TP
CK
AD
9112
IN
18
IC
WO
RF
PR
19
MR
20
Co-Payment
A
Filed 5/30
OP
OF
9202
MD
4
Primary
line 11
O
3
LINE12 COM
0
Line 13
line 22
line 26
LINE 104
23
Comment
05939
9110
PAYMENT
53377
2773
Payment
3546
1753
9111
04519
68240
3457
5
17485
T
17534
8
17659
6
TR
17493
9103
1