2007 texas medicaid fee schedule prcr404c - … schedules/2007 9-1-07...2 surgery 11200 0 999 $59.00...

9/01/2007 TEXAS MEDICAID FEE SCHEDULE- PODIATRIST

1 of 46

Texas Medicaid Fee Schedule InformationPodiatrist

2007Dear Podiatrist Provider:

The Texas Medicaid & Healthcare Partnership (TMHP) has compiled this Texas Medicaid fee schedules to help providers determine payment amounts for specific services. The schedules contain a list of procedure codes and corresponding reimbursement by the Texas Medicaid Program. This schedule is applicable to podiatrist providers only. Procedures listed in this fee schedule are payable based on the policies in effect for specific dates of service. Refer to the Texas Medicaid Provider Procedures Manual (TMPPM) and Texas Medicaid bulletins for program benefits, limitations, and approval processes.

The reimbursement methodology for podiatrists can be found in Title 1 Texas Administrative Code (TAC), §355.8081 and refers to the reimbursement methodology for physicians and certain other practitioners, which is located at 1 TAC §355.8085. Podiatrists are reimbursed for clinical laboratory services in accordance with 1 TAC §355.8610.

The following paragraphs are an overview of the current Texas Medicaid reimbursement methodologies used in this report.

Resource-based fees (RBFs) and access-based fees (ABFs). RBFs are based on relative value units (RVUs) times the applicable Texas Medicaid conversion factor. ABFs are developed to account for deficiencies in RBFs relating to adequacy of access to health-care services for Medicaid clients.

The fee schedule field descriptions below are a guide for using the fee schedule. TMHP hopes this information is helpful in determining payment amounts for services provided. Thank you for your participation in the Texas Medicaid Program.

Field DescriptionsTOS: Type of service. One-character TOS and corresponding description.

Proc code: Procedure code.Mod 1: 1st Modifier, if required for pricing determination.Mod 2: 2nd Modifier, if required for pricing determination.

Client Age From: From age, if required for pricing determination. This is not the age restriction of the procedure. See the TMPPM for exact age limitations.

Client Age Through: Through age, if required for pricing determination. This is not the age restriction of the procedure. See the TMPPM for exact age limitations.

TMRM Payable: Texas Medicaid reimbursement methodology per 1 TAC §355.8085. The payable amount for the TOS and procedure code for providers, specifically RBFs. The payable amount is calculated by multiplying the total RVUs by the applicable Texas Medicaid conversion factor.

Total RVUs: The current RVUs in TMHP files for the procedure code.Conv Factor: The conversion factor amounts for determining either the TMRM payable or the anesthesia payable amount.

PPS Fee: Prospective Payment System (PPS) fee.Access-Based or Max Fee: The ABF amount or maximum fee.

Note Codes: Note code indicator. Providers should review each note code to identify specific payment explanation or limitation.

Note code description: 1 In an outpatient setting, this procedure is subject to a 60-percent payable if the diagnosis is nonemergency. 2 Clinical laboratory fee schedule procedure. 5 This procedure is manually reviewed to determine pricing.

Texas Medicaid & Healthcare Partnership, 12365-A Riata Trace Parkway, Austin, TX 78727

Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.


2 of 46

TOS TOS DescProc Code Mod 1 Mod 2

Client Age From

Client Age Through

TMRM Payable

Total RVUs

Conv Factor PPS Fee

Access Based or Max Fee

Note Codes

2 Surgery 10040 0 999 $73.32 2.56 28.64 $0.00 $0.002 Surgery 10060 0 999 $80.76 2.82 28.64 $0.00 $0.002 Surgery 10061 0 999 $120.86 4.22 28.64 $0.00 $0.002 Surgery 10120 0 999 $65.87 2.3 28.64 $0.00 $0.002 Surgery 10121 0 999 $134.61 4.7 28.64 $0.00 $0.002 Surgery 10140 0 999 $114.56 4 28.64 $0.00 $0.002 Surgery 10160 0 999 $69.60 2.43 28.64 $0.00 $0.002 Surgery 10180 0 999 $127.45 4.45 28.64 $0.00 $0.002 Surgery 11000 0 999 $0.00 0 0 $0.00 $40.672 Surgery 11001 0 20 $21.00 0.77 27.276 $0.00 $0.002 Surgery 11001 21 999 $0.00 0 0 $0.00 $22.052 Surgery 11010 0 999 $0.00 0 0 $0.00 $250.892 Surgery 11011 0 999 $0.00 0 0 $0.00 $299.002 Surgery 11012 0 999 $0.00 0 0 $0.00 $415.562 Surgery 11040 0 999 $0.00 0 0 $0.00 $31.502 Surgery 11041 0 999 $0.00 0 0 $0.00 $46.402 Surgery 11042 0 999 $0.00 0 0 $0.00 $59.862 Surgery 11043 0 999 $173.84 6.07 28.64 $0.00 $0.002 Surgery 11044 0 20 $166.38 6.1 27.276 $0.00 $0.002 Surgery 11044 21 999 $235.42 8.22 28.64 $0.00 $0.002 Surgery 11056 0 20 $21.00 0.77 27.276 $0.00 $0.002 Surgery 11056 21 999 $44.96 1.57 28.64 $0.00 $0.002 Surgery 11057 0 20 $22.09 0.81 27.276 $0.00 $0.002 Surgery 11057 21 999 $54.13 1.89 28.64 $0.00 $0.002 Surgery 11100 0 999 $78.19 2.73 28.64 $0.00 $0.002 Surgery 11101 0 999 $24.34 0.85 28.64 $0.00 $0.002 Surgery 11200 0 999 $59.00 2.06 28.64 $0.00 $0.002 Surgery 11201 0 20 $12.55 0.46 27.276 $0.00 $0.002 Surgery 11201 21 999 $13.46 0.47 28.64 $0.00 $0.002 Surgery 11300 0 999 $49.55 1.73 28.64 $0.00 $0.002 Surgery 11301 0 999 $68.74 2.4 28.64 $0.00 $0.002 Surgery 11302 0 999 $82.48 2.88 28.64 $0.00 $0.002 Surgery 11303 0 20 $77.46 2.84 27.276 $0.00 $0.002 Surgery 11303 21 999 $95.66 3.34 28.64 $0.00 $0.002 Surgery 11305 0 999 $51.84 1.81 28.64 $0.00 $0.002 Surgery 11306 0 999 $71.31 2.49 28.64 $0.00 $0.002 Surgery 11307 0 20 $60.83 2.23 27.276 $0.00 $0.002 Surgery 11307 21 999 $83.63 2.92 28.64 $0.00 $0.002 Surgery 11308 0 999 $94.23 3.29 28.64 $0.00 $0.002 Surgery 11420 0 20 $45.55 1.67 27.276 $0.00 $0.002 Surgery 11420 21 999 $83.63 2.92 28.64 $0.00 $0.002 Surgery 11421 0 999 $108.55 3.79 28.64 $0.00 $0.002 Surgery 11422 0 999 $95.66 3.34 28.64 $0.00 $0.002 Surgery 11423 0 20 $102.56 3.76 27.276 $0.00 $0.002 Surgery 11423 21 999 $139.76 4.88 28.64 $0.00 $0.002 Surgery 11424 0 20 $118.38 4.34 27.276 $0.00 $0.002 Surgery 11424 21 999 $162.39 5.67 28.64 $0.00 $0.002 Surgery 11426 0 999 $194.75 6.8 28.64 $0.00 $0.002 Surgery 11620 0 20 $78.83 2.89 27.276 $0.00 $0.002 Surgery 11620 21 999 $129.74 4.53 28.64 $0.00 $0.002 Surgery 11621 0 20 $109.92 4.03 27.276 $0.00 $0.002 Surgery 11621 21 999 $162.10 5.66 28.64 $0.00 $0.002 Surgery 11622 0 20 $134.47 4.93 27.276 $0.00 $0.00



3 of 46

2 Surgery 11622 21 999 $183.58 6.41 28.64 $0.00 $0.002 Surgery 11623 0 20 $159.29 5.84 27.276 $0.00 $0.002 Surgery 11623 21 999 $211.65 7.39 28.64 $0.00 $0.002 Surgery 11624 0 20 $198.57 7.28 27.276 $0.00 $0.002 Surgery 11624 21 999 $237.14 8.28 28.64 $0.00 $0.002 Surgery 11626 0 20 $234.03 8.58 27.276 $0.00 $0.002 Surgery 11626 21 999 $285.54 9.97 28.64 $0.00 $0.002 Surgery 11719 0 20 $10.09 0.37 27.276 $0.00 $0.002 Surgery 11719 21 999 $16.32 0.57 28.64 $0.00 $0.002 Surgery 11720 0 20 $18.27 0.67 27.276 $0.00 $0.002 Surgery 11720 21 999 $23.77 0.83 28.64 $0.00 $0.002 Surgery 11721 0 20 $30.82 1.13 27.276 $0.00 $0.002 Surgery 11721 21 999 $33.22 1.16 28.64 $0.00 $0.002 Surgery 11730 0 999 $74.18 2.59 28.64 $0.00 $0.002 Surgery 11732 0 999 $34.08 1.19 28.64 $0.00 $0.002 Surgery 11740 0 999 $24.34 0.85 28.64 $0.00 $0.002 Surgery 11750 0 999 $160.67 5.61 28.64 $0.00 $0.002 Surgery 11752 0 999 $228.26 7.97 28.64 $0.00 $0.002 Surgery 11755 0 999 $99.95 3.49 28.64 $0.00 $0.002 Surgery 11760 0 999 $93.37 3.26 28.64 $0.00 $0.002 Surgery 11762 0 20 $162.29 5.95 27.276 $0.00 $0.002 Surgery 11762 21 999 $200.77 7.01 28.64 $0.00 $0.002 Surgery 11765 0 999 $99.67 3.48 28.64 $0.00 $0.002 Surgery 12001 0 999 $74.46 2.6 28.64 $0.00 $0.002 Surgery 12002 0 999 $82.77 2.89 28.64 $0.00 $0.002 Surgery 12004 0 999 $0.00 0 0 $0.00 $103.102 Surgery 12005 0 999 $0.00 0 0 $0.00 $133.172 Surgery 12006 0 20 $160.66 5.89 27.276 $0.00 $0.002 Surgery 12006 21 999 $0.00 0 0 $0.00 $168.692 Surgery 12007 0 20 $174.02 6.38 27.276 $0.00 $0.002 Surgery 12007 21 999 $0.00 0 0 $0.00 $182.722 Surgery 12020 0 999 $191.60 6.69 28.64 $0.00 $0.002 Surgery 12041 0 999 $124.87 4.36 28.64 $0.00 $0.002 Surgery 12042 0 999 $145.20 5.07 28.64 $0.00 $0.002 Surgery 12044 0 999 $153.80 5.37 28.64 $0.00 $0.002 Surgery 12045 0 20 $171.02 6.27 27.276 $0.00 $0.002 Surgery 12045 21 999 $0.00 0 0 $0.00 $179.572 Surgery 12046 0 20 $212.21 7.78 27.276 $0.00 $0.002 Surgery 12046 21 999 $0.00 0 0 $0.00 $222.822 Surgery 12047 0 999 $0.00 0 0 $0.00 $276.95

8 Assistant Surgery 12047 0 999 $0.00 0 0 $0.00 $44.312 Surgery 13131 0 999 $199.91 6.98 28.64 $0.00 $0.002 Surgery 13132 0 999 $339.10 11.84 28.64 $0.00 $0.002 Surgery 13160 0 999 $587.41 20.51 28.64 $0.00 $0.002 Surgery 14040 0 999 $461.96 16.13 28.64 $0.00 $0.002 Surgery 14041 0 999 $656.14 22.91 28.64 $0.00 $0.002 Surgery 15574 0 999 $537.29 18.76 28.64 $0.00 $0.002 Surgery 15620 0 20 $252.30 9.25 27.276 $0.00 $0.002 Surgery 15620 21 999 $0.00 0 0 $0.00 $264.922 Surgery 15850 0 999 $0.00 0 0 $0.00 $50.752 Surgery 15851 0 20 $0.00 0 0 $0.00 $35.812 Surgery 15851 21 999 $34.10 1.25 27.276 $0.00 $0.002 Surgery 15852 0 999 $0.00 0 0 $0.00 $41.242 Surgery 16020 0 999 $41.24 1.44 28.64 $0.00 $0.002 Surgery 17000 0 999 $59.28 2.07 28.64 $0.00 $0.00



4 of 46

2 Surgery 17003 0 999 $0.00 0 0 $0.00 $8.312 Surgery 17004 0 999 $0.00 0 0 $0.00 $150.082 Surgery 17106 0 999 $277.52 9.69 28.64 $0.00 $0.002 Surgery 17110 0 999 $71.03 2.48 28.64 $0.00 $0.002 Surgery 17250 0 999 $53.84 1.88 28.64 $0.00 $0.002 Surgery 17270 0 20 $48.82 1.79 27.276 $0.00 $0.002 Surgery 17270 21 999 $110.26 3.85 28.64 $0.00 $0.002 Surgery 17271 0 20 $73.10 2.68 27.276 $0.00 $0.002 Surgery 17271 21 999 $122.01 4.26 28.64 $0.00 $0.002 Surgery 17272 0 20 $87.28 3.2 27.276 $0.00 $0.002 Surgery 17272 21 999 $139.19 4.86 28.64 $0.00 $0.002 Surgery 17273 0 20 $102.83 3.77 27.276 $0.00 $0.002 Surgery 17273 21 999 $154.66 5.4 28.64 $0.00 $0.002 Surgery 17274 0 999 $128.47 4.71 27.276 $0.00 $0.002 Surgery 17276 0 999 $159.84 5.86 27.276 $0.00 $0.002 Surgery 17311 0 999 $283.40 10.39 27.276 $0.00 $0.002 Surgery 17312 0 999 $122.20 4.48 27.276 $0.00 $0.002 Surgery 17313 0 999 $283.40 10.39 27.276 $0.00 $0.002 Surgery 17314 0 999 $122.20 4.48 27.276 $0.00 $0.002 Surgery 17315 0 999 $14.18 0.52 27.276 $0.00 $0.002 Surgery 17340 0 999 $32.94 1.15 28.64 $0.00 $0.002 Surgery 20000 0 999 $148.07 5.17 28.64 $0.00 $0.002 Surgery 20005 0 999 $173.27 6.05 28.64 $0.00 $0.002 Surgery 20200 0 20 $79.10 2.9 27.276 $0.00 $0.002 Surgery 20200 21 999 $0.00 0 0 $0.00 $83.062 Surgery 20205 0 20 $131.20 4.81 27.276 $0.00 $0.002 Surgery 20205 21 999 $0.00 0 0 $0.00 $137.762 Surgery 20206 0 20 $59.73 2.19 27.276 $0.00 $0.002 Surgery 20206 21 999 $0.00 0 0 $0.00 $62.722 Surgery 20520 0 999 $133.46 4.66 28.64 $0.00 $0.002 Surgery 20525 0 999 $178.43 6.23 28.64 $0.00 $0.002 Surgery 20526 0 20 $46.37 1.7 27.276 $0.00 $0.002 Surgery 20526 21 999 $54.13 1.89 28.64 $0.00 $0.002 Surgery 20550 0 999 $0.00 0 0 $0.00 $47.542 Surgery 20551 0 999 $0.00 0 0 $0.00 $48.692 Surgery 20552 0 999 $0.00 0 0 $0.00 $48.692 Surgery 20553 0 999 $0.00 0 0 $0.00 $48.692 Surgery 20600 0 999 $40.38 1.41 28.64 $0.00 $0.002 Surgery 20605 0 20 $34.10 1.25 27.276 $0.00 $0.002 Surgery 20605 21 999 $42.96 1.5 28.64 $0.00 $0.002 Surgery 20610 0 999 $56.13 1.96 28.64 $0.00 $0.002 Surgery 20612 0 999 $0.00 0 0 $0.00 $43.822 Surgery 20615 0 20 $79.92 2.93 27.276 $0.00 $0.002 Surgery 20615 21 999 $148.93 5.2 28.64 $0.00 $0.002 Surgery 20650 0 999 $111.98 3.91 28.64 $0.00 $0.002 Surgery 20670 0 999 $248.88 8.69 28.64 $0.00 $0.002 Surgery 20680 0 999 $302.72 10.57 28.64 $0.00 $0.00

8 Assistant Surgery 20680 0 999 $48.40 1.69 28.64 $0.00 $0.002 Surgery 26770 0 999 $168.40 5.88 28.64 $0.00 $0.002 Surgery 26775 0 20 $138.02 5.06 27.276 $0.00 $0.002 Surgery 26775 21 999 $233.42 8.15 28.64 $0.00 $0.002 Surgery 26776 0 20 $201.57 7.39 27.276 $0.00 $0.002 Surgery 26776 21 999 $305.88 10.68 28.64 $0.00 $0.002 Surgery 27605 0 20 $118.65 4.35 27.276 $0.00 $0.002 Surgery 27605 21 999 $146.06 5.1 28.64 $0.00 $0.00



5 of 46

2 Surgery 27606 0 999 $215.37 7.52 28.64 $0.00 $0.002 Surgery 27610 0 20 $454.96 16.68 27.276 $0.00 $0.002 Surgery 27610 21 999 $0.00 0 0 $0.00 $477.71

8 Assistant Surgery 27610 0 20 $72.83 2.67 27.276 $0.00 $0.00

8 Assistant Surgery 27610 21 999 $0.00 0 0 $0.00 $76.432 Surgery 27612 0 20 $468.33 17.17 27.276 $0.00 $0.002 Surgery 27612 21 999 $0.00 0 0 $0.00 $491.752 Surgery 27620 0 20 $364.68 13.37 27.276 $0.00 $0.002 Surgery 27620 21 999 $0.00 0 0 $0.00 $382.91


8 Assistant Surgery 27620 21 999 $0.00 0 0 $0.00 $61.272 Surgery 27625 0 20 $513.88 18.84 27.276 $0.00 $0.002 Surgery 27625 21 999 $0.00 0 0 $0.00 $539.57


8 Assistant Surgery 27625 21 999 $0.00 0 0 $0.00 $86.332 Surgery 27626 0 999 $609.07 22.33 27.276 $0.00 $0.002 Surgery 27647 0 20 $646.71 23.71 27.276 $0.00 $0.002 Surgery 27647 21 999 $0.00 0 0 $0.00 $679.05


8 Assistant Surgery 27647 21 999 $0.00 0 0 $0.00 $108.652 Surgery 27648 0 20 $44.19 1.62 27.276 $0.00 $0.002 Surgery 27648 21 999 $0.00 0 0 $0.00 $46.402 Surgery 27650 0 20 $506.24 18.56 27.276 $0.00 $0.002 Surgery 27650 21 999 $0.00 0 0 $0.00 $531.552 Surgery 27652 0 20 $567.89 20.82 27.276 $0.00 $0.002 Surgery 27652 21 999 $0.00 0 0 $0.00 $596.282 Surgery 27685 0 999 $349.12 12.19 28.64 $0.00 $0.002 Surgery 27690 0 999 $0.00 0 0 $0.00 $474.56

8 Assistant Surgery 27690 0 999 $0.00 0 0 $0.00 $75.932 Surgery 27691 0 999 $0.00 0 0 $0.00 $554.46







8 Assistant Surgery 27698 0 999 $0.00 0 0 $0.00 $103.97



6 of 46

2 Surgery 27700 0 20 $639.89 23.46 27.276 $0.00 $0.002 Surgery 27700 21 999 $0.00 0 0 $0.00 $671.88


8 Assistant Surgery 27700 21 999 $0.00 0 0 $0.00 $107.502 Surgery 27702 0 20 $1,182.96 43.37 27.276 $0.00 $0.002 Surgery 27702 21 999 $0.00 0 0 $0.00 $1,242.11


8 Assistant Surgery 27702 21 999 $0.00 0 0 $0.00 $198.742 Surgery 27703 0 999 $878.01 32.19 27.276 $0.00 $0.00

8 Assistant Surgery 27703 0 999 $140.47 5.15 27.276 $0.00 $0.002 Surgery 27704 0 999 $0.00 0 0 $0.00 $423.302 Surgery 27760 0 999 $207.93 7.26 28.64 $0.00 $0.002 Surgery 27762 0 20 $249.03 9.13 27.276 $0.00 $0.002 Surgery 27762 21 999 $313.32 10.94 28.64 $0.00 $0.002 Surgery 27766 0 999 $0.00 0 0 $0.00 $504.92

8 Assistant Surgery 27766 0 999 $0.00 0 0 $0.00 $80.792 Surgery 27786 0 999 $212.80 7.43 28.64 $0.00 $0.002 Surgery 27788 0 20 $231.03 8.47 27.276 $0.00 $0.002 Surgery 27788 21 999 $273.23 9.54 28.64 $0.00 $0.002 Surgery 27792 0 20 $448.14 16.43 27.276 $0.00 $0.002 Surgery 27792 21 999 $0.00 0 0 $0.00 $470.55


8 Assistant Surgery 27792 21 999 $0.00 0 0 $0.00 $75.292 Surgery 27808 0 999 $222.25 7.76 28.64 $0.00 $0.002 Surgery 27810 0 20 $306.58 11.24 27.276 $0.00 $0.002 Surgery 27810 21 999 $0.00 0 0 $0.00 $321.912 Surgery 27814 0 999 $0.00 0 0 $0.00 $647.83

8 Assistant Surgery 27814 0 999 $0.00 0 0 $0.00 $103.652 Surgery 27816 0 20 $204.02 7.48 27.276 $0.00 $0.002 Surgery 27816 21 999 $0.00 0 0 $0.00 $214.222 Surgery 27818 0 999 $0.00 0 0 $0.00 $386.642 Surgery 27822 0 999 $0.00 0 0 $0.00 $663.30


8 Assistant Surgery 27823 0 999 $0.00 0 0 $0.00 $124.282 Surgery 27824 0 999 $211.65 7.39 28.64 $0.00 $0.002 Surgery 27825 0 20 $357.86 13.12 27.276 $0.00 $0.002 Surgery 27825 21 999 $0.00 0 0 $0.00 $375.752 Surgery 27826 0 20 $576.34 21.13 27.276 $0.00 $0.002 Surgery 27826 21 999 $0.00 0 0 $0.00 $605.16



8 Assistant Surgery 27827 0 999 $126.83 4.65 27.276 $0.00 $0.002 Surgery 27828 0 999 $956.58 33.4 28.64 $0.00 $0.00



7 of 46

8 Assistant Surgery 27828 0 999 $152.94 5.34 28.64 $0.00 $0.002 Surgery 27829 0 20 $414.32 15.19 27.276 $0.00 $0.002 Surgery 27829 21 999 $0.00 0 0 $0.00 $435.04


8 Assistant Surgery 27829 21 999 $0.00 0 0 $0.00 $69.612 Surgery 27840 0 999 $250.60 8.75 28.64 $0.00 $0.002 Surgery 27842 0 20 $237.85 8.72 27.276 $0.00 $0.002 Surgery 27842 21 999 $351.13 12.26 28.64 $0.00 $0.002 Surgery 27846 0 20 $546.34 20.03 27.276 $0.00 $0.002 Surgery 27846 21 999 $0.00 0 0 $0.00 $573.66


8 Assistant Surgery 27846 21 999 $0.00 0 0 $0.00 $91.792 Surgery 27848 0 20 $578.80 21.22 27.276 $0.00 $0.002 Surgery 27848 21 999 $608.89 21.26 28.64 $0.00 $0.00


8 Assistant Surgery 27848 21 999 $97.38 3.4 28.64 $0.00 $0.002 Surgery 27860 0 999 $127.45 4.45 28.64 $0.00 $0.002 Surgery 27870 0 20 $763.46 27.99 27.276 $0.00 $0.002 Surgery 27870 21 999 $0.00 0 0 $0.00 $801.63




8 Assistant Surgery 27888 21 999 $0.00 0 0 $0.00 $95.912 Surgery 27889 0 20 $540.61 19.82 27.276 $0.00 $0.002 Surgery 27889 21 999 $0.00 0 0 $0.00 $567.642 Surgery 28001 0 999 $135.47 4.73 28.64 $0.00 $0.002 Surgery 28002 0 999 $287.83 10.05 28.64 $0.00 $0.002 Surgery 28003 0 20 $333.04 12.21 27.276 $0.00 $0.002 Surgery 28003 21 999 $422.15 14.74 28.64 $0.00 $0.002 Surgery 28005 0 999 $422.15 14.74 28.64 $0.00 $0.002 Surgery 28008 0 20 $205.93 7.55 27.276 $0.00 $0.002 Surgery 28008 21 999 $232.84 8.13 28.64 $0.00 $0.002 Surgery 28010 0 20 $198.84 7.29 27.276 $0.00 $0.002 Surgery 28010 21 999 $0.00 0 0 $0.00 $208.782 Surgery 28011 0 999 $225.40 7.87 28.64 $0.00 $0.002 Surgery 28020 0 999 $0.00 0 0 $0.00 $293.282 Surgery 28022 0 20 $214.39 7.86 27.276 $0.00 $0.002 Surgery 28022 21 999 $249.45 8.71 28.64 $0.00 $0.002 Surgery 28024 0 999 $235.71 8.23 28.64 $0.00 $0.002 Surgery 28035 0 20 $358.41 13.14 27.276 $0.00 $0.002 Surgery 28035 21 999 $0.00 0 0 $0.00 $376.33





8 of 46

2 Surgery 28043 21 999 $195.61 6.83 28.64 $0.00 $0.002 Surgery 28045 0 20 $256.12 9.39 27.276 $0.00 $0.002 Surgery 28045 21 999 $0.00 0 0 $0.00 $268.932 Surgery 28046 0 20 $447.05 16.39 27.276 $0.00 $0.002 Surgery 28046 21 999 $510.36 17.82 28.64 $0.00 $0.002 Surgery 28050 0 999 $239.48 8.78 27.276 $0.00 $0.002 Surgery 28052 0 999 $228.30 8.37 27.276 $0.00 $0.002 Surgery 28054 0 999 $164.47 6.03 27.276 $0.00 $0.002 Surgery 28055 0 999 $291.03 10.67 27.276 $0.00 $0.002 Surgery 28060 0 20 $282.31 10.35 27.276 $0.00 $0.002 Surgery 28060 21 999 $0.00 0 0 $0.00 $296.432 Surgery 28062 0 20 $406.69 14.91 27.276 $0.00 $0.002 Surgery 28062 21 999 $0.00 0 0 $0.00 $427.02


8 Assistant Surgery 28062 21 999 $0.00 0 0 $0.00 $68.322 Surgery 28070 0 999 $278.49 10.21 27.276 $0.00 $0.002 Surgery 28072 0 20 $228.57 8.38 27.276 $0.00 $0.002 Surgery 28072 21 999 $257.19 8.98 28.64 $0.00 $0.002 Surgery 28080 0 20 $225.57 8.27 27.276 $0.00 $0.002 Surgery 28080 21 999 $268.64 9.38 28.64 $0.00 $0.002 Surgery 28086 0 20 $268.40 9.84 27.276 $0.00 $0.002 Surgery 28086 21 999 $0.00 0 0 $0.00 $281.822 Surgery 28088 0 999 $219.84 8.06 27.276 $0.00 $0.002 Surgery 28090 0 20 $217.66 7.98 27.276 $0.00 $0.002 Surgery 28090 21 999 $237.43 8.29 28.64 $0.00 $0.002 Surgery 28092 0 20 $165.84 6.08 27.276 $0.00 $0.002 Surgery 28092 21 999 $207.07 7.23 28.64 $0.00 $0.002 Surgery 28100 0 20 $302.22 11.08 27.276 $0.00 $0.002 Surgery 28100 21 999 $0.00 0 0 $0.00 $317.33




8 Assistant Surgery 28104 21 999 $0.00 0 0 $0.00 $46.742 Surgery 28108 0 20 $246.58 9.04 27.276 $0.00 $0.002 Surgery 28108 21 999 $0.00 0 0 $0.00 $258.912 Surgery 28110 0 20 $220.94 8.1 27.276 $0.00 $0.002 Surgery 28110 21 999 $0.00 0 0 $0.00 $231.99


8 Assistant Surgery 28110 21 999 $0.00 0 0 $0.00 $37.122 Surgery 28111 0 20 $297.31 10.9 27.276 $0.00 $0.002 Surgery 28111 21 999 $0.00 0 0 $0.00 $312.182 Surgery 28112 0 20 $248.21 9.1 27.276 $0.00 $0.002 Surgery 28112 21 999 $0.00 0 0 $0.00 $260.622 Surgery 28113 0 20 $259.12 9.5 27.276 $0.00 $0.002 Surgery 28113 21 999 $321.63 11.23 28.64 $0.00 $0.002 Surgery 28114 0 20 $541.16 19.84 27.276 $0.00 $0.002 Surgery 28114 21 999 $612.90 21.4 28.64 $0.00 $0.00



9 of 46

2 Surgery 28116 0 20 $351.31 12.88 27.276 $0.00 $0.002 Surgery 28116 21 999 $442.20 15.44 28.64 $0.00 $0.002 Surgery 28118 0 20 $342.86 12.57 27.276 $0.00 $0.002 Surgery 28118 21 999 $0.00 0 0 $0.00 $360.00




8 Assistant Surgery 28119 21 999 $0.00 0 0 $0.00 $53.702 Surgery 28120 0 20 $353.22 12.95 27.276 $0.00 $0.002 Surgery 28120 21 999 $0.00 0 0 $0.00 $370.882 Surgery 28122 0 20 $334.68 12.27 27.276 $0.00 $0.002 Surgery 28122 21 999 $384.64 13.43 28.64 $0.00 $0.002 Surgery 28124 0 20 $254.76 9.34 27.276 $0.00 $0.002 Surgery 28124 21 999 $0.00 0 0 $0.00 $267.50


8 Assistant Surgery 28124 21 999 $0.00 0 0 $0.00 $42.802 Surgery 28126 0 20 $222.03 8.14 27.276 $0.00 $0.002 Surgery 28126 21 999 $0.00 0 0 $0.00 $233.132 Surgery 28130 0 20 $438.05 16.06 27.276 $0.00 $0.002 Surgery 28130 21 999 $473.13 16.52 28.64 $0.00 $0.00


8 Assistant Surgery 28130 21 999 $75.61 2.64 28.64 $0.00 $0.002 Surgery 28140 0 20 $345.04 12.65 27.276 $0.00 $0.002 Surgery 28140 21 999 $0.00 0 0 $0.00 $362.292 Surgery 28150 0 20 $215.48 7.9 27.276 $0.00 $0.002 Surgery 28150 21 999 $0.00 0 0 $0.00 $226.252 Surgery 28153 0 20 $222.57 8.16 27.276 $0.00 $0.002 Surgery 28153 21 999 $0.00 0 0 $0.00 $233.702 Surgery 28160 0 20 $232.39 8.52 27.276 $0.00 $0.002 Surgery 28160 21 999 $0.00 0 0 $0.00 $244.012 Surgery 28171 0 999 $513.06 18.81 27.276 $0.00 $0.00

8 Assistant Surgery 28171 0 999 $82.10 3.01 27.276 $0.00 $0.002 Surgery 28173 0 999 $468.06 17.16 27.276 $0.00 $0.002 Surgery 28175 0 999 $326.49 11.97 27.276 $0.00 $0.002 Surgery 28190 0 999 $101.96 3.56 28.64 $0.00 $0.002 Surgery 28192 0 20 $192.02 7.04 27.276 $0.00 $0.002 Surgery 28192 21 999 $245.16 8.56 28.64 $0.00 $0.002 Surgery 28193 0 999 $292.41 10.21 28.64 $0.00 $0.002 Surgery 28200 0 999 $0.00 0 0 $0.00 $302.432 Surgery 28208 0 999 $235.71 8.23 28.64 $0.00 $0.002 Surgery 28220 0 20 $246.30 9.03 27.276 $0.00 $0.002 Surgery 28220 21 999 $0.00 0 0 $0.00 $258.622 Surgery 28222 0 20 $319.13 11.7 27.276 $0.00 $0.002 Surgery 28222 21 999 $0.00 0 0 $0.00 $335.092 Surgery 28225 0 20 $173.75 6.37 27.276 $0.00 $0.002 Surgery 28225 21 999 $198.76 6.94 28.64 $0.00 $0.002 Surgery 28226 0 999 $231.85 8.5 27.276 $0.00 $0.00



10 of 46

2 Surgery 28230 0 20 $190.93 7 27.276 $0.00 $0.002 Surgery 28230 21 999 $222.53 7.77 28.64 $0.00 $0.002 Surgery 28232 0 20 $144.02 5.28 27.276 $0.00 $0.002 Surgery 28232 21 999 $188.74 6.59 28.64 $0.00 $0.002 Surgery 28234 0 20 $139.38 5.11 27.276 $0.00 $0.002 Surgery 28234 21 999 $199.33 6.96 28.64 $0.00 $0.002 Surgery 28238 0 999 $496.62 17.34 28.64 $0.00 $0.00

8 Assistant Surgery 28238 0 999 $79.33 2.77 28.64 $0.00 $0.002 Surgery 28240 0 20 $186.02 6.82 27.276 $0.00 $0.002 Surgery 28240 21 999 $229.69 8.02 28.64 $0.00 $0.002 Surgery 28250 0 20 $305.49 11.2 27.276 $0.00 $0.002 Surgery 28250 21 999 $0.00 0 0 $0.00 $320.762 Surgery 28260 0 20 $356.77 13.08 27.276 $0.00 $0.002 Surgery 28260 21 999 $401.25 14.01 28.64 $0.00 $0.002 Surgery 28261 0 20 $443.24 16.25 27.276 $0.00 $0.002 Surgery 28261 21 999 $600.87 20.98 28.64 $0.00 $0.002 Surgery 28262 0 999 $1,008.70 35.22 28.64 $0.00 $0.00

8 Assistant Surgery 28262 0 999 $161.53 5.64 28.64 $0.00 $0.002 Surgery 28264 0 20 $590.25 21.64 27.276 $0.00 $0.002 Surgery 28264 21 999 $0.00 0 0 $0.00 $619.762 Surgery 28270 0 20 $213.57 7.83 27.276 $0.00 $0.002 Surgery 28270 21 999 $256.33 8.95 28.64 $0.00 $0.002 Surgery 28272 0 20 $169.38 6.21 27.276 $0.00 $0.002 Surgery 28272 21 999 $200.48 7 28.64 $0.00 $0.002 Surgery 28280 0 20 $213.84 7.84 27.276 $0.00 $0.002 Surgery 28280 21 999 $274.94 9.6 28.64 $0.00 $0.002 Surgery 28285 0 999 $0.00 0 0 $0.00 $251.752 Surgery 28286 0 20 $240.57 8.82 27.276 $0.00 $0.002 Surgery 28286 21 999 $0.00 0 0 $0.00 $252.602 Surgery 28288 0 20 $227.21 8.33 27.276 $0.00 $0.002 Surgery 28288 21 999 $321.91 11.24 28.64 $0.00 $0.002 Surgery 28289 0 20 $279.31 10.24 27.276 $0.00 $0.002 Surgery 28289 21 999 $417.28 14.57 28.64 $0.00 $0.00







8 Assistant Surgery 28294 0 999 $83.46 3.06 27.276 $0.00 $0.002 Surgery 28296 0 999 $0.00 0 0 $0.00 $558.19




11 of 46




8 Assistant Surgery 28299 0 999 $0.00 0 0 $0.00 $94.992 Surgery 28300 0 20 $0.00 0 0 $0.00 $495.762 Surgery 28300 21 999 $495.47 17.3 28.64 $0.00 $0.00








8 Assistant Surgery 28306 21 999 $0.00 0 0 $0.00 $51.922 Surgery 28307 0 20 $364.41 13.36 27.276 $0.00 $0.002 Surgery 28307 21 999 $0.00 0 0 $0.00 $382.632 Surgery 28308 0 999 $401.53 14.02 28.64 $0.00 $0.00

8 Assistant Surgery 28308 0 999 $64.15 2.24 28.64 $0.00 $0.002 Surgery 28309 0 20 $480.06 17.6 27.276 $0.00 $0.002 Surgery 28309 21 999 $683.35 23.86 28.64 $0.00 $0.002 Surgery 28310 0 20 $277.67 10.18 27.276 $0.00 $0.002 Surgery 28310 21 999 $0.00 0 0 $0.00 $291.552 Surgery 28312 0 999 $267.58 9.81 27.276 $0.00 $0.002 Surgery 28313 0 20 $219.03 8.03 27.276 $0.00 $0.002 Surgery 28313 21 999 $271.79 9.49 28.64 $0.00 $0.002 Surgery 28315 0 20 $265.67 9.74 27.276 $0.00 $0.002 Surgery 28315 21 999 $0.00 0 0 $0.00 $278.952 Surgery 28320 0 20 $531.34 19.48 27.276 $0.00 $0.002 Surgery 28320 21 999 $0.00 0 0 $0.00 $557.91






12 of 46

8 Assistant Surgery 28322 21 999 $69.60 2.43 28.64 $0.00 $0.002 Surgery 28340 0 20 $397.41 14.57 27.276 $0.00 $0.002 Surgery 28340 21 999 $0.00 0 0 $0.00 $417.282 Surgery 28341 0 20 $473.51 17.36 27.276 $0.00 $0.002 Surgery 28341 21 999 $0.00 0 0 $0.00 $497.192 Surgery 28344 0 20 $0.00 0 0 $0.00 $247.162 Surgery 28344 21 999 $235.39 8.63 27.276 $0.00 $0.00


8 Assistant Surgery 28344 21 999 $37.64 1.38 27.276 $0.00 $0.002 Surgery 28345 0 20 $324.04 11.88 27.276 $0.00 $0.002 Surgery 28345 21 999 $0.00 0 0 $0.00 $340.242 Surgery 28360 0 20 $666.74 23.28 28.64 $0.00 $0.002 Surgery 28360 21 999 $0.00 0 0 $0.00 $355.252 Surgery 28400 0 20 $148.38 5.44 27.276 $0.00 $0.002 Surgery 28400 21 999 $157.81 5.51 28.64 $0.00 $0.002 Surgery 28405 0 999 $0.00 0 0 $0.00 $264.632 Surgery 28406 0 20 $369.04 13.53 27.276 $0.00 $0.002 Surgery 28406 21 999 $0.00 0 0 $0.00 $387.492 Surgery 28415 0 20 $568.98 20.86 27.276 $0.00 $0.002 Surgery 28415 21 999 $893.28 31.19 28.64 $0.00 $0.00



8 Assistant Surgery 28420 0 999 $131.47 4.82 27.276 $0.00 $0.002 Surgery 28430 0 20 $136.65 5.01 27.276 $0.00 $0.002 Surgery 28430 21 999 $160.10 5.59 28.64 $0.00 $0.002 Surgery 28435 0 20 $204.57 7.5 27.276 $0.00 $0.002 Surgery 28435 21 999 $222.82 7.78 28.64 $0.00 $0.002 Surgery 28436 0 999 $266.76 9.78 27.276 $0.00 $0.002 Surgery 28445 0 999 $843.73 29.46 28.64 $0.00 $0.00

8 Assistant Surgery 28445 0 999 $128.47 4.71 27.276 $0.00 $0.002 Surgery 28450 0 999 $148.07 5.17 28.64 $0.00 $0.002 Surgery 28455 0 20 $166.93 6.12 27.276 $0.00 $0.002 Surgery 28455 21 999 $190.74 6.66 28.64 $0.00 $0.002 Surgery 28456 0 20 $144.84 5.31 27.276 $0.00 $0.002 Surgery 28456 21 999 $195.32 6.82 28.64 $0.00 $0.002 Surgery 28465 0 20 $370.41 13.58 27.276 $0.00 $0.002 Surgery 28465 21 999 $0.00 0 0 $0.00 $388.932 Surgery 28470 0 999 $146.35 5.11 28.64 $0.00 $0.002 Surgery 28475 0 20 $154.65 5.67 27.276 $0.00 $0.002 Surgery 28475 21 999 $188.74 6.59 28.64 $0.00 $0.002 Surgery 28476 0 20 $188.75 6.92 27.276 $0.00 $0.002 Surgery 28476 21 999 $239.43 8.36 28.64 $0.00 $0.002 Surgery 28485 0 20 $304.67 11.17 27.276 $0.00 $0.002 Surgery 28485 21 999 $320.77 11.2 28.64 $0.00 $0.00


8 Assistant Surgery 28485 21 999 $51.27 1.79 28.64 $0.00 $0.002 Surgery 28490 0 999 $84.49 2.95 28.64 $0.00 $0.002 Surgery 28495 0 20 $78.01 2.86 27.276 $0.00 $0.00



13 of 46

2 Surgery 28495 21 999 $106.25 3.71 28.64 $0.00 $0.002 Surgery 28496 0 20 $130.65 4.79 27.276 $0.00 $0.002 Surgery 28496 21 999 $162.10 5.66 28.64 $0.00 $0.002 Surgery 28505 0 999 $221.10 7.72 28.64 $0.00 $0.002 Surgery 28510 0 999 $82.48 2.88 28.64 $0.00 $0.002 Surgery 28515 0 999 $101.10 3.53 28.64 $0.00 $0.002 Surgery 28525 0 20 $155.75 5.71 27.276 $0.00 $0.002 Surgery 28525 21 999 $194.47 6.79 28.64 $0.00 $0.002 Surgery 28530 0 20 $60.28 2.21 27.276 $0.00 $0.002 Surgery 28530 21 999 $73.89 2.58 28.64 $0.00 $0.002 Surgery 28531 0 20 $118.38 4.34 27.276 $0.00 $0.002 Surgery 28531 21 999 $143.20 5 28.64 $0.00 $0.002 Surgery 28540 0 20 $73.65 2.7 27.276 $0.00 $0.002 Surgery 28540 21 999 $147.78 5.16 28.64 $0.00 $0.002 Surgery 28545 0 20 $104.19 3.82 27.276 $0.00 $0.002 Surgery 28545 21 999 $160.96 5.62 28.64 $0.00 $0.002 Surgery 28546 0 20 $174.57 6.4 27.276 $0.00 $0.002 Surgery 28546 21 999 $208.50 7.28 28.64 $0.00 $0.002 Surgery 28555 0 20 $348.86 12.79 27.276 $0.00 $0.002 Surgery 28555 21 999 $0.00 0 0 $0.00 $366.30


8 Assistant Surgery 28555 21 999 $0.00 0 0 $0.00 $58.612 Surgery 28570 0 20 $95.47 3.5 27.276 $0.00 $0.002 Surgery 28570 21 999 $112.84 3.94 28.64 $0.00 $0.002 Surgery 28575 0 20 $175.38 6.43 27.276 $0.00 $0.002 Surgery 28575 21 999 $218.52 7.63 28.64 $0.00 $0.002 Surgery 28576 0 999 $193.93 7.11 27.276 $0.00 $0.002 Surgery 28585 0 999 $555.04 19.38 28.64 $0.00 $0.00

8 Assistant Surgery 28585 0 999 $88.78 3.1 28.64 $0.00 $0.002 Surgery 28600 0 999 $132.03 4.61 28.64 $0.00 $0.002 Surgery 28605 0 20 $144.29 5.29 27.276 $0.00 $0.002 Surgery 28605 21 999 $181.86 6.35 28.64 $0.00 $0.002 Surgery 28606 0 999 $289.84 10.12 28.64 $0.00 $0.002 Surgery 28615 0 20 $312.58 11.46 27.276 $0.00 $0.002 Surgery 28615 21 999 $494.90 17.28 28.64 $0.00 $0.00


8 Assistant Surgery 28615 21 999 $79.05 2.76 28.64 $0.00 $0.002 Surgery 28630 0 20 $79.92 2.93 27.276 $0.00 $0.002 Surgery 28630 21 999 $0.00 0 0 $0.00 $83.922 Surgery 28635 0 20 $0.00 0 0 $0.00 $105.112 Surgery 28635 21 999 $100.10 3.67 27.276 $0.00 $0.002 Surgery 28636 0 20 $157.93 5.79 27.276 $0.00 $0.002 Surgery 28636 21 999 $0.00 0 0 $0.00 $165.832 Surgery 28645 0 20 $217.66 7.98 27.276 $0.00 $0.002 Surgery 28645 21 999 $231.12 8.07 28.64 $0.00 $0.00


8 Assistant Surgery 28645 21 999 $36.95 1.29 28.64 $0.00 $0.002 Surgery 28660 0 20 $53.73 1.97 27.276 $0.00 $0.002 Surgery 28660 21 999 $62.15 2.17 28.64 $0.00 $0.002 Surgery 28665 0 999 $84.56 3.1 27.276 $0.00 $0.00



14 of 46

2 Surgery 28666 0 20 $150.84 5.53 27.276 $0.00 $0.002 Surgery 28666 21 999 $0.00 0 0 $0.00 $158.382 Surgery 28675 0 20 $161.20 5.91 27.276 $0.00 $0.002 Surgery 28675 21 999 $180.43 6.3 28.64 $0.00 $0.002 Surgery 28705 0 20 $649.71 23.82 27.276 $0.00 $0.002 Surgery 28705 21 999 $975.48 34.06 28.64 $0.00 $0.00





















15 of 46





8 Assistant Surgery 28805 21 999 $90.50 3.16 28.64 $0.00 $0.002 Surgery 28810 0 999 $329.65 11.51 28.64 $0.00 $0.002 Surgery 28820 0 20 $189.84 6.96 27.276 $0.00 $0.002 Surgery 28820 21 999 $260.91 9.11 28.64 $0.00 $0.002 Surgery 28825 0 20 $170.48 6.25 27.276 $0.00 $0.002 Surgery 28825 21 999 $211.36 7.38 28.64 $0.00 $0.002 Surgery 28899 0 999 $0.00 0 0 $0.00 $0.00 5

8 Assistant Surgery 28899 0 999 $0.00 0 0 $0.00 $0.00 52 Surgery 29345 0 20 $73.92 2.71 27.276 $0.00 $0.002 Surgery 29345 21 999 $94.51 3.3 28.64 $0.00 $0.002 Surgery 29405 0 999 $63.01 2.2 28.64 $0.00 $0.002 Surgery 29425 0 20 $60.55 2.22 27.276 $0.00 $0.002 Surgery 29425 21 999 $68.74 2.4 28.64 $0.00 $0.002 Surgery 29440 0 20 $24.00 0.88 27.276 $0.00 $0.002 Surgery 29440 21 999 $36.37 1.27 28.64 $0.00 $0.002 Surgery 29445 0 20 $102.56 3.76 27.276 $0.00 $0.002 Surgery 29445 21 999 $0.00 0 0 $0.00 $107.692 Surgery 29450 0 20 $111.41 3.89 28.64 $0.00 $0.002 Surgery 29450 21 999 $41.46 1.52 27.276 $0.00 $0.002 Surgery 29515 0 999 $0.00 0 0 $0.00 $38.092 Surgery 29540 0 999 $32.08 1.12 28.64 $0.00 $0.002 Surgery 29550 0 999 $31.50 1.1 28.64 $0.00 $0.002 Surgery 29580 0 999 $38.38 1.34 28.64 $0.00 $0.002 Surgery 29590 0 20 $30.55 1.12 27.276 $0.00 $0.002 Surgery 29590 21 999 $41.81 1.46 28.64 $0.00 $0.002 Surgery 29700 0 999 $46.11 1.61 28.64 $0.00 $0.002 Surgery 29750 0 999 $52.92 1.94 27.276 $0.00 $0.002 Surgery 29799 0 999 $0.00 0 0 $0.00 $0.00 52 Surgery 29893 0 20 $296.76 10.88 27.276 $0.00 $0.002 Surgery 29893 21 999 $327.64 11.44 28.64 $0.00 $0.002 Surgery 29894 0 20 $420.87 15.43 27.276 $0.00 $0.002 Surgery 29894 21 999 $0.00 0 0 $0.00 $441.912 Surgery 29895 0 20 $517.43 18.97 27.276 $0.00 $0.002 Surgery 29895 21 999 $0.00 0 0 $0.00 $543.302 Surgery 29897 0 20 $562.16 20.61 27.276 $0.00 $0.002 Surgery 29897 21 999 $0.00 0 0 $0.00 $590.272 Surgery 29898 0 20 $645.62 23.67 27.276 $0.00 $0.002 Surgery 29898 21 999 $0.00 0 0 $0.00 $677.902 Surgery 29999 0 999 $0.00 0 0 $0.00 $0.00 5

FAmbulatory Surgical Center 50549 0 999 $0.00 0 0 $0.00 $0.00 5

FAmbulatory Surgical Center 50949 0 999 $0.00 0 0 $0.00 $0.00 5



16 of 46

2 Surgery 64450 0 999 $77.04 2.69 28.64 $0.00 $0.002 Surgery 64704 0 20 $303.58 11.13 27.276 $0.00 $0.002 Surgery 64704 21 999 $0.00 0 0 $0.00 $318.762 Surgery 64726 0 20 $136.65 5.01 27.276 $0.00 $0.002 Surgery 64726 21 999 $215.09 7.51 28.64 $0.00 $0.002 Surgery 64776 0 20 $231.03 8.47 27.276 $0.00 $0.002 Surgery 64776 21 999 $287.83 10.05 28.64 $0.00 $0.002 Surgery 64778 0 999 $180.02 6.6 27.276 $0.00 $0.002 Surgery 64782 0 20 $315.31 11.56 27.276 $0.00 $0.002 Surgery 64782 21 999 $336.81 11.76 28.64 $0.00 $0.002 Surgery 64783 0 999 $214.39 7.86 27.276 $0.00 $0.004 Radiology 73600 0 999 $21.00 0.77 27.276 $0.00 $0.00

IProfessional Component 73600 0 999 $6.55 0.24 27.276 $0.00 $0.00

TTechnical Component 73600 0 999 $14.46 0.53 27.276 $0.00 $0.00

4 Radiology 73610 0 999 $23.18 0.85 27.276 $0.00 $0.00



4 Radiology 73620 0 999 $21.00 0.77 27.276 $0.00 $0.00



4 Radiology 73630 0 999 $23.18 0.85 27.276 $0.00 $0.00



4 Radiology 73650 0 999 $20.46 0.75 27.276 $0.00 $0.00



4 Radiology 73660 0 999 $17.73 0.65 27.276 $0.00 $0.00



4 Radiology 76880 0 999 $67.10 2.46 27.276 $0.00 $0.00



4 Radiology 76999 0 999 $0.00 0 0 $0.00 $0.00 5

IProfessional Component 76999 0 999 $0.00 0 0 $0.00 $0.00 5

TTechnical Component 76999 0 999 $0.00 0 0 $0.00 $0.00 5

5 Laboratory 78267 0 999 $0.00 0 0 $0.00 $10.86 25 Laboratory 78268 0 999 $0.00 0 0 $0.00 $93.09 25 Laboratory 80048 0 999 $0.00 0 0 $0.00 $11.70 25 Laboratory 80050 0 999 $0.00 0 0 $0.00 $48.56 25 Laboratory 80051 0 999 $0.00 0 0 $0.00 $9.69 25 Laboratory 80053 0 999 $0.00 0 0 $0.00 $14.61 25 Laboratory 80055 0 999 $0.00 0 0 $0.00 $41.895 Laboratory 80061 0 999 $0.00 0 0 $0.00 $18.51 2



17 of 46

5 Laboratory 80069 0 999 $0.00 0 0 $0.00 $12.00 25 Laboratory 80074 0 999 $0.00 0 0 $0.00 $65.82 25 Laboratory 80076 0 999 $0.00 0 0 $0.00 $11.29 25 Laboratory 80100 0 999 $0.00 0 0 $0.00 $15.36 25 Laboratory 80101 0 999 $0.00 0 0 $0.00 $19.03 25 Laboratory 80102 0 999 $0.00 0 0 $0.00 $18.31 25 Laboratory 80150 0 999 $0.00 0 0 $0.00 $20.83 25 Laboratory 80152 0 999 $0.00 0 0 $0.00 $24.74 25 Laboratory 80154 0 999 $0.00 0 0 $0.00 $25.56 25 Laboratory 80156 0 999 $0.00 0 0 $0.00 $20.12 25 Laboratory 80157 0 999 $0.00 0 0 $0.00 $13.74 25 Laboratory 80158 0 999 $0.00 0 0 $0.00 $24.95 25 Laboratory 80160 0 999 $0.00 0 0 $0.00 $23.79 25 Laboratory 80162 0 999 $0.00 0 0 $0.00 $18.35 25 Laboratory 80164 0 999 $0.00 0 0 $0.00 $18.72 25 Laboratory 80166 0 999 $0.00 0 0 $0.00 $21.42 25 Laboratory 80168 0 999 $0.00 0 0 $0.00 $18.78 25 Laboratory 80170 0 999 $0.00 0 0 $0.00 $22.65 25 Laboratory 80172 0 999 $0.00 0 0 $0.00 $22.52 25 Laboratory 80173 0 999 $0.00 0 0 $0.00 $20.12 25 Laboratory 80174 0 999 $0.00 0 0 $0.00 $23.79 25 Laboratory 80176 0 999 $0.00 0 0 $0.00 $20.30 25 Laboratory 80178 0 999 $0.00 0 0 $0.00 $9.13 25 Laboratory 80182 0 999 $0.00 0 0 $0.00 $18.72 25 Laboratory 80184 0 999 $0.00 0 0 $0.00 $15.83 25 Laboratory 80185 0 999 $0.00 0 0 $0.00 $18.32 25 Laboratory 80186 0 999 $0.00 0 0 $0.00 $19.03 25 Laboratory 80188 0 999 $0.00 0 0 $0.00 $22.93 25 Laboratory 80190 0 999 $0.00 0 0 $0.00 $23.15 25 Laboratory 80192 0 999 $0.00 0 0 $0.00 $23.15 25 Laboratory 80194 0 999 $0.00 0 0 $0.00 $20.17 25 Laboratory 80196 0 999 $0.00 0 0 $0.00 $9.81 25 Laboratory 80197 0 999 $0.00 0 0 $0.00 $18.97 25 Laboratory 80198 0 999 $0.00 0 0 $0.00 $19.56 25 Laboratory 80200 0 999 $0.00 0 0 $0.00 $22.27 25 Laboratory 80201 0 999 $0.00 0 0 $0.00 $16.48 25 Laboratory 80202 0 999 $0.00 0 0 $0.00 $18.72 25 Laboratory 80299 0 999 $0.00 0 0 $0.00 $18.92 25 Laboratory 80400 0 999 $0.00 0 0 $0.00 $45.06 25 Laboratory 80402 0 999 $0.00 0 0 $0.00 $120.14 25 Laboratory 80406 0 999 $0.00 0 0 $0.00 $107.30 25 Laboratory 80408 0 999 $0.00 0 0 $0.00 $173.44 25 Laboratory 80410 0 999 $0.00 0 0 $0.00 $111.03 25 Laboratory 80412 0 999 $0.00 0 0 $0.00 $455.46 25 Laboratory 80414 0 999 $0.00 0 0 $0.00 $71.36 25 Laboratory 80415 0 999 $0.00 0 0 $0.00 $77.24 25 Laboratory 80416 0 999 $0.00 0 0 $0.00 $182.40 25 Laboratory 80417 0 999 $0.00 0 0 $0.00 $60.80 25 Laboratory 80418 0 999 $0.00 0 0 $0.00 $800.92 25 Laboratory 80420 0 999 $0.00 0 0 $0.00 $99.54 25 Laboratory 80422 0 999 $0.00 0 0 $0.00 $63.69 25 Laboratory 80424 0 999 $0.00 0 0 $0.00 $69.80 25 Laboratory 80426 0 999 $0.00 0 0 $0.00 $205.16 25 Laboratory 80428 0 999 $0.00 0 0 $0.00 $92.16 25 Laboratory 80430 0 999 $0.00 0 0 $0.00 $108.42 2



18 of 46




19 of 46




20 of 46

5 Laboratory 82553 0 999 $0.00 0 0 $0.00 $8.50 25 Laboratory 82554 0 999 $0.00 0 0 $0.00 $8.50 25 Laboratory 82565 0 999 $0.00 0 0 $0.00 $7.07 25 Laboratory 82570 0 999 $0.00 0 0 $0.00 $7.15 25 Laboratory 82575 0 999 $0.00 0 0 $0.00 $13.06 25 Laboratory 82585 0 999 $0.00 0 0 $0.00 $11.85 25 Laboratory 82595 0 999 $0.00 0 0 $0.00 $8.95 25 Laboratory 82600 0 999 $0.00 0 0 $0.00 $26.81 25 Laboratory 82607 0 999 $0.00 0 0 $0.00 $20.83 25 Laboratory 82608 0 999 $0.00 0 0 $0.00 $19.80 25 Laboratory 82615 0 999 $0.00 0 0 $0.00 $11.29 25 Laboratory 82626 0 999 $0.00 0 0 $0.00 $34.93 25 Laboratory 82627 0 999 $0.00 0 0 $0.00 $30.72 25 Laboratory 82633 0 999 $0.00 0 0 $0.00 $28.66 25 Laboratory 82634 0 999 $0.00 0 0 $0.00 $28.66 25 Laboratory 82638 0 999 $0.00 0 0 $0.00 $16.92 25 Laboratory 82646 0 999 $0.00 0 0 $0.00 $28.54 25 Laboratory 82649 0 999 $0.00 0 0 $0.00 $35.52 25 Laboratory 82651 0 999 $0.00 0 0 $0.00 $35.68 25 Laboratory 82652 0 999 $0.00 0 0 $0.00 $53.19 25 Laboratory 82654 0 999 $0.00 0 0 $0.00 $19.14 25 Laboratory 82658 0 999 $0.00 0 0 $0.00 $24.96 25 Laboratory 82664 0 999 $0.00 0 0 $0.00 $36.14 25 Laboratory 82666 0 999 $0.00 0 0 $0.00 $27.26 25 Laboratory 82668 0 999 $0.00 0 0 $0.00 $25.97 25 Laboratory 82670 0 999 $0.00 0 0 $0.00 $38.62 25 Laboratory 82671 0 999 $0.00 0 0 $0.00 $44.64 25 Laboratory 82672 0 999 $0.00 0 0 $0.00 $12.09 25 Laboratory 82679 0 999 $0.00 0 0 $0.00 $34.50 25 Laboratory 82690 0 999 $0.00 0 0 $0.00 $23.89 25 Laboratory 82693 0 999 $0.00 0 0 $0.00 $20.59 25 Laboratory 82696 0 999 $0.00 0 0 $0.00 $32.60 25 Laboratory 82705 0 999 $0.00 0 0 $0.00 $7.04 25 Laboratory 82710 0 999 $0.00 0 0 $0.00 $23.21 25 Laboratory 82715 0 999 $0.00 0 0 $0.00 $23.53 25 Laboratory 82725 0 999 $0.00 0 0 $0.00 $18.40 25 Laboratory 82728 0 999 $0.00 0 0 $0.00 $18.83 25 Laboratory 82731 0 999 $0.00 0 0 $0.00 $89.995 Laboratory 82735 0 999 $0.00 0 0 $0.00 $25.63 25 Laboratory 82742 0 999 $0.00 0 0 $0.00 $27.36 25 Laboratory 82746 0 999 $0.00 0 0 $0.00 $20.32 25 Laboratory 82747 0 999 $0.00 0 0 $0.00 $23.89 25 Laboratory 82757 0 999 $0.00 0 0 $0.00 $23.97 25 Laboratory 82759 0 999 $0.00 0 0 $0.00 $12.47 25 Laboratory 82760 0 999 $0.00 0 0 $0.00 $15.47 25 Laboratory 82775 0 999 $0.00 0 0 $0.00 $29.11 25 Laboratory 82776 0 999 $0.00 0 0 $0.00 $11.32 25 Laboratory 82784 0 999 $0.00 0 0 $0.00 $12.85 25 Laboratory 82785 0 999 $0.00 0 0 $0.00 $22.76 25 Laboratory 82787 0 999 $0.00 0 0 $0.00 $5.79 25 Laboratory 82800 0 999 $0.00 0 0 $0.00 $11.71 25 Laboratory 82803 0 999 $0.00 0 0 $0.00 $26.74 25 Laboratory 82805 0 999 $0.00 0 0 $0.00 $39.21 25 Laboratory 82810 0 999 $0.00 0 0 $0.00 $12.06 25 Laboratory 82820 0 999 $0.00 0 0 $0.00 $13.82 2



21 of 46




22 of 46




23 of 46

5 Laboratory 83904 0 999 $0.00 0 0 $0.00 $14.07 25 Laboratory 83905 0 999 $0.00 0 0 $0.00 $14.07 25 Laboratory 83906 0 999 $0.00 0 0 $0.00 $14.07 25 Laboratory 83912 0 999 $0.00 0 0 $0.00 $5.54 25 Laboratory 83915 0 999 $0.00 0 0 $0.00 $15.41 25 Laboratory 83916 0 999 $0.00 0 0 $0.00 $27.79 25 Laboratory 83918 0 999 $0.00 0 0 $0.00 $22.75 25 Laboratory 83925 0 999 $0.00 0 0 $0.00 $26.89 25 Laboratory 83930 0 999 $0.00 0 0 $0.00 $6.81 25 Laboratory 83935 0 999 $0.00 0 0 $0.00 $6.81 25 Laboratory 83937 0 999 $0.00 0 0 $0.00 $39.35 25 Laboratory 83945 0 999 $0.00 0 0 $0.00 $17.80 25 Laboratory 83950 0 999 $0.00 0 0 $0.00 $89.01 25 Laboratory 83970 0 999 $0.00 0 0 $0.00 $57.04 25 Laboratory 83986 0 999 $0.00 0 0 $0.00 $4.95 25 Laboratory 83992 0 999 $0.00 0 0 $0.00 $20.31 25 Laboratory 84022 0 999 $0.00 0 0 $0.00 $15.70 25 Laboratory 84030 0 999 $0.00 0 0 $0.00 $7.61 25 Laboratory 84035 0 999 $0.00 0 0 $0.00 $2.81 25 Laboratory 84060 0 999 $0.00 0 0 $0.00 $10.20 25 Laboratory 84066 0 999 $0.00 0 0 $0.00 $13.35 25 Laboratory 84075 0 999 $0.00 0 0 $0.00 $7.15 25 Laboratory 84078 0 999 $0.00 0 0 $0.00 $10.09 25 Laboratory 84080 0 999 $0.00 0 0 $0.00 $12.09 25 Laboratory 84081 0 999 $0.00 0 0 $0.00 $22.84 25 Laboratory 84085 0 999 $0.00 0 0 $0.00 $9.32 25 Laboratory 84087 0 999 $0.00 0 0 $0.00 $14.27 25 Laboratory 84100 0 999 $0.00 0 0 $0.00 $6.56 25 Laboratory 84105 0 999 $0.00 0 0 $0.00 $7.15 25 Laboratory 84106 0 999 $0.00 0 0 $0.00 $5.92 25 Laboratory 84110 0 999 $0.00 0 0 $0.00 $11.68 25 Laboratory 84119 0 999 $0.00 0 0 $0.00 $11.90 25 Laboratory 84120 0 999 $0.00 0 0 $0.00 $20.33 25 Laboratory 84126 0 999 $0.00 0 0 $0.00 $35.20 25 Laboratory 84127 0 999 $0.00 0 0 $0.00 $16.10 25 Laboratory 84132 0 999 $0.00 0 0 $0.00 $6.35 25 Laboratory 84133 0 999 $0.00 0 0 $0.00 $5.94 25 Laboratory 84134 0 999 $0.00 0 0 $0.00 $11.66 25 Laboratory 84135 0 999 $0.00 0 0 $0.00 $26.44 25 Laboratory 84138 0 999 $0.00 0 0 $0.00 $24.11 25 Laboratory 84140 0 999 $0.00 0 0 $0.00 $28.58 25 Laboratory 84143 0 999 $0.00 0 0 $0.00 $31.12 25 Laboratory 84144 0 999 $0.00 0 0 $0.00 $28.83 25 Laboratory 84146 0 999 $0.00 0 0 $0.00 $26.78 25 Laboratory 84150 0 999 $0.00 0 0 $0.00 $34.50 25 Laboratory 84152 0 999 $0.00 0 0 $0.00 $25.42 25 Laboratory 84153 0 999 $0.00 0 0 $0.00 $25.42 25 Laboratory 84154 0 999 $0.00 0 0 $0.00 $25.42 25 Laboratory 84155 0 999 $0.00 0 0 $0.00 $5.06 25 Laboratory 84156 0 999 $0.00 0 0 $0.00 $5.065 Laboratory 84157 0 999 $0.00 0 0 $0.00 $5.065 Laboratory 84160 0 999 $0.00 0 0 $0.00 $7.15 25 Laboratory 84163 0 999 $0.00 0 0 $0.00 $12.20 25 Laboratory 84165 0 999 $0.00 0 0 $0.00 $14.84 25 Laboratory 84181 0 999 $0.00 0 0 $0.00 $23.54 2



24 of 46




25 of 46

5 Laboratory 84578 0 999 $0.00 0 0 $0.00 $4.48 25 Laboratory 84580 0 999 $0.00 0 0 $0.00 $7.97 25 Laboratory 84583 0 999 $0.00 0 0 $0.00 $6.95 25 Laboratory 84585 0 999 $0.00 0 0 $0.00 $21.42 25 Laboratory 84586 0 999 $0.00 0 0 $0.00 $19.28 25 Laboratory 84588 0 999 $0.00 0 0 $0.00 $46.91 25 Laboratory 84590 0 999 $0.00 0 0 $0.00 $16.02 25 Laboratory 84591 0 999 $0.00 0 0 $0.00 $16.02 25 Laboratory 84597 0 999 $0.00 0 0 $0.00 $9.39 25 Laboratory 84600 0 999 $0.00 0 0 $0.00 $22.21 25 Laboratory 84620 0 999 $0.00 0 0 $0.00 $16.37 25 Laboratory 84630 0 999 $0.00 0 0 $0.00 $15.74 25 Laboratory 84681 0 999 $0.00 0 0 $0.00 $28.75 25 Laboratory 84703 0 999 $0.00 0 0 $0.00 $10.38 25 Laboratory 85002 0 999 $0.00 0 0 $0.00 $6.22 25 Laboratory 85007 0 999 $0.00 0 0 $0.00 $4.76 25 Laboratory 85008 0 999 $0.00 0 0 $0.00 $4.76 25 Laboratory 85009 0 999 $0.00 0 0 $0.00 $5.14 25 Laboratory 85013 0 999 $0.00 0 0 $0.00 $3.27 25 Laboratory 85014 0 999 $0.00 0 0 $0.00 $3.27 25 Laboratory 85025 0 999 $0.00 0 0 $0.00 $10.74 25 Laboratory 85027 0 999 $0.00 0 0 $0.00 $8.95 25 Laboratory 85041 0 999 $0.00 0 0 $0.00 $4.16 25 Laboratory 85044 0 999 $0.00 0 0 $0.00 $5.94 25 Laboratory 85045 0 999 $0.00 0 0 $0.00 $5.54 25 Laboratory 85046 0 999 $0.00 0 0 $0.00 $7.72 25 Laboratory 85048 0 999 $0.00 0 0 $0.00 $3.52 25 Laboratory 85055 0 999 $0.00 0 0 $0.00 $37.005 Laboratory 85097 0 999 $42.01 1.54 27.276 $0.00 $0.005 Laboratory 85130 0 999 $0.00 0 0 $0.00 $16.44 25 Laboratory 85170 0 999 $0.00 0 0 $0.00 $5.00 25 Laboratory 85175 0 999 $0.00 0 0 $0.00 $6.28 25 Laboratory 85210 0 999 $0.00 0 0 $0.00 $17.95 25 Laboratory 85220 0 999 $0.00 0 0 $0.00 $24.39 25 Laboratory 85230 0 999 $0.00 0 0 $0.00 $24.75 25 Laboratory 85240 0 999 $0.00 0 0 $0.00 $8.87 25 Laboratory 85244 0 999 $0.00 0 0 $0.00 $28.22 25 Laboratory 85245 0 999 $0.00 0 0 $0.00 $11.32 25 Laboratory 85246 0 999 $0.00 0 0 $0.00 $11.32 25 Laboratory 85247 0 999 $0.00 0 0 $0.00 $11.32 25 Laboratory 85250 0 999 $0.00 0 0 $0.00 $26.31 25 Laboratory 85260 0 999 $0.00 0 0 $0.00 $24.75 25 Laboratory 85270 0 999 $0.00 0 0 $0.00 $24.75 25 Laboratory 85280 0 999 $0.00 0 0 $0.00 $26.74 25 Laboratory 85290 0 999 $0.00 0 0 $0.00 $22.58 25 Laboratory 85291 0 999 $0.00 0 0 $0.00 $12.28 25 Laboratory 85292 0 999 $0.00 0 0 $0.00 $26.17 25 Laboratory 85293 0 999 $0.00 0 0 $0.00 $26.17 25 Laboratory 85300 0 999 $0.00 0 0 $0.00 $16.38 25 Laboratory 85301 0 999 $0.00 0 0 $0.00 $14.95 25 Laboratory 85302 0 999 $0.00 0 0 $0.00 $16.61 25 Laboratory 85303 0 999 $0.00 0 0 $0.00 $19.11 25 Laboratory 85305 0 999 $0.00 0 0 $0.00 $16.02 25 Laboratory 85306 0 999 $0.00 0 0 $0.00 $19.07 25 Laboratory 85307 0 999 $0.00 0 0 $0.00 $19.07 2



26 of 46

5 Laboratory 85335 0 999 $0.00 0 0 $0.00 $17.80 25 Laboratory 85337 0 999 $0.00 0 0 $0.00 $14.41 25 Laboratory 85345 0 999 $0.00 0 0 $0.00 $5.94 25 Laboratory 85347 0 999 $0.00 0 0 $0.00 $5.88 25 Laboratory 85348 0 999 $0.00 0 0 $0.00 $5.14 25 Laboratory 85360 0 999 $0.00 0 0 $0.00 $11.61 25 Laboratory 85362 0 999 $0.00 0 0 $0.00 $9.52 25 Laboratory 85366 0 999 $0.00 0 0 $0.00 $11.32 25 Laboratory 85370 0 999 $0.00 0 0 $0.00 $12.86 25 Laboratory 85378 0 999 $0.00 0 0 $0.00 $9.86 25 Laboratory 85379 0 999 $0.00 0 0 $0.00 $12.86 25 Laboratory 85384 0 999 $0.00 0 0 $0.00 $11.74 25 Laboratory 85385 0 999 $0.00 0 0 $0.00 $11.74 25 Laboratory 85390 0 999 $0.00 0 0 $0.00 $7.13 25 Laboratory 85396 0 999 $0.00 0 0 $0.00 $7.135 Laboratory 85400 0 999 $0.00 0 0 $0.00 $12.22 25 Laboratory 85410 0 999 $0.00 0 0 $0.00 $10.66 25 Laboratory 85415 0 999 $0.00 0 0 $0.00 $23.76 25 Laboratory 85420 0 999 $0.00 0 0 $0.00 $9.04 25 Laboratory 85421 0 999 $0.00 0 0 $0.00 $11.32 25 Laboratory 85441 0 999 $0.00 0 0 $0.00 $5.81 25 Laboratory 85445 0 999 $0.00 0 0 $0.00 $9.42 25 Laboratory 85460 0 999 $0.00 0 0 $0.00 $10.69 25 Laboratory 85461 0 999 $0.00 0 0 $0.00 $9.17 25 Laboratory 85475 0 999 $0.00 0 0 $0.00 $12.26 25 Laboratory 85520 0 999 $0.00 0 0 $0.00 $18.09 25 Laboratory 85525 0 999 $0.00 0 0 $0.00 $16.38 25 Laboratory 85530 0 999 $0.00 0 0 $0.00 $18.78 25 Laboratory 85536 0 999 $0.00 0 0 $0.00 $8.95 25 Laboratory 85540 0 999 $0.00 0 0 $0.00 $11.88 25 Laboratory 85547 0 999 $0.00 0 0 $0.00 $11.88 25 Laboratory 85549 0 999 $0.00 0 0 $0.00 $25.92 25 Laboratory 85555 0 999 $0.00 0 0 $0.00 $9.24 25 Laboratory 85557 0 999 $0.00 0 0 $0.00 $12.09 25 Laboratory 85576 0 999 $0.00 0 0 $0.00 $29.69 25 Laboratory 85597 0 999 $0.00 0 0 $0.00 $20.06 25 Laboratory 85610 0 999 $0.00 0 0 $0.00 $5.43 25 Laboratory 85611 0 999 $0.00 0 0 $0.00 $5.45 25 Laboratory 85612 0 999 $0.00 0 0 $0.00 $9.66 25 Laboratory 85613 0 999 $0.00 0 0 $0.00 $9.66 25 Laboratory 85635 0 999 $0.00 0 0 $0.00 $13.61 25 Laboratory 85651 0 999 $0.00 0 0 $0.00 $4.91 25 Laboratory 85652 0 999 $0.00 0 0 $0.00 $3.73 25 Laboratory 85660 0 999 $0.00 0 0 $0.00 $7.63 25 Laboratory 85670 0 999 $0.00 0 0 $0.00 $7.98 25 Laboratory 85675 0 999 $0.00 0 0 $0.00 $8.87 25 Laboratory 85705 0 999 $0.00 0 0 $0.00 $11.75 25 Laboratory 85730 0 999 $0.00 0 0 $0.00 $8.30 25 Laboratory 85732 0 999 $0.00 0 0 $0.00 $8.95 25 Laboratory 85810 0 999 $0.00 0 0 $0.00 $16.14 25 Laboratory 86000 0 999 $0.00 0 0 $0.00 $9.65 25 Laboratory 86001 0 999 $0.00 0 0 $0.00 $6.61 25 Laboratory 86003 0 999 $0.00 0 0 $0.00 $6.61 25 Laboratory 86005 0 999 $0.00 0 0 $0.00 $11.02 25 Laboratory 86021 0 999 $0.00 0 0 $0.00 $20.80 2



27 of 46

5 Laboratory 86022 0 999 $0.00 0 0 $0.00 $13.52 25 Laboratory 86023 0 999 $0.00 0 0 $0.00 $7.97 25 Laboratory 86038 0 999 $0.00 0 0 $0.00 $16.70 25 Laboratory 86039 0 999 $0.00 0 0 $0.00 $15.43 25 Laboratory 86060 0 999 $0.00 0 0 $0.00 $10.09 25 Laboratory 86063 0 999 $0.00 0 0 $0.00 $7.98 25 Laboratory 86077 0 999 $19.37 0.71 27.276 $0.00 $0.005 Laboratory 86078 0 999 $37.10 1.36 27.276 $0.00 $0.005 Laboratory 86079 0 999 $20.18 0.74 27.276 $0.00 $0.005 Laboratory 86140 0 999 $0.00 0 0 $0.00 $7.15 25 Laboratory 86141 0 999 $0.00 0 0 $0.00 $17.89 25 Laboratory 86146 0 999 $0.00 0 0 $0.00 $10.86 25 Laboratory 86147 0 999 $0.00 0 0 $0.00 $10.86 25 Laboratory 86148 0 999 $0.00 0 0 $0.00 $10.86 25 Laboratory 86155 0 999 $0.00 0 0 $0.00 $22.08 25 Laboratory 86156 0 999 $0.00 0 0 $0.00 $9.26 25 Laboratory 86157 0 999 $0.00 0 0 $0.00 $11.14 25 Laboratory 86160 0 999 $0.00 0 0 $0.00 $16.59 25 Laboratory 86161 0 999 $0.00 0 0 $0.00 $16.59 25 Laboratory 86162 0 999 $0.00 0 0 $0.00 $25.96 25 Laboratory 86171 0 999 $0.00 0 0 $0.00 $8.87 25 Laboratory 86185 0 999 $0.00 0 0 $0.00 $12.37 25 Laboratory 86215 0 999 $0.00 0 0 $0.00 $18.32 25 Laboratory 86225 0 999 $0.00 0 0 $0.00 $18.99 25 Laboratory 86226 0 999 $0.00 0 0 $0.00 $16.73 25 Laboratory 86235 0 999 $0.00 0 0 $0.00 $24.78 25 Laboratory 86243 0 999 $0.00 0 0 $0.00 $28.36 25 Laboratory 86255 0 999 $0.00 0 0 $0.00 $16.66 25 Laboratory 86256 0 999 $0.00 0 0 $0.00 $16.66 25 Laboratory 86277 0 999 $0.00 0 0 $0.00 $21.75 25 Laboratory 86280 0 999 $0.00 0 0 $0.00 $11.31 25 Laboratory 86294 0 999 $0.00 0 0 $0.00 $27.11 25 Laboratory 86300 0 999 $0.00 0 0 $0.00 $28.76 25 Laboratory 86301 0 999 $0.00 0 0 $0.00 $28.76 25 Laboratory 86304 0 999 $0.00 0 0 $0.00 $28.76 25 Laboratory 86308 0 999 $0.00 0 0 $0.00 $7.15 25 Laboratory 86309 0 999 $0.00 0 0 $0.00 $8.95 25 Laboratory 86310 0 999 $0.00 0 0 $0.00 $10.19 25 Laboratory 86316 0 999 $0.00 0 0 $0.00 $28.76 25 Laboratory 86317 0 999 $0.00 0 0 $0.00 $20.72 25 Laboratory 86318 0 999 $0.00 0 0 $0.00 $17.89 25 Laboratory 86320 0 999 $0.00 0 0 $0.00 $30.98 25 Laboratory 86325 0 999 $0.00 0 0 $0.00 $30.90 25 Laboratory 86327 0 999 $0.00 0 0 $0.00 $31.35 25 Laboratory 86329 0 999 $0.00 0 0 $0.00 $12.73 25 Laboratory 86331 0 999 $0.00 0 0 $0.00 $16.56 25 Laboratory 86332 0 999 $0.00 0 0 $0.00 $33.68 25 Laboratory 86334 0 999 $0.00 0 0 $0.00 $30.87 25 Laboratory 86337 0 999 $0.00 0 0 $0.00 $23.91 25 Laboratory 86340 0 999 $0.00 0 0 $0.00 $20.83 25 Laboratory 86341 0 999 $0.00 0 0 $0.00 $23.91 25 Laboratory 86343 0 999 $0.00 0 0 $0.00 $17.22 25 Laboratory 86344 0 999 $0.00 0 0 $0.00 $11.04 25 Laboratory 86353 0 999 $0.00 0 0 $0.00 $67.75 25 Laboratory 86359 0 999 $0.00 0 0 $0.00 $52.13 2



28 of 46

5 Laboratory 86360 0 999 $0.00 0 0 $0.00 $64.93 25 Laboratory 86361 0 999 $0.00 0 0 $0.00 $37.00 25 Laboratory 86376 0 999 $0.00 0 0 $0.00 $20.11 25 Laboratory 86378 0 999 $0.00 0 0 $0.00 $27.22 25 Laboratory 86382 0 999 $0.00 0 0 $0.00 $23.36 25 Laboratory 86384 0 999 $0.00 0 0 $0.00 $15.91 25 Laboratory 86403 0 999 $0.00 0 0 $0.00 $14.08 25 Laboratory 86406 0 999 $0.00 0 0 $0.00 $12.41 25 Laboratory 86430 0 999 $0.00 0 0 $0.00 $7.85 25 Laboratory 86431 0 999 $0.00 0 0 $0.00 $7.85 25 Laboratory 86485 0 999 $0.00 0 0 $0.00 $5.00 25 Laboratory 86490 0 999 $8.46 0.31 27.276 $0.00 $0.005 Laboratory 86510 0 999 $9.00 0.33 27.276 $0.00 $0.005 Laboratory 86580 0 999 $7.36 0.27 27.276 $0.00 $0.005 Laboratory 86586 0 999 $0.00 0 0 $0.00 $52.70 25 Laboratory 86590 0 999 $0.00 0 0 $0.00 $15.24 25 Laboratory 86592 0 999 $0.00 0 0 $0.00 $5.90 25 Laboratory 86593 0 999 $0.00 0 0 $0.00 $6.09 25 Laboratory 86602 0 999 $0.00 0 0 $0.00 $11.31 25 Laboratory 86603 0 999 $0.00 0 0 $0.00 $11.31 25 Laboratory 86606 0 999 $0.00 0 0 $0.00 $11.31 25 Laboratory 86609 0 999 $0.00 0 0 $0.00 $11.31 25 Laboratory 86611 0 999 $0.00 0 0 $0.00 $11.31 25 Laboratory 86612 0 999 $0.00 0 0 $0.00 $11.31 25 Laboratory 86615 0 999 $0.00 0 0 $0.00 $18.23 25 Laboratory 86617 0 999 $0.00 0 0 $0.00 $21.40 25 Laboratory 86618 0 999 $0.00 0 0 $0.00 $23.54 25 Laboratory 86619 0 999 $0.00 0 0 $0.00 $18.49 25 Laboratory 86622 0 999 $0.00 0 0 $0.00 $11.31 25 Laboratory 86625 0 999 $0.00 0 0 $0.00 $11.31 25 Laboratory 86628 0 999 $0.00 0 0 $0.00 $11.31 25 Laboratory 86631 0 999 $0.00 0 0 $0.00 $11.31 25 Laboratory 86632 0 999 $0.00 0 0 $0.00 $11.31 25 Laboratory 86635 0 999 $0.00 0 0 $0.00 $11.31 25 Laboratory 86638 0 999 $0.00 0 0 $0.00 $11.31 25 Laboratory 86641 0 999 $0.00 0 0 $0.00 $11.31 25 Laboratory 86644 0 999 $0.00 0 0 $0.00 $19.89 25 Laboratory 86645 0 999 $0.00 0 0 $0.00 $11.31 25 Laboratory 86648 0 999 $0.00 0 0 $0.00 $11.31 25 Laboratory 86651 0 999 $0.00 0 0 $0.00 $11.31 25 Laboratory 86652 0 999 $0.00 0 0 $0.00 $11.31 25 Laboratory 86653 0 999 $0.00 0 0 $0.00 $11.31 25 Laboratory 86654 0 999 $0.00 0 0 $0.00 $11.31 25 Laboratory 86658 0 999 $0.00 0 0 $0.00 $11.31 25 Laboratory 86663 0 999 $0.00 0 0 $0.00 $18.13 25 Laboratory 86664 0 999 $0.00 0 0 $0.00 $21.14 25 Laboratory 86665 0 999 $0.00 0 0 $0.00 $25.07 25 Laboratory 86666 0 999 $0.00 0 0 $0.00 $11.31 25 Laboratory 86668 0 999 $0.00 0 0 $0.00 $14.38 25 Laboratory 86671 0 999 $0.00 0 0 $0.00 $11.31 25 Laboratory 86674 0 999 $0.00 0 0 $0.00 $20.34 25 Laboratory 86682 0 999 $0.00 0 0 $0.00 $11.31 25 Laboratory 86684 0 999 $0.00 0 0 $0.00 $21.90 25 Laboratory 86687 0 999 $0.00 0 0 $0.00 $11.60 25 Laboratory 86688 0 999 $0.00 0 0 $0.00 $13.79 2



29 of 46




30 of 46

5 Laboratory 86817 0 999 $0.00 0 0 $0.00 $71.74 25 Laboratory 86821 0 999 $0.00 0 0 $0.00 $71.74 25 Laboratory 86822 0 999 $0.00 0 0 $0.00 $50.52 25 Laboratory 86850 0 999 $0.00 0 0 $0.00 $16.185 Laboratory 86860 0 999 $0.00 0 0 $0.00 $13.935 Laboratory 86870 0 999 $0.00 0 0 $0.00 $16.175 Laboratory 86880 0 999 $0.00 0 0 $0.00 $7.42 25 Laboratory 86885 0 999 $0.00 0 0 $0.00 $7.90 25 Laboratory 86886 0 999 $0.00 0 0 $0.00 $7.15 25 Laboratory 86900 0 999 $0.00 0 0 $0.00 $4.12 25 Laboratory 86901 0 999 $0.00 0 0 $0.00 $9.275 Laboratory 86903 0 999 $0.00 0 0 $0.00 $13.05 25 Laboratory 86904 0 999 $0.00 0 0 $0.00 $13.14 25 Laboratory 86905 0 999 $0.00 0 0 $0.00 $5.28 25 Laboratory 86906 0 999 $0.00 0 0 $0.00 $10.71 25 Laboratory 86920 0 999 $0.00 0 0 $0.00 $13.395 Laboratory 86921 0 999 $0.00 0 0 $0.00 $32.155 Laboratory 86922 0 999 $0.00 0 0 $0.00 $32.405 Laboratory 86940 0 999 $0.00 0 0 $0.00 $11.33 25 Laboratory 86941 0 999 $0.00 0 0 $0.00 $16.73 25 Laboratory 86950 0 999 $0.00 0 0 $0.00 $0.00 55 Laboratory 86999 0 999 $0.00 0 0 $0.00 $0.00 55 Laboratory 87001 0 999 $0.00 0 0 $0.00 $18.27 25 Laboratory 87003 0 999 $0.00 0 0 $0.00 $20.06 25 Laboratory 87015 0 999 $0.00 0 0 $0.00 $9.23 25 Laboratory 87040 0 999 $0.00 0 0 $0.00 $14.27 25 Laboratory 87045 0 999 $0.00 0 0 $0.00 $13.04 25 Laboratory 87046 0 999 $0.00 0 0 $0.00 $3.26 25 Laboratory 87070 0 999 $0.00 0 0 $0.00 $11.90 25 Laboratory 87071 0 999 $0.00 0 0 $0.00 $6.52 25 Laboratory 87073 0 999 $0.00 0 0 $0.00 $6.52 25 Laboratory 87075 0 999 $0.00 0 0 $0.00 $13.08 25 Laboratory 87076 0 999 $0.00 0 0 $0.00 $11.16 25 Laboratory 87077 0 999 $0.00 0 0 $0.00 $11.16 25 Laboratory 87081 0 999 $0.00 0 0 $0.00 $9.16 25 Laboratory 87084 0 999 $0.00 0 0 $0.00 $11.90 25 Laboratory 87086 0 999 $0.00 0 0 $0.00 $11.16 25 Laboratory 87088 0 999 $0.00 0 0 $0.00 $11.18 25 Laboratory 87101 0 999 $0.00 0 0 $0.00 $10.66 25 Laboratory 87102 0 999 $0.00 0 0 $0.00 $11.61 25 Laboratory 87103 0 999 $0.00 0 0 $0.00 $12.46 25 Laboratory 87106 0 999 $0.00 0 0 $0.00 $14.27 25 Laboratory 87107 0 999 $0.00 0 0 $0.00 $14.27 25 Laboratory 87109 0 999 $0.00 0 0 $0.00 $14.40 25 Laboratory 87110 0 999 $0.00 0 0 $0.00 $27.08 25 Laboratory 87116 0 999 $0.00 0 0 $0.00 $14.93 25 Laboratory 87118 0 999 $0.00 0 0 $0.00 $15.13 25 Laboratory 87140 0 999 $0.00 0 0 $0.00 $7.71 25 Laboratory 87143 0 999 $0.00 0 0 $0.00 $17.32 25 Laboratory 87147 0 999 $0.00 0 0 $0.00 $7.15 25 Laboratory 87149 0 999 $0.00 0 0 $0.00 $27.71 25 Laboratory 87152 0 999 $0.00 0 0 $0.00 $7.23 25 Laboratory 87158 0 999 $0.00 0 0 $0.00 $7.23 25 Laboratory 87164 0 999 $0.00 0 0 $0.00 $14.84 25 Laboratory 87166 0 999 $0.00 0 0 $0.00 $15.61 2



31 of 46

5 Laboratory 87168 0 999 $0.00 0 0 $0.00 $5.90 25 Laboratory 87169 0 999 $0.00 0 0 $0.00 $5.90 25 Laboratory 87172 0 999 $0.00 0 0 $0.00 $5.90 25 Laboratory 87176 0 999 $0.00 0 0 $0.00 $8.13 25 Laboratory 87177 0 999 $0.00 0 0 $0.00 $12.09 25 Laboratory 87181 0 999 $0.00 0 0 $0.00 $6.56 25 Laboratory 87184 0 999 $0.00 0 0 $0.00 $9.53 25 Laboratory 87185 0 999 $0.00 0 0 $0.00 $6.56 25 Laboratory 87186 0 999 $0.00 0 0 $0.00 $11.94 25 Laboratory 87187 0 999 $0.00 0 0 $0.00 $14.33 25 Laboratory 87188 0 999 $0.00 0 0 $0.00 $9.17 25 Laboratory 87190 0 999 $0.00 0 0 $0.00 $7.81 25 Laboratory 87197 0 999 $0.00 0 0 $0.00 $20.76 25 Laboratory 87205 0 999 $0.00 0 0 $0.00 $5.90 25 Laboratory 87206 0 999 $0.00 0 0 $0.00 $7.42 25 Laboratory 87207 0 999 $0.00 0 0 $0.00 $8.28 25 Laboratory 87210 0 999 $0.00 0 0 $0.00 $5.90 25 Laboratory 87220 0 999 $0.00 0 0 $0.00 $5.90 25 Laboratory 87230 0 999 $0.00 0 0 $0.00 $27.28 25 Laboratory 87250 0 999 $0.00 0 0 $0.00 $27.02 25 Laboratory 87252 0 999 $0.00 0 0 $0.00 $36.02 25 Laboratory 87253 0 999 $0.00 0 0 $0.00 $23.47 25 Laboratory 87254 0 999 $0.00 0 0 $0.00 $6.76 25 Laboratory 87260 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87265 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87269 0 999 $0.00 0 0 $0.00 $16.585 Laboratory 87270 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87272 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87273 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87274 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87275 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87276 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87277 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87278 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87279 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87280 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87281 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87283 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87285 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87290 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87299 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87300 0 999 $0.00 0 0 $0.00 $8.29 25 Laboratory 87301 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87320 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87324 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87327 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87328 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87329 0 999 $0.00 0 0 $0.00 $16.585 Laboratory 87332 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87335 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87336 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87337 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87340 0 999 $0.00 0 0 $0.00 $14.27 25 Laboratory 87341 0 999 $0.00 0 0 $0.00 $14.27 25 Laboratory 87350 0 999 $0.00 0 0 $0.00 $15.92 2



32 of 46




33 of 46

5 Laboratory 87550 0 999 $0.00 0 0 $0.00 $27.71 25 Laboratory 87551 0 999 $0.00 0 0 $0.00 $48.50 25 Laboratory 87552 0 999 $0.00 0 0 $0.00 $39.22 25 Laboratory 87555 0 999 $0.00 0 0 $0.00 $27.71 25 Laboratory 87556 0 999 $0.00 0 0 $0.00 $48.50 25 Laboratory 87557 0 999 $0.00 0 0 $0.00 $39.22 25 Laboratory 87560 0 999 $0.00 0 0 $0.00 $27.71 25 Laboratory 87561 0 999 $0.00 0 0 $0.00 $48.50 25 Laboratory 87562 0 999 $0.00 0 0 $0.00 $39.22 25 Laboratory 87580 0 999 $0.00 0 0 $0.00 $27.71 25 Laboratory 87581 0 999 $0.00 0 0 $0.00 $48.50 25 Laboratory 87582 0 999 $0.00 0 0 $0.00 $39.22 25 Laboratory 87590 0 999 $0.00 0 0 $0.00 $27.71 25 Laboratory 87591 0 999 $0.00 0 0 $0.00 $48.50 25 Laboratory 87592 0 999 $0.00 0 0 $0.00 $39.22 25 Laboratory 87620 0 999 $0.00 0 0 $0.00 $27.71 25 Laboratory 87621 0 999 $0.00 0 0 $0.00 $48.50 25 Laboratory 87622 0 999 $0.00 0 0 $0.00 $39.22 25 Laboratory 87650 0 999 $0.00 0 0 $0.00 $27.71 25 Laboratory 87651 0 999 $0.00 0 0 $0.00 $48.50 25 Laboratory 87652 0 999 $0.00 0 0 $0.00 $39.22 25 Laboratory 87797 0 999 $0.00 0 0 $0.00 $27.71 25 Laboratory 87798 0 999 $0.00 0 0 $0.00 $48.50 25 Laboratory 87799 0 999 $0.00 0 0 $0.00 $59.20 25 Laboratory 87801 0 999 $0.00 0 0 $0.00 $48.50 25 Laboratory 87802 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87803 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87804 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87807 0 999 $0.00 0 0 $0.00 $16.58 2


5 Laboratory 87810 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87850 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87880 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87899 0 999 $0.00 0 0 $0.00 $16.58 25 Laboratory 87902 0 999 $0.00 0 0 $0.00 $253.26 25 Laboratory 88104 0 999 $24.82 0.91 27.276 $0.00 $0.005 Laboratory 88106 0 999 $23.18 0.85 27.276 $0.00 $0.005 Laboratory 88107 0 999 $32.73 1.2 27.276 $0.00 $0.005 Laboratory 88108 0 999 $25.37 0.93 27.276 $0.00 $0.005 Laboratory 88112 0 999 $88.37 3.24 27.276 $0.00 $0.00



5 Laboratory 88172 0 999 $33.55 1.23 27.276 $0.00 $0.005 Laboratory 88173 0 999 $49.10 1.8 27.276 $0.00 $0.005 Laboratory 88182 0 999 $42.55 1.56 27.276 $0.00 $0.005 Laboratory 88300 0 999 $7.09 0.26 27.276 $0.00 $0.005 Laboratory 88302 0 999 $15.00 0.55 27.276 $0.00 $0.005 Laboratory 88304 0 999 $21.55 0.79 27.276 $0.00 $0.005 Laboratory 88305 0 999 $46.10 1.69 27.276 $0.00 $0.005 Laboratory 88307 0 999 $81.28 2.98 27.276 $0.00 $0.005 Laboratory 88309 0 999 $110.20 4.04 27.276 $0.00 $0.005 Laboratory 88311 0 999 $11.46 0.42 27.276 $0.00 $0.005 Laboratory 88312 0 999 $13.91 0.51 27.276 $0.00 $0.00



34 of 46

5 Laboratory 88313 0 999 $11.46 0.42 27.276 $0.00 $0.005 Laboratory 88314 0 999 $31.64 1.16 27.276 $0.00 $0.005 Laboratory 88318 0 999 $13.09 0.48 27.276 $0.00 $0.005 Laboratory 88319 0 999 $27.00 0.99 27.276 $0.00 $0.005 Laboratory 88331 0 999 $52.10 1.91 27.276 $0.00 $0.005 Laboratory 88332 0 999 $23.18 0.85 27.276 $0.00 $0.005 Laboratory 88346 0 999 $18.55 0.68 27.276 $0.00 $0.005 Laboratory 88347 0 999 $13.91 0.51 27.276 $0.00 $0.005 Laboratory 88348 0 999 $96.28 3.53 27.276 $0.00 $0.005 Laboratory 88349 0 999 $57.83 2.12 27.276 $0.00 $0.005 Laboratory 88355 0 999 $93.83 3.44 27.276 $0.00 $0.005 Laboratory 88356 0 999 $148.93 5.46 27.276 $0.00 $0.005 Laboratory 88358 0 999 $134.20 4.92 27.276 $0.00 $0.005 Laboratory 88362 0 999 $107.47 3.94 27.276 $0.00 $0.005 Laboratory 88367 0 999 $93.83 3.44 27.276 $0.00 $0.005 Laboratory 88368 0 999 $93.83 3.44 27.276 $0.00 $0.005 Laboratory 88371 0 999 $0.00 0 0 $0.00 $30.71 25 Laboratory 88372 0 999 $0.00 0 0 $0.00 $31.44 25 Laboratory 88399 0 999 $0.00 0 0 $0.00 $0.00 55 Laboratory 88400 0 999 $0.00 0 0 $0.00 $3.47 25 Laboratory 89050 0 999 $0.00 0 0 $0.00 $6.53 25 Laboratory 89051 0 999 $0.00 0 0 $0.00 $7.61 25 Laboratory 89060 0 999 $0.00 0 0 $0.00 $9.88 25 Laboratory 89100 0 999 $30.28 1.11 27.276 $0.00 $0.005 Laboratory 89105 0 999 $26.73 0.98 27.276 $0.00 $0.005 Laboratory 89125 0 999 $0.00 0 0 $0.00 $5.96 25 Laboratory 89130 0 999 $25.37 0.93 27.276 $0.00 $0.005 Laboratory 89132 0 999 $11.46 0.42 27.276 $0.00 $0.005 Laboratory 89135 0 999 $40.64 1.49 27.276 $0.00 $0.005 Laboratory 89136 0 999 $12.82 0.47 27.276 $0.00 $0.005 Laboratory 89140 0 999 $52.10 1.91 27.276 $0.00 $0.005 Laboratory 89141 0 999 $47.19 1.73 27.276 $0.00 $0.005 Laboratory 89160 0 999 $0.00 0 0 $0.00 $5.09 25 Laboratory 89190 0 999 $0.00 0 0 $0.00 $6.56 25 Laboratory 89220 0 999 $10.91 0.4 27.276 $0.00 $0.005 Laboratory 89225 0 999 $0.00 0 0 $0.00 $4.625 Laboratory 89230 0 999 $0.00 0 0 $0.00 $12.005 Laboratory 89235 0 999 $0.00 0 0 $0.00 $5.125 Laboratory 89240 0 999 $0.00 0 0 $0.00 $0.00 5


1 Medical Services 90680 U1 0 999 $0.00 0 0 $0.00 $55.941 Medical Services 90703 0 999 $0.00 0 0 $0.00 $19.391 Medical Services 90760 0 999 $47.831 Medical Services 90761 0 999 $15.181 Medical Services 90765 0 999 $58.421 Medical Services 90766 0 999 $19.481 Medical Services 90767 0 999 $32.081 Medical Services 90768 0 999 $18.621 Medical Services 90772 0 999 $0.00 0 0 $0.00 $8.001 Medical Services 90773 0 999 $14.03 0.49 28.641 Medical Services 90774 0 999 $44.39 1.55 28.64 $0.00 $0.001 Medical Services 90775 0 999 $0.00 0 0 $0.00 $20.341 Medical Services 90779 0 999 $0.00 0 0 $0.00 $0.00 55 Laboratory 93701 0 999 $26.46 0.97 27.276 $0.00 $0.004 Radiology 93922 0 999 $50.46 1.85 27.276 $0.00 $0.00



35 of 46



4 Radiology 93925 0 999 $138.29 5.07 27.276 $0.00 $0.00



4 Radiology 93926 0 999 $90.83 3.33 27.276 $0.00 $0.00



4 Radiology 93965 0 999 $58.37 2.14 27.276 $0.00 $0.00



4 Radiology 93970 0 999 $144.02 5.28 27.276 $0.00 $0.00



4 Radiology 93971 0 999 $100.38 3.68 27.276 $0.00 $0.00



5 Laboratory 95851 0 999 $15.27 0.56 27.276 $0.00 $0.005 Laboratory 95870 0 999 $25.91 0.95 27.276 $0.00 $0.001 Medical Services 95873 0 999 $38.66 1.35 28.64 $0.00 $0.001 Medical Services 95874 0 999 $38.95 1.36 28.64 $0.00 $0.005 Laboratory 95900 0 999 $30.82 1.13 27.276 $0.00 $0.00


5 Laboratory 95903 0 999 $33.82 1.24 27.276 $0.00 $0.00


5 Laboratory 95904 0 999 $26.46 0.97 27.276 $0.00 $0.00


5 Laboratory 95934 0 999 $30.00 1.1 27.276 $0.00 $0.00


5 Laboratory 95936 0 999 $31.09 1.14 27.276 $0.00 $0.00


1 Medical Services 96570 0 999 $57.01 2.09 27.276 $0.00 $0.001 Medical Services 96571 0 999 $31.09 1.14 27.276 $0.00 $0.001 Medical Services 97001 0 999 $0.00 0 0 $0.00 $140.001 Medical Services 97002 0 999 $0.00 0 0 $0.00 $140.001 Medical Services 97003 0 999 $0.00 0 0 $0.00 $140.001 Medical Services 97004 0 999 $0.00 0 0 $0.00 $140.001 Medical Services 97012 0 999 $0.00 0 0 $0.00 $35.001 Medical Services 97014 0 999 $0.00 0 0 $0.00 $35.001 Medical Services 97016 0 999 $0.00 0 0 $0.00 $35.001 Medical Services 97018 0 999 $0.00 0 0 $0.00 $35.001 Medical Services 97022 0 999 $0.00 0 0 $0.00 $35.00



36 of 46

1 Medical Services 97024 0 999 $0.00 0 0 $0.00 $35.001 Medical Services 97026 0 999 $0.00 0 0 $0.00 $35.001 Medical Services 97028 0 999 $0.00 0 0 $0.00 $35.001 Medical Services 97032 0 999 $0.00 0 0 $0.00 $35.001 Medical Services 97033 0 999 $0.00 0 0 $0.00 $35.001 Medical Services 97034 0 999 $0.00 0 0 $0.00 $35.001 Medical Services 97035 0 999 $0.00 0 0 $0.00 $35.001 Medical Services 97036 0 999 $0.00 0 0 $0.00 $35.001 Medical Services 97039 0 999 $0.00 0 0 $0.00 $35.001 Medical Services 97110 0 999 $0.00 0 0 $0.00 $35.001 Medical Services 97112 0 999 $0.00 0 0 $0.00 $35.001 Medical Services 97113 0 999 $0.00 0 0 $0.00 $35.001 Medical Services 97116 0 999 $0.00 0 0 $0.00 $35.001 Medical Services 97124 0 999 $0.00 0 0 $0.00 $35.001 Medical Services 97139 0 999 $0.00 0 0 $0.00 $35.001 Medical Services 97140 0 999 $0.00 0 0 $0.00 $35.001 Medical Services 97150 0 999 $0.00 0 0 $0.00 $17.501 Medical Services 97530 0 999 $0.00 0 0 $0.00 $35.001 Medical Services 97750 0 999 $0.00 0 0 $0.00 $35.001 Medical Services 97761 0 999 $0.00 0 0 $0.00 $35.001 Medical Services 97799 0 999 $0.00 0 0 $0.00 $35.00 51 Medical Services 98925 0 999 $21.48 0.75 28.64 $0.00 $0.001 Medical Services 98926 0 999 $0.00 0 0 $0.00 $31.221 Medical Services 98927 0 999 $38.66 1.35 28.64 $0.00 $0.001 Medical Services 98928 0 999 $45.25 1.58 28.64 $0.00 $0.001 Medical Services 98929 0 20 $44.19 1.62 27.276 $0.00 $0.001 Medical Services 98929 21 999 $0.00 0 0 $0.00 $46.401 Medical Services 99000 0 20 $0.00 0 0 $0.00 $3.731 Medical Services 99000 21 999 $0.00 0 0 $0.00 $3.821 Medical Services 99050 0 20 $0.00 0 0 $0.00 $13.221 Medical Services 99050 21 999 $0.00 0 0 $0.00 $13.641 Medical Services 99056 0 20 $0.00 0 0 $0.00 $13.221 Medical Services 99056 21 999 $0.00 0 0 $0.00 $13.641 Medical Services 99060 0 999 $0.00 0 0 $0.00 $12.691 Medical Services 99199 0 999 $0.00 0 0 $0.00 $0.00 51 Medical Services 99201 0 20 $0.00 0 0 $0.00 $28.87 11 Medical Services 99201 21 999 $0.00 0 0 $0.00 $26.041 Medical Services 99201 TH 0 20 $0.00 0 0 $0.00 $28.87 11 Medical Services 99201 TH 21 999 $0.00 0 0 $0.00 $26.042 Surgery 99201 0 20 $0.00 0 0 $0.00 $28.87 12 Surgery 99201 21 999 $0.00 0 0 $0.00 $26.041 Medical Services 99202 0 20 $0.00 0 0 $0.00 $45.56 11 Medical Services 99202 21 999 $0.00 0 0 $0.00 $41.091 Medical Services 99202 TH 0 20 $0.00 0 0 $0.00 $45.56 11 Medical Services 99202 TH 21 999 $0.00 0 0 $0.00 $41.092 Surgery 99202 0 20 $0.00 0 0 $0.00 $45.56 12 Surgery 99202 21 999 $0.00 0 0 $0.00 $41.091 Medical Services 99203 0 20 $0.00 0 0 $0.00 $61.56 11 Medical Services 99203 21 999 $0.00 0 0 $0.00 $55.521 Medical Services 99203 TH 0 20 $0.00 0 0 $0.00 $61.56 11 Medical Services 99203 TH 21 999 $0.00 0 0 $0.00 $55.522 Surgery 99203 0 20 $0.00 0 0 $0.00 $61.56 12 Surgery 99203 21 999 $0.00 0 0 $0.00 $55.521 Medical Services 99204 0 20 $0.00 0 0 $0.00 $90.07 11 Medical Services 99204 21 999 $0.00 0 0 $0.00 $81.24



37 of 46

1 Medical Services 99204 TH 0 20 $0.00 0 0 $0.00 $90.07 11 Medical Services 99204 TH 21 999 $0.00 0 0 $0.00 $81.242 Surgery 99204 0 20 $0.00 0 0 $0.00 $90.07 12 Surgery 99204 21 999 $0.00 0 0 $0.00 $81.241 Medical Services 99205 0 20 $0.00 0 0 $0.00 $111.98 11 Medical Services 99205 21 999 $0.00 0 0 $0.00 $101.001 Medical Services 99205 TH 0 20 $0.00 0 0 $0.00 $111.98 11 Medical Services 99205 TH 21 999 $0.00 0 0 $0.00 $101.002 Surgery 99205 0 20 $0.00 0 0 $0.00 $111.98 12 Surgery 99205 21 999 $0.00 0 0 $0.00 $101.001 Medical Services 99211 0 20 $0.00 0 0 $0.00 $14.96 11 Medical Services 99211 21 999 $0.00 0 0 $0.00 $13.491 Medical Services 99212 0 20 $0.00 0 0 $0.00 $25.04 11 Medical Services 99212 21 999 $0.00 0 0 $0.00 $22.591 Medical Services 99213 0 20 $0.00 0 0 $0.00 $37.64 11 Medical Services 99213 21 999 $0.00 0 0 $0.00 $33.951 Medical Services 99214 0 20 $0.00 0 0 $0.00 $52.86 11 Medical Services 99214 21 999 $0.00 0 0 $0.00 $55.521 Medical Services 99215 0 20 $0.00 0 0 $0.00 $81.38 11 Medical Services 99215 21 999 $0.00 0 0 $0.00 $73.401 Medical Services 99217 0 20 $58.081 Medical Services 99217 21 999 $52.381 Medical Services 99218 0 20 $58.241 Medical Services 99218 21 999 $52.531 Medical Services 99219 0 20 $90.591 Medical Services 99219 21 999 $81.711 Medical Services 99220 0 20 $122.951 Medical Services 99220 21 999 $110.891 Medical Services 99234 0 20 $114.761 Medical Services 99234 21 999 $103.511 Medical Services 99235 0 20 $158.581 Medical Services 99235 21 999 $143.041 Medical Services 99236 0 20 $191.281 Medical Services 99236 21 999 $172.521 Medical Services 99238 0 20 $60.511 Medical Services 99238 21 999 $54.581 Medical Services 99239 0 20 $79.991 Medical Services 99239 21 999 $72.153 Consultation 99241 0 20 $0.00 0 0 $0.00 $44.873 Consultation 99241 21 999 $0.00 0 0 $0.00 $40.473 Consultation 99242 0 20 $0.00 0 0 $0.00 $70.253 Consultation 99242 21 999 $0.00 0 0 $0.00 $63.373 Consultation 99243 0 20 $0.00 0 0 $0.00 $90.773 Consultation 99243 21 999 $0.00 0 0 $0.00 $81.873 Consultation 99244 0 20 $0.00 0 0 $0.00 $127.283 Consultation 99244 21 999 $0.00 0 0 $0.00 $114.803 Consultation 99245 0 20 $0.00 0 0 $0.00 $169.013 Consultation 99245 21 999 $0.00 0 0 $0.00 $152.443 Consultation 99251 0 20 $48.343 Consultation 99251 21 999 $0.00 0 0 $0.00 $43.603 Consultation 99252 0 20 $71.993 Consultation 99252 21 999 $0.00 0 0 $0.00 $64.933 Consultation 99253 0 20 $92.863 Consultation 99253 21 999 $0.00 0 0 $0.00 $83.753 Consultation 99254 0 20 $128.33



38 of 46

3 Consultation 99254 21 999 $0.00 0 0 $0.00 $115.753 Consultation 99255 0 20 $168.333 Consultation 99255 21 999 $0.00 0 0 $0.00 $151.821 Medical Services 99281 21 999 $26.021 Medical Services 99281 0 20 $0.00 0 0 $0.00 $22.63 11 Medical Services 99282 0 20 $45.561 Medical Services 99282 21 999 $41.091 Medical Services 99283 0 20 $61.561 Medical Services 99283 21 999 $55.521 Medical Services 99284 0 20 $90.071 Medical Services 99284 21 999 $81.241 Medical Services 99285 0 20 $111.981 Medical Services 99285 21 999 $101.001 Medical Services 99304 0 20 $49.731 Medical Services 99304 21 999 $44.851 Medical Services 99305 0 20 $59.471 Medical Services 99305 21 999 $53.641 Medical Services 99306 0 20 $80.681 Medical Services 99306 21 999 $72.771 Medical Services 99307 0 20 $30.961 Medical Services 99307 21 999 $27.921 Medical Services 99308 0 20 $41.041 Medical Services 99308 21 999 $37.021 Medical Services 99309 0 20 $55.641 Medical Services 99309 21 999 $50.191 Medical Services 99310 0 20 $55.641 Medical Services 99310 21 999 $50.191 Medical Services 99315 0 20 $45.82 1.68 27.2761 Medical Services 99315 21 999 $52.691 Medical Services 99316 0 20 $71.291 Medical Services 99316 21 999 $64.311 Medical Services 99318 0 20 $49.731 Medical Services 99318 21 999 $44.851 Medical Services 99324 0 20 $31.64 1.16 27.2761 Medical Services 99324 21 999 $36.391 Medical Services 99325 0 20 $58.081 Medical Services 99325 21 999 $52.381 Medical Services 99326 0 20 $76.511 Medical Services 99326 21 999 $69.011 Medical Services 99327 0 20 $60.01 2.2 27.2761 Medical Services 99327 21 999 $69.011 Medical Services 99328 0 20 $60.01 2.2 27.2761 Medical Services 99328 21 999 $69.011 Medical Services 99334 0 20 $41.731 Medical Services 99334 21 999 $37.641 Medical Services 99335 0 20 $63.651 Medical Services 99335 21 999 $57.411 Medical Services 99336 0 20 $93.201 Medical Services 99336 21 999 $84.071 Medical Services 99337 0 20 $73.10 2.68 27.2761 Medical Services 99337 21 999 $84.071 Medical Services 99341 0 20 $0.00 0 0 $0.00 $54.951 Medical Services 99341 21 999 $0.00 0 0 $0.00 $49.571 Medical Services 99341 TH 0 20 $0.00 0 0 $0.00 $54.951 Medical Services 99341 TH 21 999 $0.00 0 0 $0.00 $49.57



39 of 46

2 Surgery 99341 0 20 $0.00 0 0 $0.00 $54.952 Surgery 99341 21 999 $0.00 0 0 $0.00 $49.571 Medical Services 99342 0 20 $0.00 0 0 $0.00 $69.551 Medical Services 99342 21 999 $0.00 0 0 $0.00 $62.731 Medical Services 99342 TH 0 20 $0.00 0 0 $0.00 $69.551 Medical Services 99342 TH 21 999 $0.00 0 0 $0.00 $62.732 Surgery 99342 0 20 $0.00 0 0 $0.00 $69.552 Surgery 99342 21 999 $0.00 0 0 $0.00 $62.731 Medical Services 99343 0 20 $0.00 0 0 $0.00 $90.071 Medical Services 99343 21 999 $0.00 0 0 $0.00 $81.241 Medical Services 99343 TH 0 20 $0.00 0 0 $0.00 $90.071 Medical Services 99343 TH 21 999 $0.00 0 0 $0.00 $81.242 Surgery 99343 0 20 $0.00 0 0 $0.00 $90.072 Surgery 99343 21 999 $0.00 0 0 $0.00 $81.241 Medical Services 99344 0 20 $0.00 0 0 $0.00 $138.071 Medical Services 99344 21 999 $0.00 0 0 $0.00 $124.531 Medical Services 99344 TH 0 20 $0.00 0 0 $0.00 $138.071 Medical Services 99344 TH 21 999 $0.00 0 0 $0.00 $124.532 Surgery 99344 0 20 $0.00 0 0 $0.00 $138.072 Surgery 99344 21 999 $0.00 0 0 $0.00 $124.531 Medical Services 99345 0 20 $0.00 0 0 $0.00 $164.501 Medical Services 99345 21 999 $0.00 0 0 $0.00 $148.372 Surgery 99345 TH 0 20 $0.00 0 0 $0.00 $164.502 Surgery 99345 TH 21 999 $0.00 0 0 $0.00 $148.371 Medical Services 99347 0 20 $0.00 0 0 $0.00 $43.481 Medical Services 99347 21 999 $0.00 0 0 $0.00 $39.221 Medical Services 99348 0 20 $0.00 0 0 $0.00 $63.651 Medical Services 99348 21 999 $0.00 0 0 $0.00 $57.411 Medical Services 99349 0 20 $0.00 0 0 $0.00 $93.201 Medical Services 99349 21 999 $0.00 0 0 $0.00 $87.071 Medical Services 99350 0 20 $0.00 0 0 $0.00 $134.241 Medical Services 99350 21 999 $0.00 0 0 $0.00 $121.081 Medical Services 99499 0 999 $0.00 0 0 $0.00 $0.00 53 Consultation 99499 0 999 $0.00 0 0 $0.00 $0.00 5

9Other/DME Purchase - Used A4450 0 999 $0.00 0 0 $0.00 $0.09 7

1 Medical Services C9399 0 999 $0.00 0 0 $0.00 $0.00 55 Laboratory G0103 0 999 $0.00 0 0 $0.00 $25.42 22 Surgery G0105 0 20 $224.21 8.22 27.276 $0.00 $0.002 Surgery G0105 21 999 $0.00 0 0 $0.00 $235.422 Surgery G0127 0 20 $11.73 0.43 27.276 $0.00 $0.002 Surgery G0127 21 999 $16.04 0.56 28.64 $0.00 $0.005 Laboratory G0306 0 999 $0.00 0 0 $0.00 $10.745 Laboratory G0307 0 999 $0.00 0 0 $0.00 $8.951 Medical Services J0120 0 999 $0.00 0 0 $0.00 $14.971 Medical Services J0132 0 999 $0.00 0 0 $0.00 $1.951 Medical Services J0133 0 999 $0.00 0 0 $0.00 $0.031 Medical Services J0150 0 999 $0.00 0 0 $0.00 $23.481 Medical Services J0170 0 999 $0.00 0 0 $0.00 $0.801 Medical Services J0190 0 999 $0.00 0 0 $0.00 $2.981 Medical Services J0205 0 999 $0.00 0 0 $0.00 $39.221 Medical Services J0207 0 999 $0.00 0 0 $0.00 $463.581 Medical Services J0210 0 999 $0.00 0 0 $0.00 $10.081 Medical Services J0215 0 999 $0.00 0 0 $0.00 $26.301 Medical Services J0256 0 999 $0.00 0 0 $0.00 $3.411 Medical Services J0278 0 999 $0.00 0 0 $0.00 $1.10



40 of 46

1 Medical Services J0280 0 999 $0.00 0 0 $0.00 $0.391 Medical Services J0285 0 999 $0.00 0 0 $0.00 $9.201 Medical Services J0290 0 999 $0.00 0 0 $0.00 $2.361 Medical Services J0295 0 999 $0.00 0 0 $0.00 $6.091 Medical Services J0300 0 999 $0.00 0 0 $0.00 $2.611 Medical Services J0330 0 999 $0.00 0 0 $0.00 $0.181 Medical Services J0350 0 999 $0.00 0 0 $0.00 $2,537.841 Medical Services J0360 0 999 $0.00 0 0 $0.00 $6.511 Medical Services J0380 0 999 $0.00 0 0 $0.00 $1.221 Medical Services J0390 0 999 $0.00 0 0 $0.00 $15.871 Medical Services J0456 0 999 $0.00 0 0 $0.00 $36.221 Medical Services J0460 0 999 $0.00 0 0 $0.00 $0.631 Medical Services J0475 0 999 $0.00 0 0 $0.00 $192.591 Medical Services J0476 0 999 $0.00 0 0 $0.00 $71.421 Medical Services J0480 0 999 $0.00 0 0 $0.00 $1,377.971 Medical Services J0500 0 999 $0.00 0 0 $0.00 $15.271 Medical Services J0515 0 999 $0.00 0 0 $0.00 $17.091 Medical Services J0520 0 999 $0.00 0 0 $0.00 $5.031 Medical Services J0530 0 999 $0.00 0 0 $0.00 $13.161 Medical Services J0540 0 999 $0.00 0 0 $0.00 $28.371 Medical Services J0550 0 999 $0.00 0 0 $0.00 $30.491 Medical Services J0560 0 999 $0.00 0 0 $0.00 $21.341 Medical Services J0570 0 999 $0.00 0 0 $0.00 $36.441 Medical Services J0580 0 999 $0.00 0 0 $0.00 $43.111 Medical Services J0583 0 999 $0.00 0 0 $0.00 $1.761 Medical Services J0585 0 999 $0.00 0 0 $0.00 $5.101 Medical Services J0595 0 999 $0.00 0 0 $0.00 $0.721 Medical Services J0610 0 999 $0.00 0 0 $0.00 $0.591 Medical Services J0620 0 999 $0.00 0 0 $0.00 $11.081 Medical Services J0640 0 999 $0.00 0 0 $0.00 $0.961 Medical Services J0670 0 999 $0.00 0 0 $0.00 $1.511 Medical Services J0690 0 999 $0.00 0 0 $0.00 $1.461 Medical Services J0694 0 999 $0.00 0 0 $0.00 $7.091 Medical Services J0696 0 999 $0.00 0 0 $0.00 $1.761 Medical Services J0697 0 999 $0.00 0 0 $0.00 $3.951 Medical Services J0698 0 999 $0.00 0 0 $0.00 $4.431 Medical Services J0702 0 999 $0.00 0 0 $0.00 $5.181 Medical Services J0704 0 999 $0.00 0 0 $0.00 $1.331 Medical Services J0710 0 999 $0.00 0 0 $0.00 $1.471 Medical Services J0713 0 999 $0.00 0 0 $0.00 $4.011 Medical Services J0715 0 999 $0.00 0 0 $0.00 $2.981 Medical Services J0720 0 999 $0.00 0 0 $0.00 $11.231 Medical Services J0735 0 999 $0.00 0 0 $0.00 $65.841 Medical Services J0740 0 999 $0.00 0 0 $0.00 $761.491 Medical Services J0743 0 999 $0.00 0 0 $0.00 $13.661 Medical Services J0745 0 999 $0.00 0 0 $0.00 $1.051 Medical Services J0760 0 999 $0.00 0 0 $0.00 $4.571 Medical Services J0770 0 999 $0.00 0 0 $0.00 $24.451 Medical Services J0780 0 999 $0.00 0 0 $0.00 $2.041 Medical Services J0800 0 999 $0.00 0 0 $0.00 $114.531 Medical Services J0835 0 999 $0.00 0 0 $0.00 $63.921 Medical Services J0850 0 999 $0.00 0 0 $0.00 $866.581 Medical Services J0881 0 999 $0.00 0 0 $0.00 $3.091 Medical Services J0885 0 999 $0.00 0 0 $0.00 $9.331 Medical Services J0945 0 999 $0.00 0 0 $0.00 $0.80



41 of 46

1 Medical Services J1020 0 999 $0.00 0 0 $0.00 $2.181 Medical Services J1030 0 999 $0.00 0 0 $0.00 $5.111 Medical Services J1040 0 999 $0.00 0 0 $0.00 $9.451 Medical Services J1094 0 999 $0.00 0 0 $0.00 $0.231 Medical Services J1100 0 999 $0.00 0 0 $0.00 $0.111 Medical Services J1110 0 999 $0.00 0 0 $0.00 $22.681 Medical Services J1120 0 999 $0.00 0 0 $0.00 $16.101 Medical Services J1160 0 999 $0.00 0 0 $0.00 $3.361 Medical Services J1162 0 999 $0.00 0 0 $0.00 $527.781 Medical Services J1165 0 999 $0.00 0 0 $0.00 $0.731 Medical Services J1170 0 999 $0.00 0 0 $0.00 $1.331 Medical Services J1180 0 999 $0.00 0 0 $0.00 $7.441 Medical Services J1190 0 999 $0.00 0 0 $0.00 $175.191 Medical Services J1200 0 999 $0.00 0 0 $0.00 $0.801 Medical Services J1205 0 999 $0.00 0 0 $0.00 $123.841 Medical Services J1230 0 999 $0.00 0 0 $0.00 $0.671 Medical Services J1240 0 999 $0.00 0 0 $0.00 $2.931 Medical Services J1245 0 999 $0.00 0 0 $0.00 $1.471 Medical Services J1250 0 999 $0.00 0 0 $0.00 $4.241 Medical Services J1260 0 999 $0.00 0 0 $0.00 $6.331 Medical Services J1265 0 999 $0.00 0 0 $0.00 $0.821 Medical Services J1320 0 999 $0.00 0 0 $0.00 $2.011 Medical Services J1325 0 999 $0.00 0 0 $0.00 $11.311 Medical Services J1327 0 999 $0.00 0 0 $0.00 $15.871 Medical Services J1330 0 999 $0.00 0 0 $0.00 $4.561 Medical Services J1335 0 999 $0.00 0 0 $0.00 $24.301 Medical Services J1364 0 999 $0.00 0 0 $0.00 $5.991 Medical Services J1430 0 999 $0.00 0 0 $0.00 $69.721 Medical Services J1436 0 999 $0.00 0 0 $0.00 $59.971 Medical Services J1438 0 999 $0.00 0 0 $0.00 $162.391 Medical Services J1450 0 999 $0.00 0 0 $0.00 $10.621 Medical Services J1451 0 999 $0.00 0 0 $0.00 $12.261 Medical Services J1455 0 999 $0.00 0 0 $0.00 $11.701 Medical Services J1570 0 999 $0.00 0 0 $0.00 $31.551 Medical Services J1580 0 999 $0.00 0 0 $0.00 $1.071 Medical Services J1600 0 999 $0.00 0 0 $0.00 $5.411 Medical Services J1610 0 999 $0.00 0 0 $0.00 $68.041 Medical Services J1620 0 999 $0.00 0 0 $0.00 $180.301 Medical Services J1626 0 999 $0.00 0 0 $0.00 $7.641 Medical Services J1630 0 999 $0.00 0 0 $0.00 $2.121 Medical Services J1631 0 999 $0.00 0 0 $0.00 $5.251 Medical Services J1642 0 999 $0.00 0 0 $0.00 $0.051 Medical Services J1644 0 999 $0.00 0 0 $0.00 $0.231 Medical Services J1645 0 999 $0.00 0 0 $0.00 $11.161 Medical Services J1650 0 999 $0.00 0 0 $0.00 $5.641 Medical Services J1652 0 999 $0.00 0 0 $0.00 $5.851 Medical Services J1670 0 999 $0.00 0 0 $0.00 $95.911 Medical Services J1700 0 999 $0.00 0 0 $0.00 $0.321 Medical Services J1710 0 999 $0.00 0 0 $0.00 $5.001 Medical Services J1720 0 999 $0.00 0 0 $0.00 $1.991 Medical Services J1730 0 999 $0.00 0 0 $0.00 $111.851 Medical Services J1742 0 999 $0.00 0 0 $0.00 $267.821 Medical Services J1745 0 999 $0.00 0 0 $0.00 $53.731 Medical Services J1751 0 999 $0.00 0 0 $0.00 $11.691 Medical Services J1752 0 999 $0.00 0 0 $0.00 $10.40



42 of 46




43 of 46




44 of 46

1 Medical Services J3475 0 999 $0.00 0 0 $0.00 $0.151 Medical Services J3480 0 999 $0.00 0 0 $0.00 $0.021 Medical Services J3485 0 999 $0.00 0 0 $0.00 $1.061 Medical Services J3487 0 999 $0.00 0 0 $0.00 $205.001 Medical Services J3490 0 999 $0.00 0 0 $0.00 $0.00 51 Medical Services J7340 0 999 $0.00 0 0 $0.00 $28.751 Medical Services J7341 0 999 $0.00 0 0 $0.00 $1.821 Medical Services J7342 0 999 $0.00 0 0 $0.00 $14.421 Medical Services J7513 0 999 $0.00 0 0 $0.00 $314.591 Medical Services J7599 0 999 $0.00 0 0 $0.00 $0.00 51 Medical Services J7611 0 999 $0.00 0 0 $0.00 $0.101 Medical Services J7612 0 999 $0.00 0 0 $0.00 $0.991 Medical Services J7613 0 999 $0.00 0 0 $0.00 $0.071 Medical Services J7614 0 999 $0.00 0 0 $0.00 $1.391 Medical Services J7620 0 999 $0.00 0 0 $0.00 $1.051 Medical Services J7699 0 999 $0.00 0 0 $0.00 $0.00 51 Medical Services J7799 0 999 $0.00 0 0 $0.00 $0.00 51 Medical Services J9000 0 999 $0.00 0 0 $0.00 $6.241 Medical Services J9010 0 999 $0.00 0 0 $0.00 $541.301 Medical Services J9015 0 999 $0.00 0 0 $0.00 $739.521 Medical Services J9020 0 999 $0.00 0 0 $0.00 $54.771 Medical Services J9040 0 999 $0.00 0 0 $0.00 $258.991 Medical Services J9045 0 999 $0.00 0 0 $0.00 $8.941 Medical Services J9050 0 999 $0.00 0 0 $0.00 $139.781 Medical Services J9060 0 999 $0.00 0 0 $0.00 $2.451 Medical Services J9062 0 999 $0.00 0 0 $0.00 $12.261 Medical Services J9065 0 999 $0.00 0 0 $0.00 $55.241 Medical Services J9070 0 999 $0.00 0 0 $0.00 $1.921 Medical Services J9080 0 999 $0.00 0 0 $0.00 $3.831 Medical Services J9090 0 999 $0.00 0 0 $0.00 $15.751 Medical Services J9091 0 999 $0.00 0 0 $0.00 $19.171 Medical Services J9092 0 999 $0.00 0 0 $0.00 $38.341 Medical Services J9093 0 999 $0.00 0 0 $0.00 $1.991 Medical Services J9094 0 999 $0.00 0 0 $0.00 $3.971 Medical Services J9095 0 999 $0.00 0 0 $0.00 $9.931 Medical Services J9096 0 999 $0.00 0 0 $0.00 $17.091 Medical Services J9097 0 999 $0.00 0 0 $0.00 $39.711 Medical Services J9100 0 999 $0.00 0 0 $0.00 $7.331 Medical Services J9110 0 999 $0.00 0 0 $0.00 $7.651 Medical Services J9120 0 999 $0.00 0 0 $0.00 $493.431 Medical Services J9130 0 999 $0.00 0 0 $0.00 $4.671 Medical Services J9140 0 999 $0.00 0 0 $0.00 $9.341 Medical Services J9150 0 999 $0.00 0 0 $0.00 $22.781 Medical Services J9151 0 999 $0.00 0 0 $0.00 $55.921 Medical Services J9170 0 999 $0.00 0 0 $0.00 $306.131 Medical Services J9181 0 999 $0.00 0 0 $0.00 $0.511 Medical Services J9182 0 999 $0.00 0 0 $0.00 $5.131 Medical Services J9185 0 999 $0.00 0 0 $0.00 $244.051 Medical Services J9190 0 999 $0.00 0 0 $0.00 $1.851 Medical Services J9200 0 999 $0.00 0 0 $0.00 $122.441 Medical Services J9201 0 999 $0.00 0 0 $0.00 $124.551 Medical Services J9202 0 999 $0.00 0 0 $0.00 $200.431 Medical Services J9206 0 999 $0.00 0 0 $0.00 $126.671 Medical Services J9208 0 999 $0.00 0 0 $0.00 $134.591 Medical Services J9209 0 999 $0.00 0 0 $0.00 $8.89



45 of 46

1 Medical Services J9211 0 999 $0.00 0 0 $0.00 $285.381 Medical Services J9212 0 999 $0.00 0 0 $0.00 $4.651 Medical Services J9213 0 999 $0.00 0 0 $0.00 $37.291 Medical Services J9214 0 999 $0.00 0 0 $0.00 $13.821 Medical Services J9215 0 999 $0.00 0 0 $0.00 $7.311 Medical Services J9216 0 999 $0.00 0 0 $0.00 $289.871 Medical Services J9217 0 999 $0.00 0 0 $0.00 $230.381 Medical Services J9218 0 999 $0.00 0 0 $0.00 $7.231 Medical Services J9225 0 999 $0.00 0 0 $0.00 $5,370.001 Medical Services J9230 0 999 $0.00 0 0 $0.00 $141.611 Medical Services J9245 0 999 $0.00 0 0 $0.00 $1,197.781 Medical Services J9250 0 999 $0.00 0 0 $0.00 $0.251 Medical Services J9260 0 999 $0.00 0 0 $0.00 $2.591 Medical Services J9264 0 999 $0.00 0 0 $0.00 $8.671 Medical Services J9266 0 999 $0.00 0 0 $0.00 $1,687.851 Medical Services J9268 0 999 $0.00 0 0 $0.00 $1,490.131 Medical Services J9270 0 999 $0.00 0 0 $0.00 $88.371 Medical Services J9280 0 999 $0.00 0 0 $0.00 $114.021 Medical Services J9290 0 999 $0.00 0 0 $0.00 $68.521 Medical Services J9291 0 999 $0.00 0 0 $0.00 $137.031 Medical Services J9293 0 999 $0.00 0 0 $0.00 $162.371 Medical Services J9310 0 999 $0.00 0 0 $0.00 $486.551 Medical Services J9320 0 999 $0.00 0 0 $0.00 $151.741 Medical Services J9340 0 999 $0.00 0 0 $0.00 $40.611 Medical Services J9350 0 999 $0.00 0 0 $0.00 $820.561 Medical Services J9357 0 999 $0.00 0 0 $0.00 $471.241 Medical Services J9360 0 999 $0.00 0 0 $0.00 $3.671 Medical Services J9370 0 999 $0.00 0 0 $0.00 $30.411 Medical Services J9375 0 999 $0.00 0 0 $0.00 $60.821 Medical Services J9380 0 999 $0.00 0 0 $0.00 $152.071 Medical Services J9390 0 999 $0.00 0 0 $0.00 $18.371 Medical Services J9600 0 999 $0.00 0 0 $0.00 $2,505.401 Medical Services J9999 0 999 $0.00 0 0 $0.00 $0.00 5

JDME Purchase - New K0824 0 999 $0.00 0 0 $0.00 $4,842.70 7

5 Laboratory P2038 0 999 $0.00 0 0 $0.00 $6.95 25 Laboratory P7001 0 999 $0.00 0 0 $0.00 $16.67 25 Laboratory P9012 0 999 $0.00 0 0 $0.00 $7.365 Laboratory Q0095 0 999 $0.00 0 0 $0.00 $1.205 Laboratory Q0111 0 999 $0.00 0 0 $0.00 $5.90 25 Laboratory Q0112 0 999 $0.00 0 0 $0.00 $5.90 25 Laboratory Q0113 0 999 $0.00 0 0 $0.00 $7.47 25 Laboratory Q0115 0 999 $0.00 0 0 $0.00 $13.68 21 Medical Services Q2009 0 999 $0.00 0 0 $0.00 $5.551 Medical Services Q3025 0 999 $0.00 0 0 $0.00 $105.611 Medical Services Q3026 0 999 $0.00 0 0 $0.00 $118.451 Medical Services S0020 0 999 $0.00 0 0 $0.00 $1.891 Medical Services S0021 0 999 $0.00 0 0 $0.00 $16.381 Medical Services S0023 0 999 $0.00 0 0 $0.00 $3.261 Medical Services S0142 0 999 $0.00 0 0 $0.00 $0.161 Medical Services S0162 0 999 $0.00 0 0 $0.00 $343.94

9Other/DME Purchase - Used S0515 0 999 $0.00 0 0 $0.00 $0.00 5

2 Surgery S2117 0 999 $591.34 21.68 27.276 $0.00 $0.002 Surgery S2135 0 999 $231.30 8.48 27.276 $0.00 $0.005 Laboratory S3626 0 999 $0.00 0 0 $0.00 $94.37



46 of 46

1 Medical Services S8990 0 999 $0.00 0 0 $0.00 $7.37

9Other/DME Purchase - Used V2410 0 999 $0.00 0 0 $0.00 $63.22

9Other/DME Purchase - Used V2799 0 999 $0.00 0 0 $0.00 $0.00 5 6


2007 texas medicaid fee schedule prcr404c - … schedules/2007 9-1-07...2 surgery 11200 0 999 $59.00...

Documents