2016 dmepos/pen fee schedule - 3rd quarter (revised) · 2017-11-28 · revised third quarter 2016...

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Revised Third Quarter 2016 DMEPOS/PEN Fee Schedule - Jurisdiction CRevised per CR 9968Inclusion or exclusion of a fee schedule amount for an item or service does not imply any health insurance coverage

Category KeyCR=Capped Rental ItemsFS=Frequently Serviced ItemsIN=Inexpensive and Other Routinely Purchased ItemsOS=Ostomy, Tracheostomy & Urological ItemsOX=Oxygen and Oxygen EquipmentPE=Parenteral and Enteral NutritionPO=Prosthetics & OrthoticsSD=Surgical DressingsSU=SuppliesTE=Transcutaneous Electrical Nerve StimulatorsTS=Therapeutic Shoes

HCPCS 1st Mod 2nd Mod CategoryFee Schedule

Rural Fee Indicator Rural Fee

Fee Schedule


Fee Schedule


Fee Schedule


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Fee Schedule


A4216 OS $0.47 $0.49 $0.49 $0.47 $0.49 $0.49A4217 AU OS $2.95 $3.47 $3.47 $3.47 $3.47 $3.47A4217 SU $2.95 $3.47 $3.47 $3.47 $3.47 $3.47A4221 SU $22.21 $22.21 $22.21 $22.21 $22.21 $22.21A4222 SU $44.23 $44.23 $44.23 $43.24 $44.23 $44.23A4233 NU IN $0.51 $0.51 $0.51 $0.51 $0.51 $0.51A4234 NU IN $2.36 $2.36 $2.36 $2.36 $2.36 $2.36A4235 NU IN $1.00 $1.00 $1.00 $1.00 $1.00 $1.00A4236 NU IN $1.16 $1.16 $1.16 $1.16 $1.16 $1.16A4253 NU IN $8.32 $8.32 $8.32 $8.32 $8.32 $8.32A4255 SU $4.55 $4.55 $4.55 $4.32 $4.47 $4.55A4256 SU $3.38 $3.38 $3.38 $3.38 $3.38 $3.38A4257 SU $14.10 $14.10 $14.10 $14.10 $14.10 $14.10A4258 SU $2.12 $2.12 $2.12 $2.12 $2.12 $2.12A4259 SU $1.42 $1.42 $1.42 $1.42 $1.42 $1.42A4265 SU $3.76 $3.76 $3.76 $3.76 $3.76 $3.76A4280 PO $5.90 $5.90 $5.91 $5.90 $5.90 $5.90A4310 OS $7.71 $7.50 $8.54 $7.26 $7.67 $8.47A4311 OS $16.39 $16.39 $14.51 $13.93 $16.39 $16.39A4312 OS $17.19 $19.94 $16.95 $19.94 $16.95 $19.94A4313 OS $17.41 $20.46 $17.41 $17.41 $17.41 $20.48A4314 OS $24.10 $27.95 $27.95 $23.76 $25.80 $27.95A4315 OS $24.79 $27.99 $29.17 $24.79 $24.79 $27.95A4316 OS $26.68 $27.99 $31.39 $26.68 $31.39 $27.95A4320 OS $5.90 $5.90 $5.85 $5.90 $5.22 $5.90A4322 OS $3.37 $3.35 $3.36 $3.12 $3.28 $3.37A4326 OS $11.93 $11.93 $10.78 $11.93 $11.93 $11.93A4327 OS $49.31 $49.31 $49.31 $46.72 $49.31 $49.31A4328 OS $11.54 $11.20 $11.54 $10.90 $11.31 $11.20A4330 OS $7.91 $7.22 $7.91 $7.91 $7.91 $7.22A4331 OS $3.52 $3.52 $3.52 $3.52 $3.52 $3.52A4332 OS $0.13 $0.13 $0.13 $0.13 $0.13 $0.13A4333 OS $2.44 $2.44 $2.44 $2.44 $2.44 $2.44A4334 OS $5.44 $5.44 $5.44 $5.44 $5.44 $5.44A4336 OS $1.59 $1.59 $1.59 $1.59 $1.59 $1.59A4338 OS $13.56 $13.56 $13.56 $13.56 $11.53 $13.56A4340 OS $34.98 $35.10 $35.10 $35.10 $29.97 $35.10

There are three columns under each state/territory listing (Fee Schedule, Rural Fee Indicator and Rural Fee). The Rural Fee applies to the HCPCS codes with the Rural Fee Indicator of "R" for the beneficiaries residing in the rural designated Zip codes for that state.

ALABAMA ARIZONA COLORADO FLORIDA GEORGIA LOUISIANA

Revised Third Quarter 2016 DMEPOS/PEN Fee Schedule - Jurisdiction CRevised per CR 9968Inclusion or exlusion of a fee schedule amount for an item or service does not imply any health insurance coverage




Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



A4344 OS $17.50 $17.70 $17.53 $17.70 $15.05 $17.70A4346 OS $21.65 $18.40 $21.65 $21.65 $18.40 $21.65A4349 OS $2.23 $2.23 $2.23 $2.23 $2.23 $2.23A4351 OS $2.01 $1.89 $1.71 $2.01 $2.00 $1.89A4352 OS $7.10 $6.04 $6.90 $6.04 $6.97 $6.04A4353 OS $7.74 $7.74 $7.74 $7.73 $7.74 $7.74A4354 OS $13.05 $13.05 $13.05 $11.09 $11.09 $13.05A4355 OS $9.18 $9.86 $9.86 $8.38 $8.98 $9.86A4356 OS $50.44 $50.44 $42.87 $50.44 $50.44 $50.44A4357 OS $10.73 $10.73 $10.73 $10.73 $9.12 $10.73A4358 OS $6.88 $7.33 $7.33 $7.33 $7.17 $7.33A4360 OS $0.54 $0.54 $0.46 $0.54 $0.54 $0.54A4361 OS $20.31 $19.78 $19.70 $20.31 $17.83 $17.26A4362 OS $3.26 $3.83 $3.83 $3.76 $3.26 $3.83A4363 OS $2.23 $2.62 $2.62 $2.62 $2.23 $2.62A4364 OS $3.14 $3.25 $3.25 $2.90 $2.76 $3.25A4366 OS $1.43 $1.43 $1.43 $1.43 $1.43 $1.43A4367 OS $7.35 $7.72 $8.13 $8.13 $7.45 $7.33A4368 OS $0.28 $0.28 $0.28 $0.28 $0.28 $0.28A4369 OS $2.68 $2.68 $2.68 $2.68 $2.68 $2.68A4371 OS $4.03 $4.03 $4.03 $4.03 $4.03 $4.03A4372 OS $4.64 $4.64 $4.64 $4.64 $4.64 $4.64A4373 OS $6.93 $6.93 $6.93 $6.93 $6.93 $6.93A4375 OS $18.99 $18.99 $18.99 $18.99 $18.99 $18.99A4376 OS $52.61 $52.61 $52.61 $52.61 $52.61 $52.61A4377 OS $4.75 $4.75 $4.75 $4.75 $4.75 $4.75A4378 OS $33.98 $33.98 $33.98 $33.98 $33.98 $33.98A4379 OS $16.60 $16.60 $16.60 $16.60 $16.60 $16.60A4380 OS $41.26 $41.26 $41.26 $41.26 $41.26 $41.26A4381 OS $5.11 $5.11 $5.11 $5.11 $5.11 $5.11A4382 OS $27.21 $27.21 $27.21 $27.21 $27.21 $27.21A4383 OS $31.16 $31.16 $31.16 $31.16 $31.16 $31.16A4384 OS $10.63 $10.63 $10.63 $10.63 $10.63 $10.63A4385 OS $5.64 $5.64 $5.64 $5.64 $5.64 $5.64A4387 OS $2.48 $2.48 $2.48 $2.48 $2.48 $2.48A4388 OS $4.83 $4.83 $4.83 $4.83 $4.83 $4.83A4389 OS $6.87 $6.87 $6.87 $6.87 $6.87 $6.87A4390 OS $10.62 $10.62 $10.62 $10.62 $10.62 $10.62A4391 OS $7.82 $7.82 $7.82 $7.82 $7.82 $7.82A4392 OS $9.04 $9.04 $9.04 $9.04 $9.04 $9.04A4393 OS $10.00 $10.00 $10.00 $10.00 $10.00 $10.00A4394 OS $2.86 $2.86 $2.86 $2.86 $2.86 $2.86A4395 OS $0.05 $0.05 $0.05 $0.05 $0.05 $0.05A4396 OS $44.75 $44.75 $44.75 $44.75 $44.75 $44.75A4397 OS $5.29 $5.29 $5.29 $4.57 $4.88 $5.29A4398 OS $14.36 $15.28 $15.00 $15.28 $14.00 $15.28A4399 OS $13.56 $13.56 $13.56 $13.56 $11.77 $13.56A4400 OS $45.92 $54.02 $45.92 $45.92 $45.92 $54.02A4402 OS $1.77 $1.77 $1.77 $1.57 $1.50 $1.77A4404 OS $1.58 $1.86 $1.86 $1.86 $1.86 $1.86A4405 OS $3.77 $3.77 $3.77 $3.77 $3.77 $3.77A4406 OS $6.33 $6.33 $6.33 $6.33 $6.33 $6.33A4407 OS $9.68 $9.68 $9.68 $9.68 $9.68 $9.68A4408 OS $10.91 $10.91 $10.91 $10.91 $10.91 $10.91A4409 OS $6.87 $6.87 $6.87 $6.87 $6.87 $6.87A4410 OS $10.00 $10.00 $10.00 $10.00 $10.00 $10.00A4411 OS $5.64 $5.64 $5.64 $5.64 $5.64 $5.64A4412 OS $2.99 $2.99 $2.99 $2.99 $2.99 $2.99A4413 OS $6.09 $6.09 $6.09 $6.09 $6.09 $6.09A4414 OS $5.44 $5.44 $5.44 $5.44 $5.44 $5.44A4415 OS $6.62 $6.62 $6.62 $6.62 $6.62 $6.62





Fee Schedule


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A4416 OS $3.05 $3.05 $3.05 $3.05 $3.05 $3.05A4417 OS $4.11 $4.11 $4.11 $4.11 $4.11 $4.11A4418 OS $2.01 $2.01 $2.01 $2.01 $2.01 $2.01A4419 OS $1.92 $1.92 $1.92 $1.92 $1.92 $1.92A4422 OS $0.13 $0.13 $0.13 $0.13 $0.13 $0.13A4423 OS $2.06 $2.06 $2.06 $2.06 $2.06 $2.06A4424 OS $5.26 $5.26 $5.26 $5.26 $5.26 $5.26A4425 OS $3.96 $3.96 $3.96 $3.96 $3.96 $3.96A4426 OS $3.02 $3.02 $3.02 $3.02 $3.02 $3.02A4427 OS $3.08 $3.08 $3.08 $3.08 $3.08 $3.08A4428 OS $7.20 $7.20 $7.20 $7.20 $7.20 $7.20A4429 OS $9.12 $9.12 $9.12 $9.12 $9.12 $9.12A4430 OS $9.41 $9.41 $9.41 $9.41 $9.41 $9.41A4431 OS $6.87 $6.87 $6.87 $6.87 $6.87 $6.87A4432 OS $3.97 $3.97 $3.97 $3.97 $3.97 $3.97A4433 OS $3.70 $3.70 $3.70 $3.70 $3.70 $3.70A4434 OS $4.15 $4.15 $4.15 $4.15 $4.15 $4.15A4435 OS $6.38 $6.38 $6.38 $6.38 $6.38 $6.38A4450 AU OS $0.09 $0.09 $0.09 $0.09 $0.09 $0.09A4450 AV OS $0.09 $0.09 $0.09 $0.09 $0.09 $0.09A4450 AW OS $0.12 $0.12 $0.12 $0.12 $0.12 $0.12A4452 AU OS $0.40 $0.40 $0.40 $0.40 $0.40 $0.40A4452 AV OS $0.40 $0.40 $0.40 $0.40 $0.40 $0.40A4452 AW OS $0.44 $0.44 $0.44 $0.44 $0.44 $0.44A4455 OS $1.58 $1.58 $1.58 $1.34 $1.58 $1.58A4456 OS $0.27 $0.27 $0.27 $0.27 $0.27 $0.27A4461 SD $3.64 $3.64 $3.64 $3.64 $3.64 $3.64A4463 SD $14.72 $14.72 $14.72 $14.72 $14.72 $14.72A4481 OS $0.42 $0.42 $0.42 $0.41 $0.42 $0.42A4556 SU $13.43 $13.43 $13.43 $11.97 $13.43 $13.43A4557 SU $16.55 R $16.69 $17.20 R $17.34 $16.39 R $17.34 $17.20 R $17.34 $17.20 R $17.34 $17.20 R $17.34A4558 SU $6.03 $6.03 $6.03 $5.71 $6.03 $5.13A4559 SU $0.11 $0.11 $0.11 $0.11 $0.11 $0.11A4595 SU $21.48 R $21.67 $21.48 R $21.67 $20.99 R $21.67 $21.48 R $21.67 $21.48 R $21.67 $21.48 R $21.67A4602 NU IN $4.11 $4.11 $4.11 $4.11 $4.11 $4.11A4604 NU IN $51.69 R $53.81 $51.69 R $53.81 $51.70 R $53.81 $51.69 R $53.81 $51.69 R $53.81 $51.69 R $53.81A4605 NU IN $18.13 $18.13 $18.13 $18.13 $18.13 $18.13A4608 OX $55.41 $55.41 $55.41 $55.41 $55.41 $55.41A4614 IN $26.29 $26.29 $26.29 $26.29 $26.29 $26.29A4615 SU $0.80 $0.80 $0.80 $0.80 $0.80 $0.80A4616 SU $0.07 $0.07 $0.07 $0.07 $0.07 $0.07A4617 SU $3.43 $3.43 $3.43 $3.43 $3.43 $3.43A4618 NU IN $8.36 $9.83 $9.83 $8.36 $9.04 $9.83A4618 RR IN $0.97 $1.14 $1.14 $0.97 $0.97 $1.14A4618 UE IN $6.26 $7.37 $7.37 $6.26 $6.82 $7.37A4619 NU IN $2.01 $2.01 $2.01 $2.01 $2.01 $2.01A4620 SU $0.70 $0.70 $0.70 $0.66 $0.70 $0.70A4623 OS $6.15 $7.24 $7.24 $7.24 $6.92 $7.24A4624 NU IN $2.91 $2.91 $2.91 $2.91 $2.91 $2.91A4625 OS $7.66 $7.66 $7.66 $7.66 $7.66 $7.66A4626 OS $3.25 $3.53 $3.53 $3.00 $3.53 $3.53A4628 NU IN $4.13 $4.13 $4.13 $4.05 $4.13 $4.13A4629 OS $5.13 $5.13 $5.13 $5.13 $5.13 $5.13A4630 NU IN $6.90 $6.90 $6.90 $6.90 $5.87 $6.90A4633 NU IN $45.36 $45.36 $45.36 $45.36 $45.36 $45.36A4635 NU IN $4.81 $4.81 $5.66 $4.81 $4.81 $4.81A4635 RR IN $0.70 $0.72 $0.77 $0.65 $0.65 $0.73A4635 UE IN $3.20 $3.20 $3.76 $3.20 $3.20 $3.20A4636 NU KE IN $3.54 $3.45 $3.80 $3.45 $3.45 $3.80A4636 NU IN $3.25 $3.18 $3.47 $3.18 $3.18 $3.47A4636 RR KE IN $0.35 $0.35 $0.38 $0.35 $0.35 $0.38





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A4636 RR IN $0.32 $0.32 $0.35 $0.32 $0.32 $0.35A4636 UE KE IN $2.76 $2.54 $2.80 $2.54 $2.54 $2.80A4636 UE IN $2.53 $2.35 $2.56 $2.35 $2.35 $2.56A4637 NU KE IN $1.82 $1.99 $1.99 $1.82 $1.82 $1.99A4637 NU IN $1.68 $1.84 $1.84 $1.68 $1.68 $1.84A4637 RR KE IN $0.22 $0.25 $0.22 $0.22 $0.22 $0.25A4637 RR IN $0.20 $0.22 $0.20 $0.20 $0.20 $0.22A4637 UE KE IN $1.37 $1.50 $1.50 $1.37 $1.37 $1.50A4637 UE IN $1.27 $1.38 $1.38 $1.27 $1.27 $1.38A4639 RR CR $31.76 $31.76 $31.76 $31.76 $31.76 $31.76A4640 NU IN $59.46 R $63.28 $54.21 R $58.03 $60.92 R $63.28 $54.21 R $58.03 $59.46 R $63.28 $54.21 R $58.03A4640 RR IN $6.01 R $6.39 $5.67 R $6.05 $6.16 R $6.39 $5.48 R $5.86 $6.01 R $6.39 $5.67 R $6.05A4640 UE IN $43.15 R $46.01 $40.63 R $43.50 $44.24 R $46.01 $39.47 R $42.25 $43.15 R $46.01 $40.63 R $43.50A5051 OS $2.28 $2.28 $2.28 $2.28 $2.28 $2.28A5052 OS $1.64 $1.64 $1.64 $1.64 $1.64 $1.64A5053 OS $1.63 $1.92 $1.92 $1.85 $1.64 $1.92A5054 OS $1.99 $1.99 $1.99 $1.99 $1.99 $1.99A5055 OS $1.59 $1.59 $1.56 $1.59 $1.59 $1.59A5056 OS $5.16 $5.16 $5.16 $5.16 $5.16 $5.16A5057 OS $10.62 $10.62 $10.62 $10.62 $10.62 $10.62A5061 OS $3.90 $3.90 $3.90 $3.90 $3.90 $3.90A5062 OS $2.46 $2.46 $2.46 $2.30 $2.46 $2.46A5063 OS $2.99 $2.99 $2.99 $2.99 $2.99 $2.99A5071 OS $6.64 $6.64 $6.64 $6.64 $6.64 $6.64A5072 OS $3.32 $3.32 $3.32 $3.32 $3.90 $3.32A5073 OS $3.52 $3.52 $3.36 $3.04 $3.52 $3.52A5081 OS $3.66 $3.11 $3.66 $3.66 $3.11 $3.11A5082 OS $11.18 $13.15 $13.15 $11.18 $13.15 $13.15A5083 OS $0.71 $0.71 $0.71 $0.71 $0.71 $0.71A5093 OS $2.16 $2.01 $2.16 $2.16 $2.16 $2.01A5102 OS $24.96 $24.96 $24.96 $24.96 $24.96 $24.96A5105 OS $38.31 $42.27 $39.88 $38.31 $45.07 $43.44A5112 OS $38.27 $38.27 $33.09 $38.27 $38.27 $38.27A5113 OS $4.43 $5.21 $5.21 $5.21 $5.21 $5.21A5114 OS $8.42 $9.90 $9.90 $8.90 $8.42 $9.90A5120 AU OS $0.27 $0.24 $0.26 $0.27 $0.27 $0.24A5120 AV PO $0.26 $0.26 $0.25 $0.26 $0.26 $0.26A5121 OS $7.45 $8.24 $8.24 $7.00 $7.00 $8.24A5122 OS $14.10 $14.20 $14.20 $14.20 $14.20 $14.20A5126 OS $1.44 $1.45 $1.45 $1.23 $1.45 $1.45A5131 OS $17.53 $14.90 $17.53 $14.90 $17.53 $14.90A5200 OS $12.50 $12.50 $12.50 $12.48 $12.50 $12.50A5500 TS $70.29 $70.29 $70.29 $70.29 $70.29 $70.29A5501 TS $210.83 $210.83 $210.83 $210.83 $210.83 $210.83A5503 TS $34.55 $34.55 $34.55 $34.55 $34.55 $34.55A5504 TS $34.55 $34.55 $34.55 $34.55 $34.55 $34.55A5505 TS $34.55 $34.55 $34.55 $34.55 $34.55 $34.55A5506 TS $34.55 $34.55 $34.55 $34.55 $34.55 $34.55A5507 TS $34.55 $34.55 $34.55 $34.55 $34.55 $34.55A5512 TS $28.67 $28.67 $28.67 $28.67 $28.67 $28.67A5513 TS $42.79 $42.79 $42.79 $42.79 $42.79 $42.79A6010 SD $34.24 $34.24 $34.24 $34.24 $34.24 $34.24A6011 SD $2.52 $2.52 $2.52 $2.52 $2.52 $2.52A6021 SD $23.24 $23.24 $23.24 $23.24 $23.24 $23.24A6022 SD $23.24 $23.24 $23.24 $23.24 $23.24 $23.24A6023 SD $210.39 $210.39 $210.39 $210.39 $210.39 $210.39A6024 SD $6.84 $6.84 $6.84 $6.84 $6.84 $6.84A6154 SD $15.90 $15.90 $15.90 $15.41 $15.90 $15.90A6196 SD $8.13 $8.13 $8.13 $8.13 $8.13 $8.13A6197 SD $18.17 $18.17 $18.17 $18.17 $18.17 $18.17A6199 SD $5.85 $5.85 $5.85 $5.85 $5.85 $5.85





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Fee Schedule


Fee Schedule



A6203 SD $3.72 $3.72 $3.72 $3.72 $3.72 $3.72A6204 SD $6.88 $6.88 $6.88 $6.88 $6.88 $6.88A6207 SD $8.11 $8.11 $8.11 $8.11 $8.11 $8.11A6209 SD $8.26 $8.26 $8.26 $8.26 $8.26 $8.26A6210 SD $22.03 $22.03 $22.03 $22.03 $22.03 $22.03A6211 SD $32.47 $32.47 $32.47 $32.47 $32.47 $32.47A6212 SD $10.73 $10.73 $10.73 $10.73 $10.73 $10.73A6214 SD $11.37 $11.37 $11.37 $11.37 $11.37 $11.37A6216 SD $0.05 $0.05 $0.05 $0.05 $0.05 $0.05A6219 SD $1.06 $1.06 $1.06 $1.06 $1.06 $1.06A6220 SD $2.86 $2.86 $2.86 $2.86 $2.86 $2.86A6222 SD $2.35 $2.35 $2.35 $2.35 $2.35 $2.35A6223 SD $2.68 $2.68 $2.68 $2.68 $2.68 $2.68A6224 SD $3.99 $3.99 $3.99 $3.99 $3.99 $3.99A6229 SD $3.99 $3.99 $3.99 $3.99 $3.99 $3.99A6231 SD $5.18 $5.18 $5.18 $5.16 $5.18 $5.18A6232 SD $7.59 $7.59 $7.59 $7.59 $7.59 $7.59A6233 SD $21.20 $21.20 $21.20 $21.20 $21.20 $21.20A6234 SD $7.23 $7.23 $7.23 $7.23 $7.23 $7.23A6235 SD $18.59 $18.59 $18.59 $18.59 $18.59 $18.59A6236 SD $30.13 $30.13 $30.13 $30.13 $30.13 $30.13A6237 SD $8.75 $8.75 $8.75 $8.75 $8.75 $8.75A6238 SD $25.20 $25.20 $25.20 $25.20 $25.20 $25.20A6240 SD $13.54 $13.54 $13.54 $13.54 $13.54 $13.54A6241 SD $2.84 $2.84 $2.84 $2.84 $2.84 $2.84A6242 SD $6.70 $6.70 $6.70 $6.70 $6.70 $6.70A6243 SD $13.62 $13.62 $13.62 $13.62 $13.62 $13.62A6244 SD $43.43 $43.43 $43.43 $43.43 $43.43 $43.43A6245 SD $8.03 $8.03 $8.03 $8.03 $8.03 $8.03A6246 SD $10.98 $10.98 $10.98 $10.98 $10.98 $10.98A6247 SD $26.29 $26.29 $26.29 $26.29 $26.29 $26.29A6248 SD $17.96 $17.96 $17.96 $17.96 $17.96 $17.96A6251 SD $2.20 $2.20 $2.20 $2.20 $2.20 $2.20A6252 SD $3.60 $3.60 $3.60 $3.60 $3.60 $3.60A6253 SD $7.00 $7.00 $7.00 $7.00 $7.00 $7.00A6254 SD $1.33 $1.33 $1.33 $1.33 $1.33 $1.33A6255 SD $3.36 $3.36 $3.36 $3.36 $3.36 $3.36A6257 SD $1.70 $1.70 $1.70 $1.70 $1.70 $1.70A6258 SD $4.77 $4.77 $4.77 $4.77 $4.77 $4.77A6259 SD $12.10 $12.10 $12.10 $12.10 $12.10 $12.10A6266 SD $2.13 $2.13 $2.13 $2.13 $2.13 $2.13A6402 SD $0.13 $0.13 $0.13 $0.13 $0.13 $0.13A6403 SD $0.47 $0.47 $0.47 $0.47 $0.47 $0.47A6407 SD $2.08 $2.08 $2.08 $2.08 $2.08 $2.08A6410 SD $0.43 $0.43 $0.43 $0.43 $0.43 $0.43A6441 SD $0.75 $0.75 $0.75 $0.75 $0.75 $0.75A6442 SD $0.18 $0.18 $0.18 $0.18 $0.18 $0.18A6443 SD $0.31 $0.31 $0.31 $0.31 $0.31 $0.31A6444 SD $0.62 $0.62 $0.62 $0.62 $0.62 $0.62A6445 SD $0.36 $0.36 $0.36 $0.36 $0.36 $0.36A6446 SD $0.45 $0.45 $0.45 $0.45 $0.45 $0.45A6447 SD $0.75 $0.75 $0.75 $0.75 $0.75 $0.75A6448 SD $1.28 $1.28 $1.28 $1.28 $1.28 $1.28A6449 SD $1.94 $1.94 $1.94 $1.94 $1.94 $1.94A6450 SD $1.94 $1.94 $1.94 $1.94 $1.94 $1.94A6451 SD $1.94 $1.94 $1.94 $1.94 $1.94 $1.94A6452 SD $6.53 $6.53 $6.53 $6.53 $6.53 $6.53A6453 SD $0.69 $0.69 $0.69 $0.69 $0.69 $0.69A6454 SD $0.86 $0.86 $0.86 $0.86 $0.86 $0.86A6455 SD $1.54 $1.54 $1.54 $1.54 $1.54 $1.54A6456 SD $1.40 $1.40 $1.40 $1.40 $1.40 $1.40





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



A6457 SD $1.26 $1.26 $1.26 $1.26 $1.26 $1.26A6531 AW SD $47.83 $47.83 $47.83 $47.83 $47.83 $47.83A6532 AW SD $67.39 $67.39 $67.39 $67.39 $67.39 $67.39A6545 AW SD $94.17 $94.17 $94.17 $94.17 $94.17 $94.17A6550 SU $25.34 R $26.15 $25.34 R $26.15 $25.21 R $26.15 $25.34 R $26.15 $25.34 R $26.15 $25.34 R $26.15A7000 NU KE IN $9.36 R $9.71 $9.36 R $9.71 $9.54 R $9.71 $9.12 R $9.47 $9.32 R $9.66 $9.36 R $9.71A7000 NU IN $8.63 R $8.98 $8.63 R $8.98 $8.81 R $8.98 $8.43 R $8.69 $8.59 R $8.94 $8.63 R $8.98A7001 NU IN $32.92 $32.63 $32.78 $31.08 $31.98 $33.56A7002 NU IN $3.60 $3.60 $3.60 $3.60 $3.60 $3.60A7003 NU IN $2.28 R $2.35 $2.28 R $2.35 $2.25 R $2.35 $2.20 R $2.27 $2.25 R $2.32 $2.28 R $2.35A7004 NU IN $1.48 R $1.53 $1.48 R $1.53 $1.44 R $1.53 $1.48 R $1.53 $1.48 R $1.53 $1.48 R $1.53A7005 NU IN $20.66 R $21.00 $20.66 R $21.00 $21.00 R $21.00 $20.66 R $21.00 $20.66 R $21.00 $20.66 R $21.00A7006 NU IN $9.01 R $9.14 $9.01 R $9.14 $9.02 R $9.14 $8.97 R $9.10 $9.01 R $9.14 $9.01 R $9.14A7007 NU IN $4.09 R $4.15 $4.07 R $4.13 $4.07 R $4.14 $3.94 R $4.00 $4.02 R $4.09 $4.14 R $4.20A7008 NU IN $10.34 $10.34 $10.34 $10.34 $10.34 $10.34A7009 NU IN $46.19 $45.78 $45.98 $43.16 $44.90 $46.48A7010 NU IN $18.99 R $19.35 $18.99 R $19.35 $18.85 R $19.35 $18.99 R $19.35 $18.99 R $19.35 $18.99 R $19.35A7012 NU IN $3.54 R $3.60 $3.54 R $3.60 $3.50 R $3.60 $3.44 R $3.50 $3.52 R $3.58 $3.54 R $3.60A7013 NU IN $0.67 R $0.69 $0.67 R $0.69 $0.65 R $0.69 $0.67 R $0.69 $0.67 R $0.69 $0.67 R $0.69A7014 NU IN $4.09 R $4.23 $4.09 R $4.23 $4.17 R $4.23 $4.01 R $4.15 $4.09 R $4.23 $4.09 R $4.23A7015 NU IN $1.69 R $1.72 $1.69 R $1.72 $1.68 R $1.72 $1.69 R $1.72 $1.69 R $1.72 $1.69 R $1.72A7016 NU IN $7.72 $7.63 $7.66 $7.21 $7.47 $7.84A7017 NU IN $135.02 R $136.08 $135.02 R $136.08 $133.37 R $136.08 $135.02 R $136.08 $135.02 R $136.08 $135.02 R $136.08A7017 RR IN $13.51 R $13.62 $13.51 R $13.62 $13.34 R $13.62 $13.51 R $13.62 $13.51 R $13.62 $13.51 R $13.62A7017 UE IN $101.26 R $102.06 $101.26 R $102.06 $100.02 R $102.06 $101.26 R $102.06 $101.26 R $102.06 $101.26 R $102.06A7018 SU $0.34 R $0.35 $0.34 R $0.35 $0.33 R $0.35 $0.34 R $0.35 $0.34 R $0.35 $0.34 R $0.35A7020 NU IN $16.01 $16.01 $16.01 $15.42 $16.01 $16.01A7025 RR CR $48.09 $48.09 $48.09 $48.09 $48.09 $48.09A7026 NU IN $31.78 $31.78 $31.78 $31.78 $31.78 $31.78A7027 NU IN $164.57 R $168.74 $164.57 R $168.74 $163.13 R $168.74 $160.59 R $164.76 $164.57 R $168.74 $164.57 R $168.74A7028 NU IN $44.64 R $45.84 $44.64 R $45.84 $43.76 R $45.84 $44.64 R $45.84 $44.64 R $45.84 $44.64 R $45.84A7029 NU IN $18.89 R $19.63 $18.89 R $19.63 $18.54 R $19.63 $18.89 R $19.63 $18.89 R $19.63 $18.89 R $19.63A7030 NU IN $134.76 R $139.24 $134.76 R $139.24 $134.35 R $139.24 $134.76 R $139.24 $134.76 R $139.24 $134.76 R $139.24A7031 NU IN $50.59 R $52.01 $50.59 R $52.01 $50.18 R $52.01 $50.59 R $52.01 $50.59 R $52.01 $50.59 R $52.01A7032 NU IN $29.04 R $29.78 $29.04 R $29.78 $28.73 R $29.78 $29.04 R $29.78 $29.04 R $29.78 $29.04 R $29.78A7033 NU IN $21.24 R $22.03 $21.24 R $22.03 $21.27 R $22.03 $21.24 R $22.03 $21.24 R $22.03 $21.24 R $22.03A7034 NU IN $84.27 R $86.78 $84.27 R $86.78 $84.37 R $86.78 $84.27 R $86.78 $84.27 R $86.78 $84.27 R $86.78A7035 NU IN $26.88 R $27.83 $26.72 R $27.67 $26.79 R $27.74 $25.71 R $26.66 $26.39 R $27.34 $27.21 R $28.16A7036 NU IN $12.80 R $13.35 $12.73 R $13.28 $12.68 R $13.32 $12.59 R $13.14 $12.59 R $13.14 $12.94 R $13.49A7037 NU IN $25.74 R $26.28 $25.56 R $26.09 $25.61 R $26.19 $24.46 R $25.00 $25.20 R $25.74 $25.74 R $26.28A7038 NU IN $3.63 R $3.74 $3.63 R $3.74 $3.63 R $3.74 $3.50 R $3.61 $3.61 R $3.71 $3.63 R $3.74A7039 NU IN $9.27 R $9.56 $9.27 R $9.56 $9.25 R $9.56 $9.27 R $9.56 $9.27 R $9.56 $9.31 R $9.60A7044 NU IN $99.20 R $102.79 $99.20 R $102.79 $97.84 R $102.79 $99.20 R $102.79 $99.20 R $102.79 $99.20 R $102.79A7045 NU IN $15.13 R $15.92 $15.13 R $15.92 $14.82 R $15.92 $15.13 R $15.92 $15.13 R $15.92 $15.13 R $15.92A7045 RR IN $1.51 R $1.59 $1.51 R $1.59 $1.48 R $1.59 $1.51 R $1.59 $1.51 R $1.59 $1.51 R $1.59A7045 UE IN $11.36 R $11.95 $11.36 R $11.95 $11.12 R $11.95 $11.36 R $11.95 $11.36 R $11.95 $11.36 R $11.95A7046 NU IN $15.95 R $16.54 $15.95 R $16.54 $15.93 R $16.54 $15.95 R $16.54 $15.95 R $16.54 $15.95 R $16.54A7047 NU IN $133.66 $133.66 $133.66 $133.66 $133.66 $133.66A7501 OS $116.10 $116.10 $116.10 $116.10 $116.10 $116.10A7502 OS $55.19 $55.19 $55.19 $55.19 $55.19 $55.19A7503 OS $12.54 $12.54 $12.54 $12.54 $12.54 $12.54A7504 OS $0.75 $0.75 $0.75 $0.75 $0.75 $0.75A7505 OS $5.18 $5.18 $5.18 $5.18 $5.18 $5.18A7506 OS $0.37 $0.37 $0.37 $0.37 $0.37 $0.37A7507 OS $2.75 $2.75 $2.75 $2.75 $2.75 $2.75A7508 OS $3.17 $3.17 $3.17 $3.17 $3.17 $3.17A7509 OS $1.56 $1.56 $1.56 $1.56 $1.56 $1.56A7520 OS $52.49 $52.49 $52.49 $52.49 $52.49 $52.49A7521 OS $52.00 $52.00 $52.00 $52.00 $52.00 $52.00A7522 OS $49.93 $49.93 $49.93 $49.93 $49.93 $49.93A7524 OS $85.58 $85.58 $85.58 $85.58 $85.58 $85.58





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



A7525 OS $2.28 $2.28 $2.28 $2.28 $2.28 $2.28A7526 OS $3.74 $3.74 $3.74 $3.74 $3.74 $3.74A7527 OS $3.96 $3.96 $3.96 $3.96 $3.96 $3.96A8000 NU IN $169.54 $169.54 $169.54 $169.54 $169.54 $169.54A8000 RR IN $16.95 $16.95 $16.95 $16.95 $16.95 $16.95A8000 UE IN $127.18 $127.18 $127.18 $127.18 $127.18 $127.18A8001 NU IN $169.54 $169.54 $169.54 $169.54 $169.54 $169.54A8001 RR IN $16.95 $16.95 $16.95 $16.95 $16.95 $16.95A8001 UE IN $127.18 $127.18 $127.18 $127.18 $127.18 $127.18B4034 PE $4.67 R $4.80 $4.67 R $4.80 $4.69 R $4.80 $4.67 R $4.80 $4.67 R $4.80 $4.67 R $4.80B4035 PE $8.75 R $8.87 $8.75 R $8.87 $8.74 R $8.87 $8.75 R $8.87 $8.75 R $8.87 $8.75 R $8.87B4036 PE $6.22 R $6.38 $6.22 R $6.38 $6.19 R $6.38 $6.22 R $6.38 $6.22 R $6.38 $6.22 R $6.38B4081 PE $18.53 R $19.44 $18.53 R $19.44 $18.71 R $19.44 $18.53 R $19.44 $18.53 R $19.44 $18.53 R $19.44B4082 PE $13.70 R $14.23 $13.70 R $14.23 $13.65 R $14.23 $13.70 R $14.23 $13.70 R $14.23 $13.70 R $14.23B4083 PE $2.08 R $2.16 $2.08 R $2.16 $2.11 R $2.16 $2.08 R $2.16 $2.08 R $2.16 $2.08 R $2.16B4087 PE $31.22 R $32.91 $31.22 R $32.91 $32.31 R $32.91 $31.22 R $32.91 $31.22 R $32.91 $31.22 R $32.91B4088 PE $33.00 R $35.38 $33.00 R $35.38 $35.23 R $35.38 $33.00 R $35.38 $33.00 R $35.38 $33.00 R $35.38B4149 PE $1.31 R $1.36 $1.31 R $1.36 $1.31 R $1.36 $1.31 R $1.36 $1.31 R $1.36 $1.31 R $1.36B4150 PE $0.54 R $0.55 $0.54 R $0.55 $0.54 R $0.55 $0.54 R $0.55 $0.54 R $0.55 $0.54 R $0.55B4152 PE $0.44 R $0.45 $0.44 R $0.45 $0.44 R $0.45 $0.44 R $0.45 $0.44 R $0.45 $0.44 R $0.45B4153 PE $1.59 R $1.63 $1.59 R $1.63 $1.60 R $1.63 $1.59 R $1.63 $1.59 R $1.63 $1.59 R $1.63B4154 PE $0.96 R $0.98 $0.96 R $0.98 $0.96 R $0.98 $0.96 R $0.98 $0.96 R $0.98 $0.96 R $0.98B4155 PE $0.84 R $0.88 $0.84 R $0.88 $0.87 R $0.88 $0.84 R $0.88 $0.84 R $0.88 $0.84 R $0.88B4164 PE $19.50 $19.50 $19.50 $19.50 $19.50 $19.50B4168 PE $28.44 $28.44 $28.44 $28.44 $28.44 $28.44B4176 PE $55.03 $55.03 $55.03 $55.03 $55.03 $55.03B4178 PE $66.05 $66.05 $66.05 $66.05 $66.05 $66.05B4180 PE $28.00 $28.00 $28.00 $28.00 $28.00 $28.00B4185 PE $12.90 $12.90 $12.90 $12.90 $12.90 $12.90B4189 PE $204.06 $204.06 $204.06 $204.06 $204.06 $204.06B4193 PE $263.67 $263.67 $263.67 $263.67 $263.67 $263.67B4197 PE $321.01 $321.01 $321.01 $321.01 $321.01 $321.01B4199 PE $366.81 $366.81 $366.81 $366.81 $366.81 $366.81B4216 PE $8.86 $8.86 $8.86 $8.86 $8.86 $8.86B4220 PE $9.19 $9.19 $9.19 $9.19 $9.19 $9.19B4222 PE $11.33 $11.33 $11.33 $11.33 $11.33 $11.33B4224 PE $28.70 $28.70 $28.70 $28.70 $28.70 $28.70B5000 PE $13.65 $13.65 $13.65 $13.65 $13.65 $13.65B5100 PE $5.33 $5.33 $5.33 $5.33 $5.33 $5.33B9000 MS PE $44.74 R $45.72 $44.74 R $45.72 $44.04 R $45.72 $44.74 R $45.72 $44.74 R $45.72 $44.74 R $45.72B9000 NU PE $945.53 R $965.15 $945.53 R $965.15 $931.52 R $965.15 $945.53 R $965.15 $945.53 R $965.15 $945.53 R $965.15B9000 RR PE $89.48 R $91.44 $89.48 R $91.44 $88.08 R $91.44 $89.48 R $91.44 $89.48 R $91.44 $89.48 R $91.44B9000 UE PE $709.15 R $723.87 $709.15 R $723.87 $698.64 R $723.87 $709.15 R $723.87 $709.15 R $723.87 $709.15 R $723.87B9002 MS PE $46.32 R $47.28 $46.32 R $47.28 $45.59 R $47.28 $46.32 R $47.28 $46.32 R $47.28 $46.32 R $47.28B9002 NU PE $946.10 R $965.31 $946.10 R $965.31 $931.52 R $965.31 $946.10 R $965.31 $946.10 R $965.31 $946.10 R $965.31B9002 RR PE $92.64 R $94.56 $92.64 R $94.56 $91.18 R $94.56 $92.64 R $94.56 $92.64 R $94.56 $92.64 R $94.56B9002 UE PE $709.58 R $723.98 $709.58 R $723.98 $698.64 R $723.98 $709.58 R $723.98 $709.58 R $723.98 $709.58 R $723.98B9004 MS PE $229.27 $229.27 $229.27 $229.27 $229.27 $229.27B9004 NU PE $2,896.55 $2,896.55 $2,896.55 $2,896.55 $2,896.55 $2,896.55B9004 RR PE $458.53 $458.53 $458.53 $458.53 $458.53 $458.53B9004 UE PE $2,172.41 $2,172.41 $2,172.41 $2,172.41 $2,172.41 $2,172.41B9006 MS PE $229.27 $229.27 $229.27 $229.27 $229.27 $229.27B9006 NU PE $2,896.55 $2,896.55 $2,896.55 $2,896.55 $2,896.55 $2,896.55B9006 RR PE $458.53 $458.53 $458.53 $458.53 $458.53 $458.53B9006 UE PE $2,172.41 $2,172.41 $2,172.41 $2,172.41 $2,172.41 $2,172.41E0100 NU IN $23.30 $23.30 $23.30 $23.30 $23.30 $23.30E0100 RR IN $5.58 $5.58 $6.56 $5.58 $5.58 $5.58E0100 UE IN $18.57 $18.57 $18.57 $18.57 $18.47 $18.57E0105 NU IN $54.30 $54.30 $52.57 $54.30 $54.30 $54.30E0105 RR IN $8.33 $8.33 $9.80 $8.33 $8.33 $8.33E0105 UE IN $41.85 $41.85 $41.85 $41.85 $41.85 $41.85





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



E0110 NU IN $72.91 $85.78 $72.91 $80.35 $72.91 $85.78E0110 RR IN $15.02 $15.02 $15.02 $15.90 $15.02 $15.02E0110 UE IN $63.59 $64.31 $54.66 $60.26 $54.66 $64.31E0111 NU IN $52.61 $58.87 $56.91 $50.04 $54.38 $50.04E0111 RR IN $7.91 $9.31 $7.91 $7.93 $7.91 $7.91E0111 UE IN $39.45 $45.39 $45.44 $38.62 $40.79 $38.62E0112 NU IN $34.77 $40.91 $40.52 $34.77 $34.77 $40.91E0112 RR IN $9.34 $10.99 $10.99 $9.34 $9.34 $9.34E0112 UE IN $26.52 $31.20 $30.39 $26.52 $26.52 $31.20E0113 NU IN $19.86 $22.83 $20.28 $19.86 $19.86 $21.72E0113 RR IN $4.84 $4.84 $5.69 $4.84 $4.84 $4.84E0113 UE IN $14.90 $17.13 $15.22 $14.90 $14.90 $16.31E0114 NU IN $44.34 $52.17 $52.17 $46.05 $44.34 $52.17E0114 RR IN $8.05 $8.05 $9.47 $8.05 $8.05 $9.22E0114 UE IN $33.52 $39.44 $39.44 $34.52 $33.52 $39.44E0116 NU IN $26.08 $30.68 $26.08 $26.08 $26.08 $30.68E0116 RR IN $5.08 $5.98 $5.98 $5.08 $5.08 $5.08E0116 UE IN $19.63 $23.09 $19.63 $19.63 $19.63 $23.09E0117 RR CR $21.29 $21.29 $21.29 $21.29 $21.29 $21.29E0130 NU IN $57.65 R $59.53 $57.65 R $59.53 $58.17 R $59.53 $57.65 R $59.53 $57.65 R $59.53 $57.65 R $59.53E0130 RR IN $9.23 R $9.41 $9.23 R $9.41 $10.48 R $10.62 $10.43 R $10.62 $10.43 R $10.62 $9.23 R $9.41E0130 UE IN $44.22 R $45.63 $44.22 R $45.63 $44.61 R $45.63 $44.22 R $45.63 $44.22 R $45.63 $44.22 R $45.63E0135 NU IN $61.68 R $63.31 $62.04 R $63.67 $57.48 R $60.35 $62.04 R $63.67 $58.11 R $59.74 $61.59 R $63.22E0135 RR IN $9.28 R $9.44 $9.20 R $9.36 $10.30 R $10.59 $10.43 R $10.59 $10.43 R $10.59 $9.20 R $9.36E0135 UE IN $47.22 R $48.45 $47.22 R $48.45 $46.29 R $48.45 $45.41 R $46.63 $44.86 R $46.08 $47.22 R $48.45E0140 RR CR $31.04 R $31.95 $31.04 R $31.95 $30.27 R $31.95 $31.04 R $31.95 $31.04 R $31.95 $31.04 R $31.95E0141 NU IN $93.85 R $96.23 $93.85 R $96.23 $94.60 R $96.23 $93.62 R $96.00 $92.00 R $94.38 $93.85 R $96.23E0141 RR IN $12.96 R $13.19 $12.96 R $13.19 $14.63 R $14.79 $14.55 R $14.79 $12.96 R $13.19 $12.96 R $13.19E0141 UE IN $70.39 R $72.17 $70.39 R $72.17 $70.96 R $72.17 $69.94 R $71.72 $69.00 R $70.78 $70.39 R $72.17E0143 NU IN $81.51 R $82.89 $81.51 R $82.89 $79.71 R $82.89 $78.07 R $79.46 $77.32 R $78.70 $81.51 R $82.89E0143 RR IN $11.17 R $11.31 $11.17 R $11.31 $12.53 R $12.85 $12.71 R $12.85 $11.17 R $11.31 $11.17 R $11.31E0143 UE IN $59.73 R $60.76 $61.04 R $62.08 $59.69 R $62.08 $59.64 R $60.68 $57.98 R $59.02 $61.04 R $62.08E0144 RR CR $27.88 $27.88 $27.88 $27.88 $27.88 $27.88E0147 NU IN $460.82 R $478.71 $460.82 R $478.71 $460.85 R $478.71 $460.82 R $478.71 $460.82 R $478.71 $460.82 R $478.71E0147 RR IN $46.09 R $47.88 $46.09 R $47.88 $46.09 R $47.88 $46.09 R $47.88 $46.09 R $47.88 $46.09 R $47.88E0147 UE IN $345.62 R $359.04 $345.62 R $359.04 $345.64 R $359.04 $345.62 R $359.04 $345.62 R $359.04 $345.62 R $359.04E0148 NU IN $101.56 R $104.66 $101.56 R $104.66 $100.69 R $104.66 $101.56 R $104.66 $101.56 R $104.66 $101.56 R $104.66E0148 RR IN $10.16 R $10.47 $10.16 R $10.47 $10.08 R $10.47 $10.16 R $10.47 $10.16 R $10.47 $10.16 R $10.47E0148 UE IN $76.16 R $78.49 $76.16 R $78.49 $75.51 R $78.49 $76.16 R $78.49 $76.16 R $78.49 $76.16 R $78.49E0149 RR CR $16.79 R $16.90 $16.79 R $16.90 $16.19 R $16.90 $16.79 R $16.90 $16.79 R $16.90 $16.79 R $16.90E0153 NU IN $76.71 $76.71 $66.12 $65.20 $66.74 $76.71E0153 RR IN $8.18 $7.98 $8.67 $7.37 $7.37 $7.98E0153 UE IN $57.52 $57.52 $49.61 $48.89 $50.03 $57.52E0154 NU IN $55.36 R $58.33 $56.35 R $59.31 $55.49 R $57.93 $51.31 R $54.27 $56.35 R $59.31 $56.35 R $59.31E0154 RR IN $6.01 R $6.30 $6.28 R $6.58 $6.03 R $6.28 $5.80 R $6.09 $5.74 R $6.04 $6.35 R $6.65E0154 UE IN $42.59 R $44.81 $42.59 R $44.81 $42.98 R $44.81 $38.76 R $40.98 $42.26 R $44.48 $42.59 R $44.81E0155 NU IN $24.70 R $25.93 $22.67 R $23.90 $25.35 R $25.92 $23.74 R $24.98 $24.48 R $25.71 $22.67 R $23.90E0155 RR IN $2.55 R $2.67 $2.55 R $2.67 $2.89 R $2.95 $2.55 R $2.67 $2.55 R $2.67 $2.55 R $2.67E0155 UE IN $18.51 R $19.43 $17.17 R $18.09 $19.38 R $19.81 $17.80 R $18.73 $18.35 R $19.27 $17.17 R $18.09E0156 NU IN $20.44 R $20.97 $20.44 R $20.97 $18.25 R $19.08 $18.55 R $19.08 $20.44 R $20.97 $20.44 R $20.97E0156 RR IN $2.40 R $2.45 $2.40 R $2.45 $2.12 R $2.21 $2.15 R $2.21 $2.40 R $2.45 $2.40 R $2.45E0156 UE IN $15.34 R $15.74 $15.34 R $15.74 $13.70 R $14.32 $13.92 R $14.32 $15.34 R $15.74 $15.34 R $15.74E0157 NU IN $63.34 R $65.29 $66.58 R $68.53 $68.40 R $68.53 $60.72 R $62.67 $62.02 R $63.97 $66.58 R $68.53E0157 RR IN $7.04 R $7.24 $7.04 R $7.24 $7.23 R $7.24 $6.40 R $6.60 $6.40 R $6.60 $7.04 R $7.24E0157 UE IN $47.54 R $49.00 $49.93 R $51.40 $51.30 R $51.40 $45.54 R $47.00 $46.51 R $47.98 $49.93 R $51.40E0158 NU IN $25.70 R $26.78 $24.28 R $25.36 $24.69 R $25.36 $23.40 R $24.48 $25.70 R $26.78 $24.28 R $25.36E0158 RR IN $2.61 R $2.72 $2.48 R $2.58 $2.52 R $2.58 $2.48 R $2.58 $2.73 R $2.84 $2.48 R $2.58E0158 UE IN $19.35 R $20.16 $18.20 R $19.01 $18.51 R $19.01 $17.62 R $18.42 $19.35 R $20.16 $18.20 R $19.01E0159 NU IN $15.76 R $16.29 $15.76 R $16.29 $15.56 R $16.29 $15.76 R $16.29 $15.76 R $16.29 $15.76 R $16.29E0159 RR IN $1.61 R $1.66 $1.61 R $1.66 $1.59 R $1.66 $1.59 R $1.64 $1.61 R $1.66 $1.61 R $1.66E0159 UE IN $11.82 R $12.22 $11.82 R $12.22 $11.67 R $12.22 $11.82 R $12.22 $11.82 R $12.22 $11.82 R $12.22





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



E0160 NU IN $28.50 R $30.91 $28.50 R $30.91 $32.15 R $33.65 $28.50 R $30.91 $28.50 R $30.91 $31.24 R $33.65E0160 RR IN $3.34 R $3.58 $3.34 R $3.58 $3.79 R $3.94 $3.34 R $3.58 $3.34 R $3.58 $3.70 R $3.94E0160 UE IN $21.37 R $23.17 $21.37 R $23.17 $24.10 R $25.22 $21.37 R $23.17 $21.37 R $23.17 $23.42 R $25.22E0161 NU IN $26.66 R $27.67 $26.66 R $27.67 $23.50 R $24.64 $26.66 R $27.67 $26.66 R $27.67 $26.66 R $27.67E0161 RR IN $3.19 R $3.29 $3.19 R $3.29 $2.80 R $3.00 $3.04 R $3.14 $2.90 R $3.00 $3.19 R $3.29E0161 UE IN $19.97 R $20.73 $19.97 R $20.73 $17.61 R $18.45 $19.97 R $20.73 $19.97 R $20.73 $19.97 R $20.73E0162 NU IN $140.05 $161.08 $161.08 $161.08 $136.92 $161.08E0162 RR IN $14.36 $16.89 $16.89 $16.89 $14.36 $16.39E0162 UE IN $106.17 $124.91 $124.91 $124.91 $106.17 $124.91E0163 NU IN $88.30 R $89.58 $88.30 R $89.58 $84.93 R $87.19 $86.61 R $87.88 $88.30 R $89.58 $83.16 R $84.43E0163 RR IN $14.21 R $14.34 $14.21 R $14.34 $16.13 R $16.36 $16.23 R $16.36 $15.59 R $15.72 $14.21 R $14.34E0163 UE IN $67.52 R $68.48 $67.52 R $68.48 $66.78 R $68.48 $67.52 R $68.48 $64.89 R $65.84 $64.39 R $65.34E0165 RR CR $14.85 R $15.25 $14.85 R $15.25 $16.50 R $16.79 $16.38 R $16.79 $16.38 R $16.79 $14.85 R $15.25E0167 NU IN $10.53 R $11.27 $11.52 R $12.41 $10.54 R $11.27 $10.54 R $11.30 $10.53 R $11.27 $10.53 R $11.27E0167 RR IN $1.08 R $1.17 $1.18 R $1.27 $1.18 R $1.27 $1.08 R $1.17 $1.08 R $1.17 $1.08 R $1.17E0167 UE IN $8.23 R $8.89 $8.67 R $9.33 $7.93 R $8.50 $7.92 R $8.50 $8.33 R $8.99 $7.92 R $8.50E0168 NU IN $142.60 R $146.20 $142.60 R $146.20 $143.73 R $146.20 $142.60 R $146.20 $142.60 R $146.20 $142.60 R $146.20E0168 RR IN $14.30 R $14.66 $14.30 R $14.66 $14.41 R $14.66 $14.25 R $14.61 $14.30 R $14.66 $14.30 R $14.66E0168 UE IN $106.95 R $109.64 $106.95 R $109.64 $107.79 R $109.64 $106.95 R $109.64 $106.95 R $109.64 $106.95 R $109.64E0170 RR CR $167.50 R $175.50 $167.50 R $175.50 $166.32 R $175.50 $167.50 R $175.50 $167.50 R $175.50 $167.50 R $175.50E0171 RR CR $30.38 R $31.97 $30.38 R $31.97 $30.88 R $31.97 $30.38 R $31.97 $30.38 R $31.97 $30.38 R $31.97E0175 NU IN $73.23 $62.25 $73.23 $73.23 $73.23 $62.25E0175 RR IN $7.32 $6.22 $7.32 $7.32 $7.32 $6.22E0175 UE IN $53.89 $45.81 $53.89 $53.89 $53.89 $45.81E0181 RR CR $22.26 R $22.80 $22.26 R $22.80 $22.51 R $22.80 $22.26 R $22.80 $22.26 R $22.80 $22.26 R $22.80E0182 RR CR $22.28 R $23.90 $21.72 R $23.35 $24.38 R $25.52 $21.72 R $23.35 $21.72 R $23.35 $21.72 R $23.35E0184 NU IN $170.56 R $177.41 $186.70 R $193.55 $173.97 R $177.41 $186.70 R $193.55 $186.70 R $193.55 $186.70 R $193.55E0184 RR IN $21.49 R $22.17 $19.45 R $20.14 $19.79 R $20.14 $21.49 R $22.17 $20.40 R $21.08 $19.45 R $20.14E0184 UE IN $129.47 R $134.61 $140.03 R $145.17 $132.03 R $134.61 $141.85 R $146.99 $141.85 R $146.99 $141.85 R $146.99E0185 NU IN $235.61 R $241.36 $235.61 R $241.36 $254.43 R $267.88 $249.70 R $255.44 $245.79 R $251.54 $235.61 R $241.36E0185 RR IN $29.65 R $30.23 $29.65 R $30.23 $28.88 R $30.23 $29.65 R $30.23 $29.65 R $30.23 $29.65 R $30.23E0185 UE IN $179.34 R $183.65 $179.34 R $183.65 $190.82 R $200.90 $187.26 R $191.58 $184.34 R $188.65 $179.34 R $183.65E0186 RR CR $18.29 R $19.07 $18.29 R $19.07 $20.04 R $21.13 $19.97 R $21.13 $18.29 R $19.07 $18.39 R $19.29E0187 RR CR $22.32 R $24.09 $20.40 R $21.81 $22.76 R $24.09 $20.71 R $22.44 $20.40 R $21.81 $20.40 R $21.81E0188 NU IN $24.04 R $24.84 $26.23 R $27.60 $24.04 R $24.84 $24.04 R $24.84 $26.23 R $27.60 $26.23 R $27.60E0188 RR IN $2.62 R $2.76 $2.88 R $3.02 $2.62 R $2.76 $2.62 R $2.76 $2.88 R $3.02 $2.88 R $3.02E0188 UE IN $18.04 R $18.66 $19.69 R $20.71 $18.04 R $18.66 $18.04 R $18.66 $19.69 R $20.71 $19.69 R $20.71E0189 NU IN $52.80 R $54.96 $48.49 R $48.83 $48.57 R $48.83 $52.80 R $54.96 $52.80 R $54.96 $48.49 R $48.83E0189 RR IN $5.52 R $5.73 $5.05 R $5.26 $5.06 R $5.26 $5.52 R $5.73 $5.52 R $5.73 $5.05 R $5.26E0189 UE IN $39.60 R $41.22 $36.37 R $36.62 $36.43 R $36.62 $39.60 R $41.22 $39.60 R $41.22 $36.37 R $36.62E0191 NU IN $11.05 $10.36 $11.05 $10.22 $9.39 $10.64E0191 RR IN $1.14 $1.04 $1.14 $1.02 $0.97 $1.06E0191 UE IN $8.24 $7.78 $8.24 $7.67 $7.00 $8.01E0193 RR CR $765.57 R $798.23 $765.57 R $798.23 $782.85 R $798.23 $719.52 R $752.18 $741.31 R $773.98 $749.62 R $782.29E0194 RR CR $3,597.70 $3,597.70 $3,597.70 $3,173.48 $3,058.05 $3,597.70E0196 RR CR $32.60 R $34.73 $29.91 R $30.53 $33.24 R $34.73 $32.60 R $34.73 $29.91 R $30.53 $29.91 R $30.53E0197 RR CR $22.58 R $24.04 $22.58 R $24.04 $25.88 R $26.57 $22.58 R $24.04 $22.58 R $24.04 $22.58 R $24.04E0198 RR CR $20.83 $20.83 $24.50 $24.50 $20.83 $20.83E0199 NU IN $30.57 R $32.33 $29.47 R $30.13 $32.97 R $33.89 $31.40 R $33.17 $32.13 R $33.89 $29.47 R $30.13E0199 RR IN $3.06 R $3.24 $2.94 R $3.00 $3.29 R $3.38 $3.14 R $3.32 $3.20 R $3.38 $2.94 R $3.00E0199 UE IN $22.92 R $24.24 $22.10 R $22.59 $24.72 R $25.41 $23.55 R $24.88 $24.09 R $25.41 $22.10 R $22.59E0200 NU IN $87.65 $87.65 $87.65 $74.50 $87.65 $87.65E0200 RR IN $11.90 $11.90 $11.90 $10.12 $11.90 $11.90E0200 UE IN $65.77 $65.77 $65.77 $55.90 $65.77 $65.77E0202 RR CR $69.22 $69.22 $60.56 $58.84 $58.84 $69.22E0205 NU IN $182.36 $214.54 $214.54 $182.36 $214.54 $214.54E0205 RR IN $20.06 $23.60 $23.60 $20.06 $23.60 $23.60E0205 UE IN $136.77 $160.90 $160.90 $136.77 $160.90 $160.90E0210 NU IN $30.68 $30.68 $36.09 $30.68 $32.21 $34.86E0210 RR IN $2.89 $2.89 $3.40 $2.91 $3.21 $3.40E0210 UE IN $23.00 $23.00 $27.06 $23.00 $24.14 $26.15





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



E0215 NU IN $66.57 $78.32 $78.32 $66.57 $66.57 $78.32E0215 RR IN $6.96 $8.19 $8.19 $6.96 $6.96 $8.19E0215 UE IN $49.94 $58.75 $58.75 $49.94 $49.94 $58.75E0217 NU IN $545.86 $548.86 $548.86 $466.53 $545.86 $548.86E0217 RR IN $53.26 $61.10 $61.10 $51.94 $54.56 $61.10E0217 UE IN $409.38 $411.61 $411.61 $349.87 $409.38 $411.61E0225 NU IN $365.20 $411.91 $429.65 $365.20 $429.65 $423.56E0225 RR IN $36.00 $41.18 $42.35 $36.00 $42.35 $42.35E0225 UE IN $273.90 $308.92 $322.23 $273.90 $322.23 $317.68E0235 RR CR $16.73 $19.07 $19.07 $19.07 $19.07 $19.07E0236 RR CR $41.57 $48.91 $41.57 $41.57 $43.56 $48.91E0239 NU IN $497.29 $422.70 $497.29 $497.29 $497.29 $422.70E0239 RR IN $49.74 $42.28 $49.74 $49.74 $49.74 $42.28E0239 UE IN $372.98 $317.03 $372.98 $372.98 $372.98 $317.03E0249 NU IN $93.60 $97.55 $110.12 $93.60 $110.12 $100.30E0249 RR IN $10.29 $10.29 $12.11 $10.29 $12.11 $10.29E0249 UE IN $70.20 $73.17 $82.59 $70.20 $82.59 $75.24E0250 RR CR $70.76 R $74.09 $77.74 R $81.07 $78.00 R $80.31 $77.74 R $81.07 $71.72 R $75.05 $71.18 R $74.50E0251 RR CR $57.55 R $60.00 $62.84 R $66.07 $62.78 R $64.95 $62.84 R $66.07 $57.94 R $60.79 $60.49 R $63.72E0255 RR CR $80.51 R $83.76 $88.91 R $92.16 $89.88 R $92.16 $86.43 R $89.68 $80.91 R $84.16 $85.28 R $88.53E0256 RR CR $62.46 R $65.60 $68.42 R $71.56 $69.89 R $71.56 $66.29 R $69.43 $62.46 R $65.60 $68.42 R $71.56E0260 RR CR $98.02 R $100.06 $98.02 R $100.06 $96.75 R $100.06 $98.02 R $100.06 $98.02 R $100.06 $98.02 R $100.06E0261 RR CR $85.06 R $87.62 $94.85 R $97.40 $96.08 R $97.40 $85.06 R $87.62 $85.06 R $87.62 $94.85 R $97.40E0265 RR CR $148.99 $163.27 $163.27 $148.99 $148.99 $163.27E0266 RR CR $132.52 $143.81 $138.06 $131.13 $131.13 $135.82E0271 NU IN $167.67 R $171.66 $167.67 R $171.66 $171.66 R $171.66 $151.80 R $155.79 $158.61 R $162.60 $153.57 R $157.56E0271 RR IN $17.18 R $17.58 $17.18 R $17.58 $16.90 R $16.90 $15.53 R $15.93 $15.87 R $16.27 $15.53 R $15.93E0271 UE IN $129.04 R $132.04 $129.04 R $132.04 $132.04 R $132.04 $116.65 R $119.64 $118.97 R $121.96 $116.65 R $119.64E0272 NU IN $151.08 R $156.61 $165.55 R $171.08 $161.58 R $168.47 $160.11 R $165.64 $165.55 R $171.08 $165.55 R $171.08E0272 RR IN $15.47 R $16.03 $16.98 R $17.54 $16.15 R $16.83 $16.01 R $16.57 $16.98 R $17.54 $16.98 R $17.54E0272 UE IN $113.02 R $117.17 $123.82 R $127.96 $121.19 R $126.36 $120.08 R $124.23 $123.82 R $127.96 $123.82 R $127.96E0275 NU IN $15.13 R $15.90 $13.86 R $14.39 $15.10 R $15.90 $13.86 R $14.39 $15.13 R $15.90 $13.86 R $14.39E0275 RR IN $1.55 R $1.63 $1.42 R $1.50 $1.55 R $1.63 $1.42 R $1.50 $1.55 R $1.63 $1.42 R $1.50E0275 UE IN $11.34 R $11.92 $10.39 R $10.79 $11.32 R $11.92 $10.39 R $10.79 $11.34 R $11.92 $10.39 R $10.79E0276 NU IN $12.18 R $13.01 $12.90 R $13.74 $13.13 R $13.74 $12.09 R $12.92 $12.90 R $13.74 $12.90 R $13.74E0276 RR IN $1.30 R $1.38 $1.43 R $1.51 $1.45 R $1.51 $1.30 R $1.38 $1.43 R $1.51 $1.43 R $1.51E0276 UE IN $9.10 R $9.73 $9.97 R $10.60 $10.14 R $10.60 $9.10 R $9.73 $9.97 R $10.60 $9.97 R $10.60E0277 RR CR $435.22 R $437.92 $435.24 R $437.94 $431.53 R $437.92 $431.23 R $433.93 $435.22 R $437.92 $435.23 R $437.93E0280 NU IN $33.03 R $34.76 $33.03 R $34.76 $33.62 R $34.76 $32.46 R $34.18 $33.03 R $34.76 $33.03 R $34.76E0280 RR IN $3.45 R $3.62 $3.45 R $3.62 $3.51 R $3.62 $3.26 R $3.43 $3.45 R $3.62 $3.45 R $3.62E0280 UE IN $24.77 R $26.07 $24.77 R $26.07 $25.22 R $26.07 $24.34 R $25.63 $24.77 R $26.07 $24.77 R $26.07E0290 RR CR $57.59 R $60.54 $61.85 R $65.14 $64.21 R $66.22 $62.93 R $66.22 $57.59 R $60.54 $62.93 R $66.22E0291 RR CR $42.78 R $43.98 $46.66 R $49.33 $47.55 R $49.33 $46.66 R $49.33 $42.78 R $43.98 $46.66 R $49.33E0292 RR CR $63.85 R $68.06 $69.86 R $74.14 $71.91 R $74.14 $67.49 R $71.77 $63.85 R $68.06 $69.86 R $74.14E0293 RR CR $55.28 R $57.93 $60.39 R $64.05 $62.44 R $64.05 $58.39 R $62.05 $55.28 R $57.93 $60.39 R $64.05E0294 RR CR $87.14 R $89.57 $96.47 R $98.91 $95.82 R $98.91 $87.14 R $89.57 $87.14 R $89.57 $96.47 R $98.91E0295 RR CR $85.00 R $87.06 $94.10 R $96.16 $93.74 R $96.16 $85.00 R $87.06 $85.00 R $87.06 $94.10 R $96.16E0296 RR CR $119.58 $131.31 $131.31 $119.58 $119.58 $131.31E0297 RR CR $103.81 $113.86 $113.86 $103.81 $103.81 $113.86E0300 RR CR $253.53 $253.53 $253.53 $253.53 $253.53 $253.53E0301 RR CR $206.38 R $209.73 $213.08 R $216.44 $210.32 R $216.44 $209.05 R $212.40 $209.02 R $212.37 $204.27 R $207.62E0302 RR CR $577.97 R $594.85 $577.97 R $594.85 $572.32 R $594.85 $577.97 R $594.85 $577.97 R $594.85 $577.97 R $594.85E0303 RR CR $221.17 R $224.94 $227.88 R $231.65 $223.79 R $231.65 $223.86 R $227.63 $223.81 R $227.58 $219.07 R $222.84E0304 RR CR $611.42 R $624.51 $611.42 R $624.51 $598.97 R $624.51 $611.42 R $624.51 $611.42 R $624.51 $611.42 R $624.51E0305 RR CR $12.50 R $12.92 $12.50 R $12.92 $13.25 R $13.84 $12.50 R $12.92 $12.50 R $12.92 $12.50 R $12.92E0310 NU IN $141.62 R $144.44 $149.28 R $152.10 $133.67 R $138.23 $144.41 R $147.23 $149.28 R $152.10 $149.28 R $152.10E0310 RR IN $16.08 R $16.36 $16.18 R $16.46 $16.35 R $16.80 $14.89 R $15.17 $16.03 R $16.31 $16.23 R $16.51E0310 UE IN $112.59 R $114.71 $112.59 R $114.71 $111.29 R $114.71 $108.31 R $110.42 $111.98 R $114.10 $112.59 R $114.71E0316 RR CR $186.39 R $193.00 $178.38 R $184.99 $176.72 R $187.19 $186.39 R $193.00 $186.39 R $193.00 $178.51 R $185.12E0325 NU IN $9.03 R $9.51 $9.87 R $10.44 $9.05 R $9.51 $9.21 R $9.79 $9.03 R $9.51 $9.87 R $10.44E0325 RR IN $1.14 R $1.20 $1.26 R $1.32 $1.14 R $1.20 $1.14 R $1.20 $1.14 R $1.20 $1.26 R $1.32





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



E0325 UE IN $6.49 R $6.56 $6.90 R $7.33 $6.28 R $6.28 $6.90 R $7.33 $6.28 R $6.28 $6.90 R $7.33E0326 NU IN $9.62 R $10.02 $10.41 R $11.01 $9.57 R $9.86 $10.41 R $11.01 $9.70 R $10.19 $10.41 R $11.01E0326 RR IN $1.12 R $1.18 $1.08 R $1.14 $1.02 R $1.08 $1.12 R $1.18 $1.02 R $1.08 $1.10 R $1.16E0326 UE IN $7.29 R $7.67 $7.81 R $8.26 $7.18 R $7.40 $7.81 R $8.26 $7.28 R $7.64 $7.81 R $8.26E0371 RR CR $347.34 R $351.77 $351.75 R $356.18 $349.73 R $356.18 $333.83 R $338.27 $345.39 R $349.82 $347.99 R $352.43E0372 RR CR $382.97 R $386.53 $388.31 R $391.87 $380.01 R $391.87 $366.57 R $370.13 $380.59 R $384.16 $383.76 R $387.33E0373 RR CR $469.42 R $481.17 $473.95 R $485.70 $470.97 R $485.70 $450.64 R $462.39 $466.70 R $478.44 $470.34 R $482.09E0424 RR OX $126.67 R $129.37 $126.67 R $129.37 $125.73 R $129.37 $126.67 R $129.37 $126.67 R $129.37 $126.67 R $129.37E0431 RR OX $23.92 R $24.74 $23.92 R $24.74 $24.10 R $24.74 $23.92 R $24.74 $23.92 R $24.74 $23.92 R $24.74E0433 RR OX $44.71 R $46.90 $44.71 R $46.90 $45.61 R $46.90 $44.71 R $46.90 $44.71 R $46.90 $44.71 R $46.90E0434 RR OX $23.92 R $24.74 $23.92 R $24.74 $24.10 R $24.74 $23.92 R $24.74 $23.92 R $24.74 $23.92 R $24.74E0439 RR OX $126.67 R $129.37 $126.67 R $129.37 $125.73 R $129.37 $126.67 R $129.37 $126.67 R $129.37 $126.67 R $129.37E0441 OX $65.75 R $67.93 $65.75 R $67.93 $66.17 R $67.93 $65.75 R $67.93 $65.75 R $67.93 $65.75 R $67.93E0442 OX $65.75 R $67.93 $65.75 R $67.93 $66.17 R $67.93 $65.75 R $67.93 $65.75 R $67.93 $65.75 R $67.93E0443 OX $63.13 R $65.20 $63.13 R $65.20 $63.66 R $65.20 $63.13 R $65.20 $63.13 R $65.20 $63.13 R $65.20E0444 OX $63.13 R $65.20 $63.13 R $65.20 $63.66 R $65.20 $63.13 R $65.20 $63.13 R $65.20 $63.13 R $65.20E0462 RR CR $288.87 $282.66 $285.87 $322.15 $322.15 $273.83E0465 RR FS $896.95 $1,030.08 $896.95 $1,055.23 $1,055.23 $925.41E0466 RR FS $896.95 $1,030.08 $896.95 $1,055.23 $1,055.23 $925.41E0470 RR CR $166.60 R $171.42 $176.42 R $181.24 $176.11 R $181.24 $165.10 R $169.92 $176.42 R $181.24 $176.42 R $181.24E0471 RR CR $392.55 R $406.54 $392.55 R $406.54 $404.24 R $414.05 $392.55 R $406.54 $438.62 R $452.62 $392.55 R $406.54E0472 RR CR $457.04 R $477.18 $457.04 R $477.18 $457.13 R $484.69 $457.04 R $477.18 $503.12 R $523.26 $457.04 R $477.18E0480 RR CR $48.58 $41.65 $44.23 $41.29 $47.76 $41.29E0482 RR CR $465.50 $475.40 $475.40 $435.16 $461.12 $466.99E0483 RR CR $1,175.30 $1,175.30 $1,175.30 $1,175.30 $1,175.30 $1,175.30E0484 NU IN $40.83 $40.83 $40.83 $40.83 $40.83 $40.83E0484 RR IN $4.07 $4.07 $4.07 $4.07 $4.07 $4.07E0484 UE IN $30.63 $30.63 $30.63 $30.63 $30.63 $30.63E0500 RR FS $121.34 $121.34 $103.14 $121.34 $103.14 $103.14E0550 RR CR $47.11 $47.11 $55.42 $55.42 $55.42 $47.11E0560 NU IN $140.51 $163.42 $138.91 $144.82 $138.91 $163.42E0560 RR IN $17.54 $19.15 $16.28 $18.91 $17.54 $16.79E0560 UE IN $105.41 $122.57 $104.18 $108.59 $104.18 $122.57E0561 NU IN $87.15 R $89.95 $87.15 R $89.95 $84.21 R $89.95 $87.15 R $89.95 $87.15 R $89.95 $87.15 R $89.95E0561 RR IN $8.71 R $8.99 $8.71 R $8.99 $8.41 R $8.99 $8.71 R $8.99 $8.71 R $8.99 $8.71 R $8.99E0561 UE IN $65.36 R $67.46 $65.36 R $67.46 $63.15 R $67.46 $65.36 R $67.46 $65.36 R $67.46 $65.36 R $67.46E0562 NU IN $213.36 R $218.96 $213.36 R $218.96 $210.86 R $218.96 $213.36 R $218.96 $213.36 R $218.96 $213.36 R $218.96E0562 RR IN $21.33 R $21.89 $21.33 R $21.89 $21.08 R $21.89 $21.33 R $21.89 $21.33 R $21.89 $21.33 R $21.89E0562 UE IN $160.02 R $164.21 $160.02 R $164.21 $158.14 R $164.21 $160.02 R $164.21 $160.02 R $164.21 $160.02 R $164.21E0565 RR CR $49.11 R $51.30 $49.11 R $51.30 $48.58 R $51.30 $49.11 R $51.30 $54.17 R $56.36 $49.11 R $51.30E0570 RR CR $11.95 R $12.08 $11.95 R $12.08 $11.70 R $12.08 $11.94 R $12.07 $11.94 R $12.07 $11.95 R $12.08E0572 RR CR $36.02 R $36.02 $36.36 R $36.36 $36.20 R $36.36 $34.69 R $34.69 $35.85 R $35.85 $36.11 R $36.11E0574 RR CR $43.82 $44.51 $44.51 $40.96 $43.43 $43.94E0575 RR CR $113.62 $113.62 $100.83 $111.87 $111.41 $96.58E0580 NU IN $127.60 $127.60 $127.60 $127.60 $127.60 $127.60E0580 RR IN $12.76 $12.76 $12.76 $12.76 $12.76 $12.76E0580 UE IN $95.69 $95.69 $95.69 $95.69 $95.69 $95.69E0585 RR CR $31.00 R $31.59 $33.91 R $34.50 $33.33 R $34.50 $33.24 R $33.82 $31.00 R $31.59 $33.91 R $34.50E0600 RR CR $43.03 $43.03 $50.62 $50.62 $45.02 $43.03E0601 RR CR $74.24 R $75.77 $66.23 R $67.75 $66.73 R $69.18 $66.23 R $67.75 $74.24 R $75.77 $66.23 R $67.75E0602 NU IN $32.63 $32.63 $32.63 $32.63 $32.63 $32.63E0602 RR IN $3.28 $3.28 $3.28 $3.28 $3.28 $3.28E0602 UE IN $24.48 $24.48 $24.48 $24.48 $24.48 $24.48E0605 NU IN $24.84 $25.55 $29.22 $28.69 $24.84 $26.28E0605 RR IN $2.89 $2.89 $3.40 $3.38 $2.89 $2.89E0605 UE IN $20.47 $20.47 $24.08 $21.52 $20.47 $20.47E0606 RR CR $22.85 $21.57 $24.23 $21.57 $25.38 $21.57E0607 NU IN $73.86 $73.86 $73.86 $73.86 $73.86 $73.86E0607 RR IN $7.38 $7.38 $7.38 $7.38 $7.38 $7.38E0607 UE IN $55.39 $55.39 $55.39 $55.39 $55.39 $55.39E0610 NU IN $232.61 $223.51 $262.95 $262.95 $232.61 $223.51





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



E0610 RR IN $26.51 $23.57 $26.30 $27.73 $23.57 $23.57E0610 UE IN $174.44 $167.65 $197.24 $197.24 $174.44 $167.65E0615 NU IN $529.32 $449.92 $529.32 $529.32 $529.32 $449.92E0615 RR IN $64.67 $54.97 $64.67 $64.28 $64.67 $54.97E0615 UE IN $397.02 $337.47 $397.02 $397.02 $397.02 $337.47E0617 RR KF CR $373.20 $373.20 $373.20 $373.20 $373.20 $373.20E0617 RR CR $336.12 $336.12 $336.12 $336.12 $336.12 $336.12E0618 RR CR $263.46 $309.95 $302.65 $263.46 $309.95 $263.46E0620 RR CR $96.65 $96.65 $96.65 $96.65 $96.65 $96.65E0621 NU IN $84.01 R $89.72 $91.97 R $97.67 $93.27 R $97.67 $85.80 R $91.51 $84.01 R $89.72 $91.97 R $97.67E0621 RR IN $8.23 R $8.69 $9.00 R $9.57 $8.36 R $8.69 $8.58 R $9.15 $8.23 R $8.69 $9.00 R $9.57E0621 UE IN $63.18 R $67.46 $69.18 R $73.46 $70.16 R $73.46 $64.35 R $68.63 $63.18 R $67.46 $69.18 R $73.46E0627 NU IN $312.74 R $325.30 $308.81 R $321.38 $325.30 R $325.30 $312.74 R $325.30 $312.74 R $325.30 $308.81 R $321.38E0627 RR IN $31.28 R $32.53 $30.88 R $32.14 $32.53 R $32.53 $31.28 R $32.53 $31.28 R $32.53 $30.88 R $32.14E0627 UE IN $234.55 R $243.98 $231.60 R $241.03 $243.98 R $243.98 $234.55 R $243.98 $234.55 R $243.98 $231.60 R $241.03E0628 NU IN $324.33 R $337.67 $320.40 R $333.74 $337.67 R $337.67 $324.33 R $337.67 $324.33 R $337.67 $320.40 R $333.74E0628 RR IN $32.44 R $33.77 $32.04 R $33.38 $33.77 R $33.77 $32.44 R $33.77 $32.44 R $33.77 $32.04 R $33.38E0628 UE IN $243.25 R $253.25 $240.30 R $250.30 $253.25 R $253.25 $243.25 R $253.25 $243.25 R $253.25 $240.30 R $250.30E0629 NU IN $315.38 R $332.51 $315.11 R $332.25 $326.81 R $332.51 $315.38 R $332.51 $315.38 R $332.51 $315.11 R $332.25E0629 RR IN $31.54 R $33.25 $31.51 R $33.23 $32.68 R $33.25 $31.54 R $33.25 $31.54 R $33.25 $31.51 R $33.23E0629 UE IN $236.52 R $249.38 $236.32 R $249.18 $245.10 R $249.38 $236.52 R $249.38 $236.52 R $249.38 $236.32 R $249.18E0630 RR CR $81.20 R $83.65 $85.49 R $87.94 $84.70 R $87.94 $77.04 R $79.49 $79.93 R $82.38 $85.49 R $87.94E0635 RR CR $113.79 R $114.98 $123.94 R $130.04 $114.98 R $114.98 $113.79 R $114.98 $123.94 R $130.04 $123.94 R $130.04E0636 RR CR $1,061.04 R $1,108.08 $1,061.04 R $1,108.08 $1,075.62 R $1,108.08 $1,061.04 R $1,108.08 $1,061.04 R $1,108.08 $1,061.04 R $1,108.08E0639 RR CR $104.82 $123.32 $123.32 $104.82 $121.44 $123.32E0640 RR CR $104.82 $123.32 $123.32 $104.82 $121.44 $123.32E0650 NU IN $796.20 $791.78 $772.62 $735.99 $676.77 $796.20E0650 RR IN $83.51 $98.25 $83.51 $90.70 $88.28 $98.25E0650 UE IN $597.15 $593.86 $580.15 $566.19 $507.58 $597.15E0651 NU IN $1,015.31 $1,015.31 $1,015.31 $1,015.31 $1,015.31 $1,015.31E0651 RR IN $103.72 $103.72 $103.72 $103.72 $103.72 $103.72E0651 UE IN $761.50 $761.50 $761.50 $761.50 $761.50 $761.50E0652 NU IN $5,860.79 $5,860.79 $5,335.94 $5,860.79 $5,860.79 $5,860.79E0652 RR IN $579.22 $579.22 $533.57 $579.22 $579.22 $579.22E0652 UE IN $4,391.67 $4,391.67 $4,001.95 $4,391.67 $4,391.67 $4,391.67E0655 NU IN $119.32 $119.32 $119.32 $114.12 $104.36 $119.32E0655 RR IN $12.41 $14.02 $14.02 $11.92 $11.92 $14.02E0655 UE IN $89.60 $89.60 $89.60 $85.60 $89.60 $89.60E0656 RR CR $63.88 $63.88 $63.88 $63.88 $63.88 $63.88E0657 RR CR $60.01 $60.01 $60.01 $60.01 $60.01 $60.01E0660 NU IN $176.60 $176.60 $176.60 $150.79 $176.60 $176.60E0660 RR IN $17.53 $18.38 $18.38 $15.62 $18.01 $18.38E0660 UE IN $132.45 $132.45 $132.45 $113.11 $132.45 $132.45E0665 NU IN $149.47 $151.45 $135.22 $139.33 $148.18 $151.45E0665 RR IN $15.55 $15.55 $13.52 $13.94 $14.83 $15.55E0665 UE IN $113.72 $113.72 $101.40 $104.51 $113.72 $113.72E0666 NU IN $152.67 $152.67 $146.08 $152.67 $152.67 $152.67E0666 RR IN $15.68 $15.73 $14.61 $15.47 $15.73 $15.73E0666 UE IN $114.52 $114.52 $109.60 $114.52 $114.52 $114.52E0667 NU IN $357.93 $357.93 $304.24 $357.93 $357.93 $357.93E0667 RR IN $40.42 $40.42 $34.36 $40.42 $40.42 $40.42E0667 UE IN $268.45 $268.45 $228.18 $268.45 $268.45 $268.45E0668 NU IN $488.50 $485.34 $415.23 $488.50 $488.50 $488.50E0668 RR IN $48.21 $48.21 $40.98 $48.21 $48.21 $48.21E0668 UE IN $366.39 $364.01 $311.43 $366.39 $366.39 $366.39E0669 NU IN $202.66 $202.66 $202.66 $192.43 $200.13 $202.66E0669 RR IN $20.28 $20.28 $20.28 $19.25 $20.03 $20.28E0669 UE IN $152.03 $152.03 $152.03 $144.33 $150.12 $152.03E0670 NU IN $1,389.68 $1,389.68 $1,181.23 $1,389.68 $1,389.68 $1,389.68E0670 RR IN $148.77 $148.77 $126.45 $148.77 $148.77 $148.77E0670 UE IN $1,042.21 $1,042.21 $885.88 $1,042.21 $1,042.21 $1,042.21





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



E0671 NU IN $459.18 $459.18 $459.18 $459.18 $459.18 $459.18E0671 RR IN $45.94 $45.94 $45.94 $45.94 $45.94 $45.94E0671 UE IN $344.37 $344.37 $344.37 $344.37 $344.37 $344.37E0672 NU IN $356.77 $356.77 $356.77 $356.77 $356.77 $356.77E0672 RR IN $35.69 $35.69 $35.69 $35.69 $35.69 $35.69E0672 UE IN $267.60 $267.60 $267.60 $267.60 $267.60 $267.60E0673 NU IN $296.46 $296.46 $296.46 $296.46 $296.46 $296.46E0673 RR IN $29.65 $29.65 $29.65 $29.65 $29.65 $29.65E0673 UE IN $222.38 $222.38 $222.38 $222.38 $222.38 $222.38E0675 RR CR $425.12 $425.12 $425.12 $425.12 $425.12 $425.12E0691 NU IN $993.40 $993.40 $993.40 $993.40 $993.40 $993.40E0691 RR IN $99.33 $99.33 $99.33 $99.33 $99.33 $99.33E0691 UE IN $745.05 $745.05 $745.05 $745.05 $745.05 $745.05E0692 NU IN $1,247.44 $1,247.44 $1,247.44 $1,247.44 $1,247.44 $1,247.44E0692 RR IN $124.73 $124.73 $124.73 $124.73 $124.73 $124.73E0692 UE IN $935.57 $935.57 $935.57 $935.57 $935.57 $935.57E0693 NU IN $1,537.74 $1,537.74 $1,537.74 $1,537.74 $1,537.74 $1,537.74E0693 RR IN $153.78 $153.78 $153.78 $153.78 $153.78 $153.78E0693 UE IN $1,153.30 $1,153.30 $1,153.30 $1,153.30 $1,153.30 $1,153.30E0694 NU IN $4,894.46 $4,894.46 $4,894.46 $4,894.46 $4,894.46 $4,894.46E0694 RR IN $489.44 $489.44 $489.44 $489.44 $489.44 $489.44E0694 UE IN $3,670.87 $3,670.87 $3,670.87 $3,670.87 $3,670.87 $3,670.87E0705 NU KU IN $60.94 $60.94 $60.94 $59.01 $60.94 $60.94E0705 NU IN $54.50 R $55.15 $54.50 R $55.15 $53.70 R $55.15 $53.53 R $54.18 $54.50 R $55.15 $54.50 R $55.15E0705 RR KU IN $6.20 $6.20 $6.20 $5.92 $6.20 $6.20E0705 RR IN $5.50 R $5.57 $5.50 R $5.57 $5.42 R $5.57 $5.36 R $5.43 $5.50 R $5.57 $5.50 R $5.57E0705 UE KU IN $44.63 $44.63 $44.63 $44.25 $44.63 $44.63E0705 UE IN $40.34 R $40.82 $40.34 R $40.82 $39.74 R $40.82 $40.15 R $40.64 $40.34 R $40.82 $40.34 R $40.82E0720 NU TE $246.14 R $246.14 $246.14 R $246.14 $236.70 R $244.52 $246.14 R $246.14 $246.14 R $246.14 $224.11 R $224.11E0730 NU TE $244.29 R $244.29 $240.62 R $240.62 $235.47 R $242.64 $244.29 R $244.29 $244.29 R $244.29 $220.62 R $220.62E0731 NU IN $246.81 R $246.81 $246.81 R $246.81 $237.79 R $246.81 $246.81 R $246.81 $246.81 R $246.81 $246.81 R $246.81E0740 RR CR $57.82 $57.82 $57.82 $57.82 $57.82 $57.82E0744 RR CR $98.91 $100.12 $101.23 $101.23 $101.23 $94.18E0745 RR CR $98.91 $84.12 $98.08 $98.96 $98.96 $84.12E0747 NU KF IN $4,136.00 $4,329.25 $4,329.25 $4,329.25 $4,329.25 $4,329.25E0747 RR KF IN $413.63 $430.20 $430.20 $430.20 $430.20 $430.20E0747 UE KF IN $3,041.15 $3,216.55 $3,216.55 $3,216.55 $3,216.55 $3,216.55E0748 NU KF IN $4,301.21 $4,301.21 $4,301.21 $4,301.21 $4,301.21 $4,301.21E0748 RR KF IN $430.10 $430.10 $430.10 $430.10 $430.10 $430.10E0748 UE KF IN $3,225.91 $3,225.91 $3,225.91 $3,225.91 $3,225.91 $3,225.91E0760 NU KF IN $3,574.23 $3,574.23 $3,574.23 $3,574.23 $3,574.23 $3,574.23E0760 RR KF IN $357.43 $357.43 $357.43 $357.43 $357.43 $357.43E0760 UE KF IN $2,680.65 $2,680.65 $2,680.65 $2,680.65 $2,680.65 $2,680.65E0762 RR CR $121.55 $121.55 $121.55 $121.55 $121.55 $121.55E0764 RR KF CR $1,223.43 $1,223.43 $1,223.43 $1,223.43 $1,223.43 $1,223.43E0765 NU IN $93.01 $93.01 $93.01 $93.01 $93.01 $93.01E0765 RR IN $9.31 $9.31 $9.31 $9.31 $9.31 $9.31E0765 UE IN $69.78 $69.78 $69.78 $69.78 $69.78 $69.78E0776 NU BA PE $77.87 R $79.77 $77.87 R $79.77 $76.26 R $79.77 $77.87 R $79.77 $77.87 R $79.77 $77.87 R $79.77E0776 NU KE PE $86.21 R $88.11 $86.21 R $88.11 $84.61 R $88.11 $86.21 R $88.11 $86.21 R $88.11 $86.21 R $88.11E0776 NU IN $134.53 $134.53 $148.01 $148.01 $134.53 $134.53E0776 RR BA PE $15.75 R $15.94 $15.75 R $15.94 $15.59 R $15.94 $15.75 R $15.94 $15.75 R $15.94 $15.75 R $15.94E0776 RR KE PE $17.87 R $18.06 $17.87 R $18.06 $17.71 R $18.06 $17.87 R $18.06 $17.87 R $18.06 $17.87 R $18.06E0776 RR IN $15.65 $15.65 $16.76 $16.39 $15.65 $17.20E0776 UE BA PE $58.41 R $59.84 $58.41 R $59.84 $57.21 R $59.84 $58.41 R $59.84 $58.41 R $59.84 $58.41 R $59.84E0776 UE KE PE $64.66 R $66.08 $64.66 R $66.08 $63.45 R $66.08 $64.66 R $66.08 $64.66 R $66.08 $64.66 R $66.08E0776 UE IN $98.98 $98.98 $109.89 $109.89 $98.98 $98.98E0779 RR CR $18.04 $18.18 $18.18 $17.01 $17.96 $18.07E0780 NU IN $11.41 $11.41 $11.41 $11.41 $11.41 $11.41E0781 RR CR $259.34 $262.38 $262.38 $250.00 $258.00 $262.38E0784 RR CR $439.93 $439.93 $439.93 $439.88 $439.93 $439.93





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



E0791 RR CR $286.34 $289.81 $312.56 $286.34 $286.34 $286.34E0840 NU IN $74.20 $69.66 $68.84 $80.99 $78.55 $71.64E0840 RR IN $15.34 $15.34 $18.05 $18.05 $18.05 $15.34E0840 UE IN $55.69 $52.27 $51.61 $60.72 $58.89 $53.74E0849 RR CR $56.98 $56.98 $56.98 $56.98 $56.98 $56.98E0850 NU IN $98.71 $116.13 $98.71 $116.13 $98.71 $98.71E0850 RR IN $15.25 $15.95 $13.56 $15.95 $13.56 $13.56E0850 UE IN $74.04 $87.11 $74.04 $87.11 $74.04 $74.04E0855 RR CR $55.56 $55.56 $55.56 $54.65 $55.56 $55.56E0856 RR CR $17.01 $17.01 $17.01 $17.01 $17.01 $17.01E0860 NU IN $36.21 $42.60 $42.60 $41.27 $40.00 $42.60E0860 RR IN $6.12 $6.12 $6.12 $6.12 $6.12 $7.20E0860 UE IN $31.01 $32.62 $32.62 $32.62 $29.98 $32.62E0870 NU IN $109.30 $109.30 $109.30 $109.30 $109.30 $109.30E0870 RR IN $12.61 $12.61 $12.61 $14.83 $12.61 $12.61E0870 UE IN $82.34 $82.34 $82.34 $82.34 $82.34 $82.34E0880 NU IN $123.45 $117.97 $117.97 $138.79 $117.97 $117.97E0880 RR IN $18.52 $18.52 $21.79 $21.79 $18.52 $18.52E0880 UE IN $89.29 $89.29 $89.29 $105.05 $89.29 $89.29E0890 NU IN $133.10 $133.10 $113.14 $113.14 $113.14 $133.10E0890 RR IN $30.86 $30.86 $30.86 $34.29 $36.10 $36.30E0890 UE IN $107.22 $107.22 $91.14 $91.14 $91.14 $107.22E0900 NU IN $120.40 $141.65 $120.40 $120.40 $120.40 $141.65E0900 RR IN $25.96 $25.96 $25.96 $30.54 $25.96 $30.54E0900 UE IN $100.64 $106.27 $90.33 $90.33 $90.33 $106.27E0910 RR CR $13.57 R $14.00 $15.00 R $15.43 $14.82 R $15.34 $15.00 R $15.43 $14.43 R $14.86 $14.41 R $14.85E0911 RR CR $44.43 R $46.22 $44.43 R $46.22 $44.36 R $46.22 $44.43 R $46.22 $44.43 R $46.22 $44.43 R $46.22E0912 RR CR $96.08 R $98.11 $96.08 R $98.11 $93.80 R $98.11 $96.08 R $98.11 $96.08 R $98.11 $96.08 R $98.11E0920 RR CR $43.37 $43.37 $48.16 $51.02 $45.33 $43.58E0930 RR CR $42.93 $45.97 $46.00 $50.50 $42.93 $42.93E0935 RR FS $21.37 $23.58 $25.14 $25.14 $21.37 $24.23E0940 RR CR $24.37 R $25.29 $26.85 R $27.77 $26.72 R $27.77 $24.97 R $25.90 $24.37 R $25.29 $24.37 R $25.29E0941 RR CR $41.18 $43.78 $44.22 $47.98 $47.98 $43.58E0942 NU IN $18.65 $18.65 $21.94 $21.94 $19.01 $18.65E0942 RR IN $2.21 $2.21 $2.60 $2.37 $2.21 $2.21E0942 UE IN $13.97 $13.97 $16.43 $16.43 $14.23 $13.97E0944 NU IN $43.37 $43.10 $50.71 $43.10 $49.55 $43.10E0944 RR IN $4.37 $4.34 $5.10 $4.34 $4.96 $4.34E0944 UE IN $35.63 $32.33 $38.03 $32.33 $37.16 $32.33E0945 NU IN $41.65 $41.65 $49.00 $41.65 $41.65 $41.65E0945 RR IN $4.17 $4.17 $4.91 $4.17 $4.17 $4.17E0945 UE IN $32.23 $32.23 $37.92 $32.23 $32.23 $32.23E0946 RR CR $55.60 $55.60 $58.36 $56.64 $55.60 $55.60E0947 NU IN $569.88 $569.88 $670.45 $569.88 $593.94 $569.88E0947 RR IN $59.08 $59.08 $69.51 $59.08 $60.13 $59.08E0947 UE IN $427.40 $427.40 $502.82 $427.40 $445.44 $427.40E0948 NU IN $566.09 $551.21 $648.48 $551.21 $593.94 $551.21E0948 RR IN $56.98 $55.10 $64.82 $55.10 $59.40 $55.10E0948 UE IN $424.58 $388.76 $457.37 $388.76 $445.44 $388.76E0950 NU KE IN $94.28 R $97.35 $85.66 R $88.73 $95.42 R $97.35 $85.66 R $88.73 $85.66 R $88.73 $85.66 R $88.73E0950 NU KU IN $99.05 $84.19 $99.05 $84.19 $84.19 $84.19E0950 NU IN $86.34 R $89.41 $78.91 R $81.98 $87.48 R $89.41 $78.91 R $81.98 $78.91 R $81.98 $78.91 R $81.98E0950 RR KE IN $9.43 R $9.74 $8.57 R $8.88 $9.55 R $9.74 $8.57 R $8.88 $8.57 R $8.88 $8.57 R $8.88E0950 RR KU IN $9.93 $8.44 $9.93 $8.44 $8.44 $8.44E0950 RR IN $8.65 R $8.95 $7.90 R $8.21 $8.76 R $8.95 $7.90 R $8.21 $7.90 R $8.21 $7.90 R $8.21E0950 UE KE IN $70.71 R $73.01 $64.24 R $66.55 $71.56 R $73.01 $64.24 R $66.55 $64.24 R $66.55 $64.24 R $66.55E0950 UE KU IN $74.29 $63.15 $74.29 $63.15 $63.15 $63.15E0950 UE IN $64.75 R $67.06 $59.18 R $61.49 $65.61 R $67.06 $59.18 R $61.49 $59.18 R $61.49 $59.18 R $61.49E0951 NU KE IN $15.28 R $15.80 $15.28 R $15.80 $15.70 R $16.00 $16.85 R $17.37 $16.85 R $17.37 $15.28 R $15.80E0951 NU KU IN $15.38 $15.38 $15.72 $18.09 $18.09 $15.38E0951 NU IN $14.05 R $14.57 $14.05 R $14.57 $14.43 R $14.74 $15.40 R $15.92 $15.40 R $15.92 $14.05 R $14.57





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



E0951 RR KE IN $1.56 R $1.61 $1.56 R $1.61 $1.58 R $1.61 $1.72 R $1.77 $1.72 R $1.77 $1.56 R $1.61E0951 RR KU IN $1.58 $1.58 $1.58 $1.86 $1.86 $1.58E0951 RR IN $1.43 R $1.48 $1.43 R $1.48 $1.45 R $1.48 $1.57 R $1.62 $1.57 R $1.62 $1.43 R $1.48E0951 UE KE IN $11.45 R $11.84 $11.45 R $11.84 $11.77 R $12.00 $12.63 R $13.02 $12.63 R $13.02 $11.45 R $11.84E0951 UE KU IN $11.53 $11.53 $11.80 $13.56 $13.56 $11.53E0951 UE IN $10.53 R $10.92 $10.53 R $10.92 $10.83 R $11.06 $11.55 R $11.94 $11.55 R $11.94 $10.53 R $10.92E0952 NU KE IN $16.51 $18.07 $16.51 $18.07 $16.51 $18.07E0952 NU KU IN $15.26 $17.95 $15.26 $17.95 $15.26 $17.95E0952 NU IN $15.26 $16.64 $15.26 $16.64 $15.26 $16.64E0952 RR KE IN $1.69 $1.85 $1.69 $1.85 $1.69 $1.85E0952 RR KU IN $1.58 $1.86 $1.58 $1.86 $1.58 $1.86E0952 RR IN $1.56 $1.70 $1.56 $1.70 $1.56 $1.70E0952 UE KE IN $12.40 $13.57 $12.40 $13.57 $12.40 $13.57E0952 UE KU IN $11.45 $13.47 $11.45 $13.47 $11.45 $13.47E0952 UE IN $11.44 $12.49 $11.44 $12.49 $11.44 $12.49E0955 RR KE CR $18.12 R $18.81 $18.12 R $18.81 $18.13 R $18.81 $18.12 R $18.81 $18.12 R $18.81 $18.12 R $18.81E0955 RR KU CR $19.28 $19.28 $19.28 $19.28 $19.28 $19.28E0955 RR CR $16.58 R $17.27 $16.58 R $17.27 $16.59 R $17.27 $16.58 R $17.27 $16.58 R $17.27 $16.58 R $17.27E0956 NU KE IN $90.99 R $94.72 $90.99 R $94.72 $90.63 R $94.72 $90.99 R $94.72 $90.99 R $94.72 $90.99 R $94.72E0956 NU KU IN $93.92 $93.92 $93.92 $93.92 $93.92 $93.92E0956 NU IN $83.46 R $87.19 $83.46 R $87.19 $83.09 R $87.19 $83.46 R $87.19 $83.46 R $87.19 $83.46 R $87.19E0956 RR KE IN $9.10 R $9.48 $9.10 R $9.48 $9.07 R $9.48 $9.10 R $9.48 $9.10 R $9.48 $9.10 R $9.48E0956 RR KU IN $9.39 $9.39 $9.39 $9.39 $9.39 $9.39E0956 RR IN $8.35 R $8.72 $8.35 R $8.72 $8.31 R $8.72 $8.35 R $8.72 $8.35 R $8.72 $8.35 R $8.72E0956 UE KE IN $68.24 R $71.04 $68.24 R $71.04 $67.96 R $71.04 $68.24 R $71.04 $68.24 R $71.04 $68.24 R $71.04E0956 UE KU IN $70.45 $70.45 $70.45 $70.45 $70.45 $70.45E0956 UE IN $62.60 R $65.39 $62.60 R $65.39 $62.32 R $65.39 $62.60 R $65.39 $62.60 R $65.39 $62.60 R $65.39E0957 NU KE IN $133.70 R $139.17 $133.70 R $139.17 $136.05 R $139.17 $133.70 R $139.17 $133.70 R $139.17 $133.70 R $139.17E0957 NU KU IN $131.43 $131.43 $131.43 $131.43 $131.43 $131.43E0957 NU IN $123.18 R $128.64 $123.18 R $128.64 $125.52 R $128.64 $123.18 R $128.64 $123.18 R $128.64 $123.18 R $128.64E0957 RR KE IN $13.38 R $13.92 $13.38 R $13.92 $13.61 R $13.92 $13.38 R $13.92 $13.38 R $13.92 $13.38 R $13.92E0957 RR KU IN $13.15 $13.15 $13.15 $13.15 $13.15 $13.15E0957 RR IN $12.32 R $12.87 $12.32 R $12.87 $12.56 R $12.87 $12.32 R $12.87 $12.32 R $12.87 $12.32 R $12.87E0957 UE KE IN $100.28 R $104.37 $100.28 R $104.37 $102.04 R $104.37 $100.28 R $104.37 $100.28 R $104.37 $100.28 R $104.37E0957 UE KU IN $98.57 $98.57 $98.57 $98.57 $98.57 $98.57E0957 UE IN $92.38 R $96.48 $92.38 R $96.48 $94.14 R $96.48 $92.38 R $96.48 $92.38 R $96.48 $92.38 R $96.48E0958 RR CR $40.90 R $42.41 $43.81 R $45.97 $43.81 R $45.97 $41.10 R $42.81 $43.40 R $45.56 $43.81 R $45.97E0959 NU IN $41.34 R $41.54 $45.00 R $47.68 $46.73 R $47.68 $41.34 R $41.54 $41.85 R $42.57 $45.00 R $47.68E0959 RR IN $4.15 R $4.18 $4.52 R $4.78 $4.69 R $4.78 $4.15 R $4.18 $4.18 R $4.24 $4.52 R $4.78E0959 UE IN $31.14 R $31.43 $33.92 R $35.93 $35.21 R $35.93 $31.14 R $31.43 $31.37 R $31.89 $33.92 R $35.93E0960 NU KE IN $85.44 R $88.47 $85.44 R $88.47 $87.41 R $88.47 $85.44 R $88.47 $85.44 R $88.47 $85.44 R $88.47E0960 NU KU IN $86.69 $86.69 $86.69 $86.69 $86.69 $86.69E0960 NU IN $78.50 R $81.52 $78.50 R $81.52 $80.47 R $81.52 $78.50 R $81.52 $78.50 R $81.52 $78.50 R $81.52E0960 RR KE IN $8.55 R $8.85 $8.55 R $8.85 $8.75 R $8.85 $8.55 R $8.85 $8.55 R $8.85 $8.55 R $8.85E0960 RR KU IN $8.69 $8.69 $8.69 $8.69 $8.69 $8.69E0960 RR IN $7.86 R $8.16 $7.86 R $8.16 $8.06 R $8.16 $7.86 R $8.16 $7.86 R $8.16 $7.86 R $8.16E0960 UE KE IN $64.09 R $66.36 $64.09 R $66.36 $65.57 R $66.36 $64.09 R $66.36 $64.09 R $66.36 $64.09 R $66.36E0960 UE KU IN $65.03 $65.03 $65.03 $65.03 $65.03 $65.03E0960 UE IN $58.88 R $61.15 $58.88 R $61.15 $60.36 R $61.15 $58.88 R $61.15 $58.88 R $61.15 $58.88 R $61.15E0961 NU IN $23.61 R $24.75 $26.07 R $27.21 $26.25 R $27.21 $23.61 R $24.75 $23.61 R $24.75 $26.07 R $27.21E0961 RR IN $2.68 R $2.80 $2.68 R $2.80 $2.68 R $2.78 $2.42 R $2.54 $2.42 R $2.54 $2.68 R $2.80E0961 UE IN $13.95 R $13.95 $15.43 R $16.28 $15.56 R $16.28 $15.43 R $16.28 $15.43 R $16.28 $15.43 R $16.28E0966 NU IN $67.69 R $69.66 $70.10 R $74.27 $75.06 R $76.48 $69.02 R $72.31 $69.10 R $72.48 $71.24 R $75.40E0966 RR IN $7.18 R $7.60 $7.18 R $7.60 $7.31 R $7.45 $6.90 R $7.23 $6.91 R $7.24 $7.12 R $7.54E0966 UE IN $50.79 R $52.28 $52.57 R $55.70 $56.30 R $57.36 $51.78 R $54.26 $51.84 R $54.38 $53.42 R $56.54E0967 NU IN $70.58 R $72.61 $70.58 R $72.61 $71.80 R $72.61 $70.57 R $72.58 $70.58 R $72.61 $70.58 R $72.61E0967 RR IN $7.06 R $7.27 $7.06 R $7.27 $7.19 R $7.27 $7.06 R $7.26 $7.06 R $7.27 $7.06 R $7.27E0967 UE IN $52.93 R $54.44 $52.93 R $54.44 $53.85 R $54.44 $52.93 R $54.44 $52.93 R $54.44 $52.93 R $54.44E0968 RR CR $17.16 $16.84 $19.81 $19.81 $19.05 $16.84E0969 NU IN $173.16 $147.19 $160.69 $173.16 $173.16 $147.19E0969 RR IN $16.64 $14.57 $16.07 $17.14 $17.14 $14.57





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



E0969 UE IN $129.88 $110.40 $120.54 $129.88 $129.88 $110.40E0971 NU IN $39.08 R $39.93 $39.08 R $39.93 $38.33 R $39.93 $39.08 R $39.93 $39.08 R $39.93 $39.08 R $39.93E0971 RR IN $3.92 R $4.00 $3.92 R $4.00 $3.84 R $4.00 $3.92 R $4.00 $3.92 R $4.00 $3.92 R $4.00E0971 UE IN $29.33 R $29.96 $29.33 R $29.96 $28.76 R $29.96 $29.33 R $29.96 $29.33 R $29.96 $29.33 R $29.96E0973 NU KE IN $81.94 R $82.30 $81.94 R $82.30 $87.05 R $91.83 $81.94 R $82.30 $91.47 R $91.83 $81.94 R $82.30E0973 NU KU IN $93.12 $93.12 $109.55 $93.12 $109.55 $93.12E0973 NU IN $74.48 R $74.84 $74.48 R $74.84 $78.27 R $83.06 $74.48 R $74.84 $82.69 R $83.06 $74.48 R $74.84E0973 RR KE IN $7.94 R $7.98 $7.94 R $7.98 $8.41 R $8.88 $7.94 R $7.98 $8.85 R $8.88 $7.94 R $7.98E0973 RR KU IN $8.87 $8.87 $10.43 $8.87 $10.43 $8.87E0973 RR IN $7.22 R $7.26 $7.22 R $7.26 $7.56 R $8.04 $7.22 R $7.26 $8.01 R $8.04 $7.22 R $7.26E0973 UE KE IN $61.45 R $61.73 $61.45 R $61.73 $65.28 R $68.87 $61.45 R $61.73 $68.60 R $68.87 $61.45 R $61.73E0973 UE KU IN $69.84 $69.84 $82.16 $69.84 $82.16 $69.84E0973 UE IN $55.86 R $56.13 $55.86 R $56.13 $58.70 R $62.29 $55.86 R $56.13 $62.02 R $62.29 $55.86 R $56.13E0974 NU IN $71.70 R $73.68 $71.70 R $73.68 $72.94 R $73.68 $71.70 R $73.68 $78.19 R $81.83 $71.70 R $73.68E0974 RR IN $7.39 R $7.76 $7.39 R $7.76 $7.52 R $7.76 $7.39 R $7.76 $8.08 R $8.45 $7.39 R $7.76E0974 UE IN $53.98 R $55.68 $53.98 R $55.68 $54.91 R $55.68 $53.98 R $55.68 $58.89 R $61.61 $53.98 R $55.68E0978 NU KE IN $32.19 R $32.96 $32.19 R $32.96 $33.76 R $34.46 $32.19 R $32.96 $35.73 R $36.50 $32.19 R $32.96E0978 NU KU IN $34.59 $34.59 $37.19 $34.59 $40.69 $34.59E0978 NU IN $29.41 R $30.18 $29.41 R $30.18 $30.78 R $31.48 $29.41 R $30.18 $32.46 R $33.23 $29.41 R $30.18E0978 RR KE IN $3.23 R $3.31 $3.23 R $3.31 $3.38 R $3.45 $3.23 R $3.31 $3.58 R $3.66 $3.23 R $3.31E0978 RR KU IN $3.46 $3.46 $3.74 $3.46 $4.07 $3.46E0978 RR IN $2.95 R $3.02 $2.95 R $3.02 $3.09 R $3.16 $2.95 R $3.02 $3.25 R $3.33 $2.95 R $3.02E0978 UE KE IN $23.96 R $24.54 $23.96 R $24.54 $25.76 R $26.29 $23.96 R $24.54 $26.59 R $27.17 $23.96 R $24.54E0978 UE KU IN $25.64 $25.64 $28.64 $25.64 $30.17 $25.64E0978 UE IN $21.91 R $22.49 $21.91 R $22.49 $23.45 R $23.98 $21.91 R $22.49 $24.17 R $24.75 $21.91 R $22.49E0980 NU IN $31.06 $31.06 $36.54 $31.06 $31.06 $31.06E0980 RR IN $3.11 $3.11 $3.66 $3.11 $3.11 $3.11E0980 UE IN $26.30 $23.16 $27.25 $23.16 $23.16 $23.16E0981 NU KE IN $41.37 $45.28 $45.28 $45.28 $44.42 $45.16E0981 NU KU IN $38.19 $44.93 $44.93 $44.93 $43.45 $44.73E0981 NU IN $38.19 $41.68 $41.68 $41.68 $40.94 $41.58E0981 RR KE IN $4.17 $4.57 $4.21 $4.57 $4.44 $4.53E0981 RR KU IN $3.88 $4.57 $3.94 $4.57 $4.34 $4.47E0981 RR IN $3.86 $4.21 $3.89 $4.21 $4.09 $4.16E0981 UE KE IN $31.31 $34.15 $34.15 $34.15 $34.09 $33.86E0981 UE KU IN $29.13 $34.00 $34.00 $34.00 $33.90 $33.53E0981 UE IN $28.98 $31.42 $31.42 $31.42 $31.37 $31.18E0982 NU KE IN $45.50 $48.76 $48.06 $49.77 $49.77 $46.78E0982 NU KU IN $41.73 $47.36 $46.18 $49.09 $49.09 $43.95E0982 NU IN $41.73 $44.96 $44.37 $45.83 $45.83 $43.26E0982 RR KE IN $4.54 $4.88 $4.80 $4.97 $4.97 $4.69E0982 RR KU IN $4.17 $4.76 $4.63 $4.91 $4.91 $4.41E0982 RR IN $4.17 $4.51 $4.44 $4.58 $4.58 $4.33E0982 UE KE IN $34.11 $36.57 $36.05 $37.31 $37.31 $35.09E0982 UE KU IN $31.31 $35.55 $34.64 $36.83 $36.83 $32.99E0982 UE IN $31.30 $33.73 $33.28 $34.38 $34.38 $32.45E0983 RR CR $263.51 $276.31 $276.31 $268.64 $268.54 $259.49E0984 RR CR $211.20 $211.20 $189.30 $211.20 $211.20 $211.20E0985 RR KU CR $22.44 $22.44 $22.44 $22.44 $22.44 $22.44E0985 RR CR $21.27 R $22.44 $21.27 R $22.44 $21.51 R $22.44 $21.27 R $22.44 $21.27 R $22.44 $21.27 R $22.44E0986 RR CR $537.76 $537.76 $537.76 $537.76 $537.76 $537.76E0988 RR CR $330.93 $330.93 $330.93 $318.20 $330.93 $330.93E0990 NU KE IN $101.00 R $101.69 $91.26 R $91.95 $96.63 R $101.69 $101.00 R $101.69 $101.00 R $101.69 $101.00 R $101.69E0990 NU KU IN $111.89 $95.11 $111.89 $111.89 $111.89 $111.89E0990 NU IN $92.03 R $92.72 $83.64 R $84.33 $87.66 R $92.72 $92.03 R $92.72 $92.03 R $92.72 $92.03 R $92.72E0990 RR KE IN $10.91 R $10.98 $9.82 R $9.89 $10.48 R $10.98 $10.79 R $10.86 $10.11 R $10.18 $10.86 R $10.93E0990 RR KU IN $12.60 $10.71 $12.60 $12.38 $11.20 $12.49E0990 RR IN $9.91 R $9.98 $8.96 R $9.03 $9.47 R $9.98 $9.80 R $9.87 $9.21 R $9.28 $9.85 R $9.92E0990 UE KE IN $77.78 R $78.29 $70.17 R $70.69 $74.50 R $78.29 $77.78 R $78.29 $77.78 R $78.29 $77.78 R $78.29E0990 UE KU IN $87.43 $74.32 $87.43 $87.43 $87.43 $87.43E0990 UE IN $70.78 R $71.30 $64.22 R $64.74 $67.50 R $71.30 $70.78 R $71.30 $70.78 R $71.30 $70.78 R $71.30





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



E0992 NU IN $84.15 R $86.86 $92.04 R $94.75 $91.88 R $93.03 $89.75 R $92.46 $84.15 R $86.86 $92.04 R $94.75E0992 RR IN $8.29 R $8.56 $9.05 R $9.33 $9.19 R $9.30 $8.98 R $9.26 $8.37 R $8.64 $9.05 R $9.33E0992 UE IN $63.11 R $65.15 $69.03 R $71.07 $68.92 R $69.78 $67.32 R $69.35 $63.11 R $65.15 $69.03 R $71.07E0994 NU IN $16.56 $19.48 $19.48 $19.48 $16.56 $18.32E0994 RR IN $1.67 $1.97 $1.97 $1.97 $1.67 $1.84E0994 UE IN $12.43 $14.62 $14.62 $14.62 $12.43 $13.74E0995 NU KE IN $26.64 $29.16 $29.16 $26.64 $29.16 $29.16E0995 NU KU IN $24.62 $28.96 $28.96 $24.62 $28.96 $28.96E0995 NU IN $24.62 $26.83 $26.83 $24.62 $26.83 $26.83E0995 RR KE IN $2.67 $2.92 $2.92 $2.67 $2.92 $2.92E0995 RR KU IN $2.47 $2.91 $2.91 $2.47 $2.91 $2.91E0995 RR IN $2.47 $2.69 $2.69 $2.47 $2.69 $2.69E0995 UE KE IN $19.97 $21.86 $21.86 $19.97 $21.86 $21.86E0995 UE KU IN $18.45 $21.70 $21.70 $18.45 $21.70 $21.70E0995 UE IN $18.45 $20.11 $20.11 $18.45 $20.11 $20.11E1002 RR KE CR $395.41 $395.41 $395.41 $395.41 $395.41 $395.41E1002 RR KU CR $386.19 $386.19 $386.19 $386.19 $386.19 $386.19E1002 RR CR $364.46 $364.46 $364.46 $364.46 $364.46 $364.46E1003 RR KE CR $443.32 $443.32 $443.32 $443.32 $443.32 $443.32E1003 RR KU CR $418.43 $418.43 $418.43 $418.43 $418.43 $418.43E1003 RR CR $409.80 $409.80 $409.80 $409.80 $409.80 $409.80E1004 RR KE CR $489.61 $489.61 $489.61 $489.61 $489.61 $489.61E1004 RR KU CR $463.93 $463.93 $463.93 $463.93 $463.93 $463.93E1004 RR CR $452.43 $452.43 $452.43 $452.43 $452.43 $452.43E1005 RR KE CR $532.50 $532.50 $532.50 $532.50 $532.50 $532.50E1005 RR KU CR $502.17 $502.17 $502.17 $502.17 $502.17 $502.17E1005 RR CR $492.26 $492.26 $492.26 $492.26 $492.26 $492.26E1006 RR KE CR $654.19 $654.19 $654.19 $654.19 $654.19 $654.19E1006 RR KU CR $615.11 $615.11 $615.11 $615.11 $615.11 $615.11E1006 RR CR $604.91 $604.91 $604.91 $604.91 $604.91 $604.91E1007 RR KE CR $852.29 $852.29 $852.29 $852.29 $852.29 $852.29E1007 RR KU CR $832.91 $832.91 $832.91 $832.91 $832.91 $832.91E1007 RR CR $785.57 $785.57 $785.57 $785.57 $785.57 $785.57E1008 RR KE CR $861.83 $861.83 $861.83 $861.83 $861.83 $861.83E1008 RR KU CR $832.97 $832.97 $832.97 $832.97 $832.97 $832.97E1008 RR CR $795.09 $795.09 $795.09 $795.09 $795.09 $795.09E1010 RR KE CR $114.68 $114.68 $114.68 $114.68 $114.68 $114.68E1010 RR KU CR $108.99 $108.99 $108.99 $108.99 $108.99 $108.99E1010 RR CR $105.95 $105.95 $105.95 $105.95 $105.95 $105.95E1012 RR KU CR $108.99 $108.99 $108.99 $108.99 $108.99 $108.99E1012 RR CR $105.95 $105.95 $105.95 $105.95 $105.95 $105.95E1014 RR CR $40.38 $40.38 $40.38 $40.38 $40.38 $40.38E1015 NU IN $120.27 R $125.75 $120.27 R $125.75 $121.45 R $125.75 $120.27 R $125.75 $120.27 R $125.75 $120.27 R $125.75E1015 RR IN $12.02 R $12.57 $12.02 R $12.57 $12.14 R $12.57 $12.02 R $12.57 $12.02 R $12.57 $12.02 R $12.57E1015 UE IN $90.20 R $94.31 $90.20 R $94.31 $91.08 R $94.31 $90.20 R $94.31 $90.20 R $94.31 $90.20 R $94.31E1016 NU KE IN $124.12 R $130.93 $124.12 R $130.93 $126.47 R $130.93 $124.12 R $130.93 $124.12 R $130.93 $124.12 R $130.93E1016 NU KU IN $125.13 $125.13 $125.13 $125.13 $125.13 $125.13E1016 NU IN $114.10 R $120.91 $114.10 R $120.91 $116.45 R $120.91 $114.10 R $120.91 $114.10 R $120.91 $114.10 R $120.91E1016 RR KE IN $12.42 R $13.10 $12.42 R $13.10 $12.65 R $13.10 $12.42 R $13.10 $12.42 R $13.10 $12.42 R $13.10E1016 RR KU IN $12.53 $12.53 $12.53 $12.53 $12.53 $12.53E1016 RR IN $11.42 R $12.10 $11.42 R $12.10 $11.65 R $12.10 $11.42 R $12.10 $11.42 R $12.10 $11.42 R $12.10E1016 UE KE IN $93.09 R $98.20 $93.09 R $98.20 $94.86 R $98.20 $93.09 R $98.20 $93.09 R $98.20 $93.09 R $98.20E1016 UE KU IN $93.83 $93.83 $93.83 $93.83 $93.83 $93.83E1016 UE IN $85.57 R $90.68 $85.57 R $90.68 $87.33 R $90.68 $85.57 R $90.68 $85.57 R $90.68 $85.57 R $90.68E1020 RR KE CR $22.23 R $22.92 $22.23 R $22.92 $22.14 R $22.92 $22.23 R $22.92 $22.23 R $22.92 $22.23 R $22.92E1020 RR KU CR $23.18 $23.18 $23.18 $23.18 $23.18 $23.18E1020 RR CR $20.37 R $21.07 $20.37 R $21.07 $20.28 R $21.07 $20.37 R $21.07 $20.37 R $21.07 $20.37 R $21.07E1028 RR KE CR $18.15 R $18.50 $18.15 R $18.50 $17.80 R $18.50 $18.15 R $18.50 $18.15 R $18.50 $18.15 R $18.50E1028 RR KU CR $19.67 $19.67 $19.67 $19.67 $19.67 $19.67E1028 RR CR $16.57 R $16.92 $16.57 R $16.92 $16.22 R $16.92 $16.57 R $16.92 $16.57 R $16.92 $16.57 R $16.92E1029 RR KE CR $37.76 $37.76 $37.76 $37.76 $37.76 $37.76





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



E1029 RR KU CR $35.20 $35.20 $35.20 $35.20 $35.20 $35.20E1029 RR CR $34.93 $34.93 $34.93 $34.93 $34.93 $34.93E1030 RR KE CR $118.55 $118.55 $118.55 $118.55 $118.55 $118.55E1030 RR KU CR $111.03 $111.03 $111.03 $111.03 $111.03 $111.03E1030 RR CR $109.66 $109.66 $109.66 $109.66 $109.66 $109.66E1031 RR CR $44.26 R $46.19 $48.45 R $50.38 $48.35 R $50.38 $44.26 R $46.19 $44.26 R $46.19 $44.26 R $46.19E1035 RR CR $625.21 R $647.92 $625.21 R $647.92 $636.37 R $647.92 $625.21 R $647.92 $625.21 R $647.92 $625.21 R $647.92E1036 RR CR $881.16 R $924.26 $881.16 R $924.26 $884.12 R $924.26 $881.16 R $924.26 $881.16 R $924.26 $881.16 R $924.26E1037 RR CR $110.38 R $116.04 $110.38 R $116.04 $110.19 R $116.04 $110.38 R $116.04 $110.38 R $116.04 $110.38 R $116.04E1038 RR CR $17.38 R $17.64 $17.38 R $17.64 $17.16 R $17.64 $17.38 R $17.64 $17.38 R $17.64 $17.38 R $17.64E1039 RR CR $34.64 R $36.20 $34.64 R $36.20 $34.82 R $36.20 $34.64 R $36.20 $34.64 R $36.20 $34.64 R $36.20E1050 RR CR $103.64 $112.58 $99.85 $95.69 $95.69 $112.58E1060 RR CR $118.46 $139.36 $139.36 $118.46 $118.46 $121.09E1070 RR CR $102.93 $121.09 $118.46 $102.93 $102.93 $121.09E1083 RR CR $87.05 $87.05 $87.05 $73.99 $73.99 $87.05E1084 RR CR $108.45 $92.84 $108.45 $92.18 $108.45 $101.41E1087 RR CR $118.90 $124.41 $121.54 $118.90 $118.90 $120.36E1088 RR CR $141.68 $141.68 $157.49 $141.68 $152.20 $141.68E1092 RR CR $120.77 $120.77 $120.77 $120.77 $142.08 $127.88E1093 RR CR $122.18 $122.18 $103.85 $103.85 $103.85 $103.85E1100 RR CR $97.54 $114.75 $104.88 $97.54 $97.54 $103.60E1110 RR CR $100.65 $112.38 $95.52 $95.52 $95.52 $95.52E1150 RR CR $78.56 $90.18 $90.18 $76.75 $82.72 $81.94E1160 RR CR $58.74 $69.10 $69.10 $59.22 $58.74 $68.35E1161 RR CR $261.57 $261.57 $261.57 $261.57 $261.57 $261.57E1170 RR CR $98.75 $98.75 $98.75 $83.94 $83.94 $83.94E1171 RR CR $77.41 $88.61 $88.61 $75.32 $78.37 $88.61E1172 RR CR $92.06 $108.30 $104.34 $92.06 $108.30 $108.30E1180 RR CR $95.23 $112.03 $100.94 $95.23 $95.23 $95.23E1190 RR CR $110.02 $129.43 $110.02 $110.02 $110.02 $112.27E1195 RR CR $121.09 $118.05 $138.88 $118.05 $118.05 $127.88E1200 RR CR $81.76 $96.19 $81.76 $81.76 $81.76 $92.39E1221 RR CR $52.53 $47.79 $52.53 $44.65 $52.53 $44.65E1222 RR CR $74.94 $74.86 $74.94 $63.70 $74.29 $68.35E1223 RR CR $81.82 $81.82 $81.82 $69.55 $81.82 $74.74E1224 RR CR $89.71 $89.71 $86.03 $76.25 $89.71 $89.71E1225 RR CR $39.40 R $40.98 $42.08 R $43.66 $42.84 R $44.07 $39.40 R $40.98 $40.62 R $42.20 $40.66 R $42.24E1226 NU IN $495.34 R $501.19 $495.34 R $501.19 $440.80 R $455.94 $450.09 R $455.94 $495.34 R $501.19 $495.34 R $501.19E1226 RR IN $50.41 R $51.00 $50.41 R $51.00 $44.83 R $46.34 $45.76 R $46.34 $50.41 R $51.00 $50.41 R $51.00E1226 UE IN $371.48 R $375.87 $371.48 R $375.87 $330.58 R $341.94 $337.55 R $341.94 $371.48 R $375.87 $371.48 R $375.87E1227 NU IN $306.78 $260.76 $260.76 $306.78 $306.78 $260.76E1227 RR IN $30.69 $26.09 $26.09 $30.69 $30.69 $26.09E1227 UE IN $230.11 $195.59 $195.59 $230.11 $230.11 $195.59E1228 RR CR $30.98 $30.31 $26.33 $26.33 $26.33 $28.51E1230 NU IN $2,356.23 $2,500.44 $2,125.37 $2,125.37 $2,500.44 $2,220.20E1230 RR IN $233.92 $245.92 $209.03 $211.55 $245.92 $222.03E1230 UE IN $1,977.54 $1,977.54 $1,977.54 $1,680.91 $1,893.52 $1,977.54E1232 RR CR $236.42 $236.42 $236.42 $236.42 $236.42 $236.42E1233 RR CR $244.95 $244.95 $244.95 $244.95 $244.95 $244.95E1234 RR CR $213.26 $213.26 $213.26 $213.26 $213.26 $213.26E1235 RR CR $205.36 $205.36 $205.36 $205.36 $205.36 $205.36E1236 RR CR $181.16 $181.16 $181.16 $181.16 $181.16 $181.16E1237 RR CR $182.75 $182.75 $182.75 $182.75 $182.75 $182.75E1238 RR CR $181.16 $181.16 $181.16 $181.16 $181.16 $181.16E1240 RR CR $113.89 $113.89 $102.42 $96.81 $113.89 $96.81E1270 RR CR $74.18 $87.27 $83.53 $74.18 $87.27 $85.37E1280 RR CR $145.10 $123.34 $145.10 $123.34 $126.39 $123.34E1295 RR CR $114.14 $114.14 $134.28 $114.14 $134.28 $114.14E1296 NU IN $543.53 $543.53 $543.53 $543.53 $543.53 $543.53E1296 RR IN $55.22 $55.22 $55.22 $55.22 $55.22 $55.22E1296 UE IN $407.65 $407.65 $407.65 $407.65 $407.65 $407.65





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



E1297 NU IN $115.65 $115.65 $115.65 $115.65 $115.65 $115.65E1297 RR IN $12.85 $12.85 $12.85 $12.85 $12.85 $12.85E1297 UE IN $86.72 $86.72 $86.72 $86.72 $86.72 $86.72E1298 NU IN $468.36 $468.36 $398.11 $415.65 $468.36 $468.36E1298 RR IN $47.92 $47.92 $40.73 $41.57 $47.92 $47.92E1298 UE IN $351.26 $351.26 $298.57 $311.74 $351.26 $351.26E1310 NU IN $2,017.87 $2,373.97 $2,373.97 $2,017.87 $2,373.97 $2,373.97E1310 RR IN $172.58 $203.04 $203.04 $172.58 $203.04 $203.04E1310 UE IN $1,513.42 $1,780.49 $1,780.49 $1,513.42 $1,780.49 $1,780.49E1353 OX $31.31 $31.31 $31.31 $31.31 $31.31 $31.31E1355 OX $23.59 $23.59 $23.59 $23.59 $23.59 $23.59E1372 NU IN $140.05 R $141.96 $153.56 R $155.48 $152.95 R $155.48 $140.05 R $141.96 $140.05 R $141.96 $153.56 R $155.48E1372 RR IN $17.48 R $17.67 $19.44 R $19.63 $19.38 R $19.63 $17.48 R $17.67 $17.48 R $17.67 $19.44 R $19.63E1372 UE IN $104.29 R $105.73 $114.29 R $115.73 $113.83 R $115.73 $104.29 R $105.73 $104.29 R $105.73 $114.29 R $115.73E1390 RR OX $126.67 R $129.37 $126.67 R $129.37 $125.73 R $129.37 $126.67 R $129.37 $126.67 R $129.37 $126.67 R $129.37E1391 RR OX $126.67 R $129.37 $126.67 R $129.37 $125.73 R $129.37 $126.67 R $129.37 $126.67 R $129.37 $126.67 R $129.37E1392 RR OX $44.71 R $46.90 $44.71 R $46.90 $45.61 R $46.90 $44.71 R $46.90 $44.71 R $46.90 $44.71 R $46.90E1405 RR OX $157.67 R $160.96 $160.58 R $163.87 $159.05 R $163.87 $159.91 R $163.19 $157.67 R $160.96 $160.58 R $163.87E1406 RR OX $138.62 R $141.44 $138.62 R $141.44 $137.42 R $141.44 $138.61 R $141.44 $138.61 R $141.44 $138.62 R $141.44E1700 RR CR $38.13 $32.41 $35.91 $38.13 $38.13 $32.41E1701 SU $11.72 $11.72 $11.72 $11.14 $11.14 $11.72E1702 SU $24.63 $21.21 $24.95 $22.36 $22.36 $21.21E1800 RR CR $115.12 $115.12 $115.12 $115.12 $115.12 $115.12E1801 RR CR $139.67 $142.62 $142.62 $130.55 $138.35 $140.10E1802 RR CR $361.29 $361.29 $361.29 $361.29 $361.29 $361.29E1805 RR CR $118.73 $118.73 $118.73 $118.73 $118.73 $118.73E1806 RR CR $114.62 $117.10 $117.10 $107.16 $113.57 $115.00E1810 RR CR $117.07 $117.07 $117.07 $117.07 $117.07 $117.07E1811 RR CR $145.21 $148.27 $148.27 $135.74 $143.84 $145.67E1812 RR CR $95.06 $95.06 $95.06 $95.06 $95.06 $95.06E1815 RR CR $118.73 $118.73 $118.73 $118.73 $118.73 $118.73E1816 RR CR $147.49 $150.62 $150.62 $137.87 $146.08 $147.97E1818 RR CR $150.56 $153.76 $153.76 $140.77 $149.12 $151.04E1820 NU IN $90.37 $90.37 $90.37 $90.37 $90.37 $90.37E1820 RR IN $9.03 $9.03 $9.03 $9.03 $9.03 $9.03E1820 UE IN $67.79 $67.79 $67.79 $67.79 $67.79 $67.79E1821 NU IN $116.35 $116.35 $116.35 $116.35 $116.35 $116.35E1821 RR IN $11.61 $11.61 $11.61 $11.61 $11.61 $11.61E1821 UE IN $87.29 $87.29 $87.29 $87.29 $87.29 $87.29E1825 RR CR $118.73 $118.73 $118.73 $118.73 $118.73 $118.73E1830 RR CR $118.73 $118.73 $118.73 $118.73 $118.73 $118.73E1831 RR CR $73.05 $73.05 $73.05 $70.25 $73.05 $73.05E1840 RR CR $402.56 $420.19 $423.09 $401.52 $409.10 $395.29E1841 RR CR $500.78 $500.78 $500.78 $500.78 $500.78 $500.78E2000 RR CR $56.09 $57.30 $57.30 $52.43 $55.56 $56.28E2100 NU IN $604.38 $711.04 $667.29 $604.38 $604.38 $711.04E2100 RR IN $60.44 $71.11 $60.44 $60.44 $60.44 $71.11E2100 UE IN $453.30 $533.29 $453.30 $453.30 $453.30 $533.29E2101 NU IN $208.45 $208.45 $208.45 $208.45 $208.45 $208.45E2101 RR IN $20.84 $20.84 $20.84 $20.84 $20.84 $20.84E2101 UE IN $156.34 $156.34 $156.34 $156.34 $156.34 $156.34E2120 RR CR $313.44 $313.44 $313.44 $313.44 $313.44 $313.44E2201 NU IN $359.72 R $367.19 $359.72 R $367.19 $362.24 R $367.19 $359.72 R $367.19 $359.72 R $367.19 $359.72 R $367.19E2201 RR IN $35.97 R $36.72 $35.97 R $36.72 $36.22 R $36.72 $35.97 R $36.72 $35.97 R $36.72 $35.97 R $36.72E2201 UE IN $269.78 R $275.39 $269.78 R $275.39 $271.68 R $275.39 $269.78 R $275.39 $269.78 R $275.39 $269.78 R $275.39E2202 NU IN $475.32 R $494.14 $475.32 R $494.14 $494.14 R $494.14 $475.32 R $494.14 $475.32 R $494.14 $475.32 R $494.14E2202 RR IN $47.53 R $49.42 $47.53 R $49.42 $49.42 R $49.42 $47.53 R $49.42 $47.53 R $49.42 $47.53 R $49.42E2202 UE IN $356.50 R $370.62 $356.50 R $370.62 $370.62 R $370.62 $356.50 R $370.62 $356.50 R $370.62 $356.50 R $370.62E2203 NU IN $472.09 R $483.75 $472.09 R $483.75 $465.29 R $483.75 $472.09 R $483.75 $472.09 R $483.75 $472.09 R $483.75E2203 RR IN $47.20 R $48.37 $47.20 R $48.37 $46.52 R $48.37 $47.20 R $48.37 $47.20 R $48.37 $47.20 R $48.37E2203 UE IN $354.05 R $362.80 $354.05 R $362.80 $348.96 R $362.80 $354.05 R $362.80 $354.05 R $362.80 $354.05 R $362.80





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



E2204 NU IN $807.55 R $831.69 $807.55 R $831.69 $801.56 R $831.69 $807.55 R $831.69 $807.55 R $831.69 $807.55 R $831.69E2204 RR IN $80.76 R $83.17 $80.76 R $83.17 $80.16 R $83.17 $80.76 R $83.17 $80.76 R $83.17 $80.76 R $83.17E2204 UE IN $605.66 R $623.77 $605.66 R $623.77 $601.17 R $623.77 $605.66 R $623.77 $605.66 R $623.77 $605.66 R $623.77E2205 NU IN $34.66 R $36.11 $34.66 R $36.11 $34.23 R $36.11 $34.66 R $36.11 $34.66 R $36.11 $34.66 R $36.11E2205 RR IN $3.46 R $3.60 $3.46 R $3.60 $3.42 R $3.60 $3.46 R $3.60 $3.46 R $3.60 $3.46 R $3.60E2205 UE IN $26.01 R $27.11 $26.01 R $27.11 $25.69 R $27.11 $26.01 R $27.11 $26.01 R $27.11 $26.01 R $27.11E2206 NU IN $40.69 R $42.36 $40.69 R $42.36 $41.88 R $42.36 $40.69 R $42.36 $40.69 R $42.36 $40.69 R $42.36E2206 RR IN $4.06 R $4.23 $4.06 R $4.23 $4.18 R $4.23 $4.06 R $4.23 $4.06 R $4.23 $4.06 R $4.23E2206 UE IN $30.52 R $31.77 $30.52 R $31.77 $31.41 R $31.77 $30.52 R $31.77 $30.52 R $31.77 $30.52 R $31.77E2207 NU KU IN $47.92 $47.92 $47.92 $47.92 $47.92 $47.92E2207 NU IN $44.99 R $47.69 $44.99 R $47.69 $45.57 R $47.69 $44.99 R $47.69 $44.99 R $47.69 $44.99 R $47.69E2207 RR KU IN $4.81 $4.81 $4.81 $4.81 $4.81 $4.81E2207 RR IN $4.51 R $4.78 $4.51 R $4.78 $4.57 R $4.78 $4.51 R $4.78 $4.51 R $4.78 $4.51 R $4.78E2207 UE KU IN $35.95 $35.95 $35.95 $35.95 $35.95 $35.95E2207 UE IN $33.75 R $35.77 $33.75 R $35.77 $34.18 R $35.77 $33.75 R $35.77 $33.75 R $35.77 $33.75 R $35.77E2208 NU KE IN $104.45 R $105.82 $104.45 R $105.82 $102.55 R $105.82 $104.45 R $105.82 $104.45 R $105.82 $104.45 R $105.82E2208 NU KU IN $113.19 $113.19 $113.19 $113.19 $113.19 $113.19E2208 NU IN $95.38 R $96.75 $95.38 R $96.75 $93.48 R $96.75 $95.38 R $96.75 $95.38 R $96.75 $95.38 R $96.75E2208 RR KE IN $10.44 R $10.58 $10.44 R $10.58 $10.25 R $10.58 $10.44 R $10.58 $10.44 R $10.58 $10.44 R $10.58E2208 RR KU IN $11.31 $11.31 $11.31 $11.31 $11.31 $11.31E2208 RR IN $9.54 R $9.67 $9.54 R $9.67 $9.35 R $9.67 $9.54 R $9.67 $9.54 R $9.67 $9.54 R $9.67E2208 UE KE IN $78.33 R $79.36 $78.33 R $79.36 $76.91 R $79.36 $78.33 R $79.36 $78.33 R $79.36 $78.33 R $79.36E2208 UE KU IN $84.89 $84.89 $84.89 $84.89 $84.89 $84.89E2208 UE IN $71.54 R $72.56 $71.54 R $72.56 $70.11 R $72.56 $71.54 R $72.56 $71.54 R $72.56 $71.54 R $72.56E2209 NU KE IN $98.67 R $102.94 $98.67 R $102.94 $98.30 R $102.94 $98.67 R $102.94 $98.67 R $102.94 $98.67 R $102.94E2209 NU KU IN $102.11 $102.11 $102.11 $102.11 $102.11 $102.11E2209 NU IN $90.49 R $94.76 $90.49 R $94.76 $90.12 R $94.76 $90.49 R $94.76 $90.49 R $94.76 $90.49 R $94.76E2209 RR KE IN $9.89 R $10.31 $9.89 R $10.31 $9.85 R $10.31 $9.89 R $10.31 $9.89 R $10.31 $9.89 R $10.31E2209 RR KU IN $10.23 $10.23 $10.23 $10.23 $10.23 $10.23E2209 RR IN $9.06 R $9.49 $9.06 R $9.49 $9.02 R $9.49 $9.06 R $9.49 $9.06 R $9.49 $9.06 R $9.49E2209 UE KE IN $74.01 R $77.21 $74.01 R $77.21 $73.73 R $77.21 $74.01 R $77.21 $74.01 R $77.21 $74.01 R $77.21E2209 UE KU IN $76.59 $76.59 $76.59 $76.59 $76.59 $76.59E2209 UE IN $67.87 R $71.08 $67.87 R $71.08 $67.60 R $71.08 $67.87 R $71.08 $67.87 R $71.08 $67.87 R $71.08E2210 NU KE IN $6.13 R $6.40 $6.13 R $6.40 $6.37 R $6.40 $6.13 R $6.40 $6.13 R $6.40 $6.13 R $6.40E2210 NU KU IN $6.23 $6.23 $6.23 $6.23 $6.23 $6.23E2210 NU IN $5.63 R $5.89 $5.63 R $5.89 $5.87 R $5.89 $5.63 R $5.89 $5.63 R $5.89 $5.63 R $5.89E2210 RR KE IN $0.62 R $0.65 $0.62 R $0.65 $0.64 R $0.65 $0.62 R $0.65 $0.62 R $0.65 $0.62 R $0.65E2210 RR KU IN $0.63 $0.63 $0.63 $0.63 $0.63 $0.63E2210 RR IN $0.56 R $0.59 $0.56 R $0.59 $0.59 R $0.59 $0.56 R $0.59 $0.56 R $0.59 $0.56 R $0.59E2210 UE KE IN $4.60 R $4.80 $4.60 R $4.80 $4.78 R $4.80 $4.60 R $4.80 $4.60 R $4.80 $4.60 R $4.80E2210 UE KU IN $4.70 $4.70 $4.70 $4.70 $4.70 $4.70E2210 UE IN $4.23 R $4.43 $4.23 R $4.43 $4.41 R $4.43 $4.23 R $4.43 $4.23 R $4.43 $4.23 R $4.43E2211 NU IN $35.64 R $36.98 $35.76 R $37.10 $38.24 R $40.35 $39.02 R $40.35 $36.63 R $37.97 $36.30 R $37.64E2211 RR IN $3.86 R $3.99 $3.52 R $3.66 $3.78 R $3.99 $3.86 R $3.99 $3.65 R $3.79 $3.63 R $3.77E2211 UE IN $26.07 R $27.07 $26.82 R $27.82 $27.92 R $29.50 $28.50 R $29.50 $26.53 R $27.53 $27.22 R $28.22E2212 NU IN $6.15 R $6.48 $6.15 R $6.48 $6.18 R $6.48 $6.15 R $6.48 $6.15 R $6.48 $6.15 R $6.48E2212 RR IN $0.63 R $0.67 $0.63 R $0.67 $0.64 R $0.67 $0.63 R $0.67 $0.63 R $0.67 $0.63 R $0.67E2212 UE IN $4.62 R $4.87 $4.62 R $4.87 $4.65 R $4.87 $4.62 R $4.87 $4.62 R $4.87 $4.62 R $4.87E2213 NU IN $30.79 R $32.31 $30.79 R $32.31 $30.81 R $32.31 $30.79 R $32.31 $30.79 R $32.31 $30.79 R $32.31E2213 RR IN $3.09 R $3.24 $3.09 R $3.24 $3.09 R $3.24 $3.09 R $3.24 $3.09 R $3.24 $3.09 R $3.24E2213 UE IN $23.09 R $24.23 $23.09 R $24.23 $23.10 R $24.23 $23.08 R $24.22 $23.09 R $24.23 $23.09 R $24.23E2214 NU IN $31.73 R $33.83 $34.71 R $36.96 $35.80 R $36.96 $31.73 R $33.83 $31.73 R $33.83 $34.71 R $36.96E2214 RR IN $3.67 R $3.89 $3.67 R $3.89 $3.78 R $3.89 $3.34 R $3.56 $3.34 R $3.56 $3.67 R $3.89E2214 UE IN $24.62 R $26.31 $26.02 R $27.71 $26.84 R $27.71 $23.79 R $25.36 $23.79 R $25.36 $26.02 R $27.71E2215 NU IN $10.08 R $10.61 $10.08 R $10.61 $10.18 R $10.61 $10.08 R $10.61 $10.08 R $10.61 $10.08 R $10.61E2215 RR IN $1.01 R $1.06 $1.01 R $1.06 $1.02 R $1.06 $1.01 R $1.06 $1.01 R $1.06 $1.01 R $1.06E2215 UE IN $7.55 R $7.94 $7.55 R $7.94 $7.63 R $7.94 $7.55 R $7.94 $7.55 R $7.94 $7.55 R $7.94E2219 NU IN $38.54 R $39.32 $42.02 R $44.18 $39.15 R $40.03 $38.54 R $39.32 $42.02 R $44.18 $42.02 R $44.18E2219 RR IN $4.50 R $4.72 $4.50 R $4.72 $4.14 R $4.33 $4.11 R $4.33 $4.50 R $4.72 $4.50 R $4.72E2219 UE IN $28.91 R $29.49 $31.51 R $33.14 $29.37 R $30.03 $28.91 R $29.49 $31.51 R $33.14 $31.51 R $33.14E2220 NU IN $26.81 R $26.81 $29.86 R $30.97 $29.88 R $30.97 $29.86 R $30.97 $29.86 R $30.97 $29.86 R $30.97





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



E2220 RR IN $2.87 R $2.93 $2.93 R $3.04 $2.94 R $3.04 $2.93 R $3.04 $2.93 R $3.04 $2.93 R $3.04E2220 UE IN $21.25 R $21.36 $22.63 R $23.46 $22.64 R $23.46 $22.63 R $23.46 $22.63 R $23.46 $22.63 R $23.46E2221 NU IN $26.63 R $27.97 $26.63 R $27.97 $26.68 R $27.97 $26.63 R $27.97 $26.63 R $27.97 $26.63 R $27.97E2221 RR IN $2.68 R $2.81 $2.68 R $2.81 $2.69 R $2.81 $2.68 R $2.81 $2.68 R $2.81 $2.68 R $2.81E2221 UE IN $19.98 R $20.98 $19.98 R $20.98 $20.01 R $20.98 $19.98 R $20.98 $19.98 R $20.98 $19.98 R $20.98E2222 NU IN $22.23 R $23.19 $22.23 R $23.19 $21.97 R $23.19 $22.23 R $23.19 $22.23 R $23.19 $22.23 R $23.19E2222 RR IN $2.21 R $2.30 $2.21 R $2.30 $2.18 R $2.30 $2.21 R $2.30 $2.21 R $2.30 $2.21 R $2.30E2222 UE IN $16.68 R $17.40 $16.68 R $17.40 $16.48 R $17.40 $16.68 R $17.40 $16.68 R $17.40 $16.68 R $17.40E2224 NU IN $91.00 R $92.14 $99.13 R $103.35 $99.18 R $103.35 $99.13 R $103.35 $91.00 R $92.14 $92.03 R $94.20E2224 RR IN $9.33 R $9.67 $10.18 R $10.60 $10.18 R $10.60 $10.18 R $10.60 $9.33 R $9.67 $9.33 R $9.67E2224 UE IN $68.25 R $69.11 $74.35 R $77.52 $74.39 R $77.52 $74.35 R $77.52 $68.25 R $69.11 $69.02 R $70.66E2225 NU IN $18.30 R $19.24 $18.30 R $19.24 $18.53 R $19.24 $18.30 R $19.24 $18.30 R $19.24 $18.30 R $19.24E2225 RR IN $1.83 R $1.92 $1.83 R $1.92 $1.85 R $1.92 $1.83 R $1.92 $1.83 R $1.92 $1.83 R $1.92E2225 UE IN $13.72 R $14.41 $13.72 R $14.41 $13.89 R $14.41 $13.72 R $14.41 $13.72 R $14.41 $13.72 R $14.41E2226 NU IN $39.49 R $41.50 $39.49 R $41.50 $39.44 R $41.50 $39.49 R $41.50 $39.49 R $41.50 $39.49 R $41.50E2226 RR IN $3.95 R $4.15 $3.95 R $4.15 $3.94 R $4.15 $3.95 R $4.15 $3.95 R $4.15 $3.95 R $4.15E2226 UE IN $29.62 R $31.13 $29.62 R $31.13 $29.58 R $31.13 $29.62 R $31.13 $29.62 R $31.13 $29.62 R $31.13E2227 RR CR $206.82 $206.82 $206.82 $198.84 $206.82 $206.82E2228 RR CR $96.60 R $101.28 $96.60 R $101.28 $96.19 R $101.28 $96.60 R $101.28 $96.60 R $101.28 $96.60 R $101.28E2231 NU IN $152.73 R $157.26 $152.73 R $157.26 $151.61 R $157.26 $152.73 R $157.26 $152.73 R $157.26 $152.73 R $157.26E2231 RR IN $15.27 R $15.73 $15.27 R $15.73 $15.16 R $15.73 $15.27 R $15.73 $15.27 R $15.73 $15.27 R $15.73E2231 UE IN $114.55 R $117.94 $114.55 R $117.94 $113.71 R $117.94 $114.55 R $117.94 $114.55 R $117.94 $114.55 R $117.94E2310 RR KE CR $114.87 $114.87 $114.87 $114.87 $114.87 $114.87E2310 RR KU CR $111.49 $111.49 $111.49 $111.49 $111.49 $111.49E2310 RR CR $105.93 $105.93 $105.93 $105.93 $105.93 $105.93E2311 RR KE CR $232.23 $232.23 $232.23 $232.23 $232.23 $232.23E2311 RR KU CR $225.75 $225.75 $225.75 $225.75 $225.75 $225.75E2311 RR CR $214.14 $214.14 $214.14 $214.14 $214.14 $214.14E2312 RR KC CR $284.33 $284.33 $284.33 $273.43 $284.33 $284.33E2312 RR CR $222.94 $222.94 $222.94 $214.39 $222.94 $222.94E2313 RR CR $35.43 $35.43 $35.43 $34.06 $35.43 $35.43E2321 RR KC CR $234.38 $234.38 $234.38 $234.38 $234.38 $234.38E2321 RR KE CR $156.03 $156.03 $156.03 $156.03 $156.03 $156.03E2321 RR KU CR $246.66 $246.66 $246.66 $246.66 $246.66 $246.66E2321 RR CR $143.90 $143.90 $143.90 $143.90 $143.90 $143.90E2322 RR KC CR $255.80 $255.80 $255.80 $255.80 $255.80 $255.80E2322 RR KE CR $142.37 $142.37 $142.37 $142.37 $142.37 $142.37E2322 RR KU CR $261.19 $261.19 $261.19 $261.19 $261.19 $261.19E2322 RR CR $131.60 $131.60 $131.60 $131.60 $131.60 $131.60E2323 NU KE IN $69.63 $69.63 $69.63 $69.63 $69.63 $69.63E2323 NU KU IN $65.91 $65.91 $65.91 $65.91 $65.91 $65.91E2323 NU IN $64.35 $64.35 $64.35 $64.35 $64.35 $64.35E2323 RR KE IN $6.96 $6.96 $6.96 $6.96 $6.96 $6.96E2323 RR KU IN $6.58 $6.58 $6.58 $6.58 $6.58 $6.58E2323 RR IN $6.43 $6.43 $6.43 $6.43 $6.43 $6.43E2323 UE KE IN $52.22 $52.22 $52.22 $52.22 $52.22 $52.22E2323 UE KU IN $49.41 $49.41 $49.41 $49.41 $49.41 $49.41E2323 UE IN $48.26 $48.26 $48.26 $48.26 $48.26 $48.26E2324 NU KE IN $44.95 $44.95 $44.95 $44.95 $44.95 $44.95E2324 NU KU IN $41.75 $41.75 $41.75 $41.75 $41.75 $41.75E2324 NU IN $41.61 $41.61 $41.61 $41.61 $41.61 $41.61E2324 RR KE IN $4.49 $4.49 $4.49 $4.49 $4.49 $4.49E2324 RR KU IN $4.15 $4.15 $4.15 $4.15 $4.15 $4.15E2324 RR IN $4.15 $4.15 $4.15 $4.15 $4.15 $4.15E2324 UE KE IN $33.72 $33.72 $33.72 $33.72 $33.72 $33.72E2324 UE KU IN $31.31 $31.31 $31.31 $31.31 $31.31 $31.31E2324 UE IN $31.20 $31.20 $31.20 $31.20 $31.20 $31.20E2325 RR KE CR $136.03 $136.03 $136.03 $136.03 $136.03 $136.03E2325 RR KU CR $128.34 $128.34 $128.34 $128.34 $128.34 $128.34E2325 RR CR $125.74 $125.74 $125.74 $125.74 $125.74 $125.74E2326 RR KE CR $35.35 $35.35 $35.35 $35.35 $35.35 $35.35





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



E2326 RR KU CR $33.09 $33.09 $33.09 $33.09 $33.09 $33.09E2326 RR CR $32.69 $32.69 $32.69 $32.69 $32.69 $32.69E2327 RR KC CR $372.04 $372.04 $372.04 $372.04 $372.04 $372.04E2327 RR KE CR $264.83 $264.83 $264.83 $264.83 $264.83 $264.83E2327 RR KU CR $378.16 $378.16 $378.16 $378.16 $378.16 $378.16E2327 RR CR $244.88 $244.88 $244.88 $244.88 $244.88 $244.88E2328 RR KE CR $501.21 $501.21 $501.21 $501.21 $501.21 $501.21E2328 RR KU CR $472.15 $472.15 $472.15 $472.15 $472.15 $472.15E2328 RR CR $463.38 $463.38 $463.38 $463.38 $463.38 $463.38E2329 RR KE CR $179.71 $179.71 $179.71 $179.71 $179.71 $179.71E2329 RR KU CR $168.28 $168.28 $168.28 $168.28 $168.28 $168.28E2329 RR CR $166.22 $166.22 $166.22 $166.22 $166.22 $166.22E2330 RR KE CR $346.75 $346.75 $346.75 $346.75 $346.75 $346.75E2330 RR KU CR $326.06 $326.06 $326.06 $326.06 $326.06 $326.06E2330 RR CR $320.63 $320.63 $320.63 $320.63 $320.63 $320.63E2340 NU IN $396.17 $396.17 $396.17 $396.17 $396.17 $396.17E2340 RR IN $39.63 $39.63 $39.63 $39.63 $39.63 $39.63E2340 UE IN $297.16 $297.16 $297.16 $297.16 $297.16 $297.16E2341 NU IN $594.30 $594.30 $594.30 $594.30 $594.30 $594.30E2341 RR IN $59.42 $59.42 $59.42 $59.42 $59.42 $59.42E2341 UE IN $445.73 $445.73 $445.73 $445.73 $445.73 $445.73E2342 NU IN $495.25 $495.25 $495.25 $495.25 $495.25 $495.25E2342 RR IN $49.52 $49.52 $49.52 $49.52 $49.52 $49.52E2342 UE IN $371.45 $371.45 $371.45 $371.45 $371.45 $371.45E2343 NU IN $792.41 $792.41 $792.41 $792.41 $792.41 $792.41E2343 RR IN $79.23 $79.23 $79.23 $79.23 $79.23 $79.23E2343 UE IN $594.30 $594.30 $594.30 $594.30 $594.30 $594.30E2351 NU KE IN $712.77 $712.77 $712.77 $712.77 $712.77 $712.77E2351 NU KU IN $665.69 $665.69 $665.69 $665.69 $665.69 $665.69E2351 NU IN $659.43 $659.43 $659.43 $659.43 $659.43 $659.43E2351 RR KE IN $71.28 $71.28 $71.28 $71.28 $71.28 $71.28E2351 RR KU IN $66.59 $66.59 $66.59 $66.59 $66.59 $66.59E2351 RR IN $65.94 $65.94 $65.94 $65.94 $65.94 $65.94E2351 UE KE IN $534.58 $534.58 $534.58 $534.58 $534.58 $534.58E2351 UE KU IN $499.25 $499.25 $499.25 $499.25 $499.25 $499.25E2351 UE IN $494.58 $494.58 $494.58 $494.58 $494.58 $494.58E2359 NU KU IN $192.52 $192.52 $192.52 $185.09 $192.52 $192.52E2359 NU IN $175.72 R $183.39 $175.72 R $183.39 $174.94 R $183.39 $172.01 R $179.67 $175.72 R $183.39 $175.72 R $183.39E2359 RR KU IN $19.26 $19.26 $19.26 $18.51 $19.26 $19.26E2359 RR IN $17.58 R $18.34 $17.58 R $18.34 $17.50 R $18.34 $17.20 R $17.97 $17.58 R $18.34 $17.58 R $18.34E2359 UE KU IN $144.37 $144.37 $144.37 $138.82 $144.37 $144.37E2359 UE IN $131.78 R $137.53 $131.78 R $137.53 $131.20 R $137.53 $129.01 R $134.76 $131.78 R $137.53 $131.78 R $137.53E2360 NU KU IN $105.57 $105.57 $124.20 $124.20 $105.57 $124.20E2360 NU IN $100.92 R $105.58 $100.92 R $105.58 $109.98 R $115.47 $110.23 R $115.47 $100.92 R $105.58 $110.23 R $115.47E2360 RR KU IN $10.61 $10.61 $12.48 $12.48 $10.61 $12.48E2360 RR IN $10.12 R $10.61 $10.12 R $10.61 $11.03 R $11.58 $11.05 R $11.58 $10.12 R $10.61 $11.05 R $11.58E2360 UE KU IN $79.17 $79.17 $93.14 $93.14 $79.17 $93.14E2360 UE IN $75.68 R $79.16 $75.68 R $79.16 $82.48 R $86.60 $82.67 R $86.60 $75.68 R $79.16 $82.67 R $86.60E2361 NU KE IN $131.05 R $136.75 $131.05 R $136.75 $129.92 R $136.75 $131.05 R $136.75 $131.05 R $136.75 $131.05 R $136.75E2361 NU KU IN $132.89 $132.89 $132.89 $132.89 $132.89 $132.89E2361 NU IN $120.40 R $126.11 $120.40 R $126.11 $119.27 R $126.11 $120.40 R $126.11 $120.40 R $126.11 $120.40 R $126.11E2361 RR KE IN $13.11 R $13.68 $13.11 R $13.68 $13.00 R $13.68 $13.11 R $13.68 $13.11 R $13.68 $13.11 R $13.68E2361 RR KU IN $13.29 $13.29 $13.29 $13.29 $13.29 $13.29E2361 RR IN $12.04 R $12.61 $12.04 R $12.61 $11.93 R $12.61 $12.04 R $12.61 $12.04 R $12.61 $12.04 R $12.61E2361 UE KE IN $98.30 R $102.58 $98.30 R $102.58 $97.45 R $102.58 $98.30 R $102.58 $98.30 R $102.58 $98.30 R $102.58E2361 UE KU IN $99.69 $99.69 $99.69 $99.69 $99.69 $99.69E2361 UE IN $90.31 R $94.59 $90.31 R $94.59 $89.47 R $94.59 $90.31 R $94.59 $90.31 R $94.59 $90.31 R $94.59E2362 NU KU IN $101.69 $101.69 $101.69 $101.69 $101.69 $101.69E2362 NU IN $94.90 R $99.42 $94.90 R $99.42 $93.97 R $99.42 $94.90 R $99.42 $94.90 R $99.42 $94.90 R $99.42E2362 RR KU IN $10.17 $10.17 $10.17 $10.17 $10.17 $10.17E2362 RR IN $9.49 R $9.94 $9.49 R $9.94 $9.40 R $9.94 $9.49 R $9.94 $9.49 R $9.94 $9.49 R $9.94





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



E2362 UE KU IN $76.26 $76.26 $76.26 $76.26 $76.26 $76.26E2362 UE IN $71.17 R $74.56 $71.17 R $74.56 $70.48 R $74.56 $71.17 R $74.56 $71.17 R $74.56 $71.17 R $74.56E2363 NU KE IN $172.31 R $178.06 $172.31 R $178.06 $170.52 R $178.06 $172.31 R $178.06 $172.31 R $178.06 $172.31 R $178.06E2363 NU KU IN $177.24 $177.24 $177.24 $177.24 $177.24 $177.24E2363 NU IN $158.12 R $163.87 $158.12 R $163.87 $156.33 R $163.87 $158.12 R $163.87 $158.12 R $163.87 $158.12 R $163.87E2363 RR KE IN $17.24 R $17.81 $17.24 R $17.81 $17.06 R $17.81 $17.24 R $17.81 $17.24 R $17.81 $17.24 R $17.81E2363 RR KU IN $17.72 $17.72 $17.72 $17.72 $17.72 $17.72E2363 RR IN $15.81 R $16.38 $15.81 R $16.38 $15.63 R $16.38 $15.81 R $16.38 $15.81 R $16.38 $15.81 R $16.38E2363 UE KE IN $129.24 R $133.55 $129.24 R $133.55 $127.90 R $133.55 $129.24 R $133.55 $129.24 R $133.55 $129.24 R $133.55E2363 UE KU IN $132.92 $132.92 $132.92 $132.92 $132.92 $132.92E2363 UE IN $118.59 R $122.90 $118.59 R $122.90 $117.24 R $122.90 $118.59 R $122.90 $118.59 R $122.90 $118.59 R $122.90E2364 NU KU IN $105.57 $105.57 $124.20 $124.20 $105.57 $124.20E2364 NU IN $99.25 R $104.25 $99.25 R $104.25 $108.19 R $113.57 $108.56 R $113.57 $99.25 R $104.25 $108.56 R $113.57E2364 RR KU IN $10.61 $10.61 $12.48 $12.48 $10.61 $12.48E2364 RR IN $9.95 R $10.45 $9.95 R $10.45 $10.85 R $11.39 $10.89 R $11.39 $9.95 R $10.45 $10.89 R $11.39E2364 UE KU IN $79.17 $79.17 $93.14 $93.14 $79.17 $93.14E2364 UE IN $74.43 R $78.18 $74.43 R $78.18 $81.13 R $85.17 $81.41 R $85.17 $74.43 R $78.18 $81.41 R $85.17E2365 NU KE IN $99.24 R $102.11 $99.24 R $102.11 $98.45 R $102.11 $99.24 R $102.11 $99.24 R $102.11 $99.24 R $102.11E2365 NU KU IN $106.88 $106.88 $106.88 $106.88 $106.88 $106.88E2365 NU IN $90.68 R $93.55 $90.68 R $93.55 $89.89 R $93.55 $90.68 R $93.55 $90.68 R $93.55 $90.68 R $93.55E2365 RR KE IN $9.92 R $10.21 $9.92 R $10.21 $9.85 R $10.21 $9.92 R $10.21 $9.92 R $10.21 $9.92 R $10.21E2365 RR KU IN $10.68 $10.68 $10.68 $10.68 $10.68 $10.68E2365 RR IN $9.06 R $9.35 $9.06 R $9.35 $8.99 R $9.35 $9.06 R $9.35 $9.06 R $9.35 $9.06 R $9.35E2365 UE KE IN $74.44 R $76.60 $74.44 R $76.60 $73.85 R $76.60 $74.44 R $76.60 $74.44 R $76.60 $74.44 R $76.60E2365 UE KU IN $80.19 $80.19 $80.19 $80.19 $80.19 $80.19E2365 UE IN $68.02 R $70.18 $68.02 R $70.18 $67.43 R $70.18 $68.02 R $70.18 $68.02 R $70.18 $68.02 R $70.18E2366 NU KE IN $225.56 R $227.78 $225.56 R $227.78 $216.27 R $227.78 $225.56 R $227.78 $203.70 R $205.92 $225.56 R $227.78E2366 NU KU IN $251.19 $251.19 $251.19 $251.19 $213.51 $251.19E2366 NU IN $205.44 R $207.66 $205.44 R $207.66 $196.15 R $207.66 $205.44 R $207.66 $186.60 R $188.82 $205.44 R $207.66E2366 RR KE IN $22.60 R $22.82 $22.60 R $22.82 $19.48 R $20.63 $22.60 R $22.82 $20.40 R $20.63 $22.60 R $22.82E2366 RR KU IN $25.19 $25.19 $21.41 $25.19 $21.41 $25.19E2366 RR IN $20.58 R $20.80 $20.58 R $20.80 $17.76 R $18.91 $20.58 R $20.80 $18.69 R $18.91 $20.58 R $20.80E2366 UE KE IN $155.76 R $157.43 $169.17 R $170.84 $162.21 R $170.84 $169.17 R $170.84 $152.78 R $154.45 $169.17 R $170.84E2366 UE KU IN $165.26 $188.40 $188.40 $188.40 $160.14 $188.40E2366 UE IN $142.51 R $144.18 $154.08 R $155.75 $147.12 R $155.75 $154.08 R $155.75 $139.95 R $141.62 $154.08 R $155.75E2367 NU KE IN $380.45 R $399.06 $380.45 R $399.06 $384.90 R $399.06 $380.45 R $399.06 $380.45 R $399.06 $380.45 R $399.06E2367 NU KU IN $399.31 $399.31 $399.31 $399.31 $399.31 $399.31E2367 NU IN $348.46 R $367.07 $348.46 R $367.07 $352.91 R $367.07 $348.46 R $367.07 $348.46 R $367.07 $348.46 R $367.07E2367 RR KE IN $38.05 R $39.91 $38.05 R $39.91 $38.50 R $39.91 $38.05 R $39.91 $38.05 R $39.91 $38.05 R $39.91E2367 RR KU IN $39.93 $39.93 $39.93 $39.93 $39.93 $39.93E2367 RR IN $34.85 R $36.71 $34.85 R $36.71 $35.29 R $36.71 $34.85 R $36.71 $34.85 R $36.71 $34.85 R $36.71E2367 UE KE IN $285.34 R $299.30 $285.34 R $299.30 $288.68 R $299.30 $285.34 R $299.30 $285.34 R $299.30 $285.34 R $299.30E2367 UE KU IN $299.49 $299.49 $299.49 $299.49 $299.49 $299.49E2367 UE IN $261.35 R $275.31 $261.35 R $275.31 $264.69 R $275.31 $261.35 R $275.31 $261.35 R $275.31 $261.35 R $275.31E2368 RR KE CR $48.01 R $49.93 $48.01 R $49.93 $47.47 R $49.93 $48.01 R $49.93 $48.01 R $49.93 $48.01 R $49.93E2368 RR KU CR $49.22 $49.22 $49.22 $49.22 $49.22 $49.22E2368 RR CR $44.06 R $45.99 $44.06 R $45.99 $43.52 R $45.99 $44.06 R $45.99 $44.06 R $45.99 $44.06 R $45.99E2369 RR KE CR $42.98 R $44.98 $42.98 R $44.98 $43.63 R $44.98 $42.98 R $44.98 $42.98 R $44.98 $42.98 R $44.98E2369 RR KU CR $42.89 $42.89 $42.89 $42.89 $42.89 $42.89E2369 RR CR $39.54 R $41.55 $39.54 R $41.55 $40.20 R $41.55 $39.54 R $41.55 $39.54 R $41.55 $39.54 R $41.55E2370 RR KE CR $70.41 R $72.18 $70.41 R $72.18 $69.55 R $72.18 $70.41 R $72.18 $70.41 R $72.18 $70.41 R $72.18E2370 RR KU CR $76.50 $76.50 $76.50 $76.50 $76.50 $76.50E2370 RR CR $64.28 R $66.05 $64.28 R $66.05 $63.42 R $66.05 $64.28 R $66.05 $64.28 R $66.05 $64.28 R $66.05E2371 NU KE IN $148.60 R $155.80 $148.60 R $155.80 $149.76 R $155.80 $148.60 R $155.80 $148.60 R $155.80 $148.60 R $155.80E2371 NU KU IN $143.63 $143.63 $143.63 $143.63 $143.63 $143.63E2371 NU IN $137.10 R $143.63 $137.10 R $143.63 $138.26 R $143.63 $137.10 R $143.63 $137.10 R $143.63 $137.10 R $143.63E2371 RR KE IN $14.86 R $15.58 $14.86 R $15.58 $14.98 R $15.58 $14.86 R $15.58 $14.86 R $15.58 $14.86 R $15.58E2371 RR KU IN $14.37 $14.37 $14.37 $14.37 $14.37 $14.37E2371 RR IN $13.71 R $14.37 $13.71 R $14.37 $13.83 R $14.37 $13.71 R $14.37 $13.71 R $14.37 $13.71 R $14.37E2371 UE KE IN $111.45 R $116.85 $111.45 R $116.85 $112.32 R $116.85 $111.45 R $116.85 $111.45 R $116.85 $111.45 R $116.85E2371 UE KU IN $107.74 $107.74 $107.74 $107.74 $107.74 $107.74





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



E2371 UE IN $102.83 R $107.74 $102.83 R $107.74 $103.70 R $107.74 $102.83 R $107.74 $102.83 R $107.74 $102.83 R $107.74E2373 RR KC CR $116.36 $116.36 $116.36 $114.06 $116.36 $116.36E2373 RR KE CR $106.11 $106.11 $106.11 $103.44 $106.11 $106.11E2373 RR KU CR $119.90 $119.90 $119.90 $115.31 $119.90 $119.90E2373 RR CR $75.40 $75.40 $75.40 $73.93 $75.40 $75.40E2374 RR KE CR $52.64 $52.64 $52.64 $52.64 $52.64 $52.64E2374 RR KU CR $50.90 $50.90 $50.90 $50.90 $50.90 $50.90E2374 RR CR $48.57 $48.57 $48.57 $48.57 $48.57 $48.57E2375 RR KE CR $80.16 R $82.74 $80.16 R $82.74 $79.07 R $82.74 $80.16 R $82.74 $80.16 R $82.74 $80.16 R $82.74E2375 RR KU CR $81.60 $81.60 $81.60 $81.60 $81.60 $81.60E2375 RR CR $73.61 R $76.19 $73.61 R $76.19 $72.53 R $76.19 $73.61 R $76.19 $73.61 R $76.19 $73.61 R $76.19E2376 RR KE CR $131.64 $131.64 $131.64 $131.64 $131.64 $131.64E2376 RR KU CR $127.90 $127.90 $127.90 $127.90 $127.90 $127.90E2376 RR CR $121.39 $121.39 $121.39 $121.39 $121.39 $121.39E2377 RR KE CR $48.13 $48.13 $48.13 $48.13 $48.13 $48.13E2377 RR KU CR $46.27 $46.27 $46.27 $46.27 $46.27 $46.27E2377 RR CR $44.42 $44.42 $44.42 $44.42 $44.42 $44.42E2378 RR KU CR $56.57 $56.57 $56.57 $56.57 $56.57 $56.57E2378 RR CR $55.51 R $56.34 $55.51 R $56.34 $55.76 R $56.34 $55.51 R $56.34 $55.51 R $56.34 $55.51 R $56.34E2381 NU KE IN $70.67 R $73.72 $70.67 R $73.72 $71.50 R $73.72 $70.67 R $73.72 $70.67 R $73.72 $70.67 R $73.72E2381 NU KU IN $72.58 $72.58 $72.58 $72.58 $72.58 $72.58E2381 NU IN $64.85 R $67.90 $64.85 R $67.90 $65.68 R $67.90 $64.85 R $67.90 $64.85 R $67.90 $64.85 R $67.90E2381 RR KE IN $7.07 R $7.38 $7.07 R $7.38 $7.16 R $7.38 $7.07 R $7.38 $7.07 R $7.38 $7.07 R $7.38E2381 RR KU IN $7.28 $7.28 $7.28 $7.28 $7.28 $7.28E2381 RR IN $6.50 R $6.80 $6.50 R $6.80 $6.58 R $6.80 $6.50 R $6.80 $6.50 R $6.80 $6.50 R $6.80E2381 UE KE IN $53.01 R $55.30 $53.01 R $55.30 $53.63 R $55.30 $53.01 R $55.30 $53.01 R $55.30 $53.01 R $55.30E2381 UE KU IN $54.44 $54.44 $54.44 $54.44 $54.44 $54.44E2381 UE IN $48.65 R $50.93 $48.65 R $50.93 $49.27 R $50.93 $48.65 R $50.93 $48.65 R $50.93 $48.65 R $50.93E2382 NU KE IN $19.91 $19.91 $19.91 $19.91 $19.91 $19.91E2382 NU KU IN $19.78 $19.78 $19.78 $19.78 $19.78 $19.78E2382 NU IN $18.32 $18.32 $18.32 $18.32 $18.32 $18.32E2382 RR KE IN $1.98 $1.98 $1.98 $1.98 $1.98 $1.98E2382 RR KU IN $1.97 $1.97 $1.97 $1.97 $1.97 $1.97E2382 RR IN $1.83 $1.83 $1.83 $1.83 $1.83 $1.83E2382 UE KE IN $14.93 $14.93 $14.93 $14.93 $14.93 $14.93E2382 UE KU IN $14.85 $14.85 $14.85 $14.85 $14.85 $14.85E2382 UE IN $13.75 $13.75 $13.75 $13.75 $13.75 $13.75E2383 NU KE IN $142.10 R $150.34 $142.10 R $150.34 $147.17 R $150.34 $142.10 R $150.34 $142.10 R $150.34 $142.10 R $150.34E2383 NU KU IN $144.72 $144.72 $144.72 $144.72 $144.72 $144.72E2383 NU IN $130.51 R $138.75 $130.51 R $138.75 $135.58 R $138.75 $130.51 R $138.75 $130.51 R $138.75 $130.51 R $138.75E2383 RR KE IN $14.21 R $15.03 $14.21 R $15.03 $14.71 R $15.03 $14.21 R $15.03 $14.21 R $15.03 $14.21 R $15.03E2383 RR KU IN $14.47 $14.47 $14.47 $14.47 $14.47 $14.47E2383 RR IN $13.05 R $13.87 $13.05 R $13.87 $13.56 R $13.87 $13.05 R $13.87 $13.05 R $13.87 $13.05 R $13.87E2383 UE KE IN $106.58 R $112.76 $106.58 R $112.76 $110.38 R $112.76 $106.58 R $112.76 $106.58 R $112.76 $106.58 R $112.76E2383 UE KU IN $108.53 $108.53 $108.53 $108.53 $108.53 $108.53E2383 UE IN $97.88 R $104.06 $97.88 R $104.06 $101.68 R $104.06 $97.88 R $104.06 $97.88 R $104.06 $97.88 R $104.06E2384 NU KE IN $74.20 R $76.71 $74.20 R $76.71 $75.85 R $76.71 $74.20 R $76.71 $74.20 R $76.71 $74.20 R $76.71E2384 NU KU IN $77.10 $77.10 $77.10 $77.10 $77.10 $77.10E2384 NU IN $68.02 R $70.52 $68.02 R $70.52 $69.67 R $70.52 $68.02 R $70.52 $68.02 R $70.52 $68.02 R $70.52E2384 RR KE IN $7.43 R $7.68 $7.43 R $7.68 $7.59 R $7.68 $7.43 R $7.68 $7.43 R $7.68 $7.43 R $7.68E2384 RR KU IN $7.73 $7.73 $7.73 $7.73 $7.73 $7.73E2384 RR IN $6.81 R $7.06 $6.81 R $7.06 $6.98 R $7.06 $6.81 R $7.06 $6.81 R $7.06 $6.81 R $7.06E2384 UE KE IN $55.65 R $57.52 $55.65 R $57.52 $56.88 R $57.52 $55.65 R $57.52 $55.65 R $57.52 $55.65 R $57.52E2384 UE KU IN $57.84 $57.84 $57.84 $57.84 $57.84 $57.84E2384 UE IN $51.02 R $52.90 $51.02 R $52.90 $52.26 R $52.90 $51.02 R $52.90 $51.02 R $52.90 $51.02 R $52.90E2385 NU KE IN $47.59 $47.59 $47.59 $47.59 $47.59 $47.59E2385 NU KU IN $47.17 $47.17 $47.17 $47.17 $47.17 $47.17E2385 NU IN $43.81 $43.81 $43.81 $43.81 $43.81 $43.81E2385 RR KE IN $4.76 $4.76 $4.76 $4.76 $4.76 $4.76E2385 RR KU IN $4.74 $4.74 $4.74 $4.74 $4.74 $4.74E2385 RR IN $4.39 $4.39 $4.39 $4.39 $4.39 $4.39





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



E2385 UE KE IN $35.68 $35.68 $35.68 $35.68 $35.68 $35.68E2385 UE KU IN $35.36 $35.36 $35.36 $35.36 $35.36 $35.36E2385 UE IN $32.85 $32.85 $32.85 $32.85 $32.85 $32.85E2386 NU KE IN $134.88 R $136.87 $134.88 R $136.87 $133.77 R $136.87 $134.88 R $136.87 $134.88 R $136.87 $134.88 R $136.87E2386 NU KU IN $143.40 $143.40 $143.40 $143.40 $143.40 $143.40E2386 NU IN $123.38 R $125.37 $123.38 R $125.37 $122.28 R $125.37 $123.38 R $125.37 $123.38 R $125.37 $123.38 R $125.37E2386 RR KE IN $13.49 R $13.68 $13.49 R $13.68 $13.38 R $13.68 $13.49 R $13.68 $13.49 R $13.68 $13.49 R $13.68E2386 RR KU IN $14.34 $14.34 $14.34 $14.34 $14.34 $14.34E2386 RR IN $12.34 R $12.54 $12.34 R $12.54 $12.23 R $12.54 $12.34 R $12.54 $12.34 R $12.54 $12.34 R $12.54E2386 UE KE IN $101.15 R $102.64 $101.15 R $102.64 $100.32 R $102.64 $101.15 R $102.64 $101.15 R $102.64 $101.15 R $102.64E2386 UE KU IN $107.56 $107.56 $107.56 $107.56 $107.56 $107.56E2386 UE IN $92.54 R $94.03 $92.54 R $94.03 $91.71 R $94.03 $92.54 R $94.03 $92.54 R $94.03 $92.54 R $94.03E2387 NU KE IN $61.26 R $62.99 $61.26 R $62.99 $61.86 R $62.99 $59.84 R $61.58 $61.26 R $62.99 $61.26 R $62.99E2387 NU KU IN $64.30 $64.30 $64.30 $61.87 $64.30 $64.30E2387 NU IN $56.10 R $57.84 $56.10 R $57.84 $56.70 R $57.84 $54.89 R $56.62 $56.10 R $57.84 $56.10 R $57.84E2387 RR KE IN $6.13 R $6.30 $6.13 R $6.30 $6.19 R $6.30 $6.00 R $6.17 $6.13 R $6.30 $6.13 R $6.30E2387 RR KU IN $6.43 $6.43 $6.43 $6.20 $6.43 $6.43E2387 RR IN $5.61 R $5.79 $5.61 R $5.79 $5.67 R $5.79 $5.49 R $5.67 $5.61 R $5.79 $5.61 R $5.79E2387 UE KE IN $45.97 R $47.27 $45.97 R $47.27 $46.42 R $47.27 $44.90 R $46.20 $45.97 R $47.27 $45.97 R $47.27E2387 UE KU IN $48.27 $48.27 $48.27 $46.41 $48.27 $48.27E2387 UE IN $42.10 R $43.40 $42.10 R $43.40 $42.55 R $43.40 $41.17 R $42.47 $42.10 R $43.40 $42.10 R $43.40E2388 NU KE IN $49.87 $49.87 $49.87 $49.87 $49.87 $49.87E2388 NU KU IN $48.00 $48.00 $48.00 $48.00 $48.00 $48.00E2388 NU IN $46.01 $46.01 $46.01 $46.01 $46.01 $46.01E2388 RR KE IN $4.98 $4.98 $4.98 $4.98 $4.98 $4.98E2388 RR KU IN $4.81 $4.81 $4.81 $4.81 $4.81 $4.81E2388 RR IN $4.61 $4.61 $4.61 $4.61 $4.61 $4.61E2388 UE KE IN $37.40 $37.40 $37.40 $37.40 $37.40 $37.40E2388 UE KU IN $36.02 $36.02 $36.02 $36.02 $36.02 $36.02E2388 UE IN $34.51 $34.51 $34.51 $34.51 $34.51 $34.51E2389 NU KE IN $27.43 $27.43 $27.43 $27.43 $27.43 $27.43E2389 NU KU IN $26.08 $26.08 $26.08 $26.08 $26.08 $26.08E2389 NU IN $25.34 $25.34 $25.34 $25.34 $25.34 $25.34E2389 RR KE IN $2.75 $2.75 $2.75 $2.75 $2.75 $2.75E2389 RR KU IN $2.62 $2.62 $2.62 $2.62 $2.62 $2.62E2389 RR IN $2.54 $2.54 $2.54 $2.54 $2.54 $2.54E2389 UE KE IN $20.57 $20.57 $20.57 $20.57 $20.57 $20.57E2389 UE KU IN $19.53 $19.53 $19.53 $19.53 $19.53 $19.53E2389 UE IN $18.99 $18.99 $18.99 $18.99 $18.99 $18.99E2390 NU KE IN $42.70 $42.70 $42.70 $42.70 $42.70 $42.70E2390 NU KU IN $40.77 $40.77 $40.77 $40.77 $40.77 $40.77E2390 NU IN $39.43 $39.43 $39.43 $39.43 $39.43 $39.43E2390 RR KE IN $4.27 $4.27 $4.27 $4.27 $4.27 $4.27E2390 RR KU IN $4.07 $4.07 $4.07 $4.07 $4.07 $4.07E2390 RR IN $3.94 $3.94 $3.94 $3.94 $3.94 $3.94E2390 UE KE IN $32.02 $32.02 $32.02 $32.02 $32.02 $32.02E2390 UE KU IN $30.56 $30.56 $30.56 $30.56 $30.56 $30.56E2390 UE IN $29.56 $29.56 $29.56 $29.56 $29.56 $29.56E2391 NU KE IN $19.55 R $20.52 $19.55 R $20.52 $19.81 R $20.52 $19.55 R $20.52 $19.55 R $20.52 $19.55 R $20.52E2391 NU KU IN $19.52 $19.52 $19.52 $19.52 $19.52 $19.52E2391 NU IN $17.97 R $18.94 $17.97 R $18.94 $18.24 R $18.94 $17.97 R $18.94 $17.97 R $18.94 $17.97 R $18.94E2391 RR KE IN $1.95 R $2.05 $1.95 R $2.05 $1.98 R $2.05 $1.95 R $2.05 $1.95 R $2.05 $1.95 R $2.05E2391 RR KU IN $1.96 $1.96 $1.96 $1.96 $1.96 $1.96E2391 RR IN $1.80 R $1.90 $1.80 R $1.90 $1.83 R $1.90 $1.80 R $1.90 $1.80 R $1.90 $1.80 R $1.90E2391 UE KE IN $14.66 R $15.39 $14.66 R $15.39 $14.86 R $15.39 $14.66 R $15.39 $14.66 R $15.39 $14.66 R $15.39E2391 UE KU IN $14.65 $14.65 $14.65 $14.65 $14.65 $14.65E2391 UE IN $13.48 R $14.21 $13.48 R $14.21 $13.68 R $14.21 $13.48 R $14.21 $13.48 R $14.21 $13.48 R $14.21E2392 NU KE IN $49.57 R $51.75 $49.57 R $51.75 $49.46 R $51.75 $49.57 R $51.75 $49.57 R $51.75 $49.57 R $51.75E2392 NU KU IN $51.33 $51.33 $51.33 $51.33 $51.33 $51.33E2392 NU IN $45.46 R $47.64 $45.46 R $47.64 $45.36 R $47.64 $45.46 R $47.64 $45.46 R $47.64 $45.46 R $47.64E2392 RR KE IN $4.97 R $5.19 $4.97 R $5.19 $4.96 R $5.19 $4.97 R $5.19 $4.97 R $5.19 $4.97 R $5.19





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



E2392 RR KU IN $5.16 $5.16 $5.16 $5.16 $5.16 $5.16E2392 RR IN $4.56 R $4.78 $4.56 R $4.78 $4.55 R $4.78 $4.56 R $4.78 $4.56 R $4.78 $4.56 R $4.78E2392 UE KE IN $37.18 R $38.82 $37.18 R $38.82 $37.11 R $38.82 $37.18 R $38.82 $37.18 R $38.82 $37.18 R $38.82E2392 UE KU IN $38.51 $38.51 $38.51 $38.51 $38.51 $38.51E2392 UE IN $34.10 R $35.74 $34.10 R $35.74 $34.02 R $35.74 $34.10 R $35.74 $34.10 R $35.74 $34.10 R $35.74E2394 NU KE IN $70.22 R $72.89 $70.22 R $72.89 $69.60 R $72.89 $70.22 R $72.89 $70.22 R $72.89 $70.22 R $72.89E2394 NU KU IN $73.15 $73.15 $73.15 $73.15 $73.15 $73.15E2394 NU IN $64.37 R $67.03 $64.37 R $67.03 $63.75 R $67.03 $64.37 R $67.03 $64.37 R $67.03 $64.37 R $67.03E2394 RR KE IN $7.03 R $7.29 $7.03 R $7.29 $6.97 R $7.29 $7.03 R $7.29 $7.03 R $7.29 $7.03 R $7.29E2394 RR KU IN $7.33 $7.33 $7.33 $7.33 $7.33 $7.33E2394 RR IN $6.44 R $6.71 $6.44 R $6.71 $6.38 R $6.71 $6.44 R $6.71 $6.44 R $6.71 $6.44 R $6.71E2394 UE KE IN $52.66 R $54.66 $52.66 R $54.66 $52.20 R $54.66 $52.66 R $54.66 $52.66 R $54.66 $52.66 R $54.66E2394 UE KU IN $54.86 $54.86 $54.86 $54.86 $54.86 $54.86E2394 UE IN $48.28 R $50.28 $48.28 R $50.28 $47.81 R $50.28 $48.28 R $50.28 $48.28 R $50.28 $48.28 R $50.28E2395 NU KE IN $50.79 R $52.80 $50.79 R $52.80 $51.52 R $52.80 $50.79 R $52.80 $50.79 R $52.80 $50.79 R $52.80E2395 NU KU IN $51.97 $51.97 $51.97 $51.97 $51.97 $51.97E2395 NU IN $46.63 R $48.63 $46.63 R $48.63 $47.36 R $48.63 $46.63 R $48.63 $46.63 R $48.63 $46.63 R $48.63E2395 RR KE IN $5.08 R $5.28 $5.08 R $5.28 $5.16 R $5.28 $5.08 R $5.28 $5.08 R $5.28 $5.08 R $5.28E2395 RR KU IN $5.21 $5.21 $5.21 $5.21 $5.21 $5.21E2395 RR IN $4.67 R $4.87 $4.67 R $4.87 $4.74 R $4.87 $4.67 R $4.87 $4.67 R $4.87 $4.67 R $4.87E2395 UE KE IN $38.11 R $39.61 $38.11 R $39.61 $38.66 R $39.61 $38.11 R $39.61 $38.11 R $39.61 $38.11 R $39.61E2395 UE KU IN $38.99 $38.99 $38.99 $38.99 $38.99 $38.99E2395 UE IN $34.98 R $36.48 $34.98 R $36.48 $35.53 R $36.48 $34.98 R $36.48 $34.98 R $36.48 $34.98 R $36.48E2396 NU KE IN $61.60 R $64.08 $61.60 R $64.08 $56.49 R $58.56 $56.08 R $58.56 $61.60 R $64.08 $61.60 R $64.08E2396 NU KU IN $63.37 $63.37 $53.86 $53.86 $63.37 $63.37E2396 NU IN $56.52 R $59.00 $56.52 R $59.00 $52.17 R $53.86 $51.77 R $53.86 $56.52 R $59.00 $56.52 R $59.00E2396 RR KE IN $6.43 R $6.68 $6.16 R $6.41 $5.88 R $6.08 $5.84 R $6.08 $6.39 R $6.64 $6.26 R $6.51E2396 RR KU IN $6.78 $6.32 $5.76 $5.76 $6.72 $6.52E2396 RR IN $5.87 R $6.12 $5.65 R $5.89 $5.41 R $5.61 $5.37 R $5.61 $5.85 R $6.09 $5.75 R $5.99E2396 UE KE IN $46.21 R $48.06 $46.21 R $48.06 $42.37 R $43.93 $42.07 R $43.93 $46.21 R $48.06 $46.21 R $48.06E2396 UE KU IN $47.54 $47.54 $40.41 $40.41 $47.54 $47.54E2396 UE IN $42.40 R $44.26 $42.40 R $44.26 $39.13 R $40.41 $38.83 R $40.41 $42.40 R $44.26 $42.40 R $44.26E2397 NU KU IN $457.83 $457.83 $457.83 $457.83 $457.83 $457.83E2397 NU IN $433.58 R $457.83 $433.58 R $457.83 $442.90 R $457.83 $433.58 R $457.83 $433.58 R $457.83 $433.58 R $457.83E2397 RR KU IN $45.79 $45.79 $45.79 $45.79 $45.79 $45.79E2397 RR IN $43.36 R $45.79 $43.36 R $45.79 $44.29 R $45.79 $43.36 R $45.79 $43.36 R $45.79 $43.36 R $45.79E2397 UE KU IN $343.35 $343.35 $343.35 $343.34 $343.35 $343.35E2397 UE IN $325.17 R $343.35 $325.17 R $343.35 $332.17 R $343.35 $325.17 R $343.34 $325.17 R $343.35 $325.17 R $343.35E2402 RR CR $1,168.41 R $1,173.60 $1,168.41 R $1,173.60 $1,111.73 R $1,173.60 $1,168.41 R $1,173.60 $1,168.41 R $1,173.60 $1,168.41 R $1,173.60E2500 NU IN $432.30 $432.30 $432.30 $432.30 $432.30 $432.30E2500 RR IN $43.24 $43.24 $43.24 $43.24 $43.24 $43.24E2500 UE IN $324.23 $324.23 $324.23 $324.23 $324.23 $324.23E2502 NU IN $1,321.96 $1,321.96 $1,321.96 $1,321.96 $1,321.96 $1,321.96E2502 RR IN $132.20 $132.20 $132.20 $132.20 $132.20 $132.20E2502 UE IN $991.49 $991.49 $991.49 $991.49 $991.49 $991.49E2504 NU IN $1,743.84 $1,743.84 $1,743.84 $1,743.84 $1,743.84 $1,743.84E2504 RR IN $174.41 $174.41 $174.41 $174.41 $174.41 $174.41E2504 UE IN $1,307.88 $1,307.88 $1,307.88 $1,307.88 $1,307.88 $1,307.88E2506 NU IN $2,557.00 $2,557.00 $2,557.00 $2,557.00 $2,557.00 $2,557.00E2506 RR IN $255.68 $255.68 $255.68 $255.68 $255.68 $255.68E2506 UE IN $1,917.71 $1,917.71 $1,917.71 $1,917.71 $1,917.71 $1,917.71E2508 NU IN $3,953.96 $3,953.96 $3,953.96 $3,953.96 $3,953.96 $3,953.96E2508 RR IN $395.39 $395.39 $395.39 $395.39 $395.39 $395.39E2508 UE IN $2,965.48 $2,965.48 $2,965.48 $2,965.48 $2,965.48 $2,965.48E2510 NU IN $7,482.35 $7,482.35 $7,482.35 $7,482.35 $7,482.35 $7,482.35E2510 RR IN $748.24 $748.24 $748.24 $748.24 $748.24 $748.24E2510 UE IN $5,611.76 $5,611.76 $5,611.76 $5,611.76 $5,611.76 $5,611.76E2601 NU KE IN $53.22 R $54.26 $53.22 R $54.26 $51.55 R $54.26 $53.22 R $54.26 $53.22 R $54.26 $53.22 R $54.26E2601 NU KU IN $58.27 $58.27 $58.27 $58.27 $58.27 $58.27E2601 NU IN $48.55 R $49.59 $48.55 R $49.59 $46.87 R $49.59 $48.55 R $49.59 $48.55 R $49.59 $48.55 R $49.59E2601 RR KE IN $5.33 R $5.43 $5.33 R $5.43 $5.16 R $5.43 $5.33 R $5.43 $5.33 R $5.43 $5.33 R $5.43





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



E2601 RR KU IN $5.85 $5.85 $5.85 $5.85 $5.85 $5.85E2601 RR IN $4.87 R $4.97 $4.87 R $4.97 $4.70 R $4.97 $4.87 R $4.97 $4.87 R $4.97 $4.87 R $4.97E2601 UE KE IN $39.91 R $40.69 $39.91 R $40.69 $38.65 R $40.69 $39.91 R $40.69 $39.91 R $40.69 $39.91 R $40.69E2601 UE KU IN $43.71 $43.71 $43.71 $43.71 $43.71 $43.71E2601 UE IN $36.42 R $37.20 $36.42 R $37.20 $35.16 R $37.20 $36.42 R $37.20 $36.42 R $37.20 $36.42 R $37.20E2602 NU KE IN $107.44 R $110.05 $107.44 R $110.05 $107.41 R $110.05 $107.44 R $110.05 $107.44 R $110.05 $107.44 R $110.05E2602 NU KU IN $113.76 $113.76 $113.76 $113.76 $113.76 $113.76E2602 NU IN $98.32 R $100.93 $98.32 R $100.93 $98.29 R $100.93 $98.32 R $100.93 $98.32 R $100.93 $98.32 R $100.93E2602 RR KE IN $10.75 R $11.01 $10.75 R $11.01 $10.75 R $11.01 $10.75 R $11.01 $10.75 R $11.01 $10.75 R $11.01E2602 RR KU IN $11.38 $11.38 $11.38 $11.38 $11.38 $11.38E2602 RR IN $9.84 R $10.10 $9.84 R $10.10 $9.83 R $10.10 $9.84 R $10.10 $9.84 R $10.10 $9.84 R $10.10E2602 UE KE IN $80.58 R $82.54 $80.58 R $82.54 $80.56 R $82.54 $80.58 R $82.54 $80.58 R $82.54 $80.58 R $82.54E2602 UE KU IN $85.33 $85.33 $85.33 $85.33 $85.33 $85.33E2602 UE IN $73.74 R $75.70 $73.74 R $75.70 $73.72 R $75.70 $73.74 R $75.70 $73.74 R $75.70 $73.74 R $75.70E2603 NU KE IN $135.36 R $137.70 $135.36 R $137.70 $132.83 R $137.70 $135.36 R $137.70 $135.36 R $137.70 $135.36 R $137.70E2603 NU KU IN $144.43 $144.43 $144.43 $144.43 $144.43 $144.43E2603 NU IN $123.78 R $126.12 $123.78 R $126.12 $121.25 R $126.12 $123.78 R $126.12 $123.78 R $126.12 $123.78 R $126.12E2603 RR KE IN $13.54 R $13.77 $13.54 R $13.77 $13.29 R $13.77 $13.54 R $13.77 $13.54 R $13.77 $13.54 R $13.77E2603 RR KU IN $14.45 $14.45 $14.45 $14.45 $14.45 $14.45E2603 RR IN $12.38 R $12.62 $12.38 R $12.62 $12.13 R $12.62 $12.38 R $12.62 $12.38 R $12.62 $12.38 R $12.62E2603 UE KE IN $101.52 R $103.27 $101.52 R $103.27 $99.62 R $103.27 $101.52 R $103.27 $101.52 R $103.27 $101.52 R $103.27E2603 UE KU IN $108.33 $108.33 $108.33 $108.33 $108.33 $108.33E2603 UE IN $92.84 R $94.60 $92.84 R $94.60 $90.94 R $94.60 $92.84 R $94.60 $92.84 R $94.60 $92.84 R $94.60E2604 NU KE IN $174.76 R $180.53 $174.76 R $180.53 $178.69 R $180.53 $174.76 R $180.53 $174.76 R $180.53 $174.76 R $180.53E2604 NU KU IN $179.53 $179.53 $179.53 $179.53 $179.53 $179.53E2604 NU IN $160.39 R $166.15 $160.39 R $166.15 $164.31 R $166.15 $160.39 R $166.15 $160.39 R $166.15 $160.39 R $166.15E2604 RR KE IN $17.47 R $18.04 $17.47 R $18.04 $17.86 R $18.04 $17.47 R $18.04 $17.47 R $18.04 $17.47 R $18.04E2604 RR KU IN $17.95 $17.95 $17.95 $17.95 $17.95 $17.95E2604 RR IN $16.04 R $16.61 $16.04 R $16.61 $16.43 R $16.61 $16.04 R $16.61 $16.04 R $16.61 $16.04 R $16.61E2604 UE KE IN $131.09 R $135.41 $131.09 R $135.41 $134.03 R $135.41 $131.09 R $135.41 $131.09 R $135.41 $131.09 R $135.41E2604 UE KU IN $134.67 $134.67 $134.67 $134.67 $134.67 $134.67E2604 UE IN $120.30 R $124.62 $120.30 R $124.62 $123.25 R $124.62 $120.30 R $124.62 $120.30 R $124.62 $120.30 R $124.62E2605 NU KE IN $248.52 R $258.42 $248.52 R $258.42 $250.72 R $258.42 $248.52 R $258.42 $248.52 R $258.42 $248.52 R $258.42E2605 NU KU IN $256.48 $256.48 $256.48 $256.48 $256.48 $256.48E2605 NU IN $227.98 R $237.87 $227.98 R $237.87 $230.17 R $237.87 $227.98 R $237.87 $227.98 R $237.87 $227.98 R $237.87E2605 RR KE IN $24.86 R $25.85 $24.86 R $25.85 $25.08 R $25.85 $24.86 R $25.85 $24.86 R $25.85 $24.86 R $25.85E2605 RR KU IN $25.66 $25.66 $25.66 $25.66 $25.66 $25.66E2605 RR IN $22.80 R $23.79 $22.80 R $23.79 $23.02 R $23.79 $22.80 R $23.79 $22.80 R $23.79 $22.80 R $23.79E2605 UE KE IN $186.42 R $193.84 $186.42 R $193.84 $188.06 R $193.84 $186.42 R $193.84 $186.42 R $193.84 $186.42 R $193.84E2605 UE KU IN $192.39 $192.39 $192.39 $192.39 $192.39 $192.39E2605 UE IN $171.00 R $178.42 $171.00 R $178.42 $172.65 R $178.42 $171.00 R $178.42 $171.00 R $178.42 $171.00 R $178.42E2606 NU KE IN $392.69 R $407.84 $392.69 R $407.84 $397.01 R $407.84 $392.69 R $407.84 $392.69 R $407.84 $392.69 R $407.84E2606 NU KU IN $400.13 $400.13 $400.13 $400.13 $400.13 $400.13E2606 NU IN $360.63 R $375.79 $360.63 R $375.79 $364.95 R $375.79 $360.63 R $375.79 $360.63 R $375.79 $360.63 R $375.79E2606 RR KE IN $39.28 R $40.79 $39.28 R $40.79 $39.71 R $40.79 $39.28 R $40.79 $39.28 R $40.79 $39.28 R $40.79E2606 RR KU IN $40.02 $40.02 $40.02 $40.02 $40.02 $40.02E2606 RR IN $36.07 R $37.58 $36.07 R $37.58 $36.50 R $37.58 $36.07 R $37.58 $36.07 R $37.58 $36.07 R $37.58E2606 UE KE IN $294.51 R $305.88 $294.51 R $305.88 $297.76 R $305.88 $294.51 R $305.88 $294.51 R $305.88 $294.51 R $305.88E2606 UE KU IN $300.07 $300.07 $300.07 $300.07 $300.07 $300.07E2606 UE IN $270.46 R $281.83 $270.46 R $281.83 $273.70 R $281.83 $270.46 R $281.83 $270.46 R $281.83 $270.46 R $281.83E2607 NU KE IN $261.68 R $266.81 $261.68 R $266.81 $260.70 R $266.81 $261.68 R $266.81 $261.68 R $266.81 $261.68 R $266.81E2607 NU KU IN $276.18 $276.18 $276.18 $276.18 $276.18 $276.18E2607 NU IN $239.55 R $244.69 $239.55 R $244.69 $238.58 R $244.69 $239.55 R $244.69 $239.55 R $244.69 $239.55 R $244.69E2607 RR KE IN $26.17 R $26.69 $26.17 R $26.69 $26.07 R $26.69 $26.17 R $26.69 $26.17 R $26.69 $26.17 R $26.69E2607 RR KU IN $27.62 $27.62 $27.62 $27.62 $27.62 $27.62E2607 RR IN $23.96 R $24.47 $23.96 R $24.47 $23.86 R $24.47 $23.96 R $24.47 $23.96 R $24.47 $23.96 R $24.47E2607 UE KE IN $196.26 R $200.11 $196.26 R $200.11 $195.53 R $200.11 $196.26 R $200.11 $196.26 R $200.11 $196.26 R $200.11E2607 UE KU IN $207.14 $207.14 $207.14 $207.14 $207.14 $207.14E2607 UE IN $179.66 R $183.52 $179.66 R $183.52 $178.93 R $183.52 $179.66 R $183.52 $179.66 R $183.52 $179.66 R $183.52E2608 NU KE IN $317.86 R $326.94 $317.86 R $326.94 $313.97 R $326.94 $317.86 R $326.94 $317.86 R $326.94 $317.86 R $326.94E2608 NU KU IN $331.67 $331.67 $331.67 $331.67 $331.67 $331.67





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



E2608 NU IN $291.29 R $300.37 $291.29 R $300.37 $287.40 R $300.37 $291.29 R $300.37 $291.29 R $300.37 $291.29 R $300.37E2608 RR KE IN $31.78 R $32.69 $31.78 R $32.69 $31.40 R $32.69 $31.78 R $32.69 $31.78 R $32.69 $31.78 R $32.69E2608 RR KU IN $33.16 $33.16 $33.16 $33.16 $33.16 $33.16E2608 RR IN $29.12 R $30.03 $29.12 R $30.03 $28.74 R $30.03 $29.12 R $30.03 $29.12 R $30.03 $29.12 R $30.03E2608 UE KE IN $238.40 R $245.21 $238.40 R $245.21 $235.48 R $245.21 $238.40 R $245.21 $238.40 R $245.21 $238.40 R $245.21E2608 UE KU IN $248.75 $248.75 $248.75 $248.75 $248.75 $248.75E2608 UE IN $218.47 R $225.28 $218.47 R $225.28 $215.55 R $225.28 $218.47 R $225.28 $218.47 R $225.28 $218.47 R $225.28E2611 NU KE IN $254.74 R $256.25 $254.74 R $256.25 $245.33 R $256.25 $254.74 R $256.25 $254.74 R $256.25 $254.74 R $256.25E2611 NU KU IN $297.62 $297.62 $297.62 $297.62 $297.62 $297.62E2611 NU IN $230.90 R $232.42 $230.90 R $232.42 $221.50 R $232.42 $230.90 R $232.42 $230.90 R $232.42 $230.90 R $232.42E2611 RR KE IN $25.48 R $25.63 $25.48 R $25.63 $24.53 R $25.63 $25.48 R $25.63 $25.48 R $25.63 $25.48 R $25.63E2611 RR KU IN $29.75 $29.75 $29.75 $29.75 $29.75 $29.75E2611 RR IN $23.08 R $23.24 $23.08 R $23.24 $22.14 R $23.24 $23.08 R $23.24 $23.08 R $23.24 $23.08 R $23.24E2611 UE KE IN $191.07 R $192.21 $191.07 R $192.21 $184.02 R $192.21 $191.07 R $192.21 $191.07 R $192.21 $191.07 R $192.21E2611 UE KU IN $223.24 $223.24 $223.24 $223.24 $223.24 $223.24E2611 UE IN $173.19 R $174.33 $173.19 R $174.33 $166.14 R $174.33 $173.19 R $174.33 $173.19 R $174.33 $173.19 R $174.33E2612 NU KE IN $385.26 R $393.59 $385.26 R $393.59 $381.11 R $393.59 $385.26 R $393.59 $385.26 R $393.59 $385.26 R $393.59E2612 NU KU IN $402.61 $402.61 $402.61 $402.61 $402.61 $402.61E2612 NU IN $353.00 R $361.33 $353.00 R $361.33 $348.85 R $361.33 $353.00 R $361.33 $353.00 R $361.33 $353.00 R $361.33E2612 RR KE IN $38.52 R $39.35 $38.52 R $39.35 $38.11 R $39.35 $38.52 R $39.35 $38.52 R $39.35 $38.52 R $39.35E2612 RR KU IN $40.26 $40.26 $40.26 $40.26 $40.26 $40.26E2612 RR IN $35.30 R $36.13 $35.30 R $36.13 $34.89 R $36.13 $35.30 R $36.13 $35.30 R $36.13 $35.30 R $36.13E2612 UE KE IN $288.93 R $295.18 $288.93 R $295.18 $285.82 R $295.18 $288.93 R $295.18 $288.93 R $295.18 $288.93 R $295.18E2612 UE KU IN $301.96 $301.96 $301.96 $301.96 $301.96 $301.96E2612 UE IN $264.75 R $271.00 $264.75 R $271.00 $261.64 R $271.00 $264.75 R $271.00 $264.75 R $271.00 $264.75 R $271.00E2613 NU KE IN $365.88 R $378.42 $365.88 R $378.42 $369.42 R $378.42 $365.88 R $378.42 $365.88 R $378.42 $365.88 R $378.42E2613 NU KU IN $374.51 $374.51 $374.51 $374.51 $374.51 $374.51E2613 NU IN $335.87 R $348.42 $335.87 R $348.42 $339.41 R $348.42 $335.87 R $348.42 $335.87 R $348.42 $335.87 R $348.42E2613 RR KE IN $36.60 R $37.85 $36.60 R $37.85 $36.95 R $37.85 $36.60 R $37.85 $36.60 R $37.85 $36.60 R $37.85E2613 RR KU IN $37.46 $37.46 $37.46 $37.46 $37.46 $37.46E2613 RR IN $33.59 R $34.85 $33.59 R $34.85 $33.95 R $34.85 $33.59 R $34.85 $33.59 R $34.85 $33.59 R $34.85E2613 UE KE IN $274.41 R $283.81 $274.41 R $283.81 $277.06 R $283.81 $274.41 R $283.81 $274.41 R $283.81 $274.41 R $283.81E2613 UE KU IN $280.88 $280.88 $280.88 $280.88 $280.88 $280.88E2613 UE IN $251.91 R $261.31 $251.91 R $261.31 $254.56 R $261.31 $251.91 R $261.31 $251.91 R $261.31 $251.91 R $261.31E2614 NU KE IN $514.63 R $538.38 $514.63 R $538.38 $516.97 R $538.38 $514.63 R $538.38 $514.63 R $538.38 $514.63 R $538.38E2614 NU KU IN $518.29 $518.29 $518.29 $518.29 $518.29 $518.29E2614 NU IN $473.12 R $496.87 $473.12 R $496.87 $475.45 R $496.87 $473.12 R $496.87 $473.12 R $496.87 $473.12 R $496.87E2614 RR KE IN $51.47 R $53.84 $51.47 R $53.84 $51.70 R $53.84 $51.47 R $53.84 $51.47 R $53.84 $51.47 R $53.84E2614 RR KU IN $51.83 $51.83 $51.83 $51.83 $51.83 $51.83E2614 RR IN $47.31 R $49.69 $47.31 R $49.69 $47.55 R $49.69 $47.31 R $49.69 $47.31 R $49.69 $47.31 R $49.69E2614 UE KE IN $385.99 R $403.80 $385.99 R $403.80 $387.74 R $403.80 $385.99 R $403.80 $385.99 R $403.80 $385.99 R $403.80E2614 UE KU IN $388.73 $388.73 $388.73 $388.73 $388.73 $388.73E2614 UE IN $354.85 R $372.66 $354.85 R $372.66 $356.60 R $372.66 $354.85 R $372.66 $354.85 R $372.66 $354.85 R $372.66E2615 NU KE IN $419.11 R $434.22 $419.11 R $434.22 $418.37 R $434.22 $419.11 R $434.22 $419.11 R $434.22 $419.11 R $434.22E2615 NU KU IN $430.98 $430.98 $430.98 $430.98 $430.98 $430.98E2615 NU IN $384.57 R $399.68 $384.57 R $399.68 $383.83 R $399.68 $384.57 R $399.68 $384.57 R $399.68 $384.57 R $399.68E2615 RR KE IN $41.91 R $43.42 $41.91 R $43.42 $41.84 R $43.42 $41.91 R $43.42 $41.91 R $43.42 $41.91 R $43.42E2615 RR KU IN $43.11 $43.11 $43.11 $43.11 $43.11 $43.11E2615 RR IN $38.46 R $39.97 $38.46 R $39.97 $38.39 R $39.97 $38.46 R $39.97 $38.46 R $39.97 $38.46 R $39.97E2615 UE KE IN $314.31 R $325.65 $314.31 R $325.65 $313.75 R $325.65 $314.31 R $325.65 $314.31 R $325.65 $314.31 R $325.65E2615 UE KU IN $323.23 $323.23 $323.23 $323.23 $323.23 $323.23E2615 UE IN $288.42 R $299.76 $288.42 R $299.76 $287.87 R $299.76 $288.42 R $299.76 $288.42 R $299.76 $288.42 R $299.76E2616 NU KE IN $561.61 R $583.34 $561.61 R $583.34 $569.45 R $583.34 $561.61 R $583.34 $561.61 R $583.34 $561.61 R $583.34E2616 NU KU IN $579.88 $579.88 $579.88 $579.88 $579.88 $579.88E2616 NU IN $515.16 R $536.89 $515.16 R $536.89 $522.99 R $536.89 $515.16 R $536.89 $515.16 R $536.89 $515.16 R $536.89E2616 RR KE IN $56.16 R $58.33 $56.16 R $58.33 $56.95 R $58.33 $56.16 R $58.33 $56.16 R $58.33 $56.16 R $58.33E2616 RR KU IN $57.99 $57.99 $57.99 $57.99 $57.99 $57.99E2616 RR IN $51.52 R $53.69 $51.52 R $53.69 $52.30 R $53.69 $51.52 R $53.69 $51.52 R $53.69 $51.52 R $53.69E2616 UE KE IN $421.21 R $437.51 $421.21 R $437.51 $427.09 R $437.51 $421.21 R $437.51 $421.21 R $437.51 $421.21 R $437.51E2616 UE KU IN $434.92 $434.92 $434.92 $434.92 $434.92 $434.92E2616 UE IN $386.37 R $402.67 $386.37 R $402.67 $392.25 R $402.67 $386.37 R $402.67 $386.37 R $402.67 $386.37 R $402.67





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



E2619 NU KE IN $51.03 $51.03 $51.03 $51.03 $51.03 $51.03E2619 NU KU IN $48.89 $48.89 $48.89 $48.89 $48.89 $48.89E2619 NU IN $47.11 $47.11 $47.11 $47.11 $47.11 $47.11E2619 RR KE IN $5.10 $5.10 $5.10 $5.10 $5.10 $5.10E2619 RR KU IN $4.89 $4.89 $4.89 $4.89 $4.89 $4.89E2619 RR IN $4.71 $4.71 $4.71 $4.71 $4.71 $4.71E2619 UE KE IN $38.29 $38.29 $38.29 $38.29 $38.29 $38.29E2619 UE KU IN $36.70 $36.70 $36.70 $36.70 $36.70 $36.70E2619 UE IN $35.35 $35.35 $35.35 $35.35 $35.35 $35.35E2620 NU KE IN $490.06 R $500.62 $490.06 R $500.62 $488.05 R $500.62 $490.06 R $500.62 $490.06 R $500.62 $490.06 R $500.62E2620 NU KU IN $521.86 $521.86 $521.86 $521.86 $521.86 $521.86E2620 NU IN $448.25 R $458.81 $448.25 R $458.81 $446.24 R $458.81 $448.25 R $458.81 $448.25 R $458.81 $448.25 R $458.81E2620 RR KE IN $49.01 R $50.06 $49.01 R $50.06 $48.80 R $50.06 $49.01 R $50.06 $49.01 R $50.06 $49.01 R $50.06E2620 RR KU IN $52.19 $52.19 $52.19 $52.19 $52.19 $52.19E2620 RR IN $44.83 R $45.88 $44.83 R $45.88 $44.63 R $45.88 $44.83 R $45.88 $44.83 R $45.88 $44.83 R $45.88E2620 UE KE IN $367.56 R $375.48 $367.56 R $375.48 $366.05 R $375.48 $367.56 R $375.48 $367.56 R $375.48 $367.56 R $375.48E2620 UE KU IN $391.41 $391.41 $391.41 $391.41 $391.41 $391.41E2620 UE IN $336.19 R $344.11 $336.19 R $344.11 $334.68 R $344.11 $336.19 R $344.11 $336.19 R $344.11 $336.19 R $344.11E2621 NU KE IN $534.26 R $550.82 $534.26 R $550.82 $528.48 R $550.82 $534.26 R $550.82 $534.26 R $550.82 $534.26 R $550.82E2621 NU KU IN $547.66 $547.66 $547.66 $547.66 $547.66 $547.66E2621 NU IN $490.38 R $506.95 $490.38 R $506.95 $484.61 R $506.95 $490.38 R $506.95 $490.38 R $506.95 $490.38 R $506.95E2621 RR KE IN $53.42 R $55.07 $53.42 R $55.07 $52.84 R $55.07 $53.42 R $55.07 $53.42 R $55.07 $53.42 R $55.07E2621 RR KU IN $54.77 $54.77 $54.77 $54.77 $54.77 $54.77E2621 RR IN $49.04 R $50.70 $49.04 R $50.70 $48.46 R $50.70 $49.04 R $50.70 $49.04 R $50.70 $49.04 R $50.70E2621 UE KE IN $400.69 R $413.12 $400.69 R $413.12 $396.36 R $413.12 $400.69 R $413.12 $400.69 R $413.12 $400.69 R $413.12E2621 UE KU IN $410.74 $410.74 $410.74 $410.74 $410.74 $410.74E2621 UE IN $367.79 R $380.21 $367.79 R $380.21 $363.46 R $380.21 $367.79 R $380.21 $367.79 R $380.21 $367.79 R $380.21E2622 NU KE IN $326.97 $326.97 $326.97 $326.97 $326.97 $326.97E2622 NU KU IN $315.83 $315.83 $315.83 $315.83 $315.83 $315.83E2622 NU IN $301.67 $301.67 $301.67 $301.67 $301.67 $301.67E2622 RR KE IN $32.70 $32.70 $32.70 $32.70 $32.70 $32.70E2622 RR KU IN $31.59 $31.59 $31.59 $31.59 $31.59 $31.59E2622 RR IN $30.17 $30.17 $30.17 $30.17 $30.17 $30.17E2622 UE KE IN $245.23 $245.23 $245.23 $245.23 $245.23 $245.23E2622 UE KU IN $236.87 $236.87 $236.87 $236.87 $236.87 $236.87E2622 UE IN $226.25 $226.25 $226.25 $226.25 $226.25 $226.25E2623 NU KE IN $414.93 $414.93 $414.93 $414.93 $414.93 $414.93E2623 NU KU IN $401.89 $401.89 $401.89 $401.89 $401.89 $401.89E2623 NU IN $382.72 $382.72 $382.72 $382.72 $382.72 $382.72E2623 RR KE IN $41.50 $41.50 $41.50 $41.50 $41.50 $41.50E2623 RR KU IN $40.20 $40.20 $40.20 $40.20 $40.20 $40.20E2623 RR IN $38.28 $38.28 $38.28 $38.28 $38.28 $38.28E2623 UE KE IN $311.19 $311.19 $311.19 $311.19 $311.19 $311.19E2623 UE KU IN $301.40 $301.40 $301.40 $301.40 $301.40 $301.40E2623 UE IN $287.04 $287.04 $287.04 $287.04 $287.04 $287.04E2624 NU KE IN $330.80 $330.80 $330.80 $330.80 $330.80 $330.80E2624 NU KU IN $318.43 $318.43 $318.43 $318.43 $318.43 $318.43E2624 NU IN $305.29 $305.29 $305.29 $305.29 $305.29 $305.29E2624 RR KE IN $33.08 $33.08 $33.08 $33.08 $33.08 $33.08E2624 RR KU IN $31.85 $31.85 $31.85 $31.85 $31.85 $31.85E2624 RR IN $30.53 $30.53 $30.53 $30.53 $30.53 $30.53E2624 UE KE IN $248.10 $248.10 $248.10 $248.10 $248.10 $248.10E2624 UE KU IN $238.84 $238.84 $238.84 $238.84 $238.84 $238.84E2624 UE IN $228.98 $228.98 $228.98 $228.98 $228.98 $228.98E2625 NU KE IN $414.63 $414.63 $414.63 $414.63 $414.63 $414.63E2625 NU KU IN $403.11 $403.11 $403.11 $403.11 $403.11 $403.11E2625 NU IN $382.34 $382.34 $382.34 $382.34 $382.34 $382.34E2625 RR KE IN $41.47 $41.47 $41.47 $41.47 $41.47 $41.47E2625 RR KU IN $40.30 $40.30 $40.30 $40.30 $40.30 $40.30E2625 RR IN $38.23 $38.23 $38.23 $38.23 $38.23 $38.23E2625 UE KE IN $310.97 $310.97 $310.97 $310.97 $310.97 $310.97





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



E2625 UE KU IN $302.33 $302.33 $302.33 $302.33 $302.33 $302.33E2625 UE IN $286.75 $286.75 $286.75 $286.75 $286.75 $286.75E2626 NU KU IN $657.41 $583.66 $686.66 $686.66 $686.66 $583.66E2626 NU IN $626.79 R $657.41 $583.67 R $583.67 $655.57 R $679.22 $641.41 R $679.22 $641.41 R $679.22 $583.67 R $583.67E2626 RR KU IN $65.77 $58.34 $68.64 $68.64 $68.64 $58.34E2626 RR IN $62.69 R $65.77 $58.35 R $58.35 $65.55 R $67.91 $64.13 R $67.91 $64.13 R $67.91 $58.35 R $58.35E2626 UE KU IN $493.06 $437.70 $514.94 $514.94 $514.94 $437.70E2626 UE IN $470.09 R $493.06 $437.70 R $437.70 $491.65 R $509.39 $481.03 R $509.39 $481.03 R $509.39 $437.70 R $437.70E2627 NU KU IN $931.34 $931.34 $1,095.69 $1,095.69 $1,095.69 $931.34E2627 NU IN $926.05 R $931.34 $926.05 R $931.34 $1,046.16 R $1,065.84 $1,008.23 R $1,065.84 $1,008.23 R $1,065.84 $926.05 R $931.34E2627 RR KU IN $93.16 $93.16 $109.60 $109.60 $109.60 $93.16E2627 RR IN $92.62 R $93.16 $92.62 R $93.16 $104.63 R $106.60 $100.84 R $106.60 $100.84 R $106.60 $92.62 R $93.16E2627 UE KU IN $698.50 $698.50 $821.76 $821.76 $821.76 $698.50E2627 UE IN $694.54 R $698.49 $694.54 R $698.49 $784.61 R $799.38 $756.17 R $799.38 $756.17 R $799.38 $694.54 R $698.49E2628 NU KU IN $701.62 $825.43 $825.43 $825.43 $825.43 $825.43E2628 NU IN $701.61 R $701.61 $773.38 R $815.27 $796.27 R $815.27 $773.38 R $815.27 $773.38 R $815.27 $773.38 R $815.27E2628 RR KU IN $70.16 $82.54 $82.54 $82.54 $82.54 $82.54E2628 RR IN $70.16 R $70.16 $77.34 R $81.53 $79.63 R $81.53 $77.34 R $81.53 $77.34 R $81.53 $77.34 R $81.53E2628 UE KU IN $526.20 $619.06 $619.06 $619.06 $619.06 $619.06E2628 UE IN $526.21 R $526.21 $580.03 R $611.45 $597.20 R $611.45 $580.03 R $611.45 $580.03 R $611.45 $580.03 R $611.45E2629 NU KU IN $887.88 $1,044.56 $887.88 $1,044.56 $1,044.56 $1,044.56E2629 NU IN $887.87 R $887.87 $979.66 R $1,029.58 $887.87 R $887.87 $979.66 R $1,029.58 $979.66 R $1,029.58 $979.66 R $1,029.58E2629 RR KU IN $88.77 $104.44 $88.77 $104.44 $104.44 $104.44E2629 RR IN $88.77 R $88.77 $97.96 R $102.95 $88.77 R $88.77 $97.96 R $102.95 $97.96 R $102.95 $97.96 R $102.95E2629 UE KU IN $665.90 $783.41 $665.90 $783.41 $783.41 $783.41E2629 UE IN $665.91 R $665.91 $734.75 R $772.19 $665.91 R $665.91 $734.75 R $772.19 $734.75 R $772.19 $734.75 R $772.19E2630 NU KU IN $730.46 $620.89 $730.46 $730.46 $730.46 $730.46E2630 NU IN $672.76 R $708.73 $617.97 R $620.89 $683.79 R $708.73 $672.76 R $708.73 $672.76 R $708.73 $672.76 R $708.73E2630 RR KU IN $73.05 $62.09 $73.05 $73.05 $73.05 $73.05E2630 RR IN $67.28 R $70.87 $61.80 R $62.09 $68.38 R $70.87 $67.28 R $70.87 $67.28 R $70.87 $67.28 R $70.87E2630 UE KU IN $547.84 $465.66 $547.84 $547.84 $547.84 $547.84E2630 UE IN $504.57 R $531.54 $463.48 R $465.66 $512.84 R $531.54 $504.57 R $531.54 $504.57 R $531.54 $504.57 R $531.54E2631 NU KU IN $248.37 $248.37 $292.20 $292.20 $292.20 $292.20E2631 NU IN $248.36 R $248.36 $248.36 R $248.36 $278.81 R $287.96 $278.89 R $287.96 $278.89 R $287.96 $278.89 R $287.96E2631 RR KU IN $24.84 $24.84 $29.22 $29.22 $29.22 $29.22E2631 RR IN $24.84 R $24.84 $24.84 R $24.84 $27.88 R $28.80 $27.89 R $28.80 $27.89 R $28.80 $27.89 R $28.80E2631 UE KU IN $186.27 $186.27 $219.14 $219.14 $219.14 $219.14E2631 UE IN $186.27 R $186.27 $186.27 R $186.27 $209.11 R $215.97 $209.16 R $215.97 $209.16 R $215.97 $209.16 R $215.97E2632 NU KU IN $160.69 $157.92 $185.79 $185.79 $185.79 $178.42E2632 NU IN $160.32 R $160.69 $157.93 R $157.93 $175.91 R $182.43 $172.87 R $182.43 $172.87 R $182.43 $169.19 R $178.42E2632 RR KU IN $16.07 $15.79 $18.58 $18.58 $18.58 $17.84E2632 RR IN $16.03 R $16.07 $15.79 R $15.79 $17.59 R $18.24 $17.29 R $18.24 $17.29 R $18.24 $16.92 R $17.84E2632 UE KU IN $120.54 $118.44 $139.34 $139.34 $139.34 $133.79E2632 UE IN $120.25 R $120.54 $118.44 R $118.44 $131.93 R $136.82 $129.65 R $136.82 $129.65 R $136.82 $126.88 R $133.79E2633 NU KU IN $133.95 $133.95 $157.59 $154.70 $157.59 $149.92E2633 NU IN $132.28 R $133.95 $132.28 R $133.95 $147.68 R $152.64 $142.65 R $151.19 $144.10 R $152.64 $140.26 R $148.80E2633 RR KU IN $13.40 $13.40 $15.77 $15.47 $15.77 $15.02E2633 RR IN $13.23 R $13.41 $13.23 R $13.41 $14.77 R $15.27 $14.26 R $15.12 $14.41 R $15.27 $14.04 R $14.89E2633 UE KU IN $100.47 $100.47 $118.20 $116.04 $118.20 $112.44E2633 UE IN $99.21 R $100.47 $99.21 R $100.47 $110.77 R $114.48 $107.00 R $113.41 $108.08 R $114.48 $105.20 R $111.60K0001 RR CR $38.09 R $38.15 $41.87 R $41.93 $40.29 R $41.93 $38.09 R $38.15 $38.41 R $38.47 $41.86 R $41.92K0002 RR CR $66.71 R $66.71 $66.71 R $66.71 $66.14 R $66.71 $59.93 R $59.93 $59.93 R $59.93 $66.71 R $66.71K0003 RR CR $68.38 R $68.38 $68.38 R $68.38 $65.72 R $68.38 $60.95 R $60.95 $67.75 R $67.75 $68.38 R $68.38K0004 RR CR $86.19 R $86.19 $86.19 R $86.19 $82.40 R $86.19 $86.19 R $86.19 $86.19 R $86.19 $86.19 R $86.19K0005 NU IN $2,043.83 $2,043.83 $2,043.83 $2,043.83 $2,043.83 $2,043.83K0005 RR IN $204.36 $204.36 $204.36 $204.36 $204.36 $204.36K0005 UE IN $1,532.83 $1,532.83 $1,532.83 $1,532.83 $1,532.83 $1,532.83K0006 RR CR $94.42 R $94.42 $93.02 R $93.02 $102.44 R $103.42 $93.02 R $93.02 $103.42 R $103.42 $93.02 R $93.02K0007 RR CR $145.68 R $145.68 $146.40 R $146.40 $142.23 R $146.40 $139.30 R $139.30 $144.76 R $144.76 $145.99 R $145.99K0009 RR CR $82.20 $82.20 $82.20 $79.01 $82.20 $82.20K0010 RR CR $400.29 $400.29 $470.93 $400.29 $400.29 $400.29





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



K0011 RR KF CR $628.75 $628.76 $628.76 $595.10 $628.75 $628.74K0011 RR CR $566.31 $566.33 $566.33 $536.01 $566.31 $566.30K0012 RR CR $351.71 $359.21 $359.21 $328.81 $348.41 $352.86K0015 RR KE CR $16.82 R $17.43 $16.82 R $17.43 $17.43 R $17.43 $16.82 R $17.43 $16.82 R $17.43 $16.82 R $17.43K0015 RR KU CR $17.31 $17.31 $17.31 $17.31 $17.31 $17.31K0015 RR CR $15.42 R $16.03 $15.42 R $16.03 $16.03 R $16.03 $15.42 R $16.03 $15.42 R $16.03 $15.42 R $16.03K0017 NU KE IN $50.07 $50.07 $50.07 $50.07 $50.07 $50.07K0017 NU KU IN $48.69 $48.69 $48.69 $48.69 $48.69 $48.69K0017 NU IN $46.16 $46.16 $46.16 $46.16 $46.16 $46.16K0017 RR KE IN $5.00 $5.00 $5.00 $5.00 $5.00 $5.00K0017 RR KU IN $4.87 $4.87 $4.87 $4.87 $4.87 $4.87K0017 RR IN $4.62 $4.62 $4.62 $4.62 $4.62 $4.62K0017 UE KE IN $37.56 $37.56 $37.56 $37.56 $37.56 $37.56K0017 UE KU IN $36.52 $36.52 $36.52 $36.52 $36.52 $36.52K0017 UE IN $34.62 $34.62 $34.62 $34.62 $34.62 $34.62K0018 NU KE IN $28.12 $28.12 $28.12 $28.12 $28.12 $28.12K0018 NU KU IN $27.20 $27.20 $27.20 $27.20 $27.20 $27.20K0018 NU IN $25.93 $25.93 $25.93 $25.93 $25.93 $25.93K0018 RR KE IN $2.80 $2.80 $2.80 $2.80 $2.80 $2.80K0018 RR KU IN $2.71 $2.71 $2.71 $2.71 $2.71 $2.71K0018 RR IN $2.59 $2.59 $2.59 $2.59 $2.59 $2.59K0018 UE KE IN $21.09 $21.09 $21.09 $21.09 $21.09 $21.09K0018 UE KU IN $20.41 $20.41 $20.41 $20.41 $20.41 $20.41K0018 UE IN $19.45 $19.45 $19.45 $19.45 $19.45 $19.45K0019 NU KE IN $15.66 R $16.50 $15.66 R $16.50 $16.31 R $16.50 $15.17 R $16.01 $15.53 R $16.36 $15.66 R $16.50K0019 NU KU IN $16.41 $16.41 $16.41 $15.58 $16.19 $16.41K0019 NU IN $14.34 R $15.18 $14.34 R $15.18 $14.99 R $15.18 $13.92 R $14.76 $14.23 R $15.07 $14.34 R $15.18K0019 RR KE IN $1.56 R $1.65 $1.56 R $1.65 $1.63 R $1.65 $1.52 R $1.60 $1.55 R $1.64 $1.56 R $1.65K0019 RR KU IN $1.64 $1.64 $1.64 $1.56 $1.62 $1.64K0019 RR IN $1.44 R $1.52 $1.44 R $1.52 $1.50 R $1.52 $1.40 R $1.48 $1.43 R $1.51 $1.44 R $1.52K0019 UE KE IN $11.75 R $12.38 $11.75 R $12.38 $12.24 R $12.38 $11.37 R $12.00 $11.65 R $12.28 $11.75 R $12.38K0019 UE KU IN $12.32 $12.32 $12.32 $11.67 $12.15 $12.32K0019 UE IN $10.76 R $11.39 $10.76 R $11.39 $11.24 R $11.39 $10.44 R $11.06 $10.68 R $11.30 $10.76 R $11.39K0020 NU KE IN $47.05 $47.05 $47.05 $47.05 $47.05 $47.05K0020 NU KU IN $44.27 $44.27 $44.27 $44.27 $44.27 $44.27K0020 NU IN $43.51 $43.51 $43.51 $43.51 $43.51 $43.51K0020 RR KE IN $4.71 $4.71 $4.71 $4.71 $4.71 $4.71K0020 RR KU IN $4.43 $4.43 $4.43 $4.43 $4.43 $4.43K0020 RR IN $4.35 $4.35 $4.35 $4.35 $4.35 $4.35K0020 UE KE IN $35.28 $35.28 $35.28 $35.28 $35.28 $35.28K0020 UE KU IN $33.20 $33.20 $33.20 $33.20 $33.20 $33.20K0020 UE IN $32.63 $32.63 $32.63 $32.63 $32.63 $32.63K0037 NU KE IN $43.15 $43.15 $47.14 $47.14 $47.14 $43.15K0037 NU KU IN $39.01 $39.01 $45.89 $45.89 $45.89 $39.01K0037 NU IN $39.00 $39.00 $43.47 $43.47 $43.47 $39.00K0037 RR KE IN $4.05 $4.05 $4.44 $4.44 $4.44 $4.05K0037 RR KU IN $3.48 $3.48 $4.09 $4.09 $4.09 $3.48K0037 RR IN $3.48 $3.48 $4.09 $4.09 $4.09 $3.48K0037 UE KE IN $32.37 $32.37 $35.37 $35.37 $35.37 $32.37K0037 UE KU IN $29.27 $29.27 $34.43 $34.43 $34.43 $29.27K0037 UE IN $29.26 $29.26 $32.61 $32.61 $32.61 $29.26K0038 NU KE IN $24.31 $24.31 $24.31 $24.31 $24.31 $24.31K0038 NU KU IN $23.13 $23.13 $23.13 $23.13 $23.13 $23.13K0038 NU IN $22.47 $22.47 $22.47 $22.47 $22.47 $22.47K0038 RR KE IN $2.44 $2.44 $2.44 $2.44 $2.44 $2.44K0038 RR KU IN $2.31 $2.31 $2.31 $2.31 $2.31 $2.31K0038 RR IN $2.25 $2.25 $2.25 $2.25 $2.25 $2.25K0038 UE KE IN $18.24 $18.24 $18.24 $18.24 $18.24 $18.24K0038 UE KU IN $17.33 $17.33 $17.33 $17.33 $17.33 $17.33K0038 UE IN $16.84 $16.84 $16.84 $16.84 $16.84 $16.84K0039 NU KE IN $53.19 $53.19 $53.19 $53.19 $53.19 $53.19





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



K0039 NU KU IN $51.33 $51.33 $51.33 $51.33 $51.33 $51.33K0039 NU IN $49.08 $49.08 $49.08 $49.08 $49.08 $49.08K0039 RR KE IN $5.33 $5.33 $5.33 $5.33 $5.33 $5.33K0039 RR KU IN $5.16 $5.16 $5.16 $5.16 $5.16 $5.16K0039 RR IN $4.92 $4.92 $4.92 $4.92 $4.92 $4.92K0039 UE KE IN $39.90 $39.90 $39.90 $39.90 $39.90 $39.90K0039 UE KU IN $38.51 $38.51 $38.51 $38.51 $38.51 $38.51K0039 UE IN $36.81 $36.81 $36.81 $36.81 $36.81 $36.81K0040 NU KE IN $66.92 R $68.76 $66.92 R $68.76 $66.69 R $68.76 $66.92 R $68.76 $66.92 R $68.76 $66.92 R $68.76K0040 NU KU IN $71.15 $71.15 $71.15 $71.15 $71.15 $71.15K0040 NU IN $61.23 R $63.06 $61.23 R $63.06 $61.00 R $63.06 $61.23 R $63.06 $61.23 R $63.06 $61.23 R $63.06K0040 RR KE IN $6.68 R $6.86 $6.68 R $6.86 $6.66 R $6.86 $6.68 R $6.86 $6.68 R $6.86 $6.68 R $6.86K0040 RR KU IN $7.10 $7.10 $7.10 $7.10 $7.10 $7.10K0040 RR IN $6.12 R $6.30 $6.12 R $6.30 $6.09 R $6.30 $6.12 R $6.30 $6.12 R $6.30 $6.12 R $6.30K0040 UE KE IN $50.19 R $51.57 $50.19 R $51.57 $50.02 R $51.57 $50.19 R $51.57 $50.19 R $51.57 $50.19 R $51.57K0040 UE KU IN $53.34 $53.34 $53.34 $53.34 $53.34 $53.34K0040 UE IN $45.91 R $47.28 $45.91 R $47.28 $45.74 R $47.28 $45.91 R $47.28 $45.91 R $47.28 $45.91 R $47.28K0041 NU KE IN $51.62 $51.62 $51.62 $51.62 $51.62 $51.62K0041 NU KU IN $50.42 $50.42 $50.42 $50.42 $50.42 $50.42K0041 NU IN $47.58 $47.58 $47.58 $47.58 $47.58 $47.58K0041 RR KE IN $5.18 $5.18 $5.18 $5.18 $5.18 $5.18K0041 RR KU IN $5.08 $5.08 $5.08 $5.08 $5.08 $5.08K0041 RR IN $4.78 $4.78 $4.78 $4.78 $4.78 $4.78K0041 UE KE IN $38.72 $38.72 $38.72 $38.72 $38.72 $38.72K0041 UE KU IN $37.81 $37.81 $37.81 $37.81 $37.81 $37.81K0041 UE IN $35.69 $35.69 $35.69 $35.69 $35.69 $35.69K0042 NU KE IN $31.49 $32.79 $34.50 $34.50 $34.50 $33.30K0042 NU KU IN $29.51 $31.74 $34.72 $34.72 $34.72 $32.64K0042 NU IN $29.12 $30.24 $31.73 $31.73 $31.73 $30.69K0042 RR KE IN $3.15 $3.30 $3.44 $3.44 $3.44 $3.34K0042 RR KU IN $2.95 $3.20 $3.47 $3.47 $3.47 $3.28K0042 RR IN $2.91 $3.04 $3.17 $3.17 $3.17 $3.08K0042 UE KE IN $23.62 $24.59 $25.88 $25.88 $25.88 $24.99K0042 UE KU IN $22.13 $23.82 $26.03 $26.03 $26.03 $24.49K0042 UE IN $21.84 $22.69 $23.79 $23.79 $23.79 $23.02K0043 NU KE IN $19.67 $19.67 $19.67 $19.67 $19.67 $19.67K0043 NU KU IN $18.60 $18.60 $18.60 $18.60 $18.60 $18.60K0043 NU IN $18.17 $18.17 $18.17 $18.17 $18.17 $18.17K0043 RR KE IN $1.97 $1.97 $1.97 $1.97 $1.97 $1.97K0043 RR KU IN $1.85 $1.85 $1.85 $1.85 $1.85 $1.85K0043 RR IN $1.81 $1.81 $1.81 $1.81 $1.81 $1.81K0043 UE KE IN $14.76 $14.76 $14.76 $14.76 $14.76 $14.76K0043 UE KU IN $13.98 $13.98 $13.98 $13.98 $13.98 $13.98K0043 UE IN $13.65 $13.65 $13.65 $13.65 $13.65 $13.65K0044 NU KE IN $16.91 $16.91 $16.91 $16.91 $16.91 $16.91K0044 NU KU IN $15.86 $15.86 $15.86 $15.86 $15.86 $15.86K0044 NU IN $15.65 $15.65 $15.65 $15.65 $15.65 $15.65K0044 RR KE IN $1.69 $1.69 $1.69 $1.69 $1.69 $1.69K0044 RR KU IN $1.59 $1.59 $1.59 $1.59 $1.59 $1.59K0044 RR IN $1.57 $1.57 $1.57 $1.57 $1.57 $1.57K0044 UE KE IN $12.69 $12.69 $12.69 $12.69 $12.69 $12.69K0044 UE KU IN $11.89 $11.89 $11.89 $11.89 $11.89 $11.89K0044 UE IN $11.73 $11.73 $11.73 $11.73 $11.73 $11.73K0045 NU KE IN $56.69 $56.69 $56.69 $56.69 $56.69 $56.69K0045 NU KU IN $53.95 $53.95 $53.95 $53.95 $53.95 $53.95K0045 NU IN $52.36 $52.36 $52.36 $52.36 $52.36 $52.36K0045 RR KE IN $5.77 $5.77 $5.77 $5.67 $5.77 $5.77K0045 RR KU IN $5.56 $5.56 $5.56 $5.39 $5.56 $5.56K0045 RR IN $5.32 $5.32 $5.32 $5.23 $5.32 $5.32K0045 UE KE IN $42.52 $42.52 $42.52 $42.52 $42.52 $42.52K0045 UE KU IN $40.47 $40.47 $40.47 $40.47 $40.47 $40.47





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



K0045 UE IN $39.28 $39.28 $39.28 $39.28 $39.28 $39.28K0046 NU KE IN $19.73 $19.73 $19.73 $19.73 $19.73 $19.73K0046 NU KU IN $18.60 $18.60 $18.60 $18.60 $18.60 $18.60K0046 NU IN $18.23 $18.23 $18.23 $18.23 $18.23 $18.23K0046 RR KE IN $1.97 $1.97 $1.97 $1.97 $1.97 $1.97K0046 RR KU IN $1.85 $1.85 $1.85 $1.85 $1.85 $1.85K0046 RR IN $1.82 $1.82 $1.82 $1.82 $1.82 $1.82K0046 UE KE IN $14.80 $14.80 $14.80 $14.80 $14.80 $14.80K0046 UE KU IN $13.98 $13.98 $13.98 $13.98 $13.98 $13.98K0046 UE IN $13.69 $13.69 $13.69 $13.69 $13.69 $13.69K0047 NU KE IN $73.83 $73.83 $73.83 $73.83 $73.83 $73.83K0047 NU KU IN $72.87 $72.87 $72.87 $72.87 $72.87 $72.87K0047 NU IN $67.99 $67.99 $67.99 $67.99 $67.99 $67.99K0047 RR KE IN $7.39 $7.39 $7.39 $7.39 $7.39 $7.39K0047 RR KU IN $7.31 $7.31 $7.31 $7.31 $7.31 $7.31K0047 RR IN $6.81 $6.81 $6.81 $6.81 $6.81 $6.81K0047 UE KE IN $55.36 $55.36 $55.36 $55.36 $55.36 $55.36K0047 UE KU IN $54.63 $54.63 $54.63 $54.63 $54.63 $54.63K0047 UE IN $50.98 $50.98 $50.98 $50.98 $50.98 $50.98K0050 NU KE IN $32.61 $32.61 $32.61 $32.61 $32.61 $32.61K0050 NU IN $30.12 $30.12 $30.12 $30.12 $30.12 $30.12K0050 RR KE IN $3.26 $3.26 $3.26 $3.26 $3.26 $3.26K0050 RR IN $3.01 $3.01 $3.01 $3.01 $3.01 $3.01K0050 UE KE IN $24.46 $24.46 $24.46 $24.46 $24.46 $24.46K0050 UE IN $22.60 $22.60 $22.60 $22.60 $22.60 $22.60K0051 NU KE IN $52.23 $52.23 $52.23 $52.23 $52.23 $52.23K0051 NU KU IN $50.12 $50.12 $50.12 $50.12 $50.12 $50.12K0051 NU IN $48.22 $48.22 $48.22 $48.22 $48.22 $48.22K0051 RR KE IN $5.24 $5.24 $5.24 $5.24 $5.24 $5.24K0051 RR KU IN $5.04 $5.04 $5.04 $5.04 $5.04 $5.04K0051 RR IN $4.84 $4.84 $4.84 $4.84 $4.84 $4.84K0051 UE KE IN $39.17 $39.17 $39.17 $39.17 $39.17 $39.17K0051 UE KU IN $37.58 $37.58 $37.58 $37.58 $37.58 $37.58K0051 UE IN $36.16 $36.16 $36.16 $36.16 $36.16 $36.16K0052 NU KE IN $85.21 R $88.06 $85.21 R $88.06 $87.15 R $88.06 $85.21 R $88.06 $85.21 R $88.06 $85.21 R $88.06K0052 NU KU IN $88.09 $88.09 $88.09 $88.09 $88.09 $88.09K0052 NU IN $78.15 R $81.00 $78.15 R $81.00 $80.10 R $81.00 $78.15 R $81.00 $78.15 R $81.00 $78.15 R $81.00K0052 RR KE IN $8.52 R $8.80 $8.52 R $8.80 $8.71 R $8.80 $8.52 R $8.80 $8.52 R $8.80 $8.52 R $8.80K0052 RR KU IN $8.80 $8.80 $8.80 $8.80 $8.80 $8.80K0052 RR IN $7.81 R $8.10 $7.81 R $8.10 $8.01 R $8.10 $7.81 R $8.10 $7.81 R $8.10 $7.81 R $8.10K0052 UE KE IN $63.91 R $66.05 $63.91 R $66.05 $65.37 R $66.05 $63.91 R $66.05 $63.91 R $66.05 $63.91 R $66.05K0052 UE KU IN $66.04 $66.04 $66.04 $66.04 $66.04 $66.04K0052 UE IN $58.61 R $60.74 $58.61 R $60.74 $60.06 R $60.74 $58.61 R $60.74 $58.61 R $60.74 $58.61 R $60.74K0053 NU KE IN $96.40 R $100.68 $96.40 R $100.68 $97.06 R $100.68 $96.40 R $100.68 $96.40 R $100.68 $96.40 R $100.68K0053 NU KU IN $97.20 $97.20 $97.20 $97.20 $97.20 $97.20K0053 NU IN $88.61 R $92.90 $88.61 R $92.90 $89.27 R $92.90 $88.61 R $92.90 $88.61 R $92.90 $88.61 R $92.90K0053 RR KE IN $9.64 R $10.07 $9.64 R $10.07 $9.70 R $10.07 $9.64 R $10.07 $9.64 R $10.07 $9.64 R $10.07K0053 RR KU IN $9.71 $9.71 $9.71 $9.71 $9.71 $9.71K0053 RR IN $8.86 R $9.29 $8.86 R $9.29 $8.92 R $9.29 $8.86 R $9.29 $8.86 R $9.29 $8.86 R $9.29K0053 UE KE IN $72.31 R $75.52 $72.31 R $75.52 $72.81 R $75.52 $72.31 R $75.52 $72.31 R $75.52 $72.31 R $75.52K0053 UE KU IN $72.90 $72.90 $72.90 $72.90 $72.90 $72.90K0053 UE IN $66.46 R $69.67 $66.46 R $69.67 $66.95 R $69.67 $66.46 R $69.67 $66.46 R $69.67 $66.46 R $69.67K0056 NU KU IN $105.14 $105.14 $105.14 $105.14 $105.14 $105.14K0056 NU IN $97.86 R $101.38 $97.86 R $101.38 $98.86 R $101.38 $97.86 R $101.38 $97.86 R $101.38 $97.86 R $101.38K0056 RR KU IN $10.52 $10.52 $10.52 $10.52 $10.52 $10.52K0056 RR IN $9.79 R $10.14 $9.79 R $10.14 $9.89 R $10.14 $9.79 R $10.14 $9.79 R $10.14 $9.79 R $10.14K0056 UE KU IN $78.87 $78.87 $78.87 $78.87 $78.87 $78.87K0056 UE IN $73.41 R $76.04 $73.41 R $76.04 $74.15 R $76.04 $73.41 R $76.04 $73.41 R $76.04 $73.41 R $76.04K0065 NU KU IN $49.14 $49.14 $49.14 $49.14 $49.14 $49.14K0065 NU IN $46.06 R $48.86 $46.06 R $48.86 $46.97 R $48.86 $46.06 R $48.86 $46.06 R $48.86 $46.06 R $48.86K0065 RR KU IN $4.92 $4.92 $4.92 $4.92 $4.92 $4.92





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



K0065 RR IN $4.61 R $4.89 $4.61 R $4.89 $4.70 R $4.89 $4.61 R $4.89 $4.61 R $4.89 $4.61 R $4.89K0065 UE KU IN $36.86 $36.86 $36.86 $36.86 $36.86 $36.86K0065 UE IN $34.55 R $36.65 $34.55 R $36.65 $35.23 R $36.65 $34.55 R $36.65 $34.55 R $36.65 $34.55 R $36.65K0069 NU KU IN $110.48 $110.48 $110.48 $110.48 $110.48 $110.48K0069 NU IN $100.32 R $104.80 $100.32 R $104.80 $101.09 R $104.80 $100.32 R $104.80 $100.32 R $104.80 $100.32 R $104.80K0069 RR KU IN $11.50 $11.50 $11.50 $11.05 $11.50 $11.50K0069 RR IN $10.26 R $10.71 $10.26 R $10.71 $10.34 R $10.71 $10.03 R $10.48 $10.26 R $10.71 $10.26 R $10.71K0069 UE KU IN $82.85 $82.85 $82.85 $82.85 $82.85 $82.85K0069 UE IN $75.23 R $78.59 $75.23 R $78.59 $75.81 R $78.59 $75.23 R $78.59 $75.23 R $78.59 $75.23 R $78.59K0070 RR KU CR $20.27 $20.27 $20.27 $20.27 $20.27 $20.27K0070 RR CR $18.09 R $18.45 $18.09 R $18.45 $17.74 R $18.45 $18.09 R $18.45 $18.09 R $18.45 $18.09 R $18.45K0071 NU KU IN $120.77 $120.77 $120.77 $120.77 $120.77 $120.77K0071 NU IN $111.55 R $117.65 $111.55 R $117.65 $110.81 R $117.65 $111.55 R $117.65 $111.55 R $117.65 $111.55 R $117.65K0071 RR KU IN $12.09 $12.09 $12.09 $12.09 $12.09 $12.09K0071 RR IN $11.16 R $11.77 $11.16 R $11.77 $11.09 R $11.77 $11.16 R $11.77 $11.16 R $11.77 $11.16 R $11.77K0071 UE KU IN $90.56 $90.56 $90.56 $90.56 $90.56 $90.56K0071 UE IN $83.65 R $88.23 $83.65 R $88.23 $83.10 R $88.23 $83.65 R $88.23 $83.65 R $88.23 $83.65 R $88.23K0072 NU KU IN $72.71 $72.71 $72.71 $72.71 $72.71 $72.71K0072 NU IN $68.32 R $71.81 $68.32 R $71.81 $68.67 R $71.81 $68.32 R $71.81 $68.32 R $71.81 $68.32 R $71.81K0072 RR KU IN $7.27 $7.27 $7.27 $7.27 $7.27 $7.27K0072 RR IN $6.83 R $7.18 $6.83 R $7.18 $6.87 R $7.18 $6.83 R $7.18 $6.83 R $7.18 $6.83 R $7.18K0072 UE KU IN $54.52 $54.52 $54.52 $54.52 $54.52 $54.52K0072 UE IN $51.23 R $53.86 $51.23 R $53.86 $51.50 R $53.86 $51.23 R $53.86 $51.23 R $53.86 $51.23 R $53.86K0073 NU KU IN $38.48 $38.48 $38.48 $36.99 $38.48 $38.48K0073 NU IN $35.96 R $37.80 $35.96 R $37.80 $36.17 R $37.80 $35.22 R $36.99 $35.96 R $37.80 $35.96 R $37.80K0073 RR KU IN $3.85 $3.85 $3.85 $3.74 $3.85 $3.85K0073 RR IN $3.60 R $3.78 $3.60 R $3.78 $3.62 R $3.78 $3.54 R $3.72 $3.60 R $3.78 $3.60 R $3.78K0073 UE KU IN $28.85 $28.85 $28.85 $27.73 $28.85 $28.85K0073 UE IN $26.97 R $28.35 $26.97 R $28.35 $27.13 R $28.35 $26.41 R $27.73 $26.97 R $28.35 $26.97 R $28.35K0077 NU KU IN $65.07 $65.07 $65.07 $65.07 $65.07 $65.07K0077 NU IN $58.58 R $60.58 $58.58 R $60.58 $60.18 R $60.58 $58.58 R $60.58 $58.58 R $60.58 $58.58 R $60.58K0077 RR KU IN $6.49 $6.49 $6.49 $6.49 $6.49 $6.49K0077 RR IN $5.85 R $6.05 $5.85 R $6.05 $6.01 R $6.05 $5.85 R $6.05 $5.85 R $6.05 $5.85 R $6.05K0077 UE KU IN $48.78 $48.78 $48.78 $48.78 $48.78 $48.78K0077 UE IN $43.93 R $45.43 $43.93 R $45.43 $45.13 R $45.43 $43.93 R $45.43 $43.93 R $45.43 $43.93 R $45.43K0098 NU KE IN $26.21 R $27.50 $26.21 R $27.50 $26.23 R $27.50 $25.77 R $27.07 $26.21 R $27.50 $26.21 R $27.50K0098 NU KU IN $25.93 $25.93 $25.93 $25.17 $25.93 $25.93K0098 NU IN $24.13 R $25.43 $24.13 R $25.43 $24.15 R $25.43 $23.76 R $25.05 $24.13 R $25.43 $24.13 R $25.43K0098 RR KE IN $2.62 R $2.75 $2.62 R $2.75 $2.62 R $2.75 $2.58 R $2.71 $2.62 R $2.75 $2.62 R $2.75K0098 RR KU IN $2.60 $2.60 $2.60 $2.53 $2.60 $2.60K0098 RR IN $2.42 R $2.55 $2.42 R $2.55 $2.42 R $2.55 $2.38 R $2.51 $2.42 R $2.55 $2.42 R $2.55K0098 UE KE IN $19.65 R $20.62 $19.65 R $20.62 $19.66 R $20.62 $19.33 R $20.30 $19.65 R $20.62 $19.65 R $20.62K0098 UE KU IN $19.42 $19.42 $19.42 $18.87 $19.42 $19.42K0098 UE IN $18.09 R $19.06 $18.09 R $19.06 $18.11 R $19.06 $17.82 R $18.79 $18.09 R $19.06 $18.09 R $19.06K0105 NU KU IN $109.92 $109.92 $109.92 $109.92 $109.92 $109.92K0105 NU IN $102.12 R $107.20 $102.12 R $107.20 $101.99 R $107.20 $102.12 R $107.20 $102.12 R $107.20 $102.12 R $107.20K0105 RR KU IN $10.99 $10.99 $10.99 $10.99 $10.99 $10.99K0105 RR IN $10.21 R $10.72 $10.21 R $10.72 $10.20 R $10.72 $10.21 R $10.72 $10.21 R $10.72 $10.21 R $10.72K0105 UE KU IN $82.44 $82.44 $82.44 $82.44 $82.44 $82.44K0105 UE IN $76.59 R $80.40 $76.59 R $80.40 $76.49 R $80.40 $76.59 R $80.40 $76.59 R $80.40 $76.59 R $80.40K0195 RR KE CR $17.08 R $17.41 $17.08 R $17.41 $16.88 R $17.41 $16.34 R $16.67 $17.00 R $17.34 $17.08 R $17.41K0195 RR CR $15.47 R $15.81 $15.47 R $15.81 $15.28 R $15.81 $14.83 R $15.17 $15.40 R $15.74 $15.47 R $15.81K0455 RR FS $286.73 $292.81 $292.81 $268.04 $284.04 $292.81K0552 SU $2.77 $2.77 $2.77 $2.75 $2.77 $2.77K0601 NU IN $1.20 $1.20 $1.20 $1.20 $1.20 $1.20K0602 NU IN $6.84 $6.84 $6.84 $6.84 $6.84 $6.84K0603 NU IN $0.61 $0.61 $0.61 $0.61 $0.61 $0.61K0604 NU IN $6.57 $6.57 $6.57 $6.57 $6.57 $6.57K0605 NU IN $15.74 $15.74 $15.74 $15.74 $15.74 $15.74K0606 RR KF CR $2,783.98 $2,783.98 $2,783.98 $2,783.98 $2,783.98 $2,783.98K0607 RR KF CR $23.84 $23.84 $23.84 $23.84 $23.84 $23.84





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



K0607 RR CR $21.48 $21.48 $21.48 $21.48 $21.48 $21.48K0608 NU KF IN $148.79 $148.79 $148.79 $148.79 $148.79 $148.79K0608 NU IN $133.99 $133.99 $133.99 $133.99 $133.99 $133.99K0608 RR KF IN $14.90 $14.90 $14.90 $14.90 $14.90 $14.90K0608 RR IN $13.43 $13.43 $13.43 $13.43 $13.43 $13.43K0608 UE KF IN $111.58 $111.58 $111.58 $111.58 $111.58 $111.58K0608 UE IN $100.50 $100.50 $100.50 $100.50 $100.50 $100.50K0609 KF SU $989.39 $989.39 $989.39 $989.39 $989.39 $989.39K0609 SU $891.13 $891.13 $891.13 $891.13 $891.13 $891.13K0672 PO $81.28 $81.27 $81.73 $81.28 $81.28 $81.27K0730 RR CR $190.59 $190.59 $190.59 $190.59 $190.59 $190.59K0733 NU KE IN $30.00 R $31.55 $30.00 R $31.55 $30.73 R $31.55 $30.00 R $31.55 $30.00 R $31.55 $30.00 R $31.55K0733 NU KU IN $28.78 $28.78 $28.78 $28.78 $28.78 $28.78K0733 NU IN $27.68 R $28.78 $27.68 R $28.78 $28.42 R $28.78 $27.68 R $28.78 $27.68 R $28.78 $27.68 R $28.78K0733 RR KE IN $3.01 R $3.17 $3.01 R $3.17 $3.09 R $3.17 $3.01 R $3.17 $3.01 R $3.17 $3.01 R $3.17K0733 RR KU IN $2.90 $2.90 $2.90 $2.90 $2.90 $2.90K0733 RR IN $2.78 R $2.90 $2.78 R $2.90 $2.85 R $2.90 $2.78 R $2.90 $2.78 R $2.90 $2.78 R $2.90K0733 UE KE IN $22.50 R $23.66 $22.50 R $23.66 $23.05 R $23.66 $22.50 R $23.66 $22.50 R $23.66 $22.50 R $23.66K0733 UE KU IN $21.60 $21.60 $21.60 $21.60 $21.60 $21.60K0733 UE IN $20.77 R $21.60 $20.77 R $21.60 $21.32 R $21.60 $20.77 R $21.60 $20.77 R $21.60 $20.77 R $21.60K0738 RR OX $44.71 R $46.90 $44.71 R $46.90 $45.61 R $46.90 $44.71 R $46.90 $44.71 R $46.90 $44.71 R $46.90K0800 NU IN $1,031.00 R $1,058.65 $1,031.00 R $1,058.65 $1,013.08 R $1,058.65 $1,031.00 R $1,058.65 $1,031.00 R $1,058.65 $1,031.00 R $1,058.65K0800 RR IN $103.11 R $105.87 $103.11 R $105.87 $101.31 R $105.87 $103.11 R $105.87 $103.11 R $105.87 $103.11 R $105.87K0800 UE IN $773.25 R $793.99 $773.25 R $793.99 $759.81 R $793.99 $773.25 R $793.99 $773.25 R $793.99 $773.25 R $793.99K0801 NU IN $1,738.27 R $1,801.60 $1,738.27 R $1,801.60 $1,736.12 R $1,801.60 $1,738.27 R $1,801.60 $1,738.27 R $1,801.60 $1,738.27 R $1,801.60K0801 RR IN $173.81 R $180.15 $173.81 R $180.15 $173.60 R $180.15 $173.81 R $180.15 $173.81 R $180.15 $173.81 R $180.15K0801 UE IN $1,303.71 R $1,351.20 $1,303.71 R $1,351.20 $1,302.09 R $1,351.20 $1,303.71 R $1,351.20 $1,303.71 R $1,351.20 $1,303.71 R $1,351.20K0802 NU IN $2,098.31 R $2,190.53 $2,098.31 R $2,190.53 $2,088.85 R $2,190.53 $2,098.31 R $2,190.53 $2,098.31 R $2,190.53 $2,098.31 R $2,190.53K0802 RR IN $209.83 R $219.05 $209.83 R $219.05 $208.88 R $219.05 $209.83 R $219.05 $209.83 R $219.05 $209.83 R $219.05K0802 UE IN $1,573.73 R $1,642.90 $1,573.73 R $1,642.90 $1,566.63 R $1,642.90 $1,573.73 R $1,642.90 $1,573.73 R $1,642.90 $1,573.73 R $1,642.90K0806 NU IN $1,391.75 $1,391.75 $1,391.75 $1,391.75 $1,391.75 $1,391.75K0806 RR IN $139.17 $139.17 $139.17 $139.17 $139.17 $139.17K0806 UE IN $1,043.82 $1,043.82 $1,043.82 $1,043.82 $1,043.82 $1,043.82K0807 NU IN $2,132.76 $2,132.76 $2,132.76 $2,132.76 $2,132.76 $2,132.76K0807 RR IN $213.28 $213.28 $213.28 $213.28 $213.28 $213.28K0807 UE IN $1,599.58 $1,599.58 $1,599.58 $1,599.58 $1,599.58 $1,599.58K0808 NU IN $3,298.44 $3,298.44 $3,298.44 $3,298.44 $3,298.44 $3,298.44K0808 RR IN $329.84 $329.84 $329.84 $329.84 $329.84 $329.84K0808 UE IN $2,473.83 $2,473.83 $2,473.83 $2,473.83 $2,473.83 $2,473.83K0813 RR CR $298.42 R $310.79 $298.42 R $310.79 $299.79 R $310.79 $298.42 R $310.79 $298.42 R $310.79 $298.42 R $310.79K0814 RR CR $355.31 R $366.34 $355.31 R $366.34 $354.17 R $366.34 $355.31 R $366.34 $355.31 R $366.34 $355.31 R $366.34K0815 RR CR $381.08 R $393.89 $381.08 R $393.89 $383.02 R $393.89 $381.08 R $393.89 $381.08 R $393.89 $381.08 R $393.89K0816 RR CR $380.43 R $389.97 $380.43 R $389.97 $374.15 R $389.97 $380.43 R $389.97 $380.43 R $389.97 $380.43 R $389.97K0820 RR CR $313.94 R $326.76 $313.94 R $326.76 $315.89 R $326.76 $313.94 R $326.76 $313.94 R $326.76 $313.94 R $326.76K0821 RR CR $376.35 R $385.98 $376.35 R $385.98 $369.88 R $385.98 $376.35 R $385.98 $376.35 R $385.98 $376.35 R $385.98K0822 RR CR $435.17 R $445.73 $435.17 R $445.73 $425.81 R $445.73 $435.17 R $445.73 $435.17 R $445.73 $435.17 R $445.73K0823 RR CR $428.08 R $437.40 $428.08 R $437.40 $421.06 R $437.40 $428.08 R $437.40 $428.08 R $437.40 $428.08 R $437.40K0824 RR CR $561.53 R $574.86 $561.53 R $574.86 $554.72 R $574.86 $561.53 R $574.86 $561.53 R $574.86 $561.53 R $574.86K0825 RR CR $512.68 R $528.40 $512.68 R $528.40 $508.19 R $528.40 $512.68 R $528.40 $512.68 R $528.40 $512.68 R $528.40K0826 RR CR $800.24 R $830.07 $800.24 R $830.07 $805.69 R $830.07 $800.24 R $830.07 $800.24 R $830.07 $800.24 R $830.07K0827 RR CR $690.30 R $713.72 $690.30 R $713.72 $679.92 R $713.72 $690.30 R $713.72 $690.30 R $713.72 $690.30 R $713.72K0828 RR CR $902.50 R $963.75 $902.50 R $963.75 $933.71 R $963.75 $902.50 R $963.75 $902.50 R $963.75 $902.50 R $963.75K0829 RR CR $861.73 R $906.70 $861.73 R $906.70 $879.87 R $906.70 $861.73 R $906.70 $861.73 R $906.70 $861.73 R $906.70K0835 RR CR $456.11 $456.11 $456.11 $456.11 $456.11 $456.11K0836 RR CR $473.04 $473.04 $473.04 $473.04 $473.04 $473.04K0837 RR CR $559.19 $559.19 $559.19 $559.19 $559.19 $559.19K0838 RR CR $498.48 $498.48 $498.48 $498.48 $498.48 $498.48K0839 RR CR $731.13 $731.13 $731.13 $731.13 $731.13 $731.13K0840 RR CR $1,113.40 $1,113.40 $1,113.40 $1,113.40 $1,113.40 $1,113.40K0841 RR CR $495.88 $495.88 $495.88 $495.88 $495.88 $495.88K0842 RR CR $495.60 $495.60 $495.60 $495.60 $495.60 $495.60





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



K0843 RR CR $593.54 $593.54 $593.54 $593.54 $593.54 $593.54K0848 RR CR $755.28 $755.28 $755.28 $755.28 $755.28 $755.28K0849 RR CR $726.16 $726.16 $726.16 $726.16 $726.16 $726.16K0850 RR CR $876.10 $876.10 $876.10 $876.10 $876.10 $876.10K0851 RR CR $842.37 $842.37 $842.37 $842.37 $842.37 $842.37K0852 RR CR $1,012.27 $1,012.27 $1,012.27 $1,012.27 $1,012.27 $1,012.27K0853 RR CR $1,039.86 $1,039.86 $1,039.86 $1,039.86 $1,039.86 $1,039.86K0854 RR CR $1,377.59 $1,377.59 $1,377.59 $1,377.59 $1,377.59 $1,377.59K0855 RR CR $1,301.34 $1,301.34 $1,301.34 $1,301.34 $1,301.34 $1,301.34K0856 RR CR $810.71 $810.71 $810.71 $810.71 $810.71 $810.71K0857 RR CR $826.96 $826.96 $826.96 $826.96 $826.96 $826.96K0858 RR CR $1,005.86 $1,005.86 $1,005.86 $1,005.86 $1,005.86 $1,005.86K0859 RR CR $959.28 $959.28 $959.28 $959.28 $959.28 $959.28K0860 RR CR $1,436.99 $1,436.99 $1,436.99 $1,436.99 $1,436.99 $1,436.99K0861 RR KF CR $1,045.98 $1,045.98 $1,045.98 $1,045.98 $1,045.98 $1,045.98K0861 RR CR $812.01 $812.01 $812.01 $812.01 $812.01 $812.01K0862 RR CR $1,005.86 $1,005.86 $1,005.86 $1,005.86 $1,005.86 $1,005.86K0863 RR CR $1,436.99 $1,436.99 $1,436.99 $1,436.99 $1,436.99 $1,436.99K0864 RR CR $1,710.03 $1,710.03 $1,710.03 $1,710.03 $1,710.03 $1,710.03K0901 PO $860.01 $859.93 $864.78 $860.01 $860.01 $859.93K0902 PO $897.78 $834.93 $752.49 $897.78 $897.78 $834.93L0112 PO $1,341.53 $1,341.41 $1,348.92 $1,341.53 $1,341.53 $1,341.41L0113 PO $273.35 $273.33 $274.86 $273.35 $273.35 $273.33L0120 PO $26.81 $23.65 $23.65 $26.81 $26.81 $23.65L0130 PO $193.91 $145.43 $145.43 $193.91 $193.91 $145.43L0140 PO $66.91 $58.22 $64.43 $66.91 $66.91 $58.22L0150 PO $111.58 $96.33 $96.33 $111.58 $111.58 $96.33L0160 PO $158.87 $186.15 $139.61 $158.87 $158.87 $186.15L0170 PO $672.28 $609.73 $574.88 $672.28 $672.28 $609.73L0172 PO $136.31 $125.63 $117.57 $136.31 $136.31 $125.63L0174 PO $244.87 $244.87 $286.42 $244.87 $244.87 $244.87L0180 PO $333.02 $366.92 $330.28 $333.02 $333.02 $366.92L0190 PO $501.32 $475.13 $458.49 $501.32 $501.32 $475.13L0200 PO $460.32 $530.91 $497.92 $460.32 $460.32 $530.91L0220 PO $109.17 $145.56 $109.17 $109.17 $109.17 $145.56L0450 PO $180.23 $154.92 $154.92 $180.23 $180.23 $154.92L0454 PO $332.42 $332.39 $334.26 $332.42 $332.42 $332.39L0455 PO $332.42 $332.39 $334.26 $332.42 $332.42 $332.39L0456 PO $953.30 $953.21 $958.56 $953.30 $953.30 $953.21L0457 PO $953.30 $953.21 $958.56 $953.30 $953.30 $953.21L0458 PO $854.82 $854.75 $859.53 $854.82 $854.82 $854.75L0460 PO $962.18 $962.10 $967.49 $962.18 $962.18 $962.10L0462 PO $1,196.77 $1,196.64 $1,203.38 $1,196.77 $1,196.77 $1,196.64L0464 PO $1,424.74 $1,424.60 $1,432.59 $1,424.74 $1,424.74 $1,424.60L0466 PO $366.36 $381.59 $347.97 $366.36 $366.36 $381.59L0467 PO $366.36 $381.59 $347.97 $366.36 $366.36 $381.59L0468 PO $459.32 $441.79 $408.60 $459.32 $459.32 $441.79L0469 PO $459.32 $441.79 $408.60 $459.32 $459.32 $441.79L0470 PO $653.94 $568.31 $568.31 $653.94 $653.94 $568.31L0472 PO $410.48 $396.70 $360.43 $410.48 $410.48 $396.70L0480 PO $1,269.29 $1,366.87 $1,577.28 $1,269.29 $1,269.29 $1,366.87L0482 PO $1,455.08 $1,382.30 $1,763.66 $1,455.08 $1,455.08 $1,382.30L0484 PO $1,696.59 $1,584.13 $1,903.50 $1,696.59 $1,696.59 $1,584.13L0486 PO $1,680.68 $1,709.39 $1,928.66 $1,680.68 $1,680.68 $1,709.39L0488 PO $962.18 $962.10 $967.49 $962.18 $962.18 $962.10L0490 PO $271.13 $271.10 $272.60 $271.13 $271.13 $271.10L0491 PO $736.10 $736.05 $740.19 $736.10 $736.10 $736.05L0492 PO $477.07 $477.04 $466.47 $477.07 $477.07 $477.04L0621 PO $85.47 $89.04 $101.70 $85.47 $85.47 $89.04L0622 PO $231.75 $230.28 $230.28 $231.75 $231.75 $230.28L0625 PO $52.82 $52.81 $53.21 $52.82 $52.82 $52.81





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



L0626 PO $74.72 $74.71 $75.26 $74.72 $74.72 $74.71L0627 PO $394.01 $393.97 $396.95 $394.01 $394.01 $393.97L0628 PO $80.39 $80.39 $80.99 $80.39 $80.39 $80.39L0630 PO $155.21 $155.20 $156.38 $155.21 $155.21 $155.20L0631 PO $983.97 $983.90 $991.38 $983.97 $983.97 $983.90L0633 PO $274.86 $274.84 $276.92 $274.86 $274.86 $274.84L0635 PO $1,019.23 $948.28 $853.24 $1,019.23 $1,019.23 $948.28L0636 PO $1,503.93 $1,285.52 $1,484.79 $1,503.93 $1,503.93 $1,285.52L0637 PO $1,304.86 $1,164.37 $999.59 $1,304.86 $1,304.86 $1,164.37L0638 PO $1,264.17 $1,264.04 $1,271.16 $1,264.17 $1,264.17 $1,264.04L0639 PO $1,304.86 $1,164.37 $999.59 $1,304.86 $1,304.86 $1,164.37L0640 PO $1,002.97 $1,002.83 $1,008.49 $1,002.97 $1,002.97 $1,002.83L0641 PO $74.72 $74.71 $75.26 $74.72 $74.72 $74.71L0642 PO $394.01 $393.97 $396.95 $394.01 $394.01 $393.97L0643 PO $155.21 $155.20 $156.38 $155.21 $155.21 $155.20L0648 PO $983.97 $983.90 $991.38 $983.97 $983.97 $983.90L0649 PO $274.86 $274.84 $276.92 $274.86 $274.86 $274.84L0650 PO $1,304.86 $1,164.37 $999.59 $1,304.86 $1,304.86 $1,164.37L0651 PO $1,304.86 $1,164.37 $999.59 $1,304.86 $1,304.86 $1,164.37L0700 PO $2,063.66 $1,829.26 $1,823.12 $2,063.66 $2,063.66 $1,829.26L0710 PO $2,252.62 $1,970.58 $2,127.43 $2,252.62 $2,252.62 $1,970.58L0810 PO $2,393.08 $2,441.30 $2,402.11 $2,393.08 $2,393.08 $2,441.30L0820 PO $1,935.90 $2,059.38 $2,078.13 $1,935.90 $1,935.90 $2,059.38L0830 PO $2,795.23 $3,299.61 $2,795.23 $2,795.23 $2,795.23 $3,299.61L0859 PO $1,085.93 $1,447.90 $1,447.90 $1,085.93 $1,085.93 $1,447.90L0861 PO $206.59 $206.58 $207.73 $206.59 $206.59 $206.58L0970 PO $101.88 $129.60 $135.84 $101.88 $101.88 $129.60L0972 PO $104.14 $118.51 $98.68 $104.14 $104.14 $118.51L0974 PO $212.79 $179.15 $159.59 $212.79 $212.79 $179.15L0976 PO $190.04 $167.76 $180.84 $190.04 $190.04 $167.76L0978 PO $171.59 $175.75 $171.59 $171.59 $171.59 $175.75L0980 PO $15.57 $20.76 $15.57 $15.57 $15.57 $20.76L0982 PO $16.96 $19.35 $14.51 $16.96 $16.96 $19.35L0984 PO $54.12 $54.12 $59.39 $54.12 $54.12 $54.12L1000 PO $1,809.74 $1,967.54 $2,108.88 $1,809.74 $1,809.74 $1,967.54L1005 PO $3,067.82 $3,067.49 $3,084.74 $3,067.82 $3,067.82 $3,067.49L1010 PO $72.88 $70.51 $59.82 $72.88 $72.88 $70.51L1020 PO $99.58 $97.69 $77.05 $99.58 $99.58 $97.69L1025 PO $113.18 $111.16 $111.16 $113.18 $113.18 $111.16L1030 PO $75.60 $75.60 $56.70 $75.60 $75.60 $75.60L1040 PO $91.00 $79.04 $69.54 $91.00 $91.00 $79.04L1050 PO $78.79 $95.68 $74.22 $78.79 $78.79 $95.68L1060 PO $88.88 $92.85 $85.25 $88.88 $88.88 $92.85L1070 PO $90.87 $90.82 $80.21 $90.87 $90.87 $90.82L1080 PO $62.97 $51.09 $63.40 $62.97 $62.97 $51.09L1085 PO $174.92 $154.29 $137.21 $174.92 $174.92 $154.29L1090 PO $81.71 $91.37 $88.24 $81.71 $81.71 $91.37L1100 PO $144.23 $157.49 $141.75 $144.23 $144.23 $157.49L1110 PO $244.30 $229.69 $227.66 $244.30 $244.30 $229.69L1120 PO $38.92 $41.63 $38.27 $38.92 $38.92 $41.63L1200 PO $1,549.14 $1,606.29 $1,674.88 $1,549.14 $1,549.14 $1,606.29L1210 PO $233.24 $233.24 $310.99 $233.24 $233.24 $233.24L1220 PO $197.48 $225.72 $205.91 $197.48 $197.48 $225.72L1230 PO $506.72 $506.72 $673.54 $506.72 $506.72 $506.72L1240 PO $87.20 $74.74 $69.21 $87.20 $87.20 $74.74L1250 PO $85.87 $72.51 $64.40 $85.87 $85.87 $72.51L1260 PO $88.24 $72.96 $67.43 $88.24 $88.24 $72.96L1270 PO $88.14 $70.15 $69.07 $88.14 $88.14 $70.15L1280 PO $78.56 $76.90 $76.90 $78.56 $78.56 $76.90L1290 PO $89.07 $70.06 $70.06 $89.07 $89.07 $70.06L1300 PO $1,489.02 $1,716.35 $1,850.45 $1,489.02 $1,489.02 $1,716.35





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



L1310 PO $1,532.20 $1,653.38 $1,959.49 $1,532.20 $1,532.20 $1,653.38L1600 PO $114.87 $153.16 $117.48 $114.87 $114.87 $153.16L1610 PO $39.13 $40.58 $39.13 $39.13 $39.13 $40.58L1620 PO $128.86 $119.43 $119.43 $128.86 $128.86 $119.43L1630 PO $153.78 $151.05 $151.05 $153.78 $153.78 $151.05L1640 PO $411.32 $473.65 $504.66 $411.32 $411.32 $473.65L1650 PO $218.13 $217.52 $232.56 $218.13 $218.13 $217.52L1652 PO $341.69 $341.66 $343.56 $341.69 $341.69 $341.66L1660 PO $152.55 $203.40 $152.55 $152.55 $152.55 $203.40L1680 PO $1,254.18 $1,283.94 $1,086.10 $1,254.18 $1,254.18 $1,283.94L1685 PO $1,323.38 $1,060.30 $1,060.30 $1,323.38 $1,323.38 $1,060.30L1686 PO $887.81 $813.13 $916.46 $887.81 $887.81 $813.13L1690 PO $1,853.50 $1,853.31 $1,863.69 $1,853.50 $1,853.50 $1,853.31L1700 PO $1,541.99 $1,529.06 $1,361.26 $1,541.99 $1,541.99 $1,529.06L1710 PO $1,812.51 $1,966.20 $1,593.50 $1,812.51 $1,812.51 $1,966.20L1720 PO $1,338.91 $1,458.63 $1,174.61 $1,338.91 $1,338.91 $1,458.63L1730 PO $1,010.17 $1,154.61 $1,010.57 $1,010.17 $1,010.17 $1,154.61L1755 PO $1,470.33 $1,411.30 $1,411.30 $1,470.33 $1,470.33 $1,411.30L1810 PO $116.04 $95.34 $90.00 $116.04 $116.04 $95.34L1812 PO $116.04 $95.34 $90.00 $116.04 $116.04 $95.34L1820 PO $115.58 $128.25 $126.41 $115.58 $115.58 $128.25L1830 PO $96.68 $77.98 $82.35 $96.68 $96.68 $77.98L1831 PO $282.09 $282.08 $283.66 $282.09 $282.09 $282.08L1832 PO $722.59 $541.94 $541.94 $722.59 $722.59 $541.94L1833 PO $722.59 $541.94 $541.94 $722.59 $722.59 $541.94L1834 PO $850.11 $691.96 $730.93 $850.11 $850.11 $691.96L1836 PO $127.88 $127.86 $128.62 $127.88 $127.88 $127.86L1840 PO $893.61 $1,007.10 $819.62 $893.61 $893.61 $1,007.10L1843 PO $860.01 $859.93 $864.78 $860.01 $860.01 $859.93L1844 PO $1,490.21 $1,487.61 $1,600.04 $1,490.21 $1,490.21 $1,487.61L1845 PO $897.78 $834.93 $752.49 $897.78 $897.78 $834.93L1846 PO $1,139.13 $1,046.28 $1,000.48 $1,139.13 $1,139.13 $1,046.28L1847 PO $551.31 $551.25 $554.32 $551.31 $551.31 $551.25L1848 PO $551.31 $551.25 $554.32 $551.31 $551.31 $551.25L1850 PO $256.58 $296.71 $292.20 $256.58 $256.58 $296.71L1860 PO $995.18 $974.86 $956.52 $995.18 $995.18 $974.86L1900 PO $269.60 $308.81 $262.24 $269.60 $269.60 $308.81L1902 PO $73.23 $94.88 $71.16 $73.23 $73.23 $94.88L1904 PO $419.17 $419.17 $419.17 $419.17 $419.17 $419.17L1906 PO $122.49 $107.20 $142.93 $122.49 $122.49 $107.20L1907 PO $539.33 $539.29 $542.30 $539.33 $539.33 $539.29L1910 PO $238.38 $268.56 $241.00 $238.38 $238.38 $268.56L1920 PO $311.63 $322.66 $391.96 $311.63 $311.63 $322.66L1930 PO $210.87 $281.16 $230.15 $210.87 $210.87 $281.16L1932 PO $855.32 $855.26 $860.00 $855.32 $855.32 $855.26L1940 PO $476.54 $451.37 $440.84 $476.54 $476.54 $451.37L1945 PO $875.13 $825.16 $849.04 $875.13 $875.13 $825.16L1950 PO $663.95 $666.22 $718.35 $663.95 $663.95 $666.22L1951 PO $804.97 $804.90 $809.41 $804.97 $804.97 $804.90L1960 PO $494.09 $494.09 $494.09 $494.09 $494.09 $494.09L1970 PO $730.79 $634.29 $666.37 $730.79 $730.79 $634.29L1971 PO $449.27 $449.23 $451.74 $449.27 $449.27 $449.23L1980 PO $327.15 $341.98 $352.73 $327.15 $327.15 $341.98L1990 PO $420.34 $397.34 $397.34 $420.34 $420.34 $397.34L2000 PO $904.13 $904.13 $936.76 $904.13 $904.13 $904.13L2005 PO $3,927.66 $3,927.25 $3,957.24 $3,927.66 $3,927.66 $3,927.25L2010 PO $824.20 $882.91 $964.35 $824.20 $824.20 $882.91L2020 PO $1,040.84 $1,040.84 $1,040.84 $1,040.84 $1,040.84 $1,040.84L2030 PO $903.03 $912.97 $903.03 $903.03 $903.03 $912.97L2034 PO $1,968.09 $2,012.62 $2,005.87 $1,968.09 $1,968.09 $2,012.62L2035 PO $166.04 $166.03 $166.96 $166.04 $166.04 $166.03





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



L2036 PO $1,653.83 $1,737.82 $1,815.42 $1,653.83 $1,653.83 $1,737.82L2037 PO $1,524.10 $1,484.71 $1,484.71 $1,524.10 $1,524.10 $1,484.71L2038 PO $1,274.46 $1,274.46 $1,274.46 $1,274.46 $1,274.46 $1,274.46L2040 PO $162.80 $158.26 $205.64 $162.80 $162.80 $158.26L2050 PO $433.54 $503.70 $469.82 $433.54 $433.54 $503.70L2060 PO $556.42 $582.78 $527.58 $556.42 $556.42 $582.78L2070 PO $159.84 $120.77 $119.88 $159.84 $159.84 $120.77L2080 PO $340.87 $342.57 $320.62 $340.87 $340.87 $342.57L2090 PO $420.16 $415.18 $434.54 $420.16 $420.16 $415.18L2106 PO $606.08 $745.93 $606.08 $606.08 $606.08 $745.93L2108 PO $952.42 $1,036.31 $1,084.56 $952.42 $952.42 $1,036.31L2112 PO $452.22 $504.91 $415.89 $452.22 $452.22 $504.91L2114 PO $517.40 $584.48 $521.64 $517.40 $517.40 $584.48L2116 PO $681.68 $700.24 $634.58 $681.68 $681.68 $700.24L2126 PO $1,212.89 $1,067.41 $1,198.67 $1,212.89 $1,212.89 $1,067.41L2128 PO $1,528.51 $1,528.51 $1,528.51 $1,528.51 $1,528.51 $1,528.51L2132 PO $719.07 $811.20 $929.78 $719.07 $719.07 $811.20L2134 PO $862.14 $1,014.59 $862.14 $862.14 $862.14 $1,014.59L2136 PO $1,054.17 $1,148.67 $1,184.87 $1,054.17 $1,054.17 $1,148.67L2180 PO $104.39 $139.19 $135.94 $104.39 $104.39 $139.19L2182 PO $81.70 $102.26 $86.99 $81.70 $81.70 $102.26L2184 PO $147.23 $132.86 $120.96 $147.23 $147.23 $132.86L2186 PO $163.15 $134.20 $160.69 $163.15 $163.15 $134.20L2188 PO $355.95 $312.27 $266.96 $355.95 $355.95 $312.27L2190 PO $92.46 $89.24 $80.63 $92.46 $92.46 $89.24L2192 PO $317.83 $351.58 $317.83 $317.83 $317.83 $351.58L2200 PO $42.38 $56.50 $56.50 $42.38 $42.38 $56.50L2210 PO $68.77 $59.92 $79.89 $68.77 $68.77 $59.92L2220 PO $78.96 $77.88 $94.58 $78.96 $78.96 $77.88L2230 PO $68.39 $71.97 $74.61 $68.39 $68.39 $71.97L2232 PO $92.60 $92.60 $92.60 $92.60 $92.60 $92.60L2240 PO $74.55 $74.55 $74.55 $74.55 $74.55 $74.55L2250 PO $316.74 $316.74 $374.96 $316.74 $316.74 $316.74L2260 PO $178.69 $184.41 $204.34 $178.69 $178.69 $184.41L2265 PO $104.98 $139.97 $104.98 $104.98 $104.98 $139.97L2270 PO $47.87 $47.87 $52.57 $47.87 $47.87 $47.87L2275 PO $116.48 $116.47 $132.79 $116.48 $116.48 $116.47L2280 PO $432.72 $403.64 $403.64 $432.72 $432.72 $403.64L2300 PO $244.26 $320.00 $240.00 $244.26 $244.26 $320.00L2310 PO $109.66 $146.22 $119.02 $109.66 $109.66 $146.22L2320 PO $183.41 $200.10 $234.06 $183.41 $183.41 $200.10L2330 PO $350.02 $370.96 $385.79 $350.02 $350.02 $370.96L2335 PO $205.91 $202.50 $212.49 $205.91 $205.91 $202.50L2340 PO $485.89 $494.03 $398.40 $485.89 $485.89 $494.03L2350 PO $794.28 $846.38 $927.72 $794.28 $794.28 $846.38L2360 PO $46.12 $61.49 $51.25 $46.12 $46.12 $61.49L2370 PO $228.83 $261.59 $228.83 $228.83 $228.83 $261.59L2375 PO $100.72 $134.29 $100.72 $100.72 $100.72 $134.29L2380 PO $109.74 $146.32 $146.32 $109.74 $109.74 $146.32L2385 PO $119.40 $154.15 $159.20 $119.40 $119.40 $154.15L2387 PO $162.04 $147.52 $147.52 $162.04 $162.04 $147.52L2390 PO $97.58 $97.58 $130.11 $97.58 $97.58 $97.58L2395 PO $148.98 $185.96 $165.71 $148.98 $148.98 $185.96L2397 PO $104.47 $104.47 $114.79 $104.47 $104.47 $104.47L2405 PO $83.57 $83.56 $84.01 $83.57 $83.57 $83.56L2415 PO $116.44 $116.42 $117.11 $116.44 $116.44 $116.42L2425 PO $137.39 $137.38 $138.17 $137.39 $137.39 $137.38L2430 PO $137.39 $137.38 $138.17 $137.39 $137.39 $137.38L2492 PO $90.90 $101.46 $113.81 $90.90 $90.90 $101.46L2500 PO $281.21 $327.92 $281.21 $281.21 $281.21 $327.92L2510 PO $752.92 $743.75 $647.49 $752.92 $752.92 $743.75





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



L2520 PO $410.64 $469.52 $439.49 $410.64 $410.64 $469.52L2525 PO $1,408.84 $1,086.60 $1,221.74 $1,408.84 $1,408.84 $1,086.60L2526 PO $759.38 $610.56 $790.86 $759.38 $759.38 $610.56L2530 PO $209.44 $211.16 $279.26 $209.44 $209.44 $211.16L2540 PO $376.87 $400.88 $427.75 $376.87 $376.87 $400.88L2550 PO $256.01 $256.01 $341.35 $256.01 $256.01 $256.01L2570 PO $566.11 $566.11 $424.58 $566.11 $566.11 $566.11L2580 PO $536.63 $413.70 $541.12 $536.63 $536.63 $413.70L2600 PO $183.07 $244.10 $198.80 $183.07 $183.07 $244.10L2610 PO $216.48 $288.64 $226.61 $216.48 $216.48 $288.64L2620 PO $238.34 $278.89 $238.34 $238.34 $238.34 $278.89L2622 PO $273.36 $364.47 $273.36 $273.36 $273.36 $364.47L2624 PO $371.62 $316.95 $295.18 $371.62 $371.62 $316.95L2627 PO $1,531.05 $1,528.12 $2,037.49 $1,531.05 $1,531.05 $1,528.12L2628 PO $1,798.50 $1,493.44 $1,991.25 $1,798.50 $1,798.50 $1,493.44L2630 PO $220.73 $261.01 $294.31 $220.73 $220.73 $261.01L2640 PO $299.56 $343.13 $299.56 $299.56 $299.56 $343.13L2650 PO $106.97 $128.86 $106.97 $106.97 $106.97 $128.86L2660 PO $166.14 $200.67 $221.52 $166.14 $166.14 $200.67L2670 PO $152.06 $202.74 $202.74 $152.06 $152.06 $202.74L2680 PO $139.49 $185.99 $185.99 $139.49 $139.49 $185.99L2750 PO $74.51 $97.97 $74.51 $74.51 $74.51 $97.97L2755 PO $125.27 $125.26 $125.90 $125.27 $125.27 $125.26L2760 PO $54.16 $72.21 $72.21 $54.16 $54.16 $72.21L2768 PO $124.90 $124.86 $125.58 $124.90 $124.90 $124.86L2780 PO $64.07 $60.33 $60.33 $64.07 $64.07 $60.33L2785 PO $37.67 $28.25 $28.25 $37.67 $37.67 $28.25L2795 PO $75.74 $87.31 $75.74 $75.74 $75.74 $87.31L2800 PO $95.08 $95.08 $104.28 $95.08 $95.08 $95.08L2810 PO $69.62 $77.50 $69.62 $69.62 $69.62 $77.50L2820 PO $77.41 $77.41 $103.22 $77.41 $77.41 $77.41L2830 PO $87.05 $83.74 $111.66 $87.05 $87.05 $83.74L2840 PO $48.58 $51.92 $38.94 $48.58 $48.58 $51.92L2850 PO $55.19 $59.38 $70.87 $55.19 $55.19 $59.38L3000 PO $301.10 $301.07 $302.71 $301.10 $301.10 $301.07L3001 PO $126.76 $126.75 $127.48 $126.76 $126.76 $126.75L3002 PO $154.81 $154.78 $155.64 $154.81 $154.81 $154.78L3003 PO $167.00 $166.99 $167.93 $167.00 $167.00 $166.99L3010 PO $167.00 $166.99 $167.93 $167.00 $167.00 $166.99L3020 PO $190.17 $190.14 $191.20 $190.17 $190.17 $190.14L3030 PO $73.16 $73.15 $73.53 $73.16 $73.16 $73.15L3031 PO $117.38 $117.37 $118.05 $117.38 $117.38 $117.37L3040 PO $45.11 $45.10 $45.36 $45.11 $45.11 $45.10L3050 PO $45.11 $45.10 $45.36 $45.11 $45.11 $45.10L3060 PO $70.70 $70.69 $71.09 $70.70 $70.70 $70.69L3070 PO $30.48 $30.47 $30.64 $30.48 $30.48 $30.47L3080 PO $30.48 $30.47 $30.64 $30.48 $30.48 $30.47L3090 PO $39.02 $39.02 $39.20 $39.02 $39.02 $39.02L3100 PO $41.42 $41.42 $41.66 $41.42 $41.42 $41.42L3140 PO $85.34 $85.34 $85.81 $85.34 $85.34 $85.34L3150 PO $78.03 $78.01 $78.44 $78.03 $78.03 $78.01L3170 PO $48.77 $48.76 $49.05 $48.77 $48.77 $48.76L3224 PO $52.42 $52.42 $54.51 $52.42 $52.42 $52.42L3225 PO $60.30 $61.45 $72.74 $60.30 $60.30 $61.45L3300 PO $49.97 $49.97 $50.25 $49.97 $49.97 $49.97L3310 PO $78.03 $78.01 $78.44 $78.03 $78.03 $78.01L3330 PO $542.44 $542.41 $545.43 $542.44 $542.44 $542.41L3332 PO $70.70 $70.69 $71.09 $70.70 $70.70 $70.69L3334 PO $36.56 $36.56 $36.79 $36.56 $36.56 $36.56L3340 PO $81.70 $81.66 $82.12 $81.70 $81.70 $81.66L3350 PO $21.92 $21.92 $22.03 $21.92 $21.92 $21.92





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



L3360 PO $34.13 $34.13 $34.32 $34.13 $34.13 $34.13L3370 PO $47.55 $47.53 $47.81 $47.55 $47.55 $47.53L3380 PO $47.55 $47.53 $47.81 $47.55 $47.55 $47.53L3390 PO $47.55 $47.53 $47.81 $47.55 $47.55 $47.53L3400 PO $39.02 $39.02 $39.20 $39.02 $39.02 $39.02L3410 PO $89.01 $89.01 $89.50 $89.01 $89.01 $89.01L3420 PO $52.40 $52.40 $52.71 $52.40 $52.40 $52.40L3430 PO $153.59 $153.58 $154.46 $153.59 $153.59 $153.58L3440 PO $73.16 $73.15 $73.53 $73.16 $73.16 $73.15L3450 PO $101.15 $101.15 $101.72 $101.15 $101.15 $101.15L3455 PO $39.02 $39.02 $39.20 $39.02 $39.02 $39.02L3460 PO $32.90 $32.90 $33.11 $32.90 $32.90 $32.90L3465 PO $56.07 $56.07 $56.40 $56.07 $56.07 $56.07L3470 PO $59.71 $59.71 $60.08 $59.71 $59.71 $59.71L3480 PO $59.71 $59.71 $60.08 $59.71 $59.71 $59.71L3500 PO $28.06 $28.06 $28.18 $28.06 $28.06 $28.06L3510 PO $28.06 $28.06 $28.18 $28.06 $28.06 $28.06L3520 PO $30.48 $30.47 $30.64 $30.48 $30.48 $30.47L3530 PO $30.48 $30.47 $30.64 $30.48 $30.48 $30.47L3540 PO $48.77 $48.76 $49.05 $48.77 $48.77 $48.76L3550 PO $8.55 $8.55 $8.60 $8.55 $8.55 $8.55L3560 PO $21.92 $21.92 $22.03 $21.92 $21.92 $21.92L3570 PO $81.70 $81.66 $82.12 $81.70 $81.70 $81.66L3580 PO $62.16 $62.16 $62.50 $62.16 $62.16 $62.16L3590 PO $51.20 $51.20 $51.48 $51.20 $51.20 $51.20L3595 PO $40.22 $40.21 $40.43 $40.22 $40.22 $40.21L3600 PO $73.16 $73.15 $73.53 $73.16 $73.16 $73.15L3610 PO $96.30 $96.30 $96.84 $96.30 $96.30 $96.30L3620 PO $73.16 $73.15 $73.53 $73.16 $73.16 $73.15L3630 PO $96.30 $96.30 $96.84 $96.30 $96.30 $96.30L3640 PO $41.42 $41.42 $41.66 $41.42 $41.42 $41.42L3650 PO $52.21 $56.69 $51.73 $52.21 $52.21 $56.69L3660 PO $89.65 $89.65 $117.01 $89.65 $89.65 $89.65L3670 PO $124.96 $102.41 $98.64 $124.96 $124.96 $102.41L3671 PO $785.99 $785.94 $790.34 $785.99 $785.99 $785.94L3674 PO $1,031.11 $1,031.02 $1,036.82 $1,031.11 $1,031.11 $1,031.02L3675 PO $153.09 $153.08 $153.91 $153.09 $153.09 $153.08L3702 PO $251.89 $251.88 $253.28 $251.89 $251.89 $251.88L3710 PO $126.47 $129.58 $107.83 $126.47 $126.47 $129.58L3720 PO $630.98 $661.81 $570.53 $630.98 $630.98 $661.81L3730 PO $830.60 $968.01 $786.31 $830.60 $830.60 $968.01L3740 PO $933.47 $1,242.98 $932.24 $933.47 $933.47 $1,242.98L3760 PO $436.23 $436.20 $438.65 $436.23 $436.23 $436.20L3762 PO $93.80 $93.80 $94.30 $93.80 $93.80 $93.80L3763 PO $692.57 $610.67 $589.18 $692.57 $692.57 $610.67L3764 PO $690.70 $663.53 $673.51 $690.70 $690.70 $663.53L3765 PO $1,118.52 $1,118.41 $1,124.70 $1,118.52 $1,118.52 $1,118.41L3766 PO $1,184.44 $1,184.32 $1,190.97 $1,184.44 $1,184.44 $1,184.32L3806 PO $396.24 $396.21 $398.43 $396.24 $396.24 $396.21L3807 PO $218.13 $218.11 $219.29 $218.13 $218.13 $218.11L3808 PO $291.36 $291.48 $318.31 $291.36 $291.36 $291.48L3809 PO $218.13 $218.11 $219.29 $218.13 $218.13 $218.11L3900 PO $1,362.71 $1,140.18 $1,128.68 $1,362.71 $1,362.71 $1,140.18L3901 PO $1,527.95 $1,401.77 $1,796.02 $1,527.95 $1,527.95 $1,401.77L3904 PO $3,110.49 $2,554.41 $3,405.88 $3,110.49 $3,110.49 $2,554.41L3905 PO $865.07 $864.98 $869.85 $865.07 $865.07 $864.98L3906 PO $367.98 $344.67 $356.71 $367.98 $367.98 $344.67L3908 PO $52.26 $52.26 $52.26 $52.26 $52.26 $52.26L3912 PO $83.83 $108.75 $82.72 $83.83 $83.83 $108.75L3913 PO $236.27 $236.24 $237.56 $236.27 $236.27 $236.24L3915 PO $463.70 $463.66 $466.28 $463.70 $463.70 $463.66





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



L3916 PO $463.70 $463.66 $466.28 $463.70 $463.70 $463.66L3917 PO $92.15 $92.12 $92.63 $92.15 $92.15 $92.12L3918 PO $92.15 $92.12 $92.63 $92.15 $92.15 $92.12L3919 PO $236.27 $236.24 $237.56 $236.27 $236.27 $236.24L3921 PO $280.17 $280.15 $281.72 $280.17 $280.17 $280.15L3923 PO $75.88 $75.88 $75.88 $75.88 $75.88 $75.88L3924 PO $75.88 $75.88 $75.88 $75.88 $75.88 $75.88L3925 PO $46.08 $46.86 $43.06 $46.08 $46.08 $46.86L3927 PO $30.53 $30.53 $30.69 $30.53 $30.53 $30.53L3929 PO $73.44 $80.23 $68.19 $73.44 $73.44 $80.23L3930 PO $73.44 $80.23 $68.19 $73.44 $73.44 $80.23L3931 PO $177.65 $179.18 $168.44 $177.65 $177.65 $179.18L3933 PO $186.13 $186.12 $187.16 $186.13 $186.13 $186.12L3935 PO $192.74 $192.73 $193.82 $192.74 $192.74 $192.73L3960 PO $719.03 $781.63 $641.06 $719.03 $719.03 $781.63L3961 PO $1,465.59 $1,465.45 $1,473.68 $1,465.59 $1,465.59 $1,465.45L3962 PO $748.67 $625.86 $625.86 $748.67 $748.67 $625.86L3967 PO $1,730.36 $1,730.24 $1,739.92 $1,730.36 $1,730.36 $1,730.24L3971 PO $1,642.49 $1,642.36 $1,651.57 $1,642.49 $1,642.49 $1,642.36L3973 PO $1,730.36 $1,730.24 $1,739.92 $1,730.36 $1,730.36 $1,730.24L3975 PO $1,465.59 $1,465.45 $1,473.68 $1,465.59 $1,465.59 $1,465.45L3976 PO $1,465.59 $1,465.45 $1,473.68 $1,465.59 $1,465.59 $1,465.45L3977 PO $1,642.49 $1,642.36 $1,651.57 $1,642.49 $1,642.49 $1,642.36L3978 PO $1,730.36 $1,730.24 $1,739.92 $1,730.36 $1,730.36 $1,730.24L3980 PO $269.66 $321.10 $269.66 $269.66 $269.66 $321.10L3981 PO $878.03 $877.96 $884.68 $878.03 $878.03 $877.96L3982 PO $333.16 $362.36 $333.42 $333.16 $333.16 $362.36L3984 PO $355.62 $315.25 $344.98 $355.62 $355.62 $315.25L3995 PO $29.84 $37.19 $28.52 $29.84 $29.84 $37.19L4000 PO $1,162.86 $1,201.12 $1,289.00 $1,162.86 $1,162.86 $1,201.12L4010 PO $654.39 $613.85 $648.49 $654.39 $654.39 $613.85L4020 PO $817.39 $897.67 $767.79 $817.39 $817.39 $897.67L4030 PO $450.05 $587.03 $450.05 $450.05 $450.05 $587.03L4040 PO $363.86 $382.60 $379.83 $363.86 $363.86 $382.60L4045 PO $292.41 $292.41 $351.96 $292.41 $292.41 $292.41L4050 PO $368.01 $368.01 $368.01 $368.01 $368.01 $368.01L4055 PO $238.30 $242.75 $238.30 $238.30 $238.30 $242.75L4060 PO $283.29 $283.29 $377.72 $283.29 $283.29 $283.29L4070 PO $270.27 $315.79 $250.86 $270.27 $270.27 $315.79L4080 PO $95.28 $90.16 $90.16 $95.28 $95.28 $90.16L4090 PO $84.34 $101.85 $80.50 $84.34 $84.34 $101.85L4100 PO $95.12 $104.57 $92.97 $95.12 $95.12 $104.57L4110 PO $75.59 $83.64 $76.59 $75.59 $75.59 $83.64L4130 PO $520.27 $515.44 $508.26 $520.27 $520.27 $515.44L4350 PO $93.73 $81.95 $79.68 $93.73 $93.73 $81.95L4360 PO $262.24 $246.82 $266.35 $262.24 $262.24 $246.82L4361 PO $262.24 $246.82 $266.35 $262.24 $262.24 $246.82L4370 PO $168.28 $168.28 $184.59 $168.28 $168.28 $168.28L4386 PO $151.97 $151.96 $152.80 $151.97 $151.97 $151.96L4387 PO $151.97 $151.96 $152.80 $151.97 $151.97 $151.96L4392 PO $22.57 $22.57 $22.27 $22.57 $22.57 $22.57L4394 PO $16.47 $16.47 $16.26 $16.47 $16.47 $16.47L4396 PO $160.88 $160.87 $158.83 $160.88 $160.88 $160.87L4397 PO $160.88 $160.87 $158.83 $160.88 $160.88 $160.87L4398 PO $74.04 $74.04 $73.15 $74.04 $74.04 $74.04L4631 PO $1,430.38 $1,417.64 $1,326.52 $1,430.38 $1,430.38 $1,417.64L5000 PO $502.58 $639.77 $479.83 $502.58 $502.58 $639.77L5010 PO $1,213.86 $1,452.69 $1,268.38 $1,213.86 $1,213.86 $1,452.69L5020 PO $2,061.41 $2,182.31 $2,225.42 $2,061.41 $2,061.41 $2,182.31L5050 PO $2,280.29 $2,747.20 $2,364.32 $2,280.29 $2,280.29 $2,747.20L5060 PO $2,623.01 $3,104.19 $3,204.64 $2,623.01 $2,623.01 $3,104.19





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



L5100 PO $2,285.33 $2,699.58 $2,207.19 $2,285.33 $2,285.33 $2,699.58L5105 PO $3,299.12 $3,299.12 $3,619.15 $3,299.12 $3,299.12 $3,299.12L5150 PO $3,334.95 $3,932.48 $3,693.87 $3,334.95 $3,334.95 $3,932.48L5160 PO $3,627.36 $4,137.44 $4,067.92 $3,627.36 $3,627.36 $4,137.44L5200 PO $3,473.71 $3,595.75 $3,137.22 $3,473.71 $3,473.71 $3,595.75L5210 PO $2,304.46 $2,657.85 $2,483.91 $2,304.46 $2,304.46 $2,657.85L5220 PO $2,619.44 $3,339.05 $2,862.09 $2,619.44 $2,619.44 $3,339.05L5230 PO $3,612.72 $3,957.71 $4,816.96 $3,612.72 $3,612.72 $3,957.71L5250 PO $4,927.43 $5,357.99 $6,189.38 $4,927.43 $4,927.43 $5,357.99L5270 PO $4,905.56 $5,091.16 $5,645.86 $4,905.56 $4,905.56 $5,091.16L5280 PO $4,868.00 $5,542.04 $6,413.23 $4,868.00 $4,868.00 $5,542.04L5301 PO $2,612.27 $2,619.12 $2,198.44 $2,612.27 $2,612.27 $2,619.12L5312 PO $3,739.29 $3,495.76 $3,463.52 $3,739.29 $3,739.29 $3,495.76L5321 PO $3,786.56 $3,654.05 $3,121.29 $3,786.56 $3,786.56 $3,654.05L5331 PO $4,824.84 $5,501.04 $5,320.36 $4,824.84 $4,824.84 $5,501.04L5341 PO $5,022.68 $5,740.67 $5,760.85 $5,022.68 $5,022.68 $5,740.67L5400 PO $1,293.30 $1,354.38 $1,165.48 $1,293.30 $1,293.30 $1,354.38L5410 PO $396.79 $529.05 $396.79 $396.79 $396.79 $529.05L5420 PO $1,584.89 $1,734.48 $1,623.47 $1,584.89 $1,584.89 $1,734.48L5430 PO $477.89 $637.18 $477.89 $477.89 $477.89 $637.18L5450 PO $388.78 $515.87 $465.30 $388.78 $388.78 $515.87L5460 PO $517.98 $690.45 $544.97 $517.98 $517.98 $690.45L5500 PO $1,219.69 $1,362.82 $1,606.74 $1,219.69 $1,219.69 $1,362.82L5505 PO $1,686.87 $2,202.37 $1,870.29 $1,686.87 $1,686.87 $2,202.37L5510 PO $1,382.60 $1,620.20 $1,600.89 $1,382.60 $1,382.60 $1,620.20L5520 PO $1,365.68 $1,820.91 $1,365.68 $1,365.68 $1,365.68 $1,820.91L5530 PO $1,640.31 $1,881.81 $1,797.26 $1,640.31 $1,640.31 $1,881.81L5535 PO $1,610.46 $1,885.51 $1,610.46 $1,610.46 $1,610.46 $1,885.51L5540 PO $1,718.87 $2,021.61 $1,929.09 $1,718.87 $1,718.87 $2,021.61L5560 PO $1,845.77 $2,431.33 $2,255.27 $1,845.77 $1,845.77 $2,431.33L5570 PO $1,918.95 $2,400.51 $2,440.61 $1,918.95 $1,918.95 $2,400.51L5580 PO $2,240.24 $2,680.35 $2,741.40 $2,240.24 $2,240.24 $2,680.35L5585 PO $2,756.97 $2,689.18 $2,748.57 $2,756.97 $2,756.97 $2,689.18L5590 PO $2,282.95 $2,631.15 $2,915.61 $2,282.95 $2,282.95 $2,631.15L5595 PO $4,033.14 $3,823.86 $3,823.86 $4,033.14 $4,033.14 $3,823.86L5600 PO $4,335.44 $4,222.69 $4,222.69 $4,335.44 $4,335.44 $4,222.69L5610 PO $1,966.19 $2,278.79 $2,546.24 $1,966.19 $1,966.19 $2,278.79L5611 PO $1,530.09 $1,530.09 $2,040.12 $1,530.09 $1,530.09 $1,530.09L5613 PO $2,392.24 $2,356.79 $2,917.70 $2,392.24 $2,392.24 $2,356.79L5614 PO $1,620.58 $1,620.40 $1,629.53 $1,620.58 $1,620.58 $1,620.40L5616 PO $1,292.75 $1,719.74 $1,693.61 $1,292.75 $1,292.75 $1,719.74L5617 PO $537.33 $537.27 $538.63 $537.33 $537.33 $537.27L5618 PO $284.26 $286.90 $267.08 $284.26 $284.26 $286.90L5620 PO $264.02 $352.03 $264.02 $264.02 $264.02 $352.03L5622 PO $344.28 $459.04 $344.28 $344.28 $344.28 $459.04L5624 PO $345.26 $460.35 $346.33 $345.26 $345.26 $460.35L5626 PO $452.79 $505.53 $452.79 $452.79 $452.79 $505.53L5628 PO $484.15 $545.58 $458.52 $484.15 $484.15 $545.58L5629 PO $301.80 $402.40 $301.80 $301.80 $301.80 $402.40L5630 PO $426.21 $491.24 $465.45 $426.21 $426.21 $491.24L5631 PO $417.27 $556.36 $417.27 $417.27 $417.27 $556.36L5632 PO $232.88 $210.87 $259.22 $232.88 $232.88 $210.87L5634 PO $288.88 $288.88 $385.17 $288.88 $288.88 $288.88L5636 PO $241.98 $241.98 $322.64 $241.98 $241.98 $241.98L5637 PO $274.35 $365.80 $274.35 $274.35 $274.35 $365.80L5638 PO $477.91 $479.36 $616.23 $477.91 $477.91 $479.36L5639 PO $1,064.76 $1,064.76 $1,419.67 $1,064.76 $1,064.76 $1,064.76L5640 PO $607.25 $607.25 $809.67 $607.25 $607.25 $607.25L5642 PO $588.38 $606.83 $784.51 $588.38 $588.38 $606.83L5643 PO $1,478.11 $1,589.76 $1,970.81 $1,478.11 $1,478.11 $1,589.76L5644 PO $560.92 $669.14 $747.89 $560.92 $560.92 $669.14





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



L5645 PO $757.74 $759.28 $1,010.32 $757.74 $757.74 $759.28L5646 PO $520.33 $675.44 $673.96 $520.33 $520.33 $675.44L5647 PO $755.42 $755.42 $922.35 $755.42 $755.42 $755.42L5648 PO $625.24 $736.75 $833.65 $625.24 $625.24 $736.75L5649 PO $2,265.60 $2,307.44 $2,013.30 $2,265.60 $2,265.60 $2,307.44L5650 PO $463.62 $544.03 $618.16 $463.62 $463.62 $544.03L5651 PO $1,140.48 $1,520.64 $1,520.64 $1,140.48 $1,140.48 $1,520.64L5652 PO $414.04 $483.04 $552.05 $414.04 $414.04 $483.04L5653 PO $552.71 $565.76 $736.94 $552.71 $552.71 $565.76L5654 PO $314.95 $374.37 $316.64 $314.95 $314.95 $374.37L5655 PO $266.90 $291.24 $251.89 $266.90 $266.90 $291.24L5656 PO $358.04 $360.99 $363.53 $358.04 $358.04 $360.99L5658 PO $345.30 $345.30 $395.79 $345.30 $345.30 $345.30L5661 PO $577.92 $577.92 $577.92 $577.92 $577.92 $577.92L5665 PO $486.25 $519.67 $486.25 $486.25 $486.25 $519.67L5666 PO $66.48 $88.64 $66.48 $66.48 $66.48 $88.64L5668 PO $107.22 $127.87 $95.90 $107.22 $107.22 $127.87L5670 PO $257.69 $343.59 $343.59 $257.69 $257.69 $343.59L5671 PO $546.08 $546.01 $629.83 $546.08 $546.08 $546.01L5672 PO $283.18 $283.18 $377.57 $283.18 $283.18 $283.18L5673 PO $675.27 $695.74 $719.55 $675.27 $675.27 $695.74L5676 PO $344.13 $448.18 $425.61 $344.13 $344.13 $448.18L5677 PO $468.24 $624.32 $468.24 $468.24 $468.24 $624.32L5678 PO $37.71 $50.27 $49.08 $37.71 $37.71 $50.27L5679 PO $562.70 $579.76 $599.59 $562.70 $562.70 $579.76L5680 PO $314.77 $310.00 $352.89 $314.77 $314.77 $310.00L5681 PO $1,263.27 $1,263.14 $1,272.78 $1,263.27 $1,263.27 $1,263.14L5682 PO $593.91 $605.96 $593.91 $593.91 $593.91 $605.96L5683 PO $1,263.27 $1,263.14 $1,272.78 $1,263.27 $1,263.27 $1,263.14L5684 PO $45.71 $51.11 $46.60 $45.71 $45.71 $51.11L5685 PO $123.01 $122.98 $123.69 $123.01 $123.01 $122.98L5686 PO $48.52 $51.30 $57.32 $48.52 $48.52 $51.30L5688 PO $58.01 $72.93 $58.01 $58.01 $58.01 $72.93L5690 PO $92.93 $102.46 $92.93 $92.93 $92.93 $102.46L5692 PO $126.19 $168.26 $130.60 $126.19 $126.19 $168.26L5694 PO $172.28 $229.71 $192.07 $172.28 $172.28 $229.71L5695 PO $159.05 $206.50 $188.28 $159.05 $159.05 $206.50L5696 PO $175.71 $210.79 $175.71 $175.71 $175.71 $210.79L5697 PO $76.24 $76.24 $83.07 $76.24 $76.24 $76.24L5698 PO $124.67 $113.65 $99.06 $124.67 $124.67 $113.65L5699 PO $224.58 $177.07 $177.07 $224.58 $224.58 $177.07L5700 PO $2,720.99 $2,720.74 $2,694.82 $2,720.99 $2,720.99 $2,720.74L5701 PO $3,267.71 $3,267.42 $3,596.81 $3,267.71 $3,267.71 $3,267.42L5702 PO $4,134.13 $4,133.77 $4,957.41 $4,134.13 $4,134.13 $4,133.77L5703 PO $2,139.45 $2,531.08 $2,148.68 $2,139.45 $2,139.45 $2,531.08L5704 PO $509.04 $509.00 $562.35 $509.04 $509.04 $509.00L5705 PO $909.56 $909.46 $954.85 $909.56 $909.56 $909.46L5706 PO $891.60 $891.52 $942.15 $891.60 $891.60 $891.52L5707 PO $1,175.44 $1,175.37 $1,299.88 $1,175.44 $1,175.44 $1,175.37L5710 PO $355.16 $406.47 $403.04 $355.16 $355.16 $406.47L5711 PO $496.38 $514.86 $495.88 $496.38 $496.38 $514.86L5712 PO $415.91 $539.56 $409.21 $415.91 $415.91 $539.56L5714 PO $427.21 $455.85 $482.00 $427.21 $427.21 $455.85L5716 PO $692.16 $805.76 $922.87 $692.16 $692.16 $805.76L5718 PO $865.13 $888.97 $1,153.50 $865.13 $865.13 $888.97L5722 PO $913.97 $864.19 $953.86 $913.97 $913.97 $864.19L5724 PO $1,433.45 $1,911.27 $1,498.23 $1,433.45 $1,433.45 $1,911.27L5726 PO $1,652.02 $2,202.69 $1,652.02 $1,652.02 $1,652.02 $2,202.69L5728 PO $2,259.74 $2,353.30 $2,720.14 $2,259.74 $2,259.74 $2,353.30L5780 PO $1,087.29 $1,252.75 $1,091.49 $1,087.29 $1,087.29 $1,252.75L5781 PO $3,842.59 $3,842.25 $3,863.79 $3,842.59 $3,842.59 $3,842.25





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



L5782 PO $4,050.97 $4,050.56 $4,073.31 $4,050.97 $4,050.97 $4,050.56L5785 PO $611.19 $550.12 $493.41 $611.19 $611.19 $550.12L5790 PO $682.84 $910.45 $682.84 $682.84 $682.84 $910.45L5795 PO $1,359.54 $1,359.54 $1,019.65 $1,359.54 $1,359.54 $1,359.54L5810 PO $462.36 $510.50 $513.34 $462.36 $462.36 $510.50L5811 PO $692.61 $756.19 $897.13 $692.61 $692.61 $756.19L5812 PO $536.85 $572.22 $660.39 $536.85 $536.85 $572.22L5814 PO $3,566.67 $3,566.34 $3,586.35 $3,566.67 $3,566.67 $3,566.34L5816 PO $812.51 $920.44 $1,076.86 $812.51 $812.51 $920.44L5818 PO $911.99 $922.90 $1,215.99 $911.99 $911.99 $922.90L5822 PO $1,617.20 $1,617.20 $1,788.67 $1,617.20 $1,617.20 $1,617.20L5824 PO $1,456.38 $1,734.91 $1,941.85 $1,456.38 $1,456.38 $1,734.91L5826 PO $2,999.11 $2,998.84 $3,015.70 $2,999.11 $2,999.11 $2,998.84L5828 PO $2,681.82 $2,681.82 $3,015.73 $2,681.82 $2,681.82 $2,681.82L5830 PO $1,802.04 $1,977.79 $1,802.04 $1,802.04 $1,802.04 $1,977.79L5840 PO $3,331.98 $3,331.66 $3,706.16 $3,331.98 $3,331.98 $3,331.66L5845 PO $1,721.35 $1,721.18 $1,730.81 $1,721.35 $1,721.35 $1,721.18L5848 PO $1,032.68 $1,032.59 $1,038.38 $1,032.68 $1,032.68 $1,032.59L5850 PO $121.49 $161.98 $161.98 $121.49 $121.49 $161.98L5855 PO $326.44 $326.41 $388.82 $326.44 $326.44 $326.41L5856 PO $23,054.39 $23,052.22 $23,165.23 $23,054.39 $23,054.39 $23,052.22L5857 PO $8,180.54 $8,179.81 $8,209.36 $8,180.54 $8,180.54 $8,179.81L5858 PO $17,848.59 $17,846.92 $17,947.01 $17,848.59 $17,848.59 $17,846.92L5859 PO $13,934.25 $13,932.93 $14,011.07 $13,934.25 $13,934.25 $13,932.93L5910 PO $343.95 $458.60 $458.60 $343.95 $343.95 $458.60L5920 PO $503.89 $671.85 $667.24 $503.89 $503.89 $671.85L5925 PO $425.46 $425.46 $425.46 $425.46 $425.46 $425.46L5930 PO $3,232.48 $3,232.19 $3,240.20 $3,232.48 $3,232.48 $3,232.19L5940 PO $476.36 $635.15 $635.15 $476.36 $476.36 $635.15L5950 PO $744.83 $985.14 $767.69 $744.83 $744.83 $985.14L5960 PO $915.52 $1,220.70 $915.52 $915.52 $915.52 $1,220.70L5961 PO $4,365.59 $4,528.04 $4,869.39 $4,365.59 $4,365.59 $4,528.04L5962 PO $602.51 $602.47 $711.11 $602.51 $602.51 $602.47L5964 PO $889.39 $889.39 $1,004.96 $889.39 $889.39 $889.39L5966 PO $1,133.30 $1,133.30 $1,277.96 $1,133.30 $1,133.30 $1,133.30L5968 PO $3,489.90 $3,489.56 $3,509.14 $3,489.90 $3,489.90 $3,489.56L5970 PO $192.87 $216.16 $215.63 $192.87 $192.87 $216.16L5971 PO $192.87 $216.16 $215.63 $192.87 $192.87 $216.16L5972 PO $360.26 $406.91 $418.09 $360.26 $360.26 $406.91L5973 PO $16,522.78 $16,521.25 $16,842.12 $16,522.78 $16,522.78 $16,521.25L5974 PO $221.30 $251.74 $224.40 $221.30 $221.30 $251.74L5975 PO $445.24 $445.21 $447.68 $445.24 $445.24 $445.21L5976 PO $531.84 $576.46 $574.22 $531.84 $531.84 $576.46L5978 PO $277.14 $323.21 $277.14 $277.14 $277.14 $323.21L5979 PO $2,166.92 $2,166.92 $2,623.03 $2,166.92 $2,166.92 $2,166.92L5980 PO $3,521.11 $3,724.39 $4,694.81 $3,521.11 $3,521.11 $3,724.39L5981 PO $2,844.58 $2,844.31 $3,067.95 $2,844.58 $2,844.58 $2,844.31L5982 PO $549.02 $594.41 $732.02 $549.02 $549.02 $594.41L5984 PO $541.00 $638.47 $572.83 $541.00 $541.00 $638.47L5985 PO $271.19 $271.15 $271.81 $271.19 $271.19 $271.15L5986 PO $601.79 $635.29 $802.39 $601.79 $601.79 $635.29L5987 PO $6,908.62 $6,907.98 $6,946.73 $6,908.62 $6,908.62 $6,907.98L5988 PO $1,918.52 $1,918.34 $1,929.06 $1,918.52 $1,918.52 $1,918.34L5990 PO $1,742.30 $1,742.13 $1,751.91 $1,742.30 $1,742.30 $1,742.13L6000 PO $1,261.82 $1,421.43 $1,261.82 $1,261.82 $1,261.82 $1,421.43L6010 PO $1,404.20 $1,430.12 $1,494.99 $1,404.20 $1,404.20 $1,430.12L6020 PO $1,309.20 $1,422.54 $1,330.90 $1,309.20 $1,309.20 $1,422.54L6026 PO $4,747.34 $3,560.51 $4,523.37 $4,747.34 $4,747.34 $3,560.51L6050 PO $1,804.01 $2,185.33 $1,941.40 $1,804.01 $1,804.01 $2,185.33L6055 PO $2,514.34 $2,695.78 $2,687.80 $2,514.34 $2,514.34 $2,695.78L6100 PO $1,827.75 $2,242.10 $1,921.59 $1,827.75 $1,827.75 $2,242.10





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



L6110 PO $1,938.63 $2,380.02 $1,983.16 $1,938.63 $1,938.63 $2,380.02L6120 PO $2,259.20 $2,683.48 $2,489.92 $2,259.20 $2,259.20 $2,683.48L6130 PO $2,458.43 $2,486.56 $2,686.35 $2,458.43 $2,458.43 $2,486.56L6200 PO $2,590.79 $3,025.38 $2,895.78 $2,590.79 $2,590.79 $3,025.38L6205 PO $3,458.29 $3,458.29 $3,546.67 $3,458.29 $3,458.29 $3,458.29L6250 PO $2,714.55 $3,137.35 $2,578.27 $2,714.55 $2,714.55 $3,137.35L6300 PO $3,538.13 $3,778.00 $3,780.56 $3,538.13 $3,538.13 $3,778.00L6310 PO $3,055.01 $3,033.42 $2,881.88 $3,055.01 $3,055.01 $3,033.42L6320 PO $1,668.88 $1,824.96 $1,730.20 $1,668.88 $1,668.88 $1,824.96L6350 PO $3,719.80 $3,719.80 $4,343.86 $3,719.80 $3,719.80 $3,719.80L6360 PO $3,345.37 $3,024.88 $3,024.88 $3,345.37 $3,345.37 $3,024.88L6370 PO $2,001.77 $2,108.88 $1,928.86 $2,001.77 $2,001.77 $2,108.88L6380 PO $1,159.98 $1,246.64 $1,105.86 $1,159.98 $1,159.98 $1,246.64L6382 PO $1,745.13 $1,478.96 $1,503.03 $1,745.13 $1,745.13 $1,478.96L6384 PO $2,414.21 $1,833.42 $2,084.27 $2,414.21 $2,414.21 $1,833.42L6386 PO $381.37 $424.55 $381.37 $381.37 $381.37 $424.55L6388 PO $417.50 $474.46 $480.12 $417.50 $417.50 $474.46L6400 PO $2,203.62 $2,381.97 $2,938.16 $2,203.62 $2,203.62 $2,381.97L6450 PO $2,943.97 $2,927.92 $3,903.89 $2,943.97 $2,943.97 $2,927.92L6500 PO $3,080.01 $2,954.32 $3,839.02 $3,080.01 $3,080.01 $2,954.32L6550 PO $3,702.22 $3,621.34 $4,801.87 $3,702.22 $3,702.22 $3,621.34L6570 PO $4,156.60 $4,156.60 $4,996.27 $4,156.60 $4,156.60 $4,156.60L6580 PO $1,586.90 $1,560.54 $1,786.44 $1,586.90 $1,586.90 $1,560.54L6582 PO $1,437.31 $1,447.25 $1,742.72 $1,437.31 $1,437.31 $1,447.25L6584 PO $2,254.07 $2,114.25 $1,943.80 $2,254.07 $2,254.07 $2,114.25L6586 PO $2,109.45 $2,080.17 $2,022.44 $2,109.45 $2,109.45 $2,080.17L6588 PO $2,771.77 $2,863.90 $2,684.27 $2,771.77 $2,771.77 $2,863.90L6590 PO $2,632.74 $2,808.69 $2,692.18 $2,632.74 $2,632.74 $2,808.69L6600 PO $178.13 $237.51 $178.13 $178.13 $178.13 $237.51L6605 PO $175.89 $234.52 $175.89 $175.89 $175.89 $234.52L6610 PO $168.91 $192.07 $160.97 $168.91 $168.91 $192.07L6611 PO $395.38 $395.36 $397.58 $395.38 $395.38 $395.36L6615 PO $182.00 $184.38 $185.41 $182.00 $182.00 $184.38L6616 PO $67.44 $78.37 $61.60 $67.44 $67.44 $78.37L6620 PO $291.18 $318.59 $323.07 $291.18 $291.18 $318.59L6621 PO $2,196.61 $2,196.43 $2,208.78 $2,196.61 $2,196.61 $2,196.43L6623 PO $812.24 $639.69 $609.18 $812.24 $812.24 $639.69L6624 PO $3,616.79 $3,616.49 $3,636.80 $3,616.79 $3,616.79 $3,616.49L6625 PO $577.11 $673.44 $505.08 $577.11 $577.11 $673.44L6628 PO $454.94 $490.21 $606.58 $454.94 $454.94 $490.21L6629 PO $138.94 $168.55 $174.06 $138.94 $138.94 $168.55L6630 PO $204.67 $272.90 $204.67 $204.67 $204.67 $272.90L6632 PO $71.08 $61.70 $82.27 $71.08 $71.08 $61.70L6635 PO $167.27 $210.11 $196.73 $167.27 $167.27 $210.11L6637 PO $356.77 $409.41 $348.71 $356.77 $356.77 $409.41L6638 PO $2,401.61 $2,401.38 $2,414.87 $2,401.61 $2,401.61 $2,401.38L6640 PO $316.95 $342.54 $278.55 $316.95 $316.95 $342.54L6641 PO $152.35 $185.24 $153.30 $152.35 $152.35 $185.24L6642 PO $206.50 $220.55 $206.50 $206.50 $206.50 $220.55L6645 PO $381.17 $382.50 $303.16 $381.17 $381.17 $382.50L6646 PO $3,028.99 $3,028.68 $3,045.70 $3,028.99 $3,028.99 $3,028.68L6647 PO $498.66 $498.62 $501.47 $498.66 $498.66 $498.62L6648 PO $3,123.95 $3,123.67 $3,141.20 $3,123.95 $3,123.95 $3,123.67L6650 PO $395.75 $401.62 $321.45 $395.75 $395.75 $401.62L6655 PO $77.78 $87.93 $71.34 $77.78 $77.78 $87.93L6660 PO $87.17 $98.02 $89.27 $87.17 $87.17 $98.02L6665 PO $43.74 $58.32 $43.74 $43.74 $43.74 $58.32L6670 PO $48.36 $60.73 $45.54 $48.36 $48.36 $60.73L6672 PO $191.91 $168.97 $192.05 $191.91 $191.91 $168.97L6675 PO $114.05 $118.49 $114.05 $114.05 $114.05 $118.49L6676 PO $131.83 $124.56 $134.46 $131.83 $131.83 $124.56





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



L6677 PO $284.93 $284.88 $286.46 $284.93 $284.93 $284.88L6680 PO $220.33 $293.77 $233.35 $220.33 $220.33 $293.77L6682 PO $243.61 $287.66 $254.38 $243.61 $243.61 $287.66L6684 PO $331.03 $331.03 $361.60 $331.03 $331.03 $331.03L6686 PO $747.54 $615.47 $560.65 $747.54 $747.54 $615.47L6687 PO $547.78 $547.78 $730.38 $547.78 $547.78 $547.78L6688 PO $544.48 $647.43 $503.09 $544.48 $544.48 $647.43L6689 PO $652.35 $677.49 $853.19 $652.35 $652.35 $677.49L6690 PO $710.88 $735.09 $653.01 $710.88 $710.88 $735.09L6691 PO $329.03 $327.82 $327.82 $329.03 $329.03 $327.82L6692 PO $531.08 $675.73 $664.48 $531.08 $531.08 $675.73L6693 PO $2,726.45 $2,726.20 $2,741.52 $2,726.45 $2,726.45 $2,726.20L6694 PO $675.27 $695.74 $719.55 $675.27 $675.27 $695.74L6695 PO $562.70 $579.76 $599.59 $562.70 $562.70 $579.76L6696 PO $1,263.27 $1,263.14 $1,272.78 $1,263.27 $1,263.27 $1,263.14L6697 PO $1,263.27 $1,263.14 $1,272.78 $1,263.27 $1,263.27 $1,263.14L6698 PO $546.08 $546.01 $629.83 $546.08 $546.08 $546.01L6703 PO $345.24 $314.08 $351.24 $345.24 $345.24 $314.08L6704 PO $556.16 $736.54 $683.70 $556.16 $556.16 $736.54L6706 PO $331.36 $382.12 $439.48 $331.36 $331.36 $382.12L6707 PO $1,221.34 $1,359.67 $1,357.25 $1,221.34 $1,221.34 $1,359.67L6708 PO $798.43 $913.81 $945.78 $798.43 $798.43 $913.81L6709 PO $1,150.56 $1,340.74 $1,466.60 $1,150.56 $1,150.56 $1,340.74L6711 PO $645.66 $645.61 $649.27 $645.66 $645.66 $645.61L6712 PO $1,188.81 $1,188.71 $1,195.37 $1,188.81 $1,188.81 $1,188.71L6713 PO $1,500.36 $1,500.24 $1,508.67 $1,500.36 $1,500.36 $1,500.24L6714 PO $1,270.83 $1,270.71 $1,277.82 $1,270.83 $1,270.83 $1,270.71L6715 PO $3,032.02 $3,031.73 $3,054.84 $3,032.02 $3,032.02 $3,031.73L6721 PO $2,258.76 $2,258.53 $2,271.20 $2,258.76 $2,258.76 $2,258.53L6722 PO $1,947.20 $1,947.01 $1,957.96 $1,947.20 $1,947.20 $1,947.01L6805 PO $323.11 $404.12 $338.18 $323.11 $323.11 $404.12L6810 PO $183.14 $236.20 $209.08 $183.14 $183.14 $236.20L6880 PO $22,945.54 $22,943.36 $23,118.23 $22,945.54 $22,945.54 $22,943.36L6881 PO $3,926.19 $3,925.84 $3,947.84 $3,926.19 $3,926.19 $3,925.84L6882 PO $2,978.23 $2,977.95 $2,994.68 $2,978.23 $2,978.23 $2,977.95L6883 PO $1,507.02 $1,772.07 $1,627.60 $1,507.02 $1,507.02 $1,772.07L6884 PO $2,236.73 $2,659.52 $2,120.16 $2,236.73 $2,236.73 $2,659.52L6885 PO $3,345.37 $3,024.88 $3,024.88 $3,345.37 $3,345.37 $3,024.88L6890 PO $161.53 $175.07 $172.59 $161.53 $161.53 $175.07L6895 PO $594.22 $530.29 $542.00 $594.22 $594.22 $530.29L6900 PO $1,695.75 $1,468.35 $1,434.45 $1,695.75 $1,695.75 $1,468.35L6905 PO $1,686.11 $1,394.32 $1,394.32 $1,686.11 $1,686.11 $1,394.32L6910 PO $1,441.79 $1,373.99 $1,358.35 $1,441.79 $1,441.79 $1,373.99L6915 PO $726.93 $594.52 $594.52 $726.93 $726.93 $594.52L6920 PO $6,337.86 $6,959.29 $7,704.13 $6,337.86 $6,337.86 $6,959.29L6925 PO $8,531.86 $7,348.41 $8,309.21 $8,531.86 $8,531.86 $7,348.41L6930 PO $6,377.16 $7,471.61 $8,094.72 $6,377.16 $6,377.16 $7,471.61L6935 PO $8,664.26 $8,218.69 $8,690.68 $8,664.26 $8,664.26 $8,218.69L6940 PO $8,332.17 $9,337.89 $11,109.56 $8,332.17 $8,332.17 $9,337.89L6945 PO $10,180.92 $10,563.36 $12,924.69 $10,180.92 $10,180.92 $10,563.36L6950 PO $9,470.69 $9,927.98 $12,627.59 $9,470.69 $9,470.69 $9,927.98L6955 PO $11,342.44 $12,458.23 $15,123.26 $11,342.44 $11,342.44 $12,458.23L6960 PO $12,848.16 $12,284.43 $15,252.94 $12,848.16 $12,848.16 $12,284.43L6965 PO $13,703.03 $17,945.81 $16,525.72 $13,703.03 $13,703.03 $17,945.81L6970 PO $14,278.78 $18,240.69 $16,729.73 $14,278.78 $14,278.78 $18,240.69L6975 PO $15,616.38 $18,338.59 $17,924.25 $15,616.38 $15,616.38 $18,338.59L7007 PO $3,267.89 $4,357.18 $3,267.89 $3,267.89 $3,267.89 $4,357.18L7008 PO $5,143.31 $6,857.75 $5,499.28 $5,143.31 $5,143.31 $6,857.75L7009 PO $3,334.28 $4,445.70 $3,421.84 $3,334.28 $3,334.28 $4,445.70L7040 PO $2,677.30 $3,569.73 $2,677.30 $2,677.30 $2,677.30 $3,569.73L7045 PO $1,534.98 $2,046.65 $1,534.98 $1,534.98 $1,534.98 $2,046.65





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



L7170 PO $7,067.66 $7,424.56 $5,842.58 $7,067.66 $7,067.66 $7,424.56L7180 PO $31,023.06 $38,791.57 $33,907.51 $31,023.06 $31,023.06 $38,791.57L7181 PO $38,479.94 $38,476.38 $38,692.25 $38,479.94 $38,479.94 $38,476.38L7185 PO $6,979.40 $7,518.36 $6,061.59 $6,979.40 $6,979.40 $7,518.36L7186 PO $8,400.38 $10,850.81 $10,986.06 $8,400.38 $8,400.38 $10,850.81L7190 PO $7,330.75 $9,565.69 $7,669.11 $7,330.75 $7,330.75 $9,565.69L7191 PO $8,777.90 $11,534.08 $11,256.03 $8,777.90 $8,777.90 $11,534.08L7259 PO $3,035.08 $3,646.49 $3,662.12 $3,035.08 $3,035.08 $3,646.49L7360 PO $226.60 $228.68 $215.95 $226.60 $226.60 $228.68L7362 PO $237.93 $275.03 $317.24 $237.93 $237.93 $275.03L7364 PO $378.42 $501.00 $378.42 $378.42 $378.42 $501.00L7366 PO $509.75 $679.67 $509.75 $509.75 $509.75 $679.67L7367 PO $373.88 $373.85 $375.95 $373.88 $373.88 $373.85L7368 PO $484.69 $484.66 $487.37 $484.69 $484.69 $484.66L7400 PO $294.35 $294.31 $295.98 $294.35 $294.35 $294.31L7401 PO $329.52 $329.48 $331.35 $329.52 $329.52 $329.48L7402 PO $355.82 $355.80 $357.82 $355.82 $355.82 $355.80L7403 PO $353.68 $353.63 $355.61 $353.68 $353.68 $353.63L7404 PO $533.76 $533.72 $536.73 $533.76 $533.76 $533.72L7405 PO $698.10 $698.05 $701.94 $698.10 $698.10 $698.05L8000 PO $41.77 $35.64 $35.72 $41.77 $41.77 $35.64L8001 PO $120.46 $120.45 $121.12 $120.46 $120.46 $120.45L8002 PO $158.45 $158.43 $159.33 $158.45 $158.45 $158.43L8015 PO $57.56 $57.56 $57.90 $57.56 $57.56 $57.56L8020 PO $216.50 $215.77 $190.51 $216.50 $216.50 $215.77L8030 PO $313.17 $316.78 $338.08 $313.17 $313.17 $316.78L8031 PO $313.17 $316.78 $338.08 $313.17 $313.17 $316.78L8032 PO $37.62 $37.62 $37.82 $37.62 $37.62 $37.62L8035 PO $3,518.42 $3,518.08 $3,537.81 $3,518.42 $3,518.42 $3,518.08L8040 KM PO $2,205.30 $2,174.39 $2,118.97 $2,205.30 $2,205.30 $2,174.39L8040 KN PO $928.56 $915.51 $892.22 $928.56 $928.56 $915.51L8040 PO $2,321.37 $2,288.84 $2,230.50 $2,321.37 $2,321.37 $2,288.84L8041 KM PO $2,658.06 $2,620.86 $2,554.17 $2,658.06 $2,658.06 $2,620.86L8041 KN PO $1,119.20 $1,103.52 $1,075.43 $1,119.20 $1,119.20 $1,103.52L8041 PO $2,797.97 $2,758.81 $2,688.61 $2,797.97 $2,797.97 $2,758.81L8042 KM PO $2,986.58 $2,944.78 $2,869.85 $2,986.58 $2,986.58 $2,944.78L8042 KN PO $1,257.50 $1,239.92 $1,208.36 $1,257.50 $1,257.50 $1,239.92L8042 PO $3,143.77 $3,099.79 $3,020.91 $3,143.77 $3,143.77 $3,099.79L8043 KM PO $3,344.96 $3,298.17 $3,214.22 $3,344.96 $3,344.96 $3,298.17L8043 KN PO $1,408.40 $1,388.71 $1,353.33 $1,408.40 $1,408.40 $1,388.71L8043 PO $3,521.03 $3,471.75 $3,383.43 $3,521.03 $3,521.03 $3,471.75L8044 KM PO $3,703.38 $3,651.54 $3,558.63 $3,703.38 $3,703.38 $3,651.54L8044 KN PO $1,559.33 $1,537.51 $1,498.36 $1,559.33 $1,559.33 $1,537.51L8044 PO $3,898.27 $3,843.72 $3,745.92 $3,898.27 $3,898.27 $3,843.72L8045 KM PO $2,319.14 $2,286.59 $2,228.20 $2,319.14 $2,319.14 $2,286.59L8045 KN PO $976.48 $962.77 $938.18 $976.48 $976.48 $962.77L8045 PO $2,441.21 $2,406.92 $2,345.48 $2,441.21 $2,441.21 $2,406.92L8046 KM PO $2,389.26 $2,355.82 $2,295.90 $2,389.26 $2,389.26 $2,355.82L8046 KN PO $1,005.99 $991.93 $966.67 $1,005.99 $1,005.99 $991.93L8046 PO $2,515.02 $2,479.81 $2,416.71 $2,515.02 $2,515.02 $2,479.81L8047 KM PO $1,224.49 $1,207.35 $1,176.63 $1,224.49 $1,224.49 $1,207.35L8047 KN PO $515.58 $508.36 $495.43 $515.58 $515.58 $508.36L8047 PO $1,288.93 $1,270.92 $1,238.56 $1,288.93 $1,288.93 $1,270.92L8300 PO $92.49 $80.11 $91.40 $92.49 $92.49 $80.11L8310 PO $142.21 $126.48 $147.43 $142.21 $142.21 $126.48L8320 PO $62.12 $58.39 $50.77 $62.12 $62.12 $58.39L8330 PO $61.57 $62.51 $46.88 $61.57 $61.57 $62.51L8400 PO $18.00 $14.95 $14.95 $18.00 $18.00 $14.95L8410 PO $20.48 $21.86 $20.79 $20.48 $20.48 $21.86L8415 PO $20.36 $22.21 $22.47 $20.36 $20.36 $22.21L8417 PO $72.21 $72.20 $72.61 $72.21 $72.21 $72.20





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



L8420 PO $23.80 $19.74 $18.47 $23.80 $23.80 $19.74L8430 PO $26.17 $21.68 $23.32 $26.17 $26.17 $21.68L8435 PO $23.49 $22.90 $19.97 $23.49 $23.49 $22.90L8440 PO $49.79 $41.96 $39.72 $49.79 $49.79 $41.96L8460 PO $69.29 $72.99 $63.29 $69.29 $69.29 $72.99L8465 PO $61.76 $52.00 $46.32 $61.76 $61.76 $52.00L8470 PO $6.34 $7.60 $8.45 $6.34 $6.34 $7.60L8480 PO $8.74 $9.99 $11.65 $8.74 $8.74 $9.99L8485 PO $10.56 $10.56 $12.65 $10.56 $10.56 $10.56L8500 PO $626.75 $738.30 $626.75 $626.75 $626.75 $738.30L8501 PO $139.20 $114.72 $114.72 $139.20 $139.20 $114.72L8507 PO $40.23 $40.22 $40.44 $40.23 $40.23 $40.22L8510 PO $242.70 $242.68 $244.02 $242.70 $242.70 $242.68L8511 PO $69.85 $69.84 $70.23 $69.85 $69.85 $69.84L8512 PO $2.11 $2.11 $2.12 $2.11 $2.11 $2.11L8513 PO $5.00 $5.00 $5.02 $5.00 $5.00 $5.00L8514 PO $90.57 $90.56 $91.06 $90.57 $90.57 $90.56L8515 PO $60.61 $60.61 $60.96 $60.61 $60.61 $60.61V2020 PO $76.54 $63.94 $69.77 $76.54 $76.54 $63.94V2100 PO $37.20 $45.64 $49.60 $37.20 $37.20 $45.64V2101 PO $39.20 $52.27 $52.27 $39.20 $39.20 $52.27V2102 PO $55.59 $58.09 $73.52 $55.59 $55.59 $58.09V2103 PO $32.30 $34.57 $39.98 $32.30 $32.30 $34.57V2104 PO $35.77 $40.87 $45.57 $35.77 $35.77 $40.87V2105 PO $43.79 $40.01 $38.95 $43.79 $43.79 $40.01V2106 PO $44.45 $47.81 $43.22 $44.45 $44.45 $47.81V2107 PO $46.71 $51.53 $44.33 $46.71 $46.71 $51.53V2108 PO $45.31 $50.57 $53.94 $45.31 $45.31 $50.57V2109 PO $52.08 $48.48 $47.08 $52.08 $52.08 $48.48V2110 PO $60.79 $46.57 $46.46 $60.79 $60.79 $46.57V2111 PO $53.58 $54.52 $48.43 $53.58 $53.58 $54.52V2112 PO $52.87 $70.50 $52.87 $52.87 $52.87 $70.50V2113 PO $73.05 $75.88 $60.40 $73.05 $73.05 $75.88V2114 PO $64.61 $86.06 $79.25 $64.61 $64.61 $86.06V2115 PO $70.25 $93.66 $83.74 $70.25 $70.25 $93.66V2118 PO $69.64 $69.64 $69.64 $69.64 $69.64 $69.64V2121 PO $71.90 $95.87 $74.30 $71.90 $71.90 $95.87V2200 PO $48.69 $56.23 $52.17 $48.69 $48.69 $56.23V2201 PO $53.06 $59.22 $61.20 $53.06 $53.06 $59.22V2202 PO $62.44 $67.29 $80.92 $62.44 $62.44 $67.29V2203 PO $49.12 $55.23 $52.08 $49.12 $49.12 $55.23V2204 PO $53.26 $56.20 $54.12 $53.26 $53.26 $56.20V2205 PO $58.43 $58.64 $63.07 $58.43 $58.43 $58.64V2206 PO $71.14 $59.96 $59.65 $71.14 $71.14 $59.96V2207 PO $59.38 $55.86 $60.79 $59.38 $59.38 $55.86V2208 PO $60.11 $61.99 $65.39 $60.11 $60.11 $61.99V2209 PO $66.12 $61.32 $66.26 $66.12 $66.12 $61.32V2210 PO $85.07 $70.10 $70.66 $85.07 $85.07 $70.10V2211 PO $72.54 $70.13 $93.51 $72.54 $72.54 $70.13V2212 PO $78.94 $72.42 $96.56 $78.94 $78.94 $72.42V2213 PO $80.94 $77.39 $97.54 $80.94 $80.94 $77.39V2214 PO $86.77 $79.52 $92.71 $86.77 $86.77 $79.52V2215 PO $93.89 $90.68 $82.60 $93.89 $93.89 $90.68V2218 PO $96.06 $96.06 $96.06 $96.06 $96.06 $96.06V2219 PO $42.29 $48.83 $56.38 $42.29 $42.29 $48.83V2220 PO $34.29 $44.70 $35.48 $34.29 $34.29 $44.70V2221 PO $91.62 $95.50 $86.51 $91.62 $91.62 $95.50V2300 PO $63.23 $73.44 $68.64 $63.23 $63.23 $73.44V2301 PO $73.33 $96.17 $73.06 $73.33 $73.33 $96.17V2302 PO $80.33 $96.63 $77.88 $80.33 $80.33 $96.63V2303 PO $66.55 $69.79 $65.35 $66.55 $66.55 $69.79





Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



V2304 PO $69.64 $68.14 $70.06 $69.64 $69.64 $68.14V2305 PO $85.40 $84.62 $78.30 $85.40 $85.40 $84.62V2306 PO $79.63 $101.51 $88.07 $79.63 $79.63 $101.51V2307 PO $78.96 $76.29 $74.61 $78.96 $78.96 $76.29V2308 PO $84.26 $79.38 $77.70 $84.26 $84.26 $79.38V2309 PO $98.57 $88.78 $82.30 $98.57 $98.57 $88.78V2310 PO $108.42 $81.32 $81.32 $108.42 $108.42 $81.32V2311 PO $103.26 $101.69 $84.61 $103.26 $103.26 $101.69V2312 PO $91.02 $96.14 $85.10 $91.02 $91.02 $96.14V2313 PO $124.24 $100.41 $95.04 $124.24 $124.24 $100.41V2314 PO $136.09 $102.07 $102.07 $136.09 $136.09 $102.07V2315 PO $151.09 $113.31 $113.31 $151.09 $151.09 $113.31V2318 PO $139.31 $139.31 $139.31 $139.31 $139.31 $139.31V2319 PO $47.16 $53.23 $47.16 $47.16 $47.16 $53.23V2320 PO $49.75 $66.34 $49.75 $49.75 $49.75 $66.34V2321 PO $148.92 $112.98 $111.69 $148.92 $148.92 $112.98V2410 PO $85.16 $100.46 $113.54 $85.16 $85.16 $100.46V2430 PO $110.85 $116.36 $116.77 $110.85 $110.85 $116.36V2500 PO $77.19 $96.49 $81.66 $77.19 $77.19 $96.49V2501 PO $117.58 $117.58 $143.68 $117.58 $117.58 $117.58V2502 PO $144.85 $144.85 $162.22 $144.85 $144.85 $144.85V2503 PO $138.59 $133.40 $133.40 $138.59 $138.59 $133.40V2510 PO $105.37 $139.33 $117.64 $105.37 $105.37 $139.33V2511 PO $151.40 $180.70 $151.40 $151.40 $151.40 $180.70V2512 PO $178.90 $238.54 $178.90 $178.90 $178.90 $238.54V2513 PO $150.19 $200.26 $150.19 $150.19 $150.19 $200.26V2520 PO $99.04 $119.90 $99.04 $99.04 $99.04 $119.90V2521 PO $172.43 $183.36 $191.79 $172.43 $172.43 $183.36V2522 PO $167.81 $223.74 $167.81 $167.81 $167.81 $223.74V2523 PO $143.00 $174.78 $143.00 $143.00 $143.00 $174.78V2530 PO $211.81 $269.99 $230.52 $211.81 $211.81 $269.99V2531 PO $519.99 $519.93 $521.22 $519.99 $519.99 $519.93V2623 PO $852.46 $1,136.62 $901.99 $852.46 $852.46 $1,136.62V2624 PO $57.82 $75.85 $73.53 $57.82 $57.82 $75.85V2625 PO $374.48 $364.30 $463.48 $374.48 $374.48 $364.30V2626 PO $237.59 $252.63 $189.47 $237.59 $237.59 $252.63V2627 PO $1,360.18 $1,375.32 $1,590.08 $1,360.18 $1,360.18 $1,375.32V2628 PO $310.99 $357.78 $385.25 $310.99 $310.99 $357.78V2700 PO $41.60 $50.32 $49.07 $41.60 $41.60 $50.32V2710 PO $60.89 $75.54 $73.43 $60.89 $60.89 $75.54V2715 PO $11.04 $12.46 $11.04 $11.04 $11.04 $12.46V2718 PO $27.11 $30.97 $27.11 $27.11 $27.11 $30.97V2730 PO $20.03 $26.70 $20.03 $20.03 $20.03 $26.70V2744 PO $20.77 $19.83 $15.58 $20.77 $20.77 $19.83V2745 PO $11.78 $13.00 $9.98 $11.78 $11.78 $13.00V2750 PO $24.17 $24.17 $18.13 $24.17 $24.17 $24.17V2755 PO $17.47 $21.03 $16.66 $17.47 $17.47 $21.03V2760 PO $15.21 $16.83 $20.28 $15.21 $15.21 $16.83V2762 PO $57.26 $57.24 $57.56 $57.26 $57.26 $57.24V2770 PO $19.64 $20.32 $18.97 $19.64 $19.64 $20.32V2780 PO $15.87 $11.90 $11.90 $15.87 $15.87 $11.90V2782 PO $61.82 $61.82 $62.15 $61.82 $61.82 $61.82V2783 PO $69.71 $69.69 $70.10 $69.71 $69.71 $69.69V2784 PO $45.33 $45.33 $45.59 $45.33 $45.33 $45.33




HCPCS 1st Mod 2nd Mod CategoryA4216 OSA4217 AU OSA4217 SUA4221 SUA4222 SUA4233 NU INA4234 NU INA4235 NU INA4236 NU INA4253 NU INA4255 SUA4256 SUA4257 SUA4258 SUA4259 SUA4265 SUA4280 POA4310 OSA4311 OSA4312 OSA4313 OSA4314 OSA4315 OSA4316 OSA4320 OSA4322 OSA4326 OSA4327 OSA4328 OSA4330 OSA4331 OSA4332 OSA4333 OSA4334 OSA4336 OSA4338 OSA4340 OS


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


$0.49 $0.44 $0.49 $0.42 $0.43 $0.49$3.13 $2.95 $3.47 $2.99 $3.81 $2.95$3.13 $2.95 $3.47 $2.99 $3.81 $2.95

$22.21 $22.21 $22.21 $22.21 $24.72 $22.21$44.23 $43.98 $44.23 $44.23 $48.19 $44.23

$0.51 $0.51 $0.51 $0.51 $0.51 $0.51$2.36 $2.36 $2.36 $2.36 $2.36 $2.36$1.00 $1.00 $1.00 $1.00 $1.00 $1.00$1.16 $1.16 $1.16 $1.16 $1.16 $1.16$8.32 $8.32 $8.32 $8.32 $8.32 $8.32$4.55 $4.42 $4.55 $4.55 $4.75 $4.55$3.38 $3.38 $3.38 $3.38 $3.38 $3.38

$14.10 $14.10 $14.10 $14.10 $16.92 $14.10$2.12 $2.12 $2.12 $2.12 $2.12 $2.12$1.42 $1.42 $1.42 $1.42 $1.42 $1.42$3.76 $3.76 $3.76 $3.76 $4.47 $3.76$5.90 $5.90 $5.90 $5.90 $6.30 $5.90$7.26 $7.26 $8.54 $8.54 $19.57 $7.26

$16.39 $16.39 $16.39 $16.39 $12.44 $16.39$19.94 $19.94 $19.94 $19.94 $28.39 $19.94$20.48 $20.48 $20.48 $20.48 $20.62 $20.48$23.76 $27.95 $26.00 $27.09 $28.39 $27.95$29.17 $29.17 $26.00 $27.09 $28.39 $29.17$31.39 $31.39 $26.68 $27.09 $28.39 $30.31

$5.02 $5.02 $5.90 $5.90 $6.54 $5.90$3.35 $3.25 $3.34 $3.32 $3.45 $3.32

$11.93 $11.93 $11.93 $11.93 $12.60 $11.93$49.31 $49.31 $49.30 $49.31 $51.40 $49.31$11.54 $11.33 $11.54 $11.54 $11.98 $11.44

$6.72 $7.89 $6.72 $6.72 $1.37 $7.90$3.52 $3.52 $3.52 $3.52 $4.23 $3.52$0.13 $0.13 $0.13 $0.13 $0.18 $0.13$2.44 $2.44 $2.44 $2.44 $2.68 $2.44$5.44 $5.44 $5.44 $5.44 $6.00 $5.44$1.59 $1.59 $1.59 $1.59 $1.74 $1.59

$13.56 $12.01 $11.53 $11.53 $14.97 $13.56$29.84 $29.84 $32.02 $32.02 $38.60 $29.84

MISSISSIPPI NORTH CAROLINA NEW MEXICO OKLAHOMA PEURTO RICO SOUTH CAROLINA



HCPCS 1st Mod 2nd Mod CategoryA4344 OSA4346 OSA4349 OSA4351 OSA4352 OSA4353 OSA4354 OSA4355 OSA4356 OSA4357 OSA4358 OSA4360 OSA4361 OSA4362 OSA4363 OSA4364 OSA4366 OSA4367 OSA4368 OSA4369 OSA4371 OSA4372 OSA4373 OSA4375 OSA4376 OSA4377 OSA4378 OSA4379 OSA4380 OSA4381 OSA4382 OSA4383 OSA4384 OSA4385 OSA4387 OSA4388 OSA4389 OSA4390 OSA4391 OSA4392 OSA4393 OSA4394 OSA4395 OSA4396 OSA4397 OSA4398 OSA4399 OSA4400 OSA4402 OSA4404 OSA4405 OSA4406 OSA4407 OSA4408 OSA4409 OSA4410 OSA4411 OSA4412 OSA4413 OSA4414 OSA4415 OS

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$16.19 $15.87 $17.70 $17.70 $30.09 $15.73$19.19 $18.40 $21.65 $21.65 $19.11 $18.40

$2.23 $2.23 $2.23 $2.23 $2.49 $2.23$1.86 $1.71 $2.01 $2.01 $1.63 $2.01$7.10 $6.56 $6.06 $6.06 $8.59 $7.10$7.74 $7.74 $7.74 $7.74 $8.50 $7.74

$13.05 $13.05 $11.98 $12.53 $19.57 $13.05$9.86 $9.86 $8.38 $8.38 $26.15 $9.21

$46.00 $50.14 $50.44 $42.87 $36.43 $46.57$9.12 $10.73 $9.12 $9.12 $10.84 $10.73$6.55 $7.33 $7.33 $7.33 $6.15 $6.23$0.49 $0.54 $0.54 $0.46 $0.40 $0.49

$20.31 $20.31 $17.26 $17.26 $11.37 $20.31$3.26 $3.83 $3.26 $3.26 $3.88 $3.83$2.23 $2.62 $2.23 $2.23 $1.72 $2.41$3.25 $2.76 $3.25 $3.25 $7.27 $2.84$1.43 $1.43 $1.43 $1.43 $1.72 $1.43$6.91 $6.91 $8.03 $8.13 $8.09 $7.58$0.28 $0.28 $0.28 $0.28 $0.30 $0.28$2.68 $2.68 $2.68 $2.68 $3.12 $2.68$4.03 $4.03 $4.03 $4.03 $4.74 $4.03$4.64 $4.64 $4.64 $4.64 $5.09 $4.64$6.93 $6.93 $6.93 $6.93 $7.63 $6.93

$18.99 $18.99 $18.99 $18.99 $20.87 $18.99$52.61 $52.61 $52.61 $52.61 $57.87 $52.61

$4.75 $4.75 $4.75 $4.75 $5.22 $4.75$33.98 $33.98 $33.98 $33.98 $37.37 $33.98$16.60 $16.60 $16.60 $16.60 $18.27 $16.60$41.26 $41.26 $41.26 $41.26 $45.37 $41.26

$5.11 $5.11 $5.11 $5.11 $5.60 $5.11$27.21 $27.21 $27.21 $27.21 $29.88 $27.21$31.16 $31.16 $31.16 $31.16 $34.32 $31.16$10.63 $10.63 $10.63 $10.63 $11.69 $10.63

$5.64 $5.64 $5.64 $5.64 $6.19 $5.64$2.48 $2.48 $2.48 $2.48 $2.71 $2.48$4.83 $4.83 $4.83 $4.83 $5.30 $4.83$6.87 $6.87 $6.87 $6.87 $7.53 $6.87

$10.62 $10.62 $10.62 $10.62 $11.67 $10.62$7.82 $7.82 $7.82 $7.82 $8.59 $7.82$9.04 $9.04 $9.04 $9.04 $10.88 $9.04

$10.00 $10.00 $10.00 $10.00 $11.99 $10.00$2.86 $2.86 $2.86 $2.86 $3.11 $2.86$0.05 $0.05 $0.05 $0.05 $0.06 $0.05

$44.75 $44.75 $44.75 $44.75 $53.69 $44.75$4.83 $4.50 $4.50 $4.50 $8.54 $4.89

$15.28 $15.28 $15.28 $15.28 $17.21 $15.28$11.93 $13.44 $13.56 $13.56 $15.72 $13.56$45.92 $45.92 $54.02 $54.02 $62.20 $45.92

$1.50 $1.50 $1.54 $1.54 $3.50 $1.77$1.61 $1.58 $1.86 $1.86 $1.99 $1.86$3.77 $3.77 $3.77 $3.77 $4.48 $3.77$6.33 $6.33 $6.33 $6.33 $7.59 $6.33$9.68 $9.68 $9.68 $9.68 $11.60 $9.68

$10.91 $10.91 $10.91 $10.91 $13.09 $10.91$6.87 $6.87 $6.87 $6.87 $8.22 $6.87

$10.00 $10.00 $10.00 $10.00 $11.99 $10.00$5.64 $5.64 $5.64 $5.64 $6.76 $5.64$2.99 $2.99 $2.99 $2.99 $3.55 $2.99$6.09 $6.09 $6.09 $6.09 $7.32 $6.09$5.44 $5.44 $5.44 $5.44 $6.52 $5.44$6.62 $6.62 $6.62 $6.62 $7.94 $6.62



HCPCS 1st Mod 2nd Mod CategoryA4416 OSA4417 OSA4418 OSA4419 OSA4422 OSA4423 OSA4424 OSA4425 OSA4426 OSA4427 OSA4428 OSA4429 OSA4430 OSA4431 OSA4432 OSA4433 OSA4434 OSA4435 OSA4450 AU OSA4450 AV OSA4450 AW OSA4452 AU OSA4452 AV OSA4452 AW OSA4455 OSA4456 OSA4461 SDA4463 SDA4481 OSA4556 SUA4557 SUA4558 SUA4559 SUA4595 SUA4602 NU INA4604 NU INA4605 NU INA4608 OXA4614 INA4615 SUA4616 SUA4617 SUA4618 NU INA4618 RR INA4618 UE INA4619 NU INA4620 SUA4623 OSA4624 NU INA4625 OSA4626 OSA4628 NU INA4629 OSA4630 NU INA4633 NU INA4635 NU INA4635 RR INA4635 UE INA4636 NU KE INA4636 NU INA4636 RR KE IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$3.05 $3.05 $3.05 $3.05 $3.37 $3.05$4.11 $4.11 $4.11 $4.11 $4.49 $4.11$2.01 $2.01 $2.01 $2.01 $2.19 $2.01$1.92 $1.92 $1.92 $1.92 $2.12 $1.92$0.13 $0.13 $0.13 $0.13 $0.18 $0.13$2.06 $2.06 $2.06 $2.06 $2.48 $2.06$5.26 $5.26 $5.26 $5.26 $5.77 $5.26$3.96 $3.96 $3.96 $3.96 $4.35 $3.96$3.02 $3.02 $3.02 $3.02 $3.62 $3.02$3.08 $3.08 $3.08 $3.08 $3.73 $3.08$7.20 $7.20 $7.20 $7.20 $7.90 $7.20$9.12 $9.12 $9.12 $9.12 $10.97 $9.12$9.41 $9.41 $9.41 $9.41 $10.37 $9.41$6.87 $6.87 $6.87 $6.87 $8.22 $6.87$3.97 $3.97 $3.97 $3.97 $4.36 $3.97$3.70 $3.70 $3.70 $3.70 $4.03 $3.70$4.15 $4.15 $4.15 $4.15 $4.60 $4.15$6.38 $6.38 $6.38 $6.38 $7.21 $6.38$0.09 $0.09 $0.09 $0.09 $0.12 $0.09$0.09 $0.09 $0.09 $0.09 $0.12 $0.09$0.12 $0.12 $0.12 $0.12 $0.14 $0.12$0.40 $0.40 $0.40 $0.40 $0.47 $0.40$0.40 $0.40 $0.40 $0.40 $0.43 $0.40$0.44 $0.44 $0.44 $0.44 $0.53 $0.44$1.58 $1.34 $1.34 $1.34 $1.26 $1.56$0.27 $0.27 $0.27 $0.27 $0.29 $0.27$3.64 $3.64 $3.64 $3.64 $4.35 $3.64

$14.72 $14.72 $14.72 $14.72 $16.20 $14.72$0.42 $0.42 $0.42 $0.42 $0.44 $0.42

$11.42 $11.42 $13.43 $13.43 $7.83 $11.42$15.45 R $15.59 $17.20 R $17.34 $16.55 R $17.28 $14.87 R $15.59 $14.98 $17.20 R $17.34

$5.44 $6.03 $5.13 $6.03 $2.15 $5.13$0.11 $0.11 $0.11 $0.11 $0.12 $0.11

$21.48 R $21.67 $21.48 R $21.67 $21.06 R $21.67 $21.06 R $21.67 $24.85 $21.48 R $21.67$4.11 $4.11 $4.11 $4.11 $4.92 $4.11

$51.69 R $53.81 $51.69 R $53.81 $51.60 R $53.81 $51.60 R $53.81 $60.05 $51.69 R $53.81$18.13 $18.13 $18.13 $18.13 $21.71 $18.13$55.41 $55.41 $55.41 $55.41 $66.50 $55.41$26.29 $26.29 $26.29 $26.29 $31.55 $26.29

$0.80 $0.80 $0.80 $0.80 $0.98 $0.80$0.07 $0.07 $0.07 $0.07 $0.09 $0.07$3.43 $3.43 $3.43 $3.43 $4.09 $3.43$8.36 $8.36 $9.76 $9.74 $10.69 $9.83$0.97 $0.97 $0.97 $0.97 $1.32 $0.97$6.26 $6.26 $7.32 $7.30 $8.03 $7.37$2.01 $2.01 $2.01 $2.01 $2.21 $2.01$0.70 $0.70 $0.70 $0.70 $0.77 $0.70$6.15 $6.15 $6.15 $6.15 $3.37 $6.15$2.47 $2.47 $2.47 $2.47 $1.37 $2.91$6.51 $6.51 $7.66 $7.66 $48.94 $6.51$3.52 $3.00 $3.53 $3.53 $1.37 $3.00$4.13 $4.13 $4.13 $4.13 $4.88 $4.13$5.13 $5.13 $5.13 $5.13 $5.99 $5.13$6.90 $6.90 $5.87 $5.87 $5.27 $6.90

$45.36 $45.36 $45.36 $45.36 $54.43 $45.36$5.66 $4.81 $4.81 $5.66 $6.13 $4.81$0.77 $0.65 $0.73 $0.77 $0.79 $0.65$3.76 $3.20 $3.20 $3.76 $4.63 $3.20$3.80 $3.47 $3.45 $3.80 $2.63 $3.45$3.47 $3.20 $3.18 $3.47 $2.25 $3.18$0.38 $0.35 $0.35 $0.38 $0.31 $0.35



HCPCS 1st Mod 2nd Mod CategoryA4636 RR INA4636 UE KE INA4636 UE INA4637 NU KE INA4637 NU INA4637 RR KE INA4637 RR INA4637 UE KE INA4637 UE INA4639 RR CRA4640 NU INA4640 RR INA4640 UE INA5051 OSA5052 OSA5053 OSA5054 OSA5055 OSA5056 OSA5057 OSA5061 OSA5062 OSA5063 OSA5071 OSA5072 OSA5073 OSA5081 OSA5082 OSA5083 OSA5093 OSA5102 OSA5105 OSA5112 OSA5113 OSA5114 OSA5120 AU OSA5120 AV POA5121 OSA5122 OSA5126 OSA5131 OSA5200 OSA5500 TSA5501 TSA5503 TSA5504 TSA5505 TSA5506 TSA5507 TSA5512 TSA5513 TSA6010 SDA6011 SDA6021 SDA6022 SDA6023 SDA6024 SDA6154 SDA6196 SDA6197 SDA6199 SD

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$0.35 $0.32 $0.32 $0.35 $0.28 $0.32$2.80 $2.61 $2.54 $2.80 $1.99 $2.54$2.56 $2.41 $2.35 $2.56 $1.71 $2.35$1.99 $1.99 $1.82 $1.82 $2.31 $1.99$1.84 $1.84 $1.68 $1.68 $2.10 $1.84$0.24 $0.25 $0.22 $0.25 $0.27 $0.22$0.22 $0.22 $0.20 $0.22 $0.24 $0.20$1.50 $1.50 $1.37 $1.50 $1.72 $1.50$1.38 $1.38 $1.27 $1.38 $1.57 $1.38

$31.76 $31.76 $31.76 $31.76 $38.12 $31.76$54.21 R $58.03 $56.01 R $59.83 $59.33 R $63.28 $59.33 R $63.28 $72.58 $54.21 R $58.03

$5.48 R $5.86 $5.67 R $6.05 $6.00 R $6.39 $6.00 R $6.39 $8.31 $5.48 R $5.86$39.43 R $42.16 $40.34 R $43.20 $43.05 R $46.01 $43.05 R $46.01 $54.42 $39.43 R $42.16

$2.28 $2.28 $2.28 $2.28 $2.74 $2.28$1.64 $1.64 $1.64 $1.64 $2.00 $1.64$1.63 $1.63 $1.63 $1.63 $1.37 $1.63$1.99 $1.99 $1.99 $1.99 $2.35 $1.99$1.45 $1.38 $1.59 $1.59 $1.71 $1.48$5.16 $5.16 $5.16 $5.16 $5.67 $5.16

$10.62 $10.62 $10.62 $10.62 $11.67 $10.62$3.90 $3.90 $3.90 $3.90 $4.68 $3.90$2.46 $2.46 $2.46 $2.46 $2.58 $2.30$2.99 $2.99 $2.99 $2.99 $3.55 $2.99$6.64 $6.64 $6.64 $6.64 $8.01 $6.64$3.49 $3.77 $3.90 $3.90 $4.15 $3.90$2.99 $3.52 $3.50 $3.50 $3.93 $3.52$3.11 $3.21 $3.11 $3.11 $1.67 $3.11

$11.18 $12.41 $13.15 $13.15 $1.67 $11.18$0.71 $0.71 $0.71 $0.71 $0.83 $0.71$2.08 $1.84 $2.03 $2.03 $1.37 $2.06

$24.96 $24.96 $24.96 $24.96 $27.26 $24.96$45.07 $45.07 $42.27 $42.27 $22.37 $38.31$38.27 $38.27 $35.77 $35.77 $42.06 $38.27

$5.21 $4.43 $4.43 $4.43 $6.92 $5.21$8.42 $8.42 $9.90 $9.90 $6.92 $8.42$0.26 $0.26 $0.26 $0.26 $0.12 $0.26$0.26 $0.26 $0.26 $0.26 $0.14 $0.26$8.24 $8.24 $8.24 $8.24 $4.57 $8.24

$14.20 $13.88 $14.20 $14.20 $15.64 $14.20$1.45 $1.23 $1.23 $1.23 $1.99 $1.23

$17.53 $15.99 $17.53 $17.53 $55.95 $14.90$12.50 $12.50 $12.50 $12.50 $15.01 $12.50$70.29 $70.29 $70.29 $70.29 $70.29 $70.29

$210.83 $210.83 $210.83 $210.83 $210.83 $210.83$34.55 $34.55 $34.55 $34.55 $34.55 $34.55$34.55 $34.55 $34.55 $34.55 $34.55 $34.55$34.55 $34.55 $34.55 $34.55 $34.55 $34.55$34.55 $34.55 $34.55 $34.55 $34.55 $34.55$34.55 $34.55 $34.55 $34.55 $34.55 $34.55$28.67 $28.67 $28.67 $28.67 $28.67 $28.67$42.79 $42.79 $42.79 $42.79 $42.79 $42.79$34.24 $34.24 $34.24 $34.24 $41.09 $34.24

$2.52 $2.52 $2.52 $2.52 $3.04 $2.52$23.24 $23.24 $23.24 $23.24 $27.87 $23.24$23.24 $23.24 $23.24 $23.24 $27.87 $23.24

$210.39 $210.39 $210.39 $210.39 $252.47 $210.39$6.84 $6.84 $6.84 $6.84 $8.18 $6.84

$15.90 $15.88 $15.90 $15.90 $17.42 $15.90$8.13 $8.13 $8.13 $8.13 $9.76 $8.13

$18.17 $18.17 $18.17 $18.17 $21.81 $18.17$5.85 $5.85 $5.85 $5.85 $6.97 $5.85



HCPCS 1st Mod 2nd Mod CategoryA6203 SDA6204 SDA6207 SDA6209 SDA6210 SDA6211 SDA6212 SDA6214 SDA6216 SDA6219 SDA6220 SDA6222 SDA6223 SDA6224 SDA6229 SDA6231 SDA6232 SDA6233 SDA6234 SDA6235 SDA6236 SDA6237 SDA6238 SDA6240 SDA6241 SDA6242 SDA6243 SDA6244 SDA6245 SDA6246 SDA6247 SDA6248 SDA6251 SDA6252 SDA6253 SDA6254 SDA6255 SDA6257 SDA6258 SDA6259 SDA6266 SDA6402 SDA6403 SDA6407 SDA6410 SDA6441 SDA6442 SDA6443 SDA6444 SDA6445 SDA6446 SDA6447 SDA6448 SDA6449 SDA6450 SDA6451 SDA6452 SDA6453 SDA6454 SDA6455 SDA6456 SD

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$3.72 $3.72 $3.72 $3.72 $4.42 $3.72$6.88 $6.88 $6.88 $6.88 $8.24 $6.88$8.11 $8.11 $8.11 $8.11 $9.74 $8.11$8.26 $8.26 $8.26 $8.26 $9.96 $8.26

$22.03 $22.03 $22.03 $22.03 $26.42 $22.03$32.47 $32.47 $32.47 $32.47 $38.94 $32.47$10.73 $10.73 $10.73 $10.73 $12.89 $10.73$11.37 $11.37 $11.37 $11.37 $13.66 $11.37

$0.05 $0.05 $0.05 $0.05 $0.06 $0.05$1.06 $1.06 $1.06 $1.06 $1.28 $1.06$2.86 $2.86 $2.86 $2.86 $3.40 $2.86$2.35 $2.35 $2.35 $2.35 $2.84 $2.35$2.68 $2.68 $2.68 $2.68 $3.19 $2.68$3.99 $3.99 $3.99 $3.99 $4.81 $3.99$3.99 $3.99 $3.99 $3.99 $4.81 $3.99$5.18 $5.18 $5.18 $5.18 $6.18 $5.18$7.59 $7.59 $7.59 $7.59 $9.11 $7.59

$21.20 $21.20 $21.20 $21.20 $25.47 $21.20$7.23 $7.23 $7.23 $7.23 $8.67 $7.23

$18.59 $18.59 $18.59 $18.59 $22.34 $18.59$30.13 $30.13 $30.13 $30.13 $36.13 $30.13

$8.75 $8.75 $8.75 $8.75 $10.51 $8.75$25.20 $25.20 $25.20 $25.20 $30.26 $25.20$13.54 $13.54 $13.54 $13.54 $16.26 $13.54

$2.84 $2.84 $2.84 $2.84 $3.39 $2.84$6.70 $6.70 $6.70 $6.70 $8.05 $6.70

$13.62 $13.62 $13.62 $13.62 $16.32 $13.62$43.43 $43.43 $43.43 $43.43 $52.09 $43.43

$8.03 $8.03 $8.03 $8.03 $9.59 $8.03$10.98 $10.98 $10.98 $10.98 $13.17 $10.98$26.29 $26.29 $26.29 $26.29 $31.56 $26.29$17.96 $17.96 $17.96 $17.96 $21.54 $17.96

$2.20 $2.20 $2.20 $2.20 $2.65 $2.20$3.60 $3.60 $3.60 $3.60 $4.33 $3.60$7.00 $7.00 $7.00 $7.00 $8.45 $7.00$1.33 $1.33 $1.33 $1.33 $1.62 $1.33$3.36 $3.36 $3.36 $3.36 $4.00 $3.36$1.70 $1.70 $1.70 $1.70 $2.05 $1.70$4.77 $4.77 $4.77 $4.77 $5.69 $4.77

$12.10 $12.10 $12.10 $12.10 $14.51 $12.10$2.13 $2.13 $2.13 $2.13 $2.57 $2.13$0.13 $0.13 $0.13 $0.13 $0.16 $0.13$0.47 $0.47 $0.47 $0.47 $0.57 $0.47$2.08 $2.08 $2.08 $2.08 $2.49 $2.08$0.43 $0.43 $0.43 $0.43 $0.53 $0.43$0.75 $0.75 $0.75 $0.75 $0.89 $0.75$0.18 $0.18 $0.18 $0.18 $0.27 $0.18$0.31 $0.31 $0.31 $0.31 $0.38 $0.31$0.62 $0.62 $0.62 $0.62 $0.77 $0.62$0.36 $0.36 $0.36 $0.36 $0.41 $0.36$0.45 $0.45 $0.45 $0.45 $0.56 $0.45$0.75 $0.75 $0.75 $0.75 $0.89 $0.75$1.28 $1.28 $1.28 $1.28 $1.56 $1.28$1.94 $1.94 $1.94 $1.94 $2.30 $1.94$1.94 $1.94 $1.94 $1.94 $2.30 $1.94$1.94 $1.94 $1.94 $1.94 $2.30 $1.94$6.53 $6.53 $6.53 $6.53 $7.86 $6.53$0.69 $0.69 $0.69 $0.69 $0.82 $0.69$0.86 $0.86 $0.86 $0.86 $1.00 $0.86$1.54 $1.54 $1.54 $1.54 $1.81 $1.54$1.40 $1.40 $1.40 $1.40 $1.71 $1.40



HCPCS 1st Mod 2nd Mod CategoryA6457 SDA6531 AW SDA6532 AW SDA6545 AW SDA6550 SUA7000 NU KE INA7000 NU INA7001 NU INA7002 NU INA7003 NU INA7004 NU INA7005 NU INA7006 NU INA7007 NU INA7008 NU INA7009 NU INA7010 NU INA7012 NU INA7013 NU INA7014 NU INA7015 NU INA7016 NU INA7017 NU INA7017 RR INA7017 UE INA7018 SUA7020 NU INA7025 RR CRA7026 NU INA7027 NU INA7028 NU INA7029 NU INA7030 NU INA7031 NU INA7032 NU INA7033 NU INA7034 NU INA7035 NU INA7036 NU INA7037 NU INA7038 NU INA7039 NU INA7044 NU INA7045 NU INA7045 RR INA7045 UE INA7046 NU INA7047 NU INA7501 OSA7502 OSA7503 OSA7504 OSA7505 OSA7506 OSA7507 OSA7508 OSA7509 OSA7520 OSA7521 OSA7522 OSA7524 OS

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$1.26 $1.26 $1.26 $1.26 $1.54 $1.26$47.83 $47.83 $47.83 $47.83 $57.40 $47.83$67.39 $67.39 $67.39 $67.39 $80.89 $67.39$94.17 $94.17 $94.17 $94.17 $113.02 $94.17$25.34 R $26.15 $25.34 R $26.15 $25.29 R $26.15 $25.29 R $26.15 $29.18 $25.34 R $26.15

$9.36 R $9.71 $9.27 R $9.61 $9.38 R $9.71 $9.38 R $9.71 $10.46 $9.36 R $9.71$8.63 R $8.98 $8.55 R $8.90 $8.65 R $8.98 $8.65 R $8.98 $9.62 $8.63 R $8.98

$32.63 $31.71 $32.47 $32.38 $36.92 $32.32$3.60 $3.60 $3.60 $3.60 $3.00 $3.60$2.28 R $2.35 $2.23 R $2.30 $2.29 R $2.34 $2.29 R $2.34 $2.55 $2.26 R $2.33$1.48 R $1.53 $1.48 R $1.53 $1.47 R $1.53 $1.47 R $1.53 $1.33 $1.48 R $1.53

$20.66 R $21.00 $20.66 R $21.00 $20.12 R $21.00 $20.12 R $21.00 $17.77 $20.66 R $21.00$9.01 R $9.14 $9.01 R $9.14 $8.53 R $9.14 $8.53 R $9.14 $10.17 $9.01 R $9.14$4.07 R $4.13 $4.00 R $4.06 $3.87 R $4.11 $3.87 R $4.11 $4.44 $4.04 R $4.11

$10.34 $10.34 $10.34 $10.34 $9.66 $10.34$45.78 $44.47 $45.56 $45.41 $51.80 $45.33$18.99 R $19.35 $18.99 R $19.35 $17.99 R $19.35 $17.99 R $19.35 $20.06 $18.99 R $19.35

$3.54 R $3.60 $3.51 R $3.57 $3.36 R $3.60 $3.36 R $3.60 $3.91 $3.54 R $3.60$0.67 R $0.69 $0.67 R $0.69 $0.64 R $0.69 $0.64 R $0.69 $0.54 $0.67 R $0.69$4.09 R $4.23 $4.08 R $4.21 $3.99 R $4.23 $3.99 R $4.23 $4.62 $4.09 R $4.23$1.69 R $1.72 $1.69 R $1.72 $1.64 R $1.72 $1.64 R $1.72 $1.95 $1.69 R $1.72$7.63 $7.41 $7.58 $7.56 $8.63 $7.53

$135.02 R $136.08 $135.02 R $136.08 $125.01 R $136.08 $125.01 R $136.08 $150.90 $135.02 R $136.08$13.51 R $13.62 $13.51 R $13.62 $12.51 R $13.62 $12.51 R $13.62 $15.08 $13.51 R $13.62

$101.26 R $102.06 $101.26 R $102.06 $93.76 R $102.06 $93.76 R $102.06 $113.17 $101.26 R $102.06$0.34 R $0.35 $0.34 R $0.35 $0.33 R $0.35 $0.33 R $0.35 $0.31 $0.34 R $0.35

$16.01 $15.88 $16.01 $16.01 $18.47 $16.01$48.09 $48.09 $48.09 $48.09 $57.73 $48.09$31.78 $31.78 $31.78 $31.78 $38.13 $31.78


$134.76 R $139.24 $134.76 R $139.24 $134.01 R $139.24 $134.01 R $139.24 $156.85 $134.76 R $139.24$50.59 R $52.01 $50.59 R $52.01 $50.03 R $52.01 $50.03 R $52.01 $58.51 $50.59 R $52.01$29.04 R $29.78 $29.04 R $29.78 $28.73 R $29.78 $28.73 R $29.78 $33.57 $29.04 R $29.78$21.24 R $22.03 $21.24 R $22.03 $21.24 R $22.03 $21.24 R $22.03 $24.68 $21.24 R $22.03$84.27 R $86.78 $84.27 R $86.78 $84.00 R $86.78 $84.00 R $86.78 $97.78 $84.27 R $86.78$26.72 R $27.67 $26.23 R $27.18 $26.47 R $27.58 $26.43 R $27.54 $29.91 $26.55 R $27.50$12.73 R $13.28 $12.59 R $13.14 $12.57 R $13.24 $12.57 R $13.23 $14.23 $12.66 R $13.21$25.56 R $26.09 $25.01 R $25.55 $25.32 R $26.01 $25.28 R $25.97 $28.58 $25.38 R $25.92

$3.63 R $3.74 $3.59 R $3.70 $3.64 R $3.74 $3.64 R $3.74 $4.09 $3.63 R $3.74$9.27 R $9.56 $9.27 R $9.56 $9.29 R $9.56 $9.29 R $9.56 $10.20 $9.27 R $9.56

$99.20 R $102.79 $99.20 R $102.79 $96.81 R $102.79 $96.81 R $102.79 $114.07 $99.20 R $102.79$15.13 R $15.92 $15.13 R $15.92 $14.95 R $15.92 $14.95 R $15.92 $17.74 $15.13 R $15.92


$133.66 $133.66 $133.66 $133.66 $160.39 $133.66$116.10 $116.10 $116.10 $116.10 $139.33 $116.10

$55.19 $55.19 $55.19 $55.19 $66.22 $55.19$12.54 $12.54 $12.54 $12.54 $15.06 $12.54

$0.75 $0.75 $0.75 $0.75 $0.88 $0.75$5.18 $5.18 $5.18 $5.18 $6.20 $5.18$0.37 $0.37 $0.37 $0.37 $0.42 $0.37$2.75 $2.75 $2.75 $2.75 $3.36 $2.75$3.17 $3.17 $3.17 $3.17 $3.83 $3.17$1.56 $1.56 $1.56 $1.56 $1.84 $1.56

$52.49 $52.49 $52.49 $52.49 $62.98 $52.49$52.00 $52.00 $52.00 $52.00 $62.44 $52.00$49.93 $49.93 $49.93 $49.93 $59.91 $49.93$85.58 $85.58 $85.58 $85.58 $102.67 $85.58



HCPCS 1st Mod 2nd Mod CategoryA7525 OSA7526 OSA7527 OSA8000 NU INA8000 RR INA8000 UE INA8001 NU INA8001 RR INA8001 UE INB4034 PEB4035 PEB4036 PEB4081 PEB4082 PEB4083 PEB4087 PEB4088 PEB4149 PEB4150 PEB4152 PEB4153 PEB4154 PEB4155 PEB4164 PEB4168 PEB4176 PEB4178 PEB4180 PEB4185 PEB4189 PEB4193 PEB4197 PEB4199 PEB4216 PEB4220 PEB4222 PEB4224 PEB5000 PEB5100 PEB9000 MS PEB9000 NU PEB9000 RR PEB9000 UE PEB9002 MS PEB9002 NU PEB9002 RR PEB9002 UE PEB9004 MS PEB9004 NU PEB9004 RR PEB9004 UE PEB9006 MS PEB9006 NU PEB9006 RR PEB9006 UE PEE0100 NU INE0100 RR INE0100 UE INE0105 NU INE0105 RR INE0105 UE IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$2.28 $2.28 $2.28 $2.28 $2.74 $2.28$3.74 $3.74 $3.74 $3.74 $4.43 $3.74$3.96 $3.96 $3.96 $3.96 $4.75 $3.96

$169.54 $169.54 $169.54 $169.54 $203.41 $169.54$16.95 $16.95 $16.95 $16.95 $20.33 $16.95

$127.18 $127.18 $127.18 $127.18 $152.58 $127.18$169.54 $169.54 $169.54 $169.54 $203.41 $169.54

$16.95 $16.95 $16.95 $16.95 $20.33 $16.95$127.18 $127.18 $127.18 $127.18 $152.58 $127.18


$18.53 R $19.44 $18.53 R $19.44 $18.45 R $19.44 $18.45 R $19.44 $19.44 $18.53 R $19.44$13.70 R $14.23 $13.70 R $14.23 $13.44 R $14.23 $13.44 R $14.23 $14.23 $13.70 R $14.23


$1.31 R $1.36 $1.31 R $1.36 $1.30 R $1.36 $1.30 R $1.36 $1.36 $1.31 R $1.36$0.54 R $0.55 $0.54 R $0.55 $0.54 R $0.55 $0.54 R $0.55 $0.56 $0.54 R $0.55$0.44 R $0.45 $0.44 R $0.45 $0.44 R $0.45 $0.44 R $0.45 $0.46 $0.44 R $0.45$1.59 R $1.63 $1.59 R $1.63 $1.57 R $1.63 $1.57 R $1.63 $1.74 $1.59 R $1.63$0.96 R $0.98 $0.96 R $0.98 $0.95 R $0.98 $0.95 R $0.98 $0.99 $0.96 R $0.98$0.84 R $0.88 $0.84 R $0.88 $0.85 R $0.88 $0.85 R $0.88 $0.96 $0.84 R $0.88

$19.50 $19.50 $19.50 $19.50 $19.50 $19.50$28.44 $28.44 $28.44 $28.44 $28.44 $28.44$55.03 $55.03 $55.03 $55.03 $55.03 $55.03$66.05 $66.05 $66.05 $66.05 $66.05 $66.05$28.00 $28.00 $28.00 $28.00 $28.00 $28.00$12.90 $12.90 $12.90 $12.90 $12.90 $12.90

$204.06 $204.06 $204.06 $204.06 $204.06 $204.06$263.67 $263.67 $263.67 $263.67 $263.67 $263.67$321.01 $321.01 $321.01 $321.01 $321.01 $321.01$366.81 $366.81 $366.81 $366.81 $366.81 $366.81

$8.86 $8.86 $8.86 $8.86 $8.86 $8.86$9.19 $9.19 $9.19 $9.19 $9.19 $9.19

$11.33 $11.33 $11.33 $11.33 $11.33 $11.33$28.70 $28.70 $28.70 $28.70 $28.70 $28.70$13.65 $13.65 $13.65 $13.65 $13.65 $13.65

$5.33 $5.33 $5.33 $5.33 $5.33 $5.33$44.74 R $45.72 $44.74 R $45.72 $44.14 R $45.72 $44.14 R $45.72 $46.50 $44.74 R $45.72

$945.53 R $965.15 $945.53 R $965.15 $933.50 R $965.15 $933.50 R $965.15 $980.79 $945.53 R $965.15$89.48 R $91.44 $89.48 R $91.44 $88.28 R $91.44 $88.28 R $91.44 $93.00 $89.48 R $91.44

$709.15 R $723.87 $709.15 R $723.87 $700.12 R $723.87 $700.12 R $723.87 $735.60 $709.15 R $723.87$46.32 R $47.28 $46.32 R $47.28 $45.69 R $47.28 $45.69 R $47.28 $48.05 $46.32 R $47.28

$946.10 R $965.31 $946.10 R $965.31 $933.50 R $965.31 $933.50 R $965.31 $980.79 $946.10 R $965.31$92.64 R $94.56 $92.64 R $94.56 $91.38 R $94.56 $91.38 R $94.56 $96.11 $92.64 R $94.56

$709.58 R $723.98 $709.58 R $723.98 $700.12 R $723.98 $700.12 R $723.98 $735.60 $709.58 R $723.98$229.27 $229.27 $229.27 $229.27 $229.27 $229.27

$2,896.55 $2,896.55 $2,896.55 $2,896.55 $2,896.55 $2,896.55$458.53 $458.53 $458.53 $458.53 $458.53 $458.53

$2,172.41 $2,172.41 $2,172.41 $2,172.41 $2,172.41 $2,172.41$229.27 $229.27 $229.27 $229.27 $229.27 $229.27

$2,896.55 $2,896.55 $2,896.55 $2,896.55 $2,896.55 $2,896.55$458.53 $458.53 $458.53 $458.53 $458.53 $458.53

$2,172.41 $2,172.41 $2,172.41 $2,172.41 $2,172.41 $2,172.41$19.81 $19.81 $23.30 $23.30 $37.91 $21.96

$5.58 $5.58 $5.58 $5.58 $4.75 $5.58$17.67 $15.78 $18.57 $18.57 $28.46 $16.43$54.30 $52.61 $54.30 $54.30 $67.14 $54.30

$8.33 $8.33 $8.33 $8.33 $8.38 $8.33$41.85 $39.45 $41.85 $40.72 $50.36 $41.85



HCPCS 1st Mod 2nd Mod CategoryE0110 NU INE0110 RR INE0110 UE INE0111 NU INE0111 RR INE0111 UE INE0112 NU INE0112 RR INE0112 UE INE0113 NU INE0113 RR INE0113 UE INE0114 NU INE0114 RR INE0114 UE INE0116 NU INE0116 RR INE0116 UE INE0117 RR CRE0130 NU INE0130 RR INE0130 UE INE0135 NU INE0135 RR INE0135 UE INE0140 RR CRE0141 NU INE0141 RR INE0141 UE INE0143 NU INE0143 RR INE0143 UE INE0144 RR CRE0147 NU INE0147 RR INE0147 UE INE0148 NU INE0148 RR INE0148 UE INE0149 RR CRE0153 NU INE0153 RR INE0153 UE INE0154 NU INE0154 RR INE0154 UE INE0155 NU INE0155 RR INE0155 UE INE0156 NU INE0156 RR INE0156 UE INE0157 NU INE0157 RR INE0157 UE INE0158 NU INE0158 RR INE0158 UE INE0159 NU INE0159 RR INE0159 UE IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$81.31 $82.72 $85.78 $85.78 $109.85 $85.78$15.02 $15.02 $15.02 $17.67 $13.73 $15.02$60.98 $62.06 $64.31 $64.31 $82.39 $64.31$50.04 $50.04 $58.87 $58.87 $54.61 $54.34

$7.91 $7.91 $7.91 $9.31 $6.84 $7.91$38.62 $38.62 $44.56 $44.16 $40.96 $40.76$40.91 $37.16 $34.77 $40.91 $49.50 $34.77

$9.34 $9.34 $9.34 $9.34 $6.19 $9.34$31.20 $27.85 $26.52 $31.20 $37.14 $26.52$23.37 $19.86 $23.37 $23.37 $24.75 $19.86

$4.84 $4.84 $4.84 $4.84 $3.10 $4.84$17.53 $14.90 $17.53 $17.53 $18.58 $14.90$52.17 $44.34 $44.34 $52.17 $68.83 $52.17

$8.05 $8.05 $8.05 $8.05 $8.60 $8.05$39.44 $33.52 $33.52 $39.44 $51.65 $39.44$29.11 $26.08 $30.68 $30.68 $34.43 $30.68

$5.08 $5.08 $5.08 $5.08 $4.32 $5.08$23.09 $19.63 $23.09 $23.09 $25.81 $23.09$21.29 $21.29 $21.29 $21.29 $25.57 $21.29$52.73 R $54.61 $55.67 R $57.55 $55.68 R $59.53 $55.68 R $59.53 $69.38 $55.76 R $57.65


$9.62 R $9.78 $9.21 R $9.38 $9.11 R $9.36 $9.11 R $9.36 $9.30 $9.20 R $9.36$42.63 R $43.85 $47.22 R $48.45 $46.55 R $48.45 $45.38 R $47.28 $50.24 $43.53 R $44.75$31.04 R $31.95 $31.04 R $31.95 $29.73 R $31.95 $29.73 R $31.95 $35.38 $31.04 R $31.95$93.83 R $96.21 $93.85 R $96.23 $89.22 R $94.88 $90.57 R $96.23 $110.80 $89.03 R $91.42$14.55 R $14.79 $13.35 R $13.59 $12.63 R $13.19 $12.63 R $13.19 $12.82 $12.96 R $13.19$70.38 R $72.16 $70.39 R $72.17 $66.91 R $71.15 $67.93 R $72.17 $83.10 $66.78 R $68.56$76.41 R $77.80 $74.77 R $76.16 $81.04 R $82.88 $78.98 R $80.83 $98.15 $74.55 R $75.93$11.17 R $11.31 $12.71 R $12.85 $11.12 R $11.31 $11.12 R $11.31 $11.62 $11.17 R $11.31$57.32 R $58.35 $54.61 R $55.65 $60.70 R $62.08 $59.24 R $60.62 $73.61 $55.92 R $56.96$27.88 $27.88 $27.88 $27.88 $30.92 $27.88

$460.82 R $478.71 $460.82 R $478.71 $457.57 R $478.71 $457.57 R $478.71 $535.80 $460.82 R $478.71$46.09 R $47.88 $46.09 R $47.88 $45.76 R $47.88 $45.76 R $47.88 $53.58 $46.09 R $47.88

$345.62 R $359.04 $345.62 R $359.04 $343.18 R $359.04 $343.18 R $359.04 $401.85 $345.62 R $359.04$101.56 R $104.66 $101.56 R $104.66 $98.77 R $104.66 $98.77 R $104.66 $116.77 $101.56 R $104.66

$10.16 R $10.47 $10.16 R $10.47 $9.88 R $10.47 $9.88 R $10.47 $11.68 $10.16 R $10.47$76.16 R $78.49 $76.16 R $78.49 $74.07 R $78.49 $74.07 R $78.49 $87.59 $76.16 R $78.49$16.79 R $16.90 $16.79 R $16.90 $16.13 R $16.90 $16.13 R $16.90 $19.03 $16.79 R $16.90$76.71 $76.71 $68.26 $68.26 $98.70 $70.00

$8.09 $8.67 $7.37 $7.37 $12.35 $7.37$57.52 $57.52 $51.20 $51.20 $74.04 $52.52$56.35 R $59.31 $56.35 R $59.31 $55.74 R $59.31 $55.74 R $59.31 $67.03 $56.35 R $59.31






$1.61 R $1.66 $1.61 R $1.66 $1.56 R $1.66 $1.56 R $1.66 $1.71 $1.61 R $1.66$11.82 R $12.22 $11.82 R $12.22 $11.50 R $12.22 $11.50 R $12.22 $12.86 $11.82 R $12.22



HCPCS 1st Mod 2nd Mod CategoryE0160 NU INE0160 RR INE0160 UE INE0161 NU INE0161 RR INE0161 UE INE0162 NU INE0162 RR INE0162 UE INE0163 NU INE0163 RR INE0163 UE INE0165 RR CRE0167 NU INE0167 RR INE0167 UE INE0168 NU INE0168 RR INE0168 UE INE0170 RR CRE0171 RR CRE0175 NU INE0175 RR INE0175 UE INE0181 RR CRE0182 RR CRE0184 NU INE0184 RR INE0184 UE INE0185 NU INE0185 RR INE0185 UE INE0186 RR CRE0187 RR CRE0188 NU INE0188 RR INE0188 UE INE0189 NU INE0189 RR INE0189 UE INE0191 NU INE0191 RR INE0191 UE INE0193 RR CRE0194 RR CRE0196 RR CRE0197 RR CRE0198 RR CRE0199 NU INE0199 RR INE0199 UE INE0200 NU INE0200 RR INE0200 UE INE0202 RR CRE0205 NU INE0205 RR INE0205 UE INE0210 NU INE0210 RR INE0210 UE IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$31.24 R $33.65 $28.50 R $30.91 $28.76 R $30.91 $28.76 R $30.91 $6.56 $28.50 R $30.91$3.34 R $3.58 $3.34 R $3.58 $3.36 R $3.58 $3.36 R $3.58 $0.84 $3.34 R $3.58

$23.42 R $25.22 $21.37 R $23.17 $21.56 R $23.17 $21.56 R $23.17 $4.94 $21.37 R $23.17$26.66 R $27.67 $26.66 R $27.67 $23.41 R $24.64 $23.41 R $24.64 $29.58 $26.21 R $27.21

$3.19 R $3.29 $2.90 R $3.00 $2.79 R $3.00 $2.79 R $3.00 $3.37 $2.90 R $3.00$19.97 R $20.73 $19.97 R $20.73 $17.54 R $18.45 $17.54 R $18.45 $22.18 $19.64 R $20.39

$161.08 $136.92 $136.92 $136.92 $281.73 $155.77$16.87 $14.36 $14.36 $14.36 $35.23 $15.57

$124.91 $106.17 $106.17 $106.17 $211.26 $116.83$82.37 R $83.65 $79.39 R $80.67 $87.11 R $89.58 $87.11 R $89.58 $108.95 $88.30 R $89.58$14.21 R $14.34 $14.21 R $14.34 $14.09 R $14.34 $14.09 R $14.34 $12.92 $14.21 R $14.34$64.94 R $65.89 $60.47 R $61.43 $65.56 R $67.41 $66.62 R $68.48 $81.72 $67.52 R $68.48$14.85 R $15.25 $14.85 R $15.25 $14.51 R $15.25 $16.05 R $16.79 $21.01 $16.38 R $16.79$11.52 R $12.41 $11.28 R $12.17 $11.80 R $12.41 $10.91 R $11.48 $13.49 $11.20 R $12.09

$1.15 R $1.24 $1.13 R $1.22 $1.21 R $1.27 $1.10 R $1.17 $1.54 $1.08 R $1.17$8.66 R $9.32 $8.45 R $9.12 $8.87 R $9.33 $8.17 R $8.60 $10.11 $8.39 R $9.06

$142.60 R $146.20 $142.60 R $146.20 $138.06 R $146.20 $138.06 R $146.20 $162.89 $142.60 R $146.20$14.30 R $14.66 $14.30 R $14.66 $13.85 R $14.66 $13.85 R $14.66 $16.29 $14.30 R $14.66

$106.95 R $109.64 $106.95 R $109.64 $103.54 R $109.64 $103.54 R $109.64 $122.16 $106.95 R $109.64$167.50 R $175.50 $167.50 R $175.50 $167.33 R $175.50 $167.33 R $175.50 $195.82 $167.50 R $175.50

$30.38 R $31.97 $30.38 R $31.97 $30.61 R $31.97 $30.61 R $31.97 $35.43 $30.38 R $31.97$73.23 $73.23 $73.23 $73.23 $77.15 $62.25

$7.32 $7.32 $7.32 $7.32 $9.63 $6.22$53.89 $53.89 $53.89 $53.89 $57.88 $45.81$22.26 R $22.80 $22.26 R $22.80 $22.22 R $22.80 $22.22 R $22.80 $28.29 $22.26 R $22.80$21.72 R $23.35 $21.72 R $23.35 $23.98 R $24.93 $24.57 R $25.52 $32.77 $21.72 R $23.35

$186.70 R $193.55 $186.70 R $193.55 $166.35 R $177.41 $166.35 R $177.41 $213.72 $186.70 R $193.55$21.49 R $22.17 $21.49 R $22.17 $19.03 R $20.14 $19.03 R $20.14 $24.57 $21.49 R $22.17

$141.85 R $146.99 $141.85 R $146.99 $126.31 R $134.61 $126.31 R $134.61 $160.29 $141.85 R $146.99$235.61 R $241.36 $262.13 R $267.88 $262.63 R $267.88 $262.63 R $267.88 $245.68 $235.61 R $241.36

$29.65 R $30.23 $31.78 R $32.36 $32.34 R $32.87 $33.43 R $33.95 $24.58 $29.65 R $30.23$179.34 R $183.65 $199.69 R $204.00 $200.07 R $204.00 $200.07 R $204.00 $184.25 $179.34 R $183.65



$5.05 R $5.26 $5.52 R $5.73 $5.56 R $5.73 $5.56 R $5.73 $11.13 $5.52 R $5.73$36.37 R $36.62 $39.60 R $41.22 $39.96 R $41.22 $39.96 R $41.22 $83.45 $39.60 R $41.22$10.62 $9.39 $11.05 $11.05 $14.02 $9.39

$1.06 $0.97 $1.14 $1.14 $1.74 $0.97$7.98 $7.00 $8.24 $8.24 $10.52 $7.00

$701.01 R $731.72 $765.57 R $798.23 $718.21 R $748.52 $763.60 R $793.91 $925.36 $730.91 R $763.57$3,597.70 $3,145.19 $3,058.05 $3,262.33 $2,991.79 $3,058.05

$29.91 R $30.53 $32.60 R $34.73 $31.49 R $32.52 $33.18 R $34.73 $45.16 $29.91 R $30.53$22.58 R $24.04 $22.58 R $24.04 $22.82 R $24.04 $22.82 R $24.04 $16.23 $22.58 R $24.04$20.83 $24.17 $20.83 $20.83 $64.35 $20.83$29.47 R $30.13 $29.47 R $30.13 $31.49 R $32.82 $31.49 R $32.82 $94.80 $29.84 R $30.87

$2.94 R $3.00 $2.94 R $3.00 $3.16 R $3.30 $3.16 R $3.30 $10.79 $2.98 R $3.09$22.10 R $22.59 $22.10 R $22.59 $23.62 R $24.62 $23.62 R $24.62 $71.11 $22.39 R $23.18$74.50 $87.65 $83.47 $83.47 $184.08 $87.65$10.12 $11.90 $10.12 $10.12 $23.00 $11.90$55.90 $65.77 $62.60 $62.60 $138.04 $65.77$69.22 $69.22 $69.22 $69.22 $248.69 $69.22

$182.36 $214.54 $214.54 $214.54 $287.53 $214.54$20.06 $23.60 $23.60 $23.60 $35.94 $23.60

$136.77 $160.90 $160.90 $160.90 $215.62 $160.90$30.93 $30.68 $30.68 $30.68 $33.31 $30.68

$3.09 $2.89 $2.89 $2.94 $4.17 $2.89$23.21 $23.00 $23.00 $23.00 $24.99 $23.00



HCPCS 1st Mod 2nd Mod CategoryE0215 NU INE0215 RR INE0215 UE INE0217 NU INE0217 RR INE0217 UE INE0225 NU INE0225 RR INE0225 UE INE0235 RR CRE0236 RR CRE0239 NU INE0239 RR INE0239 UE INE0249 NU INE0249 RR INE0249 UE INE0250 RR CRE0251 RR CRE0255 RR CRE0256 RR CRE0260 RR CRE0261 RR CRE0265 RR CRE0266 RR CRE0271 NU INE0271 RR INE0271 UE INE0272 NU INE0272 RR INE0272 UE INE0275 NU INE0275 RR INE0275 UE INE0276 NU INE0276 RR INE0276 UE INE0277 RR CRE0280 NU INE0280 RR INE0280 UE INE0290 RR CRE0291 RR CRE0292 RR CRE0293 RR CRE0294 RR CRE0295 RR CRE0296 RR CRE0297 RR CRE0300 RR CRE0301 RR CRE0302 RR CRE0303 RR CRE0304 RR CRE0305 RR CRE0310 NU INE0310 RR INE0310 UE INE0316 RR CRE0325 NU INE0325 RR IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$66.57 $78.32 $66.57 $66.57 $120.53 $66.57$6.96 $7.83 $6.96 $6.96 $19.73 $6.96

$49.94 $58.75 $49.94 $49.94 $90.39 $49.94$545.86 $548.86 $548.86 $548.86 $490.32 $545.86

$53.27 $61.10 $54.88 $54.88 $61.30 $51.94$409.38 $411.61 $411.61 $411.61 $367.72 $409.38$429.65 $429.65 $429.65 $429.65 $529.74 $421.85

$42.35 $42.35 $42.35 $42.35 $66.22 $36.00$322.23 $322.23 $322.23 $322.23 $397.31 $316.38

$19.07 $18.21 $16.21 $18.08 $21.48 $18.07$48.91 $48.91 $45.73 $48.91 $39.05 $48.91

$497.29 $422.70 $423.73 $423.73 $435.84 $497.29$49.74 $42.28 $42.39 $49.74 $54.47 $49.74

$372.98 $317.03 $317.84 $317.84 $326.91 $372.98$93.60 $110.12 $93.60 $93.60 $140.35 $101.80$10.29 $12.11 $10.29 $12.11 $17.54 $10.29$70.20 $82.59 $70.20 $70.20 $105.26 $76.36$70.76 R $74.09 $74.67 R $78.00 $72.69 R $75.42 $78.34 R $81.07 $99.02 $71.81 R $75.14$62.58 R $65.81 $62.84 R $66.07 $58.64 R $60.00 $58.64 R $60.00 $82.93 $57.55 R $60.00$80.51 R $83.76 $83.15 R $86.40 $84.44 R $87.10 $89.50 R $92.16 $117.82 $80.51 R $83.76$62.46 R $65.60 $66.62 R $69.76 $69.50 R $71.56 $69.50 R $71.56 $91.41 $62.46 R $65.60$98.02 R $100.06 $98.02 R $100.06 $97.57 R $100.06 $97.57 R $100.06 $100.06 $98.02 R $100.06$85.06 R $87.62 $85.06 R $87.62 $89.87 R $91.75 $95.52 R $97.40 $124.78 $85.06 R $87.62

$156.68 $163.27 $156.50 $155.93 $204.09 $148.99$131.13 $142.93 $143.81 $131.97 $180.04 $131.13$151.80 R $155.79 $167.67 R $171.66 $164.27 R $171.66 $164.27 R $171.66 $230.57 $167.67 R $171.66


$15.47 R $16.03 $16.98 R $17.54 $16.64 R $17.54 $16.64 R $17.54 $21.47 $15.47 R $16.03$113.02 R $117.17 $123.82 R $127.96 $121.23 R $127.96 $121.23 R $127.96 $140.12 $123.82 R $127.96

$15.13 R $15.90 $14.76 R $15.53 $15.27 R $15.90 $15.27 R $15.90 $16.61 $15.13 R $15.90$1.55 R $1.63 $1.48 R $1.56 $1.57 R $1.63 $1.57 R $1.63 $1.88 $1.42 R $1.50

$11.34 R $11.92 $11.07 R $11.65 $11.45 R $11.92 $11.45 R $11.92 $12.47 $11.34 R $11.92$12.90 R $13.74 $11.80 R $12.50 $13.29 R $13.74 $13.29 R $13.74 $18.34 $11.80 R $12.50

$1.43 R $1.51 $1.30 R $1.38 $1.47 R $1.51 $1.47 R $1.51 $2.10 $1.30 R $1.38$9.97 R $10.60 $9.10 R $9.73 $10.27 R $10.60 $10.27 R $10.60 $13.75 $9.10 R $9.73

$435.21 R $437.91 $435.22 R $437.92 $421.60 R $422.57 $436.95 R $437.92 $437.94 $426.79 R $429.48$30.30 R $30.95 $30.30 R $30.95 $30.39 R $30.95 $30.39 R $30.95 $51.11 $33.03 R $34.76

$3.15 R $3.32 $3.15 R $3.32 $3.16 R $3.32 $3.16 R $3.32 $5.85 $3.45 R $3.62$22.72 R $23.21 $22.72 R $23.21 $22.79 R $23.21 $22.79 R $23.21 $38.33 $24.77 R $26.07$57.59 R $60.54 $58.67 R $61.96 $58.69 R $60.54 $64.03 R $66.22 $78.16 $58.37 R $61.66$45.73 R $48.40 $44.03 R $46.47 $43.72 R $43.98 $43.72 R $43.98 $57.80 $42.78 R $43.98$63.85 R $68.06 $63.85 R $68.06 $71.81 R $74.14 $71.81 R $74.14 $98.79 $63.85 R $68.06$57.48 R $61.15 $55.28 R $57.93 $62.28 R $63.88 $62.46 R $64.05 $82.36 $55.28 R $57.93$87.14 R $89.57 $87.14 R $89.57 $94.77 R $97.60 $96.08 R $98.91 $140.26 $87.14 R $89.57$85.00 R $87.06 $85.00 R $87.06 $84.75 R $87.26 $93.64 R $96.16 $89.40 $85.00 R $87.06

$119.58 $131.31 $131.26 $124.63 $157.31 $119.58$103.81 $113.86 $113.86 $110.81 $137.83 $103.81$253.53 $253.53 $253.53 $253.53 $280.58 $253.53$198.31 R $201.66 $213.08 R $216.44 $191.99 R $199.28 $209.15 R $216.44 $241.79 $208.01 R $211.36$577.97 R $594.85 $577.97 R $594.85 $576.13 R $594.85 $576.13 R $594.85 $714.28 $577.97 R $594.85$213.09 R $216.86 $227.88 R $231.65 $208.95 R $214.50 $226.10 R $231.65 $257.01 $222.80 R $226.57$611.42 R $624.51 $611.42 R $624.51 $599.60 R $624.51 $599.60 R $624.51 $697.94 $611.42 R $624.51

$13.77 R $14.19 $12.50 R $12.92 $13.76 R $14.19 $13.76 R $14.19 $9.55 $12.50 R $12.92$140.22 R $143.04 $141.53 R $144.35 $146.31 R $152.10 $146.31 R $152.10 $153.64 $149.28 R $152.10


$9.87 R $10.44 $9.03 R $9.51 $10.15 R $10.44 $10.15 R $10.44 $11.05 $9.03 R $9.51$1.14 R $1.20 $1.14 R $1.20 $1.17 R $1.20 $1.29 R $1.32 $1.27 $1.14 R $1.20



HCPCS 1st Mod 2nd Mod CategoryE0325 UE INE0326 NU INE0326 RR INE0326 UE INE0371 RR CRE0372 RR CRE0373 RR CRE0424 RR OXE0431 RR OXE0433 RR OXE0434 RR OXE0439 RR OXE0441 OXE0442 OXE0443 OXE0444 OXE0462 RR CRE0465 RR FSE0466 RR FSE0470 RR CRE0471 RR CRE0472 RR CRE0480 RR CRE0482 RR CRE0483 RR CRE0484 NU INE0484 RR INE0484 UE INE0500 RR FSE0550 RR CRE0560 NU INE0560 RR INE0560 UE INE0561 NU INE0561 RR INE0561 UE INE0562 NU INE0562 RR INE0562 UE INE0565 RR CRE0570 RR CRE0572 RR CRE0574 RR CRE0575 RR CRE0580 NU INE0580 RR INE0580 UE INE0585 RR CRE0600 RR CRE0601 RR CRE0602 NU INE0602 RR INE0602 UE INE0605 NU INE0605 RR INE0605 UE INE0606 RR CRE0607 NU INE0607 RR INE0607 UE INE0610 NU IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$6.90 R $7.33 $6.28 R $6.28 $7.12 R $7.33 $7.12 R $7.33 $8.29 $6.28 R $6.28$10.41 R $11.01 $9.54 R $9.86 $9.66 R $9.86 $9.66 R $9.86 $8.76 $9.79 R $10.36

$1.05 R $1.11 $1.02 R $1.08 $1.03 R $1.08 $1.03 R $1.08 $1.13 $1.02 R $1.08$7.81 R $8.26 $7.16 R $7.40 $7.25 R $7.40 $7.25 R $7.40 $6.55 $7.35 R $7.78

$329.75 R $334.18 $351.75 R $356.18 $313.02 R $331.61 $337.59 R $356.18 $397.83 $343.91 R $348.35$361.62 R $365.18 $388.31 R $391.87 $344.73 R $362.06 $374.54 R $391.87 $511.08 $378.79 R $382.36$444.96 R $456.71 $473.95 R $485.70 $430.89 R $453.15 $463.44 R $485.70 $567.67 $464.65 R $476.40$126.67 R $129.37 $126.67 R $129.37 $125.88 R $129.37 $125.88 R $129.37 $133.36 $126.67 R $129.37


$126.67 R $129.37 $126.67 R $129.37 $125.88 R $129.37 $125.88 R $129.37 $133.36 $126.67 R $129.37$65.75 R $67.93 $65.75 R $67.93 $65.25 R $67.93 $65.25 R $67.93 $67.93 $65.75 R $67.93$65.75 R $67.93 $65.75 R $67.93 $65.25 R $67.93 $65.25 R $67.93 $67.93 $65.75 R $67.93$63.13 R $65.20 $63.13 R $65.20 $62.85 R $65.20 $62.85 R $65.20 $65.20 $63.13 R $65.20$63.13 R $65.20 $63.13 R $65.20 $62.85 R $65.20 $62.85 R $65.20 $65.20 $63.13 R $65.20

$322.15 $305.91 $322.15 $322.15 $215.86 $289.49$896.95 $1,055.23 $1,017.22 $1,055.23 $1,754.45 $896.95$896.95 $1,055.23 $1,017.22 $1,055.23 $1,754.45 $896.95$164.72 R $169.54 $176.42 R $181.24 $171.10 R $176.50 $175.84 R $181.24 $104.67 $176.42 R $181.24$408.24 R $422.24 $438.62 R $452.62 $389.34 R $406.54 $389.34 R $406.54 $500.99 $438.62 R $452.62$472.74 R $492.88 $503.12 R $523.26 $454.26 R $477.18 $454.26 R $477.18 $571.63 $503.12 R $523.26

$41.29 $43.42 $48.58 $48.58 $48.69 $41.29$426.00 $475.40 $420.25 $475.40 $557.52 $457.80

$1,175.30 $1,175.30 $1,175.30 $1,175.30 $1,410.37 $1,175.30$40.83 $40.83 $40.83 $40.83 $48.95 $40.83

$4.07 $4.07 $4.07 $4.07 $4.91 $4.07$30.63 $30.63 $30.63 $30.63 $36.74 $30.63

$103.14 $113.16 $121.34 $121.34 $106.31 $121.34$55.42 $55.42 $47.11 $47.11 $91.58 $49.69

$161.88 $155.67 $163.42 $163.42 $174.75 $138.91$16.28 $16.28 $17.75 $17.75 $21.84 $16.28

$121.39 $116.75 $122.57 $122.57 $131.06 $104.18$87.15 R $89.95 $87.15 R $89.95 $84.72 R $89.95 $84.72 R $89.95 $99.95 $87.15 R $89.95

$8.71 R $8.99 $8.71 R $8.99 $8.46 R $8.99 $8.46 R $8.99 $10.00 $8.71 R $8.99$65.36 R $67.46 $65.36 R $67.46 $63.53 R $67.46 $63.53 R $67.46 $74.95 $65.36 R $67.46

$213.36 R $218.96 $213.36 R $218.96 $211.49 R $218.96 $211.49 R $218.96 $247.06 $213.36 R $218.96$21.33 R $21.89 $21.33 R $21.89 $21.14 R $21.89 $21.14 R $21.89 $24.71 $21.33 R $21.89

$160.02 R $164.21 $160.02 R $164.21 $158.62 R $164.21 $158.62 R $164.21 $185.30 $160.02 R $164.21$49.11 R $51.30 $54.17 R $56.36 $54.46 R $56.36 $54.46 R $56.36 $33.16 $49.11 R $51.30$11.95 R $12.08 $11.95 R $12.08 $11.82 R $12.08 $11.81 R $12.07 $11.76 $11.94 R $12.07$34.27 R $34.27 $36.36 R $36.36 $31.23 R $34.01 $33.57 R $36.36 $40.15 $35.69 R $35.69$40.07 $44.51 $39.58 $44.51 $52.46 $43.09$96.58 $96.58 $108.49 $113.62 $113.99 $113.62

$127.60 $127.60 $127.60 $127.60 $140.36 $127.60$12.76 $12.76 $12.76 $12.76 $14.04 $12.76$95.69 $95.69 $95.69 $95.69 $105.27 $95.69$31.00 R $31.59 $31.00 R $31.59 $29.34 R $31.89 $31.95 R $34.50 $41.99 $33.91 R $34.50$43.03 $50.62 $48.29 $43.82 $47.66 $45.02$68.83 R $70.35 $74.24 R $75.77 $73.90 R $75.77 $73.90 R $75.77 $78.25 $74.24 R $75.77$32.63 $32.63 $32.63 $32.63 $39.15 $32.63

$3.28 $3.28 $3.28 $3.28 $3.91 $3.28$24.48 $24.48 $24.48 $24.48 $29.37 $24.48$29.22 $24.84 $24.84 $24.84 $17.41 $28.69

$3.38 $2.89 $2.89 $2.89 $2.17 $2.89$24.08 $20.47 $20.47 $20.47 $13.06 $21.52$25.38 $25.38 $25.29 $25.38 $24.51 $22.92$73.86 $73.86 $73.86 $73.86 $84.21 $73.86

$7.38 $7.38 $7.38 $7.38 $8.44 $7.38$55.39 $55.39 $55.39 $55.39 $63.16 $55.39

$262.95 $232.61 $231.16 $224.41 $559.21 $232.61



HCPCS 1st Mod 2nd Mod CategoryE0610 RR INE0610 UE INE0615 NU INE0615 RR INE0615 UE INE0617 RR KF CRE0617 RR CRE0618 RR CRE0620 RR CRE0621 NU INE0621 RR INE0621 UE INE0627 NU INE0627 RR INE0627 UE INE0628 NU INE0628 RR INE0628 UE INE0629 NU INE0629 RR INE0629 UE INE0630 RR CRE0635 RR CRE0636 RR CRE0639 RR CRE0640 RR CRE0650 NU INE0650 RR INE0650 UE INE0651 NU INE0651 RR INE0651 UE INE0652 NU INE0652 RR INE0652 UE INE0655 NU INE0655 RR INE0655 UE INE0656 RR CRE0657 RR CRE0660 NU INE0660 RR INE0660 UE INE0665 NU INE0665 RR INE0665 UE INE0666 NU INE0666 RR INE0666 UE INE0667 NU INE0667 RR INE0667 UE INE0668 NU INE0668 RR INE0668 UE INE0669 NU INE0669 RR INE0669 UE INE0670 NU INE0670 RR INE0670 UE IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$27.73 $23.57 $23.57 $23.57 $69.89 $23.57$197.24 $174.44 $173.40 $168.34 $419.43 $174.44$529.32 $529.32 $449.92 $449.92 $559.21 $529.32

$64.67 $64.67 $54.97 $54.97 $69.89 $64.67$397.02 $397.02 $337.47 $337.47 $419.42 $397.02$373.20 $373.20 $373.20 $373.20 $447.81 $373.20$336.12 $336.12 $336.12 $336.12 $403.37 $336.12$309.95 $309.95 $309.95 $309.95 $383.64 $309.95

$96.65 $96.65 $96.65 $96.65 $116.01 $96.65$91.97 R $97.67 $85.42 R $91.12 $94.41 R $97.67 $94.41 R $97.67 $99.16 $84.01 R $89.72

$9.00 R $9.57 $8.55 R $9.12 $9.24 R $9.57 $9.24 R $9.57 $11.22 $8.27 R $8.75$69.18 R $73.46 $64.07 R $68.35 $71.01 R $73.46 $71.01 R $73.46 $74.36 $63.18 R $67.46

$309.08 R $321.65 $312.74 R $325.30 $307.03 R $321.65 $307.03 R $321.65 $369.35 $312.74 R $325.30$30.91 R $32.17 $31.28 R $32.53 $30.70 R $32.17 $30.70 R $32.17 $42.42 $31.28 R $32.53

$231.80 R $241.23 $234.55 R $243.98 $230.26 R $241.23 $230.26 R $241.23 $277.01 $234.55 R $243.98$320.67 R $334.01 $324.33 R $337.67 $313.68 R $334.01 $313.68 R $334.01 $377.92 $324.33 R $337.67


$31.54 R $33.25 $31.54 R $33.25 $31.40 R $33.25 $31.40 R $33.25 $43.27 $31.54 R $33.25$236.52 R $249.38 $236.52 R $249.38 $235.46 R $249.38 $235.46 R $249.38 $283.44 $236.52 R $249.38

$77.04 R $79.49 $85.49 R $87.94 $80.43 R $83.03 $85.33 R $87.94 $86.02 $78.63 R $81.08$123.94 R $130.04 $123.94 R $130.04 $129.03 R $130.04 $129.03 R $130.04 $192.49 $123.94 R $130.04

$1,061.04 R $1,108.08 $1,061.04 R $1,108.08 $1,070.93 R $1,108.08 $1,070.93 R $1,108.08 $1,284.49 $1,061.04 R $1,108.08$123.32 $123.32 $122.41 $123.32 $169.16 $123.32$123.32 $123.32 $122.41 $123.32 $169.16 $123.32$676.77 $701.77 $796.20 $796.20 $771.37 $676.77

$83.51 $83.51 $98.25 $98.25 $96.43 $83.51$507.58 $526.36 $597.15 $597.15 $96.43 $507.58

$1,015.31 $1,015.31 $1,015.31 $929.89 $1,043.10 $1,015.31$103.72 $103.72 $101.88 $93.00 $130.39 $103.72$761.50 $761.50 $761.50 $697.40 $782.31 $761.50

$4,981.67 $5,860.79 $5,860.79 $5,860.79 $6,998.51 $5,860.79$492.34 $579.22 $579.22 $579.22 $874.84 $579.22

$3,732.92 $4,391.67 $4,391.67 $4,391.67 $5,248.90 $4,391.67$101.42 $106.79 $119.32 $119.32 $105.62 $118.11

$11.92 $11.92 $14.02 $14.02 $13.15 $11.92$76.16 $80.08 $89.60 $89.60 $78.45 $88.60$63.88 $63.88 $63.88 $63.88 $76.65 $63.88$60.01 $60.01 $60.01 $60.01 $72.00 $60.01

$176.60 $176.60 $174.88 $174.88 $192.85 $176.60$17.82 $17.91 $17.51 $18.38 $24.12 $18.38

$132.45 $132.45 $131.17 $131.17 $144.63 $132.45$128.73 $145.36 $151.45 $151.45 $149.01 $146.98

$13.22 $14.54 $15.55 $15.55 $18.62 $14.68$96.66 $109.03 $113.72 $113.72 $111.77 $110.24

$129.77 $143.24 $152.67 $152.67 $138.48 $152.67$13.37 $14.32 $15.73 $15.73 $17.29 $15.73$97.34 $107.46 $114.52 $114.52 $103.88 $114.52

$304.24 $357.93 $357.93 $342.12 $482.09 $357.93$34.36 $40.42 $37.51 $34.36 $60.26 $40.42

$228.18 $268.45 $268.45 $256.57 $361.57 $268.45$415.23 $488.50 $488.50 $488.50 $414.99 $488.50

$40.98 $48.21 $48.21 $48.21 $46.05 $48.21$311.43 $366.39 $366.39 $366.39 $344.97 $366.39$202.66 $198.21 $202.66 $202.54 $230.92 $202.07

$20.28 $19.81 $20.28 $20.27 $23.10 $20.20$152.03 $148.65 $152.03 $151.91 $173.19 $151.54

$1,225.18 $1,389.68 $1,389.68 $1,356.49 $1,730.70 $1,389.68$126.45 $148.77 $142.35 $135.67 $197.07 $148.77$918.90 $1,042.21 $1,042.21 $1,017.36 $1,298.04 $1,042.21



HCPCS 1st Mod 2nd Mod CategoryE0671 NU INE0671 RR INE0671 UE INE0672 NU INE0672 RR INE0672 UE INE0673 NU INE0673 RR INE0673 UE INE0675 RR CRE0691 NU INE0691 RR INE0691 UE INE0692 NU INE0692 RR INE0692 UE INE0693 NU INE0693 RR INE0693 UE INE0694 NU INE0694 RR INE0694 UE INE0705 NU KU INE0705 NU INE0705 RR KU INE0705 RR INE0705 UE KU INE0705 UE INE0720 NU TEE0730 NU TEE0731 NU INE0740 RR CRE0744 RR CRE0745 RR CRE0747 NU KF INE0747 RR KF INE0747 UE KF INE0748 NU KF INE0748 RR KF INE0748 UE KF INE0760 NU KF INE0760 RR KF INE0760 UE KF INE0762 RR CRE0764 RR KF CRE0765 NU INE0765 RR INE0765 UE INE0776 NU BA PEE0776 NU KE PEE0776 NU INE0776 RR BA PEE0776 RR KE PEE0776 RR INE0776 UE BA PEE0776 UE KE PEE0776 UE INE0779 RR CRE0780 NU INE0781 RR CRE0784 RR CR

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$459.18 $459.18 $459.18 $459.18 $550.91 $459.18$45.94 $45.94 $45.94 $45.94 $55.13 $45.94

$344.37 $344.37 $344.37 $344.37 $413.25 $344.37$356.77 $356.77 $356.77 $356.77 $428.16 $356.77

$35.69 $35.69 $35.69 $35.69 $42.83 $35.69$267.60 $267.60 $267.60 $267.60 $321.12 $267.60$296.46 $296.46 $296.46 $296.46 $355.76 $296.46

$29.65 $29.65 $29.65 $29.65 $35.61 $29.65$222.38 $222.38 $222.38 $222.38 $266.82 $222.38$425.12 $425.12 $425.12 $425.12 $425.12 $425.12$993.40 $993.40 $993.40 $993.40 $1,192.11 $993.40

$99.33 $99.33 $99.33 $99.33 $119.21 $99.33$745.05 $745.05 $745.05 $745.05 $894.08 $745.05

$1,247.44 $1,247.44 $1,247.44 $1,247.44 $1,496.93 $1,247.44$124.73 $124.73 $124.73 $124.73 $149.71 $124.73$935.57 $935.57 $935.57 $935.57 $1,122.70 $935.57

$1,537.74 $1,537.74 $1,537.74 $1,537.74 $1,845.28 $1,537.74$153.78 $153.78 $153.78 $153.78 $184.53 $153.78

$1,153.30 $1,153.30 $1,153.30 $1,153.30 $1,383.98 $1,153.30$4,894.46 $4,894.46 $4,894.46 $4,894.46 $5,873.36 $4,894.46

$489.44 $489.44 $489.44 $489.44 $587.33 $489.44$3,670.87 $3,670.87 $3,670.87 $3,670.87 $4,405.02 $3,670.87

$60.94 $60.94 $60.94 $60.94 $67.79 $60.94$54.50 R $55.15 $54.50 R $55.15 $52.45 R $55.15 $52.45 R $55.15 $58.57 $54.50 R $55.15

$6.20 $6.20 $6.20 $6.20 $8.49 $6.20$5.50 R $5.57 $5.50 R $5.57 $5.30 R $5.57 $5.30 R $5.57 $6.71 $5.50 R $5.57

$44.63 $44.63 $44.63 $44.63 $50.83 $44.63$40.34 R $40.82 $40.34 R $40.82 $38.80 R $40.82 $38.80 R $40.82 $43.92 $40.34 R $40.82


$57.82 $57.82 $57.82 $57.82 $69.37 $57.82$86.05 $86.37 $99.86 $101.23 $148.22 $96.70$84.12 $86.37 $91.22 $98.96 $100.93 $90.67

$4,329.25 $4,329.25 $4,329.25 $4,329.25 $4,215.71 $4,329.25$430.20 $430.20 $421.73 $421.73 $622.39 $430.20

$3,216.55 $3,216.55 $3,162.84 $3,162.84 $840.35 $3,216.55$4,301.21 $4,301.21 $4,301.21 $4,301.21 $5,161.42 $4,301.21

$430.10 $430.10 $430.10 $430.10 $516.12 $430.10$3,225.91 $3,225.91 $3,225.91 $3,225.91 $3,871.09 $3,225.91$3,574.23 $3,574.23 $3,574.23 $3,574.23 $4,289.10 $3,574.23

$357.43 $357.43 $357.43 $357.43 $428.90 $357.43$2,680.65 $2,680.65 $2,680.65 $2,680.65 $3,216.80 $2,680.65

$121.55 $121.55 $121.55 $112.09 $92.72 $121.55$1,223.43 $1,223.43 $1,223.43 $1,223.43 $1,468.13 $1,223.43

$93.01 $93.01 $93.01 $93.01 $111.59 $93.01$9.31 $9.31 $9.31 $9.31 $11.16 $9.31

$69.78 $69.78 $69.78 $69.78 $83.71 $69.78$77.87 R $79.77 $77.87 R $79.77 $76.27 R $79.77 $76.27 R $79.77 $79.77 $77.87 R $79.77$86.21 R $88.11 $86.21 R $88.11 $84.61 R $88.11 $84.61 R $88.11 $88.11 $86.21 R $88.11

$148.01 $148.01 $146.38 $138.16 $148.65 $134.53$15.75 R $15.94 $15.75 R $15.94 $15.59 R $15.94 $15.59 R $15.94 $15.94 $15.75 R $15.94$17.87 R $18.06 $17.87 R $18.06 $17.71 R $18.06 $17.71 R $18.06 $18.06 $17.87 R $18.06$15.80 $15.65 $15.65 $15.65 $16.86 $15.65$58.41 R $59.84 $58.41 R $59.84 $57.21 R $59.84 $57.21 R $59.84 $59.84 $58.41 R $59.84$64.66 R $66.08 $64.66 R $66.08 $63.46 R $66.08 $63.46 R $66.08 $66.08 $64.66 R $66.08

$109.89 $109.89 $109.78 $103.62 $111.50 $98.98$16.66 $18.18 $16.41 $18.18 $19.84 $17.90$11.41 $11.41 $11.41 $11.41 $12.55 $11.41

$248.02 $262.38 $245.39 $262.38 $287.68 $262.38$439.93 $439.93 $439.93 $439.93 $486.07 $439.93



HCPCS 1st Mod 2nd Mod CategoryE0791 RR CRE0840 NU INE0840 RR INE0840 UE INE0849 RR CRE0850 NU INE0850 RR INE0850 UE INE0855 RR CRE0856 RR CRE0860 NU INE0860 RR INE0860 UE INE0870 NU INE0870 RR INE0870 UE INE0880 NU INE0880 RR INE0880 UE INE0890 NU INE0890 RR INE0890 UE INE0900 NU INE0900 RR INE0900 UE INE0910 RR CRE0911 RR CRE0912 RR CRE0920 RR CRE0930 RR CRE0935 RR FSE0940 RR CRE0941 RR CRE0942 NU INE0942 RR INE0942 UE INE0944 NU INE0944 RR INE0944 UE INE0945 NU INE0945 RR INE0945 UE INE0946 RR CRE0947 NU INE0947 RR INE0947 UE INE0948 NU INE0948 RR INE0948 UE INE0950 NU KE INE0950 NU KU INE0950 NU INE0950 RR KE INE0950 RR KU INE0950 RR INE0950 UE KE INE0950 UE KU INE0950 UE INE0951 NU KE INE0951 NU KU INE0951 NU IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$286.34 $312.56 $312.56 $312.56 $218.81 $304.51$80.99 $68.84 $75.36 $69.27 $129.28 $80.99$18.05 $15.34 $15.34 $15.34 $35.91 $15.34$60.72 $51.61 $56.52 $51.95 $96.98 $51.61$56.98 $56.98 $56.98 $56.98 $68.37 $56.98

$116.13 $103.71 $98.71 $98.71 $126.92 $98.71$15.95 $13.56 $13.56 $13.56 $15.88 $13.56$87.11 $77.77 $74.04 $74.04 $95.20 $74.04$55.56 $55.56 $55.56 $55.56 $65.56 $55.56$17.01 $17.01 $17.01 $17.01 $20.44 $17.01$42.60 $37.56 $42.60 $42.60 $30.35 $42.60

$6.87 $6.12 $6.12 $6.12 $3.81 $7.17$32.62 $28.17 $32.07 $32.62 $22.80 $32.62

$109.30 $109.30 $128.59 $128.59 $167.69 $109.30$14.83 $12.61 $14.83 $14.83 $20.98 $12.61$82.34 $82.34 $96.87 $96.87 $125.78 $82.34

$117.97 $117.97 $117.97 $117.97 $154.63 $117.97$18.52 $18.52 $18.52 $18.52 $19.33 $18.52$89.29 $89.29 $89.29 $89.29 $116.01 $89.29

$113.14 $113.14 $133.10 $133.10 $122.03 $118.59$30.86 $30.86 $30.86 $30.86 $15.26 $36.30$91.14 $91.14 $107.22 $107.22 $91.51 $91.14

$120.40 $120.40 $141.65 $141.65 $134.89 $120.40$25.96 $25.96 $25.96 $25.96 $16.86 $25.96$90.33 $90.33 $106.27 $106.27 $101.17 $90.33$13.87 R $14.31 $13.57 R $14.00 $13.42 R $14.00 $14.53 R $15.11 $14.99 $15.00 R $15.43$44.43 R $46.22 $44.43 R $46.22 $44.03 R $46.22 $44.03 R $46.22 $50.99 $44.43 R $46.22$96.08 R $98.11 $96.08 R $98.11 $95.01 R $98.11 $95.01 R $98.11 $113.47 $96.08 R $98.11$43.37 $51.02 $43.37 $43.37 $70.52 $43.37$42.93 $50.50 $44.44 $50.50 $52.18 $42.93$21.37 $23.22 $21.37 $21.37 $26.73 $21.37$24.37 R $25.29 $24.37 R $25.29 $24.16 R $25.32 $26.61 R $27.77 $30.66 $24.37 R $25.29$40.78 $47.98 $47.98 $47.98 $50.93 $47.98$18.65 $18.65 $18.65 $21.94 $4.89 $21.94

$2.21 $2.21 $2.21 $2.60 $0.60 $2.60$13.97 $13.97 $13.97 $16.43 $3.67 $16.43$43.37 $46.05 $43.10 $50.71 $61.34 $50.71

$4.37 $4.63 $4.34 $5.09 $7.67 $5.10$35.63 $34.52 $32.33 $38.03 $46.03 $38.03$41.65 $47.37 $41.65 $41.65 $50.86 $49.00

$4.17 $4.75 $4.17 $4.17 $6.35 $4.91$32.23 $35.54 $32.23 $32.23 $38.16 $37.92$55.60 $59.46 $55.60 $55.60 $69.04 $55.60

$569.88 $584.00 $670.45 $670.45 $866.24 $631.97$59.08 $59.08 $69.51 $69.51 $108.30 $63.23

$427.40 $437.97 $502.82 $502.82 $649.65 $473.97$566.09 $584.00 $604.95 $603.50 $863.39 $631.97

$56.98 $56.98 $60.50 $60.35 $107.93 $63.23$424.58 $437.97 $453.72 $452.63 $647.54 $457.37

$94.28 R $97.35 $94.28 R $97.35 $93.90 R $97.35 $93.90 R $97.35 $102.99 $85.66 R $88.73$99.05 $99.05 $99.05 $99.05 $108.80 $84.19$86.34 R $89.41 $86.34 R $89.41 $85.96 R $89.41 $85.96 R $89.41 $94.28 $78.91 R $81.98

$9.43 R $9.74 $9.43 R $9.74 $9.40 R $9.74 $9.40 R $9.74 $11.88 $8.57 R $8.88$9.93 $9.93 $9.93 $9.93 $13.61 $8.44$8.65 R $8.95 $8.65 R $8.95 $8.61 R $8.95 $8.61 R $8.95 $10.79 $7.90 R $8.21

$70.71 R $73.01 $70.71 R $73.01 $70.42 R $73.01 $70.42 R $73.01 $77.24 $64.24 R $66.55$74.29 $74.29 $74.29 $74.29 $81.58 $63.15$64.75 R $67.06 $64.75 R $67.06 $64.47 R $67.06 $64.47 R $67.06 $70.70 $59.18 R $61.49$15.28 R $15.80 $16.17 R $16.69 $16.39 R $17.37 $16.39 R $17.37 $18.51 $16.85 R $17.37$15.38 $16.90 $18.09 $18.09 $20.05 $18.09$14.05 R $14.57 $14.81 R $15.33 $14.94 R $15.92 $14.94 R $15.92 $16.90 $15.40 R $15.92



HCPCS 1st Mod 2nd Mod CategoryE0951 RR KE INE0951 RR KU INE0951 RR INE0951 UE KE INE0951 UE KU INE0951 UE INE0952 NU KE INE0952 NU KU INE0952 NU INE0952 RR KE INE0952 RR KU INE0952 RR INE0952 UE KE INE0952 UE KU INE0952 UE INE0955 RR KE CRE0955 RR KU CRE0955 RR CRE0956 NU KE INE0956 NU KU INE0956 NU INE0956 RR KE INE0956 RR KU INE0956 RR INE0956 UE KE INE0956 UE KU INE0956 UE INE0957 NU KE INE0957 NU KU INE0957 NU INE0957 RR KE INE0957 RR KU INE0957 RR INE0957 UE KE INE0957 UE KU INE0957 UE INE0958 RR CRE0959 NU INE0959 RR INE0959 UE INE0960 NU KE INE0960 NU KU INE0960 NU INE0960 RR KE INE0960 RR KU INE0960 RR INE0960 UE KE INE0960 UE KU INE0960 UE INE0961 NU INE0961 RR INE0961 UE INE0966 NU INE0966 RR INE0966 UE INE0967 NU INE0967 RR INE0967 UE INE0968 RR CRE0969 NU INE0969 RR IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$1.56 R $1.61 $1.63 R $1.68 $1.68 R $1.77 $1.68 R $1.77 $2.14 $1.72 R $1.77$1.58 $1.71 $1.86 $1.86 $2.50 $1.86$1.43 R $1.48 $1.49 R $1.54 $1.52 R $1.62 $1.52 R $1.62 $1.94 $1.57 R $1.62

$11.45 R $11.84 $12.13 R $12.52 $12.28 R $13.02 $12.28 R $13.02 $13.89 $12.63 R $13.02$11.53 $12.69 $13.56 $13.56 $15.04 $13.56$10.53 R $10.92 $11.11 R $11.51 $11.20 R $11.94 $11.20 R $11.94 $12.68 $11.55 R $11.94$18.07 $18.07 $18.07 $18.07 $19.21 $18.07$17.95 $17.95 $17.95 $17.95 $19.89 $17.95$16.64 $16.64 $16.64 $16.64 $17.61 $16.64

$1.85 $1.85 $1.85 $1.85 $2.22 $1.85$1.86 $1.86 $1.86 $1.86 $2.50 $1.86$1.70 $1.70 $1.70 $1.70 $2.02 $1.70

$13.57 $13.57 $13.57 $13.57 $14.40 $13.57$13.47 $13.47 $13.47 $13.47 $14.92 $13.47$12.49 $12.49 $12.49 $12.49 $13.21 $12.49$18.12 R $18.81 $18.12 R $18.81 $18.05 R $18.81 $18.05 R $18.81 $21.04 $18.12 R $18.81$19.28 $19.28 $19.28 $19.28 $23.13 $19.28$16.58 R $17.27 $16.58 R $17.27 $16.51 R $17.27 $16.51 R $17.27 $19.20 $16.58 R $17.27$90.99 R $94.72 $90.99 R $94.72 $91.08 R $94.72 $91.08 R $94.72 $105.61 $90.99 R $94.72$93.92 $93.92 $93.92 $93.92 $112.71 $93.92$83.46 R $87.19 $83.46 R $87.19 $83.54 R $87.19 $83.54 R $87.19 $96.58 $83.46 R $87.19

$9.10 R $9.48 $9.10 R $9.48 $9.11 R $9.48 $9.11 R $9.48 $10.57 $9.10 R $9.48$9.39 $9.39 $9.39 $9.39 $11.29 $9.39$8.35 R $8.72 $8.35 R $8.72 $8.35 R $8.72 $8.35 R $8.72 $9.67 $8.35 R $8.72

$68.24 R $71.04 $68.24 R $71.04 $68.30 R $71.04 $68.30 R $71.04 $79.22 $68.24 R $71.04$70.45 $70.45 $70.45 $70.45 $84.56 $70.45$62.60 R $65.39 $62.60 R $65.39 $62.66 R $65.39 $62.66 R $65.39 $72.45 $62.60 R $65.39

$133.70 R $139.17 $133.70 R $139.17 $134.95 R $139.17 $134.95 R $139.17 $157.00 $133.70 R $139.17$131.43 $131.43 $131.43 $131.43 $157.72 $131.43$123.18 R $128.64 $123.18 R $128.64 $124.42 R $128.64 $124.42 R $128.64 $144.36 $123.18 R $128.64

$13.38 R $13.92 $13.38 R $13.92 $13.50 R $13.92 $13.50 R $13.92 $15.69 $13.38 R $13.92$13.15 $13.15 $13.15 $13.15 $15.76 $13.15$12.32 R $12.87 $12.32 R $12.87 $12.44 R $12.87 $12.44 R $12.87 $14.43 $12.32 R $12.87

$100.28 R $104.37 $100.28 R $104.37 $101.21 R $104.37 $101.21 R $104.37 $117.73 $100.28 R $104.37$98.57 $98.57 $98.57 $98.57 $118.27 $98.57$92.38 R $96.48 $92.38 R $96.48 $93.31 R $96.48 $93.31 R $96.48 $108.26 $92.38 R $96.48$41.49 R $43.58 $43.81 R $45.97 $41.69 R $43.72 $43.94 R $45.97 $53.79 $43.81 R $45.97$44.55 R $47.23 $44.20 R $46.88 $45.60 R $47.68 $45.60 R $47.68 $53.29 $43.01 R $44.88

$4.46 R $4.73 $4.43 R $4.70 $4.58 R $4.78 $4.58 R $4.78 $6.06 $4.30 R $4.48$33.43 R $35.44 $33.15 R $35.16 $34.37 R $35.93 $34.37 R $35.93 $39.97 $32.25 R $33.65$85.44 R $88.47 $85.44 R $88.47 $85.14 R $88.47 $85.14 R $88.47 $103.85 $85.44 R $88.47$86.69 $86.69 $86.69 $86.69 $104.02 $86.69$78.50 R $81.52 $78.50 R $81.52 $78.20 R $81.52 $78.20 R $81.52 $95.51 $78.50 R $81.52

$8.55 R $8.85 $8.55 R $8.85 $8.52 R $8.85 $8.52 R $8.85 $10.38 $8.55 R $8.85$8.69 $8.69 $8.69 $8.69 $10.38 $8.69$7.86 R $8.16 $7.86 R $8.16 $7.83 R $8.16 $7.83 R $8.16 $9.54 $7.86 R $8.16

$64.09 R $66.36 $64.09 R $66.36 $63.86 R $66.36 $63.86 R $66.36 $77.88 $64.09 R $66.36$65.03 $65.03 $65.03 $65.03 $78.04 $65.03$58.88 R $61.15 $58.88 R $61.15 $58.65 R $61.15 $58.65 R $61.15 $71.64 $58.88 R $61.15$23.61 R $24.75 $23.61 R $24.75 $23.56 R $24.75 $26.03 R $27.21 $10.97 $26.07 R $27.21



$7.06 R $7.27 $7.06 R $7.27 $7.04 R $7.27 $7.04 R $7.27 $8.13 $7.06 R $7.27$52.93 R $54.44 $52.93 R $54.44 $52.75 R $54.44 $52.75 R $54.44 $61.07 $52.93 R $54.44$19.81 $19.81 $19.53 $19.81 $24.35 $19.63

$173.16 $173.16 $173.16 $169.89 $223.53 $173.16$17.14 $17.14 $17.14 $16.99 $27.95 $17.14



HCPCS 1st Mod 2nd Mod CategoryE0969 UE INE0971 NU INE0971 RR INE0971 UE INE0973 NU KE INE0973 NU KU INE0973 NU INE0973 RR KE INE0973 RR KU INE0973 RR INE0973 UE KE INE0973 UE KU INE0973 UE INE0974 NU INE0974 RR INE0974 UE INE0978 NU KE INE0978 NU KU INE0978 NU INE0978 RR KE INE0978 RR KU INE0978 RR INE0978 UE KE INE0978 UE KU INE0978 UE INE0980 NU INE0980 RR INE0980 UE INE0981 NU KE INE0981 NU KU INE0981 NU INE0981 RR KE INE0981 RR KU INE0981 RR INE0981 UE KE INE0981 UE KU INE0981 UE INE0982 NU KE INE0982 NU KU INE0982 NU INE0982 RR KE INE0982 RR KU INE0982 RR INE0982 UE KE INE0982 UE KU INE0982 UE INE0983 RR CRE0984 RR CRE0985 RR KU CRE0985 RR CRE0986 RR CRE0988 RR CRE0990 NU KE INE0990 NU KU INE0990 NU INE0990 RR KE INE0990 RR KU INE0990 RR INE0990 UE KE INE0990 UE KU INE0990 UE IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$129.88 $129.88 $129.88 $127.41 $167.64 $129.88$39.08 R $39.93 $39.08 R $39.93 $37.88 R $39.93 $37.88 R $39.93 $44.73 $39.08 R $39.93


$7.94 R $7.98 $8.85 R $8.88 $7.64 R $7.98 $7.64 R $7.98 $11.09 $8.85 R $8.88$8.87 $10.43 $8.87 $8.87 $13.52 $10.43$7.22 R $7.26 $8.01 R $8.04 $6.92 R $7.26 $6.92 R $7.26 $10.01 $8.01 R $8.04



$3.58 R $3.66 $3.51 R $3.59 $3.12 R $3.31 $3.17 R $3.36 $5.12 $3.55 R $3.62$4.07 $3.96 $3.46 $3.58 $6.59 $4.01$3.25 R $3.33 $3.19 R $3.27 $2.83 R $3.02 $2.89 R $3.08 $4.59 $3.22 R $3.30

$26.59 R $27.17 $26.29 R $26.87 $23.14 R $24.54 $23.82 R $25.23 $32.74 $26.59 R $27.17$30.17 $29.65 $25.64 $26.82 $39.77 $30.17$24.17 R $24.75 $23.91 R $24.49 $21.08 R $22.49 $21.67 R $23.08 $29.55 $24.17 R $24.75$36.02 $31.06 $35.84 $36.34 $37.68 $31.06

$3.60 $3.11 $3.59 $3.64 $4.73 $3.11$27.02 $23.16 $26.86 $27.25 $28.27 $23.16$41.37 $43.78 $41.37 $42.83 $44.45 $45.28$38.19 $42.34 $38.19 $40.70 $43.52 $44.93$38.19 $40.39 $38.19 $39.57 $40.98 $41.68

$4.17 $4.38 $4.17 $4.29 $5.07 $4.57$3.88 $4.24 $3.88 $4.07 $5.43 $4.57$3.86 $4.04 $3.86 $3.96 $4.64 $4.21

$31.19 $32.84 $31.19 $32.13 $33.34 $34.15$28.90 $31.74 $28.90 $30.54 $32.64 $34.00$28.87 $30.29 $28.87 $29.68 $30.73 $31.42$45.50 $45.50 $45.50 $45.50 $47.03 $49.77$41.73 $41.73 $41.73 $41.73 $44.39 $49.09$41.73 $41.73 $41.73 $41.73 $43.48 $45.83

$4.54 $4.54 $4.54 $4.54 $5.35 $4.97$4.17 $4.17 $4.17 $4.17 $5.55 $4.91$4.17 $4.17 $4.17 $4.17 $4.90 $4.58

$34.11 $34.11 $34.11 $34.11 $35.27 $37.31$31.31 $31.31 $31.31 $31.31 $33.29 $36.83$31.30 $31.30 $31.30 $31.30 $32.60 $34.38

$248.08 $276.31 $243.58 $276.31 $324.71 $266.63$211.20 $211.20 $211.20 $211.20 $313.64 $209.53

$22.44 $22.44 $22.44 $22.44 $26.88 $22.44$21.27 R $22.44 $21.27 R $22.44 $21.41 R $22.44 $21.41 R $22.44 $24.70 $21.27 R $22.44

$537.76 $537.76 $537.76 $537.76 $645.30 $537.76$330.93 $327.73 $330.93 $330.93 $339.19 $330.93

$91.26 R $91.95 $96.98 R $97.68 $96.41 R $101.14 $96.95 R $101.69 $137.33 $98.72 R $99.41$95.11 $104.99 $110.96 $111.89 $173.34 $107.98$83.64 R $84.33 $88.58 R $89.27 $87.52 R $92.26 $87.98 R $92.72 $123.45 $90.07 R $90.76

$9.82 R $9.89 $9.82 R $9.89 $9.64 R $10.11 $10.51 R $10.98 $16.25 $9.87 R $9.94$10.71 $10.71 $11.09 $12.60 $21.65 $10.79




HCPCS 1st Mod 2nd Mod CategoryE0992 NU INE0992 RR INE0992 UE INE0994 NU INE0994 RR INE0994 UE INE0995 NU KE INE0995 NU KU INE0995 NU INE0995 RR KE INE0995 RR KU INE0995 RR INE0995 UE KE INE0995 UE KU INE0995 UE INE1002 RR KE CRE1002 RR KU CRE1002 RR CRE1003 RR KE CRE1003 RR KU CRE1003 RR CRE1004 RR KE CRE1004 RR KU CRE1004 RR CRE1005 RR KE CRE1005 RR KU CRE1005 RR CRE1006 RR KE CRE1006 RR KU CRE1006 RR CRE1007 RR KE CRE1007 RR KU CRE1007 RR CRE1008 RR KE CRE1008 RR KU CRE1008 RR CRE1010 RR KE CRE1010 RR KU CRE1010 RR CRE1012 RR KU CRE1012 RR CRE1014 RR CRE1015 NU INE1015 RR INE1015 UE INE1016 NU KE INE1016 NU KU INE1016 NU INE1016 RR KE INE1016 RR KU INE1016 RR INE1016 UE KE INE1016 UE KU INE1016 UE INE1020 RR KE CRE1020 RR KU CRE1020 RR CRE1028 RR KE CRE1028 RR KU CRE1028 RR CRE1029 RR KE CR

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$91.31 R $94.03 $92.04 R $94.75 $87.91 R $92.49 $90.18 R $94.75 $180.02 $85.06 R $87.78$9.05 R $9.33 $9.05 R $9.33 $8.80 R $9.26 $8.87 R $9.33 $21.38 $8.50 R $8.77

$68.48 R $70.52 $69.03 R $71.07 $65.96 R $69.39 $67.64 R $71.07 $135.02 $63.81 R $65.85$16.56 $18.51 $19.48 $19.48 $13.50 $19.48

$1.67 $1.85 $1.97 $1.97 $1.70 $1.97$12.43 $13.91 $14.62 $14.62 $10.12 $14.62$26.64 $28.29 $29.16 $29.16 $38.82 $29.16$24.62 $27.48 $28.96 $28.96 $45.63 $28.96$24.62 $26.09 $26.83 $26.83 $35.16 $26.83

$2.67 $2.82 $2.92 $2.92 $4.54 $2.92$2.47 $2.74 $2.91 $2.91 $5.70 $2.91$2.47 $2.60 $2.69 $2.69 $4.08 $2.69

$19.97 $21.23 $21.86 $21.86 $36.28 $21.86$18.45 $20.63 $21.70 $21.70 $46.59 $21.70$18.45 $19.58 $20.11 $20.11 $32.56 $20.11

$395.41 $395.41 $395.41 $395.41 $440.22 $395.41$386.19 $386.19 $386.19 $386.19 $463.45 $386.19$364.46 $364.46 $364.46 $364.46 $403.09 $364.46$443.32 $443.32 $443.32 $443.32 $491.86 $443.32$418.43 $418.43 $418.43 $418.43 $502.09 $418.43$409.80 $409.80 $409.80 $409.80 $451.63 $409.80$489.61 $489.61 $489.61 $489.61 $543.43 $489.61$463.93 $463.93 $463.93 $463.93 $556.73 $463.93$452.43 $452.43 $452.43 $452.43 $498.83 $452.43$532.50 $532.50 $532.50 $532.50 $590.77 $532.50$502.17 $502.17 $502.17 $502.17 $602.63 $502.17$492.26 $492.26 $492.26 $492.26 $542.49 $492.26$654.19 $654.19 $654.19 $654.19 $725.58 $654.19$615.11 $615.11 $615.11 $615.11 $738.17 $615.11$604.91 $604.91 $604.91 $604.91 $666.44 $604.91$852.29 $852.29 $852.29 $852.29 $948.93 $852.29$832.91 $832.91 $832.91 $832.91 $999.49 $832.91$785.57 $785.57 $785.57 $785.57 $868.85 $785.57$861.83 $861.83 $861.83 $861.83 $958.46 $861.83$832.97 $832.97 $832.97 $832.97 $999.56 $832.97$795.09 $795.09 $795.09 $795.09 $878.39 $795.09$114.68 $114.68 $114.68 $114.68 $127.32 $114.68$108.99 $108.99 $108.99 $108.99 $130.78 $108.99$105.95 $105.95 $105.95 $105.95 $116.84 $105.95$108.99 $108.99 $108.99 $108.99 $130.78 $108.99$105.95 $105.95 $105.95 $105.95 $116.84 $105.95

$40.38 $40.38 $40.38 $40.38 $48.43 $40.38$120.27 R $125.75 $120.27 R $125.75 $119.56 R $125.75 $119.56 R $125.75 $139.57 $120.27 R $125.75

$12.02 R $12.57 $12.02 R $12.57 $11.95 R $12.57 $11.95 R $12.57 $13.97 $12.02 R $12.57$90.20 R $94.31 $90.20 R $94.31 $89.66 R $94.31 $89.66 R $94.31 $104.68 $90.20 R $94.31

$124.12 R $130.93 $124.12 R $130.93 $125.87 R $130.93 $125.87 R $130.93 $149.59 $124.12 R $130.93$125.13 $125.13 $125.13 $125.13 $150.13 $125.13$114.10 R $120.91 $114.10 R $120.91 $115.85 R $120.91 $115.85 R $120.91 $137.56 $114.10 R $120.91

$12.42 R $13.10 $12.42 R $13.10 $12.59 R $13.10 $12.59 R $13.10 $14.97 $12.42 R $13.10$12.53 $12.53 $12.53 $12.53 $15.03 $12.53$11.42 R $12.10 $11.42 R $12.10 $11.59 R $12.10 $11.59 R $12.10 $13.76 $11.42 R $12.10$93.09 R $98.20 $93.09 R $98.20 $94.41 R $98.20 $94.41 R $98.20 $112.21 $93.09 R $98.20$93.83 $93.83 $93.83 $93.83 $112.61 $93.83$85.57 R $90.68 $85.57 R $90.68 $86.88 R $90.68 $86.88 R $90.68 $103.18 $85.57 R $90.68$22.23 R $22.92 $22.23 R $22.92 $22.14 R $22.92 $22.14 R $22.92 $25.63 $22.23 R $22.92$23.18 $23.18 $23.18 $23.18 $27.83 $23.18$20.37 R $21.07 $20.37 R $21.07 $20.29 R $21.07 $20.29 R $21.07 $23.39 $20.37 R $21.07$18.15 R $18.50 $18.15 R $18.50 $17.63 R $18.50 $17.63 R $18.50 $20.77 $18.15 R $18.50$19.67 $19.67 $19.67 $19.67 $23.61 $19.67$16.57 R $16.92 $16.57 R $16.92 $16.05 R $16.92 $16.05 R $16.92 $18.88 $16.57 R $16.92$37.76 $37.76 $37.76 $37.76 $41.85 $37.76



HCPCS 1st Mod 2nd Mod CategoryE1029 RR KU CRE1029 RR CRE1030 RR KE CRE1030 RR KU CRE1030 RR CRE1031 RR CRE1035 RR CRE1036 RR CRE1037 RR CRE1038 RR CRE1039 RR CRE1050 RR CRE1060 RR CRE1070 RR CRE1083 RR CRE1084 RR CRE1087 RR CRE1088 RR CRE1092 RR CRE1093 RR CRE1100 RR CRE1110 RR CRE1150 RR CRE1160 RR CRE1161 RR CRE1170 RR CRE1171 RR CRE1172 RR CRE1180 RR CRE1190 RR CRE1195 RR CRE1200 RR CRE1221 RR CRE1222 RR CRE1223 RR CRE1224 RR CRE1225 RR CRE1226 NU INE1226 RR INE1226 UE INE1227 NU INE1227 RR INE1227 UE INE1228 RR CRE1230 NU INE1230 RR INE1230 UE INE1232 RR CRE1233 RR CRE1234 RR CRE1235 RR CRE1236 RR CRE1237 RR CRE1238 RR CRE1240 RR CRE1270 RR CRE1280 RR CRE1295 RR CRE1296 NU INE1296 RR INE1296 UE IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$35.20 $35.20 $35.20 $35.20 $42.26 $35.20$34.93 $34.93 $34.93 $34.93 $38.47 $34.93

$118.55 $118.55 $118.55 $118.55 $131.43 $118.55$111.03 $111.03 $111.03 $111.03 $133.25 $111.03$109.66 $109.66 $109.66 $109.66 $120.77 $109.66

$44.26 R $46.19 $44.26 R $46.19 $44.23 R $46.19 $48.42 R $50.38 $37.96 $44.26 R $46.19$625.21 R $647.92 $625.21 R $647.92 $621.44 R $647.92 $621.44 R $647.92 $715.72 $625.21 R $647.92$881.16 R $924.26 $881.16 R $924.26 $873.75 R $924.26 $873.75 R $924.26 $1,019.30 $881.16 R $924.26$110.38 R $116.04 $110.38 R $116.04 $109.51 R $116.04 $109.51 R $116.04 $132.17 $110.38 R $116.04

$17.38 R $17.64 $17.38 R $17.64 $17.01 R $17.64 $17.01 R $17.64 $19.62 $17.38 R $17.64$34.64 R $36.20 $34.64 R $36.20 $34.24 R $36.20 $34.24 R $36.20 $40.93 $34.64 R $36.20$95.69 $105.36 $112.58 $112.58 $127.74 $95.69

$118.46 $123.01 $139.36 $139.36 $148.57 $118.46$102.93 $111.62 $121.09 $118.48 $176.16 $121.09

$73.99 $76.97 $87.05 $86.06 $90.81 $87.05$92.18 $100.23 $108.45 $108.45 $115.06 $108.45

$118.90 $138.42 $139.88 $139.88 $191.34 $130.97$141.68 $146.78 $166.68 $166.68 $230.21 $158.95$139.05 $142.08 $142.08 $142.08 $188.65 $142.08$119.21 $122.18 $122.18 $103.85 $173.12 $122.18

$97.54 $97.54 $114.75 $114.75 $141.79 $97.54$95.52 $112.38 $112.38 $112.38 $118.05 $112.37$76.65 $80.27 $81.76 $78.30 $113.27 $82.32$58.74 $58.74 $63.89 $66.41 $87.37 $64.24

$261.57 $261.57 $261.57 $261.57 $313.88 $261.57$83.94 $83.94 $98.75 $98.75 $163.48 $83.94$75.32 $75.32 $88.61 $88.61 $130.52 $75.32$92.06 $93.22 $108.30 $108.30 $122.56 $92.77$95.23 $97.52 $112.03 $112.03 $134.81 $95.23

$110.02 $110.02 $129.43 $129.43 $168.66 $110.02$118.05 $118.05 $138.88 $138.88 $142.46 $118.05

$81.76 $82.77 $96.19 $96.19 $139.31 $81.76$52.53 $44.65 $44.65 $44.65 $68.07 $52.53$74.94 $63.70 $63.70 $66.41 $81.96 $73.06$81.82 $69.55 $69.55 $70.31 $95.09 $81.82$89.71 $76.25 $81.74 $78.30 $107.84 $89.71$40.58 R $42.17 $39.40 R $40.98 $41.10 R $43.41 $41.44 R $43.74 $48.09 $40.24 R $41.83

$495.34 R $501.19 $450.09 R $455.94 $477.53 R $501.19 $477.53 R $501.19 $584.82 $450.09 R $455.94$50.41 R $51.00 $45.76 R $46.34 $48.63 R $51.00 $48.63 R $51.00 $68.11 $45.76 R $46.34

$371.48 R $375.87 $337.55 R $341.94 $358.12 R $375.87 $358.12 R $375.87 $438.61 $337.55 R $341.94$306.78 $306.78 $306.78 $306.78 $368.12 $306.78

$30.69 $30.69 $30.69 $30.69 $46.03 $30.69$230.11 $230.11 $230.11 $230.11 $283.28 $230.11

$26.33 $26.33 $26.33 $30.42 $32.19 $26.33$2,125.37 $2,125.37 $2,459.30 $2,500.44 $2,971.49 $2,125.37

$209.03 $209.03 $245.92 $245.92 $371.45 $209.03$1,680.91 $1,680.91 $1,844.49 $1,977.54 $2,228.58 $1,680.91

$236.42 $236.42 $236.42 $236.42 $283.71 $236.42$244.95 $244.95 $244.95 $244.95 $293.93 $244.95$213.26 $213.26 $213.26 $213.26 $255.92 $213.26$205.36 $205.36 $205.36 $205.36 $246.44 $205.36$181.16 $181.16 $181.16 $181.16 $217.40 $181.16$182.75 $182.75 $182.75 $182.75 $219.29 $182.75$181.16 $181.16 $181.16 $181.16 $217.40 $181.16

$96.81 $99.70 $113.89 $113.89 $122.14 $113.89$74.18 $79.29 $87.27 $87.27 $96.25 $83.00

$123.34 $138.60 $145.10 $127.45 $229.49 $125.86$114.14 $122.07 $134.28 $121.76 $190.60 $114.14$543.53 $507.67 $543.53 $543.53 $569.75 $462.00

$54.37 $50.78 $55.22 $55.22 $71.20 $46.94$407.65 $380.78 $407.65 $407.65 $427.31 $346.50



HCPCS 1st Mod 2nd Mod CategoryE1297 NU INE1297 RR INE1297 UE INE1298 NU INE1298 RR INE1298 UE INE1310 NU INE1310 RR INE1310 UE INE1353 OXE1355 OXE1372 NU INE1372 RR INE1372 UE INE1390 RR OXE1391 RR OXE1392 RR OXE1405 RR OXE1406 RR OXE1700 RR CRE1701 SUE1702 SUE1800 RR CRE1801 RR CRE1802 RR CRE1805 RR CRE1806 RR CRE1810 RR CRE1811 RR CRE1812 RR CRE1815 RR CRE1816 RR CRE1818 RR CRE1820 NU INE1820 RR INE1820 UE INE1821 NU INE1821 RR INE1821 UE INE1825 RR CRE1830 RR CRE1831 RR CRE1840 RR CRE1841 RR CRE2000 RR CRE2100 NU INE2100 RR INE2100 UE INE2101 NU INE2101 RR INE2101 UE INE2120 RR CRE2201 NU INE2201 RR INE2201 UE INE2202 NU INE2202 RR INE2202 UE INE2203 NU INE2203 RR INE2203 UE IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$115.65 $103.76 $98.30 $98.30 $129.15 $98.30$11.55 $10.92 $10.92 $10.92 $16.15 $10.92$86.72 $77.82 $73.71 $73.71 $96.87 $73.71

$468.36 $468.36 $468.36 $468.36 $438.26 $460.19$47.92 $47.92 $47.92 $47.92 $54.80 $46.05

$351.26 $351.26 $351.26 $351.26 $328.73 $345.14$2,373.97 $2,373.97 $2,017.87 $2,030.56 $2,813.59 $2,373.97

$203.04 $203.04 $200.24 $203.04 $351.69 $203.04$1,780.49 $1,780.49 $1,513.42 $1,522.93 $2,110.19 $1,780.49

$31.31 $31.31 $31.31 $31.31 $37.59 $31.31$23.59 $23.59 $23.59 $23.59 $28.31 $23.59

$140.05 R $141.96 $143.55 R $145.47 $135.40 R $147.28 $135.40 R $147.28 $161.90 $140.05 R $141.96$17.48 R $17.67 $17.48 R $17.67 $16.48 R $17.67 $16.48 R $17.67 $18.61 $17.48 R $17.67



$38.13 $38.13 $38.13 $38.13 $48.36 $35.91$9.96 $11.72 $11.72 $11.72 $12.61 $11.72

$21.21 $24.95 $23.66 $24.05 $31.66 $24.94$115.12 $115.12 $115.12 $115.12 $109.01 $115.12$127.81 $142.62 $126.08 $142.62 $167.27 $137.38$361.29 $361.29 $361.29 $361.29 $433.55 $361.29$118.73 $118.73 $118.73 $118.73 $88.67 $118.73$104.89 $117.10 $103.49 $117.10 $137.32 $112.74$117.07 $117.07 $117.07 $117.07 $110.53 $117.07$132.88 $148.27 $131.09 $148.27 $173.90 $142.81

$95.06 $95.06 $95.06 $95.06 $114.09 $95.06$118.73 $118.73 $118.73 $118.73 $110.53 $118.73$134.94 $150.62 $133.15 $150.62 $176.63 $145.05$137.79 $153.76 $135.92 $153.76 $180.34 $148.07

$90.37 $90.37 $90.37 $90.37 $112.02 $90.37$9.03 $9.03 $9.03 $9.03 $11.21 $9.03

$67.79 $67.79 $67.79 $67.79 $84.00 $67.79$116.35 $116.35 $116.35 $116.35 $139.65 $116.35

$11.61 $11.61 $11.61 $11.61 $13.97 $11.61$87.29 $87.29 $87.29 $87.29 $104.74 $87.29

$118.73 $118.73 $118.73 $118.73 $88.67 $118.73$118.73 $118.73 $118.73 $118.73 $88.67 $118.73

$73.05 $72.33 $73.05 $73.05 $84.29 $73.05$370.80 $423.09 $367.52 $419.66 $428.67 $402.25$500.78 $500.78 $500.78 $500.78 $600.93 $500.78

$51.33 $57.30 $50.63 $57.30 $67.19 $55.19$711.04 $701.23 $711.04 $711.04 $841.46 $701.23

$71.11 $70.13 $71.11 $71.11 $105.20 $70.13$533.29 $525.95 $533.29 $533.29 $631.11 $525.95$208.45 $208.45 $208.45 $208.45 $250.11 $208.45

$20.84 $20.84 $20.84 $20.84 $25.02 $20.84$156.34 $156.34 $156.34 $156.34 $187.61 $156.34$313.44 $313.44 $313.44 $313.44 $376.14 $313.44$359.72 R $367.19 $359.72 R $367.19 $352.41 R $367.19 $352.41 R $367.19 $408.43 $359.72 R $367.19



$47.20 R $48.37 $47.20 R $48.37 $46.29 R $48.37 $46.29 R $48.37 $58.35 $47.20 R $48.37$354.05 R $362.80 $354.05 R $362.80 $347.21 R $362.80 $347.21 R $362.80 $437.71 $354.05 R $362.80



HCPCS 1st Mod 2nd Mod CategoryE2204 NU INE2204 RR INE2204 UE INE2205 NU INE2205 RR INE2205 UE INE2206 NU INE2206 RR INE2206 UE INE2207 NU KU INE2207 NU INE2207 RR KU INE2207 RR INE2207 UE KU INE2207 UE INE2208 NU KE INE2208 NU KU INE2208 NU INE2208 RR KE INE2208 RR KU INE2208 RR INE2208 UE KE INE2208 UE KU INE2208 UE INE2209 NU KE INE2209 NU KU INE2209 NU INE2209 RR KE INE2209 RR KU INE2209 RR INE2209 UE KE INE2209 UE KU INE2209 UE INE2210 NU KE INE2210 NU KU INE2210 NU INE2210 RR KE INE2210 RR KU INE2210 RR INE2210 UE KE INE2210 UE KU INE2210 UE INE2211 NU INE2211 RR INE2211 UE INE2212 NU INE2212 RR INE2212 UE INE2213 NU INE2213 RR INE2213 UE INE2214 NU INE2214 RR INE2214 UE INE2215 NU INE2215 RR INE2215 UE INE2219 NU INE2219 RR INE2219 UE INE2220 NU IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$807.55 R $831.69 $807.55 R $831.69 $791.05 R $831.69 $791.05 R $831.69 $990.54 $807.55 R $831.69$80.76 R $83.17 $80.76 R $83.17 $79.11 R $83.17 $79.11 R $83.17 $99.05 $80.76 R $83.17

$605.66 R $623.77 $605.66 R $623.77 $593.29 R $623.77 $593.29 R $623.77 $742.90 $605.66 R $623.77$34.66 R $36.11 $34.66 R $36.11 $34.34 R $36.11 $34.34 R $36.11 $39.74 $34.66 R $36.11



$4.81 $4.81 $4.81 $4.81 $5.72 $4.81$4.51 R $4.78 $4.51 R $4.78 $4.54 R $4.78 $4.54 R $4.78 $5.23 $4.51 R $4.78

$35.95 $35.95 $35.95 $35.95 $43.13 $35.95$33.75 R $35.77 $33.75 R $35.77 $34.00 R $35.77 $34.00 R $35.77 $39.36 $33.75 R $35.77

$104.45 R $105.82 $104.45 R $105.82 $101.71 R $105.82 $101.71 R $105.82 $118.94 $104.45 R $105.82$113.19 $113.19 $113.19 $113.19 $135.79 $113.19

$95.38 R $96.75 $95.38 R $96.75 $92.65 R $96.75 $92.65 R $96.75 $108.06 $95.38 R $96.75$10.44 R $10.58 $10.44 R $10.58 $10.16 R $10.58 $10.16 R $10.58 $11.88 $10.44 R $10.58$11.31 $11.31 $11.31 $11.31 $13.57 $11.31

$9.54 R $9.67 $9.54 R $9.67 $9.26 R $9.67 $9.26 R $9.67 $10.80 $9.54 R $9.67$78.33 R $79.36 $78.33 R $79.36 $76.28 R $79.36 $76.28 R $79.36 $89.21 $78.33 R $79.36$84.89 $84.89 $84.89 $84.89 $101.85 $84.89$71.54 R $72.56 $71.54 R $72.56 $69.49 R $72.56 $69.49 R $72.56 $81.05 $71.54 R $72.56$98.67 R $102.94 $98.67 R $102.94 $98.06 R $102.94 $98.06 R $102.94 $121.09 $98.67 R $102.94

$102.11 $102.11 $102.11 $102.11 $122.54 $102.11$90.49 R $94.76 $90.49 R $94.76 $89.88 R $94.76 $89.88 R $94.76 $111.27 $90.49 R $94.76

$9.89 R $10.31 $9.89 R $10.31 $9.82 R $10.31 $9.82 R $10.31 $12.11 $9.89 R $10.31$10.23 $10.23 $10.23 $10.23 $12.26 $10.23


$6.13 R $6.40 $6.13 R $6.40 $6.11 R $6.40 $6.11 R $6.40 $6.97 $6.13 R $6.40$6.23 $6.23 $6.23 $6.23 $6.84 $6.23$5.63 R $5.89 $5.63 R $5.89 $5.61 R $5.89 $5.61 R $5.89 $6.42 $5.63 R $5.89$0.62 R $0.65 $0.62 R $0.65 $0.62 R $0.65 $0.62 R $0.65 $0.71 $0.62 R $0.65$0.63 $0.63 $0.63 $0.63 $0.71 $0.63$0.56 R $0.59 $0.56 R $0.59 $0.56 R $0.59 $0.56 R $0.59 $0.65 $0.56 R $0.59$4.60 R $4.80 $4.60 R $4.80 $4.58 R $4.80 $4.58 R $4.80 $5.24 $4.60 R $4.80$4.70 $4.70 $4.70 $4.70 $5.17 $4.70$4.23 R $4.43 $4.23 R $4.43 $4.22 R $4.43 $4.22 R $4.43 $4.83 $4.23 R $4.43

$35.62 R $36.96 $39.02 R $40.35 $38.42 R $40.35 $38.42 R $40.35 $47.51 $37.62 R $38.96$3.52 R $3.66 $3.86 R $3.99 $3.80 R $3.99 $3.80 R $3.99 $5.44 $3.76 R $3.90

$26.07 R $27.07 $28.50 R $29.50 $28.05 R $29.50 $28.05 R $29.50 $35.64 $28.22 R $29.23$6.15 R $6.48 $6.15 R $6.48 $6.16 R $6.48 $6.16 R $6.48 $7.14 $6.15 R $6.48$0.63 R $0.67 $0.63 R $0.67 $0.64 R $0.67 $0.64 R $0.67 $0.73 $0.63 R $0.67$4.62 R $4.87 $4.62 R $4.87 $4.63 R $4.87 $4.63 R $4.87 $5.36 $4.62 R $4.87

$30.79 R $32.31 $30.79 R $32.31 $30.68 R $32.31 $30.68 R $32.31 $36.66 $30.79 R $32.31$3.09 R $3.24 $3.09 R $3.24 $3.08 R $3.24 $3.08 R $3.24 $3.67 $3.09 R $3.24

$23.09 R $24.23 $23.09 R $24.23 $23.00 R $24.23 $23.00 R $24.23 $27.50 $23.09 R $24.23$31.73 R $33.83 $31.73 R $33.83 $34.80 R $36.96 $34.80 R $36.96 $40.79 $31.73 R $33.83


$1.01 R $1.06 $1.01 R $1.06 $1.00 R $1.06 $1.00 R $1.06 $1.18 $1.01 R $1.06$7.55 R $7.94 $7.55 R $7.94 $7.51 R $7.94 $7.51 R $7.94 $8.75 $7.55 R $7.94

$38.54 R $39.32 $42.02 R $44.18 $37.75 R $39.32 $37.75 R $39.32 $43.54 $42.02 R $44.18$4.11 R $4.33 $4.50 R $4.72 $4.03 R $4.33 $4.03 R $4.33 $4.92 $4.50 R $4.72

$28.91 R $29.49 $31.51 R $33.14 $28.31 R $29.49 $28.31 R $29.49 $32.65 $31.51 R $33.14$29.86 R $30.97 $29.86 R $30.97 $28.86 R $30.97 $28.86 R $30.97 $35.13 $29.86 R $30.97



HCPCS 1st Mod 2nd Mod CategoryE2220 RR INE2220 UE INE2221 NU INE2221 RR INE2221 UE INE2222 NU INE2222 RR INE2222 UE INE2224 NU INE2224 RR INE2224 UE INE2225 NU INE2225 RR INE2225 UE INE2226 NU INE2226 RR INE2226 UE INE2227 RR CRE2228 RR CRE2231 NU INE2231 RR INE2231 UE INE2310 RR KE CRE2310 RR KU CRE2310 RR CRE2311 RR KE CRE2311 RR KU CRE2311 RR CRE2312 RR KC CRE2312 RR CRE2313 RR CRE2321 RR KC CRE2321 RR KE CRE2321 RR KU CRE2321 RR CRE2322 RR KC CRE2322 RR KE CRE2322 RR KU CRE2322 RR CRE2323 NU KE INE2323 NU KU INE2323 NU INE2323 RR KE INE2323 RR KU INE2323 RR INE2323 UE KE INE2323 UE KU INE2323 UE INE2324 NU KE INE2324 NU KU INE2324 NU INE2324 RR KE INE2324 RR KU INE2324 RR INE2324 UE KE INE2324 UE KU INE2324 UE INE2325 RR KE CRE2325 RR KU CRE2325 RR CRE2326 RR KE CR

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule








$3.95 R $4.15 $3.95 R $4.15 $3.93 R $4.15 $3.93 R $4.15 $4.61 $3.95 R $4.15$29.62 R $31.13 $29.62 R $31.13 $29.49 R $31.13 $29.49 R $31.13 $34.62 $29.62 R $31.13

$206.82 $204.82 $206.82 $206.82 $211.99 $206.82$96.60 R $101.28 $96.60 R $101.28 $95.70 R $101.28 $95.70 R $101.28 $114.07 $96.60 R $101.28

$152.73 R $157.26 $152.73 R $157.26 $150.42 R $157.26 $150.42 R $157.26 $174.26 $152.73 R $157.26$15.27 R $15.73 $15.27 R $15.73 $15.04 R $15.73 $15.04 R $15.73 $17.43 $15.27 R $15.73

$114.55 R $117.94 $114.55 R $117.94 $112.81 R $117.94 $112.81 R $117.94 $130.69 $114.55 R $117.94$114.87 $114.87 $114.87 $114.87 $127.81 $114.87$111.49 $111.49 $111.49 $111.49 $133.82 $111.49$105.93 $105.93 $105.93 $105.93 $117.09 $105.93$232.23 $232.23 $232.23 $232.23 $258.41 $232.23$225.75 $225.75 $225.75 $225.75 $270.90 $225.75$214.14 $214.14 $214.14 $214.14 $236.71 $214.14$284.33 $281.62 $284.33 $284.33 $291.46 $284.33$222.94 $220.81 $222.94 $222.94 $228.53 $222.94

$35.43 $35.07 $35.43 $35.43 $36.29 $35.43$234.38 $234.38 $234.38 $234.38 $259.05 $234.38$156.03 $156.03 $156.03 $156.03 $173.58 $156.03$246.66 $246.66 $246.66 $246.66 $295.98 $246.66$143.90 $143.90 $143.90 $143.90 $159.03 $143.90$255.80 $255.80 $255.80 $255.80 $281.92 $255.80$142.37 $142.37 $142.37 $142.37 $157.96 $142.37$261.19 $261.19 $261.19 $261.19 $313.43 $261.19$131.60 $131.60 $131.60 $131.60 $145.04 $131.60

$69.63 $69.63 $69.63 $69.63 $77.27 $69.63$65.91 $65.91 $65.91 $65.91 $79.06 $65.91$64.35 $64.35 $64.35 $64.35 $70.93 $64.35

$6.96 $6.96 $6.96 $6.96 $7.72 $6.96$6.58 $6.58 $6.58 $6.58 $7.89 $6.58$6.43 $6.43 $6.43 $6.43 $7.08 $6.43

$52.22 $52.22 $52.22 $52.22 $57.95 $52.22$49.41 $49.41 $49.41 $49.41 $59.31 $49.41$48.26 $48.26 $48.26 $48.26 $53.21 $48.26$44.95 $44.95 $44.95 $44.95 $49.80 $44.95$41.75 $41.75 $41.75 $41.75 $50.12 $41.75$41.61 $41.61 $41.61 $41.61 $45.79 $41.61

$4.49 $4.49 $4.49 $4.49 $4.98 $4.49$4.15 $4.15 $4.15 $4.15 $5.01 $4.15$4.15 $4.15 $4.15 $4.15 $4.58 $4.15

$33.72 $33.72 $33.72 $33.72 $37.35 $33.72$31.31 $31.31 $31.31 $31.31 $37.58 $31.31$31.20 $31.20 $31.20 $31.20 $34.34 $31.20

$136.03 $136.03 $136.03 $136.03 $150.90 $136.03$128.34 $128.34 $128.34 $128.34 $154.01 $128.34$125.74 $125.74 $125.74 $125.74 $138.57 $125.74

$35.35 $35.35 $35.35 $35.35 $39.18 $35.35



HCPCS 1st Mod 2nd Mod CategoryE2326 RR KU CRE2326 RR CRE2327 RR KC CRE2327 RR KE CRE2327 RR KU CRE2327 RR CRE2328 RR KE CRE2328 RR KU CRE2328 RR CRE2329 RR KE CRE2329 RR KU CRE2329 RR CRE2330 RR KE CRE2330 RR KU CRE2330 RR CRE2340 NU INE2340 RR INE2340 UE INE2341 NU INE2341 RR INE2341 UE INE2342 NU INE2342 RR INE2342 UE INE2343 NU INE2343 RR INE2343 UE INE2351 NU KE INE2351 NU KU INE2351 NU INE2351 RR KE INE2351 RR KU INE2351 RR INE2351 UE KE INE2351 UE KU INE2351 UE INE2359 NU KU INE2359 NU INE2359 RR KU INE2359 RR INE2359 UE KU INE2359 UE INE2360 NU KU INE2360 NU INE2360 RR KU INE2360 RR INE2360 UE KU INE2360 UE INE2361 NU KE INE2361 NU KU INE2361 NU INE2361 RR KE INE2361 RR KU INE2361 RR INE2361 UE KE INE2361 UE KU INE2361 UE INE2362 NU KU INE2362 NU INE2362 RR KU INE2362 RR IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$33.09 $33.09 $33.09 $33.09 $39.70 $33.09$32.69 $32.69 $32.69 $32.69 $36.00 $32.69

$372.04 $372.04 $372.04 $372.04 $409.86 $372.04$264.83 $264.83 $264.83 $264.83 $293.70 $264.83$378.16 $378.16 $378.16 $378.16 $453.79 $378.16$244.88 $244.88 $244.88 $244.88 $269.78 $244.88$501.21 $501.21 $501.21 $501.21 $556.00 $501.21$472.15 $472.15 $472.15 $472.15 $566.60 $472.15$463.38 $463.38 $463.38 $463.38 $510.60 $463.38$179.71 $179.71 $179.71 $179.71 $199.26 $179.71$168.28 $168.28 $168.28 $168.28 $201.98 $168.28$166.22 $166.22 $166.22 $166.22 $183.07 $166.22$346.75 $346.75 $346.75 $346.75 $384.59 $346.75$326.06 $326.06 $326.06 $326.06 $391.29 $326.06$320.63 $320.63 $320.63 $320.63 $353.24 $320.63$396.17 $396.17 $396.17 $396.17 $475.44 $396.17

$39.63 $39.63 $39.63 $39.63 $47.54 $39.63$297.16 $297.16 $297.16 $297.16 $356.57 $297.16$594.30 $594.30 $594.30 $594.30 $713.14 $594.30

$59.42 $59.42 $59.42 $59.42 $71.30 $59.42$445.73 $445.73 $445.73 $445.73 $534.88 $445.73$495.25 $495.25 $495.25 $495.25 $594.29 $495.25

$49.52 $49.52 $49.52 $49.52 $59.44 $49.52$371.45 $371.45 $371.45 $371.45 $445.72 $371.45$792.41 $792.41 $792.41 $792.41 $950.88 $792.41

$79.23 $79.23 $79.23 $79.23 $95.09 $79.23$594.30 $594.30 $594.30 $594.30 $713.14 $594.30$712.77 $712.77 $712.77 $712.77 $789.96 $712.77$665.69 $665.69 $665.69 $665.69 $798.82 $665.69$659.43 $659.43 $659.43 $659.43 $725.92 $659.43

$71.28 $71.28 $71.28 $71.28 $79.00 $71.28$66.59 $66.59 $66.59 $66.59 $79.89 $66.59$65.94 $65.94 $65.94 $65.94 $72.59 $65.94

$534.58 $534.58 $534.58 $534.58 $592.47 $534.58$499.25 $499.25 $499.25 $499.25 $599.13 $499.25$494.58 $494.58 $494.58 $494.58 $544.44 $494.58$192.52 $190.64 $192.52 $192.52 $197.29 $192.52$175.72 R $183.39 $174.78 R $182.45 $174.94 R $183.39 $174.94 R $183.39 $186.14 $175.72 R $183.39

$19.26 $19.07 $19.26 $19.26 $19.72 $19.26$17.58 R $18.34 $17.48 R $18.25 $17.50 R $18.34 $17.50 R $18.34 $18.61 $17.58 R $18.34

$144.37 $142.99 $144.37 $144.37 $147.99 $144.37$131.78 R $137.53 $131.09 R $136.84 $131.20 R $137.53 $131.20 R $137.53 $139.62 $131.78 R $137.53$105.57 $124.20 $124.20 $124.20 $106.94 $105.57$100.92 R $105.58 $110.23 R $115.47 $111.59 R $115.47 $111.59 R $115.47 $106.94 $100.92 R $105.58

$10.61 $12.48 $12.48 $12.48 $13.36 $10.61$10.12 R $10.61 $11.05 R $11.58 $11.19 R $11.58 $11.19 R $11.58 $12.29 $10.12 R $10.61$79.17 $93.14 $93.14 $93.14 $80.20 $79.17$75.68 R $79.16 $82.67 R $86.60 $83.69 R $86.60 $83.69 R $86.60 $80.20 $75.68 R $79.16

$131.05 R $136.75 $131.05 R $136.75 $130.10 R $136.75 $130.10 R $136.75 $152.18 $131.05 R $136.75$132.89 $132.89 $132.89 $132.89 $159.48 $132.89$120.40 R $126.11 $120.40 R $126.11 $119.45 R $126.11 $119.45 R $126.11 $139.40 $120.40 R $126.11


$101.69 $101.69 $101.69 $101.69 $122.03 $101.69$94.90 R $99.42 $94.90 R $99.42 $95.81 R $99.42 $95.81 R $99.42 $110.95 $94.90 R $99.42$10.17 $10.17 $10.17 $10.17 $12.19 $10.17

$9.49 R $9.94 $9.49 R $9.94 $9.58 R $9.94 $9.58 R $9.94 $11.09 $9.49 R $9.94



HCPCS 1st Mod 2nd Mod CategoryE2362 UE KU INE2362 UE INE2363 NU KE INE2363 NU KU INE2363 NU INE2363 RR KE INE2363 RR KU INE2363 RR INE2363 UE KE INE2363 UE KU INE2363 UE INE2364 NU KU INE2364 NU INE2364 RR KU INE2364 RR INE2364 UE KU INE2364 UE INE2365 NU KE INE2365 NU KU INE2365 NU INE2365 RR KE INE2365 RR KU INE2365 RR INE2365 UE KE INE2365 UE KU INE2365 UE INE2366 NU KE INE2366 NU KU INE2366 NU INE2366 RR KE INE2366 RR KU INE2366 RR INE2366 UE KE INE2366 UE KU INE2366 UE INE2367 NU KE INE2367 NU KU INE2367 NU INE2367 RR KE INE2367 RR KU INE2367 RR INE2367 UE KE INE2367 UE KU INE2367 UE INE2368 RR KE CRE2368 RR KU CRE2368 RR CRE2369 RR KE CRE2369 RR KU CRE2369 RR CRE2370 RR KE CRE2370 RR KU CRE2370 RR CRE2371 NU KE INE2371 NU KU INE2371 NU INE2371 RR KE INE2371 RR KU INE2371 RR INE2371 UE KE INE2371 UE KU IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$76.26 $76.26 $76.26 $76.26 $91.52 $76.26$71.17 R $74.56 $71.17 R $74.56 $71.86 R $74.56 $71.86 R $74.56 $83.22 $71.17 R $74.56

$172.31 R $178.06 $172.31 R $178.06 $168.07 R $178.06 $168.07 R $178.06 $198.63 $172.31 R $178.06$177.24 $177.24 $177.24 $177.24 $212.68 $177.24$158.12 R $163.87 $158.12 R $163.87 $153.88 R $163.87 $153.88 R $163.87 $181.59 $158.12 R $163.87

$17.24 R $17.81 $17.24 R $17.81 $16.82 R $17.81 $16.82 R $17.81 $19.87 $17.24 R $17.81$17.72 $17.72 $17.72 $17.72 $21.27 $17.72$15.81 R $16.38 $15.81 R $16.38 $15.39 R $16.38 $15.39 R $16.38 $18.16 $15.81 R $16.38

$129.24 R $133.55 $129.24 R $133.55 $126.06 R $133.55 $126.06 R $133.55 $148.81 $129.24 R $133.55$132.92 $132.92 $132.92 $132.92 $159.23 $132.92$118.59 R $122.90 $118.59 R $122.90 $115.40 R $122.90 $115.40 R $122.90 $136.05 $118.59 R $122.90$105.57 $124.20 $124.20 $124.20 $106.94 $105.57

$99.25 R $104.25 $108.56 R $113.57 $112.12 R $113.57 $112.12 R $113.57 $105.91 $99.25 R $104.25$10.61 $12.48 $12.48 $12.48 $13.36 $10.61


$106.88 $106.88 $106.88 $106.88 $128.28 $106.88$90.68 R $93.55 $90.68 R $93.55 $87.72 R $93.55 $87.72 R $93.55 $104.25 $90.68 R $93.55

$9.92 R $10.21 $9.92 R $10.21 $9.63 R $10.21 $9.63 R $10.21 $11.46 $9.92 R $10.21$10.68 $10.68 $10.68 $10.68 $12.84 $10.68


$225.56 R $227.78 $203.70 R $205.92 $195.47 R $205.92 $195.47 R $205.92 $305.32 $203.70 R $205.92$251.19 $213.51 $213.51 $213.51 $384.83 $213.51$205.44 R $207.66 $186.60 R $188.82 $178.36 R $188.82 $178.36 R $188.82 $274.48 $186.60 R $188.82

$22.60 R $22.82 $20.40 R $20.63 $19.58 R $20.63 $19.58 R $20.63 $36.11 $20.40 R $20.63$25.19 $21.41 $21.41 $21.41 $48.09 $21.41$20.58 R $20.80 $18.69 R $18.91 $17.87 R $18.91 $17.87 R $18.91 $32.25 $18.69 R $18.91


$38.05 R $39.91 $38.05 R $39.91 $38.34 R $39.91 $38.34 R $39.91 $43.99 $38.05 R $39.91$39.93 $39.93 $39.93 $39.93 $47.90 $39.93$34.85 R $36.71 $34.85 R $36.71 $35.13 R $36.71 $35.13 R $36.71 $40.15 $34.85 R $36.71

$285.34 R $299.30 $285.34 R $299.30 $287.50 R $299.30 $287.50 R $299.30 $330.01 $285.34 R $299.30$299.49 $299.49 $299.49 $299.49 $359.38 $299.49$261.35 R $275.31 $261.35 R $275.31 $263.50 R $275.31 $263.50 R $275.31 $301.22 $261.35 R $275.31

$48.01 R $49.93 $48.01 R $49.93 $47.60 R $49.93 $47.60 R $49.93 $58.97 $48.01 R $49.93$49.22 $49.22 $49.22 $49.22 $59.08 $49.22$44.06 R $45.99 $44.06 R $45.99 $43.65 R $45.99 $43.65 R $45.99 $54.24 $44.06 R $45.99$42.98 R $44.98 $42.98 R $44.98 $42.51 R $44.98 $42.51 R $44.98 $51.35 $42.98 R $44.98$42.89 $42.89 $42.89 $42.89 $51.45 $42.89$39.54 R $41.55 $39.54 R $41.55 $39.08 R $41.55 $39.08 R $41.55 $47.23 $39.54 R $41.55$70.41 R $72.18 $70.41 R $72.18 $69.27 R $72.18 $69.27 R $72.18 $81.06 $70.41 R $72.18$76.50 $76.50 $76.50 $76.50 $91.79 $76.50$64.28 R $66.05 $64.28 R $66.05 $63.14 R $66.05 $63.14 R $66.05 $73.70 $64.28 R $66.05

$148.60 R $155.80 $148.60 R $155.80 $148.23 R $155.80 $148.23 R $155.80 $172.46 $148.60 R $155.80$143.63 $143.63 $143.63 $143.63 $172.36 $143.63$137.10 R $143.63 $137.10 R $143.63 $136.73 R $143.63 $136.73 R $143.63 $158.66 $137.10 R $143.63

$14.86 R $15.58 $14.86 R $15.58 $14.82 R $15.58 $14.82 R $15.58 $17.25 $14.86 R $15.58$14.37 $14.37 $14.37 $14.37 $17.23 $14.37$13.71 R $14.37 $13.71 R $14.37 $13.68 R $14.37 $13.68 R $14.37 $15.86 $13.71 R $14.37

$111.45 R $116.85 $111.45 R $116.85 $111.17 R $116.85 $111.17 R $116.85 $129.36 $111.45 R $116.85$107.74 $107.74 $107.74 $107.74 $129.27 $107.74



HCPCS 1st Mod 2nd Mod CategoryE2371 UE INE2373 RR KC CRE2373 RR KE CRE2373 RR KU CRE2373 RR CRE2374 RR KE CRE2374 RR KU CRE2374 RR CRE2375 RR KE CRE2375 RR KU CRE2375 RR CRE2376 RR KE CRE2376 RR KU CRE2376 RR CRE2377 RR KE CRE2377 RR KU CRE2377 RR CRE2378 RR KU CRE2378 RR CRE2381 NU KE INE2381 NU KU INE2381 NU INE2381 RR KE INE2381 RR KU INE2381 RR INE2381 UE KE INE2381 UE KU INE2381 UE INE2382 NU KE INE2382 NU KU INE2382 NU INE2382 RR KE INE2382 RR KU INE2382 RR INE2382 UE KE INE2382 UE KU INE2382 UE INE2383 NU KE INE2383 NU KU INE2383 NU INE2383 RR KE INE2383 RR KU INE2383 RR INE2383 UE KE INE2383 UE KU INE2383 UE INE2384 NU KE INE2384 NU KU INE2384 NU INE2384 RR KE INE2384 RR KU INE2384 RR INE2384 UE KE INE2384 UE KU INE2384 UE INE2385 NU KE INE2385 NU KU INE2385 NU INE2385 RR KE INE2385 RR KU INE2385 RR IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$102.83 R $107.74 $102.83 R $107.74 $102.55 R $107.74 $102.55 R $107.74 $119.00 $102.83 R $107.74$116.36 $115.79 $116.36 $116.36 $125.58 $116.36$106.11 $105.45 $106.11 $106.11 $116.80 $106.11$119.90 $118.75 $119.90 $119.90 $138.33 $119.90

$75.40 $75.04 $75.40 $75.40 $76.37 $75.40$52.64 $52.64 $52.64 $52.64 $63.28 $52.64$50.90 $50.90 $50.90 $50.90 $69.23 $50.90$48.57 $48.57 $48.57 $48.57 $57.74 $48.57$80.16 R $82.74 $80.16 R $82.74 $78.72 R $82.74 $78.72 R $82.74 $93.04 $80.16 R $82.74$81.60 $81.60 $81.60 $81.60 $89.78 $81.60$73.61 R $76.19 $73.61 R $76.19 $72.17 R $76.19 $72.17 R $76.19 $85.84 $73.61 R $76.19

$131.64 $131.64 $131.64 $131.64 $139.06 $131.64$127.90 $127.90 $127.90 $127.90 $140.69 $127.90$121.39 $121.39 $121.39 $121.39 $127.79 $121.39

$48.13 $48.13 $48.13 $48.13 $50.81 $48.13$46.27 $46.27 $46.27 $46.27 $50.92 $46.27$44.42 $44.42 $44.42 $44.42 $46.74 $44.42$56.57 $56.57 $56.57 $56.57 $67.91 $56.57$55.51 R $56.34 $55.51 R $56.34 $54.57 R $56.34 $54.57 R $56.34 $63.68 $55.51 R $56.34$70.67 R $73.72 $70.67 R $73.72 $70.13 R $73.72 $70.13 R $73.72 $86.04 $70.67 R $73.72$72.58 $72.58 $72.58 $72.58 $87.11 $72.58$64.85 R $67.90 $64.85 R $67.90 $64.31 R $67.90 $64.31 R $67.90 $79.06 $64.85 R $67.90

$7.07 R $7.38 $7.07 R $7.38 $7.02 R $7.38 $7.02 R $7.38 $8.61 $7.07 R $7.38$7.28 $7.28 $7.28 $7.28 $8.72 $7.28$6.50 R $6.80 $6.50 R $6.80 $6.44 R $6.80 $6.44 R $6.80 $7.91 $6.50 R $6.80

$53.01 R $55.30 $53.01 R $55.30 $52.60 R $55.30 $52.60 R $55.30 $64.54 $53.01 R $55.30$54.44 $54.44 $54.44 $54.44 $65.36 $54.44$48.65 R $50.93 $48.65 R $50.93 $48.24 R $50.93 $48.24 R $50.93 $59.30 $48.65 R $50.93$19.91 $19.91 $19.91 $19.91 $22.20 $19.91$19.78 $19.78 $19.78 $19.78 $23.73 $19.78$18.32 $18.32 $18.32 $18.32 $20.30 $18.32

$1.98 $1.98 $1.98 $1.98 $2.22 $1.98$1.97 $1.97 $1.97 $1.97 $2.37 $1.97$1.83 $1.83 $1.83 $1.83 $2.03 $1.83

$14.93 $14.93 $14.93 $14.93 $16.66 $14.93$14.85 $14.85 $14.85 $14.85 $17.81 $14.85$13.75 $13.75 $13.75 $13.75 $15.23 $13.75

$142.10 R $150.34 $142.10 R $150.34 $144.07 R $150.34 $144.07 R $150.34 $171.75 $142.10 R $150.34$144.72 $144.72 $144.72 $144.72 $173.67 $144.72$130.51 R $138.75 $130.51 R $138.75 $132.48 R $138.75 $132.48 R $138.75 $157.84 $130.51 R $138.75

$14.21 R $15.03 $14.21 R $15.03 $14.40 R $15.03 $14.40 R $15.03 $17.18 $14.21 R $15.03$14.47 $14.47 $14.47 $14.47 $17.38 $14.47$13.05 R $13.87 $13.05 R $13.87 $13.25 R $13.87 $13.25 R $13.87 $15.79 $13.05 R $13.87

$106.58 R $112.76 $106.58 R $112.76 $108.06 R $112.76 $108.06 R $112.76 $128.80 $106.58 R $112.76$108.53 $108.53 $108.53 $108.53 $130.25 $108.53


$7.43 R $7.68 $7.43 R $7.68 $7.33 R $7.68 $7.33 R $7.68 $9.16 $7.43 R $7.68$7.73 $7.73 $7.73 $7.73 $9.24 $7.73$6.81 R $7.06 $6.81 R $7.06 $6.71 R $7.06 $6.71 R $7.06 $8.42 $6.81 R $7.06

$55.65 R $57.52 $55.65 R $57.52 $54.90 R $57.52 $54.90 R $57.52 $68.74 $55.65 R $57.52$57.84 $57.84 $57.84 $57.84 $69.36 $57.84$51.02 R $52.90 $51.02 R $52.90 $50.27 R $52.90 $50.27 R $52.90 $63.18 $51.02 R $52.90$47.59 $47.59 $47.59 $47.59 $53.03 $47.59$47.17 $47.17 $47.17 $47.17 $56.56 $47.17$43.81 $43.81 $43.81 $43.81 $48.51 $43.81

$4.76 $4.76 $4.76 $4.76 $5.30 $4.76$4.74 $4.74 $4.74 $4.74 $5.65 $4.74$4.39 $4.39 $4.39 $4.39 $4.85 $4.39



HCPCS 1st Mod 2nd Mod CategoryE2385 UE KE INE2385 UE KU INE2385 UE INE2386 NU KE INE2386 NU KU INE2386 NU INE2386 RR KE INE2386 RR KU INE2386 RR INE2386 UE KE INE2386 UE KU INE2386 UE INE2387 NU KE INE2387 NU KU INE2387 NU INE2387 RR KE INE2387 RR KU INE2387 RR INE2387 UE KE INE2387 UE KU INE2387 UE INE2388 NU KE INE2388 NU KU INE2388 NU INE2388 RR KE INE2388 RR KU INE2388 RR INE2388 UE KE INE2388 UE KU INE2388 UE INE2389 NU KE INE2389 NU KU INE2389 NU INE2389 RR KE INE2389 RR KU INE2389 RR INE2389 UE KE INE2389 UE KU INE2389 UE INE2390 NU KE INE2390 NU KU INE2390 NU INE2390 RR KE INE2390 RR KU INE2390 RR INE2390 UE KE INE2390 UE KU INE2390 UE INE2391 NU KE INE2391 NU KU INE2391 NU INE2391 RR KE INE2391 RR KU INE2391 RR INE2391 UE KE INE2391 UE KU INE2391 UE INE2392 NU KE INE2392 NU KU INE2392 NU INE2392 RR KE IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$35.68 $35.68 $35.68 $35.68 $39.79 $35.68$35.36 $35.36 $35.36 $35.36 $42.45 $35.36$32.85 $32.85 $32.85 $32.85 $36.39 $32.85

$134.88 R $136.87 $134.88 R $136.87 $131.64 R $136.87 $131.64 R $136.87 $153.49 $134.88 R $136.87$143.40 $143.40 $143.40 $143.40 $172.07 $143.40$123.38 R $125.37 $123.38 R $125.37 $120.15 R $125.37 $120.15 R $125.37 $139.71 $123.38 R $125.37

$13.49 R $13.68 $13.49 R $13.68 $13.16 R $13.68 $13.16 R $13.68 $15.35 $13.49 R $13.68$14.34 $14.34 $14.34 $14.34 $17.20 $14.34$12.34 R $12.54 $12.34 R $12.54 $12.02 R $12.54 $12.02 R $12.54 $13.97 $12.34 R $12.54

$101.15 R $102.64 $101.15 R $102.64 $98.72 R $102.64 $98.72 R $102.64 $115.13 $101.15 R $102.64$107.56 $107.56 $107.56 $107.56 $129.07 $107.56


$6.13 R $6.30 $6.09 R $6.26 $6.01 R $6.30 $6.01 R $6.30 $7.35 $6.13 R $6.30$6.43 $6.35 $6.43 $6.43 $7.40 $6.43$5.61 R $5.79 $5.57 R $5.75 $5.50 R $5.79 $5.50 R $5.79 $6.75 $5.61 R $5.79

$45.97 R $47.27 $45.69 R $46.99 $45.12 R $47.27 $45.12 R $47.27 $55.18 $45.97 R $47.27$48.27 $47.79 $48.27 $48.27 $55.70 $48.27$42.10 R $43.40 $41.86 R $43.16 $41.25 R $43.40 $41.25 R $43.40 $50.72 $42.10 R $43.40$49.87 $49.87 $49.87 $49.87 $52.66 $49.87$48.00 $48.00 $48.00 $48.00 $52.82 $48.00$46.01 $46.01 $46.01 $46.01 $48.42 $46.01

$4.98 $4.98 $4.98 $4.98 $5.26 $4.98$4.81 $4.81 $4.81 $4.81 $5.27 $4.81$4.61 $4.61 $4.61 $4.61 $4.84 $4.61

$37.40 $37.40 $37.40 $37.40 $39.49 $37.40$36.02 $36.02 $36.02 $36.02 $39.61 $36.02$34.51 $34.51 $34.51 $34.51 $36.31 $34.51$27.43 $27.43 $27.43 $27.43 $28.93 $27.43$26.08 $26.08 $26.08 $26.08 $28.66 $26.08$25.34 $25.34 $25.34 $25.34 $26.63 $25.34

$2.75 $2.75 $2.75 $2.75 $2.91 $2.75$2.62 $2.62 $2.62 $2.62 $2.89 $2.62$2.54 $2.54 $2.54 $2.54 $2.67 $2.54

$20.57 $20.57 $20.57 $20.57 $21.71 $20.57$19.53 $19.53 $19.53 $19.53 $21.52 $19.53$18.99 $18.99 $18.99 $18.99 $19.99 $18.99$42.70 $42.70 $42.70 $42.70 $45.04 $42.70$40.77 $40.77 $40.77 $40.77 $44.83 $40.77$39.43 $39.43 $39.43 $39.43 $41.46 $39.43

$4.27 $4.27 $4.27 $4.27 $4.51 $4.27$4.07 $4.07 $4.07 $4.07 $4.47 $4.07$3.94 $3.94 $3.94 $3.94 $4.14 $3.94

$32.02 $32.02 $32.02 $32.02 $33.79 $32.02$30.56 $30.56 $30.56 $30.56 $33.63 $30.56$29.56 $29.56 $29.56 $29.56 $31.10 $29.56$19.55 R $20.52 $19.55 R $20.52 $19.53 R $20.52 $19.53 R $20.52 $21.98 $19.55 R $20.52$19.52 $19.52 $19.52 $19.52 $21.51 $19.52$17.97 R $18.94 $17.97 R $18.94 $17.95 R $18.94 $17.95 R $18.94 $20.26 $17.97 R $18.94

$1.95 R $2.05 $1.95 R $2.05 $1.95 R $2.05 $1.95 R $2.05 $2.20 $1.95 R $2.05$1.96 $1.96 $1.96 $1.96 $2.16 $1.96$1.80 R $1.90 $1.80 R $1.90 $1.80 R $1.90 $1.80 R $1.90 $2.03 $1.80 R $1.90


$4.97 R $5.19 $4.97 R $5.19 $4.91 R $5.19 $4.91 R $5.19 $6.13 $4.97 R $5.19



HCPCS 1st Mod 2nd Mod CategoryE2392 RR KU INE2392 RR INE2392 UE KE INE2392 UE KU INE2392 UE INE2394 NU KE INE2394 NU KU INE2394 NU INE2394 RR KE INE2394 RR KU INE2394 RR INE2394 UE KE INE2394 UE KU INE2394 UE INE2395 NU KE INE2395 NU KU INE2395 NU INE2395 RR KE INE2395 RR KU INE2395 RR INE2395 UE KE INE2395 UE KU INE2395 UE INE2396 NU KE INE2396 NU KU INE2396 NU INE2396 RR KE INE2396 RR KU INE2396 RR INE2396 UE KE INE2396 UE KU INE2396 UE INE2397 NU KU INE2397 NU INE2397 RR KU INE2397 RR INE2397 UE KU INE2397 UE INE2402 RR CRE2500 NU INE2500 RR INE2500 UE INE2502 NU INE2502 RR INE2502 UE INE2504 NU INE2504 RR INE2504 UE INE2506 NU INE2506 RR INE2506 UE INE2508 NU INE2508 RR INE2508 UE INE2510 NU INE2510 RR INE2510 UE INE2601 NU KE INE2601 NU KU INE2601 NU INE2601 RR KE IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$5.16 $5.16 $5.16 $5.16 $6.17 $5.16$4.56 R $4.78 $4.56 R $4.78 $4.50 R $4.78 $4.50 R $4.78 $5.63 $4.56 R $4.78


$7.03 R $7.29 $7.03 R $7.29 $6.99 R $7.29 $6.99 R $7.29 $8.74 $7.03 R $7.29$7.33 $7.33 $7.33 $7.33 $8.78 $7.33$6.44 R $6.71 $6.44 R $6.71 $6.41 R $6.71 $6.41 R $6.71 $8.04 $6.44 R $6.71


$5.08 R $5.28 $5.08 R $5.28 $5.07 R $5.28 $5.07 R $5.28 $6.22 $5.08 R $5.28$5.21 $5.21 $5.21 $5.21 $6.23 $5.21$4.67 R $4.87 $4.67 R $4.87 $4.66 R $4.87 $4.66 R $4.87 $5.72 $4.67 R $4.87


$6.43 R $6.68 $6.43 R $6.68 $5.73 R $6.08 $6.32 R $6.68 $8.91 $6.01 R $6.26$6.78 $6.78 $5.76 $6.78 $10.64 $6.09$5.87 R $6.12 $5.87 R $6.12 $5.26 R $5.61 $5.77 R $6.12 $8.05 $5.53 R $5.77

$46.21 R $48.06 $46.21 R $48.06 $41.26 R $43.93 $45.40 R $48.06 $57.51 $45.15 R $47.01$47.54 $47.54 $40.41 $47.54 $63.80 $45.73$42.40 R $44.26 $42.40 R $44.26 $38.02 R $40.41 $41.59 R $44.26 $52.39 $41.49 R $43.35

$457.83 $457.83 $457.83 $457.83 $549.38 $457.83$433.58 R $457.83 $433.58 R $457.83 $436.81 R $457.83 $436.81 R $457.83 $506.09 $433.58 R $457.83

$45.79 $45.79 $45.79 $45.79 $54.96 $45.79$43.36 R $45.79 $43.36 R $45.79 $43.68 R $45.79 $43.68 R $45.79 $50.62 $43.36 R $45.79

$343.35 $343.35 $343.35 $343.35 $412.04 $343.35$325.17 R $343.35 $325.17 R $343.35 $327.60 R $343.35 $327.60 R $343.35 $379.57 $325.17 R $343.35

$1,168.41 R $1,173.60 $1,168.41 R $1,173.60 $1,133.00 R $1,173.60 $1,133.00 R $1,173.60 $1,342.71 $1,168.41 R $1,173.60$432.30 $432.30 $432.30 $432.30 $518.78 $432.30

$43.24 $43.24 $43.24 $43.24 $51.89 $43.24$324.23 $324.23 $324.23 $324.23 $389.07 $324.23

$1,321.96 $1,321.96 $1,321.96 $1,321.96 $1,586.35 $1,321.96$132.20 $132.20 $132.20 $132.20 $158.63 $132.20$991.49 $991.49 $991.49 $991.49 $1,189.76 $991.49

$1,743.84 $1,743.84 $1,743.84 $1,743.84 $2,092.59 $1,743.84$174.41 $174.41 $174.41 $174.41 $209.30 $174.41

$1,307.88 $1,307.88 $1,307.88 $1,307.88 $1,569.47 $1,307.88$2,557.00 $2,557.00 $2,557.00 $2,557.00 $3,068.39 $2,557.00

$255.68 $255.68 $255.68 $255.68 $306.85 $255.68$1,917.71 $1,917.71 $1,917.71 $1,917.71 $2,301.28 $1,917.71$3,953.96 $3,953.96 $3,953.96 $3,953.96 $4,744.78 $3,953.96

$395.39 $395.39 $395.39 $395.39 $474.49 $395.39$2,965.48 $2,965.48 $2,965.48 $2,965.48 $3,558.58 $2,965.48$7,482.35 $7,482.35 $7,482.35 $7,482.35 $8,978.80 $7,482.35

$748.24 $748.24 $748.24 $748.24 $897.89 $748.24$5,611.76 $5,611.76 $5,611.76 $5,611.76 $6,734.12 $5,611.76

$53.22 R $54.26 $53.22 R $54.26 $51.79 R $54.26 $51.79 R $54.26 $61.01 $53.22 R $54.26$58.27 $58.27 $58.27 $58.27 $69.91 $58.27$48.55 R $49.59 $48.55 R $49.59 $47.12 R $49.59 $47.12 R $49.59 $55.41 $48.55 R $49.59

$5.33 R $5.43 $5.33 R $5.43 $5.18 R $5.43 $5.18 R $5.43 $6.11 $5.33 R $5.43



HCPCS 1st Mod 2nd Mod CategoryE2601 RR KU INE2601 RR INE2601 UE KE INE2601 UE KU INE2601 UE INE2602 NU KE INE2602 NU KU INE2602 NU INE2602 RR KE INE2602 RR KU INE2602 RR INE2602 UE KE INE2602 UE KU INE2602 UE INE2603 NU KE INE2603 NU KU INE2603 NU INE2603 RR KE INE2603 RR KU INE2603 RR INE2603 UE KE INE2603 UE KU INE2603 UE INE2604 NU KE INE2604 NU KU INE2604 NU INE2604 RR KE INE2604 RR KU INE2604 RR INE2604 UE KE INE2604 UE KU INE2604 UE INE2605 NU KE INE2605 NU KU INE2605 NU INE2605 RR KE INE2605 RR KU INE2605 RR INE2605 UE KE INE2605 UE KU INE2605 UE INE2606 NU KE INE2606 NU KU INE2606 NU INE2606 RR KE INE2606 RR KU INE2606 RR INE2606 UE KE INE2606 UE KU INE2606 UE INE2607 NU KE INE2607 NU KU INE2607 NU INE2607 RR KE INE2607 RR KU INE2607 RR INE2607 UE KE INE2607 UE KU INE2607 UE INE2608 NU KE INE2608 NU KU IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$5.85 $5.85 $5.85 $5.85 $6.99 $5.85$4.87 R $4.97 $4.87 R $4.97 $4.72 R $4.97 $4.72 R $4.97 $5.54 $4.87 R $4.97

$39.91 R $40.69 $39.91 R $40.69 $38.84 R $40.69 $38.84 R $40.69 $45.77 $39.91 R $40.69$43.71 $43.71 $43.71 $43.71 $52.45 $43.71$36.42 R $37.20 $36.42 R $37.20 $35.35 R $37.20 $35.35 R $37.20 $41.56 $36.42 R $37.20

$107.44 R $110.05 $107.44 R $110.05 $104.57 R $110.05 $104.57 R $110.05 $123.25 $107.44 R $110.05$113.76 $113.76 $113.76 $113.76 $136.54 $113.76

$98.32 R $100.93 $98.32 R $100.93 $95.45 R $100.93 $95.45 R $100.93 $112.32 $98.32 R $100.93$10.75 R $11.01 $10.75 R $11.01 $10.46 R $11.01 $10.46 R $11.01 $12.34 $10.75 R $11.01$11.38 $11.38 $11.38 $11.38 $13.68 $11.38


$135.36 R $137.70 $135.36 R $137.70 $132.36 R $137.70 $132.36 R $137.70 $154.46 $135.36 R $137.70$144.43 $144.43 $144.43 $144.43 $173.34 $144.43$123.78 R $126.12 $123.78 R $126.12 $120.78 R $126.12 $120.78 R $126.12 $140.58 $123.78 R $126.12

$13.54 R $13.77 $13.54 R $13.77 $13.24 R $13.77 $13.24 R $13.77 $15.46 $13.54 R $13.77$14.45 $14.45 $14.45 $14.45 $17.33 $14.45$12.38 R $12.62 $12.38 R $12.62 $12.08 R $12.62 $12.08 R $12.62 $14.06 $12.38 R $12.62

$101.52 R $103.27 $101.52 R $103.27 $99.26 R $103.27 $99.26 R $103.27 $115.83 $101.52 R $103.27$108.33 $108.33 $108.33 $108.33 $129.98 $108.33


$17.47 R $18.04 $17.47 R $18.04 $17.45 R $18.04 $17.45 R $18.04 $21.50 $17.47 R $18.04$17.95 $17.95 $17.95 $17.95 $21.55 $17.95$16.04 R $16.61 $16.04 R $16.61 $16.02 R $16.61 $16.02 R $16.61 $19.78 $16.04 R $16.61


$24.86 R $25.85 $24.86 R $25.85 $24.79 R $25.85 $24.79 R $25.85 $30.71 $24.86 R $25.85$25.66 $25.66 $25.66 $25.66 $30.78 $25.66$22.80 R $23.79 $22.80 R $23.79 $22.74 R $23.79 $22.74 R $23.79 $28.24 $22.80 R $23.79


$39.28 R $40.79 $39.28 R $40.79 $39.21 R $40.79 $39.21 R $40.79 $47.91 $39.28 R $40.79$40.02 $40.02 $40.02 $40.02 $48.00 $40.02$36.07 R $37.58 $36.07 R $37.58 $36.00 R $37.58 $36.00 R $37.58 $44.05 $36.07 R $37.58


$26.17 R $26.69 $26.17 R $26.69 $25.67 R $26.69 $25.67 R $26.69 $29.89 $26.17 R $26.69$27.62 $27.62 $27.62 $27.62 $33.14 $27.62$23.96 R $24.47 $23.96 R $24.47 $23.45 R $24.47 $23.45 R $24.47 $27.23 $23.96 R $24.47

$196.26 R $200.11 $196.26 R $200.11 $192.48 R $200.11 $192.48 R $200.11 $224.14 $196.26 R $200.11$207.14 $207.14 $207.14 $207.14 $248.56 $207.14$179.66 R $183.52 $179.66 R $183.52 $175.89 R $183.52 $175.89 R $183.52 $204.23 $179.66 R $183.52$317.86 R $326.94 $317.86 R $326.94 $315.63 R $326.94 $315.63 R $326.94 $396.89 $317.86 R $326.94$331.67 $331.67 $331.67 $331.67 $398.00 $331.67



HCPCS 1st Mod 2nd Mod CategoryE2608 NU INE2608 RR KE INE2608 RR KU INE2608 RR INE2608 UE KE INE2608 UE KU INE2608 UE INE2611 NU KE INE2611 NU KU INE2611 NU INE2611 RR KE INE2611 RR KU INE2611 RR INE2611 UE KE INE2611 UE KU INE2611 UE INE2612 NU KE INE2612 NU KU INE2612 NU INE2612 RR KE INE2612 RR KU INE2612 RR INE2612 UE KE INE2612 UE KU INE2612 UE INE2613 NU KE INE2613 NU KU INE2613 NU INE2613 RR KE INE2613 RR KU INE2613 RR INE2613 UE KE INE2613 UE KU INE2613 UE INE2614 NU KE INE2614 NU KU INE2614 NU INE2614 RR KE INE2614 RR KU INE2614 RR INE2614 UE KE INE2614 UE KU INE2614 UE INE2615 NU KE INE2615 NU KU INE2615 NU INE2615 RR KE INE2615 RR KU INE2615 RR INE2615 UE KE INE2615 UE KU INE2615 UE INE2616 NU KE INE2616 NU KU INE2616 NU INE2616 RR KE INE2616 RR KU INE2616 RR INE2616 UE KE INE2616 UE KU INE2616 UE IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule





$25.48 R $25.63 $25.48 R $25.63 $24.71 R $25.63 $24.71 R $25.63 $29.07 $25.48 R $25.63$29.75 $29.75 $29.75 $29.75 $35.72 $29.75$23.08 R $23.24 $23.08 R $23.24 $22.32 R $23.24 $22.32 R $23.24 $26.22 $23.08 R $23.24


$38.52 R $39.35 $38.52 R $39.35 $37.67 R $39.35 $37.67 R $39.35 $48.23 $38.52 R $39.35$40.26 $40.26 $40.26 $40.26 $48.31 $40.26$35.30 R $36.13 $35.30 R $36.13 $34.44 R $36.13 $34.44 R $36.13 $44.35 $35.30 R $36.13


$36.60 R $37.85 $36.60 R $37.85 $36.24 R $37.85 $36.24 R $37.85 $42.19 $36.60 R $37.85$37.46 $37.46 $37.46 $37.46 $44.94 $37.46$33.59 R $34.85 $33.59 R $34.85 $33.23 R $34.85 $33.23 R $34.85 $38.59 $33.59 R $34.85


$51.47 R $53.84 $51.47 R $53.84 $51.36 R $53.84 $51.36 R $53.84 $62.07 $51.47 R $53.84$51.83 $51.83 $51.83 $51.83 $62.18 $51.83$47.31 R $49.69 $47.31 R $49.69 $47.21 R $49.69 $47.21 R $49.69 $57.09 $47.31 R $49.69


$41.91 R $43.42 $41.91 R $43.42 $41.57 R $43.42 $41.57 R $43.42 $48.42 $41.91 R $43.42$43.11 $43.11 $43.11 $43.11 $51.72 $43.11$38.46 R $39.97 $38.46 R $39.97 $38.12 R $39.97 $38.12 R $39.97 $44.28 $38.46 R $39.97


$56.16 R $58.33 $56.16 R $58.33 $55.94 R $58.33 $55.94 R $58.33 $69.47 $56.16 R $58.33$57.99 $57.99 $57.99 $57.99 $69.57 $57.99$51.52 R $53.69 $51.52 R $53.69 $51.30 R $53.69 $51.30 R $53.69 $63.89 $51.52 R $53.69

$421.21 R $437.51 $421.21 R $437.51 $419.56 R $437.51 $419.56 R $437.51 $521.00 $421.21 R $437.51$434.92 $434.92 $434.92 $434.92 $521.87 $434.92$386.37 R $402.67 $386.37 R $402.67 $384.72 R $402.67 $384.72 R $402.67 $479.19 $386.37 R $402.67



HCPCS 1st Mod 2nd Mod CategoryE2619 NU KE INE2619 NU KU INE2619 NU INE2619 RR KE INE2619 RR KU INE2619 RR INE2619 UE KE INE2619 UE KU INE2619 UE INE2620 NU KE INE2620 NU KU INE2620 NU INE2620 RR KE INE2620 RR KU INE2620 RR INE2620 UE KE INE2620 UE KU INE2620 UE INE2621 NU KE INE2621 NU KU INE2621 NU INE2621 RR KE INE2621 RR KU INE2621 RR INE2621 UE KE INE2621 UE KU INE2621 UE INE2622 NU KE INE2622 NU KU INE2622 NU INE2622 RR KE INE2622 RR KU INE2622 RR INE2622 UE KE INE2622 UE KU INE2622 UE INE2623 NU KE INE2623 NU KU INE2623 NU INE2623 RR KE INE2623 RR KU INE2623 RR INE2623 UE KE INE2623 UE KU INE2623 UE INE2624 NU KE INE2624 NU KU INE2624 NU INE2624 RR KE INE2624 RR KU INE2624 RR INE2624 UE KE INE2624 UE KU INE2624 UE INE2625 NU KE INE2625 NU KU INE2625 NU INE2625 RR KE INE2625 RR KU INE2625 RR INE2625 UE KE IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$51.03 $51.03 $51.03 $51.03 $56.70 $51.03$48.89 $48.89 $48.89 $48.89 $58.66 $48.89$47.11 $47.11 $47.11 $47.11 $51.99 $47.11

$5.10 $5.10 $5.10 $5.10 $5.68 $5.10$4.89 $4.89 $4.89 $4.89 $5.89 $4.89$4.71 $4.71 $4.71 $4.71 $5.21 $4.71

$38.29 $38.29 $38.29 $38.29 $42.51 $38.29$36.70 $36.70 $36.70 $36.70 $43.97 $36.70$35.35 $35.35 $35.35 $35.35 $38.98 $35.35

$490.06 R $500.62 $490.06 R $500.62 $484.57 R $500.62 $484.57 R $500.62 $561.17 $490.06 R $500.62$521.86 $521.86 $521.86 $521.86 $626.23 $521.86$448.25 R $458.81 $448.25 R $458.81 $442.76 R $458.81 $442.76 R $458.81 $510.99 $448.25 R $458.81

$49.01 R $50.06 $49.01 R $50.06 $48.46 R $50.06 $48.46 R $50.06 $56.12 $49.01 R $50.06$52.19 $52.19 $52.19 $52.19 $62.64 $52.19$44.83 R $45.88 $44.83 R $45.88 $44.28 R $45.88 $44.28 R $45.88 $51.11 $44.83 R $45.88


$53.42 R $55.07 $53.42 R $55.07 $53.03 R $55.07 $53.03 R $55.07 $65.58 $53.42 R $55.07$54.77 $54.77 $54.77 $54.77 $65.73 $54.77$49.04 R $50.70 $49.04 R $50.70 $48.66 R $50.70 $48.66 R $50.70 $60.31 $49.04 R $50.70

$400.69 R $413.12 $400.69 R $413.12 $397.82 R $413.12 $397.82 R $413.12 $491.83 $400.69 R $413.12$410.74 $410.74 $410.74 $410.74 $492.91 $410.74$367.79 R $380.21 $367.79 R $380.21 $364.91 R $380.21 $364.91 R $380.21 $452.33 $367.79 R $380.21$326.97 $326.97 $326.97 $326.97 $363.62 $326.97$315.83 $315.83 $315.83 $315.83 $379.02 $315.83$301.67 $301.67 $301.67 $301.67 $333.26 $301.67

$32.70 $32.70 $32.70 $32.70 $36.35 $32.70$31.59 $31.59 $31.59 $31.59 $37.86 $31.59$30.17 $30.17 $30.17 $30.17 $33.30 $30.17

$245.23 $245.23 $245.23 $245.23 $272.73 $245.23$236.87 $236.87 $236.87 $236.87 $284.28 $236.87$226.25 $226.25 $226.25 $226.25 $249.95 $226.25$414.93 $414.93 $414.93 $414.93 $461.55 $414.93$401.89 $401.89 $401.89 $401.89 $482.26 $401.89$382.72 $382.72 $382.72 $382.72 $422.91 $382.72

$41.50 $41.50 $41.50 $41.50 $46.15 $41.50$40.20 $40.20 $40.20 $40.20 $48.22 $40.20$38.28 $38.28 $38.28 $38.28 $42.29 $38.28

$311.19 $311.19 $311.19 $311.19 $346.16 $311.19$301.40 $301.40 $301.40 $301.40 $361.71 $301.40$287.04 $287.04 $287.04 $287.04 $317.19 $287.04$330.80 $330.80 $330.80 $330.80 $367.75 $330.80$318.43 $318.43 $318.43 $318.43 $382.13 $318.43$305.29 $305.29 $305.29 $305.29 $337.14 $305.29

$33.08 $33.08 $33.08 $33.08 $36.76 $33.08$31.85 $31.85 $31.85 $31.85 $38.20 $31.85$30.53 $30.53 $30.53 $30.53 $33.71 $30.53

$248.10 $248.10 $248.10 $248.10 $275.80 $248.10$238.84 $238.84 $238.84 $238.84 $286.60 $238.84$228.98 $228.98 $228.98 $228.98 $252.86 $228.98$414.63 $414.63 $414.63 $414.63 $461.40 $414.63$403.11 $403.11 $403.11 $403.11 $483.75 $403.11$382.34 $382.34 $382.34 $382.34 $422.65 $382.34

$41.47 $41.47 $41.47 $41.47 $46.15 $41.47$40.30 $40.30 $40.30 $40.30 $48.38 $40.30$38.23 $38.23 $38.23 $38.23 $42.27 $38.23

$310.97 $310.97 $310.97 $310.97 $346.06 $310.97



HCPCS 1st Mod 2nd Mod CategoryE2625 UE KU INE2625 UE INE2626 NU KU INE2626 NU INE2626 RR KU INE2626 RR INE2626 UE KU INE2626 UE INE2627 NU KU INE2627 NU INE2627 RR KU INE2627 RR INE2627 UE KU INE2627 UE INE2628 NU KU INE2628 NU INE2628 RR KU INE2628 RR INE2628 UE KU INE2628 UE INE2629 NU KU INE2629 NU INE2629 RR KU INE2629 RR INE2629 UE KU INE2629 UE INE2630 NU KU INE2630 NU INE2630 RR KU INE2630 RR INE2630 UE KU INE2630 UE INE2631 NU KU INE2631 NU INE2631 RR KU INE2631 RR INE2631 UE KU INE2631 UE INE2632 NU KU INE2632 NU INE2632 RR KU INE2632 RR INE2632 UE KU INE2632 UE INE2633 NU KU INE2633 NU INE2633 RR KU INE2633 RR INE2633 UE KU INE2633 UE INK0001 RR CRK0002 RR CRK0003 RR CRK0004 RR CRK0005 NU INK0005 RR INK0005 UE INK0006 RR CRK0007 RR CRK0009 RR CRK0010 RR CR

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$302.33 $302.33 $302.33 $302.33 $362.80 $302.33$286.75 $286.75 $286.75 $286.75 $316.99 $286.75$686.66 $686.66 $668.88 $686.66 $1,185.08 $583.66$641.41 R $679.22 $641.41 R $679.22 $626.83 R $668.88 $635.71 R $679.22 $949.84 $583.67 R $583.67

$68.64 $68.64 $66.91 $68.64 $118.52 $58.34$64.13 R $67.91 $64.13 R $67.91 $62.69 R $66.91 $63.56 R $67.91 $94.99 $58.35 R $58.35

$514.94 $514.94 $501.67 $514.94 $888.83 $437.70$481.03 R $509.39 $481.03 R $509.39 $470.12 R $501.67 $476.76 R $509.39 $712.39 $437.70 R $437.70$931.34 $1,095.69 $1,095.69 $1,095.69 $1,170.74 $931.34$926.05 R $931.34 $1,008.23 R $1,065.84 $1,021.43 R $1,065.84 $1,021.43 R $1,065.84 $1,170.74 $926.05 R $931.34

$93.16 $109.60 $109.60 $109.60 $117.10 $93.16$92.62 R $93.16 $100.84 R $106.60 $102.16 R $106.60 $102.16 R $106.60 $117.10 $92.62 R $93.16

$698.50 $821.76 $821.76 $821.76 $878.03 $698.50$694.54 R $698.49 $756.17 R $799.38 $766.07 R $799.38 $766.07 R $799.38 $878.03 $694.54 R $698.49$825.43 $819.23 $715.90 $825.43 $1,019.91 $701.62$773.38 R $815.27 $770.28 R $812.17 $708.34 R $715.90 $763.10 R $815.27 $931.29 $701.61 R $701.61

$82.54 $81.95 $71.58 $82.54 $101.98 $70.16$77.34 R $81.53 $77.04 R $81.23 $70.83 R $71.58 $76.31 R $81.53 $93.13 $70.16 R $70.16

$619.06 $614.44 $536.93 $619.06 $764.93 $526.20$580.03 R $611.45 $577.72 R $609.14 $531.26 R $536.93 $572.33 R $611.45 $698.46 $526.21 R $526.21

$1,044.56 $1,044.56 $967.92 $1,008.00 $1,307.22 $887.88$979.66 R $1,029.58 $979.66 R $1,029.58 $939.89 R $967.92 $959.93 R $1,008.00 $1,160.91 $887.87 R $887.87$104.44 $104.44 $96.79 $100.80 $130.73 $88.77

$97.96 R $102.95 $97.96 R $102.95 $93.99 R $96.79 $95.99 R $100.80 $116.10 $88.77 R $88.77$783.41 $783.41 $725.93 $756.01 $980.40 $665.90$734.75 R $772.19 $734.75 R $772.19 $704.92 R $725.93 $719.96 R $756.01 $870.68 $665.91 R $665.91$730.46 $620.89 $730.46 $730.46 $833.16 $730.46$672.76 R $708.73 $617.97 R $620.89 $681.78 R $708.73 $681.78 R $708.73 $832.59 $672.76 R $708.73

$73.05 $62.09 $73.05 $73.05 $83.35 $73.05$67.28 R $70.87 $61.80 R $62.09 $68.18 R $70.87 $68.18 R $70.87 $83.27 $67.28 R $70.87

$547.84 $465.66 $547.84 $547.84 $624.88 $547.84$504.57 R $531.54 $463.48 R $465.66 $511.34 R $531.54 $511.34 R $531.54 $624.45 $504.57 R $531.54$248.37 $292.20 $250.47 $248.37 $452.49 $292.20$248.36 R $248.36 $278.89 R $287.96 $250.47 R $250.47 $248.36 R $248.36 $403.98 $278.89 R $287.96

$24.84 $29.22 $25.06 $24.84 $45.26 $29.22$24.84 R $24.84 $27.89 R $28.80 $25.06 R $25.06 $24.84 R $24.84 $40.40 $27.89 R $28.80

$186.27 $219.14 $187.86 $186.27 $339.38 $219.14$186.27 R $186.27 $209.16 R $215.97 $187.86 R $187.86 $186.27 R $186.27 $302.99 $209.16 R $215.97$170.66 $176.71 $157.92 $185.79 $313.16 $185.79$165.31 R $170.66 $168.33 R $176.71 $157.93 R $157.93 $173.71 R $182.43 $246.11 $172.87 R $182.43

$17.08 $17.66 $15.79 $18.58 $31.34 $18.58$16.54 R $17.08 $16.83 R $17.66 $15.79 R $15.79 $17.37 R $18.24 $24.63 $17.29 R $18.24

$127.99 $132.56 $118.44 $139.34 $234.89 $139.34$123.98 R $127.99 $126.26 R $132.56 $118.44 R $118.44 $130.28 R $136.82 $184.59 $129.65 R $136.82$133.95 $133.95 $154.14 $157.59 $313.16 $153.40$132.28 R $133.95 $132.28 R $133.95 $144.48 R $150.91 $146.20 R $152.64 $230.42 $142.00 R $150.55

$13.40 $13.40 $15.43 $15.77 $31.34 $15.38$13.23 R $13.41 $13.23 R $13.41 $14.45 R $15.10 $14.62 R $15.27 $23.06 $14.22 R $15.07

$100.47 $100.47 $115.63 $118.20 $234.89 $115.03$99.21 R $100.47 $99.21 R $100.47 $108.37 R $113.20 $109.65 R $114.48 $172.83 $106.49 R $112.90$38.09 R $38.15 $38.09 R $38.15 $38.13 R $39.04 $41.02 R $41.93 $41.92 $40.77 R $40.83$59.93 R $59.93 $61.82 R $61.82 $64.09 R $66.71 $61.75 R $64.37 $70.02 $66.71 R $66.71$60.95 R $60.95 $60.95 R $60.95 $67.72 R $68.38 $66.31 R $66.98 $69.05 $68.38 R $68.38$86.19 R $86.19 $92.19 R $92.19 $96.28 R $97.27 $96.28 R $97.27 $124.44 $97.27 R $97.27

$2,043.83 $2,043.83 $2,043.83 $2,043.83 $2,051.23 $2,043.83$204.36 $204.36 $204.36 $204.36 $205.13 $204.36

$1,532.83 $1,532.83 $1,532.83 $1,532.83 $1,538.45 $1,532.83$93.02 R $93.02 $98.94 R $98.94 $100.52 R $103.42 $100.52 R $103.42 $131.86 $93.02 R $93.02

$137.36 R $137.36 $146.40 R $146.40 $130.85 R $136.13 $141.12 R $146.40 $165.03 $144.07 R $144.07$82.20 $81.39 $82.20 $82.20 $94.84 $82.20

$400.29 $400.29 $470.93 $470.93 $469.26 $400.29



HCPCS 1st Mod 2nd Mod CategoryK0011 RR KF CRK0011 RR CRK0012 RR CRK0015 RR KE CRK0015 RR KU CRK0015 RR CRK0017 NU KE INK0017 NU KU INK0017 NU INK0017 RR KE INK0017 RR KU INK0017 RR INK0017 UE KE INK0017 UE KU INK0017 UE INK0018 NU KE INK0018 NU KU INK0018 NU INK0018 RR KE INK0018 RR KU INK0018 RR INK0018 UE KE INK0018 UE KU INK0018 UE INK0019 NU KE INK0019 NU KU INK0019 NU INK0019 RR KE INK0019 RR KU INK0019 RR INK0019 UE KE INK0019 UE KU INK0019 UE INK0020 NU KE INK0020 NU KU INK0020 NU INK0020 RR KE INK0020 RR KU INK0020 RR INK0020 UE KE INK0020 UE KU INK0020 UE INK0037 NU KE INK0037 NU KU INK0037 NU INK0037 RR KE INK0037 RR KU INK0037 RR INK0037 UE KE INK0037 UE KU INK0037 UE INK0038 NU KE INK0038 NU KU INK0038 NU INK0038 RR KE INK0038 RR KU INK0038 RR INK0038 UE KE INK0038 UE KU INK0038 UE INK0039 NU KE IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$582.55 $628.76 $574.69 $628.76 $628.76 $626.05$524.70 $566.33 $517.61 $566.33 $566.33 $563.86$321.88 $359.21 $317.51 $359.21 $421.24 $345.89

$16.82 R $17.43 $16.82 R $17.43 $16.80 R $17.43 $16.80 R $17.43 $20.56 $16.82 R $17.43$17.31 $17.31 $17.31 $17.31 $20.78 $17.31$15.42 R $16.03 $15.42 R $16.03 $15.40 R $16.03 $15.40 R $16.03 $18.89 $15.42 R $16.03$50.07 $50.07 $50.07 $50.07 $55.71 $50.07$48.69 $48.69 $48.69 $48.69 $58.42 $48.69$46.16 $46.16 $46.16 $46.16 $51.02 $46.16

$5.00 $5.00 $5.00 $5.00 $5.57 $5.00$4.87 $4.87 $4.87 $4.87 $5.86 $4.87$4.62 $4.62 $4.62 $4.62 $5.11 $4.62

$37.56 $37.56 $37.56 $37.56 $41.78 $37.56$36.52 $36.52 $36.52 $36.52 $43.81 $36.52$34.62 $34.62 $34.62 $34.62 $38.27 $34.62$28.12 $28.12 $28.12 $28.12 $31.27 $28.12$27.20 $27.20 $27.20 $27.20 $32.64 $27.20$25.93 $25.93 $25.93 $25.93 $28.65 $25.93

$2.80 $2.80 $2.80 $2.80 $3.14 $2.80$2.71 $2.71 $2.71 $2.71 $3.28 $2.71$2.59 $2.59 $2.59 $2.59 $2.87 $2.59

$21.09 $21.09 $21.09 $21.09 $23.46 $21.09$20.41 $20.41 $20.41 $20.41 $24.49 $20.41$19.45 $19.45 $19.45 $19.45 $21.50 $19.45$15.66 R $16.50 $15.44 R $16.27 $15.33 R $16.50 $15.32 R $16.49 $18.65 $15.63 R $16.47$16.41 $16.05 $16.41 $16.39 $18.69 $16.36$14.34 R $15.18 $14.16 R $14.99 $14.01 R $15.18 $14.00 R $15.17 $17.16 $14.32 R $15.15

$1.56 R $1.65 $1.54 R $1.63 $1.53 R $1.65 $1.53 R $1.64 $1.86 $1.56 R $1.64$1.64 $1.61 $1.64 $1.63 $1.85 $1.63$1.44 R $1.52 $1.42 R $1.50 $1.40 R $1.52 $1.40 R $1.51 $1.71 $1.43 R $1.51

$11.75 R $12.38 $11.59 R $12.21 $11.50 R $12.38 $11.49 R $12.37 $14.00 $11.71 R $12.34$12.32 $12.03 $12.32 $12.30 $14.03 $12.27$10.76 R $11.39 $10.62 R $11.24 $10.51 R $11.39 $10.50 R $11.38 $12.88 $10.74 R $11.36$47.05 $47.05 $47.05 $47.05 $52.19 $47.05$44.27 $44.27 $44.27 $44.27 $53.12 $44.27$43.51 $43.51 $43.51 $43.51 $47.93 $43.51

$4.71 $4.71 $4.71 $4.71 $5.21 $4.71$4.43 $4.43 $4.43 $4.43 $5.29 $4.43$4.35 $4.35 $4.35 $4.35 $4.78 $4.35

$35.28 $35.28 $35.28 $35.28 $39.16 $35.28$33.20 $33.20 $33.20 $33.20 $39.87 $33.20$32.63 $32.63 $32.63 $32.63 $35.97 $32.63$43.15 $43.15 $43.65 $47.14 $58.66 $43.15$39.01 $39.01 $39.87 $45.89 $65.74 $39.01$39.00 $39.00 $39.87 $43.47 $53.39 $39.00

$4.05 $4.05 $4.38 $4.44 $6.81 $4.05$3.48 $3.48 $3.99 $4.09 $8.20 $3.48$3.48 $3.48 $3.99 $4.09 $6.15 $3.48

$32.37 $32.37 $32.73 $35.37 $44.00 $32.37$29.27 $29.27 $29.87 $34.43 $49.28 $29.27$29.26 $29.26 $29.87 $32.61 $40.04 $29.26$24.31 $24.31 $24.31 $24.31 $27.01 $24.31$23.13 $23.13 $23.13 $23.13 $27.76 $23.13$22.47 $22.47 $22.47 $22.47 $24.78 $22.47

$2.44 $2.44 $2.44 $2.44 $2.69 $2.44$2.31 $2.31 $2.31 $2.31 $2.76 $2.31$2.25 $2.25 $2.25 $2.25 $2.47 $2.25

$18.24 $18.24 $18.24 $18.24 $20.25 $18.24$17.33 $17.33 $17.33 $17.33 $20.81 $17.33$16.84 $16.84 $16.84 $16.84 $18.58 $16.84$53.19 $53.19 $53.19 $53.19 $59.16 $53.19



HCPCS 1st Mod 2nd Mod CategoryK0039 NU KU INK0039 NU INK0039 RR KE INK0039 RR KU INK0039 RR INK0039 UE KE INK0039 UE KU INK0039 UE INK0040 NU KE INK0040 NU KU INK0040 NU INK0040 RR KE INK0040 RR KU INK0040 RR INK0040 UE KE INK0040 UE KU INK0040 UE INK0041 NU KE INK0041 NU KU INK0041 NU INK0041 RR KE INK0041 RR KU INK0041 RR INK0041 UE KE INK0041 UE KU INK0041 UE INK0042 NU KE INK0042 NU KU INK0042 NU INK0042 RR KE INK0042 RR KU INK0042 RR INK0042 UE KE INK0042 UE KU INK0042 UE INK0043 NU KE INK0043 NU KU INK0043 NU INK0043 RR KE INK0043 RR KU INK0043 RR INK0043 UE KE INK0043 UE KU INK0043 UE INK0044 NU KE INK0044 NU KU INK0044 NU INK0044 RR KE INK0044 RR KU INK0044 RR INK0044 UE KE INK0044 UE KU INK0044 UE INK0045 NU KE INK0045 NU KU INK0045 NU INK0045 RR KE INK0045 RR KU INK0045 RR INK0045 UE KE INK0045 UE KU IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$51.33 $51.33 $51.33 $51.33 $61.61 $51.33$49.08 $49.08 $49.08 $49.08 $54.22 $49.08

$5.33 $5.33 $5.33 $5.33 $5.92 $5.33$5.16 $5.16 $5.16 $5.16 $6.17 $5.16$4.92 $4.92 $4.92 $4.92 $5.42 $4.92

$39.90 $39.90 $39.90 $39.90 $44.38 $39.90$38.51 $38.51 $38.51 $38.51 $46.22 $38.51$36.81 $36.81 $36.81 $36.81 $40.67 $36.81$66.92 R $68.76 $66.92 R $68.76 $66.48 R $68.76 $66.48 R $68.76 $77.01 $66.92 R $68.76$71.15 $71.15 $71.15 $71.15 $85.37 $71.15$61.23 R $63.06 $61.23 R $63.06 $60.78 R $63.06 $60.78 R $63.06 $70.17 $61.23 R $63.06

$6.68 R $6.86 $6.68 R $6.86 $6.63 R $6.86 $6.63 R $6.86 $7.71 $6.68 R $6.86$7.10 $7.10 $7.10 $7.10 $8.55 $7.10$6.12 R $6.30 $6.12 R $6.30 $6.07 R $6.30 $6.07 R $6.30 $7.02 $6.12 R $6.30

$50.19 R $51.57 $50.19 R $51.57 $49.86 R $51.57 $49.86 R $51.57 $57.76 $50.19 R $51.57$53.34 $53.34 $53.34 $53.34 $64.04 $53.34$45.91 R $47.28 $45.91 R $47.28 $45.57 R $47.28 $45.57 R $47.28 $52.64 $45.91 R $47.28$51.62 $51.62 $51.62 $51.62 $57.49 $51.62$50.42 $50.42 $50.42 $50.42 $60.53 $50.42$47.58 $47.58 $47.58 $47.58 $52.64 $47.58

$5.18 $5.18 $5.18 $5.18 $5.74 $5.18$5.08 $5.08 $5.08 $5.08 $6.05 $5.08$4.78 $4.78 $4.78 $4.78 $5.26 $4.78

$38.72 $38.72 $38.72 $38.72 $43.12 $38.72$37.81 $37.81 $37.81 $37.81 $45.39 $37.81$35.69 $35.69 $35.69 $35.69 $39.47 $35.69$31.49 $31.49 $34.50 $34.50 $52.50 $34.50$29.51 $29.51 $34.72 $34.72 $65.74 $34.72$29.12 $29.12 $31.73 $31.73 $47.24 $31.73

$3.15 $3.15 $3.44 $3.44 $6.19 $3.44$2.95 $2.95 $3.47 $3.47 $8.20 $3.47$2.91 $2.91 $3.17 $3.17 $5.54 $3.17

$23.62 $23.62 $25.88 $25.88 $39.38 $25.88$22.13 $22.13 $26.03 $26.03 $49.28 $26.03$21.84 $21.84 $23.79 $23.79 $35.42 $23.79$19.67 $19.67 $19.67 $19.67 $21.81 $19.67$18.60 $18.60 $18.60 $18.60 $22.32 $18.60$18.17 $18.17 $18.17 $18.17 $20.03 $18.17

$1.97 $1.97 $1.97 $1.97 $2.19 $1.97$1.85 $1.85 $1.85 $1.85 $2.23 $1.85$1.81 $1.81 $1.81 $1.81 $2.00 $1.81

$14.76 $14.76 $14.76 $14.76 $16.36 $14.76$13.98 $13.98 $13.98 $13.98 $16.73 $13.98$13.65 $13.65 $13.65 $13.65 $15.02 $13.65$16.91 $16.91 $16.91 $16.91 $18.75 $16.91$15.86 $15.86 $15.86 $15.86 $19.01 $15.86$15.65 $15.65 $15.65 $15.65 $17.23 $15.65

$1.69 $1.69 $1.69 $1.69 $1.87 $1.69$1.59 $1.59 $1.59 $1.59 $1.89 $1.59$1.57 $1.57 $1.57 $1.57 $1.72 $1.57

$12.69 $12.69 $12.69 $12.69 $14.06 $12.69$11.89 $11.89 $11.89 $11.89 $14.25 $11.89$11.73 $11.73 $11.73 $11.73 $12.92 $11.73$56.69 $56.69 $56.69 $56.69 $62.95 $56.69$53.95 $53.95 $53.95 $53.95 $64.73 $53.95$52.36 $52.36 $52.36 $52.36 $57.75 $52.36

$5.77 $5.77 $5.77 $5.77 $6.29 $5.77$5.56 $5.56 $5.56 $5.56 $6.46 $5.56$5.32 $5.32 $5.32 $5.32 $5.77 $5.32

$42.52 $42.52 $42.52 $42.52 $47.21 $42.52$40.47 $40.47 $40.47 $40.47 $48.56 $40.47



HCPCS 1st Mod 2nd Mod CategoryK0045 UE INK0046 NU KE INK0046 NU KU INK0046 NU INK0046 RR KE INK0046 RR KU INK0046 RR INK0046 UE KE INK0046 UE KU INK0046 UE INK0047 NU KE INK0047 NU KU INK0047 NU INK0047 RR KE INK0047 RR KU INK0047 RR INK0047 UE KE INK0047 UE KU INK0047 UE INK0050 NU KE INK0050 NU INK0050 RR KE INK0050 RR INK0050 UE KE INK0050 UE INK0051 NU KE INK0051 NU KU INK0051 NU INK0051 RR KE INK0051 RR KU INK0051 RR INK0051 UE KE INK0051 UE KU INK0051 UE INK0052 NU KE INK0052 NU KU INK0052 NU INK0052 RR KE INK0052 RR KU INK0052 RR INK0052 UE KE INK0052 UE KU INK0052 UE INK0053 NU KE INK0053 NU KU INK0053 NU INK0053 RR KE INK0053 RR KU INK0053 RR INK0053 UE KE INK0053 UE KU INK0053 UE INK0056 NU KU INK0056 NU INK0056 RR KU INK0056 RR INK0056 UE KU INK0056 UE INK0065 NU KU INK0065 NU INK0065 RR KU IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$39.28 $39.28 $39.28 $39.28 $43.32 $39.28$19.73 $19.73 $19.73 $19.73 $21.87 $19.73$18.60 $18.60 $18.60 $18.60 $22.32 $18.60$18.23 $18.23 $18.23 $18.23 $20.09 $18.23

$1.97 $1.97 $1.97 $1.97 $2.19 $1.97$1.85 $1.85 $1.85 $1.85 $2.23 $1.85$1.82 $1.82 $1.82 $1.82 $2.01 $1.82

$14.80 $14.80 $14.80 $14.80 $16.41 $14.80$13.98 $13.98 $13.98 $13.98 $16.73 $13.98$13.69 $13.69 $13.69 $13.69 $15.07 $13.69$73.83 $73.83 $73.83 $73.83 $82.28 $73.83$72.87 $72.87 $72.87 $72.87 $87.45 $72.87$67.99 $67.99 $67.99 $67.99 $75.28 $67.99

$7.39 $7.39 $7.39 $7.39 $8.23 $7.39$7.31 $7.31 $7.31 $7.31 $8.74 $7.31$6.81 $6.81 $6.81 $6.81 $7.53 $6.81

$55.36 $55.36 $55.36 $55.36 $61.71 $55.36$54.63 $54.63 $54.63 $54.63 $65.58 $54.63$50.98 $50.98 $50.98 $50.98 $56.45 $50.98$32.61 $32.61 $32.61 $32.61 $36.20 $32.61$30.12 $30.12 $30.12 $30.12 $33.22 $30.12

$3.26 $3.26 $3.26 $3.26 $3.63 $3.26$3.01 $3.01 $3.01 $3.01 $3.33 $3.01

$24.46 $24.46 $24.46 $24.46 $27.16 $24.46$22.60 $22.60 $22.60 $22.60 $24.91 $22.60$52.23 $52.23 $52.23 $52.23 $58.05 $52.23$50.12 $50.12 $50.12 $50.12 $60.15 $50.12$48.22 $48.22 $48.22 $48.22 $53.23 $48.22

$5.24 $5.24 $5.24 $5.24 $5.80 $5.24$5.04 $5.04 $5.04 $5.04 $6.02 $5.04$4.84 $4.84 $4.84 $4.84 $5.32 $4.84

$39.17 $39.17 $39.17 $39.17 $43.54 $39.17$37.58 $37.58 $37.58 $37.58 $45.11 $37.58$36.16 $36.16 $36.16 $36.16 $39.92 $36.16$85.21 R $88.06 $85.21 R $88.06 $84.50 R $88.06 $84.50 R $88.06 $98.27 $85.21 R $88.06$88.09 $88.09 $88.09 $88.09 $105.71 $88.09$78.15 R $81.00 $78.15 R $81.00 $77.45 R $81.00 $77.45 R $81.00 $89.81 $78.15 R $81.00

$8.52 R $8.80 $8.52 R $8.80 $8.45 R $8.80 $8.45 R $8.80 $9.83 $8.52 R $8.80$8.80 $8.80 $8.80 $8.80 $10.57 $8.80$7.81 R $8.10 $7.81 R $8.10 $7.74 R $8.10 $7.74 R $8.10 $8.98 $7.81 R $8.10


$9.64 R $10.07 $9.64 R $10.07 $9.60 R $10.07 $9.60 R $10.07 $11.19 $9.64 R $10.07$9.71 $9.71 $9.71 $9.71 $11.65 $9.71$8.86 R $9.29 $8.86 R $9.29 $8.82 R $9.29 $8.82 R $9.29 $10.26 $8.86 R $9.29

$72.31 R $75.52 $72.31 R $75.52 $72.04 R $75.52 $72.04 R $75.52 $83.98 $72.31 R $75.52$72.90 $72.90 $72.90 $72.90 $87.50 $72.90$66.46 R $69.67 $66.46 R $69.67 $66.18 R $69.67 $66.18 R $69.67 $76.97 $66.46 R $69.67

$105.14 $105.14 $105.14 $105.14 $126.16 $105.14$97.86 R $101.38 $97.86 R $101.38 $95.94 R $101.38 $95.94 R $101.38 $114.58 $97.86 R $101.38$10.52 $10.52 $10.52 $10.52 $12.61 $10.52

$9.79 R $10.14 $9.79 R $10.14 $9.60 R $10.14 $9.60 R $10.14 $11.45 $9.79 R $10.14$78.87 $78.87 $78.87 $78.87 $94.61 $78.87$73.41 R $76.04 $73.41 R $76.04 $71.96 R $76.04 $71.96 R $76.04 $85.93 $73.41 R $76.04$49.14 $49.14 $49.14 $49.14 $58.98 $49.14$46.06 R $48.86 $46.06 R $48.86 $46.45 R $48.86 $46.45 R $48.86 $53.78 $46.06 R $48.86

$4.92 $4.92 $4.92 $4.92 $5.92 $4.92



HCPCS 1st Mod 2nd Mod CategoryK0065 RR INK0065 UE KU INK0065 UE INK0069 NU KU INK0069 NU INK0069 RR KU INK0069 RR INK0069 UE KU INK0069 UE INK0070 RR KU CRK0070 RR CRK0071 NU KU INK0071 NU INK0071 RR KU INK0071 RR INK0071 UE KU INK0071 UE INK0072 NU KU INK0072 NU INK0072 RR KU INK0072 RR INK0072 UE KU INK0072 UE INK0073 NU KU INK0073 NU INK0073 RR KU INK0073 RR INK0073 UE KU INK0073 UE INK0077 NU KU INK0077 NU INK0077 RR KU INK0077 RR INK0077 UE KU INK0077 UE INK0098 NU KE INK0098 NU KU INK0098 NU INK0098 RR KE INK0098 RR KU INK0098 RR INK0098 UE KE INK0098 UE KU INK0098 UE INK0105 NU KU INK0105 NU INK0105 RR KU INK0105 RR INK0105 UE KU INK0105 UE INK0195 RR KE CRK0195 RR CRK0455 RR FSK0552 SUK0601 NU INK0602 NU INK0603 NU INK0604 NU INK0605 NU INK0606 RR KF CRK0607 RR KF CR

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$4.61 R $4.89 $4.61 R $4.89 $4.65 R $4.89 $4.65 R $4.89 $5.39 $4.61 R $4.89$36.86 $36.86 $36.86 $36.86 $44.23 $36.86$34.55 R $36.65 $34.55 R $36.65 $34.84 R $36.65 $34.84 R $36.65 $40.33 $34.55 R $36.65

$110.48 $110.48 $110.48 $110.48 $132.52 $110.48$100.32 R $104.80 $100.32 R $104.80 $99.45 R $104.80 $99.45 R $104.80 $120.76 $100.32 R $104.80

$11.50 $11.36 $11.50 $11.50 $13.25 $11.50$10.26 R $10.71 $10.19 R $10.64 $10.17 R $10.71 $10.17 R $10.71 $12.07 $10.26 R $10.71$82.85 $82.85 $82.85 $82.85 $99.42 $82.85$75.23 R $78.59 $75.23 R $78.59 $74.58 R $78.59 $74.58 R $78.59 $90.59 $75.23 R $78.59$20.27 $20.27 $20.27 $20.27 $24.30 $20.27$18.09 R $18.45 $18.09 R $18.45 $17.65 R $18.45 $17.65 R $18.45 $22.10 $18.09 R $18.45

$120.77 $120.77 $120.77 $120.77 $144.94 $120.77$111.55 R $117.65 $111.55 R $117.65 $111.84 R $117.65 $111.84 R $117.65 $131.97 $111.55 R $117.65

$12.09 $12.09 $12.09 $12.09 $14.50 $12.09$11.16 R $11.77 $11.16 R $11.77 $11.19 R $11.77 $11.19 R $11.77 $13.20 $11.16 R $11.77$90.56 $90.56 $90.56 $90.56 $108.68 $90.56$83.65 R $88.23 $83.65 R $88.23 $83.87 R $88.23 $83.87 R $88.23 $98.97 $83.65 R $88.23$72.71 $72.71 $72.71 $72.71 $87.23 $72.71$68.32 R $71.81 $68.32 R $71.81 $68.58 R $71.81 $68.58 R $71.81 $79.07 $68.32 R $71.81

$7.27 $7.27 $7.27 $7.27 $8.72 $7.27$6.83 R $7.18 $6.83 R $7.18 $6.86 R $7.18 $6.86 R $7.18 $7.90 $6.83 R $7.18

$54.52 $54.52 $54.52 $54.52 $65.45 $54.52$51.23 R $53.86 $51.23 R $53.86 $51.43 R $53.86 $51.43 R $53.86 $59.32 $51.23 R $53.86$38.48 $38.12 $38.48 $38.48 $44.42 $38.48$35.96 R $37.80 $35.78 R $37.62 $35.72 R $37.80 $35.72 R $37.80 $40.77 $35.96 R $37.80

$3.85 $3.82 $3.85 $3.85 $4.43 $3.85$3.60 R $3.78 $3.58 R $3.77 $3.58 R $3.78 $3.58 R $3.78 $4.07 $3.60 R $3.78

$28.85 $28.57 $28.85 $28.85 $33.30 $28.85$26.97 R $28.35 $26.83 R $28.20 $26.79 R $28.35 $26.79 R $28.35 $30.57 $26.97 R $28.35$65.07 $65.07 $65.07 $65.07 $78.06 $65.07$58.58 R $60.58 $58.58 R $60.58 $57.96 R $60.58 $57.96 R $60.58 $71.03 $58.58 R $60.58

$6.49 $6.49 $6.49 $6.49 $7.81 $6.49$5.85 R $6.05 $5.85 R $6.05 $5.79 R $6.05 $5.79 R $6.05 $7.10 $5.85 R $6.05

$48.78 $48.78 $48.78 $48.78 $58.54 $48.78$43.93 R $45.43 $43.93 R $45.43 $43.46 R $45.43 $43.46 R $45.43 $53.27 $43.93 R $45.43$26.21 R $27.50 $26.21 R $27.50 $26.29 R $27.50 $26.29 R $27.50 $29.98 $26.21 R $27.50$25.93 $25.93 $25.93 $25.93 $30.19 $25.93$24.13 R $25.43 $24.13 R $25.43 $24.22 R $25.43 $24.22 R $25.43 $27.56 $24.13 R $25.43

$2.62 R $2.75 $2.62 R $2.75 $2.63 R $2.75 $2.63 R $2.75 $3.00 $2.62 R $2.75$2.60 $2.60 $2.60 $2.60 $3.02 $2.60$2.42 R $2.55 $2.42 R $2.55 $2.43 R $2.55 $2.43 R $2.55 $2.76 $2.42 R $2.55

$19.65 R $20.62 $19.65 R $20.62 $19.72 R $20.62 $19.72 R $20.62 $22.50 $19.65 R $20.62$19.42 $19.42 $19.42 $19.42 $22.66 $19.42$18.09 R $19.06 $18.09 R $19.06 $18.16 R $19.06 $18.16 R $19.06 $20.68 $18.09 R $19.06

$109.92 $109.92 $109.92 $109.92 $131.89 $109.92$102.12 R $107.20 $102.12 R $107.20 $101.90 R $107.20 $101.90 R $107.20 $119.95 $102.12 R $107.20

$10.99 $10.99 $10.99 $10.99 $13.20 $10.99$10.21 R $10.72 $10.21 R $10.72 $10.19 R $10.72 $10.19 R $10.72 $12.00 $10.21 R $10.72$82.44 $82.44 $82.44 $82.44 $98.95 $82.44$76.59 R $80.40 $76.59 R $80.40 $76.42 R $80.40 $76.42 R $80.40 $89.98 $76.59 R $80.40$16.11 R $16.45 $17.08 R $17.41 $15.57 R $16.29 $16.69 R $17.41 $19.74 $16.90 R $17.24$14.63 R $14.96 $15.47 R $15.81 $14.12 R $14.84 $15.09 R $15.81 $17.82 $15.31 R $15.65

$264.08 $292.81 $258.82 $292.81 $343.40 $292.81$2.77 $2.75 $2.77 $2.77 $3.02 $2.77$1.20 $1.20 $1.20 $1.20 $1.32 $1.20$6.84 $6.84 $6.84 $6.84 $7.56 $6.84$0.61 $0.61 $0.61 $0.61 $0.69 $0.61$6.57 $6.57 $6.57 $6.57 $7.26 $6.57

$15.74 $15.74 $15.74 $15.74 $17.36 $15.74$2,783.98 $2,783.98 $2,783.98 $2,783.98 $2,783.98 $2,783.98

$23.84 $23.84 $23.84 $23.84 $28.60 $23.84



HCPCS 1st Mod 2nd Mod CategoryK0607 RR CRK0608 NU KF INK0608 NU INK0608 RR KF INK0608 RR INK0608 UE KF INK0608 UE INK0609 KF SUK0609 SUK0672 POK0730 RR CRK0733 NU KE INK0733 NU KU INK0733 NU INK0733 RR KE INK0733 RR KU INK0733 RR INK0733 UE KE INK0733 UE KU INK0733 UE INK0738 RR OXK0800 NU INK0800 RR INK0800 UE INK0801 NU INK0801 RR INK0801 UE INK0802 NU INK0802 RR INK0802 UE INK0806 NU INK0806 RR INK0806 UE INK0807 NU INK0807 RR INK0807 UE INK0808 NU INK0808 RR INK0808 UE INK0813 RR CRK0814 RR CRK0815 RR CRK0816 RR CRK0820 RR CRK0821 RR CRK0822 RR CRK0823 RR CRK0824 RR CRK0825 RR CRK0826 RR CRK0827 RR CRK0828 RR CRK0829 RR CRK0835 RR CRK0836 RR CRK0837 RR CRK0838 RR CRK0839 RR CRK0840 RR CRK0841 RR CRK0842 RR CR

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$21.48 $21.48 $21.48 $21.48 $25.78 $21.48$148.79 $148.79 $148.79 $148.79 $178.49 $148.79$133.99 $133.99 $133.99 $133.99 $160.78 $133.99

$14.90 $14.90 $14.90 $14.90 $17.84 $14.90$13.43 $13.43 $13.43 $13.43 $16.08 $13.43

$111.58 $111.58 $111.58 $111.58 $133.90 $111.58$100.50 $100.50 $100.50 $100.50 $120.61 $100.50$989.39 $989.39 $989.39 $989.39 $1,187.29 $989.39$891.13 $891.13 $891.13 $891.13 $1,069.39 $891.13

$81.28 $81.28 $81.27 $81.27 $86.79 $81.28$190.59 $190.59 $190.59 $190.59 $190.59 $190.59

$30.00 R $31.55 $30.00 R $31.55 $30.05 R $31.55 $30.05 R $31.55 $34.87 $30.00 R $31.55$28.78 $28.78 $28.78 $28.78 $34.55 $28.78$27.68 R $28.78 $27.68 R $28.78 $27.74 R $28.78 $27.74 R $28.78 $32.12 $27.68 R $28.78

$3.01 R $3.17 $3.01 R $3.17 $3.02 R $3.17 $3.02 R $3.17 $3.49 $3.01 R $3.17$2.90 $2.90 $2.90 $2.90 $3.47 $2.90$2.78 R $2.90 $2.78 R $2.90 $2.78 R $2.90 $2.78 R $2.90 $3.22 $2.78 R $2.90


$1,031.00 R $1,058.65 $1,031.00 R $1,058.65 $1,016.49 R $1,058.65 $1,016.49 R $1,058.65 $1,120.24 $1,031.00 R $1,058.65$103.11 R $105.87 $103.11 R $105.87 $101.66 R $105.87 $101.66 R $105.87 $112.02 $103.11 R $105.87$773.25 R $793.99 $773.25 R $793.99 $762.37 R $793.99 $762.37 R $793.99 $840.17 $773.25 R $793.99

$1,738.27 R $1,801.60 $1,738.27 R $1,801.60 $1,709.04 R $1,801.60 $1,709.04 R $1,801.60 $1,900.89 $1,738.27 R $1,801.60$173.81 R $180.15 $173.81 R $180.15 $170.89 R $180.15 $170.89 R $180.15 $190.09 $173.81 R $180.15

$1,303.71 R $1,351.20 $1,303.71 R $1,351.20 $1,281.78 R $1,351.20 $1,281.78 R $1,351.20 $1,425.66 $1,303.71 R $1,351.20$2,098.31 R $2,190.53 $2,098.31 R $2,190.53 $2,082.23 R $2,190.53 $2,082.23 R $2,190.53 $2,302.90 $2,098.31 R $2,190.53

$209.83 R $219.05 $209.83 R $219.05 $208.22 R $219.05 $208.22 R $219.05 $230.29 $209.83 R $219.05$1,573.73 R $1,642.90 $1,573.73 R $1,642.90 $1,561.67 R $1,642.90 $1,561.67 R $1,642.90 $1,727.17 $1,573.73 R $1,642.90$1,391.75 $1,391.75 $1,391.75 $1,391.75 $1,466.28 $1,391.75

$139.17 $139.17 $139.17 $139.17 $146.62 $139.17$1,043.82 $1,043.82 $1,043.82 $1,043.82 $1,099.71 $1,043.82$2,132.76 $2,132.76 $2,132.76 $2,132.76 $2,245.82 $2,132.76

$213.28 $213.28 $213.28 $213.28 $224.57 $213.28$1,599.58 $1,599.58 $1,599.58 $1,599.58 $1,684.37 $1,599.58$3,298.44 $3,298.44 $3,298.44 $3,298.44 $3,473.36 $3,298.44

$329.84 $329.84 $329.84 $329.84 $347.32 $329.84$2,473.83 $2,473.83 $2,473.83 $2,473.83 $2,605.02 $2,473.83

$298.42 R $310.79 $298.42 R $310.79 $299.14 R $310.79 $299.14 R $310.79 $328.04 $298.42 R $310.79$355.31 R $366.34 $355.31 R $366.34 $354.00 R $366.34 $354.00 R $366.34 $388.40 $355.31 R $366.34$381.08 R $393.89 $381.08 R $393.89 $382.88 R $393.89 $382.88 R $393.89 $419.02 $381.08 R $393.89$380.43 R $389.97 $380.43 R $389.97 $377.78 R $389.97 $377.78 R $389.97 $414.06 $380.43 R $389.97$313.94 R $326.76 $313.94 R $326.76 $315.75 R $326.76 $315.75 R $326.76 $345.16 $313.94 R $326.76$376.35 R $385.98 $376.35 R $385.98 $373.50 R $385.98 $373.50 R $385.98 $409.61 $376.35 R $385.98$435.17 R $445.73 $435.17 R $445.73 $434.23 R $445.73 $434.23 R $445.73 $474.31 $435.17 R $445.73$428.08 R $437.40 $428.08 R $437.40 $424.68 R $437.40 $424.68 R $437.40 $466.17 $428.08 R $437.40$561.53 R $574.86 $561.53 R $574.86 $555.97 R $574.86 $555.97 R $574.86 $609.47 $561.53 R $574.86$512.68 R $528.40 $512.68 R $528.40 $512.63 R $528.40 $512.63 R $528.40 $570.14 $512.68 R $528.40$800.24 R $830.07 $800.24 R $830.07 $781.52 R $830.07 $781.52 R $830.07 $942.62 $800.24 R $830.07$690.30 R $713.72 $690.30 R $713.72 $674.86 R $713.72 $674.86 R $713.72 $801.49 $690.30 R $713.72$902.50 R $963.75 $902.50 R $963.75 $920.72 R $963.75 $920.72 R $963.75 $1,038.65 $902.50 R $963.75$861.73 R $906.70 $861.73 R $906.70 $866.71 R $906.70 $866.71 R $906.70 $954.50 $861.73 R $906.70$456.11 $456.11 $456.11 $456.11 $485.12 $456.11$473.04 $473.04 $473.04 $473.04 $503.10 $473.04$559.19 $559.19 $559.19 $559.19 $593.80 $559.19$498.48 $498.48 $498.48 $498.48 $529.46 $498.48$731.13 $731.13 $731.13 $731.13 $775.94 $731.13

$1,113.40 $1,113.40 $1,113.40 $1,113.40 $1,181.30 $1,113.40$495.88 $495.88 $495.88 $495.88 $526.73 $495.88$495.60 $495.60 $495.60 $495.60 $526.46 $495.60



HCPCS 1st Mod 2nd Mod CategoryK0843 RR CRK0848 RR CRK0849 RR CRK0850 RR CRK0851 RR CRK0852 RR CRK0853 RR CRK0854 RR CRK0855 RR CRK0856 RR CRK0857 RR CRK0858 RR CRK0859 RR CRK0860 RR CRK0861 RR KF CRK0861 RR CRK0862 RR CRK0863 RR CRK0864 RR CRK0901 POK0902 POL0112 POL0113 POL0120 POL0130 POL0140 POL0150 POL0160 POL0170 POL0172 POL0174 POL0180 POL0190 POL0200 POL0220 POL0450 POL0454 POL0455 POL0456 POL0457 POL0458 POL0460 POL0462 POL0464 POL0466 POL0467 POL0468 POL0469 POL0470 POL0472 POL0480 POL0482 POL0484 POL0486 POL0488 POL0490 POL0491 POL0492 POL0621 POL0622 POL0625 PO

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$593.54 $593.54 $593.54 $593.54 $630.70 $593.54$755.28 $755.28 $755.28 $755.28 $830.82 $755.28$726.16 $726.16 $726.16 $726.16 $798.80 $726.16$876.10 $876.10 $876.10 $876.10 $963.71 $876.10$842.37 $842.37 $842.37 $842.37 $926.62 $842.37

$1,012.27 $1,012.27 $1,012.27 $1,012.27 $1,113.53 $1,012.27$1,039.86 $1,039.86 $1,039.86 $1,039.86 $1,143.86 $1,039.86$1,377.59 $1,377.59 $1,377.59 $1,377.59 $1,515.36 $1,377.59$1,301.34 $1,301.34 $1,301.34 $1,301.34 $1,431.48 $1,301.34

$810.71 $810.71 $810.71 $810.71 $891.80 $810.71$826.96 $826.96 $826.96 $826.96 $909.65 $826.96

$1,005.86 $1,005.86 $1,005.86 $1,005.86 $1,106.46 $1,005.86$959.28 $959.28 $959.28 $959.28 $1,055.19 $959.28

$1,436.99 $1,436.99 $1,436.99 $1,436.99 $1,580.72 $1,436.99$1,045.98 $1,045.98 $1,045.98 $1,045.98 $1,150.58 $1,045.98

$812.01 $812.01 $812.01 $812.01 $893.21 $812.01$1,005.86 $1,005.86 $1,005.86 $1,005.86 $1,106.46 $1,005.86$1,436.99 $1,436.99 $1,436.99 $1,436.99 $1,580.72 $1,436.99$1,710.03 $1,710.03 $1,710.03 $1,710.03 $1,881.04 $1,710.03

$860.01 $860.01 $859.93 $859.93 $918.39 $860.01$897.78 $897.78 $834.93 $834.93 $856.46 $897.78

$1,341.53 $1,341.53 $1,341.41 $1,341.41 $1,432.57 $1,341.53$273.35 $273.35 $273.33 $273.33 $291.91 $273.35

$26.81 $26.81 $23.65 $23.65 $44.29 $26.81$193.91 $193.91 $145.43 $145.43 $569.24 $193.91

$66.91 $66.91 $58.22 $58.22 $110.74 $66.91$111.58 $111.58 $96.33 $96.33 $125.52 $111.58$158.87 $158.87 $186.15 $186.15 $141.76 $158.87$672.28 $672.28 $609.73 $609.73 $566.28 $672.28$136.31 $136.31 $125.63 $125.63 $118.14 $136.31$244.87 $244.87 $244.87 $244.87 $191.97 $244.87$333.02 $333.02 $366.92 $366.92 $369.77 $333.02$501.32 $501.32 $475.13 $475.13 $510.76 $501.32$460.32 $460.32 $530.91 $530.91 $510.76 $460.32$109.17 $109.17 $145.56 $145.56 $140.31 $109.17$180.23 $180.23 $154.92 $154.92 $201.60 $180.23$332.42 $332.42 $332.39 $332.39 $355.00 $332.42$332.42 $332.42 $332.39 $332.39 $355.00 $332.42$953.30 $953.30 $953.21 $953.21 $1,017.98 $953.30$953.30 $953.30 $953.21 $953.21 $1,017.98 $953.30$854.82 $854.82 $854.75 $854.75 $912.84 $854.82$962.18 $962.18 $962.10 $962.10 $1,027.42 $962.18

$1,196.77 $1,196.77 $1,196.64 $1,196.64 $1,277.97 $1,196.77$1,424.74 $1,424.74 $1,424.60 $1,424.60 $1,521.41 $1,424.74

$366.36 $366.36 $381.59 $381.59 $214.13 $366.36$366.36 $366.36 $381.59 $381.59 $214.13 $366.36$459.32 $459.32 $441.79 $441.79 $1,018.88 $459.32$459.32 $459.32 $441.79 $441.79 $1,018.88 $459.32$653.94 $653.94 $568.31 $568.31 $453.39 $653.94$410.48 $410.48 $396.70 $396.70 $959.82 $410.48

$1,269.29 $1,269.29 $1,366.87 $1,366.87 $1,585.83 $1,269.29$1,455.08 $1,455.08 $1,382.30 $1,382.30 $1,845.76 $1,455.08$1,696.59 $1,696.59 $1,584.13 $1,584.13 $2,067.27 $1,696.59$1,680.68 $1,680.68 $1,709.39 $1,709.39 $2,879.42 $1,680.68

$962.18 $962.18 $962.10 $962.10 $1,027.42 $962.18$271.13 $271.13 $271.10 $271.10 $315.81 $271.13$736.10 $736.10 $736.05 $736.05 $786.06 $736.10$477.07 $477.07 $477.04 $477.04 $502.54 $477.07

$85.47 $85.47 $89.04 $89.04 $87.09 $85.47$231.75 $231.75 $230.28 $230.28 $206.00 $231.75

$52.82 $52.82 $52.81 $52.81 $56.39 $52.82



HCPCS 1st Mod 2nd Mod CategoryL0626 POL0627 POL0628 POL0630 POL0631 POL0633 POL0635 POL0636 POL0637 POL0638 POL0639 POL0640 POL0641 POL0642 POL0643 POL0648 POL0649 POL0650 POL0651 POL0700 POL0710 POL0810 POL0820 POL0830 POL0859 POL0861 POL0970 POL0972 POL0974 POL0976 POL0978 POL0980 POL0982 POL0984 POL1000 POL1005 POL1010 POL1020 POL1025 POL1030 POL1040 POL1050 POL1060 POL1070 POL1080 POL1085 POL1090 POL1100 POL1110 POL1120 POL1200 POL1210 POL1220 POL1230 POL1240 POL1250 POL1260 POL1270 POL1280 POL1290 POL1300 PO

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$74.72 $74.72 $74.71 $74.71 $79.77 $74.72$394.01 $394.01 $393.97 $393.97 $420.73 $394.01

$80.39 $80.39 $80.39 $80.39 $85.86 $80.39$155.21 $155.21 $155.20 $155.20 $165.75 $155.21$983.97 $983.97 $983.90 $983.90 $1,050.70 $983.97$274.86 $274.86 $274.84 $274.84 $293.48 $274.86

$1,019.23 $1,019.23 $948.28 $948.28 $1,015.47 $1,019.23$1,503.93 $1,503.93 $1,285.52 $1,285.52 $1,177.65 $1,503.93$1,304.86 $1,304.86 $1,164.37 $1,164.37 $1,107.47 $1,304.86$1,264.17 $1,264.17 $1,264.04 $1,264.04 $1,349.94 $1,264.17$1,304.86 $1,304.86 $1,164.37 $1,164.37 $1,107.47 $1,304.86$1,002.97 $1,002.97 $1,002.83 $1,002.83 $1,071.00 $1,002.97

$74.72 $74.72 $74.71 $74.71 $79.77 $74.72$394.01 $394.01 $393.97 $393.97 $420.73 $394.01$155.21 $155.21 $155.20 $155.20 $165.75 $155.21$983.97 $983.97 $983.90 $983.90 $1,050.70 $983.97$274.86 $274.86 $274.84 $274.84 $293.48 $274.86

$1,304.86 $1,304.86 $1,164.37 $1,164.37 $1,107.47 $1,304.86$1,304.86 $1,304.86 $1,164.37 $1,164.37 $1,107.47 $1,304.86$2,063.66 $2,063.66 $1,829.26 $1,829.26 $1,253.20 $2,063.66$2,252.62 $2,252.62 $1,970.58 $1,970.58 $1,332.49 $2,252.62$2,393.08 $2,393.08 $2,441.30 $2,441.30 $2,101.96 $2,393.08$1,935.90 $1,935.90 $2,059.38 $2,059.38 $1,364.40 $1,935.90$2,795.23 $2,795.23 $3,299.61 $3,299.61 $2,379.56 $2,795.23$1,085.93 $1,085.93 $1,447.90 $1,447.90 $1,098.62 $1,085.93

$206.59 $206.59 $206.58 $206.58 $220.59 $206.59$101.88 $101.88 $129.60 $129.60 $63.36 $101.88$104.14 $104.14 $118.51 $118.51 $63.36 $104.14$212.79 $212.79 $179.15 $179.15 $103.24 $212.79$190.04 $190.04 $167.76 $167.76 $103.24 $190.04$171.59 $171.59 $175.75 $175.75 $63.36 $171.59

$15.57 $15.57 $20.76 $20.76 $13.54 $15.57$16.96 $16.96 $19.35 $19.35 $13.54 $16.96$54.12 $54.12 $54.12 $54.12 $66.69 $54.12

$1,809.74 $1,809.74 $1,967.54 $1,967.54 $2,259.23 $1,809.74$3,067.82 $3,067.82 $3,067.49 $3,067.49 $3,275.96 $3,067.82

$72.88 $72.88 $70.51 $70.51 $39.58 $72.88$99.58 $99.58 $97.69 $97.69 $51.70 $99.58

$113.18 $113.18 $111.16 $111.16 $251.03 $113.18$75.60 $75.60 $75.60 $75.60 $55.52 $75.60$91.00 $91.00 $79.04 $79.04 $39.70 $91.00$78.79 $78.79 $95.68 $95.68 $39.70 $78.79$88.88 $88.88 $92.85 $92.85 $63.36 $88.88$90.87 $90.87 $90.82 $90.82 $53.16 $90.87$62.97 $62.97 $51.09 $51.09 $15.79 $62.97

$174.92 $174.92 $154.29 $154.29 $143.23 $174.92$81.71 $81.71 $91.37 $91.37 $55.52 $81.71

$144.23 $144.23 $157.49 $157.49 $71.31 $144.23$244.30 $244.30 $229.69 $229.69 $142.78 $244.30

$38.92 $38.92 $41.63 $41.63 $22.29 $38.92$1,549.14 $1,549.14 $1,606.29 $1,606.29 $1,427.71 $1,549.14

$233.24 $233.24 $233.24 $233.24 $482.13 $233.24$197.48 $197.48 $225.72 $225.72 $497.35 $197.48$506.72 $506.72 $506.72 $506.72 $887.88 $506.72

$87.20 $87.20 $74.74 $74.74 $64.57 $87.20$85.87 $85.87 $72.51 $72.51 $49.57 $85.87$88.24 $88.24 $72.96 $72.96 $49.57 $88.24$88.14 $88.14 $70.15 $70.15 $57.06 $88.14$78.56 $78.56 $76.90 $76.90 $79.59 $78.56$89.07 $89.07 $70.06 $70.06 $58.54 $89.07

$1,489.02 $1,489.02 $1,716.35 $1,716.35 $2,178.03 $1,489.02




Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$1,532.20 $1,532.20 $1,653.38 $1,653.38 $1,744.99 $1,532.20$114.87 $114.87 $153.16 $153.16 $255.91 $114.87

$39.13 $39.13 $40.58 $40.58 $37.57 $39.13$128.86 $128.86 $119.43 $119.43 $123.14 $128.86$153.78 $153.78 $151.05 $151.05 $132.16 $153.78$411.32 $411.32 $473.65 $473.65 $885.99 $411.32$218.13 $218.13 $217.52 $217.52 $147.14 $218.13$341.69 $341.69 $341.66 $341.66 $364.84 $341.69$152.55 $152.55 $203.40 $203.40 $142.68 $152.55

$1,254.18 $1,254.18 $1,283.94 $1,283.94 $1,107.47 $1,254.18$1,323.38 $1,323.38 $1,060.30 $1,060.30 $1,255.14 $1,323.38

$887.81 $887.81 $813.13 $813.13 $1,181.32 $887.81$1,853.50 $1,853.50 $1,853.31 $1,853.31 $2,159.18 $1,853.50$1,541.99 $1,541.99 $1,529.06 $1,529.06 $1,402.78 $1,541.99$1,812.51 $1,812.51 $1,966.20 $1,966.20 $1,624.28 $1,812.51$1,338.91 $1,338.91 $1,458.63 $1,458.63 $332.23 $1,338.91$1,010.17 $1,010.17 $1,154.61 $1,154.61 $1,166.52 $1,010.17$1,470.33 $1,470.33 $1,411.30 $1,411.30 $1,624.28 $1,470.33

$116.04 $116.04 $95.34 $95.34 $104.99 $116.04$116.04 $116.04 $95.34 $95.34 $104.99 $116.04$115.58 $115.58 $128.25 $128.25 $134.80 $115.58

$96.68 $96.68 $77.98 $77.98 $99.08 $96.68$282.09 $282.09 $282.08 $282.08 $301.25 $282.09$722.59 $722.59 $541.94 $541.94 $1,255.14 $722.59$722.59 $722.59 $541.94 $541.94 $1,255.14 $722.59$850.11 $850.11 $691.96 $691.96 $1,402.78 $850.11$127.88 $127.88 $127.86 $127.86 $136.59 $127.88$893.61 $893.61 $1,007.10 $1,007.10 $1,181.32 $893.61$860.01 $860.01 $859.93 $859.93 $918.39 $860.01

$1,490.21 $1,490.21 $1,487.61 $1,487.61 $1,736.00 $1,490.21$897.78 $897.78 $834.93 $834.93 $856.46 $897.78

$1,139.13 $1,139.13 $1,046.28 $1,046.28 $1,294.01 $1,139.13$551.31 $551.31 $551.25 $551.25 $642.21 $551.31$551.31 $551.31 $551.25 $551.25 $642.21 $551.31$256.58 $256.58 $296.71 $296.71 $369.16 $256.58$995.18 $995.18 $974.86 $974.86 $1,261.16 $995.18$269.60 $269.60 $308.81 $308.81 $273.18 $269.60

$73.23 $73.23 $94.88 $94.88 $66.45 $73.23$419.17 $419.17 $419.17 $419.17 $457.75 $419.17$122.49 $122.49 $107.20 $107.20 $110.74 $122.49$539.33 $539.33 $539.29 $539.29 $575.94 $539.33$238.38 $238.38 $268.56 $268.56 $457.75 $238.38$311.63 $311.63 $322.66 $322.66 $590.63 $311.63$210.87 $210.87 $281.16 $281.16 $174.54 $210.87$855.32 $855.32 $855.26 $855.26 $913.34 $855.32$476.54 $476.54 $451.37 $451.37 $1,181.32 $476.54$875.13 $875.13 $825.16 $825.16 $605.41 $875.13$663.95 $663.95 $666.22 $666.22 $951.85 $663.95$804.97 $804.97 $804.90 $804.90 $859.56 $804.97$494.09 $494.09 $494.09 $494.09 $1,181.32 $494.09$730.79 $730.79 $634.29 $634.29 $1,000.48 $730.79$449.27 $449.27 $449.23 $449.23 $479.76 $449.27$327.15 $327.15 $341.98 $341.98 $317.36 $327.15$420.34 $420.34 $397.34 $397.34 $959.82 $420.34$904.13 $904.13 $904.13 $904.13 $967.99 $904.13

$3,927.66 $3,927.66 $3,927.25 $3,927.25 $4,194.13 $3,927.66$824.20 $824.20 $882.91 $882.91 $990.53 $824.20

$1,040.84 $1,040.84 $1,040.84 $1,040.84 $1,439.72 $1,040.84$903.03 $903.03 $912.97 $912.97 $1,110.43 $903.03

$1,968.09 $1,968.09 $2,012.62 $2,012.62 $2,211.33 $1,968.09$166.04 $166.04 $166.03 $166.03 $177.33 $166.04




Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$1,653.83 $1,653.83 $1,737.82 $1,737.82 $3,174.73 $1,653.83$1,524.10 $1,524.10 $1,484.71 $1,484.71 $2,295.38 $1,524.10$1,274.46 $1,274.46 $1,274.46 $1,274.46 $1,624.28 $1,274.46

$162.80 $162.80 $158.26 $158.26 $117.17 $162.80$433.54 $433.54 $503.70 $503.70 $488.04 $433.54$556.42 $556.42 $582.78 $582.78 $701.39 $556.42$159.84 $159.84 $120.77 $120.77 $132.89 $159.84$340.87 $340.87 $342.57 $342.57 $406.10 $340.87$420.16 $420.16 $415.18 $415.18 $406.10 $420.16$606.08 $606.08 $745.93 $745.93 $704.35 $606.08$952.42 $952.42 $1,036.31 $1,036.31 $775.21 $952.42$452.22 $452.22 $504.91 $504.91 $516.81 $452.22$517.40 $517.40 $584.48 $584.48 $819.53 $517.40$681.68 $681.68 $700.24 $700.24 $989.34 $681.68

$1,212.89 $1,212.89 $1,067.41 $1,067.41 $1,255.14 $1,212.89$1,528.51 $1,528.51 $1,528.51 $1,528.51 $1,402.78 $1,528.51

$719.07 $719.07 $811.20 $811.20 $1,107.47 $719.07$862.14 $862.14 $1,014.59 $1,014.59 $1,328.96 $862.14

$1,054.17 $1,054.17 $1,148.67 $1,148.67 $2,214.94 $1,054.17$104.39 $104.39 $139.19 $139.19 $73.83 $104.39

$81.70 $81.70 $102.26 $102.26 $36.93 $81.70$147.23 $147.23 $132.86 $132.86 $51.70 $147.23$163.15 $163.15 $134.20 $134.20 $81.23 $163.15$355.95 $355.95 $312.27 $312.27 $95.98 $355.95

$92.46 $92.46 $89.24 $89.24 $66.45 $92.46$317.83 $317.83 $351.58 $351.58 $287.96 $317.83

$42.38 $42.38 $56.50 $56.50 $51.70 $42.38$68.77 $68.77 $59.92 $59.92 $51.70 $68.77$78.96 $78.96 $77.88 $77.88 $73.83 $78.96$68.39 $68.39 $71.97 $71.97 $39.58 $68.39$92.60 $92.60 $92.60 $92.60 $92.60 $92.60$74.55 $74.55 $74.55 $74.55 $19.74 $74.55

$316.74 $316.74 $316.74 $316.74 $270.20 $316.74$178.69 $178.69 $184.41 $184.41 $575.87 $178.69$104.98 $104.98 $139.97 $139.97 $125.52 $104.98

$47.87 $47.87 $47.87 $47.87 $125.52 $47.87$116.48 $116.48 $116.47 $116.47 $143.56 $116.48$432.72 $432.72 $403.64 $403.64 $510.57 $432.72$244.26 $244.26 $320.00 $320.00 $47.55 $244.26$109.66 $109.66 $146.22 $146.22 $47.55 $109.66$183.41 $183.41 $200.10 $200.10 $198.23 $183.41$350.02 $350.02 $370.96 $370.96 $333.11 $350.02$205.91 $205.91 $202.50 $202.50 $110.74 $205.91$485.89 $485.89 $494.03 $494.03 $442.99 $485.89$794.28 $794.28 $846.38 $846.38 $1,031.26 $794.28

$46.12 $46.12 $61.49 $61.49 $75.10 $46.12$228.83 $228.83 $261.59 $261.59 $339.64 $228.83$100.72 $100.72 $134.29 $134.29 $66.45 $100.72$109.74 $109.74 $146.32 $146.32 $44.29 $109.74$119.40 $119.40 $154.15 $154.15 $39.58 $119.40$162.04 $162.04 $147.52 $147.52 $63.36 $162.04

$97.58 $97.58 $97.58 $97.58 $59.09 $97.58$148.98 $148.98 $185.96 $185.96 $59.09 $148.98$104.47 $104.47 $104.47 $104.47 $128.75 $104.47

$83.57 $83.57 $83.56 $83.56 $89.22 $83.57$116.44 $116.44 $116.42 $116.42 $124.35 $116.44$137.39 $137.39 $137.38 $137.38 $146.73 $137.39$137.39 $137.39 $137.38 $137.38 $146.73 $137.39

$90.90 $90.90 $101.46 $101.46 $95.98 $90.90$281.21 $281.21 $327.92 $327.92 $174.54 $281.21$752.92 $752.92 $743.75 $743.75 $1,110.43 $752.92




Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$410.64 $410.64 $469.52 $469.52 $664.48 $410.64$1,408.84 $1,408.84 $1,086.60 $1,086.60 $1,250.56 $1,408.84

$759.38 $759.38 $610.56 $610.56 $1,771.93 $759.38$209.44 $209.44 $211.16 $211.16 $277.62 $209.44$376.87 $376.87 $400.88 $400.88 $396.58 $376.87$256.01 $256.01 $256.01 $256.01 $110.74 $256.01$566.11 $566.11 $566.11 $566.11 $396.58 $566.11$536.63 $536.63 $413.70 $413.70 $475.91 $536.63$183.07 $183.07 $244.10 $244.10 $79.37 $183.07$216.48 $216.48 $288.64 $288.64 $103.24 $216.48$238.34 $238.34 $278.89 $278.89 $158.59 $238.34$273.36 $273.36 $364.47 $364.47 $140.31 $273.36$371.62 $371.62 $316.95 $316.95 $199.34 $371.62

$1,531.05 $1,531.05 $1,528.12 $1,528.12 $1,639.05 $1,531.05$1,798.50 $1,798.50 $1,493.44 $1,493.44 $1,624.28 $1,798.50

$220.73 $220.73 $261.01 $261.01 $627.57 $220.73$299.56 $299.56 $343.13 $343.13 $634.60 $299.56$106.97 $106.97 $128.86 $128.86 $39.58 $106.97$166.14 $166.14 $200.67 $200.67 $63.36 $166.14$152.06 $152.06 $202.74 $202.74 $39.58 $152.06$139.49 $139.49 $185.99 $185.99 $39.58 $139.49

$74.51 $74.51 $97.97 $97.97 $31.76 $74.51$125.27 $125.27 $125.26 $125.26 $133.76 $125.27

$54.16 $54.16 $72.21 $72.21 $38.98 $54.16$124.90 $124.90 $124.86 $124.86 $133.32 $124.90

$64.07 $64.07 $60.33 $60.33 $31.76 $64.07$37.67 $37.67 $28.25 $28.25 $36.17 $37.67$75.74 $75.74 $87.31 $87.31 $53.30 $75.74$95.08 $95.08 $95.08 $95.08 $81.23 $95.08$69.62 $69.62 $77.50 $77.50 $66.45 $69.62$77.41 $77.41 $77.41 $77.41 $310.08 $77.41$87.05 $87.05 $83.74 $83.74 $310.08 $87.05$48.58 $48.58 $51.92 $51.92 $44.29 $48.58$55.19 $55.19 $59.38 $59.38 $59.09 $55.19

$301.10 $301.10 $301.07 $301.07 $321.51 $301.10$126.76 $126.76 $126.75 $126.75 $135.38 $126.76$154.81 $154.81 $154.78 $154.78 $165.33 $154.81$167.00 $167.00 $166.99 $166.99 $178.34 $167.00$167.00 $167.00 $166.99 $166.99 $178.34 $167.00$190.17 $190.17 $190.14 $190.14 $203.04 $190.17

$73.16 $73.16 $73.15 $73.15 $78.13 $73.16$117.38 $117.38 $117.37 $117.37 $125.36 $117.38

$45.11 $45.11 $45.10 $45.10 $48.17 $45.11$45.11 $45.11 $45.10 $45.10 $48.17 $45.11$70.70 $70.70 $70.69 $70.69 $75.48 $70.70$30.48 $30.48 $30.47 $30.47 $32.54 $30.48$30.48 $30.48 $30.47 $30.47 $32.54 $30.48$39.02 $39.02 $39.02 $39.02 $41.65 $39.02$41.42 $41.42 $41.42 $41.42 $44.26 $41.42$85.34 $85.34 $85.34 $85.34 $91.12 $85.34$78.03 $78.03 $78.01 $78.01 $83.34 $78.03$48.77 $48.77 $48.76 $48.76 $52.07 $48.77$52.42 $52.42 $52.42 $52.42 $118.14 $52.42$60.30 $60.30 $61.45 $61.45 $107.09 $60.30$49.97 $49.97 $49.97 $49.97 $53.38 $49.97$78.03 $78.03 $78.01 $78.01 $83.34 $78.03

$542.44 $542.44 $542.41 $542.41 $579.21 $542.44$70.70 $70.70 $70.69 $70.69 $75.48 $70.70$36.56 $36.56 $36.56 $36.56 $39.05 $36.56$81.70 $81.70 $81.66 $81.66 $87.23 $81.70$21.92 $21.92 $21.92 $21.92 $23.40 $21.92




Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$34.13 $34.13 $34.13 $34.13 $36.44 $34.13$47.55 $47.55 $47.53 $47.53 $50.78 $47.55$47.55 $47.55 $47.53 $47.53 $50.78 $47.55$47.55 $47.55 $47.53 $47.53 $50.78 $47.55$39.02 $39.02 $39.02 $39.02 $41.65 $39.02$89.01 $89.01 $89.01 $89.01 $95.01 $89.01$52.40 $52.40 $52.40 $52.40 $55.95 $52.40

$153.59 $153.59 $153.58 $153.58 $164.05 $153.59$73.16 $73.16 $73.15 $73.15 $78.13 $73.16

$101.15 $101.15 $101.15 $101.15 $108.03 $101.15$39.02 $39.02 $39.02 $39.02 $41.65 $39.02$32.90 $32.90 $32.90 $32.90 $35.15 $32.90$56.07 $56.07 $56.07 $56.07 $59.88 $56.07$59.71 $59.71 $59.71 $59.71 $63.77 $59.71$59.71 $59.71 $59.71 $59.71 $63.77 $59.71$28.06 $28.06 $28.06 $28.06 $29.92 $28.06$28.06 $28.06 $28.06 $28.06 $29.92 $28.06$30.48 $30.48 $30.47 $30.47 $32.54 $30.48$30.48 $30.48 $30.47 $30.47 $32.54 $30.48$48.77 $48.77 $48.76 $48.76 $52.07 $48.77

$8.55 $8.55 $8.55 $8.55 $9.12 $8.55$21.92 $21.92 $21.92 $21.92 $23.40 $21.92$81.70 $81.70 $81.66 $81.66 $87.23 $81.70$62.16 $62.16 $62.16 $62.16 $66.39 $62.16$51.20 $51.20 $51.20 $51.20 $54.65 $51.20$40.22 $40.22 $40.21 $40.21 $42.96 $40.22$73.16 $73.16 $73.15 $73.15 $78.13 $73.16$96.30 $96.30 $96.30 $96.30 $102.83 $96.30$73.16 $73.16 $73.15 $73.15 $78.13 $73.16$96.30 $96.30 $96.30 $96.30 $102.83 $96.30$41.42 $41.42 $41.42 $41.42 $44.26 $41.42$52.21 $52.21 $56.69 $56.69 $73.83 $52.21$89.65 $89.65 $89.65 $89.65 $87.31 $89.65

$124.96 $124.96 $102.41 $102.41 $110.74 $124.96$785.99 $785.99 $785.94 $785.94 $839.33 $785.99

$1,031.11 $1,031.11 $1,031.02 $1,031.02 $1,101.07 $1,031.11$153.09 $153.09 $153.08 $153.08 $178.34 $153.09$251.89 $251.89 $251.88 $251.88 $268.97 $251.89$126.47 $126.47 $129.58 $129.58 $39.58 $126.47$630.98 $630.98 $661.81 $661.81 $301.34 $630.98$830.60 $830.60 $968.01 $968.01 $348.96 $830.60$933.47 $933.47 $1,242.98 $1,242.98 $959.82 $933.47$436.23 $436.23 $436.20 $436.20 $508.16 $436.23

$93.80 $93.80 $93.80 $93.80 $100.17 $93.80$692.57 $692.57 $610.67 $610.67 $339.55 $692.57$690.70 $690.70 $663.53 $663.53 $508.08 $690.70

$1,118.52 $1,118.52 $1,118.41 $1,118.41 $1,194.40 $1,118.52$1,184.44 $1,184.44 $1,184.32 $1,184.32 $1,264.82 $1,184.44

$396.24 $396.24 $396.21 $396.21 $423.15 $396.24$218.13 $218.13 $218.11 $218.11 $254.12 $218.13$291.36 $291.36 $291.48 $291.48 $371.75 $291.36$218.13 $218.13 $218.11 $218.11 $254.12 $218.13

$1,362.71 $1,362.71 $1,140.18 $1,140.18 $713.92 $1,362.71$1,527.95 $1,527.95 $1,401.77 $1,401.77 $951.85 $1,527.95$3,110.49 $3,110.49 $2,554.41 $2,554.41 $1,819.59 $3,110.49

$865.07 $865.07 $864.98 $864.98 $923.76 $865.07$367.98 $367.98 $344.67 $344.67 $295.32 $367.98

$52.26 $52.26 $52.26 $52.26 $38.73 $52.26$83.83 $83.83 $108.75 $108.75 $50.80 $83.83

$236.27 $236.27 $236.24 $236.24 $252.27 $236.27$463.70 $463.70 $463.66 $463.66 $495.18 $463.70




Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$463.70 $463.70 $463.66 $463.66 $495.18 $463.70$92.15 $92.15 $92.12 $92.12 $98.36 $92.15$92.15 $92.15 $92.12 $92.12 $98.36 $92.15

$236.27 $236.27 $236.24 $236.24 $252.27 $236.27$280.17 $280.17 $280.15 $280.15 $299.20 $280.17

$75.88 $75.88 $75.88 $75.88 $55.98 $75.88$75.88 $75.88 $75.88 $75.88 $55.98 $75.88$46.08 $46.08 $46.86 $46.86 $34.97 $46.08$30.53 $30.53 $30.53 $30.53 $32.57 $30.53$73.44 $73.44 $80.23 $80.23 $70.19 $73.44$73.44 $73.44 $80.23 $80.23 $70.19 $73.44

$177.65 $177.65 $179.18 $179.18 $118.87 $177.65$186.13 $186.13 $186.12 $186.12 $198.79 $186.13$192.74 $192.74 $192.73 $192.73 $205.77 $192.74$719.03 $719.03 $781.63 $781.63 $555.39 $719.03

$1,465.59 $1,465.59 $1,465.45 $1,465.45 $1,565.02 $1,465.59$748.67 $748.67 $625.86 $625.86 $444.16 $748.67

$1,730.36 $1,730.36 $1,730.24 $1,730.24 $1,847.79 $1,730.36$1,642.49 $1,642.49 $1,642.36 $1,642.36 $1,753.95 $1,642.49$1,730.36 $1,730.36 $1,730.24 $1,730.24 $1,847.79 $1,730.36$1,465.59 $1,465.59 $1,465.45 $1,465.45 $1,565.02 $1,465.59$1,465.59 $1,465.59 $1,465.45 $1,465.45 $1,565.02 $1,465.59$1,642.49 $1,642.49 $1,642.36 $1,642.36 $1,753.95 $1,642.49$1,730.36 $1,730.36 $1,730.24 $1,730.24 $1,847.79 $1,730.36

$269.66 $269.66 $321.10 $321.10 $996.72 $269.66$878.03 $878.03 $877.96 $877.96 $937.61 $878.03$333.16 $333.16 $362.36 $362.36 $996.72 $333.16$355.62 $355.62 $315.25 $315.25 $158.59 $355.62

$29.84 $29.84 $37.19 $37.19 $44.29 $29.84$1,162.86 $1,162.86 $1,201.12 $1,201.12 $1,033.63 $1,162.86

$654.39 $654.39 $613.85 $613.85 $885.99 $654.39$817.39 $817.39 $897.67 $897.67 $1,107.47 $817.39$450.05 $450.05 $587.03 $587.03 $885.99 $450.05$363.86 $363.86 $382.60 $382.60 $1,063.14 $363.86$292.41 $292.41 $292.41 $292.41 $332.23 $292.41$368.01 $368.01 $368.01 $368.01 $885.99 $368.01$238.30 $238.30 $242.75 $242.75 $406.10 $238.30$283.29 $283.29 $283.29 $283.29 $236.27 $283.29$270.27 $270.27 $315.79 $315.79 $236.27 $270.27

$95.28 $95.28 $90.16 $90.16 $110.74 $95.28$84.34 $84.34 $101.85 $101.85 $110.74 $84.34$95.12 $95.12 $104.57 $104.57 $132.89 $95.12$75.59 $75.59 $83.64 $83.64 $132.89 $75.59

$520.27 $520.27 $515.44 $515.44 $406.10 $520.27$93.73 $93.73 $81.95 $81.95 $61.58 $93.73

$262.24 $262.24 $246.82 $246.82 $285.01 $262.24$262.24 $262.24 $246.82 $246.82 $285.01 $262.24$168.28 $168.28 $168.28 $168.28 $165.40 $168.28$151.97 $151.97 $151.96 $151.96 $162.30 $151.97$151.97 $151.97 $151.96 $151.96 $162.30 $151.97

$22.57 $22.57 $22.57 $22.57 $26.27 $22.57$16.47 $16.47 $16.47 $16.47 $19.19 $16.47

$160.88 $160.88 $160.87 $160.87 $187.38 $160.88$160.88 $160.88 $160.87 $160.87 $187.38 $160.88

$74.04 $74.04 $74.04 $74.04 $86.24 $74.04$1,430.38 $1,430.38 $1,417.64 $1,417.64 $2,348.85 $1,430.38

$502.58 $502.58 $639.77 $639.77 $775.21 $502.58$1,213.86 $1,213.86 $1,452.69 $1,452.69 $775.21 $1,213.86$2,061.41 $2,061.41 $2,182.31 $2,182.31 $1,070.85 $2,061.41$2,280.29 $2,280.29 $2,747.20 $2,747.20 $2,953.23 $2,280.29$2,623.01 $2,623.01 $3,104.19 $3,104.19 $793.25 $2,623.01




Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$2,285.33 $2,285.33 $2,699.58 $2,699.58 $2,953.23 $2,285.33$3,299.12 $3,299.12 $3,299.12 $3,299.12 $5,168.15 $3,299.12$3,334.95 $3,334.95 $3,932.48 $3,932.48 $5,168.15 $3,334.95$3,627.36 $3,627.36 $4,137.44 $4,137.44 $5,315.81 $3,627.36$3,473.71 $3,473.71 $3,595.75 $3,595.75 $4,577.52 $3,473.71$2,304.46 $2,304.46 $2,657.85 $2,657.85 $4,282.22 $2,304.46$2,619.44 $2,619.44 $3,339.05 $3,339.05 $4,134.52 $2,619.44$3,612.72 $3,612.72 $3,957.71 $3,957.71 $3,691.52 $3,612.72$4,927.43 $4,927.43 $5,357.99 $5,357.99 $9,597.99 $4,927.43$4,905.56 $4,905.56 $5,091.16 $5,091.16 $3,781.91 $4,905.56$4,868.00 $4,868.00 $5,542.04 $5,542.04 $9,893.32 $4,868.00$2,612.27 $2,612.27 $2,619.12 $2,619.12 $3,359.51 $2,612.27$3,739.29 $3,739.29 $3,495.76 $3,495.76 $3,053.73 $3,739.29$3,786.56 $3,786.56 $3,654.05 $3,654.05 $5,136.98 $3,786.56$4,824.84 $4,824.84 $5,501.04 $5,501.04 $3,769.57 $4,824.84$5,022.68 $5,022.68 $5,740.67 $5,740.67 $4,684.65 $5,022.68$1,293.30 $1,293.30 $1,354.38 $1,354.38 $674.19 $1,293.30

$396.79 $396.79 $529.05 $529.05 $206.12 $396.79$1,584.89 $1,584.89 $1,734.48 $1,734.48 $1,031.26 $1,584.89

$477.89 $477.89 $637.18 $637.18 $705.83 $477.89$388.78 $388.78 $515.87 $515.87 $285.57 $388.78$517.98 $517.98 $690.45 $690.45 $356.90 $517.98

$1,219.69 $1,219.69 $1,362.82 $1,362.82 $1,771.93 $1,219.69$1,686.87 $1,686.87 $2,202.37 $2,202.37 $3,100.88 $1,686.87$1,382.60 $1,382.60 $1,620.20 $1,620.20 $2,362.59 $1,382.60$1,365.68 $1,365.68 $1,820.91 $1,820.91 $2,362.59 $1,365.68$1,640.31 $1,640.31 $1,881.81 $1,881.81 $935.71 $1,640.31$1,610.46 $1,610.46 $1,885.51 $1,885.51 $2,480.71 $1,610.46$1,718.87 $1,718.87 $2,021.61 $2,021.61 $2,436.42 $1,718.87$1,845.77 $1,845.77 $2,431.33 $2,431.33 $3,543.89 $1,845.77$1,918.95 $1,918.95 $2,400.51 $2,400.51 $1,015.17 $1,918.95$2,240.24 $2,240.24 $2,680.35 $2,680.35 $1,348.45 $2,240.24$2,756.97 $2,756.97 $2,689.18 $2,689.18 $3,543.89 $2,756.97$2,282.95 $2,282.95 $2,631.15 $2,631.15 $3,543.89 $2,282.95$4,033.14 $4,033.14 $3,823.86 $3,823.86 $5,906.49 $4,033.14$4,335.44 $4,335.44 $4,222.69 $4,222.69 $6,644.78 $4,335.44$1,966.19 $1,966.19 $2,278.79 $2,278.79 $2,953.23 $1,966.19$1,530.09 $1,530.09 $1,530.09 $1,530.09 $1,550.43 $1,530.09$2,392.24 $2,392.24 $2,356.79 $2,356.79 $1,956.53 $2,392.24$1,620.58 $1,620.58 $1,620.40 $1,620.40 $1,730.52 $1,620.58$1,292.75 $1,292.75 $1,719.74 $1,719.74 $1,107.47 $1,292.75

$537.33 $537.33 $537.27 $537.27 $573.81 $537.33$284.26 $284.26 $286.90 $286.90 $247.81 $284.26$264.02 $264.02 $352.03 $352.03 $375.43 $264.02$344.28 $344.28 $459.04 $459.04 $959.82 $344.28$345.26 $345.26 $460.35 $460.35 $525.56 $345.26$452.79 $452.79 $505.53 $505.53 $1,181.32 $452.79$484.15 $484.15 $545.58 $545.58 $1,004.10 $484.15$301.80 $301.80 $402.40 $402.40 $442.99 $301.80$426.21 $426.21 $491.24 $491.24 $285.57 $426.21$417.27 $417.27 $556.36 $556.36 $664.48 $417.27$232.88 $232.88 $210.87 $210.87 $79.43 $232.88$288.88 $288.88 $288.88 $288.88 $111.12 $288.88$241.98 $241.98 $241.98 $241.98 $79.43 $241.98$274.35 $274.35 $365.80 $365.80 $959.82 $274.35$477.91 $477.91 $479.36 $479.36 $119.02 $477.91

$1,064.76 $1,064.76 $1,064.76 $1,064.76 $2,805.59 $1,064.76$607.25 $607.25 $607.25 $607.25 $238.02 $607.25$588.38 $588.38 $606.83 $606.83 $277.62 $588.38

$1,478.11 $1,478.11 $1,589.76 $1,589.76 $1,070.54 $1,478.11$560.92 $560.92 $669.14 $669.14 $317.36 $560.92




Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$757.74 $757.74 $759.28 $759.28 $627.57 $757.74$520.33 $520.33 $675.44 $675.44 $515.51 $520.33$755.42 $755.42 $755.42 $755.42 $716.16 $755.42$625.24 $625.24 $736.75 $736.75 $634.52 $625.24

$2,265.60 $2,265.60 $2,307.44 $2,307.44 $1,476.62 $2,265.60$463.62 $463.62 $544.03 $544.03 $1,033.63 $463.62

$1,140.48 $1,140.48 $1,520.64 $1,520.64 $1,033.63 $1,140.48$414.04 $414.04 $483.04 $483.04 $1,107.47 $414.04$552.71 $552.71 $565.76 $565.76 $1,476.62 $552.71$314.95 $314.95 $374.37 $374.37 $369.16 $314.95$266.90 $266.90 $291.24 $291.24 $812.12 $266.90$358.04 $358.04 $360.99 $360.99 $503.06 $358.04$345.30 $345.30 $345.30 $345.30 $812.12 $345.30$577.92 $577.92 $577.92 $577.92 $546.35 $577.92$486.25 $486.25 $519.67 $519.67 $516.81 $486.25

$66.48 $66.48 $88.64 $88.64 $80.33 $66.48$107.22 $107.22 $127.87 $127.87 $99.08 $107.22$257.69 $257.69 $343.59 $343.59 $150.17 $257.69$546.08 $546.08 $546.01 $546.01 $892.83 $546.08$283.18 $283.18 $283.18 $283.18 $158.59 $283.18$675.27 $675.27 $695.74 $695.74 $589.49 $675.27$344.13 $344.13 $448.18 $448.18 $701.39 $344.13$468.24 $468.24 $624.32 $624.32 $184.59 $468.24

$37.71 $37.71 $50.27 $50.27 $14.77 $37.71$562.70 $562.70 $579.76 $579.76 $491.25 $562.70$314.77 $314.77 $310.00 $310.00 $304.77 $314.77

$1,263.27 $1,263.27 $1,263.14 $1,263.14 $1,348.96 $1,263.27$593.91 $593.91 $605.96 $605.96 $553.73 $593.91

$1,263.27 $1,263.27 $1,263.14 $1,263.14 $1,348.96 $1,263.27$45.71 $45.71 $51.11 $51.11 $23.77 $45.71

$123.01 $123.01 $122.98 $122.98 $131.38 $123.01$48.52 $48.52 $51.30 $51.30 $31.76 $48.52$58.01 $58.01 $72.93 $72.93 $90.41 $58.01$92.93 $92.93 $102.46 $102.46 $88.60 $92.93

$126.19 $126.19 $168.26 $168.26 $88.74 $126.19$172.28 $172.28 $229.71 $229.71 $189.20 $172.28$159.05 $159.05 $206.50 $206.50 $146.16 $159.05$175.71 $175.71 $210.79 $210.79 $165.18 $175.71

$76.24 $76.24 $76.24 $76.24 $75.10 $76.24$124.67 $124.67 $113.65 $113.65 $154.55 $124.67$224.58 $224.58 $177.07 $177.07 $79.37 $224.58

$2,720.99 $2,720.99 $2,720.74 $2,720.74 $3,353.33 $2,720.99$3,267.71 $3,267.71 $3,267.42 $3,267.42 $4,027.10 $3,267.71$4,134.13 $4,134.13 $4,133.77 $4,133.77 $5,094.89 $4,134.13$2,139.45 $2,139.45 $2,531.08 $2,531.08 $2,694.86 $2,139.45

$509.04 $509.04 $509.00 $509.00 $627.33 $509.04$909.56 $909.56 $909.46 $909.46 $1,120.92 $909.56$891.60 $891.60 $891.52 $891.52 $1,098.82 $891.60

$1,175.44 $1,175.44 $1,175.37 $1,175.37 $1,448.62 $1,175.44$355.16 $355.16 $406.47 $406.47 $525.62 $355.16$496.38 $496.38 $514.86 $514.86 $487.29 $496.38$415.91 $415.91 $539.56 $539.56 $495.26 $415.91$427.21 $427.21 $455.85 $455.85 $198.23 $427.21$692.16 $692.16 $805.76 $805.76 $277.62 $692.16$865.13 $865.13 $888.97 $888.97 $277.62 $865.13$913.97 $913.97 $864.19 $864.19 $738.30 $913.97

$1,433.45 $1,433.45 $1,911.27 $1,911.27 $1,771.93 $1,433.45$1,652.02 $1,652.02 $2,202.69 $2,202.69 $1,245.38 $1,652.02$2,259.74 $2,259.74 $2,353.30 $2,353.30 $2,495.51 $2,259.74$1,087.29 $1,087.29 $1,252.75 $1,252.75 $666.25 $1,087.29$3,842.59 $3,842.59 $3,842.25 $3,842.25 $4,103.28 $3,842.59




Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$4,050.97 $4,050.97 $4,050.56 $4,050.56 $4,325.80 $4,050.97$611.19 $611.19 $550.12 $550.12 $553.73 $611.19$682.84 $682.84 $910.45 $910.45 $885.99 $682.84

$1,359.54 $1,359.54 $1,359.54 $1,359.54 $1,181.32 $1,359.54$462.36 $462.36 $510.50 $510.50 $369.16 $462.36$692.61 $692.61 $756.19 $756.19 $1,070.54 $692.61$536.85 $536.85 $572.22 $572.22 $701.39 $536.85

$3,566.67 $3,566.67 $3,566.34 $3,566.34 $3,808.65 $3,566.67$812.51 $812.51 $920.44 $920.44 $479.90 $812.51$911.99 $911.99 $922.90 $922.90 $1,033.63 $911.99

$1,617.20 $1,617.20 $1,617.20 $1,617.20 $1,107.47 $1,617.20$1,456.38 $1,456.38 $1,734.91 $1,734.91 $1,402.78 $1,456.38$2,999.11 $2,999.11 $2,998.84 $2,998.84 $3,202.63 $2,999.11$2,681.82 $2,681.82 $2,681.82 $2,681.82 $3,475.97 $2,681.82$1,802.04 $1,802.04 $1,977.79 $1,977.79 $1,650.89 $1,802.04$3,331.98 $3,331.98 $3,331.66 $3,331.66 $4,106.27 $3,331.98$1,721.35 $1,721.35 $1,721.18 $1,721.18 $1,838.11 $1,721.35$1,032.68 $1,032.68 $1,032.59 $1,032.59 $1,102.74 $1,032.68

$121.49 $121.49 $161.98 $161.98 $100.42 $121.49$326.44 $326.44 $326.41 $326.41 $402.32 $326.44

$23,054.39 $23,054.39 $23,052.22 $23,052.22 $24,618.53 $23,054.39$8,180.54 $8,180.54 $8,179.81 $8,179.81 $8,735.57 $8,180.54

$17,848.59 $17,848.59 $17,846.92 $17,846.92 $19,059.57 $17,848.59$13,934.25 $13,934.25 $13,932.93 $13,932.93 $14,879.62 $13,934.25

$343.95 $343.95 $458.60 $458.60 $664.48 $343.95$503.89 $503.89 $671.85 $671.85 $1,328.96 $503.89$425.46 $425.46 $425.46 $425.46 $576.09 $425.46

$3,232.48 $3,232.48 $3,232.19 $3,232.19 $3,451.82 $3,232.48$476.36 $476.36 $635.15 $635.15 $885.99 $476.36$744.83 $744.83 $985.14 $985.14 $959.82 $744.83$915.52 $915.52 $1,220.70 $1,220.70 $1,808.87 $915.52

$4,365.59 $4,365.59 $4,528.04 $4,528.04 $4,465.17 $4,365.59$602.51 $602.51 $602.47 $602.47 $742.50 $602.51$889.39 $889.39 $889.39 $889.39 $1,058.61 $889.39

$1,133.30 $1,133.30 $1,133.30 $1,133.30 $1,300.70 $1,133.30$3,489.90 $3,489.90 $3,489.56 $3,489.56 $4,065.43 $3,489.90

$192.87 $192.87 $216.16 $216.16 $258.41 $192.87$192.87 $192.87 $216.16 $216.16 $258.41 $192.87$360.26 $360.26 $406.91 $406.91 $258.41 $360.26

$16,522.78 $16,522.78 $16,521.25 $16,521.25 $18,450.62 $16,522.78$221.30 $221.30 $251.74 $251.74 $369.16 $221.30$445.24 $445.24 $445.21 $445.21 $518.64 $445.24$531.84 $531.84 $576.46 $576.46 $767.84 $531.84$277.14 $277.14 $323.21 $323.21 $177.00 $277.14

$2,166.92 $2,166.92 $2,166.92 $2,166.92 $2,650.14 $2,166.92$3,521.11 $3,521.11 $3,724.39 $3,724.39 $5,374.88 $3,521.11$2,844.58 $2,844.58 $2,844.31 $2,844.31 $3,505.61 $2,844.58

$549.02 $549.02 $594.41 $594.41 $254.19 $549.02$541.00 $541.00 $638.47 $638.47 $383.92 $541.00$271.19 $271.19 $271.15 $271.15 $289.61 $271.19$601.79 $601.79 $635.29 $635.29 $254.19 $601.79

$6,908.62 $6,908.62 $6,907.98 $6,907.98 $7,377.33 $6,908.62$1,918.52 $1,918.52 $1,918.34 $1,918.34 $2,234.91 $1,918.52$1,742.30 $1,742.30 $1,742.13 $1,742.13 $1,860.49 $1,742.30$1,261.82 $1,261.82 $1,421.43 $1,421.43 $888.50 $1,261.82$1,404.20 $1,404.20 $1,430.12 $1,430.12 $888.50 $1,404.20$1,309.20 $1,309.20 $1,422.54 $1,422.54 $920.07 $1,309.20$4,747.34 $4,747.34 $3,560.51 $3,560.51 $4,299.61 $4,747.34$1,804.01 $1,804.01 $2,185.33 $2,185.33 $951.85 $1,804.01$2,514.34 $2,514.34 $2,695.78 $2,695.78 $2,702.23 $2,514.34$1,827.75 $1,827.75 $2,242.10 $2,242.10 $1,097.14 $1,827.75




Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$1,938.63 $1,938.63 $2,380.02 $2,380.02 $1,110.43 $1,938.63$2,259.20 $2,259.20 $2,683.48 $2,683.48 $1,189.75 $2,259.20$2,458.43 $2,458.43 $2,486.56 $2,486.56 $1,213.65 $2,458.43$2,590.79 $2,590.79 $3,025.38 $3,025.38 $1,546.36 $2,590.79$3,458.29 $3,458.29 $3,458.29 $3,458.29 $3,617.70 $3,458.29$2,714.55 $2,714.55 $3,137.35 $3,137.35 $1,586.33 $2,714.55$3,538.13 $3,538.13 $3,778.00 $3,778.00 $2,062.23 $3,538.13$3,055.01 $3,055.01 $3,033.42 $3,033.42 $1,094.62 $3,055.01$1,668.88 $1,668.88 $1,824.96 $1,824.96 $777.32 $1,668.88$3,719.80 $3,719.80 $3,719.80 $3,719.80 $2,458.93 $3,719.80$3,345.37 $3,345.37 $3,024.88 $3,024.88 $1,189.75 $3,345.37$2,001.77 $2,001.77 $2,108.88 $2,108.88 $888.50 $2,001.77$1,159.98 $1,159.98 $1,246.64 $1,246.64 $1,624.28 $1,159.98$1,745.13 $1,745.13 $1,478.96 $1,478.96 $2,657.92 $1,745.13$2,414.21 $2,414.21 $1,833.42 $1,833.42 $3,100.88 $2,414.21

$381.37 $381.37 $424.55 $424.55 $1,107.47 $381.37$417.50 $417.50 $474.46 $474.46 $360.41 $417.50

$2,203.62 $2,203.62 $2,381.97 $2,381.97 $1,078.81 $2,203.62$2,943.97 $2,943.97 $2,927.92 $2,927.92 $1,546.62 $2,943.97$3,080.01 $3,080.01 $2,954.32 $2,954.32 $1,586.33 $3,080.01$3,702.22 $3,702.22 $3,621.34 $3,621.34 $2,062.23 $3,702.22$4,156.60 $4,156.60 $4,156.60 $4,156.60 $2,458.93 $4,156.60$1,586.90 $1,586.90 $1,560.54 $1,560.54 $1,488.14 $1,586.90$1,437.31 $1,437.31 $1,447.25 $1,447.25 $2,067.27 $1,437.31$2,254.07 $2,254.07 $2,114.25 $2,114.25 $2,657.92 $2,254.07$2,109.45 $2,109.45 $2,080.17 $2,080.17 $2,362.59 $2,109.45$2,771.77 $2,771.77 $2,863.90 $2,863.90 $2,740.05 $2,771.77$2,632.74 $2,632.74 $2,808.69 $2,808.69 $2,552.04 $2,632.74

$178.13 $178.13 $237.51 $237.51 $119.02 $178.13$175.89 $175.89 $234.52 $234.52 $103.24 $175.89$168.91 $168.91 $192.07 $192.07 $95.25 $168.91$395.38 $395.38 $395.36 $395.36 $422.24 $395.38$182.00 $182.00 $184.38 $184.38 $95.25 $182.00

$67.44 $67.44 $78.37 $78.37 $59.05 $67.44$291.18 $291.18 $318.59 $318.59 $206.12 $291.18

$2,196.61 $2,196.61 $2,196.43 $2,196.43 $2,345.67 $2,196.61$812.24 $812.24 $639.69 $639.69 $110.74 $812.24

$3,616.79 $3,616.79 $3,616.49 $3,616.49 $3,862.21 $3,616.79$577.11 $577.11 $673.44 $673.44 $222.09 $577.11$454.94 $454.94 $490.21 $490.21 $51.70 $454.94$138.94 $138.94 $168.55 $168.55 $81.23 $138.94$204.67 $204.67 $272.90 $272.90 $19.05 $204.67

$71.08 $71.08 $61.70 $61.70 $51.70 $71.08$167.27 $167.27 $210.11 $210.11 $119.02 $167.27$356.77 $356.77 $409.41 $409.41 $81.23 $356.77

$2,401.61 $2,401.61 $2,401.38 $2,401.38 $2,564.54 $2,401.61$316.95 $316.95 $342.54 $342.54 $119.02 $316.95$152.35 $152.35 $185.24 $185.24 $261.33 $152.35$206.50 $206.50 $220.55 $220.55 $516.81 $206.50$381.17 $381.17 $382.50 $382.50 $269.79 $381.17

$3,028.99 $3,028.99 $3,028.68 $3,028.68 $3,234.49 $3,028.99$498.66 $498.66 $498.62 $498.62 $532.45 $498.66

$3,123.95 $3,123.95 $3,123.67 $3,123.67 $3,335.91 $3,123.95$395.75 $395.75 $401.62 $401.62 $333.11 $395.75

$77.78 $77.78 $87.93 $87.93 $74.58 $77.78$87.17 $87.17 $98.02 $98.02 $79.43 $87.17$43.74 $43.74 $58.32 $58.32 $19.05 $43.74$48.36 $48.36 $60.73 $60.73 $36.48 $48.36

$191.91 $191.91 $168.97 $168.97 $442.99 $191.91$114.05 $114.05 $118.49 $118.49 $148.68 $114.05$131.83 $131.83 $124.56 $124.56 $135.02 $131.83




Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$284.93 $284.93 $284.88 $284.88 $304.21 $284.93$220.33 $220.33 $293.77 $293.77 $605.41 $220.33$243.61 $243.61 $287.66 $287.66 $753.09 $243.61$331.03 $331.03 $331.03 $331.03 $495.53 $331.03$747.54 $747.54 $615.47 $615.47 $1,055.79 $747.54$547.78 $547.78 $547.78 $547.78 $1,181.32 $547.78$544.48 $544.48 $647.43 $647.43 $1,173.95 $544.48$652.35 $652.35 $677.49 $677.49 $1,365.89 $652.35$710.88 $710.88 $735.09 $735.09 $1,439.72 $710.88$329.03 $329.03 $327.82 $327.82 $627.57 $329.03$531.08 $531.08 $675.73 $675.73 $885.99 $531.08

$2,726.45 $2,726.45 $2,726.20 $2,726.20 $3,176.12 $2,726.45$675.27 $675.27 $695.74 $695.74 $589.49 $675.27$562.70 $562.70 $579.76 $579.76 $491.25 $562.70

$1,263.27 $1,263.27 $1,263.14 $1,263.14 $1,348.96 $1,263.27$1,263.27 $1,263.27 $1,263.14 $1,263.14 $1,348.96 $1,263.27

$546.08 $546.08 $546.01 $546.01 $892.83 $546.08$345.24 $345.24 $314.08 $314.08 $356.03 $345.24$556.16 $556.16 $736.54 $736.54 $315.40 $556.16$331.36 $331.36 $382.12 $382.12 $262.71 $331.36

$1,221.34 $1,221.34 $1,359.67 $1,359.67 $1,465.31 $1,221.34$798.43 $798.43 $913.81 $913.81 $1,242.88 $798.43

$1,150.56 $1,150.56 $1,340.74 $1,340.74 $1,448.20 $1,150.56$645.66 $645.66 $645.61 $645.61 $689.51 $645.66

$1,188.81 $1,188.81 $1,188.71 $1,188.71 $1,269.47 $1,188.81$1,500.36 $1,500.36 $1,500.24 $1,500.24 $1,602.19 $1,500.36$1,270.83 $1,270.83 $1,270.71 $1,270.71 $1,357.03 $1,270.83$3,032.02 $3,032.02 $3,031.73 $3,031.73 $3,237.73 $3,032.02$2,258.76 $2,258.76 $2,258.53 $2,258.53 $2,412.02 $2,258.76$1,947.20 $1,947.20 $1,947.01 $1,947.01 $2,079.32 $1,947.20

$323.11 $323.11 $404.12 $404.12 $229.99 $323.11$183.14 $183.14 $236.20 $236.20 $184.59 $183.14

$22,945.54 $22,945.54 $22,943.36 $22,943.36 $24,502.29 $22,945.54$3,926.19 $3,926.19 $3,925.84 $3,925.84 $4,192.56 $3,926.19$2,978.23 $2,978.23 $2,977.95 $2,977.95 $3,180.30 $2,978.23$1,507.02 $1,507.02 $1,772.07 $1,772.07 $1,038.14 $1,507.02$2,236.73 $2,236.73 $2,659.52 $2,659.52 $1,108.52 $2,236.73$3,345.37 $3,345.37 $3,024.88 $3,024.88 $1,189.75 $3,345.37

$161.53 $161.53 $175.07 $175.07 $664.48 $161.53$594.22 $594.22 $530.29 $530.29 $253.83 $594.22

$1,695.75 $1,695.75 $1,468.35 $1,468.35 $1,685.59 $1,695.75$1,686.11 $1,686.11 $1,394.32 $1,394.32 $1,665.48 $1,686.11$1,441.79 $1,441.79 $1,373.99 $1,373.99 $3,100.66 $1,441.79

$726.93 $726.93 $594.52 $594.52 $812.12 $726.93$6,337.86 $6,337.86 $6,959.29 $6,959.29 $8,121.36 $6,337.86$8,531.86 $8,531.86 $7,348.41 $7,348.41 $6,841.60 $8,531.86$6,377.16 $6,377.16 $7,471.61 $7,471.61 $5,271.36 $6,377.16$8,664.26 $8,664.26 $8,218.69 $8,218.69 $6,674.31 $8,664.26$8,332.17 $8,332.17 $9,337.89 $9,337.89 $10,483.96 $8,332.17

$10,180.92 $10,180.92 $10,563.36 $10,563.36 $13,658.74 $10,180.92$9,470.69 $9,470.69 $9,927.98 $9,927.98 $13,658.74 $9,470.69

$11,342.44 $11,342.44 $12,458.23 $12,458.23 $14,103.30 $11,342.44$12,848.16 $12,848.16 $12,284.43 $12,284.43 $14,103.30 $12,848.16$13,703.03 $13,703.03 $17,945.81 $17,945.81 $14,103.30 $13,703.03$14,278.78 $14,278.78 $18,240.69 $18,240.69 $14,103.30 $14,278.78$15,616.38 $15,616.38 $18,338.59 $18,338.59 $14,103.30 $15,616.38

$3,267.89 $3,267.89 $4,357.18 $4,357.18 $3,906.99 $3,267.89$5,143.31 $5,143.31 $6,857.75 $6,857.75 $5,836.01 $5,143.31$3,334.28 $3,334.28 $4,445.70 $4,445.70 $3,614.62 $3,334.28$2,677.30 $2,677.30 $3,569.73 $3,569.73 $3,031.95 $2,677.30$1,534.98 $1,534.98 $2,046.65 $2,046.65 $1,440.89 $1,534.98



HCPCS 1st Mod 2nd Mod CategoryL7170 POL7180 POL7181 POL7185 POL7186 POL7190 POL7191 POL7259 POL7360 POL7362 POL7364 POL7366 POL7367 POL7368 POL7400 POL7401 POL7402 POL7403 POL7404 POL7405 POL8000 POL8001 POL8002 POL8015 POL8020 POL8030 POL8031 POL8032 POL8035 POL8040 KM POL8040 KN POL8040 POL8041 KM POL8041 KN POL8041 POL8042 KM POL8042 KN POL8042 POL8043 KM POL8043 KN POL8043 POL8044 KM POL8044 KN POL8044 POL8045 KM POL8045 KN POL8045 POL8046 KM POL8046 KN POL8046 POL8047 KM POL8047 KN POL8047 POL8300 POL8310 POL8320 POL8330 POL8400 POL8410 POL8415 POL8417 PO

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$7,067.66 $7,067.66 $7,424.56 $7,424.56 $5,470.72 $7,067.66$31,023.06 $31,023.06 $38,791.57 $38,791.57 $14,103.30 $31,023.06$38,479.94 $38,479.94 $38,476.38 $38,476.38 $41,090.68 $38,479.94

$6,979.40 $6,979.40 $7,518.36 $7,518.36 $6,809.71 $6,979.40$8,400.38 $8,400.38 $10,850.81 $10,850.81 $10,374.42 $8,400.38$7,330.75 $7,330.75 $9,565.69 $9,565.69 $10,400.83 $7,330.75$8,777.90 $8,777.90 $11,534.08 $11,534.08 $10,726.15 $8,777.90$3,035.08 $3,035.08 $3,646.49 $3,646.49 $3,157.06 $3,035.08

$226.60 $226.60 $228.68 $228.68 $376.54 $226.60$237.93 $237.93 $275.03 $275.03 $728.33 $237.93$378.42 $378.42 $501.00 $501.00 $728.33 $378.42$509.75 $509.75 $679.67 $679.67 $803.42 $509.75$373.88 $373.88 $373.85 $373.85 $399.27 $373.88$484.69 $484.69 $484.66 $484.66 $517.59 $484.69$294.35 $294.35 $294.31 $294.31 $314.30 $294.35$329.52 $329.52 $329.48 $329.48 $351.85 $329.52$355.82 $355.82 $355.80 $355.80 $379.99 $355.82$353.68 $353.68 $353.63 $353.63 $377.63 $353.68$533.76 $533.76 $533.72 $533.72 $570.01 $533.76$698.10 $698.10 $698.05 $698.05 $745.50 $698.10

$41.77 $41.77 $35.64 $35.64 $44.29 $41.77$120.46 $120.46 $120.45 $120.45 $128.64 $120.46$158.45 $158.45 $158.43 $158.43 $169.20 $158.45

$57.56 $57.56 $57.56 $57.56 $61.46 $57.56$216.50 $216.50 $215.77 $215.77 $284.10 $216.50$313.17 $313.17 $316.78 $316.78 $320.75 $313.17$313.17 $313.17 $316.78 $316.78 $320.75 $313.17

$37.62 $37.62 $37.62 $37.62 $40.17 $37.62$3,518.42 $3,518.42 $3,518.08 $3,518.08 $4,098.68 $3,518.42$2,205.30 $2,205.30 $2,174.39 $2,174.39 $2,086.71 $2,205.30

$928.56 $928.56 $915.51 $915.51 $878.63 $928.56$2,321.37 $2,321.37 $2,288.84 $2,288.84 $2,196.54 $2,321.37$2,658.06 $2,658.06 $2,620.86 $2,620.86 $2,515.39 $2,658.06$1,119.20 $1,119.20 $1,103.52 $1,103.52 $1,059.10 $1,119.20$2,797.97 $2,797.97 $2,758.81 $2,758.81 $2,647.80 $2,797.97$2,986.58 $2,986.58 $2,944.78 $2,944.78 $2,826.29 $2,986.58$1,257.50 $1,257.50 $1,239.92 $1,239.92 $1,190.00 $1,257.50$3,143.77 $3,143.77 $3,099.79 $3,099.79 $2,975.01 $3,143.77$3,344.96 $3,344.96 $3,298.17 $3,298.17 $3,165.42 $3,344.96$1,408.40 $1,408.40 $1,388.71 $1,388.71 $1,332.82 $1,408.40$3,521.03 $3,521.03 $3,471.75 $3,471.75 $3,332.03 $3,521.03$3,703.38 $3,703.38 $3,651.54 $3,651.54 $3,504.58 $3,703.38$1,559.33 $1,559.33 $1,537.51 $1,537.51 $1,475.60 $1,559.33$3,898.27 $3,898.27 $3,843.72 $3,843.72 $3,689.04 $3,898.27$2,319.14 $2,319.14 $2,286.59 $2,286.59 $2,187.26 $2,319.14

$976.48 $976.48 $962.77 $962.77 $920.95 $976.48$2,441.21 $2,441.21 $2,406.92 $2,406.92 $2,302.35 $2,441.21$2,389.26 $2,389.26 $2,355.82 $2,355.82 $2,261.01 $2,389.26$1,005.99 $1,005.99 $991.93 $991.93 $952.02 $1,005.99$2,515.02 $2,515.02 $2,479.81 $2,479.81 $2,380.01 $2,515.02$1,224.49 $1,224.49 $1,207.35 $1,207.35 $1,158.78 $1,224.49

$515.58 $515.58 $508.36 $508.36 $487.92 $515.58$1,288.93 $1,288.93 $1,270.92 $1,270.92 $1,219.77 $1,288.93

$92.49 $92.49 $80.11 $80.11 $132.89 $92.49$142.21 $142.21 $126.48 $126.48 $206.12 $142.21

$62.12 $62.12 $58.39 $58.39 $36.93 $62.12$61.57 $61.57 $62.51 $62.51 $51.70 $61.57$18.00 $18.00 $14.95 $14.95 $23.77 $18.00$20.48 $20.48 $21.86 $21.86 $25.42 $20.48$20.36 $20.36 $22.21 $22.21 $24.05 $20.36$72.21 $72.21 $72.20 $72.20 $77.14 $72.21



HCPCS 1st Mod 2nd Mod CategoryL8420 POL8430 POL8435 POL8440 POL8460 POL8465 POL8470 POL8480 POL8485 POL8500 POL8501 POL8507 POL8510 POL8511 POL8512 POL8513 POL8514 POL8515 POV2020 POV2100 POV2101 POV2102 POV2103 POV2104 POV2105 POV2106 POV2107 POV2108 POV2109 POV2110 POV2111 POV2112 POV2113 POV2114 POV2115 POV2118 POV2121 POV2200 POV2201 POV2202 POV2203 POV2204 POV2205 POV2206 POV2207 POV2208 POV2209 POV2210 POV2211 POV2212 POV2213 POV2214 POV2215 POV2218 POV2219 POV2220 POV2221 POV2300 POV2301 POV2302 POV2303 PO

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$23.80 $23.80 $19.74 $19.74 $36.93 $23.80$26.17 $26.17 $21.68 $21.68 $36.93 $26.17$23.49 $23.49 $22.90 $22.90 $24.05 $23.49$49.79 $49.79 $41.96 $41.96 $47.55 $49.79$69.29 $69.29 $72.99 $72.99 $103.35 $69.29$61.76 $61.76 $52.00 $52.00 $30.03 $61.76

$6.34 $6.34 $7.60 $7.60 $3.28 $6.34$8.74 $8.74 $9.99 $9.99 $4.89 $8.74

$10.56 $10.56 $10.56 $10.56 $13.02 $10.56$626.75 $626.75 $738.30 $738.30 $664.48 $626.75$139.20 $139.20 $114.72 $114.72 $118.14 $139.20

$40.23 $40.23 $40.22 $40.22 $42.97 $40.23$242.70 $242.70 $242.68 $242.68 $259.13 $242.70

$69.85 $69.85 $69.84 $69.84 $81.35 $69.85$2.11 $2.11 $2.11 $2.11 $2.41 $2.11$5.00 $5.00 $5.00 $5.00 $5.79 $5.00

$90.57 $90.57 $90.56 $90.56 $105.49 $90.57$60.61 $60.61 $60.61 $60.61 $64.72 $60.61$76.54 $76.54 $63.94 $63.94 $45.06 $76.54$37.20 $37.20 $45.64 $45.64 $45.06 $37.20$39.20 $39.20 $52.27 $52.27 $45.06 $39.20$55.59 $55.59 $58.09 $58.09 $45.06 $55.59$32.30 $32.30 $34.57 $34.57 $45.06 $32.30$35.77 $35.77 $40.87 $40.87 $45.06 $35.77$43.79 $43.79 $40.01 $40.01 $45.06 $43.79$44.45 $44.45 $47.81 $47.81 $45.06 $44.45$46.71 $46.71 $51.53 $51.53 $45.06 $46.71$45.31 $45.31 $50.57 $50.57 $45.06 $45.31$52.08 $52.08 $48.48 $48.48 $45.06 $52.08$60.79 $60.79 $46.57 $46.57 $45.06 $60.79$53.58 $53.58 $54.52 $54.52 $61.20 $53.58$52.87 $52.87 $70.50 $70.50 $61.20 $52.87$73.05 $73.05 $75.88 $75.88 $61.20 $73.05$64.61 $64.61 $86.06 $86.06 $61.20 $64.61$70.25 $70.25 $93.66 $93.66 $72.54 $70.25$69.64 $69.64 $69.64 $69.64 $82.61 $69.64$71.90 $71.90 $95.87 $95.87 $82.06 $71.90$48.69 $48.69 $56.23 $56.23 $55.93 $48.69$53.06 $53.06 $59.22 $59.22 $55.93 $53.06$62.44 $62.44 $67.29 $67.29 $55.93 $62.44$49.12 $49.12 $55.23 $55.23 $55.93 $49.12$53.26 $53.26 $56.20 $56.20 $55.93 $53.26$58.43 $58.43 $58.64 $58.64 $55.93 $58.43$71.14 $71.14 $59.96 $59.96 $55.93 $71.14$59.38 $59.38 $55.86 $55.86 $55.93 $59.38$60.11 $60.11 $61.99 $61.99 $55.93 $60.11$66.12 $66.12 $61.32 $61.32 $55.93 $66.12$85.07 $85.07 $70.10 $70.10 $55.93 $85.07$72.54 $72.54 $70.13 $70.13 $70.97 $72.54$78.94 $78.94 $72.42 $72.42 $70.97 $78.94$80.94 $80.94 $77.39 $77.39 $55.93 $80.94$86.77 $86.77 $79.52 $79.52 $70.97 $86.77$93.89 $93.89 $90.68 $90.68 $70.97 $93.89$96.06 $96.06 $96.06 $96.06 $99.80 $96.06$42.29 $42.29 $48.83 $48.83 $8.35 $42.29$34.29 $34.29 $44.70 $44.70 $75.10 $34.29$91.62 $91.62 $95.50 $95.50 $95.57 $91.62$63.23 $63.23 $73.44 $73.44 $76.57 $63.23$73.33 $73.33 $96.17 $96.17 $76.57 $73.33$80.33 $80.33 $96.63 $96.63 $75.98 $80.33$66.55 $66.55 $69.79 $69.79 $76.57 $66.55



HCPCS 1st Mod 2nd Mod CategoryV2304 POV2305 POV2306 POV2307 POV2308 POV2309 POV2310 POV2311 POV2312 POV2313 POV2314 POV2315 POV2318 POV2319 POV2320 POV2321 POV2410 POV2430 POV2500 POV2501 POV2502 POV2503 POV2510 POV2511 POV2512 POV2513 POV2520 POV2521 POV2522 POV2523 POV2530 POV2531 POV2623 POV2624 POV2625 POV2626 POV2627 POV2628 POV2700 POV2710 POV2715 POV2718 POV2730 POV2744 POV2745 POV2750 POV2755 POV2760 POV2762 POV2770 POV2780 POV2782 POV2783 POV2784 PO

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$69.64 $69.64 $68.14 $68.14 $76.57 $69.64$85.40 $85.40 $84.62 $84.62 $76.57 $85.40$79.63 $79.63 $101.51 $101.51 $76.57 $79.63$78.96 $78.96 $76.29 $76.29 $76.57 $78.96$84.26 $84.26 $79.38 $79.38 $76.57 $84.26$98.57 $98.57 $88.78 $88.78 $76.57 $98.57

$108.42 $108.42 $81.32 $81.32 $76.57 $108.42$103.26 $103.26 $101.69 $101.69 $91.61 $103.26

$91.02 $91.02 $96.14 $96.14 $91.61 $91.02$124.24 $124.24 $100.41 $100.41 $91.61 $124.24$136.09 $136.09 $102.07 $102.07 $91.61 $136.09$151.09 $151.09 $113.31 $113.31 $153.61 $151.09$139.31 $139.31 $139.31 $139.31 $202.32 $139.31

$47.16 $47.16 $53.23 $53.23 $40.61 $47.16$49.75 $49.75 $66.34 $66.34 $90.11 $49.75

$148.92 $148.92 $112.98 $112.98 $143.83 $148.92$85.16 $85.16 $100.46 $100.46 $131.77 $85.16

$110.85 $110.85 $116.36 $116.36 $189.80 $110.85$77.19 $77.19 $96.49 $96.49 $300.32 $77.19

$117.58 $117.58 $117.58 $117.58 $337.89 $117.58$144.85 $144.85 $144.85 $144.85 $336.73 $144.85$138.59 $138.59 $133.40 $133.40 $187.50 $138.59$105.37 $105.37 $139.33 $139.33 $300.32 $105.37$151.40 $151.40 $180.70 $180.70 $336.73 $151.40$178.90 $178.90 $238.54 $238.54 $336.73 $178.90$150.19 $150.19 $200.26 $200.26 $300.32 $150.19

$99.04 $99.04 $119.90 $119.90 $300.32 $99.04$172.43 $172.43 $183.36 $183.36 $337.89 $172.43$167.81 $167.81 $223.74 $223.74 $337.89 $167.81$143.00 $143.00 $174.78 $174.78 $301.65 $143.00$211.81 $211.81 $269.99 $269.99 $190.78 $211.81$519.99 $519.99 $519.93 $519.93 $555.28 $519.99$852.46 $852.46 $1,136.62 $1,136.62 $701.39 $852.46

$57.82 $57.82 $75.85 $75.85 $74.69 $57.82$374.48 $374.48 $364.30 $364.30 $287.79 $374.48$237.59 $237.59 $252.63 $252.63 $172.32 $237.59

$1,360.18 $1,360.18 $1,375.32 $1,375.32 $976.48 $1,360.18$310.99 $310.99 $357.78 $357.78 $746.72 $310.99

$41.60 $41.60 $50.32 $50.32 $45.12 $41.60$60.89 $60.89 $75.54 $75.54 $120.12 $60.89$11.04 $11.04 $12.46 $12.46 $75.85 $11.04$27.11 $27.11 $30.97 $30.97 $39.04 $27.11$20.03 $20.03 $26.70 $26.70 $5.89 $20.03$20.77 $20.77 $19.83 $19.83 $11.99 $20.77$11.78 $11.78 $13.00 $13.00 $11.99 $11.78$24.17 $24.17 $24.17 $24.17 $37.28 $24.17$17.47 $17.47 $21.03 $21.03 $12.38 $17.47$15.21 $15.21 $16.83 $16.83 $7.81 $15.21$57.26 $57.26 $57.24 $57.24 $61.10 $57.26$19.64 $19.64 $20.32 $20.32 $30.03 $19.64$15.87 $15.87 $11.90 $11.90 $30.03 $15.87$61.82 $61.82 $61.82 $61.82 $66.02 $61.82$69.71 $69.71 $69.69 $69.69 $74.45 $69.71$45.33 $45.33 $45.33 $45.33 $48.39 $45.33




HCPCS 1st Mod 2nd Mod CategoryA4216 OSA4217 AU OSA4217 SUA4221 SUA4222 SUA4233 NU INA4234 NU INA4235 NU INA4236 NU INA4253 NU INA4255 SUA4256 SUA4257 SUA4258 SUA4259 SUA4265 SUA4280 POA4310 OSA4311 OSA4312 OSA4313 OSA4314 OSA4315 OSA4316 OSA4320 OSA4322 OSA4326 OSA4327 OSA4328 OSA4330 OSA4331 OSA4332 OSA4333 OSA4334 OSA4336 OSA4338 OSA4340 OS


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


$0.43 $0.43 $0.47 $0.45 $0.47$2.95 $3.47 $3.14 $2.95 $3.47$2.95 $3.47 $3.14 $2.95 $3.47

$22.21 $22.21 $22.21 $22.21 $22.21$44.23 $43.24 $43.24 $44.23 $43.24

$0.51 $0.51 $0.51 $0.51 $0.51$2.36 $2.36 $2.36 $2.36 $2.36$1.00 $1.00 $1.00 $1.00 $1.00$1.16 $1.16 $1.16 $1.16 $1.16$8.32 $8.32 $8.32 $8.32 $8.32$4.55 $4.32 $4.32 $4.55 $4.32$3.38 $3.38 $3.38 $3.38 $3.38

$14.10 $14.10 $14.10 $14.10 $14.10$2.12 $2.12 $2.12 $2.12 $2.12$1.42 $1.42 $1.42 $1.42 $1.42$3.76 $3.76 $3.76 $3.76 $3.76$5.90 $5.90 $5.74 $6.30 $5.74$8.13 $7.26 $8.54 $8.54 $8.54

$15.77 $14.23 $13.93 $14.97 $16.39$19.94 $19.94 $16.95 $16.95 $19.94$20.48 $20.48 $17.41 $20.48 $20.48$26.86 $27.95 $23.76 $26.96 $27.95$29.17 $28.42 $24.79 $29.17 $29.17$31.39 $31.39 $26.68 $31.39 $31.39

$5.04 $5.02 $5.90 $5.39 $5.26$3.37 $3.12 $3.12 $3.37 $3.21

$11.93 $11.93 $11.93 $11.93 $11.46$49.08 $49.31 $46.72 $49.31 $46.72$10.89 $9.81 $10.90 $11.54 $11.20

$6.72 $7.84 $6.72 $6.72 $6.72$3.52 $3.52 $3.52 $3.52 $3.52$0.13 $0.13 $0.13 $0.13 $0.13$2.44 $2.44 $2.44 $2.44 $2.44$5.44 $5.44 $5.44 $5.44 $5.44$1.59 $1.59 $1.59 $1.59 $1.59

$11.95 $13.56 $13.56 $11.53 $13.56$35.10 $35.10 $35.10 $35.10 $29.84

TENNESSEE TEXAS VIRGINIA VIRGIN ISLANDS WEST VIRGINIA



HCPCS 1st Mod 2nd Mod CategoryA4344 OSA4346 OSA4349 OSA4351 OSA4352 OSA4353 OSA4354 OSA4355 OSA4356 OSA4357 OSA4358 OSA4360 OSA4361 OSA4362 OSA4363 OSA4364 OSA4366 OSA4367 OSA4368 OSA4369 OSA4371 OSA4372 OSA4373 OSA4375 OSA4376 OSA4377 OSA4378 OSA4379 OSA4380 OSA4381 OSA4382 OSA4383 OSA4384 OSA4385 OSA4387 OSA4388 OSA4389 OSA4390 OSA4391 OSA4392 OSA4393 OSA4394 OSA4395 OSA4396 OSA4397 OSA4398 OSA4399 OSA4400 OSA4402 OSA4404 OSA4405 OSA4406 OSA4407 OSA4408 OSA4409 OSA4410 OSA4411 OSA4412 OSA4413 OSA4414 OSA4415 OS

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$16.20 $15.05 $17.70 $17.70 $17.70$21.65 $18.40 $21.65 $19.63 $21.65

$2.23 $2.23 $2.23 $2.23 $2.23$1.71 $2.01 $1.80 $1.71 $1.89$6.04 $7.06 $7.10 $7.10 $6.04$7.74 $7.73 $7.73 $7.74 $7.73

$13.05 $13.05 $11.09 $11.09 $13.05$9.86 $9.86 $9.86 $9.86 $9.71

$50.44 $42.87 $42.87 $42.87 $50.44$9.12 $9.12 $9.50 $10.73 $10.73$6.23 $6.23 $7.33 $6.93 $7.33$0.54 $0.46 $0.46 $0.46 $0.54

$20.31 $20.31 $18.48 $17.26 $20.31$3.46 $3.55 $3.26 $3.83 $3.75$2.23 $2.62 $2.23 $2.23 $2.62$2.88 $2.99 $3.25 $3.25 $2.76$1.43 $1.43 $1.43 $1.43 $1.43$6.91 $7.53 $8.10 $7.56 $8.13$0.28 $0.28 $0.28 $0.28 $0.28$2.68 $2.68 $2.68 $2.68 $2.68$4.03 $4.03 $4.03 $4.03 $4.03$4.64 $4.64 $4.64 $4.64 $4.64$6.93 $6.93 $6.93 $6.93 $6.93

$18.99 $18.99 $18.99 $18.99 $18.99$52.61 $52.61 $52.61 $52.61 $52.61

$4.75 $4.75 $4.75 $4.75 $4.75$33.98 $33.98 $33.98 $33.98 $33.98$16.60 $16.60 $16.60 $16.60 $16.60$41.26 $41.26 $41.26 $41.26 $41.26

$5.11 $5.11 $5.11 $5.11 $5.11$27.21 $27.21 $27.21 $27.21 $27.21$31.16 $31.16 $31.16 $31.16 $31.16$10.63 $10.63 $10.63 $10.63 $10.63

$5.64 $5.64 $5.64 $5.64 $5.64$2.48 $2.48 $2.48 $2.48 $2.48$4.83 $4.83 $4.83 $4.83 $4.83$6.87 $6.87 $6.87 $6.87 $6.87

$10.62 $10.62 $10.62 $10.62 $10.62$7.82 $7.82 $7.82 $7.82 $7.82$9.04 $9.04 $9.04 $9.04 $9.04

$10.00 $10.00 $10.00 $10.00 $10.00$2.86 $2.86 $2.86 $2.86 $2.86$0.05 $0.05 $0.05 $0.05 $0.05

$44.75 $44.75 $44.75 $44.75 $44.75$4.50 $5.29 $4.50 $4.70 $5.29

$15.28 $13.27 $13.46 $15.28 $15.28$12.90 $11.53 $13.56 $13.56 $11.53$45.92 $54.02 $45.92 $45.92 $54.02

$1.50 $1.77 $1.77 $1.77 $1.77$1.58 $1.86 $1.86 $1.86 $1.71$3.77 $3.77 $3.77 $3.77 $3.77$6.33 $6.33 $6.33 $6.33 $6.33$9.68 $9.68 $9.68 $9.68 $9.68

$10.91 $10.91 $10.91 $10.91 $10.91$6.87 $6.87 $6.87 $6.87 $6.87

$10.00 $10.00 $10.00 $10.00 $10.00$5.64 $5.64 $5.64 $5.64 $5.64$2.99 $2.99 $2.99 $2.99 $2.99$6.09 $6.09 $6.09 $6.09 $6.09$5.44 $5.44 $5.44 $5.44 $5.44$6.62 $6.62 $6.62 $6.62 $6.62



HCPCS 1st Mod 2nd Mod CategoryA4416 OSA4417 OSA4418 OSA4419 OSA4422 OSA4423 OSA4424 OSA4425 OSA4426 OSA4427 OSA4428 OSA4429 OSA4430 OSA4431 OSA4432 OSA4433 OSA4434 OSA4435 OSA4450 AU OSA4450 AV OSA4450 AW OSA4452 AU OSA4452 AV OSA4452 AW OSA4455 OSA4456 OSA4461 SDA4463 SDA4481 OSA4556 SUA4557 SUA4558 SUA4559 SUA4595 SUA4602 NU INA4604 NU INA4605 NU INA4608 OXA4614 INA4615 SUA4616 SUA4617 SUA4618 NU INA4618 RR INA4618 UE INA4619 NU INA4620 SUA4623 OSA4624 NU INA4625 OSA4626 OSA4628 NU INA4629 OSA4630 NU INA4633 NU INA4635 NU INA4635 RR INA4635 UE INA4636 NU KE INA4636 NU INA4636 RR KE IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$3.05 $3.05 $3.05 $3.05 $3.05$4.11 $4.11 $4.11 $4.11 $4.11$2.01 $2.01 $2.01 $2.01 $2.01$1.92 $1.92 $1.92 $1.92 $1.92$0.13 $0.13 $0.13 $0.13 $0.13$2.06 $2.06 $2.06 $2.06 $2.06$5.26 $5.26 $5.26 $5.26 $5.26$3.96 $3.96 $3.96 $3.96 $3.96$3.02 $3.02 $3.02 $3.02 $3.02$3.08 $3.08 $3.08 $3.08 $3.08$7.20 $7.20 $7.20 $7.20 $7.20$9.12 $9.12 $9.12 $9.12 $9.12$9.41 $9.41 $9.41 $9.41 $9.41$6.87 $6.87 $6.87 $6.87 $6.87$3.97 $3.97 $3.97 $3.97 $3.97$3.70 $3.70 $3.70 $3.70 $3.70$4.15 $4.15 $4.15 $4.15 $4.15$6.38 $6.38 $6.38 $6.38 $6.38$0.09 $0.09 $0.09 $0.09 $0.09$0.09 $0.09 $0.09 $0.09 $0.09$0.12 $0.12 $0.12 $0.12 $0.12$0.40 $0.40 $0.40 $0.40 $0.40$0.40 $0.40 $0.40 $0.40 $0.40$0.44 $0.44 $0.44 $0.44 $0.44$1.34 $1.34 $1.57 $1.34 $1.58$0.27 $0.27 $0.27 $0.27 $0.27$3.64 $3.64 $3.64 $3.64 $3.64

$14.72 $14.72 $14.72 $14.72 $14.72$0.42 $0.41 $0.41 $0.42 $0.41

$11.42 $13.43 $13.43 $13.43 $11.42$15.60 R $15.74 $16.62 R $17.34 $15.49 R $15.64 $16.21 $15.45 R $15.59

$5.13 $5.13 $6.03 $5.13 $6.03$0.11 $0.11 $0.11 $0.11 $0.11

$21.48 R $21.67 $21.06 R $21.67 $21.48 R $21.67 $21.67 $21.48 R $21.67$4.11 $4.11 $4.11 $4.11 $4.11

$51.69 R $53.81 $51.60 R $53.81 $51.69 R $53.81 $53.68 $51.69 R $53.81$18.13 $18.13 $18.13 $18.13 $18.13$55.41 $55.41 $55.41 $55.41 $55.41$26.29 $26.29 $26.29 $26.29 $26.29

$0.80 $0.80 $0.80 $0.80 $0.80$0.07 $0.07 $0.07 $0.07 $0.07$3.43 $3.43 $3.43 $3.43 $3.43$8.36 $8.36 $9.83 $9.83 $8.36$0.97 $0.97 $1.14 $1.14 $0.97$6.26 $6.26 $7.37 $7.37 $6.26$2.01 $2.01 $2.01 $2.01 $2.01$0.70 $0.66 $0.66 $0.70 $0.70$6.15 $6.18 $7.24 $7.24 $6.15$2.47 $2.91 $2.47 $2.47 $2.91$6.51 $7.66 $7.66 $7.66 $7.66$3.00 $3.00 $3.53 $3.53 $3.53$4.13 $4.05 $4.13 $4.05 $4.13$5.13 $5.13 $5.13 $5.13 $5.13$6.90 $6.90 $6.90 $5.87 $5.87

$45.36 $45.36 $45.36 $45.36 $45.36$4.81 $4.81 $5.66 $5.66 $5.66$0.69 $0.72 $0.77 $0.71 $0.69$3.20 $3.20 $3.76 $3.75 $3.76$3.45 $3.45 $3.80 $3.80 $3.45$3.18 $3.18 $3.47 $3.47 $3.18$0.35 $0.35 $0.38 $0.37 $0.35



HCPCS 1st Mod 2nd Mod CategoryA4636 RR INA4636 UE KE INA4636 UE INA4637 NU KE INA4637 NU INA4637 RR KE INA4637 RR INA4637 UE KE INA4637 UE INA4639 RR CRA4640 NU INA4640 RR INA4640 UE INA5051 OSA5052 OSA5053 OSA5054 OSA5055 OSA5056 OSA5057 OSA5061 OSA5062 OSA5063 OSA5071 OSA5072 OSA5073 OSA5081 OSA5082 OSA5083 OSA5093 OSA5102 OSA5105 OSA5112 OSA5113 OSA5114 OSA5120 AU OSA5120 AV POA5121 OSA5122 OSA5126 OSA5131 OSA5200 OSA5500 TSA5501 TSA5503 TSA5504 TSA5505 TSA5506 TSA5507 TSA5512 TSA5513 TSA6010 SDA6011 SDA6021 SDA6022 SDA6023 SDA6024 SDA6154 SDA6196 SDA6197 SDA6199 SD

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$0.32 $0.32 $0.35 $0.34 $0.32$2.54 $2.54 $2.80 $2.80 $2.54$2.35 $2.35 $2.56 $2.56 $2.35$1.82 $1.86 $1.82 $1.82 $1.99$1.68 $1.71 $1.68 $1.68 $1.84$0.22 $0.23 $0.22 $0.22 $0.25$0.20 $0.21 $0.20 $0.20 $0.22$1.37 $1.40 $1.37 $1.40 $1.50$1.27 $1.29 $1.27 $1.29 $1.38

$31.76 $31.76 $31.76 $31.76 $31.76$56.55 R $60.36 $54.08 R $58.03 $59.46 R $63.28 $61.25 $54.45 R $58.26

$5.66 R $6.04 $5.47 R $5.86 $6.01 R $6.39 $6.27 $5.48 R $5.86$42.41 R $45.27 $39.33 R $42.16 $43.15 R $46.01 $44.66 $40.83 R $43.70

$2.28 $2.28 $2.28 $2.28 $2.28$1.64 $1.64 $1.64 $1.64 $1.64$1.63 $1.81 $1.63 $1.82 $1.92$1.99 $1.99 $1.99 $1.99 $1.99$1.35 $1.54 $1.59 $1.57 $1.46$5.16 $5.16 $5.16 $5.16 $5.16

$10.62 $10.62 $10.62 $10.62 $10.62$3.90 $3.90 $3.90 $3.90 $3.90$2.41 $2.30 $2.46 $2.46 $2.30$2.99 $2.99 $2.99 $2.99 $2.99$6.64 $6.64 $6.64 $6.64 $6.64$3.34 $3.80 $3.35 $3.90 $3.90$3.34 $3.52 $3.01 $3.38 $3.46$3.53 $3.11 $3.11 $3.66 $3.66

$11.18 $13.15 $11.18 $11.18 $13.15$0.71 $0.71 $0.71 $0.71 $0.71$1.84 $2.16 $1.84 $1.97 $1.84

$24.96 $24.78 $24.96 $24.96 $24.78$45.07 $45.07 $38.31 $45.07 $45.07$35.61 $32.53 $38.27 $33.89 $34.83

$4.43 $4.43 $5.21 $5.21 $4.43$8.42 $9.90 $8.42 $9.90 $8.42$0.26 $0.27 $0.23 $0.27 $0.24$0.26 $0.26 $0.25 $0.26 $0.25$8.24 $7.89 $7.00 $7.00 $7.89

$12.07 $12.07 $12.07 $12.60 $14.20$1.23 $1.45 $1.28 $1.23 $1.23

$16.00 $17.53 $14.90 $17.53 $14.90$12.50 $12.48 $12.48 $12.50 $12.48$70.29 $70.29 $70.29 $70.29 $70.29

$210.83 $210.83 $210.83 $210.83 $210.83$34.55 $34.55 $34.55 $34.55 $34.55$34.55 $34.55 $34.55 $34.55 $34.55$34.55 $34.55 $34.55 $34.55 $34.55$34.55 $34.55 $34.55 $34.55 $34.55$34.55 $34.55 $34.55 $34.55 $34.55$28.67 $28.67 $28.67 $28.67 $28.67$42.79 $42.79 $42.79 $42.79 $42.79$34.24 $34.24 $34.24 $34.24 $34.24

$2.52 $2.52 $2.52 $2.52 $2.52$23.24 $23.24 $23.24 $23.24 $23.24$23.24 $23.24 $23.24 $23.24 $23.24

$210.39 $210.39 $210.39 $210.39 $210.39$6.84 $6.84 $6.84 $6.84 $6.84

$15.90 $15.41 $15.41 $15.90 $15.41$8.13 $8.13 $8.13 $8.13 $8.13

$18.17 $18.17 $18.17 $18.17 $18.17$5.85 $5.85 $5.85 $5.85 $5.85



HCPCS 1st Mod 2nd Mod CategoryA6203 SDA6204 SDA6207 SDA6209 SDA6210 SDA6211 SDA6212 SDA6214 SDA6216 SDA6219 SDA6220 SDA6222 SDA6223 SDA6224 SDA6229 SDA6231 SDA6232 SDA6233 SDA6234 SDA6235 SDA6236 SDA6237 SDA6238 SDA6240 SDA6241 SDA6242 SDA6243 SDA6244 SDA6245 SDA6246 SDA6247 SDA6248 SDA6251 SDA6252 SDA6253 SDA6254 SDA6255 SDA6257 SDA6258 SDA6259 SDA6266 SDA6402 SDA6403 SDA6407 SDA6410 SDA6441 SDA6442 SDA6443 SDA6444 SDA6445 SDA6446 SDA6447 SDA6448 SDA6449 SDA6450 SDA6451 SDA6452 SDA6453 SDA6454 SDA6455 SDA6456 SD

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$3.72 $3.72 $3.72 $3.72 $3.72$6.88 $6.88 $6.88 $6.88 $6.88$8.11 $8.11 $8.11 $8.11 $8.11$8.26 $8.26 $8.26 $8.26 $8.26

$22.03 $22.03 $22.03 $22.03 $22.03$32.47 $32.47 $32.47 $32.47 $32.47$10.73 $10.73 $10.73 $10.73 $10.73$11.37 $11.37 $11.37 $11.37 $11.37

$0.05 $0.05 $0.05 $0.05 $0.05$1.06 $1.06 $1.06 $1.06 $1.06$2.86 $2.86 $2.86 $2.86 $2.86$2.35 $2.35 $2.35 $2.35 $2.35$2.68 $2.68 $2.68 $2.68 $2.68$3.99 $3.99 $3.99 $3.99 $3.99$3.99 $3.99 $3.99 $3.99 $3.99$5.18 $5.16 $5.16 $5.18 $5.16$7.59 $7.59 $7.59 $7.59 $7.59

$21.20 $21.20 $21.20 $21.20 $21.20$7.23 $7.23 $7.23 $7.23 $7.23

$18.59 $18.59 $18.59 $18.59 $18.59$30.13 $30.13 $30.13 $30.13 $30.13

$8.75 $8.75 $8.75 $8.75 $8.75$25.20 $25.20 $25.20 $25.20 $25.20$13.54 $13.54 $13.54 $13.54 $13.54

$2.84 $2.84 $2.84 $2.84 $2.84$6.70 $6.70 $6.70 $6.70 $6.70

$13.62 $13.62 $13.62 $13.62 $13.62$43.43 $43.43 $43.43 $43.43 $43.43

$8.03 $8.03 $8.03 $8.03 $8.03$10.98 $10.98 $10.98 $10.98 $10.98$26.29 $26.29 $26.29 $26.29 $26.29$17.96 $17.96 $17.96 $17.96 $17.96

$2.20 $2.20 $2.20 $2.20 $2.20$3.60 $3.60 $3.60 $3.60 $3.60$7.00 $7.00 $7.00 $7.00 $7.00$1.33 $1.33 $1.33 $1.33 $1.33$3.36 $3.36 $3.36 $3.36 $3.36$1.70 $1.70 $1.70 $1.70 $1.70$4.77 $4.77 $4.77 $4.77 $4.77

$12.10 $12.10 $12.10 $12.10 $12.10$2.13 $2.13 $2.13 $2.13 $2.13$0.13 $0.13 $0.13 $0.13 $0.13$0.47 $0.47 $0.47 $0.47 $0.47$2.08 $2.08 $2.08 $2.08 $2.08$0.43 $0.43 $0.43 $0.43 $0.43$0.75 $0.75 $0.75 $0.75 $0.75$0.18 $0.18 $0.18 $0.18 $0.18$0.31 $0.31 $0.31 $0.31 $0.31$0.62 $0.62 $0.62 $0.62 $0.62$0.36 $0.36 $0.36 $0.36 $0.36$0.45 $0.45 $0.45 $0.45 $0.45$0.75 $0.75 $0.75 $0.75 $0.75$1.28 $1.28 $1.28 $1.28 $1.28$1.94 $1.94 $1.94 $1.94 $1.94$1.94 $1.94 $1.94 $1.94 $1.94$1.94 $1.94 $1.94 $1.94 $1.94$6.53 $6.53 $6.53 $6.53 $6.53$0.69 $0.69 $0.69 $0.69 $0.69$0.86 $0.86 $0.86 $0.86 $0.86$1.54 $1.54 $1.54 $1.54 $1.54$1.40 $1.40 $1.40 $1.40 $1.40



HCPCS 1st Mod 2nd Mod CategoryA6457 SDA6531 AW SDA6532 AW SDA6545 AW SDA6550 SUA7000 NU KE INA7000 NU INA7001 NU INA7002 NU INA7003 NU INA7004 NU INA7005 NU INA7006 NU INA7007 NU INA7008 NU INA7009 NU INA7010 NU INA7012 NU INA7013 NU INA7014 NU INA7015 NU INA7016 NU INA7017 NU INA7017 RR INA7017 UE INA7018 SUA7020 NU INA7025 RR CRA7026 NU INA7027 NU INA7028 NU INA7029 NU INA7030 NU INA7031 NU INA7032 NU INA7033 NU INA7034 NU INA7035 NU INA7036 NU INA7037 NU INA7038 NU INA7039 NU INA7044 NU INA7045 NU INA7045 RR INA7045 UE INA7046 NU INA7047 NU INA7501 OSA7502 OSA7503 OSA7504 OSA7505 OSA7506 OSA7507 OSA7508 OSA7509 OSA7520 OSA7521 OSA7522 OSA7524 OS

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$1.26 $1.26 $1.26 $1.26 $1.26$47.83 $47.83 $47.83 $47.83 $47.83$67.39 $67.39 $67.39 $67.39 $67.39$94.17 $94.17 $94.17 $94.17 $94.17$25.34 R $26.15 $25.29 R $26.15 $25.34 R $26.15 $26.15 $25.34 R $26.15

$9.36 R $9.71 $9.14 R $9.47 $8.79 R $9.14 $9.04 $8.79 R $9.14$8.63 R $8.98 $8.45 R $8.69 $8.10 R $8.10 $7.94 $8.10 R $8.10

$33.19 $31.08 $36.56 $32.98 $36.56$3.60 $3.60 $4.23 $3.83 $4.23$2.28 R $2.35 $2.22 R $2.27 $2.05 R $2.12 $2.34 $2.05 R $2.12$1.48 R $1.53 $1.47 R $1.53 $1.63 R $1.68 $1.53 $1.63 R $1.68

$20.66 R $21.00 $20.12 R $21.00 $23.22 R $23.55 $21.88 $23.22 R $23.55$9.01 R $9.14 $8.49 R $9.10 $9.01 R $9.14 $8.37 $9.01 R $9.14$4.10 R $4.17 $3.76 R $4.00 $4.19 R $4.25 $3.89 $4.19 R $4.25

$10.34 $10.34 $12.16 $12.16 $12.16$46.48 $43.16 $46.48 $41.90 $46.48$18.99 R $19.35 $17.99 R $19.35 $20.95 R $21.31 $21.16 $20.95 R $21.31

$3.54 R $3.60 $3.26 R $3.50 $3.23 R $3.28 $3.49 $3.23 R $3.28$0.67 R $0.69 $0.64 R $0.69 $0.74 R $0.76 $0.72 $0.74 R $0.76$4.09 R $4.23 $3.91 R $4.15 $4.09 R $4.23 $3.98 $4.09 R $4.23$1.69 R $1.72 $1.64 R $1.72 $1.55 R $1.59 $1.59 $1.55 R $1.59$7.77 $7.21 $8.01 $7.21 $8.01

$135.02 R $136.08 $125.01 R $136.08 $135.02 R $136.08 $136.08 $135.02 R $136.08$13.51 R $13.62 $12.51 R $13.62 $13.51 R $13.62 $13.62 $13.51 R $13.62

$101.26 R $102.06 $93.76 R $102.06 $101.26 R $102.06 $102.06 $101.26 R $102.06$0.34 R $0.35 $0.33 R $0.35 $0.37 R $0.38 $0.38 $0.37 R $0.38

$16.01 $15.42 $15.42 $16.01 $16.01$48.09 $48.09 $48.09 $48.09 $48.09$31.78 $31.78 $31.78 $31.78 $31.78

$164.57 R $168.74 $157.74 R $164.76 $160.59 R $164.76 $168.32 $164.57 R $168.74$44.64 R $45.84 $43.69 R $45.84 $44.64 R $45.84 $45.88 $44.64 R $45.84$18.89 R $19.63 $18.86 R $19.63 $18.89 R $19.63 $19.58 $18.89 R $19.63

$134.76 R $139.24 $134.01 R $139.24 $134.76 R $139.24 $138.88 $134.76 R $139.24$50.59 R $52.01 $50.03 R $52.01 $50.59 R $52.01 $51.88 $50.59 R $52.01$29.04 R $29.78 $28.73 R $29.78 $29.04 R $29.78 $29.70 $29.04 R $29.78$21.24 R $22.03 $21.24 R $22.03 $21.24 R $22.03 $21.98 $21.24 R $22.03$84.27 R $86.78 $84.00 R $86.78 $84.27 R $86.78 $86.55 $84.27 R $86.78$27.01 R $27.96 $25.55 R $26.66 $28.13 R $29.08 $26.95 $28.13 R $29.08$12.85 R $13.40 $12.48 R $13.14 $12.59 R $13.14 $14.41 $12.59 R $13.14$25.74 R $26.28 $24.31 R $25.00 $25.68 R $26.21 $25.34 $25.68 R $26.21

$3.63 R $3.74 $3.51 R $3.61 $3.24 R $3.35 $3.34 $3.24 R $3.35$9.27 R $9.56 $9.29 R $9.56 $9.73 R $10.02 $10.63 $9.73 R $10.02

$99.20 R $102.79 $96.81 R $102.79 $99.20 R $102.79 $102.56 $99.20 R $102.79$15.13 R $15.92 $14.95 R $15.92 $15.13 R $15.92 $15.89 $15.13 R $15.92

$1.51 R $1.59 $1.49 R $1.59 $1.51 R $1.59 $1.59 $1.51 R $1.59$11.36 R $11.95 $11.22 R $11.95 $11.36 R $11.95 $11.92 $11.36 R $11.95$15.95 R $16.54 $15.68 R $16.54 $15.95 R $16.54 $16.50 $15.95 R $16.54

$133.66 $133.66 $133.66 $133.66 $133.66$116.10 $116.10 $116.10 $116.10 $116.10

$55.19 $55.19 $55.19 $55.19 $55.19$12.54 $12.54 $12.54 $12.54 $12.54

$0.75 $0.75 $0.75 $0.75 $0.75$5.18 $5.18 $5.18 $5.18 $5.18$0.37 $0.37 $0.37 $0.37 $0.37$2.75 $2.75 $2.75 $2.75 $2.75$3.17 $3.17 $3.17 $3.17 $3.17$1.56 $1.56 $1.56 $1.56 $1.56

$52.49 $52.49 $52.49 $52.49 $52.49$52.00 $52.00 $52.00 $52.00 $52.00$49.93 $49.93 $49.93 $49.93 $49.93$85.58 $85.58 $85.58 $85.58 $85.58



HCPCS 1st Mod 2nd Mod CategoryA7525 OSA7526 OSA7527 OSA8000 NU INA8000 RR INA8000 UE INA8001 NU INA8001 RR INA8001 UE INB4034 PEB4035 PEB4036 PEB4081 PEB4082 PEB4083 PEB4087 PEB4088 PEB4149 PEB4150 PEB4152 PEB4153 PEB4154 PEB4155 PEB4164 PEB4168 PEB4176 PEB4178 PEB4180 PEB4185 PEB4189 PEB4193 PEB4197 PEB4199 PEB4216 PEB4220 PEB4222 PEB4224 PEB5000 PEB5100 PEB9000 MS PEB9000 NU PEB9000 RR PEB9000 UE PEB9002 MS PEB9002 NU PEB9002 RR PEB9002 UE PEB9004 MS PEB9004 NU PEB9004 RR PEB9004 UE PEB9006 MS PEB9006 NU PEB9006 RR PEB9006 UE PEE0100 NU INE0100 RR INE0100 UE INE0105 NU INE0105 RR INE0105 UE IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$2.28 $2.28 $2.28 $2.28 $2.28$3.74 $3.74 $3.74 $3.74 $3.74$3.96 $3.96 $3.96 $3.96 $3.96

$169.54 $169.54 $169.54 $169.54 $169.54$16.95 $16.95 $16.95 $16.95 $16.95

$127.18 $127.18 $127.18 $127.18 $127.18$169.54 $169.54 $169.54 $169.54 $169.54

$16.95 $16.95 $16.95 $16.95 $16.95$127.18 $127.18 $127.18 $127.18 $127.18

$4.67 R $4.80 $4.63 R $4.80 $4.67 R $4.80 $4.80 $4.67 R $4.80$8.75 R $8.87 $8.55 R $8.87 $8.75 R $8.87 $9.11 $8.75 R $8.87$6.22 R $6.38 $6.12 R $6.38 $6.22 R $6.38 $6.41 $6.22 R $6.38

$18.53 R $19.44 $18.45 R $19.44 $18.53 R $19.44 $19.44 $18.53 R $19.44$13.70 R $14.23 $13.44 R $14.23 $13.70 R $14.23 $14.23 $13.70 R $14.23

$2.08 R $2.16 $2.07 R $2.16 $2.08 R $2.16 $2.16 $2.08 R $2.16$31.22 R $32.91 $31.45 R $32.91 $31.22 R $32.91 $32.91 $31.22 R $32.91$33.00 R $35.38 $33.74 R $35.38 $33.00 R $35.38 $36.42 $33.00 R $35.38

$1.31 R $1.36 $1.30 R $1.36 $1.31 R $1.36 $1.36 $1.31 R $1.36$0.54 R $0.55 $0.54 R $0.55 $0.54 R $0.55 $0.56 $0.54 R $0.55$0.44 R $0.45 $0.44 R $0.45 $0.44 R $0.45 $0.46 $0.44 R $0.45$1.59 R $1.63 $1.57 R $1.63 $1.59 R $1.63 $1.74 $1.59 R $1.63$0.96 R $0.98 $0.95 R $0.98 $0.96 R $0.98 $0.99 $0.96 R $0.98$0.84 R $0.88 $0.85 R $0.88 $0.84 R $0.88 $0.96 $0.84 R $0.88

$19.50 $19.50 $19.50 $19.50 $19.50$28.44 $28.44 $28.44 $28.44 $28.44$55.03 $55.03 $55.03 $55.03 $55.03$66.05 $66.05 $66.05 $66.05 $66.05$28.00 $28.00 $28.00 $28.00 $28.00$12.90 $12.90 $12.90 $12.90 $12.90

$204.06 $204.06 $204.06 $204.06 $204.06$263.67 $263.67 $263.67 $263.67 $263.67$321.01 $321.01 $321.01 $321.01 $321.01$366.81 $366.81 $366.81 $366.81 $366.81

$8.86 $8.86 $8.86 $8.86 $8.86$9.19 $9.19 $9.19 $9.19 $9.19

$11.33 $11.33 $11.33 $11.33 $11.33$28.70 $28.70 $28.70 $28.70 $28.70$13.65 $13.65 $13.65 $13.65 $13.65

$5.33 $5.33 $5.33 $5.33 $5.33$44.74 R $45.72 $44.14 R $45.72 $44.74 R $45.72 $46.50 $44.74 R $45.72

$945.53 R $965.15 $933.50 R $965.15 $945.53 R $965.15 $980.79 $945.53 R $965.15$89.48 R $91.44 $88.28 R $91.44 $89.48 R $91.44 $93.00 $89.48 R $91.44

$709.15 R $723.87 $700.12 R $723.87 $709.15 R $723.87 $735.60 $709.15 R $723.87$46.32 R $47.28 $45.69 R $47.28 $46.32 R $47.28 $48.05 $46.32 R $47.28

$946.10 R $965.31 $933.50 R $965.31 $946.10 R $965.31 $980.79 $946.10 R $965.31$92.64 R $94.56 $91.38 R $94.56 $92.64 R $94.56 $96.11 $92.64 R $94.56

$709.58 R $723.98 $700.12 R $723.98 $709.58 R $723.98 $735.60 $709.58 R $723.98$229.27 $229.27 $229.27 $229.27 $229.27

$2,896.55 $2,896.55 $2,896.55 $2,896.55 $2,896.55$458.53 $458.53 $458.53 $458.53 $458.53

$2,172.41 $2,172.41 $2,172.41 $2,172.41 $2,172.41$229.27 $229.27 $229.27 $229.27 $229.27

$2,896.55 $2,896.55 $2,896.55 $2,896.55 $2,896.55$458.53 $458.53 $458.53 $458.53 $458.53

$2,172.41 $2,172.41 $2,172.41 $2,172.41 $2,172.41$23.30 $21.66 $22.89 $23.30 $21.59

$5.58 $5.58 $6.56 $6.56 $6.56$18.57 $16.26 $18.57 $18.57 $17.43$53.30 $52.77 $52.44 $54.30 $50.20

$8.33 $8.33 $9.80 $9.80 $9.80$41.65 $41.76 $41.85 $41.85 $39.28



HCPCS 1st Mod 2nd Mod CategoryE0110 NU INE0110 RR INE0110 UE INE0111 NU INE0111 RR INE0111 UE INE0112 NU INE0112 RR INE0112 UE INE0113 NU INE0113 RR INE0113 UE INE0114 NU INE0114 RR INE0114 UE INE0116 NU INE0116 RR INE0116 UE INE0117 RR CRE0130 NU INE0130 RR INE0130 UE INE0135 NU INE0135 RR INE0135 UE INE0140 RR CRE0141 NU INE0141 RR INE0141 UE INE0143 NU INE0143 RR INE0143 UE INE0144 RR CRE0147 NU INE0147 RR INE0147 UE INE0148 NU INE0148 RR INE0148 UE INE0149 RR CRE0153 NU INE0153 RR INE0153 UE INE0154 NU INE0154 RR INE0154 UE INE0155 NU INE0155 RR INE0155 UE INE0156 NU INE0156 RR INE0156 UE INE0157 NU INE0157 RR INE0157 UE INE0158 NU INE0158 RR INE0158 UE INE0159 NU INE0159 RR INE0159 UE IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$77.14 $78.90 $85.78 $85.78 $72.91$15.02 $15.02 $17.67 $15.02 $17.67$57.85 $59.17 $64.31 $64.31 $54.66$50.04 $50.04 $58.87 $56.02 $53.53

$7.91 $7.91 $9.31 $7.91 $9.31$38.62 $38.62 $45.44 $41.99 $45.44$34.77 $40.91 $34.77 $40.91 $37.09

$9.34 $9.34 $10.99 $9.34 $10.99$26.52 $31.20 $31.20 $31.20 $27.80$19.86 $20.25 $22.94 $23.37 $19.86

$4.84 $4.84 $5.69 $5.69 $5.69$14.90 $15.20 $17.13 $17.53 $14.90$51.13 $45.52 $45.84 $48.62 $44.34

$8.05 $8.05 $9.47 $8.54 $9.47$38.35 $34.13 $34.43 $36.87 $39.44$26.08 $26.08 $30.68 $26.08 $26.08

$5.08 $5.08 $5.98 $5.98 $5.98$19.63 $19.63 $23.09 $19.63 $19.63$21.29 $21.29 $21.29 $21.29 $21.29$55.01 R $56.89 $53.31 R $57.16 $56.72 R $58.60 $58.72 $57.65 R $59.53$10.02 R $10.21 $9.03 R $9.41 $10.43 R $10.62 $9.41 $10.43 R $10.62$44.22 R $45.63 $41.40 R $44.29 $44.22 R $45.63 $45.63 $44.22 R $45.63$62.04 R $63.67 $61.14 R $63.67 $60.19 R $61.82 $63.67 $58.53 R $60.16

$9.81 R $9.97 $9.11 R $9.36 $10.43 R $10.59 $10.35 $10.43 R $10.59$47.22 R $48.45 $46.55 R $48.45 $47.22 R $48.45 $48.45 $44.69 R $45.92$31.04 R $31.95 $29.73 R $31.95 $31.04 R $31.95 $31.95 $31.04 R $31.95$85.61 R $87.99 $86.22 R $91.87 $89.01 R $91.39 $96.23 $85.61 R $87.99$12.96 R $13.19 $12.63 R $13.19 $14.55 R $14.79 $13.19 $14.55 R $14.79$64.67 R $66.46 $64.68 R $68.92 $66.81 R $68.60 $72.17 $64.21 R $65.99$81.31 R $82.69 $78.94 R $80.79 $77.54 R $78.93 $82.89 $72.92 R $74.30$11.17 R $11.31 $11.12 R $11.31 $11.17 R $11.31 $12.85 $12.71 R $12.85$60.98 R $62.02 $56.60 R $57.98 $58.15 R $59.19 $62.08 $54.61 R $55.65$27.88 $27.88 $27.88 $27.88 $27.88

$460.82 R $478.71 $457.57 R $478.71 $460.82 R $478.71 $481.01 $460.82 R $478.71$46.09 R $47.88 $45.76 R $47.88 $46.09 R $47.88 $48.11 $46.09 R $47.88

$345.62 R $359.04 $343.18 R $359.04 $345.62 R $359.04 $360.77 $345.62 R $359.04$101.56 R $104.66 $98.77 R $104.66 $101.56 R $104.66 $104.66 $101.56 R $104.66

$10.16 R $10.47 $9.88 R $10.47 $10.16 R $10.47 $10.47 $10.16 R $10.47$76.16 R $78.49 $74.07 R $78.49 $76.16 R $78.49 $78.49 $76.16 R $78.49$16.79 R $16.90 $16.13 R $16.90 $16.79 R $16.90 $16.90 $16.79 R $16.90$76.71 $76.71 $65.20 $76.71 $65.20

$8.67 $8.67 $8.16 $8.01 $7.37$57.52 $57.52 $48.89 $57.52 $48.89$55.72 R $58.69 $55.74 R $59.31 $51.31 R $54.27 $58.61 $51.31 R $54.27

$5.74 R $6.04 $6.29 R $6.65 $5.79 R $6.08 $6.32 $5.74 R $6.04$41.93 R $44.16 $42.13 R $44.81 $38.76 R $40.98 $44.70 $38.76 R $40.98$22.77 R $24.00 $24.65 R $26.16 $24.93 R $26.16 $25.27 $24.93 R $26.16

$2.55 R $2.67 $2.80 R $2.95 $2.82 R $2.95 $2.81 $2.82 R $2.95$17.17 R $18.09 $18.68 R $19.81 $18.88 R $19.81 $19.12 $18.88 R $19.81$19.11 R $19.64 $18.01 R $19.08 $19.78 R $20.31 $20.97 $18.55 R $19.08

$2.15 R $2.21 $2.10 R $2.21 $2.40 R $2.45 $2.45 $2.15 R $2.21$14.33 R $14.73 $13.51 R $14.32 $14.84 R $15.24 $15.74 $13.92 R $14.32$66.58 R $68.53 $57.79 R $62.67 $60.72 R $62.67 $63.62 $60.72 R $62.67

$6.97 R $7.17 $6.11 R $6.60 $6.40 R $6.60 $6.60 $6.40 R $6.60$49.93 R $51.40 $43.34 R $47.00 $45.54 R $47.00 $47.73 $45.54 R $47.00$23.40 R $24.48 $24.57 R $26.22 $23.40 R $24.48 $24.48 $25.70 R $26.78

$2.48 R $2.58 $2.67 R $2.84 $2.73 R $2.84 $2.58 $2.73 R $2.84$17.62 R $18.42 $18.43 R $19.67 $17.62 R $18.42 $18.42 $19.35 R $20.16$15.76 R $16.29 $15.33 R $16.29 $15.76 R $16.29 $16.29 $15.76 R $16.29

$1.61 R $1.66 $1.54 R $1.64 $1.61 R $1.66 $1.66 $1.61 R $1.66$11.82 R $12.22 $11.50 R $12.22 $11.82 R $12.22 $12.22 $11.82 R $12.22



HCPCS 1st Mod 2nd Mod CategoryE0160 NU INE0160 RR INE0160 UE INE0161 NU INE0161 RR INE0161 UE INE0162 NU INE0162 RR INE0162 UE INE0163 NU INE0163 RR INE0163 UE INE0165 RR CRE0167 NU INE0167 RR INE0167 UE INE0168 NU INE0168 RR INE0168 UE INE0170 RR CRE0171 RR CRE0175 NU INE0175 RR INE0175 UE INE0181 RR CRE0182 RR CRE0184 NU INE0184 RR INE0184 UE INE0185 NU INE0185 RR INE0185 UE INE0186 RR CRE0187 RR CRE0188 NU INE0188 RR INE0188 UE INE0189 NU INE0189 RR INE0189 UE INE0191 NU INE0191 RR INE0191 UE INE0193 RR CRE0194 RR CRE0196 RR CRE0197 RR CRE0198 RR CRE0199 NU INE0199 RR INE0199 UE INE0200 NU INE0200 RR INE0200 UE INE0202 RR CRE0205 NU INE0205 RR INE0205 UE INE0210 NU INE0210 RR INE0210 UE IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$28.50 R $30.91 $28.76 R $30.91 $28.50 R $30.91 $36.54 $28.50 R $30.91$3.34 R $3.58 $3.36 R $3.58 $3.34 R $3.58 $4.80 $3.70 R $3.94

$21.37 R $23.17 $21.56 R $23.17 $21.37 R $23.17 $27.38 $21.37 R $23.17$26.66 R $27.67 $23.41 R $24.64 $26.66 R $27.67 $27.67 $26.66 R $27.67

$2.90 R $3.00 $2.79 R $3.00 $2.90 R $3.00 $3.14 $3.19 R $3.29$19.97 R $20.73 $17.54 R $18.45 $19.97 R $20.73 $20.73 $19.97 R $20.73

$161.08 $136.92 $136.92 $161.08 $154.66$16.89 $14.36 $15.11 $16.89 $16.89

$124.91 $106.17 $106.17 $124.91 $112.98$86.64 R $87.91 $87.11 R $89.58 $88.30 R $89.58 $89.58 $86.14 R $87.41$14.64 R $14.76 $16.11 R $16.36 $16.23 R $16.36 $14.34 $16.23 R $16.36$65.97 R $66.93 $66.62 R $68.48 $67.52 R $68.48 $68.48 $67.52 R $68.48$14.85 R $15.25 $16.05 R $16.79 $16.28 R $16.69 $18.37 $14.85 R $15.25$11.44 R $12.33 $11.77 R $12.38 $10.82 R $11.70 $12.41 $11.52 R $12.41

$1.14 R $1.23 $1.17 R $1.24 $1.18 R $1.27 $1.26 $1.18 R $1.27$8.59 R $9.26 $8.87 R $9.33 $8.11 R $8.78 $9.33 $8.67 R $9.33

$142.60 R $146.20 $138.06 R $146.20 $142.60 R $146.20 $146.20 $142.60 R $146.20$14.30 R $14.66 $13.80 R $14.61 $14.25 R $14.61 $14.66 $14.25 R $14.61

$106.95 R $109.64 $103.54 R $109.64 $106.95 R $109.64 $109.64 $106.95 R $109.64$167.50 R $175.50 $167.33 R $175.50 $167.50 R $175.50 $177.69 $167.50 R $175.50

$30.38 R $31.97 $30.61 R $31.97 $30.38 R $31.97 $31.97 $30.38 R $31.97$73.23 $73.23 $73.23 $62.25 $67.21

$7.32 $7.32 $7.32 $6.22 $6.71$53.89 $53.89 $53.89 $45.81 $50.40$22.26 R $22.80 $22.22 R $22.80 $22.26 R $22.80 $25.40 $22.26 R $22.80$21.72 R $23.35 $22.40 R $23.35 $21.72 R $23.35 $24.79 $21.72 R $23.35

$186.70 R $193.55 $166.35 R $177.41 $186.70 R $193.55 $193.55 $170.56 R $177.41$21.49 R $22.17 $21.07 R $22.17 $20.54 R $21.22 $22.17 $21.49 R $22.17

$141.85 R $146.99 $126.31 R $134.61 $141.85 R $146.99 $146.99 $141.85 R $146.99$262.13 R $267.88 $262.63 R $267.88 $235.61 R $241.36 $267.88 $235.61 R $241.36

$33.38 R $33.95 $33.43 R $33.95 $33.38 R $33.95 $33.95 $33.38 R $33.95$199.69 R $204.00 $200.07 R $204.00 $179.34 R $183.65 $204.00 $179.34 R $183.65

$18.29 R $19.07 $20.17 R $21.13 $19.97 R $21.13 $22.44 $19.97 R $21.13$20.40 R $21.81 $23.33 R $24.09 $22.32 R $24.09 $25.66 $22.32 R $24.09$26.23 R $27.60 $23.46 R $24.84 $26.23 R $27.60 $25.56 $26.23 R $27.60

$2.88 R $3.02 $2.56 R $2.76 $2.88 R $3.02 $3.42 $2.88 R $3.02$19.69 R $20.71 $17.61 R $18.66 $19.69 R $20.71 $18.66 $19.69 R $20.71$52.80 R $54.96 $53.27 R $54.96 $52.80 R $54.96 $57.45 $52.80 R $54.96

$5.52 R $5.73 $5.56 R $5.73 $5.52 R $5.73 $6.22 $5.52 R $5.73$39.60 R $41.22 $39.96 R $41.22 $39.60 R $41.22 $42.48 $39.60 R $41.22

$9.39 $10.35 $11.05 $9.39 $10.99$0.97 $1.04 $1.14 $0.97 $1.14$7.00 $7.77 $8.24 $7.00 $8.22

$730.11 R $762.78 $767.92 R $798.23 $739.44 R $772.11 $830.42 $750.73 R $783.40$3,181.64 $3,278.64 $3,058.05 $3,058.05 $3,140.80

$29.91 R $30.53 $33.18 R $34.73 $32.60 R $34.73 $35.92 $32.10 R $34.22$22.58 R $24.04 $22.82 R $24.04 $25.12 R $26.57 $28.72 $25.12 R $26.57$24.50 $20.83 $24.50 $20.83 $24.50$32.13 R $33.89 $32.10 R $33.43 $32.13 R $33.89 $35.45 $29.47 R $30.13

$3.20 R $3.38 $3.21 R $3.34 $3.20 R $3.38 $3.53 $2.94 R $3.00$24.09 R $25.41 $24.07 R $25.07 $24.09 R $25.41 $26.57 $22.10 R $22.59$87.65 $87.65 $87.65 $87.65 $87.65$11.90 $11.90 $11.90 $11.90 $11.90$65.77 $65.77 $65.77 $65.77 $65.77$69.22 $69.22 $69.22 $69.22 $69.22

$214.54 $214.54 $214.54 $214.54 $214.54$23.59 $23.60 $23.60 $23.60 $23.60

$160.90 $160.90 $160.90 $160.90 $160.90$30.68 $30.68 $36.09 $30.68 $36.09

$2.89 $2.89 $3.40 $2.89 $3.40$23.00 $23.00 $27.06 $23.00 $27.06



HCPCS 1st Mod 2nd Mod CategoryE0215 NU INE0215 RR INE0215 UE INE0217 NU INE0217 RR INE0217 UE INE0225 NU INE0225 RR INE0225 UE INE0235 RR CRE0236 RR CRE0239 NU INE0239 RR INE0239 UE INE0249 NU INE0249 RR INE0249 UE INE0250 RR CRE0251 RR CRE0255 RR CRE0256 RR CRE0260 RR CRE0261 RR CRE0265 RR CRE0266 RR CRE0271 NU INE0271 RR INE0271 UE INE0272 NU INE0272 RR INE0272 UE INE0275 NU INE0275 RR INE0275 UE INE0276 NU INE0276 RR INE0276 UE INE0277 RR CRE0280 NU INE0280 RR INE0280 UE INE0290 RR CRE0291 RR CRE0292 RR CRE0293 RR CRE0294 RR CRE0295 RR CRE0296 RR CRE0297 RR CRE0300 RR CRE0301 RR CRE0302 RR CRE0303 RR CRE0304 RR CRE0305 RR CRE0310 NU INE0310 RR INE0310 UE INE0316 RR CRE0325 NU INE0325 RR IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$78.32 $78.32 $78.32 $66.57 $78.32$8.19 $8.19 $8.19 $6.96 $8.19

$58.75 $58.75 $58.75 $49.94 $58.75$548.86 $548.86 $466.53 $466.53 $466.53

$61.10 $61.10 $51.94 $51.94 $51.94$411.61 $411.61 $349.87 $349.87 $349.87$429.65 $429.65 $385.99 $429.65 $365.20

$42.35 $42.35 $37.23 $42.35 $36.00$322.23 $322.23 $279.39 $322.23 $273.90

$16.21 $19.07 $19.07 $19.07 $16.21$48.91 $48.91 $48.91 $42.60 $41.57

$422.70 $497.29 $497.29 $422.70 $422.70$42.28 $49.74 $49.74 $42.28 $42.28

$317.03 $372.98 $372.98 $317.03 $317.03$110.12 $110.12 $93.60 $93.60 $93.60

$12.11 $12.11 $10.29 $10.29 $10.29$82.59 $82.59 $70.20 $70.20 $70.20$70.76 R $74.09 $78.34 R $81.07 $70.76 R $74.09 $75.83 $77.74 R $81.07$58.07 R $61.04 $63.93 R $66.07 $57.56 R $60.02 $64.41 $60.23 R $63.46$85.03 R $88.28 $89.50 R $92.16 $88.91 R $92.16 $93.91 $88.91 R $92.16$62.46 R $65.60 $69.50 R $71.56 $62.46 R $65.60 $71.56 $62.46 R $65.60$98.02 R $100.06 $97.57 R $100.06 $98.02 R $100.06 $100.06 $98.02 R $100.06$85.06 R $87.62 $95.52 R $97.40 $85.17 R $87.72 $97.40 $87.83 R $90.38

$153.72 $163.27 $163.27 $163.27 $152.96$134.16 $143.81 $136.84 $143.81 $139.06$167.67 R $171.66 $156.56 R $163.95 $167.67 R $171.66 $155.79 $151.80 R $155.79

$17.18 R $17.58 $15.66 R $16.40 $17.14 R $17.54 $15.93 $15.53 R $15.93$129.04 R $132.04 $117.42 R $122.96 $129.04 R $132.04 $119.64 $116.65 R $119.64$165.55 R $171.08 $153.84 R $162.81 $165.55 R $171.08 $156.95 $159.94 R $165.47

$16.98 R $17.54 $15.38 R $16.28 $16.98 R $17.54 $16.06 $16.98 R $17.54$123.82 R $127.96 $115.38 R $122.11 $123.82 R $127.96 $117.42 $119.95 R $124.10

$14.55 R $15.32 $15.27 R $15.90 $15.13 R $15.90 $15.45 $15.13 R $15.90$1.46 R $1.54 $1.57 R $1.63 $1.55 R $1.63 $1.57 $1.55 R $1.63

$10.92 R $11.50 $11.45 R $11.92 $11.34 R $11.92 $11.57 $11.34 R $11.92$11.80 R $12.50 $13.29 R $13.74 $12.13 R $12.96 $14.71 $12.90 R $13.74

$1.30 R $1.38 $1.47 R $1.51 $1.43 R $1.51 $1.63 $1.43 R $1.51$9.10 R $9.73 $10.27 R $10.60 $9.10 R $9.73 $11.48 $9.97 R $10.60

$435.23 R $437.93 $436.95 R $437.92 $435.22 R $437.92 $437.92 $435.21 R $437.91$33.03 R $34.76 $33.12 R $34.76 $30.30 R $30.95 $36.40 $30.30 R $30.95

$3.45 R $3.62 $3.45 R $3.62 $3.19 R $3.36 $3.92 $3.15 R $3.32$24.77 R $26.07 $24.84 R $26.07 $22.72 R $23.21 $27.30 $22.72 R $23.21$57.59 R $60.54 $64.03 R $66.22 $57.59 R $60.54 $65.70 $57.59 R $60.54$42.78 R $43.98 $47.60 R $49.33 $42.78 R $43.98 $49.33 $42.78 R $43.98$63.85 R $68.06 $71.81 R $74.14 $63.85 R $68.06 $76.37 $63.85 R $68.06$55.28 R $57.93 $62.46 R $64.05 $60.39 R $64.05 $64.05 $55.28 R $57.93$87.14 R $89.57 $96.08 R $98.91 $92.03 R $94.46 $106.98 $90.24 R $92.68$85.00 R $87.06 $93.64 R $96.16 $85.00 R $87.06 $104.89 $85.62 R $87.68

$119.58 $131.31 $131.31 $131.31 $119.58$103.81 $113.86 $113.86 $113.86 $103.81$253.53 $253.53 $253.53 $253.53 $253.53$201.45 R $204.80 $209.15 R $216.44 $205.26 R $208.62 $216.44 $208.46 R $211.81$577.97 R $594.85 $576.13 R $594.85 $577.97 R $594.85 $640.85 $577.97 R $594.85$216.26 R $220.03 $226.10 R $231.65 $220.06 R $223.83 $231.65 $223.27 R $227.04$611.42 R $624.51 $599.60 R $624.51 $611.42 R $624.51 $624.51 $611.42 R $624.51

$12.50 R $12.92 $13.76 R $14.19 $13.77 R $14.19 $14.41 $12.50 R $12.92$149.28 R $152.10 $140.72 R $146.52 $146.30 R $149.12 $138.61 $144.89 R $147.71

$14.98 R $15.26 $16.06 R $16.64 $16.52 R $16.80 $15.21 $16.52 R $16.80$111.85 R $113.97 $110.36 R $114.71 $112.59 R $114.71 $104.50 $108.67 R $110.78$183.15 R $189.75 $172.93 R $183.87 $185.76 R $192.36 $185.45 $186.39 R $193.00

$9.03 R $9.51 $10.15 R $10.44 $9.87 R $10.44 $9.51 $9.03 R $9.51$1.14 R $1.20 $1.29 R $1.32 $1.26 R $1.32 $1.20 $1.14 R $1.20



HCPCS 1st Mod 2nd Mod CategoryE0325 UE INE0326 NU INE0326 RR INE0326 UE INE0371 RR CRE0372 RR CRE0373 RR CRE0424 RR OXE0431 RR OXE0433 RR OXE0434 RR OXE0439 RR OXE0441 OXE0442 OXE0443 OXE0444 OXE0462 RR CRE0465 RR FSE0466 RR FSE0470 RR CRE0471 RR CRE0472 RR CRE0480 RR CRE0482 RR CRE0483 RR CRE0484 NU INE0484 RR INE0484 UE INE0500 RR FSE0550 RR CRE0560 NU INE0560 RR INE0560 UE INE0561 NU INE0561 RR INE0561 UE INE0562 NU INE0562 RR INE0562 UE INE0565 RR CRE0570 RR CRE0572 RR CRE0574 RR CRE0575 RR CRE0580 NU INE0580 RR INE0580 UE INE0585 RR CRE0600 RR CRE0601 RR CRE0602 NU INE0602 RR INE0602 UE INE0605 NU INE0605 RR INE0605 UE INE0606 RR CRE0607 NU INE0607 RR INE0607 UE INE0610 NU IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$6.28 R $6.28 $7.12 R $7.33 $6.90 R $7.33 $6.28 $6.28 R $6.28$9.54 R $9.86 $10.53 R $11.01 $10.41 R $11.01 $10.57 $10.41 R $11.01$1.02 R $1.08 $1.13 R $1.18 $1.12 R $1.18 $1.12 $1.05 R $1.11$7.16 R $7.40 $7.90 R $8.26 $7.81 R $8.26 $7.92 $7.81 R $8.26


$23.92 R $24.74 $23.88 R $24.74 $23.92 R $24.74 $24.74 $23.92 R $24.74$44.71 R $46.90 $44.30 R $46.90 $44.71 R $46.90 $46.90 $44.71 R $46.90$23.92 R $24.74 $23.88 R $24.74 $23.92 R $24.74 $24.74 $23.92 R $24.74

$126.67 R $129.37 $125.88 R $129.37 $126.67 R $129.37 $133.36 $126.67 R $129.37$65.75 R $67.93 $65.25 R $67.93 $65.75 R $67.93 $67.93 $65.75 R $67.93$65.75 R $67.93 $65.25 R $67.93 $65.75 R $67.93 $67.93 $65.75 R $67.93$63.13 R $65.20 $62.85 R $65.20 $63.13 R $65.20 $65.20 $63.13 R $65.20$63.13 R $65.20 $62.85 R $65.20 $63.13 R $65.20 $65.20 $63.13 R $65.20

$322.15 $322.15 $322.15 $273.83 $303.95$1,055.23 $1,055.23 $1,054.10 $1,055.23 $1,055.23$1,055.23 $1,055.23 $1,054.10 $1,055.23 $1,055.23

$176.42 R $181.24 $175.84 R $181.24 $176.42 R $181.24 $180.75 $176.42 R $181.24$438.62 R $452.62 $389.34 R $406.54 $414.30 R $428.30 $451.39 $438.62 R $452.62$503.12 R $523.26 $454.26 R $477.18 $478.80 R $498.94 $522.03 $503.12 R $523.26

$41.29 $48.58 $44.15 $41.29 $44.56$445.66 $475.40 $448.84 $475.40 $459.32

$1,175.30 $1,175.30 $1,175.30 $1,175.30 $1,175.30$40.83 $40.83 $40.83 $40.83 $40.83

$4.07 $4.07 $4.07 $4.07 $4.07$30.63 $30.63 $30.63 $30.63 $30.63

$103.17 $121.34 $121.34 $121.34 $121.34$55.42 $55.42 $47.11 $55.41 $47.11

$151.25 $163.42 $159.72 $163.42 $163.42$16.28 $17.66 $19.15 $19.15 $19.15

$113.44 $122.57 $119.81 $122.57 $122.57$87.15 R $89.95 $84.72 R $89.95 $87.15 R $89.95 $89.75 $87.15 R $89.95

$8.71 R $8.99 $8.46 R $8.99 $8.71 R $8.99 $8.97 $8.71 R $8.99$65.36 R $67.46 $63.53 R $67.46 $65.36 R $67.46 $67.31 $65.36 R $67.46

$213.36 R $218.96 $211.49 R $218.96 $213.36 R $218.96 $218.38 $213.36 R $218.96$21.33 R $21.89 $21.14 R $21.89 $21.33 R $21.89 $21.83 $21.33 R $21.89

$160.02 R $164.21 $158.62 R $164.21 $160.02 R $164.21 $163.78 $160.02 R $164.21$54.17 R $56.36 $54.46 R $56.36 $52.06 R $54.24 $56.36 $49.11 R $51.30$11.94 R $12.07 $11.81 R $12.07 $11.94 R $12.07 $12.07 $11.94 R $12.07$35.15 R $35.15 $33.57 R $36.36 $35.30 R $35.30 $36.36 $35.76 R $35.76$41.95 $44.51 $42.25 $44.51 $43.24

$113.62 $113.62 $96.58 $113.62 $113.62$127.60 $127.60 $127.60 $127.60 $127.60

$12.76 $12.76 $12.76 $12.76 $12.76$95.69 $95.69 $95.69 $95.69 $95.69$32.20 R $32.79 $31.95 R $34.50 $33.91 R $34.50 $34.50 $33.91 R $34.50$43.03 $50.62 $43.03 $50.62 $50.62$74.24 R $75.77 $69.63 R $71.50 $69.95 R $71.47 $75.55 $72.69 R $74.22$32.63 $32.63 $32.63 $32.63 $32.63

$3.28 $3.28 $3.28 $3.28 $3.28$24.48 $24.48 $24.48 $24.48 $24.48$29.22 $29.22 $29.22 $29.22 $27.67

$3.38 $3.40 $3.40 $3.40 $3.40$24.08 $24.08 $24.08 $24.08 $20.74$25.38 $22.25 $21.57 $23.18 $25.38$73.86 $73.86 $73.86 $73.86 $73.86

$7.38 $7.38 $7.38 $7.38 $7.38$55.39 $55.39 $55.39 $55.39 $55.39

$262.95 $262.95 $262.95 $262.95 $262.95



HCPCS 1st Mod 2nd Mod CategoryE0610 RR INE0610 UE INE0615 NU INE0615 RR INE0615 UE INE0617 RR KF CRE0617 RR CRE0618 RR CRE0620 RR CRE0621 NU INE0621 RR INE0621 UE INE0627 NU INE0627 RR INE0627 UE INE0628 NU INE0628 RR INE0628 UE INE0629 NU INE0629 RR INE0629 UE INE0630 RR CRE0635 RR CRE0636 RR CRE0639 RR CRE0640 RR CRE0650 NU INE0650 RR INE0650 UE INE0651 NU INE0651 RR INE0651 UE INE0652 NU INE0652 RR INE0652 UE INE0655 NU INE0655 RR INE0655 UE INE0656 RR CRE0657 RR CRE0660 NU INE0660 RR INE0660 UE INE0665 NU INE0665 RR INE0665 UE INE0666 NU INE0666 RR INE0666 UE INE0667 NU INE0667 RR INE0667 UE INE0668 NU INE0668 RR INE0668 UE INE0669 NU INE0669 RR INE0669 UE INE0670 NU INE0670 RR INE0670 UE IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$27.73 $27.73 $27.73 $27.73 $27.73$197.24 $197.24 $197.24 $197.24 $197.24$529.32 $529.32 $529.32 $483.28 $490.87

$64.67 $64.67 $64.67 $54.97 $64.67$397.02 $397.02 $397.02 $358.47 $368.12$373.20 $373.20 $373.20 $373.20 $373.20$336.12 $336.12 $336.12 $336.12 $336.12$309.95 $263.46 $263.46 $309.95 $301.83

$96.65 $96.65 $96.65 $96.65 $96.65$85.42 R $91.12 $94.41 R $97.67 $91.97 R $97.67 $90.20 $84.01 R $89.72

$8.55 R $9.12 $9.24 R $9.57 $9.00 R $9.57 $8.75 $8.23 R $8.69$64.07 R $68.35 $71.01 R $73.46 $68.99 R $73.26 $67.99 $63.18 R $67.46

$312.74 R $325.30 $307.03 R $321.65 $312.74 R $325.30 $331.86 $309.08 R $321.65$31.28 R $32.53 $30.68 R $32.14 $31.28 R $32.53 $33.18 $30.91 R $32.17

$234.55 R $243.98 $230.26 R $241.23 $234.55 R $243.98 $248.90 $231.80 R $241.23$324.33 R $337.67 $313.69 R $334.02 $324.33 R $337.67 $340.43 $320.67 R $334.01

$32.44 R $33.77 $31.34 R $33.38 $32.44 R $33.77 $34.04 $32.07 R $33.40$243.25 R $253.25 $235.25 R $250.50 $243.25 R $253.25 $255.33 $240.49 R $250.50$315.38 R $332.51 $313.96 R $332.51 $315.38 R $332.51 $310.76 $315.38 R $332.51

$31.54 R $33.25 $31.37 R $33.23 $31.54 R $33.25 $31.08 $31.54 R $33.25$236.52 R $249.38 $235.46 R $249.38 $236.52 R $249.38 $233.05 $236.52 R $249.38

$85.49 R $87.94 $85.33 R $87.94 $84.85 R $87.30 $87.94 $83.50 R $85.95$123.94 R $130.04 $129.03 R $130.04 $113.79 R $114.98 $126.82 $113.79 R $114.98

$1,061.04 R $1,108.08 $1,070.93 R $1,108.08 $1,061.04 R $1,108.08 $1,165.83 $1,061.04 R $1,108.08$123.32 $123.32 $104.82 $119.72 $104.82$123.32 $123.32 $104.82 $119.72 $104.82$676.77 $772.71 $711.26 $719.95 $729.29

$98.25 $88.94 $98.25 $86.51 $98.25$507.58 $579.53 $533.45 $543.46 $546.95

$1,015.31 $1,015.31 $863.01 $863.01 $863.01$103.72 $101.53 $96.15 $96.98 $88.16$761.50 $761.50 $647.28 $647.28 $647.28

$5,860.79 $5,860.79 $4,981.67 $5,560.54 $5,792.45$579.22 $579.22 $492.34 $556.03 $579.21

$4,391.67 $4,391.67 $3,732.92 $3,956.43 $4,344.34$101.88 $115.58 $119.32 $107.99 $119.32

$11.92 $11.92 $14.02 $14.02 $14.02$76.43 $86.66 $89.51 $80.94 $89.60$63.88 $63.88 $63.88 $63.88 $63.88$60.01 $60.01 $60.01 $60.01 $60.01

$161.97 $176.60 $150.11 $175.80 $176.60$16.20 $17.98 $18.38 $17.68 $18.38

$121.45 $132.45 $112.58 $132.45 $132.45$151.45 $151.45 $130.33 $151.45 $128.73

$15.55 $15.27 $15.55 $15.29 $13.22$113.72 $113.72 $97.76 $113.72 $96.66$149.66 $152.67 $129.77 $146.40 $152.67

$15.00 $15.66 $14.15 $14.33 $15.73$112.24 $114.52 $97.34 $113.38 $114.52$357.93 $357.93 $304.24 $357.93 $357.92

$40.42 $40.42 $34.36 $40.42 $35.81$268.45 $268.45 $228.18 $268.45 $268.44$488.50 $488.50 $415.23 $415.23 $415.23

$48.21 $48.21 $40.98 $40.98 $40.98$366.39 $366.39 $311.43 $311.43 $311.43$202.66 $192.43 $192.41 $202.07 $192.41

$20.28 $19.25 $19.25 $20.20 $19.25$152.03 $144.33 $144.31 $151.54 $144.31

$1,389.68 $1,389.68 $1,181.23 $1,389.68 $1,354.48$148.77 $148.77 $126.45 $148.77 $135.37

$1,042.21 $1,042.21 $885.88 $1,042.21 $1,015.96



HCPCS 1st Mod 2nd Mod CategoryE0671 NU INE0671 RR INE0671 UE INE0672 NU INE0672 RR INE0672 UE INE0673 NU INE0673 RR INE0673 UE INE0675 RR CRE0691 NU INE0691 RR INE0691 UE INE0692 NU INE0692 RR INE0692 UE INE0693 NU INE0693 RR INE0693 UE INE0694 NU INE0694 RR INE0694 UE INE0705 NU KU INE0705 NU INE0705 RR KU INE0705 RR INE0705 UE KU INE0705 UE INE0720 NU TEE0730 NU TEE0731 NU INE0740 RR CRE0744 RR CRE0745 RR CRE0747 NU KF INE0747 RR KF INE0747 UE KF INE0748 NU KF INE0748 RR KF INE0748 UE KF INE0760 NU KF INE0760 RR KF INE0760 UE KF INE0762 RR CRE0764 RR KF CRE0765 NU INE0765 RR INE0765 UE INE0776 NU BA PEE0776 NU KE PEE0776 NU INE0776 RR BA PEE0776 RR KE PEE0776 RR INE0776 UE BA PEE0776 UE KE PEE0776 UE INE0779 RR CRE0780 NU INE0781 RR CRE0784 RR CR

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$459.18 $459.18 $459.18 $459.18 $459.18$45.94 $45.94 $45.94 $45.94 $45.94

$344.37 $344.37 $344.37 $344.37 $344.37$356.77 $356.77 $356.77 $356.77 $356.77

$35.69 $35.69 $35.69 $35.69 $35.69$267.60 $267.60 $267.60 $267.60 $267.60$296.46 $296.46 $296.46 $296.46 $296.46

$29.65 $29.65 $29.65 $29.65 $29.65$222.38 $222.38 $222.38 $222.38 $222.38$425.12 $425.12 $425.12 $425.12 $425.12$993.40 $993.40 $993.40 $993.40 $993.40

$99.33 $99.33 $99.33 $99.33 $99.33$745.05 $745.05 $745.05 $745.05 $745.05

$1,247.44 $1,247.44 $1,247.44 $1,247.44 $1,247.44$124.73 $124.73 $124.73 $124.73 $120.44$935.57 $935.57 $935.57 $935.57 $935.57

$1,537.74 $1,537.74 $1,537.74 $1,537.74 $1,537.74$153.78 $153.78 $153.78 $153.78 $153.78

$1,153.30 $1,153.30 $1,153.30 $1,153.30 $1,153.30$4,894.46 $4,894.46 $4,894.46 $4,894.46 $4,894.46

$489.44 $489.44 $489.44 $489.44 $489.44$3,670.87 $3,670.87 $3,670.87 $3,670.87 $3,670.87

$60.94 $51.80 $60.94 $58.16 $51.80$54.50 R $55.15 $47.88 R $50.57 $54.50 R $55.15 $53.76 $49.92 R $50.57

$6.13 $5.27 $6.20 $5.97 $5.27$5.47 R $5.53 $4.83 R $5.10 $5.50 R $5.57 $5.45 $5.04 R $5.10

$44.63 $37.96 $44.63 $44.63 $37.94$40.34 R $40.82 $35.47 R $37.49 $40.34 R $40.82 $40.82 $36.99 R $37.48

$242.51 R $242.51 $228.48 R $236.29 $246.14 R $246.14 $230.35 $246.14 R $246.14$239.02 R $239.02 $230.04 R $237.21 $230.94 R $230.94 $227.55 $242.57 R $242.57$246.81 R $246.81 $208.21 R $217.24 $233.87 R $233.87 $217.24 $217.24 R $217.24

$57.82 $57.82 $57.82 $57.82 $57.82$86.05 $86.05 $86.05 $101.23 $86.05$84.12 $98.96 $87.34 $98.16 $98.96

$4,329.25 $4,329.25 $3,679.86 $4,302.23 $4,329.25$430.20 $430.20 $365.67 $430.20 $430.20

$3,216.55 $3,216.55 $2,734.07 $3,216.55 $3,216.55$4,301.21 $4,301.21 $4,301.21 $4,301.21 $4,301.21

$430.10 $430.10 $430.10 $430.10 $430.10$3,225.91 $3,225.91 $3,225.91 $3,225.91 $3,225.91$3,574.23 $3,574.23 $3,574.23 $3,574.23 $3,574.23

$357.43 $357.43 $357.43 $357.43 $357.43$2,680.65 $2,680.65 $2,680.65 $2,680.65 $2,680.65

$121.55 $103.32 $121.55 $103.32 $103.32$1,223.43 $1,223.43 $1,223.43 $1,223.43 $1,223.43

$93.01 $93.01 $93.01 $93.01 $93.01$9.31 $9.31 $9.31 $9.31 $9.31

$69.78 $69.78 $69.78 $69.78 $69.78$77.87 R $79.77 $76.27 R $79.77 $77.87 R $79.77 $79.77 $77.87 R $79.77$86.21 R $88.11 $84.61 R $88.11 $86.21 R $88.11 $88.11 $86.21 R $88.11

$142.69 $134.53 $142.39 $134.53 $148.01$15.75 R $15.94 $15.59 R $15.94 $15.75 R $15.94 $15.94 $15.75 R $15.94$17.87 R $18.06 $17.71 R $18.06 $17.87 R $18.06 $18.06 $17.87 R $18.06$15.65 $15.65 $17.20 $15.65 $17.20$58.41 R $59.84 $57.21 R $59.84 $58.41 R $59.84 $59.84 $58.41 R $59.84$64.66 R $66.08 $63.46 R $66.08 $64.66 R $66.08 $66.08 $64.66 R $66.08

$107.02 $98.98 $106.81 $98.98 $109.89$17.45 $18.18 $17.56 $17.96 $17.93$11.41 $11.41 $11.41 $11.41 $11.41

$262.38 $262.38 $240.42 $262.38 $253.65$439.93 $439.88 $439.88 $439.93 $439.88



HCPCS 1st Mod 2nd Mod CategoryE0791 RR CRE0840 NU INE0840 RR INE0840 UE INE0849 RR CRE0850 NU INE0850 RR INE0850 UE INE0855 RR CRE0856 RR CRE0860 NU INE0860 RR INE0860 UE INE0870 NU INE0870 RR INE0870 UE INE0880 NU INE0880 RR INE0880 UE INE0890 NU INE0890 RR INE0890 UE INE0900 NU INE0900 RR INE0900 UE INE0910 RR CRE0911 RR CRE0912 RR CRE0920 RR CRE0930 RR CRE0935 RR FSE0940 RR CRE0941 RR CRE0942 NU INE0942 RR INE0942 UE INE0944 NU INE0944 RR INE0944 UE INE0945 NU INE0945 RR INE0945 UE INE0946 RR CRE0947 NU INE0947 RR INE0947 UE INE0948 NU INE0948 RR INE0948 UE INE0950 NU KE INE0950 NU KU INE0950 NU INE0950 RR KE INE0950 RR KU INE0950 RR INE0950 UE KE INE0950 UE KU INE0950 UE INE0951 NU KE INE0951 NU KU INE0951 NU IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$312.56 $312.56 $298.36 $286.34 $286.34$68.84 $68.84 $80.99 $80.99 $80.99$15.34 $16.95 $18.05 $18.05 $18.05$51.61 $51.61 $60.72 $60.72 $60.72$56.98 $56.98 $56.98 $56.98 $56.98

$106.40 $116.13 $116.13 $116.13 $116.13$13.56 $13.56 $15.95 $15.95 $15.95$79.82 $87.11 $87.11 $87.11 $87.11$55.56 $54.65 $54.65 $55.56 $54.65$17.01 $17.01 $17.01 $17.01 $17.01$37.71 $36.21 $36.21 $36.21 $41.12

$6.12 $6.12 $7.20 $6.12 $7.20$29.53 $27.73 $32.31 $27.84 $30.82

$109.30 $128.59 $128.59 $128.59 $128.59$12.61 $14.83 $14.83 $14.83 $14.30$82.34 $96.87 $96.87 $96.87 $96.87

$117.97 $123.01 $138.79 $117.97 $138.79$18.52 $18.52 $21.79 $18.52 $21.79$89.29 $92.26 $105.05 $89.29 $105.05

$113.14 $133.10 $117.16 $133.10 $124.55$30.86 $30.86 $36.30 $36.30 $36.30$91.14 $107.22 $92.38 $107.22 $107.22

$120.40 $130.39 $141.65 $139.48 $120.40$25.96 $25.96 $30.54 $25.96 $30.54$90.33 $97.79 $106.27 $104.48 $90.33$13.82 R $14.25 $14.85 R $15.43 $15.00 R $15.43 $15.43 $14.27 R $14.70$44.43 R $46.22 $44.03 R $46.22 $44.43 R $46.22 $46.24 $44.43 R $46.22$96.08 R $98.11 $95.01 R $98.11 $96.08 R $98.11 $102.57 $96.08 R $98.11$51.02 $51.02 $50.20 $51.02 $43.37$50.50 $50.50 $50.50 $44.73 $48.41$21.37 $25.14 $25.14 $21.37 $25.14$24.37 R $25.29 $26.61 R $27.77 $26.11 R $27.04 $29.41 $24.37 R $25.29$47.98 $47.98 $47.98 $47.98 $40.78$18.65 $21.94 $19.00 $18.65 $19.52

$2.21 $2.60 $2.60 $2.21 $2.21$13.97 $16.43 $14.22 $13.97 $14.65$47.94 $43.10 $50.71 $43.10 $50.71

$4.81 $4.34 $5.10 $4.34 $5.10$35.97 $32.33 $38.03 $32.33 $38.03$41.65 $41.65 $41.65 $41.65 $49.00

$4.17 $4.17 $4.17 $4.17 $4.91$32.23 $32.23 $32.23 $32.23 $37.92$55.60 $55.60 $55.71 $59.17 $55.60

$584.00 $569.88 $569.88 $670.45 $569.88$59.08 $59.08 $59.08 $69.51 $59.08

$437.97 $427.40 $427.40 $502.82 $427.40$584.00 $551.21 $551.21 $648.48 $551.21

$56.98 $55.10 $55.10 $64.82 $55.10$437.97 $388.76 $395.07 $457.37 $388.76

$94.28 R $97.35 $93.90 R $97.35 $94.28 R $97.35 $88.73 $85.66 R $88.73$99.05 $99.05 $99.05 $84.19 $84.19$86.34 R $89.41 $85.96 R $89.41 $86.34 R $89.41 $81.98 $78.91 R $81.98

$9.43 R $9.74 $9.40 R $9.74 $9.43 R $9.74 $8.88 $8.57 R $8.88$9.93 $9.93 $9.93 $8.44 $8.44$8.65 R $8.95 $8.61 R $8.95 $8.65 R $8.95 $8.21 $7.90 R $8.21

$70.71 R $73.01 $70.42 R $73.01 $70.71 R $73.01 $66.55 $64.24 R $66.55$74.29 $74.29 $74.29 $63.15 $63.15$64.75 R $67.06 $64.47 R $67.06 $64.75 R $67.06 $61.49 $59.18 R $61.49$15.86 R $16.38 $14.82 R $15.80 $16.85 R $17.37 $17.37 $15.28 R $15.80$16.37 $15.38 $18.09 $18.09 $15.38$14.55 R $15.07 $13.59 R $14.57 $15.40 R $15.92 $15.92 $14.05 R $14.57



HCPCS 1st Mod 2nd Mod CategoryE0951 RR KE INE0951 RR KU INE0951 RR INE0951 UE KE INE0951 UE KU INE0951 UE INE0952 NU KE INE0952 NU KU INE0952 NU INE0952 RR KE INE0952 RR KU INE0952 RR INE0952 UE KE INE0952 UE KU INE0952 UE INE0955 RR KE CRE0955 RR KU CRE0955 RR CRE0956 NU KE INE0956 NU KU INE0956 NU INE0956 RR KE INE0956 RR KU INE0956 RR INE0956 UE KE INE0956 UE KU INE0956 UE INE0957 NU KE INE0957 NU KU INE0957 NU INE0957 RR KE INE0957 RR KU INE0957 RR INE0957 UE KE INE0957 UE KU INE0957 UE INE0958 RR CRE0959 NU INE0959 RR INE0959 UE INE0960 NU KE INE0960 NU KU INE0960 NU INE0960 RR KE INE0960 RR KU INE0960 RR INE0960 UE KE INE0960 UE KU INE0960 UE INE0961 NU INE0961 RR INE0961 UE INE0966 NU INE0966 RR INE0966 UE INE0967 NU INE0967 RR INE0967 UE INE0968 RR CRE0969 NU INE0969 RR IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$1.58 R $1.63 $1.51 R $1.61 $1.70 R $1.75 $1.77 $1.56 R $1.61$1.63 $1.58 $1.83 $1.86 $1.58$1.45 R $1.51 $1.38 R $1.48 $1.55 R $1.60 $1.62 $1.43 R $1.48

$11.88 R $12.27 $11.10 R $11.84 $12.63 R $13.02 $13.02 $11.45 R $11.84$12.27 $11.53 $13.56 $13.56 $11.53$10.90 R $11.30 $10.19 R $10.92 $11.55 R $11.94 $11.94 $10.53 R $10.92$16.51 $16.98 $18.07 $18.07 $16.51$15.26 $16.06 $17.95 $17.95 $15.26$15.26 $15.70 $16.64 $16.64 $15.26

$1.69 $1.70 $1.85 $1.85 $1.69$1.58 $1.61 $1.86 $1.86 $1.58$1.56 $1.57 $1.70 $1.70 $1.56

$12.40 $12.74 $13.57 $13.57 $12.40$11.45 $12.04 $13.47 $13.47 $11.45$11.44 $11.77 $12.49 $12.49 $11.44$18.12 R $18.81 $18.05 R $18.81 $18.12 R $18.81 $18.81 $18.12 R $18.81$19.28 $19.28 $19.28 $19.28 $19.28$16.58 R $17.27 $16.51 R $17.27 $16.58 R $17.27 $17.27 $16.58 R $17.27$90.99 R $94.72 $91.08 R $94.72 $90.99 R $94.72 $94.72 $90.99 R $94.72$93.92 $93.92 $93.92 $93.92 $93.92$83.46 R $87.19 $83.54 R $87.19 $83.46 R $87.19 $87.19 $83.46 R $87.19

$9.10 R $9.48 $9.11 R $9.48 $9.10 R $9.48 $9.48 $9.10 R $9.48$9.39 $9.39 $9.39 $9.39 $9.39$8.35 R $8.72 $8.35 R $8.72 $8.35 R $8.72 $8.72 $8.35 R $8.72

$68.24 R $71.04 $68.30 R $71.04 $68.24 R $71.04 $71.04 $68.24 R $71.04$70.45 $70.45 $70.45 $70.45 $70.45$62.60 R $65.39 $62.66 R $65.39 $62.60 R $65.39 $65.39 $62.60 R $65.39

$133.70 R $139.17 $134.95 R $139.17 $133.70 R $139.17 $141.74 $133.70 R $139.17$131.43 $131.43 $131.43 $131.43 $131.43$123.18 R $128.64 $124.42 R $128.64 $123.18 R $128.64 $131.22 $123.18 R $128.64

$13.38 R $13.92 $13.50 R $13.92 $13.38 R $13.92 $14.18 $13.38 R $13.92$13.15 $13.15 $13.15 $13.15 $13.15$12.32 R $12.87 $12.44 R $12.87 $12.32 R $12.87 $13.12 $12.32 R $12.87

$100.28 R $104.37 $101.21 R $104.37 $100.28 R $104.37 $106.31 $100.28 R $104.37$98.57 $98.57 $98.57 $98.57 $98.57$92.38 R $96.48 $93.31 R $96.48 $92.38 R $96.48 $98.41 $92.38 R $96.48$41.33 R $43.27 $41.88 R $43.91 $40.20 R $41.00 $47.92 $43.81 R $45.97$44.20 R $46.88 $45.07 R $47.15 $41.34 R $41.54 $47.49 $41.34 R $41.54

$4.43 R $4.70 $4.52 R $4.73 $4.15 R $4.18 $4.74 $4.15 R $4.18$33.15 R $35.16 $33.80 R $35.36 $31.14 R $31.43 $36.76 $31.14 R $31.43$85.44 R $88.47 $85.14 R $88.47 $85.44 R $88.47 $93.79 $85.44 R $88.47$86.69 $86.69 $86.69 $86.69 $86.69$78.50 R $81.52 $78.20 R $81.52 $78.50 R $81.52 $86.69 $78.50 R $81.52

$8.55 R $8.85 $8.52 R $8.85 $8.55 R $8.85 $9.38 $8.55 R $8.85$8.69 $8.69 $8.69 $8.69 $8.69$7.86 R $8.16 $7.83 R $8.16 $7.86 R $8.16 $8.69 $7.86 R $8.16

$64.09 R $66.36 $63.86 R $66.36 $64.09 R $66.36 $70.35 $64.09 R $66.36$65.03 $65.03 $65.03 $65.03 $65.03$58.88 R $61.15 $58.65 R $61.15 $58.88 R $61.15 $65.03 $58.88 R $61.15$23.61 R $24.75 $25.17 R $26.35 $23.61 R $24.75 $24.75 $26.07 R $27.21

$2.42 R $2.54 $2.68 R $2.80 $2.42 R $2.54 $2.54 $2.68 R $2.80$13.95 R $13.95 $15.39 R $16.28 $13.95 R $13.95 $13.95 $13.95 R $13.95$71.82 R $75.98 $73.99 R $76.48 $66.40 R $67.07 $78.70 $67.10 R $68.48

$7.18 R $7.60 $7.35 R $7.60 $6.60 R $6.62 $7.79 $6.72 R $6.86$53.86 R $56.99 $55.49 R $57.36 $49.80 R $50.30 $59.03 $50.32 R $51.35$70.58 R $72.61 $70.33 R $72.58 $70.58 R $72.61 $72.58 $70.58 R $72.61

$7.06 R $7.27 $7.03 R $7.26 $7.06 R $7.27 $7.26 $7.06 R $7.27$52.93 R $54.44 $52.75 R $54.44 $52.93 R $54.44 $54.44 $52.93 R $54.44$18.07 $19.81 $19.81 $19.79 $19.81

$172.98 $157.56 $156.07 $162.80 $164.35$17.14 $15.77 $15.62 $17.14 $16.41



HCPCS 1st Mod 2nd Mod CategoryE0969 UE INE0971 NU INE0971 RR INE0971 UE INE0973 NU KE INE0973 NU KU INE0973 NU INE0973 RR KE INE0973 RR KU INE0973 RR INE0973 UE KE INE0973 UE KU INE0973 UE INE0974 NU INE0974 RR INE0974 UE INE0978 NU KE INE0978 NU KU INE0978 NU INE0978 RR KE INE0978 RR KU INE0978 RR INE0978 UE KE INE0978 UE KU INE0978 UE INE0980 NU INE0980 RR INE0980 UE INE0981 NU KE INE0981 NU KU INE0981 NU INE0981 RR KE INE0981 RR KU INE0981 RR INE0981 UE KE INE0981 UE KU INE0981 UE INE0982 NU KE INE0982 NU KU INE0982 NU INE0982 RR KE INE0982 RR KU INE0982 RR INE0982 UE KE INE0982 UE KU INE0982 UE INE0983 RR CRE0984 RR CRE0985 RR KU CRE0985 RR CRE0986 RR CRE0988 RR CRE0990 NU KE INE0990 NU KU INE0990 NU INE0990 RR KE INE0990 RR KU INE0990 RR INE0990 UE KE INE0990 UE KU INE0990 UE IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$129.73 $118.17 $117.09 $127.50 $123.25$39.08 R $39.93 $37.88 R $39.93 $39.08 R $39.93 $39.93 $39.08 R $39.93

$3.92 R $4.00 $3.80 R $4.00 $3.92 R $4.00 $4.00 $3.92 R $4.00$29.33 R $29.96 $28.43 R $29.96 $29.33 R $29.96 $29.96 $29.33 R $29.96$87.85 R $88.21 $78.87 R $82.30 $88.45 R $88.81 $89.06 $81.94 R $82.30

$103.30 $93.12 $104.33 $97.37 $93.12$79.57 R $79.93 $71.41 R $74.84 $80.09 R $80.45 $81.25 $74.48 R $74.84

$8.78 R $8.82 $7.64 R $7.98 $8.85 R $8.88 $8.70 $7.94 R $7.98$10.33 $8.87 $10.43 $9.37 $8.87

$7.96 R $7.99 $6.92 R $7.26 $8.01 R $8.04 $7.94 $7.22 R $7.26$65.89 R $66.16 $59.15 R $61.73 $66.33 R $66.61 $72.09 $61.45 R $61.73$77.48 $69.84 $78.25 $82.16 $69.84$59.68 R $59.95 $53.56 R $56.13 $60.06 R $60.34 $65.51 $55.86 R $56.13$78.19 R $81.83 $79.43 R $81.83 $76.16 R $79.80 $78.59 $78.19 R $81.83

$7.81 R $8.18 $8.21 R $8.45 $7.60 R $7.96 $8.00 $8.08 R $8.45$58.65 R $61.38 $59.82 R $61.61 $57.12 R $59.85 $60.08 $58.89 R $61.61$33.15 R $33.92 $33.92 R $35.79 $33.43 R $34.20 $36.50 $35.32 R $36.09$36.27 $39.49 $36.76 $40.69 $39.99$30.25 R $31.02 $30.76 R $32.63 $30.50 R $31.27 $33.23 $32.11 R $32.88

$3.31 R $3.39 $3.40 R $3.59 $3.33 R $3.41 $3.66 $3.54 R $3.61$3.62 $3.96 $3.66 $4.07 $3.99$3.02 R $3.10 $3.08 R $3.27 $3.04 R $3.12 $3.33 $3.21 R $3.29

$24.81 R $25.38 $25.46 R $26.87 $25.27 R $25.85 $27.17 $26.49 R $27.07$27.09 $29.63 $27.89 $30.17 $30.00$22.63 R $23.21 $23.08 R $24.48 $23.03 R $23.61 $24.75 $24.09 R $24.67$31.06 $34.23 $36.11 $31.06 $35.33

$3.11 $3.42 $3.62 $3.11 $3.52$23.16 $25.67 $27.09 $23.16 $26.50$44.55 $41.37 $45.28 $43.60 $41.37$43.67 $38.19 $44.93 $42.02 $38.19$41.06 $38.19 $41.68 $40.23 $38.19

$4.46 $4.17 $4.57 $4.37 $4.17$4.35 $3.88 $4.57 $4.21 $3.88$4.10 $3.86 $4.21 $4.03 $3.86

$33.47 $31.19 $34.15 $32.70 $31.19$32.86 $28.90 $34.00 $31.53 $28.90$30.84 $28.87 $31.42 $30.18 $28.87$45.96 $49.77 $49.49 $45.50 $45.50$42.56 $49.09 $48.63 $41.73 $41.73$42.56 $45.83 $45.60 $41.73 $41.73

$4.59 $4.97 $4.95 $4.54 $4.54$4.25 $4.91 $4.87 $4.17 $4.17$4.25 $4.58 $4.56 $4.17 $4.17

$34.54 $37.31 $37.11 $34.11 $34.11$32.03 $36.83 $36.46 $31.31 $31.31$31.98 $34.38 $34.19 $31.30 $31.30

$254.14 $276.31 $261.38 $276.31 $267.53$211.20 $211.20 $179.52 $211.20 $186.98

$22.44 $22.44 $22.44 $22.44 $22.44$21.27 R $22.44 $21.41 R $22.44 $21.27 R $22.44 $22.44 $21.27 R $22.44

$537.76 $537.76 $537.76 $537.76 $537.76$330.93 $318.20 $318.20 $330.93 $330.93

$96.98 R $97.68 $94.09 R $98.82 $97.28 R $97.97 $101.69 $91.26 R $91.95$104.99 $106.97 $105.49 $111.89 $95.11

$88.58 R $89.27 $85.52 R $90.26 $88.83 R $89.52 $92.72 $83.64 R $84.33$9.82 R $9.89 $9.41 R $9.89 $10.53 R $10.60 $10.44 $9.82 R $9.89

$10.71 $10.71 $11.91 $11.64 $10.71$8.96 R $9.03 $8.56 R $9.03 $9.57 R $9.63 $9.50 $8.96 R $9.03

$72.74 R $73.26 $70.57 R $74.13 $72.95 R $73.47 $78.29 $70.17 R $70.69$78.74 $80.24 $79.09 $87.43 $74.32$66.44 R $66.95 $64.15 R $67.70 $66.61 R $67.13 $71.30 $64.22 R $64.74



HCPCS 1st Mod 2nd Mod CategoryE0992 NU INE0992 RR INE0992 UE INE0994 NU INE0994 RR INE0994 UE INE0995 NU KE INE0995 NU KU INE0995 NU INE0995 RR KE INE0995 RR KU INE0995 RR INE0995 UE KE INE0995 UE KU INE0995 UE INE1002 RR KE CRE1002 RR KU CRE1002 RR CRE1003 RR KE CRE1003 RR KU CRE1003 RR CRE1004 RR KE CRE1004 RR KU CRE1004 RR CRE1005 RR KE CRE1005 RR KU CRE1005 RR CRE1006 RR KE CRE1006 RR KU CRE1006 RR CRE1007 RR KE CRE1007 RR KU CRE1007 RR CRE1008 RR KE CRE1008 RR KU CRE1008 RR CRE1010 RR KE CRE1010 RR KU CRE1010 RR CRE1012 RR KU CRE1012 RR CRE1014 RR CRE1015 NU INE1015 RR INE1015 UE INE1016 NU KE INE1016 NU KU INE1016 NU INE1016 RR KE INE1016 RR KU INE1016 RR INE1016 UE KE INE1016 UE KU INE1016 UE INE1020 RR KE CRE1020 RR KU CRE1020 RR CRE1028 RR KE CRE1028 RR KU CRE1028 RR CRE1029 RR KE CR

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$91.60 R $94.31 $82.29 R $86.86 $84.15 R $86.86 $89.21 $84.15 R $86.86$9.05 R $9.33 $8.10 R $8.56 $8.36 R $8.63 $8.91 $8.29 R $8.56

$68.71 R $70.74 $61.72 R $65.15 $63.11 R $65.15 $66.91 $63.11 R $65.15$19.16 $16.56 $17.71 $16.56 $19.40

$1.92 $1.67 $1.78 $1.67 $1.94$14.37 $12.43 $13.50 $12.43 $14.55$29.16 $26.64 $26.64 $26.64 $26.64$28.96 $24.62 $24.62 $24.62 $24.62$26.83 $24.62 $24.62 $24.62 $24.62

$2.92 $2.67 $2.67 $2.67 $2.67$2.91 $2.47 $2.47 $2.47 $2.47$2.69 $2.47 $2.47 $2.47 $2.47

$21.86 $19.97 $19.97 $19.97 $19.97$21.70 $18.45 $18.45 $18.45 $18.45$20.11 $18.45 $18.45 $18.45 $18.45

$395.41 $395.41 $395.41 $395.41 $395.41$386.19 $386.19 $386.19 $386.19 $386.19$364.46 $364.46 $364.46 $364.46 $364.46$443.32 $443.32 $443.32 $443.32 $443.32$418.43 $418.43 $418.43 $418.43 $418.43$409.80 $409.80 $409.80 $409.80 $409.80$489.61 $489.61 $489.61 $489.61 $489.61$463.93 $463.93 $463.93 $463.93 $463.93$452.43 $452.43 $452.43 $452.43 $452.43$532.50 $532.50 $532.50 $532.50 $532.50$502.17 $502.17 $502.17 $502.17 $502.17$492.26 $492.26 $492.26 $492.26 $492.26$654.19 $654.19 $654.19 $654.19 $654.19$615.11 $615.11 $615.11 $615.11 $615.11$604.91 $604.91 $604.91 $604.91 $604.91$852.29 $852.29 $852.29 $852.29 $852.29$832.91 $832.91 $832.91 $832.91 $832.91$785.57 $785.57 $785.57 $785.57 $785.57$861.83 $861.83 $861.83 $861.83 $861.83$832.97 $832.97 $832.97 $832.97 $832.97$795.09 $795.09 $795.09 $795.09 $795.09$114.68 $114.68 $114.68 $114.68 $114.68$108.99 $108.99 $108.99 $108.99 $108.99$105.95 $105.95 $105.95 $105.95 $105.95$108.99 $108.99 $108.99 $108.99 $108.99$105.95 $105.95 $105.95 $105.95 $105.95

$40.38 $40.38 $40.38 $40.38 $40.38$120.27 R $125.75 $119.56 R $125.75 $120.27 R $125.75 $126.81 $120.27 R $125.75

$12.02 R $12.57 $11.95 R $12.57 $12.02 R $12.57 $12.67 $12.02 R $12.57$90.20 R $94.31 $89.66 R $94.31 $90.20 R $94.31 $95.10 $90.20 R $94.31

$124.12 R $130.93 $125.87 R $130.93 $124.12 R $130.93 $135.08 $124.12 R $130.93$125.13 $125.13 $125.13 $125.13 $125.13$114.10 R $120.91 $115.85 R $120.91 $114.10 R $120.91 $125.06 $114.10 R $120.91

$12.42 R $13.10 $12.59 R $13.10 $12.42 R $13.10 $13.52 $12.42 R $13.10$12.53 $12.53 $12.53 $12.53 $12.53$11.42 R $12.10 $11.59 R $12.10 $11.42 R $12.10 $12.51 $11.42 R $12.10$93.09 R $98.20 $94.41 R $98.20 $93.09 R $98.20 $101.32 $93.09 R $98.20$93.83 $93.83 $93.83 $93.83 $93.83$85.57 R $90.68 $86.88 R $90.68 $85.57 R $90.68 $93.79 $85.57 R $90.68$22.23 R $22.92 $22.14 R $22.92 $22.23 R $22.92 $22.92 $22.23 R $22.92$23.18 $23.18 $23.18 $23.18 $23.18$20.37 R $21.07 $20.29 R $21.07 $20.37 R $21.07 $21.07 $20.37 R $21.07$18.15 R $18.50 $17.63 R $18.50 $18.15 R $18.50 $18.50 $18.15 R $18.50$19.67 $19.67 $19.67 $19.67 $19.67$16.57 R $16.92 $16.05 R $16.92 $16.57 R $16.92 $16.92 $16.57 R $16.92$37.76 $37.76 $37.76 $37.76 $37.76



HCPCS 1st Mod 2nd Mod CategoryE1029 RR KU CRE1029 RR CRE1030 RR KE CRE1030 RR KU CRE1030 RR CRE1031 RR CRE1035 RR CRE1036 RR CRE1037 RR CRE1038 RR CRE1039 RR CRE1050 RR CRE1060 RR CRE1070 RR CRE1083 RR CRE1084 RR CRE1087 RR CRE1088 RR CRE1092 RR CRE1093 RR CRE1100 RR CRE1110 RR CRE1150 RR CRE1160 RR CRE1161 RR CRE1170 RR CRE1171 RR CRE1172 RR CRE1180 RR CRE1190 RR CRE1195 RR CRE1200 RR CRE1221 RR CRE1222 RR CRE1223 RR CRE1224 RR CRE1225 RR CRE1226 NU INE1226 RR INE1226 UE INE1227 NU INE1227 RR INE1227 UE INE1228 RR CRE1230 NU INE1230 RR INE1230 UE INE1232 RR CRE1233 RR CRE1234 RR CRE1235 RR CRE1236 RR CRE1237 RR CRE1238 RR CRE1240 RR CRE1270 RR CRE1280 RR CRE1295 RR CRE1296 NU INE1296 RR INE1296 UE IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$35.20 $35.20 $35.20 $35.20 $35.20$34.93 $34.93 $34.93 $34.93 $34.93

$118.55 $118.55 $118.55 $118.55 $118.55$111.03 $111.03 $111.03 $111.03 $111.03$109.66 $109.66 $109.66 $109.66 $109.66


$17.38 R $17.64 $17.01 R $17.64 $17.38 R $17.64 $17.64 $17.38 R $17.64$34.64 R $36.20 $34.24 R $36.20 $34.64 R $36.20 $37.15 $34.64 R $36.20$95.69 $110.58 $112.58 $112.26 $95.69

$118.46 $139.36 $139.36 $121.90 $127.67$102.93 $118.47 $110.56 $114.94 $121.09

$73.99 $73.99 $75.96 $87.05 $75.18$92.18 $108.45 $108.45 $101.86 $108.45

$139.88 $139.88 $139.50 $139.88 $129.83$166.68 $166.68 $160.65 $166.68 $157.03$142.08 $142.08 $126.76 $142.08 $120.77$107.32 $122.18 $115.86 $122.18 $122.18

$97.54 $114.75 $101.50 $107.78 $97.54$107.49 $112.38 $112.38 $106.75 $107.84

$76.65 $90.18 $90.18 $90.18 $90.18$58.74 $69.10 $67.56 $69.10 $69.10

$261.57 $261.57 $261.57 $261.57 $261.57$83.94 $98.75 $98.75 $91.33 $83.94$75.32 $88.61 $88.61 $84.76 $75.32

$108.30 $108.30 $92.06 $108.30 $92.06$112.03 $112.03 $109.89 $112.03 $95.23$129.43 $129.43 $129.43 $129.43 $110.02$138.88 $138.88 $123.07 $138.88 $118.05

$96.19 $96.19 $96.19 $96.19 $81.76$46.29 $52.53 $52.53 $52.53 $52.26$63.70 $71.64 $74.94 $74.94 $71.51$70.73 $81.82 $70.47 $80.19 $81.82$76.25 $89.71 $89.71 $76.25 $78.02$39.40 R $40.98 $38.68 R $40.98 $40.60 R $42.18 $45.68 $43.15 R $44.73

$495.34 R $501.19 $432.28 R $455.94 $495.34 R $501.19 $501.19 $485.89 R $491.74$50.41 R $51.00 $43.98 R $46.34 $50.41 R $51.00 $51.00 $48.59 R $49.18

$371.48 R $375.87 $324.19 R $341.94 $371.48 R $375.87 $375.87 $364.42 R $368.81$306.78 $260.76 $306.78 $306.78 $306.78

$30.69 $26.09 $30.69 $30.69 $30.69$230.11 $195.59 $230.11 $230.11 $230.11

$26.33 $30.98 $30.98 $26.33 $30.98$2,227.88 $2,308.33 $2,290.79 $2,500.44 $2,478.53

$222.80 $245.92 $229.06 $245.92 $245.92$1,680.91 $1,731.24 $1,680.91 $1,977.54 $1,858.86

$236.42 $236.42 $236.42 $236.42 $236.42$244.95 $244.95 $244.95 $244.95 $244.95$213.26 $213.26 $213.26 $213.26 $213.26$205.36 $205.36 $205.36 $205.36 $205.36$181.16 $181.16 $181.16 $181.16 $181.16$182.75 $182.75 $182.75 $182.75 $182.75$181.16 $181.16 $181.16 $181.16 $181.16

$96.81 $113.89 $113.89 $104.35 $113.89$74.18 $87.27 $87.27 $77.77 $74.18

$123.34 $145.10 $145.10 $145.10 $123.34$134.28 $134.28 $114.14 $134.27 $114.14$479.17 $462.00 $462.00 $462.00 $462.00

$47.91 $46.94 $46.94 $46.94 $46.94$359.40 $346.50 $346.50 $346.50 $346.50



HCPCS 1st Mod 2nd Mod CategoryE1297 NU INE1297 RR INE1297 UE INE1298 NU INE1298 RR INE1298 UE INE1310 NU INE1310 RR INE1310 UE INE1353 OXE1355 OXE1372 NU INE1372 RR INE1372 UE INE1390 RR OXE1391 RR OXE1392 RR OXE1405 RR OXE1406 RR OXE1700 RR CRE1701 SUE1702 SUE1800 RR CRE1801 RR CRE1802 RR CRE1805 RR CRE1806 RR CRE1810 RR CRE1811 RR CRE1812 RR CRE1815 RR CRE1816 RR CRE1818 RR CRE1820 NU INE1820 RR INE1820 UE INE1821 NU INE1821 RR INE1821 UE INE1825 RR CRE1830 RR CRE1831 RR CRE1840 RR CRE1841 RR CRE2000 RR CRE2100 NU INE2100 RR INE2100 UE INE2101 NU INE2101 RR INE2101 UE INE2120 RR CRE2201 NU INE2201 RR INE2201 UE INE2202 NU INE2202 RR INE2202 UE INE2203 NU INE2203 RR INE2203 UE IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$100.31 $98.30 $115.65 $98.30 $98.30$10.92 $10.92 $12.85 $10.92 $10.92$75.25 $73.71 $86.72 $73.71 $73.71

$468.36 $398.11 $468.36 $409.69 $468.36$47.92 $40.73 $47.92 $40.96 $47.92

$351.26 $298.57 $351.26 $307.28 $351.26$2,373.97 $2,373.97 $2,017.87 $2,373.97 $2,017.87

$203.04 $187.55 $172.58 $193.59 $182.62$1,780.49 $1,780.49 $1,513.42 $1,780.49 $1,513.42

$31.31 $31.31 $31.31 $31.31 $31.31$23.59 $23.59 $23.59 $23.59 $23.59

$152.39 R $154.31 $143.60 R $155.48 $153.56 R $155.48 $155.48 $140.05 R $141.96$17.48 R $17.67 $18.45 R $19.63 $19.44 R $19.63 $17.67 $17.48 R $17.67

$114.29 R $115.73 $106.82 R $115.73 $114.29 R $115.73 $115.73 $104.29 R $105.73$126.67 R $129.37 $125.88 R $129.37 $126.67 R $129.37 $133.36 $126.67 R $129.37$126.67 R $129.37 $125.88 R $129.37 $126.67 R $129.37 $133.36 $126.67 R $129.37

$44.71 R $46.90 $44.30 R $46.90 $44.71 R $46.90 $46.90 $44.71 R $46.90$158.87 R $162.15 $157.83 R $163.87 $160.58 R $163.87 $167.86 $160.58 R $163.87$138.61 R $141.44 $137.69 R $141.44 $138.61 R $141.44 $145.43 $138.61 R $141.44

$38.13 $32.41 $32.41 $38.13 $32.41$11.72 $11.19 $11.20 $11.72 $11.72$24.95 $21.21 $22.48 $24.95 $24.95

$115.12 $117.45 $135.43 $115.12 $135.43$133.70 $142.62 $134.68 $142.62 $137.82$361.29 $361.29 $361.29 $361.29 $361.29$118.73 $118.73 $139.68 $118.73 $139.68$109.74 $117.10 $110.56 $117.10 $113.14$117.07 $119.08 $137.73 $117.07 $137.73$139.03 $148.27 $140.01 $148.27 $143.27

$95.06 $95.06 $95.06 $95.06 $95.06$118.73 $119.08 $139.68 $118.73 $139.68$141.22 $150.62 $142.20 $150.62 $145.53$144.12 $153.76 $145.18 $153.76 $148.54

$90.37 $90.37 $85.24 $90.37 $85.24$9.03 $9.03 $8.54 $9.03 $8.54

$67.79 $67.79 $63.94 $67.79 $63.94$116.35 $116.35 $116.35 $116.35 $116.35

$11.61 $11.61 $11.61 $11.61 $11.61$87.29 $87.29 $87.29 $87.29 $87.29

$118.73 $118.73 $139.68 $118.73 $139.68$118.73 $118.73 $139.68 $118.73 $139.68

$73.05 $70.25 $70.25 $73.05 $73.05$381.64 $423.09 $411.94 $423.09 $421.61$500.78 $500.78 $500.78 $500.78 $500.78

$53.70 $57.30 $54.06 $57.30 $55.34$711.04 $604.38 $670.60 $608.60 $711.04

$71.11 $60.44 $63.75 $71.11 $71.11$533.29 $453.30 $502.95 $497.86 $533.29$208.45 $208.45 $208.45 $208.45 $208.45

$20.84 $20.84 $20.84 $20.84 $20.84$156.34 $156.34 $156.34 $156.34 $156.34$313.44 $313.44 $313.44 $313.44 $313.44$359.72 R $367.19 $352.41 R $367.19 $359.72 R $367.19 $367.19 $359.72 R $367.19

$35.97 R $36.72 $35.24 R $36.72 $35.97 R $36.72 $36.72 $35.97 R $36.72$269.78 R $275.39 $264.30 R $275.39 $269.78 R $275.39 $275.39 $269.78 R $275.39$475.32 R $494.14 $469.31 R $494.14 $475.32 R $494.14 $523.98 $475.32 R $494.14

$47.53 R $49.42 $46.93 R $49.42 $47.53 R $49.42 $52.40 $47.53 R $49.42$356.50 R $370.62 $352.00 R $370.62 $356.50 R $370.62 $393.01 $356.50 R $370.62$472.09 R $483.75 $462.96 R $483.75 $472.09 R $483.75 $529.60 $472.09 R $483.75

$47.20 R $48.37 $46.29 R $48.37 $47.20 R $48.37 $52.95 $47.20 R $48.37$354.05 R $362.80 $347.21 R $362.80 $354.05 R $362.80 $397.17 $354.05 R $362.80



HCPCS 1st Mod 2nd Mod CategoryE2204 NU INE2204 RR INE2204 UE INE2205 NU INE2205 RR INE2205 UE INE2206 NU INE2206 RR INE2206 UE INE2207 NU KU INE2207 NU INE2207 RR KU INE2207 RR INE2207 UE KU INE2207 UE INE2208 NU KE INE2208 NU KU INE2208 NU INE2208 RR KE INE2208 RR KU INE2208 RR INE2208 UE KE INE2208 UE KU INE2208 UE INE2209 NU KE INE2209 NU KU INE2209 NU INE2209 RR KE INE2209 RR KU INE2209 RR INE2209 UE KE INE2209 UE KU INE2209 UE INE2210 NU KE INE2210 NU KU INE2210 NU INE2210 RR KE INE2210 RR KU INE2210 RR INE2210 UE KE INE2210 UE KU INE2210 UE INE2211 NU INE2211 RR INE2211 UE INE2212 NU INE2212 RR INE2212 UE INE2213 NU INE2213 RR INE2213 UE INE2214 NU INE2214 RR INE2214 UE INE2215 NU INE2215 RR INE2215 UE INE2219 NU INE2219 RR INE2219 UE INE2220 NU IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$807.55 R $831.69 $791.05 R $831.69 $807.55 R $831.69 $899.23 $807.55 R $831.69$80.76 R $83.17 $79.11 R $83.17 $80.76 R $83.17 $89.93 $80.76 R $83.17

$605.66 R $623.77 $593.29 R $623.77 $605.66 R $623.77 $674.42 $605.66 R $623.77$34.66 R $36.11 $34.34 R $36.11 $34.66 R $36.11 $36.11 $34.66 R $36.11

$3.46 R $3.60 $3.43 R $3.60 $3.46 R $3.60 $3.60 $3.46 R $3.60$26.01 R $27.11 $25.77 R $27.11 $26.01 R $27.11 $27.09 $26.01 R $27.11$40.69 R $42.36 $40.24 R $42.36 $40.69 R $42.36 $44.48 $40.69 R $42.36

$4.06 R $4.23 $4.02 R $4.23 $4.06 R $4.23 $4.44 $4.06 R $4.23$30.52 R $31.77 $30.18 R $31.77 $30.52 R $31.77 $33.36 $30.52 R $31.77$47.92 $47.92 $47.92 $47.92 $47.92$44.99 R $47.69 $45.33 R $47.69 $44.99 R $47.69 $47.69 $44.99 R $47.69

$4.81 $4.81 $4.81 $4.81 $4.81$4.51 R $4.78 $4.54 R $4.78 $4.51 R $4.78 $4.78 $4.51 R $4.78

$35.95 $35.95 $35.95 $35.95 $35.95$33.75 R $35.77 $34.00 R $35.77 $33.75 R $35.77 $35.77 $33.75 R $35.77

$104.45 R $105.82 $101.71 R $105.82 $104.45 R $105.82 $105.82 $104.45 R $105.82$113.19 $113.19 $113.19 $113.19 $113.19

$95.38 R $96.75 $92.65 R $96.75 $95.38 R $96.75 $96.75 $95.38 R $96.75$10.44 R $10.58 $10.16 R $10.58 $10.44 R $10.58 $10.58 $10.44 R $10.58$11.31 $11.31 $11.31 $11.31 $11.31

$9.54 R $9.67 $9.26 R $9.67 $9.54 R $9.67 $9.67 $9.54 R $9.67$78.33 R $79.36 $76.28 R $79.36 $78.33 R $79.36 $79.36 $78.33 R $79.36$84.89 $84.89 $84.89 $84.89 $84.89$71.54 R $72.56 $69.49 R $72.56 $71.54 R $72.56 $72.56 $71.54 R $72.56$98.67 R $102.94 $98.06 R $102.94 $98.67 R $102.94 $109.24 $98.67 R $102.94

$102.11 $102.11 $102.11 $102.11 $102.11$90.49 R $94.76 $89.88 R $94.76 $90.49 R $94.76 $101.05 $90.49 R $94.76

$9.89 R $10.31 $9.82 R $10.31 $9.89 R $10.31 $10.94 $9.89 R $10.31$10.23 $10.23 $10.23 $10.23 $10.23

$9.06 R $9.49 $9.00 R $9.49 $9.06 R $9.49 $10.11 $9.06 R $9.49$74.01 R $77.21 $73.55 R $77.21 $74.01 R $77.21 $81.93 $74.01 R $77.21$76.59 $76.59 $76.59 $76.59 $76.59$67.87 R $71.08 $67.41 R $71.08 $67.87 R $71.08 $75.80 $67.87 R $71.08

$6.13 R $6.40 $6.11 R $6.40 $6.13 R $6.40 $6.62 $6.13 R $6.40$6.23 $6.23 $6.23 $6.23 $6.23$5.63 R $5.89 $5.61 R $5.89 $5.63 R $5.89 $6.12 $5.63 R $5.89$0.62 R $0.65 $0.62 R $0.65 $0.62 R $0.65 $0.67 $0.62 R $0.65$0.63 $0.63 $0.63 $0.63 $0.63$0.56 R $0.59 $0.56 R $0.59 $0.56 R $0.59 $0.61 $0.56 R $0.59$4.60 R $4.80 $4.58 R $4.80 $4.60 R $4.80 $4.96 $4.60 R $4.80$4.70 $4.70 $4.70 $4.70 $4.70$4.23 R $4.43 $4.22 R $4.43 $4.23 R $4.43 $4.60 $4.23 R $4.43

$35.62 R $36.96 $35.02 R $36.96 $39.02 R $40.35 $40.60 $35.62 R $36.96$3.52 R $3.66 $3.46 R $3.66 $3.86 R $3.99 $4.07 $3.52 R $3.66


$30.79 R $32.31 $30.68 R $32.31 $30.79 R $32.31 $33.31 $30.79 R $32.31$3.09 R $3.24 $3.08 R $3.24 $3.09 R $3.24 $3.34 $3.09 R $3.24

$23.09 R $24.23 $23.00 R $24.22 $23.09 R $24.23 $24.97 $23.09 R $24.23$31.73 R $33.83 $31.82 R $33.83 $31.73 R $33.83 $33.83 $31.73 R $33.83

$3.34 R $3.56 $3.35 R $3.56 $3.34 R $3.56 $3.72 $3.34 R $3.56$23.81 R $25.40 $23.86 R $25.36 $23.79 R $25.36 $25.36 $23.79 R $25.36$10.08 R $10.61 $10.02 R $10.61 $10.08 R $10.61 $10.61 $10.08 R $10.61

$1.01 R $1.06 $1.00 R $1.06 $1.01 R $1.06 $1.06 $1.01 R $1.06$7.55 R $7.94 $7.51 R $7.94 $7.55 R $7.94 $7.94 $7.55 R $7.94

$38.54 R $39.32 $37.75 R $39.32 $42.02 R $44.18 $44.18 $42.02 R $44.18$4.11 R $4.33 $4.03 R $4.33 $4.44 R $4.66 $4.72 $4.50 R $4.72

$28.91 R $29.49 $28.31 R $29.49 $31.51 R $33.14 $33.14 $31.51 R $33.14$29.86 R $30.97 $26.50 R $26.81 $26.81 R $26.81 $27.28 $28.33 R $28.48



HCPCS 1st Mod 2nd Mod CategoryE2220 RR INE2220 UE INE2221 NU INE2221 RR INE2221 UE INE2222 NU INE2222 RR INE2222 UE INE2224 NU INE2224 RR INE2224 UE INE2225 NU INE2225 RR INE2225 UE INE2226 NU INE2226 RR INE2226 UE INE2227 RR CRE2228 RR CRE2231 NU INE2231 RR INE2231 UE INE2310 RR KE CRE2310 RR KU CRE2310 RR CRE2311 RR KE CRE2311 RR KU CRE2311 RR CRE2312 RR KC CRE2312 RR CRE2313 RR CRE2321 RR KC CRE2321 RR KE CRE2321 RR KU CRE2321 RR CRE2322 RR KC CRE2322 RR KE CRE2322 RR KU CRE2322 RR CRE2323 NU KE INE2323 NU KU INE2323 NU INE2323 RR KE INE2323 RR KU INE2323 RR INE2323 UE KE INE2323 UE KU INE2323 UE INE2324 NU KE INE2324 NU KU INE2324 NU INE2324 RR KE INE2324 RR KU INE2324 RR INE2324 UE KE INE2324 UE KU INE2324 UE INE2325 RR KE CRE2325 RR KU CRE2325 RR CRE2326 RR KE CR

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$2.93 R $3.04 $2.59 R $2.59 $2.59 R $2.59 $2.72 $2.84 R $2.87$22.63 R $23.46 $20.07 R $20.51 $22.63 R $23.46 $20.51 $21.25 R $21.36$26.63 R $27.97 $26.40 R $27.97 $26.63 R $27.97 $27.97 $26.63 R $27.97

$2.68 R $2.81 $2.66 R $2.81 $2.68 R $2.81 $2.81 $2.68 R $2.81$19.98 R $20.98 $19.81 R $20.98 $19.98 R $20.98 $20.98 $19.98 R $20.98$22.23 R $23.19 $22.17 R $23.19 $22.23 R $23.19 $23.19 $22.23 R $23.19

$2.21 R $2.30 $2.20 R $2.30 $2.21 R $2.30 $2.30 $2.21 R $2.30$16.68 R $17.40 $16.64 R $17.40 $16.68 R $17.40 $17.40 $16.68 R $17.40$96.14 R $100.36 $88.77 R $92.14 $91.00 R $92.14 $94.95 $91.00 R $92.14

$9.61 R $10.03 $9.11 R $9.67 $9.33 R $9.67 $9.67 $9.33 R $9.67$72.12 R $75.28 $66.58 R $69.11 $68.25 R $69.11 $71.20 $68.25 R $69.11$18.30 R $19.24 $18.34 R $19.24 $18.30 R $19.24 $19.24 $18.30 R $19.24

$1.83 R $1.92 $1.83 R $1.92 $1.83 R $1.92 $1.92 $1.83 R $1.92$13.72 R $14.41 $13.74 R $14.41 $13.72 R $14.41 $14.41 $13.72 R $14.41$39.49 R $41.50 $39.31 R $41.50 $39.49 R $41.50 $41.95 $39.49 R $41.50

$3.95 R $4.15 $3.93 R $4.15 $3.95 R $4.15 $4.19 $3.95 R $4.15$29.62 R $31.13 $29.49 R $31.13 $29.62 R $31.13 $31.46 $29.62 R $31.13

$206.82 $198.84 $198.84 $198.84 $206.82$96.60 R $101.28 $95.70 R $101.28 $96.60 R $101.28 $103.49 $96.60 R $101.28

$152.73 R $157.26 $150.42 R $157.26 $152.73 R $157.26 $157.26 $152.73 R $157.26$15.27 R $15.73 $15.04 R $15.73 $15.27 R $15.73 $15.73 $15.27 R $15.73

$114.55 R $117.94 $112.81 R $117.94 $114.55 R $117.94 $117.94 $114.55 R $117.94$114.87 $114.87 $114.87 $114.87 $114.87$111.49 $111.49 $111.49 $111.49 $111.49$105.93 $105.93 $105.93 $105.93 $105.93$232.23 $232.23 $232.23 $232.23 $232.23$225.75 $225.75 $225.75 $225.75 $225.75$214.14 $214.14 $214.14 $214.14 $214.14$284.33 $273.43 $273.43 $273.43 $284.33$222.94 $214.39 $214.39 $214.39 $222.94

$35.43 $34.06 $34.06 $34.06 $35.43$234.38 $234.38 $234.38 $234.38 $234.38$156.03 $156.03 $156.03 $156.03 $156.03$246.66 $246.66 $246.66 $246.66 $246.66$143.90 $143.90 $143.90 $143.90 $143.90$255.80 $255.80 $255.80 $255.80 $255.80$142.37 $142.37 $142.37 $142.37 $142.37$261.19 $261.19 $261.19 $261.19 $261.19$131.60 $131.60 $131.60 $131.60 $131.60

$69.63 $69.63 $69.63 $69.63 $69.63$65.91 $65.91 $65.91 $65.91 $65.91$64.35 $64.35 $64.35 $64.35 $64.35

$6.96 $6.96 $6.96 $6.96 $6.96$6.58 $6.58 $6.58 $6.58 $6.58$6.43 $6.43 $6.43 $6.43 $6.43

$52.22 $52.22 $52.22 $52.22 $52.22$49.41 $49.41 $49.41 $49.41 $49.41$48.26 $48.26 $48.26 $48.26 $48.26$44.95 $44.95 $44.95 $44.95 $44.95$41.75 $41.75 $41.75 $41.75 $41.75$41.61 $41.61 $41.61 $41.61 $41.61

$4.49 $4.49 $4.49 $4.49 $4.49$4.15 $4.15 $4.15 $4.15 $4.15$4.15 $4.15 $4.15 $4.15 $4.15

$33.72 $33.72 $33.72 $33.72 $33.72$31.31 $31.31 $31.31 $31.31 $31.31$31.20 $31.20 $31.20 $31.20 $31.20

$136.03 $136.03 $136.03 $136.03 $136.03$128.34 $128.34 $128.34 $128.34 $128.34$125.74 $125.74 $125.74 $125.74 $125.74

$35.35 $35.35 $35.35 $35.35 $35.35



HCPCS 1st Mod 2nd Mod CategoryE2326 RR KU CRE2326 RR CRE2327 RR KC CRE2327 RR KE CRE2327 RR KU CRE2327 RR CRE2328 RR KE CRE2328 RR KU CRE2328 RR CRE2329 RR KE CRE2329 RR KU CRE2329 RR CRE2330 RR KE CRE2330 RR KU CRE2330 RR CRE2340 NU INE2340 RR INE2340 UE INE2341 NU INE2341 RR INE2341 UE INE2342 NU INE2342 RR INE2342 UE INE2343 NU INE2343 RR INE2343 UE INE2351 NU KE INE2351 NU KU INE2351 NU INE2351 RR KE INE2351 RR KU INE2351 RR INE2351 UE KE INE2351 UE KU INE2351 UE INE2359 NU KU INE2359 NU INE2359 RR KU INE2359 RR INE2359 UE KU INE2359 UE INE2360 NU KU INE2360 NU INE2360 RR KU INE2360 RR INE2360 UE KU INE2360 UE INE2361 NU KE INE2361 NU KU INE2361 NU INE2361 RR KE INE2361 RR KU INE2361 RR INE2361 UE KE INE2361 UE KU INE2361 UE INE2362 NU KU INE2362 NU INE2362 RR KU INE2362 RR IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$33.09 $33.09 $33.09 $33.09 $33.09$32.69 $32.69 $32.69 $32.69 $32.69

$372.04 $372.04 $372.04 $372.04 $372.04$264.83 $264.83 $264.83 $264.83 $264.83$378.16 $378.16 $378.16 $378.16 $378.16$244.88 $244.88 $244.88 $244.88 $244.88$501.21 $501.21 $501.21 $501.21 $501.21$472.15 $472.15 $472.15 $472.15 $472.15$463.38 $463.38 $463.38 $463.38 $463.38$179.71 $179.71 $179.71 $179.71 $179.71$168.28 $168.28 $168.28 $168.28 $168.28$166.22 $166.22 $166.22 $166.22 $166.22$346.75 $346.75 $346.75 $346.75 $346.75$326.06 $326.06 $326.06 $326.06 $326.06$320.63 $320.63 $320.63 $320.63 $320.63$396.17 $396.17 $396.17 $396.17 $396.17

$39.63 $39.63 $39.63 $39.63 $39.63$297.16 $297.16 $297.16 $297.16 $297.16$594.30 $594.30 $594.30 $594.30 $594.30

$59.42 $59.42 $59.42 $59.42 $59.42$445.73 $445.73 $445.73 $445.73 $445.73$495.25 $495.25 $495.25 $495.25 $495.25

$49.52 $49.52 $49.52 $49.52 $49.52$371.45 $371.45 $371.45 $371.45 $371.45$792.41 $792.41 $792.41 $792.41 $792.41

$79.23 $79.23 $79.23 $79.23 $79.23$594.30 $594.30 $594.30 $594.30 $594.30$712.77 $712.77 $712.77 $712.77 $712.77$665.69 $665.69 $665.69 $665.69 $665.69$659.43 $659.43 $659.43 $659.43 $659.43

$71.28 $71.28 $71.28 $71.28 $71.28$66.59 $66.59 $66.59 $66.59 $66.59$65.94 $65.94 $65.94 $65.94 $65.94

$534.58 $534.58 $534.58 $534.58 $534.58$499.25 $499.25 $499.25 $499.25 $499.25$494.58 $494.58 $494.58 $494.58 $494.58$192.52 $185.09 $185.09 $192.52 $192.52$175.72 R $183.39 $171.23 R $179.67 $172.01 R $179.67 $183.76 $175.72 R $183.39

$19.26 $18.51 $18.51 $19.26 $19.26$17.58 R $18.34 $17.12 R $17.97 $17.20 R $17.97 $18.38 $17.58 R $18.34

$144.37 $138.82 $138.82 $144.37 $144.37$131.78 R $137.53 $128.43 R $134.76 $129.01 R $134.76 $137.81 $131.78 R $137.53$124.20 $119.37 $105.57 $124.20 $124.20$110.23 R $115.47 $109.18 R $113.06 $100.92 R $105.58 $118.20 $110.23 R $115.47

$12.48 $11.95 $10.61 $12.48 $12.48$11.05 R $11.58 $10.93 R $11.31 $10.12 R $10.61 $11.85 $11.05 R $11.58$93.14 $89.54 $79.17 $93.14 $93.14$82.67 R $86.60 $81.89 R $84.80 $75.68 R $79.16 $88.64 $82.67 R $86.60

$131.05 R $136.75 $130.10 R $136.75 $131.05 R $136.75 $136.75 $131.05 R $136.75$132.89 $132.89 $132.89 $132.89 $132.89$120.40 R $126.11 $119.45 R $126.11 $120.40 R $126.11 $126.11 $120.40 R $126.11


$101.69 $101.69 $101.69 $101.69 $101.69$94.90 R $99.42 $95.81 R $99.42 $94.90 R $99.42 $100.79 $94.90 R $99.42$10.17 $10.17 $10.17 $10.17 $10.17

$9.49 R $9.94 $9.58 R $9.94 $9.49 R $9.94 $10.08 $9.49 R $9.94



HCPCS 1st Mod 2nd Mod CategoryE2362 UE KU INE2362 UE INE2363 NU KE INE2363 NU KU INE2363 NU INE2363 RR KE INE2363 RR KU INE2363 RR INE2363 UE KE INE2363 UE KU INE2363 UE INE2364 NU KU INE2364 NU INE2364 RR KU INE2364 RR INE2364 UE KU INE2364 UE INE2365 NU KE INE2365 NU KU INE2365 NU INE2365 RR KE INE2365 RR KU INE2365 RR INE2365 UE KE INE2365 UE KU INE2365 UE INE2366 NU KE INE2366 NU KU INE2366 NU INE2366 RR KE INE2366 RR KU INE2366 RR INE2366 UE KE INE2366 UE KU INE2366 UE INE2367 NU KE INE2367 NU KU INE2367 NU INE2367 RR KE INE2367 RR KU INE2367 RR INE2367 UE KE INE2367 UE KU INE2367 UE INE2368 RR KE CRE2368 RR KU CRE2368 RR CRE2369 RR KE CRE2369 RR KU CRE2369 RR CRE2370 RR KE CRE2370 RR KU CRE2370 RR CRE2371 NU KE INE2371 NU KU INE2371 NU INE2371 RR KE INE2371 RR KU INE2371 RR INE2371 UE KE INE2371 UE KU IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$76.26 $76.26 $76.26 $76.26 $76.26$71.17 R $74.56 $71.86 R $74.56 $71.17 R $74.56 $75.59 $71.17 R $74.56

$172.31 R $178.06 $168.07 R $178.06 $172.31 R $178.06 $178.06 $172.31 R $178.06$177.24 $177.24 $177.24 $177.24 $177.24$158.12 R $163.87 $153.88 R $163.87 $158.12 R $163.87 $163.87 $158.12 R $163.87

$17.24 R $17.81 $16.82 R $17.81 $17.24 R $17.81 $17.81 $17.24 R $17.81$17.72 $17.72 $17.72 $17.72 $17.72$15.81 R $16.38 $15.39 R $16.38 $15.81 R $16.38 $16.38 $15.81 R $16.38

$129.24 R $133.55 $126.06 R $133.55 $129.24 R $133.55 $133.55 $129.24 R $133.55$132.92 $132.92 $132.92 $132.92 $132.92$118.59 R $122.90 $115.40 R $122.90 $118.59 R $122.90 $122.90 $118.59 R $122.90$124.20 $119.37 $105.57 $124.20 $124.20$108.56 R $113.57 $109.70 R $111.15 $99.25 R $104.25 $114.54 $108.56 R $113.57

$12.48 $11.95 $10.61 $12.48 $12.48$10.89 R $11.39 $10.98 R $11.12 $9.95 R $10.45 $11.48 $10.89 R $11.39$93.14 $89.54 $79.17 $93.14 $93.14$81.41 R $85.17 $82.28 R $83.37 $74.43 R $78.18 $85.90 $81.41 R $85.17$99.24 R $102.11 $96.27 R $102.11 $99.24 R $102.11 $102.11 $99.24 R $102.11

$106.88 $106.88 $106.88 $106.88 $106.88$90.68 R $93.55 $87.72 R $93.55 $90.68 R $93.55 $93.55 $90.68 R $93.55

$9.92 R $10.21 $9.63 R $10.21 $9.92 R $10.21 $10.21 $9.92 R $10.21$10.68 $10.68 $10.68 $10.68 $10.68

$9.06 R $9.35 $8.77 R $9.35 $9.06 R $9.35 $9.35 $9.06 R $9.35$74.44 R $76.60 $72.22 R $76.60 $74.44 R $76.60 $76.60 $74.44 R $76.60$80.19 $80.19 $80.19 $80.19 $80.19$68.02 R $70.18 $65.80 R $70.18 $68.02 R $70.18 $70.18 $68.02 R $70.18

$203.70 R $205.92 $217.32 R $227.78 $203.70 R $205.92 $224.82 $225.56 R $227.78$213.51 $251.19 $213.51 $246.08 $251.19$186.60 R $188.82 $197.20 R $207.66 $186.60 R $188.82 $205.10 $205.44 R $207.66

$20.40 R $20.63 $21.77 R $22.82 $20.40 R $20.63 $22.47 $22.60 R $22.82$21.41 $25.19 $21.41 $24.61 $25.19$18.69 R $18.91 $19.76 R $20.80 $18.69 R $18.91 $20.51 $20.58 R $20.80


$38.05 R $39.91 $38.34 R $39.91 $38.05 R $39.91 $39.38 $38.05 R $39.91$39.93 $39.93 $39.93 $39.93 $39.93$34.85 R $36.71 $35.13 R $36.71 $34.85 R $36.71 $36.17 $34.85 R $36.71

$285.34 R $299.30 $287.50 R $299.30 $285.34 R $299.30 $295.27 $285.34 R $299.30$299.49 $299.49 $299.49 $299.49 $299.49$261.35 R $275.31 $263.50 R $275.31 $261.35 R $275.31 $271.27 $261.35 R $275.31

$48.01 R $49.93 $47.60 R $49.93 $48.01 R $49.93 $53.26 $48.01 R $49.93$49.22 $49.22 $49.22 $49.22 $49.22$44.06 R $45.99 $43.65 R $45.99 $44.06 R $45.99 $49.22 $44.06 R $45.99$42.98 R $44.98 $42.51 R $44.98 $42.98 R $44.98 $46.38 $42.98 R $44.98$42.89 $42.89 $42.89 $42.89 $42.89$39.54 R $41.55 $39.08 R $41.55 $39.54 R $41.55 $42.89 $39.54 R $41.55$70.41 R $72.18 $69.27 R $72.18 $70.41 R $72.18 $72.18 $70.41 R $72.18$76.50 $76.50 $76.50 $76.50 $76.50$64.28 R $66.05 $63.14 R $66.05 $64.28 R $66.05 $66.05 $64.28 R $66.05

$148.60 R $155.80 $148.23 R $155.80 $148.60 R $155.80 $155.80 $148.60 R $155.80$143.63 $143.63 $143.63 $143.63 $143.63$137.10 R $143.63 $136.73 R $143.63 $137.10 R $143.63 $143.63 $137.10 R $143.63

$14.86 R $15.58 $14.82 R $15.58 $14.86 R $15.58 $15.58 $14.86 R $15.58$14.37 $14.37 $14.37 $14.37 $14.37$13.71 R $14.37 $13.68 R $14.37 $13.71 R $14.37 $14.37 $13.71 R $14.37

$111.45 R $116.85 $111.17 R $116.85 $111.45 R $116.85 $116.85 $111.45 R $116.85$107.74 $107.74 $107.74 $107.74 $107.74



HCPCS 1st Mod 2nd Mod CategoryE2371 UE INE2373 RR KC CRE2373 RR KE CRE2373 RR KU CRE2373 RR CRE2374 RR KE CRE2374 RR KU CRE2374 RR CRE2375 RR KE CRE2375 RR KU CRE2375 RR CRE2376 RR KE CRE2376 RR KU CRE2376 RR CRE2377 RR KE CRE2377 RR KU CRE2377 RR CRE2378 RR KU CRE2378 RR CRE2381 NU KE INE2381 NU KU INE2381 NU INE2381 RR KE INE2381 RR KU INE2381 RR INE2381 UE KE INE2381 UE KU INE2381 UE INE2382 NU KE INE2382 NU KU INE2382 NU INE2382 RR KE INE2382 RR KU INE2382 RR INE2382 UE KE INE2382 UE KU INE2382 UE INE2383 NU KE INE2383 NU KU INE2383 NU INE2383 RR KE INE2383 RR KU INE2383 RR INE2383 UE KE INE2383 UE KU INE2383 UE INE2384 NU KE INE2384 NU KU INE2384 NU INE2384 RR KE INE2384 RR KU INE2384 RR INE2384 UE KE INE2384 UE KU INE2384 UE INE2385 NU KE INE2385 NU KU INE2385 NU INE2385 RR KE INE2385 RR KU INE2385 RR IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$102.83 R $107.74 $102.55 R $107.74 $102.83 R $107.74 $107.74 $102.83 R $107.74$116.36 $114.06 $114.06 $116.36 $116.36$106.11 $103.44 $103.44 $106.11 $106.11$119.90 $115.31 $115.31 $119.90 $119.90

$75.40 $73.93 $73.93 $73.93 $75.40$52.64 $52.64 $52.64 $52.64 $52.64$50.90 $50.90 $50.90 $50.90 $50.90$48.57 $48.57 $48.57 $48.57 $48.57$80.16 R $82.74 $78.72 R $82.74 $80.16 R $82.74 $88.30 $80.16 R $82.74$81.60 $81.60 $81.60 $81.60 $81.60$73.61 R $76.19 $72.17 R $76.19 $73.61 R $76.19 $81.60 $73.61 R $76.19

$131.64 $131.64 $131.64 $131.64 $131.64$127.90 $127.90 $127.90 $127.90 $127.90$121.39 $121.39 $121.39 $121.39 $121.39

$48.13 $48.13 $48.13 $48.13 $48.13$46.27 $46.27 $46.27 $46.27 $46.27$44.42 $44.42 $44.42 $44.42 $44.42$56.57 $56.57 $56.57 $56.57 $56.57$55.51 R $56.34 $54.57 R $56.34 $55.51 R $56.34 $56.34 $55.51 R $56.34$70.67 R $73.72 $70.13 R $73.72 $70.67 R $73.72 $77.61 $70.67 R $73.72$72.58 $72.58 $72.58 $72.58 $72.58$64.85 R $67.90 $64.31 R $67.90 $64.85 R $67.90 $71.79 $64.85 R $67.90

$7.07 R $7.38 $7.02 R $7.38 $7.07 R $7.38 $7.77 $7.07 R $7.38$7.28 $7.28 $7.28 $7.28 $7.28$6.50 R $6.80 $6.44 R $6.80 $6.50 R $6.80 $7.19 $6.50 R $6.80

$53.01 R $55.30 $52.60 R $55.30 $53.01 R $55.30 $58.21 $53.01 R $55.30$54.44 $54.44 $54.44 $54.44 $54.44$48.65 R $50.93 $48.24 R $50.93 $48.65 R $50.93 $53.85 $48.65 R $50.93$19.91 $19.91 $19.91 $19.91 $19.91$19.78 $19.78 $19.78 $19.78 $19.78$18.32 $18.32 $18.32 $18.32 $18.32

$1.98 $1.98 $1.98 $1.98 $1.98$1.97 $1.97 $1.97 $1.97 $1.97$1.83 $1.83 $1.83 $1.83 $1.83

$14.93 $14.93 $14.93 $14.93 $14.93$14.85 $14.85 $14.85 $14.85 $14.85$13.75 $13.75 $13.75 $13.75 $13.75

$142.10 R $150.34 $144.07 R $150.34 $142.10 R $150.34 $154.95 $142.10 R $150.34$144.72 $144.72 $144.72 $144.72 $144.72$130.51 R $138.75 $132.48 R $138.75 $130.51 R $138.75 $143.36 $130.51 R $138.75

$14.21 R $15.03 $14.40 R $15.03 $14.21 R $15.03 $15.49 $14.21 R $15.03$14.47 $14.47 $14.47 $14.47 $14.47$13.05 R $13.87 $13.25 R $13.87 $13.05 R $13.87 $14.34 $13.05 R $13.87

$106.58 R $112.76 $108.06 R $112.76 $106.58 R $112.76 $116.22 $106.58 R $112.76$108.53 $108.53 $108.53 $108.53 $108.53

$97.88 R $104.06 $99.36 R $104.06 $97.88 R $104.06 $107.52 $97.88 R $104.06$74.20 R $76.71 $73.20 R $76.71 $74.20 R $76.71 $82.74 $74.20 R $76.71$77.10 $77.10 $77.10 $77.10 $77.10$68.02 R $70.52 $67.02 R $70.52 $68.02 R $70.52 $76.55 $68.02 R $70.52

$7.43 R $7.68 $7.33 R $7.68 $7.43 R $7.68 $8.28 $7.43 R $7.68$7.73 $7.73 $7.73 $7.73 $7.73$6.81 R $7.06 $6.71 R $7.06 $6.81 R $7.06 $7.66 $6.81 R $7.06

$55.65 R $57.52 $54.90 R $57.52 $55.65 R $57.52 $62.05 $55.65 R $57.52$57.84 $57.84 $57.84 $57.84 $57.84$51.02 R $52.90 $50.27 R $52.90 $51.02 R $52.90 $57.42 $51.02 R $52.90$47.59 $47.59 $47.59 $47.59 $47.59$47.17 $47.17 $47.17 $47.17 $47.17$43.81 $43.81 $43.81 $43.81 $43.81

$4.76 $4.76 $4.76 $4.76 $4.76$4.74 $4.74 $4.74 $4.74 $4.74$4.39 $4.39 $4.39 $4.39 $4.39



HCPCS 1st Mod 2nd Mod CategoryE2385 UE KE INE2385 UE KU INE2385 UE INE2386 NU KE INE2386 NU KU INE2386 NU INE2386 RR KE INE2386 RR KU INE2386 RR INE2386 UE KE INE2386 UE KU INE2386 UE INE2387 NU KE INE2387 NU KU INE2387 NU INE2387 RR KE INE2387 RR KU INE2387 RR INE2387 UE KE INE2387 UE KU INE2387 UE INE2388 NU KE INE2388 NU KU INE2388 NU INE2388 RR KE INE2388 RR KU INE2388 RR INE2388 UE KE INE2388 UE KU INE2388 UE INE2389 NU KE INE2389 NU KU INE2389 NU INE2389 RR KE INE2389 RR KU INE2389 RR INE2389 UE KE INE2389 UE KU INE2389 UE INE2390 NU KE INE2390 NU KU INE2390 NU INE2390 RR KE INE2390 RR KU INE2390 RR INE2390 UE KE INE2390 UE KU INE2390 UE INE2391 NU KE INE2391 NU KU INE2391 NU INE2391 RR KE INE2391 RR KU INE2391 RR INE2391 UE KE INE2391 UE KU INE2391 UE INE2392 NU KE INE2392 NU KU INE2392 NU INE2392 RR KE IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$35.68 $35.68 $35.68 $35.68 $35.68$35.36 $35.36 $35.36 $35.36 $35.36$32.85 $32.85 $32.85 $32.85 $32.85

$134.88 R $136.87 $131.64 R $136.87 $134.88 R $136.87 $136.87 $134.88 R $136.87$143.40 $143.40 $143.40 $143.40 $143.40$123.38 R $125.37 $120.15 R $125.37 $123.38 R $125.37 $125.37 $123.38 R $125.37

$13.49 R $13.68 $13.16 R $13.68 $13.49 R $13.68 $13.68 $13.49 R $13.68$14.34 $14.34 $14.34 $14.34 $14.34$12.34 R $12.54 $12.02 R $12.54 $12.34 R $12.54 $12.54 $12.34 R $12.54

$101.15 R $102.64 $98.72 R $102.64 $101.15 R $102.64 $102.64 $101.15 R $102.64$107.56 $107.56 $107.56 $107.56 $107.56

$92.54 R $94.03 $90.11 R $94.03 $92.54 R $94.03 $94.03 $92.54 R $94.03$61.26 R $62.99 $58.72 R $61.58 $59.84 R $61.58 $67.81 $59.84 R $61.58$64.30 $61.87 $61.87 $64.30 $61.87$56.10 R $57.84 $53.76 R $56.62 $54.89 R $56.62 $62.65 $54.89 R $56.62

$6.13 R $6.30 $5.88 R $6.17 $6.00 R $6.17 $6.78 $6.00 R $6.17$6.43 $6.20 $6.20 $6.43 $6.20$5.61 R $5.79 $5.38 R $5.67 $5.49 R $5.67 $6.27 $5.49 R $5.67

$45.97 R $47.27 $44.05 R $46.20 $44.90 R $46.20 $50.88 $44.90 R $46.20$48.27 $46.41 $46.41 $48.27 $46.41$42.10 R $43.40 $40.33 R $42.47 $41.17 R $42.47 $47.01 $41.17 R $42.47$49.87 $49.87 $49.87 $49.87 $49.87$48.00 $48.00 $48.00 $48.00 $48.00$46.01 $46.01 $46.01 $46.01 $46.01

$4.98 $4.98 $4.98 $4.98 $4.98$4.81 $4.81 $4.81 $4.81 $4.81$4.61 $4.61 $4.61 $4.61 $4.61

$37.40 $37.40 $37.40 $37.40 $37.40$36.02 $36.02 $36.02 $36.02 $36.02$34.51 $34.51 $34.51 $34.51 $34.51$27.43 $27.43 $27.43 $27.43 $27.43$26.08 $26.08 $26.08 $26.08 $26.08$25.34 $25.34 $25.34 $25.34 $25.34

$2.75 $2.75 $2.75 $2.75 $2.75$2.62 $2.62 $2.62 $2.62 $2.62$2.54 $2.54 $2.54 $2.54 $2.54

$20.57 $20.57 $20.57 $20.57 $20.57$19.53 $19.53 $19.53 $19.53 $19.53$18.99 $18.99 $18.99 $18.99 $18.99$42.70 $42.70 $42.70 $42.70 $42.70$40.77 $40.77 $40.77 $40.77 $40.77$39.43 $39.43 $39.43 $39.43 $39.43

$4.27 $4.27 $4.27 $4.27 $4.27$4.07 $4.07 $4.07 $4.07 $4.07$3.94 $3.94 $3.94 $3.94 $3.94

$32.02 $32.02 $32.02 $32.02 $32.02$30.56 $30.56 $30.56 $30.56 $30.56$29.56 $29.56 $29.56 $29.56 $29.56$19.55 R $20.52 $19.53 R $20.52 $19.55 R $20.52 $20.84 $19.55 R $20.52$19.52 $19.52 $19.52 $19.52 $19.52$17.97 R $18.94 $17.95 R $18.94 $17.97 R $18.94 $19.26 $17.97 R $18.94

$1.95 R $2.05 $1.95 R $2.05 $1.95 R $2.05 $2.08 $1.95 R $2.05$1.96 $1.96 $1.96 $1.96 $1.96$1.80 R $1.90 $1.80 R $1.90 $1.80 R $1.90 $1.93 $1.80 R $1.90


$4.97 R $5.19 $4.91 R $5.19 $4.97 R $5.19 $5.54 $4.97 R $5.19



HCPCS 1st Mod 2nd Mod CategoryE2392 RR KU INE2392 RR INE2392 UE KE INE2392 UE KU INE2392 UE INE2394 NU KE INE2394 NU KU INE2394 NU INE2394 RR KE INE2394 RR KU INE2394 RR INE2394 UE KE INE2394 UE KU INE2394 UE INE2395 NU KE INE2395 NU KU INE2395 NU INE2395 RR KE INE2395 RR KU INE2395 RR INE2395 UE KE INE2395 UE KU INE2395 UE INE2396 NU KE INE2396 NU KU INE2396 NU INE2396 RR KE INE2396 RR KU INE2396 RR INE2396 UE KE INE2396 UE KU INE2396 UE INE2397 NU KU INE2397 NU INE2397 RR KU INE2397 RR INE2397 UE KU INE2397 UE INE2402 RR CRE2500 NU INE2500 RR INE2500 UE INE2502 NU INE2502 RR INE2502 UE INE2504 NU INE2504 RR INE2504 UE INE2506 NU INE2506 RR INE2506 UE INE2508 NU INE2508 RR INE2508 UE INE2510 NU INE2510 RR INE2510 UE INE2601 NU KE INE2601 NU KU INE2601 NU INE2601 RR KE IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$5.16 $5.16 $5.16 $5.16 $5.16$4.56 R $4.78 $4.50 R $4.78 $4.56 R $4.78 $5.13 $4.56 R $4.78


$7.03 R $7.29 $6.99 R $7.29 $7.03 R $7.29 $7.90 $7.03 R $7.29$7.33 $7.33 $7.33 $7.33 $7.33$6.44 R $6.71 $6.41 R $6.71 $6.44 R $6.71 $7.32 $6.44 R $6.71


$5.08 R $5.28 $5.07 R $5.28 $5.08 R $5.28 $5.62 $5.08 R $5.28$5.21 $5.21 $5.21 $5.21 $5.21$4.67 R $4.87 $4.66 R $4.87 $4.67 R $4.87 $5.20 $4.67 R $4.87


$6.43 R $6.68 $5.73 R $6.08 $5.84 R $6.08 $6.08 $5.90 R $6.15$6.78 $5.76 $5.76 $5.76 $5.90$5.87 R $6.12 $5.26 R $5.61 $5.37 R $5.61 $5.61 $5.43 R $5.68

$46.21 R $48.06 $41.26 R $43.93 $43.31 R $45.17 $44.29 $44.24 R $46.10$47.54 $40.41 $42.58 $41.03 $44.15$42.40 R $44.26 $38.02 R $40.41 $39.92 R $41.78 $41.00 $40.70 R $42.56

$457.83 $457.83 $457.83 $457.83 $457.83$433.58 R $457.83 $436.81 R $457.83 $433.58 R $457.83 $457.83 $433.58 R $457.83

$45.79 $45.79 $45.79 $45.79 $45.79$43.36 R $45.79 $43.68 R $45.79 $43.36 R $45.79 $45.79 $43.36 R $45.79

$343.35 $343.34 $343.34 $343.35 $343.34$325.17 R $343.35 $327.59 R $343.34 $325.17 R $343.34 $343.35 $325.17 R $343.34

$1,168.41 R $1,173.60 $1,133.00 R $1,173.60 $1,168.41 R $1,173.60 $1,179.19 $1,168.41 R $1,173.60$432.30 $432.30 $432.30 $432.30 $432.30

$43.24 $43.24 $43.24 $43.24 $43.24$324.23 $324.23 $324.23 $324.23 $324.23

$1,321.96 $1,321.96 $1,321.96 $1,321.96 $1,321.96$132.20 $132.20 $132.20 $132.20 $132.20$991.49 $991.49 $991.49 $991.49 $991.49

$1,743.84 $1,743.84 $1,743.84 $1,743.84 $1,743.84$174.41 $174.41 $174.41 $174.41 $174.41

$1,307.88 $1,307.88 $1,307.88 $1,307.88 $1,307.88$2,557.00 $2,557.00 $2,557.00 $2,557.00 $2,557.00

$255.68 $255.68 $255.68 $255.68 $255.68$1,917.71 $1,917.71 $1,917.71 $1,917.71 $1,917.71$3,953.96 $3,953.96 $3,953.96 $3,953.96 $3,953.96

$395.39 $395.39 $395.39 $395.39 $395.39$2,965.48 $2,965.48 $2,965.48 $2,965.48 $2,965.48$7,482.35 $7,482.35 $7,482.35 $7,482.35 $7,482.35

$748.24 $748.24 $748.24 $748.24 $748.24$5,611.76 $5,611.76 $5,611.76 $5,611.76 $5,611.76

$53.22 R $54.26 $51.79 R $54.26 $53.22 R $54.26 $54.26 $53.22 R $54.26$58.27 $58.27 $58.27 $58.27 $58.27$48.55 R $49.59 $47.12 R $49.59 $48.55 R $49.59 $49.59 $48.55 R $49.59

$5.33 R $5.43 $5.18 R $5.43 $5.33 R $5.43 $5.43 $5.33 R $5.43



HCPCS 1st Mod 2nd Mod CategoryE2601 RR KU INE2601 RR INE2601 UE KE INE2601 UE KU INE2601 UE INE2602 NU KE INE2602 NU KU INE2602 NU INE2602 RR KE INE2602 RR KU INE2602 RR INE2602 UE KE INE2602 UE KU INE2602 UE INE2603 NU KE INE2603 NU KU INE2603 NU INE2603 RR KE INE2603 RR KU INE2603 RR INE2603 UE KE INE2603 UE KU INE2603 UE INE2604 NU KE INE2604 NU KU INE2604 NU INE2604 RR KE INE2604 RR KU INE2604 RR INE2604 UE KE INE2604 UE KU INE2604 UE INE2605 NU KE INE2605 NU KU INE2605 NU INE2605 RR KE INE2605 RR KU INE2605 RR INE2605 UE KE INE2605 UE KU INE2605 UE INE2606 NU KE INE2606 NU KU INE2606 NU INE2606 RR KE INE2606 RR KU INE2606 RR INE2606 UE KE INE2606 UE KU INE2606 UE INE2607 NU KE INE2607 NU KU INE2607 NU INE2607 RR KE INE2607 RR KU INE2607 RR INE2607 UE KE INE2607 UE KU INE2607 UE INE2608 NU KE INE2608 NU KU IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$5.85 $5.85 $5.85 $5.85 $5.85$4.87 R $4.97 $4.72 R $4.97 $4.87 R $4.97 $4.97 $4.87 R $4.97

$39.91 R $40.69 $38.84 R $40.69 $39.91 R $40.69 $40.69 $39.91 R $40.69$43.71 $43.71 $43.71 $43.71 $43.71$36.42 R $37.20 $35.35 R $37.20 $36.42 R $37.20 $37.20 $36.42 R $37.20

$107.44 R $110.05 $104.57 R $110.05 $107.44 R $110.05 $110.05 $107.44 R $110.05$113.76 $113.76 $113.76 $113.76 $113.76

$98.32 R $100.93 $95.45 R $100.93 $98.32 R $100.93 $100.93 $98.32 R $100.93$10.75 R $11.01 $10.46 R $11.01 $10.75 R $11.01 $11.01 $10.75 R $11.01$11.38 $11.38 $11.38 $11.38 $11.38

$9.84 R $10.10 $9.55 R $10.10 $9.84 R $10.10 $10.10 $9.84 R $10.10$80.58 R $82.54 $78.43 R $82.54 $80.58 R $82.54 $82.54 $80.58 R $82.54$85.33 $85.33 $85.33 $85.33 $85.33$73.74 R $75.70 $71.59 R $75.70 $73.74 R $75.70 $75.70 $73.74 R $75.70

$135.36 R $137.70 $132.36 R $137.70 $135.36 R $137.70 $137.70 $135.36 R $137.70$144.43 $144.43 $144.43 $144.43 $144.43$123.78 R $126.12 $120.78 R $126.12 $123.78 R $126.12 $126.12 $123.78 R $126.12

$13.54 R $13.77 $13.24 R $13.77 $13.54 R $13.77 $13.77 $13.54 R $13.77$14.45 $14.45 $14.45 $14.45 $14.45$12.38 R $12.62 $12.08 R $12.62 $12.38 R $12.62 $12.62 $12.38 R $12.62

$101.52 R $103.27 $99.26 R $103.27 $101.52 R $103.27 $103.27 $101.52 R $103.27$108.33 $108.33 $108.33 $108.33 $108.33

$92.84 R $94.60 $90.59 R $94.60 $92.84 R $94.60 $94.60 $92.84 R $94.60$174.76 R $180.53 $174.57 R $180.53 $174.76 R $180.53 $194.14 $174.76 R $180.53$179.53 $179.53 $179.53 $179.53 $179.53$160.39 R $166.15 $160.20 R $166.15 $160.39 R $166.15 $179.53 $160.39 R $166.15

$17.47 R $18.04 $17.45 R $18.04 $17.47 R $18.04 $19.40 $17.47 R $18.04$17.95 $17.95 $17.95 $17.95 $17.95$16.04 R $16.61 $16.02 R $16.61 $16.04 R $16.61 $17.95 $16.04 R $16.61


$24.86 R $25.85 $24.79 R $25.85 $24.86 R $25.85 $27.74 $24.86 R $25.85$25.66 $25.66 $25.66 $25.66 $25.66$22.80 R $23.79 $22.74 R $23.79 $22.80 R $23.79 $25.66 $22.80 R $23.79


$39.28 R $40.79 $39.21 R $40.79 $39.28 R $40.79 $43.27 $39.28 R $40.79$40.02 $40.02 $40.02 $40.02 $40.02$36.07 R $37.58 $36.00 R $37.58 $36.07 R $37.58 $40.02 $36.07 R $37.58


$26.17 R $26.69 $25.67 R $26.69 $26.17 R $26.69 $26.69 $26.17 R $26.69$27.62 $27.62 $27.62 $27.62 $27.62$23.96 R $24.47 $23.45 R $24.47 $23.96 R $24.47 $24.47 $23.96 R $24.47

$196.26 R $200.11 $192.48 R $200.11 $196.26 R $200.11 $200.11 $196.26 R $200.11$207.14 $207.14 $207.14 $207.14 $207.14$179.66 R $183.52 $175.89 R $183.52 $179.66 R $183.52 $183.52 $179.66 R $183.52$317.86 R $326.94 $315.63 R $326.94 $317.86 R $326.94 $358.40 $317.86 R $326.94$331.67 $331.67 $331.67 $331.67 $331.67



HCPCS 1st Mod 2nd Mod CategoryE2608 NU INE2608 RR KE INE2608 RR KU INE2608 RR INE2608 UE KE INE2608 UE KU INE2608 UE INE2611 NU KE INE2611 NU KU INE2611 NU INE2611 RR KE INE2611 RR KU INE2611 RR INE2611 UE KE INE2611 UE KU INE2611 UE INE2612 NU KE INE2612 NU KU INE2612 NU INE2612 RR KE INE2612 RR KU INE2612 RR INE2612 UE KE INE2612 UE KU INE2612 UE INE2613 NU KE INE2613 NU KU INE2613 NU INE2613 RR KE INE2613 RR KU INE2613 RR INE2613 UE KE INE2613 UE KU INE2613 UE INE2614 NU KE INE2614 NU KU INE2614 NU INE2614 RR KE INE2614 RR KU INE2614 RR INE2614 UE KE INE2614 UE KU INE2614 UE INE2615 NU KE INE2615 NU KU INE2615 NU INE2615 RR KE INE2615 RR KU INE2615 RR INE2615 UE KE INE2615 UE KU INE2615 UE INE2616 NU KE INE2616 NU KU INE2616 NU INE2616 RR KE INE2616 RR KU INE2616 RR INE2616 UE KE INE2616 UE KU INE2616 UE IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$291.29 R $300.37 $289.06 R $300.37 $291.29 R $300.37 $331.67 $291.29 R $300.37$31.78 R $32.69 $31.56 R $32.69 $31.78 R $32.69 $35.84 $31.78 R $32.69$33.16 $33.16 $33.16 $33.16 $33.16$29.12 R $30.03 $28.90 R $30.03 $29.12 R $30.03 $33.16 $29.12 R $30.03


$25.48 R $25.63 $24.71 R $25.63 $25.48 R $25.63 $25.63 $25.48 R $25.63$29.75 $29.75 $29.75 $29.75 $29.75$23.08 R $23.24 $22.32 R $23.24 $23.08 R $23.24 $23.24 $23.08 R $23.24


$38.52 R $39.35 $37.67 R $39.35 $38.52 R $39.35 $43.55 $38.52 R $39.35$40.26 $40.26 $40.26 $40.26 $40.26$35.30 R $36.13 $34.44 R $36.13 $35.30 R $36.13 $40.26 $35.30 R $36.13


$36.60 R $37.85 $36.24 R $37.85 $36.60 R $37.85 $37.85 $36.60 R $37.85$37.46 $37.46 $37.46 $37.46 $37.46$33.59 R $34.85 $33.23 R $34.85 $33.59 R $34.85 $34.85 $33.59 R $34.85


$51.47 R $53.84 $51.36 R $53.84 $51.47 R $53.84 $56.07 $51.47 R $53.84$51.83 $51.83 $51.83 $51.83 $51.83$47.31 R $49.69 $47.21 R $49.69 $47.31 R $49.69 $51.83 $47.31 R $49.69


$41.91 R $43.42 $41.57 R $43.42 $41.91 R $43.42 $43.42 $41.91 R $43.42$43.11 $43.11 $43.11 $43.11 $43.11$38.46 R $39.97 $38.12 R $39.97 $38.46 R $39.97 $39.97 $38.46 R $39.97


$56.16 R $58.33 $55.94 R $58.33 $56.16 R $58.33 $62.74 $56.16 R $58.33$57.99 $57.99 $57.99 $57.99 $57.99$51.52 R $53.69 $51.30 R $53.69 $51.52 R $53.69 $57.99 $51.52 R $53.69

$421.21 R $437.51 $419.56 R $437.51 $421.21 R $437.51 $470.55 $421.21 R $437.51$434.92 $434.92 $434.92 $434.92 $434.92$386.37 R $402.67 $384.72 R $402.67 $386.37 R $402.67 $434.92 $386.37 R $402.67



HCPCS 1st Mod 2nd Mod CategoryE2619 NU KE INE2619 NU KU INE2619 NU INE2619 RR KE INE2619 RR KU INE2619 RR INE2619 UE KE INE2619 UE KU INE2619 UE INE2620 NU KE INE2620 NU KU INE2620 NU INE2620 RR KE INE2620 RR KU INE2620 RR INE2620 UE KE INE2620 UE KU INE2620 UE INE2621 NU KE INE2621 NU KU INE2621 NU INE2621 RR KE INE2621 RR KU INE2621 RR INE2621 UE KE INE2621 UE KU INE2621 UE INE2622 NU KE INE2622 NU KU INE2622 NU INE2622 RR KE INE2622 RR KU INE2622 RR INE2622 UE KE INE2622 UE KU INE2622 UE INE2623 NU KE INE2623 NU KU INE2623 NU INE2623 RR KE INE2623 RR KU INE2623 RR INE2623 UE KE INE2623 UE KU INE2623 UE INE2624 NU KE INE2624 NU KU INE2624 NU INE2624 RR KE INE2624 RR KU INE2624 RR INE2624 UE KE INE2624 UE KU INE2624 UE INE2625 NU KE INE2625 NU KU INE2625 NU INE2625 RR KE INE2625 RR KU INE2625 RR INE2625 UE KE IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$51.03 $51.03 $51.03 $51.03 $51.03$48.89 $48.89 $48.89 $48.89 $48.89$47.11 $47.11 $47.11 $47.11 $47.11

$5.10 $5.10 $5.10 $5.10 $5.10$4.89 $4.89 $4.89 $4.89 $4.89$4.71 $4.71 $4.71 $4.71 $4.71

$38.29 $38.29 $38.29 $38.29 $38.29$36.70 $36.70 $36.70 $36.70 $36.70$35.35 $35.35 $35.35 $35.35 $35.35

$490.06 R $500.62 $484.57 R $500.62 $490.06 R $500.62 $500.62 $490.06 R $500.62$521.86 $521.86 $521.86 $521.86 $521.86$448.25 R $458.81 $442.76 R $458.81 $448.25 R $458.81 $458.81 $448.25 R $458.81

$49.01 R $50.06 $48.46 R $50.06 $49.01 R $50.06 $50.06 $49.01 R $50.06$52.19 $52.19 $52.19 $52.19 $52.19$44.83 R $45.88 $44.28 R $45.88 $44.83 R $45.88 $45.88 $44.83 R $45.88


$53.42 R $55.07 $53.03 R $55.07 $53.42 R $55.07 $59.21 $53.42 R $55.07$54.77 $54.77 $54.77 $54.77 $54.77$49.04 R $50.70 $48.66 R $50.70 $49.04 R $50.70 $54.77 $49.04 R $50.70

$400.69 R $413.12 $397.82 R $413.12 $400.69 R $413.12 $444.15 $400.69 R $413.12$410.74 $410.74 $410.74 $410.74 $410.74$367.79 R $380.21 $364.91 R $380.21 $367.79 R $380.21 $410.74 $367.79 R $380.21$326.97 $326.97 $326.97 $326.97 $326.97$315.83 $315.83 $315.83 $315.83 $315.83$301.67 $301.67 $301.67 $301.67 $301.67

$32.70 $32.70 $32.70 $32.70 $32.70$31.59 $31.59 $31.59 $31.59 $31.59$30.17 $30.17 $30.17 $30.17 $30.17

$245.23 $245.23 $245.23 $245.23 $245.23$236.87 $236.87 $236.87 $236.87 $236.87$226.25 $226.25 $226.25 $226.25 $226.25$414.93 $414.93 $414.93 $414.93 $414.93$401.89 $401.89 $401.89 $401.89 $401.89$382.72 $382.72 $382.72 $382.72 $382.72

$41.50 $41.50 $41.50 $41.50 $41.50$40.20 $40.20 $40.20 $40.20 $40.20$38.28 $38.28 $38.28 $38.28 $38.28

$311.19 $311.19 $311.19 $311.19 $311.19$301.40 $301.40 $301.40 $301.40 $301.40$287.04 $287.04 $287.04 $287.04 $287.04$330.80 $330.80 $330.80 $330.80 $330.80$318.43 $318.43 $318.43 $318.43 $318.43$305.29 $305.29 $305.29 $305.29 $305.29

$33.08 $33.08 $33.08 $33.08 $33.08$31.85 $31.85 $31.85 $31.85 $31.85$30.53 $30.53 $30.53 $30.53 $30.53

$248.10 $248.10 $248.10 $248.10 $248.10$238.84 $238.84 $238.84 $238.84 $238.84$228.98 $228.98 $228.98 $228.98 $228.98$414.63 $414.63 $414.63 $414.63 $414.63$403.11 $403.11 $403.11 $403.11 $403.11$382.34 $382.34 $382.34 $382.34 $382.34

$41.47 $41.47 $41.47 $41.47 $41.47$40.30 $40.30 $40.30 $40.30 $40.30$38.23 $38.23 $38.23 $38.23 $38.23

$310.97 $310.97 $310.97 $310.97 $310.97



HCPCS 1st Mod 2nd Mod CategoryE2625 UE KU INE2625 UE INE2626 NU KU INE2626 NU INE2626 RR KU INE2626 RR INE2626 UE KU INE2626 UE INE2627 NU KU INE2627 NU INE2627 RR KU INE2627 RR INE2627 UE KU INE2627 UE INE2628 NU KU INE2628 NU INE2628 RR KU INE2628 RR INE2628 UE KU INE2628 UE INE2629 NU KU INE2629 NU INE2629 RR KU INE2629 RR INE2629 UE KU INE2629 UE INE2630 NU KU INE2630 NU INE2630 RR KU INE2630 RR INE2630 UE KU INE2630 UE INE2631 NU KU INE2631 NU INE2631 RR KU INE2631 RR INE2631 UE KU INE2631 UE INE2632 NU KU INE2632 NU INE2632 RR KU INE2632 RR INE2632 UE KU INE2632 UE INE2633 NU KU INE2633 NU INE2633 RR KU INE2633 RR INE2633 UE KU INE2633 UE INK0001 RR CRK0002 RR CRK0003 RR CRK0004 RR CRK0005 NU INK0005 RR INK0005 UE INK0006 RR CRK0007 RR CRK0009 RR CRK0010 RR CR

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$302.33 $302.33 $302.33 $302.33 $302.33$286.75 $286.75 $286.75 $286.75 $286.75$686.66 $638.04 $649.96 $686.66 $677.13$641.41 R $679.22 $611.40 R $638.04 $623.06 R $649.96 $686.66 $636.65 R $674.46

$68.64 $63.82 $65.02 $68.64 $67.72$64.13 R $67.91 $61.15 R $63.82 $62.32 R $65.02 $68.64 $63.67 R $67.45

$514.94 $478.56 $487.48 $514.94 $507.82$481.03 R $509.39 $458.57 R $478.56 $467.30 R $487.48 $514.94 $477.47 R $505.83

$1,095.69 $1,095.69 $931.34 $931.34 $931.34$1,008.23 R $1,065.84 $1,021.43 R $1,065.84 $926.05 R $931.34 $931.34 $926.05 R $931.34

$109.60 $109.60 $93.16 $93.16 $93.16$100.84 R $106.60 $102.16 R $106.60 $92.62 R $93.16 $93.16 $92.62 R $93.16$821.76 $821.76 $698.50 $698.50 $698.50$756.17 R $799.38 $766.07 R $799.38 $694.54 R $698.49 $698.49 $694.54 R $698.49$825.43 $727.69 $762.64 $825.43 $701.62$773.38 R $815.27 $714.24 R $727.69 $741.98 R $762.64 $825.43 $701.61 R $701.61

$82.54 $72.77 $76.26 $82.54 $70.16$77.34 R $81.53 $71.42 R $72.77 $74.20 R $76.26 $82.54 $70.16 R $70.16

$619.06 $545.78 $571.96 $619.06 $526.20$580.03 R $611.45 $535.68 R $545.78 $556.48 R $571.96 $619.06 $526.21 R $526.21

$1,044.56 $975.22 $1,005.45 $1,044.56 $1,044.56$979.66 R $1,029.58 $943.54 R $975.22 $960.11 R $1,005.45 $1,029.58 $979.66 R $1,029.58$104.44 $97.52 $100.54 $104.44 $104.44

$97.96 R $102.95 $94.35 R $97.52 $96.01 R $100.54 $102.95 $97.96 R $102.95$783.41 $731.43 $754.05 $783.41 $783.41$734.75 R $772.19 $707.67 R $731.43 $720.07 R $754.05 $772.19 $734.75 R $772.19$620.89 $730.46 $620.89 $676.76 $620.89$617.97 R $620.89 $681.78 R $708.73 $617.97 R $620.89 $676.76 $617.97 R $620.89

$62.09 $73.05 $62.09 $67.68 $62.09$61.80 R $62.09 $68.18 R $70.87 $61.80 R $62.09 $67.68 $61.80 R $62.09

$465.66 $547.84 $465.66 $507.59 $465.66$463.48 R $465.66 $511.34 R $531.54 $463.48 R $465.66 $507.59 $463.48 R $465.66$292.20 $292.20 $292.20 $292.20 $248.37$278.89 R $287.96 $274.08 R $287.96 $278.89 R $287.96 $292.20 $248.36 R $248.36

$29.22 $29.22 $29.22 $29.22 $24.84$27.89 R $28.80 $27.41 R $28.80 $27.89 R $28.80 $29.22 $24.84 R $24.84

$219.14 $219.14 $219.14 $219.14 $186.27$209.16 R $215.97 $205.56 R $215.97 $209.16 R $215.97 $219.14 $186.27 R $186.27$184.08 $185.79 $185.79 $185.79 $157.92$172.02 R $181.57 $173.71 R $182.43 $172.87 R $182.43 $182.43 $157.93 R $157.93

$18.40 $18.58 $18.58 $18.58 $15.79$17.20 R $18.15 $17.37 R $18.24 $17.29 R $18.24 $18.24 $15.79 R $15.79

$138.06 $139.34 $139.34 $139.34 $118.44$129.01 R $136.18 $130.28 R $136.82 $129.65 R $136.82 $136.82 $118.44 R $118.44$153.40 $157.59 $157.59 $157.59 $133.95$142.00 R $150.55 $146.20 R $152.64 $144.10 R $152.64 $152.64 $132.28 R $133.95

$15.38 $15.77 $15.77 $15.77 $13.40$14.22 R $15.07 $14.62 R $15.27 $14.41 R $15.27 $15.27 $13.23 R $13.41

$115.03 $118.20 $118.20 $118.20 $100.47$106.49 R $112.90 $109.65 R $114.48 $108.08 R $114.48 $114.48 $99.21 R $100.47


$2,043.83 $2,043.83 $2,043.83 $2,043.83 $2,043.83$204.36 $204.36 $204.36 $204.36 $204.36

$1,532.83 $1,532.83 $1,532.83 $1,532.83 $1,532.83$103.42 R $103.42 $100.52 R $103.42 $93.02 R $93.02 $103.42 $93.02 R $93.02$141.51 R $141.51 $141.12 R $146.40 $142.17 R $142.17 $144.74 $144.38 R $144.38

$82.20 $79.01 $79.01 $82.20 $82.20$400.29 $400.29 $419.61 $400.29 $421.90



HCPCS 1st Mod 2nd Mod CategoryK0011 RR KF CRK0011 RR CRK0012 RR CRK0015 RR KE CRK0015 RR KU CRK0015 RR CRK0017 NU KE INK0017 NU KU INK0017 NU INK0017 RR KE INK0017 RR KU INK0017 RR INK0017 UE KE INK0017 UE KU INK0017 UE INK0018 NU KE INK0018 NU KU INK0018 NU INK0018 RR KE INK0018 RR KU INK0018 RR INK0018 UE KE INK0018 UE KU INK0018 UE INK0019 NU KE INK0019 NU KU INK0019 NU INK0019 RR KE INK0019 RR KU INK0019 RR INK0019 UE KE INK0019 UE KU INK0019 UE INK0020 NU KE INK0020 NU KU INK0020 NU INK0020 RR KE INK0020 RR KU INK0020 RR INK0020 UE KE INK0020 UE KU INK0020 UE INK0037 NU KE INK0037 NU KU INK0037 NU INK0037 RR KE INK0037 RR KU INK0037 RR INK0037 UE KE INK0037 UE KU INK0037 UE INK0038 NU KE INK0038 NU KU INK0038 NU INK0038 RR KE INK0038 RR KU INK0038 RR INK0038 UE KE INK0038 UE KU INK0038 UE INK0039 NU KE IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$609.43 $628.76 $613.79 $628.76 $628.10$548.93 $566.33 $552.81 $566.33 $565.73$336.72 $359.21 $339.12 $359.21 $347.07

$16.82 R $17.43 $16.80 R $17.43 $16.78 R $17.39 $18.55 $16.78 R $17.39$17.31 $17.31 $17.24 $17.31 $17.24$15.42 R $16.03 $15.40 R $16.03 $15.38 R $16.00 $17.16 $15.38 R $16.00$50.07 $50.07 $50.07 $50.07 $50.07$48.69 $48.69 $48.69 $48.69 $48.69$46.16 $46.16 $46.16 $46.16 $46.16

$5.00 $5.00 $5.00 $5.00 $5.00$4.87 $4.87 $4.87 $4.87 $4.87$4.62 $4.62 $4.62 $4.62 $4.62

$37.56 $37.56 $37.56 $37.56 $37.56$36.52 $36.52 $36.52 $36.52 $36.52$34.62 $34.62 $34.62 $34.62 $34.62$28.12 $28.12 $28.11 $28.12 $28.11$27.20 $27.20 $27.19 $27.20 $27.19$25.93 $25.93 $25.93 $25.93 $25.93

$2.80 $2.80 $2.80 $2.80 $2.80$2.71 $2.71 $2.71 $2.71 $2.71$2.59 $2.59 $2.59 $2.59 $2.59

$21.09 $21.09 $21.09 $21.09 $21.09$20.41 $20.41 $20.41 $20.41 $20.41$19.45 $19.45 $19.45 $19.45 $19.45$15.66 R $16.50 $14.84 R $16.01 $15.17 R $16.01 $16.85 $15.17 R $16.01$16.41 $15.58 $15.58 $15.58 $15.58$14.34 R $15.18 $13.59 R $14.76 $13.92 R $14.76 $15.58 $13.92 R $14.76

$1.56 R $1.65 $1.49 R $1.60 $1.52 R $1.60 $1.69 $1.52 R $1.60$1.64 $1.56 $1.56 $1.56 $1.56$1.44 R $1.52 $1.36 R $1.48 $1.40 R $1.48 $1.56 $1.40 R $1.48

$11.75 R $12.38 $11.12 R $12.00 $11.37 R $12.00 $12.63 $11.37 R $12.00$12.32 $11.67 $11.67 $11.67 $11.67$10.76 R $11.39 $10.19 R $11.06 $10.44 R $11.06 $11.67 $10.44 R $11.06$47.05 $47.05 $47.05 $47.05 $47.05$44.27 $44.27 $44.27 $44.27 $44.27$43.51 $43.51 $43.51 $43.51 $43.51

$4.71 $4.71 $4.71 $4.71 $4.71$4.43 $4.43 $4.43 $4.43 $4.43$4.35 $4.35 $4.35 $4.35 $4.35

$35.28 $35.28 $35.28 $35.28 $35.28$33.20 $33.20 $33.20 $33.20 $33.20$32.63 $32.63 $32.63 $32.63 $32.63$45.86 $47.14 $43.15 $43.15 $43.15$43.68 $45.89 $39.01 $39.01 $39.01$42.37 $43.47 $39.00 $39.00 $39.00

$4.44 $4.44 $4.05 $4.13 $4.12$4.09 $4.09 $3.48 $3.59 $3.58$4.09 $4.09 $3.48 $3.59 $3.58

$34.40 $35.37 $32.37 $32.37 $32.37$32.76 $34.43 $29.27 $29.27 $29.27$31.78 $32.61 $29.26 $29.26 $29.26$24.31 $24.31 $24.31 $24.31 $24.31$23.13 $23.13 $23.13 $23.13 $23.13$22.47 $22.47 $22.47 $22.47 $22.47

$2.44 $2.44 $2.44 $2.44 $2.44$2.31 $2.31 $2.31 $2.31 $2.31$2.25 $2.25 $2.25 $2.25 $2.25

$18.24 $18.24 $18.24 $18.24 $18.24$17.33 $17.33 $17.33 $17.33 $17.33$16.84 $16.84 $16.84 $16.84 $16.84$53.19 $53.19 $53.19 $53.19 $53.19



HCPCS 1st Mod 2nd Mod CategoryK0039 NU KU INK0039 NU INK0039 RR KE INK0039 RR KU INK0039 RR INK0039 UE KE INK0039 UE KU INK0039 UE INK0040 NU KE INK0040 NU KU INK0040 NU INK0040 RR KE INK0040 RR KU INK0040 RR INK0040 UE KE INK0040 UE KU INK0040 UE INK0041 NU KE INK0041 NU KU INK0041 NU INK0041 RR KE INK0041 RR KU INK0041 RR INK0041 UE KE INK0041 UE KU INK0041 UE INK0042 NU KE INK0042 NU KU INK0042 NU INK0042 RR KE INK0042 RR KU INK0042 RR INK0042 UE KE INK0042 UE KU INK0042 UE INK0043 NU KE INK0043 NU KU INK0043 NU INK0043 RR KE INK0043 RR KU INK0043 RR INK0043 UE KE INK0043 UE KU INK0043 UE INK0044 NU KE INK0044 NU KU INK0044 NU INK0044 RR KE INK0044 RR KU INK0044 RR INK0044 UE KE INK0044 UE KU INK0044 UE INK0045 NU KE INK0045 NU KU INK0045 NU INK0045 RR KE INK0045 RR KU INK0045 RR INK0045 UE KE INK0045 UE KU IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$51.33 $51.33 $51.33 $51.33 $51.33$49.08 $49.08 $49.08 $49.08 $49.08

$5.33 $5.33 $5.33 $5.33 $5.33$5.16 $5.16 $5.16 $5.16 $5.16$4.92 $4.92 $4.92 $4.92 $4.92

$39.90 $39.90 $39.90 $39.90 $39.90$38.51 $38.51 $38.51 $38.51 $38.51$36.81 $36.81 $36.81 $36.81 $36.81$66.92 R $68.76 $66.48 R $68.76 $66.92 R $68.76 $68.76 $66.92 R $68.76$71.15 $71.15 $71.15 $71.15 $71.15$61.23 R $63.06 $60.78 R $63.06 $61.23 R $63.06 $63.06 $61.23 R $63.06

$6.68 R $6.86 $6.63 R $6.86 $6.68 R $6.86 $6.86 $6.68 R $6.86$7.10 $7.10 $7.10 $7.10 $7.10$6.12 R $6.30 $6.07 R $6.30 $6.12 R $6.30 $6.30 $6.12 R $6.30

$50.19 R $51.57 $49.86 R $51.57 $50.19 R $51.57 $51.57 $50.19 R $51.57$53.34 $53.34 $53.34 $53.34 $53.34$45.91 R $47.28 $45.57 R $47.28 $45.91 R $47.28 $47.28 $45.91 R $47.28$51.62 $51.62 $51.62 $51.62 $51.62$50.42 $50.42 $50.42 $50.42 $50.42$47.58 $47.58 $47.58 $47.58 $47.58

$5.18 $5.18 $5.18 $5.18 $5.18$5.08 $5.08 $5.08 $5.08 $5.08$4.78 $4.78 $4.78 $4.78 $4.78

$38.72 $38.72 $38.72 $38.72 $38.72$37.81 $37.81 $37.81 $37.81 $37.81$35.69 $35.69 $35.69 $35.69 $35.69$34.50 $34.50 $34.50 $34.50 $34.50$34.72 $34.72 $34.70 $34.72 $34.72$31.73 $31.73 $31.72 $31.73 $31.73

$3.44 $3.44 $3.44 $3.44 $3.44$3.47 $3.47 $3.47 $3.47 $3.47$3.17 $3.17 $3.17 $3.17 $3.17

$25.88 $25.88 $25.88 $25.88 $25.88$26.03 $26.03 $26.03 $26.03 $26.03$23.79 $23.79 $23.79 $23.79 $23.79$19.67 $19.67 $19.67 $19.67 $19.67$18.60 $18.60 $18.60 $18.60 $18.60$18.17 $18.17 $18.17 $18.17 $18.17

$1.97 $1.97 $1.97 $1.97 $1.97$1.85 $1.85 $1.85 $1.85 $1.85$1.81 $1.81 $1.81 $1.81 $1.81

$14.76 $14.76 $14.75 $14.76 $14.75$13.98 $13.98 $13.96 $13.98 $13.96$13.65 $13.65 $13.64 $13.65 $13.64$16.91 $16.91 $16.91 $16.91 $16.91$15.86 $15.86 $15.86 $15.86 $15.86$15.65 $15.65 $15.65 $15.65 $15.65

$1.69 $1.69 $1.69 $1.69 $1.69$1.59 $1.59 $1.59 $1.59 $1.59$1.57 $1.57 $1.57 $1.57 $1.57

$12.69 $12.69 $12.69 $12.69 $12.69$11.89 $11.89 $11.89 $11.89 $11.89$11.73 $11.73 $11.73 $11.73 $11.73$56.69 $56.69 $56.69 $56.69 $56.69$53.95 $53.95 $53.95 $53.95 $53.95$52.36 $52.36 $52.36 $52.36 $52.36

$5.77 $5.67 $5.67 $5.67 $5.67$5.56 $5.39 $5.39 $5.39 $5.39$5.32 $5.23 $5.23 $5.23 $5.23

$42.52 $42.52 $42.52 $42.52 $42.52$40.47 $40.47 $40.47 $40.47 $40.47



HCPCS 1st Mod 2nd Mod CategoryK0045 UE INK0046 NU KE INK0046 NU KU INK0046 NU INK0046 RR KE INK0046 RR KU INK0046 RR INK0046 UE KE INK0046 UE KU INK0046 UE INK0047 NU KE INK0047 NU KU INK0047 NU INK0047 RR KE INK0047 RR KU INK0047 RR INK0047 UE KE INK0047 UE KU INK0047 UE INK0050 NU KE INK0050 NU INK0050 RR KE INK0050 RR INK0050 UE KE INK0050 UE INK0051 NU KE INK0051 NU KU INK0051 NU INK0051 RR KE INK0051 RR KU INK0051 RR INK0051 UE KE INK0051 UE KU INK0051 UE INK0052 NU KE INK0052 NU KU INK0052 NU INK0052 RR KE INK0052 RR KU INK0052 RR INK0052 UE KE INK0052 UE KU INK0052 UE INK0053 NU KE INK0053 NU KU INK0053 NU INK0053 RR KE INK0053 RR KU INK0053 RR INK0053 UE KE INK0053 UE KU INK0053 UE INK0056 NU KU INK0056 NU INK0056 RR KU INK0056 RR INK0056 UE KU INK0056 UE INK0065 NU KU INK0065 NU INK0065 RR KU IN

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$39.28 $39.28 $39.28 $39.28 $39.28$19.73 $19.73 $19.73 $19.73 $19.73$18.60 $18.60 $18.60 $18.60 $18.60$18.23 $18.23 $18.23 $18.23 $18.23

$1.97 $1.97 $1.97 $1.97 $1.97$1.85 $1.85 $1.85 $1.85 $1.85$1.82 $1.82 $1.82 $1.82 $1.82

$14.80 $14.80 $14.80 $14.80 $14.80$13.98 $13.98 $13.98 $13.98 $13.98$13.69 $13.69 $13.69 $13.69 $13.69$73.83 $73.83 $73.83 $73.83 $73.83$72.87 $72.87 $72.87 $72.87 $72.87$67.99 $67.99 $67.99 $67.99 $67.99

$7.39 $7.39 $7.39 $7.39 $7.39$7.31 $7.31 $7.31 $7.31 $7.31$6.81 $6.81 $6.81 $6.81 $6.81

$55.36 $55.36 $55.36 $55.36 $55.36$54.63 $54.63 $54.63 $54.63 $54.63$50.98 $50.98 $50.98 $50.98 $50.98$32.61 $32.61 $32.61 $32.61 $32.61$30.12 $30.12 $30.12 $30.12 $30.12

$3.26 $3.26 $3.26 $3.26 $3.26$3.01 $3.01 $3.01 $3.01 $3.01

$24.46 $24.46 $24.46 $24.46 $24.46$22.60 $22.60 $22.60 $22.60 $22.60$52.23 $52.23 $52.23 $52.23 $52.23$50.12 $50.12 $50.12 $50.12 $50.12$48.22 $48.22 $48.22 $48.22 $48.22

$5.24 $5.24 $5.24 $5.24 $5.24$5.04 $5.04 $5.04 $5.04 $5.04$4.84 $4.84 $4.84 $4.84 $4.84

$39.17 $39.17 $39.17 $39.17 $39.17$37.58 $37.58 $37.58 $37.58 $37.58$36.16 $36.16 $36.16 $36.16 $36.16$85.21 R $88.06 $84.50 R $88.06 $85.21 R $88.06 $88.06 $85.21 R $88.06$88.09 $88.09 $88.09 $88.09 $88.09$78.15 R $81.00 $77.45 R $81.00 $78.15 R $81.00 $81.00 $78.15 R $81.00

$8.52 R $8.80 $8.45 R $8.80 $8.52 R $8.80 $8.80 $8.52 R $8.80$8.80 $8.80 $8.80 $8.80 $8.80$7.81 R $8.10 $7.74 R $8.10 $7.81 R $8.10 $8.10 $7.81 R $8.10


$9.64 R $10.07 $9.60 R $10.07 $9.64 R $10.07 $10.07 $9.64 R $10.07$9.71 $9.71 $9.71 $9.71 $9.71$8.86 R $9.29 $8.82 R $9.29 $8.86 R $9.29 $9.29 $8.86 R $9.29

$72.31 R $75.52 $72.04 R $75.52 $72.31 R $75.52 $75.52 $72.31 R $75.52$72.90 $72.90 $72.90 $72.90 $72.90$66.46 R $69.67 $66.18 R $69.67 $66.46 R $69.67 $69.67 $66.46 R $69.67

$105.14 $105.14 $105.14 $105.14 $105.14$97.86 R $101.38 $95.94 R $101.38 $97.86 R $101.38 $104.07 $97.86 R $101.38$10.52 $10.52 $10.52 $10.52 $10.52

$9.79 R $10.14 $9.60 R $10.14 $9.79 R $10.14 $10.41 $9.79 R $10.14$78.87 $78.87 $78.87 $78.87 $78.87$73.41 R $76.04 $71.96 R $76.04 $73.41 R $76.04 $78.06 $73.41 R $76.04$49.14 $49.14 $49.14 $49.14 $49.14$46.06 R $48.86 $46.45 R $48.86 $46.06 R $48.86 $48.86 $46.06 R $48.86

$4.92 $4.92 $4.92 $4.92 $4.92



HCPCS 1st Mod 2nd Mod CategoryK0065 RR INK0065 UE KU INK0065 UE INK0069 NU KU INK0069 NU INK0069 RR KU INK0069 RR INK0069 UE KU INK0069 UE INK0070 RR KU CRK0070 RR CRK0071 NU KU INK0071 NU INK0071 RR KU INK0071 RR INK0071 UE KU INK0071 UE INK0072 NU KU INK0072 NU INK0072 RR KU INK0072 RR INK0072 UE KU INK0072 UE INK0073 NU KU INK0073 NU INK0073 RR KU INK0073 RR INK0073 UE KU INK0073 UE INK0077 NU KU INK0077 NU INK0077 RR KU INK0077 RR INK0077 UE KU INK0077 UE INK0098 NU KE INK0098 NU KU INK0098 NU INK0098 RR KE INK0098 RR KU INK0098 RR INK0098 UE KE INK0098 UE KU INK0098 UE INK0105 NU KU INK0105 NU INK0105 RR KU INK0105 RR INK0105 UE KU INK0105 UE INK0195 RR KE CRK0195 RR CRK0455 RR FSK0552 SUK0601 NU INK0602 NU INK0603 NU INK0604 NU INK0605 NU INK0606 RR KF CRK0607 RR KF CR

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$4.61 R $4.89 $4.65 R $4.89 $4.61 R $4.89 $4.89 $4.61 R $4.89$36.86 $36.86 $36.86 $36.86 $36.86$34.55 R $36.65 $34.84 R $36.65 $34.55 R $36.65 $36.65 $34.55 R $36.65

$110.48 $110.48 $110.48 $110.48 $110.48$100.32 R $104.80 $99.45 R $104.80 $100.32 R $104.80 $109.74 $100.32 R $104.80

$11.50 $11.05 $11.50 $11.05 $11.50$10.26 R $10.71 $9.94 R $10.48 $10.26 R $10.71 $10.97 $10.26 R $10.71$82.85 $82.85 $82.85 $82.85 $82.85$75.23 R $78.59 $74.58 R $78.59 $75.23 R $78.59 $82.30 $75.23 R $78.59$20.27 $20.27 $20.27 $20.27 $20.27$18.09 R $18.45 $17.65 R $18.45 $18.09 R $18.45 $20.08 $18.09 R $18.45

$120.77 $120.77 $120.77 $120.77 $120.77$111.55 R $117.65 $111.84 R $117.65 $111.55 R $117.65 $119.89 $111.55 R $117.65

$12.09 $12.09 $12.09 $12.09 $12.09$11.16 R $11.77 $11.19 R $11.77 $11.16 R $11.77 $12.00 $11.16 R $11.77$90.56 $90.56 $90.56 $90.56 $90.56$83.65 R $88.23 $83.87 R $88.23 $83.65 R $88.23 $89.90 $83.65 R $88.23$72.71 $72.71 $72.71 $72.71 $72.71$68.32 R $71.81 $68.58 R $71.81 $68.32 R $71.81 $71.81 $68.32 R $71.81

$7.27 $7.27 $7.27 $7.27 $7.27$6.83 R $7.18 $6.86 R $7.18 $6.83 R $7.18 $7.18 $6.83 R $7.18

$54.52 $54.52 $54.52 $54.52 $54.52$51.23 R $53.86 $51.43 R $53.86 $51.23 R $53.86 $53.86 $51.23 R $53.86$38.48 $36.99 $36.99 $38.48 $36.99$35.96 R $37.80 $34.98 R $36.99 $35.22 R $36.99 $37.80 $35.22 R $36.99

$3.85 $3.74 $3.74 $3.85 $3.74$3.60 R $3.78 $3.52 R $3.72 $3.54 R $3.72 $3.78 $3.54 R $3.72

$28.85 $27.73 $27.73 $28.85 $27.73$26.97 R $28.35 $26.23 R $27.73 $26.41 R $27.73 $28.35 $26.41 R $27.73$65.07 $65.07 $65.07 $65.07 $65.07$58.58 R $60.58 $57.96 R $60.58 $58.58 R $60.58 $64.53 $58.58 R $60.58

$6.49 $6.49 $6.49 $6.49 $6.49$5.85 R $6.05 $5.79 R $6.05 $5.85 R $6.05 $6.45 $5.85 R $6.05

$48.78 $48.78 $48.78 $48.78 $48.78$43.93 R $45.43 $43.46 R $45.43 $43.93 R $45.43 $48.39 $43.93 R $45.43$26.21 R $27.50 $25.86 R $27.07 $25.77 R $27.07 $27.50 $25.77 R $27.07$25.93 $25.17 $25.17 $25.93 $25.17$24.13 R $25.43 $23.84 R $25.05 $23.76 R $25.05 $25.43 $23.76 R $25.05

$2.62 R $2.75 $2.59 R $2.71 $2.58 R $2.71 $2.75 $2.58 R $2.71$2.60 $2.53 $2.53 $2.60 $2.53$2.42 R $2.55 $2.39 R $2.51 $2.38 R $2.51 $2.55 $2.38 R $2.51

$19.65 R $20.62 $19.39 R $20.30 $19.33 R $20.30 $20.62 $19.33 R $20.30$19.42 $18.87 $18.87 $19.42 $18.87$18.09 R $19.06 $17.88 R $18.79 $17.82 R $18.79 $19.06 $17.82 R $18.79

$109.92 $109.92 $109.92 $109.92 $109.92$102.12 R $107.20 $101.90 R $107.20 $102.12 R $107.20 $108.96 $102.12 R $107.20

$10.99 $10.99 $10.99 $10.99 $10.99$10.21 R $10.72 $10.19 R $10.72 $10.21 R $10.72 $10.89 $10.21 R $10.72$82.44 $82.44 $82.44 $82.44 $82.44$76.59 R $80.40 $76.42 R $80.40 $76.59 R $80.40 $81.72 $76.59 R $80.40$16.60 R $16.94 $16.69 R $17.41 $15.33 R $15.67 $17.41 $16.93 R $17.27$15.07 R $15.40 $15.09 R $15.81 $13.96 R $14.30 $15.81 $15.33 R $15.67

$292.81 $292.81 $248.89 $292.81 $275.34$2.77 $2.75 $2.75 $2.77 $2.75$1.20 $1.20 $1.20 $1.20 $1.20$6.84 $6.84 $6.84 $6.84 $6.84$0.61 $0.61 $0.61 $0.61 $0.61$6.57 $6.57 $6.57 $6.57 $6.57

$15.74 $15.74 $15.74 $15.74 $15.74$2,783.98 $2,783.98 $2,783.98 $2,783.98 $2,783.98

$23.84 $23.84 $23.84 $23.84 $23.84



HCPCS 1st Mod 2nd Mod CategoryK0607 RR CRK0608 NU KF INK0608 NU INK0608 RR KF INK0608 RR INK0608 UE KF INK0608 UE INK0609 KF SUK0609 SUK0672 POK0730 RR CRK0733 NU KE INK0733 NU KU INK0733 NU INK0733 RR KE INK0733 RR KU INK0733 RR INK0733 UE KE INK0733 UE KU INK0733 UE INK0738 RR OXK0800 NU INK0800 RR INK0800 UE INK0801 NU INK0801 RR INK0801 UE INK0802 NU INK0802 RR INK0802 UE INK0806 NU INK0806 RR INK0806 UE INK0807 NU INK0807 RR INK0807 UE INK0808 NU INK0808 RR INK0808 UE INK0813 RR CRK0814 RR CRK0815 RR CRK0816 RR CRK0820 RR CRK0821 RR CRK0822 RR CRK0823 RR CRK0824 RR CRK0825 RR CRK0826 RR CRK0827 RR CRK0828 RR CRK0829 RR CRK0835 RR CRK0836 RR CRK0837 RR CRK0838 RR CRK0839 RR CRK0840 RR CRK0841 RR CRK0842 RR CR

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$21.48 $21.48 $21.48 $21.48 $21.48$148.79 $148.79 $148.79 $148.79 $148.79$133.99 $133.99 $133.99 $133.99 $133.99

$14.90 $14.90 $14.90 $14.90 $14.90$13.43 $13.43 $13.43 $13.43 $13.43

$111.58 $111.58 $111.58 $111.58 $111.58$100.50 $100.50 $100.50 $100.50 $100.50$989.39 $989.39 $989.39 $989.39 $989.39$891.13 $891.13 $891.13 $891.13 $891.13

$81.28 $81.27 $78.88 $86.79 $78.88$190.59 $190.59 $190.59 $190.59 $190.59

$30.00 R $31.55 $30.05 R $31.55 $30.00 R $31.55 $31.55 $30.00 R $31.55$28.78 $28.78 $28.78 $28.78 $28.78$27.68 R $28.78 $27.74 R $28.78 $27.68 R $28.78 $28.78 $27.68 R $28.78

$3.01 R $3.17 $3.02 R $3.17 $3.01 R $3.17 $3.17 $3.01 R $3.17$2.90 $2.90 $2.90 $2.90 $2.90$2.78 R $2.90 $2.78 R $2.90 $2.78 R $2.90 $2.90 $2.78 R $2.90

$22.50 R $23.66 $22.54 R $23.66 $22.50 R $23.66 $23.66 $22.50 R $23.66$21.60 $21.60 $21.60 $21.60 $21.60$20.77 R $21.60 $20.81 R $21.60 $20.77 R $21.60 $21.60 $20.77 R $21.60$44.71 R $46.90 $44.30 R $46.90 $44.71 R $46.90 $46.90 $44.71 R $46.90

$1,031.00 R $1,058.65 $1,016.49 R $1,058.65 $1,031.00 R $1,058.65 $1,058.65 $1,031.00 R $1,058.65$103.11 R $105.87 $101.66 R $105.87 $103.11 R $105.87 $105.87 $103.11 R $105.87$773.25 R $793.99 $762.37 R $793.99 $773.25 R $793.99 $793.99 $773.25 R $793.99

$1,738.27 R $1,801.60 $1,709.04 R $1,801.60 $1,738.27 R $1,801.60 $1,801.60 $1,738.27 R $1,801.60$173.81 R $180.15 $170.89 R $180.15 $173.81 R $180.15 $180.15 $173.81 R $180.15

$1,303.71 R $1,351.20 $1,281.78 R $1,351.20 $1,303.71 R $1,351.20 $1,351.20 $1,303.71 R $1,351.20$2,098.31 R $2,190.53 $2,082.23 R $2,190.53 $2,098.31 R $2,190.53 $2,190.53 $2,098.31 R $2,190.53

$209.83 R $219.05 $208.22 R $219.05 $209.83 R $219.05 $219.05 $209.83 R $219.05$1,573.73 R $1,642.90 $1,561.67 R $1,642.90 $1,573.73 R $1,642.90 $1,642.90 $1,573.73 R $1,642.90$1,391.75 $1,391.75 $1,391.75 $1,391.75 $1,391.75

$139.17 $139.17 $139.17 $139.17 $139.17$1,043.82 $1,043.82 $1,043.82 $1,043.82 $1,043.82$2,132.76 $2,132.76 $2,132.76 $2,132.76 $2,132.76

$213.28 $213.28 $213.28 $213.28 $213.28$1,599.58 $1,599.58 $1,599.58 $1,599.58 $1,599.58$3,298.44 $3,298.44 $3,298.44 $3,298.44 $3,298.44

$329.84 $329.84 $329.84 $329.84 $329.84$2,473.83 $2,473.83 $2,473.83 $2,473.83 $2,473.83

$298.42 R $310.79 $299.14 R $310.79 $298.42 R $310.79 $310.79 $298.42 R $310.79$355.31 R $366.34 $354.00 R $366.34 $355.31 R $366.34 $366.34 $355.31 R $366.34$381.08 R $393.89 $382.88 R $393.89 $381.08 R $393.89 $393.89 $381.08 R $393.89$380.43 R $389.97 $377.78 R $389.97 $380.43 R $389.97 $389.97 $380.43 R $389.97$313.94 R $326.76 $315.75 R $326.76 $313.94 R $326.76 $326.76 $313.94 R $326.76$376.35 R $385.98 $373.50 R $385.98 $376.35 R $385.98 $385.98 $376.35 R $385.98$435.17 R $445.73 $434.23 R $445.73 $435.17 R $445.73 $445.73 $435.17 R $445.73$428.08 R $437.40 $424.68 R $437.40 $428.08 R $437.40 $437.40 $428.08 R $437.40$561.53 R $574.86 $555.97 R $574.86 $561.53 R $574.86 $574.86 $561.53 R $574.86$512.68 R $528.40 $512.63 R $528.40 $512.68 R $528.40 $538.47 $512.68 R $528.40$800.24 R $830.07 $781.52 R $830.07 $800.24 R $830.07 $896.08 $800.24 R $830.07$690.30 R $713.72 $674.86 R $713.72 $690.30 R $713.72 $761.92 $690.30 R $713.72$902.50 R $963.75 $920.72 R $963.75 $902.50 R $963.75 $987.36 $902.50 R $963.75$861.73 R $906.70 $866.71 R $906.70 $861.73 R $906.70 $906.70 $861.73 R $906.70$456.11 $456.11 $456.11 $456.11 $456.11$473.04 $473.04 $473.04 $473.04 $473.04$559.19 $559.19 $559.19 $559.19 $559.19$498.48 $498.48 $498.48 $498.48 $498.48$731.13 $731.13 $731.13 $731.13 $731.13

$1,113.40 $1,113.40 $1,113.40 $1,113.40 $1,113.40$495.88 $495.88 $495.88 $495.88 $495.88$495.60 $495.60 $495.60 $495.60 $495.60



HCPCS 1st Mod 2nd Mod CategoryK0843 RR CRK0848 RR CRK0849 RR CRK0850 RR CRK0851 RR CRK0852 RR CRK0853 RR CRK0854 RR CRK0855 RR CRK0856 RR CRK0857 RR CRK0858 RR CRK0859 RR CRK0860 RR CRK0861 RR KF CRK0861 RR CRK0862 RR CRK0863 RR CRK0864 RR CRK0901 POK0902 POL0112 POL0113 POL0120 POL0130 POL0140 POL0150 POL0160 POL0170 POL0172 POL0174 POL0180 POL0190 POL0200 POL0220 POL0450 POL0454 POL0455 POL0456 POL0457 POL0458 POL0460 POL0462 POL0464 POL0466 POL0467 POL0468 POL0469 POL0470 POL0472 POL0480 POL0482 POL0484 POL0486 POL0488 POL0490 POL0491 POL0492 POL0621 POL0622 POL0625 PO

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$593.54 $593.54 $593.54 $593.54 $593.54$755.28 $755.28 $755.28 $755.28 $755.28$726.16 $726.16 $726.16 $726.16 $726.16$876.10 $876.10 $876.10 $876.10 $876.10$842.37 $842.37 $842.37 $842.37 $842.37

$1,012.27 $1,012.27 $1,012.27 $1,012.27 $1,012.27$1,039.86 $1,039.86 $1,039.86 $1,039.86 $1,039.86$1,377.59 $1,377.59 $1,377.59 $1,377.59 $1,377.59$1,301.34 $1,301.34 $1,301.34 $1,301.34 $1,301.34

$810.71 $810.71 $810.71 $810.71 $810.71$826.96 $826.96 $826.96 $826.96 $826.96

$1,005.86 $1,005.86 $1,005.86 $1,005.86 $1,005.86$959.28 $959.28 $959.28 $959.28 $959.28

$1,436.99 $1,436.99 $1,436.99 $1,436.99 $1,436.99$1,045.98 $1,045.98 $1,045.98 $1,045.98 $1,045.98

$812.01 $812.01 $812.01 $812.01 $812.01$1,005.86 $1,005.86 $1,005.86 $1,005.86 $1,005.86$1,436.99 $1,436.99 $1,436.99 $1,436.99 $1,436.99$1,710.03 $1,710.03 $1,710.03 $1,710.03 $1,710.03

$860.01 $859.93 $834.89 $918.39 $834.89$897.78 $834.93 $866.38 $915.75 $866.38

$1,341.53 $1,341.41 $1,302.31 $1,432.57 $1,302.31$273.35 $273.33 $265.34 $291.91 $265.34

$26.81 $23.65 $24.93 $23.65 $24.93$193.91 $145.43 $176.19 $193.91 $176.19

$66.91 $58.22 $58.26 $57.06 $58.26$111.58 $96.33 $106.89 $110.24 $106.89$158.87 $186.15 $139.61 $149.38 $139.61$672.28 $609.73 $574.88 $574.88 $574.88$136.31 $125.63 $124.65 $130.46 $124.65$244.87 $244.87 $244.87 $244.87 $244.87$333.02 $366.92 $339.56 $361.52 $339.56$501.32 $475.13 $441.56 $484.22 $441.56$460.32 $530.91 $460.32 $466.29 $460.32$109.17 $145.56 $125.72 $137.60 $125.72$180.23 $154.92 $157.84 $181.46 $157.84$332.42 $332.39 $322.71 $355.00 $322.71$332.42 $332.39 $322.71 $355.00 $322.71$953.30 $953.21 $925.43 $1,017.98 $925.43$953.30 $953.21 $925.43 $1,017.98 $925.43$854.82 $854.75 $829.83 $912.84 $829.83$962.18 $962.10 $934.02 $1,027.42 $934.02

$1,196.77 $1,196.64 $1,161.79 $1,277.97 $1,161.79$1,424.74 $1,424.60 $1,383.09 $1,521.41 $1,383.09

$366.36 $381.59 $336.17 $333.04 $336.17$366.36 $381.59 $336.17 $333.04 $336.17$459.32 $441.79 $445.36 $408.60 $445.36$459.32 $441.79 $445.36 $408.60 $445.36$653.94 $568.31 $568.31 $568.31 $568.31$410.48 $396.70 $360.43 $431.64 $360.43

$1,269.29 $1,366.87 $1,269.29 $1,532.51 $1,269.29$1,455.08 $1,382.30 $1,474.34 $1,707.88 $1,474.34$1,696.59 $1,584.13 $1,584.13 $1,696.74 $1,584.13$1,680.68 $1,709.39 $1,680.68 $1,803.99 $1,680.68

$962.18 $962.10 $934.02 $1,027.42 $934.02$271.13 $271.10 $263.23 $315.81 $263.23$736.10 $736.05 $714.61 $786.06 $714.61$477.07 $477.04 $469.97 $502.54 $469.97

$85.47 $89.04 $82.20 $86.21 $82.20$231.75 $230.28 $269.23 $230.28 $269.23

$52.82 $52.81 $51.24 $56.39 $51.24




Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$74.72 $74.71 $72.52 $79.77 $72.52$394.01 $393.97 $382.48 $420.73 $382.48

$80.39 $80.39 $78.07 $85.86 $78.07$155.21 $155.20 $150.70 $165.75 $150.70$983.97 $983.90 $955.20 $1,050.70 $955.20$274.86 $274.84 $266.82 $293.48 $266.82

$1,019.23 $948.28 $853.24 $907.06 $853.24$1,503.93 $1,285.52 $1,263.11 $1,345.24 $1,263.11$1,304.86 $1,164.37 $999.59 $999.59 $999.59$1,264.17 $1,264.04 $1,227.21 $1,349.94 $1,227.21$1,304.86 $1,164.37 $999.59 $999.59 $999.59$1,002.97 $1,002.83 $973.66 $1,071.00 $973.66

$74.72 $74.71 $72.52 $79.77 $72.52$394.01 $393.97 $382.48 $420.73 $382.48$155.21 $155.20 $150.70 $165.75 $150.70$983.97 $983.90 $955.20 $1,050.70 $955.20$274.86 $274.84 $266.82 $293.48 $266.82

$1,304.86 $1,164.37 $999.59 $999.59 $999.59$1,304.86 $1,164.37 $999.59 $999.59 $999.59$2,063.66 $1,829.26 $1,822.27 $1,802.14 $1,822.27$2,252.62 $1,970.58 $1,861.69 $1,870.74 $1,861.69$2,393.08 $2,441.30 $2,328.27 $2,334.96 $2,328.27$1,935.90 $2,059.38 $2,089.78 $1,925.49 $2,089.78$2,795.23 $3,299.61 $2,945.10 $2,795.23 $2,945.10$1,085.93 $1,447.90 $1,227.35 $1,085.93 $1,227.35

$206.59 $206.58 $200.55 $220.59 $200.55$101.88 $129.60 $119.86 $105.45 $119.86$104.14 $118.51 $107.66 $101.64 $107.66$212.79 $179.15 $159.87 $159.59 $159.87$190.04 $167.76 $142.53 $142.53 $142.53$171.59 $175.75 $188.14 $171.59 $188.14

$15.57 $20.76 $20.54 $15.57 $20.54$16.96 $19.35 $14.51 $14.51 $14.51$54.12 $54.12 $60.26 $58.36 $60.26

$1,809.74 $1,967.54 $1,828.29 $1,809.74 $1,828.29$3,067.82 $3,067.49 $2,978.12 $3,275.96 $2,978.12

$72.88 $70.51 $59.82 $59.82 $59.82$99.58 $97.69 $77.05 $77.05 $77.05

$113.18 $111.16 $147.07 $148.21 $147.07$75.60 $75.60 $56.70 $56.70 $56.70$91.00 $79.04 $74.20 $69.54 $74.20$78.79 $95.68 $89.46 $74.22 $89.46$88.88 $92.85 $107.29 $85.25 $107.29$90.87 $90.82 $104.77 $80.21 $104.77$62.97 $51.09 $58.94 $49.33 $58.94

$174.92 $154.29 $159.43 $137.21 $159.43$81.71 $91.37 $105.47 $89.67 $105.47

$144.23 $157.49 $168.43 $145.53 $168.43$244.30 $229.69 $227.66 $227.66 $227.66

$38.92 $41.63 $38.50 $35.40 $38.50$1,549.14 $1,606.29 $1,396.66 $1,396.66 $1,396.66

$233.24 $233.24 $233.24 $310.99 $233.24$197.48 $225.72 $222.81 $263.31 $222.81$506.72 $506.72 $571.14 $675.62 $571.14

$87.20 $74.74 $77.21 $69.85 $77.21$85.87 $72.51 $77.21 $64.40 $77.21$88.24 $72.96 $78.83 $67.43 $78.83$88.14 $70.15 $80.08 $69.07 $80.08$78.56 $76.90 $92.12 $82.61 $92.12$89.07 $70.06 $72.92 $70.06 $72.92

$1,489.02 $1,716.35 $1,641.90 $1,985.35 $1,641.90




Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$1,532.20 $1,653.38 $1,687.06 $1,977.40 $1,687.06$114.87 $153.16 $114.87 $114.87 $114.87

$39.13 $40.58 $50.69 $42.75 $50.69$128.86 $119.43 $143.57 $132.16 $143.57$153.78 $151.05 $151.05 $151.05 $151.05$411.32 $473.65 $459.79 $480.60 $459.79$218.13 $217.52 $232.67 $206.38 $232.67$341.69 $341.66 $331.68 $364.84 $331.68$152.55 $203.40 $152.55 $152.55 $152.55

$1,254.18 $1,283.94 $1,086.10 $1,086.10 $1,086.10$1,323.38 $1,060.30 $1,108.42 $1,060.30 $1,108.42

$887.81 $813.13 $1,023.48 $1,084.17 $1,023.48$1,853.50 $1,853.31 $1,799.30 $2,159.18 $1,799.30$1,541.99 $1,529.06 $1,361.26 $1,361.26 $1,361.26$1,812.51 $1,966.20 $1,593.50 $1,593.50 $1,593.50$1,338.91 $1,458.63 $1,174.61 $1,174.61 $1,174.61$1,010.17 $1,154.61 $1,008.87 $1,035.90 $1,008.87$1,470.33 $1,411.30 $1,601.02 $1,452.65 $1,601.02

$116.04 $95.34 $87.79 $95.76 $87.79$116.04 $95.34 $87.79 $95.76 $87.79$115.58 $128.25 $136.01 $131.21 $136.01

$96.68 $77.98 $82.70 $92.45 $82.70$282.09 $282.08 $273.85 $301.25 $273.85$722.59 $541.94 $630.43 $722.59 $630.43$722.59 $541.94 $630.43 $722.59 $630.43$850.11 $691.96 $691.96 $783.42 $691.96$127.88 $127.86 $124.16 $136.59 $124.16$893.61 $1,007.10 $921.71 $922.44 $921.71$860.01 $859.93 $834.89 $918.39 $834.89

$1,490.21 $1,487.61 $1,447.11 $1,457.47 $1,447.11$897.78 $834.93 $866.38 $915.75 $866.38

$1,139.13 $1,046.28 $1,062.25 $1,201.56 $1,062.25$551.31 $551.25 $535.18 $642.21 $535.18$551.31 $551.25 $535.18 $642.21 $535.18$256.58 $296.71 $270.96 $281.76 $270.96$995.18 $974.86 $956.52 $1,165.02 $956.52$269.60 $308.81 $240.47 $240.47 $240.47

$73.23 $94.88 $83.10 $93.11 $83.10$419.17 $419.17 $499.71 $433.50 $499.71$122.49 $107.20 $107.20 $108.32 $107.20$539.33 $539.29 $523.57 $575.94 $523.57$238.38 $268.56 $243.46 $296.55 $243.46$311.63 $322.66 $311.63 $333.38 $311.63$210.87 $281.16 $210.87 $210.87 $210.87$855.32 $855.26 $830.32 $913.34 $830.32$476.54 $451.37 $440.84 $559.56 $440.84$875.13 $825.16 $1,053.96 $825.16 $1,053.96$663.95 $666.22 $698.83 $885.27 $698.83$804.97 $804.90 $781.44 $859.56 $781.44$494.09 $494.09 $527.07 $658.79 $527.07$730.79 $634.29 $634.29 $841.28 $634.29$449.27 $449.23 $436.14 $479.76 $436.14$327.15 $341.98 $327.15 $367.21 $327.15$420.34 $397.34 $397.34 $473.84 $397.34$904.13 $904.13 $941.37 $1,019.53 $941.37

$3,927.66 $3,927.25 $3,812.84 $4,194.13 $3,812.84$824.20 $882.91 $878.15 $1,098.94 $878.15

$1,040.84 $1,040.84 $1,105.72 $1,130.79 $1,105.72$903.03 $912.97 $1,003.74 $1,159.41 $1,003.74

$1,968.09 $2,012.62 $1,895.86 $2,211.33 $1,895.86$166.04 $166.03 $162.82 $193.42 $162.82




Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$1,653.83 $1,737.82 $1,713.85 $2,205.11 $1,713.85$1,524.10 $1,484.71 $1,598.93 $1,951.15 $1,598.93$1,274.46 $1,274.46 $1,624.27 $1,674.26 $1,624.27

$162.80 $158.26 $196.99 $158.26 $196.99$433.54 $503.70 $424.63 $435.33 $424.63$556.42 $582.78 $517.54 $547.93 $517.54$159.84 $120.77 $132.89 $120.66 $132.89$340.87 $342.57 $320.62 $340.19 $320.62$420.16 $415.18 $390.87 $390.87 $390.87$606.08 $745.93 $606.08 $777.62 $606.08$952.42 $1,036.31 $1,055.29 $1,155.89 $1,055.29$452.22 $504.91 $485.37 $528.24 $485.37$517.40 $584.48 $608.80 $689.32 $608.80$681.68 $700.24 $700.48 $758.36 $700.48

$1,212.89 $1,067.41 $1,171.78 $1,423.22 $1,171.78$1,528.51 $1,528.51 $1,659.31 $1,841.47 $1,659.31

$719.07 $811.20 $899.61 $958.77 $899.61$862.14 $1,014.59 $959.96 $1,149.52 $959.96

$1,054.17 $1,148.67 $1,145.78 $1,405.56 $1,145.78$104.39 $139.19 $106.94 $104.39 $106.94

$81.70 $102.26 $88.60 $81.70 $88.60$147.23 $132.86 $121.11 $110.42 $121.11$163.15 $134.20 $168.00 $147.57 $168.00$355.95 $312.27 $321.71 $355.95 $321.71

$92.46 $89.24 $83.13 $83.81 $83.13$317.83 $351.58 $365.01 $405.62 $365.01

$42.38 $56.50 $42.38 $43.91 $42.38$68.77 $59.92 $61.34 $65.47 $61.34$78.96 $77.88 $73.00 $82.81 $73.00$68.39 $71.97 $68.39 $68.39 $68.39$92.60 $92.60 $92.60 $92.60 $92.60$74.55 $74.55 $84.66 $74.55 $84.66

$316.74 $316.74 $343.22 $316.74 $343.22$178.69 $184.41 $178.69 $238.26 $178.69$104.98 $139.97 $104.98 $104.98 $104.98

$47.87 $47.87 $49.22 $48.93 $49.22$116.48 $116.47 $116.04 $112.36 $116.04$432.72 $403.64 $405.79 $465.39 $405.79$244.26 $320.00 $254.44 $320.00 $254.44$109.66 $146.22 $127.42 $109.66 $127.42$183.41 $200.10 $183.41 $219.52 $183.41$350.02 $370.96 $383.92 $466.69 $383.92$205.91 $202.50 $237.03 $202.50 $237.03$485.89 $494.03 $513.14 $433.01 $513.14$794.28 $846.38 $886.25 $1,055.63 $886.25

$46.12 $61.49 $46.12 $61.49 $46.12$228.83 $261.59 $298.86 $305.10 $298.86$100.72 $134.29 $126.23 $100.72 $126.23$109.74 $146.32 $109.74 $109.74 $109.74$119.40 $154.15 $119.40 $119.40 $119.40$162.04 $147.52 $172.02 $147.52 $172.02

$97.58 $97.58 $99.97 $104.01 $99.97$148.98 $185.96 $139.47 $139.47 $139.47$104.47 $104.47 $108.66 $105.22 $108.66

$83.57 $83.56 $81.11 $89.22 $81.11$116.44 $116.42 $113.01 $124.35 $113.01$137.39 $137.38 $133.38 $146.73 $133.38$137.39 $137.38 $133.38 $146.73 $133.38

$90.90 $101.46 $121.09 $103.57 $121.09$281.21 $327.92 $289.70 $281.21 $289.70$752.92 $743.75 $649.99 $753.64 $649.99




Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$410.64 $469.52 $428.77 $505.96 $428.77$1,408.84 $1,086.60 $1,156.82 $1,250.64 $1,156.82

$759.38 $610.56 $660.15 $610.56 $660.15$209.44 $211.16 $209.44 $272.93 $209.44$376.87 $400.88 $376.87 $384.98 $376.87$256.01 $256.01 $256.01 $311.12 $256.01$566.11 $566.11 $424.58 $424.58 $424.58$536.63 $413.70 $413.70 $474.67 $413.70$183.07 $244.10 $226.54 $183.07 $226.54$216.48 $288.64 $239.95 $252.62 $239.95$238.34 $278.89 $269.80 $317.78 $269.80$273.36 $364.47 $305.88 $273.36 $305.88$371.62 $316.95 $295.18 $316.09 $295.18

$1,531.05 $1,528.12 $1,610.71 $1,859.15 $1,610.71$1,798.50 $1,493.44 $1,584.38 $1,919.61 $1,584.38

$220.73 $261.01 $220.73 $268.82 $220.73$299.56 $343.13 $299.56 $399.41 $299.56$106.97 $128.86 $127.54 $109.84 $127.54$166.14 $200.67 $166.14 $166.14 $166.14$152.06 $202.74 $161.12 $187.81 $161.12$139.49 $185.99 $149.25 $174.57 $149.25

$74.51 $97.97 $74.51 $87.71 $74.51$125.27 $125.26 $121.55 $133.76 $121.55

$54.16 $72.21 $54.16 $66.62 $54.16$124.90 $124.86 $121.22 $133.32 $121.22

$64.07 $60.33 $60.33 $72.63 $60.33$37.67 $28.25 $28.37 $33.27 $28.37$75.74 $87.31 $76.94 $85.10 $76.94$95.08 $95.08 $118.25 $95.08 $118.25$69.62 $77.50 $92.83 $69.62 $92.83$77.41 $77.41 $77.41 $88.91 $77.41$87.05 $83.74 $83.74 $103.11 $83.74$48.58 $51.92 $49.50 $46.07 $49.50$55.19 $59.38 $55.19 $59.25 $55.19

$301.10 $301.07 $292.29 $321.51 $292.29$126.76 $126.75 $123.08 $135.38 $123.08$154.81 $154.78 $150.28 $165.33 $150.28$167.00 $166.99 $162.15 $178.34 $162.15$167.00 $166.99 $162.15 $178.34 $162.15$190.17 $190.14 $184.61 $203.04 $184.61

$73.16 $73.15 $71.01 $78.13 $71.01$117.38 $117.37 $113.97 $119.65 $113.97

$45.11 $45.10 $43.78 $48.17 $43.78$45.11 $45.10 $43.78 $48.17 $43.78$70.70 $70.69 $68.62 $75.48 $68.62$30.48 $30.47 $29.55 $32.54 $29.55$30.48 $30.47 $29.55 $32.54 $29.55$39.02 $39.02 $37.87 $41.65 $37.87$41.42 $41.42 $40.23 $44.26 $40.23$85.34 $85.34 $82.85 $91.12 $82.85$78.03 $78.01 $75.74 $83.34 $75.74$48.77 $48.76 $47.36 $52.07 $47.36$52.42 $52.42 $59.29 $57.74 $59.29$60.30 $61.45 $60.89 $64.81 $60.89$49.97 $49.97 $48.51 $53.38 $48.51$78.03 $78.01 $75.74 $83.34 $75.74

$542.44 $542.41 $526.60 $579.21 $526.60$70.70 $70.69 $68.62 $75.48 $68.62$36.56 $36.56 $35.52 $39.05 $35.52$81.70 $81.66 $79.31 $87.23 $79.31$21.92 $21.92 $21.32 $23.40 $21.32




Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$34.13 $34.13 $33.13 $36.44 $33.13$47.55 $47.53 $46.12 $50.78 $46.12$47.55 $47.53 $46.12 $50.78 $46.12$47.55 $47.53 $46.12 $50.78 $46.12$39.02 $39.02 $37.87 $41.65 $37.87$89.01 $89.01 $86.38 $95.01 $86.38$52.40 $52.40 $50.90 $55.95 $50.90

$153.59 $153.58 $149.11 $164.05 $149.11$73.16 $73.15 $71.01 $78.13 $71.01

$101.15 $101.15 $98.23 $108.03 $98.23$39.02 $39.02 $37.87 $41.65 $37.87$32.90 $32.90 $31.93 $35.15 $31.93$56.07 $56.07 $54.44 $59.88 $54.44$59.71 $59.71 $57.98 $63.77 $57.98$59.71 $59.71 $57.98 $63.77 $57.98$28.06 $28.06 $27.21 $29.92 $27.21$28.06 $28.06 $27.21 $29.92 $27.21$30.48 $30.47 $29.55 $32.54 $29.55$30.48 $30.47 $29.55 $32.54 $29.55$48.77 $48.76 $47.36 $52.07 $47.36

$8.55 $8.55 $8.26 $9.12 $8.26$21.92 $21.92 $21.32 $23.40 $21.32$81.70 $81.66 $79.31 $87.23 $79.31$62.16 $62.16 $60.35 $66.39 $60.35$51.20 $51.20 $49.70 $54.65 $49.70$40.22 $40.21 $39.04 $42.96 $39.04$73.16 $73.15 $71.01 $78.13 $71.01$96.30 $96.30 $93.48 $102.83 $93.48$73.16 $73.15 $71.01 $78.13 $71.01$96.30 $96.30 $93.48 $102.83 $93.48$41.42 $41.42 $40.23 $44.26 $40.23$52.21 $56.69 $59.27 $59.41 $59.27$89.65 $89.65 $89.65 $91.75 $89.65

$124.96 $102.41 $118.48 $116.95 $118.48$785.99 $785.94 $763.06 $839.33 $763.06

$1,031.11 $1,031.02 $1,000.97 $1,101.07 $1,000.97$153.09 $153.08 $148.61 $178.34 $148.61$251.89 $251.88 $244.52 $268.97 $244.52$126.47 $129.58 $136.31 $112.54 $136.31$630.98 $661.81 $608.21 $760.71 $608.21$830.60 $968.01 $786.31 $1,025.49 $786.31$933.47 $1,242.98 $932.24 $1,150.07 $932.24$436.23 $436.20 $423.48 $508.16 $423.48

$93.80 $93.80 $91.05 $100.17 $91.05$692.57 $610.67 $594.42 $670.11 $594.42$690.70 $663.53 $775.86 $849.77 $775.86

$1,118.52 $1,118.41 $1,085.82 $1,194.40 $1,085.82$1,184.44 $1,184.32 $1,149.80 $1,264.82 $1,149.80

$396.24 $396.21 $384.67 $423.15 $384.67$218.13 $218.11 $211.75 $254.12 $211.75$291.36 $291.48 $316.66 $343.60 $316.66$218.13 $218.11 $211.75 $254.12 $211.75

$1,362.71 $1,140.18 $1,234.75 $1,128.68 $1,234.75$1,527.95 $1,401.77 $1,402.21 $1,550.83 $1,402.21$3,110.49 $2,554.41 $2,554.41 $2,554.41 $2,554.41

$865.07 $864.98 $839.80 $923.76 $839.80$367.98 $344.67 $372.87 $356.17 $372.87

$52.26 $52.26 $58.68 $69.68 $58.68$83.83 $108.75 $101.65 $82.72 $101.65

$236.27 $236.24 $229.35 $252.27 $229.35$463.70 $463.66 $450.13 $495.18 $450.13




Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$463.70 $463.66 $450.13 $495.18 $450.13$92.15 $92.12 $89.48 $98.36 $89.48$92.15 $92.12 $89.48 $98.36 $89.48

$236.27 $236.24 $229.35 $252.27 $229.35$280.17 $280.15 $272.01 $299.20 $272.01

$75.88 $75.88 $81.73 $75.88 $81.73$75.88 $75.88 $81.73 $75.88 $81.73$46.08 $46.86 $43.83 $43.06 $43.83$30.53 $30.53 $29.60 $32.57 $29.60$73.44 $80.23 $77.67 $68.19 $77.67$73.44 $80.23 $77.67 $68.19 $77.67

$177.65 $179.18 $159.05 $166.56 $159.05$186.13 $186.12 $180.67 $198.79 $180.67$192.74 $192.73 $187.07 $205.77 $187.07$719.03 $781.63 $641.64 $657.56 $641.64

$1,465.59 $1,465.45 $1,422.75 $1,565.02 $1,422.75$748.67 $625.86 $625.86 $625.86 $625.86

$1,730.36 $1,730.24 $1,679.78 $1,847.79 $1,679.78$1,642.49 $1,642.36 $1,594.52 $1,753.95 $1,594.52$1,730.36 $1,730.24 $1,679.78 $1,847.79 $1,679.78$1,465.59 $1,465.45 $1,422.75 $1,565.02 $1,422.75$1,465.59 $1,465.45 $1,422.75 $1,565.02 $1,422.75$1,642.49 $1,642.36 $1,594.52 $1,753.95 $1,594.52$1,730.36 $1,730.24 $1,679.78 $1,847.79 $1,679.78

$269.66 $321.10 $279.31 $308.34 $279.31$878.03 $877.96 $852.38 $937.61 $852.38$333.16 $362.36 $325.63 $434.18 $325.63$355.62 $315.25 $300.23 $321.17 $300.23

$29.84 $37.19 $31.11 $38.03 $31.11$1,162.86 $1,201.12 $1,227.10 $1,136.57 $1,227.10

$654.39 $613.85 $598.23 $705.45 $598.23$817.39 $897.67 $836.64 $979.20 $836.64$450.05 $587.03 $450.05 $600.07 $450.05$363.86 $382.60 $367.25 $430.23 $367.25$292.41 $292.41 $292.41 $292.41 $292.41$368.01 $368.01 $368.01 $490.68 $368.01$238.30 $242.75 $238.30 $238.30 $238.30$283.29 $283.29 $283.29 $283.29 $283.29$270.27 $315.79 $250.86 $250.86 $250.86

$95.28 $90.16 $102.90 $92.15 $102.90$84.34 $101.85 $81.19 $95.81 $81.19$95.12 $104.57 $106.61 $115.51 $106.61$75.59 $83.64 $80.32 $99.66 $80.32

$520.27 $515.44 $450.38 $442.25 $450.38$93.73 $81.95 $89.22 $79.68 $89.22

$262.24 $246.82 $274.29 $256.06 $274.29$262.24 $246.82 $274.29 $256.06 $274.29$168.28 $168.28 $181.39 $168.28 $181.39$151.97 $151.96 $147.53 $162.30 $147.53$151.97 $151.96 $147.53 $162.30 $147.53

$22.57 $22.57 $21.89 $21.89 $21.89$16.47 $16.47 $15.97 $15.97 $15.97

$160.88 $160.87 $156.13 $156.13 $156.13$160.88 $160.87 $156.13 $156.13 $156.13

$74.04 $74.04 $71.89 $71.89 $71.89$1,430.38 $1,417.64 $1,483.67 $1,692.11 $1,483.67

$502.58 $639.77 $529.31 $479.83 $529.31$1,213.86 $1,452.69 $1,156.17 $1,467.68 $1,156.17$2,061.41 $2,182.31 $1,882.02 $1,882.02 $1,882.02$2,280.29 $2,747.20 $2,179.46 $2,323.11 $2,179.46$2,623.01 $3,104.19 $2,623.01 $3,497.34 $2,623.01




Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$2,285.33 $2,699.58 $2,270.42 $2,406.86 $2,270.42$3,299.12 $3,299.12 $3,603.63 $4,020.70 $3,603.63$3,334.95 $3,932.48 $3,334.95 $3,704.14 $3,334.95$3,627.36 $4,137.44 $3,627.36 $3,627.36 $3,627.36$3,473.71 $3,595.75 $3,159.74 $3,138.61 $3,159.74$2,304.46 $2,657.85 $2,304.46 $3,072.61 $2,304.46$2,619.44 $3,339.05 $2,619.44 $2,804.52 $2,619.44$3,612.72 $3,957.71 $3,612.72 $3,612.72 $3,612.72$4,927.43 $5,357.99 $4,927.43 $5,263.14 $4,927.43$4,905.56 $5,091.16 $4,884.26 $4,884.26 $4,884.26$4,868.00 $5,542.04 $4,835.42 $4,835.42 $4,835.42$2,612.27 $2,619.12 $2,180.48 $2,180.48 $2,180.48$3,739.29 $3,495.76 $3,132.49 $3,132.49 $3,132.49$3,786.56 $3,654.05 $3,121.29 $3,121.29 $3,121.29$4,824.84 $5,501.04 $4,416.75 $4,416.75 $4,416.75$5,022.68 $5,740.67 $4,799.61 $4,799.61 $4,799.61$1,293.30 $1,354.38 $1,142.97 $1,142.97 $1,142.97

$396.79 $529.05 $500.76 $396.79 $500.76$1,584.89 $1,734.48 $1,443.52 $1,443.52 $1,443.52

$477.89 $637.18 $637.18 $637.18 $637.18$388.78 $515.87 $407.62 $430.41 $407.62$517.98 $690.45 $600.79 $517.84 $600.79

$1,219.69 $1,362.82 $1,219.69 $1,219.69 $1,219.69$1,686.87 $2,202.37 $1,651.78 $1,651.78 $1,651.78$1,382.60 $1,620.20 $1,382.60 $1,382.60 $1,382.60$1,365.68 $1,820.91 $1,365.68 $1,668.51 $1,365.68$1,640.31 $1,881.81 $1,728.67 $1,640.31 $1,728.67$1,610.46 $1,885.51 $1,703.59 $1,801.34 $1,703.59$1,718.87 $2,021.61 $1,798.92 $1,718.87 $1,798.92$1,845.77 $2,431.33 $1,845.77 $2,156.77 $1,845.77$1,918.95 $2,400.51 $1,918.95 $2,172.39 $1,918.95$2,240.24 $2,680.35 $2,240.24 $2,462.30 $2,240.24$2,756.97 $2,689.18 $2,429.80 $2,429.80 $2,429.80$2,282.95 $2,631.15 $2,282.95 $2,533.46 $2,282.95$4,033.14 $3,823.86 $4,012.82 $4,221.29 $4,012.82$4,335.44 $4,222.69 $4,376.87 $4,669.94 $4,376.87$1,966.19 $2,278.79 $1,966.19 $1,966.19 $1,966.19$1,530.09 $1,530.09 $1,530.09 $1,530.09 $1,530.09$2,392.24 $2,356.79 $2,327.36 $2,327.36 $2,327.36$1,620.58 $1,620.40 $1,573.20 $1,730.52 $1,573.20$1,292.75 $1,719.74 $1,289.81 $1,289.81 $1,289.81

$537.33 $537.27 $521.62 $573.81 $521.62$284.26 $286.90 $300.49 $281.48 $300.49$264.02 $352.03 $264.02 $312.37 $264.02$344.28 $459.04 $403.22 $459.04 $403.22$345.26 $460.35 $384.71 $398.92 $384.71$452.79 $505.53 $540.76 $452.79 $540.76$484.15 $545.58 $512.18 $473.43 $512.18$301.80 $402.40 $391.12 $402.40 $391.12$426.21 $491.24 $426.21 $430.54 $426.21$417.27 $556.36 $509.67 $556.36 $509.67$232.88 $210.87 $210.87 $229.70 $210.87$288.88 $288.88 $288.88 $338.65 $288.88$241.98 $241.98 $241.98 $322.64 $241.98$274.35 $365.80 $323.23 $350.01 $323.23$477.91 $479.36 $462.17 $556.04 $462.17

$1,064.76 $1,064.76 $1,084.22 $1,356.40 $1,084.22$607.25 $607.25 $660.11 $809.67 $660.11$588.38 $606.83 $590.97 $702.17 $590.97

$1,478.11 $1,589.76 $1,478.11 $1,478.11 $1,478.11$560.92 $669.14 $560.92 $560.92 $560.92




Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$757.74 $759.28 $757.74 $757.74 $757.74$520.33 $675.44 $520.33 $550.99 $520.33$755.42 $755.42 $755.42 $790.72 $755.42$625.24 $736.75 $625.24 $694.89 $625.24

$2,265.60 $2,307.44 $1,898.14 $1,808.12 $1,898.14$463.62 $544.03 $463.62 $618.16 $463.62

$1,140.48 $1,520.64 $1,140.48 $1,140.48 $1,140.48$414.04 $483.04 $414.04 $414.04 $414.04$552.71 $565.76 $552.71 $552.71 $552.71$314.95 $374.37 $314.95 $333.55 $314.95$266.90 $291.24 $266.67 $324.08 $266.67$358.04 $360.99 $375.64 $460.38 $375.64$345.30 $345.30 $365.82 $371.75 $365.82$577.92 $577.92 $635.72 $579.61 $635.72$486.25 $519.67 $486.25 $486.25 $486.25

$66.48 $88.64 $72.25 $74.68 $72.25$107.22 $127.87 $96.47 $99.96 $96.47$257.69 $343.59 $293.69 $266.61 $293.69$546.08 $546.01 $472.38 $472.38 $472.38$283.18 $283.18 $358.86 $283.18 $358.86$675.27 $695.74 $667.21 $636.26 $667.21$344.13 $448.18 $344.13 $344.13 $344.13$468.24 $624.32 $468.24 $468.24 $468.24

$37.71 $50.27 $37.71 $37.71 $37.71$562.70 $579.76 $555.99 $530.23 $555.99$314.77 $310.00 $328.92 $370.16 $328.92

$1,263.27 $1,263.14 $1,226.33 $1,348.96 $1,226.33$593.91 $605.96 $593.91 $619.12 $593.91

$1,263.27 $1,263.14 $1,226.33 $1,348.96 $1,226.33$45.71 $51.11 $45.71 $46.92 $45.71

$123.01 $122.98 $119.41 $131.38 $119.41$48.52 $51.30 $61.65 $64.69 $61.65$58.01 $72.93 $58.01 $77.35 $58.01$92.93 $102.46 $112.33 $98.32 $112.33

$126.19 $168.26 $130.39 $126.19 $130.39$172.28 $229.71 $172.28 $172.28 $172.28$159.05 $206.50 $180.73 $180.13 $180.73$175.71 $210.79 $197.51 $190.87 $197.51

$76.24 $76.24 $80.23 $76.24 $80.23$124.67 $113.65 $99.77 $124.38 $99.77$224.58 $177.07 $177.07 $180.63 $177.07

$2,720.99 $2,720.74 $2,735.93 $2,649.18 $2,735.93$3,267.71 $3,267.42 $3,394.17 $3,286.53 $3,394.17$4,134.13 $4,133.77 $4,277.85 $4,142.18 $4,277.85$2,139.45 $2,531.08 $1,986.59 $2,648.78 $1,986.59

$509.04 $509.00 $557.85 $540.16 $557.85$909.56 $909.46 $1,022.75 $990.29 $1,022.75$891.60 $891.52 $997.56 $965.90 $997.56

$1,175.44 $1,175.37 $1,340.21 $1,297.69 $1,340.21$355.16 $406.47 $341.56 $359.44 $341.56$496.38 $514.86 $518.13 $539.68 $518.13$415.91 $539.56 $409.21 $467.71 $409.21$427.21 $455.85 $422.00 $412.04 $422.00$692.16 $805.76 $692.16 $692.16 $692.16$865.13 $888.97 $865.13 $865.13 $865.13$913.97 $864.19 $902.79 $857.43 $902.79

$1,433.45 $1,911.27 $1,433.45 $1,785.32 $1,433.45$1,652.02 $2,202.69 $1,882.27 $1,652.02 $1,882.27$2,259.74 $2,353.30 $2,345.06 $2,514.30 $2,345.06$1,087.29 $1,252.75 $1,130.68 $1,087.29 $1,130.68$3,842.59 $3,842.25 $3,730.25 $4,103.28 $3,730.25




Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$4,050.97 $4,050.56 $3,932.53 $4,325.80 $3,932.53$611.19 $550.12 $493.41 $493.41 $493.41$682.84 $910.45 $682.84 $682.84 $682.84

$1,359.54 $1,359.54 $1,019.65 $1,019.65 $1,019.65$462.36 $510.50 $474.35 $477.74 $474.35$692.61 $756.19 $692.61 $692.61 $692.61$536.85 $572.22 $536.85 $536.85 $536.85

$3,566.67 $3,566.34 $3,462.39 $3,808.65 $3,462.39$812.51 $920.44 $807.65 $807.65 $807.65$911.99 $922.90 $911.99 $977.40 $911.99

$1,617.20 $1,617.20 $1,769.34 $2,005.20 $1,769.34$1,456.38 $1,734.91 $1,456.38 $1,803.19 $1,456.38$2,999.11 $2,998.84 $2,940.58 $3,493.72 $2,940.58$2,681.82 $2,681.82 $2,776.18 $3,277.11 $2,776.18$1,802.04 $1,977.79 $1,972.59 $1,933.86 $1,972.59$3,331.98 $3,331.66 $3,478.43 $3,368.09 $3,478.43$1,721.35 $1,721.18 $1,671.01 $2,005.23 $1,671.01$1,032.68 $1,032.59 $1,002.52 $1,102.74 $1,002.52

$121.49 $161.98 $126.14 $127.31 $126.14$326.44 $326.41 $293.29 $293.29 $293.29

$23,054.39 $23,052.22 $22,380.48 $22,380.48 $22,380.48$8,180.54 $8,179.81 $7,941.46 $7,941.46 $7,941.46

$17,848.59 $17,846.92 $17,326.84 $19,059.57 $17,326.84$13,934.25 $13,932.93 $13,526.93 $14,879.62 $13,526.93

$343.95 $458.60 $346.39 $376.26 $346.39$503.89 $671.85 $503.89 $503.89 $503.89$425.46 $425.46 $319.10 $319.10 $319.10

$3,232.48 $3,232.19 $3,138.02 $3,451.82 $3,138.02$476.36 $635.15 $476.36 $517.50 $476.36$744.83 $985.14 $804.76 $838.94 $804.76$915.52 $1,220.70 $963.95 $1,215.34 $963.95

$4,365.59 $4,528.04 $4,320.50 $4,457.29 $4,320.50$602.51 $602.47 $558.21 $558.21 $558.21$889.39 $889.39 $999.88 $968.17 $999.88

$1,133.30 $1,133.30 $1,287.99 $1,247.14 $1,287.99$3,489.90 $3,489.56 $3,387.87 $4,065.43 $3,387.87

$192.87 $216.16 $208.48 $192.87 $208.48$192.87 $216.16 $208.48 $257.16 $208.48$360.26 $406.91 $334.69 $334.69 $334.69

$16,522.78 $16,521.25 $16,321.93 $17,892.03 $16,321.93$221.30 $251.74 $282.38 $221.30 $282.38$445.24 $445.21 $432.19 $518.64 $432.19$531.84 $576.46 $531.84 $671.09 $531.84$277.14 $323.21 $277.14 $277.14 $277.14

$2,166.92 $2,166.92 $2,223.88 $2,166.92 $2,223.88$3,521.11 $3,724.39 $3,521.11 $4,623.77 $3,521.11$2,844.58 $2,844.31 $3,043.54 $2,947.00 $3,043.54

$549.02 $594.41 $549.02 $549.02 $549.02$541.00 $638.47 $544.14 $541.00 $544.14$271.19 $271.15 $263.28 $289.61 $263.28$601.79 $635.29 $604.99 $601.79 $604.99

$6,908.62 $6,907.98 $6,706.65 $7,377.33 $6,706.65$1,918.52 $1,918.34 $1,862.45 $2,234.91 $1,862.45$1,742.30 $1,742.13 $1,691.39 $1,860.49 $1,691.39$1,261.82 $1,421.43 $1,261.82 $1,290.54 $1,261.82$1,404.20 $1,430.12 $1,404.20 $1,474.38 $1,404.20$1,309.20 $1,422.54 $1,309.20 $1,309.20 $1,309.20$4,747.34 $3,560.51 $4,016.07 $4,484.15 $4,016.07$1,804.01 $2,185.33 $1,804.01 $2,104.65 $1,804.01$2,514.34 $2,695.78 $2,867.56 $2,742.70 $2,867.56$1,827.75 $2,242.10 $1,827.75 $2,437.00 $1,827.75




Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$1,938.63 $2,380.02 $1,938.63 $2,584.85 $1,938.63$2,259.20 $2,683.48 $2,259.20 $2,808.06 $2,259.20$2,458.43 $2,486.56 $2,458.43 $3,038.98 $2,458.43$2,590.79 $3,025.38 $2,590.79 $2,590.79 $2,590.79$3,458.29 $3,458.29 $4,317.27 $3,888.12 $4,317.27$2,714.55 $3,137.35 $2,550.20 $2,687.54 $2,550.20$3,538.13 $3,778.00 $3,538.13 $4,294.40 $3,538.13$3,055.01 $3,033.42 $2,909.65 $3,066.36 $2,909.65$1,668.88 $1,824.96 $1,622.93 $1,622.93 $1,622.93$3,719.80 $3,719.80 $3,719.80 $4,959.73 $3,719.80$3,345.37 $3,024.88 $3,053.74 $3,024.88 $3,053.74$2,001.77 $2,108.88 $2,298.99 $2,571.82 $2,298.99$1,159.98 $1,246.64 $1,241.66 $1,314.89 $1,241.66$1,745.13 $1,478.96 $1,485.82 $1,874.87 $1,485.82$2,414.21 $1,833.42 $1,813.11 $2,414.21 $1,813.11

$381.37 $424.55 $434.80 $508.50 $434.80$417.50 $474.46 $417.50 $417.50 $417.50

$2,203.62 $2,381.97 $2,208.26 $2,564.79 $2,208.26$2,943.97 $2,927.92 $2,927.92 $2,946.55 $2,927.92$3,080.01 $2,954.32 $2,930.32 $3,036.31 $2,930.32$3,702.22 $3,621.34 $3,621.34 $3,621.34 $3,621.34$4,156.60 $4,156.60 $4,393.92 $4,426.31 $4,393.92$1,586.90 $1,560.54 $1,533.76 $1,488.15 $1,533.76$1,437.31 $1,447.25 $1,307.04 $1,314.89 $1,307.04$2,254.07 $2,114.25 $2,117.18 $1,995.72 $2,117.18$2,109.45 $2,080.17 $1,852.09 $1,788.64 $1,852.09$2,771.77 $2,863.90 $3,057.37 $2,740.07 $3,057.37$2,632.74 $2,808.69 $2,796.64 $2,552.14 $2,796.64

$178.13 $237.51 $188.70 $237.51 $188.70$175.89 $234.52 $176.15 $234.52 $176.15$168.91 $192.07 $158.11 $158.11 $158.11$395.38 $395.36 $383.86 $422.24 $383.86$182.00 $184.38 $194.96 $174.53 $194.96

$67.44 $78.37 $82.13 $71.83 $82.13$291.18 $318.59 $305.99 $287.95 $305.99

$2,196.61 $2,196.43 $2,132.44 $2,345.67 $2,132.44$812.24 $639.69 $700.39 $609.18 $700.39

$3,616.79 $3,616.49 $3,511.12 $3,862.21 $3,511.12$577.11 $673.44 $509.65 $505.08 $509.65$454.94 $490.21 $520.82 $454.94 $520.82$138.94 $168.55 $138.94 $166.42 $138.94$204.67 $272.90 $204.67 $204.67 $204.67

$71.08 $61.70 $68.26 $61.70 $68.26$167.27 $210.11 $189.57 $191.92 $189.57$356.77 $409.41 $393.52 $348.71 $393.52

$2,401.61 $2,401.38 $2,331.42 $2,564.54 $2,331.42$316.95 $342.54 $268.55 $354.68 $268.55$152.35 $185.24 $178.48 $203.13 $178.48$206.50 $220.55 $254.12 $275.34 $254.12$381.17 $382.50 $308.60 $306.49 $308.60

$3,028.99 $3,028.68 $2,940.45 $3,234.49 $2,940.45$498.66 $498.62 $484.07 $532.45 $484.07

$3,123.95 $3,123.67 $3,032.65 $3,335.91 $3,032.65$395.75 $401.62 $321.45 $368.15 $321.45

$77.78 $87.93 $71.34 $75.92 $71.34$87.17 $98.02 $87.17 $87.17 $87.17$43.74 $58.32 $49.83 $50.64 $49.83$48.36 $60.73 $47.25 $56.13 $47.25

$191.91 $168.97 $160.13 $194.66 $160.13$114.05 $118.49 $114.05 $129.09 $114.05$131.83 $124.56 $115.17 $138.56 $115.17




Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$284.93 $284.88 $276.56 $304.21 $276.56$220.33 $293.77 $220.33 $277.67 $220.33$243.61 $287.66 $246.94 $297.79 $246.94$331.03 $331.03 $331.03 $422.72 $331.03$747.54 $615.47 $615.59 $568.87 $615.59$547.78 $547.78 $547.78 $557.46 $547.78$544.48 $647.43 $529.88 $517.67 $529.88$652.35 $677.49 $639.89 $853.19 $639.89$710.88 $735.09 $692.96 $733.84 $692.96$329.03 $327.82 $414.43 $350.00 $414.43$531.08 $675.73 $531.08 $538.67 $531.08

$2,726.45 $2,726.20 $2,646.78 $3,176.12 $2,646.78$675.27 $695.74 $667.21 $634.59 $667.21$562.70 $579.76 $555.99 $528.81 $555.99

$1,263.27 $1,263.14 $1,226.33 $1,348.96 $1,226.33$1,263.27 $1,263.14 $1,226.33 $1,348.96 $1,226.33

$546.08 $546.01 $472.38 $629.83 $472.38$345.24 $314.08 $335.86 $411.64 $335.86$556.16 $736.54 $556.16 $557.22 $556.16$331.36 $382.12 $331.36 $331.36 $331.36

$1,221.34 $1,359.67 $1,396.54 $1,373.06 $1,396.54$798.43 $913.81 $794.37 $872.43 $794.37

$1,150.56 $1,340.74 $1,285.65 $1,167.94 $1,285.65$645.66 $645.61 $626.77 $689.51 $626.77

$1,188.81 $1,188.71 $1,154.04 $1,269.47 $1,154.04$1,500.36 $1,500.24 $1,456.54 $1,602.19 $1,456.54$1,270.83 $1,270.71 $1,233.66 $1,357.03 $1,233.66$3,032.02 $3,031.73 $2,943.37 $3,237.73 $2,943.37$2,258.76 $2,258.53 $2,192.71 $2,412.02 $2,192.71$1,947.20 $1,947.01 $1,890.29 $2,185.65 $1,890.29

$323.11 $404.12 $341.85 $379.27 $341.85$183.14 $236.20 $186.34 $177.15 $186.34

$22,945.54 $22,943.36 $22,274.81 $24,502.29 $22,274.81$3,926.19 $3,925.84 $3,811.44 $4,192.56 $3,811.44$2,978.23 $2,977.95 $2,891.15 $3,180.30 $2,891.15$1,507.02 $1,772.07 $1,507.02 $1,507.02 $1,507.02$2,236.73 $2,659.52 $2,120.16 $2,120.16 $2,120.16$3,345.37 $3,024.88 $3,053.74 $3,024.88 $3,053.74

$161.53 $175.07 $161.53 $215.37 $161.53$594.22 $530.29 $587.90 $530.29 $587.90

$1,695.75 $1,468.35 $1,525.78 $1,685.65 $1,525.78$1,686.11 $1,394.32 $1,497.89 $1,665.53 $1,497.89$1,441.79 $1,373.99 $1,537.69 $1,731.76 $1,537.69

$726.93 $594.52 $594.52 $594.52 $594.52$6,337.86 $6,959.29 $7,320.30 $6,337.86 $7,320.30$8,531.86 $7,348.41 $8,025.17 $7,316.97 $8,025.17$6,377.16 $7,471.61 $6,925.18 $6,377.16 $6,925.18$8,664.26 $8,218.69 $8,194.76 $7,453.95 $8,194.76$8,332.17 $9,337.89 $9,028.23 $8,833.34 $9,028.23

$10,180.92 $10,563.36 $10,097.91 $9,903.65 $10,097.91$9,470.69 $9,927.98 $9,568.00 $9,470.69 $9,568.00

$11,342.44 $12,458.23 $11,636.54 $11,342.44 $11,636.54$12,848.16 $12,284.43 $12,353.97 $11,439.71 $12,353.97$13,703.03 $17,945.81 $14,151.42 $13,459.36 $14,151.42$14,278.78 $18,240.69 $15,209.95 $13,850.91 $15,209.95$15,616.38 $18,338.59 $16,791.99 $15,176.20 $16,791.99

$3,267.89 $4,357.18 $3,444.49 $3,722.42 $3,444.49$5,143.31 $6,857.75 $5,819.01 $5,836.05 $5,819.01$3,334.28 $4,445.70 $3,522.39 $3,532.22 $3,522.39$2,677.30 $3,569.73 $2,762.64 $2,897.54 $2,762.64$1,534.98 $2,046.65 $1,534.98 $1,534.98 $1,534.98



HCPCS 1st Mod 2nd Mod CategoryL7170 POL7180 POL7181 POL7185 POL7186 POL7190 POL7191 POL7259 POL7360 POL7362 POL7364 POL7366 POL7367 POL7368 POL7400 POL7401 POL7402 POL7403 POL7404 POL7405 POL8000 POL8001 POL8002 POL8015 POL8020 POL8030 POL8031 POL8032 POL8035 POL8040 KM POL8040 KN POL8040 POL8041 KM POL8041 KN POL8041 POL8042 KM POL8042 KN POL8042 POL8043 KM POL8043 KN POL8043 POL8044 KM POL8044 KN POL8044 POL8045 KM POL8045 KN POL8045 POL8046 KM POL8046 KN POL8046 POL8047 KM POL8047 KN POL8047 POL8300 POL8310 POL8320 POL8330 POL8400 POL8410 POL8415 POL8417 PO

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$7,067.66 $7,424.56 $5,568.42 $5,568.42 $5,568.42$31,023.06 $38,791.57 $33,158.43 $34,138.58 $33,158.43$38,479.94 $38,476.38 $37,355.19 $41,090.68 $37,355.19

$6,979.40 $7,518.36 $5,701.13 $6,809.78 $5,701.13$8,400.38 $10,850.81 $8,706.10 $10,374.48 $8,706.10$7,330.75 $9,565.69 $7,422.65 $9,565.69 $7,422.65$8,777.90 $11,534.08 $9,377.19 $10,726.20 $9,377.19$3,035.08 $3,646.49 $3,959.87 $3,035.08 $3,959.87

$226.60 $228.68 $283.76 $287.93 $283.76$237.93 $275.03 $255.63 $265.36 $255.63$378.42 $501.00 $472.53 $504.56 $472.53$509.75 $679.67 $636.60 $679.67 $636.60$373.88 $373.85 $362.97 $399.27 $362.97$484.69 $484.66 $470.52 $517.59 $470.52$294.35 $294.31 $285.74 $314.30 $285.74$329.52 $329.48 $319.89 $351.85 $319.89$355.82 $355.80 $345.45 $379.99 $345.45$353.68 $353.63 $343.32 $377.63 $343.32$533.76 $533.72 $518.19 $570.01 $518.19$698.10 $698.05 $677.72 $745.50 $677.72

$41.77 $35.64 $34.67 $34.98 $34.67$120.46 $120.45 $116.94 $128.64 $116.94$158.45 $158.43 $153.80 $169.20 $153.80

$57.56 $57.56 $55.89 $67.03 $55.89$216.50 $215.77 $237.60 $227.76 $237.60$313.17 $316.78 $307.51 $307.15 $307.51$313.17 $316.78 $307.51 $307.15 $307.51

$37.62 $37.62 $36.52 $40.17 $36.52$3,518.42 $3,518.08 $3,415.58 $4,098.68 $3,415.58$2,205.30 $2,174.39 $2,257.44 $2,636.25 $2,257.44

$928.56 $915.51 $950.48 $1,110.01 $950.48$2,321.37 $2,288.84 $2,376.24 $2,775.01 $2,376.24$2,658.06 $2,620.86 $2,720.94 $3,177.58 $2,720.94$1,119.20 $1,103.52 $1,145.68 $1,337.92 $1,145.68$2,797.97 $2,758.81 $2,864.15 $3,344.81 $2,864.15$2,986.58 $2,944.78 $3,057.22 $3,570.31 $3,057.22$1,257.50 $1,239.92 $1,287.26 $1,503.27 $1,287.26$3,143.77 $3,099.79 $3,218.14 $3,758.21 $3,218.14$3,344.96 $3,298.17 $3,424.14 $3,998.71 $3,424.14$1,408.40 $1,388.71 $1,441.74 $1,683.68 $1,441.74$3,521.03 $3,471.75 $3,604.36 $4,209.17 $3,604.36$3,703.38 $3,651.54 $3,790.99 $4,427.18 $3,790.99$1,559.33 $1,537.51 $1,596.19 $1,864.08 $1,596.19$3,898.27 $3,843.72 $3,990.50 $4,660.16 $3,990.50$2,319.14 $2,286.59 $2,646.42 $2,779.67 $2,646.42

$976.48 $962.77 $1,114.28 $1,170.38 $1,114.28$2,441.21 $2,406.92 $2,785.69 $2,925.96 $2,785.69$2,389.26 $2,355.82 $2,445.80 $2,856.23 $2,445.80$1,005.99 $991.93 $1,029.80 $1,202.64 $1,029.80$2,515.02 $2,479.81 $2,574.51 $3,006.56 $2,574.51$1,224.49 $1,207.35 $1,253.49 $1,463.82 $1,253.49

$515.58 $508.36 $527.77 $616.36 $527.77$1,288.93 $1,270.92 $1,319.45 $1,540.86 $1,319.45

$92.49 $80.11 $80.11 $80.11 $80.11$142.21 $126.48 $126.48 $167.71 $126.48

$62.12 $58.39 $56.70 $50.77 $56.70$61.57 $62.51 $46.88 $46.88 $46.88$18.00 $14.95 $16.49 $19.93 $16.49$20.48 $21.86 $22.03 $24.14 $22.03$20.36 $22.21 $21.66 $22.83 $21.66$72.21 $72.20 $70.05 $77.14 $70.05



HCPCS 1st Mod 2nd Mod CategoryL8420 POL8430 POL8435 POL8440 POL8460 POL8465 POL8470 POL8480 POL8485 POL8500 POL8501 POL8507 POL8510 POL8511 POL8512 POL8513 POL8514 POL8515 POV2020 POV2100 POV2101 POV2102 POV2103 POV2104 POV2105 POV2106 POV2107 POV2108 POV2109 POV2110 POV2111 POV2112 POV2113 POV2114 POV2115 POV2118 POV2121 POV2200 POV2201 POV2202 POV2203 POV2204 POV2205 POV2206 POV2207 POV2208 POV2209 POV2210 POV2211 POV2212 POV2213 POV2214 POV2215 POV2218 POV2219 POV2220 POV2221 POV2300 POV2301 POV2302 POV2303 PO

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$23.80 $19.74 $19.45 $21.41 $19.45$26.17 $21.68 $21.02 $24.75 $21.02$23.49 $22.90 $19.97 $20.87 $19.97$49.79 $41.96 $39.72 $51.38 $39.72$69.29 $72.99 $63.29 $63.29 $63.29$61.76 $52.00 $56.03 $46.32 $56.03

$6.34 $7.60 $6.34 $6.34 $6.34$8.74 $9.99 $8.74 $8.74 $8.74

$10.56 $10.56 $10.98 $10.61 $10.98$626.75 $738.30 $835.66 $721.71 $835.66$139.20 $114.72 $114.72 $114.72 $114.72

$40.23 $40.22 $39.05 $42.97 $39.05$242.70 $242.68 $235.57 $259.13 $235.57

$69.85 $69.84 $67.81 $81.35 $67.81$2.11 $2.11 $2.02 $2.41 $2.02$5.00 $5.00 $4.85 $5.79 $4.85

$90.57 $90.56 $87.91 $105.49 $87.91$60.61 $60.61 $58.84 $64.72 $58.84$76.54 $63.94 $59.54 $59.54 $59.54$37.20 $45.64 $45.70 $49.60 $45.70$39.20 $52.27 $47.89 $52.27 $47.89$55.59 $58.09 $70.56 $60.53 $70.56$32.30 $34.57 $43.07 $43.07 $43.07$35.77 $40.87 $46.66 $47.69 $46.66$43.79 $40.01 $51.93 $51.93 $51.93$44.45 $47.81 $57.62 $57.35 $57.62$46.71 $51.53 $53.43 $54.80 $53.43$45.31 $50.57 $56.74 $54.55 $56.74$52.08 $48.48 $62.78 $60.66 $62.78$60.79 $46.57 $61.95 $61.95 $61.95$53.58 $54.52 $63.51 $64.58 $63.51$52.87 $70.50 $70.48 $70.50 $70.48$73.05 $75.88 $73.44 $77.47 $73.44$64.61 $86.06 $86.06 $86.06 $86.06$70.25 $93.66 $76.18 $72.54 $76.18$69.64 $69.64 $92.86 $79.58 $92.86$71.90 $95.87 $75.14 $80.06 $75.14$48.69 $56.23 $62.95 $64.92 $62.95$53.06 $59.22 $68.92 $70.29 $68.92$62.44 $67.29 $83.26 $79.75 $83.26$49.12 $55.23 $64.95 $65.49 $64.95$53.26 $56.20 $68.46 $67.24 $68.46$58.43 $58.64 $74.03 $73.31 $74.03$71.14 $59.96 $79.53 $74.07 $79.53$59.38 $55.86 $70.29 $68.17 $70.29$60.11 $61.99 $75.40 $70.38 $75.40$66.12 $61.32 $80.66 $71.56 $80.66$85.07 $70.10 $90.18 $76.44 $90.18$72.54 $70.13 $83.43 $79.41 $83.43$78.94 $72.42 $86.93 $80.67 $86.93$80.94 $77.39 $82.17 $83.67 $82.17$86.77 $79.52 $106.03 $101.92 $106.03$93.89 $90.68 $90.25 $94.77 $90.25$96.06 $96.06 $128.08 $123.26 $128.08$42.29 $48.83 $56.38 $53.06 $56.38$34.29 $44.70 $45.73 $45.73 $45.73$91.62 $95.50 $89.99 $91.86 $89.99$63.23 $73.44 $75.23 $80.07 $75.23$73.33 $96.17 $88.18 $77.34 $88.18$80.33 $96.63 $103.84 $78.44 $103.84$66.55 $69.79 $68.92 $76.44 $68.92



HCPCS 1st Mod 2nd Mod CategoryV2304 POV2305 POV2306 POV2307 POV2308 POV2309 POV2310 POV2311 POV2312 POV2313 POV2314 POV2315 POV2318 POV2319 POV2320 POV2321 POV2410 POV2430 POV2500 POV2501 POV2502 POV2503 POV2510 POV2511 POV2512 POV2513 POV2520 POV2521 POV2522 POV2523 POV2530 POV2531 POV2623 POV2624 POV2625 POV2626 POV2627 POV2628 POV2700 POV2710 POV2715 POV2718 POV2730 POV2744 POV2745 POV2750 POV2755 POV2760 POV2762 POV2770 POV2780 POV2782 POV2783 POV2784 PO

Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule


Fee Schedule



$69.64 $68.14 $80.57 $82.42 $80.57$85.40 $84.62 $93.31 $85.04 $93.31$79.63 $101.51 $99.06 $87.29 $99.06$78.96 $76.29 $91.41 $84.11 $91.41$84.26 $79.38 $95.01 $84.22 $95.01$98.57 $88.78 $99.31 $86.66 $99.31

$108.42 $81.32 $105.37 $88.09 $105.37$103.26 $101.69 $95.16 $84.92 $95.16

$91.02 $96.14 $95.73 $85.47 $95.73$124.24 $100.41 $99.29 $96.26 $99.29$136.09 $102.07 $127.56 $109.75 $127.56$151.09 $113.31 $113.31 $136.73 $113.31$139.31 $139.31 $177.29 $185.74 $177.29

$47.16 $53.23 $62.88 $54.04 $62.88$49.75 $66.34 $66.34 $66.34 $66.34

$148.92 $112.98 $111.69 $135.11 $111.69$85.16 $100.46 $98.87 $105.01 $98.87

$110.85 $116.36 $110.47 $136.83 $110.47$77.19 $96.49 $102.92 $102.92 $102.92

$117.58 $117.58 $139.91 $156.77 $139.91$144.85 $144.85 $184.11 $193.13 $184.11$138.59 $133.40 $177.51 $177.87 $177.51$105.37 $139.33 $139.14 $119.98 $139.14$151.40 $180.70 $180.42 $201.87 $180.42$178.90 $238.54 $221.99 $238.54 $221.99$150.19 $200.26 $180.90 $200.26 $180.90

$99.04 $119.90 $128.91 $132.05 $128.91$172.43 $183.36 $203.41 $229.91 $203.41$167.81 $223.74 $181.50 $223.74 $181.50$143.00 $174.78 $179.37 $178.25 $179.37$211.81 $269.99 $242.32 $211.81 $242.32$519.99 $519.93 $504.81 $555.28 $504.81$852.46 $1,136.62 $852.46 $1,100.64 $852.46

$57.82 $75.85 $77.09 $57.82 $77.09$374.48 $364.30 $351.49 $351.49 $351.49$237.59 $252.63 $189.47 $189.47 $189.47

$1,360.18 $1,375.32 $1,223.68 $1,501.39 $1,223.68$310.99 $357.78 $288.94 $293.48 $288.94

$41.60 $50.32 $51.12 $47.94 $51.12$60.89 $75.54 $71.42 $81.19 $71.42$11.04 $12.46 $11.68 $14.72 $11.68$27.11 $30.97 $28.12 $33.59 $28.12$20.03 $26.70 $20.03 $20.03 $20.03$20.77 $19.83 $15.58 $15.77 $15.58$11.78 $13.00 $11.07 $12.66 $11.07$24.17 $24.17 $20.65 $19.44 $20.65$17.47 $21.03 $15.77 $15.77 $15.77$15.21 $16.83 $19.51 $16.13 $19.51$57.26 $57.24 $55.56 $61.10 $55.56$19.64 $20.32 $18.53 $23.77 $18.53$15.87 $11.90 $11.90 $11.90 $11.90$61.82 $61.82 $60.02 $66.02 $60.02$69.71 $69.69 $67.67 $74.45 $67.67$45.33 $45.33 $44.00 $48.39 $44.00

Alabama– 3rd Quarter 2016 Rural Zip Codes

© Copyright 2017 CGS Administrators, LLC. Page 1

Zip Code

Effective Date

Expiration Date

35010 20160101 35011 20160101 35014 20160101 35016 20160101 35019 20160101 35032 20160101 35033 20160101 35044 20160101 35053 20160101 35055 20160101 35056 20160101 35057 20160101 35058 20160101 35070 20160101 35072 20160101 35077 20160101 35082 20160101 35083 20160101 35087 20160101 35089 20160101 35096 20160101 35098 20160101 35136 20160101 35149 20160101 35150 20160101 35151 20160101 35160 20160101 35161 20160101 35175 20160101 35179 20160101 35183 20160101 35443 20160101 35448 20160101 35459 20160101 35460 20160101 35462 20160101 35464 20160101 35469 20160101 35470 20160101 35477 20160101 35491 20160101 35540 20160101 35541 20160101 35542 20160101

Zip Code

Effective Date

Expiration Date

35543 20160101 35544 20160101 35545 20160101 35546 20160101 35548 20160101 35551 20160101 35552 20160101 35553 20160101 35554 20160101 35555 20160101 35559 20160101 35563 20160101 35564 20160101 35565 20160101 35570 20160101 35571 20160101 35572 20160101 35574 20160101 35575 20160101 35576 20160101 35577 20160101 35581 20160101 35582 20160101 35585 20160101 35586 20160101 35592 20160101 35593 20160101 35594 20160101 35653 20160101 35654 20160101 35740 20160101 35744 20160101 35745 20160101 35746 20160101 35747 20160101 35751 20160101 35752 20160101 35755 20160101 35764 20160101 35765 20160101 35766 20160101 35768 20160101 35769 20160101 35771 20160101

Zip Code

Effective Date

Expiration Date

35772 20160101 35774 20160101 35776 20160101 35950 20160101 35951 20160101 35957 20160101 35958 20160101 35959 20160101 35960 20160101 35961 20160101 35962 20160101 35963 20160101 35964 20160101 35966 20160101 35967 20160101 35968 20160101 35971 20160101 35973 20160101 35974 20160101 35975 20160101 35976 20160101 35978 20160101 35979 20160101 35980 20160101 35981 20160101 35983 20160101 35984 20160101 35986 20160101 35988 20160101 35989 20160101 36005 20160101 36009 20160101 36010 20160101 36015 20160101 36016 20160101 36017 20160101 36023 20160101 36026 20160101 36027 20160101 36028 20160101 36029 20160101 36030 20160101 36031 20160101 36033 20160101

Zip Code

Effective Date

Expiration Date

36034 20160101 36035 20160101 36037 20160101 36038 20160101 36039 20160101 36041 20160101 36042 20160101 36046 20160101 36048 20160101 36049 20160101 36053 20160101 36061 20160101 36062 20160101 36071 20160101 36072 20160101 36075 20160101 36079 20160101 36081 20160101 36082 20160101 36083 20160101 36087 20160101 36088 20160101 36089 20160101 36251 20160101 36255 20160101 36256 20160101 36258 20160101 36261 20160101 36262 20160101 36263 20160101 36264 20160101 36266 20160101 36267 20160101 36268 20160101 36269 20160101 36273 20160101 36274 20160101 36275 20160101 36276 20160101 36278 20160101 36280 20160101 36311 20160101 36322 20160101 36323 20160101

Zip Code

Effective Date

Expiration Date

36330 20160101 36331 20160101 36346 20160101 36350 20160101 36351 20160101 36360 20160101 36361 20160101 36362 20160101 36371 20160101 36374 20160101 36401 20160101 36420 20160101 36421 20160101 36425 20160101 36426 20160101 36427 20160101 36429 20160101 36432 20160101 36435 20160101 36436 20160101 36439 20160101 36441 20160101 36442 20160101 36444 20160101 36445 20160101 36446 20160101 36449 20160101 36451 20160101 36453 20160101 36454 20160101 36455 20160101 36456 20160101 36457 20160101 36458 20160101 36460 20160101 36461 20160101 36467 20160101 36470 20160101 36471 20160101 36473 20160101 36474 20160101 36475 20160101 36476 20160101 36480 20160101

Alabama– 3rd Quarter 2016 Rural Zip Codes


Zip Code

Effective Date

Expiration Date

36481 20160101 36482 20160101 36483 20160101 36502 20160101 36503 20160101 36504 20160101 36513 20160101 36515 20160101 20160630 36518 20160101 36524 20160101 36529 20160101 36538 20160101 36539 20160101 36540 20160101 36543 20160101 36545 20160101 36548 20160101 36553 20160101 36556 20160101 36558 20160101 36569 20160101 36581 20160101 36583 20160101 36584 20160101 36585 20160101 36701 20160101 36702 20160101 36703 20160101 36720 20160101 36722 20160101 36723 20160101 36726 20160101 36727 20160101 36728 20160101 36732 20160101 36736 20160101 36738 20160101 36740 20160101 36741 20160101 36742 20160101 36745 20160101 36748 20160101 36749 20160101 36751 20160101

Zip Code

Effective Date

Expiration Date

36753 20160101 36754 20160101 36756 20160101 36758 20160101 36759 20160101 36761 20160101 36763 20160101 36764 20160101 36766 20160101 36767 20160101 36768 20160101 36769 20160101 36773 20160101 36775 20160101 36782 20160101 36783 20160101 36784 20160101 36786 20160101 36850 20160101 36853 20160101 36854 20160101 36855 20160101 36861 20160101 36862 20160101 36863 20160101 36866 20160101 36901 20160101 36904 20160101 36907 20160101 36908 20160101 36910 20160101 36912 20160101 36913 20160101 36915 20160101 36916 20160101 36919 20160101 36921 20160101 36922 20160101 36925 20160101

Arkansas – 3rd Quarter 2016 Rural Zip Codes


Zip Code

Effective Date

Expiration Date

71630 20160101 71631 20160101 71635 20160101 71638 20160101 71639 20160101 71640 20160101 71642 20160101 71646 20160101 71647 20160101 71651 20160101 71653 20160101 71654 20160101 71655 20160101 71656 20160101 71657 20160101 71658 20160101 71661 20160101 71662 20160101 71663 20160101 71666 20160101 71670 20160101 71671 20160101 71674 20160101 71675 20160101 71676 20160101 71677 20160101 71701 20160101 71711 20160101 71720 20160101 71721 20160101 71722 20160101 71724 20160101 71725 20160101 71726 20160101 71728 20160101 71730 20160101 71731 20160101 71740 20160101 71742 20160101 71743 20160101 71744 20160101 71745 20160101 71747 20160101 71748 20160101

Zip Code

Effective Date

Expiration Date

71749 20160101 71750 20160101 71751 20160101 71752 20160101 71753 20160101 71754 20160101 71758 20160101 71759 20160101 71762 20160101 71763 20160101 71764 20160101 71765 20160101 71766 20160101 71770 20160101 71772 20160101 71801 20160101 71802 20160101 71823 20160101 71825 20160101 71826 20160101 71827 20160101 71828 20160101 71831 20160101 71832 20160101 71833 20160101 71835 20160101 71838 20160101 71841 20160101 71842 20160101 71845 20160101 71846 20160101 71847 20160101 71851 20160101 71852 20160101 71855 20160101 71857 20160101 71858 20160101 71859 20160101 71860 20160101 71861 20160101 71862 20160101 71864 20160101 71920 20160101 71921 20160101

Zip Code

Effective Date

Expiration Date

71922 20160101 71923 20160101 71929 20160101 71932 20160101 71933 20160101 71935 20160101 71937 20160101 71940 20160101 71941 20160101 71942 20160101 71943 20160101 71944 20160101 71945 20160101 71950 20160101 71952 20160101 71953 20160101 71957 20160101 71958 20160101 71959 20160101 71960 20160101 71961 20160101 71962 20160101 71965 20160101 71966 20160101 71969 20160101 71970 20160101 71971 20160101 71972 20160101 71973 20160101 71998 20160101 71999 20160101 72003 20160101 72005 20160101 72006 20160101 72010 20160101 72012 20160101 72013 20160101 72014 20160101 72017 20160101 72020 20160101 72021 20160101 72026 20160101 72027 20160101 72028 20160101

Zip Code

Effective Date

Expiration Date

72029 20160101 72030 20160101 72031 20160101 72036 20160101 72038 20160101 72039 20160101 72040 20160101 72041 20160101 72042 20160101 72043 20160101 72044 20160101 72045 20160101 72048 20160101 72051 20160101 72052 20160101 72055 20160101 72059 20160101 72060 20160101 72063 20160101 72064 20160101 72066 20160101 72067 20160101 72068 20160101 72069 20160101 72073 20160101 72074 20160101 72075 20160101 72080 20160101 72081 20160101 72082 20160101 72085 20160101 72088 20160101 72101 20160101 72102 20160101 72104 20160101 72105 20160101 72107 20160101 72108 20160101 72110 20160101 72112 20160101 72121 20160101 72123 20160101 72127 20160101 72130 20160101

Zip Code

Effective Date

Expiration Date

72131 20160101 72134 20160101 72136 20160101 72137 20160101 72139 20160101 72140 20160101 72141 20160101 72143 20160101 72145 20160101 72149 20160101 72153 20160101 72156 20160101 72157 20160101 72160 20160101 72165 20160101 72166 20160101 72169 20160101 72170 20160101 72178 20160101 72179 20160101 72301 20160701 72303 20160701 72310 20160101 72311 20160101 72312 20160101 72313 20160101 72315 20160101 72316 20160101 72319 20160101 72320 20160101 72321 20160101 72322 20160101 72324 20160101 72325 20160701 72326 20160101 72327 20160701 72328 20160101 72329 20160101 72330 20160101 72331 20160701 72332 20160701 72333 20160101 72335 20160101 72336 20160101



Zip Code

Effective Date

Expiration Date

72338 20160101 72339 20160701 72340 20160101 72341 20160101 72342 20160101 72346 20160101 72347 20160101 72348 20160101 72350 20160101 72351 20160101 72352 20160101 72353 20160101 72355 20160101 72358 20160101 72359 20160101 72360 20160101 72364 20160701 72366 20160101 72367 20160101 72368 20160101 72369 20160101 72370 20160101 72372 20160101 72373 20160101 72374 20160101 72376 20160701 72379 20160101 72383 20160101 72384 20160701 72387 20160101 72389 20160101 72390 20160101 72391 20160101 72392 20160101 72394 20160101 72395 20160101 72396 20160101 72410 20160101 72412 20160101 72413 20160101 72415 20160101 72422 20160101 72424 20160101 72425 20160101

Zip Code

Effective Date

Expiration Date

72426 20160101 72428 20160101 72430 20160101 72431 20160101 72433 20160101 72434 20160101 72435 20160101 72436 20160101 72438 20160101 72440 20160101 72441 20160101 72442 20160101 72443 20160101 72444 20160101 72445 20160101 72449 20160101 72450 20160101 72451 20160101 72453 20160101 72454 20160101 72455 20160101 72456 20160101 72457 20160101 72458 20160101 72459 20160101 72460 20160101 72461 20160101 72462 20160101 72464 20160101 72465 20160101 72466 20160101 72469 20160101 72470 20160101 72471 20160101 72473 20160101 72474 20160101 72476 20160101 72478 20160101 72482 20160101 72501 20160101 72503 20160101 72512 20160101 72513 20160101 72515 20160101

Zip Code

Effective Date

Expiration Date

72517 20160101 72519 20160101 72520 20160101 72521 20160101 72522 20160101 72523 20160101 72524 20160101 72525 20160101 72526 20160101 72527 20160101 72528 20160101 72529 20160101 72530 20160101 72531 20160101 72532 20160101 72533 20160101 72534 20160101 72536 20160101 72537 20160101 72538 20160101 72539 20160101 72540 20160101 72542 20160101 72543 20160101 72544 20160101 72545 20160101 72546 20160101 72550 20160101 72553 20160101 72554 20160101 72555 20160101 72556 20160101 72560 20160101 72561 20160101 72562 20160101 72564 20160101 72565 20160101 72566 20160101 72567 20160101 72568 20160101 72569 20160101 72571 20160101 72572 20160101 72573 20160101

Zip Code

Effective Date

Expiration Date

72575 20160101 72576 20160101 72577 20160101 72578 20160101 72579 20160101 72581 20160101 72583 20160101 72584 20160101 72585 20160101 72587 20160101 72601 20160101 72602 20160101 72611 20160101 72613 20160101 72615 20160101 72616 20160101 72617 20160101 72619 20160101 72623 20160101 72624 20160101 72626 20160101 72628 20160101 72629 20160101 72630 20160101 72631 20160101 72632 20160101 72633 20160101 72634 20160101 72635 20160101 72636 20160101 72638 20160101 72639 20160101 72640 20160101 72641 20160101 72642 20160101 72644 20160101 72645 20160101 72648 20160101 72650 20160101 72651 20160101 72653 20160101 72654 20160101 72655 20160101 72657 20160101

Zip Code

Effective Date

Expiration Date

72658 20160101 72659 20160101 72660 20160101 72661 20160101 72662 20160101 72663 20160101 72666 20160101 72668 20160101 72669 20160101 72670 20160101 72672 20160101 72675 20160101 72677 20160101 72679 20160101 72680 20160101 72682 20160101 72683 20160101 72685 20160101 72686 20160101 72687 20160101 72801 20160101 72802 20160101 72811 20160101 72812 20160101 72820 20160101 72821 20160101 72823 20160101 72824 20160101 72826 20160101 72827 20160101 72828 20160101 72829 20160101 72830 20160101 72832 20160101 72833 20160101 72834 20160101 72835 20160101 72837 20160101 72838 20160101 72839 20160101 72840 20160101 72841 20160101 72842 20160101 72843 20160101



Zip Code

Effective Date

Expiration Date

72845 20160101 72846 20160101 72847 20160101 72851 20160101 72852 20160101 72853 20160101 72854 20160101 72855 20160101 72856 20160101 72857 20160101 72858 20160101 72860 20160101 72863 20160101 72865 20160101 72926 20160101 72927 20160101 72928 20160101 72930 20160101 72933 20160101 72943 20160101 72949 20160101 72950 20160101 72951 20160101 72958 20160101

Colorado – 3rd Quarter 2016 Rural Zip Codes


Zip Code

Effective Date

Expiration Date

80101 20160101 80107 20160101 80117 20160101 80420 20160101 80421 20160101 80423 20160101 80424 20160101 80426 20160101 80428 20160101 80429 20160101 80430 20160101 80432 20160101 80434 20160101 80435 20160101 80436 20160101 80438 20160101 80440 20160101 80442 20160101 80443 20160101 80444 20160101 80446 20160101 80447 20160101 80448 20160101 80449 20160101 80451 20160101 80452 20160101 80456 20160101 80459 20160101 80461 20160101 80463 20160101 80467 20160101 80468 20160101 80469 20160101 80473 20160101 80475 20160101 80476 20160101 80477 20160101 80478 20160101 80479 20160101 80480 20160101 80482 20160101 80483 20160101 80487 20160101 80488 20160101

Zip Code

Effective Date

Expiration Date

80497 20160101 80498 20160101 80649 20160101 80653 20160101 80654 20160101 80701 20160101 80705 20160101 80720 20160101 80721 20160101 80722 20160101 80723 20160101 80726 20160101 80727 20160101 80728 20160101 80731 20160101 80733 20160101 80734 20160101 80735 20160101 80736 20160101 80737 20160101 80740 20160101 80741 20160101 80743 20160101 80744 20160101 80745 20160101 80746 20160101 80747 20160101 80749 20160101 80750 20160101 80751 20160101 80755 20160101 80757 20160101 80758 20160101 80759 20160101 80801 20160101 80802 20160101 80804 20160101 80805 20160101 80807 20160101 80810 20160101 80812 20160101 80815 20160101 80818 20160101 80820 20160101

Zip Code

Effective Date

Expiration Date

80821 20160101 80822 20160101 80823 20160101 80824 20160101 80825 20160101 80826 20160101 80827 20160101 80828 20160101 80830 20160101 80832 20160101 80834 20160101 80835 20160101 80836 20160101 80861 20160101 80862 20160101 81020 20160101 81021 20160101 81024 20160101 81027 20160101 81029 20160101 81030 20160101 81033 20160101 81034 20160101 81036 20160101 81038 20160101 81039 20160101 81040 20160101 81041 20160101 81043 20160101 81044 20160101 81045 20160101 81046 20160101 81047 20160101 81049 20160101 81050 20160101 81052 20160101 81054 20160101 81055 20160101 81057 20160101 81058 20160101 81059 20160101 81062 20160101 81063 20160101 81064 20160101

Zip Code

Effective Date

Expiration Date

81067 20160101 81071 20160101 81073 20160101 81076 20160101 81077 20160101 81081 20160101 81082 20160101 81084 20160101 81087 20160101 81089 20160101 81090 20160101 81091 20160101 81092 20160101 81101 20160101 81102 20160101 81120 20160101 81121 20160101 81122 20160101 81123 20160101 81124 20160101 81125 20160101 81126 20160101 81128 20160101 81129 20160101 81130 20160101 81131 20160101 81132 20160101 81133 20160101 81135 20160101 81136 20160101 81137 20160101 81138 20160101 81140 20160101 81141 20160101 81143 20160101 81144 20160101 81146 20160101 81147 20160101 81148 20160101 81149 20160101 81151 20160101 81152 20160101 81154 20160101 81155 20160101

Zip Code

Effective Date

Expiration Date

81157 20160101 81201 20160101 81210 20160101 81211 20160101 81212 20160101 81215 20160101 81220 20160101 81221 20160101 81222 20160101 81223 20160101 81224 20160101 81225 20160101 81226 20160101 81227 20160101 81228 20160101 81230 20160101 81231 20160101 81232 20160101 81233 20160101 81235 20160101 81236 20160101 81237 20160101 81239 20160101 81240 20160101 81241 20160101 81242 20160101 81243 20160101 81244 20160101 81248 20160101 81251 20160101 81252 20160101 81253 20160101 81290 20160101 81301 20160101 81302 20160101 81303 20160101 81320 20160101 81321 20160101 81323 20160101 81324 20160101 81325 20160101 81326 20160101 81327 20160101 81328 20160101

Colorado – 3rd Quarter 2016 Rural Zip Codes


Zip Code

Effective Date

Expiration Date

81329 20160101 81330 20160101 81331 20160101 81332 20160101 81334 20160101 81335 20160101 81401 20160101 81402 20160101 81403 20160101 81410 20160101 81411 20160101 81413 20160101 81414 20160101 81415 20160101 81416 20160101 81418 20160101 81419 20160101 81420 20160101 81422 20160101 81423 20160101 81424 20160101 81425 20160101 81426 20160101 81427 20160101 81428 20160101 81429 20160101 81430 20160101 81431 20160101 81432 20160101 81433 20160101 81434 20160101 81435 20160101 81601 20160101 81602 20160101 81610 20160101 81611 20160101 81612 20160101 81615 20160101 81620 20160101 81621 20160101 81623 20160101 81625 20160101 81626 20160101 81631 20160101

Zip Code

Effective Date

Expiration Date

81632 20160101 81633 20160101 81635 20160101 81636 20160101 81637 20160101 81638 20160101 81639 20160101 81640 20160101 81641 20160101 81642 20160101 81645 20160101 81647 20160101 81648 20160101 81649 20160101 81650 20160101 81652 20160101 81653 20160101 81654 20160101 81655 20160101 81656 20160101 81657 20160101 81658 20160101

Florida – 3rd Quarter 2016 Rural Zip Codes


Zip Code

Effective Date

Expiration Date

32007 20160101 32008 20160101 32013 20160101 32024 20160101 32025 20160101 32026 20160101 32038 20160101 32042 20160101 32044 20160101 32052 20160101 32053 20160101 32054 20160101 32055 20160101 32056 20160101 32058 20160101 32059 20160101 32060 20160101 32061 20160101 32062 20160101 32064 20160101 32066 20160101 32071 20160101 32083 20160101 32091 20160101 32094 20160101 32096 20160101 32110 20160101 20160630 32112 20160101 32131 20160101 32135 20160101 20160630 32136 20160101 20160630 32137 20160101 20160630 32138 20160101 32139 20160101 32140 20160101 32142 20160101 20160630 32143 20160101 20160630 32147 20160101 32148 20160101 32149 20160101 32157 20160101 32164 20160101 20160630 32177 20160101 32178 20160101

Zip Code

Effective Date

Expiration Date

32181 20160101 32185 20160101 32187 20160101 32189 20160101 32193 20160101 32320 20160101 32321 20160101 32322 20160101 32323 20160101 32328 20160101 32329 20160101 32331 20160101 32334 20160101 32335 20160101 32340 20160101 32341 20160101 32347 20160101 32348 20160101 32350 20160101 32356 20160101 32357 20160101 32359 20160101 32360 20160101 32420 20160101 32421 20160101 32423 20160101 32424 20160101 32425 20160101 32426 20160101 32427 20160101 32428 20160101 32430 20160101 32431 20160101 32432 20160101 32437 20160101 32440 20160101 32442 20160101 32443 20160101 32445 20160101 32446 20160101 32447 20160101 32448 20160101 32449 20160101 32452 20160101

Zip Code

Effective Date

Expiration Date

32455 20160101 32460 20160101 32462 20160101 32463 20160101 32464 20160101 32621 20160101 32622 20160101 32625 20160101 32626 20160101 32628 20160101 32639 20160101 32644 20160101 32648 20160101 32666 20160101 32668 20160101 32680 20160101 32683 20160101 32692 20160101 32696 20160101 32697 20160101 33001 20160101 33036 20160101 33037 20160101 33040 20160101 33041 20160101 33042 20160101 33043 20160101 33045 20160101 33050 20160101 33051 20160101 33052 20160101 33070 20160101 33440 20160101 33471 20160101 33834 20160101 20160630 33865 20160101 33873 20160101 33890 20160101 33930 20160101 33935 20160101 33944 20160101 33975 20160101 34224 20160101 20160630 34265 20160101

Zip Code

Effective Date

Expiration Date

34266 20160101 34267 20160101 34268 20160101 34269 20160101 34449 20160101 34498 20160101 34972 20160101 34973 20160101 34974 20160101

Georgia – 3rd Quarter 2016 Rural Zip Codes


Zip Code

Effective Date

Expiration Date

30055 20160101 30056 20160101 30104 20160101 30125 20160101 30138 20160101 30139 20160101 30153 20160101 30170 20160101 30204 20160101 30206 20160101 30217 20160101 30230 20160101 30240 20160101 30241 20160101 30256 20160101 30257 20160101 30258 20160101 30261 20160101 30285 20160101 30286 20160101 30292 20160101 30295 20160101 30401 20160101 30410 20160101 30411 20160101 30412 20160101 30413 20160101 30414 20160101 30415 20160101 30417 20160101 30420 20160101 30421 20160101 30423 20160101 30424 20160101 30425 20160101 30427 20160101 30428 20160101 30429 20160101 30434 20160101 30436 20160101 30438 20160101 30439 20160101 30442 20160101 30445 20160101

Zip Code

Effective Date

Expiration Date

30446 20160101 30447 20160101 30448 20160101 30449 20160101 30450 20160101 30451 20160101 30452 20160101 30453 20160101 30454 20160101 30455 20160101 30457 20160101 30458 20160101 30459 20160101 30460 20160101 30461 20160101 30464 20160101 30467 20160101 30470 20160101 30471 20160101 30473 20160101 30474 20160101 30475 20160101 30477 20160101 30499 20160101 30510 20160101 30511 20160101 30512 20160101 30513 20160101 30514 20160101 30516 20160101 30517 20160101 30520 20160101 30521 20160101 30522 20160101 30523 20160101 30525 20160101 30528 20160101 30529 20160101 30530 20160101 30531 20160101 30533 20160101 30535 20160101 30536 20160101 30537 20160101

Zip Code

Effective Date

Expiration Date

30538 20160101 30539 20160101 30540 20160101 30541 20160101 30545 20160101 30546 20160101 30547 20160101 30548 20160101 30549 20160101 30552 20160101 30553 20160101 30555 20160101 30557 20160101 30558 20160101 30559 20160101 30560 20160101 30562 20160101 30563 20160101 30564 20160101 30565 20160101 30567 20160101 30568 20160101 30571 20160101 30572 20160101 30573 20160101 30575 20160101 30576 20160101 30577 20160101 30580 20160101 30581 20160101 30582 20160101 30597 20160101 30598 20160101 30599 20160101 30607 20160101 30623 20160101 30624 20160101 30625 20160101 30631 20160101 30634 20160101 30635 20160101 30639 20160101 30642 20160101 30643 20160101

Zip Code

Effective Date

Expiration Date

30645 20160101 30650 20160101 30660 20160101 30662 20160101 30663 20160101 30664 20160101 30665 20160101 30668 20160101 30669 20160101 30673 20160101 30678 20160101 30701 20160101 30703 20160101 30730 20160101 30731 20160101 30732 20160101 30733 20160101 30734 20160101 30735 20160101 30746 20160101 30747 20160101 30753 20160101 30803 20160101 30807 20160101 30810 20160101 30817 20160101 20160630 30818 20160101 30819 20160101 30820 20160101 30821 20160101 30822 20160101 30823 20160101 30828 20160101 30833 20160101 31001 20160101 31002 20160101 31003 20160101 31006 20160101 31007 20160101 31009 20160101 31010 20160101 31011 20160101 31012 20160101 31014 20160101

Zip Code

Effective Date

Expiration Date

31015 20160101 31018 20160101 31019 20160101 31021 20160101 31022 20160101 31023 20160101 31024 20160101 31026 20160101 31027 20160101 31031 20160101 31034 20160101 31035 20160101 31037 20160101 31038 20160101 31039 20160101 31040 20160101 31041 20160101 31042 20160101 31045 20160101 31049 20160101 31051 20160101 31054 20160101 31055 20160101 31057 20160101 31059 20160101 31060 20160101 31061 20160101 31062 20160101 31063 20160101 31064 20160101 31065 20160101 31067 20160101 31068 20160101 31070 20160101 31071 20160101 31072 20160101 31075 20160101 31076 20160101 31077 20160101 31079 20160101 31081 20160101 31082 20160101 31083 20160101 31084 20160101

Georgia – 3rd Quarter 2016 Rural Zip Codes


Zip Code

Effective Date

Expiration Date

31085 20160101 31087 20160101 31089 20160101 31090 20160101 31091 20160101 31092 20160101 31094 20160101 31096 20160101 31097 20160101 31501 20160101 31502 20160101 31503 20160101 31510 20160101 31512 20160101 31513 20160101 31515 20160101 31516 20160101 31518 20160101 31519 20160101 31532 20160101 31533 20160101 31534 20160101 31535 20160101 31537 20160101 31539 20160101 31544 20160101 31545 20160101 31546 20160101 31547 20160101 31548 20160101 31549 20160101 31550 20160101 31551 20160101 31552 20160101 31554 20160101 31555 20160101 31556 20160101 31557 20160101 31558 20160101 31560 20160101 31562 20160101 31563 20160101 31564 20160101 31565 20160101

Zip Code

Effective Date

Expiration Date

31567 20160101 31568 20160101 31569 20160101 31598 20160101 31599 20160101 31620 20160101 31622 20160101 31623 20160101 31624 20160101 31626 20160101 31627 20160101 31630 20160101 31631 20160101 31634 20160101 31637 20160101 31639 20160101 31642 20160101 31645 20160101 31647 20160101 31650 20160101 31709 20160101 31711 20160101 31712 20160101 31714 20160101 31716 20160101 31719 20160101 31722 20160101 31727 20160101 31730 20160101 31733 20160101 31735 20160101 31738 20160101 31739 20160101 31743 20160101 31744 20160101 31747 20160101 31749 20160101 31750 20160101 31753 20160101 31756 20160101 31757 20160101 31758 20160101 31760 20160101 31764 20160101

Zip Code

Effective Date

Expiration Date

31765 20160101 31768 20160101 31769 20160101 31771 20160101 31773 20160101 31774 20160101 31775 20160101 31776 20160101 31779 20160101 31780 20160101 31783 20160101 31784 20160101 31788 20160101 31790 20160101 31792 20160101 31793 20160101 31794 20160101 31798 20160101 31799 20160101 31801 20160101 31806 20160101 31810 20160101 31812 20160101 31814 20160101 31815 20160101 31821 20160101 31824 20160101 31825 20160101 31826 20160101 31827 20160101 31832 20160101 31833 20160101 31836 20160101 39813 20160101 39815 20160101 39817 20160101 39818 20160101 39819 20160101 39823 20160101 39824 20160101 39825 20160101 39827 20160101 39828 20160101 39829 20160101

Zip Code

Effective Date

Expiration Date

39832 20160101 39834 20160101 39836 20160101 39837 20160101 39840 20160101 39841 20160101 39845 20160101 39846 20160101 39851 20160101 39852 20160101 39854 20160101 39859 20160101 39861 20160101 39862 20160101 39866 20160101 39867 20160101 39877 20160101 39886 20160101 39897 20160101

Louisiana – 3rd Quarter 2016 Rural Zip Codes


Zip Code

Effective Date

Expiration Date

70037 20160101 70038 20160101 70040 20160101 70041 20160101 70050 20160101 70052 20160101 20160630 70071 20160101 20160630 70081 20160101 70082 20160101 70083 20160101 70086 20160101 20160630 70090 20160101 20160630 70091 20160101 70093 20160101 70339 20160101 70340 20160101 70341 20160101 70342 20160101 70372 20160101 70381 20160101 70390 20160101 70391 20160101 70392 20160101 70393 20160101 70426 20160101 70427 20160101 70429 20160101 70438 20160101 70450 20160101 70467 20160101 70512 20160101 70514 20160101 70522 20160101 70523 20160101 70524 20160101 70532 20160101 70535 20160101 70538 20160101 70540 20160101 70541 20160101 70546 20160101 70549 20160101 70550 20160101 70551 20160101

Zip Code

Effective Date

Expiration Date

70554 20160101 70570 20160101 70571 20160101 70576 20160101 70577 20160101 70580 20160101 70581 20160101 70584 20160101 70585 20160101 70586 20160101 70589 20160101 70591 20160101 70634 20160101 70637 20160101 70638 20160101 70639 20160101 70640 20160101 70644 20160101 70648 20160101 70650 20160101 70651 20160101 70652 20160101 70653 20160101 70654 20160101 70655 20160101 70656 20160101 70657 20160101 70658 20160101 70659 20160101 70660 20160101 70662 20160101 70723 20160101 20160630 70743 20160101 20160630 70750 20160101 70763 20160101 20160630 70792 20160101 20160630 71001 20160101 71002 20160101 71003 20160101 71008 20160101 71016 20160101 71019 20160101 71028 20160101 71031 20160101

Zip Code

Effective Date

Expiration Date

71034 20160101 71038 20160101 71040 20160101 71045 20160101 71048 20160101 71065 20160101 71066 20160101 71068 20160101 71070 20160101 71079 20160101 71080 20160101 71218 20160101 71219 20160101 71220 20160101 71221 20160101 71223 20160101 71226 20160101 71227 20160101 71229 20160101 71230 20160101 71232 20160101 71233 20160101 71235 20160101 71237 20160101 71242 20160101 71243 20160101 71245 20160101 71247 20160101 71249 20160101 71250 20160101 71251 20160101 71253 20160101 71254 20160101 71259 20160101 71261 20160101 71263 20160101 71264 20160101 71266 20160101 71268 20160101 71269 20160101 71270 20160101 71272 20160101 71273 20160101 71275 20160101

Zip Code

Effective Date

Expiration Date

71276 20160101 71279 20160101 71282 20160101 71284 20160101 71286 20160101 71295 20160101 71316 20160101 71320 20160101 71322 20160101 71323 20160101 71324 20160101 71326 20160101 71327 20160101 71329 20160101 71331 20160101 71333 20160101 71334 20160101 71336 20160101 71339 20160101 71340 20160101 71341 20160101 71342 20160101 71343 20160101 71345 20160101 71350 20160101 71351 20160101 71353 20160101 71354 20160101 71355 20160101 71356 20160101 71357 20160101 71358 20160101 71362 20160101 71363 20160101 71366 20160101 71367 20160101 71368 20160101 71369 20160101 71371 20160101 71373 20160101 71375 20160101 71377 20160101 71378 20160101 71401 20160101

Zip Code

Effective Date

Expiration Date

71403 20160101 71406 20160101 71410 20160101 71411 20160101 71414 20160101 71415 20160101 71416 20160101 71418 20160101 71419 20160101 71422 20160101 71426 20160101 71428 20160101 71429 20160101 71434 20160101 71435 20160101 71439 20160101 71440 20160101 71441 20160101 71443 20160101 71446 20160101 71449 20160101 71450 20160101 71452 20160101 71456 20160101 71457 20160101 71458 20160101 71459 20160101 71460 20160101 71461 20160101 71462 20160101 71463 20160101 71465 20160101 71468 20160101 71469 20160101 71471 20160101 71473 20160101 71474 20160101 71475 20160101 71479 20160101 71480 20160101 71483 20160101 71486 20160101 71496 20160101 71497 20160101

Mississippi – 3rd Quarter 2016 Rural Zip Codes


Zip Code

Effective Date

Expiration Date

38601 20160101 38603 20160101 20160630 38606 20160101 38609 20160101 38610 20160101 38614 20160101 38617 20160101 38619 20160101 38620 20160101 38621 20160101 38622 20160101 38623 20160101 38625 20160101 38626 20160101 20160630 38627 20160101 38628 20160101 38629 20160101 38630 20160101 38631 20160101 38633 20160101 20160630 38639 20160101 38642 20160101 20160630 38643 20160101 38644 20160101 38645 20160101 38646 20160101 38647 20160101 20160630 38650 20160101 38652 20160101 38655 20160101 38658 20160101 38663 20160101 38664 20160101 20160630 38666 20160101 38669 20160101 38670 20160101 38673 20160101 38674 20160101 38675 20160101 38676 20160101 20160630 38677 20160101 38683 20160101 38701 20160101 38702 20160101

Zip Code

Effective Date

Expiration Date

38703 20160101 38704 20160101 38720 20160101 38721 20160101 38722 20160101 38723 20160101 38725 20160101 38726 20160101 38730 20160101 38731 20160101 38732 20160101 38733 20160101 38736 20160101 38737 20160101 38738 20160101 38739 20160101 38740 20160101 38744 20160101 38745 20160101 38746 20160101 38748 20160101 38749 20160101 38751 20160101 38753 20160101 38754 20160101 38756 20160101 38759 20160101 38760 20160101 38761 20160101 38762 20160101 38764 20160101 38765 20160101 38767 20160101 38768 20160101 38769 20160101 38771 20160101 38772 20160101 38773 20160101 38774 20160101 38776 20160101 38778 20160101 38780 20160101 38781 20160101 38782 20160101

Zip Code

Effective Date

Expiration Date

38801 20160101 38802 20160101 38803 20160101 38804 20160101 38820 20160101 38821 20160101 38824 20160101 38825 20160101 38826 20160101 38827 20160101 38828 20160101 38829 20160101 38833 20160101 38834 20160101 38835 20160101 38838 20160101 38839 20160101 38841 20160101 38843 20160101 38844 20160101 38846 20160101 38847 20160101 38848 20160101 38849 20160101 38850 20160101 38851 20160101 38852 20160101 38855 20160101 38856 20160101 38857 20160101 38858 20160101 38859 20160101 38860 20160101 38862 20160101 38863 20160101 38864 20160101 38865 20160101 38866 20160101 38868 20160101 38869 20160101 38870 20160101 38871 20160101 38873 20160101 38874 20160101

Zip Code

Effective Date

Expiration Date

38875 20160101 38876 20160101 38877 20160101 38878 20160101 38879 20160101 38880 20160101 38901 20160101 38902 20160101 38913 20160101 38914 20160101 38915 20160101 38916 20160101 38917 20160101 38920 20160101 38921 20160101 38922 20160101 38923 20160101 38924 20160101 38925 20160101 38926 20160101 38927 20160101 38928 20160101 38929 20160101 38930 20160101 38935 20160101 38940 20160101 38941 20160101 38943 20160101 38944 20160101 38945 20160101 38946 20160101 38947 20160101 38948 20160101 38949 20160101 38950 20160101 38951 20160101 38952 20160101 38953 20160101 38954 20160101 38955 20160101 38957 20160101 38958 20160101 38959 20160101 38960 20160101

Zip Code

Effective Date

Expiration Date

38961 20160101 38962 20160101 38963 20160101 38964 20160101 38965 20160101 38966 20160101 38967 20160101 39038 20160101 39039 20160101 20160630 39040 20160101 20160630 39051 20160101 39054 20160101 39057 20160101 39061 20160101 39063 20160101 39067 20160101 39069 20160101 39074 20160101 39079 20160101 39080 20160101 39081 20160101 39086 20160101 39087 20160101 39088 20160101 20160630 39090 20160101 39092 20160101 39094 20160101 39095 20160101 39096 20160101 39097 20160101 39098 20160101 39107 20160101 39108 20160101 39109 20160101 39113 20160101 39115 20160101 39116 20160101 39117 20160101 39119 20160101 39120 20160101 39121 20160101 39122 20160101 39140 20160101 39144 20160101

Mississippi – 3rd Quarter 2016 Rural Zip Codes


Zip Code

Effective Date

Expiration Date

39146 20160101 39150 20160101 39152 20160101 39153 20160101 39156 20160101 39159 20160101 39160 20160101 39162 20160101 20160630 39165 20160101 39166 20160101 39168 20160101 39169 20160101 39171 20160101 39173 20160101 20160630 39176 20160101 39177 20160101 39179 20160101 20160630 39180 20160101 39181 20160101 39182 20160101 39183 20160101 39189 20160101 39190 20160101 39192 20160101 39194 20160101 20160630 39301 20160101 39302 20160101 39303 20160101 39304 20160101 39305 20160101 39307 20160101 39309 20160101 39320 20160101 39322 20160101 39323 20160101 39324 20160101 39325 20160101 39326 20160101 39327 20160101 39328 20160101 39330 20160101 39332 20160101 39335 20160101 39336 20160101

Zip Code

Effective Date

Expiration Date

39337 20160101 39338 20160101 39339 20160101 39341 20160101 39342 20160101 39345 20160101 39346 20160101 39347 20160101 39348 20160101 39350 20160101 39352 20160101 39354 20160101 39355 20160101 39356 20160101 39358 20160101 39359 20160101 39360 20160101 39361 20160101 39362 20160101 39363 20160101 39364 20160101 39365 20160101 39366 20160101 39367 20160101 39421 20160101 39422 20160101 39426 20160101 39427 20160101 39428 20160101 39429 20160101 39436 20160101 39437 20160101 39439 20160101 39440 20160101 39441 20160101 39442 20160101 39443 20160101 39451 20160101 39452 20160101 39456 20160101 39457 20160101 39459 20160101 39460 20160101 39461 20160101

Zip Code

Effective Date

Expiration Date

39463 20160101 39464 20160101 39466 20160101 39470 20160101 39474 20160101 39476 20160101 39477 20160101 39478 20160101 39479 20160101 39480 20160101 39481 20160101 39483 20160101 39561 20160101 39573 20160101 39577 20160101 39601 20160101 39602 20160101 39603 20160101 39629 20160101 39630 20160101 39631 20160101 39632 20160101 39633 20160101 39635 20160101 39638 20160101 39641 20160101 39643 20160101 39645 20160101 39647 20160101 39648 20160101 39649 20160101 39652 20160101 39653 20160101 39654 20160101 39656 20160101 39657 20160101 39661 20160101 39662 20160101 39663 20160101 39664 20160101 39665 20160101 39666 20160101 39667 20160101 39668 20160101

Zip Code

Effective Date

Expiration Date

39669 20160101 39701 20160101 39702 20160101 39703 20160101 39704 20160101 39705 20160101 39710 20160101 39730 20160101 39735 20160101 39736 20160101 39737 20160101 39739 20160101 39740 20160101 39741 20160101 39743 20160101 39744 20160101 39745 20160101 39746 20160101 39747 20160101 39750 20160101 39751 20160101 39752 20160101 39753 20160101 39754 20160101 39755 20160101 39756 20160101 39759 20160101 39760 20160101 39762 20160101 39766 20160101 39767 20160101 39769 20160101 39771 20160101 39772 20160101 39773 20160101 39776 20160101

New Mexico – 3rd Quarter 2016 Rural Zip Codes


Zip Code

Effective Date

Expiration Date

87005 20160101 87006 20160101 87007 20160101 87009 20160101 87011 20160101 87012 20160101 87013 20160101 87014 20160101 87017 20160101 87018 20160101 87020 20160101 87021 20160101 87026 20160101 87027 20160101 87028 20160101 87029 20160101 87038 20160101 87040 20160101 87045 20160101 87046 20160101 87049 20160101 87051 20160101 87062 20160101 87064 20160101 87301 20160101 87302 20160101 87305 20160101 87310 20160101 87311 20160101 87312 20160101 87313 20160101 87315 20160101 87316 20160101 87317 20160101 87319 20160101 87320 20160101 87321 20160101 87322 20160101 87323 20160101 87325 20160101 87326 20160101 87327 20160101 87328 20160101 87347 20160101

Zip Code

Effective Date

Expiration Date

87357 20160101 87365 20160101 87375 20160101 87510 20160101 87511 20160101 87512 20160101 87513 20160101 87514 20160101 87515 20160101 87516 20160101 87517 20160101 87518 20160101 87519 20160101 87520 20160101 87521 20160101 87522 20160101 87523 20160101 87524 20160101 87525 20160101 87527 20160101 87528 20160101 87529 20160101 87530 20160101 87531 20160101 87532 20160101 87533 20160101 87537 20160101 87538 20160101 87539 20160101 87543 20160101 87544 20160101 87545 20160101 87547 20160701 87548 20160101 87549 20160101 87551 20160101 87552 20160101 87553 20160101 87554 20160101 87556 20160101 87557 20160101 87558 20160101 87560 20160101 87562 20160101

Zip Code

Effective Date

Expiration Date

87564 20160101 87565 20160101 87566 20160101 87569 20160101 87571 20160101 87573 20160101 87575 20160101 87576 20160101 87577 20160101 87578 20160101 87579 20160101 87580 20160101 87581 20160101 87582 20160101 87583 20160101 87654 20160101 87701 20160101 87710 20160101 87711 20160101 87712 20160101 87713 20160101 87714 20160101 87715 20160101 87718 20160101 87722 20160101 87723 20160101 87724 20160101 87728 20160101 87729 20160101 87730 20160101 87731 20160101 87732 20160101 87733 20160101 87734 20160101 87735 20160101 87736 20160101 87740 20160101 87742 20160101 87743 20160101 87745 20160101 87746 20160101 87747 20160101 87749 20160101 87750 20160101

Zip Code

Effective Date

Expiration Date

87752 20160101 87753 20160101 87801 20160101 87820 20160101 87821 20160101 87823 20160101 87824 20160101 87825 20160101 87827 20160101 87828 20160101 87829 20160101 87830 20160101 87831 20160101 87832 20160101 87901 20160101 87930 20160101 87931 20160101 87933 20160101 87935 20160101 87939 20160101 87942 20160101 87943 20160101 88009 20160101 88020 20160101 88022 20160101 88023 20160101 88025 20160101 88026 20160101 88028 20160101 88029 20160101 88030 20160101 88031 20160101 88034 20160101 88036 20160101 88038 20160101 88039 20160101 88040 20160101 88041 20160101 88042 20160101 88043 20160101 88045 20160101 88049 20160101 88051 20160101 88053 20160101

Zip Code

Effective Date

Expiration Date

88055 20160101 88056 20160101 88061 20160101 88062 20160101 88065 20160101 88101 20160101 88102 20160101 88103 20160101 88112 20160101 88113 20160101 88114 20160101 88115 20160101 88116 20160101 88118 20160101 88119 20160101 88120 20160101 88121 20160101 88122 20160101 88123 20160101 88124 20160101 88125 20160101 88126 20160101 88130 20160101 88132 20160101 88133 20160101 88134 20160101 88135 20160101 88136 20160101 88201 20160101 88202 20160101 88203 20160101 88210 20160101 88211 20160101 88213 20160101 88220 20160101 88221 20160101 88230 20160101 88231 20160101 88232 20160101 88240 20160101 88241 20160101 88242 20160101 88244 20160101 88250 20160101

New Mexico – 3rd Quarter 2016 Rural Zip Codes


Zip Code

Effective Date

Expiration Date

88252 20160101 88253 20160101 88254 20160101 88255 20160101 88256 20160101 88260 20160101 88262 20160101 88263 20160101 88264 20160101 88265 20160101 88267 20160101 88268 20160101 88301 20160101 88310 20160101 88311 20160101 88312 20160101 88314 20160101 88316 20160101 88317 20160101 88318 20160101 88321 20160101 88323 20160101 88324 20160101 88325 20160101 88330 20160101 88336 20160101 88337 20160101 88338 20160101 88339 20160101 88340 20160101 88341 20160101 88342 20160101 88343 20160101 88344 20160101 88345 20160101 88346 20160101 88347 20160101 88348 20160101 88349 20160101 88350 20160101 88351 20160101 88352 20160101 88353 20160101 88354 20160101

Zip Code

Effective Date

Expiration Date

88355 20160101 88401 20160101 88410 20160101 88411 20160101 88414 20160101 88415 20160101 88416 20160101 88417 20160101 88418 20160101 88419 20160101 88421 20160101 88422 20160101 88424 20160101 88426 20160101 88427 20160101 88430 20160101 88431 20160101 88433 20160101 88434 20160101 88435 20160101 88436 20160101 88439 20160101

North Carolina – 3rd Quarter 2016 Rural Zip Codes


Zip Code

Effective Date

Expiration Date

27007 20160101 27013 20160101 27017 20160101 27024 20160101 27030 20160101 27031 20160101 27041 20160101 27047 20160101 27049 20160101 27053 20160101 20160630 27054 20160101 27209 20160101 27212 20160101 27229 20160101 27237 20160101 27242 20160101 27247 20160101 27259 20160101 27281 20160101 27291 20160101 27305 20160101 27306 20160101 27311 20160101 27314 20160101 27315 20160101 27325 20160101 27330 20160101 27331 20160101 27332 20160101 27356 20160101 27371 20160101 27376 20160101 27379 20160101 27501 20160101 27505 20160101 27506 20160101 27507 20160101 27509 20160101 27521 20160101 27522 20160101 27536 20160101 27537 20160101 27543 20160101 27544 20160101

Zip Code

Effective Date

Expiration Date

27546 20160101 27551 20160101 27552 20160101 27553 20160101 27556 20160101 27557 20160101 20160630 27563 20160101 27565 20160101 27570 20160101 27581 20160101 27582 20160101 27584 20160101 27586 20160101 27589 20160101 27594 20160101 27805 20160101 27806 20160101 27808 20160101 27810 20160101 27813 20160101 27814 20160101 27817 20160101 27818 20160101 27820 20160101 27821 20160101 27822 20160101 27823 20160101 27824 20160101 27825 20160101 27826 20160101 27829 20160101 27831 20160101 27832 20160101 27839 20160101 27840 20160101 27841 20160101 27842 20160101 27843 20160101 27844 20160101 27845 20160101 27846 20160101 27847 20160101 27849 20160101 27850 20160101

Zip Code

Effective Date

Expiration Date

27851 20160101 27852 20160101 27853 20160101 27855 20160101 27857 20160101 27860 20160101 27861 20160101 27862 20160101 27865 20160101 27866 20160101 27867 20160101 27869 20160101 27870 20160101 27871 20160401 27872 20160101 27873 20160101 27874 20160101 27875 20160101 27876 20160101 27877 20160101 27880 20160101 27883 20160101 27885 20160101 27887 20160101 27888 20160101 27889 20160101 27890 20160101 27892 20160101 27893 20160101 27894 20160101 27895 20160101 27896 20160101 27897 20160101 27906 20160101 27907 20160101 27909 20160101 27910 20160101 27915 20160101 27916 20160701 27917 20160701 27919 20160101 27920 20160101 27921 20160101 27922 20160101

Zip Code

Effective Date

Expiration Date

27923 20160701 27924 20160101 27925 20160101 27926 20160101 27927 20160701 27928 20160101 27929 20160701 27930 20160101 27932 20160101 27935 20160101 27936 20160101 27937 20160101 27938 20160101 27939 20160701 27941 20160701 27942 20160101 27943 20160101 27944 20160101 27946 20160101 27947 20160701 27948 20160101 27949 20160101 27950 20160701 27953 20160101 27954 20160101 27956 20160701 27957 20160101 27958 20160701 27959 20160101 27960 20160101 27962 20160101 27964 20160701 27965 20160701 27966 20160701 27967 20160101 27968 20160101 27969 20160101 27970 20160101 27972 20160101 27973 20160101 27974 20160101 27976 20160101 27978 20160101 27979 20160101

Zip Code

Effective Date

Expiration Date

27980 20160101 27981 20160101 27982 20160101 27983 20160101 27985 20160101 27986 20160101 28001 20160101 28002 20160101 28009 20160101 28010 20160101 28017 20160101 28018 20160101 28019 20160101 28020 20160101 28023 20160101 28024 20160101 28033 20160101 28037 20160101 28038 20160101 28039 20160101 28040 20160101 28041 20160101 28042 20160101 28043 20160101 28071 20160101 28072 20160101 28073 20160101 28074 20160101 28076 20160101 28080 20160101 28086 20160101 28088 20160101 28089 20160101 28090 20160101 28092 20160101 28093 20160101 28097 20160101 28109 20160101 28114 20160101 28115 20160101 28117 20160101 28123 20160101 28125 20160101 28127 20160101



Zip Code

Effective Date

Expiration Date

28128 20160101 28129 20160101 28136 20160101 28137 20160101 28138 20160101 28139 20160101 28144 20160101 28145 20160101 28146 20160101 28147 20160101 28150 20160101 28151 20160101 28152 20160101 28159 20160101 28160 20160101 28163 20160101 28166 20160101 28167 20160101 28168 20160101 28169 20160101 28315 20160101 28318 20160101 28319 20160101 28320 20160101 28323 20160101 28325 20160101 28326 20160101 28327 20160101 28328 20160101 28329 20160101 28330 20160101 28332 20160101 28334 20160101 28335 20160101 28337 20160101 28338 20160101 28339 20160101 28340 20160101 28341 20160101 28343 20160101 28344 20160101 28345 20160101 28347 20160101 28349 20160101

Zip Code

Effective Date

Expiration Date

28350 20160101 28351 20160101 28352 20160101 28353 20160101 28355 20160101 28357 20160101 28358 20160101 28359 20160101 28360 20160101 28362 20160101 28363 20160101 28364 20160101 28366 20160101 28367 20160101 28368 20160101 28369 20160101 28370 20160101 28371 20160101 28372 20160101 28373 20160101 28374 20160101 28375 20160101 28377 20160101 28378 20160101 28379 20160101 28380 20160101 28382 20160101 28383 20160101 28384 20160101 28385 20160101 28386 20160101 28387 20160101 28388 20160101 28390 20160101 28392 20160101 28393 20160101 28394 20160101 28396 20160101 28398 20160101 28399 20160101 28423 20160101 28424 20160101 28430 20160101 28431 20160101

Zip Code

Effective Date

Expiration Date

28432 20160101 28433 20160101 28434 20160101 28436 20160101 28438 20160101 28439 20160101 28441 20160101 28442 20160101 28444 20160101 28447 20160101 28448 20160101 28450 20160101 28453 20160101 28455 20160101 28456 20160101 28458 20160101 28463 20160101 28464 20160101 28466 20160101 28472 20160101 28501 20160101 28502 20160101 28503 20160101 28504 20160101 28508 20160101 28511 20160101 28512 20160101 28516 20160101 28518 20160101 28520 20160101 28521 20160101 28524 20160101 28525 20160101 28528 20160101 28531 20160101 28538 20160101 28551 20160101 28553 20160101 28554 20160101 28557 20160101 28570 20160101 28572 20160101 28575 20160101 28577 20160101

Zip Code

Effective Date

Expiration Date

28579 20160101 28580 20160101 28581 20160101 28584 20160101 28589 20160101 28594 20160101 28604 20160101 28605 20160101 28606 20160101 28607 20160101 28608 20160101 28615 20160101 28616 20160101 28617 20160101 28618 20160101 28621 20160101 28622 20160101 28623 20160101 28624 20160101 28625 20160101 28626 20160101 28627 20160101 28629 20160101 28631 20160101 28634 20160101 28635 20160101 28640 20160101 28643 20160101 28644 20160101 28646 20160101 28649 20160101 28651 20160101 28652 20160101 28653 20160101 28654 20160101 28656 20160101 28657 20160101 28659 20160101 28660 20160101 28662 20160101 28663 20160101 28664 20160101 28665 20160101 28668 20160101

Zip Code

Effective Date

Expiration Date

28669 20160101 28670 20160101 28672 20160101 28675 20160101 28676 20160101 28677 20160101 28679 20160101 28683 20160101 28684 20160101 28685 20160101 28687 20160101 28688 20160101 28689 20160101 28691 20160101 28692 20160101 28693 20160101 28694 20160101 28697 20160101 28698 20160101 28699 20160101 28702 20160101 28705 20160101 28707 20160101 28708 20160101 28712 20160101 28713 20160101 28714 20160101 28717 20160101 28718 20160101 28719 20160101 28720 20160101 28722 20160101 28723 20160101 28725 20160101 28733 20160101 28734 20160101 28736 20160101 28737 20160101 28740 20160101 28741 20160101 28744 20160101 28746 20160101 28747 20160101 28749 20160101



Zip Code

Effective Date

Expiration Date

28750 20160101 28752 20160101 28755 20160101 28756 20160101 28761 20160101 28762 20160101 28763 20160101 28765 20160101 28766 20160101 28768 20160101 28771 20160101 28772 20160101 28773 20160101 28774 20160101 28775 20160101 28777 20160101 28779 20160101 28781 20160101 28782 20160101 28783 20160101 28788 20160101 28789 20160101 28901 20160101 28902 20160101 28903 20160101 28904 20160101 28905 20160101 28906 20160101 28909 20160101

Oklahoma – 3rd Quarter 2016 Rural Zip Codes


Zip Code

Effective Date

Expiration Date

73001 20160101 73005 20160101 73006 20160101 73009 20160101 73015 20160101 73016 20160101 73017 20160101 20160630 73021 20160101 73024 20160101 73029 20160101 73030 20160101 73032 20160101 73033 20160101 73038 20160101 73039 20160101 73040 20160101 73041 20160101 73042 20160101 73043 20160101 73047 20160101 73048 20160101 73052 20160101 73053 20160101 73055 20160101 73057 20160101 73061 20160101 73062 20160101 73074 20160101 73075 20160101 73077 20160101 73086 20160101 73096 20160101 73098 20160101 73401 20160101 73402 20160101 73403 20160101 73425 20160101 73430 20160101 73432 20160101 73433 20160101 73434 20160101 73435 20160101 73436 20160101 73437 20160101

Zip Code

Effective Date

Expiration Date

73438 20160101 73439 20160101 73440 20160101 73441 20160101 73442 20160101 73443 20160101 73444 20160101 73446 20160101 73447 20160101 73448 20160101 73449 20160101 73450 20160101 73453 20160101 73455 20160101 73456 20160101 73458 20160101 73459 20160101 73460 20160101 73461 20160101 73463 20160101 73481 20160101 73487 20160101 73488 20160101 73491 20160101 73520 20160101 73521 20160101 73522 20160101 73523 20160101 73526 20160101 73529 20160101 73530 20160101 73532 20160101 73533 20160101 73534 20160101 73536 20160101 73537 20160101 73539 20160101 73542 20160101 73544 20160101 73546 20160101 73547 20160101 73548 20160101 73549 20160101 73550 20160101

Zip Code

Effective Date

Expiration Date

73551 20160101 73553 20160101 73554 20160101 73555 20160101 73556 20160101 73559 20160101 73560 20160101 73561 20160101 73564 20160101 73565 20160101 73566 20160101 73569 20160101 73570 20160101 73571 20160101 73573 20160101 73601 20160101 73620 20160101 73622 20160101 73624 20160101 73625 20160101 73626 20160101 73627 20160101 73628 20160101 73632 20160101 73638 20160101 73639 20160101 73641 20160101 73642 20160101 73644 20160101 73645 20160101 73646 20160101 73647 20160101 73648 20160101 73650 20160101 73651 20160101 73654 20160101 73655 20160101 73658 20160101 73659 20160101 73660 20160101 73661 20160101 73662 20160101 73663 20160101 73664 20160101

Zip Code

Effective Date

Expiration Date

73666 20160101 73667 20160101 73668 20160101 73669 20160101 73673 20160101 73701 20160101 73702 20160101 73703 20160101 73705 20160101 73706 20160101 73716 20160101 73717 20160101 73718 20160101 73719 20160101 73720 20160101 73722 20160101 73724 20160101 73726 20160101 73727 20160101 73728 20160101 73729 20160101 73730 20160101 73731 20160101 73733 20160101 73734 20160101 73735 20160101 73736 20160101 73737 20160101 73738 20160101 73739 20160101 73741 20160101 73742 20160101 73743 20160101 73744 20160101 73746 20160101 73747 20160101 73749 20160101 73750 20160101 73753 20160101 73754 20160101 73755 20160101 73756 20160101 73757 20160101 73758 20160101

Zip Code

Effective Date

Expiration Date

73759 20160101 73760 20160101 73761 20160101 73762 20160101 73763 20160101 73764 20160101 73766 20160101 73768 20160101 73770 20160101 73771 20160101 73772 20160101 73773 20160101 73801 20160101 73802 20160101 73832 20160101 73834 20160101 73835 20160101 73838 20160101 73840 20160101 73841 20160101 73842 20160101 73843 20160101 73844 20160101 73848 20160101 73851 20160101 73852 20160101 73853 20160101 73855 20160101 73857 20160101 73858 20160101 73859 20160101 73860 20160101 73901 20160101 73931 20160101 73932 20160101 73933 20160101 73937 20160101 73938 20160101 73939 20160101 73942 20160101 73944 20160101 73945 20160101 73946 20160101 73947 20160101



Zip Code

Effective Date

Expiration Date

73949 20160101 73950 20160101 73951 20160101 74003 20160101 74004 20160101 74005 20160101 74006 20160101 74022 20160101 74023 20160101 74027 20160101 74029 20160101 74032 20160101 74042 20160101 74048 20160101 74051 20160101 74059 20160101 74061 20160101 74062 20160101 74072 20160101 74074 20160101 74075 20160101 74076 20160101 74077 20160101 74078 20160101 74082 20160101 74083 20160101 74085 20160101 74301 20160101 74330 20160101 74331 20160101 74332 20160101 74333 20160101 74335 20160101 74337 20160101 74338 20160101 74339 20160101 74340 20160101 74342 20160101 74343 20160101 74344 20160101 74345 20160101 74346 20160101 74347 20160101 74349 20160101

Zip Code

Effective Date

Expiration Date

74350 20160101 74352 20160101 74354 20160101 74355 20160101 74358 20160101 74359 20160101 74360 20160101 74361 20160101 74362 20160101 74363 20160101 74364 20160101 74365 20160101 74366 20160101 74367 20160101 74368 20160101 74369 20160101 74370 20160101 74401 20160101 74402 20160101 74403 20160101 74422 20160101 74423 20160101 74425 20160101 74426 20160101 74427 20160101 74428 20160101 74430 20160101 74432 20160101 74434 20160101 74436 20160101 74438 20160101 74439 20160101 74440 20160101 74441 20160101 74442 20160101 74444 20160101 74450 20160101 74451 20160101 74452 20160101 74455 20160101 74457 20160101 74459 20160101 74461 20160101 74462 20160101

Zip Code

Effective Date

Expiration Date

74463 20160101 74464 20160101 74465 20160101 74468 20160101 74469 20160101 74470 20160101 74471 20160101 74472 20160101 74501 20160101 74502 20160101 74521 20160101 74522 20160101 74523 20160101 74525 20160101 74528 20160101 74529 20160101 74530 20160101 74531 20160101 74533 20160101 74534 20160101 74535 20160101 74536 20160101 74538 20160101 74540 20160101 74543 20160101 74545 20160101 74546 20160101 74547 20160101 74549 20160101 74552 20160101 74553 20160101 74554 20160101 74555 20160101 74556 20160101 74557 20160101 74558 20160101 74559 20160101 74560 20160101 74561 20160101 74562 20160101 74563 20160101 74565 20160101 74567 20160101 74569 20160101

Zip Code

Effective Date

Expiration Date

74570 20160101 74571 20160101 74572 20160101 74574 20160101 74576 20160101 74578 20160101 74601 20160101 74602 20160101 74604 20160101 74630 20160101 74631 20160101 74632 20160101 74636 20160101 74640 20160101 74641 20160101 74643 20160101 74644 20160101 74646 20160101 74647 20160101 74651 20160101 74653 20160101 74701 20160101 74702 20160101 74720 20160101 74721 20160101 74722 20160101 74723 20160101 74724 20160101 74726 20160101 74727 20160101 74728 20160101 74729 20160101 74730 20160101 74731 20160101 74733 20160101 74734 20160101 74735 20160101 74736 20160101 74737 20160101 74738 20160101 74740 20160101 74741 20160101 74743 20160101 74745 20160101

Zip Code

Effective Date

Expiration Date

74747 20160101 74748 20160101 74750 20160101 74752 20160101 74753 20160101 74754 20160101 74755 20160101 74756 20160101 74759 20160101 74760 20160101 74761 20160101 74764 20160101 74766 20160101 74801 20160101 74802 20160101 74804 20160101 74818 20160101 74820 20160101 74821 20160101 74825 20160101 74826 20160101 74827 20160101 74829 20160101 74830 20160101 74833 20160101 74836 20160101 74837 20160101 74839 20160101 74840 20160101 74842 20160101 74843 20160101 74844 20160101 74845 20160101 74848 20160101 74849 20160101 74850 20160101 74851 20160101 74852 20160101 74854 20160101 74856 20160101 74859 20160101 74860 20160101 74865 20160101 74866 20160101



Zip Code

Effective Date

Expiration Date

74867 20160101 74868 20160101 74871 20160101 74872 20160101 74873 20160101 74878 20160101 74880 20160101 74883 20160101 74884 20160101 74931 20160101 74941 20160101 74943 20160101 74944 20160101 74960 20160101 74963 20160101 74964 20160101 74965 20160101

South Carolina – 3rd Quarter 2016 Rural Zip Codes


Zip Code

Effective Date

Expiration Date

29001 20160101 29003 20160101 29010 20160101 29014 20160101 29018 20160101 29037 20160101 29038 20160101 29039 20160101 29041 20160101 29042 20160101 29046 20160101 29047 20160101 29048 20160101 29051 20160101 29055 20160101 29056 20160101 29058 20160101 29059 20160101 29067 20160101 29075 20160101 29080 20160101 29081 20160101 29082 20160101 29101 20160101 29102 20160101 29104 20160101 29107 20160101 29108 20160101 29111 20160101 29112 20160101 29113 20160101 29115 20160101 29116 20160101 29117 20160101 29118 20160101 29122 20160101 29125 20160101 29126 20160101 29127 20160101 29133 20160101 29138 20160101 29142 20160101 29143 20160101 29145 20160101

Zip Code

Effective Date

Expiration Date

29146 20160101 29148 20160101 29162 20160101 29163 20160101 29166 20160101 29178 20160101 29340 20160101 29341 20160101 29342 20160101 29355 20160101 29432 20160101 29433 20160101 29435 20160101 29438 20160101 29440 20160101 29442 20160101 29446 20160101 29452 20160101 29474 20160101 29475 20160101 29481 20160101 29488 20160101 29493 20160101 29510 20160101 29512 20160101 29516 20160101 29518 20160101 29519 20160101 29520 20160101 29525 20160101 29536 20160101 29543 20160101 29546 20160101 29547 20160101 29554 20160101 29556 20160101 29563 20160101 29564 20160101 29565 20160101 29567 20160101 29570 20160101 29571 20160101 29574 20160101 29580 20160101

Zip Code

Effective Date

Expiration Date

29584 20160101 29585 20160101 29589 20160101 29590 20160101 29592 20160101 29594 20160101 29596 20160101 29620 20160101 29621 20160101 20160630 29622 20160101 20160630 29623 20160101 20160630 29624 20160101 20160630 29625 20160101 20160630 29626 20160101 20160630 29627 20160101 20160630 29628 20160101 29638 20160101 29639 20160101 29643 20160101 29646 20160101 29647 20160101 29648 20160101 29649 20160101 29653 20160101 29654 20160101 20160630 29655 20160101 20160630 29656 20160101 20160630 29658 20160101 29659 20160101 20160630 29664 20160101 29665 20160101 29666 20160101 29669 20160101 20160630 29670 20160101 20160630 29672 20160101 29675 20160101 29676 20160101 29677 20160101 20160630 29678 20160101 29679 20160101 29684 20160101 20160630 29686 20160101 29689 20160101 20160630 29691 20160101

Zip Code

Effective Date

Expiration Date

29693 20160101 29695 20160101 29696 20160101 29697 20160101 20160630 29702 20160101 29706 20160101 29707 20160101 29709 20160101 29712 20160101 29714 20160101 29718 20160101 29720 20160101 29721 20160101 29722 20160101 29724 20160101 29727 20160101 29728 20160101 29729 20160101 29741 20160101 29744 20160101 29810 20160101 29812 20160101 29813 20160101 29817 20160101 29819 20160101 29821 20160101 29826 20160101 29827 20160101 29835 20160101 29836 20160101 29838 20160101 29840 20160101 29843 20160101 29844 20160101 29845 20160101 29846 20160101 29848 20160101 29849 20160101 29853 20160101 29899 20160101 29911 20160101 29913 20160101 29916 20160101 29918 20160101

Zip Code

Effective Date

Expiration Date

29921 20160101 29922 20160101 29923 20160101 29924 20160101 29929 20160101 29932 20160101 29933 20160101 29939 20160101 29944 20160101 29945 20160101

Tennessee – 3rd Quarter 2016 Rural Zip Codes


Zip Code

Effective Date

Expiration Date

37012 20160101 37016 20160101 37018 20160101 37019 20160101 37020 20160101 37023 20160101 37026 20160101 37028 20160101 37034 20160101 37047 20160101 37050 20160101 37058 20160101 37059 20160101 37061 20160101 37078 20160101 37079 20160101 37091 20160101 37095 20160101 37096 20160101 37097 20160101 37101 20160101 37110 20160101 37111 20160101 37134 20160101 37144 20160101 37160 20160101 37161 20160101 37162 20160101 37166 20160101 37174 20160101 20160630 37175 20160101 37178 20160101 37180 20160101 37183 20160101 37185 20160101 37190 20160101 37301 20160101 37303 20160101 37305 20160101 37306 20160101 37309 20160101 37313 20160101 37314 20160101 37318 20160101

Zip Code

Effective Date

Expiration Date

37321 20160101 37322 20160101 37324 20160101 37328 20160101 37329 20160101 37330 20160101 37331 20160101 37332 20160101 37334 20160101 37335 20160101 37337 20160101 37338 20160101 37339 20160101 37342 20160101 37345 20160101 37348 20160101 37349 20160101 37352 20160101 37354 20160101 37355 20160101 37357 20160101 37359 20160101 37360 20160101 37365 20160101 37366 20160101 37367 20160101 37370 20160101 37371 20160101 37375 20160101 37376 20160101 37378 20160101 37381 20160101 37382 20160101 37383 20160101 37385 20160101 37387 20160101 37388 20160101 37389 20160101 37394 20160101 37398 20160101 37616 20160101 37640 20160101 37641 20160101 37680 20160101

Zip Code

Effective Date

Expiration Date

37681 20160101 37683 20160101 37688 20160101 37691 20160101 37707 20160101 37708 20160101 20160630 37709 20160101 20160630 37711 20160101 37713 20160101 37714 20160101 20160630 37715 20160101 37719 20160101 20160630 37722 20160101 37723 20160101 37724 20160101 37726 20160101 20160630 37727 20160101 37729 20160101 20160630 37730 20160101 37732 20160101 37733 20160101 20160630 37738 20160101 37743 20160101 37744 20160101 37745 20160101 37748 20160101 20160630 37752 20160101 37753 20160101 37755 20160101 37756 20160101 37757 20160101 20160630 37762 20160101 20160630 37763 20160101 20160630 37764 20160101 37765 20160101 37766 20160101 20160630 37770 20160101 20160630 37773 20160101 37809 20160101 37810 20160101 37818 20160101 37819 20160101 20160630 37821 20160101 37822 20160101

Zip Code

Effective Date

Expiration Date

37824 20160101 37825 20160101 37826 20160101 37829 20160101 20160630 37840 20160101 20160630 37841 20160101 37843 20160101 37845 20160101 20160630 37847 20160101 37851 20160101 37852 20160101 37854 20160101 20160630 37861 20160101 20160630 37862 20160101 37863 20160101 37864 20160101 37865 20160101 37867 20160101 37868 20160101 37869 20160101 37870 20160101 37872 20160101 20160630 37874 20160101 37876 20160101 37879 20160101 37880 20160101 20160630 37881 20160101 20160630 37885 20160101 37887 20160101 20160630 37888 20160101 20160630 37892 20160101 38007 20160101 38008 20160101 38012 20160101 38024 20160101 38025 20160101 38030 20160101 38037 20160101 38039 20160101 38040 20160101 38041 20160101 38042 20160101 38044 20160101 38047 20160101

Zip Code

Effective Date

Expiration Date

38052 20160101 38059 20160101 38061 20160101 38063 20160101 38067 20160101 38069 20160101 38070 20160101 38075 20160101 38077 20160101 38079 20160101 38080 20160101 38201 20160101 38220 20160101 38221 20160101 38222 20160101 38223 20160101 38224 20160101 38225 20160101 38226 20160101 38229 20160101 38230 20160101 38231 20160101 38232 20160101 38233 20160101 38235 20160101 38236 20160101 38237 20160101 38238 20160101 38240 20160101 38241 20160101 38242 20160101 38251 20160101 38253 20160101 38254 20160101 38255 20160101 38256 20160101 38257 20160101 38258 20160101 38259 20160101 38260 20160101 38261 20160101 38271 20160101 38281 20160101 38310 20160101

Tennessee – 3rd Quarter 2016 Rural Zip Codes


Zip Code

Effective Date

Expiration Date

38311 20160101 38315 20160101 38316 20160101 38317 20160101 38318 20160101 38320 20160101 38321 20160101 38324 20160101 38326 20160101 38327 20160101 38328 20160101 38329 20160101 38330 20160101 38331 20160101 38333 20160101 38334 20160101 38338 20160101 38339 20160101 38341 20160101 38342 20160101 38343 20160101 38344 20160101 38345 20160101 38346 20160101 38348 20160101 38351 20160101 38355 20160101 38357 20160101 38358 20160101 38361 20160101 38363 20160101 38365 20160101 38367 20160101 38368 20160101 38369 20160101 38370 20160101 38371 20160101 38372 20160101 38374 20160101 38375 20160101 38376 20160101 38377 20160101 38379 20160101 38380 20160101

Zip Code

Effective Date

Expiration Date

38381 20160101 38382 20160101 38387 20160101 38388 20160101 38389 20160101 38390 20160101 38393 20160101 38401 20160101 20160630 38402 20160101 20160630 38425 20160101 38449 20160101 38450 20160101 38451 20160101 20160630 38452 20160101 38453 20160101 38455 20160101 38456 20160101 38457 20160101 38459 20160101 38460 20160101 38461 20160101 38462 20160101 38463 20160101 38464 20160101 38468 20160101 38469 20160101 38471 20160101 38472 20160101 38473 20160101 38474 20160101 20160630 38475 20160101 38477 20160101 38478 20160101 38481 20160101 38482 20160101 20160630 38483 20160101 38485 20160101 38486 20160101 38487 20160101 20160630 38488 20160101 38501 20160101 38502 20160101 38503 20160101 38504 20160101

Zip Code

Effective Date

Expiration Date

38505 20160101 38506 20160101 38541 20160101 38542 20160101 38543 20160101 38544 20160101 38545 20160101 38548 20160101 38549 20160101 38550 20160101 38551 20160101 38553 20160101 38554 20160101 38555 20160101 38556 20160101 38557 20160101 38558 20160101 38559 20160101 38562 20160101 38564 20160101 38565 20160101 38568 20160101 38570 20160101 38571 20160101 38572 20160101 38573 20160101 38574 20160101 38575 20160101 38577 20160101 38578 20160101 38579 20160101 38580 20160101 38581 20160101 38582 20160101 38583 20160101 38585 20160101 38587 20160101 38588 20160101 38589 20160101

Texas – 3rd Quarter 2016 Rural Zip Codes


Zip Code

Effective Date

Expiration Date

73960 20160101 75102 20160101 75103 20160101 75105 20160101 75109 20160101 75110 20160101 75117 20160101 75124 20160101 75127 20160101 75140 20160101 75144 20160101 75148 20160101 75151 20160101 75153 20160101 75155 20160101 75156 20160101 75163 20160101 75169 20160101 75410 20160101 75411 20160101 75412 20160101 75413 20160101 75415 20160101 75416 20160101 75417 20160101 75418 20160101 75420 20160101 75421 20160101 75425 20160101 75426 20160101 75431 20160101 75432 20160101 75433 20160101 75434 20160101 75435 20160101 75436 20160101 75437 20160101 75438 20160101 75439 20160101 75440 20160101 75441 20160101 75443 20160101 75444 20160101 75446 20160101

Zip Code

Effective Date

Expiration Date

75447 20160101 75448 20160101 75449 20160101 75450 20160101 75451 20160101 75452 20160101 75455 20160101 75456 20160101 75457 20160101 75460 20160101 75461 20160101 75462 20160101 75468 20160101 75469 20160101 75470 20160101 75471 20160101 75472 20160101 75473 20160101 75475 20160101 75476 20160101 75477 20160101 75478 20160101 75479 20160101 75480 20160101 75481 20160101 75482 20160101 75483 20160101 75486 20160101 75487 20160101 75488 20160101 75490 20160101 75492 20160101 75493 20160101 75494 20160101 75497 20160101 75550 20160101 75551 20160101 75554 20160101 75555 20160101 75556 20160101 75558 20160101 75560 20160101 75562 20160101 75563 20160101

Zip Code

Effective Date

Expiration Date

75564 20160101 75565 20160101 75566 20160101 75568 20160101 75571 20160101 75572 20160101 75630 20160101 75631 20160101 75633 20160101 75636 20160101 75637 20160101 75638 20160101 75639 20160101 75642 20160101 75643 20160101 75650 20160101 75651 20160101 75656 20160101 75657 20160101 75659 20160101 75661 20160101 75668 20160101 75669 20160101 75670 20160101 75671 20160101 75672 20160101 75685 20160101 75686 20160101 75688 20160101 75692 20160101 75694 20160101 75751 20160101 75752 20160101 75754 20160101 75756 20160101 75757 20160101 75758 20160101 75759 20160101 75760 20160101 75763 20160101 75764 20160101 75765 20160101 75766 20160101 75770 20160101

Zip Code

Effective Date

Expiration Date

75772 20160101 75773 20160101 75778 20160101 75779 20160101 75780 20160101 75782 20160101 75783 20160101 75784 20160101 75785 20160101 75788 20160101 75790 20160101 75801 20160101 75802 20160101 75803 20160101 75831 20160101 75832 20160101 75833 20160101 75834 20160101 75835 20160101 75838 20160101 75839 20160101 75840 20160101 75844 20160101 75845 20160101 75846 20160101 75847 20160101 75848 20160101 75849 20160101 75850 20160101 75851 20160101 75852 20160101 75853 20160101 75855 20160101 75856 20160101 75858 20160101 75859 20160101 75860 20160101 75861 20160101 75862 20160101 75865 20160101 75880 20160101 75882 20160101 75884 20160101 75886 20160101

Zip Code

Effective Date

Expiration Date

75901 20160101 75902 20160101 75903 20160101 75904 20160101 75915 20160101 75925 20160101 75926 20160101 75928 20160101 20160630 75929 20160101 75930 20160101 75931 20160101 75932 20160101 20160630 75933 20160101 20160630 75934 20160101 75935 20160101 75936 20160101 75937 20160101 75938 20160101 75939 20160101 75941 20160101 75942 20160101 75943 20160101 75944 20160101 75946 20160101 75948 20160101 75949 20160101 75951 20160101 75954 20160101 75956 20160101 75958 20160101 75959 20160101 75960 20160101 75961 20160101 75962 20160101 75963 20160101 75964 20160101 75965 20160101 75966 20160101 20160630 75968 20160101 75969 20160101 75972 20160101 75973 20160101 75974 20160101 75975 20160101



Zip Code

Effective Date

Expiration Date

75976 20160101 75977 20160101 20160630 75978 20160101 75979 20160101 75980 20160101 75990 20160101 76035 20160101 76043 20160101 76048 20160101 76049 20160101 76055 20160101 76067 20160101 76068 20160101 76070 20160101 76077 20160101 76230 20160101 76238 20160101 76239 20160101 76240 20160101 76241 20160101 76250 20160101 76251 20160101 76252 20160101 76253 20160101 76255 20160101 76261 20160101 76263 20160101 76265 20160101 76272 20160101 76363 20160101 76364 20160101 76371 20160101 76372 20160101 76373 20160101 76374 20160101 76380 20160101 76384 20160101 76385 20160101 76388 20160101 76401 20160101 76402 20160101 76424 20160101 76427 20160101 76429 20160101

Zip Code

Effective Date

Expiration Date

76430 20160101 76432 20160101 76433 20160101 76435 20160101 76436 20160101 76437 20160101 76442 20160101 76444 20160101 76445 20160101 76446 20160101 76448 20160101 76449 20160101 76450 20160101 76452 20160101 76453 20160101 76454 20160101 76455 20160101 76457 20160101 76458 20160101 76459 20160101 76460 20160101 76461 20160101 76462 20160101 76463 20160101 76464 20160101 76465 20160101 76466 20160101 76467 20160101 76468 20160101 76470 20160101 76471 20160101 76472 20160101 76474 20160101 76475 20160101 76476 20160101 76481 20160101 76483 20160101 76484 20160101 76486 20160101 76491 20160101 76518 20160101 76519 20160101 20160630 76520 20160101 76523 20160101

Zip Code

Effective Date

Expiration Date

76531 20160101 76556 20160101 76565 20160101 76567 20160101 76577 20160101 76621 20160101 76622 20160101 76626 20160101 76627 20160101 76628 20160101 76631 20160101 76634 20160101 76635 20160101 76636 20160101 76637 20160101 76639 20160101 76641 20160101 76642 20160101 76644 20160101 76645 20160101 76648 20160101 76649 20160101 76650 20160101 76652 20160101 76653 20160101 76660 20160101 76665 20160101 76666 20160101 76667 20160101 76671 20160101 76673 20160101 76676 20160101 76678 20160101 76679 20160101 76681 20160101 76686 20160101 76687 20160101 76689 20160101 76690 20160101 76692 20160101 76693 20160101 76801 20160101 76802 20160101 76803 20160101

Zip Code

Effective Date

Expiration Date

76804 20160101 76820 20160101 76821 20160101 76823 20160101 76824 20160101 76825 20160101 76827 20160101 76828 20160101 76831 20160101 76832 20160101 76834 20160101 76836 20160101 76837 20160101 76841 20160101 76842 20160101 76844 20160101 76845 20160101 76848 20160101 76849 20160101 76852 20160101 76854 20160101 76855 20160101 76856 20160101 76857 20160101 76858 20160101 76859 20160101 76862 20160101 76864 20160101 76865 20160101 76866 20160101 76869 20160101 76870 20160101 76871 20160101 76872 20160101 76873 20160101 76874 20160101 76875 20160101 76877 20160101 76878 20160101 76880 20160101 76882 20160101 76883 20160101 76884 20160101 76885 20160101

Zip Code

Effective Date

Expiration Date

76887 20160101 76888 20160101 76890 20160101 76932 20160101 76933 20160101 76936 20160101 76943 20160101 76945 20160101 76949 20160101 76950 20160101 76951 20160101 76953 20160101 77320 20160101 77326 20160101 77332 20160101 77334 20160101 77335 20160101 77340 20160101 77341 20160101 77342 20160101 77343 20160101 77344 20160101 77348 20160101 77349 20160101 77350 20160101 77351 20160101 77358 20160101 20160630 77360 20160101 77363 20160101 77367 20160101 77399 20160101 77404 20160101 77412 20160101 77414 20160101 77415 20160101 77419 20160101 77420 20160101 77426 20160101 77428 20160101 77432 20160101 77434 20160101 77435 20160101 77436 20160101 77437 20160101



Zip Code

Effective Date

Expiration Date

77440 20160101 77442 20160101 77443 20160101 77448 20160101 77453 20160101 77454 20160101 77455 20160101 77456 20160101 77457 20160101 77458 20160101 77460 20160101 77465 20160101 77467 20160101 77468 20160101 77470 20160101 77475 20160101 77482 20160101 77483 20160101 77488 20160101 77612 20160101 77614 20160101 20160630 77615 20160101 77616 20160101 77624 20160101 77660 20160101 77664 20160101 77830 20160101 77831 20160101 77833 20160101 77834 20160101 77835 20160101 77850 20160101 77853 20160101 77855 20160101 77857 20160101 77861 20160101 77864 20160101 77865 20160101 77868 20160101 77871 20160101 77872 20160101 77875 20160101 77876 20160101 77880 20160101

Zip Code

Effective Date

Expiration Date

77950 20160101 77954 20160101 77957 20160101 77961 20160101 77962 20160101 77964 20160101 77967 20160101 77969 20160101 77970 20160101 77971 20160101 77974 20160101 77975 20160101 77978 20160101 77979 20160101 77982 20160101 77983 20160101 77984 20160101 77986 20160101 77987 20160101 77989 20160101 77990 20160101 77991 20160101 77994 20160101 77995 20160101 78001 20160101 78005 20160101 78007 20160101 78010 20160101 78014 20160101 78017 20160101 78019 20160101 78021 20160101 78022 20160101 78024 20160101 78025 20160101 78028 20160101 78029 20160101 78057 20160101 78058 20160101 78060 20160101 78061 20160101 78067 20160101 78071 20160101 78072 20160101

Zip Code

Effective Date

Expiration Date

78075 20160101 78076 20160101 78102 20160101 78104 20160101 78111 20160101 78116 20160101 78117 20160101 78118 20160101 78119 20160101 78122 20160101 78125 20160101 78140 20160101 78141 20160101 78142 20160101 78144 20160101 78145 20160101 78146 20160101 78151 20160101 78159 20160101 78162 20160101 78164 20160101 78332 20160101 78333 20160101 78338 20160101 78340 20160101 78341 20160101 78342 20160101 78349 20160101 78350 20160101 78353 20160101 78355 20160101 78357 20160101 78360 20160101 78361 20160101 78363 20160101 78364 20160101 78372 20160101 78375 20160101 78376 20160101 78377 20160101 78379 20160101 78383 20160101 78384 20160101 78385 20160101

Zip Code

Effective Date

Expiration Date

78389 20160101 78391 20160101 78393 20160101 78418 20160101 78536 20160101 78545 20160101 78547 20160101 78548 20160101 78561 20160101 78564 20160101 78569 20160101 78580 20160101 78582 20160101 78584 20160101 78585 20160101 78588 20160101 78590 20160101 78591 20160101 78594 20160101 78597 20160101 78598 20160101 78604 20160101 78605 20160101 78606 20160101 78607 20160101 78608 20160101 78609 20160101 78611 20160101 78614 20160101 78618 20160101 78624 20160101 78629 20160101 78631 20160101 78635 20160101 78636 20160101 78639 20160101 78643 20160101 78654 20160101 78657 20160101 78658 20160101 78663 20160101 78671 20160101 78672 20160101 78675 20160101

Zip Code

Effective Date

Expiration Date

78677 20160101 78801 20160101 78802 20160101 78827 20160101 78828 20160101 78829 20160101 78830 20160101 78832 20160101 78833 20160101 78834 20160101 78836 20160101 78837 20160101 78838 20160101 78839 20160101 78840 20160101 78841 20160101 78842 20160101 78843 20160101 78847 20160101 78851 20160101 78852 20160101 78853 20160101 78860 20160101 78870 20160101 78871 20160101 78872 20160101 78873 20160101 78877 20160101 78879 20160101 78880 20160101 78881 20160101 78884 20160101 78932 20160101 78933 20160101 78934 20160101 78935 20160101 78938 20160101 78940 20160101 78941 20160101 78942 20160101 78943 20160101 78945 20160101 78946 20160101 78947 20160101



Zip Code

Effective Date

Expiration Date

78948 20160101 78949 20160101 78951 20160101 78952 20160101 78954 20160101 78956 20160101 78959 20160101 78960 20160101 78961 20160101 78962 20160101 78963 20160101 79002 20160101 79003 20160101 79005 20160101 79007 20160101 79008 20160101 79009 20160101 79011 20160101 79013 20160101 79014 20160101 79018 20160101 79021 20160101 79022 20160101 79024 20160101 79025 20160101 79027 20160101 79029 20160101 79031 20160101 79032 20160101 79033 20160101 79034 20160101 79035 20160101 79036 20160101 79040 20160101 79041 20160101 79043 20160101 79044 20160101 79045 20160101 79046 20160101 79051 20160101 79052 20160101 79053 20160101 79054 20160101 79056 20160101

Zip Code

Effective Date

Expiration Date

79057 20160101 79058 20160101 79059 20160101 79061 20160101 79062 20160101 79063 20160101 79064 20160101 79065 20160101 79066 20160101 79070 20160101 79072 20160101 79073 20160101 79077 20160101 79078 20160101 79079 20160101 79080 20160101 79081 20160101 79082 20160101 79083 20160101 79084 20160101 79085 20160101 79086 20160101 79087 20160101 79088 20160101 79092 20160101 79093 20160101 79095 20160101 79096 20160101 79201 20160101 79220 20160101 79221 20160101 79223 20160101 79225 20160101 79226 20160101 79227 20160101 79229 20160101 79230 20160101 79231 20160101 79233 20160101 79234 20160101 79235 20160101 79236 20160101 79237 20160101 79239 20160101

Zip Code

Effective Date

Expiration Date

79240 20160101 79241 20160101 79243 20160101 79244 20160101 79245 20160101 79247 20160101 79248 20160101 79250 20160101 79251 20160101 79252 20160101 79255 20160101 79256 20160101 79257 20160101 79258 20160101 79259 20160101 79261 20160101 79311 20160101 79312 20160101 79313 20160101 79314 20160101 79316 20160101 79323 20160101 79324 20160101 79325 20160101 79326 20160101 79330 20160101 79331 20160101 79336 20160101 79338 20160101 79339 20160101 79342 20160101 79344 20160101 79345 20160101 79346 20160101 79347 20160101 79351 20160101 79353 20160101 79355 20160101 79356 20160101 79358 20160101 79359 20160101 79360 20160101 79367 20160101 79369 20160101

Zip Code

Effective Date

Expiration Date

79370 20160101 79371 20160101 79372 20160101 79376 20160101 79377 20160101 79378 20160101 79379 20160101 79380 20160101 79502 20160101 79505 20160101 79506 20160101 79511 20160101 79512 20160101 79516 20160101 79517 20160101 79518 20160101 79519 20160101 79521 20160101 79526 20160101 79527 20160101 79528 20160101 79529 20160101 79532 20160101 79534 20160101 79535 20160101 79537 20160101 79538 20160101 79539 20160101 79540 20160101 79543 20160101 79544 20160101 79545 20160101 79546 20160101 79547 20160101 79548 20160101 79549 20160101 79550 20160101 79556 20160101 79560 20160101 79565 20160101 79567 20160101 79713 20160101 79714 20160101 79718 20160101

Zip Code

Effective Date

Expiration Date

79719 20160101 79720 20160101 79721 20160101 79730 20160101 79731 20160101 79733 20160101 79734 20160101 79735 20160101 79738 20160101 79739 20160101 79740 20160101 79742 20160101 79743 20160101 79744 20160101 79745 20160101 79748 20160101 79752 20160101 79754 20160101 79755 20160101 79756 20160101 79770 20160101 79772 20160101 79777 20160101 79778 20160101 79780 20160101 79781 20160101 79785 20160101 79786 20160101 79788 20160101 79789 20160101 79830 20160101 79831 20160101 79832 20160101 79834 20160101 79837 20160101 79839 20160101 79842 20160101 79843 20160101 79845 20160101 79846 20160101 79847 20160101 79848 20160101 79851 20160101 79852 20160101



Zip Code

Effective Date

Expiration Date

79854 20160101 79855 20160101

Virginia – 3rd Quarter 2016 Rural Zip Codes


Zip Code

Effective Date

Expiration Date

20106 20160101 20160630 20130 20160101 20135 20160101 22432 20160101 22433 20160101 22435 20160101 22436 20160101 22437 20160101 22438 20160101 22442 20160101 22443 20160101 22448 20160101 22451 20160101 22454 20160101 22456 20160101 22460 20160101 22469 20160101 22472 20160101 22473 20160101 22476 20160101 22480 20160101 22481 20160101 22482 20160101 22485 20160101 22488 20160101 22503 20160101 22504 20160101 22507 20160101 22508 20160101 22509 20160101 22511 20160101 22513 20160101 22517 20160101 22520 20160101 22523 20160101 22524 20160101 22526 20160101 22528 20160101 22529 20160101 22530 20160101 22539 20160101 22542 20160101 22544 20160101 22547 20160101

Zip Code

Effective Date

Expiration Date

22548 20160101 22558 20160101 22560 20160101 22567 20160101 22570 20160101 22572 20160101 22576 20160101 22577 20160101 22578 20160101 22579 20160101 22581 20160101 22611 20160101 22620 20160101 22623 20160101 22626 20160101 22627 20160101 22640 20160101 22641 20160101 22644 20160101 22646 20160101 22649 20160701 22650 20160101 22652 20160101 22657 20160101 22660 20160101 22663 20160101 22664 20160101 22701 20160101 20160630 22709 20160101 22711 20160101 22713 20160101 20160630 22714 20160101 20160630 22715 20160101 22716 20160101 22718 20160101 20160630 22719 20160101 22722 20160101 22723 20160101 22724 20160101 20160630 22725 20160101 22726 20160101 20160630 22727 20160101 22729 20160101 20160630 22730 20160101

Zip Code

Effective Date

Expiration Date

22731 20160101 22732 20160101 22733 20160101 20160630 22735 20160101 20160630 22736 20160101 20160630 22737 20160101 20160630 22738 20160101 22740 20160101 22741 20160101 20160630 22743 20160101 22746 20160101 22747 20160101 22748 20160101 22749 20160101 22810 20160101 22824 20160101 22835 20160101 22842 20160101 22844 20160101 22845 20160101 22847 20160101 22849 20160101 22851 20160101 22923 20160101 22942 20160101 22948 20160101 22957 20160101 22960 20160101 22972 20160101 22989 20160101 23027 20160101 23031 20160101 23032 20160101 23040 20160101 23043 20160101 23070 20160101 23071 20160101 23079 20160101 23092 20160101 23115 20160101 23149 20160101 23169 20160101 23175 20160101 23176 20160101

Zip Code

Effective Date

Expiration Date

23180 20160101 23301 20160101 23302 20160101 23303 20160101 23306 20160101 23307 20160101 23308 20160101 23310 20160101 23313 20160101 23316 20160101 23336 20160101 23337 20160101 23341 20160101 23345 20160101 23347 20160101 23350 20160101 23354 20160101 23356 20160101 23357 20160101 23358 20160101 23359 20160101 23389 20160101 23395 20160101 23396 20160101 23398 20160101 23399 20160101 23401 20160101 23404 20160101 23405 20160101 23407 20160101 23408 20160101 23409 20160101 23410 20160101 23412 20160101 23413 20160101 23414 20160101 23415 20160101 23416 20160101 23417 20160101 23418 20160101 23419 20160101 23420 20160101 23421 20160101 23422 20160101

Zip Code

Effective Date

Expiration Date

23423 20160101 23426 20160101 23427 20160101 23429 20160101 23440 20160101 23441 20160101 23442 20160101 23443 20160101 23480 20160101 23482 20160101 23483 20160101 23486 20160101 23488 20160101 23821 20160101 23824 20160101 23827 20160101 23828 20160101 23829 20160101 23837 20160101 23839 20160101 23843 20160101 23844 20160101 23845 20160101 23846 20160101 23847 20160101 23851 20160101 23856 20160101 23857 20160101 23866 20160101 23867 20160101 23868 20160101 23870 20160101 23873 20160101 23874 20160101 23876 20160101 23878 20160101 23879 20160101 23881 20160101 23882 20160101 23883 20160101 23884 20160101 23887 20160101 23888 20160101 23889 20160101

Virginia – 3rd Quarter 2016 Rural Zip Codes


Zip Code

Effective Date

Expiration Date

23890 20160101 23891 20160101 23893 20160101 23897 20160101 23899 20160101 23901 20160101 23909 20160101 23915 20160101 23917 20160101 23919 20160101 23920 20160101 23922 20160101 23923 20160101 23924 20160101 23927 20160101 23930 20160101 23934 20160101 23937 20160101 23938 20160101 23941 20160101 23942 20160101 23943 20160101 23944 20160101 23947 20160101 23950 20160101 23952 20160101 23954 20160101 23955 20160101 23958 20160101 23959 20160101 23960 20160101 23962 20160101 23963 20160101 23964 20160101 23966 20160101 23967 20160101 23968 20160101 23970 20160101 23974 20160101 23976 20160101 24053 20160101 24054 20160101 24055 20160101 24069 20160101

Zip Code

Effective Date

Expiration Date

24076 20160101 24078 20160101 24082 20160101 24089 20160101 24112 20160101 24113 20160101 24114 20160101 24115 20160101 24120 20160101 24133 20160101 24139 20160101 24148 20160101 24161 20160101 24165 20160101 24168 20160101 24171 20160101 24177 20160101 24185 20160101 24215 20160101 24216 20160101 24217 20160101 24218 20160101 24219 20160101 24220 20160101 24224 20160101 24225 20160101 24226 20160101 24228 20160101 24230 20160101 24237 20160101 24239 20160101 24243 20160101 24246 20160101 24248 20160101 24256 20160101 24260 20160101 24263 20160101 24265 20160101 24266 20160101 24269 20160101 24272 20160101 24273 20160101 24277 20160101 24279 20160101

Zip Code

Effective Date

Expiration Date

24280 20160101 24281 20160101 24282 20160101 24283 20160101 24292 20160101 24293 20160101 24311 20160101 24312 20160101 24313 20160101 24314 20160101 24315 20160101 24316 20160101 24317 20160101 24318 20160101 24319 20160101 24322 20160101 24323 20160101 24325 20160101 24326 20160101 24328 20160101 24330 20160101 24333 20160101 24343 20160101 24348 20160101 24350 20160101 24351 20160101 24352 20160101 24354 20160101 24360 20160101 24363 20160101 24366 20160101 24368 20160101 24370 20160101 24374 20160101 24375 20160101 24377 20160101 24378 20160101 24381 20160101 24382 20160101 24412 20160101 24413 20160101 24415 20160101 24416 20160101 24422 20160101

Zip Code

Effective Date

Expiration Date

24426 20160101 24433 20160101 24435 20160101 24439 20160101 24442 20160101 24445 20160101 24448 20160101 24450 20160101 24457 20160101 24458 20160101 24460 20160101 24465 20160101 24468 20160101 24472 20160101 24473 20160101 24474 20160101 24483 20160101 24484 20160101 24487 20160101 24520 20160101 24527 20160101 24529 20160101 24530 20160101 24531 20160101 24534 20160101 24535 20160101 24539 20160101 24540 20160101 24541 20160101 24543 20160101 24549 20160101 24555 20160101 24557 20160101 24558 20160101 24563 20160101 24565 20160101 24566 20160101 24569 20160101 24577 20160101 24578 20160101 24579 20160101 24580 20160101 24586 20160101 24589 20160101

Zip Code

Effective Date

Expiration Date

24592 20160101 24594 20160101 24597 20160101 24598 20160101 24601 20160101 24602 20160101 24603 20160101 24604 20160101 24605 20160101 24606 20160101 24607 20160101 24608 20160101 24609 20160101 24612 20160101 24613 20160101 24614 20160101 24619 20160101 24620 20160101 24622 20160101 24624 20160101 24627 20160101 24628 20160101 24630 20160101 24631 20160101 24634 20160101 24635 20160101 24637 20160101 24639 20160101 24640 20160101 24641 20160101 24646 20160101 24647 20160101 24649 20160101 24651 20160101 24656 20160101 24657 20160101 24658 20160101

West Virginia – 3rd Quarter 2016 Rural Zip Codes


Zip Code

Effective Date

Expiration Date

24701 20160101 24712 20160101 24714 20160101 24715 20160101 24716 20160101 24719 20160101 24724 20160101 24726 20160101 24729 20160101 24731 20160101 24732 20160101 24733 20160101 24736 20160101 24737 20160101 24738 20160101 24739 20160101 24740 20160101 24747 20160101 24751 20160101 24801 20160101 24808 20160101 24811 20160101 24813 20160101 24815 20160101 24816 20160101 24817 20160101 24818 20160101 24822 20160101 24823 20160101 24826 20160101 24827 20160101 24828 20160101 24829 20160101 24830 20160101 24831 20160101 24834 20160101 24836 20160101 24839 20160101 24843 20160101 24844 20160101 24845 20160101 24846 20160101 24847 20160101 24848 20160101

Zip Code

Effective Date

Expiration Date

24849 20160101 24850 20160101 24851 20160101 24853 20160101 24854 20160101 24855 20160101 24857 20160101 24859 20160101 24860 20160101 24861 20160101 24862 20160101 24866 20160101 24867 20160101 24868 20160101 24869 20160101 24870 20160101 24871 20160101 24872 20160101 24873 20160101 24874 20160101 24878 20160101 24879 20160101 24880 20160101 24881 20160101 24882 20160101 24884 20160101 24887 20160101 24888 20160101 24892 20160101 24894 20160101 24895 20160101 24898 20160101 24901 20160101 24902 20160101 24910 20160101 24915 20160101 24916 20160101 24918 20160101 24920 20160101 24924 20160101 24925 20160101 24927 20160101 24931 20160101 24934 20160101

Zip Code

Effective Date

Expiration Date

24935 20160101 24938 20160101 24941 20160101 24943 20160101 24944 20160101 24945 20160101 24946 20160101 24951 20160101 24954 20160101 24957 20160101 24962 20160101 24963 20160101 24966 20160101 24970 20160101 24974 20160101 24976 20160101 24977 20160101 24981 20160101 24983 20160101 24984 20160101 24985 20160101 24986 20160101 24991 20160101 24993 20160101 25005 20160101 25011 20160101 20160630 25022 20160101 25033 20160101 20160630 25059 20160101 25070 20160101 20160630 25076 20160101 25082 20160101 20160630 25106 20160101 25109 20160101 20160630 25121 20160101 25123 20160101 25124 20160101 20160630 25159 20160101 20160630 25168 20160101 20160630 25183 20160101 25187 20160101 25213 20160101 20160630 25231 20160101 25234 20160101

Zip Code

Effective Date

Expiration Date

25235 20160101 25239 20160101 25241 20160101 25243 20160101 25244 20160101 25245 20160101 25247 20160101 25248 20160101 25251 20160101 25252 20160101 25253 20160101 25259 20160101 25260 20160101 25261 20160101 25262 20160101 25264 20160101 25265 20160101 25266 20160101 25267 20160101 25268 20160101 25270 20160101 25271 20160101 25275 20160101 25276 20160101 25286 20160101 25287 20160101 25410 20160701 25411 20160101 25414 20160701 25422 20160101 25423 20160701 25425 20160701 25430 20160701 25432 20160701 25438 20160701 25441 20160701 25442 20160701 25443 20160701 25446 20160701 25501 20160101 20160630 25502 20160101 25503 20160101 25505 20160101 25506 20160101 20160630

Zip Code

Effective Date

Expiration Date

25508 20160101 25515 20160101 25520 20160101 20160630 25521 20160101 20160630 25523 20160101 20160630 25524 20160101 20160630 25526 20160101 20160630 25540 20160101 20160630 25544 20160101 20160630 25547 20160101 25550 20160101 25557 20160101 20160630 25560 20160101 20160630 25564 20160101 20160630 25567 20160101 20160630 25569 20160101 20160630 25571 20160101 20160630 25572 20160101 20160630 25573 20160101 20160630 25601 20160101 25606 20160101 25607 20160101 25608 20160101 25611 20160101 25612 20160101 25614 20160101 25617 20160101 25621 20160101 25624 20160101 25625 20160101 25628 20160101 25630 20160101 25632 20160101 25634 20160101 25635 20160101 25637 20160101 25638 20160101 25639 20160101 25644 20160101 25646 20160101 25647 20160101 25649 20160101 25650 20160101 25651 20160101



Zip Code

Effective Date

Expiration Date

25652 20160101 25653 20160101 25654 20160101 25661 20160101 25665 20160101 25666 20160101 25667 20160101 25670 20160101 25671 20160101 25672 20160101 25674 20160101 20160630 25676 20160101 25678 20160101 25685 20160101 25686 20160101 25688 20160101 25690 20160101 25691 20160101 25692 20160101 25696 20160101 25810 20160101 25811 20160101 25820 20160101 25826 20160101 25841 20160101 25845 20160101 25848 20160101 25870 20160101 25875 20160101 25876 20160101 25882 20160101 25913 20160101 25916 20160101 25922 20160101 25928 20160101 25943 20160101 25951 20160101 25958 20160101 25962 20160101 25966 20160101 25969 20160101 25971 20160101 25972 20160101 25977 20160101

Zip Code

Effective Date

Expiration Date

25978 20160101 25979 20160101 25981 20160101 25984 20160101 25985 20160101 26134 20160101 26136 20160101 26137 20160101 26141 20160101 26146 20160101 26147 20160101 26148 20160101 26149 20160101 26151 20160101 26152 20160101 26155 20160101 26159 20160101 26161 20160101 26162 20160101 26164 20160101 26167 20160101 26170 20160101 26175 20160101 26178 20160101 26201 20160101 26202 20160101 26203 20160101 26205 20160101 26206 20160101 26208 20160101 26209 20160101 26210 20160101 26215 20160101 26217 20160101 26218 20160101 26219 20160101 26222 20160101 26224 20160101 26228 20160101 26229 20160101 26230 20160101 26234 20160101 26236 20160101 26237 20160101

Zip Code

Effective Date

Expiration Date

26238 20160101 26241 20160101 26250 20160101 26253 20160101 26254 20160101 26257 20160101 26259 20160101 26260 20160101 26261 20160101 26263 20160101 26264 20160101 26266 20160101 26267 20160101 26268 20160101 26269 20160101 26270 20160101 26271 20160101 26273 20160101 26275 20160101 26276 20160101 26278 20160101 26280 20160101 26282 20160101 26283 20160101 26285 20160101 26287 20160101 26288 20160101 26289 20160101 26291 20160101 26292 20160101 26293 20160101 26294 20160101 26296 20160101 26298 20160101 26301 20160101 26302 20160101 26306 20160101 26320 20160101 26321 20160101 26323 20160101 26325 20160101 26327 20160101 26330 20160101 26335 20160101

Zip Code

Effective Date

Expiration Date

26337 20160101 26338 20160101 26339 20160101 26342 20160101 26343 20160101 26346 20160101 26347 20160101 26348 20160101 26349 20160101 26351 20160101 26354 20160101 26361 20160101 26362 20160101 26366 20160101 26369 20160101 26372 20160101 26376 20160101 26377 20160101 26378 20160101 26384 20160101 26385 20160101 26386 20160101 26404 20160101 26405 20160101 26408 20160101 26411 20160101 26412 20160101 26415 20160101 26416 20160101 26419 20160101 26421 20160101 26422 20160101 26424 20160101 26426 20160101 26430 20160101 26431 20160101 26434 20160101 26435 20160101 26436 20160101 26437 20160101 26438 20160101 26440 20160101 26443 20160101 26447 20160101

Zip Code

Effective Date

Expiration Date

26448 20160101 26451 20160101 26452 20160101 26456 20160101 26463 20160101 26554 20160101 26555 20160101 26559 20160101 26560 20160101 26561 20160101 26562 20160101 26563 20160101 26566 20160101 26568 20160101 26571 20160101 26572 20160101 26574 20160101 26575 20160101 26576 20160101 26578 20160101 26581 20160101 26582 20160101 26585 20160101 26586 20160101 26587 20160101 26588 20160101 26591 20160101 26601 20160101 26610 20160101 26611 20160101 26615 20160101 26619 20160101 26621 20160101 26623 20160101 26624 20160101 26627 20160101 26629 20160101 26631 20160101 26636 20160101 26638 20160101 26651 20160101 26656 20160101 26660 20160101 26662 20160101



Zip Code

Effective Date

Expiration Date

26667 20160101 26671 20160101 26675 20160101 26676 20160101 26678 20160101 26679 20160101 26681 20160101 26684 20160101 26690 20160101 26691 20160101 26707 20160101 26720 20160101 26731 20160101 26739 20160101 26801 20160101 26802 20160101 26804 20160101 26807 20160101 26810 20160101 26812 20160101 26814 20160101 26815 20160101 26818 20160101 26833 20160101 26836 20160101 26838 20160101 26845 20160101 26847 20160101 26851 20160101 26855 20160101 26866 20160101 26884 20160101 26886 20160101

2016 dmepos/pen fee schedule - 3rd quarter (revised) · 2017-11-28 · revised third quarter 2016...

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