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<br />.. <br /> <br />PUBLIC EJÇJ'LO'TEU' Jll[l)1t.\L r. HOSPITAL CARE Art PLA. cmES AIID "EMI~ <br /> <br />Basic: (8) <br />EII'Ð. only <br />Errc. r. 1 dep. <br />EII'Ð. r. 2. Oeps. <br />Supplement to "~ic:.r~ (SM) <br />Elle. only <br />Errc. r. 1 dep. <br />Errc. r. 2. ~. <br />Cc:aèinetlon (B r. $1<) <br />Errc. (SM), 1 dep. (8) <br />Errc. (SM), 2. deps. (8) <br />Errc. r. ,. deDs. (SM), ,. d~. (8) <br />Errc. (8). 1 dep. (SM) <br />Emp. (B). 2. deps. (SM) <br />Errc. r. ,. deps. (8), 1 òe?(SK) <br /> <br />Basic: (8) <br />Errc. only <br />Errc. r. 1 dep. <br />Errc. r. 2. ~. <br />Supplement t"o "~ic:.r~ (SK) <br />Errc. only <br />Errc. r. 1 dep. <br />Errc. ~ 2. depos. <br />Corrbinetion (8 r. $!I) <br />EIIt). (SM). 1 dep. (8) <br />EIIt). (S1'I). 2. d~. (8) <br />Errc. r. ,. ~. ($1<), ,. dcpos. (8) <br />EIIt). (8), 1 dep. ($1<) <br />E~. (8). 2. ~. (~) <br />~. r. ,. depa. (I), 1 Øep.($I<) <br /> <br />. . --~.- <br /> <br />IlEALTlI ,.l.AI OF <br />THE IEn1.lCCDS <br />(HPI) <br /> <br />PLAIr <br />ctVE <br /> <br />3/,(1) <br />CZ> <br />(3) <br /> <br />37(1) <br />CZ> <br />(3) <br /> <br />37 (/. ) <br />(5 ) <br />(6) <br />en <br />(8) <br />(9) <br /> <br />'3{ 1) <br />(2) <br />(3) <br /> <br />'-4:1) <br />(2) <br />m <br /> <br />'-4('> <br />(5) <br />(6) <br />m <br />(8) <br />(9) <br /> <br />IOITHlT <br />lATE <br /> <br />$13'3.00 <br />269.00 <br />1.30.00 <br /> <br />102.20 <br />201..'0 <br />306.60 <br /> <br />~.20 <br />399 .20 <br />365./0 <br />23S .20 <br />337./0 <br />396.20 <br /> <br />IW:I CARE <br />(I"J..X) <br /> <br />$159.38 <br />297.31 <br />393./0 <br /> <br />1l.8.13 . <br />276.56 <br />363.31 <br /> <br />m.M <br />3al.15 <br />312.65 <br />287.81 <br />:m.58 <br />~.90 <br /> <br />nISEI IIOUI! <br />(D) <br /> <br />PLAII <br />C!XJ E <br /> <br />IOITHLT <br />RATE <br /> <br />56(1) $1'7.76 <br />(2) . m'.52 <br />m 393.05 <br /> <br />66(1 ) <br />(2) <br />m <br /> <br />. 66(1.) <br />(5) <br />(6) <br />(7) <br />(8) <br />(9) <br /> <br />9/..lI7 <br />189.7' <br />28lo .61 <br /> <br />2'2.63 <br />y.0.16 <br />257.27 <br />2:'2.63 <br />337.50 <br />y.0.16 <br /> <br />PAC I nCARE <br />(PAC) <br /> <br />238( 1) $131:01. <br />(2) 281.51. <br />m 397.93 <br /> <br />239(1) <br />(2) <br />m <br /> <br />239(') <br />(5 ) <br />(6) <br />(7) <br />(8) <br />(9) <br /> <br />31.81 <br />63.62 <br />95.'3 <br /> <br />1a2.31 <br />298.7'0 <br />1!C.Ol <br />162.85 <br />19/..66 <br />27'9.2' <br /> <br />PAC[ 2 <br /> <br />PLAir <br />C!XJ E <br /> <br />57(1> <br />CZ> <br />m <br /> <br />67(1) <br />(2) <br />C3> <br /> <br />67(') <br />(5) <br />(6) <br />m <br />(lI) <br />(9) <br /> <br />201(1 ) <br />m <br />C3> <br /> <br />202(1) <br />(2) <br />m <br /> <br />202(') <br />(5) <br />(6) <br />(7) <br />(II) <br />(9) <br /> <br />tAtSEI sarTI! <br />([$) <br /> <br />ÞOITHLT <br />RAlE <br /> <br />$11.9.76 <br />ZW.52 <br />'24.12 <br /> <br />!3.16 <br />160S.32 <br />2'2.'8 <br /> <br />232.92 <br />357.52 <br />290.92 <br />23::.92 <br /> <br />309.08 <br />357.52 <br /> <br />PARTl/fltS <br />(PAR) <br /> <br />$156.80 <br />316.7' <br />'51..7Z <br /> <br />116.57 <br />233.1l. <br />349.71 <br /> <br />271>.51 <br />"'.'9 <br />:371. 1 2 <br />273.31 <br />3!9 . 9/. <br />"1.35 <br /> <br />LUte r. ~I.ÐEYTAL ,.L.US . AUCUSi 1, 1991 <br /> <br />PlA. <br />C!XJ E <br /> <br />228(1) <br />CZ> <br />(3) <br /> <br />Z29(' ) <br />CZ> <br />(3) <br /> <br />22'9«() <br />(5 ) <br />(6) <br />(7) <br />(8) <br />(9) <br /> <br />L J FE QJ.UD <br />(Ll) <br /> <br />9OfTMlT <br />UTE <br /> <br />$150.00 <br />300.00 <br />"0.00 <br /> <br />133.~ <br />2'67.50 . <br />'°1.25 <br /> <br />æ.7S <br />393.7S <br />377 .50 <br />2a:s.~ <br />"1.50 <br />393.7S <br /> <br />PCA MEALTH PLANS <br />(pa.) <br /> <br />1'0(1) <br />(2) <br />m <br /> <br />11<') <br />(2) <br />(3) <br /> <br />11(') <br />(5) <br />(6) <br />(1) <br />(II) <br />(9) <br /> <br />$157.a2 <br />29'.12 <br />398.85 <br /> <br />99.16 <br />198.32 <br />297.l..8 <br /> <br />235.1.6 <br />y.0. '9 <br />303.05 <br />Z56.98 <br />356.11. <br />361.71 <br /> <br />LlIItXU lAne. <br />n:AL TII P't..U <br />(t..M,., <br /> <br />PLA- <br />CtDE <br /> <br />22'(1) <br />(Z) <br />(3) <br /> <br />ZZS (1) <br />(Z) <br />m <br /> <br />US(') <br />C5> <br />(6) <br />m <br />(8) <br />(9) <br /> <br />27Z(1) <br />m <br />m <br /> <br />273 (1J <br />CZ> <br />m <br /> <br />m(') <br />(5) <br />(6) <br />(7) <br />(II) <br />(9) <br /> <br /> lOfT H <br />UTE <br /> <br />i <br />roo <br />I <br /> <br />¡ <br /> <br />S13t. <br />2~. <br />3æ. <br /> <br />116. <br />Z33. <br />350. <br /> <br />262. <br />366. <br />337. <br />Z55. <br />3iZ. <br /> <br />359. <br /> <br />PEIS.CAIE <br />(PC) <br /> <br />SZ23. <br />'22. <br />56.3. <br /> <br />11.2. <br />2115. <br />396. <br /> <br />3/, 1. <br />~. <br />'26 <br />366 <br />'77 <br />507 <br /> <br />. <br />