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
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-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
51 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
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
52 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
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
68 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
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
69 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
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
70 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
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
71 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
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
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
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
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
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
117 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
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
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
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
122 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
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
123 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
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
124 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
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
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
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
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
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
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
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
130 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
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
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
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
132 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
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
133 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
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
136 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
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
138 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
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
140 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
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
157 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
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
158 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
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
159 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
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
160 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
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
161 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
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
162 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
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
163 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
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
164 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
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
165 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
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
166 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
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
167 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
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
168 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
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
169 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
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
170 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
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
171 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
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
172 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
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
173 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
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 #
CÓDIGOS DE CUBIERTAS / COPAGOS
174 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
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
175 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
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
176 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
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
177 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
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
178 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
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
179 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
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 #
CÓDIGOS DE CUBIERTAS / COPAGOS
180 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
B7334 $18.00 # # * * * * B7334 $5.00 # * * *
* * * * * * * * * * * * * *
* * * * * * * * * * * * * *
* * * * * * * * * * * * * *
* * * * * * * * * * * * * *
* * * * * * * * * * * * * *
* * * * * * * * * * * * * *
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* * * * * * * * * * * * * *
* * * * * * * * * * * * * *
* * * * * * * * * * * * * *
* * * * * * * * * * * * * *
* * * * * * * * * * * * * *
* * * * * * * * * * * * * *
* * * * * * * * * * * * * *
* * * * * * * * * * * * * *
* * * * * * * * * * * * * *
* * * * * * * * * * * * * *
* * * * * * * * * * * * * *
* * * * * * * * * * * * * *
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* * * * * * * * * * * * * *
* * * * * * * * * * * * * *
* * * * * * * * * * * * * *
CÓDIGOS DE CUBIERTAS / COPAGOS
181 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
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
CÓDIGOS DE CUBIERTAS / COPAGOS
182 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
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
CÓDIGOS DE CUBIERTAS / COPAGOS
183 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
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
CÓDIGOS DE CUBIERTAS / COPAGOS
184 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
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
CÓDIGOS DE CUBIERTAS / COPAGOS
185 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
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
CÓDIGOS DE CUBIERTAS / COPAGOS
186 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
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 #
CÓDIGOS DE CUBIERTAS / COPAGOS
187 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
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
188 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
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
189 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
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
190 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
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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