447.00 $578.00 $622.00 $678.00 $578.00 $622.00 $678.0020251 10 $511.00 $628.00 $676.00 $736.00 $628.00 $676.00 $736.0020500 10 $59.00 $147.00 $155.00 $160.00 $121.00 $127.00 $132.0020501 0 $60.00 $164.00 $175.00 $178.00 $56.00 $58.00 $61.0020520 10 $75.00 $287.00 $305.00 $316.00 $210.00 $223.00 $234.0020525 10 $331.00 $676.00 $722.00 $748.00 $363.00 $386.00 $412.0020526 0 $64.00 $110.00 $117.00 $124.00 $84.00 $89.00 $96.0020527 0 -------- $120.00 $128.00 $135.00 $97.00 $103.00 $110.0020550 0 $40.00 $83.00 $88.00 $92.00 $61.00 $64.00 $67.0020551 0 $62.00 $85.00 $90.00 $93.00 $62.00 $65.00 $68.0020552 0 $62.00 $78.00 $82.00 $85.00 $55.00 $58.00 $60.0020553 0 $62.00 $90.00 $95.00 $98.00 $63.00 $66.00 $69.0020555 0 -------- $480.00 $506.00 $538.00 $480.00 $506.00 $538.0020600 0 $41.00 $68.00 $71.00 $74.00 $52.00 $54.00 $57.0020604 0 -------- $102.00 $108.00 $112.00 $67.00 $70.00 $74.0020605 0 $48.00 $71.00 $75.00 $78.00 $54.00 $57.00 $60.0020606 0 -------- $113.00 $120.00 $125.00 $77.00 $81.00 $85.0020610 0 $49.00 $86.00 $91.00 $96.00 $67.00 $71.00 $76.0020611 0 -------- $130.00 $138.00 $144.00 $90.00 $95.00 $102.0020612 0 $56.00 $86.00 $91.00 $94.00 $61.00 $64.00 $68.0020615 10 $94.00 $345.00 $366.00 $378.00 $236.00 $249.00 $261.0020650 10 $170.00 $294.00 $312.00 $324.00 $226.00 $239.00 $251.0020660 0 $320.00 $374.00 $406.00 $455.00 $374.00 $406.00 $455.0020661 90 $476.00 $746.00 $810.00 $883.00 $746.00 $810.00 $883.0020662 90 $559.00 $617.00 $645.00 $662.00 $617.00 $645.00 $662.0020663 90 $465.00 $680.00 $727.00 $774.00 $680.00 $727.00 $774.0020665 10 $105.00 $149.00 $156.00 $160.00 $129.00 $135.00 $139.0020670 10 $80.00 $527.00 $563.00 $576.00 $212.00 $225.00 $236.0020680 90 $332.00 $879.00 $937.00 $979.00 $616.00 $655.00 $695.0020690 90 $298.00 $871.00 $928.00 $996.00 $871.00 $928.00 $996.0020692 90 $516.00 $1,632.00 $1,734.00 $1,847.00 $1,632.00 $1,734.00 $1,847.00



Surgery







20693 90 $477.00 $647.00 $687.00 $727.00 $647.00 $687.00 $727.0020694 90 $421.00 $607.00 $648.00 $680.00 $490.00 $523.00 $554.0020696 90 -------- $1,762.00 $1,877.00 $2,009.00 $1,762.00 $1,877.00 $2,009.0020697 0 -------- $2,707.00 $2,905.00 $2,914.00 $2,707.00 $2,905.00 $2,914.0020802 90 $3,363.00 $3,523.00 $3,712.00 $3,942.00 $3,523.00 $3,712.00 $3,942.0020805 90 $4,317.00 $4,866.00 $5,188.00 $5,588.00 $4,866.00 $5,188.00 $5,588.0020808 90 $5,324.00 $5,915.00 $6,296.00 $6,759.00 $5,915.00 $6,296.00 $6,759.0020816 90 $3,060.00 $3,053.00 $3,258.00 $3,514.00 $3,053.00 $3,258.00 $3,514.0020822 90 $2,511.00 $2,612.00 $2,771.00 $2,943.00 $2,612.00 $2,771.00 $2,943.0020824 90 $3,027.00 $3,001.00 $3,200.00 $3,450.00 $3,001.00 $3,200.00 $3,450.0020827 90 $3,920.00 $2,688.00 $2,868.00 $3,086.00 $2,688.00 $2,868.00 $3,086.0020838 90 $3,484.00 $3,558.00 $3,750.00 $3,981.00 $3,558.00 $3,750.00 $3,981.0020900 0 $454.00 $590.00 $630.00 $653.00 $280.00 $297.00 $319.0020902 0 $658.00 $422.00 $450.00 $484.00 $422.00 $450.00 $484.0020910 90 $338.00 $594.00 $629.00 $662.00 $594.00 $629.00 $662.0020912 90 $549.00 $696.00 $738.00 $778.00 $696.00 $738.00 $778.0020920 90 $460.00 $570.00 $604.00 $635.00 $570.00 $604.00 $635.0020922 90 $634.00 $881.00 $945.00 $1,009.00 $737.00 $790.00 $854.0020924 90 $583.00 $735.00 $783.00 $832.00 $735.00 $783.00 $832.0020926 90 $444.00 $626.00 $666.00 $708.00 $626.00 $666.00 $708.0020930 0 BR -------- -------- -------- -------- -------- --------20931 ZZZ $156.00 $173.00 $188.00 $212.00 $173.00 $188.00 $212.0020936 0 BR -------- -------- -------- -------- -------- --------20937 ZZZ $234.00 $254.00 $273.00 $302.00 $254.00 $273.00 $302.0020938 ZZZ $257.00 $282.00 $306.00 $342.00 $282.00 $306.00 $342.0020950 0 $123.00 $352.00 $377.00 $386.00 $133.00 $142.00 $151.0020955 90 $3,332.00 $3,682.00 $3,904.00 $4,163.00 $3,682.00 $3,904.00 $4,163.0020956 90 $3,167.00 $3,926.00 $4,193.00 $4,533.00 $3,926.00 $4,193.00 $4,533.0020957 90 $3,074.00 $3,591.00 $3,782.00 $4,002.00 $3,591.00 $3,782.00 $4,002.0020962 90 $3,122.00 $3,083.00 $3,221.00 $3,369.00 $3,083.00 $3,221.00 $3,369.0020969 90 $3,716.00 $4,067.00 $4,305.00 $4,584.00 $4,067.00 $4,305.00 $4,584.0020970 90 $3,650.00 $4,352.00 $4,672.00 $5,101.00 $4,352.00 $4,672.00 $5,101.0020972 90 $3,420.00 $3,451.00 $3,607.00 $3,779.00 $3,451.00 $3,607.00 $3,779.0020973 90 $3,821.00 $3,875.00 $4,083.00 $4,338.00 $3,875.00 $4,083.00 $4,338.0020974 0 $266.00 $109.00 $116.00 $122.00 $74.00 $79.00 $84.0020975 0 $334.00 $265.00 $284.00 $310.00 $265.00 $284.00 $310.0020979 0 $19.00 $74.00 $79.00 $82.00 $47.00 $50.00 $53.0020982 0 -------- $4,165.00 $4,455.00 $4,498.00 $560.00 $587.00 $620.0020983 0 -------- $9,971.00 $10,688.00 $10,760.00 $599.00 $634.00 $676.0020985 ZZZ -------- $219.00 $233.00 $253.00 $219.00 $233.00 $253.0020999 YYY BR -------- -------- -------- -------- -------- --------21010 90 $854.00 $1,081.00 $1,145.00 $1,210.00 $1,081.00 $1,145.00 $1,210.0021011 90 -------- $494.00 $528.00 $550.00 $374.00 $399.00 $421.0021012 90 -------- $494.00 $528.00 $564.00 $494.00 $528.00 $564.0021013 90 -------- $741.00 $790.00 $829.00 $583.00 $621.00 $659.0021014 90 -------- $760.00 $810.00 $863.00 $760.00 $810.00 $863.0021015 90 $520.00 $1,036.00 $1,103.00 $1,174.00 $1,036.00 $1,103.00 $1,174.0021016 90 -------- $1,499.00 $1,595.00 $1,705.00 $1,499.00 $1,595.00 $1,705.0021025 90 $546.00 $1,292.00 $1,375.00 $1,443.00 $1,102.00 $1,171.00 $1,238.0021026 90 $413.00 $885.00 $943.00 $981.00 $724.00 $770.00 $807.00



Surgery







21029 90 $700.00 $1,101.00 $1,171.00 $1,224.00 $926.00 $983.00 $1,035.0021030 90 $496.00 $747.00 $796.00 $830.00 $609.00 $648.00 $682.0021031 90 $310.00 $567.00 $604.00 $627.00 $430.00 $458.00 $480.0021032 90 $315.00 $576.00 $614.00 $638.00 $426.00 $454.00 $477.0021034 90 $1,140.00 $1,910.00 $2,027.00 $2,134.00 $1,697.00 $1,798.00 $1,904.0021040 90 $227.00 $752.00 $802.00 $835.00 $610.00 $649.00 $683.0021044 90 $957.00 $1,282.00 $1,358.00 $1,435.00 $1,282.00 $1,358.00 $1,435.0021045 90 $1,313.00 $1,800.00 $1,907.00 $2,020.00 $1,800.00 $1,907.00 $2,020.0021046 90 $899.00 $1,636.00 $1,740.00 $1,836.00 $1,636.00 $1,740.00 $1,836.0021047 90 $1,109.00 $1,944.00 $2,062.00 $2,192.00 $1,944.00 $2,062.00 $2,192.0021048 90 $925.00 $1,677.00 $1,784.00 $1,883.00 $1,677.00 $1,784.00 $1,883.0021049 90 $1,051.00 $1,780.00 $1,882.00 $1,994.00 $1,780.00 $1,882.00 $1,994.0021050 90 $1,026.00 $1,226.00 $1,300.00 $1,372.00 $1,226.00 $1,300.00 $1,372.0021060 90 $972.00 $1,161.00 $1,232.00 $1,300.00 $1,161.00 $1,232.00 $1,300.0021070 90 $679.00 $889.00 $941.00 $991.00 $889.00 $941.00 $991.0021073 90 -------- $554.00 $591.00 $615.00 $371.00 $394.00 $417.0021076 10 $1,192.00 $1,468.00 $1,561.00 $1,651.00 $1,244.00 $1,321.00 $1,411.0021077 90 $3,002.00 $3,682.00 $3,915.00 $4,142.00 $3,126.00 $3,318.00 $3,544.0021079 90 $2,086.00 $2,476.00 $2,633.00 $2,784.00 $2,080.00 $2,208.00 $2,358.0021080 90 $2,346.00 $2,778.00 $2,953.00 $3,119.00 $2,315.00 $2,456.00 $2,621.0021081 90 $2,138.00 $2,565.00 $2,728.00 $2,882.00 $2,130.00 $2,261.00 $2,414.0021082 90 $1,855.00 $2,421.00 $2,575.00 $2,717.00 $1,995.00 $2,119.00 $2,259.0021083 90 $1,802.00 $2,304.00 $2,451.00 $2,582.00 $1,851.00 $1,966.00 $2,096.0021084 90 $2,105.00 $2,650.00 $2,820.00 $2,973.00 $2,148.00 $2,281.00 $2,433.0021085 10 $801.00 $1,106.00 $1,177.00 $1,238.00 $842.00 $894.00 $954.0021086 90 $2,333.00 $2,738.00 $2,911.00 $3,080.00 $2,316.00 $2,459.00 $2,626.0021087 90 $2,217.00 $2,733.00 $2,907.00 $3,075.00 $2,311.00 $2,453.00 $2,620.0021088 90 BR -------- -------- -------- -------- -------- --------21089 YYY BR -------- -------- -------- -------- -------- --------21100 90 $297.00 $1,459.00 $1,571.00 $1,631.00 $731.00 $790.00 $848.0021110 90 $371.00 $1,151.00 $1,228.00 $1,271.00 $971.00 $1,036.00 $1,077.0021116 0 $207.00 $204.00 $217.00 $221.00 $65.00 $68.00 $72.0021120 90 $500.00 $939.00 $1,002.00 $1,037.00 $750.00 $800.00 $835.0021121 90 $651.00 $1,165.00 $1,242.00 $1,296.00 $981.00 $1,044.00 $1,098.0021122 90 $700.00 $953.00 $1,009.00 $1,057.00 $953.00 $1,009.00 $1,057.0021123 90 $903.00 $1,358.00 $1,446.00 $1,523.00 $1,358.00 $1,446.00 $1,523.0021125 90 $656.00 $4,269.00 $4,568.00 $4,647.00 $1,147.00 $1,218.00 $1,287.0021127 90 $909.00 $6,161.00 $6,597.00 $6,697.00 $1,311.00 $1,394.00 $1,478.0021137 90 $797.00 $1,112.00 $1,193.00 $1,287.00 $1,112.00 $1,193.00 $1,287.0021138 90 $960.00 $1,284.00 $1,352.00 $1,409.00 $1,284.00 $1,352.00 $1,409.0021139 90 $1,168.00 $1,387.00 $1,464.00 $1,545.00 $1,387.00 $1,464.00 $1,545.0021141 90 $1,438.00 $1,966.00 $2,088.00 $2,216.00 $1,966.00 $2,088.00 $2,216.0021142 90 $1,527.00 $2,062.00 $2,192.00 $2,329.00 $2,062.00 $2,192.00 $2,329.0021143 90 $1,511.00 $2,075.00 $2,200.00 $2,334.00 $2,075.00 $2,200.00 $2,334.0021145 90 $1,513.00 $2,326.00 $2,475.00 $2,647.00 $2,326.00 $2,475.00 $2,647.0021146 90 $1,570.00 $2,269.00 $2,398.00 $2,540.00 $2,269.00 $2,398.00 $2,540.0021147 90 $1,639.00 $2,567.00 $2,724.00 $2,897.00 $2,567.00 $2,724.00 $2,897.0021150 90 $1,914.00 $2,459.00 $2,601.00 $2,750.00 $2,459.00 $2,601.00 $2,750.0021151 90 $2,264.00 $2,949.00 $3,119.00 $3,280.00 $2,949.00 $3,119.00 $3,280.0021154 90 $2,364.00 $3,072.00 $3,270.00 $3,500.00 $3,072.00 $3,270.00 $3,500.00



Surgery







21155 90 $2,640.00 $3,149.00 $3,308.00 $3,460.00 $3,149.00 $3,308.00 $3,460.0021159 90 $3,302.00 $3,674.00 $3,874.00 $4,106.00 $3,674.00 $3,874.00 $4,106.0021160 90 $3,500.00 $4,658.00 $4,949.00 $5,268.00 $4,658.00 $4,949.00 $5,268.0021172 90 $2,111.00 $2,608.00 $2,726.00 $2,809.00 $2,608.00 $2,726.00 $2,809.0021175 90 $2,604.00 $3,125.00 $3,292.00 $3,455.00 $3,125.00 $3,292.00 $3,455.0021179 90 $1,826.00 $2,094.00 $2,194.00 $2,272.00 $2,094.00 $2,194.00 $2,272.0021180 90 $2,035.00 $2,260.00 $2,385.00 $2,522.00 $2,260.00 $2,385.00 $2,522.0021181 90 $813.00 $1,075.00 $1,143.00 $1,213.00 $1,075.00 $1,143.00 $1,213.0021182 90 $2,570.00 $2,858.00 $3,026.00 $3,229.00 $2,858.00 $3,026.00 $3,229.0021183 90 $2,770.00 $3,391.00 $3,601.00 $3,841.00 $3,391.00 $3,601.00 $3,841.0021184 90 $3,150.00 $3,139.00 $3,308.00 $3,516.00 $3,139.00 $3,308.00 $3,516.0021188 90 $1,786.00 $2,363.00 $2,509.00 $2,662.00 $2,363.00 $2,509.00 $2,662.0021193 90 $1,331.00 $1,783.00 $1,890.00 $2,009.00 $1,783.00 $1,890.00 $2,009.0021194 90 $1,540.00 $2,108.00 $2,235.00 $2,373.00 $2,108.00 $2,235.00 $2,373.0021195 90 $1,360.00 $1,954.00 $2,068.00 $2,176.00 $1,954.00 $2,068.00 $2,176.0021196 90 $1,764.00 $2,170.00 $2,303.00 $2,434.00 $2,170.00 $2,303.00 $2,434.0021198 90 $1,268.00 $1,708.00 $1,813.00 $1,913.00 $1,708.00 $1,813.00 $1,913.0021199 90 $1,018.00 $1,577.00 $1,675.00 $1,787.00 $1,577.00 $1,675.00 $1,787.0021206 90 $1,112.00 $1,716.00 $1,823.00 $1,924.00 $1,716.00 $1,823.00 $1,924.0021208 90 $946.00 $2,674.00 $2,854.00 $2,927.00 $1,220.00 $1,293.00 $1,362.0021209 90 $576.00 $1,161.00 $1,234.00 $1,281.00 $895.00 $949.00 $995.0021210 90 $930.00 $3,238.00 $3,461.00 $3,546.00 $1,272.00 $1,352.00 $1,431.0021215 90 $970.00 $5,706.00 $6,109.00 $6,205.00 $1,323.00 $1,406.00 $1,489.0021230 90 $956.00 $1,042.00 $1,102.00 $1,165.00 $1,042.00 $1,102.00 $1,165.0021235 90 $707.00 $1,038.00 $1,104.00 $1,150.00 $823.00 $873.00 $918.0021240 90 $1,281.00 $1,648.00 $1,751.00 $1,859.00 $1,648.00 $1,751.00 $1,859.0021242 90 $1,207.00 $1,509.00 $1,603.00 $1,702.00 $1,509.00 $1,603.00 $1,702.0021243 90 $1,501.00 $2,498.00 $2,654.00 $2,820.00 $2,498.00 $2,654.00 $2,820.0021244 90 $1,062.00 $1,553.00 $1,649.00 $1,735.00 $1,553.00 $1,649.00 $1,735.0021245 90 $1,038.00 $1,601.00 $1,699.00 $1,775.00 $1,294.00 $1,370.00 $1,445.0021246 90 $1,010.00 $1,277.00 $1,354.00 $1,437.00 $1,277.00 $1,354.00 $1,437.0021247 90 $2,003.00 $2,276.00 $2,408.00 $2,551.00 $2,276.00 $2,408.00 $2,551.0021248 90 $1,023.00 $1,613.00 $1,717.00 $1,803.00 $1,334.00 $1,417.00 $1,502.0021249 90 $1,525.00 $2,218.00 $2,360.00 $2,487.00 $1,900.00 $2,019.00 $2,145.0021255 90 $1,459.00 $2,026.00 $2,153.00 $2,274.00 $2,026.00 $2,153.00 $2,274.0021256 90 $1,470.00 $1,734.00 $1,823.00 $1,896.00 $1,734.00 $1,823.00 $1,896.0021260 90 $1,372.00 $2,021.00 $2,147.00 $2,265.00 $2,021.00 $2,147.00 $2,265.0021261 90 $2,347.00 $3,079.00 $3,250.00 $3,434.00 $3,079.00 $3,250.00 $3,434.0021263 90 $2,361.00 $2,842.00 $3,000.00 $3,168.00 $2,842.00 $3,000.00 $3,168.0021267 90 $1,539.00 $2,241.00 $2,353.00 $2,420.00 $2,241.00 $2,353.00 $2,420.0021268 90 $1,946.00 $2,536.00 $2,678.00 $2,825.00 $2,536.00 $2,678.00 $2,825.0021270 90 $890.00 $1,366.00 $1,444.00 $1,490.00 $1,037.00 $1,091.00 $1,136.0021275 90 $963.00 $1,217.00 $1,294.00 $1,373.00 $1,217.00 $1,294.00 $1,373.0021280 90 $571.00 $807.00 $850.00 $879.00 $807.00 $850.00 $879.0021282 90 $360.00 $541.00 $573.00 $594.00 $541.00 $573.00 $594.0021295 90 $144.00 $258.00 $274.00 $285.00 $258.00 $274.00 $285.0021296 90 $384.00 $621.00 $659.00 $688.00 $621.00 $659.00 $688.0021299 YYY BR -------- -------- -------- -------- -------- --------21310 0 $81.00 $184.00 $196.00 $200.00 $40.00 $42.00 $45.0021315 10 $180.00 $391.00 $416.00 $428.00 $219.00 $232.00 $243.00



Surgery







21320 10 $235.00 $363.00 $387.00 $398.00 $196.00 $208.00 $219.0021325 90 $348.00 $676.00 $720.00 $747.00 $676.00 $720.00 $747.0021330 90 $639.00 $813.00 $865.00 $901.00 $813.00 $865.00 $901.0021335 90 $852.00 $1,050.00 $1,114.00 $1,168.00 $1,050.00 $1,114.00 $1,168.0021336 90 $478.00 $924.00 $982.00 $1,023.00 $924.00 $982.00 $1,023.0021337 90 $300.00 $574.00 $612.00 $634.00 $425.00 $452.00 $473.0021338 90 $550.00 $1,035.00 $1,104.00 $1,153.00 $1,035.00 $1,104.00 $1,153.0021339 90 $689.00 $1,105.00 $1,172.00 $1,220.00 $1,105.00 $1,172.00 $1,220.0021340 90 $907.00 $1,096.00 $1,156.00 $1,216.00 $1,096.00 $1,156.00 $1,216.0021343 90 $1,043.00 $1,740.00 $1,852.00 $1,948.00 $1,740.00 $1,852.00 $1,948.0021344 90 $1,450.00 $2,037.00 $2,155.00 $2,279.00 $2,037.00 $2,155.00 $2,279.0021345 90 $738.00 $1,164.00 $1,236.00 $1,291.00 $950.00 $1,006.00 $1,060.0021346 90 $917.00 $1,314.00 $1,393.00 $1,458.00 $1,314.00 $1,393.00 $1,458.0021347 90 $1,048.00 $1,644.00 $1,749.00 $1,842.00 $1,644.00 $1,749.00 $1,842.0021348 90 $1,286.00 $1,762.00 $1,871.00 $1,990.00 $1,762.00 $1,871.00 $1,990.0021355 10 $295.00 $614.00 $652.00 $678.00 $466.00 $493.00 $519.0021356 10 $372.00 $717.00 $763.00 $795.00 $549.00 $583.00 $614.0021360 90 $590.00 $782.00 $830.00 $875.00 $782.00 $830.00 $875.0021365 90 $1,239.00 $1,627.00 $1,725.00 $1,830.00 $1,627.00 $1,725.00 $1,830.0021366 90 $1,386.00 $1,693.00 $1,790.00 $1,898.00 $1,693.00 $1,790.00 $1,898.0021385 90 $810.00 $988.00 $1,045.00 $1,097.00 $988.00 $1,045.00 $1,097.0021386 90 $812.00 $1,009.00 $1,072.00 $1,136.00 $1,009.00 $1,072.00 $1,136.0021387 90 $958.00 $1,035.00 $1,096.00 $1,154.00 $1,035.00 $1,096.00 $1,154.0021390 90 $920.00 $1,149.00 $1,214.00 $1,274.00 $1,149.00 $1,214.00 $1,274.0021395 90 $1,384.00 $1,461.00 $1,551.00 $1,646.00 $1,461.00 $1,551.00 $1,646.0021400 90 $143.00 $273.00 $291.00 $301.00 $223.00 $238.00 $248.0021401 90 $313.00 $628.00 $669.00 $693.00 $415.00 $440.00 $463.0021406 90 $852.00 $754.00 $799.00 $842.00 $754.00 $799.00 $842.0021407 90 $736.00 $935.00 $990.00 $1,041.00 $935.00 $990.00 $1,041.0021408 90 $1,007.00 $1,276.00 $1,354.00 $1,438.00 $1,276.00 $1,354.00 $1,438.0021421 90 $528.00 $1,080.00 $1,152.00 $1,195.00 $917.00 $977.00 $1,019.0021422 90 $761.00 $979.00 $1,040.00 $1,096.00 $979.00 $1,040.00 $1,096.0021423 90 $890.00 $1,190.00 $1,264.00 $1,336.00 $1,190.00 $1,264.00 $1,336.0021431 90 $598.00 $1,066.00 $1,135.00 $1,186.00 $1,066.00 $1,135.00 $1,186.0021432 90 $744.00 $952.00 $1,010.00 $1,063.00 $952.00 $1,010.00 $1,063.0021433 90 $1,981.00 $2,536.00 $2,691.00 $2,863.00 $2,536.00 $2,691.00 $2,863.0021435 90 $1,404.00 $1,847.00 $1,953.00 $2,068.00 $1,847.00 $1,953.00 $2,068.0021436 90 $2,045.00 $3,096.00 $3,330.00 $3,636.00 $3,096.00 $3,330.00 $3,636.0021440 90 $308.00 $822.00 $879.00 $903.00 $671.00 $716.00 $740.0021445 90 $533.00 $1,106.00 $1,180.00 $1,224.00 $907.00 $966.00 $1,010.0021450 90 $325.00 $882.00 $942.00 $968.00 $710.00 $758.00 $783.0021451 90 $498.00 $1,091.00 $1,164.00 $1,203.00 $921.00 $982.00 $1,021.0021452 90 $195.00 $843.00 $901.00 $918.00 $502.00 $536.00 $551.0021453 90 $902.00 $1,306.00 $1,393.00 $1,439.00 $1,125.00 $1,199.00 $1,244.0021454 90 $905.00 $863.00 $918.00 $968.00 $863.00 $918.00 $968.0021461 90 $769.00 $3,021.00 $3,230.00 $3,296.00 $1,357.00 $1,445.00 $1,506.0021462 90 $1,012.00 $3,212.00 $3,433.00 $3,511.00 $1,516.00 $1,614.00 $1,687.0021465 90 $923.00 $1,401.00 $1,489.00 $1,577.00 $1,401.00 $1,489.00 $1,577.0021470 90 $1,331.00 $1,767.00 $1,876.00 $1,990.00 $1,767.00 $1,876.00 $1,990.0021480 0 $82.00 $139.00 $148.00 $152.00 $47.00 $50.00 $53.00



Surgery







21485 90 $318.00 $1,003.00 $1,071.00 $1,104.00 $843.00 $899.00 $933.0021490 90 $865.00 $1,340.00 $1,425.00 $1,512.00 $1,340.00 $1,425.00 $1,512.0021495 90 $500.00 $1,012.00 $1,076.00 $1,116.00 $1,012.00 $1,076.00 $1,116.0021497 90 $372.00 $1,048.00 $1,119.00 $1,152.00 $876.00 $935.00 $968.0021499 YYY BR -------- -------- -------- -------- -------- --------21501 90 $315.00 $648.00 $692.00 $724.00 $468.00 $500.00 $531.0021502 90 $612.00 $786.00 $843.00 $914.00 $786.00 $843.00 $914.0021510 90 $534.00 $661.00 $710.00 $769.00 $661.00 $710.00 $769.0021550 10 $165.00 $372.00 $396.00 $409.00 $229.00 $243.00 $255.0021552 90 -------- $659.00 $706.00 $763.00 $659.00 $706.00 $763.0021554 90 -------- $1,082.00 $1,156.00 $1,249.00 $1,082.00 $1,156.00 $1,249.0021555 90 $337.00 $595.00 $636.00 $669.00 $447.00 $478.00 $510.0021556 90 $431.00 $777.00 $828.00 $886.00 $777.00 $828.00 $886.0021557 90 $794.00 $1,414.00 $1,508.00 $1,624.00 $1,414.00 $1,508.00 $1,624.0021558 90 -------- $1,996.00 $2,130.00 $2,304.00 $1,996.00 $2,130.00 $2,304.0021600 90 $631.00 $816.00 $873.00 $934.00 $816.00 $873.00 $934.0021610 90 $828.00 $1,815.00 $1,986.00 $2,235.00 $1,815.00 $1,986.00 $2,235.0021615 90 $938.00 $926.00 $992.00 $1,086.00 $926.00 $992.00 $1,086.0021616 90 $1,042.00 $1,120.00 $1,196.00 $1,299.00 $1,120.00 $1,196.00 $1,299.0021620 90 $689.00 $744.00 $795.00 $858.00 $744.00 $795.00 $858.0021627 90 $686.00 $793.00 $849.00 $912.00 $793.00 $849.00 $912.0021630 90 $1,455.00 $1,794.00 $1,915.00 $2,072.00 $1,794.00 $1,915.00 $2,072.0021632 90 $1,514.00 $1,803.00 $1,930.00 $2,104.00 $1,803.00 $1,930.00 $2,104.0021685 90 -------- $1,463.00 $1,548.00 $1,636.00 $1,463.00 $1,548.00 $1,636.0021700 90 $576.00 $555.00 $593.00 $647.00 $555.00 $593.00 $647.0021705 90 $746.00 $831.00 $890.00 $980.00 $831.00 $890.00 $980.0021720 90 $523.00 $662.00 $707.00 $756.00 $662.00 $707.00 $756.0021725 90 $588.00 $785.00 $845.00 $921.00 $785.00 $845.00 $921.0021740 90 $1,387.00 $1,527.00 $1,631.00 $1,779.00 $1,527.00 $1,631.00 $1,779.0021742 90 BR -------- -------- -------- -------- -------- --------21743 90 BR -------- -------- -------- -------- -------- --------21750 90 $1,009.00 $1,023.00 $1,096.00 $1,199.00 $1,023.00 $1,096.00 $1,199.0021811 0 -------- $919.00 $984.00 $1,082.00 $919.00 $984.00 $1,082.0021812 0 -------- $1,102.00 $1,181.00 $1,299.00 $1,102.00 $1,181.00 $1,299.0021813 0 -------- $1,438.00 $1,538.00 $1,691.00 $1,438.00 $1,538.00 $1,691.0021820 90 $143.00 $200.00 $214.00 $223.00 $205.00 $219.00 $229.0021825 90 $810.00 $799.00 $856.00 $925.00 $799.00 $856.00 $925.0021899 YYY BR -------- -------- -------- -------- -------- --------21920 10 $165.00 $364.00 $388.00 $401.00 $232.00 $247.00 $260.0021925 90 $371.00 $641.00 $686.00 $724.00 $517.00 $553.00 $591.0021930 90 $403.00 $680.00 $728.00 $770.00 $535.00 $572.00 $613.0021931 90 -------- $694.00 $744.00 $806.00 $694.00 $744.00 $806.0021932 90 -------- $979.00 $1,049.00 $1,138.00 $979.00 $1,049.00 $1,138.0021933 90 -------- $1,092.00 $1,169.00 $1,269.00 $1,092.00 $1,169.00 $1,269.0021935 90 $1,280.00 $1,518.00 $1,624.00 $1,760.00 $1,518.00 $1,624.00 $1,760.0021936 90 -------- $2,095.00 $2,241.00 $2,435.00 $2,095.00 $2,241.00 $2,435.0022010 90 -------- $1,416.00 $1,528.00 $1,670.00 $1,416.00 $1,528.00 $1,670.0022015 90 -------- $1,369.00 $1,473.00 $1,605.00 $1,369.00 $1,473.00 $1,605.0022100 90 $850.00 $1,301.00 $1,410.00 $1,549.00 $1,301.00 $1,410.00 $1,549.0022101 90 $862.00 $1,262.00 $1,360.00 $1,481.00 $1,262.00 $1,360.00 $1,481.00



Surgery







22102 90 $781.00 $1,160.00 $1,239.00 $1,330.00 $1,160.00 $1,239.00 $1,330.0022103 ZZZ $198.00 $211.00 $228.00 $251.00 $211.00 $228.00 $251.0022110 90 $889.00 $1,568.00 $1,698.00 $1,871.00 $1,568.00 $1,698.00 $1,871.0022112 90 $1,090.00 $1,455.00 $1,555.00 $1,670.00 $1,455.00 $1,555.00 $1,670.0022114 90 $1,062.00 $1,460.00 $1,560.00 $1,674.00 $1,460.00 $1,560.00 $1,674.0022116 ZZZ $195.00 $217.00 $235.00 $262.00 $217.00 $235.00 $262.0022206 90 -------- $3,677.00 $3,969.00 $4,380.00 $3,677.00 $3,969.00 $4,380.0022207 90 -------- $3,596.00 $3,874.00 $4,261.00 $3,596.00 $3,874.00 $4,261.0022208 ZZZ -------- $884.00 $953.00 $1,056.00 $884.00 $953.00 $1,056.0022210 90 $1,892.00 $2,684.00 $2,904.00 $3,204.00 $2,684.00 $2,904.00 $3,204.0022212 90 $1,668.00 $2,207.00 $2,375.00 $2,592.00 $2,207.00 $2,375.00 $2,592.0022214 90 $819.00 $2,215.00 $2,385.00 $2,604.00 $2,215.00 $2,385.00 $2,604.0022216 ZZZ $492.00 $551.00 $593.00 $656.00 $551.00 $593.00 $656.0022220 90 $1,801.00 $2,389.00 $2,575.00 $2,822.00 $2,389.00 $2,575.00 $2,822.0022222 90 $1,604.00 $2,297.00 $2,453.00 $2,643.00 $2,297.00 $2,453.00 $2,643.0022224 90 $1,731.00 $2,353.00 $2,526.00 $2,747.00 $2,353.00 $2,526.00 $2,747.0022226 ZZZ $488.00 $550.00 $593.00 $656.00 $550.00 $593.00 $656.0022305 90 $213.00 $274.00 $292.00 $308.00 $250.00 $267.00 $283.0022310 90 $272.00 $447.00 $478.00 $510.00 $414.00 $443.00 $475.0022315 90 $711.00 $1,290.00 $1,387.00 $1,489.00 $1,139.00 $1,224.00 $1,326.0022318 90 $1,755.00 $2,508.00 $2,740.00 $3,080.00 $2,508.00 $2,740.00 $3,080.0022319 90 $1,983.00 $2,796.00 $3,063.00 $3,462.00 $2,796.00 $3,063.00 $3,462.0022325 90 $1,407.00 $2,157.00 $2,334.00 $2,570.00 $2,157.00 $2,334.00 $2,570.0022326 90 $1,710.00 $2,255.00 $2,450.00 $2,724.00 $2,255.00 $2,450.00 $2,724.0022327 90 $1,660.00 $2,261.00 $2,450.00 $2,708.00 $2,261.00 $2,450.00 $2,708.0022328 ZZZ $391.00 $433.00 $470.00 $527.00 $433.00 $470.00 $527.0022505 10 $174.00 $187.00 $200.00 $214.00 $187.00 $200.00 $214.0022510 10 -------- $2,459.00 $2,623.00 $2,668.00 $664.00 $698.00 $737.0022511 10 -------- $2,432.00 $2,596.00 $2,638.00 $623.00 $655.00 $692.0022512 ZZZ -------- $1,364.00 $1,457.00 $1,484.00 $312.00 $329.00 $352.0022513 10 -------- $10,089.00 $10,819.00 $10,915.00 $800.00 $852.00 $919.0022514 10 -------- $10,073.00 $10,802.00 $10,893.00 $745.00 $793.00 $855.0022515 ZZZ -------- $6,095.00 $6,538.00 $6,589.00 $340.00 $363.00 $396.0022526 10 -------- $3,291.00 $3,521.00 $3,563.00 $514.00 $541.00 $574.0022527 ZZZ -------- $2,722.00 $2,915.00 $2,939.00 $235.00 $247.00 $263.0022532 90 -------- $2,684.00 $2,905.00 $3,212.00 $2,684.00 $2,905.00 $3,212.0022533 90 -------- $2,463.00 $2,642.00 $2,875.00 $2,463.00 $2,642.00 $2,875.0022534 ZZZ -------- $548.00 $591.00 $655.00 $548.00 $591.00 $655.0022548 90 $2,271.00 $3,037.00 $3,332.00 $3,773.00 $3,037.00 $3,332.00 $3,773.0022551 90 -------- $2,602.00 $2,825.00 $3,147.00 $2,602.00 $2,825.00 $3,147.0022552 ZZZ -------- $615.00 $668.00 $750.00 $615.00 $668.00 $750.0022554 90 $1,727.00 $1,892.00 $2,049.00 $2,265.00 $1,892.00 $2,049.00 $2,265.0022556 90 $2,054.00 $2,511.00 $2,713.00 $2,995.00 $2,511.00 $2,713.00 $2,995.0022558 90 $1,907.00 $2,309.00 $2,484.00 $2,723.00 $2,309.00 $2,484.00 $2,723.0022585 ZZZ $473.00 $503.00 $543.00 $603.00 $503.00 $543.00 $603.0022586 90 -------- $2,698.00 $2,883.00 $3,118.00 $2,698.00 $2,883.00 $3,118.0022590 90 $1,895.00 $2,403.00 $2,618.00 $2,924.00 $2,403.00 $2,618.00 $2,924.0022595 90 $1,960.00 $2,290.00 $2,493.00 $2,781.00 $2,290.00 $2,493.00 $2,781.0022600 90 $1,567.00 $1,944.00 $2,111.00 $2,338.00 $1,944.00 $2,111.00 $2,338.0022610 90 $1,494.00 $1,898.00 $2,055.00 $2,264.00 $1,898.00 $2,055.00 $2,264.00



Surgery







22612 90 $1,861.00 $2,387.00 $2,574.00 $2,830.00 $2,387.00 $2,574.00 $2,830.0022614 ZZZ $530.00 $599.00 $649.00 $724.00 $599.00 $649.00 $724.0022630 90 $1,201.00 $2,374.00 $2,578.00 $2,866.00 $2,374.00 $2,578.00 $2,866.0022632 ZZZ $442.00 $494.00 $537.00 $603.00 $494.00 $537.00 $603.0022633 90 -------- $2,799.00 $3,027.00 $3,347.00 $2,799.00 $3,027.00 $3,347.0022634 ZZZ -------- $761.00 $824.00 $920.00 $761.00 $824.00 $920.0022800 90 $1,960.00 $2,016.00 $2,169.00 $2,367.00 $2,016.00 $2,169.00 $2,367.0022802 90 $2,633.00 $3,138.00 $3,371.00 $3,684.00 $3,138.00 $3,371.00 $3,684.0022804 90 $2,951.00 $3,634.00 $3,906.00 $4,278.00 $3,634.00 $3,906.00 $4,278.0022808 90 $2,157.00 $2,764.00 $2,984.00 $3,289.00 $2,764.00 $2,984.00 $3,289.0022810 90 $2,356.00 $3,050.00 $3,284.00 $3,610.00 $3,050.00 $3,284.00 $3,610.0022812 90 $2,675.00 $3,675.00 $4,019.00 $4,534.00 $3,675.00 $4,019.00 $4,534.0022818 90 $2,701.00 $3,223.00 $3,441.00 $3,721.00 $3,223.00 $3,441.00 $3,721.0022819 90 $2,968.00 $4,270.00 $4,687.00 $5,329.00 $4,270.00 $4,687.00 $5,329.0022830 90 $1,176.00 $1,213.00 $1,308.00 $1,431.00 $1,213.00 $1,308.00 $1,431.0022840 ZZZ $943.00 $1,164.00 $1,260.00 $1,405.00 $1,164.00 $1,260.00 $1,405.0022841 0 BR -------- -------- -------- -------- -------- --------22842 ZZZ $2,352.00 $1,167.00 $1,263.00 $1,409.00 $1,167.00 $1,263.00 $1,409.0022843 ZZZ $1,028.00 $1,246.00 $1,348.00 $1,502.00 $1,246.00 $1,348.00 $1,502.0022844 ZZZ $1,277.00 $1,493.00 $1,607.00 $1,774.00 $1,493.00 $1,607.00 $1,774.0022845 ZZZ $1,853.00 $1,124.00 $1,221.00 $1,370.00 $1,124.00 $1,221.00 $1,370.0022846 ZZZ $999.00 $1,168.00 $1,268.00 $1,422.00 $1,168.00 $1,268.00 $1,422.0022847 ZZZ $1,077.00 $1,258.00 $1,355.00 $1,499.00 $1,258.00 $1,355.00 $1,499.0022848 ZZZ $529.00 $546.00 $588.00 $649.00 $546.00 $588.00 $649.0022849 90 $2,235.00 $1,955.00 $2,111.00 $2,325.00 $1,955.00 $2,111.00 $2,325.0022850 90 $872.00 $1,080.00 $1,165.00 $1,275.00 $1,080.00 $1,165.00 $1,275.0022851 ZZZ $600.00 $624.00 $676.00 $755.00 $624.00 $676.00 $755.0022852 90 $854.00 $1,034.00 $1,115.00 $1,218.00 $1,034.00 $1,115.00 $1,218.0022855 90 $1,193.00 $1,670.00 $1,808.00 $1,998.00 $1,670.00 $1,808.00 $1,998.0022856 90 -------- $2,450.00 $2,650.00 $2,932.00 $2,450.00 $2,650.00 $2,932.0022857 90 -------- $2,994.00 $3,273.00 $3,685.00 $2,994.00 $3,273.00 $3,685.0022858 ZZZ -------- $772.00 $838.00 $940.00 $772.00 $838.00 $940.0022861 90 -------- $3,004.00 $3,206.00 $3,475.00 $3,004.00 $3,206.00 $3,475.0022862 90 -------- $3,041.00 $3,304.00 $3,718.00 $3,041.00 $3,304.00 $3,718.0022864 90 -------- $3,162.00 $3,458.00 $3,903.00 $3,162.00 $3,458.00 $3,903.0022865 90 -------- $3,035.00 $3,240.00 $3,498.00 $3,035.00 $3,240.00 $3,498.0022899 YYY BR -------- -------- -------- -------- -------- --------22900 90 $446.00 $834.00 $894.00 $969.00 $834.00 $894.00 $969.0022901 90 -------- $985.00 $1,055.00 $1,146.00 $985.00 $1,055.00 $1,146.0022902 90 -------- $631.00 $677.00 $717.00 $486.00 $521.00 $560.0022903 90 -------- $649.00 $695.00 $754.00 $649.00 $695.00 $754.0022904 90 -------- $1,557.00 $1,667.00 $1,813.00 $1,557.00 $1,667.00 $1,813.0022905 90 -------- $1,978.00 $2,117.00 $2,306.00 $1,978.00 $2,117.00 $2,306.0022999 YYY BR -------- -------- -------- -------- -------- --------23000 90 $447.00 $828.00 $885.00 $921.00 $537.00 $573.00 $608.0023020 90 $807.00 $1,003.00 $1,070.00 $1,143.00 $1,003.00 $1,070.00 $1,143.0023030 10 $323.00 $625.00 $669.00 $698.00 $374.00 $399.00 $427.0023031 10 $185.00 $599.00 $641.00 $663.00 $318.00 $340.00 $361.0023035 90 $861.00 $986.00 $1,052.00 $1,124.00 $986.00 $1,052.00 $1,124.0023040 90 $898.00 $1,049.00 $1,120.00 $1,197.00 $1,049.00 $1,120.00 $1,197.00



Surgery







23044 90 $708.00 $830.00 $886.00 $949.00 $830.00 $886.00 $949.0023065 10 $171.00 $310.00 $329.00 $344.00 $243.00 $258.00 $273.0023066 90 $302.00 $788.00 $844.00 $880.00 $517.00 $553.00 $589.0023071 90 -------- $618.00 $662.00 $715.00 $618.00 $662.00 $715.0023073 90 -------- $1,022.00 $1,093.00 $1,180.00 $1,022.00 $1,093.00 $1,180.0023075 90 $247.00 $669.00 $717.00 $754.00 $477.00 $510.00 $546.0023076 90 $613.00 $792.00 $847.00 $911.00 $792.00 $847.00 $911.0023077 90 $1,228.00 $1,694.00 $1,812.00 $1,963.00 $1,694.00 $1,812.00 $1,963.0023078 90 -------- $2,125.00 $2,271.00 $2,461.00 $2,125.00 $2,271.00 $2,461.0023100 90 $616.00 $723.00 $772.00 $822.00 $723.00 $772.00 $822.0023101 90 $583.00 $660.00 $706.00 $753.00 $660.00 $706.00 $753.0023105 90 $814.00 $928.00 $990.00 $1,057.00 $928.00 $990.00 $1,057.0023106 90 $581.00 $714.00 $763.00 $813.00 $714.00 $763.00 $813.0023107 90 $851.00 $959.00 $1,023.00 $1,091.00 $959.00 $1,023.00 $1,091.0023120 90 $645.00 $847.00 $904.00 $962.00 $847.00 $904.00 $962.0023125 90 $865.00 $1,035.00 $1,106.00 $1,185.00 $1,035.00 $1,106.00 $1,185.0023130 90 $722.00 $886.00 $947.00 $1,010.00 $886.00 $947.00 $1,010.0023140 90 $597.00 $778.00 $831.00 $889.00 $778.00 $831.00 $889.0023145 90 $889.00 $1,014.00 $1,084.00 $1,160.00 $1,014.00 $1,084.00 $1,160.0023146 90 $704.00 $902.00 $962.00 $1,027.00 $902.00 $962.00 $1,027.0023150 90 $755.00 $955.00 $1,018.00 $1,085.00 $955.00 $1,018.00 $1,085.0023155 90 $945.00 $1,159.00 $1,238.00 $1,326.00 $1,159.00 $1,238.00 $1,326.0023156 90 $794.00 $985.00 $1,051.00 $1,122.00 $985.00 $1,051.00 $1,122.0023170 90 $645.00 $808.00 $863.00 $922.00 $808.00 $863.00 $922.0023172 90 $638.00 $822.00 $878.00 $935.00 $822.00 $878.00 $935.0023174 90 $882.00 $1,092.00 $1,165.00 $1,244.00 $1,092.00 $1,165.00 $1,244.0023180 90 $566.00 $973.00 $1,040.00 $1,115.00 $973.00 $1,040.00 $1,115.0023182 90 $865.00 $947.00 $1,011.00 $1,077.00 $947.00 $1,011.00 $1,077.0023184 90 $962.00 $1,070.00 $1,142.00 $1,221.00 $1,070.00 $1,142.00 $1,221.0023190 90 $656.00 $827.00 $882.00 $942.00 $827.00 $882.00 $942.0023195 90 $902.00 $1,099.00 $1,173.00 $1,256.00 $1,099.00 $1,173.00 $1,256.0023200 90 $1,095.00 $2,197.00 $2,349.00 $2,542.00 $2,197.00 $2,349.00 $2,542.0023210 90 $1,095.00 $2,615.00 $2,790.00 $3,008.00 $2,615.00 $2,790.00 $3,008.0023220 90 $1,307.00 $2,861.00 $3,050.00 $3,284.00 $2,861.00 $3,050.00 $3,284.0023330 10 $59.00 $337.00 $359.00 $372.00 $217.00 $231.00 $243.0023333 90 -------- $656.00 $698.00 $741.00 $656.00 $698.00 $741.0023334 90 -------- $1,579.00 $1,685.00 $1,808.00 $1,579.00 $1,685.00 $1,808.0023335 90 -------- $1,881.00 $2,008.00 $2,158.00 $1,881.00 $2,008.00 $2,158.0023350 0 $74.00 $182.00 $193.00 $197.00 $74.00 $77.00 $81.0023395 90 $1,366.00 $1,882.00 $2,007.00 $2,151.00 $1,882.00 $2,007.00 $2,151.0023397 90 $1,403.00 $1,674.00 $1,787.00 $1,921.00 $1,674.00 $1,787.00 $1,921.0023400 90 $1,196.00 $1,424.00 $1,520.00 $1,633.00 $1,424.00 $1,520.00 $1,633.0023405 90 $799.00 $910.00 $970.00 $1,035.00 $910.00 $970.00 $1,035.0023406 90 $977.00 $1,120.00 $1,192.00 $1,271.00 $1,120.00 $1,192.00 $1,271.0023410 90 $1,119.00 $1,200.00 $1,281.00 $1,371.00 $1,200.00 $1,281.00 $1,371.0023412 90 $1,229.00 $1,245.00 $1,329.00 $1,422.00 $1,245.00 $1,329.00 $1,422.0023415 90 $622.00 $1,015.00 $1,084.00 $1,159.00 $1,015.00 $1,084.00 $1,159.0023420 90 $1,276.00 $1,416.00 $1,511.00 $1,618.00 $1,416.00 $1,511.00 $1,618.0023430 90 $884.00 $1,087.00 $1,159.00 $1,237.00 $1,087.00 $1,159.00 $1,237.0023440 90 $906.00 $1,103.00 $1,177.00 $1,259.00 $1,103.00 $1,177.00 $1,259.00



Surgery







23450 90 $1,210.00 $1,384.00 $1,476.00 $1,583.00 $1,384.00 $1,476.00 $1,583.0023455 90 $1,340.00 $1,464.00 $1,561.00 $1,674.00 $1,464.00 $1,561.00 $1,674.0023460 90 $1,364.00 $1,601.00 $1,709.00 $1,838.00 $1,601.00 $1,709.00 $1,838.0023462 90 $1,383.00 $1,554.00 $1,657.00 $1,779.00 $1,554.00 $1,657.00 $1,779.0023465 90 $1,398.00 $1,628.00 $1,735.00 $1,858.00 $1,628.00 $1,735.00 $1,858.0023466 90 $1,332.00 $1,634.00 $1,741.00 $1,861.00 $1,634.00 $1,741.00 $1,861.0023470 90 $1,540.00 $1,766.00 $1,883.00 $2,021.00 $1,766.00 $1,883.00 $2,021.0023472 90 $1,570.00 $2,142.00 $2,282.00 $2,451.00 $2,142.00 $2,282.00 $2,451.0023473 90 -------- $2,394.00 $2,552.00 $2,743.00 $2,394.00 $2,552.00 $2,743.0023474 90 -------- $2,587.00 $2,757.00 $2,966.00 $2,587.00 $2,757.00 $2,966.0023480 90 $926.00 $1,201.00 $1,283.00 $1,377.00 $1,201.00 $1,283.00 $1,377.0023485 90 $1,181.00 $1,398.00 $1,491.00 $1,599.00 $1,398.00 $1,491.00 $1,599.0023490 90 $1,038.00 $1,229.00 $1,309.00 $1,398.00 $1,229.00 $1,309.00 $1,398.0023491 90 $1,251.00 $1,484.00 $1,585.00 $1,702.00 $1,484.00 $1,585.00 $1,702.0023500 90 $148.00 $311.00 $331.00 $347.00 $316.00 $337.00 $353.0023505 90 $293.00 $505.00 $539.00 $568.00 $479.00 $511.00 $540.0023515 90 $688.00 $1,049.00 $1,119.00 $1,195.00 $1,049.00 $1,119.00 $1,195.0023520 90 $205.00 $320.00 $342.00 $359.00 $325.00 $347.00 $364.0023525 90 $320.00 $537.00 $573.00 $603.00 $498.00 $532.00 $561.0023530 90 $659.00 $801.00 $854.00 $911.00 $801.00 $854.00 $911.0023532 90 $713.00 $900.00 $958.00 $1,019.00 $900.00 $958.00 $1,019.0023540 90 $148.00 $319.00 $340.00 $356.00 $325.00 $346.00 $362.0023545 90 $148.00 $482.00 $513.00 $534.00 $440.00 $468.00 $489.0023550 90 $701.00 $819.00 $872.00 $928.00 $819.00 $872.00 $928.0023552 90 $753.00 $953.00 $1,016.00 $1,084.00 $953.00 $1,016.00 $1,084.0023570 90 $88.00 $331.00 $353.00 $371.00 $340.00 $364.00 $382.0023575 90 $306.00 $572.00 $611.00 $646.00 $538.00 $575.00 $609.0023585 90 $809.00 $1,436.00 $1,531.00 $1,641.00 $1,436.00 $1,531.00 $1,641.0023600 90 $318.00 $463.00 $494.00 $517.00 $438.00 $467.00 $490.0023605 90 $511.00 $664.00 $708.00 $747.00 $611.00 $652.00 $691.0023615 90 $900.00 $1,292.00 $1,378.00 $1,474.00 $1,292.00 $1,378.00 $1,474.0023616 90 $1,895.00 $1,823.00 $1,944.00 $2,087.00 $1,823.00 $1,944.00 $2,087.0023620 90 $286.00 $383.00 $409.00 $428.00 $365.00 $390.00 $409.0023625 90 $422.00 $542.00 $578.00 $609.00 $506.00 $540.00 $571.0023630 90 $712.00 $1,139.00 $1,215.00 $1,297.00 $1,139.00 $1,215.00 $1,297.0023650 90 $296.00 $445.00 $473.00 $495.00 $411.00 $436.00 $458.0023655 90 $374.00 $578.00 $617.00 $653.00 $578.00 $617.00 $653.0023660 90 $712.00 $845.00 $901.00 $960.00 $845.00 $901.00 $960.0023665 90 $440.00 $608.00 $649.00 $684.00 $568.00 $606.00 $642.0023670 90 $759.00 $1,280.00 $1,365.00 $1,461.00 $1,280.00 $1,365.00 $1,461.0023675 90 $550.00 $791.00 $844.00 $892.00 $724.00 $772.00 $821.0023680 90 $1,064.00 $1,357.00 $1,447.00 $1,549.00 $1,357.00 $1,447.00 $1,549.0023700 10 $237.00 $286.00 $305.00 $326.00 $286.00 $305.00 $326.0023800 90 $1,346.00 $1,505.00 $1,607.00 $1,727.00 $1,505.00 $1,607.00 $1,727.0023802 90 $1,368.00 $1,850.00 $1,972.00 $2,112.00 $1,850.00 $1,972.00 $2,112.0023900 90 $1,561.00 $2,042.00 $2,180.00 $2,345.00 $2,042.00 $2,180.00 $2,345.0023920 90 $1,300.00 $1,650.00 $1,762.00 $1,894.00 $1,650.00 $1,762.00 $1,894.0023921 90 $497.00 $679.00 $725.00 $772.00 $679.00 $725.00 $772.0023929 YYY BR -------- -------- -------- -------- -------- --------23930 10 $71.00 $502.00 $537.00 $562.00 $316.00 $337.00 $362.00



Surgery







23931 10 $62.00 $403.00 $431.00 $445.00 $230.00 $245.00 $259.0023935 90 $630.00 $733.00 $782.00 $831.00 $733.00 $782.00 $831.0024000 90 $550.00 $690.00 $736.00 $783.00 $690.00 $736.00 $783.0024006 90 $793.00 $1,028.00 $1,095.00 $1,168.00 $1,028.00 $1,095.00 $1,168.0024065 10 $166.00 $362.00 $386.00 $400.00 $242.00 $257.00 $271.0024066 90 $461.00 $890.00 $953.00 $1,000.00 $607.00 $649.00 $695.0024071 90 -------- $597.00 $639.00 $689.00 $597.00 $639.00 $689.0024073 90 -------- $1,018.00 $1,089.00 $1,174.00 $1,018.00 $1,089.00 $1,174.0024075 90 $349.00 $699.00 $748.00 $785.00 $481.00 $515.00 $551.0024076 90 $529.00 $794.00 $849.00 $911.00 $794.00 $849.00 $911.0024077 90 $1,058.00 $1,529.00 $1,635.00 $1,770.00 $1,529.00 $1,635.00 $1,770.0024079 90 -------- $1,955.00 $2,089.00 $2,261.00 $1,955.00 $2,089.00 $2,261.0024100 90 $467.00 $605.00 $647.00 $689.00 $605.00 $647.00 $689.0024101 90 $591.00 $725.00 $773.00 $822.00 $725.00 $773.00 $822.0024102 90 $755.00 $896.00 $955.00 $1,018.00 $896.00 $955.00 $1,018.0024105 90 $360.00 $504.00 $538.00 $569.00 $504.00 $538.00 $569.0024110 90 $724.00 $842.00 $898.00 $956.00 $842.00 $898.00 $956.0024115 90 $898.00 $1,078.00 $1,151.00 $1,234.00 $1,078.00 $1,151.00 $1,234.0024116 90 $1,037.00 $1,263.00 $1,349.00 $1,448.00 $1,263.00 $1,349.00 $1,448.0024120 90 $595.00 $766.00 $817.00 $869.00 $766.00 $817.00 $869.0024125 90 $663.00 $889.00 $946.00 $1,004.00 $889.00 $946.00 $1,004.0024126 90 $731.00 $946.00 $1,011.00 $1,081.00 $946.00 $1,011.00 $1,081.0024130 90 $595.00 $736.00 $785.00 $835.00 $736.00 $785.00 $835.0024134 90 $966.00 $1,090.00 $1,163.00 $1,245.00 $1,090.00 $1,163.00 $1,245.0024136 90 $720.00 $904.00 $960.00 $1,013.00 $904.00 $960.00 $1,013.0024138 90 $697.00 $976.00 $1,043.00 $1,112.00 $976.00 $1,043.00 $1,112.0024140 90 $963.00 $1,019.00 $1,087.00 $1,161.00 $1,019.00 $1,087.00 $1,161.0024145 90 $592.00 $862.00 $921.00 $985.00 $862.00 $921.00 $985.0024147 90 $703.00 $901.00 $962.00 $1,024.00 $901.00 $962.00 $1,024.0024149 90 $1,224.00 $1,712.00 $1,824.00 $1,946.00 $1,712.00 $1,824.00 $1,946.0024150 90 $1,265.00 $2,296.00 $2,451.00 $2,642.00 $2,296.00 $2,451.00 $2,642.0024152 90 $829.00 $1,932.00 $2,049.00 $2,176.00 $1,932.00 $2,049.00 $2,176.0024155 90 $1,019.00 $1,236.00 $1,319.00 $1,415.00 $1,236.00 $1,319.00 $1,415.0024160 90 $533.00 $1,855.00 $1,977.00 $2,122.00 $1,855.00 $1,977.00 $2,122.0024164 90 $564.00 $1,067.00 $1,140.00 $1,221.00 $1,067.00 $1,140.00 $1,221.0024200 10 $58.00 $293.00 $312.00 $324.00 $202.00 $215.00 $227.0024201 90 $444.00 $776.00 $831.00 $871.00 $526.00 $562.00 $601.0024220 0 $89.00 $224.00 $238.00 $243.00 $101.00 $105.00 $110.0024300 90 $352.00 $596.00 $637.00 $668.00 $596.00 $637.00 $668.0024301 90 $869.00 $1,092.00 $1,163.00 $1,242.00 $1,092.00 $1,163.00 $1,242.0024305 90 $579.00 $835.00 $889.00 $943.00 $835.00 $889.00 $943.0024310 90 $511.00 $682.00 $726.00 $770.00 $682.00 $726.00 $770.0024320 90 $944.00 $1,142.00 $1,220.00 $1,309.00 $1,142.00 $1,220.00 $1,309.0024330 90 $845.00 $1,048.00 $1,120.00 $1,200.00 $1,048.00 $1,120.00 $1,200.0024331 90 $927.00 $1,150.00 $1,228.00 $1,318.00 $1,150.00 $1,228.00 $1,318.0024332 90 $487.00 $890.00 $951.00 $1,016.00 $890.00 $951.00 $1,016.0024340 90 $697.00 $890.00 $949.00 $1,012.00 $890.00 $949.00 $1,012.0024341 90 $702.00 $1,083.00 $1,156.00 $1,229.00 $1,083.00 $1,156.00 $1,229.0024342 90 $950.00 $1,131.00 $1,206.00 $1,288.00 $1,131.00 $1,206.00 $1,288.0024343 90 $643.00 $1,024.00 $1,092.00 $1,161.00 $1,024.00 $1,092.00 $1,161.00



Surgery







24344 90 $971.00 $1,603.00 $1,712.00 $1,835.00 $1,603.00 $1,712.00 $1,835.0024345 90 $643.00 $1,021.00 $1,089.00 $1,159.00 $1,021.00 $1,089.00 $1,159.0024346 90 $971.00 $1,598.00 $1,704.00 $1,822.00 $1,598.00 $1,704.00 $1,822.0024357 90 -------- $618.00 $657.00 $693.00 $618.00 $657.00 $693.0024358 90 -------- $756.00 $806.00 $856.00 $756.00 $806.00 $856.0024359 90 -------- $958.00 $1,021.00 $1,088.00 $958.00 $1,021.00 $1,088.0024360 90 $1,125.00 $1,295.00 $1,381.00 $1,478.00 $1,295.00 $1,381.00 $1,478.0024361 90 $1,215.00 $1,462.00 $1,561.00 $1,677.00 $1,462.00 $1,561.00 $1,677.0024362 90 $1,269.00 $1,556.00 $1,662.00 $1,786.00 $1,556.00 $1,662.00 $1,786.0024363 90 $1,663.00 $2,136.00 $2,275.00 $2,440.00 $2,136.00 $2,275.00 $2,440.0024365 90 $747.00 $927.00 $990.00 $1,059.00 $927.00 $990.00 $1,059.0024366 90 $850.00 $989.00 $1,055.00 $1,125.00 $989.00 $1,055.00 $1,125.0024370 90 -------- $2,288.00 $2,443.00 $2,632.00 $2,288.00 $2,443.00 $2,632.0024371 90 -------- $2,620.00 $2,791.00 $2,996.00 $2,620.00 $2,791.00 $2,996.0024400 90 $991.00 $1,191.00 $1,271.00 $1,360.00 $1,191.00 $1,271.00 $1,360.0024410 90 $1,319.00 $1,551.00 $1,656.00 $1,779.00 $1,551.00 $1,656.00 $1,779.0024420 90 $1,265.00 $1,428.00 $1,520.00 $1,618.00 $1,428.00 $1,520.00 $1,618.0024430 90 $1,209.00 $1,546.00 $1,648.00 $1,766.00 $1,546.00 $1,648.00 $1,766.0024435 90 $1,260.00 $1,573.00 $1,678.00 $1,794.00 $1,573.00 $1,678.00 $1,794.0024470 90 $774.00 $822.00 $868.00 $916.00 $822.00 $868.00 $916.0024495 90 $742.00 $950.00 $1,017.00 $1,090.00 $950.00 $1,017.00 $1,090.0024498 90 $1,076.00 $1,266.00 $1,351.00 $1,446.00 $1,266.00 $1,351.00 $1,446.0024500 90 $288.00 $508.00 $543.00 $568.00 $465.00 $496.00 $521.0024505 90 $574.00 $714.00 $762.00 $804.00 $650.00 $693.00 $734.0024515 90 $1,018.00 $1,279.00 $1,364.00 $1,458.00 $1,279.00 $1,364.00 $1,458.0024516 90 $1,029.00 $1,258.00 $1,343.00 $1,439.00 $1,258.00 $1,343.00 $1,439.0024530 90 $88.00 $541.00 $578.00 $606.00 $492.00 $525.00 $554.0024535 90 $671.00 $883.00 $942.00 $998.00 $819.00 $874.00 $930.0024538 90 $850.00 $1,082.00 $1,156.00 $1,235.00 $1,082.00 $1,156.00 $1,235.0024545 90 $946.00 $1,358.00 $1,449.00 $1,551.00 $1,358.00 $1,449.00 $1,551.0024546 90 $1,273.00 $1,520.00 $1,621.00 $1,737.00 $1,520.00 $1,621.00 $1,737.0024560 90 $266.00 $453.00 $483.00 $504.00 $408.00 $434.00 $455.0024565 90 $526.00 $760.00 $813.00 $860.00 $702.00 $750.00 $797.0024566 90 $705.00 $1,042.00 $1,114.00 $1,188.00 $1,042.00 $1,114.00 $1,188.0024575 90 $872.00 $1,062.00 $1,132.00 $1,207.00 $1,062.00 $1,132.00 $1,207.0024576 90 $295.00 $481.00 $513.00 $536.00 $434.00 $463.00 $486.0024577 90 $575.00 $780.00 $833.00 $881.00 $720.00 $768.00 $816.0024579 90 $964.00 $1,218.00 $1,300.00 $1,389.00 $1,218.00 $1,300.00 $1,389.0024582 90 $773.00 $1,168.00 $1,246.00 $1,325.00 $1,168.00 $1,246.00 $1,325.0024586 90 $1,314.00 $1,586.00 $1,690.00 $1,811.00 $1,586.00 $1,690.00 $1,811.0024587 90 $1,278.00 $1,581.00 $1,683.00 $1,801.00 $1,581.00 $1,683.00 $1,801.0024600 90 $360.00 $519.00 $551.00 $579.00 $478.00 $507.00 $535.0024605 90 $371.00 $678.00 $724.00 $769.00 $678.00 $724.00 $769.0024615 90 $836.00 $1,038.00 $1,107.00 $1,183.00 $1,038.00 $1,107.00 $1,183.0024620 90 $560.00 $794.00 $846.00 $898.00 $794.00 $846.00 $898.0024635 90 $1,329.00 $978.00 $1,043.00 $1,112.00 $978.00 $1,043.00 $1,112.0024650 90 $262.00 $369.00 $394.00 $411.00 $341.00 $363.00 $380.0024655 90 $436.00 $620.00 $660.00 $693.00 $567.00 $604.00 $637.0024665 90 $749.00 $945.00 $1,008.00 $1,072.00 $945.00 $1,008.00 $1,072.0024666 90 $905.00 $1,066.00 $1,137.00 $1,213.00 $1,066.00 $1,137.00 $1,213.00



Surgery







24670 90 $263.00 $412.00 $440.00 $460.00 $374.00 $399.00 $419.0024675 90 $490.00 $648.00 $691.00 $728.00 $594.00 $634.00 $670.0024685 90 $819.00 $949.00 $1,013.00 $1,078.00 $949.00 $1,013.00 $1,078.0024800 90 $984.00 $1,212.00 $1,295.00 $1,388.00 $1,212.00 $1,295.00 $1,388.0024802 90 $1,181.00 $1,431.00 $1,524.00 $1,630.00 $1,431.00 $1,524.00 $1,630.0024900 90 $858.00 $1,069.00 $1,141.00 $1,223.00 $1,069.00 $1,141.00 $1,223.0024920 90 $851.00 $1,067.00 $1,139.00 $1,219.00 $1,067.00 $1,139.00 $1,219.0024925 90 $661.00 $800.00 $855.00 $915.00 $800.00 $855.00 $915.0024930 90 $928.00 $1,125.00 $1,202.00 $1,291.00 $1,125.00 $1,202.00 $1,291.0024931 90 $1,063.00 $1,168.00 $1,233.00 $1,305.00 $1,168.00 $1,233.00 $1,305.0024935 90 $1,327.00 $1,637.00 $1,752.00 $1,898.00 $1,637.00 $1,752.00 $1,898.0024940 90 BR -------- -------- -------- -------- -------- --------24999 YYY BR -------- -------- -------- -------- -------- --------25000 90 $381.00 $482.00 $515.00 $542.00 $482.00 $515.00 $542.0025001 90 $294.00 $490.00 $523.00 $551.00 $490.00 $523.00 $551.0025020 90 $594.00 $822.00 $877.00 $921.00 $822.00 $877.00 $921.0025023 90 $1,040.00 $1,593.00 $1,699.00 $1,805.00 $1,593.00 $1,699.00 $1,805.0025024 90 $683.00 $1,128.00 $1,204.00 $1,290.00 $1,128.00 $1,204.00 $1,290.0025025 90 $1,104.00 $1,765.00 $1,879.00 $2,013.00 $1,765.00 $1,879.00 $2,013.0025028 90 $417.00 $749.00 $801.00 $844.00 $749.00 $801.00 $844.0025031 90 $266.00 $518.00 $553.00 $586.00 $518.00 $553.00 $586.0025035 90 $794.00 $839.00 $894.00 $951.00 $839.00 $894.00 $951.0025040 90 $654.00 $815.00 $868.00 $923.00 $815.00 $868.00 $923.0025065 10 $164.00 $358.00 $381.00 $394.00 $235.00 $250.00 $262.0025066 90 $322.00 $518.00 $554.00 $587.00 $518.00 $554.00 $587.0025071 90 -------- $624.00 $667.00 $717.00 $624.00 $667.00 $717.0025073 90 -------- $775.00 $827.00 $883.00 $775.00 $827.00 $883.0025075 90 $352.00 $679.00 $726.00 $760.00 $460.00 $492.00 $524.0025076 90 $544.00 $749.00 $799.00 $851.00 $749.00 $799.00 $851.0025077 90 $957.00 $1,300.00 $1,389.00 $1,497.00 $1,300.00 $1,389.00 $1,497.0025078 90 -------- $1,714.00 $1,831.00 $1,976.00 $1,714.00 $1,831.00 $1,976.0025085 90 $562.00 $649.00 $692.00 $734.00 $649.00 $692.00 $734.0025100 90 $420.00 $497.00 $531.00 $564.00 $497.00 $531.00 $564.0025101 90 $492.00 $580.00 $618.00 $654.00 $580.00 $618.00 $654.0025105 90 $635.00 $695.00 $740.00 $784.00 $695.00 $740.00 $784.0025107 90 $600.00 $888.00 $946.00 $1,002.00 $888.00 $946.00 $1,002.0025109 90 -------- $776.00 $826.00 $875.00 $776.00 $826.00 $875.0025110 90 $403.00 $493.00 $527.00 $558.00 $493.00 $527.00 $558.0025111 90 $356.00 $460.00 $491.00 $518.00 $460.00 $491.00 $518.0025112 90 $441.00 $557.00 $594.00 $630.00 $557.00 $594.00 $630.0025115 90 $837.00 $1,098.00 $1,170.00 $1,243.00 $1,098.00 $1,170.00 $1,243.0025116 90 $807.00 $864.00 $920.00 $974.00 $864.00 $920.00 $974.0025118 90 $466.00 $549.00 $585.00 $618.00 $549.00 $585.00 $618.0025119 90 $653.00 $713.00 $760.00 $804.00 $713.00 $760.00 $804.0025120 90 $712.00 $717.00 $765.00 $811.00 $717.00 $765.00 $811.0025125 90 $803.00 $844.00 $900.00 $961.00 $844.00 $900.00 $961.0025126 90 $781.00 $863.00 $922.00 $984.00 $863.00 $922.00 $984.0025130 90 $502.00 $642.00 $683.00 $721.00 $642.00 $683.00 $721.0025135 90 $631.00 $802.00 $857.00 $913.00 $802.00 $857.00 $913.0025136 90 $546.00 $709.00 $758.00 $808.00 $709.00 $758.00 $808.00



Surgery







25145 90 $713.00 $750.00 $801.00 $854.00 $750.00 $801.00 $854.0025150 90 $720.00 $821.00 $876.00 $934.00 $821.00 $876.00 $934.0025151 90 $771.00 $847.00 $905.00 $966.00 $847.00 $905.00 $966.0025170 90 $1,085.00 $2,180.00 $2,327.00 $2,508.00 $2,180.00 $2,327.00 $2,508.0025210 90 $561.00 $702.00 $747.00 $789.00 $702.00 $747.00 $789.0025215 90 $817.00 $893.00 $951.00 $1,010.00 $893.00 $951.00 $1,010.0025230 90 $531.00 $624.00 $665.00 $705.00 $624.00 $665.00 $705.0025240 90 $567.00 $615.00 $655.00 $691.00 $615.00 $655.00 $691.0025246 0 $72.00 $227.00 $241.00 $247.00 $110.00 $115.00 $120.0025248 90 $236.00 $603.00 $644.00 $687.00 $603.00 $644.00 $687.0025250 90 $616.00 $754.00 $801.00 $844.00 $754.00 $801.00 $844.0025251 90 $933.00 $1,047.00 $1,118.00 $1,199.00 $1,047.00 $1,118.00 $1,199.0025259 90 $348.00 $592.00 $632.00 $662.00 $592.00 $632.00 $662.0025260 90 $728.00 $910.00 $970.00 $1,029.00 $910.00 $970.00 $1,029.0025263 90 $809.00 $898.00 $956.00 $1,014.00 $898.00 $956.00 $1,014.0025265 90 $998.00 $1,089.00 $1,162.00 $1,242.00 $1,089.00 $1,162.00 $1,242.0025270 90 $549.00 $705.00 $751.00 $795.00 $705.00 $751.00 $795.0025272 90 $613.00 $800.00 $852.00 $906.00 $800.00 $852.00 $906.0025274 90 $887.00 $962.00 $1,024.00 $1,089.00 $962.00 $1,024.00 $1,089.0025275 90 $620.00 $973.00 $1,037.00 $1,102.00 $973.00 $1,037.00 $1,102.0025280 90 $670.00 $813.00 $865.00 $916.00 $813.00 $865.00 $916.0025290 90 $436.00 $629.00 $671.00 $710.00 $629.00 $671.00 $710.0025295 90 $562.00 $756.00 $805.00 $855.00 $756.00 $805.00 $855.0025300 90 $592.00 $987.00 $1,051.00 $1,116.00 $987.00 $1,051.00 $1,116.0025301 90 $757.00 $932.00 $993.00 $1,057.00 $932.00 $993.00 $1,057.0025310 90 $865.00 $896.00 $954.00 $1,013.00 $896.00 $954.00 $1,013.0025312 90 $968.00 $1,037.00 $1,104.00 $1,174.00 $1,037.00 $1,104.00 $1,174.0025315 90 $1,004.00 $1,125.00 $1,201.00 $1,286.00 $1,125.00 $1,201.00 $1,286.0025316 90 $1,203.00 $1,338.00 $1,429.00 $1,534.00 $1,338.00 $1,429.00 $1,534.0025320 90 $834.00 $1,428.00 $1,521.00 $1,614.00 $1,428.00 $1,521.00 $1,614.0025332 90 $1,022.00 $1,223.00 $1,302.00 $1,387.00 $1,223.00 $1,302.00 $1,387.0025335 90 $1,166.00 $1,175.00 $1,239.00 $1,312.00 $1,175.00 $1,239.00 $1,312.0025337 90 $946.00 $1,287.00 $1,371.00 $1,456.00 $1,287.00 $1,371.00 $1,456.0025350 90 $913.00 $976.00 $1,040.00 $1,106.00 $976.00 $1,040.00 $1,106.0025355 90 $1,014.00 $1,097.00 $1,169.00 $1,250.00 $1,097.00 $1,169.00 $1,250.0025360 90 $468.00 $948.00 $1,010.00 $1,075.00 $948.00 $1,010.00 $1,075.0025365 90 $1,216.00 $1,332.00 $1,421.00 $1,522.00 $1,332.00 $1,421.00 $1,522.0025370 90 $1,214.00 $1,469.00 $1,567.00 $1,677.00 $1,469.00 $1,567.00 $1,677.0025375 90 $1,280.00 $1,395.00 $1,490.00 $1,600.00 $1,395.00 $1,490.00 $1,600.0025390 90 $1,043.00 $1,118.00 $1,190.00 $1,268.00 $1,118.00 $1,190.00 $1,268.0025391 90 $1,349.00 $1,460.00 $1,559.00 $1,675.00 $1,460.00 $1,559.00 $1,675.0025392 90 $1,294.00 $1,267.00 $1,336.00 $1,415.00 $1,267.00 $1,336.00 $1,415.0025393 90 $1,473.00 $1,649.00 $1,751.00 $1,863.00 $1,649.00 $1,751.00 $1,863.0025394 90 $723.00 $1,137.00 $1,214.00 $1,299.00 $1,137.00 $1,214.00 $1,299.0025400 90 $1,112.00 $1,170.00 $1,247.00 $1,332.00 $1,170.00 $1,247.00 $1,332.0025405 90 $1,388.00 $1,513.00 $1,612.00 $1,723.00 $1,513.00 $1,612.00 $1,723.0025415 90 $1,343.00 $1,409.00 $1,503.00 $1,613.00 $1,409.00 $1,503.00 $1,613.0025420 90 $1,554.00 $1,710.00 $1,825.00 $1,959.00 $1,710.00 $1,825.00 $1,959.0025425 90 $1,403.00 $1,411.00 $1,507.00 $1,618.00 $1,411.00 $1,507.00 $1,618.0025426 90 $1,401.00 $1,651.00 $1,762.00 $1,896.00 $1,651.00 $1,762.00 $1,896.00



Surgery







25430 90 $638.00 $1,066.00 $1,138.00 $1,217.00 $1,066.00 $1,138.00 $1,217.0025431 90 $631.00 $1,146.00 $1,222.00 $1,307.00 $1,146.00 $1,222.00 $1,307.0025440 90 $931.00 $1,113.00 $1,185.00 $1,262.00 $1,113.00 $1,185.00 $1,262.0025441 90 $1,147.00 $1,354.00 $1,436.00 $1,520.00 $1,354.00 $1,436.00 $1,520.0025442 90 $936.00 $1,169.00 $1,244.00 $1,322.00 $1,169.00 $1,244.00 $1,322.0025443 90 $970.00 $1,141.00 $1,219.00 $1,306.00 $1,141.00 $1,219.00 $1,306.0025444 90 $1,031.00 $1,207.00 $1,289.00 $1,382.00 $1,207.00 $1,289.00 $1,382.0025445 90 $959.00 $1,050.00 $1,119.00 $1,194.00 $1,050.00 $1,119.00 $1,194.0025446 90 $1,542.00 $1,707.00 $1,816.00 $1,939.00 $1,707.00 $1,816.00 $1,939.0025447 90 $952.00 $1,199.00 $1,277.00 $1,358.00 $1,199.00 $1,277.00 $1,358.0025449 90 $395.00 $1,505.00 $1,601.00 $1,708.00 $1,505.00 $1,601.00 $1,708.0025450 90 $805.00 $751.00 $793.00 $836.00 $751.00 $793.00 $836.0025455 90 $899.00 $890.00 $940.00 $992.00 $890.00 $940.00 $992.0025490 90 $955.00 $1,049.00 $1,121.00 $1,200.00 $1,049.00 $1,121.00 $1,200.0025491 90 $1,006.00 $1,080.00 $1,154.00 $1,236.00 $1,080.00 $1,154.00 $1,236.0025492 90 $1,170.00 $1,323.00 $1,413.00 $1,516.00 $1,323.00 $1,413.00 $1,516.0025500 90 $200.00 $387.00 $413.00 $431.00 $357.00 $380.00 $398.0025505 90 $517.00 $718.00 $766.00 $805.00 $661.00 $704.00 $744.0025515 90 $800.00 $972.00 $1,037.00 $1,105.00 $972.00 $1,037.00 $1,105.0025520 90 $644.00 $804.00 $859.00 $910.00 $766.00 $817.00 $868.0025525 90 $1,097.00 $1,141.00 $1,217.00 $1,298.00 $1,141.00 $1,217.00 $1,298.0025526 90 $1,293.00 $1,387.00 $1,479.00 $1,581.00 $1,387.00 $1,479.00 $1,581.0025530 90 $270.00 $370.00 $395.00 $412.00 $337.00 $360.00 $376.0025535 90 $516.00 $700.00 $747.00 $787.00 $651.00 $694.00 $735.0025545 90 $803.00 $902.00 $963.00 $1,024.00 $902.00 $963.00 $1,024.0025560 90 $276.00 $393.00 $419.00 $436.00 $357.00 $380.00 $398.0025565 90 $590.00 $743.00 $792.00 $835.00 $676.00 $720.00 $763.0025574 90 $804.00 $976.00 $1,042.00 $1,110.00 $976.00 $1,042.00 $1,110.0025575 90 $974.00 $1,313.00 $1,401.00 $1,497.00 $1,313.00 $1,401.00 $1,497.0025600 90 $312.00 $463.00 $494.00 $515.00 $439.00 $468.00 $489.0025605 90 $540.00 $782.00 $833.00 $879.00 $738.00 $786.00 $832.0025606 90 -------- $961.00 $1,026.00 $1,094.00 $961.00 $1,026.00 $1,094.0025607 90 -------- $1,066.00 $1,137.00 $1,211.00 $1,066.00 $1,137.00 $1,211.0025608 90 -------- $1,197.00 $1,277.00 $1,362.00 $1,197.00 $1,277.00 $1,362.0025609 90 -------- $1,524.00 $1,624.00 $1,733.00 $1,524.00 $1,624.00 $1,733.0025622 90 $148.00 $430.00 $458.00 $478.00 $393.00 $419.00 $438.0025624 90 $482.00 $678.00 $724.00 $762.00 $621.00 $663.00 $701.0025628 90 $716.00 $1,046.00 $1,114.00 $1,186.00 $1,046.00 $1,114.00 $1,186.0025630 90 $148.00 $433.00 $461.00 $483.00 $400.00 $426.00 $447.0025635 90 $458.00 $606.00 $645.00 $675.00 $545.00 $579.00 $608.0025645 90 $668.00 $824.00 $880.00 $938.00 $824.00 $880.00 $938.0025650 90 $185.00 $454.00 $484.00 $506.00 $427.00 $455.00 $477.0025651 90 $379.00 $697.00 $742.00 $784.00 $697.00 $742.00 $784.0025652 90 $560.00 $905.00 $965.00 $1,027.00 $905.00 $965.00 $1,027.0025660 90 $378.00 $585.00 $623.00 $657.00 $585.00 $623.00 $657.0025670 90 $731.00 $879.00 $937.00 $998.00 $879.00 $937.00 $998.0025671 90 $462.00 $767.00 $819.00 $870.00 $767.00 $819.00 $870.0025675 90 $404.00 $617.00 $657.00 $688.00 $566.00 $601.00 $632.0025676 90 $741.00 $909.00 $969.00 $1,031.00 $909.00 $969.00 $1,031.0025680 90 $471.00 $680.00 $722.00 $762.00 $680.00 $722.00 $762.00



Surgery







25685 90 $887.00 $1,068.00 $1,140.00 $1,221.00 $1,068.00 $1,140.00 $1,221.0025690 90 $518.00 $686.00 $733.00 $777.00 $686.00 $733.00 $777.0025695 90 $520.00 $923.00 $986.00 $1,054.00 $923.00 $986.00 $1,054.0025800 90 $703.00 $1,063.00 $1,132.00 $1,205.00 $1,063.00 $1,132.00 $1,205.0025805 90 $1,078.00 $1,234.00 $1,318.00 $1,413.00 $1,234.00 $1,318.00 $1,413.0025810 90 $1,008.00 $1,259.00 $1,340.00 $1,426.00 $1,259.00 $1,340.00 $1,426.0025820 90 $2,276.00 $887.00 $945.00 $1,000.00 $887.00 $945.00 $1,000.0025825 90 $895.00 $1,093.00 $1,164.00 $1,233.00 $1,093.00 $1,164.00 $1,233.0025830 90 $991.00 $1,358.00 $1,448.00 $1,527.00 $1,358.00 $1,448.00 $1,527.0025900 90 $871.00 $1,030.00 $1,099.00 $1,173.00 $1,030.00 $1,099.00 $1,173.0025905 90 $900.00 $956.00 $1,026.00 $1,117.00 $956.00 $1,026.00 $1,117.0025907 90 $799.00 $848.00 $905.00 $968.00 $848.00 $905.00 $968.0025909 90 $849.00 $999.00 $1,067.00 $1,143.00 $999.00 $1,067.00 $1,143.0025915 90 $1,523.00 $1,726.00 $1,838.00 $1,968.00 $1,726.00 $1,838.00 $1,968.0025920 90 $771.00 $1,009.00 $1,079.00 $1,153.00 $1,009.00 $1,079.00 $1,153.0025922 90 $670.00 $835.00 $892.00 $955.00 $835.00 $892.00 $955.0025924 90 $768.00 $887.00 $945.00 $1,010.00 $887.00 $945.00 $1,010.0025927 90 $830.00 $1,171.00 $1,252.00 $1,328.00 $1,171.00 $1,252.00 $1,328.0025929 90 $645.00 $861.00 $920.00 $985.00 $861.00 $920.00 $985.0025931 90 $731.00 $966.00 $1,036.00 $1,113.00 $966.00 $1,036.00 $1,113.0025999 YYY BR -------- -------- -------- -------- -------- --------26010 10 $59.00 $367.00 $392.00 $401.00 $196.00 $208.00 $217.0026011 10 $223.00 $543.00 $581.00 $598.00 $266.00 $283.00 $299.0026020 90 $484.00 $624.00 $666.00 $704.00 $624.00 $666.00 $704.0026025 90 $548.00 $609.00 $649.00 $687.00 $609.00 $649.00 $687.0026030 90 $655.00 $710.00 $756.00 $801.00 $710.00 $756.00 $801.0026034 90 $601.00 $776.00 $827.00 $878.00 $776.00 $827.00 $878.0026035 90 $741.00 $1,235.00 $1,313.00 $1,389.00 $1,235.00 $1,313.00 $1,389.0026037 90 $730.00 $822.00 $875.00 $931.00 $822.00 $875.00 $931.0026040 90 $367.00 $446.00 $475.00 $500.00 $446.00 $475.00 $500.0026045 90 $621.00 $677.00 $723.00 $767.00 $677.00 $723.00 $767.0026055 90 $343.00 $778.00 $833.00 $858.00 $443.00 $473.00 $496.0026060 90 $293.00 $379.00 $404.00 $425.00 $379.00 $404.00 $425.0026070 90 $440.00 $450.00 $479.00 $504.00 $450.00 $479.00 $504.0026075 90 $400.00 $478.00 $509.00 $537.00 $478.00 $509.00 $537.0026080 90 $382.00 $560.00 $597.00 $631.00 $560.00 $597.00 $631.0026100 90 $398.00 $480.00 $512.00 $543.00 $480.00 $512.00 $543.0026105 90 $481.00 $478.00 $510.00 $538.00 $478.00 $510.00 $538.0026110 90 $282.00 $461.00 $491.00 $518.00 $461.00 $491.00 $518.0026111 90 -------- $605.00 $645.00 $685.00 $605.00 $645.00 $685.0026113 90 -------- $793.00 $845.00 $897.00 $793.00 $845.00 $897.0026115 90 $344.00 $711.00 $759.00 $790.00 $479.00 $511.00 $540.0026116 90 $544.00 $762.00 $812.00 $862.00 $762.00 $812.00 $862.0026117 90 $806.00 $1,088.00 $1,159.00 $1,234.00 $1,088.00 $1,159.00 $1,234.0026118 90 -------- $1,532.00 $1,632.00 $1,743.00 $1,532.00 $1,632.00 $1,743.0026121 90 $833.00 $864.00 $921.00 $978.00 $864.00 $921.00 $978.0026123 90 $959.00 $1,207.00 $1,286.00 $1,366.00 $1,207.00 $1,286.00 $1,366.0026125 ZZZ $342.00 $405.00 $431.00 $464.00 $405.00 $431.00 $464.0026130 90 $629.00 $669.00 $714.00 $760.00 $669.00 $714.00 $760.0026135 90 $668.00 $793.00 $844.00 $894.00 $793.00 $844.00 $894.00



Surgery







26140 90 $678.00 $727.00 $774.00 $820.00 $727.00 $774.00 $820.0026145 90 $660.00 $739.00 $787.00 $836.00 $739.00 $787.00 $836.0026160 90 $319.00 $803.00 $859.00 $887.00 $478.00 $510.00 $536.0026170 90 $452.00 $581.00 $619.00 $653.00 $581.00 $619.00 $653.0026180 90 $444.00 $636.00 $676.00 $714.00 $636.00 $676.00 $714.0026185 90 $511.00 $779.00 $827.00 $869.00 $779.00 $827.00 $869.0026200 90 $598.00 $649.00 $691.00 $732.00 $649.00 $691.00 $732.0026205 90 $788.00 $877.00 $937.00 $1,002.00 $877.00 $937.00 $1,002.0026210 90 $543.00 $636.00 $678.00 $717.00 $636.00 $678.00 $717.0026215 90 $731.00 $818.00 $874.00 $934.00 $818.00 $874.00 $934.0026230 90 $624.00 $720.00 $766.00 $812.00 $720.00 $766.00 $812.0026235 90 $612.00 $712.00 $758.00 $803.00 $712.00 $758.00 $803.0026236 90 $444.00 $636.00 $678.00 $718.00 $636.00 $678.00 $718.0026250 90 $814.00 $1,565.00 $1,663.00 $1,766.00 $1,565.00 $1,663.00 $1,766.0026260 90 $758.00 $1,162.00 $1,235.00 $1,310.00 $1,162.00 $1,235.00 $1,310.0026262 90 $624.00 $901.00 $956.00 $1,007.00 $901.00 $956.00 $1,007.0026320 90 $414.00 $498.00 $531.00 $561.00 $498.00 $531.00 $561.0026340 90 $266.00 $472.00 $505.00 $526.00 $472.00 $505.00 $526.0026341 10 -------- $140.00 $150.00 $156.00 $108.00 $115.00 $122.0026350 90 $715.00 $996.00 $1,064.00 $1,110.00 $996.00 $1,064.00 $1,110.0026352 90 $855.00 $1,156.00 $1,237.00 $1,302.00 $1,156.00 $1,237.00 $1,302.0026356 90 $886.00 $1,254.00 $1,337.00 $1,407.00 $1,254.00 $1,337.00 $1,407.0026357 90 $932.00 $1,243.00 $1,327.00 $1,412.00 $1,243.00 $1,327.00 $1,412.0026358 90 $979.00 $1,384.00 $1,478.00 $1,576.00 $1,384.00 $1,478.00 $1,576.0026370 90 $832.00 $1,064.00 $1,135.00 $1,188.00 $1,064.00 $1,135.00 $1,188.0026372 90 $945.00 $1,244.00 $1,328.00 $1,398.00 $1,244.00 $1,328.00 $1,398.0026373 90 $904.00 $1,194.00 $1,276.00 $1,343.00 $1,194.00 $1,276.00 $1,343.0026390 90 $889.00 $1,193.00 $1,276.00 $1,353.00 $1,193.00 $1,276.00 $1,353.0026392 90 $1,123.00 $1,374.00 $1,468.00 $1,551.00 $1,374.00 $1,468.00 $1,551.0026410 90 $371.00 $791.00 $845.00 $882.00 $791.00 $845.00 $882.0026412 90 $737.00 $957.00 $1,022.00 $1,071.00 $957.00 $1,022.00 $1,071.0026415 90 $846.00 $1,089.00 $1,161.00 $1,223.00 $1,089.00 $1,161.00 $1,223.0026416 90 $1,093.00 $1,031.00 $1,096.00 $1,158.00 $1,031.00 $1,096.00 $1,158.0026418 90 $444.00 $805.00 $860.00 $894.00 $805.00 $860.00 $894.0026420 90 $741.00 $994.00 $1,060.00 $1,111.00 $994.00 $1,060.00 $1,111.0026426 90 $733.00 $723.00 $770.00 $816.00 $723.00 $770.00 $816.0026428 90 $790.00 $1,063.00 $1,136.00 $1,193.00 $1,063.00 $1,136.00 $1,193.0026432 90 $430.00 $697.00 $744.00 $775.00 $697.00 $744.00 $775.0026433 90 $371.00 $744.00 $794.00 $829.00 $744.00 $794.00 $829.0026434 90 $656.00 $912.00 $974.00 $1,024.00 $912.00 $974.00 $1,024.0026437 90 $491.00 $875.00 $934.00 $978.00 $875.00 $934.00 $978.0026440 90 $458.00 $864.00 $922.00 $960.00 $864.00 $922.00 $960.0026442 90 $548.00 $1,359.00 $1,449.00 $1,521.00 $1,359.00 $1,449.00 $1,521.0026445 90 $455.00 $803.00 $857.00 $891.00 $803.00 $857.00 $891.0026449 90 $738.00 $1,000.00 $1,064.00 $1,125.00 $1,000.00 $1,064.00 $1,125.0026450 90 $353.00 $573.00 $612.00 $640.00 $573.00 $612.00 $640.0026455 90 $364.00 $563.00 $601.00 $627.00 $563.00 $601.00 $627.0026460 90 $346.00 $553.00 $590.00 $617.00 $553.00 $590.00 $617.0026471 90 $592.00 $861.00 $918.00 $959.00 $861.00 $918.00 $959.0026474 90 $586.00 $846.00 $904.00 $949.00 $846.00 $904.00 $949.00



Surgery







26476 90 $543.00 $808.00 $861.00 $896.00 $808.00 $861.00 $896.0026477 90 $553.00 $813.00 $867.00 $906.00 $813.00 $867.00 $906.0026478 90 $608.00 $871.00 $929.00 $972.00 $871.00 $929.00 $972.0026479 90 $653.00 $857.00 $912.00 $951.00 $857.00 $912.00 $951.0026480 90 $808.00 $1,051.00 $1,120.00 $1,168.00 $1,051.00 $1,120.00 $1,168.0026483 90 $986.00 $1,188.00 $1,267.00 $1,330.00 $1,188.00 $1,267.00 $1,330.0026485 90 $891.00 $1,135.00 $1,211.00 $1,268.00 $1,135.00 $1,211.00 $1,268.0026489 90 $738.00 $1,283.00 $1,364.00 $1,426.00 $1,283.00 $1,364.00 $1,426.0026490 90 $496.00 $1,110.00 $1,183.00 $1,243.00 $1,110.00 $1,183.00 $1,243.0026492 90 $971.00 $1,232.00 $1,310.00 $1,375.00 $1,232.00 $1,310.00 $1,375.0026494 90 $946.00 $1,116.00 $1,190.00 $1,253.00 $1,116.00 $1,190.00 $1,253.0026496 90 $949.00 $1,214.00 $1,293.00 $1,361.00 $1,214.00 $1,293.00 $1,361.0026497 90 $946.00 $1,235.00 $1,320.00 $1,400.00 $1,235.00 $1,320.00 $1,400.0026498 90 $1,317.00 $1,642.00 $1,754.00 $1,869.00 $1,642.00 $1,754.00 $1,869.0026499 90 $934.00 $1,182.00 $1,263.00 $1,338.00 $1,182.00 $1,263.00 $1,338.0026500 90 $557.00 $875.00 $933.00 $978.00 $875.00 $933.00 $978.0026502 90 $715.00 $978.00 $1,041.00 $1,088.00 $978.00 $1,041.00 $1,088.0026508 90 $334.00 $905.00 $968.00 $1,018.00 $905.00 $968.00 $1,018.0026510 90 $564.00 $831.00 $885.00 $923.00 $831.00 $885.00 $923.0026516 90 $630.00 $984.00 $1,049.00 $1,099.00 $984.00 $1,049.00 $1,099.0026517 90 $890.00 $1,170.00 $1,250.00 $1,321.00 $1,170.00 $1,250.00 $1,321.0026518 90 $877.00 $1,163.00 $1,237.00 $1,296.00 $1,163.00 $1,237.00 $1,296.0026520 90 $583.00 $908.00 $970.00 $1,011.00 $908.00 $970.00 $1,011.0026525 90 $531.00 $910.00 $971.00 $1,012.00 $910.00 $971.00 $1,012.0026530 90 $708.00 $774.00 $825.00 $874.00 $774.00 $825.00 $874.0026531 90 $877.00 $901.00 $960.00 $1,018.00 $901.00 $960.00 $1,018.0026535 90 $546.00 $605.00 $643.00 $678.00 $605.00 $643.00 $678.0026536 90 $770.00 $998.00 $1,064.00 $1,109.00 $998.00 $1,064.00 $1,109.0026540 90 $726.00 $924.00 $985.00 $1,032.00 $924.00 $985.00 $1,032.0026541 90 $926.00 $1,133.00 $1,207.00 $1,271.00 $1,133.00 $1,207.00 $1,271.0026542 90 $716.00 $953.00 $1,016.00 $1,065.00 $953.00 $1,016.00 $1,065.0026545 90 $722.00 $970.00 $1,034.00 $1,084.00 $970.00 $1,034.00 $1,084.0026546 90 $918.00 $1,404.00 $1,497.00 $1,576.00 $1,404.00 $1,497.00 $1,576.0026548 90 $665.00 $1,072.00 $1,142.00 $1,200.00 $1,072.00 $1,142.00 $1,200.0026550 90 $1,861.00 $2,219.00 $2,355.00 $2,492.00 $2,219.00 $2,355.00 $2,492.0026551 90 $3,901.00 $4,138.00 $4,364.00 $4,625.00 $4,138.00 $4,364.00 $4,625.0026553 90 $3,868.00 $4,797.00 $5,122.00 $5,514.00 $4,797.00 $5,122.00 $5,514.0026554 90 $4,551.00 $4,816.00 $5,078.00 $5,386.00 $4,816.00 $5,078.00 $5,386.0026555 90 $1,567.00 $1,924.00 $2,049.00 $2,171.00 $1,924.00 $2,049.00 $2,171.0026556 90 $4,005.00 $4,982.00 $5,321.00 $5,725.00 $4,982.00 $5,321.00 $5,725.0026560 90 $576.00 $786.00 $838.00 $875.00 $786.00 $838.00 $875.0026561 90 $1,067.00 $1,321.00 $1,406.00 $1,482.00 $1,321.00 $1,406.00 $1,482.0026562 90 $1,017.00 $1,932.00 $2,065.00 $2,201.00 $1,932.00 $2,065.00 $2,201.0026565 90 $730.00 $953.00 $1,016.00 $1,066.00 $953.00 $1,016.00 $1,066.0026567 90 $622.00 $958.00 $1,021.00 $1,071.00 $958.00 $1,021.00 $1,071.0026568 90 $1,003.00 $1,275.00 $1,363.00 $1,437.00 $1,275.00 $1,363.00 $1,437.0026580 90 $1,585.00 $2,103.00 $2,235.00 $2,367.00 $2,103.00 $2,235.00 $2,367.0026587 90 $792.00 $1,325.00 $1,402.00 $1,488.00 $1,325.00 $1,402.00 $1,488.0026590 90 $1,609.00 $1,958.00 $2,092.00 $2,247.00 $1,958.00 $2,092.00 $2,247.0026591 90 $431.00 $606.00 $647.00 $671.00 $606.00 $647.00 $671.00



Surgery







26593 90 $587.00 $839.00 $895.00 $934.00 $839.00 $895.00 $934.0026596 90 $809.00 $1,068.00 $1,134.00 $1,191.00 $1,068.00 $1,134.00 $1,191.0026600 90 $133.00 $415.00 $443.00 $461.00 $392.00 $418.00 $436.0026605 90 $296.00 $456.00 $486.00 $508.00 $417.00 $445.00 $467.0026607 90 $334.00 $654.00 $697.00 $738.00 $654.00 $697.00 $738.0026608 90 $497.00 $685.00 $730.00 $772.00 $685.00 $730.00 $772.0026615 90 $521.00 $832.00 $887.00 $940.00 $832.00 $887.00 $940.0026641 90 $71.00 $523.00 $556.00 $582.00 $479.00 $509.00 $535.0026645 90 $371.00 $603.00 $643.00 $679.00 $557.00 $594.00 $629.0026650 90 $533.00 $685.00 $731.00 $772.00 $685.00 $731.00 $772.0026665 90 $693.00 $917.00 $980.00 $1,045.00 $917.00 $980.00 $1,045.0026670 90 $148.00 $482.00 $512.00 $537.00 $440.00 $467.00 $491.0026675 90 $501.00 $646.00 $690.00 $729.00 $596.00 $637.00 $676.0026676 90 $527.00 $718.00 $766.00 $809.00 $718.00 $766.00 $809.0026685 90 $592.00 $831.00 $886.00 $939.00 $831.00 $886.00 $939.0026686 90 $710.00 $907.00 $969.00 $1,036.00 $907.00 $969.00 $1,036.0026700 90 $88.00 $458.00 $487.00 $510.00 $432.00 $458.00 $481.0026705 90 $296.00 $594.00 $633.00 $665.00 $547.00 $583.00 $615.0026706 90 $469.00 $633.00 $675.00 $714.00 $633.00 $675.00 $714.0026715 90 $526.00 $824.00 $878.00 $929.00 $824.00 $878.00 $929.0026720 90 $96.00 $279.00 $297.00 $309.00 $260.00 $277.00 $289.0026725 90 $187.00 $478.00 $510.00 $534.00 $434.00 $462.00 $486.0026727 90 $187.00 $673.00 $718.00 $759.00 $673.00 $718.00 $759.0026735 90 $532.00 $861.00 $918.00 $974.00 $861.00 $918.00 $974.0026740 90 $148.00 $325.00 $347.00 $362.00 $306.00 $327.00 $342.0026742 90 $148.00 $524.00 $559.00 $587.00 $479.00 $510.00 $538.0026746 90 $548.00 $1,074.00 $1,144.00 $1,217.00 $1,074.00 $1,144.00 $1,217.0026750 90 $96.00 $260.00 $276.00 $288.00 $260.00 $277.00 $288.0026755 90 $133.00 $444.00 $473.00 $493.00 $389.00 $413.00 $434.0026756 90 $366.00 $597.00 $637.00 $670.00 $597.00 $637.00 $670.0026765 90 $398.00 $720.00 $768.00 $811.00 $720.00 $768.00 $811.0026770 90 $79.00 $390.00 $413.00 $432.00 $362.00 $384.00 $402.0026775 90 $275.00 $543.00 $579.00 $606.00 $494.00 $526.00 $553.0026776 90 $401.00 $635.00 $677.00 $714.00 $635.00 $677.00 $714.0026785 90 $408.00 $789.00 $841.00 $891.00 $789.00 $841.00 $891.0026820 90 $854.00 $1,116.00 $1,192.00 $1,259.00 $1,116.00 $1,192.00 $1,259.0026841 90 $756.00 $1,023.00 $1,091.00 $1,146.00 $1,023.00 $1,091.00 $1,146.0026842 90 $901.00 $1,111.00 $1,185.00 $1,248.00 $1,111.00 $1,185.00 $1,248.0026843 90 $800.00 $1,048.00 $1,121.00 $1,185.00 $1,048.00 $1,121.00 $1,185.0026844 90 $875.00 $1,145.00 $1,219.00 $1,279.00 $1,145.00 $1,219.00 $1,279.0026850 90 $704.00 $973.00 $1,037.00 $1,088.00 $973.00 $1,037.00 $1,088.0026852 90 $829.00 $1,123.00 $1,197.00 $1,259.00 $1,123.00 $1,197.00 $1,259.0026860 90 $542.00 $789.00 $843.00 $879.00 $789.00 $843.00 $879.0026861 ZZZ $151.00 $153.00 $162.00 $175.00 $153.00 $162.00 $175.0026862 90 $747.00 $1,023.00 $1,091.00 $1,145.00 $1,023.00 $1,091.00 $1,145.0026863 ZZZ $317.00 $342.00 $365.00 $396.00 $342.00 $365.00 $396.0026910 90 $747.00 $1,020.00 $1,088.00 $1,148.00 $1,020.00 $1,088.00 $1,148.0026951 90 $444.00 $919.00 $981.00 $1,028.00 $919.00 $981.00 $1,028.0026952 90 $608.00 $908.00 $968.00 $1,016.00 $908.00 $968.00 $1,016.0026989 YYY BR -------- -------- -------- -------- -------- --------



Surgery







26990 90 $592.00 $908.00 $970.00 $1,036.00 $908.00 $970.00 $1,036.0026991 90 $466.00 $1,004.00 $1,072.00 $1,127.00 $758.00 $809.00 $863.0026992 90 $1,146.00 $1,398.00 $1,490.00 $1,592.00 $1,398.00 $1,490.00 $1,592.0027000 90 $421.00 $603.00 $640.00 $677.00 $603.00 $640.00 $677.0027001 90 $550.00 $780.00 $832.00 $887.00 $780.00 $832.00 $887.0027003 90 $698.00 $866.00 $925.00 $987.00 $866.00 $925.00 $987.0027005 90 $738.00 $1,055.00 $1,125.00 $1,202.00 $1,055.00 $1,125.00 $1,202.0027006 90 $788.00 $1,071.00 $1,142.00 $1,219.00 $1,071.00 $1,142.00 $1,219.0027025 90 $896.00 $1,336.00 $1,424.00 $1,522.00 $1,336.00 $1,424.00 $1,522.0027027 90 -------- $1,319.00 $1,408.00 $1,511.00 $1,319.00 $1,408.00 $1,511.0027030 90 $1,148.00 $1,371.00 $1,463.00 $1,570.00 $1,371.00 $1,463.00 $1,570.0027033 90 $1,173.00 $1,424.00 $1,519.00 $1,630.00 $1,424.00 $1,519.00 $1,630.0027035 90 $1,413.00 $1,683.00 $1,792.00 $1,919.00 $1,683.00 $1,792.00 $1,919.0027036 90 $1,176.00 $1,477.00 $1,575.00 $1,687.00 $1,477.00 $1,575.00 $1,687.0027040 10 $196.00 $486.00 $518.00 $537.00 $291.00 $309.00 $327.0027041 90 $699.00 $1,008.00 $1,073.00 $1,148.00 $1,008.00 $1,073.00 $1,148.0027043 90 -------- $695.00 $745.00 $808.00 $695.00 $745.00 $808.0027045 90 -------- $1,104.00 $1,181.00 $1,275.00 $1,104.00 $1,181.00 $1,275.0027047 90 $535.00 $672.00 $719.00 $762.00 $531.00 $568.00 $610.0027048 90 $588.00 $900.00 $963.00 $1,040.00 $900.00 $963.00 $1,040.0027049 90 $1,162.00 $1,997.00 $2,133.00 $2,312.00 $1,997.00 $2,133.00 $2,312.0027050 90 $449.00 $554.00 $590.00 $623.00 $554.00 $590.00 $623.0027052 90 $624.00 $838.00 $895.00 $955.00 $838.00 $895.00 $955.0027054 90 $843.00 $997.00 $1,063.00 $1,135.00 $997.00 $1,063.00 $1,135.0027057 90 -------- $1,490.00 $1,591.00 $1,713.00 $1,490.00 $1,591.00 $1,713.0027059 90 -------- $2,696.00 $2,879.00 $3,120.00 $2,696.00 $2,879.00 $3,120.0027060 90 $491.00 $672.00 $718.00 $765.00 $672.00 $718.00 $765.0027062 90 $499.00 $663.00 $708.00 $755.00 $663.00 $708.00 $755.0027065 90 $583.00 $742.00 $791.00 $842.00 $742.00 $791.00 $842.0027066 90 $931.00 $1,182.00 $1,261.00 $1,347.00 $1,182.00 $1,261.00 $1,347.0027067 90 $1,234.00 $1,498.00 $1,596.00 $1,708.00 $1,498.00 $1,596.00 $1,708.0027070 90 $1,040.00 $1,235.00 $1,317.00 $1,407.00 $1,235.00 $1,317.00 $1,407.0027071 90 $1,112.00 $1,337.00 $1,427.00 $1,525.00 $1,337.00 $1,427.00 $1,525.0027075 90 $1,485.00 $3,096.00 $3,304.00 $3,565.00 $3,096.00 $3,304.00 $3,565.0027076 90 $1,859.00 $3,740.00 $3,990.00 $4,309.00 $3,740.00 $3,990.00 $4,309.0027077 90 $1,976.00 $4,208.00 $4,492.00 $4,859.00 $4,208.00 $4,492.00 $4,859.0027078 90 $1,164.00 $3,048.00 $3,252.00 $3,508.00 $3,048.00 $3,252.00 $3,508.0027080 90 $568.00 $751.00 $804.00 $864.00 $751.00 $804.00 $864.0027086 10 $57.00 $408.00 $437.00 $453.00 $240.00 $256.00 $272.0027087 90 $555.00 $915.00 $976.00 $1,045.00 $915.00 $976.00 $1,045.0027090 90 $981.00 $1,213.00 $1,294.00 $1,386.00 $1,213.00 $1,294.00 $1,386.0027091 90 $1,482.00 $2,352.00 $2,509.00 $2,698.00 $2,352.00 $2,509.00 $2,698.0027093 0 $62.00 $262.00 $279.00 $285.00 $102.00 $107.00 $113.0027095 0 $121.00 $337.00 $359.00 $367.00 $121.00 $127.00 $135.0027096 0 $491.00 $226.00 $239.00 $245.00 $122.00 $128.00 $133.0027097 90 $795.00 $981.00 $1,047.00 $1,119.00 $981.00 $1,047.00 $1,119.0027098 90 $799.00 $973.00 $1,035.00 $1,102.00 $973.00 $1,035.00 $1,102.0027100 90 $987.00 $1,193.00 $1,271.00 $1,357.00 $1,193.00 $1,271.00 $1,357.0027105 90 $946.00 $1,268.00 $1,354.00 $1,452.00 $1,268.00 $1,354.00 $1,452.0027110 90 $1,174.00 $1,416.00 $1,512.00 $1,621.00 $1,416.00 $1,512.00 $1,621.00



Surgery







27111 90 $1,099.00 $1,317.00 $1,407.00 $1,510.00 $1,317.00 $1,407.00 $1,510.0027120 90 $1,603.00 $1,913.00 $2,043.00 $2,199.00 $1,913.00 $2,043.00 $2,199.0027122 90 $1,406.00 $1,613.00 $1,720.00 $1,846.00 $1,613.00 $1,720.00 $1,846.0027125 90 $1,371.00 $1,665.00 $1,776.00 $1,908.00 $1,665.00 $1,776.00 $1,908.0027130 90 $1,853.00 $1,996.00 $2,128.00 $2,289.00 $1,996.00 $2,128.00 $2,289.0027132 90 $2,128.00 $2,467.00 $2,630.00 $2,828.00 $2,467.00 $2,630.00 $2,828.0027134 90 $2,576.00 $2,829.00 $3,016.00 $3,249.00 $2,829.00 $3,016.00 $3,249.0027137 90 $2,190.00 $2,171.00 $2,314.00 $2,490.00 $2,171.00 $2,314.00 $2,490.0027138 90 $2,025.00 $2,256.00 $2,405.00 $2,588.00 $2,256.00 $2,405.00 $2,588.0027140 90 $1,092.00 $1,308.00 $1,395.00 $1,493.00 $1,308.00 $1,395.00 $1,493.0027146 90 $1,432.00 $1,893.00 $2,022.00 $2,177.00 $1,893.00 $2,022.00 $2,177.0027147 90 $1,744.00 $2,168.00 $2,315.00 $2,494.00 $2,168.00 $2,315.00 $2,494.0027151 90 $1,732.00 $2,340.00 $2,496.00 $2,687.00 $2,340.00 $2,496.00 $2,687.0027156 90 $2,017.00 $2,534.00 $2,706.00 $2,918.00 $2,534.00 $2,706.00 $2,918.0027158 90 $1,588.00 $2,108.00 $2,260.00 $2,454.00 $2,108.00 $2,260.00 $2,454.0027161 90 $1,443.00 $1,783.00 $1,901.00 $2,041.00 $1,783.00 $1,901.00 $2,041.0027165 90 $1,572.00 $2,018.00 $2,151.00 $2,308.00 $2,018.00 $2,151.00 $2,308.0027170 90 $1,453.00 $1,729.00 $1,844.00 $1,982.00 $1,729.00 $1,844.00 $1,982.0027175 90 $491.00 $977.00 $1,043.00 $1,120.00 $977.00 $1,043.00 $1,120.0027176 90 $1,024.00 $1,317.00 $1,404.00 $1,504.00 $1,317.00 $1,404.00 $1,504.0027177 90 $1,257.00 $1,637.00 $1,748.00 $1,879.00 $1,637.00 $1,748.00 $1,879.0027178 90 $1,020.00 $1,345.00 $1,436.00 $1,541.00 $1,345.00 $1,436.00 $1,541.0027179 90 $1,107.00 $1,432.00 $1,529.00 $1,643.00 $1,432.00 $1,529.00 $1,643.0027181 90 $1,206.00 $1,407.00 $1,484.00 $1,571.00 $1,407.00 $1,484.00 $1,571.0027185 90 $676.00 $885.00 $934.00 $987.00 $885.00 $934.00 $987.0027187 90 $1,280.00 $1,453.00 $1,550.00 $1,662.00 $1,453.00 $1,550.00 $1,662.0027193 90 $425.00 $683.00 $729.00 $776.00 $691.00 $738.00 $785.0027194 90 $740.00 $1,032.00 $1,099.00 $1,174.00 $1,032.00 $1,099.00 $1,174.0027200 90 $180.00 $258.00 $275.00 $288.00 $268.00 $286.00 $300.0027202 90 $776.00 $772.00 $823.00 $878.00 $772.00 $823.00 $878.0027215 90 $954.00 $910.00 $960.00 $1,017.00 $910.00 $960.00 $1,017.0027216 90 $1,085.00 $1,350.00 $1,424.00 $1,508.00 $1,350.00 $1,424.00 $1,508.0027217 90 $1,285.00 $1,266.00 $1,335.00 $1,414.00 $1,266.00 $1,335.00 $1,414.0027218 90 $1,570.00 $1,753.00 $1,848.00 $1,961.00 $1,753.00 $1,848.00 $1,961.0027220 90 $444.00 $770.00 $822.00 $876.00 $764.00 $815.00 $869.0027222 90 $973.00 $1,430.00 $1,526.00 $1,637.00 $1,430.00 $1,526.00 $1,637.0027226 90 $1,350.00 $1,551.00 $1,654.00 $1,776.00 $1,551.00 $1,654.00 $1,776.0027227 90 $1,967.00 $2,446.00 $2,609.00 $2,810.00 $2,446.00 $2,609.00 $2,810.0027228 90 $2,195.00 $2,791.00 $2,977.00 $3,209.00 $2,791.00 $2,977.00 $3,209.0027230 90 $491.00 $685.00 $731.00 $776.00 $681.00 $727.00 $772.0027232 90 $916.00 $1,105.00 $1,176.00 $1,263.00 $1,105.00 $1,176.00 $1,263.0027235 90 $1,128.00 $1,334.00 $1,424.00 $1,529.00 $1,334.00 $1,424.00 $1,529.0027236 90 $1,421.00 $1,758.00 $1,875.00 $2,014.00 $1,758.00 $1,875.00 $2,014.0027238 90 $504.00 $666.00 $711.00 $755.00 $666.00 $711.00 $755.0027240 90 $1,043.00 $1,402.00 $1,496.00 $1,605.00 $1,402.00 $1,496.00 $1,605.0027244 90 $1,426.00 $1,810.00 $1,931.00 $2,075.00 $1,810.00 $1,931.00 $2,075.0027245 90 $1,691.00 $1,809.00 $1,930.00 $2,073.00 $1,809.00 $1,930.00 $2,073.0027246 90 $459.00 $558.00 $595.00 $633.00 $560.00 $598.00 $636.0027248 90 $980.00 $1,089.00 $1,161.00 $1,246.00 $1,089.00 $1,161.00 $1,246.0027250 0 $535.00 $269.00 $284.00 $307.00 $269.00 $284.00 $307.00



Surgery







27252 90 $520.00 $1,111.00 $1,184.00 $1,270.00 $1,111.00 $1,184.00 $1,270.0027253 90 $1,162.00 $1,378.00 $1,471.00 $1,578.00 $1,378.00 $1,471.00 $1,578.0027254 90 $1,478.00 $1,863.00 $1,986.00 $2,134.00 $1,863.00 $1,986.00 $2,134.0027256 10 $338.00 $431.00 $457.00 $484.00 $344.00 $364.00 $390.0027257 10 $455.00 $534.00 $571.00 $614.00 $534.00 $571.00 $614.0027258 90 $1,355.00 $1,631.00 $1,742.00 $1,873.00 $1,631.00 $1,742.00 $1,873.0027259 90 $1,803.00 $2,290.00 $2,445.00 $2,634.00 $2,290.00 $2,445.00 $2,634.0027265 90 $442.00 $574.00 $609.00 $642.00 $574.00 $609.00 $642.0027266 90 $614.00 $847.00 $905.00 $967.00 $847.00 $905.00 $967.0027267 90 -------- $630.00 $672.00 $714.00 $630.00 $672.00 $714.0027268 90 -------- $774.00 $826.00 $880.00 $774.00 $826.00 $880.0027269 90 -------- $1,827.00 $1,948.00 $2,096.00 $1,827.00 $1,948.00 $2,096.0027275 10 $220.00 $263.00 $281.00 $298.00 $263.00 $281.00 $298.0027279 90 -------- $1,027.00 $1,106.00 $1,204.00 $1,027.00 $1,106.00 $1,204.0027280 90 $1,179.00 $2,037.00 $2,196.00 $2,413.00 $2,037.00 $2,196.00 $2,413.0027282 90 $990.00 $1,204.00 $1,282.00 $1,368.00 $1,204.00 $1,282.00 $1,368.0027284 90 $1,435.00 $2,296.00 $2,442.00 $2,624.00 $2,296.00 $2,442.00 $2,624.0027286 90 $1,503.00 $2,402.00 $2,555.00 $2,737.00 $2,402.00 $2,555.00 $2,737.0027290 90 $2,073.00 $2,375.00 $2,535.00 $2,735.00 $2,375.00 $2,535.00 $2,735.0027295 90 $1,594.00 $1,861.00 $1,987.00 $2,146.00 $1,861.00 $1,987.00 $2,146.0027299 YYY BR -------- -------- -------- -------- -------- --------27301 90 $193.00 $962.00 $1,030.00 $1,087.00 $732.00 $783.00 $839.0027303 90 $520.00 $929.00 $991.00 $1,059.00 $929.00 $991.00 $1,059.0027305 90 $555.00 $697.00 $744.00 $791.00 $697.00 $744.00 $791.0027306 90 $377.00 $511.00 $540.00 $566.00 $511.00 $540.00 $566.0027307 90 $503.00 $669.00 $713.00 $758.00 $669.00 $713.00 $758.0027310 90 $877.00 $1,067.00 $1,138.00 $1,217.00 $1,067.00 $1,138.00 $1,217.0027323 10 $211.00 $384.00 $410.00 $426.00 $258.00 $275.00 $291.0027324 90 $433.00 $581.00 $622.00 $667.00 $581.00 $622.00 $667.0027325 90 -------- $794.00 $847.00 $903.00 $794.00 $847.00 $903.0027326 90 -------- $755.00 $808.00 $865.00 $755.00 $808.00 $865.0027327 90 $400.00 $655.00 $701.00 $736.00 $458.00 $490.00 $524.0027328 90 $503.00 $912.00 $975.00 $1,050.00 $912.00 $975.00 $1,050.0027329 90 $1,249.00 $1,529.00 $1,634.00 $1,766.00 $1,529.00 $1,634.00 $1,766.0027330 90 $492.00 $606.00 $648.00 $690.00 $606.00 $648.00 $690.0027331 90 $585.00 $689.00 $735.00 $783.00 $689.00 $735.00 $783.0027332 90 $786.00 $932.00 $995.00 $1,062.00 $932.00 $995.00 $1,062.0027333 90 $719.00 $852.00 $911.00 $972.00 $852.00 $911.00 $972.0027334 90 $840.00 $995.00 $1,062.00 $1,134.00 $995.00 $1,062.00 $1,134.0027335 90 $959.00 $1,113.00 $1,188.00 $1,270.00 $1,113.00 $1,188.00 $1,270.0027337 90 -------- $616.00 $660.00 $713.00 $616.00 $660.00 $713.0027339 90 -------- $1,111.00 $1,189.00 $1,284.00 $1,111.00 $1,189.00 $1,284.0027340 90 $405.00 $537.00 $574.00 $610.00 $537.00 $574.00 $610.0027345 90 $565.00 $697.00 $744.00 $792.00 $697.00 $744.00 $792.0027347 90 $394.00 $769.00 $821.00 $875.00 $769.00 $821.00 $875.0027350 90 $786.00 $947.00 $1,011.00 $1,078.00 $947.00 $1,011.00 $1,078.0027355 90 $763.00 $875.00 $934.00 $997.00 $875.00 $934.00 $997.0027356 90 $882.00 $1,074.00 $1,145.00 $1,225.00 $1,074.00 $1,145.00 $1,225.0027357 90 $950.00 $1,188.00 $1,268.00 $1,358.00 $1,188.00 $1,268.00 $1,358.0027358 ZZZ $394.00 $413.00 $440.00 $476.00 $413.00 $440.00 $476.00



Surgery







27360 90 $977.00 $1,240.00 $1,323.00 $1,413.00 $1,240.00 $1,323.00 $1,413.0027364 90 -------- $2,313.00 $2,471.00 $2,675.00 $2,313.00 $2,471.00 $2,675.0027365 90 $1,421.00 $3,057.00 $3,261.00 $3,517.00 $3,057.00 $3,261.00 $3,517.0027370 0 $75.00 $216.00 $230.00 $235.00 $74.00 $78.00 $82.0027372 90 $371.00 $861.00 $921.00 $962.00 $586.00 $625.00 $666.0027380 90 $698.00 $861.00 $919.00 $978.00 $861.00 $919.00 $978.0027381 90 $1,118.00 $1,160.00 $1,237.00 $1,321.00 $1,160.00 $1,237.00 $1,321.0027385 90 $753.00 $831.00 $887.00 $942.00 $831.00 $887.00 $942.0027386 90 $1,064.00 $1,207.00 $1,288.00 $1,374.00 $1,207.00 $1,288.00 $1,374.0027390 90 $506.00 $649.00 $693.00 $737.00 $649.00 $693.00 $737.0027391 90 $647.00 $839.00 $897.00 $958.00 $839.00 $897.00 $958.0027392 90 $834.00 $1,033.00 $1,101.00 $1,173.00 $1,033.00 $1,101.00 $1,173.0027393 90 $608.00 $735.00 $784.00 $834.00 $735.00 $784.00 $834.0027394 90 $748.00 $920.00 $975.00 $1,026.00 $920.00 $975.00 $1,026.0027395 90 $1,093.00 $1,285.00 $1,373.00 $1,472.00 $1,285.00 $1,373.00 $1,472.0027396 90 $742.00 $897.00 $959.00 $1,025.00 $897.00 $959.00 $1,025.0027397 90 $989.00 $1,322.00 $1,412.00 $1,514.00 $1,322.00 $1,412.00 $1,514.0027400 90 $832.00 $1,013.00 $1,082.00 $1,158.00 $1,013.00 $1,082.00 $1,158.0027403 90 $792.00 $932.00 $995.00 $1,062.00 $932.00 $995.00 $1,062.0027405 90 $842.00 $982.00 $1,047.00 $1,117.00 $982.00 $1,047.00 $1,117.0027407 90 $918.00 $1,135.00 $1,211.00 $1,296.00 $1,135.00 $1,211.00 $1,296.0027409 90 $1,212.00 $1,395.00 $1,487.00 $1,593.00 $1,395.00 $1,487.00 $1,593.0027412 90 -------- $2,434.00 $2,598.00 $2,796.00 $2,434.00 $2,598.00 $2,796.0027415 90 -------- $2,013.00 $2,149.00 $2,309.00 $2,013.00 $2,149.00 $2,309.0027416 90 -------- $1,434.00 $1,531.00 $1,643.00 $1,434.00 $1,531.00 $1,643.0027418 90 $1,596.00 $1,210.00 $1,290.00 $1,380.00 $1,210.00 $1,290.00 $1,380.0027420 90 $927.00 $1,086.00 $1,158.00 $1,239.00 $1,086.00 $1,158.00 $1,239.0027422 90 $930.00 $1,082.00 $1,154.00 $1,233.00 $1,082.00 $1,154.00 $1,233.0027424 90 $927.00 $1,093.00 $1,168.00 $1,251.00 $1,093.00 $1,168.00 $1,251.0027425 90 $639.00 $649.00 $693.00 $738.00 $649.00 $693.00 $738.0027427 90 $1,118.00 $1,038.00 $1,106.00 $1,181.00 $1,038.00 $1,106.00 $1,181.0027428 90 $1,266.00 $1,629.00 $1,738.00 $1,861.00 $1,629.00 $1,738.00 $1,861.0027429 90 $2,333.00 $1,820.00 $1,941.00 $2,075.00 $1,820.00 $1,941.00 $2,075.0027430 90 $884.00 $1,078.00 $1,150.00 $1,228.00 $1,078.00 $1,150.00 $1,228.0027435 90 $501.00 $1,175.00 $1,253.00 $1,337.00 $1,175.00 $1,253.00 $1,337.0027437 90 $819.00 $964.00 $1,029.00 $1,102.00 $964.00 $1,029.00 $1,102.0027438 90 $1,065.00 $1,228.00 $1,310.00 $1,402.00 $1,228.00 $1,310.00 $1,402.0027440 90 $1,064.00 $1,168.00 $1,247.00 $1,338.00 $1,168.00 $1,247.00 $1,338.0027441 90 $1,006.00 $1,204.00 $1,285.00 $1,377.00 $1,204.00 $1,285.00 $1,377.0027442 90 $1,117.00 $1,271.00 $1,356.00 $1,452.00 $1,271.00 $1,356.00 $1,452.0027443 90 $1,037.00 $1,179.00 $1,258.00 $1,347.00 $1,179.00 $1,258.00 $1,347.0027445 90 $1,618.00 $1,834.00 $1,956.00 $2,101.00 $1,834.00 $1,956.00 $2,101.0027446 90 $1,764.00 $1,705.00 $1,817.00 $1,953.00 $1,705.00 $1,817.00 $1,953.0027447 90 $1,960.00 $1,996.00 $2,128.00 $2,288.00 $1,996.00 $2,128.00 $2,288.0027448 90 $1,060.00 $1,131.00 $1,201.00 $1,278.00 $1,131.00 $1,201.00 $1,278.0027450 90 $1,311.00 $1,480.00 $1,578.00 $1,690.00 $1,480.00 $1,578.00 $1,690.0027454 90 $1,524.00 $1,913.00 $2,043.00 $2,199.00 $1,913.00 $2,043.00 $2,199.0027455 90 $1,157.00 $1,378.00 $1,471.00 $1,578.00 $1,378.00 $1,471.00 $1,578.0027457 90 $1,209.00 $1,386.00 $1,476.00 $1,580.00 $1,386.00 $1,476.00 $1,580.0027465 90 $1,253.00 $1,815.00 $1,935.00 $2,078.00 $1,815.00 $1,935.00 $2,078.00



Surgery







27466 90 $1,441.00 $1,728.00 $1,842.00 $1,975.00 $1,728.00 $1,842.00 $1,975.0027468 90 $1,613.00 $1,805.00 $1,913.00 $2,041.00 $1,805.00 $1,913.00 $2,041.0027470 90 $1,501.00 $1,724.00 $1,839.00 $1,973.00 $1,724.00 $1,839.00 $1,973.0027472 90 $1,665.00 $1,855.00 $1,978.00 $2,125.00 $1,855.00 $1,978.00 $2,125.0027475 90 $782.00 $966.00 $1,032.00 $1,104.00 $966.00 $1,032.00 $1,104.0027477 90 $938.00 $1,068.00 $1,140.00 $1,220.00 $1,068.00 $1,140.00 $1,220.0027479 90 $1,123.00 $1,150.00 $1,213.00 $1,285.00 $1,150.00 $1,213.00 $1,285.0027485 90 $797.00 $979.00 $1,046.00 $1,120.00 $979.00 $1,046.00 $1,120.0027486 90 $1,771.00 $2,068.00 $2,205.00 $2,369.00 $2,068.00 $2,205.00 $2,369.0027487 90 $2,352.00 $2,591.00 $2,762.00 $2,971.00 $2,591.00 $2,762.00 $2,971.0027488 90 $1,438.00 $1,762.00 $1,879.00 $2,017.00 $1,762.00 $1,879.00 $2,017.0027495 90 $1,477.00 $1,656.00 $1,767.00 $1,897.00 $1,656.00 $1,767.00 $1,897.0027496 90 $563.00 $786.00 $840.00 $895.00 $786.00 $840.00 $895.0027497 90 $652.00 $842.00 $897.00 $956.00 $842.00 $897.00 $956.0027498 90 $701.00 $942.00 $1,006.00 $1,076.00 $942.00 $1,006.00 $1,076.0027499 90 $782.00 $1,016.00 $1,084.00 $1,158.00 $1,016.00 $1,084.00 $1,158.0027500 90 $520.00 $749.00 $799.00 $848.00 $697.00 $743.00 $792.0027501 90 $659.00 $730.00 $780.00 $831.00 $725.00 $774.00 $826.0027502 90 $909.00 $1,119.00 $1,192.00 $1,276.00 $1,119.00 $1,192.00 $1,276.0027503 90 $911.00 $1,173.00 $1,252.00 $1,342.00 $1,173.00 $1,252.00 $1,342.0027506 90 $1,522.00 $1,965.00 $2,096.00 $2,251.00 $1,965.00 $2,096.00 $2,251.0027507 90 $1,297.00 $1,429.00 $1,524.00 $1,638.00 $1,429.00 $1,524.00 $1,638.0027508 90 $400.00 $756.00 $807.00 $854.00 $715.00 $762.00 $809.0027509 90 $649.00 $931.00 $993.00 $1,055.00 $931.00 $993.00 $1,055.0027510 90 $755.00 $996.00 $1,062.00 $1,135.00 $996.00 $1,062.00 $1,135.0027511 90 $1,281.00 $1,467.00 $1,564.00 $1,683.00 $1,467.00 $1,564.00 $1,683.0027513 90 $1,562.00 $1,830.00 $1,952.00 $2,103.00 $1,830.00 $1,952.00 $2,103.0027514 90 $1,508.00 $1,422.00 $1,517.00 $1,631.00 $1,422.00 $1,517.00 $1,631.0027516 90 $579.00 $731.00 $782.00 $828.00 $689.00 $737.00 $783.0027517 90 $820.00 $986.00 $1,054.00 $1,131.00 $986.00 $1,054.00 $1,131.0027519 90 $1,311.00 $1,312.00 $1,401.00 $1,508.00 $1,312.00 $1,401.00 $1,508.0027520 90 $266.00 $459.00 $490.00 $512.00 $420.00 $448.00 $471.0027524 90 $910.00 $1,098.00 $1,172.00 $1,254.00 $1,098.00 $1,172.00 $1,254.0027530 90 $408.00 $428.00 $458.00 $478.00 $399.00 $427.00 $447.0027532 90 $641.00 $890.00 $950.00 $1,010.00 $839.00 $895.00 $955.0027535 90 $1,075.00 $1,319.00 $1,407.00 $1,513.00 $1,319.00 $1,407.00 $1,513.0027536 90 $1,282.00 $1,747.00 $1,864.00 $2,001.00 $1,747.00 $1,864.00 $2,001.0027538 90 $487.00 $677.00 $723.00 $762.00 $637.00 $679.00 $719.0027540 90 $1,106.00 $1,182.00 $1,261.00 $1,349.00 $1,182.00 $1,261.00 $1,349.0027550 90 $296.00 $725.00 $772.00 $815.00 $675.00 $719.00 $762.0027552 90 $619.00 $909.00 $970.00 $1,035.00 $909.00 $970.00 $1,035.0027556 90 $832.00 $1,285.00 $1,370.00 $1,473.00 $1,285.00 $1,370.00 $1,473.0027557 90 $1,479.00 $1,546.00 $1,651.00 $1,781.00 $1,546.00 $1,651.00 $1,781.0027558 90 $1,529.00 $1,753.00 $1,869.00 $2,012.00 $1,753.00 $1,869.00 $2,012.0027560 90 $88.00 $516.00 $549.00 $576.00 $478.00 $508.00 $535.0027562 90 $514.00 $679.00 $724.00 $769.00 $679.00 $724.00 $769.0027566 90 $1,047.00 $1,305.00 $1,393.00 $1,493.00 $1,305.00 $1,393.00 $1,493.0027570 10 $184.00 $219.00 $234.00 $249.00 $219.00 $234.00 $249.0027580 90 $1,644.00 $2,109.00 $2,250.00 $2,415.00 $2,109.00 $2,250.00 $2,415.0027590 90 $1,059.00 $1,208.00 $1,293.00 $1,413.00 $1,208.00 $1,293.00 $1,413.00



Surgery







27591 90 $1,182.00 $1,415.00 $1,510.00 $1,622.00 $1,415.00 $1,510.00 $1,622.0027592 90 $911.00 $1,022.00 $1,093.00 $1,189.00 $1,022.00 $1,093.00 $1,189.0027594 90 $600.00 $752.00 $805.00 $868.00 $752.00 $805.00 $868.0027596 90 $931.00 $1,081.00 $1,157.00 $1,256.00 $1,081.00 $1,157.00 $1,256.0027598 90 $976.00 $1,077.00 $1,153.00 $1,250.00 $1,077.00 $1,153.00 $1,250.0027599 YYY BR -------- -------- -------- -------- -------- --------27600 90 $517.00 $606.00 $648.00 $697.00 $606.00 $648.00 $697.0027601 90 $516.00 $649.00 $693.00 $743.00 $649.00 $693.00 $743.0027602 90 $621.00 $734.00 $786.00 $855.00 $734.00 $786.00 $855.0027603 90 $412.00 $760.00 $812.00 $854.00 $567.00 $606.00 $647.0027604 90 $308.00 $705.00 $752.00 $784.00 $502.00 $534.00 $565.0027605 10 $236.00 $481.00 $510.00 $522.00 $266.00 $279.00 $291.0027606 10 $362.00 $413.00 $438.00 $465.00 $413.00 $438.00 $465.0027607 90 $608.00 $886.00 $944.00 $1,006.00 $886.00 $944.00 $1,006.0027610 90 $777.00 $949.00 $1,010.00 $1,075.00 $949.00 $1,010.00 $1,075.0027612 90 $701.00 $806.00 $853.00 $898.00 $806.00 $853.00 $898.0027613 10 $165.00 $356.00 $379.00 $391.00 $235.00 $248.00 $260.0027614 90 $327.00 $825.00 $878.00 $916.00 $588.00 $624.00 $661.0027615 90 $1,106.00 $1,508.00 $1,609.00 $1,735.00 $1,508.00 $1,609.00 $1,735.0027616 90 -------- $1,877.00 $2,004.00 $2,165.00 $1,877.00 $2,004.00 $2,165.0027618 90 $421.00 $640.00 $684.00 $715.00 $447.00 $477.00 $508.0027619 90 $730.00 $683.00 $724.00 $767.00 $683.00 $724.00 $767.0027620 90 $587.00 $658.00 $699.00 $739.00 $658.00 $699.00 $739.0027625 90 $796.00 $851.00 $902.00 $955.00 $851.00 $902.00 $955.0027626 90 $863.00 $898.00 $952.00 $1,008.00 $898.00 $952.00 $1,008.0027630 90 $430.00 $797.00 $849.00 $880.00 $530.00 $563.00 $593.0027632 90 -------- $609.00 $651.00 $700.00 $609.00 $651.00 $700.0027634 90 -------- $1,009.00 $1,077.00 $1,157.00 $1,009.00 $1,077.00 $1,157.0027635 90 $781.00 $855.00 $910.00 $969.00 $855.00 $910.00 $969.0027637 90 $921.00 $1,091.00 $1,162.00 $1,237.00 $1,091.00 $1,162.00 $1,237.0027638 90 $978.00 $1,114.00 $1,186.00 $1,264.00 $1,114.00 $1,186.00 $1,264.0027640 90 $1,122.00 $1,220.00 $1,298.00 $1,386.00 $1,220.00 $1,298.00 $1,386.0027641 90 $922.00 $975.00 $1,035.00 $1,100.00 $975.00 $1,035.00 $1,100.0027645 90 $1,302.00 $2,618.00 $2,793.00 $3,010.00 $2,618.00 $2,793.00 $3,010.0027646 90 $1,212.00 $2,269.00 $2,424.00 $2,616.00 $2,269.00 $2,424.00 $2,616.0027647 90 $1,044.00 $1,482.00 $1,537.00 $1,592.00 $1,482.00 $1,537.00 $1,592.0027648 0 $72.00 $229.00 $244.00 $250.00 $77.00 $81.00 $87.0027650 90 $869.00 $955.00 $1,013.00 $1,070.00 $955.00 $1,013.00 $1,070.0027652 90 $935.00 $993.00 $1,048.00 $1,104.00 $993.00 $1,048.00 $1,104.0027654 90 $937.00 $1,027.00 $1,085.00 $1,144.00 $1,027.00 $1,085.00 $1,144.0027656 90 $458.00 $901.00 $964.00 $1,003.00 $574.00 $614.00 $652.0027658 90 $527.00 $539.00 $571.00 $600.00 $539.00 $571.00 $600.0027659 90 $725.00 $698.00 $738.00 $776.00 $698.00 $738.00 $776.0027664 90 $504.00 $521.00 $553.00 $582.00 $521.00 $553.00 $582.0027665 90 $618.00 $595.00 $631.00 $663.00 $595.00 $631.00 $663.0027675 90 $656.00 $705.00 $744.00 $782.00 $705.00 $744.00 $782.0027676 90 $762.00 $877.00 $930.00 $985.00 $877.00 $930.00 $985.0027680 90 $523.00 $623.00 $662.00 $700.00 $623.00 $662.00 $700.0027681 90 $634.00 $792.00 $846.00 $903.00 $792.00 $846.00 $903.0027685 90 $565.00 $946.00 $1,004.00 $1,040.00 $672.00 $710.00 $745.00



Surgery







27686 90 $706.00 $811.00 $863.00 $916.00 $811.00 $863.00 $916.0027687 90 $589.00 $657.00 $696.00 $733.00 $657.00 $696.00 $733.0027690 90 $757.00 $911.00 $963.00 $1,013.00 $911.00 $963.00 $1,013.0027691 90 $889.00 $1,089.00 $1,157.00 $1,227.00 $1,089.00 $1,157.00 $1,227.0027692 ZZZ $159.00 $155.00 $165.00 $177.00 $155.00 $165.00 $177.0027695 90 $658.00 $688.00 $728.00 $767.00 $688.00 $728.00 $767.0027696 90 $758.00 $806.00 $850.00 $894.00 $806.00 $850.00 $894.0027698 90 $881.00 $933.00 $988.00 $1,046.00 $933.00 $988.00 $1,046.0027700 90 $835.00 $862.00 $907.00 $951.00 $862.00 $907.00 $951.0027702 90 $1,278.00 $1,414.00 $1,504.00 $1,607.00 $1,414.00 $1,504.00 $1,607.0027703 90 $1,337.00 $1,625.00 $1,727.00 $1,844.00 $1,625.00 $1,727.00 $1,844.0027704 90 $683.00 $839.00 $893.00 $950.00 $839.00 $893.00 $950.0027705 90 $985.00 $1,109.00 $1,181.00 $1,260.00 $1,109.00 $1,181.00 $1,260.0027707 90 $484.00 $583.00 $622.00 $659.00 $583.00 $622.00 $659.0027709 90 $1,118.00 $1,713.00 $1,825.00 $1,957.00 $1,713.00 $1,825.00 $1,957.0027712 90 $1,227.00 $1,614.00 $1,721.00 $1,845.00 $1,614.00 $1,721.00 $1,845.0027715 90 $1,285.00 $1,572.00 $1,678.00 $1,803.00 $1,572.00 $1,678.00 $1,803.0027720 90 $1,147.00 $1,280.00 $1,365.00 $1,460.00 $1,280.00 $1,365.00 $1,460.0027722 90 $1,076.00 $1,286.00 $1,372.00 $1,470.00 $1,286.00 $1,372.00 $1,470.0027724 90 $1,402.00 $1,861.00 $1,985.00 $2,135.00 $1,861.00 $1,985.00 $2,135.0027725 90 $1,312.00 $1,768.00 $1,885.00 $2,019.00 $1,768.00 $1,885.00 $2,019.0027726 90 -------- $1,420.00 $1,514.00 $1,625.00 $1,420.00 $1,514.00 $1,625.0027727 90 $1,175.00 $1,522.00 $1,625.00 $1,746.00 $1,522.00 $1,625.00 $1,746.0027730 90 $647.00 $831.00 $887.00 $947.00 $831.00 $887.00 $947.0027732 90 $611.00 $588.00 $626.00 $663.00 $588.00 $626.00 $663.0027734 90 $766.00 $958.00 $1,023.00 $1,095.00 $958.00 $1,023.00 $1,095.0027740 90 $1,044.00 $1,034.00 $1,105.00 $1,183.00 $1,034.00 $1,105.00 $1,183.0027742 90 $1,045.00 $1,121.00 $1,190.00 $1,257.00 $1,121.00 $1,190.00 $1,257.0027745 90 $940.00 $1,103.00 $1,176.00 $1,258.00 $1,103.00 $1,176.00 $1,258.0027750 90 $319.00 $493.00 $526.00 $552.00 $454.00 $485.00 $510.0027752 90 $614.00 $774.00 $826.00 $875.00 $718.00 $766.00 $815.0027756 90 $708.00 $831.00 $887.00 $943.00 $831.00 $887.00 $943.0027758 90 $1,115.00 $1,303.00 $1,390.00 $1,489.00 $1,303.00 $1,390.00 $1,489.0027759 90 $1,262.00 $1,465.00 $1,563.00 $1,678.00 $1,465.00 $1,563.00 $1,678.0027760 90 $223.00 $473.00 $504.00 $526.00 $434.00 $462.00 $484.0027762 90 $495.00 $680.00 $724.00 $762.00 $623.00 $663.00 $701.0027766 90 $759.00 $888.00 $947.00 $1,009.00 $888.00 $947.00 $1,009.0027767 90 -------- $399.00 $426.00 $445.00 $402.00 $428.00 $447.0027768 90 -------- $635.00 $679.00 $720.00 $635.00 $679.00 $720.0027769 90 -------- $1,067.00 $1,139.00 $1,219.00 $1,067.00 $1,139.00 $1,219.0027780 90 $244.00 $435.00 $464.00 $485.00 $397.00 $424.00 $444.0027781 90 $296.00 $604.00 $644.00 $678.00 $562.00 $600.00 $633.0027784 90 $643.00 $1,044.00 $1,114.00 $1,190.00 $1,044.00 $1,114.00 $1,190.0027786 90 $223.00 $449.00 $478.00 $500.00 $408.00 $435.00 $456.0027788 90 $422.00 $602.00 $641.00 $674.00 $553.00 $589.00 $621.0027792 90 $706.00 $951.00 $1,014.00 $1,081.00 $951.00 $1,014.00 $1,081.0027808 90 $332.00 $474.00 $506.00 $527.00 $428.00 $456.00 $478.0027810 90 $567.00 $668.00 $712.00 $749.00 $610.00 $649.00 $686.0027814 90 $972.00 $1,127.00 $1,202.00 $1,284.00 $1,127.00 $1,202.00 $1,284.0027816 90 $386.00 $454.00 $484.00 $506.00 $410.00 $436.00 $458.00



Surgery







27818 90 $613.00 $693.00 $738.00 $777.00 $625.00 $665.00 $704.0027822 90 $1,201.00 $1,225.00 $1,306.00 $1,392.00 $1,225.00 $1,306.00 $1,392.0027823 90 $1,472.00 $1,394.00 $1,486.00 $1,587.00 $1,394.00 $1,486.00 $1,587.0027824 90 $384.00 $448.00 $478.00 $502.00 $436.00 $465.00 $489.0027825 90 $670.00 $785.00 $837.00 $887.00 $717.00 $763.00 $813.0027826 90 $1,080.00 $1,211.00 $1,291.00 $1,375.00 $1,211.00 $1,291.00 $1,375.0027827 90 $1,310.00 $1,577.00 $1,683.00 $1,797.00 $1,577.00 $1,683.00 $1,797.0027828 90 $1,823.00 $1,896.00 $2,022.00 $2,165.00 $1,896.00 $2,022.00 $2,165.0027829 90 $742.00 $993.00 $1,059.00 $1,126.00 $993.00 $1,059.00 $1,126.0027830 90 $412.00 $545.00 $583.00 $615.00 $510.00 $545.00 $578.0027831 90 $415.00 $567.00 $606.00 $645.00 $567.00 $606.00 $645.0027832 90 $617.00 $1,105.00 $1,180.00 $1,263.00 $1,105.00 $1,180.00 $1,263.0027840 90 $334.00 $529.00 $562.00 $592.00 $529.00 $562.00 $592.0027842 90 $373.00 $719.00 $767.00 $815.00 $719.00 $767.00 $815.0027846 90 $877.00 $1,059.00 $1,127.00 $1,202.00 $1,059.00 $1,127.00 $1,202.0027848 90 $1,224.00 $1,186.00 $1,263.00 $1,350.00 $1,186.00 $1,263.00 $1,350.0027860 10 $211.00 $254.00 $270.00 $286.00 $254.00 $270.00 $286.0027870 90 $1,269.00 $1,508.00 $1,604.00 $1,712.00 $1,508.00 $1,604.00 $1,712.0027871 90 $843.00 $997.00 $1,062.00 $1,131.00 $997.00 $1,062.00 $1,131.0027880 90 $1,015.00 $1,381.00 $1,478.00 $1,613.00 $1,381.00 $1,478.00 $1,613.0027881 90 $1,120.00 $1,297.00 $1,386.00 $1,500.00 $1,297.00 $1,386.00 $1,500.0027882 90 $854.00 $904.00 $967.00 $1,054.00 $904.00 $967.00 $1,054.0027884 90 $579.00 $861.00 $922.00 $999.00 $861.00 $922.00 $999.0027886 90 $835.00 $984.00 $1,053.00 $1,140.00 $984.00 $1,053.00 $1,140.0027888 90 $911.00 $1,010.00 $1,077.00 $1,157.00 $1,010.00 $1,077.00 $1,157.0027889 90 $879.00 $979.00 $1,047.00 $1,142.00 $979.00 $1,047.00 $1,142.0027892 90 $575.00 $810.00 $864.00 $925.00 $810.00 $864.00 $925.0027893 90 $574.00 $881.00 $941.00 $1,006.00 $881.00 $941.00 $1,006.0027894 90 $712.00 $1,259.00 $1,344.00 $1,447.00 $1,259.00 $1,344.00 $1,447.0027899 YYY BR -------- -------- -------- -------- -------- --------28001 10 $185.00 $393.00 $414.00 $424.00 $244.00 $255.00 $264.0028002 10 $362.00 $633.00 $667.00 $687.00 $460.00 $482.00 $502.0028003 90 $520.00 $1,017.00 $1,073.00 $1,112.00 $821.00 $862.00 $901.0028005 90 $520.00 $836.00 $877.00 $913.00 $836.00 $877.00 $913.0028008 90 $296.00 $615.00 $648.00 $664.00 $421.00 $441.00 $456.0028010 90 $235.00 $331.00 $348.00 $357.00 $299.00 $314.00 $323.0028011 90 $340.00 $461.00 $486.00 $502.00 $414.00 $435.00 $451.0028020 90 $509.00 $773.00 $821.00 $849.00 $524.00 $553.00 $580.0028022 90 $422.00 $697.00 $737.00 $758.00 $469.00 $493.00 $513.0028024 90 $371.00 $657.00 $695.00 $713.00 $439.00 $461.00 $478.0028035 90 $532.00 $751.00 $796.00 $820.00 $512.00 $539.00 $563.0028039 90 -------- $731.00 $774.00 $801.00 $509.00 $536.00 $562.0028041 90 -------- $669.00 $704.00 $738.00 $669.00 $704.00 $738.0028043 90 $305.00 $569.00 $601.00 $616.00 $377.00 $396.00 $410.0028045 90 $456.00 $707.00 $746.00 $765.00 $501.00 $524.00 $543.0028046 90 $814.00 $1,062.00 $1,116.00 $1,171.00 $1,062.00 $1,116.00 $1,171.0028047 90 -------- $1,571.00 $1,665.00 $1,775.00 $1,571.00 $1,665.00 $1,775.0028050 90 $414.00 $604.00 $636.00 $649.00 $401.00 $419.00 $431.0028052 90 $402.00 $639.00 $677.00 $696.00 $412.00 $434.00 $453.0028054 90 $236.00 $556.00 $588.00 $600.00 $351.00 $368.00 $379.00



Surgery







28055 90 -------- $541.00 $564.00 $584.00 $541.00 $564.00 $584.0028060 90 $495.00 $740.00 $783.00 $805.00 $515.00 $541.00 $562.0028062 90 $657.00 $837.00 $883.00 $906.00 $588.00 $615.00 $637.0028070 90 $476.00 $762.00 $807.00 $832.00 $514.00 $541.00 $565.0028072 90 $445.00 $723.00 $767.00 $790.00 $479.00 $506.00 $528.0028080 90 $392.00 $745.00 $789.00 $808.00 $525.00 $553.00 $571.0028086 90 $462.00 $784.00 $834.00 $863.00 $523.00 $554.00 $583.0028088 90 $414.00 $638.00 $677.00 $696.00 $407.00 $429.00 $447.0028090 90 $414.00 $671.00 $710.00 $729.00 $444.00 $467.00 $485.0028092 90 $330.00 $602.00 $637.00 $652.00 $386.00 $406.00 $420.0028100 90 $571.00 $869.00 $923.00 $955.00 $597.00 $631.00 $662.0028102 90 $700.00 $881.00 $941.00 $1,003.00 $881.00 $941.00 $1,003.0028103 90 $709.00 $564.00 $588.00 $607.00 $564.00 $588.00 $607.0028104 90 $491.00 $754.00 $798.00 $822.00 $510.00 $537.00 $560.0028106 90 $632.00 $670.00 $703.00 $733.00 $670.00 $703.00 $733.0028107 90 $517.00 $797.00 $843.00 $866.00 $539.00 $566.00 $588.0028108 90 $418.00 $627.00 $663.00 $679.00 $414.00 $434.00 $449.0028110 90 $421.00 $659.00 $698.00 $715.00 $416.00 $437.00 $454.0028111 90 $537.00 $706.00 $747.00 $770.00 $473.00 $497.00 $519.0028112 90 $457.00 $698.00 $739.00 $760.00 $452.00 $476.00 $495.0028113 90 $481.00 $844.00 $892.00 $915.00 $611.00 $642.00 $665.0028114 90 $890.00 $1,544.00 $1,637.00 $1,701.00 $1,213.00 $1,281.00 $1,345.0028116 90 $648.00 $1,084.00 $1,144.00 $1,183.00 $826.00 $867.00 $906.0028118 90 $568.00 $850.00 $901.00 $931.00 $598.00 $630.00 $660.0028119 90 $524.00 $750.00 $792.00 $814.00 $520.00 $546.00 $566.0028120 90 $601.00 $973.00 $1,032.00 $1,071.00 $722.00 $763.00 $800.0028122 90 $622.00 $857.00 $905.00 $933.00 $635.00 $667.00 $695.0028124 90 $480.00 $679.00 $716.00 $733.00 $474.00 $496.00 $512.0028126 90 $393.00 $563.00 $596.00 $609.00 $357.00 $375.00 $388.0028130 90 $727.00 $930.00 $983.00 $1,035.00 $930.00 $983.00 $1,035.0028140 90 $533.00 $861.00 $912.00 $948.00 $642.00 $676.00 $712.0028150 90 $416.00 $610.00 $645.00 $662.00 $405.00 $425.00 $441.0028153 90 $400.00 $585.00 $619.00 $633.00 $378.00 $397.00 $410.0028160 90 $412.00 $600.00 $635.00 $650.00 $388.00 $408.00 $422.0028171 90 $789.00 $1,227.00 $1,273.00 $1,318.00 $1,227.00 $1,273.00 $1,318.0028173 90 $747.00 $1,107.00 $1,154.00 $1,201.00 $1,107.00 $1,154.00 $1,201.0028175 90 $571.00 $706.00 $737.00 $764.00 $706.00 $737.00 $764.0028190 10 $75.00 $363.00 $385.00 $393.00 $192.00 $202.00 $209.0028192 90 $326.00 $673.00 $711.00 $730.00 $453.00 $476.00 $494.0028193 90 $341.00 $757.00 $799.00 $820.00 $531.00 $556.00 $576.0028200 90 $478.00 $699.00 $740.00 $760.00 $463.00 $487.00 $507.0028202 90 $613.00 $854.00 $900.00 $925.00 $615.00 $644.00 $668.0028208 90 $406.00 $676.00 $716.00 $735.00 $449.00 $472.00 $491.0028210 90 $609.00 $820.00 $865.00 $890.00 $590.00 $618.00 $643.0028220 90 $435.00 $641.00 $677.00 $693.00 $433.00 $454.00 $469.0028222 90 $555.00 $722.00 $761.00 $779.00 $502.00 $524.00 $542.0028225 90 $345.00 $583.00 $617.00 $632.00 $373.00 $391.00 $406.0028226 90 $334.00 $869.00 $930.00 $969.00 $569.00 $607.00 $645.0028230 90 $380.00 $620.00 $655.00 $670.00 $407.00 $426.00 $441.0028232 90 $286.00 $551.00 $583.00 $596.00 $349.00 $366.00 $378.00



Surgery







28234 90 $178.00 $581.00 $615.00 $629.00 $378.00 $397.00 $410.0028238 90 $695.00 $962.00 $1,015.00 $1,048.00 $705.00 $740.00 $772.0028240 90 $370.00 $630.00 $665.00 $682.00 $418.00 $438.00 $453.0028250 90 $535.00 $834.00 $884.00 $915.00 $588.00 $621.00 $651.0028260 90 $641.00 $986.00 $1,042.00 $1,080.00 $740.00 $778.00 $815.0028261 90 $881.00 $1,412.00 $1,488.00 $1,544.00 $1,126.00 $1,181.00 $1,237.0028262 90 $1,363.00 $2,138.00 $2,284.00 $2,425.00 $1,739.00 $1,857.00 $1,996.0028264 90 $912.00 $1,448.00 $1,548.00 $1,633.00 $1,117.00 $1,192.00 $1,277.0028270 90 $266.00 $701.00 $741.00 $761.00 $480.00 $504.00 $523.0028272 90 $336.00 $562.00 $593.00 $605.00 $365.00 $382.00 $394.0028280 90 $426.00 $740.00 $783.00 $806.00 $506.00 $531.00 $553.0028285 90 $463.00 $763.00 $806.00 $828.00 $543.00 $570.00 $591.0028286 90 $441.00 $644.00 $680.00 $695.00 $431.00 $450.00 $465.0028288 90 $452.00 $863.00 $914.00 $940.00 $619.00 $651.00 $677.0028289 90 $458.00 $1,050.00 $1,111.00 $1,150.00 $791.00 $832.00 $870.0028290 90 $557.00 $842.00 $893.00 $921.00 $572.00 $603.00 $630.0028292 90 $666.00 $1,127.00 $1,189.00 $1,222.00 $865.00 $907.00 $939.0028293 90 $845.00 $1,493.00 $1,573.00 $1,609.00 $1,021.00 $1,066.00 $1,101.0028294 90 $797.00 $1,102.00 $1,166.00 $1,206.00 $794.00 $835.00 $874.0028296 90 $832.00 $1,019.00 $1,074.00 $1,103.00 $750.00 $786.00 $814.0028297 90 $838.00 $1,165.00 $1,232.00 $1,276.00 $844.00 $887.00 $930.0028298 90 $755.00 $1,034.00 $1,092.00 $1,127.00 $732.00 $769.00 $803.0028299 90 $829.00 $1,287.00 $1,355.00 $1,400.00 $980.00 $1,026.00 $1,071.0028300 90 $845.00 $950.00 $1,007.00 $1,067.00 $950.00 $1,007.00 $1,067.0028302 90 $930.00 $1,046.00 $1,117.00 $1,196.00 $1,046.00 $1,117.00 $1,196.0028304 90 $776.00 $1,188.00 $1,260.00 $1,311.00 $881.00 $931.00 $981.0028305 90 $1,030.00 $968.00 $1,018.00 $1,070.00 $968.00 $1,018.00 $1,070.0028306 90 $530.00 $879.00 $932.00 $964.00 $585.00 $618.00 $648.0028307 90 $614.00 $976.00 $1,037.00 $1,074.00 $653.00 $691.00 $727.0028308 90 $516.00 $807.00 $855.00 $879.00 $543.00 $572.00 $595.0028309 90 $955.00 $1,322.00 $1,399.00 $1,483.00 $1,322.00 $1,399.00 $1,483.0028310 90 $505.00 $782.00 $827.00 $850.00 $517.00 $543.00 $565.0028312 90 $469.00 $726.00 $769.00 $789.00 $460.00 $484.00 $503.0028313 90 $436.00 $757.00 $803.00 $829.00 $519.00 $548.00 $573.0028315 90 $462.00 $688.00 $727.00 $746.00 $469.00 $492.00 $511.0028320 90 $833.00 $887.00 $937.00 $988.00 $887.00 $937.00 $988.0028322 90 $667.00 $1,137.00 $1,208.00 $1,260.00 $842.00 $891.00 $942.0028340 90 $649.00 $827.00 $868.00 $889.00 $595.00 $619.00 $639.0028341 90 $753.00 $960.00 $1,008.00 $1,032.00 $709.00 $738.00 $762.0028344 90 $414.00 $672.00 $715.00 $743.00 $454.00 $482.00 $509.0028345 90 $557.00 $745.00 $784.00 $801.00 $524.00 $547.00 $564.0028360 90 $1,197.00 $1,342.00 $1,416.00 $1,497.00 $1,342.00 $1,416.00 $1,497.0028400 90 $266.00 $354.00 $376.00 $391.00 $325.00 $346.00 $360.0028405 90 $473.00 $565.00 $599.00 $626.00 $515.00 $545.00 $573.0028406 90 $616.00 $757.00 $805.00 $852.00 $757.00 $805.00 $852.0028415 90 $1,354.00 $1,614.00 $1,715.00 $1,824.00 $1,614.00 $1,715.00 $1,824.0028420 90 $1,619.00 $1,840.00 $1,965.00 $2,109.00 $1,840.00 $1,965.00 $2,109.0028430 90 $110.00 $337.00 $359.00 $373.00 $301.00 $321.00 $335.0028435 90 $371.00 $455.00 $483.00 $503.00 $408.00 $433.00 $453.0028436 90 $463.00 $648.00 $692.00 $732.00 $648.00 $692.00 $732.00



Surgery







28445 90 $874.00 $1,553.00 $1,650.00 $1,758.00 $1,553.00 $1,650.00 $1,758.0028446 90 -------- $1,777.00 $1,896.00 $2,035.00 $1,777.00 $1,896.00 $2,035.0028450 90 $148.00 $307.00 $326.00 $338.00 $275.00 $292.00 $304.0028455 90 $321.00 $412.00 $436.00 $451.00 $373.00 $394.00 $408.0028456 90 $288.00 $457.00 $489.00 $513.00 $457.00 $489.00 $513.0028465 90 $533.00 $904.00 $958.00 $1,010.00 $904.00 $958.00 $1,010.0028470 90 $178.00 $312.00 $331.00 $344.00 $292.00 $310.00 $323.0028475 90 $296.00 $367.00 $389.00 $404.00 $327.00 $346.00 $361.0028476 90 $364.00 $504.00 $537.00 $561.00 $504.00 $537.00 $561.0028485 90 $521.00 $758.00 $800.00 $836.00 $758.00 $800.00 $836.0028490 90 $80.00 $206.00 $219.00 $225.00 $178.00 $189.00 $195.0028495 90 $133.00 $252.00 $267.00 $274.00 $213.00 $225.00 $233.0028496 90 $261.00 $620.00 $661.00 $677.00 $335.00 $356.00 $370.0028505 90 $399.00 $957.00 $1,013.00 $1,050.00 $723.00 $762.00 $798.0028510 90 $75.00 $176.00 $186.00 $192.00 $171.00 $182.00 $187.0028515 90 $115.00 $229.00 $242.00 $249.00 $203.00 $214.00 $221.0028525 90 $345.00 $809.00 $857.00 $884.00 $575.00 $606.00 $631.0028530 90 $120.00 $163.00 $173.00 $178.00 $146.00 $154.00 $158.0028531 90 $243.00 $489.00 $518.00 $526.00 $263.00 $276.00 $284.0028540 90 $145.00 $294.00 $311.00 $320.00 $266.00 $281.00 $290.0028545 90 $208.00 $417.00 $445.00 $466.00 $372.00 $397.00 $417.0028546 90 $325.00 $792.00 $848.00 $874.00 $473.00 $505.00 $531.0028555 90 $592.00 $1,269.00 $1,349.00 $1,411.00 $974.00 $1,033.00 $1,094.0028570 90 $189.00 $317.00 $338.00 $352.00 $270.00 $288.00 $302.0028575 90 $308.00 $524.00 $560.00 $589.00 $476.00 $509.00 $538.0028576 90 $382.00 $564.00 $603.00 $639.00 $564.00 $603.00 $639.0028585 90 $742.00 $1,227.00 $1,292.00 $1,335.00 $970.00 $1,016.00 $1,059.0028600 90 $144.00 $310.00 $330.00 $341.00 $268.00 $285.00 $296.0028605 90 $287.00 $466.00 $498.00 $522.00 $421.00 $450.00 $474.0028606 90 $487.00 $572.00 $608.00 $642.00 $572.00 $608.00 $642.0028615 90 $621.00 $1,146.00 $1,218.00 $1,288.00 $1,146.00 $1,218.00 $1,288.0028630 10 $145.00 $224.00 $237.00 $246.00 $159.00 $168.00 $176.0028635 10 $189.00 $249.00 $263.00 $271.00 $189.00 $199.00 $207.0028636 10 $318.00 $403.00 $425.00 $434.00 $261.00 $274.00 $282.0028645 90 $434.00 $942.00 $996.00 $1,029.00 $702.00 $738.00 $770.0028660 10 $106.00 $166.00 $176.00 $183.00 $128.00 $136.00 $142.0028665 10 $172.00 $220.00 $232.00 $240.00 $188.00 $198.00 $206.0028666 10 $309.00 $271.00 $287.00 $302.00 $271.00 $287.00 $302.0028675 90 $348.00 $835.00 $886.00 $916.00 $594.00 $628.00 $657.0028705 90 $1,353.00 $1,835.00 $1,942.00 $2,066.00 $1,835.00 $1,942.00 $2,066.0028715 90 $1,179.00 $1,367.00 $1,453.00 $1,543.00 $1,367.00 $1,453.00 $1,543.0028725 90 $1,015.00 $1,133.00 $1,202.00 $1,274.00 $1,133.00 $1,202.00 $1,274.0028730 90 $945.00 $1,066.00 $1,129.00 $1,193.00 $1,066.00 $1,129.00 $1,193.0028735 90 $961.00 $1,138.00 $1,202.00 $1,269.00 $1,138.00 $1,202.00 $1,269.0028737 90 $873.00 $1,001.00 $1,054.00 $1,107.00 $1,001.00 $1,054.00 $1,107.0028740 90 $690.00 $1,216.00 $1,290.00 $1,340.00 $904.00 $955.00 $1,005.0028750 90 $690.00 $1,168.00 $1,240.00 $1,288.00 $858.00 $907.00 $954.0028755 90 $466.00 $726.00 $769.00 $791.00 $477.00 $502.00 $523.0028760 90 $654.00 $1,132.00 $1,196.00 $1,236.00 $835.00 $878.00 $916.0028800 90 $731.00 $792.00 $836.00 $882.00 $792.00 $836.00 $882.00



Surgery







28805 90 $731.00 $1,079.00 $1,140.00 $1,213.00 $1,079.00 $1,140.00 $1,213.0028810 90 $543.00 $635.00 $674.00 $719.00 $635.00 $674.00 $719.0028820 90 $377.00 $813.00 $863.00 $895.00 $577.00 $609.00 $640.0028825 90 $339.00 $774.00 $822.00 $851.00 $540.00 $570.00 $598.0028890 90 -------- $459.00 $484.00 $497.00 $322.00 $338.00 $350.0028899 YYY BR -------- -------- -------- -------- -------- --------29000 0 $247.00 $414.00 $447.00 $476.00 $260.00 $282.00 $310.0029010 0 $271.00 $338.00 $360.00 $374.00 $214.00 $228.00 $242.0029015 0 $289.00 $404.00 $431.00 $447.00 $259.00 $275.00 $291.0029035 0 $213.00 $276.00 $293.00 $303.00 $174.00 $184.00 $193.0029040 0 $260.00 $321.00 $340.00 $353.00 $211.00 $223.00 $235.0029044 0 $260.00 $398.00 $423.00 $434.00 $218.00 $230.00 $241.0029046 0 $286.00 $345.00 $367.00 $380.00 $230.00 $243.00 $256.0029049 0 $45.00 $120.00 $128.00 $134.00 $91.00 $96.00 $102.0029055 0 $180.00 $317.00 $339.00 $354.00 $203.00 $217.00 $231.0029058 0 $110.00 $175.00 $187.00 $196.00 $135.00 $144.00 $153.0029065 0 $88.00 $137.00 $146.00 $153.00 $99.00 $106.00 $112.0029075 0 $72.00 $123.00 $132.00 $137.00 $90.00 $96.00 $102.0029085 0 $59.00 $136.00 $145.00 $151.00 $98.00 $104.00 $110.0029086 0 $54.00 $110.00 $117.00 $121.00 $73.00 $78.00 $81.0029105 0 $59.00 $125.00 $133.00 $138.00 $86.00 $91.00 $96.0029125 0 $45.00 $91.00 $97.00 $100.00 $57.00 $60.00 $63.0029126 0 $53.00 $108.00 $115.00 $119.00 $70.00 $74.00 $77.0029130 0 $26.00 $59.00 $62.00 $65.00 $42.00 $44.00 $47.0029131 0 $53.00 $72.00 $76.00 $79.00 $48.00 $50.00 $53.0029200 0 $29.00 $42.00 $43.00 $44.00 $26.00 $27.00 $28.0029240 0 $45.00 $41.00 $42.00 $43.00 $27.00 $27.00 $28.0029260 0 $26.00 $41.00 $44.00 $45.00 $28.00 $30.00 $31.0029280 0 $29.00 $42.00 $44.00 $46.00 $29.00 $31.00 $32.0029305 0 $223.00 $352.00 $377.00 $393.00 $232.00 $248.00 $264.0029325 0 $260.00 $388.00 $416.00 $435.00 $260.00 $278.00 $298.0029345 0 $126.00 $195.00 $208.00 $219.00 $147.00 $157.00 $167.0029355 0 $133.00 $202.00 $215.00 $227.00 $155.00 $165.00 $176.0029358 0 $241.00 $229.00 $245.00 $257.00 $152.00 $163.00 $174.0029365 0 $101.00 $175.00 $187.00 $196.00 $128.00 $136.00 $145.0029405 0 $96.00 $116.00 $124.00 $129.00 $87.00 $92.00 $97.0029425 0 $101.00 $112.00 $119.00 $123.00 $82.00 $87.00 $91.0029435 0 $133.00 $166.00 $177.00 $185.00 $120.00 $128.00 $136.0029440 0 $22.00 $62.00 $65.00 $67.00 $42.00 $43.00 $45.0029445 0 $214.00 $192.00 $203.00 $211.00 $151.00 $159.00 $166.0029450 0 $84.00 $205.00 $215.00 $223.00 $163.00 $170.00 $178.0029505 0 $75.00 $118.00 $125.00 $129.00 $72.00 $76.00 $80.0029515 0 $59.00 $102.00 $108.00 $112.00 $71.00 $75.00 $79.0029520 0 $22.00 $44.00 $46.00 $47.00 $27.00 $27.00 $28.0029530 0 $55.00 $41.00 $43.00 $44.00 $27.00 $28.00 $29.0029540 0 $41.00 $37.00 $39.00 $40.00 $26.00 $27.00 $28.0029550 0 $37.00 $27.00 $28.00 $29.00 $17.00 $17.00 $18.0029580 0 $39.00 $75.00 $79.00 $82.00 $51.00 $54.00 $57.0029581 0 -------- $85.00 $90.00 $91.00 $18.00 $19.00 $19.0029582 0 -------- $97.00 $103.00 $103.00 $23.00 $23.00 $23.00



Surgery







29583 0 -------- $60.00 $64.00 $65.00 $16.00 $16.00 $17.0029584 0 -------- $97.00 $103.00 $103.00 $23.00 $23.00 $23.0029700 0 $29.00 $89.00 $95.00 $98.00 $49.00 $52.00 $55.0029705 0 $26.00 $96.00 $102.00 $107.00 $69.00 $74.00 $79.0029710 0 $29.00 $175.00 $187.00 $197.00 $122.00 $130.00 $141.0029720 0 $29.00 $121.00 $129.00 $135.00 $65.00 $70.00 $75.0029730 0 $29.00 $93.00 $99.00 $103.00 $66.00 $70.00 $75.0029740 0 $37.00 $143.00 $153.00 $163.00 $104.00 $111.00 $120.0029750 0 $105.00 $128.00 $135.00 $141.00 $98.00 $103.00 $109.0029799 YYY BR -------- -------- -------- -------- -------- --------29800 90 $557.00 $741.00 $788.00 $834.00 $741.00 $788.00 $834.0029804 90 $902.00 $940.00 $1,000.00 $1,061.00 $940.00 $1,000.00 $1,061.0029805 90 $360.00 $687.00 $734.00 $783.00 $687.00 $734.00 $783.0029806 90 $1,003.00 $1,557.00 $1,662.00 $1,784.00 $1,557.00 $1,662.00 $1,784.0029807 90 $976.00 $1,519.00 $1,622.00 $1,740.00 $1,519.00 $1,622.00 $1,740.0029819 90 $756.00 $855.00 $913.00 $976.00 $855.00 $913.00 $976.0029820 90 $718.00 $776.00 $826.00 $876.00 $776.00 $826.00 $876.0029821 90 $863.00 $848.00 $902.00 $956.00 $848.00 $902.00 $956.0029822 90 $749.00 $823.00 $874.00 $926.00 $823.00 $874.00 $926.0029823 90 $1,330.00 $898.00 $954.00 $1,010.00 $898.00 $954.00 $1,010.0029824 90 $611.00 $968.00 $1,029.00 $1,089.00 $968.00 $1,029.00 $1,089.0029825 90 $941.00 $839.00 $892.00 $944.00 $839.00 $892.00 $944.0029826 ZZZ $980.00 $261.00 $279.00 $302.00 $261.00 $279.00 $302.0029827 90 $1,058.00 $1,541.00 $1,636.00 $1,739.00 $1,541.00 $1,636.00 $1,739.0029828 90 -------- $1,329.00 $1,413.00 $1,503.00 $1,329.00 $1,413.00 $1,503.0029830 90 $524.00 $658.00 $700.00 $743.00 $658.00 $700.00 $743.0029834 90 $635.00 $704.00 $749.00 $792.00 $704.00 $749.00 $792.0029835 90 $612.00 $737.00 $787.00 $841.00 $737.00 $787.00 $841.0029836 90 $680.00 $825.00 $877.00 $928.00 $825.00 $877.00 $928.0029837 90 $830.00 $759.00 $808.00 $857.00 $759.00 $808.00 $857.0029838 90 $931.00 $853.00 $908.00 $966.00 $853.00 $908.00 $966.0029840 90 $501.00 $658.00 $703.00 $750.00 $658.00 $703.00 $750.0029843 90 $580.00 $705.00 $753.00 $803.00 $705.00 $753.00 $803.0029844 90 $612.00 $717.00 $762.00 $807.00 $717.00 $762.00 $807.0029845 90 $931.00 $833.00 $886.00 $937.00 $833.00 $886.00 $937.0029846 90 $976.00 $753.00 $802.00 $850.00 $753.00 $802.00 $850.0029847 90 $1,277.00 $772.00 $819.00 $866.00 $772.00 $819.00 $866.0029848 90 $608.00 $740.00 $789.00 $837.00 $740.00 $789.00 $837.0029850 90 $752.00 $900.00 $959.00 $1,023.00 $900.00 $959.00 $1,023.0029851 90 $1,137.00 $1,294.00 $1,375.00 $1,467.00 $1,294.00 $1,375.00 $1,467.0029855 90 $1,007.00 $1,143.00 $1,219.00 $1,303.00 $1,143.00 $1,219.00 $1,303.0029856 90 $1,231.00 $1,463.00 $1,563.00 $1,679.00 $1,463.00 $1,563.00 $1,679.0029860 90 $658.00 $964.00 $1,029.00 $1,099.00 $964.00 $1,029.00 $1,099.0029861 90 $845.00 $1,049.00 $1,116.00 $1,188.00 $1,049.00 $1,116.00 $1,188.0029862 90 $907.00 $1,174.00 $1,248.00 $1,325.00 $1,174.00 $1,248.00 $1,325.0029863 90 $880.00 $1,174.00 $1,249.00 $1,326.00 $1,174.00 $1,249.00 $1,326.0029866 90 -------- $1,527.00 $1,629.00 $1,745.00 $1,527.00 $1,629.00 $1,745.0029867 90 -------- $1,856.00 $1,981.00 $2,128.00 $1,856.00 $1,981.00 $2,128.0029868 90 -------- $2,363.00 $2,515.00 $2,701.00 $2,363.00 $2,515.00 $2,701.0029870 90 $460.00 $834.00 $891.00 $934.00 $600.00 $641.00 $682.00



Surgery







29871 90 $631.00 $750.00 $802.00 $856.00 $750.00 $802.00 $856.0029873 90 $489.00 $761.00 $814.00 $865.00 $761.00 $814.00 $865.0029874 90 $676.00 $783.00 $836.00 $892.00 $783.00 $836.00 $892.0029875 90 $639.00 $721.00 $770.00 $821.00 $721.00 $770.00 $821.0029876 90 $809.00 $962.00 $1,028.00 $1,099.00 $962.00 $1,028.00 $1,099.0029877 90 $852.00 $908.00 $969.00 $1,033.00 $908.00 $969.00 $1,033.0029879 90 $1,064.00 $967.00 $1,032.00 $1,103.00 $967.00 $1,032.00 $1,103.0029880 90 $1,169.00 $819.00 $874.00 $931.00 $819.00 $874.00 $931.0029881 90 $745.00 $789.00 $842.00 $897.00 $789.00 $842.00 $897.0029882 90 $819.00 $1,025.00 $1,095.00 $1,173.00 $1,025.00 $1,095.00 $1,173.0029883 90 $1,235.00 $1,232.00 $1,314.00 $1,407.00 $1,232.00 $1,314.00 $1,407.0029884 90 $721.00 $894.00 $952.00 $1,010.00 $894.00 $952.00 $1,010.0029885 90 $832.00 $1,098.00 $1,172.00 $1,253.00 $1,098.00 $1,172.00 $1,253.0029886 90 $697.00 $931.00 $995.00 $1,064.00 $931.00 $995.00 $1,064.0029887 90 $949.00 $1,092.00 $1,166.00 $1,248.00 $1,092.00 $1,166.00 $1,248.0029888 90 $1,296.00 $1,446.00 $1,543.00 $1,654.00 $1,446.00 $1,543.00 $1,654.0029889 90 $1,255.00 $1,793.00 $1,914.00 $2,053.00 $1,793.00 $1,914.00 $2,053.0029891 90 $796.00 $984.00 $1,044.00 $1,106.00 $984.00 $1,044.00 $1,106.0029892 90 $835.00 $840.00 $875.00 $905.00 $840.00 $875.00 $905.0029893 90 $472.00 $868.00 $915.00 $934.00 $612.00 $641.00 $660.0029894 90 $690.00 $729.00 $772.00 $817.00 $729.00 $772.00 $817.0029895 90 $679.00 $693.00 $733.00 $773.00 $693.00 $733.00 $773.0029897 90 $704.00 $738.00 $782.00 $829.00 $738.00 $782.00 $829.0029898 90 $863.00 $823.00 $871.00 $921.00 $823.00 $871.00 $921.0029899 90 $973.00 $1,517.00 $1,614.00 $1,724.00 $1,517.00 $1,614.00 $1,724.0029900 90 $434.00 $650.00 $685.00 $708.00 $650.00 $685.00 $708.0029901 90 $479.00 $774.00 $827.00 $881.00 $774.00 $827.00 $881.0029902 90 $514.00 $810.00 $860.00 $906.00 $810.00 $860.00 $906.0029904 90 -------- $933.00 $997.00 $1,067.00 $933.00 $997.00 $1,067.0029905 90 -------- $1,001.00 $1,069.00 $1,143.00 $1,001.00 $1,069.00 $1,143.0029906 90 -------- $1,053.00 $1,124.00 $1,201.00 $1,053.00 $1,124.00 $1,201.0029907 90 -------- $1,285.00 $1,372.00 $1,471.00 $1,285.00 $1,372.00 $1,471.0029914 90 -------- $1,454.00 $1,545.00 $1,646.00 $1,454.00 $1,545.00 $1,646.0029915 90 -------- $1,478.00 $1,570.00 $1,670.00 $1,478.00 $1,570.00 $1,670.0029916 90 -------- $1,480.00 $1,572.00 $1,672.00 $1,480.00 $1,572.00 $1,672.0029999 YYY BR -------- -------- -------- -------- -------- --------30000 10 $96.00 $323.00 $345.00 $354.00 $170.00 $180.00 $188.0030020 10 $117.00 $328.00 $350.00 $359.00 $171.00 $182.00 $191.0030100 0 $86.00 $199.00 $212.00 $217.00 $99.00 $105.00 $110.0030110 10 $157.00 $325.00 $346.00 $356.00 $188.00 $199.00 $208.0030115 90 $360.00 $617.00 $655.00 $681.00 $617.00 $655.00 $681.0030117 90 $301.00 $1,223.00 $1,308.00 $1,329.00 $485.00 $516.00 $535.0030118 90 $819.00 $1,106.00 $1,173.00 $1,231.00 $1,106.00 $1,173.00 $1,231.0030120 90 $500.00 $740.00 $787.00 $821.00 $630.00 $669.00 $703.0030124 90 $243.00 $409.00 $434.00 $452.00 $409.00 $434.00 $452.0030125 90 $599.00 $872.00 $925.00 $969.00 $872.00 $925.00 $969.0030130 90 $275.00 $540.00 $574.00 $594.00 $540.00 $574.00 $594.0030140 90 $320.00 $624.00 $664.00 $686.00 $624.00 $664.00 $686.0030150 90 $790.00 $1,107.00 $1,176.00 $1,235.00 $1,107.00 $1,176.00 $1,235.0030160 90 $875.00 $1,111.00 $1,178.00 $1,238.00 $1,111.00 $1,178.00 $1,238.00



Surgery







30200 0 $68.00 $160.00 $171.00 $176.00 $86.00 $91.00 $95.0030210 10 $75.00 $212.00 $225.00 $232.00 $142.00 $151.00 $157.0030220 10 $154.00 $425.00 $454.00 $464.00 $180.00 $191.00 $200.0030300 10 $45.00 $261.00 $278.00 $284.00 $150.00 $160.00 $165.0030310 10 $170.00 $293.00 $312.00 $323.00 $293.00 $312.00 $323.0030320 90 $419.00 $633.00 $672.00 $699.00 $633.00 $672.00 $699.0030400 90 $741.00 $1,443.00 $1,532.00 $1,597.00 $1,443.00 $1,532.00 $1,597.0030410 90 $1,173.00 $1,693.00 $1,796.00 $1,878.00 $1,693.00 $1,796.00 $1,878.0030420 90 $1,424.00 $1,968.00 $2,088.00 $2,189.00 $1,968.00 $2,088.00 $2,189.0030430 90 $626.00 $1,364.00 $1,455.00 $1,511.00 $1,364.00 $1,455.00 $1,511.0030435 90 $1,005.00 $1,588.00 $1,685.00 $1,759.00 $1,588.00 $1,685.00 $1,759.0030450 90 $1,445.00 $2,151.00 $2,279.00 $2,391.00 $2,151.00 $2,279.00 $2,391.0030460 90 $857.00 $1,027.00 $1,085.00 $1,140.00 $1,027.00 $1,085.00 $1,140.0030462 90 $1,633.00 $2,250.00 $2,392.00 $2,530.00 $2,250.00 $2,392.00 $2,530.0030465 90 $803.00 $1,409.00 $1,494.00 $1,568.00 $1,409.00 $1,494.00 $1,568.0030520 90 $533.00 $891.00 $946.00 $986.00 $891.00 $946.00 $986.0030540 90 $643.00 $992.00 $1,053.00 $1,099.00 $992.00 $1,053.00 $1,099.0030545 90 $981.00 $1,264.00 $1,338.00 $1,401.00 $1,264.00 $1,338.00 $1,401.0030560 10 $104.00 $376.00 $402.00 $410.00 $196.00 $208.00 $216.0030580 90 $566.00 $937.00 $997.00 $1,043.00 $744.00 $790.00 $836.0030600 90 $466.00 $843.00 $896.00 $936.00 $647.00 $686.00 $725.0030620 90 $564.00 $889.00 $945.00 $983.00 $889.00 $945.00 $983.0030630 90 $624.00 $891.00 $945.00 $988.00 $891.00 $945.00 $988.0030801 10 $88.00 $321.00 $342.00 $349.00 $193.00 $205.00 $212.0030802 10 $172.00 $410.00 $437.00 $449.00 $272.00 $289.00 $301.0030901 0 $75.00 $136.00 $144.00 $151.00 $83.00 $88.00 $94.0030903 0 $110.00 $311.00 $331.00 $340.00 $119.00 $125.00 $134.0030905 0 $224.00 $382.00 $407.00 $419.00 $157.00 $166.00 $177.0030906 0 $208.00 $490.00 $523.00 $537.00 $202.00 $213.00 $227.0030915 90 $596.00 $828.00 $877.00 $920.00 $828.00 $877.00 $920.0030920 90 $862.00 $1,203.00 $1,275.00 $1,340.00 $1,203.00 $1,275.00 $1,340.0030930 10 $213.00 $176.00 $186.00 $194.00 $176.00 $186.00 $194.0030999 YYY BR -------- -------- -------- -------- -------- --------31000 10 $81.00 $259.00 $276.00 $283.00 $152.00 $161.00 $168.0031002 10 $135.00 $275.00 $292.00 $302.00 $275.00 $292.00 $302.0031020 90 $281.00 $681.00 $727.00 $745.00 $510.00 $542.00 $560.0031030 90 $531.00 $982.00 $1,046.00 $1,084.00 $759.00 $807.00 $844.0031032 90 $604.00 $824.00 $874.00 $914.00 $824.00 $874.00 $914.0031040 90 $772.00 $1,096.00 $1,163.00 $1,221.00 $1,096.00 $1,163.00 $1,221.0031050 90 $489.00 $696.00 $740.00 $773.00 $696.00 $740.00 $773.0031051 90 $654.00 $922.00 $979.00 $1,022.00 $922.00 $979.00 $1,022.0031070 90 $410.00 $626.00 $665.00 $691.00 $626.00 $665.00 $691.0031075 90 $839.00 $1,128.00 $1,198.00 $1,257.00 $1,128.00 $1,198.00 $1,257.0031080 90 $942.00 $1,486.00 $1,575.00 $1,647.00 $1,486.00 $1,575.00 $1,647.0031081 90 $1,089.00 $2,167.00 $2,358.00 $2,579.00 $2,167.00 $2,358.00 $2,579.0031084 90 $1,210.00 $1,664.00 $1,762.00 $1,846.00 $1,664.00 $1,762.00 $1,846.0031085 90 $1,281.00 $2,318.00 $2,525.00 $2,773.00 $2,318.00 $2,525.00 $2,773.0031086 90 $1,081.00 $1,619.00 $1,714.00 $1,793.00 $1,619.00 $1,714.00 $1,793.0031087 90 $1,075.00 $1,564.00 $1,659.00 $1,750.00 $1,564.00 $1,659.00 $1,750.0031090 90 $877.00 $1,462.00 $1,552.00 $1,616.00 $1,462.00 $1,552.00 $1,616.00



Surgery







31200 90 $463.00 $799.00 $845.00 $864.00 $799.00 $845.00 $864.0031201 90 $716.00 $1,059.00 $1,123.00 $1,173.00 $1,059.00 $1,123.00 $1,173.0031205 90 $851.00 $1,266.00 $1,333.00 $1,372.00 $1,266.00 $1,333.00 $1,372.0031225 90 $1,683.00 $2,714.00 $2,874.00 $3,031.00 $2,714.00 $2,874.00 $3,031.0031230 90 $1,908.00 $3,020.00 $3,199.00 $3,384.00 $3,020.00 $3,199.00 $3,384.0031231 0 $122.00 $294.00 $313.00 $320.00 $95.00 $100.00 $106.0031233 0 $221.00 $372.00 $396.00 $408.00 $199.00 $211.00 $223.0031235 0 $217.00 $424.00 $451.00 $466.00 $237.00 $250.00 $264.0031237 0 $266.00 $368.00 $391.00 $406.00 $236.00 $249.00 $264.0031238 0 $311.00 $369.00 $391.00 $407.00 $247.00 $261.00 $277.0031239 10 $775.00 $883.00 $929.00 $968.00 $883.00 $929.00 $968.0031240 0 $224.00 $236.00 $249.00 $264.00 $236.00 $249.00 $264.0031254 0 $588.00 $400.00 $423.00 $449.00 $400.00 $423.00 $449.0031255 0 $601.00 $588.00 $620.00 $660.00 $588.00 $620.00 $660.0031256 0 $292.00 $290.00 $306.00 $325.00 $290.00 $306.00 $325.0031267 0 $453.00 $466.00 $492.00 $524.00 $466.00 $492.00 $524.0031276 0 $690.00 $742.00 $783.00 $834.00 $742.00 $783.00 $834.0031287 0 $339.00 $340.00 $359.00 $381.00 $340.00 $359.00 $381.0031288 0 $396.00 $394.00 $416.00 $442.00 $394.00 $416.00 $442.0031290 10 $1,462.00 $1,693.00 $1,793.00 $1,908.00 $1,693.00 $1,793.00 $1,908.0031291 10 $1,551.00 $1,812.00 $1,926.00 $2,063.00 $1,812.00 $1,926.00 $2,063.0031292 10 $1,235.00 $1,461.00 $1,545.00 $1,637.00 $1,461.00 $1,545.00 $1,637.0031293 10 $1,346.00 $1,585.00 $1,675.00 $1,774.00 $1,585.00 $1,675.00 $1,774.0031294 10 $1,587.00 $1,813.00 $1,916.00 $2,032.00 $1,813.00 $1,916.00 $2,032.0031295 0 -------- $2,821.00 $3,023.00 $3,046.00 $240.00 $254.00 $269.0031296 0 -------- $2,879.00 $3,084.00 $3,111.00 $288.00 $305.00 $324.0031297 0 -------- $2,825.00 $3,027.00 $3,050.00 $235.00 $249.00 $264.0031299 YYY BR -------- -------- -------- -------- -------- --------31300 90 $1,295.00 $1,886.00 $2,002.00 $2,098.00 $1,886.00 $2,002.00 $2,098.0031320 90 $508.00 $983.00 $1,046.00 $1,081.00 $983.00 $1,046.00 $1,081.0031360 90 $1,630.00 $3,074.00 $3,255.00 $3,429.00 $3,074.00 $3,255.00 $3,429.0031365 90 $2,238.00 $3,802.00 $4,024.00 $4,249.00 $3,802.00 $4,024.00 $4,249.0031367 90 $1,913.00 $3,251.00 $3,442.00 $3,617.00 $3,251.00 $3,442.00 $3,617.0031368 90 $2,478.00 $3,629.00 $3,845.00 $4,043.00 $3,629.00 $3,845.00 $4,043.0031370 90 $1,891.00 $3,058.00 $3,242.00 $3,401.00 $3,058.00 $3,242.00 $3,401.0031375 90 $1,720.00 $2,889.00 $3,064.00 $3,219.00 $2,889.00 $3,064.00 $3,219.0031380 90 $1,782.00 $2,856.00 $3,027.00 $3,175.00 $2,856.00 $3,027.00 $3,175.0031382 90 $1,822.00 $3,148.00 $3,336.00 $3,502.00 $3,148.00 $3,336.00 $3,502.0031390 90 $2,513.00 $4,236.00 $4,483.00 $4,728.00 $4,236.00 $4,483.00 $4,728.0031395 90 $2,937.00 $4,472.00 $4,734.00 $4,986.00 $4,472.00 $4,734.00 $4,986.0031400 90 $969.00 $1,414.00 $1,500.00 $1,567.00 $1,414.00 $1,500.00 $1,567.0031420 90 $969.00 $1,207.00 $1,278.00 $1,344.00 $1,207.00 $1,278.00 $1,344.0031500 0 $116.00 $162.00 $169.00 $180.00 $162.00 $169.00 $180.0031502 0 $74.00 $51.00 $54.00 $57.00 $51.00 $54.00 $57.0031505 0 $62.00 $117.00 $125.00 $128.00 $71.00 $75.00 $78.0031510 0 $145.00 $299.00 $319.00 $330.00 $178.00 $188.00 $199.0031511 0 $88.00 $302.00 $321.00 $334.00 $191.00 $202.00 $214.0031512 0 $197.00 $292.00 $310.00 $322.00 $189.00 $200.00 $211.0031513 0 $182.00 $193.00 $204.00 $216.00 $193.00 $204.00 $216.0031515 0 $160.00 $262.00 $277.00 $285.00 $153.00 $160.00 $168.00



Surgery







31525 0 $234.00 $362.00 $384.00 $400.00 $236.00 $249.00 $264.0031526 0 $222.00 $232.00 $245.00 $259.00 $232.00 $245.00 $259.0031527 0 $262.00 $287.00 $303.00 $322.00 $287.00 $303.00 $322.0031528 0 $202.00 $213.00 $225.00 $238.00 $213.00 $225.00 $238.0031529 0 $217.00 $238.00 $252.00 $267.00 $238.00 $252.00 $267.0031530 0 $284.00 $292.00 $309.00 $328.00 $292.00 $309.00 $328.0031531 0 $311.00 $314.00 $332.00 $352.00 $314.00 $332.00 $352.0031535 0 $272.00 $280.00 $296.00 $314.00 $280.00 $296.00 $314.0031536 0 $308.00 $311.00 $329.00 $349.00 $311.00 $329.00 $349.0031540 0 $357.00 $357.00 $377.00 $401.00 $357.00 $377.00 $401.0031541 0 $453.00 $390.00 $412.00 $438.00 $390.00 $412.00 $438.0031545 0 -------- $536.00 $566.00 $601.00 $536.00 $566.00 $601.0031546 0 -------- $817.00 $864.00 $921.00 $817.00 $864.00 $921.0031560 0 $446.00 $463.00 $489.00 $520.00 $463.00 $489.00 $520.0031561 0 $509.00 $508.00 $536.00 $570.00 $508.00 $536.00 $570.0031570 0 $369.00 $488.00 $519.00 $543.00 $340.00 $360.00 $383.0031571 0 $363.00 $369.00 $390.00 $415.00 $369.00 $390.00 $415.0031575 0 $128.00 $162.00 $172.00 $178.00 $111.00 $118.00 $124.0031576 0 $186.00 $318.00 $338.00 $349.00 $181.00 $191.00 $202.0031577 0 $230.00 $345.00 $367.00 $381.00 $220.00 $232.00 $246.0031578 0 $264.00 $398.00 $423.00 $440.00 $253.00 $267.00 $284.0031579 0 $219.00 $301.00 $319.00 $332.00 $207.00 $218.00 $231.0031580 90 $1,213.00 $1,758.00 $1,865.00 $1,950.00 $1,758.00 $1,865.00 $1,950.0031582 90 $1,881.00 $2,730.00 $2,895.00 $3,029.00 $2,730.00 $2,895.00 $3,029.0031584 90 $1,616.00 $2,191.00 $2,324.00 $2,447.00 $2,191.00 $2,324.00 $2,447.0031587 90 $913.00 $1,458.00 $1,542.00 $1,630.00 $1,458.00 $1,542.00 $1,630.0031588 90 $1,206.00 $1,646.00 $1,744.00 $1,830.00 $1,646.00 $1,744.00 $1,830.0031590 90 $691.00 $1,275.00 $1,358.00 $1,407.00 $1,275.00 $1,358.00 $1,407.0031595 90 $773.00 $1,099.00 $1,166.00 $1,218.00 $1,099.00 $1,166.00 $1,218.0031599 YYY BR -------- -------- -------- -------- -------- --------31600 0 $306.00 $593.00 $631.00 $684.00 $593.00 $631.00 $684.0031603 0 $343.00 $333.00 $353.00 $381.00 $333.00 $353.00 $381.0031605 0 $297.00 $275.00 $292.00 $317.00 $275.00 $292.00 $317.0031610 90 $794.00 $1,035.00 $1,099.00 $1,157.00 $1,035.00 $1,099.00 $1,157.0031611 90 $614.00 $775.00 $823.00 $858.00 $775.00 $823.00 $858.0031612 0 $99.00 $120.00 $128.00 $134.00 $72.00 $77.00 $82.0031613 90 $384.00 $653.00 $695.00 $726.00 $653.00 $695.00 $726.0031614 90 $736.00 $1,086.00 $1,154.00 $1,207.00 $1,086.00 $1,154.00 $1,207.0031615 0 $213.00 $260.00 $276.00 $287.00 $188.00 $198.00 $209.0031622 0 $230.00 $428.00 $454.00 $467.00 $211.00 $221.00 $233.0031623 0 $225.00 $464.00 $491.00 $502.00 $213.00 $222.00 $232.0031624 0 $217.00 $440.00 $465.00 $476.00 $215.00 $224.00 $234.0031625 0 $235.00 $555.00 $588.00 $601.00 $247.00 $258.00 $270.0031626 0 -------- $1,263.00 $1,347.00 $1,368.00 $310.00 $325.00 $343.0031627 ZZZ -------- $1,942.00 $2,079.00 $2,093.00 $143.00 $149.00 $158.0031628 0 $269.00 $585.00 $618.00 $631.00 $274.00 $285.00 $297.0031629 0 $198.00 $696.00 $738.00 $753.00 $291.00 $303.00 $317.0031630 0 $308.00 $294.00 $309.00 $327.00 $294.00 $309.00 $327.0031631 0 $252.00 $339.00 $357.00 $381.00 $339.00 $357.00 $381.0031632 ZZZ -------- $106.00 $111.00 $114.00 $72.00 $75.00 $78.00



Surgery







31633 ZZZ -------- $131.00 $138.00 $142.00 $93.00 $96.00 $101.0031634 0 -------- $2,563.00 $2,743.00 $2,770.00 $304.00 $319.00 $339.0031635 0 $298.00 $493.00 $521.00 $538.00 $276.00 $289.00 $305.0031636 0 -------- $326.00 $342.00 $363.00 $326.00 $342.00 $363.0031637 ZZZ -------- $108.00 $112.00 $117.00 $108.00 $112.00 $117.0031638 0 -------- $373.00 $391.00 $416.00 $373.00 $391.00 $416.0031640 0 $399.00 $374.00 $393.00 $416.00 $374.00 $393.00 $416.0031641 0 $304.00 $379.00 $396.00 $418.00 $379.00 $396.00 $418.0031643 0 $208.00 $258.00 $269.00 $281.00 $258.00 $269.00 $281.0031645 0 $208.00 $455.00 $481.00 $493.00 $235.00 $245.00 $256.0031646 0 $161.00 $408.00 $431.00 $441.00 $203.00 $212.00 $221.0031647 0 -------- $324.00 $337.00 $354.00 $324.00 $337.00 $354.0031648 0 -------- $299.00 $311.00 $325.00 $299.00 $311.00 $325.0031649 ZZZ -------- $102.00 $107.00 $113.00 $102.00 $107.00 $113.0031651 ZZZ -------- $117.00 $123.00 $132.00 $117.00 $123.00 $132.0031652 0 -------- $1,254.00 $1,335.00 $1,355.00 $342.00 $356.00 $373.0031653 0 -------- $1,334.00 $1,420.00 $1,442.00 $377.00 $393.00 $412.0031654 ZZZ -------- $202.00 $214.00 $219.00 $99.00 $103.00 $108.0031660 0 -------- $306.00 $317.00 $330.00 $306.00 $317.00 $330.0031661 0 -------- $321.00 $333.00 $346.00 $321.00 $333.00 $346.0031717 0 $138.00 $364.00 $385.00 $392.00 $157.00 $163.00 $170.0031720 0 $89.00 $75.00 $78.00 $81.00 $75.00 $78.00 $81.0031725 0 $103.00 $131.00 $136.00 $143.00 $131.00 $136.00 $143.0031730 0 $199.00 $1,700.00 $1,822.00 $1,846.00 $221.00 $235.00 $255.0031750 90 $1,088.00 $2,033.00 $2,164.00 $2,266.00 $2,033.00 $2,164.00 $2,266.0031755 90 $1,448.00 $2,534.00 $2,695.00 $2,801.00 $2,534.00 $2,695.00 $2,801.0031760 90 $1,648.00 $2,092.00 $2,245.00 $2,466.00 $2,092.00 $2,245.00 $2,466.0031766 90 $2,315.00 $2,694.00 $2,889.00 $3,185.00 $2,694.00 $2,889.00 $3,185.0031770 90 $1,815.00 $2,020.00 $2,166.00 $2,386.00 $2,020.00 $2,166.00 $2,386.0031775 90 $1,973.00 $1,897.00 $1,981.00 $2,074.00 $1,897.00 $1,981.00 $2,074.0031780 90 $1,577.00 $1,749.00 $1,859.00 $2,000.00 $1,749.00 $1,859.00 $2,000.0031781 90 $1,936.00 $2,132.00 $2,254.00 $2,404.00 $2,132.00 $2,254.00 $2,404.0031785 90 $1,320.00 $1,602.00 $1,697.00 $1,814.00 $1,602.00 $1,697.00 $1,814.0031786 90 $1,866.00 $2,162.00 $2,315.00 $2,541.00 $2,162.00 $2,315.00 $2,541.0031800 90 $628.00 $1,059.00 $1,125.00 $1,175.00 $1,059.00 $1,125.00 $1,175.0031805 90 $1,175.00 $1,236.00 $1,325.00 $1,448.00 $1,236.00 $1,325.00 $1,448.0031820 90 $458.00 $622.00 $662.00 $690.00 $478.00 $506.00 $535.0031825 90 $659.00 $863.00 $916.00 $958.00 $698.00 $739.00 $781.0031830 90 $460.00 $637.00 $678.00 $709.00 $500.00 $531.00 $562.0031899 YYY BR -------- -------- -------- -------- -------- --------32035 90 $821.00 $1,071.00 $1,147.00 $1,248.00 $1,071.00 $1,147.00 $1,248.0032036 90 $908.00 $1,157.00 $1,240.00 $1,350.00 $1,157.00 $1,240.00 $1,350.0032096 90 -------- $1,209.00 $1,295.00 $1,419.00 $1,209.00 $1,295.00 $1,419.0032097 90 -------- $1,208.00 $1,294.00 $1,417.00 $1,208.00 $1,294.00 $1,417.0032098 90 -------- $1,146.00 $1,228.00 $1,344.00 $1,146.00 $1,228.00 $1,344.0032100 90 $1,120.00 $1,214.00 $1,301.00 $1,425.00 $1,214.00 $1,301.00 $1,425.0032110 90 $1,223.00 $2,195.00 $2,351.00 $2,577.00 $2,195.00 $2,351.00 $2,577.0032120 90 $1,077.00 $1,303.00 $1,396.00 $1,525.00 $1,303.00 $1,396.00 $1,525.0032124 90 $1,144.00 $1,388.00 $1,487.00 $1,627.00 $1,388.00 $1,487.00 $1,627.0032140 90 $1,284.00 $1,497.00 $1,605.00 $1,761.00 $1,497.00 $1,605.00 $1,761.00



Surgery







32141 90 $1,267.00 $2,297.00 $2,461.00 $2,705.00 $2,297.00 $2,461.00 $2,705.0032150 90 $1,226.00 $1,507.00 $1,614.00 $1,768.00 $1,507.00 $1,614.00 $1,768.0032151 90 $1,231.00 $1,502.00 $1,608.00 $1,757.00 $1,502.00 $1,608.00 $1,757.0032160 90 $842.00 $1,179.00 $1,262.00 $1,376.00 $1,179.00 $1,262.00 $1,376.0032200 90 $1,132.00 $1,699.00 $1,819.00 $1,984.00 $1,699.00 $1,819.00 $1,984.0032215 90 $1,024.00 $1,188.00 $1,270.00 $1,379.00 $1,188.00 $1,270.00 $1,379.0032220 90 $1,680.00 $2,375.00 $2,544.00 $2,785.00 $2,375.00 $2,544.00 $2,785.0032225 90 $1,268.00 $1,492.00 $1,598.00 $1,749.00 $1,492.00 $1,598.00 $1,749.0032310 90 $1,221.00 $1,363.00 $1,458.00 $1,592.00 $1,363.00 $1,458.00 $1,592.0032320 90 $1,787.00 $2,398.00 $2,568.00 $2,813.00 $2,398.00 $2,568.00 $2,813.0032400 0 $129.00 $214.00 $226.00 $232.00 $128.00 $133.00 $139.0032405 0 $159.00 $623.00 $664.00 $672.00 $151.00 $158.00 $165.0032440 90 $1,837.00 $2,355.00 $2,523.00 $2,770.00 $2,355.00 $2,523.00 $2,770.0032442 90 $2,093.00 $4,839.00 $5,194.00 $5,729.00 $4,839.00 $5,194.00 $5,729.0032445 90 $2,093.00 $5,344.00 $5,721.00 $6,285.00 $5,344.00 $5,721.00 $6,285.0032480 90 $1,622.00 $2,223.00 $2,381.00 $2,614.00 $2,223.00 $2,381.00 $2,614.0032482 90 $1,714.00 $2,376.00 $2,545.00 $2,789.00 $2,376.00 $2,545.00 $2,789.0032484 90 $1,771.00 $2,165.00 $2,320.00 $2,551.00 $2,165.00 $2,320.00 $2,551.0032486 90 $1,974.00 $3,556.00 $3,811.00 $4,203.00 $3,556.00 $3,811.00 $4,203.0032488 90 $2,094.00 $3,607.00 $3,863.00 $4,247.00 $3,607.00 $3,863.00 $4,247.0032491 90 $1,784.00 $2,216.00 $2,376.00 $2,608.00 $2,216.00 $2,376.00 $2,608.0032501 ZZZ $374.00 $372.00 $399.00 $442.00 $372.00 $399.00 $442.0032503 90 -------- $2,723.00 $2,918.00 $3,207.00 $2,723.00 $2,918.00 $3,207.0032504 90 -------- $3,109.00 $3,331.00 $3,663.00 $3,109.00 $3,331.00 $3,663.0032505 90 -------- $1,399.00 $1,499.00 $1,641.00 $1,399.00 $1,499.00 $1,641.0032506 ZZZ -------- $238.00 $255.00 $283.00 $238.00 $255.00 $283.0032507 ZZZ -------- $238.00 $255.00 $282.00 $238.00 $255.00 $282.0032540 90 $1,308.00 $2,614.00 $2,801.00 $3,078.00 $2,614.00 $2,801.00 $3,078.0032550 0 -------- $1,091.00 $1,165.00 $1,192.00 $329.00 $347.00 $372.0032551 0 -------- $253.00 $267.00 $288.00 $253.00 $267.00 $288.0032552 10 -------- $268.00 $284.00 $300.00 $234.00 $248.00 $263.0032553 0 -------- $825.00 $876.00 $891.00 $284.00 $296.00 $310.0032554 0 -------- $281.00 $298.00 $305.00 $131.00 $137.00 $144.0032555 0 -------- $405.00 $429.00 $438.00 $165.00 $171.00 $179.0032556 0 -------- $749.00 $798.00 $809.00 $181.00 $189.00 $198.0032557 0 -------- $718.00 $763.00 $776.00 $226.00 $235.00 $246.0032560 0 -------- $342.00 $366.00 $376.00 $116.00 $123.00 $133.0032561 0 -------- $133.00 $140.00 $147.00 $101.00 $106.00 $112.0032562 0 -------- $121.00 $127.00 $134.00 $92.00 $96.00 $103.0032601 0 $456.00 $465.00 $497.00 $545.00 $465.00 $497.00 $545.0032604 0 $663.00 $729.00 $782.00 $862.00 $729.00 $782.00 $862.0032606 0 $637.00 $698.00 $748.00 $824.00 $698.00 $748.00 $824.0032607 0 -------- $465.00 $498.00 $547.00 $465.00 $498.00 $547.0032608 0 -------- $571.00 $611.00 $672.00 $571.00 $611.00 $672.0032609 0 -------- $389.00 $416.00 $455.00 $389.00 $416.00 $455.0032650 90 $957.00 $995.00 $1,066.00 $1,162.00 $995.00 $1,066.00 $1,162.0032651 90 $1,166.00 $1,648.00 $1,766.00 $1,937.00 $1,648.00 $1,766.00 $1,937.0032652 90 $1,615.00 $2,504.00 $2,683.00 $2,948.00 $2,504.00 $2,683.00 $2,948.0032653 90 $1,144.00 $1,591.00 $1,704.00 $1,867.00 $1,591.00 $1,704.00 $1,867.0032654 90 $1,096.00 $1,784.00 $1,914.00 $2,105.00 $1,784.00 $1,914.00 $2,105.00



Surgery







32655 90 $1,213.00 $1,435.00 $1,538.00 $1,685.00 $1,435.00 $1,538.00 $1,685.0032656 90 $1,222.00 $1,204.00 $1,290.00 $1,411.00 $1,204.00 $1,290.00 $1,411.0032658 90 $1,142.00 $1,070.00 $1,147.00 $1,256.00 $1,070.00 $1,147.00 $1,256.0032659 90 $1,141.00 $1,095.00 $1,174.00 $1,282.00 $1,095.00 $1,174.00 $1,282.0032661 90 $1,165.00 $1,203.00 $1,291.00 $1,415.00 $1,203.00 $1,291.00 $1,415.0032662 90 $1,459.00 $1,339.00 $1,435.00 $1,571.00 $1,339.00 $1,435.00 $1,571.0032663 90 $1,636.00 $2,111.00 $2,262.00 $2,486.00 $2,111.00 $2,262.00 $2,486.0032664 90 $1,197.00 $1,279.00 $1,370.00 $1,500.00 $1,279.00 $1,370.00 $1,500.0032665 90 $1,360.00 $1,843.00 $1,973.00 $2,164.00 $1,843.00 $1,973.00 $2,164.0032666 90 -------- $1,307.00 $1,400.00 $1,532.00 $1,307.00 $1,400.00 $1,532.0032667 ZZZ -------- $239.00 $256.00 $283.00 $239.00 $256.00 $283.0032668 ZZZ -------- $238.00 $255.00 $283.00 $238.00 $255.00 $283.0032669 90 -------- $2,029.00 $2,175.00 $2,391.00 $2,029.00 $2,175.00 $2,391.0032670 90 -------- $2,414.00 $2,586.00 $2,844.00 $2,414.00 $2,586.00 $2,844.0032671 90 -------- $2,673.00 $2,863.00 $3,149.00 $2,673.00 $2,863.00 $3,149.0032672 90 -------- $2,296.00 $2,461.00 $2,705.00 $2,296.00 $2,461.00 $2,705.0032673 90 -------- $1,833.00 $1,964.00 $2,154.00 $1,833.00 $1,964.00 $2,154.0032674 ZZZ -------- $328.00 $352.00 $389.00 $328.00 $352.00 $389.0032701 0 -------- $329.00 $352.00 $388.00 $329.00 $352.00 $388.0032800 90 $1,166.00 $1,420.00 $1,523.00 $1,670.00 $1,420.00 $1,523.00 $1,670.0032810 90 $1,085.00 $1,354.00 $1,452.00 $1,591.00 $1,354.00 $1,452.00 $1,591.0032815 90 $1,917.00 $4,219.00 $4,519.00 $4,968.00 $4,219.00 $4,519.00 $4,968.0032820 90 $1,848.00 $2,005.00 $2,149.00 $2,354.00 $2,005.00 $2,149.00 $2,354.0032851 90 $3,100.00 $4,985.00 $5,346.00 $5,897.00 $4,985.00 $5,346.00 $5,897.0032852 90 $3,339.00 $5,458.00 $5,854.00 $6,465.00 $5,458.00 $5,854.00 $6,465.0032853 90 $3,787.00 $6,952.00 $7,453.00 $8,229.00 $6,952.00 $7,453.00 $8,229.0032854 90 $4,038.00 $7,390.00 $7,921.00 $8,743.00 $7,390.00 $7,921.00 $8,743.0032900 90 $1,532.00 $2,104.00 $2,252.00 $2,462.00 $2,104.00 $2,252.00 $2,462.0032905 90 $1,661.00 $2,021.00 $2,167.00 $2,381.00 $2,021.00 $2,167.00 $2,381.0032906 90 $2,100.00 $2,500.00 $2,680.00 $2,950.00 $2,500.00 $2,680.00 $2,950.0032940 90 $1,555.00 $1,859.00 $1,994.00 $2,193.00 $1,859.00 $1,994.00 $2,193.0032960 0 $126.00 $205.00 $218.00 $231.00 $149.00 $158.00 $171.0032997 0 $312.00 $502.00 $521.00 $543.00 $502.00 $521.00 $543.0032998 0 -------- $3,294.00 $3,521.00 $3,550.00 $417.00 $434.00 $455.0032999 YYY BR -------- -------- -------- -------- -------- --------33010 0 $124.00 $181.00 $194.00 $213.00 $181.00 $194.00 $213.0033011 0 $125.00 $182.00 $195.00 $215.00 $182.00 $195.00 $215.0033015 90 $555.00 $758.00 $809.00 $876.00 $758.00 $809.00 $876.0033020 90 $1,178.00 $1,320.00 $1,414.00 $1,548.00 $1,320.00 $1,414.00 $1,548.0033025 90 $1,165.00 $1,199.00 $1,285.00 $1,408.00 $1,199.00 $1,285.00 $1,408.0033030 90 $1,786.00 $3,024.00 $3,240.00 $3,566.00 $3,024.00 $3,240.00 $3,566.0033031 90 $1,816.00 $3,733.00 $3,996.00 $4,397.00 $3,733.00 $3,996.00 $4,397.0033050 90 $1,224.00 $1,498.00 $1,603.00 $1,753.00 $1,498.00 $1,603.00 $1,753.0033120 90 $2,358.00 $3,170.00 $3,395.00 $3,738.00 $3,170.00 $3,395.00 $3,738.0033130 90 $1,734.00 $2,076.00 $2,224.00 $2,440.00 $2,076.00 $2,224.00 $2,440.0033140 90 $1,571.00 $2,377.00 $2,549.00 $2,812.00 $2,377.00 $2,549.00 $2,812.0033141 ZZZ $254.00 $200.00 $214.00 $237.00 $200.00 $214.00 $237.0033202 90 -------- $1,167.00 $1,252.00 $1,374.00 $1,167.00 $1,252.00 $1,374.0033203 90 -------- $1,214.00 $1,302.00 $1,431.00 $1,214.00 $1,302.00 $1,431.0033206 90 $642.00 $689.00 $738.00 $804.00 $689.00 $738.00 $804.00



Surgery







33207 90 $753.00 $737.00 $789.00 $863.00 $737.00 $789.00 $863.0033208 90 $573.00 $798.00 $855.00 $935.00 $798.00 $855.00 $935.0033210 0 $204.00 $270.00 $289.00 $318.00 $270.00 $289.00 $318.0033211 0 $210.00 $276.00 $296.00 $325.00 $276.00 $296.00 $325.0033212 90 $511.00 $498.00 $533.00 $581.00 $498.00 $533.00 $581.0033213 90 $437.00 $519.00 $556.00 $606.00 $519.00 $556.00 $606.0033214 90 $532.00 $730.00 $782.00 $852.00 $730.00 $782.00 $852.0033215 90 $304.00 $462.00 $496.00 $541.00 $462.00 $496.00 $541.0033216 90 $402.00 $570.00 $610.00 $664.00 $570.00 $610.00 $664.0033217 90 $428.00 $559.00 $599.00 $652.00 $559.00 $599.00 $652.0033218 90 $488.00 $596.00 $639.00 $695.00 $596.00 $639.00 $695.0033220 90 $390.00 $597.00 $640.00 $696.00 $597.00 $640.00 $696.0033221 90 -------- $556.00 $596.00 $649.00 $556.00 $596.00 $649.0033222 90 $471.00 $517.00 $554.00 $601.00 $517.00 $554.00 $601.0033223 90 $585.00 $626.00 $671.00 $730.00 $626.00 $671.00 $730.0033224 0 $490.00 $776.00 $831.00 $914.00 $776.00 $831.00 $914.0033225 ZZZ $434.00 $705.00 $756.00 $832.00 $705.00 $756.00 $832.0033226 0 $472.00 $743.00 $796.00 $874.00 $743.00 $796.00 $874.0033227 90 -------- $523.00 $560.00 $610.00 $523.00 $560.00 $610.0033228 90 -------- $545.00 $585.00 $637.00 $545.00 $585.00 $637.0033229 90 -------- $575.00 $616.00 $671.00 $575.00 $616.00 $671.0033230 90 -------- $593.00 $635.00 $694.00 $593.00 $635.00 $694.0033231 90 -------- $617.00 $661.00 $721.00 $617.00 $661.00 $721.0033233 90 $270.00 $359.00 $384.00 $416.00 $359.00 $384.00 $416.0033234 90 $598.00 $741.00 $794.00 $866.00 $741.00 $794.00 $866.0033235 90 $587.00 $965.00 $1,034.00 $1,127.00 $965.00 $1,034.00 $1,127.0033236 90 $933.00 $1,173.00 $1,258.00 $1,376.00 $1,173.00 $1,258.00 $1,376.0033237 90 $1,184.00 $1,261.00 $1,352.00 $1,478.00 $1,261.00 $1,352.00 $1,478.0033238 90 $1,235.00 $1,396.00 $1,494.00 $1,630.00 $1,396.00 $1,494.00 $1,630.0033240 90 $648.00 $564.00 $605.00 $660.00 $564.00 $605.00 $660.0033241 90 $301.00 $338.00 $363.00 $393.00 $338.00 $363.00 $393.0033243 90 $1,650.00 $2,056.00 $2,202.00 $2,414.00 $2,056.00 $2,202.00 $2,414.0033244 90 $1,081.00 $1,299.00 $1,392.00 $1,520.00 $1,299.00 $1,392.00 $1,520.0033249 90 $1,271.00 $1,387.00 $1,486.00 $1,625.00 $1,387.00 $1,486.00 $1,625.0033250 90 $1,687.00 $2,212.00 $2,372.00 $2,612.00 $2,212.00 $2,372.00 $2,612.0033251 90 $2,071.00 $2,446.00 $2,619.00 $2,874.00 $2,446.00 $2,619.00 $2,874.0033254 90 -------- $2,066.00 $2,215.00 $2,434.00 $2,066.00 $2,215.00 $2,434.0033255 90 -------- $2,437.00 $2,605.00 $2,854.00 $2,437.00 $2,605.00 $2,854.0033256 90 -------- $2,951.00 $3,164.00 $3,483.00 $2,951.00 $3,164.00 $3,483.0033257 ZZZ -------- $872.00 $934.00 $1,020.00 $872.00 $934.00 $1,020.0033258 ZZZ -------- $980.00 $1,048.00 $1,145.00 $980.00 $1,048.00 $1,145.0033259 ZZZ -------- $1,266.00 $1,355.00 $1,481.00 $1,266.00 $1,355.00 $1,481.0033261 90 $1,993.00 $2,473.00 $2,650.00 $2,913.00 $2,473.00 $2,650.00 $2,913.0033262 90 -------- $574.00 $615.00 $671.00 $574.00 $615.00 $671.0033263 90 -------- $597.00 $640.00 $698.00 $597.00 $640.00 $698.0033264 90 -------- $622.00 $667.00 $728.00 $622.00 $667.00 $728.0033265 90 -------- $2,045.00 $2,189.00 $2,397.00 $2,045.00 $2,189.00 $2,397.0033266 90 -------- $2,787.00 $2,986.00 $3,284.00 $2,787.00 $2,986.00 $3,284.0033270 90 -------- $881.00 $945.00 $1,030.00 $881.00 $945.00 $1,030.0033271 90 -------- $741.00 $795.00 $865.00 $741.00 $795.00 $865.00



Surgery







33272 90 -------- $524.00 $562.00 $612.00 $524.00 $562.00 $612.0033273 90 -------- $593.00 $627.00 $666.00 $593.00 $627.00 $666.0033282 90 $470.00 $354.00 $379.00 $411.00 $354.00 $379.00 $411.0033284 90 $365.00 $312.00 $335.00 $363.00 $312.00 $335.00 $363.0033300 90 $1,576.00 $3,706.00 $3,970.00 $4,375.00 $3,706.00 $3,970.00 $4,375.0033305 90 $1,889.00 $6,215.00 $6,657.00 $7,347.00 $6,215.00 $6,657.00 $7,347.0033310 90 $1,577.00 $1,772.00 $1,900.00 $2,088.00 $1,772.00 $1,900.00 $2,088.0033315 90 $1,875.00 $2,887.00 $3,091.00 $3,400.00 $2,887.00 $3,091.00 $3,400.0033320 90 $1,485.00 $1,600.00 $1,714.00 $1,882.00 $1,600.00 $1,714.00 $1,882.0033321 90 $1,890.00 $1,853.00 $1,989.00 $2,186.00 $1,853.00 $1,989.00 $2,186.0033322 90 $1,935.00 $2,094.00 $2,243.00 $2,463.00 $2,094.00 $2,243.00 $2,463.0033330 90 $1,726.00 $2,147.00 $2,298.00 $2,522.00 $2,147.00 $2,298.00 $2,522.0033335 90 $2,336.00 $2,818.00 $3,012.00 $3,302.00 $2,818.00 $3,012.00 $3,302.0033361 0 -------- $2,057.00 $2,204.00 $2,431.00 $2,057.00 $2,204.00 $2,431.0033362 0 -------- $2,250.00 $2,411.00 $2,662.00 $2,250.00 $2,411.00 $2,662.0033363 0 -------- $2,336.00 $2,502.00 $2,759.00 $2,336.00 $2,502.00 $2,759.0033364 0 -------- $2,451.00 $2,626.00 $2,899.00 $2,451.00 $2,626.00 $2,899.0033365 0 -------- $2,698.00 $2,892.00 $3,192.00 $2,698.00 $2,892.00 $3,192.0033366 0 -------- $2,921.00 $3,131.00 $3,460.00 $2,921.00 $3,131.00 $3,460.0033367 ZZZ -------- $948.00 $1,014.00 $1,118.00 $948.00 $1,014.00 $1,118.0033368 ZZZ -------- $1,138.00 $1,220.00 $1,353.00 $1,138.00 $1,220.00 $1,353.0033369 ZZZ -------- $1,504.00 $1,613.00 $1,788.00 $1,504.00 $1,613.00 $1,788.0033400 90 $2,401.00 $3,438.00 $3,679.00 $4,044.00 $3,438.00 $3,679.00 $4,044.0033401 90 $2,228.00 $2,175.00 $2,333.00 $2,563.00 $2,175.00 $2,333.00 $2,563.0033403 90 $2,369.00 $2,235.00 $2,397.00 $2,634.00 $2,235.00 $2,397.00 $2,634.0033404 90 $2,698.00 $2,660.00 $2,852.00 $3,142.00 $2,660.00 $2,852.00 $3,142.0033405 90 $2,745.00 $3,429.00 $3,671.00 $4,038.00 $3,429.00 $3,671.00 $4,038.0033406 90 $2,962.00 $4,350.00 $4,659.00 $5,130.00 $4,350.00 $4,659.00 $5,130.0033410 90 $2,637.00 $3,826.00 $4,093.00 $4,497.00 $3,826.00 $4,093.00 $4,497.0033411 90 $2,981.00 $5,077.00 $5,435.00 $5,985.00 $5,077.00 $5,435.00 $5,985.0033412 90 $3,213.00 $4,814.00 $5,162.00 $5,708.00 $4,814.00 $5,162.00 $5,708.0033413 90 $3,282.00 $4,929.00 $5,286.00 $5,840.00 $4,929.00 $5,286.00 $5,840.0033414 90 $2,904.00 $3,277.00 $3,516.00 $3,883.00 $3,277.00 $3,516.00 $3,883.0033415 90 $2,563.00 $3,052.00 $3,261.00 $3,573.00 $3,052.00 $3,261.00 $3,573.0033416 90 $2,684.00 $3,069.00 $3,288.00 $3,617.00 $3,069.00 $3,288.00 $3,617.0033417 90 $2,756.00 $2,531.00 $2,715.00 $2,988.00 $2,531.00 $2,715.00 $2,988.0033418 90 -------- $2,702.00 $2,887.00 $3,157.00 $2,702.00 $2,887.00 $3,157.0033419 ZZZ -------- $636.00 $678.00 $741.00 $636.00 $678.00 $741.0033420 90 $1,796.00 $2,203.00 $2,363.00 $2,601.00 $2,203.00 $2,363.00 $2,601.0033422 90 $2,431.00 $2,522.00 $2,700.00 $2,963.00 $2,522.00 $2,700.00 $2,963.0033425 90 $2,509.00 $4,134.00 $4,427.00 $4,873.00 $4,134.00 $4,427.00 $4,873.0033426 90 $2,806.00 $3,597.00 $3,851.00 $4,235.00 $3,597.00 $3,851.00 $4,235.0033427 90 $3,026.00 $3,694.00 $3,954.00 $4,352.00 $3,694.00 $3,954.00 $4,352.0033430 90 $2,891.00 $4,227.00 $4,526.00 $4,979.00 $4,227.00 $4,526.00 $4,979.0033460 90 $2,215.00 $3,700.00 $3,970.00 $4,386.00 $3,700.00 $3,970.00 $4,386.0033463 90 $2,396.00 $4,674.00 $5,003.00 $5,508.00 $4,674.00 $5,003.00 $5,508.0033464 90 $2,547.00 $3,687.00 $3,945.00 $4,336.00 $3,687.00 $3,945.00 $4,336.0033465 90 $2,665.00 $4,168.00 $4,462.00 $4,911.00 $4,168.00 $4,462.00 $4,911.0033468 90 $2,952.00 $3,738.00 $4,010.00 $4,431.00 $3,738.00 $4,010.00 $4,431.0033470 90 $1,749.00 $1,950.00 $2,092.00 $2,293.00 $1,950.00 $2,092.00 $2,293.00



Surgery







33471 90 $1,929.00 $2,084.00 $2,236.00 $2,450.00 $2,084.00 $2,236.00 $2,450.0033474 90 $2,173.00 $3,316.00 $3,557.00 $3,925.00 $3,316.00 $3,557.00 $3,925.0033475 90 $2,666.00 $3,519.00 $3,767.00 $4,143.00 $3,519.00 $3,767.00 $4,143.0033476 90 $2,270.00 $2,309.00 $2,477.00 $2,725.00 $2,309.00 $2,477.00 $2,725.0033477 0 -------- $1,925.00 $2,031.00 $2,179.00 $1,925.00 $2,031.00 $2,179.0033478 90 $2,544.00 $2,387.00 $2,560.00 $2,817.00 $2,387.00 $2,560.00 $2,817.0033496 90 $2,595.00 $2,524.00 $2,705.00 $2,977.00 $2,524.00 $2,705.00 $2,977.0033500 90 $2,370.00 $2,359.00 $2,523.00 $2,763.00 $2,359.00 $2,523.00 $2,763.0033501 90 $1,546.00 $1,709.00 $1,833.00 $2,015.00 $1,709.00 $1,833.00 $2,015.0033502 90 $1,938.00 $1,933.00 $2,073.00 $2,277.00 $1,933.00 $2,073.00 $2,277.0033503 90 $1,983.00 $2,008.00 $2,154.00 $2,364.00 $2,008.00 $2,154.00 $2,364.0033504 90 $2,416.00 $2,223.00 $2,385.00 $2,622.00 $2,223.00 $2,385.00 $2,622.0033505 90 $2,423.00 $3,150.00 $3,379.00 $3,737.00 $3,150.00 $3,379.00 $3,737.0033506 90 $2,448.00 $3,134.00 $3,362.00 $3,715.00 $3,134.00 $3,362.00 $3,715.0033507 90 -------- $2,627.00 $2,818.00 $3,111.00 $2,627.00 $2,818.00 $3,111.0033508 ZZZ $17.00 $24.00 $26.00 $29.00 $24.00 $26.00 $29.0033510 90 $2,354.00 $2,917.00 $3,122.00 $3,432.00 $2,917.00 $3,122.00 $3,432.0033511 90 $2,546.00 $3,206.00 $3,433.00 $3,774.00 $3,206.00 $3,433.00 $3,774.0033512 90 $2,732.00 $3,647.00 $3,904.00 $4,295.00 $3,647.00 $3,904.00 $4,295.0033513 90 $2,933.00 $3,753.00 $4,018.00 $4,421.00 $3,753.00 $4,018.00 $4,421.0033514 90 $3,197.00 $3,949.00 $4,225.00 $4,646.00 $3,949.00 $4,225.00 $4,646.0033516 90 $3,404.00 $4,133.00 $4,432.00 $4,893.00 $4,133.00 $4,432.00 $4,893.0033517 ZZZ $219.00 $285.00 $305.00 $337.00 $285.00 $305.00 $337.0033518 ZZZ $414.00 $625.00 $669.00 $740.00 $625.00 $669.00 $740.0033519 ZZZ $607.00 $827.00 $885.00 $978.00 $827.00 $885.00 $978.0033521 ZZZ $801.00 $992.00 $1,061.00 $1,173.00 $992.00 $1,061.00 $1,173.0033522 ZZZ $994.00 $1,112.00 $1,191.00 $1,315.00 $1,112.00 $1,191.00 $1,315.0033523 ZZZ $1,189.00 $1,265.00 $1,353.00 $1,494.00 $1,265.00 $1,353.00 $1,494.0033530 ZZZ $521.00 $800.00 $856.00 $947.00 $800.00 $856.00 $947.0033533 90 $2,415.00 $2,821.00 $3,020.00 $3,319.00 $2,821.00 $3,020.00 $3,319.0033534 90 $2,654.00 $3,320.00 $3,555.00 $3,909.00 $3,320.00 $3,555.00 $3,909.0033535 90 $2,899.00 $3,703.00 $3,964.00 $4,360.00 $3,703.00 $3,964.00 $4,360.0033536 90 $3,143.00 $3,993.00 $4,273.00 $4,699.00 $3,993.00 $4,273.00 $4,699.0033542 90 $2,693.00 $3,973.00 $4,254.00 $4,685.00 $3,973.00 $4,254.00 $4,685.0033545 90 $3,250.00 $4,694.00 $5,030.00 $5,550.00 $4,694.00 $5,030.00 $5,550.0033548 90 -------- $4,476.00 $4,791.00 $5,271.00 $4,476.00 $4,791.00 $5,271.0033572 ZZZ $340.00 $350.00 $375.00 $414.00 $350.00 $375.00 $414.0033600 90 $2,644.00 $2,610.00 $2,800.00 $3,082.00 $2,610.00 $2,800.00 $3,082.0033602 90 $2,556.00 $2,533.00 $2,717.00 $2,991.00 $2,533.00 $2,717.00 $2,991.0033606 90 $2,831.00 $2,816.00 $3,021.00 $3,316.00 $2,816.00 $3,021.00 $3,316.0033608 90 $2,940.00 $2,735.00 $2,934.00 $3,232.00 $2,735.00 $2,934.00 $3,232.0033610 90 $2,871.00 $2,697.00 $2,894.00 $3,187.00 $2,697.00 $2,894.00 $3,187.0033611 90 $2,985.00 $3,114.00 $3,341.00 $3,673.00 $3,114.00 $3,341.00 $3,673.0033612 90 $3,152.00 $3,054.00 $3,276.00 $3,617.00 $3,054.00 $3,276.00 $3,617.0033615 90 $3,051.00 $3,038.00 $3,259.00 $3,594.00 $3,038.00 $3,259.00 $3,594.0033617 90 $3,272.00 $3,293.00 $3,533.00 $3,898.00 $3,293.00 $3,533.00 $3,898.0033619 90 $3,678.00 $4,146.00 $4,448.00 $4,903.00 $4,146.00 $4,448.00 $4,903.0033620 90 -------- $2,514.00 $2,696.00 $2,976.00 $2,514.00 $2,696.00 $2,976.0033621 90 -------- $1,413.00 $1,516.00 $1,667.00 $1,413.00 $1,516.00 $1,667.0033622 90 -------- $5,510.00 $5,911.00 $6,508.00 $5,510.00 $5,911.00 $6,508.00



Surgery







33641 90 $1,981.00 $2,496.00 $2,677.00 $2,953.00 $2,496.00 $2,677.00 $2,953.0033645 90 $2,352.00 $2,635.00 $2,826.00 $3,118.00 $2,635.00 $2,826.00 $3,118.0033647 90 $2,732.00 $2,770.00 $2,971.00 $3,279.00 $2,770.00 $2,971.00 $3,279.0033660 90 $2,444.00 $2,676.00 $2,871.00 $3,168.00 $2,676.00 $2,871.00 $3,168.0033665 90 $2,700.00 $2,917.00 $3,129.00 $3,454.00 $2,917.00 $3,129.00 $3,454.0033670 90 $2,820.00 $3,012.00 $3,231.00 $3,573.00 $3,012.00 $3,231.00 $3,573.0033675 90 -------- $3,006.00 $3,225.00 $3,560.00 $3,006.00 $3,225.00 $3,560.0033676 90 -------- $3,232.00 $3,467.00 $3,813.00 $3,232.00 $3,467.00 $3,813.0033677 90 -------- $3,359.00 $3,603.00 $3,962.00 $3,359.00 $3,603.00 $3,962.0033681 90 $2,657.00 $2,793.00 $2,996.00 $3,298.00 $2,793.00 $2,996.00 $3,298.0033684 90 $2,740.00 $3,014.00 $3,233.00 $3,554.00 $3,014.00 $3,233.00 $3,554.0033688 90 $2,602.00 $2,875.00 $3,084.00 $3,409.00 $2,875.00 $3,084.00 $3,409.0033690 90 $1,884.00 $1,816.00 $1,948.00 $2,138.00 $1,816.00 $1,948.00 $2,138.0033692 90 $2,816.00 $3,134.00 $3,362.00 $3,700.00 $3,134.00 $3,362.00 $3,700.0033694 90 $2,856.00 $3,114.00 $3,341.00 $3,673.00 $3,114.00 $3,341.00 $3,673.0033697 90 $3,064.00 $3,134.00 $3,362.00 $3,712.00 $3,134.00 $3,362.00 $3,712.0033702 90 $2,549.00 $2,348.00 $2,519.00 $2,773.00 $2,348.00 $2,519.00 $2,773.0033710 90 $2,731.00 $3,277.00 $3,515.00 $3,866.00 $3,277.00 $3,515.00 $3,866.0033720 90 $2,508.00 $2,349.00 $2,520.00 $2,774.00 $2,349.00 $2,520.00 $2,774.0033722 90 $2,704.00 $2,474.00 $2,653.00 $2,926.00 $2,474.00 $2,653.00 $2,926.0033724 90 -------- $2,342.00 $2,513.00 $2,770.00 $2,342.00 $2,513.00 $2,770.0033726 90 -------- $3,100.00 $3,325.00 $3,671.00 $3,100.00 $3,325.00 $3,671.0033730 90 $2,785.00 $3,052.00 $3,274.00 $3,612.00 $3,052.00 $3,274.00 $3,612.0033732 90 $2,622.00 $2,502.00 $2,684.00 $2,955.00 $2,502.00 $2,684.00 $2,955.0033735 90 $2,036.00 $1,963.00 $2,106.00 $2,313.00 $1,963.00 $2,106.00 $2,313.0033736 90 $2,288.00 $2,132.00 $2,287.00 $2,514.00 $2,132.00 $2,287.00 $2,514.0033737 90 $1,977.00 $2,043.00 $2,192.00 $2,402.00 $2,043.00 $2,192.00 $2,402.0033750 90 $1,877.00 $1,916.00 $2,056.00 $2,263.00 $1,916.00 $2,056.00 $2,263.0033755 90 $1,831.00 $1,995.00 $2,140.00 $2,351.00 $1,995.00 $2,140.00 $2,351.0033762 90 $1,900.00 $2,027.00 $2,174.00 $2,386.00 $2,027.00 $2,174.00 $2,386.0033764 90 $1,895.00 $1,995.00 $2,140.00 $2,351.00 $1,995.00 $2,140.00 $2,351.0033766 90 $2,119.00 $2,024.00 $2,171.00 $2,390.00 $2,024.00 $2,171.00 $2,390.0033767 90 $2,173.00 $2,161.00 $2,318.00 $2,554.00 $2,161.00 $2,318.00 $2,554.0033768 ZZZ -------- $638.00 $684.00 $759.00 $638.00 $684.00 $759.0033770 90 $2,954.00 $3,390.00 $3,637.00 $4,002.00 $3,390.00 $3,637.00 $4,002.0033771 90 $2,924.00 $3,497.00 $3,752.00 $4,131.00 $3,497.00 $3,752.00 $4,131.0033774 90 $2,681.00 $2,734.00 $2,932.00 $3,229.00 $2,734.00 $2,932.00 $3,229.0033775 90 $2,654.00 $2,939.00 $3,153.00 $3,462.00 $2,939.00 $3,153.00 $3,462.0033776 90 $2,844.00 $3,105.00 $3,331.00 $3,656.00 $3,105.00 $3,331.00 $3,656.0033777 90 $2,724.00 $3,011.00 $3,230.00 $3,549.00 $3,011.00 $3,230.00 $3,549.0033778 90 $3,199.00 $3,746.00 $4,019.00 $4,418.00 $3,746.00 $4,019.00 $4,418.0033779 90 $3,121.00 $3,731.00 $4,002.00 $4,406.00 $3,731.00 $4,002.00 $4,406.0033780 90 $3,232.00 $3,616.00 $3,878.00 $4,288.00 $3,616.00 $3,878.00 $4,288.0033781 90 $3,057.00 $3,715.00 $3,985.00 $4,388.00 $3,715.00 $3,985.00 $4,388.0033782 90 -------- $4,930.00 $5,289.00 $5,849.00 $4,930.00 $5,289.00 $5,849.0033783 90 -------- $5,602.00 $6,009.00 $6,616.00 $5,602.00 $6,009.00 $6,616.0033786 90 $2,970.00 $3,470.00 $3,723.00 $4,113.00 $3,470.00 $3,723.00 $4,113.0033788 90 $2,288.00 $2,433.00 $2,610.00 $2,866.00 $2,433.00 $2,610.00 $2,866.0033800 90 $1,546.00 $1,499.00 $1,608.00 $1,769.00 $1,499.00 $1,608.00 $1,769.0033802 90 $1,752.00 $1,641.00 $1,760.00 $1,931.00 $1,641.00 $1,760.00 $1,931.00



Surgery







33803 90 $1,746.00 $1,747.00 $1,874.00 $2,063.00 $1,747.00 $1,874.00 $2,063.0033813 90 $1,935.00 $1,949.00 $2,091.00 $2,290.00 $1,949.00 $2,091.00 $2,290.0033814 90 $2,464.00 $2,312.00 $2,480.00 $2,728.00 $2,312.00 $2,480.00 $2,728.0033820 90 $1,619.00 $1,469.00 $1,576.00 $1,732.00 $1,469.00 $1,576.00 $1,732.0033822 90 $1,559.00 $1,609.00 $1,726.00 $1,891.00 $1,609.00 $1,726.00 $1,891.0033824 90 $1,884.00 $1,787.00 $1,916.00 $2,105.00 $1,787.00 $1,916.00 $2,105.0033840 90 $2,029.00 $1,878.00 $2,014.00 $2,213.00 $1,878.00 $2,014.00 $2,213.0033845 90 $2,129.00 $2,021.00 $2,168.00 $2,383.00 $2,021.00 $2,168.00 $2,383.0033851 90 $2,129.00 $1,928.00 $2,069.00 $2,274.00 $1,928.00 $2,069.00 $2,274.0033852 90 $2,311.00 $2,122.00 $2,276.00 $2,504.00 $2,122.00 $2,276.00 $2,504.0033853 90 $3,057.00 $2,785.00 $2,988.00 $3,291.00 $2,785.00 $2,988.00 $3,291.0033860 90 $3,044.00 $4,863.00 $5,207.00 $5,737.00 $4,863.00 $5,207.00 $5,737.0033863 90 $3,183.00 $4,773.00 $5,110.00 $5,635.00 $4,773.00 $5,110.00 $5,635.0033864 90 -------- $4,883.00 $5,230.00 $5,770.00 $4,883.00 $5,230.00 $5,770.0033870 90 $3,638.00 $3,807.00 $4,076.00 $4,486.00 $3,807.00 $4,076.00 $4,486.0033875 90 $2,876.00 $4,167.00 $4,464.00 $4,921.00 $4,167.00 $4,464.00 $4,921.0033877 90 $3,767.00 $5,543.00 $5,939.00 $6,564.00 $5,543.00 $5,939.00 $6,564.0033880 90 -------- $2,755.00 $2,948.00 $3,251.00 $2,755.00 $2,948.00 $3,251.0033881 90 -------- $2,366.00 $2,532.00 $2,791.00 $2,366.00 $2,532.00 $2,791.0033883 90 -------- $1,709.00 $1,827.00 $2,007.00 $1,709.00 $1,827.00 $2,007.0033884 ZZZ -------- $628.00 $672.00 $743.00 $628.00 $672.00 $743.0033886 90 -------- $1,476.00 $1,578.00 $1,736.00 $1,476.00 $1,578.00 $1,736.0033889 0 -------- $1,214.00 $1,300.00 $1,442.00 $1,214.00 $1,300.00 $1,442.0033891 0 -------- $1,498.00 $1,605.00 $1,786.00 $1,498.00 $1,605.00 $1,786.0033910 90 $1,987.00 $3,977.00 $4,258.00 $4,686.00 $3,977.00 $4,258.00 $4,686.0033915 90 $1,588.00 $1,934.00 $2,068.00 $2,282.00 $1,934.00 $2,068.00 $2,282.0033916 90 $2,096.00 $6,395.00 $6,860.00 $7,587.00 $6,395.00 $6,860.00 $7,587.0033917 90 $2,345.00 $2,210.00 $2,370.00 $2,606.00 $2,210.00 $2,370.00 $2,606.0033920 90 $2,981.00 $2,882.00 $3,091.00 $3,397.00 $2,882.00 $3,091.00 $3,397.0033922 90 $2,227.00 $2,108.00 $2,261.00 $2,487.00 $2,108.00 $2,261.00 $2,487.0033924 ZZZ $421.00 $438.00 $469.00 $521.00 $438.00 $469.00 $521.0033925 90 -------- $2,617.00 $2,808.00 $3,099.00 $2,617.00 $2,808.00 $3,099.0033926 90 -------- $3,873.00 $4,155.00 $4,572.00 $3,873.00 $4,155.00 $4,572.0033935 90 $5,415.00 $7,565.00 $8,095.00 $8,898.00 $7,565.00 $8,095.00 $8,898.0033945 90 $3,813.00 $7,361.00 $7,887.00 $8,698.00 $7,361.00 $7,887.00 $8,698.0033946 0 -------- $461.00 $489.00 $533.00 $461.00 $489.00 $533.0033947 0 -------- $509.00 $541.00 $590.00 $509.00 $541.00 $590.0033948 0 -------- $363.00 $384.00 $417.00 $363.00 $384.00 $417.0033949 0 -------- $353.00 $374.00 $406.00 $353.00 $374.00 $406.0033951 0 -------- $623.00 $658.00 $706.00 $623.00 $658.00 $706.0033952 0 -------- $653.00 $700.00 $774.00 $653.00 $700.00 $774.0033953 0 -------- $696.00 $734.00 $788.00 $696.00 $734.00 $788.0033954 0 -------- $730.00 $783.00 $866.00 $730.00 $783.00 $866.0033955 0 -------- $1,245.00 $1,310.00 $1,396.00 $1,245.00 $1,310.00 $1,396.0033956 0 -------- $1,274.00 $1,364.00 $1,508.00 $1,274.00 $1,364.00 $1,508.0033957 0 -------- $276.00 $291.00 $310.00 $276.00 $291.00 $310.0033958 0 -------- $273.00 $288.00 $309.00 $273.00 $288.00 $309.0033959 0 -------- $351.00 $369.00 $393.00 $351.00 $369.00 $393.0033962 0 -------- $361.00 $386.00 $424.00 $361.00 $386.00 $424.0033963 0 -------- $702.00 $739.00 $787.00 $702.00 $739.00 $787.00



Surgery







33964 0 -------- $734.00 $774.00 $829.00 $734.00 $774.00 $829.0033965 0 -------- $276.00 $291.00 $310.00 $276.00 $291.00 $310.0033966 0 -------- $357.00 $382.00 $421.00 $357.00 $382.00 $421.0033967 0 $258.00 $393.00 $421.00 $465.00 $393.00 $421.00 $465.0033968 0 $51.00 $51.00 $54.00 $59.00 $51.00 $54.00 $59.0033969 0 -------- $409.00 $430.00 $458.00 $409.00 $430.00 $458.0033970 0 $576.00 $539.00 $577.00 $637.00 $539.00 $577.00 $637.0033971 90 $578.00 $1,067.00 $1,142.00 $1,248.00 $1,067.00 $1,142.00 $1,248.0033973 0 $756.00 $781.00 $835.00 $921.00 $781.00 $835.00 $921.0033974 90 $1,095.00 $1,334.00 $1,428.00 $1,559.00 $1,334.00 $1,428.00 $1,559.0033975 0 $1,758.00 $2,002.00 $2,144.00 $2,369.00 $2,002.00 $2,144.00 $2,369.0033976 0 $2,056.00 $2,440.00 $2,615.00 $2,892.00 $2,440.00 $2,615.00 $2,892.0033977 0 $1,561.00 $1,715.00 $1,837.00 $2,027.00 $1,715.00 $1,837.00 $2,027.0033978 0 $1,754.00 $2,030.00 $2,174.00 $2,399.00 $2,030.00 $2,174.00 $2,399.0033979 0 $2,496.00 $2,976.00 $3,189.00 $3,529.00 $2,976.00 $3,189.00 $3,529.0033980 0 $3,212.00 $2,717.00 $2,912.00 $3,217.00 $2,717.00 $2,912.00 $3,217.0033981 0 -------- $1,275.00 $1,367.00 $1,516.00 $1,275.00 $1,367.00 $1,516.0033982 0 -------- $3,013.00 $3,224.00 $3,559.00 $3,013.00 $3,224.00 $3,559.0033983 0 -------- $3,530.00 $3,781.00 $4,182.00 $3,530.00 $3,781.00 $4,182.0033984 0 -------- $434.00 $464.00 $512.00 $434.00 $464.00 $512.0033985 0 -------- $771.00 $812.00 $865.00 $771.00 $812.00 $865.0033986 0 -------- $803.00 $858.00 $943.00 $803.00 $858.00 $943.0033987 ZZZ -------- $317.00 $339.00 $374.00 $317.00 $339.00 $374.0033988 0 -------- $1,181.00 $1,264.00 $1,395.00 $1,181.00 $1,264.00 $1,395.0033989 0 -------- $762.00 $815.00 $897.00 $762.00 $815.00 $897.0033990 0 -------- $667.00 $716.00 $791.00 $667.00 $716.00 $791.0033991 0 -------- $972.00 $1,042.00 $1,151.00 $972.00 $1,042.00 $1,151.0033992 0 -------- $315.00 $338.00 $373.00 $315.00 $338.00 $373.0033993 0 -------- $277.00 $296.00 $327.00 $277.00 $296.00 $327.0033999 YYY BR -------- -------- -------- -------- -------- --------34001 90 $1,012.00 $1,491.00 $1,597.00 $1,759.00 $1,491.00 $1,597.00 $1,759.0034051 90 $1,134.00 $1,496.00 $1,605.00 $1,762.00 $1,496.00 $1,605.00 $1,762.0034101 90 $800.00 $923.00 $989.00 $1,088.00 $923.00 $989.00 $1,088.0034111 90 $669.00 $919.00 $985.00 $1,083.00 $919.00 $985.00 $1,083.0034151 90 $1,288.00 $2,152.00 $2,305.00 $2,543.00 $2,152.00 $2,305.00 $2,543.0034201 90 $777.00 $1,587.00 $1,700.00 $1,876.00 $1,587.00 $1,700.00 $1,876.0034203 90 $949.00 $1,470.00 $1,575.00 $1,736.00 $1,470.00 $1,575.00 $1,736.0034401 90 $953.00 $2,207.00 $2,359.00 $2,583.00 $2,207.00 $2,359.00 $2,583.0034421 90 $779.00 $1,119.00 $1,197.00 $1,315.00 $1,119.00 $1,197.00 $1,315.0034451 90 $1,117.00 $2,224.00 $2,378.00 $2,626.00 $2,224.00 $2,378.00 $2,626.0034471 90 $685.00 $1,666.00 $1,785.00 $1,976.00 $1,666.00 $1,785.00 $1,976.0034490 90 $660.00 $933.00 $1,000.00 $1,099.00 $933.00 $1,000.00 $1,099.0034501 90 $910.00 $1,489.00 $1,597.00 $1,753.00 $1,489.00 $1,597.00 $1,753.0034502 90 $2,044.00 $2,333.00 $2,494.00 $2,736.00 $2,333.00 $2,494.00 $2,736.0034510 90 $1,108.00 $1,807.00 $1,940.00 $2,130.00 $1,807.00 $1,940.00 $2,130.0034520 90 $1,077.00 $1,543.00 $1,653.00 $1,824.00 $1,543.00 $1,653.00 $1,824.0034530 90 $1,368.00 $1,654.00 $1,771.00 $1,931.00 $1,654.00 $1,771.00 $1,931.0034800 90 $1,159.00 $1,737.00 $1,859.00 $2,048.00 $1,737.00 $1,859.00 $2,048.0034802 90 $1,279.00 $1,915.00 $2,049.00 $2,256.00 $1,915.00 $2,049.00 $2,256.0034803 90 -------- $1,980.00 $2,118.00 $2,334.00 $1,980.00 $2,118.00 $2,334.00



Surgery







34804 90 $1,279.00 $1,914.00 $2,048.00 $2,256.00 $1,914.00 $2,048.00 $2,256.0034805 90 -------- $1,836.00 $1,967.00 $2,173.00 $1,836.00 $1,967.00 $2,173.0034806 ZZZ -------- $155.00 $166.00 $184.00 $155.00 $166.00 $184.0034808 ZZZ $220.00 $320.00 $343.00 $382.00 $320.00 $343.00 $382.0034812 0 $359.00 $521.00 $558.00 $619.00 $521.00 $558.00 $619.0034813 ZZZ $256.00 $366.00 $392.00 $436.00 $366.00 $392.00 $436.0034820 0 $519.00 $759.00 $813.00 $901.00 $759.00 $813.00 $901.0034825 90 $694.00 $1,064.00 $1,138.00 $1,247.00 $1,064.00 $1,138.00 $1,247.0034826 ZZZ $220.00 $317.00 $339.00 $375.00 $317.00 $339.00 $375.0034830 90 $1,803.00 $2,722.00 $2,912.00 $3,219.00 $2,722.00 $2,912.00 $3,219.0034831 90 $1,950.00 $2,939.00 $3,150.00 $3,494.00 $2,939.00 $3,150.00 $3,494.0034832 90 $1,950.00 $2,912.00 $3,112.00 $3,437.00 $2,912.00 $3,112.00 $3,437.0034833 0 $650.00 $939.00 $1,006.00 $1,114.00 $939.00 $1,006.00 $1,114.0034834 0 $306.00 $420.00 $450.00 $498.00 $420.00 $450.00 $498.0034900 90 $960.00 $1,375.00 $1,472.00 $1,619.00 $1,375.00 $1,472.00 $1,619.0035001 90 $1,564.00 $1,721.00 $1,843.00 $2,031.00 $1,721.00 $1,843.00 $2,031.0035002 90 $1,547.00 $1,754.00 $1,879.00 $2,080.00 $1,754.00 $1,879.00 $2,080.0035005 90 $1,268.00 $1,639.00 $1,743.00 $1,886.00 $1,639.00 $1,743.00 $1,886.0035011 90 $1,007.00 $1,541.00 $1,652.00 $1,822.00 $1,541.00 $1,652.00 $1,822.0035013 90 $1,376.00 $1,926.00 $2,064.00 $2,275.00 $1,926.00 $2,064.00 $2,275.0035021 90 $1,635.00 $1,907.00 $2,045.00 $2,251.00 $1,907.00 $2,045.00 $2,251.0035022 90 $1,686.00 $2,111.00 $2,248.00 $2,444.00 $2,111.00 $2,248.00 $2,444.0035045 90 $995.00 $1,520.00 $1,628.00 $1,788.00 $1,520.00 $1,628.00 $1,788.0035081 90 $2,175.00 $2,693.00 $2,885.00 $3,188.00 $2,693.00 $2,885.00 $3,188.0035082 90 $2,661.00 $3,384.00 $3,626.00 $4,008.00 $3,384.00 $3,626.00 $4,008.0035091 90 $2,634.00 $2,772.00 $2,969.00 $3,289.00 $2,772.00 $2,969.00 $3,289.0035092 90 $2,872.00 $4,010.00 $4,294.00 $4,749.00 $4,010.00 $4,294.00 $4,749.0035102 90 $2,346.00 $2,917.00 $3,126.00 $3,456.00 $2,917.00 $3,126.00 $3,456.0035103 90 $2,587.00 $3,467.00 $3,714.00 $4,109.00 $3,467.00 $3,714.00 $4,109.0035111 90 $1,398.00 $2,326.00 $2,495.00 $2,742.00 $2,326.00 $2,495.00 $2,742.0035112 90 $1,351.00 $2,803.00 $3,001.00 $3,289.00 $2,803.00 $3,001.00 $3,289.0035121 90 $2,000.00 $2,533.00 $2,714.00 $3,000.00 $2,533.00 $2,714.00 $3,000.0035122 90 $2,382.00 $3,274.00 $3,510.00 $3,857.00 $3,274.00 $3,510.00 $3,857.0035131 90 $1,495.00 $2,138.00 $2,290.00 $2,527.00 $2,138.00 $2,290.00 $2,527.0035132 90 $1,742.00 $2,518.00 $2,694.00 $2,979.00 $2,518.00 $2,694.00 $2,979.0035141 90 $1,231.00 $1,704.00 $1,826.00 $2,015.00 $1,704.00 $1,826.00 $2,015.0035142 90 $1,339.00 $2,038.00 $2,183.00 $2,409.00 $2,038.00 $2,183.00 $2,409.0035151 90 $1,390.00 $1,915.00 $2,051.00 $2,265.00 $1,915.00 $2,051.00 $2,265.0035152 90 $1,229.00 $2,163.00 $2,317.00 $2,566.00 $2,163.00 $2,317.00 $2,566.0035180 90 $997.00 $1,392.00 $1,479.00 $1,582.00 $1,392.00 $1,479.00 $1,582.0035182 90 $1,345.00 $2,715.00 $2,912.00 $3,209.00 $2,715.00 $2,912.00 $3,209.0035184 90 $976.00 $1,599.00 $1,716.00 $1,891.00 $1,599.00 $1,716.00 $1,891.0035188 90 $1,048.00 $1,719.00 $1,826.00 $1,949.00 $1,719.00 $1,826.00 $1,949.0035189 90 $1,380.00 $2,361.00 $2,528.00 $2,793.00 $2,361.00 $2,528.00 $2,793.0035190 90 $1,018.00 $1,163.00 $1,247.00 $1,370.00 $1,163.00 $1,247.00 $1,370.0035201 90 $852.00 $1,447.00 $1,549.00 $1,697.00 $1,447.00 $1,549.00 $1,697.0035206 90 $835.00 $1,184.00 $1,267.00 $1,390.00 $1,184.00 $1,267.00 $1,390.0035207 90 $935.00 $1,109.00 $1,179.00 $1,257.00 $1,109.00 $1,179.00 $1,257.0035211 90 $1,833.00 $2,086.00 $2,233.00 $2,451.00 $2,086.00 $2,233.00 $2,451.0035216 90 $1,494.00 $3,107.00 $3,329.00 $3,660.00 $3,107.00 $3,329.00 $3,660.00



Surgery







35221 90 $1,243.00 $2,221.00 $2,380.00 $2,622.00 $2,221.00 $2,380.00 $2,622.0035226 90 $841.00 $1,277.00 $1,368.00 $1,506.00 $1,277.00 $1,368.00 $1,506.0035231 90 $1,053.00 $1,832.00 $1,950.00 $2,107.00 $1,832.00 $1,950.00 $2,107.0035236 90 $947.00 $1,500.00 $1,604.00 $1,762.00 $1,500.00 $1,604.00 $1,762.0035241 90 $1,926.00 $2,066.00 $2,187.00 $2,351.00 $2,066.00 $2,187.00 $2,351.0035246 90 $1,701.00 $2,389.00 $2,558.00 $2,810.00 $2,389.00 $2,558.00 $2,810.0035251 90 $1,260.00 $2,605.00 $2,792.00 $3,081.00 $2,605.00 $2,792.00 $3,081.0035256 90 $1,568.00 $1,565.00 $1,676.00 $1,846.00 $1,565.00 $1,676.00 $1,846.0035261 90 $1,008.00 $1,622.00 $1,739.00 $1,915.00 $1,622.00 $1,739.00 $1,915.0035266 90 $921.00 $1,336.00 $1,431.00 $1,576.00 $1,336.00 $1,431.00 $1,576.0035271 90 $1,814.00 $2,076.00 $2,220.00 $2,432.00 $2,076.00 $2,220.00 $2,432.0035276 90 $1,541.00 $2,209.00 $2,369.00 $2,608.00 $2,209.00 $2,369.00 $2,608.0035281 90 $1,396.00 $2,481.00 $2,659.00 $2,932.00 $2,481.00 $2,659.00 $2,932.0035286 90 $1,036.00 $1,436.00 $1,539.00 $1,694.00 $1,436.00 $1,539.00 $1,694.0035301 90 $1,486.00 $1,742.00 $1,867.00 $2,060.00 $1,742.00 $1,867.00 $2,060.0035302 90 -------- $1,734.00 $1,857.00 $2,049.00 $1,734.00 $1,857.00 $2,049.0035303 90 -------- $1,919.00 $2,056.00 $2,268.00 $1,919.00 $2,056.00 $2,268.0035304 90 -------- $1,980.00 $2,120.00 $2,340.00 $1,980.00 $2,120.00 $2,340.0035305 90 -------- $1,896.00 $2,030.00 $2,241.00 $1,896.00 $2,030.00 $2,241.0035306 ZZZ -------- $708.00 $759.00 $842.00 $708.00 $759.00 $842.0035311 90 $1,999.00 $2,249.00 $2,411.00 $2,672.00 $2,249.00 $2,411.00 $2,672.0035321 90 $1,031.00 $1,369.00 $1,467.00 $1,618.00 $1,369.00 $1,467.00 $1,618.0035331 90 $1,724.00 $2,234.00 $2,392.00 $2,641.00 $2,234.00 $2,392.00 $2,641.0035341 90 $1,908.00 $2,107.00 $2,257.00 $2,492.00 $2,107.00 $2,257.00 $2,492.0035351 90 $1,555.00 $1,975.00 $2,115.00 $2,337.00 $1,975.00 $2,115.00 $2,337.0035355 90 $1,336.00 $1,598.00 $1,712.00 $1,891.00 $1,598.00 $1,712.00 $1,891.0035361 90 $1,859.00 $2,375.00 $2,544.00 $2,817.00 $2,375.00 $2,544.00 $2,817.0035363 90 $2,006.00 $2,689.00 $2,883.00 $3,182.00 $2,689.00 $2,883.00 $3,182.0035371 90 $1,006.00 $1,262.00 $1,352.00 $1,490.00 $1,262.00 $1,352.00 $1,490.0035372 90 $1,085.00 $1,513.00 $1,621.00 $1,788.00 $1,513.00 $1,621.00 $1,788.0035390 ZZZ $225.00 $246.00 $263.00 $292.00 $246.00 $263.00 $292.0035400 ZZZ $224.00 $231.00 $247.00 $275.00 $231.00 $247.00 $275.0035450 0 $643.00 $781.00 $837.00 $928.00 $781.00 $837.00 $928.0035452 0 $518.00 $527.00 $564.00 $624.00 $527.00 $564.00 $624.0035458 0 $804.00 $759.00 $814.00 $901.00 $759.00 $814.00 $901.0035460 0 $430.00 $483.00 $518.00 $572.00 $483.00 $518.00 $572.0035471 0 $626.00 $3,562.00 $3,816.00 $3,904.00 $794.00 $847.00 $926.0035472 0 $388.00 $2,565.00 $2,749.00 $2,813.00 $542.00 $579.00 $636.0035475 0 $569.00 $2,168.00 $2,316.00 $2,357.00 $499.00 $525.00 $561.0035476 0 $338.00 $1,983.00 $2,120.00 $2,152.00 $402.00 $423.00 $451.0035500 ZZZ $423.00 $493.00 $528.00 $586.00 $493.00 $528.00 $586.0035501 90 $1,569.00 $2,304.00 $2,467.00 $2,727.00 $2,304.00 $2,467.00 $2,727.0035506 90 $1,641.00 $1,973.00 $2,114.00 $2,343.00 $1,973.00 $2,114.00 $2,343.0035508 90 $1,564.00 $2,096.00 $2,250.00 $2,496.00 $2,096.00 $2,250.00 $2,496.0035509 90 $1,529.00 $2,180.00 $2,333.00 $2,581.00 $2,180.00 $2,333.00 $2,581.0035510 90 -------- $1,904.00 $2,040.00 $2,261.00 $1,904.00 $2,040.00 $2,261.0035511 90 $1,256.00 $1,734.00 $1,858.00 $2,060.00 $1,734.00 $1,858.00 $2,060.0035512 90 -------- $1,886.00 $2,021.00 $2,238.00 $1,886.00 $2,021.00 $2,238.0035515 90 $1,387.00 $2,157.00 $2,273.00 $2,414.00 $2,157.00 $2,273.00 $2,414.0035516 90 $1,391.00 $1,889.00 $2,024.00 $2,243.00 $1,889.00 $2,024.00 $2,243.00



Surgery







35518 90 $1,313.00 $1,793.00 $1,922.00 $2,129.00 $1,793.00 $1,922.00 $2,129.0035521 90 $1,393.00 $1,910.00 $2,046.00 $2,266.00 $1,910.00 $2,046.00 $2,266.0035522 90 -------- $1,863.00 $1,995.00 $2,201.00 $1,863.00 $1,995.00 $2,201.0035523 90 -------- $1,972.00 $2,111.00 $2,323.00 $1,972.00 $2,111.00 $2,323.0035525 90 -------- $1,762.00 $1,886.00 $2,079.00 $1,762.00 $1,886.00 $2,079.0035526 90 $1,527.00 $2,605.00 $2,789.00 $3,069.00 $2,605.00 $2,789.00 $3,069.0035531 90 $2,000.00 $3,120.00 $3,341.00 $3,692.00 $3,120.00 $3,341.00 $3,692.0035533 90 $1,716.00 $2,313.00 $2,474.00 $2,735.00 $2,313.00 $2,474.00 $2,735.0035535 90 -------- $2,965.00 $3,178.00 $3,524.00 $2,965.00 $3,178.00 $3,524.0035536 90 $1,888.00 $2,617.00 $2,804.00 $3,109.00 $2,617.00 $2,804.00 $3,109.0035537 90 -------- $3,382.00 $3,626.00 $4,013.00 $3,382.00 $3,626.00 $4,013.0035538 90 -------- $3,630.00 $3,886.00 $4,303.00 $3,630.00 $3,886.00 $4,303.0035539 90 -------- $3,391.00 $3,627.00 $4,011.00 $3,391.00 $3,627.00 $4,011.0035540 90 -------- $3,799.00 $4,070.00 $4,514.00 $3,799.00 $4,070.00 $4,514.0035556 90 $1,745.00 $2,162.00 $2,316.00 $2,556.00 $2,162.00 $2,316.00 $2,556.0035558 90 $1,219.00 $1,898.00 $2,032.00 $2,238.00 $1,898.00 $2,032.00 $2,238.0035560 90 $1,899.00 $2,654.00 $2,841.00 $3,143.00 $2,654.00 $2,841.00 $3,143.0035563 90 $1,115.00 $2,053.00 $2,196.00 $2,424.00 $2,053.00 $2,196.00 $2,424.0035565 90 $1,312.00 $2,043.00 $2,188.00 $2,415.00 $2,043.00 $2,188.00 $2,415.0035566 90 $2,161.00 $2,584.00 $2,767.00 $3,058.00 $2,584.00 $2,767.00 $3,058.0035570 90 -------- $2,349.00 $2,517.00 $2,782.00 $2,349.00 $2,517.00 $2,782.0035571 90 $1,612.00 $2,055.00 $2,201.00 $2,431.00 $2,055.00 $2,201.00 $2,431.0035572 ZZZ $369.00 $534.00 $572.00 $634.00 $534.00 $572.00 $634.0035583 90 $1,843.00 $2,235.00 $2,394.00 $2,643.00 $2,235.00 $2,394.00 $2,643.0035585 90 $2,277.00 $2,596.00 $2,781.00 $3,074.00 $2,596.00 $2,781.00 $3,074.0035587 90 $1,698.00 $2,108.00 $2,257.00 $2,490.00 $2,108.00 $2,257.00 $2,490.0035600 ZZZ $273.00 $388.00 $415.00 $457.00 $388.00 $415.00 $457.0035601 90 $1,495.00 $2,166.00 $2,320.00 $2,562.00 $2,166.00 $2,320.00 $2,562.0035606 90 $1,539.00 $1,812.00 $1,940.00 $2,142.00 $1,812.00 $1,940.00 $2,142.0035612 90 $1,349.00 $1,656.00 $1,775.00 $1,961.00 $1,656.00 $1,775.00 $1,961.0035616 90 $1,346.00 $1,707.00 $1,829.00 $2,027.00 $1,707.00 $1,829.00 $2,027.0035621 90 $1,265.00 $1,697.00 $1,818.00 $2,007.00 $1,697.00 $1,818.00 $2,007.0035623 90 $1,193.00 $2,034.00 $2,179.00 $2,414.00 $2,034.00 $2,179.00 $2,414.0035626 90 $1,921.00 $2,414.00 $2,586.00 $2,849.00 $2,414.00 $2,586.00 $2,849.0035631 90 $1,891.00 $2,860.00 $3,064.00 $3,389.00 $2,860.00 $3,064.00 $3,389.0035632 90 -------- $2,790.00 $2,987.00 $3,307.00 $2,790.00 $2,987.00 $3,307.0035633 90 -------- $3,096.00 $3,315.00 $3,664.00 $3,096.00 $3,315.00 $3,664.0035634 90 -------- $2,734.00 $2,927.00 $3,242.00 $2,734.00 $2,927.00 $3,242.0035636 90 $1,656.00 $2,481.00 $2,659.00 $2,949.00 $2,481.00 $2,659.00 $2,949.0035637 90 -------- $2,661.00 $2,849.00 $3,143.00 $2,661.00 $2,849.00 $3,143.0035638 90 -------- $2,721.00 $2,915.00 $3,220.00 $2,721.00 $2,915.00 $3,220.0035642 90 $1,298.00 $1,522.00 $1,631.00 $1,803.00 $1,522.00 $1,631.00 $1,803.0035645 90 $1,304.00 $1,563.00 $1,676.00 $1,846.00 $1,563.00 $1,676.00 $1,846.0035646 90 $2,105.00 $2,651.00 $2,839.00 $3,135.00 $2,651.00 $2,839.00 $3,135.0035647 90 $1,555.00 $2,403.00 $2,575.00 $2,844.00 $2,403.00 $2,575.00 $2,844.0035650 90 $1,236.00 $1,663.00 $1,781.00 $1,962.00 $1,663.00 $1,781.00 $1,962.0035654 90 $1,603.00 $2,116.00 $2,267.00 $2,503.00 $2,116.00 $2,267.00 $2,503.0035656 90 $1,589.00 $1,674.00 $1,793.00 $1,977.00 $1,674.00 $1,793.00 $1,977.0035661 90 $1,145.00 $1,673.00 $1,792.00 $1,976.00 $1,673.00 $1,792.00 $1,976.0035663 90 $1,237.00 $1,935.00 $2,071.00 $2,281.00 $1,935.00 $2,071.00 $2,281.00



Surgery







35665 90 $1,333.00 $1,810.00 $1,938.00 $2,137.00 $1,810.00 $1,938.00 $2,137.0035666 90 $1,686.00 $1,954.00 $2,093.00 $2,306.00 $1,954.00 $2,093.00 $2,306.0035671 90 $1,315.00 $1,721.00 $1,843.00 $2,028.00 $1,721.00 $1,843.00 $2,028.0035681 ZZZ $751.00 $124.00 $132.00 $146.00 $124.00 $132.00 $146.0035682 ZZZ $627.00 $547.00 $586.00 $650.00 $547.00 $586.00 $650.0035683 ZZZ $702.00 $639.00 $685.00 $761.00 $639.00 $685.00 $761.0035685 ZZZ $216.00 $308.00 $330.00 $366.00 $308.00 $330.00 $366.0035686 ZZZ $178.00 $251.00 $269.00 $299.00 $251.00 $269.00 $299.0035691 90 $1,546.00 $1,478.00 $1,581.00 $1,743.00 $1,478.00 $1,581.00 $1,743.0035693 90 $1,140.00 $1,248.00 $1,329.00 $1,450.00 $1,248.00 $1,329.00 $1,450.0035694 90 $1,353.00 $1,528.00 $1,637.00 $1,812.00 $1,528.00 $1,637.00 $1,812.0035695 90 $1,351.00 $1,618.00 $1,733.00 $1,912.00 $1,618.00 $1,733.00 $1,912.0035697 ZZZ -------- $229.00 $245.00 $272.00 $229.00 $245.00 $272.0035700 ZZZ $264.00 $237.00 $254.00 $281.00 $237.00 $254.00 $281.0035701 90 $494.00 $851.00 $906.00 $975.00 $851.00 $906.00 $975.0035721 90 $500.00 $695.00 $744.00 $814.00 $695.00 $744.00 $814.0035741 90 $499.00 $784.00 $840.00 $916.00 $784.00 $840.00 $916.0035761 90 $532.00 $586.00 $627.00 $677.00 $586.00 $627.00 $677.0035800 90 $567.00 $1,075.00 $1,147.00 $1,244.00 $1,075.00 $1,147.00 $1,244.0035820 90 $951.00 $3,044.00 $3,259.00 $3,587.00 $3,044.00 $3,259.00 $3,587.0035840 90 $771.00 $1,797.00 $1,924.00 $2,109.00 $1,797.00 $1,924.00 $2,109.0035860 90 $496.00 $1,289.00 $1,380.00 $1,518.00 $1,289.00 $1,380.00 $1,518.0035870 90 $1,583.00 $1,921.00 $2,057.00 $2,275.00 $1,921.00 $2,057.00 $2,275.0035875 90 $827.00 $914.00 $980.00 $1,078.00 $914.00 $980.00 $1,078.0035876 90 $1,232.00 $1,456.00 $1,560.00 $1,720.00 $1,456.00 $1,560.00 $1,720.0035879 90 $1,163.00 $1,423.00 $1,524.00 $1,680.00 $1,423.00 $1,524.00 $1,680.0035881 90 $1,275.00 $1,574.00 $1,686.00 $1,860.00 $1,574.00 $1,686.00 $1,860.0035883 90 -------- $1,867.00 $1,999.00 $2,208.00 $1,867.00 $1,999.00 $2,208.0035884 90 -------- $1,916.00 $2,052.00 $2,272.00 $1,916.00 $2,052.00 $2,272.0035901 90 $709.00 $724.00 $776.00 $851.00 $724.00 $776.00 $851.0035903 90 $818.00 $863.00 $925.00 $1,012.00 $863.00 $925.00 $1,012.0035905 90 $1,343.00 $2,604.00 $2,789.00 $3,088.00 $2,604.00 $2,789.00 $3,088.0035907 90 $1,335.00 $2,956.00 $3,167.00 $3,505.00 $2,956.00 $3,167.00 $3,505.0036000 0 $46.00 $36.00 $38.00 $39.00 $14.00 $14.00 $15.0036002 0 $181.00 $232.00 $246.00 $257.00 $158.00 $167.00 $178.0036005 0 $68.00 $449.00 $480.00 $487.00 $72.00 $77.00 $82.0036010 0 $136.00 $700.00 $748.00 $766.00 $184.00 $194.00 $210.0036011 0 $194.00 $1,158.00 $1,238.00 $1,259.00 $235.00 $248.00 $266.0036012 0 $186.00 $1,197.00 $1,279.00 $1,301.00 $260.00 $274.00 $294.0036013 0 $141.00 $1,087.00 $1,163.00 $1,178.00 $187.00 $196.00 $209.0036014 0 $159.00 $1,124.00 $1,201.00 $1,219.00 $223.00 $234.00 $249.0036015 0 $186.00 $1,205.00 $1,286.00 $1,303.00 $254.00 $266.00 $280.0036100 0 $176.00 $704.00 $754.00 $779.00 $235.00 $250.00 $273.0036120 0 $120.00 $591.00 $633.00 $649.00 $152.00 $161.00 $175.0036140 0 $106.00 $612.00 $655.00 $672.00 $156.00 $166.00 $182.0036147 0 -------- $1,167.00 $1,246.00 $1,269.00 $278.00 $293.00 $313.0036148 ZZZ -------- $364.00 $389.00 $395.00 $73.00 $77.00 $82.0036160 0 $196.00 $687.00 $733.00 $746.00 $183.00 $192.00 $203.0036200 0 $240.00 $873.00 $935.00 $962.00 $233.00 $249.00 $274.0036215 0 $240.00 $1,564.00 $1,672.00 $1,703.00 $351.00 $371.00 $398.00



Surgery







36216 0 $270.00 $1,665.00 $1,782.00 $1,827.00 $416.00 $443.00 $483.0036217 0 $325.00 $2,726.00 $2,920.00 $2,975.00 $494.00 $526.00 $573.0036218 ZZZ $79.00 $270.00 $288.00 $296.00 $80.00 $85.00 $92.0036221 0 -------- $1,529.00 $1,638.00 $1,676.00 $326.00 $348.00 $382.0036222 0 -------- $1,837.00 $1,969.00 $2,019.00 $447.00 $477.00 $523.0036223 0 -------- $2,146.00 $2,300.00 $2,355.00 $488.00 $521.00 $571.0036224 0 -------- $2,527.00 $2,709.00 $2,773.00 $544.00 $582.00 $640.0036225 0 -------- $2,097.00 $2,247.00 $2,300.00 $480.00 $512.00 $560.0036226 0 -------- $2,564.00 $2,750.00 $2,815.00 $546.00 $585.00 $643.0036227 ZZZ -------- $358.00 $384.00 $402.00 $172.00 $184.00 $202.0036228 ZZZ -------- $1,694.00 $1,816.00 $1,858.00 $352.00 $377.00 $414.0036245 0 $249.00 $1,904.00 $2,037.00 $2,075.00 $380.00 $403.00 $436.0036246 0 $272.00 $1,252.00 $1,340.00 $1,382.00 $407.00 $433.00 $473.0036247 0 $323.00 $2,198.00 $2,352.00 $2,401.00 $479.00 $508.00 $552.0036248 ZZZ $53.00 $214.00 $228.00 $233.00 $74.00 $77.00 $82.0036251 0 -------- $1,984.00 $2,126.00 $2,173.00 $425.00 $453.00 $495.0036252 0 -------- $2,162.00 $2,318.00 $2,384.00 $569.00 $608.00 $669.0036253 0 -------- $3,141.00 $3,357.00 $3,402.00 $562.00 $589.00 $626.0036254 0 -------- $3,071.00 $3,292.00 $3,370.00 $660.00 $706.00 $776.0036260 90 $749.00 $939.00 $1,008.00 $1,101.00 $939.00 $1,008.00 $1,101.0036261 90 $388.00 $594.00 $637.00 $691.00 $594.00 $637.00 $691.0036262 90 $297.00 $452.00 $485.00 $524.00 $452.00 $485.00 $524.0036299 YYY BR -------- -------- -------- -------- -------- --------36410 0 $18.00 $24.00 $25.00 $26.00 $14.00 $14.00 $15.0036415 0 BR -------- -------- -------- -------- -------- --------36416 0 BR -------- -------- -------- -------- -------- --------36425 0 $86.00 $59.00 $62.00 $66.00 $59.00 $62.00 $66.0036430 0 $37.00 $48.00 $51.00 $52.00 $48.00 $51.00 $52.0036455 0 $141.00 $189.00 $202.00 $221.00 $189.00 $202.00 $221.0036468 0 NC BR BR BR BR BR BR36470 10 $76.00 $211.00 $226.00 $234.00 $122.00 $130.00 $138.0036471 10 $96.00 $249.00 $265.00 $278.00 $149.00 $158.00 $170.0036475 0 -------- $2,138.00 $2,291.00 $2,340.00 $425.00 $454.00 $497.0036476 ZZZ -------- $425.00 $455.00 $477.00 $207.00 $221.00 $243.0036478 0 -------- $1,684.00 $1,804.00 $1,849.00 $422.00 $449.00 $490.0036479 ZZZ -------- $439.00 $470.00 $491.00 $206.00 $219.00 $240.0036481 0 $499.00 $2,819.00 $3,010.00 $3,043.00 $514.00 $536.00 $562.0036500 0 $159.00 $272.00 $288.00 $311.00 $272.00 $288.00 $311.0036511 0 $92.00 $135.00 $140.00 $145.00 $135.00 $140.00 $145.0036512 0 $92.00 $136.00 $141.00 $146.00 $136.00 $141.00 $146.0036513 0 $92.00 $143.00 $151.00 $160.00 $143.00 $151.00 $160.0036514 0 $92.00 $744.00 $794.00 $803.00 $135.00 $142.00 $148.0036515 0 $92.00 $2,834.00 $3,037.00 $3,054.00 $129.00 $136.00 $144.0036516 0 $92.00 $2,855.00 $3,063.00 $3,084.00 $105.00 $112.00 $124.0036522 0 $305.00 $1,920.00 $2,055.00 $2,066.00 $146.00 $153.00 $158.0036556 0 -------- $331.00 $350.00 $362.00 $178.00 $186.00 $198.0036558 10 -------- $1,096.00 $1,168.00 $1,196.00 $408.00 $430.00 $457.0036561 10 -------- $1,644.00 $1,758.00 $1,804.00 $526.00 $559.00 $600.0036563 10 -------- $1,863.00 $1,998.00 $2,059.00 $573.00 $614.00 $671.0036565 10 -------- $1,373.00 $1,472.00 $1,527.00 $526.00 $563.00 $615.00



Surgery







36566 10 -------- $7,501.00 $8,044.00 $8,117.00 $575.00 $613.00 $665.0036569 0 -------- $350.00 $371.00 $378.00 $134.00 $140.00 $146.0036571 10 -------- $1,818.00 $1,947.00 $1,992.00 $481.00 $512.00 $553.0036575 0 -------- $232.00 $247.00 $251.00 $52.00 $55.00 $58.0036576 10 -------- $552.00 $590.00 $615.00 $294.00 $313.00 $338.0036578 10 -------- $731.00 $779.00 $802.00 $319.00 $338.00 $359.0036580 0 -------- $300.00 $320.00 $326.00 $99.00 $103.00 $109.0036581 10 -------- $1,070.00 $1,141.00 $1,160.00 $289.00 $303.00 $320.0036582 10 -------- $1,538.00 $1,645.00 $1,684.00 $455.00 $483.00 $519.0036583 10 -------- $1,909.00 $2,048.00 $2,103.00 $508.00 $545.00 $595.0036584 0 -------- $285.00 $303.00 $308.00 $97.00 $102.00 $106.0036585 10 -------- $1,603.00 $1,714.00 $1,748.00 $421.00 $446.00 $476.0036589 10 -------- $238.00 $252.00 $265.00 $202.00 $214.00 $227.0036590 10 -------- $422.00 $450.00 $475.00 $304.00 $323.00 $348.0036591 0 -------- $32.00 $34.00 $35.00 $32.00 $34.00 $35.0036592 0 -------- $36.00 $39.00 $39.00 $36.00 $39.00 $39.0036593 0 -------- $43.00 $46.00 $47.00 $43.00 $46.00 $47.0036595 0 -------- $818.00 $870.00 $887.00 $272.00 $284.00 $300.0036596 0 -------- $186.00 $198.00 $203.00 $66.00 $69.00 $73.0036597 0 -------- $179.00 $190.00 $195.00 $90.00 $94.00 $99.0036598 0 -------- $154.00 $164.00 $167.00 $54.00 $57.00 $59.0036600 0 $24.00 $44.00 $47.00 $48.00 $23.00 $24.00 $25.0036620 0 $64.00 $75.00 $78.00 $82.00 $75.00 $78.00 $82.0036625 0 $133.00 $156.00 $165.00 $178.00 $156.00 $165.00 $178.0036640 0 $130.00 $172.00 $179.00 $185.00 $172.00 $179.00 $185.0036680 0 $72.00 $87.00 $92.00 $99.00 $87.00 $92.00 $99.0036800 0 $159.00 $184.00 $194.00 $209.00 $184.00 $194.00 $209.0036810 0 $345.00 $324.00 $344.00 $372.00 $324.00 $344.00 $372.0036815 0 $236.00 $222.00 $237.00 $261.00 $222.00 $237.00 $261.0036818 90 -------- $1,063.00 $1,139.00 $1,251.00 $1,063.00 $1,139.00 $1,251.0036819 90 $977.00 $1,124.00 $1,205.00 $1,326.00 $1,124.00 $1,205.00 $1,326.0036820 90 $800.00 $1,120.00 $1,201.00 $1,320.00 $1,120.00 $1,201.00 $1,320.0036821 90 $721.00 $1,018.00 $1,091.00 $1,199.00 $1,018.00 $1,091.00 $1,199.0036823 90 $1,461.00 $2,026.00 $2,170.00 $2,377.00 $2,026.00 $2,170.00 $2,377.0036825 90 $867.00 $1,226.00 $1,314.00 $1,443.00 $1,226.00 $1,314.00 $1,443.0036830 90 $967.00 $1,025.00 $1,098.00 $1,207.00 $1,025.00 $1,098.00 $1,207.0036831 90 $488.00 $946.00 $1,014.00 $1,115.00 $946.00 $1,014.00 $1,115.0036832 90 $810.00 $1,161.00 $1,245.00 $1,367.00 $1,161.00 $1,245.00 $1,367.0036833 90 $780.00 $1,246.00 $1,335.00 $1,467.00 $1,246.00 $1,335.00 $1,467.0036835 90 $542.00 $742.00 $797.00 $868.00 $742.00 $797.00 $868.0036838 90 -------- $1,761.00 $1,887.00 $2,083.00 $1,761.00 $1,887.00 $2,083.0036860 0 $166.00 $293.00 $309.00 $317.00 $161.00 $168.00 $174.0036861 0 $224.00 $200.00 $214.00 $235.00 $200.00 $214.00 $235.0036870 90 $1,755.00 $2,541.00 $2,717.00 $2,750.00 $442.00 $466.00 $492.0037140 90 $1,666.00 $3,465.00 $3,718.00 $4,093.00 $3,465.00 $3,718.00 $4,093.0037145 90 $1,741.00 $3,243.00 $3,482.00 $3,836.00 $3,243.00 $3,482.00 $3,836.0037160 90 $1,681.00 $3,331.00 $3,577.00 $3,939.00 $3,331.00 $3,577.00 $3,939.0037180 90 $1,769.00 $3,044.00 $3,237.00 $3,505.00 $3,044.00 $3,237.00 $3,505.0037181 90 $1,923.00 $3,508.00 $3,767.00 $4,150.00 $3,508.00 $3,767.00 $4,150.0037182 0 $914.00 $1,227.00 $1,277.00 $1,336.00 $1,227.00 $1,277.00 $1,336.00



Surgery







37183 0 $425.00 $8,140.00 $8,715.00 $8,766.00 $579.00 $603.00 $631.0037184 0 -------- $3,175.00 $3,402.00 $3,479.00 $698.00 $744.00 $813.0037185 ZZZ -------- $1,011.00 $1,084.00 $1,113.00 $256.00 $273.00 $300.0037186 ZZZ -------- $1,921.00 $2,058.00 $2,102.00 $379.00 $404.00 $443.0037187 0 -------- $2,872.00 $3,072.00 $3,131.00 $613.00 $648.00 $700.0037188 0 -------- $2,466.00 $2,637.00 $2,676.00 $438.00 $462.00 $494.0037191 0 -------- $3,633.00 $3,891.00 $3,928.00 $357.00 $376.00 $403.0037192 0 -------- $2,165.00 $2,316.00 $2,370.00 $554.00 $587.00 $637.0037193 0 -------- $2,231.00 $2,383.00 $2,429.00 $548.00 $577.00 $617.0037195 0 $302.00 -------- -------- -------- -------- -------- --------37197 0 -------- $2,118.00 $2,265.00 $2,309.00 $475.00 $502.00 $541.0037200 0 $232.00 $324.00 $337.00 $353.00 $324.00 $337.00 $353.0037211 0 -------- $603.00 $639.00 $692.00 $603.00 $639.00 $692.0037212 0 -------- $529.00 $560.00 $605.00 $529.00 $560.00 $605.0037213 0 -------- $370.00 $390.00 $418.00 $370.00 $390.00 $418.0037214 0 -------- $203.00 $214.00 $230.00 $203.00 $214.00 $230.0037215 90 -------- $1,526.00 $1,634.00 $1,797.00 $1,526.00 $1,634.00 $1,797.0037217 90 -------- $1,670.00 $1,786.00 $1,961.00 $1,670.00 $1,786.00 $1,961.0037218 90 -------- $1,242.00 $1,324.00 $1,443.00 $1,242.00 $1,324.00 $1,443.0037220 0 -------- $4,383.00 $4,699.00 $4,779.00 $635.00 $678.00 $746.0037221 0 -------- $6,450.00 $6,915.00 $7,016.00 $780.00 $833.00 $915.0037222 ZZZ -------- $1,240.00 $1,329.00 $1,364.00 $287.00 $307.00 $338.0037223 ZZZ -------- $3,579.00 $3,839.00 $3,884.00 $329.00 $351.00 $387.0037224 0 -------- $5,311.00 $5,694.00 $5,780.00 $698.00 $744.00 $816.0037225 0 -------- $15,183.00 $16,286.00 $16,433.00 $948.00 $1,014.00 $1,116.0037226 0 -------- $12,490.00 $13,396.00 $13,521.00 $822.00 $878.00 $966.0037227 0 -------- $20,496.00 $21,985.00 $22,169.00 $1,141.00 $1,219.00 $1,342.0037228 0 -------- $7,538.00 $8,082.00 $8,194.00 $854.00 $911.00 $1,001.0037229 0 -------- $14,980.00 $16,067.00 $16,229.00 $1,106.00 $1,181.00 $1,300.0037230 0 -------- $11,469.00 $12,301.00 $12,451.00 $1,089.00 $1,164.00 $1,281.0037231 0 -------- $18,418.00 $19,756.00 $19,936.00 $1,184.00 $1,265.00 $1,392.0037232 ZZZ -------- $1,687.00 $1,809.00 $1,846.00 $310.00 $331.00 $364.0037233 ZZZ -------- $2,049.00 $2,196.00 $2,255.00 $506.00 $540.00 $594.0037234 ZZZ -------- $5,353.00 $5,741.00 $5,804.00 $435.00 $465.00 $513.0037235 ZZZ -------- $5,648.00 $6,056.00 $6,135.00 $618.00 $659.00 $722.0037236 0 -------- $5,694.00 $6,099.00 $6,176.00 $686.00 $726.00 $787.0037237 ZZZ -------- $3,400.00 $3,646.00 $3,688.00 $325.00 $347.00 $380.0037238 0 -------- $5,790.00 $6,204.00 $6,259.00 $473.00 $500.00 $538.0037239 ZZZ -------- $2,803.00 $3,005.00 $3,036.00 $228.00 $242.00 $265.0037241 0 -------- $6,595.00 $7,064.00 $7,137.00 $678.00 $716.00 $771.0037242 0 -------- $10,565.00 $11,317.00 $11,397.00 $737.00 $773.00 $822.0037243 0 -------- $13,409.00 $14,361.00 $14,448.00 $865.00 $903.00 $950.0037244 0 -------- $9,365.00 $10,019.00 $10,102.00 $1,014.00 $1,059.00 $1,116.0037252 ZZZ -------- $1,927.00 $2,067.00 $2,088.00 $141.00 $150.00 $166.0037253 ZZZ -------- $307.00 $329.00 $342.00 $113.00 $121.00 $134.0037500 90 $739.00 $1,144.00 $1,228.00 $1,338.00 $1,144.00 $1,228.00 $1,338.0037501 YYY BR -------- -------- -------- -------- -------- --------37565 90 $364.00 $1,083.00 $1,153.00 $1,242.00 $1,083.00 $1,153.00 $1,242.0037600 90 $414.00 $1,067.00 $1,138.00 $1,236.00 $1,067.00 $1,138.00 $1,236.0037605 90 $521.00 $1,214.00 $1,301.00 $1,430.00 $1,214.00 $1,301.00 $1,430.00



Surgery







37606 90 $563.00 $868.00 $931.00 $1,010.00 $868.00 $931.00 $1,010.0037607 90 $456.00 $571.00 $612.00 $668.00 $571.00 $612.00 $668.0037609 10 $278.00 $447.00 $478.00 $503.00 $307.00 $328.00 $353.0037615 90 $495.00 $752.00 $797.00 $844.00 $752.00 $797.00 $844.0037616 90 $1,128.00 $1,661.00 $1,780.00 $1,952.00 $1,661.00 $1,780.00 $1,952.0037617 90 $1,132.00 $2,021.00 $2,162.00 $2,370.00 $2,021.00 $2,162.00 $2,370.0037618 90 $514.00 $577.00 $617.00 $670.00 $577.00 $617.00 $670.0037619 90 -------- $2,487.00 $2,662.00 $2,929.00 $2,487.00 $2,662.00 $2,929.0037650 90 $430.00 $770.00 $825.00 $902.00 $770.00 $825.00 $902.0037660 90 $789.00 $1,776.00 $1,904.00 $2,107.00 $1,776.00 $1,904.00 $2,107.0037700 90 $336.00 $376.00 $403.00 $437.00 $376.00 $403.00 $437.0037718 90 -------- $662.00 $710.00 $776.00 $662.00 $710.00 $776.0037722 90 -------- $730.00 $783.00 $858.00 $730.00 $783.00 $858.0037735 90 $847.00 $1,039.00 $1,115.00 $1,218.00 $1,039.00 $1,115.00 $1,218.0037760 90 $813.00 $938.00 $1,005.00 $1,103.00 $938.00 $1,005.00 $1,103.0037761 90 -------- $836.00 $895.00 $977.00 $836.00 $895.00 $977.0037765 90 -------- $953.00 $1,019.00 $1,082.00 $679.00 $725.00 $788.0037766 90 -------- $1,136.00 $1,214.00 $1,293.00 $831.00 $887.00 $965.0037780 90 $301.00 $384.00 $411.00 $447.00 $384.00 $411.00 $447.0037785 90 $270.00 $519.00 $556.00 $592.00 $394.00 $422.00 $457.0037788 90 $1,654.00 $1,890.00 $1,986.00 $2,100.00 $1,890.00 $1,986.00 $2,100.0037790 90 $690.00 $736.00 $778.00 $825.00 $736.00 $778.00 $825.0037799 YYY BR -------- -------- -------- -------- -------- --------38100 90 $974.00 $1,732.00 $1,857.00 $2,036.00 $1,732.00 $1,857.00 $2,036.0038101 90 $982.00 $1,735.00 $1,858.00 $2,032.00 $1,735.00 $1,858.00 $2,032.0038102 ZZZ $332.00 $396.00 $424.00 $466.00 $396.00 $424.00 $466.0038115 90 $1,020.00 $1,898.00 $2,029.00 $2,217.00 $1,898.00 $2,029.00 $2,217.0038120 90 $1,138.00 $1,576.00 $1,691.00 $1,849.00 $1,576.00 $1,691.00 $1,849.0038129 YYY BR -------- -------- -------- -------- -------- --------38200 0 $180.00 $172.00 $178.00 $187.00 $172.00 $178.00 $187.0038205 0 $79.00 $119.00 $124.00 $128.00 $119.00 $124.00 $128.0038206 0 $79.00 $120.00 $125.00 $129.00 $120.00 $125.00 $129.0038220 0 $212.00 $230.00 $245.00 $251.00 $90.00 $95.00 $100.0038221 0 $228.00 $233.00 $247.00 $251.00 $108.00 $112.00 $116.0038230 0 $265.00 $290.00 $305.00 $323.00 $290.00 $305.00 $323.0038232 0 -------- $289.00 $304.00 $321.00 $289.00 $304.00 $321.0038240 0 $128.00 $322.00 $335.00 $345.00 $322.00 $335.00 $345.0038241 0 $128.00 $241.00 $251.00 $258.00 $241.00 $251.00 $258.0038242 0 $90.00 $169.00 $176.00 $181.00 $169.00 $176.00 $181.0038243 0 -------- $169.00 $175.00 $180.00 $169.00 $175.00 $180.0038300 10 $104.00 $394.00 $421.00 $440.00 $270.00 $288.00 $306.0038305 90 $375.00 $703.00 $753.00 $814.00 $703.00 $753.00 $814.0038308 90 $425.00 $662.00 $710.00 $771.00 $662.00 $710.00 $771.0038380 90 $628.00 $831.00 $880.00 $929.00 $831.00 $880.00 $929.0038381 90 $1,087.00 $1,202.00 $1,289.00 $1,410.00 $1,202.00 $1,289.00 $1,410.0038382 90 $798.00 $921.00 $984.00 $1,073.00 $921.00 $984.00 $1,073.0038500 10 $234.00 $481.00 $516.00 $551.00 $377.00 $404.00 $439.0038505 0 $139.00 $178.00 $189.00 $194.00 $103.00 $108.00 $113.0038510 10 $349.00 $757.00 $808.00 $860.00 $623.00 $664.00 $716.0038520 90 $431.00 $687.00 $734.00 $793.00 $687.00 $734.00 $793.00



Surgery







38525 90 $369.00 $648.00 $696.00 $757.00 $648.00 $696.00 $757.0038530 90 $517.00 $813.00 $870.00 $940.00 $813.00 $870.00 $940.0038542 90 $507.00 $762.00 $810.00 $865.00 $762.00 $810.00 $865.0038550 90 $519.00 $749.00 $803.00 $870.00 $749.00 $803.00 $870.0038555 90 $1,115.00 $1,496.00 $1,605.00 $1,751.00 $1,496.00 $1,605.00 $1,751.0038562 90 $799.00 $1,036.00 $1,104.00 $1,189.00 $1,036.00 $1,104.00 $1,189.0038564 90 $831.00 $1,047.00 $1,120.00 $1,219.00 $1,047.00 $1,120.00 $1,219.0038570 10 $695.00 $742.00 $787.00 $844.00 $742.00 $787.00 $844.0038571 10 $902.00 $978.00 $1,029.00 $1,091.00 $978.00 $1,029.00 $1,091.0038572 10 $1,049.00 $1,380.00 $1,470.00 $1,591.00 $1,380.00 $1,470.00 $1,591.0038589 YYY BR -------- -------- -------- -------- -------- --------38700 90 $863.00 $1,184.00 $1,253.00 $1,331.00 $1,184.00 $1,253.00 $1,331.0038720 90 $1,328.00 $1,986.00 $2,107.00 $2,253.00 $1,986.00 $2,107.00 $2,253.0038724 90 $1,366.00 $2,141.00 $2,266.00 $2,411.00 $2,141.00 $2,266.00 $2,411.0038740 90 $539.00 $1,034.00 $1,109.00 $1,209.00 $1,034.00 $1,109.00 $1,209.0038745 90 $770.00 $1,307.00 $1,401.00 $1,530.00 $1,307.00 $1,401.00 $1,530.0038746 ZZZ $312.00 $327.00 $350.00 $387.00 $327.00 $350.00 $387.0038747 ZZZ $337.00 $403.00 $432.00 $477.00 $403.00 $432.00 $477.0038760 90 $699.00 $1,252.00 $1,340.00 $1,457.00 $1,252.00 $1,340.00 $1,457.0038765 90 $1,283.00 $1,924.00 $2,054.00 $2,235.00 $1,924.00 $2,054.00 $2,235.0038770 90 $1,111.00 $1,187.00 $1,254.00 $1,338.00 $1,187.00 $1,254.00 $1,338.0038780 90 $1,357.00 $1,506.00 $1,593.00 $1,701.00 $1,506.00 $1,593.00 $1,701.0038790 0 $158.00 $122.00 $130.00 $138.00 $122.00 $130.00 $138.0038792 0 $26.00 $58.00 $61.00 $64.00 $58.00 $61.00 $64.0038794 90 $298.00 $433.00 $454.00 $470.00 $433.00 $454.00 $470.0038900 ZZZ -------- $209.00 $224.00 $247.00 $209.00 $224.00 $247.0038999 YYY BR -------- -------- -------- -------- -------- --------39000 90 $664.00 $739.00 $791.00 $857.00 $739.00 $791.00 $857.0039010 90 $1,148.00 $1,181.00 $1,265.00 $1,384.00 $1,181.00 $1,265.00 $1,384.0039200 90 $1,249.00 $1,325.00 $1,420.00 $1,557.00 $1,325.00 $1,420.00 $1,557.0039220 90 $1,542.00 $1,708.00 $1,827.00 $1,998.00 $1,708.00 $1,827.00 $1,998.0039401 0 -------- $469.00 $503.00 $554.00 $469.00 $503.00 $554.0039402 0 -------- $614.00 $658.00 $726.00 $614.00 $658.00 $726.0039499 YYY BR -------- -------- -------- -------- -------- --------39501 90 $1,083.00 $1,267.00 $1,357.00 $1,480.00 $1,267.00 $1,357.00 $1,480.0039503 90 $2,726.00 $9,268.00 $9,948.00 $10,980.00 $9,268.00 $9,948.00 $10,980.0039540 90 $1,133.00 $1,296.00 $1,388.00 $1,517.00 $1,296.00 $1,388.00 $1,517.0039541 90 $1,179.00 $1,415.00 $1,517.00 $1,661.00 $1,415.00 $1,517.00 $1,661.0039545 90 $1,102.00 $1,339.00 $1,434.00 $1,568.00 $1,339.00 $1,434.00 $1,568.0039560 90 $968.00 $1,190.00 $1,274.00 $1,390.00 $1,190.00 $1,274.00 $1,390.0039561 90 $1,328.00 $1,850.00 $1,982.00 $2,162.00 $1,850.00 $1,982.00 $2,162.0039599 YYY BR -------- -------- -------- -------- -------- --------40490 0 $108.00 $183.00 $194.00 $201.00 $107.00 $113.00 $120.0040500 90 $422.00 $723.00 $770.00 $799.00 $530.00 $563.00 $591.0040510 90 $469.00 $696.00 $741.00 $772.00 $522.00 $555.00 $585.0040520 90 $467.00 $703.00 $748.00 $779.00 $525.00 $557.00 $588.0040525 90 $714.00 $807.00 $857.00 $906.00 $807.00 $857.00 $906.0040527 90 $851.00 $906.00 $959.00 $1,012.00 $906.00 $959.00 $1,012.0040530 90 $501.00 $776.00 $826.00 $863.00 $591.00 $628.00 $663.0040650 90 $368.00 $629.00 $670.00 $694.00 $435.00 $462.00 $485.00



Surgery







40652 90 $436.00 $696.00 $742.00 $770.00 $512.00 $543.00 $571.0040654 90 $529.00 $816.00 $869.00 $906.00 $620.00 $659.00 $695.0040700 90 $1,009.00 $1,327.00 $1,403.00 $1,484.00 $1,327.00 $1,403.00 $1,484.0040701 90 $1,452.00 $1,492.00 $1,574.00 $1,667.00 $1,492.00 $1,574.00 $1,667.0040702 90 $1,030.00 $1,235.00 $1,287.00 $1,324.00 $1,235.00 $1,287.00 $1,324.0040720 90 $1,107.00 $1,497.00 $1,591.00 $1,690.00 $1,497.00 $1,591.00 $1,690.0040761 90 $1,202.00 $1,585.00 $1,684.00 $1,791.00 $1,585.00 $1,684.00 $1,791.0040799 YYY BR -------- -------- -------- -------- -------- --------40800 10 $110.00 $304.00 $325.00 $334.00 $192.00 $205.00 $213.0040801 10 $208.00 $457.00 $487.00 $505.00 $328.00 $349.00 $366.0040804 10 $105.00 $273.00 $291.00 $299.00 $171.00 $182.00 $189.0040805 10 $245.00 $523.00 $553.00 $559.00 $321.00 $337.00 $342.0040806 0 $38.00 $159.00 $170.00 $172.00 $46.00 $49.00 $50.0040808 10 $100.00 $267.00 $285.00 $292.00 $158.00 $169.00 $175.0040810 10 $141.00 $297.00 $316.00 $325.00 $187.00 $199.00 $207.0040812 10 $202.00 $418.00 $446.00 $462.00 $292.00 $310.00 $326.0040814 90 $319.00 $560.00 $597.00 $621.00 $450.00 $479.00 $502.0040816 90 $336.00 $585.00 $623.00 $648.00 $467.00 $497.00 $521.0040818 90 $249.00 $514.00 $547.00 $562.00 $396.00 $420.00 $435.0040819 90 $208.00 $458.00 $489.00 $507.00 $353.00 $377.00 $394.0040820 10 $104.00 $379.00 $405.00 $414.00 $250.00 $266.00 $274.0040830 10 $140.00 $381.00 $406.00 $417.00 $241.00 $256.00 $267.0040831 10 $213.00 $485.00 $517.00 $534.00 $329.00 $350.00 $366.0040840 90 $687.00 $1,180.00 $1,255.00 $1,314.00 $928.00 $985.00 $1,043.0040842 90 $684.00 $1,135.00 $1,204.00 $1,258.00 $889.00 $941.00 $994.0040843 90 $947.00 $1,580.00 $1,681.00 $1,767.00 $1,260.00 $1,338.00 $1,423.0040844 90 $1,232.00 $1,894.00 $2,007.00 $2,102.00 $1,548.00 $1,636.00 $1,730.0040845 90 $1,593.00 $2,133.00 $2,262.00 $2,379.00 $1,809.00 $1,915.00 $2,031.0040899 YYY BR -------- -------- -------- -------- -------- --------41000 10 $119.00 $235.00 $250.00 $259.00 $165.00 $176.00 $184.0041005 10 $109.00 $325.00 $347.00 $355.00 $183.00 $194.00 $202.0041006 90 $237.00 $518.00 $551.00 $571.00 $371.00 $393.00 $413.0041007 90 $283.00 $506.00 $538.00 $557.00 $357.00 $378.00 $396.0041008 90 $248.00 $550.00 $586.00 $610.00 $399.00 $424.00 $447.0041009 90 $319.00 $584.00 $623.00 $647.00 $433.00 $460.00 $484.0041010 10 $91.00 $289.00 $309.00 $316.00 $158.00 $167.00 $174.0041015 90 $267.00 $657.00 $700.00 $728.00 $517.00 $550.00 $577.0041016 90 $357.00 $642.00 $684.00 $712.00 $519.00 $552.00 $580.0041017 90 $300.00 $648.00 $690.00 $719.00 $522.00 $555.00 $583.0041018 90 $424.00 $739.00 $787.00 $822.00 $612.00 $650.00 $685.0041019 0 -------- $681.00 $709.00 $736.00 $681.00 $709.00 $736.0041100 10 $140.00 $243.00 $258.00 $267.00 $159.00 $169.00 $177.0041105 10 $136.00 $247.00 $263.00 $272.00 $164.00 $175.00 $184.0041108 10 $110.00 $213.00 $227.00 $234.00 $133.00 $142.00 $148.0041110 10 $159.00 $305.00 $325.00 $335.00 $193.00 $205.00 $214.0041112 90 $255.00 $485.00 $517.00 $535.00 $372.00 $396.00 $414.0041113 90 $301.00 $531.00 $566.00 $588.00 $413.00 $439.00 $460.0041114 90 $682.00 $937.00 $994.00 $1,049.00 $937.00 $994.00 $1,049.0041115 10 $176.00 $357.00 $381.00 $393.00 $225.00 $239.00 $251.0041116 90 $242.00 $478.00 $510.00 $526.00 $324.00 $344.00 $360.00



Surgery







41120 90 $813.00 $1,580.00 $1,680.00 $1,747.00 $1,580.00 $1,680.00 $1,747.0041130 90 $937.00 $1,952.00 $2,073.00 $2,166.00 $1,952.00 $2,073.00 $2,166.0041135 90 $1,869.00 $3,221.00 $3,414.00 $3,593.00 $3,221.00 $3,414.00 $3,593.0041140 90 $2,005.00 $3,242.00 $3,437.00 $3,605.00 $3,242.00 $3,437.00 $3,605.0041145 90 $2,406.00 $4,127.00 $4,377.00 $4,607.00 $4,127.00 $4,377.00 $4,607.0041150 90 $1,897.00 $3,267.00 $3,463.00 $3,638.00 $3,267.00 $3,463.00 $3,638.0041153 90 $2,091.00 $3,561.00 $3,773.00 $3,969.00 $3,561.00 $3,773.00 $3,969.0041155 90 $2,448.00 $4,477.00 $4,744.00 $5,010.00 $4,477.00 $4,744.00 $5,010.0041250 10 $168.00 $383.00 $408.00 $419.00 $224.00 $238.00 $248.0041251 10 $203.00 $419.00 $447.00 $462.00 $268.00 $285.00 $300.0041252 10 $294.00 $455.00 $484.00 $503.00 $310.00 $329.00 $347.0041500 90 $334.00 $599.00 $635.00 $654.00 $599.00 $635.00 $654.0041510 90 $313.00 $611.00 $650.00 $670.00 $611.00 $650.00 $670.0041512 90 -------- $968.00 $1,028.00 $1,069.00 $968.00 $1,028.00 $1,069.0041520 90 $255.00 $513.00 $547.00 $567.00 $380.00 $405.00 $424.0041530 0 -------- $1,394.00 $1,491.00 $1,514.00 $547.00 $582.00 $603.0041599 YYY BR -------- -------- -------- -------- -------- --------41800 10 $107.00 $386.00 $412.00 $420.00 $213.00 $226.00 $234.0041805 10 $115.00 $369.00 $395.00 $404.00 $254.00 $271.00 $280.0041806 10 $217.00 $514.00 $548.00 $568.00 $384.00 $409.00 $428.0041820 0 NC BR BR BR BR BR BR41821 0 NC BR BR BR BR BR BR41822 10 $237.00 $425.00 $453.00 $470.00 $271.00 $288.00 $305.0041823 90 $312.00 $623.00 $664.00 $690.00 $479.00 $509.00 $535.0041825 10 $144.00 $305.00 $325.00 $335.00 $180.00 $192.00 $201.0041826 10 $211.00 $457.00 $487.00 $504.00 $314.00 $334.00 $350.0041827 90 $322.00 $640.00 $682.00 $707.00 $455.00 $483.00 $508.0041828 10 $176.00 $452.00 $482.00 $503.00 $318.00 $338.00 $359.0041830 10 $156.00 $574.00 $612.00 $636.00 $423.00 $450.00 $473.0041850 0 NC BR BR BR BR BR BR41870 0 NC BR BR BR BR BR BR41872 90 $249.00 $531.00 $565.00 $584.00 $378.00 $402.00 $421.0041874 90 $193.00 $547.00 $584.00 $606.00 $380.00 $405.00 $426.0041899 YYY BR -------- -------- -------- -------- -------- --------42000 10 $106.00 $229.00 $244.00 $252.00 $152.00 $162.00 $169.0042100 10 $122.00 $217.00 $231.00 $240.00 $161.00 $171.00 $180.0042104 10 $161.00 $311.00 $332.00 $342.00 $205.00 $218.00 $228.0042106 10 $204.00 $396.00 $422.00 $437.00 $264.00 $280.00 $294.0042107 90 $409.00 $671.00 $715.00 $743.00 $512.00 $544.00 $572.0042120 90 $573.00 $1,494.00 $1,587.00 $1,658.00 $1,494.00 $1,587.00 $1,658.0042140 90 $174.00 $363.00 $387.00 $398.00 $226.00 $240.00 $250.0042145 90 $741.00 $1,032.00 $1,093.00 $1,149.00 $1,032.00 $1,093.00 $1,149.0042160 10 $176.00 $334.00 $356.00 $368.00 $216.00 $229.00 $241.0042180 10 $222.00 $354.00 $376.00 $391.00 $271.00 $287.00 $301.0042182 10 $324.00 $466.00 $495.00 $518.00 $377.00 $399.00 $422.0042200 90 $946.00 $1,249.00 $1,322.00 $1,394.00 $1,249.00 $1,322.00 $1,394.0042205 90 $863.00 $1,304.00 $1,380.00 $1,458.00 $1,304.00 $1,380.00 $1,458.0042210 90 $1,174.00 $1,457.00 $1,542.00 $1,631.00 $1,457.00 $1,542.00 $1,631.0042215 90 $766.00 $962.00 $1,020.00 $1,073.00 $962.00 $1,020.00 $1,073.0042220 90 $586.00 $729.00 $770.00 $810.00 $729.00 $770.00 $810.00



Surgery







42225 90 $803.00 $1,277.00 $1,355.00 $1,412.00 $1,277.00 $1,355.00 $1,412.0042226 90 $848.00 $1,307.00 $1,388.00 $1,449.00 $1,307.00 $1,388.00 $1,449.0042227 90 $762.00 $1,244.00 $1,323.00 $1,389.00 $1,244.00 $1,323.00 $1,389.0042235 90 $631.00 $1,066.00 $1,132.00 $1,177.00 $1,066.00 $1,132.00 $1,177.0042260 90 $491.00 $1,187.00 $1,259.00 $1,319.00 $979.00 $1,036.00 $1,095.0042280 10 $148.00 $240.00 $256.00 $267.00 $163.00 $174.00 $184.0042281 10 $160.00 $296.00 $315.00 $327.00 $221.00 $235.00 $246.0042299 YYY BR -------- -------- -------- -------- -------- --------42300 10 $165.00 $303.00 $322.00 $334.00 $224.00 $237.00 $249.0042305 90 $448.00 $635.00 $673.00 $711.00 $635.00 $673.00 $711.0042310 10 $145.00 $233.00 $247.00 $256.00 $181.00 $192.00 $201.0042320 10 $208.00 $361.00 $384.00 $398.00 $257.00 $273.00 $287.0042330 10 $184.00 $336.00 $357.00 $370.00 $242.00 $257.00 $270.0042335 90 $287.00 $541.00 $576.00 $597.00 $379.00 $402.00 $422.0042340 90 $411.00 $671.00 $713.00 $741.00 $493.00 $522.00 $549.0042400 0 $94.00 $151.00 $160.00 $164.00 $80.00 $85.00 $88.0042405 10 $258.00 $433.00 $459.00 $479.00 $333.00 $352.00 $371.0042408 90 $377.00 $654.00 $694.00 $722.00 $478.00 $506.00 $533.0042409 90 $266.00 $478.00 $509.00 $526.00 $324.00 $343.00 $360.0042410 90 $746.00 $917.00 $973.00 $1,034.00 $917.00 $973.00 $1,034.0042415 90 $1,364.00 $1,556.00 $1,646.00 $1,746.00 $1,556.00 $1,646.00 $1,746.0042420 90 $1,577.00 $1,749.00 $1,850.00 $1,964.00 $1,749.00 $1,850.00 $1,964.0042425 90 $1,097.00 $1,231.00 $1,303.00 $1,382.00 $1,231.00 $1,303.00 $1,382.0042426 90 $1,882.00 $1,991.00 $2,105.00 $2,239.00 $1,991.00 $2,105.00 $2,239.0042440 90 $634.00 $606.00 $641.00 $678.00 $606.00 $641.00 $678.0042450 90 $395.00 $654.00 $696.00 $724.00 $525.00 $557.00 $585.0042500 90 $407.00 $628.00 $668.00 $694.00 $502.00 $532.00 $559.0042505 90 $559.00 $807.00 $857.00 $894.00 $666.00 $705.00 $743.0042507 90 $522.00 $753.00 $800.00 $840.00 $753.00 $800.00 $840.0042509 90 $915.00 $1,237.00 $1,310.00 $1,378.00 $1,237.00 $1,310.00 $1,378.0042510 90 $711.00 $940.00 $998.00 $1,049.00 $940.00 $998.00 $1,049.0042550 0 $82.00 $191.00 $202.00 $206.00 $93.00 $96.00 $101.0042600 90 $445.00 $692.00 $735.00 $764.00 $510.00 $540.00 $569.0042650 0 $67.00 $120.00 $128.00 $133.00 $86.00 $91.00 $95.0042660 0 $89.00 $187.00 $202.00 $216.00 $134.00 $145.00 $158.0042665 90 $238.00 $445.00 $473.00 $490.00 $300.00 $318.00 $334.0042699 YYY BR -------- -------- -------- -------- -------- --------42700 10 $144.00 $273.00 $290.00 $300.00 $198.00 $210.00 $219.0042720 10 $270.00 $664.00 $704.00 $741.00 $579.00 $613.00 $649.0042725 90 $720.00 $1,205.00 $1,277.00 $1,353.00 $1,205.00 $1,277.00 $1,353.0042800 10 $123.00 $228.00 $243.00 $252.00 $163.00 $173.00 $182.0042804 10 $136.00 $279.00 $298.00 $306.00 $165.00 $175.00 $183.0042806 10 $167.00 $315.00 $335.00 $345.00 $193.00 $205.00 $214.0042808 10 $250.00 $328.00 $349.00 $363.00 $238.00 $252.00 $266.0042809 10 $152.00 $291.00 $310.00 $321.00 $180.00 $190.00 $201.0042810 90 $335.00 $557.00 $593.00 $613.00 $421.00 $446.00 $466.0042815 90 $659.00 $817.00 $867.00 $910.00 $817.00 $867.00 $910.0042821 90 $378.00 $442.00 $468.00 $493.00 $442.00 $468.00 $493.0042826 90 $320.00 $368.00 $390.00 $410.00 $368.00 $390.00 $410.0042831 90 $235.00 $327.00 $346.00 $363.00 $327.00 $346.00 $363.00



Surgery







42836 90 $286.00 $352.00 $373.00 $392.00 $352.00 $373.00 $392.0042842 90 $729.00 $1,493.00 $1,584.00 $1,656.00 $1,493.00 $1,584.00 $1,656.0042844 90 $1,173.00 $2,050.00 $2,174.00 $2,276.00 $2,050.00 $2,174.00 $2,276.0042845 90 $1,958.00 $3,320.00 $3,514.00 $3,700.00 $3,320.00 $3,514.00 $3,700.0042860 90 $207.00 $274.00 $291.00 $304.00 $274.00 $291.00 $304.0042870 90 $427.00 $873.00 $928.00 $960.00 $873.00 $928.00 $960.0042890 90 $1,047.00 $2,119.00 $2,246.00 $2,356.00 $2,119.00 $2,246.00 $2,356.0042892 90 $1,262.00 $2,804.00 $2,972.00 $3,126.00 $2,804.00 $2,972.00 $3,126.0042894 90 $1,825.00 $3,526.00 $3,734.00 $3,928.00 $3,526.00 $3,734.00 $3,928.0042900 10 $429.00 $497.00 $525.00 $555.00 $497.00 $525.00 $555.0042950 90 $745.00 $1,197.00 $1,272.00 $1,322.00 $1,197.00 $1,272.00 $1,322.0042953 90 $752.00 $1,439.00 $1,531.00 $1,589.00 $1,439.00 $1,531.00 $1,589.0042955 90 $561.00 $1,131.00 $1,201.00 $1,247.00 $1,131.00 $1,201.00 $1,247.0042960 10 $178.00 $249.00 $264.00 $278.00 $249.00 $264.00 $278.0042961 90 $406.00 $621.00 $658.00 $692.00 $621.00 $658.00 $692.0042962 90 $602.00 $760.00 $805.00 $847.00 $760.00 $805.00 $847.0042970 90 $284.00 $587.00 $618.00 $642.00 $587.00 $618.00 $642.0042971 90 $472.00 $670.00 $710.00 $750.00 $670.00 $710.00 $750.0042972 90 $562.00 $751.00 $795.00 $839.00 $751.00 $795.00 $839.0042999 YYY BR -------- -------- -------- -------- -------- --------43020 90 $696.00 $786.00 $841.00 $910.00 $786.00 $841.00 $910.0043030 90 $712.00 $765.00 $810.00 $860.00 $765.00 $810.00 $860.0043045 90 $1,574.00 $1,964.00 $2,107.00 $2,312.00 $1,964.00 $2,107.00 $2,312.0043100 90 $744.00 $918.00 $971.00 $1,028.00 $918.00 $971.00 $1,028.0043101 90 $1,248.00 $1,530.00 $1,640.00 $1,798.00 $1,530.00 $1,640.00 $1,798.0043107 90 $2,325.00 $3,853.00 $4,132.00 $4,542.00 $3,853.00 $4,132.00 $4,542.0043108 90 $2,664.00 $6,905.00 $7,377.00 $8,072.00 $6,905.00 $7,377.00 $8,072.0043112 90 $2,471.00 $4,074.00 $4,369.00 $4,811.00 $4,074.00 $4,369.00 $4,811.0043113 90 $2,755.00 $6,836.00 $7,314.00 $8,013.00 $6,836.00 $7,314.00 $8,013.0043116 90 $2,509.00 $7,481.00 $7,878.00 $8,374.00 $7,481.00 $7,878.00 $8,374.0043117 90 $2,469.00 $3,732.00 $4,002.00 $4,406.00 $3,732.00 $4,002.00 $4,406.0043118 90 $2,607.00 $5,586.00 $5,985.00 $6,594.00 $5,586.00 $5,985.00 $6,594.0043121 90 $2,350.00 $4,349.00 $4,666.00 $5,146.00 $4,349.00 $4,666.00 $5,146.0043122 90 $2,287.00 $3,869.00 $4,148.00 $4,555.00 $3,869.00 $4,148.00 $4,555.0043123 90 $2,661.00 $7,141.00 $7,658.00 $8,428.00 $7,141.00 $7,658.00 $8,428.0043124 90 $2,242.00 $5,787.00 $6,197.00 $6,814.00 $5,787.00 $6,197.00 $6,814.0043130 90 $1,020.00 $1,165.00 $1,237.00 $1,322.00 $1,165.00 $1,237.00 $1,322.0043135 90 $1,332.00 $2,239.00 $2,397.00 $2,629.00 $2,239.00 $2,397.00 $2,629.0043180 90 -------- $811.00 $857.00 $908.00 $811.00 $857.00 $908.0043191 0 -------- $227.00 $240.00 $255.00 $227.00 $240.00 $255.0043192 0 -------- $251.00 $265.00 $281.00 $251.00 $265.00 $281.0043193 0 -------- $250.00 $265.00 $281.00 $250.00 $265.00 $281.0043194 0 -------- $288.00 $305.00 $328.00 $288.00 $305.00 $328.0043195 0 -------- $272.00 $288.00 $305.00 $272.00 $288.00 $305.0043196 0 -------- $292.00 $309.00 $329.00 $292.00 $309.00 $329.0043197 0 -------- $267.00 $285.00 $294.00 $123.00 $130.00 $139.0043198 0 -------- $298.00 $317.00 $329.00 $148.00 $156.00 $167.0043200 0 $266.00 $380.00 $405.00 $415.00 $139.00 $147.00 $156.0043201 0 $245.00 $387.00 $412.00 $423.00 $161.00 $170.00 $181.0043202 0 $205.00 $505.00 $539.00 $551.00 $161.00 $171.00 $181.00



Surgery







43204 0 $228.00 $209.00 $220.00 $232.00 $209.00 $220.00 $232.0043205 0 $207.00 $217.00 $229.00 $242.00 $217.00 $229.00 $242.0043206 0 -------- $463.00 $493.00 $508.00 $209.00 $220.00 $234.0043210 0 -------- $630.00 $663.00 $702.00 $630.00 $663.00 $702.0043211 0 -------- $359.00 $378.00 $400.00 $359.00 $378.00 $400.0043212 0 -------- $293.00 $311.00 $335.00 $293.00 $311.00 $335.0043213 0 -------- $1,693.00 $1,809.00 $1,838.00 $393.00 $414.00 $439.0043214 0 -------- $294.00 $309.00 $328.00 $294.00 $309.00 $328.0043215 0 $160.00 $586.00 $625.00 $642.00 $220.00 $233.00 $249.0043216 0 $149.00 $576.00 $614.00 $628.00 $207.00 $218.00 $230.0043217 0 $176.00 $625.00 $666.00 $685.00 $248.00 $262.00 $280.0043220 0 $128.00 $1,557.00 $1,667.00 $1,683.00 $184.00 $194.00 $206.0043226 0 $142.00 $532.00 $567.00 $583.00 $203.00 $215.00 $229.0043227 0 $218.00 $963.00 $1,028.00 $1,047.00 $254.00 $268.00 $284.0043229 0 -------- $1,002.00 $1,070.00 $1,091.00 $302.00 $319.00 $338.0043231 0 $182.00 $560.00 $596.00 $612.00 $246.00 $259.00 $274.0043232 0 $252.00 $669.00 $711.00 $730.00 $303.00 $318.00 $335.0043233 0 -------- $348.00 $367.00 $390.00 $348.00 $367.00 $390.0043235 0 $239.00 $435.00 $463.00 $476.00 $190.00 $201.00 $212.0043236 0 $285.00 $540.00 $576.00 $590.00 $214.00 $226.00 $239.0043237 0 -------- $299.00 $315.00 $333.00 $299.00 $315.00 $333.0043238 0 -------- $355.00 $373.00 $395.00 $355.00 $373.00 $395.0043239 0 $246.00 $554.00 $590.00 $605.00 $215.00 $226.00 $240.0043240 0 $369.00 $594.00 $625.00 $662.00 $594.00 $625.00 $662.0043241 0 $157.00 $220.00 $233.00 $247.00 $220.00 $233.00 $247.0043242 0 $384.00 $400.00 $421.00 $445.00 $400.00 $421.00 $445.0043243 0 $276.00 $362.00 $381.00 $404.00 $362.00 $381.00 $404.0043244 0 $268.00 $374.00 $393.00 $416.00 $374.00 $393.00 $416.0043245 0 $214.00 $853.00 $911.00 $932.00 $271.00 $286.00 $305.0043246 0 $485.00 $307.00 $325.00 $347.00 $307.00 $325.00 $347.0043247 0 $229.00 $583.00 $621.00 $640.00 $272.00 $287.00 $305.0043248 0 $191.00 $571.00 $608.00 $624.00 $256.00 $269.00 $284.0043249 0 $175.00 $1,478.00 $1,581.00 $1,600.00 $236.00 $249.00 $264.0043250 0 $194.00 $637.00 $680.00 $699.00 $262.00 $277.00 $296.0043251 0 $224.00 $697.00 $742.00 $762.00 $301.00 $317.00 $336.0043252 0 -------- $516.00 $549.00 $566.00 $259.00 $273.00 $290.0043253 0 -------- $399.00 $420.00 $443.00 $399.00 $420.00 $443.0043254 0 -------- $412.00 $434.00 $459.00 $412.00 $434.00 $459.0043255 0 $343.00 $1,012.00 $1,080.00 $1,101.00 $307.00 $323.00 $342.0043257 0 -------- $356.00 $375.00 $397.00 $356.00 $375.00 $397.0043259 0 $271.00 $345.00 $363.00 $383.00 $345.00 $363.00 $383.0043260 0 $349.00 $489.00 $514.00 $544.00 $489.00 $514.00 $544.0043261 0 $362.00 $513.00 $540.00 $572.00 $513.00 $540.00 $572.0043262 0 $447.00 $541.00 $569.00 $602.00 $541.00 $569.00 $602.0043263 0 $386.00 $542.00 $570.00 $604.00 $542.00 $570.00 $604.0043264 0 $522.00 $551.00 $580.00 $613.00 $551.00 $580.00 $613.0043265 0 $527.00 $655.00 $688.00 $729.00 $655.00 $688.00 $729.0043266 0 -------- $346.00 $365.00 $388.00 $346.00 $365.00 $388.0043270 0 -------- $1,045.00 $1,114.00 $1,138.00 $355.00 $373.00 $395.0043273 ZZZ -------- $179.00 $188.00 $199.00 $179.00 $188.00 $199.00



Surgery







43274 0 -------- $699.00 $735.00 $778.00 $699.00 $735.00 $778.0043275 0 -------- $570.00 $600.00 $635.00 $570.00 $600.00 $635.0043276 0 -------- $728.00 $766.00 $810.00 $728.00 $766.00 $810.0043277 0 -------- $573.00 $603.00 $638.00 $573.00 $603.00 $638.0043278 0 -------- $654.00 $688.00 $728.00 $654.00 $688.00 $728.0043279 90 -------- $1,945.00 $2,086.00 $2,291.00 $1,945.00 $2,086.00 $2,291.0043280 90 $1,314.00 $1,623.00 $1,741.00 $1,909.00 $1,623.00 $1,741.00 $1,909.0043281 90 -------- $2,325.00 $2,493.00 $2,739.00 $2,325.00 $2,493.00 $2,739.0043282 90 -------- $2,614.00 $2,803.00 $3,080.00 $2,614.00 $2,803.00 $3,080.0043283 ZZZ -------- $241.00 $258.00 $285.00 $241.00 $258.00 $285.0043289 YYY BR -------- -------- -------- -------- -------- --------43300 90 $837.00 $905.00 $958.00 $1,011.00 $905.00 $958.00 $1,011.0043305 90 $1,428.00 $1,620.00 $1,715.00 $1,823.00 $1,620.00 $1,715.00 $1,823.0043310 90 $2,138.00 $2,248.00 $2,412.00 $2,656.00 $2,248.00 $2,412.00 $2,656.0043312 90 $2,331.00 $2,446.00 $2,621.00 $2,888.00 $2,446.00 $2,621.00 $2,888.0043313 90 $2,632.00 $3,997.00 $4,213.00 $4,474.00 $3,997.00 $4,213.00 $4,474.0043314 90 $2,891.00 $4,615.00 $4,914.00 $5,321.00 $4,615.00 $4,914.00 $5,321.0043320 90 $1,299.00 $2,092.00 $2,245.00 $2,465.00 $2,092.00 $2,245.00 $2,465.0043325 90 $1,261.00 $2,011.00 $2,156.00 $2,362.00 $2,011.00 $2,156.00 $2,362.0043327 90 -------- $1,229.00 $1,319.00 $1,443.00 $1,229.00 $1,319.00 $1,443.0043328 90 -------- $1,712.00 $1,835.00 $2,018.00 $1,712.00 $1,835.00 $2,018.0043330 90 $1,236.00 $1,994.00 $2,139.00 $2,344.00 $1,994.00 $2,139.00 $2,344.0043331 90 $1,378.00 $2,025.00 $2,170.00 $2,380.00 $2,025.00 $2,170.00 $2,380.0043332 90 -------- $1,745.00 $1,872.00 $2,054.00 $1,745.00 $1,872.00 $2,054.0043333 90 -------- $1,903.00 $2,041.00 $2,240.00 $1,903.00 $2,041.00 $2,240.0043334 90 -------- $1,892.00 $2,028.00 $2,231.00 $1,892.00 $2,028.00 $2,231.0043335 90 -------- $2,030.00 $2,176.00 $2,397.00 $2,030.00 $2,176.00 $2,397.0043336 90 -------- $2,276.00 $2,439.00 $2,675.00 $2,276.00 $2,439.00 $2,675.0043337 90 -------- $2,455.00 $2,634.00 $2,894.00 $2,455.00 $2,634.00 $2,894.0043338 ZZZ -------- $177.00 $190.00 $210.00 $177.00 $190.00 $210.0043340 90 $1,292.00 $2,049.00 $2,197.00 $2,410.00 $2,049.00 $2,197.00 $2,410.0043341 90 $1,351.00 $2,121.00 $2,275.00 $2,501.00 $2,121.00 $2,275.00 $2,501.0043351 90 $1,180.00 $1,930.00 $2,061.00 $2,243.00 $1,930.00 $2,061.00 $2,243.0043352 90 $1,028.00 $1,608.00 $1,724.00 $1,887.00 $1,608.00 $1,724.00 $1,887.0043360 90 $2,277.00 $3,559.00 $3,817.00 $4,187.00 $3,559.00 $3,817.00 $4,187.0043361 90 $2,596.00 $3,860.00 $4,137.00 $4,552.00 $3,860.00 $4,137.00 $4,552.0043400 90 $1,261.00 $2,185.00 $2,301.00 $2,433.00 $2,185.00 $2,301.00 $2,433.0043401 90 $1,299.00 $2,347.00 $2,519.00 $2,772.00 $2,347.00 $2,519.00 $2,772.0043405 90 $1,330.00 $2,200.00 $2,360.00 $2,591.00 $2,200.00 $2,360.00 $2,591.0043410 90 $946.00 $1,572.00 $1,686.00 $1,840.00 $1,572.00 $1,686.00 $1,840.0043415 90 $1,382.00 $3,882.00 $4,160.00 $4,571.00 $3,882.00 $4,160.00 $4,571.0043420 90 $854.00 $1,497.00 $1,581.00 $1,676.00 $1,497.00 $1,581.00 $1,676.0043425 90 $1,338.00 $2,164.00 $2,314.00 $2,528.00 $2,164.00 $2,314.00 $2,528.0043450 0 $91.00 $295.00 $314.00 $322.00 $125.00 $132.00 $139.0043453 0 $102.00 $1,328.00 $1,422.00 $1,433.00 $135.00 $142.00 $150.0043460 0 $203.00 $317.00 $334.00 $353.00 $317.00 $334.00 $353.0043496 90 BR -------- -------- -------- -------- -------- --------43499 YYY BR -------- -------- -------- -------- -------- --------43500 90 $649.00 $1,171.00 $1,253.00 $1,367.00 $1,171.00 $1,253.00 $1,367.0043501 90 $1,105.00 $2,017.00 $2,162.00 $2,370.00 $2,017.00 $2,162.00 $2,370.00



Surgery







43502 90 $1,247.00 $2,287.00 $2,453.00 $2,694.00 $2,287.00 $2,453.00 $2,694.0043510 90 $680.00 $1,411.00 $1,515.00 $1,659.00 $1,411.00 $1,515.00 $1,659.0043520 90 $599.00 $1,029.00 $1,103.00 $1,208.00 $1,029.00 $1,103.00 $1,208.0043605 90 $686.00 $1,251.00 $1,341.00 $1,466.00 $1,251.00 $1,341.00 $1,466.0043610 90 $861.00 $1,469.00 $1,574.00 $1,724.00 $1,469.00 $1,574.00 $1,724.0043611 90 $1,001.00 $1,834.00 $1,967.00 $2,155.00 $1,834.00 $1,967.00 $2,155.0043620 90 $1,691.00 $2,941.00 $3,150.00 $3,458.00 $2,941.00 $3,150.00 $3,458.0043621 90 $1,718.00 $3,421.00 $3,669.00 $4,038.00 $3,421.00 $3,669.00 $4,038.0043622 90 $1,798.00 $3,492.00 $3,749.00 $4,131.00 $3,492.00 $3,749.00 $4,131.0043631 90 $1,445.00 $2,176.00 $2,333.00 $2,559.00 $2,176.00 $2,333.00 $2,559.0043632 90 $1,443.00 $3,058.00 $3,280.00 $3,607.00 $3,058.00 $3,280.00 $3,607.0043633 90 $1,467.00 $2,889.00 $3,098.00 $3,405.00 $2,889.00 $3,098.00 $3,405.0043634 90 $1,786.00 $3,183.00 $3,412.00 $3,748.00 $3,183.00 $3,412.00 $3,748.0043635 ZZZ $143.00 $170.00 $183.00 $202.00 $170.00 $183.00 $202.0043640 90 $1,119.00 $1,767.00 $1,895.00 $2,076.00 $1,767.00 $1,895.00 $2,076.0043641 90 $1,138.00 $1,775.00 $1,899.00 $2,069.00 $1,775.00 $1,899.00 $2,069.0043644 90 -------- $2,603.00 $2,791.00 $3,063.00 $2,603.00 $2,791.00 $3,063.0043645 90 -------- $2,784.00 $2,986.00 $3,280.00 $2,784.00 $2,986.00 $3,280.0043651 90 $716.00 $971.00 $1,039.00 $1,129.00 $971.00 $1,039.00 $1,129.0043652 90 $856.00 $1,145.00 $1,230.00 $1,346.00 $1,145.00 $1,230.00 $1,346.0043653 90 $617.00 $851.00 $913.00 $993.00 $851.00 $913.00 $993.0043659 YYY BR -------- -------- -------- -------- -------- --------43752 0 BR $60.00 $62.00 $66.00 $60.00 $62.00 $66.0043753 0 -------- $32.00 $34.00 $36.00 $32.00 $34.00 $36.0043754 0 -------- $147.00 $156.00 $158.00 $47.00 $49.00 $51.0043755 0 -------- $198.00 $212.00 $220.00 $91.00 $97.00 $105.0043756 0 -------- $284.00 $304.00 $308.00 $75.00 $79.00 $83.0043757 0 -------- $402.00 $430.00 $437.00 $114.00 $120.00 $126.0043760 0 $81.00 $670.00 $718.00 $725.00 $70.00 $73.00 $78.0043761 0 $107.00 $169.00 $177.00 $185.00 $151.00 $158.00 $166.0043770 90 -------- $1,674.00 $1,796.00 $1,964.00 $1,674.00 $1,796.00 $1,964.0043771 90 -------- $1,907.00 $2,046.00 $2,240.00 $1,907.00 $2,046.00 $2,240.0043772 90 -------- $1,421.00 $1,523.00 $1,666.00 $1,421.00 $1,523.00 $1,666.0043773 90 -------- $1,899.00 $2,034.00 $2,223.00 $1,899.00 $2,034.00 $2,223.0043774 90 -------- $1,437.00 $1,541.00 $1,686.00 $1,437.00 $1,541.00 $1,686.0043775 90 -------- $1,660.00 $1,773.00 $1,945.00 $1,660.00 $1,773.00 $1,945.0043800 90 $793.00 $1,392.00 $1,493.00 $1,635.00 $1,392.00 $1,493.00 $1,635.0043810 90 $846.00 $1,525.00 $1,636.00 $1,792.00 $1,525.00 $1,636.00 $1,792.0043820 90 $896.00 $2,012.00 $2,158.00 $2,366.00 $2,012.00 $2,158.00 $2,366.0043825 90 $1,128.00 $1,960.00 $2,103.00 $2,307.00 $1,960.00 $2,103.00 $2,307.0043830 90 $592.00 $1,042.00 $1,117.00 $1,216.00 $1,042.00 $1,117.00 $1,216.0043831 90 $593.00 $866.00 $929.00 $1,010.00 $866.00 $929.00 $1,010.0043832 90 $904.00 $1,558.00 $1,669.00 $1,826.00 $1,558.00 $1,669.00 $1,826.0043840 90 $893.00 $2,038.00 $2,186.00 $2,396.00 $2,038.00 $2,186.00 $2,396.0043843 90 $1,249.00 $1,917.00 $2,056.00 $2,253.00 $1,917.00 $2,056.00 $2,253.0043845 90 -------- $2,951.00 $3,165.00 $3,476.00 $2,951.00 $3,165.00 $3,476.0043846 90 $1,528.00 $2,422.00 $2,596.00 $2,848.00 $2,422.00 $2,596.00 $2,848.0043847 90 $1,678.00 $2,658.00 $2,842.00 $3,104.00 $2,658.00 $2,842.00 $3,104.0043848 90 $1,795.00 $2,891.00 $3,100.00 $3,402.00 $2,891.00 $3,100.00 $3,402.0043850 90 $1,425.00 $2,428.00 $2,596.00 $2,831.00 $2,428.00 $2,596.00 $2,831.00



Surgery







43855 90 $1,454.00 $2,456.00 $2,618.00 $2,842.00 $2,456.00 $2,618.00 $2,842.0043860 90 $1,435.00 $2,456.00 $2,632.00 $2,888.00 $2,456.00 $2,632.00 $2,888.0043865 90 $1,549.00 $2,559.00 $2,744.00 $3,013.00 $2,559.00 $2,744.00 $3,013.0043870 90 $590.00 $1,063.00 $1,139.00 $1,242.00 $1,063.00 $1,139.00 $1,242.0043880 90 $1,352.00 $2,400.00 $2,572.00 $2,821.00 $2,400.00 $2,572.00 $2,821.0043886 90 -------- $532.00 $571.00 $614.00 $532.00 $571.00 $614.0043887 90 -------- $478.00 $512.00 $553.00 $478.00 $512.00 $553.0043888 90 -------- $678.00 $727.00 $787.00 $678.00 $727.00 $787.0043999 YYY BR -------- -------- -------- -------- -------- --------44005 90 $1,171.00 $1,640.00 $1,757.00 $1,925.00 $1,640.00 $1,757.00 $1,925.0044010 90 $809.00 $1,286.00 $1,373.00 $1,491.00 $1,286.00 $1,373.00 $1,491.0044015 ZZZ $1,171.00 $216.00 $231.00 $255.00 $216.00 $231.00 $255.0044020 90 $891.00 $1,460.00 $1,565.00 $1,714.00 $1,460.00 $1,565.00 $1,714.0044021 90 $888.00 $1,458.00 $1,562.00 $1,707.00 $1,458.00 $1,562.00 $1,707.0044025 90 $905.00 $1,476.00 $1,580.00 $1,727.00 $1,476.00 $1,580.00 $1,727.0044050 90 $862.00 $1,402.00 $1,503.00 $1,645.00 $1,402.00 $1,503.00 $1,645.0044055 90 $957.00 $2,239.00 $2,398.00 $2,627.00 $2,239.00 $2,398.00 $2,627.0044100 0 $117.00 $161.00 $169.00 $180.00 $161.00 $169.00 $180.0044110 90 $784.00 $1,274.00 $1,365.00 $1,491.00 $1,274.00 $1,365.00 $1,491.0044111 90 $963.00 $1,472.00 $1,574.00 $1,717.00 $1,472.00 $1,574.00 $1,717.0044120 90 $1,078.00 $1,836.00 $1,967.00 $2,156.00 $1,836.00 $1,967.00 $2,156.0044121 ZZZ $308.00 $366.00 $392.00 $432.00 $366.00 $392.00 $432.0044125 90 $1,135.00 $1,770.00 $1,894.00 $2,071.00 $1,770.00 $1,894.00 $2,071.0044126 90 $1,951.00 $3,711.00 $3,983.00 $4,381.00 $3,711.00 $3,983.00 $4,381.0044127 90 $2,243.00 $4,256.00 $4,558.00 $4,999.00 $4,256.00 $4,558.00 $4,999.0044128 ZZZ $242.00 $371.00 $398.00 $440.00 $371.00 $398.00 $440.0044130 90 $938.00 $1,967.00 $2,106.00 $2,304.00 $1,967.00 $2,106.00 $2,304.0044133 0 BR -------- -------- -------- -------- -------- --------44136 0 BR -------- -------- -------- -------- -------- --------44139 ZZZ $154.00 $183.00 $196.00 $216.00 $183.00 $196.00 $216.0044140 90 $1,350.00 $2,010.00 $2,153.00 $2,356.00 $2,010.00 $2,153.00 $2,356.0044141 90 $1,488.00 $2,732.00 $2,926.00 $3,194.00 $2,732.00 $2,926.00 $3,194.0044143 90 $1,536.00 $2,494.00 $2,671.00 $2,921.00 $2,494.00 $2,671.00 $2,921.0044144 90 $1,442.00 $2,656.00 $2,844.00 $3,112.00 $2,656.00 $2,844.00 $3,112.0044145 90 $1,678.00 $2,483.00 $2,654.00 $2,896.00 $2,483.00 $2,654.00 $2,896.0044146 90 $1,840.00 $3,163.00 $3,379.00 $3,675.00 $3,163.00 $3,379.00 $3,675.0044147 90 $1,452.00 $2,919.00 $3,124.00 $3,422.00 $2,919.00 $3,124.00 $3,422.0044150 90 $1,661.00 $2,790.00 $2,985.00 $3,248.00 $2,790.00 $2,985.00 $3,248.0044151 90 $1,499.00 $3,200.00 $3,427.00 $3,740.00 $3,200.00 $3,427.00 $3,740.0044155 90 $1,892.00 $3,102.00 $3,309.00 $3,585.00 $3,102.00 $3,309.00 $3,585.0044156 90 $1,709.00 $3,436.00 $3,680.00 $4,016.00 $3,436.00 $3,680.00 $4,016.0044157 90 -------- $3,215.00 $3,436.00 $3,736.00 $3,215.00 $3,436.00 $3,736.0044158 90 -------- $3,140.00 $3,318.00 $3,533.00 $3,140.00 $3,318.00 $3,533.0044160 90 $1,236.00 $1,860.00 $1,991.00 $2,176.00 $1,860.00 $1,991.00 $2,176.0044180 90 -------- $1,374.00 $1,472.00 $1,608.00 $1,374.00 $1,472.00 $1,608.0044186 90 -------- $975.00 $1,046.00 $1,143.00 $975.00 $1,046.00 $1,143.0044187 90 -------- $1,640.00 $1,750.00 $1,889.00 $1,640.00 $1,750.00 $1,889.0044188 90 -------- $1,824.00 $1,951.00 $2,116.00 $1,824.00 $1,951.00 $2,116.0044202 90 $1,603.00 $2,080.00 $2,228.00 $2,438.00 $2,080.00 $2,228.00 $2,438.0044203 ZZZ $235.00 $364.00 $390.00 $428.00 $364.00 $390.00 $428.00



Surgery







44204 90 $1,353.00 $2,303.00 $2,461.00 $2,683.00 $2,303.00 $2,461.00 $2,683.0044205 90 $1,198.00 $2,001.00 $2,138.00 $2,329.00 $2,001.00 $2,138.00 $2,329.0044206 90 $1,480.00 $2,626.00 $2,808.00 $3,063.00 $2,626.00 $2,808.00 $3,063.0044207 90 $1,620.00 $2,722.00 $2,903.00 $3,158.00 $2,722.00 $2,903.00 $3,158.0044208 90 $1,752.00 $2,965.00 $3,162.00 $3,431.00 $2,965.00 $3,162.00 $3,431.0044210 90 $1,551.00 $2,651.00 $2,823.00 $3,053.00 $2,651.00 $2,823.00 $3,053.0044211 90 $1,926.00 $3,243.00 $3,448.00 $3,719.00 $3,243.00 $3,448.00 $3,719.0044212 90 $1,800.00 $3,038.00 $3,229.00 $3,475.00 $3,038.00 $3,229.00 $3,475.0044213 ZZZ -------- $283.00 $302.00 $330.00 $283.00 $302.00 $330.0044227 90 -------- $2,500.00 $2,675.00 $2,924.00 $2,500.00 $2,675.00 $2,924.0044238 YYY BR -------- -------- -------- -------- -------- --------44300 90 $697.00 $1,260.00 $1,351.00 $1,477.00 $1,260.00 $1,351.00 $1,477.0044310 90 $950.00 $1,560.00 $1,667.00 $1,815.00 $1,560.00 $1,667.00 $1,815.0044312 90 $453.00 $873.00 $930.00 $1,002.00 $873.00 $930.00 $1,002.0044314 90 $892.00 $1,492.00 $1,591.00 $1,722.00 $1,492.00 $1,591.00 $1,722.0044316 90 $1,229.00 $2,127.00 $2,284.00 $2,509.00 $2,127.00 $2,284.00 $2,509.0044320 90 $1,029.00 $1,795.00 $1,921.00 $2,095.00 $1,795.00 $1,921.00 $2,095.0044322 90 $1,015.00 $1,477.00 $1,585.00 $1,711.00 $1,477.00 $1,585.00 $1,711.0044340 90 $397.00 $927.00 $992.00 $1,074.00 $927.00 $992.00 $1,074.0044345 90 $816.00 $1,568.00 $1,676.00 $1,822.00 $1,568.00 $1,676.00 $1,822.0044346 90 $923.00 $1,765.00 $1,886.00 $2,052.00 $1,765.00 $1,886.00 $2,052.0044360 0 $177.00 $221.00 $233.00 $246.00 $221.00 $233.00 $246.0044361 0 $195.00 $244.00 $257.00 $272.00 $244.00 $257.00 $272.0044363 0 $213.00 $294.00 $309.00 $328.00 $294.00 $309.00 $328.0044364 0 $255.00 $312.00 $328.00 $347.00 $312.00 $328.00 $347.0044365 0 $226.00 $273.00 $286.00 $299.00 $273.00 $286.00 $299.0044366 0 $300.00 $366.00 $385.00 $407.00 $366.00 $385.00 $407.0044369 0 $308.00 $374.00 $394.00 $416.00 $374.00 $394.00 $416.0044370 0 $253.00 $406.00 $428.00 $455.00 $406.00 $428.00 $455.0044372 0 $301.00 $367.00 $387.00 $411.00 $367.00 $387.00 $411.0044373 0 $238.00 $295.00 $311.00 $331.00 $295.00 $311.00 $331.0044376 0 $305.00 $432.00 $455.00 $483.00 $432.00 $455.00 $483.0044377 0 $320.00 $456.00 $480.00 $509.00 $456.00 $480.00 $509.0044378 0 $410.00 $582.00 $612.00 $648.00 $582.00 $612.00 $648.0044379 0 $396.00 $619.00 $652.00 $690.00 $619.00 $652.00 $690.0044380 0 $91.00 $305.00 $326.00 $332.00 $91.00 $96.00 $102.0044381 0 -------- $1,372.00 $1,470.00 $1,483.00 $134.00 $142.00 $151.0044382 0 $110.00 $442.00 $472.00 $480.00 $116.00 $123.00 $129.0044384 0 -------- $233.00 $245.00 $258.00 $233.00 $245.00 $258.0044385 0 $219.00 $338.00 $360.00 $368.00 $114.00 $120.00 $127.0044386 0 $183.00 $474.00 $506.00 $516.00 $139.00 $147.00 $156.0044388 0 $326.00 $496.00 $529.00 $548.00 $242.00 $256.00 $274.0044388-53 0 -------- $246.00 $262.00 $269.00 $119.00 $125.00 $133.0044389 0 $301.00 $623.00 $663.00 $682.00 $264.00 $279.00 $297.0044390 0 $319.00 $624.00 $663.00 $684.00 $322.00 $339.00 $358.0044391 0 $376.00 $1,066.00 $1,137.00 $1,162.00 $352.00 $371.00 $393.0044392 0 $359.00 $589.00 $627.00 $650.00 $305.00 $322.00 $344.0044394 0 $395.00 $662.00 $705.00 $729.00 $346.00 $365.00 $389.0044401 0 -------- $4,467.00 $4,787.00 $4,826.00 $371.00 $392.00 $418.0044402 0 -------- $401.00 $424.00 $452.00 $401.00 $424.00 $452.00



Surgery







44403 0 -------- $460.00 $486.00 $517.00 $460.00 $486.00 $517.0044404 0 -------- $598.00 $637.00 $657.00 $266.00 $281.00 $300.0044405 0 -------- $852.00 $909.00 $931.00 $282.00 $299.00 $319.0044406 0 -------- $352.00 $372.00 $397.00 $352.00 $372.00 $397.0044407 0 -------- $422.00 $446.00 $476.00 $422.00 $446.00 $476.0044408 0 -------- $355.00 $376.00 $401.00 $355.00 $376.00 $401.0044500 0 $28.00 $36.00 $37.00 $39.00 $36.00 $37.00 $39.0044602 90 $815.00 $2,124.00 $2,275.00 $2,498.00 $2,124.00 $2,275.00 $2,498.0044603 90 $1,041.00 $2,432.00 $2,604.00 $2,854.00 $2,432.00 $2,604.00 $2,854.0044604 90 $1,027.00 $1,586.00 $1,698.00 $1,859.00 $1,586.00 $1,698.00 $1,859.0044605 90 $1,132.00 $1,956.00 $2,094.00 $2,289.00 $1,956.00 $2,094.00 $2,289.0044615 90 $994.00 $1,612.00 $1,726.00 $1,887.00 $1,612.00 $1,726.00 $1,887.0044620 90 $741.00 $1,296.00 $1,385.00 $1,506.00 $1,296.00 $1,385.00 $1,506.0044625 90 $1,277.00 $1,517.00 $1,618.00 $1,758.00 $1,517.00 $1,618.00 $1,758.0044626 90 $1,581.00 $2,407.00 $2,575.00 $2,818.00 $2,407.00 $2,575.00 $2,818.0044640 90 $1,036.00 $2,102.00 $2,248.00 $2,457.00 $2,102.00 $2,248.00 $2,457.0044650 90 $1,076.00 $2,173.00 $2,323.00 $2,538.00 $2,173.00 $2,323.00 $2,538.0044660 90 $1,050.00 $1,976.00 $2,095.00 $2,257.00 $1,976.00 $2,095.00 $2,257.0044661 90 $1,326.00 $2,319.00 $2,473.00 $2,691.00 $2,319.00 $2,473.00 $2,691.0044680 90 $1,049.00 $1,597.00 $1,711.00 $1,871.00 $1,597.00 $1,711.00 $1,871.0044700 90 $1,115.00 $1,518.00 $1,615.00 $1,747.00 $1,518.00 $1,615.00 $1,747.0044701 ZZZ $161.00 $254.00 $272.00 $298.00 $254.00 $272.00 $298.0044720 0 -------- $417.00 $448.00 $496.00 $417.00 $448.00 $496.0044721 0 -------- $584.00 $627.00 $694.00 $584.00 $627.00 $694.0044799 0 BR -------- -------- -------- -------- -------- --------44800 90 $791.00 $1,137.00 $1,217.00 $1,323.00 $1,137.00 $1,217.00 $1,323.0044820 90 $755.00 $1,253.00 $1,341.00 $1,462.00 $1,253.00 $1,341.00 $1,462.0044850 90 $708.00 $1,123.00 $1,203.00 $1,313.00 $1,123.00 $1,203.00 $1,313.0044899 YYY BR -------- -------- -------- -------- -------- --------44900 90 $644.00 $1,154.00 $1,237.00 $1,350.00 $1,154.00 $1,237.00 $1,350.0044950 90 $643.00 $963.00 $1,032.00 $1,130.00 $963.00 $1,032.00 $1,130.0044955 ZZZ $136.00 $127.00 $135.00 $149.00 $127.00 $135.00 $149.0044960 90 $790.00 $1,310.00 $1,405.00 $1,540.00 $1,310.00 $1,405.00 $1,540.0044970 90 $631.00 $897.00 $962.00 $1,050.00 $897.00 $962.00 $1,050.0044979 YYY BR -------- -------- -------- -------- -------- --------45000 90 $329.00 $622.00 $662.00 $709.00 $622.00 $662.00 $709.0045005 10 $197.00 $390.00 $417.00 $435.00 $236.00 $253.00 $270.0045020 90 $364.00 $844.00 $902.00 $973.00 $844.00 $902.00 $973.0045100 90 $321.00 $438.00 $467.00 $498.00 $438.00 $467.00 $498.0045108 90 $419.00 $541.00 $580.00 $628.00 $541.00 $580.00 $628.0045110 90 $1,801.00 $2,747.00 $2,928.00 $3,169.00 $2,747.00 $2,928.00 $3,169.0045111 90 $1,270.00 $1,617.00 $1,726.00 $1,873.00 $1,617.00 $1,726.00 $1,873.0045112 90 $1,904.00 $2,797.00 $2,974.00 $3,217.00 $2,797.00 $2,974.00 $3,217.0045113 90 $1,885.00 $2,794.00 $2,951.00 $3,146.00 $2,794.00 $2,951.00 $3,146.0045114 90 $1,732.00 $2,731.00 $2,931.00 $3,221.00 $2,731.00 $2,931.00 $3,221.0045116 90 $1,485.00 $2,466.00 $2,642.00 $2,893.00 $2,466.00 $2,642.00 $2,893.0045119 90 $1,911.00 $2,890.00 $3,072.00 $3,311.00 $2,890.00 $3,072.00 $3,311.0045120 90 $1,845.00 $2,216.00 $2,339.00 $2,490.00 $2,216.00 $2,339.00 $2,490.0045121 90 $1,870.00 $2,605.00 $2,793.00 $3,061.00 $2,605.00 $2,793.00 $3,061.0045123 90 $1,126.00 $1,659.00 $1,762.00 $1,896.00 $1,659.00 $1,762.00 $1,896.00



Surgery







45126 90 $2,444.00 $4,154.00 $4,416.00 $4,772.00 $4,154.00 $4,416.00 $4,772.0045130 90 $1,041.00 $1,610.00 $1,709.00 $1,835.00 $1,610.00 $1,709.00 $1,835.0045135 90 $1,354.00 $2,049.00 $2,196.00 $2,402.00 $2,049.00 $2,196.00 $2,402.0045136 90 $1,526.00 $2,666.00 $2,817.00 $2,997.00 $2,666.00 $2,817.00 $2,997.0045150 90 $475.00 $569.00 $602.00 $636.00 $569.00 $602.00 $636.0045160 90 $949.00 $1,527.00 $1,638.00 $1,791.00 $1,527.00 $1,638.00 $1,791.0045171 90 -------- $882.00 $941.00 $1,006.00 $882.00 $941.00 $1,006.0045172 90 -------- $1,190.00 $1,266.00 $1,355.00 $1,190.00 $1,266.00 $1,355.0045190 90 $623.00 $1,019.00 $1,083.00 $1,156.00 $1,019.00 $1,083.00 $1,156.0045300 0 $75.00 $172.00 $184.00 $189.00 $79.00 $84.00 $89.0045303 0 $72.00 $1,321.00 $1,416.00 $1,431.00 $136.00 $145.00 $156.0045305 0 $102.00 $274.00 $293.00 $303.00 $116.00 $124.00 $133.0045307 0 $172.00 $331.00 $355.00 $372.00 $159.00 $171.00 $187.0045308 0 $137.00 $304.00 $326.00 $340.00 $133.00 $142.00 $155.0045309 0 $174.00 $319.00 $342.00 $357.00 $142.00 $152.00 $165.0045315 0 $211.00 $316.00 $335.00 $341.00 $152.00 $159.00 $165.0045317 0 $209.00 $343.00 $366.00 $380.00 $173.00 $184.00 $197.0045320 0 $230.00 $345.00 $370.00 $387.00 $165.00 $177.00 $193.0045321 0 $154.00 $159.00 $170.00 $184.00 $159.00 $170.00 $184.0045327 0 $96.00 $183.00 $196.00 $214.00 $183.00 $196.00 $214.0045330 0 $87.00 $232.00 $248.00 $253.00 $82.00 $87.00 $92.0045331 0 $120.00 $355.00 $379.00 $386.00 $106.00 $112.00 $118.0045332 0 $174.00 $433.00 $462.00 $474.00 $165.00 $174.00 $185.0045333 0 $176.00 $484.00 $517.00 $528.00 $147.00 $156.00 $166.0045334 0 $171.00 $841.00 $899.00 $912.00 $183.00 $193.00 $204.0045335 0 $144.00 $400.00 $427.00 $434.00 $106.00 $112.00 $119.0045337 0 $144.00 $180.00 $190.00 $203.00 $180.00 $190.00 $203.0045338 0 $212.00 $453.00 $483.00 $495.00 $187.00 $197.00 $209.0045340 0 $328.00 $675.00 $722.00 $732.00 $123.00 $130.00 $138.0045341 0 $153.00 $192.00 $202.00 $214.00 $192.00 $202.00 $214.0045342 0 $224.00 $260.00 $274.00 $290.00 $260.00 $274.00 $290.0045346 0 -------- $4,269.00 $4,576.00 $4,604.00 $247.00 $260.00 $276.0045347 0 -------- $238.00 $251.00 $266.00 $238.00 $251.00 $266.0045349 0 -------- $304.00 $321.00 $342.00 $304.00 $321.00 $342.0045350 0 -------- $805.00 $861.00 $874.00 $157.00 $166.00 $177.0045379 0 $415.00 $673.00 $715.00 $740.00 $365.00 $385.00 $409.0045380 0 $369.00 $657.00 $699.00 $719.00 $307.00 $324.00 $343.0045381 0 $388.00 $632.00 $672.00 $692.00 $307.00 $323.00 $342.0045382 0 $481.00 $1,104.00 $1,177.00 $1,203.00 $395.00 $416.00 $440.0045384 0 $415.00 $723.00 $770.00 $796.00 $350.00 $370.00 $394.0045385 0 $479.00 $692.00 $735.00 $761.00 $388.00 $409.00 $434.0045386 0 $739.00 $913.00 $973.00 $997.00 $325.00 $342.00 $364.0045388 0 -------- $4,495.00 $4,815.00 $4,856.00 $413.00 $436.00 $464.0045389 0 -------- $442.00 $466.00 $495.00 $442.00 $466.00 $495.0045390 0 -------- $505.00 $533.00 $569.00 $505.00 $533.00 $569.0045391 0 -------- $392.00 $413.00 $437.00 $392.00 $413.00 $437.0045392 0 -------- $462.00 $487.00 $516.00 $462.00 $487.00 $516.0045393 0 -------- $387.00 $408.00 $435.00 $387.00 $408.00 $435.0045395 90 -------- $2,935.00 $3,122.00 $3,364.00 $2,935.00 $3,122.00 $3,364.0045397 90 -------- $3,192.00 $3,389.00 $3,641.00 $3,192.00 $3,389.00 $3,641.00



Surgery







45398 0 -------- $1,021.00 $1,090.00 $1,118.00 $360.00 $381.00 $407.0045400 90 -------- $1,688.00 $1,792.00 $1,927.00 $1,688.00 $1,792.00 $1,927.0045402 90 -------- $2,257.00 $2,398.00 $2,587.00 $2,257.00 $2,398.00 $2,587.0045500 90 $584.00 $759.00 $803.00 $848.00 $759.00 $803.00 $848.0045505 90 $510.00 $870.00 $927.00 $991.00 $870.00 $927.00 $991.0045520 0 $46.00 $217.00 $232.00 $236.00 $58.00 $61.00 $64.0045540 90 $1,009.00 $1,570.00 $1,669.00 $1,798.00 $1,570.00 $1,669.00 $1,798.0045541 90 $888.00 $1,398.00 $1,493.00 $1,613.00 $1,398.00 $1,493.00 $1,613.0045550 90 $1,350.00 $2,164.00 $2,300.00 $2,477.00 $2,164.00 $2,300.00 $2,477.0045560 90 $618.00 $1,003.00 $1,057.00 $1,116.00 $1,003.00 $1,057.00 $1,116.0045562 90 $915.00 $1,663.00 $1,776.00 $1,923.00 $1,663.00 $1,776.00 $1,923.0045563 90 $1,412.00 $2,467.00 $2,648.00 $2,897.00 $2,467.00 $2,648.00 $2,897.0045800 90 $1,050.00 $1,782.00 $1,895.00 $2,041.00 $1,782.00 $1,895.00 $2,041.0045805 90 $1,273.00 $2,190.00 $2,351.00 $2,573.00 $2,190.00 $2,351.00 $2,573.0045820 90 $1,066.00 $1,751.00 $1,849.00 $1,965.00 $1,751.00 $1,849.00 $1,965.0045825 90 $1,241.00 $2,033.00 $2,143.00 $2,273.00 $2,033.00 $2,143.00 $2,273.0045900 10 $120.00 $298.00 $318.00 $342.00 $298.00 $318.00 $342.0045905 10 $133.00 $248.00 $264.00 $282.00 $248.00 $264.00 $282.0045910 10 $163.00 $285.00 $303.00 $322.00 $285.00 $303.00 $322.0045915 10 $142.00 $471.00 $502.00 $522.00 $330.00 $350.00 $369.0045990 0 -------- $159.00 $170.00 $183.00 $159.00 $170.00 $183.0045999 YYY BR -------- -------- -------- -------- -------- --------46020 10 $230.00 $397.00 $424.00 $447.00 $342.00 $364.00 $387.0046030 10 $94.00 $198.00 $211.00 $221.00 $132.00 $140.00 $149.0046040 90 $393.00 $769.00 $822.00 $867.00 $606.00 $648.00 $692.0046045 90 $312.00 $636.00 $680.00 $729.00 $636.00 $680.00 $729.0046050 10 $105.00 $283.00 $302.00 $312.00 $141.00 $151.00 $160.0046060 90 $482.00 $696.00 $743.00 $792.00 $696.00 $743.00 $792.0046080 10 $246.00 $355.00 $380.00 $401.00 $236.00 $252.00 $272.0046083 10 $98.00 $249.00 $265.00 $275.00 $154.00 $164.00 $174.0046200 90 $323.00 $631.00 $674.00 $701.00 $470.00 $501.00 $528.0046220 10 $118.00 $292.00 $312.00 $324.00 $173.00 $185.00 $197.0046221 10 $124.00 $379.00 $404.00 $419.00 $275.00 $292.00 $306.0046230 10 $198.00 $389.00 $415.00 $435.00 $253.00 $269.00 $288.0046250 90 $400.00 $663.00 $709.00 $744.00 $462.00 $494.00 $528.0046255 90 $501.00 $726.00 $776.00 $816.00 $519.00 $554.00 $594.0046257 90 $504.00 $617.00 $658.00 $703.00 $617.00 $658.00 $703.0046258 90 $539.00 $689.00 $739.00 $801.00 $689.00 $739.00 $801.0046260 90 $598.00 $698.00 $745.00 $799.00 $698.00 $745.00 $799.0046261 90 $655.00 $766.00 $815.00 $872.00 $766.00 $815.00 $872.0046262 90 $686.00 $807.00 $859.00 $917.00 $807.00 $859.00 $917.0046270 90 $328.00 $728.00 $779.00 $820.00 $572.00 $611.00 $652.0046275 90 $442.00 $769.00 $820.00 $860.00 $602.00 $641.00 $681.0046280 90 $514.00 $684.00 $728.00 $774.00 $684.00 $728.00 $774.0046285 90 $335.00 $761.00 $812.00 $851.00 $599.00 $638.00 $677.0046288 90 $521.00 $804.00 $856.00 $913.00 $804.00 $856.00 $913.0046320 10 $126.00 $261.00 $278.00 $291.00 $162.00 $173.00 $184.0046500 10 $109.00 $274.00 $292.00 $302.00 $177.00 $189.00 $198.0046505 10 -------- $410.00 $437.00 $460.00 $348.00 $370.00 $393.0046600 0 $38.00 $124.00 $132.00 $136.00 $59.00 $63.00 $67.00



Surgery







46601 0 -------- $193.00 $203.00 $208.00 $135.00 $141.00 $146.0046604 0 $92.00 $851.00 $912.00 $921.00 $97.00 $103.00 $110.0046606 0 $66.00 $315.00 $337.00 $346.00 $112.00 $119.00 $127.0046607 0 -------- $271.00 $286.00 $294.00 $183.00 $192.00 $200.0046608 0 $115.00 $325.00 $348.00 $358.00 $120.00 $127.00 $137.0046610 0 $114.00 $317.00 $339.00 $350.00 $120.00 $128.00 $138.0046611 0 $149.00 $248.00 $264.00 $273.00 $120.00 $127.00 $136.0046612 0 $196.00 $362.00 $388.00 $401.00 $139.00 $148.00 $161.0046614 0 $169.00 $181.00 $193.00 $200.00 $95.00 $101.00 $107.0046615 0 $202.00 $206.00 $220.00 $231.00 $137.00 $146.00 $157.0046700 90 $585.00 $958.00 $1,018.00 $1,085.00 $958.00 $1,018.00 $1,085.0046706 10 $140.00 $241.00 $255.00 $269.00 $241.00 $255.00 $269.0046707 90 -------- $698.00 $745.00 $798.00 $698.00 $745.00 $798.0046710 90 -------- $1,544.00 $1,635.00 $1,740.00 $1,544.00 $1,635.00 $1,740.0046712 90 -------- $3,156.00 $3,346.00 $3,585.00 $3,156.00 $3,346.00 $3,585.0046715 90 $545.00 $802.00 $861.00 $934.00 $802.00 $861.00 $934.0046716 90 $906.00 $1,617.00 $1,708.00 $1,803.00 $1,617.00 $1,708.00 $1,803.0046730 90 $1,584.00 $2,669.00 $2,815.00 $2,981.00 $2,669.00 $2,815.00 $2,981.0046735 90 $1,881.00 $3,094.00 $3,263.00 $3,458.00 $3,094.00 $3,263.00 $3,458.0046740 90 $1,671.00 $3,209.00 $3,445.00 $3,769.00 $3,209.00 $3,445.00 $3,769.0046742 90 $2,236.00 $3,611.00 $3,851.00 $4,169.00 $3,611.00 $3,851.00 $4,169.0046744 90 $2,412.00 $5,296.00 $5,686.00 $6,249.00 $5,296.00 $5,686.00 $6,249.0046746 90 $2,725.00 $5,373.00 $5,662.00 $6,015.00 $5,373.00 $5,662.00 $6,015.0046748 90 $2,933.00 $5,837.00 $6,150.00 $6,535.00 $5,837.00 $6,150.00 $6,535.0046750 90 $636.00 $1,103.00 $1,166.00 $1,238.00 $1,103.00 $1,166.00 $1,238.0046753 90 $511.00 $906.00 $973.00 $1,058.00 $906.00 $973.00 $1,058.0046754 10 $188.00 $416.00 $441.00 $458.00 $329.00 $348.00 $364.0046760 90 $846.00 $1,594.00 $1,684.00 $1,781.00 $1,594.00 $1,684.00 $1,781.0046761 90 $813.00 $1,353.00 $1,431.00 $1,521.00 $1,353.00 $1,431.00 $1,521.0046762 90 $731.00 $1,356.00 $1,435.00 $1,524.00 $1,356.00 $1,435.00 $1,524.0046900 10 $128.00 $341.00 $364.00 $375.00 $199.00 $211.00 $222.0046910 10 $144.00 $362.00 $387.00 $401.00 $196.00 $208.00 $222.0046916 10 $145.00 $323.00 $344.00 $354.00 $207.00 $219.00 $229.0046917 10 $228.00 $625.00 $667.00 $679.00 $191.00 $202.00 $212.0046922 10 $189.00 $377.00 $403.00 $418.00 $198.00 $211.00 $226.0046924 10 $297.00 $744.00 $795.00 $814.00 $268.00 $285.00 $303.0046930 90 -------- $289.00 $308.00 $317.00 $210.00 $223.00 $232.0046940 10 $165.00 $325.00 $346.00 $361.00 $215.00 $227.00 $242.0046942 10 $145.00 $306.00 $326.00 $339.00 $192.00 $203.00 $216.0046945 90 $199.00 $436.00 $466.00 $484.00 $324.00 $346.00 $363.0046946 90 $270.00 $445.00 $475.00 $494.00 $325.00 $347.00 $366.0046947 90 -------- $564.00 $603.00 $650.00 $564.00 $603.00 $650.0046999 YYY BR -------- -------- -------- -------- -------- --------47000 0 $218.00 $504.00 $536.00 $544.00 $150.00 $157.00 $164.0047001 ZZZ $141.00 $157.00 $169.00 $186.00 $157.00 $169.00 $186.0047010 90 $788.00 $1,798.00 $1,926.00 $2,100.00 $1,798.00 $1,926.00 $2,100.0047015 90 $755.00 $1,707.00 $1,826.00 $1,986.00 $1,707.00 $1,826.00 $1,986.0047100 90 $550.00 $1,257.00 $1,347.00 $1,467.00 $1,257.00 $1,347.00 $1,467.0047120 90 $1,663.00 $3,496.00 $3,750.00 $4,115.00 $3,496.00 $3,750.00 $4,115.0047122 90 $2,512.00 $5,174.00 $5,552.00 $6,115.00 $5,174.00 $5,552.00 $6,115.00



Surgery







47125 90 $2,293.00 $4,622.00 $4,958.00 $5,452.00 $4,622.00 $4,958.00 $5,452.0047130 90 $2,482.00 $4,966.00 $5,327.00 $5,861.00 $4,966.00 $5,327.00 $5,861.0047135 90 $6,164.00 $8,061.00 $8,647.00 $9,486.00 $8,061.00 $8,647.00 $9,486.0047146 0 -------- $499.00 $536.00 $593.00 $499.00 $536.00 $593.0047147 0 -------- $580.00 $622.00 $687.00 $580.00 $622.00 $687.0047300 90 $778.00 $1,691.00 $1,813.00 $1,980.00 $1,691.00 $1,813.00 $1,980.0047350 90 $942.00 $2,049.00 $2,196.00 $2,401.00 $2,049.00 $2,196.00 $2,401.0047360 90 $1,305.00 $2,787.00 $2,986.00 $3,269.00 $2,787.00 $2,986.00 $3,269.0047361 90 $2,129.00 $4,538.00 $4,859.00 $5,326.00 $4,538.00 $4,859.00 $5,326.0047362 90 $849.00 $2,172.00 $2,331.00 $2,554.00 $2,172.00 $2,331.00 $2,554.0047370 90 $943.00 $1,870.00 $2,006.00 $2,199.00 $1,870.00 $2,006.00 $2,199.0047371 90 $889.00 $1,647.00 $1,719.00 $1,791.00 $1,647.00 $1,719.00 $1,791.0047379 YYY BR -------- -------- -------- -------- -------- --------47380 90 $1,107.00 $2,161.00 $2,314.00 $2,532.00 $2,161.00 $2,314.00 $2,532.0047381 90 $1,094.00 $1,949.00 $2,033.00 $2,118.00 $1,949.00 $2,033.00 $2,118.0047382 10 $660.00 $6,919.00 $7,388.00 $7,459.00 $1,130.00 $1,177.00 $1,231.0047383 10 -------- $10,361.00 $11,103.00 $11,184.00 $725.00 $765.00 $816.0047399 YYY BR -------- -------- -------- -------- -------- --------47400 90 $1,435.00 $3,229.00 $3,462.00 $3,798.00 $3,229.00 $3,462.00 $3,798.0047420 90 $1,222.00 $2,010.00 $2,156.00 $2,361.00 $2,010.00 $2,156.00 $2,361.0047425 90 $1,275.00 $2,028.00 $2,175.00 $2,382.00 $2,028.00 $2,175.00 $2,382.0047460 90 $1,039.00 $1,875.00 $2,010.00 $2,198.00 $1,875.00 $2,010.00 $2,198.0047480 90 $755.00 $1,301.00 $1,395.00 $1,516.00 $1,301.00 $1,395.00 $1,516.0047490 10 $467.00 $479.00 $503.00 $520.00 $479.00 $503.00 $520.0047531 0 -------- $516.00 $550.00 $558.00 $140.00 $147.00 $153.0047532 0 -------- $1,138.00 $1,212.00 $1,232.00 $318.00 $332.00 $350.0047533 0 -------- $1,855.00 $1,979.00 $2,011.00 $452.00 $474.00 $502.0047534 0 -------- $2,288.00 $2,440.00 $2,482.00 $600.00 $628.00 $665.0047535 0 -------- $1,532.00 $1,636.00 $1,663.00 $346.00 $363.00 $386.0047536 0 -------- $1,127.00 $1,202.00 $1,216.00 $216.00 $226.00 $236.0047537 0 -------- $560.00 $598.00 $608.00 $147.00 $155.00 $164.0047538 0 -------- $6,184.00 $6,620.00 $6,661.00 $483.00 $503.00 $526.0047539 0 -------- $6,765.00 $7,237.00 $7,287.00 $653.00 $680.00 $711.0047540 0 -------- $7,038.00 $7,526.00 $7,583.00 $780.00 $812.00 $849.0047541 0 -------- $1,637.00 $1,745.00 $1,772.00 $417.00 $435.00 $458.0047542 ZZZ -------- $723.00 $775.00 $800.00 $202.00 $217.00 $240.0047543 ZZZ -------- $1,833.00 $1,967.00 $2,000.00 $254.00 $272.00 $301.0047544 ZZZ -------- $1,135.00 $1,211.00 $1,235.00 $319.00 $335.00 $357.0047550 ZZZ $209.00 $251.00 $269.00 $297.00 $251.00 $269.00 $297.0047552 0 $364.00 $457.00 $477.00 $499.00 $457.00 $477.00 $499.0047553 0 $342.00 $452.00 $470.00 $492.00 $452.00 $470.00 $492.0047554 0 $594.00 $708.00 $746.00 $797.00 $708.00 $746.00 $797.0047555 0 $383.00 $541.00 $563.00 $589.00 $541.00 $563.00 $589.0047556 0 $425.00 $615.00 $640.00 $670.00 $615.00 $640.00 $670.0047562 90 $837.00 $982.00 $1,053.00 $1,151.00 $982.00 $1,053.00 $1,151.0047563 90 $900.00 $1,068.00 $1,146.00 $1,253.00 $1,068.00 $1,146.00 $1,253.0047564 90 $1,069.00 $1,666.00 $1,787.00 $1,955.00 $1,666.00 $1,787.00 $1,955.0047570 90 $961.00 $1,145.00 $1,228.00 $1,344.00 $1,145.00 $1,228.00 $1,344.0047579 YYY BR -------- -------- -------- -------- -------- --------47600 90 $868.00 $1,598.00 $1,713.00 $1,875.00 $1,598.00 $1,713.00 $1,875.00



Surgery







47605 90 $935.00 $1,683.00 $1,806.00 $1,978.00 $1,683.00 $1,806.00 $1,978.0047610 90 $1,164.00 $1,882.00 $2,018.00 $2,213.00 $1,882.00 $2,018.00 $2,213.0047612 90 $1,276.00 $1,906.00 $2,044.00 $2,242.00 $1,906.00 $2,044.00 $2,242.0047620 90 $1,295.00 $2,066.00 $2,217.00 $2,434.00 $2,066.00 $2,217.00 $2,434.0047700 90 $1,111.00 $1,549.00 $1,659.00 $1,806.00 $1,549.00 $1,659.00 $1,806.0047701 90 $1,913.00 $2,529.00 $2,697.00 $2,926.00 $2,529.00 $2,697.00 $2,926.0047711 90 $1,442.00 $2,331.00 $2,500.00 $2,741.00 $2,331.00 $2,500.00 $2,741.0047712 90 $1,793.00 $2,984.00 $3,199.00 $3,507.00 $2,984.00 $3,199.00 $3,507.0047715 90 $1,157.00 $1,996.00 $2,142.00 $2,348.00 $1,996.00 $2,142.00 $2,348.0047720 90 $1,040.00 $1,720.00 $1,846.00 $2,018.00 $1,720.00 $1,846.00 $2,018.0047721 90 $1,248.00 $2,033.00 $2,182.00 $2,392.00 $2,033.00 $2,182.00 $2,392.0047740 90 $1,188.00 $1,946.00 $2,085.00 $2,277.00 $1,946.00 $2,085.00 $2,277.0047741 90 $1,425.00 $2,201.00 $2,360.00 $2,583.00 $2,201.00 $2,360.00 $2,583.0047760 90 $1,568.00 $3,394.00 $3,642.00 $4,002.00 $3,394.00 $3,642.00 $4,002.0047765 90 $1,624.00 $4,562.00 $4,893.00 $5,379.00 $4,562.00 $4,893.00 $5,379.0047780 90 $1,635.00 $3,715.00 $3,984.00 $4,376.00 $3,715.00 $3,984.00 $4,376.0047785 90 $1,871.00 $4,887.00 $5,243.00 $5,768.00 $4,887.00 $5,243.00 $5,768.0047800 90 $1,485.00 $2,361.00 $2,533.00 $2,777.00 $2,361.00 $2,533.00 $2,777.0047801 90 $906.00 $1,469.00 $1,549.00 $1,643.00 $1,469.00 $1,549.00 $1,643.0047802 90 $1,352.00 $2,258.00 $2,418.00 $2,640.00 $2,258.00 $2,418.00 $2,640.0047900 90 $1,331.00 $2,051.00 $2,200.00 $2,408.00 $2,051.00 $2,200.00 $2,408.0047999 YYY BR -------- -------- -------- -------- -------- --------48000 90 $1,053.00 $2,807.00 $3,008.00 $3,297.00 $2,807.00 $3,008.00 $3,297.0048001 90 $1,305.00 $3,439.00 $3,684.00 $4,044.00 $3,439.00 $3,684.00 $4,044.0048020 90 $983.00 $1,753.00 $1,880.00 $2,057.00 $1,753.00 $1,880.00 $2,057.0048100 90 $779.00 $1,325.00 $1,420.00 $1,551.00 $1,325.00 $1,420.00 $1,551.0048102 10 $341.00 $749.00 $793.00 $811.00 $355.00 $370.00 $387.0048105 90 -------- $4,286.00 $4,595.00 $5,047.00 $4,286.00 $4,595.00 $5,047.0048120 90 $1,083.00 $1,660.00 $1,780.00 $1,949.00 $1,660.00 $1,780.00 $1,949.0048140 90 $1,546.00 $2,346.00 $2,516.00 $2,761.00 $2,346.00 $2,516.00 $2,761.0048145 90 $1,661.00 $2,441.00 $2,619.00 $2,875.00 $2,441.00 $2,619.00 $2,875.0048146 90 $1,830.00 $2,812.00 $3,017.00 $3,303.00 $2,812.00 $3,017.00 $3,303.0048148 90 $1,149.00 $1,865.00 $2,001.00 $2,190.00 $1,865.00 $2,001.00 $2,190.0048150 90 $3,101.00 $4,679.00 $5,021.00 $5,518.00 $4,679.00 $5,021.00 $5,518.0048152 90 $2,888.00 $4,313.00 $4,626.00 $5,079.00 $4,313.00 $4,626.00 $5,079.0048153 90 $3,099.00 $4,653.00 $4,991.00 $5,483.00 $4,653.00 $4,991.00 $5,483.0048154 90 $2,893.00 $4,367.00 $4,689.00 $5,155.00 $4,367.00 $4,689.00 $5,155.0048155 90 $1,855.00 $2,725.00 $2,926.00 $3,207.00 $2,725.00 $2,926.00 $3,207.0048160 0 BR -------- -------- -------- -------- -------- --------48400 ZZZ $100.00 $156.00 $164.00 $173.00 $156.00 $164.00 $173.0048500 90 $1,012.00 $1,674.00 $1,787.00 $1,934.00 $1,674.00 $1,787.00 $1,934.0048510 90 $938.00 $1,625.00 $1,742.00 $1,900.00 $1,625.00 $1,742.00 $1,900.0048520 90 $1,103.00 $1,638.00 $1,757.00 $1,925.00 $1,638.00 $1,757.00 $1,925.0048540 90 $1,350.00 $1,951.00 $2,093.00 $2,297.00 $1,951.00 $2,093.00 $2,297.0048545 90 $1,170.00 $1,998.00 $2,142.00 $2,346.00 $1,998.00 $2,142.00 $2,346.0048547 90 $1,630.00 $2,688.00 $2,883.00 $3,165.00 $2,688.00 $2,883.00 $3,165.0048548 90 -------- $2,497.00 $2,678.00 $2,938.00 $2,497.00 $2,678.00 $2,938.0048552 0 -------- $354.00 $379.00 $417.00 $354.00 $379.00 $417.0048554 90 $2,365.00 $3,797.00 $4,071.00 $4,421.00 $3,797.00 $4,071.00 $4,421.0048556 90 $1,117.00 $1,890.00 $2,027.00 $2,208.00 $1,890.00 $2,027.00 $2,208.00



Surgery







48999 YYY BR -------- -------- -------- -------- -------- --------49000 90 $862.00 $1,151.00 $1,232.00 $1,344.00 $1,151.00 $1,232.00 $1,344.0049002 90 $784.00 $1,567.00 $1,678.00 $1,836.00 $1,567.00 $1,678.00 $1,836.0049010 90 $915.00 $1,397.00 $1,494.00 $1,631.00 $1,397.00 $1,494.00 $1,631.0049020 90 $910.00 $2,382.00 $2,550.00 $2,788.00 $2,382.00 $2,550.00 $2,788.0049040 90 $763.00 $1,494.00 $1,600.00 $1,747.00 $1,494.00 $1,600.00 $1,747.0049060 90 $827.00 $1,645.00 $1,759.00 $1,920.00 $1,645.00 $1,759.00 $1,920.0049062 90 $892.00 $1,097.00 $1,173.00 $1,277.00 $1,097.00 $1,173.00 $1,277.0049082 0 -------- $268.00 $286.00 $292.00 $109.00 $115.00 $121.0049083 0 -------- $410.00 $435.00 $443.00 $159.00 $166.00 $173.0049084 0 -------- $163.00 $174.00 $191.00 $163.00 $174.00 $191.0049180 0 $212.00 $230.00 $243.00 $249.00 $125.00 $131.00 $137.0049185 0 -------- $1,369.00 $1,464.00 $1,477.00 $181.00 $189.00 $198.0049203 90 -------- $1,787.00 $1,910.00 $2,081.00 $1,787.00 $1,910.00 $2,081.0049204 90 -------- $2,289.00 $2,447.00 $2,670.00 $2,289.00 $2,447.00 $2,670.0049205 90 -------- $2,632.00 $2,817.00 $3,080.00 $2,632.00 $2,817.00 $3,080.0049215 90 $1,551.00 $3,315.00 $3,542.00 $3,860.00 $3,315.00 $3,542.00 $3,860.0049220 90 $1,182.00 $1,302.00 $1,367.00 $1,438.00 $1,302.00 $1,367.00 $1,438.0049250 90 $622.00 $872.00 $934.00 $1,015.00 $872.00 $934.00 $1,015.0049255 90 $591.00 $1,176.00 $1,258.00 $1,366.00 $1,176.00 $1,258.00 $1,366.0049320 10 $415.00 $482.00 $514.00 $555.00 $482.00 $514.00 $555.0049321 10 $443.00 $512.00 $548.00 $594.00 $512.00 $548.00 $594.0049322 10 $460.00 $544.00 $579.00 $624.00 $544.00 $579.00 $624.0049323 90 $712.00 $943.00 $1,006.00 $1,087.00 $943.00 $1,006.00 $1,087.0049324 10 -------- $583.00 $624.00 $680.00 $583.00 $624.00 $680.0049325 10 -------- $622.00 $666.00 $727.00 $622.00 $666.00 $727.0049326 ZZZ -------- $287.00 $308.00 $340.00 $287.00 $308.00 $340.0049327 ZZZ -------- $198.00 $213.00 $236.00 $198.00 $213.00 $236.0049329 YYY BR -------- -------- -------- -------- -------- --------49400 0 $127.00 $195.00 $206.00 $214.00 $139.00 $145.00 $154.0049402 90 -------- $1,281.00 $1,372.00 $1,500.00 $1,281.00 $1,372.00 $1,500.0049405 0 -------- $1,214.00 $1,292.00 $1,310.00 $311.00 $323.00 $338.0049406 0 -------- $1,214.00 $1,293.00 $1,310.00 $311.00 $323.00 $338.0049407 0 -------- $1,018.00 $1,083.00 $1,104.00 $335.00 $350.00 $368.0049411 0 -------- $764.00 $811.00 $826.00 $289.00 $302.00 $315.0049412 ZZZ -------- $126.00 $135.00 $149.00 $126.00 $135.00 $149.0049418 0 -------- $1,984.00 $2,120.00 $2,143.00 $321.00 $336.00 $353.0049419 90 $405.00 $659.00 $703.00 $758.00 $659.00 $703.00 $758.0049421 0 $452.00 $348.00 $373.00 $410.00 $348.00 $373.00 $410.0049422 10 $468.00 $569.00 $609.00 $664.00 $569.00 $609.00 $664.0049423 0 $106.00 $758.00 $810.00 $817.00 $106.00 $110.00 $115.0049424 0 $54.00 $203.00 $217.00 $220.00 $56.00 $59.00 $61.0049425 90 $914.00 $1,090.00 $1,162.00 $1,259.00 $1,090.00 $1,162.00 $1,259.0049426 90 $725.00 $914.00 $976.00 $1,064.00 $914.00 $976.00 $1,064.0049427 0 $48.00 $68.00 $72.00 $77.00 $68.00 $72.00 $77.0049428 10 $184.00 $645.00 $693.00 $758.00 $645.00 $693.00 $758.0049429 10 $522.00 $687.00 $737.00 $808.00 $687.00 $737.00 $808.0049435 ZZZ -------- $183.00 $196.00 $217.00 $183.00 $196.00 $217.0049436 10 -------- $277.00 $297.00 $322.00 $277.00 $297.00 $322.0049440 10 -------- $1,441.00 $1,537.00 $1,556.00 $325.00 $339.00 $355.00



Surgery







49441 10 -------- $1,627.00 $1,738.00 $1,765.00 $379.00 $398.00 $422.0049442 10 -------- $1,340.00 $1,429.00 $1,446.00 $324.00 $338.00 $353.0049446 0 -------- $1,383.00 $1,477.00 $1,492.00 $239.00 $249.00 $261.0049450 0 -------- $920.00 $984.00 $992.00 $99.00 $103.00 $108.0049451 0 -------- $1,005.00 $1,075.00 $1,085.00 $134.00 $140.00 $147.0049452 0 -------- $1,244.00 $1,329.00 $1,342.00 $206.00 $214.00 $224.0049460 0 -------- $1,010.00 $1,082.00 $1,089.00 $71.00 $74.00 $78.0049465 0 -------- $225.00 $240.00 $243.00 $45.00 $47.00 $49.0049505 90 $510.00 $775.00 $831.00 $904.00 $775.00 $831.00 $904.0049507 90 $636.00 $872.00 $935.00 $1,019.00 $872.00 $935.00 $1,019.0049520 90 $631.00 $943.00 $1,011.00 $1,104.00 $943.00 $1,011.00 $1,104.0049521 90 $730.00 $1,069.00 $1,147.00 $1,254.00 $1,069.00 $1,147.00 $1,254.0049525 90 $584.00 $853.00 $915.00 $997.00 $853.00 $915.00 $997.0049540 90 $668.00 $1,001.00 $1,072.00 $1,169.00 $1,001.00 $1,072.00 $1,169.0049550 90 $557.00 $857.00 $919.00 $1,002.00 $857.00 $919.00 $1,002.0049553 90 $598.00 $941.00 $1,009.00 $1,101.00 $941.00 $1,009.00 $1,101.0049555 90 $621.00 $891.00 $956.00 $1,044.00 $891.00 $956.00 $1,044.0049557 90 $715.00 $1,081.00 $1,160.00 $1,268.00 $1,081.00 $1,160.00 $1,268.0049560 90 $734.00 $1,101.00 $1,180.00 $1,289.00 $1,101.00 $1,180.00 $1,289.0049561 90 $856.00 $1,392.00 $1,493.00 $1,634.00 $1,392.00 $1,493.00 $1,634.0049565 90 $754.00 $1,146.00 $1,228.00 $1,341.00 $1,146.00 $1,228.00 $1,341.0049566 90 $881.00 $1,405.00 $1,506.00 $1,649.00 $1,405.00 $1,506.00 $1,649.0049568 ZZZ $339.00 $404.00 $433.00 $478.00 $404.00 $433.00 $478.0049570 90 $411.00 $617.00 $661.00 $717.00 $617.00 $661.00 $717.0049572 90 $491.00 $767.00 $823.00 $896.00 $767.00 $823.00 $896.0049585 90 $444.00 $660.00 $707.00 $768.00 $660.00 $707.00 $768.0049587 90 $501.00 $706.00 $757.00 $823.00 $706.00 $757.00 $823.0049590 90 $585.00 $852.00 $914.00 $996.00 $852.00 $914.00 $996.0049600 90 $774.00 $1,042.00 $1,110.00 $1,199.00 $1,042.00 $1,110.00 $1,199.0049605 90 $1,648.00 $7,465.00 $8,014.00 $8,845.00 $7,465.00 $8,014.00 $8,845.0049606 90 $1,416.00 $1,671.00 $1,788.00 $1,953.00 $1,671.00 $1,788.00 $1,953.0049610 90 $784.00 $1,029.00 $1,105.00 $1,209.00 $1,029.00 $1,105.00 $1,209.0049611 90 $770.00 $904.00 $970.00 $1,060.00 $904.00 $970.00 $1,060.0049650 90 $484.00 $636.00 $682.00 $741.00 $636.00 $682.00 $741.0049651 90 $621.00 $827.00 $887.00 $964.00 $827.00 $887.00 $964.0049652 90 -------- $1,111.00 $1,192.00 $1,302.00 $1,111.00 $1,192.00 $1,302.0049653 90 -------- $1,387.00 $1,487.00 $1,625.00 $1,387.00 $1,487.00 $1,625.0049654 90 -------- $1,264.00 $1,356.00 $1,483.00 $1,264.00 $1,356.00 $1,483.0049655 90 -------- $1,544.00 $1,656.00 $1,812.00 $1,544.00 $1,656.00 $1,812.0049656 90 -------- $1,375.00 $1,474.00 $1,613.00 $1,375.00 $1,474.00 $1,613.0049657 90 -------- $1,978.00 $2,121.00 $2,324.00 $1,978.00 $2,121.00 $2,324.0049659 YYY BR -------- -------- -------- -------- -------- --------49900 90 $512.00 $1,209.00 $1,295.00 $1,405.00 $1,209.00 $1,295.00 $1,405.0049904 90 $1,394.00 $2,114.00 $2,258.00 $2,443.00 $2,114.00 $2,258.00 $2,443.0049905 ZZZ $454.00 $532.00 $568.00 $622.00 $532.00 $568.00 $622.0049906 90 BR -------- -------- -------- -------- -------- --------49999 YYY BR -------- -------- -------- -------- -------- --------50010 90 $886.00 $1,086.00 $1,152.00 $1,235.00 $1,086.00 $1,152.00 $1,235.0050020 90 $1,084.00 $1,481.00 $1,555.00 $1,638.00 $1,481.00 $1,555.00 $1,638.0050040 90 $910.00 $1,348.00 $1,413.00 $1,487.00 $1,348.00 $1,413.00 $1,487.00



Surgery







50045 90 $1,137.00 $1,408.00 $1,486.00 $1,579.00 $1,408.00 $1,486.00 $1,579.0050060 90 $1,394.00 $1,666.00 $1,748.00 $1,843.00 $1,666.00 $1,748.00 $1,843.0050065 90 $1,514.00 $1,761.00 $1,846.00 $1,944.00 $1,761.00 $1,846.00 $1,944.0050070 90 $1,476.00 $1,727.00 $1,810.00 $1,906.00 $1,727.00 $1,810.00 $1,906.0050075 90 $1,839.00 $2,124.00 $2,226.00 $2,345.00 $2,124.00 $2,226.00 $2,345.0050080 90 $1,186.00 $1,266.00 $1,328.00 $1,397.00 $1,266.00 $1,328.00 $1,397.0050081 90 $1,635.00 $1,860.00 $1,949.00 $2,053.00 $1,860.00 $1,949.00 $2,053.0050100 90 $1,250.00 $1,554.00 $1,646.00 $1,757.00 $1,554.00 $1,646.00 $1,757.0050120 90 $1,180.00 $1,382.00 $1,449.00 $1,525.00 $1,382.00 $1,449.00 $1,525.0050125 90 $1,228.00 $1,507.00 $1,589.00 $1,685.00 $1,507.00 $1,589.00 $1,685.0050130 90 $1,301.00 $1,503.00 $1,576.00 $1,658.00 $1,503.00 $1,576.00 $1,658.0050135 90 $1,506.00 $1,664.00 $1,750.00 $1,854.00 $1,664.00 $1,750.00 $1,854.0050200 0 $151.00 $852.00 $908.00 $920.00 $208.00 $217.00 $227.0050205 90 $807.00 $1,122.00 $1,200.00 $1,307.00 $1,122.00 $1,200.00 $1,307.0050220 90 $1,316.00 $1,533.00 $1,616.00 $1,718.00 $1,533.00 $1,616.00 $1,718.0050225 90 $1,554.00 $1,760.00 $1,851.00 $1,961.00 $1,760.00 $1,851.00 $1,961.0050230 90 $1,695.00 $1,872.00 $1,964.00 $2,075.00 $1,872.00 $1,964.00 $2,075.0050234 90 $1,671.00 $1,898.00 $1,991.00 $2,101.00 $1,898.00 $1,991.00 $2,101.0050236 90 $1,873.00 $2,140.00 $2,244.00 $2,366.00 $2,140.00 $2,244.00 $2,366.0050240 90 $1,679.00 $1,930.00 $2,024.00 $2,134.00 $1,930.00 $2,024.00 $2,134.0050250 90 -------- $1,772.00 $1,857.00 $1,954.00 $1,772.00 $1,857.00 $1,954.0050280 90 $1,170.00 $1,391.00 $1,462.00 $1,543.00 $1,391.00 $1,462.00 $1,543.0050290 90 $1,080.00 $1,307.00 $1,371.00 $1,442.00 $1,307.00 $1,371.00 $1,442.0050320 90 $1,680.00 $2,149.00 $2,298.00 $2,489.00 $2,149.00 $2,298.00 $2,489.0050327 0 -------- $327.00 $350.00 $385.00 $327.00 $350.00 $385.0050328 0 -------- $287.00 $307.00 $338.00 $287.00 $307.00 $338.0050329 0 -------- $267.00 $285.00 $311.00 $267.00 $285.00 $311.0050340 90 $1,083.00 $1,389.00 $1,488.00 $1,615.00 $1,389.00 $1,488.00 $1,615.0050360 90 $2,475.00 $3,617.00 $3,875.00 $4,235.00 $3,617.00 $3,875.00 $4,235.0050365 90 $2,941.00 $4,216.00 $4,509.00 $4,905.00 $4,216.00 $4,509.00 $4,905.0050370 90 $1,128.00 $1,784.00 $1,909.00 $2,076.00 $1,784.00 $1,909.00 $2,076.0050380 90 $1,507.00 $2,958.00 $3,175.00 $3,463.00 $2,958.00 $3,175.00 $3,463.0050382 0 -------- $1,647.00 $1,755.00 $1,778.00 $397.00 $414.00 $433.0050384 0 -------- $1,316.00 $1,401.00 $1,422.00 $361.00 $376.00 $394.0050385 0 -------- $1,581.00 $1,687.00 $1,709.00 $340.00 $355.00 $373.0050386 0 -------- $1,033.00 $1,101.00 $1,118.00 $258.00 $271.00 $285.0050387 0 -------- $753.00 $804.00 $812.00 $143.00 $148.00 $155.0050389 0 -------- $411.00 $438.00 $443.00 $80.00 $83.00 $87.0050390 0 $118.00 $142.00 $147.00 $154.00 $142.00 $147.00 $154.0050391 0 -------- $175.00 $184.00 $192.00 $143.00 $150.00 $157.0050395 0 $203.00 $261.00 $273.00 $285.00 $261.00 $273.00 $285.0050396 0 $101.00 $171.00 $179.00 $186.00 $171.00 $179.00 $186.0050400 90 $1,441.00 $1,690.00 $1,773.00 $1,871.00 $1,690.00 $1,773.00 $1,871.0050405 90 $1,802.00 $2,037.00 $2,136.00 $2,251.00 $2,037.00 $2,136.00 $2,251.0050430 0 -------- $724.00 $770.00 $783.00 $244.00 $255.00 $266.0050431 0 -------- $226.00 $240.00 $244.00 $96.00 $101.00 $105.0050432 0 -------- $1,171.00 $1,247.00 $1,264.00 $323.00 $337.00 $351.0050433 0 -------- $1,575.00 $1,678.00 $1,700.00 $399.00 $416.00 $434.0050434 0 -------- $1,246.00 $1,328.00 $1,345.00 $306.00 $319.00 $333.0050435 0 -------- $653.00 $696.00 $704.00 $148.00 $155.00 $161.00



Surgery







50500 90 $1,471.00 $1,905.00 $2,041.00 $2,233.00 $1,905.00 $2,041.00 $2,233.0050520 90 $1,281.00 $1,676.00 $1,789.00 $1,942.00 $1,676.00 $1,789.00 $1,942.0050525 90 $1,644.00 $2,113.00 $2,247.00 $2,427.00 $2,113.00 $2,247.00 $2,427.0050526 90 $1,639.00 $2,174.00 $2,291.00 $2,432.00 $2,174.00 $2,291.00 $2,432.0050540 90 $1,468.00 $1,686.00 $1,774.00 $1,884.00 $1,686.00 $1,774.00 $1,884.0050541 90 $1,037.00 $1,340.00 $1,406.00 $1,481.00 $1,340.00 $1,406.00 $1,481.0050542 90 $1,093.00 $1,700.00 $1,783.00 $1,878.00 $1,700.00 $1,783.00 $1,878.0050543 90 $1,374.00 $2,167.00 $2,272.00 $2,392.00 $2,167.00 $2,272.00 $2,392.0050544 90 $1,428.00 $1,816.00 $1,902.00 $2,004.00 $1,816.00 $1,902.00 $2,004.0050545 90 $1,273.00 $1,955.00 $2,050.00 $2,162.00 $1,955.00 $2,050.00 $2,162.0050546 90 $1,325.00 $1,757.00 $1,845.00 $1,950.00 $1,757.00 $1,845.00 $1,950.0050547 90 $1,702.00 $2,392.00 $2,554.00 $2,771.00 $2,392.00 $2,554.00 $2,771.0050548 90 $1,555.00 $1,967.00 $2,062.00 $2,175.00 $1,967.00 $2,062.00 $2,175.0050549 YYY BR -------- -------- -------- -------- -------- --------50551 0 $411.00 $518.00 $545.00 $569.00 $431.00 $451.00 $476.0050553 0 $447.00 $550.00 $578.00 $603.00 $455.00 $476.00 $501.0050555 0 $668.00 $592.00 $622.00 $651.00 $497.00 $521.00 $549.0050557 0 $676.00 $604.00 $636.00 $665.00 $507.00 $531.00 $560.0050561 0 $755.00 $686.00 $722.00 $755.00 $578.00 $606.00 $639.0050562 90 $580.00 $848.00 $889.00 $937.00 $848.00 $889.00 $937.0050570 0 $549.00 $720.00 $754.00 $795.00 $720.00 $754.00 $795.0050572 0 $728.00 $779.00 $815.00 $861.00 $779.00 $815.00 $861.0050574 0 $762.00 $828.00 $867.00 $915.00 $828.00 $867.00 $915.0050575 0 $991.00 $1,046.00 $1,095.00 $1,156.00 $1,046.00 $1,095.00 $1,156.0050576 0 $801.00 $828.00 $867.00 $917.00 $828.00 $867.00 $917.0050580 0 $726.00 $892.00 $934.00 $987.00 $892.00 $934.00 $987.0050590 90 $980.00 $1,027.00 $1,083.00 $1,126.00 $824.00 $865.00 $908.0050592 10 -------- $3,505.00 $3,745.00 $3,779.00 $528.00 $551.00 $575.0050593 10 -------- $6,378.00 $6,822.00 $6,872.00 $700.00 $731.00 $763.0050600 90 $1,150.00 $1,378.00 $1,448.00 $1,531.00 $1,378.00 $1,448.00 $1,531.0050605 90 $1,054.00 $1,457.00 $1,550.00 $1,675.00 $1,457.00 $1,550.00 $1,675.0050606 ZZZ -------- $735.00 $783.00 $798.00 $232.00 $243.00 $256.0050610 90 $1,209.00 $1,428.00 $1,503.00 $1,593.00 $1,428.00 $1,503.00 $1,593.0050620 90 $1,152.00 $1,322.00 $1,388.00 $1,463.00 $1,322.00 $1,388.00 $1,463.0050630 90 $1,170.00 $1,298.00 $1,362.00 $1,434.00 $1,298.00 $1,362.00 $1,434.0050650 90 $1,297.00 $1,509.00 $1,584.00 $1,669.00 $1,509.00 $1,584.00 $1,669.0050660 90 $1,426.00 $1,677.00 $1,761.00 $1,859.00 $1,677.00 $1,761.00 $1,859.0050684 0 $74.00 $148.00 $158.00 $161.00 $73.00 $76.00 $80.0050686 0 $109.00 $202.00 $214.00 $221.00 $128.00 $135.00 $141.0050688 10 $89.00 $115.00 $121.00 $125.00 $115.00 $121.00 $125.0050690 0 $85.00 $140.00 $147.00 $152.00 $102.00 $107.00 $111.0050693 0 -------- $1,463.00 $1,560.00 $1,579.00 $320.00 $333.00 $348.0050694 0 -------- $1,615.00 $1,720.00 $1,743.00 $413.00 $431.00 $450.0050695 0 -------- $1,970.00 $2,098.00 $2,127.00 $525.00 $547.00 $571.0050700 90 $1,192.00 $1,358.00 $1,426.00 $1,504.00 $1,358.00 $1,426.00 $1,504.0050705 ZZZ -------- $2,348.00 $2,512.00 $2,537.00 $297.00 $312.00 $330.0050706 ZZZ -------- $1,060.00 $1,129.00 $1,146.00 $275.00 $287.00 $301.0050715 90 $1,397.00 $1,802.00 $1,916.00 $2,068.00 $1,802.00 $1,916.00 $2,068.0050722 90 $1,211.00 $1,487.00 $1,562.00 $1,646.00 $1,487.00 $1,562.00 $1,646.0050725 90 $1,371.00 $1,652.00 $1,740.00 $1,849.00 $1,652.00 $1,740.00 $1,849.00



Surgery







50727 90 $640.00 $736.00 $774.00 $815.00 $736.00 $774.00 $815.0050728 90 $924.00 $1,018.00 $1,069.00 $1,123.00 $1,018.00 $1,069.00 $1,123.0050740 90 $1,386.00 $1,834.00 $1,969.00 $2,161.00 $1,834.00 $1,969.00 $2,161.0050750 90 $1,457.00 $1,680.00 $1,761.00 $1,854.00 $1,680.00 $1,761.00 $1,854.0050760 90 $1,389.00 $1,659.00 $1,752.00 $1,869.00 $1,659.00 $1,752.00 $1,869.0050770 90 $1,485.00 $1,680.00 $1,763.00 $1,860.00 $1,680.00 $1,763.00 $1,860.0050780 90 $1,391.00 $1,621.00 $1,707.00 $1,810.00 $1,621.00 $1,707.00 $1,810.0050782 90 $1,465.00 $1,572.00 $1,678.00 $1,840.00 $1,572.00 $1,678.00 $1,840.0050783 90 $1,515.00 $1,653.00 $1,735.00 $1,833.00 $1,653.00 $1,735.00 $1,833.0050785 90 $1,548.00 $1,771.00 $1,859.00 $1,963.00 $1,771.00 $1,859.00 $1,963.0050800 90 $1,226.00 $1,346.00 $1,414.00 $1,491.00 $1,346.00 $1,414.00 $1,491.0050810 90 $1,527.00 $1,842.00 $1,938.00 $2,051.00 $1,842.00 $1,938.00 $2,051.0050815 90 $1,643.00 $1,784.00 $1,872.00 $1,972.00 $1,784.00 $1,872.00 $1,972.0050820 90 $1,729.00 $1,920.00 $2,016.00 $2,130.00 $1,920.00 $2,016.00 $2,130.0050825 90 $2,351.00 $2,420.00 $2,539.00 $2,682.00 $2,420.00 $2,539.00 $2,682.0050830 90 $2,292.00 $2,646.00 $2,776.00 $2,932.00 $2,646.00 $2,776.00 $2,932.0050840 90 $1,493.00 $1,795.00 $1,883.00 $1,984.00 $1,795.00 $1,883.00 $1,984.0050845 90 $1,513.00 $1,820.00 $1,909.00 $2,009.00 $1,820.00 $1,909.00 $2,009.0050860 90 $1,163.00 $1,376.00 $1,442.00 $1,517.00 $1,376.00 $1,442.00 $1,517.0050900 90 $1,043.00 $1,259.00 $1,328.00 $1,411.00 $1,259.00 $1,328.00 $1,411.0050920 90 $1,075.00 $1,283.00 $1,344.00 $1,410.00 $1,283.00 $1,344.00 $1,410.0050930 90 $1,380.00 $1,746.00 $1,862.00 $2,021.00 $1,746.00 $1,862.00 $2,021.0050940 90 $1,107.00 $1,289.00 $1,351.00 $1,418.00 $1,289.00 $1,351.00 $1,418.0050945 90 $1,096.00 $1,417.00 $1,484.00 $1,562.00 $1,417.00 $1,484.00 $1,562.0050947 90 $1,384.00 $2,029.00 $2,128.00 $2,246.00 $2,029.00 $2,128.00 $2,246.0050948 90 $1,265.00 $1,863.00 $1,953.00 $2,059.00 $1,863.00 $1,953.00 $2,059.0050949 YYY BR -------- -------- -------- -------- -------- --------50951 0 $414.00 $541.00 $569.00 $594.00 $449.00 $470.00 $496.0050953 0 $461.00 $571.00 $600.00 $627.00 $475.00 $498.00 $525.0050955 0 $546.00 $612.00 $644.00 $674.00 $516.00 $540.00 $570.0050957 0 $546.00 $618.00 $650.00 $679.00 $519.00 $543.00 $573.0050961 0 $510.00 $557.00 $585.00 $612.00 $464.00 $486.00 $513.0050970 0 $510.00 $545.00 $570.00 $602.00 $545.00 $570.00 $602.0050972 0 $408.00 $531.00 $558.00 $592.00 $531.00 $558.00 $592.0050974 0 $661.00 $693.00 $725.00 $766.00 $693.00 $725.00 $766.0050976 0 $641.00 $681.00 $713.00 $752.00 $681.00 $713.00 $752.0050980 0 $443.00 $518.00 $543.00 $572.00 $518.00 $543.00 $572.0051020 90 $587.00 $680.00 $714.00 $749.00 $680.00 $714.00 $749.0051030 90 $538.00 $688.00 $722.00 $755.00 $688.00 $722.00 $755.0051040 90 $439.00 $417.00 $439.00 $460.00 $417.00 $439.00 $460.0051045 90 $548.00 $716.00 $757.00 $804.00 $716.00 $757.00 $804.0051050 90 $596.00 $684.00 $719.00 $754.00 $684.00 $719.00 $754.0051060 90 $768.00 $846.00 $888.00 $931.00 $846.00 $888.00 $931.0051065 90 $704.00 $839.00 $881.00 $925.00 $839.00 $881.00 $925.0051080 90 $510.00 $594.00 $624.00 $655.00 $594.00 $624.00 $655.0051100 0 -------- $87.00 $92.00 $95.00 $58.00 $60.00 $64.0051101 0 -------- $174.00 $185.00 $190.00 $76.00 $80.00 $85.0051102 0 -------- $321.00 $339.00 $351.00 $211.00 $221.00 $233.0051500 90 $775.00 $928.00 $975.00 $1,026.00 $928.00 $975.00 $1,026.0051520 90 $764.00 $870.00 $915.00 $964.00 $870.00 $915.00 $964.00



Surgery







51525 90 $1,069.00 $1,251.00 $1,313.00 $1,383.00 $1,251.00 $1,313.00 $1,383.0051530 90 $957.00 $1,165.00 $1,230.00 $1,308.00 $1,165.00 $1,230.00 $1,308.0051535 90 $932.00 $1,133.00 $1,189.00 $1,250.00 $1,133.00 $1,189.00 $1,250.0051550 90 $1,171.00 $1,409.00 $1,484.00 $1,572.00 $1,409.00 $1,484.00 $1,572.0051555 90 $1,514.00 $1,853.00 $1,948.00 $2,061.00 $1,853.00 $1,948.00 $2,061.0051565 90 $1,624.00 $1,899.00 $1,995.00 $2,109.00 $1,899.00 $1,995.00 $2,109.0051570 90 $1,762.00 $2,158.00 $2,264.00 $2,391.00 $2,158.00 $2,264.00 $2,391.0051575 90 $2,284.00 $2,661.00 $2,789.00 $2,941.00 $2,661.00 $2,789.00 $2,941.0051580 90 $2,252.00 $2,764.00 $2,896.00 $3,052.00 $2,764.00 $2,896.00 $3,052.0051585 90 $2,601.00 $3,077.00 $3,225.00 $3,401.00 $3,077.00 $3,225.00 $3,401.0051590 90 $2,441.00 $2,826.00 $2,963.00 $3,128.00 $2,826.00 $2,963.00 $3,128.0051595 90 $2,900.00 $3,195.00 $3,348.00 $3,531.00 $3,195.00 $3,348.00 $3,531.0051596 90 $3,063.00 $3,433.00 $3,597.00 $3,793.00 $3,433.00 $3,597.00 $3,793.0051597 90 $2,914.00 $3,359.00 $3,525.00 $3,727.00 $3,359.00 $3,525.00 $3,727.0051600 0 $54.00 $254.00 $271.00 $275.00 $65.00 $68.00 $71.0051605 0 $83.00 $55.00 $58.00 $61.00 $55.00 $58.00 $61.0051610 0 $45.00 $150.00 $158.00 $162.00 $93.00 $97.00 $101.0051700 0 $29.00 $117.00 $124.00 $128.00 $66.00 $69.00 $73.0051701 0 $58.00 $77.00 $81.00 $84.00 $41.00 $43.00 $45.0051702 0 $92.00 $98.00 $104.00 $107.00 $44.00 $46.00 $49.0051703 0 $128.00 $183.00 $193.00 $200.00 $118.00 $124.00 $130.0051705 0 $37.00 $128.00 $135.00 $139.00 $75.00 $79.00 $83.0051710 0 $119.00 $181.00 $192.00 $198.00 $116.00 $122.00 $128.0051715 0 $322.00 $413.00 $436.00 $453.00 $292.00 $306.00 $322.0051720 0 $140.00 $155.00 $163.00 $170.00 $117.00 $122.00 $128.0051725 0 $116.00 $261.00 $276.00 $282.00 $261.00 $276.00 $282.0051725-26 0 -------- $111.00 $115.00 $120.00 $111.00 $115.00 $120.0051725-TC 0 -------- $150.00 $161.00 $162.00 $150.00 $161.00 $162.0051726 0 $136.00 $364.00 $387.00 $394.00 $364.00 $387.00 $394.0051726-26 0 -------- $124.00 $129.00 $134.00 $124.00 $129.00 $134.0051726-TC 0 -------- $240.00 $258.00 $260.00 $240.00 $258.00 $260.0051727 0 -------- $432.00 $459.00 $467.00 $432.00 $459.00 $467.0051727-26 0 -------- $155.00 $162.00 $169.00 $155.00 $162.00 $169.0051727-TC 0 -------- $277.00 $297.00 $299.00 $277.00 $297.00 $299.0051728 0 -------- $435.00 $462.00 $471.00 $435.00 $462.00 $471.0051728-26 0 -------- $152.00 $158.00 $164.00 $152.00 $158.00 $164.0051728-TC 0 -------- $284.00 $305.00 $306.00 $284.00 $305.00 $306.0051729 0 -------- $472.00 $500.00 $510.00 $472.00 $500.00 $510.0051729-26 0 -------- $183.00 $191.00 $199.00 $183.00 $191.00 $199.0051729-TC 0 -------- $288.00 $309.00 $311.00 $288.00 $309.00 $311.0051736 0 $47.00 $22.00 $23.00 $24.00 $22.00 $23.00 $24.0051736-26 0 -------- $12.00 $12.00 $13.00 $12.00 $12.00 $13.0051736-TC 0 -------- $10.00 $11.00 $11.00 $10.00 $11.00 $11.0051741 0 $81.00 $22.00 $24.00 $24.00 $22.00 $24.00 $24.0051741-26 0 -------- $12.00 $12.00 $13.00 $12.00 $12.00 $13.0051741-TC 0 -------- $10.00 $11.00 $12.00 $10.00 $11.00 $12.0051784 0 $119.00 $268.00 $284.00 $290.00 $268.00 $284.00 $290.0051784-26 0 -------- $111.00 $116.00 $121.00 $111.00 $116.00 $121.0051784-TC 0 -------- $156.00 $168.00 $169.00 $156.00 $168.00 $169.0051785 0 $52.00 $370.00 $397.00 $413.00 $370.00 $397.00 $413.00



Surgery







51785-26 0 -------- $131.00 $141.00 $155.00 $131.00 $141.00 $155.0051785-TC 0 -------- $239.00 $256.00 $258.00 $239.00 $256.00 $258.0051792 0 $143.00 $292.00 $311.00 $317.00 $292.00 $311.00 $317.0051792-26 0 -------- $80.00 $84.00 $88.00 $80.00 $84.00 $88.0051792-TC 0 -------- $212.00 $227.00 $229.00 $212.00 $227.00 $229.0051797 ZZZ $109.00 $155.00 $164.00 $167.00 $155.00 $164.00 $167.0051797-26 ZZZ -------- $58.00 $61.00 $63.00 $58.00 $61.00 $63.0051797-TC ZZZ -------- $97.00 $104.00 $104.00 $97.00 $104.00 $104.0051798 0 $20.00 $26.00 $29.00 $29.00 $26.00 $29.00 $29.0051800 90 $1,294.00 $1,516.00 $1,591.00 $1,676.00 $1,516.00 $1,591.00 $1,676.0051820 90 $1,236.00 $1,628.00 $1,718.00 $1,830.00 $1,628.00 $1,718.00 $1,830.0051840 90 $858.00 $954.00 $1,002.00 $1,055.00 $954.00 $1,002.00 $1,055.0051841 90 $1,040.00 $1,134.00 $1,192.00 $1,258.00 $1,134.00 $1,192.00 $1,258.0051845 90 $843.00 $852.00 $895.00 $942.00 $852.00 $895.00 $942.0051860 90 $912.00 $1,091.00 $1,153.00 $1,226.00 $1,091.00 $1,153.00 $1,226.0051865 90 $1,150.00 $1,307.00 $1,376.00 $1,457.00 $1,307.00 $1,376.00 $1,457.0051880 90 $590.00 $682.00 $719.00 $759.00 $682.00 $719.00 $759.0051900 90 $1,050.00 $1,217.00 $1,280.00 $1,350.00 $1,217.00 $1,280.00 $1,350.0051920 90 $881.00 $1,285.00 $1,380.00 $1,508.00 $1,285.00 $1,380.00 $1,508.0051925 90 $1,167.00 $1,623.00 $1,742.00 $1,909.00 $1,623.00 $1,742.00 $1,909.0051940 90 $2,082.00 $2,425.00 $2,553.00 $2,718.00 $2,425.00 $2,553.00 $2,718.0051960 90 $1,848.00 $2,032.00 $2,133.00 $2,252.00 $2,032.00 $2,133.00 $2,252.0051980 90 $858.00 $1,035.00 $1,086.00 $1,141.00 $1,035.00 $1,086.00 $1,141.0051990 90 $850.00 $1,090.00 $1,144.00 $1,204.00 $1,090.00 $1,144.00 $1,204.0051992 90 $925.00 $1,223.00 $1,285.00 $1,355.00 $1,223.00 $1,285.00 $1,355.0052000 0 $190.00 $288.00 $305.00 $315.00 $184.00 $193.00 $203.0052001 0 $133.00 $531.00 $560.00 $584.00 $420.00 $440.00 $464.0052005 0 $265.00 $372.00 $394.00 $406.00 $194.00 $203.00 $214.0052007 0 $230.00 $616.00 $655.00 $669.00 $242.00 $253.00 $267.0052010 0 $292.00 $520.00 $552.00 $568.00 $244.00 $257.00 $271.0052204 0 $286.00 $512.00 $545.00 $557.00 $207.00 $217.00 $228.0052214 0 $367.00 $911.00 $971.00 $988.00 $258.00 $270.00 $286.0052224 0 $339.00 $955.00 $1,017.00 $1,036.00 $299.00 $312.00 $330.0052234 0 $471.00 $360.00 $377.00 $397.00 $360.00 $377.00 $397.0052235 0 $546.00 $422.00 $442.00 $466.00 $422.00 $442.00 $466.0052240 0 $887.00 $574.00 $601.00 $634.00 $574.00 $601.00 $634.0052250 0 $311.00 $351.00 $368.00 $388.00 $351.00 $368.00 $388.0052260 0 $262.00 $307.00 $322.00 $339.00 $307.00 $322.00 $339.0052265 0 $243.00 $510.00 $542.00 $556.00 $238.00 $249.00 $263.0052270 0 $374.00 $498.00 $528.00 $543.00 $265.00 $278.00 $292.0052275 0 $446.00 $672.00 $712.00 $733.00 $363.00 $380.00 $401.0052276 0 $490.00 $387.00 $406.00 $428.00 $387.00 $406.00 $428.0052277 0 $448.00 $473.00 $496.00 $523.00 $473.00 $496.00 $523.0052281 0 $259.00 $383.00 $405.00 $418.00 $222.00 $233.00 $245.0052282 0 $560.00 $493.00 $516.00 $545.00 $493.00 $516.00 $545.0052283 0 $309.00 $394.00 $415.00 $432.00 $294.00 $308.00 $325.0052285 0 $375.00 $397.00 $419.00 $435.00 $286.00 $300.00 $316.0052287 0 -------- $438.00 $463.00 $478.00 $247.00 $259.00 $273.0052290 0 $304.00 $357.00 $374.00 $394.00 $357.00 $374.00 $394.0052300 0 $370.00 $410.00 $430.00 $453.00 $410.00 $430.00 $453.00



Surgery







52301 0 $382.00 $424.00 $444.00 $468.00 $424.00 $444.00 $468.0052305 0 $370.00 $408.00 $428.00 $451.00 $408.00 $428.00 $451.0052310 0 $348.00 $344.00 $364.00 $377.00 $222.00 $232.00 $245.0052315 0 $553.00 $585.00 $618.00 $641.00 $401.00 $420.00 $443.0052317 0 $772.00 $1,121.00 $1,190.00 $1,221.00 $509.00 $533.00 $563.0052318 0 $684.00 $694.00 $727.00 $767.00 $694.00 $727.00 $767.0052320 0 $369.00 $361.00 $378.00 $398.00 $361.00 $378.00 $398.0052325 0 $494.00 $470.00 $493.00 $520.00 $470.00 $493.00 $520.0052327 0 $369.00 $384.00 $402.00 $425.00 $384.00 $402.00 $425.0052330 0 $507.00 $693.00 $734.00 $757.00 $386.00 $404.00 $426.0052332 0 $451.00 $676.00 $720.00 $734.00 $227.00 $238.00 $251.0052334 0 $340.00 $375.00 $393.00 $414.00 $375.00 $393.00 $414.0052341 0 $317.00 $416.00 $435.00 $459.00 $416.00 $435.00 $459.0052342 0 $344.00 $452.00 $474.00 $499.00 $452.00 $474.00 $499.0052343 0 $380.00 $503.00 $527.00 $556.00 $503.00 $527.00 $556.0052344 0 $407.00 $541.00 $567.00 $599.00 $541.00 $567.00 $599.0052345 0 $433.00 $578.00 $605.00 $639.00 $578.00 $605.00 $639.0052346 0 $488.00 $653.00 $684.00 $721.00 $653.00 $684.00 $721.0052351 0 $297.00 $443.00 $464.00 $489.00 $443.00 $464.00 $489.0052352 0 $349.00 $518.00 $543.00 $572.00 $518.00 $543.00 $572.0052353 0 $404.00 $574.00 $601.00 $634.00 $574.00 $601.00 $634.0052354 0 $372.00 $610.00 $639.00 $674.00 $610.00 $639.00 $674.0052355 0 $447.00 $684.00 $716.00 $756.00 $684.00 $716.00 $756.0052356 0 -------- $609.00 $638.00 $673.00 $609.00 $638.00 $673.0052400 90 $580.00 $696.00 $730.00 $768.00 $696.00 $730.00 $768.0052402 0 -------- $391.00 $409.00 $433.00 $391.00 $409.00 $433.0052441 0 -------- $1,710.00 $1,826.00 $1,852.00 $335.00 $352.00 $373.0052442 ZZZ -------- $1,298.00 $1,390.00 $1,400.00 $89.00 $93.00 $99.0052450 90 $602.00 $681.00 $715.00 $750.00 $681.00 $715.00 $750.0052500 90 $705.00 $707.00 $743.00 $779.00 $707.00 $743.00 $779.0052601 90 $1,021.00 $1,231.00 $1,291.00 $1,358.00 $1,231.00 $1,291.00 $1,358.0052630 90 $653.00 $579.00 $608.00 $637.00 $579.00 $608.00 $637.0052640 90 $573.00 $454.00 $478.00 $499.00 $454.00 $478.00 $499.0052647 90 $858.00 $2,467.00 $2,625.00 $2,679.00 $940.00 $987.00 $1,036.0052648 90 $957.00 $2,542.00 $2,704.00 $2,762.00 $1,003.00 $1,053.00 $1,107.0052649 90 -------- $1,196.00 $1,255.00 $1,319.00 $1,196.00 $1,255.00 $1,319.0052700 90 $517.00 $639.00 $671.00 $704.00 $639.00 $671.00 $704.0053000 10 $224.00 $214.00 $225.00 $235.00 $214.00 $225.00 $235.0053010 90 $336.00 $426.00 $448.00 $468.00 $426.00 $448.00 $468.0053020 0 $153.00 $141.00 $148.00 $156.00 $141.00 $148.00 $156.0053040 90 $460.00 $568.00 $596.00 $625.00 $568.00 $596.00 $625.0053060 10 $180.00 $263.00 $277.00 $289.00 $238.00 $250.00 $262.0053080 90 $567.00 $608.00 $639.00 $669.00 $608.00 $639.00 $669.0053085 90 $836.00 $969.00 $1,019.00 $1,069.00 $969.00 $1,019.00 $1,069.0053200 0 $218.00 $226.00 $238.00 $250.00 $208.00 $218.00 $230.0053210 90 $904.00 $1,120.00 $1,174.00 $1,235.00 $1,120.00 $1,174.00 $1,235.0053215 90 $1,142.00 $1,354.00 $1,420.00 $1,496.00 $1,354.00 $1,420.00 $1,496.0053220 90 $546.00 $660.00 $694.00 $730.00 $660.00 $694.00 $730.0053230 90 $760.00 $879.00 $922.00 $969.00 $879.00 $922.00 $969.0053235 90 $607.00 $918.00 $963.00 $1,012.00 $918.00 $963.00 $1,012.00



Surgery







53240 90 $506.00 $620.00 $653.00 $686.00 $620.00 $653.00 $686.0053250 90 $464.00 $602.00 $638.00 $678.00 $602.00 $638.00 $678.0053260 10 $240.00 $290.00 $305.00 $320.00 $262.00 $275.00 $290.0053265 10 $295.00 $312.00 $329.00 $343.00 $270.00 $283.00 $298.0053270 10 $226.00 $300.00 $316.00 $331.00 $270.00 $284.00 $300.0053275 10 $332.00 $381.00 $400.00 $420.00 $381.00 $400.00 $420.0053400 90 $929.00 $1,165.00 $1,223.00 $1,287.00 $1,165.00 $1,223.00 $1,287.0053405 90 $1,088.00 $1,270.00 $1,332.00 $1,401.00 $1,270.00 $1,332.00 $1,401.0053410 90 $1,151.00 $1,423.00 $1,492.00 $1,570.00 $1,423.00 $1,492.00 $1,570.0053415 90 $1,381.00 $1,646.00 $1,726.00 $1,818.00 $1,646.00 $1,726.00 $1,818.0053420 90 $1,088.00 $1,242.00 $1,304.00 $1,372.00 $1,242.00 $1,304.00 $1,372.0053425 90 $1,150.00 $1,363.00 $1,429.00 $1,504.00 $1,363.00 $1,429.00 $1,504.0053430 90 $1,116.00 $1,403.00 $1,472.00 $1,551.00 $1,403.00 $1,472.00 $1,551.0053431 90 $1,053.00 $1,688.00 $1,771.00 $1,868.00 $1,688.00 $1,771.00 $1,868.0053440 90 $1,057.00 $1,093.00 $1,147.00 $1,205.00 $1,093.00 $1,147.00 $1,205.0053442 90 $639.00 $1,135.00 $1,192.00 $1,251.00 $1,135.00 $1,192.00 $1,251.0053444 90 $755.00 $1,152.00 $1,208.00 $1,269.00 $1,152.00 $1,208.00 $1,269.0053445 90 $1,197.00 $1,092.00 $1,146.00 $1,204.00 $1,092.00 $1,146.00 $1,204.0053446 90 $699.00 $932.00 $979.00 $1,028.00 $932.00 $979.00 $1,028.0053447 90 $991.00 $1,174.00 $1,232.00 $1,295.00 $1,174.00 $1,232.00 $1,295.0053448 90 $1,259.00 $1,875.00 $1,968.00 $2,076.00 $1,875.00 $1,968.00 $2,076.0053449 90 $784.00 $887.00 $931.00 $978.00 $887.00 $931.00 $978.0053450 90 $447.00 $593.00 $623.00 $653.00 $593.00 $623.00 $653.0053460 90 $494.00 $663.00 $696.00 $730.00 $663.00 $696.00 $730.0053500 90 -------- $1,087.00 $1,141.00 $1,201.00 $1,087.00 $1,141.00 $1,201.0053502 90 $590.00 $705.00 $740.00 $777.00 $705.00 $740.00 $777.0053505 90 $586.00 $707.00 $743.00 $780.00 $707.00 $743.00 $780.0053510 90 $777.00 $917.00 $962.00 $1,011.00 $917.00 $962.00 $1,011.0053515 90 $987.00 $1,156.00 $1,213.00 $1,275.00 $1,156.00 $1,213.00 $1,275.0053520 90 $661.00 $807.00 $847.00 $888.00 $807.00 $847.00 $888.0053600 0 $37.00 $119.00 $125.00 $130.00 $93.00 $97.00 $102.0053601 0 $37.00 $115.00 $121.00 $126.00 $78.00 $82.00 $86.0053605 0 $81.00 $95.00 $99.00 $105.00 $95.00 $99.00 $105.0053620 0 $59.00 $165.00 $174.00 $181.00 $127.00 $133.00 $140.0053621 0 $45.00 $155.00 $164.00 $170.00 $105.00 $111.00 $116.0053660 0 $49.00 $99.00 $105.00 $108.00 $61.00 $64.00 $67.0053661 0 $50.00 $97.00 $103.00 $106.00 $59.00 $62.00 $65.0053665 0 $50.00 $57.00 $59.00 $63.00 $57.00 $59.00 $63.0053850 90 $741.00 $2,858.00 $3,047.00 $3,098.00 $879.00 $924.00 $968.0053852 90 $728.00 $2,640.00 $2,812.00 $2,865.00 $904.00 $948.00 $996.0053855 0 -------- $1,060.00 $1,134.00 $1,144.00 $121.00 $127.00 $134.0053860 90 -------- $2,116.00 $2,263.00 $2,286.00 $329.00 $346.00 $363.0053899 YYY BR -------- -------- -------- -------- -------- --------54015 10 $348.00 $451.00 $474.00 $499.00 $451.00 $474.00 $499.0054050 10 $91.00 $186.00 $198.00 $204.00 $150.00 $159.00 $166.0054055 10 $106.00 $168.00 $178.00 $184.00 $133.00 $140.00 $147.0054056 10 $100.00 $200.00 $213.00 $220.00 $159.00 $168.00 $176.0054057 10 $149.00 $191.00 $202.00 $208.00 $136.00 $144.00 $150.0054060 10 $180.00 $253.00 $268.00 $278.00 $188.00 $198.00 $207.0054065 10 $281.00 $311.00 $329.00 $343.00 $250.00 $264.00 $277.00



Surgery







54100 0 $149.00 $280.00 $297.00 $308.00 $183.00 $193.00 $203.0054105 10 $261.00 $377.00 $397.00 $413.00 $309.00 $324.00 $340.0054110 90 $775.00 $919.00 $966.00 $1,017.00 $919.00 $966.00 $1,017.0054111 90 $1,035.00 $1,164.00 $1,221.00 $1,284.00 $1,164.00 $1,221.00 $1,284.0054112 90 $1,210.00 $1,368.00 $1,436.00 $1,512.00 $1,368.00 $1,436.00 $1,512.0054115 90 $588.00 $651.00 $685.00 $717.00 $615.00 $647.00 $678.0054120 90 $777.00 $917.00 $963.00 $1,011.00 $917.00 $963.00 $1,011.0054125 90 $1,092.00 $1,182.00 $1,241.00 $1,307.00 $1,182.00 $1,241.00 $1,307.0054130 90 $1,532.00 $1,733.00 $1,815.00 $1,909.00 $1,733.00 $1,815.00 $1,909.0054135 90 $1,945.00 $2,182.00 $2,281.00 $2,392.00 $2,182.00 $2,281.00 $2,392.0054162 10 $220.00 $366.00 $387.00 $402.00 $289.00 $303.00 $318.0054163 10 $207.00 $316.00 $332.00 $347.00 $316.00 $332.00 $347.0054164 10 $182.00 $278.00 $293.00 $306.00 $278.00 $293.00 $306.0054200 10 $78.00 $151.00 $159.00 $164.00 $120.00 $126.00 $131.0054205 90 $633.00 $772.00 $810.00 $850.00 $772.00 $810.00 $850.0054220 0 $189.00 $290.00 $307.00 $319.00 $196.00 $206.00 $218.0054230 0 $104.00 $138.00 $146.00 $152.00 $116.00 $121.00 $127.0054231 0 $172.00 $201.00 $211.00 $221.00 $169.00 $177.00 $186.0054235 0 $81.00 $128.00 $135.00 $141.00 $106.00 $112.00 $117.0054240 0 $109.00 $146.00 $154.00 $162.00 $146.00 $154.00 $162.0054240-26 0 -------- $98.00 $103.00 $110.00 $98.00 $103.00 $110.0054240-TC 0 -------- $48.00 $51.00 $52.00 $48.00 $51.00 $52.0054250 0 $104.00 $174.00 $182.00 $189.00 $174.00 $182.00 $189.0054250-26 0 -------- $159.00 $165.00 $173.00 $159.00 $165.00 $173.0054250-TC 0 -------- $15.00 $16.00 $17.00 $15.00 $16.00 $17.0054300 90 $830.00 $930.00 $976.00 $1,025.00 $930.00 $976.00 $1,025.0054304 90 $988.00 $1,090.00 $1,143.00 $1,202.00 $1,090.00 $1,143.00 $1,202.0054308 90 $881.00 $1,039.00 $1,090.00 $1,145.00 $1,039.00 $1,090.00 $1,145.0054312 90 $1,067.00 $1,254.00 $1,322.00 $1,401.00 $1,254.00 $1,322.00 $1,401.0054316 90 $1,316.00 $1,531.00 $1,614.00 $1,711.00 $1,531.00 $1,614.00 $1,711.0054318 90 $900.00 $1,089.00 $1,149.00 $1,216.00 $1,089.00 $1,149.00 $1,216.0054322 90 $974.00 $1,116.00 $1,168.00 $1,225.00 $1,116.00 $1,168.00 $1,225.0054324 90 $1,260.00 $1,450.00 $1,521.00 $1,597.00 $1,450.00 $1,521.00 $1,597.0054326 90 $1,212.00 $1,376.00 $1,443.00 $1,517.00 $1,376.00 $1,443.00 $1,517.0054328 90 $1,201.00 $1,367.00 $1,434.00 $1,508.00 $1,367.00 $1,434.00 $1,508.0054332 90 $1,327.00 $1,561.00 $1,645.00 $1,742.00 $1,561.00 $1,645.00 $1,742.0054336 90 $1,672.00 $1,825.00 $1,924.00 $2,041.00 $1,825.00 $1,924.00 $2,041.0054340 90 $727.00 $826.00 $868.00 $910.00 $826.00 $868.00 $910.0054344 90 $1,360.00 $1,538.00 $1,644.00 $1,786.00 $1,538.00 $1,644.00 $1,786.0054348 90 $1,318.00 $1,475.00 $1,547.00 $1,628.00 $1,475.00 $1,547.00 $1,628.0054352 90 $1,820.00 $2,064.00 $2,164.00 $2,278.00 $2,064.00 $2,164.00 $2,278.0054360 90 $898.00 $1,047.00 $1,098.00 $1,154.00 $1,047.00 $1,098.00 $1,154.0054380 90 $1,054.00 $1,162.00 $1,219.00 $1,281.00 $1,162.00 $1,219.00 $1,281.0054385 90 $1,217.00 $1,423.00 $1,501.00 $1,590.00 $1,423.00 $1,501.00 $1,590.0054390 90 $1,635.00 $1,904.00 $2,007.00 $2,129.00 $1,904.00 $2,007.00 $2,129.0054400 90 $784.00 $769.00 $807.00 $848.00 $769.00 $807.00 $848.0054401 90 $892.00 $949.00 $998.00 $1,045.00 $949.00 $998.00 $1,045.0054405 90 $1,294.00 $1,176.00 $1,233.00 $1,296.00 $1,176.00 $1,233.00 $1,296.0054406 90 $687.00 $1,062.00 $1,114.00 $1,171.00 $1,062.00 $1,114.00 $1,171.0054408 90 $724.00 $1,148.00 $1,204.00 $1,266.00 $1,148.00 $1,204.00 $1,266.00



Surgery







54410 90 $856.00 $1,249.00 $1,310.00 $1,377.00 $1,249.00 $1,310.00 $1,377.0054411 90 $933.00 $1,491.00 $1,563.00 $1,643.00 $1,491.00 $1,563.00 $1,643.0054415 90 $510.00 $766.00 $804.00 $844.00 $766.00 $804.00 $844.0054416 90 $665.00 $1,029.00 $1,081.00 $1,134.00 $1,029.00 $1,081.00 $1,134.0054417 90 $819.00 $1,306.00 $1,369.00 $1,439.00 $1,306.00 $1,369.00 $1,439.0054420 90 $899.00 $1,024.00 $1,074.00 $1,129.00 $1,024.00 $1,074.00 $1,129.0054430 90 $799.00 $929.00 $975.00 $1,024.00 $929.00 $975.00 $1,024.0054435 90 $503.00 $602.00 $632.00 $662.00 $602.00 $632.00 $662.0054437 90 -------- $991.00 $1,043.00 $1,099.00 $991.00 $1,043.00 $1,099.0054438 90 -------- $2,008.00 $2,116.00 $2,248.00 $2,008.00 $2,116.00 $2,248.0054440 90 BR -------- -------- -------- -------- -------- --------54450 0 $88.00 $101.00 $106.00 $111.00 $84.00 $88.00 $94.0054500 0 $102.00 $108.00 $113.00 $119.00 $108.00 $113.00 $119.0054505 10 $259.00 $305.00 $320.00 $335.00 $305.00 $320.00 $335.0054512 90 $519.00 $784.00 $824.00 $867.00 $784.00 $824.00 $867.0054520 90 $445.00 $473.00 $498.00 $525.00 $473.00 $498.00 $525.0054522 90 $589.00 $908.00 $963.00 $1,029.00 $908.00 $963.00 $1,029.0054530 90 $683.00 $733.00 $771.00 $809.00 $733.00 $771.00 $809.0054535 90 $922.00 $1,081.00 $1,133.00 $1,191.00 $1,081.00 $1,133.00 $1,191.0054550 90 $588.00 $716.00 $753.00 $791.00 $716.00 $753.00 $791.0054560 90 $842.00 $998.00 $1,047.00 $1,101.00 $998.00 $1,047.00 $1,101.0054600 90 $524.00 $661.00 $694.00 $728.00 $661.00 $694.00 $728.0054620 10 $373.00 $438.00 $460.00 $483.00 $438.00 $460.00 $483.0054640 90 $594.00 $696.00 $733.00 $772.00 $696.00 $733.00 $772.0054650 90 $861.00 $1,030.00 $1,080.00 $1,132.00 $1,030.00 $1,080.00 $1,132.0054660 90 $401.00 $517.00 $543.00 $569.00 $517.00 $543.00 $569.0054670 90 $485.00 $585.00 $615.00 $643.00 $585.00 $615.00 $643.0054680 90 $948.00 $1,152.00 $1,209.00 $1,271.00 $1,152.00 $1,209.00 $1,271.0054690 90 $825.00 $1,098.00 $1,177.00 $1,285.00 $1,098.00 $1,177.00 $1,285.0054692 90 $850.00 $1,274.00 $1,368.00 $1,499.00 $1,274.00 $1,368.00 $1,499.0054699 YYY BR -------- -------- -------- -------- -------- --------54700 10 $133.00 $311.00 $328.00 $346.00 $311.00 $328.00 $346.0054800 0 $257.00 $186.00 $195.00 $206.00 $186.00 $195.00 $206.0054830 90 $411.00 $540.00 $568.00 $596.00 $540.00 $568.00 $596.0054840 90 $432.00 $465.00 $489.00 $513.00 $465.00 $489.00 $513.0054860 90 $503.00 $607.00 $637.00 $668.00 $607.00 $637.00 $668.0054861 90 $696.00 $822.00 $863.00 $905.00 $822.00 $863.00 $905.0054865 90 -------- $519.00 $545.00 $571.00 $519.00 $545.00 $571.0054900 90 $969.00 $1,227.00 $1,294.00 $1,371.00 $1,227.00 $1,294.00 $1,371.0054901 90 $1,340.00 $1,620.00 $1,708.00 $1,811.00 $1,620.00 $1,708.00 $1,811.0055000 0 $109.00 $167.00 $176.00 $183.00 $124.00 $130.00 $137.0055040 90 $439.00 $490.00 $516.00 $542.00 $490.00 $516.00 $542.0055041 90 $634.00 $739.00 $777.00 $816.00 $739.00 $777.00 $816.0055060 90 $430.00 $552.00 $581.00 $610.00 $552.00 $581.00 $610.0055100 10 $156.00 $307.00 $325.00 $338.00 $241.00 $254.00 $267.0055110 90 $223.00 $562.00 $592.00 $622.00 $562.00 $592.00 $622.0055120 90 $350.00 $517.00 $544.00 $571.00 $517.00 $544.00 $571.0055150 90 $562.00 $714.00 $751.00 $790.00 $714.00 $751.00 $790.0055175 90 $426.00 $524.00 $551.00 $578.00 $524.00 $551.00 $578.0055180 90 $796.00 $1,006.00 $1,058.00 $1,113.00 $1,006.00 $1,058.00 $1,113.00



Surgery







55200 90 $310.00 $614.00 $650.00 $671.00 $403.00 $424.00 $444.0055250 90 $349.00 $539.00 $571.00 $587.00 $327.00 $345.00 $360.0055300 0 $167.00 $273.00 $286.00 $302.00 $273.00 $286.00 $302.0055400 90 $660.00 $744.00 $785.00 $832.00 $744.00 $785.00 $832.0055450 10 $391.00 $509.00 $537.00 $557.00 $373.00 $392.00 $411.0055500 90 $445.00 $578.00 $612.00 $649.00 $578.00 $612.00 $649.0055520 90 $446.00 $669.00 $717.00 $776.00 $669.00 $717.00 $776.0055530 90 $467.00 $509.00 $536.00 $562.00 $509.00 $536.00 $562.0055535 90 $496.00 $623.00 $655.00 $687.00 $623.00 $655.00 $687.0055540 90 $572.00 $802.00 $858.00 $930.00 $802.00 $858.00 $930.0055550 90 $486.00 $623.00 $654.00 $686.00 $623.00 $654.00 $686.0055559 YYY BR -------- -------- -------- -------- -------- --------55600 90 $486.00 $611.00 $641.00 $672.00 $611.00 $641.00 $672.0055605 90 $609.00 $798.00 $842.00 $890.00 $798.00 $842.00 $890.0055650 90 $853.00 $1,045.00 $1,096.00 $1,153.00 $1,045.00 $1,096.00 $1,153.0055680 90 $426.00 $515.00 $543.00 $570.00 $515.00 $543.00 $570.0055700 0 $183.00 $308.00 $326.00 $337.00 $203.00 $213.00 $225.0055705 10 $368.00 $387.00 $406.00 $426.00 $387.00 $406.00 $426.0055706 10 -------- $542.00 $569.00 $597.00 $542.00 $569.00 $597.0055720 90 $555.00 $657.00 $690.00 $724.00 $657.00 $690.00 $724.0055725 90 $670.00 $860.00 $903.00 $948.00 $860.00 $903.00 $948.0055801 90 $1,331.00 $1,605.00 $1,686.00 $1,780.00 $1,605.00 $1,686.00 $1,780.0055810 90 $1,711.00 $1,927.00 $2,023.00 $2,137.00 $1,927.00 $2,023.00 $2,137.0055812 90 $1,989.00 $2,346.00 $2,459.00 $2,590.00 $2,346.00 $2,459.00 $2,590.0055815 90 $2,328.00 $2,586.00 $2,712.00 $2,864.00 $2,586.00 $2,712.00 $2,864.0055821 90 $1,153.00 $1,272.00 $1,334.00 $1,404.00 $1,272.00 $1,334.00 $1,404.0055831 90 $1,252.00 $1,377.00 $1,443.00 $1,519.00 $1,377.00 $1,443.00 $1,519.0055840 90 $1,705.00 $1,707.00 $1,791.00 $1,886.00 $1,707.00 $1,791.00 $1,886.0055842 90 $1,859.00 $1,706.00 $1,789.00 $1,883.00 $1,706.00 $1,789.00 $1,883.0055845 90 $2,222.00 $1,989.00 $2,085.00 $2,197.00 $1,989.00 $2,085.00 $2,197.0055860 90 $1,012.00 $1,274.00 $1,336.00 $1,406.00 $1,274.00 $1,336.00 $1,406.0055862 90 $1,351.00 $1,683.00 $1,774.00 $1,882.00 $1,683.00 $1,774.00 $1,882.0055865 90 $1,890.00 $1,944.00 $2,037.00 $2,145.00 $1,944.00 $2,037.00 $2,145.0055866 90 $1,615.00 $2,024.00 $2,130.00 $2,224.00 $2,024.00 $2,130.00 $2,224.0055870 0 $166.00 $251.00 $265.00 $276.00 $208.00 $218.00 $229.0055873 90 $1,127.00 $9,706.00 $10,388.00 $10,478.00 $1,118.00 $1,174.00 $1,236.0055875 90 -------- $1,107.00 $1,161.00 $1,217.00 $1,107.00 $1,161.00 $1,217.0055876 0 -------- $192.00 $203.00 $210.00 $146.00 $153.00 $160.0055899 YYY BR -------- -------- -------- -------- -------- --------55920 0 -------- $651.00 $680.00 $712.00 $651.00 $680.00 $712.0056405 10 $131.00 $155.00 $164.00 $171.00 $154.00 $163.00 $170.0056420 10 $130.00 $172.00 $182.00 $189.00 $131.00 $138.00 $145.0056440 10 $271.00 $261.00 $275.00 $289.00 $261.00 $275.00 $289.0056441 10 $183.00 $205.00 $216.00 $225.00 $197.00 $208.00 $218.0056442 0 -------- $68.00 $72.00 $75.00 $68.00 $72.00 $75.0056501 10 $122.00 $185.00 $196.00 $204.00 $164.00 $173.00 $181.0056515 10 $200.00 $323.00 $342.00 $359.00 $290.00 $306.00 $324.0056605 0 $96.00 $117.00 $123.00 $129.00 $87.00 $92.00 $97.0056606 ZZZ $49.00 $54.00 $57.00 $60.00 $43.00 $46.00 $49.0056620 90 $607.00 $755.00 $804.00 $858.00 $755.00 $804.00 $858.00



Surgery







56625 90 $735.00 $919.00 $980.00 $1,054.00 $919.00 $980.00 $1,054.0056630 90 $1,061.00 $1,365.00 $1,457.00 $1,577.00 $1,365.00 $1,457.00 $1,577.0056631 90 $1,400.00 $1,747.00 $1,867.00 $2,026.00 $1,747.00 $1,867.00 $2,026.0056632 90 $1,636.00 $2,025.00 $2,162.00 $2,339.00 $2,025.00 $2,162.00 $2,339.0056633 90 $1,350.00 $1,790.00 $1,912.00 $2,075.00 $1,790.00 $1,912.00 $2,075.0056634 90 $1,537.00 $1,943.00 $2,086.00 $2,284.00 $1,943.00 $2,086.00 $2,284.0056637 90 $1,806.00 $2,231.00 $2,384.00 $2,592.00 $2,231.00 $2,384.00 $2,592.0056640 90 $1,777.00 $2,253.00 $2,413.00 $2,635.00 $2,253.00 $2,413.00 $2,635.0056700 10 $227.00 $266.00 $280.00 $293.00 $266.00 $280.00 $293.0056740 10 $321.00 $434.00 $459.00 $487.00 $434.00 $459.00 $487.0056800 10 $310.00 $346.00 $364.00 $384.00 $346.00 $364.00 $384.0056805 90 $1,349.00 $1,685.00 $1,780.00 $1,896.00 $1,685.00 $1,780.00 $1,896.0056810 10 $316.00 $374.00 $394.00 $415.00 $374.00 $394.00 $415.0056820 0 $119.00 $161.00 $171.00 $180.00 $127.00 $134.00 $143.0056821 0 $154.00 $212.00 $224.00 $236.00 $168.00 $178.00 $189.0057000 10 $237.00 $269.00 $283.00 $297.00 $269.00 $283.00 $297.0057010 90 $429.00 $620.00 $653.00 $686.00 $620.00 $653.00 $686.0057020 0 $118.00 $133.00 $140.00 $147.00 $117.00 $123.00 $130.0057022 10 $179.00 $243.00 $256.00 $270.00 $243.00 $256.00 $270.0057023 10 $290.00 $444.00 $467.00 $491.00 $444.00 $467.00 $491.0057061 10 $124.00 $161.00 $170.00 $177.00 $140.00 $148.00 $155.0057065 10 $251.00 $279.00 $296.00 $312.00 $252.00 $267.00 $283.0057100 0 $90.00 $127.00 $135.00 $142.00 $98.00 $103.00 $110.0057105 10 $132.00 $194.00 $206.00 $216.00 $181.00 $192.00 $202.0057106 90 $409.00 $716.00 $760.00 $809.00 $716.00 $760.00 $809.0057107 90 $1,467.00 $2,134.00 $2,269.00 $2,448.00 $2,134.00 $2,269.00 $2,448.0057109 90 $1,787.00 $2,573.00 $2,757.00 $3,016.00 $2,573.00 $2,757.00 $3,016.0057110 90 $1,015.00 $1,283.00 $1,348.00 $1,421.00 $1,283.00 $1,348.00 $1,421.0057111 90 $1,793.00 $2,325.00 $2,447.00 $2,591.00 $2,325.00 $2,447.00 $2,591.0057112 90 $1,907.00 $2,745.00 $2,938.00 $3,208.00 $2,745.00 $2,938.00 $3,208.0057120 90 $612.00 $729.00 $767.00 $806.00 $729.00 $767.00 $806.0057130 10 $220.00 $251.00 $264.00 $276.00 $227.00 $239.00 $250.0057135 10 $231.00 $274.00 $289.00 $304.00 $249.00 $262.00 $277.0057150 0 $50.00 $63.00 $67.00 $69.00 $42.00 $44.00 $46.0057155 0 $383.00 $609.00 $641.00 $660.00 $420.00 $438.00 $457.0057156 0 -------- $279.00 $293.00 $301.00 $211.00 $219.00 $227.0057160 0 $67.00 $107.00 $113.00 $117.00 $68.00 $71.00 $75.0057170 0 $74.00 $87.00 $91.00 $96.00 $70.00 $74.00 $78.0057180 10 $124.00 $198.00 $209.00 $217.00 $151.00 $159.00 $167.0057200 90 $313.00 $434.00 $459.00 $484.00 $434.00 $459.00 $484.0057210 90 $395.00 $526.00 $554.00 $583.00 $526.00 $554.00 $583.0057220 90 $378.00 $455.00 $479.00 $502.00 $455.00 $479.00 $502.0057230 90 $442.00 $565.00 $594.00 $625.00 $565.00 $594.00 $625.0057240 90 $536.00 $964.00 $1,013.00 $1,066.00 $964.00 $1,013.00 $1,066.0057250 90 $485.00 $969.00 $1,019.00 $1,073.00 $969.00 $1,019.00 $1,073.0057260 90 $700.00 $1,196.00 $1,256.00 $1,324.00 $1,196.00 $1,256.00 $1,324.0057265 90 $902.00 $1,310.00 $1,376.00 $1,450.00 $1,310.00 $1,376.00 $1,450.0057267 ZZZ -------- $371.00 $389.00 $411.00 $371.00 $389.00 $411.0057268 90 $577.00 $693.00 $730.00 $769.00 $693.00 $730.00 $769.0057270 90 $867.00 $1,153.00 $1,214.00 $1,285.00 $1,153.00 $1,214.00 $1,285.00



Surgery







57280 90 $1,071.00 $1,372.00 $1,443.00 $1,523.00 $1,372.00 $1,443.00 $1,523.0057282 90 $734.00 $716.00 $753.00 $791.00 $716.00 $753.00 $791.0057283 90 -------- $988.00 $1,039.00 $1,095.00 $988.00 $1,039.00 $1,095.0057284 90 $950.00 $1,173.00 $1,232.00 $1,298.00 $1,173.00 $1,232.00 $1,298.0057285 90 -------- $966.00 $1,014.00 $1,068.00 $966.00 $1,014.00 $1,068.0057287 90 $685.00 $976.00 $1,026.00 $1,076.00 $976.00 $1,026.00 $1,076.0057288 90 $1,009.00 $1,028.00 $1,080.00 $1,135.00 $1,028.00 $1,080.00 $1,135.0057289 90 $879.00 $1,057.00 $1,109.00 $1,164.00 $1,057.00 $1,109.00 $1,164.0057291 90 $622.00 $881.00 $934.00 $988.00 $881.00 $934.00 $988.0057292 90 $925.00 $1,182.00 $1,244.00 $1,312.00 $1,182.00 $1,244.00 $1,312.0057295 90 -------- $684.00 $719.00 $756.00 $684.00 $719.00 $756.0057296 90 -------- $1,362.00 $1,432.00 $1,511.00 $1,362.00 $1,432.00 $1,511.0057300 90 $653.00 $815.00 $864.00 $921.00 $815.00 $864.00 $921.0057305 90 $995.00 $1,371.00 $1,459.00 $1,574.00 $1,371.00 $1,459.00 $1,574.0057307 90 $997.00 $1,600.00 $1,717.00 $1,878.00 $1,600.00 $1,717.00 $1,878.0057308 90 $769.00 $952.00 $1,006.00 $1,066.00 $952.00 $1,006.00 $1,066.0057310 90 $517.00 $666.00 $700.00 $733.00 $666.00 $700.00 $733.0057311 90 $612.00 $763.00 $802.00 $842.00 $763.00 $802.00 $842.0057320 90 $693.00 $771.00 $812.00 $854.00 $771.00 $812.00 $854.0057330 90 $916.00 $1,072.00 $1,124.00 $1,181.00 $1,072.00 $1,124.00 $1,181.0057335 90 $963.00 $1,636.00 $1,716.00 $1,806.00 $1,636.00 $1,716.00 $1,806.0057400 0 $70.00 $195.00 $207.00 $220.00 $195.00 $207.00 $220.0057410 0 $57.00 $156.00 $164.00 $174.00 $156.00 $164.00 $174.0057415 10 $75.00 $229.00 $241.00 $253.00 $229.00 $241.00 $253.0057420 0 $124.00 $168.00 $179.00 $189.00 $134.00 $141.00 $151.0057421 0 $162.00 $226.00 $240.00 $253.00 $182.00 $192.00 $206.0057423 90 -------- $1,312.00 $1,378.00 $1,455.00 $1,312.00 $1,378.00 $1,455.0057425 90 -------- $1,394.00 $1,465.00 $1,545.00 $1,394.00 $1,465.00 $1,545.0057426 90 -------- $1,211.00 $1,273.00 $1,340.00 $1,211.00 $1,273.00 $1,340.0057452 0 $96.00 $155.00 $164.00 $172.00 $133.00 $140.00 $148.0057454 0 $125.00 $218.00 $230.00 $241.00 $195.00 $205.00 $216.0057455 0 $149.00 $203.00 $214.00 $224.00 $160.00 $168.00 $178.0057456 0 $141.00 $191.00 $202.00 $211.00 $149.00 $156.00 $165.0057460 0 $223.00 $396.00 $420.00 $435.00 $235.00 $247.00 $261.0057461 0 $333.00 $449.00 $476.00 $493.00 $271.00 $285.00 $302.0057500 0 $89.00 $179.00 $190.00 $196.00 $109.00 $115.00 $121.0057505 10 $105.00 $144.00 $153.00 $159.00 $131.00 $139.00 $145.0057510 10 $140.00 $186.00 $197.00 $206.00 $166.00 $174.00 $183.0057511 10 $159.00 $205.00 $217.00 $226.00 $188.00 $198.00 $207.0057513 10 $191.00 $207.00 $219.00 $230.00 $192.00 $203.00 $215.0057520 90 $359.00 $438.00 $464.00 $487.00 $396.00 $418.00 $442.0057522 90 $319.00 $374.00 $395.00 $414.00 $348.00 $367.00 $386.0057530 90 $386.00 $499.00 $527.00 $556.00 $499.00 $527.00 $556.0057531 90 $2,036.00 $2,707.00 $2,898.00 $3,163.00 $2,707.00 $2,898.00 $3,163.0057540 90 $815.00 $1,126.00 $1,186.00 $1,255.00 $1,126.00 $1,186.00 $1,255.0057545 90 $700.00 $1,225.00 $1,297.00 $1,385.00 $1,225.00 $1,297.00 $1,385.0057550 90 $486.00 $580.00 $610.00 $639.00 $580.00 $610.00 $639.0057555 90 $774.00 $858.00 $902.00 $948.00 $858.00 $902.00 $948.0057556 90 $718.00 $812.00 $855.00 $899.00 $812.00 $855.00 $899.0057558 10 -------- $176.00 $186.00 $194.00 $161.00 $170.00 $178.00



Surgery







57700 90 $279.00 $455.00 $482.00 $508.00 $455.00 $482.00 $508.0057720 90 $328.00 $437.00 $460.00 $482.00 $437.00 $460.00 $482.0057800 0 $71.00 $86.00 $91.00 $95.00 $70.00 $74.00 $77.0058100 0 $74.00 $155.00 $164.00 $171.00 $126.00 $133.00 $140.0058110 ZZZ -------- $69.00 $72.00 $76.00 $59.00 $62.00 $65.0058120 10 $297.00 $368.00 $389.00 $408.00 $315.00 $332.00 $351.0058140 90 $1,010.00 $1,333.00 $1,406.00 $1,494.00 $1,333.00 $1,406.00 $1,494.0058145 90 $677.00 $789.00 $832.00 $880.00 $789.00 $832.00 $880.0058146 90 $1,089.00 $1,651.00 $1,733.00 $1,827.00 $1,651.00 $1,733.00 $1,827.0058150 90 $1,110.00 $1,470.00 $1,555.00 $1,659.00 $1,470.00 $1,555.00 $1,659.0058152 90 $1,159.00 $1,800.00 $1,894.00 $2,006.00 $1,800.00 $1,894.00 $2,006.0058180 90 $1,118.00 $1,391.00 $1,466.00 $1,556.00 $1,391.00 $1,466.00 $1,556.0058200 90 $1,562.00 $2,012.00 $2,142.00 $2,316.00 $2,012.00 $2,142.00 $2,316.0058210 90 $2,080.00 $2,724.00 $2,907.00 $3,156.00 $2,724.00 $2,907.00 $3,156.0058240 90 $2,898.00 $4,294.00 $4,575.00 $4,957.00 $4,294.00 $4,575.00 $4,957.0058260 90 $926.00 $1,184.00 $1,245.00 $1,312.00 $1,184.00 $1,245.00 $1,312.0058262 90 $1,026.00 $1,324.00 $1,392.00 $1,469.00 $1,324.00 $1,392.00 $1,469.0058263 90 $1,120.00 $1,419.00 $1,491.00 $1,573.00 $1,419.00 $1,491.00 $1,573.0058267 90 $1,133.00 $1,514.00 $1,592.00 $1,681.00 $1,514.00 $1,592.00 $1,681.0058270 90 $1,019.00 $1,265.00 $1,330.00 $1,403.00 $1,265.00 $1,330.00 $1,403.0058275 90 $1,121.00 $1,414.00 $1,487.00 $1,572.00 $1,414.00 $1,487.00 $1,572.0058280 90 $1,132.00 $1,504.00 $1,579.00 $1,664.00 $1,504.00 $1,579.00 $1,664.0058285 90 $1,360.00 $1,943.00 $2,055.00 $2,199.00 $1,943.00 $2,055.00 $2,199.0058290 90 $1,089.00 $1,653.00 $1,737.00 $1,835.00 $1,653.00 $1,737.00 $1,835.0058291 90 $1,197.00 $1,782.00 $1,871.00 $1,973.00 $1,782.00 $1,871.00 $1,973.0058292 90 $1,268.00 $1,883.00 $1,977.00 $2,086.00 $1,883.00 $1,977.00 $2,086.0058293 90 $1,318.00 $1,956.00 $2,053.00 $2,166.00 $1,956.00 $2,053.00 $2,166.0058294 90 $1,168.00 $1,751.00 $1,840.00 $1,943.00 $1,751.00 $1,840.00 $1,943.0058301 0 $71.00 $134.00 $142.00 $148.00 $98.00 $102.00 $108.0058321 0 $81.00 $108.00 $114.00 $119.00 $71.00 $74.00 $78.0058322 0 $90.00 $121.00 $128.00 $133.00 $84.00 $89.00 $94.0058323 0 $24.00 $22.00 $23.00 $23.00 $17.00 $18.00 $19.0058340 0 $87.00 $165.00 $176.00 $180.00 $83.00 $88.00 $92.0058345 10 $335.00 $390.00 $409.00 $430.00 $390.00 $409.00 $430.0058346 90 $408.00 $637.00 $664.00 $686.00 $637.00 $664.00 $686.0058350 10 $103.00 $135.00 $142.00 $147.00 $111.00 $117.00 $122.0058353 10 $225.00 $1,379.00 $1,473.00 $1,493.00 $313.00 $329.00 $346.0058356 10 -------- $2,579.00 $2,756.00 $2,793.00 $498.00 $523.00 $554.0058400 90 $519.00 $631.00 $664.00 $698.00 $631.00 $664.00 $698.0058410 90 $752.00 $1,181.00 $1,247.00 $1,327.00 $1,181.00 $1,247.00 $1,327.0058520 90 $663.00 $1,250.00 $1,340.00 $1,464.00 $1,250.00 $1,340.00 $1,464.0058540 90 $923.00 $1,299.00 $1,364.00 $1,437.00 $1,299.00 $1,364.00 $1,437.0058541 90 -------- $1,027.00 $1,079.00 $1,137.00 $1,027.00 $1,079.00 $1,137.0058542 90 -------- $1,177.00 $1,237.00 $1,306.00 $1,177.00 $1,237.00 $1,306.0058543 90 -------- $1,189.00 $1,249.00 $1,317.00 $1,189.00 $1,249.00 $1,317.0058544 90 -------- $1,301.00 $1,371.00 $1,453.00 $1,301.00 $1,371.00 $1,453.0058545 90 $876.00 $1,305.00 $1,376.00 $1,463.00 $1,305.00 $1,376.00 $1,463.0058546 90 $1,104.00 $1,610.00 $1,691.00 $1,783.00 $1,610.00 $1,691.00 $1,783.0058548 90 -------- $2,809.00 $2,999.00 $3,259.00 $2,809.00 $2,999.00 $3,259.0058550 90 $1,038.00 $1,265.00 $1,330.00 $1,402.00 $1,265.00 $1,330.00 $1,402.00



Surgery







58552 90 $853.00 $1,426.00 $1,504.00 $1,597.00 $1,426.00 $1,504.00 $1,597.0058553 90 $1,096.00 $1,636.00 $1,721.00 $1,822.00 $1,636.00 $1,721.00 $1,822.0058554 90 $1,085.00 $1,922.00 $2,028.00 $2,159.00 $1,922.00 $2,028.00 $2,159.0058555 0 $261.00 $437.00 $463.00 $479.00 $272.00 $286.00 $302.0058558 0 $340.00 $571.00 $604.00 $628.00 $384.00 $403.00 $427.0058559 0 $436.00 $492.00 $516.00 $546.00 $492.00 $516.00 $546.0058560 0 $482.00 $554.00 $581.00 $614.00 $554.00 $581.00 $614.0058561 0 $677.00 $786.00 $825.00 $873.00 $786.00 $825.00 $873.0058562 0 $339.00 $591.00 $625.00 $650.00 $417.00 $438.00 $463.0058563 0 $450.00 $2,288.00 $2,443.00 $2,477.00 $491.00 $515.00 $544.0058565 90 -------- $2,560.00 $2,733.00 $2,773.00 $619.00 $651.00 $684.0058570 90 -------- $1,119.00 $1,178.00 $1,244.00 $1,119.00 $1,178.00 $1,244.0058571 90 -------- $1,307.00 $1,387.00 $1,488.00 $1,307.00 $1,387.00 $1,488.0058572 90 -------- $1,472.00 $1,552.00 $1,647.00 $1,472.00 $1,552.00 $1,647.0058573 90 -------- $1,770.00 $1,876.00 $2,012.00 $1,770.00 $1,876.00 $2,012.0058578 YYY BR -------- -------- -------- -------- -------- --------58579 YYY BR -------- -------- -------- -------- -------- --------58600 90 $337.00 $519.00 $546.00 $573.00 $519.00 $546.00 $573.0058605 90 $298.00 $470.00 $494.00 $518.00 $470.00 $494.00 $518.0058611 ZZZ $47.00 $111.00 $117.00 $123.00 $111.00 $117.00 $123.0058615 10 $319.00 $347.00 $365.00 $383.00 $347.00 $365.00 $383.0058660 90 $793.00 $972.00 $1,025.00 $1,088.00 $972.00 $1,025.00 $1,088.0058661 10 $804.00 $941.00 $993.00 $1,057.00 $941.00 $993.00 $1,057.0058662 90 $807.00 $1,023.00 $1,079.00 $1,144.00 $1,023.00 $1,079.00 $1,144.0058670 90 $450.00 $522.00 $550.00 $578.00 $522.00 $550.00 $578.0058671 90 $463.00 $521.00 $548.00 $576.00 $521.00 $548.00 $576.0058672 90 $872.00 $1,052.00 $1,104.00 $1,164.00 $1,052.00 $1,104.00 $1,164.0058673 90 $928.00 $1,144.00 $1,202.00 $1,267.00 $1,144.00 $1,202.00 $1,267.0058679 YYY BR -------- -------- -------- -------- -------- --------58700 90 $544.00 $1,134.00 $1,201.00 $1,284.00 $1,134.00 $1,201.00 $1,284.0058720 90 $844.00 $1,071.00 $1,135.00 $1,215.00 $1,071.00 $1,135.00 $1,215.0058740 90 $508.00 $1,279.00 $1,352.00 $1,440.00 $1,279.00 $1,352.00 $1,440.0058750 90 $949.00 $1,436.00 $1,542.00 $1,691.00 $1,436.00 $1,542.00 $1,691.0058752 90 $893.00 $1,341.00 $1,420.00 $1,518.00 $1,341.00 $1,420.00 $1,518.0058760 90 $769.00 $1,185.00 $1,251.00 $1,330.00 $1,185.00 $1,251.00 $1,330.0058770 90 $763.00 $1,361.00 $1,461.00 $1,602.00 $1,361.00 $1,461.00 $1,602.0058800 90 $343.00 $451.00 $475.00 $496.00 $425.00 $447.00 $468.0058805 90 $509.00 $576.00 $606.00 $635.00 $576.00 $606.00 $635.0058820 90 $326.00 $444.00 $467.00 $489.00 $444.00 $467.00 $489.0058822 90 $603.00 $1,102.00 $1,180.00 $1,284.00 $1,102.00 $1,180.00 $1,284.0058825 90 $469.00 $999.00 $1,051.00 $1,109.00 $999.00 $1,051.00 $1,109.0058900 90 $489.00 $665.00 $712.00 $770.00 $665.00 $712.00 $770.0058920 90 $571.00 $1,124.00 $1,205.00 $1,316.00 $1,124.00 $1,205.00 $1,316.0058925 90 $820.00 $1,082.00 $1,144.00 $1,220.00 $1,082.00 $1,144.00 $1,220.0058940 90 $592.00 $764.00 $812.00 $869.00 $764.00 $812.00 $869.0058943 90 $1,368.00 $1,732.00 $1,848.00 $2,003.00 $1,732.00 $1,848.00 $2,003.0058950 90 $1,170.00 $1,663.00 $1,775.00 $1,924.00 $1,663.00 $1,775.00 $1,924.0058951 90 $1,703.00 $2,143.00 $2,286.00 $2,480.00 $2,143.00 $2,286.00 $2,480.0058952 90 $1,876.00 $2,425.00 $2,588.00 $2,811.00 $2,425.00 $2,588.00 $2,811.0058953 90 $1,839.00 $3,001.00 $3,203.00 $3,479.00 $3,001.00 $3,203.00 $3,479.00



Surgery







58954 90 $1,999.00 $3,263.00 $3,484.00 $3,788.00 $3,263.00 $3,484.00 $3,788.0058956 90 -------- $2,032.00 $2,167.00 $2,346.00 $2,032.00 $2,167.00 $2,346.0058957 90 -------- $2,346.00 $2,506.00 $2,724.00 $2,346.00 $2,506.00 $2,724.0058958 90 -------- $2,574.00 $2,746.00 $2,979.00 $2,574.00 $2,746.00 $2,979.0058960 90 $1,174.00 $1,434.00 $1,532.00 $1,662.00 $1,434.00 $1,532.00 $1,662.0058999 YYY BR -------- -------- -------- -------- -------- --------59000 0 $123.00 $182.00 $195.00 $208.00 $121.00 $130.00 $143.0059001 0 $167.00 $271.00 $291.00 $322.00 $271.00 $291.00 $322.0059012 0 $267.00 $306.00 $329.00 $364.00 $306.00 $329.00 $364.0059015 0 $168.00 $230.00 $247.00 $269.00 $198.00 $213.00 $235.0059020 0 $85.00 $102.00 $109.00 $116.00 $102.00 $109.00 $116.0059020-26 0 -------- $55.00 $59.00 $65.00 $55.00 $59.00 $65.0059020-TC 0 -------- $46.00 $50.00 $50.00 $46.00 $50.00 $50.0059025 0 $54.00 $70.00 $75.00 $80.00 $70.00 $75.00 $80.0059025-26 0 -------- $45.00 $48.00 $52.00 $45.00 $48.00 $52.0059025-TC 0 -------- $25.00 $27.00 $28.00 $25.00 $27.00 $28.0059030 0 $155.00 $146.00 $152.00 $158.00 $146.00 $152.00 $158.0059050 0 $71.00 $77.00 $82.00 $91.00 $77.00 $82.00 $91.0059051 0 $47.00 $64.00 $68.00 $76.00 $64.00 $68.00 $76.0059100 90 $633.00 $1,170.00 $1,242.00 $1,335.00 $1,170.00 $1,242.00 $1,335.0059120 90 $893.00 $1,185.00 $1,274.00 $1,401.00 $1,185.00 $1,274.00 $1,401.0059121 90 $768.00 $1,189.00 $1,280.00 $1,409.00 $1,189.00 $1,280.00 $1,409.0059130 90 $832.00 $1,391.00 $1,497.00 $1,650.00 $1,391.00 $1,497.00 $1,650.0059135 90 $1,083.00 $1,199.00 $1,248.00 $1,292.00 $1,199.00 $1,248.00 $1,292.0059136 90 $934.00 $1,251.00 $1,330.00 $1,433.00 $1,251.00 $1,330.00 $1,433.0059140 90 $461.00 $583.00 $619.00 $659.00 $583.00 $619.00 $659.0059150 90 $543.00 $1,151.00 $1,239.00 $1,364.00 $1,151.00 $1,239.00 $1,364.0059151 90 $690.00 $1,117.00 $1,201.00 $1,320.00 $1,117.00 $1,201.00 $1,320.0059160 10 $279.00 $300.00 $323.00 $351.00 $259.00 $278.00 $306.0059200 0 $79.00 $104.00 $111.00 $119.00 $67.00 $72.00 $79.0059300 0 $179.00 $283.00 $304.00 $329.00 $223.00 $240.00 $264.0059320 0 $196.00 $228.00 $246.00 $270.00 $228.00 $246.00 $270.0059325 0 $316.00 $365.00 $393.00 $434.00 $365.00 $393.00 $434.0059350 0 $375.00 $395.00 $419.00 $454.00 $395.00 $419.00 $454.0059400 0 $1,816.00 $3,098.00 $3,325.00 $3,631.00 $3,098.00 $3,325.00 $3,631.0059409 0 $1,019.00 $1,223.00 $1,312.00 $1,447.00 $1,223.00 $1,312.00 $1,447.0059410 0 $1,123.00 $1,559.00 $1,673.00 $1,843.00 $1,559.00 $1,673.00 $1,843.0059412 0 $141.00 $156.00 $167.00 $185.00 $156.00 $167.00 $185.0059414 0 $134.00 $139.00 $149.00 $166.00 $139.00 $149.00 $166.0059425 0 $414.00 $667.00 $715.00 $773.00 $534.00 $572.00 $630.0059426 0 $708.00 $1,190.00 $1,275.00 $1,376.00 $940.00 $1,007.00 $1,107.0059430 0 $140.00 $270.00 $289.00 $311.00 $209.00 $223.00 $246.0059510 0 $2,064.00 $3,448.00 $3,708.00 $4,066.00 $3,448.00 $3,708.00 $4,066.0059514 0 $1,199.00 $1,381.00 $1,484.00 $1,640.00 $1,381.00 $1,484.00 $1,640.0059515 0 $1,324.00 $1,896.00 $2,039.00 $2,252.00 $1,896.00 $2,039.00 $2,252.0059525 ZZZ $591.00 $728.00 $782.00 $864.00 $728.00 $782.00 $864.0059610 0 $1,805.00 $3,270.00 $3,518.00 $3,860.00 $3,270.00 $3,518.00 $3,860.0059612 0 $1,113.00 $1,385.00 $1,490.00 $1,653.00 $1,385.00 $1,490.00 $1,653.0059614 0 $1,208.00 $1,720.00 $1,851.00 $2,051.00 $1,720.00 $1,851.00 $2,051.0059618 0 $2,035.00 $3,497.00 $3,762.00 $4,129.00 $3,497.00 $3,762.00 $4,129.00



Surgery







59620 0 $1,293.00 $1,415.00 $1,518.00 $1,675.00 $1,415.00 $1,518.00 $1,675.0059622 0 $1,397.00 $1,950.00 $2,099.00 $2,321.00 $1,950.00 $2,099.00 $2,321.0059812 90 $343.00 $469.00 $505.00 $549.00 $439.00 $472.00 $516.0059820 90 $389.00 $556.00 $598.00 $646.00 $525.00 $565.00 $613.0059821 90 $398.00 $562.00 $604.00 $656.00 $529.00 $568.00 $619.0059830 90 $496.00 $649.00 $698.00 $765.00 $649.00 $698.00 $765.0059840 10 $331.00 $321.00 $345.00 $376.00 $309.00 $332.00 $363.0059841 10 $443.00 $568.00 $611.00 $668.00 $539.00 $580.00 $637.0059850 90 $449.00 $501.00 $523.00 $540.00 $501.00 $523.00 $540.0059851 90 $464.00 $531.00 $554.00 $572.00 $531.00 $554.00 $572.0059852 90 $642.00 $724.00 $756.00 $780.00 $724.00 $756.00 $780.0059855 90 $477.00 $619.00 $666.00 $731.00 $619.00 $666.00 $731.0059856 90 $577.00 $729.00 $785.00 $863.00 $729.00 $785.00 $863.0059857 90 $711.00 $747.00 $778.00 $805.00 $747.00 $778.00 $805.0059866 0 $304.00 $313.00 $326.00 $337.00 $313.00 $326.00 $337.0059870 90 $348.00 $698.00 $751.00 $817.00 $698.00 $751.00 $817.0059871 0 $192.00 $200.00 $215.00 $236.00 $200.00 $215.00 $236.0059898 YYY BR -------- -------- -------- -------- -------- --------59899 YYY BR -------- -------- -------- -------- -------- --------60000 10 $114.00 $245.00 $260.00 $271.00 $221.00 $235.00 $246.0060100 0 $96.00 $161.00 $169.00 $175.00 $116.00 $121.00 $126.0060200 90 $744.00 $971.00 $1,033.00 $1,107.00 $971.00 $1,033.00 $1,107.0060210 90 $872.00 $1,047.00 $1,116.00 $1,203.00 $1,047.00 $1,116.00 $1,203.0060212 90 $1,170.00 $1,491.00 $1,589.00 $1,715.00 $1,491.00 $1,589.00 $1,715.0060220 90 $851.00 $1,044.00 $1,111.00 $1,194.00 $1,044.00 $1,111.00 $1,194.0060225 90 $1,107.00 $1,378.00 $1,469.00 $1,583.00 $1,378.00 $1,469.00 $1,583.0060240 90 $1,228.00 $1,364.00 $1,453.00 $1,570.00 $1,364.00 $1,453.00 $1,570.0060252 90 $1,427.00 $1,962.00 $2,090.00 $2,260.00 $1,962.00 $2,090.00 $2,260.0060254 90 $1,911.00 $2,482.00 $2,638.00 $2,841.00 $2,482.00 $2,638.00 $2,841.0060260 90 $1,022.00 $1,620.00 $1,724.00 $1,858.00 $1,620.00 $1,724.00 $1,858.0060270 90 $1,468.00 $2,034.00 $2,168.00 $2,350.00 $2,034.00 $2,168.00 $2,350.0060271 90 $1,210.00 $1,568.00 $1,669.00 $1,800.00 $1,568.00 $1,669.00 $1,800.0060280 90 $546.00 $646.00 $685.00 $723.00 $646.00 $685.00 $723.0060281 90 $670.00 $858.00 $908.00 $959.00 $858.00 $908.00 $959.0060300 0 -------- $167.00 $177.00 $181.00 $73.00 $77.00 $81.0060500 90 $1,232.00 $1,432.00 $1,529.00 $1,657.00 $1,432.00 $1,529.00 $1,657.0060502 90 $1,475.00 $1,914.00 $2,044.00 $2,220.00 $1,914.00 $2,044.00 $2,220.0060505 90 $1,631.00 $2,056.00 $2,190.00 $2,368.00 $2,056.00 $2,190.00 $2,368.0060512 ZZZ $310.00 $365.00 $390.00 $426.00 $365.00 $390.00 $426.0060520 90 $1,405.00 $1,558.00 $1,669.00 $1,822.00 $1,558.00 $1,669.00 $1,822.0060521 90 $1,591.00 $1,684.00 $1,804.00 $1,975.00 $1,684.00 $1,804.00 $1,975.0060522 90 $1,820.00 $2,039.00 $2,183.00 $2,393.00 $2,039.00 $2,183.00 $2,393.0060540 90 $1,272.00 $1,572.00 $1,673.00 $1,808.00 $1,572.00 $1,673.00 $1,808.0060545 90 $1,505.00 $1,805.00 $1,921.00 $2,078.00 $1,805.00 $1,921.00 $2,078.0060600 90 $1,477.00 $2,091.00 $2,231.00 $2,434.00 $2,091.00 $2,231.00 $2,434.0060605 90 $1,624.00 $2,592.00 $2,767.00 $3,030.00 $2,592.00 $2,767.00 $3,030.0060650 90 $1,340.00 $1,777.00 $1,894.00 $2,057.00 $1,777.00 $1,894.00 $2,057.0060659 YYY BR -------- -------- -------- -------- -------- --------60699 YYY BR -------- -------- -------- -------- -------- --------61020 0 $150.00 $152.00 $164.00 $181.00 $152.00 $164.00 $181.00



Surgery







61026 0 $138.00 $151.00 $160.00 $170.00 $151.00 $160.00 $170.0061050 0 $106.00 $125.00 $131.00 $137.00 $125.00 $131.00 $137.0061055 0 $143.00 $178.00 $189.00 $203.00 $178.00 $189.00 $203.0061070 0 $67.00 $85.00 $90.00 $97.00 $85.00 $90.00 $97.0061105 90 $503.00 $691.00 $754.00 $838.00 $691.00 $754.00 $838.0061107 0 $863.00 $494.00 $542.00 $620.00 $494.00 $542.00 $620.0061108 90 $959.00 $1,385.00 $1,514.00 $1,694.00 $1,385.00 $1,514.00 $1,694.0061120 90 $733.00 $1,141.00 $1,249.00 $1,403.00 $1,141.00 $1,249.00 $1,403.0061140 90 $1,389.00 $1,946.00 $2,130.00 $2,402.00 $1,946.00 $2,130.00 $2,402.0061150 90 $1,503.00 $2,064.00 $2,260.00 $2,554.00 $2,064.00 $2,260.00 $2,554.0061151 90 $795.00 $1,538.00 $1,687.00 $1,907.00 $1,538.00 $1,687.00 $1,907.0061154 90 $1,393.00 $1,951.00 $2,135.00 $2,403.00 $1,951.00 $2,135.00 $2,403.0061156 90 $1,473.00 $1,921.00 $2,105.00 $2,381.00 $1,921.00 $2,105.00 $2,381.0061210 0 $527.00 $580.00 $637.00 $730.00 $580.00 $637.00 $730.0061215 90 $637.00 $768.00 $839.00 $934.00 $768.00 $839.00 $934.0061250 90 $888.00 $1,225.00 $1,325.00 $1,461.00 $1,225.00 $1,325.00 $1,461.0061253 90 $1,042.00 $1,201.00 $1,269.00 $1,346.00 $1,201.00 $1,269.00 $1,346.0061304 90 $2,005.00 $2,540.00 $2,782.00 $3,146.00 $2,540.00 $2,782.00 $3,146.0061305 90 $2,419.00 $3,101.00 $3,400.00 $3,854.00 $3,101.00 $3,400.00 $3,854.0061312 90 $2,187.00 $3,222.00 $3,532.00 $4,007.00 $3,222.00 $3,532.00 $4,007.0061313 90 $2,207.00 $3,067.00 $3,360.00 $3,802.00 $3,067.00 $3,360.00 $3,802.0061314 90 $2,200.00 $2,813.00 $3,080.00 $3,481.00 $2,813.00 $3,080.00 $3,481.0061315 90 $2,393.00 $3,200.00 $3,508.00 $3,975.00 $3,200.00 $3,508.00 $3,975.0061316 ZZZ $88.00 $138.00 $152.00 $174.00 $138.00 $152.00 $174.0061320 90 $2,118.00 $2,941.00 $3,222.00 $3,648.00 $2,941.00 $3,222.00 $3,648.0061321 90 $2,310.00 $3,246.00 $3,554.00 $4,023.00 $3,246.00 $3,554.00 $4,023.0061322 90 $1,779.00 $3,683.00 $4,038.00 $4,581.00 $3,683.00 $4,038.00 $4,581.0061323 90 $1,842.00 $3,738.00 $4,104.00 $4,672.00 $3,738.00 $4,104.00 $4,672.0061330 90 $1,706.00 $2,351.00 $2,473.00 $2,585.00 $2,351.00 $2,473.00 $2,585.0061332 90 $2,307.00 $2,567.00 $2,682.00 $2,766.00 $2,567.00 $2,682.00 $2,766.0061333 90 $2,231.00 $2,662.00 $2,793.00 $2,909.00 $2,662.00 $2,793.00 $2,909.0061340 90 $1,584.00 $2,191.00 $2,392.00 $2,689.00 $2,191.00 $2,392.00 $2,689.0061343 90 $2,673.00 $3,396.00 $3,721.00 $4,215.00 $3,396.00 $3,721.00 $4,215.0061345 90 $2,259.00 $3,147.00 $3,449.00 $3,909.00 $3,147.00 $3,449.00 $3,909.0061450 90 $2,173.00 $2,979.00 $3,267.00 $3,708.00 $2,979.00 $3,267.00 $3,708.0061458 90 $2,433.00 $3,104.00 $3,401.00 $3,854.00 $3,104.00 $3,401.00 $3,854.0061460 90 $2,426.00 $3,279.00 $3,600.00 $4,092.00 $3,279.00 $3,600.00 $4,092.0061480 90 $1,922.00 $2,375.00 $2,504.00 $2,655.00 $2,375.00 $2,504.00 $2,655.0061500 90 $1,637.00 $2,005.00 $2,174.00 $2,413.00 $2,005.00 $2,174.00 $2,413.0061501 90 $1,353.00 $1,744.00 $1,889.00 $2,088.00 $1,744.00 $1,889.00 $2,088.0061510 90 $2,506.00 $3,372.00 $3,694.00 $4,178.00 $3,372.00 $3,694.00 $4,178.0061512 90 $2,981.00 $3,945.00 $4,322.00 $4,902.00 $3,945.00 $4,322.00 $4,902.0061514 90 $2,262.00 $2,932.00 $3,210.00 $3,630.00 $2,932.00 $3,210.00 $3,630.0061516 90 $2,253.00 $2,861.00 $3,132.00 $3,540.00 $2,861.00 $3,132.00 $3,540.0061517 ZZZ $74.00 $138.00 $152.00 $174.00 $138.00 $152.00 $174.0061518 90 $3,163.00 $4,263.00 $4,671.00 $5,294.00 $4,263.00 $4,671.00 $5,294.0061519 90 $3,450.00 $4,536.00 $4,967.00 $5,632.00 $4,536.00 $4,967.00 $5,632.0061520 90 $4,349.00 $5,817.00 $6,355.00 $7,179.00 $5,817.00 $6,355.00 $7,179.0061521 90 $3,667.00 $4,885.00 $5,354.00 $6,081.00 $4,885.00 $5,354.00 $6,081.0061522 90 $2,415.00 $3,355.00 $3,675.00 $4,165.00 $3,355.00 $3,675.00 $4,165.00



Surgery







61524 90 $2,484.00 $3,205.00 $3,514.00 $3,986.00 $3,205.00 $3,514.00 $3,986.0061526 90 $3,918.00 $5,709.00 $6,271.00 $7,152.00 $5,709.00 $6,271.00 $7,152.0061530 90 $3,611.00 $4,811.00 $5,285.00 $6,026.00 $4,811.00 $5,285.00 $6,026.0061531 90 $1,344.00 $1,872.00 $2,050.00 $2,312.00 $1,872.00 $2,050.00 $2,312.0061533 90 $1,712.00 $2,348.00 $2,573.00 $2,913.00 $2,348.00 $2,573.00 $2,913.0061534 90 $1,535.00 $2,498.00 $2,729.00 $3,070.00 $2,498.00 $2,729.00 $3,070.0061535 90 $958.00 $1,526.00 $1,670.00 $1,877.00 $1,526.00 $1,670.00 $1,877.0061536 90 $2,862.00 $4,027.00 $4,423.00 $5,037.00 $4,027.00 $4,423.00 $5,037.0061537 90 -------- $3,819.00 $4,187.00 $4,758.00 $3,819.00 $4,187.00 $4,758.0061538 90 $2,466.00 $4,163.00 $4,571.00 $5,209.00 $4,163.00 $4,571.00 $5,209.0061539 90 $2,660.00 $3,632.00 $3,977.00 $4,505.00 $3,632.00 $3,977.00 $4,505.0061540 90 -------- $3,402.00 $3,735.00 $4,247.00 $3,402.00 $3,735.00 $4,247.0061541 90 $2,363.00 $3,349.00 $3,676.00 $4,180.00 $3,349.00 $3,676.00 $4,180.0061543 90 $2,307.00 $3,251.00 $3,541.00 $3,972.00 $3,251.00 $3,541.00 $3,972.0061544 90 $2,271.00 $2,964.00 $3,254.00 $3,699.00 $2,964.00 $3,254.00 $3,699.0061545 90 $3,474.00 $4,970.00 $5,458.00 $6,213.00 $4,970.00 $5,458.00 $6,213.0061546 90 $2,695.00 $3,599.00 $3,951.00 $4,496.00 $3,599.00 $3,951.00 $4,496.0061548 90 $1,964.00 $2,407.00 $2,619.00 $2,934.00 $2,407.00 $2,619.00 $2,934.0061550 90 $1,141.00 $1,414.00 $1,495.00 $1,584.00 $1,414.00 $1,495.00 $1,584.0061552 90 $1,463.00 $1,705.00 $1,798.00 $1,908.00 $1,705.00 $1,798.00 $1,908.0061556 90 $1,760.00 $2,397.00 $2,593.00 $2,875.00 $2,397.00 $2,593.00 $2,875.0061557 90 $1,807.00 $2,449.00 $2,666.00 $2,984.00 $2,449.00 $2,666.00 $2,984.0061558 90 $2,085.00 $2,919.00 $3,204.00 $3,635.00 $2,919.00 $3,204.00 $3,635.0061559 90 $2,700.00 $3,150.00 $3,367.00 $3,654.00 $3,150.00 $3,367.00 $3,654.0061563 90 $2,175.00 $2,942.00 $3,214.00 $3,628.00 $2,942.00 $3,214.00 $3,628.0061564 90 $2,597.00 $3,527.00 $3,828.00 $4,267.00 $3,527.00 $3,828.00 $4,267.0061566 90 -------- $3,481.00 $3,817.00 $4,331.00 $3,481.00 $3,817.00 $4,331.0061567 90 -------- $3,995.00 $4,386.00 $4,989.00 $3,995.00 $4,386.00 $4,989.0061570 90 $1,975.00 $2,884.00 $3,161.00 $3,581.00 $2,884.00 $3,161.00 $3,581.0061571 90 $2,140.00 $3,077.00 $3,375.00 $3,828.00 $3,077.00 $3,375.00 $3,828.0061575 90 $2,992.00 $3,180.00 $3,371.00 $3,612.00 $3,180.00 $3,371.00 $3,612.0061576 90 $3,772.00 $5,382.00 $5,745.00 $6,191.00 $5,382.00 $5,745.00 $6,191.0061580 90 $2,383.00 $3,727.00 $4,002.00 $4,335.00 $3,727.00 $4,002.00 $4,335.0061581 90 $2,674.00 $3,893.00 $4,125.00 $4,361.00 $3,893.00 $4,125.00 $4,361.0061582 90 $2,557.00 $4,372.00 $4,757.00 $5,258.00 $4,372.00 $4,757.00 $5,258.0061583 90 $2,972.00 $4,424.00 $4,835.00 $5,425.00 $4,424.00 $4,835.00 $5,425.0061584 90 $2,830.00 $4,363.00 $4,768.00 $5,345.00 $4,363.00 $4,768.00 $5,345.0061585 90 $3,142.00 $4,961.00 $5,438.00 $6,132.00 $4,961.00 $5,438.00 $6,132.0061586 90 $2,097.00 $3,644.00 $3,980.00 $4,419.00 $3,644.00 $3,980.00 $4,419.0061590 90 $3,299.00 $4,517.00 $4,816.00 $5,181.00 $4,517.00 $4,816.00 $5,181.0061591 90 $3,491.00 $4,631.00 $4,961.00 $5,385.00 $4,631.00 $4,961.00 $5,385.0061592 90 $3,245.00 $4,855.00 $5,301.00 $5,942.00 $4,855.00 $5,301.00 $5,942.0061595 90 $2,350.00 $3,521.00 $3,779.00 $4,101.00 $3,521.00 $3,779.00 $4,101.0061596 90 $2,827.00 $3,577.00 $3,779.00 $4,000.00 $3,577.00 $3,779.00 $4,000.0061597 90 $3,046.00 $4,306.00 $4,689.00 $5,249.00 $4,306.00 $4,689.00 $5,249.0061598 90 $2,693.00 $4,344.00 $4,755.00 $5,339.00 $4,344.00 $4,755.00 $5,339.0061600 90 $2,039.00 $3,173.00 $3,400.00 $3,670.00 $3,173.00 $3,400.00 $3,670.0061601 90 $2,279.00 $3,682.00 $4,018.00 $4,486.00 $3,682.00 $4,018.00 $4,486.0061605 90 $2,299.00 $3,200.00 $3,398.00 $3,617.00 $3,200.00 $3,398.00 $3,617.0061606 90 $3,178.00 $4,553.00 $4,959.00 $5,542.00 $4,553.00 $4,959.00 $5,542.00



Surgery







61607 90 $2,961.00 $4,089.00 $4,405.00 $4,836.00 $4,089.00 $4,405.00 $4,836.0061608 90 $3,458.00 $4,988.00 $5,451.00 $6,133.00 $4,988.00 $5,451.00 $6,133.0061610 ZZZ $2,354.00 $2,296.00 $2,417.00 $2,576.00 $2,296.00 $2,417.00 $2,576.0061611 ZZZ $584.00 $574.00 $604.00 $644.00 $574.00 $604.00 $644.0061612 ZZZ $2,219.00 $2,158.00 $2,272.00 $2,421.00 $2,158.00 $2,272.00 $2,421.0061613 90 $3,375.00 $4,934.00 $5,380.00 $6,024.00 $4,934.00 $5,380.00 $6,024.0061615 90 $2,576.00 $3,347.00 $3,544.00 $3,762.00 $3,347.00 $3,544.00 $3,762.0061616 90 $3,535.00 $5,088.00 $5,540.00 $6,189.00 $5,088.00 $5,540.00 $6,189.0061618 90 $1,389.00 $1,978.00 $2,150.00 $2,398.00 $1,978.00 $2,150.00 $2,398.0061619 90 $1,682.00 $2,181.00 $2,353.00 $2,592.00 $2,181.00 $2,353.00 $2,592.0061623 0 $540.00 $861.00 $926.00 $1,024.00 $861.00 $926.00 $1,024.0061624 0 $1,073.00 $1,733.00 $1,864.00 $2,066.00 $1,733.00 $1,864.00 $2,066.0061626 0 $877.00 $1,281.00 $1,352.00 $1,451.00 $1,281.00 $1,352.00 $1,451.0061630 0 -------- $2,010.00 $2,163.00 $2,388.00 $2,010.00 $2,163.00 $2,388.0061635 0 -------- $2,151.00 $2,306.00 $2,531.00 $2,151.00 $2,306.00 $2,531.0061640 0 -------- $956.00 $1,006.00 $1,072.00 $956.00 $1,006.00 $1,072.0061641 ZZZ -------- $335.00 $353.00 $376.00 $335.00 $353.00 $376.0061642 ZZZ -------- $671.00 $706.00 $753.00 $671.00 $706.00 $753.0061645 0 -------- $1,171.00 $1,248.00 $1,367.00 $1,171.00 $1,248.00 $1,367.0061650 0 -------- $777.00 $825.00 $896.00 $777.00 $825.00 $896.0061651 ZZZ -------- $330.00 $350.00 $381.00 $330.00 $350.00 $381.0061680 90 $2,758.00 $3,465.00 $3,794.00 $4,295.00 $3,465.00 $3,794.00 $4,295.0061682 90 $4,798.00 $6,469.00 $7,092.00 $8,073.00 $6,469.00 $7,092.00 $8,073.0061684 90 $3,341.00 $4,442.00 $4,878.00 $5,556.00 $4,442.00 $4,878.00 $5,556.0061686 90 $5,012.00 $6,981.00 $7,660.00 $8,727.00 $6,981.00 $7,660.00 $8,727.0061690 90 $2,556.00 $3,351.00 $3,670.00 $4,154.00 $3,351.00 $3,670.00 $4,154.0061692 90 $4,007.00 $5,665.00 $6,211.00 $7,062.00 $5,665.00 $6,211.00 $7,062.0061697 90 $3,231.00 $6,573.00 $7,211.00 $8,210.00 $6,573.00 $7,211.00 $8,210.0061698 90 $3,103.00 $7,220.00 $7,928.00 $9,047.00 $7,220.00 $7,928.00 $9,047.0061700 90 $4,037.00 $5,276.00 $5,783.00 $6,568.00 $5,276.00 $5,783.00 $6,568.0061702 90 $4,019.00 $6,245.00 $6,853.00 $7,805.00 $6,245.00 $6,853.00 $7,805.0061703 90 $1,444.00 $2,108.00 $2,312.00 $2,619.00 $2,108.00 $2,312.00 $2,619.0061705 90 $3,043.00 $3,960.00 $4,324.00 $4,874.00 $3,960.00 $4,324.00 $4,874.0061708 90 $2,546.00 $3,123.00 $3,296.00 $3,506.00 $3,123.00 $3,296.00 $3,506.0061710 90 $2,129.00 $3,357.00 $3,686.00 $4,196.00 $3,357.00 $3,686.00 $4,196.0061711 90 $3,150.00 $4,019.00 $4,403.00 $4,994.00 $4,019.00 $4,403.00 $4,994.0061720 90 $1,558.00 $1,970.00 $2,162.00 $2,449.00 $1,970.00 $2,162.00 $2,449.0061735 90 $1,664.00 $2,437.00 $2,672.00 $3,027.00 $2,437.00 $2,672.00 $3,027.0061750 90 $1,521.00 $2,176.00 $2,386.00 $2,704.00 $2,176.00 $2,386.00 $2,704.0061751 90 $1,628.00 $2,133.00 $2,339.00 $2,644.00 $2,133.00 $2,339.00 $2,644.0061760 90 $1,670.00 $2,458.00 $2,698.00 $3,063.00 $2,458.00 $2,698.00 $3,063.0061770 90 $1,867.00 $2,510.00 $2,753.00 $3,125.00 $2,510.00 $2,753.00 $3,125.0061781 ZZZ -------- $369.00 $404.00 $462.00 $369.00 $404.00 $462.0061782 ZZZ -------- $261.00 $276.00 $295.00 $261.00 $276.00 $295.0061783 ZZZ -------- $361.00 $394.00 $446.00 $361.00 $394.00 $446.0061790 90 $952.00 $1,355.00 $1,484.00 $1,672.00 $1,355.00 $1,484.00 $1,672.0061791 90 $1,205.00 $1,640.00 $1,789.00 $2,007.00 $1,640.00 $1,789.00 $2,007.0061796 90 -------- $1,567.00 $1,717.00 $1,940.00 $1,567.00 $1,717.00 $1,940.0061797 ZZZ -------- $347.00 $382.00 $438.00 $347.00 $382.00 $438.0061798 90 -------- $2,143.00 $2,348.00 $2,661.00 $2,143.00 $2,348.00 $2,661.00



Surgery







61799 ZZZ -------- $478.00 $526.00 $602.00 $478.00 $526.00 $602.0061800 ZZZ -------- $240.00 $264.00 $300.00 $240.00 $264.00 $300.0061850 90 $1,090.00 $1,519.00 $1,665.00 $1,882.00 $1,519.00 $1,665.00 $1,882.0061860 90 $1,197.00 $2,435.00 $2,673.00 $3,035.00 $2,435.00 $2,673.00 $3,035.0061863 90 -------- $2,316.00 $2,538.00 $2,867.00 $2,316.00 $2,538.00 $2,867.0061864 ZZZ -------- $447.00 $492.00 $563.00 $447.00 $492.00 $563.0061867 90 -------- $3,531.00 $3,870.00 $4,390.00 $3,531.00 $3,870.00 $4,390.0061868 ZZZ -------- $784.00 $861.00 $985.00 $784.00 $861.00 $985.0061870 90 $616.00 $1,749.00 $1,901.00 $2,117.00 $1,749.00 $1,901.00 $2,117.0061880 90 $559.00 $868.00 $948.00 $1,057.00 $868.00 $948.00 $1,057.0061885 90 $262.00 $777.00 $846.00 $936.00 $777.00 $846.00 $936.0061886 90 $678.00 $1,279.00 $1,396.00 $1,551.00 $1,279.00 $1,396.00 $1,551.0061888 10 $331.00 $606.00 $662.00 $743.00 $606.00 $662.00 $743.0062000 90 $848.00 $1,593.00 $1,747.00 $1,974.00 $1,593.00 $1,747.00 $1,974.0062005 90 $1,282.00 $1,910.00 $2,087.00 $2,350.00 $1,910.00 $2,087.00 $2,350.0062010 90 $1,754.00 $2,360.00 $2,586.00 $2,924.00 $2,360.00 $2,586.00 $2,924.0062100 90 $1,962.00 $2,445.00 $2,663.00 $2,986.00 $2,445.00 $2,663.00 $2,986.0062115 90 $1,686.00 $1,922.00 $2,026.00 $2,150.00 $1,922.00 $2,026.00 $2,150.0062117 90 $2,211.00 $2,401.00 $2,532.00 $2,685.00 $2,401.00 $2,532.00 $2,685.0062120 90 $1,898.00 $2,442.00 $2,587.00 $2,735.00 $2,442.00 $2,587.00 $2,735.0062121 90 $1,822.00 $2,389.00 $2,568.00 $2,798.00 $2,389.00 $2,568.00 $2,798.0062140 90 $1,221.00 $1,577.00 $1,718.00 $1,922.00 $1,577.00 $1,718.00 $1,922.0062141 90 $1,955.00 $1,739.00 $1,895.00 $2,122.00 $1,739.00 $1,895.00 $2,122.0062142 90 $1,011.00 $1,355.00 $1,480.00 $1,659.00 $1,355.00 $1,480.00 $1,659.0062143 90 $1,096.00 $1,592.00 $1,741.00 $1,959.00 $1,592.00 $1,741.00 $1,959.0062145 90 $1,566.00 $2,170.00 $2,373.00 $2,674.00 $2,170.00 $2,373.00 $2,674.0062146 90 $1,327.00 $1,915.00 $2,098.00 $2,369.00 $1,915.00 $2,098.00 $2,369.0062147 90 $1,566.00 $2,168.00 $2,359.00 $2,640.00 $2,168.00 $2,359.00 $2,640.0062148 ZZZ $120.00 $200.00 $220.00 $253.00 $200.00 $220.00 $253.0062160 ZZZ $172.00 $299.00 $329.00 $378.00 $299.00 $329.00 $378.0062161 90 $1,229.00 $2,348.00 $2,573.00 $2,911.00 $2,348.00 $2,573.00 $2,911.0062162 90 $1,578.00 $2,924.00 $3,208.00 $3,639.00 $2,924.00 $3,208.00 $3,639.0062163 90 $999.00 $1,679.00 $1,809.00 $1,984.00 $1,679.00 $1,809.00 $1,984.0062164 90 $1,706.00 $3,210.00 $3,517.00 $3,979.00 $3,210.00 $3,517.00 $3,979.0062165 90 $1,336.00 $2,349.00 $2,545.00 $2,825.00 $2,349.00 $2,545.00 $2,825.0062180 90 $1,695.00 $2,466.00 $2,702.00 $3,057.00 $2,466.00 $2,702.00 $3,057.0062190 90 $1,034.00 $1,346.00 $1,467.00 $1,639.00 $1,346.00 $1,467.00 $1,639.0062192 90 $1,146.00 $1,496.00 $1,636.00 $1,839.00 $1,496.00 $1,636.00 $1,839.0062194 10 $239.00 $703.00 $767.00 $854.00 $703.00 $767.00 $854.0062200 90 $1,625.00 $2,129.00 $2,334.00 $2,644.00 $2,129.00 $2,334.00 $2,644.0062201 90 $1,200.00 $1,858.00 $2,036.00 $2,296.00 $1,858.00 $2,036.00 $2,296.0062220 90 $1,215.00 $1,580.00 $1,728.00 $1,944.00 $1,580.00 $1,728.00 $1,944.0062223 90 $1,199.00 $1,602.00 $1,750.00 $1,960.00 $1,602.00 $1,750.00 $1,960.0062225 90 $488.00 $797.00 $871.00 $970.00 $797.00 $871.00 $970.0062230 90 $935.00 $1,291.00 $1,411.00 $1,586.00 $1,291.00 $1,411.00 $1,586.0062252 0 $85.00 $126.00 $136.00 $148.00 $126.00 $136.00 $148.0062252-26 0 -------- $72.00 $79.00 $90.00 $72.00 $79.00 $90.0062252-TC 0 -------- $53.00 $57.00 $58.00 $53.00 $57.00 $58.0062256 90 $616.00 $910.00 $995.00 $1,111.00 $910.00 $995.00 $1,111.0062258 90 $1,308.00 $1,729.00 $1,891.00 $2,128.00 $1,729.00 $1,891.00 $2,128.00



Surgery







62263 10 $426.00 $913.00 $967.00 $985.00 $488.00 $511.00 $527.0062264 10 $593.00 $596.00 $629.00 $645.00 $347.00 $362.00 $377.0062267 0 -------- $353.00 $372.00 $383.00 $233.00 $243.00 $253.0062268 0 $285.00 $378.00 $395.00 $413.00 $378.00 $395.00 $413.0062269 0 $271.00 $397.00 $416.00 $439.00 $397.00 $416.00 $439.0062270 0 $109.00 $225.00 $239.00 $247.00 $114.00 $121.00 $128.0062272 0 $137.00 $285.00 $306.00 $318.00 $124.00 $133.00 $145.0062273 0 $130.00 $246.00 $259.00 $267.00 $166.00 $173.00 $180.0062280 10 $199.00 $431.00 $458.00 $472.00 $235.00 $247.00 $261.0062281 10 $186.00 $342.00 $363.00 $377.00 $229.00 $242.00 $255.0062282 10 $211.00 $412.00 $438.00 $450.00 $211.00 $223.00 $234.0062284 0 $196.00 $256.00 $272.00 $278.00 $125.00 $131.00 $138.0062287 90 $784.00 $824.00 $866.00 $906.00 $824.00 $866.00 $906.0062290 0 $235.00 $470.00 $497.00 $510.00 $251.00 $263.00 $274.0062291 0 $232.00 $465.00 $492.00 $502.00 $248.00 $259.00 $269.0062292 90 $1,064.00 $839.00 $877.00 $907.00 $839.00 $877.00 $907.0062294 90 $821.00 $1,134.00 $1,185.00 $1,225.00 $1,134.00 $1,185.00 $1,225.0062302 0 -------- $339.00 $359.00 $368.00 $179.00 $187.00 $195.0062303 0 -------- $352.00 $373.00 $382.00 $182.00 $190.00 $198.0062304 0 -------- $336.00 $355.00 $364.00 $176.00 $184.00 $192.0062305 0 -------- $366.00 $387.00 $396.00 $184.00 $192.00 $200.0062310 0 $200.00 $336.00 $356.00 $363.00 $157.00 $164.00 $171.0062311 0 $201.00 $310.00 $329.00 $335.00 $130.00 $136.00 $141.0062318 0 $208.00 $323.00 $341.00 $348.00 $145.00 $150.00 $156.0062319 0 $203.00 $237.00 $250.00 $257.00 $139.00 $145.00 $152.0062350 10 $488.00 $592.00 $630.00 $675.00 $592.00 $630.00 $675.0062351 90 $782.00 $1,305.00 $1,413.00 $1,554.00 $1,305.00 $1,413.00 $1,554.0062355 10 $402.00 $396.00 $423.00 $453.00 $396.00 $423.00 $453.0062360 10 $195.00 $461.00 $493.00 $531.00 $461.00 $493.00 $531.0062361 10 $390.00 $532.00 $569.00 $614.00 $532.00 $569.00 $614.0062362 10 $517.00 $573.00 $613.00 $662.00 $573.00 $613.00 $662.0062365 10 $418.00 $439.00 $471.00 $507.00 $439.00 $471.00 $507.0062367 0 BR $59.00 $62.00 $64.00 $37.00 $39.00 $41.0062368 0 BR $81.00 $85.00 $88.00 $52.00 $54.00 $57.0062369 0 -------- $168.00 $178.00 $182.00 $52.00 $55.00 $57.0062370 0 -------- $177.00 $188.00 $192.00 $68.00 $71.00 $75.0063001 90 $1,882.00 $1,898.00 $2,069.00 $2,319.00 $1,898.00 $2,069.00 $2,319.0063003 90 $1,591.00 $1,883.00 $2,048.00 $2,287.00 $1,883.00 $2,048.00 $2,287.0063005 90 $1,390.00 $1,792.00 $1,948.00 $2,167.00 $1,792.00 $1,948.00 $2,167.0063011 90 $1,151.00 $1,641.00 $1,768.00 $1,938.00 $1,641.00 $1,768.00 $1,938.0063012 90 $1,568.00 $1,804.00 $1,957.00 $2,173.00 $1,804.00 $1,957.00 $2,173.0063015 90 $1,862.00 $2,271.00 $2,478.00 $2,780.00 $2,271.00 $2,478.00 $2,780.0063016 90 $1,788.00 $2,314.00 $2,517.00 $2,810.00 $2,314.00 $2,517.00 $2,810.0063017 90 $1,489.00 $1,908.00 $2,078.00 $2,321.00 $1,908.00 $2,078.00 $2,321.0063020 90 $1,395.00 $1,754.00 $1,902.00 $2,107.00 $1,754.00 $1,902.00 $2,107.0063030 90 $1,145.00 $1,456.00 $1,576.00 $1,736.00 $1,456.00 $1,576.00 $1,736.0063035 ZZZ $280.00 $293.00 $317.00 $354.00 $293.00 $317.00 $354.0063040 90 $1,764.00 $2,107.00 $2,283.00 $2,532.00 $2,107.00 $2,283.00 $2,532.0063042 90 $1,620.00 $1,949.00 $2,105.00 $2,317.00 $1,949.00 $2,105.00 $2,317.0063043 ZZZ BR -------- -------- -------- -------- -------- --------



Surgery







63044 ZZZ BR -------- -------- -------- -------- -------- --------63045 90 $1,647.00 $1,961.00 $2,134.00 $2,381.00 $1,961.00 $2,134.00 $2,381.0063046 90 $2,117.00 $1,844.00 $1,999.00 $2,211.00 $1,844.00 $1,999.00 $2,211.0063047 90 $1,907.00 $1,662.00 $1,800.00 $1,987.00 $1,662.00 $1,800.00 $1,987.0063048 ZZZ $367.00 $324.00 $351.00 $393.00 $324.00 $351.00 $393.0063050 90 -------- $2,251.00 $2,435.00 $2,691.00 $2,251.00 $2,435.00 $2,691.0063051 90 -------- $2,587.00 $2,799.00 $3,099.00 $2,587.00 $2,799.00 $3,099.0063055 90 $2,029.00 $2,491.00 $2,715.00 $3,046.00 $2,491.00 $2,715.00 $3,046.0063056 90 $1,960.00 $2,245.00 $2,431.00 $2,696.00 $2,245.00 $2,431.00 $2,696.0063057 ZZZ $421.00 $490.00 $531.00 $594.00 $490.00 $531.00 $594.0063064 90 $2,200.00 $2,693.00 $2,925.00 $3,262.00 $2,693.00 $2,925.00 $3,262.0063066 ZZZ $263.00 $326.00 $359.00 $412.00 $326.00 $359.00 $412.0063075 90 $1,720.00 $2,054.00 $2,228.00 $2,472.00 $2,054.00 $2,228.00 $2,472.0063076 ZZZ $383.00 $379.00 $412.00 $462.00 $379.00 $412.00 $462.0063077 90 $1,828.00 $2,265.00 $2,446.00 $2,702.00 $2,265.00 $2,446.00 $2,702.0063078 ZZZ $261.00 $293.00 $315.00 $347.00 $293.00 $315.00 $347.0063081 90 $2,203.00 $2,667.00 $2,890.00 $3,210.00 $2,667.00 $2,890.00 $3,210.0063082 ZZZ $391.00 $409.00 $443.00 $497.00 $409.00 $443.00 $497.0063085 90 $2,416.00 $2,898.00 $3,136.00 $3,481.00 $2,898.00 $3,136.00 $3,481.0063086 ZZZ $282.00 $291.00 $315.00 $352.00 $291.00 $315.00 $352.0063087 90 $2,930.00 $3,647.00 $3,943.00 $4,371.00 $3,647.00 $3,943.00 $4,371.0063088 ZZZ $381.00 $396.00 $428.00 $476.00 $396.00 $428.00 $476.0063090 90 $2,490.00 $2,927.00 $3,140.00 $3,430.00 $2,927.00 $3,140.00 $3,430.0063091 ZZZ $249.00 $267.00 $286.00 $313.00 $267.00 $286.00 $313.0063101 90 -------- $3,528.00 $3,836.00 $4,285.00 $3,528.00 $3,836.00 $4,285.0063102 90 -------- $3,436.00 $3,716.00 $4,112.00 $3,436.00 $3,716.00 $4,112.0063103 ZZZ -------- $449.00 $486.00 $543.00 $449.00 $486.00 $543.0063170 90 $1,788.00 $2,473.00 $2,713.00 $3,075.00 $2,473.00 $2,713.00 $3,075.0063172 90 $1,672.00 $2,124.00 $2,317.00 $2,599.00 $2,124.00 $2,317.00 $2,599.0063173 90 $1,851.00 $2,645.00 $2,898.00 $3,279.00 $2,645.00 $2,898.00 $3,279.0063180 90 $1,486.00 $2,305.00 $2,528.00 $2,863.00 $2,305.00 $2,528.00 $2,863.0063182 90 $1,711.00 $2,101.00 $2,262.00 $2,494.00 $2,101.00 $2,262.00 $2,494.0063185 90 $1,347.00 $1,700.00 $1,832.00 $2,007.00 $1,700.00 $1,832.00 $2,007.0063190 90 $1,610.00 $1,882.00 $2,020.00 $2,201.00 $1,882.00 $2,020.00 $2,201.0063191 90 $1,444.00 $2,074.00 $2,262.00 $2,535.00 $2,074.00 $2,262.00 $2,535.0063194 90 $1,593.00 $2,478.00 $2,718.00 $3,079.00 $2,478.00 $2,718.00 $3,079.0063195 90 $1,603.00 $2,389.00 $2,622.00 $2,974.00 $2,389.00 $2,622.00 $2,974.0063196 90 $1,810.00 $2,078.00 $2,190.00 $2,327.00 $2,078.00 $2,190.00 $2,327.0063197 90 $1,725.00 $2,660.00 $2,919.00 $3,311.00 $2,660.00 $2,919.00 $3,311.0063198 90 $1,956.00 $2,448.00 $2,580.00 $2,741.00 $2,448.00 $2,580.00 $2,741.0063199 90 $2,258.00 $2,570.00 $2,708.00 $2,877.00 $2,570.00 $2,708.00 $2,877.0063200 90 $1,569.00 $2,358.00 $2,580.00 $2,910.00 $2,358.00 $2,580.00 $2,910.0063250 90 $3,182.00 $4,311.00 $4,687.00 $5,257.00 $4,311.00 $4,687.00 $5,257.0063251 90 $3,207.00 $4,723.00 $5,183.00 $5,899.00 $4,723.00 $5,183.00 $5,899.0063252 90 $3,319.00 $4,717.00 $5,175.00 $5,888.00 $4,717.00 $5,175.00 $5,888.0063265 90 $1,940.00 $2,562.00 $2,798.00 $3,148.00 $2,562.00 $2,798.00 $3,148.0063266 90 $2,053.00 $2,634.00 $2,875.00 $3,232.00 $2,634.00 $2,875.00 $3,232.0063267 90 $1,651.00 $2,083.00 $2,264.00 $2,524.00 $2,083.00 $2,264.00 $2,524.0063268 90 $1,469.00 $2,204.00 $2,412.00 $2,719.00 $2,204.00 $2,412.00 $2,719.0063270 90 $2,197.00 $3,226.00 $3,539.00 $4,019.00 $3,226.00 $3,539.00 $4,019.00



Surgery







63271 90 $2,401.00 $3,187.00 $3,487.00 $3,943.00 $3,187.00 $3,487.00 $3,943.0063272 90 $2,206.00 $2,894.00 $3,157.00 $3,547.00 $2,894.00 $3,157.00 $3,547.0063273 90 $2,012.00 $2,881.00 $3,158.00 $3,577.00 $2,881.00 $3,158.00 $3,577.0063275 90 $2,166.00 $2,762.00 $3,018.00 $3,399.00 $2,762.00 $3,018.00 $3,399.0063276 90 $2,135.00 $2,739.00 $2,991.00 $3,366.00 $2,739.00 $2,991.00 $3,366.0063277 90 $1,905.00 $2,361.00 $2,567.00 $2,865.00 $2,361.00 $2,567.00 $2,865.0063278 90 $1,877.00 $2,466.00 $2,706.00 $3,066.00 $2,466.00 $2,706.00 $3,066.0063280 90 $2,529.00 $3,260.00 $3,570.00 $4,039.00 $3,260.00 $3,570.00 $4,039.0063281 90 $2,496.00 $3,217.00 $3,520.00 $3,977.00 $3,217.00 $3,520.00 $3,977.0063282 90 $2,305.00 $3,024.00 $3,306.00 $3,728.00 $3,024.00 $3,306.00 $3,728.0063283 90 $2,041.00 $2,912.00 $3,188.00 $3,601.00 $2,912.00 $3,188.00 $3,601.0063285 90 $2,934.00 $4,068.00 $4,464.00 $5,075.00 $4,068.00 $4,464.00 $5,075.0063286 90 $3,003.00 $4,000.00 $4,385.00 $4,974.00 $4,000.00 $4,385.00 $4,974.0063287 90 $3,012.00 $4,286.00 $4,707.00 $5,359.00 $4,286.00 $4,707.00 $5,359.0063290 90 $3,073.00 $4,261.00 $4,660.00 $5,268.00 $4,261.00 $4,660.00 $5,268.0063295 ZZZ -------- $523.00 $574.00 $658.00 $523.00 $574.00 $658.0063300 90 $2,006.00 $2,813.00 $3,067.00 $3,442.00 $2,813.00 $3,067.00 $3,442.0063301 90 $2,209.00 $3,417.00 $3,749.00 $4,257.00 $3,417.00 $3,749.00 $4,257.0063302 90 $2,290.00 $3,360.00 $3,684.00 $4,176.00 $3,360.00 $3,684.00 $4,176.0063303 90 $2,357.00 $3,582.00 $3,930.00 $4,467.00 $3,582.00 $3,930.00 $4,467.0063304 90 $2,513.00 $3,604.00 $3,944.00 $4,460.00 $3,604.00 $3,944.00 $4,460.0063305 90 $2,574.00 $3,733.00 $4,073.00 $4,586.00 $3,733.00 $4,073.00 $4,586.0063306 90 $2,596.00 $3,490.00 $3,764.00 $4,150.00 $3,490.00 $3,764.00 $4,150.0063307 90 $2,522.00 $3,517.00 $3,813.00 $4,242.00 $3,517.00 $3,813.00 $4,242.0063308 ZZZ $425.00 $502.00 $547.00 $619.00 $502.00 $547.00 $619.0063600 90 $797.00 $1,317.00 $1,380.00 $1,438.00 $1,317.00 $1,380.00 $1,438.0063610 0 $476.00 $623.00 $647.00 $674.00 $623.00 $647.00 $674.0063615 90 $1,348.00 $1,435.00 $1,512.00 $1,606.00 $1,435.00 $1,512.00 $1,606.0063620 90 -------- $1,726.00 $1,891.00 $2,138.00 $1,726.00 $1,891.00 $2,138.0063621 ZZZ -------- $399.00 $439.00 $503.00 $399.00 $439.00 $503.0063650 10 $819.00 $1,849.00 $1,968.00 $1,999.00 $600.00 $628.00 $655.0063655 90 $1,064.00 $1,246.00 $1,352.00 $1,495.00 $1,246.00 $1,352.00 $1,495.0063661 10 -------- $821.00 $874.00 $904.00 $470.00 $497.00 $527.0063662 90 -------- $1,256.00 $1,364.00 $1,508.00 $1,256.00 $1,364.00 $1,508.0063663 10 -------- $1,122.00 $1,190.00 $1,230.00 $663.00 $697.00 $735.0063664 90 -------- $1,295.00 $1,404.00 $1,552.00 $1,295.00 $1,404.00 $1,552.0063685 10 $615.00 $543.00 $581.00 $626.00 $543.00 $581.00 $626.0063688 10 $707.00 $547.00 $584.00 $629.00 $547.00 $584.00 $629.0063700 90 $1,340.00 $1,727.00 $1,845.00 $1,989.00 $1,727.00 $1,845.00 $1,989.0063702 90 $1,512.00 $1,880.00 $2,004.00 $2,152.00 $1,880.00 $2,004.00 $2,152.0063704 90 $1,708.00 $2,553.00 $2,800.00 $3,165.00 $2,553.00 $2,800.00 $3,165.0063706 90 $1,873.00 $2,543.00 $2,736.00 $2,994.00 $2,543.00 $2,736.00 $2,994.0063707 90 $1,041.00 $1,384.00 $1,499.00 $1,654.00 $1,384.00 $1,499.00 $1,654.0063709 90 $1,310.00 $1,661.00 $1,798.00 $1,987.00 $1,661.00 $1,798.00 $1,987.0063710 90 $1,165.00 $1,632.00 $1,765.00 $1,947.00 $1,632.00 $1,765.00 $1,947.0063740 90 $1,062.00 $1,436.00 $1,566.00 $1,750.00 $1,436.00 $1,566.00 $1,750.0063741 90 $741.00 $1,023.00 $1,112.00 $1,233.00 $1,023.00 $1,112.00 $1,233.0063744 90 $738.00 $1,021.00 $1,113.00 $1,240.00 $1,021.00 $1,113.00 $1,240.0063746 90 $529.00 $918.00 $1,004.00 $1,124.00 $918.00 $1,004.00 $1,124.0064400 0 $78.00 $181.00 $193.00 $202.00 $104.00 $111.00 $120.00



Surgery







64402 0 $75.00 $186.00 $199.00 $209.00 $116.00 $124.00 $134.0064405 0 $103.00 $144.00 $154.00 $161.00 $93.00 $99.00 $107.0064408 0 $120.00 $145.00 $152.00 $157.00 $108.00 $112.00 $117.0064410 0 $109.00 $172.00 $181.00 $186.00 $101.00 $105.00 $109.0064413 0 $128.00 $180.00 $191.00 $198.00 $118.00 $125.00 $132.0064415 0 $109.00 $167.00 $175.00 $180.00 $95.00 $98.00 $103.0064416 0 $159.00 $115.00 $119.00 $124.00 $115.00 $119.00 $124.0064417 0 $105.00 $182.00 $192.00 $198.00 $103.00 $108.00 $113.0064418 0 $108.00 $204.00 $217.00 $222.00 $111.00 $116.00 $121.0064420 0 $89.00 $158.00 $167.00 $172.00 $99.00 $103.00 $108.0064421 0 $128.00 $212.00 $224.00 $230.00 $133.00 $139.00 $144.0064425 0 $116.00 $188.00 $198.00 $205.00 $136.00 $142.00 $149.0064430 0 $130.00 $195.00 $206.00 $213.00 $119.00 $125.00 $131.0064435 0 $114.00 $192.00 $203.00 $210.00 $121.00 $127.00 $134.0064445 0 $68.00 $192.00 $203.00 $210.00 $106.00 $111.00 $117.0064446 0 $165.00 $115.00 $119.00 $125.00 $115.00 $119.00 $125.0064447 0 $77.00 $169.00 $178.00 $183.00 $97.00 $100.00 $105.0064448 0 $152.00 $104.00 $107.00 $112.00 $104.00 $107.00 $112.0064449 0 -------- $123.00 $128.00 $134.00 $123.00 $128.00 $134.0064450 0 $53.00 $112.00 $118.00 $121.00 $66.00 $69.00 $72.0064455 0 -------- $68.00 $71.00 $74.00 $51.00 $53.00 $55.0064461 0 -------- $209.00 $221.00 $227.00 $126.00 $131.00 $138.0064462 ZZZ -------- $119.00 $125.00 $129.00 $80.00 $83.00 $87.0064463 0 -------- $227.00 $239.00 $245.00 $122.00 $127.00 $132.0064479 0 $224.00 $332.00 $350.00 $359.00 $191.00 $200.00 $208.0064480 ZZZ $194.00 $159.00 $168.00 $173.00 $92.00 $96.00 $100.0064483 0 $206.00 $308.00 $326.00 $333.00 $163.00 $170.00 $177.0064484 ZZZ $183.00 $124.00 $130.00 $134.00 $76.00 $79.00 $82.0064486 0 -------- $175.00 $185.00 $190.00 $92.00 $96.00 $101.0064487 0 -------- $215.00 $228.00 $234.00 $108.00 $113.00 $119.0064488 0 -------- $216.00 $229.00 $235.00 $117.00 $122.00 $128.0064489 0 -------- $299.00 $317.00 $325.00 $131.00 $137.00 $144.0064490 0 -------- $268.00 $283.00 $290.00 $154.00 $161.00 $168.0064491 ZZZ -------- $133.00 $140.00 $144.00 $88.00 $92.00 $95.0064492 ZZZ -------- $134.00 $141.00 $145.00 $89.00 $93.00 $97.0064493 0 -------- $243.00 $257.00 $263.00 $132.00 $138.00 $144.0064494 ZZZ -------- $122.00 $129.00 $133.00 $76.00 $79.00 $83.0064495 ZZZ -------- $123.00 $130.00 $133.00 $77.00 $80.00 $84.0064505 0 $104.00 $149.00 $157.00 $163.00 $126.00 $132.00 $138.0064508 0 $99.00 $90.00 $95.00 $101.00 $106.00 $112.00 $118.0064510 0 $103.00 $178.00 $188.00 $193.00 $106.00 $111.00 $115.0064517 0 -------- $257.00 $270.00 $278.00 $177.00 $184.00 $191.0064520 0 $131.00 $260.00 $276.00 $281.00 $117.00 $122.00 $127.0064530 0 $135.00 $267.00 $282.00 $288.00 $133.00 $139.00 $144.0064550 0 $23.00 $22.00 $23.00 $24.00 $13.00 $13.00 $13.0064553 10 $137.00 $295.00 $311.00 $320.00 $224.00 $235.00 $243.0064555 10 $131.00 $298.00 $315.00 $325.00 $221.00 $232.00 $242.0064561 10 $801.00 $1,139.00 $1,212.00 $1,239.00 $440.00 $462.00 $486.0064565 10 $121.00 $267.00 $283.00 $293.00 $190.00 $200.00 $210.0064566 0 -------- $176.00 $187.00 $191.00 $45.00 $47.00 $50.00



Surgery







64568 90 -------- $988.00 $1,071.00 $1,183.00 $988.00 $1,071.00 $1,183.0064569 90 -------- $1,183.00 $1,283.00 $1,423.00 $1,183.00 $1,283.00 $1,423.0064570 90 -------- $977.00 $1,057.00 $1,166.00 $977.00 $1,057.00 $1,166.0064575 90 $367.00 $466.00 $497.00 $531.00 $466.00 $497.00 $531.0064580 90 $343.00 $446.00 $478.00 $518.00 $446.00 $478.00 $518.0064581 90 $745.00 $967.00 $1,014.00 $1,071.00 $967.00 $1,014.00 $1,071.0064585 10 $37.00 $344.00 $365.00 $376.00 $207.00 $218.00 $228.0064590 10 $217.00 $373.00 $396.00 $408.00 $232.00 $245.00 $257.0064595 10 $153.00 $344.00 $366.00 $375.00 $182.00 $193.00 $202.0064600 10 $228.00 $554.00 $592.00 $617.00 $322.00 $343.00 $367.0064605 10 $319.00 $1,082.00 $1,173.00 $1,259.00 $625.00 $682.00 $767.0064610 10 $307.00 $1,085.00 $1,175.00 $1,271.00 $742.00 $807.00 $902.0064611 10 -------- $170.00 $185.00 $200.00 $150.00 $164.00 $179.0064612 10 $188.00 $190.00 $203.00 $216.00 $171.00 $183.00 $195.0064615 10 -------- $214.00 $232.00 $257.00 $188.00 $204.00 $229.0064616 10 -------- $186.00 $202.00 $222.00 $164.00 $178.00 $198.0064617 10 -------- $284.00 $307.00 $330.00 $187.00 $203.00 $226.0064620 10 $185.00 $290.00 $304.00 $314.00 $247.00 $258.00 $268.0064630 10 $202.00 $334.00 $354.00 $372.00 $281.00 $298.00 $316.0064632 10 -------- $121.00 $126.00 $130.00 $99.00 $103.00 $106.0064633 10 -------- $594.00 $628.00 $641.00 $328.00 $343.00 $355.0064634 ZZZ -------- $265.00 $282.00 $286.00 $100.00 $104.00 $108.0064635 10 -------- $587.00 $620.00 $633.00 $323.00 $338.00 $350.0064636 ZZZ -------- $241.00 $256.00 $260.00 $87.00 $91.00 $94.0064640 10 $208.00 $187.00 $197.00 $202.00 $133.00 $139.00 $144.0064642 0 -------- $205.00 $220.00 $235.00 $161.00 $172.00 $187.0064643 ZZZ -------- $135.00 $144.00 $155.00 $108.00 $116.00 $126.0064644 0 -------- $235.00 $251.00 $268.00 $176.00 $188.00 $205.0064645 ZZZ -------- $166.00 $178.00 $190.00 $124.00 $133.00 $146.0064646 0 -------- $218.00 $234.00 $251.00 $174.00 $187.00 $203.0064647 0 -------- $258.00 $277.00 $297.00 $203.00 $218.00 $238.0064650 0 -------- $110.00 $117.00 $122.00 $62.00 $66.00 $71.0064653 0 -------- $139.00 $150.00 $160.00 $82.00 $88.00 $98.0064680 10 $180.00 $434.00 $460.00 $471.00 $240.00 $252.00 $262.0064681 10 -------- $483.00 $509.00 $521.00 $276.00 $287.00 $299.0064702 90 $383.00 $720.00 $766.00 $809.00 $720.00 $766.00 $809.0064704 90 $402.00 $457.00 $481.00 $501.00 $457.00 $481.00 $501.0064708 90 $562.00 $721.00 $769.00 $817.00 $721.00 $769.00 $817.0064712 90 $678.00 $838.00 $893.00 $954.00 $838.00 $893.00 $954.0064713 90 $867.00 $1,066.00 $1,134.00 $1,218.00 $1,066.00 $1,134.00 $1,218.0064714 90 $715.00 $933.00 $985.00 $1,042.00 $933.00 $985.00 $1,042.0064716 90 $523.00 $779.00 $828.00 $875.00 $779.00 $828.00 $875.0064718 90 $558.00 $858.00 $916.00 $975.00 $858.00 $916.00 $975.0064719 90 $446.00 $580.00 $619.00 $658.00 $580.00 $619.00 $658.0064721 90 $439.00 $620.00 $663.00 $704.00 $617.00 $659.00 $700.0064722 90 $411.00 $538.00 $574.00 $611.00 $538.00 $574.00 $611.0064726 90 $271.00 $394.00 $413.00 $428.00 $394.00 $413.00 $428.0064727 ZZZ $261.00 $274.00 $293.00 $318.00 $274.00 $293.00 $318.0064732 90 $405.00 $544.00 $579.00 $615.00 $544.00 $579.00 $615.0064734 90 $432.00 $598.00 $634.00 $667.00 $598.00 $634.00 $667.00



Surgery







64736 90 $388.00 $576.00 $612.00 $646.00 $576.00 $612.00 $646.0064738 90 $475.00 $615.00 $650.00 $686.00 $615.00 $650.00 $686.0064740 90 $461.00 $662.00 $702.00 $737.00 $662.00 $702.00 $737.0064742 90 $517.00 $695.00 $730.00 $754.00 $695.00 $730.00 $754.0064744 90 $798.00 $740.00 $808.00 $899.00 $740.00 $808.00 $899.0064746 90 $494.00 $668.00 $719.00 $785.00 $668.00 $719.00 $785.0064755 90 $1,042.00 $1,379.00 $1,481.00 $1,625.00 $1,379.00 $1,481.00 $1,625.0064760 90 $578.00 $746.00 $797.00 $862.00 $746.00 $797.00 $862.0064763 90 $561.00 $747.00 $798.00 $862.00 $747.00 $798.00 $862.0064766 90 $713.00 $877.00 $927.00 $981.00 $877.00 $927.00 $981.0064771 90 $632.00 $870.00 $926.00 $983.00 $870.00 $926.00 $983.0064772 90 $636.00 $821.00 $877.00 $941.00 $821.00 $877.00 $941.0064774 90 $392.00 $607.00 $647.00 $690.00 $607.00 $647.00 $690.0064776 90 $390.00 $567.00 $601.00 $634.00 $567.00 $601.00 $634.0064778 ZZZ $249.00 $209.00 $217.00 $226.00 $209.00 $217.00 $226.0064782 90 $482.00 $656.00 $692.00 $728.00 $656.00 $692.00 $728.0064783 ZZZ $298.00 $325.00 $344.00 $367.00 $325.00 $344.00 $367.0064784 90 $751.00 $1,067.00 $1,135.00 $1,211.00 $1,067.00 $1,135.00 $1,211.0064786 90 $1,281.00 $1,580.00 $1,687.00 $1,817.00 $1,580.00 $1,687.00 $1,817.0064787 ZZZ $458.00 $358.00 $379.00 $405.00 $358.00 $379.00 $405.0064788 90 $381.00 $584.00 $625.00 $670.00 $584.00 $625.00 $670.0064790 90 $884.00 $1,246.00 $1,340.00 $1,462.00 $1,246.00 $1,340.00 $1,462.0064792 90 $1,148.00 $1,832.00 $2,007.00 $2,264.00 $1,832.00 $2,007.00 $2,264.0064795 0 $247.00 $289.00 $311.00 $342.00 $289.00 $311.00 $342.0064802 90 $711.00 $967.00 $1,018.00 $1,069.00 $967.00 $1,018.00 $1,069.0064804 90 $1,202.00 $1,512.00 $1,638.00 $1,827.00 $1,512.00 $1,638.00 $1,827.0064809 90 $1,080.00 $1,539.00 $1,674.00 $1,870.00 $1,539.00 $1,674.00 $1,870.0064818 90 $845.00 $903.00 $952.00 $1,015.00 $903.00 $952.00 $1,015.0064820 90 $838.00 $1,054.00 $1,117.00 $1,184.00 $1,054.00 $1,117.00 $1,184.0064821 90 $609.00 $996.00 $1,058.00 $1,117.00 $996.00 $1,058.00 $1,117.0064822 90 $609.00 $996.00 $1,058.00 $1,117.00 $996.00 $1,058.00 $1,117.0064823 90 $703.00 $1,136.00 $1,205.00 $1,276.00 $1,136.00 $1,205.00 $1,276.0064831 90 $592.00 $995.00 $1,060.00 $1,126.00 $995.00 $1,060.00 $1,126.0064832 ZZZ $171.00 $499.00 $530.00 $570.00 $499.00 $530.00 $570.0064834 90 $711.00 $1,081.00 $1,150.00 $1,225.00 $1,081.00 $1,150.00 $1,225.0064835 90 $834.00 $1,184.00 $1,263.00 $1,355.00 $1,184.00 $1,263.00 $1,355.0064836 90 $856.00 $1,188.00 $1,268.00 $1,360.00 $1,188.00 $1,268.00 $1,360.0064837 ZZZ $480.00 $548.00 $580.00 $619.00 $548.00 $580.00 $619.0064840 90 $1,058.00 $1,512.00 $1,633.00 $1,793.00 $1,512.00 $1,633.00 $1,793.0064856 90 $1,063.00 $1,491.00 $1,590.00 $1,709.00 $1,491.00 $1,590.00 $1,709.0064857 90 $1,137.00 $1,546.00 $1,646.00 $1,762.00 $1,546.00 $1,646.00 $1,762.0064858 90 $1,313.00 $1,663.00 $1,767.00 $1,890.00 $1,663.00 $1,767.00 $1,890.0064859 ZZZ $341.00 $372.00 $394.00 $421.00 $372.00 $394.00 $421.0064861 90 $1,524.00 $1,961.00 $2,094.00 $2,266.00 $1,961.00 $2,094.00 $2,266.0064862 90 $1,798.00 $2,359.00 $2,588.00 $2,932.00 $2,359.00 $2,588.00 $2,932.0064864 90 $970.00 $1,286.00 $1,362.00 $1,444.00 $1,286.00 $1,362.00 $1,444.0064865 90 $1,250.00 $1,646.00 $1,747.00 $1,850.00 $1,646.00 $1,747.00 $1,850.0064866 90 $1,238.00 $1,678.00 $1,776.00 $1,872.00 $1,678.00 $1,776.00 $1,872.0064868 90 $1,162.00 $1,482.00 $1,570.00 $1,661.00 $1,482.00 $1,570.00 $1,661.0064872 ZZZ $155.00 $178.00 $189.00 $203.00 $178.00 $189.00 $203.00



Surgery







64874 ZZZ $230.00 $255.00 $271.00 $292.00 $255.00 $271.00 $292.0064876 ZZZ $189.00 $261.00 $275.00 $293.00 $261.00 $275.00 $293.0064885 90 $1,382.00 $1,684.00 $1,787.00 $1,901.00 $1,684.00 $1,787.00 $1,901.0064886 90 $1,636.00 $1,910.00 $2,021.00 $2,145.00 $1,910.00 $2,021.00 $2,145.0064890 90 $1,112.00 $1,593.00 $1,691.00 $1,797.00 $1,593.00 $1,691.00 $1,797.0064891 90 $1,243.00 $1,705.00 $1,811.00 $1,928.00 $1,705.00 $1,811.00 $1,928.0064892 90 $1,177.00 $1,525.00 $1,618.00 $1,719.00 $1,525.00 $1,618.00 $1,719.0064893 90 $1,321.00 $1,658.00 $1,761.00 $1,873.00 $1,658.00 $1,761.00 $1,873.0064895 90 $1,500.00 $1,969.00 $2,100.00 $2,259.00 $1,969.00 $2,100.00 $2,259.0064896 90 $1,185.00 $2,099.00 $2,225.00 $2,364.00 $2,099.00 $2,225.00 $2,364.0064897 90 $1,419.00 $1,814.00 $1,918.00 $2,030.00 $1,814.00 $1,918.00 $2,030.0064898 90 $1,549.00 $2,016.00 $2,153.00 $2,324.00 $2,016.00 $2,153.00 $2,324.0064901 ZZZ $865.00 $825.00 $870.00 $927.00 $825.00 $870.00 $927.0064902 ZZZ $982.00 $973.00 $1,028.00 $1,098.00 $973.00 $1,028.00 $1,098.0064905 90 $1,059.00 $1,504.00 $1,600.00 $1,706.00 $1,504.00 $1,600.00 $1,706.0064907 90 $1,472.00 $2,067.00 $2,240.00 $2,484.00 $2,067.00 $2,240.00 $2,484.0064910 90 -------- $1,201.00 $1,278.00 $1,359.00 $1,201.00 $1,278.00 $1,359.0064911 90 -------- $1,473.00 $1,564.00 $1,658.00 $1,473.00 $1,564.00 $1,658.0064999 YYY BR -------- -------- -------- -------- -------- --------65091 90 $678.00 $888.00 $934.00 $956.00 $888.00 $934.00 $956.0065093 90 $712.00 $878.00 $924.00 $946.00 $878.00 $924.00 $946.0065101 90 $726.00 $1,031.00 $1,085.00 $1,110.00 $1,031.00 $1,085.00 $1,110.0065103 90 $769.00 $1,077.00 $1,133.00 $1,159.00 $1,077.00 $1,133.00 $1,159.0065105 90 $846.00 $1,188.00 $1,249.00 $1,280.00 $1,188.00 $1,249.00 $1,280.0065110 90 $1,305.00 $1,719.00 $1,806.00 $1,857.00 $1,719.00 $1,806.00 $1,857.0065112 90 $1,386.00 $2,001.00 $2,103.00 $2,168.00 $2,001.00 $2,103.00 $2,168.0065114 90 $1,456.00 $2,102.00 $2,209.00 $2,277.00 $2,102.00 $2,209.00 $2,277.0065125 90 $312.00 $633.00 $671.00 $683.00 $410.00 $432.00 $443.0065130 90 $730.00 $1,023.00 $1,076.00 $1,101.00 $1,023.00 $1,076.00 $1,101.0065135 90 $678.00 $1,039.00 $1,092.00 $1,119.00 $1,039.00 $1,092.00 $1,119.0065140 90 $738.00 $1,129.00 $1,188.00 $1,216.00 $1,129.00 $1,188.00 $1,216.0065150 90 $652.00 $799.00 $841.00 $860.00 $799.00 $841.00 $860.0065155 90 $862.00 $1,184.00 $1,245.00 $1,275.00 $1,184.00 $1,245.00 $1,275.0065175 90 $654.00 $919.00 $967.00 $990.00 $919.00 $967.00 $990.0065205 0 $45.00 $78.00 $82.00 $84.00 $62.00 $65.00 $66.0065210 0 $53.00 $96.00 $101.00 $103.00 $75.00 $78.00 $80.0065220 0 $58.00 $82.00 $86.00 $90.00 $61.00 $64.00 $67.0065222 0 $62.00 $93.00 $98.00 $100.00 $74.00 $77.00 $79.0065235 90 $627.00 $999.00 $1,049.00 $1,076.00 $999.00 $1,049.00 $1,076.0065260 90 $956.00 $1,350.00 $1,416.00 $1,454.00 $1,350.00 $1,416.00 $1,454.0065265 90 $1,104.00 $1,522.00 $1,596.00 $1,640.00 $1,522.00 $1,596.00 $1,640.0065270 10 $88.00 $369.00 $391.00 $398.00 $198.00 $208.00 $214.0065272 90 $223.00 $698.00 $737.00 $752.00 $494.00 $518.00 $532.0065273 90 $376.00 $537.00 $563.00 $578.00 $537.00 $563.00 $578.0065275 90 $75.00 $807.00 $850.00 $869.00 $651.00 $683.00 $702.0065280 90 $711.00 $945.00 $991.00 $1,018.00 $945.00 $991.00 $1,018.0065285 90 $1,177.00 $1,562.00 $1,637.00 $1,683.00 $1,562.00 $1,637.00 $1,683.0065286 90 $692.00 $979.00 $1,033.00 $1,054.00 $698.00 $732.00 $752.0065290 90 $519.00 $688.00 $722.00 $742.00 $688.00 $722.00 $742.0065400 90 $603.00 $950.00 $1,000.00 $1,023.00 $847.00 $890.00 $913.00



Surgery







65410 0 $142.00 $199.00 $210.00 $215.00 $147.00 $154.00 $159.0065420 90 $448.00 $716.00 $757.00 $771.00 $529.00 $557.00 $570.0065426 90 $534.00 $906.00 $957.00 $976.00 $672.00 $706.00 $724.0065430 0 $81.00 $160.00 $168.00 $172.00 $146.00 $152.00 $157.0065435 0 $88.00 $111.00 $117.00 $119.00 $98.00 $102.00 $105.0065436 90 $319.00 $544.00 $571.00 $586.00 $523.00 $549.00 $563.0065450 90 $52.00 $454.00 $478.00 $489.00 $450.00 $474.00 $485.0065600 90 $325.00 $550.00 $580.00 $592.00 $483.00 $507.00 $520.0065710 90 $1,124.00 $1,555.00 $1,632.00 $1,675.00 $1,555.00 $1,632.00 $1,675.0065730 90 $1,314.00 $1,726.00 $1,810.00 $1,859.00 $1,726.00 $1,810.00 $1,859.0065750 90 $1,381.00 $1,737.00 $1,821.00 $1,871.00 $1,737.00 $1,821.00 $1,871.0065755 90 $1,373.00 $1,728.00 $1,811.00 $1,861.00 $1,728.00 $1,811.00 $1,861.0065756 90 -------- $1,671.00 $1,750.00 $1,800.00 $1,671.00 $1,750.00 $1,800.0065770 90 $1,461.00 $1,979.00 $2,073.00 $2,132.00 $1,979.00 $2,073.00 $2,132.0065772 90 $449.00 $631.00 $664.00 $679.00 $571.00 $600.00 $615.0065775 90 $595.00 $774.00 $813.00 $834.00 $774.00 $813.00 $834.0065778 0 -------- $1,954.00 $2,094.00 $2,103.00 $83.00 $87.00 $89.0065779 0 -------- $1,643.00 $1,757.00 $1,769.00 $216.00 $225.00 $233.0065780 90 -------- $1,006.00 $1,059.00 $1,083.00 $1,006.00 $1,059.00 $1,083.0065781 90 -------- $1,877.00 $1,968.00 $2,022.00 $1,877.00 $1,968.00 $2,022.0065782 90 -------- $1,619.00 $1,698.00 $1,744.00 $1,619.00 $1,698.00 $1,744.0065785 90 -------- $2,905.00 $3,108.00 $3,145.00 $555.00 $587.00 $616.0065800 0 $88.00 $167.00 $175.00 $180.00 $130.00 $136.00 $140.0065810 90 $516.00 $654.00 $686.00 $704.00 $654.00 $686.00 $704.0065815 90 $327.00 $887.00 $936.00 $955.00 $671.00 $705.00 $723.0065820 90 $813.00 $1,050.00 $1,103.00 $1,130.00 $1,050.00 $1,103.00 $1,130.0065850 90 $968.00 $1,182.00 $1,239.00 $1,273.00 $1,182.00 $1,239.00 $1,273.0065855 10 $441.00 $381.00 $402.00 $410.00 $336.00 $354.00 $362.0065860 90 $339.00 $432.00 $454.00 $465.00 $357.00 $374.00 $385.0065865 90 $540.00 $663.00 $697.00 $714.00 $663.00 $697.00 $714.0065870 90 $572.00 $829.00 $871.00 $893.00 $829.00 $871.00 $893.0065875 90 $597.00 $884.00 $929.00 $952.00 $884.00 $929.00 $952.0065880 90 $641.00 $929.00 $975.00 $1,001.00 $929.00 $975.00 $1,001.0065900 90 $945.00 $1,349.00 $1,415.00 $1,452.00 $1,349.00 $1,415.00 $1,452.0065920 90 $752.00 $1,108.00 $1,163.00 $1,193.00 $1,108.00 $1,163.00 $1,193.0065930 90 $700.00 $896.00 $940.00 $965.00 $896.00 $940.00 $965.0066020 10 $164.00 $259.00 $274.00 $279.00 $185.00 $194.00 $199.0066030 10 $160.00 $230.00 $243.00 $247.00 $155.00 $164.00 $168.0066130 90 $631.00 $972.00 $1,023.00 $1,047.00 $801.00 $840.00 $864.0066150 90 $798.00 $1,229.00 $1,292.00 $1,323.00 $1,229.00 $1,292.00 $1,323.0066155 90 $795.00 $1,228.00 $1,291.00 $1,322.00 $1,228.00 $1,291.00 $1,322.0066160 90 $942.00 $1,386.00 $1,456.00 $1,493.00 $1,386.00 $1,456.00 $1,493.0066170 90 $1,089.00 $1,360.00 $1,430.00 $1,464.00 $1,360.00 $1,430.00 $1,464.0066172 90 $1,264.00 $1,709.00 $1,802.00 $1,841.00 $1,709.00 $1,802.00 $1,841.0066174 90 -------- $1,334.00 $1,398.00 $1,437.00 $1,334.00 $1,398.00 $1,437.0066175 90 -------- $1,398.00 $1,465.00 $1,505.00 $1,398.00 $1,465.00 $1,505.0066179 90 -------- $1,514.00 $1,589.00 $1,631.00 $1,514.00 $1,589.00 $1,631.0066180 90 $1,313.00 $1,599.00 $1,678.00 $1,723.00 $1,599.00 $1,678.00 $1,723.0066183 90 -------- $1,447.00 $1,519.00 $1,559.00 $1,447.00 $1,519.00 $1,559.0066184 90 -------- $1,101.00 $1,157.00 $1,186.00 $1,101.00 $1,157.00 $1,186.00



Surgery







66185 90 $769.00 $1,186.00 $1,246.00 $1,278.00 $1,186.00 $1,246.00 $1,278.0066220 90 $711.00 $1,047.00 $1,100.00 $1,128.00 $1,047.00 $1,100.00 $1,128.0066225 90 $1,006.00 $1,311.00 $1,375.00 $1,413.00 $1,311.00 $1,375.00 $1,413.0066250 90 $602.00 $1,042.00 $1,100.00 $1,122.00 $783.00 $822.00 $844.0066500 90 $359.00 $494.00 $521.00 $532.00 $494.00 $521.00 $532.0066505 90 $359.00 $542.00 $571.00 $584.00 $542.00 $571.00 $584.0066600 90 $825.00 $1,166.00 $1,226.00 $1,257.00 $1,166.00 $1,226.00 $1,257.0066605 90 $1,136.00 $1,487.00 $1,559.00 $1,602.00 $1,487.00 $1,559.00 $1,602.0066625 90 $543.00 $603.00 $633.00 $649.00 $603.00 $633.00 $649.0066630 90 $623.00 $800.00 $840.00 $861.00 $800.00 $840.00 $861.0066635 90 $595.00 $808.00 $848.00 $870.00 $808.00 $848.00 $870.0066680 90 $526.00 $727.00 $763.00 $783.00 $727.00 $763.00 $783.0066682 90 $627.00 $892.00 $939.00 $961.00 $892.00 $939.00 $961.0066700 90 $506.00 $629.00 $662.00 $678.00 $553.00 $580.00 $595.0066710 90 $513.00 $616.00 $647.00 $663.00 $552.00 $580.00 $595.0066711 90 -------- $901.00 $946.00 $970.00 $901.00 $946.00 $970.0066720 90 $506.00 $662.00 $698.00 $714.00 $594.00 $625.00 $641.0066740 90 $473.00 $612.00 $644.00 $659.00 $553.00 $580.00 $595.0066761 10 $506.00 $413.00 $436.00 $445.00 $332.00 $348.00 $358.0066762 90 $433.00 $664.00 $699.00 $715.00 $599.00 $629.00 $645.0066770 90 $483.00 $738.00 $777.00 $795.00 $680.00 $714.00 $732.0066820 90 $433.00 $548.00 $578.00 $590.00 $548.00 $578.00 $590.0066821 90 $275.00 $460.00 $485.00 $496.00 $435.00 $458.00 $469.0066825 90 $753.00 $1,065.00 $1,120.00 $1,147.00 $1,065.00 $1,120.00 $1,147.0066830 90 $651.00 $1,001.00 $1,050.00 $1,078.00 $1,001.00 $1,050.00 $1,078.0066840 90 $707.00 $980.00 $1,028.00 $1,055.00 $980.00 $1,028.00 $1,055.0066850 90 $805.00 $1,115.00 $1,170.00 $1,201.00 $1,115.00 $1,170.00 $1,201.0066852 90 $878.00 $1,189.00 $1,246.00 $1,280.00 $1,189.00 $1,246.00 $1,280.0066920 90 $785.00 $1,061.00 $1,113.00 $1,143.00 $1,061.00 $1,113.00 $1,143.0066930 90 $906.00 $1,206.00 $1,265.00 $1,300.00 $1,206.00 $1,265.00 $1,300.0066940 90 $819.00 $1,101.00 $1,155.00 $1,186.00 $1,101.00 $1,155.00 $1,186.0066982 90 $846.00 $1,120.00 $1,174.00 $1,206.00 $1,120.00 $1,174.00 $1,206.0066983 90 $763.00 $1,039.00 $1,086.00 $1,112.00 $1,039.00 $1,086.00 $1,112.0066984 90 $898.00 $899.00 $943.00 $968.00 $899.00 $943.00 $968.0066985 90 $744.00 $1,082.00 $1,136.00 $1,165.00 $1,082.00 $1,136.00 $1,165.0066986 90 $1,038.00 $1,279.00 $1,341.00 $1,377.00 $1,279.00 $1,341.00 $1,377.0066990 ZZZ $84.00 $129.00 $134.00 $139.00 $129.00 $134.00 $139.0066999 YYY BR -------- -------- -------- -------- -------- --------67005 90 $639.00 $664.00 $697.00 $715.00 $664.00 $697.00 $715.0067010 90 $647.00 $763.00 $801.00 $822.00 $763.00 $801.00 $822.0067015 90 $637.00 $814.00 $855.00 $876.00 $814.00 $855.00 $876.0067025 90 $774.00 $1,015.00 $1,068.00 $1,093.00 $889.00 $933.00 $958.0067027 90 $1,089.00 $1,201.00 $1,259.00 $1,293.00 $1,201.00 $1,259.00 $1,293.0067028 0 $338.00 $144.00 $151.00 $155.00 $142.00 $148.00 $153.0067030 90 $485.00 $745.00 $784.00 $803.00 $745.00 $784.00 $803.0067031 90 $402.00 $544.00 $572.00 $586.00 $501.00 $527.00 $540.0067036 90 $1,384.00 $1,269.00 $1,331.00 $1,367.00 $1,269.00 $1,331.00 $1,367.0067039 90 $1,490.00 $1,360.00 $1,425.00 $1,464.00 $1,360.00 $1,425.00 $1,464.0067040 90 $1,960.00 $1,470.00 $1,541.00 $1,584.00 $1,470.00 $1,541.00 $1,584.0067041 90 -------- $1,626.00 $1,703.00 $1,751.00 $1,626.00 $1,703.00 $1,751.00



Surgery







67042 90 -------- $1,626.00 $1,703.00 $1,752.00 $1,626.00 $1,703.00 $1,752.0067043 90 -------- $1,717.00 $1,798.00 $1,850.00 $1,717.00 $1,798.00 $1,850.0067101 90 $767.00 $1,095.00 $1,153.00 $1,180.00 $948.00 $994.00 $1,021.0067105 90 $941.00 $1,007.00 $1,059.00 $1,084.00 $906.00 $950.00 $976.0067107 90 $1,350.00 $1,433.00 $1,502.00 $1,544.00 $1,433.00 $1,502.00 $1,544.0067108 90 $1,878.00 $1,819.00 $1,913.00 $1,959.00 $1,819.00 $1,913.00 $1,959.0067110 90 $1,040.00 $1,063.00 $1,119.00 $1,145.00 $977.00 $1,027.00 $1,052.0067113 90 -------- $1,985.00 $2,082.00 $2,139.00 $1,985.00 $2,082.00 $2,139.0067115 90 $496.00 $701.00 $737.00 $755.00 $701.00 $737.00 $755.0067120 90 $751.00 $917.00 $966.00 $988.00 $784.00 $823.00 $845.0067121 90 $962.00 $1,279.00 $1,341.00 $1,377.00 $1,279.00 $1,341.00 $1,377.0067141 90 $536.00 $733.00 $771.00 $790.00 $685.00 $720.00 $738.0067145 90 $514.00 $738.00 $776.00 $795.00 $700.00 $735.00 $754.0067208 90 $655.00 $841.00 $883.00 $906.00 $814.00 $854.00 $877.0067210 90 $779.00 $726.00 $763.00 $782.00 $703.00 $738.00 $757.0067218 90 $1,217.00 $1,954.00 $2,045.00 $2,105.00 $1,954.00 $2,045.00 $2,105.0067220 90 $894.00 $748.00 $786.00 $805.00 $703.00 $738.00 $757.0067221 0 $325.00 $402.00 $422.00 $432.00 $303.00 $316.00 $326.0067225 ZZZ $44.00 $42.00 $44.00 $45.00 $39.00 $41.00 $42.0067227 10 $652.00 $406.00 $426.00 $437.00 $362.00 $379.00 $389.0067228 10 $1,025.00 $478.00 $502.00 $515.00 $434.00 $454.00 $467.0067229 90 -------- $1,584.00 $1,664.00 $1,728.00 $1,584.00 $1,664.00 $1,728.0067250 90 $793.00 $1,095.00 $1,151.00 $1,180.00 $1,095.00 $1,151.00 $1,180.0067255 90 $872.00 $958.00 $1,007.00 $1,032.00 $958.00 $1,007.00 $1,032.0067299 YYY BR -------- -------- -------- -------- -------- --------67311 90 $616.00 $841.00 $882.00 $906.00 $841.00 $882.00 $906.0067312 90 $773.00 $1,003.00 $1,051.00 $1,080.00 $1,003.00 $1,051.00 $1,080.0067314 90 $688.00 $947.00 $993.00 $1,020.00 $947.00 $993.00 $1,020.0067316 90 $857.00 $1,128.00 $1,183.00 $1,216.00 $1,128.00 $1,183.00 $1,216.0067318 90 $663.00 $990.00 $1,038.00 $1,066.00 $990.00 $1,038.00 $1,066.0067320 ZZZ $602.00 $459.00 $479.00 $495.00 $459.00 $479.00 $495.0067331 ZZZ $560.00 $436.00 $455.00 $470.00 $436.00 $455.00 $470.0067332 ZZZ $621.00 $473.00 $493.00 $510.00 $473.00 $493.00 $510.0067334 ZZZ $447.00 $430.00 $448.00 $463.00 $430.00 $448.00 $463.0067335 ZZZ $253.00 $211.00 $220.00 $228.00 $211.00 $220.00 $228.0067340 ZZZ $559.00 $511.00 $533.00 $550.00 $511.00 $533.00 $550.0067343 90 $628.00 $919.00 $965.00 $991.00 $919.00 $965.00 $991.0067345 10 $275.00 $345.00 $366.00 $382.00 $312.00 $331.00 $347.0067346 0 -------- $275.00 $288.00 $298.00 $275.00 $288.00 $298.0067399 YYY BR -------- -------- -------- -------- -------- --------67400 90 $960.00 $1,304.00 $1,371.00 $1,406.00 $1,304.00 $1,371.00 $1,406.0067405 90 $799.00 $1,115.00 $1,174.00 $1,206.00 $1,115.00 $1,174.00 $1,206.0067412 90 $976.00 $1,193.00 $1,255.00 $1,288.00 $1,193.00 $1,255.00 $1,288.0067413 90 $909.00 $1,201.00 $1,264.00 $1,299.00 $1,201.00 $1,264.00 $1,299.0067414 90 $1,023.00 $1,867.00 $1,959.00 $2,017.00 $1,867.00 $1,959.00 $2,017.0067415 0 $146.00 $149.00 $155.00 $160.00 $149.00 $155.00 $160.0067420 90 $1,729.00 $2,283.00 $2,399.00 $2,475.00 $2,283.00 $2,399.00 $2,475.0067430 90 $1,203.00 $1,741.00 $1,831.00 $1,881.00 $1,741.00 $1,831.00 $1,881.0067440 90 $1,257.00 $1,692.00 $1,781.00 $1,833.00 $1,692.00 $1,781.00 $1,833.0067445 90 $1,269.00 $1,976.00 $2,074.00 $2,137.00 $1,976.00 $2,074.00 $2,137.00



Surgery







67450 90 $1,300.00 $1,764.00 $1,856.00 $1,911.00 $1,764.00 $1,856.00 $1,911.0067500 0 $75.00 $112.00 $116.00 $121.00 $103.00 $107.00 $112.0067505 0 $109.00 $125.00 $131.00 $135.00 $115.00 $120.00 $124.0067515 0 $53.00 $136.00 $143.00 $147.00 $126.00 $132.00 $136.0067550 90 $946.00 $1,353.00 $1,423.00 $1,460.00 $1,353.00 $1,423.00 $1,460.0067560 90 $936.00 $1,387.00 $1,459.00 $1,498.00 $1,387.00 $1,459.00 $1,498.0067570 90 $1,148.00 $1,646.00 $1,742.00 $1,815.00 $1,646.00 $1,742.00 $1,815.0067599 YYY BR -------- -------- -------- -------- -------- --------67700 10 $87.00 $369.00 $392.00 $397.00 $164.00 $172.00 $177.0067710 10 $117.00 $307.00 $326.00 $330.00 $136.00 $144.00 $147.0067715 10 $102.00 $328.00 $349.00 $355.00 $153.00 $161.00 $166.0067800 10 $119.00 $177.00 $187.00 $191.00 $146.00 $153.00 $157.0067801 10 $189.00 $227.00 $238.00 $244.00 $189.00 $198.00 $203.0067805 10 $208.00 $282.00 $297.00 $304.00 $232.00 $244.00 $250.0067808 90 $308.00 $519.00 $545.00 $560.00 $519.00 $545.00 $560.0067810 0 $133.00 $239.00 $254.00 $261.00 $104.00 $109.00 $115.0067820 0 $36.00 $70.00 $73.00 $75.00 $75.00 $78.00 $80.0067825 10 $130.00 $179.00 $189.00 $193.00 $170.00 $179.00 $183.0067830 10 $239.00 $367.00 $390.00 $396.00 $195.00 $205.00 $210.0067835 90 $500.00 $616.00 $647.00 $664.00 $616.00 $647.00 $664.0067840 10 $187.00 $380.00 $403.00 $410.00 $223.00 $234.00 $241.0067850 10 $143.00 $298.00 $317.00 $325.00 $193.00 $204.00 $211.0067875 0 $163.00 $238.00 $252.00 $256.00 $137.00 $144.00 $149.0067880 90 $442.00 $639.00 $674.00 $689.00 $518.00 $544.00 $559.0067882 90 $643.00 $786.00 $828.00 $847.00 $664.00 $697.00 $716.0067900 90 $487.00 $895.00 $944.00 $969.00 $720.00 $756.00 $781.0067901 90 $646.00 $1,054.00 $1,112.00 $1,137.00 $813.00 $853.00 $878.0067902 90 $650.00 $1,021.00 $1,071.00 $1,104.00 $1,021.00 $1,071.00 $1,104.0067903 90 $657.00 $829.00 $873.00 $895.00 $682.00 $716.00 $737.0067904 90 $720.00 $1,022.00 $1,077.00 $1,104.00 $842.00 $884.00 $909.0067906 90 $633.00 $715.00 $750.00 $771.00 $715.00 $750.00 $771.0067908 90 $550.00 $688.00 $725.00 $742.00 $596.00 $627.00 $643.0067909 90 $577.00 $747.00 $788.00 $807.00 $617.00 $649.00 $667.0067911 90 $517.00 $792.00 $832.00 $855.00 $792.00 $832.00 $855.0067912 90 -------- $1,223.00 $1,298.00 $1,325.00 $694.00 $731.00 $757.0067914 90 $487.00 $650.00 $688.00 $701.00 $459.00 $483.00 $495.0067915 90 $252.00 $404.00 $428.00 $435.00 $277.00 $292.00 $298.0067916 90 $675.00 $823.00 $870.00 $888.00 $607.00 $638.00 $656.0067917 90 $631.00 $839.00 $885.00 $905.00 $645.00 $678.00 $696.0067921 90 $419.00 $636.00 $674.00 $685.00 $435.00 $458.00 $469.0067922 90 $243.00 $400.00 $424.00 $431.00 $276.00 $291.00 $298.0067923 90 $718.00 $821.00 $868.00 $885.00 $606.00 $636.00 $653.0067924 90 $605.00 $876.00 $925.00 $944.00 $645.00 $677.00 $696.0067930 10 $280.00 $507.00 $534.00 $546.00 $340.00 $356.00 $367.0067935 90 $520.00 $830.00 $876.00 $900.00 $627.00 $658.00 $681.0067938 10 $67.00 $333.00 $353.00 $357.00 $162.00 $170.00 $174.0067950 90 $584.00 $799.00 $843.00 $864.00 $653.00 $687.00 $707.0067961 90 $571.00 $800.00 $844.00 $863.00 $640.00 $672.00 $691.0067966 90 $645.00 $1,076.00 $1,132.00 $1,162.00 $928.00 $973.00 $1,002.0067971 90 $875.00 $1,021.00 $1,070.00 $1,102.00 $1,021.00 $1,070.00 $1,102.00



Surgery







67973 90 $1,126.00 $1,314.00 $1,377.00 $1,417.00 $1,314.00 $1,377.00 $1,417.0067974 90 $1,140.00 $1,311.00 $1,374.00 $1,415.00 $1,311.00 $1,374.00 $1,415.0067975 90 $681.00 $965.00 $1,013.00 $1,042.00 $965.00 $1,013.00 $1,042.0067999 YYY BR -------- -------- -------- -------- -------- --------68020 10 $106.00 $167.00 $176.00 $180.00 $155.00 $163.00 $167.0068040 0 $75.00 $88.00 $92.00 $94.00 $72.00 $75.00 $77.0068100 0 $137.00 $235.00 $249.00 $253.00 $137.00 $144.00 $148.0068110 10 $172.00 $312.00 $330.00 $336.00 $209.00 $219.00 $224.0068115 10 $248.00 $431.00 $456.00 $464.00 $259.00 $272.00 $279.0068130 90 $378.00 $748.00 $790.00 $806.00 $579.00 $608.00 $623.0068135 10 $146.00 $219.00 $231.00 $236.00 $212.00 $223.00 $229.0068200 0 $59.00 $58.00 $61.00 $63.00 $49.00 $52.00 $53.0068320 90 $502.00 $1,006.00 $1,063.00 $1,084.00 $757.00 $796.00 $817.0068325 90 $672.00 $928.00 $974.00 $1,002.00 $928.00 $974.00 $1,002.0068326 90 $654.00 $909.00 $954.00 $980.00 $909.00 $954.00 $980.0068328 90 $741.00 $998.00 $1,047.00 $1,077.00 $998.00 $1,047.00 $1,077.0068330 90 $488.00 $840.00 $887.00 $905.00 $648.00 $681.00 $699.0068335 90 $636.00 $911.00 $956.00 $981.00 $911.00 $956.00 $981.0068340 90 $413.00 $757.00 $799.00 $815.00 $561.00 $590.00 $605.0068360 90 $449.00 $740.00 $782.00 $799.00 $580.00 $610.00 $627.0068362 90 $691.00 $924.00 $969.00 $995.00 $924.00 $969.00 $995.0068371 10 -------- $580.00 $609.00 $624.00 $580.00 $609.00 $624.0068399 YYY BR -------- -------- -------- -------- -------- --------68400 10 $154.00 $391.00 $415.00 $421.00 $186.00 $195.00 $200.0068420 10 $191.00 $445.00 $471.00 $480.00 $238.00 $250.00 $257.0068440 10 $96.00 $142.00 $150.00 $153.00 $138.00 $146.00 $149.0068500 90 $882.00 $1,371.00 $1,439.00 $1,477.00 $1,371.00 $1,439.00 $1,477.0068505 90 $921.00 $1,363.00 $1,430.00 $1,469.00 $1,363.00 $1,430.00 $1,469.0068510 0 $491.00 $621.00 $655.00 $669.00 $415.00 $434.00 $448.0068520 90 $687.00 $968.00 $1,018.00 $1,047.00 $968.00 $1,018.00 $1,047.0068525 0 $340.00 $376.00 $392.00 $406.00 $376.00 $392.00 $406.0068530 10 $379.00 $593.00 $627.00 $639.00 $364.00 $381.00 $393.0068540 90 $875.00 $1,309.00 $1,375.00 $1,413.00 $1,309.00 $1,375.00 $1,413.0068550 90 $1,107.00 $1,571.00 $1,657.00 $1,726.00 $1,571.00 $1,657.00 $1,726.0068700 90 $628.00 $850.00 $892.00 $916.00 $850.00 $892.00 $916.0068705 10 $176.00 $328.00 $347.00 $354.00 $234.00 $246.00 $253.0068720 90 $807.00 $1,065.00 $1,118.00 $1,149.00 $1,065.00 $1,118.00 $1,149.0068745 90 $704.00 $1,068.00 $1,121.00 $1,151.00 $1,068.00 $1,121.00 $1,151.0068750 90 $792.00 $1,106.00 $1,162.00 $1,194.00 $1,106.00 $1,162.00 $1,194.0068760 10 $109.00 $279.00 $295.00 $301.00 $205.00 $216.00 $221.0068761 10 $130.00 $205.00 $216.00 $220.00 $167.00 $175.00 $179.0068770 90 $634.00 $884.00 $928.00 $952.00 $884.00 $928.00 $952.0068801 10 $202.00 $139.00 $147.00 $149.00 $121.00 $127.00 $130.0068810 10 $290.00 $270.00 $286.00 $291.00 $212.00 $223.00 $228.0068811 10 $191.00 $233.00 $246.00 $251.00 $233.00 $246.00 $251.0068815 10 $399.00 $549.00 $582.00 $591.00 $312.00 $328.00 $337.0068816 10 -------- $882.00 $941.00 $950.00 $283.00 $298.00 $305.0068840 10 $100.00 $178.00 $188.00 $191.00 $163.00 $172.00 $176.0068850 0 $76.00 $86.00 $91.00 $93.00 $79.00 $83.00 $86.0068899 YYY BR -------- -------- -------- -------- -------- --------



Surgery







69000 10 $52.00 $264.00 $280.00 $288.00 $171.00 $181.00 $188.0069005 10 $175.00 $306.00 $325.00 $338.00 $228.00 $241.00 $254.0069020 10 $109.00 $328.00 $350.00 $359.00 $204.00 $217.00 $226.0069100 0 $85.00 $141.00 $150.00 $154.00 $71.00 $75.00 $80.0069105 0 $87.00 $197.00 $210.00 $216.00 $92.00 $98.00 $103.0069110 90 $294.00 $648.00 $691.00 $714.00 $466.00 $496.00 $518.0069120 90 $274.00 $580.00 $616.00 $640.00 $580.00 $616.00 $640.0069140 90 $722.00 $1,255.00 $1,334.00 $1,382.00 $1,255.00 $1,334.00 $1,382.0069145 90 $248.00 $561.00 $598.00 $614.00 $359.00 $382.00 $397.0069150 90 $1,111.00 $1,518.00 $1,611.00 $1,693.00 $1,518.00 $1,611.00 $1,693.0069155 90 $1,680.00 $2,427.00 $2,570.00 $2,706.00 $2,427.00 $2,570.00 $2,706.0069200 0 $53.00 $140.00 $148.00 $153.00 $69.00 $72.00 $76.0069205 10 $110.00 $146.00 $155.00 $162.00 $146.00 $155.00 $162.0069209 0 -------- $18.00 $19.00 $19.00 $18.00 $19.00 $19.0069210 0 $39.00 $70.00 $74.00 $77.00 $48.00 $50.00 $53.0069220 0 $78.00 $156.00 $167.00 $172.00 $76.00 $80.00 $85.0069222 10 $123.00 $310.00 $330.00 $339.00 $197.00 $209.00 $217.0069300 YYY $522.00 $1,046.00 $1,111.00 $1,149.00 $693.00 $733.00 $770.0069310 90 $937.00 $1,568.00 $1,668.00 $1,734.00 $1,568.00 $1,668.00 $1,734.0069320 90 $1,434.00 $2,230.00 $2,371.00 $2,478.00 $2,230.00 $2,371.00 $2,478.0069399 YYY BR -------- -------- -------- -------- -------- --------69420 10 $117.00 $271.00 $289.00 $297.00 $174.00 $184.00 $193.0069421 10 $155.00 $215.00 $228.00 $239.00 $215.00 $228.00 $239.0069424 0 $84.00 $180.00 $192.00 $197.00 $90.00 $96.00 $101.0069433 10 $145.00 $287.00 $306.00 $315.00 $192.00 $203.00 $213.0069436 10 $182.00 $232.00 $246.00 $258.00 $232.00 $246.00 $258.0069440 90 $699.00 $994.00 $1,055.00 $1,101.00 $994.00 $1,055.00 $1,101.0069450 90 $525.00 $784.00 $833.00 $866.00 $784.00 $833.00 $866.0069501 90 $829.00 $1,063.00 $1,127.00 $1,181.00 $1,063.00 $1,127.00 $1,181.0069502 90 $1,118.00 $1,410.00 $1,495.00 $1,569.00 $1,410.00 $1,495.00 $1,569.0069505 90 $1,176.00 $1,733.00 $1,840.00 $1,917.00 $1,733.00 $1,840.00 $1,917.0069511 90 $1,221.00 $1,771.00 $1,880.00 $1,959.00 $1,771.00 $1,880.00 $1,959.0069530 90 $1,616.00 $2,396.00 $2,542.00 $2,661.00 $2,396.00 $2,542.00 $2,661.0069535 90 $2,824.00 $3,915.00 $4,154.00 $4,389.00 $3,915.00 $4,154.00 $4,389.0069540 10 $126.00 $294.00 $314.00 $322.00 $182.00 $194.00 $201.0069550 90 $998.00 $1,499.00 $1,592.00 $1,656.00 $1,499.00 $1,592.00 $1,656.0069552 90 $1,621.00 $2,265.00 $2,402.00 $2,516.00 $2,265.00 $2,402.00 $2,516.0069554 90 $2,600.00 $3,550.00 $3,756.00 $3,959.00 $3,550.00 $3,756.00 $3,959.0069601 90 $1,195.00 $1,517.00 $1,608.00 $1,685.00 $1,517.00 $1,608.00 $1,685.0069602 90 $1,225.00 $1,576.00 $1,671.00 $1,751.00 $1,576.00 $1,671.00 $1,751.0069603 90 $1,264.00 $1,838.00 $1,953.00 $2,041.00 $1,838.00 $1,953.00 $2,041.0069604 90 $1,263.00 $1,612.00 $1,709.00 $1,791.00 $1,612.00 $1,709.00 $1,791.0069605 90 $1,526.00 $2,256.00 $2,394.00 $2,502.00 $2,256.00 $2,394.00 $2,502.0069610 10 $41.00 $552.00 $586.00 $612.00 $425.00 $449.00 $475.0069620 90 $651.00 $989.00 $1,053.00 $1,089.00 $708.00 $751.00 $786.0069631 90 $985.00 $1,276.00 $1,354.00 $1,413.00 $1,276.00 $1,354.00 $1,413.0069632 90 $1,166.00 $1,556.00 $1,651.00 $1,726.00 $1,556.00 $1,651.00 $1,726.0069633 90 $1,110.00 $1,510.00 $1,603.00 $1,676.00 $1,510.00 $1,603.00 $1,676.0069635 90 $1,207.00 $1,783.00 $1,895.00 $1,979.00 $1,783.00 $1,895.00 $1,979.0069636 90 $1,381.00 $1,993.00 $2,116.00 $2,205.00 $1,993.00 $2,116.00 $2,205.00



Surgery







69637 90 $1,370.00 $1,982.00 $2,104.00 $2,193.00 $1,982.00 $2,104.00 $2,193.0069641 90 $1,154.00 $1,507.00 $1,599.00 $1,673.00 $1,507.00 $1,599.00 $1,673.0069642 90 $1,519.00 $1,936.00 $2,053.00 $2,151.00 $1,936.00 $2,053.00 $2,151.0069643 90 $1,389.00 $1,775.00 $1,882.00 $1,973.00 $1,775.00 $1,882.00 $1,973.0069644 90 $1,529.00 $2,134.00 $2,265.00 $2,365.00 $2,134.00 $2,265.00 $2,365.0069645 90 $1,479.00 $2,099.00 $2,228.00 $2,327.00 $2,099.00 $2,228.00 $2,327.0069646 90 $1,620.00 $2,232.00 $2,368.00 $2,475.00 $2,232.00 $2,368.00 $2,475.0069650 90 $879.00 $1,165.00 $1,236.00 $1,292.00 $1,165.00 $1,236.00 $1,292.0069660 90 $1,072.00 $1,345.00 $1,426.00 $1,496.00 $1,345.00 $1,426.00 $1,496.0069661 90 $1,412.00 $1,755.00 $1,861.00 $1,954.00 $1,755.00 $1,861.00 $1,954.0069662 90 $1,386.00 $1,685.00 $1,786.00 $1,878.00 $1,685.00 $1,786.00 $1,878.0069666 90 $887.00 $1,170.00 $1,241.00 $1,298.00 $1,170.00 $1,241.00 $1,298.0069667 90 $887.00 $1,170.00 $1,241.00 $1,299.00 $1,170.00 $1,241.00 $1,299.0069670 90 $988.00 $1,373.00 $1,456.00 $1,526.00 $1,373.00 $1,456.00 $1,526.0069676 90 $828.00 $1,200.00 $1,273.00 $1,329.00 $1,200.00 $1,273.00 $1,329.0069700 90 $702.00 $992.00 $1,052.00 $1,100.00 $992.00 $1,052.00 $1,100.0069710 0 BR -------- -------- -------- -------- -------- --------69711 90 $878.00 $1,250.00 $1,326.00 $1,386.00 $1,250.00 $1,326.00 $1,386.0069714 90 $961.00 $1,567.00 $1,661.00 $1,746.00 $1,567.00 $1,661.00 $1,746.0069715 90 $1,217.00 $1,937.00 $2,050.00 $2,159.00 $1,937.00 $2,050.00 $2,159.0069717 90 $996.00 $1,646.00 $1,744.00 $1,833.00 $1,646.00 $1,744.00 $1,833.0069718 90 $1,232.00 $1,956.00 $2,071.00 $2,181.00 $1,956.00 $2,071.00 $2,181.0069720 90 $1,307.00 $1,770.00 $1,885.00 $1,988.00 $1,770.00 $1,885.00 $1,988.0069725 90 $1,922.00 $2,744.00 $2,904.00 $3,063.00 $2,744.00 $2,904.00 $3,063.0069740 90 $1,274.00 $1,699.00 $1,799.00 $1,893.00 $1,699.00 $1,799.00 $1,893.0069745 90 $1,447.00 $2,060.00 $2,220.00 $2,405.00 $2,060.00 $2,220.00 $2,405.0069799 YYY BR -------- -------- -------- -------- -------- --------69801 0 $785.00 $280.00 $298.00 $310.00 $185.00 $195.00 $207.0069805 90 $1,187.00 $1,534.00 $1,625.00 $1,709.00 $1,534.00 $1,625.00 $1,709.0069806 90 $1,123.00 $1,373.00 $1,455.00 $1,528.00 $1,373.00 $1,455.00 $1,528.0069820 90 $876.00 $1,240.00 $1,315.00 $1,376.00 $1,240.00 $1,315.00 $1,376.0069840 90 $869.00 $1,299.00 $1,375.00 $1,427.00 $1,299.00 $1,375.00 $1,427.0069905 90 $1,013.00 $1,328.00 $1,408.00 $1,474.00 $1,328.00 $1,408.00 $1,474.0069910 90 $1,228.00 $1,479.00 $1,567.00 $1,647.00 $1,479.00 $1,567.00 $1,647.0069915 90 $1,754.00 $2,247.00 $2,377.00 $2,508.00 $2,247.00 $2,377.00 $2,508.0069930 90 $1,498.00 $1,786.00 $1,891.00 $1,993.00 $1,786.00 $1,891.00 $1,993.0069949 YYY BR -------- -------- -------- -------- -------- --------69950 90 $2,017.00 $2,609.00 $2,759.00 $2,917.00 $2,609.00 $2,759.00 $2,917.0069955 90 $2,185.00 $2,913.00 $3,084.00 $3,256.00 $2,913.00 $3,084.00 $3,256.0069960 90 $2,116.00 $2,803.00 $2,962.00 $3,123.00 $2,803.00 $2,962.00 $3,123.0069970 90 $2,306.00 $3,137.00 $3,321.00 $3,512.00 $3,137.00 $3,321.00 $3,512.0069979 YYY BR -------- -------- -------- -------- -------- --------69990 ZZZ $262.00 $342.00 $375.00 $428.00 $342.00 $375.00 $428.00G0127 0 -------- $32.00 $34.00 $34.00 $11.00 $11.00 $12.00G0168 0 -------- $142.00 $151.00 $154.00 $40.00 $43.00 $45.00G0247 ZZZ -------- $100.00 $106.00 $108.00 $33.00 $34.00 $36.00G0276 0 -------- $585.00 $620.00 $667.00 $585.00 $620.00 $667.00G0289 ZZZ -------- $130.00 $138.00 $150.00 $130.00 $138.00 $150.00G0341 0 -------- $3,170.00 $3,385.00 $3,417.00 $547.00 $570.00 $594.00G0342 90 -------- $1,024.00 $1,079.00 $1,144.00 $1,024.00 $1,079.00 $1,144.00



Surgery







G0343 90 -------- $1,849.00 $1,985.00 $2,175.00 $1,849.00 $1,985.00 $2,175.00G0364 ZZZ -------- $17.00 $18.00 $19.00 $13.00 $13.00 $13.00G0412 90 -------- $1,051.00 $1,121.00 $1,203.00 $1,051.00 $1,121.00 $1,203.00G0413 90 -------- $1,570.00 $1,676.00 $1,802.00 $1,570.00 $1,676.00 $1,802.00G0414 90 -------- $1,412.00 $1,494.00 $1,581.00 $1,412.00 $1,494.00 $1,581.00G0415 90 -------- $2,019.00 $2,154.00 $2,320.00 $2,019.00 $2,154.00 $2,320.00G0429 0 -------- $139.00 $148.00 $154.00 $103.00 $109.00 $115.00

20165 Edition



PART C


ALLOWANCES


CPT only © 2015 American Medical Association. All rights reserved. Part C, 278

Radiology

CPT Code 2003 MRA Locality 01/02 (Non-Facility MRA)






70010 $70.00 $69.00 $72.00 $75.00 $69.00 $72.00 $75.0070010-26 NC BR BR BR BR BR BR70010-TC NC BR BR BR BR BR BR70015 $58.00 $167.00 $178.00 $182.00 $167.00 $178.00 $182.0070015-26 NC $71.00 $74.00 $78.00 $71.00 $74.00 $78.0070015-TC NC $97.00 $104.00 $104.00 $97.00 $104.00 $104.0070030 $24.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.0070030-26 $10.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0070030-TC $15.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.0070100 $29.00 $35.00 $38.00 $38.00 $35.00 $38.00 $38.0070100-26 $9.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.0070100-TC $19.00 $25.00 $27.00 $27.00 $25.00 $27.00 $27.0070110 $36.00 $41.00 $43.00 $44.00 $41.00 $43.00 $44.0070110-26 $12.00 $14.00 $15.00 $15.00 $14.00 $15.00 $15.0070110-TC $22.00 $27.00 $29.00 $29.00 $27.00 $29.00 $29.0070120 $32.00 $36.00 $39.00 $40.00 $36.00 $39.00 $40.0070120-26 $9.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.0070120-TC $22.00 $26.00 $28.00 $29.00 $26.00 $28.00 $29.0070130 $46.00 $59.00 $62.00 $64.00 $59.00 $62.00 $64.0070130-26 $17.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.0070130-TC $29.00 $39.00 $42.00 $43.00 $39.00 $42.00 $43.0070134 $45.00 $55.00 $59.00 $59.00 $55.00 $59.00 $59.0070134-26 $17.00 $20.00 $20.00 $20.00 $20.00 $20.00 $20.0070134-TC $28.00 $36.00 $38.00 $39.00 $36.00 $38.00 $39.0070140 $33.00 $32.00 $34.00 $35.00 $32.00 $34.00 $35.0070140-26 $9.00 $12.00 $12.00 $13.00 $12.00 $12.00 $13.0070140-TC $22.00 $20.00 $22.00 $22.00 $20.00 $22.00 $22.0070150 $42.00 $45.00 $47.00 $48.00 $45.00 $47.00 $48.0070150-26 $12.00 $15.00 $15.00 $16.00 $15.00 $15.00 $16.0070150-TC $29.00 $30.00 $32.00 $32.00 $30.00 $32.00 $32.0070160 $29.00 $35.00 $37.00 $38.00 $35.00 $37.00 $38.0070160-26 $8.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.0070160-TC $19.00 $25.00 $27.00 $27.00 $25.00 $27.00 $27.0070170 $52.00 $388.00 $415.00 $418.00 $388.00 $415.00 $418.0070170-26 NC $17.00 $18.00 $18.00 $17.00 $18.00 $18.0070170-TC NC $371.00 $398.00 $399.00 $371.00 $398.00 $399.0070190 $34.00 $38.00 $41.00 $42.00 $38.00 $41.00 $42.0070190-26 $10.00 $13.00 $13.00 $13.00 $13.00 $13.00 $13.0070190-TC $22.00 $26.00 $28.00 $28.00 $26.00 $28.00 $28.0070200 $43.00 $45.00 $48.00 $49.00 $45.00 $48.00 $49.0070200-26 $14.00 $16.00 $16.00 $16.00 $16.00 $16.00 $16.0070200-TC $29.00 $30.00 $32.00 $32.00 $30.00 $32.00 $32.0070210 $32.00 $32.00 $34.00 $35.00 $32.00 $34.00 $35.0070210-26 $8.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.0070210-TC $22.00 $22.00 $24.00 $24.00 $22.00 $24.00 $24.0070220 $42.00 $40.00 $43.00 $44.00 $40.00 $43.00 $44.0070220-26 $12.00 $14.00 $15.00 $15.00 $14.00 $15.00 $15.0070220-TC $29.00 $26.00 $28.00 $29.00 $26.00 $28.00 $29.0070240 $26.00 $32.00 $34.00 $35.00 $32.00 $34.00 $35.0070240-26 $9.00 $11.00 $11.00 $12.00 $11.00 $11.00 $12.00



Radiology







70240-TC $15.00 $21.00 $23.00 $23.00 $21.00 $23.00 $23.0070250 $35.00 $39.00 $41.00 $42.00 $39.00 $41.00 $42.0070250-26 $12.00 $14.00 $15.00 $15.00 $14.00 $15.00 $15.0070250-TC $22.00 $25.00 $27.00 $27.00 $25.00 $27.00 $27.0070260 $50.00 $49.00 $52.00 $53.00 $49.00 $52.00 $53.0070260-26 $17.00 $20.00 $20.00 $21.00 $20.00 $20.00 $21.0070260-TC $33.00 $30.00 $32.00 $32.00 $30.00 $32.00 $32.0070300 $15.00 $16.00 $17.00 $18.00 $16.00 $17.00 $18.0070300-26 $5.00 $7.00 $7.00 $7.00 $7.00 $7.00 $7.0070300-TC $10.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.0070310 $24.00 $39.00 $42.00 $43.00 $39.00 $42.00 $43.0070310-26 $8.00 $9.00 $9.00 $10.00 $9.00 $9.00 $10.0070310-TC $15.00 $30.00 $33.00 $33.00 $30.00 $33.00 $33.0070320 $40.00 $56.00 $60.00 $61.00 $56.00 $60.00 $61.0070320-26 $11.00 $13.00 $14.00 $14.00 $13.00 $14.00 $14.0070320-TC $29.00 $43.00 $46.00 $47.00 $43.00 $46.00 $47.0070328 $28.00 $33.00 $35.00 $36.00 $33.00 $35.00 $36.0070328-26 $10.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.0070328-TC $18.00 $23.00 $25.00 $25.00 $23.00 $25.00 $25.0070330 $43.00 $51.00 $54.00 $55.00 $51.00 $54.00 $55.0070330-26 $12.00 $14.00 $15.00 $15.00 $14.00 $15.00 $15.0070330-TC $31.00 $36.00 $39.00 $40.00 $36.00 $39.00 $40.0070332 $107.00 $88.00 $93.00 $95.00 $88.00 $93.00 $95.0070332-26 NC $35.00 $37.00 $38.00 $35.00 $37.00 $38.0070332-TC NC $53.00 $57.00 $57.00 $53.00 $57.00 $57.0070336 $497.00 $345.00 $367.00 $371.00 $345.00 $367.00 $371.0070336-26 $72.00 $83.00 $86.00 $88.00 $83.00 $86.00 $88.0070336-TC $419.00 $262.00 $281.00 $283.00 $262.00 $281.00 $283.0070350 $24.00 $22.00 $23.00 $24.00 $22.00 $23.00 $24.0070350-26 $10.00 $12.00 $12.00 $13.00 $12.00 $12.00 $13.0070350-TC $14.00 $10.00 $11.00 $12.00 $10.00 $11.00 $12.0070355 $32.00 $23.00 $24.00 $25.00 $23.00 $24.00 $25.0070355-26 $10.00 $13.00 $13.00 $14.00 $13.00 $13.00 $14.0070355-TC $21.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.0070360 $24.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.0070360-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0070360-TC $15.00 $21.00 $23.00 $23.00 $21.00 $23.00 $23.0070370 $65.00 $82.00 $88.00 $89.00 $82.00 $88.00 $89.0070370-26 $16.00 $18.00 $19.00 $19.00 $18.00 $19.00 $19.0070370-TC $48.00 $64.00 $69.00 $69.00 $64.00 $69.00 $69.0070371 $122.00 $99.00 $105.00 $107.00 $99.00 $105.00 $107.0070371-26 $43.00 $48.00 $50.00 $51.00 $48.00 $50.00 $51.0070371-TC $79.00 $51.00 $55.00 $55.00 $51.00 $55.00 $55.0070380 $34.00 $39.00 $41.00 $42.00 $39.00 $41.00 $42.0070380-26 $8.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.0070380-TC $24.00 $28.00 $31.00 $31.00 $28.00 $31.00 $31.0070390 $87.00 $101.00 $107.00 $109.00 $101.00 $107.00 $109.0070390-26 NC $21.00 $22.00 $23.00 $21.00 $22.00 $23.0070390-TC NC $80.00 $85.00 $86.00 $80.00 $85.00 $86.0070450 $221.00 $126.00 $133.00 $135.00 $126.00 $133.00 $135.00



Radiology







70450-26 $43.00 $48.00 $50.00 $51.00 $48.00 $50.00 $51.0070450-TC $176.00 $78.00 $83.00 $84.00 $78.00 $83.00 $84.0070460 $271.00 $175.00 $185.00 $188.00 $175.00 $185.00 $188.0070460-26 $58.00 $63.00 $66.00 $67.00 $63.00 $66.00 $67.0070460-TC $211.00 $111.00 $120.00 $120.00 $111.00 $120.00 $120.0070470 $332.00 $207.00 $220.00 $223.00 $207.00 $220.00 $223.0070470-26 $65.00 $72.00 $74.00 $76.00 $72.00 $74.00 $76.0070470-TC $264.00 $135.00 $145.00 $146.00 $135.00 $145.00 $146.0070480 $244.00 $191.00 $202.00 $205.00 $191.00 $202.00 $205.0070480-26 $65.00 $72.00 $75.00 $77.00 $72.00 $75.00 $77.0070480-TC $176.00 $119.00 $128.00 $128.00 $119.00 $128.00 $128.0070481 $284.00 $297.00 $316.00 $319.00 $297.00 $316.00 $319.0070481-26 $70.00 $78.00 $80.00 $83.00 $78.00 $80.00 $83.0070481-TC $211.00 $219.00 $236.00 $237.00 $219.00 $236.00 $237.0070482 $340.00 $324.00 $345.00 $349.00 $324.00 $345.00 $349.0070482-26 $74.00 $81.00 $84.00 $87.00 $81.00 $84.00 $87.0070482-TC $264.00 $243.00 $261.00 $262.00 $243.00 $261.00 $262.0070486 $236.00 $151.00 $160.00 $163.00 $151.00 $160.00 $163.0070486-26 $58.00 $48.00 $50.00 $51.00 $48.00 $50.00 $51.0070486-TC $176.00 $103.00 $111.00 $111.00 $103.00 $111.00 $111.0070487 $279.00 $182.00 $193.00 $195.00 $182.00 $193.00 $195.0070487-26 $66.00 $63.00 $66.00 $67.00 $63.00 $66.00 $67.0070487-TC $211.00 $118.00 $127.00 $128.00 $118.00 $127.00 $128.0070488 $339.00 $221.00 $235.00 $238.00 $221.00 $235.00 $238.0070488-26 $72.00 $71.00 $74.00 $76.00 $71.00 $74.00 $76.0070488-TC $264.00 $150.00 $161.00 $162.00 $150.00 $161.00 $162.0070490 $244.00 $191.00 $202.00 $205.00 $191.00 $202.00 $205.0070490-26 $65.00 $72.00 $75.00 $77.00 $72.00 $75.00 $77.0070490-TC $176.00 $119.00 $128.00 $128.00 $119.00 $128.00 $128.0070491 $284.00 $254.00 $270.00 $273.00 $254.00 $270.00 $273.0070491-26 $70.00 $78.00 $81.00 $83.00 $78.00 $81.00 $83.0070491-TC $211.00 $176.00 $189.00 $190.00 $176.00 $189.00 $190.0070492 $340.00 $299.00 $318.00 $321.00 $299.00 $318.00 $321.0070492-26 $74.00 $82.00 $84.00 $87.00 $82.00 $84.00 $87.0070492-TC $264.00 $218.00 $234.00 $235.00 $218.00 $234.00 $235.0070496 $366.00 $317.00 $337.00 $341.00 $317.00 $337.00 $341.0070496-26 $92.00 $98.00 $102.00 $105.00 $98.00 $102.00 $105.0070496-TC $270.00 $219.00 $235.00 $237.00 $219.00 $235.00 $237.0070498 $366.00 $316.00 $336.00 $340.00 $316.00 $336.00 $340.0070498-26 $92.00 $98.00 $102.00 $105.00 $98.00 $102.00 $105.0070498-TC $270.00 $218.00 $234.00 $235.00 $218.00 $234.00 $235.0070540 $482.00 $364.00 $388.00 $392.00 $364.00 $388.00 $392.0070540-26 $70.00 $76.00 $78.00 $81.00 $76.00 $78.00 $81.0070540-TC $413.00 $288.00 $310.00 $311.00 $288.00 $310.00 $311.0070542 $579.00 $431.00 $459.00 $464.00 $431.00 $459.00 $464.0070542-26 $82.00 $91.00 $94.00 $97.00 $91.00 $94.00 $97.0070542-TC $495.00 $340.00 $365.00 $367.00 $340.00 $365.00 $367.0070543 $1,029.00 $528.00 $562.00 $568.00 $528.00 $562.00 $568.0070543-26 $109.00 $121.00 $125.00 $129.00 $121.00 $125.00 $129.0070543-TC $916.00 $407.00 $437.00 $439.00 $407.00 $437.00 $439.00



Radiology







70544 $481.00 $356.00 $380.00 $384.00 $356.00 $380.00 $384.0070544-26 $61.00 $68.00 $70.00 $72.00 $68.00 $70.00 $72.0070544-TC $419.00 $288.00 $310.00 $311.00 $288.00 $310.00 $311.0070545 $481.00 $415.00 $442.00 $446.00 $415.00 $442.00 $446.0070545-26 $61.00 $68.00 $70.00 $72.00 $68.00 $70.00 $72.0070545-TC $419.00 $347.00 $373.00 $374.00 $347.00 $373.00 $374.0070546 $914.00 $580.00 $619.00 $624.00 $580.00 $619.00 $624.0070546-26 $92.00 $101.00 $105.00 $108.00 $101.00 $105.00 $108.0070546-TC $820.00 $479.00 $514.00 $516.00 $479.00 $514.00 $516.0070547 $481.00 $356.00 $380.00 $384.00 $356.00 $380.00 $384.0070547-26 $61.00 $68.00 $70.00 $72.00 $68.00 $70.00 $72.0070547-TC $419.00 $288.00 $310.00 $311.00 $288.00 $310.00 $311.0070548 $481.00 $442.00 $472.00 $476.00 $442.00 $472.00 $476.0070548-26 $61.00 $68.00 $70.00 $72.00 $68.00 $70.00 $72.0070548-TC $419.00 $374.00 $402.00 $404.00 $374.00 $402.00 $404.0070549 $914.00 $580.00 $619.00 $624.00 $580.00 $619.00 $624.0070549-26 $92.00 $101.00 $105.00 $108.00 $101.00 $105.00 $108.0070549-TC $820.00 $479.00 $514.00 $516.00 $479.00 $514.00 $516.0070551 $497.00 $249.00 $264.00 $267.00 $249.00 $264.00 $267.0070551-26 $76.00 $83.00 $86.00 $89.00 $83.00 $86.00 $89.0070551-TC $419.00 $165.00 $178.00 $178.00 $165.00 $178.00 $178.0070552 $596.00 $344.00 $366.00 $370.00 $344.00 $366.00 $370.0070552-26 $91.00 $100.00 $104.00 $107.00 $100.00 $104.00 $107.0070552-TC $502.00 $244.00 $262.00 $264.00 $244.00 $262.00 $264.0070553 $1,055.00 $407.00 $432.00 $438.00 $407.00 $432.00 $438.0070553-26 $120.00 $129.00 $133.00 $138.00 $129.00 $133.00 $138.0070553-TC $931.00 $278.00 $299.00 $300.00 $278.00 $299.00 $300.0070554 --------- $485.00 $516.00 $522.00 $485.00 $516.00 $522.0070554-26 --------- $120.00 $124.00 $128.00 $120.00 $124.00 $128.0070554-TC --------- $365.00 $392.00 $394.00 $365.00 $392.00 $394.0070555 --------- BR BR BR BR BR BR70555-26 --------- $142.00 $147.00 $151.00 $142.00 $147.00 $151.0070555-TC --------- BR BR BR BR BR BR70557 --------- $452.00 $479.00 $486.00 $452.00 $479.00 $486.0070557-26 --------- $164.00 $170.00 $175.00 $164.00 $170.00 $175.0070557-TC --------- $288.00 $309.00 $311.00 $288.00 $309.00 $311.0070558 --------- $659.00 $700.00 $708.00 $659.00 $700.00 $708.0070558-26 --------- $181.00 $187.00 $193.00 $181.00 $187.00 $193.0070558-TC --------- $478.00 $513.00 $515.00 $478.00 $513.00 $515.0070559 --------- $3,046.00 $3,262.00 $3,277.00 $3,046.00 $3,262.00 $3,277.0070559-26 --------- $183.00 $189.00 $196.00 $183.00 $189.00 $196.0070559-TC --------- $2,863.00 $3,072.00 $3,082.00 $2,863.00 $3,072.00 $3,082.0071010 $27.00 $24.00 $26.00 $27.00 $24.00 $26.00 $27.0071010-26 $9.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.0071010-TC $17.00 $14.00 $15.00 $16.00 $14.00 $15.00 $16.0071015 $30.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.0071015-26 $10.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.0071015-TC $19.00 $18.00 $19.00 $20.00 $18.00 $19.00 $20.0071020 $35.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.0071020-26 $11.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.00



Radiology







71020-TC $22.00 $18.00 $19.00 $20.00 $18.00 $19.00 $20.0071021 $41.00 $37.00 $39.00 $39.00 $37.00 $39.00 $39.0071021-26 $13.00 $15.00 $16.00 $16.00 $15.00 $16.00 $16.0071021-TC $28.00 $21.00 $23.00 $23.00 $21.00 $23.00 $23.0071022 $44.00 $45.00 $48.00 $48.00 $45.00 $48.00 $48.0071022-26 $16.00 $18.00 $19.00 $19.00 $18.00 $19.00 $19.0071022-TC $28.00 $27.00 $29.00 $29.00 $27.00 $29.00 $29.0071023 $49.00 $68.00 $73.00 $74.00 $68.00 $73.00 $74.0071023-26 $19.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.0071023-TC $29.00 $47.00 $51.00 $51.00 $47.00 $51.00 $51.0071030 $45.00 $45.00 $48.00 $49.00 $45.00 $48.00 $49.0071030-26 $16.00 $18.00 $18.00 $19.00 $18.00 $18.00 $19.0071030-TC $29.00 $27.00 $29.00 $30.00 $27.00 $29.00 $30.0071034 $79.00 $90.00 $96.00 $97.00 $90.00 $96.00 $97.0071034-26 $23.00 $27.00 $28.00 $29.00 $27.00 $28.00 $29.0071034-TC $54.00 $63.00 $68.00 $69.00 $63.00 $68.00 $69.0071035 $56.00 $35.00 $38.00 $38.00 $35.00 $38.00 $38.0071035-26 $19.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.0071035-TC $38.00 $25.00 $27.00 $27.00 $25.00 $27.00 $27.0071100 $33.00 $35.00 $38.00 $38.00 $35.00 $38.00 $38.0071100-26 $11.00 $13.00 $13.00 $13.00 $13.00 $13.00 $13.0071100-TC $21.00 $23.00 $25.00 $25.00 $23.00 $25.00 $25.0071101 $38.00 $39.00 $42.00 $43.00 $39.00 $42.00 $43.0071101-26 $13.00 $15.00 $16.00 $17.00 $15.00 $16.00 $17.0071101-TC $24.00 $24.00 $26.00 $26.00 $24.00 $26.00 $26.0071110 $43.00 $40.00 $43.00 $44.00 $40.00 $43.00 $44.0071110-26 $13.00 $15.00 $16.00 $16.00 $15.00 $16.00 $16.0071110-TC $29.00 $25.00 $27.00 $27.00 $25.00 $27.00 $27.0071111 $49.00 $52.00 $55.00 $56.00 $52.00 $55.00 $56.0071111-26 $16.00 $19.00 $19.00 $20.00 $19.00 $19.00 $20.0071111-TC $33.00 $33.00 $36.00 $36.00 $33.00 $36.00 $36.0071120 $35.00 $32.00 $34.00 $35.00 $32.00 $34.00 $35.0071120-26 $10.00 $11.00 $12.00 $12.00 $11.00 $12.00 $12.0071120-TC $24.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.0071130 $38.00 $39.00 $41.00 $42.00 $39.00 $41.00 $42.0071130-26 $11.00 $13.00 $13.00 $13.00 $13.00 $13.00 $13.0071130-TC $26.00 $26.00 $28.00 $29.00 $26.00 $28.00 $29.0071250 $282.00 $177.00 $187.00 $190.00 $177.00 $187.00 $190.0071250-26 $59.00 $58.00 $60.00 $62.00 $58.00 $60.00 $62.0071250-TC $220.00 $119.00 $128.00 $128.00 $119.00 $128.00 $128.0071260 $328.00 $247.00 $262.00 $265.00 $247.00 $262.00 $265.0071260-26 $63.00 $70.00 $73.00 $75.00 $70.00 $73.00 $75.0071260-TC $264.00 $177.00 $190.00 $191.00 $177.00 $190.00 $191.0071270 $402.00 $296.00 $315.00 $318.00 $296.00 $315.00 $318.0071270-26 $70.00 $78.00 $80.00 $83.00 $78.00 $80.00 $83.0071270-TC $330.00 $218.00 $234.00 $235.00 $218.00 $234.00 $235.0071275 $431.00 $323.00 $343.00 $347.00 $323.00 $343.00 $347.0071275-26 $100.00 $102.00 $106.00 $109.00 $102.00 $106.00 $109.0071275-TC $328.00 $221.00 $237.00 $239.00 $221.00 $237.00 $239.0071550 $490.00 $370.00 $394.00 $398.00 $370.00 $394.00 $398.00



Radiology







71550-26 $75.00 $82.00 $85.00 $87.00 $82.00 $85.00 $87.0071550-TC $415.00 $288.00 $310.00 $311.00 $288.00 $310.00 $311.0071551 $587.00 $491.00 $524.00 $529.00 $491.00 $524.00 $529.0071551-26 $88.00 $97.00 $100.00 $104.00 $97.00 $100.00 $104.0071551-TC $496.00 $394.00 $423.00 $425.00 $394.00 $423.00 $425.0071552 $1,029.00 $606.00 $646.00 $652.00 $606.00 $646.00 $652.0071552-26 $114.00 $128.00 $132.00 $136.00 $128.00 $132.00 $136.0071552-TC $911.00 $479.00 $514.00 $516.00 $479.00 $514.00 $516.0071555 $514.00 $427.00 $454.00 $458.00 $427.00 $454.00 $458.0071555-26 $92.00 $101.00 $104.00 $107.00 $101.00 $104.00 $107.0071555-TC $419.00 $326.00 $350.00 $352.00 $326.00 $350.00 $352.0072020 $22.00 $24.00 $26.00 $26.00 $24.00 $26.00 $26.0072020-26 $7.00 $9.00 $9.00 $9.00 $9.00 $9.00 $9.0072020-TC $15.00 $15.00 $16.00 $17.00 $15.00 $16.00 $17.0072040 $34.00 $36.00 $38.00 $39.00 $36.00 $38.00 $39.0072040-26 $11.00 $13.00 $13.00 $13.00 $13.00 $13.00 $13.0072040-TC $22.00 $23.00 $25.00 $25.00 $23.00 $25.00 $25.0072050 $49.00 $49.00 $52.00 $53.00 $49.00 $52.00 $53.0072050-26 $16.00 $18.00 $18.00 $19.00 $18.00 $18.00 $19.0072050-TC $33.00 $31.00 $33.00 $34.00 $31.00 $33.00 $34.0072052 $61.00 $61.00 $64.00 $66.00 $61.00 $64.00 $66.0072052-26 $18.00 $21.00 $21.00 $22.00 $21.00 $21.00 $22.0072052-TC $42.00 $40.00 $43.00 $44.00 $40.00 $43.00 $44.0072070 $36.00 $37.00 $39.00 $40.00 $37.00 $39.00 $40.0072070-26 $11.00 $13.00 $13.00 $13.00 $13.00 $13.00 $13.0072070-TC $24.00 $24.00 $26.00 $26.00 $24.00 $26.00 $26.0072072 $39.00 $37.00 $40.00 $40.00 $37.00 $40.00 $40.0072072-26 $11.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.0072072-TC $28.00 $25.00 $27.00 $27.00 $25.00 $27.00 $27.0072074 $45.00 $42.00 $45.00 $46.00 $42.00 $45.00 $46.0072074-26 $11.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.0072074-TC $34.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.0072080 $36.00 $33.00 $35.00 $36.00 $33.00 $35.00 $36.0072080-26 $11.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.0072080-TC $24.00 $21.00 $23.00 $23.00 $21.00 $23.00 $23.0072081 --------- $42.00 $45.00 $46.00 $42.00 $45.00 $46.0072081-26 --------- $15.00 $16.00 $16.00 $15.00 $16.00 $16.0072081-TC --------- $27.00 $29.00 $29.00 $27.00 $29.00 $29.0072082 --------- $67.00 $71.00 $73.00 $67.00 $71.00 $73.0072082-26 --------- $18.00 $19.00 $19.00 $18.00 $19.00 $19.0072082-TC --------- $49.00 $53.00 $53.00 $49.00 $53.00 $53.0072083 --------- $73.00 $77.00 $79.00 $73.00 $77.00 $79.0072083-26 --------- $20.00 $20.00 $21.00 $20.00 $20.00 $21.0072083-TC --------- $53.00 $57.00 $58.00 $53.00 $57.00 $58.0072084 --------- $87.00 $92.00 $94.00 $87.00 $92.00 $94.0072084-26 --------- $23.00 $24.00 $24.00 $23.00 $24.00 $24.0072084-TC --------- $64.00 $69.00 $69.00 $64.00 $69.00 $69.0072100 $36.00 $38.00 $40.00 $41.00 $38.00 $40.00 $41.0072100-26 $11.00 $13.00 $13.00 $13.00 $13.00 $13.00 $13.0072100-TC $24.00 $25.00 $27.00 $27.00 $25.00 $27.00 $27.00



Radiology







72110 $50.00 $53.00 $56.00 $57.00 $53.00 $56.00 $57.0072110-26 $16.00 $18.00 $18.00 $19.00 $18.00 $18.00 $19.0072110-TC $34.00 $35.00 $38.00 $38.00 $35.00 $38.00 $38.0072114 $64.00 $67.00 $71.00 $73.00 $67.00 $71.00 $73.0072114-26 $18.00 $19.00 $19.00 $20.00 $19.00 $19.00 $20.0072114-TC $44.00 $49.00 $52.00 $53.00 $49.00 $52.00 $53.0072120 $45.00 $43.00 $46.00 $47.00 $43.00 $46.00 $47.0072120-26 $11.00 $13.00 $13.00 $13.00 $13.00 $13.00 $13.0072120-TC $33.00 $31.00 $33.00 $34.00 $31.00 $33.00 $34.0072125 $282.00 $179.00 $190.00 $193.00 $179.00 $190.00 $193.0072125-26 $59.00 $60.00 $62.00 $64.00 $60.00 $62.00 $64.0072125-TC $220.00 $119.00 $128.00 $128.00 $119.00 $128.00 $128.0072126 $328.00 $247.00 $262.00 $265.00 $247.00 $262.00 $265.0072126-26 $62.00 $69.00 $71.00 $73.00 $69.00 $71.00 $73.0072126-TC $264.00 $178.00 $191.00 $192.00 $178.00 $191.00 $192.0072127 $397.00 $291.00 $310.00 $313.00 $291.00 $310.00 $313.0072127-26 $65.00 $71.00 $74.00 $76.00 $71.00 $74.00 $76.0072127-TC $330.00 $220.00 $236.00 $237.00 $220.00 $236.00 $237.0072128 $282.00 $175.00 $186.00 $189.00 $175.00 $186.00 $189.0072128-26 $59.00 $56.00 $58.00 $60.00 $56.00 $58.00 $60.0072128-TC $220.00 $119.00 $128.00 $128.00 $119.00 $128.00 $128.0072129 $328.00 $247.00 $262.00 $265.00 $247.00 $262.00 $265.0072129-26 $62.00 $69.00 $71.00 $73.00 $69.00 $71.00 $73.0072129-TC $264.00 $178.00 $191.00 $192.00 $178.00 $191.00 $192.0072130 $397.00 $293.00 $312.00 $315.00 $293.00 $312.00 $315.0072130-26 $65.00 $71.00 $74.00 $76.00 $71.00 $74.00 $76.0072130-TC $330.00 $222.00 $238.00 $239.00 $222.00 $238.00 $239.0072131 $282.00 $175.00 $186.00 $189.00 $175.00 $186.00 $189.0072131-26 $59.00 $56.00 $58.00 $60.00 $56.00 $58.00 $60.0072131-TC $220.00 $119.00 $128.00 $128.00 $119.00 $128.00 $128.0072132 $328.00 $246.00 $262.00 $265.00 $246.00 $262.00 $265.0072132-26 $62.00 $69.00 $71.00 $73.00 $69.00 $71.00 $73.0072132-TC $264.00 $177.00 $191.00 $191.00 $177.00 $191.00 $191.0072133 $391.00 $291.00 $310.00 $313.00 $291.00 $310.00 $313.0072133-26 $65.00 $72.00 $74.00 $77.00 $72.00 $74.00 $77.0072133-TC $323.00 $219.00 $236.00 $237.00 $219.00 $236.00 $237.0072141 $503.00 $242.00 $257.00 $260.00 $242.00 $257.00 $260.0072141-26 $82.00 $84.00 $87.00 $89.00 $84.00 $87.00 $89.0072141-TC $419.00 $158.00 $170.00 $171.00 $158.00 $170.00 $171.0072142 $604.00 $350.00 $372.00 $377.00 $350.00 $372.00 $377.0072142-26 $99.00 $101.00 $105.00 $108.00 $101.00 $105.00 $108.0072142-TC $502.00 $249.00 $267.00 $269.00 $249.00 $267.00 $269.0072146 $549.00 $242.00 $257.00 $260.00 $242.00 $257.00 $260.0072146-26 $82.00 $84.00 $87.00 $89.00 $84.00 $87.00 $89.0072146-TC $465.00 $158.00 $170.00 $171.00 $158.00 $170.00 $171.0072147 $603.00 $346.00 $368.00 $372.00 $346.00 $368.00 $372.0072147-26 $98.00 $100.00 $104.00 $107.00 $100.00 $104.00 $107.0072147-TC $502.00 $246.00 $264.00 $266.00 $246.00 $264.00 $266.0072148 $543.00 $241.00 $255.00 $259.00 $241.00 $255.00 $259.0072148-26 $76.00 $84.00 $87.00 $89.00 $84.00 $87.00 $89.00



Radiology







72148-TC $465.00 $157.00 $169.00 $169.00 $157.00 $169.00 $169.0072149 $597.00 $346.00 $368.00 $373.00 $346.00 $368.00 $373.0072149-26 $92.00 $101.00 $105.00 $108.00 $101.00 $105.00 $108.0072149-TC $502.00 $245.00 $263.00 $264.00 $245.00 $263.00 $264.0072156 $1,066.00 $409.00 $434.00 $440.00 $409.00 $434.00 $440.0072156-26 $131.00 $129.00 $133.00 $138.00 $129.00 $133.00 $138.0072156-TC $931.00 $280.00 $301.00 $302.00 $280.00 $301.00 $302.0072157 $1,066.00 $410.00 $435.00 $441.00 $410.00 $435.00 $441.0072157-26 $131.00 $129.00 $133.00 $138.00 $129.00 $133.00 $138.0072157-TC $931.00 $281.00 $302.00 $303.00 $281.00 $302.00 $303.0072158 $1,056.00 $408.00 $433.00 $439.00 $408.00 $433.00 $439.0072158-26 $121.00 $129.00 $133.00 $138.00 $129.00 $133.00 $138.0072158-TC $931.00 $279.00 $300.00 $301.00 $279.00 $300.00 $301.0072159 $563.00 $448.00 $477.00 $481.00 $448.00 $477.00 $481.0072159-26 $94.00 $102.00 $105.00 $108.00 $102.00 $105.00 $108.0072159-TC $465.00 $346.00 $371.00 $373.00 $346.00 $371.00 $373.0072170 $29.00 $34.00 $36.00 $37.00 $34.00 $36.00 $37.0072170-26 $8.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.0072170-TC $19.00 $24.00 $26.00 $27.00 $24.00 $26.00 $27.0072190 $35.00 $41.00 $44.00 $44.00 $41.00 $44.00 $44.0072190-26 $10.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.0072190-TC $24.00 $29.00 $31.00 $31.00 $29.00 $31.00 $31.0072191 $413.00 $329.00 $350.00 $355.00 $329.00 $350.00 $355.0072191-26 $94.00 $102.00 $105.00 $109.00 $102.00 $105.00 $109.0072191-TC $315.00 $228.00 $244.00 $246.00 $228.00 $244.00 $246.0072192 $278.00 $158.00 $167.00 $170.00 $158.00 $167.00 $170.0072192-26 $56.00 $62.00 $64.00 $65.00 $62.00 $64.00 $65.0072192-TC $220.00 $97.00 $104.00 $104.00 $97.00 $104.00 $104.0072193 $317.00 $243.00 $259.00 $262.00 $243.00 $259.00 $262.0072193-26 $59.00 $66.00 $68.00 $70.00 $66.00 $68.00 $70.0072193-TC $256.00 $178.00 $191.00 $192.00 $178.00 $191.00 $192.0072194 $380.00 $280.00 $298.00 $301.00 $280.00 $298.00 $301.0072194-26 $62.00 $69.00 $71.00 $73.00 $69.00 $71.00 $73.0072194-TC $317.00 $211.00 $227.00 $228.00 $211.00 $227.00 $228.0072195 $491.00 $371.00 $395.00 $399.00 $371.00 $395.00 $399.0072195-26 $74.00 $82.00 $85.00 $88.00 $82.00 $85.00 $88.0072195-TC $415.00 $288.00 $310.00 $311.00 $288.00 $310.00 $311.0072196 $526.00 $442.00 $471.00 $475.00 $442.00 $471.00 $475.0072196-26 $84.00 $98.00 $101.00 $104.00 $98.00 $101.00 $104.0072196-TC $442.00 $344.00 $369.00 $371.00 $344.00 $369.00 $371.0072197 $1,037.00 $543.00 $578.00 $584.00 $543.00 $578.00 $584.0072197-26 $114.00 $128.00 $132.00 $136.00 $128.00 $132.00 $136.0072197-TC $919.00 $416.00 $446.00 $448.00 $416.00 $446.00 $448.0072198 $517.00 $431.00 $458.00 $463.00 $431.00 $458.00 $463.0072198-26 $95.00 $101.00 $104.00 $107.00 $101.00 $104.00 $107.0072198-TC $419.00 $330.00 $354.00 $356.00 $330.00 $354.00 $356.0072200 $29.00 $31.00 $33.00 $33.00 $31.00 $33.00 $33.0072200-26 $9.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.0072200-TC $19.00 $21.00 $23.00 $23.00 $21.00 $23.00 $23.0072202 $33.00 $35.00 $38.00 $38.00 $35.00 $38.00 $38.00



Radiology







72202-26 $9.00 $11.00 $11.00 $11.00 $11.00 $11.00 $11.0072202-TC $22.00 $25.00 $27.00 $27.00 $25.00 $27.00 $27.0072220 $30.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.0072220-26 $8.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.0072220-TC $21.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.0072240 $132.00 $106.00 $112.00 $114.00 $106.00 $112.00 $114.0072240-26 NC $51.00 $53.00 $55.00 $51.00 $53.00 $55.0072240-TC NC $55.00 $59.00 $60.00 $55.00 $59.00 $60.0072255 $129.00 $106.00 $112.00 $114.00 $106.00 $112.00 $114.0072255-26 NC $52.00 $54.00 $56.00 $52.00 $54.00 $56.0072255-TC NC $54.00 $58.00 $58.00 $54.00 $58.00 $58.0072265 $132.00 $100.00 $106.00 $108.00 $100.00 $106.00 $108.0072265-26 NC $47.00 $49.00 $50.00 $47.00 $49.00 $50.0072265-TC NC $53.00 $57.00 $58.00 $53.00 $57.00 $58.0072270 $176.00 $139.00 $146.00 $149.00 $139.00 $146.00 $149.0072270-26 NC $75.00 $78.00 $81.00 $75.00 $78.00 $81.0072270-TC NC $63.00 $68.00 $69.00 $63.00 $68.00 $69.0072275 $112.00 $125.00 $132.00 $134.00 $125.00 $132.00 $134.0072275-26 NC $44.00 $46.00 $47.00 $44.00 $46.00 $47.0072275-TC NC $81.00 $87.00 $87.00 $81.00 $87.00 $87.0072285 $101.00 $124.00 $131.00 $134.00 $124.00 $131.00 $134.0072285-26 NC $68.00 $71.00 $73.00 $68.00 $71.00 $73.0072285-TC NC $56.00 $60.00 $61.00 $56.00 $60.00 $61.0072295 $107.00 $107.00 $114.00 $116.00 $107.00 $114.00 $116.0072295-26 NC $49.00 $51.00 $53.00 $49.00 $51.00 $53.0072295-TC NC $58.00 $63.00 $63.00 $58.00 $63.00 $63.0073000 $28.00 $30.00 $32.00 $32.00 $30.00 $32.00 $32.0073000-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0073000-TC $19.00 $20.00 $22.00 $22.00 $20.00 $22.00 $22.0073010 $29.00 $32.00 $34.00 $35.00 $32.00 $34.00 $35.0073010-26 $8.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.0073010-TC $19.00 $22.00 $24.00 $24.00 $22.00 $24.00 $24.0073020 $26.00 $25.00 $26.00 $27.00 $25.00 $26.00 $27.0073020-26 $7.00 $9.00 $9.00 $9.00 $9.00 $9.00 $9.0073020-TC $17.00 $16.00 $17.00 $18.00 $16.00 $17.00 $18.0073030 $31.00 $31.00 $33.00 $34.00 $31.00 $33.00 $34.0073030-26 $9.00 $11.00 $11.00 $11.00 $11.00 $11.00 $11.0073030-TC $21.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.0073040 $68.00 $108.00 $114.00 $116.00 $108.00 $114.00 $116.0073040-26 NC $31.00 $32.00 $33.00 $31.00 $32.00 $33.0073040-TC NC $77.00 $83.00 $83.00 $77.00 $83.00 $83.0073050 $35.00 $38.00 $40.00 $41.00 $38.00 $40.00 $41.0073050-26 $10.00 $12.00 $12.00 $13.00 $12.00 $12.00 $13.0073050-TC $24.00 $26.00 $28.00 $29.00 $26.00 $28.00 $29.0073060 $30.00 $31.00 $33.00 $34.00 $31.00 $33.00 $34.0073060-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0073060-TC $21.00 $22.00 $23.00 $24.00 $22.00 $23.00 $24.0073070 $27.00 $29.00 $31.00 $32.00 $29.00 $31.00 $32.0073070-26 $7.00 $9.00 $9.00 $10.00 $9.00 $9.00 $10.0073070-TC $19.00 $20.00 $22.00 $22.00 $20.00 $22.00 $22.00



Radiology







73080 $30.00 $33.00 $36.00 $36.00 $33.00 $36.00 $36.0073080-26 $8.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.0073080-TC $21.00 $24.00 $25.00 $26.00 $24.00 $25.00 $26.0073085 $74.00 $105.00 $111.00 $113.00 $105.00 $111.00 $113.0073085-26 NC $32.00 $34.00 $35.00 $32.00 $34.00 $35.0073085-TC NC $72.00 $78.00 $78.00 $72.00 $78.00 $78.0073090 $28.00 $28.00 $30.00 $30.00 $28.00 $30.00 $30.0073090-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0073090-TC $19.00 $18.00 $20.00 $20.00 $18.00 $20.00 $20.0073100 $27.00 $31.00 $33.00 $34.00 $31.00 $33.00 $34.0073100-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0073100-TC $18.00 $22.00 $23.00 $24.00 $22.00 $23.00 $24.0073110 $29.00 $38.00 $40.00 $41.00 $38.00 $40.00 $41.0073110-26 $8.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.0073110-TC $19.00 $28.00 $30.00 $31.00 $28.00 $30.00 $31.0073115 $54.00 $115.00 $122.00 $124.00 $115.00 $122.00 $124.0073115-26 NC $32.00 $33.00 $35.00 $32.00 $33.00 $35.0073115-TC NC $83.00 $89.00 $90.00 $83.00 $89.00 $90.0073120 $27.00 $28.00 $30.00 $31.00 $28.00 $30.00 $31.0073120-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0073120-TC $18.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.0073130 $29.00 $33.00 $35.00 $36.00 $33.00 $35.00 $36.0073130-26 $8.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.0073130-TC $19.00 $23.00 $25.00 $25.00 $23.00 $25.00 $25.0073140 $22.00 $34.00 $36.00 $37.00 $34.00 $36.00 $37.0073140-26 $7.00 $8.00 $8.00 $9.00 $8.00 $8.00 $9.0073140-TC $15.00 $26.00 $28.00 $28.00 $26.00 $28.00 $28.0073200 $242.00 $175.00 $186.00 $189.00 $175.00 $186.00 $189.0073200-26 $56.00 $56.00 $58.00 $60.00 $56.00 $58.00 $60.0073200-TC $185.00 $119.00 $128.00 $128.00 $119.00 $128.00 $128.0073201 $282.00 $240.00 $255.00 $258.00 $240.00 $255.00 $258.0073201-26 $59.00 $66.00 $68.00 $70.00 $66.00 $68.00 $70.0073201-TC $220.00 $174.00 $187.00 $188.00 $174.00 $187.00 $188.0073202 $342.00 $298.00 $318.00 $321.00 $298.00 $318.00 $321.0073202-26 $63.00 $69.00 $71.00 $73.00 $69.00 $71.00 $73.0073202-TC $277.00 $230.00 $247.00 $248.00 $230.00 $247.00 $248.0073206 $375.00 $351.00 $373.00 $377.00 $351.00 $373.00 $377.0073206-26 $94.00 $101.00 $104.00 $108.00 $101.00 $104.00 $108.0073206-TC $277.00 $250.00 $268.00 $270.00 $250.00 $268.00 $270.0073218 $482.00 $365.00 $389.00 $393.00 $365.00 $389.00 $393.0073218-26 $68.00 $76.00 $79.00 $81.00 $76.00 $79.00 $81.0073218-TC $413.00 $288.00 $310.00 $311.00 $288.00 $310.00 $311.0073219 $579.00 $434.00 $462.00 $467.00 $434.00 $462.00 $467.0073219-26 $82.00 $92.00 $95.00 $97.00 $92.00 $95.00 $97.0073219-TC $495.00 $342.00 $368.00 $369.00 $342.00 $368.00 $369.0073220 $520.00 $537.00 $571.00 $577.00 $537.00 $571.00 $577.0073220-26 $78.00 $121.00 $125.00 $129.00 $121.00 $125.00 $129.0073220-TC $442.00 $415.00 $446.00 $448.00 $415.00 $446.00 $448.0073221 $482.00 $255.00 $270.00 $274.00 $255.00 $270.00 $274.0073221-26 $68.00 $77.00 $79.00 $82.00 $77.00 $79.00 $82.00



Radiology







73221-TC $413.00 $178.00 $191.00 $192.00 $178.00 $191.00 $192.0073222 $579.00 $406.00 $432.00 $437.00 $406.00 $432.00 $437.0073222-26 $82.00 $92.00 $95.00 $97.00 $92.00 $95.00 $97.0073222-TC $495.00 $314.00 $338.00 $339.00 $314.00 $338.00 $339.0073223 $1,029.00 $504.00 $536.00 $541.00 $504.00 $536.00 $541.0073223-26 $109.00 $121.00 $125.00 $129.00 $121.00 $125.00 $129.0073223-TC $916.00 $383.00 $411.00 $412.00 $383.00 $411.00 $412.0073225 $513.00 $435.00 $463.00 $468.00 $435.00 $463.00 $468.0073225-26 $92.00 $96.00 $100.00 $103.00 $96.00 $100.00 $103.0073225-TC $419.00 $339.00 $364.00 $365.00 $339.00 $364.00 $365.0073501 --------- $32.00 $34.00 $35.00 $32.00 $34.00 $35.0073501-26 --------- $11.00 $11.00 $11.00 $11.00 $11.00 $11.0073501-TC --------- $21.00 $23.00 $23.00 $21.00 $23.00 $23.0073502 --------- $44.00 $47.00 $48.00 $44.00 $47.00 $48.0073502-26 --------- $13.00 $13.00 $13.00 $13.00 $13.00 $13.0073502-TC --------- $32.00 $34.00 $35.00 $32.00 $34.00 $35.0073503 --------- $56.00 $59.00 $60.00 $56.00 $59.00 $60.0073503-26 --------- $16.00 $17.00 $17.00 $16.00 $17.00 $17.0073503-TC --------- $39.00 $42.00 $43.00 $39.00 $42.00 $43.0073521 --------- $43.00 $45.00 $46.00 $43.00 $45.00 $46.0073521-26 --------- $13.00 $13.00 $14.00 $13.00 $13.00 $14.0073521-TC --------- $30.00 $32.00 $32.00 $30.00 $32.00 $32.0073522 --------- $53.00 $56.00 $57.00 $53.00 $56.00 $57.0073522-26 --------- $17.00 $18.00 $18.00 $17.00 $18.00 $18.0073522-TC --------- $36.00 $38.00 $39.00 $36.00 $38.00 $39.0073523 --------- $61.00 $65.00 $66.00 $61.00 $65.00 $66.0073523-26 --------- $18.00 $19.00 $19.00 $18.00 $19.00 $19.0073523-TC --------- $43.00 $46.00 $47.00 $43.00 $46.00 $47.0073525 $84.00 $109.00 $116.00 $118.00 $109.00 $116.00 $118.0073525-26 NC $32.00 $34.00 $35.00 $32.00 $34.00 $35.0073525-TC NC $77.00 $83.00 $83.00 $77.00 $83.00 $83.0073551 --------- $30.00 $32.00 $33.00 $30.00 $32.00 $33.0073551-26 --------- $9.00 $10.00 $10.00 $9.00 $10.00 $10.0073551-TC --------- $21.00 $22.00 $23.00 $21.00 $22.00 $23.0073552 --------- $35.00 $37.00 $38.00 $35.00 $37.00 $38.0073552-26 --------- $11.00 $11.00 $11.00 $11.00 $11.00 $11.0073552-TC --------- $24.00 $26.00 $27.00 $24.00 $26.00 $27.0073560 $29.00 $33.00 $36.00 $36.00 $33.00 $36.00 $36.0073560-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0073560-TC $19.00 $24.00 $26.00 $26.00 $24.00 $26.00 $26.0073562 $31.00 $38.00 $41.00 $42.00 $38.00 $41.00 $42.0073562-26 $9.00 $11.00 $11.00 $11.00 $11.00 $11.00 $11.0073562-TC $21.00 $28.00 $30.00 $30.00 $28.00 $30.00 $30.0073564 $35.00 $42.00 $45.00 $46.00 $42.00 $45.00 $46.0073564-26 $11.00 $13.00 $13.00 $13.00 $13.00 $13.00 $13.0073564-TC $22.00 $30.00 $32.00 $32.00 $30.00 $32.00 $32.0073565 $28.00 $38.00 $41.00 $42.00 $38.00 $41.00 $42.0073565-26 $8.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.0073565-TC $18.00 $28.00 $31.00 $31.00 $28.00 $31.00 $31.0073580 $84.00 $124.00 $132.00 $134.00 $124.00 $132.00 $134.00



Radiology







73580-26 NC $32.00 $33.00 $35.00 $32.00 $33.00 $35.0073580-TC NC $92.00 $99.00 $99.00 $92.00 $99.00 $99.0073590 $29.00 $31.00 $33.00 $33.00 $31.00 $33.00 $33.0073590-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0073590-TC $19.00 $21.00 $23.00 $23.00 $21.00 $23.00 $23.0073600 $27.00 $32.00 $34.00 $35.00 $32.00 $34.00 $35.0073600-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0073600-TC $18.00 $23.00 $25.00 $25.00 $23.00 $25.00 $25.0073610 $29.00 $33.00 $36.00 $36.00 $33.00 $36.00 $36.0073610-26 $8.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.0073610-TC $19.00 $24.00 $25.00 $26.00 $24.00 $25.00 $26.0073615 $72.00 $113.00 $120.00 $121.00 $113.00 $120.00 $121.0073615-26 NC $32.00 $33.00 $34.00 $32.00 $33.00 $34.0073615-TC NC $80.00 $86.00 $87.00 $80.00 $86.00 $87.0073620 $27.00 $28.00 $30.00 $31.00 $28.00 $30.00 $31.0073620-26 $8.00 $9.00 $9.00 $9.00 $9.00 $9.00 $9.0073620-TC $18.00 $19.00 $21.00 $21.00 $19.00 $21.00 $21.0073630 $29.00 $31.00 $33.00 $34.00 $31.00 $33.00 $34.0073630-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0073630-TC $19.00 $22.00 $23.00 $24.00 $22.00 $23.00 $24.0073650 $26.00 $29.00 $31.00 $32.00 $29.00 $31.00 $32.0073650-26 $8.00 $9.00 $9.00 $10.00 $9.00 $9.00 $10.0073650-TC $17.00 $20.00 $22.00 $22.00 $20.00 $22.00 $22.0073660 $22.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.0073660-26 $7.00 $8.00 $8.00 $8.00 $8.00 $8.00 $8.0073660-TC $15.00 $23.00 $25.00 $25.00 $23.00 $25.00 $25.0073700 $242.00 $175.00 $186.00 $189.00 $175.00 $186.00 $189.0073700-26 $56.00 $56.00 $58.00 $60.00 $56.00 $58.00 $60.0073700-TC $185.00 $119.00 $128.00 $128.00 $119.00 $128.00 $128.0073701 $282.00 $243.00 $259.00 $262.00 $243.00 $259.00 $262.0073701-26 $61.00 $66.00 $68.00 $70.00 $66.00 $68.00 $70.0073701-TC $220.00 $178.00 $191.00 $192.00 $178.00 $191.00 $192.0073702 $341.00 $295.00 $314.00 $317.00 $295.00 $314.00 $317.0073702-26 $62.00 $68.00 $71.00 $73.00 $68.00 $71.00 $73.0073702-TC $277.00 $227.00 $243.00 $244.00 $227.00 $243.00 $244.0073706 $379.00 $357.00 $379.00 $384.00 $357.00 $379.00 $384.0073706-26 $98.00 $107.00 $110.00 $114.00 $107.00 $110.00 $114.0073706-TC $277.00 $250.00 $269.00 $270.00 $250.00 $269.00 $270.0073718 $482.00 $365.00 $389.00 $393.00 $365.00 $389.00 $393.0073718-26 $68.00 $76.00 $79.00 $81.00 $76.00 $79.00 $81.0073718-TC $413.00 $288.00 $310.00 $311.00 $288.00 $310.00 $311.0073719 $579.00 $434.00 $462.00 $466.00 $434.00 $462.00 $466.0073719-26 $82.00 $91.00 $94.00 $97.00 $91.00 $94.00 $97.0073719-TC $495.00 $342.00 $368.00 $369.00 $342.00 $368.00 $369.0073720 $520.00 $540.00 $574.00 $580.00 $540.00 $574.00 $580.0073720-26 $78.00 $121.00 $125.00 $129.00 $121.00 $125.00 $129.0073720-TC $442.00 $418.00 $449.00 $451.00 $418.00 $449.00 $451.0073721 $482.00 $255.00 $271.00 $275.00 $255.00 $271.00 $275.0073721-26 $68.00 $77.00 $79.00 $82.00 $77.00 $79.00 $82.0073721-TC $413.00 $178.00 $192.00 $193.00 $178.00 $192.00 $193.00



Radiology







73722 $579.00 $410.00 $436.00 $441.00 $410.00 $436.00 $441.0073722-26 $82.00 $92.00 $95.00 $97.00 $92.00 $95.00 $97.0073722-TC $495.00 $318.00 $342.00 $343.00 $318.00 $342.00 $343.0073723 $1,029.00 $506.00 $538.00 $543.00 $506.00 $538.00 $543.0073723-26 $109.00 $121.00 $125.00 $129.00 $121.00 $125.00 $129.0073723-TC $916.00 $384.00 $413.00 $415.00 $384.00 $413.00 $415.0073725 $515.00 $431.00 $459.00 $464.00 $431.00 $459.00 $464.0073725-26 $92.00 $101.00 $105.00 $108.00 $101.00 $105.00 $108.0073725-TC $419.00 $330.00 $354.00 $356.00 $330.00 $354.00 $356.0074000 $29.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.0074000-26 $9.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.0074000-TC $19.00 $15.00 $16.00 $17.00 $15.00 $16.00 $17.0074010 $33.00 $38.00 $40.00 $41.00 $38.00 $40.00 $41.0074010-26 $11.00 $13.00 $13.00 $14.00 $13.00 $13.00 $14.0074010-TC $21.00 $25.00 $27.00 $27.00 $25.00 $27.00 $27.0074020 $37.00 $41.00 $43.00 $44.00 $41.00 $43.00 $44.0074020-26 $13.00 $15.00 $16.00 $17.00 $15.00 $16.00 $17.0074020-TC $22.00 $25.00 $27.00 $27.00 $25.00 $27.00 $27.0074022 $44.00 $48.00 $51.00 $52.00 $48.00 $51.00 $52.0074022-26 $16.00 $18.00 $19.00 $19.00 $18.00 $19.00 $19.0074022-TC $28.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.0074150 $274.00 $162.00 $172.00 $174.00 $162.00 $172.00 $174.0074150-26 $60.00 $67.00 $69.00 $72.00 $67.00 $69.00 $72.0074150-TC $211.00 $95.00 $102.00 $103.00 $95.00 $102.00 $103.0074160 $322.00 $249.00 $264.00 $267.00 $249.00 $264.00 $267.0074160-26 $65.00 $72.00 $74.00 $76.00 $72.00 $74.00 $76.0074160-TC $256.00 $177.00 $190.00 $191.00 $177.00 $190.00 $191.0074170 $390.00 $282.00 $300.00 $304.00 $282.00 $300.00 $304.0074170-26 $71.00 $79.00 $82.00 $84.00 $79.00 $82.00 $84.0074170-TC $317.00 $204.00 $219.00 $219.00 $204.00 $219.00 $219.0074174 --------- $419.00 $445.00 $450.00 $419.00 $445.00 $450.0074174-26 --------- $123.00 $127.00 $132.00 $123.00 $127.00 $132.0074174-TC --------- $296.00 $317.00 $319.00 $296.00 $317.00 $319.0074175 $418.00 $331.00 $351.00 $356.00 $331.00 $351.00 $356.0074175-26 $98.00 $102.00 $105.00 $108.00 $102.00 $105.00 $108.0074175-TC $315.00 $229.00 $246.00 $247.00 $229.00 $246.00 $247.0074176 --------- $218.00 $230.00 $234.00 $218.00 $230.00 $234.0074176-26 --------- $98.00 $102.00 $105.00 $98.00 $102.00 $105.0074176-TC --------- $119.00 $128.00 $129.00 $119.00 $128.00 $129.0074177 --------- $335.00 $356.00 $360.00 $335.00 $356.00 $360.0074177-26 --------- $103.00 $106.00 $109.00 $103.00 $106.00 $109.0074177-TC --------- $233.00 $250.00 $251.00 $233.00 $250.00 $251.0074178 --------- $380.00 $404.00 $409.00 $380.00 $404.00 $409.0074178-26 --------- $113.00 $117.00 $120.00 $113.00 $117.00 $120.0074178-TC --------- $267.00 $287.00 $288.00 $267.00 $287.00 $288.0074181 $498.00 $358.00 $381.00 $385.00 $358.00 $381.00 $385.0074181-26 $85.00 $82.00 $85.00 $87.00 $82.00 $85.00 $87.0074181-TC $415.00 $276.00 $296.00 $298.00 $276.00 $296.00 $298.0074182 $587.00 $487.00 $519.00 $524.00 $487.00 $519.00 $524.0074182-26 $88.00 $98.00 $101.00 $104.00 $98.00 $101.00 $104.00



Radiology







74182-TC $496.00 $389.00 $418.00 $420.00 $389.00 $418.00 $420.0074183 $1,037.00 $544.00 $579.00 $585.00 $544.00 $579.00 $585.0074183-26 $114.00 $128.00 $132.00 $136.00 $128.00 $132.00 $136.0074183-TC $919.00 $417.00 $447.00 $449.00 $417.00 $447.00 $449.0074185 $514.00 $433.00 $461.00 $466.00 $433.00 $461.00 $466.0074185-26 $92.00 $101.00 $104.00 $107.00 $101.00 $104.00 $107.0074185-TC $419.00 $332.00 $357.00 $358.00 $332.00 $357.00 $358.0074190 $73.00 $397.00 $425.00 $428.00 $397.00 $425.00 $428.0074190-26 NC $27.00 $27.00 $28.00 $27.00 $27.00 $28.0074190-TC NC $371.00 $398.00 $399.00 $371.00 $398.00 $399.0074210 $63.00 $83.00 $89.00 $90.00 $83.00 $89.00 $90.0074210-26 $18.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.0074210-TC $44.00 $63.00 $68.00 $69.00 $63.00 $68.00 $69.0074220 $68.00 $95.00 $102.00 $103.00 $95.00 $102.00 $103.0074220-26 $23.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.0074220-TC $44.00 $69.00 $75.00 $75.00 $69.00 $75.00 $75.0074230 $77.00 $136.00 $145.00 $146.00 $136.00 $145.00 $146.0074230-26 $27.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.0074230-TC $48.00 $106.00 $114.00 $114.00 $106.00 $114.00 $114.0074235 $160.00 --------- --------- --------- --------- --------- ---------74235-26 NC $72.00 $77.00 $84.00 $72.00 $77.00 $84.0074235-TC NC BR BR BR BR BR BR74240 $91.00 $122.00 $130.00 $131.00 $122.00 $130.00 $131.0074240-26 $35.00 $39.00 $40.00 $42.00 $39.00 $40.00 $42.0074240-TC $55.00 $83.00 $89.00 $90.00 $83.00 $89.00 $90.0074241 $91.00 $127.00 $135.00 $137.00 $127.00 $135.00 $137.0074241-26 $35.00 $39.00 $40.00 $42.00 $39.00 $40.00 $42.0074241-TC $56.00 $88.00 $94.00 $95.00 $88.00 $94.00 $95.0074245 $137.00 $185.00 $196.00 $198.00 $185.00 $196.00 $198.0074245-26 $46.00 $51.00 $53.00 $55.00 $51.00 $53.00 $55.0074245-TC $89.00 $133.00 $143.00 $144.00 $133.00 $143.00 $144.0074246 $97.00 $137.00 $146.00 $148.00 $137.00 $146.00 $148.0074246-26 $35.00 $39.00 $40.00 $42.00 $39.00 $40.00 $42.0074246-TC $61.00 $98.00 $105.00 $106.00 $98.00 $105.00 $106.0074247 $99.00 $145.00 $155.00 $157.00 $145.00 $155.00 $157.0074247-26 $35.00 $39.00 $40.00 $42.00 $39.00 $40.00 $42.0074247-TC $63.00 $106.00 $114.00 $115.00 $106.00 $114.00 $115.0074249 $144.00 $198.00 $210.00 $213.00 $198.00 $210.00 $213.0074249-26 $46.00 $51.00 $53.00 $55.00 $51.00 $53.00 $55.0074249-TC $96.00 $146.00 $157.00 $158.00 $146.00 $157.00 $158.0074250 $73.00 $112.00 $119.00 $120.00 $112.00 $119.00 $120.0074250-26 $23.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.0074250-TC $48.00 $85.00 $92.00 $92.00 $85.00 $92.00 $92.0074251 $85.00 $241.00 $258.00 $260.00 $241.00 $258.00 $260.0074251-26 $34.00 $39.00 $40.00 $42.00 $39.00 $40.00 $42.0074251-TC $48.00 $202.00 $217.00 $218.00 $202.00 $217.00 $218.0074260 $82.00 $231.00 $247.00 $249.00 $231.00 $247.00 $249.0074260-26 $25.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.0074260-TC $56.00 $202.00 $217.00 $218.00 $202.00 $217.00 $218.0074261 --------- $255.00 $268.00 $273.00 $255.00 $268.00 $273.00



Radiology







74261-26 --------- $136.00 $140.00 $145.00 $136.00 $140.00 $145.0074261-TC --------- $119.00 $128.00 $128.00 $119.00 $128.00 $128.0074262 --------- $390.00 $413.00 $419.00 $390.00 $413.00 $419.0074262-26 --------- $141.00 $146.00 $150.00 $141.00 $146.00 $150.0074262-TC --------- $249.00 $268.00 $269.00 $249.00 $268.00 $269.0074263 --------- $806.00 $860.00 $865.00 $806.00 $860.00 $865.0074263-26 --------- $126.00 $130.00 $132.00 $126.00 $130.00 $132.0074263-TC --------- $680.00 $730.00 $733.00 $680.00 $730.00 $733.0074270 $100.00 $145.00 $155.00 $157.00 $145.00 $155.00 $157.0074270-26 $35.00 $39.00 $40.00 $42.00 $39.00 $40.00 $42.0074270-TC $64.00 $106.00 $114.00 $115.00 $106.00 $114.00 $115.0074280 $136.00 $229.00 $243.00 $246.00 $229.00 $243.00 $246.0074280-26 $50.00 $56.00 $58.00 $60.00 $56.00 $58.00 $60.0074280-TC $84.00 $173.00 $185.00 $186.00 $173.00 $185.00 $186.0074283 $201.00 $224.00 $236.00 $240.00 $224.00 $236.00 $240.0074283-26 $103.00 $115.00 $119.00 $123.00 $115.00 $119.00 $123.0074283-TC $95.00 $109.00 $117.00 $117.00 $109.00 $117.00 $117.0074290 $44.00 $75.00 $80.00 $81.00 $75.00 $80.00 $81.0074290-26 $16.00 $18.00 $19.00 $19.00 $18.00 $19.00 $19.0074290-TC $28.00 $57.00 $62.00 $62.00 $57.00 $62.00 $62.0074300 $31.00 --------- --------- --------- --------- --------- ---------74300-26 NC $21.00 $21.00 $22.00 $21.00 $21.00 $22.0074300-TC NC BR BR BR BR BR BR74301 BR --------- --------- --------- --------- --------- ---------74301-26 NC $12.00 $12.00 $13.00 $12.00 $12.00 $13.0074301-TC NC BR BR BR BR BR BR74328 $155.00 --------- --------- --------- --------- --------- ---------74328-26 NC $40.00 $41.00 $42.00 $40.00 $41.00 $42.0074328-TC NC BR BR BR BR BR BR74329 $155.00 --------- --------- --------- --------- --------- ---------74329-26 NC $40.00 $42.00 $43.00 $40.00 $42.00 $43.0074329-TC NC BR BR BR BR BR BR74330 $165.00 --------- --------- --------- --------- --------- ---------74330-26 NC $51.00 $53.00 $55.00 $51.00 $53.00 $55.0074330-TC NC BR BR BR BR BR BR74340 $121.00 --------- --------- --------- --------- --------- ---------74340-26 NC $30.00 $31.00 $32.00 $30.00 $31.00 $32.0074340-TC NC BR BR BR BR BR BR74355 $137.00 --------- --------- --------- --------- --------- ---------74355-26 NC $44.00 $46.00 $48.00 $44.00 $46.00 $48.0074355-TC NC BR BR BR BR BR BR74360 $145.00 --------- --------- --------- --------- --------- ---------74360-26 NC $32.00 $33.00 $35.00 $32.00 $33.00 $35.0074360-TC NC BR BR BR BR BR BR74363 $274.00 --------- --------- --------- --------- --------- ---------74363-26 NC $48.00 $50.00 $51.00 $48.00 $50.00 $51.0074363-TC NC BR BR BR BR BR BR74400 $89.00 $118.00 $126.00 $127.00 $118.00 $126.00 $127.0074400-26 $24.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.0074400-TC $63.00 $91.00 $97.00 $98.00 $91.00 $97.00 $98.00



Radiology







74410 $98.00 $116.00 $124.00 $125.00 $116.00 $124.00 $125.0074410-26 $24.00 $27.00 $28.00 $29.00 $27.00 $28.00 $29.0074410-TC $72.00 $89.00 $96.00 $96.00 $89.00 $96.00 $96.0074415 $105.00 $147.00 $156.00 $158.00 $147.00 $156.00 $158.0074415-26 $24.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.0074415-TC $79.00 $119.00 $128.00 $128.00 $119.00 $128.00 $128.0074420 $117.00 $390.00 $418.00 $420.00 $390.00 $418.00 $420.0074420-26 $18.00 $20.00 $20.00 $20.00 $20.00 $20.00 $20.0074420-TC $97.00 $371.00 $398.00 $399.00 $371.00 $398.00 $399.0074425 $68.00 $390.00 $418.00 $420.00 $390.00 $418.00 $420.0074425-26 NC $20.00 $20.00 $21.00 $20.00 $20.00 $21.0074425-TC NC $371.00 $398.00 $399.00 $371.00 $398.00 $399.0074430 $48.00 $41.00 $43.00 $44.00 $41.00 $43.00 $44.0074430-26 NC $18.00 $19.00 $19.00 $18.00 $19.00 $19.0074430-TC NC $23.00 $25.00 $25.00 $23.00 $25.00 $25.0074440 $62.00 $87.00 $93.00 $93.00 $87.00 $93.00 $93.0074440-26 NC $20.00 $21.00 $21.00 $20.00 $21.00 $21.0074440-TC NC $67.00 $72.00 $72.00 $67.00 $72.00 $72.0074445 $101.00 $431.00 $460.00 $462.00 $431.00 $460.00 $462.0074445-26 NC $60.00 $62.00 $63.00 $60.00 $62.00 $63.0074445-TC NC $371.00 $398.00 $399.00 $371.00 $398.00 $399.0074450 $60.00 $221.00 $236.00 $238.00 $221.00 $236.00 $238.0074450-26 NC $19.00 $19.00 $20.00 $19.00 $19.00 $20.0074450-TC NC $202.00 $217.00 $218.00 $202.00 $217.00 $218.0074455 $75.00 $88.00 $93.00 $94.00 $88.00 $93.00 $94.0074455-26 NC $19.00 $19.00 $20.00 $19.00 $19.00 $20.0074455-TC NC $69.00 $74.00 $75.00 $69.00 $74.00 $75.0074470 $74.00 $400.00 $428.00 $431.00 $400.00 $428.00 $431.0074470-26 NC $30.00 $31.00 $32.00 $30.00 $31.00 $32.0074470-TC NC $371.00 $398.00 $399.00 $371.00 $398.00 $399.0074485 $146.00 $99.00 $105.00 $106.00 $99.00 $105.00 $106.0074485-26 NC $29.00 $30.00 $31.00 $29.00 $30.00 $31.0074485-TC NC $70.00 $75.00 $76.00 $70.00 $75.00 $76.0074710 $57.00 $40.00 $42.00 $43.00 $40.00 $42.00 $43.0074710-26 $17.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.0074710-TC $39.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.0074712 --------- $458.00 $485.00 $492.00 $458.00 $485.00 $492.0074712-26 --------- $169.00 $175.00 $180.00 $169.00 $175.00 $180.0074712-TC --------- $288.00 $310.00 $311.00 $288.00 $310.00 $311.0074713 --------- $251.00 $265.00 $269.00 $251.00 $265.00 $269.0074713-26 --------- $101.00 $104.00 $107.00 $101.00 $104.00 $107.0074713-TC --------- $150.00 $161.00 $162.00 $150.00 $161.00 $162.0074740 $68.00 $80.00 $86.00 $87.00 $80.00 $86.00 $87.0074740-26 NC $21.00 $22.00 $23.00 $21.00 $22.00 $23.0074740-TC NC $59.00 $64.00 $64.00 $59.00 $64.00 $64.0074742 $150.00 --------- --------- --------- --------- --------- ---------74742-26 NC $33.00 $34.00 $36.00 $33.00 $34.00 $36.0074742-TC NC BR BR BR BR BR BR74775 $88.00 $237.00 $253.00 $256.00 $237.00 $253.00 $256.0074775-26 $32.00 $35.00 $36.00 $38.00 $35.00 $36.00 $38.00



Radiology







74775-TC $55.00 $202.00 $217.00 $218.00 $202.00 $217.00 $218.0075557 --------- $344.00 $364.00 $368.00 $344.00 $364.00 $368.0075557-26 --------- $130.00 $134.00 $137.00 $130.00 $134.00 $137.0075557-TC --------- $214.00 $230.00 $231.00 $214.00 $230.00 $231.0075559 --------- $470.00 $497.00 $502.00 $470.00 $497.00 $502.0075559-26 --------- $160.00 $165.00 $168.00 $160.00 $165.00 $168.0075559-TC --------- $310.00 $333.00 $334.00 $310.00 $333.00 $334.0075561 --------- $456.00 $483.00 $489.00 $456.00 $483.00 $489.0075561-26 --------- $143.00 $148.00 $152.00 $143.00 $148.00 $152.0075561-TC --------- $313.00 $336.00 $337.00 $313.00 $336.00 $337.0075563 --------- $540.00 $573.00 $578.00 $540.00 $573.00 $578.0075563-26 --------- $164.00 $169.00 $173.00 $164.00 $169.00 $173.0075563-TC --------- $376.00 $404.00 $406.00 $376.00 $404.00 $406.0075565 --------- $59.00 $62.00 $63.00 $59.00 $62.00 $63.0075565-26 --------- $14.00 $14.00 $14.00 $14.00 $14.00 $14.0075565-TC --------- $45.00 $48.00 $48.00 $45.00 $48.00 $48.0075571 --------- $46.00 $48.00 $50.00 $46.00 $48.00 $50.0075571-26 --------- $32.00 $33.00 $34.00 $32.00 $33.00 $34.0075571-TC --------- $14.00 $15.00 $15.00 $14.00 $15.00 $15.0075572 --------- $306.00 $325.00 $329.00 $306.00 $325.00 $329.0075572-26 --------- $97.00 $101.00 $103.00 $97.00 $101.00 $103.0075572-TC --------- $209.00 $224.00 $226.00 $209.00 $224.00 $226.0075573 --------- $391.00 $414.00 $420.00 $391.00 $414.00 $420.0075573-26 --------- $142.00 $146.00 $150.00 $142.00 $146.00 $150.0075573-TC --------- $250.00 $268.00 $270.00 $250.00 $268.00 $270.0075574 --------- $382.00 $405.00 $410.00 $382.00 $405.00 $410.0075574-26 --------- $133.00 $137.00 $141.00 $133.00 $137.00 $141.0075574-TC --------- $249.00 $268.00 $269.00 $249.00 $268.00 $269.0075600 $497.00 $212.00 $227.00 $229.00 $212.00 $227.00 $229.0075600-26 NC $28.00 $29.00 $30.00 $28.00 $29.00 $30.0075600-TC NC $185.00 $198.00 $199.00 $185.00 $198.00 $199.0075605 $183.00 $152.00 $161.00 $164.00 $152.00 $161.00 $164.0075605-26 NC $63.00 $66.00 $69.00 $63.00 $66.00 $69.0075605-TC NC $88.00 $95.00 $95.00 $88.00 $95.00 $95.0075625 $143.00 $152.00 $161.00 $166.00 $152.00 $161.00 $166.0075625-26 NC $64.00 $67.00 $71.00 $64.00 $67.00 $71.0075625-TC NC $88.00 $94.00 $95.00 $88.00 $94.00 $95.0075630 $239.00 $188.00 $199.00 $205.00 $188.00 $199.00 $205.0075630-26 NC $100.00 $105.00 $110.00 $100.00 $105.00 $110.0075630-TC NC $88.00 $94.00 $95.00 $88.00 $94.00 $95.0075635 $445.00 $384.00 $407.00 $413.00 $384.00 $407.00 $413.0075635-26 NC $134.00 $139.00 $143.00 $134.00 $139.00 $143.0075635-TC NC $250.00 $269.00 $270.00 $250.00 $269.00 $270.0075658 $540.00 $183.00 $195.00 $200.00 $183.00 $195.00 $200.0075658-26 NC $73.00 $76.00 $81.00 $73.00 $76.00 $81.0075658-TC NC $110.00 $119.00 $120.00 $110.00 $119.00 $120.0075705 $587.00 $269.00 $286.00 $296.00 $269.00 $286.00 $296.0075705-26 NC $131.00 $137.00 $146.00 $131.00 $137.00 $146.0075705-TC NC $138.00 $148.00 $149.00 $138.00 $148.00 $149.0075710 $194.00 $179.00 $191.00 $195.00 $179.00 $191.00 $195.00



Radiology







75710-26 NC $64.00 $67.00 $71.00 $64.00 $67.00 $71.0075710-TC NC $114.00 $123.00 $124.00 $114.00 $123.00 $124.0075716 $293.00 $205.00 $218.00 $224.00 $205.00 $218.00 $224.0075716-26 NC $74.00 $77.00 $81.00 $74.00 $77.00 $81.0075716-TC NC $132.00 $142.00 $143.00 $132.00 $142.00 $143.0075726 $530.00 $163.00 $173.00 $176.00 $163.00 $173.00 $176.0075726-26 NC $63.00 $65.00 $67.00 $63.00 $65.00 $67.0075726-TC NC $100.00 $108.00 $108.00 $100.00 $108.00 $108.0075731 $530.00 $187.00 $198.00 $201.00 $187.00 $198.00 $201.0075731-26 NC $64.00 $66.00 $68.00 $64.00 $66.00 $68.0075731-TC NC $123.00 $132.00 $133.00 $123.00 $132.00 $133.0075733 $540.00 $200.00 $212.00 $214.00 $200.00 $212.00 $214.0075733-26 NC $71.00 $73.00 $75.00 $71.00 $73.00 $75.0075733-TC NC $129.00 $138.00 $140.00 $129.00 $138.00 $140.0075736 $530.00 $176.00 $186.00 $191.00 $176.00 $186.00 $191.0075736-26 NC $63.00 $65.00 $69.00 $63.00 $65.00 $69.0075736-TC NC $113.00 $121.00 $122.00 $113.00 $121.00 $122.0075741 $540.00 $165.00 $175.00 $178.00 $165.00 $175.00 $178.0075741-26 NC $72.00 $74.00 $77.00 $72.00 $74.00 $77.0075741-TC NC $94.00 $100.00 $101.00 $94.00 $100.00 $101.0075743 $253.00 $186.00 $196.00 $200.00 $186.00 $196.00 $200.0075743-26 NC $91.00 $94.00 $98.00 $91.00 $94.00 $98.0075743-TC NC $95.00 $102.00 $102.00 $95.00 $102.00 $102.0075746 $530.00 $166.00 $176.00 $179.00 $166.00 $176.00 $179.0075746-26 NC $63.00 $65.00 $68.00 $63.00 $65.00 $68.0075746-TC NC $102.00 $110.00 $111.00 $102.00 $110.00 $111.0075756 $183.00 $183.00 $195.00 $200.00 $183.00 $195.00 $200.0075756-26 NC $64.00 $67.00 $72.00 $64.00 $67.00 $72.0075756-TC NC $119.00 $128.00 $128.00 $119.00 $128.00 $128.0075774 $80.00 $95.00 $101.00 $103.00 $95.00 $101.00 $103.0075774-26 NC $20.00 $21.00 $22.00 $20.00 $21.00 $22.0075774-TC NC $75.00 $81.00 $81.00 $75.00 $81.00 $81.0075791 --------- $353.00 $377.00 $386.00 $353.00 $377.00 $386.0075791-26 --------- $99.00 $104.00 $112.00 $99.00 $104.00 $112.0075791-TC --------- $254.00 $273.00 $274.00 $254.00 $273.00 $274.0075801 $245.00 $254.00 $272.00 $278.00 $254.00 $272.00 $278.0075801-26 NC $52.00 $55.00 $60.00 $52.00 $55.00 $60.0075801-TC NC $202.00 $217.00 $218.00 $202.00 $217.00 $218.0075803 $264.00 $769.00 $823.00 $827.00 $769.00 $823.00 $827.0075803-26 NC $66.00 $68.00 $70.00 $66.00 $68.00 $70.0075803-TC NC $703.00 $755.00 $757.00 $703.00 $755.00 $757.0075805 $271.00 $749.00 $802.00 $806.00 $749.00 $802.00 $806.0075805-26 NC $46.00 $47.00 $49.00 $46.00 $47.00 $49.0075805-TC NC $703.00 $755.00 $757.00 $703.00 $755.00 $757.0075807 $289.00 $2,930.00 $3,141.00 $3,152.00 $2,930.00 $3,141.00 $3,152.0075807-26 NC $66.00 $69.00 $71.00 $66.00 $69.00 $71.0075807-TC NC $2,863.00 $3,072.00 $3,082.00 $2,863.00 $3,072.00 $3,082.0075809 $54.00 $107.00 $114.00 $116.00 $107.00 $114.00 $116.0075809-26 NC $27.00 $28.00 $29.00 $27.00 $28.00 $29.0075809-TC NC $80.00 $86.00 $87.00 $80.00 $86.00 $87.00



Radiology







75810 $530.00 $2,928.00 $3,139.00 $3,151.00 $2,928.00 $3,139.00 $3,151.0075810-26 NC $65.00 $67.00 $69.00 $65.00 $67.00 $69.0075810-TC NC $2,863.00 $3,072.00 $3,082.00 $2,863.00 $3,072.00 $3,082.0075820 $72.00 $125.00 $133.00 $136.00 $125.00 $133.00 $136.0075820-26 NC $39.00 $41.00 $43.00 $39.00 $41.00 $43.0075820-TC NC $86.00 $92.00 $93.00 $86.00 $92.00 $93.0075822 $111.00 $150.00 $159.00 $163.00 $150.00 $159.00 $163.0075822-26 NC $59.00 $62.00 $64.00 $59.00 $62.00 $64.0075822-TC NC $91.00 $98.00 $98.00 $91.00 $98.00 $98.0075825 $194.00 $150.00 $159.00 $164.00 $150.00 $159.00 $164.0075825-26 NC $64.00 $67.00 $71.00 $64.00 $67.00 $71.0075825-TC NC $85.00 $92.00 $92.00 $85.00 $92.00 $92.0075827 $530.00 $152.00 $162.00 $167.00 $152.00 $162.00 $167.0075827-26 NC $65.00 $68.00 $72.00 $65.00 $68.00 $72.0075827-TC NC $88.00 $94.00 $95.00 $88.00 $94.00 $95.0075831 $54.00 $154.00 $163.00 $167.00 $154.00 $163.00 $167.0075831-26 NC $63.00 $65.00 $69.00 $63.00 $65.00 $69.0075831-TC NC $91.00 $98.00 $99.00 $91.00 $98.00 $99.0075833 $549.00 $181.00 $193.00 $199.00 $181.00 $193.00 $199.0075833-26 NC $83.00 $87.00 $92.00 $83.00 $87.00 $92.0075833-TC NC $99.00 $106.00 $107.00 $99.00 $106.00 $107.0075840 $531.00 $162.00 $171.00 $173.00 $162.00 $171.00 $173.0075840-26 NC $64.00 $66.00 $68.00 $64.00 $66.00 $68.0075840-TC NC $97.00 $105.00 $105.00 $97.00 $105.00 $105.0075842 $549.00 $197.00 $208.00 $211.00 $197.00 $208.00 $211.0075842-26 NC $84.00 $86.00 $89.00 $84.00 $86.00 $89.0075842-TC NC $113.00 $121.00 $122.00 $113.00 $121.00 $122.0075860 $531.00 $156.00 $166.00 $169.00 $156.00 $166.00 $169.0075860-26 NC $63.00 $66.00 $68.00 $63.00 $66.00 $68.0075860-TC NC $93.00 $100.00 $101.00 $93.00 $100.00 $101.0075870 $531.00 $161.00 $170.00 $173.00 $161.00 $170.00 $173.0075870-26 NC $64.00 $66.00 $68.00 $64.00 $66.00 $68.0075870-TC NC $97.00 $104.00 $104.00 $97.00 $104.00 $104.0075872 $530.00 $153.00 $162.00 $165.00 $153.00 $162.00 $165.0075872-26 NC $60.00 $62.00 $65.00 $60.00 $62.00 $65.0075872-TC NC $93.00 $100.00 $100.00 $93.00 $100.00 $100.0075880 $72.00 $154.00 $164.00 $166.00 $154.00 $164.00 $166.0075880-26 NC $41.00 $42.00 $43.00 $41.00 $42.00 $43.0075880-TC NC $114.00 $122.00 $123.00 $114.00 $122.00 $123.0075885 $546.00 $173.00 $183.00 $186.00 $173.00 $183.00 $186.0075885-26 NC $78.00 $81.00 $84.00 $78.00 $81.00 $84.0075885-TC NC $95.00 $102.00 $102.00 $95.00 $102.00 $102.0075887 $546.00 $174.00 $184.00 $187.00 $174.00 $184.00 $187.0075887-26 NC $79.00 $81.00 $84.00 $79.00 $81.00 $84.0075887-TC NC $95.00 $102.00 $103.00 $95.00 $102.00 $103.0075889 $530.00 $157.00 $166.00 $169.00 $157.00 $166.00 $169.0075889-26 NC $62.00 $64.00 $66.00 $62.00 $64.00 $66.0075889-TC NC $95.00 $102.00 $103.00 $95.00 $102.00 $103.0075891 $530.00 $158.00 $168.00 $170.00 $158.00 $168.00 $170.0075891-26 NC $63.00 $65.00 $67.00 $63.00 $65.00 $67.00



Radiology







75891-TC NC $95.00 $102.00 $103.00 $95.00 $102.00 $103.0075893 $499.00 $128.00 $136.00 $138.00 $128.00 $136.00 $138.0075893-26 NC $30.00 $31.00 $32.00 $30.00 $31.00 $32.0075893-TC NC $98.00 $105.00 $106.00 $98.00 $105.00 $106.0075894 $972.00 --------- --------- --------- --------- --------- ---------75894-26 NC $75.00 $79.00 $83.00 $75.00 $79.00 $83.0075894-TC NC BR BR BR BR BR BR75898 $124.00 $799.00 $855.00 $863.00 $799.00 $855.00 $863.0075898-26 $84.00 $96.00 $100.00 $106.00 $96.00 $100.00 $106.0075898-TC $39.00 $703.00 $755.00 $757.00 $703.00 $755.00 $757.0075901 $98.00 $190.00 $203.00 $205.00 $190.00 $203.00 $205.0075901-26 NC $27.00 $28.00 $29.00 $27.00 $28.00 $29.0075901-TC NC $163.00 $176.00 $176.00 $163.00 $176.00 $176.0075902 $93.00 $78.00 $83.00 $84.00 $78.00 $83.00 $84.0075902-26 NC $21.00 $22.00 $23.00 $21.00 $22.00 $23.0075902-TC NC $56.00 $61.00 $61.00 $56.00 $61.00 $61.0075952 BR --------- --------- --------- --------- --------- ---------75952-26 NC $260.00 $275.00 $299.00 $260.00 $275.00 $299.0075952-TC NC BR BR BR BR BR BR75953 BR --------- --------- --------- --------- --------- ---------75953-26 NC $79.00 $84.00 $91.00 $79.00 $84.00 $91.0075953-TC NC BR BR BR BR BR BR75954 BR --------- --------- --------- --------- --------- ---------75954-26 NC $132.00 $140.00 $153.00 $132.00 $140.00 $153.0075954-TC NC BR BR BR BR BR BR75956 --------- BR BR BR BR BR BR75956-26 --------- $406.00 $431.00 $469.00 $406.00 $431.00 $469.0075956-TC --------- BR BR BR BR BR BR75957 --------- BR BR BR BR BR BR75957-26 --------- $349.00 $370.00 $404.00 $349.00 $370.00 $404.0075957-TC --------- BR BR BR BR BR BR75958 --------- BR BR BR BR BR BR75958-26 --------- $232.00 $246.00 $268.00 $232.00 $246.00 $268.0075958-TC --------- BR BR BR BR BR BR75959 --------- BR BR BR BR BR BR75959-26 --------- $203.00 $215.00 $235.00 $203.00 $215.00 $235.0075959-TC --------- BR BR BR BR BR BR75962 $618.00 $152.00 $163.00 $165.00 $152.00 $163.00 $165.0075962-26 NC $30.00 $32.00 $34.00 $30.00 $32.00 $34.0075962-TC NC $122.00 $131.00 $132.00 $122.00 $131.00 $132.0075964 $333.00 $96.00 $103.00 $105.00 $96.00 $103.00 $105.0075964-26 NC $21.00 $22.00 $23.00 $21.00 $22.00 $23.0075964-TC NC $75.00 $81.00 $82.00 $75.00 $81.00 $82.0075966 $659.00 $187.00 $199.00 $204.00 $187.00 $199.00 $204.0075966-26 NC $73.00 $76.00 $80.00 $73.00 $76.00 $80.0075966-TC NC $114.00 $123.00 $124.00 $114.00 $123.00 $124.0075968 $333.00 $95.00 $101.00 $102.00 $95.00 $101.00 $102.0075968-26 NC $20.00 $21.00 $22.00 $20.00 $21.00 $22.0075968-TC NC $74.00 $80.00 $80.00 $74.00 $80.00 $80.0075970 $475.00 --------- --------- --------- --------- --------- ---------



Radiology







75970-26 NC $45.00 $47.00 $49.00 $45.00 $47.00 $49.0075970-TC NC BR BR BR BR BR BR75978 $617.00 $150.00 $161.00 $163.00 $150.00 $161.00 $163.0075978-26 NC $30.00 $32.00 $34.00 $30.00 $32.00 $34.0075978-TC NC $120.00 $129.00 $130.00 $120.00 $129.00 $130.0075984 $110.00 $115.00 $122.00 $124.00 $115.00 $122.00 $124.0075984-26 NC $40.00 $41.00 $42.00 $40.00 $41.00 $42.0075984-TC NC $76.00 $81.00 $82.00 $76.00 $81.00 $82.0075989 $180.00 $132.00 $139.00 $142.00 $132.00 $139.00 $142.0075989-26 NC $66.00 $68.00 $70.00 $66.00 $68.00 $70.0075989-TC NC $66.00 $71.00 $71.00 $66.00 $71.00 $71.0076000 $58.00 $51.00 $55.00 $56.00 $51.00 $55.00 $56.0076000-26 $8.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.0076000-TC $48.00 $41.00 $44.00 $45.00 $41.00 $44.00 $45.0076001 $134.00 --------- --------- --------- --------- --------- ---------76001-26 $34.00 $41.00 $43.00 $45.00 $41.00 $43.00 $45.0076001-TC $97.00 --------- --------- --------- --------- --------- ---------76080 $67.00 $60.00 $64.00 $65.00 $60.00 $64.00 $65.0076080-26 NC $30.00 $31.00 $32.00 $30.00 $31.00 $32.0076080-TC NC $31.00 $33.00 $34.00 $31.00 $33.00 $34.0076098 $23.00 $18.00 $19.00 $20.00 $18.00 $19.00 $20.0076098-26 $8.00 $9.00 $9.00 $10.00 $9.00 $9.00 $10.0076098-TC $15.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0076100 $77.00 $100.00 $106.00 $108.00 $100.00 $106.00 $108.0076100-26 $30.00 $36.00 $37.00 $39.00 $36.00 $37.00 $39.0076100-TC $46.00 $64.00 $69.00 $70.00 $64.00 $69.00 $70.0076101 $94.00 $141.00 $150.00 $152.00 $141.00 $150.00 $152.0076101-26 $36.00 $38.00 $39.00 $40.00 $38.00 $39.00 $40.0076101-TC $59.00 $104.00 $111.00 $112.00 $104.00 $111.00 $112.0076102 $95.00 $187.00 $200.00 $202.00 $187.00 $200.00 $202.0076102-26 $30.00 $38.00 $40.00 $41.00 $38.00 $40.00 $41.0076102-TC $65.00 $149.00 $160.00 $161.00 $149.00 $160.00 $161.0076120 $157.00 $90.00 $96.00 $97.00 $90.00 $96.00 $97.0076120-26 $56.00 $22.00 $22.00 $23.00 $22.00 $22.00 $23.0076120-TC $102.00 $68.00 $73.00 $74.00 $68.00 $73.00 $74.0076125 $49.00 --------- --------- --------- --------- --------- ---------76125-26 $17.00 $16.00 $17.00 $18.00 $16.00 $17.00 $18.0076125-TC $33.00 --------- --------- --------- --------- --------- ---------76140 $31.00 --------- --------- --------- --------- --------- ---------76376 --------- $25.00 $27.00 $27.00 $25.00 $27.00 $27.0076376-26 --------- $11.00 $11.00 $12.00 $11.00 $11.00 $12.0076376-TC --------- $14.00 $15.00 $16.00 $14.00 $15.00 $16.0076377 --------- $78.00 $82.00 $84.00 $78.00 $82.00 $84.0076377-26 --------- $45.00 $46.00 $48.00 $45.00 $46.00 $48.0076377-TC --------- $33.00 $36.00 $36.00 $33.00 $36.00 $36.0076380 $182.00 $120.00 $126.00 $129.00 $120.00 $126.00 $129.0076380-26 $50.00 $55.00 $57.00 $59.00 $55.00 $57.00 $59.0076380-TC $131.00 $64.00 $69.00 $70.00 $64.00 $69.00 $70.0076390 $493.00 $475.00 $506.00 $509.00 $475.00 $506.00 $509.0076390-26 $71.00 $78.00 $80.00 $81.00 $78.00 $80.00 $81.00



Radiology







76390-TC $419.00 $398.00 $427.00 $428.00 $398.00 $427.00 $428.0076496 BR --------- --------- --------- --------- --------- ---------76496-26 BR --------- --------- --------- --------- --------- ---------76496-TC BR $64.00 $69.00 $69.00 $64.00 $69.00 $69.0076497 BR --------- --------- --------- --------- --------- ---------76497-26 BR --------- --------- --------- --------- --------- ---------76497-TC BR $64.00 $69.00 $69.00 $64.00 $69.00 $69.0076498 BR --------- --------- --------- --------- --------- ---------76498-26 BR --------- --------- --------- --------- --------- ---------76498-TC BR $288.00 $309.00 $311.00 $288.00 $309.00 $311.0076499 BR --------- --------- --------- --------- --------- ---------76499-26 BR --------- --------- --------- --------- --------- ---------76499-TC BR --------- --------- --------- --------- --------- ---------76506 $88.00 $129.00 $137.00 $139.00 $129.00 $137.00 $139.0076506-26 $33.00 $36.00 $38.00 $39.00 $36.00 $38.00 $39.0076506-TC $53.00 $92.00 $99.00 $100.00 $92.00 $99.00 $100.0076510 --------- $185.00 $194.00 $195.00 $185.00 $194.00 $195.0076510-26 --------- $98.00 $101.00 $102.00 $98.00 $101.00 $102.0076510-TC --------- $87.00 $93.00 $94.00 $87.00 $93.00 $94.0076511 $96.00 $110.00 $115.00 $116.00 $110.00 $115.00 $116.0076511-26 $48.00 $58.00 $60.00 $60.00 $58.00 $60.00 $60.0076511-TC $48.00 $52.00 $55.00 $56.00 $52.00 $55.00 $56.0076512 $96.00 $101.00 $106.00 $107.00 $101.00 $106.00 $107.0076512-26 $36.00 $58.00 $60.00 $60.00 $58.00 $60.00 $60.0076512-TC $60.00 $42.00 $46.00 $46.00 $42.00 $46.00 $46.0076513 $96.00 $103.00 $109.00 $110.00 $103.00 $109.00 $110.0076513-26 $36.00 $39.00 $40.00 $41.00 $39.00 $40.00 $41.0076513-TC $60.00 $64.00 $68.00 $69.00 $64.00 $68.00 $69.0076514 --------- $17.00 $18.00 $18.00 $17.00 $18.00 $18.0076514-26 --------- $11.00 $11.00 $12.00 $11.00 $11.00 $12.0076514-TC --------- $6.00 $6.00 $7.00 $6.00 $6.00 $7.0076516 $99.00 $85.00 $90.00 $91.00 $85.00 $90.00 $91.0076516-26 $37.00 $34.00 $35.00 $36.00 $34.00 $35.00 $36.0076516-TC $63.00 $51.00 $55.00 $55.00 $51.00 $55.00 $55.0076519 $88.00 $91.00 $96.00 $97.00 $91.00 $96.00 $97.0076519-26 $31.00 $34.00 $35.00 $36.00 $34.00 $35.00 $36.0076519-TC $53.00 $56.00 $61.00 $61.00 $56.00 $61.00 $61.0076529 $86.00 $86.00 $91.00 $92.00 $86.00 $91.00 $92.0076529-26 $31.00 $36.00 $37.00 $37.00 $36.00 $37.00 $37.0076529-TC $53.00 $50.00 $54.00 $54.00 $50.00 $54.00 $54.0076536 $83.00 $126.00 $134.00 $135.00 $126.00 $134.00 $135.0076536-26 $31.00 $32.00 $33.00 $34.00 $32.00 $33.00 $34.0076536-TC $54.00 $94.00 $101.00 $102.00 $94.00 $101.00 $102.0076604 $78.00 $96.00 $101.00 $103.00 $96.00 $101.00 $103.0076604-26 $28.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.0076604-TC $48.00 $65.00 $70.00 $71.00 $65.00 $70.00 $71.0076641 --------- $117.00 $124.00 $126.00 $117.00 $124.00 $126.0076641-26 --------- $41.00 $42.00 $44.00 $41.00 $42.00 $44.0076641-TC --------- $76.00 $81.00 $82.00 $76.00 $81.00 $82.0076642 --------- $96.00 $102.00 $104.00 $96.00 $102.00 $104.00



Radiology







76642-26 --------- $38.00 $40.00 $41.00 $38.00 $40.00 $41.0076642-TC --------- $58.00 $62.00 $63.00 $58.00 $62.00 $63.0076700 $116.00 $133.00 $141.00 $143.00 $133.00 $141.00 $143.0076700-26 $42.00 $45.00 $47.00 $48.00 $45.00 $47.00 $48.0076700-TC $73.00 $88.00 $94.00 $95.00 $88.00 $94.00 $95.0076705 $84.00 $99.00 $105.00 $107.00 $99.00 $105.00 $107.0076705-26 $30.00 $33.00 $34.00 $35.00 $33.00 $34.00 $35.0076705-TC $53.00 $66.00 $71.00 $72.00 $66.00 $71.00 $72.0076770 $112.00 $123.00 $131.00 $133.00 $123.00 $131.00 $133.0076770-26 $38.00 $41.00 $43.00 $44.00 $41.00 $43.00 $44.0076770-TC $73.00 $82.00 $88.00 $88.00 $82.00 $88.00 $88.0076775 $84.00 $63.00 $67.00 $68.00 $63.00 $67.00 $68.0076775-26 $30.00 $32.00 $33.00 $34.00 $32.00 $33.00 $34.0076775-TC $53.00 $31.00 $34.00 $34.00 $31.00 $34.00 $34.0076776 --------- $170.00 $181.00 $183.00 $170.00 $181.00 $183.0076776-26 --------- $43.00 $44.00 $45.00 $43.00 $44.00 $45.0076776-TC --------- $127.00 $137.00 $137.00 $127.00 $137.00 $137.0076800 $112.00 $155.00 $166.00 $171.00 $155.00 $166.00 $171.0076800-26 $61.00 $69.00 $73.00 $78.00 $69.00 $73.00 $78.0076800-TC $54.00 $86.00 $93.00 $93.00 $86.00 $93.00 $93.0076801 $93.00 $134.00 $142.00 $145.00 $134.00 $142.00 $145.0076801-26 $51.00 $56.00 $58.00 $60.00 $56.00 $58.00 $60.0076801-TC $42.00 $78.00 $84.00 $84.00 $78.00 $84.00 $84.0076802 $73.00 $72.00 $75.00 $77.00 $72.00 $75.00 $77.0076802-26 $43.00 $48.00 $50.00 $52.00 $48.00 $50.00 $52.0076802-TC $30.00 $24.00 $26.00 $26.00 $24.00 $26.00 $26.0076805 $131.00 $155.00 $164.00 $167.00 $155.00 $164.00 $167.0076805-26 $51.00 $57.00 $59.00 $61.00 $57.00 $59.00 $61.0076805-TC $79.00 $98.00 $105.00 $106.00 $98.00 $105.00 $106.0076810 $252.00 $103.00 $108.00 $111.00 $103.00 $108.00 $111.0076810-26 $100.00 $57.00 $59.00 $61.00 $57.00 $59.00 $61.0076810-TC $151.00 $46.00 $49.00 $50.00 $46.00 $49.00 $50.0076811 $243.00 $201.00 $212.00 $218.00 $201.00 $212.00 $218.0076811-26 $100.00 $111.00 $116.00 $121.00 $111.00 $116.00 $121.0076811-TC $142.00 $90.00 $97.00 $98.00 $90.00 $97.00 $98.0076812 $145.00 $227.00 $240.00 $246.00 $227.00 $240.00 $246.0076812-26 $94.00 $104.00 $109.00 $113.00 $104.00 $109.00 $113.0076812-TC $51.00 $123.00 $132.00 $132.00 $123.00 $132.00 $132.0076813 --------- $133.00 $141.00 $145.00 $133.00 $141.00 $145.0076813-26 --------- $69.00 $72.00 $75.00 $69.00 $72.00 $75.0076813-TC --------- $64.00 $69.00 $70.00 $64.00 $69.00 $70.0076814 --------- $90.00 $95.00 $98.00 $90.00 $95.00 $98.0076814-26 --------- $58.00 $61.00 $64.00 $58.00 $61.00 $64.0076814-TC --------- $32.00 $34.00 $35.00 $32.00 $34.00 $35.0076815 $88.00 $92.00 $98.00 $99.00 $92.00 $98.00 $99.0076815-26 $33.00 $37.00 $38.00 $39.00 $37.00 $38.00 $39.0076815-TC $53.00 $55.00 $59.00 $60.00 $55.00 $59.00 $60.0076816 $72.00 $126.00 $134.00 $137.00 $126.00 $134.00 $137.0076816-26 $30.00 $50.00 $52.00 $54.00 $50.00 $52.00 $54.0076816-TC $41.00 $77.00 $82.00 $83.00 $77.00 $82.00 $83.00



Radiology







76817 $96.00 $106.00 $113.00 $115.00 $106.00 $113.00 $115.0076817-26 $39.00 $43.00 $45.00 $46.00 $43.00 $45.00 $46.0076817-TC $57.00 $63.00 $68.00 $69.00 $63.00 $68.00 $69.0076818 $105.00 $134.00 $142.00 $146.00 $134.00 $142.00 $146.0076818-26 $40.00 $62.00 $64.00 $67.00 $62.00 $64.00 $67.0076818-TC $60.00 $72.00 $78.00 $79.00 $72.00 $78.00 $79.0076819 $101.00 $97.00 $103.00 $106.00 $97.00 $103.00 $106.0076819-26 $40.00 $45.00 $47.00 $48.00 $45.00 $47.00 $48.0076819-TC $60.00 $53.00 $57.00 $57.00 $53.00 $57.00 $57.0076820 --------- $52.00 $55.00 $57.00 $52.00 $55.00 $57.0076820-26 --------- $29.00 $30.00 $31.00 $29.00 $30.00 $31.0076820-TC --------- $23.00 $25.00 $25.00 $23.00 $25.00 $25.0076821 --------- $102.00 $108.00 $111.00 $102.00 $108.00 $111.0076821-26 --------- $41.00 $43.00 $44.00 $41.00 $43.00 $44.0076821-TC --------- $61.00 $66.00 $66.00 $61.00 $66.00 $66.0076825 $160.00 $301.00 $319.00 $324.00 $301.00 $319.00 $324.0076825-26 $65.00 $94.00 $98.00 $101.00 $94.00 $98.00 $101.0076825-TC $73.00 $206.00 $222.00 $223.00 $206.00 $222.00 $223.0076826 $71.00 $177.00 $188.00 $190.00 $177.00 $188.00 $190.0076826-26 $46.00 $46.00 $48.00 $49.00 $46.00 $48.00 $49.0076826-TC $27.00 $131.00 $140.00 $141.00 $131.00 $140.00 $141.0076827 $97.00 $83.00 $88.00 $89.00 $83.00 $88.00 $89.0076827-26 $35.00 $32.00 $33.00 $34.00 $32.00 $33.00 $34.0076827-TC $65.00 $50.00 $54.00 $55.00 $50.00 $54.00 $55.0076828 $72.00 $59.00 $62.00 $64.00 $59.00 $62.00 $64.0076828-26 $29.00 $32.00 $33.00 $35.00 $32.00 $33.00 $35.0076828-TC $42.00 $27.00 $29.00 $29.00 $27.00 $29.00 $29.0076830 $93.00 $133.00 $141.00 $143.00 $133.00 $141.00 $143.0076830-26 $35.00 $39.00 $40.00 $42.00 $39.00 $40.00 $42.0076830-TC $57.00 $94.00 $100.00 $101.00 $94.00 $100.00 $101.0076831 $95.00 $129.00 $137.00 $139.00 $129.00 $137.00 $139.0076831-26 $37.00 $42.00 $43.00 $45.00 $42.00 $43.00 $45.0076831-TC $57.00 $87.00 $94.00 $95.00 $87.00 $94.00 $95.0076856 $93.00 $119.00 $127.00 $129.00 $119.00 $127.00 $129.0076856-26 $35.00 $39.00 $40.00 $41.00 $39.00 $40.00 $41.0076856-TC $57.00 $81.00 $87.00 $87.00 $81.00 $87.00 $87.0076857 $59.00 $52.00 $55.00 $57.00 $52.00 $55.00 $57.0076857-26 $19.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.0076857-TC $39.00 $24.00 $26.00 $27.00 $24.00 $26.00 $27.0076870 $90.00 $74.00 $78.00 $80.00 $74.00 $78.00 $80.0076870-26 $33.00 $36.00 $37.00 $38.00 $36.00 $37.00 $38.0076870-TC $57.00 $38.00 $41.00 $41.00 $38.00 $41.00 $41.0076872 $93.00 $102.00 $108.00 $109.00 $102.00 $108.00 $109.0076872-26 $36.00 $37.00 $38.00 $39.00 $37.00 $38.00 $39.0076872-TC $57.00 $65.00 $70.00 $70.00 $65.00 $70.00 $70.0076873 $151.00 $183.00 $193.00 $195.00 $183.00 $193.00 $195.0076873-26 $68.00 $87.00 $89.00 $91.00 $87.00 $89.00 $91.0076873-TC $80.00 $96.00 $103.00 $104.00 $96.00 $103.00 $104.0076881 --------- $124.00 $132.00 $133.00 $124.00 $132.00 $133.0076881-26 --------- $35.00 $36.00 $37.00 $35.00 $36.00 $37.00



Radiology







76881-TC --------- $89.00 $96.00 $96.00 $89.00 $96.00 $96.0076882 --------- $40.00 $42.00 $43.00 $40.00 $42.00 $43.0076882-26 --------- $28.00 $29.00 $30.00 $28.00 $29.00 $30.0076882-TC --------- $12.00 $13.00 $14.00 $12.00 $13.00 $14.0076930 $93.00 --------- --------- --------- --------- --------- ---------76930-26 NC $37.00 $38.00 $39.00 $37.00 $38.00 $39.0076930-TC NC BR BR BR BR BR BR76932 $93.00 --------- --------- --------- --------- --------- ---------76932-26 NC $37.00 $38.00 $39.00 $37.00 $38.00 $39.0076932-TC NC BR BR BR BR BR BR76936 $341.00 $299.00 $318.00 $327.00 $299.00 $318.00 $327.0076936-26 $102.00 $113.00 $119.00 $127.00 $113.00 $119.00 $127.0076936-TC $236.00 $186.00 $199.00 $201.00 $186.00 $199.00 $201.0076937 --------- $34.00 $36.00 $37.00 $34.00 $36.00 $37.0076937-26 --------- $16.00 $17.00 $17.00 $16.00 $17.00 $17.0076937-TC --------- $18.00 $19.00 $20.00 $18.00 $19.00 $20.0076940 --------- BR BR BR BR BR BR76940-26 --------- $118.00 $124.00 $131.00 $118.00 $124.00 $131.0076940-TC --------- BR BR BR BR BR BR76941 $128.00 --------- --------- --------- --------- --------- ---------76941-26 NC $78.00 $81.00 $85.00 $78.00 $81.00 $85.0076941-TC NC BR BR BR BR BR BR76942 $92.00 $67.00 $70.00 $72.00 $67.00 $70.00 $72.0076942-26 NC $38.00 $39.00 $40.00 $38.00 $39.00 $40.0076942-TC NC $29.00 $32.00 $32.00 $29.00 $32.00 $32.0076945 $93.00 --------- --------- --------- --------- --------- ---------76945-26 NC $39.00 $41.00 $43.00 $39.00 $41.00 $43.0076945-TC NC BR BR BR BR BR BR76946 $78.00 $36.00 $38.00 $40.00 $36.00 $38.00 $40.0076946-26 NC $22.00 $23.00 $24.00 $22.00 $23.00 $24.0076946-TC NC $14.00 $15.00 $16.00 $14.00 $15.00 $16.0076948 $77.00 $76.00 $81.00 $83.00 $76.00 $81.00 $83.0076948-26 NC $34.00 $35.00 $37.00 $34.00 $35.00 $37.0076948-TC NC $42.00 $45.00 $46.00 $42.00 $45.00 $46.0076965 $281.00 $99.00 $103.00 $105.00 $99.00 $103.00 $105.0076965-26 $84.00 $74.00 $76.00 $77.00 $74.00 $76.00 $77.0076965-TC $208.00 $25.00 $27.00 $28.00 $25.00 $27.00 $28.0076970 $60.00 $100.00 $107.00 $108.00 $100.00 $107.00 $108.0076970-26 $20.00 $22.00 $22.00 $23.00 $22.00 $22.00 $23.0076970-TC $39.00 $79.00 $85.00 $85.00 $79.00 $85.00 $85.0076975 $99.00 $210.00 $224.00 $227.00 $210.00 $224.00 $227.0076975-26 NC $48.00 $50.00 $52.00 $48.00 $50.00 $52.0076975-TC NC $162.00 $174.00 $175.00 $162.00 $174.00 $175.0076977 $34.00 $8.00 $9.00 $9.00 $8.00 $9.00 $9.0076977-26 $3.00 $3.00 $3.00 $4.00 $3.00 $3.00 $4.0076977-TC $31.00 $5.00 $5.00 $5.00 $5.00 $5.00 $5.0076998 --------- BR BR BR BR BR BR76998-26 --------- $73.00 $78.00 $85.00 $73.00 $78.00 $85.0076998-TC --------- BR BR BR BR BR BR76999 BR --------- --------- --------- --------- --------- ---------



Radiology







76999-26 BR --------- --------- --------- --------- --------- ---------76999-TC BR --------- --------- --------- --------- --------- ---------77001 --------- $76.00 $81.00 $82.00 $76.00 $81.00 $82.0077001-26 --------- $21.00 $22.00 $23.00 $21.00 $22.00 $23.0077001-TC --------- $54.00 $58.00 $59.00 $54.00 $58.00 $59.0077002 --------- $101.00 $107.00 $109.00 $101.00 $107.00 $109.0077002-26 --------- $32.00 $33.00 $34.00 $32.00 $33.00 $34.0077002-TC --------- $69.00 $74.00 $75.00 $69.00 $74.00 $75.0077003 --------- $93.00 $98.00 $100.00 $93.00 $98.00 $100.0077003-26 --------- $34.00 $35.00 $36.00 $34.00 $35.00 $36.0077003-TC --------- $59.00 $63.00 $64.00 $59.00 $63.00 $64.0077011 --------- $240.00 $255.00 $259.00 $240.00 $255.00 $259.0077011-26 --------- $70.00 $73.00 $75.00 $70.00 $73.00 $75.0077011-TC --------- $170.00 $183.00 $184.00 $170.00 $183.00 $184.0077012 --------- $136.00 $144.00 $146.00 $136.00 $144.00 $146.0077012-26 --------- $65.00 $67.00 $69.00 $65.00 $67.00 $69.0077012-TC --------- $71.00 $77.00 $77.00 $71.00 $77.00 $77.0077013-26 --------- $220.00 $227.00 $234.00 $220.00 $227.00 $234.0077013-TC --------- BR BR BR BR BR BR77014 --------- $128.00 $135.00 $137.00 $128.00 $135.00 $137.0077014-26 --------- $49.00 $50.00 $52.00 $49.00 $50.00 $52.0077014-TC --------- $79.00 $85.00 $85.00 $79.00 $85.00 $85.0077021 --------- $433.00 $461.00 $466.00 $433.00 $461.00 $466.0077021-26 --------- $85.00 $87.00 $90.00 $85.00 $87.00 $90.0077021-TC --------- $348.00 $374.00 $375.00 $348.00 $374.00 $375.0077022 --------- BR BR BR BR BR BR77022-26 --------- $239.00 $247.00 $255.00 $239.00 $247.00 $255.0077022-TC --------- BR BR BR BR BR BR77051 --------- $9.00 $9.00 $9.00 $9.00 $9.00 $9.0077051-26 --------- $3.00 $3.00 $3.00 $3.00 $3.00 $3.0077051-TC --------- $6.00 $6.00 $6.00 $6.00 $6.00 $6.0077052 --------- $9.00 $9.00 $9.00 $9.00 $9.00 $9.0077052-26 --------- $3.00 $3.00 $3.00 $3.00 $3.00 $3.0077052-TC --------- $6.00 $6.00 $6.00 $6.00 $6.00 $6.0077053 --------- $63.00 $67.00 $68.00 $63.00 $67.00 $68.0077053-26 --------- $20.00 $21.00 $21.00 $20.00 $21.00 $21.0077053-TC --------- $43.00 $46.00 $47.00 $43.00 $46.00 $47.0077054 --------- $83.00 $88.00 $90.00 $83.00 $88.00 $90.0077054-26 --------- $26.00 $27.00 $28.00 $26.00 $27.00 $28.0077054-TC --------- $57.00 $62.00 $62.00 $57.00 $62.00 $62.0077055 --------- $97.00 $103.00 $104.00 $97.00 $103.00 $104.0077055-26 --------- $39.00 $41.00 $42.00 $39.00 $41.00 $42.0077055-TC --------- $58.00 $62.00 $62.00 $58.00 $62.00 $62.0077056 --------- $125.00 $132.00 $134.00 $125.00 $132.00 $134.0077056-26 --------- $49.00 $51.00 $52.00 $49.00 $51.00 $52.0077056-TC --------- $76.00 $81.00 $82.00 $76.00 $81.00 $82.0077057 --------- $89.00 $94.00 $96.00 $89.00 $94.00 $96.0077057-26 --------- $39.00 $41.00 $42.00 $39.00 $41.00 $42.0077057-TC --------- $50.00 $53.00 $54.00 $50.00 $53.00 $54.0077058 --------- $570.00 $609.00 $614.00 $570.00 $609.00 $614.00



Radiology







77058-26 --------- $92.00 $95.00 $97.00 $92.00 $95.00 $97.0077058-TC --------- $479.00 $514.00 $516.00 $479.00 $514.00 $516.0077059 --------- $570.00 $609.00 $614.00 $570.00 $609.00 $614.0077059-26 --------- $92.00 $95.00 $97.00 $92.00 $95.00 $97.0077059-TC --------- $479.00 $514.00 $516.00 $479.00 $514.00 $516.0077063 --------- $60.00 $63.00 $64.00 $60.00 $63.00 $64.0077063-26 --------- $34.00 $35.00 $36.00 $34.00 $35.00 $36.0077063-TC --------- $27.00 $29.00 $29.00 $27.00 $29.00 $29.0077071 --------- $53.00 $57.00 $59.00 $53.00 $57.00 $59.0077072 --------- $25.00 $27.00 $27.00 $25.00 $27.00 $27.0077072-26 --------- $11.00 $11.00 $11.00 $11.00 $11.00 $11.0077072-TC --------- $15.00 $16.00 $16.00 $15.00 $16.00 $16.0077073 --------- $39.00 $41.00 $42.00 $39.00 $41.00 $42.0077073-26 --------- $16.00 $17.00 $17.00 $16.00 $17.00 $17.0077073-TC --------- $23.00 $25.00 $25.00 $23.00 $25.00 $25.0077074 --------- $70.00 $74.00 $75.00 $70.00 $74.00 $75.0077074-26 --------- $26.00 $27.00 $28.00 $26.00 $27.00 $28.0077074-TC --------- $44.00 $47.00 $48.00 $44.00 $47.00 $48.0077075 --------- $94.00 $100.00 $102.00 $94.00 $100.00 $102.0077075-26 --------- $30.00 $31.00 $32.00 $30.00 $31.00 $32.0077075-TC --------- $64.00 $69.00 $69.00 $64.00 $69.00 $69.0077077 --------- $41.00 $43.00 $44.00 $41.00 $43.00 $44.0077077-26 --------- $18.00 $19.00 $19.00 $18.00 $19.00 $19.0077077-TC --------- $22.00 $24.00 $25.00 $22.00 $24.00 $25.0077078 --------- $78.00 $83.00 $84.00 $78.00 $83.00 $84.0077078-26 --------- $14.00 $14.00 $14.00 $14.00 $14.00 $14.0077078-TC --------- $64.00 $69.00 $70.00 $64.00 $69.00 $70.0077080 --------- $44.00 $47.00 $48.00 $44.00 $47.00 $48.0077080-26 --------- $11.00 $12.00 $12.00 $11.00 $12.00 $12.0077080-TC --------- $33.00 $36.00 $36.00 $33.00 $36.00 $36.0077081 --------- $30.00 $32.00 $33.00 $30.00 $32.00 $33.0077081-26 --------- $12.00 $13.00 $13.00 $12.00 $13.00 $13.0077081-TC --------- $18.00 $20.00 $20.00 $18.00 $20.00 $20.0077084 --------- $379.00 $403.00 $407.00 $379.00 $403.00 $407.0077084-26 --------- $90.00 $93.00 $96.00 $90.00 $93.00 $96.0077084-TC --------- $288.00 $310.00 $311.00 $288.00 $310.00 $311.0077085 --------- $61.00 $65.00 $66.00 $61.00 $65.00 $66.0077085-26 --------- $17.00 $18.00 $19.00 $17.00 $18.00 $19.0077085-TC --------- $44.00 $47.00 $47.00 $44.00 $47.00 $47.0077086 --------- $38.00 $41.00 $42.00 $38.00 $41.00 $42.0077086-26 --------- $10.00 $10.00 $11.00 $10.00 $10.00 $11.0077086-TC --------- $28.00 $31.00 $31.00 $28.00 $31.00 $31.0077261 $73.00 $84.00 $88.00 $90.00 $84.00 $88.00 $90.0077262 $110.00 $126.00 $131.00 $136.00 $126.00 $131.00 $136.0077263 $163.00 $185.00 $192.00 $200.00 $185.00 $192.00 $200.0077280 $166.00 $293.00 $313.00 $315.00 $293.00 $313.00 $315.0077280-26 $36.00 $40.00 $41.00 $42.00 $40.00 $41.00 $42.0077280-TC $130.00 $253.00 $272.00 $273.00 $253.00 $272.00 $273.0077285 $264.00 $462.00 $494.00 $497.00 $462.00 $494.00 $497.0077285-26 $53.00 $61.00 $63.00 $64.00 $61.00 $63.00 $64.00



Radiology







77285-TC $209.00 $402.00 $431.00 $433.00 $402.00 $431.00 $433.0077290 $325.00 $553.00 $590.00 $594.00 $553.00 $590.00 $594.0077290-26 $79.00 $90.00 $93.00 $95.00 $90.00 $93.00 $95.0077290-TC $243.00 $463.00 $497.00 $499.00 $463.00 $497.00 $499.0077293 --------- $502.00 $534.00 $539.00 $502.00 $534.00 $539.0077293-26 --------- $115.00 $119.00 $122.00 $115.00 $119.00 $122.0077293-TC --------- $387.00 $416.00 $417.00 $387.00 $416.00 $417.0077295 $1,287.00 $534.00 $563.00 $571.00 $534.00 $563.00 $571.0077295-26 $232.00 $246.00 $254.00 $259.00 $246.00 $254.00 $259.0077295-TC $1,046.00 $288.00 $309.00 $312.00 $288.00 $309.00 $312.0077299 BR --------- --------- --------- --------- --------- ---------77299-26 BR --------- --------- --------- --------- --------- ---------77299-TC BR --------- --------- --------- --------- --------- ---------77300 $87.00 $73.00 $77.00 $78.00 $73.00 $77.00 $78.0077300-26 $36.00 $36.00 $37.00 $38.00 $36.00 $37.00 $38.0077300-TC $52.00 $37.00 $40.00 $40.00 $37.00 $40.00 $40.0077301 $1,473.00 $2,106.00 $2,244.00 $2,268.00 $2,106.00 $2,244.00 $2,268.0077301-26 $415.00 $459.00 $473.00 $484.00 $459.00 $473.00 $484.0077301-TC $1,046.00 $1,648.00 $1,771.00 $1,784.00 $1,648.00 $1,771.00 $1,784.0077306 --------- $163.00 $172.00 $174.00 $163.00 $172.00 $174.0077306-26 --------- $81.00 $83.00 $85.00 $81.00 $83.00 $85.0077306-TC --------- $82.00 $89.00 $89.00 $82.00 $89.00 $89.0077307 --------- $315.00 $331.00 $336.00 $315.00 $331.00 $336.0077307-26 --------- $166.00 $171.00 $175.00 $166.00 $171.00 $175.0077307-TC --------- $149.00 $160.00 $161.00 $149.00 $160.00 $161.0077316 --------- $205.00 $217.00 $220.00 $205.00 $217.00 $220.0077316-26 --------- $81.00 $83.00 $85.00 $81.00 $83.00 $85.0077316-TC --------- $124.00 $134.00 $135.00 $124.00 $134.00 $135.0077317 --------- $267.00 $283.00 $287.00 $267.00 $283.00 $287.0077317-26 --------- $105.00 $109.00 $111.00 $105.00 $109.00 $111.0077317-TC --------- $162.00 $174.00 $176.00 $162.00 $174.00 $176.0077318 --------- $386.00 $407.00 $414.00 $386.00 $407.00 $414.0077318-26 --------- $166.00 $171.00 $175.00 $166.00 $171.00 $175.0077318-TC --------- $219.00 $236.00 $239.00 $219.00 $236.00 $239.0077321 $200.00 $101.00 $107.00 $108.00 $101.00 $107.00 $108.0077321-26 $48.00 $55.00 $56.00 $58.00 $55.00 $56.00 $58.0077321-TC $150.00 $47.00 $50.00 $51.00 $47.00 $50.00 $51.0077331 $64.00 $70.00 $73.00 $75.00 $70.00 $73.00 $75.0077331-26 $45.00 $50.00 $52.00 $53.00 $50.00 $52.00 $53.0077331-TC $18.00 $20.00 $22.00 $22.00 $20.00 $22.00 $22.0077332 $78.00 $90.00 $95.00 $96.00 $90.00 $95.00 $96.0077332-26 $27.00 $31.00 $32.00 $33.00 $31.00 $32.00 $33.0077332-TC $50.00 $58.00 $63.00 $63.00 $58.00 $63.00 $63.0077333 $115.00 $59.00 $61.00 $63.00 $59.00 $61.00 $63.0077333-26 $43.00 $48.00 $50.00 $51.00 $48.00 $50.00 $51.0077333-TC $70.00 $10.00 $11.00 $12.00 $10.00 $11.00 $12.0077334 $187.00 $166.00 $175.00 $177.00 $166.00 $175.00 $177.0077334-26 $63.00 $71.00 $73.00 $75.00 $71.00 $73.00 $75.0077334-TC $121.00 $95.00 $102.00 $102.00 $95.00 $102.00 $102.0077336 $111.00 $86.00 $93.00 $95.00 $86.00 $93.00 $95.00



Radiology







77338 --------- $552.00 $583.00 $592.00 $552.00 $583.00 $592.0077338-26 --------- $246.00 $254.00 $259.00 $246.00 $254.00 $259.0077338-TC --------- $306.00 $329.00 $332.00 $306.00 $329.00 $332.0077370 $130.00 $132.00 $143.00 $147.00 $132.00 $143.00 $147.0077371 --------- BR BR BR BR BR BR77372 --------- $1,147.00 $1,232.00 $1,241.00 $1,147.00 $1,232.00 $1,241.0077373 --------- $1,458.00 $1,566.00 $1,577.00 $1,458.00 $1,566.00 $1,577.0077399 BR --------- --------- --------- --------- --------- ---------77399-26 BR --------- --------- --------- --------- --------- ---------77399-TC BR --------- --------- --------- --------- --------- ---------77401 $66.00 $26.00 $28.00 $28.00 $26.00 $28.00 $28.0077402 $66.00 --------- --------- --------- --------- --------- ---------77407 $78.00 --------- --------- --------- --------- --------- ---------77412 $87.00 --------- --------- --------- --------- --------- ---------77417 $21.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.0077422 --------- BR BR BR BR BR BR77423 --------- BR BR BR BR BR BR77427 $166.00 $207.00 $215.00 $223.00 $207.00 $215.00 $223.0077431 $95.00 $114.00 $118.00 $122.00 $114.00 $118.00 $122.0077432 $417.00 $467.00 $485.00 $503.00 $467.00 $485.00 $503.0077435 --------- $704.00 $732.00 $759.00 $704.00 $732.00 $759.0077469 --------- $358.00 $373.00 $385.00 $358.00 $373.00 $385.0077470 $527.00 $172.00 $179.00 $183.00 $172.00 $179.00 $183.0077470-26 $106.00 $120.00 $124.00 $127.00 $120.00 $124.00 $127.0077470-TC $417.00 $52.00 $56.00 $56.00 $52.00 $56.00 $56.0077499 BR --------- --------- --------- --------- --------- ---------77499-26 BR --------- --------- --------- --------- --------- ---------77499-TC BR --------- --------- --------- --------- --------- ---------77520 BR --------- --------- --------- --------- --------- ---------77522 BR --------- --------- --------- --------- --------- ---------77523 BR --------- --------- --------- --------- --------- ---------77525 BR --------- --------- --------- --------- --------- ---------77600 $196.00 $453.00 $483.00 $488.00 $453.00 $483.00 $488.0077600-26 $80.00 $91.00 $94.00 $97.00 $91.00 $94.00 $97.0077600-TC $113.00 $362.00 $389.00 $391.00 $362.00 $389.00 $391.0077605 $263.00 $862.00 $923.00 $938.00 $862.00 $923.00 $938.0077605-26 $108.00 $133.00 $141.00 $152.00 $133.00 $141.00 $152.0077605-TC $151.00 $729.00 $782.00 $786.00 $729.00 $782.00 $786.0077610 $195.00 $1,067.00 $1,145.00 $1,158.00 $1,067.00 $1,145.00 $1,158.0077610-26 $79.00 $99.00 $106.00 $115.00 $99.00 $106.00 $115.0077610-TC $113.00 $968.00 $1,039.00 $1,043.00 $968.00 $1,039.00 $1,043.0077615 $262.00 $1,140.00 $1,219.00 $1,228.00 $1,140.00 $1,219.00 $1,228.0077615-26 $106.00 $119.00 $123.00 $126.00 $119.00 $123.00 $126.0077615-TC $151.00 $1,021.00 $1,096.00 $1,102.00 $1,021.00 $1,096.00 $1,102.0077620 $196.00 $414.00 $441.00 $445.00 $414.00 $441.00 $445.0077620-26 $80.00 $90.00 $93.00 $95.00 $90.00 $93.00 $95.0077620-TC $113.00 $324.00 $348.00 $351.00 $324.00 $348.00 $351.0077750 $299.00 $408.00 $426.00 $435.00 $408.00 $426.00 $435.0077750-26 $248.00 $286.00 $295.00 $302.00 $286.00 $295.00 $302.0077750-TC $49.00 $122.00 $131.00 $132.00 $122.00 $131.00 $132.00



Radiology







77761 $284.00 $425.00 $448.00 $456.00 $425.00 $448.00 $456.0077761-26 $188.00 $219.00 $226.00 $232.00 $219.00 $226.00 $232.0077761-TC $93.00 $206.00 $222.00 $224.00 $206.00 $222.00 $224.0077762 $427.00 $567.00 $595.00 $606.00 $567.00 $595.00 $606.0077762-26 $289.00 $330.00 $341.00 $349.00 $330.00 $341.00 $349.0077762-TC $135.00 $237.00 $255.00 $257.00 $237.00 $255.00 $257.0077763 $605.00 $804.00 $843.00 $859.00 $804.00 $843.00 $859.0077763-26 $435.00 $497.00 $513.00 $525.00 $497.00 $513.00 $525.0077763-TC $167.00 $307.00 $330.00 $334.00 $307.00 $330.00 $334.0077767 --------- $243.00 $259.00 $262.00 $243.00 $259.00 $262.0077767-26 --------- $61.00 $63.00 $64.00 $61.00 $63.00 $64.0077767-TC --------- $182.00 $196.00 $197.00 $182.00 $196.00 $197.0077768 --------- $380.00 $405.00 $409.00 $380.00 $405.00 $409.0077768-26 --------- $80.00 $83.00 $85.00 $80.00 $83.00 $85.0077768-TC --------- $300.00 $322.00 $325.00 $300.00 $322.00 $325.0077770 --------- $347.00 $368.00 $373.00 $347.00 $368.00 $373.0077770-26 --------- $112.00 $115.00 $118.00 $112.00 $115.00 $118.0077770-TC --------- $235.00 $253.00 $255.00 $235.00 $253.00 $255.0077771 --------- $647.00 $686.00 $694.00 $647.00 $686.00 $694.0077771-26 --------- $218.00 $225.00 $230.00 $218.00 $225.00 $230.0077771-TC --------- $429.00 $461.00 $464.00 $429.00 $461.00 $464.0077772 --------- $987.00 $1,048.00 $1,061.00 $987.00 $1,048.00 $1,061.0077772-26 --------- $310.00 $319.00 $327.00 $310.00 $319.00 $327.0077772-TC --------- $678.00 $729.00 $734.00 $678.00 $729.00 $734.0077778 $764.00 $852.00 $897.00 $913.00 $852.00 $897.00 $913.0077778-26 $568.00 $458.00 $472.00 $483.00 $458.00 $472.00 $483.0077778-TC $192.00 $395.00 $425.00 $430.00 $395.00 $425.00 $430.0077789 $74.00 $130.00 $137.00 $139.00 $130.00 $137.00 $139.0077789-26 $57.00 $66.00 $68.00 $70.00 $66.00 $68.00 $70.0077789-TC $16.00 $64.00 $69.00 $70.00 $64.00 $69.00 $70.0077790 $72.00 $16.00 $17.00 $18.00 $16.00 $17.00 $18.0077790-26 $53.00 --------- --------- --------- --------- --------- ---------77790-TC $18.00 --------- --------- --------- --------- --------- ---------77799 BR --------- --------- --------- --------- --------- ---------77799-26 BR --------- --------- --------- --------- --------- ---------77799-TC BR --------- --------- --------- --------- --------- ---------78012 --------- $88.00 $94.00 $95.00 $88.00 $94.00 $95.0078012-26 --------- $11.00 $11.00 $11.00 $11.00 $11.00 $11.0078012-TC --------- $77.00 $83.00 $84.00 $77.00 $83.00 $84.0078013 --------- $212.00 $226.00 $229.00 $212.00 $226.00 $229.0078013-26 --------- $21.00 $21.00 $22.00 $21.00 $21.00 $22.0078013-TC --------- $191.00 $205.00 $207.00 $191.00 $205.00 $207.0078014 --------- $268.00 $287.00 $289.00 $268.00 $287.00 $289.0078014-26 --------- $28.00 $29.00 $30.00 $28.00 $29.00 $30.0078014-TC --------- $240.00 $258.00 $260.00 $240.00 $258.00 $260.0078015 $132.00 $244.00 $261.00 $263.00 $244.00 $261.00 $263.0078015-26 $34.00 $37.00 $38.00 $39.00 $37.00 $38.00 $39.0078015-TC $96.00 $208.00 $223.00 $225.00 $208.00 $223.00 $225.0078016 $173.00 $309.00 $330.00 $333.00 $309.00 $330.00 $333.0078016-26 $42.00 $38.00 $39.00 $39.00 $38.00 $39.00 $39.00



Radiology







78016-TC $130.00 $271.00 $292.00 $294.00 $271.00 $292.00 $294.0078018 $248.00 $347.00 $371.00 $374.00 $347.00 $371.00 $374.0078018-26 $44.00 $47.00 $48.00 $49.00 $47.00 $48.00 $49.0078018-TC $202.00 $300.00 $323.00 $325.00 $300.00 $323.00 $325.0078020 $35.00 $93.00 $99.00 $100.00 $93.00 $99.00 $100.0078020-26 $30.00 $31.00 $32.00 $33.00 $31.00 $32.00 $33.0078020-TC $5.00 $62.00 $67.00 $68.00 $62.00 $67.00 $68.0078070 $112.00 $332.00 $355.00 $358.00 $332.00 $355.00 $358.0078070-26 $36.00 $44.00 $45.00 $46.00 $44.00 $45.00 $46.0078070-TC $68.00 $289.00 $310.00 $312.00 $289.00 $310.00 $312.0078071 --------- $398.00 $424.00 $429.00 $398.00 $424.00 $429.0078071-26 --------- $66.00 $68.00 $70.00 $66.00 $68.00 $70.0078071-TC --------- $332.00 $356.00 $359.00 $332.00 $356.00 $359.0078072 --------- $459.00 $489.00 $494.00 $459.00 $489.00 $494.0078072-26 --------- $86.00 $88.00 $91.00 $86.00 $88.00 $91.0078072-TC --------- $373.00 $401.00 $403.00 $373.00 $401.00 $403.0078075 $242.00 $473.00 $507.00 $511.00 $473.00 $507.00 $511.0078075-26 $38.00 $39.00 $41.00 $41.00 $39.00 $41.00 $41.0078075-TC $202.00 $434.00 $466.00 $469.00 $434.00 $466.00 $469.0078099 BR --------- --------- --------- --------- --------- ---------78099-26 BR --------- --------- --------- --------- --------- ---------78099-TC BR --------- --------- --------- --------- --------- ---------78102 $106.00 $188.00 $201.00 $204.00 $188.00 $201.00 $204.0078102-26 $28.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.0078102-TC $77.00 $158.00 $170.00 $172.00 $158.00 $170.00 $172.0078103 $158.00 $247.00 $264.00 $267.00 $247.00 $264.00 $267.0078103-26 $39.00 $41.00 $42.00 $43.00 $41.00 $42.00 $43.0078103-TC $118.00 $206.00 $222.00 $223.00 $206.00 $222.00 $223.0078104 $194.00 $272.00 $291.00 $293.00 $272.00 $291.00 $293.0078104-26 $41.00 $43.00 $44.00 $46.00 $43.00 $44.00 $46.0078104-TC $152.00 $229.00 $246.00 $248.00 $229.00 $246.00 $248.0078110 $45.00 $104.00 $112.00 $113.00 $104.00 $112.00 $113.0078110-26 $9.00 $11.00 $11.00 $11.00 $11.00 $11.00 $11.0078110-TC $35.00 $93.00 $101.00 $102.00 $93.00 $101.00 $102.0078111 $108.00 $107.00 $114.00 $116.00 $107.00 $114.00 $116.0078111-26 $11.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.0078111-TC $96.00 $95.00 $102.00 $103.00 $95.00 $102.00 $103.0078120 $78.00 $104.00 $112.00 $113.00 $104.00 $112.00 $113.0078120-26 $11.00 $13.00 $13.00 $14.00 $13.00 $13.00 $14.0078120-TC $65.00 $91.00 $98.00 $99.00 $91.00 $98.00 $99.0078121 $125.00 $113.00 $121.00 $123.00 $113.00 $121.00 $123.0078121-26 $16.00 $18.00 $19.00 $19.00 $18.00 $19.00 $19.0078121-TC $108.00 $95.00 $103.00 $104.00 $95.00 $103.00 $104.0078122 $196.00 $109.00 $116.00 $118.00 $109.00 $116.00 $118.0078122-26 $22.00 $24.00 $25.00 $25.00 $24.00 $25.00 $25.0078122-TC $171.00 $85.00 $91.00 $92.00 $85.00 $91.00 $92.0078130 $139.00 $187.00 $199.00 $202.00 $187.00 $199.00 $202.0078130-26 $32.00 $34.00 $35.00 $35.00 $34.00 $35.00 $35.0078130-TC $106.00 $153.00 $165.00 $166.00 $153.00 $165.00 $166.0078135 $216.00 $387.00 $414.00 $417.00 $387.00 $414.00 $417.00



Radiology







78135-26 $33.00 $36.00 $37.00 $38.00 $36.00 $37.00 $38.0078135-TC $182.00 $351.00 $377.00 $379.00 $351.00 $377.00 $379.0078140 $179.00 $152.00 $162.00 $164.00 $152.00 $162.00 $164.0078140-26 $31.00 $34.00 $35.00 $36.00 $34.00 $35.00 $36.0078140-TC $147.00 $118.00 $127.00 $128.00 $118.00 $127.00 $128.0078185 $110.00 $235.00 $251.00 $253.00 $235.00 $251.00 $253.0078185-26 $20.00 $22.00 $23.00 $24.00 $22.00 $23.00 $24.0078185-TC $88.00 $212.00 $228.00 $230.00 $212.00 $228.00 $230.0078190 $272.00 $435.00 $464.00 $468.00 $435.00 $464.00 $468.0078190-26 $57.00 $60.00 $62.00 $63.00 $60.00 $62.00 $63.0078190-TC $214.00 $374.00 $402.00 $405.00 $374.00 $402.00 $405.0078191 $307.00 $187.00 $199.00 $202.00 $187.00 $199.00 $202.0078191-26 $31.00 $34.00 $35.00 $35.00 $34.00 $35.00 $35.0078191-TC $274.00 $153.00 $165.00 $166.00 $153.00 $165.00 $166.0078195 $216.00 $396.00 $422.00 $427.00 $396.00 $422.00 $427.0078195-26 $49.00 $66.00 $69.00 $71.00 $66.00 $69.00 $71.0078195-TC $152.00 $329.00 $354.00 $356.00 $329.00 $354.00 $356.0078199 BR --------- --------- --------- --------- --------- ---------78199-26 BR --------- --------- --------- --------- --------- ---------78199-TC BR --------- --------- --------- --------- --------- ---------78201 $112.00 $208.00 $223.00 $225.00 $208.00 $223.00 $225.0078201-26 $22.00 $24.00 $24.00 $25.00 $24.00 $24.00 $25.0078201-TC $88.00 $185.00 $198.00 $200.00 $185.00 $198.00 $200.0078202 $135.00 $224.00 $239.00 $241.00 $224.00 $239.00 $241.0078202-26 $26.00 $27.00 $28.00 $28.00 $27.00 $28.00 $28.0078202-TC $108.00 $197.00 $212.00 $213.00 $197.00 $212.00 $213.0078205 $259.00 $235.00 $251.00 $253.00 $235.00 $251.00 $253.0078205-26 $36.00 $38.00 $39.00 $40.00 $38.00 $39.00 $40.0078205-TC $220.00 $197.00 $212.00 $213.00 $197.00 $212.00 $213.0078206 $265.00 $380.00 $406.00 $410.00 $380.00 $406.00 $410.0078206-26 $46.00 $52.00 $54.00 $56.00 $52.00 $54.00 $56.0078206-TC $214.00 $328.00 $352.00 $354.00 $328.00 $352.00 $354.0078215 $135.00 $216.00 $231.00 $233.00 $216.00 $231.00 $233.0078215-26 $24.00 $27.00 $28.00 $29.00 $27.00 $28.00 $29.0078215-TC $109.00 $189.00 $203.00 $204.00 $189.00 $203.00 $204.0078216 $160.00 $140.00 $149.00 $152.00 $140.00 $149.00 $152.0078216-26 $29.00 $31.00 $32.00 $33.00 $31.00 $32.00 $33.0078216-TC $130.00 $109.00 $118.00 $119.00 $109.00 $118.00 $119.0078226 --------- $368.00 $394.00 $397.00 $368.00 $394.00 $397.0078226-26 --------- $41.00 $42.00 $44.00 $41.00 $42.00 $44.0078226-TC --------- $327.00 $351.00 $353.00 $327.00 $351.00 $353.0078227 --------- $401.00 $429.00 $432.00 $401.00 $429.00 $432.0078227-26 --------- $50.00 $52.00 $53.00 $50.00 $52.00 $53.0078227-TC --------- $351.00 $377.00 $379.00 $351.00 $377.00 $379.0078230 $106.00 $157.00 $167.00 $169.00 $157.00 $167.00 $169.0078230-26 $23.00 $21.00 $22.00 $22.00 $21.00 $22.00 $22.0078230-TC $82.00 $135.00 $146.00 $147.00 $135.00 $146.00 $147.0078231 $146.00 $145.00 $155.00 $157.00 $145.00 $155.00 $157.0078231-26 $27.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.0078231-TC $118.00 $115.00 $124.00 $125.00 $115.00 $124.00 $125.00



Radiology







78232 $157.00 $110.00 $117.00 $118.00 $110.00 $117.00 $118.0078232-26 $23.00 $22.00 $22.00 $23.00 $22.00 $22.00 $23.0078232-TC $132.00 $88.00 $95.00 $96.00 $88.00 $95.00 $96.0078258 $146.00 $246.00 $263.00 $266.00 $246.00 $263.00 $266.0078258-26 $38.00 $41.00 $42.00 $44.00 $41.00 $42.00 $44.0078258-TC $108.00 $205.00 $221.00 $222.00 $205.00 $221.00 $222.0078261 $190.00 $276.00 $295.00 $298.00 $276.00 $295.00 $298.0078261-26 $36.00 $38.00 $40.00 $41.00 $38.00 $40.00 $41.0078261-TC $152.00 $237.00 $255.00 $257.00 $237.00 $255.00 $257.0078262 $195.00 $271.00 $290.00 $292.00 $271.00 $290.00 $292.0078262-26 $35.00 $37.00 $38.00 $39.00 $37.00 $38.00 $39.0078262-TC $159.00 $234.00 $252.00 $253.00 $234.00 $252.00 $253.0078264 $195.00 $371.00 $397.00 $400.00 $371.00 $397.00 $400.0078264-26 $40.00 $41.00 $42.00 $44.00 $41.00 $42.00 $44.0078264-TC $154.00 $330.00 $354.00 $357.00 $330.00 $354.00 $357.0078265 --------- $405.00 $433.00 $437.00 $405.00 $433.00 $437.0078265-26 --------- $54.00 $56.00 $57.00 $54.00 $56.00 $57.0078265-TC --------- $351.00 $377.00 $380.00 $351.00 $377.00 $380.0078266 --------- $525.00 $562.00 $566.00 $525.00 $562.00 $566.0078266-26 --------- $60.00 $62.00 $64.00 $60.00 $62.00 $64.0078266-TC --------- $465.00 $500.00 $502.00 $465.00 $500.00 $502.0078267 BR --------- --------- --------- --------- --------- ---------78268 BR --------- --------- --------- --------- --------- ---------78270 $68.00 $112.00 $120.00 $122.00 $112.00 $120.00 $122.0078270-26 $10.00 $12.00 $12.00 $13.00 $12.00 $12.00 $13.0078270-TC $58.00 $100.00 $108.00 $109.00 $100.00 $108.00 $109.0078271 $72.00 $100.00 $107.00 $109.00 $100.00 $107.00 $109.0078271-26 $10.00 $11.00 $12.00 $12.00 $11.00 $12.00 $12.0078271-TC $61.00 $89.00 $95.00 $97.00 $89.00 $95.00 $97.0078272 $100.00 $107.00 $115.00 $116.00 $107.00 $115.00 $116.0078272-26 $14.00 $15.00 $15.00 $16.00 $15.00 $15.00 $16.0078272-TC $87.00 $92.00 $99.00 $101.00 $92.00 $99.00 $101.0078278 $234.00 $387.00 $414.00 $418.00 $387.00 $414.00 $418.0078278-26 $50.00 $55.00 $57.00 $58.00 $55.00 $57.00 $58.0078278-TC $182.00 $333.00 $357.00 $360.00 $333.00 $357.00 $360.0078282 BR $372.00 $398.00 $400.00 $372.00 $398.00 $400.0078282-26 $19.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.0078282-TC BR $350.00 $376.00 $377.00 $350.00 $376.00 $377.0078290 $149.00 $370.00 $396.00 $400.00 $370.00 $396.00 $400.0078290-26 $35.00 $38.00 $39.00 $40.00 $38.00 $39.00 $40.0078290-TC $113.00 $332.00 $357.00 $359.00 $332.00 $357.00 $359.0078291 $161.00 $280.00 $299.00 $301.00 $280.00 $299.00 $301.0078291-26 $45.00 $47.00 $49.00 $50.00 $47.00 $49.00 $50.0078291-TC $114.00 $233.00 $250.00 $252.00 $233.00 $250.00 $252.0078299 BR --------- --------- --------- --------- --------- ---------78299-26 BR --------- --------- --------- --------- --------- ---------78299-TC BR --------- --------- --------- --------- --------- ---------78300 $125.00 $201.00 $215.00 $218.00 $201.00 $215.00 $218.0078300-26 $32.00 $35.00 $36.00 $38.00 $35.00 $36.00 $38.0078300-TC $93.00 $166.00 $178.00 $180.00 $166.00 $178.00 $180.00



Radiology







78305 $181.00 $257.00 $274.00 $277.00 $257.00 $274.00 $277.0078305-26 $42.00 $46.00 $48.00 $49.00 $46.00 $48.00 $49.0078305-TC $137.00 $211.00 $226.00 $228.00 $211.00 $226.00 $228.0078306 $205.00 $280.00 $299.00 $303.00 $280.00 $299.00 $303.0078306-26 $44.00 $48.00 $49.00 $51.00 $48.00 $49.00 $51.0078306-TC $159.00 $233.00 $250.00 $252.00 $233.00 $250.00 $252.0078315 $233.00 $385.00 $411.00 $415.00 $385.00 $411.00 $415.0078315-26 $52.00 $56.00 $58.00 $60.00 $56.00 $58.00 $60.0078315-TC $179.00 $329.00 $353.00 $355.00 $329.00 $353.00 $355.0078320 $276.00 $254.00 $270.00 $273.00 $254.00 $270.00 $273.0078320-26 $53.00 $56.00 $58.00 $60.00 $56.00 $58.00 $60.0078320-TC $220.00 $197.00 $212.00 $214.00 $197.00 $212.00 $214.0078350 $40.00 $36.00 $38.00 $39.00 $36.00 $38.00 $39.0078350-26 $11.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.0078350-TC $29.00 $24.00 $25.00 $26.00 $24.00 $25.00 $26.0078351 $23.00 $17.00 $18.00 $18.00 $17.00 $18.00 $18.0078399 BR --------- --------- --------- --------- --------- ---------78399-26 BR --------- --------- --------- --------- --------- ---------78399-TC BR --------- --------- --------- --------- --------- ---------78414 BR --------- --------- --------- --------- --------- ---------78414-26 $23.00 $25.00 $26.00 $26.00 $25.00 $26.00 $26.0078414-TC BR --------- --------- --------- --------- --------- ---------78428 $126.00 $201.00 $214.00 $216.00 $201.00 $214.00 $216.0078428-26 $41.00 $42.00 $43.00 $44.00 $42.00 $43.00 $44.0078428-TC $84.00 $158.00 $170.00 $172.00 $158.00 $170.00 $172.0078445 $97.00 $194.00 $208.00 $210.00 $194.00 $208.00 $210.0078445-26 $28.00 $26.00 $27.00 $27.00 $26.00 $27.00 $27.0078445-TC $69.00 $168.00 $181.00 $182.00 $168.00 $181.00 $182.0078451 --------- $379.00 $404.00 $408.00 $379.00 $404.00 $408.0078451-26 --------- $75.00 $77.00 $79.00 $75.00 $77.00 $79.0078451-TC --------- $304.00 $327.00 $329.00 $304.00 $327.00 $329.0078452 --------- $525.00 $560.00 $566.00 $525.00 $560.00 $566.0078452-26 --------- $88.00 $91.00 $93.00 $88.00 $91.00 $93.0078452-TC --------- $437.00 $469.00 $473.00 $437.00 $469.00 $473.0078453 --------- $338.00 $361.00 $364.00 $338.00 $361.00 $364.0078453-26 --------- $55.00 $57.00 $59.00 $55.00 $57.00 $59.0078453-TC --------- $283.00 $304.00 $306.00 $283.00 $304.00 $306.0078454 --------- $485.00 $518.00 $523.00 $485.00 $518.00 $523.0078454-26 --------- $75.00 $77.00 $80.00 $75.00 $77.00 $80.0078454-TC --------- $411.00 $441.00 $444.00 $411.00 $441.00 $444.0078456 $205.00 $351.00 $374.00 $378.00 $351.00 $374.00 $378.0078456-26 $49.00 $54.00 $56.00 $57.00 $54.00 $56.00 $57.0078456-TC $151.00 $296.00 $318.00 $320.00 $296.00 $318.00 $320.0078457 $140.00 $210.00 $224.00 $228.00 $210.00 $224.00 $228.0078457-26 $39.00 $43.00 $45.00 $47.00 $43.00 $45.00 $47.0078457-TC $99.00 $166.00 $179.00 $180.00 $166.00 $179.00 $180.0078458 $198.00 $186.00 $198.00 $200.00 $186.00 $198.00 $200.0078458-26 $46.00 $43.00 $43.00 $44.00 $43.00 $43.00 $44.0078458-TC $149.00 $144.00 $155.00 $156.00 $144.00 $155.00 $156.0078459 BR $1,433.00 $1,534.00 $1,540.00 $1,433.00 $1,534.00 $1,540.00



Radiology







78459-26 $100.00 $79.00 $81.00 $83.00 $79.00 $81.00 $83.0078459-TC BR $1,353.00 $1,452.00 $1,457.00 $1,353.00 $1,452.00 $1,457.0078466 $135.00 $212.00 $226.00 $228.00 $212.00 $226.00 $228.0078466-26 $36.00 $39.00 $40.00 $41.00 $39.00 $40.00 $41.0078466-TC $97.00 $173.00 $186.00 $187.00 $173.00 $186.00 $187.0078468 $180.00 $220.00 $234.00 $237.00 $220.00 $234.00 $237.0078468-26 $41.00 $44.00 $45.00 $46.00 $44.00 $45.00 $46.0078468-TC $137.00 $176.00 $189.00 $191.00 $176.00 $189.00 $191.0078469 $244.00 $252.00 $268.00 $271.00 $252.00 $268.00 $271.0078469-26 $47.00 $51.00 $52.00 $54.00 $51.00 $52.00 $54.0078469-TC $195.00 $201.00 $216.00 $217.00 $201.00 $216.00 $217.0078472 $259.00 $255.00 $272.00 $275.00 $255.00 $272.00 $275.0078472-26 $50.00 $54.00 $55.00 $57.00 $54.00 $55.00 $57.0078472-TC $206.00 $202.00 $217.00 $218.00 $202.00 $217.00 $218.0078473 $387.00 $322.00 $342.00 $346.00 $322.00 $342.00 $346.0078473-26 $75.00 $80.00 $82.00 $84.00 $80.00 $82.00 $84.0078473-TC $308.00 $242.00 $260.00 $262.00 $242.00 $260.00 $262.0078481 $248.00 $194.00 $206.00 $208.00 $194.00 $206.00 $208.0078481-26 $51.00 $53.00 $55.00 $56.00 $53.00 $55.00 $56.0078481-TC $195.00 $141.00 $151.00 $152.00 $141.00 $151.00 $152.0078483 $373.00 $269.00 $285.00 $289.00 $269.00 $285.00 $289.0078483-26 $77.00 $80.00 $82.00 $84.00 $80.00 $82.00 $84.0078483-TC $294.00 $189.00 $204.00 $205.00 $189.00 $204.00 $205.0078491 BR $1,433.00 $1,534.00 $1,541.00 $1,433.00 $1,534.00 $1,541.0078491-26 $85.00 $80.00 $82.00 $84.00 $80.00 $82.00 $84.0078491-TC BR $1,353.00 $1,452.00 $1,457.00 $1,353.00 $1,452.00 $1,457.0078492 BR $1,453.00 $1,555.00 $1,562.00 $1,453.00 $1,555.00 $1,562.0078492-26 $100.00 $100.00 $103.00 $105.00 $100.00 $103.00 $105.0078492-TC BR $1,353.00 $1,452.00 $1,457.00 $1,353.00 $1,452.00 $1,457.0078494 $324.00 $250.00 $266.00 $269.00 $250.00 $266.00 $269.0078494-26 $59.00 $65.00 $67.00 $68.00 $65.00 $67.00 $68.0078494-TC $262.00 $185.00 $199.00 $201.00 $185.00 $199.00 $201.0078496 $92.00 $50.00 $52.00 $53.00 $50.00 $52.00 $53.0078496-26 $24.00 $27.00 $28.00 $29.00 $27.00 $28.00 $29.0078496-TC $66.00 $22.00 $24.00 $25.00 $22.00 $24.00 $25.0078499 BR --------- --------- --------- --------- --------- ---------78499-26 BR --------- --------- --------- --------- --------- ---------78499-TC BR --------- --------- --------- --------- --------- ---------78579 --------- $207.00 $221.00 $224.00 $207.00 $221.00 $224.0078579-26 --------- $26.00 $27.00 $28.00 $26.00 $27.00 $28.0078579-TC --------- $181.00 $194.00 $196.00 $181.00 $194.00 $196.0078580 $167.00 $266.00 $284.00 $287.00 $266.00 $284.00 $287.0078580-26 $38.00 $41.00 $42.00 $44.00 $41.00 $42.00 $44.0078580-TC $128.00 $225.00 $242.00 $243.00 $225.00 $242.00 $243.0078582 --------- $372.00 $398.00 $402.00 $372.00 $398.00 $402.0078582-26 --------- $59.00 $61.00 $63.00 $59.00 $61.00 $63.0078582-TC --------- $313.00 $337.00 $339.00 $313.00 $337.00 $339.0078597 --------- $225.00 $240.00 $242.00 $225.00 $240.00 $242.0078597-26 --------- $40.00 $41.00 $42.00 $40.00 $41.00 $42.0078597-TC --------- $185.00 $199.00 $200.00 $185.00 $199.00 $200.00



Radiology







78598 --------- $341.00 $364.00 $368.00 $341.00 $364.00 $368.0078598-26 --------- $47.00 $48.00 $49.00 $47.00 $48.00 $49.0078598-TC --------- $294.00 $316.00 $318.00 $294.00 $316.00 $318.0078599 BR --------- --------- --------- --------- --------- ---------78599-26 BR --------- --------- --------- --------- --------- ---------78599-TC BR --------- --------- --------- --------- --------- ---------78600 $131.00 $206.00 $220.00 $223.00 $206.00 $220.00 $223.0078600-26 $22.00 $25.00 $26.00 $27.00 $25.00 $26.00 $27.0078600-TC $108.00 $180.00 $194.00 $195.00 $180.00 $194.00 $195.0078601 $154.00 $237.00 $254.00 $256.00 $237.00 $254.00 $256.0078601-26 $26.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.0078601-TC $126.00 $209.00 $225.00 $226.00 $209.00 $225.00 $226.0078605 $155.00 $221.00 $236.00 $239.00 $221.00 $236.00 $239.0078605-26 $27.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.0078605-TC $126.00 $191.00 $205.00 $207.00 $191.00 $205.00 $207.0078606 $221.00 $367.00 $393.00 $396.00 $367.00 $393.00 $396.0078606-26 $45.00 $35.00 $36.00 $37.00 $35.00 $36.00 $37.0078606-TC $177.00 $332.00 $356.00 $359.00 $332.00 $356.00 $359.0078607 $311.00 $390.00 $416.00 $420.00 $390.00 $416.00 $420.0078607-26 $64.00 $66.00 $68.00 $70.00 $66.00 $68.00 $70.0078607-TC $245.00 $323.00 $348.00 $350.00 $323.00 $348.00 $350.0078608 BR $1,434.00 $1,535.00 $1,542.00 $1,434.00 $1,535.00 $1,542.0078608-26 --------- $80.00 $83.00 $85.00 $80.00 $83.00 $85.0078608-TC --------- $1,353.00 $1,452.00 $1,457.00 $1,353.00 $1,452.00 $1,457.0078609 BR $83.00 $85.00 $86.00 $83.00 $85.00 $86.0078609-26 --------- $83.00 $85.00 $86.00 $83.00 $85.00 $86.0078609-TC --------- BR BR BR BR BR BR78610 $74.00 $194.00 $208.00 $210.00 $194.00 $208.00 $210.0078610-26 $15.00 $17.00 $18.00 $18.00 $17.00 $18.00 $18.0078610-TC $59.00 $177.00 $190.00 $192.00 $177.00 $190.00 $192.0078630 $223.00 $375.00 $402.00 $405.00 $375.00 $402.00 $405.0078630-26 $35.00 $38.00 $39.00 $40.00 $38.00 $39.00 $40.0078630-TC $188.00 $337.00 $363.00 $365.00 $337.00 $363.00 $365.0078635 $129.00 $375.00 $402.00 $405.00 $375.00 $402.00 $405.0078635-26 $32.00 $34.00 $35.00 $36.00 $34.00 $35.00 $36.0078635-TC $95.00 $341.00 $367.00 $369.00 $341.00 $367.00 $369.0078645 $158.00 $358.00 $383.00 $386.00 $358.00 $383.00 $386.0078645-26 $29.00 $31.00 $32.00 $33.00 $31.00 $32.00 $33.0078645-TC $128.00 $326.00 $351.00 $353.00 $326.00 $351.00 $353.0078647 $268.00 $388.00 $415.00 $419.00 $388.00 $415.00 $419.0078647-26 $46.00 $51.00 $52.00 $54.00 $51.00 $52.00 $54.0078647-TC $220.00 $338.00 $363.00 $365.00 $338.00 $363.00 $365.0078650 $206.00 $365.00 $391.00 $394.00 $365.00 $391.00 $394.0078650-26 $31.00 $34.00 $35.00 $36.00 $34.00 $35.00 $36.0078650-TC $173.00 $331.00 $356.00 $358.00 $331.00 $356.00 $358.0078660 $107.00 $200.00 $214.00 $216.00 $200.00 $214.00 $216.0078660-26 $27.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.0078660-TC $79.00 $170.00 $183.00 $184.00 $170.00 $183.00 $184.0078699 BR --------- --------- --------- --------- --------- ---------78699-26 BR --------- --------- --------- --------- --------- ---------



Radiology







78699-TC BR --------- --------- --------- --------- --------- ---------78700 $137.00 $191.00 $204.00 $206.00 $191.00 $204.00 $206.0078700-26 $22.00 $25.00 $26.00 $26.00 $25.00 $26.00 $26.0078700-TC $113.00 $166.00 $178.00 $180.00 $166.00 $178.00 $180.0078701 $158.00 $234.00 $250.00 $252.00 $234.00 $250.00 $252.0078701-26 $24.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.0078701-TC $133.00 $207.00 $223.00 $224.00 $207.00 $223.00 $224.0078707 $217.00 $259.00 $276.00 $279.00 $259.00 $276.00 $279.0078707-26 $49.00 $52.00 $54.00 $56.00 $52.00 $54.00 $56.0078707-TC $166.00 $206.00 $221.00 $223.00 $206.00 $221.00 $223.0078708 $231.00 $195.00 $207.00 $210.00 $195.00 $207.00 $210.0078708-26 $61.00 $66.00 $68.00 $70.00 $66.00 $68.00 $70.0078708-TC $166.00 $128.00 $138.00 $140.00 $128.00 $138.00 $140.0078709 $241.00 $404.00 $431.00 $435.00 $404.00 $431.00 $435.0078709-26 $68.00 $77.00 $79.00 $82.00 $77.00 $79.00 $82.0078709-TC $166.00 $327.00 $352.00 $354.00 $327.00 $352.00 $354.0078710 $256.00 $222.00 $237.00 $240.00 $222.00 $237.00 $240.0078710-26 $34.00 $34.00 $35.00 $36.00 $34.00 $35.00 $36.0078710-TC $220.00 $188.00 $202.00 $204.00 $188.00 $202.00 $204.0078725 $87.00 $121.00 $129.00 $131.00 $121.00 $129.00 $131.0078725-26 $19.00 $21.00 $21.00 $22.00 $21.00 $21.00 $22.0078725-TC $66.00 $100.00 $108.00 $109.00 $100.00 $108.00 $109.0078730 $73.00 $84.00 $90.00 $91.00 $84.00 $90.00 $91.0078730-26 $18.00 $9.00 $9.00 $9.00 $9.00 $9.00 $9.0078730-TC $55.00 $76.00 $81.00 $82.00 $76.00 $81.00 $82.0078740 $109.00 $242.00 $258.00 $260.00 $242.00 $258.00 $260.0078740-26 $29.00 $31.00 $32.00 $32.00 $31.00 $32.00 $32.0078740-TC $79.00 $211.00 $227.00 $228.00 $211.00 $227.00 $228.0078761 $157.00 $232.00 $248.00 $250.00 $232.00 $248.00 $250.0078761-26 $36.00 $40.00 $42.00 $43.00 $40.00 $42.00 $43.0078761-TC $119.00 $192.00 $206.00 $208.00 $192.00 $206.00 $208.0078799 BR --------- --------- --------- --------- --------- ---------78799-26 BR --------- --------- --------- --------- --------- ---------78799-TC BR --------- --------- --------- --------- --------- ---------78800 $162.00 $213.00 $228.00 $231.00 $213.00 $228.00 $231.0078800-26 $34.00 $38.00 $40.00 $42.00 $38.00 $40.00 $42.0078800-TC $126.00 $175.00 $188.00 $189.00 $175.00 $188.00 $189.0078801 $199.00 $290.00 $310.00 $314.00 $290.00 $310.00 $314.0078801-26 $40.00 $45.00 $47.00 $49.00 $45.00 $47.00 $49.0078801-TC $158.00 $245.00 $263.00 $265.00 $245.00 $263.00 $265.0078802 $252.00 $361.00 $385.00 $389.00 $361.00 $385.00 $389.0078802-26 $44.00 $47.00 $48.00 $50.00 $47.00 $48.00 $50.0078802-TC $207.00 $314.00 $337.00 $339.00 $314.00 $337.00 $339.0078803 $303.00 $378.00 $403.00 $407.00 $378.00 $403.00 $407.0078803-26 $56.00 $58.00 $60.00 $62.00 $58.00 $60.00 $62.0078803-TC $245.00 $319.00 $343.00 $345.00 $319.00 $343.00 $345.0078804 --------- $628.00 $673.00 $678.00 $628.00 $673.00 $678.0078804-26 --------- $58.00 $60.00 $62.00 $58.00 $60.00 $62.0078804-TC --------- $570.00 $612.00 $616.00 $570.00 $612.00 $616.0078805 $166.00 $203.00 $216.00 $219.00 $203.00 $216.00 $219.00



Radiology







78805-26 $38.00 $40.00 $42.00 $43.00 $40.00 $42.00 $43.0078805-TC $126.00 $163.00 $175.00 $176.00 $163.00 $175.00 $176.0078806 $286.00 $370.00 $395.00 $399.00 $370.00 $395.00 $399.0078806-26 $44.00 $47.00 $48.00 $50.00 $47.00 $48.00 $50.0078806-TC $241.00 $323.00 $347.00 $349.00 $323.00 $347.00 $349.0078807 $303.00 $378.00 $403.00 $407.00 $378.00 $403.00 $407.0078807-26 $57.00 $58.00 $60.00 $61.00 $58.00 $60.00 $61.0078807-TC $245.00 $320.00 $343.00 $346.00 $320.00 $343.00 $346.0078808 --------- $50.00 $54.00 $55.00 $50.00 $54.00 $55.0078811 --------- $1,440.00 $1,542.00 $1,549.00 $1,440.00 $1,542.00 $1,549.0078811-26 --------- $87.00 $90.00 $93.00 $87.00 $90.00 $93.0078811-TC --------- $1,353.00 $1,452.00 $1,457.00 $1,353.00 $1,452.00 $1,457.0078812 --------- $1,459.00 $1,561.00 $1,568.00 $1,459.00 $1,561.00 $1,568.0078812-26 --------- $105.00 $108.00 $111.00 $105.00 $108.00 $111.0078812-TC --------- $1,353.00 $1,452.00 $1,457.00 $1,353.00 $1,452.00 $1,457.0078813 --------- $1,463.00 $1,566.00 $1,573.00 $1,463.00 $1,566.00 $1,573.0078813-26 --------- $110.00 $114.00 $117.00 $110.00 $114.00 $117.0078813-TC --------- $1,353.00 $1,452.00 $1,457.00 $1,353.00 $1,452.00 $1,457.0078814 --------- $1,475.00 $1,577.00 $1,585.00 $1,475.00 $1,577.00 $1,585.0078814-26 --------- $121.00 $125.00 $129.00 $121.00 $125.00 $129.0078814-TC --------- $1,353.00 $1,452.00 $1,457.00 $1,353.00 $1,452.00 $1,457.0078815 --------- $1,487.00 $1,590.00 $1,599.00 $1,487.00 $1,590.00 $1,599.0078815-26 --------- $134.00 $138.00 $142.00 $134.00 $138.00 $142.0078815-TC --------- $1,353.00 $1,452.00 $1,457.00 $1,353.00 $1,452.00 $1,457.0078816 --------- $1,489.00 $1,592.00 $1,600.00 $1,489.00 $1,592.00 $1,600.0078816-26 --------- $135.00 $139.00 $143.00 $135.00 $139.00 $143.0078816-TC --------- $1,353.00 $1,452.00 $1,457.00 $1,353.00 $1,452.00 $1,457.0078999 BR --------- --------- --------- --------- --------- ---------78999-26 BR --------- --------- --------- --------- --------- ---------78999-TC BR --------- --------- --------- --------- --------- ---------79005 --------- $151.00 $158.00 $162.00 $151.00 $158.00 $162.0079005-26 --------- $98.00 $101.00 $104.00 $98.00 $101.00 $104.0079005-TC --------- $53.00 $57.00 $58.00 $53.00 $57.00 $58.0079101 --------- $158.00 $165.00 $168.00 $158.00 $165.00 $168.0079101-26 --------- $107.00 $110.00 $112.00 $107.00 $110.00 $112.0079101-TC --------- $51.00 $55.00 $55.00 $51.00 $55.00 $55.0079200 $203.00 $176.00 $185.00 $188.00 $176.00 $185.00 $188.0079200-26 $102.00 $114.00 $117.00 $120.00 $114.00 $117.00 $120.0079200-TC $97.00 $63.00 $67.00 $68.00 $63.00 $67.00 $68.0079300 BR --------- --------- --------- --------- --------- ---------79300-26 $83.00 $89.00 $91.00 $93.00 $89.00 $91.00 $93.0079300-TC BR --------- --------- --------- --------- --------- ---------79403 --------- $213.00 $223.00 $227.00 $213.00 $223.00 $227.0079403-26 --------- $124.00 $128.00 $131.00 $124.00 $128.00 $131.0079403-TC --------- $89.00 $95.00 $97.00 $89.00 $95.00 $97.0079440 $204.00 $160.00 $167.00 $170.00 $160.00 $167.00 $170.0079440-26 $104.00 $106.00 $109.00 $111.00 $106.00 $109.00 $111.0079440-TC $97.00 $54.00 $58.00 $58.00 $54.00 $58.00 $58.0079445 --------- BR BR BR BR BR BR79445-26 --------- $129.00 $133.00 $137.00 $129.00 $133.00 $137.00



Radiology







79445-TC --------- BR BR BR BR BR BR79999 BR --------- --------- --------- --------- --------- ---------79999-26 BR --------- --------- --------- --------- --------- ---------79999-TC BR --------- --------- --------- --------- --------- ---------G0130 --------- $37.00 $39.00 $40.00 $37.00 $39.00 $40.00G0130-26 --------- $13.00 $13.00 $13.00 $13.00 $13.00 $13.00G0130-TC --------- $24.00 $26.00 $27.00 $24.00 $26.00 $27.00G0202 --------- $144.00 $153.00 $155.00 $144.00 $153.00 $155.00G0202-26 --------- $39.00 $40.00 $42.00 $39.00 $40.00 $42.00G0202-TC --------- $105.00 $113.00 $114.00 $105.00 $113.00 $114.00G0204 --------- $177.00 $188.00 $190.00 $177.00 $188.00 $190.00G0204-26 --------- $49.00 $51.00 $52.00 $49.00 $51.00 $52.00G0204-TC --------- $128.00 $137.00 $138.00 $128.00 $137.00 $138.00G0206 --------- $139.00 $147.00 $149.00 $139.00 $147.00 $149.00G0206-26 --------- $39.00 $40.00 $42.00 $39.00 $40.00 $42.00G0206-TC --------- $100.00 $107.00 $108.00 $100.00 $107.00 $108.00G0252-26 --------- $83.00 $85.00 $86.00 $83.00 $85.00 $86.00G0278 --------- $16.00 $18.00 $19.00 $16.00 $18.00 $19.00G0279 --------- $60.00 $63.00 $64.00 $60.00 $63.00 $64.00G0279-26 --------- $34.00 $35.00 $36.00 $34.00 $35.00 $36.00G0279-TC --------- $27.00 $29.00 $29.00 $27.00 $29.00 $29.00G0288 --------- $40.00 $44.00 $47.00 $40.00 $44.00 $47.00G0297 --------- $271.00 $289.00 $291.00 $271.00 $289.00 $291.00G0297-26 --------- $56.00 $58.00 $59.00 $56.00 $58.00 $59.00G0297-TC --------- $215.00 $231.00 $232.00 $215.00 $231.00 $232.00G0365 --------- $176.00 $189.00 $191.00 $176.00 $189.00 $191.00G0365-26 --------- $14.00 $15.00 $16.00 $14.00 $15.00 $16.00G0365-TC --------- $162.00 $174.00 $175.00 $162.00 $174.00 $175.00G0389 --------- $125.00 $133.00 $135.00 $125.00 $133.00 $135.00G0389-26 --------- $33.00 $34.00 $35.00 $33.00 $34.00 $35.00G0389-TC --------- $92.00 $99.00 $100.00 $92.00 $99.00 $100.00G6001 --------- $57.00 $59.00 $60.00 $57.00 $59.00 $60.00G6001-26 --------- $33.00 $34.00 $35.00 $33.00 $34.00 $35.00G6001-TC --------- $24.00 $25.00 $26.00 $24.00 $25.00 $26.00G6002 --------- $81.00 $86.00 $87.00 $81.00 $86.00 $87.00G6002-26 --------- $22.00 $23.00 $24.00 $22.00 $23.00 $24.00G6002-TC --------- $59.00 $63.00 $64.00 $59.00 $63.00 $64.00G6003 --------- $199.00 $214.00 $215.00 $199.00 $214.00 $215.00G6004 --------- $154.00 $165.00 $166.00 $154.00 $165.00 $166.00G6005 --------- $154.00 $165.00 $166.00 $154.00 $165.00 $166.00G6006 --------- $153.00 $165.00 $165.00 $153.00 $165.00 $165.00G6007 --------- $320.00 $343.00 $345.00 $320.00 $343.00 $345.00G6008 --------- $213.00 $229.00 $230.00 $213.00 $229.00 $230.00G6009 --------- $211.00 $226.00 $227.00 $211.00 $226.00 $227.00G6010 --------- $210.00 $226.00 $227.00 $210.00 $226.00 $227.00G6011 --------- $342.00 $367.00 $368.00 $342.00 $367.00 $368.00G6012 --------- $281.00 $301.00 $302.00 $281.00 $301.00 $302.00G6013 --------- $281.00 $302.00 $303.00 $281.00 $302.00 $303.00G6014 --------- $281.00 $302.00 $303.00 $281.00 $302.00 $303.00G6015 --------- $367.00 $395.00 $397.00 $367.00 $395.00 $397.00



Radiology







G6016 --------- $366.00 $393.00 $394.00 $366.00 $393.00 $394.00Q0092 --------- $27.00 $29.00 $29.00 $27.00 $29.00 $29.00



Pathology & Laboratory







80048 $23.00 --------- --------- --------- --------- --------- ---------80048-26 $4.00 --------- --------- --------- --------- --------- ---------80048-TC $19.00 --------- --------- --------- --------- --------- ---------80050 $45.00 --------- --------- --------- --------- --------- ---------80050-26 $18.00 --------- --------- --------- --------- --------- ---------80050-TC $26.00 --------- --------- --------- --------- --------- ---------80051 $16.00 --------- --------- --------- --------- --------- ---------80051-26 $6.00 --------- --------- --------- --------- --------- ---------80051-TC $10.00 --------- --------- --------- --------- --------- ---------80053 $29.00 --------- --------- --------- --------- --------- ---------80053-26 $8.00 --------- --------- --------- --------- --------- ---------80053-TC $21.00 --------- --------- --------- --------- --------- ---------80055 $67.00 --------- --------- --------- --------- --------- ---------80055-26 $21.00 --------- --------- --------- --------- --------- ---------80055-TC $43.00 --------- --------- --------- --------- --------- ---------80061 $31.00 --------- --------- --------- --------- --------- ---------80061-26 $11.00 --------- --------- --------- --------- --------- ---------80061-TC $19.00 --------- --------- --------- --------- --------- ---------80069 $26.00 --------- --------- --------- --------- --------- ---------80069-26 $6.00 --------- --------- --------- --------- --------- ---------80069-TC $20.00 --------- --------- --------- --------- --------- ---------80074 $107.00 --------- --------- --------- --------- --------- ---------80074-26 $43.00 --------- --------- --------- --------- --------- ---------80074-TC $64.00 --------- --------- --------- --------- --------- ---------80076 $18.00 --------- --------- --------- --------- --------- ---------80076-26 $7.00 --------- --------- --------- --------- --------- ---------80076-TC $11.00 --------- --------- --------- --------- --------- ---------80150 $40.00 --------- --------- --------- --------- --------- ---------80150-26 $13.00 --------- --------- --------- --------- --------- ---------80150-TC $26.00 --------- --------- --------- --------- --------- ---------80156 $35.00 --------- --------- --------- --------- --------- ---------80156-26 $11.00 --------- --------- --------- --------- --------- ---------80156-TC $23.00 --------- --------- --------- --------- --------- ---------80157 $22.00 --------- --------- --------- --------- --------- ---------80157-26 $8.00 --------- --------- --------- --------- --------- ---------80157-TC $14.00 --------- --------- --------- --------- --------- ---------80158 $35.00 --------- --------- --------- --------- --------- ---------80158-26 $12.00 --------- --------- --------- --------- --------- ---------80158-TC $22.00 --------- --------- --------- --------- --------- ---------80162 $13.00 --------- --------- --------- --------- --------- ---------80162-26 $3.00 --------- --------- --------- --------- --------- ---------80162-TC $9.00 --------- --------- --------- --------- --------- ---------80164 $43.00 --------- --------- --------- --------- --------- ---------80164-26 $14.00 --------- --------- --------- --------- --------- ---------80164-TC $29.00 --------- --------- --------- --------- --------- ---------80168 $43.00 --------- --------- --------- --------- --------- ---------80168-26 $17.00 --------- --------- --------- --------- --------- ---------80168-TC $25.00 --------- --------- --------- --------- --------- ---------80170 $18.00 --------- --------- --------- --------- --------- ---------80170-26 $6.00 --------- --------- --------- --------- --------- ---------










80170-TC $11.00 --------- --------- --------- --------- --------- ---------80173 $33.00 --------- --------- --------- --------- --------- ---------80173-26 $11.00 --------- --------- --------- --------- --------- ---------80173-TC $22.00 --------- --------- --------- --------- --------- ---------80176 $35.00 --------- --------- --------- --------- --------- ---------80176-26 $11.00 --------- --------- --------- --------- --------- ---------80176-TC $23.00 --------- --------- --------- --------- --------- ---------80178 $17.00 --------- --------- --------- --------- --------- ---------80178-26 $6.00 --------- --------- --------- --------- --------- ---------80178-TC $11.00 --------- --------- --------- --------- --------- ---------80184 $34.00 --------- --------- --------- --------- --------- ---------80184-26 $10.00 --------- --------- --------- --------- --------- ---------80184-TC $23.00 --------- --------- --------- --------- --------- ---------80185 $36.00 --------- --------- --------- --------- --------- ---------80185-26 $10.00 --------- --------- --------- --------- --------- ---------80185-TC $25.00 --------- --------- --------- --------- --------- ---------80186 $38.00 --------- --------- --------- --------- --------- ---------80186-26 $11.00 --------- --------- --------- --------- --------- ---------80186-TC $26.00 --------- --------- --------- --------- --------- ---------80188 $35.00 --------- --------- --------- --------- --------- ---------80188-26 $11.00 --------- --------- --------- --------- --------- ---------80188-TC $23.00 --------- --------- --------- --------- --------- ---------80190 $41.00 --------- --------- --------- --------- --------- ---------80190-26 $13.00 --------- --------- --------- --------- --------- ---------80190-TC $28.00 --------- --------- --------- --------- --------- ---------80192 $44.00 --------- --------- --------- --------- --------- ---------80192-26 $17.00 --------- --------- --------- --------- --------- ---------80192-TC $26.00 --------- --------- --------- --------- --------- ---------80194 $33.00 --------- --------- --------- --------- --------- ---------80194-26 $10.00 --------- --------- --------- --------- --------- ---------80194-TC $22.00 --------- --------- --------- --------- --------- ---------80197 $34.00 --------- --------- --------- --------- --------- ---------80197-26 $11.00 --------- --------- --------- --------- --------- ---------80197-TC $22.00 --------- --------- --------- --------- --------- ---------80198 $20.00 --------- --------- --------- --------- --------- ---------80198-26 $5.00 --------- --------- --------- --------- --------- ---------80198-TC $15.00 --------- --------- --------- --------- --------- ---------80200 $24.00 --------- --------- --------- --------- --------- ---------80200-26 $7.00 --------- --------- --------- --------- --------- ---------80200-TC $16.00 --------- --------- --------- --------- --------- ---------80201 $33.00 --------- --------- --------- --------- --------- ---------80201-26 $11.00 --------- --------- --------- --------- --------- ---------80201-TC $21.00 --------- --------- --------- --------- --------- ---------80202 $42.00 --------- --------- --------- --------- --------- ---------80202-26 $14.00 --------- --------- --------- --------- --------- ---------80202-TC $28.00 --------- --------- --------- --------- --------- ---------80299 BR --------- --------- --------- --------- --------- ---------80299-26 BR --------- --------- --------- --------- --------- ---------80299-TC BR --------- --------- --------- --------- --------- ---------80400 $54.00 --------- --------- --------- --------- --------- ---------










80400-26 $18.00 --------- --------- --------- --------- --------- ---------80400-TC $36.00 --------- --------- --------- --------- --------- ---------80402 $138.00 --------- --------- --------- --------- --------- ---------80402-26 $42.00 --------- --------- --------- --------- --------- ---------80402-TC $95.00 --------- --------- --------- --------- --------- ---------80406 $138.00 --------- --------- --------- --------- --------- ---------80406-26 $42.00 --------- --------- --------- --------- --------- ---------80406-TC $95.00 --------- --------- --------- --------- --------- ---------80408 $213.00 --------- --------- --------- --------- --------- ---------80408-26 $77.00 --------- --------- --------- --------- --------- ---------80408-TC $136.00 --------- --------- --------- --------- --------- ---------80410 $166.00 --------- --------- --------- --------- --------- ---------80410-26 $54.00 --------- --------- --------- --------- --------- ---------80410-TC $110.00 --------- --------- --------- --------- --------- ---------80412 $533.00 --------- --------- --------- --------- --------- ---------80412-26 $176.00 --------- --------- --------- --------- --------- ---------80412-TC $355.00 --------- --------- --------- --------- --------- ---------80414 $88.00 --------- --------- --------- --------- --------- ---------80414-26 $26.00 --------- --------- --------- --------- --------- ---------80414-TC $59.00 --------- --------- --------- --------- --------- ---------80415 $93.00 --------- --------- --------- --------- --------- ---------80415-26 $28.00 --------- --------- --------- --------- --------- ---------80415-TC $64.00 --------- --------- --------- --------- --------- ---------80416 $256.00 --------- --------- --------- --------- --------- ---------80416-26 $88.00 --------- --------- --------- --------- --------- ---------80416-TC $166.00 --------- --------- --------- --------- --------- ---------80417 $256.00 --------- --------- --------- --------- --------- ---------80417-26 $88.00 --------- --------- --------- --------- --------- ---------80417-TC $166.00 --------- --------- --------- --------- --------- ---------80418 $934.00 --------- --------- --------- --------- --------- ---------80418-26 $266.00 --------- --------- --------- --------- --------- ---------80418-TC $666.00 --------- --------- --------- --------- --------- ---------80420 $107.00 --------- --------- --------- --------- --------- ---------80420-26 $33.00 --------- --------- --------- --------- --------- ---------80420-TC $74.00 --------- --------- --------- --------- --------- ---------80422 $62.00 --------- --------- --------- --------- --------- ---------80422-26 $18.00 --------- --------- --------- --------- --------- ---------80422-TC $43.00 --------- --------- --------- --------- --------- ---------80424 $94.00 --------- --------- --------- --------- --------- ---------80424-26 $26.00 --------- --------- --------- --------- --------- ---------80424-TC $67.00 --------- --------- --------- --------- --------- ---------80426 $232.00 --------- --------- --------- --------- --------- ---------80426-26 $54.00 --------- --------- --------- --------- --------- ---------80426-TC $176.00 --------- --------- --------- --------- --------- ---------80428 $93.00 --------- --------- --------- --------- --------- ---------80428-26 $19.00 --------- --------- --------- --------- --------- ---------80428-TC $73.00 --------- --------- --------- --------- --------- ---------80430 $99.00 --------- --------- --------- --------- --------- ---------80430-26 $24.00 --------- --------- --------- --------- --------- ---------80430-TC $74.00 --------- --------- --------- --------- --------- ---------










80432 $243.00 --------- --------- --------- --------- --------- ---------80432-26 $56.00 --------- --------- --------- --------- --------- ---------80432-TC $186.00 --------- --------- --------- --------- --------- ---------80434 $161.00 --------- --------- --------- --------- --------- ---------80434-26 $49.00 --------- --------- --------- --------- --------- ---------80434-TC $110.00 --------- --------- --------- --------- --------- ---------80435 $166.00 --------- --------- --------- --------- --------- ---------80435-26 $49.00 --------- --------- --------- --------- --------- ---------80435-TC $115.00 --------- --------- --------- --------- --------- ---------80436 $119.00 --------- --------- --------- --------- --------- ---------80436-26 $35.00 --------- --------- --------- --------- --------- ---------80436-TC $85.00 --------- --------- --------- --------- --------- ---------80438 $82.00 --------- --------- --------- --------- --------- ---------80438-26 $24.00 --------- --------- --------- --------- --------- ---------80438-TC $56.00 --------- --------- --------- --------- --------- ---------80439 $176.00 --------- --------- --------- --------- --------- ---------80439-26 $33.00 --------- --------- --------- --------- --------- ---------80439-TC $144.00 --------- --------- --------- --------- --------- ---------80500 $34.00 $24.00 $25.00 $26.00 $22.00 $22.00 $23.0080500-26 $34.00 --------- --------- --------- --------- --------- ---------80500-TC BR --------- --------- --------- --------- --------- ---------80502 $72.00 $79.00 $82.00 $84.00 $77.00 $79.00 $81.0080502-26 $72.00 --------- --------- --------- --------- --------- ---------80502-TC BR --------- --------- --------- --------- --------- ---------81000 $7.00 --------- --------- --------- --------- --------- ---------81000-26 $3.00 --------- --------- --------- --------- --------- ---------81000-TC $4.00 --------- --------- --------- --------- --------- ---------81001 $7.00 --------- --------- --------- --------- --------- ---------81001-26 $3.00 --------- --------- --------- --------- --------- ---------81001-TC $4.00 --------- --------- --------- --------- --------- ---------81002 $5.00 --------- --------- --------- --------- --------- ---------81002-26 $3.00 --------- --------- --------- --------- --------- ---------81002-TC $3.00 --------- --------- --------- --------- --------- ---------81003 $5.00 --------- --------- --------- --------- --------- ---------81003-26 $2.00 --------- --------- --------- --------- --------- ---------81003-TC $3.00 --------- --------- --------- --------- --------- ---------81005 $3.00 --------- --------- --------- --------- --------- ---------81005-26 $1.00 --------- --------- --------- --------- --------- ---------81005-TC $3.00 --------- --------- --------- --------- --------- ---------81007 $5.00 --------- --------- --------- --------- --------- ---------81007-26 $2.00 --------- --------- --------- --------- --------- ---------81007-TC $4.00 --------- --------- --------- --------- --------- ---------81015 $5.00 --------- --------- --------- --------- --------- ---------81015-26 $3.00 --------- --------- --------- --------- --------- ---------81015-TC $3.00 --------- --------- --------- --------- --------- ---------81020 $8.00 --------- --------- --------- --------- --------- ---------81020-26 $3.00 --------- --------- --------- --------- --------- ---------81020-TC $5.00 --------- --------- --------- --------- --------- ---------81025 $7.00 --------- --------- --------- --------- --------- ---------81025-26 $4.00 --------- --------- --------- --------- --------- ---------










81025-TC $4.00 --------- --------- --------- --------- --------- ---------81050 $33.00 --------- --------- --------- --------- --------- ---------81050-26 $11.00 --------- --------- --------- --------- --------- ---------81050-TC $21.00 --------- --------- --------- --------- --------- ---------81099 BR --------- --------- --------- --------- --------- ---------81099-26 BR --------- --------- --------- --------- --------- ---------81099-TC BR --------- --------- --------- --------- --------- ---------82009 $10.00 --------- --------- --------- --------- --------- ---------82009-26 $3.00 --------- --------- --------- --------- --------- ---------82009-TC $6.00 --------- --------- --------- --------- --------- ---------82010 $22.00 --------- --------- --------- --------- --------- ---------82010-26 $7.00 --------- --------- --------- --------- --------- ---------82010-TC $15.00 --------- --------- --------- --------- --------- ---------82013 $24.00 --------- --------- --------- --------- --------- ---------82013-26 $7.00 --------- --------- --------- --------- --------- ---------82013-TC $17.00 --------- --------- --------- --------- --------- ---------82024 $26.00 --------- --------- --------- --------- --------- ---------82024-26 $7.00 --------- --------- --------- --------- --------- ---------82024-TC $18.00 --------- --------- --------- --------- --------- ---------82030 $43.00 --------- --------- --------- --------- --------- ---------82030-26 $17.00 --------- --------- --------- --------- --------- ---------82030-TC $25.00 --------- --------- --------- --------- --------- ---------82040 $11.00 --------- --------- --------- --------- --------- ---------82040-26 $3.00 --------- --------- --------- --------- --------- ---------82040-TC $7.00 --------- --------- --------- --------- --------- ---------82042 $12.00 --------- --------- --------- --------- --------- ---------82042-26 $3.00 --------- --------- --------- --------- --------- ---------82042-TC $8.00 --------- --------- --------- --------- --------- ---------82043 $14.00 --------- --------- --------- --------- --------- ---------82043-26 $4.00 --------- --------- --------- --------- --------- ---------82043-TC $10.00 --------- --------- --------- --------- --------- ---------82044 $12.00 --------- --------- --------- --------- --------- ---------82044-26 $4.00 --------- --------- --------- --------- --------- ---------82044-TC $9.00 --------- --------- --------- --------- --------- ---------82075 $32.00 --------- --------- --------- --------- --------- ---------82075-26 $10.00 --------- --------- --------- --------- --------- ---------82075-TC $21.00 --------- --------- --------- --------- --------- ---------82085 $24.00 --------- --------- --------- --------- --------- ---------82085-26 $7.00 --------- --------- --------- --------- --------- ---------82085-TC $17.00 --------- --------- --------- --------- --------- ---------82088 $91.00 --------- --------- --------- --------- --------- ---------82088-26 $28.00 --------- --------- --------- --------- --------- ---------82088-TC $62.00 --------- --------- --------- --------- --------- ---------82103 $21.00 --------- --------- --------- --------- --------- ---------82103-26 $7.00 --------- --------- --------- --------- --------- ---------82103-TC $14.00 --------- --------- --------- --------- --------- ---------82104 $22.00 --------- --------- --------- --------- --------- ---------82104-26 $7.00 --------- --------- --------- --------- --------- ---------82104-TC $15.00 --------- --------- --------- --------- --------- ---------82105 $26.00 --------- --------- --------- --------- --------- ---------










82164 $32.00 --------- --------- --------- --------- --------- ---------82164-26 $10.00 --------- --------- --------- --------- --------- ---------82164-TC $21.00 --------- --------- --------- --------- --------- ---------82172 $33.00 --------- --------- --------- --------- --------- ---------82172-26 $10.00 --------- --------- --------- --------- --------- ---------82172-TC $22.00 --------- --------- --------- --------- --------- ---------82175 $48.00 --------- --------- --------- --------- --------- ---------82175-26 $15.00 --------- --------- --------- --------- --------- ---------82175-TC $33.00 --------- --------- --------- --------- --------- ---------82180 $25.00 --------- --------- --------- --------- --------- ---------82180-26 $8.00 --------- --------- --------- --------- --------- ---------82180-TC $17.00 --------- --------- --------- --------- --------- ---------82190 $24.00 --------- --------- --------- --------- --------- ---------82190-26 $8.00 --------- --------- --------- --------- --------- ---------82190-TC $16.00 --------- --------- --------- --------- --------- ---------82232 $43.00 --------- --------- --------- --------- --------- ---------82232-26 $14.00 --------- --------- --------- --------- --------- ---------82232-TC $29.00 --------- --------- --------- --------- --------- ---------82239 $23.00 --------- --------- --------- --------- --------- ---------82239-26 $8.00 --------- --------- --------- --------- --------- ---------82239-TC $15.00 --------- --------- --------- --------- --------- ---------82240 $49.00 --------- --------- --------- --------- --------- ---------82240-26 $15.00 --------- --------- --------- --------- --------- ---------82240-TC $34.00 --------- --------- --------- --------- --------- ---------82247 $10.00 --------- --------- --------- --------- --------- ---------82247-26 $3.00 --------- --------- --------- --------- --------- ---------82247-TC $7.00 --------- --------- --------- --------- --------- ---------82248 $10.00 --------- --------- --------- --------- --------- ---------82248-26 $3.00 --------- --------- --------- --------- --------- ---------82248-TC $7.00 --------- --------- --------- --------- --------- ---------82252 $11.00 --------- --------- --------- --------- --------- ---------82252-26 $3.00 --------- --------- --------- --------- --------- ---------82252-TC $7.00 --------- --------- --------- --------- --------- ---------82261 $38.00 --------- --------- --------- --------- --------- ---------82261-26 $13.00 --------- --------- --------- --------- --------- ---------82261-TC $24.00 --------- --------- --------- --------- --------- ---------82270 $5.00 --------- --------- --------- --------- --------- ---------82270-26 $2.00 --------- --------- --------- --------- --------- ---------82270-TC $3.00 --------- --------- --------- --------- --------- ---------82274 BR --------- --------- --------- --------- --------- ---------82274-26 BR --------- --------- --------- --------- --------- ---------82274-TC BR --------- --------- --------- --------- --------- ---------82286 $12.00 --------- --------- --------- --------- --------- ---------82286-26 $3.00 --------- --------- --------- --------- --------- ---------82286-TC $8.00 --------- --------- --------- --------- --------- ---------82300 $48.00 --------- --------- --------- --------- --------- ---------82300-26 $15.00 --------- --------- --------- --------- --------- ---------82300-TC $33.00 --------- --------- --------- --------- --------- ---------82306 $79.00 --------- --------- --------- --------- --------- ---------82306-26 $25.00 --------- --------- --------- --------- --------- ---------










82306-TC $52.00 --------- --------- --------- --------- --------- ---------82308 $62.00 --------- --------- --------- --------- --------- ---------82308-26 $18.00 --------- --------- --------- --------- --------- ---------82308-TC $43.00 --------- --------- --------- --------- --------- ---------82310 $11.00 --------- --------- --------- --------- --------- ---------82310-26 $3.00 --------- --------- --------- --------- --------- ---------82310-TC $7.00 --------- --------- --------- --------- --------- ---------82330 $37.00 --------- --------- --------- --------- --------- ---------82330-26 $11.00 --------- --------- --------- --------- --------- ---------82330-TC $25.00 --------- --------- --------- --------- --------- ---------82331 $14.00 --------- --------- --------- --------- --------- ---------82331-26 $4.00 --------- --------- --------- --------- --------- ---------82331-TC $10.00 --------- --------- --------- --------- --------- ---------82340 $13.00 --------- --------- --------- --------- --------- ---------82340-26 $4.00 --------- --------- --------- --------- --------- ---------82340-TC $8.00 --------- --------- --------- --------- --------- ---------82355 $31.00 --------- --------- --------- --------- --------- ---------82355-26 $10.00 --------- --------- --------- --------- --------- ---------82355-TC $20.00 --------- --------- --------- --------- --------- ---------82360 $31.00 --------- --------- --------- --------- --------- ---------82360-26 $10.00 --------- --------- --------- --------- --------- ---------82360-TC $20.00 --------- --------- --------- --------- --------- ---------82365 $31.00 --------- --------- --------- --------- --------- ---------82365-26 $8.00 --------- --------- --------- --------- --------- ---------82365-TC $21.00 --------- --------- --------- --------- --------- ---------82370 $22.00 --------- --------- --------- --------- --------- ---------82370-26 $7.00 --------- --------- --------- --------- --------- ---------82370-TC $15.00 --------- --------- --------- --------- --------- ---------82373 $16.00 --------- --------- --------- --------- --------- ---------82373-26 $5.00 --------- --------- --------- --------- --------- ---------82373-TC $11.00 --------- --------- --------- --------- --------- ---------82374 $10.00 --------- --------- --------- --------- --------- ---------82374-26 $3.00 --------- --------- --------- --------- --------- ---------82374-TC $6.00 --------- --------- --------- --------- --------- ---------82375 $26.00 --------- --------- --------- --------- --------- ---------82375-26 $7.00 --------- --------- --------- --------- --------- ---------82375-TC $18.00 --------- --------- --------- --------- --------- ---------82376 $11.00 --------- --------- --------- --------- --------- ---------82376-26 $3.00 --------- --------- --------- --------- --------- ---------82376-TC $7.00 --------- --------- --------- --------- --------- ---------82378 $31.00 --------- --------- --------- --------- --------- ---------82378-26 $8.00 --------- --------- --------- --------- --------- ---------82378-TC $21.00 --------- --------- --------- --------- --------- ---------82379 $38.00 --------- --------- --------- --------- --------- ---------82379-26 $13.00 --------- --------- --------- --------- --------- ---------82379-TC $24.00 --------- --------- --------- --------- --------- ---------82380 $21.00 --------- --------- --------- --------- --------- ---------82380-26 $6.00 --------- --------- --------- --------- --------- ---------82380-TC $15.00 --------- --------- --------- --------- --------- ---------82382 $38.00 --------- --------- --------- --------- --------- ---------










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87592 $88.00 --------- --------- --------- --------- --------- ---------87592-26 $28.00 --------- --------- --------- --------- --------- ---------87592-TC $58.00 --------- --------- --------- --------- --------- ---------87650 $42.00 --------- --------- --------- --------- --------- ---------87650-26 $13.00 --------- --------- --------- --------- --------- ---------87650-TC $28.00 --------- --------- --------- --------- --------- ---------87651 $73.00 --------- --------- --------- --------- --------- ---------87651-26 $23.00 --------- --------- --------- --------- --------- ---------87651-TC $48.00 --------- --------- --------- --------- --------- ---------87652 $86.00 --------- --------- --------- --------- --------- ---------87652-26 $28.00 --------- --------- --------- --------- --------- ---------87652-TC $56.00 --------- --------- --------- --------- --------- ---------87797 $42.00 --------- --------- --------- --------- --------- ---------87797-26 $13.00 --------- --------- --------- --------- --------- ---------87797-TC $28.00 --------- --------- --------- --------- --------- ---------87798 $73.00 --------- --------- --------- --------- --------- ---------87798-26 $23.00 --------- --------- --------- --------- --------- ---------87798-TC $48.00 --------- --------- --------- --------- --------- ---------87799 $88.00 --------- --------- --------- --------- --------- ---------87799-26 $28.00 --------- --------- --------- --------- --------- ---------87799-TC $58.00 --------- --------- --------- --------- --------- ---------87800 $46.00 --------- --------- --------- --------- --------- ---------87800-26 $15.00 --------- --------- --------- --------- --------- ---------87800-TC $31.00 --------- --------- --------- --------- --------- ---------87801 $81.00 --------- --------- --------- --------- --------- ---------87801-26 $26.00 --------- --------- --------- --------- --------- ---------87801-TC $54.00 --------- --------- --------- --------- --------- ---------87802 BR --------- --------- --------- --------- --------- ---------87802-26 BR --------- --------- --------- --------- --------- ---------87802-TC BR --------- --------- --------- --------- --------- ---------87803 BR --------- --------- --------- --------- --------- ---------87803-26 BR --------- --------- --------- --------- --------- ---------87803-TC BR --------- --------- --------- --------- --------- ---------87804 BR --------- --------- --------- --------- --------- ---------87804-26 BR --------- --------- --------- --------- --------- ---------87804-TC BR --------- --------- --------- --------- --------- ---------87810 $26.00 --------- --------- --------- --------- --------- ---------87810-26 $8.00 --------- --------- --------- --------- --------- ---------87810-TC $18.00 --------- --------- --------- --------- --------- ---------87850 $26.00 --------- --------- --------- --------- --------- ---------87850-26 $8.00 --------- --------- --------- --------- --------- ---------87850-TC $18.00 --------- --------- --------- --------- --------- ---------87880 $26.00 --------- --------- --------- --------- --------- ---------87880-26 $8.00 --------- --------- --------- --------- --------- ---------87880-TC $18.00 --------- --------- --------- --------- --------- ---------87899 $26.00 --------- --------- --------- --------- --------- ---------87899-26 $8.00 --------- --------- --------- --------- --------- ---------87899-TC $18.00 --------- --------- --------- --------- --------- ---------87901 $594.00 --------- --------- --------- --------- --------- ---------87901-26 $196.00 --------- --------- --------- --------- --------- ---------










87901-TC $398.00 --------- --------- --------- --------- --------- ---------87902 BR --------- --------- --------- --------- --------- ---------87902-26 BR --------- --------- --------- --------- --------- ---------87902-TC BR --------- --------- --------- --------- --------- ---------87903 $1,126.00 --------- --------- --------- --------- --------- ---------87903-26 $371.00 --------- --------- --------- --------- --------- ---------87903-TC $755.00 --------- --------- --------- --------- --------- ---------87904 $59.00 --------- --------- --------- --------- --------- ---------87904-26 $20.00 --------- --------- --------- --------- --------- ---------87904-TC $39.00 --------- --------- --------- --------- --------- ---------87999 BR --------- --------- --------- --------- --------- ---------87999-26 BR --------- --------- --------- --------- --------- ---------87999-TC BR --------- --------- --------- --------- --------- ---------88000 $445.00 --------- --------- --------- --------- --------- ---------88000-26 $445.00 --------- --------- --------- --------- --------- ---------88000-TC BR --------- --------- --------- --------- --------- ---------88005 $500.00 --------- --------- --------- --------- --------- ---------88005-26 $500.00 --------- --------- --------- --------- --------- ---------88005-TC BR --------- --------- --------- --------- --------- ---------88007 $556.00 --------- --------- --------- --------- --------- ---------88007-26 $556.00 --------- --------- --------- --------- --------- ---------88007-TC BR --------- --------- --------- --------- --------- ---------88020 $556.00 --------- --------- --------- --------- --------- ---------88020-26 $556.00 --------- --------- --------- --------- --------- ---------88020-TC BR --------- --------- --------- --------- --------- ---------88025 $610.00 --------- --------- --------- --------- --------- ---------88025-26 $610.00 --------- --------- --------- --------- --------- ---------88025-TC BR --------- --------- --------- --------- --------- ---------88027 $666.00 --------- --------- --------- --------- --------- ---------88027-26 $666.00 --------- --------- --------- --------- --------- ---------88027-TC BR --------- --------- --------- --------- --------- ---------88036 $477.00 --------- --------- --------- --------- --------- ---------88036-26 $477.00 --------- --------- --------- --------- --------- ---------88036-TC BR --------- --------- --------- --------- --------- ---------88037 $389.00 --------- --------- --------- --------- --------- ---------88037-26 $389.00 --------- --------- --------- --------- --------- ---------88037-TC BR --------- --------- --------- --------- --------- ---------88040 $1,445.00 --------- --------- --------- --------- --------- ---------88040-26 $1,445.00 --------- --------- --------- --------- --------- ---------88040-TC BR --------- --------- --------- --------- --------- ---------88045 BR --------- --------- --------- --------- --------- ---------88045-26 BR --------- --------- --------- --------- --------- ---------88045-TC BR --------- --------- --------- --------- --------- ---------88099 BR --------- --------- --------- --------- --------- ---------88099-26 BR --------- --------- --------- --------- --------- ---------88099-TC BR --------- --------- --------- --------- --------- ---------88104 $49.00 $82.00 $87.00 $87.00 $82.00 $87.00 $87.0088104-26 $37.00 $33.00 $34.00 $34.00 $33.00 $34.00 $34.0088104-TC $10.00 $49.00 $53.00 $53.00 $49.00 $53.00 $53.0088106 $54.00 $81.00 $86.00 $87.00 $81.00 $86.00 $87.00










88106-26 $16.00 $22.00 $23.00 $23.00 $22.00 $23.00 $23.0088106-TC $38.00 $58.00 $63.00 $63.00 $58.00 $63.00 $63.0088108 $59.00 $78.00 $83.00 $84.00 $78.00 $83.00 $84.0088108-26 $47.00 $26.00 $27.00 $27.00 $26.00 $27.00 $27.0088108-TC $11.00 $52.00 $56.00 $57.00 $52.00 $56.00 $57.0088112 --------- $78.00 $82.00 $83.00 $78.00 $82.00 $83.0088112-26 --------- $32.00 $32.00 $33.00 $32.00 $32.00 $33.0088112-TC --------- $46.00 $49.00 $50.00 $46.00 $49.00 $50.0088120 --------- $678.00 $725.00 $728.00 $678.00 $725.00 $728.0088120-26 --------- $66.00 $68.00 $69.00 $66.00 $68.00 $69.0088120-TC --------- $612.00 $657.00 $660.00 $612.00 $657.00 $660.0088121 --------- $592.00 $632.00 $635.00 $592.00 $632.00 $635.0088121-26 --------- $57.00 $58.00 $59.00 $57.00 $58.00 $59.0088121-TC --------- $535.00 $574.00 $576.00 $535.00 $574.00 $576.0088125 $70.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.0088125-26 $20.00 $15.00 $16.00 $17.00 $15.00 $16.00 $17.0088125-TC $48.00 $10.00 $11.00 $12.00 $10.00 $11.00 $12.0088130 $25.00 --------- --------- --------- --------- --------- ---------88130-26 $7.00 --------- --------- --------- --------- --------- ---------88130-TC $18.00 --------- --------- --------- --------- --------- ---------88140 $18.00 --------- --------- --------- --------- --------- ---------88140-26 $5.00 --------- --------- --------- --------- --------- ---------88140-TC $13.00 --------- --------- --------- --------- --------- ---------88141 $33.00 $36.00 $37.00 $38.00 $36.00 $37.00 $38.0088141-26 NC BR BR BR BR BR BR88141-TC NC BR BR BR BR BR BR88142 $82.00 --------- --------- --------- --------- --------- ---------88142-26 $21.00 --------- --------- --------- --------- --------- ---------88142-TC $59.00 --------- --------- --------- --------- --------- ---------88143 $94.00 --------- --------- --------- --------- --------- ---------88143-26 $33.00 --------- --------- --------- --------- --------- ---------88143-TC $59.00 --------- --------- --------- --------- --------- ---------88147 $82.00 --------- --------- --------- --------- --------- ---------88147-26 NC BR BR BR BR BR BR88147-TC $82.00 --------- --------- --------- --------- --------- ---------88148 $104.00 --------- --------- --------- --------- --------- ---------88148-26 $21.00 --------- --------- --------- --------- --------- ---------88148-TC $82.00 --------- --------- --------- --------- --------- ---------88150 $13.00 --------- --------- --------- --------- --------- ---------88150-26 $3.00 --------- --------- --------- --------- --------- ---------88150-TC $9.00 --------- --------- --------- --------- --------- ---------88152 $46.00 --------- --------- --------- --------- --------- ---------88152-26 $8.00 --------- --------- --------- --------- --------- ---------88152-TC $38.00 --------- --------- --------- --------- --------- ---------88153 $82.00 --------- --------- --------- --------- --------- ---------88153-26 $21.00 --------- --------- --------- --------- --------- ---------88153-TC $59.00 --------- --------- --------- --------- --------- ---------88154 $104.00 --------- --------- --------- --------- --------- ---------88154-26 $21.00 --------- --------- --------- --------- --------- ---------88154-TC $82.00 --------- --------- --------- --------- --------- ---------










88155 $14.00 --------- --------- --------- --------- --------- ---------88155-26 $3.00 --------- --------- --------- --------- --------- ---------88155-TC $10.00 --------- --------- --------- --------- --------- ---------88160 $45.00 $78.00 $83.00 $83.00 $78.00 $83.00 $83.0088160-26 $14.00 $30.00 $31.00 $31.00 $30.00 $31.00 $31.0088160-TC $24.00 $49.00 $52.00 $53.00 $49.00 $52.00 $53.0088161 $64.00 $70.00 $74.00 $75.00 $70.00 $74.00 $75.0088161-26 $19.00 $29.00 $29.00 $30.00 $29.00 $29.00 $30.0088161-TC $37.00 $42.00 $45.00 $45.00 $42.00 $45.00 $45.0088162 $77.00 $113.00 $120.00 $121.00 $113.00 $120.00 $121.0088162-26 $22.00 $45.00 $46.00 $47.00 $45.00 $46.00 $47.0088162-TC $53.00 $68.00 $74.00 $74.00 $68.00 $74.00 $74.0088164 $54.00 --------- --------- --------- --------- --------- ---------88164-26 $21.00 --------- --------- --------- --------- --------- ---------88164-TC $33.00 --------- --------- --------- --------- --------- ---------88165 $72.00 --------- --------- --------- --------- --------- ---------88165-26 $33.00 --------- --------- --------- --------- --------- ---------88165-TC $38.00 --------- --------- --------- --------- --------- ---------88166 $82.00 --------- --------- --------- --------- --------- ---------88166-26 $21.00 --------- --------- --------- --------- --------- ---------88166-TC $59.00 --------- --------- --------- --------- --------- ---------88167 $87.00 --------- --------- --------- --------- --------- ---------88167-26 $26.00 --------- --------- --------- --------- --------- ---------88167-TC $59.00 --------- --------- --------- --------- --------- ---------88172 $70.00 $63.00 $66.00 $67.00 $63.00 $66.00 $67.0088172-26 $54.00 $41.00 $43.00 $43.00 $41.00 $43.00 $43.0088172-TC $14.00 $21.00 $23.00 $23.00 $21.00 $23.00 $23.0088173 $95.00 $167.00 $176.00 $178.00 $167.00 $176.00 $178.0088173-26 $95.00 $81.00 $83.00 $84.00 $81.00 $83.00 $84.0088173-TC $26.00 $86.00 $93.00 $94.00 $86.00 $93.00 $94.0088174 BR --------- --------- --------- --------- --------- ---------88174-26 BR --------- --------- --------- --------- --------- ---------88174-TC BR --------- --------- --------- --------- --------- ---------88175 BR --------- --------- --------- --------- --------- ---------88175-26 BR --------- --------- --------- --------- --------- ---------88175-TC BR --------- --------- --------- --------- --------- ---------88177 --------- $33.00 $35.00 $35.00 $33.00 $35.00 $35.0088177-26 --------- $25.00 $26.00 $26.00 $25.00 $26.00 $26.0088177-TC --------- $8.00 $9.00 $9.00 $8.00 $9.00 $9.0088182 $88.00 $121.00 $128.00 $130.00 $121.00 $128.00 $130.0088182-26 $33.00 $41.00 $42.00 $42.00 $41.00 $42.00 $42.0088182-TC $54.00 $80.00 $86.00 $88.00 $80.00 $86.00 $88.0088184 --------- $81.00 $87.00 $87.00 $81.00 $87.00 $87.0088185 --------- $49.00 $53.00 $53.00 $49.00 $53.00 $53.0088187 --------- $80.00 $83.00 $85.00 $80.00 $83.00 $85.0088188 --------- $102.00 $106.00 $109.00 $102.00 $106.00 $109.0088189 --------- $126.00 $129.00 $133.00 $126.00 $129.00 $133.0088199 BR --------- --------- --------- --------- --------- ---------88199-26 BR --------- --------- --------- --------- --------- ---------88199-TC BR --------- --------- --------- --------- --------- ---------










88233 $243.00 --------- --------- --------- --------- --------- ---------88233-26 $73.00 --------- --------- --------- --------- --------- ---------88233-TC $170.00 --------- --------- --------- --------- --------- ---------88235 $256.00 --------- --------- --------- --------- --------- ---------88235-26 $76.00 --------- --------- --------- --------- --------- ---------88235-TC $177.00 --------- --------- --------- --------- --------- ---------88240 $21.00 --------- --------- --------- --------- --------- ---------88240-26 $6.00 --------- --------- --------- --------- --------- ---------88240-TC $15.00 --------- --------- --------- --------- --------- ---------88241 $21.00 --------- --------- --------- --------- --------- ---------88241-26 $6.00 --------- --------- --------- --------- --------- ---------88241-TC $15.00 --------- --------- --------- --------- --------- ---------88300 $24.00 $17.00 $18.00 $19.00 $17.00 $18.00 $19.0088300-26 $19.00 $5.00 $5.00 $6.00 $5.00 $5.00 $6.0088300-TC $5.00 $11.00 $12.00 $13.00 $11.00 $12.00 $13.0088302 $53.00 $35.00 $38.00 $38.00 $35.00 $38.00 $38.0088302-26 $42.00 $8.00 $9.00 $9.00 $8.00 $9.00 $9.0088302-TC $11.00 $27.00 $29.00 $29.00 $27.00 $29.00 $29.0088304 $70.00 $49.00 $53.00 $53.00 $49.00 $53.00 $53.0088304-26 $54.00 $13.00 $13.00 $14.00 $13.00 $13.00 $14.0088304-TC $14.00 $36.00 $39.00 $40.00 $36.00 $39.00 $40.0088305 $108.00 $80.00 $84.00 $85.00 $80.00 $84.00 $85.0088305-26 $86.00 $43.00 $45.00 $45.00 $43.00 $45.00 $45.0088305-TC $21.00 $36.00 $39.00 $40.00 $36.00 $39.00 $40.0088307 $210.00 $333.00 $353.00 $356.00 $333.00 $353.00 $356.0088307-26 $168.00 $95.00 $98.00 $99.00 $95.00 $98.00 $99.0088307-TC $41.00 $238.00 $255.00 $257.00 $238.00 $255.00 $257.0088309 $322.00 $506.00 $536.00 $541.00 $506.00 $536.00 $541.0088309-26 $258.00 $169.00 $174.00 $176.00 $169.00 $174.00 $176.0088309-TC $64.00 $338.00 $363.00 $365.00 $338.00 $363.00 $365.0088311 $23.00 $24.00 $25.00 $26.00 $24.00 $25.00 $26.0088311-26 $19.00 $15.00 $15.00 $15.00 $15.00 $15.00 $15.0088311-TC $4.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0088312 $23.00 $105.00 $112.00 $113.00 $105.00 $112.00 $113.0088312-26 $7.00 $31.00 $32.00 $32.00 $31.00 $32.00 $32.0088312-TC $16.00 $75.00 $80.00 $81.00 $75.00 $80.00 $81.0088313 $23.00 $74.00 $79.00 $79.00 $74.00 $79.00 $79.0088313-26 $7.00 $14.00 $14.00 $15.00 $14.00 $14.00 $15.0088313-TC $16.00 $60.00 $64.00 $65.00 $60.00 $64.00 $65.0088314 $21.00 $83.00 $88.00 $89.00 $83.00 $88.00 $89.0088314-26 $6.00 $25.00 $26.00 $26.00 $25.00 $26.00 $26.0088314-TC $15.00 $58.00 $62.00 $62.00 $58.00 $62.00 $62.0088319 $26.00 $96.00 $102.00 $103.00 $96.00 $102.00 $103.0088319-26 $13.00 $31.00 $32.00 $32.00 $31.00 $32.00 $32.0088319-TC $14.00 $65.00 $70.00 $71.00 $65.00 $70.00 $71.0088321 $43.00 $113.00 $117.00 $120.00 $96.00 $100.00 $102.0088321-26 $43.00 --------- --------- --------- --------- --------- ---------88321-TC NC BR BR BR BR BR BR88323 $61.00 $152.00 $158.00 $160.00 $152.00 $158.00 $160.0088323-26 $61.00 $98.00 $100.00 $101.00 $98.00 $100.00 $101.00










88323-TC NC $54.00 $58.00 $58.00 $54.00 $58.00 $58.0088325 $54.00 $190.00 $198.00 $202.00 $152.00 $157.00 $161.0088325-26 $54.00 --------- --------- --------- --------- --------- ---------88325-TC NC BR BR BR BR BR BR88329 $51.00 $56.00 $58.00 $60.00 $42.00 $43.00 $45.0088329-26 $51.00 --------- --------- --------- --------- --------- ---------88329-TC NC BR BR BR BR BR BR88331 $102.00 $105.00 $110.00 $111.00 $105.00 $110.00 $111.0088331-26 $70.00 $71.00 $74.00 $75.00 $71.00 $74.00 $75.0088331-TC $33.00 $33.00 $36.00 $36.00 $33.00 $36.00 $36.0088332 $53.00 $55.00 $58.00 $59.00 $55.00 $58.00 $59.0088332-26 $36.00 $35.00 $36.00 $36.00 $35.00 $36.00 $36.0088332-TC $17.00 $20.00 $22.00 $22.00 $20.00 $22.00 $22.0088333 --------- $110.00 $115.00 $116.00 $110.00 $115.00 $116.0088333-26 --------- $72.00 $74.00 $75.00 $72.00 $74.00 $75.0088333-TC --------- $38.00 $41.00 $41.00 $38.00 $41.00 $41.0088334 --------- $68.00 $71.00 $72.00 $68.00 $71.00 $72.0088334-26 --------- $44.00 $46.00 $46.00 $44.00 $46.00 $46.0088334-TC --------- $24.00 $25.00 $26.00 $24.00 $25.00 $26.0088341 --------- $96.00 $102.00 $102.00 $96.00 $102.00 $102.0088341-26 --------- $30.00 $31.00 $32.00 $30.00 $31.00 $32.0088341-TC --------- $66.00 $71.00 $71.00 $66.00 $71.00 $71.0088342 $53.00 $115.00 $122.00 $123.00 $115.00 $122.00 $123.0088342-26 $36.00 $41.00 $42.00 $43.00 $41.00 $42.00 $43.0088342-TC $17.00 $74.00 $80.00 $80.00 $74.00 $80.00 $80.0088344 --------- $185.00 $197.00 $198.00 $185.00 $197.00 $198.0088344-26 --------- $45.00 $46.00 $47.00 $45.00 $46.00 $47.0088344-TC --------- $141.00 $151.00 $152.00 $141.00 $151.00 $152.0088346 $96.00 $101.00 $106.00 $107.00 $101.00 $106.00 $107.0088346-26 $66.00 $42.00 $43.00 $44.00 $42.00 $43.00 $44.0088346-TC $28.00 $59.00 $63.00 $64.00 $59.00 $63.00 $64.0088348 $191.00 $372.00 $395.00 $399.00 $372.00 $395.00 $399.0088348-26 $145.00 $86.00 $89.00 $90.00 $86.00 $89.00 $90.0088348-TC $44.00 $285.00 $307.00 $309.00 $285.00 $307.00 $309.0088350 --------- $77.00 $82.00 $82.00 $77.00 $82.00 $82.0088350-26 --------- $31.00 $32.00 $32.00 $31.00 $32.00 $32.0088350-TC --------- $46.00 $49.00 $50.00 $46.00 $49.00 $50.0088355 $108.00 $170.00 $178.00 $179.00 $170.00 $178.00 $179.0088355-26 $80.00 $92.00 $93.00 $94.00 $92.00 $93.00 $94.0088355-TC $26.00 $78.00 $84.00 $85.00 $78.00 $84.00 $85.0088356 $108.00 $224.00 $233.00 $236.00 $224.00 $233.00 $236.0088356-26 $80.00 $135.00 $138.00 $139.00 $135.00 $138.00 $139.0088356-TC $26.00 $89.00 $95.00 $97.00 $89.00 $95.00 $97.0088358 $108.00 $93.00 $97.00 $98.00 $93.00 $97.00 $98.0088358-26 $80.00 $51.00 $52.00 $52.00 $51.00 $52.00 $52.0088358-TC $26.00 $42.00 $45.00 $46.00 $42.00 $45.00 $46.0088360 --------- $131.00 $137.00 $139.00 $131.00 $137.00 $139.0088360-26 --------- $62.00 $63.00 $64.00 $62.00 $63.00 $64.0088360-TC --------- $69.00 $74.00 $75.00 $69.00 $74.00 $75.0088361 --------- $160.00 $169.00 $171.00 $160.00 $169.00 $171.00










88361-26 --------- $67.00 $68.00 $69.00 $67.00 $68.00 $69.0088361-TC --------- $94.00 $101.00 $101.00 $94.00 $101.00 $101.0088362 BR $281.00 $296.00 $299.00 $281.00 $296.00 $299.0088362-26 BR $123.00 $127.00 $129.00 $123.00 $127.00 $129.0088362-TC BR $157.00 $169.00 $170.00 $157.00 $169.00 $170.0088363 --------- $25.00 $26.00 $27.00 $22.00 $23.00 $23.0088364 --------- $144.00 $153.00 $155.00 $144.00 $153.00 $155.0088364-26 --------- $38.00 $40.00 $40.00 $38.00 $40.00 $40.0088364-TC --------- $106.00 $114.00 $114.00 $106.00 $114.00 $114.0088365 $24.00 $190.00 $202.00 $203.00 $190.00 $202.00 $203.0088365-26 $24.00 $50.00 $51.00 $52.00 $50.00 $51.00 $52.0088365-TC BR $140.00 $150.00 $151.00 $140.00 $150.00 $151.0088366 --------- $280.00 $298.00 $300.00 $280.00 $298.00 $300.0088366-26 --------- $71.00 $73.00 $74.00 $71.00 $73.00 $74.0088366-TC --------- $210.00 $225.00 $226.00 $210.00 $225.00 $226.0088367 --------- $114.00 $121.00 $122.00 $114.00 $121.00 $122.0088367-26 --------- $39.00 $40.00 $40.00 $39.00 $40.00 $40.0088367-TC --------- $75.00 $81.00 $82.00 $75.00 $81.00 $82.0088368 --------- $123.00 $129.00 $130.00 $123.00 $129.00 $130.0088368-26 --------- $45.00 $46.00 $46.00 $45.00 $46.00 $46.0088368-TC --------- $78.00 $83.00 $84.00 $78.00 $83.00 $84.0088369 --------- $116.00 $123.00 $124.00 $116.00 $123.00 $124.0088369-26 --------- $35.00 $36.00 $36.00 $35.00 $36.00 $36.0088369-TC --------- $81.00 $87.00 $88.00 $81.00 $87.00 $88.0088371 $34.00 --------- --------- --------- --------- --------- ---------88371-26 $10.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.0088371-TC $23.00 --------- --------- --------- --------- --------- ---------88372 $38.00 --------- --------- --------- --------- --------- ---------88372-26 $11.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.0088372-TC $26.00 --------- --------- --------- --------- --------- ---------88373 --------- $80.00 $85.00 $85.00 $80.00 $85.00 $85.0088373-26 --------- $24.00 $24.00 $24.00 $24.00 $24.00 $24.0088373-TC --------- $57.00 $61.00 $61.00 $57.00 $61.00 $61.0088374 --------- $367.00 $392.00 $394.00 $367.00 $392.00 $394.0088374-26 --------- $51.00 $52.00 $52.00 $51.00 $52.00 $52.0088374-TC --------- $317.00 $340.00 $341.00 $317.00 $340.00 $341.0088375 --------- $55.00 $57.00 $59.00 $55.00 $57.00 $59.0088377 --------- $438.00 $466.00 $469.00 $438.00 $466.00 $469.0088377-26 --------- $73.00 $74.00 $75.00 $73.00 $74.00 $75.0088377-TC --------- $365.00 $392.00 $394.00 $365.00 $392.00 $394.0088380 BR $156.00 $165.00 $167.00 $156.00 $165.00 $167.0088380-26 BR $64.00 $66.00 $67.00 $64.00 $66.00 $67.0088380-TC BR $92.00 $99.00 $100.00 $92.00 $99.00 $100.0088381 --------- $126.00 $134.00 $135.00 $126.00 $134.00 $135.0088381-26 --------- $28.00 $29.00 $29.00 $28.00 $29.00 $29.0088381-TC --------- $98.00 $105.00 $106.00 $98.00 $105.00 $106.0088387 --------- $46.00 $48.00 $49.00 $46.00 $48.00 $49.0088387-26 --------- $36.00 $38.00 $38.00 $36.00 $38.00 $38.0088387-TC --------- $10.00 $11.00 $11.00 $10.00 $11.00 $11.0088388 --------- $38.00 $40.00 $40.00 $38.00 $40.00 $40.00










88388-26 --------- $27.00 $28.00 $28.00 $27.00 $28.00 $28.0088388-TC --------- $11.00 $12.00 $12.00 $11.00 $12.00 $12.0088399 BR --------- --------- --------- --------- --------- ---------88399-26 BR --------- --------- --------- --------- --------- ---------88399-TC BR --------- --------- --------- --------- --------- ---------89049 --------- $282.00 $300.00 $304.00 $74.00 $77.00 $80.0089050 $10.00 --------- --------- --------- --------- --------- ---------89050-26 $3.00 --------- --------- --------- --------- --------- ---------89050-TC $6.00 --------- --------- --------- --------- --------- ---------89051 $13.00 --------- --------- --------- --------- --------- ---------89051-26 $4.00 --------- --------- --------- --------- --------- ---------89051-TC $8.00 --------- --------- --------- --------- --------- ---------89055 BR --------- --------- --------- --------- --------- ---------89055-26 BR --------- --------- --------- --------- --------- ---------89055-TC BR --------- --------- --------- --------- --------- ---------89060 $13.00 --------- --------- --------- --------- --------- ---------89060-26 $5.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.0089060-TC $8.00 --------- --------- --------- --------- --------- ---------89125 $14.00 --------- --------- --------- --------- --------- ---------89125-26 $4.00 --------- --------- --------- --------- --------- ---------89125-TC $10.00 --------- --------- --------- --------- --------- ---------89160 $6.00 --------- --------- --------- --------- --------- ---------89160-26 $2.00 --------- --------- --------- --------- --------- ---------89160-TC $4.00 --------- --------- --------- --------- --------- ---------89190 $10.00 --------- --------- --------- --------- --------- ---------89190-26 $3.00 --------- --------- --------- --------- --------- ---------89190-TC $6.00 --------- --------- --------- --------- --------- ---------89220 --------- $18.00 $19.00 $19.00 $18.00 $19.00 $19.0089230 --------- $6.00 $6.00 $7.00 $6.00 $6.00 $7.00G0124 --------- $36.00 $37.00 $38.00 $36.00 $37.00 $38.00G0141 --------- $36.00 $37.00 $38.00 $36.00 $37.00 $38.00G0416 --------- $570.00 $604.00 $608.00 $570.00 $604.00 $608.00G0416-26 --------- $172.00 $177.00 $179.00 $172.00 $177.00 $179.00G0416-TC --------- $398.00 $427.00 $429.00 $398.00 $427.00 $429.00G0452-26 --------- $20.00 $21.00 $21.00 $20.00 $21.00 $21.00G0455 --------- $142.00 $151.00 $156.00 $84.00 $88.00 $93.00



Medicine







90460 --------- $27.00 $29.00 $29.00 $27.00 $29.00 $29.0090461 --------- $14.00 $14.00 $15.00 $14.00 $14.00 $15.0090471 $4.00 $27.00 $29.00 $29.00 $27.00 $29.00 $29.0090472 $4.00 $14.00 $14.00 $15.00 $14.00 $14.00 $15.0090473 BR $27.00 $29.00 $29.00 $27.00 $29.00 $29.0090474 BR $14.00 $14.00 $15.00 $14.00 $14.00 $15.0090632 BR --------- --------- --------- --------- --------- ---------90636 BR --------- --------- --------- --------- --------- ---------90675 BR --------- --------- --------- --------- --------- ---------90746 BR --------- --------- --------- --------- --------- ---------90749 BR --------- --------- --------- --------- --------- ---------90785 --------- $15.00 $16.00 $16.00 $15.00 $16.00 $16.0090791 --------- $146.00 $150.00 $153.00 $142.00 $145.00 $148.0090792 --------- $162.00 $166.00 $170.00 $157.00 $161.00 $165.0090832 --------- $71.00 $72.00 $74.00 $70.00 $72.00 $73.0090833 --------- $73.00 $75.00 $77.00 $72.00 $74.00 $76.0090834 --------- $94.00 $96.00 $98.00 $94.00 $96.00 $98.0090836 --------- $93.00 $95.00 $98.00 $92.00 $94.00 $97.0090837 --------- $142.00 $145.00 $148.00 $140.00 $143.00 $147.0090838 --------- $123.00 $126.00 $129.00 $122.00 $125.00 $128.0090839 --------- $147.00 $151.00 $154.00 $147.00 $150.00 $153.0090840 --------- $70.00 $72.00 $73.00 $70.00 $71.00 $73.0090845 $85.00 $102.00 $104.00 $106.00 $101.00 $104.00 $106.0090846 $93.00 $114.00 $117.00 $120.00 $114.00 $116.00 $119.0090847 $110.00 $118.00 $121.00 $124.00 $117.00 $120.00 $123.0090849 $32.00 $38.00 $39.00 $40.00 $34.00 $35.00 $36.0090853 $32.00 $28.00 $29.00 $30.00 $28.00 $29.00 $29.0090865 $143.00 $183.00 $190.00 $193.00 $143.00 $147.00 $150.0090870 $94.00 $194.00 $203.00 $206.00 $123.00 $126.00 $129.0090875 $74.00 $68.00 $71.00 $73.00 $68.00 $71.00 $73.0090876 $112.00 $119.00 $124.00 $128.00 $108.00 $112.00 $115.0090880 $112.00 $112.00 $115.00 $118.00 $104.00 $107.00 $109.0090882 $104.00 --------- --------- --------- --------- --------- ---------90885 $49.00 $55.00 $57.00 $59.00 $55.00 $57.00 $59.0090887 $77.00 $98.00 $102.00 $105.00 $85.00 $87.00 $90.0090889 BR --------- --------- --------- --------- --------- ---------90899 BR --------- --------- --------- --------- --------- ---------90901 $46.00 $41.00 $43.00 $44.00 $22.00 $23.00 $23.0090911 $82.00 $92.00 $97.00 $99.00 $50.00 $52.00 $54.0090935 $76.00 $81.00 $84.00 $86.00 $81.00 $84.00 $86.0090937 $226.00 $116.00 $120.00 $124.00 $116.00 $120.00 $124.0090940 BR --------- --------- --------- --------- --------- ---------90945 $80.00 $96.00 $99.00 $102.00 $96.00 $99.00 $102.0090947 $125.00 $139.00 $143.00 $148.00 $139.00 $143.00 $148.0090951 --------- $1,054.00 $1,094.00 $1,135.00 $1,054.00 $1,094.00 $1,135.0090954 --------- $910.00 $942.00 $974.00 $910.00 $942.00 $974.0090955 --------- $509.00 $527.00 $544.00 $509.00 $527.00 $544.0090956 --------- $355.00 $368.00 $379.00 $355.00 $368.00 $379.0090957 --------- $719.00 $745.00 $769.00 $719.00 $745.00 $769.0090958 --------- $486.00 $503.00 $519.00 $486.00 $503.00 $519.00



Medicine







90959 --------- $330.00 $342.00 $352.00 $330.00 $342.00 $352.0090960 --------- $316.00 $327.00 $337.00 $316.00 $327.00 $337.0090961 --------- $265.00 $275.00 $283.00 $265.00 $275.00 $283.0090962 --------- $204.00 $212.00 $218.00 $204.00 $212.00 $218.0090963 --------- $607.00 $628.00 $648.00 $607.00 $628.00 $648.0090964 --------- $530.00 $550.00 $567.00 $530.00 $550.00 $567.0090965 --------- $505.00 $523.00 $539.00 $505.00 $523.00 $539.0090966 --------- $264.00 $274.00 $282.00 $264.00 $274.00 $282.0090967 --------- $20.00 $21.00 $21.00 $20.00 $21.00 $21.0090968 --------- $17.00 $18.00 $19.00 $17.00 $18.00 $19.0090969 --------- $17.00 $18.00 $18.00 $17.00 $18.00 $18.0090970 --------- $9.00 $9.00 $9.00 $9.00 $9.00 $9.0090997 $115.00 $104.00 $108.00 $111.00 $104.00 $108.00 $111.0090999 BR --------- --------- --------- --------- --------- ---------91010 $116.00 $191.00 $203.00 $206.00 $191.00 $203.00 $206.0091010-26 $76.00 $75.00 $78.00 $81.00 $75.00 $78.00 $81.0091010-TC $32.00 $116.00 $124.00 $125.00 $116.00 $124.00 $125.0091013 --------- $25.00 $26.00 $27.00 $25.00 $26.00 $27.0091013-26 --------- $11.00 $11.00 $11.00 $11.00 $11.00 $11.0091013-TC --------- $14.00 $15.00 $15.00 $14.00 $15.00 $15.0091020 $60.00 $253.00 $268.00 $272.00 $253.00 $268.00 $272.0091020-26 $49.00 $84.00 $87.00 $89.00 $84.00 $87.00 $89.0091020-TC $9.00 $169.00 $181.00 $183.00 $169.00 $181.00 $183.0091022 --------- $182.00 $192.00 $194.00 $182.00 $192.00 $194.0091022-26 --------- $84.00 $86.00 $88.00 $84.00 $86.00 $88.0091022-TC --------- $98.00 $105.00 $106.00 $98.00 $105.00 $106.0091030 $57.00 $147.00 $156.00 $158.00 $147.00 $156.00 $158.0091030-26 $47.00 $53.00 $54.00 $56.00 $53.00 $54.00 $56.0091030-TC $8.00 $95.00 $102.00 $102.00 $95.00 $102.00 $102.0091034 --------- $205.00 $218.00 $221.00 $205.00 $218.00 $221.0091034-26 --------- $58.00 $60.00 $62.00 $58.00 $60.00 $62.0091034-TC --------- $147.00 $158.00 $159.00 $147.00 $158.00 $159.0091035 --------- $516.00 $551.00 $556.00 $516.00 $551.00 $556.0091035-26 --------- $95.00 $98.00 $102.00 $95.00 $98.00 $102.0091035-TC --------- $422.00 $453.00 $454.00 $422.00 $453.00 $454.0091037 --------- $173.00 $184.00 $186.00 $173.00 $184.00 $186.0091037-26 --------- $57.00 $59.00 $60.00 $57.00 $59.00 $60.0091037-TC --------- $117.00 $125.00 $126.00 $117.00 $125.00 $126.0091038 --------- $481.00 $514.00 $518.00 $481.00 $514.00 $518.0091038-26 --------- $64.00 $66.00 $68.00 $64.00 $66.00 $68.0091038-TC --------- $417.00 $448.00 $449.00 $417.00 $448.00 $449.0091040 --------- $465.00 $497.00 $499.00 $465.00 $497.00 $499.0091040-26 --------- $56.00 $57.00 $58.00 $56.00 $57.00 $58.0091040-TC --------- $410.00 $440.00 $441.00 $410.00 $440.00 $441.0091065 $34.00 $84.00 $90.00 $90.00 $84.00 $90.00 $90.0091065-26 $23.00 $11.00 $12.00 $12.00 $11.00 $12.00 $12.0091065-TC $14.00 $72.00 $78.00 $78.00 $72.00 $78.00 $78.0091110 --------- $948.00 $1,009.00 $1,017.00 $948.00 $1,009.00 $1,017.0091110-26 --------- $212.00 $219.00 $224.00 $212.00 $219.00 $224.0091110-TC --------- $736.00 $790.00 $793.00 $736.00 $790.00 $793.00



Medicine







91111 --------- $774.00 $828.00 $833.00 $774.00 $828.00 $833.0091111-26 --------- $59.00 $61.00 $62.00 $59.00 $61.00 $62.0091111-TC --------- $715.00 $768.00 $770.00 $715.00 $768.00 $770.0091112 --------- $1,156.00 $1,236.00 $1,243.00 $1,156.00 $1,236.00 $1,243.0091112-26 --------- $123.00 $127.00 $131.00 $123.00 $127.00 $131.0091112-TC --------- $1,033.00 $1,109.00 $1,112.00 $1,033.00 $1,109.00 $1,112.0091117 --------- $155.00 $161.00 $166.00 $155.00 $161.00 $166.0091120 --------- $456.00 $487.00 $491.00 $456.00 $487.00 $491.0091120-26 --------- $57.00 $59.00 $61.00 $57.00 $59.00 $61.0091120-TC --------- $399.00 $428.00 $430.00 $399.00 $428.00 $430.0091122 $169.00 $247.00 $262.00 $267.00 $247.00 $262.00 $267.0091122-26 $122.00 $102.00 $106.00 $110.00 $102.00 $106.00 $110.0091122-TC $37.00 $145.00 $156.00 $157.00 $145.00 $156.00 $157.0091132 BR $167.00 $178.00 $181.00 $167.00 $178.00 $181.0091132-26 $28.00 $32.00 $34.00 $36.00 $32.00 $34.00 $36.0091132-TC BR $135.00 $145.00 $145.00 $135.00 $145.00 $145.0091133 BR $185.00 $197.00 $199.00 $185.00 $197.00 $199.0091133-26 $34.00 $39.00 $40.00 $41.00 $39.00 $40.00 $41.0091133-TC BR $146.00 $157.00 $158.00 $146.00 $157.00 $158.0091200 --------- $34.00 $36.00 $37.00 $34.00 $36.00 $37.0091200-26 --------- $15.00 $15.00 $15.00 $15.00 $15.00 $15.0091200-TC --------- $20.00 $21.00 $22.00 $20.00 $21.00 $22.0091299 BR --------- --------- --------- --------- --------- ---------91299-26 BR --------- --------- --------- --------- --------- ---------91299-TC BR --------- --------- --------- --------- --------- ---------92002 $63.00 $88.00 $92.00 $93.00 $53.00 $55.00 $56.0092004 $98.00 $162.00 $169.00 $172.00 $110.00 $114.00 $116.0092012 $53.00 $93.00 $97.00 $99.00 $58.00 $60.00 $62.0092014 $75.00 $135.00 $141.00 $143.00 $89.00 $92.00 $94.0092015 $34.00 $22.00 $23.00 $23.00 $22.00 $22.00 $23.0092018 $80.00 $161.00 $166.00 $170.00 $161.00 $166.00 $170.0092019 $70.00 $80.00 $82.00 $84.00 $80.00 $82.00 $84.0092020 $31.00 $29.00 $30.00 $31.00 $23.00 $24.00 $24.0092025 --------- $41.00 $44.00 $44.00 $41.00 $44.00 $44.0092025-26 --------- $22.00 $23.00 $23.00 $22.00 $23.00 $23.0092025-TC --------- $19.00 $21.00 $21.00 $19.00 $21.00 $21.0092060 $40.00 $71.00 $74.00 $75.00 $71.00 $74.00 $75.0092060-26 $32.00 $42.00 $43.00 $44.00 $42.00 $43.00 $44.0092060-TC $7.00 $28.00 $31.00 $31.00 $28.00 $31.00 $31.0092065 $34.00 $58.00 $61.00 $62.00 $58.00 $61.00 $62.0092065-26 $19.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.0092065-TC $6.00 $38.00 $40.00 $41.00 $38.00 $40.00 $41.0092071 --------- $42.00 $43.00 $44.00 $37.00 $38.00 $39.0092072 --------- $148.00 $154.00 $156.00 $114.00 $118.00 $120.0092081 $32.00 $37.00 $39.00 $39.00 $37.00 $39.00 $39.0092081-26 $19.00 $18.00 $19.00 $19.00 $18.00 $19.00 $19.0092081-TC $6.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.0092082 $48.00 $52.00 $55.00 $56.00 $52.00 $55.00 $56.0092082-26 $24.00 $24.00 $25.00 $25.00 $24.00 $25.00 $25.0092082-TC $9.00 $28.00 $30.00 $31.00 $28.00 $30.00 $31.00



Medicine







92083 $59.00 $70.00 $73.00 $74.00 $70.00 $73.00 $74.0092083-26 $31.00 $31.00 $32.00 $32.00 $31.00 $32.00 $32.0092083-TC $14.00 $39.00 $42.00 $42.00 $39.00 $42.00 $42.0092100 $40.00 $86.00 $91.00 $92.00 $38.00 $39.00 $39.0092132 --------- $38.00 $40.00 $41.00 $38.00 $40.00 $41.0092132-26 --------- $21.00 $22.00 $22.00 $21.00 $22.00 $22.0092132-TC --------- $17.00 $18.00 $18.00 $17.00 $18.00 $18.0092133 --------- $48.00 $50.00 $51.00 $48.00 $50.00 $51.0092133-26 --------- $31.00 $32.00 $32.00 $31.00 $32.00 $32.0092133-TC --------- $17.00 $19.00 $19.00 $17.00 $19.00 $19.0092134 --------- $49.00 $51.00 $52.00 $49.00 $51.00 $52.0092134-26 --------- $32.00 $33.00 $33.00 $32.00 $33.00 $33.0092134-TC --------- $18.00 $19.00 $19.00 $18.00 $19.00 $19.0092136 $93.00 $97.00 $103.00 $104.00 $97.00 $103.00 $104.0092136-26 $29.00 $34.00 $35.00 $36.00 $34.00 $35.00 $36.0092136-TC $63.00 $63.00 $68.00 $68.00 $63.00 $68.00 $68.0092140 $38.00 $69.00 $72.00 $73.00 $30.00 $31.00 $32.0092145 --------- $17.00 $18.00 $18.00 $17.00 $18.00 $18.0092145-26 --------- $9.00 $10.00 $10.00 $9.00 $10.00 $10.0092145-TC --------- $7.00 $8.00 $8.00 $7.00 $8.00 $8.0092225 $45.00 $29.00 $31.00 $31.00 $23.00 $24.00 $24.0092226 $39.00 $27.00 $28.00 $29.00 $21.00 $22.00 $22.0092227 --------- $16.00 $17.00 $17.00 $16.00 $17.00 $17.0092228 --------- $38.00 $39.00 $40.00 $38.00 $39.00 $40.0092228-26 --------- $23.00 $24.00 $24.00 $23.00 $24.00 $24.0092228-TC --------- $15.00 $16.00 $16.00 $15.00 $16.00 $16.0092230 $58.00 $63.00 $67.00 $68.00 $37.00 $39.00 $40.0092235 $104.00 $118.00 $125.00 $126.00 $118.00 $125.00 $126.0092235-26 $46.00 $52.00 $53.00 $54.00 $52.00 $53.00 $54.0092235-TC $53.00 $67.00 $72.00 $72.00 $67.00 $72.00 $72.0092240 $132.00 $274.00 $291.00 $293.00 $274.00 $291.00 $293.0092240-26 $60.00 $70.00 $73.00 $73.00 $70.00 $73.00 $73.0092240-TC $67.00 $204.00 $219.00 $219.00 $204.00 $219.00 $219.0092250 $40.00 $85.00 $90.00 $91.00 $85.00 $90.00 $91.0092250-26 $24.00 $27.00 $27.00 $28.00 $27.00 $27.00 $28.0092250-TC $7.00 $58.00 $63.00 $63.00 $58.00 $63.00 $63.0092260 $20.00 $20.00 $21.00 $21.00 $12.00 $13.00 $13.0092265 $53.00 $86.00 $91.00 $92.00 $86.00 $91.00 $92.0092265-26 $37.00 $48.00 $49.00 $50.00 $48.00 $49.00 $50.0092265-TC $10.00 $38.00 $41.00 $42.00 $38.00 $41.00 $42.0092270 $64.00 $99.00 $105.00 $106.00 $99.00 $105.00 $106.0092270-26 $45.00 $46.00 $47.00 $48.00 $46.00 $47.00 $48.0092270-TC $19.00 $53.00 $57.00 $58.00 $53.00 $57.00 $58.0092275 $80.00 $160.00 $169.00 $170.00 $160.00 $169.00 $170.0092275-26 $56.00 $60.00 $61.00 $62.00 $60.00 $61.00 $62.0092275-TC $17.00 $100.00 $108.00 $109.00 $100.00 $108.00 $109.0092283 $24.00 $60.00 $64.00 $64.00 $60.00 $64.00 $64.0092283-26 $10.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.0092283-TC $5.00 $49.00 $53.00 $53.00 $49.00 $53.00 $53.0092284 $192.00 $66.00 $70.00 $71.00 $66.00 $70.00 $71.00



Medicine







92284-26 $151.00 $14.00 $14.00 $15.00 $14.00 $14.00 $15.0092284-TC $46.00 $52.00 $56.00 $57.00 $52.00 $56.00 $57.0092285 $26.00 $22.00 $24.00 $25.00 $22.00 $24.00 $25.0092285-26 $12.00 $4.00 $4.00 $4.00 $4.00 $4.00 $4.0092285-TC $6.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.0092286 $91.00 $42.00 $44.00 $45.00 $42.00 $44.00 $45.0092286-26 $53.00 $25.00 $25.00 $26.00 $25.00 $25.00 $26.0092286-TC $29.00 $17.00 $19.00 $19.00 $17.00 $19.00 $19.0092287 $99.00 $148.00 $156.00 $158.00 $148.00 $156.00 $158.0092287-26 --------- $51.00 $53.00 $53.00 $51.00 $53.00 $53.0092287-TC --------- $96.00 $104.00 $104.00 $96.00 $104.00 $104.0092310 $86.00 $105.00 $110.00 $112.00 $67.00 $69.00 $71.0092311 $78.00 $110.00 $115.00 $117.00 $62.00 $64.00 $65.0092312 $89.00 $127.00 $133.00 $134.00 $71.00 $73.00 $74.0092313 $70.00 $105.00 $110.00 $112.00 $53.00 $54.00 $55.0092314 $54.00 $86.00 $91.00 $93.00 $39.00 $40.00 $42.0092315 $44.00 $78.00 $83.00 $84.00 $24.00 $25.00 $26.0092316 $59.00 $99.00 $104.00 $105.00 $37.00 $37.00 $38.0092317 $39.00 $82.00 $87.00 $88.00 $25.00 $26.00 $26.0092325 $14.00 $45.00 $48.00 $49.00 $45.00 $48.00 $49.0092326 $44.00 $38.00 $40.00 $41.00 $38.00 $40.00 $41.0092340 $32.00 $39.00 $41.00 $41.00 $21.00 $22.00 $22.0092341 $43.00 $44.00 $46.00 $47.00 $27.00 $28.00 $29.0092342 $43.00 $48.00 $50.00 $51.00 $30.00 $31.00 $32.0092358 $24.00 $12.00 $13.00 $14.00 $12.00 $13.00 $14.0092370 $35.00 $34.00 $35.00 $36.00 $18.00 $19.00 $19.0092371 $18.00 $13.00 $14.00 $14.00 $13.00 $14.00 $14.0092499 BR --------- --------- --------- --------- --------- ---------92499-26 BR --------- --------- --------- --------- --------- ---------92499-TC BR --------- --------- --------- --------- --------- ---------92502 $101.00 $109.00 $114.00 $117.00 $109.00 $114.00 $117.0092504 $24.00 $33.00 $35.00 $35.00 $11.00 $11.00 $11.0092507 $40.00 $87.00 $90.00 $92.00 $87.00 $90.00 $92.0092508 $42.00 $26.00 $27.00 $27.00 $26.00 $27.00 $27.0092511 $81.00 $122.00 $129.00 $131.00 $44.00 $46.00 $47.0092512 $46.00 $66.00 $70.00 $72.00 $32.00 $34.00 $35.0092516 $36.00 $76.00 $81.00 $82.00 $26.00 $27.00 $28.0092520 $47.00 $83.00 $88.00 $90.00 $47.00 $49.00 $50.0092521 --------- $122.00 $127.00 $130.00 $122.00 $127.00 $130.0092522 --------- $102.00 $106.00 $108.00 $102.00 $106.00 $108.0092523 --------- $213.00 $222.00 $226.00 $213.00 $222.00 $226.0092524 --------- $99.00 $103.00 $105.00 $99.00 $103.00 $105.0092526 $48.00 $95.00 $98.00 $100.00 $95.00 $98.00 $100.0092531 $10.00 --------- --------- --------- --------- --------- ---------92532 $14.00 --------- --------- --------- --------- --------- ---------92533 $41.00 --------- --------- --------- --------- --------- ---------92534 BR --------- --------- --------- --------- --------- ---------92537 --------- $44.00 $46.00 $47.00 $44.00 $46.00 $47.0092537-26 --------- $35.00 $36.00 $37.00 $35.00 $36.00 $37.0092537-TC --------- $9.00 $10.00 $10.00 $9.00 $10.00 $10.00



Medicine







92538 --------- $23.00 $24.00 $24.00 $23.00 $24.00 $24.0092538-26 --------- $18.00 $18.00 $18.00 $18.00 $18.00 $18.0092538-TC --------- $5.00 $6.00 $6.00 $5.00 $6.00 $6.0092540 --------- $112.00 $116.00 $118.00 $112.00 $116.00 $118.0092540-26 --------- $88.00 $91.00 $92.00 $88.00 $91.00 $92.0092540-TC --------- $24.00 $25.00 $26.00 $24.00 $25.00 $26.0092541 $37.00 $27.00 $28.00 $28.00 $27.00 $28.00 $28.0092541-26 $25.00 $23.00 $24.00 $24.00 $23.00 $24.00 $24.0092541-TC $9.00 $4.00 $4.00 $4.00 $4.00 $4.00 $4.0092542 $33.00 $31.00 $32.00 $33.00 $31.00 $32.00 $33.0092542-26 $20.00 $28.00 $29.00 $29.00 $28.00 $29.00 $29.0092542-TC $10.00 $3.00 $4.00 $4.00 $3.00 $4.00 $4.0092544 $26.00 $18.00 $19.00 $20.00 $18.00 $19.00 $20.0092544-26 $16.00 $16.00 $16.00 $16.00 $16.00 $16.00 $16.0092544-TC $8.00 $3.00 $3.00 $3.00 $3.00 $3.00 $3.0092545 $22.00 $17.00 $18.00 $18.00 $17.00 $18.00 $18.0092545-26 $14.00 $15.00 $15.00 $15.00 $15.00 $15.00 $15.0092545-TC $8.00 $2.00 $3.00 $3.00 $2.00 $3.00 $3.0092546 $29.00 $111.00 $119.00 $120.00 $111.00 $119.00 $120.0092546-26 $17.00 $16.00 $17.00 $17.00 $16.00 $17.00 $17.0092546-TC $9.00 $94.00 $102.00 $102.00 $94.00 $102.00 $102.0092547 $21.00 $6.00 $7.00 $7.00 $6.00 $7.00 $7.0092548 $92.00 $110.00 $117.00 $119.00 $110.00 $117.00 $119.0092548-26 $30.00 $29.00 $30.00 $31.00 $29.00 $30.00 $31.0092548-TC $59.00 $81.00 $87.00 $88.00 $81.00 $87.00 $88.0092550 --------- $24.00 $24.00 $25.00 $24.00 $24.00 $25.0092551 $17.00 $13.00 $14.00 $14.00 $13.00 $14.00 $14.0092552 $16.00 $33.00 $36.00 $36.00 $33.00 $36.00 $36.0092553 $24.00 $40.00 $43.00 $43.00 $40.00 $43.00 $43.0092555 $14.00 $25.00 $27.00 $27.00 $25.00 $27.00 $27.0092556 $21.00 $40.00 $43.00 $43.00 $40.00 $43.00 $43.0092557 $46.00 $41.00 $43.00 $44.00 $37.00 $38.00 $39.0092560 $23.00 --------- --------- --------- --------- --------- ---------92561 $27.00 $41.00 $44.00 $45.00 $41.00 $44.00 $45.0092562 $15.00 $50.00 $53.00 $54.00 $50.00 $53.00 $54.0092563 $14.00 $33.00 $36.00 $36.00 $33.00 $36.00 $36.0092564 $17.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.0092565 $15.00 $17.00 $19.00 $19.00 $17.00 $19.00 $19.0092567 $20.00 $16.00 $17.00 $17.00 $12.00 $13.00 $13.0092568 $14.00 $18.00 $18.00 $19.00 $17.00 $18.00 $19.0092570 --------- $36.00 $37.00 $38.00 $33.00 $35.00 $36.0092571 $14.00 $29.00 $32.00 $32.00 $29.00 $32.00 $32.0092572 $3.00 $38.00 $41.00 $42.00 $38.00 $41.00 $42.0092575 $11.00 $77.00 $83.00 $84.00 $77.00 $83.00 $84.0092576 $17.00 $38.00 $41.00 $42.00 $38.00 $41.00 $42.0092577 $28.00 $18.00 $19.00 $20.00 $18.00 $19.00 $20.0092579 $28.00 $47.00 $49.00 $50.00 $42.00 $44.00 $45.0092582 $28.00 $72.00 $78.00 $79.00 $72.00 $78.00 $79.0092583 $34.00 $56.00 $60.00 $61.00 $56.00 $60.00 $61.0092584 $94.00 $79.00 $85.00 $85.00 $79.00 $85.00 $85.00



Medicine







92585 $114.00 $146.00 $156.00 $157.00 $146.00 $156.00 $157.0092585-26 $52.00 $30.00 $31.00 $31.00 $30.00 $31.00 $31.0092585-TC $70.00 $116.00 $125.00 $126.00 $116.00 $125.00 $126.0092586 $70.00 $91.00 $98.00 $99.00 $91.00 $98.00 $99.0092587 $58.00 $24.00 $25.00 $26.00 $24.00 $25.00 $26.0092587-26 $8.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.0092587-TC $49.00 $4.00 $4.00 $4.00 $4.00 $4.00 $4.0092588 $78.00 $36.00 $38.00 $38.00 $36.00 $38.00 $38.0092588-26 $20.00 $32.00 $33.00 $33.00 $32.00 $33.00 $33.0092588-TC $57.00 $4.00 $5.00 $5.00 $4.00 $5.00 $5.0092590 $41.00 --------- --------- --------- --------- --------- ---------92591 BR --------- --------- --------- --------- --------- ---------92592 BR --------- --------- --------- --------- --------- ---------92593 BR --------- --------- --------- --------- --------- ---------92594 BR --------- --------- --------- --------- --------- ---------92595 BR --------- --------- --------- --------- --------- ---------92596 $22.00 $45.00 $49.00 $50.00 $45.00 $49.00 $50.0092597 $96.00 $80.00 $83.00 $85.00 $80.00 $83.00 $85.0092603 $88.00 $167.00 $174.00 $177.00 $136.00 $141.00 $144.0092604 $60.00 $98.00 $103.00 $104.00 $75.00 $78.00 $79.0092605 BR $104.00 $107.00 $110.00 $99.00 $103.00 $106.0092606 BR $92.00 $96.00 $98.00 $80.00 $82.00 $85.0092607 $109.00 $139.00 $145.00 $147.00 $139.00 $145.00 $147.0092608 $22.00 $58.00 $60.00 $61.00 $58.00 $60.00 $61.0092609 $59.00 $121.00 $126.00 $128.00 $121.00 $126.00 $128.0092610 $42.00 $94.00 $98.00 $100.00 $81.00 $84.00 $86.0092611 $46.00 $96.00 $101.00 $104.00 $96.00 $101.00 $104.0092612 $173.00 $202.00 $214.00 $217.00 $76.00 $79.00 $82.0092613 BR $43.00 $45.00 $47.00 $43.00 $45.00 $47.0092614 $134.00 $159.00 $168.00 $171.00 $76.00 $79.00 $81.0092615 BR $38.00 $39.00 $41.00 $37.00 $39.00 $40.0092616 $183.00 $228.00 $240.00 $244.00 $114.00 $118.00 $122.0092617 BR $47.00 $49.00 $50.00 $47.00 $49.00 $50.0092618 --------- $38.00 $39.00 $41.00 $37.00 $38.00 $40.0092620 --------- $104.00 $108.00 $110.00 $92.00 $95.00 $97.0092621 --------- $25.00 $25.00 $26.00 $21.00 $22.00 $22.0092625 --------- $77.00 $80.00 $82.00 $69.00 $72.00 $73.0092626 --------- $99.00 $102.00 $104.00 $85.00 $87.00 $89.0092627 --------- $24.00 $25.00 $26.00 $20.00 $21.00 $21.0092640 --------- $125.00 $130.00 $132.00 $107.00 $110.00 $112.0092700 BR --------- --------- --------- --------- --------- ---------92920 --------- $648.00 $694.00 $766.00 $648.00 $694.00 $766.0092924 --------- $770.00 $825.00 $910.00 $770.00 $825.00 $910.0092928 --------- $720.00 $771.00 $851.00 $720.00 $771.00 $851.0092933 --------- $806.00 $863.00 $952.00 $806.00 $863.00 $952.0092937 --------- $720.00 $771.00 $851.00 $720.00 $771.00 $851.0092941 --------- $807.00 $865.00 $954.00 $807.00 $865.00 $954.0092943 --------- $807.00 $864.00 $953.00 $807.00 $864.00 $953.0092950 $203.00 $337.00 $354.00 $366.00 $213.00 $221.00 $232.0092953 $35.00 $13.00 $13.00 $14.00 $13.00 $13.00 $14.00



Medicine







92960 $162.00 $226.00 $238.00 $243.00 $137.00 $143.00 $147.0092961 $239.00 $306.00 $327.00 $357.00 $306.00 $327.00 $357.0092970 $201.00 $218.00 $231.00 $249.00 $218.00 $231.00 $249.0092971 $100.00 $119.00 $128.00 $140.00 $119.00 $128.00 $140.0092973 $174.00 $210.00 $225.00 $248.00 $210.00 $225.00 $248.0092974 $197.00 $192.00 $205.00 $226.00 $192.00 $205.00 $226.0092975 $400.00 $464.00 $496.00 $547.00 $464.00 $496.00 $547.0092977 $302.00 $68.00 $74.00 $79.00 $68.00 $74.00 $79.0092978 $269.00 --------- --------- --------- --------- --------- ---------92978-26 $95.00 $113.00 $120.00 $131.00 $113.00 $120.00 $131.0092978-TC $170.00 --------- --------- --------- --------- --------- ---------92979 $163.00 --------- --------- --------- --------- --------- ---------92979-26 $76.00 $90.00 $96.00 $105.00 $90.00 $96.00 $105.0092979-TC $86.00 --------- --------- --------- --------- --------- ---------92986 $1,222.00 $1,573.00 $1,685.00 $1,847.00 $1,573.00 $1,685.00 $1,847.0092987 $1,271.00 $1,621.00 $1,736.00 $1,900.00 $1,621.00 $1,736.00 $1,900.0092990 $974.00 $1,279.00 $1,371.00 $1,501.00 $1,279.00 $1,371.00 $1,501.0092992 BR --------- --------- --------- --------- --------- ---------92993 BR --------- --------- --------- --------- --------- ---------92997 $765.00 $779.00 $835.00 $922.00 $779.00 $835.00 $922.0092998 $331.00 $383.00 $410.00 $452.00 $383.00 $410.00 $452.0093000 $26.00 $19.00 $20.00 $20.00 $19.00 $20.00 $20.0093005 $16.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0093010 $12.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0093015 $104.00 $83.00 $87.00 $89.00 $83.00 $87.00 $89.0093016 $25.00 $25.00 $26.00 $26.00 $25.00 $26.00 $26.0093017 $63.00 $42.00 $45.00 $46.00 $42.00 $45.00 $46.0093018 $54.00 $16.00 $17.00 $17.00 $16.00 $17.00 $17.0093024 $111.00 $122.00 $128.00 $130.00 $122.00 $128.00 $130.0093024-26 $71.00 $64.00 $65.00 $67.00 $64.00 $65.00 $67.0093024-TC $42.00 $59.00 $63.00 $64.00 $59.00 $63.00 $64.0093025 $277.00 $172.00 $183.00 $184.00 $172.00 $183.00 $184.0093025-26 --------- $41.00 $42.00 $43.00 $41.00 $42.00 $43.0093025-TC --------- $131.00 $141.00 $141.00 $131.00 $141.00 $141.0093040 $14.00 $14.00 $15.00 $16.00 $14.00 $15.00 $16.0093041 $31.00 $6.00 $7.00 $7.00 $6.00 $7.00 $7.0093042 $9.00 $8.00 $8.00 $9.00 $8.00 $8.00 $9.0093050 --------- $19.00 $20.00 $21.00 $19.00 $20.00 $21.0093050-26 --------- $9.00 $10.00 $10.00 $9.00 $10.00 $10.0093050-TC --------- $10.00 $10.00 $11.00 $10.00 $10.00 $11.0093224 $159.00 $99.00 $105.00 $106.00 $99.00 $105.00 $106.0093225 $46.00 $28.00 $31.00 $31.00 $28.00 $31.00 $31.0093226 $83.00 $41.00 $44.00 $44.00 $41.00 $44.00 $44.0093227 $50.00 $29.00 $30.00 $31.00 $29.00 $30.00 $31.0093228 --------- $29.00 $30.00 $31.00 $29.00 $30.00 $31.0093229 --------- $776.00 $833.00 $837.00 $776.00 $833.00 $837.0093260 --------- $73.00 $77.00 $78.00 $73.00 $77.00 $78.0093260-26 --------- $50.00 $51.00 $52.00 $50.00 $51.00 $52.0093260-TC --------- $24.00 $25.00 $26.00 $24.00 $25.00 $26.0093261 --------- $66.00 $69.00 $70.00 $66.00 $69.00 $70.00



Medicine







93261-26 --------- $43.00 $44.00 $45.00 $43.00 $44.00 $45.0093261-TC --------- $24.00 $25.00 $26.00 $24.00 $25.00 $26.0093268 $109.00 $220.00 $235.00 $237.00 $220.00 $235.00 $237.0093270 $46.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.0093271 $90.00 $182.00 $195.00 $196.00 $182.00 $195.00 $196.0093272 $28.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.0093278 $58.00 $33.00 $35.00 $35.00 $33.00 $35.00 $35.0093278-26 $24.00 $14.00 $14.00 $14.00 $14.00 $14.00 $14.0093278-TC $44.00 $19.00 $21.00 $21.00 $19.00 $21.00 $21.0093279 --------- $54.00 $57.00 $58.00 $54.00 $57.00 $58.0093279-26 --------- $36.00 $37.00 $37.00 $36.00 $37.00 $37.0093279-TC --------- $19.00 $20.00 $21.00 $19.00 $20.00 $21.0093280 --------- $64.00 $67.00 $68.00 $64.00 $67.00 $68.0093280-26 --------- $43.00 $44.00 $45.00 $43.00 $44.00 $45.0093280-TC --------- $21.00 $23.00 $23.00 $21.00 $23.00 $23.0093281 --------- $75.00 $78.00 $79.00 $75.00 $78.00 $79.0093281-26 --------- $50.00 $51.00 $52.00 $50.00 $51.00 $52.0093281-TC --------- $25.00 $27.00 $27.00 $25.00 $27.00 $27.0093282 --------- $69.00 $72.00 $73.00 $69.00 $72.00 $73.0093282-26 --------- $47.00 $48.00 $49.00 $47.00 $48.00 $49.0093282-TC --------- $22.00 $23.00 $24.00 $22.00 $23.00 $24.0093283 --------- $89.00 $93.00 $95.00 $89.00 $93.00 $95.0093283-26 --------- $64.00 $66.00 $67.00 $64.00 $66.00 $67.0093283-TC --------- $25.00 $27.00 $28.00 $25.00 $27.00 $28.0093284 --------- $99.00 $103.00 $105.00 $99.00 $103.00 $105.0093284-26 --------- $70.00 $72.00 $74.00 $70.00 $72.00 $74.0093284-TC --------- $29.00 $31.00 $31.00 $29.00 $31.00 $31.0093285 --------- $46.00 $48.00 $49.00 $46.00 $48.00 $49.0093285-26 --------- $29.00 $30.00 $31.00 $29.00 $30.00 $31.0093285-TC --------- $17.00 $19.00 $19.00 $17.00 $19.00 $19.0093286 --------- $30.00 $31.00 $32.00 $30.00 $31.00 $32.0093286-26 --------- $17.00 $17.00 $18.00 $17.00 $17.00 $18.0093286-TC --------- $13.00 $14.00 $14.00 $13.00 $14.00 $14.0093287 --------- $40.00 $42.00 $43.00 $40.00 $42.00 $43.0093287-26 --------- $26.00 $26.00 $27.00 $26.00 $26.00 $27.0093287-TC --------- $14.00 $15.00 $16.00 $14.00 $15.00 $16.0093288 --------- $40.00 $42.00 $43.00 $40.00 $42.00 $43.0093288-26 --------- $24.00 $24.00 $25.00 $24.00 $24.00 $25.0093288-TC --------- $17.00 $18.00 $18.00 $17.00 $18.00 $18.0093289 --------- $72.00 $75.00 $76.00 $72.00 $75.00 $76.0093289-26 --------- $51.00 $52.00 $53.00 $51.00 $52.00 $53.0093289-TC --------- $21.00 $23.00 $23.00 $21.00 $23.00 $23.0093290 --------- $34.00 $36.00 $37.00 $34.00 $36.00 $37.0093290-26 --------- $24.00 $25.00 $25.00 $24.00 $25.00 $25.0093290-TC --------- $10.00 $11.00 $12.00 $10.00 $11.00 $12.0093291 --------- $40.00 $42.00 $43.00 $40.00 $42.00 $43.0093291-26 --------- $24.00 $25.00 $25.00 $24.00 $25.00 $25.0093291-TC --------- $16.00 $17.00 $17.00 $16.00 $17.00 $17.0093292 --------- $36.00 $38.00 $39.00 $36.00 $38.00 $39.0093292-26 --------- $24.00 $25.00 $25.00 $24.00 $25.00 $25.00



Medicine







93292-TC --------- $12.00 $13.00 $13.00 $12.00 $13.00 $13.0093293 --------- $57.00 $61.00 $62.00 $57.00 $61.00 $62.0093293-26 --------- $17.00 $18.00 $18.00 $17.00 $18.00 $18.0093293-TC --------- $40.00 $43.00 $44.00 $40.00 $43.00 $44.0093294 --------- $38.00 $39.00 $41.00 $38.00 $39.00 $41.0093295 --------- $76.00 $78.00 $81.00 $76.00 $78.00 $81.0093296 --------- $28.00 $30.00 $30.00 $28.00 $30.00 $30.0093297 --------- $30.00 $31.00 $32.00 $30.00 $31.00 $32.0093298 --------- $30.00 $31.00 $32.00 $30.00 $31.00 $32.0093303 $215.00 $257.00 $273.00 $276.00 $257.00 $273.00 $276.0093303-26 $70.00 $71.00 $73.00 $75.00 $71.00 $73.00 $75.0093303-TC $144.00 $186.00 $200.00 $201.00 $186.00 $200.00 $201.0093304 $114.00 $168.00 $179.00 $180.00 $168.00 $179.00 $180.0093304-26 $43.00 $41.00 $42.00 $43.00 $41.00 $42.00 $43.0093304-TC $73.00 $127.00 $137.00 $137.00 $127.00 $137.00 $137.0093306 --------- $246.00 $261.00 $264.00 $246.00 $261.00 $264.0093306-26 --------- $71.00 $73.00 $74.00 $71.00 $73.00 $74.0093306-TC --------- $175.00 $188.00 $190.00 $175.00 $188.00 $190.0093307 $196.00 $141.00 $149.00 $151.00 $141.00 $149.00 $151.0093307-26 $56.00 $50.00 $52.00 $53.00 $50.00 $52.00 $53.0093307-TC $144.00 $91.00 $98.00 $98.00 $91.00 $98.00 $98.0093308 $118.00 $134.00 $143.00 $144.00 $134.00 $143.00 $144.0093308-26 $46.00 $29.00 $30.00 $30.00 $29.00 $30.00 $30.0093308-TC $75.00 $106.00 $113.00 $114.00 $106.00 $113.00 $114.0093312 $322.00 $333.00 $351.00 $356.00 $333.00 $351.00 $356.0093312-26 $140.00 $135.00 $139.00 $142.00 $135.00 $139.00 $142.0093312-TC $182.00 $197.00 $212.00 $213.00 $197.00 $212.00 $213.0093313 $76.00 $26.00 $26.00 $28.00 $26.00 $26.00 $28.0093314 $212.00 $326.00 $347.00 $354.00 $326.00 $347.00 $354.0093314-26 $65.00 $117.00 $122.00 $128.00 $117.00 $122.00 $128.0093314-TC $144.00 $209.00 $225.00 $226.00 $209.00 $225.00 $226.0093315 $287.00 $894.00 $953.00 $959.00 $894.00 $953.00 $959.0093315-26 $144.00 $158.00 $163.00 $167.00 $158.00 $163.00 $167.0093315-TC $141.00 $736.00 $790.00 $792.00 $736.00 $790.00 $792.0093316 $78.00 $44.00 $45.00 $47.00 $44.00 $45.00 $47.0093317 $236.00 --------- --------- --------- --------- --------- ---------93317-26 $95.00 $120.00 $125.00 $131.00 $120.00 $125.00 $131.0093317-TC $141.00 --------- --------- --------- --------- --------- ---------93318 BR $867.00 $926.00 $934.00 $867.00 $926.00 $934.0093318-26 $114.00 $131.00 $136.00 $141.00 $131.00 $136.00 $141.0093318-TC BR $736.00 $790.00 $792.00 $736.00 $790.00 $792.0093320 $86.00 $59.00 $62.00 $62.00 $59.00 $62.00 $62.0093320-26 $30.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.0093320-TC $65.00 $38.00 $41.00 $41.00 $38.00 $41.00 $41.0093321 $50.00 $29.00 $31.00 $32.00 $29.00 $31.00 $32.0093321-26 $10.00 $8.00 $9.00 $9.00 $8.00 $9.00 $9.0093321-TC $42.00 $21.00 $23.00 $23.00 $21.00 $23.00 $23.0093325 $114.00 $27.00 $29.00 $29.00 $27.00 $29.00 $29.0093325-26 $4.00 $4.00 $4.00 $4.00 $4.00 $4.00 $4.0093325-TC $110.00 $24.00 $26.00 $26.00 $24.00 $26.00 $26.00



Medicine







93350 $216.00 $260.00 $276.00 $279.00 $260.00 $276.00 $279.0093350-26 $77.00 $79.00 $82.00 $83.00 $79.00 $82.00 $83.0093350-TC $66.00 $181.00 $194.00 $196.00 $181.00 $194.00 $196.0093351 --------- $293.00 $311.00 $314.00 $293.00 $311.00 $314.0093351-26 --------- $95.00 $97.00 $99.00 $95.00 $97.00 $99.0093351-TC --------- $199.00 $213.00 $215.00 $199.00 $213.00 $215.0093352 --------- $37.00 $39.00 $40.00 $37.00 $39.00 $40.0093355 --------- $255.00 $264.00 $274.00 $255.00 $264.00 $274.0093451 --------- $852.00 $913.00 $932.00 $852.00 $913.00 $932.0093451-26 --------- $169.00 $180.00 $196.00 $169.00 $180.00 $196.0093451-TC --------- $682.00 $733.00 $736.00 $682.00 $733.00 $736.0093452 --------- $967.00 $1,035.00 $1,066.00 $967.00 $1,035.00 $1,066.0093452-26 --------- $296.00 $314.00 $342.00 $296.00 $314.00 $342.0093452-TC --------- $671.00 $721.00 $724.00 $671.00 $721.00 $724.0093453 --------- $1,249.00 $1,338.00 $1,381.00 $1,249.00 $1,338.00 $1,381.0093453-26 --------- $392.00 $417.00 $456.00 $392.00 $417.00 $456.0093453-TC --------- $857.00 $921.00 $925.00 $857.00 $921.00 $925.0093454 --------- $982.00 $1,052.00 $1,085.00 $982.00 $1,052.00 $1,085.0093454-26 --------- $300.00 $320.00 $350.00 $300.00 $320.00 $350.0093454-TC --------- $682.00 $732.00 $735.00 $682.00 $732.00 $735.0093455 --------- $1,143.00 $1,225.00 $1,263.00 $1,143.00 $1,225.00 $1,263.0093455-26 --------- $347.00 $370.00 $404.00 $347.00 $370.00 $404.0093455-TC --------- $796.00 $855.00 $859.00 $796.00 $855.00 $859.0093456 --------- $1,231.00 $1,319.00 $1,361.00 $1,231.00 $1,319.00 $1,361.0093456-26 --------- $385.00 $410.00 $448.00 $385.00 $410.00 $448.0093456-TC --------- $846.00 $908.00 $913.00 $846.00 $908.00 $913.0093457 --------- $1,392.00 $1,491.00 $1,538.00 $1,392.00 $1,491.00 $1,538.0093457-26 --------- $432.00 $461.00 $503.00 $432.00 $461.00 $503.0093457-TC --------- $960.00 $1,030.00 $1,035.00 $960.00 $1,030.00 $1,035.0093458 --------- $1,179.00 $1,263.00 $1,303.00 $1,179.00 $1,263.00 $1,303.0093458-26 --------- $367.00 $391.00 $427.00 $367.00 $391.00 $427.0093458-TC --------- $812.00 $872.00 $876.00 $812.00 $872.00 $876.0093459 --------- $1,303.00 $1,396.00 $1,441.00 $1,303.00 $1,396.00 $1,441.0093459-26 --------- $414.00 $441.00 $482.00 $414.00 $441.00 $482.0093459-TC --------- $890.00 $955.00 $959.00 $890.00 $955.00 $959.0093460 --------- $1,399.00 $1,499.00 $1,549.00 $1,399.00 $1,499.00 $1,549.0093460-26 --------- $461.00 $491.00 $537.00 $461.00 $491.00 $537.0093460-TC --------- $938.00 $1,007.00 $1,012.00 $938.00 $1,007.00 $1,012.0093461 --------- $1,599.00 $1,713.00 $1,769.00 $1,599.00 $1,713.00 $1,769.0093461-26 --------- $509.00 $542.00 $593.00 $509.00 $542.00 $593.0093461-TC --------- $1,091.00 $1,171.00 $1,176.00 $1,091.00 $1,171.00 $1,176.0093462 --------- $247.00 $265.00 $291.00 $247.00 $265.00 $291.0093463 --------- $111.00 $115.00 $119.00 $111.00 $115.00 $119.0093464 --------- $297.00 $315.00 $319.00 $297.00 $315.00 $319.0093464-26 --------- $98.00 $100.00 $103.00 $98.00 $100.00 $103.0093464-TC --------- $200.00 $215.00 $216.00 $200.00 $215.00 $216.0093503 $187.00 $148.00 $153.00 $161.00 $148.00 $153.00 $161.0093505 $318.00 $838.00 $897.00 $927.00 $838.00 $897.00 $927.0093505-26 $248.00 $274.00 $291.00 $318.00 $274.00 $291.00 $318.0093505-TC $74.00 $565.00 $606.00 $609.00 $565.00 $606.00 $609.00



Medicine







93530 $872.00 --------- --------- --------- --------- --------- ---------93530-26 $250.00 $257.00 $272.00 $294.00 $257.00 $272.00 $294.0093530-TC $634.00 --------- --------- --------- --------- --------- ---------93531 $2,268.00 --------- --------- --------- --------- --------- ---------93531-26 $467.00 $502.00 $529.00 $569.00 $502.00 $529.00 $569.0093531-TC $1,815.00 --------- --------- --------- --------- --------- ---------93532 $2,317.00 --------- --------- --------- --------- --------- ---------93532-26 $569.00 $628.00 $670.00 $734.00 $628.00 $670.00 $734.0093532-TC $1,766.00 --------- --------- --------- --------- --------- ---------93533 $2,131.00 --------- --------- --------- --------- --------- ---------93533-26 $352.00 $419.00 $447.00 $488.00 $419.00 $447.00 $488.0093533-TC $1,766.00 --------- --------- --------- --------- --------- ---------93561 $59.00 --------- --------- --------- --------- --------- ---------93561-26 $47.00 $29.00 $30.00 $32.00 $29.00 $30.00 $32.0093561-TC $20.00 --------- --------- --------- --------- --------- ---------93562 $46.00 --------- --------- --------- --------- --------- ---------93562-26 $33.00 $9.00 $9.00 $10.00 $9.00 $9.00 $10.0093562-TC $13.00 --------- --------- --------- --------- --------- ---------93563 --------- $69.00 $73.00 $80.00 $69.00 $73.00 $80.0093564 --------- $73.00 $78.00 $86.00 $73.00 $78.00 $86.0093565 --------- $54.00 $58.00 $63.00 $54.00 $58.00 $63.0093566 --------- $188.00 $201.00 $208.00 $55.00 $58.00 $64.0093567 --------- $156.00 $167.00 $175.00 $62.00 $66.00 $73.0093568 --------- $169.00 $181.00 $187.00 $56.00 $60.00 $65.0093571 $270.00 --------- --------- --------- --------- --------- ---------93571-26 $93.00 $113.00 $120.00 $131.00 $113.00 $120.00 $131.0093571-TC $170.00 --------- --------- --------- --------- --------- ---------93572 $222.00 --------- --------- --------- --------- --------- ---------93572-26 $74.00 $90.00 $96.00 $105.00 $90.00 $96.00 $105.0093572-TC $155.00 --------- --------- --------- --------- --------- ---------93580 $974.00 $1,157.00 $1,237.00 $1,359.00 $1,157.00 $1,237.00 $1,359.0093581 $1,303.00 $1,584.00 $1,699.00 $1,876.00 $1,584.00 $1,699.00 $1,876.0093582 --------- $792.00 $847.00 $931.00 $792.00 $847.00 $931.0093583 --------- $894.00 $956.00 $1,050.00 $894.00 $956.00 $1,050.0093600 $198.00 --------- --------- --------- --------- --------- ---------93600-26 $129.00 $139.00 $148.00 $161.00 $139.00 $148.00 $161.0093600-TC $73.00 --------- --------- --------- --------- --------- ---------93602 $159.00 --------- --------- --------- --------- --------- ---------93602-26 $119.00 $136.00 $145.00 $158.00 $136.00 $145.00 $158.0093602-TC $42.00 --------- --------- --------- --------- --------- ---------93603 $187.00 --------- --------- --------- --------- --------- ---------93603-26 $127.00 $136.00 $145.00 $158.00 $136.00 $145.00 $158.0093603-TC $63.00 --------- --------- --------- --------- --------- ---------93609 $578.00 --------- --------- --------- --------- --------- ---------93609-26 $481.00 $325.00 $346.00 $377.00 $325.00 $346.00 $377.0093609-TC $101.00 --------- --------- --------- --------- --------- ---------93610 $214.00 --------- --------- --------- --------- --------- ---------93610-26 $166.00 $193.00 $206.00 $224.00 $193.00 $206.00 $224.0093610-TC $52.00 --------- --------- --------- --------- --------- ---------93612 $224.00 --------- --------- --------- --------- --------- ---------



Medicine







93612-26 $167.00 $191.00 $204.00 $222.00 $191.00 $204.00 $222.0093612-TC $61.00 --------- --------- --------- --------- --------- ---------93613 $377.00 $470.00 $503.00 $553.00 $470.00 $503.00 $553.0093615 $62.00 --------- --------- --------- --------- --------- ---------93615-26 $49.00 $58.00 $60.00 $62.00 $58.00 $60.00 $62.0093615-TC $12.00 --------- --------- --------- --------- --------- ---------93616 $94.00 --------- --------- --------- --------- --------- ---------93616-26 $82.00 $73.00 $74.00 $77.00 $73.00 $74.00 $77.0093616-TC $12.00 --------- --------- --------- --------- --------- ---------93618 $399.00 --------- --------- --------- --------- --------- ---------93618-26 $258.00 $277.00 $296.00 $322.00 $277.00 $296.00 $322.0093618-TC $148.00 --------- --------- --------- --------- --------- ---------93619 $717.00 --------- --------- --------- --------- --------- ---------93619-26 $444.00 $474.00 $505.00 $551.00 $474.00 $505.00 $551.0093619-TC $290.00 --------- --------- --------- --------- --------- ---------93620 $358.00 --------- --------- --------- --------- --------- ---------93620-26 $272.00 $752.00 $801.00 $873.00 $752.00 $801.00 $873.0093620-TC $91.00 --------- --------- --------- --------- --------- ---------93621 BR --------- --------- --------- --------- --------- ---------93621-26 $769.00 $137.00 $146.00 $159.00 $137.00 $146.00 $159.0093621-TC BR --------- --------- --------- --------- --------- ---------93622 BR --------- --------- --------- --------- --------- ---------93622-26 $771.00 $200.00 $214.00 $233.00 $200.00 $214.00 $233.0093622-TC BR --------- --------- --------- --------- --------- ---------93623 BR --------- --------- --------- --------- --------- ---------93623-26 $167.00 $186.00 $198.00 $216.00 $186.00 $198.00 $216.0093623-TC BR --------- --------- --------- --------- --------- ---------93624 $333.00 --------- --------- --------- --------- --------- ---------93624-26 $256.00 $308.00 $329.00 $359.00 $308.00 $329.00 $359.0093624-TC $74.00 --------- --------- --------- --------- --------- ---------93631 $651.00 --------- --------- --------- --------- --------- ---------93631-26 $420.00 $470.00 $501.00 $550.00 $470.00 $501.00 $550.0093631-TC $239.00 --------- --------- --------- --------- --------- ---------93640 $467.00 --------- --------- --------- --------- --------- ---------93640-26 $230.00 $226.00 $241.00 $263.00 $226.00 $241.00 $263.0093640-TC $269.00 --------- --------- --------- --------- --------- ---------93641 $613.00 --------- --------- --------- --------- --------- ---------93641-26 $360.00 $383.00 $409.00 $446.00 $383.00 $409.00 $446.0093641-TC $269.00 --------- --------- --------- --------- --------- ---------93642 $549.00 $481.00 $515.00 $547.00 $481.00 $515.00 $547.0093642-26 $295.00 $318.00 $339.00 $370.00 $318.00 $339.00 $370.0093642-TC $269.00 $163.00 $176.00 $177.00 $163.00 $176.00 $177.0093644 --------- $305.00 $319.00 $323.00 $305.00 $319.00 $323.0093644-26 --------- $192.00 $198.00 $201.00 $192.00 $198.00 $201.0093644-TC --------- $113.00 $121.00 $122.00 $113.00 $121.00 $122.0093650 $639.00 $712.00 $763.00 $838.00 $712.00 $763.00 $838.0093653 --------- $1,003.00 $1,075.00 $1,182.00 $1,003.00 $1,075.00 $1,182.0093654 --------- $1,337.00 $1,432.00 $1,575.00 $1,337.00 $1,432.00 $1,575.0093655 --------- $502.00 $537.00 $591.00 $502.00 $537.00 $591.0093656 --------- $1,337.00 $1,433.00 $1,576.00 $1,337.00 $1,433.00 $1,576.00



Medicine







93657 --------- $502.00 $538.00 $591.00 $502.00 $538.00 $591.0093660 $162.00 $173.00 $181.00 $184.00 $173.00 $181.00 $184.0093660-26 $103.00 $105.00 $108.00 $110.00 $105.00 $108.00 $110.0093660-TC $61.00 $68.00 $73.00 $74.00 $68.00 $73.00 $74.0093662 BR --------- --------- --------- --------- --------- ---------93662-26 $158.00 $159.00 $164.00 $167.00 $159.00 $164.00 $167.0093662-TC BR --------- --------- --------- --------- --------- ---------93701 $36.00 $26.00 $28.00 $28.00 $26.00 $28.00 $28.0093701-26 $9.00 --------- --------- --------- --------- --------- ---------93701-TC $27.00 --------- --------- --------- --------- --------- ---------93702 --------- $115.00 $124.00 $125.00 $115.00 $124.00 $125.0093724 $411.00 $300.00 $310.00 $316.00 $300.00 $310.00 $316.0093724-26 $259.00 $270.00 $278.00 $283.00 $270.00 $278.00 $283.0093724-TC $148.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.0093740 $17.00 $9.00 $9.00 $10.00 $9.00 $9.00 $10.0093740-26 $12.00 --------- --------- --------- --------- --------- ---------93740-TC $5.00 --------- --------- --------- --------- --------- ---------93750 --------- $63.00 $66.00 $69.00 $53.00 $55.00 $58.0093770 NC NC NC NC NC NC NC93770-26 NC NC NC NC NC NC NC93770-TC NC NC NC NC NC NC NC93784 NC NC NC NC NC NC NC93786 NC NC NC NC NC NC NC93788 NC NC NC NC NC NC NC93790 NC NC NC NC NC NC NC93797 $17.00 $18.00 $19.00 $19.00 $10.00 $10.00 $11.0093798 $38.00 $28.00 $29.00 $30.00 $16.00 $16.00 $17.0093799 BR --------- --------- --------- --------- --------- ---------93799-26 BR --------- --------- --------- --------- --------- ---------93799-TC BR --------- --------- --------- --------- --------- ---------93880 $176.00 $207.00 $221.00 $225.00 $207.00 $221.00 $225.0093880-26 $31.00 $45.00 $47.00 $49.00 $45.00 $47.00 $49.0093880-TC $144.00 $162.00 $174.00 $175.00 $162.00 $174.00 $175.0093882 $117.00 $141.00 $151.00 $154.00 $141.00 $151.00 $154.0093882-26 $21.00 $29.00 $31.00 $33.00 $29.00 $31.00 $33.0093882-TC $95.00 $112.00 $120.00 $121.00 $112.00 $120.00 $121.0093886 $215.00 $215.00 $229.00 $232.00 $215.00 $229.00 $232.0093886-26 $50.00 $53.00 $56.00 $58.00 $53.00 $56.00 $58.0093886-TC $162.00 $162.00 $173.00 $174.00 $162.00 $173.00 $174.0093888 $142.00 $160.00 $171.00 $173.00 $160.00 $171.00 $173.0093888-26 $33.00 $29.00 $30.00 $31.00 $29.00 $30.00 $31.0093888-TC $109.00 $131.00 $141.00 $142.00 $131.00 $141.00 $142.0093890 --------- $220.00 $234.00 $237.00 $220.00 $234.00 $237.0093890-26 --------- $58.00 $60.00 $62.00 $58.00 $60.00 $62.0093890-TC --------- $162.00 $174.00 $175.00 $162.00 $174.00 $175.0093892 --------- $166.00 $177.00 $181.00 $166.00 $177.00 $181.0093892-26 --------- $69.00 $72.00 $76.00 $69.00 $72.00 $76.0093892-TC --------- $97.00 $105.00 $105.00 $97.00 $105.00 $105.0093893 --------- $165.00 $174.00 $177.00 $165.00 $174.00 $177.0093893-26 --------- $67.00 $70.00 $72.00 $67.00 $70.00 $72.00



Medicine







93893-TC --------- $97.00 $105.00 $105.00 $97.00 $105.00 $105.0093922 $60.00 $97.00 $103.00 $105.00 $97.00 $103.00 $105.0093922-26 $16.00 $14.00 $15.00 $16.00 $14.00 $15.00 $16.0093922-TC $44.00 $82.00 $88.00 $89.00 $82.00 $88.00 $89.0093923 $112.00 $151.00 $161.00 $164.00 $151.00 $161.00 $164.0093923-26 $28.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.0093923-TC $85.00 $125.00 $134.00 $135.00 $125.00 $134.00 $135.0093924 $122.00 $189.00 $202.00 $204.00 $189.00 $202.00 $204.0093924-26 $31.00 $28.00 $30.00 $31.00 $28.00 $30.00 $31.0093924-TC $92.00 $160.00 $172.00 $173.00 $160.00 $172.00 $173.0093925 $175.00 $206.00 $220.00 $222.00 $206.00 $220.00 $222.0093925-26 $31.00 $44.00 $46.00 $48.00 $44.00 $46.00 $48.0093925-TC $144.00 $162.00 $173.00 $174.00 $162.00 $173.00 $174.0093926 $117.00 $167.00 $178.00 $181.00 $167.00 $178.00 $181.0093926-26 $21.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.0093926-TC $96.00 $139.00 $149.00 $150.00 $139.00 $149.00 $150.0093930 $174.00 $208.00 $222.00 $225.00 $208.00 $222.00 $225.0093930-26 $26.00 $45.00 $47.00 $50.00 $45.00 $47.00 $50.0093930-TC $150.00 $162.00 $174.00 $175.00 $162.00 $174.00 $175.0093931 $118.00 $141.00 $150.00 $153.00 $141.00 $150.00 $153.0093931-26 $17.00 $28.00 $30.00 $31.00 $28.00 $30.00 $31.0093931-TC $101.00 $112.00 $121.00 $121.00 $112.00 $121.00 $121.0093965 $63.00 $130.00 $139.00 $141.00 $130.00 $139.00 $141.0093965-26 $26.00 $20.00 $21.00 $22.00 $20.00 $21.00 $22.0093965-TC $42.00 $110.00 $118.00 $119.00 $110.00 $118.00 $119.0093970 $189.00 $201.00 $215.00 $218.00 $201.00 $215.00 $218.0093970-26 $36.00 $39.00 $41.00 $43.00 $39.00 $41.00 $43.0093970-TC $154.00 $162.00 $174.00 $175.00 $162.00 $174.00 $175.0093971 $121.00 $131.00 $140.00 $142.00 $131.00 $140.00 $142.0093971-26 $23.00 $25.00 $27.00 $28.00 $25.00 $27.00 $28.0093971-TC $96.00 $106.00 $113.00 $114.00 $106.00 $113.00 $114.0093975 $277.00 $227.00 $242.00 $246.00 $227.00 $242.00 $246.0093975-26 $89.00 $66.00 $68.00 $71.00 $66.00 $68.00 $71.0093975-TC $181.00 $162.00 $173.00 $174.00 $162.00 $173.00 $174.0093976 $184.00 $178.00 $189.00 $191.00 $178.00 $189.00 $191.0093976-26 $59.00 $45.00 $47.00 $48.00 $45.00 $47.00 $48.0093976-TC $121.00 $132.00 $142.00 $143.00 $132.00 $142.00 $143.0093978 $177.00 $208.00 $222.00 $226.00 $208.00 $222.00 $226.0093978-26 $34.00 $46.00 $48.00 $51.00 $46.00 $48.00 $51.0093978-TC $143.00 $162.00 $174.00 $175.00 $162.00 $174.00 $175.0093979 $122.00 $131.00 $140.00 $143.00 $131.00 $140.00 $143.0093979-26 $23.00 $28.00 $30.00 $32.00 $28.00 $30.00 $32.0093979-TC $98.00 $103.00 $110.00 $111.00 $103.00 $110.00 $111.0093980 $183.00 $132.00 $139.00 $141.00 $132.00 $139.00 $141.0093980-26 $65.00 $68.00 $70.00 $72.00 $68.00 $70.00 $72.0093980-TC $105.00 $64.00 $68.00 $69.00 $64.00 $68.00 $69.0093981 $148.00 $80.00 $85.00 $87.00 $80.00 $85.00 $87.0093981-26 $25.00 $25.00 $26.00 $28.00 $25.00 $26.00 $28.0093981-TC $124.00 $55.00 $59.00 $60.00 $55.00 $59.00 $60.0093982 --------- $47.00 $50.00 $52.00 $47.00 $50.00 $52.00



Medicine







93990 $110.00 $126.00 $134.00 $138.00 $126.00 $134.00 $138.0093990-26 $14.00 $29.00 $30.00 $33.00 $29.00 $30.00 $33.0093990-TC $96.00 $97.00 $104.00 $105.00 $97.00 $104.00 $105.0094002 --------- $105.00 $109.00 $114.00 $105.00 $109.00 $114.0094003 --------- $76.00 $78.00 $82.00 $76.00 $78.00 $82.0094004 --------- $55.00 $57.00 $59.00 $55.00 $57.00 $59.0094010 $30.00 $39.00 $42.00 $42.00 $39.00 $42.00 $42.0094010-26 $12.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.0094010-TC $16.00 $30.00 $32.00 $32.00 $30.00 $32.00 $32.0094014 $39.00 $61.00 $65.00 $66.00 $61.00 $65.00 $66.0094015 $14.00 $33.00 $36.00 $36.00 $33.00 $36.00 $36.0094016 $26.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.0094060 $57.00 $66.00 $70.00 $71.00 $66.00 $70.00 $71.0094060-26 $18.00 $15.00 $15.00 $15.00 $15.00 $15.00 $15.0094060-TC $36.00 $51.00 $55.00 $55.00 $51.00 $55.00 $55.0094070 $32.00 $65.00 $69.00 $70.00 $65.00 $69.00 $70.0094070-26 $11.00 $32.00 $33.00 $34.00 $32.00 $33.00 $34.0094070-TC $19.00 $33.00 $36.00 $36.00 $33.00 $36.00 $36.0094150 $8.00 $27.00 $29.00 $30.00 $27.00 $29.00 $30.0094150-26 $6.00 $4.00 $5.00 $5.00 $4.00 $5.00 $5.0094150-TC $3.00 $23.00 $25.00 $25.00 $23.00 $25.00 $25.0094200 $17.00 $27.00 $29.00 $30.00 $27.00 $29.00 $30.0094200-26 $7.00 $6.00 $7.00 $7.00 $6.00 $7.00 $7.0094200-TC $9.00 $21.00 $23.00 $23.00 $21.00 $23.00 $23.0094250 $12.00 $28.00 $30.00 $31.00 $28.00 $30.00 $31.0094250-26 $8.00 $6.00 $6.00 $7.00 $6.00 $6.00 $7.0094250-TC $5.00 $22.00 $24.00 $25.00 $22.00 $24.00 $25.0094375 $34.00 $43.00 $45.00 $46.00 $43.00 $45.00 $46.0094375-26 $16.00 $17.00 $17.00 $17.00 $17.00 $17.00 $17.0094375-TC $17.00 $26.00 $28.00 $29.00 $26.00 $28.00 $29.0094400 $40.00 $61.00 $64.00 $65.00 $61.00 $64.00 $65.0094400-26 $24.00 $22.00 $23.00 $23.00 $22.00 $23.00 $23.0094400-TC $14.00 $39.00 $42.00 $42.00 $39.00 $42.00 $42.0094450 $37.00 $74.00 $79.00 $80.00 $74.00 $79.00 $80.0094450-26 $20.00 $22.00 $23.00 $24.00 $22.00 $23.00 $24.0094450-TC $15.00 $52.00 $55.00 $56.00 $52.00 $55.00 $56.0094452 --------- $62.00 $66.00 $67.00 $62.00 $66.00 $67.0094452-26 --------- $16.00 $17.00 $17.00 $16.00 $17.00 $17.0094452-TC --------- $46.00 $50.00 $50.00 $46.00 $50.00 $50.0094453 --------- $86.00 $92.00 $93.00 $86.00 $92.00 $93.0094453-26 --------- $21.00 $22.00 $23.00 $21.00 $22.00 $23.0094453-TC --------- $65.00 $70.00 $71.00 $65.00 $70.00 $71.0094610 --------- $67.00 $69.00 $71.00 $67.00 $69.00 $71.0094620 $91.00 $62.00 $65.00 $66.00 $62.00 $65.00 $66.0094620-26 $38.00 $34.00 $35.00 $36.00 $34.00 $35.00 $36.0094620-TC $54.00 $27.00 $29.00 $30.00 $27.00 $29.00 $30.0094621 $122.00 $178.00 $188.00 $191.00 $178.00 $188.00 $191.0094621-26 $71.00 $77.00 $79.00 $81.00 $77.00 $79.00 $81.0094621-TC $52.00 $101.00 $108.00 $109.00 $101.00 $108.00 $109.0094640 $19.00 $20.00 $21.00 $22.00 $20.00 $21.00 $22.00



Medicine







94642 BR --------- --------- --------- --------- --------- ---------94644 --------- $47.00 $51.00 $51.00 $47.00 $51.00 $51.0094645 --------- $15.00 $16.00 $17.00 $15.00 $16.00 $17.0094660 $54.00 $70.00 $73.00 $75.00 $43.00 $45.00 $46.0094662 $38.00 $42.00 $44.00 $46.00 $42.00 $44.00 $46.0094664 $18.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.0094667 $23.00 $28.00 $31.00 $31.00 $28.00 $31.00 $31.0094668 $16.00 $31.00 $34.00 $35.00 $31.00 $34.00 $35.0094669 --------- $35.00 $38.00 $39.00 $35.00 $38.00 $39.0094680 $47.00 $62.00 $66.00 $67.00 $62.00 $66.00 $67.0094680-26 $23.00 $14.00 $15.00 $15.00 $14.00 $15.00 $15.0094680-TC $22.00 $48.00 $51.00 $52.00 $48.00 $51.00 $52.0094681 $60.00 $57.00 $61.00 $62.00 $57.00 $61.00 $62.0094681-26 $12.00 $11.00 $11.00 $12.00 $11.00 $11.00 $12.0094681-TC $43.00 $46.00 $49.00 $50.00 $46.00 $49.00 $50.0094690 $24.00 $54.00 $58.00 $58.00 $54.00 $58.00 $58.0094690-26 $4.00 $4.00 $5.00 $5.00 $4.00 $5.00 $5.0094690-TC $20.00 $49.00 $53.00 $53.00 $49.00 $53.00 $53.0094726 --------- $57.00 $61.00 $61.00 $57.00 $61.00 $61.0094726-26 --------- $14.00 $14.00 $14.00 $14.00 $14.00 $14.0094726-TC --------- $43.00 $47.00 $47.00 $43.00 $47.00 $47.0094727 --------- $46.00 $49.00 $49.00 $46.00 $49.00 $49.0094727-26 --------- $14.00 $14.00 $14.00 $14.00 $14.00 $14.0094727-TC --------- $32.00 $34.00 $35.00 $32.00 $34.00 $35.0094728 --------- $44.00 $46.00 $47.00 $44.00 $46.00 $47.0094728-26 --------- $14.00 $15.00 $15.00 $14.00 $15.00 $15.0094728-TC --------- $30.00 $32.00 $32.00 $30.00 $32.00 $32.0094729 --------- $59.00 $63.00 $64.00 $59.00 $63.00 $64.0094729-26 --------- $10.00 $11.00 $11.00 $10.00 $11.00 $11.0094729-TC --------- $49.00 $52.00 $53.00 $49.00 $52.00 $53.0094750 $37.00 $87.00 $93.00 $94.00 $87.00 $93.00 $94.0094750-26 $14.00 $13.00 $13.00 $13.00 $13.00 $13.00 $13.0094750-TC $21.00 $74.00 $80.00 $80.00 $74.00 $80.00 $80.0094760 $9.00 $4.00 $4.00 $4.00 $4.00 $4.00 $4.0094761 $20.00 $5.00 $6.00 $6.00 $5.00 $6.00 $6.0094762 $30.00 $26.00 $28.00 $29.00 $26.00 $28.00 $29.0094770 $21.00 $8.00 $9.00 $9.00 $8.00 $9.00 $9.0094770-26 $9.00 --------- --------- --------- --------- --------- ---------94770-TC $12.00 --------- --------- --------- --------- --------- ---------94799 BR --------- --------- --------- --------- --------- ---------94799-26 BR --------- --------- --------- --------- --------- ---------94799-TC BR --------- --------- --------- --------- --------- ---------95004 $3.00 $7.00 $8.00 $8.00 $7.00 $8.00 $8.0095012 --------- $21.00 $22.00 $23.00 $21.00 $22.00 $23.0095017 --------- $9.00 $9.00 $9.00 $4.00 $4.00 $5.0095018 --------- $22.00 $24.00 $24.00 $8.00 $8.00 $9.0095024 $3.00 $8.00 $9.00 $10.00 $1.00 $1.00 $2.0095027 $5.00 $5.00 $6.00 $6.00 $5.00 $6.00 $6.0095028 $8.00 $15.00 $16.00 $16.00 $15.00 $16.00 $16.0095044 $7.00 $6.00 $7.00 $7.00 $6.00 $7.00 $7.00



Medicine







95052 $9.00 $7.00 $8.00 $8.00 $7.00 $8.00 $8.0095056 $6.00 $48.00 $51.00 $52.00 $48.00 $51.00 $52.0095060 $13.00 $38.00 $40.00 $41.00 $38.00 $40.00 $41.0095065 $7.00 $27.00 $29.00 $30.00 $27.00 $29.00 $30.0095070 $82.00 $33.00 $35.00 $36.00 $33.00 $35.00 $36.0095071 $105.00 $38.00 $41.00 $41.00 $38.00 $41.00 $41.0095076 --------- $128.00 $133.00 $135.00 $82.00 $84.00 $86.0095079 --------- $91.00 $95.00 $96.00 $75.00 $77.00 $78.0095115 $10.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.0095117 $9.00 $11.00 $12.00 $12.00 $11.00 $12.00 $12.0095120 BR --------- --------- --------- --------- --------- ---------95125 BR --------- --------- --------- --------- --------- ---------95130 BR --------- --------- --------- --------- --------- ---------95131 BR --------- --------- --------- --------- --------- ---------95132 BR --------- --------- --------- --------- --------- ---------95133 BR --------- --------- --------- --------- --------- ---------95134 BR --------- --------- --------- --------- --------- ---------95144 $9.00 $13.00 $14.00 $15.00 $4.00 $4.00 $4.0095145 $17.00 $23.00 $25.00 $25.00 $4.00 $4.00 $4.0095146 $24.00 $42.00 $45.00 $45.00 $4.00 $4.00 $4.0095147 $33.00 $38.00 $40.00 $41.00 $4.00 $4.00 $4.0095148 $32.00 $56.00 $60.00 $60.00 $4.00 $4.00 $4.0095149 $36.00 $75.00 $81.00 $81.00 $4.00 $4.00 $4.0095165 $7.00 $14.00 $15.00 $15.00 $4.00 $4.00 $4.0095170 $13.00 $10.00 $11.00 $11.00 $4.00 $4.00 $4.0095180 $103.00 $147.00 $153.00 $156.00 $113.00 $116.00 $119.0095199 BR --------- --------- --------- --------- --------- ---------95250 $114.00 $169.00 $182.00 $184.00 $169.00 $182.00 $184.0095251 --------- $49.00 $50.00 $52.00 $49.00 $50.00 $52.0095803 --------- $153.00 $163.00 $164.00 $153.00 $163.00 $164.0095803-26 --------- $49.00 $50.00 $52.00 $49.00 $50.00 $52.0095803-TC --------- $104.00 $112.00 $113.00 $104.00 $112.00 $113.0095805 $334.00 $461.00 $492.00 $497.00 $461.00 $492.00 $497.0095805-26 $94.00 $66.00 $68.00 $70.00 $66.00 $68.00 $70.0095805-TC $237.00 $395.00 $424.00 $428.00 $395.00 $424.00 $428.0095806 $232.00 $183.00 $193.00 $195.00 $183.00 $193.00 $195.0095806-26 $109.00 $68.00 $70.00 $72.00 $68.00 $70.00 $72.0095806-TC $137.00 $115.00 $123.00 $124.00 $115.00 $123.00 $124.0095807 $367.00 $515.00 $551.00 $556.00 $515.00 $551.00 $556.0095807-26 $98.00 $70.00 $72.00 $74.00 $70.00 $72.00 $74.0095807-TC $256.00 $446.00 $479.00 $482.00 $446.00 $479.00 $482.0095808 $456.00 $679.00 $726.00 $733.00 $679.00 $726.00 $733.0095808-26 $149.00 $98.00 $102.00 $104.00 $98.00 $102.00 $104.0095808-TC $256.00 $581.00 $624.00 $629.00 $581.00 $624.00 $629.0095810 $521.00 $673.00 $718.00 $725.00 $673.00 $718.00 $725.0095810-26 $183.00 $136.00 $140.00 $144.00 $136.00 $140.00 $144.0095810-TC $256.00 $537.00 $577.00 $582.00 $537.00 $577.00 $582.0095811 $644.00 $708.00 $755.00 $763.00 $708.00 $755.00 $763.0095811-26 $196.00 $142.00 $146.00 $150.00 $142.00 $146.00 $150.0095811-TC $423.00 $566.00 $608.00 $613.00 $566.00 $608.00 $613.00



Medicine







95812 $137.00 $376.00 $401.00 $405.00 $376.00 $401.00 $405.0095812-26 $58.00 $65.00 $67.00 $69.00 $65.00 $67.00 $69.0095812-TC $68.00 $311.00 $334.00 $336.00 $311.00 $334.00 $336.0095813 $177.00 $456.00 $486.00 $491.00 $456.00 $486.00 $491.0095813-26 $89.00 $103.00 $107.00 $110.00 $103.00 $107.00 $110.0095813-TC $68.00 $353.00 $379.00 $381.00 $353.00 $379.00 $381.0095816 $133.00 $390.00 $417.00 $420.00 $390.00 $417.00 $420.0095816-26 $54.00 $65.00 $67.00 $69.00 $65.00 $67.00 $69.0095816-TC $78.00 $326.00 $350.00 $352.00 $326.00 $350.00 $352.0095819 $115.00 $446.00 $476.00 $481.00 $446.00 $476.00 $481.0095819-26 $58.00 $65.00 $67.00 $69.00 $65.00 $67.00 $69.0095819-TC $56.00 $381.00 $410.00 $412.00 $381.00 $410.00 $412.0095822 $120.00 $402.00 $429.00 $433.00 $402.00 $429.00 $433.0095822-26 $58.00 $65.00 $67.00 $69.00 $65.00 $67.00 $69.0095822-TC $63.00 $337.00 $362.00 $364.00 $337.00 $362.00 $364.0095824 $51.00 --------- --------- --------- --------- --------- ---------95824-26 $41.00 $44.00 $46.00 $47.00 $44.00 $46.00 $47.0095824-TC $10.00 --------- --------- --------- --------- --------- ---------95827 $145.00 $750.00 $804.00 $811.00 $750.00 $804.00 $811.0095827-26 $59.00 $64.00 $66.00 $68.00 $64.00 $66.00 $68.0095827-TC $86.00 $686.00 $737.00 $743.00 $686.00 $737.00 $743.0095829 $328.00 $2,031.00 $2,168.00 $2,192.00 $2,031.00 $2,168.00 $2,192.0095829-26 $291.00 $380.00 $396.00 $412.00 $380.00 $396.00 $412.0095829-TC $6.00 $1,652.00 $1,773.00 $1,780.00 $1,652.00 $1,773.00 $1,780.0095830 $133.00 $267.00 $284.00 $289.00 $104.00 $108.00 $112.0095831 $26.00 $33.00 $35.00 $36.00 $17.00 $18.00 $19.0095832 $21.00 $32.00 $34.00 $36.00 $18.00 $19.00 $20.0095833 $34.00 $41.00 $43.00 $43.00 $24.00 $25.00 $25.0095834 $44.00 $56.00 $59.00 $61.00 $35.00 $36.00 $38.0095851 $18.00 $20.00 $21.00 $22.00 $9.00 $9.00 $9.0095852 $14.00 $18.00 $19.00 $19.00 $7.00 $7.00 $7.0095857 $40.00 $59.00 $63.00 $64.00 $33.00 $35.00 $36.0095860 $73.00 $133.00 $140.00 $142.00 $133.00 $140.00 $142.0095860-26 $53.00 $58.00 $60.00 $61.00 $58.00 $60.00 $61.0095860-TC $15.00 $75.00 $81.00 $81.00 $75.00 $81.00 $81.0095861 $113.00 $187.00 $198.00 $201.00 $187.00 $198.00 $201.0095861-26 $86.00 $93.00 $96.00 $99.00 $93.00 $96.00 $99.0095861-TC $28.00 $94.00 $101.00 $102.00 $94.00 $101.00 $102.0095863 $138.00 $232.00 $245.00 $248.00 $232.00 $245.00 $248.0095863-26 $102.00 $112.00 $115.00 $118.00 $112.00 $115.00 $118.0095863-TC $35.00 $120.00 $129.00 $130.00 $120.00 $129.00 $130.0095864 $177.00 $262.00 $278.00 $283.00 $262.00 $278.00 $283.0095864-26 $114.00 $122.00 $126.00 $131.00 $122.00 $126.00 $131.0095864-TC $67.00 $141.00 $151.00 $152.00 $141.00 $151.00 $152.0095865 --------- $158.00 $167.00 $171.00 $158.00 $167.00 $171.0095865-26 --------- $95.00 $99.00 $102.00 $95.00 $99.00 $102.0095865-TC --------- $63.00 $68.00 $69.00 $63.00 $68.00 $69.0095866 --------- $146.00 $153.00 $156.00 $146.00 $153.00 $156.0095866-26 --------- $75.00 $77.00 $79.00 $75.00 $77.00 $79.0095866-TC --------- $71.00 $76.00 $77.00 $71.00 $76.00 $77.00



Medicine







95867 $66.00 $103.00 $109.00 $110.00 $103.00 $109.00 $110.0095867-26 $43.00 $47.00 $48.00 $50.00 $47.00 $48.00 $50.0095867-TC $21.00 $56.00 $60.00 $61.00 $56.00 $60.00 $61.0095868 $96.00 $145.00 $153.00 $156.00 $145.00 $153.00 $156.0095868-26 $71.00 $71.00 $74.00 $76.00 $71.00 $74.00 $76.0095868-TC $26.00 $74.00 $79.00 $80.00 $74.00 $79.00 $80.0095869 $29.00 $100.00 $107.00 $108.00 $100.00 $107.00 $108.0095869-26 $21.00 $22.00 $23.00 $24.00 $22.00 $23.00 $24.0095869-TC $8.00 $78.00 $84.00 $84.00 $78.00 $84.00 $84.0095870 $29.00 $100.00 $107.00 $108.00 $100.00 $107.00 $108.0095870-26 $21.00 $22.00 $23.00 $23.00 $22.00 $23.00 $23.0095870-TC $8.00 $78.00 $84.00 $85.00 $78.00 $84.00 $85.0095872 $104.00 $217.00 $226.00 $232.00 $217.00 $226.00 $232.0095872-26 $81.00 $172.00 $178.00 $183.00 $172.00 $178.00 $183.0095872-TC $22.00 $45.00 $48.00 $49.00 $45.00 $48.00 $49.0095873 --------- $79.00 $84.00 $85.00 $79.00 $84.00 $85.0095873-26 --------- $22.00 $23.00 $23.00 $22.00 $23.00 $23.0095873-TC --------- $57.00 $61.00 $61.00 $57.00 $61.00 $61.0095874 --------- $79.00 $84.00 $85.00 $79.00 $84.00 $85.0095874-26 --------- $22.00 $23.00 $24.00 $22.00 $23.00 $24.0095874-TC --------- $57.00 $61.00 $61.00 $57.00 $61.00 $61.0095875 $43.00 $136.00 $144.00 $147.00 $136.00 $144.00 $147.0095875-26 $34.00 $66.00 $69.00 $71.00 $66.00 $69.00 $71.0095875-TC $7.00 $70.00 $75.00 $76.00 $70.00 $75.00 $76.0095885 --------- $64.00 $67.00 $68.00 $64.00 $67.00 $68.0095885-26 --------- $21.00 $22.00 $23.00 $21.00 $22.00 $23.0095885-TC --------- $42.00 $45.00 $46.00 $42.00 $45.00 $46.0095886 --------- $99.00 $105.00 $106.00 $99.00 $105.00 $106.0095886-26 --------- $52.00 $54.00 $55.00 $52.00 $54.00 $55.0095886-TC --------- $48.00 $51.00 $51.00 $48.00 $51.00 $51.0095887 --------- $88.00 $93.00 $95.00 $88.00 $93.00 $95.0095887-26 --------- $43.00 $44.00 $45.00 $43.00 $44.00 $45.0095887-TC --------- $46.00 $49.00 $49.00 $46.00 $49.00 $49.0095905 --------- $75.00 $81.00 $82.00 $75.00 $81.00 $82.0095905-26 --------- $3.00 $3.00 $4.00 $3.00 $3.00 $4.0095905-TC --------- $72.00 $77.00 $78.00 $72.00 $77.00 $78.0095907 --------- $104.00 $110.00 $112.00 $104.00 $110.00 $112.0095907-26 --------- $60.00 $62.00 $63.00 $60.00 $62.00 $63.0095907-TC --------- $45.00 $48.00 $49.00 $45.00 $48.00 $49.0095908 --------- $130.00 $136.00 $139.00 $130.00 $136.00 $139.0095908-26 --------- $75.00 $77.00 $79.00 $75.00 $77.00 $79.0095908-TC --------- $55.00 $59.00 $60.00 $55.00 $59.00 $60.0095909 --------- $158.00 $166.00 $169.00 $158.00 $166.00 $169.0095909-26 --------- $90.00 $93.00 $95.00 $90.00 $93.00 $95.0095909-TC --------- $68.00 $73.00 $74.00 $68.00 $73.00 $74.0095910 --------- $210.00 $221.00 $225.00 $210.00 $221.00 $225.0095910-26 --------- $120.00 $124.00 $127.00 $120.00 $124.00 $127.0095910-TC --------- $91.00 $97.00 $98.00 $91.00 $97.00 $98.0095911 --------- $254.00 $267.00 $272.00 $254.00 $267.00 $272.0095911-26 --------- $150.00 $155.00 $159.00 $150.00 $155.00 $159.00



Medicine







95911-TC --------- $104.00 $112.00 $113.00 $104.00 $112.00 $113.0095912 --------- $285.00 $299.00 $304.00 $285.00 $299.00 $304.0095912-26 --------- $178.00 $184.00 $189.00 $178.00 $184.00 $189.0095912-TC --------- $107.00 $115.00 $116.00 $107.00 $115.00 $116.0095913 --------- $326.00 $342.00 $348.00 $326.00 $342.00 $348.0095913-26 --------- $210.00 $218.00 $223.00 $210.00 $218.00 $223.0095913-TC --------- $116.00 $124.00 $125.00 $116.00 $124.00 $125.0095921 $61.00 $94.00 $99.00 $101.00 $94.00 $99.00 $101.0095921-26 $46.00 $51.00 $52.00 $54.00 $51.00 $52.00 $54.0095921-TC $14.00 $44.00 $47.00 $47.00 $44.00 $47.00 $47.0095922 $65.00 $110.00 $116.00 $118.00 $110.00 $116.00 $118.0095922-26 $50.00 $54.00 $56.00 $57.00 $54.00 $56.00 $57.0095922-TC $14.00 $56.00 $60.00 $60.00 $56.00 $60.00 $60.0095923 $105.00 $178.00 $189.00 $192.00 $178.00 $189.00 $192.0095923-26 $47.00 $52.00 $54.00 $56.00 $52.00 $54.00 $56.0095923-TC $57.00 $126.00 $135.00 $136.00 $126.00 $135.00 $136.0095924 --------- $164.00 $172.00 $176.00 $164.00 $172.00 $176.0095924-26 --------- $100.00 $104.00 $107.00 $100.00 $104.00 $107.0095924-TC --------- $63.00 $68.00 $69.00 $63.00 $68.00 $69.0095925 $94.00 $168.00 $179.00 $181.00 $168.00 $179.00 $181.0095925-26 $53.00 $32.00 $33.00 $34.00 $32.00 $33.00 $34.0095925-TC $41.00 $136.00 $147.00 $148.00 $136.00 $147.00 $148.0095926 $66.00 $149.00 $159.00 $160.00 $149.00 $159.00 $160.0095926-26 $34.00 $31.00 $32.00 $33.00 $31.00 $32.00 $33.0095926-TC $34.00 $118.00 $127.00 $128.00 $118.00 $127.00 $128.0095927 $67.00 $154.00 $164.00 $166.00 $154.00 $164.00 $166.0095927-26 $34.00 $31.00 $32.00 $33.00 $31.00 $32.00 $33.0095927-TC $34.00 $123.00 $132.00 $134.00 $123.00 $132.00 $134.0095928 --------- $244.00 $258.00 $262.00 $244.00 $258.00 $262.0095928-26 --------- $90.00 $93.00 $95.00 $90.00 $93.00 $95.0095928-TC --------- $154.00 $165.00 $166.00 $154.00 $165.00 $166.0095929 --------- $246.00 $261.00 $265.00 $246.00 $261.00 $265.0095929-26 --------- $91.00 $94.00 $97.00 $91.00 $94.00 $97.0095929-TC --------- $155.00 $167.00 $167.00 $155.00 $167.00 $167.0095930 $44.00 $139.00 $149.00 $150.00 $139.00 $149.00 $150.0095930-26 $25.00 $21.00 $21.00 $22.00 $21.00 $21.00 $22.0095930-TC $11.00 $119.00 $128.00 $128.00 $119.00 $128.00 $128.0095933 $62.00 $82.00 $86.00 $88.00 $82.00 $86.00 $88.0095933-26 $33.00 $35.00 $36.00 $37.00 $35.00 $36.00 $37.0095933-TC $30.00 $47.00 $50.00 $51.00 $47.00 $50.00 $51.0095937 $40.00 $89.00 $94.00 $95.00 $89.00 $94.00 $95.0095937-26 $31.00 $38.00 $40.00 $41.00 $38.00 $40.00 $41.0095937-TC $9.00 $50.00 $54.00 $54.00 $50.00 $54.00 $54.0095938 --------- $368.00 $393.00 $396.00 $368.00 $393.00 $396.0095938-26 --------- $52.00 $53.00 $55.00 $52.00 $53.00 $55.0095938-TC --------- $316.00 $340.00 $341.00 $316.00 $340.00 $341.0095939 --------- $541.00 $576.00 $582.00 $541.00 $576.00 $582.0095939-26 --------- $134.00 $139.00 $143.00 $134.00 $139.00 $143.0095939-TC --------- $407.00 $437.00 $440.00 $407.00 $437.00 $440.0095940 --------- $37.00 $38.00 $40.00 $37.00 $38.00 $40.00



Medicine







95950 $265.00 $358.00 $381.00 $385.00 $358.00 $381.00 $385.0095950-26 $84.00 $90.00 $93.00 $95.00 $90.00 $93.00 $95.0095950-TC $177.00 $268.00 $288.00 $290.00 $268.00 $288.00 $290.0095951 $34.00 --------- --------- --------- --------- --------- ---------95951-26 $14.00 $358.00 $371.00 $381.00 $358.00 $371.00 $381.0095951-TC $20.00 --------- --------- --------- --------- --------- ---------95953 $411.00 $459.00 $486.00 $494.00 $459.00 $486.00 $494.0095953-26 $165.00 $184.00 $191.00 $196.00 $184.00 $191.00 $196.0095953-TC $240.00 $275.00 $296.00 $297.00 $275.00 $296.00 $297.0095954 $208.00 $488.00 $519.00 $526.00 $488.00 $519.00 $526.0095954-26 $134.00 $140.00 $145.00 $149.00 $140.00 $145.00 $149.0095954-TC $23.00 $349.00 $375.00 $377.00 $349.00 $375.00 $377.0095955 $130.00 $234.00 $249.00 $252.00 $234.00 $249.00 $252.0095955-26 $59.00 $61.00 $63.00 $65.00 $61.00 $63.00 $65.0095955-TC $74.00 $173.00 $186.00 $187.00 $173.00 $186.00 $187.0095956 $541.00 $1,767.00 $1,891.00 $1,907.00 $1,767.00 $1,891.00 $1,907.0095956-26 $166.00 $215.00 $222.00 $229.00 $215.00 $222.00 $229.0095956-TC $314.00 $1,553.00 $1,668.00 $1,679.00 $1,553.00 $1,668.00 $1,679.0095957 $171.00 $342.00 $363.00 $367.00 $342.00 $363.00 $367.0095957-26 $104.00 $118.00 $122.00 $125.00 $118.00 $122.00 $125.0095957-TC $64.00 $224.00 $241.00 $242.00 $224.00 $241.00 $242.0095958 $296.00 $624.00 $662.00 $674.00 $624.00 $662.00 $674.0095958-26 $230.00 $254.00 $264.00 $274.00 $254.00 $264.00 $274.0095958-TC $66.00 $370.00 $398.00 $401.00 $370.00 $398.00 $401.0095961 $216.00 $324.00 $343.00 $352.00 $324.00 $343.00 $352.0095961-26 $166.00 $183.00 $192.00 $201.00 $183.00 $192.00 $201.0095961-TC $48.00 $140.00 $151.00 $152.00 $140.00 $151.00 $152.0095962 $227.00 $289.00 $304.00 $311.00 $289.00 $304.00 $311.0095962-26 $176.00 $195.00 $203.00 $210.00 $195.00 $203.00 $210.0095962-TC $48.00 $94.00 $101.00 $101.00 $94.00 $101.00 $101.0095965 BR --------- --------- --------- --------- --------- ---------95965-26 $420.00 $471.00 $487.00 $500.00 $471.00 $487.00 $500.0095965-TC BR --------- --------- --------- --------- --------- ---------95966 BR --------- --------- --------- --------- --------- ---------95966-26 $210.00 $238.00 $247.00 $254.00 $238.00 $247.00 $254.0095966-TC BR --------- --------- --------- --------- --------- ---------95967 BR --------- --------- --------- --------- --------- ---------95967-26 $184.00 $208.00 $215.00 $221.00 $208.00 $215.00 $221.0095967-TC BR --------- --------- --------- --------- --------- ---------95970 $22.00 $74.00 $78.00 $80.00 $27.00 $28.00 $29.0095971 $39.00 $56.00 $59.00 $61.00 $46.00 $48.00 $50.0095972 $78.00 $65.00 $68.00 $71.00 $47.00 $49.00 $52.0095974 $155.00 $231.00 $243.00 $252.00 $185.00 $193.00 $202.0095975 $88.00 $125.00 $131.00 $135.00 $105.00 $109.00 $114.0095978 --------- $278.00 $292.00 $304.00 $218.00 $228.00 $239.0095979 --------- $121.00 $127.00 $131.00 $101.00 $106.00 $110.0095980 --------- $54.00 $57.00 $62.00 $54.00 $57.00 $62.0095981 --------- $35.00 $37.00 $39.00 $20.00 $21.00 $23.0095982 --------- $59.00 $62.00 $65.00 $42.00 $44.00 $47.0095990 $57.00 $98.00 $106.00 $107.00 $98.00 $106.00 $107.00



Medicine







95991 --------- $132.00 $140.00 $142.00 $45.00 $47.00 $48.0095992 --------- $48.00 $50.00 $51.00 $42.00 $43.00 $44.0095999 BR --------- --------- --------- --------- --------- ---------96000 $93.00 $107.00 $111.00 $114.00 $107.00 $111.00 $114.0096001 $111.00 $121.00 $127.00 $134.00 $121.00 $127.00 $134.0096002 $21.00 $25.00 $25.00 $26.00 $25.00 $25.00 $26.0096003 $20.00 $19.00 $20.00 $20.00 $19.00 $20.00 $20.0096004 $97.00 $131.00 $136.00 $141.00 $131.00 $136.00 $141.0096020 --------- BR BR BR BR BR BR96020-26 --------- $183.00 $189.00 $194.00 $183.00 $189.00 $194.0096020-TC --------- BR BR BR BR BR BR96101 --------- $89.00 $91.00 $93.00 $89.00 $91.00 $93.0096102 --------- $69.00 $73.00 $74.00 $26.00 $27.00 $28.0096103 --------- $31.00 $32.00 $33.00 $30.00 $31.00 $33.0096105 $68.00 $118.00 $123.00 $126.00 $118.00 $123.00 $126.0096110 $88.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.0096111 $68.00 $144.00 $149.00 $153.00 $137.00 $141.00 $145.0096116 --------- $103.00 $107.00 $110.00 $97.00 $100.00 $103.0096118 --------- $108.00 $112.00 $114.00 $88.00 $90.00 $92.0096119 --------- $87.00 $92.00 $92.00 $26.00 $27.00 $28.0096120 --------- $53.00 $56.00 $57.00 $29.00 $30.00 $32.0096125 --------- $129.00 $134.00 $136.00 $129.00 $134.00 $136.0096127 --------- $6.00 $6.00 $7.00 $6.00 $6.00 $7.0096150 --------- $24.00 $25.00 $25.00 $24.00 $24.00 $25.0096151 --------- $23.00 $24.00 $24.00 $23.00 $23.00 $24.0096152 --------- $22.00 $23.00 $23.00 $22.00 $22.00 $23.0096153 --------- $5.00 $5.00 $6.00 $5.00 $5.00 $6.0096154 --------- $22.00 $22.00 $23.00 $21.00 $22.00 $23.0096155 --------- $25.00 $26.00 $27.00 $25.00 $26.00 $27.0096360 --------- $62.00 $66.00 $67.00 $62.00 $66.00 $67.0096361 --------- $17.00 $18.00 $18.00 $17.00 $18.00 $18.0096365 --------- $75.00 $80.00 $81.00 $75.00 $80.00 $81.0096366 --------- $20.00 $22.00 $22.00 $20.00 $22.00 $22.0096367 --------- $33.00 $35.00 $36.00 $33.00 $35.00 $36.0096368 --------- $22.00 $24.00 $24.00 $22.00 $24.00 $24.0096369 --------- $206.00 $220.00 $222.00 $206.00 $220.00 $222.0096370 See formula $16.00 $17.00 $17.00 $16.00 $17.00 $17.0096371 --------- $78.00 $83.00 $83.00 $78.00 $83.00 $83.0096372 --------- $27.00 $29.00 $29.00 $27.00 $29.00 $29.0096373 --------- $21.00 $22.00 $23.00 $21.00 $22.00 $23.0096374 --------- $61.00 $66.00 $67.00 $61.00 $66.00 $67.0096375 --------- $24.00 $26.00 $26.00 $24.00 $26.00 $26.0096401 --------- $80.00 $86.00 $88.00 $80.00 $86.00 $88.0096402 --------- $35.00 $37.00 $38.00 $35.00 $37.00 $38.0096405 $57.00 $89.00 $94.00 $95.00 $33.00 $35.00 $36.0096406 $86.00 $126.00 $134.00 $136.00 $52.00 $54.00 $56.0096409 --------- $119.00 $128.00 $131.00 $119.00 $128.00 $131.0096411 --------- $67.00 $72.00 $73.00 $67.00 $72.00 $73.0096413 --------- $146.00 $156.00 $159.00 $146.00 $156.00 $159.0096415 --------- $31.00 $33.00 $33.00 $31.00 $33.00 $33.00



Medicine







96416 --------- $151.00 $163.00 $165.00 $151.00 $163.00 $165.0096417 --------- $67.00 $72.00 $74.00 $67.00 $72.00 $74.0096420 $46.00 $114.00 $122.00 $125.00 $114.00 $122.00 $125.0096422 $46.00 $182.00 $196.00 $200.00 $182.00 $196.00 $200.0096423 $17.00 $85.00 $91.00 $93.00 $85.00 $91.00 $93.0096425 $54.00 $195.00 $210.00 $215.00 $195.00 $210.00 $215.0096440 $156.00 $914.00 $981.00 $1,001.00 $163.00 $175.00 $192.0096446 --------- $218.00 $236.00 $245.00 $35.00 $40.00 $48.0096450 $134.00 $198.00 $210.00 $214.00 $91.00 $95.00 $98.0096521 --------- $148.00 $159.00 $162.00 $148.00 $159.00 $162.0096522 --------- $122.00 $131.00 $134.00 $122.00 $131.00 $134.0096523 --------- $27.00 $29.00 $29.00 $27.00 $29.00 $29.0096542 $126.00 $131.00 $139.00 $142.00 $47.00 $49.00 $51.0096549 BR --------- --------- --------- --------- --------- ---------96567 $62.00 $144.00 $155.00 $156.00 $144.00 $155.00 $156.0096570 $69.00 $67.00 $71.00 $77.00 $67.00 $71.00 $77.0096571 $38.00 $31.00 $32.00 $33.00 $31.00 $32.00 $33.0096900 $17.00 $22.00 $24.00 $24.00 $22.00 $24.00 $24.0096904 --------- $67.00 $72.00 $73.00 $67.00 $72.00 $73.0096910 $21.00 $76.00 $82.00 $82.00 $76.00 $82.00 $82.0096912 $24.00 $97.00 $105.00 $105.00 $97.00 $105.00 $105.0096913 $53.00 $140.00 $150.00 $152.00 $140.00 $150.00 $152.0096920 $152.00 $169.00 $178.00 $181.00 $74.00 $77.00 $79.0096921 $155.00 $186.00 $196.00 $198.00 $84.00 $87.00 $89.0096922 $214.00 $258.00 $272.00 $276.00 $136.00 $141.00 $145.0096999 BR --------- --------- --------- --------- --------- ---------97001 $62.00 $83.00 $86.00 $88.00 $83.00 $86.00 $88.0097002 $29.00 $46.00 $48.00 $48.00 $46.00 $48.00 $48.0097003 $62.00 $93.00 $97.00 $99.00 $93.00 $97.00 $99.0097004 $29.00 $57.00 $60.00 $61.00 $57.00 $60.00 $61.0097005 NC BR BR BR BR BR BR97006 NC BR BR BR BR BR BR97010 $10.00 $7.00 $7.00 $7.00 $7.00 $7.00 $7.0097012 $16.00 $18.00 $18.00 $19.00 $18.00 $18.00 $19.0097014 $14.00 $17.00 $18.00 $19.00 $17.00 $18.00 $19.0097016 $15.00 $21.00 $22.00 $22.00 $21.00 $22.00 $22.0097018 $10.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.0097022 $15.00 $25.00 $27.00 $27.00 $25.00 $27.00 $27.0097024 $10.00 $7.00 $8.00 $8.00 $7.00 $8.00 $8.0097026 $9.00 $7.00 $7.00 $7.00 $7.00 $7.00 $7.0097028 $10.00 $8.00 $9.00 $9.00 $8.00 $9.00 $9.0097032 $16.00 $21.00 $22.00 $22.00 $21.00 $22.00 $22.0097033 $16.00 $29.00 $30.00 $30.00 $29.00 $30.00 $30.0097034 $13.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.0097035 $11.00 $14.00 $15.00 $15.00 $14.00 $15.00 $15.0097036 $19.00 $36.00 $38.00 $38.00 $36.00 $38.00 $38.0097039 $15.00 --------- --------- --------- --------- --------- ---------97110 $22.00 $35.00 $37.00 $38.00 $35.00 $37.00 $38.0097112 $23.00 $37.00 $39.00 $39.00 $37.00 $39.00 $39.0097113 $24.00 $47.00 $49.00 $49.00 $47.00 $49.00 $49.00



Medicine







97116 $21.00 $31.00 $32.00 $33.00 $31.00 $32.00 $33.0097124 $19.00 $29.00 $30.00 $30.00 $29.00 $30.00 $30.0097139 $15.00 --------- --------- --------- --------- --------- ---------97140 $26.00 $33.00 $34.00 $34.00 $33.00 $34.00 $34.0097150 $18.00 $19.00 $20.00 $20.00 $19.00 $20.00 $20.0097260 $23.00 --------- --------- --------- --------- --------- ---------97261 $17.00 --------- --------- --------- --------- --------- ---------97530 $22.00 $38.00 $40.00 $40.00 $38.00 $40.00 $40.0097532 $22.00 $29.00 $30.00 $31.00 $29.00 $30.00 $31.0097533 $24.00 $32.00 $33.00 $33.00 $32.00 $33.00 $33.0097535 $23.00 $38.00 $40.00 $41.00 $38.00 $40.00 $41.0097537 $23.00 $33.00 $34.00 $35.00 $33.00 $34.00 $35.0097542 $17.00 $34.00 $35.00 $36.00 $34.00 $35.00 $36.0097545 $83.00 --------- --------- --------- --------- --------- ---------97546 $41.00 --------- --------- --------- --------- --------- ---------97597 --------- $81.00 $86.00 $87.00 $26.00 $27.00 $27.0097598 --------- $27.00 $28.00 $28.00 $12.00 $13.00 $13.0097602 BR --------- --------- --------- --------- --------- ---------97605 --------- $45.00 $47.00 $48.00 $28.00 $29.00 $29.0097606 --------- $53.00 $55.00 $56.00 $30.00 $31.00 $32.0097610 --------- $128.00 $137.00 $137.00 $18.00 $18.00 $18.0097750 BR BR BR BR BR BR BR97752 $48.00 --------- --------- --------- --------- --------- ---------97755 --------- $39.00 $41.00 $41.00 $39.00 $41.00 $41.0097760 --------- $41.00 $43.00 $44.00 $41.00 $43.00 $44.0097761 --------- $36.00 $38.00 $38.00 $36.00 $38.00 $38.0097762 --------- $51.00 $54.00 $55.00 $51.00 $54.00 $55.0097799 BR --------- --------- --------- --------- --------- ---------97802 $26.00 $38.00 $40.00 $40.00 $36.00 $37.00 $38.0097803 $17.00 $33.00 $34.00 $35.00 $30.00 $32.00 $32.0097804 $7.00 $18.00 $18.00 $19.00 $17.00 $17.00 $18.0097810 --------- $40.00 $42.00 $43.00 $34.00 $36.00 $37.0097811 --------- $30.00 $31.00 $32.00 $28.00 $29.00 $30.0097813 --------- $43.00 $45.00 $46.00 $37.00 $38.00 $40.0097814 --------- $34.00 $35.00 $36.00 $31.00 $32.00 $33.0097850 $54.00 --------- --------- --------- --------- --------- ---------97851 $26.00 --------- --------- --------- --------- --------- ---------97852 $54.00 --------- --------- --------- --------- --------- ---------97853 $26.00 --------- --------- --------- --------- --------- ---------98925 NC NC NC NC NC NC NC98926 $32.00 $50.00 $53.00 $54.00 $40.00 $42.00 $43.0098927 NC NC NC NC NC NC NC98928 $23.00 $80.00 $83.00 $85.00 $67.00 $69.00 $71.0098929 NC NC NC NC NC NC NC98940 NC NC NC NC NC NC NC98941 $32.00 $45.00 $46.00 $47.00 $38.00 $39.00 $40.0098942 NC NC NC NC NC NC NC98943 $23.00 $30.00 $32.00 $32.00 $26.00 $27.00 $28.0098960 --------- $30.00 $33.00 $33.00 $30.00 $33.00 $33.0098961 --------- $15.00 $16.00 $16.00 $15.00 $16.00 $16.00



Medicine







98962 --------- $11.00 $12.00 $12.00 $11.00 $12.00 $12.0099000 $6.00 --------- --------- --------- --------- --------- ---------99001 $4.00 --------- --------- --------- --------- --------- ---------99002 $35.00 --------- --------- --------- --------- --------- ---------99026 BR --------- --------- --------- --------- --------- ---------99027 BR --------- --------- --------- --------- --------- ---------99070 BR --------- --------- --------- --------- --------- ---------99071 NC NC NC NC NC NC NC99075 See 440.13 --------- --------- --------- --------- --------- ---------99078 NC NC NC NC NC NC NC99082 BR --------- --------- --------- --------- --------- ---------99090 BR --------- --------- --------- --------- --------- ---------99172 BR --------- --------- --------- --------- --------- ---------99173 BR $4.00 $4.00 $4.00 $4.00 $4.00 $4.0099174 --------- BR BR BR BR BR BR99175 $53.00 $18.00 $20.00 $20.00 $18.00 $20.00 $20.0099183 $123.00 $125.00 $131.00 $139.00 $125.00 $131.00 $139.0099184 --------- $256.00 $265.00 $274.00 $256.00 $265.00 $274.0099190 BR --------- --------- --------- --------- --------- ---------99191 BR --------- --------- --------- --------- --------- ---------99192 BR --------- --------- --------- --------- --------- ---------99195 $16.00 $107.00 $116.00 $118.00 $107.00 $116.00 $118.0099199 NC NC NC NC NC NC NCG0101 --------- $42.00 $45.00 $46.00 $31.00 $33.00 $34.00G0102 --------- $21.00 $22.00 $23.00 $10.00 $10.00 $11.00G0104 --------- $182.00 $195.00 $199.00 $65.00 $68.00 $72.00G0105 --------- $419.00 $445.00 $460.00 $222.00 $235.00 $249.00G0105-53 --------- $209.00 $222.00 $229.00 $112.00 $118.00 $125.00G0106 --------- $228.00 $243.00 $245.00 $228.00 $243.00 $245.00G0106-26 --------- $56.00 $57.00 $59.00 $56.00 $57.00 $59.00G0106-TC --------- $173.00 $185.00 $186.00 $173.00 $185.00 $186.00G0108 --------- $58.00 $61.00 $62.00 $58.00 $61.00 $62.00G0109 --------- $16.00 $16.00 $17.00 $16.00 $16.00 $17.00G0117 --------- $59.00 $62.00 $63.00 $59.00 $62.00 $63.00G0118 --------- $48.00 $51.00 $51.00 $48.00 $51.00 $51.00G0120 --------- $231.00 $246.00 $250.00 $231.00 $246.00 $250.00G0120-26 --------- $58.00 $61.00 $64.00 $58.00 $61.00 $64.00G0120-TC --------- $173.00 $185.00 $186.00 $173.00 $185.00 $186.00G0121 --------- $419.00 $446.00 $461.00 $223.00 $235.00 $250.00G0121-53 --------- $209.00 $222.00 $229.00 $111.00 $117.00 $125.00G0122 --------- $288.00 $306.00 $309.00 $288.00 $306.00 $309.00G0122-26 --------- $55.00 $56.00 $57.00 $55.00 $56.00 $57.00G0122-TC --------- $233.00 $250.00 $251.00 $233.00 $250.00 $251.00G0128 --------- $8.00 $9.00 $10.00 $8.00 $9.00 $10.00G0166 --------- $148.00 $159.00 $160.00 $148.00 $159.00 $160.00G0179 --------- $45.00 $47.00 $48.00 $45.00 $47.00 $48.00G0180 --------- $59.00 $62.00 $63.00 $59.00 $62.00 $63.00G0181 --------- $119.00 $125.00 $128.00 $119.00 $125.00 $128.00G0182 --------- $120.00 $125.00 $128.00 $120.00 $125.00 $128.00G0237 --------- $11.00 $12.00 $12.00 $11.00 $12.00 $12.00



Medicine







G0238 --------- $11.00 $12.00 $13.00 $11.00 $12.00 $13.00G0239 --------- $14.00 $15.00 $16.00 $14.00 $15.00 $16.00G0248 --------- $119.00 $128.00 $129.00 $119.00 $128.00 $129.00G0249 --------- $119.00 $128.00 $128.00 $119.00 $128.00 $128.00G0250 --------- $10.00 $11.00 $11.00 $10.00 $11.00 $11.00G0268 --------- $60.00 $63.00 $66.00 $39.00 $41.00 $44.00G0270 --------- $33.00 $34.00 $35.00 $30.00 $32.00 $32.00G0271 --------- $18.00 $18.00 $19.00 $17.00 $17.00 $18.00G0277 --------- $48.00 $51.00 $52.00 $48.00 $51.00 $52.00G0281 --------- $15.00 $16.00 $16.00 $15.00 $16.00 $16.00G0283 --------- $15.00 $16.00 $16.00 $15.00 $16.00 $16.00G0329 --------- $10.00 $11.00 $11.00 $10.00 $11.00 $11.00G0403 --------- $19.00 $20.00 $20.00 $19.00 $20.00 $20.00G0404 --------- $9.00 $10.00 $10.00 $9.00 $10.00 $10.00G0405 --------- $9.00 $10.00 $10.00 $9.00 $10.00 $10.00G0422 --------- $113.00 $118.00 $121.00 $113.00 $118.00 $121.00G0423 --------- $113.00 $118.00 $121.00 $113.00 $118.00 $121.00G0424 --------- $32.00 $34.00 $35.00 $15.00 $16.00 $17.00G0453 --------- $37.00 $38.00 $40.00 $37.00 $38.00 $40.00G0454 --------- $10.00 $11.00 $11.00 $10.00 $11.00 $11.00G0459 --------- $46.00 $47.00 $48.00 $46.00 $47.00 $48.00G0473 --------- $14.00 $14.00 $15.00 $13.00 $13.00 $14.00G9157 --------- $110.00 $114.00 $119.00 $110.00 $114.00 $119.00G9187 --------- $48.00 $52.00 $53.00 $48.00 $52.00 $53.00P3001 --------- $36.00 $37.00 $38.00 $36.00 $37.00 $38.00Q0035 --------- $23.00 $24.00 $25.00 $23.00 $24.00 $25.00Q0035-26 --------- $10.00 $10.00 $11.00 $10.00 $10.00 $11.00Q0035-TC --------- $13.00 $14.00 $14.00 $13.00 $14.00 $14.00Q0091 --------- $49.00 $52.00 $53.00 $22.00 $23.00 $25.00



Evaluation and Management







99201 $35.00 $48.00 $51.00 $52.00 $30.00 $31.00 $33.0099202 $58.00 $82.00 $86.00 $89.00 $56.00 $59.00 $61.0099203 $58.00 $119.00 $126.00 $130.00 $86.00 $90.00 $95.0099204 $84.00 $182.00 $191.00 $198.00 $146.00 $152.00 $159.0099205 $84.00 $229.00 $240.00 $249.00 $189.00 $198.00 $207.0099211 $19.00 $22.00 $23.00 $23.00 $10.00 $11.00 $11.0099212 $31.00 $47.00 $50.00 $51.00 $28.00 $29.00 $31.0099213 $40.00 $80.00 $84.00 $86.00 $57.00 $59.00 $61.0099214 $40.00 $118.00 $123.00 $127.00 $87.00 $91.00 $94.0099215 $65.00 $159.00 $167.00 $171.00 $124.00 $129.00 $133.0099217 $65.00 $81.00 $84.00 $87.00 $81.00 $84.00 $87.0099218 $65.00 $111.00 $116.00 $120.00 $111.00 $116.00 $120.0099219 $109.00 $151.00 $157.00 $162.00 $151.00 $157.00 $162.0099220 $152.00 $206.00 $214.00 $222.00 $206.00 $214.00 $222.0099221 $66.00 $114.00 $119.00 $125.00 $114.00 $119.00 $125.0099222 $109.00 $153.00 $159.00 $166.00 $153.00 $159.00 $166.0099223 $152.00 $226.00 $235.00 $244.00 $226.00 $235.00 $244.0099224 --------- $44.00 $46.00 $48.00 $44.00 $46.00 $48.0099225 --------- $81.00 $84.00 $87.00 $81.00 $84.00 $87.0099226 --------- $117.00 $121.00 $125.00 $117.00 $121.00 $125.0099231 $33.00 $44.00 $46.00 $48.00 $44.00 $46.00 $48.0099232 $54.00 $80.00 $83.00 $86.00 $80.00 $83.00 $86.0099233 $77.00 $116.00 $120.00 $125.00 $116.00 $120.00 $125.0099234 $129.00 $149.00 $155.00 $162.00 $149.00 $155.00 $162.0099235 $173.00 $188.00 $195.00 $203.00 $188.00 $195.00 $203.0099236 $213.00 $242.00 $252.00 $261.00 $242.00 $252.00 $261.0099238 $66.00 $80.00 $83.00 $86.00 $80.00 $83.00 $86.0099239 $88.00 $119.00 $124.00 $127.00 $119.00 $124.00 $127.0099241 $54.00 $52.00 $55.00 $56.00 $36.00 $38.00 $39.0099242 $88.00 $99.00 $103.00 $105.00 $76.00 $79.00 $81.0099243 $117.00 $135.00 $141.00 $144.00 $107.00 $110.00 $114.0099244 $163.00 $202.00 $211.00 $216.00 $171.00 $177.00 $183.0099245 $212.00 $247.00 $257.00 $264.00 $212.00 $219.00 $226.0099251 $54.00 $55.00 $56.00 $58.00 $55.00 $56.00 $58.0099252 $70.00 $83.00 $86.00 $89.00 $83.00 $86.00 $89.0099253 $96.00 $128.00 $132.00 $136.00 $128.00 $132.00 $136.0099254 $138.00 $186.00 $192.00 $198.00 $186.00 $192.00 $198.0099255 $190.00 $224.00 $232.00 $240.00 $224.00 $232.00 $240.0099281 $18.00 $24.00 $25.00 $26.00 $24.00 $25.00 $26.0099282 $28.00 $47.00 $49.00 $51.00 $47.00 $49.00 $51.0099283 $60.00 $70.00 $73.00 $76.00 $70.00 $73.00 $76.0099284 $94.00 $133.00 $138.00 $145.00 $133.00 $138.00 $145.0099285 $103.00 $196.00 $204.00 $214.00 $196.00 $204.00 $214.0099291 $192.00 $306.00 $320.00 $332.00 $251.00 $261.00 $273.0099292 $95.00 $137.00 $143.00 $149.00 $126.00 $131.00 $137.0099304 --------- $102.00 $106.00 $109.00 $102.00 $106.00 $109.0099305 --------- $145.00 $150.00 $155.00 $145.00 $150.00 $155.0099306 --------- $184.00 $191.00 $197.00 $184.00 $191.00 $197.0099307 --------- $50.00 $52.00 $53.00 $50.00 $52.00 $53.0099308 --------- $77.00 $80.00 $82.00 $77.00 $80.00 $82.00










99309 --------- $101.00 $105.00 $108.00 $101.00 $105.00 $108.0099310 --------- $150.00 $157.00 $162.00 $150.00 $157.00 $162.0099315 $60.00 $81.00 $84.00 $87.00 $81.00 $84.00 $87.0099316 $77.00 $117.00 $122.00 $126.00 $117.00 $122.00 $126.0099318 --------- $106.00 $110.00 $114.00 $106.00 $110.00 $114.0099324 --------- $62.00 $64.00 $66.00 $62.00 $64.00 $66.0099325 --------- $90.00 $93.00 $96.00 $90.00 $93.00 $96.0099326 --------- $155.00 $160.00 $166.00 $155.00 $160.00 $166.0099327 --------- $206.00 $214.00 $221.00 $206.00 $214.00 $221.0099328 --------- $241.00 $250.00 $258.00 $241.00 $250.00 $258.0099334 --------- $67.00 $70.00 $72.00 $67.00 $70.00 $72.0099335 --------- $106.00 $110.00 $113.00 $106.00 $110.00 $113.0099336 --------- $149.00 $155.00 $160.00 $149.00 $155.00 $160.0099337 --------- $214.00 $223.00 $230.00 $214.00 $223.00 $230.0099339 --------- $85.00 $89.00 $91.00 $85.00 $89.00 $91.0099340 --------- $120.00 $125.00 $128.00 $120.00 $125.00 $128.0099341 $59.00 $61.00 $64.00 $66.00 $61.00 $64.00 $66.0099342 $85.00 $88.00 $91.00 $94.00 $88.00 $91.00 $94.0099343 $109.00 $145.00 $150.00 $155.00 $145.00 $150.00 $155.0099344 $160.00 $203.00 $210.00 $218.00 $203.00 $210.00 $218.0099345 $193.00 $246.00 $255.00 $264.00 $246.00 $255.00 $264.0099347 $46.00 $62.00 $64.00 $66.00 $62.00 $64.00 $66.0099348 $71.00 $94.00 $97.00 $101.00 $94.00 $97.00 $101.0099349 $107.00 $142.00 $148.00 $153.00 $142.00 $148.00 $153.0099350 $156.00 $198.00 $206.00 $213.00 $198.00 $206.00 $213.0099354 $106.00 $111.00 $116.00 $120.00 $104.00 $108.00 $112.0099355 $104.00 $108.00 $112.00 $116.00 $101.00 $104.00 $108.0099356 $87.00 $102.00 $106.00 $109.00 $102.00 $106.00 $109.0099357 $88.00 $101.00 $105.00 $109.00 $101.00 $105.00 $109.0099360 BR $68.00 $71.00 $73.00 $68.00 $71.00 $73.0099363 --------- $139.00 $146.00 $149.00 $94.00 $97.00 $100.0099364 --------- $48.00 $50.00 $51.00 $36.00 $37.00 $38.0099366 --------- $48.00 $49.00 $51.00 $47.00 $48.00 $50.0099367 --------- $63.00 $65.00 $67.00 $63.00 $65.00 $67.0099368 --------- $41.00 $42.00 $44.00 $41.00 $42.00 $44.0099374 $75.00 $77.00 $81.00 $83.00 $63.00 $65.00 $67.0099375 $75.00 $116.00 $120.00 $124.00 $98.00 $102.00 $105.0099377 $75.00 $77.00 $81.00 $83.00 $63.00 $65.00 $67.0099378 $104.00 $116.00 $120.00 $124.00 $98.00 $102.00 $105.0099379 $75.00 $77.00 $81.00 $83.00 $63.00 $65.00 $67.0099380 $104.00 $116.00 $120.00 $124.00 $98.00 $102.00 $105.0099406 --------- $16.00 $16.00 $17.00 $14.00 $14.00 $15.0099407 --------- $31.00 $32.00 $33.00 $29.00 $30.00 $31.0099408 --------- $39.00 $40.00 $42.00 $37.00 $38.00 $40.0099409 --------- $76.00 $79.00 $81.00 $74.00 $77.00 $79.0099415 --------- $10.00 $10.00 $11.00 $10.00 $10.00 $11.0099416 --------- $5.00 $6.00 $6.00 $5.00 $6.00 $6.0099450 NC NC NC NC NC NC NC99455 $90.00 --------- --------- --------- --------- --------- ---------99456 BR --------- --------- --------- --------- --------- ---------










99457 --------- BR BR BR BR BR BR99487 --------- BR BR BR BR BR BR99489 --------- BR BR BR BR BR BR99490 --------- $45.00 $47.00 $48.00 $35.00 $36.00 $37.0099495 --------- $180.00 $188.00 $193.00 $123.00 $127.00 $131.0099496 --------- $254.00 $266.00 $272.00 $178.00 $184.00 $190.0099497 --------- $95.00 $98.00 $101.00 $88.00 $91.00 $94.0099498 --------- $83.00 $86.00 $89.00 $82.00 $85.00 $89.0099499 BR --------- --------- --------- --------- --------- ---------99600 BR --------- --------- --------- --------- --------- ---------G0245 --------- $73.00 $76.00 $78.00 $48.00 $50.00 $52.00G0246 --------- $42.00 $44.00 $45.00 $24.00 $25.00 $26.00G0296 --------- $31.00 $33.00 $34.00 $30.00 $31.00 $32.00G0337 --------- $80.00 $83.00 $86.00 $80.00 $83.00 $86.00G0372 --------- $10.00 $10.00 $11.00 $10.00 $10.00 $11.00G0396 --------- $40.00 $41.00 $43.00 $38.00 $39.00 $40.00G0397 --------- $79.00 $82.00 $85.00 $77.00 $79.00 $82.00G0402 --------- $183.00 $191.00 $196.00 $141.00 $146.00 $151.00G0406 --------- $43.00 $45.00 $47.00 $43.00 $45.00 $47.00G0407 --------- $79.00 $82.00 $84.00 $79.00 $82.00 $84.00G0408 --------- $114.00 $118.00 $121.00 $114.00 $118.00 $121.00G0409 --------- $13.00 $14.00 $14.00 $13.00 $14.00 $14.00

2015 Edition Effective Date: ____________

Chapter 4 Billing Instructions and Forms

Bill Submission/Filing and Reporting Requirements Carrier Responsibilities A carrier is responsible for meeting its obligations under this Rule regardless

of any business arrangements with any service company/TPA, submitter, or any entity acting behalf of the carrier under which medical bills are paid, adjusted and paid, disallowed, denied, or otherwise processed or submitted to the Division. At the time of authorization for medical service(s) or upon receipt of notification of emergency care, a carrier must shall notify each health care provider in writing, of additional form completion requirements or supporting documentation that are necessary for reimbursement determinations that are in addition to the requirements of this Manual and Rule 69L-7.740, F.A.C. At the time of authorization for medical service(s), or upon receipt of notification of emergency care, a carrier must shall inform out-of-state health care providers of the specific reporting, billing and submission requirements of this Manual and Rule 69L-7.740, F.A.C. and provide in-state and out-of-state health care providers the specific address for submitting a reimbursement request.

Provider Responsibilities All health care providers are required to meet their obligations under this

Rule, regardless of any business arrangement with any entity under which medical bills are prepared, processed or submitted to the carrier.

Billing When Paid Under Payment Plan(s)

Health care providers receiving reimbursement under any payment plans (pre-payment, prospective payment, or capitation, etc.) are required to accurately complete the Form DFS-F5-DWC-9 and submit the form to the carrier for all services rendered to injured workers.


Chapter 4 Billing Instructions and Forms, continued Bill Submission/Filing and Reporting Requirements, continued Additional Information Requested by Carrier

All health care providers are required to submit any additional form completion information and supporting documentation requested in writing, by the carrier at the time of authorization.

Bill Completion Bills must shall be legibly and accurately completed by all health care

providers. A carrier can require a health care provider or other recognized practitioner to complete additional data elements that are not required by the Division on Forms DFS-F5-DWC-9, DFS-F5-DWC-10, DFS-F5-DWC-11, or DFS-F5-DWC-90 if requested by the carrier at the time of authorization.

Form DFS-F5-DWC-25 Physicians must shall utilize only the Form DFS-F5-DWC-25 to request

authorization for treatment and to report the injured worker’s medical treatment/status.:

• No other reporting forms may be used in lieu of, or supplemental to, the Form DFS-F5-DWC-25.

• Failure to accurately complete and submit the DFS-F5-DWC-25, in accordance with the instructions provided in this Manual, may result in the Division imposing sanctions or penalties pursuant to subsection 440.13(8), F.S. or subsection 440.13(11) F.S.

• Form DFS-F5-DWC-25 does not replace physician notes, medical records or Division-required medical reports.

• All information submitted on physician notes, medical records, medical records or Division-required medical reports must be consistent with information documented on the DFS-F5-DWC-25.

• Carriers must shall utilize the information submitted on the DWC-25 form to monitor the medical necessity of services provided and services requested based on the medical condition being treated during the authorization process.

Note: Interactive Form DFS-F5-DWC-25 is available under the “Forms” section on the DWC web site.



Chapter 4 Billing Instructions and Forms, continued Bill Submission/Filing and Reporting Requirements, continued Billing for a Compensable Injury

All medical bills and form(s) for medical bill(s) related to services rendered for a compensable injury must shall be submitted by a health care providerd to the carrier, service company/TPA or any entity acting on behalf of the carrier, as a requirement for billing.

Methods for Billing Medical claim form(s) or medical bill(s) may be electronically filed or

submitted via facsimile by a health care provider to the carrier, service company/TPA or any entity acting on behalf of the carrier, provided the carrier agrees.

Bill Corrections Health care providers are responsible for correcting and resubmitting any

billing forms returned by the carrier, service company/TPA or any entity acting on behalf of the carrier.

Form DFS-F5-DWC-9 (CMS-1500) Recognized Practitioners Who Bill on the DFS-F5-DWC-9 (CMS 1500)

Recognized practitioners, except physician assistants, advanced registered nurse practitioners, certified registered nurse anesthetists and anesthesia assistants, who are salaried workers of an authorized treating physician and who render direct billable services for which reimbursement is sought from a carrier, service company/TPA or any entity acting on behalf of the carrier, service company/TPA, must shall report and bill for such services on a Form DFS-F5-DWC-9 by entering the employing physician’s Florida DOH license number in Field 33b on the Form DFS-F5-DWC-9.

Home Medical Equipment

Physicians, physician assistants and ARNPs billing for Home Medical Equipment must shall enter the applicable HCPCS code in Field 24D and attach documentation indicating the cost of the supply.


Chapter 4 Billing Instructions and Forms, continued Bill Submission/Filing and Reporting Requirements, continued Form DFS-F5-DWC-9 (CMS-1500), continued Dispensing Prescription Medications

Physicians, Physician Assistants and ARNPs must shall enter the NDC number in the universal 5-4-2 format in Form Field 24D with each segment separated by a dash (-). The Workers’ Compensation Unique code DSPNS is billed in addition to the NDC code in Field 24D if the drug is dispensed from the practitioner’s office for the injured worker’s use at home.

Compounded Drugs When a physician or pharmacist compounds a drug that is not commercially

available for prescription use by the worker at home, the physician or pharmacist may bill with the Workers’ Compensation Unique code COMPD in Field 24D. The individual component drugs used in compounding are to be identified by the NDC numbers.

Administration of Injectable Medications

Health care providers must shall use the appropriate HCPCS code in Fields 24D when available. If no HCPCS code is available, use the NDC number in the universal NDC 5-4-2 format in Field 24D.

Over-the-Counter Medications

Health care providers must shall use the appropriate HCPCS code in Field 24D when available. If no HCPCS code is available, use the NDC number in the universal 5-4-2 format in Field 24D.

Medication Management Therapy Sessions

Pharmacists who provide Medication Management Therapy Sessions that are ordered by a treating physician must shall bill by entering the appropriate CPT® code in Field 24D. Note: A copy of the physician’s written prescription order for Medication Management Therapy must be submitted with the bill for reimbursement.

Non-Physician Surgical Assistant

A certified physician assistant or registered nurse first assistant who provides services as a surgical assistant, in lieu of a second physician, must shall enter the CPT® code(s) which represents the service(s) provided plus modifier AS in Field 24D.


Chapter 4 Billing Instructions and Forms, continued Bill Submission/Filing and Reporting Requirements, continued

Form DFS-F5-DWC-10 Providers Who Bill on the DFS-F5-DWC-10

Pharmacists must shall bill using the Form DFS-F5-DWC-10 for pharmaceuticals and medical supplies prescribed by a physician or recognized practitioner. Medical Suppliers must shall bill using the Form DFS-F5-DWC-10 and are required to bill using HCPCS codes for medical supplies and equipment prescribed by a physician or recognized practitioner. Note: Pharmacists and Medical suppliers may only bill on an alternate to DFS-F5-DWC-10 when a carrier has pre-approved the use of an alternate form. Forms DFS-F5-DWC-9, DFS-F5-DWC-11 or DFSW-F5-DWC-90 must shall not be approved for use as an alternate form.

Billing Policy Pharmacists must shall enter the NDC number, in the universal 5-4-2 format,

in form Field 9, with each segment separated by a dash (-). Compounded Drugs When a pharmacist compounds a drug that is not commercially available,

the pharmacist must shall enter the Workers’ Compensation unique code COMPD in Field 9 of the DWC-10. The individual component drugs used in compounding must shall be identified by the NDC numbers in the universal 5-4-2 format separated by a dash (-).

Over the Counter Medications

Pharmacists must shall enter the NDC number, in the universal 5-4-2 format, in form Field 9, with each segment separated by a dash (-).

Home Medical Equipment

Pharmacists must shall enter the applicable HCPCS code(s) in Field 21 of the DFS-F5-DWC-10. Enter the quantity or units dispensed in Field 22. Home Medical Equipment Suppliers must shall enter the applicable HCPCS code(s) in Field 21. Enter quantity or units dispensed in Field 22. The license number of the pharmacist or the home medical supplier must shall be entered in Form Locator 29.


Appendix A: Workers’ Compensation Unique Procedure Codes

DSPNS Legend or prescription drugs dispensed by a licensed practitioner. (See Chapter Rule 69L-7.730(2)(l), F.A.C. for the specific use of this code).

COMPD Compounded drugs dispensed by a pharmacist or physician. (See Chapter Rule 69L-7.730(2)(l), F.A.C. for the specific use of this code). 97260 Manipulation of spine by a physician other than an osteopathic or

chiropractic physician.

97261 Manipulation of the temporomandibular joint; upper extremities including the hand and wrist; the lower extremities; and other regions by a physician other than an osteopathic or chiropractic physician.

97752 Muscle testing manually or by automated equipment with written report

97850 Physical reconditioning assessment; per hour

97851 Physical reconditioning assessment; additional thirty minutes

97852 Physical reconditioning program; per hour

97853 Physical reconditioning program; additional thirty minutes

99456 Independent Medical Examination 99456 CN Independent Medical Examination; cancelled less than 24 hours before

appointment without good cause or failed to appear.

99457 Consensus Independent Medical Examination (CIME)


Appendix B Official Source for References As medical information pertaining to coding systems and policies are evolving, users of this manual seeking up-to-date information should use the appropriate listed reference address, telephone/fax number or web site for specific answers to questions, inquiries and products.

♦ 2009 Relative Value Guide: A Guide for Anesthesia Values

American Society of Anesthesiologists 520 N. Northwest Highway Park Ridge, Il. 60068-2573 (847) 825-5586 Web Site: http://www.asahq.org

♦ Complete Global Service Data for Orthopaedic Surgery, Vol. 1 & 2

American Academy of Orthopaedic Surgeons 6300 North River Road Rosemont, Illinois 60018-4262 (847) 823-7186 (800) 626-6726 (847) 823-8125 Fax (800) 823-8025 Fax Web site: http://www.aaos.org/

http://www.asahq.org/

http://www.aaos.org/


♦ Current Dental Procedure Codes Terminology (CDT)

American Dental Association 211 East Chicago Avenue, 6

th Floor

Chicago, Illinois 60611-2678

(312) 440-2653 (800) 621-8099 (312) 440-7494 Fax Web site: www.ada.org

ADA Order Department American Dental Association Post Office Box 776 St. Charles, Illinois 60174 (800) 947-4746

(888) 476-1880 Fax Web site link: ADA e Customer

♦ Drug Topics Red Book

Medical Economics Company, Inc. Five Paragon Drive Montvale, New Jersey 07645-1742 (201) 358-7200 (800) 232-7379 (201) 722-2680 Fax

Web site: www.pdr.net.

♦ MediSpan Wolters Kluwer Health 8425 Woodfield Crossing Boulevard, Suite 490 Indianapolis, IN 46240 (855) 539-7686 (317) 735-5300 WebSite: www.wolterskluwer.com/Pages/Home.aspx https://pricerx.medispan.com/NDCNumber.aspx

http://www.ada.org/

https://siebel.ada.org/ecustomer_enu/start.swe?SWECmd=Start&SWEHo=siebel.ada.org

http://www.pdr.net/

http://www.wolterskluwer.com/Pages/Home.aspx


♦ Current Procedural Terminology, (CPT®)

CPT® Assistant ♦ Guide To The Evaluation of Permanent Impairment, 6

th Edition

♦ HCPCS® ♦ ICD-9-CM®.ICD-10-CM®

♦ National Physician Fee Schedule Relative Value File American Medical Association (AMA) – MAIN OFFICE 515 North State Street Chicago, Illinois 60610

(312) 464-5000 (312) 464-4184 Fax

Web site: www.ama-assn.org

AMA Order Department P.O. Box 930876 Atlanta, Georgia 31193-0876

(800) 621–8335 (800) 262-3211

(312) 464-5600 Fax

For questions regarding the use of CPT®

codes, please contact the American Medical Association, CPT

® Information and Education Services, at 1-800-634-6922.

♦ 1996 Florida Uniform Permanent Impairment Rating Schedule Florida Workers’ Compensation Institute P. O. Box 200 Tallahassee, Florida 32302

(850) 425-8156 (850) 222-9766 Fax Web site: http://www.fwciweb.org

http://www.ama-assn.org/

http://www.fwciweb.org/


Appendix C Medicare Payment Localities (Counties)

Locality 01 / Locality 02: Franklin Lake Putnam Alachua Baker Gadsden Leon Santa Rosa Bay Gilchrist Levy Sarasota Bradford Glades Liberty Seminole Brevard Gulf Madison St. Johns Calhoun Hamilton Manatee Sumter Charlotte Hardee Marion Suwannee Citrus Hendry Nassau Taylor Clay Hernando Okaloosa Union Columbia Highlands Okeechobee Volusia De Soto Hillsborough Orange Wakulla Dixie Holmes Osceola Walton Duval Jackson Pasco Washington Escambia Jefferson Pinellas Flagler Lafayette Polk Locality 03:

Broward Collier Martin Indian River Lee

Locality 04: Dade Monroe


Appendix D Forms Note: The following Forms and Form Completion Instructions are incorporated by reference in Rule 69L-7.720, F.A.C. Forms Incorporated by Reference for Medical Billing, Filing and Reporting.

• Form DFS-F5-DWC-9 (CMS-1500 Health Insurance Medical bill Form, Rev 02/12).

• Form DFS-F5-DWC-10 (Statement of Charges for Drugs and Medical Supplies Form).

• Form DFS-F5-DWC-11 (American Dental Association Dental Medical bill Form, Rev. 2006).

• Form DFS-F5-DWC-25 (Florida Workers’ Compensation Uniform Medical Treatment/Status Reporting Form), Rev.2/14/06.

• Form DFS-F5-DWC-90 (UB-04 CMS-1450, Uniform Bill, Rev. 2006). Form Completion Instructions are available at the following link: DWC website, Click on Chapter 69L-7.

http://www.myfloridacfo.com/Division/WC/PublicationsFormsManualsReports/Forms/Default.htm


Appendix E Definitions 1. “Add-on Code(s) means a procedure performed in addition to a

primary procedure performed by the same physician. An ‘add-on’

code describes additional or supplemental procedure(s) associated

with the primary service and are designated with a ‘+’ sign in the

CPT® codebook.

2. “Ambulatory Surgical Center (ASC) means a health care facility as

defined in s. 440.13(1)(f), F.S.

3. “Authorization” means the approval given to a health care provider

by the carrier, self-insured employer or entity representing the

carrier or self-insured employer for the provision of medical

services to an injured worker.

4. “Division” means the Division of Workers’ Compensation of the

Department of Financial Services as defined in s. 440.02(14), F.S.

5. “Home Medical Equipment” is defined in s.400.925 (6) F.S.

6. “Home Medical Equipment provider” is defined in s.400.925 (7),

F.S.

7. “Emergency Care and Services” means emergency services and

care as defined in s. 395.002, F.S.

8. “Health Care Provider” means a provider as defined in

s.440.13 (1)(g), F.S.

9. “Home Health Agency” means an agency as defined in Chapter

400, Part III, F.S.

10. “Maximum Reimbursement Allowance (MRA)” means the

specifically listed maximum dollar amount in the schedule adopted

by the Three Member Panel for reimbursement of medical

service(s) rendered to an injured worker by a health care provider.

11. “Medically Necessary or Medical Necessity” means any medical

service or medical supply that satisfies the criteria for those

terms as defined in which meets the definition of the terms

according to s. 440.13(1)(k), F.S.


12. “Medical Record” means patient records maintained in accordance

with the form and content required under Chapter 395, F.S.

13. “Medical Record Review” means a review of the medical record of

the injured worker in order to verify the medical necessity of the

services and the care as they relate to the itemized statement for a

specific bill.

14. “Modifier 51 Exempt” means a procedure code that is a HCPCS

or a CPT® code that does not have multiple surgery pricing

reduction applied for reimbursement.

Note: See the CPT codebook for a list of “Modifier 51 Exempt”

codes”.

15. “NDC Number” means the National Drug Code number as

defined in Rule 69L-7.710(1)(oo), F.A.C.

16. “Physician” means a physician as defined in s. 440.13(1) (p), F.S.

17. “Repackaged NDC number” means the National Drug Code

number as defined in Rule 69L-7.710(1)(oo), F.A.C.

18. “Unlisted Medication” means a medication which lacks assignment

of a National Drug Code (NDC number) or a HCPCS procedure

code.

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