CÓDIGOS DE CUBIERTAS / COPAGOS VISITAS SIQUIÁTRICAS Y...

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CÓDIGOS DE CUBIERTAS / COPAGOS

1 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

A-01 NADA # # A-26 g $10.00 20 12 A-01 NADA # A-26 $5.00 20

A-02 $15.00 # # A-27 $12.00 # # A-02 $5.00 # A-27 $5.00 #

A-03 gt $10.00 20 b A-28 g $10.00 15 12 A-03 t $5.00 20 A-28 $5.00 20

A-04 $10.00 # # A-29 g $15.00 20 12 A-04 $5.00 # A-29 $5.00 20

A-05 g $15.00 20 12 A-30 g $15.00 # # A-05 $5.00 20 A-30 $5.00 #

A-06 g $10.00 20 12 A-31 g r $15.00 20 12 A-06 $5.00 20 A-31 NADA 20

A-07 * * * A-32 g $9.00 20 12 A-07 * * A-32 $5.00 20

A-08 g $10.00 20 12 A-33 $10.00 # # A-08 $5.00 20 A-33 $5.00 #

A-09 NADA # # A-34 g $10.00 20 b A-09 NADA # A-34 $5.00 20

A-10 $15.00 # # A-35 g $10.00 20 12 A-10 $5.00 20 A-35 $5.00 20

A-11 g $15.00 20 12 A-36 g $15.00 20 12 A-11 $5.00 20 A-36 $5.00 20

A-12 g $15.00 20 12 A-37 $12.00 # # A-12 $5.00 20 A-37 $5.00 #

A-13 $10.00 A-38 g $10.00 20 12 A-13 NADA * A-38 $5.00 20

A-14 g $15.00 20 12 A-39 g $5.00 20 12 A-14 $5.00 20 A-39 $5.00 20

A-15 $15.00 # # A-40 * * * A-15 $5.00 # A-40 * *

A-16 $20.00 # # A-41 s t $18.00 20 12 A-16 $5.00 # A-41 t $5.00 20

A-17 g $10.00 20 12 A-42 * * * A-17 $5.00 20 A-42 * *

A-18 * * * A-43 g $10.00 20 12 A-18 * * A-43 $5.00 20

A-19 $10.00 # # A-44 g $15.00 20 12 A-19 $10.00 # A-44 $5.00 20

A-20 $15.00 # # A-45 go $15.00 20 12 A-20 $5.00 # A-45 $5.00 20

A-21 $15.00 # # A-46 $18.00 # # A-21 $5.00 # A-46 $5.00 #

A-22 $15.00 15 15 A-47 * * * A-22 $5.00 15 A-47 * *

A-23 $15.00 15 15 A-48 g $10.00 20 12 A-23 $5.00 15 A-48 $5.00 20

A-24 * * * A-49 ogt $12.00 20 b A-24 * * A-49 o,i $5.00 20

A-25 g $15.00 15 15 A-50 g $10.00 20 12 A-25 $5.00 20 A-50 $5.00 20

CÓDIGOS DE CUBIERTAS / COPAGOS

2 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

A-01 NADA # # A-26 g $10.00 20 12 A-01 NADA # A-26 $5.00 20

A-02 $15.00 # # A-27 $12.00 # # A-02 $5.00 # A-27 $5.00 #

A-03 gt $10.00 20 b A-28 g $10.00 15 12 A-03 t $5.00 20 A-28 $5.00 20

A-04 $10.00 # # A-29 g $15.00 20 12 A-04 $5.00 # A-29 $5.00 20

A-05 g $15.00 20 12 A-30 g $15.00 # # A-05 $5.00 20 A-30 $5.00 #

A-06 g $10.00 20 12 A-31 g r $15.00 20 12 A-06 $5.00 20 A-31 NADA 20

A-07 * * * A-32 g $9.00 20 12 A-07 * * A-32 $5.00 20

A-08 g $10.00 20 12 A-33 $10.00 # # A-08 $5.00 20 A-33 $5.00 #

A-09 NADA # # A-34 g $10.00 20 b A-09 NADA # A-34 $5.00 20

A-10 $15.00 # # A-35 g $10.00 20 12 A-10 $5.00 20 A-35 $5.00 20

A-11 g $15.00 20 12 A-36 g $15.00 20 12 A-11 $5.00 20 A-36 $5.00 20

A-12 g $15.00 20 12 A-37 $12.00 # # A-12 $5.00 20 A-37 $5.00 #

A-13 $10.00 A-38 g $10.00 20 12 A-13 NADA * A-38 $5.00 20

A-14 g $15.00 20 12 A-39 g $5.00 20 12 A-14 $5.00 20 A-39 $5.00 20

A-15 $15.00 # # A-40 * * * A-15 $5.00 # A-40 * *

A-16 $20.00 # # A-41 s t $18.00 20 12 A-16 $5.00 # A-41 t $5.00 20

A-17 g $10.00 20 12 A-42 * * * A-17 $5.00 20 A-42 * *

A-18 * * * A-43 g $10.00 20 12 A-18 * * A-43 $5.00 20

A-19 $10.00 # # A-44 g $15.00 20 12 A-19 $10.00 # A-44 $5.00 20

A-20 $15.00 # # A-45 go $15.00 20 12 A-20 $5.00 # A-45 $5.00 20

A-21 $15.00 # # A-46 $18.00 # # A-21 $5.00 # A-46 $5.00 #

A-22 $15.00 15 15 A-47 * * * A-22 $5.00 15 A-47 * *

A-23 $15.00 15 15 A-48 g $10.00 20 12 A-23 $5.00 15 A-48 $5.00 20

A-24 * * * A-49 ogt $12.00 20 b A-24 * * A-49 o,i $5.00 20

A-25 g $15.00 15 15 A-50 g $10.00 20 12 A-25 $5.00 20 A-50 $5.00 20

CÓDIGOS DE CUBIERTAS / COPAGOS

3 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DE TERAPIAS

A-51 g $10.00 15 15 A-76 $15.00 # # A-51 $7.00 15 A-76 $5.00 #

A-52 g $18.00 20 12 A-77 g $7.00 20 12 A-52 $5.00 20 A-77 $5.00 20

A-53 g $15.00 20 12 A-78 g $3.00 20 12 A-53 $5.00 20 A-78 $5.00 20

A-54 g $10.00 20 12 A-79 g $12.00 20 12 A-54 $5.00 20 A-79 $5.00 20

A-55 g $10.00 20 12 A-80 $20.00 # # A-55 $5.00 20 A-80 $5.00 #

A-56 g $10.00 20 12 A-81 g $15.00 20 12 A-56 $5.00 20 A-81 $5.00 20

A-57 g $10.00 20 U A-82 g $12.00 20 12 A-57 U u A-82 $5.00 20

A-58 * * * A-83 g $10.00 20 12 A-58 * * A-83 $5.00 20

A-59 g $10.00 20 12 A-84 $35.00 # # A-59 $5.00 20 A-84 $5.00 #

A-60 g $15.00 20 12 A-85 g $10.00 20 12 A-60 $5.00 20 A-85 $5.00 20

A-61 g $15.00 20 12 A-86 g $12.00 20 12 A-61 $5.00 20 A-86 $5.00 20

A-62 * * * A-87 * * * A-62 * * A-87 * *

A-63 * * * A-88 g $15.00 15 115 A-63 * * A-88 $5.00 15

A-64 * * * A-89 $15.00 # # A-64 * * A-89 $10.00 #

A-65 g $10.00 20 12 A-90 * * * A-65 $5.00 20 A-90 * *

A-66 $15.00 # # A-91 $15.00 # # A-66 $15.00 # A-91 $10.00 #

A-67 g NADA 20 12 A-92 $15.00 # # A-67 NADA 20 A-92 $7.00 #

A-68 g $15.00 20 12 A-93 $12.00 # # A-68 $5.00 20 A-93 $10.00 #

A-69 g $12.00 15 N/C A-94 g $12.00 20 12 A-69 N/C N/C A-94 $5.00 20

A-70 g $15.00 20 12 A-95 g $10.00 E e A-70 $5.00 20 A-95 $10.00 E

A-71 $15.00 # # A-96 $10.00 # # A-71 $5.00 # A-96 $5.00 #

A-72 g $7.00 15 12 A-97 g $12.00 20 b A-72 i $5.00 20 A-97 $5.00 20

A-73 g $15.00 15 15 A-98 b 50% # # A-73 $5.00 15 A-98 50% #

A-74 $6.00 15 15 A-99 g $15.00 # # A-74 t $6.00 15 A-99 $7.00 #

A-75 g $12.00 20 12 AA-01 $15.00 # # A-75 $5.00 20 AA-01 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

4 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

AA-02 $20.00 # # AA-27g $7.00 20 12 AA-02 $5.00 # AA-27 $5.00 20

AA-03 g $2.00 12 12 AA-28 t N/C N/C N/C AA-03 $2.00 20 AA-28 t N/C N/C

AA-04 € € € AA-29 $15.00 # # AA-04 € € AA-29 $15.00 #

AA-05 t $12.00 30 30 AA-30 g t $12.00 20 12 AA-05 t $5.00 30 AA-30 t $6.50 20

AA-06 $10.00 # # AA-31 g t $10.00 20 b AA-06 $10.00 # AA-31 t $5.00 20

AA-07 g $15.00 20 12 AA-32 g $15.00 20 b AA-07 $5.00 20 AA-32 $5.00 20

AA-08 g $10.00 15 15 AA-33gpuv $10.00 20 N/C AA-08 $7.00 15 AA-33 N/C N/C

AA-09 € € € AA-34 * * * AA-09 € € AA-34 * *

AA-10 $15.00 # # AA-35 g $7.00 15 15 AA-10 $5.00 # AA-35 $5.00 15

AA-11 $12.00 # # AA-36 g $15.00 20 12 AA-11 $5.00 # AA-36 $5.00 20

AA-12 g $12.00 # # AA-37 $15.00 # # AA-12 $5.00 # AA-37 $5.00 #

AA-13 g $15.00 15 12 AA-38 g $15.00 20 12 AA-13 $5.00 20 AA-38 $5.00 20

AA-14 $12.00 # # AA-39 * * * AA-14 $5.00 # AA-39 * *

AA-15 gt $21.00 20 N/C AA-40 g $7.00 20 12 AA-15 t N/C N/C AA-40 $5.00 20

AA-16 $15.00 20 12 AA-41 g $15.00 20 12 AA-16 $5.00 20 AA-41 $5.00 20

AA-17 g $15.00 20 12 AA-42 $15.00 # # AA-17 $5.00 20 AA-42 $15.00 #

AA-18 g $12.00 20 12 AA-43 * * * AA-18 $5.00 20 AA-43 * *

AA-19 $18.00 # # AA-44 g $15.00 20 12 AA-19 $5.00 # AA-44 $5.00 20

AA-20 NADA # # AA-45 g $15.00 20 12 AA-20 NADA # AA-45 $5.00 20

AA-21 g $10.00 20 12 AA-46 g $15.00 20 12 AA-21 $5.00 20 AA-46 $5.00 20

AA-22 g $15.00 20 12 AA-47 g $12.00 20 N/C AA-22 $5.00 20 AA-47 N/C N/C

AA-23 g $10.00 20 12 AA-48 * * * AA-23 $5.00 20 AA-48 * *

AA-24 g $10.00 20 12 AA-49 g $15.00 20 N/C AA-24 $5.00 20 AA-49 N/C N/C

AA-25 g $15.00 15 N/C AA-50 $15.00 # # AA-25 N/C N/C AA-50 $5.00 #

AA-26 $10.00 # # AA-51 g $15.00 20 N/C AA-26 $5.00 # AA-51 N/C N/C

CÓDIGOS DE CUBIERTAS / COPAGOS

5 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

AA-52 $15.00 # # AA-77ag $10.00 15 12 AA-52 $5.00 # AA-77 a $7.00 15

AA-53 g $10.00 20 12 AA-78 g $10.00 15 12 AA-53 $5.00 20 AA-78 $7.00 15

AA-54 g * * * AA-79ag $12.00 15 8 AA-54 * * AA-79 a N/C N/C

AA-55 og $10.00 20 12 AA-80 g $12.00 15 8 AA-55 oi $5.00 20 AA-80 N/C N/C

AA-56 $15.00 20 12 AA-81 * * * AA-56 $5.00 20 AA-81 * *

AA-57 H 12 12 AA-82 g $15.00 # # AA-57 h 20 AA-82 $5.00 #

AA-58 g $15.00 20 12 AA-83 g $10.00 20 12 AA-58 $5.00 20 AA-83 $5.00 20

AA-59 g $15.00 15 8 AA-84 $15.00 # # AA-59 N/C AA-84 $5.00 #

AA-60g, $10.00 # # AA-85 g $10.00 20 12 AA-60 $5.00 # AA-85 $5.00 20

AA-61 * * * AA-86 g $15.00 20 12 AA-61 * * AA-86 $5.00 20

AA-62g, $10.00 20 12 AA-87 g $15.00 20 12 AA-62 $5.00 20 AA-87 $5.00 20

AA-63g, $10.00 # # AA-88 g $15.00 20 12 AA-63 $5.00 # AA-88 $5.00 20

AA-64 g $10.00 20 12 AA-89 $15.00 15 8 AA-64 $5.00 20 AA-89 N/C

AA-65 g $10.00 20 12 AA-90 g * * * AA-65 $5.00 20 AA-90 * *

AA-66g, $12.00 #, € #, € AA-91 g $7.00 30 12 AA-66 $12.00 #, € AA-91 $5.00 20

AA-67 g $15.00 20 12 AA-92g, $15.00 # # AA-67 $5.00 20 AA-92 $5.00 #

AA-68 $10.00 20 12 AA-93 g $10.00 20 12 AA-68 $5.00 20 AA-93 $5.00 20

AA-69 $20.00 #, € #, € AA-94 g, $12.00 # # AA-69 $20.00 #, € AA-94 $5.00 #

AA-70 g, $10.00 # # AA-95 g $5.00 20 12 AA-70 $5.00 # AA-95 $5.00 20

AA-71 g $10.00 20 12 AA-96 g $12.00 15 12 AA-71 $5.00 20 AA-96 $5.00 20

AA-72 $6.00 15 15 AA-97 g $15.00 20 12 AA-72 $6.00 15 AA-97 $5.00 20

AA-73og $12.00 20 12 AA-98 g $15.00 20 12 AA-73o i $5.00 20 AA-98 $5.00 20

AA-74 g $10.00 15 12 AA-99 g $10.00 20 12 AA-74 $7.00 15 AA-99 $5.00 20

AA-75 g $15.00 # # AB-01 $10.00 # # AA-75 $5.00 # AB-01 $10.00 #

AA-76 g $12.00 20 12 AB-02 g, $15.00 # # AA-76 $5.00 20 AB-02 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

6 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

AB-03 * * * AB-28 g $10.00 20 12 AB-03 * * AB-28 $5.00 20

AB-04g, $10.00 # # AB-29 g $7.00 30 12 AB-04 $5.00 # AB-29 $5.00 20

AB-05 g $18.00 20 12 AB-30 g $15.00 20 12 AB-05 $5.00 20 AB-30 $5.00 20

AB-06 g $15.00 15 b AB-31 * * * AB-06 $5.00 20 AB-31 * *

AB-07go $15.00 20 12 AB-32 $18.00 # # AB-07 $5.00 20 AB-32 $5.00 #

AB-08 g $15.00 20 12 AB-33 g $10.00 20 12 AB-08 $5.00 20 AB-33 $5.00 20

AB-09 g $20.00 # # AB-34g $15.00 20 12 AB-09 $5.00 # AB-34 $5.00 20

AB-10 g $18.00 # # AB-35 $7.00 X X AB-10 $5.00 # AB-35 * *

AB-11 g $12.00 # # AB-36 $15.00 # # AB-11 $5.00 # AB-36 $5.00 #

AB-12 g $15.00 20 12 AB-37 g $12.00 # # AB-12 $5.00 20 AB-37 $5.00 #

AB-13 g $15.00 20 12 AB-38 $15.00 # # AB-13 $5.00 20 AB-38 $5.00 #

AB-14 g $10.00 20 12 AB-39 g $10.00 20 12 AB-14 $5.00 20 AB-39 $5.00 20

AB-15 $20.00 # # AB-40 $12.00 X X AB-15 $5.00 # AB-40 * *

AB-16 $15.00 # # AB-41 g $7.00 20 12 AB-16 $5.00 # AB-41 $5.00 20

AB-17 g $10.00 30 12 AB-42 g $15.00 20 12 AB-17 $5.00 20 AB-42 $5.00 20

AB-18 g $15.00 20 12 AB-43 g $10.00 20 12 AB-18 $5.00 20 AB-43 $5.00 20

AB-19 g $10.00 20 12 AB-44 g $15.00 15 15 AB-19 $5.00 20 AB-44 $5.00 15

AB-20 g $15.00 20 12 AB-45 $10.00 # # AB-20 $5.00 20 AB-45 $5.00 #

AB-21 * * * AB-46 g $15.00 20 12 AB-21 * * AB-46 $5.00 20

AB-22 g $15.00 20 12 AB-47 $10.00 # # AB-22 $5.00 20 AB-47 $5.00 #

AB-23 * * * AB-48 g $10.00 20 12 AB-23 * * AB-48 $5.00 20

AB-24 g $10.00 20 12 AB-49 $12.00 12 12 AB-24 $5.00 20 AB-49 $5.00 20

AB-25 $12.00 # # AB-50 g $15.00 20 12 AB-25 $5.00 # AB-50 $5.00 20

AB-26 $15.00 # # AB-51 g $10.00 20 12 AB-26 $5.00 # AB-51 $5.00 20

AB-27 * * * AB-52 g $12.00 20 12 AB-27 * * AB-52 $5.00 20

CÓDIGOS DE CUBIERTAS / COPAGOS

7 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

AB-53 g $10.00 20 12 AB-78 g $10.00 20 12 AB-53 $5.00 20 AB-78 $5.00 20

AB-54 $2.00 # # AB-79 g $12.00 20 12 AB-54 NADA # AB-79 $5.00 20

AB-55 g $15.00 20 12 AB-80 g $15.00 20 12 AB-55 $5.00 20 AB-80 $5.00 20

AB-56 g $15.00 20 12 AB-81 g $8.00 20 12 AB-56 $5.00 20 AB-81 $5.00 20

AB-57 $15.00 # # AB-82 g $15.00 20 12 AB-57 $15.00 # AB-82 $5.00 20

AB-58 g $15.00 20 12 AB-83 $15.00 # # AB-58 $5.00 20 AB-83 $5.00 #

AB-59 * * * AB-84 $15.00 # # AB-59 * * AB-84 $5.00 #

AB-60 g $15.00 20 12 AB-85 g $5.00 20 12 AB-60 $5.00 20 AB-85 $5.00 20

AB-61 g $15.00 20 12 AB-86 g $10.00 20 12 AB-61 $5.00 20 AB-86 $5.00 20

AB-62 NADA # # AB-87 g * * * AB-62 NADA # AB-87 * *

AB-63 * * * AB-88 g $15.00 20 12 AB-63 * * AB-88 $5.00 20

AB-64 $8.00 # # AB-89 $10.00 # # AB-64 f $8.00 # AB-89 $5.00 #

AB-65 g $15.00 20 12 AB-90 $15.00 # # AB-65 $5.00 20 AB-90 $15.00 #

AB-66 g $7.00 20 12 AB-91 $15.00 # # AB-66 $5.00 20 AB-91 $15.00 #

AB-67 $10.00 # # AB-92 * * * AB-67 $15.00 # AB-92 * *

AB-68 g $15.00 20 12 AB-93 g * * * AB-68 $5.00 20 AB-93 * *

AB-69 $8.00 # # AB-94 g, $15.00 20 12 AB-69 $10.00 # AB-94 $15.00 20

AB-70 g $7.00 20 12 AB-95 g $10.00 20 12 AB-70 $5.00 20 AB-95 $5.00 20

AB-71 $15.00 # # AB-96 $20.00 # # AB-71 $5.00 # AB-96 $5.00 #

AB-72 * * * AB-97 ot $15.00 20 N/C AB-72 * * AB-97iot N/C N/C

AB-73 g $10.00 20 12 AB-98 € € € AB-73 $5.00 20 AB-98 € €

AB-74 g $12.00 20 12 AB-99 $20.00 # # AB-74 $5.00 20 AB-99 $5.00 #

AB-75 g $7.00 20 12 AC-01 g * * * AB-75 $5.00 20 AC-01 y y

AB-76 $15.00 # # AC-02 $15.00 # # AB-76 $5.00 # AC-02 $5.00 #

AB-77 g $10.00 20 12 AC-03 $15.00 # # AB-77 $5.00 20 AC-03 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

8 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

AC-04 g $15.00 20 12 AC-29 * * * AC-04 $5.00 20 AC-29 oi * *

AC-05 g $12.00 20 12 AC-30 * * * AC-05 $5.00 20 AC-30 * *

AC-06 $22.00 # # AC-31 * * * AC-06 $5.00 # AC-31 * *

AC-07 * * * AC-32 g $10.00 30 12 AC-07 * * AC-32 $5.00 20

AC-08 t $7.00 # # AC-33 * * * AC-08 t $5.00 # AC-33 * *

AC-09 g $15.00 20 12 AC-34 * * * AC-09 * * AC-34 * *

AC-10 g $12.00 20 b AC-35 g $15.00 15 15 AC-10 $5.00 20 AC-35 15 15

AC-11 $10.00 # # AC-36 ¥ $5.00 15 15 AC-11 $5.00 # AC-36 ¥ $5.00 15

AC-12 g $15.00 20 12 AC-37 g $15.00 20 12 AC-12 $5.00 20 AC-37 $5.00 20

AC-13 g $15.00 20 12 AC-38 g $10.00 20 12 AC-13 $5.00 20 AC-38 $5.00 20

AC-14 g $15.00 20 12 AC-39 g $12.00 20 12 AC-14 $5.00 20 AC-39 $5.00 20

AC-15 g $15.00 20 12 AC-40 g $10.00 20 12 AC-15 $5.00 20 AC-40 $5.00 20

AC-16 g $15.00 20 12 AC-41 * * * AC-16 $5.00 20 AC-41 * *

AC-17 * * * AC-42 $15.00 # # AC-17 * * AC-42 $5.00 #

AC-18 g $8.00 20 12 AC-43 * * * AC-18 $5.00 20 AC-43 * *

AC-19 g * * * AC-44 g $10.00 p q q AC-19 * * AC-44 $10.00 q

AC-20 g $10.00 20 15 AC-45 * * * AC-20 $5.00 20 AC-45 * *

AC-21 g $10.00 20 12 AC-46 * * * AC-21 $5.00 20 AC-46 * *

AC-22 g $12.00 20 12 AC-47 g $15.00 20 12 AC-22 $5.00 20 AC-47 $5.00 20

AC-23 g $12.00 20 12 AC-48 g $15.00 20 12 AC-23 $5.00 20 AC-48 $5.00 20

AC-24 g $15.00 20 15 AC-49 y AC-24 $5.00 15 AC-49 y

AC-25 g $15.00 20 12 AC-50 g $15.00 20 12 AC-25 $5.00 20 AC-50 $5.00 20

AC-26 * * * AC-51 $18.00 # # AC-26 * * AC-51 $5.00 #

AC-27 * * * AC-52 $15.00 # # AC-27 * * AC-52 $5.00 #

AC-28 * * * AC-53 $10.00 # # AC-28 i * * AC-53 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

9 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL CUBIERTA COA/DE TERAPIAS CUBIERTA COA/DED TERAPIAS

AC-54 t N/C N/C N/C AC-80 g $15.00 20 12 AC-54 t N/C N/C AC-80 $5.00 20

AC-55 $10.00 # # AC-81 g $3.00 20 12 AC-55 $10.00 # AC-81 $5.00 20

AC-56 g $12.00 20 12 AC-82 g $10.00 15 15 AC-56 $5.00 20 AC-82 $5.00 15

AC-57 $7.00 # # AC-83 g $15.00 20 12 AC-57 $7.00 # AC-83 $5.00 20

AC-58 g,u $10.00 20 12 AC-84 $10.00 # # AC-58 N/C N/C AC-84 $5.00 #

AC-59 g $10.00 20 12 AC-85 g, $7.00 20 12 AC-59 $5.00 20 AC-85 $5.00 20

AC-60 € € € AC-86 $18.00 # # AC-60 € € AC-86 $5.00 #

AC-61 g $5.00 20 12 AC-87 $10.00 # # AC-61 $5.00 20 AC-87 $5.00 #

AC-62 * * * AC-88 g $15.00 20 12 AC-62 * * AC-88 $5.00 20

AC-63 g $12.00 20 12 AC-89 $15.00 # # AC-63 50% 20 AC-89 $5.00 #

AC-64 g $10.00 20 12 AC-90 $12.00 20 b, s AC-64 $5.00 20 AC-90 $5.00 20

AC-65 g $10.00 20 b AC-91 * * * AC-65 i $5.00 20 AC-91 * *

AC-66 g $15.00 15 N/C AC-92 g $15.00 20 12 AC-66 N/C N/C AC-92 $5.00 20

AC-67 a,g $15.00 20 12 AC-93 y AC-67 a $5.00 20 AC-93 y

AC-68 * * * AC-94 g $15.00 20 12 AC-68 * * AC-94 $5.00 20

AC-69 g $10.00 20 12 AC-95 $15.00 # # AC-69 $5.00 20 AC-95 $5.00 #

AC-70 $18.00 # # AC-96 g $12.00 20 12 AC-70 $5.00 # AC-96 $5.00 20

AC-71 $15.00 # # AC-97 g $7.00 20 12 AC-71 $5.00 # AC-97 $5.00 20

AC-72 g $15.00 20 12 AC-98 $12.00 # # AC-72 $5.00 20 AC-98 $5.00 #

AC-73 s $12.00 20 12 AC-99 g $20.00 20 12 AC-73 $5.00 20 AC-99 $5.00 20

AC-74 $10.00 # # AD-18 g $10.00 15 12 AC-74 $5.00 # AD-18 $5.00 20

AC-75 $12.00 # # AD-21 g $7.00 20 12 AC-75 $5.00 # AD-21 $5.00 20

AC-76 $15.00 # # AD-22 g $10.00 20 12 AC-76 NADA # AD-22 $5.00 20

AC-77 $15.00 # # AD-23 g $20.00 20 12 AC-77 $5.00 # AD-23 $5.00 20

AC-78 $12.00 # # AD-24 g $15.00 20 12 AC-78 $5.00 # AD-24 $5.00 20

AC-79 gi $15.00 20 12 AC-79 i $5.00 20

CÓDIGOS DE CUBIERTAS / COPAGOS

10 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

AD-25 $12.00 20 12 AD-50 g $10.00 15 12 AD-25 $5.00 20 AD-50 $7.00 15

AD-26 g $10.00 20 12 AD-51 g $15.00 20 12 AD-26 $5.00 20 AD-51 $5.00 20

AD-27 $15.00 20 12 AD-52 g $7.00 20 12 AD-27 $5.00 20 AD-52 $5.00 20

AD-28 $15.00 20 12 AD-53 s,x $15.00 20 12 AD-28 $5.00 20 AD-53 $5.00 20

AD-29 $10.00 # # AD-54 g $8.00 20 12 AD-29 $10.00 # AD-54 $5.00 20

AD-30 g $12.00 15 12 AD-55 g $10.00 20 12 AD-30 $5.00 20 AD-55 $5.00 20

AD-31 g $12.00 20 12 AD-56 g $10.00 20 12 AD-31 $5.00 20 AD-56 $5.00 20

AD-32 g $15.00 20 12 AD-57 $8.00 # # AD-32 $5.00 20 AD-57 $5.00 #

AD-33 $9.00 # # AD-58 $15.00 # # AD-33 $5.00 # AD-58 $5.00 #

AD-34 $12.00 # # AD-59 g $8.00 20 12 AD-34 $5.00 # AD-59 $5.00 20

AD-35 g $10.00 20 12 AD-60 $10.00 p q q AD-35 $5.00 20 AD-60 $10.00 q

AD-36 y * * * AD-61 $15.00 # # AD-36 y * * AD-61 $5.00 #

AD-37 y * * * AD-62 g $12.00 20 12 AD-37 y * * AD-62 $5.00 20

AD-38 y * * * AD-63 * * * AD-38 y * * AD-63 * *

AD-39 y * * * AD-64 $15.00 # # AD-39 y * * AD-64 $5.00 #

AD-40 $15.00 # # AD-65 g $20.00 20 12 AD-40 $5.00 # AD-65 $5.00 20

AD-41 y * * * AD-66 * * * AD-41 y * * AD-66 * *

AD-42 * * * AD-67 * * * AD-42 * * AD-67 * *

AD-43 g $15.00 15 N/C AD-68 g $12.00 20 12 AD-43 N/C N/C AD-68 $5.00 20

AD-44 $15.00 # # AD-69 g $15.00 20 12 AD-44 $5.00 # AD-69 $5.00 20

AD-45 $12.00 20 12 AD-70 g $10.00 30 12 AD-45 $5.00 20 AD-70 $5.00 20

AD-46 $15.00 # # AD-71 g $15.00 15 15 AD-46 $7.00 # AD-71 $5.00 15

AD-47 g $10.00 20 12 AD-72 g $15.00 20 12 AD-47 $5.00 20 AD-72 $5.00 20

AD-48 * * * AD-73 g $10.00 20 12 AD-48 * * AD-73 $5.00 20

AD-49 NADA # # AD-74 g $10.00 20 12 AD-49 NADA # AD-74 $5.00 20

CÓDIGOS DE CUBIERTAS / COPAGOS

11 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

AD-75 g $10.00 20 12 AD-88 $15.00 20 12 AD-75 $5.00 20 AD-88 $5.00 20

AD-76 g $15.00 20 12 AD-89 $12.00 20 12 AD-76 $5.00 20 AD-89 $5.00 20

AD-77 g $10.00 50 50 AD-90 $10.00 20 12 AD-77 N/C N/C AD-90 $5.00 20

AD-78 g $10.00 20 12 AD-91 $15.00 20 12 AD-78 $5.00 20 AD-91 $5.00 20

AD-79 * * * AD-92 * * * AD-79 * * AD-92 * *

AD-80 g $15.00 20 12 AD-93 $15.00 20 12 AD-80 $5.00 20 AD-93 $5.00 20

AD-81 $8.00 # # AD-94 g $15.00 20 12 AD-81 $5.00 # AD-94 $5.00 20

AD-82 g $15.00 20 12 AD-95 $15.00 20 N/C AD-82 $5.00 20 AD-95 N/C N/C

AD-83 $15.00 # # AD-96 g $15.00 20 12 AD-83 $5.00 # AD-96 $5.00 20

AD-84 $10.00 # # AD-97 g $12.00 20 12 AD-84 $5.00 # AD-97 $5.00 20

AD-85 * * * AD-98 $7.00 30 12 AD-85 * * AD-98 $5.00 20

AD-86 $10.00 15 15 AD-99 y y y AD-86 $5.00 15 AD-99 * *

AD-87 $10.00 15 15 AE-01 $5.00 # # AD-87 $5.00 15 AE-01 $5.00 #

AE-02 $12.00 # # AE-14 $10.00 # # AE-02 $5.00 # AE-14 $5.00 #

AE-03 $15.00 # # AE-15 g $15.00 20 12 AE-03 $15.00 # AE-15 $5.00 20

AE-04 $10.00 # # AE-16 $10.00 # # AE-04 $5.00 # AE-16 $5.00 #

AE-05 $8.00 # # AE-17 g $7.00 12 12 AE-05 $5.00 # AE-17 NADA 20

AE-06 g $15.00 20 12 AE-18 g $7.00 12 12 AE-06 $15.00 20 AE-18 NADA 20

AE-07 g $15.00 20 12 AE-19 g $5.00 12 12 AE-07 $5.00 20 AE-19 NADA 20

AE-08 * * * AE-20 g $5.00 12 12 AE-08 * * AE-20 NADA 20

AE-09 * * * AE-21 $5.00 # # AE-09 * * AE-21 NADA #

AE-10 * * * AE-22 * * * AE-10 * * AE-22 * *

AE-11 $7.00 # # AE-23 $10.00 20 12 AE-11 $5.00 # AE-23 $5.00 20

AE-12 * * * AE-24 $12.00 # # AE-12 * * AE-24 $5.00 #

AE-13 $8.00 # # AE-25 $12.00 # # AE-13 $5.00 # AE-25 $5.00 #

AE-26 $15.00 # # AE-26 $5.00 #

AE-27 $15.00 # # AE-27 $5.00 #

AE-28 $10.00 # # AE-28 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

12 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

AE-29 $20.00 # # AE-58 $15.00 # # AE-29 $10.00 # AE-58 $5.00 #

AE-30 g $15.00 20 12 AE-59 $15.00 15 15 AE-30 $5.00 20 AE-59 $5.00 15

AE-31 g $15.00 20 12 AE-60 * * * AE-31 $5.00 20 AE-60 * *

AE-32 g $15.00 20 12 AE-61 g $15.00 20 12 AB-32 $5.00 20 AE-61 N/C N/C

AE-33 $10.00 # # AE-62 * * * AE-33 $5.00 # AE-62 * *

AE-34 g $12.00 20 12 AE-63 * * * AE-34 $5.00 20 AE-63 * *

AE-35 g $12.00 20 12 AE-64 $15.00 20 N/C AE-35 $5.00 20 AE-64 N/C N/C

AE-36 $20.00 20 12 AE-65 $12.00 20 20 AE-36 $5.00 20 AE-65 $5.00 20

AE-37 $15.00 # # AE-66 $15.00 20 20 AE-37 $5.00 # AE-66 $5.00 20

AE-38 $15.00 20 12 AE-67 NADA 15 N/C AE-38 $5.00 20 AE-67 NADA N/C

AE-39 $18.00 20 12 AE-68 $15.00 # # AE-39 $5.00 20 AE-68 $5.00 #

AE-40 $7.00 20 12 AE-69 g $15.00 20 12 AE-40 $5.00 20 AE-69 $5.00 20

AE-41 $15.00 20 12 AE-70 g $15.00 20 20 AE-41 $5.00 20 AE-70 $5.00 20

AE-42 $18.00 # # AE-71 g $15.00 20 12 AE-42 $5.00 # AE-71 $5.00 20

AE-43 g $15.00 20 12 AE-72 $15.00 # # AE-43 $5.00 20 AE-72 $5.00 #

AE-44 * * * AE-73 $15.00 # # AE-44 * * AE-73 $5.00 #

AE-45 * * * AE-74 g $20.00 20 20 AE-45 * * AE-74 $5.00 20

AE-46 $15.00 20 12 AE-75 g $15.00 20 12 AE-46 $5.00 20 AE-75 $5.00 20

AE-47 g 15.00 20 12 AE-76 g $7.00 # # AE-47 $5.00 20 AE-76 $5.00 #

AE-48 g $6.00 20 N/C AE-77 g $15.00 20 12 AE-48 N/C N/C AE-77 $5.00 20

AE-49 $12.00 30 30 AE-78 g $15.00 20 12 AE-49 $5.00 20 AE-78 $5.00 20

AE-50 $10.00 30 30 AE-79 g $15.00 20 12 AE-50 $5.00 20 AE-79 $5.00 20

AE-51 $18.00 # # AE-80 g $20.00 20 12 AE-51 $5.00 # AE-80 $10.00 20

AE-52 20% # # AE-81 g $15.00 20 12 AE-52 20% # AE-81 $5.00 20

AE-53 $7.00 # # AE-82 y * * * AE-53 $7.00 # AE-82 y * *

AE-54 g $7.00 20 12 AE-83 $18.00 20 12 AE-54 $5.00 20 AE-83 N/C N/C

AE-55 $7.00 20 12 AE-84 * * * AE-55 $5.00 20 AE-84 * *

AE-56 $15.00 # # AE-85 y * * * AE-56 $5.00 # AE-85 y * *

AE-57 g $15.00 20 12 AE-86 g $15.00 20 12 AE-57 $5.00 20 AE-86 $5.00 20

CÓDIGOS DE CUBIERTAS / COPAGOS

13 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

AE-87 $15.00 # # AF-17 g $18.00 20 12 AE-87 $15.00 # AF-17 $5.00 20

AE-88 NADA # # AF-18 * * * AE-88 NADA # AF-18 * *

AE-89 g $15.00 20 12 AF-19 $10.00 20 12 AE-89 $5.00 20 AF-19 $7.00 20

AE-90 g $10.00 # # AF-20 $10.00 20 12 AE-90 $5.00 # AF-20 $7.00 20

AE-91 g $15.00 20 12 AF-21 $15.00 20 12 AE-91 $5.00 20 AF-21 N/C

AE-92 g $12.00 20 12 AF-22 * * * AE-92 $5.00 20 AF-22 * *

AE-93 g $10.00 E e AF-23 g $10.00 20 12 AE-93 $5.00 e AF-23 $5.00 20

AE-94 g $18.00 20 12 AF-24 g $15.00 20 12 AE-94 $5.00 20 AF-24 $5.00 20

AE-95 g $15.00 20 12 AF-25 g $15.00 20 12 AE-95 $5.00 20 AF-25 $5.00 20

AE-96 $12.00 # # AF-26 $15.00 20 12 AE-96 $5.00 # AF-26 $5.00 20

AE-97 g $10.00 20 12 AF-27 g $15.00 20 12 AE-97 $5.00 20 AF-27 $5.00 20

AE-98 g $12.00 20 12 AF-28 g $12.00 20 12 AE-98 $5.00 20 AF-28 $5.00 20

AE-99 $15.00 # # AF-29 o,g $15.00 20 12 AE-99 $5.00 # AF-29 $5.00 20

AF-01 g $18.00 20 12 AF-30 * * * AF-01 $5.00 20 AF-30 * *

AF-02 80% # # AF-31 $15.00 20 12 AF-02 80% # AF-31 N/C

AF-03 $12.00 # # AF-32 $15.00 20 12 AF-03 $12.00 # AF-32 $5.00 20

AF-04 $15.00 # # AF-33 g $15.00 20 12 AF-04 $5.00 # AF-33 $5.00 20

AF-05 $15.00 # # AF-34 g $10.00 20 12 AF-05 $5.00 # AF-34 $5.00 20

AF-06 * * * AF-35 g $12.00 20 12 AF-06 * * AF-35 $5.00 20

AF-07 $10.00 20 12 AF-36 $15.00 # # AF-07 $5.00 20 AF-36 $5.00 #

AF-08 g $15.00 12 12 AF-37 g $15.00 20 12 AF-08 $5.00 20 AF-37 $5.00 20

AF-09 g $15.00 12 12 AF-38 * * * AF-09 $5.00 20 AF-38 * *

AF-10 g $12.00 12 12 AF-39 * * * AF-10 $5.00 20 AF-39 * *

AF-11 $10.00 X X AF-40 $10.00 20 12 AF-11 $10.00 20 AF-40 $5.00 20

AF-12 $25.00 20 12 AF-41 $12.00 20 12 AF-12 $5.00 20 AF-41 $5.00 20

AF-13 $20.00 # # AF-42 * * * AF-13 $5.00 # AF-42 * *

AF-14 $15.00 # # AF-43 g $15.00 15 15 AF-14 $5.00 # AF-43 $5.00 15

AF-15 g $10.00 20 12 AF-44 $15.00 15 15 AF-15 $5.00 20 AF-44 $5.00 15

AF-16 g $15.00 20 12 AF-45 $20.00 # # AF-16 $5.00 20 AF-45 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

14 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

AF-46 $8.00 20 20 AF-75 * * * AF-46 $5.00 20 AF-75 * *

AF-47 $10.00 15 15 AF-76 * * * AF-47 $5.00 15 AF-76 * *

AF-48 $10.00 15 15 AF-77 * * * AF-48 $5.00 15 AF-77 * *

AF-49 $12.00 15 15 AF-78 * * * AF-49 $5.00 15 AF-78 * *

AF-50 $12.00 15 15 AF-79 * * * AF-50 $5.00 15 AF-79 * *

AF-51 $15.00 15 15 AF-80 * * * AF-51 $5.00 15 AF-80 * *

AF-52 $15.00 15 15 AF-81 * * * AF-52 $5.00 15 AF-81 * *

AF-53 $18.00 # # AF-82 * * * AF-53 $5.00 # AF-82 * *

AF-54 $15.00 # # AF-83 * * * AF-54 $5.00 # AF-83 * *

AF-55 $18.00 # # AF-84 * * * AF-55 $5.00 # AF-84 * *

AF-56 $15.00 # # AF-85 * * * AF-56 $5.00 # AF-85 * *

AF-57 N/C N/C N/C AF-86 NADA # # AF-57 N/C N/C AF-86 NADA #

AF-58 $15.00 # # AF-87 * * * AF-58 $5.00 # AF-87 * *

AF-59 $10.00 20 12 AF-88 $15.00 20 12 AF-59 $5.00 20 AF-88 $5.00 20

AF-60 * * * AF-89 * * * AF-60 * * AF-89 * *

AF-61 $15.00 20 12 AF-90 * * * AF-61 $5.00 20 AF-90 * *

AF-62 $18.00 # # AF-91 * * * AF-62 $5.00 # AF-91 * *

AF-63 g $15.00 50 50 AF-92 $15.00 20 12 AF-63 N/C N/C AF-92 $5.00 20

AF-64 g $15.00 20 12 AF-93 * * * AF-64 $5.00 20 AF-93 * *

AF-65 g $10.00 50 50 AF-94 $10.00 # # AF-65 N/C N/C AF-94 $10.00 #

AF-66 $15.00 # # AF-95 $15.00 20 12 AF-66 $5.00 # AF-95 $5.00 20

AF-67 $15.00 20 12 AF-96 $15.00 20 12 AF-67 $5.00 20 AF-96 $5.00 20

AF-68 $18.00 # # AF-97 $15.00 20 12 AF-68 $5.00 # AF-97 $5.00 20

AF-69 $15.00 20 12 AF-98 $15.00 20 12 AF-69 NADA 20 AF-98 $5.00 20

AF-70 * * * AF-99 $15.00 20 12 AF-70 * * AF-99 $5.00 20

AF-71 * * * AG-01 $15.00 20 12 AF-71 * * AG-01 $5.00 20

AF-72 * * * AG-02 $15.00 # # AF-72 * * AG-02 $5.00 #

AF-73 * * * AG-03 $15.00 20 12 AF-73 * * AG-03 $10.00 20

AF-74 * * * AG-04 $12.00 20 12 AF-74 * * AG-04 $5.00 20

CÓDIGOS DE CUBIERTAS / COPAGOS

15 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

AG-05 $15.00 20 12 AG-34 $15.00 # # AG-05 $5.00 20 AG-34 $5.00 #

AG-06 $15.00 20 12 AG-35 $15.00 20 12 AG-06 $5.00 20 AG-35 $5.00 20

AG-07 NADA # # AG-36 NADA # # AG-07 NADA # AG-36 NADA #

AG-08 $10.00 # # AG-37 $15.00 20 12 AG-08 $5.00 # AG-37 $5.00 20

AG-09 $12.00 # # AG-38 $7.00 20 12 AG-09 $5.00 # AG-38 $5.00 20

AG-10 $12.00 # # AG-39 $8.00 # # AG-10 $12.00 # AG-39 $10.00 #

AG-11 NADA # # AG-40 $12.00 20 12 AG-11 NADA # AG-40 $5.00 20

AG-12 $15.00 # # AG-41 $10.00 20 12 AG-12 $5.00 # AG-41 $5.00 20

AG-13 $15.00 # # AG-42 $12.00 20 12 AG-13 $15.00 # AG-42 $5.00 20

AG-14 $12.00 15 15 AG-43 $15.00 20 12 AG-14 $5.00 15 AG-43 $5.00 20

AG-15 $15.00 # # AG-44 $12.00 20 12 AG-15 $5.00 # AG-44 $5.00 20

AG-16 $15.00 20 12 AG-45 $15.00 20 12 AG-16 $5.00 20 AG-45 * *

AG-17 $15.00 20 12 AG-46 $15.00 20 12 AG-17 $5.00 20 AG-46 * *

AG-18 $15.00 # # AG-47 $10.00 20 12 AG-18 $15.00 # AG-47 $5.00 20

AG-19 $15.00 20 12 AG-48 $15.00 20 12 AG-19 $5.00 20 AG-48 $5.00 20

AG-20 $10.00 # # AG-49 $18.00 * * AG-20 $10.00 # AG-49 $5.00 *

AG-21 $15.00 20 12 AG-50 $8.00 20 12 AG-21 $5.00 20 AG-50 $5.00 20

AG-22 $15.00 20 12 AG-51 * * * AG-22 $5.00 20 AG-51 * *

AG-23 $15.00 # # AG-52 $15.00 20 N/C AG-23 $15.00 # AG-52 N/C N/C

AG-24 $15.00 20 12 AG-53 $15.00 20 12 AG-24 $5.00 20 AG-53 $5.00 20

AG-25 $15.00 20 12 AG-54 $15.00 20 12 AG-25 $5.00 20 AG-54 $5.00 20

AG-26 $15.00 20 12 AG-55 $15.00 20 12 AG-26 $5.00 20 AG-55 $5.00 20

AG-27 $15.00 20 12 AG-56 $10.00 20 12 AG-27 $5.00 20 AG-56 $5.00 20

AG-28 $15.00 # # AG-57 * * * AG-28 $15.00 # AG-57 * *

AG-29 $3.00 20 12 AG-58 $10.00 20 12 AG-29 $5.00 20 AG-58 $5.00 20

AG-30 $15.00 20 12 AG-59 $17.00 # # AG-30 $5.00 20 AG-59 $5.00 #

AG-31 $15.00 20 12 AG-60 $15.00 20 12 AG-31 $5.00 20 AG-60 $5.00 20

AG-32 $15.00 20 12 AG-61 $10.00 # # AG-32 $5.00 20 AG-61 $10.00 #

AG-33 $15.00 20 12 AG-62 $10.00 20 12 AG-33 $5.00 20 AG-62 $5.00 20

CÓDIGOS DE CUBIERTAS / COPAGOS

16 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

AG-63 $10.00 20 12 AG-92 $12.00 # # AG-63 $5.00 20 AG-92 $12.00 #

AG-64 $15.00 # # AG-93 $12.00 # # AG-64 $5.00 # AG-93 $12.00 #

AG-65 $15.00 AG-94 $20.00 20 12 AG-65 $10.00 * AG-94 $5.00 20

AG-66 AG-95 $20.00 # # AG-66 * * AG-95 $20.00 #

AG-67 $15.00 20 12 AG-96 $15.00 # # AG-67 $5.00 20 AG-96 $15.00 #

AG-68 $15.00 15 15 AG-97 $15.00 15 15 AG-68 $5.00 15 AG-97 $5.00 15

AG-69 N/C N/C N/C AG-98 $10.00 # # AG-69 N/C N/C AG-98 $15.00 #

AG-70 AG-99 $15.00 # # AG-70 * * AG-99 $15.00 #

AG-71 $15.00 # # AH-01 g $15.00 20 12 AG-71 $5.00 # AH-01 $5.00 20

AG-72 $15.00 # # AH-02 g $12.00 15 15 AG-72 $5.00 # AH-02 $5.00 15

AG-73 $10.00 # # AH-03 $15.00 20 12 AG-73 $10.00 # AH-03 $5.00 20

AG-74 $15.00 20 12 AH-04 $15.00 15 15 AG-74 $5.00 20 AH-04 $5.00 15

AG-75 $20.00 20 12 AH-05 $10.00 15 15 AG-75 $5.00 20 AH-05 $5.00 15

AG-76 $15.00 # # AH-06 $10.00 # # AG-76 $15.00 # AH-06 $5.00 #

AG-77 $10.00 # # AH-07 $15.00 # # AG-77 $18.00 # AH-07 $5.00 #

AG-78 N/C AH-08 $15.00 # # AG-78 N/C AH-08 $5.00 #

AG-79 $10.00 # # AH-09 s,x $15.00 20 12 AG-79 $10.00 # AH-09 $5.00 20

AG-80 $15.00 20 12 AH-10 $15.00 15 15 AG-80 $5.00 20 AH-10 $5.00 15

AG-81 $10.00 20 12 AH-11 $10.00 20 12 AG-81 $5.00 20 AH-11 $10.00 20

AG-82 $15.00 # # AH-12 $17.00 # # AG-82 $15.00 # AH-12 $5.00 #

AG-83 $15.00 # # AH-13 $18.00 15 15 AG-83 $15.00 # AH-13 $5.00 15

AG-84 $15.00 # # AH-14 $15.00 15 15 AG-84 $15.00 # AH-14 $5.00 15

AG-85 $15.00 20 12 AH-15 $10.00 # # AG-85 $5.00 20 AH-15 $10.00 #

AG-86 $20.00 # # AH-16 $18.00 # # AG-86 $20.00 # AH-16 $18.00 #

AG-87 $15.00 20 12 AH-17 $15.00 # # AG-87 $5.00 20 AH-17 $5.00 20

AG-88 $15.00 20 12 AH-18 $10.00 # # AG-88 $5.00 20 AH-18 $10.00 #

AG-89 N/C N/C N/C AH-19 $15.00 # # AG-89 N/C N/C AH-19 $15.00 #

AG-90 $15.00 20 12 AH-20 $15.00 # # AG-90 $5.00 20 AH-20 $15.00 #

AG-91 $15.00 20 12 AH-21 $15.00 20 12 AG-91 $5.00 20 AH-21 $5.00 20

CÓDIGOS DE CUBIERTAS / COPAGOS

17 08/13/2015

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CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

AH-22 $12.00 # # AH-51 $8.00 # # AH-22 $5.00 # AH-51 $8.00 #

AH-23 $15.00 # # AH-52 $12.00 # # AH-23 $15.00 # AH-52 $12.00 #

AH-24 $15.00 # # AH-53 * * * AH-24 $5.00 # AH-53 * *

AH-25 $20.00 # # AH-54 $10.00 # # AH-25 $5.00 # AH-54 NADA #

AH-26 $12.00 # # AH-55 g $10.00 20 12 AH-26 $5.00 # AH-55 $5.00 20

AH-27 $15.00 # # AH-56 $2.00 # # AH-27 $5.00 # AH-56 NADA #

AH-28 $8.00 # # AH-57 * * * AH-28 $5.00 # AH-57 * *

AH-29 $12.00 20 12 AH-58 $10.00 # # AH-29 $5.00 20 AH-58 $10.00 #

AH-30 $20.00 # # AH-59 $15.00 20 12 AH-30 $5.00 # AH-59 $5.00 20

AH-31 $15.00 20 12 AH-60 $7.00 20 12 AH-31 $5.00 20 AH-60 $5.00 20

AH-32 $18.00 # # AH-61 $10.00 20 12 AH-32 $5.00 # AH-61 $5.00 20

AH-33 $12.00 # # AH-62 $5.00 20 12 AH-33 $5.00 # AH-62 $5.00 20

AH-34 $12.00 # # AH-63 $5.00 20 12 AH-34 $12.00 # AH-63 $5.00 20

AH-35 $12.00 # # AH-64 NADA 20 12 AH-35 $12.00 # AH-64 $5.00 20

AH-36 NADA # # AH-65 NADA 20 12 AH-36 NADA # AH-65 $5.00 20

AH-37 $15.00 # # AH-66 $5.00 20 12 AH-37 $5.00 # AH-66 $5.00 20

AH-38 $15.00 # # AH-67 NADA 20 12 AH-38 $15.00 # # $5.00 20

AH-39 $15.00 20 12 AH-68 $5.00 20 12 AH-39 $5.00 20 AH-68 $5.00 20

AH-40 $12.00 20 12 AH-69 $5.00 20 12 AH-40 $5.00 20 AH-69 $5.00 20

AH-41 $20.00 15 15 AH-70 $7.00 20 12 AH-41 $5.00 15 AH-70 $5.00 20

AH-42 $18.00 20 12 AH-71 $5.00 20 12 AH-42 $5.00 20 AH-71 $5.00 20

AH-43 $8.00 # # AH-72 $7.00 20 12 AH-43 $8.00 # AH-72 $5.00 20

AH-44 $10.00 20 12 AH-73 $20.00 # # AH-44 $5.00 20 AH-73 $5.00 #

AH-45 $12.00 20 12 AH-74 $8.00 20 12 AH-45 $5.00 20 AH-74 $5.00 20

AH-46 $8.00 # # AH-75 $8.00 20 12 AH-46 $8.00 # AH-75 $5.00 20

AH-47 $14.00 # # AH-76 $15.00 20 12 AH-47 50% # AH-76 $5.00 20

AH-48 $10.00 20 12 AH-77 $10.00 20 12 AH-48 $5.00 20 AH-77 $5.00 20

AH-49 $12.00 # # AH-78 $10.00 20 12 AH-49 $12.00 # AH-78 $5.00 20

AH-50 $8.00 # # AH-79 $20.00 20 12 AH-50 $8.00 # AH-79 $5.00 20

CÓDIGOS DE CUBIERTAS / COPAGOS

18 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

AH-80 $15.00 20 12 AI-10 $12.00 # # AH-80 $5.00 20 AI-10 $5.00 #

AH-81 $12.00 20 12 AI-11 $10.00 # # AH-81 $5.00 20 AI-11 $5.00 #

AH-82 $12.00 20 12 AI-12 $15.00 20 12 AH-82 $5.00 20 AI-12 $5.00 20

AH-83 * * * AI-13 $15.00 # # AH-83 * * AI-13 $5.00 #

AH-84 $12.00 # # AI-14 $10.00 # # AH-84 $5.00 # AI-14 $5.00 #

AH-85 $12.00 # # AI-15 $15.00 # # AH-85 $5.00 # AI-15 $5.00 #

AH-86 $12.00 # # AI-16 $15.00 # # AH-86 $5.00 # AI-16 $5.00 #

AH-87 $18.00 20 12 AI-17 $15.00 # # AH-87 $5.00 20 AI-17 $5.00 #

AH-88 $12.00 # # AI-18 $15.00 # # AH-88 $12.00 # AI-18 $5.00 #

AH-89 $10.00 # # AI-19 $15.00 # # AH-89 $10.00 # AI-19 $5.00 #

AH-90 $15.00 20 12 AI-20 $20.00 # # AH-90 $5.00 20 AI-20 $5.00 #

AH-91 $12.00 # # AI-21 $10.00 # # AH-91 $5.00 # AI-21 $5.00 #

AH-92 $12.00 # # AI-22 $15.00 # # AH-92 $5.00 # AI-22 $5.00 20

AH-93 N/C AI-23 $12.00 # # AH-93 N/C AI-23 $5.00 #

AH-94 $15.00 # # AI-24 $20.00 20 12 AH-94 $15.00 # AI-24 $5.00 20

AH-95 $10.00 # # AI-25 $12.00 # # AH-95 $10.00 # AI-25 $5.00 #

AH-96 $15.00 # # AI-26 $17.00 # # AH-96 $15.00 # AI-26 $5.00 #

AH-97 $15.00 20 12 AI-27 $18.00 # # AH-97 $5.00 20 AI-27 $5.00 #

AH-98 g $10.00 20 12 AI-28 $12.00 # # AH-98 $5.00 20 AI-28 $5.00 #

AH-99 $7.00 20 12 AI-29 $10.00 # # AH-99 $7.00 20 AI-29 $5.00 #

AI-01 g $18.00 20 12 AI-30 * * * AI-01 $5.00 20 AI-30 * *

AI-02 $10.00 # # AI-31 $15.00 20 12 AI-02 $10.00 # AI-31 $5.00 20

AI-03 $15.00 # # AI-32 $18.00 20 12 AI-03 $15.00 # AI-32 $5.00 20

AI-04 g $15.00 20 12 AI-33 $10.00 20 12 AI-04 $5.00 20 AI-33 $5.00 20

AI-05 N/C AI-34 $12.00 # # AI-05 N/C AI-34 $15.00 #

AI-06 $15.00 20 12 AI-35 $10.00 # # AI-06 $5.00 20 AI-35 $10.00 #

AI-07 $10.00 / $15.00

# # AI-36 $15.00 20 12 AI-07 NADA # AI-36 $5.00 20

AI-08 $12.00 # # AI-37 $10.00 20 12 AI-08 $5.00 # AI-37 $5.00 20

AI-09 N/C N/C N/C AI-38 $20.00 20 12 AI-09 N/C N/C AI-38 $5.00 20

CÓDIGOS DE CUBIERTAS / COPAGOS

19 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

AI-39 $15.00 20 12 AI-68 $18.00 # # AI-39 $5.00 20 AI-68 $8.00 #

AI-40 $10.00 20 12 AI-69 $12.00 # # AI-40 $5.00 20 AI-69 $12.00 #

AI-41 $10.00 20 12 AI-70 $12.00 20 12 AI-41 $5.00 20 AI-70 $5.00 20

AI-42 $15.00 # # AI-71 * * * AI-42 $15.00 # AI-71 * *

AI-43 $15.00 # # AI-72 * * * AI-43 $15.00 # AI-72 * *

AI-44 $15.00 # # AI-73 * * * AI-44 $15.00 # # * *

AI-45 $10.00 20 12 AI-74 * * * AI-45 $5.00 20 AI-74 * *

AI-46 $10.00 20 12 AI-75 * * * AI-46 $5.00 20 AI-75 * *

AI-47 $15.00 # # AI-76 * * * AI-47 $15.00 # AI-76 * *

AI-48 $10.00 # # AI-77 * * * AI-48 $5.00 # AI-77 * *

AI-49 $8.00 # # AI-78 * * * AI-49 $8.00 # AI-78 * *

AI-50 $10.00 # # AI-79 * * * AI-50 $7.00 # AI-79 * *

AI-51 * * * AI-80 * * * AI-51 * * AI-80 * *

AI-52 * * * AI-81 * * * AI-52 * * AI-81 * *

AI-53 $10.00 # # AI-82 * * * AI-53 $5.00 # AI-82 * *

AI-54 * * * AI-83 * * * AI-54 * * AI-83 * *

AI-55 * * * AI-84 $7.00 # # AI-55 * * AI-84 $5.00 #

AI-56 * * * AI-85 * * * AI-56 * * AI-85 * *

AI-57 * * * AI-86 * * * AI-57 * * AI-86 * *

AI-58 * * * AI-87 $12.00 20 12 AI-58 * * AI-87 $5.00 20

AI-59 $15.00 # # AI-88 $15.00 # # AI-59 $15.00 # AI-88 $15.00 #

AI-60 * * * AI-89 $10.00 # # AI-60 * * AI-89 $10.00 #

AI-61 * * * AI-90 * * * AI-61 * * AI-90 * *

AI-62 $12.00 # # AI-91 $15.00 20 12 AI-62 $12.00 # AI-91 $5.00 20

AI-63 * * * AI-92 $15.00 20 12 AI-63 * * AI-92 $5.00 20

AI-64 $15.00 # # AI-93 $15.00 20 12 AI-64 $15.00 # AI-93 $5.00 20

AI-65 $12.00 # # AI-94 $8.00 # # AI-65 $12.00 # AI-94 $8.00 #

AI-66 $15.00 20 12 AI-95 $10.00 # # AI-66 $5.00 20 AI-95 $10.00 #

AI-67 $15.00 20 12 AI-96 $20.00 20 12 AI-67 $5.00 20 AI-96 $5.00 20

CÓDIGOS DE CUBIERTAS / COPAGOS

20 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

AI-97 * * * AL-27 $12.00 20 12 AI-97 * * AL-27 $5.00 20

AI-98 * * * AL-28 $15.00 20 12 AI-98 * * AL-28 $5.00 20

AI-99 $10.00 20 12 AL-29 $12.00 20 12 AI-99 $5.00 20 AL-29 $5.00 20

AL-01 $15.00 # # AL-30 $12.00 20 12 AL-01 $15.00 # AL-30 $5.00 20

AL-02 $15.00 20 12 AL-31 $10.00 20 12 AL-02 $5.00 20 AL-31 $5.00 20

AL-03 $12.00 20 12 AL-32 $10.00 20 12 AL-03 $5.00 20 AL-32 $5.00 20

AL-04 $12.00 20 12 AL-33 $10.00 20 12 AL-04 $5.00 20 AL-33 $5.00 20

AL-05 $15.00 15 15 AL-34 $10.00 20 12 AL-05 $5.00 15 AL-34 $5.00 20

AL-06 $15.00 15 15 AL-35 $15.00 20 12 AL-06 $5.00 15 AL-35 $5.00 20

AL-07 $10.00 15 15 AL-36 $15.00 # # AL-07 $5.00 15 AL-36 $5.00 #

AL-08 $15.00 # # AL-37 $8.00 # # AL-08 $5.00 # AL-37 $5.00 #

AL-09 $15.00 15 15 AL-38 $8.00 # # AL-09 $5.00 15 AL-38 $5.00 #

AL-10 $10.00 15 15 AL-39 $10.00 # # AL-10 $5.00 15 AL-39 $5.00 #

AL-11 $12.00 15 15 AL-40 $10.00 # # AL-11 $5.00 15 AL-40 $5.00 #

AL-12 $12.00 15 15 AL-41 $12.00 # # AL-12 $5.00 15 AL-41 $5.00 #

AL-13 $15.00 15 15 AL-42 $10.00 15 15 AL-13 $5.00 15 AL-42 $5.00 15

AL-14 $15.00 15 15 AL-43 $12.00 # # AL-14 $5.00 15 AL-43 $5.00 #

AL-15 $15.00 15 15 AL-44 $15.00 15 15 AL-15 $5.00 15 AL-44 $5.00 15

AL-16 $15.00 # # AL-45 $15.00 # # AL-16 $5.00 # AL-45 $5.00 #

AL-17 $15.00 15 15 AL-46 $15.00 # # AL-17 $5.00 15 AL-46 $5.00 #

AL-18 $15.00 # # AL-47 $15.00 15 15 AL-18 $5.00 # AL-47 $5.00 15

AL-19 $15.00 # # AL-48 $15.00 # # AL-19 $5.00 # AL-48 $5.00 #

AL-20 $15.00 15 15 AL-49 $15.00 # # AL-20 $5.00 15 AL-49 $5.00 #

AL-21 $15.00 15 15 AL-50 $10.00 # # AL-21 $5.00 15 AL-50 $5.00 #

AL-22 $15.00 15 15 AL-51 $10.00 # # AL-22 $5.00 15 AL-51 $5.00 #

AL-23 $15.00 20 12 AL-52 $12.00 # # AL-23 $5.00 20 AL-52 $5.00 #

AL-24 $15.00 20 12 AL-53 $12.00 # # AL-24 N/C N/C AL-53 $5.00 #

AL-25 y y y AL-54 $15.00 15 15 AL-25 y y AL-54 $5.00 15

AL-26 $10.00 20 12 AL-55 $15.00 # # AL-26 $5.00 20 AL-55 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

21 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

AL-56 $15.00 # # AL-85 $12.00 20 12 AL-56 $5.00 # AL-85 $5.00 20

AL-57 $15.00 15 15 AL-86 $15.00 20 12 AL-57 $7.00 15 AL-86 $5.00 20

AL-58 $15.00 15 15 AL-87 $10.00 # # AL-58 $5.00 15 AL-87 $5.00 #

AL-59 $15.00 15 15 AL-88 * * * AL-59 $7.00 15 AL-88 * *

AL-60 $15.00 15 15 AL-89 $15.00 # # AL-60 $5.00 15 AL-89 $7.00 #

AL-61 $15.00 15 15 AL-90 * * * AL-61 $7.00 15 AL-90 * *

AL-62 $15.00 15 15 AL-91 $15.00 # # AL-62 $7.00 15 AL-91 $7.00 #

AL-63 $15.00 15 15 AL-92 * * * AL-63 $7.00 15 AL-92 * *

AL-64 $15.00 15 15 AL-93 $15.00 # # AL-64 $7.00 15 AL-93 $7.00 #

AL-65 $15.00 15 15 AL-94 $15.00 15 15 AL-65 $5.00 15 AL-94 $7.00 15

AL-66 $15.00 15 15 AL-95 $15.00 15 15 AL-66 $7.00 15 AL-95 $7.00 15

AL-67 $12.00 15 15 AL-96 $10.00 15 15 AL-67 $5.00 15 AL-96 $7.00 15

AL-68 $15.00 20 12 AL-97 $10.00 15 15 AL-68 $5.00 20 AL-97 $7.00 15

AL-69 $18.00 20 12 AL-98 $10.00 15 15 AL-69 $5.00 20 AL-98 $7.00 15

AL-70 $18.00 # # AL-99 * * * AL-70 $5.00 # AL-99 * *

AL-71 $15.00 20 12 AK-01 $12.00 # # AL-71 $5.00 20 AK-01 $12.00 #

AL-72 * * * AK-02 $5.00 # # AL-72 * * AK-02 $5.00 #

AL-73 $15.00 20 12 AK-03 $5.00 # # AL-73 $5.00 20 AK-03 $5.00 #

AL-74 $15.00 15 15 AK-04 $18.00 # # AL-74 $7.00 15 AK-04 $18.00 #

AL-75 $15.00 # # AK-05 * * * AL-75 $7.00 # AK-05 * *

AL-76 $15.00 20 12 AK-06 * * * AL-76 $5.00 20 AK-06 * *

AL-77 $12.00 20 12 AK-07 * * * AL-77 $5.00 20 AK-07 * *

AL-78 * * * AK-08 $10.00 20 12 AL-78 * * AK-08 $5.00 20

AL-79 * * * AK-09 * * * AL-79 * * AK-09 * *

AL-80 $15.00 20 12 AK-10 * * * AL-80 $5.00 20 AK-10 * *

AL-81 $15.00 20 12 AK-11 $10.00 # # AL-81 $5.00 20 AK-11 $5.00 #

AL-82 $15.00 20 12 AK-12 $12.00 # # AL-82 $5.00 20 AK-12 $5.00 #

AL-83 $15.00 20 12 AK-13 $15.00 # # AL-83 $5.00 20 AK-13 $7.00 #

AL-84 $10.00 20 12 AK-14 $10.00 20 12 AL-84 $5.00 20 AK-14 $5.00 20

CÓDIGOS DE CUBIERTAS / COPAGOS

22 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

AK-15 $20.00 # # AK-43 * * * AK-15 $5.00 # AK-43 * *

AK-16 $15.00 # # AK-44 g $15.00 15 15 AK-16 $5.00 # AK-44 $7.00 15

AK-17 $15.00 # # AK-45 $15.00 # # AK-17 $5.00 # AK-45 $7.00 #

AK-18 $10.00 20 12 AK-46 $15.00 20 12 AK-18 $5.00 20 AK-46 $5.00 20

AK-19 $15.00 20 12 AK-47 $15.00 20 12 AK-19 $5.00 20 AK-47 $5.00 20

AK-20 $10.00 20 12 AK-48 $18.00 20 20 AK-20 $5.00 20 AK-48 $5.00 20

AK-21 $10.00 20 12 AK-49 * * * AK-21 $5.00 20 AK-49 * *

AK-22 $15.00 20 12 AK-50 * * * AK-22 $5.00 20 AK-50 * *

AK-23 $15.00 20 12 AK-51 $15.00 # # AK-23 $5.00 20 AK-51 $5.00 #

AK-24 $15.00 20 12 AK-52 $16.00 # # AK-24 $5.00 20 AK-52 $5.00 #

AK-25 $15.00 # # AK-53 $18.00 20 12 AK-25 $5.00 # AK-53 $5.00 20.

AK-26 $20.00 20 12 AK-54 * * * AK-26 $5.00 20 AK-54 * *

AK-27 $15.00 # # AK-55 * * * AK-27 $5.00 # AK-55 * *

AK-28 $15.00 # # AK-56 $15.00 # # AK-28 $5.00 # AK-56 $5.00 #

AK-29 $10.00 # # AK-57 $10.00 # # AK-29 $5.00 # AK-57 $5.00 #

AK-30 $15.00 # # AK-58 $12.00 # # AK-30 $5.00 # AK-58 $5.00 #

AK-31 $20.00 # # AK-59 $10.00 20 12 AK-31 $5.00 # AK-59 $5.00 20

AK-32 $17.00 # # AK-60 $10.00 20 12 AK-32 $5.00 # AK-60 $5.00 20

AK-33 $15.00 # # AK-61 * * * AK-33 $5.00 # AK-61 * *

AK-34 $18.00 15 15 AK-62 NADA 15 15 AK-34 $5.00 15 AK-62 NADA 15

AK-35 $18.00 # # AK-63 $15.00 15 15 AK-35 $5.00 # AK-63 $5.00 15

AK-36 $18.00 # # AK-64 $15.00 15 15 AK-36 $5.00 # AK-64 $15.00 15

AK-37 $18.00 # # AK-65 * * * AK-37 $5.00 # AK-65 * *

AK-38 $15.00 # # AK-66 $15.00 # # AK-38 $5.00 # AK-66 $5.00 #

AK-39 $15.00 # # AK-67 $15.00 15 15 AK-39 $5.00 # AK-67 $5.00 15

AK-40 $15.00 # # AK-68 * * * AK-40 $5.00 # AK-68 * *

AK-41 * * * AK-69 * * * AK-41 * * AK-69 * *

AK-42 $12.00 20 12 AK-70 * * * AK-42 $5.00 20 AK-70 * *

AK-43 * * * AK-71 * * * AK-43 * * AK-71 * *

CÓDIGOS DE CUBIERTAS / COPAGOS

23 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

AK-72 $12.00 15 15 * * * * AK-72 $5.00 15 * * *

AK-73 * * * * * * * AK-73 * * * * *

AK-74 * * * * * * * AK-74 * * * * *

AK-75 $8.00 15 15 * * * * AK-75 $5.00 15 * * *

AK-76 * * * * * * * AK-76 * * * * *

AK-77 * * * * * * * AK-77 * * * * *

AK-78 * * * * * * * AK-78 * * * * *

AK-79 * * * * * * * AK-79 * * * * *

AK-80 * * * * * * * AK-80 * * * * *

AK-81 * * * * * * * AK-81 * * * * *

AK-82 * * * * * * * AK-82 * * * * *

AK-83 * * * * * * * AK-83 * * * * *

AK-84 * * * * * * * AK-84 * * * * *

AK-85 * * * * * * * AK-85 * * * * *

AK-86 $15.00 20 12 * * * * AK-86 $5.00 20 * * *

AK-87 $15.00 # # * * * * AK-87 $5.00 # * * *

AK-88 $15.00 20 12 * * * * AK-88 $5.00 20 * * *

AK-89 * * * * * * * AK-89 * * * * *

AK-90 * * * * * * * AK-90 * * * * *

AK-91 * * * * * * * AK-91 * * * * *

AK-92 * * * * * * * AK-92 * * * * *

AK-93 * * * * * * * AK-93 * * * * *

AK-94 $12.00 20 12 * * * * AK-94 $5.00 20 * * *

AK-95 $15.00 20 12 * * * * AK-95 $5.00 20 * * *

AK-96 * * * * * * * AK-96 * * * * *

AK-97 * * * * * * * AK-97 * * * * *

AK-98 * * * * * * * AK-98 * * * * *

AK-99 * * * * * * * AK-99 * * * * *

* * * * * * * * * * * *

CÓDIGOS DE CUBIERTAS / COPAGOS

24 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

AM-01 $15.00 # # AM-30 $10.00 # # AM-01 $5.00 # AM-30 NADA #

AM-02 * * * AM-31 $15.00 15 15 AM-02 * * AM-31 $15.00 15

AM-03 * * * AM-32 $15.00 15 15 AM-03 * * AM-32 $5.00 15

AM-04 $5.00 # # AM-33 $15.00 # # AM-04 NADA # AM-33 $5.00 #

AM-05 $20.00 15 15 AM-34 $10.00 # # AM-05 $5.00 15 AM-34 $5.00 #

AM-06 $10.00 # # AM-35 $12.00 # # AM-06 NADA # AM-35 $5.00 #

AM-07 $12.00 # # AM-36 $12.00 15 15 AM-07 $5.00 # AM-36 $5.00 15

AM-08 $10.00 # # AM-37 $10.00 15 15 AM-08 $10.00 # AM-37 $5.00 15

AM-09 X x x AM-38 $15.00 20 12 AM-09 x x AM-38 $5.00 15

AM-10 $15.00 15 15 AM-39 $15.00 20 12 AM-10 $5.00 15 AM-39 $5.00 15

AM-11 $12.00 # # AM-40 $15.00 15 15 AM-11 $5.00 # AM-40 $5.00 15

AM-12 $15.00 15 15 AM-41 $15.00 15 15 AM-12 $15.00 15 AM-41 $7.00 15

AM-13 $12.00 15 15 AM-42 $10.00 15 15 AM-13 $5.00 15 AM-42 $7.00 15

AM-14 $18.00 # # AM-43 $12.00 15 15 AM-14 $5.00 # AM-43 $5.00 15

AM-15 $15.00 15 15 AM-44 $7.00 15 15 AM-15 $5.00 15 AM-44 $5.00 15

AM-16 $15.00 # # AM-45 $10.00 15 15 AM-16 $7.00 # AM-45 $5.00 15

AM-17 $15.00 * * AM-46 * * * AM-17 $5.00 * AM-46 * *

AM-18 $15.00 * * AM-47 * * * AM-18 $5.00 * AM-47 * *

AM-19 $15.00 * * AM-48 * * * AM-19 $5.00 * AM-48 * *

AM-20 $15.00 * * AM-49 $15.00 15 15 AM-20 $5.00 * AM-49 $5.00 15

AM-21 $7.00 15 15 AM-50 $18.00 15 15 AM-21 $5.00 15 AM-50 $5.00 15

AM-22 * * * AM-51 $7.00 # # AM-22 * * AM-51 $5.00 #

AM-23 * * * AM-52 $7.00 # # AM-23 * * AM-52 $5.00 #

AM-24 $12.00 20 12 AM-53 $18.00 15 15 AM-24 $5.00 15 AM-53 $5.00 15

AM-25 $12.00 20 12 AM-54 $12.00 15 15 AM-25 $5.00 15 AM-54 $5.00 15

AM-26 $12.00 20 12 AM-55 $10.00 # # AM-26 $5.00 15 AM-55 $5.00 #

AM-27 $18.00 20 12 AM-56 $15.00 15 15 AM-27 $5.00 15 AM-56 $12.00 15

AM-28 * * * AM-57 $15.00 15 15 AM-28 * * AM-57 $5.00 15

AM-29 $12.00 * * AM-58 $15.00 15 15 AM-29 $5.00 * AM-58 $5.00 15

CÓDIGOS DE CUBIERTAS / COPAGOS

25 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

AM-59 $10.00 # # AM-88 &,$ $6.00 20 20 AM-59 $5.00 # AM-88 $10.00 20

AM-60 $10.00 # # AM-89 * * * AM-60 $5.00 # AM-89 * *

AM-61 * * * AM-90 $15.00 15 15 AM-61 $5.00 15 AM-90 * *

AM-62 $12.00 15 15 AM-91 $12 15 15 AM-62 $5.00 15 AM-91 $5.00 15

AM-63 $12.00 15 15 AM-92 $12 15 15 AM-63 $5.00 15 AM-92 $5.00 15

AM-64 $15.00 * * AM-93 $15 15 15 AM-64 $5.00 * AM-93 $5.00 15

AM-65 $12.00 15 15 AM-94 $15.00 # # AM-65 $5.00 15 AM-94 $15.00 #

AM-66 $12.00 15 15 AM-95 $15.00 # # AM-66 $5.00 15 AM-95 $5.00 #

AM-67 $3.00 # # AM-96 $15.00 # # AM-67 $5.00 # AM-96 $15.00 #

AM-68 * * * AM-97 $8.00 # # AM-68 * * AM-97 $8.00 #

AM-69 * * * AM-98 $8.00 # # AM-69 * * AM-98 $8.00 #

AM-70 * * * AM-99 $10.00 # # AM-70 * * AM-99 $5.00 #

AM-71 * * * AJ-01 NADA e e AM-71 * * AJ-01 NADA e

AM-72 $7.00 15 15 AJ-02 r $20.00 # # AM-72 $5.00 15 AJ-02 $20.00 #

AM-73 $15.00 15 15 AJ-03 $20.00 * * AM-73 $5.00 15 AJ-03 $20.00 *

AM-74 $12.00 15 15 AJ-04 $20.00 * * AM-74 $5.00 15 AJ-04 $20.00 *

AM-75 $15.00 15 15 AJ-05 $20.00 * * AM-75 $15.00 15 AJ-05 $20.00 *

AM-76 $18.00 15 15 AJ-06 N/C * * AM-76 $5.00 15 AJ-06 N/C *

AM-77 * * * AJ-07 s $10.00 * * AM-77 * * AJ-07 $5.00 *

AM-78 $15.00 15 15 AJ-08 $11.00 # # AM-78 $5.00 15 AJ-08 $11.00 #

AM-79 * * * AJ-09 20% * * AM-79 * * AJ-09 20% *

AM-80 $15.00 # # AJ-10 $15.00 * * AM-80 $5.00 # AJ-10 $5.00 *

AM-81 $15.00 # # AJ-11 j $15.00 20 15 AM-81 $5.00 # AJ-11 $5.00 20

AM-82 * * * AJ-12 $15.00 * * AM-82 * * AJ-12 $5.00 *

AM-83 * * * AJ-13 * * * AM-83 * * AJ-13 * *

AM-84 $20.00 15 15 AJ-14 $15.00 * * AM-84 $15.00 15 AJ-14 $5.00 *

AM-85 $10.00 15 15 AJ-15 $11.00 * * AM-85 $5.00 15 AJ-15 $5.00 *

AM-86 $10.00 15 15 AJ-16 $3.00 * * AM-86 $5.00 15 AJ-16 $3.00 *

AM-87 $15.00 15 15 AJ-17 $15.00 # # AM-87 $5.00 15 AJ-17 $5.00 15

CÓDIGOS DE CUBIERTAS / COPAGOS

26 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

AJ-18 $15.00 # # AJ-47 $10.00 # # AJ-18 $5.00 # AJ-47 $5.00 #

AJ-19 $15.00 * * AJ-48 $15.00 * * AJ-19 $5.00 * AJ-48 $5.00 *

AJ-20 $15.00 * * AJ-49 * * * AJ-20 $5.00 * AJ-49 * *

AJ-21 $15.00 * * AJ-50 $15.00 * * AJ-21 $5.00 * AJ-50 $5.00 *

AJ-22 $15.00 * * AJ-51 $15.00 * * AJ-22 $5.00 * AJ-51 $5.00 *

AJ-23 $15.00 * * AJ-52 $15.00 * * AJ-23 $5.00 * AJ-52 $12.00 *

AJ-24 $15.00 * * AJ-53 * * * AJ-24 $5.00 * AJ-53 * *

AJ-25 $10.00 # # AJ-54 $15.00 * * AJ-25 $10.00 * AJ-54 $5.00 *

AJ-26 $15.00 * * AJ-55 j $15.00 20 15 AJ-26 $5.00 * AJ-55 $5.00 20

AJ-27 $12.00 * * AJ-56 $12.00 # # AJ-27 $5.00 * AJ-56 $12.00 #

AJ-28 $11.00 * * AJ-57 y $12.00 * * AJ-28 $5.00 * AJ-57 $5.00 *

AJ-29 $15.00 * * AJ-58 $12.00 * * AJ-29 $5.00 * AJ-58 $5.00 *

AJ-30 $25.00 * * AJ-59 $15.00 * * AJ-30 $5.00 * AJ-59 $15.00 *

AJ-31 $12.00 * * AJ-60 $11.00 # # AJ-31 $5.00 * AJ-60 $5.00 #

AJ-32 $15.00 * * AJ-61 * * * AJ-32 $5.00 * AJ-61 * *

AJ-33 $15.00 * * AJ-62 $15.00 * * AJ-33 $5.00 * AJ-62 $5.00 *

AJ-34 * * * AJ-63 $12.00 * * AJ-34 * * AJ-63 $5.00 *

AJ-35 $12.00 * * AJ-64 z $11.00 * * AJ-35 $5.00 * AJ-64 $5.00 *

AJ-36 $15.00 * * AJ-65 * * * AJ-36 $5.00 * AJ-65 * *

AJ-37 $15.00 * * AJ-66 * * * AJ-37 $5.00 * AJ-66 * *

AJ-38 $15.00 # # AJ-67 $20.00 * * AJ-38 $15.00 # AJ-67 $5.00 *

AJ-39 $15.00 # # AJ-68 $15.00 * * AJ-39 $12.00 # AJ-68 $5.00 *

AJ-40 $15.00 # # AJ-69 * * * AJ-40 $15.00 # AJ-69 * *

AJ-41 $15.00 * * AJ-70 $15.00 * * AJ-41 $5.00 * AJ-70 $5.00 *

AJ-42 $15.00 * * AJ-71 $15.00 * * AJ-42 $5.00 * AJ-71 $5.00 *

AJ-43 $15.00 15 15 AJ-72 $10.00 * * AJ-43 $5.00 15 AJ-72 $5.00 *

AJ-44 * * * AJ-73 $15.00 * * AJ-44 * * AJ-73 $5.00 *

AJ-45 $15.00 * * AJ-74 * * * AJ-45 $5.00 * AJ-74 * *

AJ-46 $15.00 * * AJ-75 $15.00 * * AJ-46 $5.00 * AJ-75 $5.00 *

CÓDIGOS DE CUBIERTAS / COPAGOS

27 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

AJ-76 $15.00 * * * * * * AJ-76 $5.00 * * * *

AJ-77 * * * * * * * AJ-77 * * * * *

AJ-78 $15.00 * * * * * * AJ-78 $15.00 * * * *

AJ-79 * * * * * * * AJ-79 * * * * *

AJ-80 $15.00 * * * * * * AJ-80 $5.00 * * * *

AJ-81 $10.00 * * * * * * AJ-81 $5.00 * * * *

AJ-82 NADA * * * * * * AJ-82 NADA * * * *

AJ-83 $15.00 * * * * * * AJ-83 $15.00 * * * *

AJ-84 * * * * * * * AJ-84 * * * * *

AJ-85 $15.00 * * * * * * AJ-85 $5.00 * * * *

AJ-86 $6.00 * * * * * * AJ-86 $5.00 * * * *

AJ-87 $7.00 # # * * * * AJ-87 $7.00 # * * *

AJ-88 $12.00 * * * * * * AJ-88 $5.00 * * * *

AJ-89 $12.00 * * * * * * AJ-89 $5.00 * * * *

AJ-90 * * * * * * * AJ-90 * * * * *

AJ-91 $17.00 * * * * * * AJ-91 $17.00 * * * *

AJ-92 * * * * * * * AJ-92 * * * * *

AJ-93 $15.00 * * * * * * AJ-93 $15.00 * * * *

AJ-94 $11.00 * * * * * * AJ-94 $5.00 * * * *

AJ-95 $15.00 * * * * * * AJ-95 $5.00 * * * *

AJ-96 $15.00 * * * * * * AJ-96 $5.00 * * * *

AJ-97 $15.00 * * * * * * AJ-97 $5.00 * * * *

AJ-98 $15.00 * * * * * * AJ-98 $5.00 * * * *

AJ-99 $12.00 * * * * * * AJ-99 $5.00 * * * *

* * * * * * * * * * * * * *

* * * * * * * * * * * * * *

* * * * * * * * * * * * * *

* * * * * * * * * * * * * *

* * * * * * * * * * * * * *

CÓDIGOS DE CUBIERTAS / COPAGOS

28 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

AN-01 $10.00 # # AN-30 * * * AN-01 $10.00 # AN-30 * *

AN-02 $12.00 # # AN-31 $15.00 # # AN-02 $5.00 # AN-31 $15.00 #

AN-03 $12.00 # # AN-32 $20.00 # # AN-03 $12.00 # AN-32 $20.00 #

AN-04 $15.00 # # AN-33 $10.00 # # AN-04 $15.00 # AN-33 $10.00 #

AN-05 $15.00 # # AN-34 $10.00 # # AN-05 $15.00 # AN-34 $10.00 #

AN-06 $15.00 15 15 AN-35 $15.00 # # AN-06 $5.00 15 AN-35 $18.00 #

AN-07 $15.00 15 15 AN-36 $15.00 # # AN-07 $5.00 15 AN-36 $15.00 #

AN-08 $10.00 # # AN-37 $10.00 # # AN-08 $10.00 # AN-37 $10.00 #

AN-09 $10.00 # # AN-38 $12.00 # # AN-09 $10.00 # AN-38 $12.00 #

AN-10 $10.00 # # AN-39 $18.00 # # AN-10 $10.00 # AN-39 $18.00 #

AN-11 $10.00 # # AN-40 $20.00 # # AN-11 $10.00 # AN-40 $20.00 #

AN-12 $10.00 # # AN-41 $15.00 # # AN-12 $10.00 # AN-41 $15.00 #

AN-13 $15.00 # # AN-43 $15.00 # # AN-13 $15.00 # AN-42 $15.00 #

AN-14 $15.00 # # AN-43 $15.00 # # AN-14 $15.00 # AN-43 $15.00 #

AN-15 $15.00 # # AN-44 $10.00 # # AN-15 $15.00 # AN-44 $10.00 #

AN-16 * * * AN-45 * * * AN-16 * * AN-45 * *

AN-17 * * * AN-46 $15.00 # # AN-17 * * AN-46 $15.00 #

AN-18 * * * AN-47 $30.00 # # AN-18 * * AN-47 NADA #

AN-19 * * * AN-48 $15.00 # # AN-19 * * AN-48 NADA #

AN-20 $10.00 # # AN-49 $18.00 # # AN-20 $5.00 # AN-49 $18.00 #

AN-21 * * * AN-50 $12.00 # # AN-21 * * AN-50 $12.00 #

AN-22 $12.00 # # AN-51 $15.00 15 15 AN-22 $12.00 # AN-51 $5.00 15

AN-23 * * * AN-52 $15.00 15 15 AN-23 * * AN-52 $5.00 15

AN-24 $15.00 # # AN-53 $15.00 15 15 AN-24 $15.00 # AN-53 $5.00 15

AN-25 * * * AN-54 $20.00 # # AN-25 * * AN-54 $20.00 #

AN-26 $18.00 # # AN-55 $15.00 # # AN-26 $18.00 # AN-55 $15.00 #

AN-27 $10.00 # # AN-56 $10.00 # # AN-27 $10.00 # AN-56 $10.00 #

AN-28 $12.00 # # AN-57 $20.00 # # AN-28 $12.00 # AN-57 $20.00 #

AN-29 $17.00 # # AN-58 $8.00 # # AN-29 $5.00 # AN-58 $8.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

29 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

AN-59 $15.00 # # AN-88 $18.00 # # AN-59 $15.00 # AN-88 $18.00 #

AN-60 $10.00 # # AN-89 $15.00 # # AN-60 $10.00 # AN-89 $15.00 #

AN-61 $15.00 # # AN-90 $12.00 # # AN-61 $15.00 # AN-90 $12.00 #

AN-62 $18.00 # # AN-91 $12.00 # # AN-62 $18.00 # AN-91 $12.00 #

AN-63 NADA # # AN-92 $10.00 # # AN-63 NADA # AN-92 $10.00 #

AN-64 $15.00 15 15 AN-93 $15.00 # # AN-64 $15.00 15 AN-93 $15.00 #

AN-65 $18.00 15 15 AN-94 $15.00 # # AN-65 $18.00 15 AN-94 $15.00 #

AN-66 $15.00 # # AN-95 $12.00 # # AN-66 $15.00 # AN-95 $12.00 #

AN-67 $18.00 # # AN-96 * * * AN-67 $18.00 # AN-96 * *

AN-68 $12.00 # # AN-97 * * * AN-68 $12.00 # AN-97 * *

AN-69 $12.00 # # AN-98 $18.00 # # AN-69 $12.00 # AN-98 $18.00 #

AN-70 $15.00 # # AN-99 $18.00 # # AN-70 $15.00 # AN-99 $18.00 #

AN-71 * * * * * * * AN-71 * * * * *

AN-72 $15.00 # # * * * * AN-72 $15.00 # * * *

AN-73 $18.00 # # * * * * AN-73 $18.00 # * * *

AN-74 $15.00 # # * * * * AN-74 $15.00 # * * *

AN-75 $15.00 # # * * * * AN-75 $15.00 # * * *

AN-76 $10.00 # # * * * * AN-76 $10.00 # * * *

AN-77 $20.00 # # * * * * AN-77 $20.00 # * * *

AN-78 $20.00 # # * * * * AN-78 $20.00 # * * *

AN-79 $15.00 # # * * * * AN-79 $15.00 # * * *

AN-80 $15.00 # # * * * * AN-80 $15.00 # * * *

AN-81 $17.00 # # * * * * AN-81 $17.00 # * * *

AN-82 $18.00 # # * * * * AN-82 $18.00 # * * *

AN-83 $15.00 # # * * * * AN-83 $15.00 # * * *

AN-84 $12.00 # # * * * * AN-84 $12.00 # * * *

AN-85 $15.00 # # * * * * AN-85 $15.00 # * * *

AN-86 $15.00 # # * * * * AN-86 $15.00 # * * *

AN-87 $15.00 # # * * * * AN-87 $15.00 # * * *

CÓDIGOS DE CUBIERTAS / COPAGOS

30 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

AP-01 * * * AP-30 $15.00 * * AP-01 * * AP-30 $5.00

AP-02 $15.00 * * AP-31 20% * * AP-02 $5.00 * AP-31 20%

AP-03 $15.00 * * AP-32 $15.00 * * AP-03 $5.00 * AP-32 $5.00 *

AP-04 $15.00 * * AP-33 $15.00 * * AP-04 $5.00 * AP-33 $15.00 *

AP-05 $15.00 * * AP-34 * * * AP-05 $5.00 * AP-34 * *

AP-06 $20.00 * * AP-35 * * * AP-06 $5.00 * AP-35 * *

AP-07 $15.00 * * AP-36 * * AP-07 $5.00 * AP-36 * *

AP-08 & $11.00 * * AP-37 $15.00 # # AP-08 $5.00 * AP-37 $5.00 #

AP-09 $15.00 * * AP-38 $10.00 # # AP-09 $5.00 * AP-38 $5.00 #

AP-10 $11.00 * * AP-39 $12.00 # # AP-10 $5.00 * AP-39 $5.00 #

AP-11 $15.00 * * AP-40 $18.00 # # AP-11 $5.00 * AP-40 $5.00 #

AP-12 $10.00 # # AP-41 $15.00 # # AP-12 $10.00 # AP-41 $7.00 #

AP-13 $15.00 * * AP-42 NADA # # AP-13 $5.00 * AP-42 N/C *

AP-14 $15.00 * * AP-43 $15.00 # # AP-14 $5.00 * AP-43 $5.00 #

AP-15 $15.00 * * AP-44 $12.00 # # AP-15 $5.00 * AP-44 $5.00 #

AP-16 $15.00 * * AP-45 $15.00 # # AP-16 $5.00 * AP-45 $5.00 #

AP-17 $15.00 * * AP-46 $15.00 15 15 AP-17 $5.00 * AP-46 NADA 15

AP-18 * * * AP-47 $15.00 # # AP-18 * * AP-47 $5.00 #

AP-19 $15.00 # # AP-48 $15.00 # # AP-19 $5.00 # AP-48 $5.00 #

AP-20 $15.00 * * AP-49 $15.00 # # AP-20 $5.00 * AP-49 $5.00 #

AP-21 $18.00 # # AP-50 $15.00 # # AP-21 $15.00 # AP-50 $7.00 #

AP-22 $15.00 # # AP-51 $15.00 # # AP-22 $15.00 # AP-51 $5.00 #

AP-23 $15.00 # # AP-52 $15.00 # # AP-23 $15.00 # AP-52 $5.00 #

AP-24 $18.00 # # AP-53 $10.00 # # AP-24 $15.00 # AP-53 $5.00 #

AP-25 $15.00 * * AP-54 $20.00 # # AP-25 $5.00 * AP-54 $5.00 #

AP-26 $12.00 * * AP-55 $15.00 # # AP-26 $5.00 * AP-55 $5.00 #

AP-27 * * * AP-56 $15.00 # # AP-27 * * AP-56 $5.00 #

AP-28 $12.00 * * AP-57 $12.00 # # AP-28 $5.00 * AP-57 $5.00 #

AP-29 $15.00 * * AP-58 $18.00 # # AP-29 $5.00 * AP-58 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

31 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

AP-59 $15.00 # # AP-88 $12.00 # # AP-59 $5.00 # AP-88 $5.00 #

AP-60 $15.00 # # AP-89 $15.00 # # AP-60 $5.00 # AP-89 $15.00 #

AP-61 $20.00 # # AP-90 $18.00 # # AP-61 $5.00 # AP-90 $5.00 #

AP-62 $20.00 # # AP-91 $15.00 # # AP-62 $5.00 # AP-91 $5.00 #

AP-63 $15.00 # # AP-92 $15.00 # # AP-63 $5.00 # AP-92 $5.00 #

AP-64 $15.00 # # AP-93 * * * AP-64 $15.00 # AP-93 * *

AP-65 $12.00 # # AP-94 * * * AP-65 $12.00 # AP-94 * *

AP-66 $15.00 # # AP-95 * * * AP-66 $5.00 # AP-95 * *

AP-67 $20.00 # # AP-96 * * * AP-67 $5.00 # AP-96 * *

AP-68 $18.00 # # AP-97 * * * AP-68 $5.00 # AP-97 * *

AP-69 $15.00 # # AP-98 * * * AP-69 $5.00 # AP-98 * *

AP-70 $15.00 # # AP-99 $20.00 # # AP-70 $5.00 # AP-99 $5.00 #

AP-71 $15.00 # # * * * * AP-71 $5.00 # * * *

AP-72 $15.00 # # * * * * AP-72 $5.00 # * * *

AP-73 $15.00 # # * * * * AP-73 $5.00 # * * *

AP-74 20% # # * * * * AP-74 N/C * * * *

AP-75 $15.00 # * * * * * AP-75 $5.00 # * * *

AP-76 $12.00 # * * * * * AP-76 $5.00 # * * *

AP-77 $15.00 # * * * * * AP-77 $5.00 # * * *

AP-78 $18.00 # * * * * * AP-78 $5.00 # * * *

AP-79 $12.00 # * * * * * AP-79 $5.00 # * * *

AP-80 $15.00 # * * * * * AP-80 $5.00 # * * *

AP-81 $15.00 # * * * * * AP-81 $5.00 # * * *

AP-82 $15.00 # # * * * * AP-82 NADA # * * *

AP-83 $15.00 # # * * * * AP-83 NADA # * * *

AP-84 $15.00 # # * * * * AP-84 $5.00 # * * *

AP-85 * * * * * * * AP-85 * * * * *

AP-86 $12.00 # # * * * * AP-86 $12.00 # * * *

AP-87 $15.00 # # * * * * AP-87 $15.00 # * * *

CÓDIGOS DE CUBIERTAS / COPAGOS

Departamento de Comunicación Técnica, División de Mercadeo y Desarrollo de Productos 32 06/30/2014

VISITAS SIQUIÁTRICAS, VISITAS COLATERALES Y TERAPIAS DE GRUPO

NOTAS: El número de visitas aplica por persona asegurada. N/C No cubre * Código sin asignar (a) Aplica periodo de espera. (b) Las visitas colaterales están limitadas a 5 visitas; si el paciente es mayor de 19 años y a 12 si el

paciente es menor de 19 años. (c) 50 Visitas por combinación de visitas al siquiatra, visitas colaterales y terapias de grupo. (d) Visitas por la combinación de psicoterapia, visitas colaterales y terapias de grupo. (e) Servicios cubiertos de acuerdo a necesidad médica justificada a través del Programa de Manejo de

Condiciones Mentales. (f) Visitas colaterales limitadas a 5 visitas si el paciente es mayor de 18 años y a 20 visitas si es menor de

18 años. (g) El límite en visitas a la oficina del siquiatra aplica sólo para el tratamiento de drogadicción y

alcoholismo, las demás condiciones estarán cubiertas de acuerdo a la necesidad médica justificada. (h) Visitas 1 a la 5 NADA

Visitas 6-7-8 15% Visitas 9-10 30% Visitas 11-12 45%

(i) Las visitas colaterales pagarán el deducible de especialista especificado en la tarjeta del asegurado. (k) Sin límite. (l) 10 Visitas por semestre académico. (m) 40 Visitas en combinación de visitas al siquiatra y terapia de grupo. (n) Cubre 15 visitas adicionales por motivo de rehabilitación por drogadicción y alcoholismo sujeto a

precertificación. (o) Si la tarjeta de identificación del asegurado (a) incluye la Y, las visitas siquiátricas en la oficina para el

tratamiento de condiciones mentales se cubrirán de acuerdo a la necesidad médica justificada. El límite incluido en la Tabla corresponde solamente a las visitas colaterales, terapia de grupo y tratamiento para drogadicción y alcoholismo.

(p) Las visitas individuales para el tratamiento de condiciones mentales por siquiatra, sicólogo o

trabajadores sociales estarán cubiertas de acuerdo a la necesidad médica justificada.

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(q) Las visitas individuales para el tratamiento de abuso de sustancias, terapias de grupo para el

tratamiento de condiciones mentales y abuso de sustancias, y visitas colaterales para el tratamiento de condiciones mentales y abuso de sustancias (incluyendo servicios de sicólogos o trabajadores sociales, estarán cubiertas hasta un máximo de 20 por año.

(r) Las visitas colaterales no pagan deducible. (s) $5.00 de deducible para visitas colaterales. (t) No incluye los servicios provistos por los sicólogos clínicos contratados en la red de Triple-S Salud.

(u) No cubre visitas colaterales. (v) No cubre visitas por drogadicción y alcoholismo. (w) $12.00 de deducible para visitas colaterales. Todos los servicios por condiciones mentales y/o

drogadicción y alcoholismo estarán cubiertos de acuerdo a la necesidad médica justificada, pero deberán ser precertificados por FHC Options, siempre y cuando no sean de emergencia. De lo contrario, no se cubrirán.

(x) Aplica al Programa Medicare Advantage (y) $10.00 de deducible para visitas colaterales. (z) $7.00 de deducible para visitas colaterales. (&) $15.00 de deducible para visitas colaterales

% Visitas siquiátricas y colaterales y terapias de grupo por drogadicción y alcoholismo hasta 20 por año

póliza. & Las visitas individuales y visitas colaterales para el tratamiento de condiciones mentales por siquiatras,

sicólogos o trabajadores sociales están cubiertas de acuerdo a la necesidad médica justificada; cuando el asegurado visite un proveedor no participante, el rembolso será a base de la tarifa contratada.

$ Las 20 visitas individuales y 20 visitas colaterales para el tratamiento de abuso de sustancias.

Cuando el asegurado visite un proveedor no participante, el rembolso será a base de la tarifa contratada.

# Servicios cubiertos de acuerdo a la necesidad médica justificada. € Todo servicio por condiciones mentales y/o drogadiccion y alcoholismo, incluyendo visitas al siquiatra,

sicologo, colaterales y terapia de grupo, estaran cubiertos segun necesidad medica justificada, pero deben ser precertificados por FHC.

¥ Las visitas no usadas, pasaran al próximo año póliza.

() Versión de Cubiertas de Reforma de Salud Federal que incluyen beneficios que se considerarán como Servicios Preventivos

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Grupo Triple-S

VISITAS SIQUIÁTRICAS Y

COLATERALES

TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS

B1 $2.00 # # B1 NADA #

B2 $10.00 # # B2 $10.00 #

B3 $10.00 20 15 B3 $5.00 20

B4 $10.00 20 15 B4 $5.00 20

B5 $10.00 # # B5 NADA #

B6 $10.00 # # B6 NADA #

B7 $10.00 # # B7 NADA #

B8 $10.00 # # B8 NADA #

B9 $2.00 # # B9 NADA #

B10 $5.00 # # B10 NADA #

B11 $5.00 # # B11 NADA #

B12 $10.00 # # B12 NADA #

B13 $10.00 # # B13 NADA #

B14 $10.00 # # B14 NADA #

B15 $2.00 # # B15 NADA #

B16 $5.00 # # B16 NADA #

B17 $10.00 # # B17 $10.00 #

B18 $10.00 # # B18 NADA #

B19 $10.00 # # B19 NADA #

B20 $10.00 # # B20 NADA #

B21 $10.00 # # B21 NADA #

B22 $10.00 # # B22 NADA #

B23 $10.00 # # B23 NADA #

B24 $5.00 # # B24 NADA #

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B25 g $15.00 15 15 B50 g $15.00 15 15 B25 $5.00 15 B50 $5.00 15

B26 g $15.00 15 15 B51 g $15.00 15 15 B26 $5.00 15 B51 $5.00 15

B27 g $15.00 15 15 B52 g $15.00 15 15 B27 $5.00 15 B52 $5.00 15

B28 g $15.00 15 15 B53 g $15.00 15 15 B28 $5.00 15 B53 $5.00 15

B29 g $15.00 15 15 B54 g $15.00 15 15 B29 $5.00 15 B54 $5.00 15

B30 g $15.00 15 15 B55 g $15.00 15 15 B30 $5.00 15 B55 $5.00 15

B31 g $15.00 15 15 B56 g $15.00 15 15 B31 $5.00 15 B56 $5.00 15

B32 g $15.00 15 15 B57 g $15.00 15 15 B32 $5.00 15 B57 $5.00 15

B33 g $15.00 15 15 B58 g $15.00 15 15 B33 $5.00 15 B58 $5.00 15

B34 g $15.00 15 15 B59 g $15.00 15 15 B34 $5.00 15 B59 $5.00 15

B35 g $15.00 15 15 B60 g $15.00 15 15 B35 $5.00 15 B60 $5.00 15

B36 g $15.00 15 15 B61 g $15.00 15 15 B36 $5.00 15 B61 $5.00 15

B37 g $15.00 15 15 B62 g $15.00 15 15 B37 $5.00 15 B62 $5.00 15

B38 g $15.00 15 15 B63 g $15.00 15 15 B38 $5.00 15 B63 $5.00 15

B39 g $15.00 15 15 B64 g $15.00 15 15 B39 $5.00 15 B64 $5.00 15

B40 g $15.00 15 15 B65 g $15.00 15 15 B40 $5.00 15 B65 $5.00 15

B41 g $15.00 15 15 B66 g $15.00 15 15 B41 $5.00 15 B66 $5.00 15

B42 g $15.00 15 15 B67 g $15.00 15 15 B42 $5.00 15 B67 $5.00 15

B43 g $15.00 15 15 B68 g $15.00 15 15 B43 $5.00 15 B68 $5.00 15

B44 g $15.00 15 15 B69 g $15.00 15 15 B44 $5.00 15 B69 $5.00 15

B45 g $15.00 15 15 B70 g $15.00 15 15 B45 $5.00 15 B70 $5.00 15

B46 g $15.00 15 15 B71 g $15.00 15 15 B46 $5.00 15 B71 $5.00 15

B47 g $15.00 15 15 B72 g $15.00 15 15 B47 $5.00 15 B72 $5.00 15

B48 g $15.00 15 15 B73 g $15.00 15 15 B48 $5.00 15 B73 $5.00 15

B49 g $15.00 15 15 B74 g $15.00 15 15 B49 $5.00 15 B74 $5.00 15

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B75 g $15.00 15 15 B100 g $15.00 15 15 B75 $5.00 15 B100 $5.00 15

B76 g $15.00 15 15 B101 g $15.00 15 15 B76 $5.00 15 B101 $5.00 15

B77 g $15.00 15 15 B102 g $15.00 15 15 B77 $5.00 15 B102 $5.00 15

B78 g $15.00 15 15 B103 g $15.00 15 15 B78 $5.00 15 B103 $5.00 15

B79 g $15.00 15 15 B104 g $15.00 15 15 B79 $5.00 15 B104 $5.00 15

B80 g $15.00 15 15 B105 g $15.00 15 15 B80 $5.00 15 B105 $5.00 15

B81 g $15.00 15 15 B106 g $15.00 15 15 B81 $5.00 15 B106 $5.00 15

B82 g $15.00 15 15 B107 g $15.00 15 15 B82 $5.00 15 B107 $5.00 15

B83 g $15.00 15 15 B108 g $15.00 15 15 B83 $5.00 15 B108 $5.00 15

B84 g $15.00 15 15 B109 g $15.00 15 15 B84 $5.00 15 B109 $5.00 15

B85 g $15.00 15 15 B110 g $15.00 15 15 B85 $5.00 15 B110 $5.00 15

B86 g $15.00 15 15 B111 g $15.00 15 15 B86 $5.00 15 B111 $5.00 15

B87 g $15.00 15 15 B112 g $15.00 15 15 B87 $5.00 15 B112 $5.00 15

B88 g $15.00 15 15 B113 g $15.00 15 15 B88 $5.00 15 B113 $5.00 15

B89 g $15.00 15 15 B114 g $15.00 15 15 B89 $5.00 15 B114 $5.00 15

B90 g $15.00 15 15 B115 g $15.00 15 15 B90 $5.00 15 B115 $5.00 15

B91 g $15.00 15 15 B116 g $15.00 15 15 B91 $5.00 15 B116 $5.00 15

B92 g $15.00 15 15 B117 g $15.00 15 15 B92 $5.00 15 B117 $5.00 15

B93 g $15.00 15 15 B118 g $15.00 15 15 B93 $5.00 15 B118 $5.00 15

B94 g $15.00 15 15 B119 g $15.00 15 15 B94 $5.00 15 B119 $5.00 15

B95 g $15.00 15 15 B120 g $15.00 15 15 B95 $5.00 15 B120 $5.00 15

B96 g $15.00 15 15 B121 g $15.00 15 15 B96 $5.00 15 B121 $5.00 15

B97 g $15.00 15 15 B122 g $15.00 15 15 B97 $5.00 15 B122 $5.00 15

B98 g $15.00 15 15 B123 g $15.00 15 15 B98 $5.00 15 B123 $5.00 15

B99 g $15.00 15 15 B124 g $15.00 15 15 B99 $5.00 15 B124 $5.00 15

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B125 g $15.00 15 15 B150 g $15.00 15 15 B125 $5.00 15 B150 $5.00 15

B126 g $15.00 15 15 B151 g $15.00 15 15 B126 $5.00 15 B151 $5.00 15

B127 g $15.00 15 15 B152 g $15.00 15 15 B127 $5.00 15 B152 $5.00 15

B128 g $15.00 15 15 B153 g $15.00 15 15 B128 $5.00 15 B153 $5.00 15

B129 g $15.00 15 15 B154 g $15.00 15 15 B129 $5.00 15 B154 $5.00 15

B130 g $15.00 15 15 B155 g $15.00 15 15 B130 $5.00 15 B155 $5.00 15

B131 g $15.00 15 15 B156 g $15.00 15 15 B131 $5.00 15 B156 $5.00 15

B132 g $15.00 15 15 B157 g $15.00 15 15 B132 $5.00 15 B157 $5.00 15

B133 g $15.00 15 15 B158 g $15.00 15 15 B133 $5.00 15 B158 $5.00 15

B134 g $15.00 15 15 B159 g $15.00 15 15 B134 $5.00 15 B159 $5.00 15

B135 g $15.00 15 15 B160 g $15.00 15 15 B135 $5.00 15 B160 $5.00 15

B136 g $15.00 15 15 B161 g $15.00 15 15 B136 $5.00 15 B161 $5.00 15

B137 g $15.00 15 15 B162 g $15.00 15 15 B137 $5.00 15 B162 $5.00 15

B138 g $15.00 15 15 B163 g $15.00 15 15 B138 $5.00 15 B163 $5.00 15

B139 g $15.00 15 15 B164 g $15.00 15 15 B139 $5.00 15 B164 $5.00 15

B140 g $15.00 15 15 B165 g $15.00 15 15 B140 $5.00 15 B165 $5.00 15

B141 g $15.00 15 15 B166 g $15.00 15 15 B141 $5.00 15 B166 $5.00 15

B142 g $15.00 15 15 B167 g $15.00 15 15 B142 $5.00 15 B167 $5.00 15

B143 g $15.00 15 15 B168 g $15.00 15 15 B143 $5.00 15 B168 $5.00 15

B144 g $15.00 15 15 B169 g $15.00 15 15 B144 $5.00 15 B169 $5.00 15

B145 g $15.00 15 15 B170 g $15.00 15 15 B145 $5.00 15 B170 $5.00 15

B146 g $15.00 15 15 B171 g $15.00 15 15 B146 $5.00 15 B171 $5.00 15

B147 g $15.00 15 15 B172 g $15.00 15 15 B147 $5.00 15 B172 $5.00 15

B148 g $15.00 15 15 B173 g $15.00 15 15 B148 $5.00 15 B173 $5.00 15

B149 g $15.00 15 15 B174 g $15.00 15 15 B149 $5.00 15 B174 $5.00 15

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B175 g $15.00 15 15 B200 g $15.00 15 15 B175 $5.00 15 B200 $5.00 15

B176 g $15.00 15 15 B201 g $15.00 15 15 B176 $5.00 15 B201 $5.00 15

B177 g $15.00 15 15 B202 g $15.00 15 15 B177 $5.00 15 B202 $5.00 15

B178 g $15.00 15 15 B203 g $15.00 15 15 B178 $5.00 15 B203 $5.00 15

B179 g $15.00 15 15 B204 g $15.00 15 15 B179 $5.00 15 B204 $5.00 15

B180 g $15.00 15 15 B205 g $15.00 15 15 B180 $5.00 15 B205 $5.00 15

B181 g $15.00 15 15 B206 g $15.00 15 15 B181 $5.00 15 B206 $5.00 15

B182 g $15.00 15 15 B207 g $15.00 15 15 B182 $5.00 15 B207 $5.00 15

B183 g $15.00 15 15 B208 g $15.00 15 15 B183 $5.00 15 B208 $5.00 15

B184 g $15.00 15 15 B209 g $15.00 15 15 B184 $5.00 15 B209 $5.00 15

B185 g $15.00 15 15 B210 g $15.00 15 15 B185 $5.00 15 B210 $5.00 15

B186 g $15.00 15 15 B211 g $15.00 15 15 B186 $5.00 15 B211 $5.00 15

B187 g $15.00 15 15 B212 g $15.00 15 15 B187 $5.00 15 B212 $5.00 15

B188 g $15.00 15 15 B213 g $15.00 15 15 B188 $5.00 15 B213 $5.00 15

B189 g $15.00 15 15 B214 g $15.00 15 15 B189 $5.00 15 B214 $5.00 15

B190 g $15.00 15 15 B215 g $15.00 15 15 B190 $5.00 15 B215 $5.00 15

B191 g $15.00 15 15 B216 g $15.00 15 15 B191 $5.00 15 B216 $5.00 15

B192 g $15.00 15 15 B217 g $15.00 15 15 B192 $5.00 15 B217 $5.00 15

B193 g $15.00 15 15 B218 g $15.00 15 15 B193 $5.00 15 B218 $5.00 15

B194 g $15.00 15 15 B219 g $15.00 15 15 B194 $5.00 15 B219 $5.00 15

B195 g $15.00 15 15 B220 g $15.00 15 15 B195 $5.00 15 B220 $5.00 15

B196 g $15.00 15 15 B221 g $15.00 15 15 B196 $5.00 15 B221 $5.00 15

B197 g $15.00 15 15 B222 g $15.00 15 15 B197 $5.00 15 B222 $5.00 15

B198 g $15.00 15 15 B223 g $15.00 15 15 B198 $5.00 15 B223 $5.00 15

B199 g $15.00 15 15 B224 g $15.00 15 15 B199 $5.00 15 B224 $5.00 15

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B225 g $15.00 15 15 B250 g $15.00 15 15 B225 $5.00 15 B250 $5.00 15

B226 g $15.00 15 15 B251 g $15.00 15 15 B226 $5.00 15 B251 $5.00 15

B227 g $15.00 15 15 B252 g $15.00 15 15 B227 $5.00 15 B252 $5.00 15

B228 g $15.00 15 15 B253 g $15.00 15 15 B228 $5.00 15 B253 $5.00 15

B229 g $15.00 15 15 B254 g $15.00 15 15 B229 $5.00 15 B254 $5.00 15

B230 g $15.00 15 15 B255 g $15.00 15 15 B230 $5.00 15 B255 $5.00 15

B231 g $15.00 15 15 B256 g $15.00 15 15 B231 $5.00 15 B256 $5.00 15

B232 g $15.00 15 15 B257 g $15.00 15 15 B232 $5.00 15 B257 $5.00 15

B233 g $15.00 15 15 B258 g $15.00 15 15 B233 $5.00 15 B258 $5.00 15

B234 g $15.00 15 15 B259 g $15.00 15 15 B234 $5.00 15 B259 $5.00 15

B235 g $15.00 15 15 B250 g $15.00 20 15 B235 $5.00 15 B250 $5.00 15

B236 g $15.00 15 15 B251 g $15.00 20 15 B236 $5.00 15 B251 $5.00 15

B237 g $15.00 15 15 B252 g $15.00 20 15 B237 $5.00 15 B252 $5.00 15

B238 g $15.00 15 15 B253 g $15.00 20 15 B238 $5.00 15 B253 $5.00 15

B239 g $15.00 15 15 B254 g $15.00 20 15 B239 $5.00 15 B254 $5.00 15

B240 g $15.00 15 15 B255 g $15.00 20 15 B240 $5.00 15 B255 $5.00 15

B241 g $15.00 15 15 B256 g $15.00 20 15 B241 $5.00 15 B256 $5.00 15

B242 g $15.00 15 15 B257 g $15.00 20 15 B242 $5.00 15 B257 $5.00 15

B243 g $15.00 15 15 B258 g $15.00 20 15 B243 $5.00 15 B258 $5.00 15

B244 g $15.00 15 15 B259 g $15.00 20 15 B244 $5.00 15 B259 $5.00 15

B245 g $15.00 15 15 B260 g $15.00 20 12 B245 $5.00 15 B260 $5.00 15

B246 g $15.00 15 15 B261 g $15.00 20 12 B246 $5.00 15 B261 $5.00 15

B247 g $15.00 15 15 B262 g $15.00 20 12 B247 $5.00 15 B262 $5.00 15

B248 g $15.00 15 15 B263 g $15.00 20 12 B248 $5.00 15 B263 $5.00 15

B249 g $15.00 15 15 B264 g $15.00 20 12 B249 $5.00 15 B264 $5.00 15

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B265 g $15.00 20 15 B290 g $15.00 20 15 B265 $5.00 15 B290 $5.00 15

B266 g $15.00 20 15 B291 g $15.00 20 15 B266 $5.00 15 B291 $5.00 15

B267 g $15.00 20 15 B292 g $15.00 20 15 B267 $5.00 15 B292 $5.00 15

B268 g $15.00 20 15 B293 g $15.00 20 15 B268 $5.00 15 B293 $5.00 15

B269 g $15.00 20 15 B294 g $15.00 20 15 B269 $5.00 15 B294 $5.00 15

B270 g $15.00 20 15 B295 g $15.00 20 15 B270 $5.00 15 B295 $5.00 15

B271 g $15.00 20 15 B296 g $15.00 20 15 B271 $5.00 15 B296 $5.00 15

B272 g $15.00 20 15 B297 g $15.00 20 15 B272 $5.00 15 B297 $5.00 15

B273 g $15.00 20 15 B298 g $15.00 20 15 B273 $5.00 15 B298 $5.00 15

B274 g $15.00 20 15 B299 g $15.00 20 15 B274 $5.00 15 B299 $5.00 15

B275 g $15.00 20 15 B300 g $15.00 20 15 B275 $5.00 15 B300 $5.00 15

B276 g $15.00 20 15 B301 g $15.00 20 15 B276 $5.00 15 B301 $5.00 15

B277 g $15.00 20 15 B302 g $15.00 20 15 B277 $5.00 15 B302 $5.00 15

B278 g $15.00 20 15 B303 g $15.00 20 15 B278 $5.00 15 B303 $5.00 15

B279 g $15.00 20 15 B304 g $15.00 20 15 B279 $5.00 15 B304 $5.00 15

B280 g $15.00 20 15 B305 g $15.00 20 15 B280 $5.00 15 B305 $5.00 15

B281 g $15.00 20 15 B306 g $15.00 20 15 B281 $5.00 15 B306 $5.00 15

B282 g $15.00 20 15 B307 g $15.00 20 15 B282 $5.00 15 B307 $5.00 15

B283 g $15.00 20 15 B308 g $15.00 20 15 B283 $5.00 15 B308 $5.00 15

B284 g $15.00 20 15 B309 g $15.00 20 15 B284 $5.00 15 B309 $5.00 15

B285 g $15.00 20 15 B310 g $15.00 20 15 B285 $5.00 15 B310 $5.00 15

B286 g $15.00 20 15 B311 g $15.00 20 15 B286 $5.00 15 B311 $5.00 15

B287 g $15.00 20 15 B312 g $15.00 20 15 B287 $5.00 15 B312 $5.00 15

B288 g $15.00 20 15 B313 g $15.00 20 15 B288 $5.00 15 B313 $5.00 15

B289 g $15.00 20 15 B314 g $15.00 20 15 B289 $5.00 15 B314 $5.00 15

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B315 g $15.00 20 15 B340 g $15.00 20 15 B315 $5.00 15 B340 $5.00 15

B316 g $15.00 20 15 B341 g $15.00 20 15 B316 $5.00 15 B341 $5.00 15

B317 g $15.00 20 15 B342 g $15.00 20 15 B317 $5.00 15 B342 $5.00 15

B318 g $15.00 20 15 B343 g $15.00 20 15 B318 $5.00 15 B343 $5.00 15

B319 g $15.00 20 15 B344 g $15.00 20 15 B319 $5.00 15 B344 $5.00 15

B320 g $15.00 20 15 B345 g $15.00 20 15 B320 $5.00 15 B345 $5.00 15

B321 g $15.00 20 15 B346 g $15.00 20 15 B321 $5.00 15 B346 $5.00 15

B322 g $15.00 20 15 B347 g $15.00 20 15 B322 $5.00 15 B347 $5.00 15

B323 g $15.00 20 15 B348 g $15.00 20 15 B323 $5.00 15 B348 $5.00 15

B324 g $15.00 20 15 B349 g $15.00 20 15 B324 $5.00 15 B349 $5.00 15

B325 g $15.00 20 15 B350 g $15.00 20 15 B325 $5.00 15 B350 $5.00 15

B326 g $15.00 20 15 B351 g $15.00 20 15 B326 $5.00 15 B351 $5.00 15

B327 g $15.00 20 15 B352 g $15.00 20 15 B327 $5.00 15 B352 $5.00 15

B328 g $15.00 20 15 B353 g $15.00 20 15 B328 $5.00 15 B353 $5.00 15

B329 g $15.00 20 15 B354 g $15.00 20 15 B329 $5.00 15 B354 $5.00 15

B330 g $15.00 20 15 B355 g $15.00 20 15 B330 $5.00 15 B355 $5.00 15

B331 g $15.00 20 15 B356 g $15.00 20 15 B331 $5.00 15 B356 $5.00 15

B332 g $15.00 20 15 B357 g $15.00 20 15 B332 $5.00 15 B357 $5.00 15

B333 g $15.00 20 15 B358 g $15.00 20 15 B333 $5.00 15 B358 $5.00 15

B334 g $15.00 20 15 B359 g $15.00 20 15 B334 $5.00 15 B359 $5.00 15

B335 g $15.00 20 15 B361 g $15.00 20 15 B335 $5.00 15 B361 $5.00 15

B336 g $15.00 20 15 B362 g $15.00 20 15 B336 $5.00 15 B362 $5.00 15

B337 g $15.00 20 15 B363 g $15.00 20 15 B337 $5.00 15 B363 $5.00 15

B338 g $15.00 20 15 B364 g $15.00 20 15 B338 $5.00 15 B364 $5.00 15

B339 g $15.00 20 15 B365 g $15.00 20 15 B339 $5.00 15 B365 $5.00 15

CÓDIGOS DE CUBIERTAS / COPAGOS

43 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B366 g $15.00 20 15 B391 g $15.00 20 15 B366 $5.00 15 B391 $5.00 15

B367 g $15.00 20 15 B392 g $15.00 20 15 B367 $5.00 15 B392 $5.00 15

B368 g $15.00 20 15 B393 g $15.00 20 15 B368 $5.00 15 B393 $5.00 15

B369 g $15.00 20 15 B394 g $15.00 20 15 B369 $5.00 15 B394 $5.00 15

B370 g $15.00 20 15 B395 g $15.00 20 15 B370 $5.00 15 B395 $5.00 15

B371 g $15.00 20 15 B396 g $15.00 20 15 B371 $5.00 15 B396 $5.00 15

B372 g $15.00 20 15 B397 g $15.00 20 15 B372 $5.00 15 B397 $5.00 15

B373 g $15.00 20 15 B398 g $15.00 20 15 B373 $5.00 15 B398 $5.00 15

B374 g $15.00 20 15 B399 g $15.00 20 15 B374 $5.00 15 B399 $5.00 15

B375 g $15.00 20 15 B400 g $15.00 20 15 B375 $5.00 15 B400 $5.00 15

B376 g $15.00 20 15 B401 g $15.00 20 15 B376 $5.00 15 B401 $5.00 15

B377 g $15.00 20 15 B402 g $15.00 20 15 B377 $5.00 15 B402 $5.00 15

B378 g $15.00 20 15 B403 g $15.00 20 15 B378 $5.00 15 B403 $5.00 15

B379 g $15.00 20 15 B404 g $15.00 20 15 B379 $5.00 15 B404 $5.00 15

B380 g $15.00 20 15 B405 g $15.00 20 15 B380 $5.00 15 B405 $5.00 15

B381 g $15.00 20 15 B406 g $15.00 20 15 B381 $5.00 15 B406 $5.00 15

B382 g $15.00 20 15 B407 g $15.00 20 15 B382 $5.00 15 B407 $5.00 15

B383 g $15.00 20 15 B408 g $15.00 20 15 B383 $5.00 15 B408 $5.00 15

B384 g $15.00 20 15 B409 g $15.00 20 15 B384 $5.00 15 B409 $5.00 15

B385 g $15.00 20 15 B410 g $15.00 20 15 B385 $5.00 15 B410 $5.00 15

B386 g $15.00 20 15 B411 g $15.00 20 15 B386 $5.00 15 B411 $5.00 15

B387 g $15.00 20 15 B412 g $15.00 20 15 B387 $5.00 15 B412 $5.00 15

B388 g $15.00 20 15 B413 g $15.00 20 15 B388 $5.00 15 B413 $5.00 15

B389 g $15.00 20 15 B414 g $15.00 20 15 B389 $5.00 15 B414 $5.00 15

B390 g $15.00 20 15 B415 g $15.00 20 15 B390 $5.00 15 B415 $5.00 15

CÓDIGOS DE CUBIERTAS / COPAGOS

44 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B416 g $15.00 20 15 B441 g $15.00 15 15 B416 $5.00 15 B441 $5.00 15

B417 g $15.00 20 15 B442 g $15.00 15 15 B417 $5.00 15 B442 $5.00 15

B418 g $15.00 20 15 B443 g $15.00 15 15 B418 $5.00 15 B443 $5.00 15

B419 g $15.00 20 15 B444 g $15.00 15 15 B419 $5.00 15 B444 $5.00 15

B420 g $15.00 20 15 B445 g $15.00 15 15 B420 $5.00 15 B445 $5.00 15

B421 g $15.00 20 15 B446 g $15.00 15 15 B421 $5.00 15 B446 $5.00 15

B422 g $15.00 20 15 B447 g $15.00 15 15 B422 $5.00 15 B447 $5.00 15

B423 g $15.00 20 15 B448 g $15.00 15 15 B423 $5.00 15 B448 $5.00 15

B424 g $15.00 20 15 B449 g $15.00 15 15 B424 $5.00 15 B449 $5.00 15

B425 g $15.00 20 15 B450 g $15.00 15 15 B425 $5.00 15 B450 $5.00 15

B426 g $15.00 20 15 B451 g $15.00 15 15 B426 $5.00 15 B451 $5.00 15

B427 g $15.00 20 15 B452 g $15.00 15 15 B427 $5.00 15 B452 $5.00 15

B428 g $15.00 20 15 B453 g $15.00 15 15 B428 $5.00 15 B453 $5.00 15

B429 g $15.00 20 15 B454 g $15.00 15 15 B429 $5.00 15 B454 $5.00 15

B430 g $15.00 20 15 B455 g $15.00 15 15 B430 $5.00 15 B455 $5.00 15

B431 g $15.00 20 15 B456 g $15.00 15 15 B431 $5.00 15 B456 $5.00 15

B432 g $15.00 20 15 B457 g $15.00 15 15 B432 $5.00 15 B457 $5.00 15

B433 g $15.00 20 15 B458 g $15.00 15 15 B433 $5.00 15 B458 $5.00 15

B434 g $15.00 20 15 B459 g $15.00 15 15 B434 $5.00 15 B459 $5.00 15

B435 g $15.00 20 15 B460 g $15.00 15 15 B435 $5.00 15 B460 $5.00 15

B436 g $15.00 20 15 B461 g $15.00 15 15 B436 $5.00 15 B461 $5.00 15

B437 g $15.00 15 15 B462 g $15.00 15 15 B437 $5.00 15 B462 $5.00 15

B438 g $15.00 15 15 B463 g $15.00 15 15 B438 $5.00 15 B463 $5.00 15

B439 g $15.00 15 15 B464 g $15.00 15 15 B439 $5.00 15 B464 $5.00 15

B440 g $15.00 15 15 B465 g $15.00 15 15 B440 $5.00 15 B465 $5.00 15

CÓDIGOS DE CUBIERTAS / COPAGOS

45 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B466 g $15.00 15 15 B491 g $15.00 15 15 B466 $5.00 15 B491 $5.00 15

B467 g $15.00 15 15 B492 g $15.00 15 15 B467 $5.00 15 B492 $5.00 15

B468 g $15.00 15 15 B493 g $15.00 15 15 B468 $5.00 15 B493 $5.00 15

B469 g $15.00 15 15 B494 g $15.00 15 15 B469 $5.00 15 B494 $5.00 15

B470 g $15.00 15 15 B495 g $15.00 15 15 B470 $5.00 15 B495 $5.00 15

B471 g $15.00 15 15 B496 g $15.00 15 15 B471 $5.00 15 B496 $5.00 15

B472 g $15.00 15 15 B497 g $15.00 15 15 B472 $5.00 15 B497 $5.00 15

B473 g $15.00 15 15 B498 g $15.00 15 15 B473 $5.00 15 B498 $5.00 15

B474 g $15.00 15 15 B499 g $15.00 15 15 B474 $5.00 15 B499 $5.00 15

B475 g $15.00 15 15 B500 g $15.00 15 15 B475 $5.00 15 B500 $5.00 15

B476 g $15.00 15 15 B501 g $15.00 15 15 B476 $5.00 15 B501 $5.00 15

B477 g $15.00 15 15 B502 g $15.00 15 15 B477 $5.00 15 B502 $5.00 15

B478 g $15.00 15 15 B503 g $15.00 15 15 B478 $5.00 15 B503 $5.00 15

B479 g $15.00 15 15 B504 g $15.00 15 15 B479 $5.00 15 B504 $5.00 15

B480 g $15.00 15 15 B505 g $15.00 15 15 B480 $5.00 15 B505 $5.00 15

B481 g $15.00 15 15 B506 g $15.00 15 15 B481 $5.00 15 B506 $5.00 15

B482 g $15.00 15 15 B507 g $15.00 15 15 B482 $5.00 15 B507 $5.00 15

B483 g $15.00 15 15 B508 g $15.00 15 15 B483 $5.00 15 B508 $5.00 15

B484 g $15.00 15 15 B509 g $15.00 15 15 B484 $5.00 15 B509 $5.00 15

B485 g $15.00 15 15 B510 g $15.00 15 15 B485 $5.00 15 B510 $5.00 15

B486 g $15.00 15 15 B511 g $15.00 15 15 B486 $5.00 15 B511 $5.00 15

B487 g $15.00 15 15 B512 g $15.00 15 15 B487 $5.00 15 B512 $5.00 15

B488 g $15.00 15 15 B513 g $15.00 15 15 B488 $5.00 15 B513 $5.00 15

B489 g $15.00 15 15 B514 g $15.00 15 15 B489 $5.00 15 B514 $5.00 15

B490 g $15.00 15 15 B515 g $15.00 15 15 B490 $5.00 15 B515 $5.00 15

CÓDIGOS DE CUBIERTAS / COPAGOS

46 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B516 g $15.00 15 15 B541 g $15.00 15 15 B516 $5.00 15 B541 $5.00 15

B517 g $15.00 15 15 B542 g $15.00 15 15 B517 $5.00 15 B542 $5.00 15

B518 g $15.00 15 15 B543 g $15.00 15 15 B518 $5.00 15 B543 $5.00 15

B519 g $15.00 15 15 B544 g $15.00 15 15 B519 $5.00 15 B544 $5.00 15

B520 g $15.00 15 15 B545 g $15.00 15 15 B520 $5.00 15 B545 $5.00 15

B521 g $15.00 15 15 B546 g $15.00 15 15 B521 $5.00 15 B546 $5.00 15

B522 g $15.00 15 15 B547 g $15.00 15 15 B522 $5.00 15 B547 $5.00 15

B523 g $15.00 15 15 B548 g $15.00 15 15 B523 $5.00 15 B548 $5.00 15

B524 g $15.00 15 15 B549 g $15.00 15 15 B524 $5.00 15 B549 $5.00 15

B525 g $15.00 15 15 B550 g $15.00 15 15 B525 $5.00 15 B550 $5.00 15

B526 g $15.00 15 15 B551 g $15.00 15 15 B526 $5.00 15 B551 $5.00 15

B527 g $15.00 15 15 B552 g $15.00 15 15 B527 $5.00 15 B552 $5.00 15

B528 g $15.00 15 15 B553 g $15.00 15 15 B528 $5.00 15 B553 $5.00 15

B529 g $15.00 15 15 B554 g $15.00 15 15 B529 $5.00 15 B554 $5.00 15

B530 g $15.00 15 15 B555 g $15.00 15 15 B530 $5.00 15 B555 $5.00 15

B531 g $15.00 15 15 B556 g $15.00 15 15 B531 $5.00 15 B556 $5.00 15

B532 g $15.00 15 15 B557 g $15.00 15 15 B532 $5.00 15 B557 $5.00 15

B533 g $15.00 15 15 B558 g $15.00 15 15 B533 $5.00 15 B558 $5.00 15

B534 g $15.00 15 15 B559 g $15.00 15 15 B534 $5.00 15 B559 $5.00 15

B535 g $15.00 15 15 B560 g $15.00 15 15 B535 $5.00 15 B560 $5.00 15

B536 g $15.00 15 15 B561 g $15.00 15 15 B536 $5.00 15 B561 $5.00 15

B537 g $15.00 15 15 B562 g $15.00 15 15 B537 $5.00 15 B562 $5.00 15

B538 g $15.00 15 15 B563 g $15.00 15 15 B538 $5.00 15 B563 $5.00 15

B539 g $15.00 15 15 B564 g $15.00 15 15 B539 $5.00 15 B564 $5.00 15

B540 g $15.00 15 15 B565 g $15.00 15 15 B540 $5.00 15 B565 $5.00 15

CÓDIGOS DE CUBIERTAS / COPAGOS

47 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B566 g $15.00 15 15 B591 g $15.00 15 15 B566 $5.00 15 B591 $5.00 15

B567 g $15.00 15 15 B592 g $15.00 15 15 B567 $5.00 15 B592 $5.00 15

B568 g $15.00 15 15 B593 g $15.00 15 15 B568 $5.00 15 B593 $5.00 15

B569 g $15.00 15 15 B594 g $15.00 15 15 B569 $5.00 15 B594 $5.00 15

B570 g $15.00 15 15 B595 g $15.00 15 15 B570 $5.00 15 B595 $5.00 15

B571 g $15.00 15 15 B596 g $15.00 15 15 B571 $5.00 15 B596 $5.00 15

B572 g $15.00 15 15 B597 g $15.00 15 15 B572 $5.00 15 B597 $5.00 15

B573 g $15.00 15 15 B598 g $15.00 15 15 B573 $5.00 15 B598 $5.00 15

B574 g $15.00 15 15 B599 g $15.00 15 15 B574 $5.00 15 B599 $5.00 15

B575 g $15.00 15 15 B600 g $15.00 15 15 B575 $5.00 15 B600 $5.00 15

B576 g $15.00 15 15 B601 g $15.00 15 15 B576 $5.00 15 B601 $5.00 15

B577 g $15.00 15 15 B602 g $15.00 15 15 B577 $5.00 15 B602 $5.00 15

B578 g $15.00 15 15 B603 g $15.00 15 15 B578 $5.00 15 B603 $5.00 15

B579 g $15.00 15 15 B604 g $15.00 15 15 B579 $5.00 15 B604 $5.00 15

B580 g $15.00 15 15 B605 g $15.00 15 15 B580 $5.00 15 B605 $5.00 15

B581 g $15.00 15 15 B606 g $15.00 15 15 B581 $5.00 15 B606 $5.00 15

B582 g $15.00 15 15 B607 g $15.00 15 15 B582 $5.00 15 B607 $5.00 15

B583 g $15.00 15 15 B608 g $15.00 15 15 B583 $5.00 15 B608 $5.00 15

B584 g $15.00 15 15 B609 g $15.00 15 15 B584 $5.00 15 B609 $5.00 15

B585 g $15.00 15 15 B610 g $15.00 15 15 B585 $5.00 15 B610 $5.00 15

B586 g $15.00 15 15 B611 g $15.00 15 15 B586 $5.00 15 B611 $5.00 15

B587 g $15.00 15 15 B612 g $15.00 15 15 B587 $5.00 15 B612 $5.00 15

B588 g $15.00 15 15 B613 g $15.00 15 15 B588 $5.00 15 B613 $5.00 15

B589 g $15.00 15 15 B614 g $15.00 15 15 B589 $5.00 15 B614 $5.00 15

B590 g $15.00 15 15 B615 g $15.00 15 15 B590 $5.00 15 B615 $5.00 15

CÓDIGOS DE CUBIERTAS / COPAGOS

48 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B616 g $15.00 15 15 B641 g $15.00 15 15 B616 $5.00 15 B641 $5.00 15

B617 g $15.00 15 15 B642 g $15.00 15 15 B617 $5.00 15 B642 $5.00 15

B618 g $15.00 15 15 B643 g $15.00 15 15 B618 $5.00 15 B643 $5.00 15

B619 g $15.00 15 15 B644 g $15.00 15 15 B619 $5.00 15 B644 $5.00 15

B620 g $15.00 15 15 B645 g $15.00 15 15 B620 $5.00 15 B645 $5.00 15

B621 g $15.00 15 15 B646 g $15.00 15 15 B621 $5.00 15 B646 $5.00 15

B622 g $15.00 15 15 B647 g $15.00 15 15 B622 $5.00 15 B647 $5.00 15

B623 g $15.00 15 15 B648 g $15.00 15 15 B623 $5.00 15 B648 $5.00 15

B624 g $15.00 15 15 B649 g $15.00 15 15 B624 $5.00 15 B649 $5.00 15

B625 g $15.00 15 15 B650 g $15.00 15 15 B625 $5.00 15 B650 $5.00 15

B626 g $15.00 15 15 B651 g $15.00 15 15 B626 $5.00 15 B651 $5.00 15

B627 g $15.00 15 15 B652 g $15.00 15 15 B627 $5.00 15 B652 $5.00 15

B628 g $15.00 15 15 B653 g $15.00 15 15 B628 $5.00 15 B653 $5.00 15

B629 g $15.00 15 15 B654 g $15.00 15 15 B629 $5.00 15 B654 $5.00 15

B630 g $15.00 15 15 B655 g $15.00 15 15 B630 $5.00 15 B655 $5.00 15

B631 g $15.00 15 15 B656 g $15.00 15 15 B631 $5.00 15 B656 $5.00 15

B632 g $15.00 15 15 B657 g $15.00 15 15 B632 $5.00 15 B657 $5.00 15

B633 g $15.00 15 15 B658 g $15.00 15 15 B633 $5.00 15 B658 $5.00 15

B634 g $15.00 15 15 B659 g $15.00 15 15 B634 $5.00 15 B659 $5.00 15

B635 g $15.00 15 15 B660 g $15.00 15 15 B635 $5.00 15 B660 $5.00 15

B636 g $15.00 15 15 B661 g $15.00 15 15 B636 $5.00 15 B661 $5.00 15

B637 g $15.00 15 15 B662 g $15.00 15 15 B637 $5.00 15 B662 $5.00 15

B638 g $15.00 15 15 B663 g $15.00 15 15 B638 $5.00 15 B663 $5.00 15

B639 g $15.00 15 15 B664 g $15.00 15 15 B639 $5.00 15 B664 $5.00 15

B640 g $15.00 15 15 B665 g $15.00 15 15 B640 $5.00 15 B665 $5.00 15

CÓDIGOS DE CUBIERTAS / COPAGOS

49 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B666 g $15.00 15 15 B691 g $15.00 15 15 B666 $5.00 15 B691 $5.00 15

B667 g $15.00 15 15 B692 g $15.00 15 15 B667 $5.00 15 B692 $5.00 15

B668 g $15.00 15 15 B693 g $15.00 15 15 B668 $5.00 15 B693 $5.00 15

B669 g $15.00 15 15 B694 g $15.00 15 15 B669 $5.00 15 B694 $5.00 15

B670 g $15.00 15 15 B695 g $15.00 15 15 B670 $5.00 15 B695 $5.00 15

B671 g $15.00 15 15 B696 g $15.00 15 15 B671 $5.00 15 B696 $5.00 15

B672 g $15.00 15 15 B697 g $15.00 15 15 B672 $5.00 15 B697 $5.00 15

B673 g $15.00 15 15 B698 g $15.00 15 15 B673 $5.00 15 B698 $5.00 15

B674 g $15.00 15 15 B699 g $15.00 15 15 B674 $5.00 15 B699 $5.00 15

B675 g $15.00 15 15 B700 g $15.00 15 15 B675 $5.00 15 B700 $5.00 15

B676 g $15.00 15 15 B701 g $15.00 15 15 B676 $5.00 15 B701 $5.00 15

B677 g $15.00 15 15 B702 g $15.00 15 15 B677 $5.00 15 B702 $5.00 15

B678 g $15.00 15 15 B703 g $15.00 15 15 B678 $5.00 15 B703 $5.00 15

B679 g $15.00 15 15 B704 g $15.00 15 15 B679 $5.00 15 B704 $5.00 15

B680 g $15.00 15 15 B705 g $15.00 15 15 B680 $5.00 15 B705 $5.00 15

B681 g $15.00 15 15 B706 g $15.00 15 15 B681 $5.00 15 B706 $5.00 15

B682 g $15.00 15 15 B707 g $15.00 15 15 B682 $5.00 15 B707 $5.00 15

B683 g $15.00 15 15 B708 g $15.00 15 15 B683 $5.00 15 B708 $5.00 15

B684 g $15.00 15 15 B709 g $15.00 15 15 B684 $5.00 15 B709 $5.00 15

B685 g $15.00 15 15 B710 g $15.00 15 15 B685 $5.00 15 B710 $5.00 15

B686 g $15.00 15 15 B711 g $15.00 15 15 B686 $5.00 15 B711 $5.00 15

B687 g $15.00 15 15 B712 g $15.00 15 15 B687 $5.00 15 B712 $5.00 15

B688 g $15.00 15 15 B713 g $15.00 15 15 B688 $5.00 15 B713 $5.00 15

B689 g $15.00 15 15 B714 g $15.00 15 15 B689 $5.00 15 B714 $5.00 15

B690 g $15.00 15 15 B715 g $15.00 15 15 B690 $5.00 15 B715 $5.00 15

CÓDIGOS DE CUBIERTAS / COPAGOS

50 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B716 g $15.00 15 15 B741 g $15.00 15 15 B716 $5.00 15 B741 $5.00 15

B717 g $15.00 15 15 B742 g $15.00 15 15 B717 $5.00 15 B742 $5.00 15

B718 g $15.00 15 15 B743 g $15.00 15 15 B718 $5.00 15 B743 $5.00 15

B719 g $15.00 15 15 B744 g $15.00 15 15 B719 $5.00 15 B744 $5.00 15

B720 g $15.00 15 15 B745 g $15.00 15 15 B720 $5.00 15 B745 $5.00 15

B721 g $15.00 15 15 B746 g $15.00 15 15 B721 $5.00 15 B746 $5.00 15

B722 g $15.00 15 15 B747 g $15.00 15 15 B722 $5.00 15 B747 $5.00 15

B723 g $15.00 15 15 B748 g $15.00 15 15 B723 $5.00 15 B748 $5.00 15

B724 g $15.00 15 15 B749 g $15.00 15 15 B724 $5.00 15 B749 $5.00 15

B725 g $15.00 15 15 B750 g $15.00 15 15 B725 $5.00 15 B750 $5.00 15

B726 g $15.00 15 15 B751 g $15.00 15 15 B726 $5.00 15 B751 $5.00 15

B727 g $15.00 15 15 B752 g $15.00 15 15 B727 $5.00 15 B752 $5.00 15

B728 g $15.00 15 15 B753 g $15.00 15 15 B728 $5.00 15 B753 $5.00 15

B729 g $15.00 15 15 B754 g $15.00 15 15 B729 $5.00 15 B754 $5.00 15

B730 g $15.00 15 15 B755 g $15.00 15 15 B730 $5.00 15 B755 $5.00 15

B731 g $15.00 15 15 B756 g $15.00 15 15 B731 $5.00 15 B756 $5.00 15

B732 g $15.00 15 15 B757 g $15.00 15 15 B732 $5.00 15 B757 $5.00 15

B733 g $15.00 15 15 B758 g $15.00 15 15 B733 $5.00 15 B758 $5.00 15

B734 g $15.00 15 15 B759 g $15.00 15 15 B734 $5.00 15 B759 $5.00 15

B735 g $15.00 15 15 B760 g $15.00 15 15 B735 $5.00 15 B760 $5.00 15

B736 g $15.00 15 15 B761 g $15.00 15 15 B736 $5.00 15 B761 $5.00 15

B737 g $15.00 15 15 B762 g $15.00 15 15 B737 $5.00 15 B762 $5.00 15

B738 g $15.00 15 15 B763 g $15.00 15 15 B738 $5.00 15 B763 $5.00 15

B739 g $15.00 15 15 B764 g $15.00 15 15 B739 $5.00 15 B764 $5.00 15

B740 g $15.00 15 15 B765 g $15.00 15 15 B740 $5.00 15 B765 $5.00 15

CÓDIGOS DE CUBIERTAS / COPAGOS

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B766 g $15.00 15 15 B791 g $15.00 15 15 B766 $5.00 15 B791 $5.00 15

B767 g $15.00 15 15 B792 g $15.00 15 15 B767 $5.00 15 B792 $5.00 15

B768 g $15.00 15 15 B793 g $15.00 15 15 B768 $5.00 15 B793 $5.00 15

B769 g $15.00 15 15 B794 g $15.00 15 15 B769 $5.00 15 B794 $5.00 15

B770 g $15.00 15 15 B795 g $15.00 15 15 B770 $5.00 15 B795 $5.00 15

B771 g $15.00 15 15 B796 g $15.00 15 15 B771 $5.00 15 B796 $5.00 15

B772 g $15.00 15 15 B797 g $15.00 15 15 B772 $5.00 15 B797 $5.00 15

B773 g $15.00 15 15 B798 g $15.00 15 15 B773 $5.00 15 B798 $5.00 15

B774 g $15.00 15 15 B799 g $15.00 15 15 B774 $5.00 15 B799 $5.00 15

B775 g $15.00 15 15 B800 g $15.00 15 15 B775 $5.00 15 B800 $5.00 15

B776 g $15.00 15 15 B801 g $15.00 15 15 B776 $5.00 15 B801 $5.00 15

B777 g $15.00 15 15 B802 g $15.00 15 15 B777 $5.00 15 B802 $5.00 15

B778 g $15.00 15 15 B803 g $15.00 15 15 B778 $5.00 15 B803 $5.00 15

B779 g $15.00 15 15 B804 g $15.00 15 15 B779 $5.00 15 B804 $5.00 15

B780 g $15.00 15 15 B805 g $15.00 15 15 B780 $5.00 15 B805 $5.00 15

B781 g $15.00 15 15 B806 g $15.00 15 15 B781 $5.00 15 B806 $5.00 15

B782 g $15.00 15 15 B807 g $15.00 15 15 B782 $5.00 15 B807 $5.00 15

B783 g $15.00 15 15 B808 g $15.00 15 15 B783 $5.00 15 B808 $5.00 15

B784 g $15.00 15 15 B809 g $15.00 15 15 B784 $5.00 15 B809 $5.00 15

B785 g $15.00 15 15 B810 g $15.00 15 15 B785 $5.00 15 B810 $5.00 15

B786 g $15.00 15 15 B811 g $15.00 15 15 B786 $5.00 15 B811 $5.00 15

B787 g $15.00 15 15 B812 g $15.00 15 15 B787 $5.00 15 B812 $5.00 15

B788 g $15.00 15 15 B813 g $15.00 15 15 B788 $5.00 15 B813 $5.00 15

B789 g $15.00 15 15 B814 g $15.00 15 15 B789 $5.00 15 B814 $5.00 15

B790 g $15.00 15 15 B815 g $15.00 15 15 B790 $5.00 15 B815 $5.00 15

CÓDIGOS DE CUBIERTAS / COPAGOS

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B816 g $15.00 15 15 B841 g $15.00 15 15 B816 $5.00 15 B841 $5.00 15

B817 g $15.00 15 15 B842 g $15.00 15 15 B817 $5.00 15 B842 $5.00 15

B818 g $15.00 15 15 B843 g $15.00 15 15 B818 $5.00 15 B843 $5.00 15

B819 g $15.00 15 15 B844 g $15.00 15 15 B819 $5.00 15 B844 $5.00 15

B820 g $15.00 15 15 B845 g $15.00 15 15 B820 $5.00 15 B845 $5.00 15

B821 g $15.00 15 15 B846 g $15.00 15 15 B821 $5.00 15 B846 $5.00 15

B822 g $15.00 15 15 B847 g $15.00 15 15 B822 $5.00 15 B847 $5.00 15

B823 g $15.00 15 15 B848 g $15.00 15 15 B823 $5.00 15 B848 $5.00 15

B824 g $15.00 15 15 B849 g $15.00 15 15 B824 $5.00 15 B849 $5.00 15

B825 g $15.00 15 15 B850 g $15.00 15 15 B825 $5.00 15 B850 $5.00 15

B826 g $15.00 15 15 B851 g $15.00 15 15 B826 $5.00 15 B851 $5.00 15

B827 g $15.00 15 15 B852 g $15.00 15 15 B827 $5.00 15 B852 $5.00 15

B828 g $15.00 15 15 B853 g $15.00 15 15 B828 $5.00 15 B853 $5.00 15

B829 g $15.00 15 15 B854 g $15.00 15 15 B829 $5.00 15 B854 $5.00 15

B830 g $15.00 15 15 B855 g $15.00 15 15 B830 $5.00 15 B855 $5.00 15

B831 g $15.00 15 15 B856 g $15.00 15 15 B831 $5.00 15 B856 $5.00 15

B832 g $15.00 15 15 B857 g $15.00 15 15 B832 $5.00 15 B857 $5.00 15

B833 g $15.00 15 15 B858 g $15.00 15 15 B833 $5.00 15 B858 $5.00 15

B834 g $15.00 15 15 B859 g $15.00 15 15 B834 $5.00 15 B859 $5.00 15

B835 g $15.00 15 15 B860 g $15.00 15 15 B835 $5.00 15 B860 $5.00 15

B836 g $15.00 15 15 B861 g $15.00 15 15 B836 $5.00 15 B861 $5.00 15

B837 g $15.00 15 15 B862 g $15.00 15 15 B837 $5.00 15 B862 $5.00 15

B838 g $15.00 15 15 B863 g $15.00 15 15 B838 $5.00 15 B863 $5.00 15

B839 g $15.00 15 15 B864 g $15.00 15 15 B839 $5.00 15 B864 $5.00 15

B840 g $15.00 15 15 B865 g $15.00 15 15 B840 $5.00 15 B865 $5.00 15

CÓDIGOS DE CUBIERTAS / COPAGOS

53 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B866 g $15.00 15 15 B891 g $15.00 15 15 B866 $5.00 15 B891 $5.00 15

B867 g $15.00 15 15 B892 g $15.00 15 15 B867 $5.00 15 B892 $5.00 15

B868 g $15.00 15 15 B893 g $15.00 15 15 B868 $5.00 15 B893 $5.00 15

B869 g $15.00 15 15 B894 g $15.00 15 15 B869 $5.00 15 B894 $5.00 15

B870 g $15.00 15 15 B895 g $15.00 15 15 B870 $5.00 15 B895 $5.00 15

B871 g $15.00 15 15 B896 g $15.00 15 15 B871 $5.00 15 B896 $5.00 15

B872 g $15.00 15 15 B897 g $15.00 15 15 B872 $5.00 15 B897 $5.00 15

B873 g $15.00 15 15 B898 g $15.00 15 15 B873 $5.00 15 B898 $5.00 15

B874 g $15.00 15 15 B899 g $15.00 15 15 B874 $5.00 15 B899 $5.00 15

B875 g $15.00 15 15 B900 g $15.00 15 15 B875 $5.00 15 B900 $5.00 15

B876 g $15.00 15 15 B901 g $15.00 15 15 B876 $5.00 15 B901 $5.00 15

B877 g $15.00 15 15 B902 g $15.00 15 15 B877 $5.00 15 B902 $5.00 15

B878 g $15.00 15 15 B903 g $15.00 15 15 B878 $5.00 15 B903 $5.00 15

B879 g $15.00 15 15 B904 g $15.00 15 15 B879 $5.00 15 B904 $5.00 15

B880 g $15.00 15 15 B905 g $15.00 15 15 B880 $5.00 15 B905 $5.00 15

B881 g $15.00 15 15 B906 g $15.00 15 15 B881 $5.00 15 B906 $5.00 15

B882 g $15.00 15 15 B907 g $15.00 15 15 B882 $5.00 15 B907 $5.00 15

B883 g $15.00 15 15 B908 g $15.00 15 15 B883 $5.00 15 B908 $5.00 15

B884 g $15.00 15 15 B909 g $15.00 15 15 B884 $5.00 15 B909 $5.00 15

B885 g $15.00 15 15 B910 g $15.00 15 15 B885 $5.00 15 B910 $5.00 15

B886 g $15.00 15 15 B911 g $15.00 15 15 B886 $5.00 15 B911 $5.00 15

B887 g $15.00 15 15 B912 g $15.00 15 15 B887 $5.00 15 B912 $5.00 15

B888 g $15.00 15 15 B913 g $15.00 15 15 B888 $5.00 15 B913 $5.00 15

B889 g $15.00 15 15 B914 g $15.00 15 15 B889 $5.00 15 B914 $5.00 15

B890 g $15.00 15 15 B915 g $15.00 15 15 B890 $5.00 15 B915 $5.00 15

CÓDIGOS DE CUBIERTAS / COPAGOS

54 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B916 g $15.00 15 15 B941 g $15.00 15 15 B916 $5.00 15 B941 $5.00 15

B917 g $15.00 15 15 B942 g $15.00 15 15 B917 $5.00 15 B942 $5.00 15

B918 g $15.00 15 15 B943 g $15.00 15 15 B918 $5.00 15 B943 $5.00 15

B919 g $15.00 15 15 B944 g $15.00 15 15 B919 $5.00 15 B944 $5.00 15

B920 g $15.00 15 15 B945 g $15.00 15 15 B920 $5.00 15 B945 $5.00 15

B921 g $15.00 15 15 B946 g $15.00 15 15 B921 $5.00 15 B946 $5.00 15

B922 g $15.00 15 15 B947 g $15.00 15 15 B922 $5.00 15 B947 $5.00 15

B923 g $15.00 15 15 B948 g $15.00 15 15 B923 $5.00 15 B948 $5.00 15

B924 g $15.00 15 15 B949 g $15.00 15 15 B924 $5.00 15 B949 $5.00 15

B925 g $15.00 15 15 B950 g $15.00 15 15 B925 $5.00 15 B950 $5.00 15

B926 g $15.00 15 15 B951 g $15.00 15 15 B926 $5.00 15 B951 $5.00 15

B927 g $15.00 15 15 B952 g $15.00 15 15 B927 $5.00 15 B952 $5.00 15

B928 g $15.00 15 15 B953 g $15.00 15 15 B928 $5.00 15 B953 $5.00 15

B929 g $15.00 15 15 B954 g $15.00 15 15 B929 $5.00 15 B954 $5.00 15

B930 g $15.00 15 15 B955 g $15.00 15 15 B930 $5.00 15 B955 $5.00 15

B931 g $15.00 15 15 B956 g $15.00 15 15 B931 $5.00 15 B956 $5.00 15

B932 g $15.00 15 15 B957 g $15.00 15 15 B932 $5.00 15 B957 $5.00 15

B933 g $15.00 15 15 B958 g $15.00 15 15 B933 $5.00 15 B958 $5.00 15

B934 g $15.00 15 15 B959 g $15.00 15 15 B934 $5.00 15 B959 $5.00 15

B935 g $15.00 15 15 B960 g $15.00 15 15 B935 $5.00 15 B960 $5.00 15

B936 g $15.00 15 15 B961 g $15.00 15 15 B936 $5.00 15 B961 $5.00 15

B937 g $15.00 15 15 B962 g $15.00 15 15 B937 $5.00 15 B962 $5.00 15

B938 g $15.00 15 15 B963 g $15.00 15 15 B938 $5.00 15 B963 $5.00 15

B939 g $15.00 15 15 B964 g $15.00 15 15 B939 $5.00 15 B964 $5.00 15

B940 g $15.00 15 15 B965 g $15.00 15 15 B940 $5.00 15 B965 $5.00 15

CÓDIGOS DE CUBIERTAS / COPAGOS

55 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B966 g $15.00 15 15 B991 g $15.00 15 15 B966 $5.00 15 B991 $5.00 15

B967 g $15.00 15 15 B992 g $15.00 15 15 B967 $5.00 15 B992 $5.00 15

B968 g $15.00 15 15 B993 g $15.00 15 15 B968 $5.00 15 B993 $5.00 15

B969 g $15.00 15 15 B994 g $15.00 15 15 B969 $5.00 15 B994 $5.00 15

B970 g $15.00 15 15 B995 g $15.00 15 15 B970 $5.00 15 B995 $5.00 15

B971 g $15.00 15 15 B996 g $15.00 15 15 B971 $5.00 15 B996 $5.00 15

B972 g $15.00 15 15 B997 g $15.00 15 15 B972 $5.00 15 B997 $5.00 15

B973 g $15.00 15 15 B998 g $15.00 15 15 B973 $5.00 15 B998 $5.00 15

B974 g $15.00 15 15 B999 g $15.00 15 15 B974 $5.00 15 B999 $5.00 15

B975 g $15.00 15 15 B1000 $15.00 # # B975 $5.00 15 B1000 $5.00 #

B976 g $15.00 15 15 B1001 $15.00 # # B976 $5.00 15 B1001 $5.00 #

B977 g $15.00 15 15 B1002 $12.00 # # B977 $5.00 15 B1002 $5.00 #

B978 g $15.00 15 15 B1003 $15.00 # # B978 $5.00 15 B1003 $5.00 #

B979 g $15.00 15 15 B1004 $15.00 # # B979 $5.00 15 B1004 $5.00 #

B980 g $15.00 15 15 B1005 $15.00 # # B980 $5.00 15 B1005 $5.00 #

B981 g $15.00 15 15 B1006 $10.00 # # B981 $5.00 15 B1006 $5.00 #

B982 g $15.00 15 15 B1007 $12.00 # # B982 $5.00 15 B1007 $5.00 #

B983 g $15.00 15 15 B1008 $12.00 # # B983 $5.00 15 B1008 $5.00 #

B984 g $15.00 15 15 B1009 $15.00 # # B984 $5.00 15 B1009 $5.00 #

B985 g $15.00 15 15 B1010 $15.00 # # B985 $5.00 15 B1010 $5.00 #

B986 g $15.00 15 15 B1011 $15.00 # # B986 $5.00 15 B1011 $5.00 #

B987 g $15.00 15 15 B1012 $15.00 # # B987 $5.00 15 B1012 $5.00 #

B988 g $15.00 15 15 B1013 $15.00 # # B988 $5.00 15 B1013 $5.00 #

B989 g $15.00 15 15 B1014 $10.00 # # B989 $5.00 15 B1014 $5.00 #

B990 g $15.00 15 15 B1015 $10.00 # # B990 $5.00 15 B1015 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

56 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B1016 $10.00 # # B1041 $12.00 # # B1016 $5.00 # B1041 $5.00 #

B1017 $10.00 # # B1042 $15.00 # # B1017 $5.00 # B1042 $5.00 #

B1018 $15.00 # # B1043 $15.00 # # B1018 $5.00 # B1043 $5.00 #

B1019 $15.00 # # B1044 $15.00 # # B1019 $5.00 # B1044 $5.00 #

B1020 $15.00 # # B1045 $15.00 # # B1020 $5.00 # B1045 $5.00 #

B1021 $15.00 # # B1046 $10.00 # # B1021 $5.00 # B1046 $5.00 #

B1022 $10.00 # # B1047 $15.00 # # B1022 $5.00 # B1047 $5.00 #

B1023 $15.00 # # B1048 $15.00 # # B1023 $5.00 # B1048 $5.00 #

B1024 $10.00 # # B1049 $15.00 # # B1024 $5.00 # B1049 $5.00 #

B1025 $10.00 # # B1050 $10.00 # # B1025 $5.00 # B1050 $5.00 #

B1026 $12.00 # # B1051 $12.00 # # B1026 $5.00 # B1051 $5.00 #

B1027 $15.00 # # B1052 $15.00 # # B1027 $5.00 # B1052 $5.00 #

B1028 $10.00 # # B1053 $15.00 # # B1028 $5.00 # B1053 $5.00 #

B1029 $10.00 # # B1054 $12.00 # # B1029 $5.00 # B1054 $5.00 #

B1030 $15.00 # # B1055 $15.00 # # B1030 $5.00 # B1055 $5.00 #

B1031 $15.00 # # B1056 $10.00 # # B1031 $5.00 # B1056 $5.00 #

B1032 $15.00 # # B1057 $10.00 # # B1032 $5.00 # B1057 $5.00 #

B1033 $10.00 # # B1058 $10.00 # # B1033 $5.00 # B1058 $5.00 #

B1034 $12.00 # # B1059 $15.00 # # B1034 $5.00 # B1059 $5.00 #

B1035 $15.00 # # B1060 $10.00 # # B1035 $5.00 # B1060 $5.00 #

B1036 $15.00 # # B1061 $12.00 # # B1036 $5.00 # B1061 $5.00 #

B1037 $15.00 # # B1062 $15.00 # # B1037 $5.00 # B1062 $5.00 #

B1038 $15.00 # # B1063 $10.00 # # B1038 $5.00 # B1063 $5.00 #

B1039 $15.00 # # B1064 $15.00 # # B1039 $5.00 # B1064 $5.00 #

B1040 $10.00 # # B1065 $8.00 # # B1040 $5.00 # B1065 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

57 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B1066 $12.00 # # B1091 $15.00 # # B1066 $5.00 # B1091 $5.00 #

B1067 $15.00 # # B1092 $15.00 # # B1067 $5.00 # B1092 $5.00 #

B1068 $15.00 # # B1093 $15.00 # # B1068 $5.00 # B1093 $5.00 #

B1069 $10.00 # # B1094 $15.00 # # B1069 $5.00 # B1094 $5.00 #

B1070 $15.00 # # B1095 $12.00 # # B1070 $5.00 # B1095 $5.00 #

B1071 $15.00 # # B1096 $15.00 # # B1071 $5.00 # B1096 $5.00 #

B1072 $15.00 # # B1097 $10.00 # # B1072 $5.00 # B1097 $5.00 #

B1073 $15.00 # # B1098 $15.00 # # B1073 $5.00 # B1098 $5.00 #

B1074 $15.00 # # B1099 $15.00 # # B1074 $5.00 # B1099 $5.00 #

B1075 $15.00 # # B1100 $15.00 # # B1075 $5.00 # B1100 $5.00 #

B1076 $15.00 # # B1101 $15.00 # # B1076 $5.00 # B1101 $5.00 #

B1077 $15.00 # # B1102 $10.00 # # B1077 $5.00 # B1102 $5.00 #

B1078 $15.00 # # B1103 $15.00 # # B1078 $5.00 # B1103 $5.00 #

B1079 $12.00 # # B1104 $15.00 # # B1079 $5.00 # B1104 $5.00 #

B1080 $15.00 # # B1105 $12.00 # # B1080 $5.00 # B1105 $5.00 #

B1081 $15.00 # # B1106 $15.00 # # B1081 $5.00 # B1106 $5.00 #

B1082 $10.00 # # B1107 $15.00 # # B1082 $5.00 # B1107 $5.00 #

B1083 $15.00 # # B1108 $10.00 # # B1083 $5.00 # B1108 $5.00 #

B1084 $10.00 # # B1109 $12.00 # # B1084 $5.00 # B1109 $5.00 #

B1085 $15.00 # # B1110 $12.00 # # B1085 $5.00 # B1110 $5.00 #

B1086 $15.00 # # B1111 $10.00 # # B1086 $5.00 # B1111 $5.00 #

B1087 $15.00 # # B1112 $10.00 # # B1087 $5.00 # B1112 $5.00 #

B1088 $15.00 # # B1113 $15.00 # # B1088 $5.00 # B1113 $5.00 #

B1089 $15.00 # # B1114 $15.00 # # B1089 $5.00 # B1114 $5.00 #

B1090 $15.00 # # B1115 $12.00 # # B1090 $5.00 # B1115 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

58 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B1116 $12.00 # # B1142 $10.00 # # B1116 $5.00 # B1142 $5.00 #

B1118 $15.00 # # B1143 $12.00 # # B1118 $5.00 # B1143 $5.00 #

B1119 $10.00 # # B1144 $8.00 # # B1119 $5.00 # B1144 $5.00 #

B1120 $15.00 # # B1145 $10.00 # # B1120 $5.00 # B1145 $5.00 #

B1121 $12.00 # # B1146 $15.00 # # B1121 $5.00 # B1146 $5.00 #

B1122 $15.00 # # B1147 $15.00 # # B1122 $5.00 # B1147 $5.00 #

B1123 $15.00 # # B1148 $15.00 # # B1123 $5.00 # B1148 $5.00 #

B1124 $15.00 # # B1149 $15.00 # # B1124 $5.00 # B1149 $5.00 #

B1125 $10.00 # # B1150 $15.00 # # B1125 $5.00 # B1150 $5.00 #

B1126 $15.00 # # B1151 $8.00 # # B1126 $5.00 # B1151 $5.00 #

B1127 $15.00 # # B1152 $15.00 # # B1127 $5.00 # B1152 $5.00 #

B1128 $15.00 # # B1153 $15.00 # # B1128 $5.00 # B1153 $5.00 #

B1129 $15.00 # # B1154 $12.00 # # B1129 $5.00 # B1154 $5.00 #

B1130 $15.00 # # B1155 $15.00 # # B1130 $5.00 # B1155 $5.00 #

B1131 $15.00 # # B1156 $15.00 # # B1131 $5.00 # B1156 $5.00 #

B1132 $15.00 # # B1157 $15.00 # # B1132 $5.00 # B1157 $5.00 #

B1133 $15.00 # # B1158 $8.00 # # B1133 $5.00 # B1158 $5.00 #

B1134 $15.00 # # B1159 $15.00 # # B1134 $5.00 # B1159 $5.00 #

B1135 $15.00 # # B1160 $15.00 # # B1135 $5.00 # B1160 $5.00 #

B1136 $15.00 # # B1161 $10.00 # # B1136 $5.00 # B1161 $5.00 #

B1137 $15.00 # # B1162 $15.00 # # B1137 $5.00 # B1162 $5.00 #

B1138 $10.00 # # B1163 $15.00 # # B1138 $5.00 # B1163 $5.00 #

B1139 $10.00 # # B1164 $10.00 # # B1139 $5.00 # B1164 $5.00 #

B1140 $10.00 # # B1165 $15.00 # # B1140 $5.00 # B1165 $5.00 #

B1141 $10.00 # # B1166 $10.00 # # B1141 $5.00 # B1166 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

59 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B1167 $15.00 # # B1192 $15.00 # # B1167 $5.00 # B1192 $5.00 #

B1168 $15.00 # # B1193 $8.00 # # B1168 $5.00 # B1193 $5.00 #

B1169 $15.00 # # B1194 $10.00 # # B1169 $5.00 # B1194 $5.00 #

B1170 $15.00 # # B1195 $12.00 # # B1170 $5.00 # B1195 $5.00 #

B1171 $10.00 # # B1196 $15.00 # # B1171 $5.00 # B1196 $5.00 #

B1172 $12.00 # # B1197 $15.00 # # B1172 $5.00 # B1197 $5.00 #

B1173 $15.00 # # B1198 $15.00 # # B1173 $5.00 # B1198 $5.00 #

B1174 $15.00 # # B1199 $15.00 # # B1174 $5.00 # B1199 $5.00 #

B1175 $15.00 # # B1200 $8.00 # # B1175 $5.00 # B1200 $5.00 #

B1176 $15.00 # # B1201 $10.00 # # B1176 $5.00 # B1201 $5.00 #

B1177 $15.00 # # B1202 $15.00 # # B1177 $5.00 # B1202 $5.00 #

B1178 $8.00 # # B1203 $10.00 # # B1178 $5.00 # B1203 $5.00 #

B1179 $8.00 # # B1204 $15.00 # # B1179 $5.00 # B1204 $5.00 #

B1180 $10.00 # # B1205 $15.00 # # B1180 $5.00 # B1205 $5.00 #

B1181 $10.00 # # B1206 $15.00 # # B1181 $5.00 # B1206 $5.00 #

B1182 $12.00 # # B1207 $15.00 # # B1182 $5.00 # B1207 $5.00 #

B1183 $12.00 # # B1208 $15.00 # # B1183 $5.00 # B1208 $5.00 #

B1184 $15.00 # # B1209 $15.00 # # B1184 $5.00 # B1209 $5.00 #

B1185 $8.00 # # B1210 $15.00 # # B1185 $5.00 # B1210 $5.00 #

B1186 $10.00 # # B1211 $15.00 # # B1186 $5.00 # B1211 $5.00 #

B1187 $12.00 # # B1212 $15.00 # # B1187 $5.00 # B1212 $5.00 #

B1188 $15.00 # # B1213 $15.00 # # B1188 $5.00 # B1213 $5.00 #

B1189 $10.00 # # B1214 $15.00 # # B1189 $5.00 # B1214 $5.00 #

B1190 $10.00 # # B1215 $12.00 # # B1190 $5.00 # B1215 $5.00 #

B1191 $15.00 # # B1216 $15.00 # # B1191 $5.00 # B1216 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

60 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B1217 $15.00 # # B1242 $15.00 # # B1217 $5.00 # B1242 $5.00 #

B1218 $15.00 # # B1243 $12.00 # # B1218 $5.00 # B1243 $5.00 #

B1219 $15.00 # # B1244 $8.00 # # B1219 $5.00 # B1244 $5.00 #

B1220 $10.00 # # B1245 $15.00 # # B1220 $5.00 # B1245 $5.00 #

B1221 $15.00 # # B1246 $15.00 # # B1221 $5.00 # B1246 $5.00 #

B1222 $15.00 # # B1247 $15.00 # # B1222 $5.00 # B1247 $5.00 #

B1223 $15.00 # # B1248 $15.00 # # B1223 $5.00 # B1248 $5.00 #

B1224 $15.00 # # B1249 $15.00 # # B1224 $5.00 # B1249 $5.00 #

B1225 $15.00 # # B1250 $10.00 # # B1225 $5.00 # B1250 $5.00 #

B1226 $15.00 # # B1251 $12.00 # # B1226 $5.00 # B1251 $5.00 #

B1227 $15.00 # # B1252 $15.00 # # B1227 $5.00 # B1252 $5.00 #

B1228 $15.00 # # B1253 $10.00 # # B1228 $5.00 # B1253 $5.00 #

B1229 $8.00 # # B1254 $12.00 # # B1229 $5.00 # B1254 $5.00 #

B1230 $10.00 # # B1255 $15.00 # # B1230 $5.00 # B1255 $5.00 #

B1231 $15.00 # # B1256 $15.00 # # B1231 $5.00 # B1256 $5.00 #

B1232 $15.00 # # B1257 $12.00 # # B1232 $5.00 # B1257 $5.00 #

B1233 $15.00 # # B1258 $15.00 # # B1233 $5.00 # B1258 $5.00 #

B1234 $15.00 # # B1259 $15.00 # # B1234 $5.00 # B1259 $5.00 #

B1235 $15.00 # # B1260 $10.00 # # B1235 $5.00 # B1260 $5.00 #

B1236 $15.00 # # B1261 $15.00 # # B1236 $5.00 # B1261 $5.00 #

B1237 $15.00 # # B1262 $10.00 # # B1237 $5.00 # B1262 $5.00 #

B1238 $12.00 # # B1263 $15.00 # # B1238 $5.00 # B1263 $5.00 #

B1239 $15.00 # # B1264 $10.00 # # B1239 $5.00 # B1264 $5.00 #

B1240 $12.00 # # B1265 $12.00 # # B1240 $5.00 # B1265 $5.00 #

B1241 $15.00 # # B1266 $15.00 # # B1241 $5.00 # B1266 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

61 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B1267 $15.00 # # B1292 $15.00 # # B1267 $5.00 # B1292 $5.00 #

B1268 $12.00 # # B1293 $10.00 # # B1268 $5.00 # B1293 $5.00 #

B1269 $12.00 # # B1294 $15.00 # # B1269 $5.00 # B1294 $5.00 #

B1270 $8.00 # # B1295 $10.00 # # B1270 $5.00 # B1295 $5.00 #

B1271 $10.00 # # B1296 $15.00 # # B1271 $5.00 # B1296 $5.00 #

B1272 $10.00 # # B1297 $15.00 # # B1272 $5.00 # B1297 $5.00 #

B1273 $12.00 # # B1298 $10.00 # # B1273 $5.00 # B1298 $5.00 #

B1274 $15.00 # # B1299 $15.00 # # B1274 $5.00 # B1299 $5.00 #

B1275 $15.00 # # B1300 $10.00 # # B1275 $5.00 # B1300 $5.00 #

B1276 $10.00 # # B1301 $15.00 # # B1276 $5.00 # B1301 $5.00 #

B1277 $15.00 # # B1302 $15.00 # # B1277 $5.00 # B1302 $5.00 #

B1278 $15.00 # # B1303 $10.00 # # B1278 $5.00 # B1303 $5.00 #

B1279 $15.00 # # B1304 $10.00 # # B1279 $5.00 # B1304 $5.00 #

B1280 $15.00 # # B1305 $12.00 # # B1280 $5.00 # B1305 $5.00 #

B1281 $15.00 # # B1306 $10.00 # # B1281 $5.00 # B1306 $5.00 #

B1282 $15.00 # # B1307 $15.00 # # B1282 $5.00 # B1307 $5.00 #

B1283 $12.00 # # B1308 $10.00 # # B1283 $5.00 # B1308 $5.00 #

B1284 $15.00 # # B1309 $10.00 # # B1284 $5.00 # B1309 $5.00 #

B1285 $15.00 # # B1310 $15.00 # # B1285 $5.00 # B1310 $5.00 #

B1286 $10.00 # # B1311 $15.00 # # B1286 $5.00 # B1311 $5.00 #

B1287 $10.00 # # B1312 $15.00 # # B1287 $5.00 # B1312 $5.00 #

B1288 $12.00 # # B1313 $15.00 # # B1288 $5.00 # B1313 $5.00 #

B1289 $15.00 # # B1314 $15.00 # # B1289 $7.00 # B1314 $5.00 #

B1290 $15.00 # # B1315 $15.00 # # B1290 $7.00 # B1315 $5.00 #

B1291 $15.00 # # B1316 $12.00 # # B1291 $7.00 # B1316 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

62 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B1317 $12.00 # # B1342 $10.00 # # B1317 $5.00 # B1342 $5.00 #

B1318 $15.00 # # B1343 $10.00 # # B1318 $5.00 # B1343 $5.00 #

B1319 $15.00 # # B1344 $15.00 # # B1319 $5.00 # B1344 $5.00 #

B1320 $15.00 # # B1345 $15.00 # # B1320 $5.00 # B1345 $5.00 #

B1321 $15.00 # # B1346 $15.00 # # B1321 $5.00 # B1346 $5.00 #

B1322 $15.00 # # B1347 $15.00 # # B1322 $5.00 # B1347 $5.00 #

B1323 $15.00 # # B1348 $12.00 # # B1323 $5.00 # B1348 $5.00 #

B1324 $15.00 # # B1349 $15.00 # # B1324 $5.00 # B1349 $5.00 #

B1325 $15.00 # # B1350 $15.00 # # B1325 $5.00 # B1350 $5.00 #

B1326 $15.00 # # B1351 $15.00 # # B1326 $5.00 # B1351 $5.00 #

B1327 $15.00 # # B1352 $15.00 # # B1327 $5.00 # B1352 $5.00 #

B1328 $15.00 # # B1353 $15.00 # # B1328 $5.00 # B1353 $5.00 #

B1329 $15.00 # # B1354 $15.00 # # B1329 $5.00 # B1354 $5.00 #

B1330 $15.00 # # B1355 $12.00 # # B1330 $5.00 # B1355 $5.00 #

B1331 $15.00 # # B1356 $15.00 # # B1331 $5.00 # B1356 $5.00 #

B1332 $15.00 # # B1357 $15.00 # # B1332 $5.00 # B1357 $5.00 #

B1333 $15.00 # # B1358 $15.00 # # B1333 $5.00 # B1358 $5.00 #

B1334 $15.00 # # B1359 $15.00 # # B1334 $5.00 # B1359 $5.00 #

B1335 $15.00 # # B1360 $12.00 # # B1335 $5.00 # B1360 $5.00 #

B1336 $15.00 # # B1361 $15.00 # # B1336 $5.00 # B1361 $5.00 #

B1337 $12.00 # # B1362 $15.00 # # B1337 $5.00 # B1362 $5.00 #

B1338 $12.00 # # B1363 $12.00 # # B1338 $5.00 # B1363 $5.00 #

B1339 $15.00 # # B1364 $15.00 # # B1339 $5.00 # B1364 $5.00 #

B1340 $15.00 # # B1365 $15.00 # # B1340 $5.00 # B1365 $5.00 #

B1341 $15.00 # # B1366 $15.00 # # B1341 $5.00 # B1366 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

63 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B1367 $15.00 # # B1392 $15.00 # # B1367 $5.00 # B1392 $5.00 #

B1368 $15.00 # # B1393 $15.00 # # B1368 $5.00 # B1393 $5.00 #

B1369 $15.00 # # B1394 $15.00 # # B1369 $5.00 # B1394 $5.00 #

B1370 $10.00 # # B1395 $15.00 # # B1370 $5.00 # B1395 $5.00 #

B1371 $15.00 # # B1396 $15.00 # # B1371 $5.00 # B1396 $5.00 #

B1372 $15.00 # # B1397 $10.00 # # B1372 $5.00 # B1397 $5.00 #

B1373 $15.00 # # B1398 $15.00 # # B1373 $5.00 # B1398 $5.00 #

B1374 $15.00 # # B1399 $15.00 # # B1374 $5.00 # B1399 $5.00 #

B1375 $15.00 # # B1400 $12.00 # # B1375 $5.00 # B1400 $5.00 #

B1376 $15.00 # # B1401 $15.00 # # B1376 $5.00 # B1401 $5.00 #

B1377 $15.00 # # B1402 $15.00 # # B1377 $5.00 # B1402 $5.00 #

B1378 $15.00 # # B1403 $15.00 # # B1378 $5.00 # B1403 $5.00 #

B1379 $12.00 # # B1404 $15.00 # # B1379 $5.00 # B1404 $5.00 #

B1380 $10.00 # # B1405 $10.00 # # B1380 $5.00 # B1405 $5.00 #

B1381 $15.00 # # B1406 $15.00 # # B1381 $5.00 # B1406 $5.00 #

B1382 $10.00 # # B1407 $15.00 # # B1382 $5.00 # B1407 $5.00 #

B1383 $15.00 # # B1408 $10.00 # # B1383 $5.00 # B1408 $5.00 #

B1384 $15.00 # # B1409 $15.00 # # B1384 $5.00 # B1409 $5.00 #

B1385 $15.00 # # B1410 $15.00 # # B1385 $5.00 # B1410 $5.00 #

B1386 $15.00 # # B1411 $15.00 # # B1386 $5.00 # B1411 $5.00 #

B1387 $15.00 # # B1412 $12.00 # # B1387 $5.00 # B1412 $5.00 #

B1388 $15.00 # # B1413 $10.00 # # B1388 $5.00 # B1413 $5.00 #

B1389 $15.00 # # B1414 $15.00 # # B1389 $5.00 # B1414 $5.00 #

B1390 $10.00 # # B1415 $15.00 # # B1390 $5.00 # B1415 $5.00 #

B1391 $15.00 # # B1416 $12.00 # # B1391 $5.00 # B1416 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

64 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B1417 $15.00 # # B1442 $15.00 # # B1417 $5.00 # B1442 $5.00 #

B1418 $10.00 # # B1443 $15.00 # # B1418 $5.00 # B1443 $5.00 #

B1419 $15.00 # # B1444 $15.00 # # B1419 $5.00 # B1444 $5.00 #

B1420 $10.00 # # B1445 $15.00 # # B1420 $5.00 # B1445 $5.00 #

B1421 $15.00 # # B1446 $15.00 # # B1421 $5.00 # B1446 $5.00 #

B1422 $15.00 # # B1447 $15.00 # # B1422 $5.00 # B1447 $5.00 #

B1423 $15.00 # # B1448 $15.00 # # B1423 $5.00 # B1448 $5.00 #

B1424 $12.00 # # B1449 $15.00 # # B1424 $5.00 # B1449 $5.00 #

B1425 $10.00 # # B1450 $15.00 # # B1425 $5.00 # B1450 $5.00 #

B1426 $15.00 # # B1451 $12.00 # # B1426 $5.00 # B1451 $5.00 #

B1427 $10.00 # # B1452 $15.00 # # B1427 $5.00 # B1452 $5.00 #

B1428 $15.00 # # B1453 $15.00 # # B1428 $5.00 # B1453 $5.00 #

B1429 $15.00 # # B1454 $15.00 # # B1429 $5.00 # B1454 $5.00 #

B1430 $15.00 # # B1455 $15.00 # # B1430 $5.00 # B1455 $5.00 #

B1431 $15.00 # # B1456 $12.00 # # B1431 $5.00 # B1456 $5.00 #

B1432 $15.00 # # B1457 $15.00 # # B1432 $5.00 # B1457 $5.00 #

B1433 $15.00 # # B1458 $15.00 # # B1433 $5.00 # B1458 $5.00 #

B1434 $15.00 # # B1459 $15.00 # # B1434 $5.00 # B1459 $5.00 #

B1435 $10.00 # # B1460 $15.00 # # B1435 $5.00 # B1460 $5.00 #

B1436 $15.00 # # B1461 $15.00 # # B1436 $5.00 # B1461 $5.00 #

B1437 $15.00 # # B1462 $15.00 # # B1437 $5.00 # B1462 $5.00 #

B1438 $15.00 # # B1463 $10.00 # # B1438 $5.00 # B1463 $5.00 #

B1439 $10.00 # # B1464 $15.00 # # B1439 $5.00 # B1464 $5.00 #

B1440 $15.00 # # B1465 $10.00 # # B1440 $5.00 # B1465 $5.00 #

B1441 $15.00 # # B1466 $15.00 # # B1441 $5.00 # B1466 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

65 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B1467 $15.00 # # B1492 $10.00 # # B1467 $5.00 # B1492 $5.00 #

B1468 $10.00 # # B1493 $15.00 # # B1468 $5.00 # B1493 $5.00 #

B1469 $15.00 # # B1494 $10.00 # # B1469 $5.00 # B1494 $5.00 #

B1470 $15.00 # # B1495 $15.00 # # B1470 $5.00 # B1495 $5.00 #

B1471 $15.00 # # B1496 $12.00 # # B1471 $5.00 # B1496 $5.00 #

B1472 $15.00 # # B1497 $15.00 # # B1472 $5.00 # B1497 $5.00 #

B1473 $15.00 # # B1498 $15.00 # # B1473 $5.00 # B1498 $5.00 #

B1474 $15.00 # # B1499 $15.00 # # B1474 $5.00 # B1499 $5.00 #

B1475 $15.00 # # B1500 $15.00 # # B1475 $5.00 # B1500 $5.00 #

B1476 $15.00 # # B1501 $15.00 # # B1476 $5.00 # B1501 $5.00 #

B1477 $15.00 # # B1502 $15.00 # # B1477 $5.00 # B1502 $5.00 #

B1478 $15.00 # # B1503 $15.00 # # B1478 $5.00 # B1503 $5.00 #

B1479 $15.00 # # B1504 $15.00 # # B1479 $5.00 # B1504 $5.00 #

B1480 $15.00 # # B1505 $15.00 # # B1480 $5.00 # B1505 $5.00 #

B1481 $12.00 # # B1506 $15.00 # # B1481 $5.00 # B1506 $5.00 #

B1482 $15.00 # # B1507 $15.00 # # B1482 $5.00 # B1507 $5.00 #

B1483 $15.00 # # B1508 $15.00 # # B1483 $5.00 # B1508 $5.00 #

B1484 $10.00 # # B1509 $15.00 # # B1484 $5.00 # B1509 $5.00 #

B1485 $15.00 # # B1510 $15.00 # # B1485 $5.00 # B1510 $5.00 #

B1486 $15.00 # # B1511 $15.00 # # B1486 $5.00 # B1511 $5.00 #

B1487 $15.00 # # B1512 $10.00 # # B1487 $5.00 # B1512 $5.00 #

B1488 $15.00 # # B1513 $15.00 # # B1488 $5.00 # B1513 $5.00 #

B1489 $15.00 # # B1514 $10.00 # # B1489 $5.00 # B1514 $5.00 #

B1490 $15.00 # # B1515 $15.00 # # B1490 $5.00 # B1515 $5.00 #

B1491 $15.00 # # B1516 $15.00 # # B1491 $5.00 # B1516 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

66 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B1517 $15.00 # # B1542 $15.00 # # B1517 $5.00 # B1542 $5.00 #

B1518 $15.00 # # B1543 $15.00 # # B1518 $5.00 # B1543 $5.00 #

B1519 $15.00 # # B1544 $15.00 # # B1519 $5.00 # B1544 $5.00 #

B1520 $15.00 # # B1545 $15.00 # # B1520 $5.00 # B1545 $5.00 #

B1521 $15.00 # # B1546 $15.00 # # B1521 $5.00 # B1546 $5.00 #

B1522 $15.00 # # B1547 $15.00 # # B1522 $5.00 # B1547 $5.00 #

B1523 $15.00 # # B1548 $15.00 # # B1523 $5.00 # B1548 $5.00 #

B1524 $10.00 # # B1549 $15.00 # # B1524 $5.00 # B1549 $5.00 #

B1525 $15.00 # # B1550 $15.00 # # B1525 $5.00 # B1550 $5.00 #

B1526 $15.00 # # B1551 $15.00 # # B1526 $5.00 # B1551 $5.00 #

B1527 $15.00 # # B1552 $15.00 # # B1527 $5.00 # B1552 $5.00 #

B1528 $15.00 # # B1553 $15.00 # # B1528 $5.00 # B1553 $5.00 #

B1529 $15.00 # # B1554 $15.00 # # B1529 $5.00 # B1554 $5.00 #

B1530 $12.00 # # B1555 $15.00 # # B1530 $5.00 # B1555 $5.00 #

B1531 $15.00 # # B1556 $15.00 # # B1531 $5.00 # B1556 $5.00 #

B1532 $8.00 # # B1557 $15.00 # # B1532 $5.00 # B1557 $5.00 #

B1533 $15.00 # # B1558 $15.00 # # B1533 $5.00 # B1558 $5.00 #

B1534 $15.00 # # B1559 $15.00 # # B1534 $5.00 # B1559 $5.00 #

B1535 $15.00 # # B1560 $15.00 # # B1535 $5.00 # B1560 $5.00 #

B1536 $15.00 # # B1561 $15.00 # # B1536 $5.00 # B1561 $5.00 #

B1537 $15.00 # # B1562 $15.00 # # B1537 $5.00 # B1562 $5.00 #

B1538 $8.00 # # B1563 $10.00 # # B1538 $5.00 # B1563 $5.00 #

B1539 $15.00 # # B1564 $15.00 # # B1539 $5.00 # B1564 $5.00 #

B1540 $10.00 # # B1565 $10.00 # # B1540 $5.00 # B1565 $5.00 #

B1541 $15.00 # # B1566 $15.00 # # B1541 $5.00 # B1566 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

67 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B1567 $15.00 # # B1592 $15.00 # # B1567 $5.00 # B1592 $5.00 #

B1568 $15.00 # # B1593 $15.00 # # B1568 $5.00 # B1593 $5.00 #

B1569 $15.00 # # B1594 $15.00 # # B1569 $5.00 # B1594 $5.00 #

B1570 $15.00 # # B1595 $15.00 # # B1570 $5.00 # B1595 $5.00 #

B1571 $15.00 # # B1596 $15.00 # # B1571 $5.00 # B1596 $5.00 #

B1572 $15.00 # # B1597 $15.00 # # B1572 $5.00 # B1597 $5.00 #

B1573 $15.00 # # B1598 $10.00 # # B1573 $5.00 # B1598 $5.00 #

B1574 $15.00 # # B1599 $15.00 # # B1574 $7.00 # B1599 $5.00 #

B1575 $15.00 # # B1600 $15.00 # # B1575 $7.00 # B1600 $5.00 #

B1576 $15.00 # # B1601 $15.00 # # B1576 $7.00 # B1601 $5.00 #

B1577 $10.00 # # B1602 $15.00 # # B1577 $5.00 # B1602 $5.00 #

B1578 $12.00 # # B1603 $15.00 # # B1578 $5.00 # B1603 $5.00 #

B1579 $15.00 # # B1604 $15.00 # # B1579 $5.00 # B1604 $5.00 #

B1580 $15.00 # # B1605 $15.00 # # B1580 $5.00 # B1605 $5.00 #

B1581 $15.00 # # B1606 $10.00 # # B1581 $5.00 # B1606 N/C #

B1582 $10.00 # # B1607 $15.00 # # B1582 $5.00 # B1607 $5.00 #

B1583 $12.00 # # B1608 $15.00 # # B1583 $5.00 # B1608 $5.00 #

B1584 $15.00 # # B1609 $15.00 # # B1584 $5.00 # B1609 $5.00 #

B1585 $15.00 # # B1610 $10.00 # # B1585 $5.00 # B1610 $7.00 #

B1586 $10.00 # # B1611 $10.00 # # B1586 $5.00 # B1611 $7.00 #

B1587 $10.00 # # B1612 $10.00 # # B1587 $5.00 # B1612 $7.00 #

B1588 $15.00 # # B1613 $10.00 # # B1588 $5.00 # B1613 $7.00 #

B1589 $15.00 # # B1614 $10.00 # # B1589 $5.00 # B1614 $7.00 #

B1590 $10.00 # # B1615 $10.00 # # B1590 $5.00 # B1615 $7.00 #

B1591 $10.00 # # B1616 $10.00 # # B1591 $5.00 # B1616 $7.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B1617 $10.00 # # B1642 $10.00 # # B1617 $7.00 # B1642 $7.00 #

B1618 $10.00 # # B1643 $10.00 # # B1618 $7.00 # B1643 $7.00 #

B1619 $10.00 # # B1644 $10.00 # # B1619 $7.00 # B1644 $7.00 #

B1620 $10.00 # # B1645 $10.00 # # B1620 $7.00 # B1645 $7.00 #

B1621 $10.00 # # B1646 $10.00 # # B1621 $7.00 # B1646 $7.00 #

B1622 $10.00 # # B1647 $10.00 # # B1622 $7.00 # B1647 $7.00 #

B1623 $10.00 # # B1648 $10.00 # # B1623 $7.00 # B1648 $7.00 #

B1624 $10.00 # # B1649 $15.00 # # B1624 $7.00 # B1649 $7.00 #

B1625 $10.00 # # B1650 $15.00 # # B1625 $7.00 # B1650 $7.00 #

B1626 $10.00 # # B1651 $15.00 # # B1626 $7.00 # B1651 $7.00 #

B1627 $10.00 # # B1652 $15.00 # # B1627 $7.00 # B1652 $7.00 #

B1628 $10.00 # # B1653 $15.00 # # B1628 $7.00 # B1653 $7.00 #

B1629 $10.00 # # B1654 $15.00 # # B1629 $7.00 # B1654 $7.00 #

B1630 $10.00 # # B1655 $15.00 # # B1630 $7.00 # B1655 $7.00 #

B1631 $10.00 # # B1656 $15.00 # # B1631 $7.00 # B1656 $7.00 #

B1632 $10.00 # # B1657 $15.00 # # B1632 $7.00 # B1657 $7.00 #

B1633 $10.00 # # B1658 $15.00 # # B1633 $7.00 # B1658 $7.00 #

B1634 $10.00 # # B1659 $15.00 # # B1634 $7.00 # B1659 $7.00 #

B1635 $10.00 # # B1660 $15.00 # # B1635 $7.00 # B1660 $7.00 #

B1636 $10.00 # # B1661 $15.00 # # B1636 $7.00 # B1661 $7.00 #

B1637 $10.00 # # B1662 $15.00 # # B1637 $7.00 # B1662 $7.00 #

B1638 $10.00 # # B1663 $15.00 # # B1638 $7.00 # B1663 $7.00 #

B1639 $10.00 # # B1664 $15.00 # # B1639 $7.00 # B1664 $7.00 #

B1640 $10.00 # # B1665 $15.00 # # B1640 $7.00 # B1665 $7.00 #

B1641 $10.00 # # B1666 $15.00 # # B1641 $7.00 # B1666 $7.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B1667 $15.00 # # B1692 $10.00 # # B1667 $7.00 # B1692 $7.00 #

B1668 $15.00 # # B1693 $10.00 # # B1668 $7.00 # B1693 $7.00 #

B1669 $15.00 # # B1694 $10.00 # # B1669 $7.00 # B1694 $7.00 #

B1670 $15.00 # # B1695 $10.00 # # B1670 $7.00 # B1695 $7.00 #

B1671 $15.00 # # B1696 $10.00 # # B1671 $7.00 # B1696 $7.00 #

B1672 $15.00 # # B1697 $10.00 # # B1672 $7.00 # B1697 $7.00 #

B1673 $15.00 # # B1698 $10.00 # # B1673 $7.00 # B1698 $7.00 #

B1674 $15.00 # # B1699 $10.00 # # B1674 $7.00 # B1699 $7.00 #

B1675 $15.00 # # B1700 $10.00 # # B1675 $7.00 # B1700 $7.00 #

B1676 $15.00 # # B1701 $10.00 # # B1676 $7.00 # B1701 $7.00 #

B1677 $15.00 # # B1702 $10.00 # # B1677 $7.00 # B1702 $7.00 #

B1678 $15.00 # # B1703 $10.00 # # B1678 $7.00 # B1703 $7.00 #

B1679 $15.00 # # B1704 $10.00 # # B1679 $7.00 # B1704 $7.00 #

B1680 $15.00 # # B1705 $15.00 # # B1680 $7.00 # B1705 $5.00 #

B1681 $15.00 # # B1706 $15.00 # # B1681 $7.00 # B1706 $5.00 #

B1682 $15.00 # # B1707 $10.00 # # B1682 $7.00 # B1707 $5.00 #

B1683 $15.00 # # B1708 $10.00 # # B1683 $7.00 # B1708 $5.00 #

B1684 $15.00 # # B1709 $15.00 # # B1684 $7.00 # B1709 $5.00 #

B1685 $15.00 # # B1710 $15.00 # # B1685 $7.00 # B1710 $5.00 #

B1686 $15.00 # # B1711 $20.00 # # B1686 $7.00 # B1711 $5.00 #

B1687 $15.00 # # B1712 $18.00 # # B1687 $7.00 # B1712 $5.00 #

B1688 $15.00 # # B1713 $15.00 # # B1688 $7.00 # B1713 $5.00 #

B1689 $15.00 # # B1714 $15.00 # # B1689 $7.00 # B1714 N/C #

B1690 $15.00 # # B1715 $15.00 # # B1690 $7.00 # B1715 $5.00 #

B1691 $10.00 # # B1716 $15.00 # # B1691 $7.00 # B1716 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B1717 $15.00 # # B1742 $15.00 # # B1717 $5.00 # B1742 $5.00 #

B1718 $15.00 # # B1743 $15.00 # # B1718 $5.00 # B1743 $5.00 #

B1719 $7.00 # # B1744 $15.00 # # B1719 $5.00 # B1744 $5.00 #

B1720 $15.00 # # B1745 $15.00 # # B1720 $15.00 # B1745 $5.00 #

B1721 $15.00 # # B1746 $15.00 # # B1721 $5.00 # B1746 $5.00 #

B1722 $15.00 # # B1747 $10.00 # # B1722 $5.00 # B1747 $5.00 #

B1723 $15.00 # # B1748 $12.00 # # B1723 $5.00 # B1748 $5.00 #

B1724 $15.00 # # B1749 $15.00 # # B1724 $5.00 # B1749 $5.00 #

B1725 $15.00 # # B1750 $10.00 # # B1725 $5.00 # B1750 $5.00 #

B1726 $15.00 # # B1751 $15.00 # # B1726 $5.00 # B1751 $5.00 #

B1727 $15.00 # # B1752 $15.00 # # B1727 $5.00 # B1752 $5.00 #

B1728 $10.00 # # B1753 $15.00 # # B1728 $5.00 # B1753 $5.00 #

B1729 $15.00 # # B1754 $15.00 # # B1729 $5.00 # B1754 $5.00 #

B1730 $15.00 # # B1755 $15.00 # # B1730 $5.00 # B1755 $5.00 #

B1731 $10.00 # # B1756 $15.00 # # B1731 $5.00 # B1756 $5.00 #

B1732 $10.00 # # B1757 $15.00 # # B1732 $5.00 # B1757 $5.00 #

B1733 $15.00 # # B1758 $15.00 # # B1733 $5.00 # B1758 $5.00 #

B1734 $15.00 # # B1759 $15.00 # # B1734 $5.00 # B1759 $5.00 #

B1735 $15.00 # # B1760 $15.00 # # B1735 $5.00 # B1760 $5.00 #

B1736 $12.00 # # B1761 $10.00 # # B1736 $5.00 # B1761 $5.00 #

B1737 $15.00 # # B1762 $15.00 # # B1737 $5.00 # B1762 $7.00 #

B1738 $15.00 # # B1763 $15.00 # # B1738 $5.00 # B1763 $7.00 #

B1739 $15.00 # # B1764 $15.00 # # B1739 $5.00 # B1764 $7.00 #

B1740 $15.00 # # B1765 $15.00 # # B1740 $5.00 # B1765 $7.00 #

B1741 $15.00 # # B1766 $15.00 # # B1741 $5.00 # B1766 $7.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B1767 $15.00 # # B1792 $10.00 # # B1767 $7.00 # B1792 $7.00 #

B1768 $15.00 # # B1793 $10.00 # # B1768 $7.00 # B1793 $7.00 #

B1769 $15.00 # # B1794 $10.00 # # B1769 $7.00 # B1794 $7.00 #

B1770 $15.00 # # B1795 $10.00 # # B1770 $7.00 # B1795 $7.00 #

B1771 $15.00 # # B1796 $10.00 # # B1771 $7.00 # B1796 $7.00 #

B1772 $15.00 # # B1797 $10.00 # # B1772 $7.00 # B1797 $7.00 #

B1773 $15.00 # # B1798 $10.00 # # B1773 $7.00 # B1798 $7.00 #

B1774 $15.00 # # B1799 $10.00 # # B1774 $7.00 # B1799 $7.00 #

B1775 $15.00 # # B1800 $10.00 # # B1775 $7.00 # B1800 $7.00 #

B1776 $15.00 # # B1801 $10.00 # # B1776 $7.00 # B1801 $7.00 #

B1777 $15.00 # # B1802 $10.00 # # B1777 $7.00 # B1802 $7.00 #

B1778 $15.00 # # B1803 $10.00 # # B1778 $7.00 # B1803 $7.00 #

B1779 $15.00 # # B1804 $10.00 # # B1779 $7.00 # B1804 $7.00 #

B1780 $15.00 # # B1805 $10.00 # # B1780 $7.00 # B1805 $7.00 #

B1781 $15.00 # # B1806 $10.00 # # B1781 $7.00 # B1806 $7.00 #

B1782 $10.00 # # B1807 $10.00 # # B1782 $7.00 # B1807 $7.00 #

B1783 $10.00 # # B1808 $10.00 # # B1783 $7.00 # B1808 $7.00 #

B1784 $10.00 # # B1809 $10.00 # # B1784 $7.00 # B1809 $7.00 #

B1785 $10.00 # # B1810 $10.00 # # B1785 $7.00 # B1810 $7.00 #

B1786 $10.00 # # B1811 $10.00 # # B1786 $7.00 # B1811 $7.00 #

B1787 $10.00 # # B1812 $10.00 # # B1787 $7.00 # B1812 $7.00 #

B1788 $10.00 # # B1813 $10.00 # # B1788 $7.00 # B1813 $7.00 #

B1789 $10.00 # # B1814 $12.00 # # B1789 $7.00 # B1814 $5.00 #

B1790 $10.00 # # B1815 $15.00 # # B1790 $7.00 # B1815 $5.00 #

B1791 $10.00 # # B1816 $15.00 # # B1791 $7.00 # B1816 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

72 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B1817 $10.00 # # B1842 $15.00 # # B1817 $5.00 # B1842 $5.00 #

B1818 $15.00 # # B1843 $10.00 # # B1818 $5.00 # B1843 $5.00 #

B1819 $15.00 # # B1844 $15.00 # # B1819 $5.00 # B1844 $5.00 #

B1820 $12.00 # # B1845 $15.00 # # B1820 $5.00 # B1845 $5.00 #

B1821 $12.00 # # B1846 $15.00 # # B1821 $5.00 # B1846 $5.00 #

B1822 $15.00 # # B1847 $15.00 # # B1822 $5.00 # B1847 $5.00 #

B1823 $15.00 # # B1848 $10.00 # # B1823 $5.00 # B1848 $5.00 #

B1824 $15.00 # # B1849 $15.00 # # B1824 $5.00 # B1849 $5.00 #

B1825 $10.00 # # B1850 $15.00 # # B1825 $5.00 # B1850 $5.00 #

B1826 $15.00 # # B1851 $15.00 # # B1826 $5.00 # B1851 $5.00 #

B1827 $15.00 # # B1852 $15.00 # # B1827 $7.00 # B1852 $5.00 #

B1828 $15.00 # # B1853 $15.00 # # B1828 $5.00 # B1853 $5.00 #

B1829 $15.00 # # B1854 $15.00 # # B1829 $5.00 # B1854 $5.00 #

B1830 $15.00 # # B1855 $10.00 # # B1830 $5.00 # B1855 $7.00 #

B1831 $15.00 # # B1856 $15.00 # # B1831 $5.00 # B1856 $5.00 #

B1832 $15.00 # # B1857 $15.00 # # B1832 $5.00 # B1857 $5.00 #

B1833 $15.00 # # B1858 $15.00 # # B1833 $5.00 # B1858 $5.00 #

B1834 $15.00 # # B1859 $15.00 # # B1834 $5.00 # B1859 $5.00 #

B1835 $10.00 # # B1860 $15.00 # # B1835 $5.00 # B1860 $5.00 #

B1836 $15.00 # # B1861 $15.00 # # B1836 $5.00 # B1861 $5.00 #

B1837 $15.00 # # B1862 $15.00 # # B1837 $5.00 # B1862 $5.00 #

B1838 $10.00 # # B1863 $15.00 # # B1838 N/C # B1863 $5.00 #

B1839 $15.00 # # B1864 $15.00 # # B1839 $5.00 # B1864 $5.00 #

B1840 $15.00 # # B1865 $15.00 # # B1840 $5.00 # B1865 $5.00 #

B1841 $12.00 # # B1866 $15.00 # # B1841 $5.00 # B1866 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

73 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B1867 $15.00 # # B1892 $15.00 # # B1867 $5.00 # B1892 $5.00 #

B1868 $15.00 # # B1893 $15.00 # # B1868 $5.00 # B1893 $5.00 #

B1869 $15.00 # # B1894 $15.00 # # B1869 $5.00 # B1894 $5.00 #

B1870 $15.00 # # B1895 $15.00 # # B1870 $5.00 # B1895 $5.00 #

B1871 $15.00 # # B1896 $15.00 # # B1871 $5.00 # B1896 $5.00 #

B1872 $15.00 # # B1897 $15.00 # # B1872 $5.00 # B1897 $5.00 #

B1873 $15.00 # # B1898 $10.00 # # B1873 $5.00 # B1898 $5.00 #

B1874 $15.00 # # B1899 $15.00 # # B1874 $5.00 # B1899 $5.00 #

B1875 $10.00 # # B1900 $15.00 # # B1875 $5.00 # B1900 $5.00 #

B1876 $10.00 # # B1901 $15.00 # # B1876 $5.00 # B1901 $5.00 #

B1877 $15.00 # # B1902 $15.00 # # B1877 $5.00 # B1902 $5.00 #

B1878 $15.00 # # B1903 $10.00 # # B1878 $5.00 # B1903 $5.00 #

B1879 $12.00 # # B1904 $15.00 # # B1879 $5.00 # B1904 $5.00 #

B1880 $12.00 # # B1905 $15.00 # # B1880 $5.00 # B1905 $5.00 #

B1881 $10.00 # # B1906 $15.00 # # B1881 $5.00 # B1906 $5.00 #

B1882 $7.50 # # B1907 $12.00 # # B1882 $10.00 # B1907 $5.00 #

B1883 $15.00 # # B1908 $15.00 # # B1883 $5.00 # B1908 $5.00 #

B1884 $15.00 # # B1909 $15.00 # # B1884 $5.00 # B1909 $5.00 #

B1885 $15.00 # # B1910 $10.00 # # B1885 $5.00 # B1910 $5.00 #

B1886 $15.00 # # B1911 $15.00 # # B1886 $5.00 # B1911 $5.00 #

B1887 $10.00 # # B1912 $15.00 # # B1887 $5.00 # B1912 $5.00 #

B1888 $15.00 # # B1913 $12.00 # # B1888 $5.00 # B1913 $5.00 #

B1889 $12.00 # # B1914 $15.00 # # B1889 $5.00 # B1914 $5.00 #

B1890 $12.00 # # B1915 $10.00 # # B1890 $5.00 # B1915 $5.00 #

B1891 $15.00 # # B1916 $15.00 # # B1891 $5.00 # B1916 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

74 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B1917 $15.00 # # B1943 $10.00 # # B1917 $5.00 # B1943 $5.00 #

B1918 $15.00 # # B1944 $15.00 # # B1918 $5.00 # B1944 $5.00 #

B1919 $15.00 # # B1945 $12.00 # # B1919 $5.00 # B1945 $5.00 #

B1920 $12.00 # # B1946 $12.00 # # B1920 $5.00 # B1946 $5.00 #

B1921 $15.00 # # B1947 $15.00 # # B1921 $5.00 # B1947 $5.00 #

B1922 $15.00 # # B1948 $15.00 # # B1922 $5.00 # B1948 $5.00 #

B1923 $15.00 # # B1949 $15.00 # # B1923 $5.00 # B1949 $5.00 #

B1924 $15.00 # # B1950 $15.00 # # B1924 $5.00 # B1950 $5.00 #

B1925 $15.00 # # B1951 $15.00 # # B1925 $5.00 # B1951 $5.00 #

B1926 $15.00 # # B1952 $10.00 # # B1926 $7.00 # B1952 $5.00 #

B1927 $15.00 # # B1953 $10.00 # # B1927 $5.00 # B1953 $5.00 #

B1929 $15.00 # # B1954 $15.00 # # B1929 $5.00 # B1954 $5.00 #

B1930 $15.00 # # B1955 $15.00 # # B1930 $5.00 # B1955 $7.00 #

B1931 $15.00 # # B1956 $15.00 # # B1931 $5.00 # B1956 $5.00 #

B1932 $15.00 # # B1957 $12.00 # # B1932 $5.00 # B1957 $5.00 #

B1933 $10.00 # # B1958 $12.00 # # B1933 $5.00 # B1958 $5.00 #

B1934 $15.00 # # B1959 $15.00 # # B1934 $5.00 # B1959 $5.00 #

B1935 $10.00 # # B1960 $15.00 # # B1935 $5.00 # B1960 $5.00 #

B1936 $15.00 # # B1961 $15.00 # # B1936 $5.00 # B1961 $5.00 #

B1937 $12.00 # # B1962 $15.00 # # B1937 $5.00 # B1962 $5.00 #

B1938 $10.00 # # B1963 $15.00 # # B1938 $5.00 # B1963 $5.00 #

B1939 $15.00 # # B1964 $10.00 # # B1939 $7.00 # B1964 $5.00 #

B1940 $15.00 # # B1965 $15.00 # # B1940 $5.00 # B1965 $5.00 #

B1941 $15.00 # # B1966 $15.00 # # B1941 $5.00 # B1966 $5.00 #

B1942 $12.00 # # B1967 $15.00 # # B1942 $5.00 # B1967 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

75 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B1968 $15.00 # # B1993 $15.00 # # B1968 $5.00 # B1993 $5.00 #

B1969 $15.00 # # B1994 $15.00 # # B1969 $5.00 # B1994 $5.00 #

B1970 $15.00 # # B1995 $12.00 # # B1970 $5.00 # B1995 $5.00 #

B1971 $12.00 # # B1996 $15.00 # # B1971 $5.00 # B1996 $5.00 #

B1972 $15.00 # # B1997 $12.00 # # B1972 $5.00 # B1997 $5.00 #

B1973 $12.00 # # B1998 $15.00 # # B1973 $5.00 # B1998 $5.00 #

B1974 $12.00 # # B1999 $10.00 # # B1974 $5.00 # B1999 $5.00 #

B1975 $10.00 # # B2000 $10.00 # # B1975 $5.00 # B2000 $5.00 #

B1976 $15.00 # # B2001 $15.00 # # B1976 $5.00 # B2001 $5.00 #

B1977 $15.00 # # B2002 $15.00 # # B1977 $5.00 # B2002 $5.00 #

B1978 $12.00 # # B2003 $10.00 # # B1978 $5.00 # B2003 $5.00 #

B1979 $15.00 # # B2004 $15.00 # # B1979 $5.00 # B2004 $5.00 #

B1980 $10.00 # # B2005 $15.00 # # B1980 $5.00 # B2005 $5.00 #

B1981 $15.00 # # B2006 $10.00 # # B1981 $5.00 # B2006 $5.00 #

B1982 $15.00 # # B2007 $15.00 # # B1982 $5.00 # B2007 $5.00 #

B1983 $15.00 # # B2008 $10.00 # # B1983 $5.00 # B2008 $5.00 #

B1984 $15.00 # # B2009 $10.00 # # B1984 $5.00 # B2009 $5.00 #

B1985 $10.00 # # B2010 $12.00 # # B1985 $5.00 # B2010 $5.00 #

B1986 $15.00 # # B2011 $15.00 # # B1986 $5.00 # B2011 $5.00 #

B1987 $10.00 # # B2012 $10.00 # # B1987 $5.00 # B2012 $5.00 #

B1988 $15.00 # # B2013 $15.00 # # B1988 $5.00 # B2013 $5.00 #

B1989 $10.00 # # B2014 $15.00 # # B1989 $5.00 # B2014 $5.00 #

B1990 $15.00 # # B2015 $10.00 # # B1990 $5.00 # B2015 $5.00 #

B1991 $15.00 # # B2016 $15.00 # # B1991 $5.00 # B2016 $5.00 #

B1992 $15.00 # # B2017 $15.00 # # B1992 $5.00 # B2017 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

76 08/13/2015

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CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B2018 $15.00 # # B2043 $15.00 # # B2018 $5.00 # B2043 $5.00 #

B2019 $12.00 # # B2044 $15.00 # # B2019 $5.00 # B2044 $5.00 #

B2020 $15.00 # # B2045 $15.00 # # B2020 $5.00 # B2045 $5.00 #

B2021 $15.00 # # B2046 $12.00 # # B2021 $5.00 # B2046 $5.00 #

B2022 $15.00 # # B2047 $15.00 # # B2022 $5.00 # B2047 $5.00 #

B2023 $15.00 # # B2048 $15.00 # # B2023 $5.00 # B2048 $5.00 #

B2024 $15.00 # # B2049 $15.00 # # B2024 $5.00 # B2049 $5.00 #

B2025 $15.00 # # B2050 $15.00 # # B2025 $5.00 # B2050 $5.00 #

B2026 $15.00 # # B2051 $15.00 # # B2026 $5.00 # B2051 $5.00 #

B2027 $15.00 # # B2052 $10.00 # # B2027 $5.00 # B2052 $5.00 #

B2028 $12.00 # # B2053 $15.00 # # B2028 $5.00 # B2053 $5.00 #

B2029 $15.00 # # B2054 $12.00 # # B2029 $5.00 # B2054 $5.00 #

B2030 $12.00 # # B2055 $15.00 # # B2030 $5.00 # B2055 $5.00 #

B2031 $15.00 # # B2056 $15.00 # # B2031 $5.00 # B2056 $5.00 #

B2032 $15.00 # # B2057 $10.00 # # B2032 $5.00 # B2057 $5.00 #

B2033 $15.00 # # B2058 $15.00 # # B2033 $5.00 # B2058 $5.00 #

B2034 $15.00 # # B2059 $15.00 # # B2034 $5.00 # B2059 $5.00 #

B2035 $15.00 # # B2060 $15.00 # # B2035 $5.00 # B2060 $5.00 #

B2036 $15.00 # # B2061 $15.00 # # B2036 $5.00 # B2061 $7.00 #

B2037 $15.00 # # B2062 $10.00 # # B2037 $5.00 # B2062 $5.00 #

B2038 $12.00 # # B2063 $15.00 # # B2038 $5.00 # B2063 $5.00 #

B2039 $12.00 # # B2064 $15.00 # # B2039 $5.00 # B2064 $5.00 #

B2040 $15.00 # # B2065 $15.00 # # B2040 $5.00 # B2065 $5.00 #

B2041 $15.00 # # B2066 $20.00 # # B2041 $5.00 # B2066 $5.00 #

B2042 $15.00 # # B2067 $15.00 # # B2042 $5.00 # B2067 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

77 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B2068 $8.00 # # B2094 $15.00 # # B2068 $5.00 # B2094 $5.00 #

B2069 $15.00 # # B2095 $15.00 # # B2069 $5.00 # B2095 $5.00 #

B2070 $10.00 # # B2096 $15.00 # # B2070 $5.00 # B2096 $5.00 #

B2071 $10.00 # # B2097 $15.00 # # B2071 $5.00 # B2097 $5.00 #

B2072 $15.00 # # B2098 $15.00 # # B2072 $5.00 # B2098 $7.00 #

B2073 $20.00 # # B2099 $15.00 # # B2073 $5.00 # B2099 $7.00 #

B2074 $10.00 # # B2100 $15.00 # # B2074 $5.00 # B2100 $5.00 #

B2075 $15.00 # # B2101 $12.00 # # B2075 $5.00 # B2101 $5.00 #

B2076 $15.00 # # B2102 $15.00 # # B2076 $5.00 # B2102 $5.00 #

B2077 $15.00 # # B2103 $15.00 # # B2077 $5.00 # B2103 $5.00 #

B2079 $15.00 # # B2104 $10.00 # # B2079 $5.00 # B2104 $5.00 #

B2080 $15.00 # # B2105 $18.00 # # B2080 $5.00 # B2105 $5.00 #

B2081 $15.00 # # B2106 $18.00 # # B2081 $5.00 # B2106 $5.00 #

B2082 $15.00 # # B2107 $15.00 # # B2082 $5.00 # B2107 $5.00 #

B2083 $8.00 # # B2108 $12.00 # # B2083 $5.00 # B2108 $5.00 #

B2084 $12.00 # # B2109 $20.00 # # B2084 $5.00 # B2109 $5.00 #

B2085 $12.00 # # B2110 $15.00 # # B2085 $5.00 # B2110 $5.00 #

B2086 $20.00 # # B2111 $7.00 # # B2086 $5.00 # B2111 $7.00 #

B2087 $7.00 # # B2112 $15.00 # # B2087 $5.00 # B2112 $5.00 #

B2088 $15.00 # # B2113 $15.00 # # B2088 $5.00 # B2113 $5.00 #

B2089 $15.00 # # B2114 $15.00 # # B2089 $5.00 # B2114 $5.00 #

B2090 $15.00 # # B2115 $12.00 # # B2090 $5.00 # B2115 $5.00 #

B2091 $15.00 # # B2117 $20.00 # # B2091 $5.00 # B2117 $5.00 #

B2092 $15.00 # # B2118 $15.00 # # B2092 $5.00 # B2118 $5.00 #

B2093 $15.00 # # B2119 $15.00 # # B2093 $5.00 # B2119 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

78 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B2120 $15.00 # # B2145 $18.00 # # B2120 $5.00 # B2145 $5.00 #

B2121 $15.00 # # B2146 $18.00 # # B2121 $5.00 # B2146 $5.00 #

B2122 $15.00 # # B2147 $15.00 # # B2122 $5.00 # B2147 $5.00 #

B2123 $10.00 # # B2148 $15.00 # # B2123 $5.00 # B2148 $5.00 #

B2124 $15.00 # # B2149 $15.00 # # B2124 $5.00 # B2149 $5.00 #

B2125 $10.00 # # B2150 $15.00 # # B2125 $5.00 # B2150 $5.00 #

B2126 $15.00 # # B2151 $15.00 # # B2126 $5.00 # B2151 $5.00 #

B2127 $15.00 # # B2152 $15.00 # # B2127 $5.00 # B2152 $5.00 #

B2128 $20.00 # # B2153 $20.00 # # B2128 $5.00 # B2153 $5.00 #

B2129 $15.00 # # B2154 $12.00 # # B2129 $5.00 # B2154 $12.00 #

B2130 $35.00 # # B2155 $10.00 # # B2130 $5.00 # B2155 $5.00 #

B2131 $15.00 # # B2156 $8.00 # # B2131 $5.00 # B2156 $5.00 #

B2132 $7.00 # # B2157 $15.00 # # B2132 $5.00 # B2157 $5.00 #

B2133 $15.00 # # B2158 $15.00 # # B2133 $5.00 # B2158 $5.00 #

B2134 $12.00 # # B2159 $15.00 # # B2134 $5.00 # B2159 $5.00 #

B2135 $12.00 # # B2160 $15.00 # # B2135 $5.00 # B2160 $5.00 #

B2136 $15.00 # # B2161 $20.00 # # B2136 $5.00 # B2161 $5.00 #

B2137 $18.00 # # B2162 $15.00 # # B2137 $18.00 # B2162 $5.00 #

B2138 $15.00 # # B2163 $15.00 # # B2138 $5.00 # B2163 $5.00 #

B2139 $15.00 # # B2164 $15.00 # # B2139 $5.00 # B2164 $5.00 #

B2140 $10.00 # # B2165 $10.00 # # B2140 $5.00 # B2165 $5.00 #

B2141 $18.00 # # B2166 $15.00 # # B2141 $5.00 # B2166 $5.00 #

B2142 $18.00 # # B2167 $12.00 # # B2142 $5.00 # B2167 $5.00 #

B2143 $18.00 # # B2168 $15.00 # # B2143 $5.00 # B2168 $5.00 #

B2144 $18.00 # # B2169 $15.00 # # B2144 $5.00 # B2169 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

79 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B2170 $15.00 # # B2196 $15.00 # # B2170 $5.00 # B2196 $7.00 #

B2171 $15.00 # # B2197 $15.00 # # B2171 $5.00 # B2197 $5.00 #

B2172 $10.00 # # B2198 $15.00 # # B2172 $5.00 # B2198 $5.00 #

B2173 $15.00 # # B2199 $15.00 # # B2173 $5.00 # B2199 $5.00 #

B2175 $12.00 # # B2200 $15.00 # # B2175 $5.00 # B2200 $5.00 #

B2176 $10.00 # # B2201 $10.00 # # B2176 $5.00 # B2201 $5.00 #

B2177 $15.00 # # B2202 $15.00 # # B2177 $5.00 # B2202 $5.00 #

B2178 $15.00 # # B2203 $15.00 # # B2178 $5.00 # B2203 $5.00 #

B2179 $15.00 # # B2204 $12.00 # # B2179 $5.00 # B2204 $5.00 #

B2180 $10.00 # # B2205 $18.00 # # B2180 $5.00 # B2205 $5.00 #

B2181 $15.00 # # B2206 $10.00 # # B2181 $5.00 # B2206 $7.00 #

B2182 $15.00 # # B2207 $15.00 # # B2182 $5.00 # B2207 $5.00 #

B2183 $15.00 # # B2208 $15.00 # # B2183 $5.00 # B2208 $5.00 #

B2184 $15.00 # # B2209 $12.00 # # B2184 $5.00 # B2209 $5.00 #

B2185 $15.00 # # B2210 $15.00 # # B2185 $5.00 # B2210 $5.00 #

B2186 $15.00 # # B2211 $10.00 # # B2186 $5.00 # B2211 $5.00 #

B2187 $15.00 # # B2212 $15.00 # # B2187 $5.00 # B2212 $5.00 #

B2188 $15.00 # # B2213 $15.00 # # B2188 $5.00 # B2213 $5.00 #

B2189 $15.00 # # B2214 $15.00 # # B2189 $5.00 # B2214 $5.00 #

B2190 $15.00 # # B2215 $12.00 # # B2190 $5.00 # B2215 $5.00 #

B2191 $15.00 # # B2216 $15.00 # # B2191 $5.00 # B2216 $5.00 #

B2192 $10.00 # # B2217 $10.00 # # B2192 $5.00 # B2217 $5.00 #

B2193 $15.00 # # B2218 $10.00 # # B2193 $5.00 # B2218 $5.00 #

B2194 $15.00 # # B2219 $15.00 # # B2194 $5.00 # B2219 $5.00 #

B2195 $12.00 # # B2220 $10.00 # # B2195 $5.00 # B2220 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

80 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B2221 $15.00 # # B2246 $15.00 # # B2221 $5.00 # B2246 $5.00 #

B2222 $15.00 # # B2247 $20.00 # # B2222 $5.00 # B2247 $5.00 #

B2223 $15.00 # # B2248 $15.00 # # B2223 $5.00 # B2248 $5.00 #

B2224 $15.00 # # B2249 $12.00 # # B2224 $5.00 # B2249 $5.00 #

B2225 $15.00 # # B2250 $15.00 # # B2225 $5.00 # B2250 $5.00 #

B2226 $15.00 # # B2251 $15.00 # # B2226 $5.00 # B2251 $5.00 #

B2227 $15.00 # # B2252 $15.00 # # B2227 $5.00 # B2252 $5.00 #

B2228 $15.00 # # B2253 $10.00 # # B2228 $5.00 # B2253 $5.00 #

B2229 $15.00 # # B2254 $15.00 # # B2229 $5.00 # B2254 $5.00 #

B2230 $15.00 # # B2255 $12.00 # # B2230 $5.00 # B2255 $5.00 #

B2231 $15.00 # # B2256 $12.00 # # B2231 $5.00 # B2256 $5.00 #

B2232 $15.00 # # B2257 $15.00 # # B2232 $5.00 # B2257 $5.00 #

B2233 $15.00 # # B2258 $8.00 # # B2233 $5.00 # B2258 $5.00 #

B2234 $15.00 # # B2259 $5.00 # # B2234 $5.00 # B2259 $5.00 #

B2235 $12.00 # # B2260 $10.00 # # B2235 $5.00 # B2260 $5.00 #

B2236 NADA # # B2261 $15.00 # # B2236 $5.00 # B2261 $5.00 #

B2237 $10.00 # # B2262 $18.00 # # B2237 $5.00 # B2262 $18.00 #

B2238 $15.00 # # B2263 $18.00 # # B2238 $5.00 # B2263 $5.00 #

B2239 $15.00 # # B2264 $15.00 # # B2239 $7.00 # B2264 $5.00 #

B2240 $15.00 # # B2265 $15.00 # # B2240 $7.00 # B2265 $5.00 #

B2241 $15.00 # # B2266 $15.00 # # B2241 $5.00 # B2266 $5.00 #

B2242 $15.00 # # B2267 $15.00 # # B2242 $5.00 # B2267 $5.00 #

B2243 $15.00 # # B2268 $10.00 # # B2243 $5.00 # B2268 $10.00 #

B2244 $15.00 # # B2269 $15.00 # # B2244 $5.00 # B2269 $5.00 #

B2245 $10.00 # # B2270 $15.00 # # B2245 $5.00 # B2270 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

81 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B2271 $10.00 # # B2296 $20.00 # # B2271 $5.00 # B2296 $5.00 #

B2272 $15.00 # # B2297 $12.00 # # B2272 $15.00 # B2297 $5.00 #

B2273 $10.00 # # B2298 $12.00 # # B2273 $5.00 # B2298 $5.00 #

B2274 $15.00 # # B2299 $18.00 # # B2274 $5.00 # B2299 $5.00 #

B2275 $20.00 # # B2300 $20.00 # # B2275 $5.00 # B2300 $5.00 #

B2276 $20.00 # # B2301 $15.00 # # B2276 $5.00 # B2301 $5.00 #

B2277 $20.00 # # B2302 $10.00 # # B2277 $5.00 # B2302 $5.00 #

B2278 $20.00 # # B2303 $10.00 # # B2278 $5.00 # B2303 $5.00 #

B2279 $15.00 # # B2304 $15.00 # # B2279 $5.00 # B2304 $5.00 #

B2280 $15.00 # # B2305 $15.00 # # B2280 $5.00 # B2305 $5.00 #

B2281 $15.00 # # B2306 $15.00 # # B2281 $5.00 # B2306 $5.00 #

B2282 $12.00 # # B2307 $15.00 # # B2282 $5.00 # B2307 $5.00 #

B2283 $15.00 # # B2308 $15.00 # # B2283 $5.00 # B2308 $5.00 #

B2284 $12.00 # # B2309 $15.00 # # B2284 $5.00 # B2309 $5.00 #

B2285 $18.00 # # B2310 $15.00 # # B2285 $5.00 # B2310 $5.00 #

B2286 $15.00 # # B2311 $12.00 # # B2286 $5.00 # B2311 $5.00 #

B2287 $18.00 # # B2312 $12.00 # # B2287 $5.00 # B2312 $5.00 #

B2288 $15.00 # # B2313 $18.00 # # B2288 $5.00 # B2313 $5.00 #

B2289 $15.00 # # B2315 $15.00 # # B2289 $5.00 # B2315 $15.00 #

B2290 $17.00 # # B2316 $15.00 # # B2290 $5.00 # B2316 $15.00 #

B2291 $15.00 # # B2317 $15.00 # # B2291 $5.00 # B2317 $15.00 #

B2292 $15.00 # # B2318 $15.00 # # B2292 $5.00 # B2318 $5.00 #

B2293 $10.00 # # B2319 $15.00 # # B2293 $5.00 # B2319 $5.00 #

B2294 $18.00 # # B2320 $15.00 # # B2294 $5.00 # B2320 $5.00 #

B2295 $10.00 # # B2321 $15.00 # # B2295 $5.00 # B2321 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

82 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B2322 $12.00 # # B2347 $15.00 # # B2322 $5.00 # B2347 $5.00 #

B2323 $15.00 # # B2348 $15.00 # # B2323 $5.00 # B2348 $5.00 #

B2324 $10.00 # # B2349 $10.00 # # B2324 $5.00 # B2349 $5.00 #

B2325 $10.00 # # B2350 $15.00 # # B2325 $5.00 # B2350 $5.00 #

B2326 $15.00 # # B2351 $12.00 # # B2326 $5.00 # B2351 $5.00 #

B2327 $10.00 # # B2352 $15.00 # # B2327 $10.00 # B2352 $5.00 #

B2328 $12.00 # # B2353 $15.00 # # B2328 $12.00 # B2353 $5.00 #

B2329 $15.00 # # B2354 $15.00 # # B2329 $5.00 # B2354 $5.00 #

B2330 $18.00 # # B2355 $15.00 # # B2330 $5.00 # B2355 $5.00 #

B2331 $15.00 # # B2356 $15.00 # # B2331 $5.00 # B2356 $5.00 #

B2332 $15.00 # # B2357 $15.00 # # B2332 $5.00 # B2357 $5.00 #

B2333 $15.00 # # B2358 $12.00 # # B2333 $5.00 # B2358 $5.00 #

B2334 $12.00 # # B2359 NADA # # B2334 $5.00 # B2359 $5.00 #

B2335 $12.00 # # B2360 $10.00 # # B2335 $5.00 # B2360 $5.00 #

B2336 $15.00 # # B2361 $15.00 # # B2336 $5.00 # B2361 $5.00 #

B2337 $15.00 # # B2362 $15.00 # # B2337 $5.00 # B2362 $5.00 #

B2338 $15.00 # # B2363 $6.00 # # B2338 $5.00 # B2363 $5.00 #

B2339 $12.00 # # B2364 $15.00 # # B2339 $5.00 # B2364 $5.00 #

B2340 $15.00 # # B2365 $10.00 # # B2340 $5.00 # B2365 $5.00 #

B2341 $12.00 # # B2366 $10.00 # # B2341 $5.00 # B2366 $5.00 #

B2342 $15.00 # # B2367 $12.00 # # B2342 $5.00 # B2367 $5.00 #

B2343 $12.00 # # B2368 $15.00 # # B2343 $5.00 # B2368 $15.00 #

B2344 $15.00 # # B2369 $15.00 # # B2344 $5.00 # B2369 $15.00 #

B2345 $12.00 # # B2370 $20.00 # # B2345 $5.00 # B2370 $20.00 #

B2346 $15.00 # # B2371 $12.00 # # B2346 $5.00 # B2371 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

83 08/13/2015

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CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B2372 $15.00 # # B2397 $15.00 # # B2372 $5.00 # B2397 $15.00 #

B2373 $20.00 # # B2398 $15.00 # # B2373 $5.00 # B2398 $5.00 #

B2374 $20.00 # # B2399 $12.00 # # B2374 $5.00 # B2399 $5.00 #

B2375 $12.00 # # B2400 $10.00 # # B2375 $5.00 # B2400 $5.00 #

B2376 $15.00 # # B2401 $15.00 # # B2376 $5.00 # B2401 $5.00 #

B2377 $18.00 # # B2402 $18.00 # # B2377 $5.00 # B2402 $5.00 #

B2378 $15.00 # # B2403 $15.00 # # B2378 $5.00 # B2403 $5.00 #

B2379 $15.00 # # B2404 $15.00 # # B2379 $5.00 # B2404 $15.00 #

B2380 $15.00 # # B2405 $20.00 # # B2380 $5.00 # B2405 $5.00 #

B2381 $15.00 # # B2406 $15.00 # # B2381 $5.00 # B2406 $5.00 #

B2382 $12.00 # # B2407 $10.00 # # B2382 $5.00 # B2407 $5.00 #

B2383 $12.00 # # B2408 $15.00 # # B2383 $5.00 # B2408 $5.00 #

B2384 $15.00 # # B2409 $15.00 # # B2384 $5.00 # B2409 $5.00 #

B2385 $15.00 # # B2410 $15.00 # # B2385 $5.00 # B2410 $7.00 #

B2386 $15.00 # # B2411 $8.00 # # B2386 $5.00 # B2411 $5.00 #

B2387 $12.00 # # B2412 $15.00 # # B2387 $12.00 # B2412 $5.00 #

B2388 $12.00 # # B2413 $15.00 # # B2388 $12.00 # B2413 $5.00 #

B2389 $20.00 # # B2414 $15.00 # # B2389 $5.00 # B2414 $5.00 #

B2390 $15.00 # # B2415 $15.00 # # B2390 $5.00 # B2415 $5.00 #

B2391 $15.00 # # B2416 $15.00 # # B2391 $15.00 # B2416 $5.00 #

B2392 $10.00 # # B2417 $15.00 # # B2392 $5.00 # B2417 $5.00 #

B2393 $10.00 # # B2418 $12.00 # # B2393 $5.00 # B2418 $5.00 #

B2394 $20.00 # # B2419 $10.00 # # B2394 $5.00 # B2419 $5.00 #

B2395 $20.00 # # B2420 $15.00 # # B2395 $5.00 # B2420 $5.00 #

B2396 $10.00 # # B2421 $40.00 # # B2396 $10.00 # B2421 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

84 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B2422 $5.00 # # B2447 $15.00 # # B2422 $5.00 # B2447 $5.00 #

B2423 $5.00 # # B2448 $12.00 # # B2423 $5.00 # B2448 $5.00 #

B2424 $15.00 # # B2449 $12.00 # # B2424 $5.00 # B2449 $5.00 #

B2425 $12.00 # # B2450 $15.00 # # B2425 $5.00 # B2450 $5.00 #

B2426 $15.00 # # B2451 $10.00 # # B2426 $5.00 # B2451 $5.00 #

B2427 $15.00 # # B2452 $10.00 # # B2427 $5.00 # B2452 $5.00 #

B2428 $18.00 # # B2453 $10.00 # # B2428 $5.00 # B2453 $5.00 #

B2429 $18.00 # # B2454 $10.00 # # B2429 $5.00 # B2454 $5.00 #

B2430 $18.00 # # B2455 $20.00 # # B2430 $5.00 # B2455 $5.00 #

B2431 $18.00 # # B2456 $15.00 # # B2431 $5.00 # B2456 $5.00 #

B2432 $18.00 # # B2457 $15.00 # # B2432 $5.00 # B2457 $5.00 #

B2433 $18.00 # # B2458 $15.00 # # B2433 $5.00 # B2458 $5.00 #

B2434 $18.00 # # B2459 $15.00 # # B2434 $5.00 # B2459 $5.00 #

B2435 $18.00 # # B2460 $10.00 # # B2435 $5.00 # B2460 $5.00 #

B2436 $18.00 # # B2461 $18.00 # # B2436 $5.00 # B2461 $5.00 #

B2437 $18.00 # # B2462 $18.00 # # B2437 $5.00 # B2462 $5.00 #

B2438 $18.00 # # B2463 $15.00 # # B2438 $5.00 # B2463 $5.00 #

B2439 $18.00 # # B2464 $18.00 # # B2439 $5.00 # B2464 $5.00 #

B2440 $18.00 # # B2465 $18.00 # # B2440 $5.00 # B2465 $5.00 #

B2441 $18.00 # # B2466 $15.00 # # B2441 $5.00 # B2466 $5.00 #

B2442 $18.00 # # B2467 $15.00 # # B2442 $5.00 # B2467 $5.00 #

B2443 $18.00 # # B2468 $18.00 # # B2443 $5.00 # B2468 $5.00 #

B2444 $10.00 # # B2469 $20.00 # # B2444 $5.00 # B2469 $5.00 #

B2445 $10.00 # # B2470 $15.00 # # B2445 $5.00 # B2470 $5.00 #

B2446 $15.00 # # B2471 $15.00 # # B2446 $5.00 # B2471 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

85 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B2472 $15.00 # # B2497 $18.00 # # B2472 $5.00 # B2497 $5.00 #

B2473 $15.00 # # B2498 $15.00 # # B2473 $5.00 # B2498 $5.00 #

B2474 $10.00 # # B2499 $12.00 # # B2474 $5.00 # B2499 $5.00 #

B2475 $10.00 # # B2500 $12.00 # # B2475 $5.00 # B2500 $5.00 #

B2476 $20.00 # # B2501 $15.00 # # B2476 $5.00 # B2501 $5.00 #

B2477 $10.00 # # B2502 $18.00 # # B2477 $5.00 # B2502 $5.00 #

B2478 NADA # # B2503 $20.00 # # B2478 $5.00 # B2503 $5.00 #

B2479 $6.00 # # B2504 $15.00 # # B2479 $5.00 # B2504 $5.00 #

B2480 $6.00 # # B2505 $10.00 # # B2480 $5.00 # B2505 $5.00 #

B2481 $15.00 # # B2506 $15.00 # # B2481 $7.00 # B2506 $15.00 #

B2482 $10.00 # # B2507 $15.00 # # B2482 $10.00 # B2507 $5.00 #

B2483 $15.00 # # B2508 $10.00 # # B2483 $15.00 # B2508 $5.00 #

B2484 $7.00 # # B2509 $10.00 # # B2484 $5.00 # B2509 $5.00 #

B2485 $15.00 # # B2510 $15.00 # # B2485 $5.00 # B2510 $5.00 #

B2486 $18.00 # # B2511 $15.00 # # B2486 $5.00 # B2511 $15.00 #

B2487 $18.00 # # B2512 $10.00 # # B2487 $5.00 # B2512 $5.00 #

B2488 $18.00 # # B2513 $15.00 # # B2488 $5.00 # B2513 $5.00 #

B2489 $18.00 # # B2514 $20.00 # # B2489 $5.00 # B2514 $5.00 #

B2490 $18.00 # # B2515 $15.00 # # B2490 $5.00 # B2515 $5.00 #

B2491 $10.00 # # B2516 $15.00 # # B2491 $5.00 # B2516 $5.00 #

B2492 $18.00 # # B2517 $15.00 # # B2492 $5.00 # B2517 $5.00 #

B2493 $18.00 # # B2518 $15.00 # # B2493 $5.00 # B2518 $5.00 #

B2494 $18.00 # # B2519 $15.00 # # B2494 $5.00 # B2519 $5.00 #

B2495 $12.00 # # B2520 $15.00 # # B2495 $5.00 # B2520 $5.00 #

B2496 $8.00 # # B2521 $15.00 # # B2496 $5.00 # B2521 $15.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

86 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B2522 $15.00 # # B2547 $15.00 # # B2522 $5.00 # B2547 $5.00 #

B2523 $10.00 # # B2548 $20.00 # # B2523 $5.00 # B2548 $5.00 #

B2524 $20.00 # # B2549 $20.00 # # B2524 $5.00 # B2549 $5.00 #

B2525 $15.00 # # B2550 $18.00 # # B2525 $5.00 # B2550 $5.00 #

B2526 $15.00 # # B2551 $15.00 # # B2526 $5.00 # B2551 $5.00 #

B2527 $15.00 # # B2552 $15.00 # # B2527 $5.00 # B2552 $5.00 #

B2528 $12.00 # # B2553 $7.00 # # B2528 $5.00 # B2553 $5.00 #

B2529 $12.00 # # B2554 $20.00 # # B2529 $5.00 # B2554 $5.00 #

B2530 $15.00 # # B2555 $15.00 # # B2530 $5.00 # B2555 $5.00 #

B2531 $12.00 # # B2556 $12.00 # # B2531 $5.00 # B2556 $5.00 #

B2532 $10.00 # # B2557 $15.00 # # B2532 $5.00 # B2557 $5.00 #

B2533 $15.00 # # B2558 $15.00 # # B2533 $5.00 # B2558 $5.00 #

B2534 $15.00 # # B2559 $15.00 # # B2534 $5.00 # B2559 $5.00 #

B2535 $15.00 # # B2560 $15.00 # # B2535 $15.00 # B2560 $5.00 #

B2536 $15.00 # # B2561 $15.00 # # B2536 $5.00 # B2561 $5.00 #

B2537 $12.00 # # B2562 $15.00 # # B2537 $5.00 # B2562 $7.00 #

B2538 $15.00 # # B2563 $12.00 # # B2538 $5.00 # B2563 $5.00 #

B2539 $10.00 # # B2564 $12.00 # # B2539 $5.00 # B2564 $5.00 #

B2540 $15.00 # # B2565 $17.00 # # B2540 $5.00 # B2565 $5.00 #

B2541 $15.00 # # B2566 $20.00 # # B2541 $5.00 # B2566 $5.00 #

B2542 $15.00 # # B2567 $15.00 # # B2542 $5.00 # B2567 $5.00 #

B2543 $15.00 # # B2568 $15.00 # # B2543 $5.00 # B2568 $7.00 #

B2544 $15.00 # # B2569 $10.00 # # B2544 $5.00 # B2569 $5.00 #

B2545 $15.00 # # B2570 $15.00 # # B2545 $5.00 # B2570 $5.00 #

B2546 $15.00 # # B2571 $10.00 # # B2546 $5.00 # B2571 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

87 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B2572 $10.00 # # B2597 $15.00 # # B2572 $5.00 # B2597 $5.00 #

B2573 $12.00 # # B2598 $10.00 # # B2573 $5.00 # B2598 $5.00 #

B2574 $15.00 # # B2599 $15.00 # # B2574 $5.00 # B2599 $5.00 #

B2575 $15.00 # # B2600 $15.00 # # B2575 $5.00 # B2600 $5.00 #

B2576 $20.00 # # B2601 $15.00 # # B2576 $5.00 # B2601 $5.00 #

B2577 $15.00 # # B2602 $15.00 # # B2577 $5.00 # B2602 $5.00 #

B2578 $15.00 # # B2603 $10.00 # # B2578 $5.00 # B2603 $5.00 #

B2579 $15.00 # # B2604 $15.00 # # B2579 $5.00 # B2604 $5.00 #

B2580 $10.00 # # B2605 $15.00 # # B2580 $5.00 # B2605 $5.00 #

B2581 $15.00 # # B2606 $15.00 # # B2581 $5.00 # B2606 $5.00 #

B2582 $15.00 # # B2607 $15.00 # # B2582 $5.00 # B2607 $5.00 #

B2583 $15.00 # # B2608 $15.00 # # B2583 $5.00 # B2608 $5.00 #

B2584 $20.00 # # B2609 $15.00 # # B2584 $5.00 # B2609 $5.00 #

B2585 $15.00 # # B2610 $15.00 # # B2585 $5.00 # B2610 $5.00 #

B2586 $15.00 # # B2611 $15.00 # # B2586 $5.00 # B2611 $5.00 #

B2587 $8.00 # # B2612 $15.00 # # B2587 $5.00 # B2612 $5.00 #

B2588 $8.00 # # B2613 $15.00 # # B2588 $5.00 # B2613 $5.00 #

B2589 $15.00 # # B2614 $15.00 # # B2589 $5.00 # B2614 $5.00 #

B2590 $15.00 # # B2615 $15.00 # # B2590 $5.00 # B2615 $5.00 #

B2591 $15.00 # # B2616 $15.00 # # B2591 $7.00 # B2616 $5.00 #

B2592 $15.00 # # B2617 $15.00 # # B2592 $5.00 # B2617 $5.00 #

B2593 $15.00 # # B2618 $15.00 # # B2593 $7.00 # B2618 $5.00 #

B2594 $15.00 # # B2619 $15.00 # # B2594 $5.00 # B2619 $5.00 #

B2595 $10.00 # # B2620 $15.00 # # B2595 $5.00 # B2620 $5.00 #

B2596 $10.00 # # B2621 $15.00 # # B2596 $5.00 # B2621 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

88 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B2622 $18.00 # # B2647 $15.00 # # B2622 $5.00 # B2647 $5.00 #

B2623 $15.00 # # B2648 $15.00 # # B2623 $5.00 # B2648 $5.00 #

B2624 $15.00 # # B2649 $12.00 # # B2624 $5.00 # B2649 $5.00 #

B2625 $15.00 # # B2650 $15.00 # # B2625 $5.00 # B2650 $15.00 #

B2626 $15.00 # # B2651 $15.00 # # B2626 $5.00 # B2651 $5.00 #

B2627 $15.00 # # B2652 $15.00 # # B2627 $5.00 # B2652 $5.00 #

B2628 $15.00 # # B2653 $15.00 # # B2628 $5.00 # B2653 $5.00 #

B2629 $15.00 # # B2654 $20.00 # # B2629 $5.00 # B2654 $5.00 #

B2630 $10.00 # # B2655 $15.00 # # B2630 $5.00 # B2655 $5.00 #

B2631 $10.00 # # B2656 $15.00 # # B2631 $5.00 # B2656 $5.00 #

B2632 $10.00 # # B2657 $15.00 # # B2632 $5.00 # B2657 $5.00 #

B2633 $15.00 # # B2658 $10.00 # # B2633 $5.00 # B2658 $5.00 #

B2634 $15.00 # # B2659 $15.00 # # B2634 $5.00 # B2659 $5.00 #

B2635 $12.00 # # B2660 NADA # # B2635 $5.00 # B2660 $5.00 #

B2636 $20.00 # # B2661 $15.00 # # B2636 $5.00 # B2661 $5.00 #

B2637 $15.00 # # B2662 $10.00 # # B2637 $5.00 # B2662 $5.00 #

B2638 $12.00 # # B2663 $12.00 # # B2638 $5.00 # B2663 $5.00 #

B2639 $12.00 # # B2664 $12.00 # # B2639 $5.00 # B2664 $5.00 #

B2640 $7.00 # # B2665 $10.00 # # B2640 $5.00 # B2665 $5.00 #

B2641 $15.00 # # B2666 $15.00 # # B2641 $5.00 # B2666 $5.00 #

B2642 $7.00 # # B2667 $15.00 # # B2642 $5.00 # B2667 $5.00 #

B2643 $15.00 # # B2668 $15.00 # # B2643 $5.00 # B2668 $5.00 #

B2644 $15.00 # # B2669 $15.00 # # B2644 $5.00 # B2669 $5.00 #

B2645 $15.00 # # B2670 $10.00 # # B2645 $5.00 # B2670 $5.00 #

B2646 $15.00 # # B2671 $10.00 # # B2646 $5.00 # B2671 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

89 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B2672 $10.00 # # B2697 $17.00 # # B2672 $5.00 # B2697 $5.00 #

B2673 $15.00 # # B2698 $20.00 # # B2673 $5.00 # B2698 $5.00 #

B2674 $15.00 # # B2699 $15.00 # # B2674 $5.00 # B2699 $5.00 #

B2675 $15.00 # # B2700 $15.00 # # B2675 $5.00 # B2700 $5.00 #

B2676 $15.00 # # B2701 $15.00 # # B2676 $5.00 # B2701 $5.00 #

B2677 $10.00 # # B2702 $15.00 # # B2677 $5.00 # B2702 $5.00 #

B2678 $12.00 # # B2703 $15.00 # # B2678 $5.00 # B2703 $5.00 #

B2679 NADA # # B2704 $15.00 # # B2679 $5.00 # B2704 $5.00 #

B2680 $20.00 # # B2705 $15.00 # # B2680 $5.00 # B2705 $5.00 #

B2681 $15.00 # # B2706 $10.00 # # B2681 $5.00 # B2706 $5.00 #

B2682 $15.00 # # B2707 $15.00 # # B2682 $5.00 # B2707 $5.00 #

B2683 $18.00 # # B2708 $15.00 # # B2683 $5.00 # B2708 $5.00 #

B2684 $15.00 # # B2709 $18.00 # # B2684 $5.00 # B2709 $5.00 #

B2685 $15.00 # # B2710 $15.00 # # B2685 $5.00 # B2710 $5.00 #

B2686 $15.00 # # B2711 $18.00 # # B2686 $5.00 # B2711 $5.00 #

B2687 $15.00 # # B2712 $15.00 # # B2687 $5.00 # B2712 $5.00 #

B2688 $15.00 # # B2713 NADA # # B2688 $5.00 # B2713 $5.00 #

B2689 $12.00 # # B2714 $15.00 # # B2689 $5.00 # B2714 $5.00 #

B2690 $16.00 # # B2715 $15.00 # # B2690 $5.00 # B2715 $5.00 #

B2691 $15.00 # # B2716 $20.00 # # B2691 $5.00 # B2716 $10.00 #

B2692 $10.00 # # B2717 $12.00 # # B2692 $5.00 # B2717 $5.00 #

B2693 $12.00 # # B2718 $20.00 # # B2693 $5.00 # B2718 $20.00 #

B2694 $15.00 # # B2719 NADA # # B2694 $5.00 # B2719 $5.00 #

B2695 $15.00 # # B2720 $15.00 # # B2695 $5.00 # B2720 $5.00 #

B2696 $18.00 # # B2721 $15.00 # # B2696 $5.00 # B2721 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

90 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B2722 $18.00 # # B2747 $15.00 # # B2722 $5.00 # B2747 $5.00 #

B2723 $15.00 # # B2748 $15.00 # # B2723 $5.00 # B2748 $5.00 #

B2724 $15.00 # # B2749 $12.00 # # B2724 $5.00 # B2749 $5.00 #

B2725 $12.00 # # B2750 $12.00 # # B2725 $5.00 # B2750 $12.00 #

B2726 $15.00 # # B2751 $15.00 # # B2726 $5.00 # B2751 $15.00 #

B2727 $18.00 # # B2752 $12.00 # # B2727 $5.00 # B2752 $12.00 #

B2728 $18.00 # # B2753 $15.00 # # B2728 $5.00 # B2753 $15.00 #

B2729 $10.00 # # B2754 $15.00 # # B2729 $5.00 # B2754 $5.00 #

B2730 $15.00 # # B2755 $10.00 # # B2730 $5.00 # B2755 $5.00 #

B2731 $10.00 # # B2756 $8.00 # # B2731 $5.00 # B2756 $5.00 #

B2732 $15.00 # # B2757 $3.00 # # B2732 $5.00 # B2757 $3.00 #

B2733 NADA # # B2758 $15.00 # # B2733 $5.00 # B2758 $5.00 #

B2734 NADA # # B2759 $15.00 # # B2734 $5.00 # B2759 $5.00 #

B2735 $15.00 # # B2760 $15.00 # # B2735 $5.00 # B2760 $5.00 #

B2736 $15.00 # # B2761 $15.00 # # B2736 $7.00 # B2761 $5.00 #

B2737 $15.00 # # B2762 $15.00 # # B2737 $5.00 # B2762 $5.00 #

B2738 $15.00 # # B2763 $15.00 # # B2738 $5.00 # B2763 $5.00 #

B2739 $15.00 # # B2764 $10.00 # # B2739 $5.00 # B2764 $5.00 #

B2740 $15.00 # # B2765 $15.00 # # B2740 $5.00 # B2765 $7.00 #

B2741 $15.00 # # B2766 $15.00 # # B2741 $5.00 # B2766 $15.00 #

B2742 $15.00 # # B2767 $15.00 # # B2742 $5.00 # B2767 $7.00 #

B2743 $15.00 # # B2768 $12.00 # # B2743 $5.00 # B2768 $5.00 #

B2744 NADA # # B2769 $15.00 # # B2744 NADA # B2769 $7.00 #

B2745 NADA # # B2770 $15.00 # # B2745 NADA # B2770 $7.00 #

B2746 NADA # # B2771 $15.00 # # B2746 NADA # B2771 $7.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

91 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B2772 $15.00 # # B2797 $35.00 # # B2772 $7.00 # B2797 $5.00 #

B2773 $20.00 # # B2798 $12.00 # # B2773 $10.00 # B2798 $5.00 #

B2774 $15.00 # # B2799 $15.00 # # B2774 $5.00 # B2799 $7.00 #

B2775 $10.00 # # B2800 $15.00 # # B2775 $5.00 # B2800 $7.00 #

B2776 $10.00 # # B2801 $15.00 # # B2776 $5.00 # B2801 $7.00 #

B2777 $10.00 # # B2802 $15.00 # # B2777 $5.00 # B2802 $7.00 #

B2778 $10.00 # # B2803 $15.00 # # B2778 $5.00 # B2803 $5.00 #

B2779 $15.00 # # B2804 $12.00 # # B2779 $5.00 # B2804 $5.00 #

B2780 $15.00 # # B2805 $12.00 # # B2780 $5.00 # B2805 $5.00 #

B2781 $15.00 # # B2806 $15.00 # # B2781 $5.00 # B2806 $5.00 #

B2782 $15.00 # # B2807 $12.00 # # B2782 $5.00 # B2807 $5.00 #

B2783 $15.00 # # B2808 $15.00 # # B2783 $7.00 # B2808 $7.00 #

B2784 $15.00 # # B2809 $15.00 # # B2784 $7.00 # B2809 $5.00 #

B2785 $15.00 # # B2810 $15.00 # # B2785 $7.00 # B2810 $5.00 #

B2786 $12.00 # # B2811 $15.00 # # B2786 $5.00 # B2811 $5.00 #

B2787 $15.00 # # B2812 $15.00 # # B2787 $5.00 # B2812 $5.00 #

B2788 $12.00 # # B2813 $15.00 # # B2788 $5.00 # B2813 $5.00 #

B2789 $15.00 # # B2814 $15.00 # # B2789 $5.00 # B2814 $5.00 #

B2790 $10.00 # # B2815 $15.00 # # B2790 $5.00 # B2815 $5.00 #

B2791 $10.00 # # B2816 $15.00 # # B2791 $5.00 # B2816 $5.00 #

B2792 $10.00 # # B2817 $15.00 # # B2792 $5.00 # B2817 $5.00 #

B2793 $15.00 # # B2818 $15.00 # # B2793 $5.00 # B2818 $5.00 #

B2794 $10.00 # # B2819 $15.00 # # B2794 $5.00 # B2819 $5.00 #

B2795 $15.00 # # B2820 $20.00 # # B2795 $7.00 # B2820 $5.00 #

B2796 $10.00 # # B2821 $20.00 # # B2796 $5.00 # B2821 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

92 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B2822 $20.00 # # B2847 $15.00 # # B2822 $5.00 # B2847 $5.00 #

B2823 $10.00 # # B2848 $10.00 # # B2823 $5.00 # B2848 $5.00 #

B2824 $15.00 # # B2849 $15.00 # # B2824 $5.00 # B2849 $5.00 #

B2825 $18.00 # # B2850 $15.00 # # B2825 $5.00 # B2850 $5.00 #

B2826 $15.00 # # B2851 $15.00 # # B2826 $5.00 # B2851 $7.00 #

B2827 $15.00 # # B2852 $15.00 # # B2827 $5.00 # B2852 $5.00 #

B2828 $15.00 # # B2853 $15.00 # # B2828 $5.00 # B2853 $5.00 #

B2829 $15.00 # # B2854 $15.00 # # B2829 $15.00 # B2854 $5.00 #

B2830 $12.00 # # B2855 $10.00 # # B2830 $5.00 # B2855 $5.00 #

B2831 $12.00 # # B2856 $18.00 # # B2831 $5.00 # B2856 $5.00 #

B2832 $12.00 # # B2857 $18.00 # # B2832 $5.00 # B2857 $5.00 #

B2833 $15.00 # # B2858 $15.00 # # B2833 $5.00 # B2858 $5.00 #

B2834 $15.00 # # B2859 $10.00 # # B2834 $5.00 # B2859 $5.00 #

B2835 $15.00 # # B2860 $10.00 # # B2835 $5.00 # B2860 $5.00 #

B2836 $10.00 # # B2861 $15.00 # # B2836 $5.00 # B2861 $5.00 #

B2837 $10.00 # # B2862 $15.00 # # B2837 $5.00 # B2862 $5.00 #

B2838 $15.00 # # B2863 $15.00 # # B2838 $7.00 # B2863 $5.00 #

B2839 $12.00 # # B2864 $15.00 # # B2839 $5.00 # B2864 $5.00 #

B2840 $15.00 # # B2865 $15.00 # # B2840 $5.00 # B2865 $5.00 #

B2841 $15.00 # # B2866 $15.00 # # B2841 $5.00 # B2866 $5.00 #

B2842 $10.00 # # B2867 $10.00 # # B2842 $5.00 # B2867 $5.00 #

B2843 $15.00 # # B2868 $15.00 # # B2843 $5.00 # B2868 $5.00 #

B2844 $12.00 # # B2869 $18.00 # # B2844 $5.00 # B2869 $5.00 #

B2845 $15.00 # # B2870 $12.00 # # B2845 $5.00 # B2870 $5.00 #

B2846 $12.00 # # B2871 $15.00 # # B2846 $5.00 # B2871 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

93 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B2872 $15.00 # # B2897 $15.00 # # B2872 $5.00 # B2897 $5.00 #

B2873 $15.00 # # B2898 $10.00 # # B2873 $5.00 # B2898 $5.00 #

B2874 $15.00 # # B2899 $15.00 # # B2874 $5.00 # B2899 $7.00 #

B2875 $18.00 # # B2900 $10.00 # # B2875 $5.00 # B2900 $5.00 #

B2876 $3.00 # # B2901 $15.00 # # B2876 $3.00 # B2901 $5.00 #

B2877 $3.00 # # B2902 $15.00 # # B2877 $3.00 # B2902 $5.00 #

B2878 $15.00 # # B2903 $15.00 # # B2878 $5.00 # B2903 $5.00 #

B2879 $12.00 # # B2904 $15.00 # # B2879 $5.00 # B2904 $5.00 #

B2880 $12.00 # # B2905 $15.00 # # B2880 $5.00 # B2905 $5.00 #

B2881 $12.00 # # B2906 $15.00 # # B2881 $5.00 # B2906 $5.00 #

B2882 $10.00 # # B2907 $12.00 # # B2882 $5.00 # B2907 $5.00 #

B2883 $10.00 # # B2908 $10.00 # # B2883 $5.00 # B2908 $5.00 #

B2884 $15.00 # # B2909 $18.00 # # B2884 $5.00 # B2909 $5.00 #

B2885 $10.00 # # B2910 $15.00 # # B2885 $5.00 # B2910 $5.00 #

B2886 $10.00 # # B2911 $15.00 # # B2886 $5.00 # B2911 $5.00 #

B2887 $15.00 # # B2912 $15.00 # # B2887 $5.00 # B2912 $5.00 #

B2888 $15.00 # # B2913 $15.00 # # B2888 $5.00 # B2913 $5.00 #

B2889 $15.00 # # B2914 $18.00 # # B2889 $5.00 # B2914 $5.00 #

B2890 $15.00 # # B2915 $15.00 # # B2890 $5.00 # B2915 $5.00 #

B2891 $10.00 # # B2916 $10.00 # # B2891 $5.00 # B2916 $5.00 #

B2892 $10.00 # # B2917 $15.00 # # B2892 $5.00 # B2917 $5.00 #

B2893 $10.00 # # B2918 $10.00 # # B2893 $5.00 # B2918 $5.00 #

B2894 $15.00 # # B2919 $15.00 # # B2894 $5.00 # B2919 $5.00 #

B2895 $15.00 # # B2920 $3.00 # # B2895 $5.00 # B2920 $3.00 #

B2896 $15.00 # # B2921 $15.00 # # B2896 $5.00 # B2921 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

94 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B2922 $15.00 # # B2947 $15.00 # # B2922 $5.00 # B2947 $5.00 #

B2923 $15.00 # # B2948 $15.00 # # B2923 $5.00 # B2948 $5.00 #

B2924 $15.00 # # B2949 $15.00 # # B2924 $5.00 # B2949 $5.00 #

B2925 $15.00 # # B2950 $12.00 # # B2925 $5.00 # B2950 $5.00 #

B2926 $15.00 # # B2951 $15.00 # # B2926 $7.00 # B2951 $5.00 #

B2927 $15.00 # # B2952 $15.00 # # B2927 $5.00 # B2952 $5.00 #

B2928 $15.00 # # B2953 $15.00 # # B2928 $5.00 # B2953 $5.00 #

B2929 $15.00 # # B2954 $15.00 # # B2929 $5.00 # B2954 $5.00 #

B2930 $12.00 # # B2955 $10.00 # # B2930 $5.00 # B2955 $5.00 #

B2931 $15.00 # # B2956 $15.00 # # B2931 $5.00 # B2956 $5.00 #

B2932 $15.00 # # B2957 $15.00 # # B2932 $5.00 # B2957 $5.00 #

B2933 $15.00 # # B2958 $12.00 # # B2933 $5.00 # B2958 $5.00 #

B2934 $15.00 # # B2959 $12.00 # # B2934 $5.00 # B2959 $5.00 #

B2935 $15.00 # # B2960 $12.00 # # B2935 $5.00 # B2960 $5.00 #

B2936 $15.00 # # B2961 $10.00 # # B2936 $5.00 # B2961 $5.00 #

B2937 $10.00 # # B2962 $15.00 # # B2937 $5.00 # B2962 $5.00 #

B2938 $12.00 # # B2963 $15.00 # # B2938 $5.00 # B2963 $5.00 #

B2939 $10.00 # # B2964 $15.00 # # B2939 $5.00 # B2964 $5.00 #

B2940 $15.00 # # B2965 $12.00 # # B2940 $5.00 # B2965 $5.00 #

B2941 $15.00 # # B2966 $15.00 # # B2941 $5.00 # B2966 $5.00 #

B2942 $15.00 # # B2967 $15.00 # # B2942 $5.00 # B2967 $5.00 #

B2943 $15.00 # # B2968 $15.00 # # B2943 $5.00 # B2968 $5.00 #

B2944 $15.00 # # B2969 $15.00 # # B2944 $5.00 # B2969 $5.00 #

B2945 $15.00 # # B2970 $12.00 # # B2945 $5.00 # B2970 $5.00 #

B2946 $15.00 # # B2971 $10.00 # # B2946 $5.00 # B2971 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

95 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B2972 $15.00 # # B2997 $20.00 # # B2972 $5.00 # B2997 $5.00 #

B2973 $20.00 # # B2998 $15.00 # # B2973 $5.00 # B2998 $5.00 #

B2974 $15.00 # # B2999 $15.00 # # B2974 $5.00 # B2999 $7.00 #

B2975 $15.00 # # B3000 $15.00 # # B2975 $5.00 # B3000 $5.00 #

B2976 $15.00 # # B3001 $15.00 # # B2976 $5.00 # B3001 $5.00 #

B2977 $15.00 # # B3002 $15.00 # # B2977 $5.00 # B3002 $5.00 #

B2978 $10.00 # # B3003 $15.00 # # B2978 $5.00 # B3003 $5.00 #

B2979 $15.00 # # B3004 $15.00 # # B2979 $5.00 # B3004 $5.00 #

B2980 $15.00 # # B3005 $18.00 # # B2980 $5.00 # B3005 $5.00 #

B2981 $12.00 # # B3006 $18.00 # # B2981 # B3006 $5.00 #

B2982 $12.00 # # B3007 $15.00 # # B2982 # B3007 $5.00 #

B2983 $12.00 # # B3008 $15.00 # # B2983 $5.00 # B3008 $5.00 #

B2984 $10.00 # # B3009 $12.00 # # B2984 $5.00 # B3009 $5.00 #

B2985 $15.00 # # B3010 $8.00 # # B2985 $5.00 # B3010 $5.00 #

B2986 $15.00 # # B3011 $10.00 # # B2986 $5.00 # B3011 $5.00 #

B2987 $15.00 # # B3012 $12.00 # # B2987 $5.00 # B3012 $5.00 #

B2988 $15.00 # # B3013 $12.00 # # B2988 $5.00 # B3013 $5.00 #

B2989 $15.00 # # B3014 $15.00 # # B2989 $5.00 # B3014 $5.00 #

B2990 $15.00 # # B3015 NADA # # B2990 $5.00 # B3015 NADA #

B2991 $8.00 # # B3016 $15.00 # # B2991 $5.00 # B3016 $7.00 #

B2992 $12.00 # # B3017 $15.00 # # B2992 $5.00 # B3017 $5.00 #

B2993 $8.00 # # B3018 $15.00 # # B2993 $5.00 # B3018 $5.00 #

B2994 $18.00 # # B3019 $12.00 # # B2994 $5.00 # B3019 $5.00 #

B2995 $15.00 # # B3020 $12.00 # # B2995 $5.00 # B3020 $5.00 #

B2996 $12.00 # # B3021 $12.00 # # B2996 $5.00 # B3021 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

96 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B3022 $12.00 # # B3047 $15.00 # # B3022 $5.00 # B3047 $5.00 #

B3023 $12.00 # # B3048 $15.00 # # B3023 $5.00 # B3048 $5.00 #

B3024 $12.00 # # B3049 $10.00 # # B3024 $5.00 # B3049 $5.00 #

B3025 $15.00 # # B3050 $15.00 # # B3025 $5.00 # B3050 $5.00 #

B3026 $15.00 # # B3051 $15.00 # # B3026 $5.00 # B3051 $5.00 #

B3027 $15.00 # # B3052 $15.00 # # B3027 $5.00 # B3052 $5.00 #

B3028 $15.00 # # B3053 $12.00 # # B3028 $5.00 # B3053 $5.00 #

B3029 $20.00 # # B3054 $15.00 # # B3029 $5.00 # B3054 $5.00 #

B3030 $15.00 # # B3055 $15.00 # # B3030 $5.00 # B3055 $5.00 #

B3031 NADA # # B3056 $15.00 # # B3031 $5.00 # B3056 $5.00 #

B3032 NADA # # B3057 $15.00 # # B3032 $5.00 # B3057 $5.00 #

B3033 $15.00 # # B3058 $10.00 # # B3033 $5.00 # B3058 $5.00 #

B3034 $10.00 # # B3059 $12.00 # # B3034 $5.00 # B3059 $5.00 #

B3035 $10.00 # # B3060 $15.00 # # B3035 $5.00 # B3060 $5.00 #

B3036 $20.00 # # B3061 $15.00 # # B3036 $5.00 # B3061 $5.00 #

B3037 $20.00 # # B3062 $20.00 # # B3037 $5.00 # B3062 $5.00 #

B3038 $15.00 # # B3063 $7.00 # # B3038 $5.00 # B3063 $5.00 #

B3039 $10.00 # # B3064 $7.00 # # B3039 $5.00 # B3064 $5.00 #

B3040 $10.00 # # B3065 $15.00 # # B3040 $5.00 # B3065 $5.00 #

B3041 $12.00 # # B3066 $15.00 # # B3041 $5.00 # B3066 $5.00 #

B3042 $12.00 # # B3067 $15.00 # # B3042 $5.00 # B3067 $5.00 #

B3043 $10.00 # # B3068 NADA # # B3043 $5.00 # B3068 NADA #

B3044 $10.00 # # B3069 $10.00 # # B3044 $5.00 # B3069 $10.00 #

B3045 $15.00 # # B3070 $10.00 # # B3045 $5.00 # B3070 $10.00 #

B3046 $15.00 # # B3071 $10.00 # # B3046 $5.00 # B3071 $10.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

97 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B3072 $10.00 # # B3097 $10.00 # # B3072 $5.00 # B3097 $5.00 #

B3073 $10.00 # # B3098 NADA # # B3073 $5.00 # B3098 NADA #

B3074 $15.00 # # B3099 NADA # # B3074 $5.00 # B3099 NADA #

B3075 $15.00 # # B3100 $15.00 # # B3075 $5.00 # B3100 $5.00 #

B3076 $7.00 # # B3101 $10.00 # # B3076 $7.00 # B3101 $5.00 #

B3077 $7.00 # # B3102 $10.00 # # B3077 $7.00 # B3102 $5.00 #

B3078 $10.00 # # B3103 $15.00 # # B3078 $5.00 # B3103 $5.00 #

B3079 $15.00 # # B3104 $15.00 # # B3079 $5.00 # B3104 $5.00 #

B3080 $17.00 # # B3105 $15.00 # # B3080 $5.00 # B3105 $5.00 #

B3081 $10.00 # # B3106 $15.00 # # B3081 NADA # B3106 $15.00 #

B3082 $7.00 # # B3107 $12.00 # # B3082 $5.00 # B3107 $5.00 #

B3083 $7.00 # # B3108 $7.00 # # B3083 $5.00 # B3108 $5.00 #

B3084 $15.00 # # B3109 $10.00 # # B3084 $5.00 # B3109 $5.00 #

B3085 $10.00 # # B3110 $15.00 # # B3085 $5.00 # B3110 $5.00 #

B3086 $6.00 # # B3111 $20.00 # # B3086 $5.00 # B3111 $5.00 #

B3087 $15.00 # # B3112 $20.00 # # B3087 $5.00 # B3112 $5.00 #

B3088 $15.00 # # B3113 $10.00 # # B3088 $5.00 # B3113 $5.00 #

B3089 $15.00 # # B3114 $5.00 # # B3089 $5.00 # B3114 $5.00 #

B3090 $5.00 # # B3115 $5.00 # # B3090 $5.00 # B3115 $5.00 #

B3091 $20.00 # # B3116 $15.00 # # B3091 $5.00 # B3116 $5.00 #

B3092 $15.00 # # B3117 $10.00 # # B3092 $5.00 # B3117 $5.00 #

B3093 $7.00 # # B3118 $10.00 # # B3093 $7.00 # B3118 $5.00 #

B3094 $7.00 # # B3119 $10.00 # # B3094 $5.00 # B3119 $5.00 #

B3095 NADA # # B3120 $15.00 # # B3095 NADA # B3120 $15.00 #

B3096 NADA # # B3121 NADA # # B3096 NADA # B3121 NADA #

CÓDIGOS DE CUBIERTAS / COPAGOS

98 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B3122 $10.00 # # B3147 $15.00 # # B3122 $5.00 # B3147 $15.00 #

B3123 $7.00 # # B3148 $10.00 # # B3123 $5.00 # B3148 $10.00 #

B3124 $7.00 # # B3149 $10.00 # # B3124 NADA # B3149 $5.00 #

B3125 $20.00 # # B3150 $12.00 # # B3125 $10.00 # B3150 $5.00 #

B3126 $12.00 # # B3151 $12.00 # # B3126 $5.00 # B3151 $5.00 #

B3127 NADA # # B3152 $15.00 # # B3127 $5.00 # B3152 NADA #

B3128 $15.00 # # B3153 $15.00 # # B3128 $5.00 # B3153 $5.00 #

B3129 $10.00 # # B3154 $7.00 # # B3129 $5.00 # B3154 $5.00 #

B3130 $10.00 # # B3155 $18.00 # # B3130 $5.00 # B3155 $5.00 #

B3131 $15.00 # # B3156 $20.00 # # B3131 $5.00 # B3156 $5.00 #

B3132 $15.00 # # B3157 $15.00 # # B3132 $5.00 # B3157 $5.00 #

B3133 $10.00 # # B3158 $15.00 # # B3133 $5.00 # B3158 $0.00 #

B3134 $12.00 # # B3159 $15.00 # # B3134 $6.50 # B3159 $0.00 #

B3135 $12.00 # # B3160 $15.00 # # B3135 $6.50 # B3160 $5.00 #

B3136 $10.00 # # B3161 $12.00 # # B3136 NADA # B3161 $5.00 #

B3137 $7.00 # # B3162 $10.00 # # B3137 $5.00 # B3162 $5.00 #

B3138 $5.00 # # B3163 $15.00 # # B3138 $5.00 # B3163 $5.00 #

B3139 $0.00 # # B3164 $15.00 # # B3139 $20.00 # B3164 $5.00 #

B3140 $0.00 # # B3165 $15.00 # # B3140 $20.00 # B3165 $5.00 #

B3141 $20.00 # # B3166 $10.00 # # B3141 NADA # B3166 $5.00 #

B3142 $20.00 # # B3167 $15.00 # # B3142 NADA # B3167 $5.00 #

B3143 $20.00 # # B3168 $10.00 # # B3143 $20.00 # B3168 $5.00 #

B3144 $15.00 # # B3169 $15.00 # # B3144 $5.00 # B3169 $5.00 #

B3145 $15.00 # # B3170 $15.00 # # B3145 $5.00 # B3170 $5.00 #

B3146 $10.00 # # B3171 $10.00 # # B3146 $5.00 # B3171 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

99 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B3172 $15.00 # # B3197 $10.00 # # B3172 $5.00 # B3197 $5.00 #

B3173 $15.00 # # B3198 $10.00 # # B3173 $5.00 # B3198 $5.00 #

B3174 $12.00 # # B3199 $12.00 # # B3174 $5.00 # B3199 $5.00 #

B3175 $10.00 # # B3200 $15.00 # # B3175 $5.00 # B3200 $5.00 #

B3176 $15.00 # # B3201 $15.00 # # B3176 $5.00 # B3201 $5.00 #

B3177 $10.00 # # B3202 $15.00 # # B3177 $5.00 # B3202 $0.00 #

B3178 $10.00 # # B3203 $7.00 # # B3178 $5.00 # B3203 $5.00 #

B3179 $12.00 # # B3204 $12.00 # # B3179 $5.00 # B3204 $5.00 #

B3180 $10.00 # # B3205 $18.00 # # B3180 $5.00 # B3205 $5.00 #

B3181 $15.00 # # B3206 $15.00 # # B3181 $5.00 # B3206 $5.00 #

B3182 $10.00 # # B3207 $10.00 # # B3182 $5.00 # B3207 $5.00 #

B3183 $10.00 # # B3208 $12.00 # # B3183 $5.00 # B3208 $5.00 #

B3184 $12.00 # # B3209 $10.00 # # B3184 $5.00 # B3209 $5.00 #

B3185 $10.00 # # B3210 $20.00 # # B3185 $5.00 # B3210 $5.00 #

B3186 $12.00 # # B3211 $15.00 # # B3186 $5.00 # B3211 $5.00 #

B3187 $10.00 # # B3212 $15.00 # # B3187 $5.00 # B3212 $5.00 #

B3188 $10.00 # # B3213 $12.00 # # B3188 $5.00 # B3213 $5.00 #

B3189 $12.00 # # B3214 $15.00 # # B3189 $5.00 # B3214 $5.00 #

B3190 $12.00 # # B3215 $15.00 # # B3190 $5.00 # B3215 $7.00 #

B3191 $12.00 # # B3216 $22.00 # # B3191 $5.00 # B3216 $5.00 #

B3192 $10.00 # # B3217 $10.00 # # B3192 $5.00 # B3217 $5.00 #

B3193 $15.00 # # B3218 $15.00 # # B3193 $5.00 # B3218 $7.00 #

B3194 $15.00 # # B3219 $12.00 # # B3194 $5.00 # B3219 $5.00 #

B3195 $10.00 # # B3220 $12.00 # # B3195 $5.00 # B3220 $5.00 #

B3196 $15.00 # # B3221 $15.00 # # B3196 $5.00 # B3221 $7.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

100 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B3222 $15.00 # # B3247 $15.00 # # B3222 $5.00 # B3247 $5.00 #

B3223 $15.00 # # B3248 $15.00 # # B3223 $5.00 # B3248 $5.00 #

B3224 $10.00 # # B3249 $0.00 # # B3224 $5.00 # B3249 $20.00 #

B3225 $10.00 # # B3250 $15.00 # # B3225 $5.00 # B3250 $5.00 #

B3226 $10.00 # # B3251 $15.00 # # B3226 $5.00 # B3251 $5.00 #

B3227 $12.00 # # B3252 $15.00 # # B3227 $5.00 # B3252 $5.00 #

B3228 $3.00 # # B3253 $15.00 # # B3228 $5.00 # B3253 $5.00 #

B3229 $12.00 # # B3254 NADA # # B3229 $5.00 # B3254 $5.00 #

B3230 $12.00 # # B3255 $15.00 # # B3230 $5.00 # B3255 $5.00 #

B3231 $12.00 # # B3256 $12.00 # # B3231 $5.00 # B3256 $5.00 #

B3232 $12.00 # # B3257 $12.00 # # B3232 $5.00 # B3257 $5.00 #

B3233 $20.00 # # B3258 $15.00 # # B3233 $5.00 # B3258 $5.00 #

B3234 $12.00 # # B3259 $15.00 # # B3234 $5.00 # B3259 $5.00 #

B3235 $20.00 # # B3260 NADA # # B3235 $5.00 # B3260 $5.00 #

B3236 $20.00 # # B3261 $15.00 # # B3236 $5.00 # B3261 $5.00 #

B3237 $15.00 # # B3262 $15.00 # # B3237 $5.00 # B3262 $5.00 #

B3238 $15.00 # # B3263 $15.00 # # B3238 $5.00 # B3263 $5.00 #

B3239 $5.00 # # B3264 $15.00 # # B3239 $5.00 # B3264 $5.00 #

B3240 $15.00 # # B3265 $15.00 # # B3240 $5.00 # B3265 $5.00 #

B3241 $10.00 # # B3266 $12.00 # # B3241 $5.00 # B3266 $5.00 #

B3242 $15.00 # # B3267 $12.00 # # B3242 $5.00 # B3267 $5.00 #

B3243 $15.00 # # B3268 $0.00 # # B3243 $5.00 # B3268 $20.00 #

B3244 $12.00 # # B3269 $15.00 # # B3244 $5.00 # B3269 $5.00 #

B3245 $15.00 # # B3270 $15.00 # # B3245 $5.00 # B3270 $5.00 #

B3246 $15.00 # # B3271 $12.00 # # B3246 $5.00 # B3271 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

101 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B3272 $15.00 # # B3297 $10.00 # # B3272 $5.00 # B3297 $5.00 #

B3273 $15.00 # # B3298 NADA # # B3273 $5.00 # B3298 NADA #

B3274 $15.00 # # B3299 $10.00 # # B3274 $5.00 # B3299 $5.00 #

B3275 $15.00 # # B3300 $10.00 # # B3275 $5.00 # B3300 $5.00 #

B3276 $10.00 # # B3301 $15.00 # # B3276 $5.00 # B3301 $5.00 #

B3277 $15.00 # # B3302 $12.00 # # B3277 $5.00 # B3302 $5.00 #

B3278 $5.00 # # B3303 $12.00 # # B3278 $5.00 # B3303 $5.00 #

B3279 $5.00 # # B3304 $10.00 # # B3279 $5.00 # B3304 $5.00 #

B3280 $15.00 # # B3305 $15.00 # # B3280 $5.00 # B3305 $5.00 #

B3281 $15.00 # # B3306 $10.00 # # B3281 $5.00 # B3306 $5.00 #

B3282 $10.00 # # B3307 $12.00 # # B3282 $5.00 # B3307 $5.00 #

B3283 $10.00 # # B3308 $12.00 # # B3283 $5.00 # B3308 $5.00 #

B3284 $15.00 # # B3309 $15.00 # # B3284 $5.00 # B3309 $5.00 #

B3285 $10.00 # # B3310 NADA # # B3285 $5.00 # B3310 $5.00 #

B3286 $20.00 # # B3311 $15.00 # # B3286 $5.00 # B3311 $5.00 #

B3287 $15.00 # # B3312 $15.00 # # B3287 $5.00 # B3312 $5.00 #

B3288 $15.00 # # B3313 $12.00 # # B3288 $5.00 # B3313 $5.00 #

B3289 $15.00 # # B3314 $12.00 # # B3289 $5.00 # B3314 $5.00 #

B3290 $12.00 # # B3315 $12.00 # # B3290 $5.00 # B3315 $5.00 #

B3291 $15.00 # # B3316 $12.00 # # B3291 $7.00 # B3316 $5.00 #

B3292 $12.00 # # B3317 $10.00 # # B3292 $5.00 # B3317 $5.00 #

B3293 $10.00 # # B3318 $10.00 # # B3293 $5.00 # B3318 $5.00 #

B3294 $10.00 # # B3319 $15.00 # # B3294 $5.00 # B3319 $5.00 #

B3295 $15.00 # # B3320 $15.00 # # B3295 $5.00 # B3320 $5.00 #

B3296 $12.00 # # B3321 $15.00 # # B3296 $5.00 # B3321 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

102 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B3322 $18.00 # # B3347 $15.00 # # B3322 $5.00 # B3347 $5.00 #

B3323 $15.00 # # B3348 $15.00 # # B3323 $7.00 # B3348 $5.00 #

B3324 $15.00 # # B3349 $15.00 # # B3324 $5.00 # B3349 $5.00 #

B3325 $10.00 # # B3350 $15.00 # # B3325 $5.00 # B3350 $5.00 #

B3326 $7.00 # # B3351 $10.00 # # B3326 $5.00 # B3351 $5.00 #

B3327 $15.00 # # B3352 $15.00 # # B3327 $5.00 # B3352 $5.00 #

B3328 $15.00 # # B3353 $15.00 # # B3328 $5.00 # B3353 $5.00 #

B3329 $15.00 # # B3354 $10.00 # # B3329 $5.00 # B3354 $5.00 #

B3330 $15.00 # # B3355 $12.00 # # B3330 $5.00 # B3355 $5.00 #

B3331 $10.00 # # B3356 $15.00 # # B3331 $5.00 # B3356 $5.00 #

B3332 $15.00 # # B3357 $15.00 # # B3332 $5.00 # B3357 $5.00 #

B3333 $10.00 # # B3358 $15.00 # # B3333 $5.00 # B3358 $5.00 #

B3334 $15.00 # # B3359 $15.00 # # B3334 $5.00 # B3359 $5.00 #

B3335 $15.00 # # B3360 $15.00 # # B3335 $5.00 # B3360 $5.00 #

B3336 $15.00 # # B3361 $8.00 # # B3336 $5.00 # B3361 $5.00 #

B3337 $10.00 # # B3362 $15.00 # # B3337 $5.00 # B3362 $5.00 #

B3338 $15.00 # # B3363 $15.00 # # B3338 $5.00 # B3363 $5.00 #

B3339 $10.00 # # B3364 $15.00 # # B3339 $5.00 # B3364 $5.00 #

B3340 $10.00 # # B3365 $15.00 # # B3340 $5.00 # B3365 $5.00 #

B3341 $15.00 # # B3366 $15.00 # # B3341 $5.00 # B3366 $5.00 #

B3342 $10.00 # # B3367 $15.00 # # B3342 $5.00 # B3367 $5.00 #

B3343 $15.00 # # B3368 $12.00 # # B3343 $5.00 # B3368 $5.00 #

B3344 $15.00 # # B3369 $12.00 # # B3344 $5.00 # B3369 $5.00 #

B3345 $15.00 # # B3370 $7.00 # # B3345 $5.00 # B3370 $7.00 #

B3346 $15.00 # # B3371 $15.00 # # B3346 $5.00 # B3371 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

103 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B3372 $12.00 # # B3397 $15.00 # # B3372 $5.00 # B3397 $5.00 #

B3373 $15.00 # # B3398 $15.00 # # B3373 $5.00 # B3398 $5.00 #

B3374 $15.00 # # B3399 $15.00 # # B3374 $5.00 # B3399 $5.00 #

B3375 $15.00 # # B3400 $10.00 # # B3375 $5.00 # B3400 $5.00 #

B3376 $15.00 # # B3401 $10.00 # # B3376 $5.00 # B3401 $10.00 #

B3377 $10.00 # # B3402 $15.00 # # B3377 $5.00 # B3402 $5.00 #

B3378 $20.00 # # B3403 $15.00 # # B3378 $5.00 # B3403 $5.00 #

B3379 $15.00 # # B3404 $15.00 # # B3379 $5.00 # B3404 $5.00 #

B3380 $15.00 # # B3405 $10.00 # # B3380 $5.00 # B3405 $5.00 #

B3381 $15.00 # # B3406 $15.00 # # B3381 $5.00 # B3406 $7.00 #

B3382 $10.00 # # B3407 $15.00 # # B3382 $5.00 # B3407 $5.00 #

B3383 $10.00 # # B3408 $15.00 # # B3383 $5.00 # B3408 $5.00 #

B3384 $10.00 # # B3409 $15.00 # # B3384 $5.00 # B3409 $5.00 #

B3385 $15.00 # # B3410 $15.00 # # B3385 $5.00 # B3410 $5.00 #

B3386 $10.00 # # B3411 $10.00 # # B3386 $5.00 # B3411 $7.00 #

B3387 $10.00 # # B3412 $15.00 # # B3387 $10.00 # B3412 $5.00 #

B3388 $12.00 # # B3413 $15.00 # # B3388 $12.00 # B3413 $5.00 #

B3389 $10.00 # # B3414 $10.00 # # B3389 $10.00 # B3414 $5.00 #

B3390 $15.00 # # B3415 $15.00 # # B3390 $5.00 # B3415 $5.00 #

B3391 $15.00 # # B3416 $20.00 # # B3391 $5.00 # B3416 $5.00 #

B3392 $15.00 # # B3417 $15.00 # # B3392 $5.00 # B3417 $5.00 #

B3393 $10.00 # # B3418 $12.00 # # B3393 $5.00 # B3418 $5.00 #

B3394 $15.00 # # B3419 $12.00 # # B3394 $5.00 # B3419 $5.00 #

B3395 $10.00 # # B3420 $15.00 # # B3395 $5.00 # B3420 $5.00 #

B3396 $15.00 # # B3421 $15.00 # # B3396 $5.00 # B3421 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

104 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B3422 $15.00 # # B3447 $12.00 # # B3422 $5.00 # B3447 $5.00 #

B3423 $15.00 # # B3448 $12.00 # # B3423 $5.00 # B3448 $5.00 #

B3424 $15.00 # # B3449 $15.00 # # B3424 $5.00 # B3449 $5.00 #

B3425 $7.00 # # B3450 $10.00 # # B3425 $7.00 # B3450 $7.00 #

B3426 $10.00 # # B3451 $15.00 # # B3426 $5.00 # B3451 $7.00 #

B3427 $15.00 # # B3452 $12.00 # # B3427 $5.00 # B3452 $5.00 #

B3428 $15.00 # # B3453 $15.00 # # B3428 $5.00 # B3453 $7.00 #

B3429 $15.00 # # B3454 $10.00 # # B3429 $5.00 # B3454 $7.00 #

B3430 $10.00 # # B3455 $10.00 # # B3430 $5.00 # B3455 $7.00 #

B3431 $15.00 # # B3456 $15.00 # # B3431 $5.00 # B3456 $5.00 #

B3432 $15.00 # # B3457 $15.00 # # B3432 $5.00 # B3457 $7.00 #

B3433 $18.00 # # B3458 $15.00 # # B3433 $5.00 # B3458 $7.00 #

B3434 $18.00 # # B3459 $10.00 # # B3434 $5.00 # B3459 $7.00 #

B3435 $15.00 # # B3460 $12.00 # # B3435 $5.00 # B3460 $5.00 #

B3436 $15.00 # # B3461 $12.00 # # B3436 $15.00 # B3461 $5.00 #

B3437 $12.00 # # B3462 $15.00 # # B3437 $5.00 # B3462 $5.00 #

B3438 $12.00 # # B3463 NADA # # B3438 $5.00 # B3463 NADA #

B3439 $15.00 # # B3464 $12.00 # # B3439 $5.00 # B3464 $5.00 #

B3440 $15.00 # # B3465 $10.00 # # B3440 $5.00 # B3465 $5.00 #

B3441 $18.00 # # B3466 $18.00 # # B3441 $5.00 # B3466 $5.00 #

B3442 $15.00 # # B3467 $15.00 # # B3442 $7.00 # B3467 $5.00 #

B3443 $20.00 # # B3468 $15.00 # # B3443 $15.00 # B3468 $5.00 #

B3444 $20.00 # # B3469 $15.00 # # B3444 $15.00 # B3469 $7.00 #

B3445 $15.00 # # B3470 $10.00 # # B3445 $5.00 # B3470 $5.00 #

B3446 $15.00 # # B3471 $15.00 # # B3446 $5.00 # B3471 $7.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

105 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B3472 $15.00 # # B3497 $15.00 # # B3472 $7.00 # B3497 $5.00 #

B3473 $12.00 # # B3498 $10.00 # # B3473 $5.00 # B3498 $10.00 #

B3474 $18.00 # # B3499 $15.00 # # B3474 $5.00 # B3499 $5.00 #

B3475 $15.00 # # B3500 $15.00 # # B3475 $5.00 # B3500 $7.00 #

B3476 $15.00 # # B3501 $15.00 # # B3476 $5.00 # B3501 $5.00 #

B3477 $10.00 # # B3502 $15.00 # # B3477 $5.00 # B3502 $5.00 #

B3478 $15.00 # # B3503 $10.00 # # B3478 $5.00 # B3503 $5.00 #

B3479 $12.00 # # B3504 $15.00 # # B3479 $5.00 # B3504 $5.00 #

B3480 $15.00 # # B3505 $10.00 # # B3480 $5.00 # B3505 $7.00 #

B3481 $15.00 # # B3506 $15.00 # # B3481 $5.00 # B3506 $7.00 #

B3482 $20.00 # # B3507 $15.00 # # B3482 $5.00 # B3507 $5.00 #

B3483 NADA # # B3508 $15.00 # # B3483 $5.00 # B3508 $5.00 #

B3484 NADA # # B3509 $15.00 # # B3484 $5.00 # B3509 $7.00 #

B3485 $20.00 # # B3510 $15.00 # # B3485 $5.00 # B3510 $5.00 #

B3486 NADA # # B3511 $15.00 # # B3486 $5.00 # B3511 $5.00 #

B3487 NADA # # B3512 $12.00 # # B3487 $5.00 # B3512 $5.00 #

B3488 $20.00 # # B3513 $15.00 # # B3488 $10.00 # B3513 $5.00 #

B3489 $20.00 # # B3514 $10.00 # # B3489 $10.00 # B3514 $7.00 #

B3490 $15.00 # # B3515 $15.00 # # B3490 $5.00 # B3515 $5.00 #

B3491 $15.00 # # B3516 $10.00 # # B3491 $5.00 # B3516 $5.00 #

B3492 $15.00 # # B3517 $10.00 # # B3492 $5.00 # B3517 $7.00 #

B3493 $10.00 # # B3518 $10.00 # # B3493 $10.00 # B3518 $7.00 #

B3494 $15.00 # # B3519 $12.00 # # B3494 $15.00 # B3519 $15.00 #

B3495 $15.00 # # B3520 $12.00 # # B3495 $5.00 # B3520 $15.00 #

B3496 $10.00 # # B3521 $15.00 # # B3496 $7.00 # B3521 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

106 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B3522 $12.00 # # B3547 $10.00 # # B3522 $5.00 # B3547 $10.00 #

B3523 $7.00 # # B3548 NADA # # B3523 $5.00 # B3548 NADA #

B3524 $15.00 # # B3549 $10.00 # # B3524 $5.00 # B3549 $5.00 #

B3525 $15.00 # # B3550 $10.00 # # B3525 $5.00 # B3550 $5.00 #

B3526 $10.00 # # B3551 $10.00 # # B3526 $5.00 # B3551 $5.00 #

B3527 $15.00 # # B3552 $10.00 # # B3527 $5.00 # B3552 $5.00 #

B3528 $12.00 # # B3553 $10.00 # # B3528 $5.00 # B3553 $5.00 #

B3529 $15.00 # # B3554 $10.00 # # B3529 $7.00 # B3554 $5.00 #

B3530 $15.00 # # B3555 $10.00 # # B3530 $5.00 # B3555 $5.00 #

B3531 $10.00 # # B3556 $15.00 # # B3531 $5.00 # B3556 $5.00 #

B3532 $18.00 # # B3557 $15.00 # # B3532 $5.00 # B3557 $5.00 #

B3533 $12.00 # # B3558 $20.00 # # B3533 $5.00 # B3558 $20.00 #

B3534 $12.00 # # B3559 $15.00 # # B3534 $5.00 # B3559 $5.00 #

B3535 $12.00 # # B3560 $18.00 # # B3535 $5.00 # B3560 $5.00 #

B3536 $15.00 # # B3561 $18.00 # # B3536 $5.00 # B3561 $5.00 #

B3537 $12.00 # # B3562 $15.00 # # B3537 $5.00 # B3562 $5.00 #

B3538 $15.00 # # B3563 $15.00 # # B3538 $5.00 # B3563 $5.00 #

B3539 $10.00 # # B3564 $12.00 # # B3539 NADA # B3564 $5.00 #

B3540 $10.00 # # B3565 $12.00 # # B3540 NADA # B3565 NADA #

B3541 $10.00 # # B3566 $15.00 # # B3541 NADA # B3566 $5.00 #

B3542 $7.00 # # B3567 $10.00 # # B3542 $7.00 # B3567 $5.00 #

B3543 $10.00 # # B3568 $15.00 # # B3543 $5.00 # B3568 $5.00 #

B3544 $10.00 # # B3569 $10.00 # # B3544 $10.00 # B3569 $5.00 #

B3545 $7.00 # # B3570 $12.00 # # B3545 $7.00 # B3570 $5.00 #

B3546 $12.00 # # B3571 $12.00 # # B3546 $5.00 # B3571 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

107 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B3572 $12.00 # # B3597 $12.00 # # B3572 $5.00 # B3597 $5.00 #

B3573 $12.00 # # B3598 $15.00 # # B3573 $5.00 # B3598 $5.00 #

B3574 $15.00 # # B3599 $10.00 # # B3574 $5.00 # B3599 $5.00 #

B3575 $10.00 # # B3600 $10.00 # # B3575 $5.00 # B3600 $5.00 #

B3576 $10.00 # # B3601 $10.00 # # B3576 $5.00 # B3601 $5.00 #

B3577 $10.00 # # B3602 $10.00 # # B3577 $5.00 # B3602 $5.00 #

B3578 $8.00 # # B3603 $15.00 # # B3578 $5.00 # B3603 $5.00 #

B3579 $10.00 # # B3604 $12.00 # # B3579 $10.00 # B3604 $5.00 #

B3580 $12.00 # # B3605 $12.00 # # B3580 $5.00 # B3605 $5.00 #

B3581 $5.00 # # B3606 $10.00 # # B3581 $5.00 # B3606 $5.00 #

B3582 $10.00 # # B3607 $8.00 # # B3582 $10.00 # B3607 $5.00 #

B3583 $7.00 # # B3609 $10.00 # # B3583 $7.00 # B3609 $5.00 #

B3584 $10.00 # # B3610 $18.00 # # B3584 NADA # B3610 $18.00 #

B3585 $10.00 # # B3611 $12.00 # # B3585 NADA # B3611 $5.00 #

B3586 $10.00 # # B3612 $12.00 # # B3586 NADA # B3612 $5.00 #

B3587 $12.00 # # B3613 $15.00 # # B3587 $6.50 # B3613 $5.00 #

B3588 $10.00 # # B3614 $15.00 # # B3588 $5.00 # B3614 $5.00 #

B3589 $12.00 # # B3615 $12.00 # # B3589 $5.00 # B3615 $5.00 #

B3590 $5.00 # # B3616 $18.00 # # B3590 $5.00 # B3616 $5.00 #

B3591 $15.00 # # B3617 $15.00 # # B3591 $5.00 # B3617 $15.00 #

B3592 $10.00 # # B3618 $10.00 # # B3592 $10.00 # B3618 $5.00 #

B3593 $5.00 # # B3619 $15.00 # # B3593 $5.00 # B3619 $5.00 #

B3594 $15.00 # # B3620 $15.00 # # B3594 $5.00 # B3620 $5.00 #

B3595 $12.00 # # B3621 $6.00 # # B3595 $5.00 # B3621 $5.00 #

B3596 $10.00 # # B3622 $10.00 # # B3596 $5.00 # B3622 $10.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

108 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B3623 $15.00 # # B3648 $15.00 # # B3623 $5.00 # B3648 $5.00 #

B3624 $15.00 # # B3649 $8.00 # # B3624 $5.00 # B3649 $5.00 #

B3625 $15.00 # # B3650 $15.00 # # B3625 $5.00 # B3650 $5.00 #

B3626 $15.00 # # B3651 $15.00 # # B3626 $5.00 # B3651 $5.00 #

B3627 $15.00 # # B3652 $15.00 # # B3627 $5.00 # B3652 $5.00 #

B3628 $15.00 # # B3653 $15.00 # # B3628 $5.00 # B3653 $5.00 #

B3629 $15.00 # # B3654 $10.00 # # B3629 $5.00 # B3654 $5.00 #

B3630 $15.00 # # B3655 $15.00 # # B3630 $5.00 # B3655 $5.00 #

B3631 $12.00 # # B3656 $12.00 # # B3631 $5.00 # B3656 $5.00 #

B3632 $12.00 # # B3657 $10.00 # # B3632 $5.00 # B3657 $5.00 #

B3633 $12.00 # # B3658 $15.00 # # B3633 $5.00 # B3658 $5.00 #

B3634 $12.00 # # B3659 $15.00 # # B3634 $5.00 # B3659 $5.00 #

B3635 $15.00 # # B3660 $15.00 # # B3635 $5.00 # B3660 $5.00 #

B3636 $10.00 # # B3661 $10.00 # # B3636 $5.00 # B3661 $5.00 #

B3637 $8.00 # # B3662 $10.00 # # B3637 $5.00 # B3662 $5.00 #

B3638 $15.00 # # B3663 $10.00 # # B3638 $5.00 # B3663 $5.00 #

B3639 $15.00 # # B3664 $10.00 # # B3639 $5.00 # B3664 $5.00 #

B3640 $15.00 # # B3665 $15.00 # # B3640 $5.00 # B3665 $5.00 #

B3641 $15.00 # # B3666 $15.00 # # B3641 $5.00 # B3666 $5.00 #

B3642 $15.00 # # B3667 # # B3642 $5.00 # B3667 $5.00 #

B3643 $15.00 # # B3668 $15.00 # # B3643 $5.00 # B3668 $5.00 #

B3644 $10.00 # # B3669 $15.00 # # B3644 $5.00 # B3669 $5.00 #

B3645 $10.00 # # B3670 $15.00 # # B3645 $5.00 # B3670 $5.00 #

B3646 $15.00 # # B3671 $15.00 # # B3646 $5.00 # B3671 $5.00 #

B3647 $15.00 # # B3672 $12.00 # # B3647 $5.00 # B3672 #

CÓDIGOS DE CUBIERTAS / COPAGOS

109 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B3673 $10.00 # # B3698 $15.00 # # B3673 $5.00 # B3698 $5.00 #

B3674 $10.00 # # B3699 $10.00 # # B3674 $10.00 # B3699 $5.00 #

B3675 $7.00 # # B3700 $10.00 # # B3675 $7.00 # B3700 $5.00 #

B3676 $15.00 # # B3701 $10.00 # # B3676 $5.00 # B3701 $5.00 #

B3677 $15.00 # # B3702 $15.00 # # B3677 $5.00 # B3702 $5.00 #

B3678 $15.00 # # B3703 $15.00 # # B3678 $5.00 # B3703 $5.00 #

B3679 $10.00 # # B3704 $15.00 # # B3679 $5.00 # B3704 $5.00 #

B3680 $15.00 # # B3705 $15.00 # # B3680 $5.00 # B3705 $5.00 #

B3681 $15.00 # # B3706 $15.00 # # B3681 $5.00 # B3706 $5.00 #

B3682 $15.00 # # B3707 $15.00 # # B3682 $5.00 # B3707 $5.00 #

B3683 $18.00 # # B3708 $12.00 # # B3683 # B3708 $5.00 #

B3684 $15.00 # # B3709 $15.00 # # B3684 $7.00 # B3709 $5.00 #

B3685 $15.00 # # B3710 $10.00 # # B3685 $5.00 # B3710 $5.00 #

B3686 $15.00 # # B3711 $15.00 # # B3686 $5.00 # B3711 $5.00 #

B3687 $20.00 # # B3712 $15.00 # # B3687 $5.00 # B3712 $5.00 #

B3688 $20.00 # # B3713 $15.00 # # B3688 $5.00 # B3713 $5.00 #

B3689 $15.00 # # B3714 $15.00 # # B3689 $5.00 # B3714 $5.00 #

B3690 $10.00 # # B3715 $15.00 # # B3690 $5.00 # B3715 $5.00 #

B3691 $15.00 # # B3716 $15.00 # # B3691 $5.00 # B3716 $5.00 #

B3692 $10.00 # # B3717 $15.00 # # B3692 $5.00 # B3717 $5.00 #

B3693 $12.00 # # B3718 $12.00 # # B3693 $5.00 # B3718 $5.00 #

B3694 $15.00 # # B3719 $15.00 # # B3694 $5.00 # B3719 $5.00 #

B3695 $15.00 # # B3720 $15.00 # # B3695 $5.00 # B3720 $5.00 #

B3696 $15.00 # # B3721 $12.00 # # B3696 $5.00 # B3721 $5.00 #

B3697 $15.00 # # B3722 $20.00 # # B3697 $5.00 # B3722 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

110 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B3723 $15.00 # # B3748 $15.00 # # B3723 $5.00 # B3748 $5.00 #

B3724 # # B3749 $15.00 # # B3724 $5.00 # B3749 $5.00 #

B3725 $15.00 # # B3750 $15.00 # # B3725 $5.00 # B3750 $5.00 #

B3726 $18.00 # # B3751 $15.00 # # B3726 $5.00 # B3751 $5.00 #

B3727 $12.00 # # B3752 $15.00 # # B3727 $5.00 # B3752 $5.00 #

B3728 $12.00 # # B3753 $12.00 # # B3728 $5.00 # B3753 $5.00 #

B3729 $15.00 # # B3754 $15.00 # # B3729 $5.00 # B3754 $5.00 #

B3730 $15.00 # # B3755 $15.00 # # B3730 $5.00 # B3755 $5.00 #

B3731 $15.00 # # B3756 $15.00 # # B3731 $5.00 # B3756 $5.00 #

B3732 $15.00 # # B3757 $15.00 # # B3732 $5.00 # B3757 $5.00 #

B3733 $10.00 # # B3758 $15.00 # # B3733 $5.00 # B3758 $7.00 #

B3734 $15.00 # # B3759 $15.00 # # B3734 $5.00 # B3759 $5.00 #

B3735 $15.00 # # B3760 $15.00 # # B3735 $5.00 # B3760 $5.00 #

B3736 $12.00 # # B3761 $15.00 # # B3736 $5.00 # B3761 $5.00 #

B3737 $7.00 # # B3762 $15.00 # # B3737 $7.00 # B3762 $5.00 #

B3738 $12.00 # # B3763 $15.00 # # B3738 $5.00 # B3763 $5.00 #

B3739 $12.00 # # B3764 $15.00 # # B3739 $5.00 # B3764 $5.00 #

B3740 $12.00 # # B3765 $15.00 # # B3740 $5.00 # B3765 $5.00 #

B3741 $12.00 # # B3766 $15.00 # # B3741 $5.00 # B3766 $5.00 #

B3742 $15.00 # # B3767 $15.00 # # B3742 $5.00 # B3767 $5.00 #

B3743 $15.00 # # B3768 $15.00 # # B3743 $5.00 # B3768 $5.00 #

B3744 $15.00 # # B3769 $10.00 # # B3744 $7.00 # B3769 $5.00 #

B3745 $12.00 # # B3770 $15.00 # # B3745 $5.00 # B3770 $5.00 #

B3746 $10.00 # # B3771 $15.00 # # B3746 $5.00 # B3771 $5.00 #

B3747 $15.00 # # B3772 $15.00 # # B3747 $5.00 # B3772 $7.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

111 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B3773 $10.00 # # B3798 $15.00 # # B3773 $5.00 # B3798 $5.00 #

B3774 $10.00 # # B3799 $15.00 # # B3774 $5.00 # B3799 $5.00 #

B3775 $15.00 # # B3800 $15.00 # # B3775 $5.00 # B3800 $5.00 #

B3776 $12.00 # # B3801 $10.00 # # B3776 $5.00 # B3801 $5.00 #

B3777 $15.00 # # B3802 $15.00 # # B3777 $5.00 # B3802 $5.00 #

B3778 $15.00 # # B3803 $15.00 # # B3778 $5.00 # B3803 $5.00 #

B3779 $15.00 # # B3804 $12.00 # # B3779 $5.00 # B3804 $5.00 #

B3780 $10.00 # # B3805 $15.00 # # B3780 $5.00 # B3805 $5.00 #

B3781 $12.00 # # B3806 $15.00 # # B3781 $5.00 # B3806 $5.00 #

B3782 $15.00 # # B3807 $15.00 # # B3782 $5.00 # B3807 $5.00 #

B3783 $15.00 # # B3808 $15.00 # # B3783 $5.00 # B3808 $5.00 #

B3784 $15.00 # # B3809 $15.00 # # B3784 $5.00 # B3809 $5.00 #

B3785 $15.00 # # B3810 $15.00 # # B3785 $5.00 # B3810 $5.00 #

B3786 $10.00 # # B3811 $12.00 # # B3786 $5.00 # B3811 $5.00 #

B3787 $15.00 # # B3812 $15.00 # # B3787 $5.00 # B3812 $5.00 #

B3788 $10.00 # # B3813 $15.00 # # B3788 $5.00 # B3813 $5.00 #

B3789 $15.00 # # B3814 $10.00 # # B3789 $5.00 # B3814 $5.00 #

B3790 $15.00 # # B3815 $15.00 # # B3790 $5.00 # B3815 $5.00 #

B3791 $12.00 # # B3816 $15.00 # # B3791 $5.00 # B3816 $5.00 #

B3792 $10.00 # # B3817 $15.00 # # B3792 $5.00 # B3817 $5.00 #

B3793 $15.00 # # B3818 $15.00 # # B3793 $5.00 # B3818 $5.00 #

B3794 $15.00 # # B3819 $15.00 # # B3794 $5.00 # B3819 $5.00 #

B3795 $10.00 # # B3820 $15.00 # # B3795 $5.00 # B3820 $5.00 #

B3796 $15.00 # # B3821 $15.00 # # B3796 $5.00 # B3821 $5.00 #

B3797 $12.00 # # B3822 $15.00 # # B3797 $5.00 # B3822 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

112 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B3823 $15.00 # # B3848 $15.00 # # B3823 $5.00 # B3848 $5.00 #

B3824 $15.00 # # B3849 $15.00 # # B3824 $5.00 # B3849 $5.00 #

B3825 $15.00 # # B3850 $10.00 # # B3825 $5.00 # B3850 $5.00 #

B3826 $10.00 # # B3851 $10.00 # # B3826 $5.00 # B3851 $5.00 #

B3827 $15.00 # # B3852 $15.00 # # B3827 $5.00 # B3852 $5.00 #

B3828 $15.00 # # B3853 $10.00 # # B3828 $5.00 # B3853 $5.00 #

B3829 $12.00 # # B3854 $12.00 # # B3829 $5.00 # B3854 $5.00 #

B3830 $15.00 # # B3855 $12.00 # # B3830 $5.00 # B3855 $5.00 #

B3831 $15.00 # # B3856 $12.00 # # B3831 $5.00 # B3856 $5.00 #

B3832 $15.00 # # B3857 $15.00 # # B3832 $5.00 # B3857 $5.00 #

B3833 $15.00 # # B3858 $15.00 # # B3833 $5.00 # B3858 $5.00 #

B3834 $12.00 # # B3859 $15.00 # # B3834 $5.00 # B3859 $5.00 #

B3835 $15.00 # # B3860 $10.00 # # B3835 $5.00 # B3860 $5.00 #

B3836 $15.00 # # B3861 $15.00 # # B3836 $5.00 # B3861 $5.00 #

B3837 $15.00 # # B3862 $15.00 # # B3837 $5.00 # B3862 $5.00 #

B3838 $15.00 # # B3863 $15.00 # # B3838 $5.00 # B3863 $5.00 #

B3839 $15.00 # # B3864 $15.00 # # B3839 $5.00 # B3864 $5.00 #

B3840 $15.00 # # B3865 $15.00 # # B3840 $5.00 # B3865 $5.00 #

B3841 $15.00 # # B3866 $15.00 # # B3841 $5.00 # B3866 $5.00 #

B3842 $15.00 # # B3867 $12.00 # # B3842 $5.00 # B3867 $5.00 #

B3843 $15.00 # # B3868 $12.00 # # B3843 $5.00 # B3868 $5.00 #

B3844 $15.00 # # B3869 $12.00 # # B3844 $5.00 # B3869 $5.00 #

B3845 $15.00 # # B3870 $15.00 # # B3845 $5.00 # B3870 $5.00 #

B3846 $15.00 # # B3871 $15.00 # # B3846 $5.00 # B3871 $5.00 #

B3847 $15.00 # # B3872 $12.00 # # B3847 $5.00 # B3872 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

113 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B3873 $15.00 # # B3898 $15.00 # # B3873 $5.00 # B3898 $5.00 #

B3874 $15.00 # # B3899 NADA # # B3874 $5.00 # B3899 NADA #

B3875 $15.00 # # B3900 NADA # # B3875 $5.00 # B3900 NADA #

B3876 $15.00 # # B3901 $12.00 # # B3876 $5.00 # B3901 $5.00 #

B3877 $12.00 # # B3902 $15.00 # # B3877 $5.00 # B3902 $5.00 #

B3878 $15.00 # # B3903 $15.00 # # B3878 $5.00 # B3903 $5.00 #

B3879 $15.00 # # B3904 $15.00 # # B3879 $5.00 # B3904 $5.00 #

B3880 $15.00 # # B3905 $15.00 # # B3880 $5.00 # B3905 $5.00 #

B3881 $15.00 # # B3906 $15.00 # # B3881 $5.00 # B3906 $5.00 #

B3882 $12.00 # # B3907 $15.00 # # B3882 $5.00 # B3907 $5.00 #

B3883 $10.00 # # B3908 $15.00 # # B3883 $5.00 # B3908 $5.00 #

B3884 $15.00 # # B3909 $12.00 # # B3884 $5.00 # B3909 $5.00 #

B3885 $15.00 # # B3910 $15.00 # # B3885 $5.00 # B3910 $5.00 #

B3886 $15.00 # # B3911 $15.00 # # B3886 $5.00 # B3911 $5.00 #

B3887 $15.00 # # B3912 $10.00 # # B3887 $5.00 # B3912 $5.00 #

B3888 $15.00 # # B3913 $10.00 # # B3888 $5.00 # B3913 $5.00 #

B3889 $15.00 # # B3914 $15.00 # # B3889 $5.00 # B3914 $5.00 #

B3890 $15.00 # # B3915 $15.00 # # B3890 $5.00 # B3915 $5.00 #

B3891 $15.00 # # B3916 $15.00 # # B3891 $5.00 # B3916 $5.00 #

B3892 $10.00 # # B3917 NADA # # B3892 $5.00 # B3917 NADA #

B3893 $15.00 # # B3918 $10.00 # # B3893 $7.00 # B3918 $5.00 #

B3894 $15.00 # # B3919 $15.00 # # B3894 $5.00 # B3919 $5.00 #

B3895 $15.00 # # B3920 $15.00 # # B3895 $5.00 # B3920 $5.00 #

B3896 $15.00 # # B3921 $10.00 # # B3896 $5.00 # B3921 $5.00 #

B3897 $15.00 # # B3922 $15.00 # # B3897 $5.00 # B3922 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

114 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B3923 $15.00 # # B3948 $10.00 # # B3923 $5.00 # B3948 $5.00 #

B3924 $15.00 # # B3949 $10.00 # # B3924 $5.00 # B3949 $5.00 #

B3925 $15.00 # # B3950 $15.00 # # B3925 $5.00 # B3950 $5.00 #

B3926 $12.00 # # B3951 $15.00 # # B3926 $5.00 # B3951 $5.00 #

B3927 $15.00 # # B3952 $15.00 # # B3927 $5.00 # B3952 $5.00 #

B3928 $15.00 # # B3953 $15.00 # # B3928 $5.00 # B3953 $5.00 #

B3929 $12.00 # # B3954 $15.00 # # B3929 NADA # B3954 $5.00 #

B3930 $12.00 # # B3955 $15.00 # # B3930 $5.00 # B3955 $7.00 #

B3931 $12.00 # # B3956 $15.00 # # B3931 NADA # B3956 $5.00 #

B3932 $15.00 # # B3957 $12.00 # # B3932 $5.00 # B3957 $5.00 #

B3933 $10.00 # # B3958 $15.00 # # B3933 $5.00 # B3958 $5.00 #

B3934 $12.00 # # B3959 $15.00 # # B3934 $5.00 # B3959 $5.00 #

B3935 $10.00 # # B3960 $15.00 # # B3935 $5.00 # B3960 $5.00 #

B3936 $10.00 # # B3961 $15.00 # # B3936 $5.00 # B3961 $5.00 #

B3937 $10.00 # # B3962 $15.00 # # B3937 $5.00 # B3962 $5.00 #

B3938 $10.00 # # B3963 $15.00 # # B3938 $5.00 # B3963 $5.00 #

B3939 $10.00 # # B3964 $15.00 # # B3939 $5.00 # B3964 $7.00 #

B3940 $15.00 # # B3965 $15.00 # # B3940 $5.00 # B3965 $5.00 #

B3941 $10.00 # # B3966 $15.00 # # B3941 $5.00 # B3966 $5.00 #

B3942 $10.00 # # B3967 $18.00 # # B3942 $5.00 # B3967 $5.00 #

B3943 $15.00 # # B3968 $15.00 # # B3943 $5.00 # B3968 $5.00 #

B3944 $15.00 # # B3969 $15.00 # # B3944 $5.00 # B3969 $5.00 #

B3945 $15.00 # # B3970 $15.00 # # B3945 $5.00 # B3970 $5.00 #

B3946 $15.00 # # B3971 $15.00 # # B3946 $5.00 # B3971 $5.00 #

B3947 $15.00 # # B3972 $15.00 # # B3947 $7.00 # B3972 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

115 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B3973 $15.00 # # B3998 $15.00 # # B3973 $5.00 # B3998 $5.00 #

B3974 $15.00 # # B3999 $10.00 # # B3974 $5.00 # B3999 $5.00 #

B3975 $15.00 # # B4000 $15.00 # # B3975 $5.00 # B4000 $5.00 #

B3976 $15.00 # # B4001 $12.00 # # B3976 $5.00 # B4001 $5.00 #

B3977 $15.00 # # B4002 $12.00 # # B3977 $5.00 # B4002 $5.00 #

B3978 $10.00 # # B4003 $12.00 # # B3978 $5.00 # B4003 $5.00 #

B3979 $15.00 # # B4004 $15.00 # # B3979 $5.00 # B4004 $5.00 #

B3980 $15.00 # # B4005 $12.00 # # B3980 $5.00 # B4005 $5.00 #

B3981 $15.00 # # B4006 $15.00 # # B3981 $5.00 # B4006 $5.00 #

B3982 $15.00 # # B4007 $15.00 # # B3982 $5.00 # B4007 $5.00 #

B3983 $15.00 # # B4008 $15.00 # # B3983 $5.00 # B4008 $5.00 #

B3984 $15.00 # # B4009 $10.00 # # B3984 $5.00 # B4009 $5.00 #

B3985 $15.00 # # B4010 $12.00 # # B3985 $5.00 # B4010 $5.00 #

B3986 $10.00 # # B4011 $15.00 # # B3986 $5.00 # B4011 $5.00 #

B3987 $10.00 # # B4012 $10.00 # # B3987 $5.00 # B4012 $5.00 #

B3988 $10.00 # # B4013 $12.00 # # B3988 $5.00 # B4013 $5.00 #

B3989 $15.00 # # B4014 $10.00 # # B3989 $5.00 # B4014 $7.00 #

B3990 $15.00 # # B4015 $12.00 # # B3990 $5.00 # B4015 $5.00 #

B3991 $10.00 # # B4016 $10.00 # # B3991 $5.00 # B4016 $5.00 #

B3992 $12.00 # # B4017 $15.00 # # B3992 $5.00 # B4017 $5.00 #

B3993 $15.00 # # B4018 $15.00 # # B3993 $5.00 # B4018 $5.00 #

B3994 $15.00 # # B4019 $15.00 # # B3994 $5.00 # B4019 $5.00 #

B3995 $15.00 # # B4020 $15.00 # # B3995 $5.00 # B4020 $5.00 #

B3996 $12.00 # # B4021 NADA # # B3996 $5.00 # B4021 NADA #

B3997 $15.00 # # B4022 NADA # # B3997 $5.00 # B4022 NADA #

CÓDIGOS DE CUBIERTAS / COPAGOS

116 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B4023 NADA # # B4048 $20.00 # # B4023 NADA # B4048 $20.00 #

B4024 $10.00 # # B4049 $5.00 # # B4024 $5.00 # B4049 $5.00 #

B4025 $10.00 # # B4050 $10.00 # # B4025 $5.00 # B4050 $5.00 #

B4026 $10.00 # # B4051 $15.00 # # B4026 $5.00 # B4051 $5.00 #

B4027 $12.00 # # B4052 $10.00 # # B4027 $5.00 # B4052 $5.00 #

B4028 $15.00 # # B4053 $15.00 # # B4028 $5.00 # B4053 $5.00 #

B4029 $15.00 # # B4054 $15.00 # # B4029 $5.00 # B4054 $7.00 #

B4030 $15.00 # # B4055 $12.00 # # B4030 $5.00 # B4055 $5.00 #

B4031 $10.00 # # B4056 $15.00 # # B4031 $5.00 # B4056 $5.00 #

B4032 $15.00 # # B4057 $15.00 # # B4032 $5.00 # B4057 $5.00 #

B4033 $15.00 # # B4058 $15.00 # # B4033 $5.00 # B4058 $5.00 #

B4034 $10.00 # # B4059 $15.00 # # B4034 $5.00 # B4059 $5.00 #

B4035 $15.00 # # B4060 $15.00 # # B4035 $5.00 # B4060 $5.00 #

B4036 $15.00 # # B4061 $10.00 # # B4036 $5.00 # B4061 $5.00 #

B4037 $15.00 # # B4062 $15.00 # # B4037 $5.00 # B4062 $5.00 #

B4038 $10.00 # # B4063 $15.00 # # B4038 $5.00 # B4063 $5.00 #

B4039 $15.00 # # B4064 $15.00 # # B4039 $5.00 # B4064 $5.00 #

B4040 $10.00 # # B4065 $15.00 # # B4040 $5.00 # B4065 $5.00 #

B4041 $10.00 # # B4066 $15.00 # # B4041 $5.00 # B4066 $5.00 #

B4042 $15.00 # # B4067 $15.00 # # B4042 $5.00 # B4067 $5.00 #

B4043 $10.00 # # B4068 $10.00 # # B4043 $5.00 # B4068 $5.00 #

B4044 $10.00 # # B4069 $15.00 # # B4044 $5.00 # B4069 $5.00 #

B4045 $10.00 # # B4070 $15.00 # # B4045 $5.00 # B4070 $5.00 #

B4046 $7.00 # # B4071 $15.00 # # B4046 $5.00 # B4071 $5.00 #

B4047 $12.00 # # B4072 $15.00 # # B4047 $12.00 # B4072 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B4073 $15.00 # # B4098 $15.00 # # B4073 $5.00 # B4098 $5.00 #

B4074 $15.00 # # B4099 $12.00 # # B4074 $5.00 # B4099 $5.00 #

B4075 $10.00 # # B4100 $15.00 # # B4075 $5.00 # B4100 $5.00 #

B4076 $15.00 # # B4101 $15.00 # # B4076 $5.00 # B4101 $5.00 #

B4077 $15.00 # # B4102 $15.00 # # B4077 $5.00 # B4102 $5.00 #

B4078 $15.00 # # B4103 $15.00 # # B4078 $5.00 # B4103 $5.00 #

B4079 $15.00 # # B4104 $12.00 # # B4079 $5.00 # B4104 $5.00 #

B4080 $15.00 # # B4105 $15.00 # # B4080 $5.00 # B4105 $7.00 #

B4081 $15.00 # # B4106 $15.00 # # B4081 $5.00 # B4106 $5.00 #

B4082 $15.00 # # B4107 $15.00 # # B4082 $5.00 # B4107 $5.00 #

B4083 $12.00 # # B4108 $15.00 # # B4083 $5.00 # B4108 $5.00 #

B4084 $15.00 # # B4109 $15.00 # # B4084 $5.00 # B4109 $5.00 #

B4085 $15.00 # # B4110 $10.00 # # B4085 $5.00 # B4110 $5.00 #

B4086 $15.00 # # B4111 $15.00 # # B4086 $5.00 # B4111 $5.00 #

B4087 $10.00 # # B4112 $15.00 # # B4087 $5.00 # B4112 $5.00 #

B4088 $10.00 # # B4113 $10.00 # # B4088 $5.00 # B4113 $5.00 #

B4089 $15.00 # # B4114 $15.00 # # B4089 $5.00 # B4114 $5.00 #

B4090 $15.00 # # B4115 $15.00 # # B4090 $5.00 # B4115 $5.00 #

B4091 $10.00 # # B4116 $15.00 # # B4091 $5.00 # B4116 $5.00 #

B4092 $10.00 # # B4117 $15.00 # # B4092 $5.00 # B4117 $5.00 #

B4093 $15.00 # # B4118 $15.00 # # B4093 $5.00 # B4118 $5.00 #

B4094 $15.00 # # B4119 $12.00 # # B4094 $5.00 # B4119 $5.00 #

B4095 $15.00 # # B4120 $15.00 # # B4095 $5.00 # B4120 $5.00 #

B4096 $15.00 # # B4121 $12.00 # # B4096 $5.00 # B4121 $5.00 #

B4097 $12.00 # # B4122 $15.00 # # B4097 $5.00 # B4122 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

118 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B4123 $15.00 # # B4148 $15.00 # # B4123 $5.00 # B4148 $7.00 #

B4124 $15.00 # # B4149 $15.00 # # B4124 $5.00 # B4149 $5.00 #

B4125 $12.00 # # B4150 $15.00 # # B4125 $5.00 # B4150 $7.00 #

B4126 $15.00 # # B4151 $15.00 # # B4126 $5.00 # B4151 $7.00 #

B4127 $10.00 # # B4152 $15.00 # # B4127 $10.00 # B4152 $7.00 #

B4128 $15.00 # # B4153 $15.00 # # B4128 $15.00 # B4153 $5.00 #

B4129 $10.00 # # B4154 $15.00 # # B4129 $10.00 # B4154 $5.00 #

B4130 $15.00 # # B4155 $15.00 # # B4130 $15.00 # B4155 $5.00 #

B4131 $12.00 # # B4156 $15.00 # # B4131 $5.00 # B4156 $5.00 #

B4132 $15.00 # # B4157 $12.00 # # B4132 $5.00 # B4157 $5.00 #

B4133 $12.00 # # B4158 $15.00 # # B4133 $5.00 # B4158 $7.00 #

B4134 $15.00 # # B4159 $10.00 # # B4134 $5.00 # B4159 $5.00 #

B4135 $15.00 # # B4160 $15.00 # # B4135 $5.00 # B4160 $5.00 #

B4136 $10.00 # # B4161 NADA # # B4136 $5.00 # B4161 $5.00 #

B4137 $15.00 # # B4162 $15.00 # # B4137 $5.00 # B4162 $7.00 #

B4138 $15.00 # # B4163 $18.00 # # B4138 $5.00 # B4163 $5.00 #

B4139 $15.00 # # B4164 $15.00 # # B4139 $5.00 # B4164 $5.00 #

B4140 $10.00 # # B4165 $10.00 # # B4140 $5.00 # B4165 $5.00 #

B4141 $15.00 # # B4166 $15.00 # # B4141 $7.00 # B4166 $5.00 #

B4142 $15.00 # # B4167 $15.00 # # B4142 $5.00 # B4167 $5.00 #

B4143 $15.00 # # B4168 $10.00 # # B4143 $5.00 # B4168 $5.00 #

B4144 $10.00 # # B4169 $18.00 # # B4144 $5.00 # B4169 $5.00 #

B4145 $12.00 # # B4170 $15.00 # # B4145 $5.00 # B4170 $5.00 #

B4146 $15.00 # # B4171 $15.00 # # B4146 $5.00 # B4171 $5.00 #

B4147 $15.00 # # B4172 $15.00 # # B4147 $5.00 # B4172 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

119 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B4173 $15.00 # # B4198 $12.00 # # B4173 $5.00 # B4198 $5.00 #

B4174 $15.00 # # B4199 $15.00 # # B4174 NADA # B4199 NADA #

B4175 $15.00 # # B4200 $12.00 # # B4175 $5.00 # B4200 $5.00 #

B4176 $15.00 # # B4201 NADA # # B4176 $5.00 # B4201 NADA #

B4177 $15.00 # # B4202 $10.00 # # B4177 $7.00 # B4202 $5.00 #

B4178 $15.00 # # B4203 $5.00 # # B4178 $5.00 # B4203 $5.00 #

B4179 $15.00 # # B4204 $20.00 # # B4179 $5.00 # B4204 $5.00 #

B4180 $10.00 # # B4205 $12.00 # # B4180 $5.00 # B4205 $5.00 #

B4181 $12.00 # # B4206 $10.00 # # B4181 $12.00 # B4206 $5.00 #

B4182 $12.00 # # B4207 $15.00 # # B4182 $5.00 # B4207 $5.00 #

B4183 $10.00 # # B4208 $15.00 # # B4183 $5.00 # B4208 $5.00 #

B4184 $15.00 # # B4209 $15.00 # # B4184 $5.00 # B4209 $5.00 #

B4185 $15.00 # # B4210 NADA # # B4185 $5.00 # B4210 NADA #

B4186 $15.00 # # B4211 NADA # # B4186 $5.00 # B4211 NADA #

B4187 $15.00 # # B4212 $15.00 # # B4187 $5.00 # B4212 $5.00 #

B4188 $15.00 # # B4213 $12.00 # # B4188 $5.00 # B4213 $5.00 #

B4189 $15.00 # # B4214 $15.00 # # B4189 $5.00 # B4214 $5.00 #

B4190 $15.00 # # B4215 $15.00 # # B4190 NADA # B4215 $5.00 #

B4191 $10.00 # # B4216 $15.00 # # B4191 $5.00 # B4216 $5.00 #

B4192 $15.00 # # B4217 $15.00 # # B4192 NADA # B4217 $5.00 #

B4193 $10.00 # # B4218 $12.00 # # B4193 $5.00 # B4218 $5.00 #

B4194 $10.00 # # B4219 $10.00 # # B4194 $5.00 # B4219 $5.00 #

B4195 $15.00 # # B4220 $10.00 # # B4195 $5.00 # B4220 $5.00 #

B4196 $15.00 # # B4221 $15.00 # # B4196 $5.00 # B4221 $5.00 #

B4197 $12.00 # # B4222 $15.00 # # B4197 $5.00 # B4222 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

120 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B4223 $10.00 # # B4248 $12.00 # # B4223 $5.00 # B4248 $5.00 #

B4224 $15.00 # # B4249 $10.00 # # B4224 $5.00 # B4249 $5.00 #

B4225 $15.00 # # B4250 $15.00 # # B4225 $5.00 # B4250 $5.00 #

B4226 $15.00 # # B4251 $15.00 # # B4226 $5.00 # B4251 $5.00 #

B4227 $15.00 # # B4252 $12.00 # # B4227 $5.00 # B4252 $5.00 #

B4228 $15.00 # # B4253 $15.00 # # B4228 $5.00 # B4253 $5.00 #

B4229 $15.00 # # B4254 $15.00 # # B4229 $5.00 # B4254 $5.00 #

B4230 $15.00 # # B4255 $15.00 # # B4230 $5.00 # B4255 $5.00 #

B4231 $15.00 # # B4256 $15.00 # # B4231 $5.00 # B4256 $5.00 #

B4232 $15.00 # # B4257 $15.00 # # B4232 $5.00 # B4257 $5.00 #

B4233 $15.00 # # B4258 $12.00 # # B4233 $5.00 # B4258 $5.00 #

B4234 $15.00 # # B4259 $15.00 # # B4234 $5.00 # B4259 $5.00 #

B4235 $15.00 # # B4260 $15.00 # # B4235 $5.00 # B4260 $5.00 #

B4236 $15.00 # # B4261 $15.00 # # B4236 $5.00 # B4261 $5.00 #

B4237 $10.00 # # B4262 $15.00 # # B4237 $5.00 # B4262 $5.00 #

B4238 $15.00 # # B4263 $10.00 # # B4238 $5.00 # B4263 $5.00 #

B4239 $12.00 # # B4264 $15.00 # # B4239 $5.00 # B4264 $5.00 #

B4240 $15.00 # # B4265 $12.00 # # B4240 $5.00 # B4265 $5.00 #

B4241 $15.00 # # B4266 $15.00 # # B4241 $5.00 # B4266 $5.00 #

B4242 $12.00 # # B4267 NADA # # B4242 $5.00 # B4267 $5.00 #

B4243 $15.00 # # B4268 $15.00 # # B4243 $5.00 # B4268 $5.00 #

B4244 $15.00 # # B4269 $15.00 # # B4244 $5.00 # B4269 $5.00 #

B4245 $15.00 # # B4270 $15.00 # # B4245 $5.00 # B4270 $5.00 #

B4246 $15.00 # # B4271 $12.00 # # B4246 $5.00 # B4271 $5.00 #

B4247 $15.00 # # B4272 $10.00 # # B4247 $5.00 # B4272 $10.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

121 08/13/2015

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CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B4273 $10.00 # # B4298 $18.00 # # B4273 $10.00 # B4298 $5.00 #

B4274 $10.00 # # B4299 $15.00 # # B4274 $5.00 # B4299 $5.00 #

B4275 $15.00 # # B4300 $12.00 # # B4275 $5.00 # B4300 $5.00 #

B4276 $15.00 # # B4301 $10.00 # # B4276 $5.00 # B4301 $5.00 #

B4277 $15.00 # # B4302 $10.00 # # B4277 $5.00 # B4302 $5.00 #

B4278 $15.00 # # B4303 $15.00 # # B4278 $5.00 # B4303 $5.00 #

B4279 $15.00 # # B4304 $15.00 # # B4279 $5.00 # B4304 $5.00 #

B4280 $15.00 # # B4305 $15.00 # # B4280 $5.00 # B4305 $5.00 #

B4281 $10.00 # # B4306 $12.00 # # B4281 $5.00 # B4306 $5.00 #

B4282 $15.00 # # B4307 $12.00 # # B4282 $5.00 # B4307 $5.00 #

B4283 $15.00 # # B4308 $12.00 # # B4283 $5.00 # B4308 $5.00 #

B4284 $10.00 # # B4309 $15.00 # # B4284 $5.00 # B4309 $5.00 #

B4285 $15.00 # # B4310 $10.00 # # B4285 $5.00 # B4310 $5.00 #

B4286 $12.00 # # B4311 $12.00 # # B4286 $5.00 # B4311 $12.00 #

B4287 $15.00 # # B4312 $15.00 # # B4287 $5.00 # B4312 $7.00 #

B4288 $15.00 # # B4313 $15.00 # # B4288 $5.00 # B4313 $5.00 #

B4289 $10.00 # # B4314 $10.00 # # B4289 $5.00 # B4314 $5.00 #

B4290 $15.00 # # B4315 $15.00 # # B4290 $5.00 # B4315 $5.00 #

B4291 $15.00 # # B4316 $12.00 # # B4291 $5.00 # B4316 $5.00 #

B4292 $15.00 # # B4317 $15.00 # # B4292 $5.00 # B4317 $5.00 #

B4293 $15.00 # # B4318 $15.00 # # B4293 $5.00 # B4318 $5.00 #

B4294 $15.00 # # B4319 $15.00 # # B4294 $5.00 # B4319 $5.00 #

B4295 $10.00 # # B4320 $15.00 # # B4295 $5.00 # B4320 $5.00 #

B4296 $15.00 # # B4321 $15.00 # # B4296 $5.00 # B4321 $5.00 #

B4297 $15.00 # # B4322 $18.00 # # B4297 $5.00 # B4322 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B4323 $12.00 # # B4348 $15.00 # # B4323 $5.00 # B4348 $5.00 #

B4324 $15.00 # # B4349 $15.00 # # B4324 $5.00 # B4349 $5.00 #

B4325 $15.00 # # B4350 $10.00 # # B4325 $7.00 # B4350 $5.00 #

B4326 $15.00 # # B4351 $15.00 # # B4326 $5.00 # B4351 $5.00 #

B4327 $15.00 # # B4352 $12.00 # # B4327 $5.00 # B4352 $5.00 #

B4328 $15.00 # # B4353 $10.00 # # B4328 $5.00 # B4353 $10.00 #

B4329 $15.00 # # B4354 $10.00 # # B4329 $5.00 # B4354 $10.00 #

B4330 $12.00 # # B4355 $10.00 # # B4330 $5.00 # B4355 $10.00 #

B4331 $10.00 # # B4356 $10.00 # # B4331 $5.00 # B4356 $10.00 #

B4332 $20.00 # # B4357 $10.00 # # B4332 $5.00 # B4357 $10.00 #

B4333 $15.00 # #

B4358 , r

NADA # # B4333

$5.00 # B4358 , r

$15.00 #

B4334 $15.00 # # B4359 $15.00 # # B4334 $5.00 # B4359 $5.00 #

B4335 $15.00 # # B4360 $15.00 # # B4335 $5.00 # B4360 $5.00 #

B4336 $15.00 # # B4361 $15.00 # # B4336 $5.00 # B4361 $5.00 #

B4337 $10.00 # # B4362 $15.00 # # B4337 $5.00 # B4362 $5.00 #

B4338 $12.00 # # B4363 $15.00 # # B4338 $5.00 # B4363 $5.00 #

B4339 $15.00 # # B4364 $10.00 # # B4339 $5.00 # B4364 NADA #

B4340 $15.00 # # B4365 $10.00 # # B4340 $5.00 # B4365 $5.00 #

B4341 $15.00 # # B4366 $12.00 # # B4341 $5.00 # B4366 $5.00 #

B4342 $10.00 # # B4367 w $15.00 # # B4342 $5.00 # B4367 w $5.00 #

B4343 $15.00 # # B4368 $18.00 # # B4343 $5.00 # B4368 $5.00 #

B4344 $15.00 # # B4369 $18.00 # # B4344 $5.00 # B4369 $5.00 #

B4345 $12.00 # # B4370 w $15.00 # # B4345 $5.00 # B4370 w $5.00 #

B4346 $15.00 # # B4371 $10.00 # # B4346 $5.00 # B4371 $5.00 #

B4347 , y

$5.00 # # B4372 $15.00 # # B4347 , y

$5.00 # B4372 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B4373 $15.00 # # B4398 $15.00 # # B4373 $5.00 # B4398 $5.00 #

B4374 $10.00 # # B4399 $10.00 # # B4374 $5.00 # B4399 $5.00 #

B4375 $10.00 # # B4400 $10.00 # # B4375 $5.00 # B4400 $5.00 #

B4376 $10.00 # # B4401 $10.00 # # B4376 $5.00 # B4401 $5.00 #

B4377 $5.00 # # B4402 $10.00 # # B4377 $5.00 # B4402 $5.00 #

B4378 $5.00 # # B4403 $12.00 # # B4378 $5.00 # B4403 $5.00 #

B4379 $5.00 # # B4404 $10.00 # # B4379 $5.00 # B4404 $5.00 #

B4380 $10.00 # # B4405 $12.00 # # B4380 $6.00 # B4405 $5.00 #

B4381 $10.00 # # B4406 $15.00 # # B4381 $6.00 # B4406 $5.00 #

B4382 $12.00 # # B4407 $15.00 # # B4382 $5.00 # B4407 $5.00 #

B4383 $10.00 # # B4408 $15.00 # # B4383 NADA # B4408 $5.00 #

B4384 $10.00 # # B4409 $15.00 # # B4384 $5.00 # B4409 $5.00 #

B4385 $10.00 # # B4410 $15.00 # # B4385 $5.00 # B4410 $5.00 #

B4386 $10.00 # # B4411 $15.00 # # B4386 NADA # B4411 $5.00 #

B4387 $15.00 # # B4412 $15.00 # # B4387 $5.00 # B4412 $5.00 #

B4388 $15.00 # # B4413 $15.00 # # B4388 $5.00 # B4413 $5.00 #

B4389 $15.00 # # B4414 $15.00 # # B4389 $5.00 # B4414 $5.00 #

B4390 $15.00 # # B4415 $15.00 # # B4390 $5.00 # B4415 $5.00 #

B4391 $15.00 # # B4416 $15.00 # # B4391 $5.00 # B4416 $5.00 #

B4392 $15.00 # # B4417 $15.00 # # B4392 $5.00 # B4417 $5.00 #

B4393 $15.00 # # B4418 $15.00 # # B4393 $5.00 # B4418 $5.00 #

B4394 $15.00 # # B4419 $15.00 # # B4394 $5.00 # B4419 $5.00 #

B4395 $15.00 # # B4420 $15.00 # # B4395 $5.00 # B4420 $5.00 #

B4396 $15.00 # # B4421 $15.00 # # B4396 $5.00 # B4421 $5.00 #

B4397 $15.00 # # B4422 $15.00 # # B4397 $5.00 # B4422 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B4423 $12.00 # # B4448 NADA # # B4423 $12.00 # B4448 NADA #

B4424 $12.00 # # B4449 NADA # # B4424 $12.00 # B4449 NADA #

B4425 $12.00 # # B4450 NADA # # B4425 $12.00 # B4450 NADA #

B4426 $10.00 # # B4451 $10.00 # # B4426 $15.00 # B4451 $5.00 #

B4427 $8.00 # # B4452 $8.00 # # B4427 $10.00 # B4452 $5.00 #

B4428 $10.00 # # B4453 $8.00 # # B4428 $15.00 # B4453 $5.00 #

B4429 $15.00 # # B4454 $12.00 # # B4429 $15.00 # B4454 $12.00 #

B4430 $10.00 # # B4455 $17.00 # # B4430 $10.00 # B4455 $5.00 #

B4431 $8.00 # # B4456 $10.00 # # B4431 $8.00 # B4456 $18.00 #

B4432 $8.00 # # B4457 $8.00 # # B4432 $8.00 # B4457 $8.00 #

B4433 $8.00 # # B4458 $8.00 # # B4433 $8.00 # B4458 $8.00 #

B4434 NADA # # B4459 $15.00 # # B4434 NADA # B4459 $5.00 #

B4435 $10.00 # # B4460 $15.00 # # B4435 $15.00 # B4460 $5.00 #

B4436 NADA # # B4461 $15.00 # # B4436 NADA # B4461 $5.00 #

B4437 $7.00 # # B4462 $15.00 # # B4437 $7.00 # B4462 $5.00 #

B4438 $15.00 # # B4463 $15.00 # # B4438 $5.00 # B4463 $5.00 #

B4439 NADA # # B4464 $15.00 # # B4439 NADA # B4464 $5.00 #

B4440 $8.00 # # B4465 $10.00 # # B4440 $5.00 # B4465 $5.00 #

B4441 $10.00 # # B4466 $10.00 # # B4441 $5.00 # B4466 $5.00 #

B4442 $8.00 # # B4467 $15.00 # # B4442 $5.00 # B4467 $5.00 #

B4443 $15.00 # # B4468 $15.00 # # B4443 $15.00 # B4468 $5.00 #

B4444 $8.00 # # B4469 $15.00 # # B4444 $5.00 # B4469 $5.00 #

B4445 $8.00 # # B4470 $15.00 # # B4445 $5.00 # B4470 $5.00 #

B4446 $10.00 # # B4471 $15.00 # # B4446 $5.00 # B4471 $5.00 #

B4447 $10.00 # # B4472 $12.00 # # B4447 $10.00 # B4472 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

125 08/13/2015

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CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B4473 $15.00 # # B4498 $15.00 # # B4473 $5.00 # B4498 $5.00 #

B4474 $15.00 # # B4499 $12.00 # # B4474 $5.00 # B4499 $5.00 #

B4475 $15.00 # # B4500 $12.00 # # B4475 $5.00 # B4500 $5.00 #

B4476 $10.00 # # B4501 $12.00 # # B4476 $5.00 # B4501 $5.00 #

B4477 $15.00 # # B4502 $12.00 # # B4477 $5.00 # B4502 $5.00 #

B4478 $15.00 # # B4503 $15.00 # # B4478 $5.00 # B4503 $5.00 #

B4479 $15.00 # # B4504 $10.00 # # B4479 $5.00 # B4504 $5.00 #

B4480 $12.00 # # B4505 $16.00 # # B4480 $5.00 # B4505 $5.00 #

B4481 $15.00 # # B4506 $15.00 # # B4481 $5.00 # B4506 $5.00 #

B4482 $15.00 # # B4507 $10.00 # # B4482 $5.00 # B4507 $5.00 #

B4483 $15.00 # # B4508 $12.00 # # B4483 $5.00 # B4508 $5.00 #

B4484 $15.00 # # B4509 $15.00 # # B4484 $5.00 # B4509 $5.00 #

B4485 $12.00 # # B4510 $10.00 # # B4485 $5.00 # B4510 $5.00 #

B4486 $12.00 # # B4511 $10.00 # # B4486 $5.00 # B4511 $10.00 #

B4487 $15.00 # # B4512 $10.00 # # B4487 $5.00 # B4512 $5.00 #

B4488 $15.00 # # B4513 $15.00 # # B4488 $5.00 # B4513 $5.00 #

B4489 $15.00 # # B4514 $12.00 # # B4489 $5.00 # B4514 $5.00 #

B4490 $12.00 # # B4515 $12.00 # # B4490 $5.00 # B4515 $5.00 #

B4491 $10.00 # # B4516 $15.00 # # B4491 $5.00 # B4516 $5.00 #

B4492 $15.00 # # B4517 $10.00 # # B4492 $5.00 # B4517 $5.00 #

B4493 $15.00 # # B4518 $10.00 # # B4493 $5.00 # B4518 $5.00 #

B4494 $15.00 # # B4519 $10.00 # # B4494 $5.00 # B4519 $5.00 #

B4495 $15.00 # # B4520 $10.00 # # B4495 $5.00 # B4520 $5.00 #

B4496 $15.00 # # B4521 $12.00 # # B4496 $5.00 # B4521 $5.00 #

B4497 $15.00 # # B4522 $15.00 # # B4497 $5.00 # B4522 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

126 08/13/2015

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CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B4523 $15.00 # # B4548 $15.00 # # B4523 $5.00 # B4548 $5.00 #

B4524 $12.00 # # B4549 $15.00 # # B4524 $5.00 # B4549 $5.00 #

B4525 $10.00 # # B4550 $15.00 # # B4525 $5.00 # B4550 $5.00 #

B4526 $10.00 # # B4551 $15.00 # # B4526 $5.00 # B4551 $5.00 #

B4527 $15.00 # # B4552 $15.00 # # B4527 $5.00 # B4552 $5.00 #

B4528 $15.00 # # B4553 $12.00 # # B4528 $5.00 # B4553 $5.00 #

B4529 $10.00 # # B4554 $15.00 # # B4529 $5.00 # B4554 $5.00 #

B4530 $15.00 # # B4555 $12.00 # # B4530 $5.00 # B4555 $5.00 #

B4531 $15.00 # # B4556 $15.00 # # B4531 $5.00 # B4556 $5.00 #

B4532 $15.00 # # B4557 $12.00 # # B4532 $5.00 # B4557 $12.00 #

B4533 $15.00 # # B4558 $12.00 # # B4533 $5.00 # B4558 $5.00 #

B4534 $12.00 # # B4559 $12.00 # # B4534 $5.00 # B4559 $5.00 #

B4535 NADA # # B4560 $15.00 # # B4535 $7.00 # B4560 $5.00 #

B4536 $15.00 # # B4561 $15.00 # # B4536 $5.00 # B4561 $5.00 #

B4537 $15.00 # # B4562 $15.00 # # B4537 $5.00 # B4562 $5.00 #

B4538 $15.00 # # B4563 $12.00 # # B4538 $5.00 # B4563 $5.00 #

B4539 $15.00 # # B4564 $12.00 # # B4539 $5.00 # B4564 $5.00 #

B4540 $15.00 # # B4565 $15.00 # # B4540 $5.00 # B4565 $5.00 #

B4541 $12.00 # # B4566 $12.00 # # B4541 $5.00 # B4566 $5.00 #

B4542 $12.00 # # B4567 $12.00 # # B4542 $5.00 # B4567 $5.00 #

B4543 $10.00 # # B4568 $12.00 # # B4543 $5.00 # B4568 $5.00 #

B4544 $12.00 # # B4569 $12.00 # # B4544 $5.00 # B4569 $5.00 #

B4545 $15.00 # # B4570 $12.00 # # B4545 $5.00 # B4570 $5.00 #

B4546 $15.00 # # B4571 $12.00 # # B4546 $5.00 # B4571 $5.00 #

B4547 $8.00 # # B4572 $15.00 # # B4547 $8.00 # B4572 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

127 08/13/2015

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CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B4573 $15.00 # # B4598 $12.00 # # B4573 $5.00 # B4598 $5.00 #

B4574 $15.00 # # B4599 $12.00 # # B4574 $5.00 # B4599 $5.00 #

B4575 $12.00 # # B4600 $12.00 # # B4575 $5.00 # B4600 $5.00 #

B4576 $12.00 # # B4601 $12.00 # # B4576 $5.00 # B4601 $5.00 #

B4577 $12.00 # # B4602 $17.00 # # B4577 $5.00 # B4602 $5.00 #

B4578 $12.00 # # B4603 $15.00 # # B4578 $5.00 # B4603 $5.00 #

B4579 $12.00 # # B4604 $12.00 # # B4579 $5.00 # B4604 $5.00 #

B4580 $15.00 # # B4605 $15.00 # # B4580 $5.00 # B4605 $5.00 #

B4581 $12.00 # # B4606 $15.00 # # B4581 $5.00 # B4606 $5.00 #

B4582 $10.00 # # B4607 $15.00 # # B4582 $5.00 # B4607 $5.00 #

B4583 $12.00 # # B4608 $12.00 # # B4583 $5.00 # B4608 $5.00 #

B4584 $15.00 # # B4609 $15.00 # # B4584 $5.00 # B4609 $5.00 #

B4585 $15.00 # # B4610 $15.00 # # B4585 $5.00 # B4610 $5.00 #

B4586 $15.00 # # B4611 $15.00 # # B4586 $5.00 # B4611 $5.00 #

B4587 $12.00 # # B4612 $12.00 # # B4587 $5.00 # B4612 $5.00 #

B4588 $12.00 # # B4613 $12.00 # # B4588 $5.00 # B4613 $5.00 #

B4589 $12.00 # # B4614 $15.00 # # B4589 $5.00 # B4614 $5.00 #

B4590 $12.00 # # B4615 $15.00 # # B4590 $5.00 # B4615 $5.00 #

B4591 $12.00 # # B4616 $15.00 # # B4591 $5.00 # B4616 $5.00 #

B4592 $15.00 # # B4617 $15.00 # # B4592 $5.00 # B4617 $5.00 #

B4593 $15.00 # # B4618 $15.00 # # B4593 $5.00 # B4618 $5.00 #

B4594 $15.00 # # B4619 $15.00 # # B4594 $5.00 # B4619 $5.00 #

B4595 $15.00 # # B4620 $10.00 # # B4595 $5.00 # B4620 $5.00 #

B4596 $15.00 # # B4621 $15.00 # # B4596 $5.00 # B4621 $5.00 #

B4597 $15.00 # # B4622 $15.00 # # B4597 $5.00 # B4622 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

128 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B4623 $15.00 # # B4648 $15.00 # # B4623 $5.00 # B4648 $5.00 #

B4624 $15.00 # # B4649 $12.00 # # B4624 $5.00 # B4649 $5.00 #

B4625 $15.00 # # B4650 $10.00 # # B4625 $5.00 # B4650 $5.00 #

B4626 $10.00 # # B4651 $10.00 # # B4626 $5.00 # B4651 $5.00 #

B4627 $15.00 # # B4652 $15.00 # # B4627 $5.00 # B4652 $5.00 #

B4628 $15.00 # # B4653 $15.00 # # B4628 $5.00 # B4653 $5.00 #

B4629 $15.00 # # B4654 $15.00 # # B4629 $5.00 # B4654 $5.00 #

B4630 $15.00 # # B4655 $15.00 # # B4630 $5.00 # B4655 $5.00 #

B4631 $15.00 # # B4656 $15.00 # # B4631 $5.00 # B4656 $5.00 #

B4632 $15.00 # # B4657 $15.00 # # B4632 $5.00 # B4657 $5.00 #

B4633 $15.00 # # B4658 $15.00 # # B4633 $5.00 # B4658 $5.00 #

B4634 $15.00 # # B4659 $10.00 # # B4634 $5.00 # B4659 $5.00 #

B4635 $10.00 # # B4660 $15.00 # # B4635 $5.00 # B4660 $5.00 #

B4636 $12.00 # # B4661 $10.00 # # B4636 $5.00 # B4661 $5.00 #

B4637 $15.00 # # B4662 $15.00 # # B4637 $5.00 # B4662 $5.00 #

B4638 $15.00 # # B4663 $12.00 # # B4638 $5.00 # B4663 $5.00 #

B4639 $15.00 # # B4664 $15.00 # # B4639 $5.00 # B4664 $5.00 #

B4640 $15.00 # # B4665 $12.00 # # B4640 $5.00 # B4665 $5.00 #

B4641 $15.00 # # B4666 $15.00 # # B4641 $5.00 # B4666 $5.00 #

B4642 $15.00 # # B4667 $15.00 # # B4642 $5.00 # B4667 $5.00 #

B4643 $15.00 # # B4668 $15.00 # # B4643 $7.00 # B4668 $5.00 #

B4644 $15.00 # # B4669 $15.00 # # B4644 $5.00 # B4669 $5.00 #

B4645 $12.00 # # B4670 $15.00 # # B4645 $5.00 # B4670 $5.00 #

B4646 $20.00 # # B4671 $15.00 # # B4646 $5.00 # B4671 $5.00 #

B4647 $10.00 # # B4672 $15.00 # # B4647 $5.00 # B4672 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

129 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B4673 $10.00 # # B4698 $10.00 # # B4673 $5.00 # B4698 $10.00 #

B4674 $15.00 # # B4699 $15.00 # # B4674 $5.00 # B4699 $15.00 #

B4675 $15.00 # # B4700 $10.00 # # B4675 $5.00 # B4700 $10.00 #

B4676 $10.00 # # B4701 $10.00 # # B4676 $5.00 # B4701 $10.00 #

B4677 $15.00 # # B4702 $15.00 # # B4677 $15.00 # B4702 $5.00 #

B4678 $15.00 # # B4703 $15.00 # # B4678 $5.00 # B4703 $5.00 #

B4679 $15.00 # # B4704 $18.00 # # B4679 $5.00 # B4704 $5.00 #

B4680 $15.00 # # B4705 $15.00 # # B4680 $5.00 # B4705 $15.00 #

B4681 $10.00 # # B4706 $15.00 # # B4681 $5.00 # B4706 $5.00 #

B4682 $15.00 # # B4707 $15.00 # # B4682 $5.00 # B4707 $15.00 #

B4683 $15.00 # # B4708 $15.00 # # B4683 $5.00 # B4708 $5.00 #

B4684 $15.00 # # B4709 $15.00 # # B4684 $5.00 # B4709 $5.00 #

B4685 $15.00 # # B4710 $15.00 # # B4685 $5.00 # B4710 $5.00 #

B4686 $15.00 # # B4711 $10.00 # # B4686 $5.00 # B4711 $10.00 #

B4687 $15.00 # # B4712 $12.00 # # B4687 $15.00 # B4712 $5.00 #

B4688 $15.00 # # B4713 $12.00 # # B4688 $5.00 # B4713 $5.00 #

B4689 $15.00 # # B4714 $15.00 # # B4689 $5.00 # B4714 $5.00 #

B4690 $15.00 # # B4715 $15.00 # # B4690 $5.00 # B4715 $5.00 #

B4691 $3.00 # # B4716 $15.00 # # B4691 $5.00 # B4716 $5.00 #

B4692 $15.00 # # B4717 $15.00 # # B4692 $5.00 # B4717 $5.00 #

B4693 $10.00 # # B4718 $15.00 # # B4693 $10.00 # B4718 $5.00 #

B4694 $15.00 # # B4719 $10.00 # # B4694 $15.00 # B4719 $5.00 #

B4695 $10.00 # # B4720 $15.00 # # B4695 $10.00 # B4720 $15.00 #

B4696 $12.00 # # B4721 $15.00 # # B4696 $5.00 # B4721 $5.00 #

B4697 $15.00 # # B4722 $10.00 # # B4697 $15.00 # B4722 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B4723 $12.00 # # B4748 $15.00 # # B4723 $5.00 # B4748 $5.00 #

B4724 $7.00 # # B4749 $10.00 # # B4724 NADA # B4749 $5.00 #

B4725 $12.00 # # B4750 $12.00 # # B4725 NADA # B4750 $12.00 #

B4726 $12.00 # # B4751 $15.00 # # B4726 NADA # B4751 $15.00 #

B4727 $10.00 # # B4752 $15.00 # # B4727 $5.00 # B4752 $15.00 #

B4728 $10.00 # # B4753 $10.00 # # B4728 $5.00 # B4753 $5.00 #

B4729 $15.00 # # B4754 $15.00 # # B4729 $5.00 # B4754 $5.00 #

B4730 $15.00 # # B4755 $15.00 # # B4730 $5.00 # B4755 $5.00 #

B4731 $12.00 # # B4756 $15.00 # # B4731 $5.00 # B4756 $5.00 #

B4732 $15.00 # # B4757 $15.00 # # B4732 $5.00 # B4757 $5.00 #

B4733 $15.00 # # B4758 $15.00 # # B4733 $5.00 # B4758 $5.00 #

B4734 $15.00 # # B4759 $15.00 # # B4734 $5.00 # B4759 $5.00 #

B4735 $12.00 # # B4760 $15.00 # # B4735 $5.00 # B4760 $5.00 #

B4736 $15.00 # # B4761 $15.00 # # B4736 $5.00 # B4761 $5.00 #

B4737 $12.00 # # B4762 $10.00 # # B4737 $5.00 # B4762 $5.00 #

B4738 $15.00 # # B4763 $15.00 # # B4738 $7.00 # B4763 $5.00 #

B4739 $15.00 # # B4764 $10.00 # # B4739 $5.00 # B4764 $5.00 #

B4740 $10.00 # # B4765 $15.00 # # B4740 $5.00 # B4765 $5.00 #

B4741 $12.00 # # B4766 $15.00 # # B4741 $5.00 # B4766 $5.00 #

B4742 $15.00 # # B4767 $15.00 # # B4742 $5.00 # B4767 $5.00 #

B4743 $12.00 # # B4768 $15.00 # # B4743 $5.00 # B4768 $5.00 #

B4744 $10.00 # # B4769 $10.00 # # B4744 $5.00 # B4769 $5.00 #

B4745 $15.00 # # B4770 $15.00 # # B4745 $5.00 # B4770 $5.00 #

B4746 $15.00 # # B4771 $12.00 # # B4746 $5.00 # B4771 $5.00 #

B4747 $15.00 # # B4772 $15.00 # # B4747 $5.00 # B4772 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

131 08/13/2015

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CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B4773 $15.00 # # B4798 $15.00 # # B4773 $5.00 # B4798 $7.00 #

B4774 $15.00 # # B4799 $15.00 # # B4774 $5.00 # B4799 $5.00 #

B4775 $15.00 # # B4800 $15.00 # # B4775 $5.00 # B4800 $15.00 #

B4776 $12.00 # # B4801 $15.00 # # B4776 $5.00 # B4801 $5.00 #

B4777 $15.00 # # B4802 $15.00 # # B4777 $5.00 # B4802 $5.00 #

B4778 $15.00 # # B4803 $18.00 # # B4778 $15.00 # B4803 $5.00 #

B4779 $10.00 # # B4804 $10.00 # # B4779 $5.00 # B4804 $10.00 #

B4780 $15.00 # # B4805 $15.00 # # B4780 $5.00 # B4805 $5.00 #

B4781 $15.00 # # B4806 $15.00 # # B4781 $5.00 # B4806 $5.00 #

B4782 $15.00 # # B4807 $10.00 # # B4782 $5.00 # B4807 $5.00 #

B4783 $15.00 # # B4808 $15.00 # # B4783 $5.00 # B4808 $5.00 #

B4784 $12.00 # # B4809 $8.00 # # B4784 $5.00 # B4809 $5.00 #

B4785 $10.00 # # B4810 $12.00 # # B4785 $5.00 # B4810 $12.00 #

B4786 $15.00 # # B4811 $15.00 # # B4786 $5.00 # B4811 $15.00 #

B4787 $10.00 # # B4812 $15.00 # # B4787 $5.00 # B4812 $5.00 #

B4788 $15.00 # # B4813 $15.00 # # B4788 $5.00 # B4813 $5.00 #

B4789 $15.00 # # B4814 $15.00 # # B4789 $5.00 # B4814 $5.00 #

B4790 $15.00 # # B4815 $15.00 # # B4790 $5.00 # B4815 $5.00 #

B4791 $10.00 # # B4816 $15.00 # # B4791 $5.00 # B4816 $5.00 #

B4792 $15.00 # # B4817 $12.00 # # B4792 $5.00 # B4817 $5.00 #

B4793 NADA # # B4818 $15.00 # # B4793 $5.00 # B4818 $5.00 #

B4794 $15.00 # # B4819 $15.00 # # B4794 $5.00 # B4819 $5.00 #

B4795 NADA # # B4820 $15.00 # # B4795 $5.00 # B4820 $5.00 #

B4796 NADA # # B4821 $15.00 # # B4796 $5.00 # B4821 $5.00 #

B4797 $15.00 # # B4822 $15.00 # # B4797 $5.00 # B4822 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B4823 $12.00 # # B4848 $12.00 # # B4823 $5.00 # B4848 $12.00 #

B4824 $10.00 # # B4849 $12.00 # # B4824 $5.00 # B4849 $12.00 #

B4825 $15.00 # # B4850 $15.00 # # B4825 $5.00 # B4850 $5.00 #

B4826 $15.00 # # B4851 $15.00 # # B4826 $5.00 # B4851 $5.00 #

B4827 $12.00 # # B4852 $15.00 # # B4827 $5.00 # B4852 $5.00 #

B4828 $15.00 # # B4853 $15.00 # # B4828 $7.00 # B4853 $5.00 #

B4829 $15.00 # # B4854 $12.00 # # B4829 $5.00 # B4854 $5.00 #

B4830 $15.00 # # B4855 $15.00 # # B4830 $5.00 # B4855 $5.00 #

B4831 $12.00 # # B4856 $15.00 # # B4831 $5.00 # B4856 $5.00 #

B4832 $15.00 # # B4857 $18.00 # # B4832 $5.00 # B4857 $5.00 #

B4833 $10.00 # # B4858 $18.00 # # B4833 $5.00 # B4858 $5.00 #

B4834 $15.00 # # B4859 $15.00 # # B4834 $5.00 # B4859 $5.00 #

B4835 $10.00 # # B4860 NADA # # B4835 $5.00 # B4860 $7.00 #

B4836 $15.00 # # B4861 $15.00 # # B4836 $5.00 # B4861 $5.00 #

B4837 NADA # # B4862 $10.00 # # B4837 NADA # B4862 $5.00 #

B4838 NADA # # B4863 $12.00 # # B4838 NADA # B4863 $5.00 #

B4839 $15.00 # # B4864 $12.00 # # B4839 $15.00 # B4864 $12.00 #

B4840 $12.00 # # B4865 $10.00 # # B4840 $5.00 # B4865 $5.00 #

B4841 $15.00 # # B4866 $10.00 # # B4841 $5.00 # B4866 $5.00 #

B4842 $12.00 # # B4867 $10.00 # # B4842 $5.00 # B4867 $5.00 #

B4843 $12.00 # # B4868 $15.00 # # B4843 $5.00 # B4868 $15.00 #

B4844 $15.00 # # B4869 $12.00 # # B4844 $5.00 # B4869 $5.00 #

B4845 $20.00 # # B4870 NADA # # B4845 $15.00 # B4870 $5.00 #

B4846 $15.00 # # B4871 $15.00 # # B4846 $5.00 # B4871 $15.00 #

B4847 $15.00 # # B4872 $20.00 # # B4847 $15.00 # B4872 $15.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B4873 $20.00 # # B4898 $10.00 # # B4873 $15.00 # B4898 $10.00 #

B4874 $12.00 # # B4899 $12.00 # # B4874 $5.00 # B4899 $12.00 #

B4875 $20.00 # # B4900 $20.00 # # B4875 $5.00 # B4900 $5.00 #

B4876 $20.00 # # B4901 $15.00 # # B4876 $5.00 # B4901 $5.00 #

B4877 $12.00 # # B4902 $10.00 # # B4877 $12.00 # B4902 $5.00 #

B4878 $10.00 # # B4903 $15.00 # # B4878 $5.00 # B4903 $5.00 #

B4879 $10.00 # # B4904 $10.00 # # B4879 $5.00 # B4904 $18.00 #

B4880 $12.00 # # B4905 $15.00 # # B4880 $5.00 # B4905 $5.00 #

B4881 $10.00 # # B4906 $15.00 # # B4881 $5.00 # B4906 $5.00 #

B4882 $15.00 # # B4907 $15.00 # # B4882 $5.00 # B4907 $5.00 #

B4883 $15.00 # # B4908 $15.00 # # B4883 $5.00 # B4908 $5.00 #

B4884 $15.00 # # B4909 $15.00 # # B4884 $5.00 # B4909 $5.00 #

B4885 $15.00 # # B4910 $15.00 # # B4885 $5.00 # B4910 $5.00 #

B4886 $15.00 # # B4911 $12.00 # # B4886 $7.00 # B4911 $12.00 #

B4887 $15.00 # # B4912 $10.00 # # B4887 $5.00 # B4912 $5.00 #

B4888 $15.00 # # B4913 $15.00 # # B4888 $5.00 # B4913 $5.00 #

B4889 $15.00 # # B4914 $15.00 # # B4889 $5.00 # B4914 $5.00 #

B4890 $15.00 # # B4915 $15.00 # # B4890 $5.00 # B4915 $5.00 #

B4891 $15.00 # # B4916 $15.00 # # B4891 $5.00 # B4916 $5.00 #

B4892 $12.00 # # B4917 $15.00 # # B4892 $5.00 # B4917 $5.00 #

B4893 $15.00 # # B4918 $15.00 # # B4893 $5.00 # B4918 $5.00 #

B4894 $10.00 # # B4919 $15.00 # # B4894 $5.00 # B4919 $5.00 #

B4895 $15.00 # # B4920 $18.00 # # B4895 $5.00 # B4920 $5.00 #

B4896 $15.00 # # B4921 $5.00 # # B4896 $5.00 # B4921 $5.00 #

B4897 $15.00 # # B4922 $15.00 # # B4897 $5.00 # B4922 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

134 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B4923 $15.00 # # B4948 $15.00 # # B4923 $5.00 # B4948 $5.00 #

B4924 $15.00 # # B4949 $15.00 # # B4924 $5.00 # B4949 $5.00 #

B4925 $15.00 # # B4950 $12.00 # # B4925 $5.00 # B4950 $5.00 #

B4926 $15.00 # # B4951 $10.00 # # B4926 $5.00 # B4951 $5.00 #

B4927 $15.00 # # B4952 $15.00 # # B4927 $5.00 # B4952 $5.00 #

B4928 $15.00 # # B4953 $12.00 # # B4928 $5.00 # B4953 $5.00 #

B4929 $12.00 # # B4954 $15.00 # # B4929 $5.00 # B4954 $5.00 #

B4930 $10.00 # # B4955 $15.00 # # B4930 $5.00 # B4955 $5.00 #

B4931 $15.00 # # B4956 $15.00 # # B4931 $5.00 # B4956 $5.00 #

B4932 $15.00 # # B4957 $15.00 # # B4932 $5.00 # B4957 $5.00 #

B4933 $10.00 # # B4958 $15.00 # # B4933 $5.00 # B4958 $5.00 #

B4934 $10.00 # # B4959 $15.00 # # B4934 $10.00 # B4959 $5.00 #

B4935 $20.00 # # B4960 $15.00 # # B4935 $10.00 # B4960 $5.00 #

B4936 $20.00 # # B4961 $15.00 # # B4936 $10.00 # B4961 $5.00 #

B4937 $20.00 # # B4962 $7.00 # # B4937 $5.00 # B4962 $7.00 #

B4938 $15.00 # # B4963 $7.00 # # B4938 $5.00 # B4963 $7.00 #

B4939 $15.00 # # B4964 $15.00 # # B4939 $5.00 # B4964 $5.00 #

B4940 $12.00 # # B4965 $15.00 # # B4940 $12.00 # B4965 $5.00 #

B4941 $15.00 # # B4966 $20.00 # # B4941 $5.00 # B4966 $5.00 #

B4942 $12.00 # # B4967 $15.00 # # B4942 $12.00 # B4967 $5.00 #

B4943 $15.00 # # B4968 $18.00 # # B4943 $5.00 # B4968 $5.00 #

B4944 $15.00 # # B4969 $15.00 # # B4944 $5.00 # B4969 $5.00 #

B4945 $15.00 # # B4970 $15.00 # # B4945 $5.00 # B4970 $5.00 #

B4946 $15.00 # # B4971 $18.00 # # B4946 $5.00 # B4971 $5.00 #

B4947 $15.00 # # B4972 $18.00 # # B4947 $5.00 # B4972 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

135 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B4973 $10.00 # # B4998 $12.00 # # B4973 $5.00 # B4998 $15.00 #

B4974 $12.00 # # B4999 $12.00 # # B4974 $5.00 # B4999 $5.00 #

B4975 $15.00 # # B5000 $12.00 # # B4975 $5.00 # B5000 $5.00 #

B4976 $12.00 # # B5001 $18.00 # # B4976 $5.00 # B5001 $5.00 #

B4977 $15.00 # # B5002 $12.00 # # B4977 $5.00 # B5002 $5.00 #

B4978 $15.00 # # B5003 $10.00 # # B4978 $5.00 # B5003 $5.00 #

B4979 $12.00 # # B5004 $15.00 # # B4979 $5.00 # B5004 $5.00 #

B4980 $15.00 # # B5005 $15.00 # # B4980 $5.00 # B5005 $5.00 #

B4981 $15.00 # # B5006 $15.00 # # B4981 $5.00 # B5006 $15.00 #

B4982 $10.00 # # B5007 $12.00 # # B4982 $5.00 # B5007 $12.00 #

B4983 $15.00 # # B5008 $15.00 # # B4983 $5.00 # B5008 $5.00 #

B4984 $15.00 # # B5009 $12.00 # # B4984 $5.00 # B5009 $5.00 #

B4985 $15.00 # # B5010 $15.00 # # B4985 $5.00 # B5010 $5.00 #

B4986 $7.00 # # B5011 $15.00 # # B4986 $5.00 # B5011 $5.00 #

B4987 $15.00 # # B5012 $15.00 # # B4987 $5.00 # B5012 $15.00 #

B4988 $15.00 # # B5013 $15.00 # # B4988 $5.00 # B5013 $5.00 #

B4989 $15.00 # # B5014 $12.00 # # B4989 $5.00 # B5014 $5.00 #

B4990 $10.00 # # B5015 $7.00 # # B4990 $5.00 # B5015 $5.00 #

B4991 $12.00 # # B5016 $15.00 # # B4991 $6.50 # B5016 $5.00 #

B4992 $18.00 # # B5017 $15.00 # # B4992 $5.00 # B5017 $5.00 #

B4993 $15.00 # # B5018 $10.00 # # B4993 $5.00 # B5018 $5.00 #

B4994 $15.00 # # B5019 $15.00 # # B4994 $5.00 # B5019 $15.00 #

B4995 $15.00 # # B5020 $15.00 # # B4995 $5.00 # B5020 $5.00 #

B4996 $7.00 # # B5021 $15.00 # # B4996 $5.00 # B5021 $5.00 #

B4997 $12.00 # # B5022 $10.00 # # B4997 $15.00 # B5022 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B5023 $15.00 # # B5048 $15.00 # # B5023 $5.00 # B5048 $5.00 #

B5024 $5.00 # # B5049 $15.00 # # B5024 $5.00 # B5049 $5.00 #

B5025 $12.00 # # B5050 $12.00 # # B5025 $5.00 # B5050 $5.00 #

B5026 $15.00 # # B5051 $15.00 # # B5026 $5.00 # B5051 $5.00 #

B5027 $18.00 # # B5052 $15.00 # # B5027 $5.00 # B5052 $5.00 #

B5028 $15.00 # # B5053 $15.00 # # B5028 $5.00 # B5053 $5.00 #

B5029 $15.00 # # B5054 $12.00 # # B5029 $5.00 # B5054 $5.00 #

B5030 $15.00 # # B5055 $12.00 # # B5030 $5.00 # B5055 $5.00 #

B5031 $10.00 # # B5056 $15.00 # # B5031 $10.00 # B5056 $5.00 #

B5032 $15.00 # # B5057 $18.00 # # B5032 $5.00 # B5057 $5.00 #

B5033 $10.00 # # B5058 $12.00 # # B5033 $5.00 # B5058 $12.00 #

B5034 $18.00 # # B5059 $15.00 # # B5034 $5.00 # B5059 $5.00 #

B5035 $15.00 # # B5060 $12.00 # # B5035 $5.00 # B5060 $12.00 #

B5036 $10.00 # # B5061 $15.00 # # B5036 $5.00 # B5061 $5.00 #

B5037 $10.00 # # B5062 $10.00 # # B5037 $5.00 # B5062 $5.00 #

B5038 $15.00 # # B5063 $20.00 # # B5038 $12.00 # B5063 $5.00 #

B5039 $15.00 # # B5064 $15.00 # # B5039 $5.00 # B5064 $5.00 #

B5040 $15.00 # # B5065 $15.00 # # B5040 $5.00 # B5065 $5.00 #

B5041 $15.00 # # B5066 $15.00 # # B5041 $5.00 # B5066 $5.00 #

B5042 $15.00 # # B5067 $15.00 # # B5042 $5.00 # B5067 $5.00 #

B5043 $15.00 # # B5068 $15.00 # # B5043 $5.00 # B5068 $5.00 #

B5044 $15.00 # # B5069 $20.00 # # B5044 $5.00 # B5069 $5.00 #

B5045 $10.00 # # B5070 $15.00 # # B5045 $5.00 # B5070 $5.00 #

B5046 $15.00 # # B5071 $15.00 # # B5046 $5.00 # B5071 $5.00 #

B5047 $15.00 # # B5072 $15.00 # # B5047 $5.00 # B5072 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

137 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B5073 $15.00 # # B5098 $10.00 # # B5073 $5.00 # B5098 $5.00 #

B5074 $15.00 # # B5099 $12.00 # # B5074 $15.00 # B5099 $5.00 #

B5075 $15.00 # # B5100 $15.00 # # B5075 $7.00 # B5100 $5.00 #

B5076 $15.00 # # B5101 $12.00 # # B5076 $5.00 # B5101 $5.00 #

B5077 NADA # # B5102 $12.00 # # B5077 $7.00 # B5102 $5.00 #

B5078 $15.00 # # B5103 $15.00 # # B5078 $5.00 # B5103 $15.00 #

B5079 $15.00 # # B5104 NADA # # B5079 $5.00 # B5104 NADA #

B5080 $10.00 # # B5105 $12.00 # # B5080 $5.00 # B5105 $5.00 #

B5081 $15.00 # # B5106 $15.00 # # B5081 $5.00 # B5106 $5.00 #

B5082 $12.00 # # B5107 $10.00 # # B5082 $5.00 # B5107 $10.00 #

B5083 $15.00 # # B5108 $15.00 # # B5083 $5.00 # B5108 $5.00 #

B5084 $10.00 # # B5109 $15.00 # # B5084 $5.00 # B5109 $5.00 #

B5085 $15.00 # # B5110 $15.00 # # B5085 $5.00 # B5110 $5.00 #

B5086 $15.00 # # B5111 $20.00 # # B5086 $15.00 # B5111 $5.00 #

B5087 $10.00 # # B5112 $15.00 # # B5087 $10.00 # B5112 $5.00 #

B5088 $10.00 # # B5113 $15.00 # # B5088 $5.00 # B5113 $5.00 #

B5089 $10.00 # # B5114 $15.00 # # B5089 $5.00 # B5114 $5.00 #

B5090 $10.00 # # B5115 $15.00 # # B5090 $5.00 # B5115 $5.00 #

B5091 $15.00 # # B5116 $15.00 # # B5091 $5.00 # B5116 $5.00 #

B5092 $15.00 # # B5117 $12.00 # # B5092 $5.00 # B5117 $5.00 #

B5093 $15.00 # # B5118 $15.00 # # B5093 $15.00 # B5118 $5.00 #

B5094 $10.00 # # B5119 $10.00 # # B5094 $10.00 # B5119 $5.00 #

B5095 $15.00 # # B5120 $15.00 # # B5095 $5.00 # B5120 $5.00 #

B5096 $15.00 # # B5121 $15.00 # # B5096 $5.00 # B5121 $5.00 #

B5097 $15.00 # # B5122 $12.00 # # B5097 $15.00 # B5122 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B5123 $15.00 # # B5147 $18.00 # # B5123 $5.00 # B5147 $5.00 #

B5124 $10.00 # # B5148 $12.00 # # B5124 $5.00 # B5148 $5.00 #

B5125 $15.00 # # B5149 $15.00 # # B5125 $5.00 # B5149 $5.00 #

B5125 $15.00 # # B5150 $12.00 # # B5125 $5.00 # B5150 $5.00 #

B5126 $10.00 # # B5151 $15.00 # # B5126 $5.00 # B5151 $15.00 #

B5127 $15.00 # # B5152 $10.00 # # B5127 $5.00 # B5152 $5.00 #

B5128 $10.00 # # B5153 $12.00 # # B5128 $5.00 # B5153 $5.00 #

B5129 $15.00 # # B5154 $15.00 # # B5129 $5.00 # B5154 $5.00 #

B5130 $10.00 # # B5155 $10.00 # # B5130 $5.00 # B5155 $5.00 #

B5131 $10.00 # # B5156 $10.00 # # B5131 $5.00 # B5156 $5.00 #

B5132 $15.00 # # B5157 $10.00 # # B5132 $20.00 # B5157 $5.00 #

B5133 $15.00 # # B5158 $15.00 # # B5133 $5.00 # B5158 $5.00 #

B5134 $15.00 # # B5159 $15.00 # # B5134 $5.00 # B5159 $5.00 #

B5135 $10.00 # # B5160 $15.00 # # B5135 $5.00 # B5160 $5.00 #

B5136 $15.00 # # B5161 $15.00 # # B5136 $5.00 # B5161 $5.00 #

B5137 $15.00 # # B5162 $15.00 # # B5137 $5.00 # B5162 $5.00 #

B5138 $10.00 # # B5163 $10.00 # # B5138 $5.00 # B5163 $15.00 #

B5139 $10.00 # # B5164 $10.00 # # B5139 $5.00 # B5164 $15.00 #

B5140 $12.00 # # B5165 $8.00 # # B5140 $12.00 # B5165 $8.00 #

B5141 $15.00 # # B5166 $15.00 # # B5141 $5.00 # B5166 $5.00 #

B5142 $15.00 # # B5167 $8.00 # # B5142 $5.00 # B5167 $12.00 #

B5143 $15.00 # # B5168 $15.00 # # B5143 $5.00 # B5168 $5.00 #

B5144 $18.00 # # B5169 $15.00 # # B5144 $5.00 # B5169 $5.00 #

B5145 $15.00 # # B5170 $12.00 # # B5145 $5.00 # B5170 $5.00 #

B5146 $15.00 # # B5171 $10.00 # # B5146 $5.00 # B5171 $15.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

139 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B5172 $12.00 # # B5197 $15.00 # # B5172 $5.00 # B5197 $5.00 #

B5173 $12.00 # # B5198 $15.00 # # B5173 $5.00 # B5198 $5.00 #

B5174 $15.00 # # B5199 $15.00 # # B5174 $5.00 # B5199 $5.00 #

B5175 $15.00 # # B5200 $15.00 # # B5175 $5.00 # B5200 $5.00 #

B5176 $10.00 # # B5201 NADA # # B5176 $5.00 # B5201 NADA #

B5177 $15.00 # # B5202 NADA # # B5177 $5.00 # B5202 NADA #

B5178 $15.00 # # B5203 $10.00 # # B5178 $5.00 # B5203 $7.00 #

B5179 $18.00 # # B5204 $15.00 # # B5179 $5.00 # B5204 $5.00 #

B5180 $15.00 # # B5205 $20.00 # # B5180 $5.00 # B5205 $5.00 #

B5181 $10.00 # # B5206 $7.00 # # B5181 $5.00 # B5206 $7.00 #

B5182 $18.00 # # B5207 $10.00 # # B5182 $5.00 # B5207 $7.00 #

B5183 $18.00 # # B5208 $15.00 # # B5183 $5.00 # B5208 $5.00 #

B5184 $15.00 # # B5209 $15.00 # # B5184 $5.00 # B5209 $5.00 #

B5185 $15.00 # # B5210 $15.00 # # B5185 $5.00 # B5210 $5.00 #

B5186 $15.00 # # B5211 $12.00 # # B5186 $5.00 # B5211 $5.00 #

B5187 $10.00 # # B5212 $8.00 # # B5187 $5.00 # B5212 $5.00 #

B5188 $15.00 # # B5213 $15.00 # # B5188 $5.00 # B5213 $5.00 #

B5189 $10.00 # # B5214 $8.00 # # B5189 $5.00 # B5214 $5.00 #

B5190 $15.00 # # B5215 $10.00 # # B5190 $5.00 # B5215 $5.00 #

B5191 $15.00 # # B5216 $15.00 # # B5191 $5.00 # B5216 $5.00 #

B5192 $15.00 # # B5217 $15.00 # # B5192 $15.00 # B5217 $5.00 #

B5193 $10.00 # # B5218 $12.00 # # B5193 $5.00 # B5218 $5.00 #

B5194 $15.00 # # B5219 $5.00 # # B5194 $5.00 # B5219 $5.00 #

B5195 $18.00 # # B5220 $20.00 # # B5195 $5.00 # B5220 $5.00 #

B5196 $15.00 # # B5221 $12.00 # # B5196 $5.00 # B5221 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B5222 $15.00 # # B5247 $10.00 # # B5222 $5.00 # B5247 $5.00 #

B5223 $15.00 # # B5248 $10.00 # # B5223 $5.00 # B5248 $5.00 #

B5224 $15.00 # # B5249 $15.00 # # B5224 $5.00 # B5249 $5.00 #

B5225 $15.00 # # B5250 $15.00 # # B5225 $5.00 # B5250 $5.00 #

B5226 $12.00 # # B5251 $10.00 # # B5226 $12.00 # B5251 $5.00 #

B5227 $12.00 # # B5252 $18.00 # # B5227 $5.00 # B5252 $5.00 #

B5228 $15.00 # # B5253 $15.00 # # B5228 $5.00 # B5253 $5.00 #

B5229 $15.00 # # B5254 $12.00 # # B5229 $5.00 # B5254 $5.00 #

B5230 $15.00 # # B5255 $15.00 # # B5230 $5.00 # B5255 $15.00 #

B5231 $15.00 # # B5256 $15.00 # # B5231 $5.00 # B5256 $5.00 #

B5232 $15.00 # # B5257 $12.00 # # B5232 $5.00 # B5257 $5.00 #

B5233 $18.00 # # B5258 $15.00 # # B5233 $5.00 # B5258 $5.00 #

B5234 $15.00 # # B5259 $15.00 # # B5234 $5.00 # B5259 $5.00 #

B5235 $15.00 # # B5260 $20.00 # # B5235 $5.00 # B5260 $5.00 #

B5236 $12.00 # # B5261 $18.00 # # B5236 $12.00 # B5261 $7.00 #

B5237 $10.00 # # B5262 $12.00 # # B5237 $5.00 # B5262 $5.00 #

B5238 $10.00 # # B5263 $15.00 # # B5238 $5.00 # B5263 $5.00 #

B5239 $12.00 # # B5264 $15.00 # # B5239 $5.00 # B5264 $5.00 #

B5240 $10.00 # # B5265 $15.00 # # B5240 $5.00 # B5265 $5.00 #

B5241 $15.00 # # B5266 $15.00 # # B5241 $5.00 # B5266 $5.00 #

B5242 $15.00 # # B5267 $15.00 # # B5242 $5.00 # B5267 $5.00 #

B5243 $15.00 # # B5268 $15.00 # # B5243 $5.00 # B5268 $5.00 #

B5244 $15.00 # # B5269 $15.00 # # B5244 $7.00 # B5269 $5.00 #

B5245 $10.00 # # B5270 $15.00 # # B5245 $5.00 # B5270 $5.00 #

B5246 $10.00 # # B5271 NADA # # B5246 $5.00 # B5271 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

141 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B5272 NADA # # B5297 $15.00 # # B5272 $5.00 # B5297 $15.00 #

B5273 NADA # # B5298 $12.00 # # B5273 $5.00 # B5298 $12.00 #

B5274 NADA # # B5299 $15.00 # # B5274 $5.00 # B5299 $5.00 #

B5275 $15.00 # # B5300 $10.00 # # B5275 $5.00 # B5300 $10.00 #

B5276 $10.00 # # B5301 $10.00 # # B5276 $5.00 # B5301 $10.00 #

B5277 $15.00 # # B5302 $15.00 # # B5277 $5.00 # B5302 $5.00 #

B5278 $15.00 # # B5303 $20.00 # # B5278 $5.00 # B5303 $5.00 #

B5279 $15.00 # # B5304 $20.00 # # B5279 $5.00 # B5304 $5.00 #

B5280 $12.00 # # B5305 $15.00 # # B5280 $5.00 # B5305 $5.00 #

B5281 NADA # # B5306 $20.00 # # B5281 $5.00 # B5306 $5.00 #

B5282 $15.00 # # B5307 $20.00 # # B5282 $5.00 # B5307 $5.00 #

B5283 $15.00 # # B5308 $12.00 # # B5283 $5.00 # B5308 $12.00 #

B5284 $15.00 # # B5309 $15.00 # # B5284 $5.00 # B5309 $5.00 #

B5286 $15.00 # # B5310 $12.00 # # B5286 $5.00 # B5310 $5.00 #

B5287 $15.00 # # B5311 $15.00 # # B5287 $5.00 # B5311 $5.00 #

B5288 $15.00 # # B5312 $15.00 # # B5288 $5.00 # B5312 $5.00 #

B5289 $15.00 # # B5313 NADA # # B5289 $7.00 # B5313 NADA #

B5290 $8.00 # # B5314 $15.00 # # B5290 $5.00 # B5314 $15.00 #

B5291 $10.00 # # B5315 $15.00 # # B5291 $5.00 # B5315 $5.00 #

B5292 $12.00 # # B5316 $10.00 # # B5292 $12.00 # B5316 $5.00 #

B5293 $12.00 # # B5317 $15.00 # # B5293 $12.00 # B5317 $5.00 #

B5294 $10.00 # # B5318 $10.00 # # B5294 $5.00 # B5318 $5.00 #

B5295 $15.00 # # B5319 $12.00 # # B5295 $5.00 # B5319 $5.00 #

B5296 $12.00 # # B5320 $12.00 # # B5296 $12.00 # B5320 $5.00 #

B5286 $15.00 # # B5321 $12.00 # # B5286 $5.00 # B5321 $12.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

142 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B5322 $15.00 # # B5347 $10.00 # # B5322 $5.00 # B5347 NADA #

B5323 $15.00 # # B5348 $10.00 # # B5323 $5.00 # B5348 NADA #

B5324 $15.00 # # B5349 $10.00 # # B5324 $5.00 # B5349 NADA #

B5325 $8.00 # # B5350 $10.00 # # B5325 $5.00 # B5350 $10.00 #

B5326 $15.00 # # B5351 $10.00 # # B5326 $5.00 # B5351 NADA #

B5327 $2.00 # # B5352 $10.00 # # B5327 NADA # B5352 NADA #

B5328 $15.00 # # B5353 $10.00 # # B5328 $5.00 # B5353 NADA #

B5329 $12.00 # # B5354 $10.00 # # B5329 $5.00 # B5354 NADA #

B5330 $20.00 # # B5355 $10.00 # # B5330 $5.00 # B5355 $10.00 #

B5331 NADA # # B5356 $10.00 # # B5331 $5.00 # B5356 NADA #

B5332 $15.00 # # B5357 $10.00 # # B5332 $5.00 # B5357 NADA #

B5333 $15.00 # # B5358 $10.00 # # B5333 $5.00 # B5358 NADA #

B5334 $15.00 # # B5359 $10.00 # # B5334 $5.00 # B5359 NADA #

B5335 $12.00 # # B5360 $12.00 # # B5335 $12.00 # B5360 $12.00 #

B5336 $15.00 # # B5361 $15.00 # # B5336 $5.00 # B5361 $5.00 #

B5337 $12.00 # # B5362 $15.00 # # B5337 $12.00 # B5362 $5.00 #

B5338 $10.00 # # B5363 $10.00 # # B5338 $5.00 # B5363 $5.00 #

B5339 $15.00 # # B5364 $10.00 # # B5339 $5.00 # B5364 $5.00 #

B5340 $10.00 # # B5365 $10.00 # # B5340 $10.00 # B5365 $5.00 #

B5341 $18.00 # # B5366 $20.00 # # B5341 $5.00 # B5366 $5.00 #

B5342 $10.00 # # B5367 $20.00 # # B5342 NADA # B5367 $5.00 #

B5343 $10.00 # # B5368 $10.00 # # B5343 NADA # B5368 $5.00 #

B5344 $10.00 # # B5369 $15.00 # # B5344 $5.00 # B5369 NADA #

B5345 $10.00 # # B5370 $15.00 # # B5345 $10.00 # B5370 NADA #

B5346 $10.00 # # B5371 $15.00 # # B5346 NADA # B5371 NADA #

CÓDIGOS DE CUBIERTAS / COPAGOS

143 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B5372 $15.00 # # B5396 $15.00 # # B5372 $5.00 # B5396 $15.00 #

B5373 $15.00 # # B5397 $15.00 # # B5373 $5.00 # B5397 $15.00 #

B5374 $20.00 # # B5398 $5.00 # # B5374 $5.00 # B5398 $10.00 #

B5375 $20.00 # # B5399 $10.00 # # B5375 $5.00 # B5399 $10.00 #

B5376 $20.00 # # B5400 $15.00 # # B5376 $5.00 # B5400 $15.00 #

B5377 $15.00 # # B5401 $12.00 # # B5377 $5.00 # B5401 $12.00 #

B5378 $15.00 # # B5402 $15.00 # # B5378 $5.00 # B5402 $15.00 #

B5379 $15.00 # # B5403 $15.00 # # B5379 $5.00 # B5403 $15.00 #

B5380 $10.00 # # B5404 $15.00 # # B5380 $5.00 # B5404 $15.00 #

B5381 $12.00 # # B5405 $15.00 # # B5381 $5.00 # B5405 $15.00 #

B5382 $15.00 # # B5406 $15.00 # # B5382 $5.00 # B5406 $15.00 #

B5383 $10.00 # # B5407 $15.00 # # B5383 $5.00 # B5407 $15.00 #

B5384 $10.00 # # B5408 $15.00 # # B5384 $5.00 # B5408 $15.00 #

B5385 $15.00 # # B5409 $15.00 # # B5385 $5.00 # B5409 $15.00 #

B5386 $15.00 # # B5410 NADA # # B5386 $5.00 # B5410 NADA #

B5387 $15.00 # # B5411 $15.00 # # B5387 $5.00 # B5411 $15.00 #

B5388 $15.00 # # B5412 NADA # # B5388 $5.00 # B5412 NADA #

B5389 $15.00 # # B5413 $15.00 # # B5389 $5.00 # B5413 $15.00 #

B5390 $20.00 # # B5414 NADA # # B5390 $20.00 # B5414 NADA #

B5391 $10.00 # # B5415 $15.00 # # B5391 $10.00 # B5415 $15.00 #

B5392 $15.00 # # B5416 $17.00 # # B5392 $15.00 # B5416 $17.00 #

B5393 $12.00 # # B5417 $15.00 # # B5393 $12.00 # B5417 $15.00 #

B5394 $15.00 # # B5418 NADA # # B5394 $15.00 # B5418 $15.00 #

B5395 $10.00 # # B5419 NADA # # B5395 $10.00 # B5419 $15.00 #

B5390 $20.00 # # B5420 $10.00 # # B5390 $20.00 # B5420 $10.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

144 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B5421 $10.00 # # B5446 NADA # # B5421 $10.00 # B5446 NADA #

B5422 $10.00 # # B5447 $15.00 # # B5422 $10.00 # B5447 NADA #

B5423 $10.00 # # B5448 $15.00 # # B5423 $10.00 # B5448 NADA #

B5424 $10.00 # # B5449 $15.00 # # B5424 $10.00 # B5449 $15.00 #

B5425 $10.00 # # B5450 $15.00 # # B5425 $10.00 # B5450 $15.00 #

B5426 $15.00 # # B5451 $15.00 # # B5426 $15.00 # B5451 $15.00 #

B5427 $10.00 # # B5452 $15.00 # # B5427 $10.00 # B5452 $15.00 #

B5428 $12.00 # # B5453 $15.00 # # B5428 $12.00 # B5453 $15.00 #

B5429 $10.00 # # B5454 $15.00 # # B5429 $10.00 # B5454 $15.00 #

B5430 $15.00 # # B5455 $15.00 # # B5430 $15.00 # B5455 $15.00 #

B5431 NADA # # B5456 $15.00 # # B5431 $12.00 # B5456 $15.00 #

B5431 NADA # # B5457 $15.00 # # B5431 $12.00 # B5457 $15.00 #

B5432 NADA # # B5458 $15.00 # # B5432 NADA # B5458 $15.00 #

B5433 NADA # # B5459 $15.00 # # B5433 $12.00 # B5459 $15.00 #

B5434 $12.00 # # B5460 $12.00 # # B5434 $12.00 # B5460 $12.00 #

B5436 $15.00 # # B5461 $12.00 # # B5436 $15.00 # B5461 $12.00 #

B5437 $15.00 # # B5462 $15.00 # # B5437 $15.00 # B5462 $20.00 #

B5438 $15.00 # # B5463 $12.00 # # B5438 $15.00 # B5463 $12.00 #

B5439 $12.00 # # B5464 $15.00 # # B5439 $12.00 # B5464 $20.00 #

B5440 $15.00 # # B5465 $15.00 # # B5440 $15.00 # B5465 $15.00 #

B5441 NADA # # B5466 $15.00 # # B5441 $20.00 # B5466 $15.00 #

B5442 $15.00 # # B5467 $12.00 # # B5442 NADA # B5467 $12.00 #

B5443 $15.00 # # B5468 $15.00 # # B5443 $15.00 # B5468 $20.00 #

B5444 $12.00 # # B5469 $12.00 # # B5444 $12.00 # B5469 $12.00 #

B5445 NADA # # B5470 $12.00 # # B5445 NADA # B5470 $12.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

145 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B5471 $12.00 # # B5496 $12.00 # # B5471 $12.00 # B5496 $12.00 #

B5472 $15.00 # # B5497 $12.00 # # B5472 $15.00 # B5497 $12.00 #

B5473 $12.00 # # B5498 $12.00 # # B5473 $12.00 # B5498 $12.00 #

B5474 $12.00 # # B5499 $12.00 # # B5474 $12.00 # B5499 $12.00 #

B5475 $12.00 # # B5500 $15.00 # # B5475 $12.00 # B5500 $20.00 #

B5476 $2.00 # # B5501 $10.00 # # B5476 $2.00 # B5501 $10.00 #

B5477 $15.00 # # B5502 $7.00 # # B5477 $15.00 # B5502 $18.00 #

B5478 $15.00 # # B5503 $15.00 # # B5478 $15.00 # B5503 $15.00 #

B5479 $15.00 # # B5504 NADA # # B5479 $15.00 # B5504 NADA #

B5480 $12.00 # # B5505 NADA # # B5480 $12.00 # B5505 NADA #

B5481 $15.00 # # B5506 $15.00 # # B5481 $15.00 # B5506 $15.00 #

B5482 $15.00 # # B5507 NADA # # B5482 $15.00 # B5507 NADA #

B5483 $15.00 # # B5508 NADA # # B5483 $15.00 # B5508 NADA #

B5484 $15.00 # # B5509 $15.00 # # B5484 $15.00 # B5509 $15.00 #

B5485 $15.00 # # B5510 NADA # # B5485 $15.00 # B5510 NADA #

B5486 $18.00 # # B5511 NADA # # B5486 $18.00 # B5511 NADA #

B5487 $15.00 # # B5512 $12.00 # # B5487 $20.00 # B5512 $12.00 #

B5488 $12.00 # # B5513 $12.00 # # B5488 $12.00 # B5513 $12.00 #

B5489 $15.00 # # B5514 NADA # # B5489 $20.00 # B5514 NADA #

B5490 $15.00 # # B5515 NADA # # B5490 $15.00 # B5515 NADA #

B5491 $15.00 # # B5516 NADA # # B5491 $15.00 # B5516 NADA #

B5492 $15.00 # # B5517 $15.00 # # B5492 $15.00 # B5517 $15.00 #

B5493 $15.00 # # B5518 $15.00 # # B5493 $15.00 # B5518 $15.00 #

B5494 $15.00 # # B5519 NADA # # B5494 $15.00 # B5519 NADA #

B5495 $15.00 # # B5520 $12.00 # # B5495 $15.00 # B5520 $12.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

146 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B5521 NADA # # B5546 $15.00 # # B5521 NADA # B5546 $5.00 #

B5522 NADA # # B5547 $15.00 # # B5522 NADA # B5547 $5.00 #

B5523 NADA # # B5548 $15.00 # # B5523 NADA # B5548 $5.00 #

B5524 NADA # # B5549 $15.00 # # B5524 NADA # B5549 $5.00 #

B5525 $12.00 # # B5550 $15.00 # # B5525 $12.00 # B5550 $15.00 #

B5526 $15.00 # # B5551 $15.00 # # B5526 $15.00 # B5551 $15.00 #

B5527 $15.00 # # B5552 $12.00 # # B5527 $15.00 # B5552 $12.00 #

B5528 $15.00 # # B5553 $12.00 # # B5528 $15.00 # B5553 $12.00 #

B5529 NADA # # B5554 $15.00 # # B5529 $10.00 # B5554 $5.00 #

B5530 NADA # # B5555 $15.00 # # B5530 $10.00 # B5555 $5.00 #

B5531 NADA # # B5556 $15.00 # # B5531 NADA # B5556 $5.00 #

B5532 NADA # # B5557 $15.00 # # B5532 NADA # B5557 $5.00 #

B5533 NADA # # B5558 $15.00 # # B5533 NADA # B5558 $5.00 #

B5534 $15.00 # # B5559 $12.00 # # B5534 $15.00 # B5559 $12.00 #

B5535 $12.00 # # B5560 $15.00 # # B5535 $12.00 # B5560 $15.00 #

B5536 NADA # # B5561 $15.00 # # B5536 NADA # B5561 $5.00 #

B5537 $12.00 # # B5562 $10.00 # # B5537 $12.00 # B5562 $5.00 #

B5538 NADA # # B5563 $18.00 # # B5538 NADA # B5563 $5.00 #

B5539 $15.00 # # B5564 $15.00 # # B5539 $15.00 # B5564 $15.00 #

B5540 $15.00 # # B5565 $15.00 # # B5540 $15.00 # B5565 $15.00 #

B5541 $15.00 # # B5566 $18.00 # # B5541 $15.00 # B5566 $5.00 #

B5542 $15.00 # # B5567 $15.00 # # B5542 $15.00 # B5567 $5.00 #

B5543 $12.00 # # B5568 $15.00 # # B5543 $12.00 # B5568 $15.00 #

B5544 $10.00 # # B5569 $15.00 # # B5544 $10.00 # B5569 $5.00 #

B5545 $12.00 # # B5570 $18.00 # # B5545 $12.00 # B5570 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

147 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B5571 $18.00 # # B5596 $12.00 # # B5571 $5.00 # B5596 $5.00 #

B5572 $15.00 # # B5597 $10.00 # # B5572 $5.00 # B5597 $5.00 #

B5573 $10.00 # # B5598 $10.00 # # B5573 $10.00 # B5598 $10.00 #

B5574 $12.00 # # B5599 $10.00 # # B5574 $12.00 # B5599 $10.00 #

B5575 $12.00 # # B5600 $10.00 # # B5575 $5.00 # B5600 $10.00 #

B5576 $15.00 # # B5601 $12.00 # # B5576 $5.00 # B5601 $5.00 #

B5577 $12.00 # # B5602 $20.00 # # B5577 $12.00 # B5602 $5.00 #

B5578 $15.00 # # B5603 $20.00 # # B5578 $5.00 # B5603 $5.00 #

B5579 $18.00 # # B5604 $10.00 # # B5579 $5.00 # B5604 $5.00 #

B5580 $15.00 # # B5605 $12.00 # # B5580 $5.00 # B5605 $5.00 #

B5581 $18.00 # # B5606 $12.00 # # B5581 $7.00 # B5606 $12.00 #

B5582 $12.00 # # B5607 $12.00 # # B5582 $5.00 # B5607 $5.00 #

B5583 $12.00 # # B5608 $10.00 # # B5583 $5.00 # B5608 $5.00 #

B5584 $15.00 # # B5609 NADA # # B5584 $5.00 # B5609 $5.00 #

B5585 $15.00 # # B5610 $18.00 # # B5585 $5.00 # B5610 $5.00 #

B5586 $18.00 # # B5611 $15.00 # # B5586 $7.00 # B5611 $5.00 #

B5587 $12.00 # # B5612 $15.00 # # B5587 $12.00 # B5612 $5.00 #

B5588 $15.00 # # B5613 $18.00 # # B5588 $5.00 # B5613 $5.00 #

B5589 $15.00 # # B5614 $18.00 # # B5589 NADA # B5614 $5.00 #

B5590 NADA # # B5615 $15.00 # # B5590 NADA # B5615 $5.00 #

B5591 NADA # # B5616 $15.00 # # B5591 NADA # B5616 $5.00 #

B5592 $15.00 # # B5617 $18.00 # # B5592 NADA # B5617 $5.00 #

B5593 $15.00 # # B5618 $15.00 # # B5593 NADA # B5618 $5.00 #

B5594 $15.00 # # B5619 $15.00 # # B5594 NADA # B5619 $5.00 #

B5595 $15.00 # # B5620 $15.00 # # B5595 $5.00 # B5620 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

148 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B5621 $15.00 # # B5646 $15.00 # # B5621 $5.00 # B5646 $5.00 #

B5622 $15.00 # # B5647 $15.00 # # B5622 $5.00 # B5647 $10.00 #

B5623 $15.00 # # B5648 $15.00 # # B5623 $5.00 # B5648 $10.00 #

B5624 $15.00 # # B5649 $12.00 # # B5624 $5.00 # B5649 $5.00 #

B5625 $12.00 # # B5650 $15.00 # # B5625 $12.00 # B5650 $5.00 #

B5626 $15.00 # # B5651 $15.00 # # B5626 $5.00 # B5651 $5.00 #

B5627 $15.00 # # B5652 $15.00 # # B5627 $5.00 # B5652 $5.00 #

B5628 $15.00 # # B5653 $15.00 # # B5628 $5.00 # B5653 $5.00 #

B5629 $15.00 # # B5654 $12.00 # # B5629 $5.00 # B5654 $5.00 #

B5630 $15.00 # # B5655 $15.00 # # B5630 $15.00 # B5655 $5.00 #

B5631 $18.00 # # B5656 $15.00 # # B5631 $7.00 # B5656 $15.00 #

B5632 $18.00 # # B5657 $8.00 # # B5632 $7.00 # B5657 $5.00 #

B5633 $20.00 # # B5658 $15.00 # # B5633 $5.00 # B5658 $5.00 #

B5634 $15.00 # # B5659 $15.00 # # B5634 $7.00 # B5659 $5.00 #

B5635 $12.00 # # B5660 $15.00 # # B5635 $5.00 # B5660 $5.00 #

B5636 $15.00 # # B5661 $15.00 # # B5636 $5.00 # B5661 $5.00 #

B5637 $15.00 # # B5662 $15.00 # # B5637 $5.00 # B5662 $5.00 #

B5638 $10.00 # # B5663 $15.00 # # B5638 $10.00 # B5663 $5.00 #

B5639 $12.00 # # B5664 $15.00 # # B5639 $5.00 # B5664 $5.00 #

B5640 $15.00 # # B5665 $12.00 # # B5640 $5.00 # B5665 $12.00 #

B5641 $12.00 # # B5666 $12.00 # # B5641 $5.00 # B5666 $5.00 #

B5642 $15.00 # # B5667 $10.00 # # B5642 $5.00 # B5667 $5.00 #

B5643 $12.00 # # B5668 $12.00 # # B5643 $5.00 # B5668 $12.00 #

B5644 $15.00 # # B5669 $15.00 # # B5644 $5.00 # B5669 $15.00 #

B5645 $15.00 # # B5670 $15.00 # # B5645 $5.00 # B5670 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

149 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B5671 $15.00 # # B5696 $20.00 # # B5671 $5.00 # B5696 $5.00 #

B5672 $15.00 # # B5697 $15.00 # # B5672 $5.00 # B5697 $5.00 #

B5673 $10.00 # # B5698 $20.00 # # B5673 $10.00 # B5698 $5.00 #

B5674 $15.00 # # B5699 $15.00 # # B5674 $5.00 # B5699 $5.00 #

B5675 $12.00 # # B5700 NADA # # B5675 $5.00 # B5700 $5.00 #

B5676 $15.00 # # B5701 $10.00 # # B5676 $7.00 # B5701 $5.00 #

B5677 $15.00 # # B5702 $15.00 # # B5677 $5.00 # B5702 $5.00 #

B5678 $10.00 # # B5703 $15.00 # # B5678 $10.00 # B5703 $5.00 #

B5679 $15.00 # # B5704 $15.00 # # B5679 $7.00 # B5704 $5.00 #

B5680 $15.00 # # B5705 $15.00 # # B5680 $7.00 # B5705 $5.00 #

B5681 $15.00 # # B5706 $12.00 # # B5681 $5.00 # B5706 $12.00 #

B5682 $15.00 # # B5707 $15.00 # # B5682 $5.00 # B5707 $5.00 #

B5683 $12.00 # # B5708 $18.00 # # B5683 $5.00 # B5708 $5.00 #

B5684 $10.00 # # B5709 $18.00 # # B5684 $5.00 # B5709 $5.00 #

B5685 $10.00 # # B5710 $18.00 # # B5685 $5.00 # B5710 $5.00 #

B5686 $10.00 # # B5711 $20.00 # # B5686 $5.00 # B5711 $5.00 #

B5687 $8.00 # # B5712 $20.00 # # B5687 $5.00 # B5712 $5.00 #

B5688 $18.00 # # B5713 $12.00 # # B5688 $18.00 # B5713 $5.00 #

B5689 $5.00 # # B5714 $15.00 # # B5689 $5.00 # B5714 $5.00 #

B5690 $15.00 # # B5715 $15.00 # # B5690 $7.00 # B5715 $5.00 #

B5691 $10.00 # # B5716 $12.00 # # B5691 $5.00 # B5716 $12.00 #

B5692 $15.00 # # B5717 $12.00 # # B5692 $5.00 # B5717 $5.00 #

B5693 $15.00 # # B5718 $10.00 # # B5693 $5.00 # B5718 $5.00 #

B5694 $10.00 # # B5719 $15.00 # # B5694 $5.00 # B5719 NADA #

B5695 $15.00 # # B5720 $8.00 # # B5695 $5.00 # B5720 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

150 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B5721 $15.00 # # B5762 $12.00 # # B5721 $5.00 # B5762 $10.00 #

B5722 $15.00 # # B5764 $15.00 # # B5722 $5.00 # B5764 $5.00 #

B5725 $15.00 # # B5765 NADA # # B5725 $5.00 # B5765 NADA #

B5726 $15.00 # # B5766 $7.00 # # B5726 $5.00 # B5766 $5.00 #

B5729 $15.00 # # B5769 $12.00 # # B5729 $5.00 # B5769 NADA #

B5730 $15.00 # # B5770 $10.00 # # B5730 $15.00 # B5770 $10.00 #

B5731 $15.00 # # B5771 $10.00 # # B5731 $5.00 # B5771 $10.00 #

B5732 $12.00 # # B5772 $10.00 # # B5732 $5.00 # B5772 $10.00 #

B5733 $12.00 # # B5773 $15.00 # # B5733 $5.00 # B5773 $15.00 #

B5734 $20.00 # # B5774 $15.00 # # B5734 $5.00 # B5774 $15.00 #

B5735 $20.00 # # B5777 $15.00 # # B5735 $5.00 # B5777 NADA #

B5736 $15.00 # # B5778 $12.00 # # B5736 $5.00 # B5778 $5.00 #

B5737 $15.00 # # B5781 $18.00 # # B5737 $5.00 # B5781 $5.00 #

B5738 $15.00 # # B5782 $18.00 # # B5738 NADA # B5782 $5.00 #

B5740 $15.00 # # B5783 $15.00 # # B5740 NADA # B5783 $5.00 #

B5741 $15.00 # # B5784 $15.00 # # B5741 NADA # B5784 $5.00 #

B5742 $12.00 # # B5785 $10.00 # # B5742 NADA # B5785 $5.00 #

B5745 NADA # # B5786 $10.00 # # B5745 NADA # B5786 $5.00 #

B5746 $15.00 # # B5787 $12.00 # # B5746 $15.00 # B5787 $5.00 #

B5749 $15.00 # # B5788 $10.00 # # B5749 $5.00 # B5788 $5.00 #

B5754 $15.00 # # B5789 $12.00 # # B5754 $5.00 # B5789 $5.00 #

B5755 $10.00 # # B5790 $10.00 # # B5755 $5.00 # B5790 $5.00 #

B5757 $15.00 # # B5797 $15.00 # # B5757 $5.00 # B5797 $5.00 #

B5760 $12.00 # # B5798 $15.00 # # B5760 $5.00 # B5798 $5.00 #

B5761 $12.00 # # B5799 $15.00 # # B5761 $5.00 # B5799 NADA #

CÓDIGOS DE CUBIERTAS / COPAGOS

151 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B5800 $15.00 # # B5831 $20.00 # # B5800 NADA # B5831 $10.00 #

B5801 $10.00 # # B5832 NADA # # B5801 NADA # B5832 NADA #

B5803 $12.00 # # B5833 $15.00 # # B5803 $5.00 # B5833 NADA #

B5807 $15.00 # # B5834 NADA # # B5807 $5.00 # B5834 NADA #

B5808 $10.00 # # B5835 $7.00 # # B5808 $5.00 # B5835 $5.00 #

B5810 $12.00 # # B5836 $5.00 # # B5810 $10.00 # B5836 $5.00 #

B5811 $10.00 # # B5837 $12.00 # # B5811 $6.00 # B5837 $5.00 #

B5812 $10.00 # # B5838 $12.00 # # B5812 $6.00 # B5838 $10.00 #

B5813 $15.00 # # B5839 $20.00 # # B5813 $5.00 # B5839 $5.00 #

B5814 $12.00 # # B5840 $20.00 # # B5814 $5.00 # B5840 $5.00 #

B5815 $15.00 # # B5841 $18.00 # # B5815 $5.00 # B5841 $5.00 #

B5817 $15.00 # # B5842 $15.00 # # B5817 $5.00 # B5842 $5.00 #

B5818 $12.00 # # B5843 $18.00 # # B5818 $5.00 # B5843 $5.00 #

B5819 $10.00 # # B5844 $15.00 # # B5819 $5.00 # B5844 $5.00 #

B5820 $10.00 # # B5845 $10.00 # # B5820 $5.00 # B5845 $5.00 #

B5821 $20.00 # # B5846 $15.00 # # B5821 $5.00 # B5846 $5.00 #

B5822 $12.00 # # B5847 $15.00 # # B5822 $12.00 # B5847 $5.00 #

B5823 $10.00 # # B5848 $18.00 # # B5823 $5.00 # B5848 $5.00 #

B5824 $10.00 # # B5849 $10.00 # # B5824 $10.00 # B5849 NADA #

B5825 $10.00 # # B5850 $5.00 # # B5825 $10.00 # B5850 $5.00 #

B5826 $10.00 # # B5851 NADA # # B5826 $10.00 # B5851 NADA #

B5827 $15.00 # # B5852 $15.00 # # B5827 $10.00 # B5852 $5.00 #

B5828 $15.00 # # B5853 $8.00 # # B5828 $10.00 # B5853 $8.00 #

B5829 $20.00 # # B5854 $15.00 # # B5829 $10.00 # B5854 $5.00 #

B5830 NADA # # B5855 $18.00 # # B5830 NADA # B5855 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

152 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B5856 $15.00 # # B5881 $7.00 # # B5856 $5.00 # B5881 $7.00 #

B5857 $12.00 # # B5883 $15.00 # # B5857 $5.00 # B5883 $5.00 #

B5858 $18.00 # # B5884 $20.00 # # B5858 $5.00 # B5884 $5.00 #

B5859 $12.00 # # B5885 $10.00 # # B5859 $5.00 # B5885 $5.00 #

B5860 $10.00 # # B5886 $10.00 # # B5860 NADA # B5886 $5.00 #

B5861 $10.00 # # B5887 $15.00 # # B5861 $5.00 # B5887 $5.00 #

B5862 $5.00 # # B5888 $10.00 # # B5862 $5.00 # B5888 $5.00 #

B5863 $12.00 # # B5889 $10.00 # # B5863 $5.00 # B5889 $5.00 #

B5864 $15.00 # # B5890 $15.00 # # B5864 $15.00 # B5890 $5.00 #

B5865 $18.00 # # B5891 $10.00 # # B5865 $5.00 # B5891 $7.00 #

B5866 $15.00 # # B5892 $10.00 # # B5866 $5.00 # B5892 $5.00 #

B5867 $12.00 # # B5893 $15.00 # # B5867 $5.00 # B5893 $5.00 #

B5868 $15.00 # # B5894 $3.00 # # B5868 $5.00 # B5894 $3.00 #

B5869 $5.00 # # B5895 $15.00 # # B5869 $5.00 # B5895 $5.00 #

B5870 $15.00 # # B5896 $15.00 # # B5870 $5.00 # B5896 $5.00 #

B5871 $15.00 # # B5897 $20.00 # # B5871 $5.00 # B5897 $10.00 #

B5872 $18.00 # # B5898 $20.00 # # B5872 $5.00 # B5898 $10.00 #

B5873 $20.00 # # B5899 $18.00 # # B5873 $5.00 # B5899 NADA #

B5874 $10.00 # # B5900 $18.00 # # B5874 $5.00 # B5900 $7.00 #

B5875 $12.00 # # B5901 $12.00 # # B5875 $5.00 # B5901 $10.00 #

B5876 $10.00 # # B5902 NADA # # B5876 $5.00 # B5902 $7.00 #

B5877 $10.00 # # B5903 $15.00 # # B5877 $5.00 # B5903 $10.00 #

B5878 $15.00 # # B5904 $10.00 # # B5878 $5.00 # B5904 $5.00 #

B5879 $15.00 # # B5905 $20.00 # # B5879 $5.00 # B5905 $5.00 #

B5880 $7.00 # # B5906 $12.00 # # B5880 $7.00 # B5906 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

153 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B5907 $12.00 # # B5935 $20.00 # # B5907 $5.00 # B5935 $5.00 #

B5908 $15.00 # # B5936 $15.00 # # B5908 $5.00 # B5936 $5.00 #

B5909 $15.00 # # B5937 $15.00 # # B5909 $5.00 # B5937 $7.00 #

B5910 $15.00 # # B5938 $20.00 # # B5910 $5.00 # B5938 $10.00 #

B5911 $15.00 # # B5939 $15.00 # # B5911 $5.00 # B5939 $7.00 #

B5912 $15.00 # # B5940 $10.00 # # B5912 $5.00 # B5940 $10.00 #

B5913 $15.00 # # B5941 $10.00 # # B5913 $5.00 # B5941 $10.00 #

B5914 $12.00 # # B5942 $15.00 # # B5914 $5.00 # B5942 $7.00 #

B5915 $10.00 # # B5943 $10.00 # # B5915 $10.00 # B5943 $10.00 #

B5916 $18.00 # # B5944 $15.00 # # B5916 $5.00 # B5944 $5.00 #

B5917 $22.00 # # B5945 $15.00 # # B5917 $5.00 # B5945 $5.00 #

B5918 $15.00 # # B5946 $12.00 # # B5918 $5.00 # B5946 $5.00 #

B5919 $15.00 # # B5947 $15.00 # # B5919 $5.00 # B5947 $7.00 #

B5920 $15.00 # # B5948 $8.00 # # B5920 $5.00 # B5948 $8.00 #

B5921 $10.00 # # B5949 $8.00 # # B5921 $8.00 # B5949 $8.00 #

B5923 $5.00 # # B5950 $15.00 # # B5923 $5.00 # B5950 $7.00 #

B5924 $12.00 # # B5951 $10.00 # # B5924 $10.00 # B5951 $10.00 #

B5925 NADA # # B5952 $10.00 # # B5925 NADA # B5952 $5.00 #

B5926 $25.00 # # B5953 $8.00 # # B5926 NADA # B5953 $5.00 #

B5927 $8.00 # # B5954 $8.00 # # B5927 $8.00 # B5954 $5.00 #

B5928 $10.00 # # B5955 NADA # # B5928 $10.00 # B5955 NADA #

B5931 NADA # # B5956 $10.00 # # B5931 NADA # B5956 $5.00 #

B5932 $15.00 # # B5957 $8.00 # # B5932 $5.00 # B5957 $5.00 #

B5933 $15.00 # # B5958 $8.00 # # B5933 $5.00 # B5958 $5.00 #

B5934 $12.00 # # B5959 $15.00 # # B5934 NADA # B5959 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

154 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B5961 $15.00 # # B5986 $20.00 # # B5961 $15.00 # B5986 $5.00 #

B5962 $18.00 # # B5987 $15.00 # # B5962 $5.00 # B5987 $5.00 #

B5963 $18.00 # # B5988 $20.00 # # B5963 $5.00 # B5988 $10.00 #

B5964 $15.00 # # B5989 $10.00 # # B5964 $5.00 # B5989 $7.00 #

B5965 $8.00 # # B5990 $10.00 # # B5965 $5.00 # B5990 $10.00 #

B5966 $8.00 # # B5991 $15.00 # # B5966 $5.00 # B5991 $5.00 #

B5967 $10.00 # # B5992 $10.00 # # B5967 $5.00 # B5992 $5.00 #

B5968 $18.00 # # B5993 NADA # # B5968 $5.00 # B5993 $10.00 #

B5969 $15.00 # # B5994 $15.00 # # B5969 $5.00 # B5994 $7.00 #

B5970 $18.00 # # B5995 $15.00 # # B5970 $5.00 # B5995 $7.00 #

B5971 NADA # # B5996 $10.00 # # B5971 NADA # B5996 $7.00 #

B5972 $18.00 # # B5997 $10.00 # # B5972 $5.00 # B5997 $10.00 #

B5973 $15.00 # # B5998 $18.00 # # B5973 $5.00 # B5998 $5.00 #

B5974 $15.00 # # B5999 $12.00 # # B5974 $5.00 # B5999 NADA #

B5975 $10.00 # # B6000 $12.00 # # B5975 $10.00 # B6000 NADA #

B5976 $15.00 # # B6001 $15.00 # # B5976 $5.00 # B6001 $7.00 #

B5977 $15.00 # # B6002 $15.00 # # B5977 $5.00 # B6002 $5.00 #

B5978 $12.00 # # B6003 $5.00 # # B5978 $5.00 # B6003 $10.00 #

B5979 $15.00 # # B6004 $15.00 # # B5979 $5.00 # B6004 $5.00 #

B5980 $15.00 # # B6005 $15.00 # # B5980 $5.00 # B6005 $5.00 #

B5981 $15.00 # # B6006 $15.00 # # B5981 $7.00 # B6006 $5.00 #

B5982 $20.00 # # B6007 $15.00 # # B5982 $5.00 # B6007 $7.00 #

B5983 $15.00 # # B6008 $15.00 # # B5983 $5.00 # B6008 $7.00 #

B5984 $12.00 # # B6009 $18.00 # # B5984 $5.00 # B6009 $5.00 #

B5985 $20.00 # # B6010 NADA # # B5985 $5.00 # B6010 $7.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

155 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B6011 $10.00 # # B6037 $5.00 # # B6011 $7.00 # B6037 $10.00 #

B6012 $12.00 # # B6038 $10.00 # # B6012 $5.00 # B6038 $5.00 #

B6013 $15.00 # # B6039 $12.00 # # B6013 $5.00 # B6039 $5.00 #

B6014 $7.00 # # B6040 $20.00 # # B6014 $5.00 # B6040 NADA #

B6015 $15.00 # # B6041 $15.00 # # B6015 $5.00 # B6041 NADA #

B6016 $18.00 # # B6042 $15.00 # # B6016 $5.00 # B6042 $7.00 #

B6017 $5.00 # # B6043 $15.00 # # B6017 $10.00 # B6043 $7.00 #

B6018 $15.00 # # B6044 $15.00 # # B6018 $7.00 # B6044 $7.00 #

B6019 $10.00 # # B6045 $15.00 # # B6019 $10.00 # B6045 $7.00 #

B6020 $18.00 # # B6046 $15.00 # # B6020 $5.00 # B6046 $7.00 #

B6021 $15.00 # # B6047 $15.00 # # B6021 $5.00 # B6047 $7.00 #

B6022 $15.00 # # B6048 $15.00 # # B6022 $5.00 # B6048 $7.00 #

B6023 $15.00 # # B6049 $15.00 # # B6023 $7.00 # B6049 $5.00 #

B6024 $20.00 # # B6050 $15.00 # # B6024 $5.00 # B6050 $7.00 #

B6025 $20.00 # # B6051 $15.00 # # B6025 $5.00 # B6051 $5.00 #

B6026 $20.00 # # B6052 $15.00 # # B6026 $5.00 # B6052 $5.00 #

B6027 $10.00 # # B6053 NADA # # B6027 $7.00 # B6053 NADA #

B6028 $15.00 # # B6054 $15.00 # # B6028 $10.00 # B6054 $5.00 #

B6029 NADA # # B6055 $15.00 # # B6029 $7.00 # B6055 $5.00 #

B6030 $5.00 # # B6056 $15.00 # # B6030 $10.00 # B6056 $5.00 #

B6031 $15.00 # # B6057 $10.00 # # B6031 $7.00 # B6057 $5.00 #

B6032 $10.00 # # B6058 $10.00 # # B6032 $7.00 # B6058 $10.00 #

B6033 $10.00 # # B6059 $15.00 # # B6033 $10.00 # B6059 $5.00 #

B6034 $7.00 # # B6060 $10.00 # # B6034 $5.00 # B6060 $10.00 #

B6036 $18.00 # # B6061 $15.00 # # B6036 $10.00 # B6061 $7.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

156 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B6062 NADA # # B6087 $20.00 # # B6062 $7.00 # B6087 $5.00 #

B6063 $15.00 # # B6088 $15.00 # # B6063 NADA # B6088 $5.00 #

B6064 $15.00 # # B6089 $10.00 # # B6064 $5.00 # B6089 $10.00 #

B6065 $10.00 # # B6090 NADA # # B6065 $5.00 # B6090 NADA #

B6066 $10.00 # # B6091 $12.00 # # B6066 $10.00 # B6091 $5.00 #

B6067 $10.00 # # B6092 NADA # # B6067 $10.00 # B6092 NADA #

B6068 $10.00 # # B6093 NADA # # B6068 $5.00 # B6093 NADA #

B6069 $15.00 # # B6094 $15.00 # # B6069 $5.00 # B6094 $7.00 #

B6070 $15.00 # # B6095 $15.00 # # B6070 $5.00 # B6095 $5.00 #

B6071 $20.00 # # B6096 $15.00 # # B6071 $5.00 # B6096 $5.00 #

B6072 $17.00 # # B6097 $15.00 # # B6072 $5.00 # B6097 $5.00 #

B6073 $15.00 # # B6098 NADA # # B6073 $5.00 # B6098 $7.00 #

B6074 $18.00 # # B6099 $12.00 # # B6074 $5.00 # B6099 $5.00 #

B6075 $18.00 # # B6100 $20.00 # # B6075 $5.00 # B6100 $15.00 #

B6076 $18.00 # # B6101 $12.00 # # B6076 $5.00 # B6101 $5.00 #

B6077 $10.00 # # B6102 $15.00 # # B6077 $5.00 # B6102 $5.00 #

B6078 $10.00 # # B6103 $15.00 # # B6078 $5.00 # B6103 $5.00 #

B6079 $12.00 # # B6104 $15.00 # # B6079 $5.00 # B6104 $7.00 #

B6080 $12.00 # # B6105 $10.00 # # B6080 $10.00 # B6105 $10.00 #

B6081 $20.00 # # B6106 $15.00 # # B6081 $10.00 # B6106 NADA #

B6082 $12.00 # # B6109 $18.00 # # B6082 $5.00 # B6109 $5.00 #

B6083 $15.00 # # B6110 $15.00 # # B6083 $7.00 # B6110 $7.00 #

B6084 $18.00 # # B6111 $10.00 # # B6084 $5.00 # B6111 $10.00 #

B6085 $10.00 # # B6112 $15.00 # # B6085 $10.00 # B6112 $7.00 #

B6086 NADA # # B6113 $10.00 # # B6086 $7.00 # B6113 $10.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B6115 $15.00 # # B6140 $10.00 # # B6115 $5.00 # B6140 $10.00 #

B6116 $10.00 # # B6141 $12.00 # # B6116 $5.00 # B6141 $5.00 #

B6117 $15.00 # # B6142 $10.00 # # B6117 $5.00 # B6142 $10.00 #

B6118 $10.00 # # B6143 $12.00 # # B6118 $10.00 # B6143 $5.00 #

B6119 $10.00 # # B6144 $12.00 # # B6119 $10.00 # B6144 $7.00 #

B6120 $15.00 # # B6145 $10.00 # # B6120 $5.00 # B6145 $10.00 #

B6121 $15.00 # # B6146 $15.00 # # B6121 $5.00 # B6146 $7.00 #

B6122 $10.00 # # B6147 $10.00 # # B6122 $5.00 # B6147 $10.00 #

B6123 $10.00 # # B6148 $15.00 # # B6123 $5.00 # B6148 $7.00 #

B6124 $5.00 # # B6149 $15.00 # # B6124 $10.00 # B6149 NADA #

B6125 $10.00 # # B6150 $20.00 # # B6125 $10.00 # B6150 $5.00 #

B6126 $5.00 # # B6151 $15.00 # # B6126 $5.00 # B6151 $5.00 #

B6127 $10.00 # # B6152 $20.00 # # B6127 $10.00 # B6152 $10.00 #

B6128 $5.00 # # B6153 $20.00 # # B6128 NADA # B6153 $5.00 #

B6129 $15.00 # # B6154 $12.00 # # B6129 $5.00 # B6154 $5.00 #

B6130 $15.00 # # B6156 $15.00 # # B6130 $5.00 # B6156 $7.00 #

B6131 $15.00 # # B6159 $15.00 # # B6131 $7.00 # B6159 $5.00 #

B6132 $20.00 # # B6160 $15.00 # # B6132 NADA # B6160 $5.00 #

B6133 $15.00 # # B6163 $10.00 # # B6133 $5.00 # B6163 $10.00 #

B6134 $10.00 # # B6164 $15.00 # # B6134 $5.00 # B6164 $7.00 #

B6135 $20.00 # # B6165 $12.00 # # B6135 NADA # B6165 NADA #

B6136 $20.00 # # B6166 $18.00 # # B6136 NADA # B6166 $5.00 #

B6137 $15.00 # # B6167 $18.00 # # B6137 $5.00 # B6167 $5.00 #

B6138 $12.00 # # B6168 NADA # # B6138 $5.00 # B6168 $5.00 #

B6139 $15.00 # # B6172 $15.00 # # B6139 $5.00 # B6172 $10.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B6173 $12.00 # # B6205 $12.00 # # B6173 $5.00 # B6205 $5.00 #

B6180 $10.00 # # B6206 $18.00 # # B6180 $10.00 # B6206 $5.00 #

B6181 $15.00 # # B6207 $15.00 # # B6181 $7.00 # B6207 $5.00 #

B6182 $10.00 # # B6208 $15.00 # # B6182 $7.00 # B6208 $5.00 #

B6183 $15.00 # # B6209 $12.00 # # B6183 $5.00 # B6209 $5.00 #

B6184 $18.00 # # B6210 $10.00 # # B6184 $5.00 # B6210 $5.00 #

B6185 $18.00 # # B6211 $15.00 # # B6185 $5.00 # B6211 $5.00 #

B6187 $20.00 # # B6212 $12.00 # # B6187 NADA # B6212 $5.00 #

B6188 $20.00 # # B6213 $12.00 # # B6188 NADA # B6213 $5.00 #

B6189 NADA # # B6214 $12.00 # # B6189 $7.00 # B6214 $5.00 #

B6190 $20.00 # # B6215 $15.00 # # B6190 NADA # B6215 $5.00 #

B6191 $20.00 # # B6216 $15.00 # # B6191 NADA # B6216 $5.00 #

B6192 $7.00 # # B6217 $18.00 # # B6192 $5.00 # B6217 $10.00 #

B6193 $15.00 # # B6218 $12.00 # # B6193 $5.00 # B6218 $5.00 #

B6194 $10.00 # # B6219 $12.00 # # B6194 $5.00 # B6219 $5.00 #

B6195 $20.00 # # B6220 $10.00 # # B6195 $5.00 # B6220 $5.00 #

B6196 $18.00 # # B6221 NADA # # B6196 $10.00 # B6221 $7.00 #

B6197 $15.00 # # B6222 $12.00 # # B6197 $5.00 # B6222 $5.00 #

B6198 $20.00 # # B6223 $7.00 # # B6198 $10.00 # B6223 $5.00 #

B6199 $15.00 # # B6224 $7.00 # # B6199 $5.00 # B6224 $5.00 #

B6200 NADA # # B6225 $12.00 # # B6200 NADA # B6225 $5.00 #

B6201 $20.00 # # B6226 $20.00 # # B6201 $5.00 # B6226 $15.00 #

B6202 $20.00 # # B6227 $15.00 # # B6202 $5.00 # B6227 $5.00 #

B6203 $20.00 # # B6228 $15.00 # # B6203 NADA # B6228 $5.00 #

B6204 $15.00 # # B6229 $20.00 # # B6204 $5.00 # B6229 $15.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B6230 $20.00 # # B6256 $15.00 # # B6230 $5.00 # B6256 $5.00 #

B6231 $12.00 # # B6257 $10.00 # # B6231 NADA # B6257 $5.00 #

B6232 $12.00 # # B6258 $15.00 # # B6232 $5.00 # B6258 $5.00 #

B6233 $20.00 # # B6259 $15.00 # # B6233 $5.00 # B6259 $7.00 #

B6234 $12.00 # # B6260 $12.00 # # B6234 $5.00 # B6260 $5.00 #

B6235 NADA # # B6261 $10.00 # # B6235 NADA # B6261 $5.00 #

B6236 $20.00 # # B6262 $15.00 # # B6236 $5.00 # B6262 $5.00 #

B6237 $12.00 # # B6263 $20.00 # # B6237 $5.00 # B6263 $5.00 #

B6238 $15.00 # # B6264 $20.00 # # B6238 $7.00 # B6264 $5.00 #

B6239 $12.00 # # B6265 $20.00 # # B6239 $5.00 # B6265 $15.00 #

B6240 $20.00 # # B6266 $20.00 # # B6240 $5.00 # B6266 $5.00 #

B6241 $15.00 # # B6267 $15.00 # # B6241 $5.00 # B6267 $5.00 #

B6242 $12.00 # # B6268 $7.00 # # B6242 $5.00 # B6268 $5.00 #

B6243 $12.00 # # B6269 $18.00 # # B6243 $5.00 # B6269 $5.00 #

B6244 $12.00 # # B6270 $15.00 # # B6244 $5.00 # B6270 $5.00 #

B6245 $15.00 # # B6271 $20.00 # # B6245 $5.00 # B6271 $5.00 #

B6246 $15.00 # # B6273 $15.00 # # B6246 $7.00 # B6273 $5.00 #

B6248 $15.00 # # B6274 $10.00 # # B6248 NADA # B6274 $7.00 #

B6249 $15.00 # # B6275 $18.00 # # B6249 NADA # B6275 $5.00 #

B6250 $18.00 # # B6277 $18.00 # # B6250 $5.00 # B6277 $5.00 #

B6251 $15.00 # # B6278 $25.00 # # B6251 $5.00 # B6278 $5.00 #

B6252 $12.00 # # B6279 $15.00 # # B6252 $5.00 # B6279 $5.00 #

B6253 $20.00 # # B6280 $15.00 # # B6253 $5.00 # B6280 $5.00 #

B6254 $12.00 # # B6281 $15.00 # # B6254 $5.00 # B6281 $5.00 #

B6255 $12.00 # # B6282 $12.00 # # B6255 $5.00 # B6282 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B6283 NADA # # B6313 $15.00 # # B6283 NADA # B6313 $7.00 #

B6284 $10.00 # # B6314 $15.00 # # B6284 $5.00 # B6314 $7.00 #

B6285 NADA # # B6315 $15.00 # # B6285 NADA # B6315 NADA #

B6286 NADA # # B6316 $10.00 # # B6286 NADA # B6316 $5.00 #

B6287 $15.00 # # B6317 $10.00 # # B6287 $5.00 # B6317 $5.00 #

B6288 $15.00 # # B6319 $15.00 # # B6288 $7.00 # B6319 $5.00 #

B6289 $18.00 # # B6321 $10.00 # # B6289 $5.00 # B6321 $7.00 #

B6290 $15.00 # # B6322 $12.00 # # B6290 NADA # B6322 $5.00 #

B6291 $15.00 # # B6323 $10.00 # # B6291 $7.00 # B6323 $7.00 #

B6292 $15.00 # # B6324 $12.00 # # B6292 $7.00 # B6324 $7.00 #

B6293 $15.00 # # B6325 $18.00 # # B6293 $7.00 # B6325 $18.00 #

B6295 $18.00 # # B6326 $15.00 # # B6295 $5.00 # B6326 $7.00 #

B6296 $15.00 # # B6327 $18.00 # # B6296 $5.00 # B6327 $5.00 #

B6297 $12.00 # # B6328 $15.00 # # B6297 $5.00 # B6328 $5.00 #

B6299 $18.00 # # B6329 $20.00 # # B6299 $7.00 # B6329 $5.00 #

B6300 $10.00 # # B6330 $12.00 # # B6300 $5.00 # B6330 $5.00 #

B6301 $15.00 # # B6331 $12.00 # # B6301 $5.00 # B6331 $5.00 #

B6302 $15.00 # # B6332 $20.00 # # B6302 $5.00 # B6332 $5.00 #

B6303 $18.00 # # B6333 $15.00 # # B6303 $10.00 # B6333 $5.00 #

B6304 NADA # # B6334 $15.00 # # B6304 $7.00 # B6334 $5.00 #

B6305 $15.00 # # B6335 $15.00 # # B6305 $5.00 # B6335 $5.00 #

B6307 $15.00 # # B6336 $12.00 # # B6307 $7.00 # B6336 $5.00 #

B6308 $10.00 # # B6337 $15.00 # # B6308 $5.00 # B6337 $5.00 #

B6309 $18.00 # # B6338 $10.00 # # B6309 $7.00 # B6338 $7.00 #

B6312 $20.00 # # B6339 $10.00 # # B6312 $15.00 # B6339 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B6340 $12.00 # # B6365 $15.00 # # B6340 $7.00 # B6365 $10.00 #

B6341 $10.00 # # B6366 $15.00 # # B6341 $7.00 # B6366 $10.00 #

B6342 $15.00 # # B6367 $18.00 # # B6342 $7.00 # B6367 $5.00 #

B6343 $15.00 # # B6368 $15.00 # # B6343 $5.00 # B6368 $5.00 #

B6344 $10.00 # # B6369 $7.00 # # B6344 $7.00 # B6369 $5.00 #

B6345 $15.00 # # B6370 $15.00 # # B6345 $5.00 # B6370 $5.00 #

B6346 $5.00 # # B6371 $15.00 # # B6346 $5.00 # B6371 $7.00 #

B6347 $10.00 # # B6372 $5.00 # # B6347 $7.00 # B6372 $10.00 #

B6348 $15.00 # # B6373 $15.00 # # B6348 $5.00 # B6373 $5.00 #

B6349 $20.00 # # B6374 $18.00 # # B6349 $10.00 # B6374 $5.00 #

B6350 NADA # # B6375 $18.00 # # B6350 $7.00 # B6375 $5.00 #

B6351 $10.00 # # B6376 $18.00 # # B6351 $7.00 # B6376 $5.00 #

B6352 $12.00 # # B6377 $18.00 # # B6352 NADA # B6377 $5.00 #

B6353 $15.00 # # B6378 $12.00 # # B6353 $5.00 # B6378 $7.00 #

B6354 $20.00 # # B6379 $10.00 # # B6354 $5.00 # B6379 $7.00 #

B6355 $18.00 # # B6380 $12.00 # # B6355 $5.00 # B6380 $5.00 #

B6356 $18.00 # # B6381 $15.00 # # B6356 $5.00 # B6381 $5.00 #

B6357 $12.00 # # B6382 $12.00 # # B6357 $5.00 # B6382 $5.00 #

B6358 $12.00 # # B6383 $10.00 # # B6358 $5.00 # B6383 $5.00 #

B6359 $15.00 # # B6384 $10.00 # # B6359 $5.00 # B6384 $10.00 #

B6360 $15.00 # # B6385 $15.00 # # B6360 $5.00 # B6385 $5.00 #

B6361 $10.00 # # B6386 $15.00 # # B6361 $5.00 # B6386 $5.00 #

B6362 $15.00 # # B6387 $12.00 # # B6362 $7.00 # B6387 $5.00 #

B6363 $15.00 # # B6388 $12.00 # # B6363 $7.00 # B6388 $5.00 #

B6364 $12.00 # # B6389 $15.00 # # B6364 $5.00 # B6389 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B6390 $10.00 # # B6415 $18.00 # # B6390 $5.00 # B6415 $7.00 #

B6391 $12.00 # # B6416 $15.00 # # B6391 $5.00 # B6416 $5.00 #

B6392 $10.00 # # B6417 $18.00 # # B6392 $5.00 # B6417 $5.00 #

B6393 $15.00 # # B6418 $18.00 # # B6393 $5.00 # B6418 $5.00 #

B6394 $15.00 # # B6419 $18.00 # # B6394 $5.00 # B6419 $7.00 #

B6395 $15.00 # # B6420 $20.00 # # B6395 $5.00 # B6420 $5.00 #

B6396 $20.00 # # B6421 $15.00 # # B6396 $5.00 # B6421 $5.00 #

B6397 NADA # # B6422 $15.00 # # B6397 $7.00 # B6422 $5.00 #

B6398 NADA # # B6423 $12.00 # # B6398 $7.00 # B6423 $5.00 #

B6399 $20.00 # # B6424 $20.00 # # B6399 $5.00 # B6424 $5.00 #

B6400 $20.00 # # B6425 $5.00 # # B6400 $5.00 # B6425 NADA #

B6401 $20.00 # # B6426 $15.00 # # B6401 $5.00 # B6426 $5.00 #

B6402 $20.00 # # B6427 $15.00 # # B6402 $5.00 # B6427 $5.00 #

B6403 $12.00 # # B6428 $18.00 # # B6403 $5.00 # B6428 $5.00 #

B6404 $12.00 # # B6429 $7.00 # # B6404 $5.00 # B6429 $5.00 #

B6405 $15.00 # # B6430 $7.00 # # B6405 $5.00 # B6430 $5.00 #

B6406 $15.00 # # B6431 $20.00 # # B6406 $5.00 # B6431 $5.00 #

B6407 $15.00 # # B6432 $15.00 # # B6407 $5.00 # B6432 $7.00 #

B6408 $10.00 # # B6433 $12.00 # # B6408 $10.00 # B6433 $5.00 #

B6409 $10.00 # # B6434 $18.00 # # B6409 $5.00 # B6434 $5.00 #

B6410 $15.00 # # B6435 $12.00 # # B6410 $7.00 # B6435 $5.00 #

B6411 $15.00 # # B6436 $15.00 # # B6411 $7.00 # B6436 $5.00 #

B6412 $15.00 # # B6437 $15.00 # # B6412 $5.00 # B6437 $5.00 #

B6413 $18.00 # # B6438 $15.00 # # B6413 $5.00 # B6438 $5.00 #

B6414 $18.00 # # B6439 $15.00 # # B6414 $5.00 # B6439 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B6440 $10.00 # # B6465 $12.00 # # B6440 $7.00 # B6465 $10.00 #

B6441 $10.00 # # B6466 $15.00 # # B6441 $5.00 # B6466 $5.00 #

B6442 $15.00 # # B6467 $10.00 # # B6442 $5.00 # B6467 $10.00 #

B6443 $15.00 # # B6468 $12.00 # # B6443 $5.00 # B6468 $10.00 #

B6444 $15.00 # # B6469 $15.00 # # B6444 $7.00 # B6469 $10.00 #

B6445 $15.00 # # B6470 $10.00 # # B6445 $5.00 # B6470 $10.00 #

B6446 $10.00 # # B6471 $12.00 # # B6446 $5.00 # B6471 $10.00 #

B6447 $7.00 # # B6472 $15.00 # # B6447 $7.00 # B6472 $10.00 #

B6448 $20.00 # # B6473 $12.00 # # B6448 $5.00 # B6473 $5.00 #

B6449 $20.00 # # B6474 $20.00 # # B6449 $5.00 # B6474 NADA #

B6450 $15.00 # # B6475 $15.00 # # B6450 NADA # B6475 $5.00 #

B6451 $15.00 # # B6476 $10.00 # # B6451 NADA # B6476 $7.00 #

B6452 $15.00 # # B6477 NADA # # B6452 $5.00 # B6477 $5.00 #

B6453 $20.00 # # B6478 $15.00 # # B6453 $15.00 # B6478 $5.00 #

B6454 $12.00 # # B6479 $15.00 # # B6454 $5.00 # B6479 $5.00 #

B6455 $15.00 # # B6480 $15.00 # # B6455 $5.00 # B6480 $5.00 #

B6456 $12.00 # # B6481 $15.00 # # B6456 $5.00 # B6481 $5.00 #

B6457 $15.00 # # B6483 $15.00 # # B6457 $5.00 # B6483 $5.00 #

B6458 $15.00 # # B6484 $15.00 # # B6458 $5.00 # B6484 $5.00 #

B6459 $10.00 # # B6485 $15.00 # # B6459 NADA # B6485 $5.00 #

B6460 $20.00 # # B6486 $10.00 # # B6460 $5.00 # B6486 $10.00 #

B6461 $15.00 # # B6487 $15.00 # # B6461 $5.00 # B6487 $5.00 #

B6462 $15.00 # # B6488 $15.00 # # B6462 $5.00 # B6488 $5.00 #

B6463 $20.00 # # B6489 $18.00 # # B6463 $5.00 # B6489 $5.00 #

B6464 $12.00 # # B6490 $10.00 # # B6464 $10.00 # B6490 $10.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B6493 $10.00 # # B6524 NADA # # B6493 $5.00 # B6524 $5.00 #

B6494 $15.00 # # B6525 $15.00 # # B6494 $5.00 # B6525 $5.00 #

B6495 $15.00 # # B6526 $10.00 # # B6495 $5.00 # B6526 $10.00 #

B6496 $15.00 # # B6527 $15.00 # # B6496 NADA # B6527 $5.00 #

B6498 $7.00 # # B6528 NADA # # B6498 $7.00 # B6528 $5.00 #

B6499 $7.50 # # B6529 $12.00 # # B6499 $7.50 # B6529 $5.00 #

B6500 $12.00 # # B6530 NADA # # B6500 $5.00 # B6530 NADA #

B6501 $10.00 # # B6531 NADA # # B6501 $5.00 # B6531 NADA #

B6502 $10.00 # # B6532 $10.00 # # B6502 $5.00 # B6532 $5.00 #

B6503 $10.00 # # B6533 NADA # # B6503 $10.00 # B6533 NADA #

B6504 $10.00 # # B6534 $12.00 # # B6504 $5.00 # B6534 $5.00 #

B6506 $20.00 # # B6535 $10.00 # # B6506 $5.00 # B6535 $5.00 #

B6507 $15.00 # # B6536 $12.00 # # B6507 $5.00 # B6536 $5.00 #

B6508 $12.00 # # B6537 $8.00 # # B6508 NADA # B6537 $5.00 #

B6509 $12.00 # # B6538 $15.00 # # B6509 $5.00 # B6538 $5.00 #

B6510 $15.00 # # B6539 $20.00 # # B6510 NADA # B6539 $5.00 #

B6513 $12.00 # # B6540 $15.00 # # B6513 $5.00 # B6540 $5.00 #

B6514 $15.00 # # B6541 $15.00 # # B6514 $5.00 # B6541 $5.00 #

B6515 $15.00 # # B6542 $15.00 # # B6515 NADA # B6542 $5.00 #

B6518 $15.00 # # B6543 $10.00 # # B6518 $5.00 # B6543 $10.00 #

B6519 $15.00 # # B6544 $15.00 # # B6519 $5.00 # B6544 $15.00 #

B6520 $12.00 # # B6545 $15.00 # # B6520 $5.00 # B6545 $5.00 #

B6521 NADA # # B6546 $12.00 # # B6521 NADA # B6546 $12.00 #

B6522 $7.00 # # B6547 $20.00 # # B6522 $5.00 # B6547 $5.00 #

B6523 $15.00 # # B6548 $12.00 # # B6523 $5.00 # B6548 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B6549 $10.00 # # B6574 $15.00 # # B6549 $5.00 # B6574 $5.00 #

B6550 $8.00 # # B6575 $10.00 # # B6550 $5.00 # B6575 $5.00 #

B6551 $15.00 # # B6576 $12.00 # # B6551 $5.00 # B6576 $5.00 #

B6552 $15.00 # # B6577 $10.00 # # B6552 $5.00 # B6577 $5.00 #

B6553 $12.00 # # B6578 $15.00 # # B6553 $5.00 # B6578 $5.00 #

B6554 $15.00 # # B6579 $15.00 # # B6554 $5.00 # B6579 $5.00 #

B6555 $15.00 # # B6580 $12.00 # # B6555 $7.00 # B6580 $5.00 #

B6556 $10.00 # # B6581 $10.00 # # B6556 $10.00 # B6581 NADA #

B6557 $10.00 # # B6582 $15.00 # # B6557 $10.00 # B6582 NADA #

B6558 $20.00 # # B6583 $15.00 # # B6558 $5.00 # B6583 NADA #

B6559 $10.00 # # B6584 $15.00 # # B6559 $10.00 # B6584 NADA #

B6560 $12.00 # # B6585 $20.00 # # B6560 NADA # B6585 $5.00 #

B6561 $15.00 # # B6586 $10.00 # # B6561 $5.00 # B6586 $5.00 #

B6562 $15.00 # # B6587 $10.00 # # B6562 $5.00 # B6587 $5.00 #

B6563 $18.00 # # B6588 $10.00 # # B6563 $5.00 # B6588 $5.00 #

B6564 $7.00 # # B6589 $15.00 # # B6564 $5.00 # B6589 $5.00 #

B6565 $12.00 # # B6590 $12.00 # # B6565 $5.00 # B6590 $5.00 #

B6566 $12.00 # # B6591 $20.00 # # B6566 $5.00 # B6591 $5.00 #

B6567 $15.00 # # B6592 $20.00 # # B6567 $5.00 # B6592 $5.00 #

B6568 $7.00 # # B6593 $15.00 # # B6568 $5.00 # B6593 $5.00 #

B6569 $15.00 # # B6594 $12.00 # # B6569 $5.00 # B6594 $5.00 #

B6570 $20.00 # # B6595 $15.00 # # B6570 $5.00 # B6595 $5.00 #

B6571 $15.00 # # B6596 $15.00 # # B6571 $5.00 # B6596 $5.00 #

B6572 $10.00 # # B6597 $10.00 # # B6572 $10.00 # B6597 $5.00 #

B6573 $20.00 # # B6598 $20.00 # # B6573 $5.00 # B6598 $6.50 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B6599 $15.00 # # B6624 $15.00 # # B6599 $5.00 # B6624 $5.00 #

B6600 $15.00 # # B6625 $15.00 # # B6600 $5.00 # B6625 $12.00 #

B6601 $15.00 # # B6626 NADA # # B6601 $5.00 # B6626 NADA #

B6602 $15.00 # # B6627 NADA # # B6602 $5.00 # B6627 $10.00 #

B6603 $15.00 # # B6628 $8.00 # # B6603 $5.00 # B6628 $10.00 #

B6604 $10.00 # # B6629 $12.00 # # B6604 $5.00 # B6629 $5.00 #

B6605 $12.00 # # B6630 $15.00 # # B6605 NADA # B6630 $5.00 #

B6606 $15.00 # # B6631 $12.00 # # B6606 NADA # B6631 $7.00 #

B6607 $15.00 # # B6632 $20.00 # # B6607 $5.00 # B6632 $5.00 #

B6608 $15.00 # # B6633 $20.00 # # B6608 $5.00 # B6633 $5.00 #

B6609 $15.00 # # B6634 $8.00 # # B6609 $5.00 # B6634 $10.00 #

B6610 $20.00 # # B6635 $15.00 # # B6610 $5.00 # B6635 $5.00 #

B6611 $20.00 # # B6636 $15.00 # # B6611 $5.00 # B6636 $5.00 #

B6612 $18.00 # # B6637 $10.00 # # B6612 $5.00 # B6637 $10.00 #

B6613 $18.00 # # B6638 $10.00 # # B6613 $5.00 # B6638 $10.00 #

B6614 $15.00 # # B6639 $10.00 # # B6614 $5.00 # B6639 $10.00 #

B6615 $15.00 # # B6640 $15.00 # # B6615 $5.00 # B6640 $15.00 #

B6616 $20.00 # # B6641 $15.00 # # B6616 $5.00 # B6641 $15.00 #

B6617 $15.00 # # B6642 $20.00 # # B6617 $10.00 # B6642 $5.00 #

B6618 NADA # # B6643 $15.00 # # B6618 $5.00 # B6643 $5.00 #

B6619 $20.00 # # B6644 $10.00 # # B6619 $5.00 # B6644 $5.00 #

B6620 $12.00 # # B6645 $15.00 # # B6620 $5.00 # B6645 $5.00 #

B6621 $10.00 # # B6646 $12.00 # # B6621 $10.00 # B6646 $5.00 #

B6622 $15.00 # # B6647 $10.00 # # B6622 $5.00 # B6647 $5.00 #

B6623 $20.00 # # B6648 NADA # # B6623 $5.00 # B6648 NADA #

CÓDIGOS DE CUBIERTAS / COPAGOS

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B6649 NADA # # B6674 $10.00 # # B6649 NADA # B6674 $5.00 #

B6650 NADA # # B6675 NADA # # B6650 NADA # B6675 NADA #

B6651 $8.00 # # B6676 $20.00 # # B6651 $5.00 # B6676 $10.00 #

B6652 $10.00 # # B6677 $15.00 # # B6652 $5.00 # B6677 $10.00 #

B6653 $15.00 # # B6678 $5.00 # # B6653 $5.00 # B6678 $10.00 #

B6654 $15.00 # # B6679 $10.00 # # B6654 $5.00 # B6679 $5.00 #

B6655 $10.00 # # B6680 $15.00 # # B6655 $5.00 # B6680 $5.00 #

B6656 $12.00 # # B6681 $12.00 # # B6656 $5.00 # B6681 $5.00 #

B6657 $12.00 # # B6682 $15.00 # # B6657 $5.00 # B6682 $5.00 #

B6658 $15.00 # # B6683 $15.00 # # B6658 $15.00 # B6683 NADA #

B6659 $10.00 # # B6684 $15.00 # # B6659 $5.00 # B6684 $5.00 #

B6660 $15.00 # # B6685 $12.00 # # B6660 $7.00 # B6685 NADA #

B6661 $12.00 # # B6686 $15.00 # # B6661 $5.00 # B6686 NADA #

B6662 $15.00 # # B6687 $15.00 # # B6662 $5.00 # B6687 $5.00 #

B6663 $12.00 # # B6688 $15.00 # # B6663 $10.00 # B6688 $5.00 #

B6664 $20.00 # # B6689 $15.00 # # B6664 $5.00 # B6689 $5.00 #

B6665 $12.00 # # B6690 $15.00 # # B6665 $5.00 # B6690 $7.00 #

B6666 $20.00 # # B6691 $15.00 # # B6666 $15.00 # B6691 $7.00 #

B6667 $15.00 # # B6692 $12.00 # # B6667 $5.00 # B6692 $5.00 #

B6668 $20.00 # # B6693 $15.00 # # B6668 $5.00 # B6693 $7.00 #

B6669 $12.00 # # B6694 $15.00 # # B6669 $5.00 # B6694 $5.00 #

B6670 $12.00 # # B6695 $15.00 # # B6670 $5.00 # B6695 $5.00 #

B6671 $10.00 # # B6696 $15.00 # # B6671 $5.00 # B6696 $10.00 #

B6672 $10.00 # # B6697 $20.00 # # B6672 $5.00 # B6697 $10.00 #

B6673 $15.00 # # B6698 $12.00 # # B6673 $5.00 # B6698 $10.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B6699 $15.00 # # B6724 $20.00 # # B6699 $5.00 # B6724 $10.00 #

B6700 $15.00 # # B6725 $10.00 # # B6700 $5.00 # B6725 $5.00 #

B6701 $15.00 # # B6726 $12.00 # # B6701 $5.00 # B6726 $5.00 #

B6702 $15.00 # # B6727 $15.00 # # B6702 NADA # B6727 $5.00 #

B6703 $18.00 # # B6728 $12.00 # # B6703 $5.00 # B6728 $10.00 #

B6704 $12.00 # # B6729 $12.00 # # B6704 $5.00 # B6729 $10.00 #

B6705 $15.00 # # B6730 $7.00 # # B6705 $5.00 # B6730 $5.00 #

B6706 $15.00 # # B6731 $12.00 # # B6706 NADA # B6731 NADA #

B6707 $12.00 # # B6732 NADA # # B6707 $5.00 # B6732 NADA #

B6708 $15.00 # # B6733 $10.00 # # B6708 $5.00 # B6733 $10.00 #

B6709 $15.00 # # B6734 $10.00 # # B6709 $5.00 # B6734 $10.00 #

B6710 $15.00 # # B6735 $12.00 # # B6710 $15.00 # B6735 $5.00 #

B6711 NADA # # B6736 $15.00 # # B6711 NADA # B6736 $5.00 #

B6712 $10.00 # # B6737 $15.00 # # B6712 $10.00 # B6737 $5.00 #

B6713 $15.00 # # B6738 $15.00 # # B6713 $7.00 # B6738 $5.00 #

B6714 $10.00 # # B6739 $15.00 # # B6714 $5.00 # B6739 $5.00 #

B6715 $15.00 # # B6740 $12.00 # # B6715 $5.00 # B6740 $5.00 #

B6716 $10.00 # # B6741 $20.00 # # B6716 NADA # B6741 $5.00 #

B6717 $12.00 # # B6742 $20.00 # # B6717 $5.00 # B6742 $5.00 #

B6718 $12.00 # # B6743 $12.00 # # B6718 $5.00 # B6743 $5.00 #

B6719 $15.00 # # B6744 $15.00 # # B6719 $7.00 # B6744 $5.00 #

B6720 $10.00 # # B6745 $15.00 # # B6720 $5.00 # B6745 $5.00 #

B6721 $12.00 # # B6746 $15.00 # # B6721 $5.00 # B6746 $5.00 #

B6722 $10.00 # # B6747 $15.00 # # B6722 $5.00 # B6747 $5.00 #

B6723 $15.00 # # B6748 $20.00 # # B6723 $7.00 # B6748 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B6749 $15.00 # # B6774 $18.00 # # B6749 $5.00 # B6774 $5.00 #

B6750 $15.00 # # B6775 NADA # # B6750 $5.00 # B6775 NADA #

B6751 $15.00 # # B6776 $15.00 # # B6751 $5.00 # B6776 $5.00 #

B6752 $12.00 # # B6777 $15.00 # # B6752 $5.00 # B6777 $5.00 #

B6753 $12.00 # # B6778 $15.00 # # B6753 $5.00 # B6778 $5.00 #

B6754 $15.00 # # B6779 $18.00 # # B6754 $5.00 # B6779 $5.00 #

B6755 $10.00 # # B6780 $3.00 # # B6755 $5.00 # B6780 $3.00 #

B6756 $15.00 # # B6781 $18.00 # # B6756 $5.00 # B6781 $5.00 #

B6757 $15.00 # # B6782 $18.00 # # B6757 $5.00 # B6782 $5.00 #

B6758 $20.00 # # B6783 $15.00 # # B6758 $5.00 # B6783 $5.00 #

B6759 NADA # # B6784 $10.00 # # B6759 $5.00 # B6784 $5.00 #

B6760 $15.00 # # B6785 $15.00 # # B6760 $5.00 # B6785 $5.00 #

B6761 $15.00 # # B6788 $10.00 # # B6761 $7.00 # B6788 $7.00 #

B6762 $15.00 # # B6789 $15.00 # # B6762 $15.00 # B6789 $7.00 #

B6763 $15.00 # # B6790 $18.00 # # B6763 NADA # B6790 $5.00 #

B6764 $15.00 # # B6791 $15.00 # # B6764 NADA # B6791 $5.00 #

B6765 $15.00 # # B6792 $15.00 # # B6765 NADA # B6792 $5.00 #

B6766 NADA # # B6793 $15.00 # # B6766 NADA # B6793 $7.00 #

B6767 $10.00 # # B6794 $15.00 # # B6767 $5.00 # B6794 $7.00 #

B6768 $12.00 # # B6795 $15.00 # # B6768 NADA # B6795 $7.00 #

B6769 $12.00 # # B6796 $8.00 # # B6769 $5.00 # B6796 $5.00 #

B6770 $12.00 # # B6797 $8.00 # # B6770 $5.00 # B6797 $5.00 #

B6771 $10.00 # # B6798 $10.00 # # B6771 $5.00 # B6798 $5.00 #

B6772 $18.00 # # B6799 NADA # # B6772 $5.00 # B6799 NADA #

B6773 $15.00 # # B6800 $15.00 # # B6773 $5.00 # B6800 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B6801 $15.00 # # B6826 $15.00 # # B6801 $5.00 # B6826 $7.00 #

B6802 $12.00 # # B6827 $15.00 # # B6802 $5.00 # B6827 $7.00 #

B6803 $15.00 # # B6828 $12.00 # # B6803 $5.00 # B6828 $7.00 #

B6804 $15.00 # # B6829 $10.00 # # B6804 $5.00 # B6829 $5.00 #

B6805 $15.00 # # B6830 $10.00 # # B6805 $5.00 # B6830 $7.00 #

B6806 $15.00 # # B6831 $12.00 # # B6806 $5.00 # B6831 $7.00 #

B6807 $15.00 # # B6832 $15.00 # # B6807 $7.00 # B6832 $7.00 #

B6808 $10.00 # # B6833 $10.00 # # B6808 $10.00 # B6833 $10.00 #

B6809 $15.00 # # B6834 $10.00 # # B6809 $5.00 # B6834 $10.00 #

B6810 $15.00 # # B6835 $10.00 # # B6810 $5.00 # B6835 $5.00 #

B6811 NADA # # B6836 $15.00 # # B6811 $5.00 # B6836 $5.00 #

B6812 $15.00 # # B6837 $15.00 # # B6812 $5.00 # B6837 $7.00 #

B6813 $15.00 # # B6838 $15.00 # # B6813 $5.00 # B6838 $5.00 #

B6814 $15.00 # # B6839 $18.00 # # B6814 $5.00 # B6839 $10.00 #

B6815 $15.00 # # B6840 $12.00 # # B6815 $5.00 # B6840 $7.00 #

B6816 $10.00 # # B6841 $15.00 # # B6816 $5.00 # B6841 $7.00 #

B6817 $20.00 # # B6842 $15.00 # # B6817 $5.00 # B6842 $7.00 #

B6818 $20.00 # # B6843 $15.00 # # B6818 $10.00 # B6843 $7.00 #

B6819 $12.00 # # B6844 $12.00 # # B6819 $7.00 # B6844 $7.00 #

B6820 $15.00 # # B6845 $15.00 # # B6820 $5.00 # B6845 $7.00 #

B6821 $12.00 # # B6846 $12.00 # # B6821 $7.00 # B6846 $5.00 #

B6822 $15.00 # # B6847 $12.00 # # B6822 $5.00 # B6847 $5.00 #

B6823 $15.00 # # B6848 $15.00 # # B6823 $7.00 # B6848 $7.00 #

B6824 $15.00 # # B6849 $15.00 # # B6824 $5.00 # B6849 $7.00 #

B6825 $15.00 # # B6850 $15.00 # # B6825 $5.00 # B6850 $7.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B6851 $10.00 # # B6876 $15.00 # # B6851 $7.00 # B6876 $7.00 #

B6852 $10.00 # # B6877 $10.00 # # B6852 $10.00 # B6877 $5.00 #

B6853 $10.00 # # B6878 $20.00 # # B6853 $10.00 # B6878 $5.00 #

B6854 $15.00 # # B6879 $10.00 # # B6854 $5.00 # B6879 $10.00 #

B6855 $10.00 # # B6880 $20.00 # # B6855 $7.00 # B6880 $5.00 #

B6856 $15.00 # # B6881 $15.00 # # B6856 $5.00 # B6881 $5.00 #

B6857 $18.00 # # B6882 $15.00 # # B6857 $10.00 # B6882 $5.00 #

B6858 $12.00 # # B6883 $15.00 # # B6858 $7.00 # B6883 $7.00 #

B6859 $10.00 # # B6884 $12.00 # # B6859 $5.00 # B6884 $7.00 #

B6860 $15.00 # # B6885 $15.00 # # B6860 $7.00 # B6885 $5.00 #

B6861 $12.00 # # B6886 $20.00 # # B6861 $7.00 # B6886 $10.00 #

B6862 $10.00 # # B6887 $15.00 # # B6862 $5.00 # B6887 $7.00 #

B6863 $10.00 # # B6888 $12.00 # # B6863 $5.00 # B6888 $7.00 #

B6864 $15.00 # # B6889 $15.00 # # B6864 $5.00 # B6889 $5.00 #

B6865 $15.00 # # B6890 $10.00 # # B6865 $5.00 # B6890 $10.00 #

B6866 $10.00 # # B6891 $10.00 # # B6866 $5.00 # B6891 $7.00 #

B6867 $15.00 # # B6892 $15.00 # # B6867 $7.00 # B6892 $5.00 #

B6868 $15.00 # # B6893 $15.00 # # B6868 $5.00 # B6893 NADA #

B6869 $15.00 # # B6894 $12.00 # # B6869 $5.00 # B6894 $7.00 #

B6870 $20.00 # # B6895 $10.00 # # B6870 $10.00 # B6895 $5.00 #

B6871 $15.00 # # B6896 $8.00 # # B6871 $10.00 # B6896 $8.00 #

B6872 $8.00 # # B6897 $8.00 # # B6872 $8.00 # B6897 $8.00 #

B6873 $12.00 # # B6898 $22.00 # # B6873 $5.00 # B6898 $5.00 #

B6874 $20.00 # # B6899 $15.00 # # B6874 $5.00 # B6899 $5.00 #

B6875 $18.00 # # B6900 $15.00 # # B6875 $5.00 # B6900 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B6901 $15.00 # # B6926 $18.00 # # B6901 $7.00 # B6926 $5.00 #

B6902 $10.00 # # B6927 $15.00 # # B6902 $10.00 # B6927 $5.00 #

B6903 $15.00 # # B6928 NADA # # B6903 $5.00 # B6928 NADA #

B6904 $15.00 # # B6929 $15.00 # # B6904 $5.00 # B6929 $5.00 #

B6905 $12.00 # # B6930 $10.00 # # B6905 $5.00 # B6930 $5.00 #

B6906 $15.00 # # B6931 $12.00 # # B6906 $5.00 # B6931 $5.00 #

B6907 $12.00 # # B6932 $15.00 # # B6907 $5.00 # B6932 $7.00 #

B6908 $10.00 # # B6933 $15.00 # # B6908 $10.00 # B6933 $10.00 #

B6909 $20.00 # # B6934 $10.00 # # B6909 $5.00 # B6934 $10.00 #

B6910 $15.00 # # B6935 $15.00 # # B6910 $5.00 # B6935 $7.00 #

B6911 $15.00 # # B6936 $20.00 # # B6911 $5.00 # B6936 $10.00 #

B6912 $20.00 # # B6937 $15.00 # # B6912 $10.00 # B6937 $5.00 #

B6913 $15.00 # # B6938 $10.00 # # B6913 $15.00 # B6938 $5.00 #

B6914 $12.00 # # B6939 $15.00 # # B6914 $10.00 # B6939 $5.00 #

B6915 $18.00 # # B6940 $8.00 # # B6915 $5.00 # B6940 $5.00 #

B6916 $18.00 # # B6941 $12.00 # # B6916 $5.00 # B6941 $5.00 #

B6917 $18.00 # # B6942 $10.00 # # B6917 $5.00 # B6942 $5.00 #

B6918 $15.00 # # B6943 $15.00 # # B6918 $7.00 # B6943 $5.00 #

B6919 $20.00 # # B6944 $20.00 # # B6919 $10.00 # B6944 $5.00 #

B6920 $15.00 # # B6945 $15.00 # # B6920 $5.00 # B6945 $10.00 #

B6921 $15.00 # # B6946 $15.00 # # B6921 $5.00 # B6946 $5.00 #

B6922 $10.00 # # B6947 $15.00 # # B6922 $10.00 # B6947 $15.00 #

B6923 $10.00 # # B6948 $15.00 # # B6923 $10.00 # B6948 $7.00 #

B6924 $8.00 # # B6949 $10.00 # # B6924 $5.00 # B6949 $5.00 #

B6925 $10.00 # # B6950 $15.00 # # B6925 $5.00 # B6950 $15.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B6951 $18.00 # # B6976 $18.00 # # B6951 $5.00 # B6976 $5.00 #

B6952 $15.00 # # B6977 $10.00 # # B6952 $5.00 # B6977 $5.00 #

B6953 $15.00 # # B6978 $15.00 # # B6953 $5.00 # B6978 $7.00 #

B6954 $20.00 # # B6979 $15.00 # # B6954 $5.00 # B6979 $5.00 #

B6955 $20.00 # # B6980 $15.00 # # B6955 $5.00 # B6980 $10.00 #

B6956 $12.00 # # B6981 $10.00 # # B6956 $5.00 # B6981 $10.00 #

B6957 $15.00 # # B6982 $15.00 # # B6957 $5.00 # B6982 $5.00 #

B6958 $15.00 # # B6983 $15.00 # # B6958 $5.00 # B6983 $5.00 #

B6959 $15.00 # # B6984 $20.00 # # B6959 $5.00 # B6984 $10.00 #

B6960 $15.00 # # B6985 $10.00 # # B6960 $5.00 # B6985 $10.00 #

B6961 $15.00 # # B6986 $15.00 # # B6961 $5.00 # B6986 $5.00 #

B6962 $15.00 # # B6987 $15.00 # # B6962 $5.00 # B6987 $7.00 #

B6963 $12.00 # # B6988 $18.00 # # B6963 $5.00 # B6988 $10.00 #

B6964 $15.00 # # B6989 $12.00 # # B6964 $7.00 # B6989 $10.00 #

B6965 $15.00 # # B6990 $15.00 # # B6965 $5.00 # B6990 NADA #

B6966 $12.00 # # B6991 $15.00 # # B6966 $5.00 # B6991 $7.00 #

B6967 $10.00 # # B6992 $10.00 # # B6967 $10.00 # B6992 NADA #

B6968 $10.00 # # B6993 $15.00 # # B6968 $5.00 # B6993 $5.00 #

B6969 $10.00 # # B6994 $15.00 # # B6969 $5.00 # B6994 $5.00 #

B6970 $12.00 # # B6995 $15.00 # # B6970 $5.00 # B6995 $5.00 #

B6971 $20.00 # # B6996 $10.00 # # B6971 $5.00 # B6996 $5.00 #

B6972 $20.00 # # B6997 $15.00 # # B6972 $5.00 # B6997 $7.00 #

B6973 NADA # # B6998 $20.00 # # B6973 NADA # B6998 $5.00 #

B6974 NADA # # B6999 NADA # # B6974 NADA # B6999 NADA #

B6975 $18.00 # # B7000 NADA # # B6975 $5.00 # B7000 NADA #

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B7001 NADA # # B7028 $5.00 # # B7001 NADA # B7028 $10.00 #

B7002 NADA # # B7029 $10.00 # # B7002 NADA # B7029 $10.00 #

B7003 NADA # # B7030 $15.00 # # B7003 $10.00 # B7030 $5.00 #

B7004 $12.00 # # B7031 $15.00 # # B7004 $5.00 # B7031 $5.00 #

B7005 $15.00 # # B7032 $15.00 # # B7005 $5.00 # B7032 $5.00 #

B7006 $15.00 # # B7033 $15.00 # # B7006 $5.00 # B7033 $5.00 #

B7007 NADA # # B7034 NADA # # B7007 NADA # B7034 NADA #

B7008 $15.00 # # B7035 $10.00 # # B7008 $7.00 # B7035 $5.00 #

B7009 $15.00 # # B7036 NADA # # B7009 $5.00 # B7036 NADA #

B7010 $18.00 # # B7037 $10.00 # # B7010 $7.00 # B7037 $5.00 #

B7011 $10.00 # # B7038 $10.00 # # B7011 $5.00 # B7038 $10.00 #

B7012 $10.00 # # B7039 $15.00 # # B7012 $5.00 # B7039 $5.00 #

B7013 NADA # # B7040 $20.00 # # B7013 NADA # B7040 $5.00 #

B7014 $15.00 # # B7041 $15.00 # # B7014 $5.00 # B7041 NADA #

B7015 $15.00 # # B7042 $10.00 # # B7015 $7.00 # B7042 $10.00 #

B7016 $12.00 # # B7043 $15.00 # # B7016 $5.00 # B7043 $5.00 #

B7017 $15.00 # # B7044 $15.00 # # B7017 $5.00 # B7044 $5.00 #

B7018 $10.00 # # B7045 $15.00 # # B7018 $10.00 # B7045 $5.00 #

B7020 $18.00 # # B7046 $15.00 # # B7020 $5.00 # B7046 $5.00 #

B7022 $15.00 # # B7047 $18.00 # # B7022 $5.00 # B7047 $5.00 #

B7023 $15.00 # # B7048 $12.00 # # B7023 $5.00 # B7048 $5.00 #

B7024 $10.00 # # B7049 $12.00 # # B7024 $10.00 # B7049 $5.00 #

B7025 $10.00 # # B7050 $12.00 # # B7025 $10.00 # B7050 $7.00 #

B7026 $15.00 # # B7051 $18.00 # # B7026 $5.00 # B7051 $5.00 #

B7027 $15.00 # # B7052 $10.00 # # B7027 $5.00 # B7052 $10.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B7053 $15.00 # # B7079 $15.00 # # B7053 $5.00 # B7079 $5.00 #

B7054 $20.00 # # B7080 $15.00 # # B7054 $5.00 # B7080 $5.00 #

B7055 $7.00 # # B7081 $15.00 # # B7055 $5.00 # B7081 $7.00 #

B7056 $10.00 # # B7082 $12.00 # # B7056 $5.00 # B7082 $5.00 #

B7057 $15.00 # # B7083 $12.00 # # B7057 $5.00 # B7083 $5.00 #

B7058 $15.00 # # B7084 $15.00 # # B7058 $7.00 # B7084 $5.00 #

B7059 $12.00 # # B7085 $15.00 # # B7059 $10.00 # B7085 $5.00 #

B7060 $15.00 # # B7086 $12.00 # # B7060 $5.00 # B7086 $5.00 #

B7061 $7.00 # # B7087 $18.00 # # B7061 $5.00 # B7087 $10.00 #

B7062 $15.00 # # B7088 $15.00 # # B7062 $5.00 # B7088 $5.00 #

B7063 $18.00 # # B7089 $15.00 # # B7063 $5.00 # B7089 $5.00 #

B7064 $15.00 # # B7090 $18.00 # # B7064 $5.00 # B7090 $5.00 #

B7065 $10.00 # # B7091 $15.00 # # B7065 $5.00 # B7091 $5.00 #

B7066 $10.00 # # B7092 $15.00 # # B7066 $10.00 # B7092 $5.00 #

B7067 $10.00 # # B7093 $15.00 # # B7067 $10.00 # B7093 $5.00 #

B7068 $15.00 # # B7094 $20.00 # # B7068 $5.00 # B7094 $5.00 #

B7069 $15.00 # # B7095 $15.00 # # B7069 $5.00 # B7095 $5.00 #

B7070 $20.00 # # B7096 $20.00 # # B7070 NADA # B7096 $5.00 #

B7071 $15.00 # # B7097 NADA # # B7071 NADA # B7097 NADA #

B7072 $15.00 # # B7099 $20.00 # # B7072 $5.00 # B7099 $5.00 #

B7073 $18.00 # # B7100 $20.00 # # B7073 $5.00 # B7100 $5.00 #

B7074 $18.00 # # B7101 $10.00 # # B7074 $5.00 # B7101 $7.00 #

B7075 $24.00 # # B7104 $15.00 # # B7075 $10.00 # B7104 $10.00 #

B7076 $20.00 # # B7109 $10.00 # # B7076 NADA # B7109 $10.00 #

B7077 $15.00 # # B7111 $12.00 # # B7077 $5.00 # B7111 $7.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B7112 $15.00 # # B7137 $15.00 # # B7112 $5.00 # B7137 $5.00 #

B7113 $18.00 # # B7138 $12.00 # # B7113 $5.00 # B7138 $5.00 #

B7114 $18.00 # # B7139 $12.00 # # B7114 $5.00 # B7139 $5.00 #

B7115 $18.00 # # B7140 $15.00 # # B7115 $5.00 # B7140 $5.00 #

B7116 $12.00 # # B7141 $12.00 # # B7116 $5.00 # B7141 $7.00 #

B7117 $15.00 # # B7142 $15.00 # # B7117 $5.00 # B7142 $5.00 #

B7118 $10.00 # # B7143 $12.00 # # B7118 $5.00 # B7143 $5.00 #

B7119 $12.00 # # B7144 $20.00 # # B7119 $5.00 # B7144 $5.00 #

B7120 $12.00 # # B7145 $20.00 # # B7120 $10.00 # B7145 $5.00 #

B7121 $12.00 # # B7146 $15.00 # # B7121 $5.00 # B7146 $5.00 #

B7122 $12.00 # # B7147 $12.00 # # B7122 $5.00 # B7147 $5.00 #

B7123 $15.00 # # B7148 $12.00 # # B7123 $5.00 # B7148 $5.00 #

B7124 $15.00 # # B7149 $20.00 # # B7124 $5.00 # B7149 $5.00 #

B7125 $12.00 # # B7150 $20.00 # # B7125 $5.00 # B7150 $5.00 #

B7126 $12.00 # # B7151 $12.00 # # B7126 $5.00 # B7151 $5.00 #

B7127 $10.00 # # B7152 $15.00 # # B7127 $5.00 # B7152 $5.00 #

B7128 $12.00 # # B7153 $20.00 # # B7128 $5.00 # B7153 $5.00 #

B7129 $20.00 # # B7154 $20.00 # # B7129 $5.00 # B7154 $5.00 #

B7130 $20.00 # # B7155 $12.00 # # B7130 $5.00 # B7155 $5.00 #

B7131 $20.00 # # B7156 $10.00 # # B7131 $5.00 # B7156 $10.00 #

B7132 $10.00 # # B7157 $15.00 # # B7132 $10.00 # B7157 $5.00 #

B7133 $12.00 # # B7158 NADA # # B7133 $5.00 # B7158 $5.00 #

B7134 $12.00 # # B7159 $18.00 # # B7134 $5.00 # B7159 $5.00 #

B7135 $20.00 # # B7160 $18.00 # # B7135 $5.00 # B7160 $5.00 #

B7136 $15.00 # # B7161 $15.00 # # B7136 $5.00 # B7161 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B7162 $20.00 # # B7187 $12.00 # # B7162 NADA # B7187 $5.00 #

B7163 $20.00 # # B7188 $15.00 # # B7163 $5.00 # B7188 $5.00 #

B7164 $12.00 # # B7189 $12.00 # # B7164 $5.00 # B7189 $5.00 #

B7165 $12.00 # # B7190 $12.00 # # B7165 $5.00 # B7190 $5.00 #

B7166 $20.00 # # B7191 $20.00 # # B7166 $5.00 # B7191 $5.00 #

B7167 $10.00 # # B7192 $15.00 # # B7167 $10.00 # B7192 $5.00 #

B7168 $15.00 # # B7193 $12.00 # # B7168 $5.00 # B7193 $5.00 #

B7169 $20.00 # # B7194 $12.00 # # B7169 NADA # B7194 $5.00 #

B7170 $20.00 # # B7195 $15.00 # # B7170 NADA # B7195 $10.00 #

B7171 $20.00 # # B7196 $15.00 # # B7171 $5.00 # B7196 $10.00 #

B7172 $12.00 # # B7197 $10.00 # # B7172 $5.00 # B7197 $10.00 #

B7173 $20.00 # # B7198 $15.00 # # B7173 $5.00 # B7198 $5.00 #

B7174 $12.00 # # B7199 $12.00 # # B7174 $5.00 # B7199 $5.00 #

B7175 $15.00 # # B7200 $12.00 # # B7175 $7.00 # B7200 $5.00 #

B7176 $12.00 # # B7201 $10.00 # # B7176 $5.00 # B7201 $5.00 #

B7177 $12.00 # # B7202 $15.00 # # B7177 $5.00 # B7202 $5.00 #

B7178 $20.00 # # B7203 $7.00 # # B7178 $5.00 # B7203 $5.00 #

B7179 $12.00 # # B7204 $10.00 # # B7179 $5.00 # B7204 $5.00 #

B7180 $12.00 # # B7205 $15.00 # # B7180 $5.00 # B7205 $7.00 #

B7181 $20.00 # # B7206 $15.00 # # B7181 $5.00 # B7206 $7.00 #

B7182 $12.00 # # B7207 $18.00 # # B7182 $5.00 # B7207 $5.00 #

B7183 $10.00 # # B7208 $18.00 # # B7183 $5.00 # B7208 $7.00 #

B7184 $20.00 # # B7209 $12.00 # # B7184 $5.00 # B7209 $5.00 #

B7185 $15.00 # # B7210 $10.00 # # B7185 $5.00 # B7210 $5.00 #

B7186 $12.00 # # B7211 $15.00 # # B7186 $5.00 # B7211 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B7213 $18.00 # # B7244 $15.00 # # B7213 $5.00 # B7244 $5.00 #

B7214 $15.00 # # B7245 $15.00 # # B7214 $10.00 # B7245 $5.00 #

B7218 $15.00 # # B7246 $15.00 # # B7218 $5.00 # B7246 $5.00 #

B7219 $10.00 # # B7247 $10.00 # # B7219 $5.00 # B7247 $7.00 #

B7220 $15.00 # # B7248 $12.00 # # B7220 $5.00 # B7248 $7.00 #

B7221 $10.00 # # B7249 $15.00 # # B7221 $5.00 # B7249 $5.00 #

B7222 $10.00 # # B7250 $15.00 # # B7222 $7.00 # B7250 $5.00 #

B7223 $15.00 # # B7251 $12.00 # # B7223 $5.00 # B7251 $5.00 #

B7224 $15.00 # # B7252 $12.00 # # B7224 $5.00 # B7252 $5.00 #

B7225 $20.00 # # B7253 $15.00 # # B7225 $10.00 # B7253 $5.00 #

B7226 $18.00 # # B7254 $15.00 # # B7226 $5.00 # B7254 $5.00 #

B7227 $18.00 # # B7255 NADA # # B7227 $7.00 # B7255 $7.00 #

B7228 $15.00 # # B7256 $10.00 # # B7228 $5.00 # B7256 $5.00 #

B7229 $12.00 # # B7257 $15.00 # # B7229 $5.00 # B7257 $7.00 #

B7230 $10.00 # # B7258 $15.00 # # B7230 $5.00 # B7258 $5.00 #

B7231 $15.00 # # B7259 $15.00 # # B7231 $5.00 # B7259 $5.00 #

B7234 $10.00 # # B7260 $20.00 # # B7234 $5.00 # B7260 $5.00 #

B7235 $15.00 # # B7261 $12.00 # # B7235 $5.00 # B7261 $7.00 #

B7236 $15.00 # # B7262 $12.00 # # B7236 $5.00 # B7262 $5.00 #

B7237 $18.00 # # B7263 $15.00 # # B7237 $5.00 # B7263 $7.00 #

B7238 $12.00 # # B7264 $8.00 # # B7238 $5.00 # B7264 $5.00 #

B7240 NADA # # B7265 $8.00 # # B7240 NADA # B7265 $5.00 #

B7241 $15.00 # # B7266 $8.00 # # B7241 $5.00 # B7266 $5.00 #

B7242 $20.00 # # B7267 $8.00 # # B7242 $5.00 # B7267 $5.00 #

B7243 $10.00 # # B7268 $7.00 # # B7243 $5.00 # B7268 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B7269 NADA # # B7301 $15.00 # # B7269 NADA # B7301 $5.00 #

B7270 $7.00 # # B7303 $15.00 # # B7270 $5.00 # B7303 $5.00 #

B7271 $15.00 # # B7304 $10.00 # # B7271 $7.00 # B7304 $10.00 #

B7272 $15.00 # # B7305 $15.00 # # B7272 $7.00 # B7305 $7.00 #

B7273 $15.00 # # B7308 $15.00 # # B7273 $5.00 # B7308 $5.00 #

B7274 $10.00 # # B7309 $18.00 # # B7274 $5.00 # B7309 $5.00 #

B7275 $8.00 # # B7310 $18.00 # # B7275 $5.00 # B7310 $5.00 #

B7276 $10.00 # # B7313 $15.00 # # B7276 $5.00 # B7313 $10.00 #

B7277 $10.00 # # B7314 $15.00 # # B7277 $10.00 # B7314 $7.00 #

B7278 $20.00 # # B7315 $15.00 # # B7278 $10.00 # B7315 $7.00 #

B7279 $15.00 # # B7316 $20.00 # # B7279 $7.00 # B7316 $10.00 #

B7280 $10.00 # # B7317 $10.00 # # B7280 $5.00 # B7317 $10.00 #

B7281 $15.00 # # B7318 $20.00 # # B7281 $7.00 # B7318 $5.00 #

B7283 $15.00 # # B7319 $18.00 # # B7283 $7.00 # B7319 $5.00 #

B7284 $15.00 # # B7320 $18.00 # # B7284 $7.00 # B7320 $5.00 #

B7285 $18.00 # # B7321 $15.00 # # B7285 $10.00 # B7321 $5.00 #

B7286 $10.00 # # B7322 $18.00 # # B7286 $5.00 # B7322 $5.00 #

B7288 $15.00 # # B7323 $15.00 # # B7288 $7.00 # B7323 $5.00 #

B7290 $15.00 # # B7324 NADA # # B7290 $5.00 # B7324 $5.00 #

B7291 $15.00 # # B7325 $18.00 # # B7291 $5.00 # B7325 $10.00 #

B7292 $10.00 # # B7326 $10.00 # # B7292 $5.00 # B7326 $10.00 #

B7297 $15.00 # # B7330 $10.00 # # B7297 $7.00 # B7330 $10.00 #

B7298 $15.00 # # B7331 $15.00 # # B7298 $5.00 # B7331 $5.00 #

B7299 NADA # # B7332 $12.00 # # B7299 $5.00 # B7332 $7.00 #

B7300 $18.00 # # B7333 $18.00 # # B7300 $5.00 # B7333 $5.00 #

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CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

B7334 $18.00 # # * * * * B7334 $5.00 # * * *

* * * * * * * * * * * * * *

* * * * * * * * * * * * * *

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CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

BA1 $15.00 15 15 BA26 $15.00 15 15 BA1 $5.00 15 BA26 $5.00 15

BA2 $15.00 15 15 BA27 $15.00 15 15 BA2 $5.00 15 BA27 $5.00 15

BA3 $15.00 15 15 BA28 $15.00 15 15 BA3 $5.00 15 BA28 $5.00 15

BA4 $15.00 15 15 BA29 $15.00 15 15 BA4 $5.00 15 BA29 $5.00 15

BA5 $15.00 15 15 BA30 $15.00 15 15 BA5 $5.00 15 BA30 $5.00 15

BA6 $15.00 15 15 BA31 $15.00 15 15 BA6 $5.00 15 BA31 $5.00 15

BA7 $15.00 15 15 BA32 $15.00 15 15 BA7 $5.00 15 BA32 $5.00 15

BA8 $15.00 15 15 BA33 $15.00 15 15 BA8 $5.00 15 BA33 $5.00 15

BA9 $15.00 15 15 BA34 $15.00 15 15 BA9 $5.00 15 BA34 $5.00 15

BA10 $15.00 15 15 BA35 $15.00 15 15 BA10 $5.00 15 BA35 $5.00 15

BA11 $15.00 15 15 BA36 $15.00 15 15 BA11 $5.00 15 BA36 $5.00 15

BA12 $10.00 15 15 BA37 $15.00 15 15 BA12 $5.00 15 BA37 $5.00 15

BA13 $15.00 15 15 BA38 $15.00 15 15 BA13 $5.00 15 BA38 $5.00 15

BA14 $15.00 15 15 BA39 $15.00 15 15 BA14 $5.00 15 BA39 $5.00 15

BA15 $15.00 15 15 BA40 $15.00 15 15 BA15 $5.00 15 BA40 $5.00 15

BA16 $15.00 15 15 BA41 $15.00 15 15 BA16 $5.00 15 BA41 $5.00 15

BA17 $15.00 15 15 BA42 $15.00 15 15 BA17 $5.00 15 BA42 $5.00 15

BA18 $15.00 15 15 BA43 $15.00 15 15 BA18 $5.00 15 BA43 $5.00 15

BA19 $15.00 15 15 BA44 $15.00 15 15 BA19 $5.00 15 BA44 $5.00 15

BA20 $15.00 15 15 BA45 $15.00 15 15 BA20 $5.00 15 BA45 $5.00 15

BA21 $15.00 15 15 BA46 $15.00 15 15 BA21 $5.00 15 BA46 $5.00 15

BA22 $15.00 15 15 BA47 $15.00 15 15 BA22 $5.00 15 BA47 $5.00 15

BA23 $15.00 15 15 BA48 $15.00 15 15 BA23 $5.00 15 BA48 $5.00 15

BA24 $15.00 15 15 BA49 $15.00 15 15 BA24 $5.00 15 BA49 $5.00 15

BA25 $15.00 15 15 BA50 $15.00 15 15 BA25 $5.00 15 BA50 $5.00 15

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CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

BA51 $15.00 15 15 BA76 $15.00 15 15 BA51 $5.00 15 BA76 $5.00 15

BA52 $12.00 15 15 BA77 $10.00 15 15 BA52 $5.00 15 BA77 $5.00 15

BA53 $15.00 15 15 BA78 $12.00 15 15 BA53 $5.00 15 BA78 $5.00 15

BA54 $15.00 15 15 BA79 $15.00 15 15 BA54 $5.00 15 BA79 $5.00 15

BA55 $15.00 15 15 BA80 $15.00 15 15 BA55 $5.00 15 BA80 $5.00 15

BA56 $15.00 15 15 BA81 $15.00 15 15 BA56 $5.00 15 BA81 $5.00 15

BA57 $15.00 15 15 BA82 $12.00 15 15 BA57 $5.00 15 BA82 $5.00 15

BA58 $15.00 15 15 BA83 $15.00 15 15 BA58 $5.00 15 BA83 $5.00 15

BA59 $15.00 15 15 BA84 $15.00 15 15 BA59 $5.00 15 BA84 $5.00 15

BA60 $15.00 15 15 BA85 $15.00 15 15 BA60 $5.00 15 BA85 $5.00 15

BA61 $10.00 15 15 BA86 $15.00 15 15 BA61 $5.00 15 BA86 $5.00 15

BA62 $15.00 15 15 BA87 $15.00 15 15 BA62 $5.00 15 BA87 $5.00 15

BA63 $15.00 15 15 BA88 $15.00 15 15 BA63 $5.00 15 BA88 $5.00 15

BA64 $15.00 15 15 BA89 $15.00 15 15 BA64 $5.00 15 BA89 $5.00 15

BA65 $15.00 15 15 BA90 $15.00 15 15 BA65 $5.00 15 BA90 $5.00 15

BA66 $12.00 15 15 BA91 $15.00 15 15 BA66 $5.00 15 BA91 $5.00 15

BA67 $15.00 15 15 BA92 $12.00 15 15 BA67 $5.00 15 BA92 $5.00 15

BA68 $15.00 15 15 BA93 $15.00 15 15 BA68 $5.00 15 BA93 $5.00 15

BA69 $15.00 15 15 BA94 $15.00 15 15 BA69 $5.00 15 BA94 $5.00 15

BA70 $15.00 15 15 BA95 $15.00 15 15 BA70 $5.00 15 BA95 $5.00 15

BA71 $12.00 15 15 BA96 $15.00 15 15 BA71 $5.00 15 BA96 $5.00 15

BA72 $15.00 15 15 BA97 $15.00 15 15 BA72 $5.00 15 BA97 $5.00 15

BA73 $15.00 15 15 BA98 $15.00 15 15 BA73 $5.00 15 BA98 $5.00 15

BA74 $10.00 15 15 BA99 $15.00 15 15 BA74 $5.00 15 BA99 $5.00 15

BA75 $15.00 15 15 BA100 $10.00 15 15 BA75 $5.00 15 BA100 $5.00 15

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CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

BA101 $15.00 15 15 BA126 $15.00 15 15 BA101 $5.00 15 BA126 $5.00 15

BA102 $15.00 15 15 BA127 $15.00 15 15 BA102 $5.00 15 BA127 $5.00 15

BA103 $15.00 15 15 BA128 $15.00 15 15 BA103 $5.00 15 BA128 $5.00 15

BA104 $15.00 15 15 BA129 $15.00 15 15 BA104 $5.00 15 BA129 $5.00 15

BA105 $10.00 15 15 BA130 $15.00 15 15 BA105 $5.00 15 BA130 $5.00 15

BA106 $15.00 15 15 BA131 $15.00 15 15 BA106 $5.00 15 BA131 $5.00 15

BA107 $15.00 15 15 BA132 $15.00 15 15 BA107 $5.00 15 BA132 $5.00 15

BA108 $15.00 15 15 BA133 $15.00 15 15 BA108 $5.00 15 BA133 $5.00 15

BA109 $12.00 15 15 BA134 $15.00 15 15 BA109 $5.00 15 BA134 $5.00 15

BA110 $10.00 15 15 BA135 $15.00 15 15 BA110 $5.00 15 BA135 $5.00 15

BA111 $15.00 15 15 BA136 $10.00 15 15 BA111 $5.00 15 BA136 $5.00 15

BA112 $15.00 15 15 BA137 $15.00 15 15 BA112 $5.00 15 BA137 $5.00 15

BA113 $15.00 15 15 BA138 $15.00 15 15 BA113 $5.00 15 BA138 $5.00 15

BA114 $12.00 15 15 BA139 $15.00 15 15 BA114 $5.00 15 BA139 $5.00 15

BA115 $15.00 15 15 BA140 $15.00 15 15 BA115 $5.00 15 BA140 $5.00 15

BA116 $15.00 15 15 BA141 $15.00 15 15 BA116 $5.00 15 BA141 $5.00 15

BA117 $15.00 15 15 BA142 $15.00 15 15 BA117 $5.00 15 BA142 $5.00 15

BA118 $12.00 15 15 BA143 $15.00 15 15 BA118 $5.00 15 BA143 $5.00 15

BA119 $12.00 15 15 BA144 $15.00 15 15 BA119 $5.00 15 BA144 $5.00 15

BA120 $10.00 15 15 BA145 $15.00 15 15 BA120 $5.00 15 BA145 $5.00 15

BA121 $15.00 15 15 BA146 $15.00 15 15 BA121 $5.00 15 BA146 $5.00 15

BA122 $15.00 15 15 BA147 $10.00 15 15 BA122 $5.00 15 BA147 $5.00 15

BA123 $15.00 15 15 BA148 $12.00 15 15 BA123 $5.00 15 BA148 $5.00 15

BA124 $12.00 15 15 BA149 $15.00 15 15 BA124 $5.00 15 BA149 $5.00 15

BA125 $15.00 15 15 BA150 $8.00 15 15 BA125 $5.00 15 BA150 $5.00 15

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CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

BA151 $15.00 15 15 BA176 $15.00 15 15 BA151 $5.00 15 BA176 $5.00 15

BA152 $10.00 15 15 BA177 $15.00 15 15 BA152 $5.00 15 BA177 $5.00 15

BA153 $15.00 15 15 BA178 $15.00 15 15 BA153 $5.00 15 BA178 $5.00 15

BA154 $15.00 15 15 BA179 $15.00 15 15 BA154 $5.00 15 BA179 $5.00 15

BA155 $15.00 15 15 BA180 $15.00 15 15 BA155 $5.00 15 BA180 $5.00 15

BA156 $15.00 15 15 BA181 $15.00 15 15 BA156 $5.00 15 BA181 $5.00 15

BA157 $15.00 15 15 BA182 $15.00 15 15 BA157 $5.00 15 BA182 $5.00 15

BA158 $15.00 15 15 BA183 $15.00 15 15 BA158 $5.00 15 BA183 $5.00 15

BA159 $8.00 15 15 BA184 $15.00 15 15 BA159 $5.00 15 BA184 $5.00 15

BA160 $15.00 15 15 BA185 $15.00 15 15 BA160 $5.00 15 BA185 $5.00 15

BA161 $15.00 15 15 BA186 $15.00 15 15 BA161 $5.00 15 BA186 $5.00 15

BA162 $15.00 15 15 BA187 $15.00 15 15 BA162 $5.00 15 BA187 $5.00 15

BA163 $15.00 15 15 BA188 $15.00 15 15 BA163 $5.00 15 BA188 $5.00 15

BA164 $15.00 15 15 BA189 $15.00 15 15 BA164 $5.00 15 BA189 $5.00 15

BA165 $15.00 15 15 BA190 $15.00 15 15 BA165 $5.00 15 BA190 $5.00 15

BA166 $15.00 15 15 BA191 $15.00 15 15 BA166 $5.00 15 BA191 $5.00 15

BA167 $15.00 15 15 BA192 $15.00 15 15 BA167 $5.00 15 BA192 $5.00 15

BA168 $15.00 15 15 BA193 $15.00 15 15 BA168 $5.00 15 BA193 $5.00 15

BA169 $15.00 15 15 BA194 $15.00 15 15 BA169 $5.00 15 BA194 $5.00 15

BA170 $15.00 15 15 BA195 $15.00 15 15 BA170 $5.00 15 BA195 $5.00 15

BA171 $8.00 15 15 BA196 $15.00 15 15 BA171 $5.00 15 BA196 $5.00 15

BA172 $15.00 15 15 BA197 $15.00 15 15 BA172 $5.00 15 BA197 $5.00 15

BA173 $15.00 15 15 BA198 $15.00 15 15 BA173 $5.00 15 BA198 $5.00 15

BA174 $15.00 15 15 BA199 $15.00 15 15 BA174 $5.00 15 BA199 $5.00 15

BA175 $10.00 15 15 BA200 $15.00 15 15 BA175 $5.00 15 BA200 $5.00 15

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CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

BA201 $15.00 15 15 BA227 $15.00 15 15 BA201 $5.00 15 BA227 $5.00 15

BA202 $15.00 15 15 BA228 $15.00 15 15 BA202 $5.00 15 BA228 $5.00 15

BA203 $15.00 15 15 BA229 $15.00 15 15 BA203 $5.00 15 BA229 $5.00 15

BA204 $15.00 15 15 BA230 $15.00 15 15 BA204 $5.00 15 BA230 $5.00 15

BA205 $15.00 15 15 BA231 $8.00 15 15 BA205 $5.00 15 BA231 $5.00 15

BA206 $15.00 15 15 BA232 $10.00 15 15 BA206 $5.00 15 BA232 $5.00 15

BA207 $15.00 15 15 BA233 $15.00 15 15 BA207 $5.00 15 BA233 $5.00 15

BA208 $15.00 15 15 BA234 $10.00 15 15 BA208 $5.00 15 BA234 $5.00 15

BA209 $15.00 15 15 BA235 $15.00 15 15 BA209 $5.00 15 BA235 $5.00 15

BA210 $15.00 15 15 BA236 $15.00 15 15 BA210 $5.00 15 BA236 $5.00 15

BA211 $15.00 15 15 BA237 $10.00 15 15 BA211 $5.00 15 BA237 $5.00 15

BA212 $15.00 15 15 BA238 $15.00 15 15 BA212 $5.00 15 BA238 $5.00 15

BA213 $15.00 15 15 BA239 $15.00 15 15 BA213 $5.00 15 BA239 $5.00 15

BA214 $15.00 15 15 BA240 $12.00 15 15 BA214 $5.00 15 BA240 $5.00 15

BA215 $15.00 15 15 BA241 $10.00 15 15 BA215 $5.00 15 BA241 $5.00 15

BA216 $15.00 15 15 BA242 $10.00 15 15 BA216 $5.00 15 BA242 $5.00 15

BA217 $15.00 15 15 BA243 $12.00 15 15 BA217 $5.00 15 BA243 $5.00 15

BA218 $15.00 15 15 BA244 $15.00 15 15 BA218 $5.00 15 BA244 $5.00 15

BA219 $15.00 15 15 BA245 $15.00 15 15 BA219 $5.00 15 BA245 $5.00 15

BA220 $15.00 15 15 BA246 $15.00 15 15 BA220 $7.00 15 BA246 $5.00 15

BA222 $15.00 15 15 BA247 $10.00 15 15 BA222 $7.00 15 BA247 $5.00 15

BA223 $15.00 15 15 BA248 $15.00 15 15 BA223 $5.00 15 BA248 $5.00 15

BA224 $12.00 15 15 BA249 $10.00 15 15 BA224 $5.00 15 BA249 $5.00 15

BA225 $15.00 15 15 BA250 $15.00 15 15 BA225 $5.00 15 BA250 $5.00 15

BA226 $15.00 15 15 BA251 $10.00 15 15 BA226 $5.00 15 BA251 $5.00 15

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CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

BA252 $15.00 15 15 BA277 $10.00 15 15 BA252 $5.00 15 BA277 $5.00 15

BA253 $15.00 15 15 BA278 $15.00 15 15 BA253 $5.00 15 BA278 $5.00 15

BA254 $15.00 15 15 BA279 $15.00 15 15 BA254 $5.00 15 BA279 $5.00 15

BA255 $15.00 15 15 BA280 $15.00 15 15 BA255 $5.00 15 BA280 $5.00 15

BA256 $10.00 15 15 BA281 $15.00 15 15 BA256 $5.00 15 BA281 $5.00 15

BA257 $15.00 15 15 BA282 $15.00 15 15 BA257 $5.00 15 BA282 $5.00 15

BA258 $15.00 15 15 BA283 $15.00 15 15 BA258 $5.00 15 BA283 $5.00 15

BA259 $10.00 15 15 BA284 $15.00 15 15 BA259 $5.00 15 BA284 $5.00 15

BA260 $10.00 15 15 BA285 $12.00 15 15 BA260 $5.00 15 BA285 $5.00 15

BA261 $12.00 15 15 BA286 $15.00 15 15 BA261 $5.00 15 BA286 $5.00 15

BA262 $15.00 15 15 BA287 $15.00 15 15 BA262 $5.00 15 BA287 $5.00 15

BA263 $8.00 15 15 BA288 $10.00 15 15 BA263 $5.00 15 BA288 $5.00 15

BA264 $8.00 15 15 BA289 $15.00 15 15 BA264 $5.00 15 BA289 $5.00 15

BA265 $12.00 15 15 BA290 $12.00 15 15 BA265 $5.00 15 BA290 $5.00 15

BA266 $10.00 15 15 BA291 $15.00 15 15 BA266 $5.00 15 BA291 $5.00 15

BA267 $15.00 15 15 BA292 $12.00 # # BA267 $5.00 15 BA292 $5.00 #

BA268 $15.00 15 15 BA293 $15.00 # # BA268 $5.00 15 BA293 $5.00 #

BA269 $15.00 15 15 BA294 $15.00 # # BA269 $5.00 15 BA294 $5.00 #

BA270 $15.00 15 15 BA295 $15.00 # # BA270 $5.00 15 BA295 $5.00 #

BA271 $10.00 15 15 BA296 $15.00 # # BA271 $5.00 15 BA296 $5.00 #

BA272 $10.00 15 15 BA297 $15.00 # # BA272 $5.00 15 BA297 $5.00 #

BA273 $15.00 15 15 BA298 $15.00 # # BA273 $5.00 15 BA298 $5.00 #

BA274 $10.00 15 15 BA299 $10.00 # # BA274 $5.00 15 BA299 $5.00 #

BA275 $10.00 15 15 BA300 $12.00 # # BA275 $5.00 15 BA300 $5.00 #

BA276 $10.00 15 15 BA301 $15.00 # # BA276 $5.00 15 BA301 $5.00 #

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CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

BA302 $15.00 # # BA327 $12.00 # # BA302 $5.00 # BA327 $5.00 #

BA303 $15.00 # # BA328 $15.00 # # BA303 $5.00 # BA328 $5.00 #

BA304 $15.00 # # BA329 $15.00 # # BA304 $5.00 # BA329 $5.00 #

BA305 $15.00 # # BA330 $15.00 # # BA305 $5.00 # BA330 $5.00 #

BA306 $12.00 # # BA331 $15.00 # # BA306 $5.00 # BA331 $5.00 #

BA307 $15.00 # # BA332 $15.00 # # BA307 $5.00 # BA332 $5.00 #

BA308 $15.00 # # BA333 $12.00 # # BA308 $5.00 # BA333 $5.00 #

BA309 $8.00 # # BA334 $15.00 # # BA309 $5.00 # BA334 $5.00 #

BA310 $10.00 # # BA335 $15.00 # # BA310 $5.00 # BA335 $5.00 #

BA311 $15.00 # # BA336 $15.00 # # BA311 $5.00 # BA336 $5.00 #

BA312 $10.00 # # BA337 $15.00 # # BA312 $5.00 # BA337 $5.00 #

BA313 $15.00 # # BA338 $12.00 # # BA313 $5.00 # BA338 $5.00 #

BA314 $12.00 # # BA339 $15.00 # # BA314 $5.00 # BA339 $5.00 #

BA315 $15.00 # # BA340 $15.00 # # BA315 $5.00 # BA340 $5.00 #

BA316 $10.00 # # BA341 $15.00 # # BA316 $5.00 # BA341 $5.00 #

BA317 $8.00 # # BA342 $10.00 # # BA317 $5.00 # BA342 $5.00 #

BA318 $15.00 # # BA343 $15.00 # # BA318 $5.00 # BA343 $5.00 #

BA319 $15.00 # # BA344 $15.00 # # BA319 $5.00 # BA344 $5.00 #

BA320 $15.00 # # BA345 $15.00 # # BA320 $5.00 # BA345 $5.00 #

BA321 $15.00 # # BA346 $15.00 # # BA321 $5.00 # BA346 $5.00 #

BA322 $15.00 # # BA347 $15.00 # # BA322 $5.00 # BA347 $5.00 #

BA323 $10.00 # # BA348 $15.00 # # BA323 $5.00 # BA348 $5.00 #

BA324 $15.00 # # BA349 $15.00 # # BA324 $5.00 # BA349 $5.00 #

BA325 $15.00 # # BA350 $10.00 # # BA325 $5.00 # BA350 $5.00 #

BA326 $10.00 # # BA351 $15.00 # # BA326 $5.00 # BA351 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

BA352 $12.00 # # BA377 $15.00 # # BA352 $5.00 # BA377 $5.00 #

BA353 $10.00 # # BA378 $15.00 # # BA353 $5.00 # BA378 $5.00 #

BA354 $12.00 # # BA379 $15.00 # # BA354 $5.00 # BA379 $5.00 #

BA355 $15.00 # # BA380 $10.00 # # BA355 $5.00 # BA380 $5.00 #

BA356 $15.00 # # BA382 $12.00 # # BA356 $5.00 # BA382 $5.00 #

BA357 $15.00 # # BA383 $15.00 # # BA357 $5.00 # BA383 $5.00 #

BA358 $15.00 # # BA384 $15.00 # # BA358 $5.00 # BA384 $5.00 #

BA359 $15.00 # # BA385 $15.00 # # BA359 $5.00 # BA385 $5.00 #

BA360 $15.00 # # BA386 $15.00 # # BA360 $5.00 # BA386 $5.00 #

BA361 $15.00 # # BA387 $15.00 # # BA361 $5.00 # BA387 $5.00 #

BA362 $15.00 # # BA388 $12.00 # # BA362 $5.00 # BA388 $5.00 #

BA363 $15.00 # # BA389 $15.00 # # BA363 $5.00 # BA389 $5.00 #

BA364 $10.00 # # BA390 $15.00 # # BA364 $5.00 # BA390 $5.00 #

BA365 $15.00 # # BA391 $15.00 # # BA365 $5.00 # BA391 $5.00 #

BA366 $15.00 # # BA392 $10.00 # # BA366 $5.00 # BA392 $5.00 #

BA367 $15.00 # # BA393 $15.00 # # BA367 $5.00 # BA393 $5.00 #

BA368 $15.00 # # BA394 $15.00 # # BA368 $5.00 # BA394 $5.00 #

BA369 $15.00 # # BA395 $15.00 # # BA369 $5.00 # BA395 $5.00 #

BA370 $15.00 # # BA396 $10.00 # # BA370 $5.00 # BA396 $5.00 #

BA371 $15.00 # # BA397 $15.00 # # BA371 $5.00 # BA397 $5.00 #

BA372 $15.00 # # BA398 $15.00 # # BA372 $5.00 # BA398 $5.00 #

BA373 $10.00 # # BA399 $15.00 # # BA373 $5.00 # BA399 $5.00 #

BA374 $10.00 # # BA400 $15.00 # # BA374 $5.00 # BA400 $5.00 #

BA375 $10.00 # # BA401 $15.00 # # BA375 $5.00 # BA401 $5.00 #

BA376 $15.00 # # BA402 $15.00 # # BA376 $5.00 # BA402 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

BA403 $12.00 # # BA428 $10.00 # # BA403 $5.00 # BA428 $7.00 #

BA404 $15.00 # # BA429 $10.00 # # BA404 $5.00 # BA429 $5.00 #

BA405 $15.00 # # BA430 $10.00 # # BA405 $5.00 # BA430 $5.00 #

BA406 $15.00 # # BA431 $10.00 # # BA406 $5.00 # BA431 $5.00 #

BA407 $15.00 # # BA432 $15.00 # # BA407 $5.00 # BA432 $5.00 #

BA408 $15.00 # # BA433 $10.00 # # BA408 $5.00 # BA433 $5.00 #

BA409 $15.00 # # BA434 $15.00 # # BA409 $5.00 # BA434 $5.00 #

BA410 $12.00 # # BA435 $15.00 # # BA410 $5.00 # BA435 $5.00 #

BA411 $15.00 # # BA436 $12.00 # # BA411 $5.00 # BA436 $5.00 #

BA412 $15.00 # # BA437 $15.00 # # BA412 $5.00 # BA437 $5.00 #

BA413 $10.00 # # BA438 $10.00 # # BA413 $7.00 # BA438 $5.00 #

BA414 $15.00 # # BA439 $15.00 # # BA414 $7.00 # BA439 $5.00 #

BA415 $10.00 # # BA440 $12.00 # # BA415 $5.00 # BA440 $5.00 #

BA416 $12.00 # # BA441 $10.00 # # BA416 $5.00 # BA441 $5.00 #

BA417 $15.00 # # BA442 $15.00 # # BA417 $5.00 # BA442 $5.00 #

BA418 $15.00 # # BA443 $15.00 # # BA418 $5.00 # BA443 $5.00 #

BA419 $15.00 # # BA444 $15.00 # # BA419 $5.00 # BA444 $5.00 #

BA420 $12.00 # # BA445 $15.00 # # BA420 $5.00 # BA445 $5.00 #

BA421 $15.00 # # BA446 $12.00 # # BA421 $5.00 # BA446 $5.00 #

BA422 $15.00 # # BA447 $10.00 # # BA422 $5.00 # BA447 $5.00 #

BA423 $15.00 # # BA448 $15.00 # # BA423 $5.00 # BA448 $5.00 #

BA424 $12.00 # # BA449 $15.00 # # BA424 $5.00 # BA449 $5.00 #

BA425 $10.00 # # BA450 $15.00 # # BA425 $7.00 # BA450 $5.00 #

BA426 $15.00 # # BA451 $12.00 # # BA426 $5.00 # BA451 $5.00 #

BA427 $15.00 # # BA452 $15.00 # # BA427 $7.00 # BA452 $5.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

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CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

BA453 $8.00 # # BA478 $15.00 # # BA453 $5.00 # BA478 $5.00 #

BA454 $8.00 # # BA479 $15.00 # # BA454 $5.00 # BA479 $5.00 #

BA455 $12.00 # # BA480 $15.00 # # BA455 $5.00 # BA480 $5.00 #

BA456 $8.00 # # BA481 $15.00 # # BA456 $5.00 # BA481 $5.00 #

BA457 $15.00 # # BA482 $15.00 # # BA457 $5.00 # BA482 $5.00 #

BA458 $10.00 # # BA483 $15.00 # # BA458 $5.00 # BA483 $5.00 #

BA459 $15.00 # # BA484 $12.00 # # BA459 $5.00 # BA484 $5.00 #

BA460 $15.00 # # BA485 $15.00 # # BA460 $5.00 # BA485 $5.00 #

BA461 $15.00 # # BA486 $15.00 # # BA461 $5.00 # BA486 $5.00 #

BA462 $15.00 # # BA487 $15.00 # # BA462 $5.00 # BA487 $5.00 #

BA463 $15.00 # # BA488 $15.00 # # BA463 $5.00 # BA488 $5.00 #

BA464 $12.00 # # BA489 $8.00 # # BA464 $5.00 # BA489 $5.00 #

BA465 $15.00 # # BA490 $15.00 # # BA465 $5.00 # BA490 $5.00 #

BA466 $15.00 # # BA491 $15.00 # # BA466 $5.00 # BA491 $5.00 #

BA467 $15.00 # # BA492 $15.00 # # BA467 $5.00 # BA492 $5.00 #

BA468 $15.00 # # BA493 $15.00 # # BA468 $5.00 # BA493 $5.00 #

BA469 $15.00 # # BA494 $15.00 # # BA469 $5.00 # BA494 $5.00 #

BA470 $15.00 # # BA495 $15.00 # # BA470 $5.00 # BA495 $5.00 #

BA471 $10.00 # # BA496 $15.00 # # BA471 $5.00 # BA496 $7.00 #

BA472 $10.00 # # BA497 $15.00 # # BA472 $5.00 # BA497 $5.00 #

BA473 $15.00 # # BA498 $15.00 # # BA473 $5.00 # BA498 $5.00 #

BA474 $15.00 # # BA499 $10.00 # # BA474 $5.00 # BA499 $5.00 #

BA475 $15.00 # # BA500 $10.00 # # BA475 $5.00 # BA500 $5.00 #

BA476 $15.00 # # BA501 $10.00 # # BA476 $5.00 # BA501 $7.00 #

BA477 $15.00 # # BA502 $10.00 # # BA477 $5.00 # BA502 $7.00 #

CÓDIGOS DE CUBIERTAS / COPAGOS

191 08/13/2015

VISITAS SIQUIÁTRICAS Y COLATERALES TERAPIAS DE GRUPO

CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED VISITAS COL. CUBIERTA COA/DED TERAPIAS CUBIERTA COA/DED TERAPIAS

BA503 $10.00 # # * * * * BA503 $7.00 # * * *

BA504 $10.00 # # * * * * BA504 $7.00 # * * *

BA505 $10.00 # # * * * * BA505 $7.00 # * * *

BA506 $15.00 # # * * * * BA506 $7.00 # * * *

BA507 $15.00 # # * * * * BA507 $7.00 # * * *

BA508 $15.00 # # * * * * BA508 $7.00 # * * *

BA509 $15.00 # # * * * * BA509 $7.00 # * * *

BA510 $15.00 # # * * * * BA510 $7.00 # * * *

BA511 $10.00 # # * * * * BA511 $7.00 # * * *

BA512 $10.00 # # * * * * BA512 $7.00 # * * *

BA513 $10.00 # # * * * * BA513 $7.00 # * * *

BA514 $10.00 # # * * * * BA514 $7.00 # * * *

BA515 $10.00 # # * * * * BA515 $7.00 # * * *

BA516 $15.00 # # * * * * BA516 $7.00 # * * *

BA517 $15.00 # # * * * * BA517 $5.00 # * * *

BA518 $15.00 # # * * * * BA518 $5.00 # * * *

BA519 $15.00 # # * * * * BA519 $5.00 # * * *

BA520 $15.00 # # * * * * BA520 $5.00 # * * *

BA521 $15.00 # # * * * * BA521 $5.00 # * * *

BA522 $10.00 # # * * * * BA522 $5.00 # * * *

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