BCBSTX Fee Schedule for PCP's ONLY

Effective September 1, 2011

50000 Series

MD & DO's except Radiologist and Pathologist

 

Procedure Code Modifier Non-Faciliity Allowed Amount Facility Allowed Amount COMMENTS
50010   1,189.88 1,189.88  
50020   1,691.48 1,691.48  
50021   1,508.59 274.34  
50040   1,522.66 1,522.66  
50045   1,526.98 1,526.98  
50060   1,876.53 1,876.53  
50065   1,977.18 1,977.18  
50070   1,957.16 1,957.16  
50075   2,404.65 2,404.65  
50080   1,435.00 1,435.00  
50081   2,106.50 2,106.50  
50100   1,596.24 1,596.24  
50120   1,556.74 1,556.74  
50125   1,655.22 1,655.22  
50130   1,702.84 1,702.84  
50135   1,844.61 1,844.61  
50200   922.03 235.92  
50205   1,184.47 1,184.47  
50220   1,708.79 1,708.79  
50225   1,962.03 1,962.03  
50230   2,109.75 2,109.75  
50234   2,142.21 2,142.21  
50236   2,416.55 2,416.55  
50240   2,180.09 2,180.09  
50250   2,012.35 2,012.35  
50280   1,568.11 1,568.11  
50290   1,491.81 1,491.81  
50300   1,275.47 1,275.47  
50320   2,253.14 2,253.14  
50323   1,393.71 1,393.71  
50325   1,493.26 1,493.26  
50327   345.22 345.22  
50328   301.93 301.93  
50329   283.54 283.54  
50340   1,466.92 1,466.92  
50360   4,005.22 4,005.22  
50365   4,511.69 4,511.69  
50370   1,870.58 1,870.58  
50380   3,162.73 3,162.73  
50382   2,040.49 453.98  
50384   1,704.46 412.32  
50385   1,993.41 387.43  
50386   1,299.18 292.74  
50387   945.84 164.49  
50389   525.95 89.82  
50390   159.62 159.62  
50391   206.16 164.49  
50392   294.36 294.36  
50393   358.21 358.21  
50394   167.20 81.71  
50395   297.61 297.61  
50396   191.55 191.55  
50398   856.02 120.67  
50400   1,903.05 1,903.05  
50405   2,295.89 2,295.89  
50500   2,021.01 2,021.01  
50520   1,697.97 1,697.97  
50525   2,352.16 2,352.16  
50526   2,266.13 2,266.13  
50540   1,870.58 1,870.58  
50541   1,516.16 1,516.16  
50542   1,924.69 1,924.69  
50543   2,454.97 2,454.97  
50544   2,058.34 2,058.34  
50545   2,215.26 2,215.26  
50546   1,976.64 1,976.64  
50547   2,543.71 2,543.71  
50548   2,225.54 2,225.54  
50549   0.00 0.00 INDIVIDUAL CONSIDERATION
50551   597.92 487.53  
50553   635.25 520.54  
50555   682.87 564.37  
50557   695.31 572.48  
50561   790.01 654.19  
50562   963.16 963.16  
50570   813.81 813.81  
50572   881.99 881.99  
50574   937.73 937.73  
50575   1,183.93 1,183.93  
50576   934.48 934.48  
50580   1,004.28 1,004.28  
50590   1,409.02 930.15  
50592   5,492.16 594.67  
50593   7,555.92 773.23  
50600   1,540.51 1,540.51  
50605   1,564.86 1,564.86  
50610   1,556.20 1,556.20  
50620   1,488.57 1,488.57  
50630   1,458.81 1,458.81  
50650   1,703.92 1,703.92  
50660   1,877.62 1,877.62  
50684   240.25 81.71  
50686   235.38 153.67  
50688   130.95 130.95  
50690   160.17 114.17  
50700   1,518.87 1,518.87  
50715   1,889.52 1,889.52  
50722   1,678.49 1,678.49  
50725   1,845.69 1,845.69  
50727   829.51 829.51  
50728   1,137.39 1,137.39  
50740   1,924.69 1,924.69  
50750   1,903.59 1,903.59  
50760   1,835.95 1,835.95  
50770   1,867.34 1,867.34  
50780   1,811.06 1,811.06  
50782   1,876.53 1,876.53  
50783   1,873.83 1,873.83  
50785   1,990.71 1,990.71  
50800   1,520.49 1,520.49  
50810   2,138.97 2,138.97  
50815   2,009.10 2,009.10  
50820   2,158.99 2,158.99  
50825   2,724.98 2,724.98  
50830   2,947.91 2,947.91  
50840   2,023.17 2,023.17  
50845   2,053.47 2,053.47  
50860   1,550.79 1,550.79  
50900   1,381.97 1,381.97  
50920   1,449.61 1,449.61  
50930   1,903.59 1,903.59  
50940   1,453.39 1,453.39  
50945   1,602.20 1,602.20  
50947   2,269.37 2,269.37  
50948   2,105.96 2,105.96  
50949   0.00 0.00 INDIVIDUAL CONSIDERATION
50951   624.97 508.09  
50953   661.22 561.66  
50955   719.66 604.95  
50957   711.01 586.01  
50961   642.29 525.95  
50970   613.61 613.61  
50972   592.50 592.50  
50974   783.51 783.51  
50976   771.61 771.61  
50980   589.80 589.80  
51020   771.07 771.07  
51030   764.03 764.03  
51040   477.79 477.79  
51045   796.50 796.50  
51050   777.56 777.56  
51060   957.21 957.21  
51065   951.25 951.25  
51080   669.34 669.34  
51100   101.73 64.39  
51101   207.78 86.03  
51102   378.77 242.41  
51500   1,065.43 1,065.43  
51520   968.57 968.57  
51525   1,415.52 1,415.52  
51530   1,288.36 1,288.36  
51535   1,271.59 1,271.59  
51550   1,582.72 1,582.72  
51555   2,082.69 2,082.69  
51565   2,122.19 2,122.19  
51570   2,427.37 2,427.37  
51575   3,001.48 3,001.48  
51580   3,126.48 3,126.48  
51585   3,481.44 3,481.44  
51590   3,183.29 3,183.29  
51595   3,610.22 3,610.22  
51596   3,879.15 3,879.15  
51597   3,771.47 3,771.47  
51600   312.21 72.51  
51605   62.77 62.77  
51610   179.10 104.43  
51700   139.60 73.05  
51701   95.23 44.91  
51702   122.83 49.24  
51703   222.39 134.19  
51705   180.73 110.93  
51710   251.61 156.38  
51715   478.33 327.91  
51720   183.97 133.65  
51725   336.02 123.91  
51725 26 123.91 123.91  
51725 TC 212.11 123.91  
51726   490.78 141.23  
51726 26 141.23 141.23  
51726 TC 349.55 141.23  
51727   488.07 174.78  
51727 26 174.78 174.78  
51727 TC 313.30 174.78  
51728   483.20 170.99  
51728 26 170.99 170.99  
51728 TC 312.21 170.99  
51729   529.20 206.16  
51729 26 206.16 206.16  
51729 TC 323.04 206.16  
51736   56.27 19.48  
51736 26 19.48 19.48  
51736 TC 36.79 19.48  
51741   68.72 26.51  
51741 26 26.51 26.51  
51741 TC 42.21 26.51  
51784   327.91 125.54  
51784 26 125.54 125.54  
51784 TC 202.37 125.54  
51785   360.37 126.08  
51785 26 126.08 126.08  
51785 TC 234.30 126.08  
51792   371.19 91.45  
51792 26 91.45 91.45  
51792 TC 279.75 91.45  
51797   215.36 67.10  
51797 26 67.10 67.10  
51797 TC 148.26 67.10  
51798   31.38 31.38  
51800   1,719.62 1,719.62  
51820   1,751.54 1,751.54  
51840   1,075.71 1,075.71  
51841   1,280.24 1,280.24  
51845   967.49 967.49  
51860   1,211.52 1,211.52  
51865   1,466.38 1,466.38  
51880   768.36 768.36  
51900   1,346.80 1,346.80  
51920   1,238.04 1,238.04  
51925   1,720.70 1,720.70  
51940   2,657.88 2,657.88  
51960   2,288.85 2,288.85  
51980   1,169.86 1,169.86  
51990   1,232.08 1,232.08  
51992   1,379.26 1,379.26  
51999   0.00 0.00 INDIVIDUAL CONSIDERATION
52000   340.35 207.24  
52001   620.10 474.54  
52005   465.89 219.69  
52007   836.00 273.80  
52010   644.99 268.93  
52204   675.83 233.21  
52214   1,009.15 344.14  
52224   1,206.11 279.75  
52234   406.91 406.91  
52235   477.25 477.25  
52240   833.84 833.84  
52250   401.50 401.50  
52260   346.85 346.85  
52265   659.60 267.84  
52270   632.55 300.85  
52275   860.35 411.24  
52276   439.37 439.37  
52277   537.85 537.85  
52281   467.51 241.87  
52282   556.79 556.79  
52283   460.48 332.78  
52285   464.26 323.04  
52290   404.20 404.20  
52300   468.59 468.59  
52301   484.28 484.28  
52305   461.02 461.02  
52310   404.20 251.07  
52315   707.76 453.44  
52317   1,465.30 575.19  
52318   783.51 783.51  
52320   407.45 407.45  
52325   530.28 530.28  
52327   433.96 433.96  
52330   1,073.00 436.13  
52332   798.12 241.87  
52334   424.76 424.76  
52341   479.41 479.41  
52342   521.08 521.08  
52343   580.06 580.06  
52344   629.30 629.30  
52345   670.96 670.96  
52346   757.54 757.54  
52351   518.91 518.91  
52352   609.82 609.82  
52353   700.18 700.18  
52354   648.24 648.24  
52355   772.15 772.15  
52400   792.17 792.17  
52402   441.54 441.54  
52450   772.69 772.69  
52500   803.53 803.53  
52601   1,376.56 1,376.56  
52630   730.49 730.49  
52640   489.15 489.15  
52647   3,304.50 1,064.34  
52648   3,385.12 1,135.77  
52649   1,592.46 1,592.46  
52700   719.12 719.12  
53000   245.12 245.12  
53010   484.28 484.28  
53020   160.17 160.17  
53025   108.76 108.76  
53040   644.99 644.99  
53060   300.85 268.93  
53080   703.97 703.97  
53085   1,052.44 1,052.44  
53200   254.86 232.13  
53210   1,269.96 1,269.96  
53215   1,530.77 1,530.77  
53220   745.09 745.09  
53230   999.95 999.95  
53235   1,045.41 1,045.41  
53240   701.81 701.81  
53250   707.76 707.76  
53260   330.61 293.82  
53265   361.45 305.18  
53270   349.01 314.38  
53275   433.96 433.96  
53400   1,319.74 1,319.74  
53405   1,442.03 1,442.03  
53410   1,614.10 1,614.10  
53415   1,860.84 1,860.84  
53420   1,350.59 1,350.59  
53425   1,548.09 1,548.09  
53430   1,582.18 1,582.18  
53431   1,899.26 1,899.26  
53440   1,452.31 1,452.31  
53442   1,282.95 1,282.95  
53444   1,308.38 1,308.38  
53445   1,449.07 1,449.07  
53446   1,061.10 1,061.10  
53447   1,336.52 1,336.52  
53448   2,110.29 2,110.29  
53449   1,009.69 1,009.69  
53450   672.59 672.59  
53460   753.21 753.21  
53500   1,231.00 1,231.00  
53502   797.04 797.04  
53505   800.83 800.83  
53510   1,039.99 1,039.99  
53515   1,307.30 1,307.30  
53520   915.54 915.54  
53600   139.06 104.97  
53601   135.28 87.66  
53605   106.06 106.06  
53620   197.50 144.47  
53621   186.14 118.50  
53660   118.50 68.18  
53661   117.42 66.56  
53665   63.31 63.31  
53850   3,743.33 935.56  
53852   3,609.14 1,023.22  
53855   1,139.56 132.03  
53860   2,325.11 372.28  
53899   0.00 0.00 INDIVIDUAL CONSIDERATION
54000   251.07 176.40  
54001   311.67 228.34  
54015   508.09 508.09  
54050   209.41 167.20  
54055   191.55 148.80  
54056   224.56 177.48  
54057   225.10 153.13  
54060   300.85 213.19  
54065   352.26 275.42  
54100   319.79 203.45  
54105   445.87 352.80  
54110   1,027.01 1,027.01  
54111   1,320.83 1,320.83  
54112   1,548.09 1,548.09  
54115   743.47 696.40  
54120   1,041.08 1,041.08  
54125   1,339.76 1,339.76  
54130   1,967.98 1,967.98  
54135   2,496.09 2,496.09  
54150   268.39 161.79  
54160   372.82 237.00  
54161   324.66 324.66  
54162   436.67 326.28  
54163   360.37 360.37  
54164   318.17 318.17  
54200   179.65 139.06  
54205   880.91 880.91  
54220   341.98 222.39  
54230   159.08 130.95  
54231   231.05 192.63  
54235   148.26 120.67  
54240   162.33 106.06  
54240 26 106.06 106.06  
54240 TC 56.27 106.06  
54250   199.67 180.73  
54250 26 180.73 180.73  
54250 TC 18.94 180.73  
54300   1,063.80 1,063.80  
54304   1,243.45 1,243.45  
54308   1,206.11 1,206.11  
54312   1,381.43 1,381.43  
54316   1,682.28 1,682.28  
54318   1,179.60 1,179.60  
54322   1,294.85 1,294.85  
54324   1,607.07 1,607.07  
54326   1,536.18 1,536.18  
54328   1,546.46 1,546.46  
54332   1,677.95 1,677.95  
54336   1,948.50 1,948.50  
54340   933.40 933.40  
54344   1,598.95 1,598.95  
54348   1,852.19 1,852.19  
54352   2,620.55 2,620.55  
54360   1,194.75 1,194.75  
54380   1,324.07 1,324.07  
54385   1,622.76 1,622.76  
54390   2,022.63 2,022.63  
54400   874.96 874.96  
54401   1,081.66 1,081.66  
54405   1,334.89 1,334.89  
54406   1,203.95 1,203.95  
54408   1,302.43 1,302.43  
54410   1,419.85 1,419.85  
54411   1,689.86 1,689.86  
54415   869.55 869.55  
54416   1,169.32 1,169.32  
54417   1,480.45 1,480.45  
54420   1,165.53 1,165.53  
54430   1,058.39 1,058.39  
54435   687.74 687.74  
54440   1,035.06 1,035.06  
54450   117.42 95.23  
54500   122.83 122.83  
54505   347.93 347.93  
54512   883.62 883.62  
54520   537.31 537.31  
54522   958.83 958.83  
54530   833.84 833.84  
54535   1,214.23 1,214.23  
54550   806.78 806.78  
54560   1,108.71 1,108.71  
54600   745.09 745.09  
54620   495.65 495.65  
54640   782.43 782.43  
54650   1,163.91 1,163.91  
54660   585.47 585.47  
54670   665.55 665.55  
54680   1,286.74 1,286.74  
54690   1,126.03 1,126.03  
54692   1,252.65 1,252.65  
54699   0.00 0.00 INDIVIDUAL CONSIDERATION
54700   350.09 350.09  
54800   241.87 241.87  
54830   612.53 612.53  
54840   530.28 530.28  
54860   689.36 689.36  
54861   930.15 930.15  
54865   588.72 588.72  
54900   1,255.89 1,255.89  
54901   1,746.67 1,746.67  
55000   196.42 138.52  
55040   557.33 557.33  
55041   838.71 838.71  
55060   625.51 625.51  
55100   357.67 271.63  
55110   637.96 637.96  
55120   585.47 585.47  
55150   806.78 806.78  
55175   599.00 599.00  
55180   1,136.85 1,136.85  
55200   766.74 455.07  
55250   683.95 375.52  
55300   300.85 300.85  
55400   824.10 824.10  
55450   610.90 420.43  
55500   642.83 642.83  
55520   703.43 703.43  
55530   582.76 582.76  
55535   704.51 704.51  
55540   844.66 844.66  
55550   696.94 696.94  
55559   0.00 0.00 INDIVIDUAL CONSIDERATION
55600   694.77 694.77  
55605   855.48 855.48  
55650   1,174.73 1,174.73  
55680   560.58 560.58  
55700   371.74 228.34  
55705   441.00 441.00  
55706   616.31 616.31  
55720   742.39 742.39  
55725   971.82 971.82  
55801   1,793.75 1,793.75  
55810   2,169.27 2,169.27  
55812   2,651.39 2,651.39  
55815   2,907.87 2,907.87  
55821   1,441.49 1,441.49  
55831   1,558.91 1,558.91  
55840   2,206.61 2,206.61  
55842   2,362.44 2,362.44  
55845   2,699.55 2,699.55  
55860   1,441.49 1,441.49  
55862   1,811.06 1,811.06  
55865   2,202.82 2,202.82  
55866   2,857.55 2,857.55  
55870   288.95 236.46  
55873   10,086.10 1,379.26  
55875   1,255.35 1,255.35  
55876   224.56 166.66  
55899   0.00 0.00 INDIVIDUAL CONSIDERATION
55920   715.33 715.33  
55970   50.00% 50.00% PCT OF BILLED CHARGES
55980   50.00% 50.00% PCT OF BILLED CHARGES
56405   175.32 173.15  
56420   198.04 147.72  
56440   294.36 294.36  
56441   234.84 224.02  
56442   77.38 77.38  
56501   209.41 183.43  
56515   358.75 318.71  
56605   132.57 97.40  
56606   60.06 47.08  
56620   802.45 802.45  
56625   963.16 963.16  
56630   1,414.98 1,414.98  
56631   1,793.21 1,793.21  
56632   2,083.78 2,083.78  
56633   1,839.20 1,839.20  
56634   1,944.17 1,944.17  
56637   2,288.31 2,288.31  
56640   2,256.39 2,256.39  
56700   300.85 300.85  
56740   477.79 477.79  
56800   388.51 388.51  
56805   1,842.45 1,842.45  
56810   417.73 417.73  
56820   176.94 136.90  
56821   235.38 183.97  
57000   305.72 305.72  
57010   696.94 696.94  
57020   150.97 131.49  
57022   269.47 269.47  
57023   500.52 500.52  
57061   182.35 156.92  
57065   306.80 274.34  
57100   140.69 105.51  
57105   216.44 200.21  
57106   769.99 769.99  
57107   2,253.68 2,253.68  
57109   2,575.64 2,575.64  
57110   1,444.74 1,444.74  
57111   2,591.33 2,591.33  
57112   2,429.54 2,429.54  
57120   821.93 821.93  
57130   286.78 257.02  
57135   307.89 277.04  
57150   76.30 47.08  
57155   522.70 288.41  
57156   238.63 163.41  
57160   122.83 76.30  
57170   103.89 77.38  
57180   226.18 170.45  
57200   477.79 477.79  
57210   587.63 587.63  
57220   514.59 514.59  
57230   643.37 643.37  
57240   1,070.84 1,070.84  
57250   1,074.62 1,074.62  
57260   1,327.86 1,327.86  
57265   1,463.13 1,463.13  
57267   418.27 418.27  
57268   773.77 773.77  
57270   1,282.95 1,282.95  
57280   1,540.51 1,540.51  
57282   807.86 807.86  
57283   1,111.96 1,111.96  
57284   1,324.07 1,324.07  
57285   1,090.32 1,090.32  
57287   1,106.01 1,106.01  
57288   1,147.67 1,147.67  
57289   1,175.81 1,175.81  
57291   953.42 953.42  
57292   1,324.61 1,324.61  
57295   776.48 776.48  
57296   1,530.77 1,530.77  
57300   878.75 878.75  
57305   1,464.76 1,464.76  
57307   1,663.34 1,663.34  
57308   1,038.91 1,038.91  
57310   749.96 749.96  
57311   853.86 853.86  
57320   867.38 867.38  
57330   1,201.78 1,201.78  
57335   1,876.53 1,876.53  
57400   215.90 215.90  
57410   172.07 172.07  
57415   256.48 256.48  
57420   185.06 144.47  
57421   249.45 196.96  
57423   1,484.24 1,484.24  
57425   1,562.16 1,562.16  
57426   1,354.37 1,354.37  
57452   173.69 146.64  
57454   246.20 218.60  
57455   228.89 178.56  
57456   216.44 166.66  
57460   465.89 262.97  
57461   524.33 304.10  
57500   208.32 121.21  
57505   162.87 146.64  
57510   211.03 185.60  
57511   233.21 212.11  
57513   230.51 212.65  
57520   490.24 436.67  
57522   423.14 390.67  
57530   552.46 552.46  
57531   2,750.41 2,750.41  
57540   1,252.11 1,252.11  
57545   1,321.37 1,321.37  
57550   656.35 656.35  
57555   964.78 964.78  
57556   911.75 911.75  
57558   200.75 182.35  
57700   498.89 498.89  
57720   493.48 493.48  
57800   95.77 77.38  
58100   175.86 141.23  
58110   77.38 66.01  
58120   406.91 349.55  
58140   1,474.50 1,474.50  
58145   873.34 873.34  
58146   1,860.84 1,860.84  
58150   1,597.33 1,597.33  
58152   2,005.32 2,005.32  
58180   1,535.64 1,535.64  
58200   2,105.42 2,105.42  
58210   2,813.72 2,813.72  
58240   4,464.62 4,464.62  
58260   1,330.02 1,330.02  
58262   1,483.70 1,483.70  
58263   1,596.24 1,596.24  
58267   1,697.97 1,697.97  
58270   1,418.76 1,418.76  
58275   1,582.72 1,582.72  
58280   1,692.56 1,692.56  
58285   2,112.45 2,112.45  
58290   1,854.35 1,854.35  
58291   2,011.27 2,011.27  
58292   2,119.49 2,119.49  
58293   2,202.82 2,202.82  
58294   1,962.57 1,962.57  
58300   114.71 82.25  
58301   153.67 109.84  
58321   119.04 74.13  
58322   138.52 94.69  
58323   28.14 20.02  
58340   195.88 93.07  
58345   450.20 450.20  
58346   699.10 699.10  
58350   155.30 126.62  
58353   1,720.70 353.88  
58356   3,188.16 559.50  
58400   709.38 709.38  
58410   1,292.15 1,292.15  
58520   1,296.48 1,296.48  
58540   1,459.89 1,459.89  
58541   1,382.51 1,382.51  
58542   1,544.30 1,544.30  
58543   1,570.81 1,570.81  
58544   1,697.97 1,697.97  
58545   1,438.78 1,438.78  
58546   1,815.93 1,815.93  
58548   2,869.99 2,869.99  
58550   1,419.85 1,419.85  
58552   1,575.14 1,575.14  
58553   1,826.75 1,826.75  
58554   2,113.00 2,113.00  
58555   432.34 305.72  
58558   573.57 430.17  
58559   553.55 553.55  
58560   624.97 624.97  
58561   883.62 883.62  
58562   599.54 468.05  
58563   2,816.43 553.55  
58565   3,065.87 698.02  
58570   1,486.40 1,486.40  
58571   1,646.57 1,646.57  
58572   1,847.32 1,847.32  
58573   2,108.67 2,108.67  
58578   0.00 0.00 INDIVIDUAL CONSIDERATION
58579   0.00 0.00 INDIVIDUAL CONSIDERATION
58600   585.47 585.47  
58605   529.20 529.20  
58611   124.99 124.99  
58615   396.09 396.09  
58660   1,080.04 1,080.04  
58661   1,034.04 1,034.04  
58662   1,133.06 1,133.06  
58670   587.63 587.63  
58671   587.09 587.09  
58672   1,185.01 1,185.01  
58673   1,288.90 1,288.90  
58679   0.00 0.00 INDIVIDUAL CONSIDERATION
58700   1,241.28 1,241.28  
58720   1,157.41 1,157.41  
58740   1,406.32 1,406.32  
58750   1,452.31 1,452.31  
58752   1,369.52 1,369.52  
58760   1,306.22 1,306.22  
58770   1,359.78 1,359.78  
58800   514.04 481.04  
58805   647.70 647.70  
58820   523.24 523.24  
58822   1,161.74 1,161.74  
58823   1,453.94 278.13  
58825   1,125.49 1,125.49  
58900   700.18 700.18  
58920   1,123.32 1,123.32  
58925   1,185.55 1,185.55  
58940   824.10 824.10  
58943   1,808.90 1,808.90  
58950   1,728.27 1,728.27  
58951   2,220.67 2,220.67  
58952   2,506.38 2,506.38  
58953   3,101.04 3,101.04  
58954   3,361.31 3,361.31  
58956   2,119.49 2,119.49  
58957   2,417.09 2,417.09  
58958   2,657.34 2,657.34  
58960   1,486.40 1,486.40  
58970   340.35 303.56  
58974   404.32 404.32  
58976   385.26 333.32  
58999   0.00 0.00 INDIVIDUAL CONSIDERATION
59000   205.08 131.49  
59001   297.06 297.06  
59012   331.15 331.15  
59015   252.15 215.36  
59020   110.38 59.52  
59020 26 59.52 59.52  
59020 TC 50.86 59.52  
59025   75.21 47.62  
59025 26 47.62 47.62  
59025 TC 27.60 47.62  
59030   158.54 158.54  
59050   82.79 82.79  
59051   68.72 68.72  
59070   679.08 508.09  
59072   853.86 853.86  
59074   666.09 514.04  
59076   844.66 844.66  
59100   1,347.88 1,347.88  
59120   1,288.36 1,288.36  
59121   1,289.98 1,289.98  
59130   1,327.32 1,327.32  
59135   1,326.78 1,326.78  
59136   1,424.18 1,424.18  
59140   574.11 574.11  
59150   1,246.15 1,246.15  
59151   1,215.31 1,215.31  
59160   338.19 286.78  
59200   117.96 73.59  
59300   310.05 239.17  
59320   247.28 247.28  
59325   347.93 347.93  
59350   455.07 455.07  
59400   2,929.92 2,929.92  
59409   1,190.42 1,190.42  
59410   1,509.13 1,509.13  
59412   153.67 153.67  
59414   135.28 135.28  
59425   674.21 519.46  
59426   1,205.03 916.08  
59430   251.07 205.08  
59510   3,262.68 3,262.68  
59514   1,351.13 1,351.13  
59515   1,828.38 1,828.38  
59525   791.09 791.09  
59610   3,193.03 3,193.03  
59612   1,341.93 1,341.93  
59614   1,651.98 1,651.98  
59618   3,437.07 3,437.07  
59620   1,407.40 1,407.40  
59622   1,894.93 1,894.93  
59812   511.34 476.71  
59820   612.53 574.11  
59821   618.48 576.81  
59830   707.22 707.22  
59840   346.85 334.40  
59841   616.85 583.31  
59850   554.09 554.09  
59851   645.53 645.53  
59852   802.45 802.45  
59855   673.13 673.13  
59856   791.63 791.63  
59857   830.59 830.59  
59866   343.60 343.60  
59870   765.66 765.66  
59871   217.52 217.52  
59897   0.00 0.00 INDIVIDUAL CONSIDERATION
59898   0.00 0.00 INDIVIDUAL CONSIDERATION
59899   0.00 0.00 INDIVIDUAL CONSIDERATION