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. |
|
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) |
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 |
RR |
$645.55 |
|
E1006 |
UE |
$4,841.78 |
|
E1007 |
|