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UNITED HEALTHCARE
<br />WASHINGTON MEOICAEO AND WASHINGTON BENEFIT PLANS FOR THE UNINSURED BEHAVIORAL HEALTH PROFESSIONAL REIMBURSEMENT SCHEDULE
<br />50
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<br />0.I9pP
<br />I29.53
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<br />IE4-S!
<br />91350
<br />16
<br />Neme Ylr9 ht P12+kry[nmpnrnm[s, fnmprcM1enshre H,p, fnmpeFensxe Gam; hledlNyN 6omAle.ity
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<br />129.£3
<br />Net PreN
<br />Nm RbN
<br />129.93
<br />99350
<br />]6
<br />Home Vu'I Em PS I, PI, mponen¢:CampreM1emive Hn:CampmFwnsire Ram; ModINyM1 Cwnpk•Ny
<br />99911P
<br />129.h3
<br />IR[PreN
<br />Nos RkN
<br />F39.53
<br />99350
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<br />Name Writ Est Prl-NryCampprrnu: GrmPrnhcrvnivr Nx; 6pmpwM1rnsirc Ram; ModIHiEN Compkairy
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<br />3x9.S1
<br />Nol lwiJ
<br />Hot PreN
<br />SE9.53
<br />lan9 y rwre,W/RdongN Phryirian Alsmtlanre, hsM1 301rkn
<br />61M1P
<br />tl3.99
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<br />Nei P-
<br />e�9q
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<br />NrPiMn slanffiYS+++rire,W/RderMJ Plgeinan Anend.nre, E+rh mein
<br />o-lJpp
<br />4l J9
<br />N., pried
<br />Nos PricN
<br />J3s9
<br />99366
<br />M-d Team Conkrenu,Fa+eTo-Fa+ewilM1 P.-,N 1.,-AY MMinor More, Pa rucrpaeon hY Nnnphysi4n
<br />o-2xfrP
<br />26.E2
<br />2S.El
<br />iE9t
<br />36.81
<br />993E6
<br />MNkal Team Cmkmnrc.Fair-lo-htawllM1 PalirnlaMlpr lam4y.mM14nm Mort, Pndclparion by NonpM1ykun
<br />6dOlOP
<br />3d.P1
<br />36J1
<br />26L1
<br />26.61
<br />M
<br />kvl]e+mCnrrinprre, Fac TmFaeewlrM1 PaNnnnrdferRmdy, 3n Atinm Mar Pxrhs+parion by NonpFykkn
<br />2199971P
<br />2fi.pI
<br />]6.Bi
<br />36E1
<br />26.81
<br />[6
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<br />E1-999fNP
<br />16A5
<br />]681
<br />26.9E
<br />2E31
<br />9836i
<br />MNmtl leam[nnlerenee, panentaNyx Fms,lyNn present,30M;n er Mere; parN.ipatbn by vFysicrzn
<br />lluip
<br />EI]N
<br />Nes hkJ
<br />Hot PrkN
<br />61 N4
<br />9936i
<br />MNkai TeamCminente.Padent -fn Family Not-M.m M-1 Mote: Pardt;paton by Ph,.-
<br />18/NP
<br />E9.21
<br />Not PrkN
<br />Net Pr I.
<br />&32)
<br />Ll
<br />McdeJ leamCmrinen•e, Patlent and/w iamity Nnt Preserrt,m Miner Morr; Pxurp.ebn by PNYsit ian
<br />629/IP
<br />169T
<br />Nat FreN
<br />Ner RCN
<br />4607
<br />61
<br />of team Gnlne tlent antlfm Famiy Not Proen[,m Minor Mme; Partie4arbn by phllrn+n
<br />0.29IOP
<br />636
<br />Not Prketl
<br />Nnl hkJ
<br />m.6
<br />.I.
<br />MN ki reamCmnlercnke,PatlentandfwFamly Net Prderr1,38M6ar More, Partisy.+lbn by PlHskian
<br />ll,.AP
<br />4Eg1
<br />Net Rird
<br />Not RkN
<br />4E O1
<br />99361
<br />MNk.1 TeamConlerervae, Padem andl¢r£amily Not P..'. MMh or Mwe; PardNpatan by Phwwian
<br />ll-99Y/OP
<br />636
<br />NoraRN
<br />N-,p
<br />..6
<br />9936E
<br />MNkalTnm Conlarence, Patlen t-W.,1-1, Noi Pra ., 30 Mm or Mwn:-patron by NprgM1y3klan
<br />o-lppP
<br />22 )4
<br />1114
<br />12,]4
<br />23.14
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<br />dk+t Team Cnnkreaa, Patient W.1Family Nn[ Pres.1 M. or Mae; Parllelparbn Hy xonphnkNn
<br />LLlo/W
<br />p.M
<br />Il.l4
<br />32. )J
<br />2i.]4
<br />M
<br />eaFTeam Fnnkrence,Patlent.-Y., Family N¢I PreseM,mMn orMwe; P+rdcl,.. MNwrephwklae
<br />I1-999/Ip
<br />J.
<br />21.1i
<br />21.11
<br />22,]4
<br />993fi9
<br />Medkaf i=.xr car,lerer.a,P+[I=r,I+rrJlor F+r,.ilv3+ot Preren1, 311Mn or Mere, Wrl:Patwr by FbnPhYskian
<br />i1-99 p
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<br />11.i9
<br />22M
<br />.315
<br />PM119Han 9uptryisbn. Pa[leni. Hame HeaiNAdensy.3M M'n
<br />OFV,,
<br />63.01
<br />Net PmN
<br />rJot Prked
<br />63A1
<br />Y1115
<br />PhNblxn I--.Il-. }bmr-1-1, lcncy, m+Mn
<br />R1819p
<br />11.1
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<br />m
<br />n pe son, p Rkenk 30. wkr
<br />DMIIP
<br />-1
<br />Not PrkN
<br />Net Prksd
<br />Mot
<br />md328
<br />hrHklan SwPemabn, Mnpi.e Pauenl; 39+Mkr
<br />h1PIOP
<br />Fit
<br />N9l Prke9
<br />N.. R'retl
<br />T11
<br />9935E
<br />NrYskian Supervishn,NnsirtdFxdry Pa&en[:30•Mln
<br />M]ENP
<br />(dill
<br />Nos PreN
<br />Npr PriN
<br />6dgl
<br />99l&E
<br />phPs'ehn SupcMrbn,Nm.InSixAlly PaNer9:ld kriw
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<br />R nswe Rase-MNkne£LM W/H./Exam, New It Mknsx E Yr
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<br />6691
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<br />Nat Pried
<br />669E
<br />1
<br />al rm' nrwe Premmxe Medkme£&M W/W/F.am, New PN kkot. 31r
<br />q]E/OP
<br />I9LSE
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<br />Netp[kad
<br />Ig25fl
<br />99131
<br />Initial -prehe W.l-.. MN mELM W/Wr/'Etam, New Pe, mlaM c3 Yr
<br />wmilp
<br />.11
<br />Ner RkN
<br />Not h'nN
<br />w.55
<br />99161
<br />irialCompreMm'wt Plcmndrt hlNkine ELM WIHx!£ram. New PC Mkns+3Yr
<br />..I.P
<br />1]92
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<br />No[Prird
<br />]l.11
<br />1
<br />al R ivwe Revenkre MNkhe ELM WIHx/£iam, New N; Inlan5. l Yr
<br />620pP
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<br />liq
<br />1
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<br />0.w/cp
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<br />Nul pried
<br />12q
<br />9938E
<br />InxhlfnmpeNentl.e prerenrh=MJkm=ELM MrpN/F.rm, Mew It; -Yr
<br />u16pP
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<br />llfi9
<br />993E2
<br />I.Ift ompeM1an-Pme-Mndkha E&MW/HVNG New R; 14 Yr
<br />P£9/-
<br />Ex].l
<br />Not-
<br />Net 1—
<br />9999E
<br />IPI mmehemhe RMnlhe MJkne ELM WpwlF am, New It; 1,4 Yr
<br />IOpp
<br />51.1
<br />Nul Rigid
<br />Nor ReN
<br />53.%
<br />2
<br />al m mwe Re.enrxe MNlune ELM WIHn1Ram, New R: I Yr
<br />D1o16P
<br />..E3
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<br />6N,93
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<br />4wip
<br />1M
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<br />Nol Bred
<br />1_0
<br />99382
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<br />IMda-prMeruke Prerenrhe MJkIne EEM W/IWGam,Nw Pt; 1-a Yr
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<br />1Sq
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<br />Nat Pried
<br />I20
<br />..I
<br />Prirc-MNkhe EEM W/He/Ram, N-R; 1. Yr
<br />o-FEIFP
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<br />15.1E
<br />94N1
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<br />Not ReN
<br />115.31
<br />1
<br />aI p ercxeF.-MNkhe ELM W/Hx/h+m, 14"R; S-11 Yr
<br />&20NP
<br />5].LS
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<br />Nat RaN
<br />$1.15
<br />3
<br />lI111.1 Ccmpreherarve N-- MOEM. MM W1114Wm, New PC-Yr
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<br />993rz
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<br />InIdalCnmprckeMiue Pre.ensheMM-ELMW/IWGam,New P%-1 Yr
<br />o-mp0
<br />120
<br />NnlprtN
<br />Not Prked
<br />120
<br />..1
<br />11
<br />InitlalCompreFeMiye Reeenthe MNkhe ELM W/H:JGam, Nme I% 1l3 Yr
<br />0.Rmp
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<br />NnrihkN
<br />Nor PriN
<br />320
<br />.MI
<br />al P remove Re„ee4 MNkhe ELM W/11e/ham. New Pk lblT W
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<br />89]
<br />Na Rigid
<br />Nnr PreN
<br />E9.3
<br />9939/
<br />InlNtl �mprnc�xPx PrrPcnlbc M-hF ELM W/IWRam. New Pa U.S ]Yr
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<br />F2a.6
<br />Net Pined
<br />Nor I.kc4
<br />E-
<br />9
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<br />..I"
<br />61J
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<br />Net Rigid
<br />E]4
<br />i6a1eempeeh-Prev.- MJbine ELM WIFWham, New Pr: 12-17 Yr
<br />D20/OP
<br />99.W
<br />Nos-
<br />Net Rigid
<br />44N
<br />lr
<br />n+I[mr.pmh=rrti.e Rrr.enSi.kMJiin=EEM W/Ir fEum, Hew Pr; 12-111,
<br />-Ap
<br />IEO
<br />Nor 1-
<br />Nd bred
<br />120
<br />99M1
<br />TI
<br />kldal C¢mPmkereire Re•NnlixrMNkke ELM WlIbJGam, New Pr; lE-]lm
<br />-X,
<br />12q
<br />Nos-
<br />Not priced
<br />134
<br />993E5
<br />MINI-,n h-Rc .-MNbkt E&MW/M/9am. New R;1L-39 Yr
<br />pIENP
<br />9968
<br />Not Reed
<br />ems PriN
<br />86.66
<br />99395
<br />MIWl�mmeh=move RexMheMNkre ELM WlWIE•am. Nnw R: ]Ed9 Yr
<br />Ul9/l]P
<br />S169E
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<br />lRt PrkN
<br />120.9E
<br />5
<br />I[ p em.e Revemwe Medene EBM W/Ha/Fum, Mew%;1e-19 yr
<br />11mp
<br />64.6]
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<br />Nax PreN
<br />M61
<br />5
<br />WiWlewnpmheNm Rawemrvv MJbbe ELM WAW&.. Hew R;]&39 Yr
<br />6Mol
<br />91.3E
<br />Not Priced
<br />Not hied
<br />913t
<br />w3E3
<br />TI
<br />Ini 1-pmhemiPe Re.entiue M-' ELM W/3l5lGam, New R;-39W
<br />r}'.VrP
<br />19q
<br />Nee RiN
<br />Not Prked
<br />116
<br />993E3
<br />11
<br />Initial C¢mpmhemixe PremnArMNkhe EBM WfHxlEaam,New h; 1L39Yr
<br />G]0/1]P
<br />]ID
<br />Nm RkN
<br />Nol PrkN
<br />F10
<br />99391
<br />periodk-prcM1enxm Prom- MNMnc E&MWfHa/Eaum, hr➢t hlant+l Yr
<br />NMfIP
<br />FO99
<br />Nnr ReN
<br />ryr PrvN
<br />fa.95
<br />Nk p ensr.�PreseneK MNrune ELM W/H•A-Esl It lnknt•1Yr
<br />&W.N
<br />93.3E
<br />Net RkJ
<br />No11-
<br />92,3E
<br />91
<br />Nk p ensam I-.- ELM WfHr/E.+m, b, Pt, MraM < 11r
<br />0.2Epp
<br />I6
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<br />46
<br />9l
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<br />69.6P
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<br />Nat
<br />..I
<br />TI
<br />perlNk6amprMena]se prc.mrie Metlklrre ELM W/IM/Fom, Rr Pt; Inhnrc]Yr
<br />D1gy1P
<br />120
<br />Hw PRN
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<br />..I
<br />Tr
<br />PedNkfnmprelrenaire PrcYenrire MNk'nre EILM W/W/Eram, Esl Pt; Inhnl<1Yr
<br />tr2gygP
<br />IlN
<br />Nol pr}cd
<br />Nospriced
<br />I
<br />9939E
<br />PedNkfamPrvlrenx+a Prewnrise Med¢inn E.LM WpkfGam, Fat PG iJ Yr
<br />g58IIP
<br />Mg8
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