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Florida Workers’ Compensation

Health Care Provider Reimbursement Manual

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

2017 Edition

Effective _______

Florida Workers’ Compensation Health Care Provider Reimbursement Manual

2017 Edition Effective Date: _______

TABLE OF CONTENTS

CHAPTER 1 0BINTRODUCTION AND OVERVIEW ................................................................ 5

4BOverview ----------------------------------------------------------------------------------------------------- 5

5BE-Alert System ---------------------------------------------------------------------------------------------- 5

6BHow to Obtain or Purchase Manuals ------------------------------------------------------------------- 6

9BHealth Care Provider Use of Codes, Descriptions, and Modifiers ------------------------------- 10

Billing New Procedure Codes Not Listed in the Fee Schedule ------------------------------------ 10

10BCarrier Use of Codes, Descriptions, and References ------------------------------------------------ 11

11BGeneral Reimbursement Information ----------------------------------------------------------------- 14

Co-Payments ----------------------------------------------------------------------------------------------- 14

14BExceptions to Service Limitations ---------------------------------------------------------------------- 18

15BDisputing Reimbursement ------------------------------------------------------------------------------- 18

CHAPTER 2 MEDICAL SERVICES ........................................................................................ 21

17BAnesthesia Services ---------------------------------------------------------------------------------------- 21

Post-Operative Pain Management --------------------------------------------------------------------- 27

18BBiofeedback Services -------------------------------------------------------------------------------------- 27

19BDental Services --------------------------------------------------------------------------------------------- 28

20BElectrodiagnostic Medicine ------------------------------------------------------------------------------ 29

21BEvaluation and Management Services ----------------------------------------------------------------- 31

22BFunctional Capacity Evaluations (FCE) -------------------------------------------------------------- 32

23BHome Health Agency Services -------------------------------------------------------------------------- 33

24BIndependent Medical Examinations ------------------------------------------------------------------- 35

25BFailure to Appear for IME ------------------------------------------------------------------------------ 35

26BConsensus Independent Medical Examination ------------------------------------------------------ 35

26B27BMedications ------------------------------------------------------------------------------------------------- 36

Home Medical Equipment and 28BMedical Suppliers -------------------------------------------------- 42



29BOphthalmologic Services --------------------------------------------------------------------------------- 43

30BPermanent Impairment Ratings (PIR) ---------------------------------------------------------------- 44

31BPsychiatric and Psychological Services ---------------------------------------------------------------- 45

32BRadiology---------------------------------------------------------------------------------------------------- 47

33BThermography --------------------------------------------------------------------------------------------- 48

34BPhysical Medicine and Rehabilitation Services ------------------------------------------------------ 49

35BAcupuncture ------------------------------------------------------------------------------------------------ 57

36BOrthotics and Prosthetics -------------------------------------------------------------------------------- 58

37BTests and Measurements --------------------------------------------------------------------------------- 59

38B41BSurgical Services ------------------------------------------------------------------------------------------- 65

2BCHAPTER 3 MAXIMUM REIMBURSEMENT ALLOWANCES ........................................ 73

3BCHAPTER 4 BILLING INSTRUCTIONS AND FORMS ..................................................... 415

Bill Submission/Filing and Reporting Requirements --------------------------------------------- 415

Form DFS-F5-DWC-9/CMS-1500 -------------------------------------------------------------------- 417

Form DFS-F5-DWC-10--------------------------------------------------------------------------------- 419

APPENDIX A WORKERS’ COMPENSATION UNIQUE PROCEDURE CODES .......... 421

APPENDIX B OFFICIAL SOURCE FOR REFERENCES .................................................. 422

APPENDIX C MEDICARE PAYMENT LOCALITIES (COUNTIES) ............................... 425

APPENDIX D FORMS .............................................................................................................. 426

APPENDIX E DEFINITIONS .................................................................................................. 427



THIS PAGE INTENTIONALLY LEFT BLANK



Chapter 1 0B0BIntroduction and Overview

5B4BOverview

Changes to the Manual

It is important that health care providers (HCPs) and carriers read the

updated material in the Florida Workers’ Compensation Health Care

Provider Reimbursement Manual (Manual). Both parties have a

responsibility for performing specific duties when billing, reporting, or

reimbursing medical services rendered to injured workers.

Reimbursement Manuals will be available under the “Reimbursement

Manuals” section on the DWC website.

6B5BE-Alert System The Division of Workers’ Compensation has an electronic alert (E-Alert)

system to notify subscribers of news impacting the Workers’ Compensation

industry and dates of upcoming public meetings and workshops.

To subscribe to the “E-Alerts,” please go to the DWC website. Look for the

box entitled “Register.” Once registered, you will receive E-Alerts whenever

they are provided by the Division.

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




Chapter 1 1B0BIntroduction and Overview

7B4BOverview, continued

Background There are three different Workers’ Compensation Reimbursement

Manuals:

Florida Workers’ Compensation Reimbursement Manual for

Ambulatory Surgical Centers, Rule 69L-7.100, Florida

Administrative Code (F.A.C.);

Florida Workers’ Compensation Health Care Provider

Reimbursement Manual, Rule 69L-7.020, F.A.C.; and

Florida Workers’ Compensation Reimbursement Manual for

Hospitals, Rule 69L-7.501, F.A.C.

Other Applicable

Rules

In addition to this Manual, Rule 69L-7.020, F.A.C., also recognizes

Rule Chapter 69L-7, F.A.C.

8B6BHow to Obtain or

Purchase Manuals

This Manual can be obtained free of charge on the DWC website, under

“Reimbursement Manuals,” or may 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

Purpose The purpose of the Manual is to furnish health care providers with the

policies and procedures needed to report services rendered to injured

workers and to file medical bills to carriers or self-insured employers for

reimbursement of services rendered. The Manual also provides carriers

or self-insured employers the schedule of Maximum Reimbursement

Allowances (MRAs) approved by the Three-Member Panel for

reimbursing health care providers for medically necessary care and

treatment.

The Manual provides descriptions and instructions on how and when to

complete forms and other documentation that will assist in the medical

bill filing process, as well as how to apply the reimbursement

methodology for the schedule of MRAs to assist in the proper

reimbursement of billed services.

The administrative purpose of the Manual is to furnish HCPs with

general information, billing and reimbursement policies, and MRAs for

covered services and procedures.

Prior Authorization of

Services

Pursuant to section 440.13(3), F.S., all HCPs 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 HCPs.

Note: Exceptions to prior authorization are:

Federal facilities;

Emergency services and care, defined in section 395.002,

F.S.; or

An HCP referral for emergency treatment resulting from

emergency services.




Notification of

Emergency Treatment

A HCP who renders emergency care must notify the carrier, in writing

by U.S.P.S. mail, by electronic mail, or by facsimile, by the close of the

third state of Florida business day after care has been rendered.

If the emergency care results in admission to a health care facility, the

HCP must notify the carrier by telephone within 24 hours after initial

treatment.

Carrier Responsibilities

at Authorization

A carrier is responsible for meeting its obligations under this Manual

regardless of any business arrangements with any service company/third

party administrator (TPA), submitter, or any entity acting on behalf of a

carrier through 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 notify

each HCP, 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 inform

out-of-state HCPs of the specific reporting, billing, and submission

requirements of this Manual and provide the specific address for submitting

a reimbursement request.

Fraud Statement An HCP involved in the process of making a claim under the Workers’

Compensation program must 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 employee, insurance company, or self-insured program,

files a statement of claim containing any false or misleading information

commits insurance fraud, punishable as provided in section 817.234, F.S.”




9B9BHealth Care Provider Use

of Codes, Descriptions, and

Modifiers

All HCPs must use the codes and descriptions, modifiers, policies,

definitions, and instructions of the referenced CPT®, CDT®, HCPCS

Level II®, ICD-10®, Florida Workers’ Compensation Unique

Procedure Codes, or other materials referenced in Rule 69L-7.020

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-10-CM® valid number of digits, i.e.,

seven (7) digits where noted in the ICD-10-CM® manual.

10BBilling New

Procedure Codes

11BNot Listed in the

Fee Schedule

In the event that a new CPT® or HCPCS Level II® code is created in

the CPT® or HCPCS Level II® manuals released subsequent to the

applicable manual incorporated by reference in rule, the HCP may

bill the newly created CPT® code or HCPCS Level II® code and the

carrier must reimburse, subject to any other provision of this manual.

Note: See Codes with No MRAs in this Chapter.



Chapter 1 Introduction and Overview, continued 12B10B

13BCarrier Use of Codes,

14BDescriptions,

15Band References

Carriers must use the codes and descriptions, modifiers, policies,

definitions, and instructions of the referenced CPT®, CDT®, HCPCS

Level II®, ICD-10®, or Florida Workers’ Compensation Unique

Procedure Codes on the medical bill prior to making reimbursement

decisions.

Notice of Privacy Practices

All HCPs will, 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, the HCP must 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 HCP must notify the carrier

immediately, if possible, or by close of business on the next regular

state of Florida business day.




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

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

A complete report of the patient’s symptoms, findings, and

plan of treatment pursuant to reporting requirements of

Form DFS-F5-DWC-25(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 DWC-25, signed by the physician, associated

with the recommended or rendered care or treatment.

Failure of the HCP to forward information when requested by the

carrier may result in the billed service being disallowed payment

until sufficient documentation is provided to render a

determination.

Moreover, an HCP’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 constitute a

violation of Chapter 440, F.S., subject to penalties imposed by the

Division.

Disclosure to Injured

Workers, Employers,

and Carriers

An HCP, upon request, must furnish the injured worker, injured

worker’s attorney, employer, carrier, carrier’s designee, or carrier’s

attorney, 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.

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

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




Injured Worker’s

Requests

An HCP may charge an injured worker or his or her

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 be made to an HCP by the requesting party at the

HCP’s actual cost for x-rays, microfilm, or other non-written

records.

Carrier’s Requests An HCP, upon request, must furnish a copy of the injured

worker’s medical records, medical charts and reports to a carrier

or a carrier’s designee or attorney.

An HCP, upon request, must furnish the carrier, carrier’s designee,

or carrier’s attorney, all non-written medical records.

Division or Judge of

Compensation Claims

Requests

An HCP, upon request, must provide medical records and reports

to the Division or Judge of Compensation Claims without charge.




16B11BGeneral Reimbursement Information

Billing the Injured

Worker

HCPs must 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.

17BCo-Payments An HCP 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).

The co-payment(s):

May only be collected for evaluation and management visits

after the injured worker has received an assignment of MMI;

Will not apply to emergency care or services provided to the

injured worker;

Will not apply to laboratory, radiology, or diagnostic services;

and

Is not in addition to the MRA or fee agreement. The

reimbursement amount otherwise payable by the carrier will be

reduced by the amount of the co-payment.

Federal Facilities Federal facilities are exempt from the reimbursement provisions and

allowances in this Manual.

A carrier must reimburse a federal facility its usual charge.




General Reimbursement Information, continued

Florida Health Care

Providers

Reimbursement will be made to a Florida HCP after applying the

appropriate reimbursement policies contained in this Manual.

A carrier will reimburse an HCP either the MRA in the appropriate

reimbursement schedule or an agreed upon contract price.

Note: See Chapter 3 for MRAs and instructions on how to determine

the correct MRA.

Out-of-State Providers Prior to the delivery of medical services, a carrier and HCP 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 reimburse the greater of:

The MRA according to the out-of-state fee schedule for the

services provided; or

The MRA according to Chapter 3, Part A, of this Manual.

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

MRA will be at the maximum reimbursement allowance after the

application of any reimbursement policies contained in this Manual.

When the billed charge is less than the MRA, the reimbursement will

be the MRA amount in the fee schedule.

Note: The only exception is when there is a defined

reimbursement amount between the HCP and carrier provided in a

contractual agreement.




18B13BGeneral Reimbursement Information, continued

Codes Paid

By Report

Reimbursement will be determined by the carrier for procedure codes

listed in the fee schedule as By Report.

Payment will be based on an HCP’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 be:

The Florida Workers’ Compensation MRA for clinically

similar procedure codes in the current fee schedule.

The HCP must submit the required documentation to the carrier when

the following situations occur:

The procedure code’s MRA is listed in the fee schedule as By

Report in Chapter 3 of this Manual;

There is a valid procedure code in the CPT® or the HCPCS

Level II® Manual which corresponds to the date of service; or

The billed procedure code is not listed in this Manual.

Note: See Codes with No MRAs in this Chapter.





Codes with No MRAs Carriers must 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 will:

Determine reimbursement by comparing the billed procedure

code(s) with clinically similar procedure code(s) found in the

appropriate CPT® or HCPCS Level II® Manual;

Make reimbursement decisions based on either peer

physician recommendations or the HCP’s documentation,

medical bills, relative value data, services, and supplies; and

Reimburse all work-related and medically necessary services

provided in a documented medical or dental emergency.

The carrier’s reimbursement methodology must also be available in

response to any Petition for Resolution of Reimbursement Dispute or

upon request by the Division.

Reimbursement for

Failed Appointments

Reimbursement is not made for an injured worker’s failed

appointment.

Note: This exclusion does not apply to Independent Medical

Examinations pursuant to section 440.13(5)(d), F.S.

See Independent Medical Examinations in Chapter 2.





19B14BExceptions to Service

Limitations

When an HCP deems it medically necessary in the treatment of an

injured worker’s injury or illness to furnish medical services that

exceed the number of services in the reimbursement policies in this

Manual, an HCP 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.

Services Unrelated to

the Compensable

Injury

Carriers will not reimburse the HCP for services unrelated to the

treatment or care of a compensable injury except when the treatment is

required to stabilize or maintain the injured worker’s medical status in

order to treat the patient’s compensable injury or condition.

20B15BDisputing

Reimbursement

The HCP may elect to contest the disallowance or adjustment of

payment under section 440.13(7), F.S. The election to contest the

disallowance or adjustment of payment under section 440.13(7), F.S.,

must be made by the HCP 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 Treatment/Status, continued

General Policies

HCPs are to utilize the Workers’ Compensation specific patient

classification levels when submitting the required treatment status

on the DWC-25 to the carrier.

Classification System

The following best describes the patient classification levels:

Criteria based;

Comprised of descriptive categories to provide a means to

promote decision-making, accountability, and responsible

medical bill handling practices; or

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 an HCP; and

Enhance communication between the HCP and the carrier

to facilitate the authorization process for the provision of

medically necessary care.




16BClassification of an Injured Worker’s Treatment/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.



2BChapter 2 Medical Services

21B17BAnesthesia 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, which is

when the injured worker may be safely placed under postoperative

supervision.

Note: Anesthesia time must 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:

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.

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 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 be determined by the provider (CRNA or

anesthesiologist only) to rank the injured worker’s condition. Additional

reimbursement will 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 0

P3 A patient with severe systemic disease 1

P4 A patient with severe systemic disease

that is a constant threat to life 2

P5 A moribund patient who is not expected

to survive without the operation 3

P6 A declared brain dead patient whose organs

are being removed for donor purposes 0

CPT® only copyright 2016 American Medical Association. All rights reserved.





Difficult or

Qualifying

Circumstances

Anesthesia services that 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

CPT® only copyright 2016 American Medical Association. All rights reserved.

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 (CF) 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





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 service 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; and

Multiply the total anesthesia value by the CF 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 (CF) = $ Reimbursement

Note: CRNAs and AAs reimbursement will be limited to 85% of the total

anesthesia reimbursement allowance for an anesthesiologist for any

procedure that has no TM units.





Medical Direction

of CRNA/AA by

Anesthesiologist

Reimbursement will 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 be made to an anesthesiologist for providing medical

direction, including pre-operative and post-operative evaluations or

consultations to a CRNA/AA as previously identified by the specific protocol.

Reimbursement for a CRNA/AA requiring medical direction by an

anesthesiologist will 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 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 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 be made for general supervisory services

rendered by the anesthesiologist.

Special Billing

Requirement

All anesthesia services must be billed on Form DFS-F5-DWC-9 (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.

On the next line of Field 24D, anesthesia providers must enter the date of

service and the 5-digit qualifying circumstances code, which corresponds with

the procedure performed, if applicable.

Medical direction must be billed by the anesthesiologist by adding the HCPCS

Level II® modifier QY to the anesthesia procedure code.

The HCPCS Level II® modifier QK must be appended to the anesthesia code

when the medical direction requires more than one concurrent anesthesia

procedure.

When medical direction is required, the CRNA or AA must bill by appending

the HCPCS Level II® modifier QX to the anesthesia procedure code. The

CRNA or AA must provide his or her Florida Department of Health (DOH)

license number in Field 33b.





Special Billing

Requirements,

continued

When a CRNA provides anesthesia services, the CRNA must enter his/her DOH

license number in Field 33b.

Note: See subsection 69L-7.730(2), F.A.C.

Anesthesia

Performed by the

Operating

Surgeon

When an operating 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.

No additional reimbursement is calculated when the operating surgeon bills

with the “P” code (physical status modifier).

An operating surgeon cannot report time units in the calculation of anesthesia

reimbursement request on the medical bill. Reimbursement will 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.

Conscious

Sedation

CPT® procedure codes denoted with a bullseye symbol (ʘ), in the adopted

CPT® manual, indicate that conscious sedation is not separately reimbursable in

addition to the procedure.




22BAnesthesia Services, continued

23BPost-Operative Pain

Management

Nerve blocks for post-operative pain management will be reimbursed if ordered

by the surgeon and provided in addition to general anesthesia or conscious

sedation. Nerve blocks may be performed pre-operatively, intra-operatively, or

post-operatively. The HCP performing the nerve block must provide a separate

procedure report and submit the documentation to the carrier for

reimbursement.

Reimbursement for a nerve block will be made in accordance with the MRAs

listed in this Manual when performed by an HCP who is not the operating

surgeon.

The professional component for a nerve block must be billed by the HCP on the

DWC-9 claim form.

24BNote: If the nerve block is performed by the operating surgeon, the Billing and

Reimbursement of Multiple Surgical Procedures, under the Surgical

Services section in this manual, will apply.

25B18BBiofeedback Services

Requirements for

Reimbursement

Reimbursement for the collection and interpretation of biofeedback data

digitally stored and downloaded will be included in the reimbursement to the

HCP for the basic biofeedback service.

The written interpretation of the digitally stored biofeedback results must be

signed and dated by the HCP and maintained in the medical record.

Limitations to

Biofeedback

Services

Reimbursement for biofeedback training will 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.




26B19BDental Services

Reimbursable

Providers

A carrier will only reimburse a dentist or an oral surgeon for authorized

services.

Note: Emergency oral surgery does not require prior authorization. The carrier

must be notified by the HCP no later than the close of the third state of Florida

business day after emergency treatment.

Dental Codes and

Descriptions

Dentists must use the dental guidelines, codes and descriptors from the CDT®

or the D codes in the HCPCS Level II® for dental procedures.

Dental services are billed on Form DFS-F5-DWC-11.

Oral Surgery

Services

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

for oral and maxillofacial surgical services.

Oral surgery services are billed on the DWC-9 form.

Note: Oral Surgeons will 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 bill using a combination of the dental guidelines, codes and

descriptors from the CDT® manual and the D codes from the HCPCS Level II®

manual.

To receive reimbursement:

Dentists who provide TMJ services may use a combination of CPT®

codes and dental codes from the CDT® or HCPCS Level II®, or

Dentists will refer to the physical medicine section of this Manual for

information on physical medicine reimbursement policies.




Dental Services, continued

Reimbursement to

Dentists and Oral

Surgeons

Reimbursement to a dentist or oral surgeon for dental procedures or services

will 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.

27B20BElectrodiagnostic Medicine

Determining

Medical Necessity

The referring physician must determine the medical necessity of an

Electromyography (EMG) or a Nerve Conduction Study (NCS). Only a

physician will determine the frequency of testing or the necessity of repeat

testing.

Reimbursement

Policy for EMG

Only HCPs specifically qualified by state regulations to perform EMG will be

reimbursed.

Reimbursement must include the testing, interpretation of the studies, and a

written report of the findings.

When the initial evaluation and management service and needle EMG testing

are performed during the same visit, reimbursement will be made for both

services.

When the follow-up evaluation and management service and needle EMG

testing are performed on the same day, reimbursement will be made for both

services only if the documentation validates the medical necessity for the

follow-up evaluation and management service.




Electrodiagnostic Medicine, continued

Reimbursement

Policy for EMG,

continued

When needle EMG testing is performed in a hospital or other facility,

reimbursement will be made for an interpretation and report of the testing.

Modifier 26 must be appended to the appropriate procedure code for

reimbursement.

Nerve Conduction

Studies

An HCP, specifically qualified by regulations in his or her state, will determine

the nerves to be tested based on specific clinical findings during the

examination performed at the time of the study

Reimbursement

Policies for NCS

When the initial evaluation and management service and the NCS are

performed during the same visit, reimbursement will be made for both services.

When a follow-up evaluation and management service and the NCS are

performed on the same day, reimbursement will be made for both services only

if the documentation validates the medical necessity of the follow-up evaluation

and management service.

A technologist under the direct supervision of the physician may perform a

NCS. However, the services must be billed under the supervising physician’s

name and DOH, or out-of-state, license number.

Reimbursement will include the testing, interpretation of the studies, and a

written report of the findings.




28B21BEvaluation and Management Services

Office Visits

A carrier will reimburse an HCP for evaluation and management services (new

or established patient visits).

A new patient means an injured worker who:

Is new to the HCP,

Is an established patient who has not received service for more than 3

years from the same HCP, or

Is an established patient with a new compensable injury or illness and a

new date of accident.

Note: Reimbursement is limited to one (1) evaluation and management visit

per day at the level of care documented by the HCP.

Home Visit

Services

An HCP will not be reimbursed for home visits unless prior authorization from

the carrier has been received.

An HCP must bill for a home visit using the appropriate evaluation and

management procedure code.




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 be

reimbursed for consultations, confirmatory consultations, and follow-up

consultation services.

Reimbursement for consultations must include a review of all submitted

medical records, paper and non-paper; a physical examination of the injured

worker; and a written report.

The consultant’s opinion and any services that were ordered or performed must

be communicated by written report to the requesting physician or other

appropriate source.

29B22BFunctional Capacity Evaluations (FCE)

Reimbursement

Criteria

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).

Reimbursement for an authorized FCE will 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 be made for the CPT® code 97750, specifically designated

for use solely in reporting a FCE. The reimbursement for an FCE includes a

written program plan and a written report. The provider must provide the results

of the evaluation and recommendations to the injured worker, the carrier, and

the authorized physician without additional charge.

Reimbursement for an FCE will 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 an FCE using CPT® procedure code 97750.




30B23BHome Health Agency Services

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

assigning any licensed health care employees to render services in an injured

worker’s residence.

The carrier’s authorization to provide home health services does not authorize

home medical equipment and supplies unless such authorization is expressly

stated.

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 may include home health visits (nurses and home health

aides), therapy services (speech therapy, physical therapy, occupational

therapy), and the coordination of 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, as prescribed by the HCP, to provide medically necessary nursing,

home health aide, or therapy service(s). An injured worker’s residence cannot

be 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 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

authorization.




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 HCP’s 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 specified in the plan of care.

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

amounts agreed upon between the Home Health Agency and the carrier prior to

the services being provided in the home.

Billing for Home

Health Agency

Services

The Home Health Agency must bill on the Form DFS-F5-DWC-90 (DWC-90)

and include a copy of its contractual agreement when submitting the billing

form to the carrier for proper reimbursement.

When a Home Health Agency is billing for authorized Home Medical

Equipment (HME), on the DWC-90, a copy of the HCP’s original order for the

HME item(s) must accompany the bill submitted to the carrier.




31B24BIndependent Medical Examinations

Requirements for

Reimbursement

Components of a physician’s Independent Medical Examination (IME) must

include:

The review of applicable paper medical records,

The review of applicable non-paper medical records, and

The examination of the injured worker with production of a written

report.

Reimbursement

for IME

A physician will be reimbursed by the party requesting the IME.

IME services are reimbursed at an agreed upon contract amount.

Note: The only procedure code for billing an IME is the Workers’

Compensation Unique Procedure Code 99456.

32B25BFailure to Appear

for IME

If an injured worker fails to appear for an IME scheduled by the employer or

carrier, without good cause, and fails 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 bill using the Workers’ Compensation Unique

Procedure Code 99456 CN to indicate the injured worker failed to appear or the

appointment was canceled without proper notice.

33B26BConsensus Independent Medical Examination

Requirements for

Reimbursement

Components of a physician’s Consensus Independent Medical Examination

(CIME) must include:

The review of applicable paper and non-paper medical records;

An examination of the injured worker including determination of

MMI;

Assignment of a permanent impairment rating, as appropriate; and

A written report.




34B26BConsensus Independent Medical Examination, continued

Reimbursement

for CIME

Reimbursement for a CIME will be negotiated between the physician and the

carrier prior to rendering the service. A physician will be reimbursed by the

carrier for a CIME.

Note: CIME service must be billed with the Workers’ Compensation Unique

Procedure Code 99457 for reimbursement.

35B27BMedications

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

to treat an injured worker must be ordered by an HCP.

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 section 465.0276, F.S.




Medications, continued

Codes and

Descriptions for

Medications

All HCPs must refer to the HCPCS Level II® Manual in effect for the date

of service when reporting injection procedures, as well as immune

globulin or vaccine products.

All HCPs must use the J codes in the HCPCS Level II® Manual, as

adopted in Rule 69L-7.020, F.A.C., for reporting other injectable

medications.

If the specific medication is not listed in either of these references, the

HCP must bill the medication using the National Drug Code (NDC)

number for reimbursement.

Reimbursement for

Administration of

Injectable

Medication

Reimbursement for injectable medication will be made to an HCP as

follows:

Reimbursement will be made to an HCP using CPT® or HCPCS

Level II® J codes for specific injectable medications and CPT®

codes for the administration of injectable medications.

Reimbursement for the administration of injectable medication(s)

will be made at either the listed MRA in the appropriate schedule

or an agreed upon contract price.

Reimbursement for an injection will include a local anesthetic, if

necessary.

Reimbursement for administration of multiple medications

contained in the same syringe is limited to one administration fee.

Reimbursement will be:

1. At either the agreed upon contract price or the listed MRA,

in Chapter 3, Part A, of this Manual for the first reported

drug; and

2. At either fifty percent (50%) of the listed MRA in the

appropriate schedule for each additional drug or an amount

specified in an agreed upon contract.





Reimbursement for

Injectable

Medications

Reimbursement to HCPs for injectable medications provided in the office

will be twenty percent (20%) above the acquisition invoice cost of the

injectable medication based on submission of:

The name, strength, and dosage of the medication, vaccine, or

toxoid; and

Submission of the acquisition invoice.

Medications via

Infusion Pumps

A special reimbursement provision is allowed for identification of the

loading dose of medication(s) administered via infusion pump.

HCPs must utilize an appropriate HCPCS Level II® code when billing.

Reimbursement will be twenty percent (20%) above the documented

acquisition invoice cost of the drug or an agreed upon contract amount

between the HCP and the carrier.





Dispensing

Medications

For reimbursement purposes, the dispensing of medicinal drugs will be

limited to a pharmacist or a licensed dispensing practitioner. The

medication must be billed using the NDC number, along with the

Workers’ Compensation Unique Procedure Code DSPNS. The

reimbursement for prescription medications will be:

Average Wholesale Price (AWP) + $4.18 (dispensing fee) = $

Reimbursement

Note: See section 440.13(12)(c), F.S., for the definition of Average

Wholesale Price.

For repackaged or relabeled prescription medications dispensed by an

HCP on or after date of service July 1, 2013, see section 440.13(12)(c),

F.S., to obtain the reimbursement of repackaged prescription medications.

Note: See Rule Chapter 69L-7, F.A.C., for proper billing of repackaged

or relabeled medications.

Compounded

Drugs

Medicinal drugs may be compounded by an authorized pharmacist or an

authorized physician when the drug formulation prescribed is not

commercially available. Dispensing compounded drugs is identified as a

specialty service under section 440.13(3)(i), F.S. Compounded drugs may

not have an NDC number.

Reimbursement

for Compounded

Drugs

The provision and reimbursement of compounded drugs are limited to a

pharmacist or a physician. Compounded drugs must be billed using the

Workers’ Compensation Unique Procedure Code COMPD, along with

submission of a list which contains the NDC number and quantity used for

each component of the compounded product.

Reimbursement is the lesser of:

1. [AWP (of each component)] + $4.18 = Reimbursement; or

2. The amount the carrier has contracted for pursuant to

section 440.13(12)(c), F.S.

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

of AWP.





Unlisted

Medications

Reimbursement for unlisted medications with no MRA in Chapter 3 of this

Manual, will 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 cost of the medication.

Over the Counter

Drugs

A dispensing practitioner must use the NDC number and submit an invoice

to the carrier that provides the name, dosage, package size, and cost of the

drug(s), including applicable manufacturer’s shipping and handling.

Reimbursement will be made to a pharmacist for dispensing over-the-

counter drugs at the pharmacist’s usual charge for the drug.

Non-

Reimbursable

Drugs and

Supplies

Reimbursement will be made at the HCP’s charge or at an amount not to

exceed twenty percent (20%) above the actual cost of each drug

furnished.

Reimbursement will not be made for oral vitamins, nutrient preparations,

or dietary supplements. Reimbursement will not be made for medical food

pursuant to section 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. Authorization may be limited by

frequency, type, dosage, and reimbursement amount of such food as part

of a proposed written course of medical treatment.




HCP Supplies

Reimbursable

Materials and

Supplies

Reimbursement for materials and supplies not incidental to a service or a

procedure will be reimbursed using the specific HCPCS Level II® supply

codes.

Reimbursement is limited to twenty percent (20%) above the acquisition

invoice cost of the material(s) and supply(ies) based on submission of the

documentation that substantiates the HCP’s cost.

Unlisted Supply

Code

When a more specific code is not available for reimbursable materials and

supplies, the HCP must bill using the HCPCS Level II® miscellaneous

supply code A9999 and submit the following documentation:

A detailed description of the supply or material and the unique

medical need for the injured worker; and

A copy of the acquisition 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.

Materials and

Supplies Not

Separately

Reimbursed

Material and supplies that are necessary to perform a procedure or service

will be included in the reimbursement for the procedure or service and will

not be reimbursed separately.




36BHome Medical Equipment and 28BMedical Suppliers

Guidelines and

Requirements

All guidelines and requirements in this Manual are the same for Home

Medical Equipment (HME) providers and medical suppliers.

General

Requirements

Medical supplies and HME must be prescribed by an HCP and may be

provided to an injured worker by an HME provider through rental or

purchase.

Authorization An HME provider or medical supplier must obtain a written or electronic

authorization and a written payment agreement from the carrier prior to

furnishing an injured worker with medical supplies or equipment.

Billing

HME providers or medical suppliers must provide the carrier with a copy

of the HCP’s original order with the medical bill when requesting

reimbursement.

An HME provider or medical supplier is required to bill on the Form

DFS-F5-DWC-10 (DWC-10) using HCPCS Level II® codes. The HME

provider or medical supplier is not required to provide invoices with the

bill to document the acquisition costs of supplies and equipment.

Note: When a specific code is not available to describe the item provided,

bill HCPCS Level II® code A9999. The carrier may provide additional,

specific billing instructions at the time of authorization.




37BHome Medical Equipment and 28BMedical Suppliers, continued

Reimbursement

Reimbursement is made by the carrier to an HME provider or medical

supplier for rental or purchase of HME and supplies ordered or prescribed by

an HCP according to the written payment agreement obtained at the time of

authorization.

The carrier:

May rent the item from the HME provider or medical supplier for the

injured worker;

May write a provision in the payment agreement that when the amount

received by the HME provider or medical supplier from the rental

payments equals the purchase price, the item will become the property

of the carrier or injured worker; or

May purchase the item from the HME provider or medical supplier.

Limitations for

HME and

Supplies

All additional HME and medical supplies require explicit prior

authorization by the carrier as a requirement for reimbursement.

No reimbursement will be made for HME or medical supplies that are

automatically supplied or refilled by the supplier.

38B29BOphthalmologic Services

General

Reimbursement

Requirements

Reimbursement for ophthalmologic services will be made for all medically

necessary services. Prior authorization from the carrier is required unless

the condition is an emergency situation.

Glasses, Contacts

or Frames

Reimbursement will 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.




39B30BPermanent Impairment Ratings (PIR)

Providers Eligible to

Determine

Permanent

Impairment Rating

Only a physician licensed by the Chapters listed in section 440.15(3)(b),

F.S., will be reimbursed by the carrier for addressing Maximum Medical

Improvement (MMI) and the assignment of a Permanent Impairment

Rating (PIR).

Reimbursement

Components and

PIR

The components of a PIR must include an examination that provides:

The evaluation of an injured worker’s condition to establish the

MMI date and PIR of zero (0) percent or greater; and

The systematic completion of the required reporting form, DWC-

25, and submission to the appropriate parties in accordance with

section 440.15(3), F.S.

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

The DWC-25 must be fully completed and must document the method(s)

and guide used to assign a PIR.

Reimbursement will not be made for an evaluation and management code

on the same date of service as a PIR.

Note: The procedure code for billing a PIR is the CPT® code 99455.

The Interactive DWC-25 is available at the following link: DWC website





40B31BPsychiatric and Psychological Services

Providers Eligible

for

Reimbursement

Reimbursement for psychiatric and psychological services will be made by

the carrier to the following HCPs who provide individual psychotherapy

services within the scope of state licensure:

Medical physicians;

Osteopathic physicians;

Psychologists;

Mental health practitioners; or

Other health care practitioners.

Required

Documentation

All psychiatric and psychotherapy procedure codes that are reimbursed

based on face-to-face time with the injured worker must have a beginning

and an ending time documented in the medical record.

Individual

Psychotherapy

Combined with

Evaluation and

Management

Codes

Only an HCP may be reimbursed for individual psychotherapy in

combination with evaluation and management services provided at a

therapy session. Documentation must support the services billed.

An HCP will 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® to identify the combined procedure 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 be

reimbursed.




Psychiatric and Psychological Service, continued

Family

Psychotherapy

Reimbursement for family psychotherapy, with or without the injured

worker present, will be made if the documentation supports that the purpose

is related to the treatment of the injured worker’s compensable injury.

Reimbursement will 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 be authorized

by the carrier prior to the service being rendered.

Reimbursement of

CNS Testing

Reimbursement will be made for CNS Assessment and Testing when the

documentation includes:

An assessment and administration of a test with

interpretation and a written report;

The number of hours (units of service), supported by the

HCP’s documentation, required to perform the

assessment and testing; and

The procedure code used for billing indicating if the

service is per hour or is all inclusive.

Reimbursement will be the MRA, in Chapter 3 of this Manual, or the

agreed upon contract price.

Behavioral

Assessment

Interventions

Reimbursement will be made for Health and Behavior Assessment and

Intervention Services when authorized by the carrier.

Billing All HCPs must refer to the most specific Health and Behavior Assessment

and Intervention procedure codes when billing for health and behavioral

interventions.




41B32BRadiology

Reimbursable

Services

Reimbursement will 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 [the actual performance of the radiological

test and the production of the hard copy film(s)] is reported separately, the

service is billed by adding the HCPCS Level II® 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 Level II® modifier 26 to the procedure code when requesting

payment.

Global Services Global services may be reported when one physician 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 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 physician who is not the HCP

that reviewed, interpreted, and signed the radiology report.




Radiology, continued

Independent

Radiology

Facilities

Reimbursement will be made to an independent radiology facility for the

technical component of the service by appending the HCPCS Level II®

modifier TC to the 5-digit procedure code.

No reimbursement will 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 HCP that

interprets the radiology exam.

42B33BThermography

Requirements for

Authorization

The carrier will 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 prior to rendering the service.

Thermography

Limitations

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

major or limited.

Major body areas. (The following areas include all views.)

1. Head,

2. Cervical spine and upper extremities, and

3. Lumbosacral spine and lower extremities.

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

1. Thoracic spine, and

2. Any portion of a major area.




Transcutaneous Electrical Neurostimulators (TENS)

Reimbursement

Requirements

An authorization and a written reimbursement agreement must be

obtained from the carrier for rental or purchase of a TENS unit prior to an

HCP furnishing a TENS unit to the injured worker.

Reimbursement will be twenty percent (20%) above the HCP’s

documented cost when the TENS unit is purchased.

A copy of the HCP’s acquisition invoice must be submitted with the bill

to substantiate the HCP cost.

Training Sessions

for TENS

Reimbursement will be made to an HCP 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. The carrier must designate the number of training sessions

authorized.

43B34BPhysical Medicine and Rehabilitation Services

General

Information

Physical medicine and rehabilitation services will 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

supported in the HCP’s evaluation and in the physical medicine plan of

care.




34BPhysical 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 be documented on the

DWC-25, submitted to the carrier by the physician, and supported in

the evaluation with a physical medicine plan of care, regardless of

the location where the services are rendered or whether rendered by a

physician or other practitioner.

If the carrier questions the appropriateness of the therapy listed in the

plan of care, the carrier must contact the physician to obtain the

rationale for the ordered therapy prior to authorization.

The physician is responsible for providing the carrier the

documentation of medical necessity for the therapy in order to avoid

unnecessary delays in obtaining authorization for treatment or in

initiating therapy.

Covered Services Carriers will reimburse HCPs, as specified in this Manual, for the

following physical medicine and rehabilitation services provided to

injured workers for a compensable injury/illness:

Modalities and therapeutic procedures applied to acute

injuries to reduce symptoms, restore function, and return the

injured worker to work.

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 be for the worker to return to a job

and/or become physically reconditioned.

Interdisciplinary rehabilitation programs covering a variety of

services that are coordinated, outcome focused, and directed

at the injured worker’s needs to increase functioning or return

to work.





Authorization of

Services

Reimbursement will 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

HCP.

Exceptions to

Limitations

Exceptions may be made to the above limitation when the HCP provides

documented, objective, relevant medical findings that demonstrate the

following:

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

The injured worker does not conform to either the Level II or

Level III patient classifications based on specific documentation

of the following:

1. No systemic musculoskeletal deficit (strength, flexibility,

endurance, coordination) or substantive functional loss

requiring an intensive physical reconditioning program;

2. No behavioral or psychological issues that present a

substantive factor in the rehabilitation effort or outcome;

3. No significant vocational or return to work issues; and

4. No significant disparity between the injured worker’s

subjective complaints, response to intervention, and other

relevant clinical indicators when compared with

documented, objective, relevant medical findings.

Note: See Classification of an Injured Worker’s Treatment/Status in

Chapter 1 of this Manual.

Service

Limitations

Reimbursement for physical medicine services is limited to one visit per

day, unless additional visits are authorized by the carrier.





Physical

Medicine Initial

Evaluation

Reimbursement for an initial evaluation by an HCP will be billed as

an evaluation and management service.

Reimbursement for an initial evaluation by a therapist will be billed

using procedure codes 97161 – 97163, based on the complexity of

the evaluation. Documentation must support the time spent with the

injured worker.

Separate reimbursement will not be made to an HCP and to a

therapist for an evaluation by each on the same date of service.

Reimbursement for an initial evaluation will include the evaluation

and a plan of care or treatment.

Note: Documentation of the evaluation and preparation of a plan of

care, approved by the HCP, must be submitted to the carrier with

the medical bill. At a minimum, the documentation must include:

The evaluation findings, including any functional

limitations;

The proposed therapy, specifying the frequency and

duration of services; and

The anticipated degree of restoration of function with

measurable goals.

Physical Medicine

Re-Evaluation by a

Therapist

Reimbursement will be made for a re-evaluation by a therapist, no

more than once every four (4) weeks, when ordered by an HCP and

documented on the DWC-25.

Re-evaluations must be billed using procedure code 97164.




Physical Medicine and Rehabilitation Services, continued

Evaluation by an

Athletic Trainer

Reimbursement for an initial evaluation by an athletic trainer will be

made only after a referral from an HCP and must be billed using

procedure code(s) 97169 – 97171, according to the level of complexity.

Documentation must support the time spent with the injured worker.

Separate reimbursement will not be made to an HCP and to an athletic

trainer for an evaluation by each on the same date of service.

Reimbursement for an initial evaluation by an athletic trainer must

include the evaluation and a plan of care or treatment.

Re-Evaluation by

an Athletic

Trainer

Reimbursement will be made for a re-evaluation by an athletic trainer,

no more than once every four (4) weeks, when ordered by an HCP and

documented on the DWC-25.

Re-evaluations must be billed using procedure code 97172.

Evaluation by an

Occupational

Therapist

Reimbursement for an initial evaluation by an occupational therapist

will be made only after a referral from an HCP. The therapist must bill

using procedure code(s) 97165 – 97167, according to the level of

complexity, and documentation must support the time spent with the

injured worker.

Separate reimbursement will not be made to an HCP and to an

occupational therapist for an evaluation by each on the same date of

service.

Reimbursement for an initial evaluation by an occupational therapist

must include the evaluation and a plan of care or treatment.





Re-Evaluation by

an Occupational

Therapist

Reimbursement will be made for a re-evaluation by an occupational

therapist, no more than once every four (4) weeks, when ordered by an

HCP and documented on the DWC-25. Re-evaluations must be billed

using procedure code 97168.

Revised Plan of

Care

The physician must prepare and submit to the carrier a revised

DWC-25 to document the change in care or treatment.

Modalities and

Therapeutic

Procedures

Reimbursement to an HCP will 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 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 each equal one (1) reimbursable unit of

service for each fifteen (15) minute increment of service performed.

Code 97150 will be restricted to one (1) reimbursable unit of service

per visit.





Manipulative

Treatment

Reimbursement to a physician for a manipulative treatment will be

limited to:

One (1) visit per day, and

Two (2) body regions per visit.

Each of the following is one body region:

The entire spine.

Head.

Two (2) upper extremities.

Two (2) lower extremities.

One (1) upper and one (1) lower extremity.

Rib cage.

Abdomen.

Spinal Manipulation

by a Physician

The entire spine will be reimbursed as one (1) region for Workers’

Compensation even though there are five (5) spinal regions:

Cervical,

Thoracic,

Lumbar,

Sacral, and

Pelvic.

Reimbursement will be made to a physician for spinal manipulation

when billed using procedure code 97260.

Manipulation of

Extra-Spinal

Regions

Procedure code 97261 will be reimbursed when a physician performs a

manipulation treatment on the following:

Head region,

Lower extremities,

Upper extremities,

One upper and one lower extremity,

Rib cage and abdomen, and

Viscera region.





Osteopathic

Manipulative

Treatment

Reimbursement for osteopathic manipulative treatment to the

two (2) body regions, spinal and extra-spinal, listed in this Chapter

will be made for procedure codes 98926 and 98928, respectively.

Reimbursement will be made for code 98926 when used to bill for a

spinal manipulation. The spine will be reimbursed as one (1) region

for Workers’ Compensation, although there are five (5) spinal regions

(cervical, thoracic, lumbar, sacral, and pelvic).

Reimbursement will 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

Reimbursement for chiropractic manipulative treatment to two (2)

regions, spinal and extra-spinal, listed in this section will be made

when billed with procedure codes 98941 and 98943, respectively.

Chiropractic Spinal

Manipulations

Reimbursement will be made for procedure code 98941 when used to

bill for a spinal manipulation. The spine will 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.

Chiropractic Extra-

Spinal

Manipulations

Reimbursement will 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.





44B35BAcupuncture

Providers Eligible for

Reimbursement

Reimbursement for acupuncture will be made to an HCP

specifically licensed by the DOH 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 injured worker 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.

Acupuncture 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: An HCP may not bill the initial acupuncture treatment both

with electrical stimulation and without electrical stimulation for the

same visit.





46B36BOrthotics and Prosthetics

Reimbursement

Policies

All prosthetic or orthotic devices must be prescribed by the authorized

physician.

Reimbursement will only be made to a licensed orthotics or prosthetics

providers, occupational therapists or physical therapist providers for

custom fabricated orthotic or prosthetic device(s) when they bill on the

DWC-9 and directly provide the service. If the licensed provider is

employed by an HME provider, medical supplier, Home Health Agency,

or any other employer, the bill is submitted by the employing party.

Orthotics and prosthetics must be billed using HCPCS Level II® codes

that specifically describe the device(s).

Reimbursement Prior written authorization by the carrier is a requirement for

reimbursement of fabricated orthotics and prosthetics.

Reimbursement for orthotics and prosthetics will 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 HCP.

These services must 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 HCP is employed by an HME supplier, Home Health

Agency, or any other employer, the bill must be submitted by the

employing party.





48B37BTests and Measurements

General Policies &

Limitations

Reimbursement to an HCP will 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 authorized physician and

approved by the carrier.

Billing HCPs must bill using the Workers’ Compensation Unique Procedure Code

97752, specifically designated for both manual and automated testing.

Reimbursement Reimbursement for tests and measurements must include a written report

of the testing results.

Manual muscle testing procedure codes and range of motion procedure

codes will not be reimbursed when reported separately with procedure

code 97752.

Reimbursement will be made for range of motion measurements.

38B

Physical Reconditioning Services

Providers Eligible

for

Reimbursement

Reimbursement for physical reconditioning services will only be made to

an authorized occupational therapist, physical therapist, or athletic trainer.

Authorization

Reimbursement will only be made for carrier authorized physical

reconditioning based on a signed order from the HCP.

Physical reconditioning services must be authorized by the carrier prior to

initiation and must not begin any earlier than thirty (30) calendar days after

the injured worker’s date of accident.




49B38BPhysical Reconditioning Services, continued

Physical

Reconditioning

Assessment

Reimbursement for a physical reconditioning assessment and written report

will be determined from the number of hours reported by the HCP to

perform the assessment and the listed MRA.

Note: Reimbursement is limited to eight (8) hours for the assessment and

report.

Billing and

Reimbursement

for Physical

Reconditioning

Reimbursement will be made for Workers’ Compensation Unique

Procedure Codes 97850 and 97851, specifically designated for use in

reporting a physical reconditioning assessment.

Reimbursement will be made for procedure code 97850 when it is used to

bill for the initial hour of a physical reconditioning assessment.

Reimbursement will be made for procedure code 97851 for each additional

thirty (30) minutes of a physical reconditioning assessment subsequent to

procedure code 97850.

Reimbursement for a physical reconditioning program will be paid based on

the number of hours documented by the HCP and the listed MRA.

Note: Reimbursement will be limited to a program lasting no longer than

sixty (60) hours during a six (6) week period, which includes a physical

reconditioning assessment.

Reimbursement will be made for Workers’ Compensation Unique

Procedure Codes 97852 and 97853, specifically designated for use in

reporting a physical reconditioning program.

Reimbursement will be made for procedure code 97852 when used to bill

the initial per hour session of physical reconditioning each day.

Reimbursement will be made for procedure code 97853 when used to bill

each additional thirty (30) minutes per session of physical reconditioning

each day.




50B38BPhysical Reconditioning Services, continued

Multiple

Therapies by the

Same Provider

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

(1) physical reconditioning program for an injured worker per date of

accident, unless authorized by the carrier for an exacerbation of the injury

or surgical intervention, as documented by the authorized physician.

Note: Reimbursement for an extension of a physical reconditioning

program will be limited to reimbursement of an additional twenty (20)

hours during a two (2) week period.



51B40BChapter 2 Medical Services, continued

Interdisciplinary Rehabilitation Programs

Authorization

Reimbursement will only be made to an interdisciplinary rehabilitation

facility for carrier authorized interdisciplinary services based on a signed

order from the HCP.

Exceptions to

Policies

Approval beyond the policies provided in this section must be obtained

from the carrier, in writing, prior to an HCP furnishing the service. Any

unusual circumstances must be documented and forwarded by the HCP 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 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 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, and

Bill each additional hour of a work hardening program each day

using procedure code 97546.




Interdisciplinary Rehabilitation Programs, continued

Pain Programs Reimbursement for an interdisciplinary pain management program will 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 injured worker’s program plan.

Services billed must address all of these components in the documentation

submitted to the carrier for reimbursement.

Reimbursement

for Pain Programs

Reimbursement will 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 determine if the injured worker will

be discharged from the work hardening or pain program before

completion. If the injured worker has not completed the program and the

program director recommends discontinuance of the program, the program

director will provide discharge information to the injured worker, the

carrier, and the authorized physician without charge.

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

director, without charge, to the authorized physician and to the carrier with

the final bill. The report will include:

The injured worker’s current clinical status and plan for transition

from the program, and

Return to work recommendations and functional limitations.




Interdisciplinary Rehabilitation Programs, continued

Functional

Capacity

Evaluation

Reimbursement for a carrier authorized Functional Capacity Evaluation

(FCE) will 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.

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 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 provide written results of the evaluation and

recommendations to the injured worker, the carrier and the authorized

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 DWC-9 form.




52B41BSurgical 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, 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 be used to determine

reimbursement by the Division.

Global Surgical

Package

Reimbursement for a surgical package (global reimbursement) will include

the provision of certain services before and after surgery. Examples of

these services 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;

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, of this Manual.

1. Reimbursement for a procedure code with a ZZZ designation

for the global period will 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 be set by the carrier.

Note: The MRA to a physician for surgical procedures can be found in

Chapter 3, Part B, of this Manual.




Surgical Services, continued

Services

Reimbursed in

Addition to Global

Package

Reimbursement will be made for other services in addition to the surgical

package only in the following situations:

The preoperative visit is the initial visit made by the surgeon, when

an evaluation is necessary to prepare an injured worker for an

unscheduled surgery and when there is a need to establish the

reason for a particular type of surgery;

The preoperative visit by the surgeon is a consultation for

unscheduled surgery;

The preoperative services are not part of the usual preparation for

the particular surgical procedure; or

The services are to treat complications, exacerbations, recurrences,

or other diseases and injuries. Documentation substantiating the

medical necessity of the additional services rendered must be

submitted with the medical bill.

Surgery

Performed During

Post-Op Period

Reimbursement for surgical services will be made when an additional

surgery is performed during the postoperative period of another surgical

procedure.

Reimbursement for normal postoperative care must run concurrently and

must be made according to the separate FUD periods listed in Chapter 3,

Part B, of this Manual, unless it is a procedure code with the YYY

designation. For these codes, the FUD period will be set by the carrier.

Assistant Surgeon Reimbursement for an assistant surgeon will 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 be identified by appending the

modifier 80 to the specific procedure code.





Non-Physician

Surgical Assistants

Reimbursement will 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

Rule 69L-7.730, F.A.C.

The non-physician surgical assistant must provide his or her 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 be made for non-physician surgical assistants

performing surgical services. Reimbursement will be seventy-five percent

(75%) of twenty-five percent (25%) of the physician MRA listed in

Chapter 3, Part B, of this Manual, when the carrier has determined:

The non-physician meets state licensure requirements, and either

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 reimbursement information shall be utilized for

determining reimbursement for all procedure codes. These indicators will

come from an authoritative resource, such as the National Physician Fee

Schedule 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 be used to determine

reimbursement by the Division.

Two Surgeons

Distinct Parts

Reimbursements will be made to two (2) surgeons during the same

operative session for performing distinct parts of a surgical procedure.

The services provided must be identified by the same procedure code with

modifier 62 appended.

Two Surgeons

Separate

Procedures

Reimbursement will be made to two (2) surgeons for rendering separate

surgical procedures during the same operative session. The services must

be identified by billing different, unmodified procedure codes.

Reimbursement to each surgeon will be:

The listed MRA in Chapter 3, Part B, of this Manual; 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 be made By Report (BR) to each

team member for each surgeon’s surgical service.

Each team member must 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.

Billing and

Reimbursement

for Multiple

Surgical

Procedures

Reimbursement will 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 be identified by use of the appropriate

five-digit CPT® code and listed separately.

The primary, or most significant, procedure must be reported first.

Each additional procedure code must be listed separately and reported with

a modifier 51.

Reimbursement for the primary surgical procedure will be the MRA listed

in Chapter 3, Part B, of this Manual or the agreed upon contract price.

Reimbursement for additional surgical procedure(s) will 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 not be billed with a modifier 51.

Designated add-on procedure codes must be billed immediately following

their primary procedure codes for proper identification and reimbursement.





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 be:

The MRA listed in Chapter 3, Part B, in this Manual; or


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 were performed bilaterally for

proper reimbursement. Bill the five-digit procedure code on one line only

using modifier 50.

Reimbursement for a bilateral procedure code that does not include the word

“bilateral” in the description will 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 be:

One hundred and fifty percent (150%) of the MRA, unless otherwise

stated in this Manual; or






Billing and

Reimbursement

for Bilateral

Procedures as

Multiple Surgery

All bills must contain:

The primary procedure code on the first line without modifier 51;

Bill additional procedure code(s) using modifier 51 to indicate

multiple procedures performed during the same operative session;

and

Bill bilateral procedure code(s), using modifier 50 in the first

modifier position, followed by modifier 51 in the second modifier

position, where appropriate.

Reimbursement for these bilateral, multiple surgery codes will be according

to the multiple surgery discount rules.

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 not be billed with a modifier 51.

Billing and

Reimbursement

for Bilateral

Procedures

Performed

Unilaterally

When a procedure is listed in the CPT® as a bilateral-procedure, but is

performed unilaterally, the procedure must be identified with a modifier 52.

Reimbursement will be either:

Fifty percent (50%) of the MRA listed in Chapter 3, Part B, of this

Manual; 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:

Reason for termination of surgery;

Services, reported by CPT® code, that were actually performed;

Supplies actually provided;

Supplies not provided that would have been provided if the surgery

had not been terminated;

Time actually spent by the HCP in each stage, e.g. pre-operative,

operative, and post-operative;

Time that would have been spent in each of these stages if the

surgery had not been terminated; and

Modifier 53 must be added to the procedure code(s) to identify the

circumstances under which the services were terminated.





Reimbursement for

Terminated Procedures

Terminated Procedures will be reimbursed as follows:

No reimbursement will 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 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 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 an HCPCS Level

II® or CPT® code typically performed in addition to a primary

procedure code of the same or similar description. These additional

procedure codes are summarized, but not completely identified, in the

CPT codebook incorporated by reference in Rule 69L-7.020, F.A.C.

“Modifier 51 Exempt” procedure codes do not require modifier 51 in

Field 24D on the DWC-9 claim form and are reimbursed 100% of the

MRA.


2017 Edition Effective Date: __________

3B2BChapter 3 Maximum Reimbursement Allowances

General

Instructions

This chapter establishes the MRAs for services and procedures performed by

Florida workers’ compensation HCPs and for out-of-state providers who

have not contracted with the carrier for alternate reimbursement.

Part A Part A establishes the MRAs for services and procedures performed by

workers’ compensation HCPs not specifically addressed in this Manual and

for out-of-state providers who have not contracted with the carrier for

alternate reimbursement.

Part A includes the basic value (or base unit) on which reimbursement will

be calculated for all anesthesia services according to this Manual.

Part A also includes the MRAs for dental codes and injectable medications.

Part B Part B establishes the MRAs for Florida physicians who provide surgical

procedures and services. Physician assistants and advanced registered nurse

practitioners will 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 MRAs for Florida physicians, physical and

occupational therapists, athletic trainers, audiologists, speech pathologists,

and psychologists who provide non-surgical procedures and services.

Physician assistants and advanced registered nurse practitioners will 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 includes the reimbursement for other health services. Independent

clinical laboratories and freestanding imaging/x-ray centers are reimbursed at

the technical component (TC), non-facility MRA. Dietitians, nutritionists,

and nutrition counselors are reimbursed eighty-five percent (85%) of the

physician’s MRA and clinical social workers are reimbursed seventy-five

percent (75%) of the physician’s MRA.



Chapter 3 Maximum Reimbursement Allowances, continued

Determining the MRA

To determine the MRA that an HCP is entitled under Part B or Part C:

A. Determine the county location of the HCP 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 an HCP’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. Reimbursement will be the greater of the amount in the 2003

MRA column or the amount in the column at the point of

intersection.

2017 Edition Effective Date: ________


PART A

SCHEDULE OF MAXIMUM REIMBURSEMENT

ALLOWANCES

Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective ___________

CPT only © 2016 American Medical Association. All Rights Reserved. PartA, 77

Anesthesia Anesthesia Anesthesia

CPT Code BV + TM CPT Code BV + TM CPT Code BV + TM

00100 5 + TM 00528 8 + TM 00842 4 + TM

00102 6 + TM 00529 11 + TM 00844 7 + TM

00103 5 + TM 00530 4 + TM 00846 8 + TM

00104 4 + TM 00532 4 + TM 00848 8 + TM

00120 5 + TM 00534 7 + TM 00851 6 + TM

00124 4 + TM 00537 10 + TM 00860 6 + TM

00126 4 + TM 00539 18 + TM 00862 7 + TM

00140 5 + TM 00540 12 + TM 00864 8 + TM

00142 4 + TM 00541 15 + TM 00865 7 + TM

00144 6 + TM 00542 15 + TM 00866 10 + TM

00145 6 + TM 00546 15 + TM 00868 10 + TM

00147 6 + TM 00548 17 + TM 00870 5 + TM

00148 4 + TM 00550 10 + TM 00872 7 + TM

00160 5 + TM 00560 15 + TM 00873 5 + TM

00162 7 + TM 00562 20 + TM 00880 15 + TM

00164 4 + TM 00563 25 + TM 00882 10 + TM

00170 5 + TM 00566 25 + TM 00902 5 + TM

00172 6 + TM 00567 18 + TM 00904 7 + TM

00174 6 + TM 00580 20 + TM 00906 4 + TM

00176 7 + TM 00600 10 + TM 00908 6 + TM

00190 5 + TM 00604 13 + TM 00910 3 + TM

00192 7 + TM 00620 10 + TM 00912 5 + TM

00210 11 + TM 00625 13 + TM 00914 5 + TM

00211 10 + TM 00626 15 + TM 00916 5 + TM

00212 5 + TM 00630 8 + TM 00918 5 + TM

00214 9 + TM 00632 7 + TM 00920 3 + TM

00215 9 + TM 00635 4 + TM 00921 3 + TM

00216 15 + TM 00640 3 + TM 00922 6 + TM

00218 13 + TM 00670 13 + TM 00924 4 + TM

00220 10 + TM 00700 4 + TM 00926 4 + TM

00222 6 + TM 00702 4 + TM 00928 6 + TM

00300 5 + TM 00730 5 + TM 00930 4 + TM

00320 6 + TM 00740 5 + TM 00932 4 + TM

00322 3 + TM 00750 4 + TM 00934 6 + TM

00350 10 + TM 00752 6 + TM 00936 8 + TM

00352 5 + TM 00754 7 + TM 00938 4 + TM

00400 3 + TM 00756 7 + TM 00940 3 + TM

00402 5 + TM 00770 15 + TM 00942 4 + TM

00404 5 + TM 00790 7 + TM 00944 6 + TM

00406 13 + TM 00792 13 + TM 00948 4 + TM

00410 4 + TM 00794 8 + TM 00950 5 + TM

00450 5 + TM 00796 30 + TM 00952 4 + TM

00454 3 + TM 00797 11 + TM 01112 5 + TM

00470 6 + TM 00800 4 + TM 01120 6 + TM

00472 10 + TM 00802 5 + TM 01130 3 + TM

00474 13 + TM 00810 5 + TM 01140 15 + TM

00500 15 + TM 00820 5 + TM 01150 10 + TM

00520 6 + TM 00830 4 + TM 01160 4 + TM

00522 4 + TM 00832 6 + TM 01170 8 + TM

00524 4 + TM 00840 6 + TM 01173 12 + TM



Anesthesia Anesthesia Anesthesia

CPT Code BV + TM CPT Code BV + TM CPT Code BV + TM

01180 3 + TM 01630 5 + TM 01951 3 + TM

01190 4 + TM 01634 9 + TM 01952 5 + TM

01200 4 + TM 01636 15 + TM 01953 1 + TM

01202 4 + TM 01638 10 + TM 01960 5 + TM

01210 6 + TM 01650 6 + TM 01961 7 + TM

01212 10 + TM 01652 10 + TM 01962 8 + TM

01214 8 + TM 01654 8 + TM 01963 10 + TM

01215 10 + TM 01656 10 + TM 01967 5 + TM

01220 4 + TM 01670 4 + TM 01968 3 + TM

01230 6 + TM 01680 3 + TM 01969 5 + TM

01232 5 + TM 01682 4 + TM 01990 0

01234 8 + TM 01710 3 + TM 01991 3 + TM

01250 4 + TM 01712 5 + TM 01992 5 + TM

01260 3 + TM 01714 5 + TM 01996 3

01270 8 + TM 01716 5 + TM 01999 BR

01272 4 + TM 01730 3 + TM

01274 6 + TM 01732 3 + TM

01320 4 + TM 01740 4 + TM

01340 4 + TM 01742 5 + TM

01360 5 + TM 01744 5 + TM

01380 3 + TM 01756 6 + TM

01382 3 + TM 01758 5 + TM

01390 3 + TM 01760 7 + TM

01392 4 + TM 01770 6 + TM

01400 4 + TM 01772 6 + TM

01402 7 + TM 01780 3 + TM

01404 5 + TM 01782 4 + TM

01420 3 + TM 01810 3 + TM

01430 3 + TM 01820 3 + TM

01432 6 + TM 01829 3 + TM

01440 8 + TM 01830 3 + TM

01442 8 + TM 01832 6 + TM

01444 8 + TM 01840 6 + TM

01462 3 + TM 01842 6 + TM

01464 3 + TM 01844 6 + TM

01470 3 + TM 01850 3 + TM

01472 5 + TM 01852 4 + TM

01474 5 + TM 01860 3 + TM

01480 3 + TM 01916 5 + TM

01482 4 + TM 01920 7 + TM

01484 4 + TM 01922 7 + TM

01486 7 + TM 01924 6 + TM

01490 3 + TM 01925 8 + TM

01500 8 + TM 01926 10 + TM

01502 6 + TM 01930 5 + TM

01520 3 + TM 01931 7 + TM

01522 5 + TM 01932 7 + TM

01610 5 + TM 01933 8 + TM

01620 4 + TM 01935 5 + TM

01622 4 + TM 01936 5 + TM



Surgery Surgery Surgery

CPT Code MRA FUD CPT Code MRA FUD CPT Code MRA FUD

10021 $90.00 0 11401 $114.00 10 11762 $223.00 10

10022 $92.00 0 11402 $145.00 10 11765 $65.00 10

10030 $791.00 0 11403 $178.00 10 11770 $275.00 10

10035 $544.00 0 11404 $200.00 10 11771 $496.00 90

10036 $473.00 ZZZ 11406 $246.00 10 11772 $585.00 90

10040 $54.00 10 11420 $98.00 10 11900 $33.00 0

10060 $53.00 10 11421 $92.00 10 11901 $37.00 0

10061 $133.00 10 11422 $157.00 10 11920 $147.00 0

10080 $65.00 10 11423 $163.00 10 11921 $172.00 0

10081 $203.00 10 11424 $221.00 10 11922 $40.00 ZZZ

10120 $53.00 10 11426 $303.00 10 11950 $107.00 0

10121 $169.00 10 11440 $105.00 10 11951 $114.00 0

10140 $53.00 10 11441 $102.00 10 11952 $155.00 0

10160 $45.00 10 11442 $174.00 10 11954 $165.00 0

10180 $164.00 10 11443 $221.00 10 11960 $829.00 90

11000 $45.00 0 11444 $276.00 10 11970 $632.00 90

11001 $27.00 ZZZ 11446 $344.00 10 11971 $280.00 90

11004 $564.00 0 11450 $282.00 90 11976 $123.00 0

11005 $768.00 0 11451 $366.00 90 12001 $84.00 0

11006 $710.00 0 11462 $264.00 90 12002 $98.00 0

11008 $289.00 ZZZ 11463 $351.00 90 12004 $122.00 0

11010 $348.00 10 11470 $320.00 90 12005 $165.00 0

11011 $432.00 0 11471 $391.00 90 12006 $203.00 0

11012 $597.00 0 11600 $148.00 10 12007 $339.00 0

11042 $88.00 0 11601 $180.00 10 12011 $98.00 0

11043 $210.00 0 11602 $199.00 10 12013 $141.00 0

11044 $283.00 0 11603 $226.00 10 12014 $165.00 0

11045 $43.00 ZZZ 11604 $249.00 10 12015 $207.00 0

11046 $75.00 ZZZ 11606 $315.00 10 12016 $268.00 0

11047 $127.00 ZZZ 11620 $150.00 10 12017 $316.00 0

11055 $26.00 0 11621 $191.00 10 12018 $515.00 0

11056 $35.00 0 11622 $223.00 10 12020 $211.00 10

11057 $39.00 0 11623 $259.00 10 12021 $87.00 10

11100 $78.00 0 11624 $305.00 10 12031 $93.00 10

11101 $41.00 ZZZ 11626 $373.00 10 12032 $110.00 10

11200 $66.00 10 11640 $168.00 10 12034 $148.00 10

11201 $26.00 ZZZ 11641 $227.00 10 12035 $223.00 10

11300 $59.00 0 11642 $260.00 10 12036 $356.00 10

11301 $80.00 0 11643 $305.00 10 12037 $411.00 10

11302 $96.00 0 11644 $380.00 10 12041 $116.00 10

11303 $119.00 0 11646 $494.00 10 12042 $141.00 10

11305 $61.00 0 11719 $22.00 0 12044 $176.00 10

11306 $86.00 0 11720 $32.00 0 12045 $250.00 10

11307 $100.00 0 11721 $50.00 0 12046 $341.00 10

11308 $125.00 0 11730 $62.00 0 12047 $363.00 10

11310 $75.00 0 11732 $31.00 ZZZ 12051 $126.00 10

11311 $95.00 0 11740 $41.00 0 12052 $148.00 10

11312 $110.00 0 11750 $156.00 10 12053 $223.00 10

11313 $144.00 0 11755 $106.00 0 12054 $301.00 10

11400 $81.00 10 11760 $131.00 10 12055 $380.00 10





12056 $487.00 10 15200 $644.00 90 15819 $780.00 90

12057 $539.00 10 15201 $126.00 ZZZ 15820 $556.00 90

13100 $178.00 10 15220 $687.00 90 15821 $607.00 90

13101 $240.00 10 15221 $114.00 ZZZ 15822 $499.00 90

13102 $89.00 ZZZ 15240 $763.00 90 15823 $718.00 90

13120 $223.00 10 15241 $334.00 ZZZ 15824 BR 0

13121 $348.00 10 15260 $841.00 90 15825 BR 0

13122 $104.00 ZZZ 15261 $207.00 ZZZ 15826 BR 0

13131 $252.00 10 15271 $143.00 0 15828 BR 0

13132 $484.00 10 15272 $27.00 ZZZ 15829 BR 0

13133 $154.00 ZZZ 15273 $299.00 0 15830 $1,072.00 90

13151 $375.00 10 15274 $70.00 ZZZ 15832 $926.00 90

13152 $542.00 10 15275 $155.00 0 15833 $833.00 90

13153 $169.00 ZZZ 15276 $35.00 ZZZ 15834 $837.00 90

13160 $655.00 90 15277 $320.00 0 15835 $865.00 90

14000 $512.00 90 15278 $83.00 ZZZ 15836 $721.00 90

14001 $695.00 90 15570 $748.00 90 15837 $696.00 90

14020 $590.00 90 15572 $721.00 90 15838 $600.00 90

14021 $818.00 90 15574 $775.00 90 15839 $643.00 90

14040 $701.00 90 15576 $457.00 90 15840 $1,187.00 90

14041 $936.00 90 15600 $259.00 90 15841 $1,859.00 90

14060 $766.00 90 15610 $320.00 90 15842 $3,099.00 90

14061 $1,330.00 90 15620 $506.00 90 15845 $1,116.00 90

14301 $1,088.00 90 15630 $362.00 90 15850 $63.00 0

14302 $228.00 ZZZ 15650 $427.00 90 15851 $40.00 0

14350 $734.00 90 15731 $990.00 90 15852 $35.00 0

15002 $351.00 0 15732 $1,465.00 90 15860 $151.00 0

15003 $77.00 ZZZ 15734 $1,557.00 90 15876 BR 0

15004 $407.00 0 15736 $1,862.00 90 15877 BR 0

15005 $127.00 ZZZ 15738 $1,415.00 90 15878 BR 0

15040 $258.00 0 15740 $913.00 90 15879 BR 0

15050 $349.00 90 15750 $1,064.00 90 15920 $571.00 90

15100 $679.00 90 15756 $2,892.00 90 15922 $771.00 90

15101 $146.00 ZZZ 15757 $2,892.00 90 15931 $638.00 90

15110 $815.00 90 15758 $2,884.00 90 15933 $860.00 90

15111 $129.00 ZZZ 15760 $810.00 90 15934 $1,064.00 90

15115 $766.00 90 15770 $674.00 90 15935 $1,184.00 90

15116 $167.00 ZZZ 15775 $327.00 0 15936 $1,032.00 90

15120 $788.00 90 15776 $475.00 0 15937 $1,223.00 90

15121 $235.00 ZZZ 15777 $219.00 ZZZ 15940 $318.00 90

15130 $677.00 90 15780 $532.00 90 15941 $919.00 90

15131 $105.00 ZZZ 15781 $420.00 90 15944 $954.00 90

15135 $820.00 90 15782 $314.00 90 15945 $1,078.00 90

15136 $98.00 ZZZ 15783 $340.00 90 15946 $1,737.00 90

15150 $677.00 90 15786 $146.00 10 15950 $549.00 90

15151 $136.00 ZZZ 15787 $27.00 ZZZ 15951 $872.00 90

15152 $167.00 ZZZ 15788 $194.00 90 15952 $876.00 90

15155 $678.00 90 15789 $360.00 90 15953 $1,013.00 90

15156 $177.00 ZZZ 15792 $130.00 90 15956 $1,382.00 90

15157 $196.00 ZZZ 15793 $232.00 90 15958 $1,379.00 90





15999 BR YYY 19084 $543.00 ZZZ 19370 $662.00 90

16000 $53.00 0 19085 $1,025.00 0 19371 $788.00 90

16020 $49.00 0 19086 $817.00 ZZZ 19380 $780.00 90

16025 $67.00 0 19100 $117.00 0 19396 $231.00 0

16030 $153.00 0 19101 $338.00 10 19499 BR YYY

16035 $341.00 0 19105 $1,878.00 0 20005 $267.00 10

16036 $81.00 ZZZ 19110 $406.00 90 20100 $727.00 10

17000 $60.00 10 19112 $354.00 90 20101 $261.00 10

17003 $16.00 ZZZ 19120 $429.00 90 20102 $314.00 10

17004 $233.00 10 19125 $468.00 90 20103 $405.00 10

17106 $341.00 90 19126 $201.00 ZZZ 20150 $1,141.00 90

17107 $648.00 90 19260 $1,101.00 90 20200 $134.00 0

17108 $1,015.00 90 19271 $1,561.00 90 20205 $243.00 0

17110 $55.00 10 19272 $1,674.00 90 20206 $119.00 0

17111 $83.00 10 19281 $246.00 0 20220 $128.00 0

17250 $27.00 0 19282 $171.00 ZZZ 20225 $215.00 0

17260 $96.00 10 19283 $279.00 0 20240 $279.00 0

17261 $117.00 10 19284 $205.00 ZZZ 20245 $364.00 10

17262 $150.00 10 19285 $472.00 0 20250 $447.00 10

17263 $172.00 10 19286 $396.00 ZZZ 20251 $511.00 10

17264 $189.00 10 19287 $875.00 0 20500 $59.00 10

17266 $225.00 10 19288 $696.00 ZZZ 20501 $60.00 0

17270 $125.00 10 19296 $4,903.00 0 20520 $75.00 10

17271 $143.00 10 19297 $96.00 ZZZ 20525 $331.00 10

17272 $170.00 10 19298 $1,841.00 0 20526 $64.00 0

17273 $195.00 10 19300 $482.00 90 20527 $84.00 0

17274 $240.00 10 19301 $367.00 90 20550 $40.00 0

17276 $281.00 10 19302 $780.00 90 20551 $62.00 0

17280 $123.00 10 19303 $788.00 90 20552 $62.00 0

17281 $165.00 10 19304 $487.00 90 20553 $62.00 0

17282 $194.00 10 19305 $964.00 90 20555 $301.00 0

17283 $239.00 10 19306 $1,003.00 90 20600 $41.00 0

17284 $282.00 10 19307 $1,008.00 90 20604 $73.00 0

17286 $373.00 10 19316 $954.00 90 20605 $48.00 0

17311 $629.00 0 19318 $1,313.00 90 20606 $81.00 0

17312 $380.00 ZZZ 19324 $440.00 90 20610 $49.00 0

17313 $575.00 0 19325 $656.00 90 20611 $93.00 0

17314 $352.00 ZZZ 19328 $457.00 90 20612 $56.00 0

17315 $74.00 ZZZ 19330 $569.00 90 20615 $94.00 10

17340 $37.00 10 19340 $545.00 90 20650 $170.00 10

17360 $96.00 10 19342 $963.00 90 20660 $320.00 0

17380 BR 0 19350 $853.00 90 20661 $476.00 90

17999 BR YYY 19355 $755.00 90 20662 $559.00 90

19000 $74.00 0 19357 $1,449.00 90 20663 $465.00 90

19001 $40.00 ZZZ 19361 $1,667.00 90 20665 $105.00 10

19020 $288.00 90 19364 $2,737.00 90 20670 $80.00 10

19030 $98.00 0 19366 $1,676.00 90 20680 $332.00 90

19081 $682.00 0 19367 $2,056.00 90 20690 $298.00 90

19082 $551.00 ZZZ 19368 $2,444.00 90 20692 $516.00 90

19083 $677.00 0 19369 $2,317.00 90 20693 $477.00 90





20694 $421.00 90 21030 $496.00 90 21159 $3,302.00 90

20696 $1,156.00 90 21031 $310.00 90 21160 $3,500.00 90

20697 $1,860.00 0 21032 $315.00 90 21172 $2,111.00 90

20802 $3,363.00 90 21034 $1,140.00 90 21175 $2,604.00 90

20805 $4,317.00 90 21040 $227.00 90 21179 $1,826.00 90

20808 $5,324.00 90 21044 $957.00 90 21180 $2,035.00 90

20816 $3,060.00 90 21045 $1,313.00 90 21181 $813.00 90

20822 $2,511.00 90 21046 $899.00 90 21182 $2,570.00 90

20824 $3,027.00 90 21047 $1,109.00 90 21183 $2,770.00 90

20827 $3,920.00 90 21048 $925.00 90 21184 $3,150.00 90

20838 $3,484.00 90 21049 $1,051.00 90 21188 $1,786.00 90

20900 $454.00 0 21050 $1,026.00 90 21193 $1,331.00 90

20902 $658.00 0 21060 $972.00 90 21194 $1,540.00 90

20910 $338.00 90 21070 $679.00 90 21195 $1,360.00 90

20912 $549.00 90 21073 $337.00 90 21196 $1,764.00 90

20920 $460.00 90 21076 $1,192.00 10 21198 $1,268.00 90

20922 $634.00 90 21077 $3,002.00 90 21199 $1,018.00 90

20924 $583.00 90 21079 $2,086.00 90 21206 $1,112.00 90

20926 $444.00 90 21080 $2,346.00 90 21208 $946.00 90

20930 BR 0 21081 $2,138.00 90 21209 $576.00 90

20931 $156.00 ZZZ 21082 $1,855.00 90 21210 $930.00 90

20936 BR 0 21083 $1,802.00 90 21215 $970.00 90

20937 $234.00 ZZZ 21084 $2,105.00 90 21230 $956.00 90

20938 $257.00 ZZZ 21085 $801.00 10 21235 $707.00 90

20950 $123.00 0 21086 $2,333.00 90 21240 $1,281.00 90

20955 $3,332.00 90 21087 $2,217.00 90 21242 $1,207.00 90

20956 $3,167.00 90 21088 BR 90 21243 $1,501.00 90

20957 $3,074.00 90 21089 BR YYY 21244 $1,062.00 90

20962 $3,122.00 90 21100 $297.00 90 21245 $1,038.00 90

20969 $3,716.00 90 21110 $371.00 90 21246 $1,010.00 90

20970 $3,650.00 90 21116 $207.00 0 21247 $2,003.00 90

20972 $3,420.00 90 21120 $500.00 90 21248 $1,023.00 90

20973 $3,821.00 90 21121 $651.00 90 21249 $1,525.00 90

20974 $266.00 0 21122 $700.00 90 21255 $1,459.00 90

20975 $334.00 0 21123 $903.00 90 21256 $1,470.00 90

20979 $19.00 0 21125 $656.00 90 21260 $1,372.00 90

20982 $4,231.00 0 21127 $909.00 90 21261 $2,347.00 90

20983 $7,394.00 0 21137 $797.00 90 21263 $2,361.00 90

20985 $140.00 ZZZ 21138 $960.00 90 21267 $1,539.00 90

20999 BR YYY 21139 $1,168.00 90 21268 $1,946.00 90

21010 $854.00 90 21141 $1,438.00 90 21270 $890.00 90

21011 $349.00 90 21142 $1,527.00 90 21275 $963.00 90

21012 $341.00 90 21143 $1,511.00 90 21280 $571.00 90

21013 $521.00 90 21145 $1,513.00 90 21282 $360.00 90

21014 $528.00 90 21146 $1,570.00 90 21295 $144.00 90

21015 $520.00 90 21147 $1,639.00 90 21296 $384.00 90

21016 $1,063.00 90 21150 $1,914.00 90 21299 BR YYY

21025 $546.00 90 21151 $2,264.00 90 21310 $81.00 0

21026 $413.00 90 21154 $2,364.00 90 21315 $180.00 10

21029 $700.00 90 21155 $2,640.00 90 21320 $235.00 10





21325 $348.00 90 21490 $865.00 90 22110 $889.00 90

21330 $639.00 90 21497 $372.00 90 22112 $1,090.00 90

21335 $852.00 90 21499 BR YYY 22114 $1,062.00 90

21336 $478.00 90 21501 $315.00 90 22116 $195.00 ZZZ

21337 $300.00 90 21502 $612.00 90 22206 $2,153.00 90

21338 $550.00 90 21510 $534.00 90 22207 $2,126.00 90

21339 $689.00 90 21550 $165.00 10 22208 $545.00 ZZZ

21340 $907.00 90 21552 $453.00 90 22210 $1,892.00 90

21343 $1,043.00 90 21554 $744.00 90 22212 $1,668.00 90

21344 $1,450.00 90 21555 $337.00 90 22214 $819.00 90

21345 $738.00 90 21556 $431.00 90 22216 $492.00 ZZZ

21346 $917.00 90 21557 $794.00 90 22220 $1,801.00 90

21347 $1,048.00 90 21558 $1,380.00 90 22222 $1,604.00 90

21348 $1,286.00 90 21600 $631.00 90 22224 $1,731.00 90

21355 $295.00 10 21610 $828.00 90 22226 $488.00 ZZZ

21356 $372.00 10 21615 $938.00 90 22310 $272.00 90

21360 $590.00 90 21616 $1,042.00 90 22315 $711.00 90

21365 $1,239.00 90 21620 $689.00 90 22318 $1,755.00 90

21366 $1,386.00 90 21627 $686.00 90 22319 $1,983.00 90

21385 $810.00 90 21630 $1,455.00 90 22325 $1,407.00 90

21386 $812.00 90 21632 $1,514.00 90 22326 $1,710.00 90

21387 $958.00 90 21685 $918.00 90 22327 $1,660.00 90

21390 $920.00 90 21700 $576.00 90 22328 $391.00 ZZZ

21395 $1,384.00 90 21705 $746.00 90 22505 $174.00 10

21400 $143.00 90 21720 $523.00 90 22510 $1,804.00 10

21401 $313.00 90 21725 $588.00 90 22511 $1,786.00 10

21406 $852.00 90 21740 $1,387.00 90 22512 $1,001.00 ZZZ

21407 $736.00 90 21742 BR 90 22513 $7,471.00 10

21408 $1,007.00 90 21743 BR 90 22514 $7,462.00 10

21421 $528.00 90 21750 $1,009.00 90 22515 $4,518.00 ZZZ

21422 $761.00 90 21811 $634.00 0 22526 $2,013.00 10

21423 $890.00 90 21812 $761.00 0 22527 $1,637.00 ZZZ

21431 $598.00 90 21813 $992.00 0 22532 $1,618.00 90

21432 $744.00 90 21820 $143.00 90 22533 $1,509.00 90

21433 $1,981.00 90 21825 $810.00 90 22534 $381.00 ZZZ

21435 $1,404.00 90 21899 BR YYY 22548 $2,271.00 90

21436 $2,045.00 90 21920 $165.00 10 22551 $1,759.00 90

21440 $308.00 90 21925 $371.00 90 22552 $406.00 ZZZ

21445 $533.00 90 21930 $403.00 90 22554 $1,727.00 90

21450 $325.00 90 21931 $478.00 90 22556 $2,054.00 90

21451 $498.00 90 21932 $672.00 90 22558 $1,907.00 90

21452 $195.00 90 21933 $749.00 90 22585 $473.00 ZZZ

21453 $902.00 90 21935 $1,280.00 90 22586 $1,926.00 90

21454 $905.00 90 21936 $1,442.00 90 22590 $1,895.00 90

21461 $769.00 90 22010 $822.00 90 22595 $1,960.00 90

21462 $1,012.00 90 22015 $815.00 90 22600 $1,567.00 90

21465 $923.00 90 22100 $850.00 90 22610 $1,494.00 90

21470 $1,331.00 90 22101 $862.00 90 22612 $1,861.00 90

21480 $82.00 0 22102 $781.00 90 22614 $530.00 ZZZ

21485 $318.00 90 22103 $198.00 ZZZ 22630 $1,201.00 90





22632 $442.00 ZZZ 23031 $185.00 10 23420 $1,276.00 90

22633 $1,894.00 90 23035 $861.00 90 23430 $884.00 90

22634 $511.00 ZZZ 23040 $898.00 90 23440 $906.00 90

22800 $1,960.00 90 23044 $708.00 90 23450 $1,210.00 90

22802 $2,633.00 90 23065 $171.00 10 23455 $1,340.00 90

22804 $2,951.00 90 23066 $302.00 90 23460 $1,364.00 90

22808 $2,157.00 90 23071 $426.00 90 23462 $1,383.00 90

22810 $2,356.00 90 23073 $705.00 90 23465 $1,398.00 90

22812 $2,675.00 90 23075 $247.00 90 23466 $1,332.00 90

22818 $2,701.00 90 23076 $613.00 90 23470 $1,540.00 90

22819 $2,968.00 90 23077 $1,228.00 90 23472 $1,570.00 90

22830 $1,176.00 90 23078 $1,476.00 90 23473 $1,672.00 90

22840 $943.00 ZZZ 23100 $616.00 90 23474 $1,807.00 90

22841 BR 0 23101 $583.00 90 23480 $926.00 90

22842 $2,352.00 ZZZ 23105 $814.00 90 23485 $1,181.00 90

22843 $1,028.00 ZZZ 23106 $581.00 90 23490 $1,038.00 90

22844 $1,277.00 ZZZ 23107 $851.00 90 23491 $1,251.00 90

22845 $1,853.00 ZZZ 23120 $645.00 90 23500 $148.00 90

22846 $999.00 ZZZ 23125 $865.00 90 23505 $293.00 90

22847 $1,077.00 ZZZ 23130 $722.00 90 23515 $688.00 90

22848 $529.00 ZZZ 23140 $597.00 90 23520 $205.00 90

22849 $2,235.00 90 23145 $889.00 90 23525 $320.00 90

22850 $872.00 90 23146 $704.00 90 23530 $659.00 90

22852 $854.00 90 23150 $755.00 90 23532 $713.00 90

22853 $274.00 ZZZ 23155 $945.00 90 23540 $148.00 90

22854 $355.00 ZZZ 23156 $794.00 90 23545 $148.00 90

22855 $1,193.00 90 23170 $645.00 90 23550 $701.00 90

22856 $1,701.00 90 23172 $638.00 90 23552 $753.00 90

22857 $1,386.00 90 23174 $882.00 90 23570 $88.00 90

22858 $527.00 ZZZ 23180 $566.00 90 23575 $306.00 90

22859 $355.00 ZZZ 23182 $865.00 90 23585 $809.00 90

22861 $2,262.00 90 23184 $962.00 90 23600 $318.00 90

22862 $1,690.00 90 23190 $656.00 90 23605 $511.00 90

22864 $2,035.00 90 23195 $902.00 90 23615 $900.00 90

22865 $1,646.00 90 23200 $1,095.00 90 23616 $1,895.00 90

22867 $1,025.00 90 23210 $1,095.00 90 23620 $286.00 90

22868 $256.00 ZZZ 23220 $1,307.00 90 23625 $422.00 90

22869 $563.00 90 23330 $59.00 10 23630 $712.00 90

22870 $149.00 ZZZ 23333 $466.00 90 23650 $296.00 90

22899 BR YYY 23334 $1,100.00 90 23655 $374.00 90

22900 $446.00 90 23335 $1,312.00 90 23660 $712.00 90

22901 $673.00 90 23350 $74.00 0 23665 $440.00 90

22902 $436.00 90 23395 $1,366.00 90 23670 $759.00 90

22903 $440.00 90 23397 $1,403.00 90 23675 $550.00 90

22904 $1,069.00 90 23400 $1,196.00 90 23680 $1,064.00 90

22905 $1,362.00 90 23405 $799.00 90 23700 $237.00 10

22999 BR YYY 23406 $977.00 90 23800 $1,346.00 90

23000 $447.00 90 23410 $1,119.00 90 23802 $1,368.00 90

23020 $807.00 90 23412 $1,229.00 90 23900 $1,561.00 90

23030 $323.00 10 23415 $622.00 90 23920 $1,300.00 90





23921 $497.00 90 24341 $702.00 90 24655 $436.00 90

23929 BR YYY 24342 $950.00 90 24665 $749.00 90

23930 $71.00 10 24343 $643.00 90 24666 $905.00 90

23931 $62.00 10 24344 $971.00 90 24670 $263.00 90

23935 $630.00 90 24345 $643.00 90 24675 $490.00 90

24000 $550.00 90 24346 $971.00 90 24685 $819.00 90

24006 $793.00 90 24357 $408.00 90 24800 $984.00 90

24065 $166.00 10 24358 $478.00 90 24802 $1,181.00 90

24066 $461.00 90 24359 $587.00 90 24900 $858.00 90

24071 $413.00 90 24360 $1,125.00 90 24920 $851.00 90

24073 $704.00 90 24361 $1,215.00 90 24925 $661.00 90

24075 $349.00 90 24362 $1,269.00 90 24930 $928.00 90

24076 $529.00 90 24363 $1,663.00 90 24931 $1,063.00 90

24077 $1,058.00 90 24365 $747.00 90 24935 $1,327.00 90

24079 $1,357.00 90 24366 $850.00 90 24940 BR 90

24100 $467.00 90 24370 $1,581.00 90 24999 BR YYY

24101 $591.00 90 24371 $1,826.00 90 25000 $381.00 90

24102 $755.00 90 24400 $991.00 90 25001 $294.00 90

24105 $360.00 90 24410 $1,319.00 90 25020 $594.00 90

24110 $724.00 90 24420 $1,265.00 90 25023 $1,040.00 90

24115 $898.00 90 24430 $1,209.00 90 25024 $683.00 90

24116 $1,037.00 90 24435 $1,260.00 90 25025 $1,104.00 90

24120 $595.00 90 24470 $774.00 90 25028 $417.00 90

24125 $663.00 90 24495 $742.00 90 25031 $266.00 90

24126 $731.00 90 24498 $1,076.00 90 25035 $794.00 90

24130 $595.00 90 24500 $288.00 90 25040 $654.00 90

24134 $966.00 90 24505 $574.00 90 25065 $164.00 10

24136 $720.00 90 24515 $1,018.00 90 25066 $322.00 90

24138 $697.00 90 24516 $1,029.00 90 25071 $432.00 90

24140 $963.00 90 24530 $88.00 90 25073 $540.00 90

24145 $592.00 90 24535 $671.00 90 25075 $352.00 90

24147 $703.00 90 24538 $850.00 90 25076 $544.00 90

24149 $1,224.00 90 24545 $946.00 90 25077 $957.00 90

24150 $1,265.00 90 24546 $1,273.00 90 25078 $1,195.00 90

24152 $829.00 90 24560 $266.00 90 25085 $562.00 90

24155 $1,019.00 90 24565 $526.00 90 25100 $420.00 90

24160 $533.00 90 24566 $705.00 90 25101 $492.00 90

24164 $564.00 90 24575 $872.00 90 25105 $635.00 90

24200 $58.00 10 24576 $295.00 90 25107 $600.00 90

24201 $444.00 90 24577 $575.00 90 25109 $470.00 90

24220 $89.00 0 24579 $964.00 90 25110 $403.00 90

24300 $352.00 90 24582 $773.00 90 25111 $356.00 90

24301 $869.00 90 24586 $1,314.00 90 25112 $441.00 90

24305 $579.00 90 24587 $1,278.00 90 25115 $837.00 90

24310 $511.00 90 24600 $360.00 90 25116 $807.00 90

24320 $944.00 90 24605 $371.00 90 25118 $466.00 90

24330 $845.00 90 24615 $836.00 90 25119 $653.00 90

24331 $927.00 90 24620 $560.00 90 25120 $712.00 90

24332 $487.00 90 24635 $1,329.00 90 25125 $803.00 90

24340 $697.00 90 24650 $262.00 90 25126 $781.00 90





25130 $502.00 90 25420 $1,554.00 90 25675 $404.00 90

25135 $631.00 90 25425 $1,403.00 90 25676 $741.00 90

25136 $546.00 90 25426 $1,401.00 90 25680 $471.00 90

25145 $713.00 90 25430 $638.00 90 25685 $887.00 90

25150 $720.00 90 25431 $631.00 90 25690 $518.00 90

25151 $771.00 90 25440 $931.00 90 25695 $520.00 90

25170 $1,085.00 90 25441 $1,147.00 90 25800 $703.00 90

25210 $561.00 90 25442 $936.00 90 25805 $1,078.00 90

25215 $817.00 90 25443 $970.00 90 25810 $1,008.00 90

25230 $531.00 90 25444 $1,031.00 90 25820 $2,276.00 90

25240 $567.00 90 25445 $959.00 90 25825 $895.00 90

25246 $72.00 0 25446 $1,542.00 90 25830 $991.00 90

25248 $236.00 90 25447 $952.00 90 25900 $871.00 90

25250 $616.00 90 25449 $395.00 90 25905 $900.00 90

25251 $933.00 90 25450 $805.00 90 25907 $799.00 90

25259 $348.00 90 25455 $899.00 90 25909 $849.00 90

25260 $728.00 90 25490 $955.00 90 25915 $1,523.00 90

25263 $809.00 90 25491 $1,006.00 90 25920 $771.00 90

25265 $998.00 90 25492 $1,170.00 90 25922 $670.00 90

25270 $549.00 90 25500 $200.00 90 25924 $768.00 90

25272 $613.00 90 25505 $517.00 90 25927 $830.00 90

25274 $887.00 90 25515 $800.00 90 25929 $645.00 90

25275 $620.00 90 25520 $644.00 90 25931 $731.00 90

25280 $670.00 90 25525 $1,097.00 90 25999 BR YYY

25290 $436.00 90 25526 $1,293.00 90 26010 $59.00 10

25295 $562.00 90 25530 $270.00 90 26011 $223.00 10

25300 $592.00 90 25535 $516.00 90 26020 $484.00 90

25301 $757.00 90 25545 $803.00 90 26025 $548.00 90

25310 $865.00 90 25560 $276.00 90 26030 $655.00 90

25312 $968.00 90 25565 $590.00 90 26034 $601.00 90

25315 $1,004.00 90 25574 $804.00 90 26035 $741.00 90

25316 $1,203.00 90 25575 $974.00 90 26037 $730.00 90

25320 $834.00 90 25600 $312.00 90 26040 $367.00 90

25332 $1,022.00 90 25605 $540.00 90 26045 $621.00 90

25335 $1,166.00 90 25606 $643.00 90 26055 $343.00 90

25337 $946.00 90 25607 $645.00 90 26060 $293.00 90

25350 $913.00 90 25608 $739.00 90 26070 $440.00 90

25355 $1,014.00 90 25609 $942.00 90 26075 $400.00 90

25360 $468.00 90 25622 $148.00 90 26080 $382.00 90

25365 $1,216.00 90 25624 $482.00 90 26100 $398.00 90

25370 $1,214.00 90 25628 $716.00 90 26105 $481.00 90

25375 $1,280.00 90 25630 $148.00 90 26110 $282.00 90

25390 $1,043.00 90 25635 $458.00 90 26111 $423.00 90

25391 $1,349.00 90 25645 $668.00 90 26113 $557.00 90

25392 $1,294.00 90 25650 $185.00 90 26115 $344.00 90

25393 $1,473.00 90 25651 $379.00 90 26116 $544.00 90

25394 $723.00 90 25652 $560.00 90 26117 $806.00 90

25400 $1,112.00 90 25660 $378.00 90 26118 $1,076.00 90

25405 $1,388.00 90 25670 $731.00 90 26121 $833.00 90

25415 $1,343.00 90 25671 $462.00 90 26123 $959.00 90





26125 $342.00 ZZZ 26460 $346.00 90 26587 $792.00 90

26130 $629.00 90 26471 $592.00 90 26590 $1,609.00 90

26135 $668.00 90 26474 $586.00 90 26591 $431.00 90

26140 $678.00 90 26476 $543.00 90 26593 $587.00 90

26145 $660.00 90 26477 $553.00 90 26596 $809.00 90

26160 $319.00 90 26478 $608.00 90 26600 $133.00 90

26170 $452.00 90 26479 $653.00 90 26605 $296.00 90

26180 $444.00 90 26480 $808.00 90 26607 $334.00 90

26185 $511.00 90 26483 $986.00 90 26608 $497.00 90

26200 $598.00 90 26485 $891.00 90 26615 $521.00 90

26205 $788.00 90 26489 $738.00 90 26641 $71.00 90

26210 $543.00 90 26490 $496.00 90 26645 $371.00 90

26215 $731.00 90 26492 $971.00 90 26650 $533.00 90

26230 $624.00 90 26494 $946.00 90 26665 $693.00 90

26235 $612.00 90 26496 $949.00 90 26670 $148.00 90

26236 $444.00 90 26497 $946.00 90 26675 $501.00 90

26250 $814.00 90 26498 $1,317.00 90 26676 $527.00 90

26260 $758.00 90 26499 $934.00 90 26685 $592.00 90

26262 $624.00 90 26500 $557.00 90 26686 $710.00 90

26320 $414.00 90 26502 $715.00 90 26700 $88.00 90

26340 $266.00 90 26508 $334.00 90 26705 $296.00 90

26341 $99.00 10 26510 $564.00 90 26706 $469.00 90

26350 $715.00 90 26516 $630.00 90 26715 $526.00 90

26352 $855.00 90 26517 $890.00 90 26720 $96.00 90

26356 $886.00 90 26518 $877.00 90 26725 $187.00 90

26357 $932.00 90 26520 $583.00 90 26727 $187.00 90

26358 $979.00 90 26525 $531.00 90 26735 $532.00 90

26370 $832.00 90 26530 $708.00 90 26740 $148.00 90

26372 $945.00 90 26531 $877.00 90 26742 $148.00 90

26373 $904.00 90 26535 $546.00 90 26746 $548.00 90

26390 $889.00 90 26536 $770.00 90 26750 $96.00 90

26392 $1,123.00 90 26540 $726.00 90 26755 $133.00 90

26410 $371.00 90 26541 $926.00 90 26756 $366.00 90

26412 $737.00 90 26542 $716.00 90 26765 $398.00 90

26415 $846.00 90 26545 $722.00 90 26770 $79.00 90

26416 $1,093.00 90 26546 $918.00 90 26775 $275.00 90

26418 $444.00 90 26548 $665.00 90 26776 $401.00 90

26420 $741.00 90 26550 $1,861.00 90 26785 $408.00 90

26426 $733.00 90 26551 $3,901.00 90 26820 $854.00 90

26428 $790.00 90 26553 $3,868.00 90 26841 $756.00 90

26432 $430.00 90 26554 $4,551.00 90 26842 $901.00 90

26433 $371.00 90 26555 $1,567.00 90 26843 $800.00 90

26434 $656.00 90 26556 $4,005.00 90 26844 $875.00 90

26437 $491.00 90 26560 $576.00 90 26850 $704.00 90

26440 $458.00 90 26561 $1,067.00 90 26852 $829.00 90

26442 $548.00 90 26562 $1,017.00 90 26860 $542.00 90

26445 $455.00 90 26565 $730.00 90 26861 $151.00 ZZZ

26449 $738.00 90 26567 $622.00 90 26862 $747.00 90

26450 $353.00 90 26568 $1,003.00 90 26863 $317.00 ZZZ

26455 $364.00 90 26580 $1,585.00 90 26910 $747.00 90





26951 $444.00 90 27100 $987.00 90 27246 $459.00 90

26952 $608.00 90 27105 $946.00 90 27248 $980.00 90

26989 BR YYY 27110 $1,174.00 90 27250 $535.00 0

26990 $592.00 90 27111 $1,099.00 90 27252 $520.00 90

26991 $466.00 90 27120 $1,603.00 90 27253 $1,162.00 90

26992 $1,146.00 90 27122 $1,406.00 90 27254 $1,478.00 90

27000 $421.00 90 27125 $1,371.00 90 27256 $338.00 10

27001 $550.00 90 27130 $1,853.00 90 27257 $455.00 10

27003 $698.00 90 27132 $2,128.00 90 27258 $1,355.00 90

27005 $738.00 90 27134 $2,576.00 90 27259 $1,803.00 90

27006 $788.00 90 27137 $2,190.00 90 27265 $442.00 90

27025 $896.00 90 27138 $2,025.00 90 27266 $614.00 90

27027 $866.00 90 27140 $1,092.00 90 27267 $382.00 90

27030 $1,148.00 90 27146 $1,432.00 90 27268 $470.00 90

27033 $1,173.00 90 27147 $1,744.00 90 27269 $1,117.00 90

27035 $1,413.00 90 27151 $1,732.00 90 27275 $220.00 10

27036 $1,176.00 90 27156 $2,017.00 90 27279 $718.00 90

27040 $196.00 10 27158 $1,588.00 90 27280 $1,179.00 90

27041 $699.00 90 27161 $1,443.00 90 27282 $990.00 90

27043 $476.00 90 27165 $1,572.00 90 27284 $1,435.00 90

27045 $764.00 90 27170 $1,453.00 90 27286 $1,503.00 90

27047 $535.00 90 27175 $491.00 90 27290 $2,073.00 90

27048 $588.00 90 27176 $1,024.00 90 27295 $1,594.00 90

27049 $1,162.00 90 27177 $1,257.00 90 27299 BR YYY

27050 $449.00 90 27178 $1,020.00 90 27301 $193.00 90

27052 $624.00 90 27179 $1,107.00 90 27303 $520.00 90

27054 $843.00 90 27181 $1,206.00 90 27305 $555.00 90

27057 $972.00 90 27185 $676.00 90 27306 $377.00 90

27059 $1,849.00 90 27187 $1,280.00 90 27307 $503.00 90

27060 $491.00 90 27197 $120.00 0 27310 $877.00 90

27062 $499.00 90 27198 $306.00 0 27323 $211.00 10

27065 $583.00 90 27200 $180.00 90 27324 $433.00 90

27066 $931.00 90 27202 $776.00 90 27325 $476.00 90

27067 $1,234.00 90 27215 $954.00 90 27326 $451.00 90

27070 $1,040.00 90 27216 $1,085.00 90 27327 $400.00 90

27071 $1,112.00 90 27217 $1,285.00 90 27328 $503.00 90

27075 $1,485.00 90 27218 $1,570.00 90 27329 $1,249.00 90

27076 $1,859.00 90 27220 $444.00 90 27330 $492.00 90

27077 $1,976.00 90 27222 $973.00 90 27331 $585.00 90

27078 $1,164.00 90 27226 $1,350.00 90 27332 $786.00 90

27080 $568.00 90 27227 $1,967.00 90 27333 $719.00 90

27086 $57.00 10 27228 $2,195.00 90 27334 $840.00 90

27087 $555.00 90 27230 $491.00 90 27335 $959.00 90

27090 $981.00 90 27232 $916.00 90 27337 $425.00 90

27091 $1,482.00 90 27235 $1,128.00 90 27339 $765.00 90

27093 $62.00 0 27236 $1,421.00 90 27340 $405.00 90

27095 $121.00 0 27238 $504.00 90 27345 $565.00 90

27096 $491.00 0 27240 $1,043.00 90 27347 $394.00 90

27097 $795.00 90 27244 $1,426.00 90 27350 $786.00 90

27098 $799.00 90 27245 $1,691.00 90 27355 $763.00 90





27356 $882.00 90 27455 $1,157.00 90 27570 $184.00 10

27357 $950.00 90 27457 $1,209.00 90 27580 $1,644.00 90

27358 $394.00 ZZZ 27465 $1,253.00 90 27590 $1,059.00 90

27360 $977.00 90 27466 $1,441.00 90 27591 $1,182.00 90

27364 $1,601.00 90 27468 $1,613.00 90 27592 $911.00 90

27365 $1,421.00 90 27470 $1,501.00 90 27594 $600.00 90

27370 $75.00 0 27472 $1,665.00 90 27596 $931.00 90

27372 $371.00 90 27475 $782.00 90 27598 $976.00 90

27380 $698.00 90 27477 $938.00 90 27599 BR YYY

27381 $1,118.00 90 27479 $1,123.00 90 27600 $517.00 90

27385 $753.00 90 27485 $797.00 90 27601 $516.00 90

27386 $1,064.00 90 27486 $1,771.00 90 27602 $621.00 90

27390 $506.00 90 27487 $2,352.00 90 27603 $412.00 90

27391 $647.00 90 27488 $1,438.00 90 27604 $308.00 90

27392 $834.00 90 27495 $1,477.00 90 27605 $236.00 10

27393 $608.00 90 27496 $563.00 90 27606 $362.00 10

27394 $748.00 90 27497 $652.00 90 27607 $608.00 90

27395 $1,093.00 90 27498 $701.00 90 27610 $777.00 90

27396 $742.00 90 27499 $782.00 90 27612 $701.00 90

27397 $989.00 90 27500 $520.00 90 27613 $165.00 10

27400 $832.00 90 27501 $659.00 90 27614 $327.00 90

27403 $792.00 90 27502 $909.00 90 27615 $1,106.00 90

27405 $842.00 90 27503 $911.00 90 27616 $1,297.00 90

27407 $918.00 90 27506 $1,522.00 90 27618 $421.00 90

27409 $1,212.00 90 27507 $1,297.00 90 27619 $730.00 90

27412 $1,605.00 90 27508 $400.00 90 27620 $587.00 90

27415 $1,340.00 90 27509 $649.00 90 27625 $796.00 90

27416 $878.00 90 27510 $755.00 90 27626 $863.00 90

27418 $1,596.00 90 27511 $1,281.00 90 27630 $430.00 90

27420 $927.00 90 27513 $1,562.00 90 27632 $422.00 90

27422 $930.00 90 27514 $1,508.00 90 27634 $697.00 90

27424 $927.00 90 27516 $579.00 90 27635 $781.00 90

27425 $639.00 90 27517 $820.00 90 27637 $921.00 90

27427 $1,118.00 90 27519 $1,311.00 90 27638 $978.00 90

27428 $1,266.00 90 27520 $266.00 90 27640 $1,122.00 90

27429 $2,333.00 90 27524 $910.00 90 27641 $922.00 90

27430 $884.00 90 27530 $408.00 90 27645 $1,302.00 90

27435 $501.00 90 27532 $641.00 90 27646 $1,212.00 90

27437 $819.00 90 27535 $1,075.00 90 27647 $1,044.00 90

27438 $1,065.00 90 27536 $1,282.00 90 27648 $72.00 0

27440 $1,064.00 90 27538 $487.00 90 27650 $869.00 90

27441 $1,006.00 90 27540 $1,106.00 90 27652 $935.00 90

27442 $1,117.00 90 27550 $296.00 90 27654 $937.00 90

27443 $1,037.00 90 27552 $619.00 90 27656 $458.00 90

27445 $1,618.00 90 27556 $832.00 90 27658 $527.00 90

27446 $1,764.00 90 27557 $1,479.00 90 27659 $725.00 90

27447 $1,960.00 90 27558 $1,529.00 90 27664 $504.00 90

27448 $1,060.00 90 27560 $88.00 90 27665 $618.00 90

27450 $1,311.00 90 27562 $514.00 90 27675 $656.00 90

27454 $1,524.00 90 27566 $1,047.00 90 27676 $762.00 90





27680 $523.00 90 27810 $567.00 90 28050 $414.00 90

27681 $634.00 90 27814 $972.00 90 28052 $402.00 90

27685 $565.00 90 27816 $386.00 90 28054 $236.00 90

27686 $706.00 90 27818 $613.00 90 28055 $377.00 90

27687 $589.00 90 27822 $1,201.00 90 28060 $495.00 90

27690 $757.00 90 27823 $1,472.00 90 28062 $657.00 90

27691 $889.00 90 27824 $384.00 90 28070 $476.00 90

27692 $159.00 ZZZ 27825 $670.00 90 28072 $445.00 90

27695 $658.00 90 27826 $1,080.00 90 28080 $392.00 90

27696 $758.00 90 27827 $1,310.00 90 28086 $462.00 90

27698 $881.00 90 27828 $1,823.00 90 28088 $414.00 90

27700 $835.00 90 27829 $742.00 90 28090 $414.00 90

27702 $1,278.00 90 27830 $412.00 90 28092 $330.00 90

27703 $1,337.00 90 27831 $415.00 90 28100 $571.00 90

27704 $683.00 90 27832 $617.00 90 28102 $700.00 90

27705 $985.00 90 27840 $334.00 90 28103 $709.00 90

27707 $484.00 90 27842 $373.00 90 28104 $491.00 90

27709 $1,118.00 90 27846 $877.00 90 28106 $632.00 90

27712 $1,227.00 90 27848 $1,224.00 90 28107 $517.00 90

27715 $1,285.00 90 27860 $211.00 10 28108 $418.00 90

27720 $1,147.00 90 27870 $1,269.00 90 28110 $421.00 90

27722 $1,076.00 90 27871 $843.00 90 28111 $537.00 90

27724 $1,402.00 90 27880 $1,015.00 90 28112 $457.00 90

27725 $1,312.00 90 27881 $1,120.00 90 28113 $481.00 90

27726 $823.00 90 27882 $854.00 90 28114 $890.00 90

27727 $1,175.00 90 27884 $579.00 90 28116 $648.00 90

27730 $647.00 90 27886 $835.00 90 28118 $568.00 90

27732 $611.00 90 27888 $911.00 90 28119 $524.00 90

27734 $766.00 90 27889 $879.00 90 28120 $601.00 90

27740 $1,044.00 90 27892 $575.00 90 28122 $622.00 90

27742 $1,045.00 90 27893 $574.00 90 28124 $480.00 90

27745 $940.00 90 27894 $712.00 90 28126 $393.00 90

27750 $319.00 90 27899 BR YYY 28130 $727.00 90

27752 $614.00 90 28001 $185.00 10 28140 $533.00 90

27756 $708.00 90 28002 $362.00 10 28150 $416.00 90

27758 $1,115.00 90 28003 $520.00 90 28153 $400.00 90

27759 $1,262.00 90 28005 $520.00 90 28160 $412.00 90

27760 $223.00 90 28008 $296.00 90 28171 $789.00 90

27762 $495.00 90 28010 $235.00 90 28173 $747.00 90

27766 $759.00 90 28011 $340.00 90 28175 $571.00 90

27767 $233.00 90 28020 $509.00 90 28190 $75.00 10

27768 $361.00 90 28022 $422.00 90 28192 $326.00 90

27769 $622.00 90 28024 $371.00 90 28193 $341.00 90

27780 $244.00 90 28035 $532.00 90 28200 $478.00 90

27781 $296.00 90 28039 $525.00 90 28202 $613.00 90

27784 $643.00 90 28041 $473.00 90 28208 $406.00 90

27786 $223.00 90 28043 $305.00 90 28210 $609.00 90

27788 $422.00 90 28045 $456.00 90 28220 $435.00 90

27792 $706.00 90 28046 $814.00 90 28222 $555.00 90

27808 $332.00 90 28047 $1,056.00 90 28225 $345.00 90





28226 $334.00 90 28435 $371.00 90 28760 $654.00 90

28230 $380.00 90 28436 $463.00 90 28800 $731.00 90

28232 $286.00 90 28445 $874.00 90 28805 $731.00 90

28234 $178.00 90 28446 $1,075.00 90 28810 $543.00 90

28238 $695.00 90 28450 $148.00 90 28820 $377.00 90

28240 $370.00 90 28455 $321.00 90 28825 $339.00 90

28250 $535.00 90 28456 $288.00 90 28890 $358.00 90

28260 $641.00 90 28465 $533.00 90 28899 BR YYY

28261 $881.00 90 28470 $178.00 90 29000 $247.00 0

28262 $1,363.00 90 28475 $296.00 90 29010 $271.00 0

28264 $912.00 90 28476 $364.00 90 29015 $289.00 0

28270 $266.00 90 28485 $521.00 90 29035 $213.00 0

28272 $336.00 90 28490 $80.00 90 29040 $260.00 0

28280 $426.00 90 28495 $133.00 90 29044 $260.00 0

28285 $463.00 90 28496 $261.00 90 29046 $286.00 0

28286 $441.00 90 28505 $399.00 90 29049 $45.00 0

28288 $452.00 90 28510 $75.00 90 29055 $180.00 0

28289 $458.00 90 28515 $115.00 90 29058 $110.00 0

28291 $759.00 90 28525 $345.00 90 29065 $88.00 0

28292 $666.00 90 28530 $120.00 90 29075 $72.00 0

28295 $973.00 90 28531 $243.00 90 29085 $59.00 0

28296 $832.00 90 28540 $145.00 90 29086 $54.00 0

28297 $838.00 90 28545 $208.00 90 29105 $59.00 0

28298 $755.00 90 28546 $325.00 90 29125 $45.00 0

28299 $829.00 90 28555 $592.00 90 29126 $53.00 0

28300 $845.00 90 28570 $189.00 90 29130 $26.00 0

28302 $930.00 90 28575 $308.00 90 29131 $53.00 0

28304 $776.00 90 28576 $382.00 90 29200 $29.00 0

28305 $1,030.00 90 28585 $742.00 90 29240 $45.00 0

28306 $530.00 90 28600 $144.00 90 29260 $26.00 0

28307 $614.00 90 28605 $287.00 90 29280 $29.00 0

28308 $516.00 90 28606 $487.00 90 29305 $223.00 0

28309 $955.00 90 28615 $621.00 90 29325 $260.00 0

28310 $505.00 90 28630 $145.00 10 29345 $126.00 0

28312 $469.00 90 28635 $189.00 10 29355 $133.00 0

28313 $436.00 90 28636 $318.00 10 29358 $241.00 0

28315 $462.00 90 28645 $434.00 90 29365 $101.00 0

28320 $833.00 90 28660 $106.00 10 29405 $96.00 0

28322 $667.00 90 28665 $172.00 10 29425 $101.00 0

28340 $649.00 90 28666 $309.00 10 29435 $133.00 0

28341 $753.00 90 28675 $348.00 90 29440 $22.00 0

28344 $414.00 90 28705 $1,353.00 90 29445 $214.00 0

28345 $557.00 90 28715 $1,179.00 90 29450 $84.00 0

28360 $1,197.00 90 28725 $1,015.00 90 29505 $75.00 0

28400 $266.00 90 28730 $945.00 90 29515 $59.00 0

28405 $473.00 90 28735 $961.00 90 29520 $22.00 0

28406 $616.00 90 28737 $873.00 90 29530 $55.00 0

28415 $1,354.00 90 28740 $690.00 90 29540 $41.00 0

28420 $1,619.00 90 28750 $690.00 90 29550 $37.00 0

28430 $110.00 90 28755 $466.00 90 29580 $39.00 0





29581 $62.00 0 29868 $1,694.00 90 30150 $790.00 90

29582 $71.00 0 29870 $460.00 90 30160 $875.00 90

29583 $44.00 0 29871 $631.00 90 30200 $68.00 0

29584 $71.00 0 29873 $489.00 90 30210 $75.00 10

29700 $29.00 0 29874 $676.00 90 30220 $154.00 10

29705 $26.00 0 29875 $639.00 90 30300 $45.00 10

29710 $29.00 0 29876 $809.00 90 30310 $170.00 10

29720 $29.00 0 29877 $852.00 90 30320 $419.00 90

29730 $29.00 0 29879 $1,064.00 90 30400 $741.00 90

29740 $37.00 0 29880 $1,169.00 90 30410 $1,173.00 90

29750 $105.00 0 29881 $745.00 90 30420 $1,424.00 90

29799 BR YYY 29882 $819.00 90 30430 $626.00 90

29800 $557.00 90 29883 $1,235.00 90 30435 $1,005.00 90

29804 $902.00 90 29884 $721.00 90 30450 $1,445.00 90

29805 $360.00 90 29885 $832.00 90 30460 $857.00 90

29806 $1,003.00 90 29886 $697.00 90 30462 $1,633.00 90

29807 $976.00 90 29887 $949.00 90 30465 $803.00 90

29819 $756.00 90 29888 $1,296.00 90 30520 $533.00 90

29820 $718.00 90 29889 $1,255.00 90 30540 $643.00 90

29821 $863.00 90 29891 $796.00 90 30545 $981.00 90

29822 $749.00 90 29892 $835.00 90 30560 $104.00 10

29823 $1,330.00 90 29893 $472.00 90 30580 $566.00 90

29824 $611.00 90 29894 $690.00 90 30600 $466.00 90

29825 $941.00 90 29895 $679.00 90 30620 $564.00 90

29826 $980.00 ZZZ 29897 $704.00 90 30630 $624.00 90

29827 $1,058.00 90 29898 $863.00 90 30801 $88.00 10

29828 $830.00 90 29899 $973.00 90 30802 $172.00 10

29830 $524.00 90 29900 $434.00 90 30901 $75.00 0

29834 $635.00 90 29901 $479.00 90 30903 $110.00 0

29835 $612.00 90 29902 $514.00 90 30905 $224.00 0

29836 $680.00 90 29904 $557.00 90 30906 $208.00 0

29837 $830.00 90 29905 $601.00 90 30915 $596.00 90

29838 $931.00 90 29906 $633.00 90 30920 $862.00 90

29840 $501.00 90 29907 $775.00 90 30930 $213.00 10

29843 $580.00 90 29914 $1,036.00 90 30999 BR YYY

29844 $612.00 90 29915 $1,057.00 90 31000 $81.00 10

29845 $931.00 90 29916 $1,057.00 90 31002 $135.00 10

29846 $976.00 90 29999 BR YYY 31020 $281.00 90

29847 $1,277.00 90 30000 $96.00 10 31030 $531.00 90

29848 $608.00 90 30020 $117.00 10 31032 $604.00 90

29850 $752.00 90 30100 $86.00 0 31040 $772.00 90

29851 $1,137.00 90 30110 $157.00 10 31050 $489.00 90

29855 $1,007.00 90 30115 $360.00 90 31051 $654.00 90

29856 $1,231.00 90 30117 $301.00 90 31070 $410.00 90

29860 $658.00 90 30118 $819.00 90 31075 $839.00 90

29861 $845.00 90 30120 $500.00 90 31080 $942.00 90

29862 $907.00 90 30124 $243.00 90 31081 $1,089.00 90

29863 $880.00 90 30125 $599.00 90 31084 $1,210.00 90

29866 $1,046.00 90 30130 $275.00 90 31085 $1,281.00 90

29867 $1,250.00 90 30140 $320.00 90 31086 $1,081.00 90





31087 $1,075.00 90 31513 $182.00 0 31624 $217.00 0

31090 $877.00 90 31515 $160.00 0 31625 $235.00 0

31200 $463.00 90 31525 $234.00 0 31626 $450.00 0

31201 $716.00 90 31526 $222.00 0 31627 $1,310.00 ZZZ

31205 $851.00 90 31527 $262.00 0 31628 $269.00 0

31225 $1,683.00 90 31528 $202.00 0 31629 $198.00 0

31230 $1,908.00 90 31529 $217.00 0 31630 $308.00 0

31231 $122.00 0 31530 $284.00 0 31631 $252.00 0

31233 $221.00 0 31531 $311.00 0 31632 $73.00 ZZZ

31235 $217.00 0 31535 $272.00 0 31633 $90.00 ZZZ

31237 $266.00 0 31536 $308.00 0 31634 $1,886.00 0

31238 $311.00 0 31540 $357.00 0 31635 $298.00 0

31239 $775.00 10 31541 $453.00 0 31636 $241.00 0

31240 $224.00 0 31545 $384.00 0 31637 $86.00 ZZZ

31254 $588.00 0 31546 $587.00 0 31638 $268.00 0

31255 $601.00 0 31551 $1,462.00 90 31640 $399.00 0

31256 $292.00 0 31552 $1,478.00 90 31641 $304.00 0

31267 $453.00 0 31553 $1,612.00 90 31643 $208.00 0

31276 $690.00 0 31554 $1,697.00 90 31645 $208.00 0

31287 $339.00 0 31560 $446.00 0 31646 $161.00 0

31288 $396.00 0 31561 $509.00 0 31647 $228.00 0

31290 $1,462.00 10 31570 $369.00 0 31648 $218.00 0

31291 $1,551.00 10 31571 $363.00 0 31649 $71.00 ZZZ

31292 $1,235.00 10 31572 $508.00 0 31651 $82.00 ZZZ

31293 $1,346.00 10 31573 $270.00 0 31652 $921.00 0

31294 $1,587.00 10 31574 $1,047.00 0 31653 $979.00 0

31295 $2,104.00 0 31575 $128.00 0 31654 $147.00 ZZZ

31296 $2,136.00 0 31576 $186.00 0 31660 $218.00 0

31297 $2,101.00 0 31577 $230.00 0 31661 $230.00 0

31299 BR YYY 31578 $264.00 0 31717 $138.00 0

31300 $1,295.00 90 31579 $219.00 0 31720 $89.00 0

31320 $508.00 90 31580 $1,213.00 90 31725 $103.00 0

31360 $1,630.00 90 31584 $1,616.00 90 31730 $199.00 0

31365 $2,238.00 90 31587 $913.00 90 31750 $1,088.00 90

31367 $1,913.00 90 31590 $691.00 90 31755 $1,448.00 90

31368 $2,478.00 90 31591 $1,071.00 90 31760 $1,648.00 90

31370 $1,891.00 90 31592 $1,733.00 90 31766 $2,315.00 90

31375 $1,720.00 90 31595 $773.00 90 31770 $1,815.00 90

31380 $1,782.00 90 31599 BR YYY 31775 $1,973.00 90

31382 $1,822.00 90 31600 $306.00 0 31780 $1,577.00 90

31390 $2,513.00 90 31603 $343.00 0 31781 $1,936.00 90

31395 $2,937.00 90 31605 $297.00 0 31785 $1,320.00 90

31400 $969.00 90 31610 $794.00 90 31786 $1,866.00 90

31420 $969.00 90 31611 $614.00 90 31800 $628.00 90

31500 $116.00 0 31612 $99.00 0 31805 $1,175.00 90

31502 $74.00 0 31613 $384.00 90 31820 $458.00 90

31505 $62.00 0 31614 $736.00 90 31825 $659.00 90

31510 $145.00 0 31615 $213.00 0 31830 $460.00 90

31511 $88.00 0 31622 $230.00 0 31899 BR YYY

31512 $197.00 0 31623 $225.00 0 32035 $821.00 90





32036 $908.00 90 32606 $637.00 0 33031 $1,816.00 90

32096 $835.00 90 32607 $321.00 0 33050 $1,224.00 90

32097 $836.00 90 32608 $394.00 0 33120 $2,358.00 90

32098 $789.00 90 32609 $272.00 0 33130 $1,734.00 90

32100 $1,120.00 90 32650 $957.00 90 33140 $1,571.00 90

32110 $1,223.00 90 32651 $1,166.00 90 33141 $254.00 ZZZ

32120 $1,077.00 90 32652 $1,615.00 90 33202 $749.00 90

32124 $1,144.00 90 32653 $1,144.00 90 33203 $766.00 90

32140 $1,284.00 90 32654 $1,096.00 90 33206 $642.00 90

32141 $1,267.00 90 32655 $1,213.00 90 33207 $753.00 90

32150 $1,226.00 90 32656 $1,222.00 90 33208 $573.00 90

32151 $1,231.00 90 32658 $1,142.00 90 33210 $204.00 0

32160 $842.00 90 32659 $1,141.00 90 33211 $210.00 0

32200 $1,132.00 90 32661 $1,165.00 90 33212 $511.00 90

32215 $1,024.00 90 32662 $1,459.00 90 33213 $437.00 90

32220 $1,680.00 90 32663 $1,636.00 90 33214 $532.00 90

32225 $1,268.00 90 32664 $1,197.00 90 33215 $304.00 90

32310 $1,221.00 90 32665 $1,360.00 90 33216 $402.00 90

32320 $1,787.00 90 32666 $902.00 90 33217 $428.00 90

32400 $129.00 0 32667 $164.00 ZZZ 33218 $488.00 90

32405 $159.00 0 32668 $164.00 ZZZ 33220 $390.00 90

32440 $1,837.00 90 32669 $1,395.00 90 33221 $379.00 90

32442 $2,093.00 90 32670 $1,658.00 90 33222 $471.00 90

32445 $2,093.00 90 32671 $1,847.00 90 33223 $585.00 90

32480 $1,622.00 90 32672 $1,584.00 90 33224 $490.00 0

32482 $1,714.00 90 32673 $1,251.00 90 33225 $434.00 ZZZ

32484 $1,771.00 90 32674 $224.00 ZZZ 33226 $472.00 0

32486 $1,974.00 90 32701 $229.00 0 33227 $359.00 90

32488 $2,094.00 90 32800 $1,166.00 90 33228 $374.00 90

32491 $1,784.00 90 32810 $1,085.00 90 33229 $393.00 90

32501 $374.00 ZZZ 32815 $1,917.00 90 33230 $408.00 90

32503 $1,875.00 90 32820 $1,848.00 90 33231 $421.00 90

32504 $2,145.00 90 32851 $3,100.00 90 33233 $270.00 90

32505 $964.00 90 32852 $3,339.00 90 33234 $598.00 90

32506 $164.00 ZZZ 32853 $3,787.00 90 33235 $587.00 90

32507 $164.00 ZZZ 32854 $4,038.00 90 33236 $933.00 90

32540 $1,308.00 90 32900 $1,532.00 90 33237 $1,184.00 90

32550 $821.00 0 32905 $1,661.00 90 33238 $1,235.00 90

32551 $171.00 0 32906 $2,100.00 90 33240 $648.00 90

32552 $196.00 10 32940 $1,555.00 90 33241 $301.00 90

32553 $597.00 0 32960 $126.00 0 33243 $1,650.00 90

32554 $201.00 0 32997 $312.00 0 33244 $1,081.00 90

32555 $300.00 0 32998 $2,809.00 0 33249 $1,271.00 90

32556 $542.00 0 32999 BR YYY 33250 $1,687.00 90

32557 $578.00 0 33010 $124.00 0 33251 $2,071.00 90

32560 $302.00 0 33011 $125.00 0 33254 $1,307.00 90

32561 $97.00 0 33015 $555.00 90 33255 $1,573.00 90

32562 $87.00 0 33020 $1,178.00 90 33256 $1,879.00 90

32601 $456.00 0 33025 $1,165.00 90 33257 $565.00 ZZZ

32604 $663.00 0 33030 $1,786.00 90 33258 $639.00 ZZZ





33259 $839.00 ZZZ 33460 $2,215.00 90 33615 $3,051.00 90

33261 $1,993.00 90 33463 $2,396.00 90 33617 $3,272.00 90

33262 $394.00 90 33464 $2,547.00 90 33619 $3,678.00 90

33263 $409.00 90 33465 $2,665.00 90 33620 $1,527.00 90

33264 $427.00 90 33468 $2,952.00 90 33621 $914.00 90

33265 $1,307.00 90 33470 $1,749.00 90 33622 $3,597.00 90

33266 $1,789.00 90 33471 $1,929.00 90 33641 $1,981.00 90

33270 $614.00 90 33474 $2,173.00 90 33645 $2,352.00 90

33271 $517.00 90 33475 $2,666.00 90 33647 $2,732.00 90

33272 $364.00 90 33476 $2,270.00 90 33660 $2,444.00 90

33273 $418.00 90 33477 $1,345.00 0 33665 $2,700.00 90

33282 $470.00 90 33478 $2,544.00 90 33670 $2,820.00 90

33284 $365.00 90 33496 $2,595.00 90 33675 $2,085.00 90

33300 $1,576.00 90 33500 $2,370.00 90 33676 $2,151.00 90

33305 $1,889.00 90 33501 $1,546.00 90 33677 $2,236.00 90

33310 $1,577.00 90 33502 $1,938.00 90 33681 $2,657.00 90

33315 $1,875.00 90 33503 $1,983.00 90 33684 $2,740.00 90

33320 $1,485.00 90 33504 $2,416.00 90 33688 $2,602.00 90

33321 $1,890.00 90 33505 $2,423.00 90 33690 $1,884.00 90

33322 $1,935.00 90 33506 $2,448.00 90 33692 $2,816.00 90

33330 $1,726.00 90 33507 $1,809.00 90 33694 $2,856.00 90

33335 $2,336.00 90 33508 $17.00 ZZZ 33697 $3,064.00 90

33361 $1,404.00 0 33510 $2,354.00 90 33702 $2,549.00 90

33362 $1,535.00 0 33511 $2,546.00 90 33710 $2,731.00 90

33363 $1,589.00 0 33512 $2,732.00 90 33720 $2,508.00 90

33364 $1,671.00 0 33513 $2,933.00 90 33722 $2,704.00 90

33365 $1,843.00 0 33514 $3,197.00 90 33724 $1,491.00 90

33366 $1,995.00 0 33516 $3,404.00 90 33726 $1,963.00 90

33367 $644.00 ZZZ 33517 $219.00 ZZZ 33730 $2,785.00 90

33368 $780.00 ZZZ 33518 $414.00 ZZZ 33732 $2,622.00 90

33369 $1,030.00 ZZZ 33519 $607.00 ZZZ 33735 $2,036.00 90

33404 $2,698.00 90 33521 $801.00 ZZZ 33736 $2,288.00 90

33405 $2,745.00 90 33522 $994.00 ZZZ 33737 $1,977.00 90

33406 $2,962.00 90 33523 $1,189.00 ZZZ 33750 $1,877.00 90

33410 $2,637.00 90 33530 $521.00 ZZZ 33755 $1,831.00 90

33411 $2,981.00 90 33533 $2,415.00 90 33762 $1,900.00 90

33412 $3,213.00 90 33534 $2,654.00 90 33764 $1,895.00 90

33413 $3,282.00 90 33535 $2,899.00 90 33766 $2,119.00 90

33414 $2,904.00 90 33536 $3,143.00 90 33767 $2,173.00 90

33415 $2,563.00 90 33542 $2,693.00 90 33768 $449.00 ZZZ

33416 $2,684.00 90 33545 $3,250.00 90 33770 $2,954.00 90

33417 $2,756.00 90 33548 $2,381.00 90 33771 $2,924.00 90

33418 $1,871.00 90 33572 $340.00 ZZZ 33774 $2,681.00 90

33419 $440.00 ZZZ 33600 $2,644.00 90 33775 $2,654.00 90

33420 $1,796.00 90 33602 $2,556.00 90 33776 $2,844.00 90

33422 $2,431.00 90 33606 $2,831.00 90 33777 $2,724.00 90

33425 $2,509.00 90 33608 $2,940.00 90 33778 $3,199.00 90

33426 $2,806.00 90 33610 $2,871.00 90 33779 $3,121.00 90

33427 $3,026.00 90 33611 $2,985.00 90 33780 $3,232.00 90

33430 $2,891.00 90 33612 $3,152.00 90 33781 $3,057.00 90





33782 $3,439.00 90 33956 $875.00 0 34510 $1,108.00 90

33783 $3,834.00 90 33957 $194.00 0 34520 $1,077.00 90

33786 $2,970.00 90 33958 $191.00 0 34530 $1,368.00 90

33788 $2,288.00 90 33959 $246.00 0 34800 $1,159.00 90

33800 $1,546.00 90 33962 $249.00 0 34802 $1,279.00 90

33802 $1,752.00 90 33963 $493.00 0 34803 $1,372.00 90

33803 $1,746.00 90 33964 $513.00 0 34804 $1,279.00 90

33813 $1,935.00 90 33965 $194.00 0 34805 $1,243.00 90

33814 $2,464.00 90 33966 $246.00 0 34806 $100.00 ZZZ

33820 $1,619.00 90 33967 $258.00 0 34808 $220.00 ZZZ

33822 $1,559.00 90 33968 $51.00 0 34812 $359.00 0

33824 $1,884.00 90 33969 $287.00 0 34813 $256.00 ZZZ

33840 $2,029.00 90 33970 $576.00 0 34820 $519.00 0

33845 $2,129.00 90 33971 $578.00 90 34825 $694.00 90

33851 $2,129.00 90 33973 $756.00 0 34826 $220.00 ZZZ

33852 $2,311.00 90 33974 $1,095.00 90 34830 $1,803.00 90

33853 $3,057.00 90 33975 $1,758.00 0 34831 $1,950.00 90

33860 $3,044.00 90 33976 $2,056.00 0 34832 $1,950.00 90

33863 $3,183.00 90 33977 $1,561.00 0 34833 $650.00 0

33864 $3,035.00 90 33978 $1,754.00 0 34834 $306.00 0

33870 $3,638.00 90 33979 $2,496.00 0 34900 $960.00 90

33875 $2,876.00 90 33980 $3,212.00 0 35001 $1,564.00 90

33877 $3,767.00 90 33981 $879.00 0 35002 $1,547.00 90

33880 $1,866.00 90 33982 $2,052.00 0 35005 $1,268.00 90

33881 $1,603.00 90 33983 $2,418.00 0 35011 $1,007.00 90

33883 $1,187.00 90 33984 $298.00 0 35013 $1,376.00 90

33884 $441.00 ZZZ 33985 $541.00 0 35021 $1,635.00 90

33886 $1,025.00 90 33986 $554.00 0 35022 $1,686.00 90

33889 $882.00 0 33987 $218.00 ZZZ 35045 $995.00 90

33891 $1,126.00 0 33988 $812.00 0 35081 $2,175.00 90

33910 $1,987.00 90 33989 $525.00 0 35082 $2,661.00 90

33915 $1,588.00 90 33990 $454.00 0 35091 $2,634.00 90

33916 $2,096.00 90 33991 $662.00 0 35092 $2,872.00 90

33917 $2,345.00 90 33992 $215.00 0 35102 $2,346.00 90

33920 $2,981.00 90 33993 $188.00 0 35103 $2,587.00 90

33922 $2,227.00 90 33999 BR YYY 35111 $1,398.00 90

33924 $421.00 ZZZ 34001 $1,012.00 90 35112 $1,351.00 90

33925 $1,849.00 90 34051 $1,134.00 90 35121 $2,000.00 90

33926 $2,499.00 90 34101 $800.00 90 35122 $2,382.00 90

33935 $5,415.00 90 34111 $669.00 90 35131 $1,495.00 90

33945 $3,813.00 90 34151 $1,288.00 90 35132 $1,742.00 90

33946 $319.00 0 34201 $777.00 90 35141 $1,231.00 90

33947 $353.00 0 34203 $949.00 90 35142 $1,339.00 90

33948 $252.00 0 34401 $953.00 90 35151 $1,390.00 90

33949 $245.00 0 34421 $779.00 90 35152 $1,229.00 90

33951 $435.00 0 34451 $1,117.00 90 35180 $997.00 90

33952 $449.00 0 34471 $685.00 90 35182 $1,345.00 90

33953 $486.00 0 34490 $660.00 90 35184 $976.00 90

33954 $502.00 0 34501 $910.00 90 35188 $1,048.00 90

33955 $873.00 0 34502 $2,044.00 90 35189 $1,380.00 90





35190 $1,018.00 90 35522 $1,253.00 90 35671 $1,315.00 90

35201 $852.00 90 35523 $1,237.00 90 35681 $751.00 ZZZ

35206 $835.00 90 35525 $1,197.00 90 35682 $627.00 ZZZ

35207 $935.00 90 35526 $1,527.00 90 35683 $702.00 ZZZ

35211 $1,833.00 90 35531 $2,000.00 90 35685 $216.00 ZZZ

35216 $1,494.00 90 35533 $1,716.00 90 35686 $178.00 ZZZ

35221 $1,243.00 90 35535 $1,816.00 90 35691 $1,546.00 90

35226 $841.00 90 35536 $1,888.00 90 35693 $1,140.00 90

35231 $1,053.00 90 35537 $2,141.00 90 35694 $1,353.00 90

35236 $947.00 90 35538 $2,391.00 90 35695 $1,351.00 90

35241 $1,926.00 90 35539 $2,248.00 90 35697 $166.00 ZZZ

35246 $1,701.00 90 35540 $2,505.00 90 35700 $264.00 ZZZ

35251 $1,260.00 90 35556 $1,745.00 90 35701 $494.00 90

35256 $1,568.00 90 35558 $1,219.00 90 35721 $500.00 90

35261 $1,008.00 90 35560 $1,899.00 90 35741 $499.00 90

35266 $921.00 90 35563 $1,115.00 90 35761 $532.00 90

35271 $1,814.00 90 35565 $1,312.00 90 35800 $567.00 90

35276 $1,541.00 90 35566 $2,161.00 90 35820 $951.00 90

35281 $1,396.00 90 35570 $1,455.00 90 35840 $771.00 90

35286 $1,036.00 90 35571 $1,612.00 90 35860 $496.00 90

35301 $1,486.00 90 35572 $369.00 ZZZ 35870 $1,583.00 90

35302 $1,109.00 90 35583 $1,843.00 90 35875 $827.00 90

35303 $1,218.00 90 35585 $2,277.00 90 35876 $1,232.00 90

35304 $1,267.00 90 35587 $1,698.00 90 35879 $1,163.00 90

35305 $1,218.00 90 35600 $273.00 ZZZ 35881 $1,275.00 90

35306 $456.00 ZZZ 35601 $1,495.00 90 35883 $1,247.00 90

35311 $1,999.00 90 35606 $1,539.00 90 35884 $1,324.00 90

35321 $1,031.00 90 35612 $1,349.00 90 35901 $709.00 90

35331 $1,724.00 90 35616 $1,346.00 90 35903 $818.00 90

35341 $1,908.00 90 35621 $1,265.00 90 35905 $1,343.00 90

35351 $1,555.00 90 35623 $1,193.00 90 35907 $1,335.00 90

35355 $1,336.00 90 35626 $1,921.00 90 36000 $46.00 0

35361 $1,859.00 90 35631 $1,891.00 90 36002 $181.00 0

35363 $2,006.00 90 35632 $1,725.00 90 36005 $68.00 0

35371 $1,006.00 90 35633 $1,926.00 90 36010 $136.00 0

35372 $1,085.00 90 35634 $1,688.00 90 36011 $194.00 0

35390 $225.00 ZZZ 35636 $1,656.00 90 36012 $186.00 0

35400 $224.00 ZZZ 35637 $1,704.00 90 36013 $141.00 0

35500 $423.00 ZZZ 35638 $1,731.00 90 36014 $159.00 0

35501 $1,569.00 90 35642 $1,298.00 90 36015 $186.00 0

35506 $1,641.00 90 35645 $1,304.00 90 36100 $176.00 0

35508 $1,564.00 90 35646 $2,105.00 90 36120 $120.00 0

35509 $1,529.00 90 35647 $1,555.00 90 36140 $106.00 0

35510 $1,316.00 90 35650 $1,236.00 90 36160 $196.00 0

35511 $1,256.00 90 35654 $1,603.00 90 36200 $240.00 0

35512 $1,291.00 90 35656 $1,589.00 90 36215 $240.00 0

35515 $1,387.00 90 35661 $1,145.00 90 36216 $270.00 0

35516 $1,391.00 90 35663 $1,237.00 90 36217 $325.00 0

35518 $1,313.00 90 35665 $1,333.00 90 36218 $79.00 ZZZ

35521 $1,393.00 90 35666 $1,686.00 90 36221 $1,132.00 0





36222 $1,433.00 0 36576 $429.00 10 37160 $1,681.00 90

36223 $1,560.00 0 36578 $546.00 10 37180 $1,769.00 90

36224 $1,715.00 0 36580 $307.00 0 37181 $1,923.00 90

36225 $1,545.00 0 36581 $646.00 10 37182 $914.00 0

36226 $1,749.00 0 36582 $1,210.00 10 37183 $425.00 0

36227 $253.00 ZZZ 36583 $708.00 10 37184 $3,074.00 0

36228 $1,190.00 ZZZ 36584 $321.00 0 37185 $1,002.00 ZZZ

36245 $249.00 0 36585 $1,525.00 10 37186 $2,076.00 ZZZ

36246 $272.00 0 36589 $176.00 10 37187 $2,991.00 0

36247 $323.00 0 36590 $378.00 10 37188 $2,586.00 0

36248 $53.00 ZZZ 36591 $21.00 0 37191 $2,683.00 0

36251 $1,436.00 0 36592 $26.00 0 37192 $1,555.00 0

36252 $1,561.00 0 36593 $37.00 0 37193 $1,638.00 0

36253 $2,307.00 0 36595 $880.00 0 37195 $302.00 0

36254 $2,211.00 0 36596 $194.00 0 37197 $1,541.00 0

36260 $749.00 90 36597 $167.00 0 37200 $232.00 0

36261 $388.00 90 36598 $130.00 0 37211 $419.00 0

36262 $297.00 90 36600 $24.00 0 37212 $370.00 0

36299 BR YYY 36620 $64.00 0 37213 $258.00 0

36410 $18.00 0 36625 $133.00 0 37214 $152.00 0

36415 BR 0 36640 $130.00 0 37215 $1,095.00 90

36416 BR 0 36680 $72.00 0 37216 $1,055.00 90

36425 $86.00 0 36800 $159.00 0 37217 $1,164.00 90

36430 $37.00 0 36810 $345.00 0 37218 $861.00 90

36455 $141.00 0 36815 $236.00 0 37220 $3,236.00 0

36468 BR 0 36818 $736.00 90 37221 $4,750.00 0

36470 $76.00 10 36819 $977.00 90 37222 $911.00 ZZZ

36471 $96.00 10 36820 $800.00 90 37223 $2,638.00 ZZZ

36475 $2,216.00 0 36821 $721.00 90 37224 $3,919.00 0

36476 $434.00 ZZZ 36823 $1,461.00 90 37225 $11,190.00 0

36478 $2,041.00 0 36825 $867.00 90 37226 $9,188.00 0

36479 $438.00 ZZZ 36830 $967.00 90 37227 $15,065.00 0

36481 $499.00 0 36831 $488.00 90 37228 $5,569.00 0

36500 $159.00 0 36832 $810.00 90 37229 $11,021.00 0

36511 $92.00 0 36833 $780.00 90 37230 $8,434.00 0

36512 $92.00 0 36835 $542.00 90 37231 $13,463.00 0

36513 $92.00 0 36838 $1,230.00 90 37232 $1,238.00 ZZZ

36514 $92.00 0 36860 $166.00 0 37233 $1,486.00 ZZZ

36515 $92.00 0 36861 $224.00 0 37234 $3,935.00 ZZZ

36516 $92.00 0 36901 $581.00 0 37235 $4,017.00 ZZZ

36522 $305.00 0 36902 $1,235.00 0 37236 $2,863.00 0

36556 $316.00 0 36903 $5,663.00 0 37237 $1,243.00 ZZZ

36558 $703.00 10 36904 $1,801.00 0 37238 $4,186.00 0

36561 $1,333.00 10 36905 $2,304.00 0 37239 $2,081.00 ZZZ

36563 $1,679.00 10 36906 $6,867.00 0 37241 $4,634.00 0

36565 $1,073.00 10 36907 $739.00 ZZZ 37242 $7,805.00 0

36566 $1,121.00 10 36908 $2,722.00 ZZZ 37243 $9,853.00 0

36569 $350.00 0 36909 $1,985.00 ZZZ 37244 $6,899.00 0

36571 $1,550.00 10 37140 $1,666.00 90 37246 $2,175.00 0

36575 $172.00 0 37145 $1,741.00 90 37247 $880.00 ZZZ





37248 $1,507.00 0 38305 $375.00 90 39599 BR YYY

37249 $646.00 ZZZ 38308 $425.00 90 40490 $108.00 0

37252 $1,426.00 ZZZ 38380 $628.00 90 40500 $422.00 90

37253 $222.00 ZZZ 38381 $1,087.00 90 40510 $469.00 90

37500 $739.00 90 38382 $798.00 90 40520 $467.00 90

37501 BR YYY 38500 $234.00 10 40525 $714.00 90

37565 $364.00 90 38505 $139.00 0 40527 $851.00 90

37600 $414.00 90 38510 $349.00 10 40530 $501.00 90

37605 $521.00 90 38520 $431.00 90 40650 $368.00 90

37606 $563.00 90 38525 $369.00 90 40652 $436.00 90

37607 $456.00 90 38530 $517.00 90 40654 $529.00 90

37609 $278.00 10 38542 $507.00 90 40700 $1,009.00 90

37615 $495.00 90 38550 $519.00 90 40701 $1,452.00 90

37616 $1,128.00 90 38555 $1,115.00 90 40702 $1,030.00 90

37617 $1,132.00 90 38562 $799.00 90 40720 $1,107.00 90

37618 $514.00 90 38564 $831.00 90 40761 $1,202.00 90

37619 $1,712.00 90 38570 $695.00 10 40799 BR YYY

37650 $430.00 90 38571 $902.00 10 40800 $110.00 10

37660 $789.00 90 38572 $1,049.00 10 40801 $208.00 10

37700 $336.00 90 38589 BR YYY 40804 $105.00 10

37718 $416.00 90 38700 $863.00 90 40805 $245.00 10

37722 $495.00 90 38720 $1,328.00 90 40806 $38.00 0

37735 $847.00 90 38724 $1,366.00 90 40808 $100.00 10

37760 $813.00 90 38740 $539.00 90 40810 $141.00 10

37761 $577.00 90 38745 $770.00 90 40812 $202.00 10

37765 $462.00 90 38746 $312.00 ZZZ 40814 $319.00 90

37766 $561.00 90 38747 $337.00 ZZZ 40816 $336.00 90

37780 $301.00 90 38760 $699.00 90 40818 $249.00 90

37785 $270.00 90 38765 $1,283.00 90 40819 $208.00 90

37788 $1,654.00 90 38770 $1,111.00 90 40820 $104.00 10

37790 $690.00 90 38780 $1,357.00 90 40830 $140.00 10

37799 BR YYY 38790 $158.00 0 40831 $213.00 10

38100 $974.00 90 38792 $26.00 0 40840 $687.00 90

38101 $982.00 90 38794 $298.00 90 40842 $684.00 90

38102 $332.00 ZZZ 38900 $141.00 ZZZ 40843 $947.00 90

38115 $1,020.00 90 38999 BR YYY 40844 $1,232.00 90

38120 $1,138.00 90 39000 $664.00 90 40845 $1,593.00 90

38129 BR YYY 39010 $1,148.00 90 40899 BR YYY

38200 $180.00 0 39200 $1,249.00 90 41000 $119.00 10

38205 $79.00 0 39220 $1,542.00 90 41005 $109.00 10

38206 $79.00 0 39401 $324.00 0 41006 $237.00 90

38220 $212.00 0 39402 $423.00 0 41007 $283.00 90

38221 $228.00 0 39499 BR YYY 41008 $248.00 90

38230 $265.00 0 39501 $1,083.00 90 41009 $319.00 90

38232 $214.00 0 39503 $2,726.00 90 41010 $91.00 10

38240 $128.00 0 39540 $1,133.00 90 41015 $267.00 90

38241 $128.00 0 39541 $1,179.00 90 41016 $357.00 90

38242 $90.00 0 39545 $1,102.00 90 41017 $300.00 90

38243 $121.00 0 39560 $968.00 90 41018 $424.00 90

38300 $104.00 10 39561 $1,328.00 90 41019 $444.00 0





41100 $140.00 10 42145 $741.00 90 42804 $136.00 10

41105 $136.00 10 42160 $176.00 10 42806 $167.00 10

41108 $110.00 10 42180 $222.00 10 42808 $250.00 10

41110 $159.00 10 42182 $324.00 10 42809 $152.00 10

41112 $255.00 90 42200 $946.00 90 42810 $335.00 90

41113 $301.00 90 42205 $863.00 90 42815 $659.00 90

41114 $682.00 90 42210 $1,174.00 90 42821 $378.00 90

41115 $176.00 10 42215 $766.00 90 42826 $320.00 90

41116 $242.00 90 42220 $586.00 90 42831 $235.00 90

41120 $813.00 90 42225 $803.00 90 42836 $286.00 90

41130 $937.00 90 42226 $848.00 90 42842 $729.00 90

41135 $1,869.00 90 42227 $762.00 90 42844 $1,173.00 90

41140 $2,005.00 90 42235 $631.00 90 42845 $1,958.00 90

41145 $2,406.00 90 42260 $491.00 90 42860 $207.00 90

41150 $1,897.00 90 42280 $148.00 10 42870 $427.00 90

41153 $2,091.00 90 42281 $160.00 10 42890 $1,047.00 90

41155 $2,448.00 90 42299 BR YYY 42892 $1,262.00 90

41250 $168.00 10 42300 $165.00 10 42894 $1,825.00 90

41251 $203.00 10 42305 $448.00 90 42900 $429.00 10

41252 $294.00 10 42310 $145.00 10 42950 $745.00 90

41500 $334.00 90 42320 $208.00 10 42953 $752.00 90

41510 $313.00 90 42330 $184.00 10 42955 $561.00 90

41512 $644.00 90 42335 $287.00 90 42960 $178.00 10

41520 $255.00 90 42340 $411.00 90 42961 $406.00 90

41530 $3,327.00 0 42400 $94.00 0 42962 $602.00 90

41599 BR YYY 42405 $258.00 10 42970 $284.00 90

41800 $107.00 10 42408 $377.00 90 42971 $472.00 90

41805 $115.00 10 42409 $266.00 90 42972 $562.00 90

41806 $217.00 10 42410 $746.00 90 42999 BR YYY

41820 BR 0 42415 $1,364.00 90 43020 $696.00 90

41821 BR 0 42420 $1,577.00 90 43030 $712.00 90

41822 $237.00 10 42425 $1,097.00 90 43045 $1,574.00 90

41823 $312.00 90 42426 $1,882.00 90 43100 $744.00 90

41825 $144.00 10 42440 $634.00 90 43101 $1,248.00 90

41826 $211.00 10 42450 $395.00 90 43107 $2,325.00 90

41827 $322.00 90 42500 $407.00 90 43108 $2,664.00 90

41828 $176.00 10 42505 $559.00 90 43112 $2,471.00 90

41830 $156.00 10 42507 $522.00 90 43113 $2,755.00 90

41850 BR 0 42509 $915.00 90 43116 $2,509.00 90

41870 BR 0 42510 $711.00 90 43117 $2,469.00 90

41872 $249.00 90 42550 $82.00 0 43118 $2,607.00 90

41874 $193.00 90 42600 $445.00 90 43121 $2,350.00 90

41899 BR YYY 42650 $67.00 0 43122 $2,287.00 90

42000 $106.00 10 42660 $89.00 0 43123 $2,661.00 90

42100 $122.00 10 42665 $238.00 90 43124 $2,242.00 90

42104 $161.00 10 42699 BR YYY 43130 $1,020.00 90

42106 $204.00 10 42700 $144.00 10 43135 $1,332.00 90

42107 $409.00 90 42720 $270.00 10 43180 $573.00 90

42120 $573.00 90 42725 $720.00 90 43191 $130.00 0

42140 $174.00 90 42800 $123.00 10 43192 $155.00 0





43193 $185.00 0 43260 $349.00 0 43420 $854.00 90

43194 $168.00 0 43261 $362.00 0 43425 $1,338.00 90

43195 $186.00 0 43262 $447.00 0 43450 $91.00 0

43196 $203.00 0 43263 $386.00 0 43453 $102.00 0

43197 $188.00 0 43264 $522.00 0 43460 $203.00 0

43198 $210.00 0 43265 $527.00 0 43496 BR 90

43200 $266.00 0 43266 $241.00 0 43499 BR YYY

43201 $245.00 0 43270 $737.00 0 43500 $649.00 90

43202 $205.00 0 43273 $129.00 ZZZ 43501 $1,105.00 90

43204 $228.00 0 43274 $498.00 0 43502 $1,247.00 90

43205 $207.00 0 43275 $411.00 0 43510 $680.00 90

43206 $337.00 0 43276 $518.00 0 43520 $599.00 90

43210 $444.00 0 43277 $413.00 0 43605 $686.00 90

43211 $253.00 0 43278 $470.00 0 43610 $861.00 90

43212 $200.00 0 43279 $1,319.00 90 43611 $1,001.00 90

43213 $1,253.00 0 43280 $1,314.00 90 43620 $1,691.00 90

43214 $203.00 0 43281 $1,577.00 90 43621 $1,718.00 90

43215 $160.00 0 43282 $1,774.00 90 43622 $1,798.00 90

43216 $149.00 0 43283 $161.00 ZZZ 43631 $1,445.00 90

43217 $176.00 0 43289 BR YYY 43632 $1,443.00 90

43220 $128.00 0 43300 $837.00 90 43633 $1,467.00 90

43226 $142.00 0 43305 $1,428.00 90 43634 $1,786.00 90

43227 $218.00 0 43310 $2,138.00 90 43635 $143.00 ZZZ

43229 $739.00 0 43312 $2,331.00 90 43640 $1,119.00 90

43231 $182.00 0 43313 $2,632.00 90 43641 $1,138.00 90

43232 $252.00 0 43314 $2,891.00 90 43644 $1,598.00 90

43233 $241.00 0 43320 $1,299.00 90 43645 $1,724.00 90

43235 $239.00 0 43325 $1,261.00 90 43651 $716.00 90

43236 $285.00 0 43327 $838.00 90 43652 $856.00 90

43237 $219.00 0 43328 $1,193.00 90 43653 $617.00 90

43238 $271.00 0 43330 $1,236.00 90 43659 BR YYY

43239 $246.00 0 43331 $1,378.00 90 43752 $36.00 0

43240 $369.00 0 43332 $1,188.00 90 43753 $21.00 0

43241 $157.00 0 43333 $1,292.00 90 43754 $92.00 0

43242 $384.00 0 43334 $1,282.00 90 43755 $140.00 0

43243 $276.00 0 43335 $1,374.00 90 43756 $214.00 0

43244 $268.00 0 43336 $1,557.00 90 43757 $301.00 0

43245 $214.00 0 43337 $1,681.00 90 43760 $81.00 0

43246 $485.00 0 43338 $120.00 ZZZ 43761 $107.00 0

43247 $229.00 0 43340 $1,292.00 90 43770 $1,009.00 90

43248 $191.00 0 43341 $1,351.00 90 43771 $1,162.00 90

43249 $175.00 0 43351 $1,180.00 90 43772 $885.00 90

43250 $194.00 0 43352 $1,028.00 90 43773 $1,162.00 90

43251 $224.00 0 43360 $2,277.00 90 43774 $888.00 90

43252 $376.00 0 43361 $2,596.00 90 43775 $1,146.00 90

43253 $280.00 0 43400 $1,261.00 90 43800 $793.00 90

43254 $291.00 0 43401 $1,299.00 90 43810 $846.00 90

43255 $343.00 0 43405 $1,330.00 90 43820 $896.00 90

43257 $305.00 0 43410 $946.00 90 43825 $1,128.00 90

43259 $271.00 0 43415 $1,382.00 90 43830 $592.00 90





43831 $593.00 90 44157 $1,952.00 90 44388 $326.00 0

43832 $904.00 90 44158 $2,003.00 90 44388-53 $178.00 0

43840 $893.00 90 44160 $1,236.00 90 44389 $301.00 0

43843 $1,249.00 90 44180 $853.00 90 44390 $319.00 0

43845 $1,738.00 90 44186 $600.00 90 44391 $376.00 0

43846 $1,528.00 90 44187 $992.00 90 44392 $359.00 0

43847 $1,678.00 90 44188 $1,088.00 90 44394 $395.00 0

43848 $1,795.00 90 44202 $1,603.00 90 44401 $3,308.00 0

43850 $1,425.00 90 44203 $235.00 ZZZ 44402 $282.00 0

43855 $1,454.00 90 44204 $1,353.00 90 44403 $324.00 0

43860 $1,435.00 90 44205 $1,198.00 90 44404 $434.00 0

43865 $1,549.00 90 44206 $1,480.00 90 44405 $622.00 0

43870 $590.00 90 44207 $1,620.00 90 44406 $247.00 0

43880 $1,352.00 90 44208 $1,752.00 90 44407 $296.00 0

43886 $280.00 90 44210 $1,551.00 90 44408 $250.00 0

43887 $274.00 90 44211 $1,926.00 90 44500 $28.00 0

43888 $389.00 90 44212 $1,800.00 90 44602 $815.00 90

43999 BR YYY 44213 $196.00 ZZZ 44603 $1,041.00 90

44005 $1,171.00 90 44227 $1,536.00 90 44604 $1,027.00 90

44010 $809.00 90 44238 BR YYY 44605 $1,132.00 90

44015 $1,171.00 ZZZ 44300 $697.00 90 44615 $994.00 90

44020 $891.00 90 44310 $950.00 90 44620 $741.00 90

44021 $888.00 90 44312 $453.00 90 44625 $1,277.00 90

44025 $905.00 90 44314 $892.00 90 44626 $1,581.00 90

44050 $862.00 90 44316 $1,229.00 90 44640 $1,036.00 90

44055 $957.00 90 44320 $1,029.00 90 44650 $1,076.00 90

44100 $117.00 0 44322 $1,015.00 90 44660 $1,050.00 90

44110 $784.00 90 44340 $397.00 90 44661 $1,326.00 90

44111 $963.00 90 44345 $816.00 90 44680 $1,049.00 90

44120 $1,078.00 90 44346 $923.00 90 44700 $1,115.00 90

44121 $308.00 ZZZ 44360 $177.00 0 44701 $161.00 ZZZ

44125 $1,135.00 90 44361 $195.00 0 44720 $268.00 0

44126 $1,951.00 90 44363 $213.00 0 44721 $393.00 0

44127 $2,243.00 90 44364 $255.00 0 44799 BR YYY

44128 $242.00 ZZZ 44365 $226.00 0 44800 $791.00 90

44130 $938.00 90 44366 $300.00 0 44820 $755.00 90

44133 BR 0 44369 $308.00 0 44850 $708.00 90

44136 BR 0 44370 $253.00 0 44899 BR YYY

44139 $154.00 ZZZ 44372 $301.00 0 44900 $644.00 90

44140 $1,350.00 90 44373 $238.00 0 44950 $643.00 90

44141 $1,488.00 90 44376 $305.00 0 44955 $136.00 ZZZ

44143 $1,536.00 90 44377 $320.00 0 44960 $790.00 90

44144 $1,442.00 90 44378 $410.00 0 44970 $631.00 90

44145 $1,678.00 90 44379 $396.00 0 44979 BR YYY

44146 $1,840.00 90 44380 $91.00 0 45000 $329.00 90

44147 $1,452.00 90 44381 $1,016.00 0 45005 $197.00 10

44150 $1,661.00 90 44382 $110.00 0 45020 $364.00 90

44151 $1,499.00 90 44384 $164.00 0 45100 $321.00 90

44155 $1,892.00 90 44385 $219.00 0 45108 $419.00 90

44156 $1,709.00 90 44386 $183.00 0 45110 $1,801.00 90





45111 $1,270.00 90 45386 $739.00 0 46270 $328.00 90

45112 $1,904.00 90 45388 $3,327.00 0 46275 $442.00 90

45113 $1,885.00 90 45389 $311.00 0 46280 $514.00 90

45114 $1,732.00 90 45390 $355.00 0 46285 $335.00 90

45116 $1,485.00 90 45391 $283.00 0 46288 $521.00 90

45119 $1,911.00 90 45392 $358.00 0 46320 $126.00 10

45120 $1,845.00 90 45393 $271.00 0 46500 $109.00 10

45121 $1,870.00 90 45395 $1,813.00 90 46505 $229.00 10

45123 $1,126.00 90 45397 $1,969.00 90 46600 $38.00 0

45126 $2,444.00 90 45398 $744.00 0 46601 $140.00 0

45130 $1,041.00 90 45400 $1,058.00 90 46604 $92.00 0

45135 $1,354.00 90 45402 $1,435.00 90 46606 $66.00 0

45136 $1,526.00 90 45500 $584.00 90 46607 $195.00 0

45150 $475.00 90 45505 $510.00 90 46608 $115.00 0

45160 $949.00 90 45520 $46.00 0 46610 $114.00 0

45171 $615.00 90 45540 $1,009.00 90 46611 $149.00 0

45172 $835.00 90 45541 $888.00 90 46612 $196.00 0

45190 $623.00 90 45550 $1,350.00 90 46614 $169.00 0

45300 $75.00 0 45560 $618.00 90 46615 $202.00 0

45303 $72.00 0 45562 $915.00 90 46700 $585.00 90

45305 $102.00 0 45563 $1,412.00 90 46706 $140.00 10

45307 $172.00 0 45800 $1,050.00 90 46707 $473.00 90

45308 $137.00 0 45805 $1,273.00 90 46710 $953.00 90

45309 $174.00 0 45820 $1,066.00 90 46712 $1,999.00 90

45315 $211.00 0 45825 $1,241.00 90 46715 $545.00 90

45317 $209.00 0 45900 $120.00 10 46716 $906.00 90

45320 $230.00 0 45905 $133.00 10 46730 $1,584.00 90

45321 $154.00 0 45910 $163.00 10 46735 $1,881.00 90

45327 $96.00 0 45915 $142.00 10 46740 $1,671.00 90

45330 $87.00 0 45990 $105.00 0 46742 $2,236.00 90

45331 $120.00 0 45999 BR YYY 46744 $2,412.00 90

45332 $174.00 0 46020 $230.00 10 46746 $2,725.00 90

45333 $176.00 0 46030 $94.00 10 46748 $2,933.00 90

45334 $171.00 0 46040 $393.00 90 46750 $636.00 90

45335 $144.00 0 46045 $312.00 90 46753 $511.00 90

45337 $144.00 0 46050 $105.00 10 46754 $188.00 10

45338 $212.00 0 46060 $482.00 90 46760 $846.00 90

45340 $328.00 0 46080 $246.00 10 46761 $813.00 90

45341 $153.00 0 46083 $98.00 10 46762 $731.00 90

45342 $224.00 0 46200 $323.00 90 46900 $128.00 10

45346 $3,167.00 0 46220 $118.00 10 46910 $144.00 10

45347 $168.00 0 46221 $124.00 10 46916 $145.00 10

45349 $214.00 0 46230 $198.00 10 46917 $228.00 10

45350 $593.00 0 46250 $400.00 90 46922 $189.00 10

45379 $415.00 0 46255 $501.00 90 46924 $297.00 10

45380 $369.00 0 46257 $504.00 90 46930 $207.00 90

45381 $388.00 0 46258 $539.00 90 46940 $165.00 10

45382 $481.00 0 46260 $598.00 90 46942 $145.00 10

45384 $415.00 0 46261 $655.00 90 46945 $199.00 90

45385 $479.00 0 46262 $686.00 90 46946 $270.00 90





46947 $328.00 90 47554 $594.00 0 48510 $938.00 90

46999 BR YYY 47555 $383.00 0 48520 $1,103.00 90

47000 $218.00 0 47556 $425.00 0 48540 $1,350.00 90

47001 $141.00 ZZZ 47562 $837.00 90 48545 $1,170.00 90

47010 $788.00 90 47563 $900.00 90 48547 $1,630.00 90

47015 $755.00 90 47564 $1,069.00 90 48548 $1,460.00 90

47100 $550.00 90 47570 $961.00 90 48552 $230.00 0

47120 $1,663.00 90 47579 BR YYY 48554 $2,365.00 90

47122 $2,512.00 90 47600 $868.00 90 48556 $1,117.00 90

47125 $2,293.00 90 47605 $935.00 90 48999 BR YYY

47130 $2,482.00 90 47610 $1,164.00 90 49000 $862.00 90

47135 $6,164.00 90 47612 $1,276.00 90 49002 $784.00 90

47146 $337.00 0 47620 $1,295.00 90 49010 $915.00 90

47147 $393.00 0 47700 $1,111.00 90 49020 $910.00 90

47300 $778.00 90 47701 $1,913.00 90 49040 $763.00 90

47350 $942.00 90 47711 $1,442.00 90 49060 $827.00 90

47360 $1,305.00 90 47712 $1,793.00 90 49062 $892.00 90

47361 $2,129.00 90 47715 $1,157.00 90 49082 $193.00 0

47362 $849.00 90 47720 $1,040.00 90 49083 $300.00 0

47370 $943.00 90 47721 $1,248.00 90 49084 $104.00 0

47371 $889.00 90 47740 $1,188.00 90 49180 $212.00 0

47379 BR YYY 47741 $1,425.00 90 49185 $1,012.00 0

47380 $1,107.00 90 47760 $1,568.00 90 49203 $1,049.00 90

47381 $1,094.00 90 47765 $1,624.00 90 49204 $1,337.00 90

47382 $660.00 10 47780 $1,635.00 90 49205 $1,530.00 90

47383 $7,678.00 10 47785 $1,871.00 90 49215 $1,551.00 90

47399 BR YYY 47800 $1,485.00 90 49220 $1,182.00 90

47400 $1,435.00 90 47801 $906.00 90 49250 $622.00 90

47420 $1,222.00 90 47802 $1,352.00 90 49255 $591.00 90

47425 $1,275.00 90 47900 $1,331.00 90 49320 $415.00 10

47460 $1,039.00 90 47999 BR YYY 49321 $443.00 10

47480 $755.00 90 48000 $1,053.00 90 49322 $460.00 10

47490 $467.00 10 48001 $1,305.00 90 49323 $712.00 90

47531 $379.00 0 48020 $983.00 90 49324 $348.00 10

47532 $835.00 0 48100 $779.00 90 49325 $374.00 10

47533 $1,362.00 0 48102 $341.00 10 49326 $171.00 ZZZ

47534 $1,678.00 0 48105 $2,505.00 90 49327 $133.00 ZZZ

47535 $1,126.00 0 48120 $1,083.00 90 49329 BR YYY

47536 $831.00 0 48140 $1,546.00 90 49400 $127.00 0

47537 $411.00 0 48145 $1,661.00 90 49402 $748.00 90

47538 $4,584.00 0 48146 $1,830.00 90 49405 $886.00 0

47539 $5,009.00 0 48148 $1,149.00 90 49406 $886.00 0

47540 $5,208.00 0 48150 $3,101.00 90 49407 $749.00 0

47541 $1,202.00 0 48152 $2,888.00 90 49411 $537.00 0

47542 $526.00 ZZZ 48153 $3,099.00 90 49412 $83.00 ZZZ

47543 $1,350.00 ZZZ 48154 $2,893.00 90 49418 $1,453.00 0

47544 $831.00 ZZZ 48155 $1,855.00 90 49419 $405.00 90

47550 $209.00 ZZZ 48160 BR 0 49421 $452.00 0

47552 $364.00 0 48400 $100.00 ZZZ 49422 $468.00 10

47553 $342.00 0 48500 $1,012.00 90 49423 $106.00 0





49424 $54.00 0 49659 BR YYY 50396 $101.00 0

49425 $914.00 90 49900 $512.00 90 50400 $1,441.00 90

49426 $725.00 90 49904 $1,394.00 90 50405 $1,802.00 90

49427 $48.00 0 49905 $454.00 ZZZ 50430 $531.00 0

49428 $184.00 10 49906 BR 90 50431 $165.00 0

49429 $522.00 10 49999 BR YYY 50432 $860.00 0

49435 $110.00 ZZZ 50010 $886.00 90 50433 $1,158.00 0

49436 $164.00 10 50020 $1,084.00 90 50434 $916.00 0

49440 $1,113.00 10 50040 $910.00 90 50435 $481.00 0

49441 $1,319.00 10 50045 $1,137.00 90 50500 $1,471.00 90

49442 $1,075.00 10 50060 $1,394.00 90 50520 $1,281.00 90

49446 $1,100.00 0 50065 $1,514.00 90 50525 $1,644.00 90

49450 $771.00 0 50070 $1,476.00 90 50526 $1,639.00 90

49451 $817.00 0 50075 $1,839.00 90 50540 $1,468.00 90

49452 $998.00 0 50080 $1,186.00 90 50541 $1,037.00 90

49460 $818.00 0 50081 $1,635.00 90 50542 $1,093.00 90

49465 $170.00 0 50100 $1,250.00 90 50543 $1,374.00 90

49505 $510.00 90 50120 $1,180.00 90 50544 $1,428.00 90

49507 $636.00 90 50125 $1,228.00 90 50545 $1,273.00 90

49520 $631.00 90 50130 $1,301.00 90 50546 $1,325.00 90

49521 $730.00 90 50135 $1,506.00 90 50547 $1,702.00 90

49525 $584.00 90 50200 $151.00 0 50548 $1,555.00 90

49540 $668.00 90 50205 $807.00 90 50549 BR YYY

49550 $557.00 90 50220 $1,316.00 90 50551 $411.00 0

49553 $598.00 90 50225 $1,554.00 90 50553 $447.00 0

49555 $621.00 90 50230 $1,695.00 90 50555 $668.00 0

49557 $715.00 90 50234 $1,671.00 90 50557 $676.00 0

49560 $734.00 90 50236 $1,873.00 90 50561 $755.00 0

49561 $856.00 90 50240 $1,679.00 90 50562 $580.00 90

49565 $754.00 90 50250 $1,157.00 90 50570 $549.00 0

49566 $881.00 90 50280 $1,170.00 90 50572 $728.00 0

49568 $339.00 ZZZ 50290 $1,080.00 90 50574 $762.00 0

49570 $411.00 90 50320 $1,680.00 90 50575 $991.00 0

49572 $491.00 90 50327 $214.00 0 50576 $801.00 0

49585 $444.00 90 50328 $187.00 0 50580 $726.00 0

49587 $501.00 90 50329 $179.00 0 50590 $980.00 90

49590 $585.00 90 50340 $1,083.00 90 50592 $5,936.00 10

49600 $774.00 90 50360 $2,475.00 90 50593 $4,692.00 10

49605 $1,648.00 90 50365 $2,941.00 90 50600 $1,150.00 90

49606 $1,416.00 90 50370 $1,128.00 90 50605 $1,054.00 90

49610 $784.00 90 50380 $1,507.00 90 50606 $538.00 ZZZ

49611 $770.00 90 50382 $1,594.00 0 50610 $1,209.00 90

49650 $484.00 90 50384 $1,540.00 0 50620 $1,152.00 90

49651 $621.00 90 50385 $1,326.00 0 50630 $1,170.00 90

49652 $700.00 90 50386 $857.00 0 50650 $1,297.00 90

49653 $874.00 90 50387 $772.00 0 50660 $1,426.00 90

49654 $795.00 90 50389 $529.00 0 50684 $74.00 0

49655 $971.00 90 50390 $118.00 0 50686 $109.00 0

49656 $864.00 90 50391 $139.00 0 50688 $89.00 10

49657 $1,240.00 90 50395 $203.00 0 50690 $85.00 0





50693 $1,078.00 0 51050 $596.00 90 51736-26 $32.00 0

50694 $1,187.00 0 51060 $768.00 90 51736-TC $15.00 0

50695 $1,447.00 0 51065 $704.00 90 51741 $81.00 0

50700 $1,192.00 90 51080 $510.00 90 51741-26 $59.00 0

50705 $1,735.00 ZZZ 51100 $63.00 0 51741-TC $17.00 0

50706 $778.00 ZZZ 51101 $130.00 0 51784 $119.00 0

50715 $1,397.00 90 51102 $335.00 0 51784-26 $80.00 0

50722 $1,211.00 90 51500 $775.00 90 51784-TC $136.00 0

50725 $1,371.00 90 51520 $764.00 90 51785 $52.00 0

50727 $640.00 90 51525 $1,069.00 90 51785-26 $80.00 0

50728 $924.00 90 51530 $957.00 90 51785-TC $155.00 0

50740 $1,386.00 90 51535 $932.00 90 51792 $143.00 0

50750 $1,457.00 90 51550 $1,171.00 90 51792-26 $60.00 0

50760 $1,389.00 90 51555 $1,514.00 90 51792-TC $213.00 0

50770 $1,485.00 90 51565 $1,624.00 90 51797 $109.00 ZZZ

50780 $1,391.00 90 51570 $1,762.00 90 51797-26 $84.00 ZZZ

50782 $1,465.00 90 51575 $2,284.00 90 51797-TC $205.00 ZZZ

50783 $1,515.00 90 51580 $2,252.00 90 51798 $20.00 0

50785 $1,548.00 90 51585 $2,601.00 90 51800 $1,294.00 90

50800 $1,226.00 90 51590 $2,441.00 90 51820 $1,236.00 90

50810 $1,527.00 90 51595 $2,900.00 90 51840 $858.00 90

50815 $1,643.00 90 51596 $3,063.00 90 51841 $1,040.00 90

50820 $1,729.00 90 51597 $2,914.00 90 51845 $843.00 90

50825 $2,351.00 90 51600 $54.00 0 51860 $912.00 90

50830 $2,292.00 90 51605 $83.00 0 51865 $1,150.00 90

50840 $1,493.00 90 51610 $45.00 0 51880 $590.00 90

50845 $1,513.00 90 51700 $29.00 0 51900 $1,050.00 90

50860 $1,163.00 90 51701 $58.00 0 51920 $881.00 90

50900 $1,043.00 90 51702 $92.00 0 51925 $1,167.00 90

50920 $1,075.00 90 51703 $128.00 0 51940 $2,082.00 90

50930 $1,380.00 90 51705 $37.00 0 51960 $1,848.00 90

50940 $1,107.00 90 51710 $119.00 0 51980 $858.00 90

50945 $1,096.00 90 51715 $322.00 0 51990 $850.00 90

50947 $1,384.00 90 51720 $140.00 0 51992 $925.00 90

50948 $1,265.00 90 51725 $116.00 0 52000 $190.00 0

50949 BR YYY 51725-26 $79.00 0 52001 $133.00 0

50951 $414.00 0 51725-TC $199.00 0 52005 $265.00 0

50953 $461.00 0 51726 $136.00 0 52007 $230.00 0

50955 $546.00 0 51726-26 $90.00 0 52010 $292.00 0

50957 $546.00 0 51726-TC $274.00 0 52204 $286.00 0

50961 $510.00 0 51727 $314.00 0 52214 $367.00 0

50970 $510.00 0 51727-26 $111.00 0 52224 $339.00 0

50972 $408.00 0 51727-TC $203.00 0 52234 $471.00 0

50974 $661.00 0 51728 $315.00 0 52235 $546.00 0

50976 $641.00 0 51728-26 $108.00 0 52240 $887.00 0

50980 $443.00 0 51728-TC $207.00 0 52250 $311.00 0

51020 $587.00 90 51729 $341.00 0 52260 $262.00 0

51030 $538.00 90 51729-26 $131.00 0 52265 $243.00 0

51040 $439.00 90 51729-TC $211.00 0 52270 $374.00 0

51045 $548.00 90 51736 $47.00 0 52275 $446.00 0





52276 $490.00 0 53060 $180.00 10 53860 $1,546.00 90

52277 $448.00 0 53080 $567.00 90 53899 BR YYY

52281 $259.00 0 53085 $836.00 90 54015 $348.00 10

52282 $560.00 0 53200 $218.00 0 54050 $91.00 10

52283 $309.00 0 53210 $904.00 90 54055 $106.00 10

52285 $375.00 0 53215 $1,142.00 90 54056 $100.00 10

52287 $311.00 0 53220 $546.00 90 54057 $149.00 10

52290 $304.00 0 53230 $760.00 90 54060 $180.00 10

52300 $370.00 0 53235 $607.00 90 54065 $281.00 10

52301 $382.00 0 53240 $506.00 90 54100 $149.00 0

52305 $370.00 0 53250 $464.00 90 54105 $261.00 10

52310 $348.00 0 53260 $240.00 10 54110 $775.00 90

52315 $553.00 0 53265 $295.00 10 54111 $1,035.00 90

52317 $772.00 0 53270 $226.00 10 54112 $1,210.00 90

52318 $684.00 0 53275 $332.00 10 54115 $588.00 90

52320 $369.00 0 53400 $929.00 90 54120 $777.00 90

52325 $494.00 0 53405 $1,088.00 90 54125 $1,092.00 90

52327 $369.00 0 53410 $1,151.00 90 54130 $1,532.00 90

52330 $507.00 0 53415 $1,381.00 90 54135 $1,945.00 90

52332 $451.00 0 53420 $1,088.00 90 54162 $220.00 10

52334 $340.00 0 53425 $1,150.00 90 54163 $207.00 10

52341 $317.00 0 53430 $1,116.00 90 54164 $182.00 10

52342 $344.00 0 53431 $1,053.00 90 54200 $78.00 10

52343 $380.00 0 53440 $1,057.00 90 54205 $633.00 90

52344 $407.00 0 53442 $639.00 90 54220 $189.00 0

52345 $433.00 0 53444 $755.00 90 54230 $104.00 0

52346 $488.00 0 53445 $1,197.00 90 54231 $172.00 0

52351 $297.00 0 53446 $699.00 90 54235 $81.00 0

52352 $349.00 0 53447 $991.00 90 54240 $109.00 0

52353 $404.00 0 53448 $1,259.00 90 54240-26 $68.00 0

52354 $372.00 0 53449 $784.00 90 54240-TC $24.00 0

52355 $447.00 0 53450 $447.00 90 54250 $104.00 0

52356 $424.00 0 53460 $494.00 90 54250-26 $116.00 0

52400 $580.00 90 53500 $719.00 90 54250-TC $9.00 0

52402 $279.00 0 53502 $590.00 90 54300 $830.00 90

52441 $1,258.00 0 53505 $586.00 90 54304 $988.00 90

52442 $962.00 ZZZ 53510 $777.00 90 54308 $881.00 90

52450 $602.00 90 53515 $987.00 90 54312 $1,067.00 90

52500 $705.00 90 53520 $661.00 90 54316 $1,316.00 90

52601 $1,021.00 90 53600 $37.00 0 54318 $900.00 90

52630 $653.00 90 53601 $37.00 0 54322 $974.00 90

52640 $573.00 90 53605 $81.00 0 54324 $1,260.00 90

52647 $858.00 90 53620 $59.00 0 54326 $1,212.00 90

52648 $957.00 90 53621 $45.00 0 54328 $1,201.00 90

52649 $973.00 90 53660 $49.00 0 54332 $1,327.00 90

52700 $517.00 90 53661 $50.00 0 54336 $1,672.00 90

53000 $224.00 10 53665 $50.00 0 54340 $727.00 90

53010 $336.00 90 53850 $741.00 90 54344 $1,360.00 90

53020 $153.00 0 53852 $728.00 90 54348 $1,318.00 90

53040 $460.00 90 53855 $770.00 0 54352 $1,820.00 90





54360 $898.00 90 55040 $439.00 90 56420 $130.00 10

54380 $1,054.00 90 55041 $634.00 90 56440 $271.00 10

54385 $1,217.00 90 55060 $430.00 90 56441 $183.00 10

54390 $1,635.00 90 55100 $156.00 10 56442 $45.00 0

54400 $784.00 90 55110 $223.00 90 56501 $122.00 10

54401 $892.00 90 55120 $350.00 90 56515 $200.00 10

54405 $1,294.00 90 55150 $562.00 90 56605 $96.00 0

54406 $687.00 90 55175 $426.00 90 56606 $49.00 ZZZ

54408 $724.00 90 55180 $796.00 90 56620 $607.00 90

54410 $856.00 90 55200 $310.00 90 56625 $735.00 90

54411 $933.00 90 55250 $349.00 90 56630 $1,061.00 90

54415 $510.00 90 55300 $167.00 0 56631 $1,400.00 90

54416 $665.00 90 55400 $660.00 90 56632 $1,636.00 90

54417 $819.00 90 55450 $391.00 10 56633 $1,350.00 90

54420 $899.00 90 55500 $445.00 90 56634 $1,537.00 90

54430 $799.00 90 55520 $446.00 90 56637 $1,806.00 90

54435 $503.00 90 55530 $467.00 90 56640 $1,777.00 90

54437 $701.00 90 55535 $496.00 90 56700 $227.00 10

54438 $1,413.00 90 55540 $572.00 90 56740 $321.00 10

54440 BR 90 55550 $486.00 90 56800 $310.00 10

54450 $88.00 0 55559 BR YYY 56805 $1,349.00 90

54500 $102.00 0 55600 $486.00 90 56810 $316.00 10

54505 $259.00 10 55605 $609.00 90 56820 $119.00 0

54512 $519.00 90 55650 $853.00 90 56821 $154.00 0

54520 $445.00 90 55680 $426.00 90 57000 $237.00 10

54522 $589.00 90 55700 $183.00 0 57010 $429.00 90

54530 $683.00 90 55705 $368.00 10 57020 $118.00 0

54535 $922.00 90 55706 $373.00 10 57022 $179.00 10

54550 $588.00 90 55720 $555.00 90 57023 $290.00 10

54560 $842.00 90 55725 $670.00 90 57061 $124.00 10

54600 $524.00 90 55801 $1,331.00 90 57065 $251.00 10

54620 $373.00 10 55810 $1,711.00 90 57100 $90.00 0

54640 $594.00 90 55812 $1,989.00 90 57105 $132.00 10

54650 $861.00 90 55815 $2,328.00 90 57106 $409.00 90

54660 $401.00 90 55821 $1,153.00 90 57107 $1,467.00 90

54670 $485.00 90 55831 $1,252.00 90 57109 $1,787.00 90

54680 $948.00 90 55840 $1,705.00 90 57110 $1,015.00 90

54690 $825.00 90 55842 $1,859.00 90 57111 $1,793.00 90

54692 $850.00 90 55845 $2,222.00 90 57112 $1,907.00 90

54699 BR YYY 55860 $1,012.00 90 57120 $612.00 90

54700 $133.00 10 55862 $1,351.00 90 57130 $220.00 10

54800 $257.00 0 55865 $1,890.00 90 57135 $231.00 10

54830 $411.00 90 55866 $1,615.00 90 57150 $50.00 0

54840 $432.00 90 55870 $166.00 0 57155 $383.00 0

54860 $503.00 90 55873 $1,127.00 90 57156 $198.00 0

54861 $696.00 90 55875 $729.00 90 57160 $67.00 0

54865 $333.00 90 55876 $147.00 0 57170 $74.00 0

54900 $969.00 90 55899 BR YYY 57180 $124.00 10

54901 $1,340.00 90 55920 $420.00 0 57200 $313.00 90

55000 $109.00 0 56405 $131.00 10 57210 $395.00 90





57220 $378.00 90 57522 $319.00 90 58540 $923.00 90

57230 $442.00 90 57530 $386.00 90 58541 $793.00 90

57240 $536.00 90 57531 $2,036.00 90 58542 $877.00 90

57250 $485.00 90 57540 $815.00 90 58543 $891.00 90

57260 $700.00 90 57545 $700.00 90 58544 $965.00 90

57265 $902.00 90 57550 $486.00 90 58545 $876.00 90

57267 $284.00 ZZZ 57555 $774.00 90 58546 $1,104.00 90

57268 $577.00 90 57556 $718.00 90 58548 $1,688.00 90

57270 $867.00 90 57558 $120.00 10 58550 $1,038.00 90

57280 $1,071.00 90 57700 $279.00 90 58552 $853.00 90

57282 $734.00 90 57720 $328.00 90 58553 $1,096.00 90

57283 $673.00 90 57800 $71.00 0 58554 $1,085.00 90

57284 $950.00 90 58100 $74.00 0 58555 $261.00 0

57285 $607.00 90 58110 $53.00 ZZZ 58558 $340.00 0

57287 $685.00 90 58120 $297.00 10 58559 $436.00 0

57288 $1,009.00 90 58140 $1,010.00 90 58560 $482.00 0

57289 $879.00 90 58145 $677.00 90 58561 $677.00 0

57291 $622.00 90 58146 $1,089.00 90 58562 $339.00 0

57292 $925.00 90 58150 $1,110.00 90 58563 $450.00 0

57295 $485.00 90 58152 $1,159.00 90 58565 $2,189.00 90

57296 $880.00 90 58180 $1,118.00 90 58570 $844.00 90

57300 $653.00 90 58200 $1,562.00 90 58571 $922.00 90

57305 $995.00 90 58210 $2,080.00 90 58572 $1,047.00 90

57307 $997.00 90 58240 $2,898.00 90 58573 $1,178.00 90

57308 $769.00 90 58260 $926.00 90 58578 BR YYY

57310 $517.00 90 58262 $1,026.00 90 58579 BR YYY

57311 $612.00 90 58263 $1,120.00 90 58600 $337.00 90

57320 $693.00 90 58267 $1,133.00 90 58605 $298.00 90

57330 $916.00 90 58270 $1,019.00 90 58611 $47.00 ZZZ

57335 $963.00 90 58275 $1,121.00 90 58615 $319.00 10

57400 $70.00 0 58280 $1,132.00 90 58660 $793.00 90

57410 $57.00 0 58285 $1,360.00 90 58661 $804.00 10

57415 $75.00 10 58290 $1,089.00 90 58662 $807.00 90

57420 $124.00 0 58291 $1,197.00 90 58670 $450.00 90

57421 $162.00 0 58292 $1,268.00 90 58671 $463.00 90

57423 $848.00 90 58293 $1,318.00 90 58672 $872.00 90

57425 $902.00 90 58294 $1,168.00 90 58673 $928.00 90

57426 $879.00 90 58301 $71.00 0 58679 BR YYY

57452 $96.00 0 58321 $81.00 0 58700 $544.00 90

57454 $125.00 0 58322 $90.00 0 58720 $844.00 90

57455 $149.00 0 58323 $24.00 0 58740 $508.00 90

57456 $141.00 0 58340 $87.00 0 58750 $949.00 90

57460 $223.00 0 58345 $335.00 10 58752 $893.00 90

57461 $333.00 0 58346 $408.00 90 58760 $769.00 90

57500 $89.00 0 58350 $103.00 10 58770 $763.00 90

57505 $105.00 10 58353 $225.00 10 58800 $343.00 90

57510 $140.00 10 58356 $531.00 10 58805 $509.00 90

57511 $159.00 10 58400 $519.00 90 58820 $326.00 90

57513 $191.00 10 58410 $752.00 90 58822 $603.00 90

57520 $359.00 90 58520 $663.00 90 58825 $469.00 90





58900 $489.00 90 59430 $140.00 0 60522 $1,820.00 90

58920 $571.00 90 59510 $2,064.00 0 60540 $1,272.00 90

58925 $820.00 90 59514 $1,199.00 0 60545 $1,505.00 90

58940 $592.00 90 59515 $1,324.00 0 60600 $1,477.00 90

58943 $1,368.00 90 59525 $591.00 ZZZ 60605 $1,624.00 90

58950 $1,170.00 90 59610 $1,805.00 0 60650 $1,340.00 90

58951 $1,703.00 90 59612 $1,113.00 0 60659 BR YYY

58952 $1,876.00 90 59614 $1,208.00 0 60699 BR YYY

58953 $1,839.00 90 59618 $2,035.00 0 61020 $150.00 0

58954 $1,999.00 90 59620 $1,293.00 0 61026 $138.00 0

58956 $1,329.00 90 59622 $1,397.00 0 61050 $106.00 0

58957 $1,365.00 90 59812 $343.00 90 61055 $143.00 0

58958 $1,511.00 90 59820 $389.00 90 61070 $67.00 0

58960 $1,174.00 90 59821 $398.00 90 61105 $503.00 90

58999 BR YYY 59830 $496.00 90 61107 $863.00 0

59000 $123.00 0 59840 $331.00 10 61108 $959.00 90

59001 $167.00 0 59841 $443.00 10 61120 $733.00 90

59012 $267.00 0 59850 $449.00 90 61140 $1,389.00 90

59015 $168.00 0 59851 $464.00 90 61150 $1,503.00 90

59020 $85.00 0 59852 $642.00 90 61151 $795.00 90

59020-26 $40.00 0 59855 $477.00 90 61154 $1,393.00 90

59020-TC $23.00 0 59856 $577.00 90 61156 $1,473.00 90

59025 $54.00 0 59857 $711.00 90 61210 $527.00 0

59025-26 $32.00 0 59866 $304.00 0 61215 $637.00 90

59025-TC $10.00 0 59870 $348.00 90 61250 $888.00 90

59030 $155.00 0 59871 $192.00 0 61253 $1,042.00 90

59050 $71.00 0 59898 BR YYY 61304 $2,005.00 90

59051 $47.00 0 59899 BR YYY 61305 $2,419.00 90

59100 $633.00 90 60000 $114.00 10 61312 $2,187.00 90

59120 $893.00 90 60100 $96.00 0 61313 $2,207.00 90

59121 $768.00 90 60200 $744.00 90 61314 $2,200.00 90

59130 $832.00 90 60210 $872.00 90 61315 $2,393.00 90

59135 $1,083.00 90 60212 $1,170.00 90 61316 $88.00 ZZZ

59136 $934.00 90 60220 $851.00 90 61320 $2,118.00 90

59140 $461.00 90 60225 $1,107.00 90 61321 $2,310.00 90

59150 $543.00 90 60240 $1,228.00 90 61322 $1,779.00 90

59151 $690.00 90 60252 $1,427.00 90 61323 $1,842.00 90

59160 $279.00 10 60254 $1,911.00 90 61330 $1,706.00 90

59200 $79.00 0 60260 $1,022.00 90 61332 $2,307.00 90

59300 $179.00 0 60270 $1,468.00 90 61333 $2,231.00 90

59320 $196.00 0 60271 $1,210.00 90 61340 $1,584.00 90

59325 $316.00 0 60280 $546.00 90 61343 $2,673.00 90

59350 $375.00 0 60281 $670.00 90 61345 $2,259.00 90

59400 $1,816.00 0 60300 $99.00 0 61450 $2,173.00 90

59409 $1,019.00 0 60500 $1,232.00 90 61458 $2,433.00 90

59410 $1,123.00 0 60502 $1,475.00 90 61460 $2,426.00 90

59412 $141.00 0 60505 $1,631.00 90 61480 $1,922.00 90

59414 $134.00 0 60512 $310.00 ZZZ 61500 $1,637.00 90

59425 $414.00 0 60520 $1,405.00 90 61501 $1,353.00 90

59426 $708.00 0 60521 $1,591.00 90 61510 $2,506.00 90





61512 $2,981.00 90 61592 $3,245.00 90 61770 $1,867.00 90

61514 $2,262.00 90 61595 $2,350.00 90 61781 $240.00 ZZZ

61516 $2,253.00 90 61596 $2,827.00 90 61782 $197.00 ZZZ

61517 $74.00 ZZZ 61597 $3,046.00 90 61783 $241.00 ZZZ

61518 $3,163.00 90 61598 $2,693.00 90 61790 $952.00 90

61519 $3,450.00 90 61600 $2,039.00 90 61791 $1,205.00 90

61520 $4,349.00 90 61601 $2,279.00 90 61796 $1,027.00 90

61521 $3,667.00 90 61605 $2,299.00 90 61797 $224.00 ZZZ

61522 $2,415.00 90 61606 $3,178.00 90 61798 $1,404.00 90

61524 $2,484.00 90 61607 $2,961.00 90 61799 $308.00 ZZZ

61526 $3,918.00 90 61608 $3,458.00 90 61800 $156.00 ZZZ

61530 $3,611.00 90 61610 $2,354.00 ZZZ 61850 $1,090.00 90

61531 $1,344.00 90 61611 $584.00 ZZZ 61860 $1,197.00 90

61533 $1,712.00 90 61612 $2,219.00 ZZZ 61863 $1,231.00 90

61534 $1,535.00 90 61613 $3,375.00 90 61864 $295.00 ZZZ

61535 $958.00 90 61615 $2,576.00 90 61867 $1,863.00 90

61536 $2,862.00 90 61616 $3,535.00 90 61868 $491.00 ZZZ

61537 $1,714.00 90 61618 $1,389.00 90 61870 $616.00 90

61538 $2,466.00 90 61619 $1,682.00 90 61880 $559.00 90

61539 $2,660.00 90 61623 $540.00 0 61885 $262.00 90

61540 $2,069.00 90 61624 $1,073.00 0 61886 $678.00 90

61541 $2,363.00 90 61626 $877.00 0 61888 $331.00 10

61543 $2,307.00 90 61630 $1,245.00 0 62000 $848.00 90

61544 $2,271.00 90 61635 $1,362.00 0 62005 $1,282.00 90

61545 $3,474.00 90 61640 $555.00 0 62010 $1,754.00 90

61546 $2,695.00 90 61641 $195.00 ZZZ 62100 $1,962.00 90

61548 $1,964.00 90 61642 $390.00 ZZZ 62115 $1,686.00 90

61550 $1,141.00 90 61645 $809.00 0 62117 $2,211.00 90

61552 $1,463.00 90 61650 $540.00 0 62120 $1,898.00 90

61556 $1,760.00 90 61651 $229.00 ZZZ 62121 $1,822.00 90

61557 $1,807.00 90 61680 $2,758.00 90 62140 $1,221.00 90

61558 $2,085.00 90 61682 $4,798.00 90 62141 $1,955.00 90

61559 $2,700.00 90 61684 $3,341.00 90 62142 $1,011.00 90

61563 $2,175.00 90 61686 $5,012.00 90 62143 $1,096.00 90

61564 $2,597.00 90 61690 $2,556.00 90 62145 $1,566.00 90

61566 $2,048.00 90 61692 $4,007.00 90 62146 $1,327.00 90

61567 $2,340.00 90 61697 $3,231.00 90 62147 $1,566.00 90

61570 $1,975.00 90 61698 $3,103.00 90 62148 $120.00 ZZZ

61571 $2,140.00 90 61700 $4,037.00 90 62160 $172.00 ZZZ

61575 $2,992.00 90 61702 $4,019.00 90 62161 $1,229.00 90

61576 $3,772.00 90 61703 $1,444.00 90 62162 $1,578.00 90

61580 $2,383.00 90 61705 $3,043.00 90 62163 $999.00 90

61581 $2,674.00 90 61708 $2,546.00 90 62164 $1,706.00 90

61582 $2,557.00 90 61710 $2,129.00 90 62165 $1,336.00 90

61583 $2,972.00 90 61711 $3,150.00 90 62180 $1,695.00 90

61584 $2,830.00 90 61720 $1,558.00 90 62190 $1,034.00 90

61585 $3,142.00 90 61735 $1,664.00 90 62192 $1,146.00 90

61586 $2,097.00 90 61750 $1,521.00 90 62194 $239.00 10

61590 $3,299.00 90 61751 $1,628.00 90 62200 $1,625.00 90

61591 $3,491.00 90 61760 $1,670.00 90 62201 $1,200.00 90





62220 $1,215.00 90 63003 $1,591.00 90 63196 $1,810.00 90

62223 $1,199.00 90 63005 $1,390.00 90 63197 $1,725.00 90

62225 $488.00 90 63011 $1,151.00 90 63198 $1,956.00 90

62230 $935.00 90 63012 $1,568.00 90 63199 $2,258.00 90

62252 $85.00 0 63015 $1,862.00 90 63200 $1,569.00 90

62252-26 $49.00 0 63016 $1,788.00 90 63250 $3,182.00 90

62252-TC $42.00 0 63017 $1,489.00 90 63251 $3,207.00 90

62256 $616.00 90 63020 $1,395.00 90 63252 $3,319.00 90

62258 $1,308.00 90 63030 $1,145.00 90 63265 $1,940.00 90

62263 $426.00 10 63035 $280.00 ZZZ 63266 $2,053.00 90

62264 $593.00 10 63040 $1,764.00 90 63267 $1,651.00 90

62267 $253.00 0 63042 $1,620.00 90 63268 $1,469.00 90

62268 $285.00 0 63043 BR ZZZ 63270 $2,197.00 90

62269 $271.00 0 63044 BR ZZZ 63271 $2,401.00 90

62270 $109.00 0 63045 $1,647.00 90 63272 $2,206.00 90

62272 $137.00 0 63046 $2,117.00 90 63273 $2,012.00 90

62273 $130.00 0 63047 $1,907.00 90 63275 $2,166.00 90

62280 $199.00 10 63048 $367.00 ZZZ 63276 $2,135.00 90

62281 $186.00 10 63050 $1,411.00 90 63277 $1,905.00 90

62282 $211.00 10 63051 $1,605.00 90 63278 $1,877.00 90

62284 $196.00 0 63055 $2,029.00 90 63280 $2,529.00 90

62287 $784.00 90 63056 $1,960.00 90 63281 $2,496.00 90

62290 $235.00 0 63057 $421.00 ZZZ 63282 $2,305.00 90

62291 $232.00 0 63064 $2,200.00 90 63283 $2,041.00 90

62292 $1,064.00 90 63066 $263.00 ZZZ 63285 $2,934.00 90

62294 $821.00 90 63075 $1,720.00 90 63286 $3,003.00 90

62302 $246.00 0 63076 $383.00 ZZZ 63287 $3,012.00 90

62303 $256.00 0 63077 $1,828.00 90 63290 $3,073.00 90

62304 $244.00 0 63078 $261.00 ZZZ 63295 $319.00 ZZZ

62305 $266.00 0 63081 $2,203.00 90 63300 $2,006.00 90

62320 $170.00 0 63082 $391.00 ZZZ 63301 $2,209.00 90

62321 $253.00 0 63085 $2,416.00 90 63302 $2,290.00 90

62322 $159.00 0 63086 $282.00 ZZZ 63303 $2,357.00 90

62323 $249.00 0 63087 $2,930.00 90 63304 $2,513.00 90

62324 $149.00 0 63088 $381.00 ZZZ 63305 $2,574.00 90

62325 $225.00 0 63090 $2,490.00 90 63306 $2,596.00 90

62326 $156.00 0 63091 $249.00 ZZZ 63307 $2,522.00 90

62327 $229.00 0 63101 $2,127.00 90 63308 $425.00 ZZZ

62350 $488.00 10 63102 $2,127.00 90 63600 $797.00 90

62351 $782.00 90 63103 $249.00 ZZZ 63610 $476.00 0

62355 $402.00 10 63170 $1,788.00 90 63615 $1,348.00 90

62360 $195.00 10 63172 $1,672.00 90 63620 $1,133.00 90

62361 $390.00 10 63173 $1,851.00 90 63621 $256.00 ZZZ

62362 $517.00 10 63180 $1,486.00 90 63650 $819.00 10

62365 $418.00 10 63182 $1,711.00 90 63655 $1,064.00 90

62367 $39.00 0 63185 $1,347.00 90 63661 $584.00 10

62368 $53.00 0 63190 $1,610.00 90 63662 $792.00 90

62369 $121.00 0 63191 $1,444.00 90 63663 $811.00 10

62370 $128.00 0 63194 $1,593.00 90 63664 $820.00 90

63001 $1,882.00 90 63195 $1,603.00 90 63685 $615.00 10





63688 $707.00 10 64495 $89.00 ZZZ 64708 $562.00 90

63700 $1,340.00 90 64505 $104.00 0 64712 $678.00 90

63702 $1,512.00 90 64508 $99.00 0 64713 $867.00 90

63704 $1,708.00 90 64510 $103.00 0 64714 $715.00 90

63706 $1,873.00 90 64517 $188.00 0 64716 $523.00 90

63707 $1,041.00 90 64520 $131.00 0 64718 $558.00 90

63709 $1,310.00 90 64530 $135.00 0 64719 $446.00 90

63710 $1,165.00 90 64550 $23.00 0 64721 $439.00 90

63740 $1,062.00 90 64553 $137.00 10 64722 $411.00 90

63741 $741.00 90 64555 $131.00 10 64726 $271.00 90

63744 $738.00 90 64561 $801.00 10 64727 $261.00 ZZZ

63746 $529.00 90 64565 $121.00 10 64732 $405.00 90

64400 $78.00 0 64566 $121.00 0 64734 $432.00 90

64402 $75.00 0 64568 $628.00 90 64736 $388.00 90

64405 $103.00 0 64569 $799.00 90 64738 $475.00 90

64408 $120.00 0 64570 $709.00 90 64740 $461.00 90

64410 $109.00 0 64575 $367.00 90 64742 $517.00 90

64413 $128.00 0 64580 $343.00 90 64744 $798.00 90

64415 $109.00 0 64581 $745.00 90 64746 $494.00 90

64416 $159.00 0 64585 $37.00 10 64755 $1,042.00 90

64417 $105.00 0 64590 $217.00 10 64760 $578.00 90

64418 $108.00 0 64595 $153.00 10 64763 $561.00 90

64420 $89.00 0 64600 $228.00 10 64766 $713.00 90

64421 $128.00 0 64605 $319.00 10 64771 $632.00 90

64425 $116.00 0 64610 $307.00 10 64772 $636.00 90

64430 $130.00 0 64611 $114.00 10 64774 $392.00 90

64435 $114.00 0 64612 $188.00 10 64776 $390.00 90

64445 $68.00 0 64615 $146.00 10 64778 $249.00 ZZZ

64446 $165.00 0 64616 $125.00 10 64782 $482.00 90

64447 $77.00 0 64617 $193.00 10 64783 $298.00 ZZZ

64448 $152.00 0 64620 $185.00 10 64784 $751.00 90

64449 $152.00 0 64630 $202.00 10 64786 $1,281.00 90

64450 $53.00 0 64632 $87.00 10 64787 $458.00 ZZZ

64455 $49.00 0 64633 $441.00 10 64788 $381.00 90

64461 $151.00 0 64634 $200.00 ZZZ 64790 $884.00 90

64462 $86.00 ZZZ 64635 $435.00 10 64792 $1,148.00 90

64463 $164.00 0 64636 $181.00 ZZZ 64795 $247.00 0

64479 $224.00 0 64640 $208.00 10 64802 $711.00 90

64480 $194.00 ZZZ 64642 $142.00 0 64804 $1,202.00 90

64483 $206.00 0 64643 $93.00 ZZZ 64809 $1,080.00 90

64484 $183.00 ZZZ 64644 $162.00 0 64818 $845.00 90

64486 $127.00 0 64645 $114.00 ZZZ 64820 $838.00 90

64487 $156.00 0 64646 $152.00 0 64821 $609.00 90

64488 $156.00 0 64647 $176.00 0 64822 $609.00 90

64489 $218.00 0 64650 $62.00 0 64823 $703.00 90

64490 $196.00 0 64653 $71.00 0 64831 $592.00 90

64491 $96.00 ZZZ 64680 $180.00 10 64832 $171.00 ZZZ

64492 $97.00 ZZZ 64681 $464.00 10 64834 $711.00 90

64493 $177.00 0 64702 $383.00 90 64835 $834.00 90

64494 $88.00 ZZZ 64704 $402.00 90 64836 $856.00 90





64837 $480.00 ZZZ 65222 $62.00 0 66030 $160.00 10

64840 $1,058.00 90 65235 $627.00 90 66130 $631.00 90

64856 $1,063.00 90 65260 $956.00 90 66150 $798.00 90

64857 $1,137.00 90 65265 $1,104.00 90 66155 $795.00 90

64858 $1,313.00 90 65270 $88.00 10 66160 $942.00 90

64859 $341.00 ZZZ 65272 $223.00 90 66170 $1,089.00 90

64861 $1,524.00 90 65273 $376.00 90 66172 $1,264.00 90

64862 $1,798.00 90 65275 $75.00 90 66174 $1,006.00 90

64864 $970.00 90 65280 $711.00 90 66175 $1,140.00 90

64865 $1,250.00 90 65285 $1,177.00 90 66179 $1,092.00 90

64866 $1,238.00 90 65286 $692.00 90 66180 $1,313.00 90

64868 $1,162.00 90 65290 $519.00 90 66183 $1,090.00 90

64872 $155.00 ZZZ 65400 $603.00 90 66184 $796.00 90

64874 $230.00 ZZZ 65410 $142.00 0 66185 $769.00 90

64876 $189.00 ZZZ 65420 $448.00 90 66220 $711.00 90

64885 $1,382.00 90 65426 $534.00 90 66225 $1,006.00 90

64886 $1,636.00 90 65430 $81.00 0 66250 $602.00 90

64890 $1,112.00 90 65435 $88.00 0 66500 $359.00 90

64891 $1,243.00 90 65436 $319.00 90 66505 $359.00 90

64892 $1,177.00 90 65450 $52.00 90 66600 $825.00 90

64893 $1,321.00 90 65600 $325.00 90 66605 $1,136.00 90

64895 $1,500.00 90 65710 $1,124.00 90 66625 $543.00 90

64896 $1,185.00 90 65730 $1,314.00 90 66630 $623.00 90

64897 $1,419.00 90 65750 $1,381.00 90 66635 $595.00 90

64898 $1,549.00 90 65755 $1,373.00 90 66680 $526.00 90

64901 $865.00 ZZZ 65756 $1,201.00 90 66682 $627.00 90

64902 $982.00 ZZZ 65770 $1,461.00 90 66700 $506.00 90

64905 $1,059.00 90 65772 $449.00 90 66710 $513.00 90

64907 $1,472.00 90 65775 $595.00 90 66711 $507.00 90

64910 $645.00 90 65778 $1,389.00 0 66720 $506.00 90

64911 $783.00 90 65779 $1,238.00 0 66740 $473.00 90

64999 BR YYY 65780 $766.00 90 66761 $506.00 10

65091 $678.00 90 65781 $1,169.00 90 66762 $433.00 90

65093 $712.00 90 65782 $1,008.00 90 66770 $483.00 90

65101 $726.00 90 65785 $2,144.00 90 66820 $433.00 90

65103 $769.00 90 65800 $88.00 0 66821 $275.00 90

65105 $846.00 90 65810 $516.00 90 66825 $753.00 90

65110 $1,305.00 90 65815 $327.00 90 66830 $651.00 90

65112 $1,386.00 90 65820 $813.00 90 66840 $707.00 90

65114 $1,456.00 90 65850 $968.00 90 66850 $805.00 90

65125 $312.00 90 65855 $441.00 10 66852 $878.00 90

65130 $730.00 90 65860 $339.00 90 66920 $785.00 90

65135 $678.00 90 65865 $540.00 90 66930 $906.00 90

65140 $738.00 90 65870 $572.00 90 66940 $819.00 90

65150 $652.00 90 65875 $597.00 90 66982 $846.00 90

65155 $862.00 90 65880 $641.00 90 66983 $763.00 90

65175 $654.00 90 65900 $945.00 90 66984 $898.00 90

65205 $45.00 0 65920 $752.00 90 66985 $744.00 90

65210 $53.00 0 65930 $700.00 90 66986 $1,038.00 90

65220 $58.00 0 66020 $164.00 10 66990 $84.00 ZZZ





66999 BR YYY 67345 $275.00 10 67916 $675.00 90

67005 $639.00 90 67346 $173.00 0 67917 $631.00 90

67010 $647.00 90 67399 BR YYY 67921 $419.00 90

67015 $637.00 90 67400 $960.00 90 67922 $243.00 90

67025 $774.00 90 67405 $799.00 90 67923 $718.00 90

67027 $1,089.00 90 67412 $976.00 90 67924 $605.00 90

67028 $338.00 0 67413 $909.00 90 67930 $280.00 10

67030 $485.00 90 67414 $1,023.00 90 67935 $520.00 90

67031 $402.00 90 67415 $146.00 0 67938 $67.00 10

67036 $1,384.00 90 67420 $1,729.00 90 67950 $584.00 90

67039 $1,490.00 90 67430 $1,203.00 90 67961 $571.00 90

67040 $1,960.00 90 67440 $1,257.00 90 67966 $645.00 90

67041 $1,065.00 90 67445 $1,269.00 90 67971 $875.00 90

67042 $1,218.00 90 67450 $1,300.00 90 67973 $1,126.00 90

67043 $1,279.00 90 67500 $75.00 0 67974 $1,140.00 90

67101 $767.00 10 67505 $109.00 0 67975 $681.00 90

67105 $941.00 10 67515 $53.00 0 67999 BR YYY

67107 $1,350.00 90 67550 $946.00 90 68020 $106.00 10

67108 $1,878.00 90 67560 $936.00 90 68040 $75.00 0

67110 $1,040.00 90 67570 $1,148.00 90 68100 $137.00 0

67113 $1,405.00 90 67599 BR YYY 68110 $172.00 10

67115 $496.00 90 67700 $87.00 10 68115 $248.00 10

67120 $751.00 90 67710 $117.00 10 68130 $378.00 90

67121 $962.00 90 67715 $102.00 10 68135 $146.00 10

67141 $536.00 90 67800 $119.00 10 68200 $59.00 0

67145 $514.00 90 67801 $189.00 10 68320 $502.00 90

67208 $655.00 90 67805 $208.00 10 68325 $672.00 90

67210 $779.00 90 67808 $308.00 90 68326 $654.00 90

67218 $1,217.00 90 67810 $133.00 0 68328 $741.00 90

67220 $894.00 90 67820 $36.00 0 68330 $488.00 90

67221 $325.00 0 67825 $130.00 10 68335 $636.00 90

67225 $44.00 ZZZ 67830 $239.00 10 68340 $413.00 90

67227 $652.00 10 67835 $500.00 90 68360 $449.00 90

67228 $1,025.00 10 67840 $187.00 10 68362 $691.00 90

67229 $926.00 90 67850 $143.00 10 68371 $363.00 10

67250 $793.00 90 67875 $163.00 0 68399 BR YYY

67255 $872.00 90 67880 $442.00 90 68400 $154.00 10

67299 BR YYY 67882 $643.00 90 68420 $191.00 10

67311 $616.00 90 67900 $487.00 90 68440 $96.00 10

67312 $773.00 90 67901 $646.00 90 68500 $882.00 90

67314 $688.00 90 67902 $650.00 90 68505 $921.00 90

67316 $857.00 90 67903 $657.00 90 68510 $491.00 0

67318 $663.00 90 67904 $720.00 90 68520 $687.00 90

67320 $602.00 ZZZ 67906 $633.00 90 68525 $340.00 0

67331 $560.00 ZZZ 67908 $550.00 90 68530 $379.00 10

67332 $621.00 ZZZ 67909 $577.00 90 68540 $875.00 90

67334 $447.00 ZZZ 67911 $517.00 90 68550 $1,107.00 90

67335 $253.00 ZZZ 67912 $983.00 90 68700 $628.00 90

67340 $559.00 ZZZ 67914 $487.00 90 68705 $176.00 10

67343 $628.00 90 67915 $252.00 90 68720 $807.00 90





68745 $704.00 90 69554 $2,600.00 90 69950 $2,017.00 90

68750 $792.00 90 69601 $1,195.00 90 69955 $2,185.00 90

68760 $109.00 10 69602 $1,225.00 90 69960 $2,116.00 90

68761 $130.00 10 69603 $1,264.00 90 69970 $2,306.00 90

68770 $634.00 90 69604 $1,263.00 90 69979 BR YYY

68801 $202.00 10 69605 $1,526.00 90 69990 $262.00 ZZZ

68810 $290.00 10 69610 $41.00 10 G0127 $17.00 0

68811 $191.00 10 69620 $651.00 90 G0168 $75.00 0

68815 $399.00 10 69631 $985.00 90 G0247 $38.00 ZZZ

68816 $592.00 10 69632 $1,166.00 90 G0276 $409.00 0

68840 $100.00 10 69633 $1,110.00 90 G0289 $82.00 ZZZ

68850 $76.00 0 69635 $1,207.00 90 G0341 $333.00 0

68899 BR YYY 69636 $1,381.00 90 G0342 $622.00 90

69000 $52.00 10 69637 $1,370.00 90 G0343 $1,026.00 90

69005 $175.00 10 69641 $1,154.00 90 G0364 $12.00 ZZZ

69020 $109.00 10 69642 $1,519.00 90 G0412 $742.00 90

69100 $85.00 0 69643 $1,389.00 90 G0413 $1,092.00 90

69105 $87.00 0 69644 $1,529.00 90 G0414 $1,017.00 90

69110 $294.00 90 69645 $1,479.00 90 G0415 $1,407.00 90

69120 $274.00 90 69646 $1,620.00 90 G0429 $102.00 0

69140 $722.00 90 69650 $879.00 90

69145 $248.00 90 69660 $1,072.00 90

69150 $1,111.00 90 69661 $1,412.00 90

69155 $1,680.00 90 69662 $1,386.00 90

69200 $53.00 0 69666 $887.00 90

69205 $110.00 10 69667 $887.00 90

69209 $13.00 0 69670 $988.00 90

69210 $39.00 0 69676 $828.00 90

69220 $78.00 0 69700 $702.00 90

69222 $123.00 10 69710 BR 0

69300 $522.00 YYY 69711 $878.00 90

69310 $937.00 90 69714 $961.00 90

69320 $1,434.00 90 69715 $1,217.00 90

69399 BR YYY 69717 $996.00 90

69420 $117.00 10 69718 $1,232.00 90

69421 $155.00 10 69720 $1,307.00 90

69424 $84.00 0 69725 $1,922.00 90

69433 $145.00 10 69740 $1,274.00 90

69436 $182.00 10 69745 $1,447.00 90

69440 $699.00 90 69799 BR YYY

69450 $525.00 90 69801 $785.00 0

69501 $829.00 90 69805 $1,187.00 90

69502 $1,118.00 90 69806 $1,123.00 90

69505 $1,176.00 90 69820 $876.00 90

69511 $1,221.00 90 69840 $869.00 90

69530 $1,616.00 90 69905 $1,013.00 90

69535 $2,824.00 90 69910 $1,228.00 90

69540 $126.00 10 69915 $1,754.00 90

69550 $998.00 90 69930 $1,498.00 90

69552 $1,621.00 90 69949 BR YYY



Radiology Radiology Radiology

CPT Code MRA CPT Code MRA CPT Code MRA

70010 $70.00 70240-TC $15.00 70450-26 $43.00

70010-26 $19.00 70250 $35.00 70450-TC $176.00

70010-TC $51.00 70250-26 $12.00 70460 $271.00

70015 $58.00 70250-TC $22.00 70460-26 $58.00

70015-26 $31.00 70260 $50.00 70460-TC $211.00

70015-TC $27.00 70260-26 $17.00 70470 $332.00

70030 $24.00 70260-TC $33.00 70470-26 $65.00

70030-26 $10.00 70300 $15.00 70470-TC $264.00

70030-TC $15.00 70300-26 $5.00 70480 $244.00

70100 $29.00 70300-TC $10.00 70480-26 $65.00

70100-26 $9.00 70310 $24.00 70480-TC $176.00

70100-TC $19.00 70310-26 $8.00 70481 $284.00

70110 $36.00 70310-TC $15.00 70481-26 $70.00

70110-26 $12.00 70320 $40.00 70481-TC $211.00

70110-TC $22.00 70320-26 $11.00 70482 $340.00

70120 $32.00 70320-TC $29.00 70482-26 $74.00

70120-26 $9.00 70328 $28.00 70482-TC $264.00

70120-TC $22.00 70328-26 $10.00 70486 $236.00

70130 $46.00 70328-TC $18.00 70486-26 $58.00

70130-26 $17.00 70330 $43.00 70486-TC $176.00

70130-TC $29.00 70330-26 $12.00 70487 $279.00

70134 $45.00 70330-TC $31.00 70487-26 $66.00

70134-26 $17.00 70332 $107.00 70487-TC $211.00

70134-TC $28.00 70332-26 $27.00 70488 $339.00

70140 $33.00 70332-TC $80.00 70488-26 $72.00

70140-26 $9.00 70336 $497.00 70488-TC $264.00

70140-TC $22.00 70336-26 $72.00 70490 $244.00

70150 $42.00 70336-TC $419.00 70490-26 $65.00

70150-26 $12.00 70350 $24.00 70490-TC $176.00

70150-TC $29.00 70350-26 $10.00 70491 $284.00

70160 $29.00 70350-TC $14.00 70491-26 $70.00

70160-26 $8.00 70355 $32.00 70491-TC $211.00

70160-TC $19.00 70355-26 $10.00 70492 $340.00

70170 $52.00 70355-TC $21.00 70492-26 $74.00

70170-26 $15.00 70360 $24.00 70492-TC $264.00

70170-TC $37.00 70360-26 $8.00 70496 $366.00

70190 $34.00 70360-TC $15.00 70496-26 $92.00

70190-26 $10.00 70370 $65.00 70496-TC $270.00

70190-TC $22.00 70370-26 $16.00 70498 $366.00

70200 $43.00 70370-TC $48.00 70498-26 $92.00

70200-26 $14.00 70371 $122.00 70498-TC $270.00

70200-TC $29.00 70371-26 $43.00 70540 $482.00

70210 $32.00 70371-TC $79.00 70540-26 $70.00

70210-26 $8.00 70380 $34.00 70540-TC $413.00

70210-TC $22.00 70380-26 $8.00 70542 $579.00

70220 $42.00 70380-TC $24.00 70542-26 $82.00

70220-26 $12.00 70390 $87.00 70542-TC $495.00

70220-TC $29.00 70390-26 $19.00 70543 $1,029.00

70240 $26.00 70390-TC $68.00 70543-26 $109.00

70240-26 $9.00 70450 $221.00 70543-TC $916.00





70544 $481.00 71020-TC $22.00 71550-26 $75.00

70544-26 $61.00 71021 $41.00 71550-TC $415.00

70544-TC $419.00 71021-26 $13.00 71551 $587.00

70545 $481.00 71021-TC $28.00 71551-26 $88.00

70545-26 $61.00 71022 $44.00 71551-TC $496.00

70545-TC $419.00 71022-26 $16.00 71552 $1,029.00

70546 $914.00 71022-TC $28.00 71552-26 $114.00

70546-26 $92.00 71023 $49.00 71552-TC $911.00

70546-TC $820.00 71023-26 $19.00 71555 $514.00

70547 $481.00 71023-TC $29.00 71555-26 $92.00

70547-26 $61.00 71030 $45.00 71555-TC $419.00

70547-TC $419.00 71030-26 $16.00 72020 $22.00

70548 $481.00 71030-TC $29.00 72020-26 $7.00

70548-26 $61.00 71034 $79.00 72020-TC $15.00

70548-TC $419.00 71034-26 $23.00 72040 $34.00

70549 $914.00 71034-TC $54.00 72040-26 $11.00

70549-26 $92.00 71035 $56.00 72040-TC $22.00

70549-TC $820.00 71035-26 $19.00 72050 $49.00

70551 $497.00 71035-TC $38.00 72050-26 $16.00

70551-26 $76.00 71100 $33.00 72050-TC $33.00

70551-TC $419.00 71100-26 $11.00 72052 $61.00

70552 $596.00 71100-TC $21.00 72052-26 $18.00

70552-26 $91.00 71101 $38.00 72052-TC $42.00

70552-TC $502.00 71101-26 $13.00 72070 $36.00

70553 $1,055.00 71101-TC $24.00 72070-26 $11.00

70553-26 $120.00 71110 $43.00 72070-TC $24.00

70553-TC $931.00 71110-26 $13.00 72072 $39.00

70554 $618.00 71110-TC $29.00 72072-26 $11.00

70554-26 $99.00 71111 $49.00 72072-TC $28.00

70554-TC $520.00 71111-26 $16.00 72074 $45.00

70555 BR 71111-TC $33.00 72074-26 $11.00

70555-26 $118.00 71120 $35.00 72074-TC $34.00

70555-TC BR 71120-26 $10.00 72080 $36.00

70557 $392.00 71120-TC $24.00 72080-26 $11.00

70557-26 $148.00 71130 $38.00 72080-TC $24.00

70557-TC $349.00 71130-26 $11.00 72081 $39.00

70558 $425.00 71130-TC $26.00 72081-26 $14.00

70558-26 $164.00 71250 $282.00 72081-TC $25.00

70558-TC $376.00 71250-26 $59.00 72082 $63.00

70559 $548.00 71250-TC $220.00 72082-26 $16.00

70559-26 $164.00 71260 $328.00 72082-TC $46.00

70559-TC $499.00 71260-26 $63.00 72083 $68.00

71010 $27.00 71260-TC $264.00 72083-26 $18.00

71010-26 $9.00 71270 $402.00 72083-TC $50.00

71010-TC $17.00 71270-26 $70.00 72084 $81.00

71015 $30.00 71270-TC $330.00 72084-26 $21.00

71015-26 $10.00 71275 $431.00 72084-TC $61.00

71015-TC $19.00 71275-26 $100.00 72100 $36.00

71020 $35.00 71275-TC $328.00 72100-26 $11.00

71020-26 $11.00 71550 $490.00 72100-TC $24.00





72110 $50.00 72148-TC $465.00 72202-26 $9.00

72110-26 $16.00 72149 $597.00 72202-TC $22.00

72110-TC $34.00 72149-26 $92.00 72220 $30.00

72114 $64.00 72149-TC $502.00 72220-26 $8.00

72114-26 $18.00 72156 $1,066.00 72220-TC $21.00

72114-TC $44.00 72156-26 $131.00 72240 $132.00

72120 $45.00 72156-TC $931.00 72240-26 $26.00

72120-26 $11.00 72157 $1,066.00 72240-TC $106.00

72120-TC $33.00 72157-26 $131.00 72255 $129.00

72125 $282.00 72157-TC $931.00 72255-26 $28.00

72125-26 $59.00 72158 $1,056.00 72255-TC $101.00

72125-TC $220.00 72158-26 $121.00 72265 $132.00

72126 $328.00 72158-TC $931.00 72265-26 $28.00

72126-26 $62.00 72159 $563.00 72265-TC $104.00

72126-TC $264.00 72159-26 $94.00 72270 $176.00

72127 $397.00 72159-TC $465.00 72270-26 $39.00

72127-26 $65.00 72170 $29.00 72270-TC $137.00

72127-TC $330.00 72170-26 $8.00 72275 $112.00

72128 $282.00 72170-TC $19.00 72275-26 $34.00

72128-26 $59.00 72190 $35.00 72275-TC $78.00

72128-TC $220.00 72190-26 $10.00 72285 $101.00

72129 $328.00 72190-TC $24.00 72285-26 $15.00

72129-26 $62.00 72191 $413.00 72285-TC $86.00

72129-TC $264.00 72191-26 $94.00 72295 $107.00

72130 $397.00 72191-TC $315.00 72295-26 $13.00

72130-26 $65.00 72192 $278.00 72295-TC $94.00

72130-TC $330.00 72192-26 $56.00 73000 $28.00

72131 $282.00 72192-TC $220.00 73000-26 $8.00

72131-26 $59.00 72193 $317.00 73000-TC $19.00

72131-TC $220.00 72193-26 $59.00 73010 $29.00

72132 $328.00 72193-TC $256.00 73010-26 $8.00

72132-26 $62.00 72194 $380.00 73010-TC $19.00

72132-TC $264.00 72194-26 $62.00 73020 $26.00

72133 $391.00 72194-TC $317.00 73020-26 $7.00

72133-26 $65.00 72195 $491.00 73020-TC $17.00

72133-TC $323.00 72195-26 $74.00 73030 $31.00

72141 $503.00 72195-TC $415.00 73030-26 $9.00

72141-26 $82.00 72196 $526.00 73030-TC $21.00

72141-TC $419.00 72196-26 $84.00 73040 $68.00

72142 $604.00 72196-TC $442.00 73040-26 $17.00

72142-26 $99.00 72197 $1,037.00 73040-TC $51.00

72142-TC $502.00 72197-26 $114.00 73050 $35.00

72146 $549.00 72197-TC $919.00 73050-26 $10.00

72146-26 $82.00 72198 $517.00 73050-TC $24.00

72146-TC $465.00 72198-26 $95.00 73060 $30.00

72147 $603.00 72198-TC $419.00 73060-26 $8.00

72147-26 $98.00 72200 $29.00 73060-TC $21.00

72147-TC $502.00 72200-26 $9.00 73070 $27.00

72148 $543.00 72200-TC $19.00 73070-26 $7.00

72148-26 $76.00 72202 $33.00 73070-TC $19.00





73080 $30.00 73221-TC $413.00 73580-26 $18.00

73080-26 $8.00 73222 $579.00 73580-TC $66.00

73080-TC $21.00 73222-26 $82.00 73590 $29.00

73085 $74.00 73222-TC $495.00 73590-26 $8.00

73085-26 $19.00 73223 $1,029.00 73590-TC $19.00

73085-TC $55.00 73223-26 $109.00 73600 $27.00

73090 $28.00 73223-TC $916.00 73600-26 $8.00

73090-26 $8.00 73225 $513.00 73600-TC $18.00

73090-TC $19.00 73225-26 $92.00 73610 $29.00

73100 $27.00 73225-TC $419.00 73610-26 $8.00

73100-26 $8.00 73501 $30.00 73610-TC $19.00

73100-TC $18.00 73501-26 $10.00 73615 $72.00

73110 $29.00 73501-TC $20.00 73615-26 $19.00

73110-26 $8.00 73502 $42.00 73615-TC $53.00

73110-TC $19.00 73502-26 $11.00 73620 $27.00

73115 $54.00 73502-TC $30.00 73620-26 $8.00

73115-26 $17.00 73503 $52.00 73620-TC $18.00

73115-TC $37.00 73503-26 $15.00 73630 $29.00

73120 $27.00 73503-TC $37.00 73630-26 $8.00

73120-26 $8.00 73521 $40.00 73630-TC $19.00

73120-TC $18.00 73521-26 $12.00 73650 $26.00

73130 $29.00 73521-TC $28.00 73650-26 $8.00

73130-26 $8.00 73522 $49.00 73650-TC $17.00

73130-TC $19.00 73522-26 $15.00 73660 $22.00

73140 $22.00 73522-TC $34.00 73660-26 $7.00

73140-26 $7.00 73523 $57.00 73660-TC $15.00

73140-TC $15.00 73523-26 $16.00 73700 $242.00

73200 $242.00 73523-TC $40.00 73700-26 $56.00

73200-26 $56.00 73525 $84.00 73700-TC $185.00

73200-TC $185.00 73525-26 $21.00 73701 $282.00

73201 $282.00 73525-TC $63.00 73701-26 $61.00

73201-26 $59.00 73551 $28.00 73701-TC $220.00

73201-TC $220.00 73551-26 $9.00 73702 $341.00

73202 $342.00 73551-TC $19.00 73702-26 $62.00

73202-26 $63.00 73552 $33.00 73702-TC $277.00

73202-TC $277.00 73552-26 $10.00 73706 $379.00

73206 $375.00 73552-TC $23.00 73706-26 $98.00

73206-26 $94.00 73560 $29.00 73706-TC $277.00

73206-TC $277.00 73560-26 $8.00 73718 $482.00

73218 $482.00 73560-TC $19.00 73718-26 $68.00

73218-26 $68.00 73562 $31.00 73718-TC $413.00

73218-TC $413.00 73562-26 $9.00 73719 $579.00

73219 $579.00 73562-TC $21.00 73719-26 $82.00

73219-26 $82.00 73564 $35.00 73719-TC $495.00

73219-TC $495.00 73564-26 $11.00 73720 $520.00

73220 $520.00 73564-TC $22.00 73720-26 $78.00

73220-26 $78.00 73565 $28.00 73720-TC $442.00

73220-TC $442.00 73565-26 $8.00 73721 $482.00

73221 $482.00 73565-TC $18.00 73721-26 $68.00

73221-26 $68.00 73580 $84.00 73721-TC $413.00





73722 $579.00 74182-TC $496.00 74261-26 $122.00

73722-26 $82.00 74183 $1,037.00 74261-TC $126.00

73722-TC $495.00 74183-26 $114.00 74262 $376.00

73723 $1,029.00 74183-TC $919.00 74262-26 $127.00

73723-26 $109.00 74185 $514.00 74262-TC $249.00

73723-TC $916.00 74185-26 $92.00 74263 $757.00

73725 $515.00 74185-TC $419.00 74263-26 $117.00

73725-26 $92.00 74190 $73.00 74263-TC $639.00

73725-TC $419.00 74190-26 $24.00 74270 $100.00

74000 $29.00 74190-TC $49.00 74270-26 $35.00

74000-26 $9.00 74210 $63.00 74270-TC $64.00

74000-TC $19.00 74210-26 $18.00 74280 $136.00

74010 $33.00 74210-TC $44.00 74280-26 $50.00

74010-26 $11.00 74220 $68.00 74280-TC $84.00

74010-TC $21.00 74220-26 $23.00 74283 $201.00

74020 $37.00 74220-TC $44.00 74283-26 $103.00

74020-26 $13.00 74230 $77.00 74283-TC $95.00

74020-TC $22.00 74230-26 $27.00 74290 $44.00

74022 $44.00 74230-TC $48.00 74290-26 $16.00

74022-26 $16.00 74235 $160.00 74290-TC $28.00

74022-TC $28.00 74235-26 $60.00 74300 $31.00

74150 $274.00 74235-TC $100.00 74300-26 $19.00

74150-26 $60.00 74240 $91.00 74300-TC $104.00

74150-TC $211.00 74240-26 $35.00 74301 $107.00

74160 $322.00 74240-TC $55.00 74301-26 $11.00

74160-26 $65.00 74241 $91.00 74301-TC $104.00

74160-TC $256.00 74241-26 $35.00 74328 $155.00

74170 $390.00 74241-TC $56.00 74328-26 $35.00

74170-26 $71.00 74245 $137.00 74328-TC $120.00

74170-TC $317.00 74245-26 $46.00 74329 $155.00

74174 $502.00 74245-TC $89.00 74329-26 $35.00

74174-26 $112.00 74246 $97.00 74329-TC $120.00

74174-TC $390.00 74246-26 $35.00 74330 $165.00

74175 $418.00 74246-TC $61.00 74330-26 $45.00

74175-26 $98.00 74247 $99.00 74330-TC $120.00

74175-TC $315.00 74247-26 $35.00 74340 $121.00

74176 $219.00 74247-TC $63.00 74340-26 $26.00

74176-26 $89.00 74249 $144.00 74340-TC $95.00

74176-TC $130.00 74249-26 $46.00 74355 $137.00

74177 $327.00 74249-TC $96.00 74355-26 $38.00

74177-26 $93.00 74250 $73.00 74355-TC $99.00

74177-TC $235.00 74250-26 $23.00 74360 $145.00

74178 $381.00 74250-TC $48.00 74360-26 $27.00

74178-26 $102.00 74251 $85.00 74360-TC $118.00

74178-TC $279.00 74251-26 $34.00 74363 $274.00

74181 $498.00 74251-TC $48.00 74363-26 $44.00

74181-26 $85.00 74260 $82.00 74363-TC $230.00

74181-TC $415.00 74260-26 $25.00 74400 $89.00

74182 $587.00 74260-TC $56.00 74400-26 $24.00

74182-26 $88.00 74261 $248.00 74400-TC $63.00





74410 $98.00 74775-TC $55.00 75710-26 $21.00

74410-26 $24.00 75557 $462.00 75710-TC $173.00

74410-TC $72.00 75557-26 $79.00 75716 $293.00

74415 $105.00 75557-TC $344.00 75716-26 $35.00

74415-26 $24.00 75559 $495.00 75716-TC $258.00

74415-TC $79.00 75559-26 $99.00 75726 $530.00

74420 $117.00 75559-TC $344.00 75726-26 $56.00

74420-26 $18.00 75561 $656.00 75726-TC $474.00

74420-TC $97.00 75561-26 $87.00 75731 $530.00

74425 $68.00 75561-TC $525.00 75731-26 $56.00

74425-26 $18.00 75563 $683.00 75731-TC $474.00

74425-TC $50.00 75563-26 $101.00 75733 $540.00

74430 $48.00 75563-TC $526.00 75733-26 $65.00

74430-26 $14.00 75565 $56.00 75733-TC $475.00

74430-TC $34.00 75565-26 $13.00 75736 $530.00

74440 $62.00 75565-TC $44.00 75736-26 $56.00

74440-26 $19.00 75571 $50.00 75736-TC $474.00

74440-TC $43.00 75571-26 $28.00 75741 $540.00

74445 $101.00 75571-TC $22.00 75741-26 $65.00

74445-26 $57.00 75572 $291.00 75741-TC $475.00

74445-TC $44.00 75572-26 $87.00 75743 $253.00

74450 $60.00 75572-TC $204.00 75743-26 $37.00

74450-26 $14.00 75573 $349.00 75743-TC $216.00

74450-TC $46.00 75573-26 $126.00 75746 $530.00

74455 $75.00 75573-TC $222.00 75746-26 $56.00

74455-26 $16.00 75574 $341.00 75746-TC $474.00

74455-TC $59.00 75574-26 $119.00 75756 $183.00

74470 $74.00 75574-TC $222.00 75756-26 $20.00

74470-26 $27.00 75600 $497.00 75756-TC $163.00

74470-TC $47.00 75600-26 $25.00 75774 $80.00

74485 $146.00 75600-TC $472.00 75774-26 $3.00

74485-26 $27.00 75605 $183.00 75774-TC $77.00

74485-TC $119.00 75605-26 $20.00 75801 $245.00

74710 $57.00 75605-TC $163.00 75801-26 $41.00

74710-26 $17.00 75625 $143.00 75801-TC $204.00

74710-TC $39.00 75625-26 $15.00 75803 $264.00

74712 $426.00 75625-TC $128.00 75803-26 $58.00

74712-26 $154.00 75630 $239.00 75803-TC $206.00

74712-TC $273.00 75630-26 $37.00 75805 $271.00

74713 $233.00 75630-TC $202.00 75805-26 $40.00

74713-26 $91.00 75635 $445.00 75805-TC $231.00

74713-TC $142.00 75635-26 $75.00 75807 $289.00

74740 $68.00 75635-TC $370.00 75807-26 $58.00

74740-26 $19.00 75658 $540.00 75807-TC $231.00

74740-TC $49.00 75658-26 $66.00 75809 $54.00

74742 $150.00 75658-TC $474.00 75809-26 $24.00

74742-26 $30.00 75705 $587.00 75809-TC $30.00

74742-TC $120.00 75705-26 $109.00 75810 $530.00

74775 $88.00 75705-TC $478.00 75810-26 $56.00

74775-26 $32.00 75710 $194.00 75810-TC $474.00





75820 $72.00 75893-TC $473.00 76080-26 $27.00

75820-26 $35.00 75894 $972.00 76080-TC $40.00

75820-TC $37.00 75894-26 $65.00 76098 $23.00

75822 $111.00 75894-TC $907.00 76098-26 $8.00

75822-26 $54.00 75898 $124.00 76098-TC $15.00

75822-TC $57.00 75898-26 $84.00 76100 $77.00

75825 $194.00 75898-TC $39.00 76100-26 $30.00

75825-26 $21.00 75901 $98.00 76100-TC $46.00

75825-TC $173.00 75901-26 $23.00 76101 $94.00

75827 $530.00 75901-TC $75.00 76101-26 $36.00

75827-26 $56.00 75902 $93.00 76101-TC $59.00

75827-TC $474.00 75902-26 $19.00 76102 $95.00

75831 $54.00 75902-TC $74.00 76102-26 $30.00

75831-26 $6.00 75952 BR 76102-TC $65.00

75831-TC $48.00 75952-26 $254.00 76120 $157.00

75833 $549.00 75952-TC BR 76120-26 $56.00

75833-26 $74.00 75953 BR 76120-TC $102.00

75833-TC $475.00 75953-26 $98.00 76125 $49.00

75840 $531.00 75953-TC BR 76125-26 $17.00

75840-26 $57.00 75954 BR 76125-TC $33.00

75840-TC $474.00 75954-26 $132.00 76140 $31.00

75842 $549.00 75954-TC BR 76376 $144.00

75842-26 $73.00 75956 BR 76376-26 $11.00

75842-TC $476.00 75956-26 $394.00 76376-TC $133.00

75860 $531.00 75956-TC BR 76377 $185.00

75860-26 $57.00 75957 BR 76377-26 $43.00

75860-TC $474.00 75957-26 $338.00 76377-TC $142.00

75870 $531.00 75957-TC BR 76380 $182.00

75870-26 $57.00 75958 BR 76380-26 $50.00

75870-TC $474.00 75958-26 $225.00 76380-TC $131.00

75872 $530.00 75958-TC BR 76390 $493.00

75872-26 $56.00 75959 BR 76390-26 $71.00

75872-TC $474.00 75959-26 $197.00 76390-TC $419.00

75880 $72.00 75959-TC BR 76496 BR

75880-26 $35.00 75970 $475.00 76496-26 BR

75880-TC $37.00 75970-26 $42.00 76496-TC $79.00

75885 $546.00 75970-TC $433.00 76497 BR

75885-26 $71.00 75984 $110.00 76497-26 BR

75885-TC $475.00 75984-26 $36.00 76497-TC $94.00

75887 $546.00 75984-TC $74.00 76498 BR

75887-26 $71.00 75989 $180.00 76498-26 BR

75887-TC $475.00 75989-26 $59.00 76498-TC $280.00

75889 $530.00 75989-TC $121.00 76499 BR

75889-26 $56.00 76000 $58.00 76499-26 BR

75889-TC $474.00 76000-26 $8.00 76499-TC BR

75891 $530.00 76000-TC $48.00 76506 $88.00

75891-26 $56.00 76001 $134.00 76506-26 $33.00

75891-TC $474.00 76001-26 $34.00 76506-TC $53.00

75893 $499.00 76001-TC $97.00 76510 $171.00

75893-26 $26.00 76080 $67.00 76510-26 $86.00





76510-TC $85.00 76776-26 $36.00 76825 $160.00

76511 $96.00 76776-TC $88.00 76825-26 $65.00

76511-26 $48.00 76800 $112.00 76825-TC $73.00

76511-TC $48.00 76800-26 $61.00 76826 $71.00

76512 $96.00 76800-TC $54.00 76826-26 $46.00

76512-26 $36.00 76801 $93.00 76826-TC $27.00

76512-TC $60.00 76801-26 $51.00 76827 $97.00

76513 $96.00 76801-TC $42.00 76827-26 $35.00

76513-26 $36.00 76802 $73.00 76827-TC $65.00

76513-TC $60.00 76802-26 $43.00 76828 $72.00

76514 $12.00 76802-TC $30.00 76828-26 $29.00

76514-26 $10.00 76805 $131.00 76828-TC $42.00

76514-TC $3.00 76805-26 $51.00 76830 $93.00

76516 $99.00 76805-TC $79.00 76830-26 $35.00

76516-26 $37.00 76810 $252.00 76830-TC $57.00

76516-TC $63.00 76810-26 $100.00 76831 $95.00

76519 $88.00 76810-TC $151.00 76831-26 $37.00

76519-26 $31.00 76811 $243.00 76831-TC $57.00

76519-TC $53.00 76811-26 $100.00 76856 $93.00

76529 $86.00 76811-TC $142.00 76856-26 $35.00

76529-26 $31.00 76812 $145.00 76856-TC $57.00

76529-TC $53.00 76812-26 $94.00 76857 $59.00

76536 $83.00 76812-TC $51.00 76857-26 $19.00

76536-26 $31.00 76813 $125.00 76857-TC $39.00

76536-TC $54.00 76813-26 $55.00 76870 $90.00

76604 $78.00 76813-TC $71.00 76870-26 $33.00

76604-26 $28.00 76814 $83.00 76870-TC $57.00

76604-TC $48.00 76814-26 $46.00 76872 $93.00

76641 $109.00 76814-TC $37.00 76872-26 $36.00

76641-26 $37.00 76815 $88.00 76872-TC $57.00

76641-TC $72.00 76815-26 $33.00 76873 $151.00

76642 $90.00 76815-TC $53.00 76873-26 $68.00

76642-26 $35.00 76816 $72.00 76873-TC $80.00

76642-TC $55.00 76816-26 $30.00 76881 $120.00

76700 $116.00 76816-TC $41.00 76881-26 $32.00

76700-26 $42.00 76817 $96.00 76881-TC $88.00

76700-TC $73.00 76817-26 $39.00 76882 $36.00

76705 $84.00 76817-TC $57.00 76882-26 $25.00

76705-26 $30.00 76818 $105.00 76882-TC $11.00

76705-TC $53.00 76818-26 $40.00 76930 $93.00

76706 $95.00 76818-TC $60.00 76930-26 $34.00

76706-26 $28.00 76819 $101.00 76930-TC $59.00

76706-TC $67.00 76819-26 $40.00 76932 $93.00

76770 $112.00 76819-TC $60.00 76932-26 $34.00

76770-26 $38.00 76820 $93.00 76932-TC $59.00

76770-TC $73.00 76820-26 $27.00 76936 $341.00

76775 $84.00 76820-TC $66.00 76936-26 $102.00

76775-26 $30.00 76821 $103.00 76936-TC $236.00

76775-TC $53.00 76821-26 $38.00 76937 $34.00

76776 $124.00 76821-TC $66.00 76937-26 $17.00





76937-TC $18.00 77012-26 $55.00 77081 $40.00

76940 $171.00 77012-TC $251.00 77081-26 $11.00

76940-26 $104.00 77013-26 $191.00 77081-TC $29.00

76940-TC $68.00 77013-TC $297.00 77084 $356.00

76941 $128.00 77014 $135.00 77084-26 $77.00

76941-26 $69.00 77014-26 $41.00 77084-TC $280.00

76941-TC $59.00 77014-TC $94.00 77085 $57.00

76942 $92.00 77021 $353.00 77085-26 $16.00

76942-26 $24.00 77021-26 $73.00 77085-TC $41.00

76942-TC $68.00 77021-TC $280.00 77086 $36.00

76945 $93.00 77022 BR 77086-26 $9.00

76945-26 $34.00 77022-26 $204.00 77086-TC $27.00

76945-TC $59.00 77022-TC $280.00 77261 $73.00

76946 $78.00 77053 $102.00 77262 $110.00

76946-26 $19.00 77053-26 $17.00 77263 $163.00

76946-TC $59.00 77053-TC $85.00 77280 $166.00

76948 $77.00 77054 $126.00 77280-26 $36.00

76948-26 $19.00 77054-26 $22.00 77280-TC $130.00

76948-TC $58.00 77054-TC $104.00 77285 $264.00

76965 $281.00 77058 $804.00 77285-26 $53.00

76965-26 $84.00 77058-26 $78.00 77285-TC $209.00

76965-TC $208.00 77058-TC $726.00 77290 $325.00

76970 $60.00 77059 $994.00 77290-26 $79.00

76970-26 $20.00 77059-26 $78.00 77290-TC $243.00

76970-TC $39.00 77059-TC $917.00 77293 $432.00

76975 $99.00 77063 $56.00 77293-26 $104.00

76975-26 $41.00 77063-26 $30.00 77293-TC $328.00

76975-TC $58.00 77063-TC $25.00 77295 $1,287.00

76977 $34.00 77071 $29.00 77295-26 $232.00

76977-26 $3.00 77072 $22.00 77295-TC $1,046.00

76977-TC $31.00 77072-26 $9.00 77299 BR

76998 BR 77072-TC $14.00 77299-26 BR

76998-26 $61.00 77073 $42.00 77299-TC BR

76998-TC $96.00 77073-26 $13.00 77300 $87.00

76999 BR 77073-TC $29.00 77300-26 $36.00

76999-26 BR 77074 $64.00 77300-TC $52.00

76999-TC BR 77074-26 $22.00 77301 $1,473.00

77001 $83.00 77074-TC $42.00 77301-26 $415.00

77001-26 $18.00 77075 $89.00 77301-TC $1,046.00

77001-TC $64.00 77075-26 $26.00 77306 $151.00

77002 $75.00 77075-TC $63.00 77306-26 $73.00

77002-26 $25.00 77077 $54.00 77306-TC $78.00

77002-TC $50.00 77077-26 $15.00 77307 $292.00

77003 $73.00 77077-TC $39.00 77307-26 $151.00

77003-26 $27.00 77078 $84.00 77307-TC $140.00

77003-TC $45.00 77078-26 $12.00 77316 $191.00

77011 $309.00 77078-TC $72.00 77316-26 $73.00

77011-26 $58.00 77080 $83.00 77316-TC $117.00

77011-TC $251.00 77080-26 $11.00 77317 $248.00

77012 $306.00 77080-TC $72.00 77317-26 $96.00





77317-TC $153.00 77523 BR 77790 $72.00

77318 $358.00 77525 BR 77790-26 $53.00

77318-26 $151.00 77600 $196.00 77790-TC $18.00

77318-TC $207.00 77600-26 $80.00 77799 BR

77321 $200.00 77600-TC $113.00 77799-26 BR

77321-26 $48.00 77605 $263.00 77799-TC BR

77321-TC $150.00 77605-26 $108.00 78012 $78.00

77331 $64.00 77605-TC $151.00 78012-26 $9.00

77331-26 $45.00 77610 $195.00 78012-TC $69.00

77331-TC $18.00 77610-26 $79.00 78013 $198.00

77332 $78.00 77610-TC $113.00 78013-26 $18.00

77332-26 $27.00 77615 $262.00 78013-TC $179.00

77332-TC $50.00 77615-26 $106.00 78014 $240.00

77333 $115.00 77615-TC $151.00 78014-26 $25.00

77333-26 $43.00 77620 $196.00 78014-TC $215.00

77333-TC $70.00 77620-26 $80.00 78015 $132.00

77334 $187.00 77620-TC $113.00 78015-26 $34.00

77334-26 $63.00 77750 $299.00 78015-TC $96.00

77334-TC $121.00 77750-26 $248.00 78016 $173.00

77336 $111.00 77750-TC $49.00 78016-26 $42.00

77338 $502.00 77761 $284.00 78016-TC $130.00

77338-26 $223.00 77761-26 $188.00 78018 $248.00

77338-TC $279.00 77761-TC $93.00 78018-26 $44.00

77370 $130.00 77762 $427.00 78018-TC $202.00

77371 $1,151.00 77762-26 $289.00 78020 $35.00

77372 $874.00 77762-TC $135.00 78020-26 $30.00

77373 $1,630.00 77763 $605.00 78020-TC $5.00

77399 BR 77763-26 $435.00 78070 $112.00

77399-26 BR 77763-TC $167.00 78070-26 $36.00

77399-TC BR 77767 $227.00 78070-TC $68.00

77401 $66.00 77767-26 $55.00 78071 $357.00

77402 $66.00 77767-TC $172.00 78071-26 $59.00

77407 $78.00 77768 $356.00 78071-TC $298.00

77412 $87.00 77768-26 $73.00 78072 $446.00

77417 $21.00 77768-TC $283.00 78072-26 $80.00

77422 $70.00 77770 $324.00 78072-TC $366.00

77423 $91.00 77770-26 $102.00 78075 $242.00

77427 $166.00 77770-TC $222.00 78075-26 $38.00

77431 $95.00 77771 $604.00 78075-TC $202.00

77432 $417.00 77771-26 $199.00 78099 BR

77435 $644.00 77771-TC $405.00 78099-26 BR

77469 $313.00 77772 $922.00 78099-TC BR

77470 $527.00 77772-26 $282.00 78102 $106.00

77470-26 $106.00 77772-TC $640.00 78102-26 $28.00

77470-TC $417.00 77778 $764.00 78102-TC $77.00

77499 BR 77778-26 $568.00 78103 $158.00

77499-26 BR 77778-TC $192.00 78103-26 $39.00

77499-TC BR 77789 $74.00 78103-TC $118.00

77520 BR 77789-26 $57.00 78104 $194.00

77522 BR 77789-TC $16.00 78104-26 $41.00





78104-TC $152.00 78206-26 $46.00 78272-26 $14.00

78110 $45.00 78206-TC $214.00 78272-TC $87.00

78110-26 $9.00 78215 $135.00 78278 $234.00

78110-TC $35.00 78215-26 $24.00 78278-26 $50.00

78111 $108.00 78215-TC $109.00 78278-TC $182.00

78111-26 $11.00 78216 $160.00 78282 $230.00

78111-TC $96.00 78216-26 $29.00 78282-26 $19.00

78120 $78.00 78216-TC $130.00 78282-TC $224.00

78120-26 $11.00 78226 $339.00 78290 $149.00

78120-TC $65.00 78226-26 $37.00 78290-26 $35.00

78121 $125.00 78226-TC $301.00 78290-TC $113.00

78121-26 $16.00 78227 $418.00 78291 $161.00

78121-TC $108.00 78227-26 $45.00 78291-26 $45.00

78122 $196.00 78227-TC $373.00 78291-TC $114.00

78122-26 $22.00 78230 $106.00 78299 BR

78122-TC $171.00 78230-26 $23.00 78299-26 BR

78130 $139.00 78230-TC $82.00 78299-TC BR

78130-26 $32.00 78231 $146.00 78300 $125.00

78130-TC $106.00 78231-26 $27.00 78300-26 $32.00

78135 $216.00 78231-TC $118.00 78300-TC $93.00

78135-26 $33.00 78232 $157.00 78305 $181.00

78135-TC $182.00 78232-26 $23.00 78305-26 $42.00

78140 $179.00 78232-TC $132.00 78305-TC $137.00

78140-26 $31.00 78258 $146.00 78306 $205.00

78140-TC $147.00 78258-26 $38.00 78306-26 $44.00

78185 $110.00 78258-TC $108.00 78306-TC $159.00

78185-26 $20.00 78261 $190.00 78315 $233.00

78185-TC $88.00 78261-26 $36.00 78315-26 $52.00

78190 $272.00 78261-TC $152.00 78315-TC $179.00

78190-26 $57.00 78262 $195.00 78320 $276.00

78190-TC $214.00 78262-26 $35.00 78320-26 $53.00

78191 $307.00 78262-TC $159.00 78320-TC $220.00

78191-26 $31.00 78264 $195.00 78350 $40.00

78191-TC $274.00 78264-26 $40.00 78350-26 $11.00

78195 $216.00 78264-TC $154.00 78350-TC $29.00

78195-26 $49.00 78265 $381.00 78351 $23.00

78195-TC $152.00 78265-26 $49.00 78399 BR

78199 BR 78265-TC $332.00 78399-26 BR

78199-26 BR 78266 $494.00 78399-TC BR

78199-TC BR 78266-26 $54.00 78414 BR

78201 $112.00 78266-TC $440.00 78414-26 $23.00

78201-26 $22.00 78267 BR 78414-TC BR

78201-TC $88.00 78268 BR 78428 $126.00

78202 $135.00 78270 $68.00 78428-26 $41.00

78202-26 $26.00 78270-26 $10.00 78428-TC $84.00

78202-TC $108.00 78270-TC $58.00 78445 $97.00

78205 $259.00 78271 $72.00 78445-26 $28.00

78205-26 $36.00 78271-26 $10.00 78445-TC $69.00

78205-TC $220.00 78271-TC $61.00 78451 $351.00

78206 $265.00 78272 $100.00 78451-26 $68.00





78451-TC $283.00 78494-26 $59.00 78630 $223.00

78452 $486.00 78494-TC $262.00 78630-26 $35.00

78452-26 $80.00 78496 $92.00 78630-TC $188.00

78452-TC $407.00 78496-26 $24.00 78635 $129.00

78453 $313.00 78496-TC $66.00 78635-26 $32.00

78453-26 $51.00 78499 BR 78635-TC $95.00

78453-TC $263.00 78499-26 BR 78645 $158.00

78454 $446.00 78499-TC BR 78645-26 $29.00

78454-26 $67.00 78579 $191.00 78645-TC $128.00

78454-TC $379.00 78579-26 $24.00 78647 $268.00

78456 $205.00 78579-TC $166.00 78647-26 $46.00

78456-26 $49.00 78580 $167.00 78647-TC $220.00

78456-TC $151.00 78580-26 $38.00 78650 $206.00

78457 $140.00 78580-TC $128.00 78650-26 $31.00

78457-26 $39.00 78582 $343.00 78650-TC $173.00

78457-TC $99.00 78582-26 $53.00 78660 $107.00

78458 $198.00 78582-TC $289.00 78660-26 $27.00

78458-26 $46.00 78597 $206.00 78660-TC $79.00

78458-TC $149.00 78597-26 $36.00 78699 BR

78459 $755.00 78597-TC $171.00 78699-26 BR

78459-26 $100.00 78598 $314.00 78699-TC BR

78459-TC $731.00 78598-26 $42.00 78700 $137.00

78466 $135.00 78598-TC $272.00 78700-26 $22.00

78466-26 $36.00 78599 BR 78700-TC $113.00

78466-TC $97.00 78599-26 BR 78701 $158.00

78468 $180.00 78599-TC BR 78701-26 $24.00

78468-26 $41.00 78600 $131.00 78701-TC $133.00

78468-TC $137.00 78600-26 $22.00 78707 $217.00

78469 $244.00 78600-TC $108.00 78707-26 $49.00

78469-26 $47.00 78601 $154.00 78707-TC $166.00

78469-TC $195.00 78601-26 $26.00 78708 $231.00

78472 $259.00 78601-TC $126.00 78708-26 $61.00

78472-26 $50.00 78605 $155.00 78708-TC $166.00

78472-TC $206.00 78605-26 $27.00 78709 $241.00

78473 $387.00 78605-TC $126.00 78709-26 $68.00

78473-26 $75.00 78606 $221.00 78709-TC $166.00

78473-TC $308.00 78606-26 $45.00 78710 $256.00

78481 $248.00 78606-TC $177.00 78710-26 $34.00

78481-26 $51.00 78607 $311.00 78710-TC $220.00

78481-TC $195.00 78607-26 $64.00 78725 $87.00

78483 $373.00 78607-TC $245.00 78725-26 $19.00

78483-26 $77.00 78608 $876.00 78725-TC $66.00

78483-TC $294.00 78608-26 $78.00 78730 $73.00

78491 $756.00 78608-TC $855.00 78730-26 $18.00

78491-26 $85.00 78609 $51.00 78730-TC $55.00

78491-TC $731.00 78609-26 $78.00 78740 $109.00

78492 $764.00 78609-TC BR 78740-26 $29.00

78492-26 $100.00 78610 $74.00 78740-TC $79.00

78492-TC $731.00 78610-26 $15.00 78761 $157.00

78494 $324.00 78610-TC $59.00 78761-26 $36.00





78761-TC $119.00 79005 $199.00 G6001-TC $22.00

78799 BR 79005-26 $94.00 G6002 $76.00

78799-26 BR 79005-TC $105.00 G6002-26 $20.00

78799-TC BR 79101 $207.00 G6002-TC $55.00

78800 $162.00 79101-26 $103.00 G6003 $188.00

78800-26 $34.00 79101-TC $105.00 G6004 $146.00

78800-TC $126.00 79200 $203.00 G6005 $145.00

78801 $199.00 79200-26 $102.00 G6006 $145.00

78801-26 $40.00 79200-TC $97.00 G6007 $303.00

78801-TC $158.00 79300 BR G6008 $202.00

78802 $252.00 79300-26 $83.00 G6009 $199.00

78802-26 $44.00 79300-TC BR G6010 $199.00

78802-TC $207.00 79403 $287.00 G6011 $324.00

78803 $303.00 79403-26 $121.00 G6012 $266.00

78803-26 $56.00 79403-TC $165.00 G6013 $266.00

78803-TC $245.00 79440 $204.00 G6014 $266.00

78804 $227.00 79440-26 $104.00 G6015 $347.00

78804-26 $55.00 79440-TC $97.00 G6016 $346.00

78804-TC $171.00 79445 $232.00 Q0092 $14.00

78805 $166.00 79445-26 $127.00

78805-26 $38.00 79445-TC $105.00

78805-TC $126.00 79999 BR

78806 $286.00 79999-26 BR

78806-26 $44.00 79999-TC BR

78806-TC $241.00 G0130 $34.00

78807 $303.00 G0130-26 $10.00

78807-26 $57.00 G0130-TC $24.00

78807-TC $245.00 G0202 $120.00

78808 $47.00 G0202-26 $32.00

78811 $879.00 G0202-TC $88.00

78811-26 $83.00 G0204 $136.00

78811-TC $855.00 G0204-26 $40.00

78812 $884.00 G0204-TC $96.00

78812-26 $102.00 G0206 $109.00

78812-TC $855.00 G0206-26 $32.00

78813 $885.00 G0206-TC $77.00

78813-26 $106.00 G0252-26 $78.00

78813-TC $855.00 G0278 $13.00

78814 $982.00 G0279 $56.00

78814-26 $116.00 G0279-26 $30.00

78814-TC $950.00 G0279-TC $25.00

78815 $985.00 G0288 $201.00

78815-26 $128.00 G0297 $255.00

78815-TC $950.00 G0297-26 $52.00

78816 $986.00 G0297-TC $203.00

78816-26 $132.00 G0365 $164.00

78816-TC $950.00 G0365-26 $12.00

78999 BR G0365-TC $152.00

78999-26 BR G6001 $52.00

78999-TC BR G6001-26 $30.00



Pathology & Laboratory Pathology & Laboratory Pathology & Laboratory


80048 $23.00 80170-TC $11.00 80400-26 $18.00

80048-26 $4.00 80173 $33.00 80400-TC $36.00

80048-TC $19.00 80173-26 $11.00 80402 $138.00

80050 $45.00 80173-TC $22.00 80402-26 $42.00

80050-26 $18.00 80176 $35.00 80402-TC $95.00

80050-TC $26.00 80176-26 $11.00 80406 $138.00

80051 $16.00 80176-TC $23.00 80406-26 $42.00

80051-26 $6.00 80178 $17.00 80406-TC $95.00

80051-TC $10.00 80178-26 $6.00 80408 $213.00

80053 $29.00 80178-TC $11.00 80408-26 $77.00

80053-26 $8.00 80184 $34.00 80408-TC $136.00

80053-TC $21.00 80184-26 $10.00 80410 $166.00

80055 $67.00 80184-TC $23.00 80410-26 $54.00

80055-26 $21.00 80185 $36.00 80410-TC $110.00

80055-TC $43.00 80185-26 $10.00 80412 $533.00

80061 $31.00 80185-TC $25.00 80412-26 $176.00

80061-26 $11.00 80186 $38.00 80412-TC $355.00

80061-TC $19.00 80186-26 $11.00 80414 $88.00

80069 $26.00 80186-TC $26.00 80414-26 $26.00

80069-26 $6.00 80188 $35.00 80414-TC $59.00

80069-TC $20.00 80188-26 $11.00 80415 $93.00

80074 $107.00 80188-TC $23.00 80415-26 $28.00

80074-26 $43.00 80190 $41.00 80415-TC $64.00

80074-TC $64.00 80190-26 $13.00 80416 $256.00

80076 $18.00 80190-TC $28.00 80416-26 $88.00

80076-26 $7.00 80192 $44.00 80416-TC $166.00

80076-TC $11.00 80192-26 $17.00 80417 $256.00

80150 $40.00 80192-TC $26.00 80417-26 $88.00

80150-26 $13.00 80194 $33.00 80417-TC $166.00

80150-TC $26.00 80194-26 $10.00 80418 $934.00

80156 $35.00 80194-TC $22.00 80418-26 $266.00

80156-26 $11.00 80197 $34.00 80418-TC $666.00

80156-TC $23.00 80197-26 $11.00 80420 $107.00

80157 $22.00 80197-TC $22.00 80420-26 $33.00

80157-26 $8.00 80198 $20.00 80420-TC $74.00

80157-TC $14.00 80198-26 $5.00 80422 $62.00

80158 $35.00 80198-TC $15.00 80422-26 $18.00

80158-26 $12.00 80200 $24.00 80422-TC $43.00

80158-TC $22.00 80200-26 $7.00 80424 $94.00

80162 $13.00 80200-TC $16.00 80424-26 $26.00

80162-26 $3.00 80201 $33.00 80424-TC $67.00

80162-TC $9.00 80201-26 $11.00 80426 $232.00

80164 $43.00 80201-TC $21.00 80426-26 $54.00

80164-26 $14.00 80202 $42.00 80426-TC $176.00

80164-TC $29.00 80202-26 $14.00 80428 $93.00

80168 $43.00 80202-TC $28.00 80428-26 $19.00

80168-26 $17.00 80299 BR 80428-TC $73.00

80168-TC $25.00 80299-26 BR 80430 $99.00

80170 $18.00 80299-TC BR 80430-26 $24.00

80170-26 $6.00 80400 $54.00 80430-TC $74.00





80432 $243.00 81025-TC $4.00 82105-26 $8.00

80432-26 $56.00 81050 $33.00 82105-TC $18.00

80432-TC $186.00 81050-26 $11.00 82106 $26.00

80434 $161.00 81050-TC $21.00 82106-26 $8.00

80434-26 $49.00 81099 BR 82106-TC $18.00

80434-TC $110.00 81099-26 BR 82108 $45.00

80435 $166.00 81099-TC BR 82108-26 $14.00

80435-26 $49.00 82009 $10.00 82108-TC $32.00

80435-TC $115.00 82009-26 $3.00 82120 $9.00

80436 $119.00 82009-TC $6.00 82120-26 $3.00

80436-26 $35.00 82010 $22.00 82120-TC $5.00

80436-TC $85.00 82010-26 $7.00 82127 $33.00

80438 $82.00 82010-TC $15.00 82127-26 $11.00

80438-26 $24.00 82013 $24.00 82127-TC $22.00

80438-TC $56.00 82013-26 $7.00 82128 $26.00

80439 $176.00 82013-TC $17.00 82128-26 $6.00

80439-26 $33.00 82024 $26.00 82128-TC $19.00

80439-TC $144.00 82024-26 $7.00 82131 $57.00

80500 $34.00 82024-TC $18.00 82131-26 $13.00

80500-26 $34.00 82030 $43.00 82131-TC $44.00

80500-TC BR 82030-26 $17.00 82135 $41.00

80502 $72.00 82030-TC $25.00 82135-26 $13.00

80502-26 $72.00 82040 $11.00 82135-TC $28.00

80502-TC BR 82040-26 $3.00 82136 $38.00

81000 $7.00 82040-TC $7.00 82136-26 $14.00

81000-26 $3.00 82042 $12.00 82136-TC $23.00

81000-TC $4.00 82042-26 $3.00 82139 $38.00

81001 $7.00 82042-TC $8.00 82139-26 $14.00

81001-26 $3.00 82043 $14.00 82139-TC $23.00

81001-TC $4.00 82043-26 $4.00 82140 $40.00

81002 $5.00 82043-TC $10.00 82140-26 $12.00

81002-26 $3.00 82044 $12.00 82140-TC $28.00

81002-TC $3.00 82044-26 $4.00 82143 $28.00

81003 $5.00 82044-TC $9.00 82143-26 $8.00

81003-26 $2.00 82075 $32.00 82143-TC $19.00

81003-TC $3.00 82075-26 $10.00 82150 $16.00

81005 $3.00 82075-TC $21.00 82150-26 $5.00

81005-26 $1.00 82085 $24.00 82150-TC $11.00

81005-TC $3.00 82085-26 $7.00 82154 $34.00

81007 $5.00 82085-TC $17.00 82154-26 $13.00

81007-26 $2.00 82088 $91.00 82154-TC $20.00

81007-TC $4.00 82088-26 $28.00 82157 $57.00

81015 $5.00 82088-TC $62.00 82157-26 $17.00

81015-26 $3.00 82103 $21.00 82157-TC $40.00

81015-TC $3.00 82103-26 $7.00 82160 $67.00

81020 $8.00 82103-TC $14.00 82160-26 $21.00

81020-26 $3.00 82104 $22.00 82160-TC $43.00

81020-TC $5.00 82104-26 $7.00 82163 $42.00

81025 $7.00 82104-TC $15.00 82163-26 $12.00

81025-26 $4.00 82105 $26.00 82163-TC $31.00





82164 $32.00 82306-TC $52.00 82382-26 $12.00

82164-26 $10.00 82308 $62.00 82382-TC $25.00

82164-TC $21.00 82308-26 $18.00 82383 $62.00

82172 $33.00 82308-TC $43.00 82383-26 $18.00

82172-26 $10.00 82310 $11.00 82383-TC $43.00

82172-TC $22.00 82310-26 $3.00 82384 $62.00

82175 $48.00 82310-TC $7.00 82384-26 $18.00

82175-26 $15.00 82330 $37.00 82384-TC $43.00

82175-TC $33.00 82330-26 $11.00 82387 $34.00

82180 $25.00 82330-TC $25.00 82387-26 $10.00

82180-26 $8.00 82331 $14.00 82387-TC $23.00

82180-TC $17.00 82331-26 $4.00 82390 $24.00

82190 $24.00 82331-TC $10.00 82390-26 $7.00

82190-26 $8.00 82340 $13.00 82390-TC $17.00

82190-TC $16.00 82340-26 $4.00 82397 $22.00

82232 $43.00 82340-TC $8.00 82397-26 $7.00

82232-26 $14.00 82355 $31.00 82397-TC $15.00

82232-TC $29.00 82355-26 $10.00 82415 $28.00

82239 $23.00 82355-TC $20.00 82415-26 $8.00

82239-26 $8.00 82360 $31.00 82415-TC $19.00

82239-TC $15.00 82360-26 $10.00 82435 $8.00

82240 $49.00 82360-TC $20.00 82435-26 $2.00

82240-26 $15.00 82365 $31.00 82435-TC $6.00

82240-TC $34.00 82365-26 $8.00 82436 $14.00

82247 $10.00 82365-TC $21.00 82436-26 $4.00

82247-26 $3.00 82370 $22.00 82436-TC $10.00

82247-TC $7.00 82370-26 $7.00 82438 $13.00

82248 $10.00 82370-TC $15.00 82438-26 $4.00

82248-26 $3.00 82373 $16.00 82438-TC $8.00

82248-TC $7.00 82373-26 $5.00 82441 $16.00

82252 $11.00 82373-TC $11.00 82441-26 $5.00

82252-26 $3.00 82374 $10.00 82441-TC $11.00

82252-TC $7.00 82374-26 $3.00 82465 $8.00

82261 $38.00 82374-TC $6.00 82465-26 $2.00

82261-26 $13.00 82375 $26.00 82465-TC $6.00

82261-TC $24.00 82375-26 $7.00 82480 $23.00

82270 $5.00 82375-TC $18.00 82480-26 $6.00

82270-26 $2.00 82376 $11.00 82480-TC $17.00

82270-TC $3.00 82376-26 $3.00 82482 $23.00

82274 BR 82376-TC $7.00 82482-26 $7.00

82274-26 BR 82378 $31.00 82482-TC $15.00

82274-TC BR 82378-26 $8.00 82485 $37.00

82286 $12.00 82378-TC $21.00 82485-26 $8.00

82286-26 $3.00 82379 $38.00 82485-TC $28.00

82286-TC $8.00 82379-26 $13.00 82495 $48.00

82300 $48.00 82379-TC $24.00 82495-26 $16.00

82300-26 $15.00 82380 $21.00 82495-TC $32.00

82300-TC $33.00 82380-26 $6.00 82507 $55.00

82306 $79.00 82380-TC $15.00 82507-26 $16.00

82306-26 $25.00 82382 $38.00 82507-TC $39.00





82523 $43.00 82600-TC $28.00 82677-26 $17.00

82523-26 $17.00 82607 $38.00 82677-TC $35.00

82523-TC $25.00 82607-26 $10.00 82679 $70.00

82525 $34.00 82607-TC $27.00 82679-26 $20.00

82525-26 $10.00 82608 $40.00 82679-TC $48.00

82525-TC $23.00 82608-26 $13.00 82693 $23.00

82528 $40.00 82608-TC $26.00 82693-26 $7.00

82528-26 $13.00 82615 $17.00 82693-TC $16.00

82528-TC $26.00 82615-26 $5.00 82696 $57.00

82530 $38.00 82615-TC $12.00 82696-26 $19.00

82530-26 $12.00 82626 $59.00 82696-TC $38.00

82530-TC $25.00 82626-26 $19.00 82705 $14.00

82533 $35.00 82626-TC $40.00 82705-26 $6.00

82533-26 $10.00 82627 $37.00 82705-TC $9.00

82533-TC $24.00 82627-26 $12.00 82710 $42.00

82540 $10.00 82627-TC $24.00 82710-26 $13.00

82540-26 $3.00 82633 $81.00 82710-TC $29.00

82540-TC $6.00 82633-26 $23.00 82715 $33.00

82542 $42.00 82633-TC $56.00 82715-26 $11.00

82542-26 $13.00 82634 $81.00 82715-TC $21.00

82542-TC $28.00 82634-26 $23.00 82725 $28.00

82550 $16.00 82634-TC $56.00 82725-26 $8.00

82550-26 $4.00 82638 $23.00 82725-TC $19.00

82550-TC $12.00 82638-26 $7.00 82726 $42.00

82552 $33.00 82638-TC $16.00 82726-26 $13.00

82552-26 $10.00 82652 $89.00 82726-TC $28.00

82552-TC $22.00 82652-26 $25.00 82728 $24.00

82553 $16.00 82652-TC $62.00 82728-26 $7.00

82553-26 $5.00 82657 $42.00 82728-TC $17.00

82553-TC $11.00 82657-26 $13.00 82735 $36.00

82554 $19.00 82657-TC $28.00 82735-26 $12.00

82554-26 $6.00 82658 $42.00 82735-TC $23.00

82554-TC $13.00 82658-26 $13.00 82746 $39.00

82565 $13.00 82658-TC $28.00 82746-26 $13.00

82565-26 $2.00 82664 $40.00 82746-TC $25.00

82565-TC $11.00 82664-26 $13.00 82747 $29.00

82570 $10.00 82664-TC $26.00 82747-26 $10.00

82570-26 $2.00 82668 $45.00 82747-TC $19.00

82570-TC $7.00 82668-26 $14.00 82757 $36.00

82575 $25.00 82668-TC $32.00 82757-26 $11.00

82575-26 $8.00 82670 $61.00 82757-TC $24.00

82575-TC $17.00 82670-26 $18.00 82759 $38.00

82585 $15.00 82670-TC $42.00 82759-26 $12.00

82585-26 $3.00 82671 $61.00 82759-TC $25.00

82585-TC $12.00 82671-26 $17.00 82760 $26.00

82595 $31.00 82671-TC $43.00 82760-26 $8.00

82595-26 $10.00 82672 $57.00 82760-TC $18.00

82595-TC $21.00 82672-26 $16.00 82775 $47.00

82600 $40.00 82672-TC $41.00 82775-26 $14.00

82600-26 $12.00 82677 $52.00 82775-TC $33.00





82776 $14.00 82950-TC $7.00 83013-26 $38.00

82776-26 $3.00 82951 $22.00 83013-TC $94.00

82776-TC $11.00 82951-26 $7.00 83014 $19.00

82784 $15.00 82951-TC $15.00 83014-26 $6.00

82784-26 $5.00 82952 $11.00 83014-TC $13.00

82784-TC $11.00 82952-26 $3.00 83015 $51.00

82785 $33.00 82952-TC $7.00 83015-26 $15.00

82785-26 $11.00 82955 $25.00 83015-TC $36.00

82785-TC $21.00 82955-26 $7.00 83018 $56.00

82787 $54.00 82955-TC $18.00 83018-26 $16.00

82787-26 $17.00 82960 $14.00 83018-TC $40.00

82787-TC $37.00 82960-26 $4.00 83020 $24.00

82800 $22.00 82960-TC $10.00 83020-26 $6.00

82800-26 $6.00 82962 $5.00 83020-TC $18.00

82800-TC $16.00 82962-26 $1.00 83021 $39.00

82803 $53.00 82962-TC $4.00 83021-26 $13.00

82803-26 $16.00 82963 $54.00 83021-TC $25.00

82803-TC $37.00 82963-26 $17.00 83026 $8.00

82805 $36.00 82963-TC $37.00 83026-26 $5.00

82805-26 $10.00 82965 $16.00 83026-TC $3.00

82805-TC $24.00 82965-26 $5.00 83030 $18.00

82810 $28.00 82965-TC $11.00 83030-26 $6.00

82810-26 $8.00 82977 $16.00 83030-TC $12.00

82810-TC $19.00 82977-26 $4.00 83033 $15.00

82820 $16.00 82977-TC $12.00 83033-26 $4.00

82820-26 $5.00 82978 $25.00 83033-TC $11.00

82820-TC $11.00 82978-26 $7.00 83036 $15.00

82938 $48.00 82978-TC $18.00 83036-26 $5.00

82938-26 $16.00 82979 $18.00 83036-TC $10.00

82938-TC $32.00 82979-26 $5.00 83045 $13.00

82941 $47.00 82979-TC $13.00 83045-26 $4.00

82941-26 $15.00 82985 $41.00 83045-TC $8.00

82941-TC $32.00 82985-26 $12.00 83050 $16.00

82943 $38.00 82985-TC $29.00 83050-26 $5.00

82943-26 $12.00 83001 $40.00 83050-TC $11.00

82943-TC $25.00 83001-26 $12.00 83051 $16.00

82945 $9.00 83001-TC $28.00 83051-26 $5.00

82945-26 $3.00 83002 $42.00 83051-TC $11.00

82945-TC $5.00 83002-26 $13.00 83060 $22.00

82946 $29.00 83002-TC $29.00 83060-26 $6.00

82946-26 $7.00 83003 $36.00 83060-TC $16.00

82946-TC $21.00 83003-26 $10.00 83065 $18.00

82947 $11.00 83003-TC $25.00 83065-26 $6.00

82947-26 $3.00 83010 $26.00 83065-TC $12.00

82947-TC $7.00 83010-26 $8.00 83068 $20.00

82948 $5.00 83010-TC $18.00 83068-26 $5.00

82948-26 $3.00 83012 $36.00 83068-TC $15.00

82948-TC $3.00 83012-26 $14.00 83069 $11.00

82950 $12.00 83012-TC $21.00 83069-26 $3.00

82950-26 $4.00 83013 $133.00 83069-TC $7.00





83070 $13.00 83527-TC $23.00 83721-26 $5.00

83070-26 $4.00 83528 $43.00 83721-TC $11.00

83070-TC $8.00 83528-26 $14.00 83727 $43.00

83080 $38.00 83528-TC $29.00 83727-26 $14.00

83080-26 $11.00 83540 $16.00 83727-TC $29.00

83080-TC $26.00 83540-26 $3.00 83735 $15.00

83088 $59.00 83540-TC $13.00 83735-26 $5.00

83088-26 $18.00 83550 $20.00 83735-TC $10.00

83088-TC $41.00 83550-26 $5.00 83775 $17.00

83090 $38.00 83550-TC $15.00 83775-26 $5.00

83090-26 $13.00 83570 $23.00 83775-TC $12.00

83090-TC $25.00 83570-26 $7.00 83785 $58.00

83150 $49.00 83570-TC $16.00 83785-26 $17.00

83150-26 $16.00 83582 $34.00 83785-TC $41.00

83150-TC $33.00 83582-26 $8.00 83789 $39.00

83491 $37.00 83582-TC $24.00 83789-26 $13.00

83491-26 $11.00 83586 $38.00 83789-TC $25.00

83491-TC $25.00 83586-26 $13.00 83825 $34.00

83497 $35.00 83586-TC $24.00 83825-26 $11.00

83497-26 $11.00 83593 $59.00 83825-TC $22.00

83497-TC $23.00 83593-26 $18.00 83835 $41.00

83498 $62.00 83593-TC $41.00 83835-26 $12.00

83498-26 $20.00 83605 $19.00 83835-TC $29.00

83498-TC $41.00 83605-26 $6.00 83857 $26.00

83499 $51.00 83605-TC $13.00 83857-26 $8.00

83499-26 $15.00 83615 $16.00 83857-TC $18.00

83499-TC $36.00 83615-26 $5.00 83864 $32.00

83500 $69.00 83615-TC $11.00 83864-26 $8.00

83500-26 $21.00 83625 $23.00 83864-TC $22.00

83500-TC $45.00 83625-26 $6.00 83872 $13.00

83505 $77.00 83625-TC $17.00 83872-26 $4.00

83505-26 $21.00 83632 $42.00 83872-TC $8.00

83505-TC $54.00 83632-26 $14.00 83873 $54.00

83516 $26.00 83632-TC $28.00 83873-26 $18.00

83516-26 $8.00 83655 $31.00 83873-TC $36.00

83516-TC $18.00 83655-26 $8.00 83874 $25.00

83518 $21.00 83655-TC $21.00 83874-26 $8.00

83518-26 $7.00 83670 $18.00 83874-TC $17.00

83518-TC $14.00 83670-26 $5.00 83880 BR

83519 $21.00 83670-TC $13.00 83880-26 BR

83519-26 $7.00 83690 $18.00 83880-TC BR

83519-TC $14.00 83690-26 $6.00 83883 $11.00

83520 $20.00 83690-TC $12.00 83883-26 $3.00

83520-26 $6.00 83718 $16.00 83883-TC $7.00

83520-TC $14.00 83718-26 $5.00 83885 $45.00

83525 $31.00 83718-TC $11.00 83885-26 $14.00

83525-26 $8.00 83719 $42.00 83885-TC $32.00

83525-TC $21.00 83719-26 $14.00 83915 $31.00

83527 $35.00 83719-TC $28.00 83915-26 $10.00

83527-26 $11.00 83721 $16.00 83915-TC $20.00





83916 $54.00 84066-TC $12.00 84135-26 $19.00

83916-26 $18.00 84075 $12.00 84135-TC $38.00

83916-TC $36.00 84075-26 $3.00 84138 $56.00

83918 $41.00 84075-TC $8.00 84138-26 $18.00

83918-26 $12.00 84078 $19.00 84138-TC $38.00

83918-TC $29.00 84078-26 $5.00 84140 $41.00

83919 $42.00 84078-TC $14.00 84140-26 $8.00

83919-26 $12.00 84080 $36.00 84140-TC $33.00

83919-TC $29.00 84080-26 $11.00 84143 $62.00

83921 $37.00 84080-TC $24.00 84143-26 $20.00

83921-26 $12.00 84081 $45.00 84143-TC $41.00

83921-TC $25.00 84081-26 $15.00 84144 $38.00

83930 $11.00 84081-TC $31.00 84144-26 $7.00

83930-26 $3.00 84085 $15.00 84144-TC $31.00

83930-TC $7.00 84085-26 $5.00 84146 $53.00

83935 $17.00 84085-TC $10.00 84146-26 $17.00

83935-26 $5.00 84087 $25.00 84146-TC $36.00

83935-TC $12.00 84087-26 $7.00 84150 $69.00

83937 $29.00 84087-TC $18.00 84150-26 $20.00

83937-26 $10.00 84100 $11.00 84150-TC $47.00

83937-TC $19.00 84100-26 $3.00 84152 $42.00

83945 $32.00 84100-TC $7.00 84152-26 $14.00

83945-26 $11.00 84105 $11.00 84152-TC $27.00

83945-TC $20.00 84105-26 $3.00 84153 $33.00

83950 BR 84105-TC $7.00 84153-26 $11.00

83950-26 BR 84106 $10.00 84153-TC $21.00

83950-TC BR 84106-26 $2.00 84154 $33.00

83970 $94.00 84106-TC $7.00 84154-26 $11.00

83970-26 $31.00 84110 $21.00 84154-TC $21.00

83970-TC $62.00 84110-26 $6.00 84155 $12.00

83986 $8.00 84110-TC $15.00 84155-26 $4.00

83986-26 $3.00 84119 $21.00 84155-TC $7.00

83986-TC $5.00 84119-26 $6.00 84160 $5.00

83992 $40.00 84119-TC $15.00 84160-26 $2.00

83992-26 $12.00 84120 $38.00 84160-TC $2.00

83992-TC $28.00 84120-26 $11.00 84165 $24.00

84030 $11.00 84120-TC $26.00 84165-26 $8.00

84030-26 $3.00 84126 $71.00 84165-TC $16.00

84030-TC $7.00 84126-26 $20.00 84166 BR

84035 $12.00 84126-TC $49.00 84166-26 $20.00

84035-26 $3.00 84132 $11.00 84166-TC BR

84035-TC $8.00 84132-26 $3.00 84181 $29.00

84060 $20.00 84132-TC $7.00 84181-26 $10.00

84060-26 $6.00 84133 $11.00 84181-TC $19.00

84060-TC $14.00 84133-26 $3.00 84182 $33.00

84061 $14.00 84133-TC $7.00 84182-26 $11.00

84061-26 $4.00 84134 $24.00 84182-TC $21.00

84061-TC $10.00 84134-26 $7.00 84202 $39.00

84066 $18.00 84134-TC $17.00 84202-26 $13.00

84066-26 $6.00 84135 $57.00 84202-TC $25.00





84203 $16.00 84285-TC $42.00 84430-26 $10.00

84203-26 $5.00 84295 $10.00 84430-TC $20.00

84203-TC $11.00 84295-26 $3.00 84432 $28.00

84206 $32.00 84295-TC $6.00 84432-26 $8.00

84206-26 $10.00 84300 $10.00 84432-TC $19.00

84206-TC $21.00 84300-26 $3.00 84436 $14.00

84207 $54.00 84300-TC $6.00 84436-26 $3.00

84207-26 $16.00 84302 BR 84436-TC $11.00

84207-TC $38.00 84302-26 BR 84437 $13.00

84210 $24.00 84302-TC BR 84437-26 $4.00

84210-26 $10.00 84305 $34.00 84437-TC $8.00

84210-TC $15.00 84305-26 $11.00 84439 $16.00

84220 $25.00 84305-TC $22.00 84439-26 $4.00

84220-26 $8.00 84307 $26.00 84439-TC $12.00

84220-TC $17.00 84307-26 $8.00 84442 $25.00

84228 $32.00 84307-TC $18.00 84442-26 $6.00

84228-26 $10.00 84311 $11.00 84442-TC $19.00

84228-TC $21.00 84311-26 $3.00 84443 $32.00

84233 $116.00 84311-TC $7.00 84443-26 $7.00

84233-26 $35.00 84315 $5.00 84443-TC $23.00

84233-TC $81.00 84315-26 $2.00 84445 $98.00

84234 $116.00 84315-TC $3.00 84445-26 $29.00

84234-26 $35.00 84375 $37.00 84445-TC $69.00

84234-TC $81.00 84375-26 $11.00 84446 $35.00

84235 $114.00 84375-TC $25.00 84446-26 $11.00

84235-26 $34.00 84376 $10.00 84446-TC $23.00

84235-TC $80.00 84376-26 $3.00 84449 $38.00

84238 $97.00 84376-TC $7.00 84449-26 $13.00

84238-26 $32.00 84377 $10.00 84449-TC $24.00

84238-TC $65.00 84377-26 $3.00 84450 $11.00

84244 $47.00 84377-TC $7.00 84450-26 $3.00

84244-26 $15.00 84378 $25.00 84450-TC $7.00

84244-TC $32.00 84378-26 $8.00 84460 $13.00

84252 $47.00 84378-TC $17.00 84460-26 $4.00

84252-26 $14.00 84379 $25.00 84460-TC $8.00

84252-TC $33.00 84379-26 $8.00 84466 $22.00

84255 $58.00 84379-TC $17.00 84466-26 $7.00

84255-26 $17.00 84392 $8.00 84466-TC $15.00

84255-TC $41.00 84392-26 $2.00 84478 $12.00

84260 $54.00 84392-TC $6.00 84478-26 $3.00

84260-26 $16.00 84402 $72.00 84478-TC $8.00

84260-TC $38.00 84402-26 $21.00 84479 $15.00

84270 $36.00 84402-TC $49.00 84479-26 $5.00

84270-26 $11.00 84403 $67.00 84479-TC $10.00

84270-TC $24.00 84403-26 $19.00 84480 $20.00

84275 $37.00 84403-TC $45.00 84480-26 $6.00

84275-26 $11.00 84425 $54.00 84480-TC $14.00

84275-TC $25.00 84425-26 $17.00 84481 $33.00

84285 $59.00 84425-TC $37.00 84481-26 $10.00

84285-26 $17.00 84430 $31.00 84481-TC $22.00





84482 $45.00 84583-TC $7.00 85007-26 $3.00

84482-26 $15.00 84585 $36.00 85007-TC $4.00

84482-TC $31.00 84585-26 $11.00 85008 $5.00

84484 $21.00 84585-TC $24.00 85008-26 $2.00

84484-26 $6.00 84586 $42.00 85008-TC $3.00

84484-TC $15.00 84586-26 $14.00 85009 $8.00

84485 $15.00 84586-TC $27.00 85009-26 $3.00

84485-26 $4.00 84588 $73.00 85009-TC $5.00

84485-TC $11.00 84588-26 $23.00 85013 $3.00

84488 $15.00 84588-TC $47.00 85013-26 $1.00

84488-26 $4.00 84590 $33.00 85013-TC $2.00

84488-TC $11.00 84590-26 $11.00 85014 $4.00

84490 $15.00 84590-TC $21.00 85014-26 $1.00

84490-26 $4.00 84591 $26.00 85014-TC $3.00

84490-TC $11.00 84591-26 $9.00 85018 $5.00

84510 $26.00 84591-TC $18.00 85018-26 $2.00

84510-26 $8.00 84597 $37.00 85018-TC $3.00

84510-TC $18.00 84597-26 $11.00 85025 $20.00

84512 $17.00 84597-TC $25.00 85025-26 $6.00

84512-26 $5.00 84600 $43.00 85025-TC $14.00

84512-TC $12.00 84600-26 $13.00 85027 $15.00

84520 $12.00 84600-TC $31.00 85027-26 $5.00

84520-26 $3.00 84620 $29.00 85027-TC $10.00

84520-TC $8.00 84620-26 $8.00 85032 BR

84525 $7.00 84620-TC $20.00 85032-26 BR

84525-26 $2.00 84630 $26.00 85032-TC BR

84525-TC $5.00 84630-26 $8.00 85041 $7.00

84540 $13.00 84630-TC $18.00 85041-26 $3.00

84540-26 $4.00 84681 $52.00 85041-TC $4.00

84540-TC $8.00 84681-26 $17.00 85044 $10.00

84545 $18.00 84681-TC $35.00 85044-26 $3.00

84545-26 $5.00 84702 $38.00 85044-TC $6.00

84545-TC $13.00 84702-26 $11.00 85045 $6.00

84550 $12.00 84702-TC $26.00 85045-26 $2.00

84550-26 $4.00 84703 $22.00 85045-TC $4.00

84550-TC $7.00 84703-26 $6.00 85046 $13.00

84560 $12.00 84703-TC $15.00 85046-26 $4.00

84560-26 $3.00 84830 $17.00 85046-TC $9.00

84560-TC $8.00 84830-26 $5.00 85048 $7.00

84577 $34.00 84830-TC $12.00 85048-26 $3.00

84577-26 $11.00 84999 BR 85048-TC $4.00

84577-TC $22.00 84999-26 BR 85049 BR

84578 $7.00 84999-TC BR 85049-26 BR

84578-26 $2.00 85002 $10.00 85049-TC BR

84578-TC $5.00 85002-26 $3.00 85060 $25.00

84580 $17.00 85002-TC $6.00 85060-26 $7.00

84580-26 $5.00 85004 BR 85060-TC $18.00

84580-TC $12.00 85004-26 BR 85097 $59.00

84583 $11.00 85004-TC BR 85097-26 $59.00

84583-26 $3.00 85007 $6.00 85097-TC BR





85130 $19.00 85291-TC $14.00 85366-26 $3.00

85130-26 $6.00 85292 $51.00 85366-TC $10.00

85130-TC $13.00 85292-26 $17.00 85370 $20.00

85170 $7.00 85292-TC $34.00 85370-26 $5.00

85170-26 $2.00 85293 $51.00 85370-TC $15.00

85170-TC $5.00 85293-26 $17.00 85378 $13.00

85175 $10.00 85293-TC $34.00 85378-26 $4.00

85175-26 $3.00 85300 $35.00 85378-TC $8.00

85175-TC $6.00 85300-26 $12.00 85379 $18.00

85210 $31.00 85300-TC $23.00 85379-26 $6.00

85210-26 $8.00 85301 $29.00 85379-TC $12.00

85210-TC $21.00 85301-26 $10.00 85380 BR

85220 $47.00 85301-TC $19.00 85380-26 BR

85220-26 $15.00 85302 $33.00 85380-TC BR

85220-TC $32.00 85302-26 $11.00 85384 $11.00

85230 $47.00 85302-TC $21.00 85384-26 $3.00

85230-26 $14.00 85303 $26.00 85384-TC $7.00

85230-TC $33.00 85303-26 $8.00 85385 $16.00

85240 $48.00 85303-TC $18.00 85385-26 $5.00

85240-26 $15.00 85305 $21.00 85385-TC $11.00

85240-TC $33.00 85305-26 $7.00 85390 $10.00

85244 $49.00 85305-TC $14.00 85390-26 $2.00

85244-26 $15.00 85306 $29.00 85390-TC $7.00

85244-TC $34.00 85306-26 $10.00 85396 $22.00

85245 $54.00 85306-TC $19.00 85400 $12.00

85245-26 $18.00 85307 $35.00 85400-26 $3.00

85245-TC $36.00 85307-26 $12.00 85400-TC $8.00

85246 $54.00 85307-TC $23.00 85410 $12.00

85246-26 $18.00 85335 $21.00 85410-26 $3.00

85246-TC $36.00 85335-26 $7.00 85410-TC $8.00

85247 $54.00 85335-TC $14.00 85415 $28.00

85247-26 $18.00 85337 $19.00 85415-26 $10.00

85247-TC $36.00 85337-26 $6.00 85415-TC $18.00

85250 $49.00 85337-TC $13.00 85420 $16.00

85250-26 $14.00 85345 $10.00 85420-26 $3.00

85250-TC $35.00 85345-26 $2.00 85420-TC $13.00

85260 $49.00 85345-TC $7.00 85421 $39.00

85260-26 $14.00 85347 $8.00 85421-26 $12.00

85260-TC $35.00 85347-26 $2.00 85421-TC $26.00

85270 $49.00 85347-TC $6.00 85441 $7.00

85270-26 $14.00 85348 $10.00 85441-26 $2.00

85270-TC $35.00 85348-26 $3.00 85441-TC $5.00

85280 $49.00 85348-TC $6.00 85445 $16.00

85280-26 $14.00 85360 $16.00 85445-26 $5.00

85280-TC $35.00 85360-26 $4.00 85445-TC $11.00

85290 $44.00 85360-TC $12.00 85460 $15.00

85290-26 $13.00 85362 $18.00 85460-26 $4.00

85290-TC $32.00 85362-26 $7.00 85460-TC $11.00

85291 $20.00 85362-TC $11.00 85461 $12.00

85291-26 $6.00 85366 $13.00 85461-26 $3.00





85461-TC $8.00 85635-26 $8.00 86023 $28.00

85475 $15.00 85635-TC $18.00 86023-26 $10.00

85475-26 $4.00 85651 $8.00 86023-TC $18.00

85475-TC $11.00 85651-26 $2.00 86038 $22.00

85520 $22.00 85651-TC $6.00 86038-26 $7.00

85520-26 $6.00 85652 $8.00 86038-TC $15.00

85520-TC $16.00 85652-26 $2.00 86039 $19.00

85525 $20.00 85652-TC $6.00 86039-26 $6.00

85525-26 $6.00 85660 $10.00 86039-TC $13.00

85525-TC $14.00 85660-26 $3.00 86060 $13.00

85530 $39.00 85660-TC $6.00 86060-26 $3.00

85530-26 $12.00 85670 $13.00 86060-TC $10.00

85530-TC $26.00 85670-26 $3.00 86063 $21.00

85536 $14.00 85670-TC $10.00 86063-26 $6.00

85536-26 $4.00 85675 $13.00 86063-TC $15.00

85536-TC $10.00 85675-26 $4.00 86077 $91.00

85540 $24.00 85675-TC $8.00 86077-26 $26.00

85540-26 $7.00 85705 $13.00 86077-TC $64.00

85540-TC $17.00 85705-26 $4.00 86078 $91.00

85547 $23.00 85705-TC $8.00 86078-26 $26.00

85547-26 $6.00 85730 $11.00 86078-TC $64.00

85547-TC $17.00 85730-26 $3.00 86079 $79.00

85549 $45.00 85730-TC $7.00 86079-26 $25.00

85549-26 $15.00 85732 $17.00 86079-TC $52.00

85549-TC $31.00 85732-26 $5.00 86140 $14.00

85555 $17.00 85732-TC $12.00 86140-26 $4.00

85555-26 $5.00 85810 $19.00 86140-TC $10.00

85555-TC $12.00 85810-26 $4.00 86141 BR

85557 $34.00 85810-TC $15.00 86141-26 BR

85557-26 $10.00 85999 BR 86141-TC BR

85557-TC $23.00 85999-26 BR 86146 $58.00

85576 $21.00 85999-TC BR 86146-26 $19.00

85576-26 $5.00 86000 $16.00 86146-TC $39.00

85576-TC $16.00 86000-26 $5.00 86147 $53.00

85597 $32.00 86000-TC $11.00 86147-26 $16.00

85597-26 $10.00 86001 $12.00 86147-TC $36.00

85597-TC $21.00 86001-26 $4.00 86148 $59.00

85610 $6.00 86001-TC $8.00 86148-26 $21.00

85610-26 $3.00 86003 $6.00 86148-TC $38.00

85610-TC $4.00 86003-26 $2.00 86153-26 $35.00

85611 $6.00 86003-TC $3.00 86155 $26.00

85611-26 $2.00 86005 $11.00 86155-26 $8.00

85611-TC $4.00 86005-26 $4.00 86155-TC $18.00

85612 $22.00 86005-TC $6.00 86156 $11.00

85612-26 $6.00 86021 $41.00 86156-26 $3.00

85612-TC $16.00 86021-26 $12.00 86156-TC $7.00

85613 $15.00 86021-TC $29.00 86157 $13.00

85613-26 $4.00 86022 $57.00 86157-26 $4.00

85613-TC $11.00 86022-26 $18.00 86157-TC $8.00

85635 $26.00 86022-TC $39.00 86160 $21.00





86160-26 $5.00 86304 $47.00 86337-TC $36.00

86160-TC $16.00 86304-26 $15.00 86340 $39.00

86161 $21.00 86304-TC $32.00 86340-26 $13.00

86161-26 $5.00 86308 $8.00 86340-TC $25.00

86161-TC $16.00 86308-26 $3.00 86341 $38.00

86162 $54.00 86308-TC $5.00 86341-26 $13.00

86162-26 $18.00 86309 $12.00 86341-TC $24.00

86162-TC $36.00 86309-26 $3.00 86343 $33.00

86171 $25.00 86309-TC $8.00 86343-26 $11.00

86171-26 $7.00 86310 $19.00 86343-TC $21.00

86171-TC $18.00 86310-26 $6.00 86344 $21.00

86185 $19.00 86310-TC $13.00 86344-26 $7.00

86185-26 $6.00 86316 $37.00 86344-TC $14.00

86185-TC $13.00 86316-26 $11.00 86353 $102.00

86215 $36.00 86316-TC $25.00 86353-26 $31.00

86215-26 $12.00 86317 $31.00 86353-TC $72.00

86215-TC $23.00 86317-26 $10.00 86359 $61.00

86225 $36.00 86317-TC $20.00 86359-26 $19.00

86225-26 $11.00 86318 $23.00 86359-TC $41.00

86225-TC $24.00 86318-26 $10.00 86360 $99.00

86226 $24.00 86318-TC $14.00 86360-26 $33.00

86226-26 $8.00 86320 $49.00 86360-TC $67.00

86226-TC $16.00 86320-26 $19.00 86361 $66.00

86235 $33.00 86320-TC $29.00 86361-26 $21.00

86235-26 $10.00 86325 $49.00 86361-TC $43.00

86235-TC $22.00 86325-26 $16.00 86376 $35.00

86243 $50.00 86325-TC $33.00 86376-26 $11.00

86243-26 $15.00 86327 $62.00 86376-TC $23.00

86243-TC $35.00 86327-26 $19.00 86378 $45.00

86255 $25.00 86327-TC $42.00 86378-26 $15.00

86255-26 $8.00 86329 $37.00 86378-TC $31.00

86255-TC $17.00 86329-26 $12.00 86382 $45.00

86256 $25.00 86329-TC $24.00 86382-26 $14.00

86256-26 $8.00 86331 $22.00 86382-TC $32.00

86256-TC $17.00 86331-26 $6.00 86384 $24.00

86277 $41.00 86331-TC $15.00 86384-26 $8.00

86277-26 $14.00 86332 $54.00 86384-TC $16.00

86277-TC $26.00 86332-26 $18.00 86403 $18.00

86280 $15.00 86332-TC $36.00 86403-26 $3.00

86280-26 $3.00 86334 $65.00 86403-TC $14.00

86280-TC $12.00 86334-26 $18.00 86406 $21.00

86294 BR 86334-TC $45.00 86406-26 $5.00

86294-26 BR 86335 BR 86406-TC $16.00

86294-TC BR 86335-26 $20.00 86430 $13.00

86300 $47.00 86335-TC BR 86430-26 $4.00

86300-26 $15.00 86336 BR 86430-TC $8.00

86300-TC $32.00 86336-26 BR 86431 $17.00

86301 $47.00 86336-TC BR 86431-26 $6.00

86301-26 $15.00 86337 $54.00 86431-TC $11.00

86301-TC $32.00 86337-26 $18.00 86485 $13.00





86485-26 $4.00 86619-TC $15.00 86663-26 $7.00

86485-TC $8.00 86622 $16.00 86663-TC $14.00

86486 $6.00 86622-26 $5.00 86664 $53.00

86490 $17.00 86622-TC $11.00 86664-26 $17.00

86490-26 $5.00 86625 $21.00 86664-TC $36.00

86490-TC $12.00 86625-26 $6.00 86665 $29.00

86510 $13.00 86625-TC $15.00 86665-26 $10.00

86510-26 $4.00 86628 $20.00 86665-TC $19.00

86510-TC $8.00 86628-26 $6.00 86666 $23.00

86580 $13.00 86628-TC $14.00 86666-26 $8.00

86580-26 $4.00 86631 $20.00 86666-TC $15.00

86580-TC $8.00 86631-26 $6.00 86668 $17.00

86590 $18.00 86631-TC $14.00 86668-26 $5.00

86590-26 $6.00 86632 $20.00 86668-TC $12.00

86590-TC $12.00 86632-26 $6.00 86671 $20.00

86592 $8.00 86632-TC $14.00 86671-26 $6.00

86592-26 $2.00 86635 $18.00 86671-TC $14.00

86592-TC $6.00 86635-26 $5.00 86674 $23.00

86593 $11.00 86635-TC $13.00 86674-26 $7.00

86593-26 $3.00 86638 $20.00 86674-TC $16.00

86593-TC $7.00 86638-26 $6.00 86677 $24.00

86602 $17.00 86638-TC $14.00 86677-26 $8.00

86602-26 $5.00 86641 $21.00 86677-TC $16.00

86602-TC $12.00 86641-26 $7.00 86682 $21.00

86603 $20.00 86641-TC $14.00 86682-26 $7.00

86603-26 $6.00 86644 $22.00 86682-TC $14.00

86603-TC $14.00 86644-26 $7.00 86684 $24.00

86606 $24.00 86644-TC $15.00 86684-26 $8.00

86606-26 $8.00 86645 $28.00 86684-TC $16.00

86606-TC $16.00 86645-26 $10.00 86687 $22.00

86609 $20.00 86645-TC $18.00 86687-26 $7.00

86609-26 $6.00 86648 $24.00 86687-TC $16.00

86609-TC $14.00 86648-26 $8.00 86688 $20.00

86611 $23.00 86648-TC $16.00 86688-26 $7.00

86611-26 $8.00 86651 $21.00 86688-TC $14.00

86611-TC $15.00 86651-26 $7.00 86689 $25.00

86612 $21.00 86651-TC $14.00 86689-26 $8.00

86612-26 $6.00 86652 $21.00 86689-TC $17.00

86612-TC $15.00 86652-26 $7.00 86692 $22.00

86615 $21.00 86652-TC $14.00 86692-26 $7.00

86615-26 $6.00 86653 $21.00 86692-TC $15.00

86615-TC $15.00 86653-26 $7.00 86694 $22.00

86617 $29.00 86653-TC $14.00 86694-26 $7.00

86617-26 $10.00 86654 $21.00 86694-TC $15.00

86617-TC $19.00 86654-26 $7.00 86695 $21.00

86618 $26.00 86654-TC $14.00 86695-26 $7.00

86618-26 $8.00 86658 $21.00 86695-TC $14.00

86618-TC $18.00 86658-26 $7.00 86696 $44.00

86619 $21.00 86658-TC $14.00 86696-26 $14.00

86619-26 $6.00 86663 $21.00 86696-TC $30.00





86698 $20.00 86729-TC $13.00 86777-26 $7.00

86698-26 $6.00 86732 $21.00 86777-TC $15.00

86698-TC $14.00 86732-26 $7.00 86778 $23.00

86701 $21.00 86732-TC $14.00 86778-26 $7.00

86701-26 $7.00 86735 $21.00 86778-TC $16.00

86701-TC $15.00 86735-26 $7.00 86784 $21.00

86702 $21.00 86735-TC $14.00 86784-26 $7.00

86702-26 $7.00 86738 $21.00 86784-TC $14.00

86702-TC $14.00 86738-26 $7.00 86787 $20.00

86703 $22.00 86738-TC $14.00 86787-26 $6.00

86703-26 $7.00 86741 $21.00 86787-TC $14.00

86703-TC $15.00 86741-26 $7.00 86790 $21.00

86704 $33.00 86741-TC $14.00 86790-26 $7.00

86704-26 $11.00 86744 $21.00 86790-TC $14.00

86704-TC $21.00 86744-26 $7.00 86793 $21.00

86705 $35.00 86744-TC $14.00 86793-26 $7.00

86705-26 $11.00 86747 $23.00 86793-TC $14.00

86705-TC $23.00 86747-26 $7.00 86800 $26.00

86706 $24.00 86747-TC $16.00 86800-26 $8.00

86706-26 $8.00 86750 $21.00 86800-TC $18.00

86706-TC $16.00 86750-26 $7.00 86803 $24.00

86707 $26.00 86750-TC $14.00 86803-26 $8.00

86707-26 $8.00 86753 $20.00 86803-TC $16.00

86707-TC $18.00 86753-26 $6.00 86804 $26.00

86708 $32.00 86753-TC $14.00 86804-26 $8.00

86708-26 $10.00 86756 $20.00 86804-TC $18.00

86708-TC $21.00 86756-26 $6.00 86805 $97.00

86709 $29.00 86756-TC $14.00 86805-26 $33.00

86709-26 $10.00 86757 $44.00 86805-TC $64.00

86709-TC $19.00 86757-26 $14.00 86806 $87.00

86710 $22.00 86757-TC $30.00 86806-26 $28.00

86710-26 $7.00 86759 $21.00 86806-TC $57.00

86710-TC $15.00 86759-26 $7.00 86807 $74.00

86713 $23.00 86759-TC $14.00 86807-26 $21.00

86713-26 $7.00 86762 $22.00 86807-TC $51.00

86713-TC $16.00 86762-26 $7.00 86808 $52.00

86717 $20.00 86762-TC $15.00 86808-26 $15.00

86717-26 $6.00 86765 $20.00 86808-TC $37.00

86717-TC $14.00 86765-26 $6.00 86812 $108.00

86720 $21.00 86765-TC $14.00 86812-26 $32.00

86720-26 $7.00 86768 $21.00 86812-TC $75.00

86720-TC $14.00 86768-26 $7.00 86813 $101.00

86723 $21.00 86768-TC $14.00 86813-26 $29.00

86723-26 $7.00 86771 $21.00 86813-TC $71.00

86723-TC $14.00 86771-26 $7.00 86816 $64.00

86727 $20.00 86771-TC $14.00 86816-26 $18.00

86727-26 $6.00 86774 $23.00 86816-TC $44.00

86727-TC $14.00 86774-26 $7.00 86817 $134.00

86729 $19.00 86774-TC $16.00 86817-26 $39.00

86729-26 $6.00 86777 $22.00 86817-TC $94.00





86821 $123.00 86910-TC $57.00 86975-26 $16.00

86821-26 $36.00 86911 $19.00 86975-TC $37.00

86821-TC $86.00 86911-26 $6.00 86976 $53.00

86822 $96.00 86911-TC $13.00 86976-26 $16.00

86822-26 $32.00 86920 $19.00 86976-TC $37.00

86822-TC $64.00 86920-26 $3.00 86977 $53.00

86849 BR 86920-TC $15.00 86977-26 $16.00

86849-26 BR 86921 $23.00 86977-TC $37.00

86849-TC BR 86921-26 $7.00 86978 $65.00

86850 $10.00 86921-TC $16.00 86978-26 $19.00

86850-26 $3.00 86922 $20.00 86978-TC $44.00

86850-TC $6.00 86922-26 $6.00 86985 $35.00

86860 $44.00 86922-TC $14.00 86985-26 $12.00

86860-26 $15.00 86927 $21.00 86985-TC $23.00

86860-TC $29.00 86927-26 $5.00 86999 BR

86870 $17.00 86927-TC $16.00 86999-26 BR

86870-26 $6.00 86930 $155.00 86999-TC BR

86870-TC $11.00 86930-26 $45.00 87003 $40.00

86880 $13.00 86930-TC $108.00 87003-26 $13.00

86880-26 $4.00 86931 $155.00 87003-TC $26.00

86880-TC $8.00 86931-26 $45.00 87015 $14.00

86885 $15.00 86931-TC $108.00 87015-26 $5.00

86885-26 $4.00 86932 $161.00 87015-TC $9.00

86885-TC $11.00 86932-26 $48.00 87040 $18.00

86886 $14.00 86932-TC $111.00 87040-26 $6.00

86886-26 $4.00 86940 $18.00 87040-TC $12.00

86886-TC $10.00 86940-26 $5.00 87045 $18.00

86890 $67.00 86940-TC $13.00 87045-26 $6.00

86890-26 $11.00 86941 $31.00 87045-TC $11.00

86890-TC $54.00 86941-26 $8.00 87046 $5.00

86891 $91.00 86941-TC $21.00 87046-26 $2.00

86891-26 $26.00 86945 $35.00 87046-TC $3.00

86891-TC $64.00 86945-26 $11.00 87070 $14.00

86900 $10.00 86945-TC $23.00 87070-26 $4.00

86900-26 $3.00 86950 $99.00 87070-TC $10.00

86900-TC $6.00 86950-26 $29.00 87071 $11.00

86901 $10.00 86950-TC $70.00 87071-26 $3.00

86901-26 $3.00 86965 $25.00 87071-TC $8.00

86901-TC $6.00 86965-26 $7.00 87073 $11.00

86904 $19.00 86965-TC $18.00 87073-26 $3.00

86904-26 $6.00 86970 $41.00 87073-TC $8.00

86904-TC $13.00 86970-26 $12.00 87075 $18.00

86905 $7.00 86970-TC $29.00 87075-26 $6.00

86905-26 $1.00 86971 $20.00 87075-TC $12.00

86905-TC $6.00 86971-26 $5.00 87076 $24.00

86906 $11.00 86971-TC $15.00 87076-26 $8.00

86906-26 $3.00 86972 $20.00 87076-TC $16.00

86906-TC $7.00 86972-26 $6.00 87077 $16.00

86910 $83.00 86972-TC $14.00 87077-26 $5.00

86910-26 $24.00 86975 $53.00 87077-TC $11.00





87081 $12.00 87149-TC $31.00 87197-26 $10.00

87081-26 $3.00 87152 $12.00 87197-TC $19.00

87081-TC $8.00 87152-26 $4.00 87205 $11.00

87084 $23.00 87152-TC $8.00 87205-26 $3.00

87084-26 $7.00 87158 $5.00 87205-TC $7.00

87084-TC $16.00 87158-26 $1.00 87206 $15.00

87086 $14.00 87158-TC $3.00 87206-26 $3.00

87086-26 $3.00 87164 $24.00 87206-TC $12.00

87086-TC $11.00 87164-26 $8.00 87207 $10.00

87088 $18.00 87164-TC $16.00 87207-26 $3.00

87088-26 $6.00 87166 $24.00 87207-TC $6.00

87088-TC $12.00 87166-26 $7.00 87210 $8.00

87101 $20.00 87166-TC $17.00 87210-26 $2.00

87101-26 $6.00 87168 $10.00 87210-TC $6.00

87101-TC $14.00 87168-26 $3.00 87220 $12.00

87102 $20.00 87168-TC $7.00 87220-26 $4.00

87102-26 $6.00 87169 $10.00 87220-TC $7.00

87102-TC $14.00 87169-26 $3.00 87230 $35.00

87103 $32.00 87169-TC $7.00 87230-26 $11.00

87103-26 $11.00 87172 $10.00 87230-TC $23.00

87103-TC $20.00 87172-26 $3.00 87250 $33.00

87106 $25.00 87172-TC $7.00 87250-26 $13.00

87106-26 $7.00 87176 $16.00 87250-TC $19.00

87106-TC $18.00 87176-26 $5.00 87252 $44.00

87107 $23.00 87176-TC $11.00 87252-26 $14.00

87107-26 $8.00 87177 $18.00 87252-TC $31.00

87107-TC $15.00 87177-26 $6.00 87253 $33.00

87109 $26.00 87177-TC $12.00 87253-26 $10.00

87109-26 $8.00 87181 $13.00 87253-TC $22.00

87109-TC $18.00 87181-26 $3.00 87254 $11.00

87110 $23.00 87181-TC $8.00 87254-26 $3.00

87110-26 $7.00 87184 $13.00 87254-TC $8.00

87110-TC $15.00 87184-26 $3.00 87255 BR

87116 $15.00 87184-TC $10.00 87255-26 BR

87116-26 $3.00 87185 $11.00 87255-TC BR

87116-TC $11.00 87185-26 $3.00 87260 $26.00

87118 $28.00 87185-TC $8.00 87260-26 $8.00

87118-26 $9.00 87186 $16.00 87260-TC $18.00

87118-TC $20.00 87186-26 $4.00 87265 $26.00

87140 $24.00 87186-TC $12.00 87265-26 $8.00

87140-26 $7.00 87187 $20.00 87265-TC $18.00

87140-TC $17.00 87187-26 $3.00 87267 BR

87143 $34.00 87187-TC $17.00 87267-26 BR

87143-26 $11.00 87188 $18.00 87267-TC BR

87143-TC $22.00 87188-26 $5.00 87270 $26.00

87147 $26.00 87188-TC $13.00 87270-26 $8.00

87147-26 $8.00 87190 $7.00 87270-TC $18.00

87147-TC $18.00 87190-26 $2.00 87271 BR

87149 $46.00 87190-TC $5.00 87271-26 BR

87149-26 $15.00 87197 $29.00 87271-TC BR





87272 $26.00 87320-TC $18.00 87400-26 $4.00

87272-26 $8.00 87324 $26.00 87400-TC $9.00

87272-TC $18.00 87324-26 $8.00 87420 $26.00

87273 $27.00 87324-TC $18.00 87420-26 $8.00

87273-26 $9.00 87327 $27.00 87420-TC $18.00

87273-TC $19.00 87327-26 $9.00 87425 $26.00

87274 $26.00 87327-TC $19.00 87425-26 $8.00

87274-26 $8.00 87328 $26.00 87425-TC $18.00

87274-TC $18.00 87328-26 $8.00 87427 $27.00

87275 $27.00 87328-TC $18.00 87427-26 $9.00

87275-26 $9.00 87332 $26.00 87427-TC $19.00

87275-TC $19.00 87332-26 $8.00 87430 $26.00

87276 $26.00 87332-TC $18.00 87430-26 $8.00

87276-26 $8.00 87335 $26.00 87430-TC $18.00

87276-TC $18.00 87335-26 $8.00 87449 $26.00

87277 $27.00 87335-TC $18.00 87449-26 $8.00

87277-26 $9.00 87336 $27.00 87449-TC $18.00

87277-TC $19.00 87336-26 $9.00 87450 $21.00

87278 $26.00 87336-TC $19.00 87450-26 $6.00

87278-26 $8.00 87337 $27.00 87450-TC $15.00

87278-TC $18.00 87337-26 $9.00 87451 $19.00

87279 $27.00 87337-TC $19.00 87451-26 $7.00

87279-26 $9.00 87338 $27.00 87451-TC $12.00

87279-TC $19.00 87338-26 $7.00 87470 $42.00

87280 $26.00 87338-TC $20.00 87470-26 $13.00

87280-26 $8.00 87339 $27.00 87470-TC $28.00

87280-TC $18.00 87339-26 $9.00 87471 $73.00

87281 $27.00 87339-TC $19.00 87471-26 $23.00

87281-26 $9.00 87340 $20.00 87471-TC $48.00

87281-TC $19.00 87340-26 $6.00 87472 $88.00

87283 $27.00 87340-TC $14.00 87472-26 $28.00

87283-26 $9.00 87341 $23.00 87472-TC $58.00

87283-TC $19.00 87341-26 $8.00 87475 $40.00

87285 $26.00 87341-TC $15.00 87475-26 $13.00

87285-26 $8.00 87350 $20.00 87475-TC $26.00

87285-TC $18.00 87350-26 $6.00 87476 $73.00

87290 $26.00 87350-TC $14.00 87476-26 $23.00

87290-26 $8.00 87380 $35.00 87476-TC $48.00

87290-TC $18.00 87380-26 $11.00 87477 $88.00

87299 $26.00 87380-TC $23.00 87477-26 $28.00

87299-26 $8.00 87385 $26.00 87477-TC $58.00

87299-TC $18.00 87385-26 $8.00 87480 $42.00

87300 $13.00 87385-TC $18.00 87480-26 $13.00

87300-26 $4.00 87390 $38.00 87480-TC $28.00

87300-TC $9.00 87390-26 $13.00 87481 $73.00

87301 $26.00 87390-TC $24.00 87481-26 $23.00

87301-26 $8.00 87391 $38.00 87481-TC $48.00

87301-TC $18.00 87391-26 $13.00 87482 $86.00

87320 $26.00 87391-TC $24.00 87482-26 $28.00

87320-26 $8.00 87400 $13.00 87482-TC $56.00





87485 $42.00 87521-TC $48.00 87540-26 $13.00

87485-26 $13.00 87522 $88.00 87540-TC $28.00

87485-TC $28.00 87522-26 $28.00 87541 $73.00

87486 $73.00 87522-TC $58.00 87541-26 $23.00

87486-26 $23.00 87525 $42.00 87541-TC $48.00

87486-TC $48.00 87525-26 $13.00 87542 $86.00

87487 $88.00 87525-TC $28.00 87542-26 $28.00

87487-26 $28.00 87526 $73.00 87542-TC $56.00

87487-TC $58.00 87526-26 $23.00 87550 $42.00

87490 $42.00 87526-TC $48.00 87550-26 $13.00

87490-26 $13.00 87527 $86.00 87550-TC $28.00

87490-TC $28.00 87527-26 $28.00 87551 $73.00

87491 $73.00 87527-TC $56.00 87551-26 $23.00

87491-26 $23.00 87528 $42.00 87551-TC $48.00

87491-TC $48.00 87528-26 $13.00 87552 $88.00

87492 $73.00 87528-TC $28.00 87552-26 $28.00

87492-26 $23.00 87529 $73.00 87552-TC $58.00

87492-TC $48.00 87529-26 $23.00 87555 $42.00

87495 $42.00 87529-TC $48.00 87555-26 $13.00

87495-26 $13.00 87530 $88.00 87555-TC $28.00

87495-TC $28.00 87530-26 $28.00 87556 $73.00

87496 $73.00 87530-TC $58.00 87556-26 $23.00

87496-26 $23.00 87531 $42.00 87556-TC $48.00

87496-TC $48.00 87531-26 $13.00 87557 $88.00

87497 $88.00 87531-TC $28.00 87557-26 $28.00

87497-26 $28.00 87532 $73.00 87557-TC $58.00

87497-TC $58.00 87532-26 $23.00 87560 $42.00

87510 $42.00 87532-TC $48.00 87560-26 $13.00

87510-26 $13.00 87533 $86.00 87560-TC $28.00

87510-TC $28.00 87533-26 $28.00 87561 $73.00

87511 $73.00 87533-TC $56.00 87561-26 $23.00

87511-26 $23.00 87534 $42.00 87561-TC $48.00

87511-TC $48.00 87534-26 $13.00 87562 $88.00

87512 $86.00 87534-TC $28.00 87562-26 $28.00

87512-26 $28.00 87535 $73.00 87562-TC $58.00

87512-TC $56.00 87535-26 $23.00 87580 $42.00

87515 $42.00 87535-TC $48.00 87580-26 $13.00

87515-26 $13.00 87536 $86.00 87580-TC $28.00

87515-TC $28.00 87536-26 $28.00 87581 $73.00

87516 $73.00 87536-TC $56.00 87581-26 $23.00

87516-26 $23.00 87537 $42.00 87581-TC $48.00

87516-TC $48.00 87537-26 $13.00 87582 $86.00

87517 $88.00 87537-TC $28.00 87582-26 $28.00

87517-26 $28.00 87538 $73.00 87582-TC $56.00

87517-TC $58.00 87538-26 $23.00 87590 $42.00

87520 $42.00 87538-TC $48.00 87590-26 $13.00

87520-26 $13.00 87539 $88.00 87590-TC $28.00

87520-TC $28.00 87539-26 $28.00 87591 $73.00

87521 $73.00 87539-TC $58.00 87591-26 $23.00

87521-26 $23.00 87540 $42.00 87591-TC $48.00





87592 $88.00 87901-TC $398.00 88106-26 $16.00

87592-26 $28.00 87902 BR 88106-TC $38.00

87592-TC $58.00 87902-26 BR 88108 $59.00

87650 $42.00 87902-TC BR 88108-26 $47.00

87650-26 $13.00 87903 $1,126.00 88108-TC $11.00

87650-TC $28.00 87903-26 $371.00 88112 $121.00

87651 $73.00 87903-TC $755.00 88112-26 $65.00

87651-26 $23.00 87904 $59.00 88112-TC $56.00

87651-TC $48.00 87904-26 $20.00 88120 $619.00

87652 $86.00 87904-TC $39.00 88120-26 $59.00

87652-26 $28.00 87999 BR 88120-TC $560.00

87652-TC $56.00 87999-26 BR 88121 $535.00

87797 $42.00 87999-TC BR 88121-26 $51.00

87797-26 $13.00 88000 $445.00 88121-TC $484.00

87797-TC $28.00 88000-26 $445.00 88125 $70.00

87798 $73.00 88000-TC BR 88125-26 $20.00

87798-26 $23.00 88005 $500.00 88125-TC $48.00

87798-TC $48.00 88005-26 $500.00 88130 $25.00

87799 $88.00 88005-TC BR 88130-26 $7.00

87799-26 $28.00 88007 $556.00 88130-TC $18.00

87799-TC $58.00 88007-26 $556.00 88140 $18.00

87800 $46.00 88007-TC BR 88140-26 $5.00

87800-26 $15.00 88020 $556.00 88140-TC $13.00

87800-TC $31.00 88020-26 $556.00 88141 $33.00

87801 $81.00 88020-TC BR 88141-26 BR

87801-26 $26.00 88025 $610.00 88141-TC BR

87801-TC $54.00 88025-26 $610.00 88142 $82.00

87802 BR 88025-TC BR 88142-26 $21.00

87802-26 BR 88027 $666.00 88142-TC $59.00

87802-TC BR 88027-26 $666.00 88143 $94.00

87803 BR 88027-TC BR 88143-26 $33.00

87803-26 BR 88036 $477.00 88143-TC $59.00

87803-TC BR 88036-26 $477.00 88147 $82.00

87804 BR 88036-TC BR 88147-26 BR

87804-26 BR 88037 $389.00 88147-TC $82.00

87804-TC BR 88037-26 $389.00 88148 $104.00

87810 $26.00 88037-TC BR 88148-26 $21.00

87810-26 $8.00 88040 $1,445.00 88148-TC $82.00

87810-TC $18.00 88040-26 $1,445.00 88150 $13.00

87850 $26.00 88040-TC BR 88150-26 $3.00

87850-26 $8.00 88045 BR 88150-TC $9.00

87850-TC $18.00 88045-26 BR 88152 $46.00

87880 $26.00 88045-TC BR 88152-26 $8.00

87880-26 $8.00 88099 BR 88152-TC $38.00

87880-TC $18.00 88099-26 BR 88153 $82.00

87899 $26.00 88099-TC BR 88153-26 $21.00

87899-26 $8.00 88104 $49.00 88153-TC $59.00

87899-TC $18.00 88104-26 $37.00 88154 $104.00

87901 $594.00 88104-TC $10.00 88154-26 $21.00

87901-26 $196.00 88106 $54.00 88154-TC $82.00





88155 $14.00 88233 $243.00 88323-TC $32.00

88155-26 $3.00 88233-26 $73.00 88325 $54.00

88155-TC $10.00 88233-TC $170.00 88325-26 $54.00

88160 $45.00 88235 $256.00 88325-TC BR

88160-26 $14.00 88235-26 $76.00 88329 $51.00

88160-TC $24.00 88235-TC $177.00 88329-26 $51.00

88161 $64.00 88240 $21.00 88329-TC BR

88161-26 $19.00 88240-26 $6.00 88331 $102.00

88161-TC $37.00 88240-TC $15.00 88331-26 $70.00

88162 $77.00 88241 $21.00 88331-TC $33.00

88162-26 $22.00 88241-26 $6.00 88332 $53.00

88162-TC $53.00 88241-TC $15.00 88332-26 $36.00

88164 $54.00 88300 $24.00 88332-TC $17.00

88164-26 $21.00 88300-26 $19.00 88333 $89.00

88164-TC $33.00 88300-TC $5.00 88333-26 $67.00

88165 $72.00 88302 $53.00 88333-TC $22.00

88165-26 $33.00 88302-26 $42.00 88334 $47.00

88165-TC $38.00 88302-TC $11.00 88334-26 $33.00

88166 $82.00 88304 $70.00 88334-TC $14.00

88166-26 $21.00 88304-26 $54.00 88341 $90.00

88166-TC $59.00 88304-TC $14.00 88341-26 $28.00

88167 $87.00 88305 $108.00 88341-TC $62.00

88167-26 $26.00 88305-26 $86.00 88342 $53.00

88167-TC $59.00 88305-TC $21.00 88342-26 $36.00

88172 $70.00 88307 $210.00 88342-TC $17.00

88172-26 $54.00 88307-26 $168.00 88344 $174.00

88172-TC $14.00 88307-TC $41.00 88344-26 $41.00

88173 $95.00 88309 $322.00 88344-TC $133.00

88173-26 $95.00 88309-26 $258.00 88346 $96.00

88173-TC $26.00 88309-TC $64.00 88346-26 $66.00

88174 BR 88311 $23.00 88346-TC $28.00

88174-26 BR 88311-26 $19.00 88348 $191.00

88174-TC BR 88311-TC $4.00 88348-26 $145.00

88175 BR 88312 $23.00 88348-TC $44.00

88175-26 BR 88312-26 $7.00 88350 $72.00

88175-TC BR 88312-TC $16.00 88350-26 $29.00

88177 $30.00 88313 $23.00 88350-TC $44.00

88177-26 $22.00 88313-26 $7.00 88355 $108.00

88177-TC $8.00 88313-TC $16.00 88355-26 $80.00

88182 $88.00 88314 $21.00 88355-TC $26.00

88182-26 $33.00 88314-26 $6.00 88356 $108.00

88182-TC $54.00 88314-TC $15.00 88356-26 $80.00

88184 $51.00 88319 $26.00 88356-TC $26.00

88185 $25.00 88319-26 $13.00 88358 $108.00

88187 $69.00 88319-TC $14.00 88358-26 $80.00

88188 $86.00 88321 $43.00 88358-TC $26.00

88189 $113.00 88321-26 $43.00 88360 $110.00

88199 BR 88321-TC BR 88360-26 $62.00

88199-26 BR 88323 $61.00 88360-TC $49.00

88199-TC BR 88323-26 $61.00 88361 $139.00



Pathology & Laboratory Pathology & Laboratory

CPT Code MRA CPT Code MRA

88361-26 $55.00 88388-26 $24.00

88361-TC $84.00 88388-TC $9.00

88362 $251.00 88399 BR

88362-26 $119.00 88399-26 BR

88362-TC $132.00 88399-TC BR

88363 $22.00 89049 $190.00

88364 $135.00 89050 $10.00

88364-26 $35.00 89050-26 $3.00

88364-TC $100.00 89050-TC $6.00

88365 $24.00 89051 $13.00

88365-26 $24.00 89051-26 $4.00

88365-TC $68.00 89051-TC $8.00

88366 $263.00 89055 BR

88366-26 $65.00 89055-26 BR

88366-TC $198.00 89055-TC BR

88367 $210.00 89060 $13.00

88367-26 $72.00 89060-26 $5.00

88367-TC $138.00 89060-TC $8.00

88368 $190.00 89125 $14.00

88368-26 $78.00 89125-26 $4.00

88368-TC $112.00 89125-TC $10.00

88369 $108.00 89160 $6.00

88369-26 $32.00 89160-26 $2.00

88369-TC $77.00 89160-TC $4.00

88371 $34.00 89190 $10.00

88371-26 $10.00 89190-26 $3.00

88371-TC $23.00 89190-TC $6.00

88372 $38.00 89220 $17.00

88372-26 $11.00 89230 $5.00

88372-TC $26.00 G0124 $24.00

88373 $75.00 G0141 $24.00

88373-26 $21.00 G0416 $651.00

88373-TC $54.00 G0416-26 $184.00

88374 $346.00 G0416-TC $467.00

88374-26 $46.00 G0452-26 $19.00

88374-TC $300.00 G0455 $126.00

88375 $20.00

88377 $412.00

88377-26 $67.00

88377-TC $346.00

88380 $159.00

88380-26 $71.00

88380-TC $88.00

88381 $213.00

88381-26 $54.00

88381-TC $159.00

88387 $36.00

88387-26 $29.00

88387-TC $6.00

88388 $33.00



Medicine Medicine Medicine


90460 $25.00 90959 $298.00 91111 $743.00

90461 $13.00 90960 $287.00 91111-26 $53.00

90471 $4.00 90961 $241.00 91111-TC $690.00

90472 $4.00 90962 $186.00 91112 $1,083.00

90473 $13.00 90963 $552.00 91112-26 $113.00

90474 $9.00 90964 $481.00 91112-TC $969.00

90632 BR 90965 $456.00 91117 $152.00

90636 BR 90966 $241.00 91120 $457.00

90675 BR 90967 $18.00 91120-26 $52.00

90746 BR 90968 $15.00 91120-TC $405.00

90749 BR 90969 $15.00 91122 $169.00

90785 $14.00 90970 $8.00 91122-26 $122.00

90791 $134.00 90997 $115.00 91122-TC $37.00

90792 $144.00 90999 BR 91132 $149.00

90832 $65.00 91010 $116.00 91132-26 $28.00

90833 $66.00 91010-26 $76.00 91132-TC $122.00

90834 $86.00 91010-TC $32.00 91133 $174.00

90836 $84.00 91013 $24.00 91133-26 $34.00

90837 $129.00 91013-26 $10.00 91133-TC $139.00

90838 $111.00 91013-TC $14.00 91200 $32.00

90839 $134.00 91020 $60.00 91200-26 $13.00

90840 $64.00 91020-26 $49.00 91200-TC $19.00

90845 $85.00 91020-TC $9.00 91299 BR

90846 $93.00 91022 $227.00 91299-26 BR

90847 $110.00 91022-26 $77.00 91299-TC BR

90849 $32.00 91022-TC $150.00 92002 $63.00

90853 $32.00 91030 $57.00 92004 $98.00

90865 $143.00 91030-26 $47.00 92012 $53.00

90870 $94.00 91030-TC $8.00 92014 $75.00

90875 $74.00 91034 $240.00 92015 $34.00

90876 $112.00 91034-26 $52.00 92018 $80.00

90880 $112.00 91034-TC $188.00 92019 $70.00

90882 $104.00 91035 $474.00 92020 $31.00

90885 $49.00 91035-26 $84.00 92025 $29.00

90887 $77.00 91035-TC $390.00 92025-26 $17.00

90889 BR 91037 $152.00 92025-TC $13.00

90899 BR 91037-26 $52.00 92060 $40.00

90901 $46.00 91037-TC $100.00 92060-26 $32.00

90911 $82.00 91038 $130.00 92060-TC $7.00

90935 $76.00 91038-26 $59.00 92065 $34.00

90937 $226.00 91038-TC $72.00 92065-26 $19.00

90940 BR 91040 $463.00 92065-TC $6.00

90945 $80.00 91040-26 $52.00 92071 $39.00

90947 $125.00 91040-TC $411.00 92072 $140.00

90951 $943.00 91065 $34.00 92081 $32.00

90954 $818.00 91065-26 $23.00 92081-26 $19.00

90955 $461.00 91065-TC $14.00 92081-TC $6.00

90956 $321.00 91110 $928.00 92082 $48.00

90957 $651.00 91110-26 $185.00 92082-26 $24.00

90958 $440.00 91110-TC $743.00 92082-TC $9.00





92083 $59.00 92283-TC $5.00 92537-26 $32.00

92083-26 $31.00 92284 $192.00 92537-TC $9.00

92083-TC $14.00 92284-26 $151.00 92538 $21.00

92100 $40.00 92284-TC $46.00 92538-26 $16.00

92132 $36.00 92285 $26.00 92538-TC $5.00

92132-26 $20.00 92285-26 $12.00 92540 $102.00

92132-TC $16.00 92285-TC $6.00 92540-26 $81.00

92133 $45.00 92286 $91.00 92540-TC $22.00

92133-26 $29.00 92286-26 $53.00 92541 $37.00

92133-TC $16.00 92286-TC $29.00 92541-26 $25.00

92134 $46.00 92287 $99.00 92541-TC $9.00

92134-26 $30.00 92287-26 $48.00 92542 $33.00

92134-TC $16.00 92287-TC $77.00 92542-26 $20.00

92136 $93.00 92310 $86.00 92542-TC $10.00

92136-26 $29.00 92311 $78.00 92544 $26.00

92136-TC $63.00 92312 $89.00 92544-26 $16.00

92145 $15.00 92313 $70.00 92544-TC $8.00

92145-26 $9.00 92314 $54.00 92545 $22.00

92145-TC $7.00 92315 $44.00 92545-26 $14.00

92225 $45.00 92316 $59.00 92545-TC $8.00

92226 $39.00 92317 $39.00 92546 $29.00

92227 $14.00 92325 $14.00 92546-26 $17.00

92228 $35.00 92326 $44.00 92546-TC $9.00

92228-26 $22.00 92340 $32.00 92547 $21.00

92228-TC $14.00 92341 $43.00 92548 $92.00

92230 $58.00 92342 $43.00 92548-26 $30.00

92235 $104.00 92358 $24.00 92548-TC $59.00

92235-26 $46.00 92370 $35.00 92550 $21.00

92235-TC $53.00 92371 $18.00 92551 $17.00

92240 $132.00 92499 BR 92552 $16.00

92240-26 $60.00 92499-26 BR 92553 $24.00

92240-TC $67.00 92499-TC BR 92555 $14.00

92242 $230.00 92502 $101.00 92556 $21.00

92242-26 $56.00 92504 $24.00 92557 $46.00

92242-TC $173.00 92507 $40.00 92560 $23.00

92250 $40.00 92508 $42.00 92561 $27.00

92250-26 $24.00 92511 $81.00 92562 $15.00

92250-TC $7.00 92512 $46.00 92563 $14.00

92260 $20.00 92516 $36.00 92564 $17.00

92265 $53.00 92520 $47.00 92565 $15.00

92265-26 $37.00 92521 $114.00 92567 $20.00

92265-TC $10.00 92522 $93.00 92568 $14.00

92270 $64.00 92523 $193.00 92570 $33.00

92270-26 $45.00 92524 $97.00 92571 $14.00

92270-TC $19.00 92526 $48.00 92572 $3.00

92275 $80.00 92531 $10.00 92575 $11.00

92275-26 $56.00 92532 $14.00 92576 $17.00

92275-TC $17.00 92533 $41.00 92577 $28.00

92283 $24.00 92534 BR 92579 $28.00

92283-26 $10.00 92537 $41.00 92582 $28.00





92583 $34.00 92950 $203.00 93260-TC $22.00

92584 $94.00 92953 $35.00 93261 $61.00

92585 $114.00 92960 $162.00 93261-26 $39.00

92585-26 $52.00 92961 $239.00 93261-TC $22.00

92585-TC $70.00 92970 $201.00 93268 $109.00

92586 $70.00 92971 $100.00 93270 $46.00

92587 $58.00 92973 $174.00 93271 $90.00

92587-26 $8.00 92974 $197.00 93272 $28.00

92587-TC $49.00 92975 $400.00 93278 $58.00

92588 $78.00 92977 $302.00 93278-26 $24.00

92588-26 $20.00 92978 $269.00 93278-TC $44.00

92588-TC $57.00 92978-26 $95.00 93279 $50.00

92590 $41.00 92978-TC $170.00 93279-26 $33.00

92591 BR 92979 $163.00 93279-TC $17.00

92592 BR 92979-26 $76.00 93280 $59.00

92593 BR 92979-TC $86.00 93280-26 $39.00

92594 BR 92986 $1,222.00 93280-TC $20.00

92595 BR 92987 $1,271.00 93281 $68.00

92596 $22.00 92990 $974.00 93281-26 $45.00

92597 $96.00 92992 BR 93281-TC $23.00

92603 $88.00 92993 BR 93282 $63.00

92604 $60.00 92997 $765.00 93282-26 $43.00

92605 $95.00 92998 $331.00 93282-TC $20.00

92606 $84.00 93000 $26.00 93283 $82.00

92607 $109.00 93005 $16.00 93283-26 $58.00

92608 $22.00 93010 $12.00 93283-TC $24.00

92609 $59.00 93015 $104.00 93284 $90.00

92610 $42.00 93016 $25.00 93284-26 $63.00

92611 $46.00 93017 $63.00 93284-TC $27.00

92612 $173.00 93018 $54.00 93285 $42.00

92613 $43.00 93024 $111.00 93285-26 $26.00

92614 $134.00 93024-26 $71.00 93285-TC $16.00

92615 $39.00 93024-TC $42.00 93286 $27.00

92616 $183.00 93025 $277.00 93286-26 $15.00

92617 $48.00 93025-26 $40.00 93286-TC $12.00

92618 $34.00 93025-TC $299.00 93287 $36.00

92620 $45.00 93040 $14.00 93287-26 $23.00

92621 $12.00 93041 $31.00 93287-TC $13.00

92625 $45.00 93042 $9.00 93288 $37.00

92626 $86.00 93050 $18.00 93288-26 $21.00

92627 $22.00 93050-26 $9.00 93288-TC $16.00

92640 $53.00 93050-TC $9.00 93289 $66.00

92700 BR 93224 $159.00 93289-26 $46.00

92920 $561.00 93225 $46.00 93289-TC $19.00

92924 $668.00 93226 $83.00 93290 $31.00

92928 $623.00 93227 $50.00 93290-26 $21.00

92933 $697.00 93228 $27.00 93290-TC $9.00

92937 $623.00 93229 $669.00 93291 $36.00

92941 $699.00 93260 $68.00 93291-26 $21.00

92943 $699.00 93260-26 $45.00 93291-TC $15.00





93292 $32.00 93325-26 $4.00 93505-26 $248.00

93292-26 $21.00 93325-TC $110.00 93505-TC $74.00

93292-TC $11.00 93350 $216.00 93530 $872.00

93293 $54.00 93350-26 $77.00 93530-26 $250.00

93293-26 $16.00 93350-TC $66.00 93530-TC $634.00

93293-TC $38.00 93351 $282.00 93531 $2,268.00

93294 $34.00 93351-26 $86.00 93531-26 $467.00

93295 $68.00 93351-TC $195.00 93531-TC $1,815.00

93296 $26.00 93352 $34.00 93532 $2,317.00

93297 $27.00 93355 $230.00 93532-26 $569.00

93298 $27.00 93451 $790.00 93532-TC $1,766.00

93303 $215.00 93451-26 $151.00 93533 $2,131.00

93303-26 $70.00 93451-TC $638.00 93533-26 $352.00

93303-TC $144.00 93452 $887.00 93533-TC $1,766.00

93304 $114.00 93452-26 $265.00 93561 $59.00

93304-26 $43.00 93452-TC $622.00 93561-26 $47.00

93304-TC $73.00 93453 $1,149.00 93561-TC $20.00

93306 $229.00 93453-26 $347.00 93562 $46.00

93306-26 $64.00 93453-TC $801.00 93562-26 $33.00

93306-TC $165.00 93454 $903.00 93562-TC $13.00

93307 $196.00 93454-26 $267.00 93563 $57.00

93307-26 $56.00 93454-TC $637.00 93564 $58.00

93307-TC $144.00 93455 $1,052.00 93565 $44.00

93308 $118.00 93455-26 $308.00 93566 $173.00

93308-26 $46.00 93455-TC $744.00 93567 $142.00

93308-TC $75.00 93456 $1,132.00 93568 $154.00

93312 $322.00 93456-26 $341.00 93571 $270.00

93312-26 $140.00 93456-TC $791.00 93571-26 $93.00

93312-TC $182.00 93457 $1,280.00 93571-TC $170.00

93313 $76.00 93457-26 $383.00 93572 $222.00

93314 $212.00 93457-TC $897.00 93572-26 $74.00

93314-26 $65.00 93458 $1,084.00 93572-TC $155.00

93314-TC $144.00 93458-26 $326.00 93580 $974.00

93315 $287.00 93458-TC $758.00 93581 $1,303.00

93315-26 $144.00 93459 $1,197.00 93582 $697.00

93315-TC $141.00 93459-26 $367.00 93583 $776.00

93316 $78.00 93459-TC $830.00 93600 $198.00

93317 $236.00 93460 $1,284.00 93600-26 $129.00

93317-26 $95.00 93460-26 $408.00 93600-TC $73.00

93317-TC $141.00 93460-TC $875.00 93602 $159.00

93318 $412.00 93461 $1,468.00 93602-26 $119.00

93318-26 $114.00 93461-26 $451.00 93602-TC $42.00

93318-TC $384.00 93461-TC $1,018.00 93603 $187.00

93320 $86.00 93462 $215.00 93603-26 $127.00

93320-26 $30.00 93463 $109.00 93603-TC $63.00

93320-TC $65.00 93464 $284.00 93609 $578.00

93321 $50.00 93464-26 $99.00 93609-26 $481.00

93321-26 $10.00 93464-TC $186.00 93609-TC $101.00

93321-TC $42.00 93503 $187.00 93610 $214.00

93325 $114.00 93505 $318.00 93610-26 $166.00





93610-TC $52.00 93655 $432.00 93893 $251.00

93612 $224.00 93656 $1,153.00 93893-26 $63.00

93612-26 $167.00 93657 $433.00 93893-TC $188.00

93612-TC $61.00 93660 $162.00 93922 $60.00

93613 $377.00 93660-26 $103.00 93922-26 $16.00

93615 $62.00 93660-TC $61.00 93922-TC $44.00

93615-26 $49.00 93662 BR 93923 $112.00

93615-TC $12.00 93662-26 $158.00 93923-26 $28.00

93616 $94.00 93662-TC BR 93923-TC $85.00

93616-26 $82.00 93701 $36.00 93924 $122.00

93616-TC $12.00 93701-26 $9.00 93924-26 $31.00

93618 $399.00 93701-TC $27.00 93924-TC $92.00

93618-26 $258.00 93702 $109.00 93925 $175.00

93618-TC $148.00 93724 $411.00 93925-26 $31.00

93619 $717.00 93724-26 $259.00 93925-TC $144.00

93619-26 $444.00 93724-TC $148.00 93926 $117.00

93619-TC $290.00 93740 $17.00 93926-26 $21.00

93620 $358.00 93740-26 $12.00 93926-TC $96.00

93620-26 $272.00 93740-TC $5.00 93930 $174.00

93620-TC $91.00 93750 $55.00 93930-26 $26.00

93621 BR 93770 NC 93930-TC $150.00

93621-26 $769.00 93770-26 NC 93931 $118.00

93621-TC BR 93770-TC NC 93931-26 $17.00

93622 BR 93784 NC 93931-TC $101.00

93622-26 $771.00 93786 NC 93970 $189.00

93622-TC BR 93788 NC 93970-26 $36.00

93623 BR 93790 NC 93970-TC $154.00

93623-26 $167.00 93797 $17.00 93971 $121.00

93623-TC BR 93798 $38.00 93971-26 $23.00

93624 $333.00 93799 BR 93971-TC $96.00

93624-26 $256.00 93799-26 BR 93975 $277.00

93624-TC $74.00 93799-TC BR 93975-26 $89.00

93631 $651.00 93880 $176.00 93975-TC $181.00

93631-26 $420.00 93880-26 $31.00 93976 $184.00

93631-TC $239.00 93880-TC $144.00 93976-26 $59.00

93640 $467.00 93882 $117.00 93976-TC $121.00

93640-26 $230.00 93882-26 $21.00 93978 $177.00

93640-TC $269.00 93882-TC $95.00 93978-26 $34.00

93641 $613.00 93886 $215.00 93978-TC $143.00

93641-26 $360.00 93886-26 $50.00 93979 $122.00

93641-TC $269.00 93886-TC $162.00 93979-26 $23.00

93642 $549.00 93888 $142.00 93979-TC $98.00

93642-26 $295.00 93888-26 $33.00 93980 $183.00

93642-TC $269.00 93888-TC $109.00 93980-26 $65.00

93644 $282.00 93890 $241.00 93980-TC $105.00

93644-26 $176.00 93890-26 $55.00 93981 $148.00

93644-TC $106.00 93890-TC $185.00 93981-26 $25.00

93650 $639.00 93892 $256.00 93981-TC $124.00

93653 $865.00 93892-26 $63.00 93982 $10.00

93654 $1,152.00 93892-TC $193.00 93990 $110.00





93990-26 $14.00 94644 $36.00 95056 $6.00

93990-TC $96.00 94645 $14.00 95060 $13.00

94002 $84.00 94660 $54.00 95065 $7.00

94003 $61.00 94662 $38.00 95070 $82.00

94004 $45.00 94664 $18.00 95071 $105.00

94010 $30.00 94667 $23.00 95076 $117.00

94010-26 $12.00 94668 $16.00 95079 $84.00

94010-TC $16.00 94669 $35.00 95115 $10.00

94014 $39.00 94680 $47.00 95117 $9.00

94015 $14.00 94680-26 $23.00 95120 BR

94016 $26.00 94680-TC $22.00 95125 BR

94060 $57.00 94681 $60.00 95130 BR

94060-26 $18.00 94681-26 $12.00 95131 BR

94060-TC $36.00 94681-TC $43.00 95132 BR

94070 $32.00 94690 $24.00 95133 BR

94070-26 $11.00 94690-26 $4.00 95134 BR

94070-TC $19.00 94690-TC $20.00 95144 $9.00

94150 $8.00 94726 $53.00 95145 $17.00

94150-26 $6.00 94726-26 $13.00 95146 $24.00

94150-TC $3.00 94726-TC $41.00 95147 $33.00

94200 $17.00 94727 $42.00 95148 $32.00

94200-26 $7.00 94727-26 $13.00 95149 $36.00

94200-TC $9.00 94727-TC $30.00 95165 $7.00

94250 $12.00 94728 $40.00 95170 $13.00

94250-26 $8.00 94728-26 $13.00 95180 $103.00

94250-TC $5.00 94728-TC $28.00 95199 BR

94375 $34.00 94729 $54.00 95250 $114.00

94375-26 $16.00 94729-26 $9.00 95251 $28.00

94375-TC $17.00 94729-TC $45.00 95803 $151.00

94400 $40.00 94750 $37.00 95803-26 $44.00

94400-26 $24.00 94750-26 $14.00 95803-TC $107.00

94400-TC $14.00 94750-TC $21.00 95805 $334.00

94450 $37.00 94760 $9.00 95805-26 $94.00

94450-26 $20.00 94761 $20.00 95805-TC $237.00

94450-TC $15.00 94762 $30.00 95806 $232.00

94452 $52.00 94770 $21.00 95806-26 $109.00

94452-26 $16.00 94770-26 $9.00 95806-TC $137.00

94452-TC $36.00 94770-TC $12.00 95807 $367.00

94453 $74.00 94799 BR 95807-26 $98.00

94453-26 $20.00 94799-26 BR 95807-TC $256.00

94453-TC $53.00 94799-TC BR 95808 $456.00

94610 $63.00 95004 $3.00 95808-26 $149.00

94620 $91.00 95012 $19.00 95808-TC $256.00

94620-26 $38.00 95017 $8.00 95810 $521.00

94620-TC $54.00 95018 $20.00 95810-26 $183.00

94621 $122.00 95024 $3.00 95810-TC $256.00

94621-26 $71.00 95027 $5.00 95811 $644.00

94621-TC $52.00 95028 $8.00 95811-26 $196.00

94640 $19.00 95044 $7.00 95811-TC $423.00

94642 BR 95052 $9.00 95812 $137.00





95812-26 $58.00 95867-26 $43.00 95912 $266.00

95812-TC $68.00 95867-TC $21.00 95912-26 $161.00

95813 $177.00 95868 $96.00 95912-TC $105.00

95813-26 $89.00 95868-26 $71.00 95913 $308.00

95813-TC $68.00 95868-TC $26.00 95913-26 $191.00

95816 $133.00 95869 $29.00 95913-TC $117.00

95816-26 $54.00 95869-26 $21.00 95921 $61.00

95816-TC $78.00 95869-TC $8.00 95921-26 $46.00

95819 $115.00 95870 $29.00 95921-TC $14.00

95819-26 $58.00 95870-26 $21.00 95922 $65.00

95819-TC $56.00 95870-TC $8.00 95922-26 $50.00

95822 $120.00 95872 $104.00 95922-TC $14.00

95822-26 $58.00 95872-26 $81.00 95923 $105.00

95822-TC $63.00 95872-TC $22.00 95923-26 $47.00

95824 $51.00 95873 $29.00 95923-TC $57.00

95824-26 $41.00 95873-26 $21.00 95924 $147.00

95824-TC $10.00 95873-TC $8.00 95924-26 $90.00

95827 $145.00 95874 $30.00 95924-TC $57.00

95827-26 $59.00 95874-26 $21.00 95925 $94.00

95827-TC $86.00 95874-TC $8.00 95925-26 $53.00

95829 $328.00 95875 $43.00 95925-TC $41.00

95829-26 $291.00 95875-26 $34.00 95926 $66.00

95829-TC $6.00 95875-TC $7.00 95926-26 $34.00

95830 $133.00 95885 $59.00 95926-TC $34.00

95831 $26.00 95885-26 $19.00 95927 $67.00

95832 $21.00 95885-TC $40.00 95927-26 $34.00

95833 $34.00 95886 $92.00 95927-TC $34.00

95834 $44.00 95886-26 $47.00 95928 $175.00

95851 $18.00 95886-TC $45.00 95928-26 $84.00

95852 $14.00 95887 $87.00 95928-TC $91.00

95857 $40.00 95887-26 $38.00 95929 $182.00

95860 $73.00 95887-TC $48.00 95929-26 $84.00

95860-26 $53.00 95905 $68.00 95929-TC $98.00

95860-TC $15.00 95905-26 $3.00 95930 $44.00

95861 $113.00 95905-TC $66.00 95930-26 $25.00

95861-26 $86.00 95907 $95.00 95930-TC $11.00

95861-TC $28.00 95907-26 $54.00 95933 $62.00

95863 $138.00 95907-TC $42.00 95933-26 $33.00

95863-26 $102.00 95908 $117.00 95933-TC $30.00

95863-TC $35.00 95908-26 $67.00 95937 $40.00

95864 $177.00 95908-TC $51.00 95937-26 $31.00

95864-26 $114.00 95909 $142.00 95937-TC $9.00

95864-TC $67.00 95909-26 $80.00 95938 $339.00

95865 $119.00 95909-TC $61.00 95938-26 $47.00

95865-26 $92.00 95910 $186.00 95938-TC $292.00

95865-TC $27.00 95910-26 $107.00 95939 $495.00

95866 $80.00 95910-TC $79.00 95939-26 $122.00

95866-26 $71.00 95911 $226.00 95939-TC $373.00

95866-TC $9.00 95911-26 $134.00 95940 $33.00

95867 $66.00 95911-TC $92.00 95950 $265.00





95950-26 $84.00 95992 $44.00 96416 $186.00

95950-TC $177.00 95999 BR 96417 $85.00

95951 $34.00 96000 $93.00 96420 $46.00

95951-26 $14.00 96001 $111.00 96422 $46.00

95951-TC $20.00 96002 $21.00 96423 $17.00

95953 $411.00 96003 $20.00 96425 $54.00

95953-26 $165.00 96004 $97.00 96440 $156.00

95953-TC $240.00 96020 BR 96446 $193.00

95954 $208.00 96020-26 $156.00 96450 $134.00

95954-26 $134.00 96020-TC BR 96521 $153.00

95954-TC $23.00 96101 $97.00 96522 $111.00

95955 $130.00 96102 $44.00 96523 $28.00

95955-26 $59.00 96103 $28.00 96542 $126.00

95955-TC $74.00 96105 $68.00 96549 BR

95956 $541.00 96110 $88.00 96567 $62.00

95956-26 $166.00 96111 $68.00 96570 $69.00

95956-TC $314.00 96116 $109.00 96571 $38.00

95957 $171.00 96118 $130.00 96900 $17.00

95957-26 $104.00 96119 $66.00 96904 $70.00

95957-TC $64.00 96120 $48.00 96910 $21.00

95958 $296.00 96125 $57.00 96912 $24.00

95958-26 $230.00 96127 $5.00 96913 $53.00

95958-TC $66.00 96150 $26.00 96920 $152.00

95961 $216.00 96151 $25.00 96921 $155.00

95961-26 $166.00 96152 $24.00 96922 $214.00

95961-TC $48.00 96153 $6.00 96931 $162.00

95962 $227.00 96154 $24.00 96932 $29.00

95962-26 $176.00 96155 $22.00 96933 $46.00

95962-TC $48.00 96360 $57.00 96934 $83.00

95965 BR 96361 $15.00 96935 $35.00

95965-26 $420.00 96365 $69.00 96936 $44.00

95965-TC BR 96366 $19.00 96999 BR

95966 BR 96367 $30.00 97010 $10.00

95966-26 $210.00 96368 $20.00 97012 $16.00

95966-TC BR 96369 $195.00 97014 $14.00

95967 BR 96370 $15.00 97016 $15.00

95967-26 $184.00 96371 $91.00 97018 $10.00

95967-TC BR 96372 $25.00 97022 $15.00

95970 $22.00 96373 $19.00 97024 $10.00

95971 $39.00 96374 $56.00 97026 $9.00

95972 $78.00 96375 $22.00 97028 $10.00

95974 $155.00 96377 BR 97032 $16.00

95975 $88.00 96401 $53.00 97033 $16.00

95978 $213.00 96402 $46.00 97034 $13.00

95979 $98.00 96405 $57.00 97035 $11.00

95980 $27.00 96406 $86.00 97036 $19.00

95981 $10.00 96409 $122.00 97039 $15.00

95982 $22.00 96411 $71.00 97110 $22.00

95990 $57.00 96413 $173.00 97112 $23.00

95991 $84.00 96415 $39.00 97113 $24.00





97116 $21.00 97853 $26.00 G0118 $27.00

97124 $19.00 98925 NC G0120 $179.00

97139 $15.00 98926 $32.00 G0120-26 $46.00

97140 $26.00 98927 NC G0120-TC $132.00

97150 $18.00 98928 $23.00 G0121 $344.00

97161 $82.00 98929 NC G0121-53 $115.00

97162 $82.00 98940 NC G0122 $177.00

97163 $82.00 98941 $32.00 G0122-26 $45.00

97164 $56.00 98942 NC G0122-TC $132.00

97165 $79.00 98943 $23.00 G0128 $4.00

97166 $79.00 98960 $19.00 G0166 $138.00

97167 $79.00 98961 $9.00 G0179 $41.00

97168 $52.00 98962 $7.00 G0180 $54.00

97169 BR 99000 $6.00 G0181 $99.00

97170 BR 99001 $4.00 G0182 $102.00

97171 BR 99002 $35.00 G0237 $12.00

97172 BR 99026 BR G0238 $13.00

97260 $23.00 99027 BR G0239 $11.00

97261 $17.00 99070 BR G0248 $168.00

97530 $22.00 99071 NC G0249 $124.00

97532 $22.00 99075 See 440.13 G0250 $9.00

97533 $24.00 99078 NC G0268 $43.00

97535 $23.00 99082 BR G0270 $22.00

97537 $23.00 99090 BR G0271 $13.00

97542 $17.00 99152 $52.00 G0277 $45.00

97545 $83.00 99153 $11.00 G0281 $10.00

97546 $41.00 99156 $77.00 G0283 $10.00

97597 $49.00 99157 $58.00 G0329 $7.00

97598 $62.00 99172 BR G0403 $17.00

97602 BR 99173 $3.00 G0404 $8.00

97605 $34.00 99174 $8.00 G0405 $9.00

97606 $37.00 99175 $53.00 G0422 $103.00

97610 $121.00 99183 $123.00 G0423 $103.00

97750 BR 99184 $232.00 G0424 $30.00

97752 $48.00 99190 BR G0453 $33.00

97755 $35.00 99191 BR G0454 $9.00

97760 $31.00 99192 BR G0459 $49.00

97761 $28.00 99195 $16.00 G0473 $13.00

97762 $26.00 99199 NC G0500 $59.00

97799 BR G0101 $32.00 G0502 $143.00

97802 $26.00 G0102 $18.00 G0503 $126.00

97803 $17.00 G0104 $115.00 G0504 $66.00

97804 $7.00 G0105 $344.00 G0505 $238.00

97810 $35.00 G0105-53 $115.00 G0506 $64.00

97811 $27.00 G0106 $165.00 G9157 $112.00

97813 $37.00 G0106-26 $46.00 G9187 $48.00

97814 $30.00 G0106-TC $119.00 P3001 $24.00

97850 $54.00 G0108 $24.00 Q0035 $19.00

97851 $26.00 G0109 $14.00 Q0035-26 $8.00

97852 $54.00 G0117 $40.00 Q0035-TC $11.00



Medicine

CPT Code MRA

Q0091 $37.00



Evaluation & Management Evaluation & Management Evaluation & Managemen


99201 $35.00 99309 $80.00 99457 BR

99202 $58.00 99310 $100.00 99487 $52.00

99203 $58.00 99315 $60.00 99489 $41.00

99204 $84.00 99316 $77.00 99490 $41.00

99205 $84.00 99318 $66.00 99495 $164.00

99211 $19.00 99324 $59.00 99496 $232.00

99212 $31.00 99325 $86.00 99497 $86.00

99213 $40.00 99326 $125.00 99498 $75.00

99214 $40.00 99327 $164.00 99499 BR

99215 $65.00 99328 $203.00 99600 BR

99217 $65.00 99334 $45.00 G0245 $58.00

99218 $65.00 99335 $72.00 G0246 $34.00

99219 $109.00 99336 $111.00 G0296 $29.00

99220 $152.00 99337 $163.00 G0337 $62.00

99221 $66.00 99339 $67.00 G0372 $13.00

99222 $109.00 99340 $93.00 G0396 $29.00

99223 $152.00 99341 $59.00 G0397 $56.00

99224 $40.00 99342 $85.00 G0402 $165.00

99225 $73.00 99343 $109.00 G0406 $39.00

99226 $105.00 99344 $160.00 G0407 $72.00

99231 $33.00 99345 $193.00 G0408 $104.00

99232 $54.00 99347 $46.00 G0409 $16.00

99233 $77.00 99348 $71.00 G0507 $48.00

99234 $129.00 99349 $107.00 G0508 $201.00

99235 $173.00 99350 $156.00 G0509 $194.00

99236 $213.00 99354 $106.00 G9685 $206.00

99238 $66.00 99355 $104.00 G9686 $80.00

99239 $88.00 99356 $87.00

99241 $54.00 99357 $88.00

99242 $88.00 99360 $47.00

99243 $117.00 99363 $108.00

99244 $163.00 99364 $38.00

99245 $212.00 99366 $37.00

99251 $54.00 99367 $48.00

99252 $70.00 99368 $31.00

99253 $96.00 99374 $75.00

99254 $138.00 99375 $75.00

99255 $190.00 99377 $75.00

99281 $18.00 99378 $104.00

99282 $28.00 99379 $75.00

99283 $60.00 99380 $104.00

99284 $94.00 99406 $12.00

99285 $103.00 99407 $24.00

99291 $192.00 99408 $29.00

99292 $95.00 99409 $58.00

99304 $66.00 99415 $9.00

99305 $88.00 99416 $5.00

99306 $108.00 99450 NC

99307 $34.00 99455 $90.00

99308 $56.00 99456 BR



Dental Dental Dental

D-Code MRA D-Code MRA D-Code MRA

D0120 $17.00 D2390 $57.00 D2951 $20.00

D0140 $13.00 D2391 $43.00 D2952 $79.00

D0150 $20.00 D2392 $55.00 D2953 $133.00

D0160 $36.00 D2393 $63.00 D2954 $102.00

D0170 $18.00 D2394 $69.00 D2955 $81.00

D0180 $20.00 D2410 $163.00 D2957 $71.00

D0210 $40.00 D2420 $203.00 D2960 $121.00

D0220 $10.00 D2430 $293.00 D2961 $204.00

D0230 $5.00 D2510 $155.00 D2962 $294.00

D0240 $12.00 D2520 $259.00 D2980 $83.00

D0250 $20.00 D2530 $244.00 D2999 BR

D0270 $7.00 D2542 $302.00 D3110 $25.00

D0272 $12.00 D2543 $318.00 D3120 $20.00

D0274 $20.00 D2544 $348.00 D3220 $61.00

D0277 $18.00 D2610 $206.00 D3221 $81.00

D0310 $50.00 D2620 $266.00 D3230 $70.00

D0320 $204.00 D2630 $348.00 D3240 $75.00

D0321 $64.00 D2642 $287.00 D3310 $206.00

D0322 $105.00 D2643 $328.00 D3320 $204.00

D0330 $29.00 D2644 $378.00 D3330 $287.00

D0340 $40.00 D2650 $206.00 D3331 $102.00

D0350 $10.00 D2651 $266.00 D3332 $110.00

D0415 $34.00 D2652 $348.00 D3333 $53.00

D0425 $25.00 D2662 $266.00 D3346 $225.00

D0460 $13.00 D2663 $328.00 D3347 $274.00

D0470 $24.00 D2664 $348.00 D3348 $337.00

D0472 $30.00 D2710 $194.00 D3351 $102.00

D0473 BR D2720 $410.00 D3352 $81.00

D0474 BR D2721 $306.00 D3353 $163.00

D0480 BR D2722 $348.00 D3410 $179.00

D0502 $54.00 D2740 $410.00 D3421 $194.00

D0999 BR D2750 $451.00 D3425 $206.00

D1110 $29.00 D2751 $328.00 D3426 $77.00

D1310 $23.00 D2752 $368.00 D3430 $55.00

D1320 $48.00 D2780 $368.00 D3450 $102.00

D1330 $13.00 D2781 $266.00 D3460 $318.00

D1351 $21.00 D2782 $306.00 D3470 $204.00

D1510 $81.00 D2783 $389.00 D3910 $50.00

D1515 $121.00 D2790 $389.00 D3920 $102.00

D1520 $102.00 D2791 $287.00 D3950 $61.00

D1525 $143.00 D2792 $328.00 D3999 BR

D1550 $14.00 D2799 $204.00 D4210 $114.00

D2140 $38.00 D2910 $29.00 D4211 $50.00

D2150 $44.00 D2920 $29.00 D4240 $223.00

D2160 $54.00 D2930 $81.00 D4241 $63.00

D2161 $67.00 D2931 $121.00 D4245 $265.00

D2330 $40.00 D2932 $77.00 D4249 $208.00

D2331 $61.00 D2933 $91.00 D4260 $328.00

D2332 $66.00 D2940 $29.00 D4261 $164.00

D2335 $81.00 D2950 $81.00 D4263 $195.00





D4264 $159.00 D5750 $132.00 D5999 BR

D4265 $96.00 D5751 $163.00 D6010 $649.00

D4266 $285.00 D5760 $100.00 D6040 $3,016.00

D4267 $328.00 D5761 $163.00 D6050 $1,557.00

D4268 $273.00 D5810 $244.00 D6055 $769.00

D4270 $155.00 D5811 $244.00 D6056 $265.00

D4273 $337.00 D5820 $194.00 D6057 $303.00

D4274 $208.00 D5821 $204.00 D6058 $392.00

D4275 $178.00 D5850 $46.00 D6059 $418.00

D4276 $194.00 D5851 $50.00 D6060 $289.00

D4320 $77.00 D5862 $181.00 D6061 $379.00

D4321 $55.00 D5867 $36.00 D6062 $365.00

D4341 $79.00 D5875 $100.00 D6063 $359.00

D4342 $55.00 D5899 BR D6064 $377.00

D4355 $50.00 D5911 $81.00 D6065 $513.00

D4381 $69.00 D5912 $121.00 D6066 $513.00

D4910 $40.00 D5913 $2,052.00 D6067 $513.00

D4920 $27.00 D5914 $2,052.00 D6068 $365.00

D4999 BR D5915 $2,770.00 D6069 $359.00

D5110 $513.00 D5916 $2,874.00 D6070 $322.00

D5120 $513.00 D5919 BR D6071 $326.00

D5130 $563.00 D5922 $1,334.00 D6072 $365.00

D5140 $563.00 D5923 $1,641.00 D6073 $346.00

D5211 $256.00 D5924 BR D6074 $350.00

D5212 $259.00 D5925 BR D6075 $414.00

D5213 $614.00 D5926 $1,026.00 D6076 $402.00

D5214 $614.00 D5927 $1,026.00 D6077 $447.00

D5281 $279.00 D5928 $1,384.00 D6080 $71.00

D5410 $27.00 D5929 BR D6090 $229.00

D5411 $27.00 D5931 $656.00 D6095 $247.00

D5421 $27.00 D5932 $1,539.00 D6100 $264.00

D5422 $27.00 D5933 $306.00 D6199 BR

D5510 $61.00 D5934 $1,539.00 D6210 $410.00

D5520 $40.00 D5935 $1,539.00 D6211 $287.00

D5610 $61.00 D5936 $563.00 D6212 $328.00

D5620 $83.00 D5937 BR D6240 $451.00

D5630 $22.00 D5951 $614.00 D6241 $368.00

D5640 $53.00 D5953 $614.00 D6242 $410.00

D5650 $61.00 D5954 BR D6245 $309.00

D5660 $102.00 D5955 $1,334.00 D6250 $410.00

D5670 $305.00 D5958 $780.00 D6251 $287.00

D5671 $305.00 D5959 $244.00 D6252 $368.00

D5710 $204.00 D5960 $163.00 D6253 $51.00

D5711 $204.00 D5982 $167.00 D6545 $195.00

D5720 $163.00 D5983 BR D6548 $281.00

D5721 $163.00 D5984 BR D6600 $155.00

D5730 $121.00 D5985 $574.00 D6601 $166.00

D5731 $121.00 D5986 $61.00 D6602 $172.00

D5740 $102.00 D5987 BR D6603 $203.00

D5741 $102.00 D5988 $219.00 D6604 $110.00





D6605 $141.00 D7320 $108.00 D7852 $2,011.00

D6606 $139.00 D7340 $195.00 D7854 $2,052.00

D6607 $151.00 D7350 $410.00 D7856 BR

D6608 $170.00 D7410 $102.00 D7858 $2,298.00

D6609 $178.00 D7411 $100.00 D7860 $614.00

D6610 $203.00 D7412 $139.00 D7865 $1,723.00

D6611 $217.00 D7413 $205.00 D7870 $81.00

D6612 $141.00 D7414 $180.00 D7871 BR

D6613 $155.00 D7415 $291.00 D7872 $533.00

D6614 $151.00 D7440 $161.00 D7873 $584.00

D6615 $162.00 D7441 $247.00 D7874 $737.00

D6720 $410.00 D7450 $139.00 D7875 $789.00

D6721 $233.00 D7451 $179.00 D7876 $820.00

D6722 $348.00 D7460 $137.00 D7877 $758.00

D6740 $328.00 D7461 $195.00 D7880 $291.00

D6750 $356.00 D7465 $71.00 D7899 BR

D6751 $328.00 D7471 $174.00 D7910 $73.00

D6752 $410.00 D7472 $143.00 D7911 $110.00

D6780 $389.00 D7473 $147.00 D7912 $163.00

D6781 $320.00 D7485 $162.00 D7920 $676.00

D6782 $322.00 D7490 $2,545.00 D7940 $841.00

D6783 $324.00 D7510 $54.00 D7941 $2,874.00

D6790 $389.00 D7520 $121.00 D7943 $2,914.00

D6791 $287.00 D7530 $85.00 D7944 $2,298.00

D6792 $348.00 D7540 $121.00 D7945 $2,319.00

D6793 $30.00 D7550 $143.00 D7946 $2,566.00

D6920 $279.00 D7560 $266.00 D7947 $2,566.00

D6930 $40.00 D7610 $1,189.00 D7948 $2,874.00

D6940 $102.00 D7620 $984.00 D7949 $4,186.00

D6950 $155.00 D7630 $1,354.00 D7950 $881.00

D6980 $106.00 D7640 $820.00 D7955 $922.00

D6999 BR D7650 $1,292.00 D7960 $121.00

D7140 $45.00 D7660 $780.00 D7970 $137.00

D7210 $70.00 D7670 $410.00 D7971 $67.00

D7220 $111.00 D7671 $779.00 D7972 BR

D7230 $139.00 D7680 $1,949.00 D7980 $169.00

D7240 $147.00 D7710 $1,415.00 D7981 $820.00

D7241 $204.00 D7720 $903.00 D7982 $306.00

D7250 $81.00 D7730 $1,580.00 D7983 $244.00

D7260 $244.00 D7740 $922.00 D7990 $340.00

D7270 $147.00 D7750 $1,334.00 D7991 $820.00

D7272 $204.00 D7760 $1,046.00 D7995 BR

D7280 $121.00 D7770 $533.00 D7996 BR

D7282 $41.00 D7771 $73.00 D7997 BR

D7285 $106.00 D7780 $2,504.00 D7999 BR

D7286 $81.00 D7810 $1,292.00 D8010 $451.00

D7287 BR D7820 $110.00 D8020 $533.00

D7290 $133.00 D7830 $186.00 D8030 $718.00

D7291 $77.00 D7840 $1,764.00 D8040 $583.00

D7310 $85.00 D7850 $1,682.00 D8050 $676.00



Dental

D-Code MRA

D8060 $758.00

D8070 $1,867.00

D8080 $1,867.00

D8090 $1,949.00

D8210 $155.00

D8220 $179.00

D8660 $73.00

D8670 $54.00

D8680 $171.00

D8690 $71.00

D8691 $67.00

D8692 $104.00

D8999 BR

D9110 $40.00

D9210 $14.00

D9211 $14.00

D9212 $13.00

D9215 $7.00

D9230 $18.00

D9248 $91.00

D9310 $41.00

D9410 $61.00

D9420 $46.00

D9430 $23.00

D9440 $41.00

D9450 BR

D9610 $20.00

D9630 $10.00

D9910 $21.00

D9911 $21.00

D9920 $32.00

D9930 $34.00

D9940 $204.00

D9941 $58.00

D9950 $114.00

D9951 $46.00

D9952 $163.00

D9970 $83.00

D9971 $55.00

D9972 $113.00

D9973 $40.00

D9974 $50.00

D9999 BR



Injections Injections Injections

J-Code MRA J-Code MRA J-Code MRA

J0120 $12.00 J0702 $4.00 J1450 BR

J0130 BR J0710 $3.00 J1455 $12.00

J0190 $3.00 J0713 $8.00 J1460 $2.00

J0200 BR J0715 $6.00 J1560 BR

J0205 $38.00 J0720 $6.00 J1570 $36.00

J0207 BR J0725 $3.00 J1580 $3.00

J0210 $7.00 J0735 BR J1595 BR

J0215 BR J0740 BR J1600 $10.00

J0256 $101.00 J0743 $14.00 J1610 $27.00

J0280 $1.00 J0744 BR J1620 $69.00

J0282 BR J0745 $1.00 J1626 BR

J0285 BR J0770 $32.00 J1630 $4.00

J0287 BR J0780 $3.00 J1631 $28.00

J0288 BR J0800 $18.00 J1642 $1.00

J0289 BR J0850 $362.00 J1644 $1.00

J0290 $2.00 J0895 $10.00 J1645 BR

J0295 $7.00 J0945 $1.00 J1650 $16.00

J0300 $2.00 J1000 $3.00 J1652 BR

J0330 $1.00 J1020 $1.00 J1655 BR

J0350 $2,408.00 J1030 $2.00 J1670 $23.00

J0360 $6.00 J1040 $3.00 J1700 $1.00

J0380 $1.00 J1094 BR J1710 $5.00

J0390 $3.00 J1100 $1.00 J1720 $4.00

J0395 BR J1110 $10.00 J1730 $94.00

J0456 BR J1120 $35.00 J1742 BR

J0470 $11.00 J1160 $2.00 J1745 BR

J0475 $201.00 J1165 $1.00 J1750 BR

J0476 BR J1170 $1.00 J1756 BR

J0500 $3.00 J1180 $1.00 J1790 $4.00

J0515 $3.00 J1190 BR J1800 $10.00

J0520 $5.00 J1200 $1.00 J1810 $6.00

J0583 BR J1205 $9.00 J1815 BR

J0585 $393.00 J1212 $36.00 J1817 BR

J0587 BR J1230 $1.00 J1830 $76.00

J0592 BR J1240 $1.00 J1835 BR

J0595 BR J1245 $31.00 J1840 $7.00

J0600 $6.00 J1250 $49.00 J1850 $4.00

J0610 $1.00 J1260 BR J1885 $7.00

J0620 $3.00 J1270 BR J1890 $11.00

J0630 $21.00 J1320 $1.00 J1940 $1.00

J0636 BR J1325 BR J1950 $411.00

J0637 BR J1327 BR J1955 $37.00

J0640 $22.00 J1330 $2.00 J1956 BR

J0670 BR J1335 BR J1960 $2.00

J0690 $3.00 J1364 $6.00 J1980 $3.00

J0692 BR J1380 $1.00 J1990 $8.00

J0694 $10.00 J1410 $33.00 J2001 BR

J0696 $11.00 J1435 $1.00 J2010 $2.00

J0697 $6.00 J1436 $68.00 J2020 BR

J0698 $11.00 J1438 BR J2060 $12.00



Injections Injections Injections

J-Code MRA J-Code MRA J-Code MRA

J2150 $3.00 J2795 BR J7030 $11.00

J2175 $1.00 J2800 $3.00 J7040 $10.00

J2180 $3.00 J2810 $3.00 J7042 $10.00

J2185 BR J2820 $115.00 J7050 $10.00

J2210 $3.00 J2910 $11.00 J7060 $10.00

J2250 $2.00 J2916 BR J7070 $11.00

J2260 $32.00 J2920 $5.00 J7100 $137.00

J2270 $1.00 J2930 $13.00 J7110 $93.00

J2280 BR J2940 BR J7120 $12.00

J2300 $2.00 J2941 BR J7190 $241.00

J2310 $3.00 J2950 $1.00 J7191 BR

J2320 $5.00 J2993 BR J7192 $316.00

J2353 BR J2995 BR J7193 BR

J2354 BR J2997 BR J7194 $120.00

J2355 BR J3000 $2.00 J7195 BR

J2360 $2.00 J3010 $2.00 J7197 $284.00

J2370 $3.00 J3030 $34.00 J7198 BR

J2400 BR J3070 $4.00 J7199 BR

J2405 $6.00 J3105 $2.00 J7320 $0.00

J2410 $3.00 J3230 $2.00 J7501 $98.00

J2430 $189.00 J3240 $214.00 J7504 $282.00

J2440 $2.00 J3250 $1.00 J7505 $576.00

J2460 $1.00 J3260 $7.00 J7513 BR

J2501 BR J3265 $2.00 J7516 BR

J2505 BR J3280 $5.00 J7599 BR

J2510 $1.00 J3301 $1.00

J2515 $1.00 J3302 $1.00

J2540 $1.00 J3303 $1.00

J2543 BR J3305 $55.00

J2545 $105.00 J3310 $5.00

J2550 $1.00 J3320 $16.00

J2560 $5.00 J3350 $72.00

J2590 $1.00 J3360 $1.00

J2597 $20.00 J3364 $52.00

J2650 $1.00 J3365 $433.00

J2670 BR J3370 $9.00

J2680 $16.00 J3400 $12.00

J2690 $7.00 J3410 $1.00

J2700 $2.00 J3411 BR

J2710 $1.00 J3415 BR

J2720 $1.00 J3420 $1.00

J2725 $11.00 J3430 $2.00

J2730 $29.00 J3465 BR

J2760 $29.00 J3470 $7.00

J2765 $2.00 J3475 $1.00

J2770 BR J3480 $1.00

J2780 BR J3485 BR

J2783 BR J3486 BR

J2790 $36.00 J3490 BR

J2792 BR J3590 BR

2017 Edition Effective Date: _________


PART B


ALLOWANCES

Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2017 EditionDRAFT RULE- 69L-7.020, F.A.C., Effective _________

CPT only © 2016 American Medical Association. All rights reserved. Part B, 169

Surgery

CPT Code FUD 2003 MRALocality 01/02

(Non-Facility MRA)

Locality 03 (Non-Facility MRA)


Locality 01/02 (Facility MRA)

Locality 03 (Facility MRA)


10021 0 $90.00 $173.00 $183.00 $191.00 $102.00 $108.00 $114.00

10022 0 $92.00 $197.00 $209.00 $215.00 $96.00 $100.00 $105.00

10030 0 ---------- $969.00 $1,036.00 $1,070.00 $233.00 $250.00 $275.00

10035 0 ---------- $741.00 $789.00 $805.00 $132.00 $139.00 $148.00

10036 ZZZ ---------- $638.00 $680.00 $690.00 $65.00 $69.00 $73.00

10040 10 $54.00 $145.00 $153.00 $161.00 $127.00 $135.00 $142.00

10060 10 $53.00 $165.00 $174.00 $180.00 $139.00 $146.00 $152.00

10061 10 $133.00 $293.00 $309.00 $322.00 $258.00 $272.00 $284.00

10080 10 $65.00 $250.00 $266.00 $275.00 $147.00 $156.00 $164.00

10081 10 $203.00 $379.00 $402.00 $418.00 $245.00 $259.00 $274.00

10120 10 $53.00 $213.00 $225.00 $232.00 $147.00 $155.00 $161.00

10121 10 $169.00 $387.00 $410.00 $428.00 $269.00 $284.00 $301.00

10140 10 $53.00 $230.00 $243.00 $252.00 $170.00 $179.00 $188.00

10160 10 $45.00 $183.00 $193.00 $201.00 $137.00 $145.00 $152.00

10180 10 $164.00 $351.00 $375.00 $397.00 $261.00 $279.00 $299.00

11000 0 $45.00 $76.00 $80.00 $83.00 $42.00 $43.00 $45.00

11001 ZZZ $27.00 $31.00 $32.00 $33.00 $21.00 $22.00 $23.00

11004 0 ---------- $867.00 $923.00 $1,003.00 $867.00 $923.00 $1,003.00

11005 0 ---------- $1,182.00 $1,266.00 $1,393.00 $1,182.00 $1,266.00 $1,393.00

11006 0 ---------- $1,058.00 $1,127.00 $1,228.00 $1,058.00 $1,127.00 $1,228.00

11008 ZZZ ---------- $416.00 $446.00 $491.00 $416.00 $446.00 $491.00

11010 10 $348.00 $716.00 $764.00 $801.00 $419.00 $447.00 $481.00

11011 0 $432.00 $763.00 $815.00 $858.00 $445.00 $475.00 $515.00

11012 0 $597.00 $1,013.00 $1,081.00 $1,141.00 $632.00 $675.00 $730.00

11042 0 $88.00 $163.00 $173.00 $178.00 $90.00 $94.00 $99.00

11043 0 $210.00 $325.00 $344.00 $361.00 $229.00 $241.00 $257.00

11044 0 $283.00 $451.00 $479.00 $506.00 $341.00 $361.00 $388.00

11045 ZZZ ---------- $58.00 $62.00 $65.00 $38.00 $41.00 $43.00

11046 ZZZ ---------- $106.00 $113.00 $120.00 $84.00 $89.00 $96.00

11047 ZZZ ---------- $181.00 $193.00 $207.00 $149.00 $158.00 $172.00

11055 0 $26.00 $66.00 $70.00 $71.00 $23.00 $24.00 $25.00

11056 0 $35.00 $81.00 $85.00 $87.00 $33.00 $34.00 $35.00

11057 0 $39.00 $91.00 $96.00 $98.00 $43.00 $44.00 $46.00

11100 0 $78.00 $145.00 $154.00 $159.00 $72.00 $76.00 $80.00

11101 ZZZ $41.00 $47.00 $49.00 $52.00 $37.00 $39.00 $41.00

11200 10 $66.00 $124.00 $132.00 $137.00 $105.00 $111.00 $116.00

11201 ZZZ $26.00 $27.00 $29.00 $31.00 $24.00 $26.00 $27.00

11300 0 $59.00 $136.00 $145.00 $149.00 $52.00 $55.00 $58.00

11301 0 $80.00 $169.00 $179.00 $185.00 $79.00 $83.00 $88.00

11302 0 $96.00 $199.00 $211.00 $218.00 $93.00 $98.00 $104.00

11303 0 $119.00 $220.00 $234.00 $242.00 $109.00 $116.00 $123.00

11305 0 $61.00 $138.00 $146.00 $150.00 $57.00 $60.00 $63.00

11306 0 $86.00 $171.00 $182.00 $187.00 $76.00 $80.00 $84.00

11307 0 $100.00 $202.00 $214.00 $221.00 $98.00 $103.00 $109.00

11308 0 $125.00 $212.00 $224.00 $230.00 $108.00 $112.00 $118.00

11310 0 $75.00 $160.00 $169.00 $175.00 $70.00 $73.00 $78.00

11311 0 $95.00 $157.00 $166.00 $173.00 $96.00 $101.00 $107.00

11312 0 $110.00 $226.00 $240.00 $249.00 $115.00 $122.00 $129.00

11313 0 $144.00 $263.00 $279.00 $291.00 $148.00 $156.00 $166.00

11400 10 $81.00 $174.00 $184.00 $191.00 $115.00 $122.00 $128.00



Surgery


(Non-Facility MRA)






11401 10 $114.00 $210.00 $223.00 $231.00 $150.00 $159.00 $167.00

11402 10 $145.00 $234.00 $249.00 $259.00 $165.00 $175.00 $184.00

11403 10 $178.00 $272.00 $289.00 $304.00 $213.00 $227.00 $240.00

11404 10 $200.00 $309.00 $330.00 $347.00 $236.00 $251.00 $267.00

11406 10 $246.00 $450.00 $480.00 $509.00 $362.00 $386.00 $414.00

11420 10 $98.00 $171.00 $181.00 $187.00 $117.00 $123.00 $129.00

11421 10 $92.00 $220.00 $234.00 $243.00 $159.00 $168.00 $176.00

11422 10 $157.00 $248.00 $263.00 $274.00 $195.00 $207.00 $218.00

11423 10 $163.00 $286.00 $303.00 $318.00 $227.00 $241.00 $255.00

11424 10 $221.00 $332.00 $354.00 $372.00 $262.00 $278.00 $296.00

11426 10 $303.00 $479.00 $510.00 $541.00 $403.00 $428.00 $459.00

11440 10 $105.00 $188.00 $199.00 $206.00 $146.00 $155.00 $160.00

11441 10 $102.00 $236.00 $251.00 $261.00 $188.00 $199.00 $208.00

11442 10 $174.00 $265.00 $282.00 $294.00 $209.00 $222.00 $233.00

11443 10 $221.00 $318.00 $337.00 $354.00 $258.00 $273.00 $289.00

11444 10 $276.00 $401.00 $426.00 $448.00 $330.00 $350.00 $371.00

11446 10 $344.00 $559.00 $593.00 $626.00 $475.00 $504.00 $535.00

11450 90 $282.00 $541.00 $579.00 $609.00 $369.00 $394.00 $423.00

11451 90 $366.00 $691.00 $738.00 $778.00 $476.00 $509.00 $547.00

11462 90 $264.00 $527.00 $563.00 $591.00 $352.00 $376.00 $402.00

11463 90 $351.00 $698.00 $745.00 $782.00 $477.00 $509.00 $544.00

11470 90 $320.00 $584.00 $624.00 $656.00 $409.00 $436.00 $467.00

11471 90 $391.00 $725.00 $773.00 $812.00 $510.00 $543.00 $581.00

11600 10 $148.00 $270.00 $287.00 $298.00 $173.00 $183.00 $192.00

11601 10 $180.00 $323.00 $343.00 $357.00 $217.00 $229.00 $242.00

11602 10 $199.00 $350.00 $372.00 $387.00 $238.00 $252.00 $266.00

11603 10 $226.00 $402.00 $427.00 $446.00 $286.00 $303.00 $321.00

11604 10 $249.00 $447.00 $476.00 $498.00 $316.00 $335.00 $356.00

11606 10 $315.00 $644.00 $686.00 $724.00 $472.00 $502.00 $539.00

11620 10 $150.00 $273.00 $290.00 $302.00 $175.00 $186.00 $196.00

11621 10 $191.00 $325.00 $345.00 $360.00 $218.00 $231.00 $245.00

11622 10 $223.00 $363.00 $385.00 $402.00 $250.00 $265.00 $280.00

11623 10 $259.00 $427.00 $453.00 $475.00 $310.00 $329.00 $349.00

11624 10 $305.00 $483.00 $513.00 $539.00 $353.00 $374.00 $399.00

11626 10 $373.00 $583.00 $621.00 $655.00 $434.00 $461.00 $494.00

11640 10 $168.00 $282.00 $299.00 $311.00 $181.00 $192.00 $202.00

11641 10 $227.00 $336.00 $357.00 $372.00 $227.00 $241.00 $255.00

11642 10 $260.00 $384.00 $408.00 $427.00 $269.00 $285.00 $302.00

11643 10 $305.00 $455.00 $483.00 $507.00 $337.00 $357.00 $380.00

11644 10 $380.00 $561.00 $596.00 $626.00 $418.00 $443.00 $471.00

11646 10 $494.00 $738.00 $784.00 $828.00 $582.00 $618.00 $660.00

11719 0 $22.00 $20.00 $21.00 $21.00 $11.00 $11.00 $12.00

11720 0 $32.00 $45.00 $47.00 $48.00 $21.00 $22.00 $23.00

11721 0 $50.00 $63.00 $66.00 $68.00 $36.00 $37.00 $39.00

11730 0 $62.00 $147.00 $154.00 $158.00 $80.00 $83.00 $87.00

11732 ZZZ $31.00 $45.00 $47.00 $48.00 $26.00 $27.00 $28.00

11740 0 $41.00 $69.00 $73.00 $74.00 $46.00 $48.00 $50.00

11750 10 $156.00 $214.00 $225.00 $231.00 $161.00 $169.00 $174.00

11755 0 $106.00 $186.00 $196.00 $201.00 $111.00 $116.00 $120.00

11760 10 $131.00 $264.00 $280.00 $289.00 $165.00 $174.00 $182.00



Surgery


(Non-Facility MRA)






11762 10 $223.00 $391.00 $412.00 $424.00 $263.00 $275.00 $286.00

11765 10 $65.00 $232.00 $245.00 $250.00 $134.00 $140.00 $144.00

11770 10 $275.00 $395.00 $422.00 $446.00 $272.00 $291.00 $314.00

11771 90 $496.00 $822.00 $880.00 $936.00 $638.00 $683.00 $738.00

11772 90 $585.00 $996.00 $1,066.00 $1,134.00 $840.00 $899.00 $966.00

11900 0 $33.00 $78.00 $83.00 $86.00 $46.00 $48.00 $51.00

11901 0 $37.00 $99.00 $105.00 $110.00 $71.00 $75.00 $80.00

11920 0 $147.00 $241.00 $256.00 $267.00 $166.00 $176.00 $186.00

11921 0 $172.00 $280.00 $297.00 $311.00 $195.00 $207.00 $220.00

11922 ZZZ $40.00 $86.00 $92.00 $95.00 $44.00 $47.00 $50.00

11950 0 $107.00 $111.00 $118.00 $124.00 $78.00 $83.00 $88.00

11951 0 $114.00 $143.00 $152.00 $160.00 $107.00 $113.00 $121.00

11952 0 $155.00 $179.00 $189.00 $200.00 $138.00 $145.00 $156.00

11954 0 $165.00 $226.00 $240.00 $253.00 $169.00 $179.00 $192.00

11960 90 $829.00 $1,373.00 $1,459.00 $1,543.00 $1,373.00 $1,459.00 $1,543.00

11970 90 $632.00 $884.00 $940.00 $996.00 $884.00 $940.00 $996.00

11971 90 $280.00 $659.00 $701.00 $728.00 $456.00 $485.00 $509.00

11976 0 $123.00 $202.00 $214.00 $223.00 $138.00 $144.00 $153.00

12001 0 $84.00 $126.00 $133.00 $139.00 $65.00 $68.00 $73.00

12002 0 $98.00 $153.00 $162.00 $169.00 $86.00 $91.00 $97.00

12004 0 $122.00 $181.00 $192.00 $200.00 $108.00 $114.00 $122.00

12005 0 $165.00 $229.00 $243.00 $255.00 $141.00 $148.00 $159.00

12006 0 $203.00 $271.00 $287.00 $302.00 $173.00 $183.00 $197.00

12007 0 $339.00 $313.00 $332.00 $350.00 $217.00 $229.00 $247.00

12011 0 $98.00 $154.00 $163.00 $170.00 $81.00 $85.00 $91.00

12013 0 $141.00 $161.00 $171.00 $178.00 $86.00 $90.00 $97.00

12014 0 $165.00 $189.00 $200.00 $210.00 $110.00 $116.00 $125.00

12015 0 $207.00 $230.00 $243.00 $255.00 $139.00 $147.00 $158.00

12016 0 $268.00 $291.00 $308.00 $324.00 $190.00 $200.00 $215.00

12017 0 $316.00 $232.00 $245.00 $265.00 $232.00 $245.00 $265.00

12018 0 $515.00 $262.00 $277.00 $298.00 $262.00 $277.00 $298.00

12020 10 $211.00 $396.00 $421.00 $439.00 $274.00 $290.00 $307.00

12021 10 $87.00 $231.00 $246.00 $258.00 $199.00 $211.00 $224.00

12031 10 $93.00 $334.00 $355.00 $369.00 $222.00 $236.00 $249.00

12032 10 $110.00 $426.00 $453.00 $471.00 $283.00 $300.00 $316.00

12034 10 $148.00 $441.00 $469.00 $490.00 $303.00 $321.00 $341.00

12035 10 $223.00 $538.00 $573.00 $600.00 $351.00 $373.00 $398.00

12036 10 $356.00 $599.00 $638.00 $671.00 $410.00 $436.00 $467.00

12037 10 $411.00 $687.00 $732.00 $773.00 $484.00 $516.00 $555.00

12041 10 $116.00 $334.00 $354.00 $369.00 $219.00 $232.00 $245.00

12042 10 $141.00 $409.00 $434.00 $453.00 $292.00 $310.00 $327.00

12044 10 $176.00 $506.00 $537.00 $559.00 $314.00 $332.00 $352.00

12045 10 $250.00 $566.00 $601.00 $628.00 $393.00 $416.00 $441.00

12046 10 $341.00 $677.00 $724.00 $766.00 $456.00 $488.00 $527.00

12047 10 $363.00 $774.00 $822.00 $857.00 $537.00 $569.00 $601.00

12051 10 $126.00 $363.00 $386.00 $402.00 $249.00 $264.00 $279.00

12052 10 $148.00 $416.00 $441.00 $460.00 $297.00 $315.00 $333.00

12053 10 $223.00 $487.00 $517.00 $539.00 $318.00 $337.00 $356.00

12054 10 $301.00 $509.00 $540.00 $564.00 $326.00 $345.00 $366.00

12055 10 $380.00 $659.00 $700.00 $731.00 $445.00 $472.00 $500.00



Surgery


(Non-Facility MRA)






12056 10 $487.00 $694.00 $734.00 $765.00 $498.00 $525.00 $554.00

12057 10 $539.00 $778.00 $831.00 $882.00 $579.00 $618.00 $667.00

13100 10 $178.00 $472.00 $501.00 $522.00 $301.00 $319.00 $338.00

13101 10 $240.00 $558.00 $592.00 $617.00 $369.00 $391.00 $414.00

13102 ZZZ $89.00 $172.00 $183.00 $193.00 $110.00 $117.00 $125.00

13120 10 $223.00 $494.00 $525.00 $547.00 $344.00 $365.00 $385.00

13121 10 $348.00 $603.00 $640.00 $667.00 $392.00 $414.00 $439.00

13122 ZZZ $104.00 $190.00 $202.00 $212.00 $127.00 $135.00 $144.00

13131 10 $252.00 $545.00 $578.00 $604.00 $366.00 $388.00 $411.00

13132 10 $484.00 $674.00 $715.00 $747.00 $462.00 $489.00 $518.00

13133 ZZZ $154.00 $256.00 $271.00 $286.00 $194.00 $206.00 $220.00

13151 10 $375.00 $599.00 $635.00 $665.00 $421.00 $446.00 $473.00

13152 10 $542.00 $719.00 $763.00 $798.00 $511.00 $541.00 $574.00

13153 ZZZ $169.00 $278.00 $295.00 $311.00 $209.00 $222.00 $237.00

13160 90 $655.00 $1,177.00 $1,251.00 $1,339.00 $1,177.00 $1,251.00 $1,339.00

14000 90 $512.00 $885.00 $942.00 $990.00 $729.00 $775.00 $821.00

14001 90 $695.00 $1,146.00 $1,220.00 $1,286.00 $957.00 $1,017.00 $1,081.00

14020 90 $590.00 $990.00 $1,052.00 $1,103.00 $824.00 $874.00 $923.00

14021 90 $818.00 $1,242.00 $1,319.00 $1,385.00 $1,046.00 $1,109.00 $1,173.00

14040 90 $701.00 $1,086.00 $1,151.00 $1,207.00 $918.00 $973.00 $1,027.00

14041 90 $936.00 $1,347.00 $1,429.00 $1,499.00 $1,134.00 $1,201.00 $1,270.00

14060 90 $766.00 $1,110.00 $1,176.00 $1,235.00 $978.00 $1,036.00 $1,094.00

14061 90 $1,330.00 $1,448.00 $1,536.00 $1,612.00 $1,213.00 $1,285.00 $1,358.00

14301 90 ---------- $1,543.00 $1,638.00 $1,727.00 $1,290.00 $1,368.00 $1,454.00

14302 ZZZ ---------- $328.00 $349.00 $375.00 $328.00 $349.00 $375.00

14350 90 $734.00 $994.00 $1,043.00 $1,092.00 $994.00 $1,043.00 $1,092.00

15002 0 ---------- $495.00 $527.00 $554.00 $335.00 $356.00 $382.00

15003 ZZZ ---------- $108.00 $115.00 $121.00 $68.00 $72.00 $78.00

15004 0 ---------- $569.00 $603.00 $630.00 $396.00 $418.00 $443.00

15005 ZZZ ---------- $180.00 $192.00 $204.00 $136.00 $144.00 $156.00

15040 0 ---------- $359.00 $383.00 $400.00 $189.00 $201.00 $217.00

15050 90 $349.00 $795.00 $844.00 $883.00 $641.00 $680.00 $717.00

15100 90 $679.00 $1,232.00 $1,314.00 $1,393.00 $1,047.00 $1,115.00 $1,193.00

15101 ZZZ $146.00 $265.00 $283.00 $298.00 $165.00 $176.00 $191.00

15110 90 ---------- $1,147.00 $1,217.00 $1,289.00 $1,011.00 $1,071.00 $1,142.00

15111 ZZZ ---------- $171.00 $183.00 $199.00 $156.00 $167.00 $183.00

15115 90 ---------- $1,153.00 $1,218.00 $1,282.00 $1,016.00 $1,072.00 $1,135.00

15116 ZZZ ---------- $238.00 $253.00 $269.00 $219.00 $232.00 $249.00

15120 90 $788.00 $1,219.00 $1,295.00 $1,368.00 $1,019.00 $1,082.00 $1,152.00

15121 ZZZ $235.00 $297.00 $317.00 $334.00 $197.00 $210.00 $226.00

15130 90 ---------- $958.00 $1,021.00 $1,082.00 $817.00 $870.00 $930.00

15131 ZZZ ---------- $133.00 $141.00 $153.00 $123.00 $131.00 $142.00

15135 90 ---------- $1,203.00 $1,272.00 $1,337.00 $1,065.00 $1,125.00 $1,188.00

15136 ZZZ ---------- $126.00 $133.00 $140.00 $119.00 $125.00 $133.00

15150 90 ---------- $1,000.00 $1,071.00 $1,158.00 $924.00 $990.00 $1,075.00

15151 ZZZ ---------- $179.00 $191.00 $208.00 $166.00 $178.00 $195.00

15152 ZZZ ---------- $220.00 $237.00 $260.00 $208.00 $224.00 $247.00

15155 90 ---------- $1,034.00 $1,094.00 $1,155.00 $963.00 $1,018.00 $1,078.00

15156 ZZZ ---------- $241.00 $257.00 $278.00 $229.00 $244.00 $266.00

15157 ZZZ ---------- $269.00 $284.00 $303.00 $252.00 $267.00 $285.00



Surgery


(Non-Facility MRA)






15200 90 $644.00 $1,188.00 $1,264.00 $1,333.00 $981.00 $1,043.00 $1,109.00

15201 ZZZ $126.00 $207.00 $221.00 $231.00 $117.00 $124.00 $134.00

15220 90 $687.00 $1,098.00 $1,167.00 $1,224.00 $894.00 $949.00 $1,005.00

15221 ZZZ $114.00 $193.00 $206.00 $215.00 $106.00 $113.00 $121.00

15240 90 $763.00 $1,332.00 $1,415.00 $1,486.00 $1,164.00 $1,234.00 $1,304.00

15241 ZZZ $334.00 $262.00 $279.00 $292.00 $165.00 $175.00 $187.00

15260 90 $841.00 $1,445.00 $1,532.00 $1,605.00 $1,249.00 $1,322.00 $1,393.00

15261 ZZZ $207.00 $305.00 $324.00 $339.00 $206.00 $218.00 $232.00

15271 0 ---------- $199.00 $210.00 $220.00 $125.00 $131.00 $140.00

15272 ZZZ ---------- $39.00 $41.00 $43.00 $26.00 $27.00 $29.00

15273 0 ---------- $430.00 $458.00 $486.00 $302.00 $321.00 $348.00

15274 ZZZ ---------- $103.00 $110.00 $117.00 $69.00 $74.00 $80.00

15275 0 ---------- $211.00 $222.00 $230.00 $140.00 $146.00 $154.00

15276 ZZZ ---------- $50.00 $52.00 $55.00 $37.00 $39.00 $42.00

15277 0 ---------- $469.00 $498.00 $527.00 $338.00 $358.00 $386.00

15278 ZZZ ---------- $123.00 $132.00 $140.00 $86.00 $92.00 $100.00

15570 90 $748.00 $1,309.00 $1,393.00 $1,471.00 $1,075.00 $1,143.00 $1,219.00

15572 90 $721.00 $1,274.00 $1,355.00 $1,429.00 $1,089.00 $1,157.00 $1,229.00

15574 90 $775.00 $1,305.00 $1,385.00 $1,459.00 $1,115.00 $1,183.00 $1,254.00

15576 90 $457.00 $1,150.00 $1,219.00 $1,278.00 $974.00 $1,031.00 $1,088.00

15600 90 $259.00 $450.00 $480.00 $497.00 $296.00 $314.00 $330.00

15610 90 $320.00 $500.00 $532.00 $552.00 $347.00 $369.00 $388.00

15620 90 $506.00 $616.00 $655.00 $683.00 $467.00 $496.00 $522.00

15630 90 $362.00 $648.00 $689.00 $718.00 $499.00 $530.00 $557.00

15650 90 $427.00 $716.00 $761.00 $796.00 $554.00 $589.00 $622.00

15731 90 ---------- $1,616.00 $1,714.00 $1,808.00 $1,465.00 $1,552.00 $1,645.00

15732 90 $1,465.00 $1,836.00 $1,941.00 $2,036.00 $1,617.00 $1,707.00 $1,800.00

15734 90 $1,557.00 $2,182.00 $2,328.00 $2,490.00 $1,942.00 $2,071.00 $2,231.00

15736 90 $1,862.00 $1,908.00 $2,030.00 $2,160.00 $1,671.00 $1,778.00 $1,905.00

15738 90 $1,415.00 $2,030.00 $2,160.00 $2,303.00 $1,808.00 $1,923.00 $2,064.00

15740 90 $913.00 $1,456.00 $1,544.00 $1,623.00 $1,241.00 $1,316.00 $1,392.00

15750 90 $1,064.00 $1,338.00 $1,421.00 $1,512.00 $1,338.00 $1,421.00 $1,512.00

15756 90 $2,892.00 $3,407.00 $3,612.00 $3,858.00 $3,407.00 $3,612.00 $3,858.00

15757 90 $2,892.00 $3,358.00 $3,555.00 $3,792.00 $3,358.00 $3,555.00 $3,792.00

15758 90 $2,884.00 $3,367.00 $3,566.00 $3,804.00 $3,367.00 $3,566.00 $3,804.00

15760 90 $810.00 $1,217.00 $1,291.00 $1,354.00 $1,030.00 $1,090.00 $1,151.00

15770 90 $674.00 $970.00 $1,029.00 $1,090.00 $970.00 $1,029.00 $1,090.00

15775 0 $327.00 $430.00 $455.00 $478.00 $327.00 $345.00 $367.00

15776 0 $475.00 $691.00 $730.00 $760.00 $511.00 $538.00 $565.00

15777 ZZZ ---------- $320.00 $340.00 $367.00 $320.00 $340.00 $367.00

15780 90 $532.00 $1,220.00 $1,293.00 $1,347.00 $936.00 $989.00 $1,040.00

15781 90 $420.00 $785.00 $835.00 $873.00 $624.00 $663.00 $699.00

15782 90 $314.00 $896.00 $955.00 $993.00 $640.00 $682.00 $717.00

15783 90 $340.00 $675.00 $716.00 $746.00 $532.00 $565.00 $593.00

15786 10 $146.00 $344.00 $364.00 $375.00 $197.00 $207.00 $217.00

15787 ZZZ $27.00 $68.00 $72.00 $74.00 $25.00 $26.00 $26.00

15788 90 $194.00 $636.00 $677.00 $694.00 $348.00 $370.00 $383.00

15789 90 $360.00 $785.00 $833.00 $865.00 $610.00 $646.00 $676.00

15792 90 $130.00 $605.00 $645.00 $662.00 $364.00 $387.00 $402.00

15793 90 $232.00 $696.00 $739.00 $767.00 $528.00 $560.00 $587.00



Surgery


(Non-Facility MRA)






15819 90 $780.00 $1,151.00 $1,223.00 $1,298.00 $1,151.00 $1,223.00 $1,298.00

15820 90 $556.00 $832.00 $884.00 $930.00 $753.00 $800.00 $844.00

15821 90 $607.00 $855.00 $900.00 $931.00 $771.00 $811.00 $841.00

15822 90 $499.00 $627.00 $662.00 $684.00 $553.00 $583.00 $605.00

15823 90 $718.00 $852.00 $896.00 $923.00 $768.00 $806.00 $832.00

15824 0 NC BR BR BR BR BR BR





15830 90 ---------- $1,720.00 $1,830.00 $1,959.00 $1,720.00 $1,830.00 $1,959.00

15832 90 $926.00 $1,333.00 $1,415.00 $1,506.00 $1,333.00 $1,415.00 $1,506.00

15833 90 $833.00 $1,242.00 $1,318.00 $1,399.00 $1,242.00 $1,318.00 $1,399.00

15834 90 $837.00 $1,291.00 $1,372.00 $1,459.00 $1,291.00 $1,372.00 $1,459.00

15835 90 $865.00 $1,333.00 $1,417.00 $1,511.00 $1,333.00 $1,417.00 $1,511.00

15836 90 $721.00 $1,145.00 $1,216.00 $1,291.00 $1,145.00 $1,216.00 $1,291.00

15837 90 $696.00 $1,223.00 $1,300.00 $1,369.00 $1,034.00 $1,099.00 $1,166.00

15838 90 $600.00 $824.00 $871.00 $920.00 $824.00 $871.00 $920.00

15839 90 $643.00 $1,266.00 $1,346.00 $1,422.00 $1,075.00 $1,141.00 $1,216.00

15840 90 $1,187.00 $1,461.00 $1,546.00 $1,638.00 $1,461.00 $1,546.00 $1,638.00

15841 90 $1,859.00 $2,325.00 $2,455.00 $2,608.00 $2,325.00 $2,455.00 $2,608.00

15842 90 $3,099.00 $3,573.00 $3,774.00 $4,017.00 $3,573.00 $3,774.00 $4,017.00

15845 90 $1,116.00 $1,432.00 $1,505.00 $1,567.00 $1,432.00 $1,505.00 $1,567.00

15850 0 $63.00 $124.00 $132.00 $137.00 $61.00 $64.00 $69.00

15851 0 $40.00 $138.00 $146.00 $150.00 $67.00 $70.00 $73.00

15852 0 $35.00 $69.00 $74.00 $79.00 $69.00 $74.00 $79.00

15860 0 $151.00 $163.00 $173.00 $187.00 $163.00 $173.00 $187.00





15920 90 $571.00 $907.00 $970.00 $1,042.00 $907.00 $970.00 $1,042.00

15922 90 $771.00 $1,135.00 $1,205.00 $1,279.00 $1,135.00 $1,205.00 $1,279.00

15931 90 $638.00 $1,014.00 $1,085.00 $1,176.00 $1,014.00 $1,085.00 $1,176.00

15933 90 $860.00 $1,238.00 $1,321.00 $1,420.00 $1,238.00 $1,321.00 $1,420.00

15934 90 $1,064.00 $1,371.00 $1,464.00 $1,578.00 $1,371.00 $1,464.00 $1,578.00

15935 90 $1,184.00 $1,615.00 $1,722.00 $1,846.00 $1,615.00 $1,722.00 $1,846.00

15936 90 $1,032.00 $1,308.00 $1,395.00 $1,502.00 $1,308.00 $1,395.00 $1,502.00

15937 90 $1,223.00 $1,513.00 $1,612.00 $1,731.00 $1,513.00 $1,612.00 $1,731.00

15940 90 $318.00 $1,028.00 $1,098.00 $1,184.00 $1,028.00 $1,098.00 $1,184.00

15941 90 $919.00 $1,310.00 $1,396.00 $1,492.00 $1,310.00 $1,396.00 $1,492.00

15944 90 $954.00 $1,298.00 $1,382.00 $1,478.00 $1,298.00 $1,382.00 $1,478.00

15945 90 $1,078.00 $1,434.00 $1,526.00 $1,630.00 $1,434.00 $1,526.00 $1,630.00

15946 90 $1,737.00 $2,396.00 $2,550.00 $2,731.00 $2,396.00 $2,550.00 $2,731.00

15950 90 $549.00 $866.00 $926.00 $996.00 $866.00 $926.00 $996.00

15951 90 $872.00 $1,259.00 $1,336.00 $1,415.00 $1,259.00 $1,336.00 $1,415.00

15952 90 $876.00 $1,305.00 $1,386.00 $1,471.00 $1,305.00 $1,386.00 $1,471.00

15953 90 $1,013.00 $1,447.00 $1,537.00 $1,633.00 $1,447.00 $1,537.00 $1,633.00

15956 90 $1,382.00 $1,683.00 $1,793.00 $1,924.00 $1,683.00 $1,793.00 $1,924.00

15958 90 $1,379.00 $1,715.00 $1,826.00 $1,955.00 $1,715.00 $1,826.00 $1,955.00



Surgery


(Non-Facility MRA)






15999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

16000 0 $53.00 $98.00 $104.00 $108.00 $67.00 $71.00 $75.00

16020 0 $49.00 $115.00 $122.00 $126.00 $78.00 $82.00 $86.00

16025 0 $67.00 $210.00 $222.00 $233.00 $162.00 $172.00 $182.00

16030 0 $153.00 $265.00 $282.00 $297.00 $196.00 $208.00 $223.00

16035 0 $341.00 $287.00 $301.00 $321.00 $287.00 $301.00 $321.00

16036 ZZZ $81.00 $121.00 $129.00 $140.00 $121.00 $129.00 $140.00

17000 10 $60.00 $94.00 $99.00 $103.00 $76.00 $80.00 $84.00

17003 ZZZ $16.00 $8.00 $9.00 $9.00 $4.00 $4.00 $4.00

17004 10 $233.00 $211.00 $224.00 $233.00 $144.00 $152.00 $160.00

17106 90 $341.00 $486.00 $515.00 $538.00 $400.00 $424.00 $446.00

17107 90 $648.00 $615.00 $652.00 $681.00 $501.00 $530.00 $559.00

17108 90 $1,015.00 $918.00 $974.00 $1,022.00 $769.00 $814.00 $861.00

17110 10 $55.00 $154.00 $164.00 $168.00 $99.00 $105.00 $109.00

17111 10 $83.00 $184.00 $195.00 $201.00 $123.00 $130.00 $136.00

17250 0 $27.00 $110.00 $117.00 $121.00 $53.00 $56.00 $59.00

17260 10 $96.00 $134.00 $142.00 $148.00 $102.00 $108.00 $114.00

17261 10 $117.00 $201.00 $213.00 $221.00 $132.00 $140.00 $147.00

17262 10 $150.00 $246.00 $261.00 $272.00 $169.00 $179.00 $188.00

17263 10 $172.00 $269.00 $286.00 $297.00 $187.00 $198.00 $209.00

17264 10 $189.00 $288.00 $305.00 $318.00 $199.00 $211.00 $223.00

17266 10 $225.00 $329.00 $349.00 $364.00 $235.00 $249.00 $263.00

17270 10 $125.00 $212.00 $225.00 $234.00 $145.00 $154.00 $162.00

17271 10 $143.00 $230.00 $244.00 $254.00 $161.00 $170.00 $179.00

17272 10 $170.00 $263.00 $279.00 $290.00 $185.00 $196.00 $207.00

17273 10 $195.00 $294.00 $312.00 $325.00 $210.00 $222.00 $235.00

17274 10 $240.00 $348.00 $369.00 $386.00 $258.00 $272.00 $288.00

17276 10 $281.00 $403.00 $427.00 $446.00 $308.00 $325.00 $344.00

17280 10 $123.00 $198.00 $211.00 $219.00 $132.00 $140.00 $147.00

17281 10 $165.00 $251.00 $267.00 $278.00 $182.00 $192.00 $203.00

17282 10 $194.00 $289.00 $306.00 $320.00 $209.00 $221.00 $234.00

17283 10 $239.00 $347.00 $368.00 $385.00 $262.00 $277.00 $293.00

17284 10 $282.00 $397.00 $421.00 $441.00 $306.00 $324.00 $343.00

17286 10 $373.00 $512.00 $542.00 $571.00 $412.00 $436.00 $464.00

17311 0 ---------- $934.00 $992.00 $1,034.00 $557.00 $589.00 $627.00

17312 ZZZ ---------- $547.00 $581.00 $604.00 $296.00 $314.00 $334.00

17313 0 ---------- $872.00 $926.00 $963.00 $499.00 $528.00 $562.00

17314 ZZZ ---------- $524.00 $557.00 $578.00 $275.00 $291.00 $310.00

17315 ZZZ ---------- $114.00 $121.00 $127.00 $78.00 $83.00 $88.00

17340 10 $37.00 $74.00 $78.00 $82.00 $71.00 $74.00 $78.00

17360 10 $96.00 $183.00 $193.00 $203.00 $143.00 $151.00 $160.00


17999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

19000 0 $74.00 $158.00 $167.00 $173.00 $64.00 $68.00 $72.00

19001 ZZZ $40.00 $39.00 $41.00 $43.00 $32.00 $34.00 $36.00

19020 90 $288.00 $670.00 $717.00 $754.00 $446.00 $478.00 $513.00

19030 0 $98.00 $231.00 $244.00 $251.00 $114.00 $119.00 $125.00

19081 0 ---------- $958.00 $1,018.00 $1,040.00 $249.00 $261.00 $276.00

19082 ZZZ ---------- $786.00 $837.00 $851.00 $125.00 $131.00 $139.00

19083 0 ---------- $928.00 $987.00 $1,008.00 $234.00 $245.00 $259.00



Surgery


(Non-Facility MRA)






19084 ZZZ ---------- $755.00 $804.00 $817.00 $116.00 $122.00 $128.00

19085 0 ---------- $1,405.00 $1,494.00 $1,521.00 $273.00 $285.00 $300.00

19086 ZZZ ---------- $1,119.00 $1,192.00 $1,209.00 $136.00 $141.00 $148.00

19100 0 $117.00 $214.00 $229.00 $242.00 $105.00 $113.00 $124.00

19101 10 $338.00 $487.00 $521.00 $552.00 $327.00 $350.00 $379.00

19105 0 ---------- $3,213.00 $3,426.00 $3,474.00 $294.00 $309.00 $327.00

19110 90 $406.00 $693.00 $742.00 $787.00 $502.00 $538.00 $581.00

19112 90 $354.00 $654.00 $700.00 $739.00 $457.00 $489.00 $526.00

19120 90 $429.00 $716.00 $768.00 $825.00 $610.00 $655.00 $711.00

19125 90 $468.00 $796.00 $853.00 $919.00 $679.00 $729.00 $793.00

19126 ZZZ $201.00 $244.00 $262.00 $290.00 $244.00 $262.00 $290.00

19260 90 $1,101.00 $1,781.00 $1,909.00 $2,076.00 $1,781.00 $1,909.00 $2,076.00

19271 90 $1,561.00 $2,394.00 $2,566.00 $2,775.00 $2,394.00 $2,566.00 $2,775.00

19272 90 $1,674.00 $2,625.00 $2,813.00 $3,046.00 $2,625.00 $2,813.00 $3,046.00

19281 0 ---------- $335.00 $354.00 $364.00 $149.00 $155.00 $162.00

19282 ZZZ ---------- $231.00 $245.00 $250.00 $75.00 $78.00 $81.00

19283 0 ---------- $378.00 $401.00 $412.00 $151.00 $157.00 $166.00

19284 ZZZ ---------- $283.00 $300.00 $307.00 $76.00 $80.00 $85.00

19285 0 ---------- $712.00 $757.00 $770.00 $128.00 $133.00 $140.00

19286 ZZZ ---------- $618.00 $659.00 $668.00 $64.00 $67.00 $71.00

19287 0 ---------- $1,189.00 $1,266.00 $1,286.00 $190.00 $199.00 $208.00

19288 ZZZ ---------- $954.00 $1,016.00 $1,029.00 $95.00 $99.00 $103.00

19296 0 ---------- $5,401.00 $5,770.00 $5,857.00 $317.00 $340.00 $373.00

19297 ZZZ ---------- $144.00 $154.00 $171.00 $144.00 $154.00 $171.00

19298 0 ---------- $1,364.00 $1,451.00 $1,492.00 $464.00 $489.00 $521.00

19300 90 ---------- $751.00 $804.00 $855.00 $604.00 $647.00 $696.00

19301 90 ---------- $970.00 $1,040.00 $1,136.00 $970.00 $1,040.00 $1,136.00

19302 90 ---------- $1,339.00 $1,437.00 $1,570.00 $1,339.00 $1,437.00 $1,570.00

19303 90 ---------- $1,504.00 $1,614.00 $1,764.00 $1,504.00 $1,614.00 $1,764.00

19304 90 ---------- $849.00 $910.00 $985.00 $849.00 $910.00 $985.00

19305 90 ---------- $1,678.00 $1,800.00 $1,963.00 $1,678.00 $1,800.00 $1,963.00

19306 90 ---------- $1,762.00 $1,891.00 $2,064.00 $1,762.00 $1,891.00 $2,064.00

19307 90 ---------- $1,777.00 $1,907.00 $2,081.00 $1,777.00 $1,907.00 $2,081.00

19316 90 $954.00 $1,127.00 $1,199.00 $1,282.00 $1,127.00 $1,199.00 $1,282.00

19318 90 $1,313.00 $1,612.00 $1,711.00 $1,823.00 $1,612.00 $1,711.00 $1,823.00

19324 90 $440.00 $726.00 $777.00 $839.00 $726.00 $777.00 $839.00

19325 90 $656.00 $933.00 $990.00 $1,049.00 $933.00 $990.00 $1,049.00

19328 90 $457.00 $719.00 $765.00 $812.00 $719.00 $765.00 $812.00

19330 90 $569.00 $922.00 $981.00 $1,043.00 $922.00 $981.00 $1,043.00

19340 90 $545.00 $1,463.00 $1,554.00 $1,653.00 $1,463.00 $1,554.00 $1,653.00

19342 90 $963.00 $1,342.00 $1,425.00 $1,513.00 $1,342.00 $1,425.00 $1,513.00

19350 90 $853.00 $1,180.00 $1,255.00 $1,322.00 $980.00 $1,041.00 $1,106.00

19355 90 $755.00 $1,015.00 $1,088.00 $1,170.00 $845.00 $906.00 $987.00

19357 90 $1,449.00 $2,180.00 $2,317.00 $2,450.00 $2,180.00 $2,317.00 $2,450.00

19361 90 $1,667.00 $2,308.00 $2,450.00 $2,613.00 $2,308.00 $2,450.00 $2,613.00

19364 90 $2,737.00 $4,050.00 $4,299.00 $4,595.00 $4,050.00 $4,299.00 $4,595.00

19366 90 $1,676.00 $2,078.00 $2,210.00 $2,373.00 $2,078.00 $2,210.00 $2,373.00

19367 90 $2,056.00 $2,621.00 $2,782.00 $2,969.00 $2,621.00 $2,782.00 $2,969.00

19368 90 $2,444.00 $3,235.00 $3,434.00 $3,669.00 $3,235.00 $3,434.00 $3,669.00

19369 90 $2,317.00 $2,967.00 $3,141.00 $3,339.00 $2,967.00 $3,141.00 $3,339.00



Surgery


(Non-Facility MRA)






19370 90 $662.00 $998.00 $1,060.00 $1,126.00 $998.00 $1,060.00 $1,126.00

19371 90 $788.00 $1,141.00 $1,213.00 $1,289.00 $1,141.00 $1,213.00 $1,289.00

19380 90 $780.00 $1,125.00 $1,196.00 $1,270.00 $1,125.00 $1,196.00 $1,270.00

19396 0 $231.00 $412.00 $438.00 $455.00 $214.00 $227.00 $243.00

19499 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

20005 10 $267.00 $445.00 $473.00 $497.00 $343.00 $363.00 $386.00

20100 10 $727.00 $905.00 $966.00 $1,051.00 $905.00 $966.00 $1,051.00

20101 10 $261.00 $632.00 $677.00 $711.00 $311.00 $333.00 $364.00

20102 10 $314.00 $691.00 $739.00 $778.00 $378.00 $405.00 $441.00

20103 10 $405.00 $827.00 $880.00 $922.00 $511.00 $543.00 $581.00

20150 90 $1,141.00 $1,398.00 $1,494.00 $1,619.00 $1,398.00 $1,494.00 $1,619.00

20200 0 $134.00 $294.00 $315.00 $331.00 $143.00 $154.00 $169.00

20205 0 $243.00 $413.00 $444.00 $471.00 $234.00 $253.00 $278.00

20206 0 $119.00 $325.00 $345.00 $352.00 $86.00 $90.00 $95.00

20220 0 $128.00 $234.00 $247.00 $253.00 $105.00 $109.00 $114.00

20225 0 $215.00 $719.00 $765.00 $779.00 $158.00 $166.00 $174.00

20240 0 $279.00 $225.00 $237.00 $252.00 $225.00 $237.00 $252.00

20245 10 $364.00 $523.00 $554.00 $595.00 $523.00 $554.00 $595.00

20250 10 $447.00 $576.00 $620.00 $676.00 $576.00 $620.00 $676.00

20251 10 $511.00 $631.00 $680.00 $742.00 $631.00 $680.00 $742.00

20500 10 $59.00 $146.00 $153.00 $159.00 $120.00 $126.00 $131.00

20501 0 $60.00 $164.00 $174.00 $178.00 $56.00 $58.00 $61.00

20520 10 $75.00 $288.00 $306.00 $318.00 $211.00 $223.00 $235.00

20525 10 $331.00 $674.00 $718.00 $748.00 $362.00 $385.00 $411.00

20526 0 $64.00 $111.00 $118.00 $125.00 $85.00 $90.00 $97.00

20527 0 ---------- $121.00 $129.00 $136.00 $98.00 $104.00 $111.00

20550 0 $40.00 $75.00 $79.00 $83.00 $58.00 $61.00 $64.00

20551 0 $62.00 $86.00 $90.00 $94.00 $62.00 $65.00 $68.00

20552 0 $62.00 $78.00 $82.00 $86.00 $55.00 $58.00 $61.00

20553 0 $62.00 $90.00 $95.00 $99.00 $63.00 $66.00 $69.00

20555 0 ---------- $478.00 $502.00 $531.00 $478.00 $502.00 $531.00

20600 0 $41.00 $68.00 $72.00 $75.00 $52.00 $54.00 $57.00

20604 0 ---------- $103.00 $108.00 $113.00 $68.00 $71.00 $76.00

20605 0 $48.00 $72.00 $76.00 $79.00 $54.00 $57.00 $60.00

20606 0 ---------- $114.00 $120.00 $126.00 $78.00 $81.00 $86.00

20610 0 $49.00 $87.00 $92.00 $97.00 $68.00 $72.00 $77.00

20611 0 ---------- $130.00 $138.00 $144.00 $91.00 $96.00 $102.00

20612 0 $56.00 $86.00 $91.00 $95.00 $61.00 $64.00 $68.00

20615 10 $94.00 $341.00 $361.00 $376.00 $234.00 $248.00 $261.00

20650 10 $170.00 $297.00 $315.00 $329.00 $229.00 $242.00 $255.00

20660 0 $320.00 $376.00 $409.00 $460.00 $376.00 $409.00 $460.00

20661 90 $476.00 $746.00 $810.00 $885.00 $746.00 $810.00 $885.00

20662 90 $559.00 $621.00 $648.00 $667.00 $621.00 $648.00 $667.00

20663 90 $465.00 $658.00 $700.00 $743.00 $658.00 $700.00 $743.00

20665 10 $105.00 $150.00 $157.00 $162.00 $130.00 $136.00 $140.00

20670 10 $80.00 $527.00 $561.00 $577.00 $212.00 $225.00 $237.00

20680 90 $332.00 $879.00 $935.00 $979.00 $616.00 $654.00 $696.00

20690 90 $298.00 $874.00 $932.00 $1,001.00 $874.00 $932.00 $1,001.00

20692 90 $516.00 $1,636.00 $1,739.00 $1,855.00 $1,636.00 $1,739.00 $1,855.00

20693 90 $477.00 $645.00 $684.00 $725.00 $645.00 $684.00 $725.00



Surgery


(Non-Facility MRA)






20694 90 $421.00 $606.00 $646.00 $679.00 $490.00 $522.00 $554.00

20696 90 ---------- $1,773.00 $1,889.00 $2,027.00 $1,773.00 $1,889.00 $2,027.00

20697 0 ---------- $2,870.00 $3,065.00 $3,096.00 $2,870.00 $3,065.00 $3,096.00

20802 90 $3,363.00 $4,072.00 $4,331.00 $4,646.00 $4,072.00 $4,331.00 $4,646.00

20805 90 $4,317.00 $4,622.00 $4,915.00 $5,293.00 $4,622.00 $4,915.00 $5,293.00

20808 90 $5,324.00 $5,871.00 $6,219.00 $6,628.00 $5,871.00 $6,219.00 $6,628.00

20816 90 $3,060.00 $3,093.00 $3,284.00 $3,506.00 $3,093.00 $3,284.00 $3,506.00

20822 90 $2,511.00 $2,629.00 $2,794.00 $2,985.00 $2,629.00 $2,794.00 $2,985.00

20824 90 $3,027.00 $2,869.00 $3,036.00 $3,236.00 $2,869.00 $3,036.00 $3,236.00

20827 90 $3,920.00 $2,687.00 $2,848.00 $3,026.00 $2,687.00 $2,848.00 $3,026.00

20838 90 $3,484.00 $3,941.00 $4,160.00 $4,405.00 $3,941.00 $4,160.00 $4,405.00

20900 0 $454.00 $587.00 $625.00 $650.00 $279.00 $297.00 $319.00

20902 0 $658.00 $423.00 $450.00 $485.00 $423.00 $450.00 $485.00

20910 90 $338.00 $654.00 $695.00 $734.00 $654.00 $695.00 $734.00

20912 90 $549.00 $690.00 $731.00 $772.00 $690.00 $731.00 $772.00

20920 90 $460.00 $572.00 $606.00 $640.00 $572.00 $606.00 $640.00

20922 90 $634.00 $854.00 $913.00 $974.00 $719.00 $768.00 $828.00

20924 90 $583.00 $738.00 $786.00 $837.00 $738.00 $786.00 $837.00

20926 90 $444.00 $615.00 $653.00 $694.00 $615.00 $653.00 $694.00

20930 0 BR ---------- ---------- ---------- ---------- ---------- ----------

20931 ZZZ $156.00 $174.00 $189.00 $213.00 $174.00 $189.00 $213.00

20936 0 BR ---------- ---------- ---------- ---------- ---------- ----------

20937 ZZZ $234.00 $256.00 $275.00 $304.00 $256.00 $275.00 $304.00

20938 ZZZ $257.00 $285.00 $310.00 $347.00 $285.00 $310.00 $347.00

20950 0 $123.00 $350.00 $374.00 $385.00 $133.00 $141.00 $150.00

20955 90 $3,332.00 $3,682.00 $3,900.00 $4,162.00 $3,682.00 $3,900.00 $4,162.00

20956 90 $3,167.00 $3,939.00 $4,206.00 $4,550.00 $3,939.00 $4,206.00 $4,550.00

20957 90 $3,074.00 $3,322.00 $3,472.00 $3,646.00 $3,322.00 $3,472.00 $3,646.00

20962 90 $3,122.00 $3,139.00 $3,281.00 $3,438.00 $3,139.00 $3,281.00 $3,438.00

20969 90 $3,716.00 $4,059.00 $4,294.00 $4,578.00 $4,059.00 $4,294.00 $4,578.00

20970 90 $3,650.00 $4,257.00 $4,540.00 $4,898.00 $4,257.00 $4,540.00 $4,898.00

20972 90 $3,420.00 $3,538.00 $3,709.00 $3,915.00 $3,538.00 $3,709.00 $3,915.00

20973 90 $3,821.00 $3,624.00 $3,788.00 $3,985.00 $3,624.00 $3,788.00 $3,985.00

20974 0 $266.00 $110.00 $117.00 $124.00 $74.00 $79.00 $85.00

20975 0 $334.00 $266.00 $286.00 $313.00 $266.00 $286.00 $313.00

20979 0 $19.00 $74.00 $78.00 $82.00 $48.00 $50.00 $53.00

20982 0 ---------- $2,354.00 $2,503.00 $2,553.00 $542.00 $568.00 $599.00

20983 0 ---------- $8,602.00 $9,177.00 $9,294.00 $544.00 $571.00 $605.00

20985 ZZZ ---------- $220.00 $234.00 $254.00 $220.00 $234.00 $254.00

20999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

21010 90 $854.00 $1,104.00 $1,170.00 $1,243.00 $1,104.00 $1,170.00 $1,243.00

21011 90 ---------- $494.00 $527.00 $551.00 $375.00 $399.00 $423.00

21012 90 ---------- $495.00 $528.00 $565.00 $495.00 $528.00 $565.00

21013 90 ---------- $742.00 $790.00 $831.00 $584.00 $621.00 $661.00

21014 90 ---------- $762.00 $811.00 $865.00 $762.00 $811.00 $865.00

21015 90 $520.00 $1,033.00 $1,099.00 $1,172.00 $1,033.00 $1,099.00 $1,172.00

21016 90 ---------- $1,497.00 $1,592.00 $1,704.00 $1,497.00 $1,592.00 $1,704.00

21025 90 $546.00 $1,287.00 $1,368.00 $1,439.00 $1,099.00 $1,167.00 $1,236.00

21026 90 $413.00 $885.00 $941.00 $983.00 $724.00 $770.00 $810.00

21029 90 $700.00 $1,105.00 $1,172.00 $1,228.00 $929.00 $984.00 $1,038.00



Surgery


(Non-Facility MRA)






21030 90 $496.00 $745.00 $793.00 $829.00 $608.00 $646.00 $681.00

21031 90 $310.00 $566.00 $602.00 $628.00 $430.00 $457.00 $481.00

21032 90 $315.00 $572.00 $609.00 $634.00 $424.00 $451.00 $475.00

21034 90 $1,140.00 $1,910.00 $2,025.00 $2,140.00 $1,698.00 $1,799.00 $1,911.00

21040 90 $227.00 $750.00 $798.00 $834.00 $608.00 $646.00 $681.00

21044 90 $957.00 $1,278.00 $1,353.00 $1,434.00 $1,278.00 $1,353.00 $1,434.00

21045 90 $1,313.00 $1,792.00 $1,897.00 $2,013.00 $1,792.00 $1,897.00 $2,013.00

21046 90 $899.00 $1,631.00 $1,732.00 $1,832.00 $1,631.00 $1,732.00 $1,832.00

21047 90 $1,109.00 $1,932.00 $2,047.00 $2,178.00 $1,932.00 $2,047.00 $2,178.00

21048 90 $925.00 $1,674.00 $1,778.00 $1,882.00 $1,674.00 $1,778.00 $1,882.00

21049 90 $1,051.00 $1,766.00 $1,866.00 $1,980.00 $1,766.00 $1,866.00 $1,980.00

21050 90 $1,026.00 $1,213.00 $1,283.00 $1,355.00 $1,213.00 $1,283.00 $1,355.00

21060 90 $972.00 $1,168.00 $1,237.00 $1,308.00 $1,168.00 $1,237.00 $1,308.00

21070 90 $679.00 $883.00 $933.00 $984.00 $883.00 $933.00 $984.00

21073 90 ---------- $569.00 $606.00 $632.00 $375.00 $398.00 $423.00

21076 10 $1,192.00 $1,449.00 $1,538.00 $1,630.00 $1,228.00 $1,302.00 $1,391.00

21077 90 $3,002.00 $3,659.00 $3,884.00 $4,115.00 $3,111.00 $3,298.00 $3,523.00

21079 90 $2,086.00 $2,465.00 $2,619.00 $2,776.00 $2,074.00 $2,201.00 $2,354.00

21080 90 $2,346.00 $2,768.00 $2,939.00 $3,114.00 $2,310.00 $2,450.00 $2,620.00

21081 90 $2,138.00 $2,552.00 $2,711.00 $2,873.00 $2,124.00 $2,254.00 $2,411.00

21082 90 $1,855.00 $2,403.00 $2,553.00 $2,700.00 $1,978.00 $2,099.00 $2,242.00

21083 90 $1,802.00 $2,289.00 $2,433.00 $2,570.00 $1,841.00 $1,954.00 $2,087.00

21084 90 $2,105.00 $2,627.00 $2,791.00 $2,952.00 $2,134.00 $2,265.00 $2,420.00

21085 10 $801.00 $1,099.00 $1,168.00 $1,232.00 $838.00 $890.00 $951.00

21086 90 $2,333.00 $2,721.00 $2,891.00 $3,067.00 $2,305.00 $2,447.00 $2,619.00

21087 90 $2,217.00 $2,707.00 $2,874.00 $3,048.00 $2,289.00 $2,428.00 $2,598.00

21088 90 BR ---------- ---------- ---------- ---------- ---------- ----------

21089 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

21100 90 $297.00 $1,171.00 $1,245.00 $1,280.00 $584.00 $619.00 $647.00

21110 90 $371.00 $1,145.00 $1,219.00 $1,266.00 $966.00 $1,028.00 $1,074.00

21116 0 $207.00 $205.00 $218.00 $224.00 $65.00 $69.00 $73.00

21120 90 $500.00 $854.00 $908.00 $945.00 $687.00 $730.00 $765.00

21121 90 $651.00 $1,156.00 $1,229.00 $1,287.00 $976.00 $1,037.00 $1,093.00

21122 90 $700.00 $954.00 $1,009.00 $1,059.00 $954.00 $1,009.00 $1,059.00

21123 90 $903.00 $1,314.00 $1,397.00 $1,478.00 $1,314.00 $1,397.00 $1,478.00

21125 90 $656.00 $4,450.00 $4,742.00 $4,843.00 $1,074.00 $1,136.00 $1,203.00

21127 90 $909.00 $6,082.00 $6,487.00 $6,623.00 $1,303.00 $1,383.00 $1,469.00

21137 90 $797.00 $1,013.00 $1,073.00 $1,137.00 $1,013.00 $1,073.00 $1,137.00

21138 90 $960.00 $1,343.00 $1,426.00 $1,516.00 $1,343.00 $1,426.00 $1,516.00

21139 90 $1,168.00 $1,577.00 $1,672.00 $1,770.00 $1,577.00 $1,672.00 $1,770.00

21141 90 $1,438.00 $1,992.00 $2,115.00 $2,252.00 $1,992.00 $2,115.00 $2,252.00

21142 90 $1,527.00 $2,108.00 $2,239.00 $2,381.00 $2,108.00 $2,239.00 $2,381.00

21143 90 $1,511.00 $2,147.00 $2,280.00 $2,427.00 $2,147.00 $2,280.00 $2,427.00

21145 90 $1,513.00 $2,350.00 $2,494.00 $2,657.00 $2,350.00 $2,494.00 $2,657.00

21146 90 $1,570.00 $2,450.00 $2,601.00 $2,774.00 $2,450.00 $2,601.00 $2,774.00

21147 90 $1,639.00 $2,469.00 $2,615.00 $2,784.00 $2,469.00 $2,615.00 $2,784.00

21150 90 $1,914.00 $2,549.00 $2,705.00 $2,883.00 $2,549.00 $2,705.00 $2,883.00

21151 90 $2,264.00 $2,945.00 $3,123.00 $3,317.00 $2,945.00 $3,123.00 $3,317.00

21154 90 $2,364.00 $2,761.00 $2,912.00 $3,086.00 $2,761.00 $2,912.00 $3,086.00

21155 90 $2,640.00 $3,066.00 $3,233.00 $3,428.00 $3,066.00 $3,233.00 $3,428.00



Surgery


(Non-Facility MRA)






21159 90 $3,302.00 $3,851.00 $4,068.00 $4,321.00 $3,851.00 $4,068.00 $4,321.00

21160 90 $3,500.00 $3,997.00 $4,213.00 $4,474.00 $3,997.00 $4,213.00 $4,474.00

21172 90 $2,111.00 $3,128.00 $3,423.00 $3,853.00 $3,128.00 $3,423.00 $3,853.00

21175 90 $2,604.00 $3,072.00 $3,230.00 $3,391.00 $3,072.00 $3,230.00 $3,391.00

21179 90 $1,826.00 $2,006.00 $2,122.00 $2,264.00 $2,006.00 $2,122.00 $2,264.00

21180 90 $2,035.00 $2,366.00 $2,531.00 $2,753.00 $2,366.00 $2,531.00 $2,753.00

21181 90 $813.00 $1,080.00 $1,147.00 $1,219.00 $1,080.00 $1,147.00 $1,219.00

21182 90 $2,570.00 $2,921.00 $3,101.00 $3,329.00 $2,921.00 $3,101.00 $3,329.00

21183 90 $2,770.00 $3,217.00 $3,357.00 $3,470.00 $3,217.00 $3,357.00 $3,470.00

21184 90 $3,150.00 $4,172.00 $4,587.00 $5,217.00 $4,172.00 $4,587.00 $5,217.00

21188 90 $1,786.00 $2,382.00 $2,526.00 $2,678.00 $2,382.00 $2,526.00 $2,678.00

21193 90 $1,331.00 $1,727.00 $1,824.00 $1,933.00 $1,727.00 $1,824.00 $1,933.00

21194 90 $1,540.00 $2,172.00 $2,306.00 $2,458.00 $2,172.00 $2,306.00 $2,458.00

21195 90 $1,360.00 $1,922.00 $2,033.00 $2,147.00 $1,922.00 $2,033.00 $2,147.00

21196 90 $1,764.00 $2,171.00 $2,302.00 $2,440.00 $2,171.00 $2,302.00 $2,440.00

21198 90 $1,268.00 $1,704.00 $1,807.00 $1,910.00 $1,704.00 $1,807.00 $1,910.00

21199 90 $1,018.00 $1,485.00 $1,569.00 $1,669.00 $1,485.00 $1,569.00 $1,669.00

21206 90 $1,112.00 $1,772.00 $1,881.00 $1,987.00 $1,772.00 $1,881.00 $1,987.00

21208 90 $946.00 $2,601.00 $2,768.00 $2,859.00 $1,227.00 $1,302.00 $1,378.00

21209 90 $576.00 $1,161.00 $1,231.00 $1,282.00 $896.00 $948.00 $996.00

21210 90 $930.00 $3,196.00 $3,406.00 $3,508.00 $1,269.00 $1,348.00 $1,431.00

21215 90 $970.00 $5,586.00 $5,957.00 $6,088.00 $1,321.00 $1,403.00 $1,489.00

21230 90 $956.00 $1,088.00 $1,153.00 $1,224.00 $1,088.00 $1,153.00 $1,224.00

21235 90 $707.00 $1,034.00 $1,097.00 $1,146.00 $820.00 $869.00 $916.00

21240 90 $1,281.00 $1,645.00 $1,746.00 $1,858.00 $1,645.00 $1,746.00 $1,858.00

21242 90 $1,207.00 $1,512.00 $1,606.00 $1,707.00 $1,512.00 $1,606.00 $1,707.00

21243 90 $1,501.00 $2,512.00 $2,668.00 $2,839.00 $2,512.00 $2,668.00 $2,839.00

21244 90 $1,062.00 $1,546.00 $1,640.00 $1,730.00 $1,546.00 $1,640.00 $1,730.00

21245 90 $1,038.00 $1,584.00 $1,679.00 $1,760.00 $1,286.00 $1,359.00 $1,438.00

21246 90 $1,010.00 $1,302.00 $1,387.00 $1,487.00 $1,302.00 $1,387.00 $1,487.00

21247 90 $2,003.00 $2,247.00 $2,376.00 $2,523.00 $2,247.00 $2,376.00 $2,523.00

21248 90 $1,023.00 $1,608.00 $1,709.00 $1,801.00 $1,331.00 $1,414.00 $1,502.00

21249 90 $1,525.00 $2,200.00 $2,338.00 $2,471.00 $1,887.00 $2,003.00 $2,134.00

21255 90 $1,459.00 $2,017.00 $2,139.00 $2,262.00 $2,017.00 $2,139.00 $2,262.00

21256 90 $1,470.00 $1,734.00 $1,818.00 $1,888.00 $1,734.00 $1,818.00 $1,888.00

21260 90 $1,372.00 $1,817.00 $1,921.00 $2,028.00 $1,817.00 $1,921.00 $2,028.00

21261 90 $2,347.00 $3,085.00 $3,255.00 $3,446.00 $3,085.00 $3,255.00 $3,446.00

21263 90 $2,361.00 $2,847.00 $3,004.00 $3,178.00 $2,847.00 $3,004.00 $3,178.00

21267 90 $1,539.00 $2,278.00 $2,398.00 $2,493.00 $2,278.00 $2,398.00 $2,493.00

21268 90 $1,946.00 $2,541.00 $2,682.00 $2,834.00 $2,541.00 $2,682.00 $2,834.00

21270 90 $890.00 $1,373.00 $1,444.00 $1,485.00 $1,043.00 $1,092.00 $1,130.00

21275 90 $963.00 $1,224.00 $1,300.00 $1,383.00 $1,224.00 $1,300.00 $1,383.00

21280 90 $571.00 $810.00 $852.00 $882.00 $810.00 $852.00 $882.00

21282 90 $360.00 $541.00 $572.00 $594.00 $541.00 $572.00 $594.00

21295 90 $144.00 $265.00 $280.00 $290.00 $265.00 $280.00 $290.00

21296 90 $384.00 $637.00 $675.00 $706.00 $637.00 $675.00 $706.00

21299 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

21310 0 $81.00 $184.00 $196.00 $200.00 $40.00 $42.00 $46.00

21315 10 $180.00 $387.00 $411.00 $425.00 $218.00 $231.00 $242.00

21320 10 $235.00 $360.00 $382.00 $396.00 $195.00 $207.00 $219.00



Surgery


(Non-Facility MRA)






21325 90 $348.00 $674.00 $716.00 $746.00 $674.00 $716.00 $746.00

21330 90 $639.00 $818.00 $869.00 $909.00 $818.00 $869.00 $909.00

21335 90 $852.00 $1,041.00 $1,103.00 $1,160.00 $1,041.00 $1,103.00 $1,160.00

21336 90 $478.00 $922.00 $978.00 $1,022.00 $922.00 $978.00 $1,022.00

21337 90 $300.00 $572.00 $608.00 $632.00 $424.00 $451.00 $473.00

21338 90 $550.00 $1,074.00 $1,142.00 $1,192.00 $1,074.00 $1,142.00 $1,192.00

21339 90 $689.00 $1,215.00 $1,292.00 $1,355.00 $1,215.00 $1,292.00 $1,355.00

21340 90 $907.00 $1,147.00 $1,199.00 $1,237.00 $1,147.00 $1,199.00 $1,237.00

21343 90 $1,043.00 $1,759.00 $1,871.00 $1,976.00 $1,759.00 $1,871.00 $1,976.00

21344 90 $1,450.00 $2,032.00 $2,149.00 $2,281.00 $2,032.00 $2,149.00 $2,281.00

21345 90 $738.00 $1,155.00 $1,225.00 $1,285.00 $940.00 $995.00 $1,052.00

21346 90 $917.00 $1,307.00 $1,385.00 $1,456.00 $1,307.00 $1,385.00 $1,456.00

21347 90 $1,048.00 $1,646.00 $1,749.00 $1,845.00 $1,646.00 $1,749.00 $1,845.00

21348 90 $1,286.00 $1,754.00 $1,858.00 $1,971.00 $1,754.00 $1,858.00 $1,971.00

21355 10 $295.00 $642.00 $681.00 $711.00 $484.00 $513.00 $542.00

21356 10 $372.00 $716.00 $761.00 $795.00 $548.00 $581.00 $613.00

21360 90 $590.00 $783.00 $830.00 $876.00 $783.00 $830.00 $876.00

21365 90 $1,239.00 $1,628.00 $1,724.00 $1,833.00 $1,628.00 $1,724.00 $1,833.00

21366 90 $1,386.00 $1,661.00 $1,756.00 $1,870.00 $1,661.00 $1,756.00 $1,870.00

21385 90 $810.00 $982.00 $1,038.00 $1,095.00 $982.00 $1,038.00 $1,095.00

21386 90 $812.00 $1,012.00 $1,075.00 $1,142.00 $1,012.00 $1,075.00 $1,142.00

21387 90 $958.00 $1,027.00 $1,086.00 $1,147.00 $1,027.00 $1,086.00 $1,147.00

21390 90 $920.00 $1,151.00 $1,215.00 $1,277.00 $1,151.00 $1,215.00 $1,277.00

21395 90 $1,384.00 $1,482.00 $1,577.00 $1,685.00 $1,482.00 $1,577.00 $1,685.00

21400 90 $143.00 $272.00 $289.00 $301.00 $223.00 $237.00 $248.00

21401 90 $313.00 $688.00 $732.00 $760.00 $440.00 $467.00 $493.00

21406 90 $852.00 $830.00 $882.00 $934.00 $830.00 $882.00 $934.00

21407 90 $736.00 $935.00 $989.00 $1,040.00 $935.00 $989.00 $1,040.00

21408 90 $1,007.00 $1,300.00 $1,376.00 $1,457.00 $1,300.00 $1,376.00 $1,457.00

21421 90 $528.00 $1,200.00 $1,277.00 $1,326.00 $999.00 $1,063.00 $1,110.00

21422 90 $761.00 $983.00 $1,043.00 $1,103.00 $983.00 $1,043.00 $1,103.00

21423 90 $890.00 $1,150.00 $1,219.00 $1,292.00 $1,150.00 $1,219.00 $1,292.00

21431 90 $598.00 $1,053.00 $1,115.00 $1,163.00 $1,053.00 $1,115.00 $1,163.00

21432 90 $744.00 $989.00 $1,050.00 $1,112.00 $989.00 $1,050.00 $1,112.00

21433 90 $1,981.00 $2,551.00 $2,708.00 $2,890.00 $2,551.00 $2,708.00 $2,890.00

21435 90 $1,404.00 $1,866.00 $1,979.00 $2,114.00 $1,866.00 $1,979.00 $2,114.00

21436 90 $2,045.00 $2,787.00 $2,951.00 $3,145.00 $2,787.00 $2,951.00 $3,145.00

21440 90 $308.00 $818.00 $871.00 $900.00 $669.00 $712.00 $739.00

21445 90 $533.00 $1,095.00 $1,165.00 $1,214.00 $900.00 $957.00 $1,003.00

21450 90 $325.00 $873.00 $929.00 $959.00 $704.00 $749.00 $778.00

21451 90 $498.00 $1,165.00 $1,240.00 $1,284.00 $966.00 $1,028.00 $1,070.00

21452 90 $195.00 $799.00 $851.00 $873.00 $478.00 $508.00 $526.00

21453 90 $902.00 $1,296.00 $1,379.00 $1,430.00 $1,117.00 $1,188.00 $1,237.00

21454 90 $905.00 $840.00 $892.00 $945.00 $840.00 $892.00 $945.00

21461 90 $769.00 $2,995.00 $3,192.00 $3,275.00 $1,351.00 $1,436.00 $1,502.00

21462 90 $1,012.00 $3,191.00 $3,400.00 $3,496.00 $1,511.00 $1,606.00 $1,684.00

21465 90 $923.00 $1,374.00 $1,460.00 $1,551.00 $1,374.00 $1,460.00 $1,551.00

21470 90 $1,331.00 $1,767.00 $1,875.00 $1,993.00 $1,767.00 $1,875.00 $1,993.00

21480 0 $82.00 $138.00 $147.00 $151.00 $47.00 $50.00 $53.00

21485 90 $318.00 $990.00 $1,055.00 $1,093.00 $834.00 $888.00 $925.00



Surgery


(Non-Facility MRA)






21490 90 $865.00 $1,342.00 $1,425.00 $1,515.00 $1,342.00 $1,425.00 $1,515.00

21497 90 $372.00 $1,047.00 $1,114.00 $1,152.00 $875.00 $931.00 $967.00

21499 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

21501 90 $315.00 $644.00 $687.00 $720.00 $466.00 $497.00 $529.00

21502 90 $612.00 $751.00 $804.00 $871.00 $751.00 $804.00 $871.00

21510 90 $534.00 $659.00 $706.00 $764.00 $659.00 $706.00 $764.00

21550 10 $165.00 $371.00 $394.00 $409.00 $229.00 $242.00 $256.00

21552 90 ---------- $659.00 $706.00 $764.00 $659.00 $706.00 $764.00

21554 90 ---------- $1,081.00 $1,155.00 $1,249.00 $1,081.00 $1,155.00 $1,249.00

21555 90 $337.00 $593.00 $633.00 $668.00 $447.00 $477.00 $510.00

21556 90 $431.00 $776.00 $826.00 $886.00 $776.00 $826.00 $886.00

21557 90 $794.00 $1,415.00 $1,509.00 $1,626.00 $1,415.00 $1,509.00 $1,626.00

21558 90 ---------- $1,996.00 $2,131.00 $2,308.00 $1,996.00 $2,131.00 $2,308.00

21600 90 $631.00 $814.00 $870.00 $934.00 $814.00 $870.00 $934.00

21610 90 $828.00 $1,790.00 $1,954.00 $2,190.00 $1,790.00 $1,954.00 $2,190.00

21615 90 $938.00 $933.00 $1,000.00 $1,095.00 $933.00 $1,000.00 $1,095.00

21616 90 $1,042.00 $1,130.00 $1,212.00 $1,330.00 $1,130.00 $1,212.00 $1,330.00

21620 90 $689.00 $744.00 $796.00 $860.00 $744.00 $796.00 $860.00

21627 90 $686.00 $793.00 $848.00 $913.00 $793.00 $848.00 $913.00

21630 90 $1,455.00 $1,798.00 $1,918.00 $2,073.00 $1,798.00 $1,918.00 $2,073.00

21632 90 $1,514.00 $1,779.00 $1,901.00 $2,066.00 $1,779.00 $1,901.00 $2,066.00

21685 90 ---------- $1,449.00 $1,532.00 $1,623.00 $1,449.00 $1,532.00 $1,623.00

21700 90 $576.00 $552.00 $591.00 $645.00 $552.00 $591.00 $645.00

21705 90 $746.00 $832.00 $892.00 $984.00 $832.00 $892.00 $984.00

21720 90 $523.00 $738.00 $802.00 $884.00 $738.00 $802.00 $884.00

21725 90 $588.00 $790.00 $843.00 $904.00 $790.00 $843.00 $904.00

21740 90 $1,387.00 $1,544.00 $1,657.00 $1,821.00 $1,544.00 $1,657.00 $1,821.00

21742 90 BR ---------- ---------- ---------- ---------- ---------- ----------

21743 90 BR ---------- ---------- ---------- ---------- ---------- ----------

21750 90 $1,009.00 $1,023.00 $1,096.00 $1,200.00 $1,023.00 $1,096.00 $1,200.00

21811 0 ---------- $913.00 $977.00 $1,070.00 $913.00 $977.00 $1,070.00

21812 0 ---------- $1,097.00 $1,175.00 $1,290.00 $1,097.00 $1,175.00 $1,290.00

21813 0 ---------- $1,441.00 $1,537.00 $1,679.00 $1,441.00 $1,537.00 $1,679.00

21820 90 $143.00 $200.00 $213.00 $223.00 $205.00 $218.00 $228.00

21825 90 $810.00 $797.00 $854.00 $925.00 $797.00 $854.00 $925.00

21899 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

21920 10 $165.00 $363.00 $386.00 $401.00 $232.00 $246.00 $260.00

21925 90 $371.00 $646.00 $691.00 $733.00 $522.00 $559.00 $599.00

21930 90 $403.00 $680.00 $726.00 $770.00 $535.00 $572.00 $614.00

21931 90 ---------- $696.00 $746.00 $809.00 $696.00 $746.00 $809.00

21932 90 ---------- $981.00 $1,051.00 $1,141.00 $981.00 $1,051.00 $1,141.00

21933 90 ---------- $1,095.00 $1,173.00 $1,274.00 $1,095.00 $1,173.00 $1,274.00

21935 90 $1,280.00 $1,527.00 $1,633.00 $1,770.00 $1,527.00 $1,633.00 $1,770.00

21936 90 ---------- $2,104.00 $2,252.00 $2,450.00 $2,104.00 $2,252.00 $2,450.00

22010 90 ---------- $1,421.00 $1,533.00 $1,679.00 $1,421.00 $1,533.00 $1,679.00

22015 90 ---------- $1,398.00 $1,507.00 $1,648.00 $1,398.00 $1,507.00 $1,648.00

22100 90 $850.00 $1,387.00 $1,515.00 $1,690.00 $1,387.00 $1,515.00 $1,690.00

22101 90 $862.00 $1,264.00 $1,362.00 $1,486.00 $1,264.00 $1,362.00 $1,486.00

22102 90 $781.00 $1,150.00 $1,227.00 $1,319.00 $1,150.00 $1,227.00 $1,319.00

22103 ZZZ $198.00 $213.00 $229.00 $253.00 $213.00 $229.00 $253.00



Surgery


(Non-Facility MRA)






22110 90 $889.00 $1,566.00 $1,695.00 $1,868.00 $1,566.00 $1,695.00 $1,868.00

22112 90 $1,090.00 $1,668.00 $1,823.00 $2,038.00 $1,668.00 $1,823.00 $2,038.00

22114 90 $1,062.00 $1,462.00 $1,563.00 $1,687.00 $1,462.00 $1,563.00 $1,687.00

22116 ZZZ $195.00 $216.00 $234.00 $261.00 $216.00 $234.00 $261.00

22206 90 ---------- $3,705.00 $4,005.00 $4,431.00 $3,705.00 $4,005.00 $4,431.00

22207 90 ---------- $3,625.00 $3,911.00 $4,311.00 $3,625.00 $3,911.00 $4,311.00

22208 ZZZ ---------- $889.00 $960.00 $1,065.00 $889.00 $960.00 $1,065.00

22210 90 $1,892.00 $2,697.00 $2,920.00 $3,228.00 $2,697.00 $2,920.00 $3,228.00

22212 90 $1,668.00 $2,222.00 $2,393.00 $2,618.00 $2,222.00 $2,393.00 $2,618.00

22214 90 $819.00 $2,227.00 $2,400.00 $2,626.00 $2,227.00 $2,400.00 $2,626.00

22216 ZZZ $492.00 $555.00 $599.00 $663.00 $555.00 $599.00 $663.00

22220 90 $1,801.00 $2,400.00 $2,589.00 $2,844.00 $2,400.00 $2,589.00 $2,844.00

22222 90 $1,604.00 $2,222.00 $2,366.00 $2,544.00 $2,222.00 $2,366.00 $2,544.00

22224 90 $1,731.00 $2,361.00 $2,535.00 $2,762.00 $2,361.00 $2,535.00 $2,762.00

22226 ZZZ $488.00 $552.00 $595.00 $659.00 $552.00 $595.00 $659.00

22310 90 $272.00 $448.00 $478.00 $512.00 $415.00 $443.00 $476.00

22315 90 $711.00 $1,291.00 $1,386.00 $1,491.00 $1,140.00 $1,225.00 $1,328.00

22318 90 $1,755.00 $2,510.00 $2,744.00 $3,085.00 $2,510.00 $2,744.00 $3,085.00

22319 90 $1,983.00 $2,810.00 $3,082.00 $3,484.00 $2,810.00 $3,082.00 $3,484.00

22325 90 $1,407.00 $2,164.00 $2,342.00 $2,582.00 $2,164.00 $2,342.00 $2,582.00

22326 90 $1,710.00 $2,260.00 $2,456.00 $2,732.00 $2,260.00 $2,456.00 $2,732.00

22327 90 $1,660.00 $2,264.00 $2,455.00 $2,715.00 $2,264.00 $2,455.00 $2,715.00

22328 ZZZ $391.00 $435.00 $473.00 $531.00 $435.00 $473.00 $531.00

22505 10 $174.00 $195.00 $208.00 $224.00 $195.00 $208.00 $224.00

22510 10 ---------- $2,330.00 $2,477.00 $2,532.00 $642.00 $674.00 $712.00

22511 10 ---------- $2,307.00 $2,453.00 $2,507.00 $602.00 $633.00 $669.00

22512 ZZZ ---------- $1,325.00 $1,412.00 $1,445.00 $312.00 $329.00 $352.00

22513 10 ---------- $9,834.00 $10,500.00 $10,661.00 $776.00 $827.00 $893.00

22514 10 ---------- $9,773.00 $10,435.00 $10,590.00 $722.00 $768.00 $829.00

22515 ZZZ ---------- $5,960.00 $6,365.00 $6,457.00 $339.00 $362.00 $394.00

22526 10 ---------- $3,179.00 $3,388.00 $3,449.00 $495.00 $522.00 $554.00

22527 ZZZ ---------- $2,675.00 $2,853.00 $2,895.00 $236.00 $248.00 $264.00

22532 90 ---------- $2,682.00 $2,902.00 $3,206.00 $2,682.00 $2,902.00 $3,206.00

22533 90 ---------- $2,482.00 $2,665.00 $2,907.00 $2,482.00 $2,665.00 $2,907.00

22534 ZZZ ---------- $551.00 $595.00 $660.00 $551.00 $595.00 $660.00

22548 90 $2,271.00 $2,997.00 $3,285.00 $3,710.00 $2,997.00 $3,285.00 $3,710.00

22551 90 ---------- $2,605.00 $2,830.00 $3,152.00 $2,605.00 $2,830.00 $3,152.00

22552 ZZZ ---------- $615.00 $669.00 $751.00 $615.00 $669.00 $751.00

22554 90 $1,727.00 $1,895.00 $2,053.00 $2,271.00 $1,895.00 $2,053.00 $2,271.00

22556 90 $2,054.00 $2,523.00 $2,729.00 $3,017.00 $2,523.00 $2,729.00 $3,017.00

22558 90 $1,907.00 $2,312.00 $2,488.00 $2,729.00 $2,312.00 $2,488.00 $2,729.00

22585 ZZZ $473.00 $503.00 $544.00 $604.00 $503.00 $544.00 $604.00

22586 90 ---------- $2,888.00 $3,127.00 $3,465.00 $2,888.00 $3,127.00 $3,465.00

22590 90 $1,895.00 $2,407.00 $2,623.00 $2,930.00 $2,407.00 $2,623.00 $2,930.00

22595 90 $1,960.00 $2,294.00 $2,499.00 $2,789.00 $2,294.00 $2,499.00 $2,789.00

22600 90 $1,567.00 $1,951.00 $2,119.00 $2,350.00 $1,951.00 $2,119.00 $2,350.00

22610 90 $1,494.00 $1,902.00 $2,060.00 $2,272.00 $1,902.00 $2,060.00 $2,272.00

22612 90 $1,861.00 $2,391.00 $2,579.00 $2,836.00 $2,391.00 $2,579.00 $2,836.00

22614 ZZZ $530.00 $602.00 $653.00 $729.00 $602.00 $653.00 $729.00

22630 90 $1,201.00 $2,388.00 $2,597.00 $2,892.00 $2,388.00 $2,597.00 $2,892.00



Surgery


(Non-Facility MRA)






22632 ZZZ $442.00 $497.00 $541.00 $609.00 $497.00 $541.00 $609.00

22633 90 ---------- $2,809.00 $3,039.00 $3,364.00 $2,809.00 $3,039.00 $3,364.00

22634 ZZZ ---------- $764.00 $828.00 $925.00 $764.00 $828.00 $925.00

22800 90 $1,960.00 $2,022.00 $2,176.00 $2,378.00 $2,022.00 $2,176.00 $2,378.00

22802 90 $2,633.00 $3,155.00 $3,393.00 $3,715.00 $3,155.00 $3,393.00 $3,715.00

22804 90 $2,951.00 $3,654.00 $3,932.00 $4,314.00 $3,654.00 $3,932.00 $4,314.00

22808 90 $2,157.00 $2,795.00 $3,022.00 $3,341.00 $2,795.00 $3,022.00 $3,341.00

22810 90 $2,356.00 $3,097.00 $3,343.00 $3,690.00 $3,097.00 $3,343.00 $3,690.00

22812 90 $2,675.00 $3,258.00 $3,471.00 $3,738.00 $3,258.00 $3,471.00 $3,738.00

22818 90 $2,701.00 $3,279.00 $3,512.00 $3,823.00 $3,279.00 $3,512.00 $3,823.00

22819 90 $2,968.00 $4,187.00 $4,582.00 $5,171.00 $4,187.00 $4,582.00 $5,171.00

22830 90 $1,176.00 $1,217.00 $1,313.00 $1,438.00 $1,217.00 $1,313.00 $1,438.00

22840 ZZZ $943.00 $1,167.00 $1,265.00 $1,410.00 $1,167.00 $1,265.00 $1,410.00

22841 0 BR ---------- ---------- ---------- ---------- ---------- ----------

22842 ZZZ $2,352.00 $1,172.00 $1,270.00 $1,417.00 $1,172.00 $1,270.00 $1,417.00

22843 ZZZ $1,028.00 $1,254.00 $1,358.00 $1,514.00 $1,254.00 $1,358.00 $1,514.00

22844 ZZZ $1,277.00 $1,506.00 $1,624.00 $1,798.00 $1,506.00 $1,624.00 $1,798.00

22845 ZZZ $1,853.00 $1,127.00 $1,225.00 $1,374.00 $1,127.00 $1,225.00 $1,374.00

22846 ZZZ $999.00 $1,170.00 $1,271.00 $1,425.00 $1,170.00 $1,271.00 $1,425.00

22847 ZZZ $1,077.00 $1,272.00 $1,374.00 $1,525.00 $1,272.00 $1,374.00 $1,525.00

22848 ZZZ $529.00 $549.00 $592.00 $654.00 $549.00 $592.00 $654.00

22849 90 $2,235.00 $1,959.00 $2,115.00 $2,330.00 $1,959.00 $2,115.00 $2,330.00

22850 90 $872.00 $1,083.00 $1,169.00 $1,281.00 $1,083.00 $1,169.00 $1,281.00

22852 90 $854.00 $1,035.00 $1,116.00 $1,221.00 $1,035.00 $1,116.00 $1,221.00

22853 ZZZ ---------- $402.00 $438.00 $491.00 $402.00 $438.00 $491.00

22854 ZZZ ---------- $521.00 $567.00 $636.00 $521.00 $567.00 $636.00

22855 90 $1,193.00 $1,673.00 $1,811.00 $2,002.00 $1,673.00 $1,811.00 $2,002.00

22856 90 ---------- $2,482.00 $2,690.00 $2,984.00 $2,482.00 $2,690.00 $2,984.00

22857 90 ---------- $2,637.00 $2,815.00 $3,039.00 $2,637.00 $2,815.00 $3,039.00

22858 ZZZ ---------- $766.00 $829.00 $922.00 $766.00 $829.00 $922.00

22859 ZZZ ---------- $521.00 $567.00 $636.00 $521.00 $567.00 $636.00

22861 90 ---------- $2,966.00 $3,187.00 $3,507.00 $2,966.00 $3,187.00 $3,507.00

22862 90 ---------- $3,182.00 $3,411.00 $3,713.00 $3,182.00 $3,411.00 $3,713.00

22864 90 ---------- $3,184.00 $3,488.00 $3,941.00 $3,184.00 $3,488.00 $3,941.00

22865 90 ---------- $3,065.00 $3,303.00 $3,636.00 $3,065.00 $3,303.00 $3,636.00

22867 90 ---------- $1,483.00 $1,608.00 $1,779.00 $1,483.00 $1,608.00 $1,779.00

22868 ZZZ ---------- $375.00 $407.00 $455.00 $375.00 $407.00 $455.00

22869 90 ---------- $807.00 $870.00 $950.00 $807.00 $870.00 $950.00

22870 ZZZ ---------- $218.00 $236.00 $264.00 $218.00 $236.00 $264.00

22899 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

22900 90 $446.00 $836.00 $895.00 $971.00 $836.00 $895.00 $971.00

22901 90 ---------- $990.00 $1,061.00 $1,153.00 $990.00 $1,061.00 $1,153.00

22902 90 ---------- $631.00 $675.00 $717.00 $486.00 $520.00 $561.00

22903 90 ---------- $650.00 $697.00 $757.00 $650.00 $697.00 $757.00

22904 90 ---------- $1,564.00 $1,674.00 $1,821.00 $1,564.00 $1,674.00 $1,821.00

22905 90 ---------- $1,987.00 $2,126.00 $2,317.00 $1,987.00 $2,126.00 $2,317.00

22999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

23000 90 $447.00 $822.00 $877.00 $916.00 $535.00 $571.00 $607.00

23020 90 $807.00 $1,007.00 $1,073.00 $1,149.00 $1,007.00 $1,073.00 $1,149.00

23030 10 $323.00 $628.00 $670.00 $702.00 $375.00 $400.00 $429.00



Surgery


(Non-Facility MRA)






23031 10 $185.00 $600.00 $640.00 $666.00 $319.00 $341.00 $364.00

23035 90 $861.00 $992.00 $1,058.00 $1,132.00 $992.00 $1,058.00 $1,132.00

23040 90 $898.00 $1,048.00 $1,117.00 $1,196.00 $1,048.00 $1,117.00 $1,196.00

23044 90 $708.00 $829.00 $885.00 $949.00 $829.00 $885.00 $949.00

23065 10 $171.00 $310.00 $329.00 $345.00 $244.00 $259.00 $274.00

23066 90 $302.00 $791.00 $845.00 $885.00 $519.00 $555.00 $592.00

23071 90 ---------- $619.00 $663.00 $717.00 $619.00 $663.00 $717.00

23073 90 ---------- $1,025.00 $1,097.00 $1,185.00 $1,025.00 $1,097.00 $1,185.00

23075 90 $247.00 $670.00 $716.00 $755.00 $478.00 $510.00 $548.00

23076 90 $613.00 $793.00 $848.00 $914.00 $793.00 $848.00 $914.00

23077 90 $1,228.00 $1,697.00 $1,815.00 $1,970.00 $1,697.00 $1,815.00 $1,970.00

23078 90 ---------- $2,131.00 $2,277.00 $2,470.00 $2,131.00 $2,277.00 $2,470.00

23100 90 $616.00 $726.00 $775.00 $828.00 $726.00 $775.00 $828.00

23101 90 $583.00 $651.00 $695.00 $743.00 $651.00 $695.00 $743.00

23105 90 $814.00 $928.00 $988.00 $1,056.00 $928.00 $988.00 $1,056.00

23106 90 $581.00 $700.00 $748.00 $799.00 $700.00 $748.00 $799.00

23107 90 $851.00 $965.00 $1,029.00 $1,100.00 $965.00 $1,029.00 $1,100.00

23120 90 $645.00 $849.00 $906.00 $966.00 $849.00 $906.00 $966.00

23125 90 $865.00 $1,017.00 $1,086.00 $1,167.00 $1,017.00 $1,086.00 $1,167.00

23130 90 $722.00 $888.00 $947.00 $1,013.00 $888.00 $947.00 $1,013.00

23140 90 $597.00 $787.00 $841.00 $902.00 $787.00 $841.00 $902.00

23145 90 $889.00 $1,004.00 $1,072.00 $1,152.00 $1,004.00 $1,072.00 $1,152.00

23146 90 $704.00 $895.00 $953.00 $1,016.00 $895.00 $953.00 $1,016.00

23150 90 $755.00 $960.00 $1,023.00 $1,093.00 $960.00 $1,023.00 $1,093.00

23155 90 $945.00 $1,154.00 $1,230.00 $1,317.00 $1,154.00 $1,230.00 $1,317.00

23156 90 $794.00 $978.00 $1,043.00 $1,118.00 $978.00 $1,043.00 $1,118.00

23170 90 $645.00 $817.00 $872.00 $934.00 $817.00 $872.00 $934.00

23172 90 $638.00 $808.00 $862.00 $922.00 $808.00 $862.00 $922.00

23174 90 $882.00 $1,108.00 $1,183.00 $1,267.00 $1,108.00 $1,183.00 $1,267.00

23180 90 $566.00 $968.00 $1,034.00 $1,111.00 $968.00 $1,034.00 $1,111.00

23182 90 $865.00 $959.00 $1,023.00 $1,093.00 $959.00 $1,023.00 $1,093.00

23184 90 $962.00 $1,069.00 $1,140.00 $1,220.00 $1,069.00 $1,140.00 $1,220.00

23190 90 $656.00 $834.00 $890.00 $954.00 $834.00 $890.00 $954.00

23195 90 $902.00 $1,106.00 $1,181.00 $1,267.00 $1,106.00 $1,181.00 $1,267.00

23200 90 $1,095.00 $2,228.00 $2,376.00 $2,559.00 $2,228.00 $2,376.00 $2,559.00

23210 90 $1,095.00 $2,614.00 $2,790.00 $3,014.00 $2,614.00 $2,790.00 $3,014.00

23220 90 $1,307.00 $2,878.00 $3,069.00 $3,310.00 $2,878.00 $3,069.00 $3,310.00

23330 10 $59.00 $349.00 $372.00 $388.00 $223.00 $238.00 $252.00

23333 90 ---------- $656.00 $697.00 $741.00 $656.00 $697.00 $741.00

23334 90 ---------- $1,583.00 $1,689.00 $1,816.00 $1,583.00 $1,689.00 $1,816.00

23335 90 ---------- $1,887.00 $2,012.00 $2,166.00 $1,887.00 $2,012.00 $2,166.00

23350 0 $74.00 $182.00 $192.00 $197.00 $75.00 $78.00 $81.00

23395 90 $1,366.00 $1,881.00 $2,004.00 $2,150.00 $1,881.00 $2,004.00 $2,150.00

23397 90 $1,403.00 $1,681.00 $1,794.00 $1,932.00 $1,681.00 $1,794.00 $1,932.00

23400 90 $1,196.00 $1,385.00 $1,475.00 $1,583.00 $1,385.00 $1,475.00 $1,583.00

23405 90 $799.00 $909.00 $968.00 $1,036.00 $909.00 $968.00 $1,036.00

23406 90 $977.00 $1,125.00 $1,198.00 $1,282.00 $1,125.00 $1,198.00 $1,282.00

23410 90 $1,119.00 $1,203.00 $1,282.00 $1,374.00 $1,203.00 $1,282.00 $1,374.00

23412 90 $1,229.00 $1,247.00 $1,329.00 $1,424.00 $1,247.00 $1,329.00 $1,424.00

23415 90 $622.00 $1,019.00 $1,087.00 $1,165.00 $1,019.00 $1,087.00 $1,165.00



Surgery


(Non-Facility MRA)






23420 90 $1,276.00 $1,419.00 $1,514.00 $1,623.00 $1,419.00 $1,514.00 $1,623.00

23430 90 $884.00 $1,088.00 $1,160.00 $1,241.00 $1,088.00 $1,160.00 $1,241.00

23440 90 $906.00 $1,104.00 $1,177.00 $1,261.00 $1,104.00 $1,177.00 $1,261.00

23450 90 $1,210.00 $1,396.00 $1,490.00 $1,604.00 $1,396.00 $1,490.00 $1,604.00

23455 90 $1,340.00 $1,462.00 $1,557.00 $1,672.00 $1,462.00 $1,557.00 $1,672.00

23460 90 $1,364.00 $1,598.00 $1,704.00 $1,832.00 $1,598.00 $1,704.00 $1,832.00

23462 90 $1,383.00 $1,552.00 $1,654.00 $1,778.00 $1,552.00 $1,654.00 $1,778.00

23465 90 $1,398.00 $1,632.00 $1,739.00 $1,866.00 $1,632.00 $1,739.00 $1,866.00

23466 90 $1,332.00 $1,640.00 $1,748.00 $1,874.00 $1,640.00 $1,748.00 $1,874.00

23470 90 $1,540.00 $1,768.00 $1,884.00 $2,025.00 $1,768.00 $1,884.00 $2,025.00

23472 90 $1,570.00 $2,147.00 $2,287.00 $2,459.00 $2,147.00 $2,287.00 $2,459.00

23473 90 ---------- $2,399.00 $2,556.00 $2,751.00 $2,399.00 $2,556.00 $2,751.00

23474 90 ---------- $2,593.00 $2,762.00 $2,974.00 $2,593.00 $2,762.00 $2,974.00

23480 90 $926.00 $1,203.00 $1,284.00 $1,380.00 $1,203.00 $1,284.00 $1,380.00

23485 90 $1,181.00 $1,398.00 $1,490.00 $1,599.00 $1,398.00 $1,490.00 $1,599.00

23490 90 $1,038.00 $1,235.00 $1,319.00 $1,423.00 $1,235.00 $1,319.00 $1,423.00

23491 90 $1,251.00 $1,485.00 $1,584.00 $1,702.00 $1,485.00 $1,584.00 $1,702.00

23500 90 $148.00 $310.00 $330.00 $347.00 $315.00 $335.00 $352.00

23505 90 $293.00 $501.00 $534.00 $564.00 $475.00 $506.00 $536.00

23515 90 $688.00 $1,052.00 $1,121.00 $1,200.00 $1,052.00 $1,121.00 $1,200.00

23520 90 $205.00 $326.00 $348.00 $368.00 $331.00 $353.00 $373.00

23525 90 $320.00 $531.00 $566.00 $596.00 $494.00 $526.00 $555.00

23530 90 $659.00 $833.00 $889.00 $953.00 $833.00 $889.00 $953.00

23532 90 $713.00 $902.00 $961.00 $1,025.00 $902.00 $961.00 $1,025.00

23540 90 $148.00 $319.00 $339.00 $356.00 $323.00 $344.00 $361.00

23545 90 $148.00 $478.00 $507.00 $531.00 $437.00 $464.00 $487.00

23550 90 $701.00 $815.00 $868.00 $925.00 $815.00 $868.00 $925.00

23552 90 $753.00 $955.00 $1,018.00 $1,089.00 $955.00 $1,018.00 $1,089.00

23570 90 $88.00 $331.00 $352.00 $371.00 $341.00 $363.00 $382.00

23575 90 $306.00 $571.00 $609.00 $645.00 $537.00 $573.00 $609.00

23585 90 $809.00 $1,438.00 $1,533.00 $1,646.00 $1,438.00 $1,533.00 $1,646.00

23600 90 $318.00 $463.00 $494.00 $518.00 $438.00 $466.00 $491.00

23605 90 $511.00 $663.00 $706.00 $747.00 $610.00 $650.00 $690.00

23615 90 $900.00 $1,294.00 $1,380.00 $1,478.00 $1,294.00 $1,380.00 $1,478.00

23616 90 $1,895.00 $1,827.00 $1,948.00 $2,094.00 $1,827.00 $1,948.00 $2,094.00

23620 90 $286.00 $382.00 $407.00 $428.00 $365.00 $389.00 $409.00

23625 90 $422.00 $540.00 $575.00 $608.00 $504.00 $537.00 $569.00

23630 90 $712.00 $1,138.00 $1,213.00 $1,297.00 $1,138.00 $1,213.00 $1,297.00

23650 90 $296.00 $447.00 $474.00 $497.00 $412.00 $437.00 $460.00

23655 90 $374.00 $579.00 $617.00 $655.00 $579.00 $617.00 $655.00

23660 90 $712.00 $847.00 $903.00 $964.00 $847.00 $903.00 $964.00

23665 90 $440.00 $609.00 $649.00 $687.00 $569.00 $607.00 $644.00

23670 90 $759.00 $1,281.00 $1,365.00 $1,462.00 $1,281.00 $1,365.00 $1,462.00

23675 90 $550.00 $788.00 $840.00 $890.00 $723.00 $770.00 $819.00

23680 90 $1,064.00 $1,357.00 $1,447.00 $1,552.00 $1,357.00 $1,447.00 $1,552.00

23700 10 $237.00 $286.00 $305.00 $326.00 $286.00 $305.00 $326.00

23800 90 $1,346.00 $1,493.00 $1,591.00 $1,709.00 $1,493.00 $1,591.00 $1,709.00

23802 90 $1,368.00 $1,877.00 $2,001.00 $2,147.00 $1,877.00 $2,001.00 $2,147.00

23900 90 $1,561.00 $2,049.00 $2,186.00 $2,357.00 $2,049.00 $2,186.00 $2,357.00

23920 90 $1,300.00 $1,623.00 $1,731.00 $1,863.00 $1,623.00 $1,731.00 $1,863.00



Surgery


(Non-Facility MRA)






23921 90 $497.00 $674.00 $718.00 $762.00 $674.00 $718.00 $762.00

23929 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

23930 10 $71.00 $505.00 $539.00 $567.00 $317.00 $339.00 $365.00

23931 10 $62.00 $403.00 $429.00 $445.00 $230.00 $245.00 $259.00

23935 90 $630.00 $734.00 $783.00 $833.00 $734.00 $783.00 $833.00

24000 90 $550.00 $694.00 $740.00 $788.00 $694.00 $740.00 $788.00

24006 90 $793.00 $1,038.00 $1,106.00 $1,182.00 $1,038.00 $1,106.00 $1,182.00

24065 10 $166.00 $362.00 $385.00 $401.00 $243.00 $258.00 $272.00

24066 90 $461.00 $890.00 $952.00 $1,003.00 $608.00 $650.00 $698.00

24071 90 ---------- $598.00 $640.00 $691.00 $598.00 $640.00 $691.00

24073 90 ---------- $1,022.00 $1,093.00 $1,181.00 $1,022.00 $1,093.00 $1,181.00

24075 90 $349.00 $699.00 $747.00 $786.00 $482.00 $515.00 $552.00

24076 90 $529.00 $796.00 $850.00 $913.00 $796.00 $850.00 $913.00

24077 90 $1,058.00 $1,534.00 $1,641.00 $1,777.00 $1,534.00 $1,641.00 $1,777.00

24079 90 ---------- $1,970.00 $2,106.00 $2,281.00 $1,970.00 $2,106.00 $2,281.00

24100 90 $467.00 $600.00 $639.00 $678.00 $600.00 $639.00 $678.00

24101 90 $591.00 $723.00 $770.00 $821.00 $723.00 $770.00 $821.00

24102 90 $755.00 $898.00 $956.00 $1,021.00 $898.00 $956.00 $1,021.00

24105 90 $360.00 $504.00 $538.00 $570.00 $504.00 $538.00 $570.00

24110 90 $724.00 $848.00 $905.00 $968.00 $848.00 $905.00 $968.00

24115 90 $898.00 $1,055.00 $1,121.00 $1,191.00 $1,055.00 $1,121.00 $1,191.00

24116 90 $1,037.00 $1,267.00 $1,352.00 $1,454.00 $1,267.00 $1,352.00 $1,454.00

24120 90 $595.00 $768.00 $818.00 $872.00 $768.00 $818.00 $872.00

24125 90 $663.00 $891.00 $947.00 $1,005.00 $891.00 $947.00 $1,005.00

24126 90 $731.00 $936.00 $997.00 $1,062.00 $936.00 $997.00 $1,062.00

24130 90 $595.00 $737.00 $786.00 $838.00 $737.00 $786.00 $838.00

24134 90 $966.00 $1,094.00 $1,168.00 $1,253.00 $1,094.00 $1,168.00 $1,253.00

24136 90 $720.00 $866.00 $921.00 $983.00 $866.00 $921.00 $983.00

24138 90 $697.00 $980.00 $1,045.00 $1,116.00 $980.00 $1,045.00 $1,116.00

24140 90 $963.00 $1,027.00 $1,095.00 $1,172.00 $1,027.00 $1,095.00 $1,172.00

24145 90 $592.00 $853.00 $910.00 $974.00 $853.00 $910.00 $974.00

24147 90 $703.00 $905.00 $966.00 $1,030.00 $905.00 $966.00 $1,030.00

24149 90 $1,224.00 $1,716.00 $1,828.00 $1,953.00 $1,716.00 $1,828.00 $1,953.00

24150 90 $1,265.00 $2,302.00 $2,457.00 $2,651.00 $2,302.00 $2,457.00 $2,651.00

24152 90 $829.00 $1,960.00 $2,081.00 $2,221.00 $1,960.00 $2,081.00 $2,221.00

24155 90 $1,019.00 $1,254.00 $1,338.00 $1,439.00 $1,254.00 $1,338.00 $1,439.00

24160 90 $533.00 $1,862.00 $1,984.00 $2,131.00 $1,862.00 $1,984.00 $2,131.00

24164 90 $564.00 $1,069.00 $1,142.00 $1,225.00 $1,069.00 $1,142.00 $1,225.00

24200 10 $58.00 $292.00 $311.00 $324.00 $202.00 $214.00 $226.00

24201 90 $444.00 $780.00 $833.00 $876.00 $529.00 $565.00 $605.00

24220 0 $89.00 $222.00 $235.00 $241.00 $100.00 $105.00 $110.00

24300 90 $352.00 $595.00 $634.00 $668.00 $595.00 $634.00 $668.00

24301 90 $869.00 $1,095.00 $1,166.00 $1,247.00 $1,095.00 $1,166.00 $1,247.00

24305 90 $579.00 $836.00 $889.00 $945.00 $836.00 $889.00 $945.00

24310 90 $511.00 $679.00 $721.00 $766.00 $679.00 $721.00 $766.00

24320 90 $944.00 $1,118.00 $1,191.00 $1,277.00 $1,118.00 $1,191.00 $1,277.00

24330 90 $845.00 $1,047.00 $1,117.00 $1,196.00 $1,047.00 $1,117.00 $1,196.00

24331 90 $927.00 $1,128.00 $1,196.00 $1,267.00 $1,128.00 $1,196.00 $1,267.00

24332 90 $487.00 $893.00 $953.00 $1,020.00 $893.00 $953.00 $1,020.00

24340 90 $697.00 $892.00 $951.00 $1,015.00 $892.00 $951.00 $1,015.00



Surgery


(Non-Facility MRA)






24341 90 $702.00 $1,085.00 $1,156.00 $1,233.00 $1,085.00 $1,156.00 $1,233.00

24342 90 $950.00 $1,133.00 $1,207.00 $1,292.00 $1,133.00 $1,207.00 $1,292.00

24343 90 $643.00 $1,028.00 $1,095.00 $1,168.00 $1,028.00 $1,095.00 $1,168.00

24344 90 $971.00 $1,598.00 $1,705.00 $1,828.00 $1,598.00 $1,705.00 $1,828.00

24345 90 $643.00 $1,023.00 $1,090.00 $1,162.00 $1,023.00 $1,090.00 $1,162.00

24346 90 $971.00 $1,609.00 $1,718.00 $1,844.00 $1,609.00 $1,718.00 $1,844.00

24357 90 ---------- $608.00 $645.00 $680.00 $608.00 $645.00 $680.00

24358 90 ---------- $758.00 $807.00 $858.00 $758.00 $807.00 $858.00

24359 90 ---------- $961.00 $1,023.00 $1,092.00 $961.00 $1,023.00 $1,092.00

24360 90 $1,125.00 $1,320.00 $1,409.00 $1,514.00 $1,320.00 $1,409.00 $1,514.00

24361 90 $1,215.00 $1,471.00 $1,568.00 $1,684.00 $1,471.00 $1,568.00 $1,684.00

24362 90 $1,269.00 $1,556.00 $1,659.00 $1,780.00 $1,556.00 $1,659.00 $1,780.00

24363 90 $1,663.00 $2,143.00 $2,282.00 $2,451.00 $2,143.00 $2,282.00 $2,451.00

24365 90 $747.00 $933.00 $995.00 $1,066.00 $933.00 $995.00 $1,066.00

24366 90 $850.00 $993.00 $1,058.00 $1,132.00 $993.00 $1,058.00 $1,132.00

24370 90 ---------- $2,285.00 $2,433.00 $2,614.00 $2,285.00 $2,433.00 $2,614.00

24371 90 ---------- $2,631.00 $2,801.00 $3,012.00 $2,631.00 $2,801.00 $3,012.00

24400 90 $991.00 $1,197.00 $1,276.00 $1,366.00 $1,197.00 $1,276.00 $1,366.00

24410 90 $1,319.00 $1,555.00 $1,660.00 $1,786.00 $1,555.00 $1,660.00 $1,786.00

24420 90 $1,265.00 $1,441.00 $1,534.00 $1,641.00 $1,441.00 $1,534.00 $1,641.00

24430 90 $1,209.00 $1,552.00 $1,654.00 $1,775.00 $1,552.00 $1,654.00 $1,775.00

24435 90 $1,260.00 $1,575.00 $1,679.00 $1,799.00 $1,575.00 $1,679.00 $1,799.00

24470 90 $774.00 $980.00 $1,047.00 $1,122.00 $980.00 $1,047.00 $1,122.00

24495 90 $742.00 $790.00 $847.00 $924.00 $790.00 $847.00 $924.00

24498 90 $1,076.00 $1,266.00 $1,350.00 $1,448.00 $1,266.00 $1,350.00 $1,448.00

24500 90 $288.00 $509.00 $542.00 $570.00 $466.00 $496.00 $523.00

24505 90 $574.00 $714.00 $761.00 $804.00 $649.00 $692.00 $734.00

24515 90 $1,018.00 $1,282.00 $1,367.00 $1,464.00 $1,282.00 $1,367.00 $1,464.00

24516 90 $1,029.00 $1,260.00 $1,343.00 $1,442.00 $1,260.00 $1,343.00 $1,442.00

24530 90 $88.00 $541.00 $577.00 $607.00 $493.00 $525.00 $554.00

24535 90 $671.00 $883.00 $941.00 $998.00 $820.00 $874.00 $930.00

24538 90 $850.00 $1,087.00 $1,161.00 $1,243.00 $1,087.00 $1,161.00 $1,243.00

24545 90 $946.00 $1,362.00 $1,451.00 $1,556.00 $1,362.00 $1,451.00 $1,556.00

24546 90 $1,273.00 $1,525.00 $1,625.00 $1,744.00 $1,525.00 $1,625.00 $1,744.00

24560 90 $266.00 $454.00 $483.00 $506.00 $409.00 $435.00 $457.00

24565 90 $526.00 $762.00 $812.00 $860.00 $703.00 $750.00 $797.00

24566 90 $705.00 $1,045.00 $1,116.00 $1,193.00 $1,045.00 $1,116.00 $1,193.00

24575 90 $872.00 $1,070.00 $1,141.00 $1,219.00 $1,070.00 $1,141.00 $1,219.00

24576 90 $295.00 $481.00 $513.00 $537.00 $435.00 $463.00 $487.00

24577 90 $575.00 $782.00 $834.00 $885.00 $721.00 $770.00 $820.00

24579 90 $964.00 $1,221.00 $1,301.00 $1,392.00 $1,221.00 $1,301.00 $1,392.00

24582 90 $773.00 $1,177.00 $1,256.00 $1,342.00 $1,177.00 $1,256.00 $1,342.00

24586 90 $1,314.00 $1,588.00 $1,692.00 $1,815.00 $1,588.00 $1,692.00 $1,815.00

24587 90 $1,278.00 $1,594.00 $1,701.00 $1,831.00 $1,594.00 $1,701.00 $1,831.00

24600 90 $360.00 $520.00 $551.00 $580.00 $479.00 $507.00 $536.00

24605 90 $371.00 $678.00 $723.00 $770.00 $678.00 $723.00 $770.00

24615 90 $836.00 $1,040.00 $1,108.00 $1,186.00 $1,040.00 $1,108.00 $1,186.00

24620 90 $560.00 $795.00 $845.00 $898.00 $795.00 $845.00 $898.00

24635 90 $1,329.00 $980.00 $1,045.00 $1,116.00 $980.00 $1,045.00 $1,116.00

24650 90 $262.00 $370.00 $394.00 $412.00 $341.00 $363.00 $381.00



Surgery


(Non-Facility MRA)






24655 90 $436.00 $621.00 $661.00 $696.00 $568.00 $605.00 $639.00

24665 90 $749.00 $948.00 $1,011.00 $1,077.00 $948.00 $1,011.00 $1,077.00

24666 90 $905.00 $1,069.00 $1,140.00 $1,218.00 $1,069.00 $1,140.00 $1,218.00

24670 90 $263.00 $412.00 $439.00 $460.00 $374.00 $398.00 $419.00

24675 90 $490.00 $646.00 $688.00 $727.00 $593.00 $631.00 $669.00

24685 90 $819.00 $950.00 $1,013.00 $1,081.00 $950.00 $1,013.00 $1,081.00

24800 90 $984.00 $1,215.00 $1,297.00 $1,393.00 $1,215.00 $1,297.00 $1,393.00

24802 90 $1,181.00 $1,438.00 $1,526.00 $1,623.00 $1,438.00 $1,526.00 $1,623.00

24900 90 $858.00 $1,070.00 $1,142.00 $1,225.00 $1,070.00 $1,142.00 $1,225.00

24920 90 $851.00 $1,054.00 $1,124.00 $1,205.00 $1,054.00 $1,124.00 $1,205.00

24925 90 $661.00 $766.00 $823.00 $894.00 $766.00 $823.00 $894.00

24930 90 $928.00 $1,113.00 $1,187.00 $1,273.00 $1,113.00 $1,187.00 $1,273.00

24931 90 $1,063.00 $1,171.00 $1,235.00 $1,310.00 $1,171.00 $1,235.00 $1,310.00

24935 90 $1,327.00 $1,453.00 $1,559.00 $1,714.00 $1,453.00 $1,559.00 $1,714.00

24940 90 BR ---------- ---------- ---------- ---------- ---------- ----------

24999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

25000 90 $381.00 $482.00 $514.00 $543.00 $482.00 $514.00 $543.00

25001 90 $294.00 $493.00 $525.00 $555.00 $493.00 $525.00 $555.00

25020 90 $594.00 $824.00 $878.00 $927.00 $824.00 $878.00 $927.00

25023 90 $1,040.00 $1,593.00 $1,697.00 $1,805.00 $1,593.00 $1,697.00 $1,805.00

25024 90 $683.00 $1,133.00 $1,207.00 $1,293.00 $1,133.00 $1,207.00 $1,293.00

25025 90 $1,104.00 $1,801.00 $1,923.00 $2,072.00 $1,801.00 $1,923.00 $2,072.00

25028 90 $417.00 $751.00 $802.00 $848.00 $751.00 $802.00 $848.00

25031 90 $266.00 $525.00 $560.00 $596.00 $525.00 $560.00 $596.00

25035 90 $794.00 $847.00 $903.00 $963.00 $847.00 $903.00 $963.00

25040 90 $654.00 $817.00 $870.00 $926.00 $817.00 $870.00 $926.00

25065 10 $164.00 $357.00 $380.00 $394.00 $236.00 $250.00 $263.00

25066 90 $322.00 $520.00 $555.00 $590.00 $520.00 $555.00 $590.00

25071 90 ---------- $625.00 $668.00 $720.00 $625.00 $668.00 $720.00

25073 90 ---------- $779.00 $831.00 $890.00 $779.00 $831.00 $890.00

25075 90 $352.00 $678.00 $724.00 $759.00 $460.00 $491.00 $524.00

25076 90 $544.00 $753.00 $802.00 $856.00 $753.00 $802.00 $856.00

25077 90 $957.00 $1,310.00 $1,400.00 $1,510.00 $1,310.00 $1,400.00 $1,510.00

25078 90 ---------- $1,723.00 $1,840.00 $1,989.00 $1,723.00 $1,840.00 $1,989.00

25085 90 $562.00 $649.00 $691.00 $734.00 $649.00 $691.00 $734.00

25100 90 $420.00 $487.00 $518.00 $550.00 $487.00 $518.00 $550.00

25101 90 $492.00 $583.00 $620.00 $658.00 $583.00 $620.00 $658.00

25105 90 $635.00 $697.00 $741.00 $787.00 $697.00 $741.00 $787.00

25107 90 $600.00 $891.00 $949.00 $1,007.00 $891.00 $949.00 $1,007.00

25109 90 ---------- $780.00 $829.00 $880.00 $780.00 $829.00 $880.00

25110 90 $403.00 $493.00 $525.00 $558.00 $493.00 $525.00 $558.00

25111 90 $356.00 $461.00 $491.00 $520.00 $461.00 $491.00 $520.00

25112 90 $441.00 $559.00 $595.00 $632.00 $559.00 $595.00 $632.00

25115 90 $837.00 $1,103.00 $1,174.00 $1,250.00 $1,103.00 $1,174.00 $1,250.00

25116 90 $807.00 $868.00 $923.00 $979.00 $868.00 $923.00 $979.00

25118 90 $466.00 $550.00 $586.00 $621.00 $550.00 $586.00 $621.00

25119 90 $653.00 $714.00 $760.00 $807.00 $714.00 $760.00 $807.00

25120 90 $712.00 $720.00 $766.00 $814.00 $720.00 $766.00 $814.00

25125 90 $803.00 $851.00 $903.00 $953.00 $851.00 $903.00 $953.00

25126 90 $781.00 $859.00 $918.00 $985.00 $859.00 $918.00 $985.00



Surgery


(Non-Facility MRA)






25130 90 $502.00 $643.00 $683.00 $723.00 $643.00 $683.00 $723.00

25135 90 $631.00 $812.00 $867.00 $927.00 $812.00 $867.00 $927.00

25136 90 $546.00 $700.00 $744.00 $787.00 $700.00 $744.00 $787.00

25145 90 $713.00 $752.00 $803.00 $859.00 $752.00 $803.00 $859.00

25150 90 $720.00 $821.00 $875.00 $934.00 $821.00 $875.00 $934.00

25151 90 $771.00 $846.00 $901.00 $959.00 $846.00 $901.00 $959.00

25170 90 $1,085.00 $2,185.00 $2,335.00 $2,523.00 $2,185.00 $2,335.00 $2,523.00

25210 90 $561.00 $704.00 $748.00 $793.00 $704.00 $748.00 $793.00

25215 90 $817.00 $897.00 $954.00 $1,015.00 $897.00 $954.00 $1,015.00

25230 90 $531.00 $625.00 $666.00 $707.00 $625.00 $666.00 $707.00

25240 90 $567.00 $618.00 $657.00 $695.00 $618.00 $657.00 $695.00

25246 0 $72.00 $226.00 $239.00 $246.00 $110.00 $115.00 $121.00

25248 90 $236.00 $598.00 $638.00 $682.00 $598.00 $638.00 $682.00

25250 90 $616.00 $771.00 $824.00 $881.00 $771.00 $824.00 $881.00

25251 90 $933.00 $1,052.00 $1,123.00 $1,207.00 $1,052.00 $1,123.00 $1,207.00

25259 90 $348.00 $593.00 $633.00 $666.00 $593.00 $633.00 $666.00

25260 90 $728.00 $912.00 $971.00 $1,032.00 $912.00 $971.00 $1,032.00

25263 90 $809.00 $907.00 $968.00 $1,035.00 $907.00 $968.00 $1,035.00

25265 90 $998.00 $1,092.00 $1,166.00 $1,249.00 $1,092.00 $1,166.00 $1,249.00

25270 90 $549.00 $708.00 $753.00 $799.00 $708.00 $753.00 $799.00

25272 90 $613.00 $801.00 $853.00 $906.00 $801.00 $853.00 $906.00

25274 90 $887.00 $960.00 $1,021.00 $1,085.00 $960.00 $1,021.00 $1,085.00

25275 90 $620.00 $973.00 $1,035.00 $1,102.00 $973.00 $1,035.00 $1,102.00

25280 90 $670.00 $816.00 $868.00 $922.00 $816.00 $868.00 $922.00

25290 90 $436.00 $631.00 $671.00 $712.00 $631.00 $671.00 $712.00

25295 90 $562.00 $760.00 $809.00 $861.00 $760.00 $809.00 $861.00

25300 90 $592.00 $989.00 $1,054.00 $1,125.00 $989.00 $1,054.00 $1,125.00

25301 90 $757.00 $935.00 $995.00 $1,061.00 $935.00 $995.00 $1,061.00

25310 90 $865.00 $898.00 $956.00 $1,016.00 $898.00 $956.00 $1,016.00

25312 90 $968.00 $1,045.00 $1,112.00 $1,186.00 $1,045.00 $1,112.00 $1,186.00

25315 90 $1,004.00 $1,129.00 $1,206.00 $1,295.00 $1,129.00 $1,206.00 $1,295.00

25316 90 $1,203.00 $1,334.00 $1,422.00 $1,525.00 $1,334.00 $1,422.00 $1,525.00

25320 90 $834.00 $1,432.00 $1,524.00 $1,620.00 $1,432.00 $1,524.00 $1,620.00

25332 90 $1,022.00 $1,227.00 $1,306.00 $1,393.00 $1,227.00 $1,306.00 $1,393.00

25335 90 $1,166.00 $1,379.00 $1,467.00 $1,567.00 $1,379.00 $1,467.00 $1,567.00

25337 90 $946.00 $1,295.00 $1,379.00 $1,468.00 $1,295.00 $1,379.00 $1,468.00

25350 90 $913.00 $979.00 $1,041.00 $1,109.00 $979.00 $1,041.00 $1,109.00

25355 90 $1,014.00 $1,112.00 $1,184.00 $1,266.00 $1,112.00 $1,184.00 $1,266.00

25360 90 $468.00 $950.00 $1,012.00 $1,079.00 $950.00 $1,012.00 $1,079.00

25365 90 $1,216.00 $1,342.00 $1,432.00 $1,538.00 $1,342.00 $1,432.00 $1,538.00

25370 90 $1,214.00 $1,476.00 $1,576.00 $1,694.00 $1,476.00 $1,576.00 $1,694.00

25375 90 $1,280.00 $1,400.00 $1,494.00 $1,607.00 $1,400.00 $1,494.00 $1,607.00

25390 90 $1,043.00 $1,123.00 $1,195.00 $1,275.00 $1,123.00 $1,195.00 $1,275.00

25391 90 $1,349.00 $1,463.00 $1,561.00 $1,679.00 $1,463.00 $1,561.00 $1,679.00

25392 90 $1,294.00 $1,491.00 $1,585.00 $1,691.00 $1,491.00 $1,585.00 $1,691.00

25393 90 $1,473.00 $1,630.00 $1,723.00 $1,819.00 $1,630.00 $1,723.00 $1,819.00

25394 90 $723.00 $1,138.00 $1,208.00 $1,281.00 $1,138.00 $1,208.00 $1,281.00

25400 90 $1,112.00 $1,172.00 $1,248.00 $1,333.00 $1,172.00 $1,248.00 $1,333.00

25405 90 $1,388.00 $1,518.00 $1,616.00 $1,731.00 $1,518.00 $1,616.00 $1,731.00

25415 90 $1,343.00 $1,420.00 $1,516.00 $1,629.00 $1,420.00 $1,516.00 $1,629.00



Surgery


(Non-Facility MRA)






25420 90 $1,554.00 $1,707.00 $1,820.00 $1,955.00 $1,707.00 $1,820.00 $1,955.00

25425 90 $1,403.00 $1,413.00 $1,508.00 $1,621.00 $1,413.00 $1,508.00 $1,621.00

25426 90 $1,401.00 $1,596.00 $1,691.00 $1,797.00 $1,596.00 $1,691.00 $1,797.00

25430 90 $638.00 $1,069.00 $1,141.00 $1,223.00 $1,069.00 $1,141.00 $1,223.00

25431 90 $631.00 $1,143.00 $1,212.00 $1,284.00 $1,143.00 $1,212.00 $1,284.00

25440 90 $931.00 $1,121.00 $1,193.00 $1,272.00 $1,121.00 $1,193.00 $1,272.00

25441 90 $1,147.00 $1,359.00 $1,441.00 $1,527.00 $1,359.00 $1,441.00 $1,527.00

25442 90 $936.00 $1,173.00 $1,248.00 $1,329.00 $1,173.00 $1,248.00 $1,329.00

25443 90 $970.00 $1,135.00 $1,213.00 $1,305.00 $1,135.00 $1,213.00 $1,305.00

25444 90 $1,031.00 $1,192.00 $1,267.00 $1,349.00 $1,192.00 $1,267.00 $1,349.00

25445 90 $959.00 $1,054.00 $1,122.00 $1,200.00 $1,054.00 $1,122.00 $1,200.00

25446 90 $1,542.00 $1,718.00 $1,827.00 $1,954.00 $1,718.00 $1,827.00 $1,954.00

25447 90 $952.00 $1,205.00 $1,282.00 $1,366.00 $1,205.00 $1,282.00 $1,366.00

25449 90 $395.00 $1,510.00 $1,605.00 $1,714.00 $1,510.00 $1,605.00 $1,714.00

25450 90 $805.00 $752.00 $794.00 $839.00 $752.00 $794.00 $839.00

25455 90 $899.00 $1,060.00 $1,132.00 $1,214.00 $1,060.00 $1,132.00 $1,214.00

25490 90 $955.00 $1,051.00 $1,123.00 $1,204.00 $1,051.00 $1,123.00 $1,204.00

25491 90 $1,006.00 $1,083.00 $1,156.00 $1,241.00 $1,083.00 $1,156.00 $1,241.00

25492 90 $1,170.00 $1,326.00 $1,416.00 $1,522.00 $1,326.00 $1,416.00 $1,522.00

25500 90 $200.00 $387.00 $412.00 $432.00 $357.00 $380.00 $399.00

25505 90 $517.00 $714.00 $759.00 $800.00 $657.00 $699.00 $739.00

25515 90 $800.00 $973.00 $1,037.00 $1,108.00 $973.00 $1,037.00 $1,108.00

25520 90 $644.00 $813.00 $868.00 $924.00 $775.00 $827.00 $882.00

25525 90 $1,097.00 $1,145.00 $1,220.00 $1,304.00 $1,145.00 $1,220.00 $1,304.00

25526 90 $1,293.00 $1,390.00 $1,482.00 $1,586.00 $1,390.00 $1,482.00 $1,586.00

25530 90 $270.00 $370.00 $394.00 $413.00 $337.00 $359.00 $377.00

25535 90 $516.00 $699.00 $744.00 $787.00 $650.00 $693.00 $735.00

25545 90 $803.00 $905.00 $965.00 $1,028.00 $905.00 $965.00 $1,028.00

25560 90 $276.00 $393.00 $418.00 $438.00 $358.00 $380.00 $399.00

25565 90 $590.00 $740.00 $788.00 $832.00 $673.00 $716.00 $760.00

25574 90 $804.00 $982.00 $1,047.00 $1,118.00 $982.00 $1,047.00 $1,118.00

25575 90 $974.00 $1,316.00 $1,404.00 $1,503.00 $1,316.00 $1,404.00 $1,503.00

25600 90 $312.00 $463.00 $494.00 $516.00 $439.00 $468.00 $490.00

25605 90 $540.00 $779.00 $829.00 $876.00 $736.00 $783.00 $830.00

25606 90 ---------- $963.00 $1,028.00 $1,097.00 $963.00 $1,028.00 $1,097.00

25607 90 ---------- $1,069.00 $1,139.00 $1,215.00 $1,069.00 $1,139.00 $1,215.00

25608 90 ---------- $1,201.00 $1,280.00 $1,367.00 $1,201.00 $1,280.00 $1,367.00

25609 90 ---------- $1,529.00 $1,628.00 $1,740.00 $1,529.00 $1,628.00 $1,740.00

25622 90 $148.00 $431.00 $459.00 $480.00 $395.00 $420.00 $441.00

25624 90 $482.00 $681.00 $727.00 $768.00 $624.00 $666.00 $707.00

25628 90 $716.00 $1,049.00 $1,117.00 $1,191.00 $1,049.00 $1,117.00 $1,191.00

25630 90 $148.00 $434.00 $462.00 $485.00 $401.00 $426.00 $449.00

25635 90 $458.00 $598.00 $635.00 $665.00 $539.00 $571.00 $601.00

25645 90 $668.00 $819.00 $872.00 $928.00 $819.00 $872.00 $928.00

25650 90 $185.00 $453.00 $482.00 $505.00 $427.00 $454.00 $477.00

25651 90 $379.00 $696.00 $740.00 $784.00 $696.00 $740.00 $784.00

25652 90 $560.00 $907.00 $967.00 $1,032.00 $907.00 $967.00 $1,032.00

25660 90 $378.00 $590.00 $626.00 $661.00 $590.00 $626.00 $661.00

25670 90 $731.00 $881.00 $939.00 $1,002.00 $881.00 $939.00 $1,002.00

25671 90 $462.00 $768.00 $820.00 $873.00 $768.00 $820.00 $873.00



Surgery


(Non-Facility MRA)






25675 90 $404.00 $615.00 $653.00 $685.00 $564.00 $598.00 $629.00

25676 90 $741.00 $913.00 $973.00 $1,038.00 $913.00 $973.00 $1,038.00

25680 90 $471.00 $691.00 $734.00 $777.00 $691.00 $734.00 $777.00

25685 90 $887.00 $1,072.00 $1,144.00 $1,227.00 $1,072.00 $1,144.00 $1,227.00

25690 90 $518.00 $681.00 $725.00 $769.00 $681.00 $725.00 $769.00

25695 90 $520.00 $924.00 $986.00 $1,056.00 $924.00 $986.00 $1,056.00

25800 90 $703.00 $1,066.00 $1,135.00 $1,210.00 $1,066.00 $1,135.00 $1,210.00

25805 90 $1,078.00 $1,238.00 $1,321.00 $1,418.00 $1,238.00 $1,321.00 $1,418.00

25810 90 $1,008.00 $1,265.00 $1,345.00 $1,434.00 $1,265.00 $1,345.00 $1,434.00

25820 90 $2,276.00 $889.00 $946.00 $1,003.00 $889.00 $946.00 $1,003.00

25825 90 $895.00 $1,098.00 $1,168.00 $1,239.00 $1,098.00 $1,168.00 $1,239.00

25830 90 $991.00 $1,359.00 $1,447.00 $1,530.00 $1,359.00 $1,447.00 $1,530.00

25900 90 $871.00 $1,033.00 $1,101.00 $1,177.00 $1,033.00 $1,101.00 $1,177.00

25905 90 $900.00 $1,027.00 $1,097.00 $1,178.00 $1,027.00 $1,097.00 $1,178.00

25907 90 $799.00 $886.00 $944.00 $1,007.00 $886.00 $944.00 $1,007.00

25909 90 $849.00 $998.00 $1,066.00 $1,144.00 $998.00 $1,066.00 $1,144.00

25915 90 $1,523.00 $1,485.00 $1,565.00 $1,662.00 $1,485.00 $1,565.00 $1,662.00

25920 90 $771.00 $1,015.00 $1,083.00 $1,160.00 $1,015.00 $1,083.00 $1,160.00

25922 90 $670.00 $738.00 $779.00 $823.00 $738.00 $779.00 $823.00

25924 90 $768.00 $962.00 $1,020.00 $1,078.00 $962.00 $1,020.00 $1,078.00

25927 90 $830.00 $1,163.00 $1,242.00 $1,319.00 $1,163.00 $1,242.00 $1,319.00

25929 90 $645.00 $836.00 $894.00 $963.00 $836.00 $894.00 $963.00

25931 90 $731.00 $1,047.00 $1,118.00 $1,189.00 $1,047.00 $1,118.00 $1,189.00

25999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

26010 10 $59.00 $369.00 $392.00 $404.00 $196.00 $208.00 $218.00

26011 10 $223.00 $544.00 $580.00 $599.00 $267.00 $283.00 $300.00

26020 90 $484.00 $624.00 $665.00 $705.00 $624.00 $665.00 $705.00

26025 90 $548.00 $609.00 $649.00 $688.00 $609.00 $649.00 $688.00

26030 90 $655.00 $713.00 $759.00 $806.00 $713.00 $759.00 $806.00

26034 90 $601.00 $780.00 $832.00 $884.00 $780.00 $832.00 $884.00

26035 90 $741.00 $1,250.00 $1,334.00 $1,429.00 $1,250.00 $1,334.00 $1,429.00

26037 90 $730.00 $822.00 $875.00 $932.00 $822.00 $875.00 $932.00

26040 90 $367.00 $447.00 $476.00 $503.00 $447.00 $476.00 $503.00

26045 90 $621.00 $678.00 $722.00 $769.00 $678.00 $722.00 $769.00

26055 90 $343.00 $779.00 $832.00 $861.00 $444.00 $473.00 $498.00

26060 90 $293.00 $373.00 $397.00 $418.00 $373.00 $397.00 $418.00

26070 90 $440.00 $454.00 $483.00 $510.00 $454.00 $483.00 $510.00

26075 90 $400.00 $479.00 $510.00 $540.00 $479.00 $510.00 $540.00

26080 90 $382.00 $561.00 $598.00 $632.00 $561.00 $598.00 $632.00

26100 90 $398.00 $467.00 $497.00 $527.00 $467.00 $497.00 $527.00

26105 90 $481.00 $481.00 $513.00 $545.00 $481.00 $513.00 $545.00

26110 90 $282.00 $463.00 $493.00 $521.00 $463.00 $493.00 $521.00

26111 90 ---------- $607.00 $646.00 $687.00 $607.00 $646.00 $687.00

26113 90 ---------- $797.00 $848.00 $902.00 $797.00 $848.00 $902.00

26115 90 $344.00 $712.00 $758.00 $792.00 $480.00 $511.00 $542.00

26116 90 $544.00 $764.00 $813.00 $864.00 $764.00 $813.00 $864.00

26117 90 $806.00 $1,088.00 $1,159.00 $1,237.00 $1,088.00 $1,159.00 $1,237.00

26118 90 ---------- $1,543.00 $1,643.00 $1,758.00 $1,543.00 $1,643.00 $1,758.00

26121 90 $833.00 $866.00 $922.00 $982.00 $866.00 $922.00 $982.00

26123 90 $959.00 $1,212.00 $1,290.00 $1,373.00 $1,212.00 $1,290.00 $1,373.00



Surgery


(Non-Facility MRA)






26125 ZZZ $342.00 $407.00 $432.00 $466.00 $407.00 $432.00 $466.00

26130 90 $629.00 $669.00 $715.00 $762.00 $669.00 $715.00 $762.00

26135 90 $668.00 $796.00 $846.00 $899.00 $796.00 $846.00 $899.00

26140 90 $678.00 $729.00 $776.00 $824.00 $729.00 $776.00 $824.00

26145 90 $660.00 $743.00 $791.00 $841.00 $743.00 $791.00 $841.00

26160 90 $319.00 $803.00 $857.00 $888.00 $479.00 $510.00 $538.00

26170 90 $452.00 $585.00 $622.00 $658.00 $585.00 $622.00 $658.00

26180 90 $444.00 $638.00 $678.00 $717.00 $638.00 $678.00 $717.00

26185 90 $511.00 $781.00 $828.00 $871.00 $781.00 $828.00 $871.00

26200 90 $598.00 $649.00 $691.00 $734.00 $649.00 $691.00 $734.00

26205 90 $788.00 $869.00 $927.00 $992.00 $869.00 $927.00 $992.00

26210 90 $543.00 $638.00 $679.00 $720.00 $638.00 $679.00 $720.00

26215 90 $731.00 $812.00 $866.00 $926.00 $812.00 $866.00 $926.00

26230 90 $624.00 $723.00 $769.00 $816.00 $723.00 $769.00 $816.00

26235 90 $612.00 $712.00 $757.00 $804.00 $712.00 $757.00 $804.00

26236 90 $444.00 $637.00 $678.00 $720.00 $637.00 $678.00 $720.00

26250 90 $814.00 $1,573.00 $1,671.00 $1,780.00 $1,573.00 $1,671.00 $1,780.00

26260 90 $758.00 $1,178.00 $1,257.00 $1,349.00 $1,178.00 $1,257.00 $1,349.00

26262 90 $624.00 $917.00 $977.00 $1,045.00 $917.00 $977.00 $1,045.00

26320 90 $414.00 $499.00 $531.00 $562.00 $499.00 $531.00 $562.00

26340 90 $266.00 $473.00 $504.00 $527.00 $473.00 $504.00 $527.00

26341 10 ---------- $140.00 $149.00 $157.00 $109.00 $116.00 $123.00

26350 90 $715.00 $1,000.00 $1,065.00 $1,116.00 $1,000.00 $1,065.00 $1,116.00

26352 90 $855.00 $1,126.00 $1,196.00 $1,250.00 $1,126.00 $1,196.00 $1,250.00

26356 90 $886.00 $1,145.00 $1,219.00 $1,291.00 $1,145.00 $1,219.00 $1,291.00

26357 90 $932.00 $1,288.00 $1,374.00 $1,467.00 $1,288.00 $1,374.00 $1,467.00

26358 90 $979.00 $1,410.00 $1,496.00 $1,581.00 $1,410.00 $1,496.00 $1,581.00

26370 90 $832.00 $1,069.00 $1,138.00 $1,196.00 $1,069.00 $1,138.00 $1,196.00

26372 90 $945.00 $1,219.00 $1,299.00 $1,369.00 $1,219.00 $1,299.00 $1,369.00

26373 90 $904.00 $1,175.00 $1,248.00 $1,306.00 $1,175.00 $1,248.00 $1,306.00

26390 90 $889.00 $1,195.00 $1,276.00 $1,357.00 $1,195.00 $1,276.00 $1,357.00

26392 90 $1,123.00 $1,381.00 $1,473.00 $1,560.00 $1,381.00 $1,473.00 $1,560.00

26410 90 $371.00 $792.00 $844.00 $883.00 $792.00 $844.00 $883.00

26412 90 $737.00 $977.00 $1,043.00 $1,100.00 $977.00 $1,043.00 $1,100.00

26415 90 $846.00 $952.00 $998.00 $1,025.00 $952.00 $998.00 $1,025.00

26416 90 $1,093.00 $1,229.00 $1,309.00 $1,383.00 $1,229.00 $1,309.00 $1,383.00

26418 90 $444.00 $807.00 $860.00 $897.00 $807.00 $860.00 $897.00

26420 90 $741.00 $995.00 $1,059.00 $1,112.00 $995.00 $1,059.00 $1,112.00

26426 90 $733.00 $725.00 $771.00 $819.00 $725.00 $771.00 $819.00

26428 90 $790.00 $1,041.00 $1,105.00 $1,156.00 $1,041.00 $1,105.00 $1,156.00

26432 90 $430.00 $698.00 $744.00 $778.00 $698.00 $744.00 $778.00

26433 90 $371.00 $743.00 $792.00 $830.00 $743.00 $792.00 $830.00

26434 90 $656.00 $913.00 $974.00 $1,027.00 $913.00 $974.00 $1,027.00

26437 90 $491.00 $877.00 $934.00 $982.00 $877.00 $934.00 $982.00

26440 90 $458.00 $866.00 $923.00 $964.00 $866.00 $923.00 $964.00

26442 90 $548.00 $1,366.00 $1,455.00 $1,531.00 $1,366.00 $1,455.00 $1,531.00

26445 90 $455.00 $804.00 $857.00 $893.00 $804.00 $857.00 $893.00

26449 90 $738.00 $1,004.00 $1,068.00 $1,133.00 $1,004.00 $1,068.00 $1,133.00

26450 90 $353.00 $570.00 $607.00 $637.00 $570.00 $607.00 $637.00

26455 90 $364.00 $567.00 $603.00 $632.00 $567.00 $603.00 $632.00



Surgery


(Non-Facility MRA)






26460 90 $346.00 $553.00 $589.00 $618.00 $553.00 $589.00 $618.00

26471 90 $592.00 $865.00 $920.00 $965.00 $865.00 $920.00 $965.00

26474 90 $586.00 $846.00 $903.00 $951.00 $846.00 $903.00 $951.00

26476 90 $543.00 $810.00 $861.00 $900.00 $810.00 $861.00 $900.00

26477 90 $553.00 $819.00 $872.00 $915.00 $819.00 $872.00 $915.00

26478 90 $608.00 $872.00 $929.00 $976.00 $872.00 $929.00 $976.00

26479 90 $653.00 $863.00 $917.00 $959.00 $863.00 $917.00 $959.00

26480 90 $808.00 $1,055.00 $1,122.00 $1,174.00 $1,055.00 $1,122.00 $1,174.00

26483 90 $986.00 $1,187.00 $1,264.00 $1,330.00 $1,187.00 $1,264.00 $1,330.00

26485 90 $891.00 $1,137.00 $1,210.00 $1,271.00 $1,137.00 $1,210.00 $1,271.00

26489 90 $738.00 $1,324.00 $1,413.00 $1,495.00 $1,324.00 $1,413.00 $1,495.00

26490 90 $496.00 $1,135.00 $1,212.00 $1,286.00 $1,135.00 $1,212.00 $1,286.00

26492 90 $971.00 $1,261.00 $1,347.00 $1,432.00 $1,261.00 $1,347.00 $1,432.00

26494 90 $946.00 $1,107.00 $1,177.00 $1,240.00 $1,107.00 $1,177.00 $1,240.00

26496 90 $949.00 $1,216.00 $1,290.00 $1,357.00 $1,216.00 $1,290.00 $1,357.00

26497 90 $946.00 $1,238.00 $1,321.00 $1,405.00 $1,238.00 $1,321.00 $1,405.00

26498 90 $1,317.00 $1,620.00 $1,718.00 $1,814.00 $1,620.00 $1,718.00 $1,814.00

26499 90 $934.00 $1,162.00 $1,234.00 $1,297.00 $1,162.00 $1,234.00 $1,297.00

26500 90 $557.00 $880.00 $937.00 $985.00 $880.00 $937.00 $985.00

26502 90 $715.00 $1,006.00 $1,074.00 $1,136.00 $1,006.00 $1,074.00 $1,136.00

26508 90 $334.00 $888.00 $945.00 $992.00 $888.00 $945.00 $992.00

26510 90 $564.00 $836.00 $889.00 $932.00 $836.00 $889.00 $932.00

26516 90 $630.00 $989.00 $1,052.00 $1,106.00 $989.00 $1,052.00 $1,106.00

26517 90 $890.00 $1,114.00 $1,186.00 $1,258.00 $1,114.00 $1,186.00 $1,258.00

26518 90 $877.00 $1,167.00 $1,239.00 $1,301.00 $1,167.00 $1,239.00 $1,301.00

26520 90 $583.00 $911.00 $971.00 $1,016.00 $911.00 $971.00 $1,016.00

26525 90 $531.00 $912.00 $971.00 $1,015.00 $912.00 $971.00 $1,015.00

26530 90 $708.00 $779.00 $829.00 $880.00 $779.00 $829.00 $880.00

26531 90 $877.00 $904.00 $962.00 $1,022.00 $904.00 $962.00 $1,022.00

26535 90 $546.00 $610.00 $647.00 $684.00 $610.00 $647.00 $684.00

26536 90 $770.00 $994.00 $1,057.00 $1,106.00 $994.00 $1,057.00 $1,106.00

26540 90 $726.00 $927.00 $987.00 $1,038.00 $927.00 $987.00 $1,038.00

26541 90 $926.00 $1,137.00 $1,210.00 $1,278.00 $1,137.00 $1,210.00 $1,278.00

26542 90 $716.00 $958.00 $1,019.00 $1,072.00 $958.00 $1,019.00 $1,072.00

26545 90 $722.00 $998.00 $1,065.00 $1,125.00 $998.00 $1,065.00 $1,125.00

26546 90 $918.00 $1,413.00 $1,504.00 $1,588.00 $1,413.00 $1,504.00 $1,588.00

26548 90 $665.00 $1,073.00 $1,141.00 $1,203.00 $1,073.00 $1,141.00 $1,203.00

26550 90 $1,861.00 $2,352.00 $2,494.00 $2,638.00 $2,352.00 $2,494.00 $2,638.00

26551 90 $3,901.00 $4,864.00 $5,165.00 $5,503.00 $4,864.00 $5,165.00 $5,503.00

26553 90 $3,868.00 $4,120.00 $4,344.00 $4,610.00 $4,120.00 $4,344.00 $4,610.00

26554 90 $4,551.00 $4,827.00 $5,088.00 $5,403.00 $4,827.00 $5,088.00 $5,403.00

26555 90 $1,567.00 $1,846.00 $1,962.00 $2,086.00 $1,846.00 $1,962.00 $2,086.00

26556 90 $4,005.00 $4,995.00 $5,333.00 $5,747.00 $4,995.00 $5,333.00 $5,747.00

26560 90 $576.00 $820.00 $875.00 $922.00 $820.00 $875.00 $922.00

26561 90 $1,067.00 $1,327.00 $1,412.00 $1,494.00 $1,327.00 $1,412.00 $1,494.00

26562 90 $1,017.00 $1,905.00 $2,021.00 $2,133.00 $1,905.00 $2,021.00 $2,133.00

26565 90 $730.00 $956.00 $1,018.00 $1,072.00 $956.00 $1,018.00 $1,072.00

26567 90 $622.00 $959.00 $1,021.00 $1,075.00 $959.00 $1,021.00 $1,075.00

26568 90 $1,003.00 $1,276.00 $1,361.00 $1,439.00 $1,276.00 $1,361.00 $1,439.00

26580 90 $1,585.00 $2,150.00 $2,284.00 $2,423.00 $2,150.00 $2,284.00 $2,423.00



Surgery


(Non-Facility MRA)






26587 90 $792.00 $1,463.00 $1,554.00 $1,657.00 $1,463.00 $1,554.00 $1,657.00

26590 90 $1,609.00 $1,911.00 $2,042.00 $2,201.00 $1,911.00 $2,042.00 $2,201.00

26591 90 $431.00 $607.00 $646.00 $673.00 $607.00 $646.00 $673.00

26593 90 $587.00 $844.00 $898.00 $942.00 $844.00 $898.00 $942.00

26596 90 $809.00 $1,077.00 $1,143.00 $1,205.00 $1,077.00 $1,143.00 $1,205.00

26600 90 $133.00 $415.00 $442.00 $462.00 $392.00 $417.00 $437.00

26605 90 $296.00 $455.00 $485.00 $509.00 $417.00 $444.00 $468.00

26607 90 $334.00 $656.00 $699.00 $742.00 $656.00 $699.00 $742.00

26608 90 $497.00 $685.00 $729.00 $773.00 $685.00 $729.00 $773.00

26615 90 $521.00 $833.00 $887.00 $942.00 $833.00 $887.00 $942.00

26641 90 $71.00 $534.00 $567.00 $595.00 $489.00 $519.00 $547.00

26645 90 $371.00 $611.00 $652.00 $690.00 $564.00 $601.00 $639.00

26650 90 $533.00 $686.00 $730.00 $773.00 $686.00 $730.00 $773.00

26665 90 $693.00 $909.00 $968.00 $1,030.00 $909.00 $968.00 $1,030.00

26670 90 $148.00 $483.00 $512.00 $538.00 $441.00 $467.00 $492.00

26675 90 $501.00 $645.00 $687.00 $725.00 $596.00 $634.00 $672.00

26676 90 $527.00 $718.00 $765.00 $810.00 $718.00 $765.00 $810.00

26685 90 $592.00 $833.00 $887.00 $943.00 $833.00 $887.00 $943.00

26686 90 $710.00 $909.00 $970.00 $1,039.00 $909.00 $970.00 $1,039.00

26700 90 $88.00 $461.00 $488.00 $513.00 $434.00 $460.00 $485.00

26705 90 $296.00 $589.00 $626.00 $659.00 $542.00 $576.00 $609.00

26706 90 $469.00 $634.00 $675.00 $717.00 $634.00 $675.00 $717.00

26715 90 $526.00 $827.00 $881.00 $935.00 $827.00 $881.00 $935.00

26720 90 $96.00 $279.00 $297.00 $309.00 $260.00 $277.00 $289.00

26725 90 $187.00 $478.00 $508.00 $534.00 $434.00 $461.00 $487.00

26727 90 $187.00 $675.00 $720.00 $762.00 $675.00 $720.00 $762.00

26735 90 $532.00 $863.00 $919.00 $977.00 $863.00 $919.00 $977.00

26740 90 $148.00 $326.00 $347.00 $363.00 $307.00 $327.00 $343.00

26742 90 $148.00 $527.00 $560.00 $590.00 $480.00 $511.00 $540.00

26746 90 $548.00 $1,078.00 $1,147.00 $1,222.00 $1,078.00 $1,147.00 $1,222.00

26750 90 $96.00 $259.00 $275.00 $287.00 $260.00 $276.00 $288.00

26755 90 $133.00 $445.00 $473.00 $496.00 $390.00 $414.00 $437.00

26756 90 $366.00 $598.00 $636.00 $672.00 $598.00 $636.00 $672.00

26765 90 $398.00 $721.00 $768.00 $813.00 $721.00 $768.00 $813.00

26770 90 $79.00 $390.00 $413.00 $432.00 $363.00 $384.00 $403.00

26775 90 $275.00 $544.00 $578.00 $607.00 $495.00 $526.00 $555.00

26776 90 $401.00 $636.00 $678.00 $717.00 $636.00 $678.00 $717.00

26785 90 $408.00 $791.00 $842.00 $893.00 $791.00 $842.00 $893.00

26820 90 $854.00 $1,092.00 $1,164.00 $1,234.00 $1,092.00 $1,164.00 $1,234.00

26841 90 $756.00 $1,025.00 $1,091.00 $1,149.00 $1,025.00 $1,091.00 $1,149.00

26842 90 $901.00 $1,111.00 $1,183.00 $1,248.00 $1,111.00 $1,183.00 $1,248.00

26843 90 $800.00 $1,045.00 $1,114.00 $1,178.00 $1,045.00 $1,114.00 $1,178.00

26844 90 $875.00 $1,169.00 $1,248.00 $1,326.00 $1,169.00 $1,248.00 $1,326.00

26850 90 $704.00 $976.00 $1,039.00 $1,093.00 $976.00 $1,039.00 $1,093.00

26852 90 $829.00 $1,128.00 $1,200.00 $1,266.00 $1,128.00 $1,200.00 $1,266.00

26860 90 $542.00 $792.00 $843.00 $883.00 $792.00 $843.00 $883.00

26861 ZZZ $151.00 $154.00 $163.00 $176.00 $154.00 $163.00 $176.00

26862 90 $747.00 $1,026.00 $1,092.00 $1,149.00 $1,026.00 $1,092.00 $1,149.00

26863 ZZZ $317.00 $342.00 $363.00 $390.00 $342.00 $363.00 $390.00

26910 90 $747.00 $1,024.00 $1,091.00 $1,154.00 $1,024.00 $1,091.00 $1,154.00



Surgery


(Non-Facility MRA)






26951 90 $444.00 $919.00 $980.00 $1,030.00 $919.00 $980.00 $1,030.00

26952 90 $608.00 $909.00 $968.00 $1,019.00 $909.00 $968.00 $1,019.00

26989 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

26990 90 $592.00 $913.00 $975.00 $1,043.00 $913.00 $975.00 $1,043.00

26991 90 $466.00 $1,011.00 $1,078.00 $1,137.00 $763.00 $813.00 $869.00

26992 90 $1,146.00 $1,402.00 $1,493.00 $1,598.00 $1,402.00 $1,493.00 $1,598.00

27000 90 $421.00 $590.00 $625.00 $661.00 $590.00 $625.00 $661.00

27001 90 $550.00 $790.00 $842.00 $900.00 $790.00 $842.00 $900.00

27003 90 $698.00 $850.00 $904.00 $964.00 $850.00 $904.00 $964.00

27005 90 $738.00 $1,058.00 $1,128.00 $1,207.00 $1,058.00 $1,128.00 $1,207.00

27006 90 $788.00 $1,072.00 $1,141.00 $1,219.00 $1,072.00 $1,141.00 $1,219.00

27025 90 $896.00 $1,335.00 $1,422.00 $1,522.00 $1,335.00 $1,422.00 $1,522.00

27027 90 ---------- $1,300.00 $1,384.00 $1,483.00 $1,300.00 $1,384.00 $1,483.00

27030 90 $1,148.00 $1,375.00 $1,466.00 $1,575.00 $1,375.00 $1,466.00 $1,575.00

27033 90 $1,173.00 $1,429.00 $1,524.00 $1,637.00 $1,429.00 $1,524.00 $1,637.00

27035 90 $1,413.00 $1,536.00 $1,607.00 $1,675.00 $1,536.00 $1,607.00 $1,675.00

27036 90 $1,176.00 $1,483.00 $1,582.00 $1,698.00 $1,483.00 $1,582.00 $1,698.00

27040 10 $196.00 $487.00 $518.00 $539.00 $291.00 $309.00 $328.00

27041 90 $699.00 $1,016.00 $1,082.00 $1,161.00 $1,016.00 $1,082.00 $1,161.00

27043 90 ---------- $697.00 $746.00 $810.00 $697.00 $746.00 $810.00

27045 90 ---------- $1,105.00 $1,181.00 $1,276.00 $1,105.00 $1,181.00 $1,276.00

27047 90 $535.00 $673.00 $720.00 $765.00 $532.00 $569.00 $613.00

27048 90 $588.00 $902.00 $965.00 $1,043.00 $902.00 $965.00 $1,043.00

27049 90 $1,162.00 $1,975.00 $2,108.00 $2,285.00 $1,975.00 $2,108.00 $2,285.00

27050 90 $449.00 $560.00 $597.00 $635.00 $560.00 $597.00 $635.00

27052 90 $624.00 $845.00 $902.00 $964.00 $845.00 $902.00 $964.00

27054 90 $843.00 $999.00 $1,065.00 $1,140.00 $999.00 $1,065.00 $1,140.00

27057 90 ---------- $1,490.00 $1,591.00 $1,716.00 $1,490.00 $1,591.00 $1,716.00

27059 90 ---------- $2,696.00 $2,881.00 $3,129.00 $2,696.00 $2,881.00 $3,129.00

27060 90 $491.00 $674.00 $719.00 $768.00 $674.00 $719.00 $768.00

27062 90 $499.00 $663.00 $707.00 $755.00 $663.00 $707.00 $755.00

27065 90 $583.00 $752.00 $802.00 $858.00 $752.00 $802.00 $858.00

27066 90 $931.00 $1,189.00 $1,268.00 $1,359.00 $1,189.00 $1,268.00 $1,359.00

27067 90 $1,234.00 $1,501.00 $1,599.00 $1,714.00 $1,501.00 $1,599.00 $1,714.00

27070 90 $1,040.00 $1,245.00 $1,327.00 $1,419.00 $1,245.00 $1,327.00 $1,419.00

27071 90 $1,112.00 $1,338.00 $1,428.00 $1,529.00 $1,338.00 $1,428.00 $1,529.00

27075 90 $1,485.00 $3,093.00 $3,301.00 $3,569.00 $3,093.00 $3,301.00 $3,569.00

27076 90 $1,859.00 $3,745.00 $3,994.00 $4,317.00 $3,745.00 $3,994.00 $4,317.00

27077 90 $1,976.00 $4,171.00 $4,440.00 $4,784.00 $4,171.00 $4,440.00 $4,784.00

27078 90 $1,164.00 $3,049.00 $3,251.00 $3,508.00 $3,049.00 $3,251.00 $3,508.00

27080 90 $568.00 $750.00 $803.00 $865.00 $750.00 $803.00 $865.00

27086 10 $57.00 $391.00 $417.00 $435.00 $233.00 $248.00 $264.00

27087 90 $555.00 $905.00 $964.00 $1,034.00 $905.00 $964.00 $1,034.00

27090 90 $981.00 $1,215.00 $1,295.00 $1,389.00 $1,215.00 $1,295.00 $1,389.00

27091 90 $1,482.00 $2,356.00 $2,512.00 $2,705.00 $2,356.00 $2,512.00 $2,705.00

27093 0 $62.00 $261.00 $277.00 $284.00 $103.00 $107.00 $113.00

27095 0 $121.00 $339.00 $360.00 $371.00 $122.00 $129.00 $137.00

27096 0 $491.00 $223.00 $235.00 $241.00 $121.00 $126.00 $131.00

27097 90 $795.00 $990.00 $1,057.00 $1,133.00 $990.00 $1,057.00 $1,133.00

27098 90 $799.00 $926.00 $978.00 $1,032.00 $926.00 $978.00 $1,032.00



Surgery


(Non-Facility MRA)






27100 90 $987.00 $1,195.00 $1,273.00 $1,362.00 $1,195.00 $1,273.00 $1,362.00

27105 90 $946.00 $1,271.00 $1,357.00 $1,458.00 $1,271.00 $1,357.00 $1,458.00

27110 90 $1,174.00 $1,424.00 $1,520.00 $1,635.00 $1,424.00 $1,520.00 $1,635.00

27111 90 $1,099.00 $1,326.00 $1,418.00 $1,528.00 $1,326.00 $1,418.00 $1,528.00

27120 90 $1,603.00 $1,906.00 $2,031.00 $2,184.00 $1,906.00 $2,031.00 $2,184.00

27122 90 $1,406.00 $1,619.00 $1,727.00 $1,857.00 $1,619.00 $1,727.00 $1,857.00

27125 90 $1,371.00 $1,669.00 $1,781.00 $1,915.00 $1,669.00 $1,781.00 $1,915.00

27130 90 $1,853.00 $2,002.00 $2,133.00 $2,297.00 $2,002.00 $2,133.00 $2,297.00

27132 90 $2,128.00 $2,473.00 $2,636.00 $2,839.00 $2,473.00 $2,636.00 $2,839.00

27134 90 $2,576.00 $2,837.00 $3,024.00 $3,261.00 $2,837.00 $3,024.00 $3,261.00

27137 90 $2,190.00 $2,177.00 $2,320.00 $2,500.00 $2,177.00 $2,320.00 $2,500.00

27138 90 $2,025.00 $2,262.00 $2,411.00 $2,597.00 $2,262.00 $2,411.00 $2,597.00

27140 90 $1,092.00 $1,308.00 $1,394.00 $1,494.00 $1,308.00 $1,394.00 $1,494.00

27146 90 $1,432.00 $1,874.00 $1,997.00 $2,145.00 $1,874.00 $1,997.00 $2,145.00

27147 90 $1,744.00 $2,152.00 $2,293.00 $2,464.00 $2,152.00 $2,293.00 $2,464.00

27151 90 $1,732.00 $2,354.00 $2,512.00 $2,710.00 $2,354.00 $2,512.00 $2,710.00

27156 90 $2,017.00 $2,495.00 $2,652.00 $2,842.00 $2,495.00 $2,652.00 $2,842.00

27158 90 $1,588.00 $2,072.00 $2,212.00 $2,387.00 $2,072.00 $2,212.00 $2,387.00

27161 90 $1,443.00 $1,786.00 $1,903.00 $2,044.00 $1,786.00 $1,903.00 $2,044.00

27165 90 $1,572.00 $2,021.00 $2,154.00 $2,315.00 $2,021.00 $2,154.00 $2,315.00

27170 90 $1,453.00 $1,733.00 $1,848.00 $1,989.00 $1,733.00 $1,848.00 $1,989.00

27175 90 $491.00 $957.00 $1,016.00 $1,081.00 $957.00 $1,016.00 $1,081.00

27176 90 $1,024.00 $1,349.00 $1,440.00 $1,548.00 $1,349.00 $1,440.00 $1,548.00

27177 90 $1,257.00 $1,641.00 $1,752.00 $1,886.00 $1,641.00 $1,752.00 $1,886.00

27178 90 $1,020.00 $1,162.00 $1,218.00 $1,272.00 $1,162.00 $1,218.00 $1,272.00

27179 90 $1,107.00 $1,400.00 $1,490.00 $1,595.00 $1,400.00 $1,490.00 $1,595.00

27181 90 $1,206.00 $1,933.00 $2,119.00 $2,386.00 $1,933.00 $2,119.00 $2,386.00

27185 90 $676.00 $1,052.00 $1,123.00 $1,205.00 $1,052.00 $1,123.00 $1,205.00

27187 90 $1,280.00 $1,456.00 $1,553.00 $1,668.00 $1,456.00 $1,553.00 $1,668.00

27197 0 ---------- $168.00 $178.00 $187.00 $168.00 $178.00 $187.00

27198 0 ---------- $435.00 $460.00 $491.00 $435.00 $460.00 $491.00

27200 90 $180.00 $259.00 $276.00 $291.00 $269.00 $287.00 $302.00

27202 90 $776.00 $819.00 $881.00 $960.00 $819.00 $881.00 $960.00

27215 90 $954.00 $912.00 $962.00 $1,020.00 $912.00 $962.00 $1,020.00

27216 90 $1,085.00 $1,353.00 $1,427.00 $1,514.00 $1,353.00 $1,427.00 $1,514.00

27217 90 $1,285.00 $1,269.00 $1,338.00 $1,420.00 $1,269.00 $1,338.00 $1,420.00

27218 90 $1,570.00 $1,758.00 $1,853.00 $1,968.00 $1,758.00 $1,853.00 $1,968.00

27220 90 $444.00 $770.00 $822.00 $877.00 $765.00 $815.00 $871.00

27222 90 $973.00 $1,431.00 $1,526.00 $1,639.00 $1,431.00 $1,526.00 $1,639.00

27226 90 $1,350.00 $1,556.00 $1,659.00 $1,785.00 $1,556.00 $1,659.00 $1,785.00

27227 90 $1,967.00 $2,455.00 $2,618.00 $2,823.00 $2,455.00 $2,618.00 $2,823.00

27228 90 $2,195.00 $2,793.00 $2,978.00 $3,214.00 $2,793.00 $2,978.00 $3,214.00

27230 90 $491.00 $688.00 $733.00 $780.00 $683.00 $728.00 $775.00

27232 90 $916.00 $1,101.00 $1,171.00 $1,258.00 $1,101.00 $1,171.00 $1,258.00

27235 90 $1,128.00 $1,337.00 $1,427.00 $1,535.00 $1,337.00 $1,427.00 $1,535.00

27236 90 $1,421.00 $1,762.00 $1,879.00 $2,020.00 $1,762.00 $1,879.00 $2,020.00

27238 90 $504.00 $668.00 $712.00 $759.00 $668.00 $712.00 $759.00

27240 90 $1,043.00 $1,407.00 $1,500.00 $1,612.00 $1,407.00 $1,500.00 $1,612.00

27244 90 $1,426.00 $1,814.00 $1,935.00 $2,082.00 $1,814.00 $1,935.00 $2,082.00

27245 90 $1,691.00 $1,814.00 $1,935.00 $2,082.00 $1,814.00 $1,935.00 $2,082.00



Surgery


(Non-Facility MRA)






27246 90 $459.00 $558.00 $594.00 $634.00 $560.00 $598.00 $637.00

27248 90 $980.00 $1,091.00 $1,163.00 $1,249.00 $1,091.00 $1,163.00 $1,249.00

27250 0 $535.00 $269.00 $284.00 $307.00 $269.00 $284.00 $307.00

27252 90 $520.00 $1,112.00 $1,185.00 $1,273.00 $1,112.00 $1,185.00 $1,273.00

27253 90 $1,162.00 $1,384.00 $1,477.00 $1,587.00 $1,384.00 $1,477.00 $1,587.00

27254 90 $1,478.00 $1,868.00 $1,992.00 $2,144.00 $1,868.00 $1,992.00 $2,144.00

27256 10 $338.00 $432.00 $458.00 $486.00 $346.00 $366.00 $393.00

27257 10 $455.00 $502.00 $534.00 $574.00 $502.00 $534.00 $574.00

27258 90 $1,355.00 $1,634.00 $1,745.00 $1,880.00 $1,634.00 $1,745.00 $1,880.00

27259 90 $1,803.00 $2,296.00 $2,451.00 $2,643.00 $2,296.00 $2,451.00 $2,643.00

27265 90 $442.00 $574.00 $609.00 $644.00 $574.00 $609.00 $644.00

27266 90 $614.00 $848.00 $905.00 $969.00 $848.00 $905.00 $969.00

27267 90 ---------- $627.00 $668.00 $711.00 $627.00 $668.00 $711.00

27268 90 ---------- $772.00 $821.00 $875.00 $772.00 $821.00 $875.00

27269 90 ---------- $1,836.00 $1,958.00 $2,110.00 $1,836.00 $1,958.00 $2,110.00

27275 10 $220.00 $264.00 $281.00 $299.00 $264.00 $281.00 $299.00

27279 90 ---------- $1,025.00 $1,104.00 $1,205.00 $1,025.00 $1,104.00 $1,205.00

27280 90 $1,179.00 $2,041.00 $2,201.00 $2,419.00 $2,041.00 $2,201.00 $2,419.00

27282 90 $990.00 $1,192.00 $1,269.00 $1,358.00 $1,192.00 $1,269.00 $1,358.00

27284 90 $1,435.00 $2,162.00 $2,272.00 $2,393.00 $2,162.00 $2,272.00 $2,393.00

27286 90 $1,503.00 $2,384.00 $2,530.00 $2,702.00 $2,384.00 $2,530.00 $2,702.00

27290 90 $2,073.00 $2,379.00 $2,540.00 $2,743.00 $2,379.00 $2,540.00 $2,743.00

27295 90 $1,594.00 $1,874.00 $2,000.00 $2,163.00 $1,874.00 $2,000.00 $2,163.00

27299 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

27301 90 $193.00 $964.00 $1,030.00 $1,090.00 $734.00 $785.00 $843.00

27303 90 $520.00 $935.00 $997.00 $1,068.00 $935.00 $997.00 $1,068.00

27305 90 $555.00 $697.00 $742.00 $790.00 $697.00 $742.00 $790.00

27306 90 $377.00 $507.00 $536.00 $564.00 $507.00 $536.00 $564.00

27307 90 $503.00 $619.00 $656.00 $697.00 $619.00 $656.00 $697.00

27310 90 $877.00 $1,068.00 $1,139.00 $1,221.00 $1,068.00 $1,139.00 $1,221.00

27323 10 $211.00 $384.00 $409.00 $428.00 $259.00 $276.00 $293.00

27324 90 $433.00 $581.00 $622.00 $668.00 $581.00 $622.00 $668.00

27325 90 ---------- $754.00 $810.00 $880.00 $754.00 $810.00 $880.00

27326 90 ---------- $729.00 $781.00 $840.00 $729.00 $781.00 $840.00

27327 90 $400.00 $654.00 $699.00 $736.00 $458.00 $490.00 $524.00

27328 90 $503.00 $915.00 $978.00 $1,055.00 $915.00 $978.00 $1,055.00

27329 90 $1,249.00 $1,539.00 $1,646.00 $1,784.00 $1,539.00 $1,646.00 $1,784.00

27330 90 $492.00 $597.00 $637.00 $679.00 $597.00 $637.00 $679.00

27331 90 $585.00 $690.00 $736.00 $785.00 $690.00 $736.00 $785.00

27332 90 $786.00 $936.00 $999.00 $1,069.00 $936.00 $999.00 $1,069.00

27333 90 $719.00 $854.00 $912.00 $976.00 $854.00 $912.00 $976.00

27334 90 $840.00 $997.00 $1,063.00 $1,137.00 $997.00 $1,063.00 $1,137.00

27335 90 $959.00 $1,114.00 $1,187.00 $1,271.00 $1,114.00 $1,187.00 $1,271.00

27337 90 ---------- $616.00 $660.00 $714.00 $616.00 $660.00 $714.00

27339 90 ---------- $1,113.00 $1,190.00 $1,287.00 $1,113.00 $1,190.00 $1,287.00

27340 90 $405.00 $537.00 $573.00 $610.00 $537.00 $573.00 $610.00

27345 90 $565.00 $697.00 $743.00 $793.00 $697.00 $743.00 $793.00

27347 90 $394.00 $769.00 $820.00 $876.00 $769.00 $820.00 $876.00

27350 90 $786.00 $949.00 $1,012.00 $1,082.00 $949.00 $1,012.00 $1,082.00

27355 90 $763.00 $879.00 $937.00 $1,002.00 $879.00 $937.00 $1,002.00



Surgery


(Non-Facility MRA)






27356 90 $882.00 $1,073.00 $1,143.00 $1,223.00 $1,073.00 $1,143.00 $1,223.00

27357 90 $950.00 $1,190.00 $1,270.00 $1,361.00 $1,190.00 $1,270.00 $1,361.00

27358 ZZZ $394.00 $417.00 $445.00 $483.00 $417.00 $445.00 $483.00

27360 90 $977.00 $1,240.00 $1,322.00 $1,415.00 $1,240.00 $1,322.00 $1,415.00

27364 90 ---------- $2,314.00 $2,471.00 $2,675.00 $2,314.00 $2,471.00 $2,675.00

27365 90 $1,421.00 $3,054.00 $3,257.00 $3,515.00 $3,054.00 $3,257.00 $3,515.00

27370 0 $75.00 $214.00 $227.00 $233.00 $74.00 $78.00 $82.00

27372 90 $371.00 $857.00 $914.00 $959.00 $585.00 $623.00 $665.00

27380 90 $698.00 $861.00 $918.00 $979.00 $861.00 $918.00 $979.00

27381 90 $1,118.00 $1,165.00 $1,242.00 $1,329.00 $1,165.00 $1,242.00 $1,329.00

27385 90 $753.00 $832.00 $887.00 $944.00 $832.00 $887.00 $944.00

27386 90 $1,064.00 $1,207.00 $1,287.00 $1,375.00 $1,207.00 $1,287.00 $1,375.00

27390 90 $506.00 $641.00 $685.00 $732.00 $641.00 $685.00 $732.00

27391 90 $647.00 $832.00 $886.00 $944.00 $832.00 $886.00 $944.00

27392 90 $834.00 $1,023.00 $1,090.00 $1,168.00 $1,023.00 $1,090.00 $1,168.00

27393 90 $608.00 $742.00 $791.00 $845.00 $742.00 $791.00 $845.00

27394 90 $748.00 $921.00 $974.00 $1,028.00 $921.00 $974.00 $1,028.00

27395 90 $1,093.00 $1,289.00 $1,376.00 $1,478.00 $1,289.00 $1,376.00 $1,478.00

27396 90 $742.00 $894.00 $955.00 $1,024.00 $894.00 $955.00 $1,024.00

27397 90 $989.00 $1,325.00 $1,413.00 $1,516.00 $1,325.00 $1,413.00 $1,516.00

27400 90 $832.00 $1,001.00 $1,069.00 $1,148.00 $1,001.00 $1,069.00 $1,148.00

27403 90 $792.00 $933.00 $996.00 $1,066.00 $933.00 $996.00 $1,066.00

27405 90 $842.00 $983.00 $1,048.00 $1,121.00 $983.00 $1,048.00 $1,121.00

27407 90 $918.00 $1,132.00 $1,206.00 $1,291.00 $1,132.00 $1,206.00 $1,291.00

27409 90 $1,212.00 $1,418.00 $1,514.00 $1,628.00 $1,418.00 $1,514.00 $1,628.00

27412 90 ---------- $2,441.00 $2,605.00 $2,807.00 $2,441.00 $2,605.00 $2,807.00

27415 90 ---------- $2,025.00 $2,161.00 $2,327.00 $2,025.00 $2,161.00 $2,327.00

27416 90 ---------- $1,444.00 $1,541.00 $1,659.00 $1,444.00 $1,541.00 $1,659.00

27418 90 $1,596.00 $1,206.00 $1,285.00 $1,376.00 $1,206.00 $1,285.00 $1,376.00

27420 90 $927.00 $1,086.00 $1,157.00 $1,239.00 $1,086.00 $1,157.00 $1,239.00

27422 90 $930.00 $1,085.00 $1,157.00 $1,239.00 $1,085.00 $1,157.00 $1,239.00

27424 90 $927.00 $1,096.00 $1,170.00 $1,256.00 $1,096.00 $1,170.00 $1,256.00

27425 90 $639.00 $649.00 $693.00 $738.00 $649.00 $693.00 $738.00

27427 90 $1,118.00 $1,039.00 $1,107.00 $1,185.00 $1,039.00 $1,107.00 $1,185.00

27428 90 $1,266.00 $1,627.00 $1,734.00 $1,857.00 $1,627.00 $1,734.00 $1,857.00

27429 90 $2,333.00 $1,818.00 $1,936.00 $2,072.00 $1,818.00 $1,936.00 $2,072.00

27430 90 $884.00 $1,079.00 $1,151.00 $1,232.00 $1,079.00 $1,151.00 $1,232.00

27435 90 $501.00 $1,177.00 $1,255.00 $1,341.00 $1,177.00 $1,255.00 $1,341.00

27437 90 $819.00 $968.00 $1,033.00 $1,108.00 $968.00 $1,033.00 $1,108.00

27438 90 $1,065.00 $1,230.00 $1,311.00 $1,405.00 $1,230.00 $1,311.00 $1,405.00

27440 90 $1,064.00 $1,165.00 $1,242.00 $1,331.00 $1,165.00 $1,242.00 $1,331.00

27441 90 $1,006.00 $1,211.00 $1,292.00 $1,389.00 $1,211.00 $1,292.00 $1,389.00

27442 90 $1,117.00 $1,275.00 $1,359.00 $1,458.00 $1,275.00 $1,359.00 $1,458.00

27443 90 $1,037.00 $1,193.00 $1,273.00 $1,367.00 $1,193.00 $1,273.00 $1,367.00

27445 90 $1,618.00 $1,846.00 $1,969.00 $2,119.00 $1,846.00 $1,969.00 $2,119.00

27446 90 $1,764.00 $1,709.00 $1,822.00 $1,960.00 $1,709.00 $1,822.00 $1,960.00

27447 90 $1,960.00 $2,000.00 $2,132.00 $2,295.00 $2,000.00 $2,132.00 $2,295.00

27448 90 $1,060.00 $1,125.00 $1,193.00 $1,270.00 $1,125.00 $1,193.00 $1,270.00

27450 90 $1,311.00 $1,488.00 $1,587.00 $1,704.00 $1,488.00 $1,587.00 $1,704.00

27454 90 $1,524.00 $1,913.00 $2,041.00 $2,197.00 $1,913.00 $2,041.00 $2,197.00



Surgery


(Non-Facility MRA)






27455 90 $1,157.00 $1,381.00 $1,473.00 $1,582.00 $1,381.00 $1,473.00 $1,582.00

27457 90 $1,209.00 $1,388.00 $1,477.00 $1,584.00 $1,388.00 $1,477.00 $1,584.00

27465 90 $1,253.00 $1,817.00 $1,936.00 $2,083.00 $1,817.00 $1,936.00 $2,083.00

27466 90 $1,441.00 $1,726.00 $1,839.00 $1,975.00 $1,726.00 $1,839.00 $1,975.00

27468 90 $1,613.00 $1,983.00 $2,117.00 $2,283.00 $1,983.00 $2,117.00 $2,283.00

27470 90 $1,501.00 $1,728.00 $1,843.00 $1,980.00 $1,728.00 $1,843.00 $1,980.00

27472 90 $1,665.00 $1,859.00 $1,982.00 $2,132.00 $1,859.00 $1,982.00 $2,132.00

27475 90 $782.00 $968.00 $1,033.00 $1,108.00 $968.00 $1,033.00 $1,108.00

27477 90 $938.00 $1,075.00 $1,147.00 $1,232.00 $1,075.00 $1,147.00 $1,232.00

27479 90 $1,123.00 $1,354.00 $1,445.00 $1,555.00 $1,354.00 $1,445.00 $1,555.00

27485 90 $797.00 $975.00 $1,041.00 $1,116.00 $975.00 $1,041.00 $1,116.00

27486 90 $1,771.00 $2,074.00 $2,210.00 $2,377.00 $2,074.00 $2,210.00 $2,377.00

27487 90 $2,352.00 $2,598.00 $2,768.00 $2,982.00 $2,598.00 $2,768.00 $2,982.00

27488 90 $1,438.00 $1,766.00 $1,882.00 $2,023.00 $1,766.00 $1,882.00 $2,023.00

27495 90 $1,477.00 $1,656.00 $1,766.00 $1,900.00 $1,656.00 $1,766.00 $1,900.00

27496 90 $563.00 $782.00 $835.00 $892.00 $782.00 $835.00 $892.00

27497 90 $652.00 $845.00 $902.00 $968.00 $845.00 $902.00 $968.00

27498 90 $701.00 $950.00 $1,014.00 $1,086.00 $950.00 $1,014.00 $1,086.00

27499 90 $782.00 $1,006.00 $1,069.00 $1,138.00 $1,006.00 $1,069.00 $1,138.00

27500 90 $520.00 $750.00 $799.00 $850.00 $698.00 $743.00 $793.00

27501 90 $659.00 $732.00 $781.00 $834.00 $726.00 $775.00 $828.00

27502 90 $909.00 $1,114.00 $1,186.00 $1,271.00 $1,114.00 $1,186.00 $1,271.00

27503 90 $911.00 $1,171.00 $1,249.00 $1,340.00 $1,171.00 $1,249.00 $1,340.00

27506 90 $1,522.00 $1,970.00 $2,101.00 $2,259.00 $1,970.00 $2,101.00 $2,259.00

27507 90 $1,297.00 $1,432.00 $1,527.00 $1,643.00 $1,432.00 $1,527.00 $1,643.00

27508 90 $400.00 $756.00 $806.00 $855.00 $714.00 $761.00 $809.00

27509 90 $649.00 $932.00 $993.00 $1,058.00 $932.00 $993.00 $1,058.00

27510 90 $755.00 $998.00 $1,063.00 $1,139.00 $998.00 $1,063.00 $1,139.00

27511 90 $1,281.00 $1,471.00 $1,569.00 $1,690.00 $1,471.00 $1,569.00 $1,690.00

27513 90 $1,562.00 $1,834.00 $1,955.00 $2,110.00 $1,834.00 $1,955.00 $2,110.00

27514 90 $1,508.00 $1,426.00 $1,520.00 $1,637.00 $1,426.00 $1,520.00 $1,637.00

27516 90 $579.00 $730.00 $779.00 $826.00 $687.00 $734.00 $781.00

27517 90 $820.00 $933.00 $990.00 $1,053.00 $933.00 $990.00 $1,053.00

27519 90 $1,311.00 $1,316.00 $1,405.00 $1,515.00 $1,316.00 $1,405.00 $1,515.00

27520 90 $266.00 $459.00 $489.00 $513.00 $421.00 $448.00 $473.00

27524 90 $910.00 $1,100.00 $1,173.00 $1,257.00 $1,100.00 $1,173.00 $1,257.00

27530 90 $408.00 $428.00 $456.00 $478.00 $399.00 $425.00 $447.00

27532 90 $641.00 $891.00 $950.00 $1,013.00 $840.00 $896.00 $958.00

27535 90 $1,075.00 $1,322.00 $1,410.00 $1,518.00 $1,322.00 $1,410.00 $1,518.00

27536 90 $1,282.00 $1,750.00 $1,866.00 $2,006.00 $1,750.00 $1,866.00 $2,006.00

27538 90 $487.00 $683.00 $729.00 $771.00 $642.00 $685.00 $727.00

27540 90 $1,106.00 $1,188.00 $1,267.00 $1,357.00 $1,188.00 $1,267.00 $1,357.00

27550 90 $296.00 $729.00 $776.00 $821.00 $679.00 $723.00 $767.00

27552 90 $619.00 $913.00 $973.00 $1,040.00 $913.00 $973.00 $1,040.00

27556 90 $832.00 $1,270.00 $1,352.00 $1,452.00 $1,270.00 $1,352.00 $1,452.00

27557 90 $1,479.00 $1,506.00 $1,603.00 $1,723.00 $1,506.00 $1,603.00 $1,723.00

27558 90 $1,529.00 $1,769.00 $1,887.00 $2,037.00 $1,769.00 $1,887.00 $2,037.00

27560 90 $88.00 $513.00 $545.00 $574.00 $476.00 $505.00 $533.00

27562 90 $514.00 $688.00 $732.00 $779.00 $688.00 $732.00 $779.00

27566 90 $1,047.00 $1,304.00 $1,391.00 $1,493.00 $1,304.00 $1,391.00 $1,493.00



Surgery


(Non-Facility MRA)






27570 10 $184.00 $219.00 $234.00 $249.00 $219.00 $234.00 $249.00

27580 90 $1,644.00 $2,114.00 $2,254.00 $2,423.00 $2,114.00 $2,254.00 $2,423.00

27590 90 $1,059.00 $1,203.00 $1,289.00 $1,410.00 $1,203.00 $1,289.00 $1,410.00

27591 90 $1,182.00 $1,421.00 $1,517.00 $1,632.00 $1,421.00 $1,517.00 $1,632.00

27592 90 $911.00 $1,021.00 $1,092.00 $1,190.00 $1,021.00 $1,092.00 $1,190.00

27594 90 $600.00 $747.00 $800.00 $866.00 $747.00 $800.00 $866.00

27596 90 $931.00 $1,077.00 $1,153.00 $1,254.00 $1,077.00 $1,153.00 $1,254.00

27598 90 $976.00 $1,067.00 $1,142.00 $1,240.00 $1,067.00 $1,142.00 $1,240.00

27599 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

27600 90 $517.00 $600.00 $641.00 $690.00 $600.00 $641.00 $690.00

27601 90 $516.00 $653.00 $697.00 $747.00 $653.00 $697.00 $747.00

27602 90 $621.00 $728.00 $780.00 $850.00 $728.00 $780.00 $850.00

27603 90 $412.00 $756.00 $807.00 $851.00 $566.00 $603.00 $645.00

27604 90 $308.00 $697.00 $742.00 $775.00 $498.00 $529.00 $560.00

27605 10 $236.00 $482.00 $510.00 $525.00 $268.00 $281.00 $294.00

27606 10 $362.00 $411.00 $436.00 $464.00 $411.00 $436.00 $464.00

27607 90 $608.00 $888.00 $945.00 $1,010.00 $888.00 $945.00 $1,010.00

27610 90 $777.00 $947.00 $1,007.00 $1,074.00 $947.00 $1,007.00 $1,074.00

27612 90 $701.00 $817.00 $864.00 $912.00 $817.00 $864.00 $912.00

27613 10 $165.00 $357.00 $379.00 $393.00 $235.00 $249.00 $262.00

27614 90 $327.00 $827.00 $879.00 $921.00 $591.00 $627.00 $666.00

27615 90 $1,106.00 $1,511.00 $1,612.00 $1,740.00 $1,511.00 $1,612.00 $1,740.00

27616 90 ---------- $1,878.00 $2,004.00 $2,164.00 $1,878.00 $2,004.00 $2,164.00

27618 90 $421.00 $642.00 $685.00 $719.00 $450.00 $479.00 $511.00

27619 90 $730.00 $682.00 $722.00 $767.00 $682.00 $722.00 $767.00

27620 90 $587.00 $659.00 $700.00 $741.00 $659.00 $700.00 $741.00

27625 90 $796.00 $843.00 $892.00 $945.00 $843.00 $892.00 $945.00

27626 90 $863.00 $880.00 $930.00 $984.00 $880.00 $930.00 $984.00

27630 90 $430.00 $793.00 $842.00 $876.00 $528.00 $559.00 $590.00

27632 90 ---------- $607.00 $648.00 $698.00 $607.00 $648.00 $698.00

27634 90 ---------- $1,009.00 $1,076.00 $1,158.00 $1,009.00 $1,076.00 $1,158.00

27635 90 $781.00 $853.00 $907.00 $967.00 $853.00 $907.00 $967.00

27637 90 $921.00 $1,115.00 $1,189.00 $1,275.00 $1,115.00 $1,189.00 $1,275.00

27638 90 $978.00 $1,115.00 $1,185.00 $1,267.00 $1,115.00 $1,185.00 $1,267.00

27640 90 $1,122.00 $1,221.00 $1,299.00 $1,389.00 $1,221.00 $1,299.00 $1,389.00

27641 90 $922.00 $975.00 $1,034.00 $1,101.00 $975.00 $1,034.00 $1,101.00

27645 90 $1,302.00 $2,623.00 $2,797.00 $3,016.00 $2,623.00 $2,797.00 $3,016.00

27646 90 $1,212.00 $2,190.00 $2,331.00 $2,506.00 $2,190.00 $2,331.00 $2,506.00

27647 90 $1,044.00 $1,489.00 $1,545.00 $1,603.00 $1,489.00 $1,545.00 $1,603.00

27648 0 $72.00 $231.00 $245.00 $252.00 $78.00 $82.00 $87.00

27650 90 $869.00 $955.00 $1,012.00 $1,071.00 $955.00 $1,012.00 $1,071.00

27652 90 $935.00 $996.00 $1,050.00 $1,108.00 $996.00 $1,050.00 $1,108.00

27654 90 $937.00 $1,028.00 $1,086.00 $1,147.00 $1,028.00 $1,086.00 $1,147.00

27656 90 $458.00 $881.00 $940.00 $982.00 $566.00 $604.00 $644.00

27658 90 $527.00 $539.00 $570.00 $600.00 $539.00 $570.00 $600.00

27659 90 $725.00 $693.00 $731.00 $770.00 $693.00 $731.00 $770.00

27664 90 $504.00 $524.00 $555.00 $586.00 $524.00 $555.00 $586.00

27665 90 $618.00 $594.00 $628.00 $662.00 $594.00 $628.00 $662.00

27675 90 $656.00 $710.00 $749.00 $790.00 $710.00 $749.00 $790.00

27676 90 $762.00 $883.00 $936.00 $994.00 $883.00 $936.00 $994.00



Surgery


(Non-Facility MRA)






27680 90 $523.00 $623.00 $661.00 $701.00 $623.00 $661.00 $701.00

27681 90 $634.00 $797.00 $851.00 $911.00 $797.00 $851.00 $911.00

27685 90 $565.00 $945.00 $1,001.00 $1,040.00 $671.00 $708.00 $745.00

27686 90 $706.00 $814.00 $865.00 $921.00 $814.00 $865.00 $921.00

27687 90 $589.00 $658.00 $696.00 $734.00 $658.00 $696.00 $734.00

27690 90 $757.00 $918.00 $969.00 $1,021.00 $918.00 $969.00 $1,021.00

27691 90 $889.00 $1,089.00 $1,156.00 $1,228.00 $1,089.00 $1,156.00 $1,228.00

27692 ZZZ $159.00 $156.00 $165.00 $178.00 $156.00 $165.00 $178.00

27695 90 $658.00 $691.00 $732.00 $772.00 $691.00 $732.00 $772.00

27696 90 $758.00 $802.00 $845.00 $889.00 $802.00 $845.00 $889.00

27698 90 $881.00 $933.00 $987.00 $1,047.00 $933.00 $987.00 $1,047.00

27700 90 $835.00 $885.00 $932.00 $982.00 $885.00 $932.00 $982.00

27702 90 $1,278.00 $1,413.00 $1,501.00 $1,606.00 $1,413.00 $1,501.00 $1,606.00

27703 90 $1,337.00 $1,627.00 $1,729.00 $1,849.00 $1,627.00 $1,729.00 $1,849.00

27704 90 $683.00 $837.00 $891.00 $949.00 $837.00 $891.00 $949.00

27705 90 $985.00 $1,109.00 $1,180.00 $1,262.00 $1,109.00 $1,180.00 $1,262.00

27707 90 $484.00 $578.00 $616.00 $653.00 $578.00 $616.00 $653.00

27709 90 $1,118.00 $1,724.00 $1,837.00 $1,975.00 $1,724.00 $1,837.00 $1,975.00

27712 90 $1,227.00 $1,628.00 $1,738.00 $1,871.00 $1,628.00 $1,738.00 $1,871.00

27715 90 $1,285.00 $1,547.00 $1,650.00 $1,776.00 $1,547.00 $1,650.00 $1,776.00

27720 90 $1,147.00 $1,281.00 $1,366.00 $1,464.00 $1,281.00 $1,366.00 $1,464.00

27722 90 $1,076.00 $1,307.00 $1,394.00 $1,497.00 $1,307.00 $1,394.00 $1,497.00

27724 90 $1,402.00 $1,865.00 $1,988.00 $2,141.00 $1,865.00 $1,988.00 $2,141.00

27725 90 $1,312.00 $1,754.00 $1,871.00 $2,012.00 $1,754.00 $1,871.00 $2,012.00

27726 90 ---------- $1,416.00 $1,508.00 $1,620.00 $1,416.00 $1,508.00 $1,620.00

27727 90 $1,175.00 $1,309.00 $1,383.00 $1,473.00 $1,309.00 $1,383.00 $1,473.00

27730 90 $647.00 $807.00 $858.00 $914.00 $807.00 $858.00 $914.00

27732 90 $611.00 $537.00 $567.00 $598.00 $537.00 $567.00 $598.00

27734 90 $766.00 $960.00 $1,025.00 $1,099.00 $960.00 $1,025.00 $1,099.00

27740 90 $1,044.00 $1,008.00 $1,069.00 $1,133.00 $1,008.00 $1,069.00 $1,133.00

27742 90 $1,045.00 $1,093.00 $1,156.00 $1,218.00 $1,093.00 $1,156.00 $1,218.00

27745 90 $940.00 $1,106.00 $1,179.00 $1,262.00 $1,106.00 $1,179.00 $1,262.00

27750 90 $319.00 $494.00 $526.00 $553.00 $455.00 $484.00 $511.00

27752 90 $614.00 $773.00 $824.00 $875.00 $717.00 $764.00 $815.00

27756 90 $708.00 $839.00 $895.00 $955.00 $839.00 $895.00 $955.00

27758 90 $1,115.00 $1,306.00 $1,393.00 $1,494.00 $1,306.00 $1,393.00 $1,494.00

27759 90 $1,262.00 $1,468.00 $1,565.00 $1,682.00 $1,468.00 $1,565.00 $1,682.00

27760 90 $223.00 $472.00 $502.00 $525.00 $433.00 $460.00 $483.00

27762 90 $495.00 $674.00 $716.00 $755.00 $617.00 $655.00 $693.00

27766 90 $759.00 $886.00 $945.00 $1,008.00 $886.00 $945.00 $1,008.00

27767 90 ---------- $398.00 $424.00 $445.00 $401.00 $427.00 $447.00

27768 90 ---------- $633.00 $676.00 $719.00 $633.00 $676.00 $719.00

27769 90 ---------- $1,058.00 $1,128.00 $1,209.00 $1,058.00 $1,128.00 $1,209.00

27780 90 $244.00 $434.00 $462.00 $484.00 $397.00 $423.00 $445.00

27781 90 $296.00 $611.00 $651.00 $687.00 $569.00 $606.00 $642.00

27784 90 $643.00 $1,044.00 $1,113.00 $1,191.00 $1,044.00 $1,113.00 $1,191.00

27786 90 $223.00 $448.00 $477.00 $500.00 $408.00 $434.00 $457.00

27788 90 $422.00 $602.00 $640.00 $675.00 $552.00 $587.00 $621.00

27792 90 $706.00 $951.00 $1,014.00 $1,083.00 $951.00 $1,014.00 $1,083.00

27808 90 $332.00 $474.00 $505.00 $529.00 $428.00 $455.00 $479.00



Surgery


(Non-Facility MRA)






27810 90 $567.00 $667.00 $710.00 $749.00 $609.00 $647.00 $686.00

27814 90 $972.00 $1,127.00 $1,201.00 $1,285.00 $1,127.00 $1,201.00 $1,285.00

27816 90 $386.00 $457.00 $486.00 $510.00 $412.00 $439.00 $461.00

27818 90 $613.00 $693.00 $736.00 $777.00 $625.00 $664.00 $704.00

27822 90 $1,201.00 $1,251.00 $1,333.00 $1,421.00 $1,251.00 $1,333.00 $1,421.00

27823 90 $1,472.00 $1,422.00 $1,515.00 $1,619.00 $1,422.00 $1,515.00 $1,619.00

27824 90 $384.00 $448.00 $477.00 $502.00 $436.00 $464.00 $489.00

27825 90 $670.00 $785.00 $836.00 $888.00 $717.00 $763.00 $814.00

27826 90 $1,080.00 $1,238.00 $1,319.00 $1,406.00 $1,238.00 $1,319.00 $1,406.00

27827 90 $1,310.00 $1,606.00 $1,712.00 $1,830.00 $1,606.00 $1,712.00 $1,830.00

27828 90 $1,823.00 $1,926.00 $2,053.00 $2,200.00 $1,926.00 $2,053.00 $2,200.00

27829 90 $742.00 $1,011.00 $1,077.00 $1,145.00 $1,011.00 $1,077.00 $1,145.00

27830 90 $412.00 $540.00 $576.00 $609.00 $505.00 $539.00 $572.00

27831 90 $415.00 $545.00 $579.00 $611.00 $545.00 $579.00 $611.00

27832 90 $617.00 $1,107.00 $1,181.00 $1,267.00 $1,107.00 $1,181.00 $1,267.00

27840 90 $334.00 $528.00 $560.00 $591.00 $528.00 $560.00 $591.00

27842 90 $373.00 $716.00 $763.00 $813.00 $716.00 $763.00 $813.00

27846 90 $877.00 $1,064.00 $1,132.00 $1,209.00 $1,064.00 $1,132.00 $1,209.00

27848 90 $1,224.00 $1,180.00 $1,255.00 $1,342.00 $1,180.00 $1,255.00 $1,342.00

27860 10 $211.00 $251.00 $266.00 $282.00 $251.00 $266.00 $282.00

27870 90 $1,269.00 $1,509.00 $1,604.00 $1,714.00 $1,509.00 $1,604.00 $1,714.00

27871 90 $843.00 $999.00 $1,063.00 $1,135.00 $999.00 $1,063.00 $1,135.00

27880 90 $1,015.00 $1,377.00 $1,474.00 $1,610.00 $1,377.00 $1,474.00 $1,610.00

27881 90 $1,120.00 $1,290.00 $1,379.00 $1,495.00 $1,290.00 $1,379.00 $1,495.00

27882 90 $854.00 $899.00 $963.00 $1,050.00 $899.00 $963.00 $1,050.00

27884 90 $579.00 $857.00 $917.00 $996.00 $857.00 $917.00 $996.00

27886 90 $835.00 $979.00 $1,048.00 $1,137.00 $979.00 $1,048.00 $1,137.00

27888 90 $911.00 $1,016.00 $1,083.00 $1,164.00 $1,016.00 $1,083.00 $1,164.00

27889 90 $879.00 $972.00 $1,041.00 $1,136.00 $972.00 $1,041.00 $1,136.00

27892 90 $575.00 $814.00 $867.00 $929.00 $814.00 $867.00 $929.00

27893 90 $574.00 $884.00 $944.00 $1,010.00 $884.00 $944.00 $1,010.00

27894 90 $712.00 $1,264.00 $1,350.00 $1,456.00 $1,264.00 $1,350.00 $1,456.00

27899 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

28001 10 $185.00 $393.00 $414.00 $425.00 $244.00 $255.00 $264.00

28002 10 $362.00 $631.00 $664.00 $686.00 $460.00 $481.00 $502.00

28003 90 $520.00 $1,007.00 $1,059.00 $1,099.00 $812.00 $851.00 $888.00

28005 90 $520.00 $835.00 $874.00 $912.00 $835.00 $874.00 $912.00

28008 90 $296.00 $618.00 $650.00 $669.00 $423.00 $443.00 $460.00

28010 90 $235.00 $331.00 $347.00 $358.00 $299.00 $314.00 $324.00

28011 90 $340.00 $460.00 $483.00 $501.00 $413.00 $433.00 $450.00

28020 90 $509.00 $773.00 $819.00 $850.00 $525.00 $554.00 $583.00

28022 90 $422.00 $693.00 $732.00 $755.00 $467.00 $491.00 $512.00

28024 90 $371.00 $655.00 $691.00 $712.00 $438.00 $459.00 $478.00

28035 90 $532.00 $754.00 $797.00 $825.00 $514.00 $541.00 $566.00

28039 90 ---------- $727.00 $769.00 $798.00 $508.00 $535.00 $561.00

28041 90 ---------- $663.00 $697.00 $731.00 $663.00 $697.00 $731.00

28043 90 $305.00 $572.00 $603.00 $621.00 $380.00 $398.00 $414.00

28045 90 $456.00 $710.00 $748.00 $770.00 $503.00 $527.00 $547.00

28046 90 $814.00 $1,062.00 $1,115.00 $1,172.00 $1,062.00 $1,115.00 $1,172.00

28047 90 ---------- $1,564.00 $1,655.00 $1,766.00 $1,564.00 $1,655.00 $1,766.00



Surgery


(Non-Facility MRA)






28050 90 $414.00 $678.00 $717.00 $741.00 $447.00 $471.00 $492.00

28052 90 $402.00 $632.00 $669.00 $691.00 $410.00 $431.00 $450.00

28054 90 $236.00 $547.00 $576.00 $590.00 $345.00 $361.00 $373.00

28055 90 ---------- $545.00 $568.00 $590.00 $545.00 $568.00 $590.00

28060 90 $495.00 $739.00 $780.00 $805.00 $515.00 $540.00 $563.00

28062 90 $657.00 $840.00 $884.00 $910.00 $590.00 $616.00 $641.00

28070 90 $476.00 $768.00 $813.00 $842.00 $519.00 $547.00 $573.00

28072 90 $445.00 $728.00 $771.00 $798.00 $482.00 $509.00 $533.00

28080 90 $392.00 $749.00 $791.00 $814.00 $528.00 $555.00 $576.00

28086 90 $462.00 $780.00 $828.00 $859.00 $522.00 $551.00 $580.00

28088 90 $414.00 $636.00 $673.00 $695.00 $407.00 $429.00 $448.00

28090 90 $414.00 $671.00 $708.00 $730.00 $445.00 $467.00 $486.00

28092 90 $330.00 $604.00 $638.00 $656.00 $388.00 $407.00 $423.00

28100 90 $571.00 $869.00 $920.00 $955.00 $598.00 $631.00 $663.00

28102 90 $700.00 $884.00 $943.00 $1,008.00 $884.00 $943.00 $1,008.00

28103 90 $709.00 $573.00 $597.00 $619.00 $573.00 $597.00 $619.00

28104 90 $491.00 $755.00 $798.00 $825.00 $512.00 $538.00 $563.00

28106 90 $632.00 $619.00 $644.00 $666.00 $619.00 $644.00 $666.00

28107 90 $517.00 $738.00 $776.00 $797.00 $504.00 $526.00 $544.00

28108 90 $418.00 $627.00 $661.00 $680.00 $415.00 $435.00 $451.00

28110 90 $421.00 $660.00 $697.00 $717.00 $418.00 $438.00 $456.00

28111 90 $537.00 $706.00 $746.00 $772.00 $473.00 $497.00 $521.00

28112 90 $457.00 $699.00 $739.00 $762.00 $453.00 $476.00 $497.00

28113 90 $481.00 $845.00 $891.00 $918.00 $612.00 $643.00 $667.00

28114 90 $890.00 $1,547.00 $1,637.00 $1,708.00 $1,216.00 $1,284.00 $1,351.00

28116 90 $648.00 $1,091.00 $1,150.00 $1,192.00 $830.00 $871.00 $910.00

28118 90 $568.00 $848.00 $896.00 $929.00 $596.00 $628.00 $658.00

28119 90 $524.00 $751.00 $791.00 $816.00 $521.00 $546.00 $568.00

28120 90 $601.00 $970.00 $1,027.00 $1,068.00 $721.00 $760.00 $799.00

28122 90 $622.00 $859.00 $905.00 $937.00 $637.00 $668.00 $697.00

28124 90 $480.00 $681.00 $717.00 $737.00 $476.00 $497.00 $515.00

28126 90 $393.00 $564.00 $595.00 $611.00 $358.00 $375.00 $389.00

28130 90 $727.00 $935.00 $988.00 $1,044.00 $935.00 $988.00 $1,044.00

28140 90 $533.00 $858.00 $907.00 $945.00 $640.00 $673.00 $709.00

28150 90 $416.00 $609.00 $642.00 $661.00 $404.00 $424.00 $441.00

28153 90 $400.00 $585.00 $617.00 $634.00 $379.00 $397.00 $412.00

28160 90 $412.00 $598.00 $631.00 $649.00 $387.00 $406.00 $421.00

28171 90 $789.00 $1,230.00 $1,276.00 $1,323.00 $1,230.00 $1,276.00 $1,323.00

28173 90 $747.00 $1,104.00 $1,150.00 $1,198.00 $1,104.00 $1,150.00 $1,198.00

28175 90 $571.00 $709.00 $740.00 $769.00 $709.00 $740.00 $769.00

28190 10 $75.00 $364.00 $385.00 $395.00 $193.00 $202.00 $210.00

28192 90 $326.00 $670.00 $706.00 $728.00 $452.00 $474.00 $494.00

28193 90 $341.00 $760.00 $800.00 $824.00 $533.00 $558.00 $580.00

28200 90 $478.00 $701.00 $741.00 $765.00 $465.00 $489.00 $510.00

28202 90 $613.00 $850.00 $894.00 $921.00 $613.00 $641.00 $666.00

28208 90 $406.00 $681.00 $720.00 $743.00 $453.00 $476.00 $497.00

28210 90 $609.00 $836.00 $882.00 $912.00 $601.00 $630.00 $658.00

28220 90 $435.00 $645.00 $679.00 $699.00 $437.00 $457.00 $474.00

28222 90 $555.00 $726.00 $763.00 $784.00 $505.00 $527.00 $546.00

28225 90 $345.00 $589.00 $622.00 $640.00 $376.00 $395.00 $411.00



Surgery


(Non-Facility MRA)






28226 90 $334.00 $697.00 $734.00 $751.00 $455.00 $475.00 $490.00

28230 90 $380.00 $622.00 $655.00 $674.00 $409.00 $429.00 $445.00

28232 90 $286.00 $551.00 $582.00 $597.00 $350.00 $366.00 $380.00

28234 90 $178.00 $581.00 $613.00 $630.00 $379.00 $397.00 $412.00

28238 90 $695.00 $962.00 $1,014.00 $1,050.00 $705.00 $739.00 $773.00

28240 90 $370.00 $645.00 $681.00 $702.00 $428.00 $449.00 $467.00

28250 90 $535.00 $829.00 $877.00 $910.00 $585.00 $616.00 $646.00

28260 90 $641.00 $997.00 $1,053.00 $1,094.00 $748.00 $786.00 $826.00

28261 90 $881.00 $1,446.00 $1,525.00 $1,590.00 $1,152.00 $1,211.00 $1,273.00

28262 90 $1,363.00 $2,139.00 $2,282.00 $2,427.00 $1,742.00 $1,858.00 $1,998.00

28264 90 $912.00 $1,264.00 $1,337.00 $1,398.00 $981.00 $1,035.00 $1,094.00

28270 90 $266.00 $704.00 $743.00 $766.00 $483.00 $507.00 $527.00

28272 90 $336.00 $562.00 $591.00 $606.00 $366.00 $382.00 $395.00

28280 90 $426.00 $739.00 $780.00 $805.00 $505.00 $530.00 $553.00

28285 90 $463.00 $765.00 $806.00 $831.00 $545.00 $571.00 $594.00

28286 90 $441.00 $642.00 $676.00 $693.00 $430.00 $449.00 $464.00

28288 90 $452.00 $863.00 $911.00 $941.00 $618.00 $650.00 $677.00

28289 90 $458.00 $1,067.00 $1,128.00 $1,165.00 $673.00 $708.00 $740.00

28291 90 ---------- $1,048.00 $1,104.00 $1,141.00 $697.00 $730.00 $762.00

28292 90 $666.00 $1,066.00 $1,124.00 $1,157.00 $698.00 $731.00 $761.00

28295 90 ---------- $1,335.00 $1,408.00 $1,445.00 $774.00 $809.00 $840.00

28296 90 $832.00 $1,296.00 $1,368.00 $1,404.00 $744.00 $778.00 $808.00

28297 90 $838.00 $1,494.00 $1,581.00 $1,632.00 $874.00 $919.00 $963.00

28298 90 $755.00 $1,211.00 $1,280.00 $1,319.00 $718.00 $753.00 $787.00

28299 90 $829.00 $1,427.00 $1,507.00 $1,551.00 $839.00 $879.00 $917.00

28300 90 $845.00 $950.00 $1,005.00 $1,066.00 $950.00 $1,005.00 $1,066.00

28302 90 $930.00 $1,049.00 $1,120.00 $1,202.00 $1,049.00 $1,120.00 $1,202.00

28304 90 $776.00 $1,193.00 $1,262.00 $1,317.00 $885.00 $934.00 $986.00

28305 90 $1,030.00 $969.00 $1,019.00 $1,072.00 $969.00 $1,019.00 $1,072.00

28306 90 $530.00 $881.00 $932.00 $967.00 $586.00 $618.00 $650.00

28307 90 $614.00 $955.00 $1,011.00 $1,049.00 $640.00 $674.00 $709.00

28308 90 $516.00 $810.00 $856.00 $884.00 $545.00 $573.00 $598.00

28309 90 $955.00 $1,316.00 $1,390.00 $1,475.00 $1,316.00 $1,390.00 $1,475.00

28310 90 $505.00 $784.00 $827.00 $853.00 $519.00 $544.00 $568.00

28312 90 $469.00 $726.00 $767.00 $790.00 $461.00 $484.00 $504.00

28313 90 $436.00 $755.00 $799.00 $828.00 $518.00 $546.00 $572.00

28315 90 $462.00 $690.00 $728.00 $750.00 $471.00 $494.00 $514.00

28320 90 $833.00 $891.00 $942.00 $995.00 $891.00 $942.00 $995.00

28322 90 $667.00 $1,133.00 $1,201.00 $1,256.00 $840.00 $888.00 $940.00

28340 90 $649.00 $828.00 $868.00 $892.00 $597.00 $621.00 $642.00

28341 90 $753.00 $963.00 $1,008.00 $1,037.00 $711.00 $739.00 $765.00

28344 90 $414.00 $798.00 $850.00 $886.00 $517.00 $550.00 $583.00

28345 90 $557.00 $760.00 $799.00 $822.00 $535.00 $559.00 $580.00

28360 90 $1,197.00 $1,346.00 $1,420.00 $1,503.00 $1,346.00 $1,420.00 $1,503.00

28400 90 $266.00 $353.00 $375.00 $391.00 $324.00 $343.00 $359.00

28405 90 $473.00 $563.00 $597.00 $626.00 $514.00 $544.00 $573.00

28406 90 $616.00 $753.00 $801.00 $848.00 $753.00 $801.00 $848.00

28415 90 $1,354.00 $1,640.00 $1,741.00 $1,853.00 $1,640.00 $1,741.00 $1,853.00

28420 90 $1,619.00 $1,864.00 $1,989.00 $2,133.00 $1,864.00 $1,989.00 $2,133.00

28430 90 $110.00 $336.00 $356.00 $372.00 $300.00 $318.00 $333.00



Surgery


(Non-Facility MRA)






28435 90 $371.00 $460.00 $488.00 $511.00 $413.00 $438.00 $461.00

28436 90 $463.00 $643.00 $685.00 $726.00 $643.00 $685.00 $726.00

28445 90 $874.00 $1,557.00 $1,653.00 $1,764.00 $1,557.00 $1,653.00 $1,764.00

28446 90 ---------- $1,774.00 $1,891.00 $2,032.00 $1,774.00 $1,891.00 $2,032.00

28450 90 $148.00 $306.00 $325.00 $338.00 $274.00 $290.00 $303.00

28455 90 $321.00 $410.00 $432.00 $449.00 $370.00 $390.00 $406.00

28456 90 $288.00 $450.00 $480.00 $505.00 $450.00 $480.00 $505.00

28465 90 $533.00 $911.00 $964.00 $1,017.00 $911.00 $964.00 $1,017.00

28470 90 $178.00 $310.00 $329.00 $342.00 $291.00 $308.00 $321.00

28475 90 $296.00 $365.00 $385.00 $401.00 $326.00 $344.00 $359.00

28476 90 $364.00 $504.00 $536.00 $562.00 $504.00 $536.00 $562.00

28485 90 $521.00 $781.00 $824.00 $863.00 $781.00 $824.00 $863.00

28490 90 $80.00 $205.00 $218.00 $225.00 $177.00 $188.00 $195.00

28495 90 $133.00 $252.00 $267.00 $275.00 $214.00 $225.00 $234.00

28496 90 $261.00 $631.00 $672.00 $692.00 $341.00 $362.00 $379.00

28505 90 $399.00 $961.00 $1,016.00 $1,057.00 $726.00 $765.00 $803.00

28510 90 $75.00 $175.00 $185.00 $191.00 $170.00 $180.00 $186.00

28515 90 $115.00 $229.00 $242.00 $249.00 $203.00 $214.00 $221.00

28525 90 $345.00 $806.00 $852.00 $881.00 $573.00 $603.00 $630.00

28530 90 $120.00 $163.00 $172.00 $177.00 $145.00 $153.00 $158.00

28531 90 $243.00 $485.00 $512.00 $522.00 $261.00 $273.00 $281.00

28540 90 $145.00 $273.00 $286.00 $294.00 $247.00 $259.00 $266.00

28545 90 $208.00 $423.00 $451.00 $475.00 $377.00 $403.00 $425.00

28546 90 $325.00 $796.00 $849.00 $879.00 $477.00 $508.00 $534.00

28555 90 $592.00 $1,267.00 $1,345.00 $1,412.00 $973.00 $1,031.00 $1,095.00

28570 90 $189.00 $254.00 $268.00 $274.00 $216.00 $227.00 $233.00

28575 90 $308.00 $508.00 $541.00 $570.00 $462.00 $492.00 $520.00

28576 90 $382.00 $572.00 $610.00 $647.00 $572.00 $610.00 $647.00

28585 90 $742.00 $1,242.00 $1,307.00 $1,356.00 $981.00 $1,028.00 $1,075.00

28600 90 $144.00 $314.00 $333.00 $346.00 $271.00 $287.00 $300.00

28605 90 $287.00 $468.00 $499.00 $525.00 $422.00 $451.00 $476.00

28606 90 $487.00 $574.00 $610.00 $646.00 $574.00 $610.00 $646.00

28615 90 $621.00 $1,168.00 $1,240.00 $1,313.00 $1,168.00 $1,240.00 $1,313.00

28630 10 $145.00 $227.00 $241.00 $251.00 $161.00 $170.00 $180.00

28635 10 $189.00 $251.00 $265.00 $274.00 $191.00 $201.00 $210.00

28636 10 $318.00 $500.00 $534.00 $560.00 $327.00 $349.00 $373.00

28645 90 $434.00 $942.00 $993.00 $1,030.00 $702.00 $737.00 $771.00

28660 10 $106.00 $167.00 $177.00 $184.00 $129.00 $136.00 $143.00

28665 10 $172.00 $223.00 $234.00 $244.00 $190.00 $200.00 $209.00

28666 10 $309.00 $269.00 $284.00 $300.00 $269.00 $284.00 $300.00

28675 90 $348.00 $836.00 $885.00 $918.00 $595.00 $628.00 $659.00

28705 90 $1,353.00 $1,828.00 $1,933.00 $2,056.00 $1,828.00 $1,933.00 $2,056.00

28715 90 $1,179.00 $1,371.00 $1,455.00 $1,549.00 $1,371.00 $1,455.00 $1,549.00

28725 90 $1,015.00 $1,135.00 $1,203.00 $1,278.00 $1,135.00 $1,203.00 $1,278.00

28730 90 $945.00 $1,067.00 $1,129.00 $1,196.00 $1,067.00 $1,129.00 $1,196.00

28735 90 $961.00 $1,143.00 $1,206.00 $1,276.00 $1,143.00 $1,206.00 $1,276.00

28737 90 $873.00 $1,013.00 $1,067.00 $1,123.00 $1,013.00 $1,067.00 $1,123.00

28740 90 $690.00 $1,217.00 $1,288.00 $1,343.00 $905.00 $955.00 $1,007.00

28750 90 $690.00 $1,164.00 $1,233.00 $1,285.00 $856.00 $903.00 $952.00

28755 90 $466.00 $726.00 $767.00 $791.00 $477.00 $502.00 $523.00



Surgery


(Non-Facility MRA)






28760 90 $654.00 $1,141.00 $1,203.00 $1,248.00 $842.00 $884.00 $926.00

28800 90 $731.00 $789.00 $831.00 $878.00 $789.00 $831.00 $878.00

28805 90 $731.00 $1,077.00 $1,137.00 $1,210.00 $1,077.00 $1,137.00 $1,210.00

28810 90 $543.00 $634.00 $672.00 $717.00 $634.00 $672.00 $717.00

28820 90 $377.00 $809.00 $857.00 $891.00 $575.00 $606.00 $638.00

28825 90 $339.00 $772.00 $818.00 $849.00 $538.00 $568.00 $597.00

28890 90 ---------- $462.00 $487.00 $502.00 $325.00 $341.00 $354.00

28899 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

29000 0 $247.00 $432.00 $467.00 $499.00 $270.00 $294.00 $325.00

29010 0 $271.00 $310.00 $328.00 $341.00 $201.00 $212.00 $223.00

29015 0 $289.00 $378.00 $401.00 $417.00 $246.00 $260.00 $274.00

29035 0 $213.00 $362.00 $386.00 $403.00 $210.00 $224.00 $239.00

29040 0 $260.00 $320.00 $340.00 $353.00 $212.00 $224.00 $236.00

29044 0 $260.00 $355.00 $377.00 $394.00 $223.00 $237.00 $252.00

29046 0 $286.00 $370.00 $393.00 $408.00 $240.00 $254.00 $268.00

29049 0 $45.00 $105.00 $112.00 $117.00 $82.00 $87.00 $92.00

29055 0 $180.00 $312.00 $334.00 $350.00 $201.00 $215.00 $229.00

29058 0 $110.00 $177.00 $189.00 $200.00 $138.00 $147.00 $158.00

29065 0 $88.00 $136.00 $145.00 $152.00 $99.00 $105.00 $111.00

29075 0 $72.00 $123.00 $131.00 $137.00 $90.00 $96.00 $101.00

29085 0 $59.00 $136.00 $145.00 $151.00 $98.00 $105.00 $111.00

29086 0 $54.00 $107.00 $114.00 $117.00 $72.00 $76.00 $79.00

29105 0 $59.00 $125.00 $133.00 $138.00 $87.00 $92.00 $97.00

29125 0 $45.00 $91.00 $96.00 $100.00 $57.00 $60.00 $63.00

29126 0 $53.00 $107.00 $113.00 $118.00 $70.00 $73.00 $77.00

29130 0 $26.00 $59.00 $62.00 $65.00 $42.00 $44.00 $47.00

29131 0 $53.00 $72.00 $76.00 $80.00 $48.00 $51.00 $54.00

29200 0 $29.00 $42.00 $44.00 $45.00 $26.00 $27.00 $28.00

29240 0 $45.00 $40.00 $42.00 $43.00 $26.00 $27.00 $28.00

29260 0 $26.00 $41.00 $43.00 $45.00 $29.00 $30.00 $31.00

29280 0 $29.00 $41.00 $43.00 $44.00 $28.00 $29.00 $31.00

29305 0 $223.00 $349.00 $373.00 $391.00 $231.00 $247.00 $264.00

29325 0 $260.00 $388.00 $414.00 $434.00 $259.00 $276.00 $295.00

29345 0 $126.00 $195.00 $208.00 $219.00 $148.00 $157.00 $168.00

29355 0 $133.00 $202.00 $215.00 $227.00 $156.00 $166.00 $178.00

29358 0 $241.00 $229.00 $245.00 $257.00 $152.00 $163.00 $174.00

29365 0 $101.00 $175.00 $187.00 $197.00 $128.00 $136.00 $145.00

29405 0 $96.00 $116.00 $124.00 $129.00 $87.00 $92.00 $97.00

29425 0 $101.00 $111.00 $118.00 $122.00 $82.00 $86.00 $91.00

29435 0 $133.00 $168.00 $179.00 $187.00 $122.00 $129.00 $138.00

29440 0 $22.00 $62.00 $65.00 $67.00 $42.00 $43.00 $45.00

29445 0 $214.00 $192.00 $202.00 $211.00 $151.00 $159.00 $167.00

29450 0 $84.00 $207.00 $217.00 $226.00 $165.00 $172.00 $180.00

29505 0 $75.00 $118.00 $125.00 $130.00 $72.00 $76.00 $80.00

29515 0 $59.00 $102.00 $108.00 $112.00 $72.00 $76.00 $80.00

29520 0 $22.00 $44.00 $46.00 $47.00 $27.00 $28.00 $28.00

29530 0 $55.00 $40.00 $42.00 $43.00 $26.00 $27.00 $28.00

29540 0 $41.00 $37.00 $39.00 $40.00 $26.00 $27.00 $29.00

29550 0 $37.00 $27.00 $28.00 $29.00 $17.00 $17.00 $18.00

29580 0 $39.00 $74.00 $78.00 $82.00 $52.00 $54.00 $57.00



Surgery


(Non-Facility MRA)






29581 0 ---------- $86.00 $91.00 $92.00 $19.00 $19.00 $20.00

29582 0 ---------- $97.00 $103.00 $104.00 $23.00 $23.00 $24.00

29583 0 ---------- $61.00 $64.00 $65.00 $16.00 $17.00 $17.00

29584 0 ---------- $97.00 $103.00 $104.00 $23.00 $23.00 $24.00

29700 0 $29.00 $89.00 $95.00 $99.00 $50.00 $52.00 $56.00

29705 0 $26.00 $96.00 $102.00 $108.00 $69.00 $74.00 $79.00

29710 0 $29.00 $175.00 $187.00 $198.00 $123.00 $132.00 $143.00

29720 0 $29.00 $121.00 $129.00 $135.00 $66.00 $70.00 $76.00

29730 0 $29.00 $92.00 $98.00 $103.00 $66.00 $70.00 $75.00

29740 0 $37.00 $144.00 $154.00 $163.00 $104.00 $111.00 $121.00

29750 0 $105.00 $129.00 $135.00 $140.00 $100.00 $104.00 $108.00

29799 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

29800 90 $557.00 $771.00 $823.00 $880.00 $771.00 $823.00 $880.00

29804 90 $902.00 $940.00 $998.00 $1,060.00 $940.00 $998.00 $1,060.00

29805 90 $360.00 $688.00 $734.00 $785.00 $688.00 $734.00 $785.00

29806 90 $1,003.00 $1,561.00 $1,665.00 $1,790.00 $1,561.00 $1,665.00 $1,790.00

29807 90 $976.00 $1,521.00 $1,624.00 $1,745.00 $1,521.00 $1,624.00 $1,745.00

29819 90 $756.00 $856.00 $914.00 $978.00 $856.00 $914.00 $978.00

29820 90 $718.00 $777.00 $826.00 $878.00 $777.00 $826.00 $878.00

29821 90 $863.00 $849.00 $902.00 $958.00 $849.00 $902.00 $958.00

29822 90 $749.00 $824.00 $875.00 $928.00 $824.00 $875.00 $928.00

29823 90 $1,330.00 $899.00 $954.00 $1,012.00 $899.00 $954.00 $1,012.00

29824 90 $611.00 $968.00 $1,028.00 $1,090.00 $968.00 $1,028.00 $1,090.00

29825 90 $941.00 $839.00 $891.00 $945.00 $839.00 $891.00 $945.00

29826 ZZZ $980.00 $263.00 $280.00 $304.00 $263.00 $280.00 $304.00

29827 90 $1,058.00 $1,542.00 $1,635.00 $1,740.00 $1,542.00 $1,635.00 $1,740.00

29828 90 ---------- $1,330.00 $1,413.00 $1,504.00 $1,330.00 $1,413.00 $1,504.00

29830 90 $524.00 $665.00 $709.00 $755.00 $665.00 $709.00 $755.00

29834 90 $635.00 $707.00 $751.00 $797.00 $707.00 $751.00 $797.00

29835 90 $612.00 $728.00 $774.00 $823.00 $728.00 $774.00 $823.00

29836 90 $680.00 $830.00 $880.00 $933.00 $830.00 $880.00 $933.00

29837 90 $830.00 $759.00 $807.00 $857.00 $759.00 $807.00 $857.00

29838 90 $931.00 $856.00 $911.00 $971.00 $856.00 $911.00 $971.00

29840 90 $501.00 $654.00 $696.00 $739.00 $654.00 $696.00 $739.00

29843 90 $580.00 $706.00 $754.00 $806.00 $706.00 $754.00 $806.00

29844 90 $612.00 $719.00 $763.00 $808.00 $719.00 $763.00 $808.00

29845 90 $931.00 $835.00 $887.00 $940.00 $835.00 $887.00 $940.00

29846 90 $976.00 $755.00 $803.00 $852.00 $755.00 $803.00 $852.00

29847 90 $1,277.00 $791.00 $843.00 $901.00 $791.00 $843.00 $901.00

29848 90 $608.00 $742.00 $791.00 $841.00 $742.00 $791.00 $841.00

29850 90 $752.00 $888.00 $947.00 $1,015.00 $888.00 $947.00 $1,015.00

29851 90 $1,137.00 $1,326.00 $1,412.00 $1,516.00 $1,326.00 $1,412.00 $1,516.00

29855 90 $1,007.00 $1,145.00 $1,220.00 $1,307.00 $1,145.00 $1,220.00 $1,307.00

29856 90 $1,231.00 $1,459.00 $1,557.00 $1,674.00 $1,459.00 $1,557.00 $1,674.00

29860 90 $658.00 $966.00 $1,030.00 $1,104.00 $966.00 $1,030.00 $1,104.00

29861 90 $845.00 $1,052.00 $1,119.00 $1,192.00 $1,052.00 $1,119.00 $1,192.00

29862 90 $907.00 $1,174.00 $1,247.00 $1,325.00 $1,174.00 $1,247.00 $1,325.00

29863 90 $880.00 $1,174.00 $1,248.00 $1,327.00 $1,174.00 $1,248.00 $1,327.00

29866 90 ---------- $1,519.00 $1,618.00 $1,733.00 $1,519.00 $1,618.00 $1,733.00

29867 90 ---------- $1,885.00 $2,012.00 $2,166.00 $1,885.00 $2,012.00 $2,166.00



Surgery


(Non-Facility MRA)






29868 90 ---------- $2,432.00 $2,593.00 $2,794.00 $2,432.00 $2,593.00 $2,794.00

29870 90 $460.00 $832.00 $888.00 $934.00 $599.00 $639.00 $682.00

29871 90 $631.00 $752.00 $802.00 $859.00 $752.00 $802.00 $859.00

29873 90 $489.00 $760.00 $811.00 $864.00 $760.00 $811.00 $864.00

29874 90 $676.00 $785.00 $837.00 $894.00 $785.00 $837.00 $894.00

29875 90 $639.00 $722.00 $770.00 $823.00 $722.00 $770.00 $823.00

29876 90 $809.00 $963.00 $1,028.00 $1,102.00 $963.00 $1,028.00 $1,102.00

29877 90 $852.00 $908.00 $968.00 $1,035.00 $908.00 $968.00 $1,035.00

29879 90 $1,064.00 $969.00 $1,033.00 $1,105.00 $969.00 $1,033.00 $1,105.00

29880 90 $1,169.00 $821.00 $875.00 $934.00 $821.00 $875.00 $934.00

29881 90 $745.00 $789.00 $841.00 $898.00 $789.00 $841.00 $898.00

29882 90 $819.00 $1,029.00 $1,098.00 $1,178.00 $1,029.00 $1,098.00 $1,178.00

29883 90 $1,235.00 $1,239.00 $1,322.00 $1,419.00 $1,239.00 $1,322.00 $1,419.00

29884 90 $721.00 $894.00 $950.00 $1,010.00 $894.00 $950.00 $1,010.00

29885 90 $832.00 $1,093.00 $1,165.00 $1,247.00 $1,093.00 $1,165.00 $1,247.00

29886 90 $697.00 $929.00 $992.00 $1,063.00 $929.00 $992.00 $1,063.00

29887 90 $949.00 $1,081.00 $1,151.00 $1,230.00 $1,081.00 $1,151.00 $1,230.00

29888 90 $1,296.00 $1,448.00 $1,543.00 $1,657.00 $1,448.00 $1,543.00 $1,657.00

29889 90 $1,255.00 $1,796.00 $1,916.00 $2,059.00 $1,796.00 $1,916.00 $2,059.00

29891 90 $796.00 $978.00 $1,036.00 $1,099.00 $978.00 $1,036.00 $1,099.00

29892 90 $835.00 $940.00 $988.00 $1,037.00 $940.00 $988.00 $1,037.00

29893 90 $472.00 $869.00 $914.00 $938.00 $613.00 $641.00 $661.00

29894 90 $690.00 $723.00 $765.00 $810.00 $723.00 $765.00 $810.00

29895 90 $679.00 $694.00 $733.00 $774.00 $694.00 $733.00 $774.00

29897 90 $704.00 $733.00 $777.00 $825.00 $733.00 $777.00 $825.00

29898 90 $863.00 $821.00 $868.00 $919.00 $821.00 $868.00 $919.00

29899 90 $973.00 $1,524.00 $1,621.00 $1,736.00 $1,524.00 $1,621.00 $1,736.00

29900 90 $434.00 $600.00 $628.00 $646.00 $600.00 $628.00 $646.00

29901 90 $479.00 $760.00 $806.00 $848.00 $760.00 $806.00 $848.00

29902 90 $514.00 $705.00 $744.00 $784.00 $705.00 $744.00 $784.00

29904 90 ---------- $920.00 $981.00 $1,051.00 $920.00 $981.00 $1,051.00

29905 90 ---------- $993.00 $1,059.00 $1,132.00 $993.00 $1,059.00 $1,132.00

29906 90 ---------- $1,009.00 $1,073.00 $1,142.00 $1,009.00 $1,073.00 $1,142.00

29907 90 ---------- $1,284.00 $1,370.00 $1,470.00 $1,284.00 $1,370.00 $1,470.00

29914 90 ---------- $1,453.00 $1,543.00 $1,645.00 $1,453.00 $1,543.00 $1,645.00

29915 90 ---------- $1,479.00 $1,570.00 $1,672.00 $1,479.00 $1,570.00 $1,672.00

29916 90 ---------- $1,481.00 $1,571.00 $1,673.00 $1,481.00 $1,571.00 $1,673.00

29999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

30000 10 $96.00 $319.00 $339.00 $349.00 $168.00 $178.00 $187.00

30020 10 $117.00 $323.00 $343.00 $354.00 $170.00 $180.00 $189.00

30100 0 $86.00 $196.00 $208.00 $214.00 $99.00 $104.00 $110.00

30110 10 $157.00 $321.00 $341.00 $353.00 $186.00 $197.00 $207.00

30115 90 $360.00 $610.00 $646.00 $675.00 $610.00 $646.00 $675.00

30117 90 $301.00 $1,204.00 $1,283.00 $1,311.00 $480.00 $509.00 $530.00

30118 90 $819.00 $1,099.00 $1,165.00 $1,227.00 $1,099.00 $1,165.00 $1,227.00

30120 90 $500.00 $741.00 $787.00 $824.00 $631.00 $669.00 $705.00

30124 90 $243.00 $405.00 $429.00 $449.00 $405.00 $429.00 $449.00

30125 90 $599.00 $862.00 $913.00 $957.00 $862.00 $913.00 $957.00

30130 90 $275.00 $535.00 $568.00 $590.00 $535.00 $568.00 $590.00

30140 90 $320.00 $616.00 $655.00 $679.00 $616.00 $655.00 $679.00



Surgery


(Non-Facility MRA)






30150 90 $790.00 $1,097.00 $1,164.00 $1,226.00 $1,097.00 $1,164.00 $1,226.00

30160 90 $875.00 $1,103.00 $1,168.00 $1,230.00 $1,103.00 $1,168.00 $1,230.00

30200 0 $68.00 $157.00 $167.00 $172.00 $85.00 $90.00 $95.00

30210 10 $75.00 $209.00 $222.00 $229.00 $141.00 $150.00 $157.00

30220 10 $154.00 $419.00 $445.00 $458.00 $178.00 $189.00 $199.00

30300 10 $45.00 $247.00 $263.00 $270.00 $150.00 $158.00 $165.00

30310 10 $170.00 $291.00 $308.00 $321.00 $291.00 $308.00 $321.00

30320 90 $419.00 $638.00 $676.00 $706.00 $638.00 $676.00 $706.00

30400 90 $741.00 $1,429.00 $1,515.00 $1,584.00 $1,429.00 $1,515.00 $1,584.00

30410 90 $1,173.00 $1,671.00 $1,770.00 $1,855.00 $1,671.00 $1,770.00 $1,855.00

30420 90 $1,424.00 $1,952.00 $2,068.00 $2,174.00 $1,952.00 $2,068.00 $2,174.00

30430 90 $626.00 $1,206.00 $1,279.00 $1,333.00 $1,206.00 $1,279.00 $1,333.00

30435 90 $1,005.00 $1,784.00 $1,897.00 $1,991.00 $1,784.00 $1,897.00 $1,991.00

30450 90 $1,445.00 $2,129.00 $2,252.00 $2,367.00 $2,129.00 $2,252.00 $2,367.00

30460 90 $857.00 $1,170.00 $1,243.00 $1,317.00 $1,170.00 $1,243.00 $1,317.00

30462 90 $1,633.00 $2,025.00 $2,142.00 $2,266.00 $2,025.00 $2,142.00 $2,266.00

30465 90 $803.00 $1,398.00 $1,481.00 $1,558.00 $1,398.00 $1,481.00 $1,558.00

30520 90 $533.00 $882.00 $935.00 $979.00 $882.00 $935.00 $979.00

30540 90 $643.00 $982.00 $1,040.00 $1,090.00 $982.00 $1,040.00 $1,090.00

30545 90 $981.00 $1,265.00 $1,338.00 $1,405.00 $1,265.00 $1,338.00 $1,405.00

30560 10 $104.00 $370.00 $394.00 $404.00 $193.00 $205.00 $214.00

30580 90 $566.00 $933.00 $991.00 $1,040.00 $742.00 $788.00 $835.00

30600 90 $466.00 $807.00 $856.00 $894.00 $616.00 $651.00 $688.00

30620 90 $564.00 $882.00 $936.00 $977.00 $882.00 $936.00 $977.00

30630 90 $624.00 $883.00 $935.00 $980.00 $883.00 $935.00 $980.00

30801 10 $88.00 $316.00 $336.00 $345.00 $191.00 $203.00 $210.00

30802 10 $172.00 $405.00 $430.00 $445.00 $269.00 $285.00 $299.00

30901 0 $75.00 $135.00 $143.00 $150.00 $84.00 $88.00 $95.00

30903 0 $110.00 $308.00 $328.00 $338.00 $119.00 $125.00 $134.00

30905 0 $224.00 $379.00 $403.00 $416.00 $156.00 $165.00 $176.00

30906 0 $208.00 $485.00 $515.00 $532.00 $201.00 $212.00 $226.00

30915 90 $596.00 $820.00 $868.00 $912.00 $820.00 $868.00 $912.00

30920 90 $862.00 $1,196.00 $1,266.00 $1,334.00 $1,196.00 $1,266.00 $1,334.00

30930 10 $213.00 $174.00 $184.00 $192.00 $174.00 $184.00 $192.00

30999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

31000 10 $81.00 $256.00 $272.00 $281.00 $150.00 $159.00 $167.00

31002 10 $135.00 $268.00 $283.00 $294.00 $268.00 $283.00 $294.00

31020 90 $281.00 $676.00 $719.00 $741.00 $506.00 $538.00 $558.00

31030 90 $531.00 $971.00 $1,031.00 $1,073.00 $752.00 $798.00 $837.00

31032 90 $604.00 $816.00 $865.00 $908.00 $816.00 $865.00 $908.00

31040 90 $772.00 $1,090.00 $1,155.00 $1,217.00 $1,090.00 $1,155.00 $1,217.00

31050 90 $489.00 $685.00 $726.00 $759.00 $685.00 $726.00 $759.00

31051 90 $654.00 $914.00 $969.00 $1,014.00 $914.00 $969.00 $1,014.00

31070 90 $410.00 $618.00 $656.00 $684.00 $618.00 $656.00 $684.00

31075 90 $839.00 $1,117.00 $1,183.00 $1,241.00 $1,117.00 $1,183.00 $1,241.00

31080 90 $942.00 $1,494.00 $1,589.00 $1,682.00 $1,494.00 $1,589.00 $1,682.00

31081 90 $1,089.00 $2,182.00 $2,375.00 $2,605.00 $2,182.00 $2,375.00 $2,605.00

31084 90 $1,210.00 $1,701.00 $1,807.00 $1,912.00 $1,701.00 $1,807.00 $1,912.00

31085 90 $1,281.00 $2,334.00 $2,543.00 $2,797.00 $2,334.00 $2,543.00 $2,797.00

31086 90 $1,081.00 $1,617.00 $1,713.00 $1,802.00 $1,617.00 $1,713.00 $1,802.00



Surgery


(Non-Facility MRA)






31087 90 $1,075.00 $1,564.00 $1,659.00 $1,757.00 $1,564.00 $1,659.00 $1,757.00

31090 90 $877.00 $1,450.00 $1,537.00 $1,607.00 $1,450.00 $1,537.00 $1,607.00

31200 90 $463.00 $800.00 $844.00 $867.00 $800.00 $844.00 $867.00

31201 90 $716.00 $1,050.00 $1,113.00 $1,167.00 $1,050.00 $1,113.00 $1,167.00

31205 90 $851.00 $1,268.00 $1,334.00 $1,376.00 $1,268.00 $1,334.00 $1,376.00

31225 90 $1,683.00 $2,700.00 $2,858.00 $3,021.00 $2,700.00 $2,858.00 $3,021.00

31230 90 $1,908.00 $2,976.00 $3,145.00 $3,326.00 $2,976.00 $3,145.00 $3,326.00

31231 0 $122.00 $290.00 $308.00 $316.00 $95.00 $100.00 $106.00

31233 0 $221.00 $367.00 $390.00 $404.00 $199.00 $210.00 $222.00

31235 0 $217.00 $420.00 $445.00 $462.00 $235.00 $248.00 $262.00

31237 0 $266.00 $364.00 $386.00 $403.00 $234.00 $247.00 $263.00

31238 0 $311.00 $365.00 $387.00 $404.00 $246.00 $259.00 $275.00

31239 10 $775.00 $882.00 $927.00 $967.00 $882.00 $927.00 $967.00

31240 0 $224.00 $234.00 $247.00 $263.00 $234.00 $247.00 $263.00

31254 0 $588.00 $399.00 $421.00 $448.00 $399.00 $421.00 $448.00

31255 0 $601.00 $584.00 $617.00 $657.00 $584.00 $617.00 $657.00

31256 0 $292.00 $288.00 $304.00 $323.00 $288.00 $304.00 $323.00

31267 0 $453.00 $463.00 $489.00 $521.00 $463.00 $489.00 $521.00

31276 0 $690.00 $737.00 $778.00 $829.00 $737.00 $778.00 $829.00

31287 0 $339.00 $338.00 $357.00 $380.00 $338.00 $357.00 $380.00

31288 0 $396.00 $393.00 $415.00 $441.00 $393.00 $415.00 $441.00

31290 10 $1,462.00 $1,683.00 $1,781.00 $1,898.00 $1,683.00 $1,781.00 $1,898.00

31291 10 $1,551.00 $1,803.00 $1,915.00 $2,055.00 $1,803.00 $1,915.00 $2,055.00

31292 10 $1,235.00 $1,451.00 $1,533.00 $1,627.00 $1,451.00 $1,533.00 $1,627.00

31293 10 $1,346.00 $1,578.00 $1,668.00 $1,773.00 $1,578.00 $1,668.00 $1,773.00

31294 10 $1,587.00 $1,828.00 $1,934.00 $2,060.00 $1,828.00 $1,934.00 $2,060.00

31295 0 ---------- $2,766.00 $2,952.00 $2,994.00 $239.00 $252.00 $268.00

31296 0 ---------- $2,824.00 $3,013.00 $3,059.00 $286.00 $302.00 $321.00

31297 0 ---------- $2,770.00 $2,956.00 $2,998.00 $234.00 $247.00 $263.00

31299 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

31300 90 $1,295.00 $1,872.00 $1,983.00 $2,082.00 $1,872.00 $1,983.00 $2,082.00

31320 90 $508.00 $800.00 $849.00 $885.00 $800.00 $849.00 $885.00

31360 90 $1,630.00 $3,052.00 $3,229.00 $3,411.00 $3,052.00 $3,229.00 $3,411.00

31365 90 $2,238.00 $3,773.00 $3,990.00 $4,223.00 $3,773.00 $3,990.00 $4,223.00

31367 90 $1,913.00 $3,217.00 $3,402.00 $3,582.00 $3,217.00 $3,402.00 $3,582.00

31368 90 $2,478.00 $3,583.00 $3,791.00 $3,997.00 $3,583.00 $3,791.00 $3,997.00

31370 90 $1,891.00 $3,027.00 $3,205.00 $3,376.00 $3,027.00 $3,205.00 $3,376.00

31375 90 $1,720.00 $2,869.00 $3,037.00 $3,198.00 $2,869.00 $3,037.00 $3,198.00

31380 90 $1,782.00 $2,828.00 $2,993.00 $3,149.00 $2,828.00 $2,993.00 $3,149.00

31382 90 $1,822.00 $3,116.00 $3,299.00 $3,477.00 $3,116.00 $3,299.00 $3,477.00

31390 90 $2,513.00 $4,201.00 $4,441.00 $4,693.00 $4,201.00 $4,441.00 $4,693.00

31395 90 $2,937.00 $4,439.00 $4,696.00 $4,962.00 $4,439.00 $4,696.00 $4,962.00

31400 90 $969.00 $1,409.00 $1,492.00 $1,564.00 $1,409.00 $1,492.00 $1,564.00

31420 90 $969.00 $1,197.00 $1,267.00 $1,337.00 $1,197.00 $1,267.00 $1,337.00

31500 0 $116.00 $209.00 $219.00 $233.00 $209.00 $219.00 $233.00

31502 0 $74.00 $51.00 $54.00 $57.00 $51.00 $54.00 $57.00

31505 0 $62.00 $115.00 $122.00 $126.00 $71.00 $75.00 $78.00

31510 0 $145.00 $299.00 $318.00 $330.00 $178.00 $188.00 $199.00

31511 0 $88.00 $300.00 $318.00 $332.00 $190.00 $201.00 $213.00

31512 0 $197.00 $292.00 $310.00 $323.00 $190.00 $200.00 $212.00



Surgery


(Non-Facility MRA)






31513 0 $182.00 $193.00 $204.00 $217.00 $193.00 $204.00 $217.00

31515 0 $160.00 $256.00 $270.00 $279.00 $151.00 $158.00 $166.00

31525 0 $234.00 $359.00 $381.00 $397.00 $235.00 $248.00 $263.00

31526 0 $222.00 $230.00 $243.00 $258.00 $230.00 $243.00 $258.00

31527 0 $262.00 $286.00 $302.00 $322.00 $286.00 $302.00 $322.00

31528 0 $202.00 $212.00 $224.00 $238.00 $212.00 $224.00 $238.00

31529 0 $217.00 $237.00 $251.00 $267.00 $237.00 $251.00 $267.00

31530 0 $284.00 $291.00 $307.00 $327.00 $291.00 $307.00 $327.00

31531 0 $311.00 $311.00 $328.00 $349.00 $311.00 $328.00 $349.00

31535 0 $272.00 $278.00 $294.00 $313.00 $278.00 $294.00 $313.00

31536 0 $308.00 $310.00 $327.00 $348.00 $310.00 $327.00 $348.00

31540 0 $357.00 $356.00 $376.00 $400.00 $356.00 $376.00 $400.00

31541 0 $453.00 $388.00 $410.00 $436.00 $388.00 $410.00 $436.00

31545 0 ---------- $533.00 $562.00 $598.00 $533.00 $562.00 $598.00

31546 0 ---------- $811.00 $856.00 $912.00 $811.00 $856.00 $912.00

31551 90 ---------- $2,060.00 $2,174.00 $2,294.00 $2,060.00 $2,174.00 $2,294.00

31552 90 ---------- $2,076.00 $2,193.00 $2,309.00 $2,076.00 $2,193.00 $2,309.00

31553 90 ---------- $2,262.00 $2,390.00 $2,515.00 $2,262.00 $2,390.00 $2,515.00

31554 90 ---------- $2,377.00 $2,512.00 $2,638.00 $2,377.00 $2,512.00 $2,638.00

31560 0 $446.00 $460.00 $485.00 $516.00 $460.00 $485.00 $516.00

31561 0 $509.00 $505.00 $533.00 $568.00 $505.00 $533.00 $568.00

31570 0 $369.00 $483.00 $513.00 $538.00 $338.00 $358.00 $382.00

31571 0 $363.00 $368.00 $388.00 $413.00 $368.00 $388.00 $413.00

31572 0 ---------- $695.00 $739.00 $761.00 $265.00 $280.00 $298.00

31573 0 ---------- $374.00 $397.00 $413.00 $219.00 $231.00 $245.00

31574 0 ---------- $1,413.00 $1,506.00 $1,533.00 $219.00 $231.00 $245.00

31575 0 $128.00 $160.00 $170.00 $176.00 $98.00 $103.00 $109.00

31576 0 $186.00 $371.00 $394.00 $407.00 $174.00 $184.00 $194.00

31577 0 $230.00 $385.00 $409.00 $424.00 $197.00 $208.00 $220.00

31578 0 $264.00 $424.00 $450.00 $466.00 $219.00 $231.00 $245.00

31579 0 $219.00 $251.00 $266.00 $278.00 $174.00 $184.00 $195.00

31580 90 $1,213.00 $1,789.00 $1,896.00 $1,988.00 $1,789.00 $1,896.00 $1,988.00

31584 90 $1,616.00 $1,992.00 $2,109.00 $2,216.00 $1,992.00 $2,109.00 $2,216.00

31587 90 $913.00 $1,678.00 $1,779.00 $1,879.00 $1,678.00 $1,779.00 $1,879.00

31590 90 $691.00 $1,241.00 $1,320.00 $1,379.00 $1,241.00 $1,320.00 $1,379.00

31591 90 ---------- $1,499.00 $1,585.00 $1,664.00 $1,499.00 $1,585.00 $1,664.00

31592 90 ---------- $2,440.00 $2,575.00 $2,716.00 $2,440.00 $2,575.00 $2,716.00

31595 90 $773.00 $1,084.00 $1,149.00 $1,204.00 $1,084.00 $1,149.00 $1,204.00

31599 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

31600 0 $306.00 $592.00 $630.00 $684.00 $592.00 $630.00 $684.00

31603 0 $343.00 $332.00 $352.00 $381.00 $332.00 $352.00 $381.00

31605 0 $297.00 $276.00 $293.00 $318.00 $276.00 $293.00 $318.00

31610 90 $794.00 $1,028.00 $1,089.00 $1,150.00 $1,028.00 $1,089.00 $1,150.00

31611 90 $614.00 $766.00 $811.00 $849.00 $766.00 $811.00 $849.00

31612 0 $99.00 $119.00 $126.00 $133.00 $72.00 $76.00 $82.00

31613 90 $384.00 $648.00 $689.00 $723.00 $648.00 $689.00 $723.00

31614 90 $736.00 $1,078.00 $1,143.00 $1,200.00 $1,078.00 $1,143.00 $1,200.00

31615 0 $213.00 $239.00 $253.00 $264.00 $168.00 $177.00 $187.00

31622 0 $230.00 $340.00 $360.00 $372.00 $194.00 $203.00 $214.00

31623 0 $225.00 $380.00 $400.00 $411.00 $196.00 $204.00 $213.00



Surgery


(Non-Facility MRA)






31624 0 $217.00 $356.00 $375.00 $386.00 $199.00 $207.00 $216.00

31625 0 $235.00 $465.00 $491.00 $505.00 $230.00 $239.00 $251.00

31626 0 ---------- $1,166.00 $1,239.00 $1,266.00 $294.00 $308.00 $325.00

31627 ZZZ ---------- $1,913.00 $2,040.00 $2,067.00 $144.00 $150.00 $159.00

31628 0 $269.00 $494.00 $520.00 $534.00 $258.00 $268.00 $279.00

31629 0 $198.00 $608.00 $643.00 $660.00 $275.00 $287.00 $300.00

31630 0 $308.00 $295.00 $310.00 $329.00 $295.00 $310.00 $329.00

31631 0 $252.00 $340.00 $358.00 $383.00 $340.00 $358.00 $383.00

31632 ZZZ ---------- $92.00 $96.00 $100.00 $72.00 $75.00 $78.00

31633 ZZZ ---------- $115.00 $120.00 $125.00 $93.00 $97.00 $101.00

31634 0 ---------- $2,461.00 $2,622.00 $2,663.00 $286.00 $300.00 $318.00

31635 0 $298.00 $397.00 $418.00 $433.00 $258.00 $269.00 $284.00

31636 0 ---------- $325.00 $341.00 $361.00 $325.00 $341.00 $361.00

31637 ZZZ ---------- $109.00 $113.00 $117.00 $109.00 $113.00 $117.00

31638 0 ---------- $371.00 $389.00 $414.00 $371.00 $389.00 $414.00

31640 0 $399.00 $373.00 $391.00 $414.00 $373.00 $391.00 $414.00

31641 0 $304.00 $380.00 $398.00 $420.00 $380.00 $398.00 $420.00

31643 0 $208.00 $259.00 $270.00 $282.00 $259.00 $270.00 $282.00

31645 0 $208.00 $360.00 $378.00 $391.00 $218.00 $228.00 $238.00

31646 0 $161.00 $323.00 $341.00 $351.00 $186.00 $194.00 $203.00

31647 0 ---------- $311.00 $326.00 $345.00 $311.00 $326.00 $345.00

31648 0 ---------- $283.00 $294.00 $307.00 $283.00 $294.00 $307.00

31649 ZZZ ---------- $102.00 $107.00 $112.00 $102.00 $107.00 $112.00

31651 ZZZ ---------- $109.00 $113.00 $119.00 $109.00 $113.00 $119.00

31652 0 ---------- $1,146.00 $1,215.00 $1,240.00 $326.00 $340.00 $356.00

31653 0 ---------- $1,213.00 $1,287.00 $1,314.00 $361.00 $376.00 $395.00

31654 ZZZ ---------- $178.00 $187.00 $194.00 $100.00 $104.00 $109.00

31660 0 ---------- $287.00 $298.00 $310.00 $287.00 $298.00 $310.00

31661 0 ---------- $302.00 $314.00 $327.00 $302.00 $314.00 $327.00

31717 0 $138.00 $363.00 $383.00 $392.00 $158.00 $164.00 $170.00

31720 0 $89.00 $76.00 $80.00 $84.00 $76.00 $80.00 $84.00

31725 0 $103.00 $115.00 $120.00 $126.00 $115.00 $120.00 $126.00

31730 0 $199.00 $1,701.00 $1,816.00 $1,852.00 $224.00 $238.00 $259.00

31750 90 $1,088.00 $2,011.00 $2,136.00 $2,245.00 $2,011.00 $2,136.00 $2,245.00

31755 90 $1,448.00 $2,528.00 $2,681.00 $2,794.00 $2,528.00 $2,681.00 $2,794.00

31760 90 $1,648.00 $2,092.00 $2,247.00 $2,471.00 $2,092.00 $2,247.00 $2,471.00

31766 90 $2,315.00 $2,692.00 $2,890.00 $3,187.00 $2,692.00 $2,890.00 $3,187.00

31770 90 $1,815.00 $2,014.00 $2,163.00 $2,383.00 $2,014.00 $2,163.00 $2,383.00

31775 90 $1,973.00 $1,870.00 $1,948.00 $2,037.00 $1,870.00 $1,948.00 $2,037.00

31780 90 $1,577.00 $1,739.00 $1,848.00 $1,989.00 $1,739.00 $1,848.00 $1,989.00

31781 90 $1,936.00 $2,098.00 $2,253.00 $2,486.00 $2,098.00 $2,253.00 $2,486.00

31785 90 $1,320.00 $1,589.00 $1,682.00 $1,800.00 $1,589.00 $1,682.00 $1,800.00

31786 90 $1,866.00 $2,203.00 $2,329.00 $2,485.00 $2,203.00 $2,329.00 $2,485.00

31800 90 $628.00 $1,050.00 $1,113.00 $1,165.00 $1,050.00 $1,113.00 $1,165.00

31805 90 $1,175.00 $1,225.00 $1,314.00 $1,438.00 $1,225.00 $1,314.00 $1,438.00

31820 90 $458.00 $616.00 $653.00 $683.00 $473.00 $501.00 $530.00

31825 90 $659.00 $856.00 $906.00 $950.00 $693.00 $733.00 $775.00

31830 90 $460.00 $628.00 $667.00 $699.00 $496.00 $526.00 $556.00

31899 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

32035 90 $821.00 $1,077.00 $1,152.00 $1,251.00 $1,077.00 $1,152.00 $1,251.00



Surgery


(Non-Facility MRA)






32036 90 $908.00 $1,153.00 $1,235.00 $1,346.00 $1,153.00 $1,235.00 $1,346.00

32096 90 ---------- $1,212.00 $1,299.00 $1,425.00 $1,212.00 $1,299.00 $1,425.00

32097 90 ---------- $1,208.00 $1,294.00 $1,419.00 $1,208.00 $1,294.00 $1,419.00

32098 90 ---------- $1,145.00 $1,227.00 $1,345.00 $1,145.00 $1,227.00 $1,345.00

32100 90 $1,120.00 $1,218.00 $1,307.00 $1,433.00 $1,218.00 $1,307.00 $1,433.00

32110 90 $1,223.00 $2,200.00 $2,358.00 $2,587.00 $2,200.00 $2,358.00 $2,587.00

32120 90 $1,077.00 $1,306.00 $1,400.00 $1,532.00 $1,306.00 $1,400.00 $1,532.00

32124 90 $1,144.00 $1,391.00 $1,491.00 $1,634.00 $1,391.00 $1,491.00 $1,634.00

32140 90 $1,284.00 $1,482.00 $1,590.00 $1,745.00 $1,482.00 $1,590.00 $1,745.00

32141 90 $1,267.00 $2,298.00 $2,463.00 $2,709.00 $2,298.00 $2,463.00 $2,709.00

32150 90 $1,226.00 $1,508.00 $1,617.00 $1,771.00 $1,508.00 $1,617.00 $1,771.00

32151 90 $1,231.00 $1,503.00 $1,611.00 $1,762.00 $1,503.00 $1,611.00 $1,762.00

32160 90 $842.00 $1,183.00 $1,267.00 $1,383.00 $1,183.00 $1,267.00 $1,383.00

32200 90 $1,132.00 $1,686.00 $1,803.00 $1,964.00 $1,686.00 $1,803.00 $1,964.00

32215 90 $1,024.00 $1,192.00 $1,277.00 $1,393.00 $1,192.00 $1,277.00 $1,393.00

32220 90 $1,680.00 $2,375.00 $2,546.00 $2,788.00 $2,375.00 $2,546.00 $2,788.00

32225 90 $1,268.00 $1,490.00 $1,596.00 $1,748.00 $1,490.00 $1,596.00 $1,748.00

32310 90 $1,221.00 $1,370.00 $1,468.00 $1,605.00 $1,370.00 $1,468.00 $1,605.00

32320 90 $1,787.00 $2,400.00 $2,573.00 $2,822.00 $2,400.00 $2,573.00 $2,822.00

32400 0 $129.00 $213.00 $225.00 $232.00 $128.00 $133.00 $140.00

32405 0 $159.00 $536.00 $570.00 $580.00 $133.00 $139.00 $145.00

32440 90 $1,837.00 $2,355.00 $2,524.00 $2,772.00 $2,355.00 $2,524.00 $2,772.00

32442 90 $2,093.00 $4,661.00 $5,005.00 $5,532.00 $4,661.00 $5,005.00 $5,532.00

32445 90 $2,093.00 $5,366.00 $5,761.00 $6,359.00 $5,366.00 $5,761.00 $6,359.00

32480 90 $1,622.00 $2,226.00 $2,386.00 $2,621.00 $2,226.00 $2,386.00 $2,621.00

32482 90 $1,714.00 $2,379.00 $2,551.00 $2,800.00 $2,379.00 $2,551.00 $2,800.00

32484 90 $1,771.00 $2,164.00 $2,321.00 $2,552.00 $2,164.00 $2,321.00 $2,552.00

32486 90 $1,974.00 $3,557.00 $3,816.00 $4,209.00 $3,557.00 $3,816.00 $4,209.00

32488 90 $2,094.00 $3,626.00 $3,889.00 $4,281.00 $3,626.00 $3,889.00 $4,281.00

32491 90 $1,784.00 $2,215.00 $2,375.00 $2,608.00 $2,215.00 $2,375.00 $2,608.00

32501 ZZZ $374.00 $372.00 $399.00 $441.00 $372.00 $399.00 $441.00

32503 90 ---------- $2,724.00 $2,922.00 $3,214.00 $2,724.00 $2,922.00 $3,214.00

32504 90 ---------- $3,134.00 $3,365.00 $3,709.00 $3,134.00 $3,365.00 $3,709.00

32505 90 ---------- $1,398.00 $1,499.00 $1,643.00 $1,398.00 $1,499.00 $1,643.00

32506 ZZZ ---------- $238.00 $255.00 $282.00 $238.00 $255.00 $282.00

32507 ZZZ ---------- $238.00 $255.00 $282.00 $238.00 $255.00 $282.00

32540 90 $1,308.00 $2,614.00 $2,804.00 $3,082.00 $2,614.00 $2,804.00 $3,082.00

32550 0 ---------- $991.00 $1,055.00 $1,085.00 $310.00 $328.00 $351.00

32551 0 ---------- $236.00 $250.00 $270.00 $236.00 $250.00 $270.00

32552 10 ---------- $266.00 $282.00 $298.00 $233.00 $246.00 $262.00

32553 0 ---------- $727.00 $769.00 $787.00 $266.00 $277.00 $290.00

32554 0 ---------- $283.00 $300.00 $309.00 $132.00 $138.00 $146.00

32555 0 ---------- $404.00 $427.00 $438.00 $165.00 $171.00 $179.00

32556 0 ---------- $765.00 $814.00 $831.00 $182.00 $190.00 $202.00

32557 0 ---------- $710.00 $752.00 $768.00 $225.00 $234.00 $245.00

32560 0 ---------- $341.00 $363.00 $375.00 $117.00 $124.00 $133.00

32561 0 ---------- $133.00 $140.00 $147.00 $101.00 $106.00 $112.00

32562 0 ---------- $120.00 $126.00 $133.00 $91.00 $96.00 $102.00

32601 0 $456.00 $465.00 $498.00 $546.00 $465.00 $498.00 $546.00

32604 0 $663.00 $732.00 $786.00 $868.00 $732.00 $786.00 $868.00



Surgery


(Non-Facility MRA)






32606 0 $637.00 $699.00 $750.00 $826.00 $699.00 $750.00 $826.00

32607 0 ---------- $465.00 $498.00 $547.00 $465.00 $498.00 $547.00

32608 0 ---------- $572.00 $612.00 $673.00 $572.00 $612.00 $673.00

32609 0 ---------- $389.00 $416.00 $456.00 $389.00 $416.00 $456.00

32650 90 $957.00 $995.00 $1,066.00 $1,163.00 $995.00 $1,066.00 $1,163.00

32651 90 $1,166.00 $1,647.00 $1,766.00 $1,938.00 $1,647.00 $1,766.00 $1,938.00

32652 90 $1,615.00 $2,503.00 $2,684.00 $2,950.00 $2,503.00 $2,684.00 $2,950.00

32653 90 $1,144.00 $1,591.00 $1,705.00 $1,870.00 $1,591.00 $1,705.00 $1,870.00

32654 90 $1,096.00 $1,784.00 $1,915.00 $2,108.00 $1,784.00 $1,915.00 $2,108.00

32655 90 $1,213.00 $1,435.00 $1,538.00 $1,685.00 $1,435.00 $1,538.00 $1,685.00

32656 90 $1,222.00 $1,200.00 $1,287.00 $1,407.00 $1,200.00 $1,287.00 $1,407.00

32658 90 $1,142.00 $1,069.00 $1,147.00 $1,256.00 $1,069.00 $1,147.00 $1,256.00

32659 90 $1,141.00 $1,095.00 $1,174.00 $1,284.00 $1,095.00 $1,174.00 $1,284.00

32661 90 $1,165.00 $1,201.00 $1,289.00 $1,415.00 $1,201.00 $1,289.00 $1,415.00

32662 90 $1,459.00 $1,339.00 $1,435.00 $1,572.00 $1,339.00 $1,435.00 $1,572.00

32663 90 $1,636.00 $2,111.00 $2,264.00 $2,488.00 $2,111.00 $2,264.00 $2,488.00

32664 90 $1,197.00 $1,266.00 $1,355.00 $1,481.00 $1,266.00 $1,355.00 $1,481.00

32665 90 $1,360.00 $1,857.00 $1,989.00 $2,181.00 $1,857.00 $1,989.00 $2,181.00

32666 90 ---------- $1,307.00 $1,401.00 $1,535.00 $1,307.00 $1,401.00 $1,535.00

32667 ZZZ ---------- $239.00 $256.00 $283.00 $239.00 $256.00 $283.00

32668 ZZZ ---------- $239.00 $256.00 $283.00 $239.00 $256.00 $283.00

32669 90 ---------- $2,028.00 $2,175.00 $2,391.00 $2,028.00 $2,175.00 $2,391.00

32670 90 ---------- $2,417.00 $2,590.00 $2,847.00 $2,417.00 $2,590.00 $2,847.00

32671 90 ---------- $2,682.00 $2,876.00 $3,164.00 $2,682.00 $2,876.00 $3,164.00

32672 90 ---------- $2,299.00 $2,466.00 $2,713.00 $2,299.00 $2,466.00 $2,713.00

32673 90 ---------- $1,831.00 $1,964.00 $2,157.00 $1,831.00 $1,964.00 $2,157.00

32674 ZZZ ---------- $328.00 $352.00 $390.00 $328.00 $352.00 $390.00

32701 0 ---------- $323.00 $344.00 $376.00 $323.00 $344.00 $376.00

32800 90 $1,166.00 $1,416.00 $1,516.00 $1,655.00 $1,416.00 $1,516.00 $1,655.00

32810 90 $1,085.00 $1,338.00 $1,433.00 $1,567.00 $1,338.00 $1,433.00 $1,567.00

32815 90 $1,917.00 $4,211.00 $4,515.00 $4,968.00 $4,211.00 $4,515.00 $4,968.00

32820 90 $1,848.00 $2,107.00 $2,262.00 $2,475.00 $2,107.00 $2,262.00 $2,475.00

32851 90 $3,100.00 $4,992.00 $5,357.00 $5,907.00 $4,992.00 $5,357.00 $5,907.00

32852 90 $3,339.00 $5,459.00 $5,862.00 $6,475.00 $5,459.00 $5,862.00 $6,475.00

32853 90 $3,787.00 $6,972.00 $7,484.00 $8,267.00 $6,972.00 $7,484.00 $8,267.00

32854 90 $4,038.00 $7,403.00 $7,946.00 $8,778.00 $7,403.00 $7,946.00 $8,778.00

32900 90 $1,532.00 $2,110.00 $2,260.00 $2,471.00 $2,110.00 $2,260.00 $2,471.00

32905 90 $1,661.00 $2,023.00 $2,169.00 $2,381.00 $2,023.00 $2,169.00 $2,381.00

32906 90 $2,100.00 $2,497.00 $2,678.00 $2,944.00 $2,497.00 $2,678.00 $2,944.00

32940 90 $1,555.00 $1,865.00 $2,002.00 $2,202.00 $1,865.00 $2,002.00 $2,202.00

32960 0 $126.00 $183.00 $191.00 $198.00 $136.00 $141.00 $147.00

32997 0 $312.00 $501.00 $519.00 $542.00 $501.00 $519.00 $542.00

32998 0 ---------- $2,662.00 $2,832.00 $2,877.00 $416.00 $433.00 $455.00

32999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

33010 0 $124.00 $162.00 $173.00 $190.00 $162.00 $173.00 $190.00

33011 0 $125.00 $164.00 $176.00 $193.00 $164.00 $176.00 $193.00

33015 90 $555.00 $764.00 $816.00 $887.00 $764.00 $816.00 $887.00

33020 90 $1,178.00 $1,322.00 $1,416.00 $1,551.00 $1,322.00 $1,416.00 $1,551.00

33025 90 $1,165.00 $1,201.00 $1,287.00 $1,412.00 $1,201.00 $1,287.00 $1,412.00

33030 90 $1,786.00 $3,029.00 $3,248.00 $3,576.00 $3,029.00 $3,248.00 $3,576.00



Surgery


(Non-Facility MRA)






33031 90 $1,816.00 $3,736.00 $4,004.00 $4,406.00 $3,736.00 $4,004.00 $4,406.00

33050 90 $1,224.00 $1,499.00 $1,605.00 $1,755.00 $1,499.00 $1,605.00 $1,755.00

33120 90 $2,358.00 $3,177.00 $3,406.00 $3,751.00 $3,177.00 $3,406.00 $3,751.00

33130 90 $1,734.00 $2,086.00 $2,240.00 $2,466.00 $2,086.00 $2,240.00 $2,466.00

33140 90 $1,571.00 $2,388.00 $2,562.00 $2,823.00 $2,388.00 $2,562.00 $2,823.00

33141 ZZZ $254.00 $200.00 $215.00 $237.00 $200.00 $215.00 $237.00

33202 90 ---------- $1,169.00 $1,254.00 $1,378.00 $1,169.00 $1,254.00 $1,378.00

33203 90 ---------- $1,215.00 $1,304.00 $1,434.00 $1,215.00 $1,304.00 $1,434.00

33206 90 $642.00 $675.00 $724.00 $789.00 $675.00 $724.00 $789.00

33207 90 $753.00 $722.00 $774.00 $846.00 $722.00 $774.00 $846.00

33208 90 $573.00 $784.00 $840.00 $919.00 $784.00 $840.00 $919.00

33210 0 $204.00 $251.00 $268.00 $295.00 $251.00 $268.00 $295.00

33211 0 $210.00 $256.00 $275.00 $302.00 $256.00 $275.00 $302.00

33212 90 $511.00 $479.00 $513.00 $559.00 $479.00 $513.00 $559.00

33213 90 $437.00 $501.00 $537.00 $586.00 $501.00 $537.00 $586.00

33214 90 $532.00 $715.00 $766.00 $834.00 $715.00 $766.00 $834.00

33215 90 $304.00 $465.00 $499.00 $544.00 $465.00 $499.00 $544.00

33216 90 $402.00 $553.00 $592.00 $644.00 $553.00 $592.00 $644.00

33217 90 $428.00 $542.00 $581.00 $632.00 $542.00 $581.00 $632.00

33218 90 $488.00 $581.00 $622.00 $677.00 $581.00 $622.00 $677.00

33220 90 $390.00 $581.00 $623.00 $677.00 $581.00 $623.00 $677.00

33221 90 ---------- $539.00 $578.00 $629.00 $539.00 $578.00 $629.00

33222 90 $471.00 $500.00 $536.00 $580.00 $500.00 $536.00 $580.00

33223 90 $585.00 $609.00 $653.00 $712.00 $609.00 $653.00 $712.00

33224 0 $490.00 $781.00 $838.00 $920.00 $781.00 $838.00 $920.00

33225 ZZZ $434.00 $713.00 $765.00 $841.00 $713.00 $765.00 $841.00

33226 0 $472.00 $751.00 $806.00 $885.00 $751.00 $806.00 $885.00

33227 90 ---------- $505.00 $541.00 $590.00 $505.00 $541.00 $590.00

33228 90 ---------- $528.00 $566.00 $617.00 $528.00 $566.00 $617.00

33229 90 ---------- $560.00 $600.00 $654.00 $560.00 $600.00 $654.00

33230 90 ---------- $573.00 $615.00 $671.00 $573.00 $615.00 $671.00

33231 90 ---------- $603.00 $646.00 $704.00 $603.00 $646.00 $704.00

33233 90 $270.00 $340.00 $364.00 $394.00 $340.00 $364.00 $394.00

33234 90 $598.00 $726.00 $779.00 $849.00 $726.00 $779.00 $849.00

33235 90 $587.00 $954.00 $1,023.00 $1,115.00 $954.00 $1,023.00 $1,115.00

33236 90 $933.00 $1,176.00 $1,262.00 $1,381.00 $1,176.00 $1,262.00 $1,381.00

33237 90 $1,184.00 $1,257.00 $1,348.00 $1,476.00 $1,257.00 $1,348.00 $1,476.00

33238 90 $1,235.00 $1,398.00 $1,496.00 $1,632.00 $1,398.00 $1,496.00 $1,632.00

33240 90 $648.00 $547.00 $586.00 $640.00 $547.00 $586.00 $640.00

33241 90 $301.00 $319.00 $342.00 $371.00 $319.00 $342.00 $371.00

33243 90 $1,650.00 $2,062.00 $2,210.00 $2,423.00 $2,062.00 $2,210.00 $2,423.00

33244 90 $1,081.00 $1,290.00 $1,384.00 $1,512.00 $1,290.00 $1,384.00 $1,512.00

33249 90 $1,271.00 $1,377.00 $1,476.00 $1,613.00 $1,377.00 $1,476.00 $1,613.00

33250 90 $1,687.00 $2,187.00 $2,338.00 $2,558.00 $2,187.00 $2,338.00 $2,558.00

33251 90 $2,071.00 $2,457.00 $2,637.00 $2,906.00 $2,457.00 $2,637.00 $2,906.00

33254 90 ---------- $2,061.00 $2,212.00 $2,433.00 $2,061.00 $2,212.00 $2,433.00

33255 90 ---------- $2,485.00 $2,668.00 $2,938.00 $2,485.00 $2,668.00 $2,938.00

33256 90 ---------- $2,938.00 $3,149.00 $3,463.00 $2,938.00 $3,149.00 $3,463.00

33257 ZZZ ---------- $873.00 $935.00 $1,022.00 $873.00 $935.00 $1,022.00

33258 ZZZ ---------- $982.00 $1,052.00 $1,149.00 $982.00 $1,052.00 $1,149.00



Surgery


(Non-Facility MRA)






33259 ZZZ ---------- $1,268.00 $1,359.00 $1,486.00 $1,268.00 $1,359.00 $1,486.00

33261 90 $1,993.00 $2,456.00 $2,636.00 $2,906.00 $2,456.00 $2,636.00 $2,906.00

33262 90 ---------- $558.00 $598.00 $652.00 $558.00 $598.00 $652.00

33263 90 ---------- $581.00 $623.00 $680.00 $581.00 $623.00 $680.00

33264 90 ---------- $606.00 $650.00 $709.00 $606.00 $650.00 $709.00

33265 90 ---------- $2,046.00 $2,192.00 $2,403.00 $2,046.00 $2,192.00 $2,403.00

33266 90 ---------- $2,790.00 $2,991.00 $3,290.00 $2,790.00 $2,991.00 $3,290.00

33270 90 ---------- $884.00 $948.00 $1,033.00 $884.00 $948.00 $1,033.00

33271 90 ---------- $736.00 $788.00 $855.00 $736.00 $788.00 $855.00

33272 90 ---------- $521.00 $558.00 $608.00 $521.00 $558.00 $608.00

33273 90 ---------- $609.00 $651.00 $707.00 $609.00 $651.00 $707.00

33282 90 $470.00 $335.00 $359.00 $389.00 $335.00 $359.00 $389.00

33284 90 $365.00 $294.00 $315.00 $341.00 $294.00 $315.00 $341.00

33300 90 $1,576.00 $3,711.00 $3,978.00 $4,383.00 $3,711.00 $3,978.00 $4,383.00

33305 90 $1,889.00 $6,225.00 $6,675.00 $7,368.00 $6,225.00 $6,675.00 $7,368.00

33310 90 $1,577.00 $1,769.00 $1,889.00 $2,058.00 $1,769.00 $1,889.00 $2,058.00

33315 90 $1,875.00 $2,894.00 $3,100.00 $3,411.00 $2,894.00 $3,100.00 $3,411.00

33320 90 $1,485.00 $1,601.00 $1,715.00 $1,882.00 $1,601.00 $1,715.00 $1,882.00

33321 90 $1,890.00 $1,792.00 $1,918.00 $2,100.00 $1,792.00 $1,918.00 $2,100.00

33322 90 $1,935.00 $2,093.00 $2,242.00 $2,460.00 $2,093.00 $2,242.00 $2,460.00

33330 90 $1,726.00 $2,157.00 $2,313.00 $2,541.00 $2,157.00 $2,313.00 $2,541.00

33335 90 $2,336.00 $2,834.00 $3,036.00 $3,336.00 $2,834.00 $3,036.00 $3,336.00

33361 0 ---------- $2,068.00 $2,219.00 $2,448.00 $2,068.00 $2,219.00 $2,448.00

33362 0 ---------- $2,258.00 $2,422.00 $2,673.00 $2,258.00 $2,422.00 $2,673.00

33363 0 ---------- $2,373.00 $2,546.00 $2,806.00 $2,373.00 $2,546.00 $2,806.00

33364 0 ---------- $2,464.00 $2,644.00 $2,917.00 $2,464.00 $2,644.00 $2,917.00

33365 0 ---------- $2,711.00 $2,908.00 $3,210.00 $2,711.00 $2,908.00 $3,210.00

33366 0 ---------- $2,934.00 $3,148.00 $3,477.00 $2,934.00 $3,148.00 $3,477.00

33367 ZZZ ---------- $953.00 $1,022.00 $1,130.00 $953.00 $1,022.00 $1,130.00

33368 ZZZ ---------- $1,140.00 $1,223.00 $1,354.00 $1,140.00 $1,223.00 $1,354.00

33369 ZZZ ---------- $1,508.00 $1,619.00 $1,795.00 $1,508.00 $1,619.00 $1,795.00

33404 90 $2,698.00 $2,648.00 $2,835.00 $3,109.00 $2,648.00 $2,835.00 $3,109.00

33405 90 $2,745.00 $3,432.00 $3,678.00 $4,046.00 $3,432.00 $3,678.00 $4,046.00

33406 90 $2,962.00 $4,358.00 $4,671.00 $5,144.00 $4,358.00 $4,671.00 $5,144.00

33410 90 $2,637.00 $3,848.00 $4,123.00 $4,536.00 $3,848.00 $4,123.00 $4,536.00

33411 90 $2,981.00 $5,084.00 $5,447.00 $5,998.00 $5,084.00 $5,447.00 $5,998.00

33412 90 $3,213.00 $4,814.00 $5,163.00 $5,698.00 $4,814.00 $5,163.00 $5,698.00

33413 90 $3,282.00 $4,816.00 $5,073.00 $5,401.00 $4,816.00 $5,073.00 $5,401.00

33414 90 $2,904.00 $3,277.00 $3,519.00 $3,887.00 $3,277.00 $3,519.00 $3,887.00

33415 90 $2,563.00 $3,072.00 $3,287.00 $3,608.00 $3,072.00 $3,287.00 $3,608.00

33416 90 $2,684.00 $3,069.00 $3,289.00 $3,616.00 $3,069.00 $3,289.00 $3,616.00

33417 90 $2,756.00 $2,531.00 $2,717.00 $2,993.00 $2,531.00 $2,717.00 $2,993.00

33418 90 ---------- $2,724.00 $2,916.00 $3,196.00 $2,724.00 $2,916.00 $3,196.00

33419 ZZZ ---------- $646.00 $692.00 $761.00 $646.00 $692.00 $761.00

33420 90 $1,796.00 $2,210.00 $2,372.00 $2,612.00 $2,210.00 $2,372.00 $2,612.00

33422 90 $2,431.00 $2,526.00 $2,709.00 $2,981.00 $2,526.00 $2,709.00 $2,981.00

33425 90 $2,509.00 $4,132.00 $4,426.00 $4,868.00 $4,132.00 $4,426.00 $4,868.00

33426 90 $2,806.00 $3,602.00 $3,860.00 $4,245.00 $3,602.00 $3,860.00 $4,245.00

33427 90 $3,026.00 $3,702.00 $3,966.00 $4,364.00 $3,702.00 $3,966.00 $4,364.00

33430 90 $2,891.00 $4,232.00 $4,535.00 $4,990.00 $4,232.00 $4,535.00 $4,990.00



Surgery


(Non-Facility MRA)






33460 90 $2,215.00 $3,681.00 $3,948.00 $4,355.00 $3,681.00 $3,948.00 $4,355.00

33463 90 $2,396.00 $4,680.00 $5,013.00 $5,518.00 $4,680.00 $5,013.00 $5,518.00

33464 90 $2,547.00 $3,693.00 $3,956.00 $4,349.00 $3,693.00 $3,956.00 $4,349.00

33465 90 $2,665.00 $4,178.00 $4,477.00 $4,931.00 $4,178.00 $4,477.00 $4,931.00

33468 90 $2,952.00 $3,738.00 $4,014.00 $4,436.00 $3,738.00 $4,014.00 $4,436.00

33470 90 $1,749.00 $1,956.00 $2,100.00 $2,303.00 $1,956.00 $2,100.00 $2,303.00

33471 90 $1,929.00 $2,090.00 $2,244.00 $2,460.00 $2,090.00 $2,244.00 $2,460.00

33474 90 $2,173.00 $3,315.00 $3,560.00 $3,929.00 $3,315.00 $3,560.00 $3,929.00

33475 90 $2,666.00 $3,529.00 $3,783.00 $4,164.00 $3,529.00 $3,783.00 $4,164.00

33476 90 $2,270.00 $2,308.00 $2,477.00 $2,727.00 $2,308.00 $2,477.00 $2,727.00

33477 0 ---------- $1,960.00 $2,076.00 $2,240.00 $1,960.00 $2,076.00 $2,240.00

33478 90 $2,544.00 $2,385.00 $2,561.00 $2,819.00 $2,385.00 $2,561.00 $2,819.00

33496 90 $2,595.00 $2,530.00 $2,712.00 $2,983.00 $2,530.00 $2,712.00 $2,983.00

33500 90 $2,370.00 $2,362.00 $2,531.00 $2,781.00 $2,362.00 $2,531.00 $2,781.00

33501 90 $1,546.00 $1,683.00 $1,806.00 $1,989.00 $1,683.00 $1,806.00 $1,989.00

33502 90 $1,938.00 $1,932.00 $2,074.00 $2,280.00 $1,932.00 $2,074.00 $2,280.00

33503 90 $1,983.00 $2,006.00 $2,153.00 $2,365.00 $2,006.00 $2,153.00 $2,365.00

33504 90 $2,416.00 $2,222.00 $2,386.00 $2,625.00 $2,222.00 $2,386.00 $2,625.00

33505 90 $2,423.00 $3,150.00 $3,383.00 $3,741.00 $3,150.00 $3,383.00 $3,741.00

33506 90 $2,448.00 $3,133.00 $3,364.00 $3,718.00 $3,133.00 $3,364.00 $3,718.00

33507 90 ---------- $2,626.00 $2,820.00 $3,114.00 $2,626.00 $2,820.00 $3,114.00

33508 ZZZ $17.00 $25.00 $26.00 $29.00 $25.00 $26.00 $29.00

33510 90 $2,354.00 $2,921.00 $3,129.00 $3,440.00 $2,921.00 $3,129.00 $3,440.00

33511 90 $2,546.00 $3,211.00 $3,440.00 $3,783.00 $3,211.00 $3,440.00 $3,783.00

33512 90 $2,732.00 $3,651.00 $3,912.00 $4,304.00 $3,651.00 $3,912.00 $4,304.00

33513 90 $2,933.00 $3,760.00 $4,029.00 $4,433.00 $3,760.00 $4,029.00 $4,433.00

33514 90 $3,197.00 $3,972.00 $4,256.00 $4,685.00 $3,972.00 $4,256.00 $4,685.00

33516 90 $3,404.00 $4,165.00 $4,472.00 $4,938.00 $4,165.00 $4,472.00 $4,938.00

33517 ZZZ $219.00 $285.00 $306.00 $338.00 $285.00 $306.00 $338.00

33518 ZZZ $414.00 $627.00 $672.00 $742.00 $627.00 $672.00 $742.00

33519 ZZZ $607.00 $829.00 $888.00 $981.00 $829.00 $888.00 $981.00

33521 ZZZ $801.00 $994.00 $1,066.00 $1,178.00 $994.00 $1,066.00 $1,178.00

33522 ZZZ $994.00 $1,116.00 $1,195.00 $1,320.00 $1,116.00 $1,195.00 $1,320.00

33523 ZZZ $1,189.00 $1,264.00 $1,354.00 $1,494.00 $1,264.00 $1,354.00 $1,494.00

33530 ZZZ $521.00 $801.00 $858.00 $949.00 $801.00 $858.00 $949.00

33533 90 $2,415.00 $2,824.00 $3,026.00 $3,326.00 $2,824.00 $3,026.00 $3,326.00

33534 90 $2,654.00 $3,325.00 $3,563.00 $3,919.00 $3,325.00 $3,563.00 $3,919.00

33535 90 $2,899.00 $3,713.00 $3,979.00 $4,379.00 $3,713.00 $3,979.00 $4,379.00

33536 90 $3,143.00 $4,002.00 $4,288.00 $4,717.00 $4,002.00 $4,288.00 $4,717.00

33542 90 $2,693.00 $3,973.00 $4,256.00 $4,684.00 $3,973.00 $4,256.00 $4,684.00

33545 90 $3,250.00 $4,696.00 $5,035.00 $5,552.00 $4,696.00 $5,035.00 $5,552.00

33548 90 ---------- $4,489.00 $4,811.00 $5,295.00 $4,489.00 $4,811.00 $5,295.00

33572 ZZZ $340.00 $350.00 $375.00 $414.00 $350.00 $375.00 $414.00

33600 90 $2,644.00 $2,609.00 $2,801.00 $3,085.00 $2,609.00 $2,801.00 $3,085.00

33602 90 $2,556.00 $2,532.00 $2,718.00 $2,993.00 $2,532.00 $2,718.00 $2,993.00

33606 90 $2,831.00 $2,701.00 $2,900.00 $3,195.00 $2,701.00 $2,900.00 $3,195.00

33608 90 $2,940.00 $2,733.00 $2,935.00 $3,233.00 $2,733.00 $2,935.00 $3,233.00

33610 90 $2,871.00 $2,696.00 $2,895.00 $3,190.00 $2,696.00 $2,895.00 $3,190.00

33611 90 $2,985.00 $2,974.00 $3,194.00 $3,526.00 $2,974.00 $3,194.00 $3,526.00

33612 90 $3,152.00 $3,054.00 $3,279.00 $3,621.00 $3,054.00 $3,279.00 $3,621.00



Surgery


(Non-Facility MRA)






33615 90 $3,051.00 $3,037.00 $3,261.00 $3,598.00 $3,037.00 $3,261.00 $3,598.00

33617 90 $3,272.00 $3,292.00 $3,535.00 $3,901.00 $3,292.00 $3,535.00 $3,901.00

33619 90 $3,678.00 $4,145.00 $4,451.00 $4,908.00 $4,145.00 $4,451.00 $4,908.00

33620 90 ---------- $2,515.00 $2,701.00 $2,982.00 $2,515.00 $2,701.00 $2,982.00

33621 90 ---------- $1,412.00 $1,515.00 $1,667.00 $1,412.00 $1,515.00 $1,667.00

33622 90 ---------- $5,530.00 $5,936.00 $6,537.00 $5,530.00 $5,936.00 $6,537.00

33641 90 $1,981.00 $2,496.00 $2,680.00 $2,958.00 $2,496.00 $2,680.00 $2,958.00

33645 90 $2,352.00 $2,635.00 $2,830.00 $3,123.00 $2,635.00 $2,830.00 $3,123.00

33647 90 $2,732.00 $2,769.00 $2,973.00 $3,282.00 $2,769.00 $2,973.00 $3,282.00

33660 90 $2,444.00 $2,675.00 $2,872.00 $3,170.00 $2,675.00 $2,872.00 $3,170.00

33665 90 $2,700.00 $2,989.00 $3,209.00 $3,535.00 $2,989.00 $3,209.00 $3,535.00

33670 90 $2,820.00 $3,013.00 $3,236.00 $3,578.00 $3,013.00 $3,236.00 $3,578.00

33675 90 ---------- $3,006.00 $3,228.00 $3,564.00 $3,006.00 $3,228.00 $3,564.00

33676 90 ---------- $3,242.00 $3,481.00 $3,828.00 $3,242.00 $3,481.00 $3,828.00

33677 90 ---------- $3,369.00 $3,617.00 $3,978.00 $3,369.00 $3,617.00 $3,978.00

33681 90 $2,657.00 $2,791.00 $2,997.00 $3,300.00 $2,791.00 $2,997.00 $3,300.00

33684 90 $2,740.00 $2,879.00 $3,091.00 $3,413.00 $2,879.00 $3,091.00 $3,413.00

33688 90 $2,602.00 $3,026.00 $3,248.00 $3,575.00 $3,026.00 $3,248.00 $3,575.00

33690 90 $1,884.00 $1,815.00 $1,948.00 $2,140.00 $1,815.00 $1,948.00 $2,140.00

33692 90 $2,816.00 $3,144.00 $3,376.00 $3,715.00 $3,144.00 $3,376.00 $3,715.00

33694 90 $2,856.00 $2,974.00 $3,194.00 $3,526.00 $2,974.00 $3,194.00 $3,526.00

33697 90 $3,064.00 $3,134.00 $3,365.00 $3,716.00 $3,134.00 $3,365.00 $3,716.00

33702 90 $2,549.00 $2,347.00 $2,520.00 $2,775.00 $2,347.00 $2,520.00 $2,775.00

33710 90 $2,731.00 $3,128.00 $3,358.00 $3,709.00 $3,128.00 $3,358.00 $3,709.00

33720 90 $2,508.00 $2,348.00 $2,521.00 $2,777.00 $2,348.00 $2,521.00 $2,777.00

33722 90 $2,704.00 $2,473.00 $2,655.00 $2,929.00 $2,473.00 $2,655.00 $2,929.00

33724 90 ---------- $2,342.00 $2,515.00 $2,774.00 $2,342.00 $2,515.00 $2,774.00

33726 90 ---------- $3,100.00 $3,329.00 $3,676.00 $3,100.00 $3,329.00 $3,676.00

33730 90 $2,785.00 $3,052.00 $3,277.00 $3,615.00 $3,052.00 $3,277.00 $3,615.00

33732 90 $2,622.00 $2,501.00 $2,685.00 $2,957.00 $2,501.00 $2,685.00 $2,957.00

33735 90 $2,036.00 $1,962.00 $2,106.00 $2,315.00 $1,962.00 $2,106.00 $2,315.00

33736 90 $2,288.00 $2,131.00 $2,288.00 $2,516.00 $2,131.00 $2,288.00 $2,516.00

33737 90 $1,977.00 $1,967.00 $2,111.00 $2,322.00 $1,967.00 $2,111.00 $2,322.00

33750 90 $1,877.00 $2,001.00 $2,148.00 $2,357.00 $2,001.00 $2,148.00 $2,357.00

33755 90 $1,831.00 $2,074.00 $2,226.00 $2,440.00 $2,074.00 $2,226.00 $2,440.00

33762 90 $1,900.00 $2,033.00 $2,182.00 $2,395.00 $2,033.00 $2,182.00 $2,395.00

33764 90 $1,895.00 $1,994.00 $2,140.00 $2,353.00 $1,994.00 $2,140.00 $2,353.00

33766 90 $2,119.00 $2,116.00 $2,271.00 $2,493.00 $2,116.00 $2,271.00 $2,493.00

33767 90 $2,173.00 $2,162.00 $2,321.00 $2,559.00 $2,162.00 $2,321.00 $2,559.00

33768 ZZZ ---------- $677.00 $727.00 $802.00 $677.00 $727.00 $802.00

33770 90 $2,954.00 $3,401.00 $3,651.00 $4,018.00 $3,401.00 $3,651.00 $4,018.00

33771 90 $2,924.00 $3,509.00 $3,768.00 $4,149.00 $3,509.00 $3,768.00 $4,149.00

33774 90 $2,681.00 $2,732.00 $2,933.00 $3,231.00 $2,732.00 $2,933.00 $3,231.00

33775 90 $2,654.00 $2,948.00 $3,164.00 $3,475.00 $2,948.00 $3,164.00 $3,475.00

33776 90 $2,844.00 $3,114.00 $3,342.00 $3,670.00 $3,114.00 $3,342.00 $3,670.00

33777 90 $2,724.00 $2,879.00 $3,091.00 $3,411.00 $2,879.00 $3,091.00 $3,411.00

33778 90 $3,199.00 $3,579.00 $3,843.00 $4,243.00 $3,579.00 $3,843.00 $4,243.00

33779 90 $3,121.00 $3,742.00 $4,018.00 $4,423.00 $3,742.00 $4,018.00 $4,423.00

33780 90 $3,232.00 $3,808.00 $4,089.00 $4,501.00 $3,808.00 $4,089.00 $4,501.00

33781 90 $3,057.00 $3,726.00 $4,000.00 $4,406.00 $3,726.00 $4,000.00 $4,406.00



Surgery


(Non-Facility MRA)






33782 90 ---------- $4,932.00 $5,296.00 $5,857.00 $4,932.00 $5,296.00 $5,857.00

33783 90 ---------- $5,330.00 $5,723.00 $6,331.00 $5,330.00 $5,723.00 $6,331.00

33786 90 $2,970.00 $3,652.00 $3,920.00 $4,313.00 $3,652.00 $3,920.00 $4,313.00

33788 90 $2,288.00 $2,441.00 $2,620.00 $2,878.00 $2,441.00 $2,620.00 $2,878.00

33800 90 $1,546.00 $1,499.00 $1,609.00 $1,772.00 $1,499.00 $1,609.00 $1,772.00

33802 90 $1,752.00 $1,640.00 $1,760.00 $1,933.00 $1,640.00 $1,760.00 $1,933.00

33803 90 $1,746.00 $1,746.00 $1,875.00 $2,065.00 $1,746.00 $1,875.00 $2,065.00

33813 90 $1,935.00 $1,955.00 $2,098.00 $2,300.00 $1,955.00 $2,098.00 $2,300.00

33814 90 $2,464.00 $2,310.00 $2,480.00 $2,729.00 $2,310.00 $2,480.00 $2,729.00

33820 90 $1,619.00 $1,468.00 $1,576.00 $1,733.00 $1,468.00 $1,576.00 $1,733.00

33822 90 $1,559.00 $1,615.00 $1,733.00 $1,900.00 $1,615.00 $1,733.00 $1,900.00

33824 90 $1,884.00 $1,786.00 $1,917.00 $2,107.00 $1,786.00 $1,917.00 $2,107.00

33840 90 $2,029.00 $1,953.00 $2,096.00 $2,297.00 $1,953.00 $2,096.00 $2,297.00

33845 90 $2,129.00 $2,020.00 $2,168.00 $2,384.00 $2,020.00 $2,168.00 $2,384.00

33851 90 $2,129.00 $2,008.00 $2,155.00 $2,363.00 $2,008.00 $2,155.00 $2,363.00

33852 90 $2,311.00 $2,122.00 $2,278.00 $2,508.00 $2,122.00 $2,278.00 $2,508.00

33853 90 $3,057.00 $2,785.00 $2,990.00 $3,295.00 $2,785.00 $2,990.00 $3,295.00

33860 90 $3,044.00 $4,870.00 $5,219.00 $5,750.00 $4,870.00 $5,219.00 $5,750.00

33863 90 $3,183.00 $4,781.00 $5,124.00 $5,649.00 $4,781.00 $5,124.00 $5,649.00

33864 90 ---------- $4,898.00 $5,250.00 $5,787.00 $4,898.00 $5,250.00 $5,787.00

33870 90 $3,638.00 $3,828.00 $4,104.00 $4,521.00 $3,828.00 $4,104.00 $4,521.00

33875 90 $2,876.00 $4,159.00 $4,459.00 $4,918.00 $4,159.00 $4,459.00 $4,918.00

33877 90 $3,767.00 $5,538.00 $5,942.00 $6,571.00 $5,538.00 $5,942.00 $6,571.00

33880 90 ---------- $2,746.00 $2,941.00 $3,245.00 $2,746.00 $2,941.00 $3,245.00

33881 90 ---------- $2,358.00 $2,526.00 $2,787.00 $2,358.00 $2,526.00 $2,787.00

33883 90 ---------- $1,708.00 $1,829.00 $2,014.00 $1,708.00 $1,829.00 $2,014.00

33884 ZZZ ---------- $632.00 $677.00 $748.00 $632.00 $677.00 $748.00

33886 90 ---------- $1,471.00 $1,576.00 $1,737.00 $1,471.00 $1,576.00 $1,737.00

33889 0 ---------- $1,208.00 $1,294.00 $1,433.00 $1,208.00 $1,294.00 $1,433.00

33891 0 ---------- $1,507.00 $1,618.00 $1,799.00 $1,507.00 $1,618.00 $1,799.00

33910 90 $1,987.00 $3,993.00 $4,280.00 $4,712.00 $3,993.00 $4,280.00 $4,712.00

33915 90 $1,588.00 $1,937.00 $2,076.00 $2,298.00 $1,937.00 $2,076.00 $2,298.00

33916 90 $2,096.00 $6,383.00 $6,852.00 $7,573.00 $6,383.00 $6,852.00 $7,573.00

33917 90 $2,345.00 $2,210.00 $2,372.00 $2,610.00 $2,210.00 $2,372.00 $2,610.00

33920 90 $2,981.00 $2,890.00 $3,103.00 $3,410.00 $2,890.00 $3,103.00 $3,410.00

33922 90 $2,227.00 $2,107.00 $2,262.00 $2,489.00 $2,107.00 $2,262.00 $2,489.00

33924 ZZZ $421.00 $438.00 $471.00 $522.00 $438.00 $471.00 $522.00

33925 90 ---------- $2,618.00 $2,812.00 $3,105.00 $2,618.00 $2,812.00 $3,105.00

33926 90 ---------- $3,885.00 $4,171.00 $4,591.00 $3,885.00 $4,171.00 $4,591.00

33935 90 $5,415.00 $7,553.00 $8,108.00 $8,959.00 $7,553.00 $8,108.00 $8,959.00

33945 90 $3,813.00 $7,374.00 $7,909.00 $8,723.00 $7,374.00 $7,909.00 $8,723.00

33946 0 ---------- $467.00 $497.00 $544.00 $467.00 $497.00 $544.00

33947 0 ---------- $519.00 $554.00 $608.00 $519.00 $554.00 $608.00

33948 0 ---------- $358.00 $379.00 $409.00 $358.00 $379.00 $409.00

33949 0 ---------- $352.00 $374.00 $406.00 $352.00 $374.00 $406.00

33951 0 ---------- $638.00 $671.00 $715.00 $638.00 $671.00 $715.00

33952 0 ---------- $651.00 $698.00 $770.00 $651.00 $698.00 $770.00

33953 0 ---------- $712.00 $750.00 $799.00 $712.00 $750.00 $799.00

33954 0 ---------- $728.00 $781.00 $863.00 $728.00 $781.00 $863.00

33955 0 ---------- $1,248.00 $1,314.00 $1,401.00 $1,248.00 $1,314.00 $1,401.00



Surgery


(Non-Facility MRA)






33956 0 ---------- $1,269.00 $1,359.00 $1,498.00 $1,269.00 $1,359.00 $1,498.00

33957 0 ---------- $278.00 $293.00 $312.00 $278.00 $293.00 $312.00

33958 0 ---------- $272.00 $288.00 $309.00 $272.00 $288.00 $309.00

33959 0 ---------- $352.00 $371.00 $395.00 $352.00 $371.00 $395.00

33962 0 ---------- $359.00 $385.00 $425.00 $359.00 $385.00 $425.00

33963 0 ---------- $704.00 $741.00 $791.00 $704.00 $741.00 $791.00

33964 0 ---------- $722.00 $759.00 $811.00 $722.00 $759.00 $811.00

33965 0 ---------- $278.00 $293.00 $312.00 $278.00 $293.00 $312.00

33966 0 ---------- $362.00 $389.00 $430.00 $362.00 $389.00 $430.00

33967 0 $258.00 $395.00 $423.00 $467.00 $395.00 $423.00 $467.00

33968 0 $51.00 $51.00 $54.00 $60.00 $51.00 $54.00 $60.00

33969 0 ---------- $421.00 $452.00 $501.00 $421.00 $452.00 $501.00

33970 0 $576.00 $541.00 $580.00 $640.00 $541.00 $580.00 $640.00

33971 90 $578.00 $1,068.00 $1,144.00 $1,251.00 $1,068.00 $1,144.00 $1,251.00

33973 0 $756.00 $784.00 $841.00 $928.00 $784.00 $841.00 $928.00

33974 90 $1,095.00 $1,344.00 $1,439.00 $1,573.00 $1,344.00 $1,439.00 $1,573.00

33975 0 $1,758.00 $1,998.00 $2,144.00 $2,372.00 $1,998.00 $2,144.00 $2,372.00

33976 0 $2,056.00 $2,439.00 $2,619.00 $2,903.00 $2,439.00 $2,619.00 $2,903.00

33977 0 $1,561.00 $1,713.00 $1,837.00 $2,024.00 $1,713.00 $1,837.00 $2,024.00

33978 0 $1,754.00 $2,034.00 $2,184.00 $2,416.00 $2,034.00 $2,184.00 $2,416.00

33979 0 $2,496.00 $2,980.00 $3,196.00 $3,536.00 $2,980.00 $3,196.00 $3,536.00

33980 0 $3,212.00 $2,717.00 $2,914.00 $3,218.00 $2,717.00 $2,914.00 $3,218.00

33981 0 ---------- $1,264.00 $1,353.00 $1,493.00 $1,264.00 $1,353.00 $1,493.00

33982 0 ---------- $2,988.00 $3,202.00 $3,536.00 $2,988.00 $3,202.00 $3,536.00

33983 0 ---------- $3,536.00 $3,792.00 $4,194.00 $3,536.00 $3,792.00 $4,194.00

33984 0 ---------- $437.00 $469.00 $519.00 $437.00 $469.00 $519.00

33985 0 ---------- $790.00 $848.00 $939.00 $790.00 $848.00 $939.00

33986 0 ---------- $798.00 $857.00 $949.00 $798.00 $857.00 $949.00

33987 ZZZ ---------- $321.00 $345.00 $382.00 $321.00 $345.00 $382.00

33988 0 ---------- $1,197.00 $1,285.00 $1,422.00 $1,197.00 $1,285.00 $1,422.00

33989 0 ---------- $759.00 $815.00 $903.00 $759.00 $815.00 $903.00

33990 0 ---------- $648.00 $695.00 $767.00 $648.00 $695.00 $767.00

33991 0 ---------- $949.00 $1,017.00 $1,121.00 $949.00 $1,017.00 $1,121.00

33992 0 ---------- $305.00 $327.00 $361.00 $305.00 $327.00 $361.00

33993 0 ---------- $266.00 $285.00 $314.00 $266.00 $285.00 $314.00

33999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

34001 90 $1,012.00 $1,478.00 $1,583.00 $1,742.00 $1,478.00 $1,583.00 $1,742.00

34051 90 $1,134.00 $1,360.00 $1,459.00 $1,613.00 $1,360.00 $1,459.00 $1,613.00

34101 90 $800.00 $915.00 $981.00 $1,081.00 $915.00 $981.00 $1,081.00

34111 90 $669.00 $914.00 $980.00 $1,079.00 $914.00 $980.00 $1,079.00

34151 90 $1,288.00 $2,147.00 $2,302.00 $2,540.00 $2,147.00 $2,302.00 $2,540.00

34201 90 $777.00 $1,579.00 $1,694.00 $1,871.00 $1,579.00 $1,694.00 $1,871.00

34203 90 $949.00 $1,461.00 $1,567.00 $1,729.00 $1,461.00 $1,567.00 $1,729.00

34401 90 $953.00 $2,217.00 $2,371.00 $2,598.00 $2,217.00 $2,371.00 $2,598.00

34421 90 $779.00 $1,107.00 $1,186.00 $1,305.00 $1,107.00 $1,186.00 $1,305.00

34451 90 $1,117.00 $2,483.00 $2,665.00 $2,931.00 $2,483.00 $2,665.00 $2,931.00

34471 90 $685.00 $1,666.00 $1,783.00 $1,964.00 $1,666.00 $1,783.00 $1,964.00

34490 90 $660.00 $928.00 $995.00 $1,096.00 $928.00 $995.00 $1,096.00

34501 90 $910.00 $1,363.00 $1,455.00 $1,590.00 $1,363.00 $1,455.00 $1,590.00

34502 90 $2,044.00 $2,333.00 $2,494.00 $2,731.00 $2,333.00 $2,494.00 $2,731.00



Surgery


(Non-Facility MRA)






34510 90 $1,108.00 $1,811.00 $1,945.00 $2,137.00 $1,811.00 $1,945.00 $2,137.00

34520 90 $1,077.00 $1,602.00 $1,714.00 $1,880.00 $1,602.00 $1,714.00 $1,880.00

34530 90 $1,368.00 $1,456.00 $1,562.00 $1,726.00 $1,456.00 $1,562.00 $1,726.00

34800 90 $1,159.00 $1,728.00 $1,851.00 $2,040.00 $1,728.00 $1,851.00 $2,040.00

34802 90 $1,279.00 $1,907.00 $2,042.00 $2,249.00 $1,907.00 $2,042.00 $2,249.00

34803 90 ---------- $1,979.00 $2,120.00 $2,338.00 $1,979.00 $2,120.00 $2,338.00

34804 90 $1,279.00 $1,911.00 $2,048.00 $2,258.00 $1,911.00 $2,048.00 $2,258.00

34805 90 ---------- $1,828.00 $1,960.00 $2,166.00 $1,828.00 $1,960.00 $2,166.00

34806 ZZZ ---------- $154.00 $165.00 $184.00 $154.00 $165.00 $184.00

34808 ZZZ $220.00 $320.00 $343.00 $381.00 $320.00 $343.00 $381.00

34812 0 $359.00 $519.00 $557.00 $618.00 $519.00 $557.00 $618.00

34813 ZZZ $256.00 $364.00 $390.00 $433.00 $364.00 $390.00 $433.00

34820 0 $519.00 $753.00 $807.00 $895.00 $753.00 $807.00 $895.00

34825 90 $694.00 $1,060.00 $1,134.00 $1,244.00 $1,060.00 $1,134.00 $1,244.00

34826 ZZZ $220.00 $316.00 $338.00 $374.00 $316.00 $338.00 $374.00

34830 90 $1,803.00 $2,769.00 $2,973.00 $3,299.00 $2,769.00 $2,973.00 $3,299.00

34831 90 $1,950.00 $2,932.00 $3,146.00 $3,491.00 $2,932.00 $3,146.00 $3,491.00

34832 90 $1,950.00 $2,907.00 $3,114.00 $3,447.00 $2,907.00 $3,114.00 $3,447.00

34833 0 $650.00 $934.00 $1,002.00 $1,109.00 $934.00 $1,002.00 $1,109.00

34834 0 $306.00 $418.00 $448.00 $496.00 $418.00 $448.00 $496.00

34900 90 $960.00 $1,364.00 $1,461.00 $1,607.00 $1,364.00 $1,461.00 $1,607.00

35001 90 $1,564.00 $1,706.00 $1,828.00 $2,015.00 $1,706.00 $1,828.00 $2,015.00

35002 90 $1,547.00 $1,751.00 $1,873.00 $2,062.00 $1,751.00 $1,873.00 $2,062.00

35005 90 $1,268.00 $1,714.00 $1,843.00 $2,031.00 $1,714.00 $1,843.00 $2,031.00

35011 90 $1,007.00 $1,539.00 $1,651.00 $1,822.00 $1,539.00 $1,651.00 $1,822.00

35013 90 $1,376.00 $1,917.00 $2,056.00 $2,266.00 $1,917.00 $2,056.00 $2,266.00

35021 90 $1,635.00 $1,882.00 $2,018.00 $2,219.00 $1,882.00 $2,018.00 $2,219.00

35022 90 $1,686.00 $2,167.00 $2,318.00 $2,540.00 $2,167.00 $2,318.00 $2,540.00

35045 90 $995.00 $1,506.00 $1,614.00 $1,773.00 $1,506.00 $1,614.00 $1,773.00

35081 90 $2,175.00 $2,676.00 $2,871.00 $3,174.00 $2,676.00 $2,871.00 $3,174.00

35082 90 $2,661.00 $3,369.00 $3,614.00 $3,997.00 $3,369.00 $3,614.00 $3,997.00

35091 90 $2,634.00 $2,757.00 $2,957.00 $3,277.00 $2,757.00 $2,957.00 $3,277.00

35092 90 $2,872.00 $4,003.00 $4,294.00 $4,753.00 $4,003.00 $4,294.00 $4,753.00

35102 90 $2,346.00 $2,894.00 $3,103.00 $3,431.00 $2,894.00 $3,103.00 $3,431.00

35103 90 $2,587.00 $3,457.00 $3,708.00 $4,104.00 $3,457.00 $3,708.00 $4,104.00

35111 90 $1,398.00 $2,040.00 $2,189.00 $2,427.00 $2,040.00 $2,189.00 $2,427.00

35112 90 $1,351.00 $2,876.00 $3,090.00 $3,403.00 $2,876.00 $3,090.00 $3,403.00

35121 90 $2,000.00 $2,533.00 $2,716.00 $3,001.00 $2,533.00 $2,716.00 $3,001.00

35122 90 $2,382.00 $3,294.00 $3,539.00 $3,900.00 $3,294.00 $3,539.00 $3,900.00

35131 90 $1,495.00 $2,131.00 $2,285.00 $2,524.00 $2,131.00 $2,285.00 $2,524.00

35132 90 $1,742.00 $2,512.00 $2,691.00 $2,977.00 $2,512.00 $2,691.00 $2,977.00

35141 90 $1,231.00 $1,695.00 $1,818.00 $2,007.00 $1,695.00 $1,818.00 $2,007.00

35142 90 $1,339.00 $2,029.00 $2,176.00 $2,403.00 $2,029.00 $2,176.00 $2,403.00

35151 90 $1,390.00 $1,904.00 $2,042.00 $2,256.00 $1,904.00 $2,042.00 $2,256.00

35152 90 $1,229.00 $2,138.00 $2,292.00 $2,537.00 $2,138.00 $2,292.00 $2,537.00

35180 90 $997.00 $1,424.00 $1,516.00 $1,630.00 $1,424.00 $1,516.00 $1,630.00

35182 90 $1,345.00 $2,713.00 $2,913.00 $3,210.00 $2,713.00 $2,913.00 $3,210.00

35184 90 $976.00 $1,703.00 $1,829.00 $2,009.00 $1,703.00 $1,829.00 $2,009.00

35188 90 $1,048.00 $1,611.00 $1,724.00 $1,882.00 $1,611.00 $1,724.00 $1,882.00

35189 90 $1,380.00 $2,430.00 $2,602.00 $2,865.00 $2,430.00 $2,602.00 $2,865.00



Surgery


(Non-Facility MRA)






35190 90 $1,018.00 $1,158.00 $1,242.00 $1,365.00 $1,158.00 $1,242.00 $1,365.00

35201 90 $852.00 $1,436.00 $1,538.00 $1,688.00 $1,436.00 $1,538.00 $1,688.00

35206 90 $835.00 $1,183.00 $1,267.00 $1,391.00 $1,183.00 $1,267.00 $1,391.00

35207 90 $935.00 $1,109.00 $1,179.00 $1,259.00 $1,109.00 $1,179.00 $1,259.00

35211 90 $1,833.00 $2,081.00 $2,227.00 $2,441.00 $2,081.00 $2,227.00 $2,441.00

35216 90 $1,494.00 $3,101.00 $3,323.00 $3,651.00 $3,101.00 $3,323.00 $3,651.00

35221 90 $1,243.00 $2,224.00 $2,385.00 $2,627.00 $2,224.00 $2,385.00 $2,627.00

35226 90 $841.00 $1,273.00 $1,364.00 $1,503.00 $1,273.00 $1,364.00 $1,503.00

35231 90 $1,053.00 $1,850.00 $1,968.00 $2,123.00 $1,850.00 $1,968.00 $2,123.00

35236 90 $947.00 $1,500.00 $1,607.00 $1,767.00 $1,500.00 $1,607.00 $1,767.00

35241 90 $1,926.00 $2,063.00 $2,185.00 $2,354.00 $2,063.00 $2,185.00 $2,354.00

35246 90 $1,701.00 $2,388.00 $2,562.00 $2,822.00 $2,388.00 $2,562.00 $2,822.00

35251 90 $1,260.00 $2,618.00 $2,809.00 $3,103.00 $2,618.00 $2,809.00 $3,103.00

35256 90 $1,568.00 $1,558.00 $1,671.00 $1,842.00 $1,558.00 $1,671.00 $1,842.00

35261 90 $1,008.00 $1,621.00 $1,739.00 $1,914.00 $1,621.00 $1,739.00 $1,914.00

35266 90 $921.00 $1,324.00 $1,420.00 $1,564.00 $1,324.00 $1,420.00 $1,564.00

35271 90 $1,814.00 $2,097.00 $2,249.00 $2,471.00 $2,097.00 $2,249.00 $2,471.00

35276 90 $1,541.00 $2,217.00 $2,377.00 $2,614.00 $2,217.00 $2,377.00 $2,614.00

35281 90 $1,396.00 $2,467.00 $2,645.00 $2,915.00 $2,467.00 $2,645.00 $2,915.00

35286 90 $1,036.00 $1,426.00 $1,529.00 $1,685.00 $1,426.00 $1,529.00 $1,685.00

35301 90 $1,486.00 $1,735.00 $1,861.00 $2,055.00 $1,735.00 $1,861.00 $2,055.00

35302 90 ---------- $1,724.00 $1,849.00 $2,042.00 $1,724.00 $1,849.00 $2,042.00

35303 90 ---------- $1,903.00 $2,041.00 $2,254.00 $1,903.00 $2,041.00 $2,254.00

35304 90 ---------- $1,975.00 $2,118.00 $2,340.00 $1,975.00 $2,118.00 $2,340.00

35305 90 ---------- $1,889.00 $2,025.00 $2,237.00 $1,889.00 $2,025.00 $2,237.00

35306 ZZZ ---------- $687.00 $736.00 $818.00 $687.00 $736.00 $818.00

35311 90 $1,999.00 $2,371.00 $2,541.00 $2,795.00 $2,371.00 $2,541.00 $2,795.00

35321 90 $1,031.00 $1,363.00 $1,462.00 $1,614.00 $1,363.00 $1,462.00 $1,614.00

35331 90 $1,724.00 $2,225.00 $2,385.00 $2,633.00 $2,225.00 $2,385.00 $2,633.00

35341 90 $1,908.00 $2,103.00 $2,255.00 $2,493.00 $2,103.00 $2,255.00 $2,493.00

35351 90 $1,555.00 $1,963.00 $2,105.00 $2,327.00 $1,963.00 $2,105.00 $2,327.00

35355 90 $1,336.00 $1,587.00 $1,702.00 $1,881.00 $1,587.00 $1,702.00 $1,881.00

35361 90 $1,859.00 $2,344.00 $2,514.00 $2,785.00 $2,344.00 $2,514.00 $2,785.00

35363 90 $2,006.00 $2,701.00 $2,899.00 $3,199.00 $2,701.00 $2,899.00 $3,199.00

35371 90 $1,006.00 $1,254.00 $1,345.00 $1,483.00 $1,254.00 $1,345.00 $1,483.00

35372 90 $1,085.00 $1,504.00 $1,613.00 $1,780.00 $1,504.00 $1,613.00 $1,780.00

35390 ZZZ $225.00 $246.00 $263.00 $292.00 $246.00 $263.00 $292.00

35400 ZZZ $224.00 $230.00 $246.00 $274.00 $230.00 $246.00 $274.00

35500 ZZZ $423.00 $492.00 $528.00 $585.00 $492.00 $528.00 $585.00

35501 90 $1,569.00 $2,301.00 $2,467.00 $2,726.00 $2,301.00 $2,467.00 $2,726.00

35506 90 $1,641.00 $1,963.00 $2,106.00 $2,333.00 $1,963.00 $2,106.00 $2,333.00

35508 90 $1,564.00 $2,056.00 $2,206.00 $2,443.00 $2,056.00 $2,206.00 $2,443.00

35509 90 $1,529.00 $2,174.00 $2,332.00 $2,586.00 $2,174.00 $2,332.00 $2,586.00

35510 90 ---------- $1,888.00 $2,024.00 $2,242.00 $1,888.00 $2,024.00 $2,242.00

35511 90 $1,256.00 $1,864.00 $2,002.00 $2,210.00 $1,864.00 $2,002.00 $2,210.00

35512 90 ---------- $2,092.00 $2,243.00 $2,462.00 $2,092.00 $2,243.00 $2,462.00

35515 90 $1,387.00 $2,162.00 $2,278.00 $2,422.00 $2,162.00 $2,278.00 $2,422.00

35516 90 $1,391.00 $1,876.00 $2,012.00 $2,232.00 $1,876.00 $2,012.00 $2,232.00

35518 90 $1,313.00 $1,784.00 $1,914.00 $2,120.00 $1,784.00 $1,914.00 $2,120.00

35521 90 $1,393.00 $1,884.00 $2,022.00 $2,240.00 $1,884.00 $2,022.00 $2,240.00



Surgery


(Non-Facility MRA)






35522 90 ---------- $1,856.00 $1,991.00 $2,199.00 $1,856.00 $1,991.00 $2,199.00

35523 90 ---------- $1,960.00 $2,101.00 $2,316.00 $1,960.00 $2,101.00 $2,316.00

35525 90 ---------- $1,760.00 $1,887.00 $2,082.00 $1,760.00 $1,887.00 $2,082.00

35526 90 $1,527.00 $2,585.00 $2,776.00 $3,068.00 $2,585.00 $2,776.00 $3,068.00

35531 90 $2,000.00 $3,114.00 $3,339.00 $3,692.00 $3,114.00 $3,339.00 $3,692.00

35533 90 $1,716.00 $2,304.00 $2,469.00 $2,734.00 $2,304.00 $2,469.00 $2,734.00

35535 90 ---------- $2,951.00 $3,167.00 $3,514.00 $2,951.00 $3,167.00 $3,514.00

35536 90 $1,888.00 $2,616.00 $2,781.00 $3,026.00 $2,616.00 $2,781.00 $3,026.00

35537 90 ---------- $3,621.00 $3,881.00 $4,260.00 $3,621.00 $3,881.00 $4,260.00

35538 90 ---------- $3,623.00 $3,888.00 $4,315.00 $3,623.00 $3,888.00 $4,315.00

35539 90 ---------- $3,436.00 $3,693.00 $4,107.00 $3,436.00 $3,693.00 $4,107.00

35540 90 ---------- $3,930.00 $4,212.00 $4,650.00 $3,930.00 $4,212.00 $4,650.00

35556 90 $1,745.00 $2,150.00 $2,305.00 $2,546.00 $2,150.00 $2,305.00 $2,546.00

35558 90 $1,219.00 $1,887.00 $2,021.00 $2,226.00 $1,887.00 $2,021.00 $2,226.00

35560 90 $1,899.00 $2,631.00 $2,823.00 $3,131.00 $2,631.00 $2,823.00 $3,131.00

35563 90 $1,115.00 $2,279.00 $2,441.00 $2,673.00 $2,279.00 $2,441.00 $2,673.00

35565 90 $1,312.00 $2,042.00 $2,190.00 $2,417.00 $2,042.00 $2,190.00 $2,417.00

35566 90 $2,161.00 $2,568.00 $2,754.00 $3,045.00 $2,568.00 $2,754.00 $3,045.00

35570 90 ---------- $2,319.00 $2,485.00 $2,744.00 $2,319.00 $2,485.00 $2,744.00

35571 90 $1,612.00 $2,039.00 $2,187.00 $2,417.00 $2,039.00 $2,187.00 $2,417.00

35572 ZZZ $369.00 $532.00 $571.00 $633.00 $532.00 $571.00 $633.00

35583 90 $1,843.00 $2,224.00 $2,385.00 $2,635.00 $2,224.00 $2,385.00 $2,635.00

35585 90 $2,277.00 $2,579.00 $2,767.00 $3,059.00 $2,579.00 $2,767.00 $3,059.00

35587 90 $1,698.00 $2,103.00 $2,256.00 $2,492.00 $2,103.00 $2,256.00 $2,492.00

35600 ZZZ $273.00 $389.00 $416.00 $459.00 $389.00 $416.00 $459.00

35601 90 $1,495.00 $2,152.00 $2,307.00 $2,549.00 $2,152.00 $2,307.00 $2,549.00

35606 90 $1,539.00 $1,803.00 $1,933.00 $2,135.00 $1,803.00 $1,933.00 $2,135.00

35612 90 $1,349.00 $1,634.00 $1,754.00 $1,940.00 $1,634.00 $1,754.00 $1,940.00

35616 90 $1,346.00 $1,702.00 $1,826.00 $2,024.00 $1,702.00 $1,826.00 $2,024.00

35621 90 $1,265.00 $1,688.00 $1,811.00 $2,001.00 $1,688.00 $1,811.00 $2,001.00

35623 90 $1,193.00 $2,032.00 $2,179.00 $2,410.00 $2,032.00 $2,179.00 $2,410.00

35626 90 $1,921.00 $2,406.00 $2,580.00 $2,845.00 $2,406.00 $2,580.00 $2,845.00

35631 90 $1,891.00 $2,850.00 $3,058.00 $3,385.00 $2,850.00 $3,058.00 $3,385.00

35632 90 ---------- $2,781.00 $2,985.00 $3,312.00 $2,781.00 $2,985.00 $3,312.00

35633 90 ---------- $3,084.00 $3,308.00 $3,662.00 $3,084.00 $3,308.00 $3,662.00

35634 90 ---------- $2,767.00 $2,965.00 $3,276.00 $2,767.00 $2,965.00 $3,276.00

35636 90 $1,656.00 $2,498.00 $2,681.00 $2,971.00 $2,498.00 $2,681.00 $2,971.00

35637 90 ---------- $2,664.00 $2,857.00 $3,156.00 $2,664.00 $2,857.00 $3,156.00

35638 90 ---------- $2,708.00 $2,905.00 $3,210.00 $2,708.00 $2,905.00 $3,210.00

35642 90 $1,298.00 $1,671.00 $1,794.00 $1,972.00 $1,671.00 $1,794.00 $1,972.00

35645 90 $1,304.00 $1,592.00 $1,709.00 $1,882.00 $1,592.00 $1,709.00 $1,882.00

35646 90 $2,105.00 $2,637.00 $2,828.00 $3,125.00 $2,637.00 $2,828.00 $3,125.00

35647 90 $1,555.00 $2,387.00 $2,560.00 $2,827.00 $2,387.00 $2,560.00 $2,827.00

35650 90 $1,236.00 $1,667.00 $1,787.00 $1,970.00 $1,667.00 $1,787.00 $1,970.00

35654 90 $1,603.00 $2,106.00 $2,259.00 $2,496.00 $2,106.00 $2,259.00 $2,496.00

35656 90 $1,589.00 $1,663.00 $1,784.00 $1,968.00 $1,663.00 $1,784.00 $1,968.00

35661 90 $1,145.00 $1,666.00 $1,786.00 $1,970.00 $1,666.00 $1,786.00 $1,970.00

35663 90 $1,237.00 $1,918.00 $2,055.00 $2,267.00 $1,918.00 $2,055.00 $2,267.00

35665 90 $1,333.00 $1,799.00 $1,929.00 $2,128.00 $1,799.00 $1,929.00 $2,128.00

35666 90 $1,686.00 $1,939.00 $2,079.00 $2,293.00 $1,939.00 $2,079.00 $2,293.00



Surgery


(Non-Facility MRA)






35671 90 $1,315.00 $1,709.00 $1,832.00 $2,019.00 $1,709.00 $1,832.00 $2,019.00

35681 ZZZ $751.00 $124.00 $133.00 $148.00 $124.00 $133.00 $148.00

35682 ZZZ $627.00 $545.00 $585.00 $649.00 $545.00 $585.00 $649.00

35683 ZZZ $702.00 $631.00 $676.00 $750.00 $631.00 $676.00 $750.00

35685 ZZZ $216.00 $307.00 $329.00 $365.00 $307.00 $329.00 $365.00

35686 ZZZ $178.00 $247.00 $265.00 $295.00 $247.00 $265.00 $295.00

35691 90 $1,546.00 $1,440.00 $1,542.00 $1,700.00 $1,440.00 $1,542.00 $1,700.00

35693 90 $1,140.00 $1,273.00 $1,360.00 $1,490.00 $1,273.00 $1,360.00 $1,490.00

35694 90 $1,353.00 $1,519.00 $1,630.00 $1,805.00 $1,519.00 $1,630.00 $1,805.00

35695 90 $1,351.00 $1,601.00 $1,718.00 $1,902.00 $1,601.00 $1,718.00 $1,902.00

35697 ZZZ ---------- $228.00 $244.00 $271.00 $228.00 $244.00 $271.00

35700 ZZZ $264.00 $235.00 $252.00 $280.00 $235.00 $252.00 $280.00

35701 90 $494.00 $844.00 $898.00 $967.00 $844.00 $898.00 $967.00

35721 90 $500.00 $694.00 $744.00 $814.00 $694.00 $744.00 $814.00

35741 90 $499.00 $776.00 $830.00 $907.00 $776.00 $830.00 $907.00

35761 90 $532.00 $585.00 $625.00 $676.00 $585.00 $625.00 $676.00

35800 90 $567.00 $1,074.00 $1,146.00 $1,243.00 $1,074.00 $1,146.00 $1,243.00

35820 90 $951.00 $3,050.00 $3,269.00 $3,598.00 $3,050.00 $3,269.00 $3,598.00

35840 90 $771.00 $1,801.00 $1,931.00 $2,118.00 $1,801.00 $1,931.00 $2,118.00

35860 90 $496.00 $1,281.00 $1,373.00 $1,511.00 $1,281.00 $1,373.00 $1,511.00

35870 90 $1,583.00 $1,913.00 $2,051.00 $2,271.00 $1,913.00 $2,051.00 $2,271.00

35875 90 $827.00 $910.00 $976.00 $1,075.00 $910.00 $976.00 $1,075.00

35876 90 $1,232.00 $1,451.00 $1,555.00 $1,715.00 $1,451.00 $1,555.00 $1,715.00

35879 90 $1,163.00 $1,413.00 $1,515.00 $1,670.00 $1,413.00 $1,515.00 $1,670.00

35881 90 $1,275.00 $1,564.00 $1,676.00 $1,849.00 $1,564.00 $1,676.00 $1,849.00

35883 90 ---------- $1,855.00 $1,990.00 $2,199.00 $1,855.00 $1,990.00 $2,199.00

35884 90 ---------- $1,907.00 $2,046.00 $2,270.00 $1,907.00 $2,046.00 $2,270.00

35901 90 $709.00 $751.00 $805.00 $880.00 $751.00 $805.00 $880.00

35903 90 $818.00 $855.00 $917.00 $1,004.00 $855.00 $917.00 $1,004.00

35905 90 $1,343.00 $2,712.00 $2,908.00 $3,209.00 $2,712.00 $2,908.00 $3,209.00

35907 90 $1,335.00 $2,941.00 $3,155.00 $3,494.00 $2,941.00 $3,155.00 $3,494.00

36000 0 $46.00 $36.00 $38.00 $39.00 $14.00 $14.00 $15.00

36002 0 $181.00 $231.00 $244.00 $256.00 $158.00 $167.00 $178.00

36005 0 $68.00 $444.00 $474.00 $484.00 $72.00 $76.00 $82.00

36010 0 $136.00 $670.00 $714.00 $734.00 $165.00 $175.00 $189.00

36011 0 $194.00 $1,143.00 $1,218.00 $1,246.00 $235.00 $248.00 $267.00

36012 0 $186.00 $1,179.00 $1,256.00 $1,285.00 $260.00 $274.00 $294.00

36013 0 $141.00 $1,060.00 $1,129.00 $1,150.00 $184.00 $193.00 $206.00

36014 0 $159.00 $1,101.00 $1,172.00 $1,198.00 $225.00 $237.00 $254.00

36015 0 $186.00 $1,188.00 $1,263.00 $1,289.00 $254.00 $266.00 $282.00

36100 0 $176.00 $671.00 $717.00 $747.00 $234.00 $250.00 $276.00

36120 0 $120.00 $584.00 $623.00 $642.00 $153.00 $163.00 $178.00

36140 0 $106.00 $587.00 $626.00 $645.00 $137.00 $146.00 $160.00

36160 0 $196.00 $680.00 $723.00 $739.00 $184.00 $193.00 $204.00

36200 0 $240.00 $783.00 $836.00 $865.00 $214.00 $229.00 $252.00

36215 0 $240.00 $1,553.00 $1,654.00 $1,693.00 $350.00 $370.00 $397.00

36216 0 $270.00 $1,612.00 $1,719.00 $1,771.00 $410.00 $436.00 $475.00

36217 0 $325.00 $2,625.00 $2,801.00 $2,870.00 $488.00 $519.00 $566.00

36218 ZZZ $79.00 $259.00 $276.00 $285.00 $78.00 $83.00 $90.00

36221 0 ---------- $1,427.00 $1,523.00 $1,566.00 $306.00 $327.00 $358.00



Surgery


(Non-Facility MRA)






36222 0 ---------- $1,674.00 $1,790.00 $1,849.00 $429.00 $459.00 $506.00

36223 0 ---------- $2,050.00 $2,190.00 $2,257.00 $473.00 $507.00 $557.00

36224 0 ---------- $2,607.00 $2,788.00 $2,871.00 $539.00 $580.00 $641.00

36225 0 ---------- $1,974.00 $2,111.00 $2,178.00 $472.00 $506.00 $559.00

36226 0 ---------- $2,473.00 $2,644.00 $2,723.00 $531.00 $570.00 $629.00

36227 ZZZ ---------- $360.00 $386.00 $407.00 $177.00 $190.00 $209.00

36228 ZZZ ---------- $1,770.00 $1,893.00 $1,949.00 $362.00 $389.00 $430.00

36245 0 $249.00 $1,798.00 $1,917.00 $1,964.00 $361.00 $382.00 $414.00

36246 0 $272.00 $1,151.00 $1,228.00 $1,274.00 $388.00 $413.00 $452.00

36247 0 $323.00 $2,072.00 $2,210.00 $2,269.00 $460.00 $487.00 $529.00

36248 ZZZ $53.00 $212.00 $225.00 $231.00 $73.00 $76.00 $81.00

36251 0 ---------- $1,899.00 $2,027.00 $2,080.00 $401.00 $427.00 $465.00

36252 0 ---------- $2,068.00 $2,210.00 $2,285.00 $550.00 $589.00 $647.00

36253 0 ---------- $3,032.00 $3,227.00 $3,288.00 $539.00 $565.00 $599.00

36254 0 ---------- $2,964.00 $3,168.00 $3,261.00 $643.00 $688.00 $757.00

36260 90 $749.00 $956.00 $1,026.00 $1,122.00 $956.00 $1,026.00 $1,122.00

36261 90 $388.00 $490.00 $526.00 $580.00 $490.00 $526.00 $580.00

36262 90 $297.00 $442.00 $474.00 $511.00 $442.00 $474.00 $511.00

36299 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

36410 0 $18.00 $24.00 $25.00 $26.00 $14.00 $14.00 $15.00

36415 0 BR ---------- ---------- ---------- ---------- ---------- ----------

36416 0 BR ---------- ---------- ---------- ---------- ---------- ----------

36425 0 $86.00 $59.00 $62.00 $66.00 $59.00 $62.00 $66.00

36430 0 $37.00 $48.00 $52.00 $53.00 $48.00 $52.00 $53.00

36455 0 $141.00 $193.00 $205.00 $225.00 $193.00 $205.00 $225.00


36470 10 $76.00 $208.00 $221.00 $230.00 $122.00 $129.00 $138.00

36471 10 $96.00 $248.00 $264.00 $277.00 $149.00 $158.00 $170.00

36475 0 ---------- $2,101.00 $2,244.00 $2,304.00 $424.00 $453.00 $496.00

36476 ZZZ ---------- $420.00 $448.00 $473.00 $207.00 $222.00 $244.00

36478 0 ---------- $1,669.00 $1,781.00 $1,835.00 $421.00 $448.00 $489.00

36479 ZZZ ---------- $439.00 $468.00 $491.00 $207.00 $221.00 $242.00

36481 0 $499.00 $2,699.00 $2,872.00 $2,923.00 $498.00 $520.00 $549.00

36500 0 $159.00 $274.00 $290.00 $313.00 $274.00 $290.00 $313.00

36511 0 $92.00 $136.00 $141.00 $146.00 $136.00 $141.00 $146.00

36512 0 $92.00 $137.00 $142.00 $147.00 $137.00 $142.00 $147.00

36513 0 $92.00 $143.00 $151.00 $161.00 $143.00 $151.00 $161.00

36514 0 $92.00 $744.00 $791.00 $805.00 $136.00 $142.00 $149.00

36515 0 $92.00 $2,843.00 $3,033.00 $3,070.00 $131.00 $137.00 $145.00

36516 0 $92.00 $2,870.00 $3,066.00 $3,106.00 $105.00 $113.00 $125.00

36522 0 $305.00 $1,940.00 $2,068.00 $2,092.00 $148.00 $154.00 $159.00

36556 0 ---------- $330.00 $349.00 $362.00 $178.00 $187.00 $198.00

36558 10 ---------- $999.00 $1,062.00 $1,094.00 $389.00 $409.00 $435.00

36561 10 ---------- $1,517.00 $1,617.00 $1,668.00 $505.00 $536.00 $576.00

36563 10 ---------- $1,718.00 $1,837.00 $1,904.00 $553.00 $593.00 $647.00

36565 10 ---------- $1,247.00 $1,333.00 $1,391.00 $503.00 $538.00 $588.00

36566 10 ---------- $7,410.00 $7,913.00 $8,036.00 $558.00 $596.00 $647.00

36569 0 ---------- $348.00 $368.00 $377.00 $134.00 $140.00 $146.00

36571 10 ---------- $1,686.00 $1,800.00 $1,852.00 $461.00 $491.00 $530.00

36575 0 ---------- $229.00 $244.00 $250.00 $52.00 $54.00 $58.00



Surgery


(Non-Facility MRA)






36576 10 ---------- $448.00 $477.00 $502.00 $274.00 $291.00 $314.00

36578 10 ---------- $630.00 $670.00 $694.00 $300.00 $317.00 $339.00

36580 0 ---------- $297.00 $316.00 $324.00 $98.00 $103.00 $109.00

36581 10 ---------- $975.00 $1,036.00 $1,060.00 $270.00 $283.00 $299.00

36582 10 ---------- $1,403.00 $1,495.00 $1,539.00 $433.00 $459.00 $493.00

36583 10 ---------- $1,737.00 $1,857.00 $1,918.00 $484.00 $520.00 $568.00

36584 0 ---------- $284.00 $301.00 $307.00 $97.00 $101.00 $106.00

36585 10 ---------- $1,493.00 $1,591.00 $1,634.00 $406.00 $430.00 $462.00

36589 10 ---------- $236.00 $250.00 $263.00 $202.00 $213.00 $226.00

36590 10 ---------- $323.00 $343.00 $366.00 $283.00 $301.00 $324.00

36591 0 ---------- $32.00 $35.00 $35.00 $32.00 $35.00 $35.00

36592 0 ---------- $36.00 $39.00 $40.00 $36.00 $39.00 $40.00

36593 0 ---------- $43.00 $46.00 $48.00 $43.00 $46.00 $48.00

36595 0 ---------- $814.00 $863.00 $884.00 $271.00 $283.00 $299.00

36596 0 ---------- $183.00 $194.00 $199.00 $65.00 $69.00 $72.00

36597 0 ---------- $178.00 $188.00 $194.00 $90.00 $94.00 $99.00

36598 0 ---------- $154.00 $163.00 $167.00 $54.00 $57.00 $60.00

36600 0 $24.00 $44.00 $46.00 $47.00 $22.00 $23.00 $24.00

36620 0 $64.00 $75.00 $78.00 $82.00 $75.00 $78.00 $82.00

36625 0 $133.00 $156.00 $165.00 $179.00 $156.00 $165.00 $179.00

36640 0 $130.00 $167.00 $173.00 $180.00 $167.00 $173.00 $180.00

36680 0 $72.00 $87.00 $92.00 $99.00 $87.00 $92.00 $99.00

36800 0 $159.00 $184.00 $193.00 $207.00 $184.00 $193.00 $207.00

36810 0 $345.00 $323.00 $343.00 $371.00 $323.00 $343.00 $371.00

36815 0 $236.00 $209.00 $224.00 $248.00 $209.00 $224.00 $248.00

36818 90 ---------- $1,058.00 $1,135.00 $1,248.00 $1,058.00 $1,135.00 $1,248.00

36819 90 $977.00 $1,119.00 $1,200.00 $1,322.00 $1,119.00 $1,200.00 $1,322.00

36820 90 $800.00 $1,117.00 $1,198.00 $1,317.00 $1,117.00 $1,198.00 $1,317.00

36821 90 $721.00 $1,013.00 $1,086.00 $1,195.00 $1,013.00 $1,086.00 $1,195.00

36823 90 $1,461.00 $2,088.00 $2,241.00 $2,457.00 $2,088.00 $2,241.00 $2,457.00

36825 90 $867.00 $1,218.00 $1,307.00 $1,438.00 $1,218.00 $1,307.00 $1,438.00

36830 90 $967.00 $1,019.00 $1,093.00 $1,203.00 $1,019.00 $1,093.00 $1,203.00

36831 90 $488.00 $941.00 $1,009.00 $1,110.00 $941.00 $1,009.00 $1,110.00

36832 90 $810.00 $1,154.00 $1,238.00 $1,361.00 $1,154.00 $1,238.00 $1,361.00

36833 90 $780.00 $1,239.00 $1,329.00 $1,462.00 $1,239.00 $1,329.00 $1,462.00

36835 90 $542.00 $738.00 $792.00 $864.00 $738.00 $792.00 $864.00

36838 90 ---------- $1,755.00 $1,883.00 $2,079.00 $1,755.00 $1,883.00 $2,079.00

36860 0 $166.00 $294.00 $310.00 $319.00 $162.00 $169.00 $176.00

36861 0 $224.00 $204.00 $219.00 $241.00 $204.00 $219.00 $241.00

36901 0 ---------- $792.00 $844.00 $869.00 $217.00 $230.00 $249.00

36902 0 ---------- $1,676.00 $1,787.00 $1,829.00 $324.00 $343.00 $371.00

36903 0 ---------- $7,611.00 $8,124.00 $8,237.00 $443.00 $469.00 $508.00

36904 0 ---------- $2,446.00 $2,608.00 $2,672.00 $511.00 $541.00 $585.00

36905 0 ---------- $3,129.00 $3,336.00 $3,418.00 $641.00 $679.00 $734.00

36906 0 ---------- $9,244.00 $9,866.00 $10,020.00 $748.00 $792.00 $858.00

36907 ZZZ ---------- $1,002.00 $1,069.00 $1,094.00 $187.00 $198.00 $214.00

36908 ZZZ ---------- $3,663.00 $3,910.00 $3,969.00 $280.00 $296.00 $321.00

36909 ZZZ ---------- $2,676.00 $2,856.00 $2,904.00 $266.00 $281.00 $304.00

37140 90 $1,666.00 $3,494.00 $3,750.00 $4,123.00 $3,494.00 $3,750.00 $4,123.00

37145 90 $1,741.00 $3,250.00 $3,492.00 $3,847.00 $3,250.00 $3,492.00 $3,847.00



Surgery


(Non-Facility MRA)






37160 90 $1,681.00 $3,339.00 $3,587.00 $3,952.00 $3,339.00 $3,587.00 $3,952.00

37180 90 $1,769.00 $3,212.00 $3,452.00 $3,802.00 $3,212.00 $3,452.00 $3,802.00

37181 90 $1,923.00 $3,202.00 $3,383.00 $3,625.00 $3,202.00 $3,383.00 $3,625.00

37182 0 $914.00 $1,223.00 $1,272.00 $1,332.00 $1,223.00 $1,272.00 $1,332.00

37183 0 $425.00 $7,938.00 $8,462.00 $8,567.00 $559.00 $582.00 $609.00

37184 0 ---------- $3,077.00 $3,286.00 $3,380.00 $684.00 $730.00 $799.00

37185 ZZZ ---------- $981.00 $1,048.00 $1,083.00 $257.00 $274.00 $302.00

37186 ZZZ ---------- $1,848.00 $1,973.00 $2,027.00 $376.00 $401.00 $439.00

37187 0 ---------- $2,723.00 $2,902.00 $2,974.00 $592.00 $626.00 $675.00

37188 0 ---------- $2,316.00 $2,468.00 $2,519.00 $418.00 $441.00 $472.00

37191 0 ---------- $3,514.00 $3,748.00 $3,807.00 $338.00 $356.00 $382.00

37192 0 ---------- $2,208.00 $2,346.00 $2,393.00 $537.00 $561.00 $591.00

37193 0 ---------- $2,116.00 $2,252.00 $2,308.00 $527.00 $555.00 $595.00

37195 0 $302.00 ---------- ---------- ---------- ---------- ---------- ----------

37197 0 ---------- $1,994.00 $2,125.00 $2,179.00 $455.00 $482.00 $520.00

37200 0 $232.00 $324.00 $337.00 $353.00 $324.00 $337.00 $353.00

37211 0 ---------- $583.00 $619.00 $671.00 $583.00 $619.00 $671.00

37212 0 ---------- $507.00 $536.00 $579.00 $507.00 $536.00 $579.00

37213 0 ---------- $351.00 $370.00 $397.00 $351.00 $370.00 $397.00

37214 0 ---------- $185.00 $195.00 $210.00 $185.00 $195.00 $210.00

37215 90 ---------- $1,515.00 $1,625.00 $1,788.00 $1,515.00 $1,625.00 $1,788.00

37216 90 ---------- BR BR BR BR BR BR

37217 90 ---------- $1,674.00 $1,792.00 $1,970.00 $1,674.00 $1,792.00 $1,970.00

37218 90 ---------- $1,238.00 $1,326.00 $1,456.00 $1,238.00 $1,326.00 $1,456.00

37220 0 ---------- $4,217.00 $4,504.00 $4,608.00 $615.00 $658.00 $724.00

37221 0 ---------- $6,240.00 $6,665.00 $6,803.00 $760.00 $812.00 $893.00

37222 ZZZ ---------- $1,193.00 $1,275.00 $1,316.00 $287.00 $307.00 $338.00

37223 ZZZ ---------- $3,494.00 $3,732.00 $3,800.00 $328.00 $351.00 $386.00

37224 0 ---------- $5,108.00 $5,455.00 $5,573.00 $679.00 $725.00 $796.00

37225 0 ---------- $14,881.00 $15,895.00 $16,141.00 $929.00 $994.00 $1,094.00

37226 0 ---------- $12,197.00 $13,027.00 $13,233.00 $802.00 $857.00 $943.00

37227 0 ---------- $20,148.00 $21,520.00 $21,840.00 $1,119.00 $1,197.00 $1,318.00

37228 0 ---------- $7,306.00 $7,803.00 $7,959.00 $833.00 $890.00 $978.00

37229 0 ---------- $14,683.00 $15,683.00 $15,941.00 $1,085.00 $1,161.00 $1,277.00

37230 0 ---------- $11,238.00 $12,004.00 $12,226.00 $1,072.00 $1,147.00 $1,262.00

37231 0 ---------- $18,151.00 $19,386.00 $19,686.00 $1,162.00 $1,242.00 $1,365.00

37232 ZZZ ---------- $1,640.00 $1,752.00 $1,798.00 $310.00 $331.00 $364.00

37233 ZZZ ---------- $1,993.00 $2,129.00 $2,198.00 $504.00 $538.00 $592.00

37234 ZZZ ---------- $5,319.00 $5,682.00 $5,779.00 $436.00 $467.00 $513.00

37235 ZZZ ---------- $5,725.00 $6,114.00 $6,230.00 $604.00 $645.00 $708.00

37236 0 ---------- $5,426.00 $5,792.00 $5,904.00 $670.00 $712.00 $774.00

37237 ZZZ ---------- $3,311.00 $3,536.00 $3,601.00 $326.00 $348.00 $382.00

37238 0 ---------- $5,639.00 $6,016.00 $6,107.00 $452.00 $477.00 $513.00

37239 ZZZ ---------- $2,742.00 $2,928.00 $2,978.00 $230.00 $246.00 $269.00

37241 0 ---------- $6,495.00 $6,930.00 $7,049.00 $668.00 $707.00 $764.00

37242 0 ---------- $10,157.00 $10,836.00 $10,987.00 $722.00 $759.00 $811.00

37243 0 ---------- $13,186.00 $14,062.00 $14,237.00 $844.00 $880.00 $926.00

37244 0 ---------- $9,220.00 $9,822.00 $9,963.00 $994.00 $1,037.00 $1,092.00

37246 0 ---------- $2,949.00 $3,146.00 $3,219.00 $533.00 $565.00 $612.00

37247 ZZZ ---------- $1,197.00 $1,276.00 $1,310.00 $264.00 $280.00 $304.00



Surgery


(Non-Facility MRA)






37248 0 ---------- $2,049.00 $2,185.00 $2,243.00 $458.00 $486.00 $527.00

37249 ZZZ ---------- $880.00 $939.00 $966.00 $225.00 $238.00 $259.00

37252 ZZZ ---------- $1,887.00 $2,016.00 $2,050.00 $141.00 $151.00 $167.00

37253 ZZZ ---------- $292.00 $312.00 $327.00 $114.00 $122.00 $135.00

37500 90 $739.00 $984.00 $1,055.00 $1,162.00 $984.00 $1,055.00 $1,162.00

37501 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

37565 90 $364.00 $1,087.00 $1,150.00 $1,226.00 $1,087.00 $1,150.00 $1,226.00

37600 90 $414.00 $1,064.00 $1,132.00 $1,224.00 $1,064.00 $1,132.00 $1,224.00

37605 90 $521.00 $1,199.00 $1,285.00 $1,414.00 $1,199.00 $1,285.00 $1,414.00

37606 90 $563.00 $783.00 $841.00 $923.00 $783.00 $841.00 $923.00

37607 90 $456.00 $568.00 $608.00 $666.00 $568.00 $608.00 $666.00

37609 10 $278.00 $443.00 $473.00 $500.00 $306.00 $327.00 $352.00

37615 90 $495.00 $747.00 $792.00 $841.00 $747.00 $792.00 $841.00

37616 90 $1,128.00 $1,660.00 $1,778.00 $1,947.00 $1,660.00 $1,778.00 $1,947.00

37617 90 $1,132.00 $2,025.00 $2,168.00 $2,377.00 $2,025.00 $2,168.00 $2,377.00

37618 90 $514.00 $574.00 $615.00 $669.00 $574.00 $615.00 $669.00

37619 90 ---------- $2,504.00 $2,686.00 $2,961.00 $2,504.00 $2,686.00 $2,961.00

37650 90 $430.00 $703.00 $753.00 $828.00 $703.00 $753.00 $828.00

37660 90 $789.00 $1,962.00 $2,105.00 $2,311.00 $1,962.00 $2,105.00 $2,311.00

37700 90 $336.00 $372.00 $399.00 $434.00 $372.00 $399.00 $434.00

37718 90 ---------- $654.00 $701.00 $767.00 $654.00 $701.00 $767.00

37722 90 ---------- $722.00 $775.00 $850.00 $722.00 $775.00 $850.00

37735 90 $847.00 $891.00 $955.00 $1,055.00 $891.00 $955.00 $1,055.00

37760 90 $813.00 $931.00 $997.00 $1,095.00 $931.00 $997.00 $1,095.00

37761 90 ---------- $828.00 $887.00 $969.00 $828.00 $887.00 $969.00

37765 90 ---------- $945.00 $1,008.00 $1,074.00 $676.00 $722.00 $785.00

37766 90 ---------- $1,124.00 $1,200.00 $1,282.00 $827.00 $882.00 $961.00

37780 90 $301.00 $377.00 $404.00 $441.00 $377.00 $404.00 $441.00

37785 90 $270.00 $516.00 $552.00 $589.00 $392.00 $420.00 $456.00

37788 90 $1,654.00 $1,854.00 $1,943.00 $2,048.00 $1,854.00 $1,943.00 $2,048.00

37790 90 $690.00 $713.00 $748.00 $786.00 $713.00 $748.00 $786.00

37799 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

38100 90 $974.00 $1,735.00 $1,861.00 $2,041.00 $1,735.00 $1,861.00 $2,041.00

38101 90 $982.00 $1,736.00 $1,861.00 $2,038.00 $1,736.00 $1,861.00 $2,038.00

38102 ZZZ $332.00 $397.00 $426.00 $469.00 $397.00 $426.00 $469.00

38115 90 $1,020.00 $1,907.00 $2,042.00 $2,234.00 $1,907.00 $2,042.00 $2,234.00

38120 90 $1,138.00 $1,578.00 $1,693.00 $1,853.00 $1,578.00 $1,693.00 $1,853.00

38129 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

38200 0 $180.00 $198.00 $206.00 $215.00 $198.00 $206.00 $215.00

38205 0 $79.00 $121.00 $125.00 $130.00 $121.00 $125.00 $130.00

38206 0 $79.00 $121.00 $125.00 $130.00 $121.00 $125.00 $130.00

38220 0 $212.00 $234.00 $249.00 $257.00 $91.00 $96.00 $102.00

38221 0 $228.00 $234.00 $247.00 $252.00 $108.00 $112.00 $116.00

38230 0 $265.00 $291.00 $305.00 $321.00 $291.00 $305.00 $321.00

38232 0 ---------- $288.00 $303.00 $321.00 $288.00 $303.00 $321.00

38240 0 $128.00 $324.00 $337.00 $348.00 $324.00 $337.00 $348.00

38241 0 $128.00 $242.00 $252.00 $260.00 $242.00 $252.00 $260.00

38242 0 $90.00 $171.00 $178.00 $184.00 $171.00 $178.00 $184.00

38243 0 ---------- $171.00 $178.00 $184.00 $171.00 $178.00 $184.00

38300 10 $104.00 $386.00 $412.00 $432.00 $265.00 $283.00 $302.00



Surgery


(Non-Facility MRA)






38305 90 $375.00 $676.00 $721.00 $776.00 $676.00 $721.00 $776.00

38308 90 $425.00 $664.00 $711.00 $773.00 $664.00 $711.00 $773.00

38380 90 $628.00 $821.00 $871.00 $929.00 $821.00 $871.00 $929.00

38381 90 $1,087.00 $1,207.00 $1,294.00 $1,417.00 $1,207.00 $1,294.00 $1,417.00

38382 90 $798.00 $1,003.00 $1,075.00 $1,173.00 $1,003.00 $1,075.00 $1,173.00

38500 10 $234.00 $481.00 $515.00 $551.00 $378.00 $405.00 $440.00

38505 0 $139.00 $177.00 $187.00 $192.00 $104.00 $109.00 $113.00

38510 10 $349.00 $754.00 $804.00 $858.00 $622.00 $663.00 $715.00

38520 90 $431.00 $687.00 $734.00 $794.00 $687.00 $734.00 $794.00

38525 90 $369.00 $650.00 $697.00 $760.00 $650.00 $697.00 $760.00

38530 90 $517.00 $821.00 $878.00 $951.00 $821.00 $878.00 $951.00

38542 90 $507.00 $761.00 $809.00 $865.00 $761.00 $809.00 $865.00

38550 90 $519.00 $747.00 $801.00 $869.00 $747.00 $801.00 $869.00

38555 90 $1,115.00 $1,516.00 $1,628.00 $1,779.00 $1,516.00 $1,628.00 $1,779.00

38562 90 $799.00 $1,044.00 $1,113.00 $1,201.00 $1,044.00 $1,113.00 $1,201.00

38564 90 $831.00 $1,044.00 $1,117.00 $1,214.00 $1,044.00 $1,117.00 $1,214.00

38570 10 $695.00 $746.00 $791.00 $849.00 $746.00 $791.00 $849.00

38571 10 $902.00 $985.00 $1,037.00 $1,100.00 $985.00 $1,037.00 $1,100.00

38572 10 $1,049.00 $1,400.00 $1,494.00 $1,622.00 $1,400.00 $1,494.00 $1,622.00

38589 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

38700 90 $863.00 $1,180.00 $1,248.00 $1,329.00 $1,180.00 $1,248.00 $1,329.00

38720 90 $1,328.00 $1,979.00 $2,099.00 $2,249.00 $1,979.00 $2,099.00 $2,249.00

38724 90 $1,366.00 $2,132.00 $2,255.00 $2,404.00 $2,132.00 $2,255.00 $2,404.00

38740 90 $539.00 $1,036.00 $1,112.00 $1,214.00 $1,036.00 $1,112.00 $1,214.00

38745 90 $770.00 $1,311.00 $1,407.00 $1,538.00 $1,311.00 $1,407.00 $1,538.00

38746 ZZZ $312.00 $327.00 $351.00 $388.00 $327.00 $351.00 $388.00

38747 ZZZ $337.00 $404.00 $434.00 $478.00 $404.00 $434.00 $478.00

38760 90 $699.00 $1,258.00 $1,346.00 $1,465.00 $1,258.00 $1,346.00 $1,465.00

38765 90 $1,283.00 $1,937.00 $2,071.00 $2,257.00 $1,937.00 $2,071.00 $2,257.00

38770 90 $1,111.00 $1,194.00 $1,262.00 $1,348.00 $1,194.00 $1,262.00 $1,348.00

38780 90 $1,357.00 $1,519.00 $1,608.00 $1,721.00 $1,519.00 $1,608.00 $1,721.00

38790 0 $158.00 $122.00 $130.00 $139.00 $122.00 $130.00 $139.00

38792 0 $26.00 $58.00 $61.00 $64.00 $58.00 $61.00 $64.00

38794 90 $298.00 $434.00 $454.00 $471.00 $434.00 $454.00 $471.00

38900 ZZZ ---------- $210.00 $225.00 $249.00 $210.00 $225.00 $249.00

38999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

39000 90 $664.00 $738.00 $789.00 $856.00 $738.00 $789.00 $856.00

39010 90 $1,148.00 $1,182.00 $1,267.00 $1,387.00 $1,182.00 $1,267.00 $1,387.00

39200 90 $1,249.00 $1,312.00 $1,406.00 $1,542.00 $1,312.00 $1,406.00 $1,542.00

39220 90 $1,542.00 $1,704.00 $1,825.00 $1,997.00 $1,704.00 $1,825.00 $1,997.00

39401 0 ---------- $470.00 $504.00 $555.00 $470.00 $504.00 $555.00

39402 0 ---------- $615.00 $660.00 $728.00 $615.00 $660.00 $728.00

39499 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

39501 90 $1,083.00 $1,270.00 $1,360.00 $1,485.00 $1,270.00 $1,360.00 $1,485.00

39503 90 $2,726.00 $8,949.00 $9,567.00 $10,486.00 $8,949.00 $9,567.00 $10,486.00

39540 90 $1,133.00 $1,305.00 $1,399.00 $1,533.00 $1,305.00 $1,399.00 $1,533.00

39541 90 $1,179.00 $1,418.00 $1,521.00 $1,668.00 $1,418.00 $1,521.00 $1,668.00

39545 90 $1,102.00 $1,329.00 $1,424.00 $1,557.00 $1,329.00 $1,424.00 $1,557.00

39560 90 $968.00 $1,196.00 $1,281.00 $1,399.00 $1,196.00 $1,281.00 $1,399.00

39561 90 $1,328.00 $1,861.00 $1,996.00 $2,181.00 $1,861.00 $1,996.00 $2,181.00



Surgery


(Non-Facility MRA)






39599 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

40490 0 $108.00 $183.00 $194.00 $202.00 $108.00 $114.00 $121.00

40500 90 $422.00 $721.00 $766.00 $797.00 $528.00 $560.00 $590.00

40510 90 $469.00 $693.00 $736.00 $770.00 $520.00 $552.00 $584.00

40520 90 $467.00 $700.00 $744.00 $778.00 $523.00 $554.00 $586.00

40525 90 $714.00 $806.00 $854.00 $905.00 $806.00 $854.00 $905.00

40527 90 $851.00 $912.00 $964.00 $1,021.00 $912.00 $964.00 $1,021.00

40530 90 $501.00 $769.00 $817.00 $856.00 $587.00 $622.00 $659.00

40650 90 $368.00 $624.00 $662.00 $689.00 $434.00 $460.00 $484.00

40652 90 $436.00 $701.00 $745.00 $776.00 $514.00 $546.00 $575.00

40654 90 $529.00 $818.00 $870.00 $910.00 $622.00 $660.00 $698.00

40700 90 $1,009.00 $1,480.00 $1,572.00 $1,671.00 $1,480.00 $1,572.00 $1,671.00

40701 90 $1,452.00 $1,756.00 $1,865.00 $1,985.00 $1,756.00 $1,865.00 $1,985.00

40702 90 $1,030.00 $1,321.00 $1,394.00 $1,475.00 $1,321.00 $1,394.00 $1,475.00

40720 90 $1,107.00 $1,463.00 $1,552.00 $1,650.00 $1,463.00 $1,552.00 $1,650.00

40761 90 $1,202.00 $1,426.00 $1,506.00 $1,599.00 $1,426.00 $1,506.00 $1,599.00

40799 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

40800 10 $110.00 $302.00 $322.00 $332.00 $191.00 $204.00 $213.00

40801 10 $208.00 $453.00 $482.00 $502.00 $327.00 $347.00 $366.00

40804 10 $105.00 $261.00 $278.00 $287.00 $165.00 $175.00 $183.00

40805 10 $245.00 $463.00 $493.00 $514.00 $342.00 $364.00 $384.00

40806 0 $38.00 $147.00 $157.00 $160.00 $48.00 $51.00 $54.00

40808 10 $100.00 $264.00 $281.00 $290.00 $157.00 $167.00 $174.00

40810 10 $141.00 $294.00 $313.00 $323.00 $186.00 $197.00 $206.00

40812 10 $202.00 $415.00 $442.00 $460.00 $290.00 $308.00 $325.00

40814 90 $319.00 $557.00 $593.00 $619.00 $448.00 $476.00 $501.00

40816 90 $336.00 $581.00 $617.00 $644.00 $464.00 $493.00 $518.00

40818 90 $249.00 $515.00 $546.00 $563.00 $396.00 $420.00 $436.00

40819 90 $208.00 $454.00 $483.00 $502.00 $351.00 $373.00 $391.00

40820 10 $104.00 $376.00 $401.00 $412.00 $249.00 $265.00 $275.00

40830 10 $140.00 $382.00 $406.00 $419.00 $242.00 $256.00 $268.00

40831 10 $213.00 $483.00 $514.00 $533.00 $329.00 $350.00 $367.00

40840 90 $687.00 $1,170.00 $1,242.00 $1,305.00 $922.00 $977.00 $1,037.00

40842 90 $684.00 $1,185.00 $1,260.00 $1,327.00 $957.00 $1,017.00 $1,081.00

40843 90 $947.00 $1,577.00 $1,676.00 $1,767.00 $1,264.00 $1,341.00 $1,430.00

40844 90 $1,232.00 $1,873.00 $1,983.00 $2,086.00 $1,544.00 $1,632.00 $1,732.00

40845 90 $1,593.00 $2,123.00 $2,249.00 $2,372.00 $1,804.00 $1,909.00 $2,028.00

40899 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

41000 10 $119.00 $232.00 $247.00 $257.00 $164.00 $174.00 $183.00

41005 10 $109.00 $321.00 $342.00 $352.00 $181.00 $192.00 $200.00

41006 90 $237.00 $557.00 $593.00 $618.00 $397.00 $422.00 $446.00

41007 90 $283.00 $548.00 $584.00 $608.00 $385.00 $409.00 $431.00

41008 90 $248.00 $549.00 $584.00 $610.00 $399.00 $424.00 $448.00

41009 90 $319.00 $583.00 $620.00 $648.00 $433.00 $460.00 $486.00

41010 10 $91.00 $283.00 $301.00 $309.00 $155.00 $164.00 $171.00

41015 90 $267.00 $657.00 $698.00 $729.00 $515.00 $548.00 $577.00

41016 90 $357.00 $638.00 $678.00 $709.00 $517.00 $549.00 $578.00

41017 90 $300.00 $646.00 $687.00 $717.00 $520.00 $553.00 $582.00

41018 90 $424.00 $735.00 $781.00 $818.00 $609.00 $646.00 $682.00

41019 0 ---------- $688.00 $716.00 $744.00 $688.00 $716.00 $744.00



Surgery


(Non-Facility MRA)






41100 10 $140.00 $240.00 $255.00 $265.00 $158.00 $167.00 $176.00

41105 10 $136.00 $245.00 $260.00 $271.00 $164.00 $174.00 $184.00

41108 10 $110.00 $211.00 $225.00 $233.00 $132.00 $141.00 $148.00

41110 10 $159.00 $302.00 $321.00 $332.00 $191.00 $203.00 $213.00

41112 90 $255.00 $481.00 $512.00 $532.00 $370.00 $393.00 $413.00

41113 90 $301.00 $528.00 $561.00 $585.00 $411.00 $436.00 $458.00

41114 90 $682.00 $934.00 $990.00 $1,047.00 $934.00 $990.00 $1,047.00

41115 10 $176.00 $350.00 $372.00 $385.00 $211.00 $224.00 $235.00

41116 90 $242.00 $474.00 $504.00 $522.00 $321.00 $341.00 $358.00

41120 90 $813.00 $1,562.00 $1,657.00 $1,730.00 $1,562.00 $1,657.00 $1,730.00

41130 90 $937.00 $1,932.00 $2,047.00 $2,147.00 $1,932.00 $2,047.00 $2,147.00

41135 90 $1,869.00 $3,201.00 $3,390.00 $3,579.00 $3,201.00 $3,390.00 $3,579.00

41140 90 $2,005.00 $3,218.00 $3,408.00 $3,590.00 $3,218.00 $3,408.00 $3,590.00

41145 90 $2,406.00 $4,070.00 $4,307.00 $4,536.00 $4,070.00 $4,307.00 $4,536.00

41150 90 $1,897.00 $3,235.00 $3,425.00 $3,608.00 $3,235.00 $3,425.00 $3,608.00

41153 90 $2,091.00 $3,523.00 $3,728.00 $3,932.00 $3,523.00 $3,728.00 $3,932.00

41155 90 $2,448.00 $4,452.00 $4,713.00 $4,990.00 $4,452.00 $4,713.00 $4,990.00

41250 10 $168.00 $380.00 $403.00 $417.00 $224.00 $237.00 $248.00

41251 10 $203.00 $410.00 $436.00 $453.00 $265.00 $282.00 $297.00

41252 10 $294.00 $456.00 $484.00 $505.00 $311.00 $330.00 $349.00

41500 90 $334.00 $648.00 $689.00 $718.00 $648.00 $689.00 $718.00

41510 90 $313.00 $609.00 $647.00 $669.00 $609.00 $647.00 $669.00

41512 90 ---------- $955.00 $1,012.00 $1,056.00 $955.00 $1,012.00 $1,056.00

41520 90 $255.00 $506.00 $539.00 $561.00 $377.00 $401.00 $421.00

41530 0 ---------- $1,368.00 $1,457.00 $1,488.00 $540.00 $573.00 $596.00

41599 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

41800 10 $107.00 $389.00 $414.00 $424.00 $213.00 $226.00 $234.00

41805 10 $115.00 $351.00 $374.00 $386.00 $247.00 $263.00 $273.00

41806 10 $217.00 $508.00 $541.00 $563.00 $380.00 $404.00 $424.00



41822 10 $237.00 $451.00 $480.00 $500.00 $274.00 $291.00 $308.00

41823 90 $312.00 $660.00 $703.00 $732.00 $490.00 $521.00 $549.00

41825 10 $144.00 $303.00 $322.00 $334.00 $179.00 $190.00 $200.00

41826 10 $211.00 $454.00 $483.00 $502.00 $313.00 $333.00 $350.00

41827 90 $322.00 $638.00 $678.00 $706.00 $455.00 $483.00 $509.00

41828 10 $176.00 $447.00 $476.00 $499.00 $319.00 $339.00 $361.00

41830 10 $156.00 $568.00 $604.00 $630.00 $418.00 $444.00 $468.00



41872 90 $249.00 $541.00 $575.00 $597.00 $386.00 $409.00 $430.00

41874 90 $193.00 $548.00 $583.00 $608.00 $380.00 $404.00 $427.00

41899 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

42000 10 $106.00 $228.00 $242.00 $251.00 $152.00 $161.00 $169.00

42100 10 $122.00 $215.00 $229.00 $238.00 $160.00 $169.00 $178.00

42104 10 $161.00 $308.00 $327.00 $340.00 $203.00 $216.00 $227.00

42106 10 $204.00 $393.00 $418.00 $435.00 $263.00 $279.00 $294.00

42107 90 $409.00 $665.00 $706.00 $738.00 $508.00 $538.00 $568.00

42120 90 $573.00 $1,476.00 $1,564.00 $1,639.00 $1,476.00 $1,564.00 $1,639.00

42140 90 $174.00 $357.00 $380.00 $392.00 $223.00 $237.00 $248.00



Surgery


(Non-Facility MRA)






42145 90 $741.00 $1,025.00 $1,084.00 $1,143.00 $1,025.00 $1,084.00 $1,143.00

42160 10 $176.00 $331.00 $352.00 $365.00 $215.00 $227.00 $239.00

42180 10 $222.00 $349.00 $370.00 $386.00 $267.00 $282.00 $298.00

42182 10 $324.00 $462.00 $489.00 $513.00 $375.00 $396.00 $419.00

42200 90 $946.00 $1,244.00 $1,314.00 $1,385.00 $1,244.00 $1,314.00 $1,385.00

42205 90 $863.00 $1,335.00 $1,413.00 $1,498.00 $1,335.00 $1,413.00 $1,498.00

42210 90 $1,174.00 $1,522.00 $1,613.00 $1,710.00 $1,522.00 $1,613.00 $1,710.00

42215 90 $766.00 $1,056.00 $1,122.00 $1,187.00 $1,056.00 $1,122.00 $1,187.00

42220 90 $586.00 $769.00 $814.00 $857.00 $769.00 $814.00 $857.00

42225 90 $803.00 $1,260.00 $1,335.00 $1,397.00 $1,260.00 $1,335.00 $1,397.00

42226 90 $848.00 $1,315.00 $1,399.00 $1,476.00 $1,315.00 $1,399.00 $1,476.00

42227 90 $762.00 $1,236.00 $1,311.00 $1,377.00 $1,236.00 $1,311.00 $1,377.00

42235 90 $631.00 $1,052.00 $1,115.00 $1,166.00 $1,052.00 $1,115.00 $1,166.00

42260 90 $491.00 $1,217.00 $1,291.00 $1,358.00 $1,022.00 $1,083.00 $1,148.00

42280 10 $148.00 $236.00 $251.00 $263.00 $164.00 $174.00 $185.00

42281 10 $160.00 $293.00 $311.00 $324.00 $219.00 $232.00 $245.00

42299 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

42300 10 $165.00 $299.00 $317.00 $330.00 $222.00 $235.00 $247.00

42305 90 $448.00 $632.00 $669.00 $709.00 $632.00 $669.00 $709.00

42310 10 $145.00 $230.00 $244.00 $255.00 $180.00 $190.00 $200.00

42320 10 $208.00 $354.00 $376.00 $391.00 $254.00 $269.00 $283.00

42330 10 $184.00 $332.00 $352.00 $367.00 $240.00 $254.00 $268.00

42335 90 $287.00 $534.00 $567.00 $590.00 $375.00 $397.00 $418.00

42340 90 $411.00 $667.00 $708.00 $738.00 $492.00 $520.00 $549.00

42400 0 $94.00 $149.00 $157.00 $162.00 $80.00 $84.00 $88.00

42405 10 $258.00 $429.00 $455.00 $477.00 $331.00 $350.00 $370.00

42408 90 $377.00 $650.00 $690.00 $720.00 $477.00 $505.00 $533.00

42409 90 $266.00 $475.00 $504.00 $523.00 $323.00 $342.00 $360.00

42410 90 $746.00 $911.00 $965.00 $1,027.00 $911.00 $965.00 $1,027.00

42415 90 $1,364.00 $1,549.00 $1,637.00 $1,740.00 $1,549.00 $1,637.00 $1,740.00

42420 90 $1,577.00 $1,739.00 $1,838.00 $1,955.00 $1,739.00 $1,838.00 $1,955.00

42425 90 $1,097.00 $1,225.00 $1,295.00 $1,376.00 $1,225.00 $1,295.00 $1,376.00

42426 90 $1,882.00 $1,985.00 $2,098.00 $2,235.00 $1,985.00 $2,098.00 $2,235.00

42440 90 $634.00 $601.00 $636.00 $674.00 $601.00 $636.00 $674.00

42450 90 $395.00 $649.00 $689.00 $719.00 $521.00 $552.00 $580.00

42500 90 $407.00 $622.00 $660.00 $689.00 $497.00 $527.00 $554.00

42505 90 $559.00 $798.00 $846.00 $886.00 $659.00 $697.00 $736.00

42507 90 $522.00 $727.00 $770.00 $809.00 $727.00 $770.00 $809.00

42509 90 $915.00 $1,228.00 $1,299.00 $1,370.00 $1,228.00 $1,299.00 $1,370.00

42510 90 $711.00 $937.00 $993.00 $1,047.00 $937.00 $993.00 $1,047.00

42550 0 $82.00 $191.00 $201.00 $207.00 $93.00 $97.00 $101.00

42600 90 $445.00 $674.00 $714.00 $744.00 $500.00 $528.00 $555.00

42650 0 $67.00 $119.00 $126.00 $131.00 $85.00 $90.00 $95.00

42660 0 $89.00 $187.00 $201.00 $215.00 $134.00 $145.00 $158.00

42665 90 $238.00 $449.00 $477.00 $496.00 $302.00 $320.00 $337.00

42699 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

42700 10 $144.00 $270.00 $286.00 $297.00 $196.00 $208.00 $218.00

42720 10 $270.00 $658.00 $696.00 $735.00 $575.00 $607.00 $644.00

42725 90 $720.00 $1,204.00 $1,276.00 $1,358.00 $1,204.00 $1,276.00 $1,358.00

42800 10 $123.00 $226.00 $240.00 $249.00 $162.00 $172.00 $181.00



Surgery


(Non-Facility MRA)






42804 10 $136.00 $275.00 $293.00 $302.00 $163.00 $173.00 $181.00

42806 10 $167.00 $310.00 $330.00 $341.00 $191.00 $202.00 $212.00

42808 10 $250.00 $325.00 $345.00 $360.00 $237.00 $250.00 $264.00

42809 10 $152.00 $286.00 $303.00 $316.00 $179.00 $189.00 $200.00

42810 90 $335.00 $551.00 $584.00 $607.00 $417.00 $442.00 $463.00

42815 90 $659.00 $811.00 $859.00 $905.00 $811.00 $859.00 $905.00

42821 90 $378.00 $439.00 $464.00 $490.00 $439.00 $464.00 $490.00

42826 90 $320.00 $365.00 $387.00 $408.00 $365.00 $387.00 $408.00

42831 90 $235.00 $324.00 $343.00 $360.00 $324.00 $343.00 $360.00

42836 90 $286.00 $350.00 $370.00 $390.00 $350.00 $370.00 $390.00

42842 90 $729.00 $1,476.00 $1,564.00 $1,640.00 $1,476.00 $1,564.00 $1,640.00

42844 90 $1,173.00 $2,035.00 $2,155.00 $2,264.00 $2,035.00 $2,155.00 $2,264.00

42845 90 $1,958.00 $3,286.00 $3,474.00 $3,666.00 $3,286.00 $3,474.00 $3,666.00

42860 90 $207.00 $272.00 $288.00 $302.00 $272.00 $288.00 $302.00

42870 90 $427.00 $859.00 $911.00 $947.00 $859.00 $911.00 $947.00

42890 90 $1,047.00 $2,102.00 $2,225.00 $2,341.00 $2,102.00 $2,225.00 $2,341.00

42892 90 $1,262.00 $2,780.00 $2,942.00 $3,103.00 $2,780.00 $2,942.00 $3,103.00

42894 90 $1,825.00 $3,496.00 $3,698.00 $3,902.00 $3,496.00 $3,698.00 $3,902.00

42900 10 $429.00 $495.00 $523.00 $554.00 $495.00 $523.00 $554.00

42950 90 $745.00 $1,183.00 $1,255.00 $1,309.00 $1,183.00 $1,255.00 $1,309.00

42953 90 $752.00 $1,420.00 $1,508.00 $1,573.00 $1,420.00 $1,508.00 $1,573.00

42955 90 $561.00 $1,104.00 $1,171.00 $1,224.00 $1,104.00 $1,171.00 $1,224.00

42960 10 $178.00 $248.00 $262.00 $277.00 $248.00 $262.00 $277.00

42961 90 $406.00 $614.00 $649.00 $684.00 $614.00 $649.00 $684.00

42962 90 $602.00 $758.00 $802.00 $847.00 $758.00 $802.00 $847.00

42970 90 $284.00 $595.00 $629.00 $662.00 $595.00 $629.00 $662.00

42971 90 $472.00 $672.00 $711.00 $753.00 $672.00 $711.00 $753.00

42972 90 $562.00 $746.00 $789.00 $834.00 $746.00 $789.00 $834.00

42999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

43020 90 $696.00 $783.00 $826.00 $873.00 $783.00 $826.00 $873.00

43030 90 $712.00 $759.00 $803.00 $854.00 $759.00 $803.00 $854.00

43045 90 $1,574.00 $1,958.00 $2,101.00 $2,307.00 $1,958.00 $2,101.00 $2,307.00

43100 90 $744.00 $908.00 $959.00 $1,015.00 $908.00 $959.00 $1,015.00

43101 90 $1,248.00 $1,601.00 $1,719.00 $1,884.00 $1,601.00 $1,719.00 $1,884.00

43107 90 $2,325.00 $3,859.00 $4,142.00 $4,556.00 $3,859.00 $4,142.00 $4,556.00

43108 90 $2,664.00 $7,058.00 $7,576.00 $8,348.00 $7,058.00 $7,576.00 $8,348.00

43112 90 $2,471.00 $4,083.00 $4,384.00 $4,828.00 $4,083.00 $4,384.00 $4,828.00

43113 90 $2,755.00 $6,621.00 $7,110.00 $7,857.00 $6,621.00 $7,110.00 $7,857.00

43116 90 $2,509.00 $7,778.00 $8,214.00 $8,764.00 $7,778.00 $8,214.00 $8,764.00

43117 90 $2,469.00 $3,732.00 $4,005.00 $4,410.00 $3,732.00 $4,005.00 $4,410.00

43118 90 $2,607.00 $5,725.00 $6,141.00 $6,756.00 $5,725.00 $6,141.00 $6,756.00

43121 90 $2,350.00 $4,319.00 $4,632.00 $5,099.00 $4,319.00 $4,632.00 $5,099.00

43122 90 $2,287.00 $3,865.00 $4,147.00 $4,556.00 $3,865.00 $4,147.00 $4,556.00

43123 90 $2,661.00 $7,112.00 $7,628.00 $8,391.00 $7,112.00 $7,628.00 $8,391.00

43124 90 $2,242.00 $5,802.00 $6,212.00 $6,818.00 $5,802.00 $6,212.00 $6,818.00

43130 90 $1,020.00 $1,158.00 $1,229.00 $1,318.00 $1,158.00 $1,229.00 $1,318.00

43135 90 $1,332.00 $2,237.00 $2,396.00 $2,629.00 $2,237.00 $2,396.00 $2,629.00

43180 90 ---------- $806.00 $851.00 $904.00 $806.00 $851.00 $904.00

43191 0 ---------- $227.00 $240.00 $256.00 $227.00 $240.00 $256.00

43192 0 ---------- $250.00 $264.00 $280.00 $250.00 $264.00 $280.00



Surgery


(Non-Facility MRA)






43193 0 ---------- $250.00 $264.00 $281.00 $250.00 $264.00 $281.00

43194 0 ---------- $288.00 $306.00 $329.00 $288.00 $306.00 $329.00

43195 0 ---------- $273.00 $288.00 $307.00 $273.00 $288.00 $307.00

43196 0 ---------- $292.00 $308.00 $329.00 $292.00 $308.00 $329.00

43197 0 ---------- $266.00 $283.00 $294.00 $124.00 $131.00 $141.00

43198 0 ---------- $295.00 $314.00 $326.00 $148.00 $156.00 $167.00

43200 0 $266.00 $303.00 $322.00 $333.00 $130.00 $138.00 $147.00

43201 0 $245.00 $310.00 $330.00 $341.00 $154.00 $162.00 $173.00

43202 0 $205.00 $428.00 $455.00 $469.00 $154.00 $163.00 $174.00

43204 0 $228.00 $203.00 $213.00 $226.00 $203.00 $213.00 $226.00

43205 0 $207.00 $211.00 $222.00 $234.00 $211.00 $222.00 $234.00

43206 0 ---------- $374.00 $396.00 $411.00 $199.00 $210.00 $222.00

43210 0 ---------- $649.00 $688.00 $741.00 $649.00 $688.00 $741.00

43211 0 ---------- $353.00 $371.00 $394.00 $353.00 $371.00 $394.00

43212 0 ---------- $287.00 $305.00 $329.00 $287.00 $305.00 $329.00

43213 0 ---------- $1,591.00 $1,695.00 $1,734.00 $387.00 $408.00 $435.00

43214 0 ---------- $288.00 $304.00 $323.00 $288.00 $304.00 $323.00

43215 0 $160.00 $504.00 $537.00 $555.00 $213.00 $225.00 $241.00

43216 0 $149.00 $497.00 $528.00 $543.00 $201.00 $211.00 $224.00

43217 0 $176.00 $533.00 $566.00 $586.00 $241.00 $255.00 $272.00

43220 0 $128.00 $1,470.00 $1,568.00 $1,593.00 $176.00 $186.00 $198.00

43226 0 $142.00 $445.00 $473.00 $489.00 $195.00 $207.00 $220.00

43227 0 $218.00 $870.00 $926.00 $948.00 $247.00 $260.00 $276.00

43229 0 ---------- $897.00 $954.00 $980.00 $295.00 $312.00 $331.00

43231 0 $182.00 $470.00 $498.00 $515.00 $239.00 $251.00 $265.00

43232 0 $252.00 $565.00 $598.00 $618.00 $295.00 $310.00 $327.00

43233 0 ---------- $341.00 $360.00 $384.00 $341.00 $360.00 $384.00

43235 0 $239.00 $360.00 $382.00 $396.00 $184.00 $194.00 $206.00

43236 0 $285.00 $460.00 $488.00 $503.00 $207.00 $218.00 $230.00

43237 0 ---------- $292.00 $308.00 $326.00 $292.00 $308.00 $326.00

43238 0 ---------- $349.00 $367.00 $389.00 $349.00 $367.00 $389.00

43239 0 $246.00 $479.00 $508.00 $524.00 $207.00 $219.00 $232.00

43240 0 $369.00 $588.00 $619.00 $657.00 $588.00 $619.00 $657.00

43241 0 $157.00 $213.00 $225.00 $239.00 $213.00 $225.00 $239.00

43242 0 $384.00 $393.00 $413.00 $437.00 $393.00 $413.00 $437.00

43243 0 $276.00 $355.00 $374.00 $397.00 $355.00 $374.00 $397.00

43244 0 $268.00 $367.00 $386.00 $409.00 $367.00 $386.00 $409.00

43245 0 $214.00 $768.00 $818.00 $842.00 $263.00 $278.00 $297.00

43246 0 $485.00 $301.00 $318.00 $340.00 $301.00 $318.00 $340.00

43247 0 $229.00 $493.00 $523.00 $542.00 $265.00 $279.00 $297.00

43248 0 $191.00 $492.00 $521.00 $539.00 $248.00 $261.00 $277.00

43249 0 $175.00 $1,397.00 $1,489.00 $1,516.00 $230.00 $242.00 $257.00

43250 0 $194.00 $557.00 $593.00 $614.00 $256.00 $270.00 $289.00

43251 0 $224.00 $617.00 $655.00 $677.00 $293.00 $309.00 $328.00

43252 0 ---------- $427.00 $452.00 $471.00 $252.00 $266.00 $283.00

43253 0 ---------- $393.00 $413.00 $437.00 $393.00 $413.00 $437.00

43254 0 ---------- $405.00 $426.00 $452.00 $405.00 $426.00 $452.00

43255 0 $343.00 $923.00 $981.00 $1,006.00 $301.00 $316.00 $335.00

43257 0 ---------- $349.00 $368.00 $392.00 $349.00 $368.00 $392.00

43259 0 $271.00 $338.00 $356.00 $377.00 $338.00 $356.00 $377.00



Surgery


(Non-Facility MRA)






43260 0 $349.00 $482.00 $507.00 $537.00 $482.00 $507.00 $537.00

43261 0 $362.00 $507.00 $533.00 $564.00 $507.00 $533.00 $564.00

43262 0 $447.00 $535.00 $563.00 $596.00 $535.00 $563.00 $596.00

43263 0 $386.00 $536.00 $564.00 $599.00 $536.00 $564.00 $599.00

43264 0 $522.00 $545.00 $573.00 $607.00 $545.00 $573.00 $607.00

43265 0 $527.00 $649.00 $683.00 $723.00 $649.00 $683.00 $723.00

43266 0 ---------- $328.00 $346.00 $369.00 $328.00 $346.00 $369.00

43270 0 ---------- $928.00 $986.00 $1,013.00 $336.00 $354.00 $375.00

43273 ZZZ ---------- $180.00 $189.00 $201.00 $180.00 $189.00 $201.00

43274 0 ---------- $693.00 $729.00 $773.00 $693.00 $729.00 $773.00

43275 0 ---------- $564.00 $593.00 $629.00 $564.00 $593.00 $629.00

43276 0 ---------- $722.00 $759.00 $804.00 $722.00 $759.00 $804.00

43277 0 ---------- $567.00 $596.00 $632.00 $567.00 $596.00 $632.00

43278 0 ---------- $649.00 $682.00 $723.00 $649.00 $682.00 $723.00

43279 90 ---------- $1,946.00 $2,087.00 $2,293.00 $1,946.00 $2,087.00 $2,293.00

43280 90 $1,314.00 $1,626.00 $1,745.00 $1,914.00 $1,626.00 $1,745.00 $1,914.00

43281 90 ---------- $2,329.00 $2,498.00 $2,745.00 $2,329.00 $2,498.00 $2,745.00

43282 90 ---------- $2,621.00 $2,812.00 $3,092.00 $2,621.00 $2,812.00 $3,092.00

43283 ZZZ ---------- $241.00 $259.00 $286.00 $241.00 $259.00 $286.00

43289 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

43300 90 $837.00 $906.00 $960.00 $1,020.00 $906.00 $960.00 $1,020.00

43305 90 $1,428.00 $1,604.00 $1,695.00 $1,805.00 $1,604.00 $1,695.00 $1,805.00

43310 90 $2,138.00 $2,229.00 $2,390.00 $2,629.00 $2,229.00 $2,390.00 $2,629.00

43312 90 $2,331.00 $2,427.00 $2,594.00 $2,840.00 $2,427.00 $2,594.00 $2,840.00

43313 90 $2,632.00 $4,008.00 $4,223.00 $4,490.00 $4,008.00 $4,223.00 $4,490.00

43314 90 $2,891.00 $4,480.00 $4,782.00 $5,217.00 $4,480.00 $4,782.00 $5,217.00

43320 90 $1,299.00 $2,082.00 $2,229.00 $2,437.00 $2,082.00 $2,229.00 $2,437.00

43325 90 $1,261.00 $2,009.00 $2,153.00 $2,358.00 $2,009.00 $2,153.00 $2,358.00

43327 90 ---------- $1,231.00 $1,320.00 $1,445.00 $1,231.00 $1,320.00 $1,445.00

43328 90 ---------- $1,703.00 $1,827.00 $2,009.00 $1,703.00 $1,827.00 $2,009.00

43330 90 $1,236.00 $2,011.00 $2,160.00 $2,374.00 $2,011.00 $2,160.00 $2,374.00

43331 90 $1,378.00 $2,015.00 $2,160.00 $2,367.00 $2,015.00 $2,160.00 $2,367.00

43332 90 ---------- $1,748.00 $1,876.00 $2,059.00 $1,748.00 $1,876.00 $2,059.00

43333 90 ---------- $1,910.00 $2,050.00 $2,253.00 $1,910.00 $2,050.00 $2,253.00

43334 90 ---------- $1,892.00 $2,030.00 $2,234.00 $1,892.00 $2,030.00 $2,234.00

43335 90 ---------- $2,031.00 $2,180.00 $2,402.00 $2,031.00 $2,180.00 $2,402.00

43336 90 ---------- $2,273.00 $2,438.00 $2,675.00 $2,273.00 $2,438.00 $2,675.00

43337 90 ---------- $2,451.00 $2,631.00 $2,890.00 $2,451.00 $2,631.00 $2,890.00

43338 ZZZ ---------- $177.00 $190.00 $211.00 $177.00 $190.00 $211.00

43340 90 $1,292.00 $2,060.00 $2,212.00 $2,428.00 $2,060.00 $2,212.00 $2,428.00

43341 90 $1,351.00 $2,120.00 $2,276.00 $2,504.00 $2,120.00 $2,276.00 $2,504.00

43351 90 $1,180.00 $2,064.00 $2,212.00 $2,411.00 $2,064.00 $2,212.00 $2,411.00

43352 90 $1,028.00 $1,611.00 $1,728.00 $1,895.00 $1,611.00 $1,728.00 $1,895.00

43360 90 $2,277.00 $3,557.00 $3,814.00 $4,182.00 $3,557.00 $3,814.00 $4,182.00

43361 90 $2,596.00 $3,891.00 $4,167.00 $4,571.00 $3,891.00 $4,167.00 $4,571.00

43400 90 $1,261.00 $2,193.00 $2,309.00 $2,444.00 $2,193.00 $2,309.00 $2,444.00

43401 90 $1,299.00 $2,181.00 $2,298.00 $2,443.00 $2,181.00 $2,298.00 $2,443.00

43405 90 $1,330.00 $2,291.00 $2,453.00 $2,675.00 $2,291.00 $2,453.00 $2,675.00

43410 90 $946.00 $1,573.00 $1,686.00 $1,839.00 $1,573.00 $1,686.00 $1,839.00

43415 90 $1,382.00 $3,878.00 $4,157.00 $4,565.00 $3,878.00 $4,157.00 $4,565.00



Surgery


(Non-Facility MRA)






43420 90 $854.00 $1,497.00 $1,583.00 $1,687.00 $1,497.00 $1,583.00 $1,687.00

43425 90 $1,338.00 $2,196.00 $2,354.00 $2,583.00 $2,196.00 $2,354.00 $2,583.00

43450 0 $91.00 $220.00 $234.00 $242.00 $118.00 $124.00 $131.00

43453 0 $102.00 $1,244.00 $1,327.00 $1,346.00 $128.00 $134.00 $142.00

43460 0 $203.00 $318.00 $335.00 $355.00 $318.00 $335.00 $355.00

43496 90 BR ---------- ---------- ---------- ---------- ---------- ----------

43499 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

43500 90 $649.00 $1,177.00 $1,260.00 $1,376.00 $1,177.00 $1,260.00 $1,376.00

43501 90 $1,105.00 $2,026.00 $2,174.00 $2,386.00 $2,026.00 $2,174.00 $2,386.00

43502 90 $1,247.00 $2,270.00 $2,438.00 $2,684.00 $2,270.00 $2,438.00 $2,684.00

43510 90 $680.00 $1,390.00 $1,493.00 $1,638.00 $1,390.00 $1,493.00 $1,638.00

43520 90 $599.00 $1,030.00 $1,105.00 $1,210.00 $1,030.00 $1,105.00 $1,210.00

43605 90 $686.00 $1,262.00 $1,355.00 $1,486.00 $1,262.00 $1,355.00 $1,486.00

43610 90 $861.00 $1,472.00 $1,579.00 $1,730.00 $1,472.00 $1,579.00 $1,730.00

43611 90 $1,001.00 $1,838.00 $1,972.00 $2,163.00 $1,838.00 $1,972.00 $2,163.00

43620 90 $1,691.00 $2,965.00 $3,179.00 $3,490.00 $2,965.00 $3,179.00 $3,490.00

43621 90 $1,718.00 $3,425.00 $3,675.00 $4,041.00 $3,425.00 $3,675.00 $4,041.00

43622 90 $1,798.00 $3,459.00 $3,709.00 $4,074.00 $3,459.00 $3,709.00 $4,074.00

43631 90 $1,445.00 $2,183.00 $2,342.00 $2,571.00 $2,183.00 $2,342.00 $2,571.00

43632 90 $1,443.00 $3,065.00 $3,289.00 $3,616.00 $3,065.00 $3,289.00 $3,616.00

43633 90 $1,467.00 $2,898.00 $3,110.00 $3,419.00 $2,898.00 $3,110.00 $3,419.00

43634 90 $1,786.00 $3,198.00 $3,431.00 $3,773.00 $3,198.00 $3,431.00 $3,773.00

43635 ZZZ $143.00 $171.00 $184.00 $204.00 $171.00 $184.00 $204.00

43640 90 $1,119.00 $1,771.00 $1,900.00 $2,083.00 $1,771.00 $1,900.00 $2,083.00

43641 90 $1,138.00 $1,789.00 $1,915.00 $2,091.00 $1,789.00 $1,915.00 $2,091.00

43644 90 ---------- $2,609.00 $2,799.00 $3,073.00 $2,609.00 $2,799.00 $3,073.00

43645 90 ---------- $2,781.00 $2,983.00 $3,275.00 $2,781.00 $2,983.00 $3,275.00

43651 90 $716.00 $976.00 $1,048.00 $1,146.00 $976.00 $1,048.00 $1,146.00

43652 90 $856.00 $1,147.00 $1,232.00 $1,349.00 $1,147.00 $1,232.00 $1,349.00

43653 90 $617.00 $853.00 $915.00 $996.00 $853.00 $915.00 $996.00

43659 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

43752 0 BR $60.00 $63.00 $66.00 $60.00 $63.00 $66.00

43753 0 ---------- $32.00 $34.00 $36.00 $32.00 $34.00 $36.00

43754 0 ---------- $169.00 $181.00 $185.00 $51.00 $54.00 $57.00

43755 0 ---------- $193.00 $206.00 $213.00 $89.00 $94.00 $100.00

43756 0 ---------- $279.00 $297.00 $304.00 $74.00 $78.00 $82.00

43757 0 ---------- $403.00 $428.00 $438.00 $114.00 $120.00 $127.00

43760 0 $81.00 $672.00 $717.00 $728.00 $70.00 $74.00 $79.00

43761 0 $107.00 $170.00 $178.00 $187.00 $152.00 $159.00 $168.00

43770 90 ---------- $1,679.00 $1,802.00 $1,972.00 $1,679.00 $1,802.00 $1,972.00

43771 90 ---------- $1,907.00 $2,045.00 $2,238.00 $1,907.00 $2,045.00 $2,238.00

43772 90 ---------- $1,421.00 $1,522.00 $1,665.00 $1,421.00 $1,522.00 $1,665.00

43773 90 ---------- $1,913.00 $2,053.00 $2,249.00 $1,913.00 $2,053.00 $2,249.00

43774 90 ---------- $1,439.00 $1,544.00 $1,691.00 $1,439.00 $1,544.00 $1,691.00

43775 90 ---------- $1,664.00 $1,779.00 $1,952.00 $1,664.00 $1,779.00 $1,952.00

43800 90 $793.00 $1,397.00 $1,499.00 $1,642.00 $1,397.00 $1,499.00 $1,642.00

43810 90 $846.00 $1,524.00 $1,634.00 $1,790.00 $1,524.00 $1,634.00 $1,790.00

43820 90 $896.00 $2,018.00 $2,165.00 $2,375.00 $2,018.00 $2,165.00 $2,375.00

43825 90 $1,128.00 $1,942.00 $2,081.00 $2,278.00 $1,942.00 $2,081.00 $2,278.00

43830 90 $592.00 $1,043.00 $1,118.00 $1,218.00 $1,043.00 $1,118.00 $1,218.00



Surgery


(Non-Facility MRA)






43831 90 $593.00 $833.00 $888.00 $957.00 $833.00 $888.00 $957.00

43832 90 $904.00 $1,556.00 $1,668.00 $1,826.00 $1,556.00 $1,668.00 $1,826.00

43840 90 $893.00 $2,044.00 $2,192.00 $2,405.00 $2,044.00 $2,192.00 $2,405.00

43843 90 $1,249.00 $1,908.00 $2,046.00 $2,241.00 $1,908.00 $2,046.00 $2,241.00

43845 90 ---------- $2,953.00 $3,168.00 $3,477.00 $2,953.00 $3,168.00 $3,477.00

43846 90 $1,528.00 $2,437.00 $2,615.00 $2,871.00 $2,437.00 $2,615.00 $2,871.00

43847 90 $1,678.00 $2,666.00 $2,854.00 $3,121.00 $2,666.00 $2,854.00 $3,121.00

43848 90 $1,795.00 $2,896.00 $3,106.00 $3,410.00 $2,896.00 $3,106.00 $3,410.00

43850 90 $1,425.00 $2,428.00 $2,601.00 $2,850.00 $2,428.00 $2,601.00 $2,850.00

43855 90 $1,454.00 $2,486.00 $2,641.00 $2,847.00 $2,486.00 $2,641.00 $2,847.00

43860 90 $1,435.00 $2,462.00 $2,640.00 $2,897.00 $2,462.00 $2,640.00 $2,897.00

43865 90 $1,549.00 $2,547.00 $2,729.00 $2,989.00 $2,547.00 $2,729.00 $2,989.00

43870 90 $590.00 $1,064.00 $1,140.00 $1,245.00 $1,064.00 $1,140.00 $1,245.00

43880 90 $1,352.00 $2,408.00 $2,584.00 $2,836.00 $2,408.00 $2,584.00 $2,836.00

43886 90 ---------- $534.00 $573.00 $618.00 $534.00 $573.00 $618.00

43887 90 ---------- $482.00 $518.00 $560.00 $482.00 $518.00 $560.00

43888 90 ---------- $679.00 $727.00 $788.00 $679.00 $727.00 $788.00

43999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

44005 90 $1,171.00 $1,646.00 $1,766.00 $1,935.00 $1,646.00 $1,766.00 $1,935.00

44010 90 $809.00 $1,289.00 $1,376.00 $1,494.00 $1,289.00 $1,376.00 $1,494.00

44015 ZZZ $1,171.00 $217.00 $233.00 $257.00 $217.00 $233.00 $257.00

44020 90 $891.00 $1,462.00 $1,567.00 $1,717.00 $1,462.00 $1,567.00 $1,717.00

44021 90 $888.00 $1,461.00 $1,565.00 $1,712.00 $1,461.00 $1,565.00 $1,712.00

44025 90 $905.00 $1,474.00 $1,578.00 $1,723.00 $1,474.00 $1,578.00 $1,723.00

44050 90 $862.00 $1,403.00 $1,505.00 $1,648.00 $1,403.00 $1,505.00 $1,648.00

44055 90 $957.00 $2,244.00 $2,405.00 $2,638.00 $2,244.00 $2,405.00 $2,638.00

44100 0 $117.00 $162.00 $171.00 $182.00 $162.00 $171.00 $182.00

44110 90 $784.00 $1,277.00 $1,368.00 $1,494.00 $1,277.00 $1,368.00 $1,494.00

44111 90 $963.00 $1,469.00 $1,570.00 $1,709.00 $1,469.00 $1,570.00 $1,709.00

44120 90 $1,078.00 $1,841.00 $1,973.00 $2,163.00 $1,841.00 $1,973.00 $2,163.00

44121 ZZZ $308.00 $367.00 $394.00 $434.00 $367.00 $394.00 $434.00

44125 90 $1,135.00 $1,773.00 $1,899.00 $2,076.00 $1,773.00 $1,899.00 $2,076.00

44126 90 $1,951.00 $3,666.00 $3,927.00 $4,304.00 $3,666.00 $3,927.00 $4,304.00

44127 90 $2,243.00 $4,166.00 $4,457.00 $4,880.00 $4,166.00 $4,457.00 $4,880.00

44128 ZZZ $242.00 $371.00 $397.00 $437.00 $371.00 $397.00 $437.00

44130 90 $938.00 $1,973.00 $2,113.00 $2,312.00 $1,973.00 $2,113.00 $2,312.00

44133 0 BR ---------- ---------- ---------- ---------- ---------- ----------

44136 0 BR ---------- ---------- ---------- ---------- ---------- ----------

44139 ZZZ $154.00 $184.00 $197.00 $217.00 $184.00 $197.00 $217.00

44140 90 $1,350.00 $2,015.00 $2,160.00 $2,364.00 $2,015.00 $2,160.00 $2,364.00

44141 90 $1,488.00 $2,739.00 $2,935.00 $3,206.00 $2,739.00 $2,935.00 $3,206.00

44143 90 $1,536.00 $2,501.00 $2,680.00 $2,931.00 $2,501.00 $2,680.00 $2,931.00

44144 90 $1,442.00 $2,659.00 $2,849.00 $3,119.00 $2,659.00 $2,849.00 $3,119.00

44145 90 $1,678.00 $2,490.00 $2,662.00 $2,906.00 $2,490.00 $2,662.00 $2,906.00

44146 90 $1,840.00 $3,177.00 $3,397.00 $3,697.00 $3,177.00 $3,397.00 $3,697.00

44147 90 $1,452.00 $2,923.00 $3,130.00 $3,426.00 $2,923.00 $3,130.00 $3,426.00

44150 90 $1,661.00 $2,796.00 $2,991.00 $3,256.00 $2,796.00 $2,991.00 $3,256.00

44151 90 $1,499.00 $3,198.00 $3,425.00 $3,737.00 $3,198.00 $3,425.00 $3,737.00

44155 90 $1,892.00 $3,113.00 $3,322.00 $3,602.00 $3,113.00 $3,322.00 $3,602.00

44156 90 $1,709.00 $3,408.00 $3,655.00 $4,004.00 $3,408.00 $3,655.00 $4,004.00



Surgery


(Non-Facility MRA)






44157 90 ---------- $3,229.00 $3,450.00 $3,752.00 $3,229.00 $3,450.00 $3,752.00

44158 90 ---------- $3,359.00 $3,605.00 $3,952.00 $3,359.00 $3,605.00 $3,952.00

44160 90 $1,236.00 $1,864.00 $1,997.00 $2,183.00 $1,864.00 $1,997.00 $2,183.00

44180 90 ---------- $1,379.00 $1,478.00 $1,616.00 $1,379.00 $1,478.00 $1,616.00

44186 90 ---------- $976.00 $1,047.00 $1,145.00 $976.00 $1,047.00 $1,145.00

44187 90 ---------- $1,643.00 $1,752.00 $1,893.00 $1,643.00 $1,752.00 $1,893.00

44188 90 ---------- $1,827.00 $1,954.00 $2,120.00 $1,827.00 $1,954.00 $2,120.00

44202 90 $1,603.00 $2,082.00 $2,231.00 $2,442.00 $2,082.00 $2,231.00 $2,442.00

44203 ZZZ $235.00 $365.00 $390.00 $428.00 $365.00 $390.00 $428.00

44204 90 $1,353.00 $2,309.00 $2,469.00 $2,693.00 $2,309.00 $2,469.00 $2,693.00

44205 90 $1,198.00 $2,007.00 $2,144.00 $2,336.00 $2,007.00 $2,144.00 $2,336.00

44206 90 $1,480.00 $2,628.00 $2,811.00 $3,067.00 $2,628.00 $2,811.00 $3,067.00

44207 90 $1,620.00 $2,730.00 $2,912.00 $3,167.00 $2,730.00 $2,912.00 $3,167.00

44208 90 $1,752.00 $2,974.00 $3,173.00 $3,445.00 $2,974.00 $3,173.00 $3,445.00

44210 90 $1,551.00 $2,658.00 $2,830.00 $3,060.00 $2,658.00 $2,830.00 $3,060.00

44211 90 $1,926.00 $3,258.00 $3,466.00 $3,740.00 $3,258.00 $3,466.00 $3,740.00

44212 90 $1,800.00 $3,048.00 $3,239.00 $3,488.00 $3,048.00 $3,239.00 $3,488.00

44213 ZZZ ---------- $285.00 $304.00 $332.00 $285.00 $304.00 $332.00

44227 90 ---------- $2,506.00 $2,682.00 $2,932.00 $2,506.00 $2,682.00 $2,932.00

44238 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

44300 90 $697.00 $1,262.00 $1,354.00 $1,482.00 $1,262.00 $1,354.00 $1,482.00

44310 90 $950.00 $1,564.00 $1,672.00 $1,821.00 $1,564.00 $1,672.00 $1,821.00

44312 90 $453.00 $876.00 $934.00 $1,007.00 $876.00 $934.00 $1,007.00

44314 90 $892.00 $1,496.00 $1,595.00 $1,727.00 $1,496.00 $1,595.00 $1,727.00

44316 90 $1,229.00 $2,133.00 $2,289.00 $2,511.00 $2,133.00 $2,289.00 $2,511.00

44320 90 $1,029.00 $1,801.00 $1,928.00 $2,104.00 $1,801.00 $1,928.00 $2,104.00

44322 90 $1,015.00 $1,473.00 $1,579.00 $1,706.00 $1,473.00 $1,579.00 $1,706.00

44340 90 $397.00 $926.00 $991.00 $1,073.00 $926.00 $991.00 $1,073.00

44345 90 $816.00 $1,573.00 $1,682.00 $1,830.00 $1,573.00 $1,682.00 $1,830.00

44346 90 $923.00 $1,771.00 $1,893.00 $2,061.00 $1,771.00 $1,893.00 $2,061.00

44360 0 $177.00 $215.00 $226.00 $239.00 $215.00 $226.00 $239.00

44361 0 $195.00 $237.00 $250.00 $264.00 $237.00 $250.00 $264.00

44363 0 $213.00 $287.00 $303.00 $321.00 $287.00 $303.00 $321.00

44364 0 $255.00 $306.00 $321.00 $340.00 $306.00 $321.00 $340.00

44365 0 $226.00 $269.00 $282.00 $297.00 $269.00 $282.00 $297.00

44366 0 $300.00 $359.00 $378.00 $400.00 $359.00 $378.00 $400.00

44369 0 $308.00 $368.00 $387.00 $410.00 $368.00 $387.00 $410.00

44370 0 $253.00 $399.00 $421.00 $447.00 $399.00 $421.00 $447.00

44372 0 $301.00 $361.00 $381.00 $405.00 $361.00 $381.00 $405.00

44373 0 $238.00 $288.00 $304.00 $324.00 $288.00 $304.00 $324.00

44376 0 $305.00 $426.00 $449.00 $476.00 $426.00 $449.00 $476.00

44377 0 $320.00 $449.00 $472.00 $501.00 $449.00 $472.00 $501.00

44378 0 $410.00 $576.00 $606.00 $642.00 $576.00 $606.00 $642.00

44379 0 $396.00 $614.00 $646.00 $685.00 $614.00 $646.00 $685.00

44380 0 $91.00 $233.00 $248.00 $254.00 $83.00 $88.00 $92.00

44381 0 ---------- $1,281.00 $1,367.00 $1,386.00 $126.00 $133.00 $141.00

44382 0 $110.00 $362.00 $385.00 $394.00 $109.00 $115.00 $121.00

44384 0 ---------- $228.00 $239.00 $252.00 $228.00 $239.00 $252.00

44385 0 $219.00 $266.00 $283.00 $292.00 $107.00 $113.00 $120.00

44386 0 $183.00 $396.00 $422.00 $433.00 $133.00 $140.00 $149.00



Surgery


(Non-Facility MRA)






44388 0 $326.00 $409.00 $434.00 $453.00 $235.00 $248.00 $266.00

44388-53 0 ---------- $203.00 $215.00 $224.00 $116.00 $122.00 $130.00

44389 0 $301.00 $532.00 $565.00 $586.00 $258.00 $272.00 $290.00

44390 0 $319.00 $529.00 $560.00 $582.00 $315.00 $332.00 $351.00

44391 0 $376.00 $964.00 $1,025.00 $1,053.00 $345.00 $363.00 $386.00

44392 0 $359.00 $496.00 $527.00 $550.00 $298.00 $314.00 $336.00

44394 0 $395.00 $572.00 $607.00 $633.00 $338.00 $357.00 $381.00

44401 0 ---------- $4,349.00 $4,640.00 $4,707.00 $364.00 $384.00 $409.00

44402 0 ---------- $390.00 $411.00 $436.00 $390.00 $411.00 $436.00

44403 0 ---------- $455.00 $479.00 $508.00 $455.00 $479.00 $508.00

44404 0 ---------- $506.00 $537.00 $556.00 $257.00 $271.00 $288.00

44405 0 ---------- $750.00 $798.00 $821.00 $274.00 $289.00 $307.00

44406 0 ---------- $344.00 $363.00 $385.00 $344.00 $363.00 $385.00

44407 0 ---------- $412.00 $435.00 $462.00 $412.00 $435.00 $462.00

44408 0 ---------- $347.00 $366.00 $388.00 $347.00 $366.00 $388.00

44500 0 $28.00 $28.00 $29.00 $31.00 $28.00 $29.00 $31.00

44602 90 $815.00 $2,129.00 $2,282.00 $2,506.00 $2,129.00 $2,282.00 $2,506.00

44603 90 $1,041.00 $2,442.00 $2,617.00 $2,869.00 $2,442.00 $2,617.00 $2,869.00

44604 90 $1,027.00 $1,592.00 $1,706.00 $1,869.00 $1,592.00 $1,706.00 $1,869.00

44605 90 $1,132.00 $1,957.00 $2,095.00 $2,290.00 $1,957.00 $2,095.00 $2,290.00

44615 90 $994.00 $1,612.00 $1,726.00 $1,886.00 $1,612.00 $1,726.00 $1,886.00

44620 90 $741.00 $1,299.00 $1,389.00 $1,512.00 $1,299.00 $1,389.00 $1,512.00

44625 90 $1,277.00 $1,521.00 $1,623.00 $1,763.00 $1,521.00 $1,623.00 $1,763.00

44626 90 $1,581.00 $2,413.00 $2,583.00 $2,828.00 $2,413.00 $2,583.00 $2,828.00

44640 90 $1,036.00 $2,108.00 $2,256.00 $2,467.00 $2,108.00 $2,256.00 $2,467.00

44650 90 $1,076.00 $2,174.00 $2,325.00 $2,541.00 $2,174.00 $2,325.00 $2,541.00

44660 90 $1,050.00 $1,995.00 $2,118.00 $2,285.00 $1,995.00 $2,118.00 $2,285.00

44661 90 $1,326.00 $2,326.00 $2,481.00 $2,701.00 $2,326.00 $2,481.00 $2,701.00

44680 90 $1,049.00 $1,604.00 $1,720.00 $1,883.00 $1,604.00 $1,720.00 $1,883.00

44700 90 $1,115.00 $1,517.00 $1,614.00 $1,743.00 $1,517.00 $1,614.00 $1,743.00

44701 ZZZ $161.00 $255.00 $272.00 $299.00 $255.00 $272.00 $299.00

44720 0 ---------- $451.00 $478.00 $512.00 $451.00 $478.00 $512.00

44721 0 ---------- $585.00 $629.00 $695.00 $585.00 $629.00 $695.00

44799 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

44800 90 $791.00 $1,143.00 $1,224.00 $1,333.00 $1,143.00 $1,224.00 $1,333.00

44820 90 $755.00 $1,252.00 $1,341.00 $1,463.00 $1,252.00 $1,341.00 $1,463.00

44850 90 $708.00 $1,122.00 $1,202.00 $1,312.00 $1,122.00 $1,202.00 $1,312.00

44899 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

44900 90 $644.00 $1,147.00 $1,227.00 $1,337.00 $1,147.00 $1,227.00 $1,337.00

44950 90 $643.00 $964.00 $1,034.00 $1,132.00 $964.00 $1,034.00 $1,132.00

44955 ZZZ $136.00 $127.00 $136.00 $150.00 $127.00 $136.00 $150.00

44960 90 $790.00 $1,314.00 $1,410.00 $1,546.00 $1,314.00 $1,410.00 $1,546.00

44970 90 $631.00 $898.00 $963.00 $1,052.00 $898.00 $963.00 $1,052.00

44979 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

45000 90 $329.00 $623.00 $663.00 $710.00 $623.00 $663.00 $710.00

45005 10 $197.00 $390.00 $417.00 $437.00 $237.00 $253.00 $271.00

45020 90 $364.00 $849.00 $907.00 $981.00 $849.00 $907.00 $981.00

45100 90 $321.00 $439.00 $467.00 $499.00 $439.00 $467.00 $499.00

45108 90 $419.00 $540.00 $578.00 $626.00 $540.00 $578.00 $626.00

45110 90 $1,801.00 $2,754.00 $2,936.00 $3,178.00 $2,754.00 $2,936.00 $3,178.00



Surgery


(Non-Facility MRA)






45111 90 $1,270.00 $1,623.00 $1,734.00 $1,883.00 $1,623.00 $1,734.00 $1,883.00

45112 90 $1,904.00 $2,803.00 $2,980.00 $3,222.00 $2,803.00 $2,980.00 $3,222.00

45113 90 $1,885.00 $2,877.00 $3,057.00 $3,294.00 $2,877.00 $3,057.00 $3,294.00

45114 90 $1,732.00 $2,717.00 $2,912.00 $3,191.00 $2,717.00 $2,912.00 $3,191.00

45116 90 $1,485.00 $2,428.00 $2,597.00 $2,836.00 $2,428.00 $2,597.00 $2,836.00

45119 90 $1,911.00 $2,898.00 $3,078.00 $3,317.00 $2,898.00 $3,078.00 $3,317.00

45120 90 $1,845.00 $2,386.00 $2,561.00 $2,808.00 $2,386.00 $2,561.00 $2,808.00

45121 90 $1,870.00 $2,464.00 $2,608.00 $2,794.00 $2,464.00 $2,608.00 $2,794.00

45123 90 $1,126.00 $1,665.00 $1,769.00 $1,905.00 $1,665.00 $1,769.00 $1,905.00

45126 90 $2,444.00 $4,158.00 $4,414.00 $4,757.00 $4,158.00 $4,414.00 $4,757.00

45130 90 $1,041.00 $1,617.00 $1,717.00 $1,845.00 $1,617.00 $1,717.00 $1,845.00

45135 90 $1,354.00 $2,050.00 $2,198.00 $2,403.00 $2,050.00 $2,198.00 $2,403.00

45136 90 $1,526.00 $2,868.00 $3,079.00 $3,373.00 $2,868.00 $3,079.00 $3,373.00

45150 90 $475.00 $526.00 $552.00 $580.00 $526.00 $552.00 $580.00

45160 90 $949.00 $1,531.00 $1,643.00 $1,799.00 $1,531.00 $1,643.00 $1,799.00

45171 90 ---------- $882.00 $941.00 $1,007.00 $882.00 $941.00 $1,007.00

45172 90 ---------- $1,193.00 $1,269.00 $1,359.00 $1,193.00 $1,269.00 $1,359.00

45190 90 $623.00 $1,023.00 $1,087.00 $1,160.00 $1,023.00 $1,087.00 $1,160.00

45300 0 $75.00 $173.00 $184.00 $190.00 $80.00 $84.00 $90.00

45303 0 $72.00 $1,238.00 $1,322.00 $1,344.00 $129.00 $137.00 $148.00

45305 0 $102.00 $202.00 $215.00 $224.00 $109.00 $116.00 $124.00

45307 0 $172.00 $237.00 $252.00 $265.00 $145.00 $154.00 $166.00

45308 0 $137.00 $227.00 $243.00 $257.00 $126.00 $135.00 $148.00

45309 0 $174.00 $237.00 $254.00 $269.00 $134.00 $144.00 $158.00

45315 0 $211.00 $258.00 $276.00 $293.00 $158.00 $169.00 $184.00

45317 0 $209.00 $260.00 $276.00 $290.00 $167.00 $177.00 $189.00

45320 0 $230.00 $254.00 $272.00 $288.00 $157.00 $168.00 $184.00

45321 0 $154.00 $152.00 $162.00 $175.00 $152.00 $162.00 $175.00

45327 0 $96.00 $168.00 $177.00 $188.00 $168.00 $177.00 $188.00

45330 0 $87.00 $232.00 $247.00 $253.00 $83.00 $88.00 $93.00

45331 0 $120.00 $355.00 $377.00 $386.00 $107.00 $113.00 $119.00

45332 0 $174.00 $351.00 $374.00 $386.00 $157.00 $166.00 $177.00

45333 0 $176.00 $408.00 $435.00 $447.00 $141.00 $149.00 $159.00

45334 0 $171.00 $760.00 $809.00 $826.00 $176.00 $185.00 $196.00

45335 0 $144.00 $324.00 $345.00 $353.00 $99.00 $104.00 $111.00

45337 0 $144.00 $173.00 $183.00 $196.00 $173.00 $183.00 $196.00

45338 0 $212.00 $377.00 $400.00 $414.00 $180.00 $190.00 $202.00

45340 0 $328.00 $594.00 $633.00 $645.00 $116.00 $122.00 $130.00

45341 0 $153.00 $185.00 $194.00 $206.00 $185.00 $194.00 $206.00

45342 0 $224.00 $254.00 $267.00 $282.00 $254.00 $267.00 $282.00

45346 0 ---------- $4,170.00 $4,451.00 $4,507.00 $240.00 $253.00 $269.00

45347 0 ---------- $231.00 $243.00 $258.00 $231.00 $243.00 $258.00

45349 0 ---------- $297.00 $313.00 $332.00 $297.00 $313.00 $332.00

45350 0 ---------- $722.00 $770.00 $785.00 $150.00 $159.00 $168.00

45379 0 $415.00 $578.00 $613.00 $639.00 $359.00 $378.00 $403.00

45380 0 $369.00 $569.00 $604.00 $626.00 $300.00 $317.00 $336.00

45381 0 $388.00 $545.00 $577.00 $599.00 $300.00 $316.00 $335.00

45382 0 $481.00 $1,004.00 $1,066.00 $1,097.00 $388.00 $408.00 $433.00

45384 0 $415.00 $634.00 $673.00 $701.00 $343.00 $363.00 $388.00

45385 0 $479.00 $603.00 $638.00 $665.00 $381.00 $401.00 $426.00



Surgery


(Non-Facility MRA)






45386 0 $739.00 $816.00 $867.00 $894.00 $318.00 $335.00 $357.00

45388 0 ---------- $4,393.00 $4,687.00 $4,756.00 $406.00 $429.00 $457.00

45389 0 ---------- $435.00 $458.00 $487.00 $435.00 $458.00 $487.00

45390 0 ---------- $498.00 $524.00 $557.00 $498.00 $524.00 $557.00

45391 0 ---------- $386.00 $406.00 $430.00 $386.00 $406.00 $430.00

45392 0 ---------- $455.00 $479.00 $508.00 $455.00 $479.00 $508.00

45393 0 ---------- $380.00 $401.00 $428.00 $380.00 $401.00 $428.00

45395 90 ---------- $2,943.00 $3,130.00 $3,373.00 $2,943.00 $3,130.00 $3,373.00

45397 90 ---------- $3,199.00 $3,396.00 $3,649.00 $3,199.00 $3,396.00 $3,649.00

45398 0 ---------- $937.00 $996.00 $1,025.00 $352.00 $371.00 $394.00

45400 90 ---------- $1,694.00 $1,799.00 $1,934.00 $1,694.00 $1,799.00 $1,934.00

45402 90 ---------- $2,266.00 $2,407.00 $2,597.00 $2,266.00 $2,407.00 $2,597.00

45500 90 $584.00 $762.00 $806.00 $852.00 $762.00 $806.00 $852.00

45505 90 $510.00 $870.00 $927.00 $992.00 $870.00 $927.00 $992.00

45520 0 $46.00 $215.00 $229.00 $233.00 $59.00 $62.00 $65.00

45540 90 $1,009.00 $1,573.00 $1,671.00 $1,800.00 $1,573.00 $1,671.00 $1,800.00

45541 90 $888.00 $1,402.00 $1,497.00 $1,619.00 $1,402.00 $1,497.00 $1,619.00

45550 90 $1,350.00 $2,177.00 $2,314.00 $2,496.00 $2,177.00 $2,314.00 $2,496.00

45560 90 $618.00 $1,008.00 $1,061.00 $1,122.00 $1,008.00 $1,061.00 $1,122.00

45562 90 $915.00 $1,674.00 $1,789.00 $1,941.00 $1,674.00 $1,789.00 $1,941.00

45563 90 $1,412.00 $2,458.00 $2,636.00 $2,880.00 $2,458.00 $2,636.00 $2,880.00

45800 90 $1,050.00 $1,791.00 $1,904.00 $2,054.00 $1,791.00 $1,904.00 $2,054.00

45805 90 $1,273.00 $2,136.00 $2,280.00 $2,471.00 $2,136.00 $2,280.00 $2,471.00

45820 90 $1,066.00 $1,658.00 $1,739.00 $1,834.00 $1,658.00 $1,739.00 $1,834.00

45825 90 $1,241.00 $2,108.00 $2,223.00 $2,359.00 $2,108.00 $2,223.00 $2,359.00

45900 10 $120.00 $299.00 $319.00 $343.00 $299.00 $319.00 $343.00

45905 10 $133.00 $248.00 $264.00 $282.00 $248.00 $264.00 $282.00

45910 10 $163.00 $284.00 $302.00 $322.00 $284.00 $302.00 $322.00

45915 10 $142.00 $472.00 $501.00 $523.00 $331.00 $350.00 $371.00

45990 0 ---------- $160.00 $171.00 $184.00 $160.00 $171.00 $184.00

45999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

46020 10 $230.00 $398.00 $424.00 $448.00 $342.00 $364.00 $388.00

46030 10 $94.00 $198.00 $211.00 $222.00 $133.00 $141.00 $151.00

46040 90 $393.00 $770.00 $822.00 $870.00 $607.00 $648.00 $694.00

46045 90 $312.00 $638.00 $682.00 $731.00 $638.00 $682.00 $731.00

46050 10 $105.00 $283.00 $302.00 $313.00 $142.00 $151.00 $161.00

46060 90 $482.00 $697.00 $743.00 $793.00 $697.00 $743.00 $793.00

46080 10 $246.00 $357.00 $381.00 $403.00 $237.00 $253.00 $274.00

46083 10 $98.00 $250.00 $266.00 $277.00 $155.00 $165.00 $175.00

46200 90 $323.00 $634.00 $676.00 $706.00 $471.00 $502.00 $531.00

46220 10 $118.00 $292.00 $311.00 $325.00 $174.00 $185.00 $197.00

46221 10 $124.00 $380.00 $404.00 $421.00 $276.00 $292.00 $308.00

46230 10 $198.00 $390.00 $416.00 $437.00 $254.00 $270.00 $290.00

46250 90 $400.00 $662.00 $706.00 $743.00 $462.00 $493.00 $528.00

46255 90 $501.00 $726.00 $775.00 $817.00 $520.00 $555.00 $595.00

46257 90 $504.00 $617.00 $658.00 $705.00 $617.00 $658.00 $705.00

46258 90 $539.00 $686.00 $736.00 $798.00 $686.00 $736.00 $798.00

46260 90 $598.00 $699.00 $746.00 $801.00 $699.00 $746.00 $801.00

46261 90 $655.00 $768.00 $817.00 $875.00 $768.00 $817.00 $875.00

46262 90 $686.00 $812.00 $864.00 $923.00 $812.00 $864.00 $923.00



Surgery


(Non-Facility MRA)






46270 90 $328.00 $729.00 $778.00 $822.00 $572.00 $611.00 $653.00

46275 90 $442.00 $771.00 $821.00 $864.00 $603.00 $642.00 $683.00

46280 90 $514.00 $685.00 $729.00 $776.00 $685.00 $729.00 $776.00

46285 90 $335.00 $766.00 $816.00 $857.00 $602.00 $641.00 $681.00

46288 90 $521.00 $807.00 $858.00 $917.00 $807.00 $858.00 $917.00

46320 10 $126.00 $262.00 $279.00 $292.00 $163.00 $174.00 $186.00

46500 10 $109.00 $265.00 $282.00 $293.00 $178.00 $189.00 $199.00

46505 10 ---------- $410.00 $436.00 $461.00 $348.00 $370.00 $394.00

46600 0 $38.00 $124.00 $132.00 $136.00 $60.00 $63.00 $67.00

46601 0 ---------- $193.00 $203.00 $210.00 $137.00 $143.00 $149.00

46604 0 $92.00 $854.00 $911.00 $926.00 $98.00 $104.00 $111.00

46606 0 $66.00 $316.00 $336.00 $347.00 $112.00 $119.00 $127.00

46607 0 ---------- $273.00 $289.00 $300.00 $186.00 $196.00 $206.00

46608 0 $115.00 $329.00 $352.00 $367.00 $125.00 $134.00 $146.00

46610 0 $114.00 $320.00 $341.00 $354.00 $121.00 $129.00 $140.00

46611 0 $149.00 $249.00 $265.00 $275.00 $120.00 $128.00 $137.00

46612 0 $196.00 $350.00 $374.00 $388.00 $137.00 $146.00 $158.00

46614 0 $169.00 $181.00 $193.00 $200.00 $95.00 $101.00 $107.00

46615 0 $202.00 $205.00 $219.00 $231.00 $137.00 $146.00 $158.00

46700 90 $585.00 $961.00 $1,021.00 $1,090.00 $961.00 $1,021.00 $1,090.00

46706 10 $140.00 $259.00 $277.00 $301.00 $259.00 $277.00 $301.00

46707 90 ---------- $691.00 $737.00 $790.00 $691.00 $737.00 $790.00

46710 90 ---------- $1,534.00 $1,623.00 $1,729.00 $1,534.00 $1,623.00 $1,729.00

46712 90 ---------- $3,119.00 $3,293.00 $3,505.00 $3,119.00 $3,293.00 $3,505.00

46715 90 $545.00 $803.00 $862.00 $937.00 $803.00 $862.00 $937.00

46716 90 $906.00 $1,620.00 $1,710.00 $1,808.00 $1,620.00 $1,710.00 $1,808.00

46730 90 $1,584.00 $2,675.00 $2,821.00 $2,991.00 $2,675.00 $2,821.00 $2,991.00

46735 90 $1,881.00 $3,101.00 $3,270.00 $3,470.00 $3,101.00 $3,270.00 $3,470.00

46740 90 $1,671.00 $2,989.00 $3,157.00 $3,355.00 $2,989.00 $3,157.00 $3,355.00

46742 90 $2,236.00 $3,999.00 $4,246.00 $4,525.00 $3,999.00 $4,246.00 $4,525.00

46744 90 $2,412.00 $5,308.00 $5,703.00 $6,270.00 $5,308.00 $5,703.00 $6,270.00

46746 90 $2,725.00 $5,285.00 $5,561.00 $5,906.00 $5,285.00 $5,561.00 $5,906.00

46748 90 $2,933.00 $5,851.00 $6,165.00 $6,558.00 $5,851.00 $6,165.00 $6,558.00

46750 90 $636.00 $1,107.00 $1,170.00 $1,243.00 $1,107.00 $1,170.00 $1,243.00

46753 90 $511.00 $845.00 $894.00 $946.00 $845.00 $894.00 $946.00

46754 10 $188.00 $416.00 $437.00 $448.00 $325.00 $340.00 $350.00

46760 90 $846.00 $1,622.00 $1,715.00 $1,819.00 $1,622.00 $1,715.00 $1,819.00

46761 90 $813.00 $1,357.00 $1,434.00 $1,526.00 $1,357.00 $1,434.00 $1,526.00

46762 90 $731.00 $1,338.00 $1,411.00 $1,494.00 $1,338.00 $1,411.00 $1,494.00

46900 10 $128.00 $341.00 $363.00 $376.00 $199.00 $211.00 $223.00

46910 10 $144.00 $362.00 $385.00 $400.00 $195.00 $207.00 $221.00

46916 10 $145.00 $325.00 $345.00 $357.00 $208.00 $219.00 $231.00

46917 10 $228.00 $632.00 $672.00 $688.00 $193.00 $204.00 $214.00

46922 10 $189.00 $377.00 $403.00 $420.00 $199.00 $212.00 $227.00

46924 10 $297.00 $745.00 $793.00 $817.00 $269.00 $285.00 $304.00

46930 90 ---------- $290.00 $308.00 $318.00 $210.00 $223.00 $233.00

46940 10 $165.00 $326.00 $346.00 $362.00 $215.00 $228.00 $243.00

46942 10 $145.00 $307.00 $326.00 $340.00 $193.00 $204.00 $217.00

46945 90 $199.00 $437.00 $466.00 $485.00 $325.00 $346.00 $364.00

46946 90 $270.00 $445.00 $474.00 $495.00 $326.00 $347.00 $367.00



Surgery


(Non-Facility MRA)






46947 90 ---------- $564.00 $603.00 $651.00 $564.00 $603.00 $651.00

46999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

47000 0 $218.00 $424.00 $450.00 $459.00 $132.00 $138.00 $144.00

47001 ZZZ $141.00 $158.00 $170.00 $188.00 $158.00 $170.00 $188.00

47010 90 $788.00 $1,806.00 $1,936.00 $2,116.00 $1,806.00 $1,936.00 $2,116.00

47015 90 $755.00 $1,740.00 $1,867.00 $2,042.00 $1,740.00 $1,867.00 $2,042.00

47100 90 $550.00 $1,259.00 $1,350.00 $1,471.00 $1,259.00 $1,350.00 $1,471.00

47120 90 $1,663.00 $3,506.00 $3,764.00 $4,131.00 $3,506.00 $3,764.00 $4,131.00

47122 90 $2,512.00 $5,174.00 $5,553.00 $6,108.00 $5,174.00 $5,553.00 $6,108.00

47125 90 $2,293.00 $4,637.00 $4,977.00 $5,474.00 $4,637.00 $4,977.00 $5,474.00

47130 90 $2,482.00 $4,984.00 $5,349.00 $5,885.00 $4,984.00 $5,349.00 $5,885.00

47135 90 $6,164.00 $8,076.00 $8,666.00 $9,510.00 $8,076.00 $8,666.00 $9,510.00

47146 0 ---------- $502.00 $539.00 $596.00 $502.00 $539.00 $596.00

47147 0 ---------- $581.00 $624.00 $689.00 $581.00 $624.00 $689.00

47300 90 $778.00 $1,695.00 $1,818.00 $1,985.00 $1,695.00 $1,818.00 $1,985.00

47350 90 $942.00 $2,051.00 $2,199.00 $2,404.00 $2,051.00 $2,199.00 $2,404.00

47360 90 $1,305.00 $2,780.00 $2,977.00 $3,256.00 $2,780.00 $2,977.00 $3,256.00

47361 90 $2,129.00 $4,573.00 $4,903.00 $5,384.00 $4,573.00 $4,903.00 $5,384.00

47362 90 $849.00 $2,179.00 $2,339.00 $2,564.00 $2,179.00 $2,339.00 $2,564.00

47370 90 $943.00 $1,876.00 $2,013.00 $2,208.00 $1,876.00 $2,013.00 $2,208.00

47371 90 $889.00 $1,857.00 $1,983.00 $2,158.00 $1,857.00 $1,983.00 $2,158.00

47379 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

47380 90 $1,107.00 $2,163.00 $2,316.00 $2,534.00 $2,163.00 $2,316.00 $2,534.00

47381 90 $1,094.00 $2,043.00 $2,153.00 $2,292.00 $2,043.00 $2,153.00 $2,292.00

47382 10 $660.00 $6,646.00 $7,068.00 $7,180.00 $1,106.00 $1,152.00 $1,205.00

47383 10 ---------- $9,294.00 $9,909.00 $10,031.00 $667.00 $695.00 $727.00

47399 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

47400 90 $1,435.00 $3,209.00 $3,440.00 $3,770.00 $3,209.00 $3,440.00 $3,770.00

47420 90 $1,222.00 $2,012.00 $2,159.00 $2,365.00 $2,012.00 $2,159.00 $2,365.00

47425 90 $1,275.00 $1,959.00 $2,096.00 $2,289.00 $1,959.00 $2,096.00 $2,289.00

47460 90 $1,039.00 $1,888.00 $2,026.00 $2,218.00 $1,888.00 $2,026.00 $2,218.00

47480 90 $755.00 $1,306.00 $1,401.00 $1,525.00 $1,306.00 $1,401.00 $1,525.00

47490 10 $467.00 $478.00 $501.00 $520.00 $478.00 $501.00 $520.00

47531 0 ---------- $432.00 $459.00 $467.00 $104.00 $109.00 $114.00

47532 0 ---------- $1,111.00 $1,179.00 $1,204.00 $317.00 $331.00 $348.00

47533 0 ---------- $1,709.00 $1,815.00 $1,849.00 $397.00 $414.00 $435.00

47534 0 ---------- $2,038.00 $2,162.00 $2,205.00 $553.00 $575.00 $603.00

47535 0 ---------- $1,401.00 $1,489.00 $1,515.00 $294.00 $306.00 $321.00

47536 0 ---------- $951.00 $1,010.00 $1,028.00 $197.00 $205.00 $214.00

47537 0 ---------- $507.00 $537.00 $548.00 $143.00 $149.00 $155.00

47538 0 ---------- $5,896.00 $6,288.00 $6,363.00 $350.00 $364.00 $382.00

47539 0 ---------- $6,539.00 $6,967.00 $7,060.00 $635.00 $661.00 $692.00

47540 0 ---------- $6,703.00 $7,142.00 $7,238.00 $658.00 $686.00 $719.00

47541 0 ---------- $1,627.00 $1,725.00 $1,763.00 $496.00 $517.00 $543.00

47542 ZZZ ---------- $640.00 $678.00 $693.00 $202.00 $210.00 $220.00

47543 ZZZ ---------- $804.00 $858.00 $887.00 $241.00 $257.00 $280.00

47544 ZZZ ---------- $1,497.00 $1,593.00 $1,621.00 $241.00 $252.00 $267.00

47550 ZZZ $209.00 $251.00 $270.00 $298.00 $251.00 $270.00 $298.00

47552 0 $364.00 $456.00 $475.00 $498.00 $456.00 $475.00 $498.00

47553 0 $342.00 $454.00 $472.00 $496.00 $454.00 $472.00 $496.00



Surgery


(Non-Facility MRA)






47554 0 $594.00 $704.00 $741.00 $789.00 $704.00 $741.00 $789.00

47555 0 $383.00 $538.00 $560.00 $587.00 $538.00 $560.00 $587.00

47556 0 $425.00 $614.00 $639.00 $669.00 $614.00 $639.00 $669.00

47562 90 $837.00 $984.00 $1,056.00 $1,155.00 $984.00 $1,056.00 $1,155.00

47563 90 $900.00 $1,070.00 $1,148.00 $1,257.00 $1,070.00 $1,148.00 $1,257.00

47564 90 $1,069.00 $1,669.00 $1,791.00 $1,961.00 $1,669.00 $1,791.00 $1,961.00

47570 90 $961.00 $1,166.00 $1,252.00 $1,374.00 $1,166.00 $1,252.00 $1,374.00

47579 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

47600 90 $868.00 $1,601.00 $1,717.00 $1,880.00 $1,601.00 $1,717.00 $1,880.00

47605 90 $935.00 $1,687.00 $1,810.00 $1,984.00 $1,687.00 $1,810.00 $1,984.00

47610 90 $1,164.00 $1,886.00 $2,024.00 $2,221.00 $1,886.00 $2,024.00 $2,221.00

47612 90 $1,276.00 $1,904.00 $2,042.00 $2,238.00 $1,904.00 $2,042.00 $2,238.00

47620 90 $1,295.00 $2,059.00 $2,209.00 $2,421.00 $2,059.00 $2,209.00 $2,421.00

47700 90 $1,111.00 $1,554.00 $1,666.00 $1,818.00 $1,554.00 $1,666.00 $1,818.00

47701 90 $1,913.00 $2,557.00 $2,733.00 $2,977.00 $2,557.00 $2,733.00 $2,977.00

47711 90 $1,442.00 $2,339.00 $2,510.00 $2,753.00 $2,339.00 $2,510.00 $2,753.00

47712 90 $1,793.00 $3,003.00 $3,223.00 $3,540.00 $3,003.00 $3,223.00 $3,540.00

47715 90 $1,157.00 $1,989.00 $2,134.00 $2,337.00 $1,989.00 $2,134.00 $2,337.00

47720 90 $1,040.00 $1,707.00 $1,829.00 $1,994.00 $1,707.00 $1,829.00 $1,994.00

47721 90 $1,248.00 $2,030.00 $2,180.00 $2,392.00 $2,030.00 $2,180.00 $2,392.00

47740 90 $1,188.00 $1,960.00 $2,102.00 $2,300.00 $1,960.00 $2,102.00 $2,300.00

47741 90 $1,425.00 $2,178.00 $2,335.00 $2,555.00 $2,178.00 $2,335.00 $2,555.00

47760 90 $1,568.00 $3,394.00 $3,643.00 $4,001.00 $3,394.00 $3,643.00 $4,001.00

47765 90 $1,624.00 $4,588.00 $4,928.00 $5,424.00 $4,588.00 $4,928.00 $5,424.00

47780 90 $1,635.00 $3,730.00 $4,004.00 $4,403.00 $3,730.00 $4,004.00 $4,403.00

47785 90 $1,871.00 $4,892.00 $5,249.00 $5,772.00 $4,892.00 $5,249.00 $5,772.00

47800 90 $1,485.00 $2,367.00 $2,538.00 $2,779.00 $2,367.00 $2,538.00 $2,779.00

47801 90 $906.00 $1,479.00 $1,560.00 $1,659.00 $1,479.00 $1,560.00 $1,659.00

47802 90 $1,352.00 $2,291.00 $2,461.00 $2,701.00 $2,291.00 $2,461.00 $2,701.00

47900 90 $1,331.00 $2,060.00 $2,211.00 $2,422.00 $2,060.00 $2,211.00 $2,422.00

47999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

48000 90 $1,053.00 $2,806.00 $3,007.00 $3,296.00 $2,806.00 $3,007.00 $3,296.00

48001 90 $1,305.00 $3,492.00 $3,752.00 $4,134.00 $3,492.00 $3,752.00 $4,134.00

48020 90 $983.00 $1,741.00 $1,866.00 $2,040.00 $1,741.00 $1,866.00 $2,040.00

48100 90 $779.00 $1,334.00 $1,431.00 $1,566.00 $1,334.00 $1,431.00 $1,566.00

48102 10 $341.00 $747.00 $789.00 $810.00 $355.00 $370.00 $387.00

48105 90 ---------- $4,293.00 $4,604.00 $5,056.00 $4,293.00 $4,604.00 $5,056.00

48120 90 $1,083.00 $1,663.00 $1,784.00 $1,955.00 $1,663.00 $1,784.00 $1,955.00

48140 90 $1,546.00 $2,353.00 $2,526.00 $2,772.00 $2,353.00 $2,526.00 $2,772.00

48145 90 $1,661.00 $2,442.00 $2,620.00 $2,874.00 $2,442.00 $2,620.00 $2,874.00

48146 90 $1,830.00 $2,812.00 $3,017.00 $3,305.00 $2,812.00 $3,017.00 $3,305.00

48148 90 $1,149.00 $1,869.00 $2,007.00 $2,204.00 $1,869.00 $2,007.00 $2,204.00

48150 90 $3,101.00 $4,696.00 $5,042.00 $5,545.00 $4,696.00 $5,042.00 $5,545.00

48152 90 $2,888.00 $4,350.00 $4,672.00 $5,136.00 $4,350.00 $4,672.00 $5,136.00

48153 90 $3,099.00 $4,668.00 $5,011.00 $5,507.00 $4,668.00 $5,011.00 $5,507.00

48154 90 $2,893.00 $4,347.00 $4,667.00 $5,130.00 $4,347.00 $4,667.00 $5,130.00

48155 90 $1,855.00 $2,729.00 $2,929.00 $3,210.00 $2,729.00 $2,929.00 $3,210.00

48160 0 BR ---------- ---------- ---------- ---------- ---------- ----------

48400 ZZZ $100.00 $161.00 $171.00 $187.00 $161.00 $171.00 $187.00

48500 90 $1,012.00 $1,683.00 $1,796.00 $1,944.00 $1,683.00 $1,796.00 $1,944.00



Surgery


(Non-Facility MRA)






48510 90 $938.00 $1,629.00 $1,746.00 $1,904.00 $1,629.00 $1,746.00 $1,904.00

48520 90 $1,103.00 $1,639.00 $1,756.00 $1,922.00 $1,639.00 $1,756.00 $1,922.00

48540 90 $1,350.00 $1,974.00 $2,120.00 $2,329.00 $1,974.00 $2,120.00 $2,329.00

48545 90 $1,170.00 $2,023.00 $2,173.00 $2,387.00 $2,023.00 $2,173.00 $2,387.00

48547 90 $1,630.00 $2,683.00 $2,876.00 $3,152.00 $2,683.00 $2,876.00 $3,152.00

48548 90 ---------- $2,493.00 $2,673.00 $2,931.00 $2,493.00 $2,673.00 $2,931.00

48552 0 ---------- $356.00 $381.00 $421.00 $356.00 $381.00 $421.00

48554 90 $2,365.00 $3,799.00 $4,072.00 $4,425.00 $3,799.00 $4,072.00 $4,425.00

48556 90 $1,117.00 $1,893.00 $2,032.00 $2,216.00 $1,893.00 $2,032.00 $2,216.00

48999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

49000 90 $862.00 $1,152.00 $1,234.00 $1,346.00 $1,152.00 $1,234.00 $1,346.00

49002 90 $784.00 $1,570.00 $1,682.00 $1,841.00 $1,570.00 $1,682.00 $1,841.00

49010 90 $915.00 $1,402.00 $1,500.00 $1,638.00 $1,402.00 $1,500.00 $1,638.00

49020 90 $910.00 $2,388.00 $2,559.00 $2,799.00 $2,388.00 $2,559.00 $2,799.00

49040 90 $763.00 $1,497.00 $1,603.00 $1,751.00 $1,497.00 $1,603.00 $1,751.00

49060 90 $827.00 $1,646.00 $1,761.00 $1,922.00 $1,646.00 $1,761.00 $1,922.00

49062 90 $892.00 $1,106.00 $1,184.00 $1,290.00 $1,106.00 $1,184.00 $1,290.00

49082 0 ---------- $269.00 $286.00 $294.00 $109.00 $115.00 $121.00

49083 0 ---------- $409.00 $433.00 $443.00 $159.00 $166.00 $174.00

49084 0 ---------- $164.00 $175.00 $192.00 $164.00 $175.00 $192.00

49180 0 $212.00 $230.00 $242.00 $249.00 $126.00 $131.00 $137.00

49185 0 ---------- $1,344.00 $1,431.00 $1,452.00 $179.00 $187.00 $196.00

49203 90 ---------- $1,793.00 $1,917.00 $2,090.00 $1,793.00 $1,917.00 $2,090.00

49204 90 ---------- $2,300.00 $2,460.00 $2,685.00 $2,300.00 $2,460.00 $2,685.00

49205 90 ---------- $2,644.00 $2,831.00 $3,096.00 $2,644.00 $2,831.00 $3,096.00

49215 90 $1,551.00 $3,323.00 $3,549.00 $3,862.00 $3,323.00 $3,549.00 $3,862.00

49220 90 $1,182.00 $1,460.00 $1,568.00 $1,720.00 $1,460.00 $1,568.00 $1,720.00

49250 90 $622.00 $877.00 $939.00 $1,022.00 $877.00 $939.00 $1,022.00

49255 90 $591.00 $1,180.00 $1,262.00 $1,372.00 $1,180.00 $1,262.00 $1,372.00

49320 10 $415.00 $483.00 $516.00 $558.00 $483.00 $516.00 $558.00

49321 10 $443.00 $513.00 $548.00 $594.00 $513.00 $548.00 $594.00

49322 10 $460.00 $548.00 $584.00 $631.00 $548.00 $584.00 $631.00

49323 90 $712.00 $946.00 $1,009.00 $1,090.00 $946.00 $1,009.00 $1,090.00

49324 10 ---------- $582.00 $623.00 $680.00 $582.00 $623.00 $680.00

49325 10 ---------- $621.00 $666.00 $727.00 $621.00 $666.00 $727.00

49326 ZZZ ---------- $287.00 $308.00 $341.00 $287.00 $308.00 $341.00

49327 ZZZ ---------- $199.00 $213.00 $236.00 $199.00 $213.00 $236.00

49329 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

49400 0 $127.00 $193.00 $204.00 $213.00 $138.00 $145.00 $153.00

49402 90 ---------- $1,283.00 $1,375.00 $1,503.00 $1,283.00 $1,375.00 $1,503.00

49405 0 ---------- $1,116.00 $1,184.00 $1,207.00 $293.00 $305.00 $319.00

49406 0 ---------- $1,116.00 $1,184.00 $1,207.00 $293.00 $305.00 $319.00

49407 0 ---------- $911.00 $965.00 $987.00 $312.00 $325.00 $342.00

49411 0 ---------- $672.00 $710.00 $727.00 $271.00 $282.00 $295.00

49412 ZZZ ---------- $124.00 $133.00 $146.00 $124.00 $133.00 $146.00

49418 0 ---------- $1,875.00 $1,996.00 $2,029.00 $302.00 $316.00 $333.00

49419 90 $405.00 $661.00 $705.00 $762.00 $661.00 $705.00 $762.00

49421 0 $452.00 $348.00 $372.00 $410.00 $348.00 $372.00 $410.00

49422 10 $468.00 $569.00 $610.00 $666.00 $569.00 $610.00 $666.00

49423 0 $106.00 $751.00 $799.00 $811.00 $106.00 $110.00 $115.00



Surgery


(Non-Facility MRA)






49424 0 $54.00 $202.00 $214.00 $219.00 $56.00 $59.00 $62.00

49425 90 $914.00 $1,072.00 $1,141.00 $1,233.00 $1,072.00 $1,141.00 $1,233.00

49426 90 $725.00 $914.00 $978.00 $1,067.00 $914.00 $978.00 $1,067.00

49427 0 $48.00 $68.00 $72.00 $77.00 $68.00 $72.00 $77.00

49428 10 $184.00 $693.00 $751.00 $833.00 $693.00 $751.00 $833.00

49429 10 $522.00 $690.00 $741.00 $813.00 $690.00 $741.00 $813.00

49435 ZZZ ---------- $182.00 $195.00 $216.00 $182.00 $195.00 $216.00

49436 10 ---------- $277.00 $298.00 $324.00 $277.00 $298.00 $324.00

49440 10 ---------- $1,338.00 $1,421.00 $1,447.00 $305.00 $319.00 $334.00

49441 10 ---------- $1,512.00 $1,609.00 $1,643.00 $359.00 $377.00 $399.00

49442 10 ---------- $1,256.00 $1,334.00 $1,358.00 $306.00 $320.00 $333.00

49446 0 ---------- $1,282.00 $1,363.00 $1,386.00 $221.00 $230.00 $242.00

49450 0 ---------- $913.00 $972.00 $986.00 $99.00 $103.00 $108.00

49451 0 ---------- $999.00 $1,064.00 $1,080.00 $134.00 $140.00 $147.00

49452 0 ---------- $1,237.00 $1,315.00 $1,336.00 $206.00 $214.00 $224.00

49460 0 ---------- $1,007.00 $1,074.00 $1,088.00 $71.00 $74.00 $78.00

49465 0 ---------- $226.00 $240.00 $244.00 $46.00 $47.00 $49.00

49505 90 $510.00 $776.00 $832.00 $907.00 $776.00 $832.00 $907.00

49507 90 $636.00 $873.00 $937.00 $1,022.00 $873.00 $937.00 $1,022.00

49520 90 $631.00 $945.00 $1,013.00 $1,108.00 $945.00 $1,013.00 $1,108.00

49521 90 $730.00 $1,072.00 $1,151.00 $1,259.00 $1,072.00 $1,151.00 $1,259.00

49525 90 $584.00 $855.00 $917.00 $1,001.00 $855.00 $917.00 $1,001.00

49540 90 $668.00 $1,007.00 $1,081.00 $1,181.00 $1,007.00 $1,081.00 $1,181.00

49550 90 $557.00 $859.00 $922.00 $1,006.00 $859.00 $922.00 $1,006.00

49553 90 $598.00 $942.00 $1,011.00 $1,104.00 $942.00 $1,011.00 $1,104.00

49555 90 $621.00 $893.00 $958.00 $1,046.00 $893.00 $958.00 $1,046.00

49557 90 $715.00 $1,084.00 $1,164.00 $1,273.00 $1,084.00 $1,164.00 $1,273.00

49560 90 $734.00 $1,104.00 $1,184.00 $1,294.00 $1,104.00 $1,184.00 $1,294.00

49561 90 $856.00 $1,395.00 $1,497.00 $1,640.00 $1,395.00 $1,497.00 $1,640.00

49565 90 $754.00 $1,149.00 $1,232.00 $1,346.00 $1,149.00 $1,232.00 $1,346.00

49566 90 $881.00 $1,408.00 $1,510.00 $1,654.00 $1,408.00 $1,510.00 $1,654.00

49568 ZZZ $339.00 $405.00 $435.00 $479.00 $405.00 $435.00 $479.00

49570 90 $411.00 $618.00 $663.00 $720.00 $618.00 $663.00 $720.00

49572 90 $491.00 $769.00 $825.00 $900.00 $769.00 $825.00 $900.00

49585 90 $444.00 $661.00 $709.00 $771.00 $661.00 $709.00 $771.00

49587 90 $501.00 $706.00 $758.00 $825.00 $706.00 $758.00 $825.00

49590 90 $585.00 $855.00 $917.00 $1,001.00 $855.00 $917.00 $1,001.00

49600 90 $774.00 $963.00 $1,009.00 $1,060.00 $963.00 $1,009.00 $1,060.00

49605 90 $1,648.00 $7,483.00 $8,042.00 $8,876.00 $7,483.00 $8,042.00 $8,876.00

49606 90 $1,416.00 $1,707.00 $1,834.00 $2,018.00 $1,707.00 $1,834.00 $2,018.00

49610 90 $784.00 $959.00 $1,012.00 $1,077.00 $959.00 $1,012.00 $1,077.00

49611 90 $770.00 $823.00 $868.00 $920.00 $823.00 $868.00 $920.00

49650 90 $484.00 $637.00 $683.00 $743.00 $637.00 $683.00 $743.00

49651 90 $621.00 $829.00 $889.00 $968.00 $829.00 $889.00 $968.00

49652 90 ---------- $1,113.00 $1,194.00 $1,305.00 $1,113.00 $1,194.00 $1,305.00

49653 90 ---------- $1,389.00 $1,490.00 $1,630.00 $1,389.00 $1,490.00 $1,630.00

49654 90 ---------- $1,267.00 $1,360.00 $1,488.00 $1,267.00 $1,360.00 $1,488.00

49655 90 ---------- $1,547.00 $1,660.00 $1,817.00 $1,547.00 $1,660.00 $1,817.00

49656 90 ---------- $1,376.00 $1,476.00 $1,616.00 $1,376.00 $1,476.00 $1,616.00

49657 90 ---------- $1,985.00 $2,129.00 $2,335.00 $1,985.00 $2,129.00 $2,335.00



Surgery


(Non-Facility MRA)






49659 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

49900 90 $512.00 $1,212.00 $1,298.00 $1,410.00 $1,212.00 $1,298.00 $1,410.00

49904 90 $1,394.00 $2,112.00 $2,256.00 $2,444.00 $2,112.00 $2,256.00 $2,444.00

49905 ZZZ $454.00 $534.00 $571.00 $626.00 $534.00 $571.00 $626.00

49906 90 BR ---------- ---------- ---------- ---------- ---------- ----------

49999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

50010 90 $886.00 $1,092.00 $1,158.00 $1,240.00 $1,092.00 $1,158.00 $1,240.00

50020 90 $1,084.00 $1,488.00 $1,561.00 $1,645.00 $1,488.00 $1,561.00 $1,645.00

50040 90 $910.00 $1,358.00 $1,424.00 $1,500.00 $1,358.00 $1,424.00 $1,500.00

50045 90 $1,137.00 $1,381.00 $1,451.00 $1,535.00 $1,381.00 $1,451.00 $1,535.00

50060 90 $1,394.00 $1,674.00 $1,754.00 $1,848.00 $1,674.00 $1,754.00 $1,848.00

50065 90 $1,514.00 $1,775.00 $1,860.00 $1,960.00 $1,775.00 $1,860.00 $1,960.00

50070 90 $1,476.00 $1,825.00 $1,923.00 $2,044.00 $1,825.00 $1,923.00 $2,044.00

50075 90 $1,839.00 $2,144.00 $2,247.00 $2,371.00 $2,144.00 $2,247.00 $2,371.00

50080 90 $1,186.00 $1,275.00 $1,336.00 $1,408.00 $1,275.00 $1,336.00 $1,408.00

50081 90 $1,635.00 $1,873.00 $1,963.00 $2,069.00 $1,873.00 $1,963.00 $2,069.00

50100 90 $1,250.00 $1,626.00 $1,730.00 $1,860.00 $1,626.00 $1,730.00 $1,860.00

50120 90 $1,180.00 $1,419.00 $1,493.00 $1,584.00 $1,419.00 $1,493.00 $1,584.00

50125 90 $1,228.00 $1,511.00 $1,593.00 $1,691.00 $1,511.00 $1,593.00 $1,691.00

50130 90 $1,301.00 $1,513.00 $1,586.00 $1,670.00 $1,513.00 $1,586.00 $1,670.00

50135 90 $1,506.00 $1,646.00 $1,725.00 $1,818.00 $1,646.00 $1,725.00 $1,818.00

50200 0 $151.00 $740.00 $787.00 $802.00 $190.00 $199.00 $209.00

50205 90 $807.00 $1,126.00 $1,205.00 $1,313.00 $1,126.00 $1,205.00 $1,313.00

50220 90 $1,316.00 $1,542.00 $1,625.00 $1,728.00 $1,542.00 $1,625.00 $1,728.00

50225 90 $1,554.00 $1,768.00 $1,859.00 $1,971.00 $1,768.00 $1,859.00 $1,971.00

50230 90 $1,695.00 $1,887.00 $1,980.00 $2,095.00 $1,887.00 $1,980.00 $2,095.00

50234 90 $1,671.00 $1,913.00 $2,007.00 $2,120.00 $1,913.00 $2,007.00 $2,120.00

50236 90 $1,873.00 $2,155.00 $2,259.00 $2,384.00 $2,155.00 $2,259.00 $2,384.00

50240 90 $1,679.00 $1,943.00 $2,037.00 $2,149.00 $1,943.00 $2,037.00 $2,149.00

50250 90 ---------- $1,774.00 $1,858.00 $1,957.00 $1,774.00 $1,858.00 $1,957.00

50280 90 $1,170.00 $1,409.00 $1,482.00 $1,570.00 $1,409.00 $1,482.00 $1,570.00

50290 90 $1,080.00 $1,316.00 $1,380.00 $1,454.00 $1,316.00 $1,380.00 $1,454.00

50320 90 $1,680.00 $2,241.00 $2,406.00 $2,624.00 $2,241.00 $2,406.00 $2,624.00

50327 0 ---------- $328.00 $352.00 $387.00 $328.00 $352.00 $387.00

50328 0 ---------- $288.00 $308.00 $339.00 $288.00 $308.00 $339.00

50329 0 ---------- $271.00 $289.00 $316.00 $271.00 $289.00 $316.00

50340 90 $1,083.00 $1,408.00 $1,511.00 $1,646.00 $1,408.00 $1,511.00 $1,646.00

50360 90 $2,475.00 $3,624.00 $3,884.00 $4,247.00 $3,624.00 $3,884.00 $4,247.00

50365 90 $2,941.00 $4,269.00 $4,571.00 $4,983.00 $4,269.00 $4,571.00 $4,983.00

50370 90 $1,128.00 $1,792.00 $1,919.00 $2,089.00 $1,792.00 $1,919.00 $2,089.00

50380 90 $1,507.00 $2,863.00 $3,065.00 $3,333.00 $2,863.00 $3,065.00 $3,333.00

50382 0 ---------- $1,534.00 $1,629.00 $1,660.00 $380.00 $396.00 $415.00

50384 0 ---------- $1,207.00 $1,279.00 $1,306.00 $343.00 $357.00 $375.00

50385 0 ---------- $1,491.00 $1,585.00 $1,614.00 $323.00 $337.00 $355.00

50386 0 ---------- $953.00 $1,013.00 $1,034.00 $241.00 $253.00 $267.00

50387 0 ---------- $675.00 $718.00 $730.00 $125.00 $130.00 $136.00

50389 0 ---------- $410.00 $435.00 $443.00 $80.00 $83.00 $87.00

50390 0 $118.00 $142.00 $147.00 $154.00 $142.00 $147.00 $154.00

50391 0 ---------- $176.00 $184.00 $192.00 $144.00 $150.00 $158.00

50395 0 $203.00 $261.00 $273.00 $286.00 $261.00 $273.00 $286.00



Surgery


(Non-Facility MRA)






50396 0 $101.00 $171.00 $178.00 $186.00 $171.00 $178.00 $186.00

50400 90 $1,441.00 $1,701.00 $1,784.00 $1,882.00 $1,701.00 $1,784.00 $1,882.00

50405 90 $1,802.00 $2,054.00 $2,153.00 $2,271.00 $2,054.00 $2,153.00 $2,271.00

50430 0 ---------- $634.00 $672.00 $686.00 $225.00 $235.00 $245.00

50431 0 ---------- $227.00 $240.00 $246.00 $97.00 $101.00 $105.00

50432 0 ---------- $1,069.00 $1,134.00 $1,156.00 $305.00 $318.00 $332.00

50433 0 ---------- $1,461.00 $1,550.00 $1,580.00 $381.00 $397.00 $415.00

50434 0 ---------- $1,146.00 $1,217.00 $1,240.00 $288.00 $300.00 $314.00

50435 0 ---------- $650.00 $691.00 $703.00 $148.00 $154.00 $161.00

50500 90 $1,471.00 $1,702.00 $1,785.00 $1,884.00 $1,702.00 $1,785.00 $1,884.00

50520 90 $1,281.00 $1,511.00 $1,583.00 $1,666.00 $1,511.00 $1,583.00 $1,666.00

50525 90 $1,644.00 $2,390.00 $2,584.00 $2,860.00 $2,390.00 $2,584.00 $2,860.00

50526 90 $1,639.00 $2,202.00 $2,338.00 $2,524.00 $2,202.00 $2,338.00 $2,524.00

50540 90 $1,468.00 $1,669.00 $1,745.00 $1,831.00 $1,669.00 $1,745.00 $1,831.00

50541 90 $1,037.00 $1,349.00 $1,414.00 $1,490.00 $1,349.00 $1,414.00 $1,490.00

50542 90 $1,093.00 $1,711.00 $1,793.00 $1,890.00 $1,711.00 $1,793.00 $1,890.00

50543 90 $1,374.00 $2,184.00 $2,289.00 $2,413.00 $2,184.00 $2,289.00 $2,413.00

50544 90 $1,428.00 $1,832.00 $1,920.00 $2,026.00 $1,832.00 $1,920.00 $2,026.00

50545 90 $1,273.00 $1,970.00 $2,065.00 $2,180.00 $1,970.00 $2,065.00 $2,180.00

50546 90 $1,325.00 $1,769.00 $1,858.00 $1,965.00 $1,769.00 $1,858.00 $1,965.00

50547 90 $1,702.00 $2,399.00 $2,563.00 $2,783.00 $2,399.00 $2,563.00 $2,783.00

50548 90 $1,555.00 $1,982.00 $2,077.00 $2,193.00 $1,982.00 $2,077.00 $2,193.00

50549 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

50551 0 $411.00 $522.00 $548.00 $575.00 $434.00 $455.00 $480.00

50553 0 $447.00 $556.00 $584.00 $611.00 $461.00 $482.00 $508.00

50555 0 $668.00 $598.00 $628.00 $658.00 $503.00 $526.00 $555.00

50557 0 $676.00 $609.00 $640.00 $670.00 $510.00 $535.00 $564.00

50561 0 $755.00 $689.00 $724.00 $759.00 $581.00 $608.00 $642.00

50562 90 $580.00 $854.00 $895.00 $943.00 $854.00 $895.00 $943.00

50570 0 $549.00 $728.00 $763.00 $807.00 $728.00 $763.00 $807.00

50572 0 $728.00 $785.00 $822.00 $868.00 $785.00 $822.00 $868.00

50574 0 $762.00 $834.00 $873.00 $922.00 $834.00 $873.00 $922.00

50575 0 $991.00 $1,055.00 $1,105.00 $1,168.00 $1,055.00 $1,105.00 $1,168.00

50576 0 $801.00 $832.00 $871.00 $920.00 $832.00 $871.00 $920.00

50580 0 $726.00 $897.00 $939.00 $992.00 $897.00 $939.00 $992.00

50590 90 $980.00 $1,034.00 $1,089.00 $1,136.00 $830.00 $870.00 $915.00

50592 10 ---------- $1,707.00 $1,810.00 $1,846.00 $508.00 $530.00 $554.00

50593 10 ---------- $6,200.00 $6,604.00 $6,694.00 $682.00 $710.00 $743.00

50600 90 $1,150.00 $1,383.00 $1,451.00 $1,531.00 $1,383.00 $1,451.00 $1,531.00

50605 90 $1,054.00 $1,467.00 $1,562.00 $1,690.00 $1,467.00 $1,562.00 $1,690.00

50606 ZZZ ---------- $973.00 $1,033.00 $1,054.00 $231.00 $241.00 $254.00

50610 90 $1,209.00 $1,420.00 $1,490.00 $1,572.00 $1,420.00 $1,490.00 $1,572.00

50620 90 $1,152.00 $1,322.00 $1,385.00 $1,457.00 $1,322.00 $1,385.00 $1,457.00

50630 90 $1,170.00 $1,316.00 $1,380.00 $1,454.00 $1,316.00 $1,380.00 $1,454.00

50650 90 $1,297.00 $1,520.00 $1,594.00 $1,682.00 $1,520.00 $1,594.00 $1,682.00

50660 90 $1,426.00 $1,703.00 $1,789.00 $1,893.00 $1,703.00 $1,789.00 $1,893.00

50684 0 $74.00 $149.00 $158.00 $162.00 $73.00 $77.00 $80.00

50686 0 $109.00 $208.00 $220.00 $227.00 $131.00 $138.00 $145.00

50688 10 $89.00 $115.00 $120.00 $125.00 $115.00 $120.00 $125.00

50690 0 $85.00 $140.00 $148.00 $153.00 $103.00 $107.00 $112.00



Surgery


(Non-Facility MRA)






50693 0 ---------- $1,362.00 $1,447.00 $1,472.00 $302.00 $314.00 $329.00

50694 0 ---------- $1,499.00 $1,590.00 $1,621.00 $395.00 $412.00 $431.00

50695 0 ---------- $1,841.00 $1,953.00 $1,992.00 $507.00 $528.00 $553.00

50700 90 $1,192.00 $1,353.00 $1,419.00 $1,494.00 $1,353.00 $1,419.00 $1,494.00

50705 ZZZ ---------- $2,656.00 $2,829.00 $2,871.00 $295.00 $308.00 $324.00

50706 ZZZ ---------- $1,377.00 $1,464.00 $1,491.00 $278.00 $290.00 $306.00

50715 90 $1,397.00 $1,816.00 $1,933.00 $2,089.00 $1,816.00 $1,933.00 $2,089.00

50722 90 $1,211.00 $1,548.00 $1,636.00 $1,746.00 $1,548.00 $1,636.00 $1,746.00

50725 90 $1,371.00 $1,659.00 $1,745.00 $1,852.00 $1,659.00 $1,745.00 $1,852.00

50727 90 $640.00 $744.00 $783.00 $826.00 $744.00 $783.00 $826.00

50728 90 $924.00 $1,021.00 $1,070.00 $1,125.00 $1,021.00 $1,070.00 $1,125.00

50740 90 $1,386.00 $1,819.00 $1,951.00 $2,137.00 $1,819.00 $1,951.00 $2,137.00

50750 90 $1,457.00 $1,681.00 $1,758.00 $1,847.00 $1,681.00 $1,758.00 $1,847.00

50760 90 $1,389.00 $1,661.00 $1,752.00 $1,867.00 $1,661.00 $1,752.00 $1,867.00

50770 90 $1,485.00 $1,731.00 $1,822.00 $1,936.00 $1,731.00 $1,822.00 $1,936.00

50780 90 $1,391.00 $1,631.00 $1,717.00 $1,823.00 $1,631.00 $1,717.00 $1,823.00

50782 90 $1,465.00 $1,786.00 $1,914.00 $2,092.00 $1,786.00 $1,914.00 $2,092.00

50783 90 $1,515.00 $1,664.00 $1,746.00 $1,844.00 $1,664.00 $1,746.00 $1,844.00

50785 90 $1,548.00 $1,783.00 $1,871.00 $1,977.00 $1,783.00 $1,871.00 $1,977.00

50800 90 $1,226.00 $1,354.00 $1,421.00 $1,499.00 $1,354.00 $1,421.00 $1,499.00

50810 90 $1,527.00 $2,037.00 $2,175.00 $2,362.00 $2,037.00 $2,175.00 $2,362.00

50815 90 $1,643.00 $1,799.00 $1,887.00 $1,990.00 $1,799.00 $1,887.00 $1,990.00

50820 90 $1,729.00 $1,933.00 $2,029.00 $2,145.00 $1,933.00 $2,029.00 $2,145.00

50825 90 $2,351.00 $2,440.00 $2,561.00 $2,709.00 $2,440.00 $2,561.00 $2,709.00

50830 90 $2,292.00 $2,678.00 $2,813.00 $2,980.00 $2,678.00 $2,813.00 $2,980.00

50840 90 $1,493.00 $1,806.00 $1,894.00 $1,997.00 $1,806.00 $1,894.00 $1,997.00

50845 90 $1,513.00 $1,833.00 $1,922.00 $2,025.00 $1,833.00 $1,922.00 $2,025.00

50860 90 $1,163.00 $1,398.00 $1,468.00 $1,551.00 $1,398.00 $1,468.00 $1,551.00

50900 90 $1,043.00 $1,264.00 $1,333.00 $1,416.00 $1,264.00 $1,333.00 $1,416.00

50920 90 $1,075.00 $1,344.00 $1,414.00 $1,496.00 $1,344.00 $1,414.00 $1,496.00

50930 90 $1,380.00 $1,616.00 $1,692.00 $1,781.00 $1,616.00 $1,692.00 $1,781.00

50940 90 $1,107.00 $1,291.00 $1,352.00 $1,419.00 $1,291.00 $1,352.00 $1,419.00

50945 90 $1,096.00 $1,435.00 $1,506.00 $1,590.00 $1,435.00 $1,506.00 $1,590.00

50947 90 $1,384.00 $2,040.00 $2,139.00 $2,259.00 $2,040.00 $2,139.00 $2,259.00

50948 90 $1,265.00 $1,876.00 $1,966.00 $2,075.00 $1,876.00 $1,966.00 $2,075.00

50949 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

50951 0 $414.00 $545.00 $573.00 $600.00 $452.00 $473.00 $500.00

50953 0 $461.00 $576.00 $605.00 $634.00 $480.00 $502.00 $530.00

50955 0 $546.00 $617.00 $648.00 $679.00 $519.00 $544.00 $574.00

50957 0 $546.00 $623.00 $655.00 $686.00 $523.00 $548.00 $578.00

50961 0 $510.00 $561.00 $590.00 $619.00 $468.00 $490.00 $518.00

50970 0 $510.00 $546.00 $572.00 $603.00 $546.00 $572.00 $603.00

50972 0 $408.00 $528.00 $552.00 $583.00 $528.00 $552.00 $583.00

50974 0 $661.00 $698.00 $730.00 $771.00 $698.00 $730.00 $771.00

50976 0 $641.00 $688.00 $720.00 $760.00 $688.00 $720.00 $760.00

50980 0 $443.00 $525.00 $549.00 $580.00 $525.00 $549.00 $580.00

51020 90 $587.00 $684.00 $718.00 $754.00 $684.00 $718.00 $754.00

51030 90 $538.00 $686.00 $720.00 $755.00 $686.00 $720.00 $755.00

51040 90 $439.00 $421.00 $442.00 $464.00 $421.00 $442.00 $464.00

51045 90 $548.00 $716.00 $757.00 $803.00 $716.00 $757.00 $803.00



Surgery


(Non-Facility MRA)






51050 90 $596.00 $689.00 $723.00 $759.00 $689.00 $723.00 $759.00

51060 90 $768.00 $845.00 $885.00 $928.00 $845.00 $885.00 $928.00

51065 90 $704.00 $846.00 $888.00 $934.00 $846.00 $888.00 $934.00

51080 90 $510.00 $598.00 $628.00 $660.00 $598.00 $628.00 $660.00

51100 0 ---------- $88.00 $93.00 $97.00 $58.00 $60.00 $64.00

51101 0 ---------- $173.00 $184.00 $189.00 $76.00 $80.00 $84.00

51102 0 ---------- $323.00 $340.00 $353.00 $212.00 $222.00 $234.00

51500 90 $775.00 $934.00 $980.00 $1,032.00 $934.00 $980.00 $1,032.00

51520 90 $764.00 $871.00 $914.00 $962.00 $871.00 $914.00 $962.00

51525 90 $1,069.00 $1,260.00 $1,322.00 $1,393.00 $1,260.00 $1,322.00 $1,393.00

51530 90 $957.00 $1,174.00 $1,240.00 $1,320.00 $1,174.00 $1,240.00 $1,320.00

51535 90 $932.00 $1,144.00 $1,200.00 $1,264.00 $1,144.00 $1,200.00 $1,264.00

51550 90 $1,171.00 $1,421.00 $1,496.00 $1,587.00 $1,421.00 $1,496.00 $1,587.00

51555 90 $1,514.00 $1,865.00 $1,960.00 $2,075.00 $1,865.00 $1,960.00 $2,075.00

51565 90 $1,624.00 $1,912.00 $2,008.00 $2,124.00 $1,912.00 $2,008.00 $2,124.00

51570 90 $1,762.00 $2,175.00 $2,281.00 $2,411.00 $2,175.00 $2,281.00 $2,411.00

51575 90 $2,284.00 $2,678.00 $2,806.00 $2,962.00 $2,678.00 $2,806.00 $2,962.00

51580 90 $2,252.00 $2,832.00 $2,977.00 $3,155.00 $2,832.00 $2,977.00 $3,155.00

51585 90 $2,601.00 $3,112.00 $3,264.00 $3,450.00 $3,112.00 $3,264.00 $3,450.00

51590 90 $2,441.00 $2,845.00 $2,983.00 $3,152.00 $2,845.00 $2,983.00 $3,152.00

51595 90 $2,900.00 $3,218.00 $3,371.00 $3,559.00 $3,218.00 $3,371.00 $3,559.00

51596 90 $3,063.00 $3,461.00 $3,627.00 $3,829.00 $3,461.00 $3,627.00 $3,829.00

51597 90 $2,914.00 $3,372.00 $3,537.00 $3,738.00 $3,372.00 $3,537.00 $3,738.00

51600 0 $54.00 $254.00 $270.00 $275.00 $65.00 $68.00 $71.00

51605 0 $83.00 $56.00 $59.00 $62.00 $56.00 $59.00 $62.00

51610 0 $45.00 $150.00 $159.00 $163.00 $94.00 $98.00 $102.00

51700 0 $29.00 $102.00 $108.00 $111.00 $52.00 $55.00 $57.00

51701 0 $58.00 $67.00 $71.00 $74.00 $38.00 $40.00 $42.00

51702 0 $92.00 $88.00 $94.00 $96.00 $38.00 $40.00 $42.00

51703 0 $128.00 $177.00 $187.00 $194.00 $113.00 $118.00 $125.00

51705 0 $37.00 $128.00 $136.00 $140.00 $76.00 $80.00 $84.00

51710 0 $119.00 $182.00 $192.00 $199.00 $117.00 $123.00 $129.00

51715 0 $322.00 $415.00 $438.00 $456.00 $293.00 $308.00 $325.00

51720 0 $140.00 $124.00 $131.00 $135.00 $93.00 $98.00 $102.00

51725 0 $116.00 $262.00 $276.00 $284.00 $262.00 $276.00 $284.00

51725-26 0 ---------- $112.00 $116.00 $121.00 $112.00 $116.00 $121.00

51725-TC 0 ---------- $150.00 $160.00 $162.00 $150.00 $160.00 $162.00

51726 0 $136.00 $367.00 $388.00 $397.00 $367.00 $388.00 $397.00

51726-26 0 ---------- $125.00 $130.00 $135.00 $125.00 $130.00 $135.00

51726-TC 0 ---------- $242.00 $259.00 $262.00 $242.00 $259.00 $262.00

51727 0 ---------- $434.00 $459.00 $470.00 $434.00 $459.00 $470.00

51727-26 0 ---------- $157.00 $163.00 $170.00 $157.00 $163.00 $170.00

51727-TC 0 ---------- $277.00 $296.00 $300.00 $277.00 $296.00 $300.00

51728 0 ---------- $438.00 $464.00 $475.00 $438.00 $464.00 $475.00

51728-26 0 ---------- $153.00 $159.00 $166.00 $153.00 $159.00 $166.00

51728-TC 0 ---------- $285.00 $305.00 $309.00 $285.00 $305.00 $309.00

51729 0 ---------- $474.00 $502.00 $514.00 $474.00 $502.00 $514.00

51729-26 0 ---------- $185.00 $192.00 $201.00 $185.00 $192.00 $201.00

51729-TC 0 ---------- $290.00 $310.00 $313.00 $290.00 $310.00 $313.00

51736 0 $47.00 $22.00 $23.00 $24.00 $22.00 $23.00 $24.00



Surgery


(Non-Facility MRA)






51736-26 0 ---------- $12.00 $13.00 $13.00 $12.00 $13.00 $13.00

51736-TC 0 ---------- $10.00 $11.00 $11.00 $10.00 $11.00 $11.00

51741 0 $81.00 $22.00 $24.00 $25.00 $22.00 $24.00 $25.00

51741-26 0 ---------- $12.00 $13.00 $13.00 $12.00 $13.00 $13.00

51741-TC 0 ---------- $10.00 $11.00 $12.00 $10.00 $11.00 $12.00

51784 0 $119.00 $98.00 $103.00 $106.00 $98.00 $103.00 $106.00

51784-26 0 ---------- $55.00 $57.00 $59.00 $55.00 $57.00 $59.00

51784-TC 0 ---------- $43.00 $46.00 $47.00 $43.00 $46.00 $47.00

51785 0 $52.00 $373.00 $400.00 $419.00 $373.00 $400.00 $419.00

51785-26 0 ---------- $134.00 $145.00 $161.00 $134.00 $145.00 $161.00

51785-TC 0 ---------- $238.00 $255.00 $258.00 $238.00 $255.00 $258.00

51792 0 $143.00 $293.00 $311.00 $318.00 $293.00 $311.00 $318.00

51792-26 0 ---------- $81.00 $84.00 $87.00 $81.00 $84.00 $87.00

51792-TC 0 ---------- $213.00 $227.00 $230.00 $213.00 $227.00 $230.00

51797 ZZZ $109.00 $156.00 $165.00 $169.00 $156.00 $165.00 $169.00

51797-26 ZZZ ---------- $59.00 $61.00 $64.00 $59.00 $61.00 $64.00

51797-TC ZZZ ---------- $97.00 $104.00 $105.00 $97.00 $104.00 $105.00

51798 0 $20.00 $27.00 $29.00 $30.00 $27.00 $29.00 $30.00

51800 90 $1,294.00 $1,535.00 $1,610.00 $1,699.00 $1,535.00 $1,610.00 $1,699.00

51820 90 $1,236.00 $1,743.00 $1,855.00 $2,002.00 $1,743.00 $1,855.00 $2,002.00

51840 90 $858.00 $960.00 $1,008.00 $1,062.00 $960.00 $1,008.00 $1,062.00

51841 90 $1,040.00 $1,148.00 $1,208.00 $1,278.00 $1,148.00 $1,208.00 $1,278.00

51845 90 $843.00 $853.00 $895.00 $942.00 $853.00 $895.00 $942.00

51860 90 $912.00 $1,099.00 $1,161.00 $1,238.00 $1,099.00 $1,161.00 $1,238.00

51865 90 $1,150.00 $1,317.00 $1,387.00 $1,471.00 $1,317.00 $1,387.00 $1,471.00

51880 90 $590.00 $685.00 $722.00 $763.00 $685.00 $722.00 $763.00

51900 90 $1,050.00 $1,231.00 $1,295.00 $1,370.00 $1,231.00 $1,295.00 $1,370.00

51920 90 $881.00 $1,153.00 $1,218.00 $1,297.00 $1,153.00 $1,218.00 $1,297.00

51925 90 $1,167.00 $1,515.00 $1,597.00 $1,694.00 $1,515.00 $1,597.00 $1,694.00

51940 90 $2,082.00 $2,431.00 $2,548.00 $2,688.00 $2,431.00 $2,548.00 $2,688.00

51960 90 $1,848.00 $2,034.00 $2,132.00 $2,248.00 $2,034.00 $2,132.00 $2,248.00

51980 90 $858.00 $1,043.00 $1,093.00 $1,149.00 $1,043.00 $1,093.00 $1,149.00

51990 90 $850.00 $1,101.00 $1,156.00 $1,220.00 $1,101.00 $1,156.00 $1,220.00

51992 90 $925.00 $1,231.00 $1,293.00 $1,367.00 $1,231.00 $1,293.00 $1,367.00

52000 0 $190.00 $231.00 $245.00 $253.00 $148.00 $155.00 $163.00

52001 0 $133.00 $536.00 $564.00 $590.00 $423.00 $444.00 $468.00

52005 0 $265.00 $375.00 $396.00 $409.00 $196.00 $205.00 $217.00

52007 0 $230.00 $620.00 $657.00 $675.00 $244.00 $256.00 $270.00

52010 0 $292.00 $516.00 $546.00 $563.00 $244.00 $256.00 $270.00

52204 0 $286.00 $516.00 $547.00 $562.00 $208.00 $218.00 $230.00

52214 0 $367.00 $917.00 $974.00 $996.00 $261.00 $273.00 $289.00

52224 0 $339.00 $962.00 $1,021.00 $1,046.00 $301.00 $316.00 $334.00

52234 0 $471.00 $363.00 $380.00 $401.00 $363.00 $380.00 $401.00

52235 0 $546.00 $425.00 $446.00 $470.00 $425.00 $446.00 $470.00

52240 0 $887.00 $578.00 $605.00 $639.00 $578.00 $605.00 $639.00

52250 0 $311.00 $352.00 $369.00 $390.00 $352.00 $369.00 $390.00

52260 0 $262.00 $310.00 $325.00 $342.00 $310.00 $325.00 $342.00

52265 0 $243.00 $512.00 $543.00 $559.00 $239.00 $250.00 $264.00

52270 0 $374.00 $502.00 $530.00 $548.00 $268.00 $280.00 $296.00

52275 0 $446.00 $677.00 $716.00 $740.00 $366.00 $384.00 $405.00



Surgery


(Non-Facility MRA)






52276 0 $490.00 $390.00 $409.00 $432.00 $390.00 $409.00 $432.00

52277 0 $448.00 $476.00 $499.00 $526.00 $476.00 $499.00 $526.00

52281 0 $259.00 $386.00 $408.00 $422.00 $224.00 $235.00 $247.00

52282 0 $560.00 $496.00 $520.00 $550.00 $496.00 $520.00 $550.00

52283 0 $309.00 $397.00 $418.00 $437.00 $296.00 $311.00 $328.00

52285 0 $375.00 $400.00 $422.00 $440.00 $288.00 $302.00 $319.00

52287 0 ---------- $441.00 $465.00 $482.00 $249.00 $261.00 $276.00

52290 0 $304.00 $359.00 $376.00 $397.00 $359.00 $376.00 $397.00

52300 0 $370.00 $413.00 $433.00 $457.00 $413.00 $433.00 $457.00

52301 0 $382.00 $427.00 $448.00 $472.00 $427.00 $448.00 $472.00

52305 0 $370.00 $411.00 $431.00 $455.00 $411.00 $431.00 $455.00

52310 0 $348.00 $346.00 $365.00 $380.00 $223.00 $234.00 $247.00

52315 0 $553.00 $589.00 $621.00 $647.00 $404.00 $424.00 $447.00

52317 0 $772.00 $1,129.00 $1,195.00 $1,231.00 $512.00 $536.00 $566.00

52318 0 $684.00 $698.00 $731.00 $772.00 $698.00 $731.00 $772.00

52320 0 $369.00 $364.00 $381.00 $403.00 $364.00 $381.00 $403.00

52325 0 $494.00 $474.00 $496.00 $524.00 $474.00 $496.00 $524.00

52327 0 $369.00 $387.00 $405.00 $429.00 $387.00 $405.00 $429.00

52330 0 $507.00 $699.00 $738.00 $764.00 $389.00 $407.00 $430.00

52332 0 $451.00 $681.00 $723.00 $741.00 $229.00 $240.00 $253.00

52334 0 $340.00 $376.00 $394.00 $416.00 $376.00 $394.00 $416.00

52341 0 $317.00 $419.00 $439.00 $463.00 $419.00 $439.00 $463.00

52342 0 $344.00 $456.00 $478.00 $505.00 $456.00 $478.00 $505.00

52343 0 $380.00 $507.00 $531.00 $560.00 $507.00 $531.00 $560.00

52344 0 $407.00 $544.00 $570.00 $602.00 $544.00 $570.00 $602.00

52345 0 $433.00 $581.00 $609.00 $642.00 $581.00 $609.00 $642.00

52346 0 $488.00 $658.00 $688.00 $727.00 $658.00 $688.00 $727.00

52351 0 $297.00 $446.00 $467.00 $493.00 $446.00 $467.00 $493.00

52352 0 $349.00 $521.00 $546.00 $576.00 $521.00 $546.00 $576.00

52353 0 $404.00 $578.00 $605.00 $639.00 $578.00 $605.00 $639.00

52354 0 $372.00 $615.00 $644.00 $679.00 $615.00 $644.00 $679.00

52355 0 $447.00 $689.00 $722.00 $763.00 $689.00 $722.00 $763.00

52356 0 ---------- $613.00 $642.00 $677.00 $613.00 $642.00 $677.00

52400 90 $580.00 $701.00 $735.00 $775.00 $701.00 $735.00 $775.00

52402 0 ---------- $394.00 $413.00 $437.00 $394.00 $413.00 $437.00

52441 0 ---------- $1,711.00 $1,820.00 $1,855.00 $335.00 $350.00 $370.00

52442 ZZZ ---------- $1,300.00 $1,386.00 $1,404.00 $89.00 $93.00 $99.00

52450 90 $602.00 $685.00 $719.00 $755.00 $685.00 $719.00 $755.00

52500 90 $705.00 $712.00 $747.00 $784.00 $712.00 $747.00 $784.00

52601 90 $1,021.00 $1,240.00 $1,300.00 $1,369.00 $1,240.00 $1,300.00 $1,369.00

52630 90 $653.00 $583.00 $612.00 $642.00 $583.00 $612.00 $642.00

52640 90 $573.00 $457.00 $481.00 $503.00 $457.00 $481.00 $503.00

52647 90 $858.00 $2,484.00 $2,635.00 $2,702.00 $947.00 $993.00 $1,045.00

52648 90 $957.00 $2,558.00 $2,712.00 $2,784.00 $1,009.00 $1,059.00 $1,114.00

52649 90 ---------- $1,205.00 $1,263.00 $1,330.00 $1,205.00 $1,263.00 $1,330.00

52700 90 $517.00 $645.00 $677.00 $711.00 $645.00 $677.00 $711.00

53000 10 $224.00 $215.00 $226.00 $237.00 $215.00 $226.00 $237.00

53010 90 $336.00 $428.00 $450.00 $471.00 $428.00 $450.00 $471.00

53020 0 $153.00 $143.00 $150.00 $158.00 $143.00 $150.00 $158.00

53040 90 $460.00 $572.00 $601.00 $631.00 $572.00 $601.00 $631.00



Surgery


(Non-Facility MRA)






53060 10 $180.00 $265.00 $279.00 $293.00 $240.00 $252.00 $265.00

53080 90 $567.00 $612.00 $643.00 $674.00 $612.00 $643.00 $674.00

53085 90 $836.00 $966.00 $1,018.00 $1,078.00 $966.00 $1,018.00 $1,078.00

53200 0 $218.00 $227.00 $239.00 $252.00 $210.00 $220.00 $233.00

53210 90 $904.00 $1,142.00 $1,200.00 $1,268.00 $1,142.00 $1,200.00 $1,268.00

53215 90 $1,142.00 $1,362.00 $1,428.00 $1,506.00 $1,362.00 $1,428.00 $1,506.00

53220 90 $546.00 $669.00 $704.00 $742.00 $669.00 $704.00 $742.00

53230 90 $760.00 $886.00 $929.00 $978.00 $886.00 $929.00 $978.00

53235 90 $607.00 $928.00 $974.00 $1,026.00 $928.00 $974.00 $1,026.00

53240 90 $506.00 $619.00 $650.00 $683.00 $619.00 $650.00 $683.00

53250 90 $464.00 $596.00 $627.00 $658.00 $596.00 $627.00 $658.00

53260 10 $240.00 $291.00 $306.00 $321.00 $262.00 $275.00 $290.00

53265 10 $295.00 $314.00 $331.00 $346.00 $271.00 $285.00 $300.00

53270 10 $226.00 $298.00 $314.00 $329.00 $269.00 $282.00 $297.00

53275 10 $332.00 $385.00 $404.00 $426.00 $385.00 $404.00 $426.00

53400 90 $929.00 $1,171.00 $1,228.00 $1,292.00 $1,171.00 $1,228.00 $1,292.00

53405 90 $1,088.00 $1,288.00 $1,352.00 $1,426.00 $1,288.00 $1,352.00 $1,426.00

53410 90 $1,151.00 $1,433.00 $1,502.00 $1,583.00 $1,433.00 $1,502.00 $1,583.00

53415 90 $1,381.00 $1,658.00 $1,738.00 $1,831.00 $1,658.00 $1,738.00 $1,831.00

53420 90 $1,088.00 $1,233.00 $1,293.00 $1,362.00 $1,233.00 $1,293.00 $1,362.00

53425 90 $1,150.00 $1,374.00 $1,440.00 $1,517.00 $1,374.00 $1,440.00 $1,517.00

53430 90 $1,116.00 $1,418.00 $1,487.00 $1,569.00 $1,418.00 $1,487.00 $1,569.00

53431 90 $1,053.00 $1,693.00 $1,774.00 $1,869.00 $1,693.00 $1,774.00 $1,869.00

53440 90 $1,057.00 $1,102.00 $1,155.00 $1,216.00 $1,102.00 $1,155.00 $1,216.00

53442 90 $639.00 $1,143.00 $1,200.00 $1,261.00 $1,143.00 $1,200.00 $1,261.00

53444 90 $755.00 $1,161.00 $1,217.00 $1,281.00 $1,161.00 $1,217.00 $1,281.00

53445 90 $1,197.00 $1,101.00 $1,155.00 $1,214.00 $1,101.00 $1,155.00 $1,214.00

53446 90 $699.00 $938.00 $984.00 $1,034.00 $938.00 $984.00 $1,034.00

53447 90 $991.00 $1,183.00 $1,241.00 $1,306.00 $1,183.00 $1,241.00 $1,306.00

53448 90 $1,259.00 $1,882.00 $1,974.00 $2,083.00 $1,882.00 $1,974.00 $2,083.00

53449 90 $784.00 $894.00 $937.00 $986.00 $894.00 $937.00 $986.00

53450 90 $447.00 $595.00 $625.00 $656.00 $595.00 $625.00 $656.00

53460 90 $494.00 $668.00 $701.00 $737.00 $668.00 $701.00 $737.00

53500 90 ---------- $1,095.00 $1,149.00 $1,211.00 $1,095.00 $1,149.00 $1,211.00

53502 90 $590.00 $710.00 $745.00 $783.00 $710.00 $745.00 $783.00

53505 90 $586.00 $709.00 $744.00 $782.00 $709.00 $744.00 $782.00

53510 90 $777.00 $923.00 $968.00 $1,018.00 $923.00 $968.00 $1,018.00

53515 90 $987.00 $1,156.00 $1,211.00 $1,274.00 $1,156.00 $1,211.00 $1,274.00

53520 90 $661.00 $812.00 $852.00 $895.00 $812.00 $852.00 $895.00

53600 0 $37.00 $119.00 $126.00 $131.00 $94.00 $98.00 $103.00

53601 0 $37.00 $116.00 $122.00 $127.00 $79.00 $83.00 $87.00

53605 0 $81.00 $95.00 $100.00 $105.00 $95.00 $100.00 $105.00

53620 0 $59.00 $167.00 $176.00 $184.00 $129.00 $135.00 $142.00

53621 0 $45.00 $156.00 $164.00 $171.00 $106.00 $111.00 $117.00

53660 0 $49.00 $100.00 $105.00 $109.00 $61.00 $64.00 $68.00

53661 0 $50.00 $98.00 $104.00 $107.00 $59.00 $62.00 $66.00

53665 0 $50.00 $57.00 $60.00 $64.00 $57.00 $60.00 $64.00

53850 90 $741.00 $2,875.00 $3,054.00 $3,122.00 $885.00 $929.00 $975.00

53852 90 $728.00 $2,659.00 $2,823.00 $2,891.00 $910.00 $955.00 $1,004.00

53855 0 ---------- $1,068.00 $1,138.00 $1,155.00 $122.00 $128.00 $135.00



Surgery


(Non-Facility MRA)






53860 90 ---------- $2,156.00 $2,296.00 $2,334.00 $330.00 $346.00 $364.00

53899 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

54015 10 $348.00 $451.00 $473.00 $498.00 $451.00 $473.00 $498.00

54050 10 $91.00 $188.00 $199.00 $207.00 $153.00 $161.00 $169.00

54055 10 $106.00 $169.00 $178.00 $186.00 $134.00 $142.00 $148.00

54056 10 $100.00 $201.00 $213.00 $221.00 $160.00 $169.00 $177.00

54057 10 $149.00 $193.00 $204.00 $211.00 $137.00 $145.00 $151.00

54060 10 $180.00 $255.00 $270.00 $280.00 $189.00 $199.00 $209.00

54065 10 $281.00 $312.00 $330.00 $345.00 $251.00 $265.00 $279.00

54100 0 $149.00 $281.00 $298.00 $309.00 $184.00 $194.00 $204.00

54105 10 $261.00 $379.00 $399.00 $417.00 $311.00 $327.00 $343.00

54110 90 $775.00 $916.00 $961.00 $1,012.00 $916.00 $961.00 $1,012.00

54111 90 $1,035.00 $1,183.00 $1,240.00 $1,307.00 $1,183.00 $1,240.00 $1,307.00

54112 90 $1,210.00 $1,375.00 $1,441.00 $1,518.00 $1,375.00 $1,441.00 $1,518.00

54115 90 $588.00 $659.00 $693.00 $726.00 $623.00 $654.00 $687.00

54120 90 $777.00 $924.00 $970.00 $1,020.00 $924.00 $970.00 $1,020.00

54125 90 $1,092.00 $1,194.00 $1,252.00 $1,321.00 $1,194.00 $1,252.00 $1,321.00

54130 90 $1,532.00 $1,751.00 $1,835.00 $1,933.00 $1,751.00 $1,835.00 $1,933.00

54135 90 $1,945.00 $2,221.00 $2,327.00 $2,454.00 $2,221.00 $2,327.00 $2,454.00

54162 10 $220.00 $367.00 $387.00 $403.00 $290.00 $304.00 $319.00

54163 10 $207.00 $318.00 $334.00 $350.00 $318.00 $334.00 $350.00

54164 10 $182.00 $281.00 $296.00 $310.00 $281.00 $296.00 $310.00

54200 10 $78.00 $152.00 $160.00 $166.00 $121.00 $127.00 $132.00

54205 90 $633.00 $777.00 $815.00 $856.00 $777.00 $815.00 $856.00

54220 0 $189.00 $292.00 $309.00 $322.00 $197.00 $208.00 $220.00

54230 0 $104.00 $139.00 $146.00 $153.00 $116.00 $122.00 $128.00

54231 0 $172.00 $202.00 $213.00 $222.00 $171.00 $179.00 $189.00

54235 0 $81.00 $130.00 $136.00 $142.00 $107.00 $112.00 $118.00

54240 0 $109.00 $151.00 $160.00 $170.00 $151.00 $160.00 $170.00

54240-26 0 ---------- $103.00 $109.00 $118.00 $103.00 $109.00 $118.00

54240-TC 0 ---------- $48.00 $51.00 $52.00 $48.00 $51.00 $52.00

54250 0 $104.00 $176.00 $183.00 $191.00 $176.00 $183.00 $191.00

54250-26 0 ---------- $161.00 $167.00 $174.00 $161.00 $167.00 $174.00

54250-TC 0 ---------- $15.00 $16.00 $17.00 $15.00 $16.00 $17.00

54300 90 $830.00 $940.00 $986.00 $1,038.00 $940.00 $986.00 $1,038.00

54304 90 $988.00 $1,095.00 $1,147.00 $1,206.00 $1,095.00 $1,147.00 $1,206.00

54308 90 $881.00 $1,046.00 $1,097.00 $1,155.00 $1,046.00 $1,097.00 $1,155.00

54312 90 $1,067.00 $1,257.00 $1,326.00 $1,406.00 $1,257.00 $1,326.00 $1,406.00

54316 90 $1,316.00 $1,535.00 $1,618.00 $1,717.00 $1,535.00 $1,618.00 $1,717.00

54318 90 $900.00 $1,040.00 $1,091.00 $1,147.00 $1,040.00 $1,091.00 $1,147.00

54322 90 $974.00 $1,134.00 $1,190.00 $1,256.00 $1,134.00 $1,190.00 $1,256.00

54324 90 $1,260.00 $1,417.00 $1,485.00 $1,562.00 $1,417.00 $1,485.00 $1,562.00

54326 90 $1,212.00 $1,386.00 $1,453.00 $1,530.00 $1,386.00 $1,453.00 $1,530.00

54328 90 $1,201.00 $1,395.00 $1,459.00 $1,525.00 $1,395.00 $1,459.00 $1,525.00

54332 90 $1,327.00 $1,550.00 $1,627.00 $1,713.00 $1,550.00 $1,627.00 $1,713.00

54336 90 $1,672.00 $1,744.00 $1,828.00 $1,925.00 $1,744.00 $1,828.00 $1,925.00

54340 90 $727.00 $825.00 $863.00 $904.00 $825.00 $863.00 $904.00

54344 90 $1,360.00 $1,390.00 $1,457.00 $1,534.00 $1,390.00 $1,457.00 $1,534.00

54348 90 $1,318.00 $1,487.00 $1,559.00 $1,642.00 $1,487.00 $1,559.00 $1,642.00

54352 90 $1,820.00 $2,080.00 $2,179.00 $2,297.00 $2,080.00 $2,179.00 $2,297.00



Surgery


(Non-Facility MRA)






54360 90 $898.00 $1,055.00 $1,107.00 $1,165.00 $1,055.00 $1,107.00 $1,165.00

54380 90 $1,054.00 $1,170.00 $1,228.00 $1,292.00 $1,170.00 $1,228.00 $1,292.00

54385 90 $1,217.00 $1,422.00 $1,495.00 $1,577.00 $1,422.00 $1,495.00 $1,577.00

54390 90 $1,635.00 $1,820.00 $1,908.00 $2,010.00 $1,820.00 $1,908.00 $2,010.00

54400 90 $784.00 $774.00 $811.00 $853.00 $774.00 $811.00 $853.00

54401 90 $892.00 $953.00 $1,001.00 $1,049.00 $953.00 $1,001.00 $1,049.00

54405 90 $1,294.00 $1,184.00 $1,242.00 $1,307.00 $1,184.00 $1,242.00 $1,307.00

54406 90 $687.00 $1,069.00 $1,122.00 $1,180.00 $1,069.00 $1,122.00 $1,180.00

54408 90 $724.00 $1,157.00 $1,214.00 $1,278.00 $1,157.00 $1,214.00 $1,278.00

54410 90 $856.00 $1,258.00 $1,319.00 $1,388.00 $1,258.00 $1,319.00 $1,388.00

54411 90 $933.00 $1,503.00 $1,576.00 $1,660.00 $1,503.00 $1,576.00 $1,660.00

54415 90 $510.00 $772.00 $810.00 $852.00 $772.00 $810.00 $852.00

54416 90 $665.00 $1,037.00 $1,089.00 $1,144.00 $1,037.00 $1,089.00 $1,144.00

54417 90 $819.00 $1,317.00 $1,380.00 $1,454.00 $1,317.00 $1,380.00 $1,454.00

54420 90 $899.00 $1,029.00 $1,080.00 $1,136.00 $1,029.00 $1,080.00 $1,136.00

54430 90 $799.00 $935.00 $981.00 $1,032.00 $935.00 $981.00 $1,032.00

54435 90 $503.00 $608.00 $638.00 $669.00 $608.00 $638.00 $669.00

54437 90 ---------- $992.00 $1,042.00 $1,097.00 $992.00 $1,042.00 $1,097.00

54438 90 ---------- $1,985.00 $2,089.00 $2,218.00 $1,985.00 $2,089.00 $2,218.00

54440 90 BR ---------- ---------- ---------- ---------- ---------- ----------

54450 0 $88.00 $102.00 $107.00 $112.00 $85.00 $89.00 $95.00

54500 0 $102.00 $109.00 $115.00 $120.00 $109.00 $115.00 $120.00

54505 10 $259.00 $306.00 $322.00 $338.00 $306.00 $322.00 $338.00

54512 90 $519.00 $791.00 $831.00 $877.00 $791.00 $831.00 $877.00

54520 90 $445.00 $477.00 $502.00 $529.00 $477.00 $502.00 $529.00

54522 90 $589.00 $865.00 $908.00 $954.00 $865.00 $908.00 $954.00

54530 90 $683.00 $737.00 $774.00 $814.00 $737.00 $774.00 $814.00

54535 90 $922.00 $1,102.00 $1,158.00 $1,222.00 $1,102.00 $1,158.00 $1,222.00

54550 90 $588.00 $725.00 $762.00 $802.00 $725.00 $762.00 $802.00

54560 90 $842.00 $1,055.00 $1,112.00 $1,179.00 $1,055.00 $1,112.00 $1,179.00

54600 90 $524.00 $665.00 $699.00 $735.00 $665.00 $699.00 $735.00

54620 10 $373.00 $439.00 $460.00 $484.00 $439.00 $460.00 $484.00

54640 90 $594.00 $698.00 $734.00 $773.00 $698.00 $734.00 $773.00

54650 90 $861.00 $1,069.00 $1,128.00 $1,199.00 $1,069.00 $1,128.00 $1,199.00

54660 90 $401.00 $530.00 $557.00 $585.00 $530.00 $557.00 $585.00

54670 90 $485.00 $597.00 $628.00 $660.00 $597.00 $628.00 $660.00

54680 90 $948.00 $1,176.00 $1,235.00 $1,302.00 $1,176.00 $1,235.00 $1,302.00

54690 90 $825.00 $969.00 $1,017.00 $1,073.00 $969.00 $1,017.00 $1,073.00

54692 90 $850.00 $1,182.00 $1,252.00 $1,342.00 $1,182.00 $1,252.00 $1,342.00

54699 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

54700 10 $133.00 $312.00 $329.00 $347.00 $312.00 $329.00 $347.00

54800 0 $257.00 $196.00 $207.00 $220.00 $196.00 $207.00 $220.00

54830 90 $411.00 $543.00 $571.00 $600.00 $543.00 $571.00 $600.00

54840 90 $432.00 $468.00 $492.00 $516.00 $468.00 $492.00 $516.00

54860 90 $503.00 $611.00 $641.00 $673.00 $611.00 $641.00 $673.00

54861 90 $696.00 $826.00 $867.00 $911.00 $826.00 $867.00 $911.00

54865 90 ---------- $523.00 $549.00 $576.00 $523.00 $549.00 $576.00

54900 90 $969.00 $1,230.00 $1,297.00 $1,376.00 $1,230.00 $1,297.00 $1,376.00

54901 90 $1,340.00 $1,547.00 $1,622.00 $1,708.00 $1,547.00 $1,622.00 $1,708.00

55000 0 $109.00 $167.00 $177.00 $184.00 $125.00 $131.00 $138.00



Surgery


(Non-Facility MRA)






55040 90 $439.00 $493.00 $519.00 $546.00 $493.00 $519.00 $546.00

55041 90 $634.00 $745.00 $783.00 $824.00 $745.00 $783.00 $824.00

55060 90 $430.00 $555.00 $584.00 $614.00 $555.00 $584.00 $614.00

55100 10 $156.00 $307.00 $325.00 $339.00 $241.00 $254.00 $267.00

55110 90 $223.00 $566.00 $596.00 $627.00 $566.00 $596.00 $627.00

55120 90 $350.00 $525.00 $553.00 $582.00 $525.00 $553.00 $582.00

55150 90 $562.00 $719.00 $756.00 $796.00 $719.00 $756.00 $796.00

55175 90 $426.00 $531.00 $558.00 $586.00 $531.00 $558.00 $586.00

55180 90 $796.00 $1,006.00 $1,057.00 $1,113.00 $1,006.00 $1,057.00 $1,113.00

55200 90 $310.00 $614.00 $649.00 $672.00 $399.00 $419.00 $440.00

55250 90 $349.00 $544.00 $576.00 $595.00 $331.00 $348.00 $365.00

55300 0 $167.00 $276.00 $289.00 $305.00 $276.00 $289.00 $305.00

55400 90 $660.00 $728.00 $764.00 $803.00 $728.00 $764.00 $803.00

55450 10 $391.00 $525.00 $555.00 $579.00 $383.00 $404.00 $427.00

55500 90 $445.00 $580.00 $613.00 $651.00 $580.00 $613.00 $651.00

55520 90 $446.00 $672.00 $719.00 $780.00 $672.00 $719.00 $780.00

55530 90 $467.00 $513.00 $539.00 $566.00 $513.00 $539.00 $566.00

55535 90 $496.00 $627.00 $658.00 $691.00 $627.00 $658.00 $691.00

55540 90 $572.00 $822.00 $882.00 $962.00 $822.00 $882.00 $962.00

55550 90 $486.00 $625.00 $656.00 $689.00 $625.00 $656.00 $689.00

55559 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

55600 90 $486.00 $615.00 $645.00 $677.00 $615.00 $645.00 $677.00

55605 90 $609.00 $799.00 $843.00 $892.00 $799.00 $843.00 $892.00

55650 90 $853.00 $1,053.00 $1,105.00 $1,164.00 $1,053.00 $1,105.00 $1,164.00

55680 90 $426.00 $535.00 $567.00 $605.00 $535.00 $567.00 $605.00

55700 0 $183.00 $350.00 $370.00 $383.00 $193.00 $202.00 $213.00

55705 10 $368.00 $390.00 $409.00 $430.00 $390.00 $409.00 $430.00

55706 10 ---------- $543.00 $570.00 $598.00 $543.00 $570.00 $598.00

55720 90 $555.00 $660.00 $693.00 $728.00 $660.00 $693.00 $728.00

55725 90 $670.00 $969.00 $1,034.00 $1,116.00 $969.00 $1,034.00 $1,116.00

55801 90 $1,331.00 $1,609.00 $1,689.00 $1,781.00 $1,609.00 $1,689.00 $1,781.00

55810 90 $1,711.00 $1,924.00 $2,016.00 $2,125.00 $1,924.00 $2,016.00 $2,125.00

55812 90 $1,989.00 $2,447.00 $2,584.00 $2,763.00 $2,447.00 $2,584.00 $2,763.00

55815 90 $2,328.00 $2,598.00 $2,721.00 $2,867.00 $2,598.00 $2,721.00 $2,867.00

55821 90 $1,153.00 $1,281.00 $1,343.00 $1,415.00 $1,281.00 $1,343.00 $1,415.00

55831 90 $1,252.00 $1,386.00 $1,452.00 $1,530.00 $1,386.00 $1,452.00 $1,530.00

55840 90 $1,705.00 $1,720.00 $1,803.00 $1,900.00 $1,720.00 $1,803.00 $1,900.00

55842 90 $1,859.00 $1,719.00 $1,802.00 $1,900.00 $1,719.00 $1,802.00 $1,900.00

55845 90 $2,222.00 $2,002.00 $2,098.00 $2,212.00 $2,002.00 $2,098.00 $2,212.00

55860 90 $1,012.00 $1,282.00 $1,342.00 $1,410.00 $1,282.00 $1,342.00 $1,410.00

55862 90 $1,351.00 $1,648.00 $1,732.00 $1,832.00 $1,648.00 $1,732.00 $1,832.00

55865 90 $1,890.00 $1,958.00 $2,052.00 $2,163.00 $1,958.00 $2,052.00 $2,163.00

55866 90 $1,615.00 $2,121.00 $2,222.00 $2,342.00 $2,121.00 $2,222.00 $2,342.00

55870 0 $166.00 $253.00 $267.00 $279.00 $209.00 $219.00 $231.00

55873 90 $1,127.00 $9,691.00 $10,328.00 $10,480.00 $1,119.00 $1,174.00 $1,236.00

55875 90 ---------- $1,115.00 $1,168.00 $1,226.00 $1,115.00 $1,168.00 $1,226.00

55876 0 ---------- $194.00 $204.00 $212.00 $147.00 $154.00 $162.00

55899 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

55920 0 ---------- $654.00 $682.00 $713.00 $654.00 $682.00 $713.00

56405 10 $131.00 $156.00 $165.00 $173.00 $155.00 $164.00 $172.00



Surgery


(Non-Facility MRA)






56420 10 $130.00 $172.00 $182.00 $189.00 $132.00 $139.00 $146.00

56440 10 $271.00 $263.00 $276.00 $291.00 $263.00 $276.00 $291.00

56441 10 $183.00 $206.00 $217.00 $227.00 $199.00 $209.00 $220.00

56442 0 ---------- $68.00 $72.00 $75.00 $68.00 $72.00 $75.00

56501 10 $122.00 $186.00 $197.00 $205.00 $165.00 $174.00 $182.00

56515 10 $200.00 $325.00 $344.00 $362.00 $291.00 $308.00 $326.00

56605 0 $96.00 $118.00 $124.00 $130.00 $88.00 $93.00 $98.00

56606 ZZZ $49.00 $55.00 $58.00 $61.00 $44.00 $46.00 $50.00

56620 90 $607.00 $760.00 $808.00 $864.00 $760.00 $808.00 $864.00

56625 90 $735.00 $930.00 $993.00 $1,071.00 $930.00 $993.00 $1,071.00

56630 90 $1,061.00 $1,377.00 $1,470.00 $1,593.00 $1,377.00 $1,470.00 $1,593.00

56631 90 $1,400.00 $1,756.00 $1,876.00 $2,036.00 $1,756.00 $1,876.00 $2,036.00

56632 90 $1,636.00 $2,047.00 $2,187.00 $2,373.00 $2,047.00 $2,187.00 $2,373.00

56633 90 $1,350.00 $1,800.00 $1,923.00 $2,087.00 $1,800.00 $1,923.00 $2,087.00

56634 90 $1,537.00 $1,935.00 $2,074.00 $2,265.00 $1,935.00 $2,074.00 $2,265.00

56637 90 $1,806.00 $2,254.00 $2,411.00 $2,626.00 $2,254.00 $2,411.00 $2,626.00

56640 90 $1,777.00 $2,276.00 $2,441.00 $2,671.00 $2,276.00 $2,441.00 $2,671.00

56700 10 $227.00 $270.00 $284.00 $299.00 $270.00 $284.00 $299.00

56740 10 $321.00 $436.00 $461.00 $490.00 $436.00 $461.00 $490.00

56800 10 $310.00 $348.00 $366.00 $387.00 $348.00 $366.00 $387.00

56805 90 $1,349.00 $1,838.00 $1,944.00 $2,066.00 $1,838.00 $1,944.00 $2,066.00

56810 10 $316.00 $376.00 $396.00 $418.00 $376.00 $396.00 $418.00

56820 0 $119.00 $162.00 $171.00 $181.00 $128.00 $135.00 $145.00

56821 0 $154.00 $212.00 $225.00 $237.00 $170.00 $179.00 $191.00

57000 10 $237.00 $265.00 $279.00 $293.00 $265.00 $279.00 $293.00

57010 90 $429.00 $624.00 $657.00 $691.00 $624.00 $657.00 $691.00

57020 0 $118.00 $133.00 $140.00 $147.00 $117.00 $123.00 $130.00

57022 10 $179.00 $249.00 $263.00 $281.00 $249.00 $263.00 $281.00

57023 10 $290.00 $446.00 $468.00 $494.00 $446.00 $468.00 $494.00

57061 10 $124.00 $161.00 $170.00 $178.00 $141.00 $149.00 $156.00

57065 10 $251.00 $281.00 $298.00 $315.00 $253.00 $268.00 $285.00

57100 0 $90.00 $129.00 $137.00 $145.00 $99.00 $105.00 $112.00

57105 10 $132.00 $195.00 $207.00 $218.00 $182.00 $193.00 $204.00

57106 90 $409.00 $719.00 $763.00 $814.00 $719.00 $763.00 $814.00

57107 90 $1,467.00 $2,144.00 $2,280.00 $2,461.00 $2,144.00 $2,280.00 $2,461.00

57109 90 $1,787.00 $2,625.00 $2,819.00 $3,094.00 $2,625.00 $2,819.00 $3,094.00

57110 90 $1,015.00 $1,289.00 $1,355.00 $1,430.00 $1,289.00 $1,355.00 $1,430.00

57111 90 $1,793.00 $2,357.00 $2,484.00 $2,641.00 $2,357.00 $2,484.00 $2,641.00

57112 90 $1,907.00 $2,667.00 $2,840.00 $3,074.00 $2,667.00 $2,840.00 $3,074.00

57120 90 $612.00 $731.00 $769.00 $809.00 $731.00 $769.00 $809.00

57130 10 $220.00 $252.00 $266.00 $278.00 $228.00 $239.00 $252.00

57135 10 $231.00 $275.00 $291.00 $306.00 $250.00 $264.00 $279.00

57150 0 $50.00 $64.00 $67.00 $70.00 $42.00 $44.00 $47.00

57155 0 $383.00 $519.00 $544.00 $564.00 $403.00 $421.00 $440.00

57156 0 ---------- $281.00 $294.00 $304.00 $212.00 $221.00 $229.00

57160 0 $67.00 $108.00 $114.00 $119.00 $68.00 $71.00 $76.00

57170 0 $74.00 $87.00 $92.00 $96.00 $71.00 $74.00 $79.00

57180 10 $124.00 $199.00 $210.00 $219.00 $152.00 $160.00 $168.00

57200 90 $313.00 $436.00 $461.00 $488.00 $436.00 $461.00 $488.00

57210 90 $395.00 $527.00 $555.00 $585.00 $527.00 $555.00 $585.00



Surgery


(Non-Facility MRA)






57220 90 $378.00 $459.00 $483.00 $508.00 $459.00 $483.00 $508.00

57230 90 $442.00 $567.00 $597.00 $628.00 $567.00 $597.00 $628.00

57240 90 $536.00 $969.00 $1,018.00 $1,073.00 $969.00 $1,018.00 $1,073.00

57250 90 $485.00 $975.00 $1,024.00 $1,080.00 $975.00 $1,024.00 $1,080.00

57260 90 $700.00 $1,201.00 $1,262.00 $1,332.00 $1,201.00 $1,262.00 $1,332.00

57265 90 $902.00 $1,317.00 $1,384.00 $1,461.00 $1,317.00 $1,384.00 $1,461.00

57267 ZZZ ---------- $373.00 $391.00 $414.00 $373.00 $391.00 $414.00

57268 90 $577.00 $696.00 $733.00 $773.00 $696.00 $733.00 $773.00

57270 90 $867.00 $1,162.00 $1,224.00 $1,299.00 $1,162.00 $1,224.00 $1,299.00

57280 90 $1,071.00 $1,381.00 $1,451.00 $1,534.00 $1,381.00 $1,451.00 $1,534.00

57282 90 $734.00 $719.00 $756.00 $795.00 $719.00 $756.00 $795.00

57283 90 ---------- $994.00 $1,044.00 $1,102.00 $994.00 $1,044.00 $1,102.00

57284 90 $950.00 $1,179.00 $1,238.00 $1,308.00 $1,179.00 $1,238.00 $1,308.00

57285 90 ---------- $971.00 $1,020.00 $1,075.00 $971.00 $1,020.00 $1,075.00

57287 90 $685.00 $983.00 $1,032.00 $1,085.00 $983.00 $1,032.00 $1,085.00

57288 90 $1,009.00 $1,035.00 $1,087.00 $1,144.00 $1,035.00 $1,087.00 $1,144.00

57289 90 $879.00 $1,066.00 $1,118.00 $1,176.00 $1,066.00 $1,118.00 $1,176.00

57291 90 $622.00 $759.00 $798.00 $839.00 $759.00 $798.00 $839.00

57292 90 $925.00 $1,182.00 $1,243.00 $1,315.00 $1,182.00 $1,243.00 $1,315.00

57295 90 ---------- $687.00 $723.00 $760.00 $687.00 $723.00 $760.00

57296 90 ---------- $1,355.00 $1,423.00 $1,504.00 $1,355.00 $1,423.00 $1,504.00

57300 90 $653.00 $819.00 $869.00 $927.00 $819.00 $869.00 $927.00

57305 90 $995.00 $1,381.00 $1,471.00 $1,591.00 $1,381.00 $1,471.00 $1,591.00

57307 90 $997.00 $1,564.00 $1,676.00 $1,832.00 $1,564.00 $1,676.00 $1,832.00

57308 90 $769.00 $919.00 $966.00 $1,018.00 $919.00 $966.00 $1,018.00

57310 90 $517.00 $672.00 $706.00 $742.00 $672.00 $706.00 $742.00

57311 90 $612.00 $763.00 $800.00 $840.00 $763.00 $800.00 $840.00

57320 90 $693.00 $772.00 $811.00 $854.00 $772.00 $811.00 $854.00

57330 90 $916.00 $1,097.00 $1,152.00 $1,217.00 $1,097.00 $1,152.00 $1,217.00

57335 90 $963.00 $1,810.00 $1,911.00 $2,026.00 $1,810.00 $1,911.00 $2,026.00

57400 0 $70.00 $196.00 $207.00 $220.00 $196.00 $207.00 $220.00

57410 0 $57.00 $156.00 $165.00 $175.00 $156.00 $165.00 $175.00

57415 10 $75.00 $230.00 $242.00 $255.00 $230.00 $242.00 $255.00

57420 0 $124.00 $170.00 $180.00 $190.00 $135.00 $143.00 $153.00

57421 0 $162.00 $226.00 $240.00 $253.00 $182.00 $192.00 $206.00

57423 90 ---------- $1,318.00 $1,384.00 $1,462.00 $1,318.00 $1,384.00 $1,462.00

57425 90 ---------- $1,404.00 $1,475.00 $1,558.00 $1,404.00 $1,475.00 $1,558.00

57426 90 ---------- $1,215.00 $1,277.00 $1,346.00 $1,215.00 $1,277.00 $1,346.00

57452 0 $96.00 $156.00 $165.00 $173.00 $134.00 $141.00 $149.00

57454 0 $125.00 $219.00 $231.00 $242.00 $197.00 $207.00 $218.00

57455 0 $149.00 $204.00 $215.00 $226.00 $161.00 $170.00 $180.00

57456 0 $141.00 $192.00 $203.00 $212.00 $150.00 $158.00 $167.00

57460 0 $223.00 $397.00 $420.00 $436.00 $236.00 $248.00 $262.00

57461 0 $333.00 $451.00 $477.00 $496.00 $273.00 $287.00 $305.00

57500 0 $89.00 $179.00 $190.00 $197.00 $110.00 $116.00 $122.00

57505 10 $105.00 $145.00 $153.00 $160.00 $132.00 $140.00 $146.00

57510 10 $140.00 $187.00 $197.00 $207.00 $167.00 $175.00 $185.00

57511 10 $159.00 $206.00 $217.00 $227.00 $189.00 $199.00 $209.00

57513 10 $191.00 $208.00 $220.00 $231.00 $193.00 $204.00 $216.00

57520 90 $359.00 $441.00 $467.00 $492.00 $399.00 $422.00 $446.00



Surgery


(Non-Facility MRA)






57522 90 $319.00 $376.00 $397.00 $417.00 $350.00 $369.00 $389.00

57530 90 $386.00 $501.00 $529.00 $560.00 $501.00 $529.00 $560.00

57531 90 $2,036.00 $2,744.00 $2,943.00 $3,223.00 $2,744.00 $2,943.00 $3,223.00

57540 90 $815.00 $1,240.00 $1,328.00 $1,445.00 $1,240.00 $1,328.00 $1,445.00

57545 90 $700.00 $1,214.00 $1,284.00 $1,370.00 $1,214.00 $1,284.00 $1,370.00

57550 90 $486.00 $581.00 $611.00 $641.00 $581.00 $611.00 $641.00

57555 90 $774.00 $869.00 $915.00 $968.00 $869.00 $915.00 $968.00

57556 90 $718.00 $812.00 $853.00 $897.00 $812.00 $853.00 $897.00

57558 10 ---------- $177.00 $186.00 $195.00 $162.00 $171.00 $179.00

57700 90 $279.00 $449.00 $474.00 $498.00 $449.00 $474.00 $498.00

57720 90 $328.00 $441.00 $464.00 $488.00 $441.00 $464.00 $488.00

57800 0 $71.00 $86.00 $91.00 $95.00 $70.00 $74.00 $78.00

58100 0 $74.00 $156.00 $164.00 $172.00 $127.00 $134.00 $141.00

58110 ZZZ ---------- $69.00 $72.00 $76.00 $60.00 $63.00 $66.00

58120 10 $297.00 $370.00 $390.00 $411.00 $317.00 $334.00 $354.00

58140 90 $1,010.00 $1,332.00 $1,404.00 $1,491.00 $1,332.00 $1,404.00 $1,491.00

58145 90 $677.00 $792.00 $835.00 $884.00 $792.00 $835.00 $884.00

58146 90 $1,089.00 $1,667.00 $1,751.00 $1,850.00 $1,667.00 $1,751.00 $1,850.00

58150 90 $1,110.00 $1,483.00 $1,568.00 $1,676.00 $1,483.00 $1,568.00 $1,676.00

58152 90 $1,159.00 $1,809.00 $1,903.00 $2,016.00 $1,809.00 $1,903.00 $2,016.00

58180 90 $1,118.00 $1,397.00 $1,472.00 $1,564.00 $1,397.00 $1,472.00 $1,564.00

58200 90 $1,562.00 $2,032.00 $2,165.00 $2,345.00 $2,032.00 $2,165.00 $2,345.00

58210 90 $2,080.00 $2,746.00 $2,932.00 $3,188.00 $2,746.00 $2,932.00 $3,188.00

58240 90 $2,898.00 $4,315.00 $4,597.00 $4,980.00 $4,315.00 $4,597.00 $4,980.00

58260 90 $926.00 $1,190.00 $1,251.00 $1,320.00 $1,190.00 $1,251.00 $1,320.00

58262 90 $1,026.00 $1,330.00 $1,397.00 $1,477.00 $1,330.00 $1,397.00 $1,477.00

58263 90 $1,120.00 $1,427.00 $1,499.00 $1,582.00 $1,427.00 $1,499.00 $1,582.00

58267 90 $1,133.00 $1,512.00 $1,587.00 $1,673.00 $1,512.00 $1,587.00 $1,673.00

58270 90 $1,019.00 $1,273.00 $1,338.00 $1,414.00 $1,273.00 $1,338.00 $1,414.00

58275 90 $1,121.00 $1,420.00 $1,493.00 $1,578.00 $1,420.00 $1,493.00 $1,578.00

58280 90 $1,132.00 $1,513.00 $1,589.00 $1,677.00 $1,513.00 $1,589.00 $1,677.00

58285 90 $1,360.00 $2,126.00 $2,279.00 $2,493.00 $2,126.00 $2,279.00 $2,493.00

58290 90 $1,089.00 $1,662.00 $1,746.00 $1,846.00 $1,662.00 $1,746.00 $1,846.00

58291 90 $1,197.00 $1,791.00 $1,880.00 $1,984.00 $1,791.00 $1,880.00 $1,984.00

58292 90 $1,268.00 $1,889.00 $1,981.00 $2,091.00 $1,889.00 $1,981.00 $2,091.00

58293 90 $1,318.00 $1,966.00 $2,064.00 $2,179.00 $1,966.00 $2,064.00 $2,179.00

58294 90 $1,168.00 $1,752.00 $1,839.00 $1,942.00 $1,752.00 $1,839.00 $1,942.00

58301 0 $71.00 $135.00 $142.00 $149.00 $98.00 $103.00 $109.00

58321 0 $81.00 $109.00 $115.00 $120.00 $71.00 $74.00 $79.00

58322 0 $90.00 $122.00 $128.00 $134.00 $85.00 $89.00 $95.00

58323 0 $24.00 $22.00 $23.00 $23.00 $17.00 $18.00 $19.00

58340 0 $87.00 $166.00 $176.00 $181.00 $84.00 $88.00 $92.00

58345 10 $335.00 $400.00 $420.00 $442.00 $400.00 $420.00 $442.00

58346 90 $408.00 $655.00 $685.00 $714.00 $655.00 $685.00 $714.00

58350 10 $103.00 $136.00 $144.00 $150.00 $112.00 $119.00 $124.00

58353 10 $225.00 $1,381.00 $1,469.00 $1,498.00 $315.00 $331.00 $349.00

58356 10 ---------- $2,584.00 $2,750.00 $2,803.00 $500.00 $525.00 $556.00

58400 90 $519.00 $634.00 $666.00 $702.00 $634.00 $666.00 $702.00

58410 90 $752.00 $1,166.00 $1,228.00 $1,301.00 $1,166.00 $1,228.00 $1,301.00

58520 90 $663.00 $1,234.00 $1,321.00 $1,441.00 $1,234.00 $1,321.00 $1,441.00



Surgery


(Non-Facility MRA)






58540 90 $923.00 $1,298.00 $1,363.00 $1,437.00 $1,298.00 $1,363.00 $1,437.00

58541 90 ---------- $1,033.00 $1,086.00 $1,145.00 $1,033.00 $1,086.00 $1,145.00

58542 90 ---------- $1,182.00 $1,242.00 $1,313.00 $1,182.00 $1,242.00 $1,313.00

58543 90 ---------- $1,192.00 $1,251.00 $1,319.00 $1,192.00 $1,251.00 $1,319.00

58544 90 ---------- $1,304.00 $1,373.00 $1,455.00 $1,304.00 $1,373.00 $1,455.00

58545 90 $876.00 $1,312.00 $1,384.00 $1,472.00 $1,312.00 $1,384.00 $1,472.00

58546 90 $1,104.00 $1,619.00 $1,699.00 $1,794.00 $1,619.00 $1,699.00 $1,794.00

58548 90 ---------- $2,829.00 $3,022.00 $3,286.00 $2,829.00 $3,022.00 $3,286.00

58550 90 $1,038.00 $1,272.00 $1,337.00 $1,412.00 $1,272.00 $1,337.00 $1,412.00

58552 90 $853.00 $1,432.00 $1,509.00 $1,604.00 $1,432.00 $1,509.00 $1,604.00

58553 90 $1,096.00 $1,646.00 $1,731.00 $1,835.00 $1,646.00 $1,731.00 $1,835.00

58554 90 $1,085.00 $1,928.00 $2,033.00 $2,164.00 $1,928.00 $2,033.00 $2,164.00

58555 0 $261.00 $377.00 $399.00 $414.00 $223.00 $235.00 $248.00

58558 0 $340.00 $1,869.00 $1,990.00 $2,028.00 $342.00 $360.00 $381.00

58559 0 $436.00 $421.00 $443.00 $469.00 $421.00 $443.00 $469.00

58560 0 $482.00 $461.00 $484.00 $511.00 $461.00 $484.00 $511.00

58561 0 $677.00 $631.00 $664.00 $697.00 $631.00 $664.00 $697.00

58562 0 $339.00 $481.00 $508.00 $530.00 $337.00 $355.00 $375.00

58563 0 $450.00 $2,180.00 $2,322.00 $2,362.00 $396.00 $416.00 $438.00

58565 90 ---------- $2,585.00 $2,751.00 $2,806.00 $624.00 $656.00 $690.00

58570 90 ---------- $1,127.00 $1,187.00 $1,256.00 $1,127.00 $1,187.00 $1,256.00

58571 90 ---------- $1,314.00 $1,394.00 $1,497.00 $1,314.00 $1,394.00 $1,497.00

58572 90 ---------- $1,482.00 $1,562.00 $1,660.00 $1,482.00 $1,562.00 $1,660.00

58573 90 ---------- $1,782.00 $1,889.00 $2,029.00 $1,782.00 $1,889.00 $2,029.00

58578 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

58579 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

58600 90 $337.00 $520.00 $545.00 $572.00 $520.00 $545.00 $572.00

58605 90 $298.00 $472.00 $496.00 $522.00 $472.00 $496.00 $522.00

58611 ZZZ $47.00 $112.00 $117.00 $124.00 $112.00 $117.00 $124.00

58615 10 $319.00 $359.00 $378.00 $401.00 $359.00 $378.00 $401.00

58660 90 $793.00 $977.00 $1,030.00 $1,095.00 $977.00 $1,030.00 $1,095.00

58661 10 $804.00 $946.00 $998.00 $1,064.00 $946.00 $998.00 $1,064.00

58662 90 $807.00 $1,031.00 $1,087.00 $1,155.00 $1,031.00 $1,087.00 $1,155.00

58670 90 $450.00 $524.00 $551.00 $580.00 $524.00 $551.00 $580.00

58671 90 $463.00 $522.00 $548.00 $577.00 $522.00 $548.00 $577.00

58672 90 $872.00 $1,057.00 $1,110.00 $1,171.00 $1,057.00 $1,110.00 $1,171.00

58673 90 $928.00 $1,151.00 $1,209.00 $1,277.00 $1,151.00 $1,209.00 $1,277.00

58679 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

58700 90 $544.00 $1,135.00 $1,201.00 $1,284.00 $1,135.00 $1,201.00 $1,284.00

58720 90 $844.00 $1,078.00 $1,144.00 $1,226.00 $1,078.00 $1,144.00 $1,226.00

58740 90 $508.00 $1,286.00 $1,360.00 $1,451.00 $1,286.00 $1,360.00 $1,451.00

58750 90 $949.00 $1,411.00 $1,504.00 $1,626.00 $1,411.00 $1,504.00 $1,626.00

58752 90 $893.00 $1,314.00 $1,385.00 $1,472.00 $1,314.00 $1,385.00 $1,472.00

58760 90 $769.00 $1,163.00 $1,221.00 $1,288.00 $1,163.00 $1,221.00 $1,288.00

58770 90 $763.00 $1,274.00 $1,353.00 $1,457.00 $1,274.00 $1,353.00 $1,457.00

58800 90 $343.00 $452.00 $476.00 $500.00 $426.00 $448.00 $472.00

58805 90 $509.00 $582.00 $612.00 $643.00 $582.00 $612.00 $643.00

58820 90 $326.00 $473.00 $503.00 $537.00 $473.00 $503.00 $537.00

58822 90 $603.00 $1,004.00 $1,055.00 $1,111.00 $1,004.00 $1,055.00 $1,111.00

58825 90 $469.00 $1,112.00 $1,189.00 $1,292.00 $1,112.00 $1,189.00 $1,292.00



Surgery


(Non-Facility MRA)






58900 90 $489.00 $594.00 $625.00 $658.00 $594.00 $625.00 $658.00

58920 90 $571.00 $1,114.00 $1,195.00 $1,305.00 $1,114.00 $1,195.00 $1,305.00

58925 90 $820.00 $1,087.00 $1,150.00 $1,228.00 $1,087.00 $1,150.00 $1,228.00

58940 90 $592.00 $768.00 $816.00 $875.00 $768.00 $816.00 $875.00

58943 90 $1,368.00 $1,737.00 $1,851.00 $2,006.00 $1,737.00 $1,851.00 $2,006.00

58950 90 $1,170.00 $1,674.00 $1,786.00 $1,937.00 $1,674.00 $1,786.00 $1,937.00

58951 90 $1,703.00 $2,162.00 $2,308.00 $2,508.00 $2,162.00 $2,308.00 $2,508.00

58952 90 $1,876.00 $2,447.00 $2,615.00 $2,843.00 $2,447.00 $2,615.00 $2,843.00

58953 90 $1,839.00 $3,030.00 $3,236.00 $3,521.00 $3,030.00 $3,236.00 $3,521.00

58954 90 $1,999.00 $3,294.00 $3,520.00 $3,834.00 $3,294.00 $3,520.00 $3,834.00

58956 90 ---------- $2,052.00 $2,190.00 $2,376.00 $2,052.00 $2,190.00 $2,376.00

58957 90 ---------- $2,365.00 $2,528.00 $2,751.00 $2,365.00 $2,528.00 $2,751.00

58958 90 ---------- $2,607.00 $2,784.00 $3,026.00 $2,607.00 $2,784.00 $3,026.00

58960 90 $1,174.00 $1,435.00 $1,532.00 $1,661.00 $1,435.00 $1,532.00 $1,661.00

58999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

59000 0 $123.00 $182.00 $195.00 $209.00 $122.00 $131.00 $145.00

59001 0 $167.00 $271.00 $292.00 $322.00 $271.00 $292.00 $322.00

59012 0 $267.00 $307.00 $331.00 $366.00 $307.00 $331.00 $366.00

59015 0 $168.00 $231.00 $249.00 $272.00 $201.00 $216.00 $239.00

59020 0 $85.00 $102.00 $109.00 $116.00 $102.00 $109.00 $116.00

59020-26 0 ---------- $56.00 $60.00 $66.00 $56.00 $60.00 $66.00

59020-TC 0 ---------- $46.00 $50.00 $50.00 $46.00 $50.00 $50.00

59025 0 $54.00 $70.00 $75.00 $80.00 $70.00 $75.00 $80.00

59025-26 0 ---------- $45.00 $48.00 $53.00 $45.00 $48.00 $53.00

59025-TC 0 ---------- $25.00 $27.00 $28.00 $25.00 $27.00 $28.00

59030 0 $155.00 $146.00 $151.00 $157.00 $146.00 $151.00 $157.00

59050 0 $71.00 $72.00 $76.00 $82.00 $72.00 $76.00 $82.00

59051 0 $47.00 $64.00 $69.00 $77.00 $64.00 $69.00 $77.00

59100 90 $633.00 $1,155.00 $1,220.00 $1,301.00 $1,155.00 $1,220.00 $1,301.00

59120 90 $893.00 $1,186.00 $1,275.00 $1,400.00 $1,186.00 $1,275.00 $1,400.00

59121 90 $768.00 $1,188.00 $1,276.00 $1,398.00 $1,188.00 $1,276.00 $1,398.00

59130 90 $832.00 $1,398.00 $1,506.00 $1,659.00 $1,398.00 $1,506.00 $1,659.00

59135 90 $1,083.00 $1,202.00 $1,250.00 $1,296.00 $1,202.00 $1,250.00 $1,296.00

59136 90 $934.00 $1,324.00 $1,425.00 $1,571.00 $1,324.00 $1,425.00 $1,571.00

59140 90 $461.00 $535.00 $558.00 $577.00 $535.00 $558.00 $577.00

59150 90 $543.00 $1,150.00 $1,235.00 $1,355.00 $1,150.00 $1,235.00 $1,355.00

59151 90 $690.00 $1,124.00 $1,210.00 $1,332.00 $1,124.00 $1,210.00 $1,332.00

59160 10 $279.00 $300.00 $323.00 $351.00 $260.00 $280.00 $307.00

59200 0 $79.00 $104.00 $112.00 $120.00 $68.00 $73.00 $80.00

59300 0 $179.00 $282.00 $303.00 $326.00 $222.00 $238.00 $262.00

59320 0 $196.00 $230.00 $248.00 $273.00 $230.00 $248.00 $273.00

59325 0 $316.00 $367.00 $395.00 $437.00 $367.00 $395.00 $437.00

59350 0 $375.00 $413.00 $440.00 $478.00 $413.00 $440.00 $478.00

59400 0 $1,816.00 $3,114.00 $3,342.00 $3,651.00 $3,114.00 $3,342.00 $3,651.00

59409 0 $1,019.00 $1,229.00 $1,320.00 $1,455.00 $1,229.00 $1,320.00 $1,455.00

59410 0 $1,123.00 $1,568.00 $1,684.00 $1,855.00 $1,568.00 $1,684.00 $1,855.00

59412 0 $141.00 $155.00 $167.00 $184.00 $155.00 $167.00 $184.00

59414 0 $134.00 $140.00 $151.00 $167.00 $140.00 $151.00 $167.00

59425 0 $414.00 $671.00 $719.00 $779.00 $538.00 $577.00 $636.00

59426 0 $708.00 $1,198.00 $1,283.00 $1,387.00 $948.00 $1,016.00 $1,116.00



Surgery


(Non-Facility MRA)






59430 0 $140.00 $271.00 $291.00 $314.00 $210.00 $225.00 $248.00

59510 0 $2,064.00 $3,466.00 $3,729.00 $4,090.00 $3,466.00 $3,729.00 $4,090.00

59514 0 $1,199.00 $1,388.00 $1,493.00 $1,650.00 $1,388.00 $1,493.00 $1,650.00

59515 0 $1,324.00 $1,909.00 $2,055.00 $2,270.00 $1,909.00 $2,055.00 $2,270.00

59525 ZZZ $591.00 $738.00 $795.00 $881.00 $738.00 $795.00 $881.00

59610 0 $1,805.00 $3,289.00 $3,540.00 $3,888.00 $3,289.00 $3,540.00 $3,888.00

59612 0 $1,113.00 $1,393.00 $1,501.00 $1,664.00 $1,393.00 $1,501.00 $1,664.00

59614 0 $1,208.00 $1,730.00 $1,864.00 $2,064.00 $1,730.00 $1,864.00 $2,064.00

59618 0 $2,035.00 $3,515.00 $3,783.00 $4,154.00 $3,515.00 $3,783.00 $4,154.00

59620 0 $1,293.00 $1,416.00 $1,520.00 $1,676.00 $1,416.00 $1,520.00 $1,676.00

59622 0 $1,397.00 $1,941.00 $2,086.00 $2,297.00 $1,941.00 $2,086.00 $2,297.00

59812 90 $343.00 $472.00 $507.00 $553.00 $442.00 $475.00 $520.00

59820 90 $389.00 $558.00 $600.00 $650.00 $528.00 $568.00 $617.00

59821 90 $398.00 $564.00 $606.00 $657.00 $530.00 $570.00 $621.00

59830 90 $496.00 $653.00 $703.00 $771.00 $653.00 $703.00 $771.00

59840 10 $331.00 $321.00 $345.00 $375.00 $309.00 $332.00 $362.00

59841 10 $443.00 $571.00 $614.00 $672.00 $542.00 $583.00 $641.00

59850 90 $449.00 $570.00 $613.00 $674.00 $570.00 $613.00 $674.00

59851 90 $464.00 $596.00 $641.00 $702.00 $596.00 $641.00 $702.00

59852 90 $642.00 $725.00 $756.00 $782.00 $725.00 $756.00 $782.00

59855 90 $477.00 $623.00 $670.00 $736.00 $623.00 $670.00 $736.00

59856 90 $577.00 $734.00 $790.00 $870.00 $734.00 $790.00 $870.00

59857 90 $711.00 $748.00 $779.00 $807.00 $748.00 $779.00 $807.00

59866 0 $304.00 $313.00 $326.00 $338.00 $313.00 $326.00 $338.00

59870 90 $348.00 $701.00 $754.00 $822.00 $701.00 $754.00 $822.00

59871 0 $192.00 $202.00 $218.00 $240.00 $202.00 $218.00 $240.00

59898 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

59899 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

60000 10 $114.00 $226.00 $239.00 $249.00 $205.00 $216.00 $226.00

60100 0 $96.00 $161.00 $169.00 $176.00 $116.00 $121.00 $127.00

60200 90 $744.00 $971.00 $1,034.00 $1,110.00 $971.00 $1,034.00 $1,110.00

60210 90 $872.00 $1,045.00 $1,114.00 $1,202.00 $1,045.00 $1,114.00 $1,202.00

60212 90 $1,170.00 $1,494.00 $1,593.00 $1,722.00 $1,494.00 $1,593.00 $1,722.00

60220 90 $851.00 $1,040.00 $1,106.00 $1,189.00 $1,040.00 $1,106.00 $1,189.00

60225 90 $1,107.00 $1,374.00 $1,464.00 $1,578.00 $1,374.00 $1,464.00 $1,578.00

60240 90 $1,228.00 $1,361.00 $1,451.00 $1,569.00 $1,361.00 $1,451.00 $1,569.00

60252 90 $1,427.00 $1,960.00 $2,088.00 $2,259.00 $1,960.00 $2,088.00 $2,259.00

60254 90 $1,911.00 $2,468.00 $2,622.00 $2,826.00 $2,468.00 $2,622.00 $2,826.00

60260 90 $1,022.00 $1,618.00 $1,721.00 $1,857.00 $1,618.00 $1,721.00 $1,857.00

60270 90 $1,468.00 $2,035.00 $2,168.00 $2,349.00 $2,035.00 $2,168.00 $2,349.00

60271 90 $1,210.00 $1,566.00 $1,666.00 $1,798.00 $1,566.00 $1,666.00 $1,798.00

60280 90 $546.00 $641.00 $680.00 $719.00 $641.00 $680.00 $719.00

60281 90 $670.00 $864.00 $918.00 $981.00 $864.00 $918.00 $981.00

60300 0 ---------- $166.00 $175.00 $181.00 $73.00 $77.00 $81.00

60500 90 $1,232.00 $1,433.00 $1,530.00 $1,659.00 $1,433.00 $1,530.00 $1,659.00

60502 90 $1,475.00 $1,916.00 $2,047.00 $2,224.00 $1,916.00 $2,047.00 $2,224.00

60505 90 $1,631.00 $2,050.00 $2,180.00 $2,350.00 $2,050.00 $2,180.00 $2,350.00

60512 ZZZ $310.00 $365.00 $389.00 $425.00 $365.00 $389.00 $425.00

60520 90 $1,405.00 $1,561.00 $1,672.00 $1,829.00 $1,561.00 $1,672.00 $1,829.00

60521 90 $1,591.00 $1,684.00 $1,805.00 $1,978.00 $1,684.00 $1,805.00 $1,978.00



Surgery


(Non-Facility MRA)






60522 90 $1,820.00 $2,048.00 $2,196.00 $2,409.00 $2,048.00 $2,196.00 $2,409.00

60540 90 $1,272.00 $1,585.00 $1,688.00 $1,827.00 $1,585.00 $1,688.00 $1,827.00

60545 90 $1,505.00 $1,816.00 $1,936.00 $2,100.00 $1,816.00 $1,936.00 $2,100.00

60600 90 $1,477.00 $2,088.00 $2,231.00 $2,442.00 $2,088.00 $2,231.00 $2,442.00

60605 90 $1,624.00 $2,858.00 $3,030.00 $3,244.00 $2,858.00 $3,030.00 $3,244.00

60650 90 $1,340.00 $1,782.00 $1,900.00 $2,064.00 $1,782.00 $1,900.00 $2,064.00

60659 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

60699 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

61020 0 $150.00 $152.00 $164.00 $181.00 $152.00 $164.00 $181.00

61026 0 $138.00 $154.00 $163.00 $175.00 $154.00 $163.00 $175.00

61050 0 $106.00 $126.00 $132.00 $138.00 $126.00 $132.00 $138.00

61055 0 $143.00 $181.00 $192.00 $207.00 $181.00 $192.00 $207.00

61070 0 $67.00 $85.00 $90.00 $97.00 $85.00 $90.00 $97.00

61105 90 $503.00 $671.00 $731.00 $812.00 $671.00 $731.00 $812.00

61107 0 $863.00 $494.00 $543.00 $621.00 $494.00 $543.00 $621.00

61108 90 $959.00 $1,384.00 $1,514.00 $1,695.00 $1,384.00 $1,514.00 $1,695.00

61120 90 $733.00 $1,144.00 $1,253.00 $1,407.00 $1,144.00 $1,253.00 $1,407.00

61140 90 $1,389.00 $1,944.00 $2,130.00 $2,401.00 $1,944.00 $2,130.00 $2,401.00

61150 90 $1,503.00 $2,099.00 $2,304.00 $2,609.00 $2,099.00 $2,304.00 $2,609.00

61151 90 $795.00 $1,542.00 $1,692.00 $1,914.00 $1,542.00 $1,692.00 $1,914.00

61154 90 $1,393.00 $1,955.00 $2,142.00 $2,412.00 $1,955.00 $2,142.00 $2,412.00

61156 90 $1,473.00 $1,931.00 $2,120.00 $2,400.00 $1,931.00 $2,120.00 $2,400.00

61210 0 $527.00 $582.00 $641.00 $734.00 $582.00 $641.00 $734.00

61215 90 $637.00 $773.00 $845.00 $942.00 $773.00 $845.00 $942.00

61250 90 $888.00 $1,260.00 $1,368.00 $1,518.00 $1,260.00 $1,368.00 $1,518.00

61253 90 $1,042.00 $1,194.00 $1,261.00 $1,340.00 $1,194.00 $1,261.00 $1,340.00

61304 90 $2,005.00 $2,530.00 $2,771.00 $3,131.00 $2,530.00 $2,771.00 $3,131.00

61305 90 $2,419.00 $3,136.00 $3,446.00 $3,914.00 $3,136.00 $3,446.00 $3,914.00

61312 90 $2,187.00 $3,229.00 $3,544.00 $4,019.00 $3,229.00 $3,544.00 $4,019.00

61313 90 $2,207.00 $3,070.00 $3,367.00 $3,809.00 $3,070.00 $3,367.00 $3,809.00

61314 90 $2,200.00 $2,830.00 $3,103.00 $3,510.00 $2,830.00 $3,103.00 $3,510.00

61315 90 $2,393.00 $3,213.00 $3,526.00 $3,998.00 $3,213.00 $3,526.00 $3,998.00

61316 ZZZ $88.00 $140.00 $154.00 $177.00 $140.00 $154.00 $177.00

61320 90 $2,118.00 $2,945.00 $3,229.00 $3,655.00 $2,945.00 $3,229.00 $3,655.00

61321 90 $2,310.00 $3,280.00 $3,598.00 $4,077.00 $3,280.00 $3,598.00 $4,077.00

61322 90 $1,779.00 $3,695.00 $4,056.00 $4,602.00 $3,695.00 $4,056.00 $4,602.00

61323 90 $1,842.00 $3,753.00 $4,127.00 $4,699.00 $3,753.00 $4,127.00 $4,699.00

61330 90 $1,706.00 $2,711.00 $2,963.00 $3,335.00 $2,711.00 $2,963.00 $3,335.00

61332 90 $2,307.00 $2,491.00 $2,611.00 $2,733.00 $2,491.00 $2,611.00 $2,733.00

61333 90 $2,231.00 $2,620.00 $2,738.00 $2,840.00 $2,620.00 $2,738.00 $2,840.00

61340 90 $1,584.00 $2,250.00 $2,471.00 $2,800.00 $2,250.00 $2,471.00 $2,800.00

61343 90 $2,673.00 $3,403.00 $3,731.00 $4,224.00 $3,403.00 $3,731.00 $4,224.00

61345 90 $2,259.00 $3,158.00 $3,467.00 $3,933.00 $3,158.00 $3,467.00 $3,933.00

61450 90 $2,173.00 $3,005.00 $3,303.00 $3,756.00 $3,005.00 $3,303.00 $3,756.00

61458 90 $2,433.00 $3,118.00 $3,422.00 $3,879.00 $3,118.00 $3,422.00 $3,879.00

61460 90 $2,426.00 $3,192.00 $3,497.00 $3,954.00 $3,192.00 $3,497.00 $3,954.00

61480 90 $1,922.00 $3,033.00 $3,334.00 $3,792.00 $3,033.00 $3,334.00 $3,792.00

61500 90 $1,637.00 $2,004.00 $2,174.00 $2,414.00 $2,004.00 $2,174.00 $2,414.00

61501 90 $1,353.00 $1,735.00 $1,878.00 $2,076.00 $1,735.00 $1,878.00 $2,076.00

61510 90 $2,506.00 $3,379.00 $3,705.00 $4,191.00 $3,379.00 $3,705.00 $4,191.00



Surgery


(Non-Facility MRA)






61512 90 $2,981.00 $3,956.00 $4,341.00 $4,924.00 $3,956.00 $4,341.00 $4,924.00

61514 90 $2,262.00 $2,945.00 $3,229.00 $3,653.00 $2,945.00 $3,229.00 $3,653.00

61516 90 $2,253.00 $2,873.00 $3,148.00 $3,558.00 $2,873.00 $3,148.00 $3,558.00

61517 ZZZ $74.00 $138.00 $152.00 $174.00 $138.00 $152.00 $174.00

61518 90 $3,163.00 $4,276.00 $4,690.00 $5,316.00 $4,276.00 $4,690.00 $5,316.00

61519 90 $3,450.00 $4,570.00 $5,014.00 $5,690.00 $4,570.00 $5,014.00 $5,690.00

61520 90 $4,349.00 $5,831.00 $6,379.00 $7,210.00 $5,831.00 $6,379.00 $7,210.00

61521 90 $3,667.00 $4,945.00 $5,429.00 $6,169.00 $4,945.00 $5,429.00 $6,169.00

61522 90 $2,415.00 $3,417.00 $3,756.00 $4,271.00 $3,417.00 $3,756.00 $4,271.00

61524 90 $2,484.00 $3,237.00 $3,556.00 $4,037.00 $3,237.00 $3,556.00 $4,037.00

61526 90 $3,918.00 $5,725.00 $6,297.00 $7,180.00 $5,725.00 $6,297.00 $7,180.00

61530 90 $3,611.00 $4,771.00 $5,240.00 $5,962.00 $4,771.00 $5,240.00 $5,962.00

61531 90 $1,344.00 $1,855.00 $2,033.00 $2,293.00 $1,855.00 $2,033.00 $2,293.00

61533 90 $1,712.00 $2,342.00 $2,567.00 $2,901.00 $2,342.00 $2,567.00 $2,901.00

61534 90 $1,535.00 $2,561.00 $2,813.00 $3,190.00 $2,561.00 $2,813.00 $3,190.00

61535 90 $958.00 $1,515.00 $1,659.00 $1,868.00 $1,515.00 $1,659.00 $1,868.00

61536 90 $2,862.00 $3,975.00 $4,358.00 $4,938.00 $3,975.00 $4,358.00 $4,938.00

61537 90 ---------- $3,859.00 $4,241.00 $4,826.00 $3,859.00 $4,241.00 $4,826.00

61538 90 $2,466.00 $4,161.00 $4,573.00 $5,205.00 $4,161.00 $4,573.00 $5,205.00

61539 90 $2,660.00 $3,692.00 $4,060.00 $4,620.00 $3,692.00 $4,060.00 $4,620.00

61540 90 ---------- $3,356.00 $3,682.00 $4,174.00 $3,356.00 $3,682.00 $4,174.00

61541 90 $2,363.00 $3,357.00 $3,691.00 $4,196.00 $3,357.00 $3,691.00 $4,196.00

61543 90 $2,307.00 $3,216.00 $3,500.00 $3,914.00 $3,216.00 $3,500.00 $3,914.00

61544 90 $2,271.00 $2,971.00 $3,266.00 $3,713.00 $2,971.00 $3,266.00 $3,713.00

61545 90 $3,474.00 $4,984.00 $5,480.00 $6,239.00 $4,984.00 $5,480.00 $6,239.00

61546 90 $2,695.00 $3,586.00 $3,940.00 $4,478.00 $3,586.00 $3,940.00 $4,478.00

61548 90 $1,964.00 $2,418.00 $2,636.00 $2,957.00 $2,418.00 $2,636.00 $2,957.00

61550 90 $1,141.00 $1,831.00 $2,009.00 $2,265.00 $1,831.00 $2,009.00 $2,265.00

61552 90 $1,463.00 $1,710.00 $1,802.00 $1,915.00 $1,710.00 $1,802.00 $1,915.00

61556 90 $1,760.00 $2,361.00 $2,551.00 $2,821.00 $2,361.00 $2,551.00 $2,821.00

61557 90 $1,807.00 $2,614.00 $2,871.00 $3,253.00 $2,614.00 $2,871.00 $3,253.00

61558 90 $2,085.00 $2,926.00 $3,214.00 $3,648.00 $2,926.00 $3,214.00 $3,648.00

61559 90 $2,700.00 $3,482.00 $3,766.00 $4,162.00 $3,482.00 $3,766.00 $4,162.00

61563 90 $2,175.00 $3,060.00 $3,357.00 $3,803.00 $3,060.00 $3,357.00 $3,803.00

61564 90 $2,597.00 $3,508.00 $3,813.00 $4,258.00 $3,508.00 $3,813.00 $4,258.00

61566 90 ---------- $3,513.00 $3,862.00 $4,392.00 $3,513.00 $3,862.00 $4,392.00

61567 90 ---------- $3,709.00 $4,087.00 $4,688.00 $3,709.00 $4,087.00 $4,688.00

61570 90 $1,975.00 $2,846.00 $3,117.00 $3,520.00 $2,846.00 $3,117.00 $3,520.00

61571 90 $2,140.00 $3,104.00 $3,411.00 $3,875.00 $3,104.00 $3,411.00 $3,875.00

61575 90 $2,992.00 $3,859.00 $4,231.00 $4,794.00 $3,859.00 $4,231.00 $4,794.00

61576 90 $3,772.00 $5,034.00 $5,337.00 $5,705.00 $5,034.00 $5,337.00 $5,705.00

61580 90 $2,383.00 $3,657.00 $3,917.00 $4,235.00 $3,657.00 $3,917.00 $4,235.00

61581 90 $2,674.00 $3,869.00 $4,095.00 $4,339.00 $3,869.00 $4,095.00 $4,339.00

61582 90 $2,557.00 $4,560.00 $4,983.00 $5,553.00 $4,560.00 $4,983.00 $5,553.00

61583 90 $2,972.00 $4,422.00 $4,835.00 $5,423.00 $4,422.00 $4,835.00 $5,423.00

61584 90 $2,830.00 $4,340.00 $4,744.00 $5,318.00 $4,340.00 $4,744.00 $5,318.00

61585 90 $3,142.00 $4,857.00 $5,316.00 $5,980.00 $4,857.00 $5,316.00 $5,980.00

61586 90 $2,097.00 $3,587.00 $3,913.00 $4,342.00 $3,587.00 $3,913.00 $4,342.00

61590 90 $3,299.00 $4,506.00 $4,805.00 $5,180.00 $4,506.00 $4,805.00 $5,180.00

61591 90 $3,491.00 $4,584.00 $4,906.00 $5,325.00 $4,584.00 $4,906.00 $5,325.00



Surgery


(Non-Facility MRA)






61592 90 $3,245.00 $4,857.00 $5,308.00 $5,954.00 $4,857.00 $5,308.00 $5,954.00

61595 90 $2,350.00 $3,488.00 $3,740.00 $4,060.00 $3,488.00 $3,740.00 $4,060.00

61596 90 $2,827.00 $3,581.00 $3,786.00 $4,026.00 $3,581.00 $3,786.00 $4,026.00

61597 90 $3,046.00 $4,365.00 $4,759.00 $5,332.00 $4,365.00 $4,759.00 $5,332.00

61598 90 $2,693.00 $4,274.00 $4,673.00 $5,236.00 $4,274.00 $4,673.00 $5,236.00

61600 90 $2,039.00 $3,144.00 $3,366.00 $3,637.00 $3,144.00 $3,366.00 $3,637.00

61601 90 $2,279.00 $3,641.00 $3,971.00 $4,430.00 $3,641.00 $3,971.00 $4,430.00

61605 90 $2,299.00 $3,174.00 $3,367.00 $3,588.00 $3,174.00 $3,367.00 $3,588.00

61606 90 $3,178.00 $4,513.00 $4,916.00 $5,495.00 $4,513.00 $4,916.00 $5,495.00

61607 90 $2,961.00 $4,051.00 $4,361.00 $4,785.00 $4,051.00 $4,361.00 $4,785.00

61608 90 $3,458.00 $4,993.00 $5,462.00 $6,148.00 $4,993.00 $5,462.00 $6,148.00

61610 ZZZ $2,354.00 $2,476.00 $2,631.00 $2,843.00 $2,476.00 $2,631.00 $2,843.00

61611 ZZZ $584.00 $576.00 $606.00 $646.00 $576.00 $606.00 $646.00

61612 ZZZ $2,219.00 $1,768.00 $1,828.00 $1,915.00 $1,768.00 $1,828.00 $1,915.00

61613 90 $3,375.00 $4,927.00 $5,372.00 $6,011.00 $4,927.00 $5,372.00 $6,011.00

61615 90 $2,576.00 $3,701.00 $3,986.00 $4,365.00 $3,701.00 $3,986.00 $4,365.00

61616 90 $3,535.00 $5,075.00 $5,529.00 $6,179.00 $5,075.00 $5,529.00 $6,179.00

61618 90 $1,389.00 $1,973.00 $2,146.00 $2,393.00 $1,973.00 $2,146.00 $2,393.00

61619 90 $1,682.00 $2,165.00 $2,335.00 $2,572.00 $2,165.00 $2,335.00 $2,572.00

61623 0 $540.00 $870.00 $938.00 $1,040.00 $870.00 $938.00 $1,040.00

61624 0 $1,073.00 $1,752.00 $1,890.00 $2,101.00 $1,752.00 $1,890.00 $2,101.00

61626 0 $877.00 $1,289.00 $1,363.00 $1,467.00 $1,289.00 $1,363.00 $1,467.00

61630 0 ---------- $2,045.00 $2,208.00 $2,446.00 $2,045.00 $2,208.00 $2,446.00

61635 0 ---------- $2,173.00 $2,334.00 $2,567.00 $2,173.00 $2,334.00 $2,567.00

61640 0 ---------- $733.00 $768.00 $834.00 $733.00 $768.00 $834.00

61641 ZZZ ---------- $257.00 $270.00 $292.00 $257.00 $270.00 $292.00

61642 ZZZ ---------- $514.00 $539.00 $585.00 $514.00 $539.00 $585.00

61645 0 ---------- $1,187.00 $1,268.00 $1,392.00 $1,187.00 $1,268.00 $1,392.00

61650 0 ---------- $813.00 $872.00 $962.00 $813.00 $872.00 $962.00

61651 ZZZ ---------- $346.00 $371.00 $409.00 $346.00 $371.00 $409.00

61680 90 $2,758.00 $3,505.00 $3,845.00 $4,356.00 $3,505.00 $3,845.00 $4,356.00

61682 90 $4,798.00 $6,494.00 $7,128.00 $8,107.00 $6,494.00 $7,128.00 $8,107.00

61684 90 $3,341.00 $4,454.00 $4,897.00 $5,577.00 $4,454.00 $4,897.00 $5,577.00

61686 90 $5,012.00 $7,056.00 $7,761.00 $8,854.00 $7,056.00 $7,761.00 $8,854.00

61690 90 $2,556.00 $3,378.00 $3,706.00 $4,198.00 $3,378.00 $3,706.00 $4,198.00

61692 90 $4,007.00 $5,715.00 $6,282.00 $7,155.00 $5,715.00 $6,282.00 $7,155.00

61697 90 $3,231.00 $6,575.00 $7,221.00 $8,217.00 $6,575.00 $7,221.00 $8,217.00

61698 90 $3,103.00 $7,256.00 $7,979.00 $9,097.00 $7,256.00 $7,979.00 $9,097.00

61700 90 $4,037.00 $5,304.00 $5,821.00 $6,612.00 $5,304.00 $5,821.00 $6,612.00

61702 90 $4,019.00 $6,252.00 $6,863.00 $7,801.00 $6,252.00 $6,863.00 $7,801.00

61703 90 $1,444.00 $1,884.00 $2,045.00 $2,278.00 $1,884.00 $2,045.00 $2,278.00

61705 90 $3,043.00 $4,076.00 $4,482.00 $5,104.00 $4,076.00 $4,482.00 $5,104.00

61708 90 $2,546.00 $3,569.00 $3,879.00 $4,344.00 $3,569.00 $3,879.00 $4,344.00

61710 90 $2,129.00 $3,314.00 $3,637.00 $4,130.00 $3,314.00 $3,637.00 $4,130.00

61711 90 $3,150.00 $4,058.00 $4,457.00 $5,063.00 $4,058.00 $4,457.00 $5,063.00

61720 90 $1,558.00 $1,975.00 $2,169.00 $2,458.00 $1,975.00 $2,169.00 $2,458.00

61735 90 $1,664.00 $2,476.00 $2,720.00 $3,086.00 $2,476.00 $2,720.00 $3,086.00

61750 90 $1,521.00 $2,183.00 $2,397.00 $2,717.00 $2,183.00 $2,397.00 $2,717.00

61751 90 $1,628.00 $2,135.00 $2,343.00 $2,649.00 $2,135.00 $2,343.00 $2,649.00

61760 90 $1,670.00 $2,453.00 $2,694.00 $3,057.00 $2,453.00 $2,694.00 $3,057.00



Surgery


(Non-Facility MRA)






61770 90 $1,867.00 $2,534.00 $2,785.00 $3,164.00 $2,534.00 $2,785.00 $3,164.00

61781 ZZZ ---------- $371.00 $407.00 $465.00 $371.00 $407.00 $465.00

61782 ZZZ ---------- $260.00 $275.00 $295.00 $260.00 $275.00 $295.00

61783 ZZZ ---------- $361.00 $395.00 $446.00 $361.00 $395.00 $446.00

61790 90 $952.00 $1,354.00 $1,484.00 $1,672.00 $1,354.00 $1,484.00 $1,672.00

61791 90 $1,205.00 $1,687.00 $1,847.00 $2,081.00 $1,687.00 $1,847.00 $2,081.00

61796 90 ---------- $1,572.00 $1,725.00 $1,950.00 $1,572.00 $1,725.00 $1,950.00

61797 ZZZ ---------- $348.00 $384.00 $440.00 $348.00 $384.00 $440.00

61798 90 ---------- $2,146.00 $2,354.00 $2,667.00 $2,146.00 $2,354.00 $2,667.00

61799 ZZZ ---------- $482.00 $530.00 $608.00 $482.00 $530.00 $608.00

61800 ZZZ ---------- $241.00 $265.00 $301.00 $241.00 $265.00 $301.00

61850 90 $1,090.00 $1,523.00 $1,671.00 $1,890.00 $1,523.00 $1,671.00 $1,890.00

61860 90 $1,197.00 $2,400.00 $2,628.00 $2,969.00 $2,400.00 $2,628.00 $2,969.00

61863 90 ---------- $2,325.00 $2,550.00 $2,883.00 $2,325.00 $2,550.00 $2,883.00

61864 ZZZ ---------- $449.00 $494.00 $566.00 $449.00 $494.00 $566.00

61867 90 ---------- $3,546.00 $3,893.00 $4,419.00 $3,546.00 $3,893.00 $4,419.00

61868 ZZZ ---------- $788.00 $867.00 $992.00 $788.00 $867.00 $992.00

61870 90 $616.00 $1,564.00 $1,686.00 $1,858.00 $1,564.00 $1,686.00 $1,858.00

61880 90 $559.00 $864.00 $944.00 $1,053.00 $864.00 $944.00 $1,053.00

61885 90 $262.00 $776.00 $846.00 $936.00 $776.00 $846.00 $936.00

61886 90 $678.00 $1,280.00 $1,397.00 $1,554.00 $1,280.00 $1,397.00 $1,554.00

61888 10 $331.00 $607.00 $664.00 $745.00 $607.00 $664.00 $745.00

62000 90 $848.00 $1,466.00 $1,595.00 $1,781.00 $1,466.00 $1,595.00 $1,781.00

62005 90 $1,282.00 $1,943.00 $2,126.00 $2,397.00 $1,943.00 $2,126.00 $2,397.00

62010 90 $1,754.00 $2,369.00 $2,600.00 $2,944.00 $2,369.00 $2,600.00 $2,944.00

62100 90 $1,962.00 $2,430.00 $2,647.00 $2,965.00 $2,430.00 $2,647.00 $2,965.00

62115 90 $1,686.00 $1,927.00 $2,031.00 $2,158.00 $1,927.00 $2,031.00 $2,158.00

62117 90 $2,211.00 $3,066.00 $3,371.00 $3,834.00 $3,066.00 $3,371.00 $3,834.00

62120 90 $1,898.00 $2,425.00 $2,565.00 $2,715.00 $2,425.00 $2,565.00 $2,715.00

62121 90 $1,822.00 $2,381.00 $2,561.00 $2,795.00 $2,381.00 $2,561.00 $2,795.00

62140 90 $1,221.00 $1,583.00 $1,726.00 $1,932.00 $1,583.00 $1,726.00 $1,932.00

62141 90 $1,955.00 $1,750.00 $1,910.00 $2,141.00 $1,750.00 $1,910.00 $2,141.00

62142 90 $1,011.00 $1,359.00 $1,486.00 $1,666.00 $1,359.00 $1,486.00 $1,666.00

62143 90 $1,096.00 $1,603.00 $1,755.00 $1,976.00 $1,603.00 $1,755.00 $1,976.00

62145 90 $1,566.00 $2,186.00 $2,394.00 $2,704.00 $2,186.00 $2,394.00 $2,704.00

62146 90 $1,327.00 $1,838.00 $2,004.00 $2,243.00 $1,838.00 $2,004.00 $2,243.00

62147 90 $1,566.00 $2,185.00 $2,383.00 $2,671.00 $2,185.00 $2,383.00 $2,671.00

62148 ZZZ $120.00 $200.00 $220.00 $252.00 $200.00 $220.00 $252.00

62160 ZZZ $172.00 $301.00 $331.00 $379.00 $301.00 $331.00 $379.00

62161 90 $1,229.00 $2,344.00 $2,571.00 $2,907.00 $2,344.00 $2,571.00 $2,907.00

62162 90 $1,578.00 $2,929.00 $3,215.00 $3,642.00 $2,929.00 $3,215.00 $3,642.00

62163 90 $999.00 $1,897.00 $2,083.00 $2,354.00 $1,897.00 $2,083.00 $2,354.00

62164 90 $1,706.00 $3,219.00 $3,531.00 $3,997.00 $3,219.00 $3,531.00 $3,997.00

62165 90 $1,336.00 $2,342.00 $2,537.00 $2,817.00 $2,342.00 $2,537.00 $2,817.00

62180 90 $1,695.00 $2,494.00 $2,740.00 $3,109.00 $2,494.00 $2,740.00 $3,109.00

62190 90 $1,034.00 $1,073.00 $1,139.00 $1,225.00 $1,073.00 $1,139.00 $1,225.00

62192 90 $1,146.00 $1,502.00 $1,643.00 $1,845.00 $1,502.00 $1,643.00 $1,845.00

62194 10 $239.00 $671.00 $729.00 $809.00 $671.00 $729.00 $809.00

62200 90 $1,625.00 $2,091.00 $2,291.00 $2,587.00 $2,091.00 $2,291.00 $2,587.00

62201 90 $1,200.00 $1,856.00 $2,035.00 $2,296.00 $1,856.00 $2,035.00 $2,296.00



Surgery


(Non-Facility MRA)






62220 90 $1,215.00 $1,590.00 $1,741.00 $1,962.00 $1,590.00 $1,741.00 $1,962.00

62223 90 $1,199.00 $1,599.00 $1,747.00 $1,957.00 $1,599.00 $1,747.00 $1,957.00

62225 90 $488.00 $768.00 $838.00 $931.00 $768.00 $838.00 $931.00

62230 90 $935.00 $1,291.00 $1,412.00 $1,587.00 $1,291.00 $1,412.00 $1,587.00

62252 0 $85.00 $125.00 $136.00 $148.00 $125.00 $136.00 $148.00

62252-26 0 ---------- $73.00 $80.00 $91.00 $73.00 $80.00 $91.00

62252-TC 0 ---------- $53.00 $56.00 $57.00 $53.00 $56.00 $57.00

62256 90 $616.00 $914.00 $999.00 $1,117.00 $914.00 $999.00 $1,117.00

62258 90 $1,308.00 $1,722.00 $1,885.00 $2,123.00 $1,722.00 $1,885.00 $2,123.00

62263 10 $426.00 $844.00 $891.00 $912.00 $465.00 $487.00 $504.00

62264 10 $593.00 $589.00 $620.00 $638.00 $345.00 $359.00 $375.00

62267 0 ---------- $352.00 $371.00 $383.00 $233.00 $243.00 $254.00

62268 0 $285.00 $379.00 $397.00 $417.00 $379.00 $397.00 $417.00

62269 0 $271.00 $393.00 $412.00 $435.00 $393.00 $412.00 $435.00

62270 0 $109.00 $223.00 $237.00 $246.00 $115.00 $121.00 $129.00

62272 0 $137.00 $284.00 $304.00 $318.00 $125.00 $134.00 $146.00

62273 0 $130.00 $244.00 $256.00 $265.00 $165.00 $172.00 $180.00

62280 10 $199.00 $424.00 $449.00 $465.00 $234.00 $246.00 $260.00

62281 10 $186.00 $342.00 $362.00 $377.00 $229.00 $241.00 $254.00

62282 10 $211.00 $415.00 $440.00 $454.00 $213.00 $224.00 $236.00

62284 0 $196.00 $263.00 $278.00 $287.00 $129.00 $135.00 $143.00

62287 90 $784.00 $834.00 $879.00 $926.00 $834.00 $879.00 $926.00

62290 0 $235.00 $461.00 $487.00 $500.00 $248.00 $259.00 $270.00

62291 0 $232.00 $463.00 $488.00 $500.00 $245.00 $256.00 $266.00

62292 90 $1,064.00 $833.00 $872.00 $907.00 $833.00 $872.00 $907.00

62294 90 $821.00 $1,468.00 $1,611.00 $1,822.00 $1,468.00 $1,611.00 $1,822.00

62302 0 ---------- $341.00 $359.00 $370.00 $180.00 $187.00 $196.00

62303 0 ---------- $351.00 $370.00 $381.00 $181.00 $189.00 $198.00

62304 0 ---------- $336.00 $354.00 $364.00 $176.00 $184.00 $192.00

62305 0 ---------- $365.00 $385.00 $396.00 $184.00 $192.00 $201.00

62320 0 ---------- $236.00 $250.00 $260.00 $149.00 $157.00 $166.00

62321 0 ---------- $348.00 $369.00 $381.00 $161.00 $169.00 $179.00

62322 0 ---------- $220.00 $232.00 $241.00 $128.00 $135.00 $142.00

62323 0 ---------- $341.00 $361.00 $371.00 $147.00 $154.00 $162.00

62324 0 ---------- $208.00 $220.00 $230.00 $138.00 $144.00 $154.00

62325 0 ---------- $311.00 $329.00 $342.00 $158.00 $166.00 $177.00

62326 0 ---------- $217.00 $230.00 $239.00 $134.00 $141.00 $149.00

62327 0 ---------- $315.00 $334.00 $345.00 $143.00 $150.00 $159.00

62350 10 $488.00 $588.00 $626.00 $672.00 $588.00 $626.00 $672.00

62351 90 $782.00 $1,289.00 $1,393.00 $1,530.00 $1,289.00 $1,393.00 $1,530.00

62355 10 $402.00 $393.00 $420.00 $450.00 $393.00 $420.00 $450.00

62360 10 $195.00 $456.00 $487.00 $525.00 $456.00 $487.00 $525.00

62361 10 $390.00 $638.00 $696.00 $775.00 $638.00 $696.00 $775.00

62362 10 $517.00 $569.00 $608.00 $657.00 $569.00 $608.00 $657.00

62365 10 $418.00 $440.00 $472.00 $510.00 $440.00 $472.00 $510.00

62367 0 BR $58.00 $61.00 $64.00 $37.00 $39.00 $41.00

62368 0 BR $80.00 $84.00 $87.00 $51.00 $54.00 $57.00

62369 0 ---------- $164.00 $174.00 $178.00 $52.00 $54.00 $57.00

62370 0 ---------- $174.00 $184.00 $189.00 $67.00 $70.00 $74.00

63001 90 $1,882.00 $1,900.00 $2,073.00 $2,323.00 $1,900.00 $2,073.00 $2,323.00



Surgery


(Non-Facility MRA)






63003 90 $1,591.00 $1,894.00 $2,063.00 $2,305.00 $1,894.00 $2,063.00 $2,305.00

63005 90 $1,390.00 $1,798.00 $1,956.00 $2,178.00 $1,798.00 $1,956.00 $2,178.00

63011 90 $1,151.00 $1,640.00 $1,767.00 $1,938.00 $1,640.00 $1,767.00 $1,938.00

63012 90 $1,568.00 $1,808.00 $1,964.00 $2,182.00 $1,808.00 $1,964.00 $2,182.00

63015 90 $1,862.00 $2,271.00 $2,480.00 $2,781.00 $2,271.00 $2,480.00 $2,781.00

63016 90 $1,788.00 $2,333.00 $2,541.00 $2,844.00 $2,333.00 $2,541.00 $2,844.00

63017 90 $1,489.00 $1,919.00 $2,092.00 $2,340.00 $1,919.00 $2,092.00 $2,340.00

63020 90 $1,395.00 $1,759.00 $1,909.00 $2,116.00 $1,759.00 $1,909.00 $2,116.00

63030 90 $1,145.00 $1,462.00 $1,583.00 $1,746.00 $1,462.00 $1,583.00 $1,746.00

63035 ZZZ $280.00 $294.00 $319.00 $356.00 $294.00 $319.00 $356.00

63040 90 $1,764.00 $2,115.00 $2,293.00 $2,544.00 $2,115.00 $2,293.00 $2,544.00

63042 90 $1,620.00 $1,953.00 $2,110.00 $2,325.00 $1,953.00 $2,110.00 $2,325.00

63043 ZZZ BR ---------- ---------- ---------- ---------- ---------- ----------

63044 ZZZ BR ---------- ---------- ---------- ---------- ---------- ----------

63045 90 $1,647.00 $1,964.00 $2,139.00 $2,387.00 $1,964.00 $2,139.00 $2,387.00

63046 90 $2,117.00 $1,851.00 $2,006.00 $2,222.00 $1,851.00 $2,006.00 $2,222.00

63047 90 $1,907.00 $1,664.00 $1,802.00 $1,990.00 $1,664.00 $1,802.00 $1,990.00

63048 ZZZ $367.00 $325.00 $353.00 $394.00 $325.00 $353.00 $394.00

63050 90 ---------- $2,280.00 $2,470.00 $2,737.00 $2,280.00 $2,470.00 $2,737.00

63051 90 ---------- $2,593.00 $2,807.00 $3,109.00 $2,593.00 $2,807.00 $3,109.00

63055 90 $2,029.00 $2,498.00 $2,726.00 $3,059.00 $2,498.00 $2,726.00 $3,059.00

63056 90 $1,960.00 $2,252.00 $2,442.00 $2,710.00 $2,252.00 $2,442.00 $2,710.00

63057 ZZZ $421.00 $492.00 $534.00 $597.00 $492.00 $534.00 $597.00

63064 90 $2,200.00 $2,713.00 $2,953.00 $3,304.00 $2,713.00 $2,953.00 $3,304.00

63066 ZZZ $263.00 $324.00 $356.00 $407.00 $324.00 $356.00 $407.00

63075 90 $1,720.00 $2,055.00 $2,229.00 $2,473.00 $2,055.00 $2,229.00 $2,473.00

63076 ZZZ $383.00 $382.00 $415.00 $466.00 $382.00 $415.00 $466.00

63077 90 $1,828.00 $2,259.00 $2,441.00 $2,698.00 $2,259.00 $2,441.00 $2,698.00

63078 ZZZ $261.00 $295.00 $318.00 $351.00 $295.00 $318.00 $351.00

63081 90 $2,203.00 $2,671.00 $2,896.00 $3,217.00 $2,671.00 $2,896.00 $3,217.00

63082 ZZZ $391.00 $410.00 $445.00 $499.00 $410.00 $445.00 $499.00

63085 90 $2,416.00 $2,915.00 $3,159.00 $3,511.00 $2,915.00 $3,159.00 $3,511.00

63086 ZZZ $282.00 $293.00 $317.00 $353.00 $293.00 $317.00 $353.00

63087 90 $2,930.00 $3,669.00 $3,973.00 $4,412.00 $3,669.00 $3,973.00 $4,412.00

63088 ZZZ $381.00 $399.00 $432.00 $482.00 $399.00 $432.00 $482.00

63090 90 $2,490.00 $2,941.00 $3,157.00 $3,455.00 $2,941.00 $3,157.00 $3,455.00

63091 ZZZ $249.00 $269.00 $289.00 $317.00 $269.00 $289.00 $317.00

63101 90 ---------- $3,537.00 $3,848.00 $4,298.00 $3,537.00 $3,848.00 $4,298.00

63102 90 ---------- $3,448.00 $3,733.00 $4,135.00 $3,448.00 $3,733.00 $4,135.00

63103 ZZZ ---------- $450.00 $488.00 $545.00 $450.00 $488.00 $545.00

63170 90 $1,788.00 $2,478.00 $2,722.00 $3,085.00 $2,478.00 $2,722.00 $3,085.00

63172 90 $1,672.00 $2,177.00 $2,387.00 $2,697.00 $2,177.00 $2,387.00 $2,697.00

63173 90 $1,851.00 $2,639.00 $2,891.00 $3,265.00 $2,639.00 $2,891.00 $3,265.00

63180 90 $1,486.00 $2,026.00 $2,185.00 $2,405.00 $2,026.00 $2,185.00 $2,405.00

63182 90 $1,711.00 $2,539.00 $2,789.00 $3,163.00 $2,539.00 $2,789.00 $3,163.00

63185 90 $1,347.00 $1,720.00 $1,857.00 $2,043.00 $1,720.00 $1,857.00 $2,043.00

63190 90 $1,610.00 $1,926.00 $2,076.00 $2,279.00 $1,926.00 $2,076.00 $2,279.00

63191 90 $1,444.00 $1,901.00 $2,043.00 $2,230.00 $1,901.00 $2,043.00 $2,230.00

63194 90 $1,593.00 $2,099.00 $2,251.00 $2,458.00 $2,099.00 $2,251.00 $2,458.00

63195 90 $1,603.00 $1,869.00 $1,970.00 $2,091.00 $1,869.00 $1,970.00 $2,091.00



Surgery


(Non-Facility MRA)






63196 90 $1,810.00 $2,083.00 $2,195.00 $2,333.00 $2,083.00 $2,195.00 $2,333.00

63197 90 $1,725.00 $2,081.00 $2,194.00 $2,328.00 $2,081.00 $2,194.00 $2,328.00

63198 90 $1,956.00 $2,455.00 $2,587.00 $2,752.00 $2,455.00 $2,587.00 $2,752.00

63199 90 $2,258.00 $2,577.00 $2,715.00 $2,888.00 $2,577.00 $2,715.00 $2,888.00

63200 90 $1,569.00 $2,372.00 $2,600.00 $2,938.00 $2,372.00 $2,600.00 $2,938.00

63250 90 $3,182.00 $4,655.00 $5,120.00 $5,836.00 $4,655.00 $5,120.00 $5,836.00

63251 90 $3,207.00 $4,703.00 $5,164.00 $5,870.00 $4,703.00 $5,164.00 $5,870.00

63252 90 $3,319.00 $4,719.00 $5,183.00 $5,891.00 $4,719.00 $5,183.00 $5,891.00

63265 90 $1,940.00 $2,564.00 $2,802.00 $3,151.00 $2,564.00 $2,802.00 $3,151.00

63266 90 $2,053.00 $2,643.00 $2,888.00 $3,248.00 $2,643.00 $2,888.00 $3,248.00

63267 90 $1,651.00 $2,085.00 $2,268.00 $2,528.00 $2,085.00 $2,268.00 $2,528.00

63268 90 $1,469.00 $2,128.00 $2,313.00 $2,574.00 $2,128.00 $2,313.00 $2,574.00

63270 90 $2,197.00 $3,225.00 $3,541.00 $4,018.00 $3,225.00 $3,541.00 $4,018.00

63271 90 $2,401.00 $3,187.00 $3,490.00 $3,944.00 $3,187.00 $3,490.00 $3,944.00

63272 90 $2,206.00 $2,902.00 $3,169.00 $3,563.00 $2,902.00 $3,169.00 $3,563.00

63273 90 $2,012.00 $2,821.00 $3,083.00 $3,468.00 $2,821.00 $3,083.00 $3,468.00

63275 90 $2,166.00 $2,768.00 $3,027.00 $3,410.00 $2,768.00 $3,027.00 $3,410.00

63276 90 $2,135.00 $2,753.00 $3,010.00 $3,390.00 $2,753.00 $3,010.00 $3,390.00

63277 90 $1,905.00 $2,367.00 $2,575.00 $2,873.00 $2,367.00 $2,575.00 $2,873.00

63278 90 $1,877.00 $2,441.00 $2,678.00 $3,029.00 $2,441.00 $2,678.00 $3,029.00

63280 90 $2,529.00 $3,261.00 $3,574.00 $4,041.00 $3,261.00 $3,574.00 $4,041.00

63281 90 $2,496.00 $3,237.00 $3,549.00 $4,014.00 $3,237.00 $3,549.00 $4,014.00

63282 90 $2,305.00 $3,040.00 $3,328.00 $3,756.00 $3,040.00 $3,328.00 $3,756.00

63283 90 $2,041.00 $2,918.00 $3,198.00 $3,614.00 $2,918.00 $3,198.00 $3,614.00

63285 90 $2,934.00 $4,094.00 $4,501.00 $5,122.00 $4,094.00 $4,501.00 $5,122.00

63286 90 $3,003.00 $3,972.00 $4,351.00 $4,921.00 $3,972.00 $4,351.00 $4,921.00

63287 90 $3,012.00 $4,297.00 $4,725.00 $5,379.00 $4,297.00 $4,725.00 $5,379.00

63290 90 $3,073.00 $4,344.00 $4,771.00 $5,423.00 $4,344.00 $4,771.00 $5,423.00

63295 ZZZ ---------- $524.00 $577.00 $661.00 $524.00 $577.00 $661.00

63300 90 $2,006.00 $2,813.00 $3,067.00 $3,438.00 $2,813.00 $3,067.00 $3,438.00

63301 90 $2,209.00 $3,179.00 $3,455.00 $3,859.00 $3,179.00 $3,455.00 $3,859.00

63302 90 $2,290.00 $3,337.00 $3,661.00 $4,150.00 $3,337.00 $3,661.00 $4,150.00

63303 90 $2,357.00 $3,492.00 $3,828.00 $4,339.00 $3,492.00 $3,828.00 $4,339.00

63304 90 $2,513.00 $3,584.00 $3,921.00 $4,425.00 $3,584.00 $3,921.00 $4,425.00

63305 90 $2,574.00 $3,717.00 $4,064.00 $4,587.00 $3,717.00 $4,064.00 $4,587.00

63306 90 $2,596.00 $3,152.00 $3,392.00 $3,746.00 $3,152.00 $3,392.00 $3,746.00

63307 90 $2,522.00 $3,287.00 $3,534.00 $3,881.00 $3,287.00 $3,534.00 $3,881.00

63308 ZZZ $425.00 $501.00 $547.00 $618.00 $501.00 $547.00 $618.00

63600 90 $797.00 $1,299.00 $1,359.00 $1,418.00 $1,299.00 $1,359.00 $1,418.00

63610 0 $476.00 $656.00 $682.00 $710.00 $656.00 $682.00 $710.00

63615 90 $1,348.00 $1,926.00 $2,116.00 $2,400.00 $1,926.00 $2,116.00 $2,400.00

63620 90 ---------- $1,734.00 $1,902.00 $2,151.00 $1,734.00 $1,902.00 $2,151.00

63621 ZZZ ---------- $394.00 $432.00 $493.00 $394.00 $432.00 $493.00

63650 10 $819.00 $1,818.00 $1,928.00 $1,969.00 $597.00 $624.00 $652.00

63655 90 $1,064.00 $1,251.00 $1,358.00 $1,504.00 $1,251.00 $1,358.00 $1,504.00

63661 10 ---------- $820.00 $872.00 $907.00 $471.00 $499.00 $530.00

63662 90 ---------- $1,263.00 $1,372.00 $1,519.00 $1,263.00 $1,372.00 $1,519.00

63663 10 ---------- $1,107.00 $1,171.00 $1,215.00 $656.00 $690.00 $729.00

63664 90 ---------- $1,305.00 $1,417.00 $1,570.00 $1,305.00 $1,417.00 $1,570.00

63685 10 $615.00 $539.00 $577.00 $622.00 $539.00 $577.00 $622.00



Surgery


(Non-Facility MRA)






63688 10 $707.00 $548.00 $586.00 $633.00 $548.00 $586.00 $633.00

63700 90 $1,340.00 $1,707.00 $1,819.00 $1,956.00 $1,707.00 $1,819.00 $1,956.00

63702 90 $1,512.00 $1,902.00 $2,030.00 $2,191.00 $1,902.00 $2,030.00 $2,191.00

63704 90 $1,708.00 $2,154.00 $2,287.00 $2,444.00 $2,154.00 $2,287.00 $2,444.00

63706 90 $1,873.00 $2,633.00 $2,845.00 $3,134.00 $2,633.00 $2,845.00 $3,134.00

63707 90 $1,041.00 $1,389.00 $1,505.00 $1,663.00 $1,389.00 $1,505.00 $1,663.00

63709 90 $1,310.00 $1,664.00 $1,802.00 $1,992.00 $1,664.00 $1,802.00 $1,992.00

63710 90 $1,165.00 $1,633.00 $1,767.00 $1,949.00 $1,633.00 $1,767.00 $1,949.00

63740 90 $1,062.00 $1,425.00 $1,554.00 $1,736.00 $1,425.00 $1,554.00 $1,736.00

63741 90 $741.00 $1,025.00 $1,115.00 $1,240.00 $1,025.00 $1,115.00 $1,240.00

63744 90 $738.00 $1,005.00 $1,093.00 $1,217.00 $1,005.00 $1,093.00 $1,217.00

63746 90 $529.00 $920.00 $1,007.00 $1,128.00 $920.00 $1,007.00 $1,128.00

64400 0 $78.00 $181.00 $194.00 $204.00 $105.00 $112.00 $122.00

64402 0 $75.00 $191.00 $205.00 $217.00 $120.00 $128.00 $140.00

64405 0 $103.00 $143.00 $153.00 $161.00 $93.00 $99.00 $107.00

64408 0 $120.00 $169.00 $179.00 $187.00 $126.00 $133.00 $141.00

64410 0 $109.00 $191.00 $202.00 $209.00 $110.00 $116.00 $122.00

64413 0 $128.00 $181.00 $192.00 $200.00 $119.00 $125.00 $134.00

64415 0 $109.00 $165.00 $173.00 $179.00 $95.00 $98.00 $103.00

64416 0 $159.00 $115.00 $119.00 $125.00 $115.00 $119.00 $125.00

64417 0 $105.00 $180.00 $189.00 $195.00 $102.00 $106.00 $111.00

64418 0 $108.00 $203.00 $215.00 $222.00 $111.00 $116.00 $122.00

64420 0 $89.00 $156.00 $164.00 $170.00 $98.00 $102.00 $107.00

64421 0 $128.00 $211.00 $221.00 $228.00 $133.00 $138.00 $144.00

64425 0 $116.00 $187.00 $196.00 $204.00 $136.00 $142.00 $149.00

64430 0 $130.00 $193.00 $204.00 $210.00 $118.00 $123.00 $129.00

64435 0 $114.00 $191.00 $202.00 $209.00 $121.00 $127.00 $134.00

64445 0 $68.00 $191.00 $201.00 $208.00 $106.00 $110.00 $116.00

64446 0 $165.00 $115.00 $119.00 $125.00 $115.00 $119.00 $125.00

64447 0 $77.00 $168.00 $176.00 $182.00 $97.00 $100.00 $105.00

64448 0 $152.00 $104.00 $108.00 $113.00 $104.00 $108.00 $113.00

64449 0 ---------- $123.00 $127.00 $134.00 $123.00 $127.00 $134.00

64450 0 $53.00 $112.00 $118.00 $122.00 $65.00 $68.00 $71.00

64455 0 ---------- $68.00 $71.00 $74.00 $51.00 $53.00 $55.00

64461 0 ---------- $209.00 $220.00 $228.00 $127.00 $133.00 $140.00

64462 ZZZ ---------- $119.00 $126.00 $130.00 $80.00 $83.00 $88.00

64463 0 ---------- $235.00 $247.00 $256.00 $131.00 $137.00 $144.00

64479 0 $224.00 $328.00 $346.00 $356.00 $191.00 $199.00 $208.00

64480 ZZZ $194.00 $158.00 $167.00 $172.00 $92.00 $97.00 $101.00

64483 0 $206.00 $303.00 $320.00 $328.00 $161.00 $168.00 $175.00

64484 ZZZ $183.00 $123.00 $129.00 $133.00 $75.00 $78.00 $82.00

64486 0 ---------- $171.00 $181.00 $187.00 $91.00 $96.00 $101.00

64487 0 ---------- $189.00 $199.00 $205.00 $99.00 $102.00 $107.00

64488 0 ---------- $197.00 $207.00 $214.00 $108.00 $113.00 $119.00

64489 0 ---------- $250.00 $263.00 $270.00 $115.00 $119.00 $125.00

64490 0 ---------- $264.00 $278.00 $286.00 $154.00 $160.00 $167.00

64491 ZZZ ---------- $132.00 $138.00 $143.00 $88.00 $91.00 $95.00

64492 ZZZ ---------- $132.00 $139.00 $144.00 $89.00 $92.00 $96.00

64493 0 ---------- $239.00 $252.00 $259.00 $131.00 $137.00 $142.00

64494 ZZZ ---------- $121.00 $127.00 $132.00 $76.00 $79.00 $82.00



Surgery


(Non-Facility MRA)






64495 ZZZ ---------- $122.00 $128.00 $132.00 $76.00 $80.00 $83.00

64505 0 $104.00 $151.00 $159.00 $167.00 $127.00 $134.00 $141.00

64508 0 $99.00 $87.00 $92.00 $98.00 $104.00 $110.00 $116.00

64510 0 $103.00 $177.00 $187.00 $192.00 $105.00 $110.00 $114.00

64517 0 ---------- $261.00 $274.00 $282.00 $179.00 $187.00 $194.00

64520 0 $131.00 $257.00 $272.00 $279.00 $117.00 $122.00 $127.00

64530 0 $135.00 $263.00 $278.00 $284.00 $132.00 $138.00 $143.00

64550 0 $23.00 $22.00 $23.00 $24.00 $13.00 $13.00 $13.00

64553 10 $137.00 $286.00 $301.00 $311.00 $218.00 $228.00 $237.00

64555 10 $131.00 $297.00 $314.00 $325.00 $220.00 $231.00 $241.00

64561 10 $801.00 $1,149.00 $1,219.00 $1,251.00 $444.00 $466.00 $491.00

64565 10 $121.00 $273.00 $289.00 $300.00 $194.00 $204.00 $215.00

64566 0 ---------- $176.00 $187.00 $191.00 $44.00 $46.00 $49.00

64568 90 ---------- $980.00 $1,062.00 $1,175.00 $980.00 $1,062.00 $1,175.00

64569 90 ---------- $1,184.00 $1,285.00 $1,428.00 $1,184.00 $1,285.00 $1,428.00

64570 90 ---------- $988.00 $1,070.00 $1,183.00 $988.00 $1,070.00 $1,183.00

64575 90 $367.00 $470.00 $502.00 $539.00 $470.00 $502.00 $539.00

64580 90 $343.00 $446.00 $478.00 $518.00 $446.00 $478.00 $518.00

64581 90 $745.00 $974.00 $1,022.00 $1,080.00 $974.00 $1,022.00 $1,080.00

64585 10 $37.00 $345.00 $365.00 $378.00 $208.00 $219.00 $230.00

64590 10 $217.00 $374.00 $397.00 $411.00 $234.00 $246.00 $259.00

64595 10 $153.00 $345.00 $366.00 $377.00 $183.00 $193.00 $203.00

64600 10 $228.00 $557.00 $594.00 $623.00 $325.00 $346.00 $372.00

64605 10 $319.00 $863.00 $918.00 $960.00 $509.00 $540.00 $579.00

64610 10 $307.00 $1,087.00 $1,176.00 $1,276.00 $747.00 $812.00 $908.00

64611 10 ---------- $172.00 $187.00 $203.00 $153.00 $166.00 $182.00

64612 10 $188.00 $188.00 $201.00 $213.00 $170.00 $181.00 $193.00

64615 10 ---------- $216.00 $235.00 $261.00 $190.00 $207.00 $233.00

64616 10 ---------- $189.00 $205.00 $226.00 $166.00 $181.00 $201.00

64617 10 ---------- $259.00 $278.00 $297.00 $177.00 $190.00 $208.00

64620 10 $185.00 $290.00 $303.00 $314.00 $247.00 $258.00 $268.00

64630 10 $202.00 $331.00 $351.00 $370.00 $280.00 $296.00 $314.00

64632 10 ---------- $121.00 $126.00 $130.00 $99.00 $103.00 $106.00

64633 10 ---------- $585.00 $616.00 $632.00 $325.00 $339.00 $352.00

64634 ZZZ ---------- $261.00 $276.00 $282.00 $99.00 $103.00 $108.00

64635 10 ---------- $578.00 $609.00 $625.00 $321.00 $334.00 $347.00

64636 ZZZ ---------- $237.00 $250.00 $256.00 $86.00 $90.00 $94.00

64640 10 $208.00 $185.00 $195.00 $200.00 $132.00 $139.00 $143.00

64642 0 ---------- $206.00 $221.00 $237.00 $162.00 $174.00 $190.00

64643 ZZZ ---------- $135.00 $144.00 $154.00 $108.00 $115.00 $125.00

64644 0 ---------- $236.00 $253.00 $271.00 $177.00 $190.00 $207.00

64645 ZZZ ---------- $167.00 $179.00 $193.00 $126.00 $135.00 $148.00

64646 0 ---------- $217.00 $233.00 $251.00 $174.00 $187.00 $205.00

64647 0 ---------- $260.00 $280.00 $303.00 $207.00 $224.00 $247.00

64650 0 ---------- $110.00 $117.00 $123.00 $63.00 $67.00 $72.00

64653 0 ---------- $136.00 $146.00 $155.00 $81.00 $88.00 $97.00

64680 10 $180.00 $428.00 $453.00 $466.00 $238.00 $249.00 $260.00

64681 10 ---------- $746.00 $803.00 $851.00 $406.00 $439.00 $484.00

64702 90 $383.00 $723.00 $769.00 $814.00 $723.00 $769.00 $814.00

64704 90 $402.00 $460.00 $483.00 $505.00 $460.00 $483.00 $505.00



Surgery


(Non-Facility MRA)






64708 90 $562.00 $724.00 $772.00 $822.00 $724.00 $772.00 $822.00

64712 90 $678.00 $850.00 $907.00 $972.00 $850.00 $907.00 $972.00

64713 90 $867.00 $1,134.00 $1,212.00 $1,311.00 $1,134.00 $1,212.00 $1,311.00

64714 90 $715.00 $1,038.00 $1,103.00 $1,177.00 $1,038.00 $1,103.00 $1,177.00

64716 90 $523.00 $773.00 $820.00 $868.00 $773.00 $820.00 $868.00

64718 90 $558.00 $859.00 $917.00 $977.00 $859.00 $917.00 $977.00

64719 90 $446.00 $581.00 $619.00 $659.00 $581.00 $619.00 $659.00

64721 90 $439.00 $621.00 $663.00 $705.00 $618.00 $659.00 $701.00

64722 90 $411.00 $528.00 $562.00 $599.00 $528.00 $562.00 $599.00

64726 90 $271.00 $393.00 $411.00 $427.00 $393.00 $411.00 $427.00

64727 ZZZ $261.00 $276.00 $296.00 $322.00 $276.00 $296.00 $322.00

64732 90 $405.00 $545.00 $579.00 $614.00 $545.00 $579.00 $614.00

64734 90 $432.00 $755.00 $826.00 $918.00 $755.00 $826.00 $918.00

64736 90 $388.00 $564.00 $599.00 $634.00 $564.00 $599.00 $634.00

64738 90 $475.00 $670.00 $711.00 $755.00 $670.00 $711.00 $755.00

64740 90 $461.00 $653.00 $691.00 $727.00 $653.00 $691.00 $727.00

64742 90 $517.00 $661.00 $699.00 $739.00 $661.00 $699.00 $739.00

64744 90 $798.00 $737.00 $804.00 $893.00 $737.00 $804.00 $893.00

64746 90 $494.00 $628.00 $671.00 $726.00 $628.00 $671.00 $726.00

64755 90 $1,042.00 $1,316.00 $1,413.00 $1,555.00 $1,316.00 $1,413.00 $1,555.00

64760 90 $578.00 $734.00 $784.00 $848.00 $734.00 $784.00 $848.00

64763 90 $561.00 $705.00 $749.00 $802.00 $705.00 $749.00 $802.00

64766 90 $713.00 $819.00 $858.00 $899.00 $819.00 $858.00 $899.00

64771 90 $632.00 $876.00 $932.00 $993.00 $876.00 $932.00 $993.00

64772 90 $636.00 $827.00 $883.00 $948.00 $827.00 $883.00 $948.00

64774 90 $392.00 $605.00 $644.00 $687.00 $605.00 $644.00 $687.00

64776 90 $390.00 $563.00 $595.00 $628.00 $563.00 $595.00 $628.00

64778 ZZZ $249.00 $207.00 $214.00 $223.00 $207.00 $214.00 $223.00

64782 90 $482.00 $660.00 $697.00 $735.00 $660.00 $697.00 $735.00

64783 ZZZ $298.00 $327.00 $347.00 $371.00 $327.00 $347.00 $371.00

64784 90 $751.00 $1,067.00 $1,135.00 $1,212.00 $1,067.00 $1,135.00 $1,212.00

64786 90 $1,281.00 $1,600.00 $1,709.00 $1,844.00 $1,600.00 $1,709.00 $1,844.00

64787 ZZZ $458.00 $360.00 $381.00 $409.00 $360.00 $381.00 $409.00

64788 90 $381.00 $583.00 $622.00 $666.00 $583.00 $622.00 $666.00

64790 90 $884.00 $1,260.00 $1,355.00 $1,480.00 $1,260.00 $1,355.00 $1,480.00

64792 90 $1,148.00 $1,589.00 $1,689.00 $1,803.00 $1,589.00 $1,689.00 $1,803.00

64795 0 $247.00 $291.00 $314.00 $346.00 $291.00 $314.00 $346.00

64802 90 $711.00 $944.00 $1,000.00 $1,065.00 $944.00 $1,000.00 $1,065.00

64804 90 $1,202.00 $1,338.00 $1,427.00 $1,554.00 $1,338.00 $1,427.00 $1,554.00

64809 90 $1,080.00 $1,357.00 $1,459.00 $1,603.00 $1,357.00 $1,459.00 $1,603.00

64818 90 $845.00 $834.00 $868.00 $909.00 $834.00 $868.00 $909.00

64820 90 $838.00 $1,033.00 $1,092.00 $1,158.00 $1,033.00 $1,092.00 $1,158.00

64821 90 $609.00 $1,002.00 $1,063.00 $1,125.00 $1,002.00 $1,063.00 $1,125.00

64822 90 $609.00 $1,001.00 $1,062.00 $1,124.00 $1,001.00 $1,062.00 $1,124.00

64823 90 $703.00 $1,156.00 $1,233.00 $1,323.00 $1,156.00 $1,233.00 $1,323.00

64831 90 $592.00 $999.00 $1,063.00 $1,131.00 $999.00 $1,063.00 $1,131.00

64832 ZZZ $171.00 $501.00 $532.00 $572.00 $501.00 $532.00 $572.00

64834 90 $711.00 $1,092.00 $1,161.00 $1,240.00 $1,092.00 $1,161.00 $1,240.00

64835 90 $834.00 $1,182.00 $1,259.00 $1,348.00 $1,182.00 $1,259.00 $1,348.00

64836 90 $856.00 $1,204.00 $1,279.00 $1,363.00 $1,204.00 $1,279.00 $1,363.00



Surgery


(Non-Facility MRA)






64837 ZZZ $480.00 $564.00 $599.00 $642.00 $564.00 $599.00 $642.00

64840 90 $1,058.00 $1,436.00 $1,535.00 $1,656.00 $1,436.00 $1,535.00 $1,656.00

64856 90 $1,063.00 $1,491.00 $1,588.00 $1,706.00 $1,491.00 $1,588.00 $1,706.00

64857 90 $1,137.00 $1,551.00 $1,651.00 $1,769.00 $1,551.00 $1,651.00 $1,769.00

64858 90 $1,313.00 $1,728.00 $1,841.00 $1,980.00 $1,728.00 $1,841.00 $1,980.00

64859 ZZZ $341.00 $371.00 $393.00 $420.00 $371.00 $393.00 $420.00

64861 90 $1,524.00 $1,845.00 $1,956.00 $2,096.00 $1,845.00 $1,956.00 $2,096.00

64862 90 $1,798.00 $2,082.00 $2,242.00 $2,462.00 $2,082.00 $2,242.00 $2,462.00

64864 90 $970.00 $1,287.00 $1,362.00 $1,447.00 $1,287.00 $1,362.00 $1,447.00

64865 90 $1,250.00 $1,624.00 $1,718.00 $1,816.00 $1,624.00 $1,718.00 $1,816.00

64866 90 $1,238.00 $1,666.00 $1,761.00 $1,861.00 $1,666.00 $1,761.00 $1,861.00

64868 90 $1,162.00 $1,512.00 $1,607.00 $1,713.00 $1,512.00 $1,607.00 $1,713.00

64872 ZZZ $155.00 $175.00 $186.00 $202.00 $175.00 $186.00 $202.00

64874 ZZZ $230.00 $244.00 $257.00 $275.00 $244.00 $257.00 $275.00

64876 ZZZ $189.00 $262.00 $276.00 $295.00 $262.00 $276.00 $295.00

64885 90 $1,382.00 $1,667.00 $1,767.00 $1,884.00 $1,667.00 $1,767.00 $1,884.00

64886 90 $1,636.00 $1,906.00 $2,016.00 $2,145.00 $1,906.00 $2,016.00 $2,145.00

64890 90 $1,112.00 $1,598.00 $1,696.00 $1,806.00 $1,598.00 $1,696.00 $1,806.00

64891 90 $1,243.00 $1,690.00 $1,790.00 $1,904.00 $1,690.00 $1,790.00 $1,904.00

64892 90 $1,177.00 $1,540.00 $1,642.00 $1,768.00 $1,540.00 $1,642.00 $1,768.00

64893 90 $1,321.00 $1,669.00 $1,772.00 $1,889.00 $1,669.00 $1,772.00 $1,889.00

64895 90 $1,500.00 $1,983.00 $2,113.00 $2,274.00 $1,983.00 $2,113.00 $2,274.00

64896 90 $1,185.00 $2,116.00 $2,247.00 $2,403.00 $2,116.00 $2,247.00 $2,403.00

64897 90 $1,419.00 $1,892.00 $2,013.00 $2,158.00 $1,892.00 $2,013.00 $2,158.00

64898 90 $1,549.00 $2,237.00 $2,431.00 $2,706.00 $2,237.00 $2,431.00 $2,706.00

64901 ZZZ $865.00 $823.00 $868.00 $926.00 $823.00 $868.00 $926.00

64902 ZZZ $982.00 $966.00 $1,022.00 $1,096.00 $966.00 $1,022.00 $1,096.00

64905 90 $1,059.00 $1,518.00 $1,615.00 $1,728.00 $1,518.00 $1,615.00 $1,728.00

64907 90 $1,472.00 $1,951.00 $2,071.00 $2,211.00 $1,951.00 $2,071.00 $2,211.00

64910 90 ---------- $1,199.00 $1,275.00 $1,358.00 $1,199.00 $1,275.00 $1,358.00

64911 90 ---------- $1,484.00 $1,575.00 $1,673.00 $1,484.00 $1,575.00 $1,673.00

64999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

65091 90 $678.00 $891.00 $936.00 $962.00 $891.00 $936.00 $962.00

65093 90 $712.00 $880.00 $924.00 $950.00 $880.00 $924.00 $950.00

65101 90 $726.00 $1,034.00 $1,087.00 $1,117.00 $1,034.00 $1,087.00 $1,117.00

65103 90 $769.00 $1,079.00 $1,133.00 $1,164.00 $1,079.00 $1,133.00 $1,164.00

65105 90 $846.00 $1,189.00 $1,248.00 $1,283.00 $1,189.00 $1,248.00 $1,283.00

65110 90 $1,305.00 $1,725.00 $1,810.00 $1,867.00 $1,725.00 $1,810.00 $1,867.00

65112 90 $1,386.00 $2,005.00 $2,104.00 $2,174.00 $2,005.00 $2,104.00 $2,174.00

65114 90 $1,456.00 $2,088.00 $2,188.00 $2,258.00 $2,088.00 $2,188.00 $2,258.00

65125 90 $312.00 $626.00 $663.00 $679.00 $406.00 $428.00 $442.00

65130 90 $730.00 $1,024.00 $1,075.00 $1,105.00 $1,024.00 $1,075.00 $1,105.00

65135 90 $678.00 $1,040.00 $1,092.00 $1,122.00 $1,040.00 $1,092.00 $1,122.00

65140 90 $738.00 $1,131.00 $1,186.00 $1,219.00 $1,131.00 $1,186.00 $1,219.00

65150 90 $652.00 $810.00 $851.00 $875.00 $810.00 $851.00 $875.00

65155 90 $862.00 $1,185.00 $1,244.00 $1,279.00 $1,185.00 $1,244.00 $1,279.00

65175 90 $654.00 $921.00 $967.00 $994.00 $921.00 $967.00 $994.00

65205 0 $45.00 $79.00 $82.00 $84.00 $62.00 $65.00 $67.00

65210 0 $53.00 $96.00 $100.00 $103.00 $75.00 $78.00 $81.00

65220 0 $58.00 $82.00 $87.00 $90.00 $61.00 $64.00 $68.00



Surgery


(Non-Facility MRA)






65222 0 $62.00 $94.00 $98.00 $100.00 $74.00 $77.00 $79.00

65235 90 $627.00 $999.00 $1,047.00 $1,078.00 $999.00 $1,047.00 $1,078.00

65260 90 $956.00 $1,352.00 $1,416.00 $1,458.00 $1,352.00 $1,416.00 $1,458.00

65265 90 $1,104.00 $1,523.00 $1,595.00 $1,642.00 $1,523.00 $1,595.00 $1,642.00

65270 10 $88.00 $367.00 $388.00 $396.00 $198.00 $207.00 $214.00

65272 90 $223.00 $699.00 $736.00 $754.00 $495.00 $518.00 $534.00

65273 90 $376.00 $538.00 $564.00 $583.00 $538.00 $564.00 $583.00

65275 90 $75.00 $807.00 $848.00 $870.00 $651.00 $681.00 $702.00

65280 90 $711.00 $947.00 $992.00 $1,022.00 $947.00 $992.00 $1,022.00

65285 90 $1,177.00 $1,565.00 $1,637.00 $1,688.00 $1,565.00 $1,637.00 $1,688.00

65286 90 $692.00 $980.00 $1,032.00 $1,057.00 $699.00 $731.00 $754.00

65290 90 $519.00 $694.00 $728.00 $752.00 $694.00 $728.00 $752.00

65400 90 $603.00 $951.00 $999.00 $1,026.00 $848.00 $890.00 $915.00

65410 0 $142.00 $199.00 $210.00 $215.00 $148.00 $155.00 $160.00

65420 90 $448.00 $717.00 $756.00 $773.00 $530.00 $556.00 $572.00

65426 90 $534.00 $907.00 $955.00 $978.00 $674.00 $706.00 $727.00

65430 0 $81.00 $160.00 $168.00 $173.00 $146.00 $153.00 $158.00

65435 0 $88.00 $112.00 $117.00 $120.00 $98.00 $103.00 $106.00

65436 90 $319.00 $544.00 $571.00 $587.00 $524.00 $549.00 $565.00

65450 90 $52.00 $454.00 $478.00 $490.00 $450.00 $473.00 $485.00

65600 90 $325.00 $551.00 $579.00 $594.00 $484.00 $507.00 $522.00

65710 90 $1,124.00 $1,557.00 $1,630.00 $1,679.00 $1,557.00 $1,630.00 $1,679.00

65730 90 $1,314.00 $1,729.00 $1,811.00 $1,865.00 $1,729.00 $1,811.00 $1,865.00

65750 90 $1,381.00 $1,740.00 $1,821.00 $1,877.00 $1,740.00 $1,821.00 $1,877.00

65755 90 $1,373.00 $1,731.00 $1,812.00 $1,867.00 $1,731.00 $1,812.00 $1,867.00

65756 90 ---------- $1,674.00 $1,750.00 $1,806.00 $1,674.00 $1,750.00 $1,806.00

65770 90 $1,461.00 $1,979.00 $2,070.00 $2,134.00 $1,979.00 $2,070.00 $2,134.00

65772 90 $449.00 $632.00 $663.00 $681.00 $572.00 $599.00 $617.00

65775 90 $595.00 $775.00 $812.00 $836.00 $775.00 $812.00 $836.00

65778 0 ---------- $1,931.00 $2,060.00 $2,082.00 $82.00 $85.00 $87.00

65779 0 ---------- $1,641.00 $1,747.00 $1,769.00 $216.00 $226.00 $233.00

65780 90 ---------- $936.00 $982.00 $1,009.00 $936.00 $982.00 $1,009.00

65781 90 ---------- $1,881.00 $1,968.00 $2,028.00 $1,881.00 $1,968.00 $2,028.00

65782 90 ---------- $1,622.00 $1,698.00 $1,749.00 $1,622.00 $1,698.00 $1,749.00

65785 90 ---------- $2,898.00 $3,088.00 $3,144.00 $555.00 $587.00 $617.00

65800 0 $88.00 $167.00 $175.00 $180.00 $130.00 $136.00 $141.00

65810 90 $516.00 $654.00 $686.00 $706.00 $654.00 $686.00 $706.00

65815 90 $327.00 $887.00 $934.00 $957.00 $672.00 $705.00 $725.00

65820 90 $813.00 $1,050.00 $1,102.00 $1,133.00 $1,050.00 $1,102.00 $1,133.00

65850 90 $968.00 $1,184.00 $1,239.00 $1,276.00 $1,184.00 $1,239.00 $1,276.00

65855 10 $441.00 $343.00 $360.00 $370.00 $294.00 $308.00 $318.00

65860 90 $339.00 $432.00 $454.00 $466.00 $358.00 $375.00 $386.00

65865 90 $540.00 $664.00 $697.00 $717.00 $664.00 $697.00 $717.00

65870 90 $572.00 $831.00 $871.00 $897.00 $831.00 $871.00 $897.00

65875 90 $597.00 $886.00 $929.00 $956.00 $886.00 $929.00 $956.00

65880 90 $641.00 $933.00 $978.00 $1,007.00 $933.00 $978.00 $1,007.00

65900 90 $945.00 $1,356.00 $1,421.00 $1,462.00 $1,356.00 $1,421.00 $1,462.00

65920 90 $752.00 $1,108.00 $1,162.00 $1,195.00 $1,108.00 $1,162.00 $1,195.00

65930 90 $700.00 $898.00 $940.00 $968.00 $898.00 $940.00 $968.00

66020 10 $164.00 $259.00 $273.00 $279.00 $185.00 $194.00 $199.00



Surgery


(Non-Facility MRA)






66030 10 $160.00 $230.00 $243.00 $248.00 $155.00 $163.00 $167.00

66130 90 $631.00 $974.00 $1,023.00 $1,051.00 $804.00 $841.00 $867.00

66150 90 $798.00 $1,230.00 $1,291.00 $1,327.00 $1,230.00 $1,291.00 $1,327.00

66155 90 $795.00 $1,230.00 $1,290.00 $1,326.00 $1,230.00 $1,290.00 $1,326.00

66160 90 $942.00 $1,388.00 $1,455.00 $1,497.00 $1,388.00 $1,455.00 $1,497.00

66170 90 $1,089.00 $1,540.00 $1,613.00 $1,661.00 $1,540.00 $1,613.00 $1,661.00

66172 90 $1,264.00 $1,674.00 $1,755.00 $1,805.00 $1,674.00 $1,755.00 $1,805.00

66174 90 ---------- $1,337.00 $1,399.00 $1,442.00 $1,337.00 $1,399.00 $1,442.00

66175 90 ---------- $1,400.00 $1,465.00 $1,510.00 $1,400.00 $1,465.00 $1,510.00

66179 90 ---------- $1,517.00 $1,589.00 $1,636.00 $1,517.00 $1,589.00 $1,636.00

66180 90 $1,313.00 $1,602.00 $1,677.00 $1,727.00 $1,602.00 $1,677.00 $1,727.00

66183 90 ---------- $1,449.00 $1,518.00 $1,562.00 $1,449.00 $1,518.00 $1,562.00

66184 90 ---------- $1,103.00 $1,156.00 $1,189.00 $1,103.00 $1,156.00 $1,189.00

66185 90 $769.00 $1,187.00 $1,244.00 $1,280.00 $1,187.00 $1,244.00 $1,280.00

66220 90 $711.00 $1,002.00 $1,053.00 $1,090.00 $1,002.00 $1,053.00 $1,090.00

66225 90 $1,006.00 $1,314.00 $1,376.00 $1,417.00 $1,314.00 $1,376.00 $1,417.00

66250 90 $602.00 $1,043.00 $1,098.00 $1,125.00 $785.00 $822.00 $847.00

66500 90 $359.00 $496.00 $521.00 $535.00 $496.00 $521.00 $535.00

66505 90 $359.00 $547.00 $576.00 $593.00 $547.00 $576.00 $593.00

66600 90 $825.00 $1,169.00 $1,226.00 $1,261.00 $1,169.00 $1,226.00 $1,261.00

66605 90 $1,136.00 $1,489.00 $1,559.00 $1,606.00 $1,489.00 $1,559.00 $1,606.00

66625 90 $543.00 $603.00 $633.00 $651.00 $603.00 $633.00 $651.00

66630 90 $623.00 $801.00 $840.00 $865.00 $801.00 $840.00 $865.00

66635 90 $595.00 $809.00 $847.00 $872.00 $809.00 $847.00 $872.00

66680 90 $526.00 $728.00 $764.00 $786.00 $728.00 $764.00 $786.00

66682 90 $627.00 $894.00 $938.00 $964.00 $894.00 $938.00 $964.00

66700 90 $506.00 $630.00 $662.00 $680.00 $554.00 $580.00 $597.00

66710 90 $513.00 $616.00 $646.00 $664.00 $554.00 $580.00 $597.00

66711 90 ---------- $904.00 $947.00 $974.00 $904.00 $947.00 $974.00

66720 90 $506.00 $643.00 $676.00 $693.00 $574.00 $603.00 $620.00

66740 90 $473.00 $612.00 $642.00 $660.00 $554.00 $580.00 $597.00

66761 10 $506.00 $413.00 $434.00 $445.00 $332.00 $348.00 $358.00

66762 90 $433.00 $665.00 $698.00 $717.00 $600.00 $629.00 $647.00

66770 90 $483.00 $740.00 $777.00 $798.00 $681.00 $714.00 $735.00

66820 90 $433.00 $550.00 $579.00 $594.00 $550.00 $579.00 $594.00

66821 90 $275.00 $460.00 $484.00 $497.00 $436.00 $458.00 $470.00

66825 90 $753.00 $1,066.00 $1,119.00 $1,150.00 $1,066.00 $1,119.00 $1,150.00

66830 90 $651.00 $1,005.00 $1,052.00 $1,084.00 $1,005.00 $1,052.00 $1,084.00

66840 90 $707.00 $981.00 $1,028.00 $1,059.00 $981.00 $1,028.00 $1,059.00

66850 90 $805.00 $1,117.00 $1,170.00 $1,205.00 $1,117.00 $1,170.00 $1,205.00

66852 90 $878.00 $1,190.00 $1,246.00 $1,284.00 $1,190.00 $1,246.00 $1,284.00

66920 90 $785.00 $1,063.00 $1,113.00 $1,147.00 $1,063.00 $1,113.00 $1,147.00

66930 90 $906.00 $1,206.00 $1,262.00 $1,300.00 $1,206.00 $1,262.00 $1,300.00

66940 90 $819.00 $1,102.00 $1,154.00 $1,188.00 $1,102.00 $1,154.00 $1,188.00

66982 90 $846.00 $1,122.00 $1,174.00 $1,210.00 $1,122.00 $1,174.00 $1,210.00

66983 90 $763.00 $1,045.00 $1,090.00 $1,119.00 $1,045.00 $1,090.00 $1,119.00

66984 90 $898.00 $902.00 $944.00 $972.00 $902.00 $944.00 $972.00

66985 90 $744.00 $1,084.00 $1,135.00 $1,168.00 $1,084.00 $1,135.00 $1,168.00

66986 90 $1,038.00 $1,281.00 $1,341.00 $1,382.00 $1,281.00 $1,341.00 $1,382.00

66990 ZZZ $84.00 $129.00 $134.00 $139.00 $129.00 $134.00 $139.00



Surgery


(Non-Facility MRA)






66999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

67005 90 $639.00 $664.00 $697.00 $717.00 $664.00 $697.00 $717.00

67010 90 $647.00 $764.00 $800.00 $824.00 $764.00 $800.00 $824.00

67015 90 $637.00 $815.00 $855.00 $880.00 $815.00 $855.00 $880.00

67025 90 $774.00 $1,016.00 $1,067.00 $1,096.00 $890.00 $933.00 $961.00

67027 90 $1,089.00 $1,202.00 $1,258.00 $1,297.00 $1,202.00 $1,258.00 $1,297.00

67028 0 $338.00 $144.00 $151.00 $156.00 $142.00 $149.00 $154.00

67030 90 $485.00 $746.00 $784.00 $806.00 $746.00 $784.00 $806.00

67031 90 $402.00 $545.00 $572.00 $588.00 $502.00 $526.00 $542.00

67036 90 $1,384.00 $1,270.00 $1,330.00 $1,370.00 $1,270.00 $1,330.00 $1,370.00

67039 90 $1,490.00 $1,362.00 $1,426.00 $1,469.00 $1,362.00 $1,426.00 $1,469.00

67040 90 $1,960.00 $1,473.00 $1,541.00 $1,589.00 $1,473.00 $1,541.00 $1,589.00

67041 90 ---------- $1,627.00 $1,702.00 $1,755.00 $1,627.00 $1,702.00 $1,755.00

67042 90 ---------- $1,629.00 $1,703.00 $1,757.00 $1,629.00 $1,703.00 $1,757.00

67043 90 ---------- $1,721.00 $1,799.00 $1,856.00 $1,721.00 $1,799.00 $1,856.00

67101 10 $767.00 $458.00 $482.00 $494.00 $400.00 $420.00 $431.00

67105 10 $941.00 $416.00 $437.00 $449.00 $387.00 $406.00 $418.00

67107 90 $1,350.00 $1,600.00 $1,674.00 $1,726.00 $1,600.00 $1,674.00 $1,726.00

67108 90 $1,878.00 $1,698.00 $1,775.00 $1,831.00 $1,698.00 $1,775.00 $1,831.00

67110 90 $1,040.00 $1,229.00 $1,290.00 $1,325.00 $1,144.00 $1,198.00 $1,233.00

67113 90 ---------- $1,894.00 $1,981.00 $2,043.00 $1,894.00 $1,981.00 $2,043.00

67115 90 $496.00 $703.00 $737.00 $759.00 $703.00 $737.00 $759.00

67120 90 $751.00 $919.00 $966.00 $992.00 $786.00 $823.00 $848.00

67121 90 $962.00 $1,281.00 $1,341.00 $1,381.00 $1,281.00 $1,341.00 $1,381.00

67141 90 $536.00 $734.00 $770.00 $792.00 $687.00 $720.00 $741.00

67145 90 $514.00 $739.00 $775.00 $797.00 $701.00 $735.00 $756.00

67208 90 $655.00 $843.00 $884.00 $910.00 $815.00 $854.00 $880.00

67210 90 $779.00 $728.00 $763.00 $785.00 $704.00 $738.00 $760.00

67218 90 $1,217.00 $1,958.00 $2,046.00 $2,112.00 $1,958.00 $2,046.00 $2,112.00

67220 90 $894.00 $749.00 $786.00 $808.00 $704.00 $738.00 $760.00

67221 0 $325.00 $402.00 $422.00 $434.00 $304.00 $317.00 $328.00

67225 ZZZ $44.00 $42.00 $44.00 $45.00 $40.00 $42.00 $43.00

67227 10 $652.00 $407.00 $427.00 $439.00 $363.00 $380.00 $391.00

67228 10 $1,025.00 $479.00 $502.00 $517.00 $435.00 $455.00 $469.00

67229 90 ---------- $1,647.00 $1,722.00 $1,776.00 $1,647.00 $1,722.00 $1,776.00

67250 90 $793.00 $1,096.00 $1,150.00 $1,182.00 $1,096.00 $1,150.00 $1,182.00

67255 90 $872.00 $961.00 $1,007.00 $1,036.00 $961.00 $1,007.00 $1,036.00

67299 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

67311 90 $616.00 $842.00 $882.00 $908.00 $842.00 $882.00 $908.00

67312 90 $773.00 $1,003.00 $1,050.00 $1,082.00 $1,003.00 $1,050.00 $1,082.00

67314 90 $688.00 $947.00 $992.00 $1,022.00 $947.00 $992.00 $1,022.00

67316 90 $857.00 $1,131.00 $1,183.00 $1,219.00 $1,131.00 $1,183.00 $1,219.00

67318 90 $663.00 $993.00 $1,041.00 $1,071.00 $993.00 $1,041.00 $1,071.00

67320 ZZZ $602.00 $460.00 $479.00 $497.00 $460.00 $479.00 $497.00

67331 ZZZ $560.00 $437.00 $455.00 $472.00 $437.00 $455.00 $472.00

67332 ZZZ $621.00 $474.00 $494.00 $512.00 $474.00 $494.00 $512.00

67334 ZZZ $447.00 $430.00 $448.00 $464.00 $430.00 $448.00 $464.00

67335 ZZZ $253.00 $212.00 $221.00 $229.00 $212.00 $221.00 $229.00

67340 ZZZ $559.00 $512.00 $533.00 $552.00 $512.00 $533.00 $552.00

67343 90 $628.00 $922.00 $966.00 $995.00 $922.00 $966.00 $995.00



Surgery


(Non-Facility MRA)






67345 10 $275.00 $344.00 $364.00 $381.00 $312.00 $329.00 $346.00

67346 0 ---------- $275.00 $287.00 $297.00 $275.00 $287.00 $297.00

67399 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

67400 90 $960.00 $1,306.00 $1,370.00 $1,410.00 $1,306.00 $1,370.00 $1,410.00

67405 90 $799.00 $1,113.00 $1,170.00 $1,207.00 $1,113.00 $1,170.00 $1,207.00

67412 90 $976.00 $1,195.00 $1,254.00 $1,291.00 $1,195.00 $1,254.00 $1,291.00

67413 90 $909.00 $1,199.00 $1,259.00 $1,296.00 $1,199.00 $1,259.00 $1,296.00

67414 90 $1,023.00 $1,873.00 $1,962.00 $2,025.00 $1,873.00 $1,962.00 $2,025.00

67415 0 $146.00 $150.00 $156.00 $162.00 $150.00 $156.00 $162.00

67420 90 $1,729.00 $2,288.00 $2,400.00 $2,483.00 $2,288.00 $2,400.00 $2,483.00

67430 90 $1,203.00 $1,739.00 $1,826.00 $1,883.00 $1,739.00 $1,826.00 $1,883.00

67440 90 $1,257.00 $1,693.00 $1,775.00 $1,826.00 $1,693.00 $1,775.00 $1,826.00

67445 90 $1,269.00 $1,980.00 $2,074.00 $2,142.00 $1,980.00 $2,074.00 $2,142.00

67450 90 $1,300.00 $1,758.00 $1,846.00 $1,903.00 $1,758.00 $1,846.00 $1,903.00

67500 0 $75.00 $112.00 $116.00 $121.00 $103.00 $107.00 $112.00

67505 0 $109.00 $125.00 $131.00 $135.00 $115.00 $120.00 $124.00

67515 0 $53.00 $137.00 $143.00 $148.00 $127.00 $133.00 $137.00

67550 90 $946.00 $1,355.00 $1,422.00 $1,465.00 $1,355.00 $1,422.00 $1,465.00

67560 90 $936.00 $1,389.00 $1,457.00 $1,500.00 $1,389.00 $1,457.00 $1,500.00

67570 90 $1,148.00 $1,656.00 $1,751.00 $1,832.00 $1,656.00 $1,751.00 $1,832.00

67599 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

67700 10 $87.00 $368.00 $390.00 $398.00 $164.00 $172.00 $177.00

67710 10 $117.00 $306.00 $324.00 $330.00 $136.00 $143.00 $147.00

67715 10 $102.00 $330.00 $350.00 $357.00 $153.00 $161.00 $167.00

67800 10 $119.00 $177.00 $186.00 $191.00 $146.00 $153.00 $158.00

67801 10 $189.00 $227.00 $238.00 $245.00 $188.00 $197.00 $203.00

67805 10 $208.00 $282.00 $296.00 $304.00 $233.00 $243.00 $251.00

67808 90 $308.00 $519.00 $544.00 $561.00 $519.00 $544.00 $561.00

67810 0 $133.00 $239.00 $254.00 $262.00 $104.00 $110.00 $116.00

67820 0 $36.00 $71.00 $74.00 $75.00 $75.00 $78.00 $80.00

67825 10 $130.00 $179.00 $188.00 $193.00 $170.00 $179.00 $183.00

67830 10 $239.00 $366.00 $387.00 $395.00 $194.00 $204.00 $210.00

67835 90 $500.00 $619.00 $648.00 $668.00 $619.00 $648.00 $668.00

67840 10 $187.00 $380.00 $402.00 $411.00 $223.00 $234.00 $241.00

67850 10 $143.00 $300.00 $317.00 $327.00 $193.00 $204.00 $212.00

67875 0 $163.00 $238.00 $251.00 $257.00 $138.00 $145.00 $150.00

67880 90 $442.00 $639.00 $672.00 $690.00 $519.00 $544.00 $560.00

67882 90 $643.00 $788.00 $828.00 $850.00 $665.00 $697.00 $718.00

67900 90 $487.00 $896.00 $944.00 $973.00 $722.00 $757.00 $784.00

67901 90 $646.00 $1,056.00 $1,112.00 $1,142.00 $815.00 $854.00 $882.00

67902 90 $650.00 $1,022.00 $1,072.00 $1,108.00 $1,022.00 $1,072.00 $1,108.00

67903 90 $657.00 $830.00 $873.00 $897.00 $684.00 $716.00 $739.00

67904 90 $720.00 $1,024.00 $1,077.00 $1,108.00 $844.00 $885.00 $914.00

67906 90 $633.00 $718.00 $751.00 $774.00 $718.00 $751.00 $774.00

67908 90 $550.00 $689.00 $724.00 $743.00 $597.00 $626.00 $644.00

67909 90 $577.00 $749.00 $789.00 $811.00 $619.00 $650.00 $671.00

67911 90 $517.00 $794.00 $832.00 $859.00 $794.00 $832.00 $859.00

67912 90 ---------- $1,220.00 $1,292.00 $1,326.00 $694.00 $730.00 $759.00

67914 90 $487.00 $651.00 $687.00 $704.00 $460.00 $484.00 $498.00

67915 90 $252.00 $403.00 $426.00 $435.00 $276.00 $291.00 $298.00



Surgery


(Non-Facility MRA)






67916 90 $675.00 $824.00 $869.00 $891.00 $608.00 $638.00 $659.00

67917 90 $631.00 $840.00 $884.00 $908.00 $646.00 $678.00 $699.00

67921 90 $419.00 $636.00 $672.00 $687.00 $435.00 $457.00 $470.00

67922 90 $243.00 $400.00 $423.00 $431.00 $276.00 $291.00 $298.00

67923 90 $718.00 $822.00 $866.00 $887.00 $607.00 $636.00 $655.00

67924 90 $605.00 $877.00 $923.00 $947.00 $646.00 $677.00 $698.00

67930 10 $280.00 $508.00 $535.00 $550.00 $342.00 $357.00 $370.00

67935 90 $520.00 $832.00 $877.00 $904.00 $629.00 $659.00 $684.00

67938 10 $67.00 $335.00 $354.00 $360.00 $163.00 $171.00 $176.00

67950 90 $584.00 $800.00 $843.00 $867.00 $655.00 $687.00 $710.00

67961 90 $571.00 $802.00 $844.00 $866.00 $642.00 $673.00 $693.00

67966 90 $645.00 $1,077.00 $1,131.00 $1,164.00 $930.00 $974.00 $1,005.00

67971 90 $875.00 $1,023.00 $1,071.00 $1,105.00 $1,023.00 $1,071.00 $1,105.00

67973 90 $1,126.00 $1,317.00 $1,378.00 $1,423.00 $1,317.00 $1,378.00 $1,423.00

67974 90 $1,140.00 $1,313.00 $1,374.00 $1,418.00 $1,313.00 $1,374.00 $1,418.00

67975 90 $681.00 $967.00 $1,013.00 $1,046.00 $967.00 $1,013.00 $1,046.00

67999 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

68020 10 $106.00 $167.00 $176.00 $180.00 $155.00 $163.00 $167.00

68040 0 $75.00 $87.00 $91.00 $93.00 $72.00 $74.00 $77.00

68100 0 $137.00 $235.00 $248.00 $254.00 $138.00 $144.00 $149.00

68110 10 $172.00 $312.00 $329.00 $336.00 $209.00 $219.00 $225.00

68115 10 $248.00 $431.00 $455.00 $465.00 $260.00 $272.00 $280.00

68130 90 $378.00 $749.00 $789.00 $808.00 $579.00 $607.00 $625.00

68135 10 $146.00 $220.00 $230.00 $237.00 $212.00 $223.00 $229.00

68200 0 $59.00 $58.00 $61.00 $63.00 $49.00 $52.00 $54.00

68320 90 $502.00 $1,007.00 $1,061.00 $1,087.00 $759.00 $796.00 $819.00

68325 90 $672.00 $929.00 $974.00 $1,004.00 $929.00 $974.00 $1,004.00

68326 90 $654.00 $911.00 $954.00 $983.00 $911.00 $954.00 $983.00

68328 90 $741.00 $1,001.00 $1,049.00 $1,083.00 $1,001.00 $1,049.00 $1,083.00

68330 90 $488.00 $841.00 $885.00 $908.00 $649.00 $681.00 $701.00

68335 90 $636.00 $914.00 $958.00 $987.00 $914.00 $958.00 $987.00

68340 90 $413.00 $757.00 $797.00 $816.00 $562.00 $589.00 $606.00

68360 90 $449.00 $741.00 $780.00 $801.00 $581.00 $609.00 $628.00

68362 90 $691.00 $925.00 $969.00 $999.00 $925.00 $969.00 $999.00

68371 10 ---------- $581.00 $609.00 $627.00 $581.00 $609.00 $627.00

68399 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

68400 10 $154.00 $391.00 $413.00 $421.00 $186.00 $195.00 $201.00

68420 10 $191.00 $444.00 $469.00 $479.00 $238.00 $250.00 $258.00

68440 10 $96.00 $142.00 $149.00 $153.00 $138.00 $145.00 $149.00

68500 90 $882.00 $1,380.00 $1,447.00 $1,493.00 $1,380.00 $1,447.00 $1,493.00

68505 90 $921.00 $1,367.00 $1,432.00 $1,477.00 $1,367.00 $1,432.00 $1,477.00

68510 0 $491.00 $620.00 $652.00 $670.00 $415.00 $433.00 $449.00

68520 90 $687.00 $968.00 $1,015.00 $1,046.00 $968.00 $1,015.00 $1,046.00

68525 0 $340.00 $377.00 $394.00 $408.00 $377.00 $394.00 $408.00

68530 10 $379.00 $593.00 $625.00 $640.00 $365.00 $382.00 $394.00

68540 90 $875.00 $1,309.00 $1,371.00 $1,412.00 $1,309.00 $1,371.00 $1,412.00

68550 90 $1,107.00 $1,577.00 $1,657.00 $1,721.00 $1,577.00 $1,657.00 $1,721.00

68700 90 $628.00 $852.00 $892.00 $919.00 $852.00 $892.00 $919.00

68705 10 $176.00 $329.00 $346.00 $355.00 $234.00 $246.00 $253.00

68720 90 $807.00 $1,067.00 $1,118.00 $1,153.00 $1,067.00 $1,118.00 $1,153.00



Surgery


(Non-Facility MRA)






68745 90 $704.00 $1,070.00 $1,121.00 $1,154.00 $1,070.00 $1,121.00 $1,154.00

68750 90 $792.00 $1,108.00 $1,162.00 $1,197.00 $1,108.00 $1,162.00 $1,197.00

68760 10 $109.00 $279.00 $294.00 $301.00 $205.00 $215.00 $221.00

68761 10 $130.00 $205.00 $216.00 $221.00 $167.00 $175.00 $179.00

68770 90 $634.00 $888.00 $931.00 $960.00 $888.00 $931.00 $960.00

68801 10 $202.00 $123.00 $129.00 $132.00 $110.00 $116.00 $119.00

68810 10 $290.00 $219.00 $231.00 $236.00 $179.00 $188.00 $193.00

68811 10 $191.00 $192.00 $202.00 $208.00 $192.00 $202.00 $208.00

68815 10 $399.00 $548.00 $580.00 $592.00 $312.00 $328.00 $337.00

68816 10 ---------- $882.00 $937.00 $952.00 $230.00 $241.00 $249.00

68840 10 $100.00 $178.00 $187.00 $192.00 $163.00 $171.00 $176.00

68850 0 $76.00 $87.00 $92.00 $95.00 $80.00 $84.00 $87.00

68899 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

69000 10 $52.00 $262.00 $278.00 $288.00 $170.00 $180.00 $188.00

69005 10 $175.00 $304.00 $322.00 $336.00 $226.00 $239.00 $252.00

69020 10 $109.00 $324.00 $344.00 $355.00 $203.00 $215.00 $224.00

69100 0 $85.00 $141.00 $150.00 $155.00 $72.00 $76.00 $80.00

69105 0 $87.00 $195.00 $207.00 $213.00 $92.00 $97.00 $102.00

69110 90 $294.00 $645.00 $686.00 $712.00 $464.00 $493.00 $517.00

69120 90 $274.00 $577.00 $611.00 $637.00 $577.00 $611.00 $637.00

69140 90 $722.00 $1,241.00 $1,317.00 $1,370.00 $1,241.00 $1,317.00 $1,370.00

69145 90 $248.00 $553.00 $588.00 $607.00 $355.00 $377.00 $394.00

69150 90 $1,111.00 $1,509.00 $1,599.00 $1,686.00 $1,509.00 $1,599.00 $1,686.00

69155 90 $1,680.00 $2,407.00 $2,546.00 $2,685.00 $2,407.00 $2,546.00 $2,685.00

69200 0 $53.00 $116.00 $123.00 $128.00 $69.00 $73.00 $77.00

69205 10 $110.00 $145.00 $154.00 $161.00 $145.00 $154.00 $161.00

69209 0 ---------- $17.00 $19.00 $19.00 $17.00 $19.00 $19.00

69210 0 $39.00 $69.00 $73.00 $76.00 $48.00 $50.00 $53.00

69220 0 $78.00 $127.00 $135.00 $140.00 $75.00 $79.00 $84.00

69222 10 $123.00 $306.00 $325.00 $336.00 $195.00 $206.00 $216.00

69300 YYY $522.00 $843.00 $894.00 $935.00 $665.00 $704.00 $743.00

69310 90 $937.00 $1,552.00 $1,647.00 $1,720.00 $1,552.00 $1,647.00 $1,720.00

69320 90 $1,434.00 $2,176.00 $2,305.00 $2,411.00 $2,176.00 $2,305.00 $2,411.00

69399 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

69420 10 $117.00 $267.00 $284.00 $294.00 $172.00 $182.00 $191.00

69421 10 $155.00 $213.00 $226.00 $237.00 $213.00 $226.00 $237.00

69424 0 $84.00 $178.00 $189.00 $195.00 $90.00 $95.00 $100.00

69433 10 $145.00 $284.00 $301.00 $312.00 $189.00 $201.00 $211.00

69436 10 $182.00 $230.00 $244.00 $256.00 $230.00 $244.00 $256.00

69440 90 $699.00 $983.00 $1,042.00 $1,090.00 $983.00 $1,042.00 $1,090.00

69450 90 $525.00 $776.00 $822.00 $859.00 $776.00 $822.00 $859.00

69501 90 $829.00 $1,053.00 $1,115.00 $1,171.00 $1,053.00 $1,115.00 $1,171.00

69502 90 $1,118.00 $1,405.00 $1,489.00 $1,569.00 $1,405.00 $1,489.00 $1,569.00

69505 90 $1,176.00 $1,717.00 $1,820.00 $1,903.00 $1,717.00 $1,820.00 $1,903.00

69511 90 $1,221.00 $1,762.00 $1,868.00 $1,956.00 $1,762.00 $1,868.00 $1,956.00

69530 90 $1,616.00 $2,400.00 $2,545.00 $2,680.00 $2,400.00 $2,545.00 $2,680.00

69535 90 $2,824.00 $3,901.00 $4,135.00 $4,380.00 $3,901.00 $4,135.00 $4,380.00

69540 10 $126.00 $291.00 $309.00 $318.00 $180.00 $191.00 $199.00

69550 90 $998.00 $1,483.00 $1,572.00 $1,642.00 $1,483.00 $1,572.00 $1,642.00

69552 90 $1,621.00 $2,238.00 $2,367.00 $2,485.00 $2,238.00 $2,367.00 $2,485.00



Surgery


(Non-Facility MRA)






69554 90 $2,600.00 $3,644.00 $3,854.00 $4,069.00 $3,644.00 $3,854.00 $4,069.00

69601 90 $1,195.00 $1,503.00 $1,591.00 $1,674.00 $1,503.00 $1,591.00 $1,674.00

69602 90 $1,225.00 $1,570.00 $1,663.00 $1,750.00 $1,570.00 $1,663.00 $1,750.00

69603 90 $1,264.00 $1,812.00 $1,921.00 $2,013.00 $1,812.00 $1,921.00 $2,013.00

69604 90 $1,263.00 $1,598.00 $1,692.00 $1,779.00 $1,598.00 $1,692.00 $1,779.00

69605 90 $1,526.00 $2,421.00 $2,587.00 $2,752.00 $2,421.00 $2,587.00 $2,752.00

69610 10 $41.00 $547.00 $580.00 $608.00 $423.00 $447.00 $474.00

69620 90 $651.00 $976.00 $1,036.00 $1,076.00 $700.00 $742.00 $778.00

69631 90 $985.00 $1,263.00 $1,339.00 $1,402.00 $1,263.00 $1,339.00 $1,402.00

69632 90 $1,166.00 $1,544.00 $1,636.00 $1,716.00 $1,544.00 $1,636.00 $1,716.00

69633 90 $1,110.00 $1,496.00 $1,586.00 $1,664.00 $1,496.00 $1,586.00 $1,664.00

69635 90 $1,207.00 $1,767.00 $1,875.00 $1,966.00 $1,767.00 $1,875.00 $1,966.00

69636 90 $1,381.00 $1,970.00 $2,088.00 $2,185.00 $1,970.00 $2,088.00 $2,185.00

69637 90 $1,370.00 $2,005.00 $2,130.00 $2,238.00 $2,005.00 $2,130.00 $2,238.00

69641 90 $1,154.00 $1,494.00 $1,582.00 $1,662.00 $1,494.00 $1,582.00 $1,662.00

69642 90 $1,519.00 $1,919.00 $2,031.00 $2,135.00 $1,919.00 $2,031.00 $2,135.00

69643 90 $1,389.00 $1,758.00 $1,862.00 $1,958.00 $1,758.00 $1,862.00 $1,958.00

69644 90 $1,529.00 $2,115.00 $2,241.00 $2,348.00 $2,115.00 $2,241.00 $2,348.00

69645 90 $1,479.00 $2,078.00 $2,202.00 $2,307.00 $2,078.00 $2,202.00 $2,307.00

69646 90 $1,620.00 $2,210.00 $2,341.00 $2,454.00 $2,210.00 $2,341.00 $2,454.00

69650 90 $879.00 $1,158.00 $1,228.00 $1,290.00 $1,158.00 $1,228.00 $1,290.00

69660 90 $1,072.00 $1,333.00 $1,411.00 $1,485.00 $1,333.00 $1,411.00 $1,485.00

69661 90 $1,412.00 $1,735.00 $1,836.00 $1,932.00 $1,735.00 $1,836.00 $1,932.00

69662 90 $1,386.00 $1,675.00 $1,773.00 $1,870.00 $1,675.00 $1,773.00 $1,870.00

69666 90 $887.00 $1,166.00 $1,235.00 $1,298.00 $1,166.00 $1,235.00 $1,298.00

69667 90 $887.00 $1,166.00 $1,236.00 $1,299.00 $1,166.00 $1,236.00 $1,299.00

69670 90 $988.00 $1,363.00 $1,444.00 $1,517.00 $1,363.00 $1,444.00 $1,517.00

69676 90 $828.00 $1,188.00 $1,259.00 $1,319.00 $1,188.00 $1,259.00 $1,319.00

69700 90 $702.00 $995.00 $1,054.00 $1,106.00 $995.00 $1,054.00 $1,106.00

69710 0 BR ---------- ---------- ---------- ---------- ---------- ----------

69711 90 $878.00 $1,236.00 $1,309.00 $1,374.00 $1,236.00 $1,309.00 $1,374.00

69714 90 $961.00 $1,554.00 $1,645.00 $1,734.00 $1,554.00 $1,645.00 $1,734.00

69715 90 $1,217.00 $2,009.00 $2,139.00 $2,285.00 $2,009.00 $2,139.00 $2,285.00

69717 90 $996.00 $1,636.00 $1,732.00 $1,828.00 $1,636.00 $1,732.00 $1,828.00

69718 90 $1,232.00 $1,941.00 $2,053.00 $2,168.00 $1,941.00 $2,053.00 $2,168.00

69720 90 $1,307.00 $1,758.00 $1,871.00 $1,983.00 $1,758.00 $1,871.00 $1,983.00

69725 90 $1,922.00 $2,724.00 $2,880.00 $3,044.00 $2,724.00 $2,880.00 $3,044.00

69740 90 $1,274.00 $1,736.00 $1,847.00 $1,969.00 $1,736.00 $1,847.00 $1,969.00

69745 90 $1,447.00 $1,683.00 $1,769.00 $1,844.00 $1,683.00 $1,769.00 $1,844.00

69799 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

69801 0 $785.00 $277.00 $294.00 $307.00 $184.00 $195.00 $207.00

69805 90 $1,187.00 $1,522.00 $1,610.00 $1,698.00 $1,522.00 $1,610.00 $1,698.00

69806 90 $1,123.00 $1,362.00 $1,441.00 $1,518.00 $1,362.00 $1,441.00 $1,518.00

69820 90 $876.00 $1,199.00 $1,267.00 $1,327.00 $1,199.00 $1,267.00 $1,327.00

69840 90 $869.00 $1,294.00 $1,371.00 $1,436.00 $1,294.00 $1,371.00 $1,436.00

69905 90 $1,013.00 $1,315.00 $1,393.00 $1,462.00 $1,315.00 $1,393.00 $1,462.00

69910 90 $1,228.00 $1,477.00 $1,564.00 $1,650.00 $1,477.00 $1,564.00 $1,650.00

69915 90 $1,754.00 $2,316.00 $2,465.00 $2,638.00 $2,316.00 $2,465.00 $2,638.00

69930 90 $1,498.00 $1,771.00 $1,873.00 $1,979.00 $1,771.00 $1,873.00 $1,979.00

69949 YYY BR ---------- ---------- ---------- ---------- ---------- ----------



Surgery


(Non-Facility MRA)






69950 90 $2,017.00 $2,655.00 $2,821.00 $3,019.00 $2,655.00 $2,821.00 $3,019.00

69955 90 $2,185.00 $2,856.00 $3,016.00 $3,184.00 $2,856.00 $3,016.00 $3,184.00

69960 90 $2,116.00 $2,796.00 $2,955.00 $3,129.00 $2,796.00 $2,955.00 $3,129.00

69970 90 $2,306.00 $3,110.00 $3,287.00 $3,480.00 $3,110.00 $3,287.00 $3,480.00

69979 YYY BR ---------- ---------- ---------- ---------- ---------- ----------

69990 ZZZ $262.00 $343.00 $376.00 $430.00 $343.00 $376.00 $430.00

G0127 0 ---------- $32.00 $34.00 $34.00 $11.00 $11.00 $12.00

G0168 0 ---------- $141.00 $151.00 $154.00 $41.00 $43.00 $45.00

G0247 ZZZ ---------- $100.00 $106.00 $108.00 $33.00 $34.00 $36.00

G0276 0 ---------- $587.00 $622.00 $671.00 $587.00 $622.00 $671.00

G0289 ZZZ ---------- $131.00 $139.00 $151.00 $131.00 $139.00 $151.00

G0341 0 ---------- $2,846.00 $3,031.00 $3,093.00 $550.00 $579.00 $617.00

G0342 90 ---------- $1,026.00 $1,082.00 $1,148.00 $1,026.00 $1,082.00 $1,148.00

G0343 90 ---------- $1,893.00 $2,024.00 $2,196.00 $1,893.00 $2,024.00 $2,196.00

G0364 ZZZ ---------- $17.00 $18.00 $19.00 $13.00 $13.00 $13.00

G0412 90 ---------- $1,058.00 $1,128.00 $1,212.00 $1,058.00 $1,128.00 $1,212.00

G0413 90 ---------- $1,573.00 $1,678.00 $1,807.00 $1,573.00 $1,678.00 $1,807.00

G0414 90 ---------- $1,431.00 $1,517.00 $1,614.00 $1,431.00 $1,517.00 $1,614.00

G0415 90 ---------- $2,020.00 $2,154.00 $2,322.00 $2,020.00 $2,154.00 $2,322.00

G0429 0 ---------- $141.00 $149.00 $156.00 $104.00 $110.00 $116.00

2017 Edition Effective Date: _________


PART C


ALLOWANCES


CPT only © 2016 American Medical Association. All rights reserved. Part C, 284

Radiology

CPT Code 2003 MRALocality 01/02

(Non-Facility MRA)






70010 $70.00 $76.00 $81.00 $86.00 $76.00 $81.00 $86.00

70010-26 NC BR BR BR BR BR BR

70010-TC NC BR BR BR BR BR BR

70015 $58.00 $170.00 $181.00 $186.00 $170.00 $181.00 $186.00

70015-26 NC $72.00 $75.00 $80.00 $72.00 $75.00 $80.00

70015-TC NC $99.00 $105.00 $107.00 $99.00 $105.00 $107.00

70030 $24.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.00

70030-26 $10.00 $10.00 $10.00 $10.00 $10.00 $10.00 $10.00

70030-TC $15.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.00

70100 $29.00 $36.00 $38.00 $39.00 $36.00 $38.00 $39.00

70100-26 $9.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.00

70100-TC $19.00 $25.00 $27.00 $28.00 $25.00 $27.00 $28.00

70110 $36.00 $41.00 $44.00 $44.00 $41.00 $44.00 $44.00

70110-26 $12.00 $14.00 $15.00 $15.00 $14.00 $15.00 $15.00

70110-TC $22.00 $27.00 $29.00 $29.00 $27.00 $29.00 $29.00

70120 $32.00 $36.00 $39.00 $40.00 $36.00 $39.00 $40.00

70120-26 $9.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.00

70120-TC $22.00 $26.00 $28.00 $29.00 $26.00 $28.00 $29.00

70130 $46.00 $59.00 $63.00 $64.00 $59.00 $63.00 $64.00

70130-26 $17.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.00

70130-TC $29.00 $40.00 $43.00 $43.00 $40.00 $43.00 $43.00

70134 $45.00 $56.00 $59.00 $60.00 $56.00 $59.00 $60.00

70134-26 $17.00 $20.00 $20.00 $21.00 $20.00 $20.00 $21.00

70134-TC $28.00 $36.00 $39.00 $40.00 $36.00 $39.00 $40.00

70140 $33.00 $32.00 $34.00 $35.00 $32.00 $34.00 $35.00

70140-26 $9.00 $12.00 $12.00 $13.00 $12.00 $12.00 $13.00

70140-TC $22.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.00

70150 $42.00 $45.00 $48.00 $48.00 $45.00 $48.00 $48.00

70150-26 $12.00 $15.00 $15.00 $16.00 $15.00 $15.00 $16.00

70150-TC $29.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.00

70160 $29.00 $35.00 $38.00 $38.00 $35.00 $38.00 $38.00

70160-26 $8.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.00

70160-TC $19.00 $25.00 $27.00 $28.00 $25.00 $27.00 $28.00

70170 $52.00 $255.00 $271.00 $275.00 $255.00 $271.00 $275.00

70170-26 NC $17.00 $18.00 $18.00 $17.00 $18.00 $18.00

70170-TC NC $238.00 $254.00 $257.00 $238.00 $254.00 $257.00

70190 $34.00 $38.00 $41.00 $42.00 $38.00 $41.00 $42.00

70190-26 $10.00 $13.00 $13.00 $13.00 $13.00 $13.00 $13.00

70190-TC $22.00 $26.00 $28.00 $28.00 $26.00 $28.00 $28.00

70200 $43.00 $46.00 $48.00 $49.00 $46.00 $48.00 $49.00

70200-26 $14.00 $16.00 $16.00 $17.00 $16.00 $16.00 $17.00

70200-TC $29.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.00

70210 $32.00 $32.00 $34.00 $35.00 $32.00 $34.00 $35.00

70210-26 $8.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.00

70210-TC $22.00 $22.00 $24.00 $25.00 $22.00 $24.00 $25.00

70220 $42.00 $41.00 $43.00 $44.00 $41.00 $43.00 $44.00

70220-26 $12.00 $14.00 $15.00 $15.00 $14.00 $15.00 $15.00

70220-TC $29.00 $27.00 $29.00 $29.00 $27.00 $29.00 $29.00

70240 $26.00 $33.00 $35.00 $36.00 $33.00 $35.00 $36.00

70240-26 $9.00 $11.00 $11.00 $12.00 $11.00 $11.00 $12.00



Radiology


(Non-Facility MRA)






70240-TC $15.00 $22.00 $23.00 $24.00 $22.00 $23.00 $24.00

70250 $35.00 $39.00 $41.00 $42.00 $39.00 $41.00 $42.00

70250-26 $12.00 $14.00 $15.00 $15.00 $14.00 $15.00 $15.00

70250-TC $22.00 $25.00 $27.00 $27.00 $25.00 $27.00 $27.00

70260 $50.00 $50.00 $53.00 $54.00 $50.00 $53.00 $54.00

70260-26 $17.00 $20.00 $20.00 $21.00 $20.00 $20.00 $21.00

70260-TC $33.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.00

70300 $15.00 $16.00 $17.00 $18.00 $16.00 $17.00 $18.00

70300-26 $5.00 $7.00 $7.00 $7.00 $7.00 $7.00 $7.00

70300-TC $10.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.00

70310 $24.00 $39.00 $42.00 $43.00 $39.00 $42.00 $43.00

70310-26 $8.00 $9.00 $9.00 $10.00 $9.00 $9.00 $10.00

70310-TC $15.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.00

70320 $40.00 $57.00 $61.00 $63.00 $57.00 $61.00 $63.00

70320-26 $11.00 $14.00 $15.00 $15.00 $14.00 $15.00 $15.00

70320-TC $29.00 $44.00 $47.00 $47.00 $44.00 $47.00 $47.00

70328 $28.00 $33.00 $35.00 $36.00 $33.00 $35.00 $36.00

70328-26 $10.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.00

70328-TC $18.00 $23.00 $24.00 $25.00 $23.00 $24.00 $25.00

70330 $43.00 $52.00 $55.00 $56.00 $52.00 $55.00 $56.00

70330-26 $12.00 $14.00 $15.00 $15.00 $14.00 $15.00 $15.00

70330-TC $31.00 $38.00 $41.00 $41.00 $38.00 $41.00 $41.00

70332 $107.00 $87.00 $92.00 $94.00 $87.00 $92.00 $94.00

70332-26 NC $35.00 $36.00 $37.00 $35.00 $36.00 $37.00

70332-TC NC $52.00 $56.00 $57.00 $52.00 $56.00 $57.00

70336 $497.00 $321.00 $340.00 $346.00 $321.00 $340.00 $346.00

70336-26 $72.00 $83.00 $86.00 $88.00 $83.00 $86.00 $88.00

70336-TC $419.00 $238.00 $254.00 $257.00 $238.00 $254.00 $257.00

70350 $24.00 $22.00 $23.00 $24.00 $22.00 $23.00 $24.00

70350-26 $10.00 $12.00 $12.00 $13.00 $12.00 $12.00 $13.00

70350-TC $14.00 $10.00 $11.00 $12.00 $10.00 $11.00 $12.00

70355 $32.00 $23.00 $24.00 $26.00 $23.00 $24.00 $26.00

70355-26 $10.00 $13.00 $13.00 $14.00 $13.00 $13.00 $14.00

70355-TC $21.00 $10.00 $11.00 $12.00 $10.00 $11.00 $12.00

70360 $24.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.00

70360-26 $8.00 $10.00 $10.00 $10.00 $10.00 $10.00 $10.00

70360-TC $15.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.00

70370 $65.00 $83.00 $88.00 $90.00 $83.00 $88.00 $90.00

70370-26 $16.00 $18.00 $19.00 $20.00 $18.00 $19.00 $20.00

70370-TC $48.00 $65.00 $69.00 $70.00 $65.00 $69.00 $70.00

70371 $122.00 $98.00 $103.00 $105.00 $98.00 $103.00 $105.00

70371-26 $43.00 $47.00 $48.00 $50.00 $47.00 $48.00 $50.00

70371-TC $79.00 $51.00 $55.00 $56.00 $51.00 $55.00 $56.00

70380 $34.00 $39.00 $41.00 $42.00 $39.00 $41.00 $42.00

70380-26 $8.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.00

70380-TC $24.00 $28.00 $31.00 $31.00 $28.00 $31.00 $31.00

70390 $87.00 $101.00 $107.00 $109.00 $101.00 $107.00 $109.00

70390-26 NC $21.00 $22.00 $23.00 $21.00 $22.00 $23.00

70390-TC NC $79.00 $85.00 $86.00 $79.00 $85.00 $86.00

70450 $221.00 $126.00 $133.00 $136.00 $126.00 $133.00 $136.00



Radiology


(Non-Facility MRA)






70450-26 $43.00 $48.00 $50.00 $52.00 $48.00 $50.00 $52.00

70450-TC $176.00 $78.00 $83.00 $84.00 $78.00 $83.00 $84.00

70460 $271.00 $176.00 $186.00 $189.00 $176.00 $186.00 $189.00

70460-26 $58.00 $64.00 $66.00 $68.00 $64.00 $66.00 $68.00

70460-TC $211.00 $112.00 $120.00 $121.00 $112.00 $120.00 $121.00

70470 $332.00 $208.00 $220.00 $224.00 $208.00 $220.00 $224.00

70470-26 $65.00 $72.00 $74.00 $77.00 $72.00 $74.00 $77.00

70470-TC $264.00 $136.00 $145.00 $147.00 $136.00 $145.00 $147.00

70480 $244.00 $191.00 $202.00 $205.00 $191.00 $202.00 $205.00

70480-26 $65.00 $72.00 $75.00 $77.00 $72.00 $75.00 $77.00

70480-TC $176.00 $119.00 $127.00 $128.00 $119.00 $127.00 $128.00

70481 $284.00 $297.00 $315.00 $320.00 $297.00 $315.00 $320.00

70481-26 $70.00 $78.00 $81.00 $83.00 $78.00 $81.00 $83.00

70481-TC $211.00 $219.00 $234.00 $237.00 $219.00 $234.00 $237.00

70482 $340.00 $324.00 $344.00 $350.00 $324.00 $344.00 $350.00

70482-26 $74.00 $81.00 $84.00 $87.00 $81.00 $84.00 $87.00

70482-TC $264.00 $243.00 $260.00 $263.00 $243.00 $260.00 $263.00

70486 $236.00 $151.00 $159.00 $162.00 $151.00 $159.00 $162.00

70486-26 $58.00 $48.00 $50.00 $52.00 $48.00 $50.00 $52.00

70486-TC $176.00 $102.00 $110.00 $111.00 $102.00 $110.00 $111.00

70487 $279.00 $182.00 $192.00 $195.00 $182.00 $192.00 $195.00

70487-26 $66.00 $64.00 $66.00 $68.00 $64.00 $66.00 $68.00

70487-TC $211.00 $118.00 $126.00 $128.00 $118.00 $126.00 $128.00

70488 $339.00 $221.00 $234.00 $238.00 $221.00 $234.00 $238.00

70488-26 $72.00 $72.00 $74.00 $76.00 $72.00 $74.00 $76.00

70488-TC $264.00 $150.00 $160.00 $162.00 $150.00 $160.00 $162.00

70490 $244.00 $191.00 $202.00 $205.00 $191.00 $202.00 $205.00

70490-26 $65.00 $72.00 $75.00 $77.00 $72.00 $75.00 $77.00

70490-TC $176.00 $119.00 $127.00 $128.00 $119.00 $127.00 $128.00

70491 $284.00 $255.00 $270.00 $274.00 $255.00 $270.00 $274.00

70491-26 $70.00 $78.00 $81.00 $84.00 $78.00 $81.00 $84.00

70491-TC $211.00 $176.00 $189.00 $191.00 $176.00 $189.00 $191.00

70492 $340.00 $300.00 $317.00 $323.00 $300.00 $317.00 $323.00

70492-26 $74.00 $82.00 $85.00 $87.00 $82.00 $85.00 $87.00

70492-TC $264.00 $218.00 $233.00 $235.00 $218.00 $233.00 $235.00

70496 $366.00 $317.00 $336.00 $342.00 $317.00 $336.00 $342.00

70496-26 $92.00 $99.00 $102.00 $106.00 $99.00 $102.00 $106.00

70496-TC $270.00 $218.00 $234.00 $236.00 $218.00 $234.00 $236.00

70498 $366.00 $317.00 $335.00 $341.00 $317.00 $335.00 $341.00

70498-26 $92.00 $99.00 $102.00 $106.00 $99.00 $102.00 $106.00

70498-TC $270.00 $218.00 $233.00 $236.00 $218.00 $233.00 $236.00

70540 $482.00 $314.00 $332.00 $338.00 $314.00 $332.00 $338.00

70540-26 $70.00 $76.00 $79.00 $81.00 $76.00 $79.00 $81.00

70540-TC $413.00 $238.00 $254.00 $257.00 $238.00 $254.00 $257.00

70542 $579.00 $366.00 $388.00 $394.00 $366.00 $388.00 $394.00

70542-26 $82.00 $92.00 $95.00 $98.00 $92.00 $95.00 $98.00

70542-TC $495.00 $274.00 $293.00 $297.00 $274.00 $293.00 $297.00

70543 $1,029.00 $450.00 $476.00 $484.00 $450.00 $476.00 $484.00

70543-26 $109.00 $121.00 $125.00 $129.00 $121.00 $125.00 $129.00

70543-TC $916.00 $329.00 $351.00 $355.00 $329.00 $351.00 $355.00



Radiology


(Non-Facility MRA)






70544 $481.00 $306.00 $324.00 $329.00 $306.00 $324.00 $329.00

70544-26 $61.00 $68.00 $70.00 $73.00 $68.00 $70.00 $73.00

70544-TC $419.00 $238.00 $254.00 $257.00 $238.00 $254.00 $257.00

70545 $481.00 $347.00 $368.00 $374.00 $347.00 $368.00 $374.00

70545-26 $61.00 $68.00 $70.00 $72.00 $68.00 $70.00 $72.00

70545-TC $419.00 $279.00 $298.00 $302.00 $279.00 $298.00 $302.00

70546 $914.00 $550.00 $584.00 $593.00 $550.00 $584.00 $593.00

70546-26 $92.00 $102.00 $105.00 $108.00 $102.00 $105.00 $108.00

70546-TC $820.00 $449.00 $479.00 $485.00 $449.00 $479.00 $485.00

70547 $481.00 $306.00 $324.00 $329.00 $306.00 $324.00 $329.00

70547-26 $61.00 $68.00 $70.00 $73.00 $68.00 $70.00 $73.00

70547-TC $419.00 $238.00 $254.00 $257.00 $238.00 $254.00 $257.00

70548 $481.00 $347.00 $368.00 $374.00 $347.00 $368.00 $374.00

70548-26 $61.00 $68.00 $70.00 $73.00 $68.00 $70.00 $73.00

70548-TC $419.00 $279.00 $298.00 $301.00 $279.00 $298.00 $301.00

70549 $914.00 $550.00 $584.00 $593.00 $550.00 $584.00 $593.00

70549-26 $92.00 $102.00 $105.00 $108.00 $102.00 $105.00 $108.00

70549-TC $820.00 $449.00 $479.00 $485.00 $449.00 $479.00 $485.00

70551 $497.00 $250.00 $264.00 $269.00 $250.00 $264.00 $269.00

70551-26 $76.00 $83.00 $86.00 $89.00 $83.00 $86.00 $89.00

70551-TC $419.00 $167.00 $178.00 $180.00 $167.00 $178.00 $180.00

70552 $596.00 $346.00 $366.00 $373.00 $346.00 $366.00 $373.00

70552-26 $91.00 $101.00 $104.00 $108.00 $101.00 $104.00 $108.00

70552-TC $502.00 $245.00 $262.00 $265.00 $245.00 $262.00 $265.00

70553 $1,055.00 $409.00 $432.00 $440.00 $409.00 $432.00 $440.00

70553-26 $120.00 $129.00 $134.00 $138.00 $129.00 $134.00 $138.00

70553-TC $931.00 $279.00 $298.00 $302.00 $279.00 $298.00 $302.00

70554 ---------- $485.00 $514.00 $522.00 $485.00 $514.00 $522.00

70554-26 ---------- $120.00 $124.00 $128.00 $120.00 $124.00 $128.00

70554-TC ---------- $365.00 $390.00 $394.00 $365.00 $390.00 $394.00

70555 ---------- BR BR BR BR BR BR

70555-26 ---------- $141.00 $146.00 $150.00 $141.00 $146.00 $150.00

70555-TC ---------- BR BR BR BR BR BR

70557 ---------- $403.00 $426.00 $434.00 $403.00 $426.00 $434.00

70557-26 ---------- $166.00 $172.00 $178.00 $166.00 $172.00 $178.00

70557-TC ---------- $238.00 $254.00 $257.00 $238.00 $254.00 $257.00

70558 ---------- $629.00 $666.00 $677.00 $629.00 $666.00 $677.00

70558-26 ---------- $181.00 $187.00 $193.00 $181.00 $187.00 $193.00

70558-TC ---------- $449.00 $479.00 $484.00 $449.00 $479.00 $484.00

70559 ---------- $462.00 $488.00 $498.00 $462.00 $488.00 $498.00

70559-26 ---------- $183.00 $190.00 $197.00 $183.00 $190.00 $197.00

70559-TC ---------- $279.00 $298.00 $301.00 $279.00 $298.00 $301.00

71010 $27.00 $25.00 $26.00 $27.00 $25.00 $26.00 $27.00

71010-26 $9.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.00

71010-TC $17.00 $14.00 $16.00 $16.00 $14.00 $16.00 $16.00

71015 $30.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.00

71015-26 $10.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.00

71015-TC $19.00 $18.00 $19.00 $20.00 $18.00 $19.00 $20.00

71020 $35.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.00

71020-26 $11.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.00



Radiology


(Non-Facility MRA)






71020-TC $22.00 $18.00 $20.00 $20.00 $18.00 $20.00 $20.00

71021 $41.00 $37.00 $39.00 $40.00 $37.00 $39.00 $40.00

71021-26 $13.00 $15.00 $16.00 $16.00 $15.00 $16.00 $16.00

71021-TC $28.00 $22.00 $23.00 $24.00 $22.00 $23.00 $24.00

71022 $44.00 $45.00 $47.00 $48.00 $45.00 $47.00 $48.00

71022-26 $16.00 $18.00 $19.00 $19.00 $18.00 $19.00 $19.00

71022-TC $28.00 $27.00 $29.00 $29.00 $27.00 $29.00 $29.00

71023 $49.00 $69.00 $73.00 $74.00 $69.00 $73.00 $74.00

71023-26 $19.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.00

71023-TC $29.00 $47.00 $51.00 $51.00 $47.00 $51.00 $51.00

71030 $45.00 $46.00 $48.00 $49.00 $46.00 $48.00 $49.00

71030-26 $16.00 $18.00 $18.00 $19.00 $18.00 $18.00 $19.00

71030-TC $29.00 $28.00 $30.00 $30.00 $28.00 $30.00 $30.00

71034 $79.00 $89.00 $95.00 $97.00 $89.00 $95.00 $97.00

71034-26 $23.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.00

71034-TC $54.00 $63.00 $68.00 $69.00 $63.00 $68.00 $69.00

71035 $56.00 $35.00 $38.00 $38.00 $35.00 $38.00 $38.00

71035-26 $19.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.00

71035-TC $38.00 $25.00 $27.00 $27.00 $25.00 $27.00 $27.00

71100 $33.00 $36.00 $38.00 $39.00 $36.00 $38.00 $39.00

71100-26 $11.00 $13.00 $13.00 $13.00 $13.00 $13.00 $13.00

71100-TC $21.00 $23.00 $25.00 $25.00 $23.00 $25.00 $25.00

71101 $38.00 $40.00 $42.00 $43.00 $40.00 $42.00 $43.00

71101-26 $13.00 $15.00 $16.00 $17.00 $15.00 $16.00 $17.00

71101-TC $24.00 $24.00 $26.00 $27.00 $24.00 $26.00 $27.00

71110 $43.00 $41.00 $43.00 $44.00 $41.00 $43.00 $44.00

71110-26 $13.00 $15.00 $16.00 $16.00 $15.00 $16.00 $16.00

71110-TC $29.00 $25.00 $27.00 $28.00 $25.00 $27.00 $28.00

71111 $49.00 $52.00 $55.00 $57.00 $52.00 $55.00 $57.00

71111-26 $16.00 $19.00 $19.00 $20.00 $19.00 $19.00 $20.00

71111-TC $33.00 $34.00 $36.00 $37.00 $34.00 $36.00 $37.00

71120 $35.00 $32.00 $34.00 $35.00 $32.00 $34.00 $35.00

71120-26 $10.00 $11.00 $12.00 $12.00 $11.00 $12.00 $12.00

71120-TC $24.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.00

71130 $38.00 $39.00 $41.00 $42.00 $39.00 $41.00 $42.00

71130-26 $11.00 $13.00 $13.00 $13.00 $13.00 $13.00 $13.00

71130-TC $26.00 $26.00 $28.00 $29.00 $26.00 $28.00 $29.00

71250 $282.00 $176.00 $187.00 $190.00 $176.00 $187.00 $190.00

71250-26 $59.00 $58.00 $60.00 $62.00 $58.00 $60.00 $62.00

71250-TC $220.00 $119.00 $127.00 $128.00 $119.00 $127.00 $128.00

71260 $328.00 $248.00 $262.00 $267.00 $248.00 $262.00 $267.00

71260-26 $63.00 $70.00 $73.00 $75.00 $70.00 $73.00 $75.00

71260-TC $264.00 $178.00 $190.00 $192.00 $178.00 $190.00 $192.00

71270 $402.00 $297.00 $314.00 $319.00 $297.00 $314.00 $319.00

71270-26 $70.00 $78.00 $81.00 $83.00 $78.00 $81.00 $83.00

71270-TC $330.00 $219.00 $234.00 $236.00 $219.00 $234.00 $236.00

71275 $431.00 $325.00 $344.00 $350.00 $325.00 $344.00 $350.00

71275-26 $100.00 $103.00 $106.00 $110.00 $103.00 $106.00 $110.00

71275-TC $328.00 $222.00 $238.00 $241.00 $222.00 $238.00 $241.00

71550 $490.00 $320.00 $339.00 $344.00 $320.00 $339.00 $344.00



Radiology


(Non-Facility MRA)






71550-26 $75.00 $82.00 $85.00 $88.00 $82.00 $85.00 $88.00

71550-TC $415.00 $238.00 $254.00 $257.00 $238.00 $254.00 $257.00

71551 $587.00 $497.00 $527.00 $535.00 $497.00 $527.00 $535.00

71551-26 $88.00 $98.00 $101.00 $104.00 $98.00 $101.00 $104.00

71551-TC $496.00 $399.00 $426.00 $431.00 $399.00 $426.00 $431.00

71552 $1,029.00 $577.00 $612.00 $622.00 $577.00 $612.00 $622.00

71552-26 $114.00 $128.00 $132.00 $136.00 $128.00 $132.00 $136.00

71552-TC $911.00 $449.00 $480.00 $485.00 $449.00 $480.00 $485.00

71555 $514.00 $429.00 $455.00 $462.00 $429.00 $455.00 $462.00

71555-26 $92.00 $101.00 $104.00 $107.00 $101.00 $104.00 $107.00

71555-TC $419.00 $328.00 $351.00 $355.00 $328.00 $351.00 $355.00

72020 $22.00 $24.00 $25.00 $26.00 $24.00 $25.00 $26.00

72020-26 $7.00 $9.00 $9.00 $9.00 $9.00 $9.00 $9.00

72020-TC $15.00 $15.00 $16.00 $17.00 $15.00 $16.00 $17.00

72040 $34.00 $36.00 $38.00 $39.00 $36.00 $38.00 $39.00

72040-26 $11.00 $13.00 $13.00 $13.00 $13.00 $13.00 $13.00

72040-TC $22.00 $23.00 $25.00 $25.00 $23.00 $25.00 $25.00

72050 $49.00 $49.00 $52.00 $53.00 $49.00 $52.00 $53.00

72050-26 $16.00 $18.00 $18.00 $19.00 $18.00 $18.00 $19.00

72050-TC $33.00 $31.00 $34.00 $34.00 $31.00 $34.00 $34.00

72052 $61.00 $61.00 $64.00 $66.00 $61.00 $64.00 $66.00

72052-26 $18.00 $21.00 $21.00 $22.00 $21.00 $21.00 $22.00

72052-TC $42.00 $40.00 $43.00 $44.00 $40.00 $43.00 $44.00

72070 $36.00 $37.00 $39.00 $40.00 $37.00 $39.00 $40.00

72070-26 $11.00 $13.00 $13.00 $13.00 $13.00 $13.00 $13.00

72070-TC $24.00 $24.00 $26.00 $27.00 $24.00 $26.00 $27.00

72072 $39.00 $37.00 $39.00 $40.00 $37.00 $39.00 $40.00

72072-26 $11.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.00

72072-TC $28.00 $25.00 $27.00 $27.00 $25.00 $27.00 $27.00

72074 $45.00 $42.00 $45.00 $46.00 $42.00 $45.00 $46.00

72074-26 $11.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.00

72074-TC $34.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.00

72080 $36.00 $33.00 $35.00 $36.00 $33.00 $35.00 $36.00

72080-26 $11.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.00

72080-TC $24.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.00

72081 ---------- $42.00 $45.00 $46.00 $42.00 $45.00 $46.00

72081-26 ---------- $15.00 $16.00 $16.00 $15.00 $16.00 $16.00

72081-TC ---------- $27.00 $29.00 $30.00 $27.00 $29.00 $30.00

72082 ---------- $67.00 $72.00 $73.00 $67.00 $72.00 $73.00

72082-26 ---------- $18.00 $19.00 $20.00 $18.00 $19.00 $20.00

72082-TC ---------- $49.00 $53.00 $54.00 $49.00 $53.00 $54.00

72083 ---------- $73.00 $78.00 $79.00 $73.00 $78.00 $79.00

72083-26 ---------- $20.00 $20.00 $21.00 $20.00 $20.00 $21.00

72083-TC ---------- $53.00 $57.00 $58.00 $53.00 $57.00 $58.00

72084 ---------- $87.00 $92.00 $94.00 $87.00 $92.00 $94.00

72084-26 ---------- $23.00 $24.00 $24.00 $23.00 $24.00 $24.00

72084-TC ---------- $64.00 $68.00 $69.00 $64.00 $68.00 $69.00

72100 $36.00 $38.00 $40.00 $41.00 $38.00 $40.00 $41.00

72100-26 $11.00 $13.00 $13.00 $13.00 $13.00 $13.00 $13.00

72100-TC $24.00 $25.00 $27.00 $28.00 $25.00 $27.00 $28.00



Radiology


(Non-Facility MRA)






72110 $50.00 $53.00 $56.00 $58.00 $53.00 $56.00 $58.00

72110-26 $16.00 $18.00 $18.00 $19.00 $18.00 $18.00 $19.00

72110-TC $34.00 $35.00 $38.00 $38.00 $35.00 $38.00 $38.00

72114 $64.00 $67.00 $71.00 $73.00 $67.00 $71.00 $73.00

72114-26 $18.00 $19.00 $19.00 $20.00 $19.00 $19.00 $20.00

72114-TC $44.00 $48.00 $52.00 $53.00 $48.00 $52.00 $53.00

72120 $45.00 $44.00 $46.00 $47.00 $44.00 $46.00 $47.00

72120-26 $11.00 $13.00 $13.00 $13.00 $13.00 $13.00 $13.00

72120-TC $33.00 $31.00 $33.00 $34.00 $31.00 $33.00 $34.00

72125 $282.00 $179.00 $189.00 $193.00 $179.00 $189.00 $193.00

72125-26 $59.00 $61.00 $63.00 $65.00 $61.00 $63.00 $65.00

72125-TC $220.00 $119.00 $127.00 $128.00 $119.00 $127.00 $128.00

72126 $328.00 $247.00 $261.00 $266.00 $247.00 $261.00 $266.00

72126-26 $62.00 $69.00 $71.00 $73.00 $69.00 $71.00 $73.00

72126-TC $264.00 $178.00 $190.00 $192.00 $178.00 $190.00 $192.00

72127 $397.00 $291.00 $308.00 $313.00 $291.00 $308.00 $313.00

72127-26 $65.00 $72.00 $74.00 $76.00 $72.00 $74.00 $76.00

72127-TC $330.00 $219.00 $234.00 $237.00 $219.00 $234.00 $237.00

72128 $282.00 $175.00 $185.00 $189.00 $175.00 $185.00 $189.00

72128-26 $59.00 $57.00 $59.00 $61.00 $57.00 $59.00 $61.00

72128-TC $220.00 $119.00 $127.00 $128.00 $119.00 $127.00 $128.00

72129 $328.00 $248.00 $262.00 $267.00 $248.00 $262.00 $267.00

72129-26 $62.00 $69.00 $72.00 $74.00 $69.00 $72.00 $74.00

72129-TC $264.00 $179.00 $191.00 $193.00 $179.00 $191.00 $193.00

72130 $397.00 $292.00 $310.00 $315.00 $292.00 $310.00 $315.00

72130-26 $65.00 $72.00 $74.00 $76.00 $72.00 $74.00 $76.00

72130-TC $330.00 $221.00 $236.00 $238.00 $221.00 $236.00 $238.00

72131 $282.00 $175.00 $185.00 $189.00 $175.00 $185.00 $189.00

72131-26 $59.00 $57.00 $59.00 $61.00 $57.00 $59.00 $61.00

72131-TC $220.00 $119.00 $127.00 $128.00 $119.00 $127.00 $128.00

72132 $328.00 $246.00 $261.00 $265.00 $246.00 $261.00 $265.00

72132-26 $62.00 $69.00 $71.00 $73.00 $69.00 $71.00 $73.00

72132-TC $264.00 $178.00 $190.00 $192.00 $178.00 $190.00 $192.00

72133 $391.00 $291.00 $308.00 $313.00 $291.00 $308.00 $313.00

72133-26 $65.00 $72.00 $74.00 $76.00 $72.00 $74.00 $76.00

72133-TC $323.00 $219.00 $234.00 $237.00 $219.00 $234.00 $237.00

72141 $503.00 $243.00 $257.00 $262.00 $243.00 $257.00 $262.00

72141-26 $82.00 $84.00 $87.00 $90.00 $84.00 $87.00 $90.00

72141-TC $419.00 $159.00 $170.00 $172.00 $159.00 $170.00 $172.00

72142 $604.00 $351.00 $372.00 $379.00 $351.00 $372.00 $379.00

72142-26 $99.00 $101.00 $104.00 $108.00 $101.00 $104.00 $108.00

72142-TC $502.00 $251.00 $268.00 $271.00 $251.00 $268.00 $271.00

72146 $549.00 $244.00 $258.00 $263.00 $244.00 $258.00 $263.00

72146-26 $82.00 $84.00 $87.00 $90.00 $84.00 $87.00 $90.00

72146-TC $465.00 $160.00 $171.00 $173.00 $160.00 $171.00 $173.00

72147 $603.00 $349.00 $370.00 $376.00 $349.00 $370.00 $376.00

72147-26 $98.00 $101.00 $104.00 $108.00 $101.00 $104.00 $108.00

72147-TC $502.00 $248.00 $265.00 $269.00 $248.00 $265.00 $269.00

72148 $543.00 $243.00 $256.00 $261.00 $243.00 $256.00 $261.00

72148-26 $76.00 $84.00 $87.00 $90.00 $84.00 $87.00 $90.00



Radiology


(Non-Facility MRA)






72148-TC $465.00 $158.00 $169.00 $171.00 $158.00 $169.00 $171.00

72149 $597.00 $348.00 $368.00 $375.00 $348.00 $368.00 $375.00

72149-26 $92.00 $101.00 $105.00 $109.00 $101.00 $105.00 $109.00

72149-TC $502.00 $246.00 $263.00 $267.00 $246.00 $263.00 $267.00

72156 $1,066.00 $411.00 $435.00 $443.00 $411.00 $435.00 $443.00

72156-26 $131.00 $129.00 $134.00 $138.00 $129.00 $134.00 $138.00

72156-TC $931.00 $282.00 $301.00 $305.00 $282.00 $301.00 $305.00

72157 $1,066.00 $412.00 $436.00 $444.00 $412.00 $436.00 $444.00

72157-26 $131.00 $129.00 $134.00 $138.00 $129.00 $134.00 $138.00

72157-TC $931.00 $283.00 $302.00 $306.00 $283.00 $302.00 $306.00

72158 $1,056.00 $410.00 $433.00 $441.00 $410.00 $433.00 $441.00

72158-26 $121.00 $130.00 $134.00 $138.00 $130.00 $134.00 $138.00

72158-TC $931.00 $280.00 $299.00 $303.00 $280.00 $299.00 $303.00

72159 $563.00 $448.00 $476.00 $483.00 $448.00 $476.00 $483.00

72159-26 $94.00 $102.00 $105.00 $109.00 $102.00 $105.00 $109.00

72159-TC $465.00 $346.00 $370.00 $374.00 $346.00 $370.00 $374.00

72170 $29.00 $35.00 $37.00 $38.00 $35.00 $37.00 $38.00

72170-26 $8.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.00

72170-TC $19.00 $25.00 $26.00 $27.00 $25.00 $26.00 $27.00

72190 $35.00 $41.00 $44.00 $44.00 $41.00 $44.00 $44.00

72190-26 $10.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.00

72190-TC $24.00 $29.00 $31.00 $32.00 $29.00 $31.00 $32.00

72191 $413.00 $331.00 $351.00 $357.00 $331.00 $351.00 $357.00

72191-26 $94.00 $102.00 $106.00 $109.00 $102.00 $106.00 $109.00

72191-TC $315.00 $229.00 $245.00 $248.00 $229.00 $245.00 $248.00

72192 $278.00 $159.00 $168.00 $171.00 $159.00 $168.00 $171.00

72192-26 $56.00 $62.00 $64.00 $66.00 $62.00 $64.00 $66.00

72192-TC $220.00 $97.00 $104.00 $105.00 $97.00 $104.00 $105.00

72193 $317.00 $244.00 $259.00 $263.00 $244.00 $259.00 $263.00

72193-26 $59.00 $66.00 $68.00 $70.00 $66.00 $68.00 $70.00

72193-TC $256.00 $178.00 $191.00 $193.00 $178.00 $191.00 $193.00

72194 $380.00 $280.00 $297.00 $302.00 $280.00 $297.00 $302.00

72194-26 $62.00 $69.00 $71.00 $73.00 $69.00 $71.00 $73.00

72194-TC $317.00 $211.00 $226.00 $229.00 $211.00 $226.00 $229.00

72195 $491.00 $320.00 $339.00 $345.00 $320.00 $339.00 $345.00

72195-26 $74.00 $83.00 $85.00 $88.00 $83.00 $85.00 $88.00

72195-TC $415.00 $238.00 $254.00 $257.00 $238.00 $254.00 $257.00

72196 $526.00 $442.00 $469.00 $477.00 $442.00 $469.00 $477.00

72196-26 $84.00 $98.00 $101.00 $105.00 $98.00 $101.00 $105.00

72196-TC $442.00 $344.00 $368.00 $372.00 $344.00 $368.00 $372.00

72197 $1,037.00 $545.00 $578.00 $587.00 $545.00 $578.00 $587.00

72197-26 $114.00 $128.00 $132.00 $136.00 $128.00 $132.00 $136.00

72197-TC $919.00 $417.00 $446.00 $451.00 $417.00 $446.00 $451.00

72198 $517.00 $433.00 $459.00 $466.00 $433.00 $459.00 $466.00

72198-26 $95.00 $101.00 $104.00 $107.00 $101.00 $104.00 $107.00

72198-TC $419.00 $332.00 $354.00 $359.00 $332.00 $354.00 $359.00

72200 $29.00 $31.00 $33.00 $34.00 $31.00 $33.00 $34.00

72200-26 $9.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.00

72200-TC $19.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.00

72202 $33.00 $36.00 $38.00 $39.00 $36.00 $38.00 $39.00



Radiology


(Non-Facility MRA)






72202-26 $9.00 $11.00 $11.00 $11.00 $11.00 $11.00 $11.00

72202-TC $22.00 $25.00 $27.00 $27.00 $25.00 $27.00 $27.00

72220 $30.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.00

72220-26 $8.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.00

72220-TC $21.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.00

72240 $132.00 $107.00 $113.00 $116.00 $107.00 $113.00 $116.00

72240-26 NC $51.00 $53.00 $54.00 $51.00 $53.00 $54.00

72240-TC NC $56.00 $60.00 $61.00 $56.00 $60.00 $61.00

72255 $129.00 $108.00 $114.00 $117.00 $108.00 $114.00 $117.00

72255-26 NC $53.00 $55.00 $57.00 $53.00 $55.00 $57.00

72255-TC NC $55.00 $59.00 $60.00 $55.00 $59.00 $60.00

72265 $132.00 $101.00 $106.00 $109.00 $101.00 $106.00 $109.00

72265-26 NC $47.00 $48.00 $50.00 $47.00 $48.00 $50.00

72265-TC NC $54.00 $58.00 $59.00 $54.00 $58.00 $59.00

72270 $176.00 $140.00 $147.00 $150.00 $140.00 $147.00 $150.00

72270-26 NC $76.00 $78.00 $81.00 $76.00 $78.00 $81.00

72270-TC NC $64.00 $68.00 $69.00 $64.00 $68.00 $69.00

72275 $112.00 $125.00 $132.00 $135.00 $125.00 $132.00 $135.00

72275-26 NC $44.00 $45.00 $47.00 $44.00 $45.00 $47.00

72275-TC NC $81.00 $87.00 $88.00 $81.00 $87.00 $88.00

72285 $101.00 $124.00 $130.00 $133.00 $124.00 $130.00 $133.00

72285-26 NC $68.00 $70.00 $73.00 $68.00 $70.00 $73.00

72285-TC NC $56.00 $60.00 $60.00 $56.00 $60.00 $60.00

72295 $107.00 $107.00 $113.00 $115.00 $107.00 $113.00 $115.00

72295-26 NC $49.00 $51.00 $53.00 $49.00 $51.00 $53.00

72295-TC NC $58.00 $62.00 $63.00 $58.00 $62.00 $63.00

73000 $28.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.00

73000-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.00

73000-TC $19.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.00

73010 $29.00 $33.00 $35.00 $36.00 $33.00 $35.00 $36.00

73010-26 $8.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.00

73010-TC $19.00 $22.00 $24.00 $25.00 $22.00 $24.00 $25.00

73020 $26.00 $25.00 $27.00 $27.00 $25.00 $27.00 $27.00

73020-26 $7.00 $9.00 $9.00 $10.00 $9.00 $9.00 $10.00

73020-TC $17.00 $16.00 $17.00 $18.00 $16.00 $17.00 $18.00

73030 $31.00 $32.00 $33.00 $34.00 $32.00 $33.00 $34.00

73030-26 $9.00 $11.00 $11.00 $11.00 $11.00 $11.00 $11.00

73030-TC $21.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.00

73040 $68.00 $108.00 $114.00 $116.00 $108.00 $114.00 $116.00

73040-26 NC $31.00 $32.00 $33.00 $31.00 $32.00 $33.00

73040-TC NC $77.00 $83.00 $84.00 $77.00 $83.00 $84.00

73050 $35.00 $38.00 $41.00 $42.00 $38.00 $41.00 $42.00

73050-26 $10.00 $12.00 $12.00 $13.00 $12.00 $12.00 $13.00

73050-TC $24.00 $27.00 $29.00 $29.00 $27.00 $29.00 $29.00

73060 $30.00 $32.00 $33.00 $34.00 $32.00 $33.00 $34.00

73060-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.00

73060-TC $21.00 $22.00 $24.00 $24.00 $22.00 $24.00 $24.00

73070 $27.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.00

73070-26 $7.00 $9.00 $9.00 $10.00 $9.00 $9.00 $10.00

73070-TC $19.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.00



Radiology


(Non-Facility MRA)






73080 $30.00 $34.00 $36.00 $37.00 $34.00 $36.00 $37.00

73080-26 $8.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.00

73080-TC $21.00 $24.00 $26.00 $26.00 $24.00 $26.00 $26.00

73085 $74.00 $104.00 $110.00 $112.00 $104.00 $110.00 $112.00

73085-26 NC $32.00 $34.00 $35.00 $32.00 $34.00 $35.00

73085-TC NC $71.00 $76.00 $77.00 $71.00 $76.00 $77.00

73090 $28.00 $28.00 $30.00 $31.00 $28.00 $30.00 $31.00

73090-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.00

73090-TC $19.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.00

73100 $27.00 $32.00 $33.00 $34.00 $32.00 $33.00 $34.00

73100-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.00

73100-TC $18.00 $22.00 $24.00 $24.00 $22.00 $24.00 $24.00

73110 $29.00 $38.00 $41.00 $42.00 $38.00 $41.00 $42.00

73110-26 $8.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.00

73110-TC $19.00 $28.00 $31.00 $31.00 $28.00 $31.00 $31.00

73115 $54.00 $115.00 $122.00 $124.00 $115.00 $122.00 $124.00

73115-26 NC $32.00 $33.00 $35.00 $32.00 $33.00 $35.00

73115-TC NC $83.00 $89.00 $90.00 $83.00 $89.00 $90.00

73120 $27.00 $29.00 $30.00 $31.00 $29.00 $30.00 $31.00

73120-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.00

73120-TC $18.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.00

73130 $29.00 $33.00 $36.00 $36.00 $33.00 $36.00 $36.00

73130-26 $8.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.00

73130-TC $19.00 $24.00 $25.00 $26.00 $24.00 $25.00 $26.00

73140 $22.00 $34.00 $36.00 $37.00 $34.00 $36.00 $37.00

73140-26 $7.00 $8.00 $8.00 $9.00 $8.00 $8.00 $9.00

73140-TC $15.00 $26.00 $28.00 $29.00 $26.00 $28.00 $29.00

73200 $242.00 $175.00 $185.00 $189.00 $175.00 $185.00 $189.00

73200-26 $56.00 $57.00 $59.00 $61.00 $57.00 $59.00 $61.00

73200-TC $185.00 $119.00 $127.00 $128.00 $119.00 $127.00 $128.00

73201 $282.00 $240.00 $254.00 $259.00 $240.00 $254.00 $259.00

73201-26 $59.00 $66.00 $68.00 $70.00 $66.00 $68.00 $70.00

73201-TC $220.00 $175.00 $187.00 $189.00 $175.00 $187.00 $189.00

73202 $342.00 $298.00 $317.00 $322.00 $298.00 $317.00 $322.00

73202-26 $63.00 $69.00 $71.00 $73.00 $69.00 $71.00 $73.00

73202-TC $277.00 $230.00 $245.00 $248.00 $230.00 $245.00 $248.00

73206 $375.00 $355.00 $376.00 $382.00 $355.00 $376.00 $382.00

73206-26 $94.00 $101.00 $105.00 $108.00 $101.00 $105.00 $108.00

73206-TC $277.00 $254.00 $271.00 $274.00 $254.00 $271.00 $274.00

73218 $482.00 $315.00 $334.00 $340.00 $315.00 $334.00 $340.00

73218-26 $68.00 $77.00 $79.00 $82.00 $77.00 $79.00 $82.00

73218-TC $413.00 $238.00 $255.00 $258.00 $238.00 $255.00 $258.00

73219 $579.00 $432.00 $459.00 $466.00 $432.00 $459.00 $466.00

73219-26 $82.00 $92.00 $95.00 $98.00 $92.00 $95.00 $98.00

73219-TC $495.00 $341.00 $364.00 $368.00 $341.00 $364.00 $368.00

73220 $520.00 $538.00 $571.00 $580.00 $538.00 $571.00 $580.00

73220-26 $78.00 $121.00 $125.00 $129.00 $121.00 $125.00 $129.00

73220-TC $442.00 $417.00 $446.00 $451.00 $417.00 $446.00 $451.00

73221 $482.00 $257.00 $272.00 $277.00 $257.00 $272.00 $277.00

73221-26 $68.00 $77.00 $80.00 $82.00 $77.00 $80.00 $82.00



Radiology


(Non-Facility MRA)






73221-TC $413.00 $180.00 $192.00 $195.00 $180.00 $192.00 $195.00

73222 $579.00 $407.00 $432.00 $439.00 $407.00 $432.00 $439.00

73222-26 $82.00 $92.00 $95.00 $98.00 $92.00 $95.00 $98.00

73222-TC $495.00 $315.00 $337.00 $341.00 $315.00 $337.00 $341.00

73223 $1,029.00 $507.00 $537.00 $546.00 $507.00 $537.00 $546.00

73223-26 $109.00 $122.00 $126.00 $130.00 $122.00 $126.00 $130.00

73223-TC $916.00 $385.00 $411.00 $416.00 $385.00 $411.00 $416.00

73225 $513.00 $440.00 $467.00 $475.00 $440.00 $467.00 $475.00

73225-26 $92.00 $97.00 $100.00 $104.00 $97.00 $100.00 $104.00

73225-TC $419.00 $343.00 $367.00 $371.00 $343.00 $367.00 $371.00

73501 ---------- $32.00 $34.00 $35.00 $32.00 $34.00 $35.00

73501-26 ---------- $11.00 $11.00 $11.00 $11.00 $11.00 $11.00

73501-TC ---------- $22.00 $23.00 $24.00 $22.00 $23.00 $24.00

73502 ---------- $45.00 $48.00 $49.00 $45.00 $48.00 $49.00

73502-26 ---------- $13.00 $13.00 $13.00 $13.00 $13.00 $13.00

73502-TC ---------- $32.00 $35.00 $35.00 $32.00 $35.00 $35.00

73503 ---------- $56.00 $59.00 $61.00 $56.00 $59.00 $61.00

73503-26 ---------- $16.00 $17.00 $18.00 $16.00 $17.00 $18.00

73503-TC ---------- $40.00 $43.00 $43.00 $40.00 $43.00 $43.00

73521 ---------- $43.00 $46.00 $46.00 $43.00 $46.00 $46.00

73521-26 ---------- $13.00 $13.00 $14.00 $13.00 $13.00 $14.00

73521-TC ---------- $30.00 $32.00 $33.00 $30.00 $32.00 $33.00

73522 ---------- $53.00 $56.00 $58.00 $53.00 $56.00 $58.00

73522-26 ---------- $17.00 $18.00 $18.00 $17.00 $18.00 $18.00

73522-TC ---------- $36.00 $39.00 $39.00 $36.00 $39.00 $39.00

73523 ---------- $61.00 $65.00 $67.00 $61.00 $65.00 $67.00

73523-26 ---------- $18.00 $19.00 $20.00 $18.00 $19.00 $20.00

73523-TC ---------- $43.00 $46.00 $47.00 $43.00 $46.00 $47.00

73525 $84.00 $110.00 $117.00 $119.00 $110.00 $117.00 $119.00

73525-26 NC $32.00 $34.00 $35.00 $32.00 $34.00 $35.00

73525-TC NC $78.00 $83.00 $84.00 $78.00 $83.00 $84.00

73551 ---------- $30.00 $32.00 $33.00 $30.00 $32.00 $33.00

73551-26 ---------- $9.00 $10.00 $10.00 $9.00 $10.00 $10.00

73551-TC ---------- $21.00 $22.00 $23.00 $21.00 $22.00 $23.00

73552 ---------- $35.00 $38.00 $38.00 $35.00 $38.00 $38.00

73552-26 ---------- $11.00 $11.00 $11.00 $11.00 $11.00 $11.00

73552-TC ---------- $25.00 $26.00 $27.00 $25.00 $26.00 $27.00

73560 $29.00 $33.00 $36.00 $36.00 $33.00 $36.00 $36.00

73560-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.00

73560-TC $19.00 $24.00 $26.00 $26.00 $24.00 $26.00 $26.00

73562 $31.00 $39.00 $41.00 $42.00 $39.00 $41.00 $42.00

73562-26 $9.00 $11.00 $11.00 $11.00 $11.00 $11.00 $11.00

73562-TC $21.00 $28.00 $30.00 $31.00 $28.00 $30.00 $31.00

73564 $35.00 $43.00 $46.00 $46.00 $43.00 $46.00 $46.00

73564-26 $11.00 $13.00 $13.00 $13.00 $13.00 $13.00 $13.00

73564-TC $22.00 $30.00 $33.00 $33.00 $30.00 $33.00 $33.00

73565 $28.00 $39.00 $41.00 $42.00 $39.00 $41.00 $42.00

73565-26 $8.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.00

73565-TC $18.00 $29.00 $31.00 $32.00 $29.00 $31.00 $32.00

73580 $84.00 $123.00 $130.00 $133.00 $123.00 $130.00 $133.00



Radiology


(Non-Facility MRA)






73580-26 NC $32.00 $33.00 $34.00 $32.00 $33.00 $34.00

73580-TC NC $91.00 $97.00 $99.00 $91.00 $97.00 $99.00

73590 $29.00 $31.00 $33.00 $34.00 $31.00 $33.00 $34.00

73590-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.00

73590-TC $19.00 $22.00 $23.00 $24.00 $22.00 $23.00 $24.00

73600 $27.00 $32.00 $34.00 $35.00 $32.00 $34.00 $35.00

73600-26 $8.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.00

73600-TC $18.00 $23.00 $24.00 $25.00 $23.00 $24.00 $25.00

73610 $29.00 $34.00 $36.00 $37.00 $34.00 $36.00 $37.00

73610-26 $8.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.00

73610-TC $19.00 $24.00 $26.00 $27.00 $24.00 $26.00 $27.00

73615 $72.00 $114.00 $120.00 $123.00 $114.00 $120.00 $123.00

73615-26 NC $32.00 $33.00 $34.00 $32.00 $33.00 $34.00

73615-TC NC $82.00 $87.00 $89.00 $82.00 $87.00 $89.00

73620 $27.00 $28.00 $30.00 $31.00 $28.00 $30.00 $31.00

73620-26 $8.00 $9.00 $9.00 $9.00 $9.00 $9.00 $9.00

73620-TC $18.00 $19.00 $21.00 $21.00 $19.00 $21.00 $21.00

73630 $29.00 $32.00 $33.00 $34.00 $32.00 $33.00 $34.00

73630-26 $8.00 $10.00 $10.00 $10.00 $10.00 $10.00 $10.00

73630-TC $19.00 $22.00 $24.00 $24.00 $22.00 $24.00 $24.00

73650 $26.00 $29.00 $31.00 $32.00 $29.00 $31.00 $32.00

73650-26 $8.00 $9.00 $9.00 $10.00 $9.00 $9.00 $10.00

73650-TC $17.00 $20.00 $22.00 $22.00 $20.00 $22.00 $22.00

73660 $22.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.00

73660-26 $7.00 $8.00 $8.00 $8.00 $8.00 $8.00 $8.00

73660-TC $15.00 $23.00 $24.00 $25.00 $23.00 $24.00 $25.00

73700 $242.00 $175.00 $185.00 $189.00 $175.00 $185.00 $189.00

73700-26 $56.00 $57.00 $59.00 $61.00 $57.00 $59.00 $61.00

73700-TC $185.00 $119.00 $127.00 $128.00 $119.00 $127.00 $128.00

73701 $282.00 $244.00 $259.00 $263.00 $244.00 $259.00 $263.00

73701-26 $61.00 $66.00 $68.00 $70.00 $66.00 $68.00 $70.00

73701-TC $220.00 $178.00 $191.00 $193.00 $178.00 $191.00 $193.00

73702 $341.00 $295.00 $313.00 $318.00 $295.00 $313.00 $318.00

73702-26 $62.00 $69.00 $71.00 $73.00 $69.00 $71.00 $73.00

73702-TC $277.00 $226.00 $242.00 $244.00 $226.00 $242.00 $244.00

73706 $379.00 $384.00 $407.00 $415.00 $384.00 $407.00 $415.00

73706-26 $98.00 $107.00 $110.00 $114.00 $107.00 $110.00 $114.00

73706-TC $277.00 $277.00 $297.00 $301.00 $277.00 $297.00 $301.00

73718 $482.00 $314.00 $334.00 $339.00 $314.00 $334.00 $339.00

73718-26 $68.00 $76.00 $79.00 $82.00 $76.00 $79.00 $82.00

73718-TC $413.00 $238.00 $255.00 $258.00 $238.00 $255.00 $258.00

73719 $579.00 $371.00 $393.00 $399.00 $371.00 $393.00 $399.00

73719-26 $82.00 $92.00 $95.00 $98.00 $92.00 $95.00 $98.00

73719-TC $495.00 $279.00 $298.00 $302.00 $279.00 $298.00 $302.00

73720 $520.00 $541.00 $574.00 $583.00 $541.00 $574.00 $583.00

73720-26 $78.00 $121.00 $125.00 $129.00 $121.00 $125.00 $129.00

73720-TC $442.00 $420.00 $448.00 $453.00 $420.00 $448.00 $453.00

73721 $482.00 $256.00 $271.00 $277.00 $256.00 $271.00 $277.00

73721-26 $68.00 $77.00 $79.00 $82.00 $77.00 $79.00 $82.00

73721-TC $413.00 $180.00 $192.00 $195.00 $180.00 $192.00 $195.00



Radiology


(Non-Facility MRA)






73722 $579.00 $411.00 $436.00 $442.00 $411.00 $436.00 $442.00

73722-26 $82.00 $92.00 $95.00 $98.00 $92.00 $95.00 $98.00

73722-TC $495.00 $319.00 $341.00 $345.00 $319.00 $341.00 $345.00

73723 $1,029.00 $507.00 $538.00 $546.00 $507.00 $538.00 $546.00

73723-26 $109.00 $121.00 $125.00 $129.00 $121.00 $125.00 $129.00

73723-TC $916.00 $386.00 $412.00 $417.00 $386.00 $412.00 $417.00

73725 $515.00 $433.00 $459.00 $466.00 $433.00 $459.00 $466.00

73725-26 $92.00 $102.00 $105.00 $108.00 $102.00 $105.00 $108.00

73725-TC $419.00 $331.00 $354.00 $358.00 $331.00 $354.00 $358.00

74000 $29.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.00

74000-26 $9.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.00

74000-TC $19.00 $16.00 $17.00 $17.00 $16.00 $17.00 $17.00

74010 $33.00 $38.00 $40.00 $41.00 $38.00 $40.00 $41.00

74010-26 $11.00 $13.00 $13.00 $14.00 $13.00 $13.00 $14.00

74010-TC $21.00 $25.00 $27.00 $27.00 $25.00 $27.00 $27.00

74020 $37.00 $41.00 $43.00 $45.00 $41.00 $43.00 $45.00

74020-26 $13.00 $15.00 $16.00 $17.00 $15.00 $16.00 $17.00

74020-TC $22.00 $25.00 $27.00 $28.00 $25.00 $27.00 $28.00

74022 $44.00 $49.00 $51.00 $53.00 $49.00 $51.00 $53.00

74022-26 $16.00 $18.00 $19.00 $20.00 $18.00 $19.00 $20.00

74022-TC $28.00 $30.00 $33.00 $33.00 $30.00 $33.00 $33.00

74150 $274.00 $163.00 $172.00 $175.00 $163.00 $172.00 $175.00

74150-26 $60.00 $67.00 $70.00 $72.00 $67.00 $70.00 $72.00

74150-TC $211.00 $96.00 $102.00 $104.00 $96.00 $102.00 $104.00

74160 $322.00 $249.00 $264.00 $269.00 $249.00 $264.00 $269.00

74160-26 $65.00 $72.00 $74.00 $77.00 $72.00 $74.00 $77.00

74160-TC $256.00 $178.00 $190.00 $192.00 $178.00 $190.00 $192.00

74170 $390.00 $283.00 $300.00 $305.00 $283.00 $300.00 $305.00

74170-26 $71.00 $79.00 $82.00 $84.00 $79.00 $82.00 $84.00

74170-TC $317.00 $204.00 $218.00 $221.00 $204.00 $218.00 $221.00

74174 ---------- $403.00 $426.00 $434.00 $403.00 $426.00 $434.00

74174-26 ---------- $124.00 $128.00 $132.00 $124.00 $128.00 $132.00

74174-TC ---------- $279.00 $298.00 $302.00 $279.00 $298.00 $302.00

74175 $418.00 $332.00 $351.00 $358.00 $332.00 $351.00 $358.00

74175-26 $98.00 $102.00 $105.00 $109.00 $102.00 $105.00 $109.00

74175-TC $315.00 $230.00 $246.00 $249.00 $230.00 $246.00 $249.00

74176 ---------- $219.00 $231.00 $236.00 $219.00 $231.00 $236.00

74176-26 ---------- $99.00 $102.00 $105.00 $99.00 $102.00 $105.00

74176-TC ---------- $121.00 $129.00 $130.00 $121.00 $129.00 $130.00

74177 ---------- $337.00 $356.00 $362.00 $337.00 $356.00 $362.00

74177-26 ---------- $103.00 $106.00 $110.00 $103.00 $106.00 $110.00

74177-TC ---------- $234.00 $250.00 $253.00 $234.00 $250.00 $253.00

74178 ---------- $382.00 $404.00 $411.00 $382.00 $404.00 $411.00

74178-26 ---------- $113.00 $117.00 $121.00 $113.00 $117.00 $121.00

74178-TC ---------- $269.00 $287.00 $291.00 $269.00 $287.00 $291.00

74181 $498.00 $320.00 $339.00 $345.00 $320.00 $339.00 $345.00

74181-26 $85.00 $82.00 $85.00 $88.00 $82.00 $85.00 $88.00

74181-TC $415.00 $238.00 $254.00 $257.00 $238.00 $254.00 $257.00

74182 $587.00 $489.00 $519.00 $527.00 $489.00 $519.00 $527.00

74182-26 $88.00 $98.00 $101.00 $105.00 $98.00 $101.00 $105.00



Radiology


(Non-Facility MRA)






74182-TC $496.00 $391.00 $418.00 $422.00 $391.00 $418.00 $422.00

74183 $1,037.00 $546.00 $579.00 $588.00 $546.00 $579.00 $588.00

74183-26 $114.00 $128.00 $132.00 $136.00 $128.00 $132.00 $136.00

74183-TC $919.00 $418.00 $447.00 $452.00 $418.00 $447.00 $452.00

74185 $514.00 $434.00 $461.00 $468.00 $434.00 $461.00 $468.00

74185-26 $92.00 $101.00 $104.00 $107.00 $101.00 $104.00 $107.00

74185-TC $419.00 $334.00 $356.00 $361.00 $334.00 $356.00 $361.00

74190 $73.00 $499.00 $532.00 $539.00 $499.00 $532.00 $539.00

74190-26 NC $27.00 $27.00 $28.00 $27.00 $27.00 $28.00

74190-TC NC $473.00 $505.00 $510.00 $473.00 $505.00 $510.00

74210 $63.00 $84.00 $89.00 $90.00 $84.00 $89.00 $90.00

74210-26 $18.00 $21.00 $21.00 $22.00 $21.00 $21.00 $22.00

74210-TC $44.00 $63.00 $68.00 $69.00 $63.00 $68.00 $69.00

74220 $68.00 $95.00 $101.00 $103.00 $95.00 $101.00 $103.00

74220-26 $23.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.00

74220-TC $44.00 $69.00 $74.00 $75.00 $69.00 $74.00 $75.00

74230 $77.00 $138.00 $146.00 $149.00 $138.00 $146.00 $149.00

74230-26 $27.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.00

74230-TC $48.00 $108.00 $115.00 $117.00 $108.00 $115.00 $117.00

74235 $160.00 ---------- ---------- ---------- ---------- ---------- ----------

74235-26 NC $69.00 $72.00 $74.00 $69.00 $72.00 $74.00


74240 $91.00 $122.00 $129.00 $132.00 $122.00 $129.00 $132.00

74240-26 $35.00 $39.00 $40.00 $42.00 $39.00 $40.00 $42.00

74240-TC $55.00 $83.00 $89.00 $90.00 $83.00 $89.00 $90.00

74241 $91.00 $127.00 $135.00 $137.00 $127.00 $135.00 $137.00

74241-26 $35.00 $39.00 $40.00 $42.00 $39.00 $40.00 $42.00

74241-TC $56.00 $88.00 $94.00 $95.00 $88.00 $94.00 $95.00

74245 $137.00 $185.00 $196.00 $199.00 $185.00 $196.00 $199.00

74245-26 $46.00 $51.00 $53.00 $55.00 $51.00 $53.00 $55.00

74245-TC $89.00 $133.00 $143.00 $144.00 $133.00 $143.00 $144.00

74246 $97.00 $137.00 $145.00 $148.00 $137.00 $145.00 $148.00

74246-26 $35.00 $39.00 $40.00 $42.00 $39.00 $40.00 $42.00

74246-TC $61.00 $98.00 $105.00 $106.00 $98.00 $105.00 $106.00

74247 $99.00 $153.00 $162.00 $165.00 $153.00 $162.00 $165.00

74247-26 $35.00 $39.00 $40.00 $42.00 $39.00 $40.00 $42.00

74247-TC $63.00 $113.00 $121.00 $123.00 $113.00 $121.00 $123.00

74249 $144.00 $198.00 $210.00 $213.00 $198.00 $210.00 $213.00

74249-26 $46.00 $51.00 $53.00 $55.00 $51.00 $53.00 $55.00

74249-TC $96.00 $147.00 $157.00 $159.00 $147.00 $157.00 $159.00

74250 $73.00 $112.00 $119.00 $121.00 $112.00 $119.00 $121.00

74250-26 $23.00 $27.00 $28.00 $29.00 $27.00 $28.00 $29.00

74250-TC $48.00 $85.00 $91.00 $92.00 $85.00 $91.00 $92.00

74251 $85.00 $158.00 $168.00 $171.00 $158.00 $168.00 $171.00

74251-26 $34.00 $39.00 $40.00 $42.00 $39.00 $40.00 $42.00

74251-TC $48.00 $119.00 $127.00 $129.00 $119.00 $127.00 $129.00

74260 $82.00 $148.00 $157.00 $159.00 $148.00 $157.00 $159.00

74260-26 $25.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.00

74260-TC $56.00 $119.00 $127.00 $129.00 $119.00 $127.00 $129.00

74261 ---------- $255.00 $268.00 $274.00 $255.00 $268.00 $274.00



Radiology


(Non-Facility MRA)






74261-26 ---------- $136.00 $141.00 $145.00 $136.00 $141.00 $145.00

74261-TC ---------- $119.00 $127.00 $128.00 $119.00 $127.00 $128.00

74262 ---------- $420.00 $444.00 $452.00 $420.00 $444.00 $452.00

74262-26 ---------- $142.00 $146.00 $151.00 $142.00 $146.00 $151.00

74262-TC ---------- $279.00 $298.00 $301.00 $279.00 $298.00 $301.00

74263 ---------- $808.00 $858.00 $868.00 $808.00 $858.00 $868.00

74263-26 ---------- $127.00 $130.00 $133.00 $127.00 $130.00 $133.00

74263-TC ---------- $681.00 $728.00 $735.00 $681.00 $728.00 $735.00

74270 $100.00 $158.00 $167.00 $170.00 $158.00 $167.00 $170.00

74270-26 $35.00 $39.00 $40.00 $42.00 $39.00 $40.00 $42.00

74270-TC $64.00 $119.00 $127.00 $128.00 $119.00 $127.00 $128.00

74280 $136.00 $175.00 $185.00 $189.00 $175.00 $185.00 $189.00

74280-26 $50.00 $56.00 $58.00 $60.00 $56.00 $58.00 $60.00

74280-TC $84.00 $119.00 $127.00 $128.00 $119.00 $127.00 $128.00

74283 $201.00 $228.00 $240.00 $245.00 $228.00 $240.00 $245.00

74283-26 $103.00 $116.00 $120.00 $124.00 $116.00 $120.00 $124.00

74283-TC $95.00 $112.00 $120.00 $121.00 $112.00 $120.00 $121.00

74290 $44.00 $76.00 $80.00 $82.00 $76.00 $80.00 $82.00

74290-26 $16.00 $18.00 $19.00 $20.00 $18.00 $19.00 $20.00

74290-TC $28.00 $58.00 $62.00 $62.00 $58.00 $62.00 $62.00

74300 $31.00 ---------- ---------- ---------- ---------- ---------- ----------

74300-26 NC $21.00 $22.00 $22.00 $21.00 $22.00 $22.00


74301 BR ---------- ---------- ---------- ---------- ---------- ----------

74301-26 NC $12.00 $12.00 $13.00 $12.00 $12.00 $13.00


74328 $155.00 ---------- ---------- ---------- ---------- ---------- ----------

74328-26 NC $40.00 $42.00 $43.00 $40.00 $42.00 $43.00


74329 $155.00 ---------- ---------- ---------- ---------- ---------- ----------

74329-26 NC $40.00 $42.00 $43.00 $40.00 $42.00 $43.00


74330 $165.00 ---------- ---------- ---------- ---------- ---------- ----------

74330-26 NC $51.00 $53.00 $55.00 $51.00 $53.00 $55.00


74340 $121.00 ---------- ---------- ---------- ---------- ---------- ----------

74340-26 NC $30.00 $31.00 $32.00 $30.00 $31.00 $32.00


74355 $137.00 ---------- ---------- ---------- ---------- ---------- ----------

74355-26 NC $43.00 $44.00 $46.00 $43.00 $44.00 $46.00


74360 $145.00 ---------- ---------- ---------- ---------- ---------- ----------

74360-26 NC $32.00 $33.00 $35.00 $32.00 $33.00 $35.00


74363 $274.00 ---------- ---------- ---------- ---------- ---------- ----------

74363-26 NC $48.00 $50.00 $52.00 $48.00 $50.00 $52.00


74400 $89.00 $119.00 $126.00 $128.00 $119.00 $126.00 $128.00

74400-26 $24.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.00

74400-TC $63.00 $91.00 $97.00 $99.00 $91.00 $97.00 $99.00



Radiology


(Non-Facility MRA)






74410 $98.00 $117.00 $124.00 $127.00 $117.00 $124.00 $127.00

74410-26 $24.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.00

74410-TC $72.00 $90.00 $96.00 $97.00 $90.00 $96.00 $97.00

74415 $105.00 $147.00 $156.00 $158.00 $147.00 $156.00 $158.00

74415-26 $24.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.00

74415-TC $79.00 $119.00 $127.00 $129.00 $119.00 $127.00 $129.00

74420 $117.00 $492.00 $525.00 $531.00 $492.00 $525.00 $531.00

74420-26 $18.00 $20.00 $20.00 $21.00 $20.00 $20.00 $21.00

74420-TC $97.00 $473.00 $505.00 $510.00 $473.00 $505.00 $510.00

74425 $68.00 $492.00 $525.00 $531.00 $492.00 $525.00 $531.00

74425-26 NC $20.00 $20.00 $21.00 $20.00 $20.00 $21.00

74425-TC NC $473.00 $505.00 $510.00 $473.00 $505.00 $510.00

74430 $48.00 $41.00 $44.00 $45.00 $41.00 $44.00 $45.00

74430-26 NC $18.00 $19.00 $20.00 $18.00 $19.00 $20.00

74430-TC NC $23.00 $25.00 $25.00 $23.00 $25.00 $25.00

74440 $62.00 $88.00 $93.00 $95.00 $88.00 $93.00 $95.00

74440-26 NC $21.00 $22.00 $22.00 $21.00 $22.00 $22.00

74440-TC NC $67.00 $71.00 $72.00 $67.00 $71.00 $72.00

74445 $101.00 $179.00 $189.00 $192.00 $179.00 $189.00 $192.00

74445-26 NC $61.00 $62.00 $64.00 $61.00 $62.00 $64.00

74445-TC NC $119.00 $127.00 $128.00 $119.00 $127.00 $128.00

74450 $60.00 $256.00 $273.00 $277.00 $256.00 $273.00 $277.00

74450-26 NC $19.00 $19.00 $20.00 $19.00 $19.00 $20.00

74450-TC NC $238.00 $254.00 $257.00 $238.00 $254.00 $257.00

74455 $75.00 $88.00 $94.00 $95.00 $88.00 $94.00 $95.00

74455-26 NC $19.00 $19.00 $20.00 $19.00 $19.00 $20.00

74455-TC NC $70.00 $74.00 $75.00 $70.00 $74.00 $75.00

74470 $74.00 $267.00 $284.00 $288.00 $267.00 $284.00 $288.00

74470-26 NC $30.00 $31.00 $32.00 $30.00 $31.00 $32.00

74470-TC NC $238.00 $254.00 $257.00 $238.00 $254.00 $257.00

74485 $146.00 $99.00 $105.00 $107.00 $99.00 $105.00 $107.00

74485-26 NC $29.00 $30.00 $31.00 $29.00 $30.00 $31.00

74485-TC NC $70.00 $75.00 $76.00 $70.00 $75.00 $76.00

74710 $57.00 $40.00 $43.00 $44.00 $40.00 $43.00 $44.00

74710-26 $17.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.00

74710-TC $39.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.00

74712 ---------- $289.00 $302.00 $309.00 $289.00 $302.00 $309.00

74712-26 ---------- $170.00 $175.00 $181.00 $170.00 $175.00 $181.00

74712-TC ---------- $119.00 $127.00 $128.00 $119.00 $127.00 $128.00

74713 ---------- $253.00 $267.00 $272.00 $253.00 $267.00 $272.00

74713-26 ---------- $105.00 $108.00 $112.00 $105.00 $108.00 $112.00

74713-TC ---------- $148.00 $159.00 $161.00 $148.00 $159.00 $161.00

74740 $68.00 $81.00 $86.00 $87.00 $81.00 $86.00 $87.00

74740-26 NC $21.00 $22.00 $23.00 $21.00 $22.00 $23.00

74740-TC NC $59.00 $64.00 $64.00 $59.00 $64.00 $64.00

74742 $150.00 ---------- ---------- ---------- ---------- ---------- ----------

74742-26 NC $34.00 $35.00 $36.00 $34.00 $35.00 $36.00


74775 $88.00 $273.00 $290.00 $294.00 $273.00 $290.00 $294.00

74775-26 $32.00 $35.00 $37.00 $38.00 $35.00 $37.00 $38.00



Radiology


(Non-Facility MRA)






74775-TC $55.00 $238.00 $254.00 $257.00 $238.00 $254.00 $257.00

75557 ---------- $347.00 $366.00 $372.00 $347.00 $366.00 $372.00

75557-26 ---------- $130.00 $134.00 $138.00 $130.00 $134.00 $138.00

75557-TC ---------- $217.00 $232.00 $234.00 $217.00 $232.00 $234.00

75559 ---------- $398.00 $419.00 $425.00 $398.00 $419.00 $425.00

75559-26 ---------- $160.00 $165.00 $169.00 $160.00 $165.00 $169.00

75559-TC ---------- $238.00 $254.00 $257.00 $238.00 $254.00 $257.00

75561 ---------- $460.00 $486.00 $494.00 $460.00 $486.00 $494.00

75561-26 ---------- $144.00 $148.00 $152.00 $144.00 $148.00 $152.00

75561-TC ---------- $315.00 $337.00 $341.00 $315.00 $337.00 $341.00

75563 ---------- $547.00 $578.00 $587.00 $547.00 $578.00 $587.00

75563-26 ---------- $165.00 $169.00 $174.00 $165.00 $169.00 $174.00

75563-TC ---------- $382.00 $408.00 $413.00 $382.00 $408.00 $413.00

75565 ---------- $59.00 $63.00 $63.00 $59.00 $63.00 $63.00

75565-26 ---------- $14.00 $14.00 $15.00 $14.00 $14.00 $15.00

75565-TC ---------- $45.00 $48.00 $49.00 $45.00 $48.00 $49.00

75571 ---------- $96.00 $101.00 $103.00 $96.00 $101.00 $103.00

75571-26 ---------- $32.00 $33.00 $34.00 $32.00 $33.00 $34.00

75571-TC ---------- $63.00 $68.00 $69.00 $63.00 $68.00 $69.00

75572 ---------- $307.00 $325.00 $330.00 $307.00 $325.00 $330.00

75572-26 ---------- $98.00 $101.00 $104.00 $98.00 $101.00 $104.00

75572-TC ---------- $209.00 $224.00 $227.00 $209.00 $224.00 $227.00

75573 ---------- $421.00 $445.00 $453.00 $421.00 $445.00 $453.00

75573-26 ---------- $142.00 $147.00 $151.00 $142.00 $147.00 $151.00

75573-TC ---------- $279.00 $298.00 $302.00 $279.00 $298.00 $302.00

75574 ---------- $413.00 $436.00 $444.00 $413.00 $436.00 $444.00

75574-26 ---------- $134.00 $138.00 $142.00 $134.00 $138.00 $142.00

75574-TC ---------- $279.00 $299.00 $303.00 $279.00 $299.00 $303.00

75600 $497.00 $212.00 $226.00 $230.00 $212.00 $226.00 $230.00

75600-26 NC $28.00 $29.00 $30.00 $28.00 $29.00 $30.00

75600-TC NC $185.00 $197.00 $200.00 $185.00 $197.00 $200.00

75605 $183.00 $151.00 $159.00 $164.00 $151.00 $159.00 $164.00

75605-26 NC $63.00 $66.00 $69.00 $63.00 $66.00 $69.00

75605-TC NC $87.00 $93.00 $95.00 $87.00 $93.00 $95.00

75625 $143.00 $151.00 $160.00 $165.00 $151.00 $160.00 $165.00

75625-26 NC $64.00 $67.00 $71.00 $64.00 $67.00 $71.00

75625-TC NC $87.00 $93.00 $94.00 $87.00 $93.00 $94.00

75630 $239.00 $187.00 $198.00 $204.00 $187.00 $198.00 $204.00

75630-26 NC $100.00 $104.00 $110.00 $100.00 $104.00 $110.00

75630-TC NC $87.00 $93.00 $95.00 $87.00 $93.00 $95.00

75635 $445.00 $414.00 $437.00 $446.00 $414.00 $437.00 $446.00

75635-26 NC $135.00 $139.00 $144.00 $135.00 $139.00 $144.00

75635-TC NC $279.00 $298.00 $302.00 $279.00 $298.00 $302.00

75658 $540.00 $184.00 $196.00 $202.00 $184.00 $196.00 $202.00

75658-26 NC $74.00 $77.00 $82.00 $74.00 $77.00 $82.00

75658-TC NC $111.00 $119.00 $120.00 $111.00 $119.00 $120.00

75705 $587.00 $273.00 $290.00 $301.00 $273.00 $290.00 $301.00

75705-26 NC $132.00 $139.00 $149.00 $132.00 $139.00 $149.00

75705-TC NC $141.00 $151.00 $153.00 $141.00 $151.00 $153.00

75710 $194.00 $177.00 $188.00 $194.00 $177.00 $188.00 $194.00



Radiology


(Non-Facility MRA)






75710-26 NC $64.00 $67.00 $71.00 $64.00 $67.00 $71.00

75710-TC NC $113.00 $121.00 $122.00 $113.00 $121.00 $122.00

75716 $293.00 $204.00 $216.00 $222.00 $204.00 $216.00 $222.00

75716-26 NC $73.00 $76.00 $80.00 $73.00 $76.00 $80.00

75716-TC NC $131.00 $140.00 $142.00 $131.00 $140.00 $142.00

75726 $530.00 $163.00 $172.00 $176.00 $163.00 $172.00 $176.00

75726-26 NC $63.00 $65.00 $68.00 $63.00 $65.00 $68.00

75726-TC NC $100.00 $107.00 $108.00 $100.00 $107.00 $108.00

75731 $530.00 $186.00 $197.00 $201.00 $186.00 $197.00 $201.00

75731-26 NC $65.00 $67.00 $69.00 $65.00 $67.00 $69.00

75731-TC NC $122.00 $130.00 $132.00 $122.00 $130.00 $132.00

75733 $540.00 $202.00 $213.00 $217.00 $202.00 $213.00 $217.00

75733-26 NC $71.00 $74.00 $76.00 $71.00 $74.00 $76.00

75733-TC NC $130.00 $140.00 $142.00 $130.00 $140.00 $142.00

75736 $530.00 $174.00 $185.00 $190.00 $174.00 $185.00 $190.00

75736-26 NC $63.00 $65.00 $68.00 $63.00 $65.00 $68.00

75736-TC NC $112.00 $119.00 $121.00 $112.00 $119.00 $121.00

75741 $540.00 $164.00 $173.00 $177.00 $164.00 $173.00 $177.00

75741-26 NC $72.00 $74.00 $77.00 $72.00 $74.00 $77.00

75741-TC NC $93.00 $99.00 $100.00 $93.00 $99.00 $100.00

75743 $253.00 $185.00 $194.00 $199.00 $185.00 $194.00 $199.00

75743-26 NC $91.00 $94.00 $98.00 $91.00 $94.00 $98.00

75743-TC NC $94.00 $100.00 $102.00 $94.00 $100.00 $102.00

75746 $530.00 $167.00 $176.00 $180.00 $167.00 $176.00 $180.00

75746-26 NC $63.00 $66.00 $68.00 $63.00 $66.00 $68.00

75746-TC NC $103.00 $110.00 $112.00 $103.00 $110.00 $112.00

75756 $183.00 $186.00 $197.00 $204.00 $186.00 $197.00 $204.00

75756-26 NC $65.00 $69.00 $73.00 $65.00 $69.00 $73.00

75756-TC NC $120.00 $129.00 $131.00 $120.00 $129.00 $131.00

75774 $80.00 $93.00 $99.00 $101.00 $93.00 $99.00 $101.00

75774-26 NC $20.00 $21.00 $22.00 $20.00 $21.00 $22.00

75774-TC NC $73.00 $78.00 $80.00 $73.00 $78.00 $80.00

75801 $245.00 $771.00 $824.00 $837.00 $771.00 $824.00 $837.00

75801-26 NC $52.00 $55.00 $61.00 $52.00 $55.00 $61.00

75801-TC NC $719.00 $768.00 $776.00 $719.00 $768.00 $776.00

75803 $264.00 $788.00 $839.00 $850.00 $788.00 $839.00 $850.00

75803-26 NC $69.00 $71.00 $74.00 $69.00 $71.00 $74.00

75803-TC NC $719.00 $768.00 $776.00 $719.00 $768.00 $776.00

75805 $271.00 $765.00 $816.00 $825.00 $765.00 $816.00 $825.00

75805-26 NC $46.00 $48.00 $49.00 $46.00 $48.00 $49.00

75805-TC NC $719.00 $768.00 $776.00 $719.00 $768.00 $776.00

75807 $289.00 $2,548.00 $2,719.00 $2,748.00 $2,548.00 $2,719.00 $2,748.00

75807-26 NC $66.00 $69.00 $71.00 $66.00 $69.00 $71.00

75807-TC NC $2,482.00 $2,650.00 $2,677.00 $2,482.00 $2,650.00 $2,677.00

75809 $54.00 $107.00 $113.00 $115.00 $107.00 $113.00 $115.00

75809-26 NC $27.00 $28.00 $29.00 $27.00 $28.00 $29.00

75809-TC NC $80.00 $85.00 $86.00 $80.00 $85.00 $86.00

75810 $530.00 $784.00 $835.00 $845.00 $784.00 $835.00 $845.00

75810-26 NC $65.00 $67.00 $69.00 $65.00 $67.00 $69.00

75810-TC NC $719.00 $768.00 $776.00 $719.00 $768.00 $776.00



Radiology


(Non-Facility MRA)






75820 $72.00 $125.00 $133.00 $136.00 $125.00 $133.00 $136.00

75820-26 NC $39.00 $41.00 $43.00 $39.00 $41.00 $43.00

75820-TC NC $86.00 $92.00 $93.00 $86.00 $92.00 $93.00

75822 $111.00 $149.00 $158.00 $162.00 $149.00 $158.00 $162.00

75822-26 NC $59.00 $62.00 $65.00 $59.00 $62.00 $65.00

75822-TC NC $90.00 $96.00 $97.00 $90.00 $96.00 $97.00

75825 $194.00 $149.00 $157.00 $163.00 $149.00 $157.00 $163.00

75825-26 NC $64.00 $67.00 $71.00 $64.00 $67.00 $71.00

75825-TC NC $84.00 $90.00 $91.00 $84.00 $90.00 $91.00

75827 $530.00 $152.00 $161.00 $167.00 $152.00 $161.00 $167.00

75827-26 NC $64.00 $68.00 $72.00 $64.00 $68.00 $72.00

75827-TC NC $87.00 $93.00 $95.00 $87.00 $93.00 $95.00

75831 $54.00 $153.00 $162.00 $166.00 $153.00 $162.00 $166.00

75831-26 NC $63.00 $65.00 $68.00 $63.00 $65.00 $68.00

75831-TC NC $90.00 $97.00 $98.00 $90.00 $97.00 $98.00

75833 $549.00 $181.00 $192.00 $200.00 $181.00 $192.00 $200.00

75833-26 NC $83.00 $87.00 $93.00 $83.00 $87.00 $93.00

75833-TC NC $98.00 $105.00 $107.00 $98.00 $105.00 $107.00

75840 $531.00 $162.00 $171.00 $175.00 $162.00 $171.00 $175.00

75840-26 NC $65.00 $67.00 $69.00 $65.00 $67.00 $69.00

75840-TC NC $98.00 $104.00 $106.00 $98.00 $104.00 $106.00

75842 $549.00 $196.00 $207.00 $212.00 $196.00 $207.00 $212.00

75842-26 NC $83.00 $86.00 $89.00 $83.00 $86.00 $89.00

75842-TC NC $113.00 $121.00 $123.00 $113.00 $121.00 $123.00

75860 $531.00 $157.00 $166.00 $170.00 $157.00 $166.00 $170.00

75860-26 NC $63.00 $66.00 $69.00 $63.00 $66.00 $69.00

75860-TC NC $93.00 $100.00 $101.00 $93.00 $100.00 $101.00

75870 $531.00 $162.00 $171.00 $175.00 $162.00 $171.00 $175.00

75870-26 NC $65.00 $67.00 $69.00 $65.00 $67.00 $69.00

75870-TC NC $98.00 $104.00 $106.00 $98.00 $104.00 $106.00

75872 $530.00 $169.00 $179.00 $183.00 $169.00 $179.00 $183.00

75872-26 NC $64.00 $67.00 $69.00 $64.00 $67.00 $69.00

75872-TC NC $105.00 $112.00 $113.00 $105.00 $112.00 $113.00

75880 $72.00 $158.00 $168.00 $170.00 $158.00 $168.00 $170.00

75880-26 NC $40.00 $41.00 $42.00 $40.00 $41.00 $42.00

75880-TC NC $118.00 $126.00 $128.00 $118.00 $126.00 $128.00

75885 $546.00 $171.00 $180.00 $183.00 $171.00 $180.00 $183.00

75885-26 NC $77.00 $79.00 $82.00 $77.00 $79.00 $82.00

75885-TC NC $94.00 $100.00 $102.00 $94.00 $100.00 $102.00

75887 $546.00 $173.00 $182.00 $185.00 $173.00 $182.00 $185.00

75887-26 NC $78.00 $80.00 $83.00 $78.00 $80.00 $83.00

75887-TC NC $95.00 $101.00 $103.00 $95.00 $101.00 $103.00

75889 $530.00 $156.00 $165.00 $169.00 $156.00 $165.00 $169.00

75889-26 NC $62.00 $64.00 $66.00 $62.00 $64.00 $66.00

75889-TC NC $95.00 $101.00 $102.00 $95.00 $101.00 $102.00

75891 $530.00 $158.00 $167.00 $171.00 $158.00 $167.00 $171.00

75891-26 NC $63.00 $65.00 $67.00 $63.00 $65.00 $67.00

75891-TC NC $95.00 $102.00 $103.00 $95.00 $102.00 $103.00

75893 $499.00 $128.00 $136.00 $138.00 $128.00 $136.00 $138.00

75893-26 NC $30.00 $31.00 $32.00 $30.00 $31.00 $32.00



Radiology


(Non-Facility MRA)






75893-TC NC $98.00 $105.00 $106.00 $98.00 $105.00 $106.00

75894 $972.00 ---------- ---------- ---------- ---------- ---------- ----------

75894-26 NC $78.00 $82.00 $87.00 $78.00 $82.00 $87.00


75898 $124.00 $818.00 $872.00 $887.00 $818.00 $872.00 $887.00

75898-26 $84.00 $99.00 $104.00 $111.00 $99.00 $104.00 $111.00

75898-TC $39.00 $719.00 $768.00 $776.00 $719.00 $768.00 $776.00

75901 $98.00 $190.00 $202.00 $205.00 $190.00 $202.00 $205.00

75901-26 NC $27.00 $27.00 $28.00 $27.00 $27.00 $28.00

75901-TC NC $164.00 $175.00 $177.00 $164.00 $175.00 $177.00

75902 $93.00 $78.00 $83.00 $85.00 $78.00 $83.00 $85.00

75902-26 NC $22.00 $22.00 $23.00 $22.00 $22.00 $23.00

75902-TC NC $57.00 $61.00 $62.00 $57.00 $61.00 $62.00

75952 BR ---------- ---------- ---------- ---------- ---------- ----------

75952-26 NC $259.00 $275.00 $299.00 $259.00 $275.00 $299.00


75953 BR ---------- ---------- ---------- ---------- ---------- ----------

75953-26 NC $79.00 $84.00 $91.00 $79.00 $84.00 $91.00


75954 BR ---------- ---------- ---------- ---------- ---------- ----------

75954-26 NC $132.00 $141.00 $154.00 $132.00 $141.00 $154.00


75956 ---------- BR BR BR BR BR BR

75956-26 ---------- $405.00 $430.00 $469.00 $405.00 $430.00 $469.00

75956-TC ---------- BR BR BR BR BR BR

75957 ---------- BR BR BR BR BR BR

75957-26 ---------- $348.00 $369.00 $403.00 $348.00 $369.00 $403.00

75957-TC ---------- BR BR BR BR BR BR

75958 ---------- BR BR BR BR BR BR

75958-26 ---------- $232.00 $246.00 $268.00 $232.00 $246.00 $268.00

75958-TC ---------- BR BR BR BR BR BR

75959 ---------- BR BR BR BR BR BR

75959-26 ---------- $199.00 $212.00 $233.00 $199.00 $212.00 $233.00

75959-TC ---------- BR BR BR BR BR BR

75970 $475.00 ---------- ---------- ---------- ---------- ---------- ----------

75970-26 NC $45.00 $47.00 $48.00 $45.00 $47.00 $48.00


75984 $110.00 $115.00 $121.00 $124.00 $115.00 $121.00 $124.00

75984-26 NC $39.00 $40.00 $42.00 $39.00 $40.00 $42.00

75984-TC NC $76.00 $81.00 $82.00 $76.00 $81.00 $82.00

75989 $180.00 $132.00 $139.00 $142.00 $132.00 $139.00 $142.00

75989-26 NC $66.00 $68.00 $70.00 $66.00 $68.00 $70.00

75989-TC NC $67.00 $71.00 $72.00 $67.00 $71.00 $72.00

76000 $58.00 $51.00 $55.00 $56.00 $51.00 $55.00 $56.00

76000-26 $8.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.00

76000-TC $48.00 $41.00 $44.00 $45.00 $41.00 $44.00 $45.00

76001 $134.00 ---------- ---------- ---------- ---------- ---------- ----------

76001-26 $34.00 $42.00 $44.00 $47.00 $42.00 $44.00 $47.00

76001-TC $97.00 ---------- ---------- ---------- ---------- ---------- ----------

76080 $67.00 $60.00 $64.00 $65.00 $60.00 $64.00 $65.00



Radiology


(Non-Facility MRA)






76080-26 NC $30.00 $31.00 $32.00 $30.00 $31.00 $32.00

76080-TC NC $31.00 $33.00 $34.00 $31.00 $33.00 $34.00

76098 $23.00 $18.00 $19.00 $20.00 $18.00 $19.00 $20.00

76098-26 $8.00 $9.00 $9.00 $10.00 $9.00 $9.00 $10.00

76098-TC $15.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.00

76100 $77.00 $100.00 $106.00 $108.00 $100.00 $106.00 $108.00

76100-26 $30.00 $36.00 $37.00 $39.00 $36.00 $37.00 $39.00

76100-TC $46.00 $64.00 $68.00 $69.00 $64.00 $68.00 $69.00

76101 $94.00 $143.00 $152.00 $156.00 $143.00 $152.00 $156.00

76101-26 $36.00 $40.00 $42.00 $45.00 $40.00 $42.00 $45.00

76101-TC $59.00 $103.00 $110.00 $111.00 $103.00 $110.00 $111.00

76102 $95.00 $156.00 $166.00 $168.00 $156.00 $166.00 $168.00

76102-26 $30.00 $37.00 $38.00 $39.00 $37.00 $38.00 $39.00

76102-TC $65.00 $119.00 $127.00 $129.00 $119.00 $127.00 $129.00

76120 $157.00 $85.00 $90.00 $92.00 $85.00 $90.00 $92.00

76120-26 $56.00 $22.00 $22.00 $23.00 $22.00 $22.00 $23.00

76120-TC $102.00 $63.00 $68.00 $69.00 $63.00 $68.00 $69.00

76125 $49.00 ---------- ---------- ---------- ---------- ---------- ----------

76125-26 $17.00 $16.00 $17.00 $18.00 $16.00 $17.00 $18.00

76125-TC $33.00 ---------- ---------- ---------- ---------- ---------- ----------

76140 $31.00 ---------- ---------- ---------- ---------- ---------- ----------

76376 ---------- $26.00 $27.00 $28.00 $26.00 $27.00 $28.00

76376-26 ---------- $11.00 $11.00 $12.00 $11.00 $11.00 $12.00

76376-TC ---------- $14.00 $16.00 $16.00 $14.00 $16.00 $16.00

76377 ---------- $79.00 $83.00 $85.00 $79.00 $83.00 $85.00

76377-26 ---------- $45.00 $47.00 $48.00 $45.00 $47.00 $48.00

76377-TC ---------- $33.00 $36.00 $36.00 $33.00 $36.00 $36.00

76380 $182.00 $119.00 $125.00 $128.00 $119.00 $125.00 $128.00

76380-26 $50.00 $55.00 $57.00 $59.00 $55.00 $57.00 $59.00

76380-TC $131.00 $63.00 $68.00 $69.00 $63.00 $68.00 $69.00

76390 $493.00 $476.00 $506.00 $512.00 $476.00 $506.00 $512.00

76390-26 $71.00 $78.00 $80.00 $81.00 $78.00 $80.00 $81.00

76390-TC $419.00 $399.00 $426.00 $430.00 $399.00 $426.00 $430.00

76496 BR ---------- ---------- ---------- ---------- ---------- ----------

76496-26 BR ---------- ---------- ---------- ---------- ---------- ----------

76496-TC BR $63.00 $68.00 $69.00 $63.00 $68.00 $69.00

76497 BR ---------- ---------- ---------- ---------- ---------- ----------

76497-26 BR ---------- ---------- ---------- ---------- ---------- ----------

76497-TC BR $63.00 $68.00 $69.00 $63.00 $68.00 $69.00

76498 BR ---------- ---------- ---------- ---------- ---------- ----------

76498-26 BR ---------- ---------- ---------- ---------- ---------- ----------

76498-TC BR $63.00 $68.00 $69.00 $63.00 $68.00 $69.00

76499 BR ---------- ---------- ---------- ---------- ---------- ----------

76499-26 BR ---------- ---------- ---------- ---------- ---------- ----------

76499-TC BR ---------- ---------- ---------- ---------- ---------- ----------

76506 $88.00 $129.00 $137.00 $140.00 $129.00 $137.00 $140.00

76506-26 $33.00 $37.00 $38.00 $40.00 $37.00 $38.00 $40.00

76506-TC $53.00 $92.00 $99.00 $100.00 $92.00 $99.00 $100.00

76510 ---------- $184.00 $193.00 $195.00 $184.00 $193.00 $195.00

76510-26 ---------- $98.00 $101.00 $102.00 $98.00 $101.00 $102.00



Radiology


(Non-Facility MRA)






76510-TC ---------- $86.00 $92.00 $93.00 $86.00 $92.00 $93.00

76511 $96.00 $111.00 $116.00 $117.00 $111.00 $116.00 $117.00

76511-26 $48.00 $59.00 $60.00 $61.00 $59.00 $60.00 $61.00

76511-TC $48.00 $52.00 $56.00 $56.00 $52.00 $56.00 $56.00

76512 $96.00 $101.00 $105.00 $107.00 $101.00 $105.00 $107.00

76512-26 $36.00 $58.00 $60.00 $60.00 $58.00 $60.00 $60.00

76512-TC $60.00 $42.00 $45.00 $46.00 $42.00 $45.00 $46.00

76513 $96.00 $103.00 $108.00 $110.00 $103.00 $108.00 $110.00

76513-26 $36.00 $39.00 $40.00 $41.00 $39.00 $40.00 $41.00

76513-TC $60.00 $64.00 $68.00 $69.00 $64.00 $68.00 $69.00

76514 ---------- $17.00 $18.00 $18.00 $17.00 $18.00 $18.00

76514-26 ---------- $11.00 $11.00 $12.00 $11.00 $11.00 $12.00

76514-TC ---------- $6.00 $6.00 $7.00 $6.00 $6.00 $7.00

76516 $99.00 $85.00 $90.00 $91.00 $85.00 $90.00 $91.00

76516-26 $37.00 $34.00 $35.00 $36.00 $34.00 $35.00 $36.00

76516-TC $63.00 $51.00 $54.00 $55.00 $51.00 $54.00 $55.00

76519 $88.00 $91.00 $96.00 $98.00 $91.00 $96.00 $98.00

76519-26 $31.00 $35.00 $36.00 $36.00 $35.00 $36.00 $36.00

76519-TC $53.00 $57.00 $61.00 $62.00 $57.00 $61.00 $62.00

76529 $86.00 $85.00 $90.00 $91.00 $85.00 $90.00 $91.00

76529-26 $31.00 $35.00 $36.00 $37.00 $35.00 $36.00 $37.00

76529-TC $53.00 $50.00 $53.00 $54.00 $50.00 $53.00 $54.00

76536 $83.00 $126.00 $134.00 $136.00 $126.00 $134.00 $136.00

76536-26 $31.00 $32.00 $33.00 $34.00 $32.00 $33.00 $34.00

76536-TC $54.00 $95.00 $101.00 $103.00 $95.00 $101.00 $103.00

76604 $78.00 $96.00 $102.00 $104.00 $96.00 $102.00 $104.00

76604-26 $28.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.00

76604-TC $48.00 $66.00 $70.00 $71.00 $66.00 $70.00 $71.00

76641 ---------- $117.00 $124.00 $126.00 $117.00 $124.00 $126.00

76641-26 ---------- $41.00 $42.00 $44.00 $41.00 $42.00 $44.00

76641-TC ---------- $76.00 $81.00 $82.00 $76.00 $81.00 $82.00

76642 ---------- $97.00 $102.00 $104.00 $97.00 $102.00 $104.00

76642-26 ---------- $38.00 $40.00 $41.00 $38.00 $40.00 $41.00

76642-TC ---------- $58.00 $62.00 $63.00 $58.00 $62.00 $63.00

76700 $116.00 $133.00 $141.00 $144.00 $133.00 $141.00 $144.00

76700-26 $42.00 $45.00 $47.00 $48.00 $45.00 $47.00 $48.00

76700-TC $73.00 $88.00 $94.00 $95.00 $88.00 $94.00 $95.00

76705 $84.00 $100.00 $105.00 $107.00 $100.00 $105.00 $107.00

76705-26 $30.00 $33.00 $34.00 $35.00 $33.00 $34.00 $35.00

76705-TC $53.00 $67.00 $71.00 $72.00 $67.00 $71.00 $72.00

76706 ---------- $102.00 $108.00 $110.00 $102.00 $108.00 $110.00

76706-26 ---------- $31.00 $32.00 $33.00 $31.00 $32.00 $33.00

76706-TC ---------- $71.00 $76.00 $77.00 $71.00 $76.00 $77.00

76770 $112.00 $124.00 $131.00 $133.00 $124.00 $131.00 $133.00

76770-26 $38.00 $42.00 $43.00 $44.00 $42.00 $43.00 $44.00

76770-TC $73.00 $82.00 $88.00 $89.00 $82.00 $88.00 $89.00

76775 $84.00 $64.00 $68.00 $69.00 $64.00 $68.00 $69.00

76775-26 $30.00 $32.00 $33.00 $34.00 $32.00 $33.00 $34.00

76775-TC $53.00 $32.00 $34.00 $35.00 $32.00 $34.00 $35.00

76776 ---------- $170.00 $181.00 $184.00 $170.00 $181.00 $184.00



Radiology


(Non-Facility MRA)






76776-26 ---------- $43.00 $44.00 $45.00 $43.00 $44.00 $45.00

76776-TC ---------- $128.00 $137.00 $138.00 $128.00 $137.00 $138.00

76800 $112.00 $132.00 $140.00 $146.00 $132.00 $140.00 $146.00

76800-26 $61.00 $69.00 $73.00 $78.00 $69.00 $73.00 $78.00

76800-TC $54.00 $63.00 $68.00 $69.00 $63.00 $68.00 $69.00

76801 $93.00 $136.00 $143.00 $146.00 $136.00 $143.00 $146.00

76801-26 $51.00 $57.00 $59.00 $61.00 $57.00 $59.00 $61.00

76801-TC $42.00 $79.00 $85.00 $86.00 $79.00 $85.00 $86.00

76802 $73.00 $72.00 $75.00 $77.00 $72.00 $75.00 $77.00

76802-26 $43.00 $48.00 $50.00 $52.00 $48.00 $50.00 $52.00

76802-TC $30.00 $24.00 $25.00 $26.00 $24.00 $25.00 $26.00

76805 $131.00 $156.00 $165.00 $169.00 $156.00 $165.00 $169.00

76805-26 $51.00 $57.00 $59.00 $62.00 $57.00 $59.00 $62.00

76805-TC $79.00 $99.00 $106.00 $107.00 $99.00 $106.00 $107.00

76810 $252.00 $103.00 $108.00 $111.00 $103.00 $108.00 $111.00

76810-26 $100.00 $57.00 $59.00 $61.00 $57.00 $59.00 $61.00

76810-TC $151.00 $46.00 $50.00 $50.00 $46.00 $50.00 $50.00

76811 $243.00 $204.00 $215.00 $222.00 $204.00 $215.00 $222.00

76811-26 $100.00 $112.00 $116.00 $122.00 $112.00 $116.00 $122.00

76811-TC $142.00 $92.00 $99.00 $100.00 $92.00 $99.00 $100.00

76812 $145.00 $227.00 $240.00 $247.00 $227.00 $240.00 $247.00

76812-26 $94.00 $106.00 $110.00 $115.00 $106.00 $110.00 $115.00

76812-TC $51.00 $122.00 $130.00 $132.00 $122.00 $130.00 $132.00

76813 ---------- $135.00 $143.00 $147.00 $135.00 $143.00 $147.00

76813-26 ---------- $70.00 $72.00 $76.00 $70.00 $72.00 $76.00

76813-TC ---------- $66.00 $70.00 $71.00 $66.00 $70.00 $71.00

76814 ---------- $91.00 $96.00 $99.00 $91.00 $96.00 $99.00

76814-26 ---------- $59.00 $61.00 $64.00 $59.00 $61.00 $64.00

76814-TC ---------- $32.00 $35.00 $35.00 $32.00 $35.00 $35.00

76815 $88.00 $93.00 $98.00 $101.00 $93.00 $98.00 $101.00

76815-26 $33.00 $37.00 $39.00 $40.00 $37.00 $39.00 $40.00

76815-TC $53.00 $56.00 $60.00 $61.00 $56.00 $60.00 $61.00

76816 $72.00 $128.00 $135.00 $138.00 $128.00 $135.00 $138.00

76816-26 $30.00 $50.00 $52.00 $54.00 $50.00 $52.00 $54.00

76816-TC $41.00 $78.00 $83.00 $84.00 $78.00 $83.00 $84.00

76817 $96.00 $107.00 $113.00 $116.00 $107.00 $113.00 $116.00

76817-26 $39.00 $43.00 $45.00 $46.00 $43.00 $45.00 $46.00

76817-TC $57.00 $64.00 $68.00 $69.00 $64.00 $68.00 $69.00

76818 $105.00 $137.00 $145.00 $149.00 $137.00 $145.00 $149.00

76818-26 $40.00 $62.00 $65.00 $68.00 $62.00 $65.00 $68.00

76818-TC $60.00 $75.00 $80.00 $81.00 $75.00 $80.00 $81.00

76819 $101.00 $100.00 $105.00 $108.00 $100.00 $105.00 $108.00

76819-26 $40.00 $45.00 $47.00 $49.00 $45.00 $47.00 $49.00

76819-TC $60.00 $55.00 $59.00 $60.00 $55.00 $59.00 $60.00

76820 ---------- $54.00 $57.00 $59.00 $54.00 $57.00 $59.00

76820-26 ---------- $29.00 $31.00 $32.00 $29.00 $31.00 $32.00

76820-TC ---------- $24.00 $26.00 $27.00 $24.00 $26.00 $27.00

76821 ---------- $103.00 $109.00 $112.00 $103.00 $109.00 $112.00

76821-26 ---------- $41.00 $43.00 $45.00 $41.00 $43.00 $45.00

76821-TC ---------- $61.00 $66.00 $67.00 $61.00 $66.00 $67.00



Radiology


(Non-Facility MRA)






76825 $160.00 $304.00 $322.00 $328.00 $304.00 $322.00 $328.00

76825-26 $65.00 $95.00 $98.00 $102.00 $95.00 $98.00 $102.00

76825-TC $73.00 $209.00 $223.00 $226.00 $209.00 $223.00 $226.00

76826 $71.00 $178.00 $189.00 $192.00 $178.00 $189.00 $192.00

76826-26 $46.00 $47.00 $48.00 $49.00 $47.00 $48.00 $49.00

76826-TC $27.00 $131.00 $141.00 $142.00 $131.00 $141.00 $142.00

76827 $97.00 $83.00 $88.00 $90.00 $83.00 $88.00 $90.00

76827-26 $35.00 $33.00 $34.00 $35.00 $33.00 $34.00 $35.00

76827-TC $65.00 $50.00 $54.00 $55.00 $50.00 $54.00 $55.00

76828 $72.00 $60.00 $63.00 $65.00 $60.00 $63.00 $65.00

76828-26 $29.00 $33.00 $34.00 $35.00 $33.00 $34.00 $35.00

76828-TC $42.00 $27.00 $29.00 $30.00 $27.00 $29.00 $30.00

76830 $93.00 $133.00 $141.00 $144.00 $133.00 $141.00 $144.00

76830-26 $35.00 $39.00 $40.00 $42.00 $39.00 $40.00 $42.00

76830-TC $57.00 $94.00 $101.00 $102.00 $94.00 $101.00 $102.00

76831 $95.00 $131.00 $139.00 $141.00 $131.00 $139.00 $141.00

76831-26 $37.00 $42.00 $43.00 $45.00 $42.00 $43.00 $45.00

76831-TC $57.00 $89.00 $95.00 $97.00 $89.00 $95.00 $97.00

76856 $93.00 $120.00 $127.00 $130.00 $120.00 $127.00 $130.00

76856-26 $35.00 $39.00 $40.00 $42.00 $39.00 $40.00 $42.00

76856-TC $57.00 $81.00 $87.00 $88.00 $81.00 $87.00 $88.00

76857 $59.00 $53.00 $56.00 $58.00 $53.00 $56.00 $58.00

76857-26 $19.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.00

76857-TC $39.00 $25.00 $27.00 $27.00 $25.00 $27.00 $27.00

76870 $90.00 $75.00 $79.00 $81.00 $75.00 $79.00 $81.00

76870-26 $33.00 $36.00 $38.00 $39.00 $36.00 $38.00 $39.00

76870-TC $57.00 $39.00 $41.00 $42.00 $39.00 $41.00 $42.00

76872 $93.00 $104.00 $109.00 $111.00 $104.00 $109.00 $111.00

76872-26 $36.00 $37.00 $38.00 $39.00 $37.00 $38.00 $39.00

76872-TC $57.00 $66.00 $71.00 $72.00 $66.00 $71.00 $72.00

76873 $151.00 $187.00 $197.00 $200.00 $187.00 $197.00 $200.00

76873-26 $68.00 $87.00 $90.00 $92.00 $87.00 $90.00 $92.00

76873-TC $80.00 $100.00 $107.00 $108.00 $100.00 $107.00 $108.00

76881 ---------- $129.00 $136.00 $138.00 $129.00 $136.00 $138.00

76881-26 ---------- $36.00 $37.00 $38.00 $36.00 $37.00 $38.00

76881-TC ---------- $93.00 $99.00 $101.00 $93.00 $99.00 $101.00

76882 ---------- $40.00 $42.00 $43.00 $40.00 $42.00 $43.00

76882-26 ---------- $28.00 $29.00 $30.00 $28.00 $29.00 $30.00

76882-TC ---------- $12.00 $13.00 $14.00 $12.00 $13.00 $14.00

76930 $93.00 ---------- ---------- ---------- ---------- ---------- ----------

76930-26 NC $37.00 $38.00 $39.00 $37.00 $38.00 $39.00


76932 $93.00 ---------- ---------- ---------- ---------- ---------- ----------

76932-26 NC $37.00 $38.00 $39.00 $37.00 $38.00 $39.00


76936 $341.00 $299.00 $318.00 $328.00 $299.00 $318.00 $328.00

76936-26 $102.00 $112.00 $118.00 $125.00 $112.00 $118.00 $125.00

76936-TC $236.00 $187.00 $200.00 $203.00 $187.00 $200.00 $203.00

76937 ---------- $34.00 $36.00 $37.00 $34.00 $36.00 $37.00

76937-26 ---------- $16.00 $17.00 $18.00 $16.00 $17.00 $18.00



Radiology


(Non-Facility MRA)






76937-TC ---------- $18.00 $19.00 $20.00 $18.00 $19.00 $20.00

76940 ---------- BR BR BR BR BR BR

76940-26 ---------- $119.00 $125.00 $132.00 $119.00 $125.00 $132.00

76940-TC ---------- BR BR BR BR BR BR

76941 $128.00 ---------- ---------- ---------- ---------- ---------- ----------

76941-26 NC $72.00 $74.00 $76.00 $72.00 $74.00 $76.00


76942 $92.00 $66.00 $70.00 $71.00 $66.00 $70.00 $71.00

76942-26 NC $36.00 $37.00 $38.00 $36.00 $37.00 $38.00

76942-TC NC $30.00 $32.00 $33.00 $30.00 $32.00 $33.00

76945 $93.00 ---------- ---------- ---------- ---------- ---------- ----------

76945-26 NC $40.00 $41.00 $43.00 $40.00 $41.00 $43.00


76946 $78.00 $36.00 $38.00 $40.00 $36.00 $38.00 $40.00

76946-26 NC $22.00 $23.00 $24.00 $22.00 $23.00 $24.00

76946-TC NC $14.00 $15.00 $16.00 $14.00 $15.00 $16.00

76948 $77.00 $79.00 $83.00 $85.00 $79.00 $83.00 $85.00

76948-26 NC $38.00 $39.00 $41.00 $38.00 $39.00 $41.00

76948-TC NC $41.00 $43.00 $44.00 $41.00 $43.00 $44.00

76965 $281.00 $101.00 $105.00 $107.00 $101.00 $105.00 $107.00

76965-26 $84.00 $75.00 $77.00 $79.00 $75.00 $77.00 $79.00

76965-TC $208.00 $26.00 $28.00 $28.00 $26.00 $28.00 $28.00

76970 $60.00 $85.00 $90.00 $92.00 $85.00 $90.00 $92.00

76970-26 $20.00 $22.00 $22.00 $23.00 $22.00 $22.00 $23.00

76970-TC $39.00 $63.00 $68.00 $69.00 $63.00 $68.00 $69.00

76975 $99.00 $285.00 $303.00 $308.00 $285.00 $303.00 $308.00

76975-26 NC $48.00 $49.00 $51.00 $48.00 $49.00 $51.00

76975-TC NC $238.00 $254.00 $257.00 $238.00 $254.00 $257.00

76977 $34.00 $8.00 $9.00 $10.00 $8.00 $9.00 $10.00

76977-26 $3.00 $3.00 $3.00 $4.00 $3.00 $3.00 $4.00

76977-TC $31.00 $5.00 $6.00 $6.00 $5.00 $6.00 $6.00

76998 ---------- BR BR BR BR BR BR

76998-26 ---------- $74.00 $78.00 $85.00 $74.00 $78.00 $85.00

76998-TC ---------- BR BR BR BR BR BR

76999 BR ---------- ---------- ---------- ---------- ---------- ----------

76999-26 BR ---------- ---------- ---------- ---------- ---------- ----------

76999-TC BR ---------- ---------- ---------- ---------- ---------- ----------

77001 ---------- $91.00 $97.00 $99.00 $91.00 $97.00 $99.00

77001-26 ---------- $21.00 $22.00 $23.00 $21.00 $22.00 $23.00

77001-TC ---------- $70.00 $74.00 $75.00 $70.00 $74.00 $75.00

77002 ---------- $101.00 $107.00 $109.00 $101.00 $107.00 $109.00

77002-26 ---------- $32.00 $33.00 $34.00 $32.00 $33.00 $34.00

77002-TC ---------- $69.00 $74.00 $75.00 $69.00 $74.00 $75.00

77003 ---------- $102.00 $108.00 $110.00 $102.00 $108.00 $110.00

77003-26 ---------- $34.00 $35.00 $36.00 $34.00 $35.00 $36.00

77003-TC ---------- $68.00 $73.00 $74.00 $68.00 $73.00 $74.00

77011 ---------- $242.00 $257.00 $261.00 $242.00 $257.00 $261.00

77011-26 ---------- $71.00 $73.00 $76.00 $71.00 $73.00 $76.00

77011-TC ---------- $171.00 $183.00 $185.00 $171.00 $183.00 $185.00

77012 ---------- $136.00 $143.00 $146.00 $136.00 $143.00 $146.00



Radiology


(Non-Facility MRA)






77012-26 ---------- $65.00 $67.00 $69.00 $65.00 $67.00 $69.00

77012-TC ---------- $71.00 $76.00 $77.00 $71.00 $76.00 $77.00

77013-26 ---------- $219.00 $227.00 $234.00 $219.00 $227.00 $234.00

77013-TC ---------- BR BR BR BR BR BR

77014 ---------- $129.00 $136.00 $138.00 $129.00 $136.00 $138.00

77014-26 ---------- $49.00 $51.00 $52.00 $49.00 $51.00 $52.00

77014-TC ---------- $79.00 $85.00 $86.00 $79.00 $85.00 $86.00

77021 ---------- $431.00 $457.00 $464.00 $431.00 $457.00 $464.00

77021-26 ---------- $84.00 $87.00 $90.00 $84.00 $87.00 $90.00

77021-TC ---------- $347.00 $370.00 $374.00 $347.00 $370.00 $374.00

77022 ---------- BR BR BR BR BR BR

77022-26 ---------- $240.00 $248.00 $256.00 $240.00 $248.00 $256.00

77022-TC ---------- BR BR BR BR BR BR

77053 ---------- $64.00 $67.00 $69.00 $64.00 $67.00 $69.00

77053-26 ---------- $21.00 $21.00 $22.00 $21.00 $21.00 $22.00

77053-TC ---------- $43.00 $46.00 $47.00 $43.00 $46.00 $47.00

77054 ---------- $84.00 $89.00 $91.00 $84.00 $89.00 $91.00

77054-26 ---------- $26.00 $27.00 $28.00 $26.00 $27.00 $28.00

77054-TC ---------- $58.00 $62.00 $63.00 $58.00 $62.00 $63.00

77058 ---------- $541.00 $575.00 $583.00 $541.00 $575.00 $583.00

77058-26 ---------- $92.00 $95.00 $98.00 $92.00 $95.00 $98.00

77058-TC ---------- $449.00 $480.00 $485.00 $449.00 $480.00 $485.00

77059 ---------- $541.00 $575.00 $583.00 $541.00 $575.00 $583.00

77059-26 ---------- $92.00 $95.00 $98.00 $92.00 $95.00 $98.00

77059-TC ---------- $449.00 $480.00 $485.00 $449.00 $480.00 $485.00

77063 ---------- $61.00 $64.00 $65.00 $61.00 $64.00 $65.00

77063-26 ---------- $34.00 $35.00 $36.00 $34.00 $35.00 $36.00

77063-TC ---------- $27.00 $29.00 $29.00 $27.00 $29.00 $29.00

77071 ---------- $53.00 $57.00 $59.00 $53.00 $57.00 $59.00

77072 ---------- $25.00 $27.00 $27.00 $25.00 $27.00 $27.00

77072-26 ---------- $11.00 $11.00 $11.00 $11.00 $11.00 $11.00

77072-TC ---------- $14.00 $16.00 $16.00 $14.00 $16.00 $16.00

77073 ---------- $39.00 $41.00 $43.00 $39.00 $41.00 $43.00

77073-26 ---------- $16.00 $17.00 $18.00 $16.00 $17.00 $18.00

77073-TC ---------- $23.00 $24.00 $25.00 $23.00 $24.00 $25.00

77074 ---------- $70.00 $74.00 $76.00 $70.00 $74.00 $76.00

77074-26 ---------- $26.00 $27.00 $28.00 $26.00 $27.00 $28.00

77074-TC ---------- $44.00 $47.00 $48.00 $44.00 $47.00 $48.00

77075 ---------- $94.00 $100.00 $102.00 $94.00 $100.00 $102.00

77075-26 ---------- $30.00 $31.00 $32.00 $30.00 $31.00 $32.00

77075-TC ---------- $64.00 $68.00 $69.00 $64.00 $68.00 $69.00

77077 ---------- $41.00 $43.00 $44.00 $41.00 $43.00 $44.00

77077-26 ---------- $18.00 $19.00 $20.00 $18.00 $19.00 $20.00

77077-TC ---------- $22.00 $24.00 $25.00 $22.00 $24.00 $25.00

77078 ---------- $77.00 $82.00 $83.00 $77.00 $82.00 $83.00

77078-26 ---------- $14.00 $14.00 $15.00 $14.00 $14.00 $15.00

77078-TC ---------- $63.00 $68.00 $69.00 $63.00 $68.00 $69.00

77080 ---------- $44.00 $47.00 $48.00 $44.00 $47.00 $48.00

77080-26 ---------- $11.00 $12.00 $12.00 $11.00 $12.00 $12.00

77080-TC ---------- $33.00 $35.00 $36.00 $33.00 $35.00 $36.00



Radiology


(Non-Facility MRA)






77081 ---------- $30.00 $32.00 $33.00 $30.00 $32.00 $33.00

77081-26 ---------- $12.00 $13.00 $13.00 $12.00 $13.00 $13.00

77081-TC ---------- $18.00 $20.00 $20.00 $18.00 $20.00 $20.00

77084 ---------- $420.00 $446.00 $453.00 $420.00 $446.00 $453.00

77084-26 ---------- $91.00 $94.00 $97.00 $91.00 $94.00 $97.00

77084-TC ---------- $329.00 $352.00 $356.00 $329.00 $352.00 $356.00

77085 ---------- $61.00 $64.00 $66.00 $61.00 $64.00 $66.00

77085-26 ---------- $17.00 $18.00 $19.00 $17.00 $18.00 $19.00

77085-TC ---------- $43.00 $46.00 $47.00 $43.00 $46.00 $47.00

77086 ---------- $38.00 $41.00 $42.00 $38.00 $41.00 $42.00

77086-26 ---------- $10.00 $10.00 $11.00 $10.00 $10.00 $11.00

77086-TC ---------- $28.00 $31.00 $31.00 $28.00 $31.00 $31.00

77261 $73.00 $85.00 $89.00 $92.00 $85.00 $89.00 $92.00

77262 $110.00 $127.00 $132.00 $136.00 $127.00 $132.00 $136.00

77263 $163.00 $187.00 $194.00 $201.00 $187.00 $194.00 $201.00

77280 $166.00 $295.00 $314.00 $318.00 $295.00 $314.00 $318.00

77280-26 $36.00 $41.00 $42.00 $43.00 $41.00 $42.00 $43.00

77280-TC $130.00 $255.00 $272.00 $275.00 $255.00 $272.00 $275.00

77285 $264.00 $470.00 $500.00 $506.00 $470.00 $500.00 $506.00

77285-26 $53.00 $61.00 $63.00 $64.00 $61.00 $63.00 $64.00

77285-TC $209.00 $409.00 $437.00 $441.00 $409.00 $437.00 $441.00

77290 $325.00 $556.00 $591.00 $599.00 $556.00 $591.00 $599.00

77290-26 $79.00 $91.00 $93.00 $96.00 $91.00 $93.00 $96.00

77290-TC $243.00 $466.00 $498.00 $503.00 $466.00 $498.00 $503.00

77293 ---------- $504.00 $535.00 $543.00 $504.00 $535.00 $543.00

77293-26 ---------- $116.00 $120.00 $123.00 $116.00 $120.00 $123.00

77293-TC ---------- $388.00 $415.00 $420.00 $388.00 $415.00 $420.00

77295 $1,287.00 $536.00 $564.00 $575.00 $536.00 $564.00 $575.00

77295-26 $232.00 $248.00 $255.00 $261.00 $248.00 $255.00 $261.00

77295-TC $1,046.00 $289.00 $309.00 $314.00 $289.00 $309.00 $314.00

77299 BR ---------- ---------- ---------- ---------- ---------- ----------

77299-26 BR ---------- ---------- ---------- ---------- ---------- ----------

77299-TC BR ---------- ---------- ---------- ---------- ---------- ----------

77300 $87.00 $73.00 $77.00 $79.00 $73.00 $77.00 $79.00

77300-26 $36.00 $36.00 $37.00 $38.00 $36.00 $37.00 $38.00

77300-TC $52.00 $37.00 $39.00 $40.00 $37.00 $39.00 $40.00

77301 $1,473.00 $2,115.00 $2,245.00 $2,281.00 $2,115.00 $2,245.00 $2,281.00

77301-26 $415.00 $462.00 $476.00 $488.00 $462.00 $476.00 $488.00

77301-TC $1,046.00 $1,653.00 $1,769.00 $1,793.00 $1,653.00 $1,769.00 $1,793.00

77306 ---------- $164.00 $172.00 $176.00 $164.00 $172.00 $176.00

77306-26 ---------- $81.00 $84.00 $86.00 $81.00 $84.00 $86.00

77306-TC ---------- $83.00 $88.00 $90.00 $83.00 $88.00 $90.00

77307 ---------- $317.00 $332.00 $339.00 $317.00 $332.00 $339.00

77307-26 ---------- $168.00 $173.00 $177.00 $168.00 $173.00 $177.00

77307-TC ---------- $149.00 $160.00 $162.00 $149.00 $160.00 $162.00

77316 ---------- $206.00 $217.00 $221.00 $206.00 $217.00 $221.00

77316-26 ---------- $81.00 $84.00 $86.00 $81.00 $84.00 $86.00

77316-TC ---------- $125.00 $133.00 $136.00 $125.00 $133.00 $136.00

77317 ---------- $268.00 $283.00 $289.00 $268.00 $283.00 $289.00

77317-26 ---------- $106.00 $109.00 $112.00 $106.00 $109.00 $112.00



Radiology


(Non-Facility MRA)






77317-TC ---------- $162.00 $174.00 $177.00 $162.00 $174.00 $177.00

77318 ---------- $388.00 $409.00 $417.00 $388.00 $409.00 $417.00

77318-26 ---------- $168.00 $173.00 $177.00 $168.00 $173.00 $177.00

77318-TC ---------- $220.00 $236.00 $240.00 $220.00 $236.00 $240.00

77321 $200.00 $102.00 $107.00 $109.00 $102.00 $107.00 $109.00

77321-26 $48.00 $55.00 $57.00 $58.00 $55.00 $57.00 $58.00

77321-TC $150.00 $47.00 $50.00 $51.00 $47.00 $50.00 $51.00

77331 $64.00 $71.00 $74.00 $76.00 $71.00 $74.00 $76.00

77331-26 $45.00 $50.00 $52.00 $53.00 $50.00 $52.00 $53.00

77331-TC $18.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.00

77332 $78.00 $73.00 $77.00 $79.00 $73.00 $77.00 $79.00

77332-26 $27.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.00

77332-TC $50.00 $47.00 $50.00 $51.00 $47.00 $50.00 $51.00

77333 $115.00 $105.00 $111.00 $113.00 $105.00 $111.00 $113.00

77333-26 $43.00 $43.00 $45.00 $46.00 $43.00 $45.00 $46.00

77333-TC $70.00 $62.00 $66.00 $67.00 $62.00 $66.00 $67.00

77334 $187.00 $143.00 $150.00 $153.00 $143.00 $150.00 $153.00

77334-26 $63.00 $67.00 $69.00 $70.00 $67.00 $69.00 $70.00

77334-TC $121.00 $76.00 $82.00 $83.00 $76.00 $82.00 $83.00

77336 $111.00 $86.00 $93.00 $96.00 $86.00 $93.00 $96.00

77338 ---------- $555.00 $584.00 $595.00 $555.00 $584.00 $595.00

77338-26 ---------- $248.00 $255.00 $261.00 $248.00 $255.00 $261.00

77338-TC ---------- $307.00 $329.00 $334.00 $307.00 $329.00 $334.00

77370 $130.00 $132.00 $143.00 $148.00 $132.00 $143.00 $148.00

77371 ---------- BR BR BR BR BR BR

77372 ---------- $1,152.00 $1,232.00 $1,249.00 $1,152.00 $1,232.00 $1,249.00

77373 ---------- $1,462.00 $1,564.00 $1,585.00 $1,462.00 $1,564.00 $1,585.00

77399 BR ---------- ---------- ---------- ---------- ---------- ----------

77399-26 BR ---------- ---------- ---------- ---------- ---------- ----------

77399-TC BR ---------- ---------- ---------- ---------- ---------- ----------

77401 $66.00 $27.00 $29.00 $29.00 $27.00 $29.00 $29.00

77402 $66.00 ---------- ---------- ---------- ---------- ---------- ----------

77407 $78.00 ---------- ---------- ---------- ---------- ---------- ----------

77412 $87.00 ---------- ---------- ---------- ---------- ---------- ----------

77417 $21.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.00

77422 ---------- BR BR BR BR BR BR

77423 ---------- BR BR BR BR BR BR

77427 $166.00 $208.00 $217.00 $225.00 $208.00 $217.00 $225.00

77431 $95.00 $115.00 $119.00 $124.00 $115.00 $119.00 $124.00

77432 $417.00 $470.00 $489.00 $508.00 $470.00 $489.00 $508.00

77435 ---------- $709.00 $736.00 $764.00 $709.00 $736.00 $764.00

77469 ---------- $360.00 $374.00 $387.00 $360.00 $374.00 $387.00

77470 $527.00 $159.00 $166.00 $170.00 $159.00 $166.00 $170.00

77470-26 $106.00 $118.00 $121.00 $125.00 $118.00 $121.00 $125.00

77470-TC $417.00 $42.00 $45.00 $45.00 $42.00 $45.00 $45.00

77499 BR ---------- ---------- ---------- ---------- ---------- ----------

77499-26 BR ---------- ---------- ---------- ---------- ---------- ----------

77499-TC BR ---------- ---------- ---------- ---------- ---------- ----------

77520 BR ---------- ---------- ---------- ---------- ---------- ----------

77522 BR ---------- ---------- ---------- ---------- ---------- ----------



Radiology


(Non-Facility MRA)






77523 BR ---------- ---------- ---------- ---------- ---------- ----------

77525 BR ---------- ---------- ---------- ---------- ---------- ----------

77600 $196.00 $447.00 $476.00 $483.00 $447.00 $476.00 $483.00

77600-26 $80.00 $78.00 $81.00 $83.00 $78.00 $81.00 $83.00

77600-TC $113.00 $369.00 $395.00 $400.00 $369.00 $395.00 $400.00

77605 $263.00 $842.00 $899.00 $918.00 $842.00 $899.00 $918.00

77605-26 $108.00 $117.00 $124.00 $134.00 $117.00 $124.00 $134.00

77605-TC $151.00 $725.00 $775.00 $784.00 $725.00 $775.00 $784.00

77610 $195.00 $925.00 $987.00 $1,003.00 $925.00 $987.00 $1,003.00

77610-26 $79.00 $79.00 $83.00 $88.00 $79.00 $83.00 $88.00

77610-TC $113.00 $847.00 $905.00 $915.00 $847.00 $905.00 $915.00

77615 $262.00 $1,102.00 $1,174.00 $1,190.00 $1,102.00 $1,174.00 $1,190.00

77615-26 $106.00 $106.00 $110.00 $112.00 $106.00 $110.00 $112.00

77615-TC $151.00 $996.00 $1,065.00 $1,078.00 $996.00 $1,065.00 $1,078.00

77620 $196.00 $503.00 $537.00 $552.00 $503.00 $537.00 $552.00

77620-26 $80.00 $100.00 $107.00 $117.00 $100.00 $107.00 $117.00

77620-TC $113.00 $403.00 $430.00 $436.00 $403.00 $430.00 $436.00

77750 $299.00 $411.00 $429.00 $438.00 $411.00 $429.00 $438.00

77750-26 $248.00 $289.00 $298.00 $305.00 $289.00 $298.00 $305.00

77750-TC $49.00 $122.00 $131.00 $133.00 $122.00 $131.00 $133.00

77761 $284.00 $429.00 $451.00 $461.00 $429.00 $451.00 $461.00

77761-26 $188.00 $221.00 $228.00 $235.00 $221.00 $228.00 $235.00

77761-TC $93.00 $208.00 $223.00 $226.00 $208.00 $223.00 $226.00

77762 $427.00 $575.00 $603.00 $618.00 $575.00 $603.00 $618.00

77762-26 $289.00 $334.00 $346.00 $356.00 $334.00 $346.00 $356.00

77762-TC $135.00 $241.00 $258.00 $262.00 $241.00 $258.00 $262.00

77763 $605.00 $810.00 $847.00 $866.00 $810.00 $847.00 $866.00

77763-26 $435.00 $501.00 $516.00 $529.00 $501.00 $516.00 $529.00

77763-TC $167.00 $309.00 $331.00 $337.00 $309.00 $331.00 $337.00

77767 ---------- $244.00 $259.00 $263.00 $244.00 $259.00 $263.00

77767-26 ---------- $61.00 $63.00 $65.00 $61.00 $63.00 $65.00

77767-TC ---------- $183.00 $196.00 $198.00 $183.00 $196.00 $198.00

77768 ---------- $382.00 $406.00 $412.00 $382.00 $406.00 $412.00

77768-26 ---------- $81.00 $84.00 $86.00 $81.00 $84.00 $86.00

77768-TC ---------- $301.00 $322.00 $327.00 $301.00 $322.00 $327.00

77770 ---------- $349.00 $369.00 $375.00 $349.00 $369.00 $375.00

77770-26 ---------- $113.00 $116.00 $119.00 $113.00 $116.00 $119.00

77770-TC ---------- $236.00 $253.00 $256.00 $236.00 $253.00 $256.00

77771 ---------- $650.00 $687.00 $699.00 $650.00 $687.00 $699.00

77771-26 ---------- $220.00 $226.00 $232.00 $220.00 $226.00 $232.00

77771-TC ---------- $430.00 $460.00 $467.00 $430.00 $460.00 $467.00

77772 ---------- $992.00 $1,050.00 $1,068.00 $992.00 $1,050.00 $1,068.00

77772-26 ---------- $311.00 $321.00 $329.00 $311.00 $321.00 $329.00

77772-TC ---------- $681.00 $729.00 $739.00 $681.00 $729.00 $739.00

77778 $764.00 $902.00 $946.00 $967.00 $902.00 $946.00 $967.00

77778-26 $568.00 $506.00 $522.00 $535.00 $506.00 $522.00 $535.00

77778-TC $192.00 $396.00 $424.00 $432.00 $396.00 $424.00 $432.00

77789 $74.00 $130.00 $137.00 $139.00 $130.00 $137.00 $139.00

77789-26 $57.00 $66.00 $68.00 $70.00 $66.00 $68.00 $70.00

77789-TC $16.00 $64.00 $68.00 $69.00 $64.00 $68.00 $69.00



Radiology


(Non-Facility MRA)






77790 $72.00 $16.00 $17.00 $18.00 $16.00 $17.00 $18.00

77790-26 $53.00 ---------- ---------- ---------- ---------- ---------- ----------

77790-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

77799 BR ---------- ---------- ---------- ---------- ---------- ----------

77799-26 BR ---------- ---------- ---------- ---------- ---------- ----------

77799-TC BR ---------- ---------- ---------- ---------- ---------- ----------

78012 ---------- $89.00 $95.00 $97.00 $89.00 $95.00 $97.00

78012-26 ---------- $11.00 $11.00 $11.00 $11.00 $11.00 $11.00

78012-TC ---------- $79.00 $84.00 $86.00 $79.00 $84.00 $86.00

78013 ---------- $212.00 $226.00 $230.00 $212.00 $226.00 $230.00

78013-26 ---------- $21.00 $21.00 $22.00 $21.00 $21.00 $22.00

78013-TC ---------- $192.00 $205.00 $208.00 $192.00 $205.00 $208.00

78014 ---------- $269.00 $286.00 $291.00 $269.00 $286.00 $291.00

78014-26 ---------- $28.00 $29.00 $30.00 $28.00 $29.00 $30.00

78014-TC ---------- $240.00 $257.00 $261.00 $240.00 $257.00 $261.00

78015 $132.00 $247.00 $263.00 $267.00 $247.00 $263.00 $267.00

78015-26 $34.00 $37.00 $38.00 $40.00 $37.00 $38.00 $40.00

78015-TC $96.00 $210.00 $225.00 $228.00 $210.00 $225.00 $228.00

78016 $173.00 $316.00 $336.00 $340.00 $316.00 $336.00 $340.00

78016-26 $42.00 $39.00 $39.00 $39.00 $39.00 $39.00 $39.00

78016-TC $130.00 $277.00 $297.00 $301.00 $277.00 $297.00 $301.00

78018 $248.00 $348.00 $371.00 $376.00 $348.00 $371.00 $376.00

78018-26 $44.00 $47.00 $48.00 $49.00 $47.00 $48.00 $49.00

78018-TC $202.00 $302.00 $323.00 $327.00 $302.00 $323.00 $327.00

78020 $35.00 $93.00 $99.00 $101.00 $93.00 $99.00 $101.00

78020-26 $30.00 $31.00 $32.00 $33.00 $31.00 $32.00 $33.00

78020-TC $5.00 $62.00 $67.00 $68.00 $62.00 $67.00 $68.00

78070 $112.00 $334.00 $355.00 $361.00 $334.00 $355.00 $361.00

78070-26 $36.00 $44.00 $46.00 $47.00 $44.00 $46.00 $47.00

78070-TC $68.00 $290.00 $310.00 $314.00 $290.00 $310.00 $314.00

78071 ---------- $398.00 $423.00 $430.00 $398.00 $423.00 $430.00

78071-26 ---------- $66.00 $68.00 $70.00 $66.00 $68.00 $70.00

78071-TC ---------- $332.00 $355.00 $360.00 $332.00 $355.00 $360.00

78072 ---------- $459.00 $488.00 $495.00 $459.00 $488.00 $495.00

78072-26 ---------- $86.00 $89.00 $91.00 $86.00 $89.00 $91.00

78072-TC ---------- $373.00 $399.00 $404.00 $373.00 $399.00 $404.00

78075 $242.00 $493.00 $526.00 $533.00 $493.00 $526.00 $533.00

78075-26 $38.00 $42.00 $43.00 $44.00 $42.00 $43.00 $44.00

78075-TC $202.00 $451.00 $483.00 $489.00 $451.00 $483.00 $489.00

78099 BR ---------- ---------- ---------- ---------- ---------- ----------

78099-26 BR ---------- ---------- ---------- ---------- ---------- ----------

78099-TC BR ---------- ---------- ---------- ---------- ---------- ----------

78102 $106.00 $190.00 $202.00 $206.00 $190.00 $202.00 $206.00

78102-26 $28.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.00

78102-TC $77.00 $160.00 $171.00 $174.00 $160.00 $171.00 $174.00

78103 $158.00 $244.00 $260.00 $264.00 $244.00 $260.00 $264.00

78103-26 $39.00 $40.00 $41.00 $42.00 $40.00 $41.00 $42.00

78103-TC $118.00 $205.00 $219.00 $222.00 $205.00 $219.00 $222.00

78104 $194.00 $273.00 $290.00 $295.00 $273.00 $290.00 $295.00

78104-26 $41.00 $43.00 $44.00 $46.00 $43.00 $44.00 $46.00



Radiology


(Non-Facility MRA)






78104-TC $152.00 $230.00 $246.00 $249.00 $230.00 $246.00 $249.00

78110 $45.00 $111.00 $119.00 $121.00 $111.00 $119.00 $121.00

78110-26 $9.00 $11.00 $11.00 $12.00 $11.00 $11.00 $12.00

78110-TC $35.00 $100.00 $107.00 $109.00 $100.00 $107.00 $109.00

78111 $108.00 $106.00 $113.00 $115.00 $106.00 $113.00 $115.00

78111-26 $11.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.00

78111-TC $96.00 $94.00 $100.00 $102.00 $94.00 $100.00 $102.00

78120 $78.00 $104.00 $111.00 $114.00 $104.00 $111.00 $114.00

78120-26 $11.00 $13.00 $13.00 $14.00 $13.00 $13.00 $14.00

78120-TC $65.00 $91.00 $98.00 $100.00 $91.00 $98.00 $100.00

78121 $125.00 $116.00 $123.00 $126.00 $116.00 $123.00 $126.00

78121-26 $16.00 $18.00 $18.00 $19.00 $18.00 $18.00 $19.00

78121-TC $108.00 $98.00 $105.00 $107.00 $98.00 $105.00 $107.00

78122 $196.00 $108.00 $114.00 $117.00 $108.00 $114.00 $117.00

78122-26 $22.00 $24.00 $24.00 $25.00 $24.00 $24.00 $25.00

78122-TC $171.00 $84.00 $90.00 $92.00 $84.00 $90.00 $92.00

78130 $139.00 $187.00 $198.00 $202.00 $187.00 $198.00 $202.00

78130-26 $32.00 $34.00 $35.00 $35.00 $34.00 $35.00 $35.00

78130-TC $106.00 $153.00 $164.00 $166.00 $153.00 $164.00 $166.00

78135 $216.00 $387.00 $413.00 $419.00 $387.00 $413.00 $419.00

78135-26 $33.00 $36.00 $38.00 $39.00 $36.00 $38.00 $39.00

78135-TC $182.00 $351.00 $375.00 $380.00 $351.00 $375.00 $380.00

78140 $179.00 $154.00 $164.00 $167.00 $154.00 $164.00 $167.00

78140-26 $31.00 $34.00 $35.00 $36.00 $34.00 $35.00 $36.00

78140-TC $147.00 $120.00 $129.00 $131.00 $120.00 $129.00 $131.00

78185 $110.00 $235.00 $250.00 $254.00 $235.00 $250.00 $254.00

78185-26 $20.00 $23.00 $23.00 $24.00 $23.00 $23.00 $24.00

78185-TC $88.00 $212.00 $227.00 $230.00 $212.00 $227.00 $230.00

78190 $272.00 $437.00 $465.00 $471.00 $437.00 $465.00 $471.00

78190-26 $57.00 $60.00 $62.00 $63.00 $60.00 $62.00 $63.00

78190-TC $214.00 $376.00 $403.00 $408.00 $376.00 $403.00 $408.00

78191 $307.00 $187.00 $198.00 $202.00 $187.00 $198.00 $202.00

78191-26 $31.00 $34.00 $35.00 $35.00 $34.00 $35.00 $35.00

78191-TC $274.00 $153.00 $164.00 $166.00 $153.00 $164.00 $166.00

78195 $216.00 $397.00 $422.00 $429.00 $397.00 $422.00 $429.00

78195-26 $49.00 $67.00 $69.00 $71.00 $67.00 $69.00 $71.00

78195-TC $152.00 $330.00 $353.00 $358.00 $330.00 $353.00 $358.00

78199 BR ---------- ---------- ---------- ---------- ---------- ----------

78199-26 BR ---------- ---------- ---------- ---------- ---------- ----------

78199-TC BR ---------- ---------- ---------- ---------- ---------- ----------

78201 $112.00 $210.00 $224.00 $227.00 $210.00 $224.00 $227.00

78201-26 $22.00 $24.00 $24.00 $25.00 $24.00 $24.00 $25.00

78201-TC $88.00 $186.00 $199.00 $202.00 $186.00 $199.00 $202.00

78202 $135.00 $222.00 $237.00 $240.00 $222.00 $237.00 $240.00

78202-26 $26.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.00

78202-TC $108.00 $196.00 $210.00 $213.00 $196.00 $210.00 $213.00

78205 $259.00 $235.00 $250.00 $254.00 $235.00 $250.00 $254.00

78205-26 $36.00 $38.00 $39.00 $40.00 $38.00 $39.00 $40.00

78205-TC $220.00 $197.00 $211.00 $214.00 $197.00 $211.00 $214.00

78206 $265.00 $381.00 $405.00 $412.00 $381.00 $405.00 $412.00



Radiology


(Non-Facility MRA)






78206-26 $46.00 $53.00 $54.00 $56.00 $53.00 $54.00 $56.00

78206-TC $214.00 $328.00 $351.00 $356.00 $328.00 $351.00 $356.00

78215 $135.00 $216.00 $230.00 $234.00 $216.00 $230.00 $234.00

78215-26 $24.00 $27.00 $28.00 $29.00 $27.00 $28.00 $29.00

78215-TC $109.00 $189.00 $202.00 $205.00 $189.00 $202.00 $205.00

78216 $160.00 $142.00 $150.00 $153.00 $142.00 $150.00 $153.00

78216-26 $29.00 $31.00 $32.00 $33.00 $31.00 $32.00 $33.00

78216-TC $130.00 $111.00 $119.00 $121.00 $111.00 $119.00 $121.00

78226 ---------- $368.00 $392.00 $398.00 $368.00 $392.00 $398.00

78226-26 ---------- $41.00 $42.00 $44.00 $41.00 $42.00 $44.00

78226-TC ---------- $327.00 $349.00 $354.00 $327.00 $349.00 $354.00

78227 ---------- $499.00 $531.00 $539.00 $499.00 $531.00 $539.00

78227-26 ---------- $50.00 $52.00 $54.00 $50.00 $52.00 $54.00

78227-TC ---------- $448.00 $479.00 $486.00 $448.00 $479.00 $486.00

78230 $106.00 $195.00 $207.00 $211.00 $195.00 $207.00 $211.00

78230-26 $23.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.00

78230-TC $82.00 $169.00 $181.00 $183.00 $169.00 $181.00 $183.00

78231 $146.00 $144.00 $153.00 $156.00 $144.00 $153.00 $156.00

78231-26 $27.00 $29.00 $30.00 $31.00 $29.00 $30.00 $31.00

78231-TC $118.00 $114.00 $123.00 $125.00 $114.00 $123.00 $125.00

78232 $157.00 $112.00 $118.00 $121.00 $112.00 $118.00 $121.00

78232-26 $23.00 $22.00 $22.00 $23.00 $22.00 $22.00 $23.00

78232-TC $132.00 $90.00 $96.00 $98.00 $90.00 $96.00 $98.00

78258 $146.00 $251.00 $267.00 $271.00 $251.00 $267.00 $271.00

78258-26 $38.00 $42.00 $43.00 $44.00 $42.00 $43.00 $44.00

78258-TC $108.00 $209.00 $224.00 $227.00 $209.00 $224.00 $227.00

78261 $190.00 $273.00 $291.00 $295.00 $273.00 $291.00 $295.00

78261-26 $36.00 $38.00 $39.00 $40.00 $38.00 $39.00 $40.00

78261-TC $152.00 $235.00 $252.00 $255.00 $235.00 $252.00 $255.00

78262 $195.00 $270.00 $287.00 $291.00 $270.00 $287.00 $291.00

78262-26 $35.00 $37.00 $38.00 $39.00 $37.00 $38.00 $39.00

78262-TC $159.00 $233.00 $249.00 $252.00 $233.00 $249.00 $252.00

78264 $195.00 $374.00 $398.00 $404.00 $374.00 $398.00 $404.00

78264-26 $40.00 $44.00 $45.00 $47.00 $44.00 $45.00 $47.00

78264-TC $154.00 $330.00 $353.00 $358.00 $330.00 $353.00 $358.00

78265 ---------- $406.00 $432.00 $439.00 $406.00 $432.00 $439.00

78265-26 ---------- $55.00 $56.00 $58.00 $55.00 $56.00 $58.00

78265-TC ---------- $351.00 $375.00 $381.00 $351.00 $375.00 $381.00

78266 ---------- $512.00 $545.00 $553.00 $512.00 $545.00 $553.00

78266-26 ---------- $60.00 $62.00 $64.00 $60.00 $62.00 $64.00

78266-TC ---------- $452.00 $483.00 $489.00 $452.00 $483.00 $489.00

78267 BR ---------- ---------- ---------- ---------- ---------- ----------

78268 BR ---------- ---------- ---------- ---------- ---------- ----------

78270 $68.00 $113.00 $120.00 $123.00 $113.00 $120.00 $123.00

78270-26 $10.00 $12.00 $12.00 $13.00 $12.00 $12.00 $13.00

78270-TC $58.00 $101.00 $108.00 $110.00 $101.00 $108.00 $110.00

78271 $72.00 $100.00 $107.00 $109.00 $100.00 $107.00 $109.00

78271-26 $10.00 $11.00 $12.00 $12.00 $11.00 $12.00 $12.00

78271-TC $61.00 $88.00 $95.00 $97.00 $88.00 $95.00 $97.00

78272 $100.00 $109.00 $116.00 $118.00 $109.00 $116.00 $118.00



Radiology


(Non-Facility MRA)






78272-26 $14.00 $15.00 $15.00 $16.00 $15.00 $15.00 $16.00

78272-TC $87.00 $94.00 $101.00 $103.00 $94.00 $101.00 $103.00

78278 $234.00 $388.00 $413.00 $419.00 $388.00 $413.00 $419.00

78278-26 $50.00 $55.00 $57.00 $58.00 $55.00 $57.00 $58.00

78278-TC $182.00 $333.00 $356.00 $361.00 $333.00 $356.00 $361.00

78282 BR $372.00 $396.00 $401.00 $372.00 $396.00 $401.00

78282-26 $19.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.00

78282-TC BR $350.00 $374.00 $378.00 $350.00 $374.00 $378.00

78290 $149.00 $369.00 $393.00 $399.00 $369.00 $393.00 $399.00

78290-26 $35.00 $38.00 $39.00 $41.00 $38.00 $39.00 $41.00

78290-TC $113.00 $331.00 $354.00 $359.00 $331.00 $354.00 $359.00

78291 $161.00 $285.00 $303.00 $308.00 $285.00 $303.00 $308.00

78291-26 $45.00 $48.00 $50.00 $52.00 $48.00 $50.00 $52.00

78291-TC $114.00 $237.00 $253.00 $257.00 $237.00 $253.00 $257.00

78299 BR ---------- ---------- ---------- ---------- ---------- ----------

78299-26 BR ---------- ---------- ---------- ---------- ---------- ----------

78299-TC BR ---------- ---------- ---------- ---------- ---------- ----------

78300 $125.00 $202.00 $215.00 $219.00 $202.00 $215.00 $219.00

78300-26 $32.00 $35.00 $37.00 $38.00 $35.00 $37.00 $38.00

78300-TC $93.00 $167.00 $179.00 $181.00 $167.00 $179.00 $181.00

78305 $181.00 $259.00 $275.00 $280.00 $259.00 $275.00 $280.00

78305-26 $42.00 $47.00 $48.00 $50.00 $47.00 $48.00 $50.00

78305-TC $137.00 $212.00 $227.00 $230.00 $212.00 $227.00 $230.00

78306 $205.00 $280.00 $298.00 $302.00 $280.00 $298.00 $302.00

78306-26 $44.00 $47.00 $49.00 $50.00 $47.00 $49.00 $50.00

78306-TC $159.00 $233.00 $249.00 $252.00 $233.00 $249.00 $252.00

78315 $233.00 $385.00 $410.00 $416.00 $385.00 $410.00 $416.00

78315-26 $52.00 $56.00 $58.00 $60.00 $56.00 $58.00 $60.00

78315-TC $179.00 $329.00 $351.00 $356.00 $329.00 $351.00 $356.00

78320 $276.00 $255.00 $270.00 $275.00 $255.00 $270.00 $275.00

78320-26 $53.00 $57.00 $59.00 $60.00 $57.00 $59.00 $60.00

78320-TC $220.00 $198.00 $212.00 $215.00 $198.00 $212.00 $215.00

78350 $40.00 $36.00 $38.00 $39.00 $36.00 $38.00 $39.00

78350-26 $11.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.00

78350-TC $29.00 $24.00 $25.00 $26.00 $24.00 $25.00 $26.00

78351 $23.00 $17.00 $18.00 $19.00 $17.00 $18.00 $19.00

78399 BR ---------- ---------- ---------- ---------- ---------- ----------

78399-26 BR ---------- ---------- ---------- ---------- ---------- ----------

78399-TC BR ---------- ---------- ---------- ---------- ---------- ----------

78414 BR ---------- ---------- ---------- ---------- ---------- ----------

78414-26 $23.00 $25.00 $26.00 $26.00 $25.00 $26.00 $26.00

78414-TC BR ---------- ---------- ---------- ---------- ---------- ----------

78428 $126.00 $202.00 $214.00 $218.00 $202.00 $214.00 $218.00

78428-26 $41.00 $42.00 $43.00 $44.00 $42.00 $43.00 $44.00

78428-TC $84.00 $160.00 $171.00 $174.00 $160.00 $171.00 $174.00

78445 $97.00 $202.00 $215.00 $219.00 $202.00 $215.00 $219.00

78445-26 $28.00 $27.00 $28.00 $29.00 $27.00 $28.00 $29.00

78445-TC $69.00 $175.00 $187.00 $190.00 $175.00 $187.00 $190.00

78451 ---------- $378.00 $402.00 $408.00 $378.00 $402.00 $408.00

78451-26 ---------- $75.00 $78.00 $80.00 $75.00 $78.00 $80.00



Radiology


(Non-Facility MRA)






78451-TC ---------- $303.00 $324.00 $328.00 $303.00 $324.00 $328.00

78452 ---------- $525.00 $558.00 $566.00 $525.00 $558.00 $566.00

78452-26 ---------- $88.00 $91.00 $93.00 $88.00 $91.00 $93.00

78452-TC ---------- $436.00 $467.00 $473.00 $436.00 $467.00 $473.00

78453 ---------- $338.00 $359.00 $365.00 $338.00 $359.00 $365.00

78453-26 ---------- $56.00 $57.00 $59.00 $56.00 $57.00 $59.00

78453-TC ---------- $282.00 $302.00 $306.00 $282.00 $302.00 $306.00

78454 ---------- $486.00 $517.00 $525.00 $486.00 $517.00 $525.00

78454-26 ---------- $75.00 $78.00 $80.00 $75.00 $78.00 $80.00

78454-TC ---------- $411.00 $439.00 $445.00 $411.00 $439.00 $445.00

78456 $205.00 $355.00 $378.00 $384.00 $355.00 $378.00 $384.00

78456-26 $49.00 $55.00 $56.00 $58.00 $55.00 $56.00 $58.00

78456-TC $151.00 $301.00 $322.00 $326.00 $301.00 $322.00 $326.00

78457 $140.00 $196.00 $208.00 $211.00 $196.00 $208.00 $211.00

78457-26 $39.00 $42.00 $43.00 $44.00 $42.00 $43.00 $44.00

78457-TC $99.00 $154.00 $165.00 $167.00 $154.00 $165.00 $167.00

78458 $198.00 $228.00 $243.00 $247.00 $228.00 $243.00 $247.00

78458-26 $46.00 $51.00 $53.00 $54.00 $51.00 $53.00 $54.00

78458-TC $149.00 $177.00 $190.00 $193.00 $177.00 $190.00 $193.00

78459 BR $1,277.00 $1,360.00 $1,375.00 $1,277.00 $1,360.00 $1,375.00

78459-26 $100.00 $79.00 $82.00 $84.00 $79.00 $82.00 $84.00

78459-TC BR $1,197.00 $1,279.00 $1,292.00 $1,197.00 $1,279.00 $1,292.00

78466 $135.00 $218.00 $231.00 $235.00 $218.00 $231.00 $235.00

78466-26 $36.00 $39.00 $41.00 $42.00 $39.00 $41.00 $42.00

78466-TC $97.00 $178.00 $191.00 $193.00 $178.00 $191.00 $193.00

78468 $180.00 $216.00 $230.00 $233.00 $216.00 $230.00 $233.00

78468-26 $41.00 $44.00 $45.00 $46.00 $44.00 $45.00 $46.00

78468-TC $137.00 $173.00 $185.00 $187.00 $173.00 $185.00 $187.00

78469 $244.00 $253.00 $268.00 $272.00 $253.00 $268.00 $272.00

78469-26 $47.00 $50.00 $52.00 $53.00 $50.00 $52.00 $53.00

78469-TC $195.00 $202.00 $217.00 $220.00 $202.00 $217.00 $220.00

78472 $259.00 $255.00 $271.00 $275.00 $255.00 $271.00 $275.00

78472-26 $50.00 $54.00 $56.00 $58.00 $54.00 $56.00 $58.00

78472-TC $206.00 $201.00 $215.00 $218.00 $201.00 $215.00 $218.00

78473 $387.00 $322.00 $341.00 $347.00 $322.00 $341.00 $347.00

78473-26 $75.00 $80.00 $82.00 $84.00 $80.00 $82.00 $84.00

78473-TC $308.00 $242.00 $259.00 $263.00 $242.00 $259.00 $263.00

78481 $248.00 $195.00 $206.00 $210.00 $195.00 $206.00 $210.00

78481-26 $51.00 $54.00 $55.00 $57.00 $54.00 $55.00 $57.00

78481-TC $195.00 $141.00 $151.00 $153.00 $141.00 $151.00 $153.00

78483 $373.00 $270.00 $286.00 $291.00 $270.00 $286.00 $291.00

78483-26 $77.00 $80.00 $82.00 $84.00 $80.00 $82.00 $84.00

78483-TC $294.00 $190.00 $204.00 $207.00 $190.00 $204.00 $207.00

78491 BR $1,470.00 $1,566.00 $1,583.00 $1,470.00 $1,566.00 $1,583.00

78491-26 $85.00 $80.00 $82.00 $84.00 $80.00 $82.00 $84.00

78491-TC BR $1,389.00 $1,484.00 $1,499.00 $1,389.00 $1,484.00 $1,499.00

78492 BR $1,490.00 $1,587.00 $1,604.00 $1,490.00 $1,587.00 $1,604.00

78492-26 $100.00 $101.00 $103.00 $106.00 $101.00 $103.00 $106.00

78492-TC BR $1,389.00 $1,484.00 $1,499.00 $1,389.00 $1,484.00 $1,499.00

78494 $324.00 $250.00 $265.00 $269.00 $250.00 $265.00 $269.00



Radiology


(Non-Facility MRA)






78494-26 $59.00 $65.00 $67.00 $69.00 $65.00 $67.00 $69.00

78494-TC $262.00 $185.00 $198.00 $201.00 $185.00 $198.00 $201.00

78496 $92.00 $49.00 $52.00 $53.00 $49.00 $52.00 $53.00

78496-26 $24.00 $27.00 $28.00 $29.00 $27.00 $28.00 $29.00

78496-TC $66.00 $22.00 $24.00 $24.00 $22.00 $24.00 $24.00

78499 BR ---------- ---------- ---------- ---------- ---------- ----------

78499-26 BR ---------- ---------- ---------- ---------- ---------- ----------

78499-TC BR ---------- ---------- ---------- ---------- ---------- ----------

78579 ---------- $207.00 $220.00 $223.00 $207.00 $220.00 $223.00

78579-26 ---------- $27.00 $28.00 $28.00 $27.00 $28.00 $28.00

78579-TC ---------- $180.00 $192.00 $195.00 $180.00 $192.00 $195.00

78580 $167.00 $266.00 $283.00 $288.00 $266.00 $283.00 $288.00

78580-26 $38.00 $41.00 $42.00 $44.00 $41.00 $42.00 $44.00

78580-TC $128.00 $225.00 $241.00 $244.00 $225.00 $241.00 $244.00

78582 ---------- $373.00 $397.00 $403.00 $373.00 $397.00 $403.00

78582-26 ---------- $60.00 $62.00 $64.00 $60.00 $62.00 $64.00

78582-TC ---------- $313.00 $335.00 $339.00 $313.00 $335.00 $339.00

78597 ---------- $225.00 $239.00 $242.00 $225.00 $239.00 $242.00

78597-26 ---------- $40.00 $41.00 $42.00 $40.00 $41.00 $42.00

78597-TC ---------- $185.00 $198.00 $200.00 $185.00 $198.00 $200.00

78598 ---------- $340.00 $362.00 $368.00 $340.00 $362.00 $368.00

78598-26 ---------- $47.00 $48.00 $49.00 $47.00 $48.00 $49.00

78598-TC ---------- $294.00 $314.00 $319.00 $294.00 $314.00 $319.00

78599 BR ---------- ---------- ---------- ---------- ---------- ----------

78599-26 BR ---------- ---------- ---------- ---------- ---------- ----------

78599-TC BR ---------- ---------- ---------- ---------- ---------- ----------

78600 $131.00 $206.00 $220.00 $224.00 $206.00 $220.00 $224.00

78600-26 $22.00 $25.00 $26.00 $27.00 $25.00 $26.00 $27.00

78600-TC $108.00 $181.00 $194.00 $196.00 $181.00 $194.00 $196.00

78601 $154.00 $239.00 $254.00 $259.00 $239.00 $254.00 $259.00

78601-26 $26.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.00

78601-TC $126.00 $211.00 $225.00 $228.00 $211.00 $225.00 $228.00

78605 $155.00 $223.00 $237.00 $241.00 $223.00 $237.00 $241.00

78605-26 $27.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.00

78605-TC $126.00 $193.00 $206.00 $209.00 $193.00 $206.00 $209.00

78606 $221.00 $366.00 $390.00 $396.00 $366.00 $390.00 $396.00

78606-26 $45.00 $35.00 $36.00 $37.00 $35.00 $36.00 $37.00

78606-TC $177.00 $331.00 $354.00 $359.00 $331.00 $354.00 $359.00

78607 $311.00 $392.00 $416.00 $423.00 $392.00 $416.00 $423.00

78607-26 $64.00 $67.00 $69.00 $71.00 $67.00 $69.00 $71.00

78607-TC $245.00 $325.00 $347.00 $352.00 $325.00 $347.00 $352.00

78608 BR $1,470.00 $1,567.00 $1,584.00 $1,470.00 $1,567.00 $1,584.00

78608-26 ---------- $81.00 $83.00 $85.00 $81.00 $83.00 $85.00

78608-TC ---------- $1,389.00 $1,484.00 $1,499.00 $1,389.00 $1,484.00 $1,499.00

78609 BR $83.00 $85.00 $87.00 $83.00 $85.00 $87.00

78609-26 ---------- $83.00 $85.00 $87.00 $83.00 $85.00 $87.00

78609-TC ---------- BR BR BR BR BR BR

78610 $74.00 $195.00 $208.00 $211.00 $195.00 $208.00 $211.00

78610-26 $15.00 $17.00 $18.00 $18.00 $17.00 $18.00 $18.00

78610-TC $59.00 $177.00 $190.00 $193.00 $177.00 $190.00 $193.00



Radiology


(Non-Facility MRA)






78630 $223.00 $376.00 $401.00 $407.00 $376.00 $401.00 $407.00

78630-26 $35.00 $38.00 $39.00 $41.00 $38.00 $39.00 $41.00

78630-TC $188.00 $338.00 $362.00 $367.00 $338.00 $362.00 $367.00

78635 $129.00 $380.00 $405.00 $411.00 $380.00 $405.00 $411.00

78635-26 $32.00 $35.00 $37.00 $38.00 $35.00 $37.00 $38.00

78635-TC $95.00 $345.00 $369.00 $374.00 $345.00 $369.00 $374.00

78645 $158.00 $360.00 $384.00 $390.00 $360.00 $384.00 $390.00

78645-26 $29.00 $31.00 $32.00 $33.00 $31.00 $32.00 $33.00

78645-TC $128.00 $329.00 $352.00 $356.00 $329.00 $352.00 $356.00

78647 $268.00 $394.00 $420.00 $426.00 $394.00 $420.00 $426.00

78647-26 $46.00 $52.00 $53.00 $55.00 $52.00 $53.00 $55.00

78647-TC $220.00 $343.00 $366.00 $371.00 $343.00 $366.00 $371.00

78650 $206.00 $368.00 $392.00 $398.00 $368.00 $392.00 $398.00

78650-26 $31.00 $34.00 $35.00 $36.00 $34.00 $35.00 $36.00

78650-TC $173.00 $334.00 $357.00 $362.00 $334.00 $357.00 $362.00

78660 $107.00 $200.00 $213.00 $217.00 $200.00 $213.00 $217.00

78660-26 $27.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.00

78660-TC $79.00 $170.00 $182.00 $185.00 $170.00 $182.00 $185.00

78699 BR ---------- ---------- ---------- ---------- ---------- ----------

78699-26 BR ---------- ---------- ---------- ---------- ---------- ----------

78699-TC BR ---------- ---------- ---------- ---------- ---------- ----------

78700 $137.00 $191.00 $203.00 $206.00 $191.00 $203.00 $206.00

78700-26 $22.00 $25.00 $26.00 $26.00 $25.00 $26.00 $26.00

78700-TC $113.00 $166.00 $177.00 $180.00 $166.00 $177.00 $180.00

78701 $158.00 $235.00 $250.00 $254.00 $235.00 $250.00 $254.00

78701-26 $24.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.00

78701-TC $133.00 $208.00 $223.00 $226.00 $208.00 $223.00 $226.00

78707 $217.00 $260.00 $276.00 $280.00 $260.00 $276.00 $280.00

78707-26 $49.00 $53.00 $54.00 $56.00 $53.00 $54.00 $56.00

78707-TC $166.00 $207.00 $221.00 $224.00 $207.00 $221.00 $224.00

78708 $231.00 $197.00 $209.00 $213.00 $197.00 $209.00 $213.00

78708-26 $61.00 $67.00 $69.00 $71.00 $67.00 $69.00 $71.00

78708-TC $166.00 $130.00 $140.00 $142.00 $130.00 $140.00 $142.00

78709 $241.00 $406.00 $432.00 $439.00 $406.00 $432.00 $439.00

78709-26 $68.00 $77.00 $79.00 $82.00 $77.00 $79.00 $82.00

78709-TC $166.00 $329.00 $352.00 $357.00 $329.00 $352.00 $357.00

78710 $256.00 $224.00 $238.00 $242.00 $224.00 $238.00 $242.00

78710-26 $34.00 $34.00 $35.00 $36.00 $34.00 $35.00 $36.00

78710-TC $220.00 $189.00 $202.00 $205.00 $189.00 $202.00 $205.00

78725 $87.00 $119.00 $126.00 $129.00 $119.00 $126.00 $129.00

78725-26 $19.00 $21.00 $21.00 $22.00 $21.00 $21.00 $22.00

78725-TC $66.00 $98.00 $105.00 $107.00 $98.00 $105.00 $107.00

78730 $73.00 $78.00 $83.00 $84.00 $78.00 $83.00 $84.00

78730-26 $18.00 $8.00 $8.00 $8.00 $8.00 $8.00 $8.00

78730-TC $55.00 $70.00 $75.00 $76.00 $70.00 $75.00 $76.00

78740 $109.00 $243.00 $259.00 $263.00 $243.00 $259.00 $263.00

78740-26 $29.00 $31.00 $32.00 $32.00 $31.00 $32.00 $32.00

78740-TC $79.00 $213.00 $227.00 $231.00 $213.00 $227.00 $231.00

78761 $157.00 $238.00 $253.00 $257.00 $238.00 $253.00 $257.00

78761-26 $36.00 $40.00 $42.00 $43.00 $40.00 $42.00 $43.00



Radiology


(Non-Facility MRA)






78761-TC $119.00 $197.00 $211.00 $214.00 $197.00 $211.00 $214.00

78799 BR ---------- ---------- ---------- ---------- ---------- ----------

78799-26 BR ---------- ---------- ---------- ---------- ---------- ----------

78799-TC BR ---------- ---------- ---------- ---------- ---------- ----------

78800 $162.00 $215.00 $229.00 $234.00 $215.00 $229.00 $234.00

78800-26 $34.00 $38.00 $40.00 $42.00 $38.00 $40.00 $42.00

78800-TC $126.00 $177.00 $189.00 $192.00 $177.00 $189.00 $192.00

78801 $199.00 $293.00 $312.00 $318.00 $293.00 $312.00 $318.00

78801-26 $40.00 $45.00 $47.00 $50.00 $45.00 $47.00 $50.00

78801-TC $158.00 $247.00 $264.00 $268.00 $247.00 $264.00 $268.00

78802 $252.00 $360.00 $383.00 $389.00 $360.00 $383.00 $389.00

78802-26 $44.00 $47.00 $48.00 $50.00 $47.00 $48.00 $50.00

78802-TC $207.00 $313.00 $335.00 $339.00 $313.00 $335.00 $339.00

78803 $303.00 $380.00 $404.00 $411.00 $380.00 $404.00 $411.00

78803-26 $56.00 $59.00 $60.00 $62.00 $59.00 $60.00 $62.00

78803-TC $245.00 $322.00 $344.00 $349.00 $322.00 $344.00 $349.00

78804 ---------- $629.00 $670.00 $680.00 $629.00 $670.00 $680.00

78804-26 ---------- $58.00 $60.00 $62.00 $58.00 $60.00 $62.00

78804-TC ---------- $570.00 $610.00 $618.00 $570.00 $610.00 $618.00

78805 $166.00 $204.00 $217.00 $221.00 $204.00 $217.00 $221.00

78805-26 $38.00 $40.00 $42.00 $43.00 $40.00 $42.00 $43.00

78805-TC $126.00 $164.00 $175.00 $178.00 $164.00 $175.00 $178.00

78806 $286.00 $371.00 $395.00 $401.00 $371.00 $395.00 $401.00

78806-26 $44.00 $47.00 $48.00 $50.00 $47.00 $48.00 $50.00

78806-TC $241.00 $324.00 $346.00 $351.00 $324.00 $346.00 $351.00

78807 $303.00 $381.00 $405.00 $411.00 $381.00 $405.00 $411.00

78807-26 $57.00 $59.00 $60.00 $62.00 $59.00 $60.00 $62.00

78807-TC $245.00 $323.00 $345.00 $350.00 $323.00 $345.00 $350.00

78808 ---------- $49.00 $52.00 $54.00 $49.00 $52.00 $54.00

78811 ---------- $1,284.00 $1,368.00 $1,384.00 $1,284.00 $1,368.00 $1,384.00

78811-26 ---------- $87.00 $89.00 $92.00 $87.00 $89.00 $92.00

78811-TC ---------- $1,197.00 $1,279.00 $1,292.00 $1,197.00 $1,279.00 $1,292.00

78812 ---------- $1,495.00 $1,593.00 $1,610.00 $1,495.00 $1,593.00 $1,610.00

78812-26 ---------- $105.00 $109.00 $112.00 $105.00 $109.00 $112.00

78812-TC ---------- $1,389.00 $1,484.00 $1,499.00 $1,389.00 $1,484.00 $1,499.00

78813 ---------- $1,499.00 $1,597.00 $1,615.00 $1,499.00 $1,597.00 $1,615.00

78813-26 ---------- $110.00 $113.00 $117.00 $110.00 $113.00 $117.00

78813-TC ---------- $1,389.00 $1,484.00 $1,499.00 $1,389.00 $1,484.00 $1,499.00

78814 ---------- $1,512.00 $1,610.00 $1,629.00 $1,512.00 $1,610.00 $1,629.00

78814-26 ---------- $122.00 $126.00 $130.00 $122.00 $126.00 $130.00

78814-TC ---------- $1,389.00 $1,484.00 $1,499.00 $1,389.00 $1,484.00 $1,499.00

78815 ---------- $1,524.00 $1,622.00 $1,641.00 $1,524.00 $1,622.00 $1,641.00

78815-26 ---------- $134.00 $139.00 $142.00 $134.00 $139.00 $142.00

78815-TC ---------- $1,389.00 $1,484.00 $1,499.00 $1,389.00 $1,484.00 $1,499.00

78816 ---------- $1,525.00 $1,624.00 $1,643.00 $1,525.00 $1,624.00 $1,643.00

78816-26 ---------- $136.00 $140.00 $144.00 $136.00 $140.00 $144.00

78816-TC ---------- $1,389.00 $1,484.00 $1,499.00 $1,389.00 $1,484.00 $1,499.00

78999 BR ---------- ---------- ---------- ---------- ---------- ----------

78999-26 BR ---------- ---------- ---------- ---------- ---------- ----------

78999-TC BR ---------- ---------- ---------- ---------- ---------- ----------



Radiology


(Non-Facility MRA)






79005 ---------- $152.00 $159.00 $162.00 $152.00 $159.00 $162.00

79005-26 ---------- $99.00 $102.00 $104.00 $99.00 $102.00 $104.00

79005-TC ---------- $53.00 $57.00 $58.00 $53.00 $57.00 $58.00

79101 ---------- $159.00 $166.00 $169.00 $159.00 $166.00 $169.00

79101-26 ---------- $108.00 $111.00 $113.00 $108.00 $111.00 $113.00

79101-TC ---------- $51.00 $55.00 $56.00 $51.00 $55.00 $56.00

79200 $203.00 $155.00 $161.00 $164.00 $155.00 $161.00 $164.00

79200-26 $102.00 $96.00 $98.00 $99.00 $96.00 $98.00 $99.00

79200-TC $97.00 $59.00 $63.00 $64.00 $59.00 $63.00 $64.00

79300 BR ---------- ---------- ---------- ---------- ---------- ----------

79300-26 $83.00 $90.00 $93.00 $96.00 $90.00 $93.00 $96.00

79300-TC BR ---------- ---------- ---------- ---------- ---------- ----------

79403 ---------- $212.00 $222.00 $228.00 $212.00 $222.00 $228.00

79403-26 ---------- $124.00 $127.00 $131.00 $124.00 $127.00 $131.00

79403-TC ---------- $89.00 $95.00 $97.00 $89.00 $95.00 $97.00

79440 $204.00 $164.00 $171.00 $175.00 $164.00 $171.00 $175.00

79440-26 $104.00 $109.00 $113.00 $116.00 $109.00 $113.00 $116.00

79440-TC $97.00 $54.00 $58.00 $59.00 $54.00 $58.00 $59.00

79445 ---------- BR BR BR BR BR BR

79445-26 ---------- $130.00 $134.00 $138.00 $130.00 $134.00 $138.00

79445-TC ---------- BR BR BR BR BR BR

79999 BR ---------- ---------- ---------- ---------- ---------- ----------

79999-26 BR ---------- ---------- ---------- ---------- ---------- ----------

79999-TC BR ---------- ---------- ---------- ---------- ---------- ----------

G0130 ---------- $37.00 $39.00 $40.00 $37.00 $39.00 $40.00

G0130-26 ---------- $13.00 $13.00 $13.00 $13.00 $13.00 $13.00

G0130-TC ---------- $25.00 $26.00 $27.00 $25.00 $26.00 $27.00

G0202 ---------- $147.00 $156.00 $159.00 $147.00 $156.00 $159.00

G0202-26 ---------- $42.00 $43.00 $44.00 $42.00 $43.00 $44.00

G0202-TC ---------- $106.00 $113.00 $115.00 $106.00 $113.00 $115.00

G0204 ---------- $183.00 $193.00 $197.00 $183.00 $193.00 $197.00

G0204-26 ---------- $55.00 $57.00 $58.00 $55.00 $57.00 $58.00

G0204-TC ---------- $128.00 $137.00 $139.00 $128.00 $137.00 $139.00

G0206 ---------- $144.00 $153.00 $156.00 $144.00 $153.00 $156.00

G0206-26 ---------- $44.00 $46.00 $47.00 $44.00 $46.00 $47.00

G0206-TC ---------- $100.00 $107.00 $108.00 $100.00 $107.00 $108.00

G0252-26 ---------- $83.00 $85.00 $87.00 $83.00 $85.00 $87.00

G0278 ---------- $16.00 $18.00 $20.00 $16.00 $18.00 $20.00

G0279 ---------- $61.00 $64.00 $65.00 $61.00 $64.00 $65.00

G0279-26 ---------- $34.00 $35.00 $36.00 $34.00 $35.00 $36.00

G0279-TC ---------- $27.00 $29.00 $29.00 $27.00 $29.00 $29.00

G0288 ---------- $40.00 $44.00 $47.00 $40.00 $44.00 $47.00

G0297 ---------- $272.00 $288.00 $292.00 $272.00 $288.00 $292.00

G0297-26 ---------- $57.00 $58.00 $59.00 $57.00 $58.00 $59.00

G0297-TC ---------- $215.00 $230.00 $233.00 $215.00 $230.00 $233.00

G0365 ---------- $133.00 $142.00 $144.00 $133.00 $142.00 $144.00

G0365-26 ---------- $14.00 $15.00 $16.00 $14.00 $15.00 $16.00

G0365-TC ---------- $119.00 $127.00 $128.00 $119.00 $127.00 $128.00

G6001 ---------- $57.00 $60.00 $61.00 $57.00 $60.00 $61.00

G6001-26 ---------- $33.00 $34.00 $35.00 $33.00 $34.00 $35.00



Radiology


(Non-Facility MRA)






G6001-TC ---------- $24.00 $25.00 $26.00 $24.00 $25.00 $26.00

G6002 ---------- $82.00 $87.00 $89.00 $82.00 $87.00 $89.00

G6002-26 ---------- $23.00 $24.00 $24.00 $23.00 $24.00 $24.00

G6002-TC ---------- $59.00 $64.00 $64.00 $59.00 $64.00 $64.00

G6003 ---------- $204.00 $218.00 $220.00 $204.00 $218.00 $220.00

G6004 ---------- $155.00 $165.00 $167.00 $155.00 $165.00 $167.00

G6005 ---------- $154.00 $165.00 $167.00 $154.00 $165.00 $167.00

G6006 ---------- $154.00 $165.00 $167.00 $154.00 $165.00 $167.00

G6007 ---------- $318.00 $340.00 $343.00 $318.00 $340.00 $343.00

G6008 ---------- $213.00 $227.00 $230.00 $213.00 $227.00 $230.00

G6009 ---------- $212.00 $226.00 $229.00 $212.00 $226.00 $229.00

G6010 ---------- $211.00 $226.00 $228.00 $211.00 $226.00 $228.00

G6011 ---------- $308.00 $329.00 $333.00 $308.00 $329.00 $333.00

G6012 ---------- $281.00 $301.00 $304.00 $281.00 $301.00 $304.00

G6013 ---------- $282.00 $301.00 $304.00 $282.00 $301.00 $304.00

G6014 ---------- $282.00 $301.00 $305.00 $282.00 $301.00 $305.00

G6015 ---------- $369.00 $394.00 $399.00 $369.00 $394.00 $399.00

G6016 ---------- $367.00 $392.00 $396.00 $367.00 $392.00 $396.00

Q0092 ---------- $27.00 $29.00 $29.00 $27.00 $29.00 $29.00



Pathology & Laboratory


(Non-Facility MRA)






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 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






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 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






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 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






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 $26.00 $27.00 $28.00 $22.00 $23.00 $24.00

80500-26 $34.00 ---------- ---------- ---------- ---------- ---------- ----------

80500-TC BR ---------- ---------- ---------- ---------- ---------- ----------

80502 $72.00 $82.00 $85.00 $88.00 $79.00 $82.00 $84.00

80502-26 $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 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






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 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






82105-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

82105-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

82106 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

82106-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

82106-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

82108 $45.00 ---------- ---------- ---------- ---------- ---------- ----------

82108-26 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

82108-TC $32.00 ---------- ---------- ---------- ---------- ---------- ----------

82120 $9.00 ---------- ---------- ---------- ---------- ---------- ----------

82120-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

82120-TC $5.00 ---------- ---------- ---------- ---------- ---------- ----------

82127 $33.00 ---------- ---------- ---------- ---------- ---------- ----------

82127-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

82127-TC $22.00 ---------- ---------- ---------- ---------- ---------- ----------

82128 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

82128-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

82128-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------

82131 $57.00 ---------- ---------- ---------- ---------- ---------- ----------

82131-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

82131-TC $44.00 ---------- ---------- ---------- ---------- ---------- ----------

82135 $41.00 ---------- ---------- ---------- ---------- ---------- ----------

82135-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

82135-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

82136 $38.00 ---------- ---------- ---------- ---------- ---------- ----------

82136-26 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

82136-TC $23.00 ---------- ---------- ---------- ---------- ---------- ----------

82139 $38.00 ---------- ---------- ---------- ---------- ---------- ----------

82139-26 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

82139-TC $23.00 ---------- ---------- ---------- ---------- ---------- ----------

82140 $40.00 ---------- ---------- ---------- ---------- ---------- ----------

82140-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

82140-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

82143 $28.00 ---------- ---------- ---------- ---------- ---------- ----------

82143-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

82143-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------

82150 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

82150-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

82150-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

82154 $34.00 ---------- ---------- ---------- ---------- ---------- ----------

82154-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

82154-TC $20.00 ---------- ---------- ---------- ---------- ---------- ----------

82157 $57.00 ---------- ---------- ---------- ---------- ---------- ----------

82157-26 $17.00 ---------- ---------- ---------- ---------- ---------- ----------

82157-TC $40.00 ---------- ---------- ---------- ---------- ---------- ----------

82160 $67.00 ---------- ---------- ---------- ---------- ---------- ----------

82160-26 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

82160-TC $43.00 ---------- ---------- ---------- ---------- ---------- ----------

82163 $42.00 ---------- ---------- ---------- ---------- ---------- ----------

82163-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

82163-TC $31.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






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 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






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 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






82382-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

82382-TC $25.00 ---------- ---------- ---------- ---------- ---------- ----------

82383 $62.00 ---------- ---------- ---------- ---------- ---------- ----------

82383-26 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

82383-TC $43.00 ---------- ---------- ---------- ---------- ---------- ----------

82384 $62.00 ---------- ---------- ---------- ---------- ---------- ----------

82384-26 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

82384-TC $43.00 ---------- ---------- ---------- ---------- ---------- ----------

82387 $34.00 ---------- ---------- ---------- ---------- ---------- ----------

82387-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

82387-TC $23.00 ---------- ---------- ---------- ---------- ---------- ----------

82390 $24.00 ---------- ---------- ---------- ---------- ---------- ----------

82390-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

82390-TC $17.00 ---------- ---------- ---------- ---------- ---------- ----------

82397 $22.00 ---------- ---------- ---------- ---------- ---------- ----------

82397-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

82397-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

82415 $28.00 ---------- ---------- ---------- ---------- ---------- ----------

82415-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

82415-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------

82435 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

82435-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------

82435-TC $6.00 ---------- ---------- ---------- ---------- ---------- ----------

82436 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

82436-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

82436-TC $10.00 ---------- ---------- ---------- ---------- ---------- ----------

82438 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

82438-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

82438-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

82441 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

82441-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

82441-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

82465 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

82465-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------

82465-TC $6.00 ---------- ---------- ---------- ---------- ---------- ----------

82480 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

82480-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

82480-TC $17.00 ---------- ---------- ---------- ---------- ---------- ----------

82482 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

82482-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

82482-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

82485 $37.00 ---------- ---------- ---------- ---------- ---------- ----------

82485-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

82485-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

82495 $48.00 ---------- ---------- ---------- ---------- ---------- ----------

82495-26 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

82495-TC $32.00 ---------- ---------- ---------- ---------- ---------- ----------

82507 $55.00 ---------- ---------- ---------- ---------- ---------- ----------

82507-26 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

82507-TC $39.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






82523 $43.00 ---------- ---------- ---------- ---------- ---------- ----------

82523-26 $17.00 ---------- ---------- ---------- ---------- ---------- ----------

82523-TC $25.00 ---------- ---------- ---------- ---------- ---------- ----------

82525 $34.00 ---------- ---------- ---------- ---------- ---------- ----------

82525-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

82525-TC $23.00 ---------- ---------- ---------- ---------- ---------- ----------

82528 $40.00 ---------- ---------- ---------- ---------- ---------- ----------

82528-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

82528-TC $26.00 ---------- ---------- ---------- ---------- ---------- ----------

82530 $38.00 ---------- ---------- ---------- ---------- ---------- ----------

82530-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

82530-TC $25.00 ---------- ---------- ---------- ---------- ---------- ----------

82533 $35.00 ---------- ---------- ---------- ---------- ---------- ----------

82533-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

82533-TC $24.00 ---------- ---------- ---------- ---------- ---------- ----------

82540 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

82540-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

82540-TC $6.00 ---------- ---------- ---------- ---------- ---------- ----------

82542 $42.00 ---------- ---------- ---------- ---------- ---------- ----------

82542-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

82542-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

82550 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

82550-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

82550-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

82552 $33.00 ---------- ---------- ---------- ---------- ---------- ----------

82552-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

82552-TC $22.00 ---------- ---------- ---------- ---------- ---------- ----------

82553 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

82553-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

82553-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

82554 $19.00 ---------- ---------- ---------- ---------- ---------- ----------

82554-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

82554-TC $13.00 ---------- ---------- ---------- ---------- ---------- ----------

82565 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

82565-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------

82565-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

82570 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

82570-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------

82570-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

82575 $25.00 ---------- ---------- ---------- ---------- ---------- ----------

82575-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

82575-TC $17.00 ---------- ---------- ---------- ---------- ---------- ----------

82585 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

82585-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

82585-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

82595 $31.00 ---------- ---------- ---------- ---------- ---------- ----------

82595-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

82595-TC $21.00 ---------- ---------- ---------- ---------- ---------- ----------

82600 $40.00 ---------- ---------- ---------- ---------- ---------- ----------

82600-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






82600-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

82607 $38.00 ---------- ---------- ---------- ---------- ---------- ----------

82607-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

82607-TC $27.00 ---------- ---------- ---------- ---------- ---------- ----------

82608 $40.00 ---------- ---------- ---------- ---------- ---------- ----------

82608-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

82608-TC $26.00 ---------- ---------- ---------- ---------- ---------- ----------

82615 $17.00 ---------- ---------- ---------- ---------- ---------- ----------

82615-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

82615-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

82626 $59.00 ---------- ---------- ---------- ---------- ---------- ----------

82626-26 $19.00 ---------- ---------- ---------- ---------- ---------- ----------

82626-TC $40.00 ---------- ---------- ---------- ---------- ---------- ----------

82627 $37.00 ---------- ---------- ---------- ---------- ---------- ----------

82627-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

82627-TC $24.00 ---------- ---------- ---------- ---------- ---------- ----------

82633 $81.00 ---------- ---------- ---------- ---------- ---------- ----------

82633-26 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

82633-TC $56.00 ---------- ---------- ---------- ---------- ---------- ----------

82634 $81.00 ---------- ---------- ---------- ---------- ---------- ----------

82634-26 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

82634-TC $56.00 ---------- ---------- ---------- ---------- ---------- ----------

82638 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

82638-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

82638-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

82652 $89.00 ---------- ---------- ---------- ---------- ---------- ----------

82652-26 $25.00 ---------- ---------- ---------- ---------- ---------- ----------

82652-TC $62.00 ---------- ---------- ---------- ---------- ---------- ----------

82657 $42.00 ---------- ---------- ---------- ---------- ---------- ----------

82657-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

82657-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

82658 $42.00 ---------- ---------- ---------- ---------- ---------- ----------

82658-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

82658-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

82664 $40.00 ---------- ---------- ---------- ---------- ---------- ----------

82664-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

82664-TC $26.00 ---------- ---------- ---------- ---------- ---------- ----------

82668 $45.00 ---------- ---------- ---------- ---------- ---------- ----------

82668-26 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

82668-TC $32.00 ---------- ---------- ---------- ---------- ---------- ----------

82670 $61.00 ---------- ---------- ---------- ---------- ---------- ----------

82670-26 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

82670-TC $42.00 ---------- ---------- ---------- ---------- ---------- ----------

82671 $61.00 ---------- ---------- ---------- ---------- ---------- ----------

82671-26 $17.00 ---------- ---------- ---------- ---------- ---------- ----------

82671-TC $43.00 ---------- ---------- ---------- ---------- ---------- ----------

82672 $57.00 ---------- ---------- ---------- ---------- ---------- ----------

82672-26 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

82672-TC $41.00 ---------- ---------- ---------- ---------- ---------- ----------

82677 $52.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






82677-26 $17.00 ---------- ---------- ---------- ---------- ---------- ----------

82677-TC $35.00 ---------- ---------- ---------- ---------- ---------- ----------

82679 $70.00 ---------- ---------- ---------- ---------- ---------- ----------

82679-26 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

82679-TC $48.00 ---------- ---------- ---------- ---------- ---------- ----------

82693 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

82693-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

82693-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

82696 $57.00 ---------- ---------- ---------- ---------- ---------- ----------

82696-26 $19.00 ---------- ---------- ---------- ---------- ---------- ----------

82696-TC $38.00 ---------- ---------- ---------- ---------- ---------- ----------

82705 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

82705-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

82705-TC $9.00 ---------- ---------- ---------- ---------- ---------- ----------

82710 $42.00 ---------- ---------- ---------- ---------- ---------- ----------

82710-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

82710-TC $29.00 ---------- ---------- ---------- ---------- ---------- ----------

82715 $33.00 ---------- ---------- ---------- ---------- ---------- ----------

82715-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

82715-TC $21.00 ---------- ---------- ---------- ---------- ---------- ----------

82725 $28.00 ---------- ---------- ---------- ---------- ---------- ----------

82725-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

82725-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------

82726 $42.00 ---------- ---------- ---------- ---------- ---------- ----------

82726-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

82726-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

82728 $24.00 ---------- ---------- ---------- ---------- ---------- ----------

82728-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

82728-TC $17.00 ---------- ---------- ---------- ---------- ---------- ----------

82735 $36.00 ---------- ---------- ---------- ---------- ---------- ----------

82735-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

82735-TC $23.00 ---------- ---------- ---------- ---------- ---------- ----------

82746 $39.00 ---------- ---------- ---------- ---------- ---------- ----------

82746-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

82746-TC $25.00 ---------- ---------- ---------- ---------- ---------- ----------

82747 $29.00 ---------- ---------- ---------- ---------- ---------- ----------

82747-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

82747-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------

82757 $36.00 ---------- ---------- ---------- ---------- ---------- ----------

82757-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

82757-TC $24.00 ---------- ---------- ---------- ---------- ---------- ----------

82759 $38.00 ---------- ---------- ---------- ---------- ---------- ----------

82759-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

82759-TC $25.00 ---------- ---------- ---------- ---------- ---------- ----------

82760 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

82760-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

82760-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

82775 $47.00 ---------- ---------- ---------- ---------- ---------- ----------

82775-26 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

82775-TC $33.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






82776 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

82776-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

82776-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

82784 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

82784-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

82784-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

82785 $33.00 ---------- ---------- ---------- ---------- ---------- ----------

82785-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

82785-TC $21.00 ---------- ---------- ---------- ---------- ---------- ----------

82787 $54.00 ---------- ---------- ---------- ---------- ---------- ----------

82787-26 $17.00 ---------- ---------- ---------- ---------- ---------- ----------

82787-TC $37.00 ---------- ---------- ---------- ---------- ---------- ----------

82800 $22.00 ---------- ---------- ---------- ---------- ---------- ----------

82800-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

82800-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

82803 $53.00 ---------- ---------- ---------- ---------- ---------- ----------

82803-26 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

82803-TC $37.00 ---------- ---------- ---------- ---------- ---------- ----------

82805 $36.00 ---------- ---------- ---------- ---------- ---------- ----------

82805-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

82805-TC $24.00 ---------- ---------- ---------- ---------- ---------- ----------

82810 $28.00 ---------- ---------- ---------- ---------- ---------- ----------

82810-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

82810-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------

82820 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

82820-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

82820-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

82938 $48.00 ---------- ---------- ---------- ---------- ---------- ----------

82938-26 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

82938-TC $32.00 ---------- ---------- ---------- ---------- ---------- ----------

82941 $47.00 ---------- ---------- ---------- ---------- ---------- ----------

82941-26 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

82941-TC $32.00 ---------- ---------- ---------- ---------- ---------- ----------

82943 $38.00 ---------- ---------- ---------- ---------- ---------- ----------

82943-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

82943-TC $25.00 ---------- ---------- ---------- ---------- ---------- ----------

82945 $9.00 ---------- ---------- ---------- ---------- ---------- ----------

82945-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

82945-TC $5.00 ---------- ---------- ---------- ---------- ---------- ----------

82946 $29.00 ---------- ---------- ---------- ---------- ---------- ----------

82946-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

82946-TC $21.00 ---------- ---------- ---------- ---------- ---------- ----------

82947 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

82947-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

82947-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

82948 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

82948-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

82948-TC $3.00 ---------- ---------- ---------- ---------- ---------- ----------

82950 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

82950-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






82950-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

82951 $22.00 ---------- ---------- ---------- ---------- ---------- ----------

82951-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

82951-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

82952 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

82952-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

82952-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

82955 $25.00 ---------- ---------- ---------- ---------- ---------- ----------

82955-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

82955-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

82960 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

82960-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

82960-TC $10.00 ---------- ---------- ---------- ---------- ---------- ----------

82962 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

82962-26 $1.00 ---------- ---------- ---------- ---------- ---------- ----------

82962-TC $4.00 ---------- ---------- ---------- ---------- ---------- ----------

82963 $54.00 ---------- ---------- ---------- ---------- ---------- ----------

82963-26 $17.00 ---------- ---------- ---------- ---------- ---------- ----------

82963-TC $37.00 ---------- ---------- ---------- ---------- ---------- ----------

82965 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

82965-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

82965-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

82977 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

82977-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

82977-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

82978 $25.00 ---------- ---------- ---------- ---------- ---------- ----------

82978-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

82978-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

82979 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

82979-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

82979-TC $13.00 ---------- ---------- ---------- ---------- ---------- ----------

82985 $41.00 ---------- ---------- ---------- ---------- ---------- ----------

82985-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

82985-TC $29.00 ---------- ---------- ---------- ---------- ---------- ----------

83001 $40.00 ---------- ---------- ---------- ---------- ---------- ----------

83001-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

83001-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

83002 $42.00 ---------- ---------- ---------- ---------- ---------- ----------

83002-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

83002-TC $29.00 ---------- ---------- ---------- ---------- ---------- ----------

83003 $36.00 ---------- ---------- ---------- ---------- ---------- ----------

83003-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

83003-TC $25.00 ---------- ---------- ---------- ---------- ---------- ----------

83010 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

83010-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

83010-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

83012 $36.00 ---------- ---------- ---------- ---------- ---------- ----------

83012-26 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

83012-TC $21.00 ---------- ---------- ---------- ---------- ---------- ----------

83013 $133.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






83013-26 $38.00 ---------- ---------- ---------- ---------- ---------- ----------

83013-TC $94.00 ---------- ---------- ---------- ---------- ---------- ----------

83014 $19.00 ---------- ---------- ---------- ---------- ---------- ----------

83014-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

83014-TC $13.00 ---------- ---------- ---------- ---------- ---------- ----------

83015 $51.00 ---------- ---------- ---------- ---------- ---------- ----------

83015-26 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

83015-TC $36.00 ---------- ---------- ---------- ---------- ---------- ----------

83018 $56.00 ---------- ---------- ---------- ---------- ---------- ----------

83018-26 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

83018-TC $40.00 ---------- ---------- ---------- ---------- ---------- ----------

83020 $24.00 ---------- ---------- ---------- ---------- ---------- ----------

83020-26 $6.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00

83020-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

83021 $39.00 ---------- ---------- ---------- ---------- ---------- ----------

83021-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

83021-TC $25.00 ---------- ---------- ---------- ---------- ---------- ----------

83026 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

83026-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

83026-TC $3.00 ---------- ---------- ---------- ---------- ---------- ----------

83030 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

83030-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

83030-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

83033 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

83033-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

83033-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

83036 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

83036-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

83036-TC $10.00 ---------- ---------- ---------- ---------- ---------- ----------

83045 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

83045-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

83045-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

83050 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

83050-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

83050-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

83051 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

83051-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

83051-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

83060 $22.00 ---------- ---------- ---------- ---------- ---------- ----------

83060-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

83060-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

83065 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

83065-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

83065-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

83068 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

83068-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

83068-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

83069 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

83069-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

83069-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






83070 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

83070-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

83070-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

83080 $38.00 ---------- ---------- ---------- ---------- ---------- ----------

83080-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

83080-TC $26.00 ---------- ---------- ---------- ---------- ---------- ----------

83088 $59.00 ---------- ---------- ---------- ---------- ---------- ----------

83088-26 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

83088-TC $41.00 ---------- ---------- ---------- ---------- ---------- ----------

83090 $38.00 ---------- ---------- ---------- ---------- ---------- ----------

83090-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

83090-TC $25.00 ---------- ---------- ---------- ---------- ---------- ----------

83150 $49.00 ---------- ---------- ---------- ---------- ---------- ----------

83150-26 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

83150-TC $33.00 ---------- ---------- ---------- ---------- ---------- ----------

83491 $37.00 ---------- ---------- ---------- ---------- ---------- ----------

83491-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

83491-TC $25.00 ---------- ---------- ---------- ---------- ---------- ----------

83497 $35.00 ---------- ---------- ---------- ---------- ---------- ----------

83497-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

83497-TC $23.00 ---------- ---------- ---------- ---------- ---------- ----------

83498 $62.00 ---------- ---------- ---------- ---------- ---------- ----------

83498-26 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

83498-TC $41.00 ---------- ---------- ---------- ---------- ---------- ----------

83499 $51.00 ---------- ---------- ---------- ---------- ---------- ----------

83499-26 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

83499-TC $36.00 ---------- ---------- ---------- ---------- ---------- ----------

83500 $69.00 ---------- ---------- ---------- ---------- ---------- ----------

83500-26 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

83500-TC $45.00 ---------- ---------- ---------- ---------- ---------- ----------

83505 $77.00 ---------- ---------- ---------- ---------- ---------- ----------

83505-26 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

83505-TC $54.00 ---------- ---------- ---------- ---------- ---------- ----------

83516 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

83516-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

83516-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

83518 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

83518-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

83518-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

83519 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

83519-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

83519-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

83520 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

83520-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

83520-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

83525 $31.00 ---------- ---------- ---------- ---------- ---------- ----------

83525-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

83525-TC $21.00 ---------- ---------- ---------- ---------- ---------- ----------

83527 $35.00 ---------- ---------- ---------- ---------- ---------- ----------

83527-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






83527-TC $23.00 ---------- ---------- ---------- ---------- ---------- ----------

83528 $43.00 ---------- ---------- ---------- ---------- ---------- ----------

83528-26 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

83528-TC $29.00 ---------- ---------- ---------- ---------- ---------- ----------

83540 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

83540-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

83540-TC $13.00 ---------- ---------- ---------- ---------- ---------- ----------

83550 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

83550-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

83550-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

83570 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

83570-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

83570-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

83582 $34.00 ---------- ---------- ---------- ---------- ---------- ----------

83582-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

83582-TC $24.00 ---------- ---------- ---------- ---------- ---------- ----------

83586 $38.00 ---------- ---------- ---------- ---------- ---------- ----------

83586-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

83586-TC $24.00 ---------- ---------- ---------- ---------- ---------- ----------

83593 $59.00 ---------- ---------- ---------- ---------- ---------- ----------

83593-26 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

83593-TC $41.00 ---------- ---------- ---------- ---------- ---------- ----------

83605 $19.00 ---------- ---------- ---------- ---------- ---------- ----------

83605-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

83605-TC $13.00 ---------- ---------- ---------- ---------- ---------- ----------

83615 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

83615-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

83615-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

83625 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

83625-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

83625-TC $17.00 ---------- ---------- ---------- ---------- ---------- ----------

83632 $42.00 ---------- ---------- ---------- ---------- ---------- ----------

83632-26 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

83632-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

83655 $31.00 ---------- ---------- ---------- ---------- ---------- ----------

83655-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

83655-TC $21.00 ---------- ---------- ---------- ---------- ---------- ----------

83670 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

83670-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

83670-TC $13.00 ---------- ---------- ---------- ---------- ---------- ----------

83690 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

83690-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

83690-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

83718 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

83718-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

83718-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

83719 $42.00 ---------- ---------- ---------- ---------- ---------- ----------

83719-26 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

83719-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

83721 $16.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






83721-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

83721-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

83727 $43.00 ---------- ---------- ---------- ---------- ---------- ----------

83727-26 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

83727-TC $29.00 ---------- ---------- ---------- ---------- ---------- ----------

83735 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

83735-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

83735-TC $10.00 ---------- ---------- ---------- ---------- ---------- ----------

83775 $17.00 ---------- ---------- ---------- ---------- ---------- ----------

83775-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

83775-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

83785 $58.00 ---------- ---------- ---------- ---------- ---------- ----------

83785-26 $17.00 ---------- ---------- ---------- ---------- ---------- ----------

83785-TC $41.00 ---------- ---------- ---------- ---------- ---------- ----------

83789 $39.00 ---------- ---------- ---------- ---------- ---------- ----------

83789-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

83789-TC $25.00 ---------- ---------- ---------- ---------- ---------- ----------

83825 $34.00 ---------- ---------- ---------- ---------- ---------- ----------

83825-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

83825-TC $22.00 ---------- ---------- ---------- ---------- ---------- ----------

83835 $41.00 ---------- ---------- ---------- ---------- ---------- ----------

83835-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

83835-TC $29.00 ---------- ---------- ---------- ---------- ---------- ----------

83857 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

83857-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

83857-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

83864 $32.00 ---------- ---------- ---------- ---------- ---------- ----------

83864-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

83864-TC $22.00 ---------- ---------- ---------- ---------- ---------- ----------

83872 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

83872-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

83872-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

83873 $54.00 ---------- ---------- ---------- ---------- ---------- ----------

83873-26 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

83873-TC $36.00 ---------- ---------- ---------- ---------- ---------- ----------

83874 $25.00 ---------- ---------- ---------- ---------- ---------- ----------

83874-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

83874-TC $17.00 ---------- ---------- ---------- ---------- ---------- ----------

83880 BR ---------- ---------- ---------- ---------- ---------- ----------

83880-26 BR ---------- ---------- ---------- ---------- ---------- ----------

83880-TC BR ---------- ---------- ---------- ---------- ---------- ----------

83883 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

83883-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

83883-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

83885 $45.00 ---------- ---------- ---------- ---------- ---------- ----------

83885-26 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

83885-TC $32.00 ---------- ---------- ---------- ---------- ---------- ----------

83915 $31.00 ---------- ---------- ---------- ---------- ---------- ----------

83915-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

83915-TC $20.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






83916 $54.00 ---------- ---------- ---------- ---------- ---------- ----------

83916-26 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

83916-TC $36.00 ---------- ---------- ---------- ---------- ---------- ----------

83918 $41.00 ---------- ---------- ---------- ---------- ---------- ----------

83918-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

83918-TC $29.00 ---------- ---------- ---------- ---------- ---------- ----------

83919 $42.00 ---------- ---------- ---------- ---------- ---------- ----------

83919-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

83919-TC $29.00 ---------- ---------- ---------- ---------- ---------- ----------

83921 $37.00 ---------- ---------- ---------- ---------- ---------- ----------

83921-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

83921-TC $25.00 ---------- ---------- ---------- ---------- ---------- ----------

83930 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

83930-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

83930-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

83935 $17.00 ---------- ---------- ---------- ---------- ---------- ----------

83935-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

83935-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

83937 $29.00 ---------- ---------- ---------- ---------- ---------- ----------

83937-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

83937-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------

83945 $32.00 ---------- ---------- ---------- ---------- ---------- ----------

83945-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

83945-TC $20.00 ---------- ---------- ---------- ---------- ---------- ----------

83950 BR ---------- ---------- ---------- ---------- ---------- ----------

83950-26 BR ---------- ---------- ---------- ---------- ---------- ----------

83950-TC BR ---------- ---------- ---------- ---------- ---------- ----------

83970 $94.00 ---------- ---------- ---------- ---------- ---------- ----------

83970-26 $31.00 ---------- ---------- ---------- ---------- ---------- ----------

83970-TC $62.00 ---------- ---------- ---------- ---------- ---------- ----------

83986 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

83986-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

83986-TC $5.00 ---------- ---------- ---------- ---------- ---------- ----------

83992 $40.00 ---------- ---------- ---------- ---------- ---------- ----------

83992-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

83992-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

84030 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

84030-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

84030-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

84035 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

84035-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

84035-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

84060 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

84060-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

84060-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

84061 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

84061-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

84061-TC $10.00 ---------- ---------- ---------- ---------- ---------- ----------

84066 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

84066-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






84066-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

84075 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

84075-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

84075-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

84078 $19.00 ---------- ---------- ---------- ---------- ---------- ----------

84078-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

84078-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

84080 $36.00 ---------- ---------- ---------- ---------- ---------- ----------

84080-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

84080-TC $24.00 ---------- ---------- ---------- ---------- ---------- ----------

84081 $45.00 ---------- ---------- ---------- ---------- ---------- ----------

84081-26 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

84081-TC $31.00 ---------- ---------- ---------- ---------- ---------- ----------

84085 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

84085-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

84085-TC $10.00 ---------- ---------- ---------- ---------- ---------- ----------

84087 $25.00 ---------- ---------- ---------- ---------- ---------- ----------

84087-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

84087-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

84100 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

84100-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

84100-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

84105 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

84105-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

84105-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

84106 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

84106-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------

84106-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

84110 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

84110-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

84110-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

84119 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

84119-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

84119-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

84120 $38.00 ---------- ---------- ---------- ---------- ---------- ----------

84120-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

84120-TC $26.00 ---------- ---------- ---------- ---------- ---------- ----------

84126 $71.00 ---------- ---------- ---------- ---------- ---------- ----------

84126-26 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

84126-TC $49.00 ---------- ---------- ---------- ---------- ---------- ----------

84132 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

84132-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

84132-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

84133 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

84133-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

84133-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

84134 $24.00 ---------- ---------- ---------- ---------- ---------- ----------

84134-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

84134-TC $17.00 ---------- ---------- ---------- ---------- ---------- ----------

84135 $57.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






84135-26 $19.00 ---------- ---------- ---------- ---------- ---------- ----------

84135-TC $38.00 ---------- ---------- ---------- ---------- ---------- ----------

84138 $56.00 ---------- ---------- ---------- ---------- ---------- ----------

84138-26 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

84138-TC $38.00 ---------- ---------- ---------- ---------- ---------- ----------

84140 $41.00 ---------- ---------- ---------- ---------- ---------- ----------

84140-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

84140-TC $33.00 ---------- ---------- ---------- ---------- ---------- ----------

84143 $62.00 ---------- ---------- ---------- ---------- ---------- ----------

84143-26 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

84143-TC $41.00 ---------- ---------- ---------- ---------- ---------- ----------

84144 $38.00 ---------- ---------- ---------- ---------- ---------- ----------

84144-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

84144-TC $31.00 ---------- ---------- ---------- ---------- ---------- ----------

84146 $53.00 ---------- ---------- ---------- ---------- ---------- ----------

84146-26 $17.00 ---------- ---------- ---------- ---------- ---------- ----------

84146-TC $36.00 ---------- ---------- ---------- ---------- ---------- ----------

84150 $69.00 ---------- ---------- ---------- ---------- ---------- ----------

84150-26 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

84150-TC $47.00 ---------- ---------- ---------- ---------- ---------- ----------

84152 $42.00 ---------- ---------- ---------- ---------- ---------- ----------

84152-26 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

84152-TC $27.00 ---------- ---------- ---------- ---------- ---------- ----------

84153 $33.00 ---------- ---------- ---------- ---------- ---------- ----------

84153-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

84153-TC $21.00 ---------- ---------- ---------- ---------- ---------- ----------

84154 $33.00 ---------- ---------- ---------- ---------- ---------- ----------

84154-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

84154-TC $21.00 ---------- ---------- ---------- ---------- ---------- ----------

84155 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

84155-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

84155-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

84160 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

84160-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------

84160-TC $2.00 ---------- ---------- ---------- ---------- ---------- ----------

84165 $24.00 ---------- ---------- ---------- ---------- ---------- ----------

84165-26 $8.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00

84165-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

84166 ---------- BR BR BR BR BR BR

84166-26 ---------- $20.00 $21.00 $21.00 $20.00 $21.00 $21.00

84166-TC ---------- BR BR BR BR BR BR

84181 $29.00 ---------- ---------- ---------- ---------- ---------- ----------

84181-26 $10.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00

84181-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------

84182 $33.00 ---------- ---------- ---------- ---------- ---------- ----------

84182-26 $11.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00

84182-TC $21.00 ---------- ---------- ---------- ---------- ---------- ----------

84202 $39.00 ---------- ---------- ---------- ---------- ---------- ----------

84202-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

84202-TC $25.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






84203 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

84203-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

84203-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

84206 $32.00 ---------- ---------- ---------- ---------- ---------- ----------

84206-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

84206-TC $21.00 ---------- ---------- ---------- ---------- ---------- ----------

84207 $54.00 ---------- ---------- ---------- ---------- ---------- ----------

84207-26 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

84207-TC $38.00 ---------- ---------- ---------- ---------- ---------- ----------

84210 $24.00 ---------- ---------- ---------- ---------- ---------- ----------

84210-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

84210-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

84220 $25.00 ---------- ---------- ---------- ---------- ---------- ----------

84220-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

84220-TC $17.00 ---------- ---------- ---------- ---------- ---------- ----------

84228 $32.00 ---------- ---------- ---------- ---------- ---------- ----------

84228-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

84228-TC $21.00 ---------- ---------- ---------- ---------- ---------- ----------

84233 $116.00 ---------- ---------- ---------- ---------- ---------- ----------

84233-26 $35.00 ---------- ---------- ---------- ---------- ---------- ----------

84233-TC $81.00 ---------- ---------- ---------- ---------- ---------- ----------

84234 $116.00 ---------- ---------- ---------- ---------- ---------- ----------

84234-26 $35.00 ---------- ---------- ---------- ---------- ---------- ----------

84234-TC $81.00 ---------- ---------- ---------- ---------- ---------- ----------

84235 $114.00 ---------- ---------- ---------- ---------- ---------- ----------

84235-26 $34.00 ---------- ---------- ---------- ---------- ---------- ----------

84235-TC $80.00 ---------- ---------- ---------- ---------- ---------- ----------

84238 $97.00 ---------- ---------- ---------- ---------- ---------- ----------

84238-26 $32.00 ---------- ---------- ---------- ---------- ---------- ----------

84238-TC $65.00 ---------- ---------- ---------- ---------- ---------- ----------

84244 $47.00 ---------- ---------- ---------- ---------- ---------- ----------

84244-26 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

84244-TC $32.00 ---------- ---------- ---------- ---------- ---------- ----------

84252 $47.00 ---------- ---------- ---------- ---------- ---------- ----------

84252-26 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

84252-TC $33.00 ---------- ---------- ---------- ---------- ---------- ----------

84255 $58.00 ---------- ---------- ---------- ---------- ---------- ----------

84255-26 $17.00 ---------- ---------- ---------- ---------- ---------- ----------

84255-TC $41.00 ---------- ---------- ---------- ---------- ---------- ----------

84260 $54.00 ---------- ---------- ---------- ---------- ---------- ----------

84260-26 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

84260-TC $38.00 ---------- ---------- ---------- ---------- ---------- ----------

84270 $36.00 ---------- ---------- ---------- ---------- ---------- ----------

84270-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

84270-TC $24.00 ---------- ---------- ---------- ---------- ---------- ----------

84275 $37.00 ---------- ---------- ---------- ---------- ---------- ----------

84275-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

84275-TC $25.00 ---------- ---------- ---------- ---------- ---------- ----------

84285 $59.00 ---------- ---------- ---------- ---------- ---------- ----------

84285-26 $17.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






84285-TC $42.00 ---------- ---------- ---------- ---------- ---------- ----------

84295 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

84295-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

84295-TC $6.00 ---------- ---------- ---------- ---------- ---------- ----------

84300 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

84300-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

84300-TC $6.00 ---------- ---------- ---------- ---------- ---------- ----------

84302 BR ---------- ---------- ---------- ---------- ---------- ----------

84302-26 BR ---------- ---------- ---------- ---------- ---------- ----------

84302-TC BR ---------- ---------- ---------- ---------- ---------- ----------

84305 $34.00 ---------- ---------- ---------- ---------- ---------- ----------

84305-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

84305-TC $22.00 ---------- ---------- ---------- ---------- ---------- ----------

84307 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

84307-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

84307-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

84311 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

84311-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

84311-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

84315 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

84315-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------

84315-TC $3.00 ---------- ---------- ---------- ---------- ---------- ----------

84375 $37.00 ---------- ---------- ---------- ---------- ---------- ----------

84375-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

84375-TC $25.00 ---------- ---------- ---------- ---------- ---------- ----------

84376 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

84376-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

84376-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

84377 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

84377-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

84377-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

84378 $25.00 ---------- ---------- ---------- ---------- ---------- ----------

84378-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

84378-TC $17.00 ---------- ---------- ---------- ---------- ---------- ----------

84379 $25.00 ---------- ---------- ---------- ---------- ---------- ----------

84379-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

84379-TC $17.00 ---------- ---------- ---------- ---------- ---------- ----------

84392 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

84392-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------

84392-TC $6.00 ---------- ---------- ---------- ---------- ---------- ----------

84402 $72.00 ---------- ---------- ---------- ---------- ---------- ----------

84402-26 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

84402-TC $49.00 ---------- ---------- ---------- ---------- ---------- ----------

84403 $67.00 ---------- ---------- ---------- ---------- ---------- ----------

84403-26 $19.00 ---------- ---------- ---------- ---------- ---------- ----------

84403-TC $45.00 ---------- ---------- ---------- ---------- ---------- ----------

84425 $54.00 ---------- ---------- ---------- ---------- ---------- ----------

84425-26 $17.00 ---------- ---------- ---------- ---------- ---------- ----------

84425-TC $37.00 ---------- ---------- ---------- ---------- ---------- ----------

84430 $31.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






84430-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

84430-TC $20.00 ---------- ---------- ---------- ---------- ---------- ----------

84432 $28.00 ---------- ---------- ---------- ---------- ---------- ----------

84432-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

84432-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------

84436 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

84436-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

84436-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

84437 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

84437-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

84437-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

84439 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

84439-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

84439-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

84442 $25.00 ---------- ---------- ---------- ---------- ---------- ----------

84442-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

84442-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------

84443 $32.00 ---------- ---------- ---------- ---------- ---------- ----------

84443-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

84443-TC $23.00 ---------- ---------- ---------- ---------- ---------- ----------

84445 $98.00 ---------- ---------- ---------- ---------- ---------- ----------

84445-26 $29.00 ---------- ---------- ---------- ---------- ---------- ----------

84445-TC $69.00 ---------- ---------- ---------- ---------- ---------- ----------

84446 $35.00 ---------- ---------- ---------- ---------- ---------- ----------

84446-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

84446-TC $23.00 ---------- ---------- ---------- ---------- ---------- ----------

84449 $38.00 ---------- ---------- ---------- ---------- ---------- ----------

84449-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

84449-TC $24.00 ---------- ---------- ---------- ---------- ---------- ----------

84450 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

84450-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

84450-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

84460 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

84460-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

84460-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

84466 $22.00 ---------- ---------- ---------- ---------- ---------- ----------

84466-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

84466-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

84478 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

84478-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

84478-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

84479 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

84479-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

84479-TC $10.00 ---------- ---------- ---------- ---------- ---------- ----------

84480 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

84480-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

84480-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

84481 $33.00 ---------- ---------- ---------- ---------- ---------- ----------

84481-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

84481-TC $22.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






84482 $45.00 ---------- ---------- ---------- ---------- ---------- ----------

84482-26 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

84482-TC $31.00 ---------- ---------- ---------- ---------- ---------- ----------

84484 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

84484-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

84484-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

84485 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

84485-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

84485-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

84488 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

84488-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

84488-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

84490 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

84490-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

84490-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

84510 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

84510-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

84510-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

84512 $17.00 ---------- ---------- ---------- ---------- ---------- ----------

84512-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

84512-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

84520 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

84520-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

84520-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

84525 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

84525-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------

84525-TC $5.00 ---------- ---------- ---------- ---------- ---------- ----------

84540 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

84540-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

84540-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

84545 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

84545-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

84545-TC $13.00 ---------- ---------- ---------- ---------- ---------- ----------

84550 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

84550-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

84550-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

84560 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

84560-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

84560-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

84577 $34.00 ---------- ---------- ---------- ---------- ---------- ----------

84577-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

84577-TC $22.00 ---------- ---------- ---------- ---------- ---------- ----------

84578 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

84578-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------

84578-TC $5.00 ---------- ---------- ---------- ---------- ---------- ----------

84580 $17.00 ---------- ---------- ---------- ---------- ---------- ----------

84580-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

84580-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

84583 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

84583-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






84583-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

84585 $36.00 ---------- ---------- ---------- ---------- ---------- ----------

84585-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

84585-TC $24.00 ---------- ---------- ---------- ---------- ---------- ----------

84586 $42.00 ---------- ---------- ---------- ---------- ---------- ----------

84586-26 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

84586-TC $27.00 ---------- ---------- ---------- ---------- ---------- ----------

84588 $73.00 ---------- ---------- ---------- ---------- ---------- ----------

84588-26 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

84588-TC $47.00 ---------- ---------- ---------- ---------- ---------- ----------

84590 $33.00 ---------- ---------- ---------- ---------- ---------- ----------

84590-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

84590-TC $21.00 ---------- ---------- ---------- ---------- ---------- ----------

84591 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

84591-26 $9.00 ---------- ---------- ---------- ---------- ---------- ----------

84591-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

84597 $37.00 ---------- ---------- ---------- ---------- ---------- ----------

84597-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

84597-TC $25.00 ---------- ---------- ---------- ---------- ---------- ----------

84600 $43.00 ---------- ---------- ---------- ---------- ---------- ----------

84600-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

84600-TC $31.00 ---------- ---------- ---------- ---------- ---------- ----------

84620 $29.00 ---------- ---------- ---------- ---------- ---------- ----------

84620-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

84620-TC $20.00 ---------- ---------- ---------- ---------- ---------- ----------

84630 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

84630-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

84630-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

84681 $52.00 ---------- ---------- ---------- ---------- ---------- ----------

84681-26 $17.00 ---------- ---------- ---------- ---------- ---------- ----------

84681-TC $35.00 ---------- ---------- ---------- ---------- ---------- ----------

84702 $38.00 ---------- ---------- ---------- ---------- ---------- ----------

84702-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

84702-TC $26.00 ---------- ---------- ---------- ---------- ---------- ----------

84703 $22.00 ---------- ---------- ---------- ---------- ---------- ----------

84703-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

84703-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

84830 $17.00 ---------- ---------- ---------- ---------- ---------- ----------

84830-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

84830-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

84999 BR ---------- ---------- ---------- ---------- ---------- ----------

84999-26 BR ---------- ---------- ---------- ---------- ---------- ----------

84999-TC BR ---------- ---------- ---------- ---------- ---------- ----------

85002 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

85002-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

85002-TC $6.00 ---------- ---------- ---------- ---------- ---------- ----------

85004 BR ---------- ---------- ---------- ---------- ---------- ----------

85004-26 BR ---------- ---------- ---------- ---------- ---------- ----------

85004-TC BR ---------- ---------- ---------- ---------- ---------- ----------

85007 $6.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






85007-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

85007-TC $4.00 ---------- ---------- ---------- ---------- ---------- ----------

85008 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

85008-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------

85008-TC $3.00 ---------- ---------- ---------- ---------- ---------- ----------

85009 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

85009-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

85009-TC $5.00 ---------- ---------- ---------- ---------- ---------- ----------

85013 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

85013-26 $1.00 ---------- ---------- ---------- ---------- ---------- ----------

85013-TC $2.00 ---------- ---------- ---------- ---------- ---------- ----------

85014 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

85014-26 $1.00 ---------- ---------- ---------- ---------- ---------- ----------

85014-TC $3.00 ---------- ---------- ---------- ---------- ---------- ----------

85018 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

85018-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------

85018-TC $3.00 ---------- ---------- ---------- ---------- ---------- ----------

85025 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

85025-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

85025-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

85027 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

85027-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

85027-TC $10.00 ---------- ---------- ---------- ---------- ---------- ----------

85032 BR ---------- ---------- ---------- ---------- ---------- ----------

85032-26 BR ---------- ---------- ---------- ---------- ---------- ----------

85032-TC BR ---------- ---------- ---------- ---------- ---------- ----------

85041 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

85041-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

85041-TC $4.00 ---------- ---------- ---------- ---------- ---------- ----------

85044 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

85044-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

85044-TC $6.00 ---------- ---------- ---------- ---------- ---------- ----------

85045 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

85045-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------

85045-TC $4.00 ---------- ---------- ---------- ---------- ---------- ----------

85046 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

85046-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

85046-TC $9.00 ---------- ---------- ---------- ---------- ---------- ----------

85048 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

85048-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

85048-TC $4.00 ---------- ---------- ---------- ---------- ---------- ----------

85049 BR ---------- ---------- ---------- ---------- ---------- ----------

85049-26 BR ---------- ---------- ---------- ---------- ---------- ----------

85049-TC BR ---------- ---------- ---------- ---------- ---------- ----------

85060 $25.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.00

85060-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

85060-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

85097 $59.00 $99.00 $104.00 $106.00 $56.00 $58.00 $60.00

85097-26 $59.00 ---------- ---------- ---------- ---------- ---------- ----------

85097-TC BR ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






85130 $19.00 ---------- ---------- ---------- ---------- ---------- ----------

85130-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

85130-TC $13.00 ---------- ---------- ---------- ---------- ---------- ----------

85170 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

85170-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------

85170-TC $5.00 ---------- ---------- ---------- ---------- ---------- ----------

85175 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

85175-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

85175-TC $6.00 ---------- ---------- ---------- ---------- ---------- ----------

85210 $31.00 ---------- ---------- ---------- ---------- ---------- ----------

85210-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

85210-TC $21.00 ---------- ---------- ---------- ---------- ---------- ----------

85220 $47.00 ---------- ---------- ---------- ---------- ---------- ----------

85220-26 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

85220-TC $32.00 ---------- ---------- ---------- ---------- ---------- ----------

85230 $47.00 ---------- ---------- ---------- ---------- ---------- ----------

85230-26 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

85230-TC $33.00 ---------- ---------- ---------- ---------- ---------- ----------

85240 $48.00 ---------- ---------- ---------- ---------- ---------- ----------

85240-26 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

85240-TC $33.00 ---------- ---------- ---------- ---------- ---------- ----------

85244 $49.00 ---------- ---------- ---------- ---------- ---------- ----------

85244-26 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

85244-TC $34.00 ---------- ---------- ---------- ---------- ---------- ----------

85245 $54.00 ---------- ---------- ---------- ---------- ---------- ----------

85245-26 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

85245-TC $36.00 ---------- ---------- ---------- ---------- ---------- ----------

85246 $54.00 ---------- ---------- ---------- ---------- ---------- ----------

85246-26 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

85246-TC $36.00 ---------- ---------- ---------- ---------- ---------- ----------

85247 $54.00 ---------- ---------- ---------- ---------- ---------- ----------

85247-26 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

85247-TC $36.00 ---------- ---------- ---------- ---------- ---------- ----------

85250 $49.00 ---------- ---------- ---------- ---------- ---------- ----------

85250-26 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

85250-TC $35.00 ---------- ---------- ---------- ---------- ---------- ----------

85260 $49.00 ---------- ---------- ---------- ---------- ---------- ----------

85260-26 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

85260-TC $35.00 ---------- ---------- ---------- ---------- ---------- ----------

85270 $49.00 ---------- ---------- ---------- ---------- ---------- ----------

85270-26 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

85270-TC $35.00 ---------- ---------- ---------- ---------- ---------- ----------

85280 $49.00 ---------- ---------- ---------- ---------- ---------- ----------

85280-26 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

85280-TC $35.00 ---------- ---------- ---------- ---------- ---------- ----------

85290 $44.00 ---------- ---------- ---------- ---------- ---------- ----------

85290-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

85290-TC $32.00 ---------- ---------- ---------- ---------- ---------- ----------

85291 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

85291-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






85291-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

85292 $51.00 ---------- ---------- ---------- ---------- ---------- ----------

85292-26 $17.00 ---------- ---------- ---------- ---------- ---------- ----------

85292-TC $34.00 ---------- ---------- ---------- ---------- ---------- ----------

85293 $51.00 ---------- ---------- ---------- ---------- ---------- ----------

85293-26 $17.00 ---------- ---------- ---------- ---------- ---------- ----------

85293-TC $34.00 ---------- ---------- ---------- ---------- ---------- ----------

85300 $35.00 ---------- ---------- ---------- ---------- ---------- ----------

85300-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

85300-TC $23.00 ---------- ---------- ---------- ---------- ---------- ----------

85301 $29.00 ---------- ---------- ---------- ---------- ---------- ----------

85301-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

85301-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------

85302 $33.00 ---------- ---------- ---------- ---------- ---------- ----------

85302-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

85302-TC $21.00 ---------- ---------- ---------- ---------- ---------- ----------

85303 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

85303-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

85303-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

85305 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

85305-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

85305-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

85306 $29.00 ---------- ---------- ---------- ---------- ---------- ----------

85306-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

85306-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------

85307 $35.00 ---------- ---------- ---------- ---------- ---------- ----------

85307-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

85307-TC $23.00 ---------- ---------- ---------- ---------- ---------- ----------

85335 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

85335-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

85335-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

85337 $19.00 ---------- ---------- ---------- ---------- ---------- ----------

85337-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

85337-TC $13.00 ---------- ---------- ---------- ---------- ---------- ----------

85345 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

85345-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------

85345-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

85347 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

85347-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------

85347-TC $6.00 ---------- ---------- ---------- ---------- ---------- ----------

85348 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

85348-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

85348-TC $6.00 ---------- ---------- ---------- ---------- ---------- ----------

85360 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

85360-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

85360-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

85362 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

85362-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

85362-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

85366 $13.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






85366-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

85366-TC $10.00 ---------- ---------- ---------- ---------- ---------- ----------

85370 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

85370-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

85370-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

85378 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

85378-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

85378-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

85379 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

85379-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

85379-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

85380 BR ---------- ---------- ---------- ---------- ---------- ----------

85380-26 BR ---------- ---------- ---------- ---------- ---------- ----------

85380-TC BR ---------- ---------- ---------- ---------- ---------- ----------

85384 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

85384-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

85384-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

85385 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

85385-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

85385-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

85390 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

85390-26 $2.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00

85390-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

85396 ---------- $23.00 $24.00 $25.00 $23.00 $24.00 $25.00

85400 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

85400-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

85400-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

85410 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

85410-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

85410-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

85415 $28.00 ---------- ---------- ---------- ---------- ---------- ----------

85415-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

85415-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

85420 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

85420-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

85420-TC $13.00 ---------- ---------- ---------- ---------- ---------- ----------

85421 $39.00 ---------- ---------- ---------- ---------- ---------- ----------

85421-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

85421-TC $26.00 ---------- ---------- ---------- ---------- ---------- ----------

85441 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

85441-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------

85441-TC $5.00 ---------- ---------- ---------- ---------- ---------- ----------

85445 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

85445-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

85445-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

85460 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

85460-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

85460-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

85461 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

85461-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






85461-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

85475 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

85475-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

85475-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

85520 $22.00 ---------- ---------- ---------- ---------- ---------- ----------

85520-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

85520-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

85525 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

85525-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

85525-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

85530 $39.00 ---------- ---------- ---------- ---------- ---------- ----------

85530-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

85530-TC $26.00 ---------- ---------- ---------- ---------- ---------- ----------

85536 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

85536-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

85536-TC $10.00 ---------- ---------- ---------- ---------- ---------- ----------

85540 $24.00 ---------- ---------- ---------- ---------- ---------- ----------

85540-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

85540-TC $17.00 ---------- ---------- ---------- ---------- ---------- ----------

85547 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

85547-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

85547-TC $17.00 ---------- ---------- ---------- ---------- ---------- ----------

85549 $45.00 ---------- ---------- ---------- ---------- ---------- ----------

85549-26 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

85549-TC $31.00 ---------- ---------- ---------- ---------- ---------- ----------

85555 $17.00 ---------- ---------- ---------- ---------- ---------- ----------

85555-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

85555-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

85557 $34.00 ---------- ---------- ---------- ---------- ---------- ----------

85557-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

85557-TC $23.00 ---------- ---------- ---------- ---------- ---------- ----------

85576 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

85576-26 $5.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00

85576-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

85597 $32.00 ---------- ---------- ---------- ---------- ---------- ----------

85597-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

85597-TC $21.00 ---------- ---------- ---------- ---------- ---------- ----------

85610 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

85610-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

85610-TC $4.00 ---------- ---------- ---------- ---------- ---------- ----------

85611 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

85611-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------

85611-TC $4.00 ---------- ---------- ---------- ---------- ---------- ----------

85612 $22.00 ---------- ---------- ---------- ---------- ---------- ----------

85612-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

85612-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

85613 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

85613-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

85613-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

85635 $26.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






85635-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

85635-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

85651 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

85651-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------

85651-TC $6.00 ---------- ---------- ---------- ---------- ---------- ----------

85652 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

85652-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------

85652-TC $6.00 ---------- ---------- ---------- ---------- ---------- ----------

85660 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

85660-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

85660-TC $6.00 ---------- ---------- ---------- ---------- ---------- ----------

85670 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

85670-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

85670-TC $10.00 ---------- ---------- ---------- ---------- ---------- ----------

85675 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

85675-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

85675-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

85705 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

85705-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

85705-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

85730 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

85730-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

85730-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

85732 $17.00 ---------- ---------- ---------- ---------- ---------- ----------

85732-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

85732-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

85810 $19.00 ---------- ---------- ---------- ---------- ---------- ----------

85810-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

85810-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

85999 BR ---------- ---------- ---------- ---------- ---------- ----------

85999-26 BR ---------- ---------- ---------- ---------- ---------- ----------

85999-TC BR ---------- ---------- ---------- ---------- ---------- ----------

86000 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

86000-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

86000-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

86001 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

86001-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

86001-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

86003 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86003-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------

86003-TC $3.00 ---------- ---------- ---------- ---------- ---------- ----------

86005 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

86005-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

86005-TC $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86021 $41.00 ---------- ---------- ---------- ---------- ---------- ----------

86021-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

86021-TC $29.00 ---------- ---------- ---------- ---------- ---------- ----------

86022 $57.00 ---------- ---------- ---------- ---------- ---------- ----------

86022-26 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

86022-TC $39.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






86023 $28.00 ---------- ---------- ---------- ---------- ---------- ----------

86023-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

86023-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

86038 $22.00 ---------- ---------- ---------- ---------- ---------- ----------

86038-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86038-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

86039 $19.00 ---------- ---------- ---------- ---------- ---------- ----------

86039-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86039-TC $13.00 ---------- ---------- ---------- ---------- ---------- ----------

86060 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

86060-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

86060-TC $10.00 ---------- ---------- ---------- ---------- ---------- ----------

86063 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86063-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86063-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

86077 $91.00 $63.00 $65.00 $67.00 $59.00 $61.00 $62.00

86077-26 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

86077-TC $64.00 ---------- ---------- ---------- ---------- ---------- ----------

86078 $91.00 $63.00 $65.00 $67.00 $58.00 $60.00 $62.00

86078-26 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

86078-TC $64.00 ---------- ---------- ---------- ---------- ---------- ----------

86079 $79.00 $62.00 $65.00 $67.00 $58.00 $60.00 $62.00

86079-26 $25.00 ---------- ---------- ---------- ---------- ---------- ----------

86079-TC $52.00 ---------- ---------- ---------- ---------- ---------- ----------

86140 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86140-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

86140-TC $10.00 ---------- ---------- ---------- ---------- ---------- ----------

86141 BR ---------- ---------- ---------- ---------- ---------- ----------

86141-26 BR ---------- ---------- ---------- ---------- ---------- ----------

86141-TC BR ---------- ---------- ---------- ---------- ---------- ----------

86146 $58.00 ---------- ---------- ---------- ---------- ---------- ----------

86146-26 $19.00 ---------- ---------- ---------- ---------- ---------- ----------

86146-TC $39.00 ---------- ---------- ---------- ---------- ---------- ----------

86147 $53.00 ---------- ---------- ---------- ---------- ---------- ----------

86147-26 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

86147-TC $36.00 ---------- ---------- ---------- ---------- ---------- ----------

86148 $59.00 ---------- ---------- ---------- ---------- ---------- ----------

86148-26 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86148-TC $38.00 ---------- ---------- ---------- ---------- ---------- ----------

86153-26 ---------- $38.00 $40.00 $40.00 $38.00 $40.00 $40.00

86155 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

86155-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

86155-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

86156 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

86156-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

86156-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86157 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

86157-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

86157-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

86160 $21.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






86160-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

86160-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

86161 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86161-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

86161-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

86162 $54.00 ---------- ---------- ---------- ---------- ---------- ----------

86162-26 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

86162-TC $36.00 ---------- ---------- ---------- ---------- ---------- ----------

86171 $25.00 ---------- ---------- ---------- ---------- ---------- ----------

86171-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86171-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

86185 $19.00 ---------- ---------- ---------- ---------- ---------- ----------

86185-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86185-TC $13.00 ---------- ---------- ---------- ---------- ---------- ----------

86215 $36.00 ---------- ---------- ---------- ---------- ---------- ----------

86215-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

86215-TC $23.00 ---------- ---------- ---------- ---------- ---------- ----------

86225 $36.00 ---------- ---------- ---------- ---------- ---------- ----------

86225-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

86225-TC $24.00 ---------- ---------- ---------- ---------- ---------- ----------

86226 $24.00 ---------- ---------- ---------- ---------- ---------- ----------

86226-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

86226-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

86235 $33.00 ---------- ---------- ---------- ---------- ---------- ----------

86235-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

86235-TC $22.00 ---------- ---------- ---------- ---------- ---------- ----------

86243 $50.00 ---------- ---------- ---------- ---------- ---------- ----------

86243-26 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

86243-TC $35.00 ---------- ---------- ---------- ---------- ---------- ----------

86255 $25.00 ---------- ---------- ---------- ---------- ---------- ----------

86255-26 $8.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00

86255-TC $17.00 ---------- ---------- ---------- ---------- ---------- ----------

86256 $25.00 ---------- ---------- ---------- ---------- ---------- ----------

86256-26 $8.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00

86256-TC $17.00 ---------- ---------- ---------- ---------- ---------- ----------

86277 $41.00 ---------- ---------- ---------- ---------- ---------- ----------

86277-26 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86277-TC $26.00 ---------- ---------- ---------- ---------- ---------- ----------

86280 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

86280-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

86280-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

86294 BR ---------- ---------- ---------- ---------- ---------- ----------

86294-26 BR ---------- ---------- ---------- ---------- ---------- ----------

86294-TC BR ---------- ---------- ---------- ---------- ---------- ----------

86300 $47.00 ---------- ---------- ---------- ---------- ---------- ----------

86300-26 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

86300-TC $32.00 ---------- ---------- ---------- ---------- ---------- ----------

86301 $47.00 ---------- ---------- ---------- ---------- ---------- ----------

86301-26 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

86301-TC $32.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






86304 $47.00 ---------- ---------- ---------- ---------- ---------- ----------

86304-26 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

86304-TC $32.00 ---------- ---------- ---------- ---------- ---------- ----------

86308 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

86308-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

86308-TC $5.00 ---------- ---------- ---------- ---------- ---------- ----------

86309 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

86309-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

86309-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

86310 $19.00 ---------- ---------- ---------- ---------- ---------- ----------

86310-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86310-TC $13.00 ---------- ---------- ---------- ---------- ---------- ----------

86316 $37.00 ---------- ---------- ---------- ---------- ---------- ----------

86316-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

86316-TC $25.00 ---------- ---------- ---------- ---------- ---------- ----------

86317 $31.00 ---------- ---------- ---------- ---------- ---------- ----------

86317-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

86317-TC $20.00 ---------- ---------- ---------- ---------- ---------- ----------

86318 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

86318-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

86318-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86320 $49.00 ---------- ---------- ---------- ---------- ---------- ----------

86320-26 $19.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00

86320-TC $29.00 ---------- ---------- ---------- ---------- ---------- ----------

86325 $49.00 ---------- ---------- ---------- ---------- ---------- ----------

86325-26 $16.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00

86325-TC $33.00 ---------- ---------- ---------- ---------- ---------- ----------

86327 $62.00 ---------- ---------- ---------- ---------- ---------- ----------

86327-26 $19.00 $23.00 $24.00 $24.00 $23.00 $24.00 $24.00

86327-TC $42.00 ---------- ---------- ---------- ---------- ---------- ----------

86329 $37.00 ---------- ---------- ---------- ---------- ---------- ----------

86329-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

86329-TC $24.00 ---------- ---------- ---------- ---------- ---------- ----------

86331 $22.00 ---------- ---------- ---------- ---------- ---------- ----------

86331-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86331-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

86332 $54.00 ---------- ---------- ---------- ---------- ---------- ----------

86332-26 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

86332-TC $36.00 ---------- ---------- ---------- ---------- ---------- ----------

86334 $65.00 ---------- ---------- ---------- ---------- ---------- ----------

86334-26 $18.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00

86334-TC $45.00 ---------- ---------- ---------- ---------- ---------- ----------

86335 ---------- BR BR BR BR BR BR

86335-26 ---------- $20.00 $21.00 $21.00 $20.00 $21.00 $21.00

86335-TC ---------- BR BR BR BR BR BR

86336 BR ---------- ---------- ---------- ---------- ---------- ----------

86336-26 BR ---------- ---------- ---------- ---------- ---------- ----------

86336-TC BR ---------- ---------- ---------- ---------- ---------- ----------

86337 $54.00 ---------- ---------- ---------- ---------- ---------- ----------

86337-26 $18.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






86337-TC $36.00 ---------- ---------- ---------- ---------- ---------- ----------

86340 $39.00 ---------- ---------- ---------- ---------- ---------- ----------

86340-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

86340-TC $25.00 ---------- ---------- ---------- ---------- ---------- ----------

86341 $38.00 ---------- ---------- ---------- ---------- ---------- ----------

86341-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

86341-TC $24.00 ---------- ---------- ---------- ---------- ---------- ----------

86343 $33.00 ---------- ---------- ---------- ---------- ---------- ----------

86343-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

86343-TC $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86344 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86344-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86344-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86353 $102.00 ---------- ---------- ---------- ---------- ---------- ----------

86353-26 $31.00 ---------- ---------- ---------- ---------- ---------- ----------

86353-TC $72.00 ---------- ---------- ---------- ---------- ---------- ----------

86359 $61.00 ---------- ---------- ---------- ---------- ---------- ----------

86359-26 $19.00 ---------- ---------- ---------- ---------- ---------- ----------

86359-TC $41.00 ---------- ---------- ---------- ---------- ---------- ----------

86360 $99.00 ---------- ---------- ---------- ---------- ---------- ----------

86360-26 $33.00 ---------- ---------- ---------- ---------- ---------- ----------

86360-TC $67.00 ---------- ---------- ---------- ---------- ---------- ----------

86361 $66.00 ---------- ---------- ---------- ---------- ---------- ----------

86361-26 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86361-TC $43.00 ---------- ---------- ---------- ---------- ---------- ----------

86376 $35.00 ---------- ---------- ---------- ---------- ---------- ----------

86376-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

86376-TC $23.00 ---------- ---------- ---------- ---------- ---------- ----------

86378 $45.00 ---------- ---------- ---------- ---------- ---------- ----------

86378-26 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

86378-TC $31.00 ---------- ---------- ---------- ---------- ---------- ----------

86382 $45.00 ---------- ---------- ---------- ---------- ---------- ----------

86382-26 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86382-TC $32.00 ---------- ---------- ---------- ---------- ---------- ----------

86384 $24.00 ---------- ---------- ---------- ---------- ---------- ----------

86384-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

86384-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

86403 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

86403-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

86403-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86406 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86406-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

86406-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

86430 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

86430-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

86430-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

86431 $17.00 ---------- ---------- ---------- ---------- ---------- ----------

86431-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86431-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

86485 $13.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






86485-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

86485-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

86486 ---------- $5.00 $6.00 $6.00 $5.00 $6.00 $6.00

86490 $17.00 $78.00 $83.00 $84.00 $78.00 $83.00 $84.00

86490-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

86490-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

86510 $13.00 $7.00 $7.00 $8.00 $7.00 $7.00 $8.00

86510-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

86510-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

86580 $13.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.00

86580-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

86580-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

86590 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

86590-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86590-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

86592 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

86592-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------

86592-TC $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86593 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

86593-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

86593-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86602 $17.00 ---------- ---------- ---------- ---------- ---------- ----------

86602-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

86602-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

86603 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

86603-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86603-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86606 $24.00 ---------- ---------- ---------- ---------- ---------- ----------

86606-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

86606-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

86609 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

86609-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86609-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86611 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

86611-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

86611-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

86612 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86612-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86612-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

86615 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86615-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86615-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

86617 $29.00 ---------- ---------- ---------- ---------- ---------- ----------

86617-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

86617-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------

86618 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

86618-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

86618-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

86619 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86619-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






86619-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

86622 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

86622-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

86622-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

86625 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86625-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86625-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

86628 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

86628-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86628-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86631 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

86631-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86631-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86632 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

86632-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86632-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86635 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

86635-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

86635-TC $13.00 ---------- ---------- ---------- ---------- ---------- ----------

86638 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

86638-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86638-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86641 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86641-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86641-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86644 $22.00 ---------- ---------- ---------- ---------- ---------- ----------

86644-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86644-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

86645 $28.00 ---------- ---------- ---------- ---------- ---------- ----------

86645-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

86645-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

86648 $24.00 ---------- ---------- ---------- ---------- ---------- ----------

86648-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

86648-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

86651 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86651-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86651-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86652 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86652-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86652-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86653 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86653-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86653-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86654 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86654-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86654-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86658 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86658-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86658-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86663 $21.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






86663-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86663-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86664 $53.00 ---------- ---------- ---------- ---------- ---------- ----------

86664-26 $17.00 ---------- ---------- ---------- ---------- ---------- ----------

86664-TC $36.00 ---------- ---------- ---------- ---------- ---------- ----------

86665 $29.00 ---------- ---------- ---------- ---------- ---------- ----------

86665-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

86665-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------

86666 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

86666-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

86666-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

86668 $17.00 ---------- ---------- ---------- ---------- ---------- ----------

86668-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

86668-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

86671 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

86671-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86671-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86674 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

86674-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86674-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

86677 $24.00 ---------- ---------- ---------- ---------- ---------- ----------

86677-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

86677-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

86682 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86682-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86682-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86684 $24.00 ---------- ---------- ---------- ---------- ---------- ----------

86684-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

86684-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

86687 $22.00 ---------- ---------- ---------- ---------- ---------- ----------

86687-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86687-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

86688 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

86688-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86688-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86689 $25.00 ---------- ---------- ---------- ---------- ---------- ----------

86689-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

86689-TC $17.00 ---------- ---------- ---------- ---------- ---------- ----------

86692 $22.00 ---------- ---------- ---------- ---------- ---------- ----------

86692-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86692-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

86694 $22.00 ---------- ---------- ---------- ---------- ---------- ----------

86694-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86694-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

86695 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86695-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86695-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86696 $44.00 ---------- ---------- ---------- ---------- ---------- ----------

86696-26 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86696-TC $30.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






86698 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

86698-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86698-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86701 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86701-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86701-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

86702 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86702-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86702-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86703 $22.00 ---------- ---------- ---------- ---------- ---------- ----------

86703-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86703-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

86704 $33.00 ---------- ---------- ---------- ---------- ---------- ----------

86704-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

86704-TC $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86705 $35.00 ---------- ---------- ---------- ---------- ---------- ----------

86705-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

86705-TC $23.00 ---------- ---------- ---------- ---------- ---------- ----------

86706 $24.00 ---------- ---------- ---------- ---------- ---------- ----------

86706-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

86706-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

86707 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

86707-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

86707-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

86708 $32.00 ---------- ---------- ---------- ---------- ---------- ----------

86708-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

86708-TC $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86709 $29.00 ---------- ---------- ---------- ---------- ---------- ----------

86709-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

86709-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------

86710 $22.00 ---------- ---------- ---------- ---------- ---------- ----------

86710-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86710-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

86713 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

86713-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86713-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

86717 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

86717-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86717-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86720 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86720-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86720-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86723 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86723-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86723-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86727 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

86727-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86727-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86729 $19.00 ---------- ---------- ---------- ---------- ---------- ----------

86729-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






86729-TC $13.00 ---------- ---------- ---------- ---------- ---------- ----------

86732 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86732-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86732-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86735 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86735-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86735-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86738 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86738-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86738-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86741 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86741-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86741-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86744 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86744-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86744-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86747 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

86747-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86747-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

86750 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86750-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86750-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86753 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

86753-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86753-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86756 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

86756-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86756-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86757 $44.00 ---------- ---------- ---------- ---------- ---------- ----------

86757-26 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86757-TC $30.00 ---------- ---------- ---------- ---------- ---------- ----------

86759 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86759-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86759-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86762 $22.00 ---------- ---------- ---------- ---------- ---------- ----------

86762-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86762-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

86765 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

86765-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86765-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86768 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86768-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86768-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86771 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86771-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86771-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86774 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

86774-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86774-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

86777 $22.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






86777-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86777-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

86778 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

86778-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86778-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

86784 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86784-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86784-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86787 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

86787-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86787-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86790 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86790-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86790-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86793 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86793-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86793-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86800 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

86800-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

86800-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

86803 $24.00 ---------- ---------- ---------- ---------- ---------- ----------

86803-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

86803-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

86804 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

86804-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

86804-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

86805 $97.00 ---------- ---------- ---------- ---------- ---------- ----------

86805-26 $33.00 ---------- ---------- ---------- ---------- ---------- ----------

86805-TC $64.00 ---------- ---------- ---------- ---------- ---------- ----------

86806 $87.00 ---------- ---------- ---------- ---------- ---------- ----------

86806-26 $28.00 ---------- ---------- ---------- ---------- ---------- ----------

86806-TC $57.00 ---------- ---------- ---------- ---------- ---------- ----------

86807 $74.00 ---------- ---------- ---------- ---------- ---------- ----------

86807-26 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86807-TC $51.00 ---------- ---------- ---------- ---------- ---------- ----------

86808 $52.00 ---------- ---------- ---------- ---------- ---------- ----------

86808-26 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

86808-TC $37.00 ---------- ---------- ---------- ---------- ---------- ----------

86812 $108.00 ---------- ---------- ---------- ---------- ---------- ----------

86812-26 $32.00 ---------- ---------- ---------- ---------- ---------- ----------

86812-TC $75.00 ---------- ---------- ---------- ---------- ---------- ----------

86813 $101.00 ---------- ---------- ---------- ---------- ---------- ----------

86813-26 $29.00 ---------- ---------- ---------- ---------- ---------- ----------

86813-TC $71.00 ---------- ---------- ---------- ---------- ---------- ----------

86816 $64.00 ---------- ---------- ---------- ---------- ---------- ----------

86816-26 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

86816-TC $44.00 ---------- ---------- ---------- ---------- ---------- ----------

86817 $134.00 ---------- ---------- ---------- ---------- ---------- ----------

86817-26 $39.00 ---------- ---------- ---------- ---------- ---------- ----------

86817-TC $94.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






86821 $123.00 ---------- ---------- ---------- ---------- ---------- ----------

86821-26 $36.00 ---------- ---------- ---------- ---------- ---------- ----------

86821-TC $86.00 ---------- ---------- ---------- ---------- ---------- ----------

86822 $96.00 ---------- ---------- ---------- ---------- ---------- ----------

86822-26 $32.00 ---------- ---------- ---------- ---------- ---------- ----------

86822-TC $64.00 ---------- ---------- ---------- ---------- ---------- ----------

86849 BR ---------- ---------- ---------- ---------- ---------- ----------

86849-26 BR ---------- ---------- ---------- ---------- ---------- ----------

86849-TC BR ---------- ---------- ---------- ---------- ---------- ----------

86850 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

86850-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

86850-TC $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86860 $44.00 ---------- ---------- ---------- ---------- ---------- ----------

86860-26 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

86860-TC $29.00 ---------- ---------- ---------- ---------- ---------- ----------

86870 $17.00 ---------- ---------- ---------- ---------- ---------- ----------

86870-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86870-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

86880 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

86880-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

86880-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

86885 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

86885-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

86885-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

86886 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86886-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

86886-TC $10.00 ---------- ---------- ---------- ---------- ---------- ----------

86890 $67.00 ---------- ---------- ---------- ---------- ---------- ----------

86890-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

86890-TC $54.00 ---------- ---------- ---------- ---------- ---------- ----------

86891 $91.00 ---------- ---------- ---------- ---------- ---------- ----------

86891-26 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

86891-TC $64.00 ---------- ---------- ---------- ---------- ---------- ----------

86900 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

86900-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

86900-TC $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86901 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

86901-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

86901-TC $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86904 $19.00 ---------- ---------- ---------- ---------- ---------- ----------

86904-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86904-TC $13.00 ---------- ---------- ---------- ---------- ---------- ----------

86905 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86905-26 $1.00 ---------- ---------- ---------- ---------- ---------- ----------

86905-TC $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86906 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

86906-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

86906-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86910 $83.00 ---------- ---------- ---------- ---------- ---------- ----------

86910-26 $24.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






86910-TC $57.00 ---------- ---------- ---------- ---------- ---------- ----------

86911 $19.00 ---------- ---------- ---------- ---------- ---------- ----------

86911-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86911-TC $13.00 ---------- ---------- ---------- ---------- ---------- ----------

86920 $19.00 ---------- ---------- ---------- ---------- ---------- ----------

86920-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

86920-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

86921 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

86921-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86921-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

86922 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

86922-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86922-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86927 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86927-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

86927-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

86930 $155.00 ---------- ---------- ---------- ---------- ---------- ----------

86930-26 $45.00 ---------- ---------- ---------- ---------- ---------- ----------

86930-TC $108.00 ---------- ---------- ---------- ---------- ---------- ----------

86931 $155.00 ---------- ---------- ---------- ---------- ---------- ----------

86931-26 $45.00 ---------- ---------- ---------- ---------- ---------- ----------

86931-TC $108.00 ---------- ---------- ---------- ---------- ---------- ----------

86932 $161.00 ---------- ---------- ---------- ---------- ---------- ----------

86932-26 $48.00 ---------- ---------- ---------- ---------- ---------- ----------

86932-TC $111.00 ---------- ---------- ---------- ---------- ---------- ----------

86940 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

86940-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

86940-TC $13.00 ---------- ---------- ---------- ---------- ---------- ----------

86941 $31.00 ---------- ---------- ---------- ---------- ---------- ----------

86941-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

86941-TC $21.00 ---------- ---------- ---------- ---------- ---------- ----------

86945 $35.00 ---------- ---------- ---------- ---------- ---------- ----------

86945-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

86945-TC $23.00 ---------- ---------- ---------- ---------- ---------- ----------

86950 $99.00 ---------- ---------- ---------- ---------- ---------- ----------

86950-26 $29.00 ---------- ---------- ---------- ---------- ---------- ----------

86950-TC $70.00 ---------- ---------- ---------- ---------- ---------- ----------

86965 $25.00 ---------- ---------- ---------- ---------- ---------- ----------

86965-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

86965-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

86970 $41.00 ---------- ---------- ---------- ---------- ---------- ----------

86970-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

86970-TC $29.00 ---------- ---------- ---------- ---------- ---------- ----------

86971 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

86971-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

86971-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

86972 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

86972-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

86972-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

86975 $53.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






86975-26 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

86975-TC $37.00 ---------- ---------- ---------- ---------- ---------- ----------

86976 $53.00 ---------- ---------- ---------- ---------- ---------- ----------

86976-26 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

86976-TC $37.00 ---------- ---------- ---------- ---------- ---------- ----------

86977 $53.00 ---------- ---------- ---------- ---------- ---------- ----------

86977-26 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

86977-TC $37.00 ---------- ---------- ---------- ---------- ---------- ----------

86978 $65.00 ---------- ---------- ---------- ---------- ---------- ----------

86978-26 $19.00 ---------- ---------- ---------- ---------- ---------- ----------

86978-TC $44.00 ---------- ---------- ---------- ---------- ---------- ----------

86985 $35.00 ---------- ---------- ---------- ---------- ---------- ----------

86985-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

86985-TC $23.00 ---------- ---------- ---------- ---------- ---------- ----------

86999 BR ---------- ---------- ---------- ---------- ---------- ----------

86999-26 BR ---------- ---------- ---------- ---------- ---------- ----------

86999-TC BR ---------- ---------- ---------- ---------- ---------- ----------

87003 $40.00 ---------- ---------- ---------- ---------- ---------- ----------

87003-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

87003-TC $26.00 ---------- ---------- ---------- ---------- ---------- ----------

87015 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

87015-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

87015-TC $9.00 ---------- ---------- ---------- ---------- ---------- ----------

87040 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87040-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

87040-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

87045 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87045-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

87045-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

87046 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

87046-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------

87046-TC $3.00 ---------- ---------- ---------- ---------- ---------- ----------

87070 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

87070-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

87070-TC $10.00 ---------- ---------- ---------- ---------- ---------- ----------

87071 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

87071-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

87071-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87073 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

87073-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

87073-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87075 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87075-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

87075-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

87076 $24.00 ---------- ---------- ---------- ---------- ---------- ----------

87076-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87076-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

87077 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

87077-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

87077-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






87081 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

87081-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

87081-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87084 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

87084-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

87084-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

87086 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

87086-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

87086-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

87088 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87088-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

87088-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

87101 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

87101-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

87101-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

87102 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

87102-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

87102-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

87103 $32.00 ---------- ---------- ---------- ---------- ---------- ----------

87103-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

87103-TC $20.00 ---------- ---------- ---------- ---------- ---------- ----------

87106 $25.00 ---------- ---------- ---------- ---------- ---------- ----------

87106-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

87106-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87107 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

87107-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87107-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

87109 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

87109-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87109-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87110 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

87110-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

87110-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

87116 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

87116-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

87116-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

87118 $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87118-26 $9.00 ---------- ---------- ---------- ---------- ---------- ----------

87118-TC $20.00 ---------- ---------- ---------- ---------- ---------- ----------

87140 $24.00 ---------- ---------- ---------- ---------- ---------- ----------

87140-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

87140-TC $17.00 ---------- ---------- ---------- ---------- ---------- ----------

87143 $34.00 ---------- ---------- ---------- ---------- ---------- ----------

87143-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

87143-TC $22.00 ---------- ---------- ---------- ---------- ---------- ----------

87147 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

87147-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87147-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87149 $46.00 ---------- ---------- ---------- ---------- ---------- ----------

87149-26 $15.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






87149-TC $31.00 ---------- ---------- ---------- ---------- ---------- ----------

87152 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

87152-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

87152-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87158 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

87158-26 $1.00 ---------- ---------- ---------- ---------- ---------- ----------

87158-TC $3.00 ---------- ---------- ---------- ---------- ---------- ----------

87164 $24.00 ---------- ---------- ---------- ---------- ---------- ----------

87164-26 $8.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00

87164-TC $16.00 ---------- ---------- ---------- ---------- ---------- ----------

87166 $24.00 ---------- ---------- ---------- ---------- ---------- ----------

87166-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

87166-TC $17.00 ---------- ---------- ---------- ---------- ---------- ----------

87168 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

87168-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

87168-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

87169 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

87169-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

87169-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

87172 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

87172-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

87172-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

87176 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

87176-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

87176-TC $11.00 ---------- ---------- ---------- ---------- ---------- ----------

87177 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87177-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

87177-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

87181 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

87181-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

87181-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87184 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

87184-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

87184-TC $10.00 ---------- ---------- ---------- ---------- ---------- ----------

87185 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

87185-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

87185-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87186 $16.00 ---------- ---------- ---------- ---------- ---------- ----------

87186-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

87186-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

87187 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

87187-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

87187-TC $17.00 ---------- ---------- ---------- ---------- ---------- ----------

87188 $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87188-26 $5.00 ---------- ---------- ---------- ---------- ---------- ----------

87188-TC $13.00 ---------- ---------- ---------- ---------- ---------- ----------

87190 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

87190-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------

87190-TC $5.00 ---------- ---------- ---------- ---------- ---------- ----------

87197 $29.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






87197-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

87197-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------

87205 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

87205-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

87205-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

87206 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

87206-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

87206-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

87207 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

87207-26 $3.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00

87207-TC $6.00 ---------- ---------- ---------- ---------- ---------- ----------

87210 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87210-26 $2.00 ---------- ---------- ---------- ---------- ---------- ----------

87210-TC $6.00 ---------- ---------- ---------- ---------- ---------- ----------

87220 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

87220-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

87220-TC $7.00 ---------- ---------- ---------- ---------- ---------- ----------

87230 $35.00 ---------- ---------- ---------- ---------- ---------- ----------

87230-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

87230-TC $23.00 ---------- ---------- ---------- ---------- ---------- ----------

87250 $33.00 ---------- ---------- ---------- ---------- ---------- ----------

87250-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

87250-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------

87252 $44.00 ---------- ---------- ---------- ---------- ---------- ----------

87252-26 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

87252-TC $31.00 ---------- ---------- ---------- ---------- ---------- ----------

87253 $33.00 ---------- ---------- ---------- ---------- ---------- ----------

87253-26 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

87253-TC $22.00 ---------- ---------- ---------- ---------- ---------- ----------

87254 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

87254-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

87254-TC $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87255 BR ---------- ---------- ---------- ---------- ---------- ----------

87255-26 BR ---------- ---------- ---------- ---------- ---------- ----------

87255-TC BR ---------- ---------- ---------- ---------- ---------- ----------

87260 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

87260-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87260-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87265 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

87265-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87265-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87267 BR ---------- ---------- ---------- ---------- ---------- ----------

87267-26 BR ---------- ---------- ---------- ---------- ---------- ----------

87267-TC BR ---------- ---------- ---------- ---------- ---------- ----------

87270 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

87270-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87270-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87271 BR ---------- ---------- ---------- ---------- ---------- ----------

87271-26 BR ---------- ---------- ---------- ---------- ---------- ----------

87271-TC BR ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






87272 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

87272-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87272-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87273 $27.00 ---------- ---------- ---------- ---------- ---------- ----------

87273-26 $9.00 ---------- ---------- ---------- ---------- ---------- ----------

87273-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------

87274 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

87274-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87274-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87275 $27.00 ---------- ---------- ---------- ---------- ---------- ----------

87275-26 $9.00 ---------- ---------- ---------- ---------- ---------- ----------

87275-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------

87276 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

87276-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87276-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87277 $27.00 ---------- ---------- ---------- ---------- ---------- ----------

87277-26 $9.00 ---------- ---------- ---------- ---------- ---------- ----------

87277-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------

87278 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

87278-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87278-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87279 $27.00 ---------- ---------- ---------- ---------- ---------- ----------

87279-26 $9.00 ---------- ---------- ---------- ---------- ---------- ----------

87279-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------

87280 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

87280-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87280-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87281 $27.00 ---------- ---------- ---------- ---------- ---------- ----------

87281-26 $9.00 ---------- ---------- ---------- ---------- ---------- ----------

87281-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------

87283 $27.00 ---------- ---------- ---------- ---------- ---------- ----------

87283-26 $9.00 ---------- ---------- ---------- ---------- ---------- ----------

87283-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------

87285 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

87285-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87285-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87290 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

87290-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87290-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87299 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

87299-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87299-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87300 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

87300-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

87300-TC $9.00 ---------- ---------- ---------- ---------- ---------- ----------

87301 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

87301-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87301-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87320 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

87320-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






87320-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87324 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

87324-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87324-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87327 $27.00 ---------- ---------- ---------- ---------- ---------- ----------

87327-26 $9.00 ---------- ---------- ---------- ---------- ---------- ----------

87327-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------

87328 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

87328-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87328-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87332 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

87332-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87332-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87335 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

87335-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87335-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87336 $27.00 ---------- ---------- ---------- ---------- ---------- ----------

87336-26 $9.00 ---------- ---------- ---------- ---------- ---------- ----------

87336-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------

87337 $27.00 ---------- ---------- ---------- ---------- ---------- ----------

87337-26 $9.00 ---------- ---------- ---------- ---------- ---------- ----------

87337-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------

87338 $27.00 ---------- ---------- ---------- ---------- ---------- ----------

87338-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

87338-TC $20.00 ---------- ---------- ---------- ---------- ---------- ----------

87339 $27.00 ---------- ---------- ---------- ---------- ---------- ----------

87339-26 $9.00 ---------- ---------- ---------- ---------- ---------- ----------

87339-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------

87340 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

87340-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

87340-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

87341 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

87341-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87341-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

87350 $20.00 ---------- ---------- ---------- ---------- ---------- ----------

87350-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

87350-TC $14.00 ---------- ---------- ---------- ---------- ---------- ----------

87380 $35.00 ---------- ---------- ---------- ---------- ---------- ----------

87380-26 $11.00 ---------- ---------- ---------- ---------- ---------- ----------

87380-TC $23.00 ---------- ---------- ---------- ---------- ---------- ----------

87385 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

87385-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87385-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87390 $38.00 ---------- ---------- ---------- ---------- ---------- ----------

87390-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

87390-TC $24.00 ---------- ---------- ---------- ---------- ---------- ----------

87391 $38.00 ---------- ---------- ---------- ---------- ---------- ----------

87391-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

87391-TC $24.00 ---------- ---------- ---------- ---------- ---------- ----------

87400 $13.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






87400-26 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

87400-TC $9.00 ---------- ---------- ---------- ---------- ---------- ----------

87420 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

87420-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87420-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87425 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

87425-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87425-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87427 $27.00 ---------- ---------- ---------- ---------- ---------- ----------

87427-26 $9.00 ---------- ---------- ---------- ---------- ---------- ----------

87427-TC $19.00 ---------- ---------- ---------- ---------- ---------- ----------

87430 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

87430-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87430-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87449 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

87449-26 $8.00 ---------- ---------- ---------- ---------- ---------- ----------

87449-TC $18.00 ---------- ---------- ---------- ---------- ---------- ----------

87450 $21.00 ---------- ---------- ---------- ---------- ---------- ----------

87450-26 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

87450-TC $15.00 ---------- ---------- ---------- ---------- ---------- ----------

87451 $19.00 ---------- ---------- ---------- ---------- ---------- ----------

87451-26 $7.00 ---------- ---------- ---------- ---------- ---------- ----------

87451-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

87470 $42.00 ---------- ---------- ---------- ---------- ---------- ----------

87470-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

87470-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87471 $73.00 ---------- ---------- ---------- ---------- ---------- ----------

87471-26 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

87471-TC $48.00 ---------- ---------- ---------- ---------- ---------- ----------

87472 $88.00 ---------- ---------- ---------- ---------- ---------- ----------

87472-26 $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87472-TC $58.00 ---------- ---------- ---------- ---------- ---------- ----------

87475 $40.00 ---------- ---------- ---------- ---------- ---------- ----------

87475-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

87475-TC $26.00 ---------- ---------- ---------- ---------- ---------- ----------

87476 $73.00 ---------- ---------- ---------- ---------- ---------- ----------

87476-26 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

87476-TC $48.00 ---------- ---------- ---------- ---------- ---------- ----------

87477 $88.00 ---------- ---------- ---------- ---------- ---------- ----------

87477-26 $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87477-TC $58.00 ---------- ---------- ---------- ---------- ---------- ----------

87480 $42.00 ---------- ---------- ---------- ---------- ---------- ----------

87480-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

87480-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87481 $73.00 ---------- ---------- ---------- ---------- ---------- ----------

87481-26 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

87481-TC $48.00 ---------- ---------- ---------- ---------- ---------- ----------

87482 $86.00 ---------- ---------- ---------- ---------- ---------- ----------

87482-26 $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87482-TC $56.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






87485 $42.00 ---------- ---------- ---------- ---------- ---------- ----------

87485-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

87485-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87486 $73.00 ---------- ---------- ---------- ---------- ---------- ----------

87486-26 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

87486-TC $48.00 ---------- ---------- ---------- ---------- ---------- ----------

87487 $88.00 ---------- ---------- ---------- ---------- ---------- ----------

87487-26 $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87487-TC $58.00 ---------- ---------- ---------- ---------- ---------- ----------

87490 $42.00 ---------- ---------- ---------- ---------- ---------- ----------

87490-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

87490-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87491 $73.00 ---------- ---------- ---------- ---------- ---------- ----------

87491-26 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

87491-TC $48.00 ---------- ---------- ---------- ---------- ---------- ----------

87492 $73.00 ---------- ---------- ---------- ---------- ---------- ----------

87492-26 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

87492-TC $48.00 ---------- ---------- ---------- ---------- ---------- ----------

87495 $42.00 ---------- ---------- ---------- ---------- ---------- ----------

87495-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

87495-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87496 $73.00 ---------- ---------- ---------- ---------- ---------- ----------

87496-26 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

87496-TC $48.00 ---------- ---------- ---------- ---------- ---------- ----------

87497 $88.00 ---------- ---------- ---------- ---------- ---------- ----------

87497-26 $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87497-TC $58.00 ---------- ---------- ---------- ---------- ---------- ----------

87510 $42.00 ---------- ---------- ---------- ---------- ---------- ----------

87510-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

87510-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87511 $73.00 ---------- ---------- ---------- ---------- ---------- ----------

87511-26 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

87511-TC $48.00 ---------- ---------- ---------- ---------- ---------- ----------

87512 $86.00 ---------- ---------- ---------- ---------- ---------- ----------

87512-26 $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87512-TC $56.00 ---------- ---------- ---------- ---------- ---------- ----------

87515 $42.00 ---------- ---------- ---------- ---------- ---------- ----------

87515-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

87515-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87516 $73.00 ---------- ---------- ---------- ---------- ---------- ----------

87516-26 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

87516-TC $48.00 ---------- ---------- ---------- ---------- ---------- ----------

87517 $88.00 ---------- ---------- ---------- ---------- ---------- ----------

87517-26 $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87517-TC $58.00 ---------- ---------- ---------- ---------- ---------- ----------

87520 $42.00 ---------- ---------- ---------- ---------- ---------- ----------

87520-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

87520-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87521 $73.00 ---------- ---------- ---------- ---------- ---------- ----------

87521-26 $23.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






87521-TC $48.00 ---------- ---------- ---------- ---------- ---------- ----------

87522 $88.00 ---------- ---------- ---------- ---------- ---------- ----------

87522-26 $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87522-TC $58.00 ---------- ---------- ---------- ---------- ---------- ----------

87525 $42.00 ---------- ---------- ---------- ---------- ---------- ----------

87525-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

87525-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87526 $73.00 ---------- ---------- ---------- ---------- ---------- ----------

87526-26 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

87526-TC $48.00 ---------- ---------- ---------- ---------- ---------- ----------

87527 $86.00 ---------- ---------- ---------- ---------- ---------- ----------

87527-26 $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87527-TC $56.00 ---------- ---------- ---------- ---------- ---------- ----------

87528 $42.00 ---------- ---------- ---------- ---------- ---------- ----------

87528-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

87528-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87529 $73.00 ---------- ---------- ---------- ---------- ---------- ----------

87529-26 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

87529-TC $48.00 ---------- ---------- ---------- ---------- ---------- ----------

87530 $88.00 ---------- ---------- ---------- ---------- ---------- ----------

87530-26 $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87530-TC $58.00 ---------- ---------- ---------- ---------- ---------- ----------

87531 $42.00 ---------- ---------- ---------- ---------- ---------- ----------

87531-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

87531-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87532 $73.00 ---------- ---------- ---------- ---------- ---------- ----------

87532-26 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

87532-TC $48.00 ---------- ---------- ---------- ---------- ---------- ----------

87533 $86.00 ---------- ---------- ---------- ---------- ---------- ----------

87533-26 $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87533-TC $56.00 ---------- ---------- ---------- ---------- ---------- ----------

87534 $42.00 ---------- ---------- ---------- ---------- ---------- ----------

87534-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

87534-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87535 $73.00 ---------- ---------- ---------- ---------- ---------- ----------

87535-26 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

87535-TC $48.00 ---------- ---------- ---------- ---------- ---------- ----------

87536 $86.00 ---------- ---------- ---------- ---------- ---------- ----------

87536-26 $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87536-TC $56.00 ---------- ---------- ---------- ---------- ---------- ----------

87537 $42.00 ---------- ---------- ---------- ---------- ---------- ----------

87537-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

87537-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87538 $73.00 ---------- ---------- ---------- ---------- ---------- ----------

87538-26 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

87538-TC $48.00 ---------- ---------- ---------- ---------- ---------- ----------

87539 $88.00 ---------- ---------- ---------- ---------- ---------- ----------

87539-26 $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87539-TC $58.00 ---------- ---------- ---------- ---------- ---------- ----------

87540 $42.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






87540-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

87540-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87541 $73.00 ---------- ---------- ---------- ---------- ---------- ----------

87541-26 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

87541-TC $48.00 ---------- ---------- ---------- ---------- ---------- ----------

87542 $86.00 ---------- ---------- ---------- ---------- ---------- ----------

87542-26 $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87542-TC $56.00 ---------- ---------- ---------- ---------- ---------- ----------

87550 $42.00 ---------- ---------- ---------- ---------- ---------- ----------

87550-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

87550-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87551 $73.00 ---------- ---------- ---------- ---------- ---------- ----------

87551-26 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

87551-TC $48.00 ---------- ---------- ---------- ---------- ---------- ----------

87552 $88.00 ---------- ---------- ---------- ---------- ---------- ----------

87552-26 $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87552-TC $58.00 ---------- ---------- ---------- ---------- ---------- ----------

87555 $42.00 ---------- ---------- ---------- ---------- ---------- ----------

87555-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

87555-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87556 $73.00 ---------- ---------- ---------- ---------- ---------- ----------

87556-26 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

87556-TC $48.00 ---------- ---------- ---------- ---------- ---------- ----------

87557 $88.00 ---------- ---------- ---------- ---------- ---------- ----------

87557-26 $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87557-TC $58.00 ---------- ---------- ---------- ---------- ---------- ----------

87560 $42.00 ---------- ---------- ---------- ---------- ---------- ----------

87560-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

87560-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87561 $73.00 ---------- ---------- ---------- ---------- ---------- ----------

87561-26 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

87561-TC $48.00 ---------- ---------- ---------- ---------- ---------- ----------

87562 $88.00 ---------- ---------- ---------- ---------- ---------- ----------

87562-26 $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87562-TC $58.00 ---------- ---------- ---------- ---------- ---------- ----------

87580 $42.00 ---------- ---------- ---------- ---------- ---------- ----------

87580-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

87580-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87581 $73.00 ---------- ---------- ---------- ---------- ---------- ----------

87581-26 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

87581-TC $48.00 ---------- ---------- ---------- ---------- ---------- ----------

87582 $86.00 ---------- ---------- ---------- ---------- ---------- ----------

87582-26 $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87582-TC $56.00 ---------- ---------- ---------- ---------- ---------- ----------

87590 $42.00 ---------- ---------- ---------- ---------- ---------- ----------

87590-26 $13.00 ---------- ---------- ---------- ---------- ---------- ----------

87590-TC $28.00 ---------- ---------- ---------- ---------- ---------- ----------

87591 $73.00 ---------- ---------- ---------- ---------- ---------- ----------

87591-26 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

87591-TC $48.00 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






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 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






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 $81.00 $85.00 $86.00 $81.00 $85.00 $86.00

88104-26 $37.00 $33.00 $34.00 $34.00 $33.00 $34.00 $34.00

88104-TC $10.00 $48.00 $51.00 $52.00 $48.00 $51.00 $52.00

88106 $54.00 $69.00 $73.00 $74.00 $69.00 $73.00 $74.00





(Non-Facility MRA)






88106-26 $16.00 $22.00 $23.00 $23.00 $22.00 $23.00 $23.00

88106-TC $38.00 $47.00 $50.00 $51.00 $47.00 $50.00 $51.00

88108 $59.00 $68.00 $72.00 $73.00 $68.00 $72.00 $73.00

88108-26 $47.00 $26.00 $27.00 $27.00 $26.00 $27.00 $27.00

88108-TC $11.00 $42.00 $45.00 $46.00 $42.00 $45.00 $46.00

88112 ---------- $74.00 $78.00 $79.00 $74.00 $78.00 $79.00

88112-26 ---------- $32.00 $32.00 $33.00 $32.00 $32.00 $33.00

88112-TC ---------- $42.00 $45.00 $46.00 $42.00 $45.00 $46.00

88120 ---------- $677.00 $720.00 $728.00 $677.00 $720.00 $728.00

88120-26 ---------- $66.00 $68.00 $69.00 $66.00 $68.00 $69.00

88120-TC ---------- $611.00 $652.00 $659.00 $611.00 $652.00 $659.00

88121 ---------- $585.00 $622.00 $629.00 $585.00 $622.00 $629.00

88121-26 ---------- $57.00 $58.00 $59.00 $57.00 $58.00 $59.00

88121-TC ---------- $528.00 $564.00 $570.00 $528.00 $564.00 $570.00

88125 $70.00 $23.00 $24.00 $25.00 $23.00 $24.00 $25.00

88125-26 $20.00 $15.00 $15.00 $15.00 $15.00 $15.00 $15.00

88125-TC $48.00 $8.00 $9.00 $10.00 $8.00 $9.00 $10.00

88130 $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 $38.00



88142 $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-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 ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






88155 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

88155-26 $3.00 ---------- ---------- ---------- ---------- ---------- ----------

88155-TC $10.00 ---------- ---------- ---------- ---------- ---------- ----------

88160 $45.00 $79.00 $83.00 $84.00 $79.00 $83.00 $84.00

88160-26 $14.00 $30.00 $31.00 $31.00 $30.00 $31.00 $31.00

88160-TC $24.00 $49.00 $52.00 $53.00 $49.00 $52.00 $53.00

88161 $64.00 $71.00 $75.00 $76.00 $71.00 $75.00 $76.00

88161-26 $19.00 $29.00 $29.00 $30.00 $29.00 $29.00 $30.00

88161-TC $37.00 $42.00 $45.00 $46.00 $42.00 $45.00 $46.00

88162 $77.00 $108.00 $114.00 $116.00 $108.00 $114.00 $116.00

88162-26 $22.00 $45.00 $46.00 $47.00 $45.00 $46.00 $47.00

88162-TC $53.00 $64.00 $68.00 $70.00 $64.00 $68.00 $70.00

88164 $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 $67.00

88172-26 $54.00 $42.00 $43.00 $43.00 $42.00 $43.00 $43.00

88172-TC $14.00 $21.00 $23.00 $23.00 $21.00 $23.00 $23.00

88173 $95.00 $167.00 $175.00 $178.00 $167.00 $175.00 $178.00

88173-26 $95.00 $81.00 $83.00 $84.00 $81.00 $83.00 $84.00

88173-TC $26.00 $86.00 $92.00 $94.00 $86.00 $92.00 $94.00

88174 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 $35.00

88177-26 ---------- $25.00 $26.00 $27.00 $25.00 $26.00 $27.00

88177-TC ---------- $8.00 $8.00 $9.00 $8.00 $8.00 $9.00

88182 $88.00 $130.00 $137.00 $139.00 $130.00 $137.00 $139.00

88182-26 $33.00 $42.00 $43.00 $44.00 $42.00 $43.00 $44.00

88182-TC $54.00 $87.00 $94.00 $95.00 $87.00 $94.00 $95.00

88184 ---------- $65.00 $70.00 $71.00 $65.00 $70.00 $71.00

88185 ---------- $40.00 $42.00 $43.00 $40.00 $42.00 $43.00

88187 ---------- $64.00 $67.00 $69.00 $64.00 $67.00 $69.00

88188 ---------- $82.00 $85.00 $88.00 $82.00 $85.00 $88.00

88189 ---------- $102.00 $105.00 $108.00 $102.00 $105.00 $108.00

88199 BR ---------- ---------- ---------- ---------- ---------- ----------

88199-26 BR ---------- ---------- ---------- ---------- ---------- ----------

88199-TC BR ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






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 $18.00 $19.00 $20.00 $18.00 $19.00 $20.00

88300-26 $19.00 $5.00 $5.00 $6.00 $5.00 $5.00 $6.00

88300-TC $5.00 $13.00 $14.00 $14.00 $13.00 $14.00 $14.00

88302 $53.00 $33.00 $36.00 $36.00 $33.00 $36.00 $36.00

88302-26 $42.00 $8.00 $9.00 $9.00 $8.00 $9.00 $9.00

88302-TC $11.00 $25.00 $27.00 $27.00 $25.00 $27.00 $27.00

88304 $70.00 $44.00 $47.00 $48.00 $44.00 $47.00 $48.00

88304-26 $54.00 $13.00 $14.00 $14.00 $13.00 $14.00 $14.00

88304-TC $14.00 $31.00 $33.00 $34.00 $31.00 $33.00 $34.00

88305 $108.00 $75.00 $78.00 $80.00 $75.00 $78.00 $80.00

88305-26 $86.00 $43.00 $45.00 $45.00 $43.00 $45.00 $45.00

88305-TC $21.00 $31.00 $34.00 $34.00 $31.00 $34.00 $34.00

88307 $210.00 $287.00 $304.00 $308.00 $287.00 $304.00 $308.00

88307-26 $168.00 $96.00 $99.00 $100.00 $96.00 $99.00 $100.00

88307-TC $41.00 $192.00 $205.00 $208.00 $192.00 $205.00 $208.00

88309 $322.00 $442.00 $465.00 $472.00 $442.00 $465.00 $472.00

88309-26 $258.00 $169.00 $174.00 $177.00 $169.00 $174.00 $177.00

88309-TC $64.00 $272.00 $291.00 $295.00 $272.00 $291.00 $295.00

88311 $23.00 $24.00 $26.00 $27.00 $24.00 $26.00 $27.00

88311-26 $19.00 $15.00 $15.00 $15.00 $15.00 $15.00 $15.00

88311-TC $4.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.00

88312 $23.00 $106.00 $112.00 $114.00 $106.00 $112.00 $114.00

88312-26 $7.00 $31.00 $32.00 $32.00 $31.00 $32.00 $32.00

88312-TC $16.00 $75.00 $81.00 $82.00 $75.00 $81.00 $82.00

88313 $23.00 $75.00 $80.00 $81.00 $75.00 $80.00 $81.00

88313-26 $7.00 $14.00 $14.00 $15.00 $14.00 $14.00 $15.00

88313-TC $16.00 $61.00 $66.00 $67.00 $61.00 $66.00 $67.00

88314 $21.00 $84.00 $89.00 $91.00 $84.00 $89.00 $91.00

88314-26 $6.00 $25.00 $26.00 $26.00 $25.00 $26.00 $26.00

88314-TC $15.00 $59.00 $63.00 $64.00 $59.00 $63.00 $64.00

88319 $26.00 $96.00 $101.00 $103.00 $96.00 $101.00 $103.00

88319-26 $13.00 $31.00 $31.00 $32.00 $31.00 $31.00 $32.00

88319-TC $14.00 $65.00 $70.00 $71.00 $65.00 $70.00 $71.00

88321 $43.00 $114.00 $119.00 $122.00 $97.00 $100.00 $103.00

88321-26 $43.00 ---------- ---------- ---------- ---------- ---------- ----------


88323 $61.00 $142.00 $147.00 $149.00 $142.00 $147.00 $149.00

88323-26 $61.00 $99.00 $101.00 $102.00 $99.00 $101.00 $102.00





(Non-Facility MRA)






88323-TC NC $44.00 $47.00 $47.00 $44.00 $47.00 $47.00

88325 $54.00 $208.00 $217.00 $222.00 $173.00 $179.00 $184.00

88325-26 $54.00 ---------- ---------- ---------- ---------- ---------- ----------


88329 $51.00 $58.00 $60.00 $62.00 $42.00 $43.00 $45.00

88329-26 $51.00 ---------- ---------- ---------- ---------- ---------- ----------


88331 $102.00 $106.00 $111.00 $113.00 $106.00 $111.00 $113.00

88331-26 $70.00 $72.00 $74.00 $75.00 $72.00 $74.00 $75.00

88331-TC $33.00 $34.00 $37.00 $38.00 $34.00 $37.00 $38.00

88332 $53.00 $58.00 $60.00 $61.00 $58.00 $60.00 $61.00

88332-26 $36.00 $36.00 $36.00 $37.00 $36.00 $36.00 $37.00

88332-TC $17.00 $22.00 $24.00 $24.00 $22.00 $24.00 $24.00

88333 ---------- $103.00 $107.00 $109.00 $103.00 $107.00 $109.00

88333-26 ---------- $72.00 $74.00 $76.00 $72.00 $74.00 $76.00

88333-TC ---------- $31.00 $33.00 $34.00 $31.00 $33.00 $34.00

88334 ---------- $65.00 $68.00 $69.00 $65.00 $68.00 $69.00

88334-26 ---------- $44.00 $46.00 $46.00 $44.00 $46.00 $46.00

88334-TC ---------- $21.00 $22.00 $23.00 $21.00 $22.00 $23.00

88341 ---------- $98.00 $103.00 $105.00 $98.00 $103.00 $105.00

88341-26 ---------- $32.00 $33.00 $34.00 $32.00 $33.00 $34.00

88341-TC ---------- $66.00 $70.00 $71.00 $66.00 $70.00 $71.00

88342 $53.00 $116.00 $122.00 $124.00 $116.00 $122.00 $124.00

88342-26 $36.00 $41.00 $42.00 $43.00 $41.00 $42.00 $43.00

88342-TC $17.00 $75.00 $80.00 $81.00 $75.00 $80.00 $81.00

88344 ---------- $186.00 $197.00 $199.00 $186.00 $197.00 $199.00

88344-26 ---------- $45.00 $46.00 $47.00 $45.00 $46.00 $47.00

88344-TC ---------- $141.00 $151.00 $152.00 $141.00 $151.00 $152.00

88346 $96.00 $102.00 $108.00 $109.00 $102.00 $108.00 $109.00

88346-26 $66.00 $41.00 $42.00 $43.00 $41.00 $42.00 $43.00

88346-TC $28.00 $61.00 $65.00 $66.00 $61.00 $65.00 $66.00

88348 $191.00 $373.00 $396.00 $401.00 $373.00 $396.00 $401.00

88348-26 $145.00 $87.00 $89.00 $90.00 $87.00 $89.00 $90.00

88348-TC $44.00 $286.00 $307.00 $311.00 $286.00 $307.00 $311.00

88350 ---------- $79.00 $83.00 $84.00 $79.00 $83.00 $84.00

88350-26 ---------- $33.00 $34.00 $34.00 $33.00 $34.00 $34.00

88350-TC ---------- $46.00 $50.00 $50.00 $46.00 $50.00 $50.00

88355 $108.00 $156.00 $161.00 $163.00 $156.00 $161.00 $163.00

88355-26 $80.00 $92.00 $94.00 $94.00 $92.00 $94.00 $94.00

88355-TC $26.00 $63.00 $68.00 $69.00 $63.00 $68.00 $69.00

88356 $108.00 $229.00 $238.00 $241.00 $229.00 $238.00 $241.00

88356-26 $80.00 $137.00 $139.00 $141.00 $137.00 $139.00 $141.00

88356-TC $26.00 $92.00 $99.00 $101.00 $92.00 $99.00 $101.00

88358 $108.00 $98.00 $102.00 $104.00 $98.00 $102.00 $104.00

88358-26 $80.00 $52.00 $53.00 $54.00 $52.00 $53.00 $54.00

88358-TC $26.00 $45.00 $49.00 $49.00 $45.00 $49.00 $49.00

88360 ---------- $152.00 $160.00 $162.00 $152.00 $160.00 $162.00

88360-26 ---------- $63.00 $64.00 $65.00 $63.00 $64.00 $65.00

88360-TC ---------- $89.00 $95.00 $97.00 $89.00 $95.00 $97.00

88361 ---------- $168.00 $176.00 $179.00 $168.00 $176.00 $179.00





(Non-Facility MRA)






88361-26 ---------- $67.00 $68.00 $70.00 $67.00 $68.00 $70.00

88361-TC ---------- $101.00 $108.00 $109.00 $101.00 $108.00 $109.00

88362 BR $252.00 $264.00 $268.00 $252.00 $264.00 $268.00

88362-26 BR $125.00 $129.00 $131.00 $125.00 $129.00 $131.00

88362-TC BR $127.00 $136.00 $138.00 $127.00 $136.00 $138.00

88363 ---------- $26.00 $27.00 $28.00 $22.00 $23.00 $24.00

88364 ---------- $142.00 $150.00 $152.00 $142.00 $150.00 $152.00

88364-26 ---------- $40.00 $41.00 $42.00 $40.00 $41.00 $42.00

88364-TC ---------- $102.00 $109.00 $110.00 $102.00 $109.00 $110.00

88365 $24.00 $191.00 $202.00 $205.00 $191.00 $202.00 $205.00

88365-26 $24.00 $51.00 $52.00 $53.00 $51.00 $52.00 $53.00

88365-TC BR $141.00 $150.00 $152.00 $141.00 $150.00 $152.00

88366 ---------- $276.00 $292.00 $296.00 $276.00 $292.00 $296.00

88366-26 ---------- $71.00 $73.00 $74.00 $71.00 $73.00 $74.00

88366-TC ---------- $205.00 $220.00 $222.00 $205.00 $220.00 $222.00

88367 ---------- $114.00 $120.00 $122.00 $114.00 $120.00 $122.00

88367-26 ---------- $40.00 $40.00 $41.00 $40.00 $40.00 $41.00

88367-TC ---------- $75.00 $80.00 $81.00 $75.00 $80.00 $81.00

88368 ---------- $126.00 $133.00 $134.00 $126.00 $133.00 $134.00

88368-26 ---------- $46.00 $47.00 $48.00 $46.00 $47.00 $48.00

88368-TC ---------- $80.00 $86.00 $87.00 $80.00 $86.00 $87.00

88369 ---------- $115.00 $122.00 $123.00 $115.00 $122.00 $123.00

88369-26 ---------- $36.00 $37.00 $38.00 $36.00 $37.00 $38.00

88369-TC ---------- $79.00 $85.00 $86.00 $79.00 $85.00 $86.00

88371 $34.00 ---------- ---------- ---------- ---------- ---------- ----------

88371-26 $10.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00

88371-TC $23.00 ---------- ---------- ---------- ---------- ---------- ----------

88372 $38.00 ---------- ---------- ---------- ---------- ---------- ----------

88372-26 $11.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00

88372-TC $26.00 ---------- ---------- ---------- ---------- ---------- ----------

88373 ---------- $85.00 $90.00 $91.00 $85.00 $90.00 $91.00

88373-26 ---------- $31.00 $32.00 $32.00 $31.00 $32.00 $32.00

88373-TC ---------- $54.00 $58.00 $58.00 $54.00 $58.00 $58.00

88374 ---------- $363.00 $386.00 $390.00 $363.00 $386.00 $390.00

88374-26 ---------- $51.00 $52.00 $53.00 $51.00 $52.00 $53.00

88374-TC ---------- $313.00 $334.00 $338.00 $313.00 $334.00 $338.00

88375 ---------- $52.00 $53.00 $55.00 $52.00 $53.00 $55.00

88377 ---------- $434.00 $461.00 $466.00 $434.00 $461.00 $466.00

88377-26 ---------- $73.00 $74.00 $75.00 $73.00 $74.00 $75.00

88377-TC ---------- $361.00 $386.00 $391.00 $361.00 $386.00 $391.00

88380 BR $148.00 $156.00 $158.00 $148.00 $156.00 $158.00

88380-26 BR $63.00 $64.00 $65.00 $63.00 $64.00 $65.00

88380-TC BR $86.00 $92.00 $93.00 $86.00 $92.00 $93.00

88381 ---------- $131.00 $139.00 $141.00 $131.00 $139.00 $141.00

88381-26 ---------- $29.00 $29.00 $30.00 $29.00 $29.00 $30.00

88381-TC ---------- $102.00 $109.00 $111.00 $102.00 $109.00 $111.00

88387 ---------- $42.00 $44.00 $45.00 $42.00 $44.00 $45.00

88387-26 ---------- $34.00 $35.00 $36.00 $34.00 $35.00 $36.00

88387-TC ---------- $8.00 $9.00 $9.00 $8.00 $9.00 $9.00

88388 ---------- $38.00 $40.00 $41.00 $38.00 $40.00 $41.00





(Non-Facility MRA)






88388-26 ---------- $27.00 $28.00 $29.00 $27.00 $28.00 $29.00

88388-TC ---------- $11.00 $12.00 $12.00 $11.00 $12.00 $12.00

88399 BR ---------- ---------- ---------- ---------- ---------- ----------

88399-26 BR ---------- ---------- ---------- ---------- ---------- ----------

88399-TC BR ---------- ---------- ---------- ---------- ---------- ----------

89049 ---------- $289.00 $306.00 $312.00 $75.00 $77.00 $81.00

89050 $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 $21.00

89060-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 $19.00

89230 ---------- $5.00 $5.00 $5.00 $5.00 $5.00 $5.00

G0124 ---------- $36.00 $37.00 $38.00 $36.00 $37.00 $38.00

G0141 ---------- $36.00 $37.00 $38.00 $36.00 $37.00 $38.00

G0416 ---------- $524.00 $552.00 $559.00 $524.00 $552.00 $559.00

G0416-26 ---------- $203.00 $209.00 $212.00 $203.00 $209.00 $212.00

G0416-TC ---------- $321.00 $343.00 $347.00 $321.00 $343.00 $347.00

G0452-26 ---------- $20.00 $21.00 $21.00 $20.00 $21.00 $21.00

G0455 ---------- $142.00 $150.00 $156.00 $84.00 $89.00 $94.00



Medicine


(Non-Facility MRA)






90460 ---------- $28.00 $29.00 $30.00 $28.00 $29.00 $30.00

90461 ---------- $14.00 $15.00 $15.00 $14.00 $15.00 $15.00

90471 $4.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.00

90472 $4.00 $14.00 $15.00 $15.00 $14.00 $15.00 $15.00

90473 BR $28.00 $29.00 $30.00 $28.00 $29.00 $30.00

90474 BR $14.00 $15.00 $15.00 $14.00 $15.00 $15.00

90632 BR ---------- ---------- ---------- ---------- ---------- ----------

90636 BR ---------- ---------- ---------- ---------- ---------- ----------

90675 BR ---------- ---------- ---------- ---------- ---------- ----------

90746 BR ---------- ---------- ---------- ---------- ---------- ----------

90749 BR ---------- ---------- ---------- ---------- ---------- ----------

90785 ---------- $15.00 $16.00 $16.00 $15.00 $16.00 $16.00

90791 ---------- $146.00 $149.00 $153.00 $141.00 $144.00 $148.00

90792 ---------- $164.00 $168.00 $173.00 $159.00 $163.00 $168.00

90832 ---------- $71.00 $72.00 $74.00 $70.00 $72.00 $73.00

90833 ---------- $74.00 $76.00 $78.00 $73.00 $75.00 $77.00

90834 ---------- $94.00 $96.00 $99.00 $94.00 $95.00 $98.00

90836 ---------- $93.00 $95.00 $98.00 $92.00 $95.00 $97.00

90837 ---------- $142.00 $145.00 $148.00 $141.00 $144.00 $147.00

90838 ---------- $123.00 $126.00 $130.00 $122.00 $125.00 $129.00

90839 ---------- $148.00 $151.00 $154.00 $147.00 $150.00 $153.00

90840 ---------- $71.00 $72.00 $74.00 $70.00 $72.00 $73.00

90845 $85.00 $101.00 $104.00 $106.00 $101.00 $103.00 $106.00

90846 $93.00 $114.00 $117.00 $120.00 $113.00 $116.00 $119.00

90847 $110.00 $119.00 $121.00 $124.00 $118.00 $120.00 $123.00

90849 $32.00 $38.00 $40.00 $41.00 $35.00 $36.00 $37.00

90853 $32.00 $28.00 $29.00 $30.00 $28.00 $29.00 $29.00

90865 $143.00 $184.00 $191.00 $195.00 $143.00 $147.00 $150.00

90870 $94.00 $194.00 $202.00 $206.00 $124.00 $127.00 $130.00

90875 $74.00 $69.00 $71.00 $73.00 $68.00 $71.00 $73.00

90876 $112.00 $120.00 $125.00 $128.00 $108.00 $112.00 $116.00

90880 $112.00 $113.00 $115.00 $118.00 $104.00 $106.00 $109.00

90882 $104.00 ---------- ---------- ---------- ---------- ---------- ----------

90885 $49.00 $55.00 $57.00 $59.00 $55.00 $57.00 $59.00

90887 $77.00 $98.00 $102.00 $105.00 $85.00 $88.00 $91.00

90889 BR ---------- ---------- ---------- ---------- ---------- ----------

90899 BR ---------- ---------- ---------- ---------- ---------- ----------

90901 $46.00 $40.00 $42.00 $43.00 $22.00 $22.00 $23.00

90911 $82.00 $93.00 $97.00 $100.00 $50.00 $52.00 $54.00

90935 $76.00 $81.00 $83.00 $86.00 $81.00 $83.00 $86.00

90937 $226.00 $116.00 $120.00 $124.00 $116.00 $120.00 $124.00

90940 BR ---------- ---------- ---------- ---------- ---------- ----------

90945 $80.00 $95.00 $99.00 $102.00 $95.00 $99.00 $102.00

90947 $125.00 $139.00 $143.00 $148.00 $139.00 $143.00 $148.00

90951 ---------- $1,055.00 $1,092.00 $1,130.00 $1,055.00 $1,092.00 $1,130.00

90954 ---------- $911.00 $943.00 $975.00 $911.00 $943.00 $975.00

90955 ---------- $512.00 $530.00 $548.00 $512.00 $530.00 $548.00

90956 ---------- $355.00 $368.00 $380.00 $355.00 $368.00 $380.00

90957 ---------- $719.00 $744.00 $769.00 $719.00 $744.00 $769.00

90958 ---------- $486.00 $503.00 $519.00 $486.00 $503.00 $519.00



Medicine


(Non-Facility MRA)






90959 ---------- $330.00 $342.00 $352.00 $330.00 $342.00 $352.00

90960 ---------- $315.00 $327.00 $337.00 $315.00 $327.00 $337.00

90961 ---------- $265.00 $275.00 $283.00 $265.00 $275.00 $283.00

90962 ---------- $204.00 $211.00 $218.00 $204.00 $211.00 $218.00

90963 ---------- $608.00 $629.00 $650.00 $608.00 $629.00 $650.00

90964 ---------- $532.00 $551.00 $569.00 $532.00 $551.00 $569.00

90965 ---------- $506.00 $524.00 $541.00 $506.00 $524.00 $541.00

90966 ---------- $264.00 $273.00 $282.00 $264.00 $273.00 $282.00

90967 ---------- $20.00 $21.00 $22.00 $20.00 $21.00 $22.00

90968 ---------- $17.00 $18.00 $19.00 $17.00 $18.00 $19.00

90969 ---------- $17.00 $18.00 $18.00 $17.00 $18.00 $18.00

90970 ---------- $9.00 $9.00 $9.00 $9.00 $9.00 $9.00

90997 $115.00 $101.00 $104.00 $108.00 $101.00 $104.00 $108.00

90999 BR ---------- ---------- ---------- ---------- ---------- ----------

91010 $116.00 $191.00 $202.00 $206.00 $191.00 $202.00 $206.00

91010-26 $76.00 $76.00 $78.00 $81.00 $76.00 $78.00 $81.00

91010-TC $32.00 $116.00 $124.00 $125.00 $116.00 $124.00 $125.00

91013 ---------- $25.00 $27.00 $27.00 $25.00 $27.00 $27.00

91013-26 ---------- $11.00 $11.00 $11.00 $11.00 $11.00 $11.00

91013-TC ---------- $15.00 $16.00 $16.00 $15.00 $16.00 $16.00

91020 $60.00 $252.00 $266.00 $271.00 $252.00 $266.00 $271.00

91020-26 $49.00 $84.00 $86.00 $88.00 $84.00 $86.00 $88.00

91020-TC $9.00 $168.00 $180.00 $182.00 $168.00 $180.00 $182.00

91022 ---------- $182.00 $192.00 $195.00 $182.00 $192.00 $195.00

91022-26 ---------- $84.00 $87.00 $89.00 $84.00 $87.00 $89.00

91022-TC ---------- $98.00 $105.00 $106.00 $98.00 $105.00 $106.00

91030 $57.00 $145.00 $153.00 $156.00 $145.00 $153.00 $156.00

91030-26 $47.00 $52.00 $54.00 $55.00 $52.00 $54.00 $55.00

91030-TC $8.00 $93.00 $99.00 $101.00 $93.00 $99.00 $101.00

91034 ---------- $203.00 $216.00 $220.00 $203.00 $216.00 $220.00

91034-26 ---------- $57.00 $60.00 $62.00 $57.00 $60.00 $62.00

91034-TC ---------- $146.00 $156.00 $158.00 $146.00 $156.00 $158.00

91035 ---------- $516.00 $549.00 $557.00 $516.00 $549.00 $557.00

91035-26 ---------- $95.00 $98.00 $102.00 $95.00 $98.00 $102.00

91035-TC ---------- $421.00 $450.00 $455.00 $421.00 $450.00 $455.00

91037 ---------- $173.00 $183.00 $186.00 $173.00 $183.00 $186.00

91037-26 ---------- $57.00 $59.00 $60.00 $57.00 $59.00 $60.00

91037-TC ---------- $116.00 $124.00 $126.00 $116.00 $124.00 $126.00

91038 ---------- $480.00 $511.00 $518.00 $480.00 $511.00 $518.00

91038-26 ---------- $65.00 $67.00 $69.00 $65.00 $67.00 $69.00

91038-TC ---------- $416.00 $444.00 $449.00 $416.00 $444.00 $449.00

91040 ---------- $457.00 $486.00 $492.00 $457.00 $486.00 $492.00

91040-26 ---------- $56.00 $58.00 $59.00 $56.00 $58.00 $59.00

91040-TC ---------- $401.00 $428.00 $432.00 $401.00 $428.00 $432.00

91065 $34.00 $80.00 $85.00 $87.00 $80.00 $85.00 $87.00

91065-26 $23.00 $11.00 $12.00 $12.00 $11.00 $12.00 $12.00

91065-TC $14.00 $69.00 $74.00 $75.00 $69.00 $74.00 $75.00

91110 ---------- $907.00 $963.00 $975.00 $907.00 $963.00 $975.00

91110-26 ---------- $171.00 $177.00 $181.00 $171.00 $177.00 $181.00

91110-TC ---------- $736.00 $786.00 $794.00 $736.00 $786.00 $794.00



Medicine


(Non-Facility MRA)






91111 ---------- $794.00 $847.00 $856.00 $794.00 $847.00 $856.00

91111-26 ---------- $59.00 $61.00 $62.00 $59.00 $61.00 $62.00

91111-TC ---------- $736.00 $786.00 $794.00 $736.00 $786.00 $794.00

91112 ---------- $1,151.00 $1,225.00 $1,239.00 $1,151.00 $1,225.00 $1,239.00

91112-26 ---------- $123.00 $127.00 $130.00 $123.00 $127.00 $130.00

91112-TC ---------- $1,028.00 $1,098.00 $1,109.00 $1,028.00 $1,098.00 $1,109.00

91117 ---------- $157.00 $164.00 $169.00 $157.00 $164.00 $169.00

91120 ---------- $456.00 $486.00 $492.00 $456.00 $486.00 $492.00

91120-26 ---------- $57.00 $59.00 $61.00 $57.00 $59.00 $61.00

91120-TC ---------- $399.00 $427.00 $431.00 $399.00 $427.00 $431.00

91122 $169.00 $250.00 $264.00 $270.00 $250.00 $264.00 $270.00

91122-26 $122.00 $103.00 $107.00 $111.00 $103.00 $107.00 $111.00

91122-TC $37.00 $147.00 $157.00 $159.00 $147.00 $157.00 $159.00

91132 BR $158.00 $168.00 $170.00 $158.00 $168.00 $170.00

91132-26 $28.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.00

91132-TC BR $128.00 $137.00 $139.00 $128.00 $137.00 $139.00

91133 BR $185.00 $196.00 $199.00 $185.00 $196.00 $199.00

91133-26 $34.00 $39.00 $40.00 $41.00 $39.00 $40.00 $41.00

91133-TC BR $146.00 $156.00 $158.00 $146.00 $156.00 $158.00

91200 ---------- $42.00 $44.00 $45.00 $42.00 $44.00 $45.00

91200-26 ---------- $15.00 $16.00 $16.00 $15.00 $16.00 $16.00

91200-TC ---------- $27.00 $29.00 $29.00 $27.00 $29.00 $29.00

91299 BR ---------- ---------- ---------- ---------- ---------- ----------

91299-26 BR ---------- ---------- ---------- ---------- ---------- ----------

91299-TC BR ---------- ---------- ---------- ---------- ---------- ----------

92002 $63.00 $88.00 $92.00 $94.00 $53.00 $55.00 $56.00

92004 $98.00 $163.00 $170.00 $173.00 $111.00 $115.00 $117.00

92012 $53.00 $93.00 $98.00 $99.00 $59.00 $61.00 $62.00

92014 $75.00 $135.00 $141.00 $144.00 $89.00 $92.00 $94.00

92015 $34.00 $22.00 $23.00 $24.00 $22.00 $22.00 $23.00

92018 $80.00 $161.00 $167.00 $171.00 $161.00 $167.00 $171.00

92019 $70.00 $81.00 $83.00 $85.00 $81.00 $83.00 $85.00

92020 $31.00 $29.00 $31.00 $31.00 $23.00 $24.00 $25.00

92025 ---------- $41.00 $43.00 $44.00 $41.00 $43.00 $44.00

92025-26 ---------- $22.00 $23.00 $23.00 $22.00 $23.00 $23.00

92025-TC ---------- $19.00 $20.00 $21.00 $19.00 $20.00 $21.00

92060 $40.00 $71.00 $74.00 $75.00 $71.00 $74.00 $75.00

92060-26 $32.00 $42.00 $44.00 $44.00 $42.00 $44.00 $44.00

92060-TC $7.00 $28.00 $31.00 $31.00 $28.00 $31.00 $31.00

92065 $34.00 $59.00 $62.00 $63.00 $59.00 $62.00 $63.00

92065-26 $19.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00

92065-TC $6.00 $39.00 $41.00 $42.00 $39.00 $41.00 $42.00

92071 ---------- $42.00 $43.00 $44.00 $37.00 $38.00 $39.00

92072 ---------- $148.00 $153.00 $156.00 $114.00 $118.00 $120.00

92081 $32.00 $37.00 $39.00 $40.00 $37.00 $39.00 $40.00

92081-26 $19.00 $18.00 $19.00 $19.00 $18.00 $19.00 $19.00

92081-TC $6.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.00

92082 $48.00 $53.00 $55.00 $56.00 $53.00 $55.00 $56.00

92082-26 $24.00 $24.00 $25.00 $25.00 $24.00 $25.00 $25.00

92082-TC $9.00 $28.00 $31.00 $31.00 $28.00 $31.00 $31.00



Medicine


(Non-Facility MRA)






92083 $59.00 $70.00 $74.00 $75.00 $70.00 $74.00 $75.00

92083-26 $31.00 $31.00 $32.00 $32.00 $31.00 $32.00 $32.00

92083-TC $14.00 $39.00 $42.00 $43.00 $39.00 $42.00 $43.00

92100 $40.00 $87.00 $91.00 $92.00 $38.00 $39.00 $40.00

92132 ---------- $34.00 $36.00 $37.00 $34.00 $36.00 $37.00

92132-26 ---------- $18.00 $19.00 $19.00 $18.00 $19.00 $19.00

92132-TC ---------- $16.00 $17.00 $17.00 $16.00 $17.00 $17.00

92133 ---------- $41.00 $43.00 $44.00 $41.00 $43.00 $44.00

92133-26 ---------- $25.00 $26.00 $26.00 $25.00 $26.00 $26.00

92133-TC ---------- $16.00 $17.00 $18.00 $16.00 $17.00 $18.00

92134 ---------- $45.00 $47.00 $48.00 $45.00 $47.00 $48.00

92134-26 ---------- $28.00 $29.00 $30.00 $28.00 $29.00 $30.00

92134-TC ---------- $16.00 $18.00 $18.00 $16.00 $18.00 $18.00

92136 $93.00 $97.00 $103.00 $104.00 $97.00 $103.00 $104.00

92136-26 $29.00 $35.00 $36.00 $36.00 $35.00 $36.00 $36.00

92136-TC $63.00 $62.00 $67.00 $68.00 $62.00 $67.00 $68.00

92145 ---------- $20.00 $21.00 $22.00 $20.00 $21.00 $22.00

92145-26 ---------- $11.00 $11.00 $12.00 $11.00 $11.00 $12.00

92145-TC ---------- $9.00 $10.00 $10.00 $9.00 $10.00 $10.00

92225 $45.00 $29.00 $31.00 $31.00 $24.00 $25.00 $25.00

92226 $39.00 $27.00 $28.00 $29.00 $21.00 $22.00 $22.00

92227 ---------- $16.00 $17.00 $17.00 $16.00 $17.00 $17.00

92228 ---------- $38.00 $40.00 $41.00 $38.00 $40.00 $41.00

92228-26 ---------- $23.00 $24.00 $25.00 $23.00 $24.00 $25.00

92228-TC ---------- $14.00 $16.00 $16.00 $14.00 $16.00 $16.00

92230 $58.00 $63.00 $66.00 $67.00 $37.00 $38.00 $39.00

92235 $104.00 $93.00 $98.00 $99.00 $93.00 $98.00 $99.00

92235-26 $46.00 $48.00 $49.00 $50.00 $48.00 $49.00 $50.00

92235-TC $53.00 $45.00 $48.00 $49.00 $45.00 $48.00 $49.00

92240 $132.00 $223.00 $237.00 $240.00 $223.00 $237.00 $240.00

92240-26 $60.00 $52.00 $53.00 $54.00 $52.00 $53.00 $54.00

92240-TC $67.00 $172.00 $184.00 $186.00 $172.00 $184.00 $186.00

92242 ---------- $244.00 $258.00 $261.00 $244.00 $258.00 $261.00

92242-26 ---------- $61.00 $63.00 $64.00 $61.00 $63.00 $64.00

92242-TC ---------- $182.00 $195.00 $197.00 $182.00 $195.00 $197.00

92250 $40.00 $71.00 $75.00 $76.00 $71.00 $75.00 $76.00

92250-26 $24.00 $24.00 $25.00 $25.00 $24.00 $25.00 $25.00

92250-TC $7.00 $47.00 $50.00 $51.00 $47.00 $50.00 $51.00

92260 $20.00 $20.00 $21.00 $22.00 $12.00 $13.00 $13.00

92265 $53.00 $93.00 $97.00 $98.00 $93.00 $97.00 $98.00

92265-26 $37.00 $51.00 $53.00 $53.00 $51.00 $53.00 $53.00

92265-TC $10.00 $41.00 $44.00 $45.00 $41.00 $44.00 $45.00

92270 $64.00 $100.00 $105.00 $106.00 $100.00 $105.00 $106.00

92270-26 $45.00 $45.00 $47.00 $47.00 $45.00 $47.00 $47.00

92270-TC $19.00 $54.00 $58.00 $59.00 $54.00 $58.00 $59.00

92275 $80.00 $161.00 $169.00 $171.00 $161.00 $169.00 $171.00

92275-26 $56.00 $60.00 $62.00 $62.00 $60.00 $62.00 $62.00

92275-TC $17.00 $101.00 $108.00 $109.00 $101.00 $108.00 $109.00

92283 $24.00 $60.00 $64.00 $65.00 $60.00 $64.00 $65.00

92283-26 $10.00 $11.00 $11.00 $11.00 $11.00 $11.00 $11.00



Medicine


(Non-Facility MRA)






92283-TC $5.00 $50.00 $53.00 $54.00 $50.00 $53.00 $54.00

92284 $192.00 $68.00 $72.00 $73.00 $68.00 $72.00 $73.00

92284-26 $151.00 $14.00 $15.00 $15.00 $14.00 $15.00 $15.00

92284-TC $46.00 $53.00 $57.00 $58.00 $53.00 $57.00 $58.00

92285 $26.00 $23.00 $24.00 $25.00 $23.00 $24.00 $25.00

92285-26 $12.00 $4.00 $4.00 $4.00 $4.00 $4.00 $4.00

92285-TC $6.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.00

92286 $91.00 $42.00 $44.00 $45.00 $42.00 $44.00 $45.00

92286-26 $53.00 $25.00 $25.00 $26.00 $25.00 $25.00 $26.00

92286-TC $29.00 $18.00 $19.00 $19.00 $18.00 $19.00 $19.00

92287 $99.00 $149.00 $157.00 $159.00 $149.00 $157.00 $159.00

92287-26 ---------- $52.00 $53.00 $54.00 $52.00 $53.00 $54.00

92287-TC ---------- $97.00 $104.00 $105.00 $97.00 $104.00 $105.00

92310 $86.00 $105.00 $110.00 $113.00 $67.00 $69.00 $71.00

92311 $78.00 $110.00 $115.00 $117.00 $62.00 $64.00 $65.00

92312 $89.00 $128.00 $134.00 $136.00 $72.00 $74.00 $75.00

92313 $70.00 $105.00 $110.00 $111.00 $53.00 $54.00 $55.00

92314 $54.00 $87.00 $91.00 $93.00 $40.00 $41.00 $42.00

92315 $44.00 $80.00 $84.00 $86.00 $25.00 $26.00 $26.00

92316 $59.00 $100.00 $106.00 $107.00 $37.00 $38.00 $39.00

92317 $39.00 $82.00 $87.00 $88.00 $26.00 $27.00 $28.00

92325 $14.00 $45.00 $48.00 $49.00 $45.00 $48.00 $49.00

92326 $44.00 $38.00 $40.00 $41.00 $38.00 $40.00 $41.00

92340 $32.00 $39.00 $41.00 $41.00 $21.00 $22.00 $22.00

92341 $43.00 $44.00 $46.00 $48.00 $27.00 $28.00 $29.00

92342 $43.00 $48.00 $50.00 $51.00 $30.00 $31.00 $32.00

92358 $24.00 $12.00 $13.00 $14.00 $12.00 $13.00 $14.00

92370 $35.00 $34.00 $35.00 $36.00 $18.00 $19.00 $20.00

92371 $18.00 $13.00 $14.00 $14.00 $13.00 $14.00 $14.00

92499 BR ---------- ---------- ---------- ---------- ---------- ----------

92499-26 BR ---------- ---------- ---------- ---------- ---------- ----------

92499-TC BR ---------- ---------- ---------- ---------- ---------- ----------

92502 $101.00 $108.00 $112.00 $116.00 $108.00 $112.00 $116.00

92504 $24.00 $32.00 $34.00 $35.00 $11.00 $11.00 $11.00

92507 $40.00 $87.00 $90.00 $92.00 $87.00 $90.00 $92.00

92508 $42.00 $25.00 $26.00 $27.00 $25.00 $26.00 $27.00

92511 $81.00 $119.00 $126.00 $129.00 $42.00 $44.00 $46.00

92512 $46.00 $66.00 $70.00 $71.00 $32.00 $33.00 $35.00

92516 $36.00 $76.00 $80.00 $81.00 $26.00 $27.00 $28.00

92520 $47.00 $83.00 $87.00 $90.00 $46.00 $48.00 $50.00

92521 ---------- $123.00 $127.00 $130.00 $123.00 $127.00 $130.00

92522 ---------- $102.00 $106.00 $108.00 $102.00 $106.00 $108.00

92523 ---------- $216.00 $225.00 $229.00 $216.00 $225.00 $229.00

92524 ---------- $98.00 $102.00 $104.00 $98.00 $102.00 $104.00

92526 $48.00 $95.00 $98.00 $100.00 $95.00 $98.00 $100.00

92531 $10.00 ---------- ---------- ---------- ---------- ---------- ----------

92532 $14.00 ---------- ---------- ---------- ---------- ---------- ----------

92533 $41.00 ---------- ---------- ---------- ---------- ---------- ----------

92534 BR ---------- ---------- ---------- ---------- ---------- ----------

92537 ---------- $45.00 $46.00 $47.00 $45.00 $46.00 $47.00



Medicine


(Non-Facility MRA)






92537-26 ---------- $35.00 $36.00 $37.00 $35.00 $36.00 $37.00

92537-TC ---------- $9.00 $10.00 $10.00 $9.00 $10.00 $10.00

92538 ---------- $23.00 $24.00 $24.00 $23.00 $24.00 $24.00

92538-26 ---------- $18.00 $18.00 $19.00 $18.00 $18.00 $19.00

92538-TC ---------- $5.00 $6.00 $6.00 $5.00 $6.00 $6.00

92540 ---------- $113.00 $117.00 $119.00 $113.00 $117.00 $119.00

92540-26 ---------- $89.00 $91.00 $93.00 $89.00 $91.00 $93.00

92540-TC ---------- $24.00 $26.00 $26.00 $24.00 $26.00 $26.00

92541 $37.00 $27.00 $28.00 $29.00 $27.00 $28.00 $29.00

92541-26 $25.00 $23.00 $24.00 $25.00 $23.00 $24.00 $25.00

92541-TC $9.00 $4.00 $4.00 $5.00 $4.00 $4.00 $5.00

92542 $33.00 $31.00 $32.00 $33.00 $31.00 $32.00 $33.00

92542-26 $20.00 $28.00 $29.00 $29.00 $28.00 $29.00 $29.00

92542-TC $10.00 $3.00 $4.00 $4.00 $3.00 $4.00 $4.00

92544 $26.00 $19.00 $20.00 $20.00 $19.00 $20.00 $20.00

92544-26 $16.00 $16.00 $17.00 $17.00 $16.00 $17.00 $17.00

92544-TC $8.00 $3.00 $3.00 $3.00 $3.00 $3.00 $3.00

92545 $22.00 $17.00 $18.00 $18.00 $17.00 $18.00 $18.00

92545-26 $14.00 $15.00 $15.00 $15.00 $15.00 $15.00 $15.00

92545-TC $8.00 $2.00 $3.00 $3.00 $2.00 $3.00 $3.00

92546 $29.00 $110.00 $118.00 $119.00 $110.00 $118.00 $119.00

92546-26 $17.00 $17.00 $17.00 $17.00 $17.00 $17.00 $17.00

92546-TC $9.00 $94.00 $101.00 $102.00 $94.00 $101.00 $102.00

92547 $21.00 $6.00 $7.00 $7.00 $6.00 $7.00 $7.00

92548 $92.00 $107.00 $114.00 $116.00 $107.00 $114.00 $116.00

92548-26 $30.00 $29.00 $30.00 $31.00 $29.00 $30.00 $31.00

92548-TC $59.00 $78.00 $84.00 $85.00 $78.00 $84.00 $85.00

92550 ---------- $24.00 $24.00 $25.00 $24.00 $24.00 $25.00

92551 $17.00 $13.00 $14.00 $14.00 $13.00 $14.00 $14.00

92552 $16.00 $34.00 $36.00 $37.00 $34.00 $36.00 $37.00

92553 $24.00 $40.00 $43.00 $44.00 $40.00 $43.00 $44.00

92555 $14.00 $25.00 $27.00 $27.00 $25.00 $27.00 $27.00

92556 $21.00 $41.00 $43.00 $44.00 $41.00 $43.00 $44.00

92557 $46.00 $42.00 $44.00 $45.00 $37.00 $38.00 $39.00

92560 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

92561 $27.00 $41.00 $45.00 $46.00 $41.00 $45.00 $46.00

92562 $15.00 $50.00 $53.00 $54.00 $50.00 $53.00 $54.00

92563 $14.00 $33.00 $35.00 $36.00 $33.00 $35.00 $36.00

92564 $17.00 $29.00 $31.00 $32.00 $29.00 $31.00 $32.00

92565 $15.00 $17.00 $18.00 $18.00 $17.00 $18.00 $18.00

92567 $20.00 $16.00 $17.00 $17.00 $12.00 $13.00 $13.00

92568 $14.00 $18.00 $18.00 $19.00 $17.00 $18.00 $19.00

92570 ---------- $36.00 $37.00 $38.00 $33.00 $35.00 $36.00

92571 $14.00 $29.00 $31.00 $32.00 $29.00 $31.00 $32.00

92572 $3.00 $34.00 $36.00 $37.00 $34.00 $36.00 $37.00

92575 $11.00 $63.00 $67.00 $68.00 $63.00 $67.00 $68.00

92576 $17.00 $39.00 $42.00 $43.00 $39.00 $42.00 $43.00

92577 $28.00 $16.00 $18.00 $18.00 $16.00 $18.00 $18.00

92579 $28.00 $50.00 $52.00 $53.00 $43.00 $44.00 $45.00

92582 $28.00 $72.00 $77.00 $78.00 $72.00 $77.00 $78.00



Medicine


(Non-Facility MRA)






92583 $34.00 $54.00 $58.00 $58.00 $54.00 $58.00 $58.00

92584 $94.00 $79.00 $84.00 $86.00 $79.00 $84.00 $86.00

92585 $114.00 $146.00 $155.00 $158.00 $146.00 $155.00 $158.00

92585-26 $52.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.00

92585-TC $70.00 $116.00 $124.00 $126.00 $116.00 $124.00 $126.00

92586 $70.00 $92.00 $99.00 $100.00 $92.00 $99.00 $100.00

92587 $58.00 $24.00 $25.00 $26.00 $24.00 $25.00 $26.00

92587-26 $8.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00

92587-TC $49.00 $4.00 $4.00 $4.00 $4.00 $4.00 $4.00

92588 $78.00 $37.00 $38.00 $39.00 $37.00 $38.00 $39.00

92588-26 $20.00 $33.00 $34.00 $34.00 $33.00 $34.00 $34.00

92588-TC $57.00 $4.00 $5.00 $5.00 $4.00 $5.00 $5.00

92590 $41.00 ---------- ---------- ---------- ---------- ---------- ----------

92591 BR ---------- ---------- ---------- ---------- ---------- ----------

92592 BR ---------- ---------- ---------- ---------- ---------- ----------

92593 BR ---------- ---------- ---------- ---------- ---------- ----------

92594 BR ---------- ---------- ---------- ---------- ---------- ----------

92595 BR ---------- ---------- ---------- ---------- ---------- ----------

92596 $22.00 $44.00 $48.00 $49.00 $44.00 $48.00 $49.00

92597 $96.00 $81.00 $84.00 $86.00 $81.00 $84.00 $86.00

92603 $88.00 $168.00 $174.00 $178.00 $136.00 $141.00 $144.00

92604 $60.00 $99.00 $103.00 $105.00 $76.00 $78.00 $80.00

92605 BR $104.00 $108.00 $111.00 $100.00 $103.00 $106.00

92606 BR $92.00 $96.00 $99.00 $80.00 $83.00 $85.00

92607 $109.00 $141.00 $146.00 $149.00 $141.00 $146.00 $149.00

92608 $22.00 $58.00 $61.00 $62.00 $58.00 $61.00 $62.00

92609 $59.00 $121.00 $126.00 $128.00 $121.00 $126.00 $128.00

92610 $42.00 $95.00 $99.00 $101.00 $81.00 $84.00 $86.00

92611 $46.00 $96.00 $100.00 $103.00 $96.00 $100.00 $103.00

92612 $173.00 $204.00 $215.00 $219.00 $77.00 $80.00 $83.00

92613 BR $43.00 $45.00 $47.00 $43.00 $45.00 $47.00

92614 $134.00 $158.00 $166.00 $170.00 $75.00 $78.00 $81.00

92615 BR $38.00 $39.00 $40.00 $38.00 $39.00 $40.00

92616 $183.00 $226.00 $238.00 $243.00 $113.00 $118.00 $122.00

92617 BR $47.00 $49.00 $50.00 $47.00 $49.00 $50.00

92618 ---------- $38.00 $39.00 $41.00 $37.00 $39.00 $40.00

92620 ---------- $105.00 $109.00 $111.00 $92.00 $95.00 $97.00

92621 ---------- $25.00 $25.00 $26.00 $21.00 $22.00 $22.00

92625 ---------- $78.00 $81.00 $83.00 $70.00 $72.00 $74.00

92626 ---------- $99.00 $103.00 $105.00 $85.00 $88.00 $90.00

92627 ---------- $25.00 $25.00 $26.00 $20.00 $21.00 $21.00

92640 ---------- $123.00 $128.00 $131.00 $107.00 $110.00 $113.00

92700 BR ---------- ---------- ---------- ---------- ---------- ----------

92920 ---------- $635.00 $681.00 $751.00 $635.00 $681.00 $751.00

92924 ---------- $759.00 $814.00 $898.00 $759.00 $814.00 $898.00

92928 ---------- $707.00 $759.00 $837.00 $707.00 $759.00 $837.00

92933 ---------- $794.00 $851.00 $939.00 $794.00 $851.00 $939.00

92937 ---------- $707.00 $758.00 $836.00 $707.00 $758.00 $836.00

92941 ---------- $795.00 $853.00 $941.00 $795.00 $853.00 $941.00

92943 ---------- $794.00 $852.00 $939.00 $794.00 $852.00 $939.00



Medicine


(Non-Facility MRA)






92950 $203.00 $337.00 $354.00 $367.00 $214.00 $223.00 $234.00

92953 $35.00 $1.00 $1.00 $2.00 $1.00 $1.00 $2.00

92960 $162.00 $175.00 $183.00 $189.00 $124.00 $129.00 $134.00

92961 $239.00 $295.00 $315.00 $345.00 $295.00 $315.00 $345.00

92970 $201.00 $215.00 $226.00 $240.00 $215.00 $226.00 $240.00

92971 $100.00 $120.00 $129.00 $141.00 $120.00 $129.00 $141.00

92973 $174.00 $211.00 $226.00 $249.00 $211.00 $226.00 $249.00

92974 $197.00 $194.00 $208.00 $230.00 $194.00 $208.00 $230.00

92975 $400.00 $450.00 $483.00 $532.00 $450.00 $483.00 $532.00

92977 $302.00 $75.00 $82.00 $85.00 $75.00 $82.00 $85.00

92978 $269.00 ---------- ---------- ---------- ---------- ---------- ----------

92978-26 $95.00 $113.00 $121.00 $132.00 $113.00 $121.00 $132.00

92978-TC $170.00 ---------- ---------- ---------- ---------- ---------- ----------

92979 $163.00 ---------- ---------- ---------- ---------- ---------- ----------

92979-26 $76.00 $91.00 $97.00 $106.00 $91.00 $97.00 $106.00

92979-TC $86.00 ---------- ---------- ---------- ---------- ---------- ----------

92986 $1,222.00 $1,566.00 $1,679.00 $1,841.00 $1,566.00 $1,679.00 $1,841.00

92987 $1,271.00 $1,616.00 $1,732.00 $1,898.00 $1,616.00 $1,732.00 $1,898.00

92990 $974.00 $1,288.00 $1,381.00 $1,515.00 $1,288.00 $1,381.00 $1,515.00

92992 BR ---------- ---------- ---------- ---------- ---------- ----------

92993 BR ---------- ---------- ---------- ---------- ---------- ----------

92997 $765.00 $768.00 $819.00 $893.00 $768.00 $819.00 $893.00

92998 $331.00 $379.00 $403.00 $438.00 $379.00 $403.00 $438.00

93000 $26.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.00

93005 $16.00 $9.00 $10.00 $10.00 $9.00 $10.00 $10.00

93010 $12.00 $10.00 $10.00 $10.00 $10.00 $10.00 $10.00

93015 $104.00 $83.00 $88.00 $89.00 $83.00 $88.00 $89.00

93016 $25.00 $25.00 $26.00 $26.00 $25.00 $26.00 $26.00

93017 $63.00 $42.00 $45.00 $46.00 $42.00 $45.00 $46.00

93018 $54.00 $17.00 $17.00 $17.00 $17.00 $17.00 $17.00

93024 $111.00 $122.00 $128.00 $131.00 $122.00 $128.00 $131.00

93024-26 $71.00 $64.00 $65.00 $67.00 $64.00 $65.00 $67.00

93024-TC $42.00 $58.00 $63.00 $64.00 $58.00 $63.00 $64.00

93025 $277.00 $176.00 $186.00 $189.00 $176.00 $186.00 $189.00

93025-26 ---------- $41.00 $43.00 $44.00 $41.00 $43.00 $44.00

93025-TC ---------- $134.00 $143.00 $145.00 $134.00 $143.00 $145.00

93040 $14.00 $14.00 $15.00 $16.00 $14.00 $15.00 $16.00

93041 $31.00 $6.00 $7.00 $7.00 $6.00 $7.00 $7.00

93042 $9.00 $8.00 $8.00 $9.00 $8.00 $8.00 $9.00

93050 ---------- $19.00 $21.00 $21.00 $19.00 $21.00 $21.00

93050-26 ---------- $10.00 $10.00 $11.00 $10.00 $10.00 $11.00

93050-TC ---------- $10.00 $10.00 $11.00 $10.00 $10.00 $11.00

93224 $159.00 $99.00 $105.00 $107.00 $99.00 $105.00 $107.00

93225 $46.00 $28.00 $31.00 $31.00 $28.00 $31.00 $31.00

93226 $83.00 $41.00 $43.00 $44.00 $41.00 $43.00 $44.00

93227 $50.00 $30.00 $31.00 $31.00 $30.00 $31.00 $31.00

93228 ---------- $29.00 $30.00 $31.00 $29.00 $30.00 $31.00

93229 ---------- $767.00 $820.00 $830.00 $767.00 $820.00 $830.00

93260 ---------- $72.00 $75.00 $76.00 $72.00 $75.00 $76.00

93260-26 ---------- $49.00 $50.00 $51.00 $49.00 $50.00 $51.00



Medicine


(Non-Facility MRA)






93260-TC ---------- $23.00 $24.00 $25.00 $23.00 $24.00 $25.00

93261 ---------- $66.00 $69.00 $70.00 $66.00 $69.00 $70.00

93261-26 ---------- $43.00 $44.00 $45.00 $43.00 $44.00 $45.00

93261-TC ---------- $23.00 $24.00 $25.00 $23.00 $24.00 $25.00

93268 $109.00 $219.00 $233.00 $236.00 $219.00 $233.00 $236.00

93270 $46.00 $10.00 $11.00 $11.00 $10.00 $11.00 $11.00

93271 $90.00 $181.00 $193.00 $195.00 $181.00 $193.00 $195.00

93272 $28.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.00

93278 $58.00 $33.00 $35.00 $36.00 $33.00 $35.00 $36.00

93278-26 $24.00 $14.00 $14.00 $15.00 $14.00 $14.00 $15.00

93278-TC $44.00 $19.00 $21.00 $21.00 $19.00 $21.00 $21.00

93279 ---------- $55.00 $58.00 $59.00 $55.00 $58.00 $59.00

93279-26 ---------- $36.00 $37.00 $38.00 $36.00 $37.00 $38.00

93279-TC ---------- $19.00 $20.00 $21.00 $19.00 $20.00 $21.00

93280 ---------- $64.00 $67.00 $69.00 $64.00 $67.00 $69.00

93280-26 ---------- $43.00 $44.00 $45.00 $43.00 $44.00 $45.00

93280-TC ---------- $21.00 $23.00 $23.00 $21.00 $23.00 $23.00

93281 ---------- $75.00 $79.00 $80.00 $75.00 $79.00 $80.00

93281-26 ---------- $50.00 $52.00 $53.00 $50.00 $52.00 $53.00

93281-TC ---------- $25.00 $27.00 $27.00 $25.00 $27.00 $27.00

93282 ---------- $70.00 $73.00 $74.00 $70.00 $73.00 $74.00

93282-26 ---------- $48.00 $49.00 $50.00 $48.00 $49.00 $50.00

93282-TC ---------- $22.00 $24.00 $24.00 $22.00 $24.00 $24.00

93283 ---------- $90.00 $94.00 $96.00 $90.00 $94.00 $96.00

93283-26 ---------- $64.00 $66.00 $68.00 $64.00 $66.00 $68.00

93283-TC ---------- $25.00 $27.00 $28.00 $25.00 $27.00 $28.00

93284 ---------- $100.00 $104.00 $106.00 $100.00 $104.00 $106.00

93284-26 ---------- $70.00 $73.00 $74.00 $70.00 $73.00 $74.00

93284-TC ---------- $29.00 $31.00 $32.00 $29.00 $31.00 $32.00

93285 ---------- $46.00 $48.00 $50.00 $46.00 $48.00 $50.00

93285-26 ---------- $29.00 $30.00 $31.00 $29.00 $30.00 $31.00

93285-TC ---------- $17.00 $18.00 $19.00 $17.00 $18.00 $19.00

93286 ---------- $30.00 $31.00 $32.00 $30.00 $31.00 $32.00

93286-26 ---------- $17.00 $17.00 $18.00 $17.00 $17.00 $18.00

93286-TC ---------- $13.00 $14.00 $14.00 $13.00 $14.00 $14.00

93287 ---------- $40.00 $42.00 $44.00 $40.00 $42.00 $44.00

93287-26 ---------- $26.00 $27.00 $27.00 $26.00 $27.00 $27.00

93287-TC ---------- $14.00 $16.00 $16.00 $14.00 $16.00 $16.00

93288 ---------- $41.00 $43.00 $44.00 $41.00 $43.00 $44.00

93288-26 ---------- $24.00 $25.00 $25.00 $24.00 $25.00 $25.00

93288-TC ---------- $17.00 $18.00 $19.00 $17.00 $18.00 $19.00

93289 ---------- $72.00 $75.00 $77.00 $72.00 $75.00 $77.00

93289-26 ---------- $51.00 $53.00 $54.00 $51.00 $53.00 $54.00

93289-TC ---------- $21.00 $23.00 $23.00 $21.00 $23.00 $23.00

93290 ---------- $35.00 $36.00 $37.00 $35.00 $36.00 $37.00

93290-26 ---------- $24.00 $25.00 $26.00 $24.00 $25.00 $26.00

93290-TC ---------- $10.00 $11.00 $12.00 $10.00 $11.00 $12.00

93291 ---------- $40.00 $42.00 $44.00 $40.00 $42.00 $44.00

93291-26 ---------- $24.00 $25.00 $26.00 $24.00 $25.00 $26.00

93291-TC ---------- $16.00 $17.00 $18.00 $16.00 $17.00 $18.00



Medicine


(Non-Facility MRA)






93292 ---------- $36.00 $38.00 $39.00 $36.00 $38.00 $39.00

93292-26 ---------- $24.00 $25.00 $25.00 $24.00 $25.00 $25.00

93292-TC ---------- $12.00 $13.00 $13.00 $12.00 $13.00 $13.00

93293 ---------- $58.00 $62.00 $63.00 $58.00 $62.00 $63.00

93293-26 ---------- $18.00 $18.00 $19.00 $18.00 $18.00 $19.00

93293-TC ---------- $41.00 $43.00 $44.00 $41.00 $43.00 $44.00

93294 ---------- $38.00 $39.00 $41.00 $38.00 $39.00 $41.00

93295 ---------- $76.00 $79.00 $82.00 $76.00 $79.00 $82.00

93296 ---------- $28.00 $30.00 $31.00 $28.00 $30.00 $31.00

93297 ---------- $30.00 $31.00 $32.00 $30.00 $31.00 $32.00

93298 ---------- $30.00 $31.00 $32.00 $30.00 $31.00 $32.00

93303 $215.00 $256.00 $271.00 $275.00 $256.00 $271.00 $275.00

93303-26 $70.00 $71.00 $73.00 $75.00 $71.00 $73.00 $75.00

93303-TC $144.00 $184.00 $197.00 $200.00 $184.00 $197.00 $200.00

93304 $114.00 $168.00 $177.00 $180.00 $168.00 $177.00 $180.00

93304-26 $43.00 $41.00 $42.00 $43.00 $41.00 $42.00 $43.00

93304-TC $73.00 $127.00 $135.00 $137.00 $127.00 $135.00 $137.00

93306 ---------- $247.00 $261.00 $265.00 $247.00 $261.00 $265.00

93306-26 ---------- $71.00 $73.00 $75.00 $71.00 $73.00 $75.00

93306-TC ---------- $175.00 $188.00 $190.00 $175.00 $188.00 $190.00

93307 $196.00 $141.00 $148.00 $151.00 $141.00 $148.00 $151.00

93307-26 $56.00 $50.00 $52.00 $53.00 $50.00 $52.00 $53.00

93307-TC $144.00 $90.00 $97.00 $98.00 $90.00 $97.00 $98.00

93308 $118.00 $135.00 $143.00 $145.00 $135.00 $143.00 $145.00

93308-26 $46.00 $29.00 $30.00 $30.00 $29.00 $30.00 $30.00

93308-TC $75.00 $106.00 $113.00 $115.00 $106.00 $113.00 $115.00

93312 $322.00 $268.00 $282.00 $287.00 $268.00 $282.00 $287.00

93312-26 $140.00 $123.00 $126.00 $129.00 $123.00 $126.00 $129.00

93312-TC $182.00 $146.00 $156.00 $158.00 $146.00 $156.00 $158.00

93313 $76.00 $13.00 $14.00 $14.00 $13.00 $14.00 $14.00

93314 $212.00 $258.00 $273.00 $281.00 $258.00 $273.00 $281.00

93314-26 $65.00 $104.00 $108.00 $113.00 $104.00 $108.00 $113.00

93314-TC $144.00 $155.00 $165.00 $168.00 $155.00 $165.00 $168.00

93315 $287.00 $617.00 $654.00 $662.00 $617.00 $654.00 $662.00

93315-26 $144.00 $145.00 $149.00 $152.00 $145.00 $149.00 $152.00

93315-TC $141.00 $473.00 $505.00 $510.00 $473.00 $505.00 $510.00

93316 $78.00 $31.00 $32.00 $34.00 $31.00 $32.00 $34.00

93317 $236.00 ---------- ---------- ---------- ---------- ---------- ----------

93317-26 $95.00 $106.00 $111.00 $117.00 $106.00 $111.00 $117.00

93317-TC $141.00 ---------- ---------- ---------- ---------- ---------- ----------

93318 BR $592.00 $628.00 $639.00 $592.00 $628.00 $639.00

93318-26 $114.00 $119.00 $123.00 $129.00 $119.00 $123.00 $129.00

93318-TC BR $473.00 $505.00 $510.00 $473.00 $505.00 $510.00

93320 $86.00 $59.00 $62.00 $62.00 $59.00 $62.00 $62.00

93320-26 $30.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00

93320-TC $65.00 $38.00 $41.00 $41.00 $38.00 $41.00 $41.00

93321 $50.00 $29.00 $31.00 $32.00 $29.00 $31.00 $32.00

93321-26 $10.00 $8.00 $9.00 $9.00 $8.00 $9.00 $9.00

93321-TC $42.00 $21.00 $23.00 $23.00 $21.00 $23.00 $23.00

93325 $114.00 $27.00 $29.00 $29.00 $27.00 $29.00 $29.00



Medicine


(Non-Facility MRA)






93325-26 $4.00 $4.00 $4.00 $4.00 $4.00 $4.00 $4.00

93325-TC $110.00 $24.00 $25.00 $26.00 $24.00 $25.00 $26.00

93350 $216.00 $260.00 $275.00 $279.00 $260.00 $275.00 $279.00

93350-26 $77.00 $80.00 $82.00 $83.00 $80.00 $82.00 $83.00

93350-TC $66.00 $181.00 $193.00 $196.00 $181.00 $193.00 $196.00

93351 ---------- $293.00 $310.00 $315.00 $293.00 $310.00 $315.00

93351-26 ---------- $95.00 $98.00 $100.00 $95.00 $98.00 $100.00

93351-TC ---------- $198.00 $212.00 $215.00 $198.00 $212.00 $215.00

93352 ---------- $37.00 $39.00 $40.00 $37.00 $39.00 $40.00

93355 ---------- $257.00 $266.00 $277.00 $257.00 $266.00 $277.00

93451 ---------- $787.00 $840.00 $862.00 $787.00 $840.00 $862.00

93451-26 ---------- $155.00 $165.00 $180.00 $155.00 $165.00 $180.00

93451-TC ---------- $632.00 $675.00 $682.00 $632.00 $675.00 $682.00

93452 ---------- $903.00 $963.00 $997.00 $903.00 $963.00 $997.00

93452-26 ---------- $282.00 $300.00 $326.00 $282.00 $300.00 $326.00

93452-TC ---------- $621.00 $664.00 $671.00 $621.00 $664.00 $671.00

93453 ---------- $1,174.00 $1,254.00 $1,300.00 $1,174.00 $1,254.00 $1,300.00

93453-26 ---------- $378.00 $403.00 $440.00 $378.00 $403.00 $440.00

93453-TC ---------- $796.00 $851.00 $860.00 $796.00 $851.00 $860.00

93454 ---------- $917.00 $979.00 $1,015.00 $917.00 $979.00 $1,015.00

93454-26 ---------- $286.00 $305.00 $333.00 $286.00 $305.00 $333.00

93454-TC ---------- $631.00 $674.00 $682.00 $631.00 $674.00 $682.00

93455 ---------- $1,072.00 $1,145.00 $1,186.00 $1,072.00 $1,145.00 $1,186.00

93455-26 ---------- $333.00 $355.00 $388.00 $333.00 $355.00 $388.00

93455-TC ---------- $739.00 $790.00 $798.00 $739.00 $790.00 $798.00

93456 ---------- $1,160.00 $1,239.00 $1,284.00 $1,160.00 $1,239.00 $1,284.00

93456-26 ---------- $372.00 $396.00 $433.00 $372.00 $396.00 $433.00

93456-TC ---------- $788.00 $842.00 $852.00 $788.00 $842.00 $852.00

93457 ---------- $1,315.00 $1,404.00 $1,456.00 $1,315.00 $1,404.00 $1,456.00

93457-26 ---------- $419.00 $447.00 $488.00 $419.00 $447.00 $488.00

93457-TC ---------- $896.00 $957.00 $968.00 $896.00 $957.00 $968.00

93458 ---------- $1,105.00 $1,181.00 $1,225.00 $1,105.00 $1,181.00 $1,225.00

93458-26 ---------- $353.00 $377.00 $411.00 $353.00 $377.00 $411.00

93458-TC ---------- $752.00 $804.00 $813.00 $752.00 $804.00 $813.00

93459 ---------- $1,226.00 $1,309.00 $1,359.00 $1,226.00 $1,309.00 $1,359.00

93459-26 ---------- $400.00 $427.00 $466.00 $400.00 $427.00 $466.00

93459-TC ---------- $826.00 $883.00 $893.00 $826.00 $883.00 $893.00

93460 ---------- $1,322.00 $1,412.00 $1,467.00 $1,322.00 $1,412.00 $1,467.00

93460-26 ---------- $448.00 $477.00 $522.00 $448.00 $477.00 $522.00

93460-TC ---------- $875.00 $935.00 $945.00 $875.00 $935.00 $945.00

93461 ---------- $1,512.00 $1,615.00 $1,675.00 $1,512.00 $1,615.00 $1,675.00

93461-26 ---------- $495.00 $528.00 $577.00 $495.00 $528.00 $577.00

93461-TC ---------- $1,017.00 $1,087.00 $1,098.00 $1,017.00 $1,087.00 $1,098.00

93462 ---------- $249.00 $267.00 $294.00 $249.00 $267.00 $294.00

93463 ---------- $112.00 $116.00 $120.00 $112.00 $116.00 $120.00

93464 ---------- $277.00 $292.00 $296.00 $277.00 $292.00 $296.00

93464-26 ---------- $98.00 $101.00 $103.00 $98.00 $101.00 $103.00

93464-TC ---------- $179.00 $191.00 $193.00 $179.00 $191.00 $193.00

93503 $187.00 $148.00 $154.00 $161.00 $148.00 $154.00 $161.00

93505 $318.00 $768.00 $820.00 $852.00 $768.00 $820.00 $852.00



Medicine


(Non-Facility MRA)






93505-26 $248.00 $259.00 $276.00 $302.00 $259.00 $276.00 $302.00

93505-TC $74.00 $509.00 $544.00 $550.00 $509.00 $544.00 $550.00

93530 $872.00 ---------- ---------- ---------- ---------- ---------- ----------

93530-26 $250.00 $243.00 $258.00 $278.00 $243.00 $258.00 $278.00

93530-TC $634.00 ---------- ---------- ---------- ---------- ---------- ----------

93531 $2,268.00 ---------- ---------- ---------- ---------- ---------- ----------

93531-26 $467.00 $502.00 $529.00 $567.00 $502.00 $529.00 $567.00

93531-TC $1,815.00 ---------- ---------- ---------- ---------- ---------- ----------

93532 $2,317.00 ---------- ---------- ---------- ---------- ---------- ----------

93532-26 $569.00 $632.00 $675.00 $738.00 $632.00 $675.00 $738.00

93532-TC $1,766.00 ---------- ---------- ---------- ---------- ---------- ----------

93533 $2,131.00 ---------- ---------- ---------- ---------- ---------- ----------

93533-26 $352.00 $422.00 $451.00 $493.00 $422.00 $451.00 $493.00

93533-TC $1,766.00 ---------- ---------- ---------- ---------- ---------- ----------

93561 $59.00 ---------- ---------- ---------- ---------- ---------- ----------

93561-26 $47.00 $15.00 $16.00 $17.00 $15.00 $16.00 $17.00

93561-TC $20.00 ---------- ---------- ---------- ---------- ---------- ----------

93562 $46.00 ---------- ---------- ---------- ---------- ---------- ----------

93562-26 $33.00 $1.00 $1.00 $2.00 $1.00 $1.00 $2.00

93562-TC $13.00 ---------- ---------- ---------- ---------- ---------- ----------

93563 ---------- $69.00 $74.00 $80.00 $69.00 $74.00 $80.00

93564 ---------- $73.00 $79.00 $87.00 $73.00 $79.00 $87.00

93565 ---------- $54.00 $57.00 $62.00 $54.00 $57.00 $62.00

93566 ---------- $177.00 $189.00 $197.00 $55.00 $59.00 $65.00

93567 ---------- $151.00 $162.00 $169.00 $63.00 $67.00 $74.00

93568 ---------- $159.00 $170.00 $177.00 $56.00 $60.00 $66.00

93571 $270.00 ---------- ---------- ---------- ---------- ---------- ----------

93571-26 $93.00 $113.00 $121.00 $132.00 $113.00 $121.00 $132.00

93571-TC $170.00 ---------- ---------- ---------- ---------- ---------- ----------

93572 $222.00 ---------- ---------- ---------- ---------- ---------- ----------

93572-26 $74.00 $91.00 $97.00 $106.00 $91.00 $97.00 $106.00

93572-TC $155.00 ---------- ---------- ---------- ---------- ---------- ----------

93580 $974.00 $1,165.00 $1,247.00 $1,370.00 $1,165.00 $1,247.00 $1,370.00

93581 $1,303.00 $1,603.00 $1,720.00 $1,897.00 $1,603.00 $1,720.00 $1,897.00

93582 ---------- $778.00 $831.00 $908.00 $778.00 $831.00 $908.00

93583 ---------- $885.00 $948.00 $1,044.00 $885.00 $948.00 $1,044.00

93600 $198.00 ---------- ---------- ---------- ---------- ---------- ----------

93600-26 $129.00 $140.00 $150.00 $163.00 $140.00 $150.00 $163.00

93600-TC $73.00 ---------- ---------- ---------- ---------- ---------- ----------

93602 $159.00 ---------- ---------- ---------- ---------- ---------- ----------

93602-26 $119.00 $137.00 $146.00 $159.00 $137.00 $146.00 $159.00

93602-TC $42.00 ---------- ---------- ---------- ---------- ---------- ----------

93603 $187.00 ---------- ---------- ---------- ---------- ---------- ----------

93603-26 $127.00 $137.00 $146.00 $159.00 $137.00 $146.00 $159.00

93603-TC $63.00 ---------- ---------- ---------- ---------- ---------- ----------

93609 $578.00 ---------- ---------- ---------- ---------- ---------- ----------

93609-26 $481.00 $329.00 $351.00 $382.00 $329.00 $351.00 $382.00

93609-TC $101.00 ---------- ---------- ---------- ---------- ---------- ----------

93610 $214.00 ---------- ---------- ---------- ---------- ---------- ----------

93610-26 $166.00 $194.00 $207.00 $226.00 $194.00 $207.00 $226.00



Medicine


(Non-Facility MRA)






93610-TC $52.00 ---------- ---------- ---------- ---------- ---------- ----------

93612 $224.00 ---------- ---------- ---------- ---------- ---------- ----------

93612-26 $167.00 $192.00 $205.00 $223.00 $192.00 $205.00 $223.00

93612-TC $61.00 ---------- ---------- ---------- ---------- ---------- ----------

93613 $377.00 $473.00 $508.00 $558.00 $473.00 $508.00 $558.00

93615 $62.00 ---------- ---------- ---------- ---------- ---------- ----------

93615-26 $49.00 $43.00 $45.00 $46.00 $43.00 $45.00 $46.00

93615-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

93616 $94.00 ---------- ---------- ---------- ---------- ---------- ----------

93616-26 $82.00 $60.00 $62.00 $64.00 $60.00 $62.00 $64.00

93616-TC $12.00 ---------- ---------- ---------- ---------- ---------- ----------

93618 $399.00 ---------- ---------- ---------- ---------- ---------- ----------

93618-26 $258.00 $262.00 $280.00 $305.00 $262.00 $280.00 $305.00

93618-TC $148.00 ---------- ---------- ---------- ---------- ---------- ----------

93619 $717.00 ---------- ---------- ---------- ---------- ---------- ----------

93619-26 $444.00 $462.00 $493.00 $538.00 $462.00 $493.00 $538.00

93619-TC $290.00 ---------- ---------- ---------- ---------- ---------- ----------

93620 $358.00 ---------- ---------- ---------- ---------- ---------- ----------

93620-26 $272.00 $743.00 $793.00 $864.00 $743.00 $793.00 $864.00

93620-TC $91.00 ---------- ---------- ---------- ---------- ---------- ----------

93621 BR ---------- ---------- ---------- ---------- ---------- ----------

93621-26 $769.00 $139.00 $149.00 $162.00 $139.00 $149.00 $162.00

93621-TC BR ---------- ---------- ---------- ---------- ---------- ----------

93622 BR ---------- ---------- ---------- ---------- ---------- ----------

93622-26 $771.00 $204.00 $218.00 $237.00 $204.00 $218.00 $237.00

93622-TC BR ---------- ---------- ---------- ---------- ---------- ----------

93623 BR ---------- ---------- ---------- ---------- ---------- ----------

93623-26 $167.00 $189.00 $201.00 $220.00 $189.00 $201.00 $220.00

93623-TC BR ---------- ---------- ---------- ---------- ---------- ----------

93624 $333.00 ---------- ---------- ---------- ---------- ---------- ----------

93624-26 $256.00 $287.00 $307.00 $336.00 $287.00 $307.00 $336.00

93624-TC $74.00 ---------- ---------- ---------- ---------- ---------- ----------

93631 $651.00 ---------- ---------- ---------- ---------- ---------- ----------

93631-26 $420.00 $472.00 $504.00 $552.00 $472.00 $504.00 $552.00

93631-TC $239.00 ---------- ---------- ---------- ---------- ---------- ----------

93640 $467.00 ---------- ---------- ---------- ---------- ---------- ----------

93640-26 $230.00 $212.00 $226.00 $247.00 $212.00 $226.00 $247.00

93640-TC $269.00 ---------- ---------- ---------- ---------- ---------- ----------

93641 $613.00 ---------- ---------- ---------- ---------- ---------- ----------

93641-26 $360.00 $370.00 $395.00 $430.00 $370.00 $395.00 $430.00

93641-TC $269.00 ---------- ---------- ---------- ---------- ---------- ----------

93642 $549.00 $392.00 $419.00 $450.00 $392.00 $419.00 $450.00

93642-26 $295.00 $304.00 $325.00 $354.00 $304.00 $325.00 $354.00

93642-TC $269.00 $87.00 $94.00 $95.00 $87.00 $94.00 $95.00

93644 ---------- $240.00 $250.00 $255.00 $240.00 $250.00 $255.00

93644-26 ---------- $178.00 $184.00 $188.00 $178.00 $184.00 $188.00

93644-TC ---------- $62.00 $66.00 $67.00 $62.00 $66.00 $67.00

93650 $639.00 $703.00 $754.00 $827.00 $703.00 $754.00 $827.00

93653 ---------- $996.00 $1,068.00 $1,174.00 $996.00 $1,068.00 $1,174.00

93654 ---------- $1,334.00 $1,430.00 $1,573.00 $1,334.00 $1,430.00 $1,573.00



Medicine


(Non-Facility MRA)






93655 ---------- $508.00 $544.00 $599.00 $508.00 $544.00 $599.00

93656 ---------- $1,338.00 $1,435.00 $1,577.00 $1,338.00 $1,435.00 $1,577.00

93657 ---------- $506.00 $543.00 $598.00 $506.00 $543.00 $598.00

93660 $162.00 $174.00 $182.00 $185.00 $174.00 $182.00 $185.00

93660-26 $103.00 $105.00 $108.00 $111.00 $105.00 $108.00 $111.00

93660-TC $61.00 $68.00 $73.00 $74.00 $68.00 $73.00 $74.00

93662 BR ---------- ---------- ---------- ---------- ---------- ----------

93662-26 $158.00 $161.00 $165.00 $169.00 $161.00 $165.00 $169.00

93662-TC BR ---------- ---------- ---------- ---------- ---------- ----------

93701 $36.00 $26.00 $28.00 $29.00 $26.00 $28.00 $29.00

93701-26 $9.00 ---------- ---------- ---------- ---------- ---------- ----------

93701-TC $27.00 ---------- ---------- ---------- ---------- ---------- ----------

93702 ---------- $132.00 $141.00 $143.00 $132.00 $141.00 $143.00

93724 $411.00 $302.00 $311.00 $318.00 $302.00 $311.00 $318.00

93724-26 $259.00 $272.00 $279.00 $286.00 $272.00 $279.00 $286.00

93724-TC $148.00 $30.00 $32.00 $33.00 $30.00 $32.00 $33.00

93740 $17.00 $9.00 $9.00 $10.00 $9.00 $9.00 $10.00

93740-26 $12.00 ---------- ---------- ---------- ---------- ---------- ----------

93740-TC $5.00 ---------- ---------- ---------- ---------- ---------- ----------

93750 ---------- $63.00 $66.00 $69.00 $53.00 $55.00 $58.00

93770 NC NC NC NC NC NC NC

93770-26 NC NC NC NC NC NC NC

93770-TC NC NC NC NC NC NC NC





93797 $17.00 $18.00 $19.00 $19.00 $10.00 $10.00 $11.00

93798 $38.00 $28.00 $29.00 $30.00 $16.00 $16.00 $17.00

93799 BR ---------- ---------- ---------- ---------- ---------- ----------

93799-26 BR ---------- ---------- ---------- ---------- ---------- ----------

93799-TC BR ---------- ---------- ---------- ---------- ---------- ----------

93880 $176.00 $219.00 $233.00 $238.00 $219.00 $233.00 $238.00

93880-26 $31.00 $45.00 $47.00 $50.00 $45.00 $47.00 $50.00

93880-TC $144.00 $174.00 $186.00 $188.00 $174.00 $186.00 $188.00

93882 $117.00 $140.00 $149.00 $153.00 $140.00 $149.00 $153.00

93882-26 $21.00 $29.00 $31.00 $33.00 $29.00 $31.00 $33.00

93882-TC $95.00 $111.00 $118.00 $120.00 $111.00 $118.00 $120.00

93886 $215.00 $291.00 $309.00 $314.00 $291.00 $309.00 $314.00

93886-26 $50.00 $53.00 $55.00 $57.00 $53.00 $55.00 $57.00

93886-TC $162.00 $238.00 $254.00 $257.00 $238.00 $254.00 $257.00

93888 $142.00 $148.00 $158.00 $161.00 $148.00 $158.00 $161.00

93888-26 $33.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.00

93888-TC $109.00 $119.00 $127.00 $128.00 $119.00 $127.00 $128.00

93890 ---------- $295.00 $314.00 $319.00 $295.00 $314.00 $319.00

93890-26 ---------- $58.00 $60.00 $62.00 $58.00 $60.00 $62.00

93890-TC ---------- $238.00 $254.00 $257.00 $238.00 $254.00 $257.00

93892 ---------- $187.00 $197.00 $202.00 $187.00 $197.00 $202.00

93892-26 ---------- $68.00 $71.00 $74.00 $68.00 $71.00 $74.00

93892-TC ---------- $119.00 $127.00 $128.00 $119.00 $127.00 $128.00



Medicine


(Non-Facility MRA)






93893 ---------- $186.00 $196.00 $200.00 $186.00 $196.00 $200.00

93893-26 ---------- $67.00 $70.00 $72.00 $67.00 $70.00 $72.00

93893-TC ---------- $119.00 $127.00 $128.00 $119.00 $127.00 $128.00

93922 $60.00 $96.00 $102.00 $104.00 $96.00 $102.00 $104.00

93922-26 $16.00 $14.00 $15.00 $16.00 $14.00 $15.00 $16.00

93922-TC $44.00 $81.00 $87.00 $88.00 $81.00 $87.00 $88.00

93923 $112.00 $149.00 $159.00 $162.00 $149.00 $159.00 $162.00

93923-26 $28.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.00

93923-TC $85.00 $123.00 $132.00 $134.00 $123.00 $132.00 $134.00

93924 $122.00 $185.00 $198.00 $201.00 $185.00 $198.00 $201.00

93924-26 $31.00 $28.00 $30.00 $31.00 $28.00 $30.00 $31.00

93924-TC $92.00 $157.00 $168.00 $170.00 $157.00 $168.00 $170.00

93925 $175.00 $279.00 $297.00 $302.00 $279.00 $297.00 $302.00

93925-26 $31.00 $45.00 $46.00 $48.00 $45.00 $46.00 $48.00

93925-TC $144.00 $235.00 $251.00 $254.00 $235.00 $251.00 $254.00

93926 $117.00 $146.00 $156.00 $159.00 $146.00 $156.00 $159.00

93926-26 $21.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.00

93926-TC $96.00 $119.00 $127.00 $129.00 $119.00 $127.00 $129.00

93930 $174.00 $225.00 $240.00 $245.00 $225.00 $240.00 $245.00

93930-26 $26.00 $46.00 $48.00 $50.00 $46.00 $48.00 $50.00

93930-TC $150.00 $180.00 $192.00 $195.00 $180.00 $192.00 $195.00

93931 $118.00 $139.00 $148.00 $151.00 $139.00 $148.00 $151.00

93931-26 $17.00 $28.00 $29.00 $31.00 $28.00 $29.00 $31.00

93931-TC $101.00 $111.00 $119.00 $120.00 $111.00 $119.00 $120.00

93970 $189.00 $213.00 $227.00 $231.00 $213.00 $227.00 $231.00

93970-26 $36.00 $39.00 $41.00 $43.00 $39.00 $41.00 $43.00

93970-TC $154.00 $174.00 $186.00 $188.00 $174.00 $186.00 $188.00

93971 $121.00 $130.00 $138.00 $140.00 $130.00 $138.00 $140.00

93971-26 $23.00 $25.00 $26.00 $27.00 $25.00 $26.00 $27.00

93971-TC $96.00 $105.00 $112.00 $113.00 $105.00 $112.00 $113.00

93975 $277.00 $303.00 $323.00 $329.00 $303.00 $323.00 $329.00

93975-26 $89.00 $66.00 $68.00 $72.00 $66.00 $68.00 $72.00

93975-TC $181.00 $238.00 $254.00 $257.00 $238.00 $254.00 $257.00

93976 $184.00 $164.00 $174.00 $177.00 $164.00 $174.00 $177.00

93976-26 $59.00 $45.00 $47.00 $48.00 $45.00 $47.00 $48.00

93976-TC $121.00 $119.00 $127.00 $128.00 $119.00 $127.00 $128.00

93978 $177.00 $207.00 $220.00 $225.00 $207.00 $220.00 $225.00

93978-26 $34.00 $45.00 $47.00 $50.00 $45.00 $47.00 $50.00

93978-TC $143.00 $161.00 $173.00 $175.00 $161.00 $173.00 $175.00

93979 $122.00 $130.00 $138.00 $142.00 $130.00 $138.00 $142.00

93979-26 $23.00 $29.00 $30.00 $32.00 $29.00 $30.00 $32.00

93979-TC $98.00 $101.00 $108.00 $110.00 $101.00 $108.00 $110.00

93980 $183.00 $133.00 $139.00 $142.00 $133.00 $139.00 $142.00

93980-26 $65.00 $69.00 $71.00 $73.00 $69.00 $71.00 $73.00

93980-TC $105.00 $64.00 $68.00 $69.00 $64.00 $68.00 $69.00

93981 $148.00 $80.00 $85.00 $87.00 $80.00 $85.00 $87.00

93981-26 $25.00 $25.00 $26.00 $27.00 $25.00 $26.00 $27.00

93981-TC $124.00 $55.00 $59.00 $60.00 $55.00 $59.00 $60.00

93982 ---------- $48.00 $51.00 $53.00 $48.00 $51.00 $53.00

93990 $110.00 $147.00 $157.00 $162.00 $147.00 $157.00 $162.00



Medicine


(Non-Facility MRA)






93990-26 $14.00 $28.00 $30.00 $33.00 $28.00 $30.00 $33.00

93990-TC $96.00 $119.00 $127.00 $129.00 $119.00 $127.00 $129.00

94002 ---------- $105.00 $109.00 $114.00 $105.00 $109.00 $114.00

94003 ---------- $76.00 $79.00 $82.00 $76.00 $79.00 $82.00

94004 ---------- $56.00 $58.00 $60.00 $56.00 $58.00 $60.00

94010 $30.00 $39.00 $41.00 $42.00 $39.00 $41.00 $42.00

94010-26 $12.00 $10.00 $10.00 $10.00 $10.00 $10.00 $10.00

94010-TC $16.00 $29.00 $31.00 $32.00 $29.00 $31.00 $32.00

94014 $39.00 $62.00 $65.00 $66.00 $62.00 $65.00 $66.00

94015 $14.00 $33.00 $36.00 $36.00 $33.00 $36.00 $36.00

94016 $26.00 $28.00 $29.00 $30.00 $28.00 $29.00 $30.00

94060 $57.00 $66.00 $70.00 $71.00 $66.00 $70.00 $71.00

94060-26 $18.00 $15.00 $15.00 $15.00 $15.00 $15.00 $15.00

94060-TC $36.00 $51.00 $55.00 $56.00 $51.00 $55.00 $56.00

94070 $32.00 $66.00 $69.00 $71.00 $66.00 $69.00 $71.00

94070-26 $11.00 $32.00 $33.00 $34.00 $32.00 $33.00 $34.00

94070-TC $19.00 $33.00 $36.00 $36.00 $33.00 $36.00 $36.00

94150 $8.00 $27.00 $29.00 $30.00 $27.00 $29.00 $30.00

94150-26 $6.00 $4.00 $5.00 $5.00 $4.00 $5.00 $5.00

94150-TC $3.00 $23.00 $24.00 $25.00 $23.00 $24.00 $25.00

94200 $17.00 $28.00 $30.00 $31.00 $28.00 $30.00 $31.00

94200-26 $7.00 $6.00 $7.00 $7.00 $6.00 $7.00 $7.00

94200-TC $9.00 $22.00 $23.00 $24.00 $22.00 $23.00 $24.00

94250 $12.00 $29.00 $31.00 $32.00 $29.00 $31.00 $32.00

94250-26 $8.00 $6.00 $7.00 $7.00 $6.00 $7.00 $7.00

94250-TC $5.00 $22.00 $24.00 $25.00 $22.00 $24.00 $25.00

94375 $34.00 $43.00 $45.00 $46.00 $43.00 $45.00 $46.00

94375-26 $16.00 $17.00 $17.00 $17.00 $17.00 $17.00 $17.00

94375-TC $17.00 $27.00 $29.00 $29.00 $27.00 $29.00 $29.00

94400 $40.00 $62.00 $65.00 $67.00 $62.00 $65.00 $67.00

94400-26 $24.00 $22.00 $23.00 $23.00 $22.00 $23.00 $23.00

94400-TC $14.00 $40.00 $43.00 $43.00 $40.00 $43.00 $43.00

94450 $37.00 $75.00 $80.00 $81.00 $75.00 $80.00 $81.00

94450-26 $20.00 $23.00 $23.00 $24.00 $23.00 $23.00 $24.00

94450-TC $15.00 $53.00 $56.00 $57.00 $53.00 $56.00 $57.00

94452 ---------- $62.00 $66.00 $67.00 $62.00 $66.00 $67.00

94452-26 ---------- $16.00 $17.00 $17.00 $16.00 $17.00 $17.00

94452-TC ---------- $46.00 $49.00 $50.00 $46.00 $49.00 $50.00

94453 ---------- $86.00 $92.00 $93.00 $86.00 $92.00 $93.00

94453-26 ---------- $21.00 $22.00 $23.00 $21.00 $22.00 $23.00

94453-TC ---------- $65.00 $70.00 $71.00 $65.00 $70.00 $71.00

94610 ---------- $63.00 $65.00 $68.00 $63.00 $65.00 $68.00

94620 $91.00 $62.00 $65.00 $66.00 $62.00 $65.00 $66.00

94620-26 $38.00 $34.00 $35.00 $36.00 $34.00 $35.00 $36.00

94620-TC $54.00 $27.00 $29.00 $30.00 $27.00 $29.00 $30.00

94621 $122.00 $177.00 $187.00 $190.00 $177.00 $187.00 $190.00

94621-26 $71.00 $77.00 $80.00 $82.00 $77.00 $80.00 $82.00

94621-TC $52.00 $100.00 $107.00 $109.00 $100.00 $107.00 $109.00

94640 $19.00 $20.00 $21.00 $22.00 $20.00 $21.00 $22.00

94642 BR ---------- ---------- ---------- ---------- ---------- ----------



Medicine


(Non-Facility MRA)






94644 ---------- $47.00 $51.00 $51.00 $47.00 $51.00 $51.00

94645 ---------- $16.00 $17.00 $17.00 $16.00 $17.00 $17.00

94660 $54.00 $70.00 $74.00 $76.00 $43.00 $45.00 $47.00

94662 $38.00 $40.00 $42.00 $44.00 $40.00 $42.00 $44.00

94664 $18.00 $19.00 $20.00 $21.00 $19.00 $20.00 $21.00

94667 $23.00 $29.00 $31.00 $32.00 $29.00 $31.00 $32.00

94668 $16.00 $31.00 $34.00 $34.00 $31.00 $34.00 $34.00

94669 ---------- $35.00 $38.00 $39.00 $35.00 $38.00 $39.00

94680 $47.00 $62.00 $65.00 $66.00 $62.00 $65.00 $66.00

94680-26 $23.00 $14.00 $15.00 $15.00 $14.00 $15.00 $15.00

94680-TC $22.00 $47.00 $51.00 $51.00 $47.00 $51.00 $51.00

94681 $60.00 $58.00 $62.00 $63.00 $58.00 $62.00 $63.00

94681-26 $12.00 $11.00 $12.00 $12.00 $11.00 $12.00 $12.00

94681-TC $43.00 $47.00 $50.00 $51.00 $47.00 $50.00 $51.00

94690 $24.00 $55.00 $59.00 $60.00 $55.00 $59.00 $60.00

94690-26 $4.00 $4.00 $5.00 $5.00 $4.00 $5.00 $5.00

94690-TC $20.00 $51.00 $54.00 $55.00 $51.00 $54.00 $55.00

94726 ---------- $57.00 $60.00 $62.00 $57.00 $60.00 $62.00

94726-26 ---------- $14.00 $14.00 $15.00 $14.00 $14.00 $15.00

94726-TC ---------- $43.00 $46.00 $47.00 $43.00 $46.00 $47.00

94727 ---------- $46.00 $48.00 $49.00 $46.00 $48.00 $49.00

94727-26 ---------- $14.00 $14.00 $15.00 $14.00 $14.00 $15.00

94727-TC ---------- $32.00 $34.00 $35.00 $32.00 $34.00 $35.00

94728 ---------- $43.00 $46.00 $46.00 $43.00 $46.00 $46.00

94728-26 ---------- $14.00 $15.00 $15.00 $14.00 $15.00 $15.00

94728-TC ---------- $29.00 $31.00 $32.00 $29.00 $31.00 $32.00

94729 ---------- $59.00 $62.00 $64.00 $59.00 $62.00 $64.00

94729-26 ---------- $10.00 $11.00 $11.00 $10.00 $11.00 $11.00

94729-TC ---------- $48.00 $52.00 $53.00 $48.00 $52.00 $53.00

94750 $37.00 $85.00 $90.00 $92.00 $85.00 $90.00 $92.00

94750-26 $14.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.00

94750-TC $21.00 $73.00 $78.00 $79.00 $73.00 $78.00 $79.00

94760 $9.00 $4.00 $4.00 $4.00 $4.00 $4.00 $4.00

94761 $20.00 $5.00 $6.00 $6.00 $5.00 $6.00 $6.00

94762 $30.00 $26.00 $28.00 $29.00 $26.00 $28.00 $29.00

94770 $21.00 $8.00 $9.00 $9.00 $8.00 $9.00 $9.00

94770-26 $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 $8.00

95012 ---------- $21.00 $22.00 $23.00 $21.00 $22.00 $23.00

95017 ---------- $9.00 $9.00 $9.00 $4.00 $4.00 $5.00

95018 ---------- $22.00 $24.00 $24.00 $8.00 $8.00 $9.00

95024 $3.00 $8.00 $9.00 $10.00 $1.00 $1.00 $2.00

95027 $5.00 $5.00 $6.00 $6.00 $5.00 $6.00 $6.00

95028 $8.00 $14.00 $16.00 $16.00 $14.00 $16.00 $16.00

95044 $7.00 $6.00 $7.00 $7.00 $6.00 $7.00 $7.00

95052 $9.00 $7.00 $8.00 $8.00 $7.00 $8.00 $8.00



Medicine


(Non-Facility MRA)






95056 $6.00 $47.00 $51.00 $51.00 $47.00 $51.00 $51.00

95060 $13.00 $38.00 $41.00 $41.00 $38.00 $41.00 $41.00

95065 $7.00 $27.00 $29.00 $29.00 $27.00 $29.00 $29.00

95070 $82.00 $33.00 $36.00 $37.00 $33.00 $36.00 $37.00

95071 $105.00 $39.00 $42.00 $43.00 $39.00 $42.00 $43.00

95076 ---------- $127.00 $133.00 $135.00 $82.00 $84.00 $86.00

95079 ---------- $91.00 $95.00 $97.00 $75.00 $77.00 $79.00

95115 $10.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.00

95117 $9.00 $11.00 $12.00 $12.00 $11.00 $12.00 $12.00

95120 BR ---------- ---------- ---------- ---------- ---------- ----------

95125 BR ---------- ---------- ---------- ---------- ---------- ----------

95130 BR ---------- ---------- ---------- ---------- ---------- ----------

95131 BR ---------- ---------- ---------- ---------- ---------- ----------

95132 BR ---------- ---------- ---------- ---------- ---------- ----------

95133 BR ---------- ---------- ---------- ---------- ---------- ----------

95134 BR ---------- ---------- ---------- ---------- ---------- ----------

95144 $9.00 $14.00 $15.00 $16.00 $4.00 $4.00 $4.00

95145 $17.00 $27.00 $29.00 $29.00 $4.00 $4.00 $4.00

95146 $24.00 $49.00 $53.00 $53.00 $4.00 $4.00 $4.00

95147 $33.00 $52.00 $56.00 $57.00 $4.00 $4.00 $4.00

95148 $32.00 $74.00 $79.00 $80.00 $4.00 $4.00 $4.00

95149 $36.00 $98.00 $104.00 $106.00 $4.00 $4.00 $4.00

95165 $7.00 $14.00 $15.00 $16.00 $4.00 $4.00 $4.00

95170 $13.00 $10.00 $11.00 $12.00 $4.00 $4.00 $4.00

95180 $103.00 $147.00 $153.00 $156.00 $113.00 $116.00 $119.00

95199 BR ---------- ---------- ---------- ---------- ---------- ----------

95250 $114.00 $169.00 $181.00 $183.00 $169.00 $181.00 $183.00

95251 ---------- $49.00 $51.00 $52.00 $49.00 $51.00 $52.00

95803 ---------- $153.00 $161.00 $164.00 $153.00 $161.00 $164.00

95803-26 ---------- $49.00 $50.00 $52.00 $49.00 $50.00 $52.00

95803-TC ---------- $104.00 $111.00 $112.00 $104.00 $111.00 $112.00

95805 $334.00 $460.00 $490.00 $498.00 $460.00 $490.00 $498.00

95805-26 $94.00 $66.00 $68.00 $70.00 $66.00 $68.00 $70.00

95805-TC $237.00 $394.00 $422.00 $428.00 $394.00 $422.00 $428.00

95806 $232.00 $184.00 $194.00 $197.00 $184.00 $194.00 $197.00

95806-26 $109.00 $69.00 $71.00 $72.00 $69.00 $71.00 $72.00

95806-TC $137.00 $115.00 $123.00 $125.00 $115.00 $123.00 $125.00

95807 $367.00 $500.00 $532.00 $541.00 $500.00 $532.00 $541.00

95807-26 $98.00 $70.00 $72.00 $74.00 $70.00 $72.00 $74.00

95807-TC $256.00 $430.00 $460.00 $467.00 $430.00 $460.00 $467.00

95808 $456.00 $688.00 $732.00 $743.00 $688.00 $732.00 $743.00

95808-26 $149.00 $99.00 $102.00 $105.00 $99.00 $102.00 $105.00

95808-TC $256.00 $589.00 $630.00 $638.00 $589.00 $630.00 $638.00

95810 $521.00 $671.00 $713.00 $725.00 $671.00 $713.00 $725.00

95810-26 $183.00 $137.00 $141.00 $144.00 $137.00 $141.00 $144.00

95810-TC $256.00 $535.00 $572.00 $580.00 $535.00 $572.00 $580.00

95811 $644.00 $705.00 $749.00 $762.00 $705.00 $749.00 $762.00

95811-26 $196.00 $142.00 $146.00 $150.00 $142.00 $146.00 $150.00

95811-TC $423.00 $563.00 $603.00 $612.00 $563.00 $603.00 $612.00

95812 $137.00 $348.00 $370.00 $376.00 $348.00 $370.00 $376.00



Medicine


(Non-Facility MRA)






95812-26 $58.00 $65.00 $67.00 $69.00 $65.00 $67.00 $69.00

95812-TC $68.00 $284.00 $303.00 $307.00 $284.00 $303.00 $307.00

95813 $177.00 $440.00 $467.00 $474.00 $440.00 $467.00 $474.00

95813-26 $89.00 $98.00 $101.00 $104.00 $98.00 $101.00 $104.00

95813-TC $68.00 $342.00 $366.00 $370.00 $342.00 $366.00 $370.00

95816 $133.00 $389.00 $413.00 $420.00 $389.00 $413.00 $420.00

95816-26 $54.00 $65.00 $67.00 $69.00 $65.00 $67.00 $69.00

95816-TC $78.00 $324.00 $346.00 $351.00 $324.00 $346.00 $351.00

95819 $115.00 $446.00 $475.00 $482.00 $446.00 $475.00 $482.00

95819-26 $58.00 $65.00 $67.00 $69.00 $65.00 $67.00 $69.00

95819-TC $56.00 $381.00 $408.00 $413.00 $381.00 $408.00 $413.00

95822 $120.00 $403.00 $429.00 $435.00 $403.00 $429.00 $435.00

95822-26 $58.00 $65.00 $67.00 $69.00 $65.00 $67.00 $69.00

95822-TC $63.00 $338.00 $362.00 $366.00 $338.00 $362.00 $366.00

95824 $51.00 ---------- ---------- ---------- ---------- ---------- ----------

95824-26 $41.00 $44.00 $46.00 $47.00 $44.00 $46.00 $47.00

95824-TC $10.00 ---------- ---------- ---------- ---------- ---------- ----------

95827 $145.00 $713.00 $761.00 $773.00 $713.00 $761.00 $773.00

95827-26 $59.00 $64.00 $66.00 $68.00 $64.00 $66.00 $68.00

95827-TC $86.00 $649.00 $694.00 $705.00 $649.00 $694.00 $705.00

95829 $328.00 $2,062.00 $2,193.00 $2,229.00 $2,062.00 $2,193.00 $2,229.00

95829-26 $291.00 $381.00 $397.00 $413.00 $381.00 $397.00 $413.00

95829-TC $6.00 $1,681.00 $1,797.00 $1,816.00 $1,681.00 $1,797.00 $1,816.00

95830 $133.00 $239.00 $252.00 $258.00 $103.00 $108.00 $112.00

95831 $26.00 $35.00 $37.00 $38.00 $18.00 $19.00 $20.00

95832 $21.00 $34.00 $37.00 $38.00 $19.00 $21.00 $22.00

95833 $34.00 $41.00 $43.00 $43.00 $24.00 $25.00 $25.00

95834 $44.00 $57.00 $60.00 $62.00 $35.00 $37.00 $38.00

95851 $18.00 $20.00 $21.00 $21.00 $9.00 $9.00 $9.00

95852 $14.00 $17.00 $18.00 $18.00 $6.00 $7.00 $7.00

95857 $40.00 $59.00 $62.00 $64.00 $34.00 $35.00 $36.00

95860 $73.00 $133.00 $140.00 $143.00 $133.00 $140.00 $143.00

95860-26 $53.00 $58.00 $60.00 $61.00 $58.00 $60.00 $61.00

95860-TC $15.00 $75.00 $81.00 $82.00 $75.00 $81.00 $82.00

95861 $113.00 $190.00 $200.00 $204.00 $190.00 $200.00 $204.00

95861-26 $86.00 $93.00 $96.00 $99.00 $93.00 $96.00 $99.00

95861-TC $28.00 $97.00 $103.00 $105.00 $97.00 $103.00 $105.00

95863 $138.00 $238.00 $250.00 $255.00 $238.00 $250.00 $255.00

95863-26 $102.00 $112.00 $116.00 $119.00 $112.00 $116.00 $119.00

95863-TC $35.00 $126.00 $135.00 $136.00 $126.00 $135.00 $136.00

95864 $177.00 $268.00 $282.00 $288.00 $268.00 $282.00 $288.00

95864-26 $114.00 $121.00 $125.00 $129.00 $121.00 $125.00 $129.00

95864-TC $67.00 $147.00 $157.00 $159.00 $147.00 $157.00 $159.00

95865 ---------- $161.00 $169.00 $173.00 $161.00 $169.00 $173.00

95865-26 ---------- $95.00 $99.00 $102.00 $95.00 $99.00 $102.00

95865-TC ---------- $66.00 $70.00 $71.00 $66.00 $70.00 $71.00

95866 ---------- $148.00 $156.00 $159.00 $148.00 $156.00 $159.00

95866-26 ---------- $76.00 $78.00 $81.00 $76.00 $78.00 $81.00

95866-TC ---------- $72.00 $77.00 $78.00 $72.00 $77.00 $78.00

95867 $66.00 $106.00 $111.00 $114.00 $106.00 $111.00 $114.00



Medicine


(Non-Facility MRA)






95867-26 $43.00 $47.00 $48.00 $50.00 $47.00 $48.00 $50.00

95867-TC $21.00 $59.00 $63.00 $64.00 $59.00 $63.00 $64.00

95868 $96.00 $147.00 $155.00 $158.00 $147.00 $155.00 $158.00

95868-26 $71.00 $71.00 $74.00 $76.00 $71.00 $74.00 $76.00

95868-TC $26.00 $76.00 $81.00 $82.00 $76.00 $81.00 $82.00

95869 $29.00 $99.00 $105.00 $107.00 $99.00 $105.00 $107.00

95869-26 $21.00 $22.00 $23.00 $24.00 $22.00 $23.00 $24.00

95869-TC $8.00 $76.00 $82.00 $83.00 $76.00 $82.00 $83.00

95870 $29.00 $100.00 $106.00 $108.00 $100.00 $106.00 $108.00

95870-26 $21.00 $22.00 $23.00 $24.00 $22.00 $23.00 $24.00

95870-TC $8.00 $78.00 $83.00 $84.00 $78.00 $83.00 $84.00

95872 $104.00 $218.00 $228.00 $234.00 $218.00 $228.00 $234.00

95872-26 $81.00 $173.00 $179.00 $185.00 $173.00 $179.00 $185.00

95872-TC $22.00 $45.00 $48.00 $49.00 $45.00 $48.00 $49.00

95873 ---------- $79.00 $83.00 $84.00 $79.00 $83.00 $84.00

95873-26 ---------- $22.00 $23.00 $23.00 $22.00 $23.00 $23.00

95873-TC ---------- $57.00 $60.00 $61.00 $57.00 $60.00 $61.00

95874 ---------- $80.00 $85.00 $86.00 $80.00 $85.00 $86.00

95874-26 ---------- $22.00 $23.00 $24.00 $22.00 $23.00 $24.00

95874-TC ---------- $57.00 $61.00 $62.00 $57.00 $61.00 $62.00

95875 $43.00 $128.00 $135.00 $138.00 $128.00 $135.00 $138.00

95875-26 $34.00 $66.00 $69.00 $71.00 $66.00 $69.00 $71.00

95875-TC $7.00 $62.00 $66.00 $67.00 $62.00 $66.00 $67.00

95885 ---------- $64.00 $67.00 $68.00 $64.00 $67.00 $68.00

95885-26 ---------- $21.00 $22.00 $23.00 $21.00 $22.00 $23.00

95885-TC ---------- $42.00 $45.00 $46.00 $42.00 $45.00 $46.00

95886 ---------- $99.00 $104.00 $106.00 $99.00 $104.00 $106.00

95886-26 ---------- $52.00 $54.00 $55.00 $52.00 $54.00 $55.00

95886-TC ---------- $48.00 $51.00 $51.00 $48.00 $51.00 $51.00

95887 ---------- $88.00 $92.00 $94.00 $88.00 $92.00 $94.00

95887-26 ---------- $43.00 $44.00 $45.00 $43.00 $44.00 $45.00

95887-TC ---------- $45.00 $48.00 $49.00 $45.00 $48.00 $49.00

95905 ---------- $77.00 $82.00 $83.00 $77.00 $82.00 $83.00

95905-26 ---------- $3.00 $3.00 $4.00 $3.00 $3.00 $4.00

95905-TC ---------- $73.00 $78.00 $80.00 $73.00 $78.00 $80.00

95907 ---------- $107.00 $112.00 $115.00 $107.00 $112.00 $115.00

95907-26 ---------- $60.00 $62.00 $64.00 $60.00 $62.00 $64.00

95907-TC ---------- $47.00 $50.00 $51.00 $47.00 $50.00 $51.00

95908 ---------- $137.00 $144.00 $147.00 $137.00 $144.00 $147.00

95908-26 ---------- $76.00 $78.00 $80.00 $76.00 $78.00 $80.00

95908-TC ---------- $62.00 $66.00 $67.00 $62.00 $66.00 $67.00

95909 ---------- $163.00 $172.00 $175.00 $163.00 $172.00 $175.00

95909-26 ---------- $90.00 $93.00 $96.00 $90.00 $93.00 $96.00

95909-TC ---------- $73.00 $78.00 $79.00 $73.00 $78.00 $79.00

95910 ---------- $216.00 $227.00 $232.00 $216.00 $227.00 $232.00

95910-26 ---------- $121.00 $125.00 $128.00 $121.00 $125.00 $128.00

95910-TC ---------- $95.00 $102.00 $103.00 $95.00 $102.00 $103.00

95911 ---------- $258.00 $270.00 $276.00 $258.00 $270.00 $276.00

95911-26 ---------- $151.00 $156.00 $160.00 $151.00 $156.00 $160.00

95911-TC ---------- $107.00 $114.00 $116.00 $107.00 $114.00 $116.00



Medicine


(Non-Facility MRA)






95912 ---------- $285.00 $298.00 $305.00 $285.00 $298.00 $305.00

95912-26 ---------- $178.00 $184.00 $190.00 $178.00 $184.00 $190.00

95912-TC ---------- $107.00 $114.00 $115.00 $107.00 $114.00 $115.00

95913 ---------- $328.00 $343.00 $350.00 $328.00 $343.00 $350.00

95913-26 ---------- $211.00 $218.00 $224.00 $211.00 $218.00 $224.00

95913-TC ---------- $116.00 $124.00 $126.00 $116.00 $124.00 $126.00

95921 $61.00 $93.00 $98.00 $100.00 $93.00 $98.00 $100.00

95921-26 $46.00 $51.00 $52.00 $54.00 $51.00 $52.00 $54.00

95921-TC $14.00 $42.00 $45.00 $46.00 $42.00 $45.00 $46.00

95922 $65.00 $109.00 $115.00 $117.00 $109.00 $115.00 $117.00

95922-26 $50.00 $54.00 $56.00 $57.00 $54.00 $56.00 $57.00

95922-TC $14.00 $55.00 $59.00 $60.00 $55.00 $59.00 $60.00

95923 $105.00 $153.00 $162.00 $165.00 $153.00 $162.00 $165.00

95923-26 $47.00 $52.00 $54.00 $55.00 $52.00 $54.00 $55.00

95923-TC $57.00 $101.00 $108.00 $110.00 $101.00 $108.00 $110.00

95924 ---------- $168.00 $176.00 $181.00 $168.00 $176.00 $181.00

95924-26 ---------- $101.00 $105.00 $109.00 $101.00 $105.00 $109.00

95924-TC ---------- $67.00 $71.00 $72.00 $67.00 $71.00 $72.00

95925 $94.00 $150.00 $159.00 $162.00 $150.00 $159.00 $162.00

95925-26 $53.00 $31.00 $32.00 $33.00 $31.00 $32.00 $33.00

95925-TC $41.00 $118.00 $127.00 $129.00 $118.00 $127.00 $129.00

95926 $66.00 $145.00 $154.00 $157.00 $145.00 $154.00 $157.00

95926-26 $34.00 $31.00 $32.00 $33.00 $31.00 $32.00 $33.00

95926-TC $34.00 $114.00 $122.00 $124.00 $114.00 $122.00 $124.00

95927 $67.00 $149.00 $158.00 $161.00 $149.00 $158.00 $161.00

95927-26 $34.00 $31.00 $32.00 $33.00 $31.00 $32.00 $33.00

95927-TC $34.00 $118.00 $126.00 $128.00 $118.00 $126.00 $128.00

95928 ---------- $232.00 $245.00 $249.00 $232.00 $245.00 $249.00

95928-26 ---------- $90.00 $93.00 $96.00 $90.00 $93.00 $96.00

95928-TC ---------- $142.00 $151.00 $153.00 $142.00 $151.00 $153.00

95929 ---------- $239.00 $252.00 $256.00 $239.00 $252.00 $256.00

95929-26 ---------- $90.00 $93.00 $96.00 $90.00 $93.00 $96.00

95929-TC ---------- $148.00 $158.00 $160.00 $148.00 $158.00 $160.00

95930 $44.00 $139.00 $148.00 $150.00 $139.00 $148.00 $150.00

95930-26 $25.00 $21.00 $21.00 $22.00 $21.00 $21.00 $22.00

95930-TC $11.00 $118.00 $127.00 $129.00 $118.00 $127.00 $129.00

95933 $62.00 $84.00 $88.00 $90.00 $84.00 $88.00 $90.00

95933-26 $33.00 $35.00 $37.00 $38.00 $35.00 $37.00 $38.00

95933-TC $30.00 $48.00 $51.00 $52.00 $48.00 $51.00 $52.00

95937 $40.00 $89.00 $94.00 $96.00 $89.00 $94.00 $96.00

95937-26 $31.00 $39.00 $40.00 $41.00 $39.00 $40.00 $41.00

95937-TC $9.00 $51.00 $54.00 $55.00 $51.00 $54.00 $55.00

95938 ---------- $368.00 $392.00 $398.00 $368.00 $392.00 $398.00

95938-26 ---------- $52.00 $54.00 $56.00 $52.00 $54.00 $56.00

95938-TC ---------- $316.00 $338.00 $342.00 $316.00 $338.00 $342.00

95939 ---------- $545.00 $578.00 $588.00 $545.00 $578.00 $588.00

95939-26 ---------- $135.00 $139.00 $144.00 $135.00 $139.00 $144.00

95939-TC ---------- $410.00 $439.00 $444.00 $410.00 $439.00 $444.00

95940 ---------- $37.00 $38.00 $40.00 $37.00 $38.00 $40.00

95950 $265.00 $360.00 $382.00 $388.00 $360.00 $382.00 $388.00



Medicine


(Non-Facility MRA)






95950-26 $84.00 $90.00 $93.00 $96.00 $90.00 $93.00 $96.00

95950-TC $177.00 $270.00 $289.00 $293.00 $270.00 $289.00 $293.00

95951 $34.00 ---------- ---------- ---------- ---------- ---------- ----------

95951-26 $14.00 $360.00 $372.00 $383.00 $360.00 $372.00 $383.00

95951-TC $20.00 ---------- ---------- ---------- ---------- ---------- ----------

95953 $411.00 $461.00 $487.00 $497.00 $461.00 $487.00 $497.00

95953-26 $165.00 $185.00 $191.00 $197.00 $185.00 $191.00 $197.00

95953-TC $240.00 $277.00 $296.00 $300.00 $277.00 $296.00 $300.00

95954 $208.00 $491.00 $520.00 $530.00 $491.00 $520.00 $530.00

95954-26 $134.00 $142.00 $147.00 $152.00 $142.00 $147.00 $152.00

95954-TC $23.00 $349.00 $373.00 $379.00 $349.00 $373.00 $379.00

95955 $130.00 $231.00 $245.00 $249.00 $231.00 $245.00 $249.00

95955-26 $59.00 $60.00 $62.00 $64.00 $60.00 $62.00 $64.00

95955-TC $74.00 $171.00 $182.00 $185.00 $171.00 $182.00 $185.00

95956 $541.00 $1,751.00 $1,866.00 $1,894.00 $1,751.00 $1,866.00 $1,894.00

95956-26 $166.00 $215.00 $223.00 $230.00 $215.00 $223.00 $230.00

95956-TC $314.00 $1,536.00 $1,643.00 $1,665.00 $1,536.00 $1,643.00 $1,665.00

95957 $171.00 $332.00 $351.00 $358.00 $332.00 $351.00 $358.00

95957-26 $104.00 $118.00 $122.00 $126.00 $118.00 $122.00 $126.00

95957-TC $64.00 $214.00 $229.00 $232.00 $214.00 $229.00 $232.00

95958 $296.00 $633.00 $669.00 $684.00 $633.00 $669.00 $684.00

95958-26 $230.00 $255.00 $265.00 $274.00 $255.00 $265.00 $274.00

95958-TC $66.00 $377.00 $404.00 $409.00 $377.00 $404.00 $409.00

95961 $216.00 $337.00 $356.00 $367.00 $337.00 $356.00 $367.00

95961-26 $166.00 $184.00 $193.00 $202.00 $184.00 $193.00 $202.00

95961-TC $48.00 $153.00 $163.00 $165.00 $153.00 $163.00 $165.00

95962 $227.00 $290.00 $304.00 $313.00 $290.00 $304.00 $313.00

95962-26 $176.00 $196.00 $204.00 $212.00 $196.00 $204.00 $212.00

95962-TC $48.00 $94.00 $100.00 $102.00 $94.00 $100.00 $102.00

95965 BR ---------- ---------- ---------- ---------- ---------- ----------

95965-26 $420.00 $474.00 $490.00 $504.00 $474.00 $490.00 $504.00

95965-TC BR ---------- ---------- ---------- ---------- ---------- ----------

95966 BR ---------- ---------- ---------- ---------- ---------- ----------

95966-26 $210.00 $237.00 $245.00 $253.00 $237.00 $245.00 $253.00

95966-TC BR ---------- ---------- ---------- ---------- ---------- ----------

95967 BR ---------- ---------- ---------- ---------- ---------- ----------

95967-26 $184.00 $208.00 $215.00 $222.00 $208.00 $215.00 $222.00

95967-TC BR ---------- ---------- ---------- ---------- ---------- ----------

95970 $22.00 $74.00 $79.00 $80.00 $27.00 $29.00 $30.00

95971 $39.00 $56.00 $59.00 $61.00 $46.00 $48.00 $50.00

95972 $78.00 $65.00 $68.00 $71.00 $48.00 $50.00 $52.00

95974 $155.00 $232.00 $244.00 $254.00 $187.00 $195.00 $205.00

95975 $88.00 $125.00 $131.00 $136.00 $105.00 $110.00 $115.00

95978 ---------- $279.00 $293.00 $305.00 $219.00 $229.00 $240.00

95979 ---------- $121.00 $127.00 $132.00 $102.00 $106.00 $111.00

95980 ---------- $54.00 $57.00 $63.00 $54.00 $57.00 $63.00

95981 ---------- $35.00 $38.00 $39.00 $20.00 $21.00 $23.00

95982 ---------- $59.00 $63.00 $66.00 $42.00 $44.00 $47.00

95990 $57.00 $97.00 $104.00 $106.00 $97.00 $104.00 $106.00

95991 ---------- $129.00 $137.00 $140.00 $45.00 $47.00 $49.00



Medicine


(Non-Facility MRA)






95992 ---------- $48.00 $50.00 $51.00 $42.00 $43.00 $45.00

95999 BR ---------- ---------- ---------- ---------- ---------- ----------

96000 $93.00 $107.00 $111.00 $115.00 $107.00 $111.00 $115.00

96001 $111.00 $140.00 $149.00 $160.00 $140.00 $149.00 $160.00

96002 $21.00 $25.00 $26.00 $27.00 $25.00 $26.00 $27.00

96003 $20.00 $19.00 $19.00 $19.00 $19.00 $19.00 $19.00

96004 $97.00 $132.00 $137.00 $143.00 $132.00 $137.00 $143.00

96020 ---------- BR BR BR BR BR BR

96020-26 ---------- $181.00 $186.00 $190.00 $181.00 $186.00 $190.00

96020-TC ---------- BR BR BR BR BR BR

96101 ---------- $89.00 $91.00 $93.00 $88.00 $90.00 $93.00

96102 ---------- $67.00 $71.00 $72.00 $27.00 $27.00 $28.00

96103 ---------- $31.00 $32.00 $33.00 $30.00 $31.00 $32.00

96105 $68.00 $119.00 $123.00 $126.00 $119.00 $123.00 $126.00

96110 $88.00 $10.00 $11.00 $12.00 $10.00 $11.00 $12.00

96111 $68.00 $147.00 $151.00 $156.00 $140.00 $145.00 $149.00

96116 ---------- $103.00 $106.00 $109.00 $97.00 $99.00 $102.00

96118 ---------- $108.00 $111.00 $114.00 $88.00 $90.00 $92.00

96119 ---------- $86.00 $90.00 $92.00 $27.00 $27.00 $28.00

96120 ---------- $53.00 $56.00 $57.00 $29.00 $31.00 $32.00

96125 ---------- $128.00 $133.00 $136.00 $128.00 $133.00 $136.00

96127 ---------- $6.00 $7.00 $7.00 $6.00 $7.00 $7.00

96150 ---------- $24.00 $25.00 $25.00 $24.00 $24.00 $25.00

96151 ---------- $23.00 $24.00 $25.00 $23.00 $24.00 $24.00

96152 ---------- $22.00 $23.00 $23.00 $22.00 $22.00 $23.00

96153 ---------- $5.00 $5.00 $6.00 $5.00 $5.00 $5.00

96154 ---------- $22.00 $22.00 $23.00 $21.00 $22.00 $23.00

96155 ---------- $25.00 $26.00 $27.00 $25.00 $26.00 $27.00

96360 ---------- $62.00 $66.00 $68.00 $62.00 $66.00 $68.00

96361 ---------- $17.00 $18.00 $18.00 $17.00 $18.00 $18.00

96365 ---------- $75.00 $80.00 $81.00 $75.00 $80.00 $81.00

96366 ---------- $20.00 $22.00 $22.00 $20.00 $22.00 $22.00

96367 ---------- $33.00 $35.00 $36.00 $33.00 $35.00 $36.00

96368 ---------- $22.00 $24.00 $24.00 $22.00 $24.00 $24.00

96369 ---------- $191.00 $203.00 $206.00 $191.00 $203.00 $206.00

96370 See formula $17.00 $17.00 $18.00 $17.00 $17.00 $18.00

96371 ---------- $73.00 $78.00 $79.00 $73.00 $78.00 $79.00

96372 ---------- $28.00 $29.00 $30.00 $28.00 $29.00 $30.00

96373 ---------- $21.00 $22.00 $22.00 $21.00 $22.00 $22.00

96374 ---------- $62.00 $66.00 $68.00 $62.00 $66.00 $68.00

96375 ---------- $24.00 $26.00 $26.00 $24.00 $26.00 $26.00

96377 ---------- BR BR BR BR BR BR

96401 ---------- $80.00 $86.00 $88.00 $80.00 $86.00 $88.00

96402 ---------- $35.00 $38.00 $38.00 $35.00 $38.00 $38.00

96405 $57.00 $89.00 $94.00 $95.00 $34.00 $35.00 $36.00

96406 $86.00 $130.00 $137.00 $140.00 $52.00 $54.00 $56.00

96409 ---------- $120.00 $128.00 $131.00 $120.00 $128.00 $131.00

96411 ---------- $67.00 $72.00 $74.00 $67.00 $72.00 $74.00

96413 ---------- $149.00 $159.00 $163.00 $149.00 $159.00 $163.00

96415 ---------- $31.00 $33.00 $34.00 $31.00 $33.00 $34.00



Medicine


(Non-Facility MRA)






96416 ---------- $150.00 $160.00 $164.00 $150.00 $160.00 $164.00

96417 ---------- $70.00 $75.00 $77.00 $70.00 $75.00 $77.00

96420 $46.00 $115.00 $123.00 $126.00 $115.00 $123.00 $126.00

96422 $46.00 $199.00 $213.00 $218.00 $199.00 $213.00 $218.00

96423 $17.00 $81.00 $87.00 $89.00 $81.00 $87.00 $89.00

96425 $54.00 $197.00 $212.00 $217.00 $197.00 $212.00 $217.00

96440 $156.00 $842.00 $899.00 $922.00 $146.00 $157.00 $172.00

96446 ---------- $221.00 $238.00 $249.00 $36.00 $41.00 $49.00

96450 $134.00 $198.00 $209.00 $214.00 $91.00 $95.00 $99.00

96521 ---------- $150.00 $161.00 $165.00 $150.00 $161.00 $165.00

96522 ---------- $123.00 $132.00 $136.00 $123.00 $132.00 $136.00

96523 ---------- $27.00 $28.00 $29.00 $27.00 $28.00 $29.00

96542 $126.00 $135.00 $143.00 $145.00 $47.00 $49.00 $51.00

96549 BR ---------- ---------- ---------- ---------- ---------- ----------

96567 $62.00 $144.00 $155.00 $157.00 $144.00 $155.00 $157.00

96570 $69.00 $66.00 $70.00 $76.00 $66.00 $70.00 $76.00

96571 $38.00 $30.00 $31.00 $32.00 $30.00 $31.00 $32.00

96900 $17.00 $22.00 $24.00 $25.00 $22.00 $24.00 $25.00

96904 ---------- $67.00 $72.00 $73.00 $67.00 $72.00 $73.00

96910 $21.00 $76.00 $81.00 $82.00 $76.00 $81.00 $82.00

96912 $24.00 $98.00 $104.00 $106.00 $98.00 $104.00 $106.00

96913 $53.00 $139.00 $148.00 $151.00 $139.00 $148.00 $151.00

96920 $152.00 $169.00 $179.00 $182.00 $75.00 $78.00 $80.00

96921 $155.00 $187.00 $197.00 $200.00 $85.00 $88.00 $91.00

96922 $214.00 $259.00 $272.00 $277.00 $137.00 $142.00 $146.00

96931 ---------- $173.00 $185.00 $190.00 $173.00 $185.00 $190.00

96932 ---------- $30.00 $33.00 $33.00 $30.00 $33.00 $33.00

96933 ---------- $52.00 $54.00 $58.00 $52.00 $54.00 $58.00

96934 ---------- $91.00 $96.00 $101.00 $91.00 $96.00 $101.00

96935 ---------- $37.00 $40.00 $40.00 $37.00 $40.00 $40.00

96936 ---------- $49.00 $52.00 $56.00 $49.00 $52.00 $56.00

96999 BR ---------- ---------- ---------- ---------- ---------- ----------

97010 $10.00 $7.00 $7.00 $7.00 $7.00 $7.00 $7.00

97012 $16.00 $18.00 $19.00 $19.00 $18.00 $19.00 $19.00

97014 $14.00 $17.00 $18.00 $19.00 $17.00 $18.00 $19.00

97016 $15.00 $21.00 $22.00 $23.00 $21.00 $22.00 $23.00

97018 $10.00 $12.00 $13.00 $13.00 $12.00 $13.00 $13.00

97022 $15.00 $26.00 $27.00 $28.00 $26.00 $27.00 $28.00

97024 $10.00 $7.00 $8.00 $8.00 $7.00 $8.00 $8.00

97026 $9.00 $7.00 $7.00 $7.00 $7.00 $7.00 $7.00

97028 $10.00 $8.00 $9.00 $9.00 $8.00 $9.00 $9.00

97032 $16.00 $21.00 $22.00 $22.00 $21.00 $22.00 $22.00

97033 $16.00 $24.00 $25.00 $26.00 $24.00 $25.00 $26.00

97034 $13.00 $20.00 $21.00 $21.00 $20.00 $21.00 $21.00

97035 $11.00 $14.00 $15.00 $15.00 $14.00 $15.00 $15.00

97036 $19.00 $36.00 $38.00 $38.00 $36.00 $38.00 $38.00

97039 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

97110 $22.00 $36.00 $37.00 $38.00 $36.00 $37.00 $38.00

97112 $23.00 $37.00 $39.00 $40.00 $37.00 $39.00 $40.00

97113 $24.00 $47.00 $49.00 $50.00 $47.00 $49.00 $50.00



Medicine


(Non-Facility MRA)






97116 $21.00 $31.00 $32.00 $33.00 $31.00 $32.00 $33.00

97124 $19.00 $29.00 $30.00 $30.00 $29.00 $30.00 $30.00

97139 $15.00 ---------- ---------- ---------- ---------- ---------- ----------

97140 $26.00 $33.00 $34.00 $35.00 $33.00 $34.00 $35.00

97150 $18.00 $19.00 $20.00 $20.00 $19.00 $20.00 $20.00

97161 ---------- $90.00 $94.00 $97.00 $90.00 $94.00 $97.00

97162 ---------- $90.00 $94.00 $97.00 $90.00 $94.00 $97.00

97163 ---------- $90.00 $94.00 $97.00 $90.00 $94.00 $97.00

97164 ---------- $61.00 $64.00 $66.00 $61.00 $64.00 $66.00

97165 ---------- $87.00 $91.00 $94.00 $87.00 $91.00 $94.00

97166 ---------- $87.00 $91.00 $94.00 $87.00 $91.00 $94.00

97167 ---------- $87.00 $91.00 $94.00 $87.00 $91.00 $94.00

97168 ---------- $57.00 $60.00 $62.00 $57.00 $60.00 $62.00

97169 ---------- BR BR BR BR BR BR

97170 ---------- BR BR BR BR BR BR

97171 ---------- BR BR BR BR BR BR

97172 ---------- BR BR BR BR BR BR

97260 $23.00 ---------- ---------- ---------- ---------- ---------- ----------

97261 $17.00 ---------- ---------- ---------- ---------- ---------- ----------

97530 $22.00 $38.00 $40.00 $40.00 $38.00 $40.00 $40.00

97532 $22.00 $29.00 $30.00 $31.00 $24.00 $25.00 $25.00

97533 $24.00 $32.00 $33.00 $34.00 $32.00 $33.00 $34.00

97535 $23.00 $38.00 $40.00 $41.00 $38.00 $40.00 $41.00

97537 $23.00 $34.00 $35.00 $36.00 $34.00 $35.00 $36.00

97542 $17.00 $34.00 $35.00 $36.00 $34.00 $35.00 $36.00

97545 $83.00 ---------- ---------- ---------- ---------- ---------- ----------

97546 $41.00 ---------- ---------- ---------- ---------- ---------- ----------

97597 ---------- $82.00 $86.00 $87.00 $26.00 $27.00 $27.00

97598 ---------- $27.00 $28.00 $29.00 $12.00 $13.00 $13.00

97602 BR ---------- ---------- ---------- ---------- ---------- ----------

97605 ---------- $45.00 $47.00 $48.00 $28.00 $29.00 $29.00

97606 ---------- $53.00 $56.00 $57.00 $30.00 $31.00 $32.00

97610 ---------- $129.00 $137.00 $138.00 $18.00 $18.00 $18.00

97750 BR BR BR BR BR BR BR

97752 $48.00 ---------- ---------- ---------- ---------- ---------- ----------

97755 ---------- $39.00 $41.00 $42.00 $39.00 $41.00 $42.00

97760 ---------- $42.00 $44.00 $45.00 $42.00 $44.00 $45.00

97761 ---------- $37.00 $38.00 $39.00 $37.00 $38.00 $39.00

97762 ---------- $52.00 $55.00 $56.00 $52.00 $55.00 $56.00

97799 BR ---------- ---------- ---------- ---------- ---------- ----------

97802 $26.00 $38.00 $40.00 $40.00 $36.00 $37.00 $38.00

97803 $17.00 $33.00 $34.00 $35.00 $31.00 $32.00 $32.00

97804 $7.00 $18.00 $18.00 $19.00 $17.00 $17.00 $18.00

97810 ---------- $41.00 $42.00 $44.00 $34.00 $36.00 $37.00

97811 ---------- $30.00 $31.00 $33.00 $28.00 $29.00 $30.00

97813 ---------- $43.00 $45.00 $46.00 $37.00 $39.00 $40.00

97814 ---------- $34.00 $35.00 $37.00 $31.00 $32.00 $33.00

97850 $54.00 ---------- ---------- ---------- ---------- ---------- ----------

97851 $26.00 ---------- ---------- ---------- ---------- ---------- ----------

97852 $54.00 ---------- ---------- ---------- ---------- ---------- ----------



Medicine


(Non-Facility MRA)






97853 $26.00 ---------- ---------- ---------- ---------- ---------- ----------


98926 $32.00 $51.00 $53.00 $54.00 $40.00 $42.00 $43.00


98928 $23.00 $81.00 $84.00 $86.00 $67.00 $69.00 $71.00



98941 $32.00 $45.00 $46.00 $47.00 $39.00 $39.00 $40.00


98943 $23.00 $30.00 $32.00 $33.00 $27.00 $27.00 $28.00

98960 ---------- $30.00 $32.00 $33.00 $30.00 $32.00 $33.00

98961 ---------- $14.00 $16.00 $16.00 $14.00 $16.00 $16.00

98962 ---------- $11.00 $12.00 $12.00 $11.00 $12.00 $12.00

99000 $6.00 ---------- ---------- ---------- ---------- ---------- ----------

99001 $4.00 ---------- ---------- ---------- ---------- ---------- ----------

99002 $35.00 ---------- ---------- ---------- ---------- ---------- ----------

99026 BR ---------- ---------- ---------- ---------- ---------- ----------

99027 BR ---------- ---------- ---------- ---------- ---------- ----------

99070 BR ---------- ---------- ---------- ---------- ---------- ----------


99075 See 440.13 ---------- ---------- ---------- ---------- ---------- ----------


99082 BR ---------- ---------- ---------- ---------- ---------- ----------

99090 BR ---------- ---------- ---------- ---------- ---------- ----------

99152 ---------- $55.00 $59.00 $60.00 $14.00 $14.00 $15.00

99153 ---------- $12.00 $13.00 $13.00 $12.00 $13.00 $13.00

99156 ---------- $86.00 $90.00 $94.00 $86.00 $90.00 $94.00

99157 ---------- $65.00 $68.00 $71.00 $65.00 $68.00 $71.00

99172 BR ---------- ---------- ---------- ---------- ---------- ----------

99173 BR $4.00 $4.00 $4.00 $4.00 $4.00 $4.00

99174 ---------- BR BR BR BR BR BR

99175 $53.00 $17.00 $18.00 $19.00 $17.00 $18.00 $19.00

99183 $123.00 $126.00 $132.00 $140.00 $126.00 $132.00 $140.00

99184 ---------- $241.00 $250.00 $262.00 $241.00 $250.00 $262.00

99190 BR ---------- ---------- ---------- ---------- ---------- ----------

99191 BR ---------- ---------- ---------- ---------- ---------- ----------

99192 BR ---------- ---------- ---------- ---------- ---------- ----------

99195 $16.00 $108.00 $116.00 $119.00 $108.00 $116.00 $119.00


G0101 ---------- $43.00 $45.00 $47.00 $32.00 $33.00 $35.00

G0102 ---------- $22.00 $23.00 $23.00 $10.00 $10.00 $11.00

G0104 ---------- $182.00 $194.00 $199.00 $65.00 $69.00 $73.00

G0105 ---------- $351.00 $372.00 $388.00 $217.00 $229.00 $243.00

G0105-53 ---------- $175.00 $186.00 $193.00 $109.00 $115.00 $122.00

G0106 ---------- $228.00 $242.00 $245.00 $228.00 $242.00 $245.00

G0106-26 ---------- $55.00 $56.00 $57.00 $55.00 $56.00 $57.00

G0106-TC ---------- $174.00 $186.00 $188.00 $174.00 $186.00 $188.00

G0108 ---------- $59.00 $62.00 $63.00 $59.00 $62.00 $63.00

G0109 ---------- $16.00 $17.00 $17.00 $16.00 $17.00 $17.00

G0117 ---------- $59.00 $62.00 $63.00 $59.00 $62.00 $63.00



Medicine


(Non-Facility MRA)






G0118 ---------- $46.00 $49.00 $50.00 $46.00 $49.00 $50.00

G0120 ---------- $234.00 $249.00 $256.00 $234.00 $249.00 $256.00

G0120-26 ---------- $60.00 $64.00 $68.00 $60.00 $64.00 $68.00

G0120-TC ---------- $174.00 $186.00 $188.00 $174.00 $186.00 $188.00

G0121 ---------- $352.00 $373.00 $390.00 $218.00 $230.00 $245.00

G0121-53 ---------- $176.00 $186.00 $194.00 $109.00 $115.00 $123.00

G0122 ---------- $287.00 $304.00 $308.00 $287.00 $304.00 $308.00

G0122-26 ---------- $55.00 $56.00 $58.00 $55.00 $56.00 $58.00

G0122-TC ---------- $232.00 $247.00 $250.00 $232.00 $247.00 $250.00

G0128 ---------- $8.00 $9.00 $10.00 $8.00 $9.00 $10.00

G0166 ---------- $148.00 $159.00 $161.00 $148.00 $159.00 $161.00

G0179 ---------- $45.00 $48.00 $49.00 $45.00 $48.00 $49.00

G0180 ---------- $59.00 $62.00 $64.00 $59.00 $62.00 $64.00

G0181 ---------- $120.00 $125.00 $129.00 $120.00 $125.00 $129.00

G0182 ---------- $121.00 $125.00 $129.00 $121.00 $125.00 $129.00

G0237 ---------- $11.00 $12.00 $12.00 $11.00 $12.00 $12.00

G0238 ---------- $11.00 $12.00 $12.00 $11.00 $12.00 $12.00

G0239 ---------- $14.00 $15.00 $16.00 $14.00 $15.00 $16.00

G0248 ---------- $117.00 $125.00 $127.00 $117.00 $125.00 $127.00

G0249 ---------- $117.00 $125.00 $127.00 $117.00 $125.00 $127.00

G0250 ---------- $10.00 $11.00 $11.00 $10.00 $11.00 $11.00

G0268 ---------- $59.00 $63.00 $66.00 $39.00 $41.00 $44.00

G0270 ---------- $33.00 $34.00 $35.00 $31.00 $32.00 $32.00

G0271 ---------- $18.00 $18.00 $19.00 $17.00 $17.00 $18.00

G0277 ---------- $53.00 $57.00 $58.00 $53.00 $57.00 $58.00

G0281 ---------- $15.00 $16.00 $16.00 $15.00 $16.00 $16.00

G0283 ---------- $15.00 $16.00 $16.00 $15.00 $16.00 $16.00

G0329 ---------- $11.00 $12.00 $12.00 $11.00 $12.00 $12.00

G0403 ---------- $19.00 $20.00 $21.00 $19.00 $20.00 $21.00

G0404 ---------- $9.00 $10.00 $10.00 $9.00 $10.00 $10.00

G0405 ---------- $10.00 $10.00 $10.00 $10.00 $10.00 $10.00

G0422 ---------- $120.00 $125.00 $128.00 $120.00 $125.00 $128.00

G0423 ---------- $120.00 $125.00 $128.00 $120.00 $125.00 $128.00

G0424 ---------- $32.00 $34.00 $35.00 $16.00 $16.00 $17.00

G0453 ---------- $37.00 $38.00 $40.00 $37.00 $38.00 $40.00

G0454 ---------- $10.00 $11.00 $11.00 $10.00 $11.00 $11.00

G0459 ---------- $46.00 $47.00 $48.00 $46.00 $47.00 $48.00

G0473 ---------- $14.00 $15.00 $15.00 $13.00 $13.00 $14.00

G0500 ---------- $63.00 $67.00 $68.00 $7.00 $7.00 $8.00

G0502 ---------- $155.00 $162.00 $166.00 $99.00 $103.00 $107.00

G0503 ---------- $137.00 $144.00 $147.00 $89.00 $93.00 $96.00

G0504 ---------- $72.00 $75.00 $77.00 $48.00 $50.00 $51.00

G0505 ---------- $260.00 $271.00 $278.00 $196.00 $203.00 $209.00

G0506 ---------- $70.00 $73.00 $75.00 $51.00 $53.00 $55.00

G9157 ---------- $110.00 $114.00 $119.00 $110.00 $114.00 $119.00

G9187 ---------- $48.00 $52.00 $53.00 $48.00 $52.00 $53.00

P3001 ---------- $36.00 $37.00 $38.00 $36.00 $37.00 $38.00

Q0035 ---------- $22.00 $24.00 $25.00 $22.00 $24.00 $25.00

Q0035-26 ---------- $10.00 $10.00 $11.00 $10.00 $10.00 $11.00

Q0035-TC ---------- $13.00 $14.00 $14.00 $13.00 $14.00 $14.00

Q0091 ---------- $49.00 $52.00 $54.00 $22.00 $23.00 $25.00



Evaluation and Management


(Non-Facility MRA)






99201 $35.00 $48.00 $51.00 $53.00 $30.00 $32.00 $33.00

99202 $58.00 $82.00 $87.00 $89.00 $57.00 $59.00 $62.00

99203 $58.00 $120.00 $126.00 $131.00 $87.00 $91.00 $95.00

99204 $84.00 $182.00 $191.00 $198.00 $146.00 $152.00 $159.00

99205 $84.00 $230.00 $241.00 $251.00 $190.00 $198.00 $208.00

99211 $19.00 $22.00 $23.00 $24.00 $10.00 $11.00 $11.00

99212 $31.00 $48.00 $50.00 $52.00 $29.00 $30.00 $31.00

99213 $40.00 $80.00 $84.00 $87.00 $57.00 $59.00 $62.00

99214 $40.00 $118.00 $124.00 $127.00 $88.00 $91.00 $94.00

99215 $65.00 $160.00 $167.00 $172.00 $124.00 $129.00 $134.00

99217 $65.00 $81.00 $85.00 $88.00 $81.00 $85.00 $88.00

99218 $65.00 $112.00 $116.00 $121.00 $112.00 $116.00 $121.00

99219 $109.00 $152.00 $158.00 $164.00 $152.00 $158.00 $164.00

99220 $152.00 $208.00 $216.00 $224.00 $208.00 $216.00 $224.00

99221 $66.00 $115.00 $120.00 $126.00 $115.00 $120.00 $126.00

99222 $109.00 $154.00 $160.00 $167.00 $154.00 $160.00 $167.00

99223 $152.00 $227.00 $236.00 $246.00 $227.00 $236.00 $246.00

99224 ---------- $45.00 $47.00 $49.00 $45.00 $47.00 $49.00

99225 ---------- $82.00 $84.00 $87.00 $82.00 $84.00 $87.00

99226 ---------- $118.00 $122.00 $126.00 $118.00 $122.00 $126.00

99231 $33.00 $44.00 $46.00 $48.00 $44.00 $46.00 $48.00

99232 $54.00 $81.00 $84.00 $87.00 $81.00 $84.00 $87.00

99233 $77.00 $117.00 $121.00 $126.00 $117.00 $121.00 $126.00

99234 $129.00 $150.00 $156.00 $162.00 $150.00 $156.00 $162.00

99235 $173.00 $189.00 $197.00 $204.00 $189.00 $197.00 $204.00

99236 $213.00 $244.00 $253.00 $263.00 $244.00 $253.00 $263.00

99238 $66.00 $81.00 $84.00 $87.00 $81.00 $84.00 $87.00

99239 $88.00 $120.00 $124.00 $128.00 $120.00 $124.00 $128.00

99241 $54.00 $52.00 $55.00 $56.00 $36.00 $38.00 $39.00

99242 $88.00 $99.00 $103.00 $106.00 $76.00 $79.00 $82.00

99243 $117.00 $135.00 $141.00 $145.00 $107.00 $110.00 $114.00

99244 $163.00 $203.00 $211.00 $217.00 $172.00 $178.00 $184.00

99245 $212.00 $247.00 $257.00 $264.00 $213.00 $220.00 $227.00

99251 $54.00 $55.00 $57.00 $58.00 $55.00 $57.00 $58.00

99252 $70.00 $84.00 $86.00 $89.00 $84.00 $86.00 $89.00

99253 $96.00 $128.00 $132.00 $137.00 $128.00 $132.00 $137.00

99254 $138.00 $186.00 $193.00 $199.00 $186.00 $193.00 $199.00

99255 $190.00 $225.00 $233.00 $240.00 $225.00 $233.00 $240.00

99281 $18.00 $24.00 $25.00 $26.00 $24.00 $25.00 $26.00

99282 $28.00 $47.00 $49.00 $51.00 $47.00 $49.00 $51.00

99283 $60.00 $70.00 $73.00 $77.00 $70.00 $73.00 $77.00

99284 $94.00 $133.00 $138.00 $146.00 $133.00 $138.00 $146.00

99285 $103.00 $197.00 $205.00 $215.00 $197.00 $205.00 $215.00

99291 $192.00 $306.00 $320.00 $333.00 $252.00 $262.00 $275.00

99292 $95.00 $138.00 $144.00 $150.00 $127.00 $132.00 $138.00

99304 ---------- $102.00 $106.00 $110.00 $102.00 $106.00 $110.00

99305 ---------- $145.00 $151.00 $156.00 $145.00 $151.00 $156.00

99306 ---------- $186.00 $193.00 $199.00 $186.00 $193.00 $199.00

99307 ---------- $50.00 $52.00 $53.00 $50.00 $52.00 $53.00

99308 ---------- $77.00 $80.00 $83.00 $77.00 $80.00 $83.00





(Non-Facility MRA)






99309 ---------- $102.00 $106.00 $109.00 $102.00 $106.00 $109.00

99310 ---------- $151.00 $157.00 $163.00 $151.00 $157.00 $163.00

99315 $60.00 $82.00 $85.00 $87.00 $82.00 $85.00 $87.00

99316 $77.00 $118.00 $123.00 $127.00 $118.00 $123.00 $127.00

99318 ---------- $107.00 $111.00 $115.00 $107.00 $111.00 $115.00

99324 ---------- $62.00 $64.00 $66.00 $62.00 $64.00 $66.00

99325 ---------- $90.00 $93.00 $96.00 $90.00 $93.00 $96.00

99326 ---------- $156.00 $162.00 $167.00 $156.00 $162.00 $167.00

99327 ---------- $207.00 $215.00 $222.00 $207.00 $215.00 $222.00

99328 ---------- $243.00 $252.00 $261.00 $243.00 $252.00 $261.00

99334 ---------- $67.00 $70.00 $72.00 $67.00 $70.00 $72.00

99335 ---------- $106.00 $110.00 $113.00 $106.00 $110.00 $113.00

99336 ---------- $150.00 $156.00 $162.00 $150.00 $156.00 $162.00

99337 ---------- $216.00 $224.00 $232.00 $216.00 $224.00 $232.00

99339 ---------- $85.00 $89.00 $91.00 $85.00 $89.00 $91.00

99340 ---------- $120.00 $125.00 $129.00 $120.00 $125.00 $129.00

99341 $59.00 $61.00 $64.00 $66.00 $61.00 $64.00 $66.00

99342 $85.00 $89.00 $92.00 $95.00 $89.00 $92.00 $95.00

99343 $109.00 $146.00 $151.00 $157.00 $146.00 $151.00 $157.00

99344 $160.00 $204.00 $212.00 $219.00 $204.00 $212.00 $219.00

99345 $193.00 $247.00 $257.00 $267.00 $247.00 $257.00 $267.00

99347 $46.00 $62.00 $64.00 $66.00 $62.00 $64.00 $66.00

99348 $71.00 $94.00 $98.00 $101.00 $94.00 $98.00 $101.00

99349 $107.00 $143.00 $149.00 $154.00 $143.00 $149.00 $154.00

99350 $156.00 $199.00 $207.00 $214.00 $199.00 $207.00 $214.00

99354 $106.00 $145.00 $150.00 $156.00 $137.00 $142.00 $147.00

99355 $104.00 $109.00 $113.00 $117.00 $101.00 $105.00 $109.00

99356 $87.00 $103.00 $107.00 $110.00 $103.00 $107.00 $110.00

99357 $88.00 $103.00 $107.00 $110.00 $103.00 $107.00 $110.00

99360 BR $68.00 $71.00 $73.00 $68.00 $71.00 $73.00

99363 ---------- $139.00 $146.00 $150.00 $94.00 $97.00 $101.00

99364 ---------- $48.00 $50.00 $51.00 $36.00 $37.00 $39.00

99366 ---------- $48.00 $50.00 $51.00 $47.00 $49.00 $50.00

99367 ---------- $63.00 $65.00 $68.00 $63.00 $65.00 $68.00

99368 ---------- $41.00 $42.00 $44.00 $41.00 $42.00 $44.00

99374 $75.00 $78.00 $81.00 $83.00 $63.00 $65.00 $68.00

99375 $75.00 $116.00 $120.00 $124.00 $98.00 $102.00 $105.00

99377 $75.00 $78.00 $81.00 $83.00 $63.00 $65.00 $68.00

99378 $104.00 $116.00 $120.00 $124.00 $98.00 $102.00 $105.00

99379 $75.00 $78.00 $81.00 $83.00 $63.00 $65.00 $68.00

99380 $104.00 $116.00 $120.00 $124.00 $98.00 $102.00 $105.00

99406 ---------- $16.00 $17.00 $18.00 $14.00 $14.00 $15.00

99407 ---------- $31.00 $33.00 $34.00 $29.00 $30.00 $31.00

99408 ---------- $39.00 $41.00 $42.00 $37.00 $39.00 $40.00

99409 ---------- $76.00 $79.00 $82.00 $74.00 $77.00 $80.00

99415 ---------- $10.00 $10.00 $11.00 $10.00 $10.00 $11.00

99416 ---------- $5.00 $5.00 $5.00 $5.00 $5.00 $5.00


99455 $90.00 ---------- ---------- ---------- ---------- ---------- ----------

99456 BR ---------- ---------- ---------- ---------- ---------- ----------





(Non-Facility MRA)






99457 BR ---------- ---------- ---------- ---------- ---------- ----------

99487 ---------- $101.00 $106.00 $109.00 $58.00 $60.00 $62.00

99489 ---------- $51.00 $53.00 $54.00 $29.00 $30.00 $31.00

99490 ---------- $47.00 $49.00 $50.00 $36.00 $37.00 $39.00

99495 ---------- $180.00 $188.00 $193.00 $123.00 $128.00 $132.00

99496 ---------- $254.00 $266.00 $273.00 $179.00 $185.00 $191.00

99497 ---------- $91.00 $94.00 $98.00 $86.00 $89.00 $92.00

99498 ---------- $80.00 $83.00 $85.00 $80.00 $83.00 $85.00

99499 BR ---------- ---------- ---------- ---------- ---------- ----------

99600 BR ---------- ---------- ---------- ---------- ---------- ----------

G0245 ---------- $73.00 $76.00 $78.00 $48.00 $50.00 $52.00

G0246 ---------- $42.00 $44.00 $45.00 $24.00 $25.00 $26.00

G0296 ---------- $32.00 $33.00 $34.00 $30.00 $31.00 $32.00

G0337 ---------- $81.00 $84.00 $86.00 $81.00 $84.00 $86.00

G0372 ---------- $10.00 $10.00 $11.00 $10.00 $10.00 $11.00

G0396 ---------- $40.00 $42.00 $43.00 $38.00 $39.00 $41.00

G0397 ---------- $79.00 $81.00 $84.00 $76.00 $79.00 $82.00

G0402 ---------- $184.00 $192.00 $197.00 $142.00 $147.00 $152.00

G0406 ---------- $43.00 $44.00 $46.00 $43.00 $44.00 $46.00

G0407 ---------- $80.00 $83.00 $86.00 $80.00 $83.00 $86.00

G0408 ---------- $115.00 $119.00 $123.00 $115.00 $119.00 $123.00

G0409 ---------- $12.00 $13.00 $13.00 $12.00 $13.00 $13.00

G0507 ---------- $52.00 $54.00 $56.00 $36.00 $37.00 $38.00

G0508 ---------- $223.00 $231.00 $239.00 $223.00 $231.00 $239.00

G0509 ---------- $215.00 $222.00 $231.00 $215.00 $222.00 $231.00

G9685 ---------- $227.00 $236.00 $246.00 $227.00 $236.00 $246.00

G9686 ---------- $88.00 $91.00 $94.00 $88.00 $91.00 $94.00



4B3BChapter 4 Billing Instructions and Forms

53BBill Submission/Filing and Reporting Requirements

Carrier

Responsibilities

A carrier is responsible for meeting its obligations under this Manual

regardless of any business arrangements with any service company/TPA,

submitter, or any entity acting on 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 notify each HCP, 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 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 HCPs the specific address for submitting a reimbursement request.

Provider

Responsibilities

All HCPs are required to meet their obligations under this Manual,

regardless of any business arrangement with any entity under which medical

bills are prepared, processed, or submitted to the carrier.

Billing for Services

Under Payment

Plan(s)

HCPs receiving reimbursement under any payment plan(s) (pre-payment,

prospective payment, or capitation, etc.) are required to accurately complete

the 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 HCPs 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 be legibly and accurately completed by all HCPs.

A carrier can require an HCP to complete additional data elements that are

not required by the Division on the DWC-9, DWC-10, DWC-11, or DWC-

90, if requested by the carrier, in writing, at the time of authorization.

Form

DFS-F5-DWC-25

Physicians must utilize only the DWC-25 to request authorization for

treatment, to report the injured worker’s medical treatment/status and:

No other reporting forms may be used in lieu of the DWC-25;

Failure to accurately complete and submit the DWC-25 in

accordance with the instructions provided in this Manual may result

in the Division imposing sanctions or penalties pursuant to section

440.13(8), F.S., or section 440.13(11) F.S.;

The DWC-25 does not replace physician notes, medical records or

Division-required medical reports;

All information submitted on physician notes, medical records, or

Division-required medical reports must be consistent with

information documented on the DWC-25; and

Carriers must utilize the information submitted on the DWC-25 to

monitor the medical necessity of services provided and services

requested based on the medical condition being treated during the

authorization process.

Note: The Interactive Form DWC-25 is available under the “Forms” section

on the DWC website.





Bill Submission/Filing and Reporting Requirements, continued

Billing for a

Compensable

Injury

All medical bills and forms related to services rendered for a compensable

injury must be submitted by an HCP 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 forms or medical bills may be electronically filed or

submitted via facsimile by an HCP to the carrier, service company/TPA, or

any entity acting on behalf of the carrier, provided the carrier agrees.

Bill Corrections HCPs 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.

54BForm DFS-F5-DWC-9/CMS-1500

Health Care

Providers Who

Bill on the

DWC-9

HCPs, except physician assistants, advanced registered nurse practitioners,

certified registered nurse anesthetists, and anesthesia assistants, who are

salaried workers of an authorized 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 or service

company/TPA, must report and bill for such services on a DWC-9 by

entering the employing physician’s DOH license number in Field 33b on the

DWC-9.

Home Medical

Equipment

Physicians, physician assistants, and ARNPs billing for Home Medical

Equipment must enter the applicable HCPCS Level II® code in Field 24D on

the DWC-9 and attach the acquisition invoice documenting the cost of the

supply.




Form DFS-F5-DWC-9/CMS-1500, continued

Dispensing

Prescription

Medications

Physicians, Physician Assistants, and ARNPs must enter the NDC number in

the universal 5 4 2 format, with no dashes, in Form Field 24D when billing

for dispensed medication.

The Workers’ Compensation Unique Procedure Code DSPNS must be billed

in addition to the NDC number in Field 24D if the drug is dispensed from

the practitioner’s office for the injured worker’s use at home.

Compounded Drugs Pursuant to paragraph 69L-7.730(2)(l), F.A.C., when a physician or

pharmacist compounds a drug that is not commercially available for

prescription use by the injured worker at home, the physician or pharmacist

must bill the Workers’ Compensation Unique Procedure Code COMPD in

Field 24D.

Submission of an itemized list which contains the NDC number and quantity

used for each component is a reimbursement requirement for compounded

drugs.

Reimbursement is the lesser of:

1. [AWP (of each component)] + $4.18 = Reimbursement; or

2. The amount the carrier has contracted for pursuant to

section 440.13(12)(c), F.S.

Note: Please refer to section 440.13(12)(c), F.S., for the

definition of AWP.

Administration of

Injectable

Medications

HCPs must use the appropriate HCPCS Level II® code in Fields 24D when

available. If no HCPCS Level II® code is available, use the NDC number in

the universal NDC 5 4 2 format, with no dashes, in Field 24D.

Over-the-Counter

Medications

HCPs must use the appropriate HCPCS Level II® code in Field 24D when

available. If no HCPCS Level II® code is available, use the NDC number in

the universal 5 4 2 format, with no dashes, in Field 24D.




Form DFS-F5-DWC-9/CMS-1500, continued

Medication

Management

Therapy Services

Pharmacists who provide Medication Management Therapy Services that are

ordered by an HCP must bill by entering the appropriate CPT® code in Field

24D.

Note: A copy of the written prescription order for Medication Management

Therapy Services 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

enter the CPT® code(s) which represents the service(s) provided with

modifier AS in Field 24D.

55BForm DFS-F5-DWC-10

Health Care

Providers Who

Bill on the

DWC-10

Pharmacists must bill using the DWC-10 for pharmaceuticals and medical

supplies prescribed by an HCP.

Medical Suppliers must bill using the DWC-10 and are required to bill using

HCPCS Level II® codes for medical supplies and equipment prescribed by

an HCP.

Note: Pharmacists and medical suppliers may only bill on an alternate to

DWC-10 when a carrier has pre-approved the use of an alternate form. The

DWC-9, DWC-11, or DWC-90 must not be approved for use as an alternate

form.

Billing Policy Pharmacists must enter the NDC number, in the universal 5 4 2 format, with

no dashes, in form Field 9.




Form DFS-F5-DWC-10, continued

Compounded

Drugs

When a pharmacist compounds a drug that is not commercially available, the

pharmacist must enter the Workers’ Compensation Unique Procedure Code

COMPD in Field 9a of the DWC-10.

Submission of an itemized list which contains the NDC number and quantity

used for each component is a requirement for compounded drugs.

The individual drug components used in compounding must be identified by

the NDC numbers in the universal 5 4 2 format, with no dashes.

Over the

Counter

Medications

Pharmacists must enter the NDC number, in the universal 5 4 2 format, with

no dashes, in form Field 9a.

Home Medical

Equipment

Pharmacists must enter the applicable HCPCS Level II® code(s) in Field 21

of the DWC-10. Enter the quantity or units dispensed in Field 22.

HME providers or medical suppliers must enter the applicable HCPCS Level

II® code(s) in Field 21, and the quantity or units dispensed in Field 22.

The license number of the pharmacist, HME provider or medical supplier

must be entered in Field 29.



Appendix A Workers’ Compensation Unique Procedure Codes

DSPNS Legend or prescription drugs dispensed by a licensed dispensing

practitioner. (See subsection 69L-7.720(1), F.A.C., for the

specific use of this code).

COMPD Compounded drugs dispensed by a pharmacist or physician.

(See subsection 69L-7.720(1), 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.

♦ Relative Value Guide: A Guide for Anesthesia Values

American Society of Anesthesiologists

520 N. Northwest Highway

Park Ridge, Il. 60068-2573

(847) 825-5586

Website: http://www.asahq.org

♦ Current Dental Terminology (CDT)

American Dental Association

211 East Chicago Avenue, 6th Floor

Chicago, Illinois 60611-2678

(312) 440-2653

(800) 621-8099

(312) 440-7494 Fax

Website: www.ada.org

ADA Order Department

American Dental Association

Post Office Box 776

St. Charles, Illinois 60174

(800) 947-4746

(888) 476-1880 Fax

Website link: ADA e Customer

♦ MediSpan

Wolters Kluwer Health, Inc.

8425 Woodfield Crossing Boulevard, Suite 490

Indianapolis, IN 46240

(855) 539-7686

(317) 735-5300

Website: www.wolterskluwer.com/Pages/Home.aspx

http://www.asahq.org/

http://www.ada.org/

http://www.ada.org/en/publications/ada-catalog

http://www.wolterskluwer.com/Pages/Home.aspx



Appendix B Official Source for References, continued

Current Procedural Terminology, (CPT®

)

CPT® Assistant

Guide To The Evaluation of Permanent Impairment, 6th Edition

HCPCS Level II®

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

Website: 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.

American Academy of Orthopedic Surgeons (AAOS)

Complete Global Service Data for Orthopaedic Surgery, Vol. 1 & 2

9400 W. Higgins Road

Rosemont, Illinois 60018

(847) 823-7186

(847 ) 823-8125 Fax

Website: www.orthoguidelines.org/

http://www.ama-assn.org/

http://www.orthoguidelines.org/



Appendix C Medicare Payment Localities (Counties)

Locality 01 / Locality 02:

Alachua Gulf Okaloosa

Baker Hamilton Okeechobee

Bay Hardee Orange

Bradford Hendry Osceola

Brevard Hernando Pasco

Calhoun Highlands Pinellas

Charlotte Hillsborough Polk

Citrus Holmes Putnam

Clay Jackson Santa Rosa

Columbia Jefferson Sarasota

De Soto Lafayette St. Johns

Dixie Lake Sumter

Duval Leon Suwannee

Escambia Levy Taylor

Flagler Liberty Union

Franklin Madison Volusia

Gadsden Manatee Wakulla

Gilchrist Marion Walton

Glades Nassau Washington

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

Indian

River

Lee

Martin

Palm Beach

St. Lucie

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 Claim Form, Rev 02/12).

Form DFS-F5-DWC-10 (Statement of Charges for Drugs and Medical Equipment

& Supplies Form).

Form DFS-F5-DWC-11 (American Dental Association Dental Claim Form,

Rev.2012).

Form DFS-F5-DWC-25 (Florida Workers’ Compensation Uniform Medical

Treatment/Status Reporting Form), Rev. 01/31/2008.

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 section

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 section 440.02(14), F.S.

5. “Home Medical Equipment” is defined in section 400.925(6), F.S.

6. “Home Medical Equipment provider” is defined in section 400.925(7), F.S.

7. “Emergency Care and Services” means emergency services and care as defined in section

395.002, F.S.

8. “Health Care Provider (HCP)” means a provider as defined in section 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 section 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.



Appendix E Definitions, continued

14.“Modifier 51 Exempt” means a HCPCS Level II® or CPT© procedure code that does

not require a modifier 51 or 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 paragraph 69L-

7.710(1)(oo), F.A.C.

16.“Physician” means a physician as defined in section 440.13(1)(p), F.S.

17.“Repackaged NDC number” means the National Drug Code number as defined in

paragraph 69L-7.710(1)(oo), F.A.C.

18.“Unlisted Medication” means a medication that lacks assignment of a National Drug

Code (NDC number) or a HCPCS Level II® procedure code.

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