Medical Fee Schedule: DME/Supply Section


In Accordance with the N.C. Industrial Commission’s
Medical Fee Schedule & Subsequent Updates, 1996-2012


Bernadine Singh
Chief Medical Fee Examiner
N.C. Industrial Commission
E-mail: Bernadine.Singh@ic.nc.gov

NOTE 1: To purchase a complete copy of the American Medical Association’s Current Procedural Technology Codes, telephone OptumInsight™ at (800) 464-3649, option 1, or go to http://www.optumcoding.com/ to order a CPT® code book online.

NOTE 2: Please report any problems or errors directly to Bernadine.Singh@ic.nc.gov.

NOTE 3: This page was last revised on February 6, 2013.


TABLE OF CONTENTS

Introduction
 
CPT Codes and Fees  Commission Assigned Codes
 
Evaluation and Management Section 3 Physical Medicine Section 10
Anesthesia Section 4 (effective April 1, 2000) Chiropractic Fee Schedule Section 11 (effective March 1, 2001)
Surgery Section 5 Industrial Rehabilitation Section 12 (effective January 1996)
Radiology Section 6 Dental Fee Schedule Section 13 (effective January 1, 2007)
Pathology and Laboratory Section 7 Hospital and Ambulatory Surgical Center Section 14 (effective July 15, 2002)
Medicine Section 8 Forms Section 16 (effective February 1, 2000)
Special Services Section 9 Durable Medical Equipment/Supply Fee Schedule (effective January 1, 2008)

Durable Medical Equipment/Supply Fee Schedule

The North Carolina Industrial Commission has adopted nearly 1,100 HCPCS billing codes to describe supplies and equipment used in workers’ compensation treatment. However, the Commission has not yet incorporated into its fee schedule all of the HCPCS level codes for supplies and equipments. For example, none of the “J” codes have been adopted. If an HCPCS code is billed, and the code does not have a fee assigned in the Commission schedule, the Commission will allow a provider to use CPT code 99070. The provider is entitled to 20% above invoice cost for these codes only.

If a custom-made orthotic or prosthetic is not contained in the Commission schedule, these items should be paid per agreement between provider and payor.

Procedure for Submission of Invoices for Durable Medical Equipment and Rate of Payment
Effective August 1, 2008

When a charge for durable medical equipment (DME) code is not on the fee schedule and exceeds $100.00, the insurance carrier, self-insured employer or third party administrator may request an invoice from the medical provider and shall pay at the invoice cost plus twenty percent (20%). When the charge is $100.00 or less, the insurance carrier, self-insured employer or third party administrator shall pay the medical provider the charge billed without requesting an invoice.

ABBREVIATIONS: HCPCS = Health Care Procedure Coding System and Mod = Modifier.
 

HCPCS

Mod

Allowance

A4216

 

$0.38

A4217

 

$2.66

A4217

AU

$2.66

A4221

 

$22.26

A4222

 

$44.17

A4233

NU

$0.80

A4234

NU

$3.63

A4235

NU

$2.34

A4236

NU

$1.68

A4253

NU

$34.70

A4255

 

$4.11

A4256

 

$11.44

A4257

 

$12.75

A4258

 

$17.75

A4259

 

$10.88

A4265

 

$3.39

A4280

 

$5.05

A4310

 

$6.56

A4311

 

$12.61

A4312

 

$15.33

A4313

 

$15.74

A4314

 

$21.50

A4315

 

$22.43

A4316

 

$24.14

A4320

 

$5.33

A4321

 

$0.00

A4322

 

$2.65

A4326

 

$10.79

A4327

 

$44.62

A4328

 

$9.88

A4330

 

$6.93

A4331

 

$3.18

A4332

 

$0.12

A4333

 

$2.20

A4334

 

$4.93

A4338

 

$12.26

A4340

 

$31.75

A4344

 

$13.62

A4346

 

$16.65

A4349

 

$2.02

A4351

 

$1.54

A4352

 

$6.42

A4353

 

$7.00

A4354

 

$11.09

A4355

 

$7.57

A4356

 

$38.79

A4357

 

$8.25

A4358

 

$5.64

A4361

 

$18.37

A4362

 

$3.46

A4363

 

$2.36

A4364

 

$2.93

A4365

 

$11.32

A4366

 

$1.30

A4367

 

$6.90

A4368

 

$0.26

A4369

 

$2.06

A4371

 

$3.60

A4372

 

$4.18

A4373

 

$6.28

A4375

 

$17.18

A4376

 

$47.58

A4377

 

$4.29

A4378

 

$30.75

A4379

 

$15.02

A4380

 

$37.33

A4381

 

$4.61

A4382

 

$24.62

A4383

 

$28.19

A4384

 

$9.62

A4385

 

$5.10

A4387

 

$0.00

A4388

 

$4.36

A4389

 

$6.22

A4390

 

$9.61

A4391

 

$7.07

A4392

 

$8.18

A4393

 

$9.04

A4394

 

$2.58

A4395

 

$0.05

A4396

 

$40.48

A4397

 

$4.79

A4398

 

$13.81

A4399

 

$10.42

A4400

 

$48.87

A4402

 

$1.39

A4404

 

$1.69

A4405

 

$3.40

A4406

 

$5.74

A4407

 

$8.76

A4408

 

$9.87

A4409

 

$6.22

A4410

 

$9.04

A4411

 

$5.10

A4412

 

$2.70

A4413

 

$5.50

A4414

 

$4.93

A4415

 

$6.00

A4416

 

$2.75

A4417

 

$3.72

A4418

 

$1.81

A4419

 

$1.74

A4420

 

$0.00

A4422

 

$0.12

A4423

 

$1.86

A4424

 

$4.75

A4425

 

$3.58

A4426

 

$2.73

A4427

 

$2.78

A4428

 

$6.51

A4429

 

$8.25

A4430

 

$8.52

A4431

 

$6.22

A4432

 

$3.59

A4433

 

$3.34

A4434

 

$3.76

A4450

AU

$0.09

A4450

AV

$0.09

A4450

AW

$0.11

A4452

AU

$0.36

A4452

AV

$0.36

A4452

AW

$0.40

A4455

 

$1.43

A4461

 

$3.29

A4463

 

$0.00

A4481

 

$0.38

A4483

 

$0.00

A4556

 

$10.32

A4557

 

$21.10

A4558

 

$5.45

A4559

 

$0.00

A4561

 

$19.43

A4562

 

$48.37

A4595

 

$28.35

A4604

NU

$66.81

A4605

NU

$16.40

A4608

 

$58.15

A4611

NU

$166.98

A4611

RR

$17.31

A4611

UE

$125.24

A4612

NU

$79.93

A4612

RR

$8.14

A4612

UE

$60.95

A4613

NU

$144.21

A4613

RR

$14.43

A4613

UE

$104.29

A4614

 

$23.78

A4618

NU

$7.56

A4618

RR

$0.87

A4618

UE

$5.67

A4619

 

$1.21

A4623

 

$5.57

A4624

NU

$2.63

A4625

 

$5.89

A4626

 

$2.71

A4628

NU

$3.65

A4629

 

$4.61

A4630

NU

$6.25

A4633

NU

$41.04

A4635

NU

$4.35

A4635

RR

$0.69

A4635

UE

$2.90

A4636

NU

$4.21

A4636

RR

$0.43

A4636

UE

$3.07

A4637

NU

$1.81

A4637

RR

$0.26

A4637

UE

$1.37

A4638

NU

$0.00

A4638

RR

$0.00

A4638

UE

$0.00

A4639

NU

$287.21

A4640

NU

$53.82

A4640

RR

$5.84

A4640

UE

$40.33

A5051

 

$2.07

A5052

 

$1.49

A5053

 

$1.74

A5054

 

$1.79

A5055

 

$1.39

A5061

 

$3.52

A5062

 

$2.09

A5063

 

$2.70

A5071

 

$6.01

A5072

 

$2.99

A5073

 

$2.90

A5081

 

$2.81

A5082

 

$10.15

A5093

 

$1.68

A5102

 

$22.42

A5105

 

$40.76

A5112

 

$34.62

A5113

 

$4.00

A5114

 

$7.60

A5120

AU

$0.25

A5120

AV

$0.21

A5121

 

$6.34

A5122

 

$10.92

A5126

 

$1.12

A5131

 

$13.48

A5200

 

$11.29

A5500

 

$61.91

A5501

 

$185.70

A5503

 

$27.54

A5504

 

$27.54

A5505

 

$27.54

A5506

 

$27.54

A5507

 

$27.54

A5512

 

$25.26

A5513

 

$37.69

A6010

 

$30.96

A6011

 

$2.28

A6021

 

$21.02

A6022

 

$21.02

A6023

 

$190.30

A6024

 

$6.19

A6154

 

$14.36

A6196

 

$7.35

A6197

 

$16.44

A6199

 

$5.29

A6200

 

$9.50

A6201

 

$20.80

A6202

 

$34.88

A6203

 

$3.35

A6204

 

$6.23

A6207

 

$7.34

A6209

 

$7.48

A6210

 

$19.92

A6211

 

$29.37

A6212

 

$9.70

A6214

 

$10.29

A6216

 

$0.05

A6217

 

$0.00

A6219

 

$0.95

A6220

 

$2.58

A6222

 

$2.13

A6223

 

$2.42

A6224

 

$3.61

A6229

 

$3.61

A6231

 

$4.68

A6232

 

$6.88

A6233

 

$19.19

A6234

 

$6.54

A6235

 

$16.82

A6236

 

$27.25

A6237

 

$7.91

A6238

 

$22.79

A6240

 

$12.24

A6241

 

$2.57

A6242

 

$6.07

A6243

 

$12.31

A6244

 

$39.28

A6245

 

$7.27

A6246

 

$9.92

A6247

 

$23.78

A6248

 

$16.24

A6251

 

$1.99

A6252

 

$3.25

A6253

 

$6.34

A6254

 

$1.21

A6255

 

$3.03

A6257

 

$1.53

A6258

 

$4.30

A6259

 

$10.94

A6266

 

$1.92

A6402

 

$0.12

A6403

 

$0.43

A6407

 

$1.88

A6410

 

$0.39

A6411

 

$0.00

A6441

 

$0.67

A6442

 

$0.17

A6443

 

$0.29

A6444

 

$0.56

A6445

 

$0.32

A6446

 

$0.41

A6447

 

$0.67

A6448

 

$1.16

A6449

 

$1.75

A6450

 

$0.00

A6451

 

$0.00

A6452

 

$5.91

A6453

 

$0.61

A6454

 

$0.77

A6455

 

$1.39

A6456

 

$1.28

A6457

 

$1.14

A6501

 

$0.00

A6502

 

$0.00

A6503

 

$0.00

A6504

 

$0.00

A6505

 

$0.00

A6506

 

$0.00

A6507

 

$0.00

A6508

 

$0.00

A6509

 

$0.00

A6510

 

$0.00

A6511

 

$0.00

A6513

 

$0.00

A6531

AW

$43.27

A6532

AW

$60.96

A6550

 

$27.42

A7000

NU

$9.54

A7001

NU

$33.08

A7002

NU

$3.83

A7003

NU

$2.74

A7004

NU

$1.80

A7005

NU

$30.83

A7006

NU

$9.54

A7007

NU

$4.61

A7008

NU

$11.00

A7009

NU

$42.04

A7010

NU

$23.59

A7012

NU

$3.78

A7013

NU

$0.83

A7014

NU

$4.49

A7015

NU

$1.88

A7016

NU

$7.25

A7017

NU

$134.04

A7017

RR

$13.40

A7017

UE

$100.52

A7018

 

$0.38

A7025

NU

$434.94

A7026

NU

$28.75

A7030

NU

$188.64

A7031

NU

$69.77

A7032

NU

$40.53

A7033

NU

$28.41

A7034

NU

$117.64

A7035

NU

$39.75

A7036

NU

$18.20

A7037

NU

$41.02

A7038

NU

$5.39

A7039

NU

$15.33

A7040

 

$38.44

A7041

 

$72.24

A7042

 

$174.56

A7043

 

$27.37

A7044

NU

$120.91

A7045

NU

$19.47

A7045

RR

$1.95

A7045

UE

$14.60

A7046

NU

$19.51

A7501

 

$105.03

A7502

 

$49.91

A7503

 

$11.33

A7504

 

$0.67

A7505

 

$4.68

A7506

 

$0.33

A7507

 

$2.49

A7508

 

$2.87

A7509

 

$1.41

A7520

 

$47.48

A7521

 

$47.05

A7522

 

$45.16

A7524

 

$77.40

A7525

 

$2.07

A7526

 

$3.37

A7527

 

$3.58

A8000

NU

$153.35

A8000

RR

$15.33

A8000

UE

$115.03

A8001

NU

$153.35

A8001

RR

$15.33

A8001

UE

$115.03

A8002

NU

$0.00

A8002

RR

$0.00

A8002

UE

$0.00

A8003

NU

$0.00

A8003

RR

$0.00

A8003

UE

$0.00

A8004

NU

$0.00

A8004

RR

$0.00

A8004

UE

$0.00

E0100

NU

$17.91

E0100

RR

$5.94

E0100

UE

$14.28

E0105

NU

$46.43

E0105

RR

$8.86

E0105

UE

$34.80

E0110

NU

$69.29

E0110

RR

$15.99

E0110

UE

$51.96

E0111

NU

$45.27

E0111

RR

$7.17

E0111

UE

$34.94

E0112

NU

$37.00

E0112

RR

$9.93

E0112

UE

$28.23

E0113

NU

$21.13

E0113

RR

$4.38

E0113

UE

$15.86

E0114

NU

$42.99

E0114

RR

$8.57

E0114

UE

$32.25

E0116

NU

$27.74

E0116

RR

$4.59

E0116

UE

$20.88

E0117

NU

$192.71

E0117

RR

$19.26

E0117

UE

$144.55

E0130

NU

$70.23

E0130

RR

$16.82

E0130

UE

$54.73

E0135

NU

$81.23

E0135

RR

$16.87

E0135

UE

$60.92

E0140

NU

$360.71

E0140

RR

$36.08

E0140

UE

$270.54

E0141

NU

$115.29

E0141

RR

$19.01

E0141

UE

$86.47

E0143

NU

$106.50

E0143

RR

$19.61

E0143

UE

$79.86

E0144

NU

$318.45

E0144

RR

$31.86

E0144

UE

$238.83

E0147

NU

$574.81

E0147

RR

$57.48

E0147

UE

$431.13

E0148

NU

$127.05

E0148

RR

$12.72

E0148

UE

$95.28

E0149

NU

$223.20

E0149

RR

$22.32

E0149

UE

$167.39

E0153

NU

$69.38

E0153

RR

$7.84

E0153

UE

$52.03

E0154

NU

$70.51

E0154

RR

$8.56

E0154

UE

$53.57

E0155

NU

$26.83

E0155

RR

$3.27

E0155

UE

$20.44

E0156

NU

$26.43

E0156

RR

$3.38

E0156

UE

$19.85

E0157

NU

$81.92

E0157

RR

$8.99

E0157

UE

$61.45

E0158

NU

$32.18

E0158

RR

$3.55

E0158

UE

$24.29

E0159

NU

$17.87

E0159

RR

$1.80

E0159

UE

$13.40

E0160

NU

$33.06

E0160

RR

$4.33

E0160

UE

$24.77

E0161

NU

$26.23

E0161

RR

$3.57

E0161

UE

$19.64

E0162

NU

$123.85

E0162

RR

$13.00

E0162

UE

$96.05

E0163

NU

$110.29

E0163

RR

$20.77

E0163

UE

$85.05

E0165

RR

$18.58

E0167

NU

$12.00

E0167

RR

$1.26

E0167

UE

$9.04

E0168

NU

$150.92

E0168

RR

$15.09

E0168

UE

$113.18

E0170

RR

$160.72

E0171

RR

$28.92

E0175

NU

$66.23

E0175

RR

$6.62

E0175

UE

$48.74

E0181

RR

$26.06

E0182

RR

$26.18

E0184

NU

$194.70

E0184

RR

$24.38

E0184

UE

$149.32

E0185

NU

$319.86

E0185

RR

$43.91

E0185

UE

$245.48

E0186

RR

$20.30

E0187

RR

$23.21

E0188

NU

$23.99

E0188

RR

$2.64

E0188

UE

$18.01

E0189

NU

$51.96

E0189

RR

$5.63

E0189

UE

$38.98

E0191

NU

$9.99

E0191

RR

$1.02

E0191

UE

$7.46

E0193

RR

$903.46

E0194

RR

$3,254.34

E0196

RR

$27.62

E0197

NU

$221.58

E0197

RR

$30.57

E0197

UE

$194.64

E0198

NU

$221.58

E0198

RR

$22.95

E0198

UE

$168.14

E0199

NU

$32.05

E0199

RR

$3.19

E0199

UE

$24.04

E0200

NU

$79.28

E0200

RR

$9.25

E0200

UE

$59.49

E0202

RR

$53.22

E0205

NU

$164.95

E0205

RR

$18.14

E0205

UE

$123.71

E0210

NU

$27.74

E0210

RR

$2.67

E0210

UE

$20.81

E0215

NU

$70.84

E0215

RR

$7.41

E0215

UE

$53.14

E0217

NU

$496.47

E0217

RR

$55.28

E0217

UE

$372.32

E0220

NU

$8.47

E0220

RR

$0.86

E0220

UE

$6.33

E0225

NU

$388.65

E0225

RR

$38.31

E0225

UE

$291.48

E0230

NU

$8.48

E0230

RR

$0.95

E0230

UE

$6.34

E0235

RR

$16.46

E0236

RR

$44.13

E0238

NU

$27.03

E0238

RR

$2.72

E0238

UE

$19.88

E0239

NU

$382.36

E0239

RR

$38.24

E0239

UE

$286.78

E0249

NU

$99.60

E0249

RR

$9.95

E0249

UE

$74.70

E0250

RR

$92.04

E0251

RR

$70.43

E0255

RR

$99.86

E0256

RR

$76.16

E0260

RR

$140.46

E0261

RR

$136.94

E0265

RR

$199.88

E0266

RR

$167.61

E0271

NU

$222.04

E0271

RR

$23.06

E0271

UE

$173.46

E0272

NU

$172.01

E0272

RR

$17.96

E0272

UE

$128.39

E0275

NU

$15.31

E0275

RR

$1.60

E0275

UE

$11.48

E0276

NU

$11.37

E0276

RR

$1.33

E0276

UE

$8.94

E0277

RR

$703.47

E0280

NU

$35.83

E0280

RR

$3.59

E0280

UE

$26.88

E0290

RR

$69.47

E0291

RR

$49.66

E0292

RR

$77.02

E0293

RR

$62.15

E0294

RR

$130.65

E0295

RR

$127.35

E0296

RR

$164.20

E0297

RR

$139.63

E0300

NU

$2,838.62

E0300

RR

$283.86

E0300

UE

$2,128.96

E0301

RR

$270.72

E0302

RR

$715.44

E0303

RR

$303.98

E0304

RR

$770.67

E0305

RR

$16.97

E0310

NU

$173.23

E0310

RR

$20.62

E0310

UE

$129.95

E0316

RR

$201.27

E0325

NU

$10.11

E0325

RR

$1.51

E0325

UE

$6.69

E0326

NU

$9.59

E0326

RR

$1.01

E0326

UE

$7.18

E0371

RR

$444.48

E0372

RR

$539.34

E0373

RR

$614.47

E0424

RR

$198.40

E0431

RR

$31.79

E0434

RR

$31.79

E0439

RR

$198.40

E0441

 

$77.45

E0442

 

$77.45

E0443

 

$77.45

E0444

 

$77.45

E0450

RR

$818.61

E0457

NU

$614.51

E0457

RR

$61.45

E0457

UE

$460.85

E0459

RR

$50.89

E0460

RR

$733.57

E0461

RR

$818.61

E0462

RR

$291.40

E0463

RR

$1,406.38

E0464

RR

$1,406.38

E0470

RR

$256.60

E0471

RR

$642.17

E0472

RR

$642.17

E0480

RR

$43.94

E0482

RR

$430.02

E0483

RR

$1,063.13

E0484

NU

$36.92

E0484

RR

$3.69

E0484

UE

$27.70

E0485

NU

$0.00

E0485

RR

$0.00

E0485

UE

$0.00

E0486

NU

$0.00

E0486

RR

$0.00

E0486

UE

$0.00

E0500

RR

$100.83

E0550

RR

$50.13

E0560

NU

$160.13

E0560

RR

$17.09

E0560

UE

$120.10

E0561

NU

$107.00

E0561

RR

$10.69

E0561

UE

$80.24

E0562

NU

$301.22

E0562

RR

$30.11

E0562

UE

$225.91

E0565

RR

$58.77

E0570

RR

$16.10

E0571

RR

$29.97

E0572

RR

$38.09

E0574

RR

$40.26

E0575

RR

$99.97

E0580

NU

$134.04

E0580

RR

$13.40

E0580

UE

$100.52

E0585

RR

$29.81

E0600

RR

$45.79

E0601

RR

$111.71

E0602

NU

$29.52

E0602

RR

$2.96

E0602

UE

$22.14

E0605

NU

$26.43

E0605

RR

$2.89

E0605

UE

$21.77

E0606

RR

$22.94

E0607

NU

$66.82

E0607

RR

$6.68

E0607

UE

$50.10

E0610

NU

$224.67

E0610

RR

$22.46

E0610

UE

$168.50

E0615

NU

$478.82

E0615

RR

$51.62

E0615

UE

$359.12

E0617

RR

$304.05

E0618

RR

$280.35

E0619

RR

$0.00

E0620

NU

$874.39

E0620

RR

$87.43

E0620

UE

$655.79

E0621

NU

$87.62

E0621

RR

$8.76

E0621

UE

$65.72

E0627

NU

$337.32

E0627

RR

$33.74

E0627

UE

$253.00

E0628

NU

$337.32

E0628

RR

$33.74

E0628

UE

$253.00

E0629

NU

$330.71

E0629

RR

$33.08

E0629

UE

$248.01

E0630

RR

$99.38

E0635

RR

$122.36

E0636

RR

$1,054.56

E0650

NU

$720.22

E0650

RR

$79.97

E0650

UE

$540.16

E0651

NU

$918.42

E0651

RR

$93.82

E0651

UE

$688.82

E0652

NU

$4,570.77

E0652

RR

$457.07

E0652

UE

$3,428.07

E0655

NU

$107.92

E0655

RR

$11.11

E0655

UE

$81.05

E0660

NU

$159.75

E0660

RR

$16.63

E0660

UE

$119.80

E0665

NU

$136.99

E0665

RR

$14.07

E0665

UE

$102.88

E0666

NU

$138.08

E0666

RR

$14.23

E0666

UE

$103.59

E0667

NU

$323.77

E0667

RR

$36.56

E0667

UE

$242.83

E0668

NU

$375.60

E0668

RR

$37.07

E0668

UE

$281.71

E0669

NU

$183.31

E0669

RR

$18.34

E0669

UE

$137.51

E0671

NU

$415.35

E0671

RR

$41.54

E0671

UE

$311.50

E0672

NU

$322.73

E0672

RR

$32.28

E0672

UE

$242.06

E0673

NU

$268.17

E0673

RR

$26.82

E0673

UE

$201.15

E0675

RR

$384.55

E0691

NU

$898.59

E0691

RR

$89.86

E0691

UE

$673.94

E0692

NU

$1,128.37

E0692

RR

$112.83

E0692

UE

$846.29

E0693

NU

$1,390.98

E0693

RR

$139.10

E0693

UE

$1,043.24

E0694

NU

$4,427.34

E0694

RR

$442.73

E0694

UE

$3,320.53

E0705

NU

$50.68

E0705

RR

$5.07

E0705

UE

$37.99

E0720

NU

$367.58

E0730

NU

$370.56

E0731

NU

$311.85

E0740

NU

$522.87

E0740

RR

$52.29

E0740

UE

$392.18

E0744

RR

$91.57

E0745

RR

$89.51

E0747

NU

$3,813.12

E0747

RR

$378.92

E0747

UE

$2,833.08

E0748

NU

$3,788.41

E0748

RR

$378.84

E0748

UE

$2,841.32

E0749

RR

$276.89

E0760

NU

$3,148.10

E0760

RR

$314.82

E0760

UE

$2,361.08

E0764

NU

$10,775.87

E0764

RR

$1,077.58

E0764

UE

$8,081.91

E0765

NU

$84.13

E0765

RR

$8.43

E0765

UE

$63.12

E0776

NU

$143.16

E0776

RR

$18.65

E0776

UE

$105.33

E0779

RR

$16.73

E0780

NU

$10.37

E0781

RR

$264.87

E0782

NU

$4,180.54

E0782

RR

$418.07

E0782

UE

$3,135.41

E0783

NU

$7,720.15

E0783

RR

$772.01

E0783

UE

$5,790.10

E0784

RR

$417.49

E0785

KF

$391.07

E0786

NU

$7,775.89

E0786

RR

$777.58

E0786

UE

$5,831.91

E0791

RR

$316.20

E0840

NU

$73.28

E0840

RR

$16.32

E0840

UE

$54.93

E0849

NU

$515.31

E0849

RR

$51.53

E0849

UE

$386.46

E0850

NU

$93.30

E0850

RR

$14.43

E0850

UE

$69.98

E0855

NU

$494.22

E0855

RR

$49.44

E0855

UE

$370.65

E0860

NU

$38.53

E0860

RR

$6.51

E0860

UE

$29.51

E0870

NU

$116.31

E0870

RR

$11.70

E0870

UE

$87.62

E0880

NU

$125.54

E0880

RR

$19.71

E0880

UE

$95.02

E0890

NU

$120.41

E0890

RR

$29.30

E0890

UE

$96.99

E0900

NU

$128.12

E0900

RR

$27.62

E0900

UE

$96.12

E0910

RR

$18.58

E0911

RR

$49.85

E0912

RR

$114.47

E0920

RR

$39.22

E0930

RR

$45.69

E0935

RR

$19.32

E0940

RR

$34.77

E0941

RR

$36.90

E0942

NU

$19.85

E0942

RR

$2.34

E0942

UE

$14.88

E0944

NU

$45.45

E0944

RR

$4.55

E0944

UE

$34.09

E0945

NU

$40.61

E0945

RR

$4.06

E0945

UE

$30.45

E0946

RR

$59.16

E0947

NU

$515.49

E0947

RR

$53.46

E0947

UE

$386.61

E0948

NU

$586.59

E0948

RR

$58.64

E0948

UE

$413.70

E0950

NU

$103.95

E0950

RR

$10.41

E0950

UE

$77.97

E0951

NU

$18.98

E0951

RR

$1.96

E0951

UE

$14.22

E0952

NU

$18.83

E0952

RR

$1.96

E0952

UE

$14.13

E0955

NU

$202.18

E0955

RR

$20.23

E0955

UE

$151.63

E0956

NU

$98.58

E0956

RR

$9.87

E0956

UE

$73.93

E0957

NU

$137.93

E0957

RR

$13.79

E0957

UE

$103.45

E0958

RR

$43.63

E0959

NU

$44.21

E0959

RR

$4.45

E0959

UE

$33.46

E0960

NU

$90.98

E0960

RR

$9.10

E0960

UE

$68.24

E0961

NU

$25.28

E0961

RR

$2.64

E0961

UE

$13.00

E0966

NU

$71.37

E0966

RR

$7.04

E0966

UE

$53.52

E0967

NU

$64.59

E0967

RR

$6.46

E0967

UE

$48.43

E0968

RR

$15.24

E0969

NU

$156.63

E0969

RR

$15.51

E0969

UE

$117.48

E0971

NU

$43.39

E0971

RR

$4.34

E0971

UE

$32.56

E0973

NU

$114.97

E0973

RR

$10.95

E0973

UE

$86.23

E0974

NU

$78.41

E0974

RR

$8.31

E0974

UE

$59.25

E0978

NU

$41.10

E0978

RR

$4.11

E0978

UE

$30.84

E0980

NU

$33.06

E0980

RR

$3.30

E0980

UE

$24.66

E0981

NU

$47.15

E0981

RR

$4.80

E0981

UE

$35.70

E0982

NU

$51.53

E0982

RR

$5.15

E0982

UE

$38.64

E0983

RR

$249.93

E0984

NU

$1,623.99

E0984

RR

$150.95

E0984

UE

$1,253.13

E0985

NU

$202.85

E0985

RR

$20.30

E0985

UE

$152.12

E0986

NU

$4,864.24

E0986

RR

$486.43

E0986

UE

$3,648.20

E0990

NU

$117.43

E0990

RR

$13.22

E0990

UE

$91.75

E0992

NU

$95.15

E0992

RR

$9.25

E0992

UE

$71.37

E0994

NU

$17.63

E0994

RR

$1.78

E0994

UE

$13.23

E0995

NU

$29.59

E0995

RR

$2.98

E0995

UE

$22.21

E1002

NU

$4,113.02

E1002

RR

$411.33

E1002

UE

$3,084.76

E1003

NU

$4,391.30

E1003

RR

$439.14

E1003

UE

$3,293.48

E1004

NU

$4,869.05

E1004

RR

$486.90

E1004

UE

$3,651.77

E1005

NU

$5,270.36

E1005

RR

$527.03

E1005

UE

$3,952.78

E1006

NU

$6,455.70

E1006