Medical Fee Schedule: DME/Supply Section

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

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.

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	NU	$8,741.27
E1007	RR	$874.13
E1007	UE	$6,555.94
E1008	NU	$8,742.05
E1008	RR	$874.20
E1008	UE	$6,556.55
E1009	NU	$0.00
E1009	RR	$0.00
E1009	UE	$0.00
E1010	NU	$1,143.79
E1010	RR	$114.38
E1010	UE	$857.86
E1011	NU	$0.00
E1011	RR	$0.00
E1011	UE	$0.00
E1014	NU	$365.14
E1014	RR	$36.52
E1014	UE	$273.85
E1015	NU	$114.70
E1015	RR	$11.46
E1015	UE	$86.02
E1016	NU	$131.31
E1016	RR	$13.14
E1016	UE	$98.48
E1017	NU	$0.00
E1017	RR	$0.00
E1017	UE	$0.00
E1018	NU	$0.00
E1018	RR	$0.00
E1018	UE	$0.00
E1020	NU	$243.41
E1020	RR	$24.32
E1020	UE	$182.55
E1028	NU	$206.54
E1028	RR	$20.65
E1028	UE	$154.89
E1029	NU	$369.54
E1029	RR	$36.95
E1029	UE	$277.15
E1030	NU	$1,165.27
E1030	RR	$116.53
E1030	UE	$873.96
E1031	RR	$42.93
E1035	RR	$613.20
E1037	RR	$108.49
E1038	RR	$18.03
E1039	RR	$34.20
E1050	RR	$86.56
E1060	RR	$123.01
E1070	RR	$109.53
E1083	RR	$78.74
E1084	RR	$83.39
E1087	RR	$126.51
E1088	RR	$150.77
E1092	RR	$128.51
E1093	RR	$110.52
E1100	RR	$103.81
E1110	RR	$101.66
E1150	RR	$75.49
E1160	RR	$57.61
E1161	NU	$2,366.09
E1161	RR	$236.61
E1161	UE	$1,774.59
E1170	RR	$89.31
E1171	RR	$80.15
E1172	RR	$97.95
E1180	RR	$101.34
E1190	RR	$117.07
E1195	RR	$125.63
E1200	RR	$87.01
E1221	RR	$40.38
E1222	RR	$67.79
E1223	RR	$74.02
E1224	RR	$69.46
E1225	RR	$45.20
E1226	NU	$545.65
E1226	RR	$56.16
E1226	UE	$409.20
E1227	NU	$267.14
E1227	RR	$26.71
E1227	UE	$200.36
E1228	RR	$28.02
E1230	NU	$1,922.52
E1230	RR	$189.08
E1230	UE	$1,520.49
E1231	NU	$0.00
E1231	RR	$0.00
E1231	UE	$0.00
E1232	NU	$2,138.41
E1232	RR	$213.85
E1232	UE	$1,603.82
E1233	NU	$2,215.73
E1233	RR	$221.57
E1233	UE	$1,661.79
E1234	NU	$1,928.95
E1234	RR	$192.91
E1234	UE	$1,446.70
E1235	NU	$1,857.43
E1235	RR	$185.75
E1235	UE	$1,393.07
E1236	NU	$1,638.73
E1236	RR	$163.87
E1236	UE	$1,229.05
E1237	NU	$1,653.05
E1237	RR	$165.30
E1237	UE	$1,239.80
E1238	NU	$1,638.73
E1238	RR	$163.87
E1238	UE	$1,229.05
E1240	RR	$103.02
E1270	RR	$78.94
E1280	RR	$131.26
E1295	RR	$121.47
E1296	NU	$431.61
E1296	RR	$43.16
E1296	UE	$323.72
E1297	NU	$104.61
E1297	RR	$11.62
E1297	UE	$78.45
E1298	NU	$360.10
E1298	RR	$36.85
E1298	UE	$270.07
E1310	NU	$2,147.40
E1310	RR	$183.67
E1310	UE	$1,610.55
E1372	NU	$163.03
E1372	RR	$20.14
E1372	UE	$120.68
E1390	RR	$198.40
E1391	RR	$198.40
E1392	RR	$51.63
E1405	RR	$228.21
E1406	RR	$214.50
E1700	NU	$344.84
E1700	RR	$33.82
E1700	UE	$258.63
E1701		$10.61
E1702		$22.57
E1800	RR	$122.50
E1801	RR	$129.00
E1802	RR	$326.80
E1805	RR	$126.34
E1806	RR	$105.91
E1810	RR	$124.58
E1811	RR	$134.12
E1812	RR	$85.99
E1815	RR	$126.34
E1816	RR	$136.24
E1818	RR	$139.09
E1820	NU	$77.11
E1820	RR	$7.72
E1820	UE	$57.83
E1821	NU	$105.25
E1821	RR	$10.51
E1821	UE	$78.95
E1825	RR	$126.34
E1830	RR	$126.34
E1840	RR	$382.71
E1841	RR	$453.00
E2000	RR	$51.83
E2100	NU	$546.71
E2100	RR	$54.67
E2100	UE	$410.04
E2101	NU	$188.56
E2101	RR	$18.86
E2101	UE	$141.42
E2120	RR	$283.52
E2201	NU	$373.10
E2201	RR	$37.31
E2201	UE	$279.83
E2202	NU	$473.98
E2202	RR	$47.40
E2202	UE	$355.50
E2203	NU	$479.05
E2203	RR	$47.89
E2203	UE	$359.28
E2204	NU	$813.40
E2204	RR	$81.35
E2204	UE	$610.05
E2205	NU	$32.10
E2205	RR	$3.19
E2205	UE	$24.10
E2206	NU	$40.01
E2206	RR	$3.99
E2206	UE	$30.01
E2207	NU	$42.62
E2207	RR	$4.27
E2207	UE	$31.97
E2208	NU	$116.80
E2208	RR	$11.68
E2208	UE	$87.59
E2209	NU	$105.39
E2209	RR	$10.52
E2209	UE	$79.04
E2210	NU	$6.55
E2210	RR	$0.66
E2210	UE	$4.92
E2211	NU	$34.77
E2211	RR	$3.41
E2211	UE	$25.44
E2212	NU	$5.78
E2212	RR	$0.61
E2212	UE	$4.34
E2213	NU	$29.91
E2213	RR	$3.01
E2213	UE	$22.41
E2214	NU	$36.00
E2214	RR	$3.81
E2214	UE	$26.99
E2215	NU	$9.45
E2215	RR	$0.94
E2215	UE	$7.08
E2216	NU	$0.00
E2216	RR	$0.00
E2216	UE	$0.00
E2217	NU	$0.00
E2217	RR	$0.00
E2217	UE	$0.00
E2218	NU	$0.00
E2218	RR	$0.00
E2218	UE	$0.00
E2219	NU	$41.85
E2219	RR	$4.72
E2219	UE	$31.39
E2220	NU	$28.52
E2220	RR	$2.75
E2220	UE	$21.81
E2221	NU	$25.12
E2221	RR	$2.49
E2221	UE	$18.86
E2222	NU	$21.06
E2222	RR	$2.09
E2222	UE	$15.81
E2223	NU	$5.61
E2223	RR	$0.56
E2223	UE	$4.21
E2224	NU	$92.46
E2224	RR	$9.25
E2224	UE	$69.34
E2225	NU	$17.40
E2225	RR	$1.74
E2225	UE	$13.04
E2226	NU	$37.94
E2226	RR	$3.79
E2226	UE	$28.46
E2310	NU	$1,170.24
E2310	RR	$117.02
E2310	UE	$877.68
E2311	NU	$2,369.20
E2311	RR	$236.93
E2311	UE	$1,776.90
E2321	NU	$1,589.10
E2321	RR	$158.92
E2321	UE	$1,191.84
E2322	NU	$1,410.36
E2322	RR	$141.03
E2322	UE	$1,057.78
E2323	NU	$69.16
E2323	RR	$6.92
E2323	UE	$51.87
E2324	NU	$43.82
E2324	RR	$4.37
E2324	UE	$32.87
E2325	NU	$1,346.83
E2325	RR	$134.70
E2325	UE	$1,010.13
E2326	NU	$347.14
E2326	RR	$34.73
E2326	UE	$260.34
E2327	NU	$2,612.38
E2327	RR	$261.24
E2327	UE	$1,959.28
E2328	NU	$4,955.32
E2328	RR	$495.52
E2328	UE	$3,716.50
E2329	NU	$1,766.13
E2329	RR	$176.61
E2329	UE	$1,324.60
E2330	NU	$3,422.09
E2330	RR	$342.20
E2330	UE	$2,566.58
E2340	NU	$358.36
E2340	RR	$35.85
E2340	UE	$268.79
E2341	NU	$537.58
E2341	RR	$53.76
E2341	UE	$403.19
E2342	NU	$447.98
E2342	RR	$44.80
E2342	UE	$335.99
E2343	NU	$716.78
E2343	RR	$71.67
E2343	UE	$537.58
E2351	NU	$698.63
E2351	RR	$69.88
E2351	UE	$523.96
E2360	NU	$112.34
E2360	RR	$11.29
E2360	UE	$84.26
E2361	NU	$137.15
E2361	RR	$13.72
E2361	UE	$102.86
E2362	NU	$90.44
E2362	RR	$9.04
E2362	UE	$67.82
E2363	NU	$182.89
E2363	RR	$18.30
E2363	UE	$137.17
E2364	NU	$112.34
E2364	RR	$11.29
E2364	UE	$84.26
E2365	NU	$110.31
E2365	RR	$11.03
E2365	UE	$82.75
E2366	NU	$224.08
E2366	RR	$22.47
E2366	UE	$168.06
E2367	NU	$419.08
E2367	RR	$41.91
E2367	UE	$314.31
E2368	NU	$516.57
E2368	RR	$51.67
E2368	UE	$387.44
E2369	NU	$449.94
E2369	RR	$45.00
E2369	UE	$337.45
E2370	NU	$802.84
E2370	RR	$80.29
E2370	UE	$602.12
E2371	NU	$150.74
E2371	RR	$15.08
E2371	UE	$113.06
E2372	NU	$0.00
E2372	RR	$0.00
E2372	UE	$0.00
E2373	NU	$0.00
E2373	RR	$0.00
E2373	UE	$0.00
E2374	NU	$0.00
E2374	RR	$0.00
E2374	UE	$0.00
E2375	NU	$0.00
E2375	RR	$0.00
E2375	UE	$0.00
E2376	NU	$0.00
E2376	RR	$0.00
E2376	UE	$0.00
E2377	NU	$0.00
E2377	RR	$0.00
E2377	UE	$0.00
E2381	NU	$74.90
E2381	RR	$7.47
E2381	UE	$56.18
E2382	NU	$20.41
E2382	RR	$2.02
E2382	UE	$15.32
E2383	NU	$149.34
E2383	RR	$14.93
E2383	UE	$112.02
E2384	NU	$79.57
E2384	RR	$7.94
E2384	UE	$59.67
E2385	NU	$48.67
E2385	RR	$4.85
E2385	UE	$36.50
E2386	NU	$147.98
E2386	RR	$14.80
E2386	UE	$111.01
E2387	NU	$63.84
E2387	RR	$6.37
E2387	UE	$47.87
E2388	NU	$0.00
E2388	RR	$0.00
E2388	UE	$0.00
E2389	NU	$0.00
E2389	RR	$0.00
E2389	UE	$0.00
E2390	NU	$0.00
E2390	RR	$0.00
E2390	UE	$0.00
E2391	NU	$0.00
E2391	RR	$0.00
E2391	UE	$0.00
E2392	NU	$0.00
E2392	RR	$0.00
E2392	UE	$0.00
E2393	NU	$0.00
E2393	RR	$0.00
E2393	UE	$0.00
E2394	NU	$0.00
E2394	RR	$0.00
E2394	UE	$0.00
E2395	NU	$0.00
E2395	RR	$0.00
E2395	UE	$0.00
E2396	NU	$63.62
E2396	RR	$6.36
E2396	UE	$47.71
E2402	RR	$1,716.46
E2500	NU	$391.06
E2500	RR	$39.11
E2500	UE	$293.29
E2502	NU	$1,195.80
E2502	RR	$119.59
E2502	UE	$896.86
E2504	NU	$1,577.42
E2504	RR	$157.76
E2504	UE	$1,183.05
E2506	NU	$2,312.96
E2506	RR	$231.29
E2506	UE	$1,734.69
E2508	NU	$3,576.61
E2508	RR	$357.67
E2508	UE	$2,682.47
E2510	NU	$6,768.25
E2510	RR	$676.82
E2510	UE	$5,076.18
E2511	NU	$0.00
E2511	RR	$0.00
E2511	UE	$0.00
E2512	NU	$0.00
E2512	RR	$0.00
E2512	UE	$0.00
E2601	NU	$61.16
E2601	RR	$6.13
E2601	UE	$45.87
E2602	NU	$119.40
E2602	RR	$11.94
E2602	UE	$89.55
E2603	NU	$151.59
E2603	RR	$15.17
E2603	UE	$113.69
E2604	NU	$188.41
E2604	RR	$18.83
E2604	UE	$141.33
E2605	NU	$269.17
E2605	RR	$26.93
E2605	UE	$201.91
E2606	NU	$419.93
E2606	RR	$42.01
E2606	UE	$314.94
E2607	NU	$289.85
E2607	RR	$28.99
E2607	UE	$217.39
E2608	NU	$348.09
E2608	RR	$34.80
E2608	UE	$261.07
E2611	NU	$312.35
E2611	RR	$31.23
E2611	UE	$234.29
E2612	NU	$422.54
E2612	RR	$42.25
E2612	UE	$316.89
E2613	NU	$393.04
E2613	RR	$39.31
E2613	UE	$294.78
E2614	NU	$543.93
E2614	RR	$54.40
E2614	UE	$407.97
E2615	NU	$452.32
E2615	RR	$45.24
E2615	UE	$339.23
E2616	NU	$608.58
E2616	RR	$60.86
E2616	UE	$456.45
E2619	NU	$51.32
E2619	RR	$5.13
E2619	UE	$38.51
E2620	NU	$547.70
E2620	RR	$54.77
E2620	UE	$410.79
E2621	NU	$574.76
E2621	RR	$57.47
E2621	UE	$431.08
K0001	RR	$48.41
K0002	RR	$69.56
K0003	RR	$76.15
K0004	RR	$133.64
K0005	NU	$1,817.84
K0005	RR	$181.78
K0005	UE	$1,363.39
K0006	RR	$116.10
K0007	RR	$178.50
K0010	RR	$425.99
K0011	RR	$512.28
K0012	RR	$324.92
K0015	NU	$178.67
K0015	RR	$17.86
K0015	UE	$134.01
K0017	NU	$50.25
K0017	RR	$5.03
K0017	UE	$37.68
K0018	NU	$28.09
K0018	RR	$2.80
K0018	UE	$21.06
K0019	NU	$17.24
K0019	RR	$1.72
K0019	UE	$12.93
K0020	NU	$45.67
K0020	RR	$4.58
K0020	UE	$34.26
K0037	NU	$40.94
K0037	RR	$3.66
K0037	UE	$30.71
K0038	NU	$23.84
K0038	RR	$2.38
K0038	UE	$17.88
K0039	NU	$52.99
K0039	RR	$5.32
K0039	UE	$39.73
K0040	NU	$73.41
K0040	RR	$7.35
K0040	UE	$55.07
K0041	NU	$52.05
K0041	RR	$5.19
K0041	UE	$39.02
K0042	NU	$30.97
K0042	RR	$3.09
K0042	UE	$23.22
K0043	NU	$19.20
K0043	RR	$1.92
K0043	UE	$14.41
K0044	NU	$16.37
K0044	RR	$1.64
K0044	UE	$12.25
K0045	NU	$48.13
K0045	RR	$4.96
K0045	UE	$36.10
K0046	NU	$19.20
K0046	RR	$1.92
K0046	UE	$14.41
K0047	NU	$75.18
K0047	RR	$7.52
K0047	UE	$56.40
K0050	NU	$31.96
K0050	RR	$3.18
K0050	UE	$23.98
K0051	NU	$51.72
K0051	RR	$5.16
K0051	UE	$38.79
K0052	NU	$90.90
K0052	RR	$9.10
K0052	UE	$68.16
K0053	NU	$100.31
K0053	RR	$10.04
K0053	UE	$75.22
K0056	NU	$93.51
K0056	RR	$9.36
K0056	UE	$70.15
K0065	NU	$43.71
K0065	RR	$4.36
K0065	UE	$32.79
K0069	NU	$98.23
K0069	RR	$9.84
K0069	UE	$73.68
K0070	NU	$180.11
K0070	RR	$18.02
K0070	UE	$135.09
K0071	NU	$107.41
K0071	RR	$10.77
K0071	UE	$80.56
K0072	NU	$60.76
K0072	RR	$6.08
K0072	UE	$45.58
K0073	NU	$32.90
K0073	RR	$3.29
K0073	UE	$24.68
K0077	NU	$57.84
K0077	RR	$5.78
K0077	UE	$43.38
K0098	NU	$25.96
K0098	RR	$2.61
K0098	UE	$19.51
K0105	NU	$97.76
K0105	RR	$9.76
K0105	UE	$73.34
K0195	RR	$19.02
K0455	RR	$264.87
K0552		$2.61
K0601	NU	$1.10
K0602	NU	$6.36
K0603	NU	$0.57
K0604	NU	$6.09
K0605	NU	$14.60
K0606	RR	$2,268.20
K0607	NU	$194.23
K0607	RR	$19.43
K0607	UE	$145.67
K0608	NU	$121.21
K0608	RR	$12.14
K0608	UE	$90.91
K0609		$806.09
K0609	KF	$871.43
K0730	RR	$172.40
K0733	NU	$30.21
K0733	RR	$3.04
K0733	UE	$22.67
K0734	NU	$331.47
K0734	RR	$33.15
K0734	UE	$248.60
K0735	NU	$421.78
K0735	RR	$42.19
K0735	UE	$316.33
K0736	NU	$334.19
K0736	RR	$33.42
K0736	UE	$250.66
K0737	NU	$423.06
K0737	RR	$42.30
K0737	UE	$317.29
K0738	RR	$51.63
K0800	NU	$1,292.77
K0800	RR	$129.28
K0800	UE	$969.58
K0801	NU	$2,084.22
K0801	RR	$208.40
K0801	UE	$1,563.15
K0802	NU	$2,358.66
K0802	RR	$235.86
K0802	UE	$1,769.01
K0806	NU	$1,563.91
K0806	RR	$156.39
K0806	UE	$1,172.93
K0807	NU	$2,373.05
K0807	RR	$237.30
K0807	UE	$1,779.80
K0808	NU	$3,671.60
K0808	RR	$367.15
K0808	UE	$2,753.69
K0813	RR	$241.24
K0814	RR	$308.78
K0815	RR	$351.63
K0816	RR	$336.74
K0820	RR	$257.66
K0821	RR	$330.77
K0822	RR	$400.81
K0823	RR	$402.37
K0824	RR	$484.27
K0825	RR	$422.96
K0826	RR	$626.93
K0827	RR	$480.93
K0828	RR	$690.82
K0829	RR	$601.18
K0830	RR	$391.41
K0831	RR	$391.41
K0835	RR	$413.23
K0836	RR	$420.75
K0837	RR	$484.27
K0838	RR	$437.22
K0839	RR	$626.93
K0840	RR	$949.83
K0841	RR	$431.86
K0842	RR	$431.86
K0843	RR	$519.96
K0848	RR	$543.36
K0849	RR	$508.07
K0850	RR	$613.99
K0851	RR	$574.14
K0852	RR	$708.26
K0853	RR	$727.56
K0854	RR	$963.86
K0855	RR	$910.51
K0856	RR	$567.23
K0857	RR	$578.60
K0858	RR	$703.76
K0859	RR	$653.81
K0860	RR	$1,005.41
K0861	RR	$568.14
K0862	RR	$703.76
K0863	RR	$1,005.41
K0864	RR	$1,256.75
L0112		$1,147.06
L0120		$27.77
L0130		$154.55
L0140		$67.02
L0150		$89.25
L0160		$122.96
L0170		$596.47
L0172		$107.65
L0174		$226.64
L0180		$330.46
L0190		$464.93
L0200		$519.14
L0210		$34.77
L0220		$103.44
L0430		$1,052.01
L0450		$180.20
L0452		$0.00
L0454		$284.24
L0456		$815.11
L0458		$730.90
L0460		$822.67
L0462		$1,023.27
L0464		$1,218.19
L0466		$370.42
L0468		$444.62
L0470		$533.66
L0472		$378.97
L0480		$1,306.73
L0482		$1,331.76
L0484		$1,395.27
L0486		$1,480.30
L0488		$822.67
L0490		$231.84
L0491		$629.42
L0492		$414.00
L0621		$94.88
L0622		$251.81
L0623		$0.00
L0624		$0.00
L0625		$45.13
L0626		$63.88
L0627		$336.87
L0628		$68.75
L0629		$0.00
L0630		$132.73
L0631		$841.33
L0632		$0.00
L0633		$235.00
L0634		$0.00
L0635		$866.01
L0636		$1,129.15
L0637		$921.14
L0638		$1,080.91
L0639		$921.14
L0640		$857.57
L0700		$1,587.28
L0710		$1,792.81
L0810		$2,158.69
L0820		$2,120.00
L0830		$2,973.59
L0859		$956.46
L0861		$176.64
L0960		$56.00
L0970		$89.73
L0972		$80.80
L0974		$145.44
L0976		$153.70
L0978		$161.10
L0980		$14.58
L0982		$13.60
L0984		$53.67
L1000		$1,909.11
L1001		$0.00
L1005		$2,623.07
L1010		$54.65
L1020		$80.13
L1025		$97.90
L1030		$51.31
L1040		$75.76
L1050		$80.47
L1060		$88.48
L1070		$79.96
L1080		$49.43
L1085		$129.03
L1090		$78.03
L1100		$141.81
L1110		$234.66
L1120		$38.59
L1200		$1,640.21
L1210		$205.44
L1220		$212.78
L1230		$446.31
L1240		$65.16
L1250		$59.60
L1260		$62.91
L1270		$60.83
L1280		$70.47
L1290		$63.04
L1300		$1,326.30
L1310		$1,485.56
L1500		$1,742.00
L1510		$1,109.69
L1520		$2,166.26
L1600		$101.17
L1610		$34.47
L1620		$110.83
L1630		$143.69
L1640		$378.99
L1650		$181.78
L1652		$292.14
L1660		$145.61
L1680		$1,275.49
L1685		$933.89
L1686		$726.23
L1690		$1,584.79
L1700		$1,289.48
L1710		$1,560.15
L1720		$1,088.34
L1730		$928.59
L1755		$1,243.04
L1800		$53.02
L1810		$89.51
L1815		$92.28
L1820		$113.25
L1825		$50.43
L1830		$87.78
L1831		$241.20
L1832		$477.33
L1834		$609.46
L1836		$109.35
L1840		$835.07
L1843		$735.35
L1844		$1,651.84
L1845		$666.46
L1846		$1,035.30
L1847		$471.37
L1850		$252.36
L1860		$1,030.06
L1900		$233.51
L1901		$14.51
L1902		$76.85
L1904		$369.21
L1906		$94.42
L1907		$461.15
L1910		$265.58
L1920		$351.80
L1930		$216.91
L1932		$731.33
L1940		$417.11
L1945		$820.12
L1950		$779.73
L1951		$688.29
L1960		$435.19
L1970		$580.76
L1971		$384.14
L1980		$368.52
L1990		$445.30
L2000		$1,061.79
L2005		$3,358.27
L2010		$958.49
L2020		$1,222.34
L2030		$1,052.69
L2034		$1,661.91
L2035		$147.48
L2036		$1,879.17
L2037		$1,550.29
L2038		$1,305.97
L2040		$179.39
L2050		$379.31
L2060		$537.04
L2070		$105.59
L2080		$325.54
L2090		$459.03
L2106		$550.23
L2108		$940.86
L2112		$379.79
L2114		$466.04
L2116		$558.93
L2126		$940.15
L2128		$1,795.04
L2132		$633.34
L2134		$794.09
L2136		$928.49
L2180		$91.94
L2182		$84.61
L2184		$97.26
L2186		$136.09
L2188		$254.78
L2190		$68.57
L2192		$279.94
L2200		$49.77
L2210		$55.32
L2220		$75.99
L2230		$73.96
L2232		$81.56
L2240		$66.28
L2250		$371.97
L2260		$157.39
L2265		$92.46
L2270		$56.22
L2275		$122.79
L2280		$356.05
L2300		$263.56
L2310		$128.78
L2320		$206.36
L2330		$364.72
L2335		$195.27
L2340		$433.31
L2350		$789.25
L2360		$54.16
L2370		$215.37
L2375		$88.71
L2380		$98.41
L2385		$105.16
L2387		$159.44
L2390		$85.94
L2395		$122.84
L2397		$103.76
L2405		$71.45
L2415		$99.53
L2425		$117.48
L2430		$117.48
L2492		$83.02
L2500		$265.93
L2510		$648.73
L2520		$382.19
L2525		$1,018.79
L2526		$717.02
L2530		$192.62
L2540		$418.69
L2550		$246.04
L2570		$385.25
L2580		$430.64
L2600		$186.77
L2610		$225.09
L2620		$246.93
L2622		$240.77
L2624		$259.99
L2627		$1,345.93
L2628		$1,753.85
L2630		$205.37
L2640		$320.07
L2650		$125.63
L2660		$146.33
L2670		$138.46
L2680		$122.86
L2750		$77.10
L2755		$107.10
L2760		$48.71
L2768		$106.78
L2770		$48.48
L2780		$70.84
L2785		$27.47
L2795		$82.70
L2800		$96.00
L2810		$61.32
L2820		$68.18
L2830		$73.76
L2840		$34.30
L2850		$48.61
L3000		$257.44
L3001		$108.39
L3002		$132.36
L3003		$142.81
L3010		$142.81
L3020		$162.61
L3030		$62.55
L3031		$0.00
L3040		$38.56
L3050		$38.56
L3060		$60.46
L3070		$26.03
L3080		$26.03
L3090		$33.37
L3100		$35.43
L3140		$72.97
L3150		$66.71
L3170		$41.71
L3224		$46.17
L3225		$53.11
L3300		$42.73
L3310		$66.71
L3330		$463.82
L3332		$60.46
L3334		$31.27
L3340		$69.84
L3350		$18.77
L3360		$29.18
L3370		$40.62
L3380		$40.62
L3390		$40.62
L3400		$33.37
L3410		$76.08
L3420		$44.82
L3430		$131.33
L3440		$62.55
L3450		$86.51
L3455		$33.37
L3460		$28.13
L3465		$47.96
L3470		$51.07
L3480		$51.07
L3500		$23.97
L3510		$23.97
L3520		$26.03
L3530		$26.03
L3540		$41.71
L3550		$7.28
L3560		$18.77
L3570		$69.84
L3580		$53.15
L3590		$43.77
L3595		$34.39
L3600		$62.55
L3610		$82.33
L3620		$62.55
L3630		$82.33
L3640		$35.43
L3650		$48.56
L3651		$49.11
L3652		$148.00
L3660		$78.97
L3670		$90.30
L3671		$710.98
L3672		$835.77
L3673		$910.90
L3675		$130.89
L3700		$60.56
L3701		$16.07
L3702		$215.37
L3710		$94.97
L3720		$600.23
L3730		$807.53
L3740		$844.38
L3760		$294.60
L3762		$80.20
L3763		$626.48
L3764		$1,012.73
L3765		$956.37
L3766		$1,012.73
L3806		$0.00
L3807		$186.50
L3808		$263.56
L3900		$1,118.87
L3901		$1,383.26
L3904		$2,249.88
L3905		$739.69
L3906		$332.87
L3908		$61.38
L3909		$10.52
L3911		$19.57
L3912		$97.15
L3913		$213.71
L3915		$440.42
L3917		$78.79
L3919		$202.02
L3921		$239.59
L3923		$29.02
L3928		$44.91
L3929		$66.43
L3933		$168.37
L3935		$164.77
L3942		$54.77
L3956		$0.00
L3960		$634.89
L3961		$1,253.13
L3962		$686.10
L3964	NU	$621.11
L3964	RR	$62.10
L3964	UE	$465.80
L3965	NU	$991.11
L3965	RR	$99.13
L3965	UE	$743.33
L3966	NU	$746.64
L3966	RR	$74.67
L3966	UE	$559.98
L3967		$1,479.53
L3968	NU	$944.86
L3968	RR	$94.48
L3968	UE	$708.65
L3969	NU	$660.74
L3969	RR	$66.08
L3969	UE	$495.54
L3970	NU	$224.66
L3970	RR	$22.47
L3970	UE	$168.50
L3971		$1,404.41
L3972	NU	$142.86
L3972	RR	$14.29
L3972	UE	$107.14
L3973		$1,479.53
L3974	NU	$142.55
L3974	RR	$14.27
L3974	UE	$106.91
L3975		$1,253.13
L3976		$1,253.13
L3977		$1,404.41
L3978		$1,479.53
L3980		$237.51
L3982		$286.81
L3984		$276.00
L3995		$27.89
L4000		$1,137.28
L4002		$0.00
L4010		$628.38
L4020		$752.34
L4030		$518.77
L4040		$427.32
L4045		$259.80
L4050		$390.53
L4055		$212.92
L4060		$317.24
L4070		$261.53
L4080		$94.05
L4090		$94.45
L4100		$109.19
L4110		$88.78
L4130		$519.37
L4350		$77.29
L4360		$289.85
L4370		$197.63
L4380		$108.16
L4386		$129.94
L4392		$18.97
L4394		$13.82
L4396		$135.24
L4398		$62.26
L5000		$422.63
L5010		$1,018.33
L5020		$1,888.51
L5050		$2,254.76
L5060		$2,992.01
L5100		$2,337.08
L5105		$3,298.40
L5150		$3,410.52
L5160		$4,160.93
L5200		$3,407.25
L5210		$2,706.29
L5220		$3,076.19
L5230		$4,114.22
L5250		$5,353.83
L5270		$5,735.95
L5280		$5,678.59
L5301		$2,343.39
L5311		$3,678.71
L5321		$3,620.14
L5331		$5,136.55
L5341		$5,361.16
L5400		$1,118.59
L5410		$429.98
L5420		$1,351.09
L5430		$421.72
L5450		$369.06
L5460		$488.66
L5500		$1,074.28
L5505		$1,454.86
L5510		$1,319.54
L5520		$1,202.86
L5530		$1,678.61
L5535		$1,733.88
L5540		$1,850.69
L5560		$1,808.03
L5570		$1,901.69
L5580		$2,178.52
L5585		$2,414.53
L5590		$2,113.83
L5595		$3,775.93
L5600		$4,759.29
L5610		$2,221.75
L5611		$1,475.74
L5613		$2,049.89
L5614		$1,385.64
L5616		$1,136.04
L5617		$459.44
L5618		$261.29
L5620		$248.12
L5622		$349.93
L5624		$315.04
L5626		$457.38
L5628		$505.73
L5629		$265.83
L5630		$423.62
L5631		$367.52
L5632		$247.63
L5634		$295.01
L5636		$262.93
L5637		$249.03
L5638		$461.45
L5639		$1,056.99
L5640		$700.04
L5642		$690.98
L5643		$1,494.54
L5644		$551.61
L5645		$667.40
L5646		$490.60
L5647		$665.36
L5648		$550.70
L5649		$1,683.41
L5650		$480.03
L5651		$1,004.51
L5652		$364.68
L5653		$598.32
L5654		$324.06
L5655		$290.37
L5656		$413.71
L5658		$405.51
L5661		$509.02
L5665		$428.28
L5666		$59.42
L5668		$93.85
L5670		$247.74
L5671		$554.75
L5672		$269.91
L5673		$599.16
L5676		$353.10
L5677		$449.49
L5678		$39.58
L5679		$499.30
L5680		$296.56
L5681		$1,080.12
L5682		$528.86
L5683		$1,080.12
L5684		$53.68
L5685		$105.17
L5686		$53.32
L5688		$58.37
L5690		$88.77
L5692		$130.44
L5694		$201.54
L5695		$136.41
L5696		$206.35
L5697		$89.53
L5698		$104.60
L5699		$205.61
L5700		$3,054.22
L5701		$3,711.52
L5702		$4,444.22
L5703		$2,049.56
L5704		$510.08
L5705		$837.38
L5706		$829.95
L5707		$1,179.82
L5710		$380.59
L5711		$515.23
L5712		$462.54
L5714		$349.87
L5716		$609.64
L5718		$761.98
L5722		$887.22
L5724		$1,343.44
L5726		$1,625.86
L5728		$2,163.81
L5780		$957.66
L5781		$3,285.53
L5782		$3,463.70
L5785		$519.15
L5790		$625.08
L5795		$898.09
L5810		$465.05
L5811		$610.04
L5812		$527.96
L5814		$3,049.64
L5816		$711.36
L5818		$803.27
L5822		$1,424.39
L5824		$1,282.75
L5826		$2,663.86
L5828		$2,362.09
L5830		$2,059.55
L5840		$3,376.08
L5845		$1,471.79
L5848		$883.00
L5850		$107.00
L5855		$344.43
L5856		$19,712.29
L5857		$6,994.67
L5858		$15,261.14
L5910		$302.94
L5920		$443.81
L5925		$364.80
L5930		$2,763.90
L5940		$521.66
L5950		$749.82
L5960		$857.01
L5962		$655.55
L5964		$943.71
L5966		$1,223.48
L5968		$2,983.98
L5970		$205.18
L5971		$205.18
L5972		$327.91
L5974		$259.89
L5975		$380.67
L5976		$523.65
L5978		$295.95
L5979		$2,521.28
L5980		$3,390.98
L5981		$2,739.90
L5982		$639.18
L5984		$604.27
L5985		$231.88
L5986		$639.57
L5987		$5,907.10
L5988		$1,640.41
L5990		$1,489.73
L5993		$0.00
L5994		$0.00
L5995		$0.00
L6000		$1,481.85
L6010		$1,649.06
L6020		$1,537.48
L6025		$6,571.12
L6050		$1,816.02
L6055		$2,711.59
L6100		$1,956.09
L6110		$1,995.07
L6120		$2,508.75
L6130		$2,887.12
L6200		$2,962.96
L6205		$3,712.15
L6250		$2,763.16
L6300		$3,886.75
L6310		$3,226.32
L6320		$1,429.45
L6350		$4,368.43
L6360		$3,552.34
L6370		$1,698.90
L6380		$1,143.82
L6382		$1,346.54
L6384		$1,704.72
L6386		$386.12
L6388		$424.39
L6400		$2,165.56
L6450		$2,939.72
L6500		$2,973.31
L6550		$3,977.45
L6570		$4,433.70
L6580		$1,506.74
L6582		$1,197.36
L6584		$2,034.39
L6586		$1,738.70
L6588		$2,943.96
L6590		$2,712.63
L6600		$170.00
L6605		$160.38
L6610		$146.28
L6611		$0.00
L6615		$178.76
L6616		$65.15
L6620		$279.99
L6621		$1,878.21
L6623		$602.33
L6624		$0.00
L6625		$515.13
L6628		$483.76
L6629		$122.60
L6630		$180.27
L6632		$54.34
L6635		$158.04
L6637		$363.44
L6638		$2,053.47
L6639		$0.00
L6640		$288.17
L6641		$143.63
L6642		$194.27
L6645		$331.60
L6646		$2,589.88
L6647		$426.37
L6648		$2,671.10
L6650		$285.99
L6655		$83.78
L6660		$88.70
L6665		$41.24
L6670		$42.65
L6672		$161.92
L6675		$100.45
L6676		$123.50
L6677		$243.58
L6680		$198.99
L6682		$253.16
L6684		$387.92
L6686		$556.12
L6687		$482.48
L6688		$590.80
L6689		$723.11
L6690		$766.87
L6691		$331.76
L6692		$467.77
L6693		$2,331.24
L6694		$599.16
L6695		$499.30
L6696		$1,080.12
L6697		$1,080.12
L6698		$554.75
L6703		$276.16
L6704		$524.18
L6706		$333.43
L6707		$1,176.32
L6708		$820.83
L6709		$1,177.07
L6805		$353.78
L6810		$167.40
L6881		$3,357.05
L6882		$2,546.47
L6883		$1,714.08
L6884		$2,342.29
L6885		$3,552.34
L6890		$155.32
L6895		$518.56
L6900		$1,624.17
L6905		$1,637.45
L6910		$1,343.92
L6915		$607.36
L6920		$6,508.73
L6925		$7,118.24
L6930		$7,061.90
L6935		$7,463.43
L6940		$8,455.09
L6945		$9,368.19
L6950		$8,831.08
L6955		$9,990.20
L6960		$10,880.46
L6965		$12,287.11
L6970		$12,199.61
L6975		$13,366.90
L7007		$2,918.26
L7008		$5,054.32
L7009		$3,156.09
L7040		$2,519.44
L7045		$1,351.99
L7170		$5,107.47
L7180		$30,645.69
L7181		$32,901.71
L7185		$5,364.76
L7186		$7,398.89
L7190		$6,664.67
L7191		$7,731.40
L7260		$1,898.55
L7261		$3,979.10
L7266		$828.15
L7272		$1,994.29
L7274		$5,950.17
L7360		$222.00
L7362		$230.11
L7364		$435.87
L7366		$563.39
L7367		$319.69
L7368		$414.43
L7400		$251.67
L7401		$281.74
L7402		$304.26
L7403		$302.40
L7404		$456.40
L7405		$596.91
L7900		$444.63
L8000		$34.55
L8001		$102.99
L8002		$135.46
L8015		$51.12
L8020		$201.53
L8030		$263.89
L8035		$3,008.38
L8040		$2,052.99
L8040	KM	$1,950.33
L8040	KN	$821.20
L8041		$2,474.68
L8041	KM	$2,350.93
L8041	KN	$989.87
L8042		$2,780.53
L8042	KM	$2,641.50
L8042	KN	$1,112.20
L8043		$3,114.20
L8043	KM	$2,958.48
L8043	KN	$1,245.68
L8044		$3,447.86
L8044	KM	$3,275.47
L8044	KN	$1,379.14
L8045		$2,164.35
L8045	KM	$2,056.13
L8045	KN	$865.73
L8046		$2,224.42
L8046	KM	$2,113.20
L8046	KN	$889.76
L8047		$1,140.01
L8047	KM	$1,083.02
L8047	KN	$456.01
L8300		$87.66
L8310		$122.78
L8320		$46.75
L8330		$41.30
L8400		$15.52
L8410		$22.11
L8415		$22.71
L8417		$61.75
L8420		$16.79
L8430		$19.17
L8435		$23.45
L8440		$34.98
L8460		$73.00
L8465		$40.80
L8470		$5.58
L8480		$10.26
L8485		$12.03
L8500		$653.03
L8501		$101.04
L8507		$34.40
L8509		$89.68
L8510		$207.49
L8511		$59.72
L8512		$1.77
L8513		$4.26
L8514		$77.43
L8515		$51.83
L8600		$610.02
L8603		$368.45
L8606		$186.84
L8609		$5,350.13
L8610		$554.89
L8612		$605.77
L8613		$251.77
L8614		$15,713.48
L8615		$370.34
L8616		$86.26
L8617		$75.34
L8618		$21.53
L8619		$6,745.68
L8621		$0.51
L8622		$0.27
L8623		$53.12
L8624		$132.42
L8630		$281.81
L8631		$1,782.63
L8641		$390.39
L8642		$256.91
L8658		$340.39
L8659		$1,584.56
L8670		$465.61
L8680		$391.84
L8681		$902.36
L8682		$5,085.39
L8683		$4,476.32
L8684		$662.51
L8685		$11,154.71
L8686		$7,117.61
L8687		$14,516.72
L8688		$9,262.83
L8689		$1,416.44
L8690		$0.00
L8691		$0.00
L8695		$13.67
Q0480		$73,956.06
Q0481		$11,931.94
Q0482		$3,737.31
Q0483		$15,396.04
Q0484		$2,989.86
Q0485		$288.67
Q0486		$240.26
Q0487		$280.30
Q0489		$13,347.54
Q0490		$577.34
Q0491		$907.66
Q0492		$73.12
Q0493		$208.22
Q0494		$176.19
Q0495		$3,429.97
Q0496		$1,231.07
Q0497		$384.41
Q0498		$421.78
Q0499		$137.04
Q0500		$25.07
Q0501		$419.36
Q0502		$533.89
Q0503		$1,067.80
Q0504		$563.46
V2020		$59.30
V2100		$37.46
V2101		$38.53
V2102		$48.57
V2103		$35.58
V2104		$36.63
V2105		$41.30
V2106		$44.31
V2107		$38.42
V2108		$37.48
V2109		$46.01
V2110		$40.92
V2111		$42.66
V2112		$47.25
V2113		$55.84
V2114		$60.83
V2115		$73.45
V2118		$69.32
V2121		$77.58
V2200		$53.30
V2201		$53.52
V2202		$58.87
V2203		$52.31
V2204		$52.56
V2205		$54.39
V2206		$54.82
V2207		$51.13
V2208		$50.16
V2209		$57.89
V2210		$65.65
V2211		$71.70
V2212		$72.24
V2213		$69.59
V2214		$73.05
V2215		$87.73
V2218		$91.84
V2219		$37.24
V2220		$30.20
V2221		$81.03
V2300		$63.16
V2301		$66.33
V2302		$68.59
V2303		$62.75
V2304		$57.97
V2305		$65.34
V2306		$67.06
V2307		$68.19
V2308		$75.62
V2309		$78.18
V2310		$74.66
V2311		$74.52
V2312		$76.75
V2313		$86.07
V2314		$89.90
V2315		$101.76
V2318		$122.70
V2319		$41.54
V2320		$49.59
V2321		$98.38
V2410		$88.74
V2430		$92.65
V2500		$90.65
V2501		$103.56
V2502		$127.57
V2503		$125.34
V2510		$116.19
V2511		$133.35
V2512		$157.57
V2513		$144.45
V2520		$97.85
V2521		$151.88
V2522		$147.80
V2523		$128.62
V2530		$186.55
V2531		$444.63
V2623		$899.90
V2624		$67.89
V2625		$412.78
V2626		$222.51
V2627		$1,437.06
V2628		$339.32
V2700		$36.64
V2710		$53.63
V2715		$11.95
V2718		$23.88
V2730		$17.64
V2744		$15.20
V2745		$10.28
V2750		$15.97
V2755		$14.87
V2760		$13.40
V2762		$48.94
V2770		$16.47
V2780		$10.48
V2782		$52.86
V2783		$59.60
V2784		$38.76
V2786		$0.00

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)

Medical Fee Schedule: DME/Supply Section

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

Durable Medical Equipment/Supply Fee Schedule

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