CPT code PA RequiredNon-Facility Fee Facility Fee 26 Fee TC Fee Notes

36415 $2.39 $2.3980047 $10.92 $10.9280048 $8.30 $8.3080051 $6.88 $6.8880053 $10.37 $10.3780055 $46.92 $46.9280061 $13.14 $13.1480069 $8.52 $8.5280074 $46.75 $46.75 80076 $8.02 $8.0280081 $73.47 $73.4780150 $14.79 $14.7980155 $30.66 $30.6680156 $14.29 $14.2980157 $13.01 $13.0180158 $17.71 $17.7180159 $18.15 $18.1580162 $13.03 $13.0380163 $13.03 $13.0380164 $13.29 $13.2980165 $13.29 $13.2980168 $16.04 $16.0480169 $13.48 $13.4880170 $16.07 $16.0780171 $17.23 $17.2380173 $14.29 $14.2980175 $13.01 $13.0180176 $14.42 $14.4280177 $13.01 $13.0180178 $6.49 $6.4980180 $17.71 $17.7180183 $13.01 $13.0180184 $12.16 $12.1680185 $13.01 $13.0180186 $13.51 $13.5180188 $16.28 $16.2880190 $47.70 $47.7080192 $16.44 $16.4480194 $14.33 $14.3380195 $13.48 $13.4880197 $13.48 $13.4880198 $13.88 $13.8880199 $21.55 $21.5580200 $15.83 $15.8380201 $11.70 $11.7080202 $13.29 $13.2980203 $13.01 $13.0180305 $10.02 $10.02 Reimbursed by Beacon80306 $13.63 $13.63 Reimbursed by Beacon80307 $51.40 $51.40 Reimbursed by Beacon80400 $32.01 $32.0180402 $85.34 $85.3480406 $76.81 $76.8180408 $123.18 $123.1880410 $71.00 $71.0080412 $637.29 $637.2980414 $50.68 $50.6880415 $54.85 $54.8580416 $166.41 $166.4180417 $43.18 $43.1880418 $568.77 $568.77

80420 $128.69 $128.6980422 $45.22 $45.2280424 $49.56 $49.5680426 $145.66 $145.6680428 $65.47 $65.4780430 $102.82 $102.8280432 $132.60 $132.6080434 $226.60 $226.6080435 $101.11 $101.1180436 $89.48 $89.4880438 $49.48 $49.4880439 $65.97 $65.9780500 19.74 $16.9280502 63.54 $60.7181000 $3.20 $3.2081001 $3.12 $3.1281002 $2.77 $2.7781003 $2.20 $2.2081005 $2.12 $2.1281007 $23.83 $23.8381015 $2.99 $2.9981020 $3.74 $3.7481025 $6.84 $6.8481050 $2.95 $2.9581105 $119.96 $119.9681106 $119.96 $119.9681107 $119.96 $119.9681108 $119.96 $119.9681109 $119.96 $119.9681110 $119.96 $119.9681111 $119.96 $119.9681112 $119.96 $119.9681121 $235.15 $235.1581161 $221.81 $221.8181162 $1,791.08 $1,791.08 81163 $372.06 $372.0681164 $464.46 $464.4681165 $224.89 $224.8981166 $239.57 $239.5781167 $224.89 $224.8981170 $238.50 $238.5081173 P $239.57 $239.5781174 P $147.23 $147.2381177 $108.92 $108.9281178 $108.92 $108.92 81179 $108.92 $108.92 81180 $108.92 $108.92 81181 $108.92 $108.92 81182 P $108.92 $108.92 81183 P $108.92 $108.92 81184 P $108.92 $108.92 81185 P $672.78 $672.7881186 P $147.23 $147.2381187 $108.92 $108.9281200 $37.56 $37.5681201 $620.10 $620.1081202 $222.60 $222.6081203 $159.00 $159.0081204 $108.92 $108.9281205 $75.52 $75.5281206 $160.92 $160.9281207 $142.15 $142.1581208 $170.62 $170.62

81209 $31.25 $31.2581210 $139.44 $139.4481212 $349.80 $349.8081215 $298.32 $298.3281216 $147.17 $147.1781217 $298.32 $298.3281218 $237.42 $237.4281219 $119.38 $119.3881220 $442.50 $442.5081221 $77.29 $77.2981222 $345.88 $345.8881223 $396.71 $396.7181224 $134.16 $134.16 end dated 2/28/1981225 $231.63 $231.6381226 $358.47 $358.4781227 $138.97 $138.9781228 P $715.50 $715.5081229 P $922.20 $922.2081233 $139.44 $139.4481234 $108.92 $108.9281235 $258.04 $258.0481236 $224.89 $224.8981237 $139.44 $139.4481239 $218.48 $218.4981240 $52.22 $52.2281241 $59.97 $59.9781242 $29.11 $29.1181243 $45.35 $45.3581244 $35.69 $35.6981245 $131.58 $131.5881246 $65.99 $65.9981250 $46.50 $46.5081251 $37.56 $37.5681252 $80.39 $80.3981253 $48.91 $48.9181254 $27.83 $27.8381255 $40.90 $40.9081256 $64.15 $64.1581257 $81.30 $81.00 end dated 2/28/1981260 $31.25 $31.2581261 $194.32 $194.3281262 $54.50 $54.5081263 $289.06 $289.0681264 $146.56 $146.5681265 $211.06 $211.06 end dated 2/28/1981266 $242.32 $242.32 end dated 2/28/1981267 $203.62 $203.6281268 $255.96 $255.9681270 $89.97 $89.9781271 P $108.92 $108.9281272 $261.96 $261.9681273 $99.27 $99.2781274 P $218.49 $218.4981275 $153.63 $153.6381276 $153.63 $153.6381283 $59.97 $59.97 end dated 2/28/1981284 $108.92 $108.9281285 $218.49 $218.4981286 $218.49 $218.4981287 $99.09 $99.0981288 $152.89 $152.8981289 $147.23 $147.2381290 $31.25 $31.25

81291 $51.95 $51.9581292 $536.94 $536.9481293 $263.15 $263.1581294 $160.91 $160.9181295 $303.45 $303.4581296 $268.50 $268.5081297 $169.57 $169.5781298 $510.27 $510.2781299 $244.86 $244.8681300 $189.21 $189.2181301 $284.20 $284.2081302 $419.66 $419.6681303 $95.40 $95.4081304 $119.25 $119.2581305 $139.44 $139.4481310 $195.98 $195.9881311 $235.15 $235.1581313 $202.76 $202.76 end dated 2/28/1981314 $261.96 $261.9681315 $203.47 $203.4781316 $203.47 $203.4781317 $562.08 $562.0881318 $263.15 $263.1581319 $161.78 $161.7881321 $477.00 $477.0081322 $42.02 $42.0281323 $238.50 $238.5081324 $602.90 $602.9081325 $611.82 $611.8281326 $42.02 $42.0281329 $108.92 $108.9281330 $37.37 $37.3781331 $40.60 $40.6081332 $42.84 $42.8481336 $239.57 $239.5781337 $147.23 $147.2381340 $205.05 $205.0581341 $48.67 $48.6781342 $197.76 $197.7681343 P $108.92 $108.9281344 P $108.92 $108.9281345 P $147.23 $147.2381350 $186.03 $186.03 end dated 2/28/1981355 $70.12 $70.12 end dated 2/28/1981370 $394.68 $394.6881371 $321.59 $321.5981372 320.85 $320.8581373 $109.30 $109.3081374 $71.40 $71.4081375 $216.65 $216.6581376 $119.96 $119.9681377 $90.11 $90.1181378 $339.17 $339.1781379 $329.17 $329.1781380 $173.97 $173.9781381 $135.07 $135.0781382 $121.39 $121.3981383 $107.11 $107.1181406 P $224.89 $224.89 PALB2 testing ONLY; see General Provider transmittal No. 8581410 $400.68 $400.68 end dated 2/28/1981411 $1,073.40 $1,073.40 end dated 2/28/1981412 P $1,946.61 $1,946.61 81413 $574.07 $574.07 end dated 2/28/19

81414 $574.07 $574.07 end dated 2/28/1981420 P $603.44 $603.44 Non-Invasive Prenatal Testing81422 $603.44 $603.44 end dated 2/28/1981430 $1,291.88 $1,291.88 end dated 2/28/1981431 $540.26 $540.26 end dated 2/28/1981432 $666.47 $666.47 end dated 2/28/1981433 $430.80 $430.80 end dated 2/28/1981435 $574.07 $574.07 end dated 2/28/1981436 $574.07 $574.07 end dated 2/28/1981437 $430.80 $430.80 end dated 2/28/1981438 $430.80 $430.80 end dated 2/28/1981439 $574.07 $574.07 end dated 2/28/1981440 $2,642.58 $2,642.58 end dated 2/28/1981434 $475.34 $475.3481442 P $1,704.16 $1,704.16 81445 $475.34 $475.34 end dated 2/28/1981450 $603.83 $603.83 end dated 2/28/1981455 $2,321.08 $2,321.08 end dated 2/28/1981460 $1,023.17 $1,023.17 end dated 2/28/1981465 $744.12 $744.12 end dated 2/28/1981490 $668.32 $668.32 end dated 2/28/1981493 $834.75 $834.75 end dated 2/28/1981500 $207.10 $207.10 end dated 2/28/1981503 $713.12 $713.12 end dated 2/28/1981504 $413.40 $413.40 end dated 2/28/1981506 $64.42 $64.42 end dated 2/28/1981507 $632.03 $632.03 end dated 2/28/1981508 $43.17 $43.1781509 $1,182.46 $1,182.46 end dates 2/28/1981510 $44.15 $44.1581511 $122.03 $122.0381512 $55.27 $55.27 end dated 2/28/1981519 P $3,079.04 $3,079.04 81525 $2,477.22 $2,477.22 end dated 2/28/1981535 $460.67 $460.67 end dated 2/28/1981536 $141.16 $141.16 end dated 2/28/1981538 P $2,282.45 $2,282.45 81539 $604.20 $604.20 end dated 2/28/1981540 $2,981.25 $2,981.25 end dated 2/28/1981545 P $2,862.00 $2,862.00 81595 $2,575.80 $2,575.80 82009 $4.44 $4.4482010 $8.02 $8.0282013 $10.96 $10.9682016 $13.62 $13.6282017 $16.56 $16.5682024 $37.91 $37.9182030 $25.32 $25.3282040 $4.86 $4.8682042 $6.19 $6.1982043 $5.68 $5.6882044 $4.95 $4.9582045 $33.31 $33.3182075 $23.85 $23.8582085 $9.53 $9.5382088 $40.00 $40.0082103 $13.19 $13.1982104 $14.20 $14.2082105 $16.46 $16.4682106 $16.46 $16.4682107 $63.22 $63.2282108 $25.01 $25.0182120 $4.76 $4.76

82127 $13.62 $13.6282128 $13.62 $13.6282131 $18.27 $18.2782135 $16.15 $16.1582136 $16.56 $16.5682139 $16.56 $16.5682140 $14.30 $14.3082143 $7.43 $7.4382150 $6.36 $6.3682154 $28.30 $28.3082157 $28.73 $28.7382160 $24.54 $24.5482163 $20.15 $20.1582164 $14.33 $14.3382172 $16.77 $16.7782175 $18.62 $18.6282180 $9.70 $9.7082190 $14.64 $14.6482232 $15.88 $15.8882239 $16.81 $16.8182240 $26.08 $26.0882247 $4.92 $4.9282248 $4.92 $4.9282252 $4.48 $4.4882261 $16.56 $16.5682270 $3.48 $3.4882271 $4.23 $4.2382272 $3.36 $3.3682274 $15.61 $15.6182286 $5.06 $5.0682300 $22.72 $22.7282306 $29.06 $29.0682308 $26.30 $26.3082310 $5.06 $5.0682330 $13.42 $13.4282331 $10.61 $10.6182340 $5.91 $5.9182355 $11.36 $11.3682360 $12.63 $12.6382365 $12.66 $12.6682370 $12.29 $12.2982373 $17.72 $17.7282374 $4.79 $4.7982375 $12.09 $12.0982376 $11.19 $11.1982378 $18.61 $18.6182379 $16.56 $16.5682380 $9.06 $9.0682382 $21.70 $21.7082383 $24.59 $24.5982384 $24.79 $24.7982387 $17.72 $17.7282390 $10.54 $10.5482397 $13.86 $13.8682415 $12.43 $12.4382435 $4.52 $4.5282436 $4.94 $4.9482438 $4.79 $4.7982441 $5.90 $5.9082465 $4.27 $4.2782480 $7.73 $7.7382482 $7.80 $7.8082485 $20.27 $20.27

82495 $19.91 $19.9182507 $27.29 $27.2982523 $18.34 $18.3482525 $12.18 $12.1882528 $22.10 $22.1082530 $16.40 $16.4082533 $16.00 $16.0082540 $4.55 $4.5582542 $19.15 $19.1582550 $6.39 $6.3982552 $13.14 $13.1482553 $11.34 $11.3482554 $11.65 $11.6582565 $5.03 $5.0382570 $5.08 $5.0882575 $9.28 $9.2882585 $11.24 $11.2482595 $6.34 $6.3482600 $19.04 $19.0482607 $14.79 $14.7982608 $14.06 $14.0682610 $14.72 $14.7282615 $8.01 $8.0182626 $24.80 $24.8082627 $21.82 $21.8282633 $30.41 $30.4182634 $28.73 $28.7382638 $12.02 $12.0282642 $25.86 $25.8682652 $37.79 $37.7982656 $11.32 $11.3282657 $17.72 $17.7282658 $35.00 $35.0082664 $48.89 $48.8982668 $18.44 $18.4482670 $27.42 $27.4282671 $31.70 $31.7082672 $21.29 $21.2982677 $23.73 $23.7382679 $24.49 $24.4982693 $14.63 $14.6382696 $23.15 $23.1582705 $5.00 $5.0082710 $16.50 $16.5082715 $18.26 $18.2682725 $14.92 $14.9282726 $17.72 $17.7282728 $13.38 $13.3882731 $63.22 $63.2282735 $18.20 $18.2082746 $14.43 $14.4382747 $17.00 $17.0082757 $17.01 $17.0182759 $21.08 $21.0882760 $10.99 $10.9982775 $20.68 $20.6882776 $9.33 $9.3382777 $35.18 $35.1882784 $9.13 $9.1382785 $16.15 $16.1582787 $7.87 $7.8782800 $8.75 $8.7582803 $20.73 $20.73

82805 $62.62 $62.6282810 $8.56 $8.5682820 $10.61 $10.6182930 $5.34 $5.3482938 $17.36 $17.3682941 $17.31 $17.3182943 $14.02 $14.0282945 $3.86 $3.8682946 $14.79 $14.7982947 $3.86 $3.8682948 $4.01 $4.0182950 $4.66 $4.6682951 $12.63 $12.6382952 $3.85 $3.8582955 $9.52 $9.5282960 $5.94 $5.9482962 $2.61 $2.6182963 $21.08 $21.0882965 $10.45 $10.4582977 $7.07 $7.0782978 $13.99 $13.9982979 $9.27 $9.2782985 $14.79 $14.7983001 $18.24 $18.2483002 $18.17 $18.1783003 $16.36 $16.3683006 $60.10 $60.1083009 $66.11 $66.1183010 $12.35 $12.3583012 $21.38 $21.3883013 $66.11 $66.1183014 $7.71 $7.7183015 $18.48 $18.4883018 $21.56 $21.5683020 $12.63 $12.63 $17.3483021 $17.72 $17.7283026 $3.19 $3.1983030 $8.54 $8.5483033 $6.36 $6.3683036 $9.53 $9.5383037 $9.53 $9.5383045 $5.16 $5.1683050 $7.19 $7.1983051 $7.18 $7.1883060 $8.12 $8.1283065 $7.16 $7.1683068 $8.31 $8.3183069 $3.88 $3.8883070 $4.66 $4.6683080 $16.56 $16.5683088 $28.99 $28.9983090 $16.56 $16.5683150 $18.99 $18.9983491 $17.20 $17.2083497 $12.66 $12.6683498 $26.66 $26.6683500 $22.23 $22.2383505 $23.86 $23.8683516 $11.32 $11.3283518 $8.32 $8.3283519 $14.63 $14.6383520 $13.73 $13.7383525 $11.22 $11.22

83527 $12.70 $12.7083528 $15.76 $15.7683540 $6.35 $6.3583550 $8.58 $8.5883570 $8.69 $8.6983582 $13.91 $13.9183586 $12.56 $12.5683593 $25.81 $25.8183605 $10.49 $10.4983615 $5.92 $5.9283625 $12.56 $12.5683630 $19.27 $19.2783631 $19.27 $19.2783632 $19.85 $19.8583633 $8.94 $8.9483655 $11.89 $11.8983661 $21.58 $21.5883662 $18.56 $18.5683663 $18.56 $18.5683664 $18.56 $18.5683670 $8.99 $8.9983690 $6.77 $6.7783695 $12.70 $12.7083698 $36.82 $36.8283700 $11.05 $11.0583701 $26.92 $26.9283704 $30.97 $30.9783718 $8.05 $8.0583719 $11.42 $11.4283721 $9.37 $9.3783727 $16.87 $16.8783735 $6.57 $6.5783775 $7.23 $7.2383785 $24.14 $24.1483789 $19.17 $19.1783825 $15.96 $15.9683835 $16.63 $16.6383857 $10.54 $10.5483861 $17.87 $17.8783864 $22.66 $22.6683872 $5.76 $5.7683873 $16.89 $16.8983874 $12.68 $12.6883876 $40.43 $40.4383880 $33.31 $33.3183883 $13.35 $13.3583885 $24.06 $24.0683915 $10.95 $10.9583916 $21.78 $21.7883918 $18.76 $18.7683919 $16.15 $16.1583921 $16.86 $16.8683930 $6.49 $6.4983935 $6.69 $6.6983937 $29.30 $29.3083945 $12.63 $12.6383950 $63.22 $63.2283951 $63.22 $63.2283970 $40.51 $40.5183986 $3.51 $3.5183987 $3.51 $3.5183993 $19.27 $19.2784030 $5.40 $5.40

84035 $3.59 $3.5984060 $7.25 $7.2584066 $9.48 $9.4884075 $5.08 $5.0884078 $7.16 $7.1684080 $14.51 $14.5184081 $16.21 $16.2184085 $9.27 $9.2784087 $10.13 $10.1384100 $4.65 $4.6584105 $5.08 $5.0884106 $4.63 $4.6384110 $8.28 $8.2884112 $78.00 $78.0084119 $10.62 $10.6284120 $14.44 $14.4484126 $31.09 $31.0984132 $4.52 $4.5284133 $4.23 $4.2384134 $14.32 $14.3284135 $18.79 $18.7984138 $18.58 $18.5884140 $20.29 $20.2984143 $22.39 $22.3984144 $20.48 $20.4884145 $26.30 $26.3084146 $19.02 $19.0284150 $33.21 $33.2184152 $18.05 $18.0584153 $18.05 $18.0584154 $18.05 $18.0584155 $3.60 $3.6084156 $3.60 $3.6084157 $3.60 $3.6084160 $5.08 $5.0884163 $14.78 $14.7884165 $10.54 $10.54 $17.3484166 $17.50 $17.50 $17.3484181 $16.71 $16.71 $17.3484182 $23.22 $23.22 $15.6084202 $14.08 $14.0884203 $8.45 $8.4584206 $21.22 $21.2284207 $27.58 $27.5884210 $11.51 $11.5184220 $9.27 $9.2784228 $11.42 $11.4284233 $69.86 $69.8684234 $63.68 $63.6884235 $56.63 $56.6384238 $35.89 $35.8984244 $21.58 $21.5884252 $19.86 $19.8684255 $25.06 $25.0684260 $30.41 $30.4184270 $21.33 $21.3384275 $13.19 $13.1984285 $23.10 $23.1084295 $4.72 $4.7284300 $4.77 $4.7784302 $4.77 $4.7784305 $20.87 $20.8784307 $17.94 $17.94

84311 $6.86 $6.8684315 $2.61 $2.6184375 $31.01 $31.0184376 $5.40 $5.4084377 $5.40 $5.4084378 $11.31 $11.3184379 $11.31 $11.3184392 $4.66 $4.6684402 $25.00 $25.0084403 $25.34 $25.3484410 $50.34 $50.3484425 $20.84 $20.8484430 $11.42 $11.4284431 $27.91 $27.9184432 $15.76 $15.7684436 $6.74 $6.7484437 $6.34 $6.3484439 $8.85 $8.8584442 $14.51 $14.5184443 $16.50 $16.5084445 $49.91 $49.9184446 $13.92 $13.9284449 $17.66 $17.6684450 $5.08 $5.0884460 $5.20 $5.2084466 $12.53 $12.5384478 $5.64 $5.6484479 $6.34 $6.3484480 $13.92 $13.9284481 $16.63 $16.6384482 $15.47 $15.4784484 $9.91 $9.9184485 $7.07 $7.0784488 $7.16 $7.1684490 $7.89 $7.8984510 $10.21 $10.2184512 $8.02 $8.0284520 $3.88 $3.8884525 $4.08 $4.0884540 $4.66 $4.6684545 $6.49 $6.4984550 $4.44 $4.4484560 $4.66 $4.6684577 $16.50 $16.5084578 $3.55 $3.5584580 $8.01 $8.0184583 $4.94 $4.9484585 $15.21 $15.2184586 $34.68 $34.6884588 $33.31 $33.3184590 $11.39 $11.3984591 $13.56 $13.5684597 $13.47 $13.4784600 $15.78 $15.7884620 $11.63 $11.6384630 $11.18 $11.1884681 $20.43 $20.4384702 $14.78 $14.7884703 $7.39 $7.3984704 $14.78 $14.7884830 $10.10 $10.1085002 $4.43 $4.4385004 $6.34 $6.34

85007 $3.37 $3.3785008 $3.37 $3.3785009 $4.03 $4.0385013 $5.57 $5.5785014 $2.33 $2.3385018 $2.33 $2.3385025 $7.62 $7.6285027 $6.34 $6.3485032 $4.23 $4.2385041 $2.97 $2.9785044 $4.23 $4.2385045 $3.92 $3.9285046 $5.47 $5.4785048 $2.49 $2.4985049 $4.40 $4.4085055 $28.41 $28.4185060 21.15 $21.1585097 $71.58 $47.5785130 $11.67 $11.6785170 $12.96 $12.9685175 $16.19 $16.1985210 $12.74 $12.7485220 $17.32 $17.3285230 $17.57 $17.5785240 $17.57 $17.5785244 $20.04 $20.0485245 $22.51 $22.5185246 $22.51 $22.5185247 $22.51 $22.5185250 $18.69 $18.6985260 $17.57 $17.5785270 $17.57 $17.5785280 $18.99 $18.9985290 $16.04 $16.0485291 $8.73 $8.7385292 $18.58 $18.5885293 $18.58 $18.5885300 $11.63 $11.6385301 $10.61 $10.6185302 $11.79 $11.7985303 $13.58 $13.5885305 $11.39 $11.3985306 $15.04 $15.0485307 $15.04 $15.0485335 $12.63 $12.6385337 $13.73 $13.7385345 $4.23 $4.2385347 $4.18 $4.1885348 $3.66 $3.6685360 $8.25 $8.2585362 $6.77 $6.7785366 $63.97 $63.9785370 $11.15 $11.1585378 $7.73 $7.7385379 $9.99 $9.9985380 $9.99 $9.9985384 $8.34 $8.3485385 $11.50 $11.5085390 $12.31 $12.31 $31.8385396 17.55 $17.5585397 $24.53 $24.5385400 $7.56 $7.5685410 $7.56 $7.56

85415 $16.87 $16.8785420 $6.41 $6.4185421 $9.99 $9.9985441 $4.12 $4.1285445 $6.69 $6.6985460 $7.59 $7.5985461 $7.44 $7.4485475 $8.71 $8.7185520 $12.85 $12.8585525 $11.62 $11.6285530 $12.85 $12.8585536 $6.34 $6.3485540 $8.44 $8.4485547 $8.44 $8.4485549 $18.40 $18.4085555 $6.56 $6.5685557 $13.11 $13.1185576 $21.08 $21.08 $16.6185597 $17.64 $17.6485598 $17.64 $17.6485610 $3.86 $3.8685611 $3.87 $3.8785612 $13.90 $13.9085613 $9.40 $9.4085635 $9.67 $9.6785651 $3.48 $3.4885652 $2.65 $2.6585660 $5.41 $5.4185670 $5.66 $5.6685675 $6.72 $6.7285705 $9.45 $9.4585730 $5.90 $5.9085732 $6.34 $6.3485810 $11.46 $11.4686000 $6.85 $6.8586001 $6.22 $6.2286003 $5.12 $5.1286005 $7.82 $7.8286008 $17.60 $17.6086021 $14.78 $14.7886022 $18.03 $18.0386023 $12.23 $12.2386038 $11.86 $11.8686039 $10.96 $10.9686060 $7.16 $7.1686063 $5.66 $5.6686077 $47.60 $44.1586078 $47.60 $44.1586079 $47.29 $43.8686140 $5.08 $5.0886141 $12.70 $12.7086146 $24.98 $24.9886147 $24.98 $24.9886148 $15.77 $15.7786152 $241.16 $241.1686153 $28.13 $28.13 $28.1386155 $15.69 $15.6986156 $6.57 $6.5786157 $7.91 $7.9186160 $11.77 $11.7786161 $11.77 $11.7786162 $19.95 $19.9586171 $9.83 $9.83

86200 $12.70 $12.7086215 $13.00 $13.0086225 $13.49 $13.4986226 $11.89 $11.8986235 $17.60 $17.6086255 $11.83 $11.83 $17.3486256 $11.83 $11.83 $17.3486277 $15.45 $15.4586280 $8.05 $8.0586294 $20.33 $20.3386300 $20.43 $20.4386301 $20.43 $20.4386304 $20.43 $20.4386305 $20.43 $20.4386308 $5.08 $5.0886309 $6.34 $6.3486310 $7.23 $7.2386316 $20.43 $20.4386317 $14.71 $14.7186318 $14.38 $14.3886320 $23.79 $23.79 $15.6186325 $21.95 $21.95 $17.3486327 $23.79 $23.79 $19.2786329 $13.79 $13.7986331 $11.76 $11.7686332 $23.92 $23.9286334 $21.93 $21.93 $17.3486335 $28.80 $28.80 $17.3486336 $15.30 $15.3086337 $21.01 $21.0186340 $14.79 $14.7986341 $19.42 $19.4286343 $12.23 $12.2386344 $8.26 $8.2686352 $133.35 $133.3586353 $48.12 $48.1286355 $37.03 $37.0386356 $26.28 $26.2886357 $37.03 $37.0386359 $37.03 $37.0386360 $46.12 $46.1286361 $26.28 $26.2886367 $61.84 $61.8486376 $14.28 $14.2886382 $16.60 $16.6086384 $11.18 $11.1886386 $17.32 $17.3286403 $10.00 $10.0086406 $10.44 $10.4486430 $5.57 $5.5786431 $5.57 $5.5786480 $60.83 $60.8386481 $79.50 $79.5086485 $4.46 $4.4686486 $4.76 $4.7686490 $78.17 $78.1786510 $6.07 $6.0786580 $7.58 $7.5886590 $10.84 $10.8486592 $4.19 $4.1986593 $4.32 $4.3286602 $9.99 $9.9986603 $12.63 $12.63

86606 $14.78 $14.7886609 $12.64 $12.6486611 $9.99 $9.9986612 $12.66 $12.6686615 $12.94 $12.9486617 $15.21 $15.2186618 $16.71 $16.7186619 $13.13 $13.1386622 $8.77 $8.7786625 $12.88 $12.8886628 $11.78 $11.7886631 $11.61 $11.6186632 $12.45 $12.4586635 $11.27 $11.2786638 $11.90 $11.9086641 $14.14 $14.1486644 $14.13 $14.1386645 $16.54 $16.5486648 $14.92 $14.9286651 $12.94 $12.9486652 $12.94 $12.9486653 $12.94 $12.9486654 $12.94 $12.9486658 $12.78 $12.7886663 $12.88 $12.8886664 $15.01 $15.0186665 $17.81 $17.8186666 $9.99 $9.9986668 $11.26 $11.2686671 $12.03 $12.0386674 $14.45 $14.4586677 $14.24 $14.2486682 $12.77 $12.7786684 $15.55 $15.5586687 $8.24 $8.2486688 $13.75 $13.7586689 $19.00 $19.0086692 $16.85 $16.8586694 $14.13 $14.1386695 $12.94 $12.9486696 $19.00 $19.0086698 $12.27 $12.2786701 $8.72 $8.7286702 $13.27 $13.2786703 $13.45 $13.4586704 $11.83 $11.8386705 $11.56 $11.5686706 $10.54 $10.5486707 $11.35 $11.3586708 $12.16 $12.1686709 $11.05 $11.0586710 $13.30 $13.3086711 $14.13 $14.1386713 $15.02 $15.0286717 $12.02 $12.0286720 $12.94 $12.9486723 $12.94 $12.9486727 $12.63 $12.6386732 $12.94 $12.9486735 $12.81 $12.8186738 $12.99 $12.9986741 $12.94 $12.9486744 $12.94 $12.94

86747 $14.76 $14.7686750 $12.94 $12.9486753 $12.16 $12.1686756 $12.65 $12.6586757 $19.00 $19.0086759 $14.49 $14.4986762 $14.13 $14.1386765 $12.64 $12.6486768 $12.94 $12.9486771 $19.46 $19.4686774 $14.52 $14.5286777 $14.13 $14.1386778 $14.14 $14.1486780 $12.99 $12.9986784 $12.33 $12.3386787 $12.64 $12.6486788 $16.54 $16.5486789 $14.13 $14.1386790 $12.64 $12.6486793 $12.94 $12.9486794 $16.54 $16.5486800 $15.61 $15.6186803 $14.00 $14.0086804 $15.21 $15.2186805 $150.66 $150.6686806 $46.71 $46.7186807 $62.53 $62.5386808 $29.13 $29.1386812 $25.33 $25.3386813 $56.92 $56.9286816 $27.34 $27.3486817 $84.38 $84.3886821 $35.89 $35.8986825 $87.04 $87.0486826 $29.04 $29.0486828 $51.03 $51.0386829 $51.03 $51.0386830 $79.25 $79.2586831 $67.92 $67.9286832 $257.38 $257.3886833 $259.01 $259.0186834 $350.94 $350.9486835 $316.98 $316.9886850 $7.77 $7.7786880 $5.29 $5.2986885 $5.62 $5.6286886 $5.08 $5.0886900 $2.93 $2.9386901 $2.93 $2.9386902 $5.05 $5.0586904 $12.99 $12.9986905 $3.76 $3.7686906 $7.61 $7.6187003 $16.53 $16.5387015 $6.55 $6.5587040 $10.13 $10.1387045 $9.27 $9.2787046 $9.27 $9.2787070 $8.46 $8.4687071 $9.27 $9.2787073 $9.27 $9.2787075 $9.29 $9.2987076 $7.93 $7.93

87077 $7.93 $7.9387081 $6.50 $6.5087084 $21.52 $21.5287086 $7.92 $7.9287088 $7.94 $7.9487101 $7.56 $7.5687102 $8.25 $8.2587103 $16.27 $16.2787106 $10.13 $10.1387107 $10.13 $10.1387109 $15.11 $15.1187110 $19.23 $19.2387116 $10.61 $10.6187118 $11.61 $11.6187140 $5.47 $5.4787143 $12.29 $12.2987147 $5.08 $5.0887149 $19.68 $19.6887150 $34.45 $34.4587152 $6.15 $6.1587153 $113.22 $113.2287158 $6.15 $6.1587164 $10.54 $10.54 $19.0987166 $11.09 $11.0987168 $4.19 $4.1987169 $4.19 $4.1987172 $4.19 $4.1987176 $5.77 $5.7787177 $8.74 $8.7487181 $4.66 $4.6687184 $6.77 $6.7787185 $4.66 $4.6687186 $8.48 $8.4887187 $31.94 $31.9487188 $6.52 $6.5287190 $5.81 $5.8187197 $14.75 $14.7587205 $4.19 $4.1987206 $5.29 $5.2987207 $5.88 $5.88 $17.3387209 $17.64 $17.6487210 $4.63 $4.6387220 $4.19 $4.1987230 $19.37 $19.3787250 $19.20 $19.2087252 $25.58 $25.5887253 $19.83 $19.8387254 $19.20 $19.2087255 $33.24 $33.2487260 $11.77 $11.7787265 $11.77 $11.7787267 $11.77 $11.7787269 $11.77 $11.7787270 $11.77 $11.7787271 $11.77 $11.7787272 $11.77 $11.7787273 $11.77 $11.7787274 $11.77 $11.7787275 $11.77 $11.7787276 $12.78 $12.7887278 $12.40 $12.4087279 $13.06 $13.0687280 $11.77 $11.77

87281 $11.77 $11.7787283 $48.34 $48.3487285 $11.77 $11.7787290 $11.77 $11.7787299 $12.80 $12.8087300 $11.77 $11.7787301 $11.77 $11.7787305 $11.77 $11.7787320 $11.93 $11.9387324 $11.77 $11.7787327 $11.77 $11.7787328 $11.77 $11.7787329 $11.77 $11.7787332 $11.77 $11.7787335 $11.77 $11.7787336 $12.72 $12.7287337 $11.77 $11.7787338 $14.12 $14.1287339 $12.72 $12.7287340 $10.14 $10.1487341 $10.14 $10.1487350 $11.31 $11.3187380 $16.11 $16.1187385 $11.77 $11.7787389 $23.64 $23.6487390 $19.13 $19.1387391 $17.41 $17.4187400 $11.77 $11.7787420 $11.77 $11.7787425 $11.77 $11.7787427 $11.77 $11.7787430 $13.36 $13.3687449 $11.77 $11.7787450 $9.41 $9.4187451 $9.41 $9.4187471 $34.45 $34.4587472 $42.04 $42.0487475 $19.68 $19.6887476 $34.45 $34.4587480 $19.68 $19.6887481 $34.45 $34.4587482 $44.31 $44.3187483 $409.07 $409.0787485 $19.68 $19.6887486 $34.45 $34.4587487 $42.04 $42.0487490 $19.68 $19.6887491 $34.45 $34.4587492 $42.51 $42.5187493 $34.45 $34.4587495 $23.87 $23.8787496 $34.45 $34.4587497 $42.04 $42.0487498 $34.45 $34.4587500 $34.45 $34.4587501 $50.36 $50.3687502 $83.52 $83.5287503 $23.23 $23.2387505 $125.91 $125.9187506 $209.47 $209.4787507 $409.07 $409.0787510 $19.68 $19.6887511 $34.45 $34.45

87512 $40.98 $40.9887516 $34.45 $34.4587517 $42.04 $42.0487520 $24.82 $24.8287521 $34.45 $34.4587522 $42.04 $42.0487525 $23.69 $23.6987526 $34.45 $34.4587527 $40.98 $40.9887528 $19.68 $19.6887529 $34.45 $34.4587530 $42.04 $42.0487531 $46.11 $46.1187532 $34.45 $34.4587533 $40.98 $40.9887534 $19.68 $19.6887535 $34.45 $34.4587536 $83.52 $83.5287537 $19.68 $19.6887538 $34.45 $34.4587539 $46.60 $46.6087540 $19.68 $19.6887541 $34.45 $34.4587542 $40.98 $40.9887550 $19.68 $19.6887551 $38.35 $38.3587552 $42.04 $42.0487555 $21.37 $21.3787556 $34.45 $34.4587557 $42.04 $42.0487560 $21.70 $21.7087561 $34.45 $34.4587562 $42.04 $42.0487580 $19.68 $19.6887581 $34.45 $34.4587582 $240.58 $240.5887590 $21.37 $21.3787591 $34.45 $34.4587592 $42.04 $42.0487623 $34.45 $34.4587624 $34.45 $34.4587625 $34.45 $34.4587631 $125.91 $125.9187632 $209.47 $209.4787633 $409.07 $409.0787634 $68.89 $68.8987640 $34.45 $34.4587641 $34.45 $34.4587650 $19.68 $19.6887651 $34.45 $34.4587652 $40.98 $40.9887653 $34.45 $34.4587660 $19.68 $19.6887661 $34.45 $34.4587662 $50.36 $50.3687797 $23.87 $23.8787798 $34.45 $34.4587799 $42.04 $42.0487800 $39.38 $39.3887801 $68.89 $68.8987802 $11.77 $11.7787803 $12.72 $12.7287804 $13.16 $13.16

87806 $26.05 $26.0587807 $11.77 $11.7787808 $12.16 $12.1687809 $17.30 $17.3087810 $28.06 $28.0687850 $19.53 $19.5387880 $13.14 $13.1487899 $12.78 $12.7887900 $127.93 $127.9387901 $252.68 $252.6887902 $252.68 $252.6887903 $479.61 $479.6187904 $25.58 $25.5887905 $11.99 $11.9987906 $126.34 $126.3487910 $252.68 $252.6887912 $252.68 $252.6887999 Report Report88104 $61.08 $61.08 $24.63 $36.4588106 $60.21 $60.21 $18.09 $42.1288108 $57.12 $57.12 $21.12 $36.0088112 $66.74 $66.74 $27.70 $39.0488120 $527.70 $527.70 $50.08 $477.6288121 $423.21 $423.21 $42.62 $380.6488130 $17.64 $17.6488140 $7.84 $7.8488141 $27.48 $27.4888142 $19.88 $19.8888143 $19.88 $19.8888147 $40.20 $40.2088148 $14.91 $14.9188150 $11.92 $11.9288152 $21.97 $21.9788153 $19.10 $19.1088155 $11.65 $11.6588160 $62.15 $62.15 $22.55 $39.6088161 $57.75 $57.75 $21.93 $35.8288162 $83.37 $83.37 $33.37 $50.0088164 $11.92 $11.9288165 $33.56 $33.5688166 $11.92 $11.9288167 $11.92 $11.9288172 $48.95 $48.95 $31.64 $17.3188173 $132.95 $132.95 $61.62 $71.3388174 $20.97 $20.9788175 $26.00 $26.0088177 $25.54 $25.54 $19.27 $6.2788182 $117.60 $117.60 $33.66 $83.9388184 $59.20 $59.2088185 $27.23 $27.2388187 $40.92 $40.9288188 $59.85 $59.8588189 $76.75 $76.7588230 $114.34 $114.3488233 $138.12 $138.1288235 $144.54 $144.5488237 $123.96 $123.9688239 $144.79 $144.7988240 $10.39 $10.3988241 $9.91 $9.9188245 $169.97 $169.9788248 $169.97 $169.9788249 $169.97 $169.97

88261 $210.15 $210.1588262 $122.33 $122.3388263 $147.50 $147.5088264 $122.33 $122.3388267 $176.45 $176.4588269 $163.25 $163.2588271 $21.02 $21.0288272 $32.36 $32.3688273 $31.53 $31.5388274 $34.17 $34.1788275 $40.70 $40.7088280 $26.61 $26.6188283 $67.33 $67.3388285 $21.39 $21.3988289 $33.80 $33.8088291 $28.53 $28.5388300 $17.69 $17.69 $4.99 $12.7088302 $30.58 $30.58 $6.83 $23.7588304 $40.64 $40.64 $11.42 $29.2288305 $67.05 $67.05 $37.09 $29.9788307 $235.18 $235.18 $72.55 $162.6388309 $356.53 $356.53 $128.28 $228.2588311 $18.75 $18.75 $10.86 $7.9088312 $87.78 $87.78 $23.10 $64.6988313 $63.93 $63.93 $10.54 $53.3988314 $80.76 $80.76 $19.53 $61.2388319 $87.70 $87.70 $23.85 $63.8488321 $86.51 $73.0288323 $106.91 $106.91 $81.53 $25.3888325 $155.55 $129.5188329 $44.97 $31.4888331 $84.05 $84.05 $54.82 $29.2388332 $46.27 $46.27 $27.08 $19.1988333 $77.13 $77.13 $54.79 $22.3388334 $48.18 $48.18 $33.43 $14.7588341 $81.10 $81.10 $24.94 $56.1688342 $93.16 $93.16 $30.99 $62.1788344 $150.43 $150.43 $33.67 $116.7688346 $96.22 $96.22 $31.53 $64.6988348 $343.38 $343.38 $72.18 $271.2088350 $67.23 $67.23 $24.88 $42.3588355 $138.39 $138.39 $85.73 $52.6688356 $222.37 $222.37 $124.55 $97.8288358 $111.47 $111.47 $43.65 $67.8288360 $111.36 $111.36 $36.95 $74.4188361 $125.76 $125.76 $43.30 $82.4688362 $202.49 $202.49 $107.99 $94.4888363 $22.94 $19.4188364 $116.06 $116.06 $30.36 $85.7188365 $154.91 $154.91 $38.14 $116.7788366 $231.08 $231.08 $54.07 $177.0188367 $104.22 $104.22 $32.75 $71.4688368 $114.84 $114.84 $37.52 $77.3288369 $97.18 $97.18 $28.10 $69.0888371 $21.81 $21.81 $19.0888372 $22.32 $22.32 $16.7188373 $65.05 $65.05 $23.33 $41.7388374 $286.20 $286.20 $38.29 $247.9188377 $340.24 $340.24 $55.56 $284.6888380 $121.76 $121.76 $49.81 $71.9588381 $135.24 $135.24 $21.87 $113.3788387 $35.31 $35.31 $28.29 $7.0288388 $30.56 $30.56 $20.77 $9.79

88720 $4.92 $4.9288738 $4.92 $4.9288740 $7.45 $7.4588741 $7.45 $7.4589049 $219.29 $53.3389050 $4.63 $4.6389051 $5.41 $5.4189055 $4.19 $4.1989060 $7.02 $7.02 $17.3389125 $4.67 $4.6789160 $3.86 $3.8689190 $4.66 $4.6689220 $14.48 $14.4889230 $3.23 $3.2389300 $8.77 $8.7789310 $8.45 $8.4589320 $11.83 $11.8389321 $11.83 $11.8389322 $15.21 $15.2189325 $10.48 $10.4889329 $19.22 $19.2289330 $9.71 $9.7189331 $19.22 $19.22G0027 $6.38 $6.38 end dated 2/28/19G0103 $18.05 $18.05 end dated 2/28/19G0123 $19.88 $19.88 end dated 2/28/19G0143 $21.50 $21.50 end dated 2/28/19G0144 $34.96 $34.96 end dated 2/28/19G0145 $26.00 $26.00 end dated 2/28/19G0147 $11.65 $11.65 end dated 2/28/19G0148 $25.39 $25.39 end dated 2/28/19G0306 $7.62 $7.62 end dated 2/28/19G0307 $6.34 $6.34 end dated 2/28/19G0328 $15.61 $15.61 end dated 2/28/19G0432 $15.56 $15.56 end dated 2/28/19G0433 $14.54 $14.54 end dated 2/28/19G0435 $11.77 $11.77 end dated 2/28/19G0471 $3.98 $3.98 end dated 2/28/19G0472 $36.85 $36.85 end dated 2/28/19G0475 $23.64 $23.64 end dated 2/28/19G0476 $34.45 $34.45 end dated 2/28/19G0480 $90.97 $90.97 Reimbursed by Beacon HealthG0481 $124.49 $124.49 Reimbursed by Beacon HealthG0499 $27.75 $27.75 end dated 2/28/19