MEDICAL FEE SCHEDULE MAINE WORKERS ......90-351 Chapter 5 page 5 treatment of conditions that are unrelated to the compensable injury or disease. See 39-A M.R.S. 206 (13). NOTE: Health

MEDICAL FEE SCHEDULE

MAINE WORKERS' COMPENSATION BOARD

90-351

CHAPTER 5

BOARD RULES

WITH APPENDICES I - V

MAINE WORKERS' COMPENSATION BOARD

OFFICE OF MEDICAL/REHABILITATION SERVICES 27 STATE HOUSE STATION

AUGUSTA, MAINE 04333-0027

EFFECTIVE FOR INPATIENT FACILITY FEE BILLS WITH DATES OF DISCHARGE FROM OCTOBER 1, 2014 THROUGH SEPTEMBER 30, 2015.

EFFECTIVE FOR PROFESSIONAL FEE AND OUTPATIENT FACILITY FEE BILLS FOR DATES OF SERVICE

FROM JANUARY 1, 2015 THROUGH DECEMBER 31, 2015.

90-351 Chapter 5 page 2

90-351 WORKERS’ COMPENSATION BOARD Chapter 5: MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING

REQUIREMENTS SUMMARY: This Chapter outlines billing procedures and reimbursement levels for health care providers who treat injured employees. It also describes the dispute resolution process when there is a dispute regarding reimbursement and/or appropriateness of care. Finally, this Chapter sets standards for health care reporting. SECTION 1. GENERAL PROVISIONS

1.01 DATE OF INJURY

This Chapter is promulgated pursuant to 39-A M.R.S. §§ 208 and 209. It shall apply to all bills for medical services provided on or after the effective date of this rule, regardless of the employee's date of injury.

1.02 PAYMENT UNDER PILOT PROJECTS

Payment of medical costs for a work related injury made pursuant to a comprehensive health insurance policy created pursuant to 39-A M.R.S. §403(2) shall be considered a payment under a decision pursuant to a petition for purposes of 39-A M.R.S. §306.

1.03 DEFINITIONS

1. “Acute care hospital”: A health care facility as defined in 22 M.R.S. §7932(2-A).An acute care hospital must be licensed by the Department of Health and Human Services pursuant to 10-144 COMAR Chapter 112.

2. “Ambulatory Payment Classification System (APC)”:Medicare’s grouping methodology for determining payment for outpatient services. Medicare assigns CPT®/HCPCS codes (defined in §1.04(17) of this rule)to an APC group which is then given a relative weight.

3. “Ambulatory Surgical Center (ASC)”:A health care facility as defined in 22 M.R.S. §7932(9).An ASC must be licensed by the Department of Health and Human Services pursuant to 10-144 COMAR Chapter 125.

4. “Bill”: A request by a health care provider that is submitted to an employer/insurer for payment of services provided in relationship to a compensable injury or illness.

5. “Board”: The Maine Workers' Compensation Board pursuant to 39-A M.R.S. §151.

6. “By Report (BR)”: When a procedure has not been assigned a maximum allowable payment amount, designated by a “BR,” it shall be justified by a written report.

7. “Critical Access Hospital”: A health care facility as defined in 22 M.R.S. §7932(10). A critical access hospital must be licensed by the Department of Health and Human Services pursuant to 10-144 COMAR Chapter 112, subchapter XXVII.

8. “Follow-up Days (FUD)”: The maximum number of days of care following a surgical procedure that are included in the procedures maximum allowable payment but does not include care for complications, exacerbations, recurrence, or other diseases or injuries.


9. “Health Care Provider/Practitioner”: a person or facility licensed, registered, or certified by the State of Maine and practicing within the scope of the health care provider’s license. This paragraph may not be construed as enlarging the scope and limitations of practice of any health care provider/Practitioner.

10. “Implantable”: An object or device that is made to replace and act as a missing biological structure that is surgically implanted, embedded, inserted, or otherwise applied. The term also includes any related equipment necessary to operate, program, and recharge the implantable.

11. “Incidental Surgery”: A surgery which is performed on the same patient, on the same day, by the same health care provider but is not related to the diagnosis.

12. “Inpatient services”: Services rendered to a person who is formally admitted to a hospital and whose length of stay exceeds 23 hours.

13. “Maximum Allowable Payment (MAP)”: The maximum fee for a procedure listed in Appendices III, IV, or V which has been established by the Maine Workers' Compensation Board or the health care provider's usual and customary charge, whichever is less.

14. “Medicare Severity-Diagnosis Related Group (MS-DRG)”:A system adopted by the Centers for Medicare and Medicaid Services which groups related hospital admissions based on diagnosis codes, surgical procedures and patient demographics.

15. “Modifier”: used to indicate that the service rendered differs in some material respect from the service described in the2005 edition of the CPT®. Applicable modifiers are set forth in Appendix A of the 2005edition of the CPT® manual. The CPT® manual is published by and may be purchased from the American Medical Association, PO Box 930876, Atlanta, GA31193-0876.

16. “Outlier payments”: Outlier payments are payments that are required when facilities incur an abnormal amount of costs while taking care of a patient. There is a threshold in place, which the costs must exceed, in order for the hospital to be eligible to charge for outlier payments.

17. “Outpatient services”: Services provided to a patient who is not admitted for inpatient or residential care.

18. “Procedure Code”: A code adopted by the Centers for Medicare & Medicaid Services that is divided into two principal subsystems, referred to as level I and level II of the Healthcare Common Procedure Coding System (HCPCS).Level I is comprised of Current Procedural Terminology (CPT®-4), a numeric coding system maintained by the American Medical Association. Level II is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT®-4 codes. The CPT® manual is published by and may be purchased from the American Medical Association, PO Box 930876, Atlanta, GA31193-0876.

1.04 REIMBURSEMENT

1. An employer/insurer is not liable under the Workers' Compensation Act for charges for health care services to an injured employee in excess of amounts listed in Appendices III, IV, or V of this chapter.

2. The employer/insurer shall pay the health care provider's usual and customary charge or the maximum allowable payment under this Medical Fee Schedule, whichever is less, within 30 days of receipt of a properly coded bill unless the bill or previous bills from the same


health care provider or the underlying injury has been controverted or denied. If an employer/insurer controverts whether a health care provider’s bill is reasonable and proper under § 206 of the Act, the employer/insurer shall send a copy of the notice of controversy to the health care provider.

3. Payment of a medical bill is not an admission by the employer/insurer as to the reasonableness of subsequent medical bills.

1.05 MEDICAL EXAMINATIONS

Medical examinations not for purposes of treatment are not subject to this Medical Fee Schedule.

1.06 BILLING PROCEDURES

1. Bills submitted by employees, their representatives or health care providers to employers/insurers for reimbursement of medical services must specify the date and type of service, the appropriate procedure code, the condition treated, and the charges for each service.

Bills properly submitted on forms mandated by the Bureau of Insurance pursuant to 24-A M.R.S. §2753 shall be sufficient to comply with this requirement. Uncoded bills may be returned for coding.

2. The amount billed for a procedure, for which the Medical Fee Schedule does not provide a maximum allowable payment amount, as indicated by a “BR,” shall be justified by a written report. The health care provider may not charge a fee for this report.

3. The employer/insurer shall undertake reasonable investigations to ascertain whether a service is subject to the maximum allowable payment contained in the Medical Fee Schedule. When there is a dispute regarding medical bills and the provision of medical services, the employer/insurer shall pay the undisputed amount, if any.

The employer/insurer shall send written notice to the health care provider from whom the bill originated that the requested fee has been adjusted and the explanation for such adjustment. Notice is not required when bills are reduced to the fee schedule maximum allowable payment.

The notification to the health care provider shall be made at the time the employer/insurer pays the fee to which it believes the health care provider is entitled.

4. If the health care provider disputes any payment received or denied, the health care provider, employee or other interested party shall be entitled to file Form 190 or 190(A), Petition to Fix the Amount to be Allowed.

Any health care provider, employee, or other interested party shall be entitled to file Form 190 or Form 190(A) for determination of any issue regarding medical services and/or medical billing.

Forms 190 and 190 (A) may be obtained by contacting the Workers’ Compensation Board, Office of Medical/Rehabilitation Services, 27 State House Station, Augusta, Maine 04333-0027, Tel: 207-287-7080.

Health care providers, employees or other interested parties are permitted to reproduce Forms 190 and 190 (A) in Appendix II for their use.

5. The injured employee is not liable for payment of any health care services for the treatment of a work-related injury or disease. Except as provided by 39-A M.R.S. §206(2) (B), the health care provider may charge the patient directly only for the


treatment of conditions that are unrelated to the compensable injury or disease. See 39-A M.R.S. §206 (13).

NOTE: Health care providers may use the most current procedure codes when billing workers’ compensation claims. If the codes utilized are not included in the current Medical Fee Schedule, the item will be considered a “BR” procedure, one which is not assigned a maximum allowable payment, and must be justified by report.

1.07 FEES FOR REPORTS

1. A health care provider may charge a fee for completing the initial Practitioner's Report (Form M-1) required by the Workers’ Compensation Board pursuant to 39-A M.R.S. §208.

2. The maximum fee for copies shall be $10 for the first page and 35 cents per page thereafter. An itemized invoice shall accompany the copies. The copying charge shall be paid by the party requesting the records.

3. A health care provider or facility shall, at the written request of the employer/insurer or the employee, furnish copies of the health care records for that particular worker's compensation injury or illness within 10 business days from receipt of the request. Supplemental reports shall be identified by using CPT® Code 99080 and appropriately billed on a CMS 1500 form.

4. The maximum fee for preparing a narrative report or the initialM-1 shall be: Each 10 minutes: $30.00

1.08 FEES FOR DEPOSITIONS

1. The maximum fee for preparing to testify at depositions and hearings shall be: First ½ hour: $180.00 Each subsequent 1/4 hour: $90.00

2. Maximum fees for attendance at depositions and hearings for the purposes of giving testimony shall be: First hour or any fraction thereof: $400.00 Each subsequent 1/4 hour: $90.00 (Use Code 99075)

3. "Portal-to-portal" reimbursement is permitted. Fees for "portal-to-portal" travel should be limited to:

A. Actual, reasonable and necessary travel costs. Travel costs must be agreed upon in advance by the employer/insurer.

B. Actual and necessary travel time shall be reimbursed at $300.00 per hour.

These reimbursement levels apply when a deposition is more than ten miles from the health care provider’s home base.

4. Health care providers shall receive a maximum of $350.00 per canceled deposition when the cancellation occurs less than 24 hours prior to the scheduled start of the deposition. Health care providers shall receive a maximum of $300 per canceled deposition when the cancellation takes place less than 48 but more than 24 hours prior to the scheduled start of the deposition. The party canceling the deposition is responsible for the incurred cost.


1.09 EXPENSES

1. The employer/insurer must pay the employee’s travel-related expenses incurred for treatment related to the claimed injury as follows:

A. $.44 per mile for mileage reimbursements.

B. Actual costs or a maximum of $120.00 per evening for overnight lodging. Reimbursement for overnight lodging is allowed only when the employee has traveled 100 miles or more, one way, from the employee's place of residence.

C. $6.00 for breakfast, $6.00 for lunch, and $16.00 for dinner. Reimbursement for meals is allowed only when the employee has traveled 50 miles or more, one way, from the employee’s place of residence.

D. Actual charges for tolls, accompanied by a receipt.

1.10 HEALTH CARE REPORTING OF PROVIDERS PURSUANT TO TITLE 39-A M.R.S. §208

1. Except for medical only claims, the primary health care provider shall submit medical reports for the initial service/visit to the employer/insurer and employee on the Practitioner's Report (Form M-1) within five days pursuant to 39-A M.R.S. §208(2)(A). Failure to submit the Practitioner’s Report (Form M-1) within the five business day time line may result in assessment of penalties up to $500.00 per violation.

2. The primary health care provider shall submit updated medical reports to the employer/insurer and the employee on the Practitioner’s Report (Form M-1) every 30 days as long as the health care provider has evaluated/treated the patient within the previous 30 days.

3. Within five business days from the termination of treatment, a final medical report shall be submitted by the primary health care provider to the employer/insurer and employee on the Practitioner’s Report (Form M-1).

4. If the treating health care provider refuses to release information, the health care provider shall notify the employer/insurer of the reasons for withholding this information.

5. Health care providers are permitted to reproduce the Practitioner’s Report (Form M-1 in Appendix I) for their use.

1.11 PERMANENT IMPAIRMENT RATINGS

1. Permanent impairment shall be determined by the use of the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, copyright 1993.

2. Permanent Impairment examinations performed by the employee’s treating health care provider will have a maximum charge of $450.00.

SECTION 2. PROFESSIONAL SERVICES

2.01 PAYMENT FOR PROFESSIONAL SERVICES

Payments for professional services are based on the Medicare Resource Based Relative Value System. Payments are calculated for procedure codes by multiplying the applicable conversion factor times the Work relative value unit plus the PE relative value unit plus the MP relative value unit. The conversion factor for anesthesia codes is $50.00.

2.02 PROCEDURE CODES

1. For purposes of this section, health care services shall be identified by current procedural terminology codes (CPT® codes) and descriptions listed in the 2005edition of the Current Procedural Terminology published by the American Medical Association, P.O. Box 10946, Chicago, Illinois.

2. The Maine Workers' Compensation Medical Fee Schedule includes data that is proprietary to the American Medical Association, therefore, certain restrictions apply. These restrictions are established by the AMA and are set out below:

A. The five character codes included in the Maine Workers' Compensation Medical Fee Schedule are obtained from the 2005Current Procedural Terminology, Copyright 2004by the American Medical Association (CPT®). CPT® is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians.

B. The responsibility for the content of the Maine Workers' Compensation Medical Fee Schedule is with the State of Maine Workers’ Compensation Board and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in the Maine Workers' Compensation Medical Fee Schedule. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT®. Any use of CPT® outside of the Maine Workers' Compensation Medical Fee Schedule should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT® codes and descriptive terms. Applicable FARS/DFARS apply.

3. The 2005Current Procedural Terminology, Copyright 2004by the American Medical Association (CPT®) is adopted herein by reference.

2.03 MODIFIERS

1. Modifier codes shall be used in the manner set forth in Appendix A of the 2005 edition of the Physicians' Current Procedural Terminology published by the American Medical Association, P.O. Box 10946, Chicago, Illinois.

2. Applicable modifier codes are set forth in Appendix A of the 2005edition of the Physicians' Current Procedural Terminology published by the American Medical Association, P.O. Box 10946, Chicago, Illinois.


2.04 ANESTHESIA GUIDELINES

1. The anesthesia guidelines in the 2005edition of the Physicians' Current Procedural Terminology published by the American Medical Association, P.O. Box 10946, Chicago, Illinois are incorporated by reference into this rule.

2. To be eligible for reimbursement, the anesthesia service shall include: performance of a pre-anesthetic examination and evaluation; prescription of the anesthesia care required; personal participation in, or medical direction of, the entire plan of care; continuous physical presence of the anesthesiologist or, in the case of medical direction, of the qualified individual (one who is qualified to perform those tasks not personally performed by the anesthesiologist, such as a CRNA, resident or other individual authorized by the hospital or facility to perform such services) being medically directed; proximate presence or (in the case of medical direction) availability of the anesthesiologist for diagnosis or treatment of emergencies and medical direction of not more than four concurrent anesthesia procedures.

3. Reimbursement will be determined by the addition of the base unit, time units and modifying units (if any) and multiplying this total value by a conversion factor of $50.00per unit. The definition of the unit components will follow.

4. With respect to anesthesia care team payments for claims from two separate billing entities, the total payment to the anesthesia care team is the same as the payment level for an individually performing anesthesiologist or health care provider, with 50% of the total payment paid to each of the billing entities.

5. Definition of the Unit Components

A. One time unit is allowed for each 15 minute time interval, or fraction thereof (7.5 minutes or more) of anesthesia time. If anesthesia time extends beyond three hours, 1.0 unit for each 10 minutes or significant faction thereof (5 minutes or more) is allowed after the first three hours. Documentation of actual anesthesia time may be required, such as a copy of the anesthesia record in the hospital file.

B. Modifying Units: Physical status modifying units will be reimbursed if the patient is ranked in one of the following:

RANK VALUE UNIT

P-1 - 0 P-2 - 0 P-3 - 1 P-4 - 2 P-5 - 3

P-6 - 0

Qualifying Circumstances (more than one may be selected): Many anesthesia services are provided under particularly difficult circumstances depending on factors such as the extraordinary condition of the patient, notable operative conditions, and unusual risk factors. This section includes a list of important qualifying circumstances that significantly impact on the character of the anesthetic service provided. These procedures would not be reported alone, but would be reported as additional procedure numbers qualifying as an anesthesia procedure or service.


CPT® VALUE UNIT 99100 - 1 99116 - 5 99135 - 5 99140 - 2

6. Reimbursement for Pain Management Services: Reimbursement for pain management services (evaluation and management, medical or surgical services) will be separate from any reimbursement for anesthesia services. Reimbursement for services for pain management will be based on the appropriate evaluation and management, medical or surgical fee schedule.

7. Cost Containment: Nothing in this section shall preclude an employer/insurer from entering into payment agreements to promote the continuity of care and the reduction of health care costs. Such payment agreements, if less, will supersede the limitation amounts specified herein.

8. Supplemental Skills: When warranted by the necessity of supplemental skills, values for

the services of two or more health care providers and/or anesthetists will be allowed. Substantiate by report.

9. Monitoring Services: When an anesthesiologist or anesthetist is required to participate in

and be responsible for monitoring the general care of the patient during a surgical procedure but does not administer anesthesia, these services are charged on the basis of the extent of the services rendered. Payment is to be made on the basis of the time units the anesthesiologist or anesthetist is in constant attendance for the sole purpose of the monitoring services; Relative Unit Values are not to be added.

10. Anesthesia Administered, Other Than By An Anesthesiologist or Anesthetist:

Anesthesia fees are not payable when local infiltration, digital block, or topical anesthesia is administered by the operating surgeon or surgical assistants. Such services are included in the Unit Value for the surgical procedure.

11. Other Fees: The Unit Values for surgery, X-rays, laboratory procedures, consultation and

other medical services, and office and hospital visits are listed in the following sections: Surgery, Radiology, Pathology, Medicine and Other. A consultation fee is not payable to an anesthesiologist examining the patient prior to administering anesthesia to that patient. No additional charge is to be made for routine follow-up care and observation.

12. Special Report: A service that is rarely provided, unusual, variable, or new may require

a special report in determining medical appropriateness of the service. Pertinent information should include an adequate definition of description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service. Additional items which may be included are:

• Complexity of symptoms • Final diagnosis • Pertinent physical findings (such as size, locations, and number of

lesion(s), if appropriate)


• Diagnostic and therapeutic procedures (including major and supplementary surgical procedures, if appropriate)

• Concurrent problems • Follow-up care

13. Calculation Examples A. In a procedure with a Relative Value Unit of 3.0 requiring one hour of anesthesia

time, the total value should be determined as follows:

Base Unit 3.0 units 60 min divided by 15 min + 4.0 units Total value = 7.0 units

B. In a procedure with a Relative Value Unit of 10.0 requiring four hours and thirty minutes of anesthesia time, the total value should be determined as follows:

Relative Value Unit 10.0 units First three hours + 12.0 units Subsequent 90 minutes + 9.0 units

Total value = 31.0 units C. In both cases, the maximum allowable payment is determined by multiplying the

total value units by the conversion factor. In billing, list the Relative Value Unit (showing the procedure code and all modifiers) and Time Units separately, as in the following:

Procedure Code + Modifier(s) = Base Unit Anesthesia Time =Time Units Total Value =Total Units Total units X Conversion Factor = Maximum Allowable Fee

CONVERSION FACTOR = $50.00

2.05 SURGICAL GUIDELINES

1. The surgical guidelines in the 2005edition of the Physicians' Current Procedural Terminology published by the American Medical Association, P.O. Box 10946, Chicago, Illinois are incorporated by reference into this rule.

2. For surgical procedures that usually mandate a variety of attendant services, the

reimbursement allowances are based on a global reimbursement concept. Global reimbursement covers the performance of the basic service and the normal range of care required before and after surgery. The normal range of post-surgical care is indicated under “FUD” in Appendix III. A surgical procedure shall include all of the following:

A. All office and hospital visits which occur after the need for surgery is determined and are related to or preparatory to the surgery.

B. Surgery.


C. Post surgical care. The number of follow-up days is indicated in the Medical Fee Schedule which will determine the normal range of post surgical care for that particular procedure.

D. Removal of sutures.

3. An office visit shall not be billed in addition to the surgical procedure when the principal

function of the office visit is the determination that the surgical procedure is needed.

4. The following four exceptions to the global reimbursement policy may warrant additional reimbursement for services provided before surgery:

A. When a pre-operative visit is the initial visit and prolonged detention or evaluation is necessary to prepare the patient or to establish the need for a particular type of surgery.

B. When the pre-operative visit is a Consultation.

C. When pre-operative services are provided that are usually not part of the preparation for a particular surgical procedure. For example, bronchoscopy prior to chest surgery.

D. When a procedure would normally be performed in the office, but circumstances mandate hospitalization.

5. Additional charges and reimbursement may be warranted for additional services rendered to treat complications, exacerbation, recurrence, or other diseases and injuries. Under such circumstances, additional reimbursement may be requested. Documentation substantiating the medical necessity of the additional services rendered must be submitted with the medical bill.

6. An incidental surgery which is not part of the primary procedure performed and for

which there is no diagnostic evidence relating it to the injury, shall not be paid under the Workers' Compensation system.

7. Reimbursement for the concurrent services of two or more health care providers may be

warranted for:

A. Identifiable medical services provided preoperatively, during the surgical procedure or in the post-operative period.

B. Modifier -80 shall identify the procedure or the procedures which may be performed by the Surgical Assistant. Reimbursement for surgical assistants is limited to health care providers who assist with surgery and must not exceed 25% of the total surgical procedure.

C. Two Surgeons

(1) Under certain circumstances, the skills of two surgeons (usually with different specialties) may be required to complete a surgery. For example, a neurosurgeon and an orthopedist to complete a laminectomy and an arthrodesis.

(2) Reimbursement will be made according to the information on the health care provider's medical bill and the substantiating documentation submitted. Each provider must submit an individual claim for services.


D. A Surgical Team. Some highly complex procedures require the concomitant services of several physicians, often of different specialties. Such complex services may also involve other highly skilled and specially trained personnel, as well as various types of sophisticated equipment. This type of complicated procedure may be carried out under the "surgical team" concept with a single, global reimbursement for the total service. The services included in the global reimbursement vary widely. The charges should be supported "By Report" and include itemization of the physician services, paramedical personnel and equipment included in the charge.

8. Multiple or Bilateral Procedures

A. When multiple or bilateral procedures are provided at the same operative session, the first major procedure should be coded as listed on one line of the HCFA 1500 claim form and the additional procedure(s) on the following line(s) with modifier -50 or -51.

B. The total reimbursement for all services shall be the maximum reimbursement allowance of the major procedure in addition to 50% for the secondary procedure, 25% for the tertiary procedure and 10% for each lesser procedure thereafter. The lesser procedure(s) should be coded using the appropriate modifier -50 (bilateral procedure) or -51 (multiple procedures).

C. Except when specifically stated, initial dressings, immobilization, or casting is included in the basic allowance for the basic procedure.

9. Primary, Secondary, or Delayed procedures: A primary procedure is one that is

attempted or performed for the first time, irrespective of the relationship to the date of injury or the onset of the condition being treated. Secondary refers to a procedure performed when a condition has been previously treated. Delayed procedures have the same maximum allowable fee as the primary procedure.

2.06 RADIOLOGY GUIDELINES

1. The radiology guidelines in the 2005edition of the Physicians' Current Procedural Terminology published by the American Medical Association, P.O. Box 10946, Chicago, Illinois are incorporated by reference into this rule.

2. The maximum allowable payment for a radiology procedure includes the professional component identified by the modifier -26 and the technical component identified by the modifier -TC. These are found in Appendix III under Radiology.

3. Bills from one entity do not need to indicate the breakdown of the technical and professional components. These charges shall be reimbursed as indicated by the total maximum allowable payment in radiology.

4. When two bills are submitted for radiological procedure, the professional component shall be identified by using modifier -26. The technical component, identified by modifier -TC, covers materials and facilities/space for the diagnostic or therapeutic service.

5. Billings for radiologic services are not reimbursable without a report of findings.

6. Duplication of X-Rays: Every attempt should be made to minimize the number of X-Rays taken. The treating health care provider or any other person or institution having


possession of X-rays, which pertain to the patient and are deemed to be needed for diagnostic or treatment purposes, should make those X-rays available upon request.

2.07 PHYSICAL MEDICINE GUIDELINES

1. The physical medicine guidelines in the 2005edition of the Physicians' Current Procedural Terminology published by the American Medical Association, P.O. Box 10946, Chicago, Illinois are incorporated by reference into this rule.

2. Reimbursement of physical medicine services, procedure code 97010-97999, applies when the care is provided by, under the direct supervision of or upon written referral by the treating health care provider defined in section 1.04(9)of this rule and when the care provided is within the scope of the health care provider’s license.

3. The license number, certificate number, or National Provider Identifier of the health care provider providing physical medicine services shall be included on each bill for services rendered.

4. Separate Procedures: Some listed procedures are commonly carried out as an integral part of a total service and do not warrant a separate identification. When such a procedure is performed independently of other services to which the procedure is not immediately related, the maximum allowable payment in the Medical Fee Schedule is applicable for the "separate procedure" where identified as such.

5. Concurrent Care: When the condition of the patient requires the skills of two or more health care providers to treat different conditions, payment is due each health care provider who plays an active role in the treatment program. The services rendered by each provider shall be distinct, identifiable and adequately documented in the records and reports.

6. Alternating Health Care Providers: When health care providers of similar skills alternate in the care of a patient (e.g., partners of the same facility, covering health care providers on weekends or vacation periods), each health care provider shall charge individually for the services personally rendered and such charges shall be in accordance with the Medical Fee Schedule.

7. Failure of a Patient to Keep a Scheduled Appointment: In the event a patient fails to keep a scheduled appointment, the health care provider is not to bill for any services that would have been provided by said appointment nor shall there be any reimbursement for such scheduled services. This rule does not apply with regard to a deposition, testimony or Section 312 IME.

2.08 DURABLE MEDICAL EQUIPMENT AND SUPPLIES

1. The employer/insurer shall pay for the purchase or rental of all compensable durable medical equipment, medical supplies and other devices that are ordered and approved by the treating health care provider. Reimbursement is set at the actual amount paid plus 20% or $500.00, whichever is less.

2. Durable medical equipment is equipment that:

a. can withstand repeated use; b. is primarily and customarily used to serve a medical purpose; c. generally is not useful to a person in the absence of illness or injury; and d. is appropriate for use in the home.


3. All requirements of the definition must be met before an item is considered to be durable medical equipment.

4. Medical supplies of an expendable nature such as incontinent pads, lambs wool pads, catheters, ace bandages, elastic stockings, surgical face masks, irrigating kits, sheets and bags are not considered “durable” within the meaning of the definition. There are other items which, although durable in nature, may fall into other coverage categories such as braces, prosthetic devices, artificial arms, legs and eyes.

5. Health care providers shall submit a substantiating invoice for any durable medical equipment, medical supply or device with a price greater than $100.00 or upon the request of the employer/insurer.


SECTION 3. INPATIENT FACILITY FEES

3.01 BILLING

Bills for inpatient services must be submitted on a CMS Uniform Billing (UB-04) form.

3.02 CRITICAL ACCESS HOSPITALS

Payments for inpatient services in a critical access hospital are based on the MS-DRG system. The payment is calculated by multiplying the base rate times the MS-DRG weight. The base rate for inpatient services at critical access hospitals is $10,907.00.

3.03 ACUTE CARE HOSPITALS

Payments for inpatient services in an acute care hospital are based on the MS-DRG system. The payment is calculated by multiplying the base rate times the MS-DRG weight. The base rate for inpatient services at acute care hospitals is $8,923.00.

3.04 MAXIMUM REIMBURSEMENT

Except as provided in subsections 3.05 and 3.06, acute care hospitals shall be paid the maximum allowable payment established in Appendix IV or its usual and customary charge, whichever is less, for inpatient services.

3.05 OUTLIER PAYMENTS

The threshold for outlier payments is $75,000.00 plus the maximum allowable payment established in Appendix IV. If the outlier threshold is met, the outlier payment must be the maximum allowable payment plus the charges above the sum of the threshold and the maximum allowable payment multiplied by 75%.The total payment for the services is the outlier payment plus the maximum allowable payment.

3.06 IMPLANTABLES

Where an implantable exceeds $10,000 in cost, acute care hospitals may seek additional reimbursement beyond the maximum allowable charge. Reimbursement is set at the actual amount paid plus 20%or $500.00, whichever is less. When an acute care hospital seeks additional reimbursement pursuant to this rule, the implantable charge is excluded from any calculation for an outlier payment. Handling and freight charges must be included in the acute care hospital's invoiced cost and are not to be reimbursed separately.

3.07 SERVICES INCLUDED

All services provided during an uninterrupted patient encounter leading to an inpatient admittance must be included in the inpatient stay.


3.08 FACILITY TRANSFERS

The following applies to facility transfers when a patient is transferred for continuation of medical treatment between two acute care hospitals:

1. A hospital transferring a patient is paid as follows: The MS-DRG reimbursement amount is divided by the number of days duration listed for the DRG; the resultant per diem amount is then multiplied by two for the first day of stay at the transferring hospital; the per diem amount is multiplied by one for each subsequent day of stay at the transferring hospital; and the amounts for each day of stay at the transferring hospital are totaled. If the result is greater than the MS-DRG reimbursement amount, the transferring hospital is paid the MS-DRG reimbursement amount. Associated outliers and add-ons are then added to the payment.

2. A hospital discharging a patient is paid the full MS-DRG payment plus any appropriate outliers and add-ons.

3. Facility transfers do not include costs related to transportation of a patient to obtain medical care.

3.09 PAYMENT FOR SERVICES WITHOUT A MAXIMUM CHARGE

Services provided by an acute care hospital that do not have a maximum charge in Appendix IV shall be paid at 75% of the hospital’s usual and customary charge.

3.10 OTHER INPATIENT FACILITY FEES

Services provided at specialty hospitals shall be reimbursed using the 2007 Medicare pricer tool for the appropriate specialty hospital found at www.cms.gov/PCPricer/. The maximum reimbursement shall be the Grand Total Amount multiplied by 170%.Payment shall be made within 30 days after the specialty hospital provides the required medical and billing information.

3.11 PROFESSIONAL SERVICES NOT INCLUDED

Individual health care providers who furnish professional services in an inpatient setting must bill employers/insurers directly and must be reimbursed using the maximum fees set forth in Appendix III. The individual health care provider’s charges are excluded from any calculation of outlier payments.


SECTION 4. OUTPATIENT AND AMBULATORY SURGICAL CENTERS

4.01 BILLING

Bills for outpatient and ASC services must be submitted on a CMS Uniform Billing (UB-04) form.

4.02 BASE RATE FOR ACUTE CARE HOSPITALS

The base rate for outpatient services at acute care hospitals is $108.42.

4.03 BASE RATE FOR CRITICAL ACCESS HOSPITALS

The base rate for outpatient services at critical access hospitals is $132.53.

4.04 BASE RATE FOR AMBULATORY SURGICAL CENTERS

The base rate for outpatient services at ambulatory surgical centers is $81.32.

4.05 OBSERVATION INCLUDED

Outpatient services include observation in an outpatient status.

4.06 MAXIMUM REIMBURSEMENT

Except as provided in subsections 4.07 and 4.08, acute care hospitals and ambulatory surgical centers shall be paid the maximum allowable payment established in Appendix V or its usual and customary charge, whichever is less, for outpatient services.

4.07 PAYMENT CALCULATION

Payments for outpatient services in an outpatient hospital or an ambulatory surgical center are based on the APC system. The payment must be calculated by multiplying the base rate times the APC weight.

1. If the ACH Rate, CAH Rate or ASC Rate is listed as$0.00 or null for a procedure code with status indicator of A, B, C, D, E, F, K, L, M, Q, S, T, V, X, Y then reimbursement must be paid at 75% of usual and customary charges. For procedure codes with a status indicator of N or services with no CPT®/HCPCS code, there is no separate payment.

2. When two or more services with a status indicator of T are billed on the same date of service, the highest weighted code is paid at 100% of the APC payment and subsequent T status code items are paid at 50% of the APC payment.

3. Procedure codes with a “Q” status indicator will not be discounted.


4.08 OUTLIERS

The threshold for outlier payments is $2,500.00 per procedure code plus the maximum allowable charge as defined in paragraph 4.06.If the outlier threshold is met, the outlier payment must be the maximum allowable charge as defined in paragraph 4.06, plus the charges above the threshold multiplied by 75%.

4.09 IMPLANTABLES

Where an implantable exceeds $250.00 in cost, hospitals or ambulatory surgical centers may seek additional reimbursement. Reimbursement is set at the actual amount paid plus 20%or $500.00, whichever is less. When an ambulatory surgical center or hospital seeks additional reimbursement pursuant to this rule, the implantable charge is excluded from any calculation for an outlier payment. Handling and freight charges must be included in the facility's invoiced cost and are not to be reimbursed separately.

4.10 TRANSFERS

The following applies to patient transfers from an acute care hospital or ambulatory surgical center to an acute care hospital:

1. An acute care hospital or ambulatory surgical center transferring a patient is paid the maximum allowable charge established in this section.

2. The acute care hospital to which the patient is transferred is paid the maximum allowable charge established in section 3.

3. Facility transfers do not include costs related to transportation of a patient to obtain medical care.

4.11 PROFESSIONAL SERVICES NOT INCLUDED

Individual health care providers who furnish professional services in a hospital, ASC, or other facility setting must bill insurers directly and must be reimbursed using the maximum fees set forth in Appendix III. The individual medical provider’s charges are excluded from any calculation of outlier payments.

STATUTORY AUTHORITY: 39-A M.R.S.A. §§ 152(2) and 209 EFFECTIVE DATE: January 15, 1993 (EMERGENCY) EFFECTIVE DATE OF PERMANENT RULE: April 17, 1993 REPEALED AND REPLACED: April 4, 1994 EFFECTIVE DATE (ELECTRONIC CONVERSION): April 28, 1996 AMENDED: January 1, 1997 - agency asserts §16 as effective retroactively to April 4, 1994 July 1, 1997 - changed address in §9 (4), replaced Appendix III May 1, 1999 - updated CPT copyright year, replaced Appendices I, II, & III NON-SUBSTANTIVE CORRECTIONS: October 25, 1999 - minor formatting; date corrections from paper filing in 4.1 - 4.4. AMENDED: July 1, 2001 July 1, 2002 - refiled June 13, 2002 to include some codes missing from the previous

filing September 24, 2002 - filing 2002-349 affecting §7 sub-§2 NON-SUBSTANTIVE CORRECTIONS: January 8, 2003 - character spacing only in §§ 1-19 AMENDED: November 5, 2006 - Amendments to Sections 4, 6(4), 10 & replaced Appendix III REPEALED AND REPLACED: December 11, 2011 - filing 2011-430

CHAPTER 5

APPENDIX I


PRACTITIONER’S REPORT (FORM M-1)

REASON FOR REPORT

SELECT ONE

INITIAL

PROGRESS

FINAL

M-1

PRACTITIONER'S REPORT STATE OF MAINE

WORKERS' COMPENSATION BOARD

Office of Medical/Rehabilitation Services

TYPE OF PRACTITIONER

SELECT ONE

MD

DO

DC

LIST OTHER _____________________

EM P L O Y E E

EMPLOYER NAME: EMPLOYEE LAST NAME: FIRST NAME: M.I.:

EMPLOYER MAILING ADDRESS & PHONE #: ADDRESS - NUMBER AND STREET:

INSURER NAME:

CITY: STATE: ZIP: HOME PHONE:

INSURER MAILING ADDRESS: DATE OF INJURY: SSN:

XXX-XX-

PATIENT'S COMPLAINTS:

ICD-9 CODE: IN MY OPINION, THIS PROBLEM IS WORK RELATED NOT WORK RELATED IS NOT YET IDENTIFIED AS TO CAUSE HAVE DIAGNOSTIC TESTS BEEN PERFORMED? YES NO RESULTS: DATE OF THIS EXAMINATION : / / IS TREATMENT TO CONTINUE? YES NO DATE PATIENT TO BE SEEN AGAIN: / / ESTIMATED LENGTH OF TREATMENT? TREATMENT PLAN: LIST ANY MEDICATION PRESCRIBED FOR THIS DIAGNOSIS/CONDITION THAT WOULD PREVENT YOUR PATIENT FROM DRIVING AND/OR WORKING SAFELY: IF UNABLE TO WORK, ADVISE ESTIMATED DATE OF RETURN : / / P.I. RATING : / / WORK CAPACITY: REGULAR DUTY MODIFIED DUTY NO WORK CAPACITY

RESTRICTIONS YES/NO

DESCRIBE:

P

R

A

C

T

I

T

I

O

N

E

R

IS PERMANENT IMPAIRMENT EXPECTED? YES NO HAS MMI BEEN REACHED? YES NO SIGNATURE OF PRACTITIONER PRINT NAME AND ADDRESS

TELEPHONE #: NARRATIVES ATTACHED? YES NO

WCB M-1 (6/99) DISTRIBUTION: PRACTITIONER (1) EMPLOYEE (2) EMPLOYER (3) INSURANCE COMPANY (4)

HOW TO COMPLETE THE PRACTITIONERôS REPORT (FORM M-1) Pursuant to 39-A M.R.S.A. §208(2)(A)(B) & (C) and Workers’ Compensation Board Rule Chapter 5 §19, the Practitioner’s Report (Form M-1) shall be submitted by the health care provider (HCP)/Practitioner to the employee and the employer as follows:

1. Within 5 business days of completion of the initial examination (except for medical claims only); 2. By the primary health care provider every thirty days if the employee has been evaluated/treated; and 3. Within 5 business days of termination of treatment. The Employee’s box should be filled out as completely as possible by the employee. A copy of the First Report is helpful in filling out this information. The remainder of the M-1 is to be completed by the health care provider. At the top of the form, the HCP should indicate initial, progress or final report and the type of practitioner. The remainder of the form should be completed as it applies to the patient/case. This information is vital to the administration of the claim and the employee’s return to work. The attachment of narratives is optional; however, the employer/insurer may request medical records (for a fee) and the records must be provided within ten days of receipt of a written request. A medical release is not necessary, see 39-A M.R.S.A. §208, if the information pertains to an injury claimed to be compensable under the Act. In the check-off portion of the form, check only those restrictions/limitations that apply. The HCP must sign the form and print the name and address information for ease in identification. Distribution is indicated at the bottom of the form.

THE M-1 FORM IS NOT SUBMITTED/FILED WITH THE BOARD

A HCP may not charge a fee for the completion and submission of the Practitioner’s Report (Form M-1). PLEASE NOTE: Penalties may be assessed for failure to complete and submit the Practitioner’s Report (Form M01). Additionally, payment of fees may be withheld.

CHAPTER 5

APPENDIX II


PETITION TO FIX THE AMOUNT TO BE ALLOWED

FORM 190 AND 190-A

PROVIDER'S PETITION FOR PAYMENT OF MEDICAL AND RELATED SERVICES

STATE OF MAINE WORKERS' COMPENSATION BOARD

27 STATE HOUSE STATION AUGUSTA, MAINE 04333-0027

HEALTH CARE PROVIDER NAME: STREET/P.O. BOX: __________________________________________ CITY, STATE, ZIP: TELEPHONE NUMBER: _______________________________________ EMPLOYEE NAME: __________________________________________ EMPLOYEE SOCIAL SECURITY NUMBER: XXX-XX-________________ DATE OF INJURY: ___________________________________________ BOARD FILE NUMBER: ________________________________________

(IF KNOWN)

) ) ) ) ) ) ) )

EMPLOYER NAME: _____________________________________________________ STREET/P.O. BOX: CITY, STATE, ZIP: ___________________________________________ INSURANCE COMPANY NAME: _____________________________________________________ STREET/P.O. BOX: __________________________________________ CITY, STATE, ZIP: ___________________________________________

1. On ,

MONTH DAY Y EAR EMPLOYEE NAME

experienced a work-related injury while working for . EMPLOYER NAME

2. The charges for medical and related services in connection with this injury amount to: $________________________.

ATTACH COPIES OF ALL BILLS

WHEREFORE, the health care provider asks the Board to order payment of the attached work-related medical bills and services pursuant to 39-A M.R.S.A. __________________________________________________________

SIGNATURE OF HEALTH CARE REPRESENTATIVE FILING INSTRUCTIONS 1. Mail original petition to the Workers= Compensation Board at the

above address by regular mail. 2. Mail one (1) copy by certified mail, return receipt requested to the

insurance company. 3. Mail one (1) copy by certified mail, return receipt requested to the

employer. 4. Keep one (1) copy for yourself and keep the green certified mail

cards when returned to you by the U.S. Post Office.

DATED:____________________________________________________

MONTH DAY YEAR __________________________________________________________

NAME OF PROVIDER'S ATTORNEY (IF ANY) __________________________________________________________

STREET/P.O. BOX __________________________________________________________

CITY, STATE, ZIP

THE STATE OF MAINE DOES NOT DISCRIMINATE ON THE BASIS OF DISABILITY IN ADMISSION TO, ACCESS TO, OR OPERATION OF ITS PROGRAMS, SERVICES, OR ACTIVITIES. THIS FORM IS AVAILABLE IN ALTERNATIVE FORMAT. FOR FURTHER ASSISTANCE, CONTACT THE MAINE WORKERS’ COMPENSATION BOARD, ADA COORDINATOR, TELEPHONE: 1-888-801-9087 OR TTY Maine Relay 711. WCB-190A (eff. 1/1/13)

PETITION FOR PAYMENT OF MEDICAL AND RELATED SERVICES

STATE OF MAINE WORKERS' COMPENSATION BOARD

27 STATE HOUSE STATION AUGUSTA, MAINE 04333-0027

EMPLOYEE NAME: STREET/P.O. BOX: CITY, STATE, ZIP: TELEPHONE NUMBER: _______________________________________ EMPLOYEE SOCIAL SECURITY NUMBER: XXX-XX-________________ BOARD FILE NUMBER: ________________________________________

(IF KNOWN)

) ) ) ) ) ) )

EMPLOYER NAME: STREET/P.O. BOX: CITY, STATE, ZIP: INSURANCE COMPANY NAME: _____________________________________________________ STREET/P.O. BOX: __________________________________________ CITY, STATE, ZIP: ___________________________________________

1. On , MONTH DAY YEAR EMPLOYEE NAME

experienced a work-related injury while working for . EMPLOYER NAME

2. Describe how the injury occurred: 3. List body part(s) injured: 4. The charges for medical and related services such as prescriptions and mileage in connection with this injury amount

to: $________________________. ATTACH COPIES OF ALL BILLS

WHEREFORE, the employee asks the Board to order payment of the attached work-related medical bills and services pursuant to 39-A M.R.S.A. ____________________________________________________ SIGNATURE OF EMPLOYEE FILING INSTRUCTIONS 1. Mail original petition to the Workers= Compensation Board at the

above address by regular mail. 2. Mail one (1) copy by certified mail, return receipt requested to the

insurance company. 3. Mail one (1) copy by certified mail, return receipt requested to the

employer. 4. Keep one (1) copy for yourself and keep the green certified mail

cards when returned to you by the U.S. Post Office.

DATED: ___________________________________________________

MONTH DAY YEAR NAME OF EMPLOYEE'S ATTORNEY OR ADVOCATE (IF ANY)

STREET/P.O. BOX CITY, STATE, ZIP

THE STATE OF MAINE DOES NOT DISCRIMINATE ON THE BASIS OF DISABILITY IN ADMISSION TO, ACCESS TO, OR OPERATION OF ITS PROGRAMS, SERVICES, OR ACTIVITIES. THIS FORM IS AVAILABLE IN ALTERNATIVE FORMAT. FOR FURTHER ASSISTANCE, CONTACT THE MAINE WORKERS’ COMPENSATION BOARD, ADA COORDINATOR, TELEPHONE: 1-888-801-9087 OR TTY Maine Relay 711 WCB-190 (eff. 1/1/13)

CHAPTER 5

APPENDIX III


PROFESSIONAL SERVICES

Professional Services - Anesthesia

Maine Workers' Compensation Medical Fee Schedule2015 Annual Update

1

CPT Codes, Copyright 2014, American Medical Association

Code Base Unit00100 500102 600103 500104 400120 500124 400126 400140 500142 400144 600145 600147 400148 400160 500162 700164 400170 500172 600174 600176 700190 500192 700210 1100211 1000212 500214 900215 900216 1500218 1300220 1000222 600300 500320 600322 300326 700350 1000352 500400 300402 500404 500406 1300410 400450 500452 600454 300470 600472 1000474 1300500 1500520 600522 4



2


Code Base Unit00524 400528 800529 1100530 400532 400534 700537 700539 1800540 1200542 1500541 1500546 1500548 1700550 1000560 1500561 2500562 2000563 2500566 2500567 1800580 2000600 1000604 1300620 1000622 1300625 1300626 1500630 800632 700634 1000635 400640 300670 1300700 400702 400730 500740 500750 400752 600754 700756 700770 1500790 700792 1300794 800796 3000797 1100800 400802 500810 500820 5



3


Code Base Unit00830 400832 600834 500836 600840 600842 400844 700846 800848 800851 600860 600862 700864 800865 700866 1000868 1000870 500872 700873 500880 1500882 1000902 500904 700906 400908 600910 300912 500914 500916 500918 500920 300921 300922 600924 400926 400928 600930 400932 400934 600936 800938 400940 300942 400944 600948 400950 500952 401112 501120 601130 301140 15



4


Code Base Unit01150 1001160 401170 801173 1201180 301190 401200 401202 401210 601212 1001214 801215 1001220 401230 601232 501234 801250 401260 301270 801272 401274 601320 401340 401360 501380 301382 301390 301392 401400 401402 701404 501420 301430 301432 601440 801442 801444 801462 301464 301470 301472 501474 501480 301482 401484 401486 701490 301500 801502 601520 301522 5



5


Code Base Unit01610 501620 401622 401630 501634 901636 1501638 1001650 601652 1001654 801656 1001670 401680 301682 401710 301712 501714 501716 501730 301732 301740 401742 501744 501756 601758 501760 701770 601772 601780 301782 401810 301820 301829 301830 301832 601840 601842 601844 601850 301852 401860 301916 501920 701922 701924 501925 701926 801930 501931 701932 601933 7



6


Code Base Unit01935 501936 501951 301952 501953 101958 501960 501961 701962 801963 801965 401966 401967 501968 201969 501990 701991 301992 501996 301999 0

Professional Services - Other


1


HCPCS MOD FUD MAX FEE10021 XXX $253.2010022 XXX $240.6010030 XXX $1,333.8010040 010 $172.2010060 010 $198.6010061 010 $350.4010080 010 $305.4010081 010 $456.0010120 010 $258.6010121 010 $465.0010140 010 $277.2010160 010 $220.8010180 010 $419.4011000 000 $92.4011001 ZZZ $35.4011004 000 $1,000.8011005 000 $1,351.2011006 000 $1,212.0011008 ZZZ $475.2011010 010 $835.2011011 000 $895.8011012 000 $1,207.8011042 000 $198.0011043 000 $387.0011044 000 $536.4011045 ZZZ $69.6011046 ZZZ $124.8011047 ZZZ $210.6011055 000 $80.4011056 000 $98.4011057 000 $111.0011100 000 $174.0011101 ZZZ $55.2011200 010 $148.8011201 ZZZ $31.8011300 000 $164.4011301 000 $201.6011302 000 $237.6011303 000 $264.0011305 000 $166.8011306 000 $205.2011307 000 $241.2011308 000 $253.8011310 000 $191.4011311 000 $189.0011312 000 $270.6011313 000 $313.2011400 010 $209.4011401 010 $252.6011402 010 $280.8011403 010 $324.60



2


HCPCS MOD FUD MAX FEE11404 010 $368.4011406 010 $532.2011420 010 $207.0011421 010 $265.8011422 010 $297.6011423 010 $343.2011424 010 $397.8011426 010 $566.4011440 010 $227.4011441 010 $284.4011442 010 $318.0011443 010 $379.2011444 010 $478.2011446 010 $663.6011450 090 $651.0011451 090 $821.4011462 090 $629.4011463 090 $837.0011470 090 $697.8011471 090 $861.0011600 010 $326.4011601 010 $387.0011602 010 $418.8011603 010 $478.2011604 010 $533.4011606 010 $763.8011620 010 $330.0011621 010 $388.8011622 010 $433.2011623 010 $509.4011624 010 $574.2011626 010 $693.0011640 010 $339.0011641 010 $402.6011642 010 $459.0011643 010 $543.0011644 010 $668.4011646 010 $876.0011719 000 $23.4011720 000 $54.6011721 000 $76.2011730 000 $167.4011732 ZZZ $60.6011740 000 $84.0011750 010 $379.8011752 010 $552.0011755 000 $225.6011760 010 $388.2011762 010 $480.0011765 010 $283.8011770 010 $469.80



3


HCPCS MOD FUD MAX FEE11771 090 $975.6011772 090 $1,185.6011900 000 $93.6011901 000 $117.6011920 000 $288.6011921 000 $336.0011922 ZZZ $103.8011950 000 $132.6011951 000 $179.4011952 000 $217.8011954 000 $268.8011960 090 $1,615.2011970 090 $1,042.8011971 090 $799.2011976 000 $243.0011980 000 $159.0011981 XXX $239.4011982 XXX $270.6011983 XXX $378.6012001 000 $151.2012002 000 $185.4012004 000 $217.8012005 000 $281.4012006 000 $337.8012007 000 $393.0012011 000 $185.4012013 000 $203.4012014 000 $240.0012015 000 $290.4012016 000 $360.6012017 000 $264.6012018 000 $298.8012020 010 $475.8012021 010 $277.8012031 010 $401.4012032 010 $512.4012034 010 $527.4012035 010 $647.4012036 010 $711.0012037 010 $815.4012041 010 $408.6012042 010 $487.8012044 010 $608.4012045 010 $684.6012046 010 $819.0012047 010 $949.2012051 010 $436.2012052 010 $497.4012053 010 $584.4012054 010 $622.2012055 010 $806.40



4


HCPCS MOD FUD MAX FEE12056 010 $845.4012057 010 $988.2013100 010 $566.4013101 010 $669.0013102 ZZZ $205.8013120 010 $592.2013121 010 $721.8013122 ZZZ $226.2013131 010 $651.6013132 010 $805.2013133 ZZZ $302.4013151 010 $714.6013152 010 $858.0013153 ZZZ $329.4013160 090 $1,386.6014000 090 $1,056.6014001 090 $1,357.8014020 090 $1,181.4014021 090 $1,477.2014040 090 $1,292.4014041 090 $1,599.0014060 090 $1,318.8014061 090 $1,721.4014301 090 $1,831.2014302 ZZZ $381.0014350 090 $1,189.8015002 000 $589.8015003 ZZZ $129.0015004 000 $684.0015005 ZZZ $211.2015040 000 $432.0015050 090 $967.8015100 090 $1,464.0015101 ZZZ $316.2015110 090 $1,392.0015111 ZZZ $198.6015115 090 $1,410.6015116 ZZZ $287.4015120 090 $1,449.0015121 ZZZ $354.0015130 090 $1,157.4015131 ZZZ $156.0015135 090 $1,436.4015136 ZZZ $162.0015150 090 $1,189.2015151 ZZZ $207.0015152 ZZZ $253.8015155 090 $1,180.8015156 ZZZ $277.8015157 ZZZ $268.2015200 090 $1,411.20



5


HCPCS MOD FUD MAX FEE15201 ZZZ $251.4015220 090 $1,309.8015221 ZZZ $232.8015240 090 $1,586.4015241 ZZZ $314.4015260 090 $1,719.0015261 ZZZ $364.2015271 000 $238.8015272 ZZZ $46.2015273 000 $505.8015274 ZZZ $121.2015275 000 $254.4015276 ZZZ $58.2015277 000 $550.2015278 ZZZ $145.8015570 090 $1,553.4015572 090 $1,509.0015574 090 $1,555.8015576 090 $1,371.0015600 090 $550.2015610 090 $606.0015620 090 $746.4015630 090 $781.2015650 090 $862.8015731 090 $1,925.4015732 090 $2,189.4015734 090 $2,563.2015736 090 $2,248.2015738 090 $2,391.6015740 090 $1,734.0015750 090 $1,584.0015756 090 $4,004.4015757 090 $3,970.2015758 090 $3,960.0015760 090 $1,453.8015770 090 $1,149.0015775 000 $496.8015776 000 $811.8015777 ZZZ $366.6015780 090 $1,445.4015781 090 $940.2015782 090 $1,090.2015783 090 $822.0015786 010 $412.8015787 ZZZ $82.8015788 090 $781.2015789 090 $944.4015792 090 $735.0015793 090 $836.4015819 090 $1,356.6015820 090 $972.00



6


HCPCS MOD FUD MAX FEE15821 090 $1,027.8015822 090 $757.2015823 090 $1,030.2015830 090 $2,013.6015832 090 $1,567.8015833 090 $1,493.4015834 090 $1,521.6015835 090 $1,607.4015836 090 $1,352.4015837 090 $1,512.0015838 090 $979.2015839 090 $1,503.6015840 090 $1,726.2015841 090 $2,756.4015842 090 $4,209.6015845 090 $1,719.0015850 XXX $147.6015851 000 $167.4015852 000 $81.6015860 000 $190.8015920 090 $1,029.0015922 090 $1,338.0015931 090 $1,177.8015933 090 $1,455.6015934 090 $1,597.8015935 090 $1,887.0015936 090 $1,522.2015937 090 $1,762.8015940 090 $1,198.2015941 090 $1,546.2015944 090 $1,537.2015945 090 $1,673.4015946 090 $2,803.2015950 090 $1,011.0015951 090 $1,504.8015952 090 $1,548.0015953 090 $1,704.0015956 090 $1,972.8015958 090 $2,017.2016000 000 $116.4016020 000 $138.6016025 000 $250.8016030 000 $309.6016035 000 $334.2016036 ZZZ $139.2017000 010 $112.2017003 ZZZ $9.6017004 010 $254.4017106 090 $580.2017107 090 $730.8017108 090 $1,088.40



7


HCPCS MOD FUD MAX FEE17110 010 $186.6017111 010 $222.0017250 000 $134.4017260 010 $159.0017261 010 $242.4017262 010 $295.8017263 010 $322.2017264 010 $346.2017266 010 $392.4017270 010 $254.4017271 010 $276.0017272 010 $314.4017273 010 $351.6017274 010 $414.0017276 010 $479.4017280 010 $238.2017281 010 $300.6017282 010 $345.6017283 010 $413.4017284 010 $472.8017286 010 $608.4017311 000 $1,117.2017312 ZZZ $657.0017313 000 $1,045.2017314 ZZZ $630.6017315 ZZZ $135.0017340 010 $87.6017360 010 $218.4019000 000 $192.0019001 ZZZ $46.2019020 090 $804.0019030 000 $282.0019081 000 $1,134.0019082 ZZZ $924.6019083 000 $1,107.6019084 ZZZ $891.0019085 000 $1,777.2019086 ZZZ $1,395.6019100 000 $256.8019101 010 $581.4019105 000 $4,191.6019110 090 $825.6019112 090 $785.4019120 090 $841.8019125 090 $933.6019126 ZZZ $279.6019260 090 $2,071.2019271 090 $2,803.8019272 090 $3,076.8019281 000 $408.6019282 ZZZ $292.20



8


HCPCS MOD FUD MAX FEE19283 000 $465.0019284 ZZZ $350.4019285 000 $759.6019286 ZZZ $651.6019287 000 $1,488.6019288 ZZZ $1,195.2019296 000 $6,660.6019297 ZZZ $163.2019298 000 $1,780.2019300 090 $892.8019301 090 $1,120.8019302 090 $1,545.0019303 090 $1,735.8019304 090 $985.8019305 090 $1,937.4019306 090 $2,057.4019307 090 $2,054.4019316 090 $1,320.6019318 090 $1,893.6019324 090 $841.8019325 090 $1,100.4019328 090 $849.0019330 090 $1,085.4019340 090 $1,722.0019342 090 $1,582.2019350 090 $1,405.2019355 090 $1,198.8019357 090 $2,581.2019361 090 $2,704.8019364 090 $4,738.8019366 090 $2,419.8019367 090 $3,078.0019368 090 $3,786.6019369 090 $3,513.0019370 090 $1,176.0019371 090 $1,345.8019380 090 $1,325.4019396 000 $497.4020005 010 $525.6020100 010 $1,050.6020101 010 $770.4020102 010 $836.4020103 010 $992.4020150 090 $1,565.4020200 000 $354.6020205 000 $493.2020206 000 $403.2020220 000 $286.8020225 000 $897.0020240 010 $372.0020245 010 $1,060.20



9


HCPCS MOD FUD MAX FEE20250 010 $678.0020251 010 $726.0020500 010 $177.0020501 000 $201.6020520 010 $347.4020525 010 $820.2020526 000 $132.6020527 000 $144.0020550 000 $99.6020551 000 $102.6020552 000 $94.2020553 000 $108.6020555 000 $571.8020600 000 $81.0020604 000 $121.2020605 000 $84.6020606 000 $133.2020610 000 $102.0020611 000 $153.0020612 000 $103.2020615 010 $421.2020650 010 $352.2020660 000 $429.0020661 090 $874.8020662 090 $799.2020663 090 $677.4020664 090 $1,524.6020665 010 $177.6020670 010 $648.0020680 090 $1,059.0020690 090 $1,025.4020692 090 $1,927.8020693 090 $771.0020694 090 $727.2020696 090 $2,086.8020697 000 $3,602.4020802 090 $4,774.8020805 090 $5,666.4020808 090 $6,861.0020816 090 $3,623.4020822 090 $3,096.6020824 090 $3,507.6020827 090 $3,183.6020838 090 $3,732.6020900 000 $718.2020902 000 $495.6020910 090 $785.4020912 090 $825.0020920 090 $678.0020922 090 $1,035.0020924 090 $875.40



10


HCPCS MOD FUD MAX FEE20926 090 $739.8020931 ZZZ $196.8020937 ZZZ $293.4020938 ZZZ $325.2020950 000 $421.8020955 090 $4,354.8020956 090 $4,591.2020957 090 $3,636.6020962 090 $3,500.4020969 090 $4,761.0020970 090 $4,966.8020972 090 $3,963.6020973 090 $4,372.2020974 000 $130.2020975 000 $309.0020979 000 $88.2020982 000 $6,400.2020983 000 $11,782.8020985 ZZZ $255.6021010 090 $1,312.2021011 090 $595.8021012 090 $581.4021013 090 $886.8021014 090 $895.8021015 090 $1,215.0021016 090 $1,758.6021025 090 $1,543.8021026 090 $1,068.6021029 090 $1,317.0021030 090 $897.0021031 090 $684.0021032 090 $693.0021034 090 $2,281.2021040 090 $905.4021044 090 $1,521.6021045 090 $2,121.6021046 090 $1,945.2021047 090 $2,291.4021048 090 $1,998.0021049 090 $2,096.4021050 090 $1,453.8021060 090 $1,405.2021070 090 $1,065.0021073 090 $682.2021076 010 $1,741.2021077 090 $4,373.4021079 090 $2,941.2021080 090 $3,292.2021081 090 $3,046.8021082 090 $2,887.8021083 090 $2,752.20



11


HCPCS MOD FUD MAX FEE21084 090 $3,148.2021085 010 $1,323.0021086 090 $3,251.4021087 090 $3,251.4021100 090 $1,989.6021110 090 $1,401.0021116 000 $254.4021120 090 $1,033.8021121 090 $1,383.6021122 090 $1,104.6021123 090 $1,333.2021125 090 $5,400.0021127 090 $7,472.4021137 090 $1,191.6021138 090 $1,518.0021139 090 $1,938.0021141 090 $2,335.2021142 090 $2,498.4021143 090 $2,520.0021145 090 $2,831.4021146 090 $2,948.4021147 090 $3,114.6021150 090 $2,905.2021151 090 $3,552.6021154 090 $3,819.6021155 090 $4,070.4021159 090 $4,161.6021160 090 $4,513.8021172 090 $3,054.0021175 090 $3,980.4021179 090 $2,260.2021180 090 $2,641.8021181 090 $1,272.0021182 090 $3,305.4021183 090 $3,848.4021184 090 $4,152.0021188 090 $2,701.8021193 090 $2,052.6021194 090 $2,590.8021195 090 $2,320.2021196 090 $2,557.2021198 090 $2,014.2021199 090 $1,735.8021206 090 $2,140.8021208 090 $3,291.6021209 090 $1,393.2021210 090 $3,964.8021215 090 $7,086.6021230 090 $1,312.2021235 090 $1,246.2021240 090 $1,944.00



12


HCPCS MOD FUD MAX FEE21242 090 $1,781.4021243 090 $2,952.0021244 090 $1,846.2021245 090 $1,903.8021246 090 $1,555.2021247 090 $2,634.0021248 090 $1,927.2021249 090 $2,646.6021255 090 $2,276.4021256 090 $2,060.4021260 090 $1,977.6021261 090 $3,508.8021263 090 $3,242.4021267 090 $2,715.0021268 090 $3,185.4021270 090 $1,656.6021275 090 $1,438.8021280 090 $973.2021282 090 $650.4021295 090 $325.2021296 090 $723.6021310 000 $225.6021315 010 $477.6021320 010 $439.8021325 090 $820.2021330 090 $988.8021335 090 $1,251.0021336 090 $1,111.2021337 090 $697.8021338 090 $1,296.0021339 090 $1,467.6021340 090 $1,377.6021343 090 $2,095.2021344 090 $2,400.0021345 090 $1,342.8021346 090 $1,559.4021347 090 $1,960.8021348 090 $2,080.2021355 010 $830.4021356 010 $863.4021360 090 $927.0021365 090 $1,918.8021366 090 $1,998.6021385 090 $1,175.4021386 090 $1,197.0021387 090 $1,225.2021390 090 $1,363.2021395 090 $1,735.2021400 090 $333.0021401 090 $845.4021406 090 $985.20



13


HCPCS MOD FUD MAX FEE21407 090 $1,108.8021408 090 $1,548.0021421 090 $1,452.6021422 090 $1,165.2021423 090 $1,365.0021431 090 $1,361.4021432 090 $1,105.8021433 090 $2,997.6021435 090 $2,177.4021436 090 $3,518.4021440 090 $1,000.8021445 090 $1,340.4021450 090 $1,081.2021451 090 $1,424.4021452 090 $994.2021453 090 $1,587.0021454 090 $993.6021461 090 $3,688.8021462 090 $3,922.8021465 090 $1,616.4021470 090 $2,091.6021480 000 $169.2021485 090 $1,221.0021490 090 $1,594.8021495 090 $1,104.0021497 090 $1,276.8021501 090 $775.2021502 090 $875.4021510 090 $757.8021550 010 $449.4021552 090 $767.4021554 090 $1,260.6021555 090 $712.2021556 090 $911.4021557 090 $1,652.4021558 090 $2,319.0021600 090 $961.2021610 090 $2,116.2021615 090 $1,080.0021616 090 $1,262.4021620 090 $870.6021627 090 $936.0021630 090 $2,075.4021632 090 $2,078.4021685 090 $1,715.4021700 090 $633.0021705 090 $947.4021720 090 $829.8021725 090 $931.2021740 090 $1,782.6021750 090 $1,182.60



14


HCPCS MOD FUD MAX FEE21805 090 $467.4021811 000 $914.4021812 000 $1,094.4021813 000 $1,495.8021820 090 $243.0021825 090 $932.4021920 010 $437.4021925 090 $766.2021930 090 $808.2021931 090 $808.8021932 090 $1,138.8021933 090 $1,272.6021935 090 $1,767.0021936 090 $2,434.8022010 090 $1,648.8022015 090 $1,566.0022100 090 $1,623.0022101 090 $1,423.2022102 090 $1,378.2022103 ZZZ $244.2022110 090 $1,817.4022112 090 $1,970.4022114 090 $1,721.4022116 ZZZ $247.8022206 090 $4,258.2022207 090 $4,168.2022208 ZZZ $1,001.4022210 090 $3,115.8022212 090 $2,583.6022214 090 $2,579.4022216 ZZZ $635.4022220 090 $2,775.0022222 090 $2,708.4022224 090 $2,745.0022226 ZZZ $630.6022305 090 $327.0022310 090 $528.6022315 090 $1,529.4022318 090 $2,868.6022319 090 $3,226.8022325 090 $2,493.0022326 090 $2,611.2022327 090 $2,620.8022328 ZZZ $495.0022505 010 $229.2022510 010 $2,937.6022511 010 $2,910.0022512 ZZZ $1,626.6022513 010 $12,393.0022514 010 $12,346.8022515 ZZZ $7,492.20



15


HCPCS MOD FUD MAX FEE22526 010 $4,046.4022527 ZZZ $3,367.2022532 090 $3,098.4022533 090 $2,867.4022534 ZZZ $628.8022548 090 $3,467.4022551 090 $2,997.6022552 ZZZ $701.4022554 090 $2,193.0022556 090 $2,917.8022558 090 $2,680.2022585 ZZZ $576.6022586 090 $3,522.0022590 090 $2,760.6022595 090 $2,640.0022600 090 $2,253.0022610 090 $2,202.6022612 090 $2,767.8022614 ZZZ $687.0022630 090 $2,740.2022632 ZZZ $563.4022633 090 $3,237.0022634 ZZZ $870.6022800 090 $2,352.0022802 090 $3,651.6022804 090 $4,232.4022808 090 $3,218.4022810 090 $3,518.4022812 090 $3,840.0022818 090 $3,772.2022819 090 $4,857.6022830 090 $1,413.0022840 ZZZ $1,335.0022842 ZZZ $1,338.6022843 ZZZ $1,433.4022844 ZZZ $1,727.4022845 ZZZ $1,285.8022846 ZZZ $1,335.6022847 ZZZ $1,396.8022848 ZZZ $629.4022849 090 $2,269.8022850 090 $1,259.4022851 ZZZ $715.2022852 090 $1,206.6022855 090 $1,932.6022856 090 $2,808.6022857 090 $3,085.2022858 ZZZ $1,126.2022861 090 $3,343.2022862 090 $3,040.8022864 090 $3,671.40



16


HCPCS MOD FUD MAX FEE22865 090 $3,558.0022900 090 $970.8022901 090 $1,144.2022902 090 $751.8022903 090 $755.4022904 090 $1,815.0022905 090 $2,289.6023000 090 $1,006.8023020 090 $1,186.8023030 010 $756.0023031 010 $732.6023035 090 $1,172.4023040 090 $1,237.8023044 090 $984.6023065 010 $369.0023066 090 $952.8023071 090 $722.4023073 090 $1,194.0023075 090 $800.4023076 090 $927.6023077 090 $1,965.0023078 090 $2,465.4023100 090 $862.2023101 090 $772.8023105 090 $1,096.2023106 090 $855.6023107 090 $1,134.6023120 090 $1,004.4023125 090 $1,222.2023130 090 $1,050.6023140 090 $907.2023145 090 $1,198.2023146 090 $1,069.8023150 090 $1,141.2023155 090 $1,368.0023156 090 $1,168.2023170 090 $964.8023172 090 $975.6023174 090 $1,308.0023180 090 $1,149.6023182 090 $1,135.8023184 090 $1,265.4023190 090 $985.2023195 090 $1,303.8023200 090 $2,625.0023210 090 $3,087.0023220 090 $3,382.8023330 010 $412.2023333 090 $965.4023334 090 $1,923.0023335 090 $2,237.40



17


HCPCS MOD FUD MAX FEE23350 000 $222.6023395 090 $2,214.0023397 090 $1,973.4023400 090 $1,676.4023405 090 $1,075.2023406 090 $1,327.2023410 090 $1,416.0023412 090 $1,468.8023415 090 $1,201.2023420 090 $1,671.0023430 090 $1,285.2023440 090 $1,302.0023450 090 $1,638.6023455 090 $1,728.0023460 090 $1,883.4023462 090 $1,839.6023465 090 $1,936.2023466 090 $1,939.2023470 090 $2,076.6023472 090 $2,517.6023473 090 $2,811.0023474 090 $3,040.8023480 090 $1,417.8023485 090 $1,645.2023490 090 $1,488.0023491 090 $1,748.4023500 090 $372.6023505 090 $603.6023515 090 $1,239.0023520 090 $396.6023525 090 $659.4023530 090 $986.4023532 090 $1,074.6023540 090 $383.4023545 090 $581.4023550 090 $974.4023552 090 $1,122.6023570 090 $397.2023575 090 $687.0023585 090 $1,689.6023600 090 $556.8023605 090 $793.8023615 090 $1,524.6023616 090 $2,142.6023620 090 $461.4023625 090 $650.4023630 090 $1,347.0023650 090 $535.2023655 090 $688.2023660 090 $997.2023665 090 $726.60



18


HCPCS MOD FUD MAX FEE23670 090 $1,512.6023675 090 $946.8023680 090 $1,603.8023700 010 $338.4023800 090 $1,771.2023802 090 $2,220.6023900 090 $2,401.8023920 090 $1,949.4023921 090 $791.4023930 010 $599.4023931 010 $489.6023935 090 $870.0024000 090 $820.2024006 090 $1,224.0024065 010 $436.2024066 090 $1,069.8024071 090 $697.8024073 090 $1,195.8024075 090 $838.2024076 090 $931.8024077 090 $1,780.2024079 090 $2,285.4024100 090 $719.4024101 090 $859.8024102 090 $1,056.6024105 090 $601.8024110 090 $1,012.2024115 090 $1,272.0024116 090 $1,488.0024120 090 $906.6024125 090 $1,068.6024126 090 $1,118.4024130 090 $871.8024134 090 $1,289.4024136 090 $995.4024138 090 $1,162.2024140 090 $1,210.8024145 090 $1,019.4024147 090 $1,072.2024149 090 $2,020.2024150 090 $2,695.2024152 090 $2,340.0024155 090 $1,473.0024160 090 $2,210.4024164 090 $1,253.4024200 010 $354.0024201 090 $955.8024220 000 $273.0024300 090 $716.4024301 090 $1,282.2024305 090 $988.20



19


HCPCS MOD FUD MAX FEE24310 090 $811.2024320 090 $1,347.0024330 090 $1,237.8024331 090 $1,356.6024332 090 $1,055.4024340 090 $1,052.4024341 090 $1,284.0024342 090 $1,336.2024343 090 $1,213.8024344 090 $1,897.2024345 090 $1,219.8024346 090 $1,897.2024357 090 $741.0024358 090 $898.2024359 090 $1,131.6024360 090 $1,552.8024361 090 $1,738.2024362 090 $1,831.8024363 090 $2,514.0024365 090 $1,102.2024366 090 $1,171.2024370 090 $2,681.4024371 090 $3,104.4024400 090 $1,408.8024410 090 $1,826.4024420 090 $1,714.8024430 090 $1,822.2024435 090 $1,858.8024470 090 $1,156.8024495 090 $922.8024498 090 $1,497.6024500 090 $612.0024505 090 $854.4024515 090 $1,510.2024516 090 $1,482.6024530 090 $649.2024535 090 $1,050.6024538 090 $1,282.2024545 090 $1,602.6024546 090 $1,792.2024560 090 $546.6024565 090 $913.8024566 090 $1,235.4024575 090 $1,263.6024576 090 $581.4024577 090 $942.0024579 090 $1,438.2024582 090 $1,393.8024586 090 $1,867.2024587 090 $1,879.8024600 090 $621.00



20


HCPCS MOD FUD MAX FEE24605 090 $807.6024615 090 $1,221.0024620 090 $936.0024635 090 $1,156.2024640 010 $237.6024650 090 $446.4024655 090 $741.6024665 090 $1,120.2024666 090 $1,261.2024670 090 $497.4024675 090 $778.8024685 090 $1,124.4024800 090 $1,431.0024802 090 $1,729.8024900 090 $1,246.2024920 090 $1,263.6024925 090 $878.4024930 090 $1,335.6024931 090 $1,325.4024935 090 $1,556.4025000 090 $575.4025001 090 $589.8025020 090 $982.8025023 090 $1,891.2025024 090 $1,339.2025025 090 $2,121.0025028 090 $897.0025031 090 $627.0025035 090 $998.4025040 090 $966.0025065 010 $433.8025066 090 $617.4025071 090 $731.4025073 090 $914.4025075 090 $815.4025076 090 $887.4025077 090 $1,524.0025078 090 $2,005.8025085 090 $774.6025100 090 $595.2025101 090 $691.8025105 090 $825.0025107 090 $1,057.8025109 090 $920.4025110 090 $585.6025111 090 $548.4025112 090 $661.2025115 090 $1,301.4025116 090 $1,027.2025118 090 $653.4025119 090 $856.80



21


HCPCS MOD FUD MAX FEE25120 090 $852.0025125 090 $1,029.6025126 090 $1,028.4025130 090 $764.4025135 090 $959.4025136 090 $849.0025145 090 $889.8025150 090 $976.2025151 090 $1,010.4025170 090 $2,560.2025210 090 $834.0025215 090 $1,057.8025230 090 $742.2025240 090 $731.4025246 000 $277.2025248 090 $711.0025250 090 $912.6025251 090 $1,216.2025259 090 $714.0025260 090 $1,079.4025263 090 $1,078.8025265 090 $1,290.6025270 090 $838.8025272 090 $953.4025274 090 $1,155.6025275 090 $1,150.2025280 090 $964.8025290 090 $748.2025295 090 $895.8025300 090 $1,179.6025301 090 $1,102.2025310 090 $1,060.8025312 090 $1,232.4025315 090 $1,329.0025316 090 $1,576.8025320 090 $1,694.4025332 090 $1,442.4025335 090 $1,626.6025337 090 $1,525.2025350 090 $1,156.8025355 090 $1,321.2025360 090 $1,123.8025365 090 $1,578.0025370 090 $1,737.0025375 090 $1,643.4025390 090 $1,321.2025391 090 $1,719.0025392 090 $1,733.4025393 090 $1,936.8025394 090 $1,371.0025400 090 $1,381.20



22


HCPCS MOD FUD MAX FEE25405 090 $1,779.6025415 090 $1,669.8025420 090 $2,018.4025425 090 $1,661.4025426 090 $1,942.2025430 090 $1,260.0025431 090 $1,344.6025440 090 $1,319.4025441 090 $1,600.2025442 090 $1,367.4025443 090 $1,346.4025444 090 $1,425.0025445 090 $1,239.0025446 090 $2,011.2025447 090 $1,419.6025449 090 $1,770.6025450 090 $858.0025455 090 $1,014.6025490 090 $1,141.2025491 090 $1,275.6025492 090 $1,560.0025500 090 $465.0025505 090 $858.0025515 090 $1,150.8025520 090 $974.4025525 090 $1,350.6025526 090 $1,648.8025530 090 $448.2025535 090 $838.2025545 090 $1,071.0025560 090 $473.4025565 090 $888.0025574 090 $1,158.6025575 090 $1,550.4025600 090 $559.8025605 090 $933.0025606 090 $1,138.8025607 090 $1,262.4025608 090 $1,417.2025609 090 $1,801.2025622 090 $517.8025624 090 $819.6025628 090 $1,237.2025630 090 $520.8025635 090 $762.6025645 090 $981.6025650 090 $544.8025651 090 $829.8025652 090 $1,071.0025660 090 $700.2025670 090 $1,036.80



23


HCPCS MOD FUD MAX FEE25671 090 $912.0025675 090 $745.8025676 090 $1,081.8025680 090 $802.2025685 090 $1,269.0025690 090 $826.2025695 090 $1,090.8025800 090 $1,255.2025805 090 $1,456.8025810 090 $1,489.8025820 090 $1,054.8025825 090 $1,296.6025830 090 $1,636.8025900 090 $1,211.4025905 090 $1,208.4025907 090 $1,054.8025909 090 $1,180.2025915 090 $1,677.0025920 090 $1,200.0025922 090 $1,051.8025924 090 $1,171.2025927 090 $1,395.0025929 090 $939.6025931 090 $1,279.8026010 010 $449.4026011 010 $662.4026020 090 $742.8026025 090 $723.6026030 090 $843.0026034 090 $923.4026035 090 $1,479.0026037 090 $969.0026040 090 $532.2026045 090 $802.8026055 090 $951.6026060 090 $450.0026070 090 $540.6026075 090 $571.8026080 090 $667.8026100 090 $576.0026105 090 $580.2026110 090 $549.0026111 090 $718.2026113 090 $939.6026115 090 $860.4026116 090 $903.6026117 090 $1,280.4026118 090 $1,816.8026121 090 $1,022.4026123 090 $1,428.6026125 ZZZ $473.40



24


HCPCS MOD FUD MAX FEE26130 090 $795.0026135 090 $939.0026140 090 $862.8026145 090 $877.8026160 090 $977.4026170 090 $695.4026180 090 $758.4026185 090 $929.4026200 090 $768.6026205 090 $1,036.2026210 090 $757.2026215 090 $968.4026230 090 $854.4026235 090 $844.2026236 090 $755.4026250 090 $1,851.0026260 090 $1,386.6026262 090 $1,092.0026320 090 $593.4026340 090 $570.0026341 010 $169.2026350 090 $1,201.2026352 090 $1,372.2026356 090 $1,851.6026357 090 $1,480.2026358 090 $1,519.2026370 090 $1,282.8026372 090 $1,504.8026373 090 $1,404.0026390 090 $1,422.0026392 090 $1,656.6026410 090 $951.6026412 090 $1,174.8026415 090 $1,155.6026416 090 $1,506.0026418 090 $973.8026420 090 $1,195.2026426 090 $858.0026428 090 $1,248.6026432 090 $843.0026433 090 $897.0026434 090 $1,098.6026437 090 $1,050.6026440 090 $1,043.4026442 090 $1,631.4026445 090 $969.6026449 090 $1,191.0026450 090 $685.2026455 090 $680.4026460 090 $661.2026471 090 $1,035.00



25


HCPCS MOD FUD MAX FEE26474 090 $1,019.4026476 090 $990.6026477 090 $972.0026478 090 $1,041.6026479 090 $1,030.8026480 090 $1,266.0026483 090 $1,421.4026485 090 $1,362.6026489 090 $1,591.2026490 090 $1,353.6026492 090 $1,501.2026494 090 $1,317.0026496 090 $1,443.0026497 090 $1,473.0026498 090 $1,962.0026499 090 $1,380.0026500 090 $1,050.6026502 090 $1,206.0026508 090 $1,066.2026510 090 $1,000.8026516 090 $1,180.2026517 090 $1,402.8026518 090 $1,390.2026520 090 $1,098.0026525 090 $1,098.0026530 090 $921.0026531 090 $1,066.8026535 090 $722.4026536 090 $1,199.4026540 090 $1,107.0026541 090 $1,353.0026542 090 $1,146.6026545 090 $1,200.0026546 090 $1,683.0026548 090 $1,281.0026550 090 $2,812.8026551 090 $5,676.6026553 090 $4,658.4026554 090 $5,450.4026555 090 $2,341.8026556 090 $4,444.8026560 090 $1,001.4026561 090 $1,574.4026562 090 $2,256.6026565 090 $1,150.2026567 090 $1,146.0026568 090 $1,530.6026580 090 $2,586.6026587 090 $1,645.8026590 090 $2,407.2026591 090 $730.20



26


HCPCS MOD FUD MAX FEE26593 090 $1,012.2026596 090 $1,276.2026600 090 $501.0026605 090 $549.6026607 090 $784.8026608 090 $814.8026615 090 $988.8026641 090 $644.4026645 090 $733.8026650 090 $820.2026665 090 $1,078.8026670 090 $573.6026675 090 $778.8026676 090 $856.8026685 090 $989.4026686 090 $1,073.4026700 090 $547.8026705 090 $710.4026706 090 $745.8026715 090 $980.4026720 090 $337.2026725 090 $573.6026727 090 $802.8026735 090 $1,023.6026740 090 $390.6026742 090 $625.2026746 090 $1,272.6026750 090 $312.6026755 090 $535.2026756 090 $713.4026765 090 $858.0026770 090 $468.0026775 090 $652.2026776 090 $758.4026785 090 $936.6026820 090 $1,337.4026841 090 $1,226.4026842 090 $1,326.6026843 090 $1,254.0026844 090 $1,364.4026850 090 $1,167.0026852 090 $1,341.6026860 090 $952.2026861 ZZZ $178.2026862 090 $1,225.2026863 ZZZ $394.8026910 090 $1,210.2026951 090 $1,102.8026952 090 $1,087.2026990 090 $1,077.0026991 090 $1,204.20



27


HCPCS MOD FUD MAX FEE26992 090 $1,647.0027000 090 $716.4027001 090 $927.6027003 090 $1,026.6027005 090 $1,248.0027006 090 $1,266.0027025 090 $1,570.2027027 090 $1,529.4027030 090 $1,616.4027033 090 $1,676.4027035 090 $1,849.8027036 090 $1,744.8027040 010 $589.2027041 090 $1,182.0027043 090 $808.8027045 090 $1,291.2027047 090 $805.2027048 090 $1,048.8027049 090 $2,307.0027050 090 $692.4027052 090 $999.0027054 090 $1,177.8027057 090 $1,752.6027059 090 $3,144.0027060 090 $801.0027062 090 $786.0027065 090 $892.2027066 090 $1,401.0027067 090 $1,786.2027070 090 $1,460.4027071 090 $1,575.6027075 090 $3,643.2027076 090 $4,411.2027077 090 $4,924.2027078 090 $3,591.6027080 090 $884.4027086 010 $504.6027087 090 $1,075.2027090 090 $1,425.0027091 090 $2,761.2027093 000 $321.0027095 000 $412.2027096 000 $272.4027097 090 $1,175.4027098 090 $1,196.4027100 090 $1,425.0027105 090 $1,495.2027110 090 $1,673.4027111 090 $1,553.4027120 090 $2,250.6027122 090 $1,896.00



28


HCPCS MOD FUD MAX FEE27125 090 $1,959.0027130 090 $2,344.8027132 090 $2,895.6027134 090 $3,315.0027137 090 $2,547.0027138 090 $2,646.6027140 090 $1,549.2027146 090 $2,217.6027147 090 $2,547.0027151 090 $2,757.0027156 090 $2,973.0027158 090 $2,427.0027161 090 $2,100.6027165 090 $2,370.0027170 090 $2,035.2027175 090 $1,150.8027176 090 $1,586.4027177 090 $1,926.6027178 090 $1,586.4027179 090 $1,686.6027181 090 $1,943.4027185 090 $1,007.4027187 090 $1,711.8027193 090 $808.2027194 090 $1,227.6027200 090 $308.4027202 090 $919.2027215 090 $1,033.8027216 090 $1,530.6027217 090 $1,437.6027218 090 $1,981.8027220 090 $912.0027222 090 $1,688.4027226 090 $1,828.2027227 090 $2,871.6027228 090 $3,274.2027230 090 $814.8027232 090 $1,299.6027235 090 $1,570.8027236 090 $2,068.2027238 090 $791.4027240 090 $1,652.4027244 090 $2,128.8027245 090 $2,128.2027246 090 $662.4027248 090 $1,282.8027250 000 $312.0027252 090 $1,309.8027253 090 $1,623.6027254 090 $2,200.2027256 010 $518.40



29


HCPCS MOD FUD MAX FEE27257 010 $589.8027258 090 $1,920.6027259 090 $2,689.2027265 090 $682.8027266 090 $1,001.4027267 090 $744.0027268 090 $927.0027269 090 $2,151.6027275 010 $313.8027279 090 $961.8027280 090 $1,805.4027282 090 $1,284.6027284 090 $2,641.2027286 090 $2,864.4027290 090 $2,814.0027295 090 $2,174.4027301 090 $1,134.6027303 090 $1,095.6027305 090 $828.0027306 090 $618.0027307 090 $826.8027310 090 $1,258.2027323 010 $460.2027324 090 $682.8027325 090 $876.6027326 090 $885.0027327 090 $785.4027328 090 $1,069.2027329 090 $1,785.0027330 090 $715.8027331 090 $819.0027332 090 $1,106.4027333 090 $1,008.6027334 090 $1,177.2027335 090 $1,315.2027337 090 $719.4027339 090 $1,297.8027340 090 $639.0027345 090 $828.6027347 090 $910.8027350 090 $1,120.2027355 090 $1,038.6027356 090 $1,273.2027357 090 $1,401.0027358 ZZZ $484.8027360 090 $1,467.0027364 090 $2,702.4027365 090 $3,574.8027370 000 $264.0027372 090 $1,041.6027380 090 $1,020.00



30


HCPCS MOD FUD MAX FEE27381 090 $1,371.6027385 090 $988.8027386 090 $1,427.4027390 090 $772.2027391 090 $993.6027392 090 $1,227.6027393 090 $879.0027394 090 $1,119.6027395 090 $1,515.6027396 090 $1,060.2027397 090 $1,582.8027400 090 $1,197.6027403 090 $1,102.2027405 090 $1,164.0027407 090 $1,366.2027409 090 $1,666.8027412 090 $2,863.8027415 090 $2,379.0027416 090 $1,695.0027418 090 $1,425.0027420 090 $1,272.6027422 090 $1,278.0027424 090 $1,291.2027425 090 $771.6027427 090 $1,228.8027428 090 $1,924.8027429 090 $2,163.0027430 090 $1,267.8027435 090 $1,389.0027437 090 $1,140.0027438 090 $1,450.2027440 090 $1,377.0027441 090 $1,423.8027442 090 $1,499.4027443 090 $1,410.0027445 090 $2,164.8027446 090 $2,004.0027447 090 $2,344.2027448 090 $1,318.8027450 090 $1,741.8027454 090 $2,250.6027455 090 $1,627.8027457 090 $1,659.6027465 090 $2,159.4027466 090 $2,048.4027468 090 $2,325.0027470 090 $2,031.0027472 090 $2,185.8027475 090 $1,141.2027477 090 $1,265.4027479 090 $1,590.00



31


HCPCS MOD FUD MAX FEE27485 090 $1,156.2027486 090 $2,430.6027487 090 $3,039.0027488 090 $2,074.2027495 090 $1,948.2027496 090 $936.6027497 090 $1,017.0027498 090 $1,129.2027499 090 $1,207.2027500 090 $892.8027501 090 $865.2027502 090 $1,319.4027503 090 $1,381.8027506 090 $2,312.4027507 090 $1,679.4027508 090 $900.6027509 090 $1,107.6027510 090 $1,177.8027511 090 $1,722.0027513 090 $2,145.6027514 090 $1,671.6027516 090 $873.6027517 090 $1,182.0027519 090 $1,542.0027520 090 $553.2027524 090 $1,298.4027530 090 $516.6027532 090 $1,060.8027535 090 $1,549.8027536 090 $2,056.2027538 090 $813.6027540 090 $1,398.6027550 090 $862.8027552 090 $1,077.0027556 090 $1,516.2027557 090 $1,813.2027558 090 $2,068.8027560 090 $613.8027562 090 $833.4027566 090 $1,543.2027570 010 $259.2027580 090 $2,478.6027590 090 $1,398.6027591 090 $1,671.0027592 090 $1,189.2027594 090 $876.6027596 090 $1,250.4027598 090 $1,247.4027600 090 $717.0027601 090 $772.8027602 090 $851.40



32


HCPCS MOD FUD MAX FEE27603 090 $907.8027604 090 $840.0027605 010 $582.6027606 010 $493.2027607 090 $1,053.0027610 090 $1,123.8027612 090 $973.8027613 010 $427.8027614 090 $981.6027615 090 $1,759.2027616 090 $2,188.8027618 090 $771.6027619 090 $814.2027620 090 $790.8027625 090 $1,006.8027626 090 $1,062.6027630 090 $963.0027632 090 $714.0027634 090 $1,180.2027635 090 $1,011.6027637 090 $1,318.8027638 090 $1,339.2027640 090 $1,443.0027641 090 $1,152.6027645 090 $3,087.0027646 090 $2,676.6027647 090 $1,767.0027648 000 $276.6027650 090 $1,134.6027652 090 $1,182.6027654 090 $1,218.0027656 090 $1,093.2027658 090 $645.0027659 090 $826.8027664 090 $627.0027665 090 $705.0027675 090 $830.4027676 090 $1,021.2027680 090 $743.4027681 090 $941.4027685 090 $1,140.6027686 090 $970.8027687 090 $786.0027690 090 $1,084.2027691 090 $1,294.2027692 ZZZ $180.0027695 090 $821.4027696 090 $948.6027698 090 $1,100.4027700 090 $1,006.2027702 090 $1,675.80



33


HCPCS MOD FUD MAX FEE27703 090 $1,920.6027704 090 $992.4027705 090 $1,294.8027707 090 $693.0027709 090 $2,028.6027712 090 $1,912.2027715 090 $1,814.4027720 090 $1,510.2027722 090 $1,538.4027724 090 $2,190.0027725 090 $2,110.8027726 090 $1,669.2027727 090 $1,472.4027730 090 $1,009.8027732 090 $770.4027734 090 $1,131.0027740 090 $1,221.6027742 090 $1,343.4027745 090 $1,308.6027750 090 $592.8027752 090 $921.6027756 090 $993.0027758 090 $1,538.4027759 090 $1,725.0027760 090 $570.0027762 090 $811.2027766 090 $1,054.2027767 090 $482.4027768 090 $757.8027769 090 $1,251.6027780 090 $523.2027781 090 $724.8027784 090 $1,235.4027786 090 $541.8027788 090 $720.6027792 090 $1,126.2027808 090 $571.8027810 090 $800.4027814 090 $1,333.2027816 090 $549.6027818 090 $828.6027822 090 $1,450.2027823 090 $1,650.0027824 090 $534.6027825 090 $936.6027826 090 $1,435.8027827 090 $1,866.6027828 090 $2,236.8027829 090 $1,179.0027830 090 $644.4027831 090 $688.80



34


HCPCS MOD FUD MAX FEE27832 090 $1,305.6027840 090 $630.0027842 090 $855.6027846 090 $1,263.0027848 090 $1,404.0027860 010 $297.0027870 090 $1,781.4027871 090 $1,180.2027880 090 $1,602.6027881 090 $1,503.6027882 090 $1,047.6027884 090 $1,002.6027886 090 $1,146.6027888 090 $1,191.0027889 090 $1,128.6027892 090 $945.6027893 090 $1,051.2027894 090 $1,492.8028001 010 $484.2028002 010 $763.2028003 090 $1,221.6028005 090 $1,000.2028008 090 $748.2028010 090 $400.2028011 090 $556.2028020 090 $945.0028022 090 $848.4028024 090 $802.2028035 090 $913.2028039 090 $878.4028041 090 $791.4028043 090 $691.8028045 090 $856.2028046 090 $1,259.4028047 090 $1,858.2028050 090 $832.8028052 090 $760.8028054 090 $649.2028055 090 $654.0028060 090 $895.8028062 090 $1,008.6028070 090 $915.6028072 090 $892.8028080 090 $912.0028086 090 $955.8028088 090 $759.6028090 090 $817.2028092 090 $732.0028100 090 $1,059.0028102 090 $1,045.8028103 090 $675.60



35


HCPCS MOD FUD MAX FEE28104 090 $922.8028106 090 $739.8028107 090 $893.4028108 090 $767.4028110 090 $804.0028111 090 $858.0028112 090 $852.0028113 090 $1,029.6028114 090 $1,870.8028116 090 $1,308.0028118 090 $1,027.8028119 090 $910.2028120 090 $1,172.4028122 090 $1,038.0028124 090 $826.8028126 090 $685.2028130 090 $1,053.6028140 090 $1,030.8028150 090 $741.0028153 090 $714.6028160 090 $731.4028171 090 $1,464.0028173 090 $1,315.2028175 090 $844.8028190 010 $445.2028192 090 $813.6028193 090 $923.4028200 090 $847.8028202 090 $1,026.0028208 090 $823.8028210 090 $1,009.2028220 090 $781.2028222 090 $871.8028225 090 $706.8028226 090 $762.6028230 090 $757.8028232 090 $671.4028234 090 $711.0028238 090 $1,173.6028240 090 $765.6028250 090 $1,006.2028260 090 $1,190.4028261 090 $1,727.4028262 090 $2,546.4028264 090 $1,462.8028270 090 $853.2028272 090 $684.0028280 090 $891.0028285 090 $927.0028286 090 $778.8028288 090 $1,044.60



36


HCPCS MOD FUD MAX FEE28289 090 $1,271.4028290 090 $1,026.0028292 090 $1,368.6028293 090 $1,807.2028294 090 $1,324.8028296 090 $1,235.4028297 090 $1,405.2028298 090 $1,247.4028299 090 $1,555.2028300 090 $1,128.0028302 090 $1,234.2028304 090 $1,437.0028305 090 $1,126.2028306 090 $1,064.4028307 090 $1,231.2028308 090 $978.6028309 090 $1,575.0028310 090 $950.4028312 090 $898.2028313 090 $916.8028315 090 $837.6028320 090 $1,048.8028322 090 $1,368.6028340 090 $1,003.2028341 090 $1,162.2028344 090 $958.8028345 090 $906.0028360 090 $1,412.4028400 090 $427.8028405 090 $684.0028406 090 $907.2028415 090 $1,911.6028420 090 $2,170.2028430 090 $406.8028435 090 $556.2028436 090 $775.2028445 090 $1,843.8028446 090 $2,119.2028450 090 $371.4028455 090 $495.6028456 090 $549.6028465 090 $1,065.0028470 090 $376.8028475 090 $441.0028476 090 $604.8028485 090 $907.2028490 090 $251.4028495 090 $310.2028496 090 $766.8028505 090 $1,170.0028510 090 $212.40



37


HCPCS MOD FUD MAX FEE28515 090 $279.6028525 090 $966.6028530 090 $198.0028531 090 $594.0028540 090 $331.2028545 090 $510.0028546 090 $1,000.2028555 090 $1,527.0028570 090 $293.4028575 090 $624.6028576 090 $683.4028585 090 $1,476.0028600 090 $373.2028605 090 $563.4028606 090 $679.2028615 090 $1,360.2028630 010 $268.2028635 010 $295.2028636 010 $604.8028645 090 $1,133.4028660 010 $200.4028665 010 $266.4028666 010 $330.6028675 090 $1,023.0028705 090 $2,173.8028715 090 $1,621.8028725 090 $1,342.8028730 090 $1,261.2028735 090 $1,348.8028737 090 $1,196.4028740 090 $1,466.4028750 090 $1,413.0028755 090 $880.2028760 090 $1,371.0028800 090 $942.6028805 090 $1,268.4028810 090 $748.2028820 090 $981.0028825 090 $937.8028890 090 $559.2029000 000 $522.0029010 000 $380.4029015 000 $474.6029035 000 $383.4029040 000 $379.2029044 000 $444.0029046 000 $407.4029049 000 $126.6029055 000 $382.8029058 000 $213.6029065 000 $165.60



38


HCPCS MOD FUD MAX FEE29075 000 $148.2029085 000 $163.8029086 000 $132.6029105 000 $150.0029125 000 $109.8029126 000 $131.4029130 000 $69.6029131 000 $87.6029200 000 $50.4029240 000 $49.2029260 000 $49.2029280 000 $49.8029305 000 $426.0029325 000 $471.0029345 000 $234.0029355 000 $241.8029358 000 $276.6029365 000 $210.0029405 000 $139.8029425 000 $134.4029435 000 $202.2029440 000 $75.0029445 000 $232.8029450 000 $247.8029505 000 $142.2029515 000 $122.4029520 000 $52.8029530 000 $48.0029540 000 $44.4029550 000 $32.4029580 000 $89.4029581 000 $106.2029582 000 $120.6029583 000 $75.6029584 000 $120.6029700 000 $104.4029705 000 $114.6029710 000 $213.0029720 000 $147.0029730 000 $108.6029740 000 $171.0029750 000 $163.8029800 090 $893.4029804 090 $1,105.8029805 090 $814.8029806 090 $1,833.0029807 090 $1,789.8029819 090 $1,011.6029820 090 $921.0029821 090 $1,004.4029822 090 $975.60



39


HCPCS MOD FUD MAX FEE29823 090 $1,063.2029824 090 $1,145.4029825 090 $994.8029826 ZZZ $304.8029827 090 $1,816.8029828 090 $1,567.2029830 090 $788.4029834 090 $835.2029835 090 $868.8029836 090 $995.4029837 090 $902.4029838 090 $1,008.6029840 090 $780.0029843 090 $836.4029844 090 $849.6029845 090 $990.0029846 090 $892.2029847 090 $937.8029848 090 $877.8029850 090 $1,077.6029851 090 $1,612.2029855 090 $1,356.0029856 090 $1,723.8029860 090 $1,152.6029861 090 $1,232.4029862 090 $1,389.0029863 090 $1,386.0029866 090 $1,815.0029867 090 $2,214.6029868 090 $2,901.6029870 090 $1,005.0029871 090 $888.0029873 090 $905.4029874 090 $926.4029875 090 $855.0029876 090 $1,136.4029877 090 $1,072.8029879 090 $1,143.0029880 090 $969.6029881 090 $934.2029882 090 $1,208.4029883 090 $1,456.8029884 090 $1,056.6029885 090 $1,302.0029886 090 $1,100.4029887 090 $1,287.6029888 090 $1,699.8029889 090 $2,118.0029891 090 $1,172.4029892 090 $1,079.4029893 090 $1,059.00



40


HCPCS MOD FUD MAX FEE29894 090 $865.8029895 090 $835.2029897 090 $874.8029898 090 $978.0029899 090 $1,806.0029900 090 $720.6029901 090 $904.8029902 090 $836.4029904 090 $1,103.4029905 090 $1,120.8029906 090 $1,219.8029907 090 $1,515.6029914 090 $1,710.6029915 090 $1,741.8029916 090 $1,747.2030000 010 $393.6030020 010 $398.4030100 000 $240.6030110 010 $394.2030115 090 $738.6030117 090 $1,500.6030118 090 $1,310.4030120 090 $885.6030124 090 $488.4030125 090 $1,039.8030130 090 $652.2030140 090 $754.2030150 090 $1,314.6030160 090 $1,321.8030200 000 $193.8030210 010 $256.8030220 010 $517.8030300 010 $393.6030310 010 $350.4030320 090 $773.4030400 090 $1,720.2030410 090 $2,019.0030420 090 $2,349.0030430 090 $1,481.4030435 090 $2,133.6030450 090 $2,559.0030460 090 $1,391.4030462 090 $2,421.0030465 090 $1,678.2030520 090 $1,067.4030540 090 $1,176.6030545 090 $1,463.4030560 010 $460.2030580 090 $1,120.8030600 090 $976.8030620 090 $1,069.20



41


HCPCS MOD FUD MAX FEE30630 090 $1,070.4030801 010 $391.8030802 010 $496.8030901 000 $162.6030903 000 $352.2030905 000 $439.8030906 000 $480.0030915 090 $985.2030920 090 $1,428.6030930 010 $211.2031000 010 $315.0031002 010 $330.6031020 090 $833.4031030 090 $1,186.2031032 090 $983.4031040 090 $1,314.6031050 090 $828.6031051 090 $1,103.4031070 090 $750.0031075 090 $1,336.2031080 090 $1,761.6031081 090 $2,608.2031084 090 $1,971.6031085 090 $2,517.6031086 090 $1,915.8031087 090 $1,849.8031090 090 $1,750.2031200 090 $971.4031201 090 $1,266.6031205 090 $1,527.6031225 090 $3,216.0031230 090 $3,557.4031231 000 $358.8031233 000 $448.8031235 000 $511.8031237 000 $442.2031238 000 $441.6031239 010 $1,054.2031240 000 $276.6031254 000 $469.8031255 000 $690.6031256 000 $342.0031267 000 $547.2031276 000 $871.2031287 000 $400.2031288 000 $463.2031290 010 $1,995.6031291 010 $2,126.4031292 010 $1,718.4031293 010 $1,864.2031294 010 $2,135.40



42


HCPCS MOD FUD MAX FEE31295 000 $3,505.2031296 000 $3,555.6031297 000 $3,491.4031300 090 $2,168.4031320 090 $1,124.4031360 090 $3,571.8031365 090 $4,420.2031367 090 $3,784.8031368 090 $4,195.8031370 090 $3,556.2031375 090 $3,376.8031380 090 $3,328.8031382 090 $3,651.0031390 090 $4,900.2031395 090 $5,157.6031400 090 $1,713.0031420 090 $1,432.2031500 000 $189.0031502 000 $60.0031505 000 $142.2031510 000 $363.0031511 000 $361.2031512 000 $354.6031513 000 $229.2031515 000 $354.6031520 000 $271.8031525 000 $434.4031526 000 $272.4031527 000 $340.2031528 000 $250.2031529 000 $280.2031530 000 $341.4031531 000 $369.0031535 000 $330.0031536 000 $366.0031540 000 $420.0031541 000 $457.8031545 000 $629.4031546 000 $957.0031560 000 $544.8031561 000 $595.2031570 000 $583.2031571 000 $433.8031575 000 $195.6031576 000 $382.8031577 000 $414.6031578 000 $477.6031579 000 $360.6031580 090 $2,098.2031582 090 $3,256.8031584 090 $2,594.40



43


HCPCS MOD FUD MAX FEE31587 090 $1,720.8031588 090 $1,958.4031590 090 $1,528.8031595 090 $1,313.4031600 000 $686.4031601 000 $472.8031603 000 $386.4031605 000 $317.4031610 090 $1,229.4031611 090 $927.0031612 000 $147.6031613 090 $780.0031614 090 $1,301.4031615 000 $310.8031620 ZZZ $669.6031622 000 $535.2031623 000 $565.2031624 000 $535.8031625 000 $568.8031626 000 $765.0031627 ZZZ $2,392.8031628 000 $634.8031629 000 $1,007.4031630 000 $346.8031631 000 $399.6031632 ZZZ $121.8031633 ZZZ $150.0031634 000 $3,213.0031635 000 $597.6031636 000 $384.0031637 ZZZ $127.2031638 000 $438.0031640 000 $439.8031641 000 $445.8031643 000 $304.8031645 000 $553.2031646 000 $496.8031647 000 $385.2031648 000 $351.0031649 ZZZ $117.0031651 ZZZ $127.8031660 000 $360.0031661 000 $376.8031717 000 $447.0031720 000 $87.6031725 000 $154.8031730 000 $2,094.0031750 090 $2,366.4031755 090 $2,957.4031760 090 $2,389.2031766 090 $2,933.40



44


HCPCS MOD FUD MAX FEE31770 090 $2,321.4031775 090 $2,133.0031780 090 $2,047.2031781 090 $2,413.2031785 090 $1,853.4031786 090 $2,740.2031800 090 $1,224.6031805 090 $1,419.6031820 090 $744.0031825 090 $1,033.2031830 090 $759.6032035 090 $1,256.4032036 090 $1,347.6032096 090 $1,395.6032097 090 $1,396.2032098 090 $1,324.2032100 090 $1,403.4032110 090 $2,536.2032120 090 $1,507.2032124 090 $1,608.6032140 090 $1,729.8032141 090 $2,645.4032150 090 $1,744.8032151 090 $1,755.6032160 090 $1,366.8032200 090 $1,986.6032215 090 $1,388.4032220 090 $2,746.2032225 090 $1,721.4032310 090 $1,565.4032320 090 $2,772.0032400 000 $259.8032405 000 $768.6032440 090 $2,713.8032442 090 $5,347.8032445 090 $6,166.8032480 090 $2,563.2032482 090 $2,749.2032484 090 $2,494.8032486 090 $4,087.2032488 090 $4,195.8032491 090 $2,566.2032501 ZZZ $426.0032503 090 $3,144.6032504 090 $3,606.6032505 090 $1,615.8032506 ZZZ $273.0032507 ZZZ $272.4032540 090 $3,007.8032550 000 $1,336.2032551 000 $295.20



45


HCPCS MOD FUD MAX FEE32552 010 $318.6032553 000 $1,011.0032554 000 $343.2032555 000 $493.2032556 000 $946.2032557 000 $870.6032560 000 $415.8032561 000 $159.6032562 000 $144.6032601 000 $534.6032604 000 $841.2032606 000 $801.6032607 000 $535.8032608 000 $657.6032609 000 $450.6032650 090 $1,153.8032651 090 $1,902.0032652 090 $2,883.0032653 090 $1,836.6032654 090 $1,984.2032655 090 $1,657.8032656 090 $1,392.0032658 090 $1,242.6032659 090 $1,270.2032661 090 $1,392.0032662 090 $1,551.6032663 090 $2,431.8032664 090 $1,477.8032665 090 $2,149.8032666 090 $1,511.4032667 ZZZ $274.2032668 ZZZ $273.6032669 090 $2,335.8032670 090 $2,787.0032671 090 $3,102.0032672 090 $2,641.2032673 090 $2,114.4032674 ZZZ $375.0032701 XXX $372.0032800 090 $1,656.6032810 090 $1,570.8032815 090 $4,869.0032820 090 $2,436.0032851 090 $5,721.6032852 090 $6,270.0032853 090 $7,996.2032854 090 $8,488.8032900 090 $2,478.0032905 090 $2,331.0032906 090 $2,879.4032940 090 $2,152.80



46


HCPCS MOD FUD MAX FEE32960 000 $217.2032997 000 $591.6032998 000 $5,053.8033010 000 $208.8033011 000 $210.6033015 090 $880.8033020 090 $1,529.4033025 090 $1,385.4033030 090 $3,478.8033031 090 $4,284.0033050 090 $1,747.2033120 090 $3,645.0033130 090 $2,410.8033140 090 $2,755.2033141 ZZZ $228.6033202 090 $1,345.8033203 090 $1,398.6033206 090 $800.4033207 090 $851.4033208 090 $921.6033210 000 $310.2033211 000 $316.2033212 090 $576.0033213 090 $602.4033214 090 $844.2033215 090 $534.6033216 090 $662.4033217 090 $649.8033218 090 $694.8033220 090 $693.6033221 090 $645.0033222 090 $603.0033223 090 $726.0033224 000 $892.2033225 ZZZ $810.0033226 000 $856.2033227 090 $606.6033228 090 $633.0033229 090 $664.8033230 090 $681.0033231 090 $718.8033233 090 $419.4033234 090 $861.0033235 090 $1,118.4033236 090 $1,359.0033237 090 $1,459.2033238 090 $1,623.6033240 090 $654.0033241 090 $395.4033243 090 $2,379.0033244 090 $1,505.40



47


HCPCS MOD FUD MAX FEE33249 090 $1,603.8033250 090 $2,569.2033251 090 $2,820.0033254 090 $2,365.2033255 090 $2,847.6033256 090 $3,388.2033257 ZZZ $1,011.0033258 ZZZ $1,142.4033259 ZZZ $1,465.2033261 090 $2,820.0033262 090 $666.0033263 090 $691.8033264 090 $720.6033265 090 $2,359.2033266 090 $3,214.8033270 090 $1,101.0033271 090 $837.0033272 090 $745.8033273 090 $673.8033282 090 $412.2033284 090 $364.8033300 090 $4,254.0033305 090 $7,131.6033310 090 $2,082.0033315 090 $3,330.6033320 090 $1,849.8033321 090 $2,091.6033322 090 $2,407.2033335 090 $3,286.8033361 000 $2,360.4033362 000 $2,580.0033363 000 $2,710.2033364 000 $2,808.6033365 000 $3,092.4033366 000 $3,369.6033367 ZZZ $1,084.2033368 ZZZ $1,302.0033369 ZZZ $1,719.0033400 090 $3,959.4033401 090 $2,512.2033403 090 $2,577.6033404 090 $3,085.8033405 090 $3,941.4033406 090 $4,994.4033410 090 $4,408.8033411 090 $5,828.4033412 090 $5,524.8033413 090 $5,697.6033414 090 $3,732.6033415 090 $3,532.2033416 090 $3,530.40



48


HCPCS MOD FUD MAX FEE33417 090 $2,884.2033418 090 $2,979.0033419 ZZZ $956.4033420 090 $2,509.8033422 090 $2,912.4033425 090 $4,744.2033426 090 $4,135.8033427 090 $4,245.0033430 090 $4,858.2033460 090 $4,246.8033463 090 $5,374.8033464 090 $4,242.0033465 090 $4,791.0033468 090 $4,255.2033470 090 $2,143.8033471 090 $2,184.0033475 090 $4,078.8033476 090 $2,652.6033478 090 $2,727.0033496 090 $2,913.6033500 090 $2,730.6033501 090 $1,950.0033502 090 $2,215.8033503 090 $2,298.6033504 090 $2,541.0033505 090 $3,582.6033506 090 $3,763.8033507 090 $2,991.0033508 ZZZ $27.6033510 090 $3,355.2033511 090 $3,687.0033512 090 $4,193.4033513 090 $4,315.2033514 090 $4,560.6033516 090 $4,777.2033517 ZZZ $326.4033518 ZZZ $715.8033519 ZZZ $946.8033521 ZZZ $1,135.2033522 ZZZ $1,276.2033523 ZZZ $1,458.6033530 ZZZ $914.4033533 090 $3,244.8033534 090 $3,818.4033535 090 $4,260.0033536 090 $4,596.6033542 090 $4,559.4033545 090 $5,381.4033548 090 $5,148.0033572 ZZZ $402.0033600 090 $3,006.60



49


HCPCS MOD FUD MAX FEE33602 090 $2,917.2033606 090 $2,941.2033608 090 $3,122.4033610 090 $3,105.6033611 090 $3,240.0033612 090 $3,478.8033615 090 $3,494.4033617 090 $3,754.2033619 090 $4,514.4033620 090 $2,332.8033621 090 $1,625.4033622 090 $5,281.2033641 090 $2,839.2033645 090 $3,003.0033647 090 $3,155.4033660 090 $3,076.8033665 090 $3,322.8033670 090 $3,453.6033675 090 $3,454.2033676 090 $3,361.2033677 090 $3,493.2033681 090 $3,199.8033684 090 $3,308.4033688 090 $3,271.8033690 090 $2,097.0033692 090 $3,253.8033694 090 $3,388.2033697 090 $3,651.6033702 090 $2,682.6033710 090 $3,647.4033720 090 $2,706.6033722 090 $2,841.0033724 090 $2,671.8033726 090 $3,561.6033730 090 $3,510.0033732 090 $2,883.0033735 090 $2,266.8033736 090 $2,437.2033737 090 $2,141.4033750 090 $2,313.6033755 090 $2,170.8033762 090 $2,119.2033764 090 $2,170.8033766 090 $2,440.8033767 090 $2,467.2033768 ZZZ $695.4033770 090 $3,520.2033771 090 $3,625.8033774 090 $3,148.2033775 090 $3,067.8033776 090 $3,243.00



50


HCPCS MOD FUD MAX FEE33777 090 $3,136.8033778 090 $3,898.8033779 090 $3,870.0033780 090 $3,939.6033781 090 $3,850.8033782 090 $5,650.2033783 090 $5,807.4033786 090 $3,781.8033788 090 $2,682.6033800 090 $1,810.8033802 090 $1,989.0033803 090 $1,902.6033813 090 $2,044.2033814 090 $2,665.8033820 090 $1,680.0033822 090 $1,687.2033824 090 $2,044.2033840 090 $2,042.4033845 090 $2,312.4033851 090 $2,098.2033852 090 $2,424.6033853 090 $3,178.8033860 090 $5,581.2033863 090 $5,476.2033864 090 $5,613.6033870 090 $4,381.8033875 090 $4,780.2033877 090 $6,353.4033880 090 $3,162.0033881 090 $2,716.2033883 090 $1,968.0033884 ZZZ $726.6033886 090 $1,699.8033889 000 $1,393.8033891 000 $1,708.2033910 090 $4,580.4033915 090 $2,229.6033916 090 $7,332.6033917 090 $2,549.4033920 090 $3,165.6033922 090 $2,407.8033924 ZZZ $497.4033925 090 $3,007.2033926 090 $4,423.2033935 090 $8,643.0033945 090 $8,451.6033946 XXX $549.0033947 XXX $598.2033948 XXX $419.4033949 XXX $409.2033951 000 $677.40



51


HCPCS MOD FUD MAX FEE33952 000 $660.0033953 000 $754.2033954 000 $735.0033955 000 $1,553.4033956 000 $1,468.8033957 000 $517.2033958 000 $505.8033959 000 $597.0033962 000 $570.0033963 000 $972.6033964 000 $984.6033965 000 $511.8033966 000 $566.4033967 000 $450.6033968 000 $58.2033969 000 $595.8033970 000 $616.8033971 090 $1,234.8033973 000 $897.0033974 090 $1,552.8033975 XXX $2,284.2033976 XXX $2,782.2033977 XXX $1,969.2033978 XXX $2,335.2033979 XXX $3,405.0033980 XXX $3,105.0033981 XXX $1,457.4033982 XXX $3,425.4033983 XXX $4,046.4033984 000 $583.2033985 000 $1,102.2033986 000 $1,050.6033987 ZZZ $442.2033988 000 $1,290.0033989 000 $861.6033990 XXX $763.2033991 XXX $1,105.8033992 XXX $370.8033993 XXX $327.0034001 090 $1,740.6034051 090 $1,574.4034101 090 $1,062.0034111 090 $1,056.6034151 090 $2,475.0034201 090 $1,821.6034203 090 $1,683.0034401 090 $2,571.0034421 090 $1,284.0034451 090 $2,899.8034471 090 $1,908.0034490 090 $1,076.40



52


HCPCS MOD FUD MAX FEE34501 090 $1,579.8034502 090 $2,687.4034510 090 $2,079.0034520 090 $1,749.6034530 090 $1,930.8034800 090 $1,989.6034802 090 $2,200.2034803 090 $2,271.0034804 090 $2,196.6034805 090 $2,117.4034806 ZZZ $176.4034808 ZZZ $367.8034812 000 $594.6034813 ZZZ $418.2034820 000 $864.6034825 090 $1,226.4034826 ZZZ $361.8034830 090 $3,120.0034831 090 $3,354.6034832 090 $3,354.6034833 000 $1,078.8034834 000 $480.6034900 090 $1,577.4035001 090 $1,994.4035002 090 $2,008.2035005 090 $2,028.0035011 090 $1,767.6035013 090 $2,197.2035021 090 $2,215.8035022 090 $2,538.6035045 090 $1,751.4035081 090 $3,087.0035082 090 $3,876.0035091 090 $3,170.4035092 090 $4,614.6035102 090 $3,342.0035103 090 $3,981.6035111 090 $2,350.2035112 090 $3,294.6035121 090 $2,904.6035122 090 $3,801.6035131 090 $2,455.2035132 090 $2,892.6035141 090 $1,957.8035142 090 $2,330.4035151 090 $2,197.2035152 090 $2,473.8035180 090 $1,582.8035182 090 $2,855.4035184 090 $1,962.0035188 090 $1,867.80



53


HCPCS MOD FUD MAX FEE35189 090 $2,672.4035190 090 $1,339.2035201 090 $1,682.4035206 090 $1,362.0035207 090 $1,301.4035211 090 $2,401.2035216 090 $3,576.0035221 090 $2,548.2035226 090 $1,466.4035231 090 $2,149.8035236 090 $1,727.4035241 090 $2,515.2035246 090 $2,760.6035251 090 $3,002.4035256 090 $1,795.2035261 090 $1,888.2035266 090 $1,525.8035271 090 $2,415.6035276 090 $2,562.6035281 090 $2,859.0035286 090 $1,647.0035301 090 $1,999.2035302 090 $1,991.4035303 090 $2,194.8035304 090 $2,270.4035305 090 $2,162.4035306 ZZZ $790.2035311 090 $2,743.8035321 090 $1,569.6035331 090 $2,570.4035341 090 $2,403.0035351 090 $2,262.6035355 090 $1,830.0035361 090 $2,693.4035363 090 $3,097.8035371 090 $1,449.6035372 090 $1,735.2035390 ZZZ $282.6035400 ZZZ $264.0035450 000 $884.4035452 000 $602.4035458 000 $862.8035460 000 $553.2035471 000 $4,369.8035472 000 $3,198.0035475 000 $2,665.2035476 000 $2,436.6035500 ZZZ $563.4035501 090 $2,658.6035506 090 $2,257.2035508 090 $2,353.20



54


HCPCS MOD FUD MAX FEE35509 090 $2,504.4035510 090 $2,179.2035511 090 $1,984.2035512 090 $2,436.6035515 090 $2,696.4035516 090 $2,161.2035518 090 $2,022.6035521 090 $2,172.0035522 090 $2,148.6035523 090 $2,284.8035525 090 $2,031.6035526 090 $3,055.2035531 090 $3,575.4035533 090 $2,667.0035535 090 $3,369.6035536 090 $2,992.2035537 090 $4,188.6035538 090 $4,134.0035539 090 $3,882.6035540 090 $4,539.6035556 090 $2,477.4035558 090 $2,170.8035560 090 $3,017.4035563 090 $2,680.8035565 090 $2,349.6035566 090 $2,957.4035570 090 $2,685.6035571 090 $2,352.6035572 ZZZ $609.6035583 090 $2,568.6035585 090 $2,974.2035587 090 $2,427.6035600 ZZZ $445.2035601 090 $2,481.6035606 090 $2,083.2035612 090 $1,848.6035616 090 $1,952.4035621 090 $1,948.2035623 090 $2,324.4035626 090 $2,772.6035631 090 $3,276.6035632 090 $3,199.2035633 090 $3,564.6035634 090 $3,241.8035636 090 $2,823.0035637 090 $3,080.4035638 090 $3,122.4035642 090 $2,026.8035645 090 $1,674.0035646 090 $3,039.6035647 090 $2,744.40



55


HCPCS MOD FUD MAX FEE35650 090 $1,926.6035654 090 $2,428.8035656 090 $1,918.2035661 090 $1,920.6035663 090 $2,234.4035665 090 $2,074.8035666 090 $2,238.0035671 090 $1,977.0035681 ZZZ $141.6035682 ZZZ $624.6035683 ZZZ $724.8035685 ZZZ $351.0035686 ZZZ $285.6035691 090 $1,672.8035693 090 $1,476.0035694 090 $1,746.6035695 090 $1,813.2035697 ZZZ $261.6035700 ZZZ $270.6035701 090 $991.8035721 090 $803.4035741 090 $900.0035761 090 $687.6035800 090 $1,249.8035820 090 $3,497.4035840 090 $2,065.8035860 090 $1,479.0035870 090 $2,202.6035875 090 $1,050.0035876 090 $1,669.8035879 090 $1,631.4035881 090 $1,799.4035883 090 $2,139.0035884 090 $2,196.6035901 090 $870.0035903 090 $996.6035905 090 $3,108.6035907 090 $3,379.8036000 XXX $43.2036002 000 $278.4036005 000 $551.4036010 XXX $855.0036011 XXX $1,425.6036012 XXX $1,473.6036013 XXX $1,333.2036014 XXX $1,387.8036015 XXX $1,472.4036100 XXX $837.6036120 XXX $717.6036140 XXX $745.2036147 XXX $1,427.40



56


HCPCS MOD FUD MAX FEE36148 ZZZ $445.8036160 XXX $845.4036200 000 $1,066.8036215 XXX $1,923.6036216 XXX $2,000.4036217 XXX $3,234.0036218 ZZZ $315.6036221 000 $1,868.4036222 000 $2,163.6036223 000 $2,597.4036224 000 $3,238.8036225 000 $2,506.8036226 000 $3,163.2036227 ZZZ $448.2036228 ZZZ $2,152.8036245 XXX $2,337.0036246 000 $1,524.0036247 000 $2,692.8036248 ZZZ $260.4036251 000 $2,429.4036252 000 $2,637.6036253 000 $3,870.6036254 000 $3,763.2036260 090 $1,119.0036261 090 $627.6036262 090 $530.4036400 XXX $48.0036405 XXX $45.0036406 XXX $34.8036410 XXX $28.8036420 XXX $87.6036425 XXX $68.4036430 XXX $58.8036440 XXX $96.6036450 XXX $204.0036455 XXX $222.0036460 XXX $597.6036470 010 $255.0036471 010 $298.2036475 000 $2,625.6036476 ZZZ $507.0036478 000 $2,049.6036479 ZZZ $526.8036481 000 $3,520.8036500 000 $315.0036510 000 $158.4036511 000 $159.0036512 000 $162.0036513 000 $166.8036514 000 $911.4036515 000 $3,498.00



57


HCPCS MOD FUD MAX FEE36516 000 $3,531.0036522 000 $2,370.0036555 000 $433.8036556 000 $399.6036557 010 $1,747.8036558 010 $1,338.0036560 010 $1,830.6036561 010 $2,010.0036563 010 $2,283.6036565 010 $1,651.2036566 010 $9,453.6036568 000 $519.0036569 000 $427.2036570 010 $2,032.8036571 010 $2,235.6036575 000 $283.8036576 010 $664.8036578 010 $892.8036580 000 $368.4036581 010 $1,312.2036582 010 $1,875.6036583 010 $2,335.2036584 000 $349.2036585 010 $1,980.0036589 010 $283.2036590 010 $502.8036591 XXX $39.6036592 XXX $43.8036593 XXX $52.2036595 000 $1,000.8036596 000 $227.4036597 000 $217.8036598 000 $187.8036600 XXX $53.4036620 000 $87.6036625 000 $177.6036640 000 $206.4036660 000 $104.4036680 000 $102.0036800 000 $214.2036810 000 $372.6036815 000 $240.6036818 090 $1,221.6036819 090 $1,293.6036820 090 $1,284.6036821 090 $1,171.8036823 090 $2,410.2036825 090 $1,413.0036830 090 $1,177.8036831 090 $1,089.6036832 090 $1,336.80



58


HCPCS MOD FUD MAX FEE36833 090 $1,429.2036835 090 $876.6036838 090 $2,020.2036860 000 $356.4036861 000 $230.4036870 090 $3,131.4037140 090 $4,014.0037145 090 $3,722.4037160 090 $3,822.6037180 090 $3,678.0037181 090 $4,014.0037182 000 $1,462.2037183 000 $10,090.8037184 000 $3,886.8037185 ZZZ $1,230.0037186 ZZZ $2,356.8037187 000 $3,529.8037188 000 $3,013.2037191 000 $4,501.2037192 000 $2,871.0037193 000 $2,739.0037197 000 $2,599.8037200 000 $386.4037202 000 $524.4037211 000 $699.6037212 000 $613.8037213 000 $433.2037214 000 $238.8037215 090 $1,903.8037217 090 $1,992.0037218 090 $1,399.8037220 000 $5,395.2037221 000 $7,958.4037222 ZZZ $1,513.8037223 ZZZ $4,434.6037224 000 $6,547.8037225 000 $18,840.0037226 000 $15,491.4037227 000 $25,443.6037228 000 $9,312.0037229 000 $18,585.0037230 000 $14,209.2037231 000 $22,833.0037232 ZZZ $2,077.2037233 ZZZ $2,512.2037234 ZZZ $6,628.2037235 ZZZ $7,116.6037236 000 $7,057.2037237 ZZZ $4,247.4037238 000 $7,024.8037239 ZZZ $3,482.40



59


HCPCS MOD FUD MAX FEE37241 000 $7,845.0037242 000 $13,224.6037243 000 $16,693.8037244 000 $11,681.4037250 ZZZ $187.8037251 ZZZ $139.8037500 090 $1,126.8037565 090 $1,278.6037600 090 $1,265.4037605 090 $1,389.0037606 090 $849.6037607 090 $660.6037609 010 $533.4037615 090 $881.4037616 090 $1,928.4037617 090 $2,341.8037618 090 $669.0037619 090 $2,848.8037650 090 $812.4037660 090 $2,275.2037700 090 $437.4037718 090 $767.4037722 090 $839.4037735 090 $1,029.6037760 090 $1,077.0037761 090 $976.2037765 090 $1,130.4037766 090 $1,342.2037780 090 $451.2037785 090 $621.6037788 090 $2,171.4037790 090 $837.0038100 090 $1,993.2038101 090 $2,015.4038102 ZZZ $453.6038115 090 $2,206.8038120 090 $1,820.4038200 000 $232.8038204 XXX $172.8038205 000 $141.6038206 000 $142.2038207 XXX $76.8038208 XXX $48.0038209 XXX $20.4038210 XXX $136.2038211 XXX $123.0038212 XXX $81.6038213 XXX $20.4038214 XXX $70.2038215 XXX $81.6038220 XXX $280.80



60


HCPCS MOD FUD MAX FEE38221 XXX $285.0038230 000 $341.4038232 000 $350.4038240 XXX $384.6038241 XXX $289.8038242 000 $205.2038243 000 $204.0038300 010 $470.4038305 090 $798.0038308 090 $766.2038380 090 $967.8038381 090 $1,390.8038382 090 $1,173.0038500 010 $568.2038505 000 $216.6038510 010 $893.4038520 090 $799.2038525 090 $752.4038530 090 $942.6038542 090 $895.2038550 090 $876.0038555 090 $1,737.0038562 090 $1,215.0038564 090 $1,215.6038570 010 $928.2038571 010 $1,376.4038572 010 $1,698.6038700 090 $1,392.6038720 090 $2,324.4038724 090 $2,515.8038740 090 $1,196.4038745 090 $1,510.2038746 ZZZ $374.4038747 ZZZ $462.0038760 090 $1,452.0038765 090 $2,231.4038770 090 $1,391.4038780 090 $1,769.4038790 000 $144.0038792 000 $68.4038794 090 $522.0038900 ZZZ $238.2039000 090 $861.6039010 090 $1,367.4039200 090 $1,526.4039220 090 $1,977.0039400 010 $883.2039501 090 $1,470.0039503 090 $10,654.2039540 090 $1,502.4039541 090 $1,639.20



61


HCPCS MOD FUD MAX FEE39545 090 $1,547.4039560 090 $1,380.6039561 090 $2,143.8040490 000 $220.2040500 090 $871.8040510 090 $837.0040520 090 $846.0040525 090 $954.6040527 090 $1,071.0040530 090 $931.8040650 090 $754.2040652 090 $850.2040654 090 $981.0040700 090 $1,741.8040701 090 $1,692.6040702 090 $1,625.4040720 090 $1,780.2040761 090 $1,690.8040800 010 $371.4040801 010 $553.8040804 010 $370.8040805 010 $565.8040806 000 $187.2040808 010 $327.0040810 010 $361.2040812 010 $504.6040814 090 $676.2040816 090 $703.2040818 090 $628.2040819 090 $550.8040820 010 $465.6040830 010 $463.8040831 010 $587.4040840 090 $1,415.4040842 090 $1,428.0040843 090 $1,896.0040844 090 $2,247.0040845 090 $2,548.2041000 010 $283.8041005 010 $396.0041006 090 $670.8041007 090 $660.0041008 090 $664.8041009 090 $703.8041010 010 $353.4041015 090 $792.0041016 090 $769.8041017 090 $782.4041018 090 $883.8041019 000 $801.6041100 010 $292.80



62


HCPCS MOD FUD MAX FEE41105 010 $298.2041108 010 $258.6041110 010 $370.2041112 090 $586.2041113 090 $642.0041114 090 $1,112.4041115 010 $429.6041116 090 $577.8041120 090 $1,827.0041130 090 $2,259.6041135 090 $3,750.0041140 090 $3,768.6041145 090 $4,768.8041150 090 $3,785.4041153 090 $4,133.4041155 090 $5,201.4041250 010 $468.6041251 010 $508.2041252 010 $549.6041500 090 $796.8041510 090 $696.6041512 090 $1,109.4041520 090 $620.4041530 010 $5,568.6041800 010 $469.8041805 010 $435.0041806 010 $622.8041822 010 $543.0041823 090 $793.8041825 010 $371.4041826 010 $552.0041827 090 $775.2041828 010 $540.0041830 010 $691.2041872 090 $654.6041874 090 $662.4042000 010 $275.4042100 010 $262.2042104 010 $375.6042106 010 $478.8042107 090 $803.4042120 090 $1,731.6042140 090 $439.2042145 090 $1,224.6042160 010 $405.0042180 010 $423.0042182 010 $556.2042200 090 $1,476.6042205 090 $1,540.8042210 090 $1,874.4042215 090 $1,250.40



63


HCPCS MOD FUD MAX FEE42220 090 $930.6042225 090 $1,528.2042226 090 $1,555.8042227 090 $1,458.0042235 090 $1,278.0042260 090 $1,498.8042280 010 $287.4042281 010 $355.8042300 010 $363.6042305 090 $749.4042310 010 $280.2042320 010 $432.6042330 010 $403.8042335 090 $651.6042340 090 $811.2042400 000 $183.0042405 010 $517.8042408 090 $784.8042409 090 $579.0042410 090 $1,077.0042415 090 $1,833.0042420 090 $2,059.2042425 090 $1,448.4042426 090 $2,344.2042440 090 $715.8042450 090 $787.8042500 090 $753.0042505 090 $964.8042507 090 $891.0042509 090 $1,468.2042510 090 $1,091.4042550 000 $232.2042600 090 $831.6042650 000 $144.6042660 000 $220.2042665 090 $540.0042700 010 $329.4042720 010 $787.2042725 090 $1,422.6042800 010 $275.4042804 010 $339.0042806 010 $379.8042808 010 $393.6042809 010 $299.4042810 090 $673.8042815 090 $973.8042820 090 $504.0042821 090 $523.2042825 090 $455.4042826 090 $436.8042830 090 $360.00



64


HCPCS MOD FUD MAX FEE42831 090 $388.8042835 090 $334.2042836 090 $418.8042842 090 $1,730.4042844 090 $2,379.6042845 090 $3,846.6042860 090 $327.0042870 090 $1,006.8042890 090 $2,449.2042892 090 $3,256.8042894 090 $4,081.8042900 010 $588.6042950 090 $1,379.4042953 090 $1,659.0042955 090 $1,306.8042960 010 $295.8042961 090 $736.2042962 090 $902.4042970 090 $720.6042971 090 $795.6042972 090 $889.2043020 090 $979.2043030 090 $901.8043045 090 $2,269.8043100 090 $1,088.4043101 090 $1,843.8043107 090 $4,445.4043108 090 $8,146.2043112 090 $4,686.0043113 090 $7,607.4043116 090 $9,074.4043117 090 $4,287.6043118 090 $6,640.8043121 090 $4,995.0043122 090 $4,441.8043123 090 $8,253.0043124 090 $6,656.4043130 090 $1,365.0043135 090 $2,592.6043180 090 $911.4043191 000 $213.0043192 000 $252.6043193 000 $300.0043194 000 $270.0043195 000 $300.6043196 000 $351.6043197 000 $316.8043198 000 $354.6043200 000 $463.2043201 000 $473.4043202 000 $621.60



65


HCPCS MOD FUD MAX FEE43204 000 $249.6043205 000 $258.6043206 000 $559.8043211 000 $404.4043212 000 $334.2043213 000 $2,121.6043214 000 $339.6043215 000 $700.8043216 000 $721.2043217 000 $770.4043220 000 $1,951.2043226 000 $654.0043227 000 $679.2043229 000 $1,249.2043231 000 $693.6043232 000 $811.8043233 000 $402.0043235 000 $537.0043236 000 $669.6043237 000 $358.8043238 000 $412.2043239 000 $687.0043240 000 $712.8043241 000 $263.4043242 000 $466.2043243 000 $433.2043244 000 $449.4043245 000 $1,062.0043246 000 $365.4043247 000 $699.0043248 000 $709.8043249 000 $1,864.2043250 000 $788.4043251 000 $865.2043252 000 $621.0043253 000 $466.2043254 000 $474.0043255 000 $743.4043257 000 $411.0043259 000 $414.6043260 000 $587.4043261 000 $616.8043262 000 $649.8043263 000 $652.8043264 000 $662.4043265 000 $786.6043266 000 $402.0043270 000 $1,300.8043273 ZZZ $214.2043274 000 $829.2043275 000 $684.60



66


HCPCS MOD FUD MAX FEE43276 000 $864.6043277 000 $688.8043278 000 $782.4043279 090 $2,239.2043280 090 $1,870.2043281 090 $2,673.0043282 090 $3,006.0043283 ZZZ $276.0043300 090 $1,068.0043305 090 $1,894.8043310 090 $2,567.4043312 090 $2,790.0043313 090 $4,513.2043314 090 $4,870.8043320 090 $2,415.6043325 090 $2,329.2043327 090 $1,413.0043328 090 $1,969.8043330 090 $2,308.8043331 090 $2,340.0043332 090 $2,010.6043333 090 $2,188.8043334 090 $2,177.4043335 090 $2,340.6043336 090 $2,638.2043337 090 $2,835.6043338 ZZZ $202.2043340 090 $2,385.6043341 090 $2,567.4043351 090 $2,413.2043352 090 $1,861.8043360 090 $4,128.0043361 090 $4,450.8043400 090 $2,634.6043401 090 $2,719.8043405 090 $2,668.2043410 090 $1,822.8043415 090 $4,455.6043420 090 $1,767.0043425 090 $2,521.2043450 000 $367.2043453 000 $1,677.0043460 000 $381.6043500 090 $1,355.4043501 090 $2,329.8043502 090 $2,640.0043510 090 $1,635.0043520 090 $1,186.8043605 090 $1,443.6043610 090 $1,696.8043611 090 $2,110.80



67


HCPCS MOD FUD MAX FEE43620 090 $3,405.6043621 090 $3,928.8043622 090 $4,006.2043631 090 $2,508.0043632 090 $3,514.2043633 090 $3,321.0043634 090 $3,683.4043635 ZZZ $195.6043640 090 $2,036.4043641 090 $2,079.0043644 090 $2,996.4043645 090 $3,201.0043651 090 $1,131.6043652 090 $1,321.8043653 090 $988.2043752 000 $70.2043753 000 $37.2043754 000 $223.8043755 000 $237.6043756 000 $353.4043757 000 $505.8043760 000 $838.8043761 000 $201.0043770 090 $1,933.2043771 090 $2,195.4043772 090 $1,644.0043773 090 $2,213.4043774 090 $1,657.8043800 090 $1,606.2043810 090 $1,762.2043820 090 $2,317.8043825 090 $2,265.6043830 090 $1,207.2043831 090 $1,026.6043832 090 $1,799.4043840 090 $2,347.8043842 090 $1,979.4043843 090 $2,215.2043845 090 $3,397.2043846 090 $2,789.4043847 090 $3,120.0043848 090 $3,327.6043850 090 $2,820.0043855 090 $2,926.2043860 090 $2,832.0043865 090 $2,961.0043870 090 $1,233.0043880 090 $2,757.6043886 090 $625.8043887 090 $565.2043888 090 $793.80



68


HCPCS MOD FUD MAX FEE44005 090 $1,890.6044010 090 $1,498.8044015 ZZZ $246.6044020 090 $1,684.8044021 090 $1,687.2044025 090 $1,705.2044050 090 $1,615.8044055 090 $2,574.6044100 000 $192.6044110 090 $1,473.0044111 090 $1,698.6044120 090 $2,113.8044121 ZZZ $420.0044125 090 $2,041.2044126 090 $4,271.4044127 090 $4,940.4044128 ZZZ $423.6044130 090 $2,269.8044139 ZZZ $210.0044140 090 $2,319.6044141 090 $3,158.4044143 090 $2,879.4044144 090 $3,061.8044145 090 $2,869.8044146 090 $3,675.0044147 090 $3,363.6044150 090 $3,238.8044151 090 $3,724.2044155 090 $3,602.4044156 090 $4,006.8044157 090 $3,778.2044158 090 $3,670.2044160 090 $2,146.8044180 090 $1,587.6044186 090 $1,127.4044187 090 $1,918.8044188 090 $2,120.4044202 090 $2,396.4044203 ZZZ $423.6044204 090 $2,662.2044205 090 $2,316.0044206 090 $3,036.6044207 090 $3,155.4044208 090 $3,447.6044210 090 $3,086.4044211 090 $3,769.2044212 090 $3,556.2044213 ZZZ $327.6044227 090 $2,889.0044300 090 $1,453.2044310 090 $1,805.40



69


HCPCS MOD FUD MAX FEE44312 090 $1,020.0044314 090 $1,736.4044316 090 $2,447.4044320 090 $2,077.2044322 090 $1,731.0044340 090 $1,078.8044345 090 $1,819.2044346 090 $2,046.0044360 000 $266.4044361 000 $294.6044363 000 $351.6044364 000 $375.6044365 000 $327.0044366 000 $439.8044369 000 $450.0044370 000 $487.2044372 000 $437.4044373 000 $352.2044376 000 $516.0044377 000 $546.0044378 000 $700.2044379 000 $745.2044380 000 $98.4044382 000 $120.6044385 000 $454.8044386 000 $605.4044388 000 $603.6044389 000 $676.2044390 000 $792.6044391 000 $850.8044392 000 $750.6044394 000 $847.8044500 000 $42.6044602 090 $2,439.0044603 090 $2,803.8044604 090 $1,830.6044605 090 $2,259.0044615 090 $1,853.4044620 090 $1,502.4044625 090 $1,761.0044626 090 $2,773.2044640 090 $2,424.6044650 090 $2,513.4044660 090 $2,311.8044661 090 $2,684.4044680 090 $1,845.0044700 090 $1,765.2044701 ZZZ $290.4044720 XXX $476.4044721 XXX $666.6044800 090 $1,324.20



70


HCPCS MOD FUD MAX FEE44820 090 $1,466.4044850 090 $1,298.4044900 090 $1,339.8044950 090 $1,109.4044955 ZZZ $145.2044960 090 $1,509.0044970 090 $1,038.0045000 090 $727.8045005 010 $466.2045020 090 $983.4045100 090 $518.4045108 090 $637.2045110 090 $3,200.4045111 090 $1,882.2045112 090 $3,259.8045113 090 $3,272.4045114 090 $3,147.0045116 090 $2,685.0045119 090 $3,379.2045120 090 $2,754.0045121 090 $2,850.6045123 090 $1,941.6045126 090 $4,704.0045130 090 $1,883.4045135 090 $2,383.2045136 090 $3,124.2045150 090 $619.2045160 090 $1,768.2045171 090 $1,038.0045172 090 $1,400.4045190 090 $1,199.4045300 000 $210.6045303 000 $1,655.4045305 000 $335.4045307 000 $383.4045308 000 $376.8045309 000 $379.2045315 000 $424.8045317 000 $415.2045320 000 $420.6045321 000 $185.4045327 000 $211.2045330 000 $234.0045331 000 $279.0045332 000 $498.6045333 000 $507.0045334 000 $279.0045335 000 $469.8045337 000 $244.2045338 000 $544.8045340 000 $831.60



71


HCPCS MOD FUD MAX FEE45341 000 $266.4045342 000 $405.6045378 53 000 $234.0045378 000 $663.6045379 000 $853.8045380 000 $789.0045381 000 $792.6045382 000 $1,026.0045384 000 $792.6045385 000 $891.6045386 000 $1,137.6045391 000 $504.0045392 000 $642.0045395 090 $3,432.0045397 090 $3,736.8045400 090 $1,971.6045402 090 $2,633.4045500 090 $907.2045505 090 $1,027.2045520 000 $273.0045540 090 $1,835.4045541 090 $1,623.0045550 090 $2,528.4045560 090 $1,190.4045562 090 $1,979.4045563 090 $2,853.0045800 090 $2,140.2045805 090 $2,389.2045820 090 $1,940.4045825 090 $2,503.8045900 010 $351.6045905 010 $292.8045910 010 $336.6045915 010 $569.4045990 000 $186.0046020 010 $475.2046030 010 $238.2046040 090 $918.6046045 090 $749.4046050 010 $346.2046060 090 $821.4046070 090 $380.4046080 010 $424.8046083 010 $301.2046200 090 $765.0046220 010 $353.4046221 010 $463.2046230 010 $468.6046250 090 $794.4046255 090 $871.2046257 090 $726.00



72


HCPCS MOD FUD MAX FEE46258 090 $803.4046260 090 $821.4046261 090 $899.4046262 090 $954.6046270 090 $872.4046275 090 $924.6046280 090 $810.0046285 090 $915.6046288 090 $950.4046320 010 $313.8046500 010 $410.4046505 010 $489.0046600 000 $151.2046604 000 $1,073.4046606 000 $386.4046608 000 $407.4046610 000 $387.0046611 000 $298.8046612 000 $470.4046614 000 $221.4046615 000 $247.2046700 090 $1,129.2046705 090 $835.2046706 010 $303.0046707 090 $817.8046710 090 $1,810.8046712 090 $3,468.0046715 090 $933.6046716 090 $1,845.6046730 090 $3,390.0046735 090 $3,507.0046740 090 $3,705.6046742 090 $3,855.0046744 090 $6,091.2046746 090 $6,016.8046748 090 $6,582.6046750 090 $1,299.6046751 090 $992.4046753 090 $997.2046754 010 $508.8046760 090 $1,890.6046761 090 $1,596.0046762 090 $1,595.4046900 010 $416.4046910 010 $438.6046916 010 $391.8046917 010 $771.0046922 010 $457.8046924 010 $919.8046930 090 $354.6046940 010 $393.60



73


HCPCS MOD FUD MAX FEE46942 010 $372.6046945 090 $529.2046946 090 $541.2046947 090 $657.6047000 000 $621.0047001 ZZZ $180.6047010 090 $2,080.8047015 090 $2,010.0047100 090 $1,460.4047120 090 $4,029.0047122 090 $5,936.4047125 090 $5,313.0047130 090 $5,709.6047135 090 $8,451.6047136 090 $7,261.8047140 090 $5,565.6047141 090 $7,380.0047142 090 $8,137.2047146 XXX $570.6047147 XXX $662.4047300 090 $1,962.0047350 090 $2,369.4047360 090 $3,232.2047361 090 $5,243.4047362 090 $2,508.6047370 090 $2,155.8047371 090 $2,172.6047380 090 $2,489.4047381 090 $2,332.2047382 010 $8,546.4047383 010 $12,972.0047400 090 $3,729.6047420 090 $2,319.6047425 090 $2,364.6047460 090 $2,194.2047480 090 $1,512.6047490 010 $577.8047500 000 $168.6047505 000 $64.8047510 090 $818.4047511 090 $1,001.4047525 000 $888.6047530 090 $2,352.0047550 ZZZ $286.8047552 000 $546.0047553 000 $541.8047554 000 $838.2047555 000 $643.8047556 000 $732.0047560 000 $464.4047561 000 $510.00



74


HCPCS MOD FUD MAX FEE47562 090 $1,135.8047563 090 $1,233.6047564 090 $1,921.2047570 090 $1,340.4047600 090 $1,843.8047605 090 $1,940.4047610 090 $2,168.4047612 090 $2,195.4047620 090 $2,385.6047630 090 $927.0047700 090 $1,819.8047701 090 $3,002.4047711 090 $2,684.4047712 090 $3,460.8047715 090 $2,301.6047720 090 $1,995.0047721 090 $2,342.4047740 090 $2,270.4047741 090 $2,554.8047760 090 $3,904.2047765 090 $5,263.2047780 090 $4,273.2047785 090 $5,617.8047800 090 $2,733.6047801 090 $1,735.2047802 090 $2,641.8047900 090 $2,376.0048000 090 $3,253.8048001 090 $3,999.0048020 090 $2,035.8048100 090 $1,523.4048102 010 $915.0048105 090 $4,925.4048120 090 $1,912.2048140 090 $2,703.0048145 090 $2,827.8048146 090 $3,252.0048148 090 $2,160.6048150 090 $5,380.2048152 090 $4,998.0048153 090 $5,353.2048154 090 $5,019.6048155 090 $3,138.0048400 ZZZ $186.6048500 090 $1,990.2048510 090 $1,898.4048520 090 $1,892.4048540 090 $2,268.6048545 090 $2,328.0048547 090 $3,104.4048548 090 $2,885.40



75


HCPCS MOD FUD MAX FEE48552 XXX $410.4048554 090 $4,422.0048556 090 $2,203.2049000 090 $1,330.2049002 090 $1,808.4049010 090 $1,610.4049020 090 $2,755.2049040 090 $1,729.8049060 090 $1,899.6049062 090 $1,279.8049082 000 $331.2049083 000 $501.0049084 000 $188.4049180 000 $280.2049203 090 $2,070.6049204 090 $2,647.2049205 090 $3,035.4049215 090 $3,802.8049220 090 $1,678.8049250 090 $1,008.6049255 090 $1,363.2049320 010 $562.2049321 010 $594.6049322 010 $634.2049323 090 $1,103.4049324 010 $674.4049325 010 $720.0049326 ZZZ $328.2049327 ZZZ $226.8049400 000 $234.0049402 090 $1,478.4049405 000 $1,494.6049406 000 $1,496.4049407 000 $1,251.0049411 000 $937.2049412 ZZZ $142.8049418 000 $2,445.0049419 090 $770.4049421 000 $399.0049422 010 $657.6049423 000 $937.8049424 000 $249.6049425 090 $1,260.6049426 090 $1,054.8049427 000 $78.0049428 010 $921.6049429 010 $793.8049435 ZZZ $207.6049436 010 $322.2049440 010 $1,776.6049441 010 $1,987.20



76


HCPCS MOD FUD MAX FEE49442 010 $1,652.4049446 000 $1,707.0049450 000 $1,137.6049451 000 $1,242.6049452 000 $1,536.0049460 000 $1,251.0049465 000 $277.8049491 090 $1,289.4049492 090 $1,483.8049495 090 $643.2049496 090 $945.0049500 090 $710.4049501 090 $1,044.6049505 090 $897.6049507 090 $1,009.8049520 090 $1,090.2049521 090 $1,235.4049525 090 $988.2049540 090 $1,161.0049550 090 $993.0049553 090 $1,089.0049555 090 $1,029.0049557 090 $1,248.6049560 090 $1,272.0049561 090 $1,605.6049565 090 $1,324.8049566 090 $1,619.4049568 ZZZ $462.6049570 090 $716.4049572 090 $890.4049580 090 $574.2049582 090 $832.2049585 090 $766.2049587 090 $819.6049590 090 $987.6049600 090 $1,199.4049605 090 $8,548.8049606 090 $1,957.8049610 090 $1,187.4049611 090 $933.0049650 090 $737.4049651 090 $959.4049652 090 $1,283.4049653 090 $1,602.6049654 090 $1,460.4049655 090 $1,782.0049656 090 $1,586.4049657 090 $2,280.0049900 090 $1,406.4049904 090 $2,458.2049905 ZZZ $612.00



77


HCPCS MOD FUD MAX FEE50010 090 $1,281.6050020 090 $1,738.2050040 090 $1,593.6050045 090 $1,602.0050060 090 $1,960.2050065 090 $2,078.4050070 090 $2,038.2050075 090 $2,506.8050080 090 $1,494.0050081 090 $2,194.8050100 090 $1,864.2050120 090 $1,631.4050125 090 $1,688.4050130 090 $1,776.0050135 090 $1,928.4050200 000 $1,048.8050205 090 $1,297.8050220 090 $1,798.2050225 090 $2,065.2050230 090 $2,204.4050234 090 $2,235.0050236 090 $2,522.4050240 090 $2,275.2050250 090 $2,090.4050280 090 $1,642.2050290 090 $1,543.8050320 090 $2,595.0050327 XXX $376.2050328 XXX $329.4050329 XXX $316.2050340 090 $1,635.6050360 090 $4,178.4050365 090 $4,899.6050370 090 $2,070.0050380 090 $3,456.0050382 000 $2,025.6050384 000 $1,612.8050385 000 $1,947.6050386 000 $1,266.6050387 000 $928.8050389 000 $505.8050390 000 $168.6050391 000 $209.4050392 000 $310.8050393 000 $378.6050394 000 $177.6050395 000 $309.6050396 000 $205.8050398 000 $853.2050400 090 $1,989.0050405 090 $2,403.60



78


HCPCS MOD FUD MAX FEE50500 090 $1,983.6050520 090 $1,780.8050525 090 $2,625.6050526 090 $2,455.8050540 090 $1,972.8050541 090 $1,578.6050542 090 $2,004.6050543 090 $2,556.6050544 090 $2,141.4050545 090 $2,303.4050546 090 $2,067.6050547 090 $2,771.4050548 090 $2,316.6050551 000 $615.6050553 000 $658.8050555 000 $706.8050557 000 $719.4050561 000 $813.0050562 090 $1,000.2050570 000 $847.8050572 000 $916.2050574 000 $975.0050575 000 $1,231.2050576 000 $972.6050580 000 $1,048.2050590 090 $1,228.8050592 010 $5,372.4050593 010 $7,879.8050600 090 $1,614.0050605 090 $1,694.4050610 090 $1,625.4050620 090 $1,554.6050630 090 $1,535.4050650 090 $1,779.0050660 090 $1,965.6050684 000 $180.6050686 000 $264.6050688 010 $137.4050690 000 $168.6050700 090 $1,591.2050715 090 $2,101.2050722 090 $1,772.4050725 090 $1,911.0050727 090 $873.6050728 090 $1,200.0050740 090 $2,113.2050750 090 $1,983.6050760 090 $1,944.0050770 090 $1,983.6050780 090 $1,908.0050782 090 $1,929.00



79


HCPCS MOD FUD MAX FEE50783 090 $1,937.4050785 090 $2,086.2050800 090 $1,591.8050810 090 $2,414.4050815 090 $2,101.8050820 090 $2,265.0050825 090 $2,846.4050830 090 $3,100.8050840 090 $2,112.6050845 090 $2,146.8050860 090 $1,624.2050900 090 $1,459.8050920 090 $1,513.8050930 090 $1,893.6050940 090 $1,524.0050945 090 $1,673.4050947 090 $2,389.2050948 090 $2,193.6050951 000 $642.6050953 000 $682.2050955 000 $728.4050957 000 $735.6050961 000 $662.4050970 000 $639.6050972 000 $618.0050974 000 $816.0050976 000 $804.6050980 000 $614.4051020 090 $804.0051030 090 $807.6051040 090 $496.2051045 090 $842.4051050 090 $811.2051060 090 $997.8051065 090 $993.6051080 090 $702.0051100 000 $105.6051101 000 $211.8051102 000 $387.0051500 090 $1,093.2051520 090 $1,020.0051525 090 $1,476.0051530 090 $1,344.6051535 090 $1,339.2051550 090 $1,657.2051555 090 $2,182.2051565 090 $2,237.4051570 090 $2,545.8051575 090 $3,133.2051580 090 $3,260.4051585 090 $3,630.00



80


HCPCS MOD FUD MAX FEE51590 090 $3,325.2051595 090 $3,764.4051596 090 $4,042.8051597 090 $3,947.4051600 000 $312.0051605 000 $65.4051610 000 $181.8051700 000 $141.0051701 000 $92.4051702 000 $118.8051703 000 $220.8051705 000 $154.2051710 000 $219.0051715 000 $495.6051720 000 $186.0051725 26 000 $130.8051725 TC 000 $186.0051725 000 $316.8051726 26 000 $147.6051726 TC 000 $298.8051726 000 $446.4051727 26 000 $184.8051727 TC 000 $343.8051727 000 $528.6051728 26 000 $180.0051728 TC 000 $352.2051728 000 $532.2051729 26 000 $218.4051729 TC 000 $358.8051729 000 $577.2051736 26 XXX $14.4051736 TC XXX $12.0051736 XXX $26.4051741 26 XXX $14.4051741 TC XXX $12.6051741 XXX $27.0051784 26 000 $131.4051784 TC 000 $193.8051784 000 $325.2051785 26 000 $143.4051785 TC 000 $283.8051785 000 $427.2051792 26 000 $94.2051792 TC 000 $263.4051792 000 $357.6051797 26 ZZZ $68.4051797 TC ZZZ $121.2051797 ZZZ $189.6051798 XXX $31.8051800 090 $1,794.6051820 090 $2,095.20



81


HCPCS MOD FUD MAX FEE51840 090 $1,127.4051841 090 $1,330.2051845 090 $1,006.8051860 090 $1,281.6051865 090 $1,542.6051880 090 $806.4051900 090 $1,431.0051920 090 $1,309.8051925 090 $1,928.4051940 090 $2,823.6051960 090 $2,388.0051980 090 $1,225.2051990 090 $1,291.2051992 090 $1,447.8052000 000 $347.4052001 000 $633.6052005 000 $450.6052007 000 $750.6052010 000 $621.6052204 000 $624.6052214 000 $1,116.6052224 000 $1,169.4052234 000 $424.2052235 000 $496.8052240 000 $676.2052250 000 $412.8052260 000 $363.6052265 000 $621.0052270 000 $603.0052275 000 $814.2052276 000 $456.0052277 000 $557.4052281 000 $462.0052282 000 $581.4052283 000 $471.6052285 000 $476.4052287 000 $528.0052290 000 $420.6052300 000 $483.6052301 000 $500.4052305 000 $480.0052310 000 $412.8052315 000 $703.2052317 000 $1,363.2052318 000 $816.6052320 000 $425.4052325 000 $552.6052327 000 $451.2052330 000 $837.6052332 000 $826.8052334 000 $441.60



82


HCPCS MOD FUD MAX FEE52341 000 $489.0052342 000 $532.2052343 000 $594.0052344 000 $637.2052345 000 $679.8052346 000 $772.8052351 000 $521.4052352 000 $610.8052353 000 $676.2052354 000 $719.4052355 000 $806.4052356 000 $714.0052400 090 $822.6052402 000 $459.6052441 000 $2,108.4052442 ZZZ $1,638.0052450 090 $806.4052500 090 $838.2052601 090 $1,452.6052630 090 $687.6052640 090 $541.2052647 090 $3,015.0052648 090 $3,103.8052649 090 $1,413.6052700 090 $757.2053000 010 $253.8053010 090 $505.8053020 000 $167.4053025 000 $117.0053040 090 $674.4053060 010 $315.0053080 090 $734.4053085 090 $1,115.4053200 000 $267.6053210 090 $1,326.6053215 090 $1,595.4053220 090 $781.8053230 090 $1,041.6053235 090 $1,087.2053240 090 $729.0053250 090 $679.8053260 010 $343.8053265 010 $371.4053270 010 $351.0053275 010 $451.8053400 090 $1,375.8053405 090 $1,500.0053410 090 $1,682.4053415 090 $1,942.2053420 090 $1,444.2053425 090 $1,609.80



83


HCPCS MOD FUD MAX FEE53430 090 $1,656.0053431 090 $1,984.8053440 090 $1,292.4053442 090 $1,344.0053444 090 $1,362.6053445 090 $1,292.4053446 090 $1,103.4053447 090 $1,388.4053448 090 $2,201.4053449 090 $1,050.0053450 090 $703.2053460 090 $786.0053500 090 $1,285.8053502 090 $835.2053505 090 $834.6053510 090 $1,084.8053515 090 $1,366.8053520 090 $956.4053600 000 $141.0053601 000 $137.4053605 000 $111.6053620 000 $198.0053621 000 $186.6053660 000 $119.4053661 000 $117.0053665 000 $66.6053850 090 $3,508.8053852 090 $3,234.0053855 000 $1,312.2053860 090 $2,650.8054000 010 $252.0054001 010 $314.4054015 010 $525.6054050 010 $225.6054055 010 $203.4054056 010 $241.2054057 010 $229.8054060 010 $305.4054065 010 $372.0054100 000 $337.2054105 010 $450.6054110 090 $1,071.6054111 090 $1,375.8054112 090 $1,611.6054115 090 $774.0054120 090 $1,086.6054125 090 $1,395.0054130 090 $2,051.4054135 090 $2,599.2054150 000 $262.2054160 010 $373.20



84


HCPCS MOD FUD MAX FEE54161 010 $337.8054162 010 $437.4054163 010 $375.0054164 010 $331.2054200 010 $181.8054205 090 $915.0054220 000 $347.4054230 000 $165.0054231 000 $239.4054235 000 $153.6054240 26 000 $109.8054240 TC 000 $59.4054240 000 $169.2054250 26 000 $189.0054250 TC 000 $18.6054250 000 $207.6054300 090 $1,102.8054304 090 $1,288.2054308 090 $1,228.8054312 090 $1,405.8054316 090 $1,714.8054318 090 $1,237.2054322 090 $1,342.2054324 090 $1,665.0054326 090 $1,626.0054328 090 $1,615.2054332 090 $1,742.4054336 090 $2,044.8054340 090 $979.2054344 090 $1,629.0054348 090 $1,761.6054352 090 $2,436.0054360 090 $1,238.4054380 090 $1,373.4054385 090 $1,789.8054390 090 $2,153.4054400 090 $910.2054401 090 $1,125.0054405 090 $1,389.0054406 090 $1,254.0054408 090 $1,358.4054410 090 $1,476.6054411 090 $1,762.8054415 090 $909.0054416 090 $1,219.8054417 090 $1,544.4054420 090 $1,211.4054430 090 $1,100.4054435 090 $716.4054450 000 $118.8054500 000 $129.00



85


HCPCS MOD FUD MAX FEE54505 010 $360.0054512 090 $930.6054520 090 $560.4054522 090 $1,014.0054530 090 $868.8054535 090 $1,278.0054550 090 $844.8054560 090 $1,168.2054600 090 $778.2054620 010 $515.4054640 090 $824.4054650 090 $1,222.8054660 090 $613.2054670 090 $696.6054680 090 $1,353.0054690 090 $1,130.4054692 090 $1,304.4054700 010 $368.4054800 000 $216.6054830 090 $640.8054840 090 $551.4054860 090 $719.4054861 090 $972.6054865 090 $615.6054900 090 $1,392.6054901 090 $1,834.8055000 000 $199.8055040 090 $580.8055041 090 $877.8055060 090 $655.2055100 010 $366.6055110 090 $666.6055120 090 $614.4055150 090 $847.8055175 090 $622.8055180 090 $1,185.0055200 090 $741.6055250 090 $651.6055300 000 $322.2055400 090 $856.2055450 010 $611.4055500 090 $680.4055520 090 $779.4055530 090 $606.0055535 090 $739.2055540 090 $952.8055550 090 $736.2055600 090 $724.8055605 090 $909.0055650 090 $1,232.4055680 090 $604.80



86


HCPCS MOD FUD MAX FEE55700 000 $370.2055705 010 $458.4055706 010 $641.4055720 090 $777.0055725 090 $1,090.8055801 090 $1,879.2055810 090 $2,266.2055812 090 $2,767.8055815 090 $3,033.0055821 090 $1,500.0055831 090 $1,624.8055840 090 $2,015.4055842 090 $2,013.6055845 090 $2,345.4055860 090 $1,503.6055862 090 $1,904.4055865 090 $2,294.4055866 090 $2,981.4055870 000 $300.0055873 090 $11,677.2055875 090 $1,308.6055876 000 $231.0055920 000 $766.2056405 010 $186.6056420 010 $207.6056440 010 $310.8056441 010 $246.0056442 000 $81.6056501 010 $222.6056515 010 $385.8056605 000 $140.4056606 ZZZ $63.6056620 090 $889.2056625 090 $1,078.2056630 090 $1,587.6056631 090 $2,018.4056632 090 $2,366.4056633 090 $2,079.6056634 090 $2,240.4056637 090 $2,596.8056640 090 $2,623.2056700 010 $318.0056740 010 $513.0056800 010 $411.6056805 090 $1,944.6056810 010 $443.4056820 000 $191.4056821 000 $251.4057000 010 $314.4057010 090 $737.4057020 000 $158.40



87


HCPCS MOD FUD MAX FEE57022 010 $285.0057023 010 $527.4057061 010 $193.8057065 010 $333.0057100 000 $152.4057105 010 $232.2057106 090 $844.2057107 090 $2,493.6057109 090 $3,000.6057110 090 $1,521.6057111 090 $2,725.8057112 090 $3,211.8057120 090 $867.0057130 010 $300.0057135 010 $325.8057150 000 $76.2057155 000 $727.8057156 000 $333.6057160 000 $129.0057170 000 $102.6057180 010 $239.4057200 090 $514.8057210 090 $627.6057220 090 $543.6057230 090 $671.4057240 090 $1,143.6057250 090 $1,150.2057260 090 $1,419.0057265 090 $1,552.8057267 ZZZ $437.4057268 090 $823.8057270 090 $1,357.2057280 090 $1,625.4057282 090 $853.2057283 090 $1,172.4057284 090 $1,388.4057285 090 $1,144.8057287 090 $1,160.4057288 090 $1,219.2057289 090 $1,251.6057291 090 $900.6057292 090 $1,387.2057295 090 $814.8057296 090 $1,592.4057300 090 $969.0057305 090 $1,608.6057307 090 $1,850.4057308 090 $1,087.2057310 090 $790.2057311 090 $900.0057320 090 $906.00



88


HCPCS MOD FUD MAX FEE57330 090 $1,269.0057335 090 $1,911.6057400 000 $226.2057410 000 $184.2057415 010 $272.4057420 000 $200.4057421 000 $268.2057423 090 $1,557.0057425 090 $1,651.2057426 090 $1,436.4057452 000 $186.0057454 000 $260.4057455 000 $243.0057456 000 $229.2057460 000 $479.4057461 000 $543.6057500 000 $217.2057505 010 $174.0057510 010 $222.0057511 010 $246.6057513 010 $246.6057520 090 $521.4057522 090 $448.2057530 090 $594.0057531 090 $3,167.4057540 090 $1,366.2057545 090 $1,396.2057550 090 $693.0057555 090 $1,021.8057556 090 $966.0057558 010 $211.8057700 090 $528.0057720 090 $522.0057800 000 $103.2058100 000 $186.0058110 ZZZ $81.6058120 010 $439.8058140 090 $1,570.2058145 090 $934.2058146 090 $1,959.0058150 090 $1,730.4058152 090 $2,135.4058180 090 $1,642.8058200 090 $2,343.6058210 090 $3,159.0058240 090 $4,995.6058260 090 $1,406.4058262 090 $1,570.2058263 090 $1,682.4058267 090 $1,796.4058270 090 $1,500.00



89


HCPCS MOD FUD MAX FEE58275 090 $1,678.8058280 090 $1,785.6058285 090 $2,451.6058290 090 $1,953.6058291 090 $2,115.0058292 090 $2,232.6058293 090 $2,320.8058294 090 $2,068.8058300 XXX $118.8058301 000 $161.4058321 000 $129.0058322 000 $144.6058323 000 $26.4058340 000 $201.6058345 010 $473.4058346 090 $755.4058350 010 $162.6058353 010 $1,700.4058356 010 $3,175.8058400 090 $748.2058410 090 $1,365.6058520 090 $1,363.2058540 090 $1,542.6058541 090 $1,391.4058542 090 $1,564.2058543 090 $1,587.6058544 090 $1,745.4058545 090 $1,542.0058546 090 $1,911.0058548 090 $3,254.4058550 090 $1,500.6058552 090 $1,683.6058553 090 $1,927.8058554 090 $2,259.6058555 000 $515.4058558 000 $673.2058559 000 $580.8058560 000 $656.4058561 000 $931.2058562 000 $697.2058563 000 $2,811.6058565 090 $3,160.2058570 090 $1,510.2058571 090 $1,738.2058572 090 $1,904.4058573 090 $2,240.4058600 090 $619.8058605 090 $559.2058611 ZZZ $132.0058615 010 $414.6058660 090 $1,147.80



90


HCPCS MOD FUD MAX FEE58661 010 $1,106.4058662 090 $1,209.0058670 090 $620.4058671 090 $619.8058672 090 $1,248.6058673 090 $1,356.6058700 090 $1,335.6058720 090 $1,255.8058740 090 $1,507.2058750 090 $1,551.0058752 090 $1,483.8058760 090 $1,374.6058770 090 $1,447.2058800 090 $539.4058805 090 $687.0058820 090 $530.4058822 090 $1,188.6058825 090 $1,296.0058900 090 $702.0058920 090 $1,213.8058925 090 $1,274.4058940 090 $897.6058943 090 $2,008.8058950 090 $1,935.6058951 090 $2,483.4058952 090 $2,817.0058953 090 $3,481.2058954 090 $3,775.2058956 090 $2,368.2058957 090 $2,722.8058958 090 $2,991.0058960 090 $1,671.6058970 000 $378.0058976 000 $415.8059000 000 $215.4059001 000 $312.0059012 000 $351.6059015 000 $268.8059020 26 000 $64.8059020 TC 000 $57.6059020 000 $122.4059025 26 000 $51.0059025 TC 000 $31.2059025 000 $82.2059030 000 $172.2059050 XXX $88.2059051 XXX $73.2059070 000 $706.8059072 000 $807.0059074 000 $678.0059076 000 $807.00



91


HCPCS MOD FUD MAX FEE59100 090 $1,444.2059120 090 $1,374.6059121 090 $1,375.8059130 090 $1,446.6059135 090 $1,428.6059136 090 $1,521.6059140 090 $693.0059150 090 $1,332.0059151 090 $1,295.4059160 010 $351.6059200 000 $123.6059300 000 $332.4059320 000 $264.0059325 000 $421.8059350 000 $489.0059400 MMM $3,621.0059409 MMM $1,417.8059410 MMM $1,807.8059412 MMM $180.0059414 MMM $159.6059425 MMM $785.4059426 MMM $1,406.4059430 MMM $319.2059510 MMM $4,000.8059514 MMM $1,592.4059515 MMM $2,187.6059525 ZZZ $843.0059610 MMM $3,793.8059612 MMM $1,591.2059614 MMM $1,977.6059618 MMM $4,055.4059620 MMM $1,647.0059622 MMM $2,246.4059812 090 $548.4059820 090 $654.0059821 090 $658.8059830 090 $753.6059840 010 $374.4059841 010 $658.8059850 090 $597.6059851 090 $688.8059852 090 $865.8059855 090 $717.6059856 090 $843.6059857 090 $889.2059866 000 $372.6059870 090 $813.6059871 000 $232.2060000 010 $272.4060100 000 $194.4060200 090 $1,138.20



92


HCPCS MOD FUD MAX FEE60210 090 $1,220.4060212 090 $1,742.4060220 090 $1,219.2060225 090 $1,609.2060240 090 $1,587.0060252 090 $2,280.0060254 090 $2,896.2060260 090 $1,888.2060270 090 $2,365.8060271 090 $1,826.4060280 090 $766.2060281 090 $1,016.4060300 000 $202.2060500 090 $1,665.6060502 090 $2,223.0060505 090 $2,398.8060512 ZZZ $421.2060520 090 $1,807.2060521 090 $1,947.0060522 090 $2,359.8060540 090 $1,823.4060545 090 $2,101.2060600 090 $2,427.0060605 090 $3,461.4060650 090 $2,056.2061000 000 $154.2061001 000 $140.4061020 000 $183.6061026 000 $178.8061050 000 $148.2061055 000 $210.6061070 000 $100.2061105 090 $817.2061107 000 $555.6061108 090 $1,605.6061120 090 $1,320.6061140 090 $2,223.0061150 090 $2,400.0061151 090 $1,759.2061154 090 $2,236.8061156 090 $2,205.6061210 000 $654.0061215 090 $886.2061250 090 $1,533.6061253 090 $1,632.0061304 090 $2,887.8061305 090 $3,561.6061312 090 $3,670.2061313 090 $3,495.0061314 090 $3,215.4061315 090 $3,648.60



93


HCPCS MOD FUD MAX FEE61316 ZZZ $156.0061320 090 $3,342.6061321 090 $3,774.6061322 090 $4,194.0061323 090 $4,231.2061330 090 $2,662.2061332 090 $3,078.6061333 090 $3,147.6061340 090 $2,560.8061343 090 $3,873.0061345 090 $3,616.2061450 090 $3,409.8061458 090 $3,540.6061460 090 $3,729.6061480 090 $3,439.8061500 090 $2,310.6061501 090 $2,029.2061510 090 $3,850.8061512 090 $4,494.0061514 090 $3,367.8061516 090 $3,281.4061517 ZZZ $156.0061518 090 $4,856.4061519 090 $5,199.6061520 090 $6,616.8061521 090 $5,577.6061522 090 $3,877.2061524 090 $3,691.2061526 090 $6,477.0061530 090 $5,459.4061531 090 $2,163.0061533 090 $2,691.0061534 090 $2,914.2061535 090 $1,767.0061536 090 $4,573.8061537 090 $4,335.6061538 090 $4,736.4061539 090 $4,186.2061540 090 $3,869.4061541 090 $3,809.4061543 090 $3,850.2061544 090 $3,371.4061545 090 $5,647.2061546 090 $4,091.4061548 090 $2,759.4061550 090 $1,686.0061552 090 $1,928.4061556 090 $3,018.0061557 090 $2,976.6061558 090 $2,944.2061559 090 $4,237.20



94


HCPCS MOD FUD MAX FEE61563 090 $3,510.0061564 090 $4,267.2061566 090 $3,984.0061567 090 $4,157.4061570 090 $3,309.6061571 090 $3,525.0061575 090 $4,443.0061576 090 $5,923.8061580 090 $4,347.6061581 090 $4,570.2061582 090 $5,295.6061583 090 $5,087.4061584 090 $5,016.0061585 090 $5,679.6061586 090 $4,249.8061590 090 $5,277.0061591 090 $5,415.6061592 090 $5,596.8061595 090 $4,111.8061596 090 $4,239.0061597 090 $5,091.6061598 090 $5,010.6061600 090 $3,702.0061601 090 $4,227.6061605 090 $3,768.0061606 090 $5,359.8061607 090 $4,672.8061608 090 $5,736.6061611 ZZZ $644.4061612 ZZZ $2,420.4061613 090 $5,811.0061615 090 $4,753.2061616 090 $5,827.2061618 090 $2,274.0061619 090 $2,517.6061623 000 $981.6061624 000 $1,987.8061626 000 $1,498.8061630 XXX $2,299.8061635 XXX $2,430.6061640 000 $1,071.0061641 ZZZ $376.8061642 ZZZ $753.0061680 090 $3,967.8061682 090 $7,379.4061684 090 $5,045.4061686 090 $7,991.4061690 090 $3,874.2061692 090 $6,499.2061697 090 $7,466.4061698 090 $8,232.60



95


HCPCS MOD FUD MAX FEE61700 090 $6,023.4061702 090 $7,148.4061703 090 $2,405.4061705 090 $4,617.0061708 090 $4,515.0061710 090 $3,814.8061711 090 $4,578.0061720 090 $2,248.8061735 090 $2,816.4061750 090 $2,479.2061751 090 $2,433.6061760 090 $2,800.2061770 090 $2,877.6061781 ZZZ $417.0061782 ZZZ $305.4061783 ZZZ $412.2061790 090 $1,548.0061791 090 $1,989.6061796 090 $1,791.6061797 ZZZ $391.2061798 090 $2,445.6061799 ZZZ $540.0061800 ZZZ $274.2061850 090 $1,737.6061860 090 $2,772.6061863 090 $2,655.6061864 ZZZ $506.4061867 090 $4,023.0061868 ZZZ $887.4061880 090 $998.4061885 090 $901.8061886 090 $1,483.8061888 010 $693.6062000 090 $1,822.8062005 090 $2,249.4062010 090 $2,712.6062100 090 $2,820.0062115 090 $2,385.0062117 090 $3,479.4062120 090 $2,877.6062121 090 $2,809.8062140 090 $1,817.4062141 090 $2,010.0062142 090 $1,556.4062143 090 $1,837.2062145 090 $2,486.4062146 090 $2,170.2062147 090 $2,583.6062148 ZZZ $225.6062160 ZZZ $339.0062161 090 $2,689.80



96


HCPCS MOD FUD MAX FEE62162 090 $3,348.6062163 090 $2,166.6062164 090 $3,700.8062165 090 $2,704.8062180 090 $2,835.0062190 090 $1,017.0062192 090 $1,721.4062194 010 $858.0062200 090 $2,437.2062201 090 $2,126.4062220 090 $1,805.4062223 090 $1,843.8062225 090 $923.4062230 090 $1,482.0062252 26 XXX $80.4062252 TC XXX $66.6062252 XXX $147.0062256 090 $1,056.0062258 090 $1,978.2062263 010 $1,081.8062264 010 $715.8062267 000 $427.8062268 000 $455.4062269 000 $466.8062270 000 $272.4062272 000 $345.0062273 000 $297.0062280 010 $511.8062281 010 $399.6062282 010 $502.8062284 000 $312.6062287 090 $988.8062290 000 $571.2062291 000 $576.6062292 090 $1,006.8062294 090 $1,368.0062302 000 $412.2062303 000 $428.4062304 000 $406.2062305 000 $443.4062310 000 $411.0062311 000 $378.6062318 000 $392.4062319 000 $286.2062350 010 $695.4062351 090 $1,503.0062355 010 $469.2062360 010 $529.2062361 010 $753.0062362 010 $672.0062365 010 $518.40



97


HCPCS MOD FUD MAX FEE62367 XXX $69.6062368 XXX $96.6062369 XXX $205.2062370 XXX $216.0063001 090 $2,179.8063003 090 $2,169.6063005 090 $2,068.2063011 090 $1,921.8063012 090 $2,079.0063015 090 $2,604.6063016 090 $2,662.8063017 090 $2,196.6063020 090 $2,038.8063030 090 $1,690.8063035 ZZZ $336.0063040 090 $2,436.0063042 090 $2,259.6063045 090 $2,232.6063046 090 $2,110.2063047 090 $1,926.6063048 ZZZ $372.0063050 090 $2,597.4063051 090 $2,991.6063055 090 $2,861.4063056 090 $2,592.0063057 ZZZ $560.4063064 090 $3,103.2063066 ZZZ $368.4063075 090 $2,367.6063076 ZZZ $433.8063077 090 $2,623.2063078 ZZZ $331.8063081 090 $3,072.0063082 ZZZ $468.6063085 090 $3,346.8063086 ZZZ $335.4063087 090 $4,212.0063088 ZZZ $460.2063090 090 $3,396.0063091 ZZZ $309.6063101 090 $4,069.2063102 090 $3,978.0063103 ZZZ $517.2063170 090 $2,820.6063172 090 $2,511.0063173 090 $3,057.6063180 090 $2,631.0063182 090 $2,889.6063185 090 $1,992.6063190 090 $2,194.2063191 090 $2,440.20



98


HCPCS MOD FUD MAX FEE63194 090 $2,829.0063195 090 $2,017.8063196 090 $2,344.8063197 090 $3,031.8063198 090 $2,762.4063199 090 $2,898.6063200 090 $2,694.6063250 090 $5,267.4063251 090 $5,383.8063252 090 $5,382.6063265 090 $2,930.4063266 090 $3,021.6063267 090 $2,400.0063268 090 $2,547.0063270 090 $3,680.4063271 090 $3,655.8063272 090 $3,319.8063273 090 $3,304.8063275 090 $3,174.0063276 090 $3,144.0063277 090 $2,722.2063278 090 $2,814.0063280 090 $3,742.2063281 090 $3,687.6063282 090 $3,469.8063283 090 $3,365.4063285 090 $4,639.8063286 090 $4,587.6063287 090 $4,869.0063290 090 $4,952.4063295 ZZZ $592.8063300 090 $3,230.4063301 090 $3,816.0063302 090 $3,861.0063303 090 $4,104.0063304 090 $4,165.8063305 090 $4,435.8063306 090 $3,468.6063307 090 $3,817.2063308 ZZZ $570.0063600 090 $1,569.0063610 000 $673.2063615 090 $1,860.6063620 090 $1,966.8063621 ZZZ $448.8063650 010 $2,264.4063655 090 $1,444.8063661 010 $990.6063662 090 $1,464.6063663 010 $1,346.4063664 090 $1,497.60



99


HCPCS MOD FUD MAX FEE63685 010 $636.6063688 010 $643.2063700 090 $2,027.4063702 090 $2,470.8063704 090 $2,580.6063706 090 $2,927.4063707 090 $1,602.6063709 090 $1,920.6063710 090 $1,887.0063740 090 $1,686.0063741 090 $1,189.8063744 090 $1,189.2063746 090 $1,058.4064400 000 $217.2064402 000 $221.4064405 000 $172.8064408 000 $198.0064410 000 $204.6064412 000 $242.4064413 000 $220.2064415 000 $199.8064416 000 $136.2064417 000 $219.6064418 000 $250.2064420 000 $190.8064421 000 $255.6064425 000 $225.0064430 000 $238.2064435 000 $231.0064445 000 $231.0064446 000 $136.8064447 000 $202.2064448 000 $121.8064449 000 $144.0064450 000 $136.8064455 000 $81.0064479 000 $402.0064480 ZZZ $191.4064483 000 $373.8064484 ZZZ $149.4064486 000 $209.4064487 000 $256.2064488 000 $257.4064489 000 $358.2064490 000 $324.6064491 ZZZ $159.6064492 ZZZ $160.8064493 000 $292.8064494 ZZZ $147.6064495 ZZZ $148.2064505 000 $178.20



100


HCPCS MOD FUD MAX FEE64508 000 $106.8064510 000 $216.6064517 000 $309.0064520 000 $317.4064530 000 $324.6064550 000 $27.0064553 010 $365.4064555 010 $361.8064561 010 $1,392.0064565 010 $324.0064566 000 $205.8064568 090 $1,152.6064569 090 $1,371.6064570 090 $1,165.2064575 090 $550.2064580 090 $519.0064581 090 $1,140.6064585 010 $418.8064590 010 $451.8064595 010 $419.4064600 010 $662.4064605 010 $1,015.8064610 010 $1,261.2064611 010 $199.8064612 010 $223.2064615 010 $250.2064616 010 $213.0064617 010 $326.4064620 010 $351.6064630 010 $399.6064632 010 $145.8064633 010 $718.2064634 ZZZ $322.2064635 010 $711.0064636 ZZZ $293.4064640 010 $226.2064642 000 $241.8064643 ZZZ $159.6064644 000 $277.8064645 ZZZ $195.0064646 000 $262.2064647 000 $303.0064650 000 $133.2064653 000 $162.6064680 010 $535.2064681 010 $689.4064702 090 $858.6064704 090 $544.8064708 090 $859.2064712 090 $985.2064713 090 $1,243.20



101


HCPCS MOD FUD MAX FEE64714 090 $1,114.2064716 090 $919.2064718 090 $1,016.4064719 090 $688.2064721 090 $738.6064722 090 $640.2064726 090 $473.4064727 ZZZ $318.6064732 090 $654.0064734 090 $876.6064736 090 $687.0064738 090 $794.4064740 090 $786.0064742 090 $789.0064744 090 $867.0064746 090 $748.2064755 090 $1,588.2064760 090 $886.8064763 090 $878.4064766 090 $978.6064771 090 $1,027.2064772 090 $980.4064774 090 $717.6064776 090 $669.0064778 ZZZ $245.4064782 090 $774.6064783 ZZZ $380.4064784 090 $1,254.6064786 090 $1,872.6064787 ZZZ $422.4064788 090 $704.4064790 090 $1,455.0064792 090 $1,864.8064795 000 $332.4064802 090 $1,147.8064804 090 $1,620.0064809 090 $1,920.0064818 090 $954.0064820 090 $1,251.6064821 090 $1,180.2064822 090 $1,180.2064823 090 $1,360.8064831 090 $1,178.4064832 ZZZ $584.4064834 090 $1,269.6064835 090 $1,408.8064836 090 $1,411.8064837 ZZZ $658.2064840 090 $1,671.6064856 090 $1,748.4064857 090 $1,812.60



102


HCPCS MOD FUD MAX FEE64858 090 $2,040.6064859 ZZZ $436.2064861 090 $2,190.0064862 090 $1,985.4064864 090 $1,503.0064865 090 $1,917.6064866 090 $1,987.2064868 090 $1,754.4064872 ZZZ $204.6064874 ZZZ $285.6064876 ZZZ $293.4064885 090 $1,932.6064886 090 $2,241.6064890 090 $1,887.0064891 090 $2,010.6064892 090 $1,819.8064893 090 $1,959.6064895 090 $2,329.8064896 090 $2,800.8064897 090 $2,188.2064898 090 $2,374.2064901 ZZZ $970.8064902 ZZZ $1,124.4064905 090 $1,767.6064907 090 $2,544.6064910 090 $1,422.6064911 090 $1,750.8065091 090 $1,076.4065093 090 $1,064.4065101 090 $1,250.4065103 090 $1,302.0065105 090 $1,440.0065110 090 $2,071.2065112 090 $2,402.4065114 090 $2,517.6065125 090 $774.0065130 090 $1,239.6065135 090 $1,258.2065140 090 $1,368.6065150 090 $979.2065155 090 $1,434.0065175 090 $1,113.6065205 000 $94.8065210 000 $116.4065220 000 $97.8065222 000 $113.4065235 090 $1,207.2065260 090 $1,624.8065265 090 $1,830.6065270 010 $452.4065272 090 $850.80



103


HCPCS MOD FUD MAX FEE65273 090 $646.2065275 090 $980.4065280 090 $1,140.0065285 090 $1,882.8065286 090 $1,194.0065290 090 $832.8065400 090 $1,152.6065410 000 $241.8065420 090 $873.6065426 090 $1,105.2065430 000 $193.2065435 000 $134.4065436 090 $656.4065450 090 $551.4065600 090 $668.4065710 090 $1,879.2065730 090 $2,083.2065750 090 $2,095.2065755 090 $2,084.4065756 090 $2,012.4065770 090 $2,387.4065772 090 $764.4065775 090 $936.6065778 010 $2,338.8065779 010 $2,076.0065780 090 $1,510.8065781 090 $2,265.0065782 090 $1,954.2065800 000 $201.6065810 090 $790.2065815 090 $1,081.2065820 090 $1,269.0065850 090 $1,425.6065855 010 $573.6065860 090 $523.2065865 090 $802.8065870 090 $1,003.2065875 090 $1,069.2065880 090 $1,125.6065900 090 $1,635.0065920 090 $1,339.2065930 090 $1,081.8066020 010 $315.6066030 010 $280.2066130 090 $1,180.2066150 090 $1,480.2066155 090 $1,486.8066160 090 $1,676.4066170 090 $2,038.2066172 090 $2,571.6066174 090 $1,608.60



104


HCPCS MOD FUD MAX FEE66175 090 $1,686.0066179 090 $1,528.2066180 090 $1,931.4066183 090 $1,741.8066184 090 $1,065.6066185 090 $1,435.2066220 090 $1,261.8066225 090 $1,581.6066250 090 $1,269.6066500 090 $600.6066505 090 $657.6066600 090 $1,414.2066605 090 $1,794.0066625 090 $727.8066630 090 $966.6066635 090 $976.2066680 090 $878.4066682 090 $1,081.8066700 090 $762.6066710 090 $745.8066711 090 $1,090.2066720 090 $805.2066740 090 $740.4066761 010 $501.6066762 090 $804.6066770 090 $895.8066820 090 $667.2066821 090 $559.2066825 090 $1,288.2066830 090 $1,209.0066840 090 $1,182.6066850 090 $1,345.8066852 090 $1,433.4066920 090 $1,281.0066930 090 $1,454.4066940 090 $1,328.4066982 090 $1,350.0066983 090 $1,245.6066984 090 $1,085.4066985 090 $1,307.4066986 090 $1,543.2066990 ZZZ $153.6067005 090 $802.8067010 090 $921.6067015 090 $984.6067025 090 $1,231.2067027 090 $1,446.6067028 000 $172.2067030 090 $903.6067031 090 $658.2067036 090 $1,531.20



105


HCPCS MOD FUD MAX FEE67039 090 $1,641.0067040 090 $1,772.4067041 090 $1,957.8067042 090 $1,957.8067043 090 $2,068.2067101 090 $1,329.0067105 090 $1,219.2067107 090 $2,062.8067108 090 $2,724.6067110 090 $1,474.8067112 090 $2,253.0067113 090 $2,961.6067115 090 $848.4067120 090 $1,114.2067121 090 $1,542.6067141 090 $888.6067145 090 $894.0067208 090 $1,015.8067210 090 $879.0067218 090 $2,346.0067220 090 $906.6067221 000 $486.0067225 ZZZ $50.4067227 090 $1,036.2067228 090 $1,698.0067229 090 $1,980.0067250 090 $1,325.4067255 090 $1,159.2067311 090 $1,015.8067312 090 $1,209.0067314 090 $1,143.0067316 090 $1,362.0067318 090 $1,195.8067320 ZZZ $549.0067331 ZZZ $520.2067332 ZZZ $564.6067334 ZZZ $513.6067335 ZZZ $253.8067340 ZZZ $611.4067343 090 $1,109.4067345 010 $411.0067346 000 $330.6067400 090 $1,578.0067405 090 $1,345.2067412 090 $1,444.2067413 090 $1,450.2067414 090 $2,250.0067415 000 $177.6067420 090 $2,748.0067430 090 $2,115.0067440 090 $2,046.00



106


HCPCS MOD FUD MAX FEE67445 090 $2,379.0067450 090 $2,128.2067500 000 $132.6067505 000 $150.6067515 000 $163.8067550 090 $1,634.4067560 090 $1,676.4067570 090 $1,959.6067700 010 $451.8067710 010 $377.4067715 010 $402.6067800 010 $214.8067801 010 $275.4067805 010 $342.0067808 090 $625.8067810 000 $289.8067820 000 $84.6067825 010 $217.2067830 010 $449.4067835 090 $745.8067840 010 $465.6067850 010 $363.0067875 000 $289.8067880 090 $775.8067882 090 $955.2067900 090 $1,083.6067901 090 $1,281.0067902 090 $1,229.4067903 090 $1,004.4067904 090 $1,239.6067906 090 $863.4067908 090 $835.2067909 090 $909.0067911 090 $954.6067912 090 $1,492.8067914 090 $794.4067915 090 $494.4067916 090 $1,002.6067917 090 $1,020.6067921 090 $778.2067922 090 $489.6067923 090 $1,001.4067924 090 $1,067.4067930 010 $616.2067935 090 $1,006.2067938 010 $408.0067950 090 $969.6067961 090 $973.2067966 090 $1,302.6067971 090 $1,229.4067973 090 $1,582.20



107


HCPCS MOD FUD MAX FEE67974 090 $1,578.6067975 090 $1,164.0068020 010 $202.2068040 000 $105.6068100 000 $286.2068110 010 $381.0068115 010 $526.8068130 090 $910.8068135 010 $264.6068200 000 $69.6068320 090 $1,227.0068325 090 $1,120.8068326 090 $1,096.2068328 090 $1,203.0068330 090 $1,023.0068335 090 $1,099.8068340 090 $921.6068360 090 $897.6068362 090 $1,114.8068371 010 $700.8068400 010 $480.0068420 010 $543.0068440 010 $173.4068500 090 $1,656.0068505 090 $1,647.6068510 000 $755.4068520 090 $1,166.4068525 000 $448.8068530 010 $723.0068540 090 $1,577.4068550 090 $1,822.8068700 090 $1,025.4068705 010 $400.2068720 090 $1,284.0068745 090 $1,290.6068750 090 $1,335.0068760 010 $340.2068761 010 $249.0068770 090 $1,068.0068801 010 $211.2068810 010 $409.8068811 010 $351.0068815 010 $759.0068816 010 $1,255.2068840 010 $216.0068850 000 $103.8069000 010 $319.8069005 010 $368.4069020 010 $398.4069100 000 $169.8069105 000 $239.40



108


HCPCS MOD FUD MAX FEE69110 090 $784.8069120 090 $693.6069140 090 $1,513.8069145 090 $681.0069150 090 $1,808.4069155 090 $2,874.0069200 000 $209.4069205 010 $174.6069210 000 $83.4069220 000 $234.0069222 010 $376.2069300 YYY $1,256.4069310 090 $1,881.0069320 090 $2,637.6069420 010 $328.2069421 010 $256.8069424 000 $219.0069433 010 $346.8069436 010 $276.0069440 090 $1,189.2069450 090 $939.6069501 090 $1,263.0069502 090 $1,680.6069505 090 $2,078.4069511 090 $2,127.6069530 090 $2,854.8069535 090 $4,624.8069540 010 $357.6069550 090 $1,797.0069552 090 $2,711.4069554 090 $4,353.6069601 090 $1,806.0069602 090 $1,878.0069603 090 $2,176.8069604 090 $1,920.6069605 090 $2,693.4069610 010 $658.8069620 090 $1,192.8069631 090 $1,526.4069632 090 $1,860.0069633 090 $1,801.8069635 090 $2,127.6069636 090 $2,382.6069637 090 $2,422.2069641 090 $1,797.6069642 090 $2,310.6069643 090 $2,115.6069644 090 $2,557.8069645 090 $2,513.4069646 090 $2,665.8069650 090 $1,386.00



109


HCPCS MOD FUD MAX FEE69660 090 $1,603.8069661 090 $2,086.8069662 090 $2,004.6069666 090 $1,398.6069667 090 $1,398.0069670 090 $1,628.4069676 090 $1,434.6069700 090 $1,183.2069711 090 $1,489.2069714 090 $1,863.6069715 090 $2,295.0069717 090 $1,950.0069718 090 $2,319.6069720 090 $2,071.2069725 090 $3,249.6069740 090 $2,016.6069745 090 $2,145.0069801 000 $336.0069805 090 $1,821.6069806 090 $1,633.2069820 090 $1,479.6069840 090 $1,575.0069905 090 $1,584.0069910 090 $1,756.2069915 090 $2,658.6069930 090 $2,116.8069950 090 $3,081.6069955 090 $3,419.4069960 090 $3,327.0069970 090 $3,703.2069990 ZZZ $387.0070010 XXX $121.8070015 26 XXX $102.6070015 TC XXX $157.8070015 XXX $260.4070030 26 XXX $14.4070030 TC XXX $31.8070030 XXX $46.2070100 26 XXX $15.6070100 TC XXX $39.6070100 XXX $55.2070110 26 XXX $21.6070110 TC XXX $42.0070110 XXX $63.6070120 26 XXX $15.6070120 TC XXX $41.4070120 XXX $57.0070130 26 XXX $29.4070130 TC XXX $62.4070130 XXX $91.8070134 26 XXX $30.00



110


HCPCS MOD FUD MAX FEE70134 TC XXX $55.8070134 XXX $85.8070140 26 XXX $18.0070140 TC XXX $31.8070140 XXX $49.8070150 26 XXX $22.8070150 TC XXX $46.2070150 XXX $69.0070160 26 XXX $15.0070160 TC XXX $39.6070160 XXX $54.6070170 26 XXX $26.4070170 TC XXX $0.0070170 XXX $26.4070190 26 XXX $19.2070190 TC XXX $39.6070190 XXX $58.8070200 26 XXX $24.0070200 TC XXX $46.2070200 XXX $70.2070210 26 XXX $15.0070210 TC XXX $34.8070210 XXX $49.8070220 26 XXX $21.6070220 TC XXX $40.8070220 XXX $62.4070240 26 XXX $17.4070240 TC XXX $33.0070240 XXX $50.4070250 26 XXX $21.6070250 TC XXX $38.4070250 XXX $60.0070260 26 XXX $29.4070260 TC XXX $46.2070260 XXX $75.6070300 26 XXX $10.2070300 TC XXX $15.0070300 XXX $25.2070310 26 XXX $14.4070310 TC XXX $50.4070310 XXX $64.8070320 26 XXX $21.6070320 TC XXX $67.8070320 XXX $89.4070328 26 XXX $16.2070328 TC XXX $35.4070328 XXX $51.6070330 26 XXX $22.2070330 TC XXX $56.4070330 XXX $78.6070332 26 XXX $54.60



111





112


HCPCS MOD FUD MAX FEE70487 TC XXX $186.6070487 XXX $283.2070488 26 XXX $108.0070488 TC XXX $237.0070488 XXX $345.0070490 26 XXX $109.2070490 TC XXX $215.4070490 XXX $324.6070491 26 XXX $118.2070491 TC XXX $277.8070491 XXX $396.0070492 26 XXX $123.6070492 TC XXX $343.2070492 XXX $466.8070496 26 XXX $148.8070496 TC XXX $345.0070496 XXX $493.8070498 26 XXX $148.8070498 TC XXX $342.6070498 XXX $491.4070540 26 XXX $114.0070540 TC XXX $487.8070540 XXX $601.8070542 26 XXX $138.0070542 TC XXX $538.8070542 XXX $676.8070543 26 XXX $182.4070543 TC XXX $645.0070543 XXX $827.4070544 26 XXX $102.6070544 TC XXX $556.8070544 XXX $659.4070545 26 XXX $102.0070545 TC XXX $547.8070545 XXX $649.8070546 26 XXX $153.6070546 TC XXX $855.6070546 XXX $1,009.2070547 26 XXX $102.6070547 TC XXX $559.8070547 XXX $662.4070548 26 XXX $102.6070548 TC XXX $592.8070548 XXX $695.4070549 26 XXX $153.6070549 TC XXX $859.8070549 XXX $1,013.4070551 26 XXX $126.0070551 TC XXX $261.0070551 XXX $387.0070552 26 XXX $152.40



113





114





115





116





117





118





119





120





121





122





123


HCPCS MOD FUD MAX FEE74247 TC XXX $177.6074247 XXX $237.0074249 26 XXX $78.0074249 TC XXX $231.0074249 XXX $309.0074250 26 XXX $40.2074250 TC XXX $133.8074250 XXX $174.0074251 26 XXX $59.4074251 TC XXX $644.4074251 XXX $703.8074260 26 XXX $43.2074260 TC XXX $544.8074260 XXX $588.0074261 26 XXX $207.6074261 TC XXX $611.4074261 XXX $819.0074262 26 XXX $216.0074262 TC XXX $700.2074262 XXX $916.2074263 26 XXX $193.8074263 TC XXX $1,077.6074263 XXX $1,271.4074270 26 XXX $59.4074270 TC XXX $192.6074270 XXX $252.0074280 26 XXX $85.2074280 TC XXX $272.4074280 XXX $357.6074283 26 XXX $178.8074283 TC XXX $170.4074283 XXX $349.2074290 26 XXX $27.6074290 TC XXX $89.4074290 XXX $117.0074300 26 XXX $31.8074300 TC XXX $0.0074300 XXX $31.8074301 26 ZZZ $18.6074301 TC ZZZ $0.0074301 ZZZ $18.6074305 26 XXX $36.0074305 TC XXX $0.0074305 XXX $36.0074320 26 XXX $45.0074320 TC XXX $111.6074320 XXX $156.6074327 26 XXX $58.8074327 TC XXX $166.8074327 XXX $225.6074328 26 XXX $62.40



124





125


HCPCS MOD FUD MAX FEE74470 TC XXX $0.0074470 XXX $45.0074475 26 XXX $45.0074475 TC XXX $110.4074475 XXX $155.4074480 26 XXX $45.0074480 TC XXX $110.4074480 XXX $155.4074485 26 XXX $43.8074485 TC XXX $110.4074485 XXX $154.2074710 26 XXX $30.0074710 TC XXX $36.6074710 XXX $66.6074740 26 XXX $33.0074740 TC XXX $93.6074740 XXX $126.6074742 26 XXX $53.4074742 TC XXX $0.0074742 XXX $53.4074775 26 XXX $54.0074775 TC XXX $0.0074775 XXX $54.0075557 26 XXX $198.0075557 TC XXX $337.2075557 XXX $535.2075559 26 XXX $243.0075559 TC XXX $485.4075559 XXX $728.4075561 26 XXX $218.4075561 TC XXX $494.4075561 XXX $712.8075563 26 XXX $250.2075563 TC XXX $595.8075563 XXX $846.0075565 26 ZZZ $21.0075565 TC ZZZ $72.0075565 ZZZ $93.0075571 26 XXX $49.2075571 TC XXX $120.0075571 XXX $169.2075572 26 XXX $148.2075572 TC XXX $330.6075572 XXX $478.8075573 26 XXX $212.4075573 TC XXX $441.6075573 XXX $654.0075574 26 XXX $201.0075574 TC XXX $502.8075574 XXX $703.8075600 26 XXX $43.80



126


HCPCS MOD FUD MAX FEE75600 TC XXX $293.4075600 XXX $337.2075605 26 XXX $96.0075605 TC XXX $138.0075605 XXX $234.0075625 26 XXX $97.2075625 TC XXX $137.4075625 XXX $234.6075630 26 XXX $152.4075630 TC XXX $138.0075630 XXX $290.4075635 26 XXX $202.8075635 TC XXX $435.0075635 XXX $637.8075658 26 XXX $111.6075658 TC XXX $169.2075658 XXX $280.8075705 26 XXX $181.8075705 TC XXX $216.6075705 XXX $398.4075710 26 XXX $92.4075710 TC XXX $178.8075710 XXX $271.2075716 26 XXX $110.4075716 TC XXX $204.6075716 XXX $315.0075726 26 XXX $96.0075726 TC XXX $156.6075726 XXX $252.6075731 26 XXX $96.6075731 TC XXX $191.4075731 XXX $288.0075733 26 XXX $108.6075733 TC XXX $200.4075733 XXX $309.0075736 26 XXX $99.6075736 TC XXX $175.2075736 XXX $274.8075741 26 XXX $108.6075741 TC XXX $147.0075741 XXX $255.6075743 26 XXX $137.4075743 TC XXX $148.8075743 XXX $286.2075746 26 XXX $94.8075746 TC XXX $163.2075746 XXX $258.0075756 26 XXX $100.2075756 TC XXX $186.0075756 XXX $286.2075774 26 ZZZ $30.60



127


HCPCS MOD FUD MAX FEE75774 TC ZZZ $117.0075774 ZZZ $147.6075791 26 XXX $139.8075791 TC XXX $400.2075791 XXX $540.0075801 26 XXX $77.4075801 TC XXX $0.0075801 XXX $77.4075803 26 XXX $102.6075803 TC XXX $0.0075803 XXX $102.6075805 26 XXX $70.8075805 TC XXX $0.0075805 XXX $70.8075807 26 XXX $102.6075807 TC XXX $0.0075807 XXX $102.6075809 26 XXX $40.2075809 TC XXX $126.6075809 XXX $166.8075810 26 XXX $100.2075810 TC XXX $0.0075810 XXX $100.2075820 26 XXX $60.0075820 TC XXX $135.0075820 XXX $195.0075822 26 XXX $88.8075822 TC XXX $142.2075822 XXX $231.0075825 26 XXX $97.8075825 TC XXX $133.8075825 XXX $231.6075827 26 XXX $95.4075827 TC XXX $137.4075827 XXX $232.8075831 26 XXX $93.0075831 TC XXX $144.0075831 XXX $237.0075833 26 XXX $130.2075833 TC XXX $153.0075833 XXX $283.2075840 26 XXX $98.4075840 TC XXX $152.4075840 XXX $250.8075842 26 XXX $128.4075842 TC XXX $175.8075842 XXX $304.2075860 26 XXX $96.0075860 TC XXX $146.4075860 XXX $242.4075870 26 XXX $98.40



128


HCPCS MOD FUD MAX FEE75870 TC XXX $151.8075870 XXX $250.2075872 26 XXX $98.4075872 TC XXX $153.0075872 XXX $251.4075880 26 XXX $61.2075880 TC XXX $184.2075880 XXX $245.4075885 26 XXX $118.2075885 TC XXX $148.2075885 XXX $266.4075887 26 XXX $120.0075887 TC XXX $150.0075887 XXX $270.0075889 26 XXX $94.2075889 TC XXX $148.8075889 XXX $243.0075891 26 XXX $95.4075891 TC XXX $150.0075891 XXX $245.4075893 26 XXX $46.2075893 TC XXX $153.6075893 XXX $199.8075894 26 XXX $114.0075894 TC XXX $0.0075894 XXX $114.0075896 26 XXX $117.6075896 TC XXX $0.0075896 XXX $117.6075898 26 XXX $145.8075898 TC XXX $0.0075898 XXX $145.8075901 26 XXX $39.6075901 TC XXX $255.6075901 XXX $295.2075902 26 XXX $32.4075902 TC XXX $87.6075902 XXX $120.0075945 26 XXX $34.2075945 TC XXX $0.0075945 XXX $34.2075946 26 ZZZ $34.2075946 TC ZZZ $0.0075946 ZZZ $34.2075952 26 XXX $390.6075952 TC XXX $0.0075952 XXX $390.6075953 26 XXX $118.2075953 TC XXX $0.0075953 XXX $118.2075954 26 XXX $198.60



129


HCPCS MOD FUD MAX FEE75954 TC XXX $0.0075954 XXX $198.6075956 26 XXX $608.4075956 TC XXX $0.0075956 XXX $608.4075957 26 XXX $523.2075957 TC XXX $0.0075957 XXX $523.2075958 26 XXX $348.0075958 TC XXX $0.0075958 XXX $348.0075959 26 XXX $300.0075959 TC XXX $0.0075959 XXX $300.0075962 26 XXX $43.8075962 TC XXX $189.6075962 XXX $233.4075964 26 ZZZ $29.4075964 TC ZZZ $115.8075964 ZZZ $145.2075966 26 XXX $109.2075966 TC XXX $179.4075966 XXX $288.6075968 26 ZZZ $30.6075968 TC ZZZ $118.8075968 ZZZ $149.4075970 26 XXX $69.6075970 TC XXX $0.0075970 XXX $69.6075978 26 XXX $44.4075978 TC XXX $186.6075978 XXX $231.0075980 26 XXX $124.8075980 TC XXX $0.0075980 XXX $124.8075982 26 XXX $123.6075982 TC XXX $0.0075982 XXX $123.6075984 26 XXX $60.0075984 TC XXX $118.8075984 XXX $178.8075989 26 XXX $100.2075989 TC XXX $103.8075989 XXX $204.0076000 26 XXX $15.0076000 TC XXX $64.2076000 XXX $79.2076001 26 XXX $61.8076001 TC XXX $0.0076001 XXX $61.8076010 26 XXX $15.60



130


HCPCS MOD FUD MAX FEE76010 TC XXX $28.2076010 XXX $43.8076080 26 XXX $45.0076080 TC XXX $48.0076080 XXX $93.0076098 26 XXX $13.8076098 TC XXX $13.8076098 XXX $27.6076100 26 XXX $54.6076100 TC XXX $101.4076100 XXX $156.0076101 26 XXX $60.0076101 TC XXX $163.2076101 XXX $223.2076102 26 XXX $60.0076102 TC XXX $234.0076102 XXX $294.0076120 26 XXX $34.2076120 TC XXX $118.2076120 XXX $152.4076125 26 ZZZ $25.2076125 TC ZZZ $0.0076125 ZZZ $25.2076376 26 XXX $16.8076376 TC XXX $21.6076376 XXX $38.4076377 26 XXX $67.2076377 TC XXX $40.8076377 XXX $108.0076380 26 XXX $83.4076380 TC XXX $162.6076380 XXX $246.0076390 26 XXX $119.4076390 TC XXX $630.0076390 XXX $749.4076506 26 XXX $54.6076506 TC XXX $145.8076506 XXX $200.4076510 26 XXX $150.6076510 TC XXX $137.4076510 XXX $288.0076511 26 XXX $90.6076511 TC XXX $82.8076511 XXX $173.4076512 26 XXX $90.0076512 TC XXX $67.2076512 XXX $157.2076513 26 XXX $61.2076513 TC XXX $101.4076513 XXX $162.6076514 26 XXX $16.80



131


HCPCS MOD FUD MAX FEE76514 TC XXX $9.0076514 XXX $25.8076516 26 XXX $52.8076516 TC XXX $80.4076516 XXX $133.2076519 26 XXX $52.8076519 TC XXX $89.4076519 XXX $142.2076529 26 XXX $55.2076529 TC XXX $79.2076529 XXX $134.4076536 26 XXX $47.4076536 TC XXX $148.8076536 XXX $196.2076604 26 XXX $46.8076604 TC XXX $102.6076604 XXX $149.4076641 26 XXX $61.2076641 TC XXX $120.0076641 XXX $181.2076642 26 XXX $57.0076642 TC XXX $91.8076642 XXX $148.8076700 26 XXX $69.0076700 TC XXX $148.8076700 XXX $217.8076705 26 XXX $50.4076705 TC XXX $128.4076705 XXX $178.8076770 26 XXX $62.4076770 TC XXX $129.0076770 XXX $191.4076775 26 XXX $48.6076775 TC XXX $48.6076775 XXX $97.2076776 26 XXX $64.8076776 TC XXX $200.4076776 XXX $265.2076800 26 XXX $96.6076800 TC XXX $136.8076800 XXX $233.4076801 26 XXX $87.0076801 TC XXX $123.6076801 XXX $210.6076802 26 ZZZ $73.2076802 TC ZZZ $37.8076802 ZZZ $111.0076805 26 XXX $87.0076805 TC XXX $154.2076805 XXX $241.2076810 26 ZZZ $86.40



132


HCPCS MOD FUD MAX FEE76810 TC ZZZ $74.4076810 ZZZ $160.8076811 26 XXX $169.2076811 TC XXX $141.0076811 XXX $310.2076812 26 ZZZ $159.0076812 TC ZZZ $192.0076812 ZZZ $351.0076813 26 XXX $104.4076813 TC XXX $101.4076813 XXX $205.8076814 26 XXX $87.6076814 TC XXX $50.4076814 XXX $138.0076815 26 XXX $56.4076815 TC XXX $87.0076815 XXX $143.4076816 26 XXX $75.0076816 TC XXX $120.0076816 XXX $195.0076817 26 XXX $66.0076817 TC XXX $99.6076817 XXX $165.6076818 26 XXX $93.0076818 TC XXX $112.8076818 XXX $205.8076819 26 XXX $67.8076819 TC XXX $82.8076819 XXX $150.6076820 26 XXX $43.8076820 TC XXX $36.6076820 XXX $80.4076821 26 XXX $61.8076821 TC XXX $96.0076821 XXX $157.8076825 26 XXX $144.6076825 TC XXX $325.8076825 XXX $470.4076826 26 XXX $72.0076826 TC XXX $207.0076826 XXX $279.0076827 26 XXX $49.8076827 TC XXX $79.8076827 XXX $129.6076828 26 XXX $48.6076828 TC XXX $42.6076828 XXX $91.2076830 26 XXX $60.0076830 TC XXX $147.0076830 XXX $207.0076831 26 XXX $63.60



133


HCPCS MOD FUD MAX FEE76831 TC XXX $138.0076831 XXX $201.6076856 26 XXX $58.2076856 TC XXX $127.2076856 XXX $185.4076857 26 XXX $40.8076857 TC XXX $38.4076857 XXX $79.2076870 26 XXX $53.4076870 TC XXX $59.4076870 XXX $112.8076872 26 XXX $57.0076872 TC XXX $101.4076872 XXX $158.4076873 26 XXX $131.4076873 TC XXX $150.0076873 XXX $281.4076881 26 XXX $54.0076881 TC XXX $142.8076881 XXX $196.8076882 26 XXX $42.0076882 TC XXX $19.2076882 XXX $61.2076885 26 XXX $62.4076885 TC XXX $182.4076885 XXX $244.8076886 26 XXX $53.4076886 TC XXX $126.6076886 XXX $180.0076930 26 XXX $57.0076930 TC XXX $0.0076930 XXX $57.0076932 26 XXX $72.0076932 TC YYY $0.0076932 YYY $72.0076936 26 XXX $171.0076936 TC XXX $292.8076936 XXX $463.8076937 26 ZZZ $25.2076937 TC ZZZ $28.8076937 ZZZ $54.0076940 26 XXX $40.2076940 TC YYY $0.0076940 YYY $40.2076941 26 XXX $117.6076941 TC XXX $0.0076941 XXX $117.6076942 26 XXX $57.0076942 TC XXX $45.6076942 XXX $102.6076945 26 XXX $60.00



134


HCPCS MOD FUD MAX FEE76945 TC XXX $0.0076945 XXX $60.0076946 26 XXX $33.6076946 TC XXX $22.2076946 XXX $55.8076948 26 XXX $81.6076948 TC XXX $22.2076948 XXX $103.8076965 26 XXX $108.6076965 TC XXX $39.6076965 XXX $148.2076970 26 XXX $34.8076970 TC XXX $122.4076970 XXX $157.2076975 26 XXX $74.4076975 TC XXX $0.0076975 XXX $74.4076977 26 XXX $4.8076977 TC XXX $7.2076977 XXX $12.0076998 26 XXX $110.4076998 TC XXX $0.0076998 XXX $110.4077001 26 ZZZ $31.8077001 TC ZZZ $86.4077001 ZZZ $118.2077002 26 XXX $47.4077002 TC XXX $108.0077002 XXX $155.4077003 26 XXX $51.6077003 TC XXX $91.8077003 XXX $143.4077011 26 XXX $105.0077011 TC XXX $265.8077011 XXX $370.8077012 26 XXX $97.8077012 TC XXX $111.6077012 XXX $209.4077013 26 XXX $342.6077013 TC XXX $0.0077013 XXX $342.6077014 26 XXX $73.8077014 TC XXX $122.4077014 XXX $196.2077021 26 XXX $128.4077021 TC XXX $564.6077021 XXX $693.0077022 26 XXX $372.6077022 TC XXX $0.0077022 XXX $372.6077051 26 ZZZ $5.40



135


HCPCS MOD FUD MAX FEE77051 TC ZZZ $9.6077051 ZZZ $15.0077052 26 ZZZ $5.4077052 TC ZZZ $9.6077052 ZZZ $15.0077053 26 XXX $30.6077053 TC XXX $67.2077053 XXX $97.8077054 26 XXX $39.0077054 TC XXX $89.4077054 XXX $128.4077055 26 XXX $60.0077055 TC XXX $91.2077055 XXX $151.2077056 26 XXX $74.4077056 TC XXX $120.0077056 XXX $194.4077057 26 XXX $60.0077057 TC XXX $78.6077057 XXX $138.6077058 26 XXX $139.2077058 TC XXX $771.6077058 XXX $910.8077059 26 XXX $139.2077059 TC XXX $762.6077059 XXX $901.8077063 26 XXX $51.6077063 TC XXX $43.2077063 XXX $94.8077071 XXX $81.6077072 26 XXX $16.2077072 TC XXX $22.2077072 XXX $38.4077073 26 XXX $25.2077073 TC XXX $36.0077073 XXX $61.2077074 26 XXX $38.4077074 TC XXX $68.4077074 XXX $106.8077075 26 XXX $46.2077075 TC XXX $100.2077075 XXX $146.4077076 26 XXX $60.0077076 TC XXX $100.2077076 XXX $160.2077077 26 XXX $28.8077077 TC XXX $34.8077077 XXX $63.6077078 26 XXX $21.0077078 TC XXX $169.8077078 XXX $190.80



136


HCPCS MOD FUD MAX FEE77080 26 XXX $17.4077080 TC XXX $50.4077080 XXX $67.8077081 26 XXX $18.6077081 TC XXX $28.8077081 XXX $47.4077084 26 XXX $138.0077084 TC XXX $519.6077084 XXX $657.6077085 26 XXX $25.8077085 TC XXX $69.0077085 XXX $94.8077086 26 XXX $15.0077086 TC XXX $45.0077086 XXX $60.0077261 XXX $126.6077262 XXX $190.8077263 XXX $278.4077280 26 XXX $60.6077280 TC XXX $394.8077280 XXX $455.4077285 26 XXX $91.2077285 TC XXX $626.4077285 XXX $717.6077290 26 XXX $135.0077290 TC XXX $723.0077290 XXX $858.0077293 26 ZZZ $173.4077293 TC ZZZ $605.4077293 ZZZ $778.8077295 26 XXX $373.2077295 TC XXX $447.6077295 XXX $820.8077300 26 XXX $54.0077300 TC XXX $52.2077300 XXX $106.2077301 26 XXX $693.6077301 TC XXX $2,564.4077301 XXX $3,258.0077306 26 XXX $118.8077306 TC XXX $123.0077306 XXX $241.8077307 26 XXX $246.6077307 TC XXX $225.0077307 XXX $471.6077316 26 XXX $119.4077316 TC XXX $190.8077316 XXX $310.2077317 26 XXX $157.2077317 TC XXX $249.0077317 XXX $406.20



137


HCPCS MOD FUD MAX FEE77318 26 XXX $247.8077318 TC XXX $337.8077318 XXX $585.6077321 26 XXX $82.2077321 TC XXX $72.6077321 XXX $154.8077331 26 XXX $75.6077331 TC XXX $31.8077331 XXX $107.4077332 26 XXX $47.4077332 TC XXX $91.2077332 XXX $138.6077333 26 XXX $73.2077333 TC XXX $15.6077333 XXX $88.8077334 26 XXX $107.4077334 TC XXX $147.6077334 XXX $255.0077336 XXX $129.0077338 26 XXX $372.6077338 TC XXX $475.8077338 XXX $848.4077370 XXX $196.2077372 XXX $1,785.0077373 XXX $2,267.4077401 XXX $34.8077417 XXX $18.0077422 XXX $55.8077423 XXX $109.8077427 XXX $312.0077431 XXX $172.2077432 XXX $701.4077435 XXX $1,058.4077469 XXX $539.4077470 26 XXX $181.2077470 TC XXX $79.8077470 XXX $261.0077600 26 XXX $135.6077600 TC XXX $542.4077600 XXX $678.0077605 26 XXX $180.0077605 TC XXX $1,103.4077605 XXX $1,283.4077610 26 XXX $131.4077610 TC XXX $1,600.8077610 XXX $1,732.2077615 26 XXX $181.2077615 TC XXX $1,520.4077615 XXX $1,701.6077620 26 XXX $147.0077620 TC XXX $634.20



138


HCPCS MOD FUD MAX FEE77620 XXX $781.2077750 26 090 $434.4077750 TC 090 $187.8077750 090 $622.2077761 26 090 $331.2077761 TC 090 $321.6077761 090 $652.8077762 26 090 $548.4077762 TC 090 $369.6077762 090 $918.0077763 26 090 $751.8077763 TC 090 $477.0077763 090 $1,228.8077776 26 090 $401.4077776 TC 090 $386.4077776 090 $787.8077777 26 090 $657.0077777 TC 090 $329.4077777 090 $986.4077778 26 090 $981.0077778 TC 090 $485.4077778 090 $1,466.4077785 26 XXX $123.0077785 TC XXX $279.0077785 XXX $402.0077786 26 XXX $283.2077786 TC XXX $540.6077786 XXX $823.8077787 26 XXX $424.8077787 TC XXX $888.6077787 XXX $1,313.4077789 26 000 $99.0077789 TC 000 $100.8077789 000 $199.8077790 26 XXX $90.0077790 TC XXX $72.0077790 XXX $162.0078012 26 XXX $16.2078012 TC XXX $121.8078012 XXX $138.0078013 26 XXX $30.6078013 TC XXX $300.0078013 XXX $330.6078014 26 XXX $41.4078014 TC XXX $378.0078014 XXX $419.4078015 26 XXX $55.2078015 TC XXX $328.8078015 XXX $384.0078016 26 XXX $58.8078016 TC XXX $433.80



139


HCPCS MOD FUD MAX FEE78016 XXX $492.6078018 26 XXX $70.2078018 TC XXX $472.8078018 XXX $543.0078020 26 ZZZ $47.4078020 TC ZZZ $97.2078020 ZZZ $144.6078070 26 XXX $67.2078070 TC XXX $455.4078070 XXX $522.6078071 26 XXX $99.6078071 TC XXX $522.6078071 XXX $622.2078072 26 XXX $129.6078072 TC XXX $583.8078072 XXX $713.4078075 26 XXX $64.2078075 TC XXX $724.8078075 XXX $789.0078102 26 XXX $45.6078102 TC XXX $250.2078102 XXX $295.8078103 26 XXX $60.0078103 TC XXX $324.0078103 XXX $384.0078104 26 XXX $64.2078104 TC XXX $362.4078104 XXX $426.6078110 26 XXX $16.8078110 TC XXX $161.4078110 XXX $178.2078111 26 XXX $18.6078111 TC XXX $148.2078111 XXX $166.8078120 26 XXX $19.8078120 TC XXX $142.8078120 XXX $162.6078121 26 XXX $27.0078121 TC XXX $155.4078121 XXX $182.4078122 26 XXX $35.4078122 TC XXX $130.8078122 XXX $166.2078130 26 XXX $49.2078130 TC XXX $225.0078130 XXX $274.2078135 26 XXX $55.2078135 TC XXX $555.6078135 XXX $610.8078140 26 XXX $51.0078140 TC XXX $184.20



140


HCPCS MOD FUD MAX FEE78140 XXX $235.2078185 26 XXX $34.2078185 TC XXX $334.8078185 XXX $369.0078190 26 XXX $93.0078190 TC XXX $591.6078190 XXX $684.6078191 26 XXX $52.8078191 TC XXX $237.6078191 XXX $290.4078195 26 XXX $100.2078195 TC XXX $519.6078195 XXX $619.8078201 26 XXX $36.6078201 TC XXX $291.6078201 XXX $328.2078202 26 XXX $40.2078202 TC XXX $309.6078202 XXX $349.8078205 26 XXX $57.6078205 TC XXX $309.0078205 XXX $366.6078206 26 XXX $80.4078206 TC XXX $517.2078206 XXX $597.6078215 26 XXX $40.8078215 TC XXX $297.0078215 XXX $337.8078216 26 XXX $47.4078216 TC XXX $170.4078216 XXX $217.8078226 26 XXX $62.4078226 TC XXX $515.4078226 XXX $577.8078227 26 XXX $76.2078227 TC XXX $708.0078227 XXX $784.2078230 26 XXX $38.4078230 TC XXX $263.4078230 XXX $301.8078231 26 XXX $43.8078231 TC XXX $181.2078231 XXX $225.0078232 26 XXX $34.8078232 TC XXX $136.8078232 XXX $171.6078258 26 XXX $60.6078258 TC XXX $321.6078258 XXX $382.2078261 26 XXX $59.4078261 TC XXX $381.00



141


HCPCS MOD FUD MAX FEE78261 XXX $440.4078262 26 XXX $55.8078262 TC XXX $367.8078262 XXX $423.6078264 26 XXX $67.2078264 TC XXX $436.8078264 XXX $504.0078270 26 XXX $18.0078270 TC XXX $157.8078270 XXX $175.8078271 26 XXX $17.4078271 TC XXX $139.2078271 XXX $156.6078272 26 XXX $22.8078272 TC XXX $145.2078272 XXX $168.0078278 26 XXX $84.0078278 TC XXX $524.4078278 XXX $608.4078282 26 XXX $33.0078282 TC XXX $0.0078282 XXX $33.0078290 26 XXX $57.6078290 TC XXX $522.0078290 XXX $579.6078291 26 XXX $72.0078291 TC XXX $361.2078291 XXX $433.2078300 26 XXX $53.4078300 TC XXX $261.0078300 XXX $314.4078305 26 XXX $69.6078305 TC XXX $331.8078305 XXX $401.4078306 26 XXX $72.0078306 TC XXX $366.6078306 XXX $438.6078315 26 XXX $85.8078315 TC XXX $518.4078315 XXX $604.2078320 26 XXX $85.8078320 TC XXX $311.4078320 XXX $397.2078350 26 XXX $18.6078350 TC XXX $37.2078350 XXX $55.8078351 XXX $25.8078414 26 XXX $38.4078414 TC XXX $0.0078414 XXX $38.4078428 26 XXX $64.20



142





143


HCPCS MOD FUD MAX FEE78491 TC XXX $0.0078491 XXX $123.6078492 26 XXX $156.0078492 TC XXX $0.0078492 XXX $156.0078494 26 XXX $98.4078494 TC XXX $291.6078494 XXX $390.0078496 26 ZZZ $41.4078496 TC ZZZ $35.4078496 ZZZ $76.8078579 26 XXX $39.6078579 TC XXX $282.0078579 XXX $321.6078580 26 XXX $61.8078580 TC XXX $354.6078580 XXX $416.4078582 26 XXX $90.0078582 TC XXX $493.2078582 XXX $583.2078597 26 XXX $61.8078597 TC XXX $291.0078597 XXX $352.8078598 26 XXX $70.8078598 TC XXX $462.6078598 XXX $533.4078600 26 XXX $37.2078600 TC XXX $283.8078600 XXX $321.0078601 26 XXX $42.6078601 TC XXX $331.2078601 XXX $373.8078605 26 XXX $45.0078605 TC XXX $301.2078605 XXX $346.2078606 26 XXX $53.4078606 TC XXX $526.2078606 XXX $579.6078607 26 XXX $100.8078607 TC XXX $513.0078607 XXX $613.8078608 26 XXX $124.8078608 TC XXX $0.0078608 XXX $124.8078609 26 XXX $129.6078609 TC XXX $0.0078609 XXX $129.6078610 26 XXX $25.2078610 TC XXX $277.8078610 XXX $303.0078630 26 XXX $57.60



144


HCPCS MOD FUD MAX FEE78630 TC XXX $533.4078630 XXX $591.0078635 26 XXX $52.8078635 TC XXX $540.0078635 XXX $592.8078645 26 XXX $47.4078645 TC XXX $516.6078645 XXX $564.0078647 26 XXX $75.0078647 TC XXX $535.8078647 XXX $610.8078650 26 XXX $51.6078650 TC XXX $530.4078650 XXX $582.0078660 26 XXX $43.8078660 TC XXX $263.4078660 XXX $307.2078700 26 XXX $37.2078700 TC XXX $261.6078700 XXX $298.8078701 26 XXX $40.2078701 TC XXX $326.4078701 XXX $366.6078707 26 XXX $79.2078707 TC XXX $325.2078707 XXX $404.4078708 26 XXX $100.8078708 TC XXX $201.0078708 XXX $301.8078709 26 XXX $115.2078709 TC XXX $513.6078709 XXX $628.8078710 26 XXX $50.4078710 TC XXX $294.0078710 XXX $344.4078725 26 XXX $30.6078725 TC XXX $157.2078725 XXX $187.8078730 26 ZZZ $13.2078730 TC ZZZ $120.0078730 ZZZ $133.2078740 26 XXX $47.4078740 TC XXX $333.0078740 XXX $380.4078761 26 XXX $61.2078761 TC XXX $306.0078761 XXX $367.2078800 26 XXX $56.4078800 TC XXX $275.4078800 XXX $331.8078801 26 XXX $67.80



145


HCPCS MOD FUD MAX FEE78801 TC XXX $385.8078801 XXX $453.6078802 26 XXX $72.0078802 TC XXX $493.2078802 XXX $565.2078803 26 XXX $88.8078803 TC XXX $504.0078803 XXX $592.8078804 26 XXX $88.8078804 TC XXX $904.8078804 XXX $993.6078805 26 XXX $61.2078805 TC XXX $255.6078805 XXX $316.8078806 26 XXX $71.4078806 TC XXX $508.8078806 XXX $580.2078807 26 XXX $87.6078807 TC XXX $505.8078807 XXX $593.4078808 XXX $76.2078811 26 XXX $135.0078811 TC XXX $0.0078811 XXX $135.0078812 26 XXX $165.0078812 TC XXX $0.0078812 XXX $165.0078813 26 XXX $172.2078813 TC XXX $0.0078813 XXX $172.2078814 26 XXX $190.8078814 TC XXX $0.0078814 XXX $190.8078815 26 XXX $209.4078815 TC XXX $0.0078815 XXX $209.4078816 26 XXX $211.2078816 TC XXX $0.0078816 XXX $211.2079005 26 XXX $148.8079005 TC XXX $82.8079005 XXX $231.6079101 26 XXX $160.8079101 TC XXX $81.0079101 XXX $241.8079200 26 XXX $142.8079200 TC XXX $87.6079200 XXX $230.4079300 26 XXX $123.0079300 TC XXX $0.0079300 XXX $123.00



146


HCPCS MOD FUD MAX FEE79403 26 XXX $186.6079403 TC XXX $135.6079403 XXX $322.2079440 26 XXX $150.0079440 TC XXX $67.8079440 XXX $217.8079445 26 XXX $201.6079445 TC XXX $0.0079445 XXX $201.6080500 XXX $39.0080502 XXX $123.0083020 26 XXX $31.8083020 XXX $31.8084165 26 XXX $31.8084165 XXX $31.8084166 26 XXX $31.8084166 XXX $31.8084181 26 XXX $31.8084181 XXX $31.8084182 26 XXX $31.8084182 XXX $31.8085060 XXX $42.0085097 XXX $149.4085390 26 XXX $31.8085390 XXX $31.8085396 XXX $34.8085576 26 XXX $31.8085576 XXX $31.8086077 XXX $94.8086078 XXX $94.2086079 XXX $92.4086153 26 XXX $59.4086255 26 XXX $31.8086255 XXX $31.8086256 26 XXX $31.8086256 XXX $31.8086320 26 XXX $31.8086320 XXX $31.8086325 26 XXX $31.8086325 XXX $31.8086327 26 XXX $36.6086327 XXX $36.6086334 26 XXX $31.8086334 XXX $31.8086335 26 XXX $31.8086335 XXX $31.8086486 XXX $8.4086490 XXX $11.4086510 XXX $10.2086580 XXX $13.2087164 26 XXX $31.80



147


HCPCS MOD FUD MAX FEE87164 XXX $31.8087207 26 XXX $31.8087207 XXX $31.8088104 26 XXX $49.8088104 TC XXX $76.2088104 XXX $126.0088106 26 XXX $33.6088106 TC XXX $113.4088106 XXX $147.0088108 26 XXX $39.6088108 TC XXX $102.6088108 XXX $142.2088112 26 XXX $48.0088112 TC XXX $60.6088112 XXX $108.6088120 26 XXX $99.0088120 TC XXX $948.6088120 XXX $1,047.6088121 26 XXX $86.4088121 TC XXX $844.8088121 XXX $931.2088125 26 XXX $24.6088125 TC XXX $19.8088125 XXX $44.4088141 XXX $54.0088160 26 XXX $45.0088160 TC XXX $67.8088160 XXX $112.8088161 26 XXX $43.2088161 TC XXX $58.8088161 XXX $102.0088162 26 XXX $69.0088162 TC XXX $99.0088162 XXX $168.0088172 26 XXX $62.4088172 TC XXX $33.0088172 XXX $95.4088173 26 XXX $121.2088173 TC XXX $133.2088173 XXX $254.4088177 26 ZZZ $38.4088177 TC ZZZ $12.6088177 ZZZ $51.0088182 26 XXX $60.6088182 TC XXX $121.2088182 XXX $181.8088184 XXX $157.2088185 ZZZ $95.4088187 XXX $121.2088188 XXX $153.6088189 XXX $189.60



148


HCPCS MOD FUD MAX FEE88291 XXX $53.4088300 26 XXX $7.8088300 TC XXX $18.0088300 XXX $25.8088302 26 XXX $12.0088302 TC XXX $42.0088302 XXX $54.0088304 26 XXX $19.8088304 TC XXX $57.0088304 XXX $76.8088305 26 XXX $65.4088305 TC XXX $57.0088305 XXX $122.4088307 26 XXX $144.6088307 TC XXX $370.2088307 XXX $514.8088309 26 XXX $254.4088309 TC XXX $525.0088309 XXX $779.4088311 26 XXX $21.6088311 TC XXX $13.8088311 XXX $35.4088312 26 XXX $46.8088312 TC XXX $117.0088312 XXX $163.8088313 26 XXX $21.0088313 TC XXX $93.0088313 XXX $114.0088314 26 XXX $38.4088314 TC XXX $87.0088314 XXX $125.4088319 26 XXX $47.4088319 TC XXX $101.4088319 XXX $148.8088321 XXX $162.0088323 26 XXX $150.0088323 TC XXX $105.6088323 XXX $255.6088325 XXX $361.2088329 XXX $99.0088331 26 XXX $108.0088331 TC XXX $64.8088331 XXX $172.8088332 26 XXX $53.4088332 TC XXX $22.8088332 XXX $76.2088333 26 XXX $109.2088333 TC XXX $74.4088333 XXX $183.6088334 26 XXX $66.6088334 TC XXX $45.60



149


HCPCS MOD FUD MAX FEE88334 XXX $112.2088341 26 ZZZ $36.6088341 TC ZZZ $76.2088341 ZZZ $112.8088342 26 XXX $61.2088342 TC XXX $90.6088342 XXX $151.8088344 26 XXX $67.2088344 TC XXX $129.0088344 XXX $196.2088346 26 XXX $73.2088346 TC XXX $111.6088346 XXX $184.8088347 26 XXX $72.0088347 TC XXX $84.0088347 XXX $156.0088348 26 XXX $130.8088348 TC XXX $222.0088348 XXX $352.8088355 26 XXX $139.8088355 TC XXX $153.6088355 XXX $293.4088356 26 XXX $205.2088356 TC XXX $139.8088356 XXX $345.0088358 26 XXX $76.2088358 TC XXX $65.4088358 XXX $141.6088360 26 XXX $93.0088360 TC XXX $135.0088360 XXX $228.0088361 26 XXX $100.8088361 TC XXX $183.0088361 XXX $283.8088362 26 XXX $189.0088362 TC XXX $307.8088362 XXX $496.8088363 XXX $38.4088364 26 ZZZ $45.6088364 TC ZZZ $117.6088364 ZZZ $163.2088365 26 XXX $75.0088365 TC XXX $188.4088365 XXX $263.4088366 26 XXX $105.6088366 TC XXX $144.6088366 XXX $250.2088367 26 XXX $59.4088367 TC XXX $120.6088367 XXX $180.0088368 26 XXX $69.00



150


HCPCS MOD FUD MAX FEE88368 TC XXX $113.4088368 XXX $182.4088369 26 ZZZ $42.0088369 TC ZZZ $81.6088369 ZZZ $123.6088371 26 XXX $31.8088371 XXX $31.8088372 26 XXX $31.8088372 XXX $31.8088373 26 ZZZ $35.4088373 TC ZZZ $65.4088373 ZZZ $100.8088374 26 XXX $75.6088374 TC XXX $268.2088374 XXX $343.8088375 XXX $78.0088377 26 XXX $109.8088377 TC XXX $249.6088377 XXX $359.4088380 26 XXX $94.8088380 TC XXX $127.8088380 XXX $222.6088381 26 XXX $43.8088381 TC XXX $165.0088381 XXX $208.8088387 26 XXX $55.2088387 TC XXX $16.8088387 XXX $72.0088388 26 XXX $41.4088388 TC XXX $16.2088388 XXX $57.6089049 XXX $405.0089060 26 XXX $31.8089060 XXX $31.8089220 XXX $26.4089230 XXX $4.2090460 XXX $42.6090461 ZZZ $21.0090471 XXX $42.6090472 ZZZ $21.0090473 XXX $42.6090474 ZZZ $21.0090785 ZZZ $27.6090791 XXX $219.0090792 XXX $243.0090832 XXX $109.2090833 ZZZ $112.2090834 XXX $143.4090836 ZZZ $140.4090837 XXX $212.4090838 ZZZ $183.60



151


HCPCS MOD FUD MAX FEE90839 XXX $222.6090840 ZZZ $106.8090845 XXX $153.0090846 XXX $172.8090847 XXX $178.8090849 XXX $59.4090853 XXX $43.2090865 XXX $283.2090870 000 $298.2090875 XXX $103.8090876 XXX $183.0090880 XXX $171.0090885 XXX $84.0090887 XXX $149.4090901 000 $63.6090911 000 $142.8090935 000 $122.4090937 000 $175.8090945 000 $144.6090947 000 $210.0090951 XXX $1,590.0090954 XXX $1,385.4090955 XXX $775.8090956 XXX $541.2090957 XXX $1,091.4090958 XXX $736.8090959 XXX $499.8090960 XXX $480.0090961 XXX $403.2090962 XXX $311.4090963 XXX $922.2090964 XXX $805.2090965 XXX $768.0090966 XXX $402.6090967 XXX $30.6090968 XXX $26.4090969 XXX $25.8090970 XXX $13.2090997 000 $159.6091010 26 000 $115.8091010 TC 000 $185.4091010 000 $301.2091013 26 ZZZ $16.2091013 TC ZZZ $24.0091013 ZZZ $40.2091020 26 000 $128.4091020 TC 000 $270.6091020 000 $399.0091022 26 000 $129.0091022 TC 000 $159.6091022 000 $288.60



152


HCPCS MOD FUD MAX FEE91030 26 000 $81.0091030 TC 000 $152.4091030 000 $233.4091034 26 000 $85.8091034 TC 000 $234.0091034 000 $319.8091035 26 000 $142.2091035 TC 000 $679.8091035 000 $822.0091037 26 000 $87.6091037 TC 000 $187.2091037 000 $274.8091038 26 000 $100.2091038 TC 000 $673.8091038 000 $774.0091040 26 000 $87.0091040 TC 000 $661.8091040 000 $748.8091065 26 000 $18.0091065 TC 000 $120.0091065 000 $138.0091110 26 XXX $327.6091110 TC XXX $1,192.8091110 XXX $1,520.4091111 26 XXX $89.4091111 TC XXX $1,158.0091111 XXX $1,247.4091112 26 XXX $188.4091112 TC XXX $1,660.8091112 XXX $1,849.2091117 000 $241.2091120 26 XXX $87.0091120 TC XXX $645.0091120 XXX $732.0091122 26 000 $152.4091122 TC 000 $230.4091122 000 $382.8091132 26 XXX $46.8091132 TC XXX $207.0091132 XXX $253.8091133 26 XXX $58.8091133 TC XXX $235.2091133 XXX $294.0091200 26 XXX $25.2091200 TC XXX $36.0091200 XXX $61.2092002 XXX $136.8092004 XXX $250.2092012 XXX $143.4092014 XXX $208.2092015 XXX $33.60



153


HCPCS MOD FUD MAX FEE92018 XXX $245.4092019 XXX $121.8092020 XXX $45.0092025 26 XXX $34.2092025 TC XXX $30.0092025 XXX $64.2092060 26 XXX $64.8092060 TC XXX $45.0092060 XXX $109.8092065 26 XXX $30.6092065 TC XXX $59.4092065 XXX $90.0092071 XXX $64.2092072 XXX $226.8092081 26 XXX $27.6092081 TC XXX $29.4092081 XXX $57.0092082 26 XXX $36.6092082 TC XXX $44.4092082 XXX $81.0092083 26 XXX $47.4092083 TC XXX $61.2092083 XXX $108.6092100 XXX $135.0092132 26 XXX $32.4092132 TC XXX $26.4092132 XXX $58.8092133 26 XXX $47.4092133 TC XXX $27.0092133 XXX $74.4092134 26 XXX $48.6092134 TC XXX $27.6092134 XXX $76.2092136 26 XXX $52.8092136 TC XXX $99.0092136 XXX $151.8092140 XXX $106.2092145 26 XXX $15.0092145 TC XXX $11.4092145 XXX $26.4092225 XXX $45.6092226 XXX $42.0092227 XXX $24.6092228 26 XXX $36.6092228 TC XXX $23.4092228 XXX $60.0092230 XXX $97.8092235 26 XXX $79.8092235 TC XXX $105.6092235 XXX $185.4092240 26 XXX $108.00



154


HCPCS MOD FUD MAX FEE92240 TC XXX $322.8092240 XXX $430.8092250 26 XXX $40.8092250 TC XXX $92.4092250 XXX $133.2092260 XXX $31.2092265 26 XXX $79.2092265 TC XXX $65.4092265 XXX $144.6092270 26 XXX $70.2092270 TC XXX $85.2092270 XXX $155.4092275 26 XXX $90.6092275 TC XXX $157.2092275 XXX $247.8092283 26 XXX $16.2092283 TC XXX $78.6092283 XXX $94.8092284 26 XXX $21.6092284 TC XXX $84.0092284 XXX $105.6092285 26 XXX $5.4092285 TC XXX $29.4092285 XXX $34.8092286 26 XXX $37.8092286 TC XXX $27.0092286 XXX $64.8092287 26 XXX $79.2092287 TC XXX $153.0092287 XXX $232.2092310 XXX $162.0092311 XXX $170.4092312 XXX $198.6092313 XXX $164.4092314 XXX $134.4092315 XXX $122.4092316 XXX $154.2092317 XXX $128.4092325 XXX $71.4092326 XXX $59.4092340 XXX $60.0092341 XXX $68.4092342 XXX $73.8092352 XXX $68.4092353 XXX $79.8092354 XXX $22.8092355 XXX $35.4092358 XXX $19.2092370 XXX $52.2092371 XXX $19.8092502 000 $164.40



155


HCPCS MOD FUD MAX FEE92504 XXX $51.0092507 XXX $133.2092508 XXX $39.6092511 000 $231.6092512 XXX $103.8092516 XXX $119.4092520 XXX $127.2092521 XXX $183.0092522 XXX $157.2092523 XXX $313.2092524 XXX $148.8092526 XXX $145.2092540 26 XXX $134.4092540 TC XXX $37.8092540 XXX $172.2092541 26 XXX $35.4092541 TC XXX $2.4092541 XXX $37.8092542 26 XXX $42.0092542 TC XXX $2.4092542 XXX $44.4092543 26 XXX $9.6092543 TC XXX $17.4092543 XXX $27.0092544 26 XXX $24.0092544 TC XXX $2.4092544 XXX $26.4092545 26 XXX $24.0092545 TC XXX $2.4092545 XXX $26.4092546 26 XXX $25.2092546 TC XXX $148.2092546 XXX $173.4092547 ZZZ $10.8092548 26 XXX $44.4092548 TC XXX $130.2092548 XXX $174.6092550 XXX $35.4092551 XXX $20.4092552 XXX $52.2092553 XXX $62.4092555 XXX $39.0092556 XXX $63.0092557 XXX $63.0092561 XXX $63.6092562 XXX $77.4092563 XXX $52.2092564 XXX $48.0092565 XXX $26.4092567 XXX $24.6092568 XXX $26.40



156


HCPCS MOD FUD MAX FEE92570 XXX $54.0092571 XXX $45.6092572 XXX $52.2092575 XXX $119.4092576 XXX $59.4092577 XXX $26.4092579 XXX $76.2092582 XXX $120.6092583 XXX $85.2092584 XXX $124.8092585 26 XXX $45.0092585 TC XXX $183.6092585 XXX $228.6092586 XXX $141.0092587 26 XXX $31.2092587 TC XXX $4.8092587 XXX $36.0092588 26 XXX $49.2092588 TC XXX $6.6092588 XXX $55.8092596 XXX $70.2092597 XXX $121.8092601 XXX $232.2092602 XXX $151.2092603 XXX $251.4092604 XXX $150.6092605 XXX $158.4092606 XXX $141.6092607 XXX $209.4092608 ZZZ $89.4092609 XXX $186.6092610 XXX $144.0092611 XXX $145.8092612 XXX $293.4092613 XXX $65.4092614 XXX $243.6092615 XXX $57.0092616 XXX $348.6092617 XXX $71.4092618 ZZZ $57.6092620 XXX $159.0092621 ZZZ $37.8092625 XXX $118.2092626 XXX $151.8092627 ZZZ $37.2092640 XXX $191.4092920 000 $945.0092924 000 $1,123.2092928 000 $1,050.0092933 000 $1,173.6092937 000 $1,048.80



157


HCPCS MOD FUD MAX FEE92941 000 $1,176.0092943 000 $1,175.4092950 000 $517.8092953 000 $19.2092960 000 $350.4092961 000 $450.6092970 000 $321.6092971 000 $174.0092973 ZZZ $307.2092974 ZZZ $279.6092975 000 $678.0092977 XXX $97.2092978 26 ZZZ $168.0092978 TC ZZZ $0.0092978 ZZZ $168.0092979 26 ZZZ $134.4092979 TC ZZZ $0.0092979 ZZZ $134.4092986 090 $2,308.2092987 090 $2,379.6092990 090 $1,882.2092997 000 $1,148.4092998 ZZZ $562.8093000 XXX $28.8093005 XXX $14.4093010 XXX $14.4093015 XXX $129.0093016 XXX $37.8093017 XXX $66.6093018 XXX $24.6093024 26 XXX $97.2093024 TC XXX $93.0093024 XXX $190.2093025 26 XXX $63.0093025 TC XXX $213.6093025 XXX $276.6093040 XXX $21.6093041 XXX $9.6093042 XXX $12.0093224 XXX $154.2093225 XXX $45.0093226 XXX $64.2093227 XXX $45.0093228 XXX $44.4093229 XXX $1,143.0093260 26 XXX $75.6093260 TC XXX $35.4093260 XXX $111.0093261 26 XXX $66.0093261 TC XXX $35.4093261 XXX $101.40



158


HCPCS MOD FUD MAX FEE93268 XXX $347.4093270 XXX $15.6093271 XXX $288.6093272 XXX $43.2093278 26 XXX $21.0093278 TC XXX $30.0093278 XXX $51.0093279 26 XXX $54.6093279 TC XXX $29.4093279 XXX $84.0093280 26 XXX $65.4093280 TC XXX $33.0093280 XXX $98.4093281 26 XXX $76.2093281 TC XXX $39.0093281 XXX $115.2093282 26 XXX $72.6093282 TC XXX $34.8093282 XXX $107.4093283 26 XXX $97.8093283 TC XXX $40.2093283 XXX $138.0093284 26 XXX $106.2093284 TC XXX $45.6093284 XXX $151.8093285 26 XXX $44.4093285 TC XXX $27.0093285 XXX $71.4093286 26 XXX $25.8093286 TC XXX $20.4093286 XXX $46.2093287 26 XXX $39.0093287 TC XXX $22.2093287 XXX $61.2093288 26 XXX $36.0093288 TC XXX $26.4093288 XXX $62.4093289 26 XXX $77.4093289 TC XXX $33.0093289 XXX $110.4093290 26 XXX $36.0093290 TC XXX $16.2093290 XXX $52.2093291 26 XXX $36.6093291 TC XXX $24.6093291 XXX $61.2093292 26 XXX $36.0093292 TC XXX $18.6093292 XXX $54.6093293 26 XXX $26.4093293 TC XXX $63.60



159


HCPCS MOD FUD MAX FEE93293 XXX $90.0093294 XXX $57.6093295 XXX $114.0093296 XXX $43.8093297 XXX $45.0093298 XXX $45.0093303 26 XXX $108.0093303 TC XXX $293.4093303 XXX $401.4093304 26 XXX $62.4093304 TC XXX $199.8093304 XXX $262.2093306 26 XXX $108.0093306 TC XXX $276.6093306 XXX $384.6093307 26 XXX $76.8093307 TC XXX $142.8093307 XXX $219.6093308 26 XXX $43.8093308 TC XXX $166.8093308 XXX $210.6093312 26 XXX $205.8093312 TC XXX $311.4093312 XXX $517.2093313 XXX $38.4093314 26 XXX $168.0093314 TC XXX $329.4093314 XXX $497.4093315 26 XXX $247.2093315 TC XXX $0.0093315 XXX $247.2093316 XXX $64.8093317 26 XXX $183.6093317 TC XXX $0.0093317 XXX $183.6093318 26 XXX $202.8093318 TC XXX $0.0093318 XXX $202.8093320 26 ZZZ $31.2093320 TC ZZZ $61.8093320 ZZZ $93.0093321 26 ZZZ $12.6093321 TC ZZZ $34.2093321 ZZZ $46.8093325 26 ZZZ $6.0093325 TC ZZZ $38.4093325 ZZZ $44.4093350 26 XXX $121.2093350 TC XXX $286.2093350 XXX $407.4093351 26 XXX $145.20



160


HCPCS MOD FUD MAX FEE93351 TC XXX $312.6093351 XXX $457.8093352 ZZZ $57.6093355 XXX $384.0093451 26 000 $250.2093451 TC 000 $1,083.0093451 000 $1,333.2093452 26 000 $438.6093452 TC 000 $1,066.8093452 000 $1,505.4093453 26 000 $577.8093453 TC 000 $1,361.4093453 000 $1,939.2093454 26 000 $441.6093454 TC 000 $1,081.8093454 000 $1,523.4093455 26 000 $511.2093455 TC 000 $1,262.4093455 000 $1,773.6093456 26 000 $568.2093456 TC 000 $1,338.6093456 000 $1,906.8093457 26 000 $636.0093457 TC 000 $1,518.0093457 000 $2,154.0093458 26 000 $538.2093458 TC 000 $1,287.6093458 000 $1,825.8093459 26 000 $607.2093459 TC 000 $1,410.0093459 000 $2,017.2093460 26 000 $676.2093460 TC 000 $1,488.0093460 000 $2,164.2093461 26 000 $747.0093461 TC 000 $1,728.6093461 000 $2,475.6093462 ZZZ $360.0093463 ZZZ $169.8093464 26 ZZZ $148.8093464 TC ZZZ $317.4093464 ZZZ $466.2093503 000 $221.4093505 26 000 $403.2093505 TC 000 $897.0093505 000 $1,300.2093530 26 000 $387.6093530 TC 000 $0.0093530 000 $387.6093531 26 000 $756.6093531 TC 000 $0.00



161


HCPCS MOD FUD MAX FEE93531 000 $756.6093532 26 000 $937.8093532 TC 000 $0.0093532 000 $937.8093533 26 000 $627.6093533 TC 000 $0.0093533 000 $627.6093561 26 000 $42.0093561 TC 000 $0.0093561 000 $42.0093562 26 000 $13.8093562 TC 000 $0.0093562 000 $13.8093563 ZZZ $102.0093564 ZZZ $106.2093565 ZZZ $80.4093566 ZZZ $291.6093567 ZZZ $240.6093568 ZZZ $261.6093571 26 ZZZ $168.0093571 TC ZZZ $0.0093571 ZZZ $168.0093572 26 ZZZ $134.4093572 TC ZZZ $0.0093572 ZZZ $134.4093580 000 $1,690.2093581 000 $2,308.8093582 000 $1,232.4093583 000 $1,348.2093600 26 000 $208.2093600 TC 000 $0.0093600 000 $208.2093602 26 000 $202.8093602 TC 000 $0.0093602 000 $202.8093603 26 000 $203.4093603 TC 000 $0.0093603 000 $203.4093609 26 ZZZ $487.2093609 TC ZZZ $0.0093609 ZZZ $487.2093610 26 000 $288.0093610 TC 000 $0.0093610 000 $288.0093612 26 000 $285.6093612 TC 000 $0.0093612 000 $285.6093613 ZZZ $685.2093615 26 000 $88.2093615 TC 000 $0.0093615 000 $88.20



162


HCPCS MOD FUD MAX FEE93616 26 000 $111.0093616 TC 000 $0.0093616 000 $111.0093618 26 000 $414.0093618 TC 000 $0.0093618 000 $414.0093619 26 000 $709.2093619 TC 000 $0.0093619 000 $709.2093620 26 000 $1,128.0093620 TC 000 $0.0093620 000 $1,128.0093621 26 ZZZ $205.8093621 TC ZZZ $0.0093621 ZZZ $205.8093622 26 ZZZ $300.0093622 TC ZZZ $0.0093622 ZZZ $300.0093623 26 ZZZ $279.0093623 TC ZZZ $0.0093623 ZZZ $279.0093624 26 000 $450.6093624 TC 000 $0.0093624 000 $450.6093631 26 000 $699.0093631 TC 000 $0.0093631 000 $699.0093640 26 000 $337.8093640 TC 000 $0.0093640 000 $337.8093641 26 000 $574.2093641 TC 000 $0.0093641 000 $574.2093642 26 000 $468.6093642 TC 000 $257.4093642 000 $726.0093644 26 000 $346.2093644 TC 000 $177.0093644 000 $523.2093650 000 $1,044.0093653 000 $1,467.6093654 000 $1,951.8093655 ZZZ $732.0093656 000 $1,960.2093657 ZZZ $732.0093660 26 000 $160.2093660 TC 000 $107.4093660 000 $267.6093662 26 ZZZ $249.0093662 TC ZZZ $0.0093662 ZZZ $249.00



163


HCPCS MOD FUD MAX FEE93668 XXX $32.4093701 XXX $41.4093702 XXX $192.6093724 26 000 $415.8093724 TC 000 $48.0093724 000 $463.8093740 XXX $13.8093750 XXX $94.2093770 XXX $13.8093784 XXX $91.2093786 XXX $50.4093788 XXX $9.0093790 XXX $31.8093797 000 $27.6093798 000 $42.6093880 26 XXX $67.2093880 TC XXX $276.0093880 XXX $343.2093882 26 XXX $42.0093882 TC XXX $176.4093882 XXX $218.4093886 26 XXX $79.2093886 TC XXX $408.0093886 XXX $487.2093888 26 XXX $43.2093888 TC XXX $210.0093888 XXX $253.2093890 26 XXX $86.4093890 TC XXX $406.8093890 XXX $493.2093892 26 XXX $100.2093892 TC XXX $471.6093892 XXX $571.8093893 26 XXX $100.2093893 TC XXX $486.6093893 XXX $586.8093922 26 XXX $21.0093922 TC XXX $130.8093922 XXX $151.8093923 26 XXX $37.8093923 TC XXX $197.4093923 XXX $235.2093924 26 XXX $42.0093924 TC XXX $252.0093924 XXX $294.0093925 26 XXX $67.2093925 TC XXX $376.8093925 XXX $444.0093926 26 XXX $42.6093926 TC XXX $218.4093926 XXX $261.00



164


HCPCS MOD FUD MAX FEE93930 26 XXX $67.2093930 TC XXX $288.6093930 XXX $355.8093931 26 XXX $42.6093931 TC XXX $177.6093931 XXX $220.2093965 26 XXX $29.4093965 TC XXX $174.6093965 XXX $204.0093970 26 XXX $59.4093970 TC XXX $276.0093970 XXX $335.4093971 26 XXX $38.4093971 TC XXX $166.8093971 XXX $205.2093975 26 XXX $97.8093975 TC XXX $381.6093975 XXX $479.4093976 26 XXX $67.8093976 TC XXX $209.4093976 XXX $277.2093978 26 XXX $67.2093978 TC XXX $258.0093978 XXX $325.2093979 26 XXX $42.0093979 TC XXX $162.0093979 XXX $204.0093980 26 XXX $103.2093980 TC XXX $99.6093980 XXX $202.8093981 26 XXX $36.0093981 TC XXX $85.2093981 XXX $121.2093982 XXX $73.2093990 26 XXX $42.6093990 TC XXX $230.4093990 XXX $273.0094002 XXX $157.8094003 XXX $113.4094004 XXX $83.4094005 XXX $157.2094010 26 XXX $14.4094010 TC XXX $46.8094010 XXX $61.2094011 XXX $169.2094012 XXX $280.8094013 XXX $53.4094014 XXX $94.8094015 XXX $51.6094016 XXX $43.2094060 26 XXX $22.20



165


HCPCS MOD FUD MAX FEE94060 TC XXX $81.0094060 XXX $103.2094070 26 XXX $48.6094070 TC XXX $51.6094070 XXX $100.2094150 26 XXX $6.6094150 TC XXX $36.0094150 XXX $42.6094200 26 XXX $9.6094200 TC XXX $33.6094200 XXX $43.2094250 26 XXX $9.0094250 TC XXX $35.4094250 XXX $44.4094375 26 XXX $25.2094375 TC XXX $41.4094375 XXX $66.6094400 26 XXX $33.0094400 TC XXX $63.0094400 XXX $96.0094450 26 XXX $33.0094450 TC XXX $79.8094450 XXX $112.8094452 26 XXX $24.6094452 TC XXX $72.6094452 XXX $97.2094453 26 XXX $32.4094453 TC XXX $102.6094453 XXX $135.0094610 XXX $95.4094620 26 XXX $51.6094620 TC XXX $43.2094620 XXX $94.8094621 26 XXX $117.0094621 TC XXX $160.2094621 XXX $277.2094640 XXX $31.2094644 XXX $73.8094645 XXX $23.4094660 XXX $106.2094662 XXX $58.2094664 XXX $29.4094667 XXX $44.4094668 XXX $48.6094669 XXX $59.4094680 26 XXX $21.6094680 TC XXX $75.0094680 XXX $96.6094681 26 XXX $16.8094681 TC XXX $73.2094681 XXX $90.00



166


HCPCS MOD FUD MAX FEE94690 26 XXX $6.6094690 TC XXX $77.4094690 XXX $84.0094726 26 XXX $21.0094726 TC XXX $68.4094726 XXX $89.4094727 26 XXX $21.0094727 TC XXX $50.4094727 XXX $71.4094728 26 XXX $21.0094728 TC XXX $45.6094728 XXX $66.6094729 26 ZZZ $15.6094729 TC ZZZ $76.8094729 ZZZ $92.4094750 26 XXX $19.2094750 TC XXX $117.6094750 XXX $136.8094760 XXX $5.4094761 XXX $8.4094762 XXX $41.4094770 XXX $12.6094780 XXX $106.2094781 ZZZ $39.0095004 XXX $10.8095012 XXX $33.0095017 XXX $13.2095018 XXX $31.8095024 XXX $13.2095027 XXX $7.8095028 XXX $22.8095044 XXX $9.6095052 XXX $11.4095056 XXX $75.0095060 XXX $58.8095065 XXX $42.6095070 XXX $51.0095071 XXX $58.2095076 XXX $196.2095079 ZZZ $139.8095115 XXX $15.0095117 XXX $17.4095144 XXX $21.0095145 XXX $37.2095146 XXX $66.0095147 XXX $59.4095148 XXX $88.2095149 XXX $118.8095165 XXX $21.6095170 XXX $16.2095180 XXX $226.20



167


HCPCS MOD FUD MAX FEE95250 XXX $267.0095251 XXX $73.2095782 26 XXX $207.0095782 TC XXX $1,338.6095782 XXX $1,545.6095783 26 XXX $250.2095783 TC XXX $1,855.8095783 XXX $2,106.0095800 26 XXX $88.2095800 TC XXX $217.2095800 XXX $305.4095801 26 XXX $84.0095801 TC XXX $71.4095801 XXX $155.4095803 26 XXX $73.2095803 TC XXX $165.6095803 XXX $238.8095805 26 XXX $100.2095805 TC XXX $610.2095805 XXX $710.4095806 26 XXX $103.2095806 TC XXX $180.6095806 XXX $283.8095807 26 XXX $105.0095807 TC XXX $688.2095807 XXX $793.2095808 26 XXX $147.0095808 TC XXX $872.4095808 XXX $1,019.4095810 26 XXX $205.8095810 TC XXX $844.8095810 XXX $1,050.6095811 26 XXX $214.2095811 TC XXX $889.2095811 XXX $1,103.4095812 26 XXX $97.8095812 TC XXX $610.2095812 XXX $708.0095813 26 XXX $156.6095813 TC XXX $690.0095813 XXX $846.6095816 26 XXX $97.8095816 TC XXX $509.4095816 XXX $607.2095819 26 XXX $97.8095819 TC XXX $594.6095819 XXX $692.4095822 26 XXX $97.8095822 TC XXX $528.0095822 XXX $625.8095824 26 XXX $68.40



168


HCPCS MOD FUD MAX FEE95824 TC XXX $0.0095824 XXX $68.4095827 26 XXX $97.2095827 TC XXX $1,230.0095827 XXX $1,327.2095829 26 XXX $562.2095829 TC XXX $2,626.2095829 XXX $3,188.4095830 XXX $417.0095831 XXX $52.2095832 XXX $51.6095833 XXX $63.6095834 XXX $85.8095851 XXX $31.2095852 XXX $27.6095857 XXX $90.6095860 26 XXX $88.2095860 TC XXX $119.4095860 XXX $207.6095861 26 XXX $139.8095861 TC XXX $151.8095861 XXX $291.6095863 26 XXX $171.0095863 TC XXX $189.6095863 XXX $360.6095864 26 XXX $181.8095864 TC XXX $228.6095864 XXX $410.4095865 26 XXX $142.2095865 TC XXX $100.8095865 XXX $243.0095866 26 XXX $115.2095866 TC XXX $109.8095866 XXX $225.0095867 26 XXX $71.4095867 TC XXX $87.0095867 XXX $158.4095868 26 XXX $107.4095868 TC XXX $115.8095868 XXX $223.2095869 26 XXX $33.6095869 TC XXX $104.4095869 XXX $138.0095870 26 XXX $33.0095870 TC XXX $115.8095870 XXX $148.8095872 26 XXX $261.0095872 TC XXX $73.2095872 XXX $334.2095873 26 ZZZ $34.2095873 TC ZZZ $91.20



169


HCPCS MOD FUD MAX FEE95873 ZZZ $125.4095874 26 ZZZ $33.6095874 TC ZZZ $88.2095874 ZZZ $121.8095875 26 XXX $99.0095875 TC XXX $105.0095875 XXX $204.0095885 26 ZZZ $31.8095885 TC ZZZ $67.2095885 ZZZ $99.0095886 26 ZZZ $78.0095886 TC ZZZ $75.6095886 ZZZ $153.6095887 26 ZZZ $64.8095887 TC ZZZ $73.2095887 ZZZ $138.0095905 26 XXX $4.8095905 TC XXX $116.4095905 XXX $121.2095907 26 XXX $90.6095907 TC XXX $73.8095907 XXX $164.4095908 26 XXX $114.6095908 TC XXX $96.6095908 XXX $211.2095909 26 XXX $136.8095909 TC XXX $113.4095909 XXX $250.2095910 26 XXX $182.4095910 TC XXX $148.8095910 XXX $331.2095911 26 XXX $227.4095911 TC XXX $167.4095911 XXX $394.8095912 26 XXX $269.4095912 TC XXX $169.8095912 XXX $439.2095913 26 XXX $319.2095913 TC XXX $180.6095913 XXX $499.8095921 26 XXX $77.4095921 TC XXX $70.2095921 XXX $147.6095922 26 XXX $82.2095922 TC XXX $87.6095922 XXX $169.8095923 26 XXX $78.0095923 TC XXX $246.6095923 XXX $324.6095924 26 XXX $150.6095924 TC XXX $108.00



170


HCPCS MOD FUD MAX FEE95924 XXX $258.6095925 26 XXX $48.0095925 TC XXX $218.4095925 XXX $266.4095926 26 XXX $46.2095926 TC XXX $197.4095926 XXX $243.6095927 26 XXX $46.8095927 TC XXX $211.2095927 XXX $258.0095928 26 XXX $136.2095928 TC XXX $302.4095928 XXX $438.6095929 26 XXX $133.2095929 TC XXX $304.8095929 XXX $438.0095930 26 XXX $31.2095930 TC XXX $185.4095930 XXX $216.6095933 26 XXX $53.4095933 TC XXX $88.8095933 XXX $142.2095937 26 XXX $58.8095937 TC XXX $81.0095937 XXX $139.8095938 26 XXX $77.4095938 TC XXX $499.8095938 XXX $577.2095939 26 XXX $206.4095939 TC XXX $645.0095939 XXX $851.4095940 XXX $55.8095950 26 XXX $135.6095950 TC XXX $420.6095950 XXX $556.2095951 26 XXX $555.6095951 TC XXX $0.0095951 XXX $555.6095953 26 XXX $279.0095953 TC XXX $429.0095953 XXX $708.0095954 26 XXX $211.8095954 TC XXX $565.2095954 XXX $777.0095955 26 XXX $91.2095955 TC XXX $270.0095955 XXX $361.2095956 26 XXX $325.8095956 TC XXX $2,498.4095956 XXX $2,824.2095957 26 XXX $178.80



171


HCPCS MOD FUD MAX FEE95957 TC XXX $356.4095957 XXX $535.2095958 26 XXX $381.6095958 TC XXX $601.8095958 XXX $983.4095961 26 XXX $268.2095961 TC XXX $223.2095961 XXX $491.4095962 26 ZZZ $285.6095962 TC ZZZ $147.6095962 ZZZ $433.2095965 26 XXX $736.2095965 TC XXX $0.0095965 XXX $736.2095966 26 XXX $369.6095966 TC XXX $0.0095966 XXX $369.6095967 26 ZZZ $323.4095967 TC ZZZ $0.0095967 ZZZ $323.4095970 XXX $113.4095971 XXX $97.2095972 XXX $93.6095973 ZZZ $106.8095974 XXX $352.2095975 ZZZ $189.6095978 XXX $422.4095979 ZZZ $183.6095980 XXX $78.6095981 XXX $54.0095982 XXX $89.4095990 XXX $152.4095991 XXX $204.0095992 XXX $72.0096000 XXX $161.4096001 XXX $172.2096002 XXX $37.2096003 XXX $32.4096004 XXX $199.8096020 26 XXX $286.2096020 TC XXX $0.0096020 XXX $286.2096040 XXX $79.2096101 XXX $134.4096102 XXX $107.4096103 XXX $46.2096105 XXX $176.4096110 XXX $16.2096111 XXX $216.0096116 XXX $156.6096118 XXX $164.40



172


HCPCS MOD FUD MAX FEE96119 XXX $136.2096120 XXX $80.4096125 XXX $197.4096127 XXX $9.0096150 XXX $36.6096151 XXX $34.8096152 XXX $33.0096153 XXX $7.8096154 XXX $32.4096155 XXX $38.4096360 XXX $97.2096361 ZZZ $25.8096365 XXX $117.0096366 ZZZ $31.8096367 ZZZ $51.0096368 ZZZ $34.8096369 XXX $328.8096370 ZZZ $25.8096371 ZZZ $151.2096372 XXX $42.6096373 XXX $33.0096374 XXX $95.4096375 ZZZ $37.8096401 XXX $125.4096402 XXX $54.0096405 000 $138.0096406 000 $200.4096409 XXX $186.0096411 ZZZ $104.4096413 XXX $228.0096415 ZZZ $46.8096416 XXX $237.0096417 ZZZ $105.0096420 XXX $175.8096422 XXX $286.8096423 ZZZ $132.6096425 XXX $304.2096440 000 $1,453.2096446 XXX $338.4096450 000 $307.2096521 XXX $233.4096522 XXX $191.4096523 XXX $42.0096542 XXX $202.2096567 XXX $229.2096570 ZZZ $98.4096571 ZZZ $45.0096900 XXX $34.8096902 XXX $37.2096904 XXX $106.2096910 XXX $120.60



173


HCPCS MOD FUD MAX FEE96912 XXX $154.8096913 XXX $218.4096920 000 $262.2096921 000 $289.8096922 000 $400.8097001 XXX $126.6097002 XXX $70.8097003 XXX $143.4097004 XXX $88.8097010 XXX $10.2097012 XXX $27.0097014 XXX $27.0097016 XXX $32.4097018 XXX $18.6097022 XXX $39.6097024 XXX $10.8097026 XXX $10.2097028 XXX $12.6097032 XXX $32.4097033 XXX $55.2097034 XXX $30.6097035 XXX $21.6097036 XXX $56.4097110 XXX $54.6097112 XXX $56.4097113 XXX $72.6097116 XXX $48.0097124 XXX $45.0097140 XXX $50.4097150 XXX $29.4097530 XXX $58.8097532 XXX $45.6097533 XXX $49.2097535 XXX $58.8097537 XXX $51.0097542 XXX $51.6097597 000 $128.4097598 ZZZ $42.6097605 XXX $73.2097606 XXX $87.0097610 XXX $205.8097750 XXX $55.8097755 XXX $60.6097760 XXX $64.2097761 XXX $55.8097762 XXX $80.4097802 XXX $58.8097803 XXX $50.4097804 XXX $27.0097810 XXX $61.8097811 ZZZ $46.20



174


HCPCS MOD FUD MAX FEE97813 XXX $66.0097814 ZZZ $52.2098925 000 $52.8098926 000 $76.8098927 000 $100.2098928 000 $123.6098929 000 $147.0098940 000 $47.4098941 000 $69.0098942 000 $90.0098943 XXX $46.2098960 XXX $47.4098961 XXX $22.8098962 XXX $16.8098966 XXX $24.0098967 XXX $45.6098968 XXX $67.8099091 XXX $95.4099170 000 $271.2099173 XXX $5.4099175 XXX $28.8099183 XXX $343.8099184 XXX $396.0099195 XXX $169.8099201 XXX $73.2099202 XXX $125.4099203 XXX $183.0099204 XXX $277.8099205 XXX $348.6099211 XXX $33.6099212 XXX $73.2099213 XXX $122.4099214 XXX $180.6099215 XXX $244.8099217 XXX $122.4099218 XXX $169.8099219 XXX $229.8099220 XXX $313.8099221 XXX $172.2099222 XXX $232.2099223 XXX $342.0099224 XXX $66.6099225 XXX $123.0099226 XXX $177.0099231 XXX $66.0099232 XXX $122.4099233 XXX $177.0099234 XXX $226.8099235 XXX $286.2099236 XXX $368.4099238 XXX $122.40



175


HCPCS MOD FUD MAX FEE99239 XXX $181.2099241 XXX $82.2099242 XXX $154.2099243 XXX $210.6099244 XXX $311.4099245 XXX $381.0099251 XXX $83.4099252 XXX $127.8099253 XXX $195.0099254 XXX $281.4099255 XXX $340.2099281 XXX $35.4099282 XXX $69.6099283 XXX $104.4099284 XXX $199.8099285 XXX $294.6099291 XXX $464.4099292 ZZZ $208.2099304 XXX $154.2099305 XXX $220.8099306 XXX $281.4099307 XXX $75.0099308 XXX $115.8099309 XXX $153.6099310 XXX $228.6099315 XXX $123.0099316 XXX $177.0099318 XXX $161.4099324 XXX $93.0099325 XXX $135.0099326 XXX $234.6099327 XXX $312.6099328 XXX $365.4099334 XXX $101.4099335 XXX $159.6099336 XXX $226.8099337 XXX $324.6099339 XXX $131.4099340 XXX $183.6099341 XXX $93.0099342 XXX $133.8099343 XXX $219.0099344 XXX $306.6099345 XXX $370.8099347 XXX $93.0099348 XXX $141.0099349 XXX $216.0099350 XXX $298.2099354 ZZZ $168.0099355 ZZZ $162.6099356 ZZZ $154.80



176


HCPCS MOD FUD MAX FEE99357 ZZZ $153.0099358 XXX $185.4099359 ZZZ $88.8099360 XXX $103.8099363 XXX $214.8099364 XXX $73.2099366 XXX $72.6099367 XXX $95.4099368 XXX $62.4099374 XXX $118.2099375 XXX $177.6099377 XXX $118.2099378 XXX $177.6099379 XXX $118.2099380 XXX $177.6099381 XXX $186.0099382 XXX $195.0099383 XXX $203.4099384 XXX $229.2099385 XXX $222.0099386 XXX $258.6099387 XXX $280.2099391 XXX $167.4099392 XXX $178.8099393 XXX $178.2099394 XXX $196.2099395 XXX $200.4099396 XXX $213.6099397 XXX $229.2099401 XXX $61.2099402 XXX $104.4099403 XXX $145.8099404 XXX $188.4099406 XXX $24.0099407 XXX $46.2099408 XXX $59.4099409 XXX $115.8099411 XXX $27.6099412 XXX $36.6099420 XXX $18.6099441 XXX $24.0099442 XXX $45.6099443 XXX $67.8099460 XXX $167.4099461 XXX $152.4099462 XXX $70.2099463 XXX $202.8099464 XXX $125.4099465 XXX $255.0099466 XXX $416.4099467 ZZZ $209.40



177


HCPCS MOD FUD MAX FEE99468 XXX $1,551.0099469 XXX $672.0099471 XXX $1,473.6099472 XXX $689.4099475 XXX $975.0099476 XXX $586.8099477 XXX $609.0099478 XXX $239.4099479 XXX $210.6099480 XXX $202.2099485 XXX $129.6099486 XXX $112.8099487 XXX $63.6099489 ZZZ $31.8099490 XXX $71.4099495 XXX $276.0099496 XXX $390.60G0101 XXX $64.80G0102 XXX $33.00G0104 000 $234.00G0105 53 000 $234.00G0105 000 $643.80G0106 26 XXX $85.20G0106 TC XXX $272.40G0106 XXX $357.60G0108 XXX $88.80G0109 XXX $24.00G0117 XXX $91.80G0118 XXX $76.20G0120 26 XXX $85.20G0120 TC XXX $272.40G0120 XXX $357.60G0121 53 000 $234.00G0121 000 $643.80G0122 26 XXX $84.00G0122 TC XXX $366.60G0122 XXX $450.60G0124 XXX $54.00G0127 000 $39.00G0128 XXX $13.20G0130 26 XXX $19.20G0130 TC XXX $39.00G0130 XXX $58.20G0141 XXX $54.00G0166 XXX $232.80G0168 000 $172.80G0179 XXX $69.60G0180 XXX $90.60G0181 XXX $181.80G0182 XXX $183.00G0202 26 XXX $59.40



178


HCPCS MOD FUD MAX FEEG0202 TC XXX $166.80G0202 XXX $226.20G0204 26 XXX $74.40G0204 TC XXX $201.60G0204 XXX $276.00G0206 26 XXX $59.40G0206 TC XXX $157.80G0206 XXX $217.20G0237 XXX $17.40G0238 XXX $18.00G0239 XXX $22.20G0245 XXX $111.00G0246 XXX $64.80G0247 ZZZ $123.00G0248 XXX $187.80G0249 XXX $187.80G0250 XXX $15.60G0252 26 XXX $129.60G0252 TC XXX $0.00G0252 XXX $129.60G0268 000 $90.00G0270 XXX $50.40G0271 XXX $27.00G0276 000 $684.60G0277 XXX $79.20G0278 ZZZ $23.40G0279 26 ZZZ $51.60G0279 TC ZZZ $43.20G0279 ZZZ $94.80G0281 XXX $23.40G0283 XXX $23.40G0288 XXX $55.20G0289 ZZZ $151.20G0329 XXX $16.80G0337 XXX $123.00G0341 000 $3,983.40G0342 090 $1,160.40G0343 090 $2,132.40G0364 ZZZ $21.00G0365 26 XXX $21.00G0365 TC XXX $316.20G0365 XXX $337.20G0372 XXX $15.00G0389 26 XXX $48.60G0389 TC XXX $146.40G0389 XXX $195.00G0396 XXX $61.20G0397 XXX $117.60G0402 XXX $282.00G0403 XXX $28.80G0404 XXX $14.40



179


HCPCS MOD FUD MAX FEEG0405 XXX $14.40G0406 XXX $66.00G0407 XXX $122.40G0408 XXX $177.00G0409 XXX $18.60G0412 090 $1,256.40G0413 090 $1,845.00G0414 090 $1,668.60G0415 090 $2,369.40G0416 26 XXX $305.40G0416 TC XXX $781.80G0416 XXX $1,087.20G0420 XXX $181.80G0421 XXX $42.00G0422 XXX $172.80G0423 XXX $172.80G0424 XXX $50.40G0425 XXX $172.20G0426 XXX $232.20G0427 XXX $342.00G0429 000 $168.60G0436 XXX $24.00G0437 XXX $47.40G0438 XXX $290.40G0439 XXX $195.60G0442 XXX $30.60G0443 XXX $43.80G0444 XXX $30.60G0445 XXX $44.40G0446 XXX $43.80G0447 XXX $43.80G0451 XXX $16.20G0452 26 XXX $31.80G0453 XXX $55.80G0454 XXX $15.60G0455 000 $211.80G0459 XXX $69.00G0473 XXX $22.20G6001 26 XXX $49.80G6001 TC XXX $36.60G6001 XXX $86.40G6002 26 XXX $33.60G6002 TC XXX $91.80G6002 XXX $125.40G6003 XXX $271.80G6004 XXX $210.00G6005 XXX $235.20G6006 XXX $234.00G6007 XXX $432.00G6008 XXX $291.00G6009 XXX $322.20



180


HCPCS MOD FUD MAX FEEG6010 XXX $322.20G6011 XXX $462.00G6012 XXX $382.20G6013 XXX $430.80G6014 XXX $430.20G6015 XXX $670.80G6016 XXX $670.80G6018 000 $274.20G6019 000 $842.40G6020 000 $447.60G6022 000 $568.20G6023 000 $284.40G6024 000 $932.40G6025 000 $563.40G9157 XXX $165.00G9187 XXX $83.40P3001 XXX $54.00Q0035 26 XXX $15.00Q0035 TC XXX $20.40Q0035 XXX $35.40Q0091 XXX $76.20Q0092 XXX $42.60

CHAPTER 5

APPENDIX IV


INPATIENT FACILITY FEES

Inpatient Facility Maine Workers' Compensation Medical Fee Schedule2015 Annual Update

1


MS-DRG TYPE MS-DRG TitleGeometric Mean LOS Weight ACH Fee CAH Fee

001 SURG

IMPLANT OF HEART 28.2 25.39199 $226,572.73 $276,950.43002 SURG

IMPLANT OF HEART 15.8 15.682006 $139,930.54 $171,043.64

003 SURG

96+ HRS OR PDX EXC 26.2 17.6399 $157,400.83 $192,398.39004 SURG

PDX EXC FACE, MOUTH & 20.2 10.85326 $96,843.64 $118,376.51

005 SURG

MCC OR INTESTINAL 15.1 10.497321 $93,667.60 $114,494.28006 SURG

MCC 7.9 4.746126 $42,349.68 $51,766.00

007 SURG LUNG TRANSPLANT 15.8 9.298635 $82,971.72 $101,420.21008 SURG

PANCREAS/KIDNEY 9.8 5.330196 $47,561.34 $58,136.45

010 SURG PANCREAS TRANSPLANT 7.9 4.084867 $36,449.27 $44,553.64011 SURG

FACE,MOUTH & NECK 11.3 4.737991 $42,277.09 $51,677.27

012 SURG

FACE,MOUTH & NECK 8.3 3.329332 $29,707.63 $36,313.02013 SURG

FACE,MOUTH & NECK 5.8 2.135729 $19,057.11 $23,294.40

014 SURG

MARROW TRANSPLANT 19.7 10.988256 $98,048.21 $119,848.91016 SURG

MARROW TRANSPLANT W 17.5 5.877955 $52,448.99 $64,110.86

017 SURG

MARROW TRANSPLANT 8.8 4.160306 $37,122.41 $45,376.46020 SURG

PROCEDURES W PDX 13.9 9.442271 $84,253.38 $102,986.85

021 SURG

PROCEDURES W PDX 11.9 7.155545 $63,848.93 $78,045.53022 SURG

PROCEDURES W PDX 6.4 4.493388 $40,094.50 $49,009.38

023 SURG

IMPL/ACUTE COMPLEX 7.9 5.293943 $47,237.85 $57,741.04024 SURG

IMPL/ACUTE COMPLEX 4.4 3.746118 $33,426.61 $40,858.91

025 SURG

ENDOVASCULAR 7.4 4.337409 $38,702.70 $47,308.12026 SURG

ENDOVASCULAR 4.7 3.00109 $26,778.73 $32,732.89

027 SURG

ENDOVASCULAR 2.5 2.282422 $20,366.05 $24,894.38028 SURG

MCC 9.5 5.396808 $48,155.72 $58,862.98

029 SURG

CC OR SPINAL 4.8 3.157347 $28,173.01 $34,437.18030 SURG

CC/MCC 2.6 1.783533 $15,914.46 $19,452.99

031 SURG

PROCEDURES W MCC 7.7 4.149303 $37,024.23 $45,256.45032 SURG

PROCEDURES W CC 3.3 2.032535 $18,136.31 $22,168.86

033 SURG

PROCEDURES W/O 2.0 1.560156 $13,921.27 $17,016.62034 SURG

PROCEDURE W MCC 4.5 3.700819 $33,022.41 $40,364.83

035 SURG

PROCEDURE W CC 2.0 2.210948 $19,728.29 $24,114.81036 SURG

PROCEDURE W/O CC/MCC 1.3 1.731304 $15,448.43 $18,883.33

037 SURG


PROCEDURES W CC 2.3 1.586993 $14,160.74 $17,309.33

039 SURG


OTHER NERV SYST PROC 8.1 3.795973 $33,871.47 $41,402.68

041 SURG

OTHER NERV SYST PROC 4.7 2.126747 $18,976.96 $23,196.43042 SURG

OTHER NERV SYST PROC 2.5 1.858616 $16,584.43 $20,271.92

052 MED

INJURIES W CC/MCC 4.2 1.581253 $14,109.52 $17,246.73053 MED

INJURIES W/O CC/MCC 2.7 0.929406 $8,293.09 $10,137.03

054 MED

NEOPLASMS W MCC 3.9 1.304775 $11,642.51 $14,231.18055 MED

NEOPLASMS W/O MCC 3.0 1.019076 $9,093.22 $11,115.06


2



056 MED

SYSTEM DISORDERS W 5.2 1.761467 $15,717.57 $19,212.32057 MED

SYSTEM DISORDERS W/O 3.5 1.009894 $9,011.28 $11,014.91

058 MED

CEREBELLAR ATAXIA W 5.2 1.633552 $14,576.18 $17,817.15059 MED

CEREBELLAR ATAXIA W 3.8 1.028986 $9,181.64 $11,223.15

060 MED

CEREBELLAR ATAXIA W/O 3.0 0.786651 $7,019.29 $8,580.00061 MED

W USE OF THROMBOLYTIC 5.7 2.757098 $24,601.59 $30,071.67

062 MED

W USE OF THROMBOLYTIC 4.1 1.855485 $16,556.49 $20,237.77063 MED

W USE OF THROMBOLYTIC 3.0 1.509841 $13,472.31 $16,467.84

064 MED

HEMORRHAGE OR 4.6 1.73807 $15,508.80 $18,957.13065 MED

HEMORRHAGE OR 3.4 1.064253 $9,496.33 $11,607.81

066 MED

HEMORRHAGE OR 2.4 0.75298 $6,718.84 $8,212.75067 MED

PRECEREBRAL 4.0 1.452744 $12,962.83 $15,845.08

068 MED

PRECEREBRAL 2.3 0.839532 $7,491.14 $9,156.78069 MED TRANSIENT ISCHEMIA 2.0 0.698485 $6,232.58 $7,618.38070 MED

CEREBROVASCULAR 4.8 1.643771 $14,667.37 $17,928.61

071 MED

CEREBROVASCULAR 3.4 0.974823 $8,698.35 $10,632.39072 MED

CEREBROVASCULAR 2.2 0.694746 $6,199.22 $7,577.59

073 MED

NERVE DISORDERS W 3.9 1.328952 $11,858.24 $14,494.88074 MED

NERVE DISORDERS W/O 2.9 0.884715 $7,894.31 $9,649.59

075 MED

CC/MCC 5.2 1.659511 $14,807.82 $18,100.29076 MED

CC/MCC 3.2 0.862927 $7,699.90 $9,411.94

077 MED

ENCEPHALOPATHY W 4.6 1.624472 $14,495.16 $17,718.12078 MED

ENCEPHALOPATHY W CC 3.2 0.936057 $8,352.44 $10,209.57

079 MED

ENCEPHALOPATHY W/O 2.2 0.667736 $5,958.21 $7,283.00080 MED

& COMA W MCC 3.7 1.279006 $11,412.57 $13,950.12

081 MED

& COMA W/O MCC 2.6 0.784962 $7,004.22 $8,561.58082 MED

COMA, COMA >1 HR W 3.2 1.914181 $17,080.24 $20,877.97

083 MED

COMA, COMA >1 HR W CC 3.3 1.240077 $11,065.21 $13,525.52084 MED

COMA, COMA >1 HR W/O 2.1 0.859194 $7,666.59 $9,371.23

085 MED

COMA, COMA <1 HR W 4.7 1.977016 $17,640.91 $21,563.31086 MED

COMA, COMA <1 HR W CC 3.2 1.118119 $9,976.98 $12,195.32

087 MED

COMA, COMA <1 HR W/O 2.1 0.745967 $6,656.26 $8,136.26088 MED CONCUSSION W MCC 3.7 1.570754 $14,015.84 $17,132.21089 MED CONCUSSION W CC 2.6 0.958815 $8,555.51 $10,457.80090 MED

CC/MCC 1.8 0.735281 $6,560.91 $8,019.71

091 MED

NERVOUS SYSTEM W MCC 4.2 1.597816 $14,257.31 $17,427.38092 MED

NERVOUS SYSTEM W CC 3.0 0.898904 $8,020.92 $9,804.35

093 MED

NERVOUS SYSTEM W/O 2.1 0.678294 $6,052.42 $7,398.15094 MED

TUBERCULOUS 8.2 3.335695 $29,764.41 $36,382.43

095 MED

TUBERCULOUS 5.9 2.384405 $21,276.05 $26,006.71096 MED

TUBERCULOUS 4.5 2.072586 $18,493.68 $22,605.70

097 MED

OF NERVOUS SYS EXC 8.5 3.162471 $28,218.73 $34,493.07


3



098 MED

OF NERVOUS SYS EXC 5.4 1.718922 $15,337.94 $18,748.28099 MED

OF NERVOUS SYS EXC 3.8 1.160914 $10,358.84 $12,662.09

100 MED SEIZURES W MCC 4.1 1.530375 $13,655.54 $16,691.80101 MED SEIZURES W/O MCC 2.5 0.756698 $6,752.02 $8,253.31102 MED HEADACHES W MCC 2.9 1.007272 $8,987.89 $10,986.32103 MED HEADACHES W/O MCC 2.2 0.691536 $6,170.58 $7,542.58113 SURG

CC/MCC 3.7 1.861058 $16,606.22 $20,298.56

114 SURG

W/O CC/MCC 2.2 1.156775 $10,321.90 $12,616.94115 SURG

PROCEDURES EXCEPT 3.3 1.277951 $11,403.16 $13,938.61

116 SURG

PROCEDURES W CC/MCC 3.2 1.400522 $12,496.86 $15,275.49117 SURG

PROCEDURES W/O 1.7 0.823867 $7,351.37 $8,985.92

121 MED

INFECTIONS W CC/MCC 3.9 1.063527 $9,489.85 $11,599.89122 MED

INFECTIONS W/O CC/MCC 3.1 0.635176 $5,667.68 $6,927.86

123 MED

DISORDERS 2.0 0.673157 $6,006.58 $7,342.12124 MED

THE EYE W MCC 3.4 1.143212 $10,200.88 $12,469.01

125 MED

THE EYE W/O MCC 2.4 0.68521 $6,114.13 $7,473.59129 SURG

PROCEDURES W CC/MCC 3.8 2.328418 $20,776.47 $25,396.06

130 SURG



132 SURG


MOUTH & THROAT O.R. 3.6 1.864404 $16,636.08 $20,335.05

134 SURG

MOUTH & THROAT O.R. 1.7 1.008266 $8,996.76 $10,997.16135 SURG


136 SURG


CC/MCC 3.6 1.373456 $12,255.35 $14,980.28

138 SURG

W/O CC/MCC 1.8 0.788758 $7,038.09 $8,602.98139 SURG

PROCEDURES 1.4 0.985618 $8,794.67 $10,750.14

146 MED

THROAT MALIGNANCY W 5.8 1.974863 $17,621.70 $21,539.83147 MED

, , THROAT MALIGNANCY W 3.8 1.286862 $11,482.67 $14,035.80

148 MED

THROAT MALIGNANCY 2.2 0.820516 $7,321.46 $8,949.37149 MED DYSEQUILIBRIUM 2.0 0.634243 $5,659.35 $6,917.69150 MED EPISTAXIS W MCC 3.6 1.294309 $11,549.12 $14,117.03151 MED EPISTAXIS W/O MCC 2.2 0.668972 $5,969.24 $7,296.48152 MED

MCC 3.5 1.016225 $9,067.78 $11,083.97

153 MED

MCC 2.6 0.688383 $6,142.44 $7,508.19154 MED

MOUTH & THROAT 4.0 1.370261 $12,226.84 $14,945.44

155 MED

MOUTH & THROAT 3.1 0.884802 $7,895.09 $9,650.54156 MED

, , MOUTH & THROAT 2.2 0.651551 $5,813.79 $7,106.47

157 MED

W MCC 4.6 1.581361 $14,110.48 $17,247.90158 MED

W CC 2.9 0.851864 $7,601.18 $9,291.28

159 MED

W/O CC/MCC 2.0 0.59354 $5,296.16 $6,473.74163 SURG

PROCEDURES W MCC 10.7 5.033188 $44,911.14 $54,896.98


4



164 SURG

PROCEDURES W CC 5.4 2.600954 $23,208.31 $28,368.61165 SURG

PROCEDURES W/O 3.2 1.822047 $16,258.13 $19,873.07

166 SURG


PROCEDURES W CC 5.1 1.981774 $17,683.37 $21,615.21

168 SURG

PROCEDURES W/O 2.9 1.32912 $11,859.74 $14,496.71175 MED

MCC 5.2 1.527054 $13,625.90 $16,655.58

176 MED

W/O MCC 3.5 0.96698 $8,628.36 $10,546.85177 MED

INFECTIONS & 6.2 1.949237 $17,393.04 $21,260.33

178 MED

INFECTIONS & 5.0 1.390941 $12,411.37 $15,170.99179 MED

INFECTIONS & 3.6 0.969293 $8,649.00 $10,572.08

180 MED

NEOPLASMS W MCC 5.3 1.686937 $15,052.54 $18,399.42181 MED

NEOPLASMS W CC 3.7 1.158169 $10,334.34 $12,632.15

182 MED

NEOPLASMS W/O CC/MCC 2.4 0.808786 $7,216.80 $8,821.43183 MED

MCC 4.8 1.510106 $13,474.68 $16,470.73

184 MED

CC 3.3 0.9889 $8,823.95 $10,785.93185 MED

W/O CC/MCC 2.4 0.662798 $5,914.15 $7,229.14

186 MED

MCC 4.8 1.545187 $13,787.70 $16,853.35187 MED PLEURAL EFFUSION W CC 3.5 1.069081 $9,539.41 $11,660.47188 MED

CC/MCC 2.5 0.760946 $6,789.92 $8,299.64

189 MED

RESPIRATORY FAILURE 3.9 1.213574 $10,828.72 $13,236.45190 MED

PULMONARY DISEASE W 4.2 1.174313 $10,478.39 $12,808.23

191 MED

PULMONARY DISEASE W 3.4 0.936985 $8,360.72 $10,219.70192 MED

PULMONARY DISEASE W/O 2.7 0.719007 $6,415.70 $7,842.21

193 MED

PLEURISY W MCC 4.9 1.449089 $12,930.22 $15,805.21194 MED

PLEURISY W CC 3.8 0.96884 $8,644.96 $10,567.14

195 MED

PLEURISY W/O CC/MCC 2.9 0.70438 $6,285.18 $7,682.67196 MED

DISEASE W MCC 5.4 1.663525 $14,843.63 $18,144.07

197 MED

DISEASE W CC 3.7 1.061496 $9,471.73 $11,577.74198 MED

DISEASE W/O CC/MCC 2.7 0.805436 $7,186.91 $8,784.89

199 MED PNEUMOTHORAX W MCC 5.8 1.834483 $16,369.09 $20,008.71200 MED PNEUMOTHORAX W CC 3.4 1.008378 $8,997.76 $10,998.38201 MED

CC/MCC 2.5 0.709634 $6,332.06 $7,739.98

202 MED

CC/MCC 3.2 0.877471 $7,829.67 $9,570.58203 MED

W/O CC/MCC 2.5 0.653463 $5,830.85 $7,127.32

204 MED

SYMPTOMS 2.1 0.704053 $6,282.26 $7,679.11205 MED

SYSTEM DIAGNOSES W 4.0 1.399901 $12,491.32 $15,268.72

206 MED

SYSTEM DIAGNOSES W/O 2.4 0.794176 $7,086.43 $8,662.08207 MED

DIAGNOSIS W 12.4 5.342451 $47,670.69 $58,270.11

208 MED

DIAGNOSIS W 5.0 2.296925 $20,495.46 $25,052.56215 SURG

SYSTEM IMPLANT 11.3 15.434814 $137,724.85 $168,347.52

216 SURG

MAJ CARDIOTHORACIC 13.0 9.523763 $84,980.54 $103,875.68217 SURG

MAJ CARDIOTHORACIC 8.7 6.329147 $56,474.98 $69,032.01


5



218 SURG



220 SURG



222 SURG

W CARDIAC CATH W 9.9 8.656976 $77,246.20 $94,421.64223 SURG

W CARDIAC CATH W 4.4 6.292367 $56,146.79 $68,630.85

224 SURG

W CARDIAC CATH W/O 7.9 7.673295 $68,468.81 $83,692.63225 SURG

W CARDIAC CATH W/O 4.1 5.86104 $52,298.06 $63,926.36

226 SURG

IMPLANT W/O CARDIAC 6.3 6.957333 $62,080.28 $75,883.63227 SURG

IMPLANT W/O CARDIAC 2.2 5.449307 $48,624.17 $59,435.59

228 SURG


PROCEDURES W CC 6.5 4.460618 $39,802.09 $48,651.96

230 SURG


PTCA W MCC 10.6 7.724652 $68,927.07 $84,252.78

232 SURG

PTCA W/O MCC 7.9 5.597612 $49,947.49 $61,053.15233 SURG

CARDIAC CATH W MCC 11.8 7.349289 $65,577.71 $80,158.70

234 SURG

CARDIAC CATH W/O MCC 8.0 4.881602 $43,558.53 $53,243.63235 SURG

CARDIAC CATH W MCC 9.0 5.7089 $50,940.51 $62,266.97

236 SURG

CARDIAC CATH W/O MCC 6.0 3.795224 $33,864.78 $41,394.51237 SURG

PROCEDURES W MCC 6.7 5.084348 $45,367.64 $55,454.98

238 SURG

PROCEDURES W/O MCC 2.6 3.424103 $30,553.27 $37,346.69239 SURG

SYS DISORDERS EXC 10.6 4.759027 $42,464.80 $51,906.71

240 SURG

SYS DISORDERS EXC 7.2 2.759374 $24,621.89 $30,096.49241 SURG

SYS DISORDERS EXC 4.4 1.411091 $12,591.16 $15,390.77

242 SURG

PACEMAKER IMPLANT W 5.8 3.724195 $33,230.99 $40,619.79243 SURG

PACEMAKER IMPLANT W 3.6 2.669472 $23,819.70 $29,115.93

244 SURG

PACEMAKER IMPLANT W/O 2.4 2.155482 $19,233.37 $23,509.84245 SURG

PROCEDURES 3.2 4.648537 $41,478.90 $50,701.59

246 SURG

W DRUG-ELUTING STENT 3.9 3.236762 $28,881.63 $35,303.36247 SURG

W DRUG-ELUTING STENT 2.0 2.058608 $18,368.96 $22,453.24

248 SURG

W NON-DRUG-ELUTING 4.8 3.041117 $27,135.89 $33,169.46249 SURG

W NON-DRUG-ELUTING 2.4 1.880848 $16,782.81 $20,514.41

250 SURG

W/O CORONARY ARTERY 5.0 2.988455 $26,665.98 $32,595.08251 SURG

W/O CORONARY ARTERY 2.1 2.039926 $18,202.26 $22,249.47

252 SURG


PROCEDURES W CC 3.9 2.553223 $22,782.41 $27,848.00

254 SURG


AMPUTATION FOR CIRC 6.5 2.605057 $23,244.92 $28,413.36

256 SURG

AMPUTATION FOR CIRC 5.3 1.698624 $15,156.82 $18,526.89257 SURG

AMPUTATION FOR CIRC 3.0 1.055773 $9,420.66 $11,515.32

258 SURG

DEVICE REPLACEMENT W 4.9 2.761347 $24,639.50 $30,118.01259 SURG

DEVICE REPLACEMENT 2.6 1.992432 $17,778.47 $21,731.46


6



260 SURG

REVISION EXCEPT DEVICE 7.9 3.745563 $33,421.66 $40,852.86261 SURG

REVISION EXCEPT DEVICE 3.4 1.855207 $16,554.01 $20,234.74

262 SURG

REVISION EXCEPT DEVICE 2.3 1.397765 $12,472.26 $15,245.42263 SURG

STRIPPING 3.4 1.866382 $16,653.73 $20,356.63

264 SURG

SYSTEM O.R. 5.4 2.829166 $25,244.65 $30,857.71265 SURG AICD LEAD PROCEDURES 2.7 2.864082 $25,556.20 $31,238.54266 SURG

VALVE REPLACEMENT W 8.4 8.99203 $80,235.88 $98,076.07

267 SURG

VALVE REPLACEMENT 5.0 6.751674 $60,245.19 $73,640.51280 MED

INFARCTION, 4.7 1.728916 $15,427.12 $18,857.29

281 MED

INFARCTION, 3.0 1.024652 $9,142.97 $11,175.88282 MED

INFARCTION, 2.0 0.756186 $6,747.45 $8,247.72

283 MED

INFARCTION, EXPIRED W 3.0 1.675297 $14,948.68 $18,272.46284 MED

INFARCTION, EXPIRED W 1.8 0.770342 $6,873.76 $8,402.12

285 MED

INFARCTION, EXPIRED 1.3 0.506516 $4,519.64 $5,524.57286 MED

DISORDERS EXCEPT AMI, 5.0 2.123999 $18,952.44 $23,166.46

287 MED

DISORDERS EXCEPT AMI, 2.3 1.129016 $10,074.21 $12,314.18288 MED

ENDOCARDITIS W MCC 7.6 2.713783 $24,215.09 $29,599.23

289 MED

ENDOCARDITIS W CC 5.8 1.699095 $15,161.02 $18,532.03290 MED

ENDOCARDITIS W/O 3.9 1.2476 $11,132.33 $13,607.57

291 MED

W MCC 4.6 1.509739 $13,471.40 $16,466.72292 MED

W CC 3.6 0.982415 $8,766.09 $10,715.20

293 MED

W/O CC/MCC 2.6 0.676202 $6,033.75 $7,375.34294 MED

THROMBOPHLEBITIS W 4.1 1.047992 $9,351.23 $11,430.45

295 MED

THROMBOPHLEBITIS W/O 3.1 0.692641 $6,180.44 $7,554.64296 MED

UNEXPLAINED W MCC 1.8 1.234659 $11,016.86 $13,466.43

297 MED ,

UNEXPLAINED W CC 1.3 0.647499 $5,777.63 $7,062.27298 MED

UNEXPLAINED W/O 1.1 0.422697 $3,771.73 $4,610.36

299 MED

DISORDERS W MCC 4.4 1.409393 $12,576.01 $15,372.25300 MED

DISORDERS W CC 3.5 0.977038 $8,718.11 $10,656.55

301 MED

DISORDERS W/O CC/MCC 2.6 0.677586 $6,046.10 $7,390.43302 MED

MCC 2.8 1.031123 $9,200.71 $11,246.46

303 MED

MCC 1.8 0.610066 $5,443.62 $6,653.99304 MED HYPERTENSION W MCC 3.2 1.00163 $8,937.54 $10,924.78305 MED HYPERTENSION W/O MCC 2.1 0.627158 $5,596.13 $6,840.41306 MED

VALVULAR DISORDERS W 3.9 1.368696 $12,212.87 $14,928.37

307 MED

VALVULAR DISORDERS 2.4 0.769811 $6,869.02 $8,396.33308 MED

CONDUCTION DISORDERS 3.8 1.210668 $10,802.79 $13,204.76

309 MED

CONDUCTION DISORDERS 2.6 0.786471 $7,017.68 $8,578.04310 MED

CONDUCTION DISORDERS 1.9 0.549339 $4,901.75 $5,991.64

311 MED ANGINA PECTORIS 1.8 0.566158 $5,051.83 $6,175.09312 MED SYNCOPE & COLLAPSE 2.3 0.742299 $6,623.53 $8,096.26313 MED CHEST PAIN 1.6 0.613777 $5,476.73 $6,694.47


7



314 MED

SYSTEM DIAGNOSES W 4.9 1.919522 $17,127.89 $20,936.23315 MED


316 MED

SYSTEM DIAGNOSES W/O 1.9 0.621032 $5,541.47 $6,773.60326 SURG

& DUODENAL PROC W 11.2 5.384664 $48,047.36 $58,730.53

327 SURG,

& DUODENAL PROC W CC 5.8 2.653236 $23,674.82 $28,938.85328 SURG

& DUODENAL PROC W/O 2.4 1.494932 $13,339.28 $16,305.22

329 SURG

BOWEL PROCEDURES W 11.7 5.077641 $45,307.79 $55,381.83330 SURG

BOWEL PROCEDURES W 7.1 2.549081 $22,745.45 $27,802.83

331 SURG

BOWEL PROCEDURES 4.3 1.658 $14,794.33 $18,083.81332 SURG

MCC 10.5 4.70478 $41,980.75 $51,315.04

333 SURG RECTAL RESECTION W CC 6.3 2.472793 $22,064.73 $26,970.75334 SURG

CC/MCC 3.6 1.603238 $14,305.69 $17,486.52

335 SURG

ADHESIOLYSIS W MCC 10.9 4.288123 $38,262.92 $46,770.56336 SURG

ADHESIOLYSIS W CC 6.8 2.35394 $21,004.21 $25,674.42

337 SURG

ADHESIOLYSIS W/O 3.9 1.559626 $13,916.54 $17,010.84338 SURG

COMPLICATED PRINCIPAL 7.5 3.070136 $27,394.82 $33,485.97

339 SURG

COMPLICATED PRINCIPAL 5.0 1.734019 $15,472.65 $18,912.95340 SURG


341 SURG



343 SURG


BOWEL PROCEDURES W 8.7 3.307905 $29,516.44 $36,079.32

345 SURG

BOWEL PROCEDURES W 5.4 1.710699 $15,264.57 $18,658.59346 SURG

BOWEL PROCEDURES 3.8 1.199112 $10,699.68 $13,078.71

347 SURG


PROCEDURES W CC 3.9 1.382487 $12,335.93 $15,078.79

349 SURG


HERNIA PROCEDURES W 5.5 2.466491 $22,008.50 $26,902.02

351 SURG

HERNIA PROCEDURES W 3.4 1.402428 $12,513.87 $15,296.28352 SURG

HERNIA PROCEDURES 1.9 0.928759 $8,287.32 $10,129.97

353 SURG

EXCEPT INGUINAL & 6.2 2.907731 $25,945.68 $31,714.62354 SURG

EXCEPT INGUINAL & 3.9 1.691488 $15,093.15 $18,449.06

355 SURG

EXCEPT INGUINAL & 2.4 1.252097 $11,172.46 $13,656.62356 SURG

SYSTEM O.R. 8.4 3.857258 $34,418.31 $42,071.11

357 SURG

SYSTEM O.R. 5.1 2.107206 $18,802.60 $22,983.30358 SURG

SYSTEM O.R. 2.9 1.373736 $12,257.85 $14,983.34

368 MED


DISORDERS W CC 3.4 1.070344 $9,550.68 $11,674.24

370 MED


GASTROINTESTINAL 6.0 1.863346 $16,626.64 $20,323.51

372 MED

GASTROINTESTINAL 4.6 1.13425 $10,120.91 $12,371.26373 MED

GASTROINTESTINAL 3.4 0.80134 $7,150.36 $8,740.22


8



374 MED

W MCC 6.0 2.018213 $18,008.51 $22,012.65375 MED

W CC 4.1 1.242913 $11,090.51 $13,556.45

376 MED

W/O CC/MCC 2.7 0.902059 $8,049.07 $9,838.76377 MED G.I. HEMORRHAGE W MCC 4.7 1.777542 $15,861.01 $19,387.65378 MED G.I. HEMORRHAGE W CC 3.2 1.002061 $8,941.39 $10,929.48379 MED

CC/MCC 2.3 0.677632 $6,046.51 $7,390.93

380 MED

ULCER W MCC 5.4 1.926474 $17,189.93 $21,012.05381 MED

ULCER W CC 3.5 1.087456 $9,703.37 $11,860.88

382 MED

ULCER W/O CC/MCC 2.6 0.759076 $6,773.24 $8,279.24383 MED

ULCER W MCC 4.2 1.321451 $11,791.31 $14,413.07

384 MED

ULCER W/O MCC 2.8 0.850959 $7,593.11 $9,281.41385 MED

DISEASE W MCC 5.9 1.764859 $15,747.84 $19,249.32

386 MED

DISEASE W CC 3.9 1.004031 $8,958.97 $10,950.97387 MED

DISEASE W/O CC/MCC 2.9 0.744894 $6,646.69 $8,124.56

388 MED G.I. OBSTRUCTION W MCC 5.3 1.610043 $14,366.41 $17,560.74389 MED G.I. OBSTRUCTION W CC 3.5 0.87169 $7,778.09 $9,507.52390 MED

CC/MCC 2.6 0.603385 $5,384.00 $6,581.12

391 MED

GASTROENT & MISC 3.7 1.197559 $10,685.82 $13,061.78392 MED

GASTROENT & MISC 2.7 0.73882 $6,592.49 $8,058.31

393 MED

SYSTEM DIAGNOSES W 4.6 1.689305 $15,073.67 $18,425.25394 MED


395 MED

SYSTEM DIAGNOSES W/O 2.3 0.657443 $5,866.36 $7,170.73405 SURG

, SHUNT PROCEDURES W 10.7 5.538697 $49,421.79 $60,410.57

406 SURG

SHUNT PROCEDURES W 5.9 2.806707 $25,044.25 $30,612.75407 SURG

SHUNT PROCEDURES W/O 3.9 1.947196 $17,374.83 $21,238.07

408 SURG

EXCEPT ONLY 10.0 3.896671 $34,770.00 $42,500.99409 SURG

EXCEPT ONLY 6.3 2.221766 $19,824.82 $24,232.80

410 SURG

EXCEPT ONLY 4.4 1.62055 $14,460.17 $17,675.34411 SURG

C.D.E. W MCC 9.4 3.62605 $32,355.24 $39,549.33

412 SURG

C.D.E. W CC 6.3 2.416627 $21,563.56 $26,358.15413 SURG

C.D.E. W/O CC/MCC 4.2 1.770786 $15,800.72 $19,313.96

414 SURG

EXCEPT BY 8.7 3.554526 $31,717.04 $38,769.22415 SURG

EXCEPT BY 5.6 2.026679 $18,084.06 $22,104.99

416 SURG

EXCEPT BY 3.6 1.346533 $12,015.11 $14,686.64417 SURG

CHOLECYSTECTOMY W/O 5.8 2.435276 $21,729.97 $26,561.56

418 SURG

CHOLECYSTECTOMY W/O 3.9 1.65999 $14,812.09 $18,105.51419 SURG

CHOLECYSTECTOMY W/O 2.4 1.231585 $10,989.43 $13,432.90

420 SURG

DIAGNOSTIC 8.0 3.462127 $30,892.56 $37,761.42421 SURG

DIAGNOSTIC 3.9 1.769882 $15,792.66 $19,304.10

422 SURG

DIAGNOSTIC 2.7 1.235155 $11,021.29 $13,471.84423 SURG

OR PANCREAS O.R. 9.8 4.196103 $37,441.83 $45,766.90

424 SURG

OR PANCREAS O.R. 6.1 2.299295 $20,516.61 $25,078.41


9



425 SURG

OR PANCREAS O.R. 3.7 1.379279 $12,307.31 $15,043.80432 MED

HEPATITIS W MCC 4.7 1.671003 $14,910.36 $18,225.63

433 MED

HEPATITIS W CC 3.3 0.917319 $8,185.24 $10,005.20434 MED

HEPATITIS W/O CC/MCC 2.3 0.622902 $5,558.15 $6,793.99

435 MED

HEPATOBILIARY SYSTEM 5.1 1.752397 $15,636.64 $19,113.39436 MED

HEPATOBILIARY SYSTEM 3.8 1.163994 $10,386.32 $12,695.68

437 MED

HEPATOBILIARY SYSTEM 2.6 0.897128 $8,005.07 $9,784.98438 MED

PANCREAS EXCEPT 5.0 1.702302 $15,189.64 $18,567.01

439 MED

PANCREAS EXCEPT 3.5 0.90705 $8,093.61 $9,893.19440 MED

PANCREAS EXCEPT 2.7 0.642331 $5,731.52 $7,005.90

441 MED

EXCEPT MALIG,CIRR,ALC 4.9 1.883501 $16,806.48 $20,543.35442 MED

EXCEPT MALIG,CIRR,ALC 3.3 0.926583 $8,267.90 $10,106.24

443 MED

EXCEPT MALIG,CIRR,ALC 2.5 0.651243 $5,811.04 $7,103.11444 MED

BILIARY TRACT W MCC 4.6 1.621227 $14,466.21 $17,682.72

445 MED

BILIARY TRACT W CC 3.3 1.065354 $9,506.15 $11,619.82446 MED

BILIARY TRACT W/O 2.3 0.756886 $6,753.69 $8,255.36

453 SURG

ANTERIOR/POSTERIOR 9.4 11.163726 $99,613.93 $121,762.76454 SURG

ANTERIOR/POSTERIOR 4.9 8.018419 $71,548.35 $87,456.90

455 SURG

ANTERIOR/POSTERIOR 3.1 6.250283 $55,771.28 $68,171.84456 SURG

SPINAL 9.9 9.403924 $83,911.21 $102,568.60

457 SURG

SPINAL 5.5 6.907382 $61,634.57 $75,338.82458 SURG

SPINAL 3.4 5.26368 $46,967.82 $57,410.96

459 SURG

CERVICAL W MCC 6.8 6.668648 $59,504.35 $72,734.94460 SURG

CERVICAL W/O MCC 3.0 3.999807 $35,690.28 $43,625.89

461 SURG

MAJOR JOINT PROCS OF 6.3 5.020208 $44,795.32 $54,755.41462 SURG

MAJOR JOINT PROCS OF 3.4 3.490457 $31,145.35 $38,070.41

463 SURG

EXC HAND, FOR MUSCULO- 10.6 5.33449 $47,599.65 $58,183.28464 SURG

EXC HAND, FOR MUSCULO- 6.2 3.008467 $26,844.55 $32,813.35

465 SURG

EXC HAND, FOR MUSCULO- 3.7 1.94626 $17,366.48 $21,227.86466 SURG

REPLACEMENT W MCC 6.7 5.151274 $45,964.82 $56,184.95

467 SURG

REPLACEMENT W CC 3.8 3.42306 $30,543.96 $37,335.32468 SURG

REPLACEMENT W/O 2.9 2.765194 $24,673.83 $30,159.97

469 SURG

REPLACEMENT OR 6.1 3.390474 $30,253.20 $36,979.90470 SURG

REPLACEMENT OR 3.0 2.113709 $18,860.63 $23,054.22

471 SURG

W MCC 6.3 4.873677 $43,487.82 $53,157.20472 SURG

W CC 2.4 2.91655 $26,024.38 $31,810.81

473 SURG

W/O CC/MCC 1.5 2.265509 $20,215.14 $24,709.91474 SURG

MUSCULOSKELETAL SYS & 8.5 3.594299 $32,071.93 $39,203.02

475 SURG

MUSCULOSKELETAL SYS & 5.8 2.050354 $18,295.31 $22,363.21476 SURG


477 SURG

MUSCULOSKELETAL 8.5 3.163751 $28,230.15 $34,507.03478 SURG

MUSCULOSKELETAL 5.4 2.244082 $20,023.94 $24,476.20


10



479 SURG

MUSCULOSKELETAL 3.2 1.731213 $15,447.61 $18,882.34480 SURG


481 SURG

PROCEDURES EXCEPT 4.7 1.977592 $17,646.05 $21,569.60482 SURG


483 SURG

REATTACHMENT 2.0 2.420518 $21,598.28 $26,400.59485 SURG

PDX OF INFECTION W MCC 7.9 3.094893 $27,615.73 $33,756.00

486 SURG

PDX OF INFECTION W CC 5.5 2.065557 $18,430.97 $22,529.03487 SURG

PDX OF INFECTION W/O 3.9 1.563 $13,946.65 $17,047.64

488 SURG

PDX OF INFECTION W 3.4 1.722545 $15,370.27 $18,787.80489 SURG

PDX OF INFECTION W/O 2.3 1.318641 $11,766.23 $14,382.42

492 SURG

PROC EXCEPT 6.4 3.18729 $28,440.19 $34,763.77493 SURG

PROC EXCEPT 3.9 2.035367 $18,161.58 $22,199.75

494 SURG

PROC EXCEPT 2.6 1.539669 $13,738.47 $16,793.17495 SURG

REMOVAL INT FIX 7.2 3.047618 $27,193.90 $33,240.37

496 SURG

REMOVAL INT FIX 3.9 1.728919 $15,427.14 $18,857.32497 SURG

REMOVAL INT FIX 2.0 1.22297 $10,912.56 $13,338.93

498 SURG

REMOVAL INT FIX 5.2 2.141617 $19,109.65 $23,358.62499 SURG

REMOVAL INT FIX 2.0 1.075339 $9,595.25 $11,728.72

500 SURG


PROCEDURES W CC 4.2 1.647382 $14,699.59 $17,968.00

502 SURG


MCC 6.8 2.333771 $20,824.24 $25,454.44

504 SURG FOOT PROCEDURES W CC 4.8 1.569121 $14,001.27 $17,114.40505 SURG

CC/MCC 2.6 1.247358 $11,130.18 $13,604.93

506 SURG

PROCEDURES 3.2 1.288062 $11,493.38 $14,048.89507 SURG

ELBOW JOINT 4.1 1.915438 $17,091.45 $20,891.68

508 SURG

ELBOW JOINT 1.9 1.519781 $13,561.01 $16,576.25509 SURG ARTHROSCOPY 3.1 1.549404 $13,825.33 $16,899.35510 SURG

, FOREARM PROC,EXC 4.7 2.285704 $20,395.34 $24,930.17

511 SURG

FOREARM PROC,EXC 3.2 1.6509 $14,730.98 $18,006.37512 SURG

FOREARM PROC,EXC 1.9 1.296265 $11,566.57 $14,138.36

513 SURG ,

EXCEPT MAJOR THUMB 3.5 1.446172 $12,904.19 $15,773.40514 SURG

EXCEPT MAJOR THUMB 2.1 0.899554 $8,026.72 $9,811.44

515 SURG

SYS & CONN TISS O.R. 7.1 3.223492 $28,763.22 $35,158.63516 SURG

SYS & CONN TISS O.R. 4.3 2.043382 $18,233.10 $22,287.17

517 SURG

SYS & CONN TISS O.R. 2.6 1.725084 $15,392.92 $18,815.49518 SURG

SPINAL FUSION W MCC OR 4.2 3.062847 $27,329.78 $33,406.47

519 SURG

SPINAL FUSION W CC 3.0 1.646836 $14,694.72 $17,962.04520 SURG

SPINAL FUSION W/O 1.7 1.13964 $10,169.01 $12,430.05

533 MED

MCC 4.3 1.449459 $12,933.52 $15,809.25534 MED

W/O MCC 2.9 0.759376 $6,775.91 $8,282.51

535 MED

PELVIS W MCC 4.1 1.241014 $11,073.57 $13,535.74


11



536 MED

PELVIS W/O MCC 3.0 0.720085 $6,425.32 $7,853.97537 MED

, , DISLOCATIONS OF HIP, 3.3 0.897472 $8,008.14 $9,788.73

538 MED

DISLOCATIONS OF HIP, 2.5 0.691698 $6,172.02 $7,544.35539 MED OSTEOMYELITIS W MCC 6.1 1.827643 $16,308.06 $19,934.10540 MED OSTEOMYELITIS W CC 4.7 1.296694 $11,570.40 $14,143.04541 MED

CC/MCC 3.5 0.921804 $8,225.26 $10,054.12

542 MED

FRACTURES & 6.0 1.947196 $17,374.83 $21,238.07543 MED

FRACTURES & 4.0 1.122721 $10,018.04 $12,245.52

544 MED

FRACTURES & 3.1 0.793598 $7,081.27 $8,655.77545 MED

DISORDERS W MCC 6.0 2.534085 $22,611.64 $27,639.27

546 MED

DISORDERS W CC 3.9 1.171118 $10,449.89 $12,773.38547 MED

DISORDERS W/O CC/MCC 2.8 0.79853 $7,125.28 $8,709.57

548 MED SEPTIC ARTHRITIS W MCC 6.1 1.9123 $17,063.45 $20,857.46549 MED SEPTIC ARTHRITIS W CC 4.4 1.151429 $10,274.20 $12,558.64550 MED

CC/MCC 3.1 0.839 $7,486.40 $9,150.97

551 MED

W MCC 4.7 1.555622 $13,880.82 $16,967.17552 MED

W/O MCC 3.0 0.869808 $7,761.30 $9,487.00

553 MED

ARTHROPATHIES W MCC 4.1 1.218652 $10,874.03 $13,291.84554 MED

ARTHROPATHIES W/O 2.8 0.727361 $6,490.24 $7,933.33

555 MED

MUSCULOSKELETAL 3.8 1.263554 $11,274.69 $13,781.58556 MED


557 MED

BURSITIS W MCC 5.0 1.426937 $12,732.56 $15,563.60558 MED

, BURSITIS W/O MCC 3.4 0.852167 $7,603.89 $9,294.59

559 MED



561 MED,


EXCEPT FEMUR, HIP, 4.3 1.370618 $12,230.02 $14,949.33

563 MED

EXCEPT FEMUR, HIP, 2.9 0.775642 $6,921.05 $8,459.93564 MED


565 MED

MUSCULOSKELETAL SYS & 3.5 0.939845 $8,386.24 $10,250.89566 MED


570 SURG

MCC 7.1 2.395203 $21,372.40 $26,124.48571 SURG SKIN DEBRIDEMENT W CC 5.1 1.466406 $13,084.74 $15,994.09572 SURG

CC/MCC 3.7 0.991933 $8,851.02 $10,819.01

573 SURG

ULCER OR CELLULITIS W 8.5 3.70735 $33,080.68 $40,436.07574 SURG

ULCER OR CELLULITIS W 7.0 2.629799 $23,465.70 $28,683.22

575 SURG

ULCER OR CELLULITIS 4.2 1.492583 $13,318.32 $16,279.60576 SURG

SKIN ULCER OR 7.6 4.142336 $36,962.06 $45,180.46

577 SURG

SKIN ULCER OR 3.7 1.981178 $17,678.05 $21,608.71578 SURG

SKIN ULCER OR 2.3 1.316191 $11,744.37 $14,355.70

579 SURG ,

TISS & BREAST PROC W 6.9 2.726304 $24,326.81 $29,735.80580 SURG

TISS & BREAST PROC W 3.8 1.572711 $14,033.30 $17,153.56


12



581 SURG

TISS & BREAST PROC W/O 2.0 1.133827 $10,117.14 $12,366.65582 SURG

MALIGNANCY W CC/MCC 2.0 1.300333 $11,602.87 $14,182.73

583 SURG

MALIGNANCY W/O CC/MCC 1.5 1.093234 $9,754.93 $11,923.90584 SURG

EXCISION & OTHER 3.5 1.768193 $15,777.59 $19,285.68

585 SURG ,

EXCISION & OTHER 1.9 1.375156 $12,270.52 $14,998.83592 MED SKIN ULCERS W MCC 5.1 1.424918 $12,714.54 $15,541.58593 MED SKIN ULCERS W CC 4.2 1.019598 $9,097.87 $11,120.76594 MED

CC/MCC 3.0 0.712381 $6,356.58 $7,769.94

595 MED

W MCC 5.5 1.962852 $17,514.53 $21,408.83596 MED

W/O MCC 3.5 0.952712 $8,501.05 $10,391.23

597 MED


DISORDERS W CC 3.7 1.123511 $10,025.09 $12,254.13

599 MED


DISORDERS W CC/MCC 3.8 0.980256 $8,746.82 $10,691.65

601 MED

DISORDERS W/O CC/MCC 2.6 0.631392 $5,633.91 $6,886.59602 MED CELLULITIS W MCC 5.0 1.455654 $12,988.80 $15,876.82603 MED CELLULITIS W/O MCC 3.5 0.844652 $7,536.83 $9,212.62604 MED

SUBCUT TISS & BREAST W 3.8 1.262382 $11,264.23 $13,768.80

605 MED

SUBCUT TISS & BREAST 2.5 0.766423 $6,838.79 $8,359.38606 MED

W MCC 4.1 1.366371 $12,192.13 $14,903.01

607 MED

W/O MCC 2.7 0.729552 $6,509.79 $7,957.22614 SURG


615 SURG


FOR 10.7 4.161091 $37,129.41 $45,385.02

617 SURG

FOR 6.0 1.995563 $17,806.41 $21,765.61618 SURG

FOR 4.0 1.351214 $12,056.88 $14,737.69

619 SURG

OBESITY W MCC 4.2 3.288955 $29,347.35 $35,872.63620 SURG

OBESITY W CC 2.5 1.846953 $16,480.36 $20,144.72

621 SURG

OBESITY W/O CC/MCC 1.8 1.543377 $13,771.55 $16,833.61622 SURG

DEBRID FOR ENDOC, 9.1 3.80465 $33,948.89 $41,497.32

623 SURG

DEBRID FOR ENDOC, 5.6 1.830757 $16,335.84 $19,968.07624 SURG

DEBRID FOR ENDOC, 3.6 1.131449 $10,095.92 $12,340.71

625 SURG

THYROGLOSSAL 4.5 2.489633 $22,215.00 $27,154.43626 SURG

THYROGLOSSAL 2.1 1.30798 $11,671.11 $14,266.14

627 SURG,

THYROGLOSSAL 1.3 0.866268 $7,729.71 $9,448.39628 SURG

NUTRIT & METAB O.R. 6.6 3.293514 $29,388.03 $35,922.36

629 SURG

NUTRIT & METAB O.R. 6.1 2.247086 $20,050.75 $24,508.97630 SURG

, NUTRIT & METAB O.R. 3.1 1.430466 $12,764.05 $15,602.09

637 MED DIABETES W MCC 4.1 1.394399 $12,442.22 $15,208.71638 MED DIABETES W CC 3.0 0.826055 $7,370.89 $9,009.78639 MED DIABETES W/O CC/MCC 2.2 0.606774 $5,414.24 $6,618.08640 MED

NUTRITION,METABOLISM,F 3.2 1.104434 $9,854.86 $12,046.06


13



641 MED

NUTRITION,METABOLISM,F 2.6 0.705146 $6,292.02 $7,691.03642 MED

DISORDERS OF 3.3 1.142922 $10,198.29 $12,465.85

643 MED

W MCC 5.4 1.646043 $14,687.64 $17,953.39644 MED

W CC 3.8 1.01991 $9,100.66 $11,124.16

645 MED

W/O CC/MCC 2.7 0.717968 $6,406.43 $7,830.88652 SURG KIDNEY TRANSPLANT 5.7 3.150199 $28,109.23 $34,359.22653 SURG

PROCEDURES W MCC 12.1 5.795802 $51,715.94 $63,214.81

654 SURG

PROCEDURES W CC 7.6 3.097306 $27,637.26 $33,782.32655 SURG

PROCEDURES W/O 4.8 2.258971 $20,156.80 $24,638.60

656 SURG

PROCEDURES FOR 6.9 3.451742 $30,799.89 $37,648.15657 SURG

PROCEDURES FOR 4.3 2.011134 $17,945.35 $21,935.44

658 SURG

PROCEDURES FOR 2.6 1.529914 $13,651.42 $16,686.77659 SURG

PROCEDURES FOR NON- 7.5 3.38126 $30,170.98 $36,879.40

660 SURG

PROCEDURES FOR NON- 4.1 1.888814 $16,853.89 $20,601.29661 SURG

PROCEDURES FOR NON- 2.2 1.349361 $12,040.35 $14,717.48

662 SURG


PROCEDURES W CC 3.8 1.528515 $13,638.94 $16,671.51

664 SURG

PROCEDURES W/O 1.8 1.240634 $11,070.18 $13,531.60665 SURG PROSTATECTOMY W MCC 9.1 3.158498 $28,183.28 $34,449.74666 SURG PROSTATECTOMY W CC 4.5 1.751185 $15,625.82 $19,100.17667 SURG

CC/MCC 2.0 0.969028 $8,646.64 $10,569.19

668 SURG


PROCEDURES W CC 2.9 1.266205 $11,298.35 $13,810.50

670 SURG


W CC/MCC 4.0 1.617043 $14,428.87 $17,637.09

672 SURG

W/O CC/MCC 1.8 0.849606 $7,581.03 $9,266.65673 SURG

TRACT PROCEDURES W 6.8 3.502307 $31,251.09 $38,199.66

674 SURG

TRACT PROCEDURES W 5.1 2.260047 $20,166.40 $24,650.33675 SURG

TRACT PROCEDURES W/O 2.0 1.444316 $12,887.63 $15,753.15

682 MED RENAL FAILURE W MCC 4.6 1.519358 $13,557.23 $16,571.64683 MED RENAL FAILURE W CC 3.5 0.951165 $8,487.25 $10,374.36684 MED

CC/MCC 2.4 0.608489 $5,429.55 $6,636.79

685 MED

DIALYSIS 2.5 1.002516 $8,945.45 $10,934.44686 MED

NEOPLASMS W MCC 5.2 1.763687 $15,737.38 $19,236.53

687 MED

NEOPLASMS W CC 3.5 1.005386 $8,971.06 $10,965.75688 MED

NEOPLASMS W/O CC/MCC 2.0 0.69113 $6,166.95 $7,538.15

689 MED

INFECTIONS W MCC 4.2 1.117184 $9,968.63 $12,185.13690 MED

INFECTIONS W/O MCC 3.1 0.77938 $6,954.41 $8,500.70

691 MED

LITHOTRIPSY W CC/MCC 2.8 1.623789 $14,489.07 $17,710.67692 MED

LITHOTRIPSY W/O CC/MCC 1.6 1.128555 $10,070.10 $12,309.15

693 MED

ESW LITHOTRIPSY W MCC 3.8 1.343275 $11,986.04 $14,651.10694 MED

ESW LITHOTRIPSY W/O 1.9 0.685949 $6,120.72 $7,481.65


14



695 MED

SIGNS & SYMPTOMS W 4.0 1.244957 $11,108.75 $13,578.75696 MED

SIGNS & SYMPTOMS W/O 2.4 0.66186 $5,905.78 $7,218.91

697 MED URETHRAL STRICTURE 2.5 0.922888 $8,234.93 $10,065.94698 MED

TRACT DIAGNOSES W 5.1 1.562523 $13,942.39 $17,042.44

699 MED

TRACT DIAGNOSES W CC 3.5 1.016986 $9,074.57 $11,092.27700 MED

TRACT DIAGNOSES W/O 2.6 0.710974 $6,344.02 $7,754.59

707 SURG

PROCEDURES W CC/MCC 2.9 1.815529 $16,199.97 $19,801.97708 SURG

PROCEDURES W/O 1.4 1.326164 $11,833.36 $14,464.47

709 SURG

CC/MCC 4.0 2.134122 $19,042.77 $23,276.87710 SURG

CC/MCC 1.5 1.294928 $11,554.64 $14,123.78

711 SURG

CC/MCC 5.7 2.254706 $20,118.74 $24,592.08712 SURG

W/O CC/MCC 2.3 1.063247 $9,487.35 $11,596.84

713 SURG

PROSTATECTOMY W 3.2 1.482804 $13,231.06 $16,172.94714 SURG

PROSTATECTOMY W/O 1.6 0.793295 $7,078.57 $8,652.47

715 SURG

REPRODUCTIVE SYSTEM 4.6 2.005148 $17,891.94 $21,870.15716 SURG

REPRODUCTIVE SYSTEM 1.5 1.185663 $10,579.67 $12,932.03

717 SURG



722 MED

REPRODUCTIVE SYSTEM 5.6 1.756913 $15,676.93 $19,162.65723 MED

, REPRODUCTIVE SYSTEM 3.8 1.063492 $9,489.54 $11,599.51

724 MED


HYPERTROPHY W MCC 4.3 1.178995 $10,520.17 $12,859.30

726 MED

HYPERTROPHY W/O MCC 2.6 0.702904 $6,272.01 $7,666.57727 MED

MALE REPRODUCTIVE 4.9 1.419465 $12,665.89 $15,482.10

728 MED

MALE REPRODUCTIVE 3.2 0.800645 $7,144.16 $8,732.64729 MED


730 MED


RAD HYSTERECTOMY & 4.5 2.570439 $22,936.03 $28,035.78

735 SURG ,

RAD HYSTERECTOMY & 1.8 1.226468 $10,943.77 $13,377.09736 SURG

FOR OVARIAN OR 10.1 4.434056 $39,565.08 $48,362.25

737 SURG

FOR OVARIAN OR 5.2 2.019778 $18,022.48 $22,029.72738 SURG

FOR OVARIAN OR 2.9 1.274582 $11,373.10 $13,901.87

739 SURG

FOR NON- 6.6 3.313279 $29,564.39 $36,137.93740 SURG

FOR NON- 3.0 1.606921 $14,338.56 $17,526.69

741 SURG,

FOR NON- 1.7 1.184591 $10,570.11 $12,920.33742 SURG

FOR NON-MALIGNANCY W 2.9 1.543555 $13,773.14 $16,835.55

743 SURG

FOR NON-MALIGNANCY 1.7 0.995391 $8,881.87 $10,856.73744 SURG

, , LAPAROSCOPY & TUBAL 4.1 1.748366 $15,600.67 $19,069.43

745 SURG

LAPAROSCOPY & TUBAL 1.8 0.95527 $8,523.87 $10,419.13746 SURG


747 SURG,


SYSTEM 1.5 1.084533 $9,677.29 $11,829.00


15



749 SURG



754 MED



756 MED,



758 MED


, REPRODUCTIVE SYSTEM 3.0 0.69305 $6,184.09 $7,559.10

760 MED

FEMALE REPRODUCTIVE 2.7 0.839915 $7,494.56 $9,160.95761 MED

FEMALE REPRODUCTIVE 1.7 0.498812 $4,450.90 $5,440.54

765 SURG

CC/MCC 3.8 1.092406 $9,747.54 $11,914.87766 SURG

CC/MCC 2.9 0.756195 $6,747.53 $8,247.82

767 SURG

STERILIZATION &/OR D&C 2.7 0.851261 $7,595.80 $9,284.70768 SURG

PROC EXCEPT STERIL 4.7 1.11840577 $9,979.53 $12,198.45

769 SURG

ABORTION DIAGNOSES W 3.5 1.892996 $16,891.20 $20,646.91770 SURG

ASPIRATION CURETTAGE 1.7 0.802922 $7,164.47 $8,757.47

774 MED

COMPLICATING 2.6 0.716797 $6,395.98 $7,818.10775 MED

COMPLICATING 2.1 0.564269 $5,034.97 $6,154.48

776 MED

ABORTION DIAGNOSES 2.7 0.811672 $7,242.55 $8,852.91777 MED ECTOPIC PREGNANCY 1.7 1.014501 $9,052.39 $11,065.16778 MED THREATENED ABORTION 2.1 0.563763 $5,030.46 $6,148.96779 MED ABORTION W/O D&C 1.5 0.638906 $5,700.96 $6,968.55780 MED FALSE LABOR 1.2 0.287954 $2,569.41 $3,140.71781 MED

DIAGNOSES W MEDICAL 2.6 0.754618 $6,733.46 $8,230.62

782 MED

DIAGNOSES W/O MEDICAL 1.7 0.405686 $3,619.94 $4,424.82789 MED

, TRANSFERRED TO 1.8 1.55473043 $13,872.86 $16,957.44

790 MED

RESPIRATORY DISTRESS 17.9 5.12683604 $45,746.76 $55,918.40791 MED

PROBLEMS 13.3 3.50147835 $31,243.69 $38,190.62

792 MED

MAJOR PROBLEMS 8.6 2.11271682 $18,851.77 $23,043.40793 MED

MAJOR PROBLEMS 4.7 3.59681998 $32,094.42 $39,230.52

794 MED

SIGNIFICANT PROBLEMS 3.4 1.27305007 $11,359.43 $13,885.16795 MED NORMAL NEWBORN 3.1 0.17238015 $1,538.15 $1,880.15799 SURG SPLENECTOMY W MCC 9.4 5.013081 $44,731.72 $54,677.67800 SURG SPLENECTOMY W CC 5.5 2.64029 $23,559.31 $28,797.64801 SURG

CC/MCC 2.7 1.547714 $13,810.25 $16,880.92

802 SURG

BLOOD & BLOOD FORMING 7.9 3.360054 $29,981.76 $36,648.11803 SURG

BLOOD & BLOOD FORMING 4.4 1.843976 $16,453.80 $20,112.25

804 SURG

BLOOD & BLOOD FORMING 2.3 1.22647 $10,943.79 $13,377.11808 MED

DIAG EXC SICKLE CELL 6.0 2.225991 $19,862.52 $24,278.88

809 MED

DIAG EXC SICKLE CELL 3.7 1.203703 $10,740.64 $13,128.79810 MED

DIAG EXC SICKLE CELL 2.6 0.840944 $7,503.74 $9,172.18

811 MED

DISORDERS W MCC 3.6 1.282897 $11,447.29 $13,992.56


16



812 MED

DISORDERS W/O MCC 2.6 0.816152 $7,282.52 $8,901.77813 MED

DISORDERS 3.5 1.6534 $14,753.29 $18,033.63

814 MED

IMMUNITY DISORDERS W 4.9 1.704801 $15,211.94 $18,594.26815 MED

IMMUNITY DISORDERS W 3.3 0.994834 $8,876.90 $10,850.65

816 MED

IMMUNITY DISORDERS 2.3 0.688152 $6,140.38 $7,505.67820 SURG

MAJOR O.R. PROCEDURE 11.6 5.522563 $49,277.83 $60,234.59

821 SURG

MAJOR O.R. PROCEDURE 4.5 2.306374 $20,579.78 $25,155.62822 SURG


823 SURG

LEUKEMIA W OTHER O.R. 11.4 4.462159 $39,815.84 $48,668.77824 SURG

LEUKEMIA W OTHER O.R. 5.8 2.295064 $20,478.86 $25,032.26

825 SURG

LEUKEMIA W OTHER O.R. 2.7 1.38028 $12,316.24 $15,054.71826 SURG

POORLY DIFF NEOPL W 10.4 5.08997 $45,417.80 $55,516.30

827 SURG

POORLY DIFF NEOPL W 5.1 2.321435 $20,714.16 $25,319.89828 SURG


829 SURG

POORLY DIFF NEOPL W 6.7 3.423091 $30,544.24 $37,335.65830 SURG


834 MED

MAJOR O.R. PROCEDURE 10.1 5.273517 $47,055.59 $57,518.25835 MED


836 MED

MAJOR O.R. PROCEDURE 2.7 1.169333 $10,433.96 $12,753.92837 MED

LEUKEMIA AS SDX OR W 16.3 6.46311 $57,670.33 $70,493.14

838 MED

LEUKEMIA AS SDX W CC 6.8 2.792266 $24,915.39 $30,455.25839 MED

LEUKEMIA AS SDX W/O 4.9 1.252549 $11,176.49 $13,661.55

840 MED

LEUKEMIA W MCC 7.6 3.105841 $27,713.42 $33,875.41841 MED

LEUKEMIA W CC 4.7 1.622627 $14,478.70 $17,697.99

842 MED

LEUKEMIA W/O CC/MCC 2.9 1.077745 $9,616.72 $11,754.96843 MED

OR POORLY DIFF NEOPL 5.5 1.790244 $15,974.35 $19,526.19

844 MED

OR POORLY DIFF NEOPL 4.1 1.205839 $10,759.70 $13,152.09845 MED

OR POORLY DIFF NEOPL 2.9 0.855058 $7,629.68 $9,326.12

846 MED

ACUTE LEUKEMIA AS 5.5 2.326386 $20,758.34 $25,373.89847 MED

ACUTE LEUKEMIA AS 2.9 1.156852 $10,322.59 $12,617.78

848 MED

ACUTE LEUKEMIA AS 2.4 0.845391 $7,543.42 $9,220.68849 MED RADIOTHERAPY 4.4 1.465675 $13,078.22 $15,986.12853 SURG

DISEASES W O.R. 10.8 5.20677 $46,460.01 $56,790.24

854 SURG

DISEASES W O.R. 6.7 2.387728 $21,305.70 $26,042.95855 SURG

DISEASES W O.R. 3.3 1.705673 $15,219.72 $18,603.78

856 SURG

TRAUMATIC INFECTIONS 10.0 4.817679 $42,988.15 $52,546.42857 SURG

TRAUMATIC INFECTIONS 5.6 2.049969 $18,291.87 $22,359.01

858 SURG

TRAUMATIC INFECTIONS 3.7 1.339022 $11,948.09 $14,604.71862 MED

TRAUMATIC INFECTIONS 5.5 1.850609 $16,512.98 $20,184.59

863 MED

TRAUMATIC INFECTIONS 3.7 0.983628 $8,776.91 $10,728.43864 MED FEVER 2.8 0.84189 $7,512.18 $9,182.49865 MED VIRAL ILLNESS W MCC 4.2 1.513108 $13,501.46 $16,503.47


17



866 MED VIRAL ILLNESS W/O MCC 2.7 0.742539 $6,625.68 $8,098.87867 MED

PARASITIC DISEASES 7.0 2.724471 $24,310.45 $29,715.81

868 MED

PARASITIC DISEASES 3.9 1.089671 $9,723.13 $11,885.04869 MED

PARASITIC DISEASES 2.7 0.687708 $6,136.42 $7,500.83

870 MED

SEPSIS W MV 96+ HOURS 12.6 5.869825 $52,376.45 $64,022.18871 MED

SEPSIS W/O MV 96+ 5.1 1.807154 $16,125.24 $19,710.63

872 MED

SEPSIS W/O MV 96+ 4.0 1.052783 $9,393.98 $11,482.70876 SURG

PRINCIPAL DIAGNOSES OF 7.4 3.353258 $29,921.12 $36,573.99

880 MED

REACTION & 2.2 0.670354 $5,981.57 $7,311.55881 MED DEPRESSIVE NEUROSES 3.3 0.646389 $5,767.73 $7,050.16882 MED

DEPRESSIVE 3.2 0.693464 $6,187.78 $7,563.61

883 MED

PERSONALITY & IMPULSE 4.4 1.30624 $11,655.58 $14,247.16884 MED

& MENTAL RETARDATION 4.1 1.078323 $9,621.88 $11,761.27

885 MED PSYCHOSES 5.4 1.021722 $9,116.83 $11,143.92886 MED

DEVELOPMENTAL 3.8 0.828809 $7,395.46 $9,039.82

887 MED

DISORDER DIAGNOSES 3.0 0.932915 $8,324.40 $10,175.30894 MED

OR DEPENDENCE, LEFT 2.1 0.444987 $3,970.62 $4,853.47

895 MED

OR DEPENDENCE W 9.6 1.215171 $10,842.97 $13,253.87896 MED

OR DEPENDENCE W/O 4.7 1.524354 $13,601.81 $16,626.13

897 MED

OR DEPENDENCE W/O 3.2 0.69047 $6,161.06 $7,530.96901 SURG

FOR INJURIES W MCC 8.9 3.99286 $35,628.29 $43,550.12

902 SURG

FOR INJURIES W CC 4.9 1.743254 $15,555.06 $19,013.67903 SURG

FOR INJURIES W/O 3.0 1.127996 $10,065.11 $12,303.05

904 SURG

INJURIES W CC/MCC 7.0 3.363663 $30,013.96 $36,687.47905 SURG

INJURIES W/O CC/MCC 3.3 1.388876 $12,392.94 $15,148.47

906 SURG

INJURIES 2.3 1.178943 $10,519.71 $12,858.73907 SURG

FOR INJURIES W MCC 7.4 3.78725 $33,793.63 $41,307.54

908 SURG

FOR INJURIES W CC 4.2 1.957508 $17,466.84 $21,350.54909 SURG

FOR INJURIES W/O 2.5 1.255607 $11,203.78 $13,694.91

913 MED

MCC 3.4 1.140995 $10,181.10 $12,444.83914 MED

MCC 2.3 0.700894 $6,254.08 $7,644.65

915 MED

MCC 3.6 1.538145 $13,724.87 $16,776.55916 MED

W/O MCC 1.7 0.51371 $4,583.83 $5,603.03

917 MED

EFFECTS OF DRUGS W 3.4 1.405102 $12,537.73 $15,325.45918 MED

EFFECTS OF DRUGS W/O 2.1 0.641231 $5,721.70 $6,993.91

919 MED

TREATMENT W MCC 4.3 1.674963 $14,945.69 $18,268.82920 MED

TREATMENT W CC 3.0 0.984969 $8,788.88 $10,743.06

921 MED

TREATMENT W/O CC/MCC 2.1 0.660191 $5,890.88 $7,200.70922 MED

POISONING & TOXIC 3.8 1.495322 $13,342.76 $16,309.48

923 MED

POISONING & TOXIC 2.2 0.734795 $6,556.58 $8,014.41927 SURG

FULL THICKNESS BURNS 23.0 15.549932 $138,752.04 $169,603.11

928 SURG

SKIN GRAFT OR INHAL INJ 11.0 5.381978 $48,023.39 $58,701.23


18



929 SURG

SKIN GRAFT OR INHAL INJ 5.4 2.334383 $20,829.70 $25,461.12933 MED

FULL THICKNESS BURNS 2.3 2.755727 $24,589.35 $30,056.71

934 MED

W/O SKIN GRFT OR INHAL 4.0 1.574832 $14,052.23 $17,176.69935 MED NON-EXTENSIVE BURNS 3.2 1.471739 $13,132.33 $16,052.26939 SURG

OF OTHER CONTACT W 6.0 2.764657 $24,669.03 $30,154.11

940 SURG

OF OTHER CONTACT W 3.5 1.82737 $16,305.62 $19,931.12941 SURG

OF OTHER CONTACT W 2.1 1.353074 $12,073.48 $14,757.98

945 MED

CC/MCC 8.5 1.270902 $11,340.26 $13,861.73946 MED

CC/MCC 6.5 1.066188 $9,513.60 $11,628.91

947 MED

MCC 3.5 1.136766 $10,143.36 $12,398.71948 MED

MCC 2.6 0.713144 $6,363.38 $7,778.26

949 MED AFTERCARE W CC/MCC 2.9 1.05249 $9,391.37 $11,479.51950 MED AFTERCARE W/O CC/MCC 2.3 0.550768 $4,914.50 $6,007.23951 MED

INFLUENCING HEALTH 2.4 0.918759 $8,198.09 $10,020.90

955 SURG

MULTIPLE SIGNIFICANT 8.0 5.572742 $49,725.58 $60,781.90956 SURG

& FEMUR PROC FOR 6.6 3.669221 $32,740.46 $40,020.19

957 SURG

FOR MULTIPLE 10.0 6.845281 $61,080.44 $74,661.48958 SURG

FOR MULTIPLE 7.3 3.86023 $34,444.83 $42,103.53

959 SURG

FOR MULTIPLE 4.6 2.544727 $22,706.60 $27,755.34963 MED

SIGNIFICANT TRAUMA W 5.6 2.707114 $24,155.58 $29,526.49

964 MED

SIGNIFICANT TRAUMA W 4.2 1.476898 $13,178.36 $16,108.53965 MED

SIGNIFICANT TRAUMA W/O 2.9 0.941838 $8,404.02 $10,272.63

969 SURG

PROCEDURE W MCC 12.3 6.081453 $54,264.81 $66,330.41970 SURG

PROCEDURE W/O MCC 5.4 2.208466 $19,706.14 $24,087.74

974 MED

CONDITION W MCC 6.7 2.684903 $23,957.39 $29,284.24975 MED

CONDITION W CC 4.5 1.30467 $11,641.57 $14,230.04

976 MED

CONDITION W/O CC/MCC 3.1 0.877419 $7,829.21 $9,570.01977 MED

RELATED CONDITION 3.5 1.130493 $10,087.39 $12,330.29

981 SURG

PROCEDURE UNRELATED 9.9 4.996817 $44,586.60 $54,500.28982 SURG

PROCEDURE UNRELATED 5.7 2.815013 $25,118.36 $30,703.35

983 SURG



985 SURG



987 SURG

PROC UNRELATED TO 8.3 3.300784 $29,452.90 $36,001.65988 SURG

PROC UNRELATED TO 4.7 1.764278 $15,742.65 $19,242.98

989 SURG

PROC UNRELATED TO 2.2 1.045413 $9,328.22 $11,402.32

CHAPTER 5

APPENDIX V


OUTPATIENT FACILITY FEES

Outpatient Facility Maine Workers' Compensation Medical Fee Schedule2015 Annual Update

1


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee0001F E $0.00 $0.00 $0.000001M E $0.00 $0.00 $0.000002M E $0.00 $0.00 $0.000003M E $0.00 $0.00 $0.000004M E $0.00 $0.00 $0.000005F E $0.00 $0.00 $0.000006M E $0.00 $0.00 $0.000007M E $0.00 $0.00 $0.000008M E $0.00 $0.00 $0.0000100 N $0.00 $0.00 $0.00 00102 N $0.00 $0.00 $0.00 00103 N $0.00 $0.00 $0.00 00104 N $0.00 $0.00 $0.00 00120 N $0.00 $0.00 $0.00 00124 N $0.00 $0.00 $0.00 00126 N $0.00 $0.00 $0.00 0012F E $0.00 $0.00 $0.0000140 N $0.00 $0.00 $0.00 00142 N $0.00 $0.00 $0.00 00144 N $0.00 $0.00 $0.00 00145 N $0.00 $0.00 $0.00 00147 N $0.00 $0.00 $0.00 00148 N $0.00 $0.00 $0.00 0014F E $0.00 $0.00 $0.000015F E $0.00 $0.00 $0.0000160 N $0.00 $0.00 $0.00 00162 N $0.00 $0.00 $0.00 00164 N $0.00 $0.00 $0.00 00170 N $0.00 $0.00 $0.00 00172 N $0.00 $0.00 $0.00 00174 N $0.00 $0.00 $0.00 00176 C $0.00 $0.00 $0.0000190 N $0.00 $0.00 $0.00 00192 C $0.00 $0.00 $0.000019T A $0.00 $0.00 $0.0000210 N $0.00 $0.00 $0.00 00211 C $0.00 $0.00 $0.0000212 N $0.00 $0.00 $0.00 00214 C $0.00 $0.00 $0.0000215 C $0.00 $0.00 $0.0000216 N $0.00 $0.00 $0.00 00218 N $0.00 $0.00 $0.00 00220 N $0.00 $0.00 $0.00 00222 N $0.00 $0.00 $0.00 00300 N $0.00 $0.00 $0.00 00320 N $0.00 $0.00 $0.00 00322 N $0.00 $0.00 $0.00 00326 N $0.00 $0.00 $0.00 00350 N $0.00 $0.00 $0.00 00352 N $0.00 $0.00 $0.00 00400 N $0.00 $0.00 $0.00


2


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee00402 N $0.00 $0.00 $0.00 00404 N $0.00 $0.00 $0.00 00406 N $0.00 $0.00 $0.00 00410 N $0.00 $0.00 $0.00 0042T N $0.00 $0.00 $0.00 00450 N $0.00 $0.00 $0.00 00454 N $0.00 $0.00 $0.00 00470 N $0.00 $0.00 $0.00 00472 N $0.00 $0.00 $0.00 00474 C $0.00 $0.00 $0.0000500 N $0.00 $0.00 $0.00 0051T C $0.00 $0.00 $0.0000520 N $0.00 $0.00 $0.00 00522 N $0.00 $0.00 $0.00 00524 C $0.00 $0.00 $0.0000528 N $0.00 $0.00 $0.00 00529 N $0.00 $0.00 $0.00 0052T C $0.00 $0.00 $0.0000530 N $0.00 $0.00 $0.00 00532 N $0.00 $0.00 $0.00 00534 N $0.00 $0.00 $0.00 00537 N $0.00 $0.00 $0.00 00539 N $0.00 $0.00 $0.00 0053T C $0.00 $0.00 $0.0000540 C $0.00 $0.00 $0.0000541 N $0.00 $0.00 $0.00 00542 C $0.00 $0.00 $0.0000546 C $0.00 $0.00 $0.0000548 N $0.00 $0.00 $0.00 0054T N $0.00 $0.00 $0.00 00550 N $0.00 $0.00 $0.00 0055T N $0.00 $0.00 $0.00 00560 C $0.00 $0.00 $0.0000561 C $0.00 $0.00 $0.0000562 C $0.00 $0.00 $0.0000563 N $0.00 $0.00 $0.00 00566 N $0.00 $0.00 $0.00 00567 C $0.00 $0.00 $0.0000580 C $0.00 $0.00 $0.000058T Q1 0433 2.4765 $268.50 $328.21 $201.39 00600 N $0.00 $0.00 $0.00 00604 C $0.00 $0.00 $0.0000620 N $0.00 $0.00 $0.00 00625 N $0.00 $0.00 $0.00 00626 N $0.00 $0.00 $0.00 00630 N $0.00 $0.00 $0.00 00632 C $0.00 $0.00 $0.0000635 N $0.00 $0.00 $0.00 00640 N $0.00 $0.00 $0.00 00670 C $0.00 $0.00 $0.0000700 N $0.00 $0.00 $0.00


3


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee00702 N $0.00 $0.00 $0.00 0071T S 0066 25.6592 $2,781.97 $3,400.61 $2,086.61 0072T S 0066 25.6592 $2,781.97 $3,400.61 $2,086.61 00730 N $0.00 $0.00 $0.00 00740 N $0.00 $0.00 $0.00 00750 N $0.00 $0.00 $0.00 00752 N $0.00 $0.00 $0.00 00754 N $0.00 $0.00 $0.00 00756 N $0.00 $0.00 $0.00 0075T C $0.00 $0.00 $0.000076T C $0.00 $0.00 $0.0000770 N $0.00 $0.00 $0.00 00790 N $0.00 $0.00 $0.00 00792 C $0.00 $0.00 $0.0000794 C $0.00 $0.00 $0.0000796 C $0.00 $0.00 $0.0000797 N $0.00 $0.00 $0.00 00800 N $0.00 $0.00 $0.00 00802 C $0.00 $0.00 $0.0000810 N $0.00 $0.00 $0.00 00820 N $0.00 $0.00 $0.00 00830 N $0.00 $0.00 $0.00 00832 N $0.00 $0.00 $0.00 00834 N $0.00 $0.00 $0.00 00836 N $0.00 $0.00 $0.00 00840 N $0.00 $0.00 $0.00 00842 N $0.00 $0.00 $0.00 00844 C $0.00 $0.00 $0.0000846 C $0.00 $0.00 $0.0000848 C $0.00 $0.00 $0.0000851 N $0.00 $0.00 $0.00 0085T E $0.00 $0.00 $0.0000860 N $0.00 $0.00 $0.00 00862 N $0.00 $0.00 $0.00 00864 C $0.00 $0.00 $0.0000865 C $0.00 $0.00 $0.0000866 C $0.00 $0.00 $0.0000868 C $0.00 $0.00 $0.0000870 N $0.00 $0.00 $0.00 00872 N $0.00 $0.00 $0.00 00873 N $0.00 $0.00 $0.00 00880 N $0.00 $0.00 $0.00 00882 C $0.00 $0.00 $0.0000902 N $0.00 $0.00 $0.00 00904 C $0.00 $0.00 $0.0000906 N $0.00 $0.00 $0.00 00908 C $0.00 $0.00 $0.0000910 N $0.00 $0.00 $0.00 00912 N $0.00 $0.00 $0.00 00914 N $0.00 $0.00 $0.00 00916 N $0.00 $0.00 $0.00


4


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee00918 N $0.00 $0.00 $0.00 00920 N $0.00 $0.00 $0.00 00921 N $0.00 $0.00 $0.00 00922 N $0.00 $0.00 $0.00 00924 N $0.00 $0.00 $0.00 00926 N $0.00 $0.00 $0.00 00928 N $0.00 $0.00 $0.00 00930 N $0.00 $0.00 $0.00 00932 C $0.00 $0.00 $0.0000934 C $0.00 $0.00 $0.0000936 C $0.00 $0.00 $0.0000938 N $0.00 $0.00 $0.00 00940 N $0.00 $0.00 $0.00 00942 N $0.00 $0.00 $0.00 00944 C $0.00 $0.00 $0.0000948 N $0.00 $0.00 $0.00 00950 N $0.00 $0.00 $0.00 00952 N $0.00 $0.00 $0.00 0095T C $0.00 $0.00 $0.000098T C $0.00 $0.00 $0.000099T T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 0100T T 0673 42.0983 $4,564.30 $5,579.29 $3,423.43 0101T T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 0102T T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 0103T A $0.00 $0.00 $0.000106T Q1 0340 0.7061 $76.56 $93.58 $57.42 0107T Q1 0340 0.7061 $76.56 $93.58 $57.42 0108T Q1 0420 1.7762 $192.58 $235.40 $144.44 0109T Q1 0340 0.7061 $76.56 $93.58 $57.42 0110T Q1 0340 0.7061 $76.56 $93.58 $57.42 01112 N $0.00 $0.00 $0.00 0111T A $0.00 $0.00 $0.0001120 N $0.00 $0.00 $0.00 01130 N $0.00 $0.00 $0.00 01140 C $0.00 $0.00 $0.0001150 C $0.00 $0.00 $0.0001160 N $0.00 $0.00 $0.00 01170 N $0.00 $0.00 $0.00 01173 N $0.00 $0.00 $0.00 01180 N $0.00 $0.00 $0.00 01190 N $0.00 $0.00 $0.00 01200 N $0.00 $0.00 $0.00 01202 N $0.00 $0.00 $0.00 01210 N $0.00 $0.00 $0.00 01212 C $0.00 $0.00 $0.0001214 C $0.00 $0.00 $0.0001215 N $0.00 $0.00 $0.00 01220 N $0.00 $0.00 $0.00 01230 N $0.00 $0.00 $0.00 01232 C $0.00 $0.00 $0.0001234 C $0.00 $0.00 $0.00


5


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee0123T T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 01250 N $0.00 $0.00 $0.00 01260 N $0.00 $0.00 $0.00 0126T Q1 0340 0.7061 $76.56 $93.58 $57.42 01270 N $0.00 $0.00 $0.00 01272 C $0.00 $0.00 $0.0001274 C $0.00 $0.00 $0.0001320 N $0.00 $0.00 $0.00 01340 N $0.00 $0.00 $0.00 01360 N $0.00 $0.00 $0.00 01380 N $0.00 $0.00 $0.00 01382 N $0.00 $0.00 $0.00 01390 N $0.00 $0.00 $0.00 01392 N $0.00 $0.00 $0.00 01400 N $0.00 $0.00 $0.00 01402 C $0.00 $0.00 $0.0001404 C $0.00 $0.00 $0.0001420 N $0.00 $0.00 $0.00 01430 N $0.00 $0.00 $0.00 01432 N $0.00 $0.00 $0.00 01440 N $0.00 $0.00 $0.00 01442 C $0.00 $0.00 $0.0001444 C $0.00 $0.00 $0.0001462 N $0.00 $0.00 $0.00 01464 N $0.00 $0.00 $0.00 01470 N $0.00 $0.00 $0.00 01472 N $0.00 $0.00 $0.00 01474 N $0.00 $0.00 $0.00 01480 N $0.00 $0.00 $0.00 01482 N $0.00 $0.00 $0.00 01484 N $0.00 $0.00 $0.00 01486 C $0.00 $0.00 $0.0001490 N $0.00 $0.00 $0.00 01500 N $0.00 $0.00 $0.00 01502 C $0.00 $0.00 $0.0001520 N $0.00 $0.00 $0.00 01522 N $0.00 $0.00 $0.00 0159T N $0.00 $0.00 $0.00 01610 N $0.00 $0.00 $0.00 01620 N $0.00 $0.00 $0.00 01622 N $0.00 $0.00 $0.00 01630 N $0.00 $0.00 $0.00 01634 C $0.00 $0.00 $0.0001636 C $0.00 $0.00 $0.0001638 C $0.00 $0.00 $0.000163T C $0.00 $0.00 $0.000164T C $0.00 $0.00 $0.0001650 N $0.00 $0.00 $0.00 01652 C $0.00 $0.00 $0.0001654 C $0.00 $0.00 $0.0001656 C $0.00 $0.00 $0.00


6


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee0165T C $0.00 $0.00 $0.0001670 N $0.00 $0.00 $0.00 01680 N $0.00 $0.00 $0.00 01682 N $0.00 $0.00 $0.00 0169T C $0.00 $0.00 $0.0001710 N $0.00 $0.00 $0.00 01712 N $0.00 $0.00 $0.00 01714 N $0.00 $0.00 $0.00 01716 N $0.00 $0.00 $0.00 0171T J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 0172T N $0.00 $0.00 $0.00 01730 N $0.00 $0.00 $0.00 01732 N $0.00 $0.00 $0.00 01740 N $0.00 $0.00 $0.00 01742 N $0.00 $0.00 $0.00 01744 N $0.00 $0.00 $0.00 0174T N $0.00 $0.00 $0.00 01756 C $0.00 $0.00 $0.0001758 N $0.00 $0.00 $0.00 0175T N $0.00 $0.00 $0.00 01760 N $0.00 $0.00 $0.00 01770 N $0.00 $0.00 $0.00 01772 N $0.00 $0.00 $0.00 01780 N $0.00 $0.00 $0.00 01782 N $0.00 $0.00 $0.00 0178T B $0.00 $0.00 $0.000179T S 0100 3.2093 $347.95 $425.33 $260.98 0180T B $0.00 $0.00 $0.0001810 N $0.00 $0.00 $0.00 01820 N $0.00 $0.00 $0.00 01829 N $0.00 $0.00 $0.00 0182T S 0313 9.8375 $1,066.58 $1,303.76 $799.99 01830 N $0.00 $0.00 $0.00 01832 N $0.00 $0.00 $0.00 01840 N $0.00 $0.00 $0.00 01842 N $0.00 $0.00 $0.00 01844 N $0.00 $0.00 $0.00 0184T T 0150 35.0675 $3,802.02 $4,647.50 $2,851.69 01850 N $0.00 $0.00 $0.00 01852 N $0.00 $0.00 $0.00 01860 N $0.00 $0.00 $0.00 0188T M $0.00 $0.00 $0.000189T M $0.00 $0.00 $0.000190T N $0.00 $0.00 $0.00 01916 N $0.00 $0.00 $0.00 0191T T 0673 42.0983 $4,564.30 $5,579.29 $3,423.43 01920 N $0.00 $0.00 $0.00 01922 N $0.00 $0.00 $0.00 01924 N $0.00 $0.00 $0.00 01925 N $0.00 $0.00 $0.00 01926 N $0.00 $0.00 $0.00


7


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee01930 N $0.00 $0.00 $0.00 01931 N $0.00 $0.00 $0.00 01932 N $0.00 $0.00 $0.00 01933 N $0.00 $0.00 $0.00 01935 N $0.00 $0.00 $0.00 01936 N $0.00 $0.00 $0.00 01951 N $0.00 $0.00 $0.00 01952 N $0.00 $0.00 $0.00 01953 N $0.00 $0.00 $0.00 01958 N $0.00 $0.00 $0.00 0195T C $0.00 $0.00 $0.0001960 N $0.00 $0.00 $0.00 01961 N $0.00 $0.00 $0.00 01962 N $0.00 $0.00 $0.00 01963 N $0.00 $0.00 $0.00 01965 N $0.00 $0.00 $0.00 01966 N $0.00 $0.00 $0.00 01967 N $0.00 $0.00 $0.00 01968 N $0.00 $0.00 $0.00 01969 N $0.00 $0.00 $0.00 0196T C $0.00 $0.00 $0.000198T Q1 0698 1.3596 $147.41 $180.19 $110.56 01990 C $0.00 $0.00 $0.0001991 N $0.00 $0.00 $0.00 01992 N $0.00 $0.00 $0.00 01996 N $0.00 $0.00 $0.00 01999 N $0.00 $0.00 $0.00 0200T T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 0201T T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 0202T C $0.00 $0.00 $0.000205T N $0.00 $0.00 $0.00 0206T Q1 0420 1.7762 $192.58 $235.40 $144.44 0207T Q1 0230 0.7019 $76.10 $93.02 $57.08 0208T Q1 0364 0.5841 $63.33 $77.41 $47.50 0209T Q1 0364 0.5841 $63.33 $77.41 $47.50 0210T Q1 0364 0.5841 $63.33 $77.41 $47.50 0211T Q1 0364 0.5841 $63.33 $77.41 $47.50 0212T Q1 0365 1.5902 $172.41 $210.75 $129.32 0213T T 0207 9.0607 $982.36 $1,200.81 $736.82 0214T N $0.00 $0.00 $0.00 0215T N $0.00 $0.00 $0.00 0216T T 0207 9.0607 $982.36 $1,200.81 $736.82 0217T N $0.00 $0.00 $0.00 0218T N $0.00 $0.00 $0.00 0219T C $0.00 $0.00 $0.000220T C $0.00 $0.00 $0.000221T T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 0222T N $0.00 $0.00 $0.00 0223T Q1 0099 1.0579 $114.70 $140.20 $86.03 0224T Q1 0690 0.4739 $51.38 $62.81 $38.54 0225T Q1 0690 0.4739 $51.38 $62.81 $38.54


8


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee0228T T 0207 9.0607 $982.36 $1,200.81 $736.82 0229T N $0.00 $0.00 $0.00 0230T T 0207 9.0607 $982.36 $1,200.81 $736.82 0231T N $0.00 $0.00 $0.00 0232T Q1 0420 1.7762 $192.58 $235.40 $144.44 0233T A $0.00 $0.00 $0.000234T J1 0229 129.8028 $14,073.22 $17,202.77 $10,555.56 0235T C $0.00 $0.00 $0.000236T J1 0229 129.8028 $14,073.22 $17,202.77 $10,555.56 0237T J1 0229 129.8028 $14,073.22 $17,202.77 $10,555.56 0238T J1 0319 200.1597 $21,701.31 $26,527.17 $16,276.99 0240T S 0361 4.432 $480.52 $587.37 $360.41 0241T N $0.00 $0.00 $0.00 0243T Q1 0077 2.2195 $240.64 $294.15 $180.49 0244T S 0369 3.1934 $346.23 $423.22 $259.69 0249T T 0150 35.0675 $3,802.02 $4,647.50 $2,851.69 0253T T 0673 42.0983 $4,564.30 $5,579.29 $3,423.43 0254T C $0.00 $0.00 $0.000255T C $0.00 $0.00 $0.000262T C $0.00 $0.00 $0.000263T S 0112 38.3671 $4,159.76 $5,084.79 $3,120.01 0264T S 0112 38.3671 $4,159.76 $5,084.79 $3,120.01 0265T S 0112 38.3671 $4,159.76 $5,084.79 $3,120.01 0266T C $0.00 $0.00 $0.000267T T 0688 28.7006 $3,111.72 $3,803.69 $2,333.93 0268T J1 0039 230.6235 $25,004.20 $30,564.53 $18,754.30 0269T Q2 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 0270T Q2 0688 28.7006 $3,111.72 $3,803.69 $2,333.93 0271T Q2 0688 28.7006 $3,111.72 $3,803.69 $2,333.93 0272T S 0218 2.1417 $232.20 $283.84 $174.16 0273T S 0218 2.1417 $232.20 $283.84 $174.16 0274T T 0208 55.4537 $6,012.29 $7,349.28 $4,509.49 0275T T 0208 55.4537 $6,012.29 $7,349.28 $4,509.49 0278T Q1 0215 1.2804 $138.82 $169.69 $104.12 0281T C $0.00 $0.00 $0.000282T J1 0061 71.3285 $7,733.44 $9,453.17 $5,800.43 0283T J1 0318 352.7212 $38,242.03 $46,746.14 $28,683.29 0284T Q2 0688 28.7006 $3,111.72 $3,803.69 $2,333.93 0285T S 0216 3.6766 $398.62 $487.26 $298.98 0286T N $0.00 $0.00 $0.00 0287T N $0.00 $0.00 $0.00 0288T T 0150 35.0675 $3,802.02 $4,647.50 $2,851.69 0289T N $0.00 $0.00 $0.00 0290T N $0.00 $0.00 $0.00 0291T N $0.00 $0.00 $0.00 0292T N $0.00 $0.00 $0.00 0293T C $0.00 $0.00 $0.000294T C $0.00 $0.00 $0.000295T M $0.00 $0.00 $0.000296T Q1 0099 1.0579 $114.70 $140.20 $86.03 0297T Q1 0099 1.0579 $114.70 $140.20 $86.03


9


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee0298T M $0.00 $0.00 $0.000299T T 0326 2.9651 $321.48 $392.96 $241.12 0300T N $0.00 $0.00 $0.00 0301T S 0066 25.6592 $2,781.97 $3,400.61 $2,086.61 0302T J1 0089 127.9907 $13,876.75 $16,962.61 $10,408.20 0303T J1 0090 88.2442 $9,567.44 $11,695.00 $7,176.02 0304T J1 0090 88.2442 $9,567.44 $11,695.00 $7,176.02 0305T Q1 0690 0.4739 $51.38 $62.81 $38.54 0306T Q1 0690 0.4739 $51.38 $62.81 $38.54 0307T Q2 0105 31.6455 $3,431.01 $4,193.98 $2,573.41 0308T J1 0351 311.2228 $33,742.78 $41,246.36 $25,308.64 0309T C $0.00 $0.00 $0.000310T S 0218 2.1417 $232.20 $283.84 $174.16 0311T Q1 0099 1.0579 $114.70 $140.20 $86.03 0312T C $0.00 $0.00 $0.000313T T 0688 28.7006 $3,111.72 $3,803.69 $2,333.93 0314T Q2 0688 28.7006 $3,111.72 $3,803.69 $2,333.93 0315T Q2 0688 28.7006 $3,111.72 $3,803.69 $2,333.93 0316T J1 0039 230.6235 $25,004.20 $30,564.53 $18,754.30 0317T Q1 0690 0.4739 $51.38 $62.81 $38.54 0329T E $0.00 $0.00 $0.000330T Q1 0230 0.7019 $76.10 $93.02 $57.08 0331T S 0377 15.3768 $1,667.15 $2,037.89 $1,250.44 0332T S 0377 15.3768 $1,667.15 $2,037.89 $1,250.44 0333T E $0.00 $0.00 $0.000335T T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 0336T T 0174 108.7985 $11,795.93 $14,419.07 $8,847.49 0337T S 0097 1.5196 $164.76 $201.39 $123.57 0338T S 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 0339T S 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 0340T T 0423 55.2208 $5,987.04 $7,318.41 $4,490.56 0341T N $0.00 $0.00 $0.00 0342T S 0112 38.3671 $4,159.76 $5,084.79 $3,120.01 0345T C $0.00 $0.00 $0.000346T N $0.00 $0.00 $0.00 0347T Q1 0420 1.7762 $192.58 $235.40 $144.44 0348T Q1 0261 1.281 $138.89 $169.77 $104.17 0349T Q1 0261 1.281 $138.89 $169.77 $104.17 0350T Q1 0261 1.281 $138.89 $169.77 $104.17 0351T N $0.00 $0.00 $0.00 0352T B $0.00 $0.00 $0.000353T N $0.00 $0.00 $0.00 0354T B $0.00 $0.00 $0.000355T T 0142 11.4924 $1,246.01 $1,523.09 $934.56 0356T S 0698 1.3596 $147.41 $180.19 $110.56 0357T Q1 0433 2.4765 $268.50 $328.21 $201.39 0358T Q1 0340 0.7061 $76.56 $93.58 $57.42 0359T V 0632 1.4327 $155.33 $189.88 $116.51 0360T V 0632 1.4327 $155.33 $189.88 $116.51 0361T N $0.00 $0.00 $0.00 0362T V 0632 1.4327 $155.33 $189.88 $116.51


10


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee0363T N $0.00 $0.00 $0.00 0364T S 0322 1.2065 $130.81 $159.90 $98.11 0365T N $0.00 $0.00 $0.00 0366T S 0325 0.8905 $96.55 $118.02 $72.42 0367T N $0.00 $0.00 $0.00 0368T S 0322 1.2065 $130.81 $159.90 $98.11 0369T N $0.00 $0.00 $0.00 0370T S 0324 1.6717 $181.25 $221.55 $135.94 0371T S 0324 1.6717 $181.25 $221.55 $135.94 0372T S 0325 0.8905 $96.55 $118.02 $72.42 0373T S 0323 1.5574 $168.85 $206.40 $126.65 0374T N $0.00 $0.00 $0.00 0375T C $0.00 $0.00 $0.000376T N $0.00 $0.00 $0.00 0377T T 0150 35.0675 $3,802.02 $4,647.50 $2,851.69 0378T B $0.00 $0.00 $0.000379T Q1 0230 0.7019 $76.10 $93.02 $57.08 0380T Q1 0230 0.7019 $76.10 $93.02 $57.08 0381T M $0.00 $0.00 $0.000382T M $0.00 $0.00 $0.000383T M $0.00 $0.00 $0.000384T M $0.00 $0.00 $0.000385T M $0.00 $0.00 $0.000386T M $0.00 $0.00 $0.000387T J1 0319 200.1597 $21,701.31 $26,527.17 $16,276.99 0388T T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 0389T Q1 0690 0.4739 $51.38 $62.81 $38.54 0390T N $0.00 $0.00 $0.00 0391T Q1 0690 0.4739 $51.38 $62.81 $38.54 0500F E $0.00 $0.00 $0.000501F E $0.00 $0.00 $0.000502F E $0.00 $0.00 $0.000503F E $0.00 $0.00 $0.000505F E $0.00 $0.00 $0.000507F E $0.00 $0.00 $0.000509F M $0.00 $0.00 $0.000513F M $0.00 $0.00 $0.000514F E $0.00 $0.00 $0.000516F E $0.00 $0.00 $0.000517F M $0.00 $0.00 $0.000518F M $0.00 $0.00 $0.000519F E $0.00 $0.00 $0.000520F M $0.00 $0.00 $0.000521F M $0.00 $0.00 $0.000525F E $0.00 $0.00 $0.000526F M $0.00 $0.00 $0.000528F M $0.00 $0.00 $0.000529F M $0.00 $0.00 $0.000535F E $0.00 $0.00 $0.000540F M $0.00 $0.00 $0.000545F E $0.00 $0.00 $0.00


11


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee0550F E $0.00 $0.00 $0.000551F E $0.00 $0.00 $0.000555F E $0.00 $0.00 $0.000556F E $0.00 $0.00 $0.000557F M $0.00 $0.00 $0.000575F E $0.00 $0.00 $0.000580F E $0.00 $0.00 $0.000581F E $0.00 $0.00 $0.000582F E $0.00 $0.00 $0.000583F E $0.00 $0.00 $0.000584F E $0.00 $0.00 $0.001000F E $0.00 $0.00 $0.0010021 T 0016 3.8173 $413.87 $505.91 $310.42 10022 T 0004 6.5703 $712.35 $870.76 $534.30 1002F E $0.00 $0.00 $0.0010030 T 0007 11.6749 $1,265.79 $1,547.27 $949.40 1003F E $0.00 $0.00 $0.0010040 Q1 0012 1.3279 $143.97 $175.99 $107.98 1004F E $0.00 $0.00 $0.001005F E $0.00 $0.00 $0.0010060 T 0006 2.1836 $236.75 $289.39 $177.57 10061 T 0006 2.1836 $236.75 $289.39 $177.57 1006F M $0.00 $0.00 $0.001007F E $0.00 $0.00 $0.0010080 T 0006 2.1836 $236.75 $289.39 $177.57 10081 T 0007 11.6749 $1,265.79 $1,547.27 $949.40 1008F E $0.00 $0.00 $0.001010F M $0.00 $0.00 $0.001011F M $0.00 $0.00 $0.0010120 T 0016 3.8173 $413.87 $505.91 $310.42 10121 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 1012F M $0.00 $0.00 $0.0010140 T 0007 11.6749 $1,265.79 $1,547.27 $949.40 1015F E $0.00 $0.00 $0.0010160 T 0006 2.1836 $236.75 $289.39 $177.57 10180 T 0008 22.0535 $2,391.04 $2,922.75 $1,793.39 1018F E $0.00 $0.00 $0.001019F E $0.00 $0.00 $0.001022F E $0.00 $0.00 $0.001026F E $0.00 $0.00 $0.001030F E $0.00 $0.00 $0.001031F E $0.00 $0.00 $0.001032F E $0.00 $0.00 $0.001033F E $0.00 $0.00 $0.001034F E $0.00 $0.00 $0.001035F E $0.00 $0.00 $0.001036F M $0.00 $0.00 $0.001038F M $0.00 $0.00 $0.001039F M $0.00 $0.00 $0.001040F E $0.00 $0.00 $0.001050F E $0.00 $0.00 $0.00


12


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee1052F E $0.00 $0.00 $0.001055F E $0.00 $0.00 $0.001060F E $0.00 $0.00 $0.001061F E $0.00 $0.00 $0.001065F E $0.00 $0.00 $0.001066F E $0.00 $0.00 $0.001070F E $0.00 $0.00 $0.001071F E $0.00 $0.00 $0.001090F M $0.00 $0.00 $0.001091F E $0.00 $0.00 $0.0011000 T 0016 3.8173 $413.87 $505.91 $310.42 11001 N $0.00 $0.00 $0.00 11004 C $0.00 $0.00 $0.0011005 C $0.00 $0.00 $0.0011006 C $0.00 $0.00 $0.0011008 C $0.00 $0.00 $0.001100F M $0.00 $0.00 $0.0011010 T 0020 11.144 $1,208.23 $1,476.91 $906.23 11011 T 0019 5.1037 $553.34 $676.39 $415.03 11012 T 0020 11.144 $1,208.23 $1,476.91 $906.23 1101F M $0.00 $0.00 $0.0011042 T 0016 3.8173 $413.87 $505.91 $310.42 11043 T 0016 3.8173 $413.87 $505.91 $310.42 11044 T 0020 11.144 $1,208.23 $1,476.91 $906.23 11045 N $0.00 $0.00 $0.00 11046 N $0.00 $0.00 $0.00 11047 N $0.00 $0.00 $0.00 11055 Q1 0012 1.3279 $143.97 $175.99 $107.98 11056 T 0015 1.9702 $213.61 $261.11 $160.22 11057 T 0015 1.9702 $213.61 $261.11 $160.22 11100 T 0015 1.9702 $213.61 $261.11 $160.22 11101 N $0.00 $0.00 $0.00 1110F E $0.00 $0.00 $0.001111F M $0.00 $0.00 $0.001116F E $0.00 $0.00 $0.001118F E $0.00 $0.00 $0.001119F E $0.00 $0.00 $0.0011200 Q1 0012 1.3279 $143.97 $175.99 $107.98 11201 N $0.00 $0.00 $0.00 1121F E $0.00 $0.00 $0.001123F M $0.00 $0.00 $0.001124F M $0.00 $0.00 $0.001125F M $0.00 $0.00 $0.001126F M $0.00 $0.00 $0.001127F E $0.00 $0.00 $0.001128F E $0.00 $0.00 $0.0011300 T 0015 1.9702 $213.61 $261.11 $160.22 11301 T 0015 1.9702 $213.61 $261.11 $160.22 11302 T 0015 1.9702 $213.61 $261.11 $160.22 11303 T 0015 1.9702 $213.61 $261.11 $160.22 11305 Q1 0012 1.3279 $143.97 $175.99 $107.98


13


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee11306 T 0015 1.9702 $213.61 $261.11 $160.22 11307 T 0015 1.9702 $213.61 $261.11 $160.22 11308 T 0015 1.9702 $213.61 $261.11 $160.22 1130F E $0.00 $0.00 $0.0011310 T 0015 1.9702 $213.61 $261.11 $160.22 11311 T 0015 1.9702 $213.61 $261.11 $160.22 11312 T 0015 1.9702 $213.61 $261.11 $160.22 11313 T 0015 1.9702 $213.61 $261.11 $160.22 1134F E $0.00 $0.00 $0.001135F E $0.00 $0.00 $0.001136F E $0.00 $0.00 $0.001137F E $0.00 $0.00 $0.0011400 T 0019 5.1037 $553.34 $676.39 $415.03 11401 T 0019 5.1037 $553.34 $676.39 $415.03 11402 T 0019 5.1037 $553.34 $676.39 $415.03 11403 T 0020 11.144 $1,208.23 $1,476.91 $906.23 11404 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 11406 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 11420 T 0020 11.144 $1,208.23 $1,476.91 $906.23 11421 T 0020 11.144 $1,208.23 $1,476.91 $906.23 11422 T 0020 11.144 $1,208.23 $1,476.91 $906.23 11423 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 11424 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 11426 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 11440 T 0019 5.1037 $553.34 $676.39 $415.03 11441 T 0019 5.1037 $553.34 $676.39 $415.03 11442 T 0020 11.144 $1,208.23 $1,476.91 $906.23 11443 T 0020 11.144 $1,208.23 $1,476.91 $906.23 11444 T 0020 11.144 $1,208.23 $1,476.91 $906.23 11446 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 11450 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 11451 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 11462 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 11463 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 11470 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 11471 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 1150F E $0.00 $0.00 $0.001151F E $0.00 $0.00 $0.001152F E $0.00 $0.00 $0.001153F E $0.00 $0.00 $0.001157F E $0.00 $0.00 $0.001158F M $0.00 $0.00 $0.001159F E $0.00 $0.00 $0.0011600 T 0020 11.144 $1,208.23 $1,476.91 $906.23 11601 T 0019 5.1037 $553.34 $676.39 $415.03 11602 T 0019 5.1037 $553.34 $676.39 $415.03 11603 T 0020 11.144 $1,208.23 $1,476.91 $906.23 11604 T 0020 11.144 $1,208.23 $1,476.91 $906.23 11606 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 1160F E $0.00 $0.00 $0.0011620 T 0020 11.144 $1,208.23 $1,476.91 $906.23


14


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee11621 T 0020 11.144 $1,208.23 $1,476.91 $906.23 11622 T 0020 11.144 $1,208.23 $1,476.91 $906.23 11623 T 0020 11.144 $1,208.23 $1,476.91 $906.23 11624 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 11626 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 11640 T 0020 11.144 $1,208.23 $1,476.91 $906.23 11641 T 0020 11.144 $1,208.23 $1,476.91 $906.23 11642 T 0020 11.144 $1,208.23 $1,476.91 $906.23 11643 T 0020 11.144 $1,208.23 $1,476.91 $906.23 11644 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 11646 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 1170F M $0.00 $0.00 $0.0011719 Q1 0340 0.7061 $76.56 $93.58 $57.42 11720 Q1 0340 0.7061 $76.56 $93.58 $57.42 11721 Q1 0340 0.7061 $76.56 $93.58 $57.42 11730 T 0015 1.9702 $213.61 $261.11 $160.22 11732 N $0.00 $0.00 $0.00 11740 Q1 0340 0.7061 $76.56 $93.58 $57.42 11750 T 0019 5.1037 $553.34 $676.39 $415.03 11752 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 11755 T 0019 5.1037 $553.34 $676.39 $415.03 1175F M $0.00 $0.00 $0.0011760 T 0326 2.9651 $321.48 $392.96 $241.12 11762 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 11765 T 0015 1.9702 $213.61 $261.11 $160.22 11770 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 11771 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 11772 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 1180F E $0.00 $0.00 $0.001181F M $0.00 $0.00 $0.001182F E $0.00 $0.00 $0.001183F E $0.00 $0.00 $0.0011900 Q1 0012 1.3279 $143.97 $175.99 $107.98 11901 Q1 0012 1.3279 $143.97 $175.99 $107.98 11920 T 0327 5.7989 $628.72 $768.53 $471.57 11921 T 0327 5.7989 $628.72 $768.53 $471.57 11922 N $0.00 $0.00 $0.00 11950 T 0327 5.7989 $628.72 $768.53 $471.57 11951 T 0327 5.7989 $628.72 $768.53 $471.57 11952 T 0327 5.7989 $628.72 $768.53 $471.57 11954 T 0326 2.9651 $321.48 $392.96 $241.12 11960 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 11970 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 11971 Q2 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 11976 Q2 0019 5.1037 $553.34 $676.39 $415.03 11980 Q1 0420 1.7762 $192.58 $235.40 $144.44 11981 Q1 0420 1.7762 $192.58 $235.40 $144.44 11982 Q1 0420 1.7762 $192.58 $235.40 $144.44 11983 Q1 0420 1.7762 $192.58 $235.40 $144.44 12001 Q1 0012 1.3279 $143.97 $175.99 $107.98 12002 Q1 0012 1.3279 $143.97 $175.99 $107.98


15


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee12004 Q1 0012 1.3279 $143.97 $175.99 $107.98 12005 T 0015 1.9702 $213.61 $261.11 $160.22 12006 T 0326 2.9651 $321.48 $392.96 $241.12 12007 T 0015 1.9702 $213.61 $261.11 $160.22 1200F E $0.00 $0.00 $0.0012011 Q1 0012 1.3279 $143.97 $175.99 $107.98 12013 Q1 0012 1.3279 $143.97 $175.99 $107.98 12014 Q1 0012 1.3279 $143.97 $175.99 $107.98 12015 T 0015 1.9702 $213.61 $261.11 $160.22 12016 T 0015 1.9702 $213.61 $261.11 $160.22 12017 T 0015 1.9702 $213.61 $261.11 $160.22 12018 T 0015 1.9702 $213.61 $261.11 $160.22 12020 T 0327 5.7989 $628.72 $768.53 $471.57 12021 T 0326 2.9651 $321.48 $392.96 $241.12 12031 T 0326 2.9651 $321.48 $392.96 $241.12 12032 T 0326 2.9651 $321.48 $392.96 $241.12 12034 T 0326 2.9651 $321.48 $392.96 $241.12 12035 T 0327 5.7989 $628.72 $768.53 $471.57 12036 T 0327 5.7989 $628.72 $768.53 $471.57 12037 T 0327 5.7989 $628.72 $768.53 $471.57 12041 T 0326 2.9651 $321.48 $392.96 $241.12 12042 T 0326 2.9651 $321.48 $392.96 $241.12 12044 T 0326 2.9651 $321.48 $392.96 $241.12 12045 T 0326 2.9651 $321.48 $392.96 $241.12 12046 T 0326 2.9651 $321.48 $392.96 $241.12 12047 T 0327 5.7989 $628.72 $768.53 $471.57 12051 T 0326 2.9651 $321.48 $392.96 $241.12 12052 T 0326 2.9651 $321.48 $392.96 $241.12 12053 T 0326 2.9651 $321.48 $392.96 $241.12 12054 T 0326 2.9651 $321.48 $392.96 $241.12 12055 T 0326 2.9651 $321.48 $392.96 $241.12 12056 T 0326 2.9651 $321.48 $392.96 $241.12 12057 T 0326 2.9651 $321.48 $392.96 $241.12 1205F E $0.00 $0.00 $0.001220F E $0.00 $0.00 $0.0013100 T 0327 5.7989 $628.72 $768.53 $471.57 13101 T 0327 5.7989 $628.72 $768.53 $471.57 13102 N $0.00 $0.00 $0.00 13120 T 0326 2.9651 $321.48 $392.96 $241.12 13121 T 0327 5.7989 $628.72 $768.53 $471.57 13122 N $0.00 $0.00 $0.00 13131 T 0326 2.9651 $321.48 $392.96 $241.12 13132 T 0327 5.7989 $628.72 $768.53 $471.57 13133 N $0.00 $0.00 $0.00 13151 T 0327 5.7989 $628.72 $768.53 $471.57 13152 T 0327 5.7989 $628.72 $768.53 $471.57 13153 N $0.00 $0.00 $0.00 13160 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 14000 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 14001 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 1400F M $0.00 $0.00 $0.00


16


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee14020 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 14021 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 14040 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 14041 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 14060 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 14061 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 14301 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 14302 N $0.00 $0.00 $0.00 14350 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 1450F E $0.00 $0.00 $0.001451F E $0.00 $0.00 $0.001460F M $0.00 $0.00 $0.001461F M $0.00 $0.00 $0.001490F M $0.00 $0.00 $0.001491F M $0.00 $0.00 $0.001493F M $0.00 $0.00 $0.001494F M $0.00 $0.00 $0.0015002 T 0327 5.7989 $628.72 $768.53 $471.57 15003 N $0.00 $0.00 $0.00 15004 T 0327 5.7989 $628.72 $768.53 $471.57 15005 N $0.00 $0.00 $0.00 1500F E $0.00 $0.00 $0.001501F E $0.00 $0.00 $0.001502F E $0.00 $0.00 $0.001503F E $0.00 $0.00 $0.0015040 T 0327 5.7989 $628.72 $768.53 $471.57 1504F E $0.00 $0.00 $0.0015050 T 0327 5.7989 $628.72 $768.53 $471.57 1505F E $0.00 $0.00 $0.0015100 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 15101 N $0.00 $0.00 $0.00 15110 T 0327 5.7989 $628.72 $768.53 $471.57 15111 N $0.00 $0.00 $0.00 15115 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15116 N $0.00 $0.00 $0.00 15120 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 15121 N $0.00 $0.00 $0.00 15130 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 15131 N $0.00 $0.00 $0.00 15135 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15136 N $0.00 $0.00 $0.00 15150 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15151 N $0.00 $0.00 $0.00 15152 N $0.00 $0.00 $0.00 15155 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 15156 N $0.00 $0.00 $0.00 15157 N $0.00 $0.00 $0.00 15200 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 15201 N $0.00 $0.00 $0.00 15220 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15221 N $0.00 $0.00 $0.00


17


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee15240 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15241 N $0.00 $0.00 $0.00 15260 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15261 N $0.00 $0.00 $0.00 15271 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15272 N $0.00 $0.00 $0.00 15273 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 15274 N $0.00 $0.00 $0.00 15275 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15276 N $0.00 $0.00 $0.00 15277 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15278 N $0.00 $0.00 $0.00 15570 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15572 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15574 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15576 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15600 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 15610 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 15620 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15630 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15650 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15731 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 15732 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15734 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 15736 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15738 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 15740 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15750 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15756 C $0.00 $0.00 $0.0015757 C $0.00 $0.00 $0.0015758 C $0.00 $0.00 $0.0015760 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15770 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 15775 T 0326 2.9651 $321.48 $392.96 $241.12 15776 T 0326 2.9651 $321.48 $392.96 $241.12 15777 N $0.00 $0.00 $0.00 15780 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 15781 T 0020 11.144 $1,208.23 $1,476.91 $906.23 15782 T 0019 5.1037 $553.34 $676.39 $415.03 15783 T 0016 3.8173 $413.87 $505.91 $310.42 15786 Q1 0012 1.3279 $143.97 $175.99 $107.98 15787 N $0.00 $0.00 $0.00 15788 Q1 0012 1.3279 $143.97 $175.99 $107.98 15789 T 0015 1.9702 $213.61 $261.11 $160.22 15792 Q1 0012 1.3279 $143.97 $175.99 $107.98 15793 Q1 0012 1.3279 $143.97 $175.99 $107.98 15819 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15820 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15821 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15822 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15823 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03


18


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee15824 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15825 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15826 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 15828 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 15829 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 15830 T 0030 55.9563 $6,066.78 $7,415.89 $4,550.37 15832 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 15833 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 15834 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 15835 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 15836 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 15837 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 15838 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 15839 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 15840 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 15841 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 15842 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 15845 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 15847 N $0.00 $0.00 $0.00 15850 T 0017 17.361 $1,882.28 $2,300.85 $1,411.80 15851 T 0017 17.361 $1,882.28 $2,300.85 $1,411.80 15852 Q1 0420 1.7762 $192.58 $235.40 $144.44 15860 Q1 0420 1.7762 $192.58 $235.40 $144.44 15876 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 15877 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 15878 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 15879 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 15920 T 0020 11.144 $1,208.23 $1,476.91 $906.23 15922 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15931 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 15933 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 15934 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 15935 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 15936 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15937 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15940 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 15941 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 15944 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15945 T 0327 5.7989 $628.72 $768.53 $471.57 15946 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 15950 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 15951 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 15952 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 15953 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 15956 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 15958 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 15999 T 0019 5.1037 $553.34 $676.39 $415.03 16000 Q1 0012 1.3279 $143.97 $175.99 $107.98 16020 T 0015 1.9702 $213.61 $261.11 $160.22 16025 T 0015 1.9702 $213.61 $261.11 $160.22 16030 T 0016 3.8173 $413.87 $505.91 $310.42


19


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee16035 T 0016 3.8173 $413.87 $505.91 $310.42 16036 C $0.00 $0.00 $0.0017000 T 0015 1.9702 $213.61 $261.11 $160.22 17003 N $0.00 $0.00 $0.00 17004 T 0016 3.8173 $413.87 $505.91 $310.42 17106 T 0016 3.8173 $413.87 $505.91 $310.42 17107 T 0016 3.8173 $413.87 $505.91 $310.42 17108 T 0016 3.8173 $413.87 $505.91 $310.42 17110 Q1 0012 1.3279 $143.97 $175.99 $107.98 17111 T 0015 1.9702 $213.61 $261.11 $160.22 17250 T 0015 1.9702 $213.61 $261.11 $160.22 17260 T 0015 1.9702 $213.61 $261.11 $160.22 17261 T 0015 1.9702 $213.61 $261.11 $160.22 17262 T 0015 1.9702 $213.61 $261.11 $160.22 17263 T 0015 1.9702 $213.61 $261.11 $160.22 17264 T 0015 1.9702 $213.61 $261.11 $160.22 17266 T 0016 3.8173 $413.87 $505.91 $310.42 17270 T 0015 1.9702 $213.61 $261.11 $160.22 17271 T 0015 1.9702 $213.61 $261.11 $160.22 17272 T 0015 1.9702 $213.61 $261.11 $160.22 17273 T 0016 3.8173 $413.87 $505.91 $310.42 17274 T 0016 3.8173 $413.87 $505.91 $310.42 17276 T 0016 3.8173 $413.87 $505.91 $310.42 17280 T 0015 1.9702 $213.61 $261.11 $160.22 17281 T 0015 1.9702 $213.61 $261.11 $160.22 17282 T 0016 3.8173 $413.87 $505.91 $310.42 17283 T 0016 3.8173 $413.87 $505.91 $310.42 17284 T 0016 3.8173 $413.87 $505.91 $310.42 17286 T 0016 3.8173 $413.87 $505.91 $310.42 17311 T 0327 5.7989 $628.72 $768.53 $471.57 17312 N $0.00 $0.00 $0.00 17313 T 0327 5.7989 $628.72 $768.53 $471.57 17314 N $0.00 $0.00 $0.00 17315 N $0.00 $0.00 $0.00 17340 Q1 0340 0.7061 $76.56 $93.58 $57.42 17360 T 0015 1.9702 $213.61 $261.11 $160.22 17380 T 0016 3.8173 $413.87 $505.91 $310.42 17999 Q1 0012 1.3279 $143.97 $175.99 $107.98 19000 T 0004 6.5703 $712.35 $870.76 $534.30 19001 N $0.00 $0.00 $0.00 19020 T 0008 22.0535 $2,391.04 $2,922.75 $1,793.39 19030 N $0.00 $0.00 $0.00 19081 T 0005 14.1916 $1,538.65 $1,880.81 $1,154.06 19082 N $0.00 $0.00 $0.00 19083 T 0005 14.1916 $1,538.65 $1,880.81 $1,154.06 19084 N $0.00 $0.00 $0.00 19085 T 0005 14.1916 $1,538.65 $1,880.81 $1,154.06 19086 N $0.00 $0.00 $0.00 19100 T 0004 6.5703 $712.35 $870.76 $534.30 19101 T 0028 29.2241 $3,168.48 $3,873.07 $2,376.50 19105 T 0029 40.6181 $4,403.81 $5,383.12 $3,303.06


20


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee19110 T 0028 29.2241 $3,168.48 $3,873.07 $2,376.50 19112 T 0028 29.2241 $3,168.48 $3,873.07 $2,376.50 19120 T 0028 29.2241 $3,168.48 $3,873.07 $2,376.50 19125 T 0028 29.2241 $3,168.48 $3,873.07 $2,376.50 19126 N $0.00 $0.00 $0.00 19260 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 19271 C $0.00 $0.00 $0.0019272 C $0.00 $0.00 $0.0019281 Q1 0420 1.7762 $192.58 $235.40 $144.44 19282 N $0.00 $0.00 $0.00 19283 Q1 0420 1.7762 $192.58 $235.40 $144.44 19284 N $0.00 $0.00 $0.00 19285 Q1 0420 1.7762 $192.58 $235.40 $144.44 19286 N $0.00 $0.00 $0.00 19287 Q1 0420 1.7762 $192.58 $235.40 $144.44 19288 N $0.00 $0.00 $0.00 19296 J1 0648 100.6339 $10,910.73 $13,337.01 $8,183.55 19297 N $0.00 $0.00 $0.00 19298 J1 0648 100.6339 $10,910.73 $13,337.01 $8,183.55 19300 T 0028 29.2241 $3,168.48 $3,873.07 $2,376.50 19301 T 0028 29.2241 $3,168.48 $3,873.07 $2,376.50 19302 T 0030 55.9563 $6,066.78 $7,415.89 $4,550.37 19303 T 0029 40.6181 $4,403.81 $5,383.12 $3,303.06 19304 T 0029 40.6181 $4,403.81 $5,383.12 $3,303.06 19305 C $0.00 $0.00 $0.0019306 C $0.00 $0.00 $0.0019307 T 0030 55.9563 $6,066.78 $7,415.89 $4,550.37 19316 T 0029 40.6181 $4,403.81 $5,383.12 $3,303.06 19318 T 0030 55.9563 $6,066.78 $7,415.89 $4,550.37 19324 T 0030 55.9563 $6,066.78 $7,415.89 $4,550.37 19325 J1 0648 100.6339 $10,910.73 $13,337.01 $8,183.55 19328 Q2 0029 40.6181 $4,403.81 $5,383.12 $3,303.06 19330 Q2 0029 40.6181 $4,403.81 $5,383.12 $3,303.06 19340 T 0030 55.9563 $6,066.78 $7,415.89 $4,550.37 19342 J1 0648 100.6339 $10,910.73 $13,337.01 $8,183.55 19350 T 0028 29.2241 $3,168.48 $3,873.07 $2,376.50 19355 T 0029 40.6181 $4,403.81 $5,383.12 $3,303.06 19357 J1 0648 100.6339 $10,910.73 $13,337.01 $8,183.55 19361 C $0.00 $0.00 $0.0019364 C $0.00 $0.00 $0.0019366 T 0029 40.6181 $4,403.81 $5,383.12 $3,303.06 19367 C $0.00 $0.00 $0.0019368 C $0.00 $0.00 $0.0019369 C $0.00 $0.00 $0.0019370 T 0029 40.6181 $4,403.81 $5,383.12 $3,303.06 19371 T 0029 40.6181 $4,403.81 $5,383.12 $3,303.06 19380 T 0030 55.9563 $6,066.78 $7,415.89 $4,550.37 19396 T 0029 40.6181 $4,403.81 $5,383.12 $3,303.06 19499 T 0028 29.2241 $3,168.48 $3,873.07 $2,376.50 20005 T 0020 11.144 $1,208.23 $1,476.91 $906.23 2000F M $0.00 $0.00 $0.00


21


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee2001F E $0.00 $0.00 $0.002002F E $0.00 $0.00 $0.002004F E $0.00 $0.00 $0.0020100 T 0252 8.7183 $945.24 $1,155.44 $708.97 20101 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 20102 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 20103 T 0007 11.6749 $1,265.79 $1,547.27 $949.40 2010F E $0.00 $0.00 $0.002014F E $0.00 $0.00 $0.0020150 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 2015F E $0.00 $0.00 $0.002016F E $0.00 $0.00 $0.002018F E $0.00 $0.00 $0.002019F M $0.00 $0.00 $0.0020200 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 20205 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 20206 T 0005 14.1916 $1,538.65 $1,880.81 $1,154.06 2020F E $0.00 $0.00 $0.002021F E $0.00 $0.00 $0.0020220 T 0020 11.144 $1,208.23 $1,476.91 $906.23 20225 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 2022F M $0.00 $0.00 $0.0020240 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 20245 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 2024F M $0.00 $0.00 $0.0020250 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 20251 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 2026F M $0.00 $0.00 $0.002027F M $0.00 $0.00 $0.002028F E $0.00 $0.00 $0.002029F E $0.00 $0.00 $0.002030F E $0.00 $0.00 $0.002031F E $0.00 $0.00 $0.002035F E $0.00 $0.00 $0.002040F E $0.00 $0.00 $0.002044F E $0.00 $0.00 $0.0020500 T 0252 8.7183 $945.24 $1,155.44 $708.97 20501 N $0.00 $0.00 $0.00 2050F E $0.00 $0.00 $0.0020520 T 0020 11.144 $1,208.23 $1,476.91 $906.23 20525 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 20526 T 0204 2.8475 $308.73 $377.38 $231.56 20527 T 0204 2.8475 $308.73 $377.38 $231.56 20550 T 0204 2.8475 $308.73 $377.38 $231.56 20551 T 0204 2.8475 $308.73 $377.38 $231.56 20552 T 0204 2.8475 $308.73 $377.38 $231.56 20553 T 0204 2.8475 $308.73 $377.38 $231.56 20555 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 20600 T 0204 2.8475 $308.73 $377.38 $231.56 20604 T 0204 2.8475 $308.73 $377.38 $231.56 20605 T 0204 2.8475 $308.73 $377.38 $231.56


22


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee20606 T 0204 2.8475 $308.73 $377.38 $231.56 2060F E $0.00 $0.00 $0.0020610 T 0204 2.8475 $308.73 $377.38 $231.56 20611 T 0204 2.8475 $308.73 $377.38 $231.56 20612 T 0204 2.8475 $308.73 $377.38 $231.56 20615 T 0004 6.5703 $712.35 $870.76 $534.30 20650 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 20660 Q2 0139 9.6161 $1,042.58 $1,274.42 $781.98 20661 C $0.00 $0.00 $0.0020662 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 20663 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 20664 C $0.00 $0.00 $0.0020665 Q1 0420 1.7762 $192.58 $235.40 $144.44 20670 Q2 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 20680 Q2 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 20690 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 20692 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 20693 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 20694 Q2 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 20696 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 20697 T 0139 9.6161 $1,042.58 $1,274.42 $781.98 20802 C $0.00 $0.00 $0.0020805 C $0.00 $0.00 $0.0020808 C $0.00 $0.00 $0.0020816 C $0.00 $0.00 $0.0020822 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 20824 C $0.00 $0.00 $0.0020827 C $0.00 $0.00 $0.0020838 C $0.00 $0.00 $0.0020900 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 20902 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 20910 T 0327 5.7989 $628.72 $768.53 $471.57 20912 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 20920 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 20922 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 20924 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 20926 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 20930 N $0.00 $0.00 $0.00 20931 N $0.00 $0.00 $0.00 20936 C $0.00 $0.00 $0.0020937 C $0.00 $0.00 $0.0020938 C $0.00 $0.00 $0.0020950 T 0006 2.1836 $236.75 $289.39 $177.57 20955 C $0.00 $0.00 $0.0020956 C $0.00 $0.00 $0.0020957 C $0.00 $0.00 $0.0020962 C $0.00 $0.00 $0.0020969 C $0.00 $0.00 $0.0020970 C $0.00 $0.00 $0.0020972 T 0056 70.3645 $7,628.92 $9,325.41 $5,722.04 20973 T 0056 70.3645 $7,628.92 $9,325.41 $5,722.04


23


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee20974 A $0.00 $0.00 $0.0020975 N $0.00 $0.00 $0.00 20979 Q1 0340 0.7061 $76.56 $93.58 $57.42 20982 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 20983 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 20985 N $0.00 $0.00 $0.00 20999 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 21010 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21011 T 0020 11.144 $1,208.23 $1,476.91 $906.23 21012 T 0020 11.144 $1,208.23 $1,476.91 $906.23 21013 T 0020 11.144 $1,208.23 $1,476.91 $906.23 21014 T 0020 11.144 $1,208.23 $1,476.91 $906.23 21015 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 21016 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 21025 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21026 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 21029 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 21030 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 21031 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 21032 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 21034 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21040 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 21044 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21045 C $0.00 $0.00 $0.0021046 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21047 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21048 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21049 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21050 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21060 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21070 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21073 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 21076 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 21077 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21079 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21080 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21081 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21082 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21083 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21084 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21085 T 0252 8.7183 $945.24 $1,155.44 $708.97 21086 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21087 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21088 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21089 T 0250 1.7489 $189.62 $231.78 $142.22 21100 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21110 Q2 0252 8.7183 $945.24 $1,155.44 $708.97 21116 N $0.00 $0.00 $0.00 21120 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21121 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 21122 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72


24


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee21123 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 21125 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 21127 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21137 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 21138 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21139 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21141 C $0.00 $0.00 $0.0021142 C $0.00 $0.00 $0.0021143 C $0.00 $0.00 $0.0021145 C $0.00 $0.00 $0.0021146 C $0.00 $0.00 $0.0021147 C $0.00 $0.00 $0.0021150 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21151 C $0.00 $0.00 $0.0021154 C $0.00 $0.00 $0.0021155 C $0.00 $0.00 $0.0021159 C $0.00 $0.00 $0.0021160 C $0.00 $0.00 $0.0021172 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21175 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21179 C $0.00 $0.00 $0.0021180 C $0.00 $0.00 $0.0021181 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21182 C $0.00 $0.00 $0.0021183 C $0.00 $0.00 $0.0021184 C $0.00 $0.00 $0.0021188 C $0.00 $0.00 $0.0021193 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21194 C $0.00 $0.00 $0.0021195 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21196 C $0.00 $0.00 $0.0021198 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 21199 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21206 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21208 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21209 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21210 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21215 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21230 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21235 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 21240 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21242 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21243 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21244 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21245 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21246 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21247 C $0.00 $0.00 $0.0021248 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21249 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21255 C $0.00 $0.00 $0.0021256 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44


25


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee21260 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21261 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21263 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21267 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21268 C $0.00 $0.00 $0.0021270 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21275 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21280 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21282 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 21295 T 0252 8.7183 $945.24 $1,155.44 $708.97 21296 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 21299 T 0250 1.7489 $189.62 $231.78 $142.22 21310 T 0250 1.7489 $189.62 $231.78 $142.22 21315 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 21320 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 21325 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 21330 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 21335 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 21336 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 21337 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 21338 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21339 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 21340 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21343 C $0.00 $0.00 $0.0021344 C $0.00 $0.00 $0.0021345 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 21346 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21347 C $0.00 $0.00 $0.0021348 C $0.00 $0.00 $0.0021355 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21356 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 21360 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21365 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21366 C $0.00 $0.00 $0.0021385 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21386 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21387 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21390 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21395 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21400 T 0252 8.7183 $945.24 $1,155.44 $708.97 21401 T 0252 8.7183 $945.24 $1,155.44 $708.97 21406 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21407 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21408 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21421 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21422 C $0.00 $0.00 $0.0021423 C $0.00 $0.00 $0.0021431 C $0.00 $0.00 $0.0021432 C $0.00 $0.00 $0.0021433 C $0.00 $0.00 $0.0021435 C $0.00 $0.00 $0.00


26


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee21436 C $0.00 $0.00 $0.0021440 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 21445 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21450 T 0251 4.8979 $531.03 $649.12 $398.30 21451 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 21452 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 21453 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21454 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21461 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21462 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21465 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21470 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21480 T 0250 1.7489 $189.62 $231.78 $142.22 21485 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 21490 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 21495 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 21497 T 0252 8.7183 $945.24 $1,155.44 $708.97 21499 T 0250 1.7489 $189.62 $231.78 $142.22 21501 T 0008 22.0535 $2,391.04 $2,922.75 $1,793.39 21502 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 21510 C $0.00 $0.00 $0.0021550 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 21552 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 21554 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 21555 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 21556 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 21557 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 21558 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 21600 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 21610 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 21615 C $0.00 $0.00 $0.0021616 C $0.00 $0.00 $0.0021620 C $0.00 $0.00 $0.0021627 C $0.00 $0.00 $0.0021630 C $0.00 $0.00 $0.0021632 C $0.00 $0.00 $0.0021685 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 21700 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 21705 C $0.00 $0.00 $0.0021720 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 21725 T 0006 2.1836 $236.75 $289.39 $177.57 21740 C $0.00 $0.00 $0.0021742 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 21743 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 21750 C $0.00 $0.00 $0.0021805 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 21811 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 21812 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 21813 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 21820 T 0129 2.2797 $247.17 $302.13 $185.39 21825 C $0.00 $0.00 $0.00


27


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee21899 T 0250 1.7489 $189.62 $231.78 $142.22 21920 T 0020 11.144 $1,208.23 $1,476.91 $906.23 21925 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 21930 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 21931 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 21932 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 21933 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 21935 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 21936 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 22010 C $0.00 $0.00 $0.0022015 C $0.00 $0.00 $0.0022100 T 0208 55.4537 $6,012.29 $7,349.28 $4,509.49 22101 T 0208 55.4537 $6,012.29 $7,349.28 $4,509.49 22102 T 0208 55.4537 $6,012.29 $7,349.28 $4,509.49 22103 N $0.00 $0.00 $0.00 22110 C $0.00 $0.00 $0.0022112 C $0.00 $0.00 $0.0022114 C $0.00 $0.00 $0.0022116 C $0.00 $0.00 $0.0022206 C $0.00 $0.00 $0.0022207 C $0.00 $0.00 $0.0022208 C $0.00 $0.00 $0.0022210 C $0.00 $0.00 $0.0022212 C $0.00 $0.00 $0.0022214 C $0.00 $0.00 $0.0022216 C $0.00 $0.00 $0.0022220 C $0.00 $0.00 $0.0022222 C $0.00 $0.00 $0.0022224 C $0.00 $0.00 $0.0022226 C $0.00 $0.00 $0.0022305 T 0129 2.2797 $247.17 $302.13 $185.39 22310 T 0138 2.8828 $312.55 $382.06 $234.43 22315 T 0431 17.6908 $1,918.04 $2,344.56 $1,438.62 22318 C $0.00 $0.00 $0.0022319 C $0.00 $0.00 $0.0022325 C $0.00 $0.00 $0.0022326 C $0.00 $0.00 $0.0022327 C $0.00 $0.00 $0.0022328 C $0.00 $0.00 $0.0022505 T 0045 15.5135 $1,681.97 $2,056.00 $1,261.56 22510 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 22511 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 22512 N $0.00 $0.00 $0.00 22513 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 22514 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 22515 N $0.00 $0.00 $0.00 22526 E $0.00 $0.00 $0.0022527 E $0.00 $0.00 $0.0022532 C $0.00 $0.00 $0.0022533 C $0.00 $0.00 $0.0022534 C $0.00 $0.00 $0.00


28


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee22548 C $0.00 $0.00 $0.0022551 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 22552 C $0.00 $0.00 $0.0022554 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 22556 C $0.00 $0.00 $0.0022558 C $0.00 $0.00 $0.0022585 C $0.00 $0.00 $0.0022586 C $0.00 $0.00 $0.0022590 C $0.00 $0.00 $0.0022595 C $0.00 $0.00 $0.0022600 C $0.00 $0.00 $0.0022610 C $0.00 $0.00 $0.0022612 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 22614 N $0.00 $0.00 $0.00 22630 C $0.00 $0.00 $0.0022632 C $0.00 $0.00 $0.0022633 C $0.00 $0.00 $0.0022634 C $0.00 $0.00 $0.0022800 C $0.00 $0.00 $0.0022802 C $0.00 $0.00 $0.0022804 C $0.00 $0.00 $0.0022808 C $0.00 $0.00 $0.0022810 C $0.00 $0.00 $0.0022812 C $0.00 $0.00 $0.0022818 C $0.00 $0.00 $0.0022819 C $0.00 $0.00 $0.0022830 C $0.00 $0.00 $0.0022840 C $0.00 $0.00 $0.0022841 C $0.00 $0.00 $0.0022842 C $0.00 $0.00 $0.0022843 C $0.00 $0.00 $0.0022844 C $0.00 $0.00 $0.0022845 C $0.00 $0.00 $0.0022846 C $0.00 $0.00 $0.0022847 C $0.00 $0.00 $0.0022848 C $0.00 $0.00 $0.0022849 C $0.00 $0.00 $0.0022850 C $0.00 $0.00 $0.0022851 N $0.00 $0.00 $0.00 22852 C $0.00 $0.00 $0.0022855 C $0.00 $0.00 $0.0022856 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 22857 C $0.00 $0.00 $0.0022858 C $0.00 $0.00 $0.0022861 C $0.00 $0.00 $0.0022862 C $0.00 $0.00 $0.0022864 C $0.00 $0.00 $0.0022865 C $0.00 $0.00 $0.0022899 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 22900 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 22901 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09


29


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee22902 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 22903 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 22904 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 22905 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 22999 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 23000 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 23020 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 23030 T 0008 22.0535 $2,391.04 $2,922.75 $1,793.39 23031 T 0008 22.0535 $2,391.04 $2,922.75 $1,793.39 23035 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 23040 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 23044 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 23065 T 0020 11.144 $1,208.23 $1,476.91 $906.23 23066 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 23071 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 23073 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 23075 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 23076 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 23077 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 23078 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 23100 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 23101 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 23105 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 23106 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 23107 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 23120 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 23125 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 23130 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 23140 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 23145 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 23146 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 23150 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 23155 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 23156 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 23170 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 23172 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 23174 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 23180 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 23182 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 23184 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 23190 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 23195 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 23200 C $0.00 $0.00 $0.0023210 C $0.00 $0.00 $0.0023220 C $0.00 $0.00 $0.0023330 T 0020 11.144 $1,208.23 $1,476.91 $906.23 23333 T 0020 11.144 $1,208.23 $1,476.91 $906.23 23334 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 23335 C $0.00 $0.00 $0.0023350 N $0.00 $0.00 $0.00 23395 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58


30


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee23397 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 23400 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 23405 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 23406 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 23410 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 23412 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 23415 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 23420 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 23430 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 23440 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 23450 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 23455 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 23460 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 23462 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 23465 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 23466 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 23470 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 23472 C $0.00 $0.00 $0.0023473 T 0047 45.3575 $4,917.66 $6,011.23 $3,688.47 23474 C $0.00 $0.00 $0.0023480 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 23485 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 23490 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 23491 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 23500 T 0129 2.2797 $247.17 $302.13 $185.39 23505 T 0139 9.6161 $1,042.58 $1,274.42 $781.98 23515 T 0064 75.0875 $8,140.99 $9,951.35 $6,106.12 23520 T 0431 17.6908 $1,918.04 $2,344.56 $1,438.62 23525 T 0138 2.8828 $312.55 $382.06 $234.43 23530 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 23532 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 23540 T 0138 2.8828 $312.55 $382.06 $234.43 23545 T 0138 2.8828 $312.55 $382.06 $234.43 23550 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 23552 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 23570 T 0129 2.2797 $247.17 $302.13 $185.39 23575 T 0138 2.8828 $312.55 $382.06 $234.43 23585 T 0064 75.0875 $8,140.99 $9,951.35 $6,106.12 23600 T 0138 2.8828 $312.55 $382.06 $234.43 23605 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 23615 T 0064 75.0875 $8,140.99 $9,951.35 $6,106.12 23616 T 0064 75.0875 $8,140.99 $9,951.35 $6,106.12 23620 T 0138 2.8828 $312.55 $382.06 $234.43 23625 T 0431 17.6908 $1,918.04 $2,344.56 $1,438.62 23630 T 0064 75.0875 $8,140.99 $9,951.35 $6,106.12 23650 T 0138 2.8828 $312.55 $382.06 $234.43 23655 T 0045 15.5135 $1,681.97 $2,056.00 $1,261.56 23660 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 23665 T 0139 9.6161 $1,042.58 $1,274.42 $781.98 23670 T 0064 75.0875 $8,140.99 $9,951.35 $6,106.12 23675 T 0138 2.8828 $312.55 $382.06 $234.43


31


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee23680 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 23700 T 0045 15.5135 $1,681.97 $2,056.00 $1,261.56 23800 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 23802 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 23900 C $0.00 $0.00 $0.0023920 C $0.00 $0.00 $0.0023921 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 23929 T 0129 2.2797 $247.17 $302.13 $185.39 23930 T 0008 22.0535 $2,391.04 $2,922.75 $1,793.39 23931 T 0007 11.6749 $1,265.79 $1,547.27 $949.40 23935 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 24000 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 24006 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 24065 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 24066 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 24071 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 24073 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 24075 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 24076 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 24077 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 24079 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 24100 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 24101 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 24102 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 24105 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 24110 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 24115 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 24116 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 24120 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 24125 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 24126 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 24130 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 24134 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 24136 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 24138 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 24140 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 24145 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 24147 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 24149 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 24150 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 24152 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 24155 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 24160 Q2 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 24164 Q2 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 24200 T 0020 11.144 $1,208.23 $1,476.91 $906.23 24201 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 24220 N $0.00 $0.00 $0.00 24300 T 0045 15.5135 $1,681.97 $2,056.00 $1,261.56 24301 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 24305 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 24310 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86


32


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee24320 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 24330 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 24331 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 24332 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 24340 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 24341 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 24342 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 24343 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 24344 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 24345 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 24346 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 24357 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 24358 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 24359 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 24360 T 0047 45.3575 $4,917.66 $6,011.23 $3,688.47 24361 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 24362 T 0047 45.3575 $4,917.66 $6,011.23 $3,688.47 24363 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 24365 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 24366 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 24370 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 24371 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 24400 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 24410 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 24420 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 24430 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 24435 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 24470 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 24495 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 24498 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 24500 T 0138 2.8828 $312.55 $382.06 $234.43 24505 T 0138 2.8828 $312.55 $382.06 $234.43 24515 T 0064 75.0875 $8,140.99 $9,951.35 $6,106.12 24516 T 0064 75.0875 $8,140.99 $9,951.35 $6,106.12 24530 T 0138 2.8828 $312.55 $382.06 $234.43 24535 T 0138 2.8828 $312.55 $382.06 $234.43 24538 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 24545 T 0064 75.0875 $8,140.99 $9,951.35 $6,106.12 24546 T 0064 75.0875 $8,140.99 $9,951.35 $6,106.12 24560 T 0129 2.2797 $247.17 $302.13 $185.39 24565 T 0138 2.8828 $312.55 $382.06 $234.43 24566 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 24575 T 0064 75.0875 $8,140.99 $9,951.35 $6,106.12 24576 T 0138 2.8828 $312.55 $382.06 $234.43 24577 T 0138 2.8828 $312.55 $382.06 $234.43 24579 T 0064 75.0875 $8,140.99 $9,951.35 $6,106.12 24582 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 24586 T 0064 75.0875 $8,140.99 $9,951.35 $6,106.12 24587 T 0064 75.0875 $8,140.99 $9,951.35 $6,106.12 24600 T 0138 2.8828 $312.55 $382.06 $234.43 24605 T 0045 15.5135 $1,681.97 $2,056.00 $1,261.56


33


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee24615 T 0064 75.0875 $8,140.99 $9,951.35 $6,106.12 24620 T 0431 17.6908 $1,918.04 $2,344.56 $1,438.62 24635 T 0064 75.0875 $8,140.99 $9,951.35 $6,106.12 24640 T 0138 2.8828 $312.55 $382.06 $234.43 24650 T 0138 2.8828 $312.55 $382.06 $234.43 24655 T 0138 2.8828 $312.55 $382.06 $234.43 24665 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 24666 T 0064 75.0875 $8,140.99 $9,951.35 $6,106.12 24670 T 0129 2.2797 $247.17 $302.13 $185.39 24675 T 0138 2.8828 $312.55 $382.06 $234.43 24685 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 24800 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 24802 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 24900 C $0.00 $0.00 $0.0024920 C $0.00 $0.00 $0.0024925 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 24930 C $0.00 $0.00 $0.0024931 C $0.00 $0.00 $0.0024935 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 24940 C $0.00 $0.00 $0.0024999 T 0129 2.2797 $247.17 $302.13 $185.39 25000 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 25001 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 25020 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25023 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25024 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25025 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25028 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 25031 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 25035 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 25040 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25065 T 0020 11.144 $1,208.23 $1,476.91 $906.23 25066 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 25071 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 25073 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 25075 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 25076 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 25077 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 25078 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 25085 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 25100 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 25101 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25105 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25107 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25109 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 25110 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 25111 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 25112 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 25115 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 25116 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 25118 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86


34


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee25119 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25120 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25125 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25126 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25130 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25135 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25136 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25145 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25150 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25151 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25170 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25210 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25215 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25230 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25240 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25246 N $0.00 $0.00 $0.00 25248 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 25250 Q2 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25251 Q2 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25259 T 0431 17.6908 $1,918.04 $2,344.56 $1,438.62 25260 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25263 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25265 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25270 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25272 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25274 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25275 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25280 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25290 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25295 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 25300 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25301 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25310 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25312 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 25315 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25316 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 25320 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 25332 T 0047 45.3575 $4,917.66 $6,011.23 $3,688.47 25335 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 25337 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 25350 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 25355 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 25360 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 25365 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 25370 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 25375 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 25390 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 25391 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 25392 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 25393 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 25394 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58


35


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee25400 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 25405 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 25415 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 25420 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 25425 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 25426 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 25430 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 25431 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 25440 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 25441 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 25442 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 25443 T 0047 45.3575 $4,917.66 $6,011.23 $3,688.47 25444 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 25445 T 0047 45.3575 $4,917.66 $6,011.23 $3,688.47 25446 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 25447 T 0047 45.3575 $4,917.66 $6,011.23 $3,688.47 25449 T 0047 45.3575 $4,917.66 $6,011.23 $3,688.47 25450 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 25455 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 25490 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 25491 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 25492 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 25500 T 0129 2.2797 $247.17 $302.13 $185.39 25505 T 0139 9.6161 $1,042.58 $1,274.42 $781.98 25515 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 25520 T 0138 2.8828 $312.55 $382.06 $234.43 25525 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 25526 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 25530 T 0129 2.2797 $247.17 $302.13 $185.39 25535 T 0138 2.8828 $312.55 $382.06 $234.43 25545 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 25560 T 0129 2.2797 $247.17 $302.13 $185.39 25565 T 0138 2.8828 $312.55 $382.06 $234.43 25574 T 0064 75.0875 $8,140.99 $9,951.35 $6,106.12 25575 T 0064 75.0875 $8,140.99 $9,951.35 $6,106.12 25600 T 0138 2.8828 $312.55 $382.06 $234.43 25605 T 0139 9.6161 $1,042.58 $1,274.42 $781.98 25606 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 25607 T 0064 75.0875 $8,140.99 $9,951.35 $6,106.12 25608 T 0064 75.0875 $8,140.99 $9,951.35 $6,106.12 25609 T 0064 75.0875 $8,140.99 $9,951.35 $6,106.12 25622 T 0138 2.8828 $312.55 $382.06 $234.43 25624 T 0139 9.6161 $1,042.58 $1,274.42 $781.98 25628 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 25630 T 0138 2.8828 $312.55 $382.06 $234.43 25635 T 0138 2.8828 $312.55 $382.06 $234.43 25645 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 25650 T 0138 2.8828 $312.55 $382.06 $234.43 25651 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 25652 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 25660 T 0138 2.8828 $312.55 $382.06 $234.43


36


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee25670 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 25671 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 25675 T 0138 2.8828 $312.55 $382.06 $234.43 25676 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 25680 T 0129 2.2797 $247.17 $302.13 $185.39 25685 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 25690 T 0431 17.6908 $1,918.04 $2,344.56 $1,438.62 25695 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 25800 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 25805 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 25810 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 25820 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 25825 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 25830 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 25900 C $0.00 $0.00 $0.0025905 C $0.00 $0.00 $0.0025907 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 25909 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 25915 C $0.00 $0.00 $0.0025920 C $0.00 $0.00 $0.0025922 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 25924 C $0.00 $0.00 $0.0025927 C $0.00 $0.00 $0.0025929 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 25931 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 25999 T 0129 2.2797 $247.17 $302.13 $185.39 26010 T 0006 2.1836 $236.75 $289.39 $177.57 26011 T 0007 11.6749 $1,265.79 $1,547.27 $949.40 26020 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26025 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26030 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26034 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26035 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26037 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26040 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26045 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26055 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26060 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26070 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26075 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26080 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26100 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26105 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26110 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26111 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 26113 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 26115 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 26116 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 26117 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 26118 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 26121 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07


37


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee26123 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26125 N $0.00 $0.00 $0.00 26130 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26135 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26140 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26145 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26160 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26170 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26180 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26185 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26200 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26205 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26210 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26215 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26230 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26235 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26236 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26250 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26260 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26262 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26320 Q2 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 26340 T 0138 2.8828 $312.55 $382.06 $234.43 26341 T 0138 2.8828 $312.55 $382.06 $234.43 26350 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26352 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26356 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26357 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26358 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26370 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26372 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26373 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26390 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26392 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26410 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26412 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26415 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26416 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26418 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26420 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26426 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26428 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26432 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26433 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26434 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26437 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26440 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26442 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26445 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26449 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26450 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26455 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68


38


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee26460 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26471 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26474 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26476 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26477 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26478 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26479 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26480 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26483 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26485 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26489 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26490 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26492 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26494 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26496 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26497 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26498 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26499 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26500 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26502 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26508 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26510 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26516 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26517 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26518 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26520 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26525 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26530 T 0047 45.3575 $4,917.66 $6,011.23 $3,688.47 26531 T 0047 45.3575 $4,917.66 $6,011.23 $3,688.47 26535 T 0047 45.3575 $4,917.66 $6,011.23 $3,688.47 26536 T 0047 45.3575 $4,917.66 $6,011.23 $3,688.47 26540 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26541 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26542 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26545 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26546 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26548 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26550 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26551 C $0.00 $0.00 $0.0026553 C $0.00 $0.00 $0.0026554 C $0.00 $0.00 $0.0026555 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26556 C $0.00 $0.00 $0.0026560 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26561 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26562 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26565 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26567 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26568 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26580 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26587 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68


39


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee26590 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26591 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26593 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26596 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26600 T 0138 2.8828 $312.55 $382.06 $234.43 26605 T 0138 2.8828 $312.55 $382.06 $234.43 26607 T 0431 17.6908 $1,918.04 $2,344.56 $1,438.62 26608 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 26615 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 26641 T 0138 2.8828 $312.55 $382.06 $234.43 26645 T 0138 2.8828 $312.55 $382.06 $234.43 26650 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 26665 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 26670 T 0129 2.2797 $247.17 $302.13 $185.39 26675 T 0138 2.8828 $312.55 $382.06 $234.43 26676 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 26685 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 26686 T 0064 75.0875 $8,140.99 $9,951.35 $6,106.12 26700 T 0138 2.8828 $312.55 $382.06 $234.43 26705 T 0138 2.8828 $312.55 $382.06 $234.43 26706 T 0431 17.6908 $1,918.04 $2,344.56 $1,438.62 26715 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 26720 T 0129 2.2797 $247.17 $302.13 $185.39 26725 T 0138 2.8828 $312.55 $382.06 $234.43 26727 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 26735 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 26740 T 0138 2.8828 $312.55 $382.06 $234.43 26742 T 0138 2.8828 $312.55 $382.06 $234.43 26746 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 26750 T 0129 2.2797 $247.17 $302.13 $185.39 26755 T 0138 2.8828 $312.55 $382.06 $234.43 26756 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 26765 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 26770 T 0129 2.2797 $247.17 $302.13 $185.39 26775 S 0058 3.0104 $326.39 $398.97 $244.81 26776 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 26785 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 26820 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26841 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26842 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26843 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26844 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26850 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26852 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26860 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26861 N $0.00 $0.00 $0.00 26862 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26863 N $0.00 $0.00 $0.00 26910 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 26951 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68 26952 T 0053 16.5603 $1,795.47 $2,194.74 $1,346.68


40


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee26989 T 0129 2.2797 $247.17 $302.13 $185.39 26990 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 26991 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 26992 C $0.00 $0.00 $0.0027000 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 27001 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27003 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27005 C $0.00 $0.00 $0.0027006 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27025 C $0.00 $0.00 $0.0027027 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27030 C $0.00 $0.00 $0.0027033 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 27035 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27036 C $0.00 $0.00 $0.0027040 T 0020 11.144 $1,208.23 $1,476.91 $906.23 27041 T 0020 11.144 $1,208.23 $1,476.91 $906.23 27043 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 27045 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 27047 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 27048 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 27049 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 27050 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 27052 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 27054 C $0.00 $0.00 $0.0027057 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 27059 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 27060 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 27062 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 27065 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 27066 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27067 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27070 C $0.00 $0.00 $0.0027071 C $0.00 $0.00 $0.0027075 C $0.00 $0.00 $0.0027076 C $0.00 $0.00 $0.0027077 C $0.00 $0.00 $0.0027078 C $0.00 $0.00 $0.0027080 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27086 T 0020 11.144 $1,208.23 $1,476.91 $906.23 27087 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 27090 C $0.00 $0.00 $0.0027091 C $0.00 $0.00 $0.0027093 N $0.00 $0.00 $0.00 27095 N $0.00 $0.00 $0.00 27096 B $0.00 $0.00 $0.0027097 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27098 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27100 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 27105 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 27110 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58


41


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee27111 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 27120 C $0.00 $0.00 $0.0027122 C $0.00 $0.00 $0.0027125 C $0.00 $0.00 $0.0027130 C $0.00 $0.00 $0.0027132 C $0.00 $0.00 $0.0027134 C $0.00 $0.00 $0.0027137 C $0.00 $0.00 $0.0027138 C $0.00 $0.00 $0.0027140 C $0.00 $0.00 $0.0027146 C $0.00 $0.00 $0.0027147 C $0.00 $0.00 $0.0027151 C $0.00 $0.00 $0.0027156 C $0.00 $0.00 $0.0027158 C $0.00 $0.00 $0.0027161 C $0.00 $0.00 $0.0027165 C $0.00 $0.00 $0.0027170 C $0.00 $0.00 $0.0027175 C $0.00 $0.00 $0.0027176 C $0.00 $0.00 $0.0027177 C $0.00 $0.00 $0.0027178 C $0.00 $0.00 $0.0027179 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 27181 C $0.00 $0.00 $0.0027185 C $0.00 $0.00 $0.0027187 C $0.00 $0.00 $0.0027193 T 0138 2.8828 $312.55 $382.06 $234.43 27194 T 0139 9.6161 $1,042.58 $1,274.42 $781.98 27200 T 0129 2.2797 $247.17 $302.13 $185.39 27202 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 27215 E $0.00 $0.00 $0.0027216 E $0.00 $0.00 $0.0027217 E $0.00 $0.00 $0.0027218 E $0.00 $0.00 $0.0027220 T 0129 2.2797 $247.17 $302.13 $185.39 27222 C $0.00 $0.00 $0.0027226 C $0.00 $0.00 $0.0027227 C $0.00 $0.00 $0.0027228 C $0.00 $0.00 $0.0027230 T 0138 2.8828 $312.55 $382.06 $234.43 27232 C $0.00 $0.00 $0.0027235 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27236 C $0.00 $0.00 $0.0027238 T 0138 2.8828 $312.55 $382.06 $234.43 27240 C $0.00 $0.00 $0.0027244 C $0.00 $0.00 $0.0027245 C $0.00 $0.00 $0.0027246 T 0138 2.8828 $312.55 $382.06 $234.43 27248 C $0.00 $0.00 $0.0027250 T 0138 2.8828 $312.55 $382.06 $234.43 27252 T 0139 9.6161 $1,042.58 $1,274.42 $781.98


42


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee27253 C $0.00 $0.00 $0.0027254 C $0.00 $0.00 $0.0027256 T 0129 2.2797 $247.17 $302.13 $185.39 27257 T 0139 9.6161 $1,042.58 $1,274.42 $781.98 27258 C $0.00 $0.00 $0.0027259 C $0.00 $0.00 $0.0027265 T 0138 2.8828 $312.55 $382.06 $234.43 27266 T 0045 15.5135 $1,681.97 $2,056.00 $1,261.56 27267 T 0431 17.6908 $1,918.04 $2,344.56 $1,438.62 27268 C $0.00 $0.00 $0.0027269 C $0.00 $0.00 $0.0027275 T 0045 15.5135 $1,681.97 $2,056.00 $1,261.56 27279 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 27280 C $0.00 $0.00 $0.0027282 C $0.00 $0.00 $0.0027284 C $0.00 $0.00 $0.0027286 C $0.00 $0.00 $0.0027290 C $0.00 $0.00 $0.0027295 C $0.00 $0.00 $0.0027299 T 0129 2.2797 $247.17 $302.13 $185.39 27301 T 0008 22.0535 $2,391.04 $2,922.75 $1,793.39 27303 C $0.00 $0.00 $0.0027305 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 27306 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 27307 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27310 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27323 T 0020 11.144 $1,208.23 $1,476.91 $906.23 27324 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 27325 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 27326 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 27327 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 27328 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 27329 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 27330 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27331 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27332 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27333 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27334 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27335 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27337 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 27339 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 27340 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 27345 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 27347 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 27350 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27355 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27356 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27357 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27358 N $0.00 $0.00 $0.00 27360 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27364 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09


43


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee27365 C $0.00 $0.00 $0.0027370 N $0.00 $0.00 $0.00 27372 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 27380 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27381 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27385 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27386 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27390 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 27391 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 27392 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27393 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27394 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27395 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 27396 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27397 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 27400 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 27403 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27405 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 27407 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 27409 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 27412 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 27415 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 27416 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 27418 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 27420 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 27422 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 27424 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 27425 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27427 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 27428 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 27429 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 27430 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 27435 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27437 T 0047 45.3575 $4,917.66 $6,011.23 $3,688.47 27438 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 27440 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 27441 T 0047 45.3575 $4,917.66 $6,011.23 $3,688.47 27442 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 27443 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 27445 C $0.00 $0.00 $0.0027446 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 27447 C $0.00 $0.00 $0.0027448 C $0.00 $0.00 $0.0027450 C $0.00 $0.00 $0.0027454 C $0.00 $0.00 $0.0027455 C $0.00 $0.00 $0.0027457 C $0.00 $0.00 $0.0027465 C $0.00 $0.00 $0.0027466 C $0.00 $0.00 $0.0027468 C $0.00 $0.00 $0.0027470 C $0.00 $0.00 $0.00


44


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee27472 C $0.00 $0.00 $0.0027475 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27477 C $0.00 $0.00 $0.0027479 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27485 C $0.00 $0.00 $0.0027486 C $0.00 $0.00 $0.0027487 C $0.00 $0.00 $0.0027488 C $0.00 $0.00 $0.0027495 C $0.00 $0.00 $0.0027496 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27497 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 27498 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27499 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27500 T 0138 2.8828 $312.55 $382.06 $234.43 27501 T 0138 2.8828 $312.55 $382.06 $234.43 27502 T 0431 17.6908 $1,918.04 $2,344.56 $1,438.62 27503 T 0138 2.8828 $312.55 $382.06 $234.43 27506 C $0.00 $0.00 $0.0027507 C $0.00 $0.00 $0.0027508 T 0138 2.8828 $312.55 $382.06 $234.43 27509 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 27510 T 0138 2.8828 $312.55 $382.06 $234.43 27511 C $0.00 $0.00 $0.0027513 C $0.00 $0.00 $0.0027514 C $0.00 $0.00 $0.0027516 T 0129 2.2797 $247.17 $302.13 $185.39 27517 T 0138 2.8828 $312.55 $382.06 $234.43 27519 C $0.00 $0.00 $0.0027520 T 0138 2.8828 $312.55 $382.06 $234.43 27524 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 27530 T 0138 2.8828 $312.55 $382.06 $234.43 27532 T 0431 17.6908 $1,918.04 $2,344.56 $1,438.62 27535 C $0.00 $0.00 $0.0027536 C $0.00 $0.00 $0.0027538 T 0138 2.8828 $312.55 $382.06 $234.43 27540 C $0.00 $0.00 $0.0027550 T 0138 2.8828 $312.55 $382.06 $234.43 27552 T 0045 15.5135 $1,681.97 $2,056.00 $1,261.56 27556 C $0.00 $0.00 $0.0027557 C $0.00 $0.00 $0.0027558 C $0.00 $0.00 $0.0027560 T 0129 2.2797 $247.17 $302.13 $185.39 27562 T 0139 9.6161 $1,042.58 $1,274.42 $781.98 27566 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 27570 T 0045 15.5135 $1,681.97 $2,056.00 $1,261.56 27580 C $0.00 $0.00 $0.0027590 C $0.00 $0.00 $0.0027591 C $0.00 $0.00 $0.0027592 C $0.00 $0.00 $0.0027594 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 27596 C $0.00 $0.00 $0.00


45


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee27598 C $0.00 $0.00 $0.0027599 T 0129 2.2797 $247.17 $302.13 $185.39 27600 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 27601 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 27602 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27603 T 0008 22.0535 $2,391.04 $2,922.75 $1,793.39 27604 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27605 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 27606 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 27607 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 27610 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27612 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27613 T 0020 11.144 $1,208.23 $1,476.91 $906.23 27614 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 27615 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 27616 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 27618 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 27619 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 27620 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27625 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27626 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27630 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 27632 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 27634 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 27635 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27637 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27638 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27640 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27641 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27645 C $0.00 $0.00 $0.0027646 C $0.00 $0.00 $0.0027647 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27648 N $0.00 $0.00 $0.00 27650 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 27652 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 27654 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 27656 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 27658 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 27659 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 27664 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27665 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27675 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 27676 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27680 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27681 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27685 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27686 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27687 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27690 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 27691 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 27692 N $0.00 $0.00 $0.00


46


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee27695 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27696 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27698 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27700 T 0047 45.3575 $4,917.66 $6,011.23 $3,688.47 27702 C $0.00 $0.00 $0.0027703 C $0.00 $0.00 $0.0027704 Q2 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 27705 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 27707 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27709 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27712 C $0.00 $0.00 $0.0027715 C $0.00 $0.00 $0.0027720 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 27722 T 0064 75.0875 $8,140.99 $9,951.35 $6,106.12 27724 C $0.00 $0.00 $0.0027725 C $0.00 $0.00 $0.0027726 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 27727 C $0.00 $0.00 $0.0027730 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27732 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27734 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27740 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27742 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 27745 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 27750 T 0138 2.8828 $312.55 $382.06 $234.43 27752 T 0431 17.6908 $1,918.04 $2,344.56 $1,438.62 27756 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 27758 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 27759 T 0064 75.0875 $8,140.99 $9,951.35 $6,106.12 27760 T 0138 2.8828 $312.55 $382.06 $234.43 27762 T 0431 17.6908 $1,918.04 $2,344.56 $1,438.62 27766 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 27767 T 0129 2.2797 $247.17 $302.13 $185.39 27768 T 0129 2.2797 $247.17 $302.13 $185.39 27769 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 27780 T 0138 2.8828 $312.55 $382.06 $234.43 27781 T 0139 9.6161 $1,042.58 $1,274.42 $781.98 27784 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 27786 T 0138 2.8828 $312.55 $382.06 $234.43 27788 T 0138 2.8828 $312.55 $382.06 $234.43 27792 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 27808 T 0138 2.8828 $312.55 $382.06 $234.43 27810 T 0139 9.6161 $1,042.58 $1,274.42 $781.98 27814 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 27816 T 0138 2.8828 $312.55 $382.06 $234.43 27818 T 0139 9.6161 $1,042.58 $1,274.42 $781.98 27822 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 27823 T 0064 75.0875 $8,140.99 $9,951.35 $6,106.12 27824 T 0138 2.8828 $312.55 $382.06 $234.43 27825 T 0431 17.6908 $1,918.04 $2,344.56 $1,438.62 27826 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83


47


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee27827 T 0064 75.0875 $8,140.99 $9,951.35 $6,106.12 27828 T 0064 75.0875 $8,140.99 $9,951.35 $6,106.12 27829 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 27830 T 0129 2.2797 $247.17 $302.13 $185.39 27831 T 0139 9.6161 $1,042.58 $1,274.42 $781.98 27832 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 27840 T 0138 2.8828 $312.55 $382.06 $234.43 27842 T 0045 15.5135 $1,681.97 $2,056.00 $1,261.56 27846 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 27848 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 27860 T 0045 15.5135 $1,681.97 $2,056.00 $1,261.56 27870 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 27871 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 27880 C $0.00 $0.00 $0.0027881 C $0.00 $0.00 $0.0027882 C $0.00 $0.00 $0.0027884 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 27886 C $0.00 $0.00 $0.0027888 C $0.00 $0.00 $0.0027889 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27892 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27893 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27894 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 27899 T 0129 2.2797 $247.17 $302.13 $185.39 28001 T 0007 11.6749 $1,265.79 $1,547.27 $949.40 28002 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 28003 T 0049 22.3913 $2,427.66 $2,967.52 $1,820.86 28005 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28008 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28010 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28011 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28020 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28022 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28024 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28035 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 28039 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 28041 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 28043 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 28045 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 28046 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 28047 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 28050 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28052 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28054 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28055 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 28060 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28062 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28070 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28072 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28080 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28086 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52


48


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee28088 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28090 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28092 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28100 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28102 T 0056 70.3645 $7,628.92 $9,325.41 $5,722.04 28103 T 0056 70.3645 $7,628.92 $9,325.41 $5,722.04 28104 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28106 T 0056 70.3645 $7,628.92 $9,325.41 $5,722.04 28107 T 0056 70.3645 $7,628.92 $9,325.41 $5,722.04 28108 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28110 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28111 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28112 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28113 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28114 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28116 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28118 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28119 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28120 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28122 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28124 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28126 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28130 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28140 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28150 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28153 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28160 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28171 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28173 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28175 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28190 T 0020 11.144 $1,208.23 $1,476.91 $906.23 28192 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 28193 T 0020 11.144 $1,208.23 $1,476.91 $906.23 28200 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28202 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28208 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28210 T 0056 70.3645 $7,628.92 $9,325.41 $5,722.04 28220 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28222 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28225 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28226 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28230 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28232 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28234 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28238 T 0056 70.3645 $7,628.92 $9,325.41 $5,722.04 28240 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28250 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28260 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28261 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28262 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28264 T 0056 70.3645 $7,628.92 $9,325.41 $5,722.04


49


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee28270 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28272 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28280 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28285 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28286 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28288 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28289 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28290 T 0057 36.084 $3,912.23 $4,782.21 $2,934.35 28292 T 0057 36.084 $3,912.23 $4,782.21 $2,934.35 28293 T 0057 36.084 $3,912.23 $4,782.21 $2,934.35 28294 T 0057 36.084 $3,912.23 $4,782.21 $2,934.35 28296 T 0057 36.084 $3,912.23 $4,782.21 $2,934.35 28297 T 0057 36.084 $3,912.23 $4,782.21 $2,934.35 28298 T 0057 36.084 $3,912.23 $4,782.21 $2,934.35 28299 T 0057 36.084 $3,912.23 $4,782.21 $2,934.35 28300 T 0056 70.3645 $7,628.92 $9,325.41 $5,722.04 28302 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28304 T 0056 70.3645 $7,628.92 $9,325.41 $5,722.04 28305 T 0056 70.3645 $7,628.92 $9,325.41 $5,722.04 28306 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28307 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28308 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28309 T 0056 70.3645 $7,628.92 $9,325.41 $5,722.04 28310 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28312 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28313 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28315 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28320 T 0056 70.3645 $7,628.92 $9,325.41 $5,722.04 28322 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28340 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28341 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28344 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28345 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28360 T 0056 70.3645 $7,628.92 $9,325.41 $5,722.04 28400 T 0138 2.8828 $312.55 $382.06 $234.43 28405 T 0139 9.6161 $1,042.58 $1,274.42 $781.98 28406 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 28415 T 0064 75.0875 $8,140.99 $9,951.35 $6,106.12 28420 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 28430 T 0129 2.2797 $247.17 $302.13 $185.39 28435 T 0431 17.6908 $1,918.04 $2,344.56 $1,438.62 28436 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 28445 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 28446 T 0056 70.3645 $7,628.92 $9,325.41 $5,722.04 28450 T 0129 2.2797 $247.17 $302.13 $185.39 28455 T 0129 2.2797 $247.17 $302.13 $185.39 28456 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 28465 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 28470 T 0138 2.8828 $312.55 $382.06 $234.43 28475 T 0138 2.8828 $312.55 $382.06 $234.43 28476 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47


50


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee28485 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 28490 T 0129 2.2797 $247.17 $302.13 $185.39 28495 T 0138 2.8828 $312.55 $382.06 $234.43 28496 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 28505 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 28510 T 0129 2.2797 $247.17 $302.13 $185.39 28515 T 0138 2.8828 $312.55 $382.06 $234.43 28525 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 28530 T 0129 2.2797 $247.17 $302.13 $185.39 28531 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 28540 T 0129 2.2797 $247.17 $302.13 $185.39 28545 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 28546 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 28555 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 28570 T 0138 2.8828 $312.55 $382.06 $234.43 28575 T 0431 17.6908 $1,918.04 $2,344.56 $1,438.62 28576 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 28585 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 28600 T 0129 2.2797 $247.17 $302.13 $185.39 28605 T 0129 2.2797 $247.17 $302.13 $185.39 28606 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 28615 T 0063 57.0073 $6,180.73 $7,555.18 $4,635.83 28630 T 0138 2.8828 $312.55 $382.06 $234.43 28635 T 0431 17.6908 $1,918.04 $2,344.56 $1,438.62 28636 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 28645 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 28660 T 0129 2.2797 $247.17 $302.13 $185.39 28665 S 0058 3.0104 $326.39 $398.97 $244.81 28666 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 28675 T 0062 27.539 $2,985.78 $3,649.74 $2,239.47 28705 T 0056 70.3645 $7,628.92 $9,325.41 $5,722.04 28715 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 28725 T 0056 70.3645 $7,628.92 $9,325.41 $5,722.04 28730 T 0056 70.3645 $7,628.92 $9,325.41 $5,722.04 28735 T 0056 70.3645 $7,628.92 $9,325.41 $5,722.04 28737 T 0056 70.3645 $7,628.92 $9,325.41 $5,722.04 28740 T 0056 70.3645 $7,628.92 $9,325.41 $5,722.04 28750 T 0056 70.3645 $7,628.92 $9,325.41 $5,722.04 28755 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28760 T 0056 70.3645 $7,628.92 $9,325.41 $5,722.04 28800 C $0.00 $0.00 $0.0028805 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28810 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28820 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28825 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 28890 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 28899 T 0129 2.2797 $247.17 $302.13 $185.39 29000 S 0058 3.0104 $326.39 $398.97 $244.81 29010 S 0058 3.0104 $326.39 $398.97 $244.81 29015 S 0058 3.0104 $326.39 $398.97 $244.81 29035 S 0058 3.0104 $326.39 $398.97 $244.81


51


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee29040 S 0058 3.0104 $326.39 $398.97 $244.81 29044 S 0059 1.724 $186.92 $228.48 $140.20 29046 S 0058 3.0104 $326.39 $398.97 $244.81 29049 S 0058 3.0104 $326.39 $398.97 $244.81 29055 S 0058 3.0104 $326.39 $398.97 $244.81 29058 S 0058 3.0104 $326.39 $398.97 $244.81 29065 S 0058 3.0104 $326.39 $398.97 $244.81 29075 S 0058 3.0104 $326.39 $398.97 $244.81 29085 S 0058 3.0104 $326.39 $398.97 $244.81 29086 S 0059 1.724 $186.92 $228.48 $140.20 29105 S 0059 1.724 $186.92 $228.48 $140.20 29125 Q1 0420 1.7762 $192.58 $235.40 $144.44 29126 Q1 0340 0.7061 $76.56 $93.58 $57.42 29130 Q1 0340 0.7061 $76.56 $93.58 $57.42 29131 Q1 0340 0.7061 $76.56 $93.58 $57.42 29200 S 0059 1.724 $186.92 $228.48 $140.20 29240 Q1 0340 0.7061 $76.56 $93.58 $57.42 29260 Q1 0340 0.7061 $76.56 $93.58 $57.42 29280 Q1 0340 0.7061 $76.56 $93.58 $57.42 29305 S 0058 3.0104 $326.39 $398.97 $244.81 29325 S 0058 3.0104 $326.39 $398.97 $244.81 29345 S 0058 3.0104 $326.39 $398.97 $244.81 29355 S 0058 3.0104 $326.39 $398.97 $244.81 29358 S 0058 3.0104 $326.39 $398.97 $244.81 29365 S 0058 3.0104 $326.39 $398.97 $244.81 29405 S 0058 3.0104 $326.39 $398.97 $244.81 29425 S 0058 3.0104 $326.39 $398.97 $244.81 29435 S 0058 3.0104 $326.39 $398.97 $244.81 29440 S 0059 1.724 $186.92 $228.48 $140.20 29445 S 0058 3.0104 $326.39 $398.97 $244.81 29450 S 0058 3.0104 $326.39 $398.97 $244.81 29505 S 0059 1.724 $186.92 $228.48 $140.20 29515 S 0059 1.724 $186.92 $228.48 $140.20 29520 Q1 0340 0.7061 $76.56 $93.58 $57.42 29530 Q1 0340 0.7061 $76.56 $93.58 $57.42 29540 S 0059 1.724 $186.92 $228.48 $140.20 29550 Q1 0340 0.7061 $76.56 $93.58 $57.42 29580 S 0059 1.724 $186.92 $228.48 $140.20 29581 S 0059 1.724 $186.92 $228.48 $140.20 29582 S 0059 1.724 $186.92 $228.48 $140.20 29583 S 0059 1.724 $186.92 $228.48 $140.20 29584 S 0059 1.724 $186.92 $228.48 $140.20 29700 S 0059 1.724 $186.92 $228.48 $140.20 29705 S 0058 3.0104 $326.39 $398.97 $244.81 29710 S 0058 3.0104 $326.39 $398.97 $244.81 29720 S 0059 1.724 $186.92 $228.48 $140.20 29730 S 0059 1.724 $186.92 $228.48 $140.20 29740 S 0059 1.724 $186.92 $228.48 $140.20 29750 S 0058 3.0104 $326.39 $398.97 $244.81 29799 S 0059 1.724 $186.92 $228.48 $140.20 29800 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89


52


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee29804 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29805 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29806 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29807 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29819 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29820 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29821 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29822 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29823 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29824 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29825 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29826 N $0.00 $0.00 $0.00 29827 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29828 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29830 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29834 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29835 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29836 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29837 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29838 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29840 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29843 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29844 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29845 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29846 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29847 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29848 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29850 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29851 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29855 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29856 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29860 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29861 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29862 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29863 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29866 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29867 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29868 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29870 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29871 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29873 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29874 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29875 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29876 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29877 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29879 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29880 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29881 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29882 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29883 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29884 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89


53


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee29885 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29886 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29887 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29888 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 29889 T 0052 85.2438 $9,242.13 $11,297.36 $6,932.03 29891 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29892 T 0051 50.7327 $5,500.44 $6,723.60 $4,125.58 29893 T 0055 23.5061 $2,548.53 $3,115.26 $1,911.52 29894 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29895 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29897 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29898 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29899 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29900 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29901 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29902 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29904 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29905 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29906 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 29907 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29914 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29915 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29916 T 0042 58.5867 $6,351.97 $7,764.50 $4,764.27 29999 T 0041 29.0075 $3,144.99 $3,844.36 $2,358.89 30000 T 0250 1.7489 $189.62 $231.78 $142.22 30020 T 0251 4.8979 $531.03 $649.12 $398.30 3006F E $0.00 $0.00 $0.003008F E $0.00 $0.00 $0.0030100 T 0252 8.7183 $945.24 $1,155.44 $708.97 30110 T 0252 8.7183 $945.24 $1,155.44 $708.97 30115 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 30117 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 30118 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 3011F E $0.00 $0.00 $0.0030120 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 30124 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 30125 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 30130 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 30140 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 3014F M $0.00 $0.00 $0.0030150 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 3015F E $0.00 $0.00 $0.0030160 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 3016F M $0.00 $0.00 $0.003017F M $0.00 $0.00 $0.003018F E $0.00 $0.00 $0.003019F E $0.00 $0.00 $0.0030200 T 0252 8.7183 $945.24 $1,155.44 $708.97 3020F E $0.00 $0.00 $0.0030210 T 0252 8.7183 $945.24 $1,155.44 $708.97 3021F M $0.00 $0.00 $0.00


54


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee30220 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 3022F M $0.00 $0.00 $0.003023F M $0.00 $0.00 $0.003025F E $0.00 $0.00 $0.003027F E $0.00 $0.00 $0.003028F E $0.00 $0.00 $0.0030300 Q1 0420 1.7762 $192.58 $235.40 $144.44 30310 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 30320 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 3035F E $0.00 $0.00 $0.003037F E $0.00 $0.00 $0.003038F E $0.00 $0.00 $0.0030400 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 3040F E $0.00 $0.00 $0.0030410 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 30420 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 3042F E $0.00 $0.00 $0.0030430 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 30435 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 3044F M $0.00 $0.00 $0.0030450 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 3045F M $0.00 $0.00 $0.0030460 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 30462 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 30465 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 3046F M $0.00 $0.00 $0.003048F E $0.00 $0.00 $0.003049F E $0.00 $0.00 $0.003050F E $0.00 $0.00 $0.0030520 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 30540 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 30545 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 3055F E $0.00 $0.00 $0.0030560 T 0251 4.8979 $531.03 $649.12 $398.30 3056F E $0.00 $0.00 $0.0030580 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 30600 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 3060F M $0.00 $0.00 $0.003061F M $0.00 $0.00 $0.0030620 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 3062F M $0.00 $0.00 $0.0030630 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 3066F M $0.00 $0.00 $0.003072F M $0.00 $0.00 $0.003073F E $0.00 $0.00 $0.003074F E $0.00 $0.00 $0.003075F E $0.00 $0.00 $0.003077F E $0.00 $0.00 $0.003078F E $0.00 $0.00 $0.003079F E $0.00 $0.00 $0.0030801 T 0252 8.7183 $945.24 $1,155.44 $708.97


55


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee30802 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 3080F E $0.00 $0.00 $0.003082F E $0.00 $0.00 $0.003083F E $0.00 $0.00 $0.003084F E $0.00 $0.00 $0.003085F E $0.00 $0.00 $0.003088F E $0.00 $0.00 $0.003089F E $0.00 $0.00 $0.0030901 Q1 0420 1.7762 $192.58 $235.40 $144.44 30903 T 0250 1.7489 $189.62 $231.78 $142.22 30905 T 0250 1.7489 $189.62 $231.78 $142.22 30906 T 0250 1.7489 $189.62 $231.78 $142.22 3090F E $0.00 $0.00 $0.0030915 T 0219 29.2791 $3,174.44 $3,880.36 $2,380.98 3091F E $0.00 $0.00 $0.0030920 T 0219 29.2791 $3,174.44 $3,880.36 $2,380.98 3092F E $0.00 $0.00 $0.0030930 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 3093F E $0.00 $0.00 $0.003095F M $0.00 $0.00 $0.003096F M $0.00 $0.00 $0.0030999 T 0250 1.7489 $189.62 $231.78 $142.22 31000 T 0251 4.8979 $531.03 $649.12 $398.30 31002 T 0252 8.7183 $945.24 $1,155.44 $708.97 3100F M $0.00 $0.00 $0.0031020 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 31030 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 31032 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 31040 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 31050 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 31051 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 31070 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 31075 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 31080 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 31081 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 31084 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 31085 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 31086 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 31087 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 31090 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 3110F E $0.00 $0.00 $0.003111F E $0.00 $0.00 $0.003112F E $0.00 $0.00 $0.003115F E $0.00 $0.00 $0.003117F E $0.00 $0.00 $0.003118F E $0.00 $0.00 $0.003119F E $0.00 $0.00 $0.0031200 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 31201 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 31205 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 3120F M $0.00 $0.00 $0.00


56


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee31225 C $0.00 $0.00 $0.0031230 C $0.00 $0.00 $0.0031231 T 0071 2.0314 $220.24 $269.22 $165.19 31233 T 0072 5.2094 $564.80 $690.40 $423.63 31235 T 0073 16.9813 $1,841.11 $2,250.53 $1,380.92 31237 T 0073 16.9813 $1,841.11 $2,250.53 $1,380.92 31238 T 0073 16.9813 $1,841.11 $2,250.53 $1,380.92 31239 T 0074 27.1023 $2,938.43 $3,591.87 $2,203.96 31240 T 0074 27.1023 $2,938.43 $3,591.87 $2,203.96 31254 T 0074 27.1023 $2,938.43 $3,591.87 $2,203.96 31255 T 0075 41.4 $4,488.59 $5,486.74 $3,366.65 31256 T 0074 27.1023 $2,938.43 $3,591.87 $2,203.96 31267 T 0074 27.1023 $2,938.43 $3,591.87 $2,203.96 3126F M $0.00 $0.00 $0.0031276 T 0075 41.4 $4,488.59 $5,486.74 $3,366.65 31287 T 0075 41.4 $4,488.59 $5,486.74 $3,366.65 31288 T 0075 41.4 $4,488.59 $5,486.74 $3,366.65 31290 C $0.00 $0.00 $0.0031291 C $0.00 $0.00 $0.0031292 T 0075 41.4 $4,488.59 $5,486.74 $3,366.65 31293 T 0075 41.4 $4,488.59 $5,486.74 $3,366.65 31294 T 0075 41.4 $4,488.59 $5,486.74 $3,366.65 31295 T 0075 41.4 $4,488.59 $5,486.74 $3,366.65 31296 T 0075 41.4 $4,488.59 $5,486.74 $3,366.65 31297 T 0074 27.1023 $2,938.43 $3,591.87 $2,203.96 31299 T 0250 1.7489 $189.62 $231.78 $142.22 31300 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 3130F E $0.00 $0.00 $0.0031320 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 3132F E $0.00 $0.00 $0.0031360 C $0.00 $0.00 $0.0031365 C $0.00 $0.00 $0.0031367 C $0.00 $0.00 $0.0031368 C $0.00 $0.00 $0.0031370 C $0.00 $0.00 $0.0031375 C $0.00 $0.00 $0.0031380 C $0.00 $0.00 $0.0031382 C $0.00 $0.00 $0.0031390 C $0.00 $0.00 $0.0031395 C $0.00 $0.00 $0.0031400 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 3140F E $0.00 $0.00 $0.003141F E $0.00 $0.00 $0.0031420 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 3142F E $0.00 $0.00 $0.0031500 T 0250 1.7489 $189.62 $231.78 $142.22 31502 T 0250 1.7489 $189.62 $231.78 $142.22 31505 T 0071 2.0314 $220.24 $269.22 $165.19 3150F E $0.00 $0.00 $0.0031510 T 0073 16.9813 $1,841.11 $2,250.53 $1,380.92 31511 T 0071 2.0314 $220.24 $269.22 $165.19


57


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee31512 T 0074 27.1023 $2,938.43 $3,591.87 $2,203.96 31513 T 0072 5.2094 $564.80 $690.40 $423.63 31515 T 0073 16.9813 $1,841.11 $2,250.53 $1,380.92 31520 T 0072 5.2094 $564.80 $690.40 $423.63 31525 T 0073 16.9813 $1,841.11 $2,250.53 $1,380.92 31526 T 0073 16.9813 $1,841.11 $2,250.53 $1,380.92 31527 T 0074 27.1023 $2,938.43 $3,591.87 $2,203.96 31528 T 0074 27.1023 $2,938.43 $3,591.87 $2,203.96 31529 T 0074 27.1023 $2,938.43 $3,591.87 $2,203.96 31530 T 0073 16.9813 $1,841.11 $2,250.53 $1,380.92 31531 T 0073 16.9813 $1,841.11 $2,250.53 $1,380.92 31535 T 0074 27.1023 $2,938.43 $3,591.87 $2,203.96 31536 T 0074 27.1023 $2,938.43 $3,591.87 $2,203.96 31540 T 0074 27.1023 $2,938.43 $3,591.87 $2,203.96 31541 T 0074 27.1023 $2,938.43 $3,591.87 $2,203.96 31545 T 0074 27.1023 $2,938.43 $3,591.87 $2,203.96 31546 T 0075 41.4 $4,488.59 $5,486.74 $3,366.65 3155F M $0.00 $0.00 $0.0031560 T 0075 41.4 $4,488.59 $5,486.74 $3,366.65 31561 T 0074 27.1023 $2,938.43 $3,591.87 $2,203.96 31570 T 0073 16.9813 $1,841.11 $2,250.53 $1,380.92 31571 T 0074 27.1023 $2,938.43 $3,591.87 $2,203.96 31575 T 0071 2.0314 $220.24 $269.22 $165.19 31576 T 0073 16.9813 $1,841.11 $2,250.53 $1,380.92 31577 T 0072 5.2094 $564.80 $690.40 $423.63 31578 T 0073 16.9813 $1,841.11 $2,250.53 $1,380.92 31579 T 0072 5.2094 $564.80 $690.40 $423.63 31580 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 31582 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 31584 C $0.00 $0.00 $0.0031587 C $0.00 $0.00 $0.0031588 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 31590 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 31595 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 31599 T 0250 1.7489 $189.62 $231.78 $142.22 31600 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 31601 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 31603 T 0252 8.7183 $945.24 $1,155.44 $708.97 31605 T 0252 8.7183 $945.24 $1,155.44 $708.97 3160F M $0.00 $0.00 $0.0031610 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 31611 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 31612 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 31613 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 31614 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 31615 T 0252 8.7183 $945.24 $1,155.44 $708.97 31620 N $0.00 $0.00 $0.00 31622 T 0076 14.2251 $1,542.29 $1,885.25 $1,156.79 31623 T 0076 14.2251 $1,542.29 $1,885.25 $1,156.79 31624 T 0076 14.2251 $1,542.29 $1,885.25 $1,156.79 31625 T 0076 14.2251 $1,542.29 $1,885.25 $1,156.79


58


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee31626 T 0415 30.4203 $3,298.17 $4,031.60 $2,473.78 31627 N $0.00 $0.00 $0.00 31628 T 0076 14.2251 $1,542.29 $1,885.25 $1,156.79 31629 T 0415 30.4203 $3,298.17 $4,031.60 $2,473.78 31630 T 0415 30.4203 $3,298.17 $4,031.60 $2,473.78 31631 T 0415 30.4203 $3,298.17 $4,031.60 $2,473.78 31632 N $0.00 $0.00 $0.00 31633 N $0.00 $0.00 $0.00 31634 T 0415 30.4203 $3,298.17 $4,031.60 $2,473.78 31635 T 0076 14.2251 $1,542.29 $1,885.25 $1,156.79 31636 T 0415 30.4203 $3,298.17 $4,031.60 $2,473.78 31637 N $0.00 $0.00 $0.00 31638 T 0415 30.4203 $3,298.17 $4,031.60 $2,473.78 31640 T 0415 30.4203 $3,298.17 $4,031.60 $2,473.78 31641 T 0415 30.4203 $3,298.17 $4,031.60 $2,473.78 31643 T 0076 14.2251 $1,542.29 $1,885.25 $1,156.79 31645 T 0076 14.2251 $1,542.29 $1,885.25 $1,156.79 31646 T 0076 14.2251 $1,542.29 $1,885.25 $1,156.79 31647 T 0415 30.4203 $3,298.17 $4,031.60 $2,473.78 31648 T 0415 30.4203 $3,298.17 $4,031.60 $2,473.78 31649 Q2 0076 14.2251 $1,542.29 $1,885.25 $1,156.79 31651 N $0.00 $0.00 $0.00 31660 T 0415 30.4203 $3,298.17 $4,031.60 $2,473.78 31661 T 0415 30.4203 $3,298.17 $4,031.60 $2,473.78 3170F M $0.00 $0.00 $0.0031717 T 0072 5.2094 $564.80 $690.40 $423.63 31720 Q1 0077 2.2195 $240.64 $294.15 $180.49 31725 C $0.00 $0.00 $0.0031730 T 0072 5.2094 $564.80 $690.40 $423.63 31750 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 31755 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 31760 C $0.00 $0.00 $0.0031766 C $0.00 $0.00 $0.0031770 C $0.00 $0.00 $0.0031775 C $0.00 $0.00 $0.0031780 C $0.00 $0.00 $0.0031781 C $0.00 $0.00 $0.0031785 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 31786 C $0.00 $0.00 $0.0031800 C $0.00 $0.00 $0.0031805 C $0.00 $0.00 $0.0031820 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 31825 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 31830 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 31899 T 0076 14.2251 $1,542.29 $1,885.25 $1,156.79 3200F E $0.00 $0.00 $0.0032035 C $0.00 $0.00 $0.0032036 C $0.00 $0.00 $0.0032096 C $0.00 $0.00 $0.0032097 C $0.00 $0.00 $0.0032098 C $0.00 $0.00 $0.00


59


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee32100 C $0.00 $0.00 $0.003210F M $0.00 $0.00 $0.0032110 C $0.00 $0.00 $0.0032120 C $0.00 $0.00 $0.0032124 C $0.00 $0.00 $0.0032140 C $0.00 $0.00 $0.0032141 C $0.00 $0.00 $0.0032150 C $0.00 $0.00 $0.0032151 C $0.00 $0.00 $0.003215F M $0.00 $0.00 $0.0032160 C $0.00 $0.00 $0.003216F E $0.00 $0.00 $0.003218F E $0.00 $0.00 $0.0032200 C $0.00 $0.00 $0.003220F E $0.00 $0.00 $0.0032215 C $0.00 $0.00 $0.0032220 C $0.00 $0.00 $0.0032225 C $0.00 $0.00 $0.003230F E $0.00 $0.00 $0.0032310 C $0.00 $0.00 $0.0032320 C $0.00 $0.00 $0.0032400 T 0005 14.1916 $1,538.65 $1,880.81 $1,154.06 32405 T 0005 14.1916 $1,538.65 $1,880.81 $1,154.06 32440 C $0.00 $0.00 $0.0032442 C $0.00 $0.00 $0.0032445 C $0.00 $0.00 $0.0032480 C $0.00 $0.00 $0.0032482 C $0.00 $0.00 $0.0032484 C $0.00 $0.00 $0.0032486 C $0.00 $0.00 $0.0032488 C $0.00 $0.00 $0.0032491 C $0.00 $0.00 $0.0032501 C $0.00 $0.00 $0.0032503 C $0.00 $0.00 $0.0032504 C $0.00 $0.00 $0.0032505 C $0.00 $0.00 $0.0032506 C $0.00 $0.00 $0.0032507 C $0.00 $0.00 $0.003250F M $0.00 $0.00 $0.0032540 C $0.00 $0.00 $0.0032550 T 0652 30.85 $3,344.76 $4,088.55 $2,508.72 32551 T 0070 6.5974 $715.29 $874.35 $536.50 32552 Q2 0070 6.5974 $715.29 $874.35 $536.50 32553 S 0310 14.0014 $1,518.03 $1,855.61 $1,138.59 32554 T 0070 6.5974 $715.29 $874.35 $536.50 32555 T 0070 6.5974 $715.29 $874.35 $536.50 32556 T 0070 6.5974 $715.29 $874.35 $536.50 32557 T 0070 6.5974 $715.29 $874.35 $536.50 32560 T 0070 6.5974 $715.29 $874.35 $536.50 32561 T 0070 6.5974 $715.29 $874.35 $536.50 32562 T 0070 6.5974 $715.29 $874.35 $536.50


60


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee32601 T 0069 41.4417 $4,493.11 $5,492.27 $3,370.04 32604 T 0069 41.4417 $4,493.11 $5,492.27 $3,370.04 32606 T 0069 41.4417 $4,493.11 $5,492.27 $3,370.04 32607 T 0069 41.4417 $4,493.11 $5,492.27 $3,370.04 32608 T 0069 41.4417 $4,493.11 $5,492.27 $3,370.04 32609 T 0069 41.4417 $4,493.11 $5,492.27 $3,370.04 3260F M $0.00 $0.00 $0.0032650 C $0.00 $0.00 $0.0032651 C $0.00 $0.00 $0.0032652 C $0.00 $0.00 $0.0032653 C $0.00 $0.00 $0.0032654 C $0.00 $0.00 $0.0032655 C $0.00 $0.00 $0.0032656 C $0.00 $0.00 $0.0032658 C $0.00 $0.00 $0.0032659 C $0.00 $0.00 $0.003265F E $0.00 $0.00 $0.0032661 C $0.00 $0.00 $0.0032662 C $0.00 $0.00 $0.0032663 C $0.00 $0.00 $0.0032664 C $0.00 $0.00 $0.0032665 C $0.00 $0.00 $0.0032666 C $0.00 $0.00 $0.0032667 C $0.00 $0.00 $0.0032668 C $0.00 $0.00 $0.0032669 C $0.00 $0.00 $0.003266F E $0.00 $0.00 $0.0032670 C $0.00 $0.00 $0.0032671 C $0.00 $0.00 $0.0032672 C $0.00 $0.00 $0.0032673 C $0.00 $0.00 $0.0032674 C $0.00 $0.00 $0.003267F M $0.00 $0.00 $0.003268F E $0.00 $0.00 $0.003269F M $0.00 $0.00 $0.0032701 B $0.00 $0.00 $0.003270F M $0.00 $0.00 $0.003271F M $0.00 $0.00 $0.003272F E $0.00 $0.00 $0.003273F E $0.00 $0.00 $0.003274F E $0.00 $0.00 $0.003278F E $0.00 $0.00 $0.003279F E $0.00 $0.00 $0.0032800 C $0.00 $0.00 $0.003280F E $0.00 $0.00 $0.0032810 C $0.00 $0.00 $0.0032815 C $0.00 $0.00 $0.003281F E $0.00 $0.00 $0.0032820 C $0.00 $0.00 $0.003284F M $0.00 $0.00 $0.0032850 C $0.00 $0.00 $0.00


61


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee32851 C $0.00 $0.00 $0.0032852 C $0.00 $0.00 $0.0032853 C $0.00 $0.00 $0.0032854 C $0.00 $0.00 $0.0032855 C $0.00 $0.00 $0.0032856 C $0.00 $0.00 $0.003285F M $0.00 $0.00 $0.003288F M $0.00 $0.00 $0.0032900 C $0.00 $0.00 $0.0032905 C $0.00 $0.00 $0.0032906 C $0.00 $0.00 $0.003290F E $0.00 $0.00 $0.003291F E $0.00 $0.00 $0.003292F E $0.00 $0.00 $0.003293F E $0.00 $0.00 $0.0032940 C $0.00 $0.00 $0.003294F E $0.00 $0.00 $0.0032960 T 0070 6.5974 $715.29 $874.35 $536.50 32997 C $0.00 $0.00 $0.0032998 T 0423 55.2208 $5,987.04 $7,318.41 $4,490.56 32999 T 0070 6.5974 $715.29 $874.35 $536.50 3300F M $0.00 $0.00 $0.0033010 T 0070 6.5974 $715.29 $874.35 $536.50 33011 T 0070 6.5974 $715.29 $874.35 $536.50 33015 C $0.00 $0.00 $0.003301F M $0.00 $0.00 $0.0033020 C $0.00 $0.00 $0.0033025 C $0.00 $0.00 $0.0033030 C $0.00 $0.00 $0.0033031 C $0.00 $0.00 $0.0033050 C $0.00 $0.00 $0.0033120 C $0.00 $0.00 $0.0033130 C $0.00 $0.00 $0.0033140 C $0.00 $0.00 $0.0033141 C $0.00 $0.00 $0.003315F M $0.00 $0.00 $0.003316F M $0.00 $0.00 $0.003317F E $0.00 $0.00 $0.003318F E $0.00 $0.00 $0.003319F M $0.00 $0.00 $0.0033202 C $0.00 $0.00 $0.0033203 C $0.00 $0.00 $0.0033206 J1 0089 127.9907 $13,876.75 $16,962.61 $10,408.20 33207 J1 0089 127.9907 $13,876.75 $16,962.61 $10,408.20 33208 J1 0089 127.9907 $13,876.75 $16,962.61 $10,408.20 3320F M $0.00 $0.00 $0.0033210 J1 0090 88.2442 $9,567.44 $11,695.00 $7,176.02 33211 J1 0090 88.2442 $9,567.44 $11,695.00 $7,176.02 33212 J1 0090 88.2442 $9,567.44 $11,695.00 $7,176.02 33213 J1 0089 127.9907 $13,876.75 $16,962.61 $10,408.20 33214 J1 0089 127.9907 $13,876.75 $16,962.61 $10,408.20


62


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee33215 T 0103 21.2483 $2,303.74 $2,816.04 $1,727.91 33216 J1 0090 88.2442 $9,567.44 $11,695.00 $7,176.02 33217 J1 0090 88.2442 $9,567.44 $11,695.00 $7,176.02 33218 T 0105 31.6455 $3,431.01 $4,193.98 $2,573.41 3321F M $0.00 $0.00 $0.0033220 T 0105 31.6455 $3,431.01 $4,193.98 $2,573.41 33221 J1 0655 221.2044 $23,982.98 $29,316.22 $17,988.34 33222 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 33223 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 33224 J1 0089 127.9907 $13,876.75 $16,962.61 $10,408.20 33225 N $0.00 $0.00 $0.00 33226 T 0103 21.2483 $2,303.74 $2,816.04 $1,727.91 33227 J1 0090 88.2442 $9,567.44 $11,695.00 $7,176.02 33228 J1 0089 127.9907 $13,876.75 $16,962.61 $10,408.20 33229 J1 0655 221.2044 $23,982.98 $29,316.22 $17,988.34 3322F M $0.00 $0.00 $0.0033230 J1 0107 308.9615 $33,497.61 $40,946.67 $25,124.75 33231 J1 0108 415.4941 $45,047.87 $55,065.43 $33,787.98 33233 J1 0090 88.2442 $9,567.44 $11,695.00 $7,176.02 33234 Q2 0105 31.6455 $3,431.01 $4,193.98 $2,573.41 33235 Q2 0105 31.6455 $3,431.01 $4,193.98 $2,573.41 33236 C $0.00 $0.00 $0.0033237 C $0.00 $0.00 $0.0033238 C $0.00 $0.00 $0.003323F E $0.00 $0.00 $0.0033240 J1 0107 308.9615 $33,497.61 $40,946.67 $25,124.75 33241 Q2 0105 31.6455 $3,431.01 $4,193.98 $2,573.41 33243 C $0.00 $0.00 $0.0033244 Q2 0105 31.6455 $3,431.01 $4,193.98 $2,573.41 33249 J1 0108 415.4941 $45,047.87 $55,065.43 $33,787.98 3324F E $0.00 $0.00 $0.0033250 C $0.00 $0.00 $0.0033251 C $0.00 $0.00 $0.0033254 C $0.00 $0.00 $0.0033255 C $0.00 $0.00 $0.0033256 C $0.00 $0.00 $0.0033257 C $0.00 $0.00 $0.0033258 C $0.00 $0.00 $0.0033259 C $0.00 $0.00 $0.003325F E $0.00 $0.00 $0.0033261 C $0.00 $0.00 $0.0033262 J1 0107 308.9615 $33,497.61 $40,946.67 $25,124.75 33263 J1 0107 308.9615 $33,497.61 $40,946.67 $25,124.75 33264 J1 0108 415.4941 $45,047.87 $55,065.43 $33,787.98 33265 C $0.00 $0.00 $0.0033266 C $0.00 $0.00 $0.0033270 J1 0108 415.4941 $45,047.87 $55,065.43 $33,787.98 33271 J1 0090 88.2442 $9,567.44 $11,695.00 $7,176.02 33272 Q2 0105 31.6455 $3,431.01 $4,193.98 $2,573.41 33273 T 0105 31.6455 $3,431.01 $4,193.98 $2,573.41 33282 J1 0090 88.2442 $9,567.44 $11,695.00 $7,176.02


63


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee33284 Q2 0020 11.144 $1,208.23 $1,476.91 $906.23 3328F E $0.00 $0.00 $0.0033300 C $0.00 $0.00 $0.0033305 C $0.00 $0.00 $0.003330F E $0.00 $0.00 $0.0033310 C $0.00 $0.00 $0.0033315 C $0.00 $0.00 $0.003331F E $0.00 $0.00 $0.0033320 C $0.00 $0.00 $0.0033321 C $0.00 $0.00 $0.0033322 C $0.00 $0.00 $0.0033330 C $0.00 $0.00 $0.0033335 C $0.00 $0.00 $0.0033361 C $0.00 $0.00 $0.0033362 C $0.00 $0.00 $0.0033363 C $0.00 $0.00 $0.0033364 C $0.00 $0.00 $0.0033365 C $0.00 $0.00 $0.0033366 C $0.00 $0.00 $0.0033367 C $0.00 $0.00 $0.0033368 C $0.00 $0.00 $0.0033369 C $0.00 $0.00 $0.0033400 C $0.00 $0.00 $0.0033401 C $0.00 $0.00 $0.0033403 C $0.00 $0.00 $0.0033404 C $0.00 $0.00 $0.0033405 C $0.00 $0.00 $0.0033406 C $0.00 $0.00 $0.003340F M $0.00 $0.00 $0.0033410 C $0.00 $0.00 $0.0033411 C $0.00 $0.00 $0.0033412 C $0.00 $0.00 $0.0033413 C $0.00 $0.00 $0.0033414 C $0.00 $0.00 $0.0033415 C $0.00 $0.00 $0.0033416 C $0.00 $0.00 $0.0033417 C $0.00 $0.00 $0.0033418 C $0.00 $0.00 $0.0033419 N $0.00 $0.00 $0.00 3341F M $0.00 $0.00 $0.0033420 C $0.00 $0.00 $0.0033422 C $0.00 $0.00 $0.0033425 C $0.00 $0.00 $0.0033426 C $0.00 $0.00 $0.0033427 C $0.00 $0.00 $0.003342F M $0.00 $0.00 $0.0033430 C $0.00 $0.00 $0.003343F M $0.00 $0.00 $0.003344F M $0.00 $0.00 $0.003345F M $0.00 $0.00 $0.0033460 C $0.00 $0.00 $0.00


64


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee33463 C $0.00 $0.00 $0.0033464 C $0.00 $0.00 $0.0033465 C $0.00 $0.00 $0.0033468 C $0.00 $0.00 $0.0033470 C $0.00 $0.00 $0.0033471 C $0.00 $0.00 $0.0033474 C $0.00 $0.00 $0.0033475 C $0.00 $0.00 $0.0033476 C $0.00 $0.00 $0.0033478 C $0.00 $0.00 $0.0033496 C $0.00 $0.00 $0.0033500 C $0.00 $0.00 $0.0033501 C $0.00 $0.00 $0.0033502 C $0.00 $0.00 $0.0033503 C $0.00 $0.00 $0.0033504 C $0.00 $0.00 $0.0033505 C $0.00 $0.00 $0.0033506 C $0.00 $0.00 $0.0033507 C $0.00 $0.00 $0.0033508 N $0.00 $0.00 $0.00 3350F M $0.00 $0.00 $0.0033510 C $0.00 $0.00 $0.0033511 C $0.00 $0.00 $0.0033512 C $0.00 $0.00 $0.0033513 C $0.00 $0.00 $0.0033514 C $0.00 $0.00 $0.0033516 C $0.00 $0.00 $0.0033517 C $0.00 $0.00 $0.0033518 C $0.00 $0.00 $0.0033519 C $0.00 $0.00 $0.003351F E $0.00 $0.00 $0.0033521 C $0.00 $0.00 $0.0033522 C $0.00 $0.00 $0.0033523 C $0.00 $0.00 $0.003352F E $0.00 $0.00 $0.0033530 C $0.00 $0.00 $0.0033533 C $0.00 $0.00 $0.0033534 C $0.00 $0.00 $0.0033535 C $0.00 $0.00 $0.0033536 C $0.00 $0.00 $0.003353F E $0.00 $0.00 $0.0033542 C $0.00 $0.00 $0.0033545 C $0.00 $0.00 $0.0033548 C $0.00 $0.00 $0.003354F E $0.00 $0.00 $0.0033572 C $0.00 $0.00 $0.0033600 C $0.00 $0.00 $0.0033602 C $0.00 $0.00 $0.0033606 C $0.00 $0.00 $0.0033608 C $0.00 $0.00 $0.0033610 C $0.00 $0.00 $0.00


65


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee33611 C $0.00 $0.00 $0.0033612 C $0.00 $0.00 $0.0033615 C $0.00 $0.00 $0.0033617 C $0.00 $0.00 $0.0033619 C $0.00 $0.00 $0.0033620 C $0.00 $0.00 $0.0033621 C $0.00 $0.00 $0.0033622 C $0.00 $0.00 $0.0033641 C $0.00 $0.00 $0.0033645 C $0.00 $0.00 $0.0033647 C $0.00 $0.00 $0.0033660 C $0.00 $0.00 $0.0033665 C $0.00 $0.00 $0.0033670 C $0.00 $0.00 $0.0033675 C $0.00 $0.00 $0.0033676 C $0.00 $0.00 $0.0033677 C $0.00 $0.00 $0.0033681 C $0.00 $0.00 $0.0033684 C $0.00 $0.00 $0.0033688 C $0.00 $0.00 $0.0033690 C $0.00 $0.00 $0.0033692 C $0.00 $0.00 $0.0033694 C $0.00 $0.00 $0.0033697 C $0.00 $0.00 $0.0033702 C $0.00 $0.00 $0.003370F M $0.00 $0.00 $0.0033710 C $0.00 $0.00 $0.0033720 C $0.00 $0.00 $0.0033722 C $0.00 $0.00 $0.0033724 C $0.00 $0.00 $0.0033726 C $0.00 $0.00 $0.003372F M $0.00 $0.00 $0.0033730 C $0.00 $0.00 $0.0033732 C $0.00 $0.00 $0.0033735 C $0.00 $0.00 $0.0033736 C $0.00 $0.00 $0.0033737 C $0.00 $0.00 $0.003374F M $0.00 $0.00 $0.0033750 C $0.00 $0.00 $0.0033755 C $0.00 $0.00 $0.0033762 C $0.00 $0.00 $0.0033764 C $0.00 $0.00 $0.0033766 C $0.00 $0.00 $0.0033767 C $0.00 $0.00 $0.0033768 C $0.00 $0.00 $0.003376F M $0.00 $0.00 $0.0033770 C $0.00 $0.00 $0.0033771 C $0.00 $0.00 $0.0033774 C $0.00 $0.00 $0.0033775 C $0.00 $0.00 $0.0033776 C $0.00 $0.00 $0.00


66


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee33777 C $0.00 $0.00 $0.0033778 C $0.00 $0.00 $0.0033779 C $0.00 $0.00 $0.0033780 C $0.00 $0.00 $0.0033781 C $0.00 $0.00 $0.0033782 C $0.00 $0.00 $0.0033783 C $0.00 $0.00 $0.0033786 C $0.00 $0.00 $0.0033788 C $0.00 $0.00 $0.003378F M $0.00 $0.00 $0.0033800 C $0.00 $0.00 $0.0033802 C $0.00 $0.00 $0.0033803 C $0.00 $0.00 $0.003380F M $0.00 $0.00 $0.0033813 C $0.00 $0.00 $0.0033814 C $0.00 $0.00 $0.0033820 C $0.00 $0.00 $0.0033822 C $0.00 $0.00 $0.0033824 C $0.00 $0.00 $0.003382F M $0.00 $0.00 $0.0033840 C $0.00 $0.00 $0.0033845 C $0.00 $0.00 $0.003384F M $0.00 $0.00 $0.0033851 C $0.00 $0.00 $0.0033852 C $0.00 $0.00 $0.0033853 C $0.00 $0.00 $0.0033860 C $0.00 $0.00 $0.0033863 C $0.00 $0.00 $0.0033864 C $0.00 $0.00 $0.003386F M $0.00 $0.00 $0.0033870 C $0.00 $0.00 $0.0033875 C $0.00 $0.00 $0.0033877 C $0.00 $0.00 $0.0033880 C $0.00 $0.00 $0.0033881 C $0.00 $0.00 $0.0033883 C $0.00 $0.00 $0.0033884 C $0.00 $0.00 $0.0033886 C $0.00 $0.00 $0.0033889 C $0.00 $0.00 $0.003388F M $0.00 $0.00 $0.0033891 C $0.00 $0.00 $0.003390F M $0.00 $0.00 $0.0033910 C $0.00 $0.00 $0.0033915 C $0.00 $0.00 $0.0033916 C $0.00 $0.00 $0.0033917 C $0.00 $0.00 $0.0033920 C $0.00 $0.00 $0.0033922 C $0.00 $0.00 $0.0033924 C $0.00 $0.00 $0.0033925 C $0.00 $0.00 $0.0033926 C $0.00 $0.00 $0.00


67


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee33930 C $0.00 $0.00 $0.0033933 C $0.00 $0.00 $0.0033935 C $0.00 $0.00 $0.0033940 C $0.00 $0.00 $0.0033944 C $0.00 $0.00 $0.0033945 C $0.00 $0.00 $0.0033946 C $0.00 $0.00 $0.0033947 C $0.00 $0.00 $0.0033948 C $0.00 $0.00 $0.0033949 C $0.00 $0.00 $0.003394F M $0.00 $0.00 $0.0033951 C $0.00 $0.00 $0.0033952 C $0.00 $0.00 $0.0033953 C $0.00 $0.00 $0.0033954 C $0.00 $0.00 $0.0033955 C $0.00 $0.00 $0.0033956 C $0.00 $0.00 $0.0033957 C $0.00 $0.00 $0.0033958 C $0.00 $0.00 $0.0033959 C $0.00 $0.00 $0.003395F M $0.00 $0.00 $0.0033962 C $0.00 $0.00 $0.0033963 C $0.00 $0.00 $0.0033964 C $0.00 $0.00 $0.0033965 C $0.00 $0.00 $0.0033966 C $0.00 $0.00 $0.0033967 C $0.00 $0.00 $0.0033968 C $0.00 $0.00 $0.0033969 C $0.00 $0.00 $0.0033970 C $0.00 $0.00 $0.0033971 C $0.00 $0.00 $0.0033973 C $0.00 $0.00 $0.0033974 C $0.00 $0.00 $0.0033975 C $0.00 $0.00 $0.0033976 C $0.00 $0.00 $0.0033977 C $0.00 $0.00 $0.0033978 C $0.00 $0.00 $0.0033979 C $0.00 $0.00 $0.0033980 C $0.00 $0.00 $0.0033981 C $0.00 $0.00 $0.0033982 C $0.00 $0.00 $0.0033983 C $0.00 $0.00 $0.0033984 C $0.00 $0.00 $0.0033985 C $0.00 $0.00 $0.0033986 C $0.00 $0.00 $0.0033987 C $0.00 $0.00 $0.0033988 C $0.00 $0.00 $0.0033989 C $0.00 $0.00 $0.0033990 C $0.00 $0.00 $0.0033991 C $0.00 $0.00 $0.0033992 C $0.00 $0.00 $0.00


68


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee33993 C $0.00 $0.00 $0.0033999 T 0070 6.5974 $715.29 $874.35 $536.50 34001 C $0.00 $0.00 $0.0034051 C $0.00 $0.00 $0.0034101 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 34111 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 34151 C $0.00 $0.00 $0.0034201 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 34203 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 34401 C $0.00 $0.00 $0.0034421 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 34451 C $0.00 $0.00 $0.0034471 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 34490 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 34501 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 34502 C $0.00 $0.00 $0.003450F E $0.00 $0.00 $0.0034510 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 3451F E $0.00 $0.00 $0.0034520 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 3452F E $0.00 $0.00 $0.0034530 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 3455F M $0.00 $0.00 $0.003470F M $0.00 $0.00 $0.003471F M $0.00 $0.00 $0.003472F M $0.00 $0.00 $0.003475F M $0.00 $0.00 $0.003476F M $0.00 $0.00 $0.0034800 C $0.00 $0.00 $0.0034802 C $0.00 $0.00 $0.0034803 C $0.00 $0.00 $0.0034804 C $0.00 $0.00 $0.0034805 C $0.00 $0.00 $0.0034806 C $0.00 $0.00 $0.0034808 C $0.00 $0.00 $0.0034812 C $0.00 $0.00 $0.0034813 C $0.00 $0.00 $0.0034820 C $0.00 $0.00 $0.0034825 C $0.00 $0.00 $0.0034826 C $0.00 $0.00 $0.0034830 C $0.00 $0.00 $0.0034831 C $0.00 $0.00 $0.0034832 C $0.00 $0.00 $0.0034833 C $0.00 $0.00 $0.0034834 C $0.00 $0.00 $0.0034839 B $0.00 $0.00 $0.0034841 C $0.00 $0.00 $0.0034842 C $0.00 $0.00 $0.0034843 C $0.00 $0.00 $0.0034844 C $0.00 $0.00 $0.0034845 C $0.00 $0.00 $0.00


69


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee34846 C $0.00 $0.00 $0.0034847 C $0.00 $0.00 $0.0034848 C $0.00 $0.00 $0.0034900 C $0.00 $0.00 $0.003490F E $0.00 $0.00 $0.003491F E $0.00 $0.00 $0.003492F E $0.00 $0.00 $0.003493F E $0.00 $0.00 $0.003494F M $0.00 $0.00 $0.003495F M $0.00 $0.00 $0.003496F M $0.00 $0.00 $0.003497F E $0.00 $0.00 $0.003498F E $0.00 $0.00 $0.0035001 C $0.00 $0.00 $0.0035002 C $0.00 $0.00 $0.0035005 C $0.00 $0.00 $0.003500F E $0.00 $0.00 $0.0035011 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 35013 C $0.00 $0.00 $0.0035021 C $0.00 $0.00 $0.0035022 C $0.00 $0.00 $0.003502F E $0.00 $0.00 $0.003503F E $0.00 $0.00 $0.0035045 T 0093 33.7207 $3,656.00 $4,469.00 $2,742.17 35081 C $0.00 $0.00 $0.0035082 C $0.00 $0.00 $0.0035091 C $0.00 $0.00 $0.0035092 C $0.00 $0.00 $0.0035102 C $0.00 $0.00 $0.0035103 C $0.00 $0.00 $0.003510F M $0.00 $0.00 $0.0035111 C $0.00 $0.00 $0.0035112 C $0.00 $0.00 $0.003511F E $0.00 $0.00 $0.0035121 C $0.00 $0.00 $0.0035122 C $0.00 $0.00 $0.003512F E $0.00 $0.00 $0.0035131 C $0.00 $0.00 $0.0035132 C $0.00 $0.00 $0.003513F E $0.00 $0.00 $0.0035141 C $0.00 $0.00 $0.0035142 C $0.00 $0.00 $0.003514F E $0.00 $0.00 $0.0035151 C $0.00 $0.00 $0.0035152 C $0.00 $0.00 $0.003515F E $0.00 $0.00 $0.003517F M $0.00 $0.00 $0.0035180 T 0093 33.7207 $3,656.00 $4,469.00 $2,742.17 35182 C $0.00 $0.00 $0.0035184 T 0093 33.7207 $3,656.00 $4,469.00 $2,742.17 35188 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21


70


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee35189 C $0.00 $0.00 $0.0035190 T 0093 33.7207 $3,656.00 $4,469.00 $2,742.17 35201 T 0093 33.7207 $3,656.00 $4,469.00 $2,742.17 35206 T 0093 33.7207 $3,656.00 $4,469.00 $2,742.17 35207 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 3520F E $0.00 $0.00 $0.0035211 C $0.00 $0.00 $0.0035216 C $0.00 $0.00 $0.0035221 C $0.00 $0.00 $0.0035226 T 0020 11.144 $1,208.23 $1,476.91 $906.23 35231 T 0093 33.7207 $3,656.00 $4,469.00 $2,742.17 35236 T 0093 33.7207 $3,656.00 $4,469.00 $2,742.17 35241 C $0.00 $0.00 $0.0035246 C $0.00 $0.00 $0.0035251 C $0.00 $0.00 $0.0035256 T 0093 33.7207 $3,656.00 $4,469.00 $2,742.17 35261 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 35266 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 35271 C $0.00 $0.00 $0.0035276 C $0.00 $0.00 $0.0035281 C $0.00 $0.00 $0.0035286 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 35301 C $0.00 $0.00 $0.0035302 C $0.00 $0.00 $0.0035303 C $0.00 $0.00 $0.0035304 C $0.00 $0.00 $0.0035305 C $0.00 $0.00 $0.0035306 C $0.00 $0.00 $0.0035311 C $0.00 $0.00 $0.0035321 T 0093 33.7207 $3,656.00 $4,469.00 $2,742.17 35331 C $0.00 $0.00 $0.0035341 C $0.00 $0.00 $0.0035351 C $0.00 $0.00 $0.0035355 C $0.00 $0.00 $0.0035361 C $0.00 $0.00 $0.0035363 C $0.00 $0.00 $0.0035371 C $0.00 $0.00 $0.0035372 C $0.00 $0.00 $0.0035390 C $0.00 $0.00 $0.0035400 C $0.00 $0.00 $0.0035450 C $0.00 $0.00 $0.0035452 C $0.00 $0.00 $0.0035458 J1 0083 61.1978 $6,635.07 $8,110.54 $4,976.61 35460 J1 0083 61.1978 $6,635.07 $8,110.54 $4,976.61 35471 J1 0083 61.1978 $6,635.07 $8,110.54 $4,976.61 35472 J1 0083 61.1978 $6,635.07 $8,110.54 $4,976.61 35475 J1 0083 61.1978 $6,635.07 $8,110.54 $4,976.61 35476 J1 0083 61.1978 $6,635.07 $8,110.54 $4,976.61 35500 N $0.00 $0.00 $0.00 35501 C $0.00 $0.00 $0.0035506 C $0.00 $0.00 $0.00


71


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee35508 C $0.00 $0.00 $0.0035509 C $0.00 $0.00 $0.003550F E $0.00 $0.00 $0.0035510 C $0.00 $0.00 $0.0035511 C $0.00 $0.00 $0.0035512 C $0.00 $0.00 $0.0035515 C $0.00 $0.00 $0.0035516 C $0.00 $0.00 $0.0035518 C $0.00 $0.00 $0.003551F E $0.00 $0.00 $0.0035521 C $0.00 $0.00 $0.0035522 C $0.00 $0.00 $0.0035523 C $0.00 $0.00 $0.0035525 C $0.00 $0.00 $0.0035526 C $0.00 $0.00 $0.003552F E $0.00 $0.00 $0.0035531 C $0.00 $0.00 $0.0035533 C $0.00 $0.00 $0.0035535 C $0.00 $0.00 $0.0035536 C $0.00 $0.00 $0.0035537 C $0.00 $0.00 $0.0035538 C $0.00 $0.00 $0.0035539 C $0.00 $0.00 $0.0035540 C $0.00 $0.00 $0.0035556 C $0.00 $0.00 $0.0035558 C $0.00 $0.00 $0.003555F E $0.00 $0.00 $0.0035560 C $0.00 $0.00 $0.0035563 C $0.00 $0.00 $0.0035565 C $0.00 $0.00 $0.0035566 C $0.00 $0.00 $0.0035570 C $0.00 $0.00 $0.0035571 C $0.00 $0.00 $0.0035572 N $0.00 $0.00 $0.00 35583 C $0.00 $0.00 $0.0035585 C $0.00 $0.00 $0.0035587 C $0.00 $0.00 $0.0035600 C $0.00 $0.00 $0.0035601 C $0.00 $0.00 $0.0035606 C $0.00 $0.00 $0.0035612 C $0.00 $0.00 $0.0035616 C $0.00 $0.00 $0.0035621 C $0.00 $0.00 $0.0035623 C $0.00 $0.00 $0.0035626 C $0.00 $0.00 $0.0035631 C $0.00 $0.00 $0.0035632 C $0.00 $0.00 $0.0035633 C $0.00 $0.00 $0.0035634 C $0.00 $0.00 $0.0035636 C $0.00 $0.00 $0.0035637 C $0.00 $0.00 $0.00


72


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee35638 C $0.00 $0.00 $0.0035642 C $0.00 $0.00 $0.0035645 C $0.00 $0.00 $0.0035646 C $0.00 $0.00 $0.0035647 C $0.00 $0.00 $0.0035650 C $0.00 $0.00 $0.0035654 C $0.00 $0.00 $0.0035656 C $0.00 $0.00 $0.0035661 C $0.00 $0.00 $0.0035663 C $0.00 $0.00 $0.0035665 C $0.00 $0.00 $0.0035666 C $0.00 $0.00 $0.0035671 C $0.00 $0.00 $0.0035681 C $0.00 $0.00 $0.0035682 C $0.00 $0.00 $0.0035683 C $0.00 $0.00 $0.0035685 N $0.00 $0.00 $0.00 35686 N $0.00 $0.00 $0.00 35691 C $0.00 $0.00 $0.0035693 C $0.00 $0.00 $0.0035694 C $0.00 $0.00 $0.0035695 C $0.00 $0.00 $0.0035697 C $0.00 $0.00 $0.0035700 C $0.00 $0.00 $0.0035701 C $0.00 $0.00 $0.003570F M $0.00 $0.00 $0.0035721 C $0.00 $0.00 $0.003572F E $0.00 $0.00 $0.003573F E $0.00 $0.00 $0.0035741 C $0.00 $0.00 $0.0035761 T 0093 33.7207 $3,656.00 $4,469.00 $2,742.17 35800 C $0.00 $0.00 $0.0035820 C $0.00 $0.00 $0.0035840 C $0.00 $0.00 $0.0035860 T 0093 33.7207 $3,656.00 $4,469.00 $2,742.17 35870 C $0.00 $0.00 $0.0035875 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 35876 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 35879 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 35881 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 35883 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 35884 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 35901 C $0.00 $0.00 $0.0035903 T 0093 33.7207 $3,656.00 $4,469.00 $2,742.17 35905 C $0.00 $0.00 $0.0035907 C $0.00 $0.00 $0.0036000 N $0.00 $0.00 $0.00 36002 S 0267 2.5565 $277.18 $338.81 $207.89 36005 N $0.00 $0.00 $0.00 36010 N $0.00 $0.00 $0.00 36011 N $0.00 $0.00 $0.00


73


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee36012 N $0.00 $0.00 $0.00 36013 N $0.00 $0.00 $0.00 36014 N $0.00 $0.00 $0.00 36015 N $0.00 $0.00 $0.00 36100 N $0.00 $0.00 $0.00 36120 N $0.00 $0.00 $0.00 36140 N $0.00 $0.00 $0.00 36147 T 0668 11.1566 $1,209.60 $1,478.58 $907.25 36148 N $0.00 $0.00 $0.00 36160 N $0.00 $0.00 $0.00 36200 N $0.00 $0.00 $0.00 36215 N $0.00 $0.00 $0.00 36216 N $0.00 $0.00 $0.00 36217 N $0.00 $0.00 $0.00 36218 N $0.00 $0.00 $0.00 36221 Q2 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 36222 Q2 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 36223 Q2 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 36224 Q2 0280 71.7863 $7,783.07 $9,513.84 $5,837.66 36225 Q2 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 36226 Q2 0280 71.7863 $7,783.07 $9,513.84 $5,837.66 36227 N $0.00 $0.00 $0.00 36228 N $0.00 $0.00 $0.00 36245 N $0.00 $0.00 $0.00 36246 N $0.00 $0.00 $0.00 36247 N $0.00 $0.00 $0.00 36248 N $0.00 $0.00 $0.00 36251 Q2 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 36252 Q2 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 36253 Q2 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 36254 Q2 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 36260 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 36261 T 0105 31.6455 $3,431.01 $4,193.98 $2,573.41 36262 Q2 0105 31.6455 $3,431.01 $4,193.98 $2,573.41 36299 N $0.00 $0.00 $0.00 36400 N $0.00 $0.00 $0.00 36405 N $0.00 $0.00 $0.00 36406 N $0.00 $0.00 $0.00 36410 N $0.00 $0.00 $0.00 36415 N $0.00 $0.00 $0.00 36416 N $0.00 $0.00 $0.00 36420 Q1 0420 1.7762 $192.58 $235.40 $144.44 36425 Q1 0420 1.7762 $192.58 $235.40 $144.44 36430 S 0110 4.0082 $434.57 $531.21 $325.95 36440 S 0110 4.0082 $434.57 $531.21 $325.95 36450 S 0110 4.0082 $434.57 $531.21 $325.95 36455 S 0110 4.0082 $434.57 $531.21 $325.95 36460 S 0110 4.0082 $434.57 $531.21 $325.95 36468 T 0015 1.9702 $213.61 $261.11 $160.22 36470 T 0016 3.8173 $413.87 $505.91 $310.42 36471 T 0015 1.9702 $213.61 $261.11 $160.22


74


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee36475 T 0219 29.2791 $3,174.44 $3,880.36 $2,380.98 36476 N $0.00 $0.00 $0.00 36478 T 0219 29.2791 $3,174.44 $3,880.36 $2,380.98 36479 N $0.00 $0.00 $0.00 36481 N $0.00 $0.00 $0.00 36500 N $0.00 $0.00 $0.00 3650F E $0.00 $0.00 $0.0036510 N $0.00 $0.00 $0.00 36511 S 0111 14.2289 $1,542.70 $1,885.76 $1,157.09 36512 S 0111 14.2289 $1,542.70 $1,885.76 $1,157.09 36513 S 0111 14.2289 $1,542.70 $1,885.76 $1,157.09 36514 S 0111 14.2289 $1,542.70 $1,885.76 $1,157.09 36515 S 0112 38.3671 $4,159.76 $5,084.79 $3,120.01 36516 S 0112 38.3671 $4,159.76 $5,084.79 $3,120.01 36522 S 0112 38.3671 $4,159.76 $5,084.79 $3,120.01 36555 T 0621 11.372 $1,232.95 $1,507.13 $924.77 36556 T 0621 11.372 $1,232.95 $1,507.13 $924.77 36557 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 36558 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 36560 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 36561 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 36563 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 36565 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 36566 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 36568 T 0621 11.372 $1,232.95 $1,507.13 $924.77 36569 T 0621 11.372 $1,232.95 $1,507.13 $924.77 36570 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 36571 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 36575 T 0121 6.58 $713.40 $872.05 $535.09 36576 T 0621 11.372 $1,232.95 $1,507.13 $924.77 36578 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 36580 T 0621 11.372 $1,232.95 $1,507.13 $924.77 36581 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 36582 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 36583 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 36584 T 0621 11.372 $1,232.95 $1,507.13 $924.77 36585 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 36589 Q2 0121 6.58 $713.40 $872.05 $535.09 36590 Q2 0621 11.372 $1,232.95 $1,507.13 $924.77 36591 Q1 0624 1.0626 $115.21 $140.83 $86.41 36592 Q1 0624 1.0626 $115.21 $140.83 $86.41 36593 T 0676 2.6317 $285.33 $348.78 $214.01 36595 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 36596 T 0621 11.372 $1,232.95 $1,507.13 $924.77 36597 T 0621 11.372 $1,232.95 $1,507.13 $924.77 36598 T 0676 2.6317 $285.33 $348.78 $214.01 36600 Q3 0420 1.7762 $192.58 $235.40 $144.44 36620 N $0.00 $0.00 $0.00 36625 N $0.00 $0.00 $0.00 36640 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 36660 C $0.00 $0.00 $0.00


75


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee36680 Q1 0420 1.7762 $192.58 $235.40 $144.44 36800 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 36810 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 36815 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 36818 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 36819 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 36820 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 36821 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 36823 C $0.00 $0.00 $0.0036825 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 36830 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 36831 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 36832 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 36833 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 36835 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 36838 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 36860 T 0676 2.6317 $285.33 $348.78 $214.01 36861 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 36870 J1 0083 61.1978 $6,635.07 $8,110.54 $4,976.61 3700F M $0.00 $0.00 $0.0037140 C $0.00 $0.00 $0.0037145 C $0.00 $0.00 $0.0037160 C $0.00 $0.00 $0.0037180 C $0.00 $0.00 $0.0037181 C $0.00 $0.00 $0.0037182 C $0.00 $0.00 $0.0037183 J1 0083 61.1978 $6,635.07 $8,110.54 $4,976.61 37184 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 37185 N $0.00 $0.00 $0.00 37186 N $0.00 $0.00 $0.00 37187 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 37188 T 0088 43.4236 $4,707.99 $5,754.93 $3,531.21 37191 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 37192 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 37193 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 37195 T 0676 2.6317 $285.33 $348.78 $214.01 37197 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 37200 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 37202 T 0103 21.2483 $2,303.74 $2,816.04 $1,727.91 3720F M $0.00 $0.00 $0.0037211 T 0621 11.372 $1,232.95 $1,507.13 $924.77 37212 T 0621 11.372 $1,232.95 $1,507.13 $924.77 37213 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 37214 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 37215 C $0.00 $0.00 $0.0037216 E $0.00 $0.00 $0.0037217 C $0.00 $0.00 $0.0037218 C $0.00 $0.00 $0.0037220 J1 0083 61.1978 $6,635.07 $8,110.54 $4,976.61 37221 J1 0229 129.8028 $14,073.22 $17,202.77 $10,555.56 37222 N $0.00 $0.00 $0.00


76


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee37223 N $0.00 $0.00 $0.00 37224 J1 0083 61.1978 $6,635.07 $8,110.54 $4,976.61 37225 J1 0229 129.8028 $14,073.22 $17,202.77 $10,555.56 37226 J1 0229 129.8028 $14,073.22 $17,202.77 $10,555.56 37227 J1 0319 200.1597 $21,701.31 $26,527.17 $16,276.99 37228 J1 0229 129.8028 $14,073.22 $17,202.77 $10,555.56 37229 J1 0319 200.1597 $21,701.31 $26,527.17 $16,276.99 37230 J1 0319 200.1597 $21,701.31 $26,527.17 $16,276.99 37231 J1 0319 200.1597 $21,701.31 $26,527.17 $16,276.99 37232 N $0.00 $0.00 $0.00 37233 N $0.00 $0.00 $0.00 37234 N $0.00 $0.00 $0.00 37235 N $0.00 $0.00 $0.00 37236 J1 0229 129.8028 $14,073.22 $17,202.77 $10,555.56 37237 N $0.00 $0.00 $0.00 37238 J1 0229 129.8028 $14,073.22 $17,202.77 $10,555.56 37239 N $0.00 $0.00 $0.00 37241 J1 0229 129.8028 $14,073.22 $17,202.77 $10,555.56 37242 J1 0229 129.8028 $14,073.22 $17,202.77 $10,555.56 37243 J1 0229 129.8028 $14,073.22 $17,202.77 $10,555.56 37244 J1 0229 129.8028 $14,073.22 $17,202.77 $10,555.56 37250 N $0.00 $0.00 $0.00 37251 N $0.00 $0.00 $0.00 3725F M $0.00 $0.00 $0.0037500 T 0219 29.2791 $3,174.44 $3,880.36 $2,380.98 37501 T 0219 29.2791 $3,174.44 $3,880.36 $2,380.98 3750F E $0.00 $0.00 $0.003751F E $0.00 $0.00 $0.003752F E $0.00 $0.00 $0.003753F E $0.00 $0.00 $0.003754F E $0.00 $0.00 $0.003755F E $0.00 $0.00 $0.0037565 T 0093 33.7207 $3,656.00 $4,469.00 $2,742.17 3756F E $0.00 $0.00 $0.003757F E $0.00 $0.00 $0.003758F E $0.00 $0.00 $0.003759F E $0.00 $0.00 $0.0037600 T 0093 33.7207 $3,656.00 $4,469.00 $2,742.17 37605 T 0219 29.2791 $3,174.44 $3,880.36 $2,380.98 37606 T 0219 29.2791 $3,174.44 $3,880.36 $2,380.98 37607 T 0219 29.2791 $3,174.44 $3,880.36 $2,380.98 37609 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 3760F E $0.00 $0.00 $0.0037615 T 0219 29.2791 $3,174.44 $3,880.36 $2,380.98 37616 C $0.00 $0.00 $0.0037617 C $0.00 $0.00 $0.0037618 C $0.00 $0.00 $0.0037619 T 0219 29.2791 $3,174.44 $3,880.36 $2,380.98 3761F E $0.00 $0.00 $0.003762F E $0.00 $0.00 $0.003763F E $0.00 $0.00 $0.00


77


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee37650 T 0219 29.2791 $3,174.44 $3,880.36 $2,380.98 37660 C $0.00 $0.00 $0.0037700 T 0219 29.2791 $3,174.44 $3,880.36 $2,380.98 37718 T 0219 29.2791 $3,174.44 $3,880.36 $2,380.98 37722 T 0219 29.2791 $3,174.44 $3,880.36 $2,380.98 37735 T 0219 29.2791 $3,174.44 $3,880.36 $2,380.98 3775F M $0.00 $0.00 $0.0037760 T 0219 29.2791 $3,174.44 $3,880.36 $2,380.98 37761 T 0219 29.2791 $3,174.44 $3,880.36 $2,380.98 37765 T 0219 29.2791 $3,174.44 $3,880.36 $2,380.98 37766 T 0219 29.2791 $3,174.44 $3,880.36 $2,380.98 3776F M $0.00 $0.00 $0.0037780 T 0219 29.2791 $3,174.44 $3,880.36 $2,380.98 37785 T 0219 29.2791 $3,174.44 $3,880.36 $2,380.98 37788 C $0.00 $0.00 $0.0037790 T 0181 30.1349 $3,267.23 $3,993.78 $2,450.57 37799 Q1 0624 1.0626 $115.21 $140.83 $86.41 38100 C $0.00 $0.00 $0.0038101 C $0.00 $0.00 $0.0038102 C $0.00 $0.00 $0.0038115 C $0.00 $0.00 $0.0038120 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 38129 T 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 38200 N $0.00 $0.00 $0.00 38204 N $0.00 $0.00 $0.00 38205 B $0.00 $0.00 $0.0038206 S 0111 14.2289 $1,542.70 $1,885.76 $1,157.09 38207 S 0110 4.0082 $434.57 $531.21 $325.95 38208 S 0110 4.0082 $434.57 $531.21 $325.95 38209 S 0110 4.0082 $434.57 $531.21 $325.95 38210 S 0393 8.4693 $918.24 $1,122.44 $688.72 38211 S 0393 8.4693 $918.24 $1,122.44 $688.72 38212 S 0393 8.4693 $918.24 $1,122.44 $688.72 38213 S 0393 8.4693 $918.24 $1,122.44 $688.72 38214 S 0393 8.4693 $918.24 $1,122.44 $688.72 38215 S 0393 8.4693 $918.24 $1,122.44 $688.72 38220 T 0020 11.144 $1,208.23 $1,476.91 $906.23 38221 T 0020 11.144 $1,208.23 $1,476.91 $906.23 38230 S 0112 38.3671 $4,159.76 $5,084.79 $3,120.01 38232 S 0112 38.3671 $4,159.76 $5,084.79 $3,120.01 38240 S 0112 38.3671 $4,159.76 $5,084.79 $3,120.01 38241 S 0112 38.3671 $4,159.76 $5,084.79 $3,120.01 38242 S 0111 14.2289 $1,542.70 $1,885.76 $1,157.09 38243 S 0111 14.2289 $1,542.70 $1,885.76 $1,157.09 38300 T 0007 11.6749 $1,265.79 $1,547.27 $949.40 38305 T 0008 22.0535 $2,391.04 $2,922.75 $1,793.39 38308 T 0113 31.6086 $3,427.00 $4,189.09 $2,570.41 38380 C $0.00 $0.00 $0.0038381 C $0.00 $0.00 $0.0038382 C $0.00 $0.00 $0.0038500 T 0113 31.6086 $3,427.00 $4,189.09 $2,570.41


78


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee38505 T 0005 14.1916 $1,538.65 $1,880.81 $1,154.06 38510 T 0113 31.6086 $3,427.00 $4,189.09 $2,570.41 38520 T 0113 31.6086 $3,427.00 $4,189.09 $2,570.41 38525 T 0113 31.6086 $3,427.00 $4,189.09 $2,570.41 38530 T 0113 31.6086 $3,427.00 $4,189.09 $2,570.41 38542 T 0114 57.1584 $6,197.11 $7,575.20 $4,648.12 38550 T 0113 31.6086 $3,427.00 $4,189.09 $2,570.41 38555 T 0113 31.6086 $3,427.00 $4,189.09 $2,570.41 38562 C $0.00 $0.00 $0.0038564 C $0.00 $0.00 $0.0038570 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 38571 T 0132 73.8696 $8,008.94 $9,789.94 $6,007.08 38572 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 38589 T 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 38700 T 0113 31.6086 $3,427.00 $4,189.09 $2,570.41 38720 T 0113 31.6086 $3,427.00 $4,189.09 $2,570.41 38724 C $0.00 $0.00 $0.0038740 T 0114 57.1584 $6,197.11 $7,575.20 $4,648.12 38745 T 0114 57.1584 $6,197.11 $7,575.20 $4,648.12 38746 C $0.00 $0.00 $0.0038747 C $0.00 $0.00 $0.0038760 T 0113 31.6086 $3,427.00 $4,189.09 $2,570.41 38765 C $0.00 $0.00 $0.0038770 C $0.00 $0.00 $0.0038780 C $0.00 $0.00 $0.0038790 N $0.00 $0.00 $0.00 38792 Q1 0392 3.7786 $409.68 $500.78 $307.28 38794 N $0.00 $0.00 $0.00 38900 N $0.00 $0.00 $0.00 38999 S 0110 4.0082 $434.57 $531.21 $325.95 39000 C $0.00 $0.00 $0.0039010 C $0.00 $0.00 $0.0039200 C $0.00 $0.00 $0.0039220 C $0.00 $0.00 $0.0039400 T 0069 41.4417 $4,493.11 $5,492.27 $3,370.04 39499 C $0.00 $0.00 $0.0039501 C $0.00 $0.00 $0.0039503 C $0.00 $0.00 $0.0039540 C $0.00 $0.00 $0.0039541 C $0.00 $0.00 $0.0039545 C $0.00 $0.00 $0.0039560 C $0.00 $0.00 $0.0039561 C $0.00 $0.00 $0.0039599 C $0.00 $0.00 $0.004000F E $0.00 $0.00 $0.004001F E $0.00 $0.00 $0.004003F E $0.00 $0.00 $0.004004F M $0.00 $0.00 $0.004005F M $0.00 $0.00 $0.004008F M $0.00 $0.00 $0.004010F M $0.00 $0.00 $0.00


79


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee4011F E $0.00 $0.00 $0.004012F E $0.00 $0.00 $0.004013F E $0.00 $0.00 $0.004014F E $0.00 $0.00 $0.004015F E $0.00 $0.00 $0.004016F E $0.00 $0.00 $0.004017F E $0.00 $0.00 $0.004018F E $0.00 $0.00 $0.004019F E $0.00 $0.00 $0.004025F M $0.00 $0.00 $0.004030F E $0.00 $0.00 $0.004033F E $0.00 $0.00 $0.004035F E $0.00 $0.00 $0.004037F E $0.00 $0.00 $0.004040F M $0.00 $0.00 $0.004041F E $0.00 $0.00 $0.004042F M $0.00 $0.00 $0.004043F E $0.00 $0.00 $0.004044F M $0.00 $0.00 $0.004045F E $0.00 $0.00 $0.004046F M $0.00 $0.00 $0.004047F E $0.00 $0.00 $0.004048F E $0.00 $0.00 $0.0040490 T 0251 4.8979 $531.03 $649.12 $398.30 4049F M $0.00 $0.00 $0.0040500 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 4050F E $0.00 $0.00 $0.0040510 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 4051F E $0.00 $0.00 $0.0040520 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 40525 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 40527 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 4052F E $0.00 $0.00 $0.0040530 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 4053F E $0.00 $0.00 $0.004054F E $0.00 $0.00 $0.004055F E $0.00 $0.00 $0.004056F E $0.00 $0.00 $0.004058F E $0.00 $0.00 $0.004060F E $0.00 $0.00 $0.004062F E $0.00 $0.00 $0.004063F E $0.00 $0.00 $0.004064F E $0.00 $0.00 $0.0040650 T 0252 8.7183 $945.24 $1,155.44 $708.97 40652 T 0252 8.7183 $945.24 $1,155.44 $708.97 40654 T 0252 8.7183 $945.24 $1,155.44 $708.97 4065F E $0.00 $0.00 $0.004066F E $0.00 $0.00 $0.004067F E $0.00 $0.00 $0.004069F E $0.00 $0.00 $0.0040700 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44


80


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee40701 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 40702 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 4070F E $0.00 $0.00 $0.0040720 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 4073F E $0.00 $0.00 $0.004075F M $0.00 $0.00 $0.0040761 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 4077F E $0.00 $0.00 $0.0040799 T 0250 1.7489 $189.62 $231.78 $142.22 4079F E $0.00 $0.00 $0.0040800 T 0006 2.1836 $236.75 $289.39 $177.57 40801 T 0252 8.7183 $945.24 $1,155.44 $708.97 40804 Q1 0420 1.7762 $192.58 $235.40 $144.44 40805 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 40806 T 0251 4.8979 $531.03 $649.12 $398.30 40808 T 0251 4.8979 $531.03 $649.12 $398.30 40810 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 40812 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 40814 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 40816 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 40818 T 0251 4.8979 $531.03 $649.12 $398.30 40819 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 40820 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 40830 T 0251 4.8979 $531.03 $649.12 $398.30 40831 T 0252 8.7183 $945.24 $1,155.44 $708.97 40840 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 40842 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 40843 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 40844 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 40845 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 4084F E $0.00 $0.00 $0.004086F M $0.00 $0.00 $0.0040899 T 0250 1.7489 $189.62 $231.78 $142.22 4090F M $0.00 $0.00 $0.004095F E $0.00 $0.00 $0.0041000 T 0252 8.7183 $945.24 $1,155.44 $708.97 41005 T 0251 4.8979 $531.03 $649.12 $398.30 41006 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 41007 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 41008 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 41009 T 0251 4.8979 $531.03 $649.12 $398.30 4100F M $0.00 $0.00 $0.0041010 T 0252 8.7183 $945.24 $1,155.44 $708.97 41015 T 0251 4.8979 $531.03 $649.12 $398.30 41016 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 41017 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 41018 T 0252 8.7183 $945.24 $1,155.44 $708.97 41019 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 41100 T 0252 8.7183 $945.24 $1,155.44 $708.97 41105 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 41108 T 0020 11.144 $1,208.23 $1,476.91 $906.23


81


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee4110F M $0.00 $0.00 $0.0041110 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 41112 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 41113 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 41114 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 41115 T 0252 8.7183 $945.24 $1,155.44 $708.97 41116 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 41120 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 41130 C $0.00 $0.00 $0.0041135 C $0.00 $0.00 $0.0041140 C $0.00 $0.00 $0.0041145 C $0.00 $0.00 $0.0041150 C $0.00 $0.00 $0.0041153 C $0.00 $0.00 $0.0041155 C $0.00 $0.00 $0.004115F M $0.00 $0.00 $0.004120F M $0.00 $0.00 $0.004124F M $0.00 $0.00 $0.0041250 T 0250 1.7489 $189.62 $231.78 $142.22 41251 T 0251 4.8979 $531.03 $649.12 $398.30 41252 T 0252 8.7183 $945.24 $1,155.44 $708.97 4130F M $0.00 $0.00 $0.004131F M $0.00 $0.00 $0.004132F M $0.00 $0.00 $0.004133F E $0.00 $0.00 $0.004134F E $0.00 $0.00 $0.004135F E $0.00 $0.00 $0.004136F E $0.00 $0.00 $0.004140F M $0.00 $0.00 $0.004142F M $0.00 $0.00 $0.004144F M $0.00 $0.00 $0.004145F E $0.00 $0.00 $0.004148F M $0.00 $0.00 $0.004149F M $0.00 $0.00 $0.0041500 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 4150F E $0.00 $0.00 $0.0041510 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 41512 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 4151F M $0.00 $0.00 $0.0041520 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 41530 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 4153F E $0.00 $0.00 $0.004155F E $0.00 $0.00 $0.004157F E $0.00 $0.00 $0.004158F E $0.00 $0.00 $0.0041599 T 0250 1.7489 $189.62 $231.78 $142.22 4159F E $0.00 $0.00 $0.004163F E $0.00 $0.00 $0.004164F M $0.00 $0.00 $0.004165F E $0.00 $0.00 $0.004167F E $0.00 $0.00 $0.00


82


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee4168F E $0.00 $0.00 $0.004169F E $0.00 $0.00 $0.004171F E $0.00 $0.00 $0.004172F E $0.00 $0.00 $0.004174F E $0.00 $0.00 $0.004175F M $0.00 $0.00 $0.004176F E $0.00 $0.00 $0.004177F M $0.00 $0.00 $0.004178F E $0.00 $0.00 $0.004179F M $0.00 $0.00 $0.0041800 T 0006 2.1836 $236.75 $289.39 $177.57 41805 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 41806 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 4180F E $0.00 $0.00 $0.004181F E $0.00 $0.00 $0.0041820 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 41821 T 0252 8.7183 $945.24 $1,155.44 $708.97 41822 T 0252 8.7183 $945.24 $1,155.44 $708.97 41823 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 41825 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 41826 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 41827 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 41828 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 4182F E $0.00 $0.00 $0.0041830 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 41850 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 4185F E $0.00 $0.00 $0.004186F E $0.00 $0.00 $0.0041870 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 41872 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 41874 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 4187F M $0.00 $0.00 $0.004188F E $0.00 $0.00 $0.0041899 T 0250 1.7489 $189.62 $231.78 $142.22 4189F E $0.00 $0.00 $0.004190F E $0.00 $0.00 $0.004191F E $0.00 $0.00 $0.004192F M $0.00 $0.00 $0.004193F M $0.00 $0.00 $0.004194F M $0.00 $0.00 $0.004195F M $0.00 $0.00 $0.004196F M $0.00 $0.00 $0.0042000 T 0251 4.8979 $531.03 $649.12 $398.30 4200F E $0.00 $0.00 $0.004201F E $0.00 $0.00 $0.0042100 T 0252 8.7183 $945.24 $1,155.44 $708.97 42104 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 42106 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 42107 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 4210F E $0.00 $0.00 $0.0042120 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72


83


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee42140 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 42145 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 42160 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 42180 T 0251 4.8979 $531.03 $649.12 $398.30 42182 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 42200 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 42205 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 4220F E $0.00 $0.00 $0.0042210 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 42215 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 4221F E $0.00 $0.00 $0.0042220 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 42225 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 42226 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 42227 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 42235 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 42260 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 42280 T 0251 4.8979 $531.03 $649.12 $398.30 42281 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 42299 T 0250 1.7489 $189.62 $231.78 $142.22 42300 T 0252 8.7183 $945.24 $1,155.44 $708.97 42305 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 4230F E $0.00 $0.00 $0.0042310 T 0251 4.8979 $531.03 $649.12 $398.30 42320 T 0251 4.8979 $531.03 $649.12 $398.30 42330 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 42335 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 42340 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 42400 T 0004 6.5703 $712.35 $870.76 $534.30 42405 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 42408 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 42409 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 4240F E $0.00 $0.00 $0.0042410 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 42415 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 42420 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 42425 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 42426 C $0.00 $0.00 $0.004242F E $0.00 $0.00 $0.0042440 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 42450 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 4245F E $0.00 $0.00 $0.004248F E $0.00 $0.00 $0.0042500 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 42505 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 42507 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 42509 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 4250F M $0.00 $0.00 $0.0042510 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 42550 N $0.00 $0.00 $0.00 4255F M $0.00 $0.00 $0.00


84


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee4256F E $0.00 $0.00 $0.0042600 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 4260F E $0.00 $0.00 $0.004261F E $0.00 $0.00 $0.0042650 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 4265F E $0.00 $0.00 $0.0042660 T 0251 4.8979 $531.03 $649.12 $398.30 42665 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 4266F E $0.00 $0.00 $0.004267F E $0.00 $0.00 $0.004268F E $0.00 $0.00 $0.0042699 T 0250 1.7489 $189.62 $231.78 $142.22 4269F E $0.00 $0.00 $0.0042700 T 0251 4.8979 $531.03 $649.12 $398.30 4270F E $0.00 $0.00 $0.004271F E $0.00 $0.00 $0.0042720 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 42725 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 4274F E $0.00 $0.00 $0.004276F E $0.00 $0.00 $0.004279F E $0.00 $0.00 $0.0042800 T 0252 8.7183 $945.24 $1,155.44 $708.97 42804 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 42806 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 42808 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 42809 Q1 0420 1.7762 $192.58 $235.40 $144.44 4280F E $0.00 $0.00 $0.0042810 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 42815 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 42820 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 42821 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 42825 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 42826 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 42830 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 42831 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 42835 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 42836 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 42842 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 42844 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 42845 C $0.00 $0.00 $0.0042860 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 42870 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 42890 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 42892 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 42894 C $0.00 $0.00 $0.0042900 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 4290F E $0.00 $0.00 $0.004293F E $0.00 $0.00 $0.0042950 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 42953 C $0.00 $0.00 $0.0042955 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72


85


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee42960 T 0250 1.7489 $189.62 $231.78 $142.22 42961 C $0.00 $0.00 $0.0042962 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 42970 T 0250 1.7489 $189.62 $231.78 $142.22 42971 C $0.00 $0.00 $0.0042972 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 42999 T 0250 1.7489 $189.62 $231.78 $142.22 4300F E $0.00 $0.00 $0.004301F E $0.00 $0.00 $0.0043020 T 0252 8.7183 $945.24 $1,155.44 $708.97 43030 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 43045 C $0.00 $0.00 $0.004305F E $0.00 $0.00 $0.004306F E $0.00 $0.00 $0.0043100 C $0.00 $0.00 $0.0043101 C $0.00 $0.00 $0.0043107 C $0.00 $0.00 $0.0043108 C $0.00 $0.00 $0.0043112 C $0.00 $0.00 $0.0043113 C $0.00 $0.00 $0.0043116 C $0.00 $0.00 $0.0043117 C $0.00 $0.00 $0.0043118 C $0.00 $0.00 $0.0043121 C $0.00 $0.00 $0.0043122 C $0.00 $0.00 $0.0043123 C $0.00 $0.00 $0.0043124 C $0.00 $0.00 $0.0043130 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 43135 C $0.00 $0.00 $0.0043180 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 43191 T 0141 10.0522 $1,089.86 $1,332.22 $817.44 43192 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43193 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43194 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43195 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43196 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43197 T 0141 10.0522 $1,089.86 $1,332.22 $817.44 43198 T 0141 10.0522 $1,089.86 $1,332.22 $817.44 43200 T 0141 10.0522 $1,089.86 $1,332.22 $817.44 43201 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43202 T 0141 10.0522 $1,089.86 $1,332.22 $817.44 43204 T 0141 10.0522 $1,089.86 $1,332.22 $817.44 43205 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43206 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 4320F E $0.00 $0.00 $0.0043211 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43212 J1 0384 42.8063 $4,641.06 $5,673.12 $3,481.01 43213 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43214 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43215 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43216 T 0422 25.8201 $2,799.42 $3,421.94 $2,099.69


86


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee43217 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43220 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43226 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43227 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43229 T 0422 25.8201 $2,799.42 $3,421.94 $2,099.69 4322F M $0.00 $0.00 $0.0043231 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43232 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43233 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43235 T 0141 10.0522 $1,089.86 $1,332.22 $817.44 43236 T 0141 10.0522 $1,089.86 $1,332.22 $817.44 43237 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43238 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43239 T 0141 10.0522 $1,089.86 $1,332.22 $817.44 43240 T 0422 25.8201 $2,799.42 $3,421.94 $2,099.69 43241 T 0141 10.0522 $1,089.86 $1,332.22 $817.44 43242 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43243 T 0141 10.0522 $1,089.86 $1,332.22 $817.44 43244 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43245 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43246 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43247 T 0141 10.0522 $1,089.86 $1,332.22 $817.44 43248 T 0141 10.0522 $1,089.86 $1,332.22 $817.44 43249 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 4324F E $0.00 $0.00 $0.0043250 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43251 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43252 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43253 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43254 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43255 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43257 T 0422 25.8201 $2,799.42 $3,421.94 $2,099.69 43259 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 4325F M $0.00 $0.00 $0.0043260 T 0151 26.3312 $2,854.83 $3,489.67 $2,141.25 43261 T 0151 26.3312 $2,854.83 $3,489.67 $2,141.25 43262 T 0151 26.3312 $2,854.83 $3,489.67 $2,141.25 43263 T 0151 26.3312 $2,854.83 $3,489.67 $2,141.25 43264 T 0151 26.3312 $2,854.83 $3,489.67 $2,141.25 43265 T 0151 26.3312 $2,854.83 $3,489.67 $2,141.25 43266 J1 0384 42.8063 $4,641.06 $5,673.12 $3,481.01 4326F E $0.00 $0.00 $0.0043270 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43273 N $0.00 $0.00 $0.00 43274 J1 0384 42.8063 $4,641.06 $5,673.12 $3,481.01 43275 T 0151 26.3312 $2,854.83 $3,489.67 $2,141.25 43276 J1 0384 42.8063 $4,641.06 $5,673.12 $3,481.01 43277 T 0151 26.3312 $2,854.83 $3,489.67 $2,141.25 43278 T 0151 26.3312 $2,854.83 $3,489.67 $2,141.25 43279 C $0.00 $0.00 $0.0043280 T 0132 73.8696 $8,008.94 $9,789.94 $6,007.08


87


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee43281 T 0132 73.8696 $8,008.94 $9,789.94 $6,007.08 43282 C $0.00 $0.00 $0.0043283 C $0.00 $0.00 $0.0043289 T 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 4328F M $0.00 $0.00 $0.0043300 C $0.00 $0.00 $0.0043305 C $0.00 $0.00 $0.004330F E $0.00 $0.00 $0.0043310 C $0.00 $0.00 $0.0043312 C $0.00 $0.00 $0.0043313 C $0.00 $0.00 $0.0043314 C $0.00 $0.00 $0.0043320 C $0.00 $0.00 $0.0043325 C $0.00 $0.00 $0.0043327 C $0.00 $0.00 $0.0043328 C $0.00 $0.00 $0.0043330 C $0.00 $0.00 $0.0043331 C $0.00 $0.00 $0.0043332 C $0.00 $0.00 $0.0043333 C $0.00 $0.00 $0.0043334 C $0.00 $0.00 $0.0043335 C $0.00 $0.00 $0.0043336 C $0.00 $0.00 $0.0043337 C $0.00 $0.00 $0.0043338 C $0.00 $0.00 $0.0043340 C $0.00 $0.00 $0.0043341 C $0.00 $0.00 $0.0043351 C $0.00 $0.00 $0.0043352 C $0.00 $0.00 $0.0043360 C $0.00 $0.00 $0.0043361 C $0.00 $0.00 $0.0043400 C $0.00 $0.00 $0.0043401 C $0.00 $0.00 $0.0043405 C $0.00 $0.00 $0.004340F M $0.00 $0.00 $0.0043410 C $0.00 $0.00 $0.0043415 C $0.00 $0.00 $0.0043420 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 43425 C $0.00 $0.00 $0.0043450 T 0141 10.0522 $1,089.86 $1,332.22 $817.44 43453 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 43460 C $0.00 $0.00 $0.0043496 C $0.00 $0.00 $0.0043499 T 0141 10.0522 $1,089.86 $1,332.22 $817.44 43500 C $0.00 $0.00 $0.0043501 C $0.00 $0.00 $0.0043502 C $0.00 $0.00 $0.004350F E $0.00 $0.00 $0.0043510 T 0141 10.0522 $1,089.86 $1,332.22 $817.44 43520 C $0.00 $0.00 $0.0043605 C $0.00 $0.00 $0.00


88


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee43610 C $0.00 $0.00 $0.0043611 C $0.00 $0.00 $0.0043620 C $0.00 $0.00 $0.0043621 C $0.00 $0.00 $0.0043622 C $0.00 $0.00 $0.0043631 C $0.00 $0.00 $0.0043632 C $0.00 $0.00 $0.0043633 C $0.00 $0.00 $0.0043634 C $0.00 $0.00 $0.0043635 C $0.00 $0.00 $0.0043640 C $0.00 $0.00 $0.0043641 C $0.00 $0.00 $0.0043644 C $0.00 $0.00 $0.0043645 C $0.00 $0.00 $0.0043647 J1 0061 71.3285 $7,733.44 $9,453.17 $5,800.43 43648 Q2 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 43651 T 0132 73.8696 $8,008.94 $9,789.94 $6,007.08 43652 T 0132 73.8696 $8,008.94 $9,789.94 $6,007.08 43653 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 43659 T 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 43752 Q3 0277 2.0357 $220.71 $269.79 $165.54 43753 Q1 0420 1.7762 $192.58 $235.40 $144.44 43754 Q1 0420 1.7762 $192.58 $235.40 $144.44 43755 S 0096 4.4459 $482.02 $589.22 $361.54 43756 S 0272 2.1508 $233.19 $285.05 $174.90 43757 S 0272 2.1508 $233.19 $285.05 $174.90 43760 T 0676 2.6317 $285.33 $348.78 $214.01 43761 T 0141 10.0522 $1,089.86 $1,332.22 $817.44 43770 T 0132 73.8696 $8,008.94 $9,789.94 $6,007.08 43771 C $0.00 $0.00 $0.0043772 C $0.00 $0.00 $0.0043773 C $0.00 $0.00 $0.0043774 C $0.00 $0.00 $0.0043775 C $0.00 $0.00 $0.0043800 C $0.00 $0.00 $0.0043810 C $0.00 $0.00 $0.0043820 C $0.00 $0.00 $0.0043825 C $0.00 $0.00 $0.0043830 T 0422 25.8201 $2,799.42 $3,421.94 $2,099.69 43831 T 0141 10.0522 $1,089.86 $1,332.22 $817.44 43832 C $0.00 $0.00 $0.0043840 C $0.00 $0.00 $0.0043842 E $0.00 $0.00 $0.0043843 C $0.00 $0.00 $0.0043845 C $0.00 $0.00 $0.0043846 C $0.00 $0.00 $0.0043847 C $0.00 $0.00 $0.0043848 C $0.00 $0.00 $0.0043850 C $0.00 $0.00 $0.0043855 C $0.00 $0.00 $0.0043860 C $0.00 $0.00 $0.00


89


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee43865 C $0.00 $0.00 $0.0043870 T 0422 25.8201 $2,799.42 $3,421.94 $2,099.69 43880 C $0.00 $0.00 $0.0043881 C $0.00 $0.00 $0.0043882 C $0.00 $0.00 $0.0043886 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 43887 Q2 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 43888 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 43999 T 0141 10.0522 $1,089.86 $1,332.22 $817.44 44005 C $0.00 $0.00 $0.004400F M $0.00 $0.00 $0.0044010 C $0.00 $0.00 $0.0044015 C $0.00 $0.00 $0.0044020 C $0.00 $0.00 $0.0044021 C $0.00 $0.00 $0.0044025 C $0.00 $0.00 $0.0044050 C $0.00 $0.00 $0.0044055 C $0.00 $0.00 $0.0044100 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 44110 C $0.00 $0.00 $0.0044111 C $0.00 $0.00 $0.0044120 C $0.00 $0.00 $0.0044121 C $0.00 $0.00 $0.0044125 C $0.00 $0.00 $0.0044126 C $0.00 $0.00 $0.0044127 C $0.00 $0.00 $0.0044128 C $0.00 $0.00 $0.0044130 C $0.00 $0.00 $0.0044132 C $0.00 $0.00 $0.0044133 C $0.00 $0.00 $0.0044135 C $0.00 $0.00 $0.0044136 C $0.00 $0.00 $0.0044137 C $0.00 $0.00 $0.0044139 C $0.00 $0.00 $0.0044140 C $0.00 $0.00 $0.0044141 C $0.00 $0.00 $0.0044143 C $0.00 $0.00 $0.0044144 C $0.00 $0.00 $0.0044145 C $0.00 $0.00 $0.0044146 C $0.00 $0.00 $0.0044147 C $0.00 $0.00 $0.0044150 C $0.00 $0.00 $0.0044151 C $0.00 $0.00 $0.0044155 C $0.00 $0.00 $0.0044156 C $0.00 $0.00 $0.0044157 C $0.00 $0.00 $0.0044158 C $0.00 $0.00 $0.0044160 C $0.00 $0.00 $0.0044180 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 44186 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 44187 C $0.00 $0.00 $0.00


90


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee44188 C $0.00 $0.00 $0.0044202 C $0.00 $0.00 $0.0044203 C $0.00 $0.00 $0.0044204 C $0.00 $0.00 $0.0044205 C $0.00 $0.00 $0.0044206 C $0.00 $0.00 $0.0044207 C $0.00 $0.00 $0.0044208 C $0.00 $0.00 $0.0044210 C $0.00 $0.00 $0.0044211 C $0.00 $0.00 $0.0044212 C $0.00 $0.00 $0.0044213 C $0.00 $0.00 $0.0044227 C $0.00 $0.00 $0.0044238 T 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 44300 C $0.00 $0.00 $0.0044310 C $0.00 $0.00 $0.0044312 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 44314 C $0.00 $0.00 $0.0044316 C $0.00 $0.00 $0.0044320 C $0.00 $0.00 $0.0044322 C $0.00 $0.00 $0.0044340 T 0329 31.0293 $3,364.20 $4,112.31 $2,523.30 44345 C $0.00 $0.00 $0.0044346 C $0.00 $0.00 $0.0044360 T 0142 11.4924 $1,246.01 $1,523.09 $934.56 44361 T 0142 11.4924 $1,246.01 $1,523.09 $934.56 44363 T 0142 11.4924 $1,246.01 $1,523.09 $934.56 44364 T 0424 16.8444 $1,826.27 $2,232.39 $1,369.79 44365 T 0424 16.8444 $1,826.27 $2,232.39 $1,369.79 44366 T 0424 16.8444 $1,826.27 $2,232.39 $1,369.79 44369 T 0424 16.8444 $1,826.27 $2,232.39 $1,369.79 44370 J1 0384 42.8063 $4,641.06 $5,673.12 $3,481.01 44372 T 0424 16.8444 $1,826.27 $2,232.39 $1,369.79 44373 T 0424 16.8444 $1,826.27 $2,232.39 $1,369.79 44376 T 0142 11.4924 $1,246.01 $1,523.09 $934.56 44377 T 0424 16.8444 $1,826.27 $2,232.39 $1,369.79 44378 T 0424 16.8444 $1,826.27 $2,232.39 $1,369.79 44379 J1 0384 42.8063 $4,641.06 $5,673.12 $3,481.01 44380 T 0142 11.4924 $1,246.01 $1,523.09 $934.56 44381 T 0142 11.4924 $1,246.01 $1,523.09 $934.56 44382 T 0142 11.4924 $1,246.01 $1,523.09 $934.56 44384 T 0142 11.4924 $1,246.01 $1,523.09 $934.56 44385 T 0143 10.6489 $1,154.55 $1,411.30 $865.97 44386 T 0143 10.6489 $1,154.55 $1,411.30 $865.97 44388 T 0143 10.6489 $1,154.55 $1,411.30 $865.97 44389 T 0143 10.6489 $1,154.55 $1,411.30 $865.97 44390 T 0143 10.6489 $1,154.55 $1,411.30 $865.97 44391 T 0143 10.6489 $1,154.55 $1,411.30 $865.97 44392 T 0143 10.6489 $1,154.55 $1,411.30 $865.97 44394 T 0143 10.6489 $1,154.55 $1,411.30 $865.97 44401 T 0143 10.6489 $1,154.55 $1,411.30 $865.97


91


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee44402 T 0143 10.6489 $1,154.55 $1,411.30 $865.97 44403 T 0143 10.6489 $1,154.55 $1,411.30 $865.97 44404 T 0143 10.6489 $1,154.55 $1,411.30 $865.97 44405 T 0143 10.6489 $1,154.55 $1,411.30 $865.97 44406 T 0143 10.6489 $1,154.55 $1,411.30 $865.97 44407 T 0143 10.6489 $1,154.55 $1,411.30 $865.97 44408 T 0143 10.6489 $1,154.55 $1,411.30 $865.97 44500 T 0121 6.58 $713.40 $872.05 $535.09 4450F E $0.00 $0.00 $0.0044602 C $0.00 $0.00 $0.0044603 C $0.00 $0.00 $0.0044604 C $0.00 $0.00 $0.0044605 C $0.00 $0.00 $0.0044615 C $0.00 $0.00 $0.0044620 C $0.00 $0.00 $0.0044625 C $0.00 $0.00 $0.0044626 C $0.00 $0.00 $0.0044640 C $0.00 $0.00 $0.0044650 C $0.00 $0.00 $0.0044660 C $0.00 $0.00 $0.0044661 C $0.00 $0.00 $0.0044680 C $0.00 $0.00 $0.0044700 C $0.00 $0.00 $0.0044701 N $0.00 $0.00 $0.00 44705 B $0.00 $0.00 $0.004470F E $0.00 $0.00 $0.0044715 C $0.00 $0.00 $0.0044720 C $0.00 $0.00 $0.0044721 C $0.00 $0.00 $0.0044799 T 0153 30.8186 $3,341.35 $4,084.39 $2,506.17 44800 C $0.00 $0.00 $0.004480F E $0.00 $0.00 $0.004481F E $0.00 $0.00 $0.0044820 C $0.00 $0.00 $0.0044850 C $0.00 $0.00 $0.0044899 C $0.00 $0.00 $0.0044900 C $0.00 $0.00 $0.0044950 T 0153 30.8186 $3,341.35 $4,084.39 $2,506.17 44955 N $0.00 $0.00 $0.00 44960 C $0.00 $0.00 $0.0044970 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 44979 T 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 45000 T 0149 26.1743 $2,837.82 $3,468.88 $2,128.49 45005 T 0155 19.6184 $2,127.03 $2,600.03 $1,595.37 4500F M $0.00 $0.00 $0.0045020 T 0155 19.6184 $2,127.03 $2,600.03 $1,595.37 45100 T 0155 19.6184 $2,127.03 $2,600.03 $1,595.37 45108 T 0149 26.1743 $2,837.82 $3,468.88 $2,128.49 4510F M $0.00 $0.00 $0.0045110 C $0.00 $0.00 $0.0045111 C $0.00 $0.00 $0.00


92


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee45112 C $0.00 $0.00 $0.0045113 C $0.00 $0.00 $0.0045114 C $0.00 $0.00 $0.0045116 C $0.00 $0.00 $0.0045119 C $0.00 $0.00 $0.0045120 C $0.00 $0.00 $0.0045121 C $0.00 $0.00 $0.0045123 C $0.00 $0.00 $0.0045126 C $0.00 $0.00 $0.0045130 C $0.00 $0.00 $0.0045135 C $0.00 $0.00 $0.0045136 C $0.00 $0.00 $0.0045150 T 0149 26.1743 $2,837.82 $3,468.88 $2,128.49 45160 T 0149 26.1743 $2,837.82 $3,468.88 $2,128.49 45171 T 0149 26.1743 $2,837.82 $3,468.88 $2,128.49 45172 T 0150 35.0675 $3,802.02 $4,647.50 $2,851.69 45190 T 0149 26.1743 $2,837.82 $3,468.88 $2,128.49 4525F M $0.00 $0.00 $0.004526F M $0.00 $0.00 $0.0045300 T 0146 6.6559 $721.63 $882.11 $541.26 45303 T 0147 11.1553 $1,209.46 $1,478.41 $907.15 45305 T 0147 11.1553 $1,209.46 $1,478.41 $907.15 45307 T 0428 22.3487 $2,423.05 $2,961.87 $1,817.40 45308 T 0147 11.1553 $1,209.46 $1,478.41 $907.15 45309 T 0147 11.1553 $1,209.46 $1,478.41 $907.15 45315 T 0147 11.1553 $1,209.46 $1,478.41 $907.15 45317 T 0147 11.1553 $1,209.46 $1,478.41 $907.15 45320 T 0428 22.3487 $2,423.05 $2,961.87 $1,817.40 45321 T 0428 22.3487 $2,423.05 $2,961.87 $1,817.40 45327 J1 0384 42.8063 $4,641.06 $5,673.12 $3,481.01 45330 T 0146 6.6559 $721.63 $882.11 $541.26 45331 T 0146 6.6559 $721.63 $882.11 $541.26 45332 T 0147 11.1553 $1,209.46 $1,478.41 $907.15 45333 T 0146 6.6559 $721.63 $882.11 $541.26 45334 T 0147 11.1553 $1,209.46 $1,478.41 $907.15 45335 T 0146 6.6559 $721.63 $882.11 $541.26 45337 T 0147 11.1553 $1,209.46 $1,478.41 $907.15 45338 T 0147 11.1553 $1,209.46 $1,478.41 $907.15 45340 T 0147 11.1553 $1,209.46 $1,478.41 $907.15 45341 T 0147 11.1553 $1,209.46 $1,478.41 $907.15 45342 T 0147 11.1553 $1,209.46 $1,478.41 $907.15 45346 T 0147 11.1553 $1,209.46 $1,478.41 $907.15 45347 T 0147 11.1553 $1,209.46 $1,478.41 $907.15 45349 T 0147 11.1553 $1,209.46 $1,478.41 $907.15 45350 T 0147 11.1553 $1,209.46 $1,478.41 $907.15 45378 T 0143 10.6489 $1,154.55 $1,411.30 $865.97 45379 T 0143 10.6489 $1,154.55 $1,411.30 $865.97 45380 T 0143 10.6489 $1,154.55 $1,411.30 $865.97 45381 T 0143 10.6489 $1,154.55 $1,411.30 $865.97 45382 T 0143 10.6489 $1,154.55 $1,411.30 $865.97 45384 T 0143 10.6489 $1,154.55 $1,411.30 $865.97


93


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee45385 T 0143 10.6489 $1,154.55 $1,411.30 $865.97 45386 T 0143 10.6489 $1,154.55 $1,411.30 $865.97 45388 T 0143 10.6489 $1,154.55 $1,411.30 $865.97 45389 T 0143 10.6489 $1,154.55 $1,411.30 $865.97 45390 T 0143 10.6489 $1,154.55 $1,411.30 $865.97 45391 T 0143 10.6489 $1,154.55 $1,411.30 $865.97 45392 T 0143 10.6489 $1,154.55 $1,411.30 $865.97 45393 T 0143 10.6489 $1,154.55 $1,411.30 $865.97 45395 C $0.00 $0.00 $0.0045397 C $0.00 $0.00 $0.0045398 T 0143 10.6489 $1,154.55 $1,411.30 $865.97 45399 T 0143 10.6489 $1,154.55 $1,411.30 $865.97 45400 C $0.00 $0.00 $0.0045402 C $0.00 $0.00 $0.004540F E $0.00 $0.00 $0.004541F E $0.00 $0.00 $0.0045499 T 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 45500 T 0149 26.1743 $2,837.82 $3,468.88 $2,128.49 45505 T 0150 35.0675 $3,802.02 $4,647.50 $2,851.69 4550F E $0.00 $0.00 $0.004551F E $0.00 $0.00 $0.0045520 T 0015 1.9702 $213.61 $261.11 $160.22 4552F E $0.00 $0.00 $0.004553F E $0.00 $0.00 $0.0045540 C $0.00 $0.00 $0.0045541 T 0150 35.0675 $3,802.02 $4,647.50 $2,851.69 4554F E $0.00 $0.00 $0.0045550 C $0.00 $0.00 $0.004555F E $0.00 $0.00 $0.0045560 T 0150 35.0675 $3,802.02 $4,647.50 $2,851.69 45562 C $0.00 $0.00 $0.0045563 C $0.00 $0.00 $0.004556F E $0.00 $0.00 $0.004557F E $0.00 $0.00 $0.004558F E $0.00 $0.00 $0.004559F E $0.00 $0.00 $0.004560F E $0.00 $0.00 $0.004561F E $0.00 $0.00 $0.004562F E $0.00 $0.00 $0.004563F E $0.00 $0.00 $0.0045800 C $0.00 $0.00 $0.0045805 C $0.00 $0.00 $0.0045820 C $0.00 $0.00 $0.0045825 C $0.00 $0.00 $0.0045900 T 0148 5.9659 $646.82 $790.66 $485.15 45905 T 0155 19.6184 $2,127.03 $2,600.03 $1,595.37 45910 T 0155 19.6184 $2,127.03 $2,600.03 $1,595.37 45915 T 0155 19.6184 $2,127.03 $2,600.03 $1,595.37 45990 T 0155 19.6184 $2,127.03 $2,600.03 $1,595.37 45999 T 0148 5.9659 $646.82 $790.66 $485.15 46020 T 0149 26.1743 $2,837.82 $3,468.88 $2,128.49


94


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee46030 T 0148 5.9659 $646.82 $790.66 $485.15 46040 T 0155 19.6184 $2,127.03 $2,600.03 $1,595.37 46045 T 0149 26.1743 $2,837.82 $3,468.88 $2,128.49 46050 T 0148 5.9659 $646.82 $790.66 $485.15 46060 T 0155 19.6184 $2,127.03 $2,600.03 $1,595.37 46070 T 0155 19.6184 $2,127.03 $2,600.03 $1,595.37 46080 T 0155 19.6184 $2,127.03 $2,600.03 $1,595.37 46083 T 0164 2.8822 $312.49 $381.98 $234.38 46200 T 0149 26.1743 $2,837.82 $3,468.88 $2,128.49 46220 T 0155 19.6184 $2,127.03 $2,600.03 $1,595.37 46221 T 0148 5.9659 $646.82 $790.66 $485.15 46230 T 0155 19.6184 $2,127.03 $2,600.03 $1,595.37 46250 T 0149 26.1743 $2,837.82 $3,468.88 $2,128.49 46255 T 0149 26.1743 $2,837.82 $3,468.88 $2,128.49 46257 T 0149 26.1743 $2,837.82 $3,468.88 $2,128.49 46258 T 0149 26.1743 $2,837.82 $3,468.88 $2,128.49 46260 T 0149 26.1743 $2,837.82 $3,468.88 $2,128.49 46261 T 0149 26.1743 $2,837.82 $3,468.88 $2,128.49 46262 T 0149 26.1743 $2,837.82 $3,468.88 $2,128.49 46270 T 0149 26.1743 $2,837.82 $3,468.88 $2,128.49 46275 T 0149 26.1743 $2,837.82 $3,468.88 $2,128.49 46280 T 0149 26.1743 $2,837.82 $3,468.88 $2,128.49 46285 T 0149 26.1743 $2,837.82 $3,468.88 $2,128.49 46288 T 0150 35.0675 $3,802.02 $4,647.50 $2,851.69 46320 T 0155 19.6184 $2,127.03 $2,600.03 $1,595.37 46500 T 0148 5.9659 $646.82 $790.66 $485.15 46505 T 0155 19.6184 $2,127.03 $2,600.03 $1,595.37 46600 Q1 0420 1.7762 $192.58 $235.40 $144.44 46601 Q1 0420 1.7762 $192.58 $235.40 $144.44 46604 T 0147 11.1553 $1,209.46 $1,478.41 $907.15 46606 T 0147 11.1553 $1,209.46 $1,478.41 $907.15 46607 T 0147 11.1553 $1,209.46 $1,478.41 $907.15 46608 T 0147 11.1553 $1,209.46 $1,478.41 $907.15 46610 T 0428 22.3487 $2,423.05 $2,961.87 $1,817.40 46611 T 0147 11.1553 $1,209.46 $1,478.41 $907.15 46612 T 0428 22.3487 $2,423.05 $2,961.87 $1,817.40 46614 T 0147 11.1553 $1,209.46 $1,478.41 $907.15 46615 T 0428 22.3487 $2,423.05 $2,961.87 $1,817.40 46700 T 0149 26.1743 $2,837.82 $3,468.88 $2,128.49 46705 C $0.00 $0.00 $0.0046706 T 0149 26.1743 $2,837.82 $3,468.88 $2,128.49 46707 T 0150 35.0675 $3,802.02 $4,647.50 $2,851.69 46710 C $0.00 $0.00 $0.0046712 C $0.00 $0.00 $0.0046715 C $0.00 $0.00 $0.0046716 C $0.00 $0.00 $0.0046730 C $0.00 $0.00 $0.0046735 C $0.00 $0.00 $0.0046740 C $0.00 $0.00 $0.0046742 C $0.00 $0.00 $0.0046744 C $0.00 $0.00 $0.00


95


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee46746 C $0.00 $0.00 $0.0046748 C $0.00 $0.00 $0.0046750 T 0150 35.0675 $3,802.02 $4,647.50 $2,851.69 46751 C $0.00 $0.00 $0.0046753 T 0149 26.1743 $2,837.82 $3,468.88 $2,128.49 46754 T 0155 19.6184 $2,127.03 $2,600.03 $1,595.37 46760 T 0150 35.0675 $3,802.02 $4,647.50 $2,851.69 46761 T 0150 35.0675 $3,802.02 $4,647.50 $2,851.69 46762 T 0150 35.0675 $3,802.02 $4,647.50 $2,851.69 46900 T 0016 3.8173 $413.87 $505.91 $310.42 46910 T 0017 17.361 $1,882.28 $2,300.85 $1,411.80 46916 T 0015 1.9702 $213.61 $261.11 $160.22 46917 T 0149 26.1743 $2,837.82 $3,468.88 $2,128.49 46922 T 0149 26.1743 $2,837.82 $3,468.88 $2,128.49 46924 T 0149 26.1743 $2,837.82 $3,468.88 $2,128.49 46930 T 0148 5.9659 $646.82 $790.66 $485.15 46940 T 0155 19.6184 $2,127.03 $2,600.03 $1,595.37 46942 T 0148 5.9659 $646.82 $790.66 $485.15 46945 T 0149 26.1743 $2,837.82 $3,468.88 $2,128.49 46946 T 0149 26.1743 $2,837.82 $3,468.88 $2,128.49 46947 T 0150 35.0675 $3,802.02 $4,647.50 $2,851.69 46999 T 0148 5.9659 $646.82 $790.66 $485.15 47000 T 0005 14.1916 $1,538.65 $1,880.81 $1,154.06 47001 N $0.00 $0.00 $0.00 47010 C $0.00 $0.00 $0.0047015 C $0.00 $0.00 $0.0047100 C $0.00 $0.00 $0.0047120 C $0.00 $0.00 $0.0047122 C $0.00 $0.00 $0.0047125 C $0.00 $0.00 $0.0047130 C $0.00 $0.00 $0.0047133 C $0.00 $0.00 $0.0047135 C $0.00 $0.00 $0.0047136 C $0.00 $0.00 $0.0047140 C $0.00 $0.00 $0.0047141 C $0.00 $0.00 $0.0047142 C $0.00 $0.00 $0.0047143 C $0.00 $0.00 $0.0047144 C $0.00 $0.00 $0.0047145 C $0.00 $0.00 $0.0047146 C $0.00 $0.00 $0.0047147 C $0.00 $0.00 $0.0047300 C $0.00 $0.00 $0.0047350 C $0.00 $0.00 $0.0047360 C $0.00 $0.00 $0.0047361 C $0.00 $0.00 $0.0047362 C $0.00 $0.00 $0.0047370 T 0174 108.7985 $11,795.93 $14,419.07 $8,847.49 47371 T 0174 108.7985 $11,795.93 $14,419.07 $8,847.49 47379 T 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 47380 C $0.00 $0.00 $0.00


96


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee47381 C $0.00 $0.00 $0.0047382 T 0423 55.2208 $5,987.04 $7,318.41 $4,490.56 47383 T 0423 55.2208 $5,987.04 $7,318.41 $4,490.56 47399 T 0004 6.5703 $712.35 $870.76 $534.30 47400 C $0.00 $0.00 $0.0047420 C $0.00 $0.00 $0.0047425 C $0.00 $0.00 $0.0047460 C $0.00 $0.00 $0.0047480 C $0.00 $0.00 $0.0047490 T 0152 24.7191 $2,680.04 $3,276.02 $2,010.16 47500 N $0.00 $0.00 $0.00 47505 N $0.00 $0.00 $0.00 47510 T 0152 24.7191 $2,680.04 $3,276.02 $2,010.16 47511 T 0423 55.2208 $5,987.04 $7,318.41 $4,490.56 47525 T 0427 17.3792 $1,884.25 $2,303.27 $1,413.28 47530 T 0427 17.3792 $1,884.25 $2,303.27 $1,413.28 47550 C $0.00 $0.00 $0.0047552 T 0152 24.7191 $2,680.04 $3,276.02 $2,010.16 47553 T 0423 55.2208 $5,987.04 $7,318.41 $4,490.56 47554 T 0152 24.7191 $2,680.04 $3,276.02 $2,010.16 47555 T 0152 24.7191 $2,680.04 $3,276.02 $2,010.16 47556 T 0423 55.2208 $5,987.04 $7,318.41 $4,490.56 47560 T 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 47561 T 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 47562 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 47563 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 47564 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 47570 C $0.00 $0.00 $0.0047579 T 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 47600 C $0.00 $0.00 $0.0047605 C $0.00 $0.00 $0.0047610 C $0.00 $0.00 $0.0047612 C $0.00 $0.00 $0.0047620 C $0.00 $0.00 $0.0047630 T 0152 24.7191 $2,680.04 $3,276.02 $2,010.16 47700 C $0.00 $0.00 $0.0047701 C $0.00 $0.00 $0.0047711 C $0.00 $0.00 $0.0047712 C $0.00 $0.00 $0.0047715 C $0.00 $0.00 $0.0047720 C $0.00 $0.00 $0.0047721 C $0.00 $0.00 $0.0047740 C $0.00 $0.00 $0.0047741 C $0.00 $0.00 $0.0047760 C $0.00 $0.00 $0.0047765 C $0.00 $0.00 $0.0047780 C $0.00 $0.00 $0.0047785 C $0.00 $0.00 $0.0047800 C $0.00 $0.00 $0.0047801 C $0.00 $0.00 $0.0047802 C $0.00 $0.00 $0.00


97


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee47900 C $0.00 $0.00 $0.0047999 T 0152 24.7191 $2,680.04 $3,276.02 $2,010.16 48000 C $0.00 $0.00 $0.0048001 C $0.00 $0.00 $0.0048020 C $0.00 $0.00 $0.0048100 C $0.00 $0.00 $0.0048102 T 0005 14.1916 $1,538.65 $1,880.81 $1,154.06 48105 C $0.00 $0.00 $0.0048120 C $0.00 $0.00 $0.0048140 C $0.00 $0.00 $0.0048145 C $0.00 $0.00 $0.0048146 C $0.00 $0.00 $0.0048148 C $0.00 $0.00 $0.0048150 C $0.00 $0.00 $0.0048152 C $0.00 $0.00 $0.0048153 C $0.00 $0.00 $0.0048154 C $0.00 $0.00 $0.0048155 C $0.00 $0.00 $0.0048160 E $0.00 $0.00 $0.0048400 C $0.00 $0.00 $0.0048500 C $0.00 $0.00 $0.0048510 C $0.00 $0.00 $0.0048520 C $0.00 $0.00 $0.0048540 C $0.00 $0.00 $0.0048545 C $0.00 $0.00 $0.0048547 C $0.00 $0.00 $0.0048548 C $0.00 $0.00 $0.0048550 E $0.00 $0.00 $0.0048551 C $0.00 $0.00 $0.0048552 C $0.00 $0.00 $0.0048554 C $0.00 $0.00 $0.0048556 C $0.00 $0.00 $0.0048999 T 0004 6.5703 $712.35 $870.76 $534.30 49000 C $0.00 $0.00 $0.0049002 C $0.00 $0.00 $0.0049010 C $0.00 $0.00 $0.0049020 C $0.00 $0.00 $0.0049040 C $0.00 $0.00 $0.0049060 C $0.00 $0.00 $0.0049062 C $0.00 $0.00 $0.0049082 T 0070 6.5974 $715.29 $874.35 $536.50 49083 T 0070 6.5974 $715.29 $874.35 $536.50 49084 T 0070 6.5974 $715.29 $874.35 $536.50 49180 T 0005 14.1916 $1,538.65 $1,880.81 $1,154.06 49203 C $0.00 $0.00 $0.0049204 C $0.00 $0.00 $0.0049205 C $0.00 $0.00 $0.0049215 C $0.00 $0.00 $0.0049220 C $0.00 $0.00 $0.0049250 T 0153 30.8186 $3,341.35 $4,084.39 $2,506.17 49255 C $0.00 $0.00 $0.00


98


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee49320 T 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 49321 T 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 49322 T 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 49323 T 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 49324 T 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 49325 T 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 49326 N $0.00 $0.00 $0.00 49327 N $0.00 $0.00 $0.00 49329 T 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 49400 N $0.00 $0.00 $0.00 49402 T 0153 30.8186 $3,341.35 $4,084.39 $2,506.17 49405 T 0005 14.1916 $1,538.65 $1,880.81 $1,154.06 49406 T 0005 14.1916 $1,538.65 $1,880.81 $1,154.06 49407 T 0005 14.1916 $1,538.65 $1,880.81 $1,154.06 49411 S 0310 14.0014 $1,518.03 $1,855.61 $1,138.59 49412 C $0.00 $0.00 $0.0049418 T 0652 30.85 $3,344.76 $4,088.55 $2,508.72 49419 T 0622 30.1495 $3,268.81 $3,995.71 $2,451.76 49421 T 0652 30.85 $3,344.76 $4,088.55 $2,508.72 49422 Q2 0103 21.2483 $2,303.74 $2,816.04 $1,727.91 49423 T 0427 17.3792 $1,884.25 $2,303.27 $1,413.28 49424 N $0.00 $0.00 $0.00 49425 C $0.00 $0.00 $0.0049426 T 0153 30.8186 $3,341.35 $4,084.39 $2,506.17 49427 N $0.00 $0.00 $0.00 49428 C $0.00 $0.00 $0.0049429 Q2 0103 21.2483 $2,303.74 $2,816.04 $1,727.91 49435 N $0.00 $0.00 $0.00 49436 T 0427 17.3792 $1,884.25 $2,303.27 $1,413.28 49440 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 49441 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 49442 T 0155 19.6184 $2,127.03 $2,600.03 $1,595.37 49446 T 0419 14.3565 $1,556.53 $1,902.67 $1,167.47 49450 T 0121 6.58 $713.40 $872.05 $535.09 49451 T 0121 6.58 $713.40 $872.05 $535.09 49452 T 0121 6.58 $713.40 $872.05 $535.09 49460 T 0121 6.58 $713.40 $872.05 $535.09 49465 S 0277 2.0357 $220.71 $269.79 $165.54 49491 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 49492 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 49495 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 49496 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 49500 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 49501 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 49505 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 49507 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 49520 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 49521 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 49525 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 49540 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 49550 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22


99


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee49553 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 49555 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 49557 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 49560 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 49561 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 49565 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 49566 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 49568 N $0.00 $0.00 $0.00 49570 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 49572 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 49580 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 49582 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 49585 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 49587 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 49590 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 49600 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 49605 C $0.00 $0.00 $0.0049606 C $0.00 $0.00 $0.0049610 C $0.00 $0.00 $0.0049611 C $0.00 $0.00 $0.0049650 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 49651 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 49652 T 0132 73.8696 $8,008.94 $9,789.94 $6,007.08 49653 T 0132 73.8696 $8,008.94 $9,789.94 $6,007.08 49654 T 0132 73.8696 $8,008.94 $9,789.94 $6,007.08 49655 T 0132 73.8696 $8,008.94 $9,789.94 $6,007.08 49656 T 0132 73.8696 $8,008.94 $9,789.94 $6,007.08 49657 T 0132 73.8696 $8,008.94 $9,789.94 $6,007.08 49659 T 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 49900 C $0.00 $0.00 $0.0049904 C $0.00 $0.00 $0.0049905 C $0.00 $0.00 $0.0049906 C $0.00 $0.00 $0.0049999 T 0153 30.8186 $3,341.35 $4,084.39 $2,506.17 50010 C $0.00 $0.00 $0.0050020 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 50040 C $0.00 $0.00 $0.0050045 C $0.00 $0.00 $0.005005F E $0.00 $0.00 $0.0050060 C $0.00 $0.00 $0.0050065 C $0.00 $0.00 $0.0050070 C $0.00 $0.00 $0.0050075 C $0.00 $0.00 $0.0050080 T 0163 41.9797 $4,551.44 $5,563.57 $3,413.79 50081 T 0163 41.9797 $4,551.44 $5,563.57 $3,413.79 50100 C $0.00 $0.00 $0.005010F M $0.00 $0.00 $0.0050120 C $0.00 $0.00 $0.0050125 C $0.00 $0.00 $0.0050130 C $0.00 $0.00 $0.0050135 C $0.00 $0.00 $0.00


100


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee5015F M $0.00 $0.00 $0.0050200 T 0005 14.1916 $1,538.65 $1,880.81 $1,154.06 50205 C $0.00 $0.00 $0.005020F E $0.00 $0.00 $0.0050220 C $0.00 $0.00 $0.0050225 C $0.00 $0.00 $0.0050230 C $0.00 $0.00 $0.0050234 C $0.00 $0.00 $0.0050236 C $0.00 $0.00 $0.0050240 C $0.00 $0.00 $0.0050250 C $0.00 $0.00 $0.0050280 C $0.00 $0.00 $0.0050290 C $0.00 $0.00 $0.0050300 C $0.00 $0.00 $0.0050320 C $0.00 $0.00 $0.0050323 C $0.00 $0.00 $0.0050325 C $0.00 $0.00 $0.0050327 C $0.00 $0.00 $0.0050328 C $0.00 $0.00 $0.0050329 C $0.00 $0.00 $0.0050340 C $0.00 $0.00 $0.0050360 C $0.00 $0.00 $0.0050365 C $0.00 $0.00 $0.0050370 C $0.00 $0.00 $0.0050380 C $0.00 $0.00 $0.0050382 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 50384 Q2 0161 16.5418 $1,793.46 $2,192.28 $1,345.18 50385 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 50386 Q2 0160 7.4007 $802.38 $980.81 $601.82 50387 T 0427 17.3792 $1,884.25 $2,303.27 $1,413.28 50389 Q2 0160 7.4007 $802.38 $980.81 $601.82 50390 T 0005 14.1916 $1,538.65 $1,880.81 $1,154.06 50391 T 0164 2.8822 $312.49 $381.98 $234.38 50392 T 0161 16.5418 $1,793.46 $2,192.28 $1,345.18 50393 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 50394 N $0.00 $0.00 $0.00 50395 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 50396 T 0164 2.8822 $312.49 $381.98 $234.38 50398 T 0427 17.3792 $1,884.25 $2,303.27 $1,413.28 50400 C $0.00 $0.00 $0.0050405 C $0.00 $0.00 $0.0050500 C $0.00 $0.00 $0.005050F M $0.00 $0.00 $0.0050520 C $0.00 $0.00 $0.0050525 C $0.00 $0.00 $0.0050526 C $0.00 $0.00 $0.0050540 C $0.00 $0.00 $0.0050541 T 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 50542 T 0174 108.7985 $11,795.93 $14,419.07 $8,847.49 50543 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 50544 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56


101


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee50545 C $0.00 $0.00 $0.0050546 C $0.00 $0.00 $0.0050547 C $0.00 $0.00 $0.0050548 C $0.00 $0.00 $0.0050549 T 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 50551 T 0160 7.4007 $802.38 $980.81 $601.82 50553 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 50555 T 0160 7.4007 $802.38 $980.81 $601.82 50557 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 50561 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 50562 T 0160 7.4007 $802.38 $980.81 $601.82 50570 T 0160 7.4007 $802.38 $980.81 $601.82 50572 T 0160 7.4007 $802.38 $980.81 $601.82 50574 T 0160 7.4007 $802.38 $980.81 $601.82 50575 T 0163 41.9797 $4,551.44 $5,563.57 $3,413.79 50576 T 0161 16.5418 $1,793.46 $2,192.28 $1,345.18 50580 T 0161 16.5418 $1,793.46 $2,192.28 $1,345.18 50590 T 0163 41.9797 $4,551.44 $5,563.57 $3,413.79 50592 T 0423 55.2208 $5,987.04 $7,318.41 $4,490.56 50593 T 0423 55.2208 $5,987.04 $7,318.41 $4,490.56 50600 C $0.00 $0.00 $0.0050605 C $0.00 $0.00 $0.005060F E $0.00 $0.00 $0.0050610 C $0.00 $0.00 $0.0050620 C $0.00 $0.00 $0.005062F E $0.00 $0.00 $0.0050630 C $0.00 $0.00 $0.0050650 C $0.00 $0.00 $0.0050660 C $0.00 $0.00 $0.0050684 N $0.00 $0.00 $0.00 50686 T 0126 1.5266 $165.51 $202.32 $124.14 50688 T 0427 17.3792 $1,884.25 $2,303.27 $1,413.28 50690 N $0.00 $0.00 $0.00 50700 C $0.00 $0.00 $0.0050715 C $0.00 $0.00 $0.0050722 C $0.00 $0.00 $0.0050725 C $0.00 $0.00 $0.0050727 T 0165 18.548 $2,010.97 $2,458.17 $1,508.32 50728 C $0.00 $0.00 $0.0050740 C $0.00 $0.00 $0.0050750 C $0.00 $0.00 $0.0050760 C $0.00 $0.00 $0.0050770 C $0.00 $0.00 $0.0050780 C $0.00 $0.00 $0.0050782 C $0.00 $0.00 $0.0050783 C $0.00 $0.00 $0.0050785 C $0.00 $0.00 $0.0050800 C $0.00 $0.00 $0.0050810 C $0.00 $0.00 $0.0050815 C $0.00 $0.00 $0.0050820 C $0.00 $0.00 $0.00


102


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee50825 C $0.00 $0.00 $0.0050830 C $0.00 $0.00 $0.0050840 C $0.00 $0.00 $0.0050845 C $0.00 $0.00 $0.0050860 C $0.00 $0.00 $0.0050900 C $0.00 $0.00 $0.0050920 C $0.00 $0.00 $0.0050930 C $0.00 $0.00 $0.0050940 C $0.00 $0.00 $0.0050945 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 50947 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 50948 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 50949 T 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 50951 T 0160 7.4007 $802.38 $980.81 $601.82 50953 T 0160 7.4007 $802.38 $980.81 $601.82 50955 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 50957 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 50961 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 50970 T 0160 7.4007 $802.38 $980.81 $601.82 50972 T 0160 7.4007 $802.38 $980.81 $601.82 50974 T 0161 16.5418 $1,793.46 $2,192.28 $1,345.18 50976 T 0161 16.5418 $1,793.46 $2,192.28 $1,345.18 50980 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 5100F E $0.00 $0.00 $0.0051020 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 51030 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 51040 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 51045 T 0160 7.4007 $802.38 $980.81 $601.82 51050 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 51060 T 0163 41.9797 $4,551.44 $5,563.57 $3,413.79 51065 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 51080 T 0008 22.0535 $2,391.04 $2,922.75 $1,793.39 51100 T 0164 2.8822 $312.49 $381.98 $234.38 51101 T 0126 1.5266 $165.51 $202.32 $124.14 51102 T 0165 18.548 $2,010.97 $2,458.17 $1,508.32 51500 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 51520 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 51525 C $0.00 $0.00 $0.0051530 C $0.00 $0.00 $0.0051535 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 51550 C $0.00 $0.00 $0.0051555 C $0.00 $0.00 $0.0051565 C $0.00 $0.00 $0.0051570 C $0.00 $0.00 $0.0051575 C $0.00 $0.00 $0.0051580 C $0.00 $0.00 $0.0051585 C $0.00 $0.00 $0.0051590 C $0.00 $0.00 $0.0051595 C $0.00 $0.00 $0.0051596 C $0.00 $0.00 $0.0051597 C $0.00 $0.00 $0.00


103


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee51600 N $0.00 $0.00 $0.00 51605 N $0.00 $0.00 $0.00 51610 N $0.00 $0.00 $0.00 51700 T 0164 2.8822 $312.49 $381.98 $234.38 51701 Q1 0420 1.7762 $192.58 $235.40 $144.44 51702 Q1 0420 1.7762 $192.58 $235.40 $144.44 51703 T 0126 1.5266 $165.51 $202.32 $124.14 51705 T 0164 2.8822 $312.49 $381.98 $234.38 51710 T 0121 6.58 $713.40 $872.05 $535.09 51715 T 0168 33.834 $3,668.28 $4,484.02 $2,751.38 51720 T 0164 2.8822 $312.49 $381.98 $234.38 51725 T 0164 2.8822 $312.49 $381.98 $234.38 51726 T 0156 5.0397 $546.40 $667.91 $409.83 51727 T 0156 5.0397 $546.40 $667.91 $409.83 51728 T 0156 5.0397 $546.40 $667.91 $409.83 51729 T 0156 5.0397 $546.40 $667.91 $409.83 51736 Q1 0420 1.7762 $192.58 $235.40 $144.44 51741 T 0126 1.5266 $165.51 $202.32 $124.14 51784 T 0126 1.5266 $165.51 $202.32 $124.14 51785 T 0164 2.8822 $312.49 $381.98 $234.38 51792 T 0126 1.5266 $165.51 $202.32 $124.14 51797 N $0.00 $0.00 $0.00 51798 Q1 0340 0.7061 $76.56 $93.58 $57.42 51800 C $0.00 $0.00 $0.0051820 C $0.00 $0.00 $0.0051840 C $0.00 $0.00 $0.0051841 C $0.00 $0.00 $0.0051845 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 51860 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 51865 C $0.00 $0.00 $0.0051880 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 51900 C $0.00 $0.00 $0.0051920 C $0.00 $0.00 $0.0051925 C $0.00 $0.00 $0.0051940 C $0.00 $0.00 $0.0051960 C $0.00 $0.00 $0.0051980 C $0.00 $0.00 $0.0051990 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 51992 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 51999 T 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 52000 T 0160 7.4007 $802.38 $980.81 $601.82 52001 T 0161 16.5418 $1,793.46 $2,192.28 $1,345.18 52005 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52007 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 5200F E $0.00 $0.00 $0.0052010 T 0160 7.4007 $802.38 $980.81 $601.82 52204 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52214 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52224 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52234 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52235 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73


104


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee52240 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52250 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52260 T 0161 16.5418 $1,793.46 $2,192.28 $1,345.18 52265 T 0160 7.4007 $802.38 $980.81 $601.82 52270 T 0161 16.5418 $1,793.46 $2,192.28 $1,345.18 52275 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52276 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52277 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52281 T 0161 16.5418 $1,793.46 $2,192.28 $1,345.18 52282 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52283 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52285 T 0161 16.5418 $1,793.46 $2,192.28 $1,345.18 52287 T 0161 16.5418 $1,793.46 $2,192.28 $1,345.18 52290 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52300 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52301 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52305 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52310 T 0161 16.5418 $1,793.46 $2,192.28 $1,345.18 52315 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52317 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52318 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52320 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52325 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52327 T 0163 41.9797 $4,551.44 $5,563.57 $3,413.79 52330 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52332 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52334 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52341 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52342 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52343 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52344 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52345 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52346 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52351 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52352 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52353 T 0163 41.9797 $4,551.44 $5,563.57 $3,413.79 52354 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52355 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52356 T 0163 41.9797 $4,551.44 $5,563.57 $3,413.79 52400 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52402 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52441 B $0.00 $0.00 $0.0052442 B $0.00 $0.00 $0.0052450 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52500 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 5250F E $0.00 $0.00 $0.0052601 T 0163 41.9797 $4,551.44 $5,563.57 $3,413.79 52630 T 0163 41.9797 $4,551.44 $5,563.57 $3,413.79 52640 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 52647 T 0163 41.9797 $4,551.44 $5,563.57 $3,413.79 52648 T 0163 41.9797 $4,551.44 $5,563.57 $3,413.79


105


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee52649 T 0163 41.9797 $4,551.44 $5,563.57 $3,413.79 52700 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 53000 T 0166 21.9589 $2,380.78 $2,910.21 $1,785.70 53010 T 0166 21.9589 $2,380.78 $2,910.21 $1,785.70 53020 T 0166 21.9589 $2,380.78 $2,910.21 $1,785.70 53025 T 0166 21.9589 $2,380.78 $2,910.21 $1,785.70 53040 T 0166 21.9589 $2,380.78 $2,910.21 $1,785.70 53060 T 0166 21.9589 $2,380.78 $2,910.21 $1,785.70 53080 T 0166 21.9589 $2,380.78 $2,910.21 $1,785.70 53085 T 0166 21.9589 $2,380.78 $2,910.21 $1,785.70 53200 T 0166 21.9589 $2,380.78 $2,910.21 $1,785.70 53210 T 0168 33.834 $3,668.28 $4,484.02 $2,751.38 53215 T 0166 21.9589 $2,380.78 $2,910.21 $1,785.70 53220 T 0168 33.834 $3,668.28 $4,484.02 $2,751.38 53230 T 0168 33.834 $3,668.28 $4,484.02 $2,751.38 53235 T 0166 21.9589 $2,380.78 $2,910.21 $1,785.70 53240 T 0168 33.834 $3,668.28 $4,484.02 $2,751.38 53250 T 0166 21.9589 $2,380.78 $2,910.21 $1,785.70 53260 T 0166 21.9589 $2,380.78 $2,910.21 $1,785.70 53265 T 0166 21.9589 $2,380.78 $2,910.21 $1,785.70 53270 T 0166 21.9589 $2,380.78 $2,910.21 $1,785.70 53275 T 0166 21.9589 $2,380.78 $2,910.21 $1,785.70 53400 T 0168 33.834 $3,668.28 $4,484.02 $2,751.38 53405 T 0168 33.834 $3,668.28 $4,484.02 $2,751.38 53410 T 0168 33.834 $3,668.28 $4,484.02 $2,751.38 53415 C $0.00 $0.00 $0.0053420 T 0168 33.834 $3,668.28 $4,484.02 $2,751.38 53425 T 0168 33.834 $3,668.28 $4,484.02 $2,751.38 53430 T 0168 33.834 $3,668.28 $4,484.02 $2,751.38 53431 T 0168 33.834 $3,668.28 $4,484.02 $2,751.38 53440 J1 0385 92.0148 $9,976.24 $12,194.72 $7,482.64 53442 T 0168 33.834 $3,668.28 $4,484.02 $2,751.38 53444 J1 0385 92.0148 $9,976.24 $12,194.72 $7,482.64 53445 J1 0386 188.3897 $20,425.21 $24,967.29 $15,319.85 53446 Q2 0168 33.834 $3,668.28 $4,484.02 $2,751.38 53447 J1 0386 188.3897 $20,425.21 $24,967.29 $15,319.85 53448 C $0.00 $0.00 $0.0053449 T 0168 33.834 $3,668.28 $4,484.02 $2,751.38 53450 T 0168 33.834 $3,668.28 $4,484.02 $2,751.38 53460 T 0166 21.9589 $2,380.78 $2,910.21 $1,785.70 53500 T 0168 33.834 $3,668.28 $4,484.02 $2,751.38 53502 T 0166 21.9589 $2,380.78 $2,910.21 $1,785.70 53505 T 0168 33.834 $3,668.28 $4,484.02 $2,751.38 53510 T 0166 21.9589 $2,380.78 $2,910.21 $1,785.70 53515 T 0168 33.834 $3,668.28 $4,484.02 $2,751.38 53520 T 0168 33.834 $3,668.28 $4,484.02 $2,751.38 53600 T 0164 2.8822 $312.49 $381.98 $234.38 53601 T 0126 1.5266 $165.51 $202.32 $124.14 53605 T 0161 16.5418 $1,793.46 $2,192.28 $1,345.18 53620 T 0160 7.4007 $802.38 $980.81 $601.82 53621 T 0164 2.8822 $312.49 $381.98 $234.38


106


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee53660 T 0126 1.5266 $165.51 $202.32 $124.14 53661 T 0126 1.5266 $165.51 $202.32 $124.14 53665 T 0166 21.9589 $2,380.78 $2,910.21 $1,785.70 53850 T 0161 16.5418 $1,793.46 $2,192.28 $1,345.18 53852 T 0163 41.9797 $4,551.44 $5,563.57 $3,413.79 53855 T 0160 7.4007 $802.38 $980.81 $601.82 53860 T 0165 18.548 $2,010.97 $2,458.17 $1,508.32 53899 T 0126 1.5266 $165.51 $202.32 $124.14 54000 T 0166 21.9589 $2,380.78 $2,910.21 $1,785.70 54001 T 0166 21.9589 $2,380.78 $2,910.21 $1,785.70 54015 T 0008 22.0535 $2,391.04 $2,922.75 $1,793.39 54050 T 0015 1.9702 $213.61 $261.11 $160.22 54055 T 0017 17.361 $1,882.28 $2,300.85 $1,411.80 54056 Q1 0012 1.3279 $143.97 $175.99 $107.98 54057 T 0017 17.361 $1,882.28 $2,300.85 $1,411.80 54060 T 0017 17.361 $1,882.28 $2,300.85 $1,411.80 54065 T 0017 17.361 $1,882.28 $2,300.85 $1,411.80 54100 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 54105 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 54110 T 0205 46.059 $4,993.72 $6,104.20 $3,745.52 54111 T 0205 46.059 $4,993.72 $6,104.20 $3,745.52 54112 T 0205 46.059 $4,993.72 $6,104.20 $3,745.52 54115 T 0008 22.0535 $2,391.04 $2,922.75 $1,793.39 54120 T 0181 30.1349 $3,267.23 $3,993.78 $2,450.57 54125 C $0.00 $0.00 $0.0054130 C $0.00 $0.00 $0.0054135 C $0.00 $0.00 $0.0054150 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 54160 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 54161 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 54162 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 54163 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 54164 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 54200 T 0164 2.8822 $312.49 $381.98 $234.38 54205 T 0181 30.1349 $3,267.23 $3,993.78 $2,450.57 54220 T 0164 2.8822 $312.49 $381.98 $234.38 54230 N $0.00 $0.00 $0.00 54231 T 0165 18.548 $2,010.97 $2,458.17 $1,508.32 54235 T 0164 2.8822 $312.49 $381.98 $234.38 54240 T 0126 1.5266 $165.51 $202.32 $124.14 54250 T 0164 2.8822 $312.49 $381.98 $234.38 54300 T 0205 46.059 $4,993.72 $6,104.20 $3,745.52 54304 T 0205 46.059 $4,993.72 $6,104.20 $3,745.52 54308 T 0205 46.059 $4,993.72 $6,104.20 $3,745.52 54312 T 0181 30.1349 $3,267.23 $3,993.78 $2,450.57 54316 T 0181 30.1349 $3,267.23 $3,993.78 $2,450.57 54318 T 0181 30.1349 $3,267.23 $3,993.78 $2,450.57 54322 T 0181 30.1349 $3,267.23 $3,993.78 $2,450.57 54324 T 0205 46.059 $4,993.72 $6,104.20 $3,745.52 54326 T 0181 30.1349 $3,267.23 $3,993.78 $2,450.57 54328 T 0205 46.059 $4,993.72 $6,104.20 $3,745.52


107


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee54332 T 0181 30.1349 $3,267.23 $3,993.78 $2,450.57 54336 T 0181 30.1349 $3,267.23 $3,993.78 $2,450.57 54340 T 0181 30.1349 $3,267.23 $3,993.78 $2,450.57 54344 T 0181 30.1349 $3,267.23 $3,993.78 $2,450.57 54348 T 0181 30.1349 $3,267.23 $3,993.78 $2,450.57 54352 T 0205 46.059 $4,993.72 $6,104.20 $3,745.52 54360 T 0205 46.059 $4,993.72 $6,104.20 $3,745.52 54380 T 0181 30.1349 $3,267.23 $3,993.78 $2,450.57 54385 T 0181 30.1349 $3,267.23 $3,993.78 $2,450.57 54390 C $0.00 $0.00 $0.0054400 J1 0385 92.0148 $9,976.24 $12,194.72 $7,482.64 54401 J1 0386 188.3897 $20,425.21 $24,967.29 $15,319.85 54405 J1 0386 188.3897 $20,425.21 $24,967.29 $15,319.85 54406 Q2 0181 30.1349 $3,267.23 $3,993.78 $2,450.57 54408 T 0205 46.059 $4,993.72 $6,104.20 $3,745.52 54410 J1 0386 188.3897 $20,425.21 $24,967.29 $15,319.85 54411 C $0.00 $0.00 $0.0054415 Q2 0181 30.1349 $3,267.23 $3,993.78 $2,450.57 54416 J1 0386 188.3897 $20,425.21 $24,967.29 $15,319.85 54417 C $0.00 $0.00 $0.0054420 T 0181 30.1349 $3,267.23 $3,993.78 $2,450.57 54430 C $0.00 $0.00 $0.0054435 T 0181 30.1349 $3,267.23 $3,993.78 $2,450.57 54440 T 0181 30.1349 $3,267.23 $3,993.78 $2,450.57 54450 T 0164 2.8822 $312.49 $381.98 $234.38 54500 T 0005 14.1916 $1,538.65 $1,880.81 $1,154.06 54505 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 54512 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 54520 T 0181 30.1349 $3,267.23 $3,993.78 $2,450.57 54522 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 54530 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 54535 T 0181 30.1349 $3,267.23 $3,993.78 $2,450.57 54550 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 54560 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 54600 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 54620 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 54640 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 54650 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 54660 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 54670 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 54680 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 54690 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 54692 T 0132 73.8696 $8,008.94 $9,789.94 $6,007.08 54699 T 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 54700 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 54800 T 0004 6.5703 $712.35 $870.76 $534.30 54830 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 54840 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 54860 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 54861 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 54865 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79


108


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee54900 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 54901 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 55000 T 0004 6.5703 $712.35 $870.76 $534.30 55040 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 55041 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 55060 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 55100 T 0007 11.6749 $1,265.79 $1,547.27 $949.40 55110 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 55120 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 55150 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 55175 T 0205 46.059 $4,993.72 $6,104.20 $3,745.52 55180 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 55200 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 55250 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 55300 N $0.00 $0.00 $0.00 55400 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 55450 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 55500 T 0181 30.1349 $3,267.23 $3,993.78 $2,450.57 55520 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 55530 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 55535 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 55540 T 0154 36.0701 $3,910.72 $4,780.37 $2,933.22 55550 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 55559 T 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 55600 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 55605 C $0.00 $0.00 $0.0055650 C $0.00 $0.00 $0.0055680 T 0183 24.4318 $2,648.90 $3,237.95 $1,986.79 55700 T 0184 19.7147 $2,137.47 $2,612.79 $1,603.20 55705 T 0184 19.7147 $2,137.47 $2,612.79 $1,603.20 55706 T 0184 19.7147 $2,137.47 $2,612.79 $1,603.20 55720 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 55725 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 55801 C $0.00 $0.00 $0.0055810 C $0.00 $0.00 $0.0055812 C $0.00 $0.00 $0.0055815 C $0.00 $0.00 $0.0055821 C $0.00 $0.00 $0.0055831 C $0.00 $0.00 $0.0055840 C $0.00 $0.00 $0.0055842 C $0.00 $0.00 $0.0055845 C $0.00 $0.00 $0.0055860 T 0165 18.548 $2,010.97 $2,458.17 $1,508.32 55862 C $0.00 $0.00 $0.0055865 C $0.00 $0.00 $0.0055866 C $0.00 $0.00 $0.0055870 T 0192 6.5691 $712.22 $870.60 $534.20 55873 J1 0385 92.0148 $9,976.24 $12,194.72 $7,482.64 55875 Q3 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 55876 S 0310 14.0014 $1,518.03 $1,855.61 $1,138.59 55899 T 0126 1.5266 $165.51 $202.32 $124.14


109


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee55920 T 0153 30.8186 $3,341.35 $4,084.39 $2,506.17 55970 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 55980 T 0205 46.059 $4,993.72 $6,104.20 $3,745.52 56405 T 0189 3.0491 $330.58 $404.10 $247.95 56420 T 0188 1.7659 $191.46 $234.03 $143.60 56440 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 56441 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 56442 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 56501 T 0017 17.361 $1,882.28 $2,300.85 $1,411.80 56515 T 0017 17.361 $1,882.28 $2,300.85 $1,411.80 56605 T 0192 6.5691 $712.22 $870.60 $534.20 56606 N $0.00 $0.00 $0.00 56620 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 56625 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 56630 C $0.00 $0.00 $0.0056631 C $0.00 $0.00 $0.0056632 C $0.00 $0.00 $0.0056633 C $0.00 $0.00 $0.0056634 C $0.00 $0.00 $0.0056637 C $0.00 $0.00 $0.0056640 C $0.00 $0.00 $0.0056700 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 56740 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 56800 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 56805 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 56810 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 56820 T 0188 1.7659 $191.46 $234.03 $143.60 56821 T 0189 3.0491 $330.58 $404.10 $247.95 57000 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57010 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57020 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57022 T 0007 11.6749 $1,265.79 $1,547.27 $949.40 57023 T 0008 22.0535 $2,391.04 $2,922.75 $1,793.39 57061 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57065 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57100 T 0192 6.5691 $712.22 $870.60 $534.20 57105 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57106 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57107 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57109 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57110 C $0.00 $0.00 $0.0057111 C $0.00 $0.00 $0.0057112 C $0.00 $0.00 $0.0057120 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 57130 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57135 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57150 T 0188 1.7659 $191.46 $234.03 $143.60 57155 T 0192 6.5691 $712.22 $870.60 $534.20 57156 T 0189 3.0491 $330.58 $404.10 $247.95 57160 T 0188 1.7659 $191.46 $234.03 $143.60 57170 T 0188 1.7659 $191.46 $234.03 $143.60


110


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee57180 T 0188 1.7659 $191.46 $234.03 $143.60 57200 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57210 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57220 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 57230 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57240 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 57250 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 57260 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 57265 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 57267 N $0.00 $0.00 $0.00 57268 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57270 C $0.00 $0.00 $0.0057280 C $0.00 $0.00 $0.0057282 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 57283 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 57284 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 57285 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 57287 Q2 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57288 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 57289 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 57291 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57292 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 57295 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57296 C $0.00 $0.00 $0.0057300 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57305 C $0.00 $0.00 $0.0057307 C $0.00 $0.00 $0.0057308 C $0.00 $0.00 $0.0057310 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 57311 C $0.00 $0.00 $0.0057320 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 57330 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 57335 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57400 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57410 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57415 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57420 T 0189 3.0491 $330.58 $404.10 $247.95 57421 T 0192 6.5691 $712.22 $870.60 $534.20 57423 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 57425 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 57426 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 57452 T 0188 1.7659 $191.46 $234.03 $143.60 57454 T 0189 3.0491 $330.58 $404.10 $247.95 57455 T 0189 3.0491 $330.58 $404.10 $247.95 57456 T 0189 3.0491 $330.58 $404.10 $247.95 57460 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57461 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57500 T 0192 6.5691 $712.22 $870.60 $534.20 57505 T 0192 6.5691 $712.22 $870.60 $534.20 57510 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57511 T 0189 3.0491 $330.58 $404.10 $247.95


111


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee57513 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57520 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57522 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57530 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57531 C $0.00 $0.00 $0.0057540 C $0.00 $0.00 $0.0057545 C $0.00 $0.00 $0.0057550 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57555 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 57556 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 57558 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57700 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57720 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 57800 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 58100 T 0189 3.0491 $330.58 $404.10 $247.95 58110 N $0.00 $0.00 $0.00 58120 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 58140 C $0.00 $0.00 $0.0058145 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 58146 C $0.00 $0.00 $0.0058150 C $0.00 $0.00 $0.0058152 C $0.00 $0.00 $0.0058180 C $0.00 $0.00 $0.0058200 C $0.00 $0.00 $0.0058210 C $0.00 $0.00 $0.0058240 C $0.00 $0.00 $0.0058260 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 58262 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 58263 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 58267 C $0.00 $0.00 $0.0058270 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 58275 C $0.00 $0.00 $0.0058280 C $0.00 $0.00 $0.0058285 C $0.00 $0.00 $0.0058290 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 58291 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 58292 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 58293 C $0.00 $0.00 $0.0058294 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 58300 E $0.00 $0.00 $0.0058301 Q2 0189 3.0491 $330.58 $404.10 $247.95 58321 T 0189 3.0491 $330.58 $404.10 $247.95 58322 T 0188 1.7659 $191.46 $234.03 $143.60 58323 T 0188 1.7659 $191.46 $234.03 $143.60 58340 N $0.00 $0.00 $0.00 58345 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 58346 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 58350 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 58353 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 58356 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 58400 C $0.00 $0.00 $0.00


112


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee58410 C $0.00 $0.00 $0.0058520 C $0.00 $0.00 $0.0058540 C $0.00 $0.00 $0.0058541 T 0132 73.8696 $8,008.94 $9,789.94 $6,007.08 58542 T 0132 73.8696 $8,008.94 $9,789.94 $6,007.08 58543 T 0132 73.8696 $8,008.94 $9,789.94 $6,007.08 58544 T 0132 73.8696 $8,008.94 $9,789.94 $6,007.08 58545 T 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 58546 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 58548 C $0.00 $0.00 $0.0058550 T 0132 73.8696 $8,008.94 $9,789.94 $6,007.08 58552 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 58553 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 58554 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 58555 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 58558 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 58559 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 58560 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 58561 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 58562 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 58563 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 58565 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 58570 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 58571 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 58572 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 58573 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 58578 T 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 58579 T 0188 1.7659 $191.46 $234.03 $143.60 58600 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 58605 C $0.00 $0.00 $0.0058611 C $0.00 $0.00 $0.0058615 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 58660 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 58661 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 58662 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 58670 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 58671 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 58672 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 58673 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 58679 T 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 58700 C $0.00 $0.00 $0.0058720 C $0.00 $0.00 $0.0058740 C $0.00 $0.00 $0.0058750 C $0.00 $0.00 $0.0058752 C $0.00 $0.00 $0.0058760 C $0.00 $0.00 $0.0058770 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 58800 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 58805 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 58820 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 58822 C $0.00 $0.00 $0.00


113


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee58825 C $0.00 $0.00 $0.0058900 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 58920 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 58925 J1 0202 53.6473 $5,816.44 $7,109.88 $4,362.60 58940 C $0.00 $0.00 $0.0058943 C $0.00 $0.00 $0.0058950 C $0.00 $0.00 $0.0058951 C $0.00 $0.00 $0.0058952 C $0.00 $0.00 $0.0058953 C $0.00 $0.00 $0.0058954 C $0.00 $0.00 $0.0058956 C $0.00 $0.00 $0.0058957 C $0.00 $0.00 $0.0058958 C $0.00 $0.00 $0.0058960 C $0.00 $0.00 $0.0058970 T 0192 6.5691 $712.22 $870.60 $534.20 58974 T 0192 6.5691 $712.22 $870.60 $534.20 58976 T 0189 3.0491 $330.58 $404.10 $247.95 58999 T 0188 1.7659 $191.46 $234.03 $143.60 59000 T 0192 6.5691 $712.22 $870.60 $534.20 59001 T 0189 3.0491 $330.58 $404.10 $247.95 59012 T 0189 3.0491 $330.58 $404.10 $247.95 59015 T 0192 6.5691 $712.22 $870.60 $534.20 59020 T 0188 1.7659 $191.46 $234.03 $143.60 59025 T 0188 1.7659 $191.46 $234.03 $143.60 59030 T 0189 3.0491 $330.58 $404.10 $247.95 59050 M $0.00 $0.00 $0.0059051 B $0.00 $0.00 $0.0059070 T 0192 6.5691 $712.22 $870.60 $534.20 59072 T 0189 3.0491 $330.58 $404.10 $247.95 59074 T 0189 3.0491 $330.58 $404.10 $247.95 59076 T 0189 3.0491 $330.58 $404.10 $247.95 59100 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 59120 C $0.00 $0.00 $0.0059121 C $0.00 $0.00 $0.0059130 C $0.00 $0.00 $0.0059135 C $0.00 $0.00 $0.0059136 C $0.00 $0.00 $0.0059140 C $0.00 $0.00 $0.0059150 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 59151 T 0131 50.9538 $5,524.41 $6,752.91 $4,143.56 59160 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 59200 T 0189 3.0491 $330.58 $404.10 $247.95 59300 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 59320 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 59325 C $0.00 $0.00 $0.0059350 C $0.00 $0.00 $0.0059400 B $0.00 $0.00 $0.0059409 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 59410 B $0.00 $0.00 $0.0059412 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09


114


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee59414 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 59425 B $0.00 $0.00 $0.0059426 B $0.00 $0.00 $0.0059430 B $0.00 $0.00 $0.0059510 B $0.00 $0.00 $0.0059514 C $0.00 $0.00 $0.0059515 B $0.00 $0.00 $0.0059525 C $0.00 $0.00 $0.0059610 B $0.00 $0.00 $0.0059612 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 59614 B $0.00 $0.00 $0.0059618 B $0.00 $0.00 $0.0059620 C $0.00 $0.00 $0.0059622 B $0.00 $0.00 $0.0059812 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 59820 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 59821 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 59830 C $0.00 $0.00 $0.0059840 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 59841 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 59850 C $0.00 $0.00 $0.0059851 C $0.00 $0.00 $0.0059852 C $0.00 $0.00 $0.0059855 C $0.00 $0.00 $0.0059856 C $0.00 $0.00 $0.0059857 C $0.00 $0.00 $0.0059866 T 0189 3.0491 $330.58 $404.10 $247.95 59870 T 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 59871 Q2 0193 24.8904 $2,698.62 $3,298.72 $2,024.09 59897 T 0188 1.7659 $191.46 $234.03 $143.60 59898 T 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 59899 T 0188 1.7659 $191.46 $234.03 $143.60 60000 T 0252 8.7183 $945.24 $1,155.44 $708.97 6005F E $0.00 $0.00 $0.0060100 T 0004 6.5703 $712.35 $870.76 $534.30 6010F E $0.00 $0.00 $0.006015F E $0.00 $0.00 $0.0060200 T 0114 57.1584 $6,197.11 $7,575.20 $4,648.12 6020F E $0.00 $0.00 $0.0060210 T 0114 57.1584 $6,197.11 $7,575.20 $4,648.12 60212 T 0114 57.1584 $6,197.11 $7,575.20 $4,648.12 60220 T 0114 57.1584 $6,197.11 $7,575.20 $4,648.12 60225 T 0114 57.1584 $6,197.11 $7,575.20 $4,648.12 60240 T 0114 57.1584 $6,197.11 $7,575.20 $4,648.12 60252 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 60254 C $0.00 $0.00 $0.0060260 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 60270 C $0.00 $0.00 $0.0060271 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 60280 T 0114 57.1584 $6,197.11 $7,575.20 $4,648.12 60281 T 0114 57.1584 $6,197.11 $7,575.20 $4,648.12


115


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee60300 T 0004 6.5703 $712.35 $870.76 $534.30 6030F M $0.00 $0.00 $0.006040F E $0.00 $0.00 $0.006045F M $0.00 $0.00 $0.0060500 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 60502 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 60505 C $0.00 $0.00 $0.0060512 N $0.00 $0.00 $0.00 60520 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 60521 C $0.00 $0.00 $0.0060522 C $0.00 $0.00 $0.0060540 C $0.00 $0.00 $0.0060545 C $0.00 $0.00 $0.0060600 C $0.00 $0.00 $0.0060605 C $0.00 $0.00 $0.0060650 C $0.00 $0.00 $0.0060659 T 0130 40.6743 $4,409.91 $5,390.57 $3,307.63 60699 T 0114 57.1584 $6,197.11 $7,575.20 $4,648.12 6070F E $0.00 $0.00 $0.006080F E $0.00 $0.00 $0.006090F E $0.00 $0.00 $0.0061000 T 0207 9.0607 $982.36 $1,200.81 $736.82 61001 T 0207 9.0607 $982.36 $1,200.81 $736.82 6100F E $0.00 $0.00 $0.006101F M $0.00 $0.00 $0.0061020 T 0207 9.0607 $982.36 $1,200.81 $736.82 61026 T 0207 9.0607 $982.36 $1,200.81 $736.82 6102F M $0.00 $0.00 $0.0061050 T 0203 19.819 $2,148.78 $2,626.61 $1,611.68 61055 T 0207 9.0607 $982.36 $1,200.81 $736.82 61070 T 0121 6.58 $713.40 $872.05 $535.09 61105 C $0.00 $0.00 $0.0061107 C $0.00 $0.00 $0.0061108 C $0.00 $0.00 $0.006110F M $0.00 $0.00 $0.0061120 C $0.00 $0.00 $0.0061140 C $0.00 $0.00 $0.0061150 C $0.00 $0.00 $0.0061151 C $0.00 $0.00 $0.0061154 C $0.00 $0.00 $0.0061156 C $0.00 $0.00 $0.0061210 C $0.00 $0.00 $0.0061215 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 61250 C $0.00 $0.00 $0.0061253 C $0.00 $0.00 $0.0061304 C $0.00 $0.00 $0.0061305 C $0.00 $0.00 $0.0061312 C $0.00 $0.00 $0.0061313 C $0.00 $0.00 $0.0061314 C $0.00 $0.00 $0.0061315 C $0.00 $0.00 $0.00


116


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee61316 C $0.00 $0.00 $0.0061320 C $0.00 $0.00 $0.0061321 C $0.00 $0.00 $0.0061322 C $0.00 $0.00 $0.0061323 C $0.00 $0.00 $0.0061330 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 61332 C $0.00 $0.00 $0.0061333 C $0.00 $0.00 $0.0061340 C $0.00 $0.00 $0.0061343 C $0.00 $0.00 $0.0061345 C $0.00 $0.00 $0.0061450 C $0.00 $0.00 $0.0061458 C $0.00 $0.00 $0.0061460 C $0.00 $0.00 $0.0061480 C $0.00 $0.00 $0.0061500 C $0.00 $0.00 $0.0061501 C $0.00 $0.00 $0.006150F M $0.00 $0.00 $0.0061510 C $0.00 $0.00 $0.0061512 C $0.00 $0.00 $0.0061514 C $0.00 $0.00 $0.0061516 C $0.00 $0.00 $0.0061517 C $0.00 $0.00 $0.0061518 C $0.00 $0.00 $0.0061519 C $0.00 $0.00 $0.0061520 C $0.00 $0.00 $0.0061521 C $0.00 $0.00 $0.0061522 C $0.00 $0.00 $0.0061524 C $0.00 $0.00 $0.0061526 C $0.00 $0.00 $0.0061530 C $0.00 $0.00 $0.0061531 C $0.00 $0.00 $0.0061533 C $0.00 $0.00 $0.0061534 C $0.00 $0.00 $0.0061535 C $0.00 $0.00 $0.0061536 C $0.00 $0.00 $0.0061537 C $0.00 $0.00 $0.0061538 C $0.00 $0.00 $0.0061539 C $0.00 $0.00 $0.0061540 C $0.00 $0.00 $0.0061541 C $0.00 $0.00 $0.0061543 C $0.00 $0.00 $0.0061544 C $0.00 $0.00 $0.0061545 C $0.00 $0.00 $0.0061546 C $0.00 $0.00 $0.0061548 C $0.00 $0.00 $0.0061550 C $0.00 $0.00 $0.0061552 C $0.00 $0.00 $0.0061556 C $0.00 $0.00 $0.0061557 C $0.00 $0.00 $0.0061558 C $0.00 $0.00 $0.00


117


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee61559 C $0.00 $0.00 $0.0061563 C $0.00 $0.00 $0.0061564 C $0.00 $0.00 $0.0061566 C $0.00 $0.00 $0.0061567 C $0.00 $0.00 $0.0061570 C $0.00 $0.00 $0.0061571 C $0.00 $0.00 $0.0061575 C $0.00 $0.00 $0.0061576 C $0.00 $0.00 $0.0061580 C $0.00 $0.00 $0.0061581 C $0.00 $0.00 $0.0061582 C $0.00 $0.00 $0.0061583 C $0.00 $0.00 $0.0061584 C $0.00 $0.00 $0.0061585 C $0.00 $0.00 $0.0061586 C $0.00 $0.00 $0.0061590 C $0.00 $0.00 $0.0061591 C $0.00 $0.00 $0.0061592 C $0.00 $0.00 $0.0061595 C $0.00 $0.00 $0.0061596 C $0.00 $0.00 $0.0061597 C $0.00 $0.00 $0.0061598 C $0.00 $0.00 $0.0061600 C $0.00 $0.00 $0.0061601 C $0.00 $0.00 $0.0061605 C $0.00 $0.00 $0.0061606 C $0.00 $0.00 $0.0061607 C $0.00 $0.00 $0.0061608 C $0.00 $0.00 $0.0061610 C $0.00 $0.00 $0.0061611 C $0.00 $0.00 $0.0061612 C $0.00 $0.00 $0.0061613 C $0.00 $0.00 $0.0061615 C $0.00 $0.00 $0.0061616 C $0.00 $0.00 $0.0061618 C $0.00 $0.00 $0.0061619 C $0.00 $0.00 $0.0061623 J1 0229 129.8028 $14,073.22 $17,202.77 $10,555.56 61624 C $0.00 $0.00 $0.0061626 J1 0229 129.8028 $14,073.22 $17,202.77 $10,555.56 61630 C $0.00 $0.00 $0.0061635 C $0.00 $0.00 $0.0061640 E $0.00 $0.00 $0.0061641 E $0.00 $0.00 $0.0061642 E $0.00 $0.00 $0.0061680 C $0.00 $0.00 $0.0061682 C $0.00 $0.00 $0.0061684 C $0.00 $0.00 $0.0061686 C $0.00 $0.00 $0.0061690 C $0.00 $0.00 $0.0061692 C $0.00 $0.00 $0.00


118


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee61697 C $0.00 $0.00 $0.0061698 C $0.00 $0.00 $0.0061700 C $0.00 $0.00 $0.0061702 C $0.00 $0.00 $0.0061703 C $0.00 $0.00 $0.0061705 C $0.00 $0.00 $0.0061708 C $0.00 $0.00 $0.0061710 C $0.00 $0.00 $0.0061711 C $0.00 $0.00 $0.0061720 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 61735 C $0.00 $0.00 $0.0061750 C $0.00 $0.00 $0.0061751 C $0.00 $0.00 $0.0061760 C $0.00 $0.00 $0.0061770 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 61781 N $0.00 $0.00 $0.00 61782 N $0.00 $0.00 $0.00 61783 N $0.00 $0.00 $0.00 61790 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 61791 T 0203 19.819 $2,148.78 $2,626.61 $1,611.68 61796 B $0.00 $0.00 $0.0061797 B $0.00 $0.00 $0.0061798 B $0.00 $0.00 $0.0061799 B $0.00 $0.00 $0.0061800 B $0.00 $0.00 $0.0061850 C $0.00 $0.00 $0.0061860 C $0.00 $0.00 $0.0061863 C $0.00 $0.00 $0.0061864 C $0.00 $0.00 $0.0061867 C $0.00 $0.00 $0.0061868 C $0.00 $0.00 $0.0061870 C $0.00 $0.00 $0.0061880 Q2 0688 28.7006 $3,111.72 $3,803.69 $2,333.93 61885 J1 0039 230.6235 $25,004.20 $30,564.53 $18,754.30 61886 J1 0318 352.7212 $38,242.03 $46,746.14 $28,683.29 61888 J1 0061 71.3285 $7,733.44 $9,453.17 $5,800.43 62000 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 62005 C $0.00 $0.00 $0.0062010 C $0.00 $0.00 $0.0062100 C $0.00 $0.00 $0.0062115 C $0.00 $0.00 $0.0062117 C $0.00 $0.00 $0.0062120 C $0.00 $0.00 $0.0062121 C $0.00 $0.00 $0.0062140 C $0.00 $0.00 $0.0062141 C $0.00 $0.00 $0.0062142 C $0.00 $0.00 $0.0062143 C $0.00 $0.00 $0.0062145 C $0.00 $0.00 $0.0062146 C $0.00 $0.00 $0.0062147 C $0.00 $0.00 $0.00


119


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee62148 C $0.00 $0.00 $0.0062160 N $0.00 $0.00 $0.00 62161 C $0.00 $0.00 $0.0062162 C $0.00 $0.00 $0.0062163 C $0.00 $0.00 $0.0062164 C $0.00 $0.00 $0.0062165 C $0.00 $0.00 $0.0062180 C $0.00 $0.00 $0.0062190 C $0.00 $0.00 $0.0062192 C $0.00 $0.00 $0.0062194 T 0203 19.819 $2,148.78 $2,626.61 $1,611.68 62200 C $0.00 $0.00 $0.0062201 C $0.00 $0.00 $0.0062220 C $0.00 $0.00 $0.0062223 C $0.00 $0.00 $0.0062225 T 0427 17.3792 $1,884.25 $2,303.27 $1,413.28 62230 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 62252 S 0692 1.7288 $187.44 $229.12 $140.59 62256 C $0.00 $0.00 $0.0062258 C $0.00 $0.00 $0.0062263 T 0203 19.819 $2,148.78 $2,626.61 $1,611.68 62264 T 0207 9.0607 $982.36 $1,200.81 $736.82 62267 T 0004 6.5703 $712.35 $870.76 $534.30 62268 T 0207 9.0607 $982.36 $1,200.81 $736.82 62269 T 0005 14.1916 $1,538.65 $1,880.81 $1,154.06 62270 T 0206 5.0256 $544.88 $666.04 $408.68 62272 T 0206 5.0256 $544.88 $666.04 $408.68 62273 T 0207 9.0607 $982.36 $1,200.81 $736.82 62280 T 0207 9.0607 $982.36 $1,200.81 $736.82 62281 T 0203 19.819 $2,148.78 $2,626.61 $1,611.68 62282 T 0203 19.819 $2,148.78 $2,626.61 $1,611.68 62284 N $0.00 $0.00 $0.00 62287 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 62290 N $0.00 $0.00 $0.00 62291 N $0.00 $0.00 $0.00 62292 T 0203 19.819 $2,148.78 $2,626.61 $1,611.68 62294 T 0207 9.0607 $982.36 $1,200.81 $736.82 62302 Q2 0274 8.2817 $897.90 $1,097.57 $673.47 62303 Q2 0274 8.2817 $897.90 $1,097.57 $673.47 62304 Q2 0274 8.2817 $897.90 $1,097.57 $673.47 62305 Q2 0274 8.2817 $897.90 $1,097.57 $673.47 62310 T 0207 9.0607 $982.36 $1,200.81 $736.82 62311 T 0207 9.0607 $982.36 $1,200.81 $736.82 62318 T 0207 9.0607 $982.36 $1,200.81 $736.82 62319 T 0207 9.0607 $982.36 $1,200.81 $736.82 62350 T 0224 49.3784 $5,353.61 $6,544.12 $4,015.45 62351 T 0208 55.4537 $6,012.29 $7,349.28 $4,509.49 62355 Q2 0203 19.819 $2,148.78 $2,626.61 $1,611.68 62360 T 0224 49.3784 $5,353.61 $6,544.12 $4,015.45 62361 J1 0227 209.9474 $22,762.50 $27,824.33 $17,072.92 62362 J1 0227 209.9474 $22,762.50 $27,824.33 $17,072.92


120


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee62365 Q2 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 62367 S 0691 3.3374 $361.84 $442.31 $271.40 62368 S 0691 3.3374 $361.84 $442.31 $271.40 62369 S 0691 3.3374 $361.84 $442.31 $271.40 62370 S 0691 3.3374 $361.84 $442.31 $271.40 63001 T 0208 55.4537 $6,012.29 $7,349.28 $4,509.49 63003 T 0208 55.4537 $6,012.29 $7,349.28 $4,509.49 63005 T 0208 55.4537 $6,012.29 $7,349.28 $4,509.49 63011 T 0208 55.4537 $6,012.29 $7,349.28 $4,509.49 63012 T 0208 55.4537 $6,012.29 $7,349.28 $4,509.49 63015 T 0208 55.4537 $6,012.29 $7,349.28 $4,509.49 63016 T 0208 55.4537 $6,012.29 $7,349.28 $4,509.49 63017 T 0208 55.4537 $6,012.29 $7,349.28 $4,509.49 63020 T 0208 55.4537 $6,012.29 $7,349.28 $4,509.49 63030 T 0208 55.4537 $6,012.29 $7,349.28 $4,509.49 63035 N $0.00 $0.00 $0.00 63040 T 0208 55.4537 $6,012.29 $7,349.28 $4,509.49 63042 T 0208 55.4537 $6,012.29 $7,349.28 $4,509.49 63043 N $0.00 $0.00 $0.00 63044 N $0.00 $0.00 $0.00 63045 T 0208 55.4537 $6,012.29 $7,349.28 $4,509.49 63046 T 0208 55.4537 $6,012.29 $7,349.28 $4,509.49 63047 T 0208 55.4537 $6,012.29 $7,349.28 $4,509.49 63048 N $0.00 $0.00 $0.00 63050 C $0.00 $0.00 $0.0063051 C $0.00 $0.00 $0.0063055 T 0208 55.4537 $6,012.29 $7,349.28 $4,509.49 63056 T 0208 55.4537 $6,012.29 $7,349.28 $4,509.49 63057 N $0.00 $0.00 $0.00 63064 T 0208 55.4537 $6,012.29 $7,349.28 $4,509.49 63066 N $0.00 $0.00 $0.00 63075 T 0208 55.4537 $6,012.29 $7,349.28 $4,509.49 63076 N $0.00 $0.00 $0.00 63077 C $0.00 $0.00 $0.0063078 C $0.00 $0.00 $0.0063081 C $0.00 $0.00 $0.0063082 C $0.00 $0.00 $0.0063085 C $0.00 $0.00 $0.0063086 C $0.00 $0.00 $0.0063087 C $0.00 $0.00 $0.0063088 C $0.00 $0.00 $0.0063090 C $0.00 $0.00 $0.0063091 C $0.00 $0.00 $0.0063101 C $0.00 $0.00 $0.0063102 C $0.00 $0.00 $0.0063103 C $0.00 $0.00 $0.0063170 C $0.00 $0.00 $0.0063172 C $0.00 $0.00 $0.0063173 C $0.00 $0.00 $0.0063180 C $0.00 $0.00 $0.0063182 C $0.00 $0.00 $0.00


121


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee63185 C $0.00 $0.00 $0.0063190 C $0.00 $0.00 $0.0063191 C $0.00 $0.00 $0.0063194 C $0.00 $0.00 $0.0063195 C $0.00 $0.00 $0.0063196 C $0.00 $0.00 $0.0063197 C $0.00 $0.00 $0.0063198 C $0.00 $0.00 $0.0063199 C $0.00 $0.00 $0.0063200 C $0.00 $0.00 $0.0063250 C $0.00 $0.00 $0.0063251 C $0.00 $0.00 $0.0063252 C $0.00 $0.00 $0.0063265 C $0.00 $0.00 $0.0063266 C $0.00 $0.00 $0.0063267 C $0.00 $0.00 $0.0063268 C $0.00 $0.00 $0.0063270 C $0.00 $0.00 $0.0063271 C $0.00 $0.00 $0.0063272 C $0.00 $0.00 $0.0063273 C $0.00 $0.00 $0.0063275 C $0.00 $0.00 $0.0063276 C $0.00 $0.00 $0.0063277 C $0.00 $0.00 $0.0063278 C $0.00 $0.00 $0.0063280 C $0.00 $0.00 $0.0063281 C $0.00 $0.00 $0.0063282 C $0.00 $0.00 $0.0063283 C $0.00 $0.00 $0.0063285 C $0.00 $0.00 $0.0063286 C $0.00 $0.00 $0.0063287 C $0.00 $0.00 $0.0063290 C $0.00 $0.00 $0.0063295 C $0.00 $0.00 $0.0063300 C $0.00 $0.00 $0.0063301 C $0.00 $0.00 $0.0063302 C $0.00 $0.00 $0.0063303 C $0.00 $0.00 $0.0063304 C $0.00 $0.00 $0.0063305 C $0.00 $0.00 $0.0063306 C $0.00 $0.00 $0.0063307 C $0.00 $0.00 $0.0063308 C $0.00 $0.00 $0.0063600 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 63610 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 63615 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 63620 B $0.00 $0.00 $0.0063621 B $0.00 $0.00 $0.0063650 J1 0061 71.3285 $7,733.44 $9,453.17 $5,800.43 63655 J1 0039 230.6235 $25,004.20 $30,564.53 $18,754.30 63661 Q2 0220 18.66 $2,023.12 $2,473.01 $1,517.43


122


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee63662 Q2 0688 28.7006 $3,111.72 $3,803.69 $2,333.93 63663 J1 0061 71.3285 $7,733.44 $9,453.17 $5,800.43 63664 J1 0061 71.3285 $7,733.44 $9,453.17 $5,800.43 63685 J1 0318 352.7212 $38,242.03 $46,746.14 $28,683.29 63688 Q2 0688 28.7006 $3,111.72 $3,803.69 $2,333.93 63700 C $0.00 $0.00 $0.0063702 C $0.00 $0.00 $0.0063704 C $0.00 $0.00 $0.0063706 C $0.00 $0.00 $0.0063707 C $0.00 $0.00 $0.0063709 C $0.00 $0.00 $0.0063710 C $0.00 $0.00 $0.0063740 C $0.00 $0.00 $0.0063741 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 63744 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 63746 Q2 0203 19.819 $2,148.78 $2,626.61 $1,611.68 64400 T 0204 2.8475 $308.73 $377.38 $231.56 64402 Q1 0420 1.7762 $192.58 $235.40 $144.44 64405 T 0206 5.0256 $544.88 $666.04 $408.68 64408 T 0204 2.8475 $308.73 $377.38 $231.56 64410 T 0204 2.8475 $308.73 $377.38 $231.56 64412 T 0206 5.0256 $544.88 $666.04 $408.68 64413 T 0206 5.0256 $544.88 $666.04 $408.68 64415 T 0206 5.0256 $544.88 $666.04 $408.68 64416 T 0207 9.0607 $982.36 $1,200.81 $736.82 64417 T 0206 5.0256 $544.88 $666.04 $408.68 64418 T 0206 5.0256 $544.88 $666.04 $408.68 64420 T 0206 5.0256 $544.88 $666.04 $408.68 64421 T 0207 9.0607 $982.36 $1,200.81 $736.82 64425 T 0206 5.0256 $544.88 $666.04 $408.68 64430 T 0207 9.0607 $982.36 $1,200.81 $736.82 64435 T 0206 5.0256 $544.88 $666.04 $408.68 64445 T 0207 9.0607 $982.36 $1,200.81 $736.82 64446 T 0207 9.0607 $982.36 $1,200.81 $736.82 64447 T 0206 5.0256 $544.88 $666.04 $408.68 64448 T 0203 19.819 $2,148.78 $2,626.61 $1,611.68 64449 T 0207 9.0607 $982.36 $1,200.81 $736.82 64450 T 0206 5.0256 $544.88 $666.04 $408.68 64455 T 0204 2.8475 $308.73 $377.38 $231.56 64479 T 0207 9.0607 $982.36 $1,200.81 $736.82 64480 N $0.00 $0.00 $0.00 64483 T 0207 9.0607 $982.36 $1,200.81 $736.82 64484 N $0.00 $0.00 $0.00 64486 N $0.00 $0.00 $0.00 64487 N $0.00 $0.00 $0.00 64488 N $0.00 $0.00 $0.00 64489 N $0.00 $0.00 $0.00 64490 T 0207 9.0607 $982.36 $1,200.81 $736.82 64491 N $0.00 $0.00 $0.00 64492 N $0.00 $0.00 $0.00 64493 T 0207 9.0607 $982.36 $1,200.81 $736.82


123


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee64494 N $0.00 $0.00 $0.00 64495 N $0.00 $0.00 $0.00 64505 T 0204 2.8475 $308.73 $377.38 $231.56 64508 T 0204 2.8475 $308.73 $377.38 $231.56 64510 T 0207 9.0607 $982.36 $1,200.81 $736.82 64517 T 0207 9.0607 $982.36 $1,200.81 $736.82 64520 T 0207 9.0607 $982.36 $1,200.81 $736.82 64530 T 0207 9.0607 $982.36 $1,200.81 $736.82 64550 A $0.00 $0.00 $0.0064553 J1 0061 71.3285 $7,733.44 $9,453.17 $5,800.43 64555 J1 0061 71.3285 $7,733.44 $9,453.17 $5,800.43 64561 J1 0061 71.3285 $7,733.44 $9,453.17 $5,800.43 64565 J1 0061 71.3285 $7,733.44 $9,453.17 $5,800.43 64566 T 0204 2.8475 $308.73 $377.38 $231.56 64568 J1 0318 352.7212 $38,242.03 $46,746.14 $28,683.29 64569 J1 0061 71.3285 $7,733.44 $9,453.17 $5,800.43 64570 Q2 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 64575 J1 0061 71.3285 $7,733.44 $9,453.17 $5,800.43 64580 J1 0039 230.6235 $25,004.20 $30,564.53 $18,754.30 64581 J1 0061 71.3285 $7,733.44 $9,453.17 $5,800.43 64585 Q2 0688 28.7006 $3,111.72 $3,803.69 $2,333.93 64590 J1 0039 230.6235 $25,004.20 $30,564.53 $18,754.30 64595 Q2 0688 28.7006 $3,111.72 $3,803.69 $2,333.93 64600 T 0203 19.819 $2,148.78 $2,626.61 $1,611.68 64605 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64610 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64611 T 0204 2.8475 $308.73 $377.38 $231.56 64612 T 0204 2.8475 $308.73 $377.38 $231.56 64615 T 0204 2.8475 $308.73 $377.38 $231.56 64616 T 0206 5.0256 $544.88 $666.04 $408.68 64617 T 0206 5.0256 $544.88 $666.04 $408.68 64620 T 0203 19.819 $2,148.78 $2,626.61 $1,611.68 64630 T 0207 9.0607 $982.36 $1,200.81 $736.82 64632 T 0204 2.8475 $308.73 $377.38 $231.56 64633 T 0203 19.819 $2,148.78 $2,626.61 $1,611.68 64634 N $0.00 $0.00 $0.00 64635 T 0203 19.819 $2,148.78 $2,626.61 $1,611.68 64636 N $0.00 $0.00 $0.00 64640 T 0207 9.0607 $982.36 $1,200.81 $736.82 64642 T 0206 5.0256 $544.88 $666.04 $408.68 64643 N $0.00 $0.00 $0.00 64644 T 0206 5.0256 $544.88 $666.04 $408.68 64645 N $0.00 $0.00 $0.00 64646 T 0206 5.0256 $544.88 $666.04 $408.68 64647 T 0206 5.0256 $544.88 $666.04 $408.68 64650 T 0204 2.8475 $308.73 $377.38 $231.56 64653 T 0204 2.8475 $308.73 $377.38 $231.56 64680 T 0203 19.819 $2,148.78 $2,626.61 $1,611.68 64681 T 0207 9.0607 $982.36 $1,200.81 $736.82 64702 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64704 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43


124


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee64708 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64712 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64713 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64714 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64716 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64718 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64719 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64721 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64722 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64726 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64727 N $0.00 $0.00 $0.00 64732 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64734 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64736 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64738 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64740 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64742 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64744 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64746 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64755 C $0.00 $0.00 $0.0064760 C $0.00 $0.00 $0.0064763 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64766 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 64771 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64772 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64774 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64776 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64778 N $0.00 $0.00 $0.00 64782 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64783 N $0.00 $0.00 $0.00 64784 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64786 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 64787 N $0.00 $0.00 $0.00 64788 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64790 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64792 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 64795 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64802 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64804 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64809 C $0.00 $0.00 $0.0064818 C $0.00 $0.00 $0.0064820 T 0220 18.66 $2,023.12 $2,473.01 $1,517.43 64821 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 64822 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 64823 T 0054 29.7967 $3,230.56 $3,948.96 $2,423.07 64831 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 64832 N $0.00 $0.00 $0.00 64834 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 64835 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 64836 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 64837 N $0.00 $0.00 $0.00


125


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee64840 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 64856 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 64857 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 64858 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 64859 N $0.00 $0.00 $0.00 64861 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 64862 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 64864 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 64865 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 64866 C $0.00 $0.00 $0.0064868 C $0.00 $0.00 $0.0064872 N $0.00 $0.00 $0.00 64874 N $0.00 $0.00 $0.00 64876 N $0.00 $0.00 $0.00 64885 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 64886 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 64890 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 64891 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 64892 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 64893 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 64895 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 64896 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 64897 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 64898 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 64901 N $0.00 $0.00 $0.00 64902 N $0.00 $0.00 $0.00 64905 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 64907 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 64910 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 64911 T 0221 39.7387 $4,308.47 $5,266.57 $3,231.55 64999 T 0204 2.8475 $308.73 $377.38 $231.56 65091 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 65093 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 65101 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 65103 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 65105 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 65110 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 65112 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 65114 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 65125 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 65130 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 65135 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 65140 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 65150 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 65155 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 65175 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 65205 Q1 0698 1.3596 $147.41 $180.19 $110.56 65210 Q1 0698 1.3596 $147.41 $180.19 $110.56 65220 Q1 0698 1.3596 $147.41 $180.19 $110.56 65222 Q1 0698 1.3596 $147.41 $180.19 $110.56 65235 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49


126


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee65260 S 0231 4.2389 $459.58 $561.78 $344.71 65265 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 65270 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 65272 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 65273 C $0.00 $0.00 $0.0065275 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 65280 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 65285 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 65286 T 0255 10.1409 $1,099.48 $1,343.97 $824.66 65290 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 65400 T 0239 9.4598 $1,025.63 $1,253.71 $769.27 65410 T 0239 9.4598 $1,025.63 $1,253.71 $769.27 65420 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 65426 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 65430 Q1 0698 1.3596 $147.41 $180.19 $110.56 65435 T 0239 9.4598 $1,025.63 $1,253.71 $769.27 65436 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 65450 T 0238 4.0224 $436.11 $533.09 $327.10 65600 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 65710 T 0673 42.0983 $4,564.30 $5,579.29 $3,423.43 65730 T 0673 42.0983 $4,564.30 $5,579.29 $3,423.43 65750 T 0673 42.0983 $4,564.30 $5,579.29 $3,423.43 65755 T 0673 42.0983 $4,564.30 $5,579.29 $3,423.43 65756 T 0673 42.0983 $4,564.30 $5,579.29 $3,423.43 65757 N $0.00 $0.00 $0.00 65760 E $0.00 $0.00 $0.0065765 E $0.00 $0.00 $0.0065767 E $0.00 $0.00 $0.0065770 J1 0293 113.9208 $12,351.29 $15,097.92 $9,264.04 65771 E $0.00 $0.00 $0.0065772 T 0239 9.4598 $1,025.63 $1,253.71 $769.27 65775 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 65778 Q2 0239 9.4598 $1,025.63 $1,253.71 $769.27 65779 Q2 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 65780 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 65781 T 0673 42.0983 $4,564.30 $5,579.29 $3,423.43 65782 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 65800 S 0231 4.2389 $459.58 $561.78 $344.71 65810 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 65815 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 65820 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 65850 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 65855 T 0247 5.981 $648.46 $792.66 $486.37 65860 T 0247 5.981 $648.46 $792.66 $486.37 65865 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 65870 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 65875 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 65880 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 65900 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 65920 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 65930 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49


127


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee66020 T 0255 10.1409 $1,099.48 $1,343.97 $824.66 66030 T 0255 10.1409 $1,099.48 $1,343.97 $824.66 66130 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 66150 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 66155 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 66160 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 66170 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 66172 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 66174 T 0673 42.0983 $4,564.30 $5,579.29 $3,423.43 66175 T 0673 42.0983 $4,564.30 $5,579.29 $3,423.43 66179 T 0673 42.0983 $4,564.30 $5,579.29 $3,423.43 66180 T 0673 42.0983 $4,564.30 $5,579.29 $3,423.43 66183 T 0673 42.0983 $4,564.30 $5,579.29 $3,423.43 66184 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 66185 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 66220 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 66225 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 66250 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 66500 S 0231 4.2389 $459.58 $561.78 $344.71 66505 T 0255 10.1409 $1,099.48 $1,343.97 $824.66 66600 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 66605 T 0673 42.0983 $4,564.30 $5,579.29 $3,423.43 66625 T 0255 10.1409 $1,099.48 $1,343.97 $824.66 66630 T 0255 10.1409 $1,099.48 $1,343.97 $824.66 66635 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 66680 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 66682 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 66700 T 0255 10.1409 $1,099.48 $1,343.97 $824.66 66710 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 66711 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 66720 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 66740 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 66761 T 0247 5.981 $648.46 $792.66 $486.37 66762 T 0247 5.981 $648.46 $792.66 $486.37 66770 T 0247 5.981 $648.46 $792.66 $486.37 66820 S 0231 4.2389 $459.58 $561.78 $344.71 66821 T 0247 5.981 $648.46 $792.66 $486.37 66825 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 66830 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 66840 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 66850 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 66852 T 0673 42.0983 $4,564.30 $5,579.29 $3,423.43 66920 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 66930 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 66940 T 0255 10.1409 $1,099.48 $1,343.97 $824.66 66982 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 66983 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 66984 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 66985 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 66986 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 66990 N $0.00 $0.00 $0.00


128


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee66999 T 0255 10.1409 $1,099.48 $1,343.97 $824.66 67005 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 67010 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 67015 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 67025 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 67027 T 0673 42.0983 $4,564.30 $5,579.29 $3,423.43 67028 S 0231 4.2389 $459.58 $561.78 $344.71 67030 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 67031 T 0247 5.981 $648.46 $792.66 $486.37 67036 T 0673 42.0983 $4,564.30 $5,579.29 $3,423.43 67039 T 0673 42.0983 $4,564.30 $5,579.29 $3,423.43 67040 T 0673 42.0983 $4,564.30 $5,579.29 $3,423.43 67041 T 0673 42.0983 $4,564.30 $5,579.29 $3,423.43 67042 T 0673 42.0983 $4,564.30 $5,579.29 $3,423.43 67043 T 0673 42.0983 $4,564.30 $5,579.29 $3,423.43 67101 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 67105 T 0247 5.981 $648.46 $792.66 $486.37 67107 T 0673 42.0983 $4,564.30 $5,579.29 $3,423.43 67108 T 0673 42.0983 $4,564.30 $5,579.29 $3,423.43 67110 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 67112 T 0673 42.0983 $4,564.30 $5,579.29 $3,423.43 67113 T 0673 42.0983 $4,564.30 $5,579.29 $3,423.43 67115 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 67120 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 67121 T 0673 42.0983 $4,564.30 $5,579.29 $3,423.43 67141 T 0238 4.0224 $436.11 $533.09 $327.10 67145 T 0247 5.981 $648.46 $792.66 $486.37 67208 T 0238 4.0224 $436.11 $533.09 $327.10 67210 T 0247 5.981 $648.46 $792.66 $486.37 67218 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67220 T 0247 5.981 $648.46 $792.66 $486.37 67221 T 0247 5.981 $648.46 $792.66 $486.37 67225 N $0.00 $0.00 $0.00 67227 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 67228 T 0247 5.981 $648.46 $792.66 $486.37 67229 T 0247 5.981 $648.46 $792.66 $486.37 67250 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67255 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 67299 T 0255 10.1409 $1,099.48 $1,343.97 $824.66 67311 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67312 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67314 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67316 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67318 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67320 N $0.00 $0.00 $0.00 67331 N $0.00 $0.00 $0.00 67332 N $0.00 $0.00 $0.00 67334 N $0.00 $0.00 $0.00 67335 N $0.00 $0.00 $0.00 67340 N $0.00 $0.00 $0.00 67343 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54


129


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee67345 T 0238 4.0224 $436.11 $533.09 $327.10 67346 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67399 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67400 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 67405 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67412 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67413 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67414 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 67415 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67420 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 67430 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 67440 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 67445 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 67450 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 67500 T 0238 4.0224 $436.11 $533.09 $327.10 67505 T 0238 4.0224 $436.11 $533.09 $327.10 67515 T 0238 4.0224 $436.11 $533.09 $327.10 67550 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 67560 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67570 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67599 T 0238 4.0224 $436.11 $533.09 $327.10 67700 T 0238 4.0224 $436.11 $533.09 $327.10 67710 T 0239 9.4598 $1,025.63 $1,253.71 $769.27 67715 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67800 T 0238 4.0224 $436.11 $533.09 $327.10 67801 T 0239 9.4598 $1,025.63 $1,253.71 $769.27 67805 T 0238 4.0224 $436.11 $533.09 $327.10 67808 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67810 T 0238 4.0224 $436.11 $533.09 $327.10 67820 Q1 0698 1.3596 $147.41 $180.19 $110.56 67825 T 0238 4.0224 $436.11 $533.09 $327.10 67830 T 0239 9.4598 $1,025.63 $1,253.71 $769.27 67835 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67840 T 0239 9.4598 $1,025.63 $1,253.71 $769.27 67850 T 0239 9.4598 $1,025.63 $1,253.71 $769.27 67875 T 0239 9.4598 $1,025.63 $1,253.71 $769.27 67880 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67882 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67900 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67901 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67902 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 67903 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67904 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67906 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67908 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67909 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67911 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67912 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67914 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67915 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67916 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54


130


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee67917 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67921 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67922 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67923 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67924 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67930 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67935 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67938 T 0238 4.0224 $436.11 $533.09 $327.10 67950 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67961 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67966 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67971 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67973 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67974 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67975 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 67999 T 0238 4.0224 $436.11 $533.09 $327.10 68020 T 0239 9.4598 $1,025.63 $1,253.71 $769.27 68040 T 0238 4.0224 $436.11 $533.09 $327.10 68100 T 0239 9.4598 $1,025.63 $1,253.71 $769.27 68110 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 68115 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 68130 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 68135 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 68200 Q1 0698 1.3596 $147.41 $180.19 $110.56 68320 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 68325 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 68326 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 68328 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 68330 T 0233 23.6288 $2,561.83 $3,131.52 $1,921.49 68335 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 68340 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 68360 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 68362 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 68371 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 68399 T 0238 4.0224 $436.11 $533.09 $327.10 68400 T 0239 9.4598 $1,025.63 $1,253.71 $769.27 68420 T 0239 9.4598 $1,025.63 $1,253.71 $769.27 68440 T 0238 4.0224 $436.11 $533.09 $327.10 68500 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 68505 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 68510 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 68520 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 68525 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 68530 T 0238 4.0224 $436.11 $533.09 $327.10 68540 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 68550 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 68700 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 68705 T 0238 4.0224 $436.11 $533.09 $327.10 68720 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 68745 T 0242 35.9699 $3,899.86 $4,767.09 $2,925.07 68750 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54


131


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee68760 T 0238 4.0224 $436.11 $533.09 $327.10 68761 T 0238 4.0224 $436.11 $533.09 $327.10 68770 T 0239 9.4598 $1,025.63 $1,253.71 $769.27 68801 Q1 0698 1.3596 $147.41 $180.19 $110.56 68810 T 0238 4.0224 $436.11 $533.09 $327.10 68811 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 68815 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 68816 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 68840 T 0238 4.0224 $436.11 $533.09 $327.10 68850 N $0.00 $0.00 $0.00 68899 T 0238 4.0224 $436.11 $533.09 $327.10 69000 T 0006 2.1836 $236.75 $289.39 $177.57 69005 T 0007 11.6749 $1,265.79 $1,547.27 $949.40 69020 T 0006 2.1836 $236.75 $289.39 $177.57 69090 E $0.00 $0.00 $0.0069100 T 0251 4.8979 $531.03 $649.12 $398.30 69105 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 69110 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 69120 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 69140 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69145 T 0021 18.0849 $1,960.76 $2,396.79 $1,470.66 69150 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 69155 C $0.00 $0.00 $0.0069200 Q1 0420 1.7762 $192.58 $235.40 $144.44 69205 T 0022 24.5953 $2,666.62 $3,259.62 $2,000.09 69210 Q1 0340 0.7061 $76.56 $93.58 $57.42 69220 Q1 0012 1.3279 $143.97 $175.99 $107.98 69222 T 0252 8.7183 $945.24 $1,155.44 $708.97 69300 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 69310 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69320 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69399 T 0250 1.7489 $189.62 $231.78 $142.22 69420 T 0251 4.8979 $531.03 $649.12 $398.30 69421 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 69424 Q2 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 69433 T 0251 4.8979 $531.03 $649.12 $398.30 69436 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 69440 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69450 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69501 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69502 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69505 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69511 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69530 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69535 C $0.00 $0.00 $0.0069540 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 69550 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69552 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69554 C $0.00 $0.00 $0.0069601 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69602 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44


132


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee69603 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69604 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69605 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69610 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 69620 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 69631 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69632 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69633 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69635 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69636 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69637 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69641 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69642 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69643 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69644 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69645 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69646 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69650 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69660 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69661 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69662 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69666 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 69667 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 69670 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69676 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 69700 T 0254 26.2386 $2,844.79 $3,477.40 $2,133.72 69710 E $0.00 $0.00 $0.0069711 Q2 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69714 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 69715 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 69717 T 0047 45.3575 $4,917.66 $6,011.23 $3,688.47 69718 J1 0425 137.8399 $14,944.60 $18,267.92 $11,209.14 69720 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69725 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69740 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69745 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69799 T 0250 1.7489 $189.62 $231.78 $142.22 69801 T 0253 17.0798 $1,851.79 $2,263.59 $1,388.93 69805 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69806 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69820 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69840 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69905 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69910 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69915 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69930 J1 0259 400.6642 $43,440.01 $53,100.03 $32,582.01 69949 T 0250 1.7489 $189.62 $231.78 $142.22 69950 C $0.00 $0.00 $0.0069955 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69960 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44 69970 T 0256 50.2882 $5,452.25 $6,664.70 $4,089.44


133


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee69979 T 0250 1.7489 $189.62 $231.78 $142.22 69990 N $0.00 $0.00 $0.00 70010 Q2 0274 8.2817 $897.90 $1,097.57 $673.47 70015 Q2 0274 8.2817 $897.90 $1,097.57 $673.47 70030 Q1 0260 0.8004 $86.78 $106.08 $65.09 70100 Q1 0260 0.8004 $86.78 $106.08 $65.09 7010F M $0.00 $0.00 $0.0070110 Q1 0261 1.281 $138.89 $169.77 $104.17 70120 Q1 0260 0.8004 $86.78 $106.08 $65.09 70130 Q1 0261 1.281 $138.89 $169.77 $104.17 70134 Q1 0261 1.281 $138.89 $169.77 $104.17 70140 Q1 0260 0.8004 $86.78 $106.08 $65.09 70150 Q1 0261 1.281 $138.89 $169.77 $104.17 70160 Q1 0260 0.8004 $86.78 $106.08 $65.09 70170 Q2 0263 4.5438 $492.64 $602.19 $369.50 70190 Q1 0261 1.281 $138.89 $169.77 $104.17 70200 Q1 0261 1.281 $138.89 $169.77 $104.17 7020F E $0.00 $0.00 $0.0070210 Q1 0260 0.8004 $86.78 $106.08 $65.09 70220 Q1 0261 1.281 $138.89 $169.77 $104.17 70240 Q1 0260 0.8004 $86.78 $106.08 $65.09 70250 Q1 0261 1.281 $138.89 $169.77 $104.17 7025F M $0.00 $0.00 $0.0070260 Q1 0261 1.281 $138.89 $169.77 $104.17 70300 Q1 0260 0.8004 $86.78 $106.08 $65.09 70310 Q1 0261 1.281 $138.89 $169.77 $104.17 70320 Q1 0260 0.8004 $86.78 $106.08 $65.09 70328 Q1 0260 0.8004 $86.78 $106.08 $65.09 70330 Q1 0260 0.8004 $86.78 $106.08 $65.09 70332 Q2 0275 4.5657 $495.01 $605.09 $371.28 70336 Q3 0336 3.8614 $418.65 $511.75 $314.01 70350 Q1 0260 0.8004 $86.78 $106.08 $65.09 70355 Q1 0260 0.8004 $86.78 $106.08 $65.09 70360 Q1 0260 0.8004 $86.78 $106.08 $65.09 70370 S 0272 2.1508 $233.19 $285.05 $174.90 70371 S 0272 2.1508 $233.19 $285.05 $174.90 70373 Q2 0263 4.5438 $492.64 $602.19 $369.50 70380 Q1 0260 0.8004 $86.78 $106.08 $65.09 70390 Q2 0263 4.5438 $492.64 $602.19 $369.50 70450 Q3 0332 1.6181 $175.43 $214.45 $131.58 70460 Q3 0283 3.2481 $352.16 $430.47 $264.14 70470 Q3 0333 3.6362 $394.24 $481.91 $295.70 70480 Q3 0332 1.6181 $175.43 $214.45 $131.58 70481 Q3 0283 3.2481 $352.16 $430.47 $264.14 70482 Q3 0333 3.6362 $394.24 $481.91 $295.70 70486 Q3 0332 1.6181 $175.43 $214.45 $131.58 70487 Q3 0283 3.2481 $352.16 $430.47 $264.14 70488 Q3 0333 3.6362 $394.24 $481.91 $295.70 70490 Q3 0332 1.6181 $175.43 $214.45 $131.58 70491 Q3 0283 3.2481 $352.16 $430.47 $264.14 70492 Q3 0333 3.6362 $394.24 $481.91 $295.70


134


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee70496 Q3 0662 3.8011 $412.12 $503.76 $309.11 70498 Q3 0662 3.8011 $412.12 $503.76 $309.11 70540 Q3 0336 3.8614 $418.65 $511.75 $314.01 70542 Q3 0284 5.7574 $624.22 $763.03 $468.19 70543 Q3 0337 6.5129 $706.13 $863.15 $529.63 70544 Q3 0336 3.8614 $418.65 $511.75 $314.01 70545 Q3 0284 5.7574 $624.22 $763.03 $468.19 70546 Q3 0337 6.5129 $706.13 $863.15 $529.63 70547 Q3 0336 3.8614 $418.65 $511.75 $314.01 70548 Q3 0284 5.7574 $624.22 $763.03 $468.19 70549 Q3 0337 6.5129 $706.13 $863.15 $529.63 70551 Q3 0336 3.8614 $418.65 $511.75 $314.01 70552 Q3 0284 5.7574 $624.22 $763.03 $468.19 70553 Q3 0337 6.5129 $706.13 $863.15 $529.63 70554 Q3 0336 3.8614 $418.65 $511.75 $314.01 70555 S 0336 3.8614 $418.65 $511.75 $314.01 70557 S 0336 3.8614 $418.65 $511.75 $314.01 70558 S 0284 5.7574 $624.22 $763.03 $468.19 70559 S 0337 6.5129 $706.13 $863.15 $529.63 71010 Q3 0260 0.8004 $86.78 $106.08 $65.09 71015 Q3 0260 0.8004 $86.78 $106.08 $65.09 71020 Q3 0260 0.8004 $86.78 $106.08 $65.09 71021 Q1 0260 0.8004 $86.78 $106.08 $65.09 71022 Q1 0261 1.281 $138.89 $169.77 $104.17 71023 Q1 0261 1.281 $138.89 $169.77 $104.17 71030 Q1 0261 1.281 $138.89 $169.77 $104.17 71034 S 0272 2.1508 $233.19 $285.05 $174.90 71035 Q1 0260 0.8004 $86.78 $106.08 $65.09 71100 Q1 0260 0.8004 $86.78 $106.08 $65.09 71101 Q1 0261 1.281 $138.89 $169.77 $104.17 71110 Q1 0261 1.281 $138.89 $169.77 $104.17 71111 Q1 0261 1.281 $138.89 $169.77 $104.17 71120 Q1 0260 0.8004 $86.78 $106.08 $65.09 71130 Q1 0260 0.8004 $86.78 $106.08 $65.09 71250 Q3 0332 1.6181 $175.43 $214.45 $131.58 71260 Q3 0283 3.2481 $352.16 $430.47 $264.14 71270 Q3 0333 3.6362 $394.24 $481.91 $295.70 71275 Q3 0662 3.8011 $412.12 $503.76 $309.11 71550 Q3 0336 3.8614 $418.65 $511.75 $314.01 71551 Q3 0284 5.7574 $624.22 $763.03 $468.19 71552 Q3 0337 6.5129 $706.13 $863.15 $529.63 71555 B $0.00 $0.00 $0.0072010 S 0272 2.1508 $233.19 $285.05 $174.90 72020 Q1 0260 0.8004 $86.78 $106.08 $65.09 72040 Q1 0261 1.281 $138.89 $169.77 $104.17 72050 Q1 0261 1.281 $138.89 $169.77 $104.17 72052 Q1 0261 1.281 $138.89 $169.77 $104.17 72069 Q1 0260 0.8004 $86.78 $106.08 $65.09 72070 Q1 0261 1.281 $138.89 $169.77 $104.17 72072 Q1 0261 1.281 $138.89 $169.77 $104.17 72074 Q1 0261 1.281 $138.89 $169.77 $104.17


135


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee72080 Q1 0260 0.8004 $86.78 $106.08 $65.09 72090 Q1 0261 1.281 $138.89 $169.77 $104.17 72100 Q1 0261 1.281 $138.89 $169.77 $104.17 72110 Q1 0261 1.281 $138.89 $169.77 $104.17 72114 Q1 0261 1.281 $138.89 $169.77 $104.17 72120 Q1 0261 1.281 $138.89 $169.77 $104.17 72125 Q3 0332 1.6181 $175.43 $214.45 $131.58 72126 Q3 0283 3.2481 $352.16 $430.47 $264.14 72127 Q3 0333 3.6362 $394.24 $481.91 $295.70 72128 Q3 0332 1.6181 $175.43 $214.45 $131.58 72129 Q3 0283 3.2481 $352.16 $430.47 $264.14 72130 Q3 0333 3.6362 $394.24 $481.91 $295.70 72131 Q3 0332 1.6181 $175.43 $214.45 $131.58 72132 Q3 0283 3.2481 $352.16 $430.47 $264.14 72133 Q3 0333 3.6362 $394.24 $481.91 $295.70 72141 Q3 0336 3.8614 $418.65 $511.75 $314.01 72142 Q3 0284 5.7574 $624.22 $763.03 $468.19 72146 Q3 0336 3.8614 $418.65 $511.75 $314.01 72147 Q3 0284 5.7574 $624.22 $763.03 $468.19 72148 Q3 0336 3.8614 $418.65 $511.75 $314.01 72149 Q3 0284 5.7574 $624.22 $763.03 $468.19 72156 Q3 0337 6.5129 $706.13 $863.15 $529.63 72157 Q3 0337 6.5129 $706.13 $863.15 $529.63 72158 Q3 0337 6.5129 $706.13 $863.15 $529.63 72159 B $0.00 $0.00 $0.0072170 Q1 0261 1.281 $138.89 $169.77 $104.17 72190 Q1 0261 1.281 $138.89 $169.77 $104.17 72191 Q3 0662 3.8011 $412.12 $503.76 $309.11 72192 Q3 0332 1.6181 $175.43 $214.45 $131.58 72193 Q3 0283 3.2481 $352.16 $430.47 $264.14 72194 Q3 0333 3.6362 $394.24 $481.91 $295.70 72195 Q3 0336 3.8614 $418.65 $511.75 $314.01 72196 Q3 0284 5.7574 $624.22 $763.03 $468.19 72197 Q3 0337 6.5129 $706.13 $863.15 $529.63 72198 B $0.00 $0.00 $0.0072200 Q1 0260 0.8004 $86.78 $106.08 $65.09 72202 Q1 0261 1.281 $138.89 $169.77 $104.17 72220 Q1 0260 0.8004 $86.78 $106.08 $65.09 72240 Q2 0274 8.2817 $897.90 $1,097.57 $673.47 72255 Q2 0274 8.2817 $897.90 $1,097.57 $673.47 72265 Q2 0274 8.2817 $897.90 $1,097.57 $673.47 72270 Q2 0274 8.2817 $897.90 $1,097.57 $673.47 72275 N $0.00 $0.00 $0.00 72285 Q2 0388 44.9321 $4,871.54 $5,954.85 $3,653.88 72295 Q2 0388 44.9321 $4,871.54 $5,954.85 $3,653.88 73000 Q1 0260 0.8004 $86.78 $106.08 $65.09 73010 Q1 0260 0.8004 $86.78 $106.08 $65.09 73020 Q1 0260 0.8004 $86.78 $106.08 $65.09 73030 Q1 0261 1.281 $138.89 $169.77 $104.17 73040 Q2 0275 4.5657 $495.01 $605.09 $371.28 73050 Q1 0261 1.281 $138.89 $169.77 $104.17


136


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee73060 Q1 0260 0.8004 $86.78 $106.08 $65.09 73070 Q1 0260 0.8004 $86.78 $106.08 $65.09 73080 Q1 0260 0.8004 $86.78 $106.08 $65.09 73085 Q2 0275 4.5657 $495.01 $605.09 $371.28 73090 Q1 0260 0.8004 $86.78 $106.08 $65.09 73092 Q1 0261 1.281 $138.89 $169.77 $104.17 73100 Q1 0260 0.8004 $86.78 $106.08 $65.09 73110 Q1 0260 0.8004 $86.78 $106.08 $65.09 73115 Q2 0275 4.5657 $495.01 $605.09 $371.28 73120 Q1 0261 1.281 $138.89 $169.77 $104.17 73130 Q1 0260 0.8004 $86.78 $106.08 $65.09 73140 Q1 0260 0.8004 $86.78 $106.08 $65.09 73200 Q3 0332 1.6181 $175.43 $214.45 $131.58 73201 Q3 0283 3.2481 $352.16 $430.47 $264.14 73202 Q3 0333 3.6362 $394.24 $481.91 $295.70 73206 Q3 0662 3.8011 $412.12 $503.76 $309.11 73218 Q3 0336 3.8614 $418.65 $511.75 $314.01 73219 Q3 0284 5.7574 $624.22 $763.03 $468.19 73220 Q3 0337 6.5129 $706.13 $863.15 $529.63 73221 Q3 0336 3.8614 $418.65 $511.75 $314.01 73222 Q3 0284 5.7574 $624.22 $763.03 $468.19 73223 Q3 0337 6.5129 $706.13 $863.15 $529.63 73225 B $0.00 $0.00 $0.0073500 Q1 0260 0.8004 $86.78 $106.08 $65.09 73510 Q1 0260 0.8004 $86.78 $106.08 $65.09 73520 Q1 0261 1.281 $138.89 $169.77 $104.17 73525 Q2 0275 4.5657 $495.01 $605.09 $371.28 73530 N $0.00 $0.00 $0.00 73540 Q1 0260 0.8004 $86.78 $106.08 $65.09 73550 Q1 0260 0.8004 $86.78 $106.08 $65.09 73560 Q1 0260 0.8004 $86.78 $106.08 $65.09 73562 Q1 0261 1.281 $138.89 $169.77 $104.17 73564 Q1 0261 1.281 $138.89 $169.77 $104.17 73565 Q1 0260 0.8004 $86.78 $106.08 $65.09 73580 Q2 0275 4.5657 $495.01 $605.09 $371.28 73590 Q1 0260 0.8004 $86.78 $106.08 $65.09 73592 Q1 0261 1.281 $138.89 $169.77 $104.17 73600 Q1 0261 1.281 $138.89 $169.77 $104.17 73610 Q1 0261 1.281 $138.89 $169.77 $104.17 73615 Q2 0275 4.5657 $495.01 $605.09 $371.28 73620 Q1 0260 0.8004 $86.78 $106.08 $65.09 73630 Q1 0260 0.8004 $86.78 $106.08 $65.09 73650 Q1 0260 0.8004 $86.78 $106.08 $65.09 73660 Q1 0260 0.8004 $86.78 $106.08 $65.09 73700 Q3 0332 1.6181 $175.43 $214.45 $131.58 73701 Q3 0283 3.2481 $352.16 $430.47 $264.14 73702 Q3 0333 3.6362 $394.24 $481.91 $295.70 73706 Q3 0662 3.8011 $412.12 $503.76 $309.11 73718 Q3 0336 3.8614 $418.65 $511.75 $314.01 73719 Q3 0284 5.7574 $624.22 $763.03 $468.19 73720 Q3 0337 6.5129 $706.13 $863.15 $529.63


137


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee73721 Q3 0336 3.8614 $418.65 $511.75 $314.01 73722 Q3 0284 5.7574 $624.22 $763.03 $468.19 73723 Q3 0337 6.5129 $706.13 $863.15 $529.63 73725 B $0.00 $0.00 $0.0074000 Q1 0260 0.8004 $86.78 $106.08 $65.09 74010 Q1 0260 0.8004 $86.78 $106.08 $65.09 74020 Q1 0261 1.281 $138.89 $169.77 $104.17 74022 Q1 0261 1.281 $138.89 $169.77 $104.17 74150 Q3 0332 1.6181 $175.43 $214.45 $131.58 74160 Q3 0283 3.2481 $352.16 $430.47 $264.14 74170 Q3 0333 3.6362 $394.24 $481.91 $295.70 74174 S 0334 5.0634 $548.97 $671.05 $411.76 74175 Q3 0662 3.8011 $412.12 $503.76 $309.11 74176 Q3 0331 3.1933 $346.22 $423.21 $259.68 74177 Q3 0334 5.0634 $548.97 $671.05 $411.76 74178 Q3 0334 5.0634 $548.97 $671.05 $411.76 74181 Q3 0336 3.8614 $418.65 $511.75 $314.01 74182 Q3 0284 5.7574 $624.22 $763.03 $468.19 74183 Q3 0337 6.5129 $706.13 $863.15 $529.63 74185 B $0.00 $0.00 $0.0074190 Q2 0263 4.5438 $492.64 $602.19 $369.50 74210 S 0276 1.371 $148.64 $181.70 $111.49 74220 S 0276 1.371 $148.64 $181.70 $111.49 74230 S 0276 1.371 $148.64 $181.70 $111.49 74235 N $0.00 $0.00 $0.00 74240 S 0277 2.0357 $220.71 $269.79 $165.54 74241 S 0277 2.0357 $220.71 $269.79 $165.54 74245 S 0277 2.0357 $220.71 $269.79 $165.54 74246 S 0277 2.0357 $220.71 $269.79 $165.54 74247 S 0277 2.0357 $220.71 $269.79 $165.54 74249 S 0277 2.0357 $220.71 $269.79 $165.54 74250 S 0276 1.371 $148.64 $181.70 $111.49 74251 S 0277 2.0357 $220.71 $269.79 $165.54 74260 S 0276 1.371 $148.64 $181.70 $111.49 74261 Q3 0332 1.6181 $175.43 $214.45 $131.58 74262 Q3 0283 3.2481 $352.16 $430.47 $264.14 74263 E $0.00 $0.00 $0.0074270 S 0277 2.0357 $220.71 $269.79 $165.54 74280 S 0277 2.0357 $220.71 $269.79 $165.54 74283 S 0277 2.0357 $220.71 $269.79 $165.54 74290 S 0276 1.371 $148.64 $181.70 $111.49 74300 N $0.00 $0.00 $0.00 74301 N $0.00 $0.00 $0.00 74305 Q2 0263 4.5438 $492.64 $602.19 $369.50 74320 Q2 0317 10.9636 $1,188.67 $1,453.01 $891.56 74327 N $0.00 $0.00 $0.00 74328 N $0.00 $0.00 $0.00 74329 N $0.00 $0.00 $0.00 74330 N $0.00 $0.00 $0.00 74340 N $0.00 $0.00 $0.00 74355 N $0.00 $0.00 $0.00


138


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee74360 N $0.00 $0.00 $0.00 74363 N $0.00 $0.00 $0.00 74400 S 0278 3.5761 $387.72 $473.94 $290.81 74410 S 0278 3.5761 $387.72 $473.94 $290.81 74415 S 0278 3.5761 $387.72 $473.94 $290.81 74420 S 0278 3.5761 $387.72 $473.94 $290.81 74425 Q2 0278 3.5761 $387.72 $473.94 $290.81 74430 Q2 0278 3.5761 $387.72 $473.94 $290.81 74440 Q2 0278 3.5761 $387.72 $473.94 $290.81 74445 Q2 0278 3.5761 $387.72 $473.94 $290.81 74450 Q2 0278 3.5761 $387.72 $473.94 $290.81 74455 Q2 0278 3.5761 $387.72 $473.94 $290.81 74470 Q2 0317 10.9636 $1,188.67 $1,453.01 $891.56 74475 Q2 0161 16.5418 $1,793.46 $2,192.28 $1,345.18 74480 Q2 0161 16.5418 $1,793.46 $2,192.28 $1,345.18 74485 Q2 0161 16.5418 $1,793.46 $2,192.28 $1,345.18 74710 Q1 0261 1.281 $138.89 $169.77 $104.17 74740 Q2 0263 4.5438 $492.64 $602.19 $369.50 74742 N $0.00 $0.00 $0.00 74775 S 0278 3.5761 $387.72 $473.94 $290.81 75557 Q3 0336 3.8614 $418.65 $511.75 $314.01 75559 Q3 0336 3.8614 $418.65 $511.75 $314.01 75561 Q3 0337 6.5129 $706.13 $863.15 $529.63 75563 Q3 0377 15.3768 $1,667.15 $2,037.89 $1,250.44 75565 N $0.00 $0.00 $0.00 75571 Q1 0450 0.3942 $42.74 $52.24 $32.06 75572 S 0383 2.9128 $315.81 $386.03 $236.87 75573 S 0383 2.9128 $315.81 $386.03 $236.87 75574 S 0383 2.9128 $315.81 $386.03 $236.87 75600 Q2 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 75605 Q2 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 75625 Q2 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 75630 Q2 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 75635 Q2 0662 3.8011 $412.12 $503.76 $309.11 75658 Q2 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 75705 Q2 0280 71.7863 $7,783.07 $9,513.84 $5,837.66 75710 Q2 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 75716 Q2 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 75726 Q2 0280 71.7863 $7,783.07 $9,513.84 $5,837.66 75731 Q2 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 75733 Q2 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 75736 Q2 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 75741 Q2 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 75743 Q2 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 75746 Q2 0668 11.1566 $1,209.60 $1,478.58 $907.25 75756 Q2 0668 11.1566 $1,209.60 $1,478.58 $907.25 75774 N $0.00 $0.00 $0.00 75791 Q2 0668 11.1566 $1,209.60 $1,478.58 $907.25 75801 Q2 0263 4.5438 $492.64 $602.19 $369.50 75803 Q2 0317 10.9636 $1,188.67 $1,453.01 $891.56 75805 Q2 0317 10.9636 $1,188.67 $1,453.01 $891.56


139


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee75807 Q2 0317 10.9636 $1,188.67 $1,453.01 $891.56 75809 Q2 0261 1.281 $138.89 $169.77 $104.17 75810 Q2 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 75820 Q2 0668 11.1566 $1,209.60 $1,478.58 $907.25 75822 Q2 0317 10.9636 $1,188.67 $1,453.01 $891.56 75825 Q2 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 75827 Q2 0668 11.1566 $1,209.60 $1,478.58 $907.25 75831 Q2 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 75833 Q2 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 75840 Q2 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 75842 Q2 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 75860 Q2 0668 11.1566 $1,209.60 $1,478.58 $907.25 75870 Q2 0263 4.5438 $492.64 $602.19 $369.50 75872 Q2 0668 11.1566 $1,209.60 $1,478.58 $907.25 75880 Q2 0668 11.1566 $1,209.60 $1,478.58 $907.25 75885 Q2 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 75887 Q2 0668 11.1566 $1,209.60 $1,478.58 $907.25 75889 Q2 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 75891 Q2 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 75893 Q2 0279 34.5196 $3,742.62 $4,574.88 $2,807.13 75894 N $0.00 $0.00 $0.00 75896 N $0.00 $0.00 $0.00 75898 Q1 0668 11.1566 $1,209.60 $1,478.58 $907.25 75901 N $0.00 $0.00 $0.00 75902 N $0.00 $0.00 $0.00 75945 Q2 0267 2.5565 $277.18 $338.81 $207.89 75946 N $0.00 $0.00 $0.00 75952 C $0.00 $0.00 $0.0075953 C $0.00 $0.00 $0.0075954 C $0.00 $0.00 $0.0075956 C $0.00 $0.00 $0.0075957 C $0.00 $0.00 $0.0075958 C $0.00 $0.00 $0.0075959 C $0.00 $0.00 $0.0075962 N $0.00 $0.00 $0.00 75964 N $0.00 $0.00 $0.00 75966 N $0.00 $0.00 $0.00 75968 N $0.00 $0.00 $0.00 75970 N $0.00 $0.00 $0.00 75978 Q2 0093 33.7207 $3,656.00 $4,469.00 $2,742.17 75980 N $0.00 $0.00 $0.00 75982 N $0.00 $0.00 $0.00 75984 N $0.00 $0.00 $0.00 75989 N $0.00 $0.00 $0.00 76000 S 0272 2.1508 $233.19 $285.05 $174.90 76001 N $0.00 $0.00 $0.00 76010 Q1 0260 0.8004 $86.78 $106.08 $65.09 76080 Q2 0263 4.5438 $492.64 $602.19 $369.50 76098 Q2 0263 4.5438 $492.64 $602.19 $369.50 76100 Q1 0261 1.281 $138.89 $169.77 $104.17 76101 S 0263 4.5438 $492.64 $602.19 $369.50


140


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee76102 S 0263 4.5438 $492.64 $602.19 $369.50 76120 S 0272 2.1508 $233.19 $285.05 $174.90 76125 N $0.00 $0.00 $0.00 76140 E $0.00 $0.00 $0.0076376 N $0.00 $0.00 $0.00 76377 N $0.00 $0.00 $0.00 76380 Q1 0260 0.8004 $86.78 $106.08 $65.09 76390 E $0.00 $0.00 $0.0076496 S 0272 2.1508 $233.19 $285.05 $174.90 76497 Q1 0260 0.8004 $86.78 $106.08 $65.09 76498 S 0336 3.8614 $418.65 $511.75 $314.01 76499 Q1 0260 0.8004 $86.78 $106.08 $65.09 76506 S 0266 1.8181 $197.12 $240.95 $147.85 76510 Q1 0698 1.3596 $147.41 $180.19 $110.56 76511 S 0266 1.8181 $197.12 $240.95 $147.85 76512 S 0266 1.8181 $197.12 $240.95 $147.85 76513 S 0266 1.8181 $197.12 $240.95 $147.85 76514 Q1 0450 0.3942 $42.74 $52.24 $32.06 76516 Q1 0265 1.2362 $134.03 $163.83 $100.53 76519 Q1 0265 1.2362 $134.03 $163.83 $100.53 76529 S 0266 1.8181 $197.12 $240.95 $147.85 76536 S 0266 1.8181 $197.12 $240.95 $147.85 76604 Q3 0266 1.8181 $197.12 $240.95 $147.85 76641 Q1 0265 1.2362 $134.03 $163.83 $100.53 76642 Q1 0265 1.2362 $134.03 $163.83 $100.53 76700 Q3 0266 1.8181 $197.12 $240.95 $147.85 76705 Q3 0266 1.8181 $197.12 $240.95 $147.85 76770 Q3 0266 1.8181 $197.12 $240.95 $147.85 76775 Q3 0266 1.8181 $197.12 $240.95 $147.85 76776 Q3 0266 1.8181 $197.12 $240.95 $147.85 76800 Q1 0265 1.2362 $134.03 $163.83 $100.53 76801 S 0266 1.8181 $197.12 $240.95 $147.85 76802 N $0.00 $0.00 $0.00 76805 S 0266 1.8181 $197.12 $240.95 $147.85 76810 N $0.00 $0.00 $0.00 76811 S 0267 2.5565 $277.18 $338.81 $207.89 76812 N $0.00 $0.00 $0.00 76813 S 0266 1.8181 $197.12 $240.95 $147.85 76814 N $0.00 $0.00 $0.00 76815 S 0266 1.8181 $197.12 $240.95 $147.85 76816 Q1 0265 1.2362 $134.03 $163.83 $100.53 76817 S 0266 1.8181 $197.12 $240.95 $147.85 76818 S 0266 1.8181 $197.12 $240.95 $147.85 76819 S 0266 1.8181 $197.12 $240.95 $147.85 76820 Q1 0265 1.2362 $134.03 $163.83 $100.53 76821 Q1 0265 1.2362 $134.03 $163.83 $100.53 76825 S 0269 5.6995 $617.94 $755.35 $463.48 76826 S 0269 5.6995 $617.94 $755.35 $463.48 76827 Q1 0265 1.2362 $134.03 $163.83 $100.53 76828 Q1 0265 1.2362 $134.03 $163.83 $100.53 76830 S 0266 1.8181 $197.12 $240.95 $147.85


141


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee76831 Q3 0267 2.5565 $277.18 $338.81 $207.89 76856 Q3 0266 1.8181 $197.12 $240.95 $147.85 76857 Q3 0265 1.2362 $134.03 $163.83 $100.53 76870 Q3 0266 1.8181 $197.12 $240.95 $147.85 76872 S 0266 1.8181 $197.12 $240.95 $147.85 76873 S 0267 2.5565 $277.18 $338.81 $207.89 76881 S 0266 1.8181 $197.12 $240.95 $147.85 76882 Q1 0265 1.2362 $134.03 $163.83 $100.53 76885 Q1 0265 1.2362 $134.03 $163.83 $100.53 76886 Q1 0265 1.2362 $134.03 $163.83 $100.53 76930 N $0.00 $0.00 $0.00 76932 N $0.00 $0.00 $0.00 76936 S 0096 4.4459 $482.02 $589.22 $361.54 76937 N $0.00 $0.00 $0.00 76940 N $0.00 $0.00 $0.00 76941 N $0.00 $0.00 $0.00 76942 N $0.00 $0.00 $0.00 76945 N $0.00 $0.00 $0.00 76946 N $0.00 $0.00 $0.00 76948 N $0.00 $0.00 $0.00 76965 N $0.00 $0.00 $0.00 76970 Q1 0265 1.2362 $134.03 $163.83 $100.53 76975 Q2 0267 2.5565 $277.18 $338.81 $207.89 76977 S 0340 0.7061 $76.56 $93.58 $57.42 76998 N $0.00 $0.00 $0.00 76999 Q1 0265 1.2362 $134.03 $163.83 $100.53 77001 N $0.00 $0.00 $0.00 77002 N $0.00 $0.00 $0.00 77003 N $0.00 $0.00 $0.00 77011 N $0.00 $0.00 $0.00 77012 N $0.00 $0.00 $0.00 77013 N $0.00 $0.00 $0.00 77014 N $0.00 $0.00 $0.00 77021 N $0.00 $0.00 $0.00 77022 N $0.00 $0.00 $0.00 77051 A $0.00 $0.00 $0.0077052 A $0.00 $0.00 $0.0077053 Q2 0263 4.5438 $492.64 $602.19 $369.50 77054 Q2 0263 4.5438 $492.64 $602.19 $369.50 77055 A $0.00 $0.00 $0.0077056 A $0.00 $0.00 $0.0077057 A $0.00 $0.00 $0.0077058 B $0.00 $0.00 $0.0077059 B $0.00 $0.00 $0.0077061 E $0.00 $0.00 $0.0077062 E $0.00 $0.00 $0.0077063 A $0.00 $0.00 $0.0077071 Q1 0260 0.8004 $86.78 $106.08 $65.09 77072 Q1 0261 1.281 $138.89 $169.77 $104.17 77073 Q1 0261 1.281 $138.89 $169.77 $104.17 77074 Q1 0261 1.281 $138.89 $169.77 $104.17


142


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee77075 S 0272 2.1508 $233.19 $285.05 $174.90 77076 Q1 0261 1.281 $138.89 $169.77 $104.17 77077 Q1 0261 1.281 $138.89 $169.77 $104.17 77078 S 0260 0.8004 $86.78 $106.08 $65.09 77080 S 0261 1.281 $138.89 $169.77 $104.17 77081 S 0260 0.8004 $86.78 $106.08 $65.09 77084 S 0336 3.8614 $418.65 $511.75 $314.01 77085 Q1 0261 1.281 $138.89 $169.77 $104.17 77086 Q1 0260 0.8004 $86.78 $106.08 $65.09 77261 B $0.00 $0.00 $0.0077262 B $0.00 $0.00 $0.0077263 B $0.00 $0.00 $0.0077280 S 0304 1.5257 $165.42 $202.20 $124.07 77285 S 0305 4.2408 $459.79 $562.03 $344.86 77290 S 0305 4.2408 $459.79 $562.03 $344.86 77293 N $0.00 $0.00 $0.00 77295 S 0310 14.0014 $1,518.03 $1,855.61 $1,138.59 77299 S 0304 1.5257 $165.42 $202.20 $124.07 77300 S 0304 1.5257 $165.42 $202.20 $124.07 77301 S 0310 14.0014 $1,518.03 $1,855.61 $1,138.59 77306 S 0304 1.5257 $165.42 $202.20 $124.07 77307 S 0304 1.5257 $165.42 $202.20 $124.07 77316 S 0304 1.5257 $165.42 $202.20 $124.07 77317 S 0305 4.2408 $459.79 $562.03 $344.86 77318 S 0305 4.2408 $459.79 $562.03 $344.86 77321 S 0305 4.2408 $459.79 $562.03 $344.86 77331 S 0304 1.5257 $165.42 $202.20 $124.07 77332 S 0303 2.9071 $315.19 $385.28 $236.41 77333 S 0303 2.9071 $315.19 $385.28 $236.41 77334 S 0303 2.9071 $315.19 $385.28 $236.41 77336 S 0304 1.5257 $165.42 $202.20 $124.07 77338 S 0305 4.2408 $459.79 $562.03 $344.86 77370 S 0304 1.5257 $165.42 $202.20 $124.07 77371 J1 0067 131.7086 $14,279.85 $17,455.34 $10,710.54 77372 J1 0067 131.7086 $14,279.85 $17,455.34 $10,710.54 77373 S 0066 25.6592 $2,781.97 $3,400.61 $2,086.61 77385 S 0412 6.8455 $742.19 $907.23 $556.68 77386 S 0412 6.8455 $742.19 $907.23 $556.68 77387 N $0.00 $0.00 $0.00 77399 S 0304 1.5257 $165.42 $202.20 $124.07 77401 S 0300 1.35 $146.37 $178.92 $109.78 77402 S 0300 1.35 $146.37 $178.92 $109.78 77407 S 0300 1.35 $146.37 $178.92 $109.78 77412 S 0301 2.6053 $282.47 $345.28 $211.86 77417 N $0.00 $0.00 $0.00 77422 S 0301 2.6053 $282.47 $345.28 $211.86 77423 S 0301 2.6053 $282.47 $345.28 $211.86 77424 J1 0648 100.6339 $10,910.73 $13,337.01 $8,183.55 77425 J1 0648 100.6339 $10,910.73 $13,337.01 $8,183.55 77427 B $0.00 $0.00 $0.0077431 B $0.00 $0.00 $0.00


143


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee77432 B $0.00 $0.00 $0.0077435 N $0.00 $0.00 $0.00 77469 B $0.00 $0.00 $0.0077470 S 0412 6.8455 $742.19 $907.23 $556.68 77499 B $0.00 $0.00 $0.0077520 S 0412 6.8455 $742.19 $907.23 $556.68 77522 S 0667 14.4577 $1,567.50 $1,916.08 $1,175.70 77523 S 0667 14.4577 $1,567.50 $1,916.08 $1,175.70 77525 S 0667 14.4577 $1,567.50 $1,916.08 $1,175.70 77600 S 0301 2.6053 $282.47 $345.28 $211.86 77605 S 0412 6.8455 $742.19 $907.23 $556.68 77610 S 0412 6.8455 $742.19 $907.23 $556.68 77615 S 0412 6.8455 $742.19 $907.23 $556.68 77620 S 0412 6.8455 $742.19 $907.23 $556.68 77750 S 0301 2.6053 $282.47 $345.28 $211.86 77761 S 0312 5.3378 $578.72 $707.42 $434.07 77762 S 0312 5.3378 $578.72 $707.42 $434.07 77763 S 0312 5.3378 $578.72 $707.42 $434.07 77776 S 0312 5.3378 $578.72 $707.42 $434.07 77777 S 0312 5.3378 $578.72 $707.42 $434.07 77778 Q3 0651 12.8413 $1,392.25 $1,701.86 $1,044.25 77785 S 0313 9.8375 $1,066.58 $1,303.76 $799.99 77786 S 0313 9.8375 $1,066.58 $1,303.76 $799.99 77787 S 0313 9.8375 $1,066.58 $1,303.76 $799.99 77789 S 0301 2.6053 $282.47 $345.28 $211.86 77790 N $0.00 $0.00 $0.00 77799 S 0312 5.3378 $578.72 $707.42 $434.07 78012 S 0389 2.5502 $276.49 $337.98 $207.38 78013 S 0390 2.5605 $277.61 $339.34 $208.22 78014 S 0391 3.8019 $412.20 $503.87 $309.17 78015 S 0406 5.0871 $551.54 $674.19 $413.68 78016 S 0406 5.0871 $551.54 $674.19 $413.68 78018 S 0406 5.0871 $551.54 $674.19 $413.68 78020 N $0.00 $0.00 $0.00 78070 S 0391 3.8019 $412.20 $503.87 $309.17 78071 S 0406 5.0871 $551.54 $674.19 $413.68 78072 S 0406 5.0871 $551.54 $674.19 $413.68 78075 S 0408 16.0266 $1,737.60 $2,124.01 $1,303.28 78099 S 0390 2.5605 $277.61 $339.34 $208.22 78102 S 0400 4.983 $540.26 $660.40 $405.22 78103 S 0400 4.983 $540.26 $660.40 $405.22 78104 S 0400 4.983 $540.26 $660.40 $405.22 78110 S 0393 8.4693 $918.24 $1,122.44 $688.72 78111 S 0393 8.4693 $918.24 $1,122.44 $688.72 78120 S 0393 8.4693 $918.24 $1,122.44 $688.72 78121 S 0393 8.4693 $918.24 $1,122.44 $688.72 78122 S 0393 8.4693 $918.24 $1,122.44 $688.72 78130 S 0393 8.4693 $918.24 $1,122.44 $688.72 78135 S 0393 8.4693 $918.24 $1,122.44 $688.72 78140 S 0393 8.4693 $918.24 $1,122.44 $688.72 78185 S 0400 4.983 $540.26 $660.40 $405.22


144


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee78190 S 0392 3.7786 $409.68 $500.78 $307.28 78191 S 0392 3.7786 $409.68 $500.78 $307.28 78195 S 0400 4.983 $540.26 $660.40 $405.22 78199 S 0400 4.983 $540.26 $660.40 $405.22 78201 S 0394 5.0295 $545.30 $666.56 $409.00 78202 S 0394 5.0295 $545.30 $666.56 $409.00 78205 S 0394 5.0295 $545.30 $666.56 $409.00 78206 S 0394 5.0295 $545.30 $666.56 $409.00 78215 S 0394 5.0295 $545.30 $666.56 $409.00 78216 S 0394 5.0295 $545.30 $666.56 $409.00 78226 S 0394 5.0295 $545.30 $666.56 $409.00 78227 S 0394 5.0295 $545.30 $666.56 $409.00 78230 S 0395 4.408 $477.92 $584.19 $358.46 78231 S 0395 4.408 $477.92 $584.19 $358.46 78232 S 0395 4.408 $477.92 $584.19 $358.46 78258 S 0395 4.408 $477.92 $584.19 $358.46 78261 S 0395 4.408 $477.92 $584.19 $358.46 78262 S 0395 4.408 $477.92 $584.19 $358.46 78264 S 0395 4.408 $477.92 $584.19 $358.46 78267 A $0.00 $0.00 $0.0078268 A $0.00 $0.00 $0.0078270 S 0392 3.7786 $409.68 $500.78 $307.28 78271 S 0392 3.7786 $409.68 $500.78 $307.28 78272 S 0392 3.7786 $409.68 $500.78 $307.28 78278 S 0395 4.408 $477.92 $584.19 $358.46 78282 S 0395 4.408 $477.92 $584.19 $358.46 78290 S 0395 4.408 $477.92 $584.19 $358.46 78291 S 0395 4.408 $477.92 $584.19 $358.46 78299 S 0395 4.408 $477.92 $584.19 $358.46 78300 S 0396 4.4802 $485.74 $593.76 $364.33 78305 S 0396 4.4802 $485.74 $593.76 $364.33 78306 S 0396 4.4802 $485.74 $593.76 $364.33 78315 S 0396 4.4802 $485.74 $593.76 $364.33 78320 S 0396 4.4802 $485.74 $593.76 $364.33 78350 E $0.00 $0.00 $0.0078351 E $0.00 $0.00 $0.0078399 S 0396 4.4802 $485.74 $593.76 $364.33 78414 S 0398 5.0364 $546.05 $667.47 $409.56 78428 S 0398 5.0364 $546.05 $667.47 $409.56 78445 S 0263 4.5438 $492.64 $602.19 $369.50 78451 S 0377 15.3768 $1,667.15 $2,037.89 $1,250.44 78452 S 0377 15.3768 $1,667.15 $2,037.89 $1,250.44 78453 S 0377 15.3768 $1,667.15 $2,037.89 $1,250.44 78454 S 0377 15.3768 $1,667.15 $2,037.89 $1,250.44 78456 S 0317 10.9636 $1,188.67 $1,453.01 $891.56 78457 S 0263 4.5438 $492.64 $602.19 $369.50 78458 S 0263 4.5438 $492.64 $602.19 $369.50 78459 S 0308 17.3409 $1,880.10 $2,298.19 $1,410.16 78466 S 0398 5.0364 $546.05 $667.47 $409.56 78468 S 0398 5.0364 $546.05 $667.47 $409.56 78469 S 0398 5.0364 $546.05 $667.47 $409.56


145


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee78472 S 0398 5.0364 $546.05 $667.47 $409.56 78473 S 0398 5.0364 $546.05 $667.47 $409.56 78481 S 0398 5.0364 $546.05 $667.47 $409.56 78483 S 0377 15.3768 $1,667.15 $2,037.89 $1,250.44 78491 S 0308 17.3409 $1,880.10 $2,298.19 $1,410.16 78492 S 0308 17.3409 $1,880.10 $2,298.19 $1,410.16 78494 S 0398 5.0364 $546.05 $667.47 $409.56 78496 N $0.00 $0.00 $0.00 78499 S 0398 5.0364 $546.05 $667.47 $409.56 78579 S 0401 4.2588 $461.74 $564.42 $346.33 78580 S 0401 4.2588 $461.74 $564.42 $346.33 78582 S 0378 5.9367 $643.66 $786.79 $482.77 78597 S 0401 4.2588 $461.74 $564.42 $346.33 78598 S 0378 5.9367 $643.66 $786.79 $482.77 78599 S 0401 4.2588 $461.74 $564.42 $346.33 78600 S 0403 2.3871 $258.81 $316.36 $194.12 78601 S 0402 7.5128 $814.54 $995.67 $610.94 78605 S 0402 7.5128 $814.54 $995.67 $610.94 78606 S 0402 7.5128 $814.54 $995.67 $610.94 78607 S 0408 16.0266 $1,737.60 $2,124.01 $1,303.28 78608 S 0308 17.3409 $1,880.10 $2,298.19 $1,410.16 78609 E $0.00 $0.00 $0.0078610 S 0402 7.5128 $814.54 $995.67 $610.94 78630 S 0402 7.5128 $814.54 $995.67 $610.94 78635 S 0402 7.5128 $814.54 $995.67 $610.94 78645 S 0402 7.5128 $814.54 $995.67 $610.94 78647 S 0402 7.5128 $814.54 $995.67 $610.94 78650 S 0402 7.5128 $814.54 $995.67 $610.94 78660 S 0403 2.3871 $258.81 $316.36 $194.12 78699 S 0403 2.3871 $258.81 $316.36 $194.12 78700 S 0404 5.6713 $614.88 $751.62 $461.19 78701 S 0404 5.6713 $614.88 $751.62 $461.19 78707 S 0404 5.6713 $614.88 $751.62 $461.19 78708 S 0404 5.6713 $614.88 $751.62 $461.19 78709 S 0404 5.6713 $614.88 $751.62 $461.19 78710 S 0404 5.6713 $614.88 $751.62 $461.19 78725 S 0392 3.7786 $409.68 $500.78 $307.28 78730 N $0.00 $0.00 $0.00 78740 S 0404 5.6713 $614.88 $751.62 $461.19 78761 S 0404 5.6713 $614.88 $751.62 $461.19 78799 S 0404 5.6713 $614.88 $751.62 $461.19 78800 S 0406 5.0871 $551.54 $674.19 $413.68 78801 S 0406 5.0871 $551.54 $674.19 $413.68 78802 S 0414 9.5281 $1,033.04 $1,262.76 $774.83 78803 S 0414 9.5281 $1,033.04 $1,262.76 $774.83 78804 S 0408 16.0266 $1,737.60 $2,124.01 $1,303.28 78805 S 0414 9.5281 $1,033.04 $1,262.76 $774.83 78806 S 0414 9.5281 $1,033.04 $1,262.76 $774.83 78807 S 0414 9.5281 $1,033.04 $1,262.76 $774.83 78808 Q1 0392 3.7786 $409.68 $500.78 $307.28 78811 S 0308 17.3409 $1,880.10 $2,298.19 $1,410.16


146


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee78812 S 0308 17.3409 $1,880.10 $2,298.19 $1,410.16 78813 S 0308 17.3409 $1,880.10 $2,298.19 $1,410.16 78814 S 0308 17.3409 $1,880.10 $2,298.19 $1,410.16 78815 S 0308 17.3409 $1,880.10 $2,298.19 $1,410.16 78816 S 0308 17.3409 $1,880.10 $2,298.19 $1,410.16 78999 S 0389 2.5502 $276.49 $337.98 $207.38 79005 S 0407 3.7336 $404.80 $494.81 $303.62 79101 S 0407 3.7336 $404.80 $494.81 $303.62 79200 S 0407 3.7336 $404.80 $494.81 $303.62 79300 S 0407 3.7336 $404.80 $494.81 $303.62 79403 S 0407 3.7336 $404.80 $494.81 $303.62 79440 S 0407 3.7336 $404.80 $494.81 $303.62 79445 S 0407 3.7336 $404.80 $494.81 $303.62 79999 S 0407 3.7336 $404.80 $494.81 $303.62 80047 N $0.00 $0.00 $0.00 80048 N $0.00 $0.00 $0.00 80050 E $0.00 $0.00 $0.0080051 N $0.00 $0.00 $0.00 80053 N $0.00 $0.00 $0.00 80055 E $0.00 $0.00 $0.0080061 N $0.00 $0.00 $0.00 80069 N $0.00 $0.00 $0.00 80074 N $0.00 $0.00 $0.00 80076 N $0.00 $0.00 $0.00 80150 N $0.00 $0.00 $0.00 80155 A $0.00 $0.00 $0.0080156 N $0.00 $0.00 $0.00 80157 N $0.00 $0.00 $0.00 80158 N $0.00 $0.00 $0.00 80159 A $0.00 $0.00 $0.0080162 N $0.00 $0.00 $0.00 80163 N $0.00 $0.00 $0.00 80164 N $0.00 $0.00 $0.00 80165 N $0.00 $0.00 $0.00 80168 N $0.00 $0.00 $0.00 80169 A $0.00 $0.00 $0.0080170 N $0.00 $0.00 $0.00 80171 A $0.00 $0.00 $0.0080173 N $0.00 $0.00 $0.00 80175 A $0.00 $0.00 $0.0080176 N $0.00 $0.00 $0.00 80177 A $0.00 $0.00 $0.0080178 N $0.00 $0.00 $0.00 80180 A $0.00 $0.00 $0.0080183 A $0.00 $0.00 $0.0080184 N $0.00 $0.00 $0.00 80185 N $0.00 $0.00 $0.00 80186 N $0.00 $0.00 $0.00 80188 N $0.00 $0.00 $0.00 80190 N $0.00 $0.00 $0.00 80192 N $0.00 $0.00 $0.00


147


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee80194 N $0.00 $0.00 $0.00 80195 N $0.00 $0.00 $0.00 80197 N $0.00 $0.00 $0.00 80198 N $0.00 $0.00 $0.00 80199 A $0.00 $0.00 $0.0080200 N $0.00 $0.00 $0.00 80201 N $0.00 $0.00 $0.00 80202 N $0.00 $0.00 $0.00 80203 A $0.00 $0.00 $0.0080299 N $0.00 $0.00 $0.00 80300 B $0.00 $0.00 $0.0080301 B $0.00 $0.00 $0.0080302 B $0.00 $0.00 $0.0080303 B $0.00 $0.00 $0.0080304 B $0.00 $0.00 $0.0080320 B $0.00 $0.00 $0.0080321 B $0.00 $0.00 $0.0080322 B $0.00 $0.00 $0.0080323 B $0.00 $0.00 $0.0080324 B $0.00 $0.00 $0.0080325 B $0.00 $0.00 $0.0080326 B $0.00 $0.00 $0.0080327 B $0.00 $0.00 $0.0080328 B $0.00 $0.00 $0.0080329 B $0.00 $0.00 $0.0080330 B $0.00 $0.00 $0.0080331 B $0.00 $0.00 $0.0080332 B $0.00 $0.00 $0.0080333 B $0.00 $0.00 $0.0080334 B $0.00 $0.00 $0.0080335 B $0.00 $0.00 $0.0080336 B $0.00 $0.00 $0.0080337 B $0.00 $0.00 $0.0080338 B $0.00 $0.00 $0.0080339 B $0.00 $0.00 $0.0080340 B $0.00 $0.00 $0.0080341 B $0.00 $0.00 $0.0080342 B $0.00 $0.00 $0.0080343 B $0.00 $0.00 $0.0080344 B $0.00 $0.00 $0.0080345 B $0.00 $0.00 $0.0080346 B $0.00 $0.00 $0.0080347 B $0.00 $0.00 $0.0080348 B $0.00 $0.00 $0.0080349 B $0.00 $0.00 $0.0080350 B $0.00 $0.00 $0.0080351 B $0.00 $0.00 $0.0080352 B $0.00 $0.00 $0.0080353 B $0.00 $0.00 $0.0080354 B $0.00 $0.00 $0.0080355 B $0.00 $0.00 $0.00


148


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee80356 B $0.00 $0.00 $0.0080357 B $0.00 $0.00 $0.0080358 B $0.00 $0.00 $0.0080359 B $0.00 $0.00 $0.0080360 B $0.00 $0.00 $0.0080361 B $0.00 $0.00 $0.0080362 B $0.00 $0.00 $0.0080363 B $0.00 $0.00 $0.0080364 B $0.00 $0.00 $0.0080365 B $0.00 $0.00 $0.0080366 B $0.00 $0.00 $0.0080367 B $0.00 $0.00 $0.0080368 B $0.00 $0.00 $0.0080369 B $0.00 $0.00 $0.0080370 B $0.00 $0.00 $0.0080371 B $0.00 $0.00 $0.0080372 B $0.00 $0.00 $0.0080373 B $0.00 $0.00 $0.0080374 B $0.00 $0.00 $0.0080375 B $0.00 $0.00 $0.0080376 B $0.00 $0.00 $0.0080377 B $0.00 $0.00 $0.0080400 N $0.00 $0.00 $0.00 80402 N $0.00 $0.00 $0.00 80406 N $0.00 $0.00 $0.00 80408 N $0.00 $0.00 $0.00 80410 N $0.00 $0.00 $0.00 80412 N $0.00 $0.00 $0.00 80414 N $0.00 $0.00 $0.00 80415 N $0.00 $0.00 $0.00 80416 N $0.00 $0.00 $0.00 80417 N $0.00 $0.00 $0.00 80418 N $0.00 $0.00 $0.00 80420 N $0.00 $0.00 $0.00 80422 N $0.00 $0.00 $0.00 80424 N $0.00 $0.00 $0.00 80426 N $0.00 $0.00 $0.00 80428 N $0.00 $0.00 $0.00 80430 N $0.00 $0.00 $0.00 80432 N $0.00 $0.00 $0.00 80434 N $0.00 $0.00 $0.00 80435 N $0.00 $0.00 $0.00 80436 N $0.00 $0.00 $0.00 80438 N $0.00 $0.00 $0.00 80439 N $0.00 $0.00 $0.00 80500 Q1 0433 2.4765 $268.50 $328.21 $201.39 80502 Q1 0342 0.7318 $79.34 $96.99 $59.51 81000 N $0.00 $0.00 $0.00 81001 N $0.00 $0.00 $0.00 81002 N $0.00 $0.00 $0.00 81003 N $0.00 $0.00 $0.00


149


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee81005 N $0.00 $0.00 $0.00 81007 N $0.00 $0.00 $0.00 81015 N $0.00 $0.00 $0.00 81020 N $0.00 $0.00 $0.00 81025 N $0.00 $0.00 $0.00 81050 N $0.00 $0.00 $0.00 81099 N $0.00 $0.00 $0.00 81161 E $0.00 $0.00 $0.0081200 A $0.00 $0.00 $0.0081201 A $0.00 $0.00 $0.0081202 A $0.00 $0.00 $0.0081203 A $0.00 $0.00 $0.0081205 A $0.00 $0.00 $0.0081206 A $0.00 $0.00 $0.0081207 A $0.00 $0.00 $0.0081208 A $0.00 $0.00 $0.0081209 A $0.00 $0.00 $0.0081210 A $0.00 $0.00 $0.0081211 A $0.00 $0.00 $0.0081212 A $0.00 $0.00 $0.0081213 A $0.00 $0.00 $0.0081214 A $0.00 $0.00 $0.0081215 A $0.00 $0.00 $0.0081216 A $0.00 $0.00 $0.0081217 A $0.00 $0.00 $0.0081220 A $0.00 $0.00 $0.0081221 A $0.00 $0.00 $0.0081222 A $0.00 $0.00 $0.0081223 A $0.00 $0.00 $0.0081224 A $0.00 $0.00 $0.0081225 A $0.00 $0.00 $0.0081226 A $0.00 $0.00 $0.0081227 A $0.00 $0.00 $0.0081228 A $0.00 $0.00 $0.0081229 A $0.00 $0.00 $0.0081235 A $0.00 $0.00 $0.0081240 A $0.00 $0.00 $0.0081241 A $0.00 $0.00 $0.0081242 A $0.00 $0.00 $0.0081243 A $0.00 $0.00 $0.0081244 A $0.00 $0.00 $0.0081245 A $0.00 $0.00 $0.0081246 A $0.00 $0.00 $0.0081250 A $0.00 $0.00 $0.0081251 A $0.00 $0.00 $0.0081252 A $0.00 $0.00 $0.0081253 A $0.00 $0.00 $0.0081254 A $0.00 $0.00 $0.0081255 A $0.00 $0.00 $0.0081256 A $0.00 $0.00 $0.0081257 A $0.00 $0.00 $0.00


150


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee81260 A $0.00 $0.00 $0.0081261 A $0.00 $0.00 $0.0081262 A $0.00 $0.00 $0.0081263 A $0.00 $0.00 $0.0081264 A $0.00 $0.00 $0.0081265 A $0.00 $0.00 $0.0081266 A $0.00 $0.00 $0.0081267 A $0.00 $0.00 $0.0081268 A $0.00 $0.00 $0.0081270 A $0.00 $0.00 $0.0081275 A $0.00 $0.00 $0.0081280 A $0.00 $0.00 $0.0081281 A $0.00 $0.00 $0.0081282 A $0.00 $0.00 $0.0081287 A $0.00 $0.00 $0.0081288 A $0.00 $0.00 $0.0081290 A $0.00 $0.00 $0.0081291 A $0.00 $0.00 $0.0081292 A $0.00 $0.00 $0.0081293 A $0.00 $0.00 $0.0081294 A $0.00 $0.00 $0.0081295 A $0.00 $0.00 $0.0081296 A $0.00 $0.00 $0.0081297 A $0.00 $0.00 $0.0081298 A $0.00 $0.00 $0.0081299 A $0.00 $0.00 $0.0081300 A $0.00 $0.00 $0.0081301 A $0.00 $0.00 $0.0081302 A $0.00 $0.00 $0.0081303 A $0.00 $0.00 $0.0081304 A $0.00 $0.00 $0.0081310 A $0.00 $0.00 $0.0081313 A $0.00 $0.00 $0.0081315 A $0.00 $0.00 $0.0081316 A $0.00 $0.00 $0.0081317 A $0.00 $0.00 $0.0081318 A $0.00 $0.00 $0.0081319 A $0.00 $0.00 $0.0081321 A $0.00 $0.00 $0.0081322 A $0.00 $0.00 $0.0081323 A $0.00 $0.00 $0.0081324 A $0.00 $0.00 $0.0081325 A $0.00 $0.00 $0.0081326 A $0.00 $0.00 $0.0081330 A $0.00 $0.00 $0.0081331 A $0.00 $0.00 $0.0081332 A $0.00 $0.00 $0.0081340 A $0.00 $0.00 $0.0081341 A $0.00 $0.00 $0.0081342 A $0.00 $0.00 $0.0081350 A $0.00 $0.00 $0.00


151


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee81355 A $0.00 $0.00 $0.0081370 A $0.00 $0.00 $0.0081371 A $0.00 $0.00 $0.0081372 A $0.00 $0.00 $0.0081373 A $0.00 $0.00 $0.0081374 A $0.00 $0.00 $0.0081375 A $0.00 $0.00 $0.0081376 A $0.00 $0.00 $0.0081377 A $0.00 $0.00 $0.0081378 A $0.00 $0.00 $0.0081379 A $0.00 $0.00 $0.0081380 A $0.00 $0.00 $0.0081381 A $0.00 $0.00 $0.0081382 A $0.00 $0.00 $0.0081383 A $0.00 $0.00 $0.0081400 A $0.00 $0.00 $0.0081401 A $0.00 $0.00 $0.0081402 A $0.00 $0.00 $0.0081403 A $0.00 $0.00 $0.0081404 A $0.00 $0.00 $0.0081405 A $0.00 $0.00 $0.0081406 A $0.00 $0.00 $0.0081407 A $0.00 $0.00 $0.0081408 A $0.00 $0.00 $0.0081410 N $0.00 $0.00 $0.00 81411 N $0.00 $0.00 $0.00 81415 N $0.00 $0.00 $0.00 81416 N $0.00 $0.00 $0.00 81417 N $0.00 $0.00 $0.00 81420 N $0.00 $0.00 $0.00 81425 N $0.00 $0.00 $0.00 81426 N $0.00 $0.00 $0.00 81427 N $0.00 $0.00 $0.00 81430 N $0.00 $0.00 $0.00 81431 N $0.00 $0.00 $0.00 81435 N $0.00 $0.00 $0.00 81436 N $0.00 $0.00 $0.00 81440 N $0.00 $0.00 $0.00 81445 N $0.00 $0.00 $0.00 81450 N $0.00 $0.00 $0.00 81455 N $0.00 $0.00 $0.00 81460 N $0.00 $0.00 $0.00 81465 N $0.00 $0.00 $0.00 81470 N $0.00 $0.00 $0.00 81471 N $0.00 $0.00 $0.00 81479 A $0.00 $0.00 $0.0081500 E $0.00 $0.00 $0.0081503 E $0.00 $0.00 $0.0081504 A $0.00 $0.00 $0.0081506 E $0.00 $0.00 $0.0081507 A $0.00 $0.00 $0.00


152


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee81508 E $0.00 $0.00 $0.0081509 E $0.00 $0.00 $0.0081510 E $0.00 $0.00 $0.0081511 E $0.00 $0.00 $0.0081512 E $0.00 $0.00 $0.0081519 N $0.00 $0.00 $0.00 81599 E $0.00 $0.00 $0.0082009 N $0.00 $0.00 $0.00 82010 N $0.00 $0.00 $0.00 82013 N $0.00 $0.00 $0.00 82016 N $0.00 $0.00 $0.00 82017 N $0.00 $0.00 $0.00 82024 N $0.00 $0.00 $0.00 82030 N $0.00 $0.00 $0.00 82040 N $0.00 $0.00 $0.00 82042 N $0.00 $0.00 $0.00 82043 N $0.00 $0.00 $0.00 82044 N $0.00 $0.00 $0.00 82045 N $0.00 $0.00 $0.00 82075 N $0.00 $0.00 $0.00 82085 N $0.00 $0.00 $0.00 82088 N $0.00 $0.00 $0.00 82103 N $0.00 $0.00 $0.00 82104 N $0.00 $0.00 $0.00 82105 N $0.00 $0.00 $0.00 82106 N $0.00 $0.00 $0.00 82107 N $0.00 $0.00 $0.00 82108 N $0.00 $0.00 $0.00 82120 N $0.00 $0.00 $0.00 82127 N $0.00 $0.00 $0.00 82128 N $0.00 $0.00 $0.00 82131 N $0.00 $0.00 $0.00 82135 N $0.00 $0.00 $0.00 82136 N $0.00 $0.00 $0.00 82139 N $0.00 $0.00 $0.00 82140 N $0.00 $0.00 $0.00 82143 N $0.00 $0.00 $0.00 82150 N $0.00 $0.00 $0.00 82154 N $0.00 $0.00 $0.00 82157 N $0.00 $0.00 $0.00 82160 N $0.00 $0.00 $0.00 82163 N $0.00 $0.00 $0.00 82164 N $0.00 $0.00 $0.00 82172 N $0.00 $0.00 $0.00 82175 N $0.00 $0.00 $0.00 82180 N $0.00 $0.00 $0.00 82190 N $0.00 $0.00 $0.00 82232 N $0.00 $0.00 $0.00 82239 N $0.00 $0.00 $0.00 82240 N $0.00 $0.00 $0.00 82247 N $0.00 $0.00 $0.00


153


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee82248 N $0.00 $0.00 $0.00 82252 N $0.00 $0.00 $0.00 82261 N $0.00 $0.00 $0.00 82270 N $0.00 $0.00 $0.00 82271 N $0.00 $0.00 $0.00 82272 N $0.00 $0.00 $0.00 82274 N $0.00 $0.00 $0.00 82286 N $0.00 $0.00 $0.00 82300 N $0.00 $0.00 $0.00 82306 N $0.00 $0.00 $0.00 82308 N $0.00 $0.00 $0.00 82310 N $0.00 $0.00 $0.00 82330 N $0.00 $0.00 $0.00 82331 N $0.00 $0.00 $0.00 82340 N $0.00 $0.00 $0.00 82355 N $0.00 $0.00 $0.00 82360 N $0.00 $0.00 $0.00 82365 N $0.00 $0.00 $0.00 82370 N $0.00 $0.00 $0.00 82373 N $0.00 $0.00 $0.00 82374 N $0.00 $0.00 $0.00 82375 N $0.00 $0.00 $0.00 82376 N $0.00 $0.00 $0.00 82378 N $0.00 $0.00 $0.00 82379 N $0.00 $0.00 $0.00 82380 N $0.00 $0.00 $0.00 82382 N $0.00 $0.00 $0.00 82383 N $0.00 $0.00 $0.00 82384 N $0.00 $0.00 $0.00 82387 N $0.00 $0.00 $0.00 82390 N $0.00 $0.00 $0.00 82397 N $0.00 $0.00 $0.00 82415 N $0.00 $0.00 $0.00 82435 N $0.00 $0.00 $0.00 82436 N $0.00 $0.00 $0.00 82438 N $0.00 $0.00 $0.00 82441 N $0.00 $0.00 $0.00 82465 N $0.00 $0.00 $0.00 82480 N $0.00 $0.00 $0.00 82482 N $0.00 $0.00 $0.00 82485 N $0.00 $0.00 $0.00 82486 N $0.00 $0.00 $0.00 82487 N $0.00 $0.00 $0.00 82488 N $0.00 $0.00 $0.00 82489 N $0.00 $0.00 $0.00 82491 N $0.00 $0.00 $0.00 82492 N $0.00 $0.00 $0.00 82495 N $0.00 $0.00 $0.00 82507 N $0.00 $0.00 $0.00 82523 N $0.00 $0.00 $0.00 82525 N $0.00 $0.00 $0.00


154




155




156




157




158




159




160


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee84600 N $0.00 $0.00 $0.00 84620 N $0.00 $0.00 $0.00 84630 N $0.00 $0.00 $0.00 84681 N $0.00 $0.00 $0.00 84702 N $0.00 $0.00 $0.00 84703 N $0.00 $0.00 $0.00 84704 N $0.00 $0.00 $0.00 84830 N $0.00 $0.00 $0.00 84999 N $0.00 $0.00 $0.00 85002 N $0.00 $0.00 $0.00 85004 N $0.00 $0.00 $0.00 85007 N $0.00 $0.00 $0.00 85008 N $0.00 $0.00 $0.00 85009 N $0.00 $0.00 $0.00 85013 N $0.00 $0.00 $0.00 85014 N $0.00 $0.00 $0.00 85018 N $0.00 $0.00 $0.00 85025 N $0.00 $0.00 $0.00 85027 N $0.00 $0.00 $0.00 85032 N $0.00 $0.00 $0.00 85041 N $0.00 $0.00 $0.00 85044 N $0.00 $0.00 $0.00 85045 N $0.00 $0.00 $0.00 85046 N $0.00 $0.00 $0.00 85048 N $0.00 $0.00 $0.00 85049 N $0.00 $0.00 $0.00 85055 N $0.00 $0.00 $0.00 85060 B $0.00 $0.00 $0.0085097 S 0661 3.9671 $430.11 $525.76 $322.60 85130 N $0.00 $0.00 $0.00 85170 N $0.00 $0.00 $0.00 85175 N $0.00 $0.00 $0.00 85210 N $0.00 $0.00 $0.00 85220 N $0.00 $0.00 $0.00 85230 N $0.00 $0.00 $0.00 85240 N $0.00 $0.00 $0.00 85244 N $0.00 $0.00 $0.00 85245 N $0.00 $0.00 $0.00 85246 N $0.00 $0.00 $0.00 85247 N $0.00 $0.00 $0.00 85250 N $0.00 $0.00 $0.00 85260 N $0.00 $0.00 $0.00 85270 N $0.00 $0.00 $0.00 85280 N $0.00 $0.00 $0.00 85290 N $0.00 $0.00 $0.00 85291 N $0.00 $0.00 $0.00 85292 N $0.00 $0.00 $0.00 85293 N $0.00 $0.00 $0.00 85300 N $0.00 $0.00 $0.00 85301 N $0.00 $0.00 $0.00 85302 N $0.00 $0.00 $0.00


161




162


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee85670 N $0.00 $0.00 $0.00 85675 N $0.00 $0.00 $0.00 85705 N $0.00 $0.00 $0.00 85730 N $0.00 $0.00 $0.00 85732 N $0.00 $0.00 $0.00 85810 N $0.00 $0.00 $0.00 85999 N $0.00 $0.00 $0.00 86000 N $0.00 $0.00 $0.00 86001 N $0.00 $0.00 $0.00 86003 N $0.00 $0.00 $0.00 86005 N $0.00 $0.00 $0.00 86021 N $0.00 $0.00 $0.00 86022 N $0.00 $0.00 $0.00 86023 N $0.00 $0.00 $0.00 86038 N $0.00 $0.00 $0.00 86039 N $0.00 $0.00 $0.00 86060 N $0.00 $0.00 $0.00 86063 N $0.00 $0.00 $0.00 86077 Q1 0450 0.3942 $42.74 $52.24 $32.06 86078 Q1 0433 2.4765 $268.50 $328.21 $201.39 86079 Q1 0433 2.4765 $268.50 $328.21 $201.39 86140 N $0.00 $0.00 $0.00 86141 N $0.00 $0.00 $0.00 86146 N $0.00 $0.00 $0.00 86147 N $0.00 $0.00 $0.00 86148 N $0.00 $0.00 $0.00 86152 N $0.00 $0.00 $0.00 86153 B $0.00 $0.00 $0.0086155 N $0.00 $0.00 $0.00 86156 N $0.00 $0.00 $0.00 86157 N $0.00 $0.00 $0.00 86160 N $0.00 $0.00 $0.00 86161 N $0.00 $0.00 $0.00 86162 N $0.00 $0.00 $0.00 86171 N $0.00 $0.00 $0.00 86185 N $0.00 $0.00 $0.00 86200 N $0.00 $0.00 $0.00 86215 N $0.00 $0.00 $0.00 86225 N $0.00 $0.00 $0.00 86226 N $0.00 $0.00 $0.00 86235 N $0.00 $0.00 $0.00 86243 N $0.00 $0.00 $0.00 86255 N $0.00 $0.00 $0.00 86256 N $0.00 $0.00 $0.00 86277 N $0.00 $0.00 $0.00 86280 N $0.00 $0.00 $0.00 86294 N $0.00 $0.00 $0.00 86300 N $0.00 $0.00 $0.00 86301 N $0.00 $0.00 $0.00 86304 N $0.00 $0.00 $0.00 86305 N $0.00 $0.00 $0.00


163


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee86308 N $0.00 $0.00 $0.00 86309 N $0.00 $0.00 $0.00 86310 N $0.00 $0.00 $0.00 86316 N $0.00 $0.00 $0.00 86317 N $0.00 $0.00 $0.00 86318 N $0.00 $0.00 $0.00 86320 N $0.00 $0.00 $0.00 86325 N $0.00 $0.00 $0.00 86327 N $0.00 $0.00 $0.00 86329 N $0.00 $0.00 $0.00 86331 N $0.00 $0.00 $0.00 86332 N $0.00 $0.00 $0.00 86334 N $0.00 $0.00 $0.00 86335 N $0.00 $0.00 $0.00 86336 N $0.00 $0.00 $0.00 86337 N $0.00 $0.00 $0.00 86340 N $0.00 $0.00 $0.00 86341 N $0.00 $0.00 $0.00 86343 N $0.00 $0.00 $0.00 86344 N $0.00 $0.00 $0.00 86352 N $0.00 $0.00 $0.00 86353 N $0.00 $0.00 $0.00 86355 N $0.00 $0.00 $0.00 86356 N $0.00 $0.00 $0.00 86357 N $0.00 $0.00 $0.00 86359 N $0.00 $0.00 $0.00 86360 N $0.00 $0.00 $0.00 86361 N $0.00 $0.00 $0.00 86367 N $0.00 $0.00 $0.00 86376 N $0.00 $0.00 $0.00 86378 N $0.00 $0.00 $0.00 86382 N $0.00 $0.00 $0.00 86384 N $0.00 $0.00 $0.00 86386 N $0.00 $0.00 $0.00 86403 N $0.00 $0.00 $0.00 86406 N $0.00 $0.00 $0.00 86430 N $0.00 $0.00 $0.00 86431 N $0.00 $0.00 $0.00 86480 N $0.00 $0.00 $0.00 86481 N $0.00 $0.00 $0.00 86485 Q1 0340 0.7061 $76.56 $93.58 $57.42 86486 Q1 0340 0.7061 $76.56 $93.58 $57.42 86490 Q1 0420 1.7762 $192.58 $235.40 $144.44 86510 Q1 0340 0.7061 $76.56 $93.58 $57.42 86580 Q1 0450 0.3942 $42.74 $52.24 $32.06 86590 N $0.00 $0.00 $0.00 86592 N $0.00 $0.00 $0.00 86593 N $0.00 $0.00 $0.00 86602 N $0.00 $0.00 $0.00 86603 N $0.00 $0.00 $0.00 86606 N $0.00 $0.00 $0.00


164




165




166


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee86832 N $0.00 $0.00 $0.00 86833 N $0.00 $0.00 $0.00 86834 N $0.00 $0.00 $0.00 86835 N $0.00 $0.00 $0.00 86849 N $0.00 $0.00 $0.00 86850 Q1 0345 1.0256 $111.20 $135.92 $83.40 86860 S 0346 1.6869 $182.89 $223.56 $137.18 86870 Q1 0433 2.4765 $268.50 $328.21 $201.39 86880 S 0346 1.6869 $182.89 $223.56 $137.18 86885 S 0346 1.6869 $182.89 $223.56 $137.18 86886 Q1 0433 2.4765 $268.50 $328.21 $201.39 86890 S 0346 1.6869 $182.89 $223.56 $137.18 86891 S 0346 1.6869 $182.89 $223.56 $137.18 86900 Q1 0345 1.0256 $111.20 $135.92 $83.40 86901 Q1 0345 1.0256 $111.20 $135.92 $83.40 86902 Q1 0345 1.0256 $111.20 $135.92 $83.40 86904 Q1 0345 1.0256 $111.20 $135.92 $83.40 86905 Q1 0345 1.0256 $111.20 $135.92 $83.40 86906 Q1 0345 1.0256 $111.20 $135.92 $83.40 86910 E $0.00 $0.00 $0.0086911 E $0.00 $0.00 $0.0086920 S 0346 1.6869 $182.89 $223.56 $137.18 86921 Q1 0345 1.0256 $111.20 $135.92 $83.40 86922 S 0346 1.6869 $182.89 $223.56 $137.18 86923 S 0346 1.6869 $182.89 $223.56 $137.18 86927 S 0438 1.4593 $158.22 $193.40 $118.67 86930 Q1 0345 1.0256 $111.20 $135.92 $83.40 86931 S 0346 1.6869 $182.89 $223.56 $137.18 86932 Q1 0345 1.0256 $111.20 $135.92 $83.40 86940 N $0.00 $0.00 $0.00 86941 N $0.00 $0.00 $0.00 86945 Q1 0345 1.0256 $111.20 $135.92 $83.40 86950 Q1 0345 1.0256 $111.20 $135.92 $83.40 86960 S 0346 1.6869 $182.89 $223.56 $137.18 86965 S 0346 1.6869 $182.89 $223.56 $137.18 86970 Q1 0450 0.3942 $42.74 $52.24 $32.06 86971 S 0346 1.6869 $182.89 $223.56 $137.18 86972 S 0346 1.6869 $182.89 $223.56 $137.18 86975 S 0346 1.6869 $182.89 $223.56 $137.18 86976 Q1 0345 1.0256 $111.20 $135.92 $83.40 86977 Q1 0345 1.0256 $111.20 $135.92 $83.40 86978 Q1 0345 1.0256 $111.20 $135.92 $83.40 86985 S 0346 1.6869 $182.89 $223.56 $137.18 86999 Q1 0345 1.0256 $111.20 $135.92 $83.40 87003 N $0.00 $0.00 $0.00 87015 N $0.00 $0.00 $0.00 87040 N $0.00 $0.00 $0.00 87045 N $0.00 $0.00 $0.00 87046 N $0.00 $0.00 $0.00 87070 N $0.00 $0.00 $0.00 87071 N $0.00 $0.00 $0.00


167




168




169




170


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee87540 N $0.00 $0.00 $0.00 87541 N $0.00 $0.00 $0.00 87542 N $0.00 $0.00 $0.00 87550 N $0.00 $0.00 $0.00 87551 N $0.00 $0.00 $0.00 87552 N $0.00 $0.00 $0.00 87555 N $0.00 $0.00 $0.00 87556 N $0.00 $0.00 $0.00 87557 N $0.00 $0.00 $0.00 87560 N $0.00 $0.00 $0.00 87561 N $0.00 $0.00 $0.00 87562 N $0.00 $0.00 $0.00 87580 N $0.00 $0.00 $0.00 87581 N $0.00 $0.00 $0.00 87582 N $0.00 $0.00 $0.00 87590 N $0.00 $0.00 $0.00 87591 N $0.00 $0.00 $0.00 87592 N $0.00 $0.00 $0.00 87623 N $0.00 $0.00 $0.00 87624 N $0.00 $0.00 $0.00 87625 N $0.00 $0.00 $0.00 87631 N $0.00 $0.00 $0.00 87632 N $0.00 $0.00 $0.00 87633 N $0.00 $0.00 $0.00 87640 N $0.00 $0.00 $0.00 87641 N $0.00 $0.00 $0.00 87650 N $0.00 $0.00 $0.00 87651 N $0.00 $0.00 $0.00 87652 N $0.00 $0.00 $0.00 87653 N $0.00 $0.00 $0.00 87660 N $0.00 $0.00 $0.00 87661 A $0.00 $0.00 $0.0087797 N $0.00 $0.00 $0.00 87798 N $0.00 $0.00 $0.00 87799 N $0.00 $0.00 $0.00 87800 N $0.00 $0.00 $0.00 87801 N $0.00 $0.00 $0.00 87802 N $0.00 $0.00 $0.00 87803 N $0.00 $0.00 $0.00 87804 N $0.00 $0.00 $0.00 87806 N $0.00 $0.00 $0.00 87807 N $0.00 $0.00 $0.00 87808 N $0.00 $0.00 $0.00 87809 N $0.00 $0.00 $0.00 87810 N $0.00 $0.00 $0.00 87850 N $0.00 $0.00 $0.00 87880 N $0.00 $0.00 $0.00 87899 N $0.00 $0.00 $0.00 87900 N $0.00 $0.00 $0.00 87901 N $0.00 $0.00 $0.00 87902 N $0.00 $0.00 $0.00


171


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee87903 N $0.00 $0.00 $0.00 87904 N $0.00 $0.00 $0.00 87905 N $0.00 $0.00 $0.00 87906 N $0.00 $0.00 $0.00 87910 N $0.00 $0.00 $0.00 87912 N $0.00 $0.00 $0.00 87999 N $0.00 $0.00 $0.00 88000 E $0.00 $0.00 $0.0088005 E $0.00 $0.00 $0.0088007 E $0.00 $0.00 $0.0088012 E $0.00 $0.00 $0.0088014 E $0.00 $0.00 $0.0088016 E $0.00 $0.00 $0.0088020 E $0.00 $0.00 $0.0088025 E $0.00 $0.00 $0.0088027 E $0.00 $0.00 $0.0088028 E $0.00 $0.00 $0.0088029 E $0.00 $0.00 $0.0088036 E $0.00 $0.00 $0.0088037 E $0.00 $0.00 $0.0088040 E $0.00 $0.00 $0.0088045 E $0.00 $0.00 $0.0088099 E $0.00 $0.00 $0.0088104 Q1 0450 0.3942 $42.74 $52.24 $32.06 88106 Q1 0450 0.3942 $42.74 $52.24 $32.06 88108 Q1 0450 0.3942 $42.74 $52.24 $32.06 88112 Q1 0342 0.7318 $79.34 $96.99 $59.51 88120 Q1 0433 2.4765 $268.50 $328.21 $201.39 88121 Q1 0433 2.4765 $268.50 $328.21 $201.39 88125 Q1 0433 2.4765 $268.50 $328.21 $201.39 88130 N $0.00 $0.00 $0.00 88140 N $0.00 $0.00 $0.00 88141 N $0.00 $0.00 $0.00 88142 N $0.00 $0.00 $0.00 88143 N $0.00 $0.00 $0.00 88147 N $0.00 $0.00 $0.00 88148 N $0.00 $0.00 $0.00 88150 N $0.00 $0.00 $0.00 88152 N $0.00 $0.00 $0.00 88153 N $0.00 $0.00 $0.00 88154 N $0.00 $0.00 $0.00 88155 N $0.00 $0.00 $0.00 88160 Q1 0450 0.3942 $42.74 $52.24 $32.06 88161 Q1 0450 0.3942 $42.74 $52.24 $32.06 88162 Q1 0342 0.7318 $79.34 $96.99 $59.51 88164 N $0.00 $0.00 $0.00 88165 N $0.00 $0.00 $0.00 88166 N $0.00 $0.00 $0.00 88167 N $0.00 $0.00 $0.00 88172 Q1 0342 0.7318 $79.34 $96.99 $59.51 88173 Q1 0342 0.7318 $79.34 $96.99 $59.51


172


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee88174 N $0.00 $0.00 $0.00 88175 N $0.00 $0.00 $0.00 88177 N $0.00 $0.00 $0.00 88182 S 0661 3.9671 $430.11 $525.76 $322.60 88184 Q1 0433 2.4765 $268.50 $328.21 $201.39 88185 N $0.00 $0.00 $0.00 88187 B $0.00 $0.00 $0.0088188 B $0.00 $0.00 $0.0088189 B $0.00 $0.00 $0.0088199 Q1 0342 0.7318 $79.34 $96.99 $59.51 88230 N $0.00 $0.00 $0.00 88233 N $0.00 $0.00 $0.00 88235 N $0.00 $0.00 $0.00 88237 N $0.00 $0.00 $0.00 88239 N $0.00 $0.00 $0.00 88240 N $0.00 $0.00 $0.00 88241 N $0.00 $0.00 $0.00 88245 N $0.00 $0.00 $0.00 88248 N $0.00 $0.00 $0.00 88249 N $0.00 $0.00 $0.00 88261 N $0.00 $0.00 $0.00 88262 N $0.00 $0.00 $0.00 88263 N $0.00 $0.00 $0.00 88264 N $0.00 $0.00 $0.00 88267 N $0.00 $0.00 $0.00 88269 N $0.00 $0.00 $0.00 88271 N $0.00 $0.00 $0.00 88272 N $0.00 $0.00 $0.00 88273 N $0.00 $0.00 $0.00 88274 N $0.00 $0.00 $0.00 88275 N $0.00 $0.00 $0.00 88280 N $0.00 $0.00 $0.00 88283 N $0.00 $0.00 $0.00 88285 N $0.00 $0.00 $0.00 88289 N $0.00 $0.00 $0.00 88291 M $0.00 $0.00 $0.0088299 Q1 0342 0.7318 $79.34 $96.99 $59.51 88300 Q1 0450 0.3942 $42.74 $52.24 $32.06 88302 Q1 0450 0.3942 $42.74 $52.24 $32.06 88304 Q1 0342 0.7318 $79.34 $96.99 $59.51 88305 Q1 0342 0.7318 $79.34 $96.99 $59.51 88307 Q1 0433 2.4765 $268.50 $328.21 $201.39 88309 S 0661 3.9671 $430.11 $525.76 $322.60 88311 N $0.00 $0.00 $0.00 88312 Q1 0342 0.7318 $79.34 $96.99 $59.51 88313 Q1 0342 0.7318 $79.34 $96.99 $59.51 88314 N $0.00 $0.00 $0.00 88319 S 0661 3.9671 $430.11 $525.76 $322.60 88321 Q1 0450 0.3942 $42.74 $52.24 $32.06 88323 Q1 0433 2.4765 $268.50 $328.21 $201.39 88325 Q1 0342 0.7318 $79.34 $96.99 $59.51


173


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee88329 Q1 0450 0.3942 $42.74 $52.24 $32.06 88331 Q1 0433 2.4765 $268.50 $328.21 $201.39 88332 N $0.00 $0.00 $0.00 88333 S 0661 3.9671 $430.11 $525.76 $322.60 88334 N $0.00 $0.00 $0.00 88341 N $0.00 $0.00 $0.00 88342 E $0.00 $0.00 $0.0088344 N $0.00 $0.00 $0.00 88346 Q1 0433 2.4765 $268.50 $328.21 $201.39 88347 Q1 0433 2.4765 $268.50 $328.21 $201.39 88348 S 0661 3.9671 $430.11 $525.76 $322.60 88355 Q1 0433 2.4765 $268.50 $328.21 $201.39 88356 Q1 0342 0.7318 $79.34 $96.99 $59.51 88358 S 0661 3.9671 $430.11 $525.76 $322.60 88360 Q1 0433 2.4765 $268.50 $328.21 $201.39 88361 Q1 0433 2.4765 $268.50 $328.21 $201.39 88362 S 0661 3.9671 $430.11 $525.76 $322.60 88363 Q1 0450 0.3942 $42.74 $52.24 $32.06 88364 N $0.00 $0.00 $0.00 88365 Q1 0342 0.7318 $79.34 $96.99 $59.51 88366 N $0.00 $0.00 $0.00 88367 Q1 0433 2.4765 $268.50 $328.21 $201.39 88368 Q1 0433 2.4765 $268.50 $328.21 $201.39 88369 N $0.00 $0.00 $0.00 88371 N $0.00 $0.00 $0.00 88372 N $0.00 $0.00 $0.00 88373 N $0.00 $0.00 $0.00 88374 Q1 0433 2.4765 $268.50 $328.21 $201.39 88375 Q1 0342 0.7318 $79.34 $96.99 $59.51 88377 Q1 0433 2.4765 $268.50 $328.21 $201.39 88380 B $0.00 $0.00 $0.0088381 B $0.00 $0.00 $0.0088387 B $0.00 $0.00 $0.0088388 N $0.00 $0.00 $0.00 88399 Q1 0342 0.7318 $79.34 $96.99 $59.51 88720 N $0.00 $0.00 $0.00 88738 N $0.00 $0.00 $0.00 88740 N $0.00 $0.00 $0.00 88741 N $0.00 $0.00 $0.00 88749 N $0.00 $0.00 $0.00 89049 Q1 0433 2.4765 $268.50 $328.21 $201.39 89050 N $0.00 $0.00 $0.00 89051 N $0.00 $0.00 $0.00 89055 N $0.00 $0.00 $0.00 89060 N $0.00 $0.00 $0.00 89125 N $0.00 $0.00 $0.00 89160 N $0.00 $0.00 $0.00 89190 N $0.00 $0.00 $0.00 89220 Q1 0433 2.4765 $268.50 $328.21 $201.39 89230 Q1 0342 0.7318 $79.34 $96.99 $59.51 89240 Q1 0342 0.7318 $79.34 $96.99 $59.51


174


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee89250 Q1 0433 2.4765 $268.50 $328.21 $201.39 89251 Q1 0433 2.4765 $268.50 $328.21 $201.39 89253 Q1 0433 2.4765 $268.50 $328.21 $201.39 89254 Q1 0433 2.4765 $268.50 $328.21 $201.39 89255 Q1 0433 2.4765 $268.50 $328.21 $201.39 89257 Q1 0342 0.7318 $79.34 $96.99 $59.51 89258 S 0661 3.9671 $430.11 $525.76 $322.60 89259 Q1 0433 2.4765 $268.50 $328.21 $201.39 89260 Q1 0342 0.7318 $79.34 $96.99 $59.51 89261 Q1 0342 0.7318 $79.34 $96.99 $59.51 89264 Q1 0433 2.4765 $268.50 $328.21 $201.39 89268 Q1 0433 2.4765 $268.50 $328.21 $201.39 89272 S 0661 3.9671 $430.11 $525.76 $322.60 89280 S 0661 3.9671 $430.11 $525.76 $322.60 89281 Q1 0433 2.4765 $268.50 $328.21 $201.39 89290 Q1 0433 2.4765 $268.50 $328.21 $201.39 89291 Q1 0433 2.4765 $268.50 $328.21 $201.39 89300 N $0.00 $0.00 $0.00 89310 N $0.00 $0.00 $0.00 89320 N $0.00 $0.00 $0.00 89321 N $0.00 $0.00 $0.00 89322 N $0.00 $0.00 $0.00 89325 N $0.00 $0.00 $0.00 89329 N $0.00 $0.00 $0.00 89330 N $0.00 $0.00 $0.00 89331 N $0.00 $0.00 $0.00 89335 Q1 0342 0.7318 $79.34 $96.99 $59.51 89337 Q1 0433 2.4765 $268.50 $328.21 $201.39 89342 Q1 0433 2.4765 $268.50 $328.21 $201.39 89343 Q1 0342 0.7318 $79.34 $96.99 $59.51 89344 Q1 0433 2.4765 $268.50 $328.21 $201.39 89346 Q1 0433 2.4765 $268.50 $328.21 $201.39 89352 Q1 0433 2.4765 $268.50 $328.21 $201.39 89353 Q1 0433 2.4765 $268.50 $328.21 $201.39 89354 Q1 0433 2.4765 $268.50 $328.21 $201.39 89356 Q1 0433 2.4765 $268.50 $328.21 $201.39 89398 Q1 0342 0.7318 $79.34 $96.99 $59.51 9001F E $0.00 $0.00 $0.009002F E $0.00 $0.00 $0.009003F M $0.00 $0.00 $0.009004F M $0.00 $0.00 $0.009005F E $0.00 $0.00 $0.009006F M $0.00 $0.00 $0.009007F M $0.00 $0.00 $0.0090281 E $0.00 $0.00 $0.0090283 E $0.00 $0.00 $0.0090284 E $0.00 $0.00 $0.0090287 E $0.00 $0.00 $0.0090288 E $0.00 $0.00 $0.0090291 E $0.00 $0.00 $0.0090296 E $0.00 $0.00 $0.00


175


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee90371 K 1630 $0.00 $0.00 $0.0090375 K 9133 $0.00 $0.00 $0.0090376 K 9134 $0.00 $0.00 $0.0090378 K 9003 $0.00 $0.00 $0.0090384 E $0.00 $0.00 $0.0090385 N $0.00 $0.00 $0.00 90386 E $0.00 $0.00 $0.0090389 E $0.00 $0.00 $0.0090393 E $0.00 $0.00 $0.0090396 K 9135 $0.00 $0.00 $0.0090399 E $0.00 $0.00 $0.0090460 B $0.00 $0.00 $0.0090461 B $0.00 $0.00 $0.0090471 S 0437 0.7218 $78.26 $95.66 $58.70 90472 N $0.00 $0.00 $0.00 90473 S 0437 0.7218 $78.26 $95.66 $58.70 90474 N $0.00 $0.00 $0.00 90476 N $0.00 $0.00 $0.00 90477 E $0.00 $0.00 $0.0090581 K 1422 $0.00 $0.00 $0.0090585 K 9137 $0.00 $0.00 $0.0090586 B $0.00 $0.00 $0.0090630 E $0.00 $0.00 $0.0090632 N $0.00 $0.00 $0.00 90633 N $0.00 $0.00 $0.00 90634 N $0.00 $0.00 $0.00 90636 N $0.00 $0.00 $0.00 90644 E $0.00 $0.00 $0.0090645 N $0.00 $0.00 $0.00 90646 N $0.00 $0.00 $0.00 90647 N $0.00 $0.00 $0.00 90648 N $0.00 $0.00 $0.00 90649 M $0.00 $0.00 $0.0090650 M $0.00 $0.00 $0.0090651 E $0.00 $0.00 $0.0090653 E $0.00 $0.00 $0.0090654 L $0.00 $0.00 $0.0090655 L $0.00 $0.00 $0.0090656 L $0.00 $0.00 $0.0090657 L $0.00 $0.00 $0.0090658 E $0.00 $0.00 $0.0090660 L $0.00 $0.00 $0.0090661 L $0.00 $0.00 $0.0090662 L $0.00 $0.00 $0.0090664 E $0.00 $0.00 $0.0090666 E $0.00 $0.00 $0.0090667 E $0.00 $0.00 $0.0090668 E $0.00 $0.00 $0.0090669 L $0.00 $0.00 $0.0090670 L $0.00 $0.00 $0.0090672 L $0.00 $0.00 $0.00


176


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee90673 L $0.00 $0.00 $0.0090675 K 9139 $0.00 $0.00 $0.0090676 K 9140 $0.00 $0.00 $0.0090680 N $0.00 $0.00 $0.00 90681 E $0.00 $0.00 $0.0090685 L $0.00 $0.00 $0.0090686 L $0.00 $0.00 $0.0090687 L $0.00 $0.00 $0.0090688 L $0.00 $0.00 $0.0090690 N $0.00 $0.00 $0.00 90691 N $0.00 $0.00 $0.00 90692 N $0.00 $0.00 $0.00 90693 B $0.00 $0.00 $0.0090696 N $0.00 $0.00 $0.00 90698 N $0.00 $0.00 $0.00 90700 N $0.00 $0.00 $0.00 90702 N $0.00 $0.00 $0.00 90703 N $0.00 $0.00 $0.00 90704 N $0.00 $0.00 $0.00 90705 N $0.00 $0.00 $0.00 90706 N $0.00 $0.00 $0.00 90707 N $0.00 $0.00 $0.00 90708 N $0.00 $0.00 $0.00 90710 N $0.00 $0.00 $0.00 90712 N $0.00 $0.00 $0.00 90713 N $0.00 $0.00 $0.00 90714 N $0.00 $0.00 $0.00 90715 N $0.00 $0.00 $0.00 90716 M $0.00 $0.00 $0.0090717 N $0.00 $0.00 $0.00 90719 N $0.00 $0.00 $0.00 90720 N $0.00 $0.00 $0.00 90721 N $0.00 $0.00 $0.00 90723 E $0.00 $0.00 $0.0090725 N $0.00 $0.00 $0.00 90727 E $0.00 $0.00 $0.0090732 L $0.00 $0.00 $0.0090733 K 9143 $0.00 $0.00 $0.0090734 N $0.00 $0.00 $0.00 90735 K 9144 $0.00 $0.00 $0.0090736 M $0.00 $0.00 $0.0090738 M $0.00 $0.00 $0.0090739 E $0.00 $0.00 $0.0090740 F $0.00 $0.00 $0.0090743 F $0.00 $0.00 $0.0090744 F $0.00 $0.00 $0.0090746 F $0.00 $0.00 $0.0090747 F $0.00 $0.00 $0.0090748 E $0.00 $0.00 $0.0090749 N $0.00 $0.00 $0.00 90785 N $0.00 $0.00 $0.00


177


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee90791 Q3 0323 1.5574 $168.85 $206.40 $126.65 90792 Q3 0323 1.5574 $168.85 $206.40 $126.65 90832 Q3 0322 1.2065 $130.81 $159.90 $98.11 90833 N $0.00 $0.00 $0.00 90834 Q3 0323 1.5574 $168.85 $206.40 $126.65 90836 N $0.00 $0.00 $0.00 90837 Q3 0323 1.5574 $168.85 $206.40 $126.65 90838 N $0.00 $0.00 $0.00 90839 Q3 0323 1.5574 $168.85 $206.40 $126.65 90840 N $0.00 $0.00 $0.00 90845 Q3 0323 1.5574 $168.85 $206.40 $126.65 90846 Q3 0324 1.6717 $181.25 $221.55 $135.94 90847 Q3 0324 1.6717 $181.25 $221.55 $135.94 90849 Q3 0325 0.8905 $96.55 $118.02 $72.42 90853 Q3 0325 0.8905 $96.55 $118.02 $72.42 90863 E $0.00 $0.00 $0.0090865 Q3 0323 1.5574 $168.85 $206.40 $126.65 90867 S 0218 2.1417 $232.20 $283.84 $174.16 90868 S 0218 2.1417 $232.20 $283.84 $174.16 90869 S 0218 2.1417 $232.20 $283.84 $174.16 90870 S 0320 6.0169 $652.35 $797.42 $489.29 90875 E $0.00 $0.00 $0.0090876 E $0.00 $0.00 $0.0090880 Q3 0323 1.5574 $168.85 $206.40 $126.65 90882 E $0.00 $0.00 $0.0090885 N $0.00 $0.00 $0.00 90887 N $0.00 $0.00 $0.00 90889 N $0.00 $0.00 $0.00 90899 Q3 0322 1.2065 $130.81 $159.90 $98.11 90901 A $0.00 $0.00 $0.0090911 T 0126 1.5266 $165.51 $202.32 $124.14 90935 S 0170 8.2721 $896.86 $1,096.30 $672.69 90937 B $0.00 $0.00 $0.0090940 N $0.00 $0.00 $0.00 90945 V 0633 5.2168 $565.61 $691.38 $424.23 90947 B $0.00 $0.00 $0.0090951 M $0.00 $0.00 $0.0090952 M $0.00 $0.00 $0.0090953 M $0.00 $0.00 $0.0090954 M $0.00 $0.00 $0.0090955 M $0.00 $0.00 $0.0090956 M $0.00 $0.00 $0.0090957 M $0.00 $0.00 $0.0090958 M $0.00 $0.00 $0.0090959 M $0.00 $0.00 $0.0090960 M $0.00 $0.00 $0.0090961 M $0.00 $0.00 $0.0090962 M $0.00 $0.00 $0.0090963 M $0.00 $0.00 $0.0090964 M $0.00 $0.00 $0.0090965 M $0.00 $0.00 $0.00


178


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee90966 M $0.00 $0.00 $0.0090967 M $0.00 $0.00 $0.0090968 M $0.00 $0.00 $0.0090969 M $0.00 $0.00 $0.0090970 M $0.00 $0.00 $0.0090989 B $0.00 $0.00 $0.0090993 B $0.00 $0.00 $0.0090997 B $0.00 $0.00 $0.0090999 B $0.00 $0.00 $0.0091010 S 0361 4.432 $480.52 $587.37 $360.41 91013 N $0.00 $0.00 $0.00 91020 S 0361 4.432 $480.52 $587.37 $360.41 91022 S 0361 4.432 $480.52 $587.37 $360.41 91030 S 0361 4.432 $480.52 $587.37 $360.41 91034 S 0361 4.432 $480.52 $587.37 $360.41 91035 S 0361 4.432 $480.52 $587.37 $360.41 91037 S 0360 1.9033 $206.36 $252.24 $154.78 91038 S 0361 4.432 $480.52 $587.37 $360.41 91040 S 0360 1.9033 $206.36 $252.24 $154.78 91065 S 0360 1.9033 $206.36 $252.24 $154.78 91110 T 0142 11.4924 $1,246.01 $1,523.09 $934.56 91111 T 0142 11.4924 $1,246.01 $1,523.09 $934.56 91112 T 0142 11.4924 $1,246.01 $1,523.09 $934.56 91117 T 0164 2.8822 $312.49 $381.98 $234.38 91120 T 0126 1.5266 $165.51 $202.32 $124.14 91122 T 0164 2.8822 $312.49 $381.98 $234.38 91132 S 0360 1.9033 $206.36 $252.24 $154.78 91133 S 0360 1.9033 $206.36 $252.24 $154.78 91200 S 0266 1.8181 $197.12 $240.95 $147.85 91299 S 0360 1.9033 $206.36 $252.24 $154.78 92002 V 0632 1.4327 $155.33 $189.88 $116.51 92004 V 0632 1.4327 $155.33 $189.88 $116.51 92012 V 0632 1.4327 $155.33 $189.88 $116.51 92014 V 0632 1.4327 $155.33 $189.88 $116.51 92015 E $0.00 $0.00 $0.0092018 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 92019 T 0240 20.6904 $2,243.25 $2,742.10 $1,682.54 92020 Q1 0230 0.7019 $76.10 $93.02 $57.08 92025 Q1 0230 0.7019 $76.10 $93.02 $57.08 92060 Q1 0230 0.7019 $76.10 $93.02 $57.08 92065 Q1 0230 0.7019 $76.10 $93.02 $57.08 92071 N $0.00 $0.00 $0.00 92072 N $0.00 $0.00 $0.00 92081 Q1 0230 0.7019 $76.10 $93.02 $57.08 92082 Q1 0230 0.7019 $76.10 $93.02 $57.08 92083 Q1 0698 1.3596 $147.41 $180.19 $110.56 92100 N $0.00 $0.00 $0.00 92132 Q1 0230 0.7019 $76.10 $93.02 $57.08 92133 Q1 0230 0.7019 $76.10 $93.02 $57.08 92134 Q1 0230 0.7019 $76.10 $93.02 $57.08 92136 Q1 0698 1.3596 $147.41 $180.19 $110.56


179


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee92140 Q1 0230 0.7019 $76.10 $93.02 $57.08 92145 Q1 0230 0.7019 $76.10 $93.02 $57.08 92225 Q1 0230 0.7019 $76.10 $93.02 $57.08 92226 Q1 0230 0.7019 $76.10 $93.02 $57.08 92227 Q1 0340 0.7061 $76.56 $93.58 $57.42 92228 Q1 0420 1.7762 $192.58 $235.40 $144.44 92230 Q1 0698 1.3596 $147.41 $180.19 $110.56 92235 S 0231 4.2389 $459.58 $561.78 $344.71 92240 S 0231 4.2389 $459.58 $561.78 $344.71 92250 Q1 0698 1.3596 $147.41 $180.19 $110.56 92260 Q1 0230 0.7019 $76.10 $93.02 $57.08 92265 Q1 0698 1.3596 $147.41 $180.19 $110.56 92270 Q1 0698 1.3596 $147.41 $180.19 $110.56 92275 S 0231 4.2389 $459.58 $561.78 $344.71 92283 Q1 0230 0.7019 $76.10 $93.02 $57.08 92284 Q1 0698 1.3596 $147.41 $180.19 $110.56 92285 Q1 0230 0.7019 $76.10 $93.02 $57.08 92286 Q1 0698 1.3596 $147.41 $180.19 $110.56 92287 Q1 0698 1.3596 $147.41 $180.19 $110.56 92310 E $0.00 $0.00 $0.0092311 Q1 0698 1.3596 $147.41 $180.19 $110.56 92312 Q1 0698 1.3596 $147.41 $180.19 $110.56 92313 Q1 0698 1.3596 $147.41 $180.19 $110.56 92314 E $0.00 $0.00 $0.0092315 Q1 0698 1.3596 $147.41 $180.19 $110.56 92316 Q1 0698 1.3596 $147.41 $180.19 $110.56 92317 Q1 0230 0.7019 $76.10 $93.02 $57.08 92325 Q1 0698 1.3596 $147.41 $180.19 $110.56 92326 Q1 0698 1.3596 $147.41 $180.19 $110.56 92340 E $0.00 $0.00 $0.0092341 E $0.00 $0.00 $0.0092342 E $0.00 $0.00 $0.0092352 Q1 0698 1.3596 $147.41 $180.19 $110.56 92353 Q1 0698 1.3596 $147.41 $180.19 $110.56 92354 Q1 0230 0.7019 $76.10 $93.02 $57.08 92355 Q1 0230 0.7019 $76.10 $93.02 $57.08 92358 Q1 0698 1.3596 $147.41 $180.19 $110.56 92370 E $0.00 $0.00 $0.0092371 Q1 0698 1.3596 $147.41 $180.19 $110.56 92499 Q1 0230 0.7019 $76.10 $93.02 $57.08 92502 T 0251 4.8979 $531.03 $649.12 $398.30 92504 N $0.00 $0.00 $0.00 92507 A $0.00 $0.00 $0.0092508 A $0.00 $0.00 $0.0092511 T 0071 2.0314 $220.24 $269.22 $165.19 92512 S 0363 1.928 $209.03 $255.52 $156.79 92516 S 0363 1.928 $209.03 $255.52 $156.79 92520 Q1 0340 0.7061 $76.56 $93.58 $57.42 92521 A $0.00 $0.00 $0.0092522 A $0.00 $0.00 $0.0092523 A $0.00 $0.00 $0.00


180


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee92524 A $0.00 $0.00 $0.0092526 A $0.00 $0.00 $0.0092531 N $0.00 $0.00 $0.00 92532 N $0.00 $0.00 $0.00 92533 N $0.00 $0.00 $0.00 92534 N $0.00 $0.00 $0.00 92540 S 0363 1.928 $209.03 $255.52 $156.79 92541 Q1 0420 1.7762 $192.58 $235.40 $144.44 92542 Q1 0340 0.7061 $76.56 $93.58 $57.42 92543 S 0363 1.928 $209.03 $255.52 $156.79 92544 S 0363 1.928 $209.03 $255.52 $156.79 92545 S 0363 1.928 $209.03 $255.52 $156.79 92546 S 0363 1.928 $209.03 $255.52 $156.79 92547 N $0.00 $0.00 $0.00 92548 S 0363 1.928 $209.03 $255.52 $156.79 92550 Q1 0365 1.5902 $172.41 $210.75 $129.32 92551 E $0.00 $0.00 $0.0092552 Q1 0365 1.5902 $172.41 $210.75 $129.32 92553 Q1 0365 1.5902 $172.41 $210.75 $129.32 92555 Q1 0364 0.5841 $63.33 $77.41 $47.50 92556 Q1 0364 0.5841 $63.33 $77.41 $47.50 92557 Q1 0365 1.5902 $172.41 $210.75 $129.32 92558 E $0.00 $0.00 $0.0092559 E $0.00 $0.00 $0.0092560 E $0.00 $0.00 $0.0092561 Q1 0365 1.5902 $172.41 $210.75 $129.32 92562 Q1 0365 1.5902 $172.41 $210.75 $129.32 92563 Q1 0364 0.5841 $63.33 $77.41 $47.50 92564 Q1 0364 0.5841 $63.33 $77.41 $47.50 92565 Q1 0364 0.5841 $63.33 $77.41 $47.50 92567 Q1 0364 0.5841 $63.33 $77.41 $47.50 92568 Q1 0450 0.3942 $42.74 $52.24 $32.06 92570 Q1 0365 1.5902 $172.41 $210.75 $129.32 92571 Q1 0364 0.5841 $63.33 $77.41 $47.50 92572 Q1 0365 1.5902 $172.41 $210.75 $129.32 92575 Q1 0364 0.5841 $63.33 $77.41 $47.50 92576 Q1 0364 0.5841 $63.33 $77.41 $47.50 92577 Q1 0365 1.5902 $172.41 $210.75 $129.32 92579 Q1 0365 1.5902 $172.41 $210.75 $129.32 92582 Q1 0365 1.5902 $172.41 $210.75 $129.32 92583 Q1 0364 0.5841 $63.33 $77.41 $47.50 92584 S 0218 2.1417 $232.20 $283.84 $174.16 92585 S 0216 3.6766 $398.62 $487.26 $298.98 92586 S 0218 2.1417 $232.20 $283.84 $174.16 92587 S 0363 1.928 $209.03 $255.52 $156.79 92588 S 0363 1.928 $209.03 $255.52 $156.79 92590 E $0.00 $0.00 $0.0092591 E $0.00 $0.00 $0.0092592 E $0.00 $0.00 $0.0092593 E $0.00 $0.00 $0.0092594 E $0.00 $0.00 $0.00


181


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee92595 E $0.00 $0.00 $0.0092596 Q1 0364 0.5841 $63.33 $77.41 $47.50 92597 A $0.00 $0.00 $0.0092601 Q1 0365 1.5902 $172.41 $210.75 $129.32 92602 Q1 0365 1.5902 $172.41 $210.75 $129.32 92603 Q1 0365 1.5902 $172.41 $210.75 $129.32 92604 Q1 0365 1.5902 $172.41 $210.75 $129.32 92605 A $0.00 $0.00 $0.0092606 A $0.00 $0.00 $0.0092607 A $0.00 $0.00 $0.0092608 A $0.00 $0.00 $0.0092609 A $0.00 $0.00 $0.0092610 A $0.00 $0.00 $0.0092611 A $0.00 $0.00 $0.0092612 A $0.00 $0.00 $0.0092613 B $0.00 $0.00 $0.0092614 A $0.00 $0.00 $0.0092615 E $0.00 $0.00 $0.0092616 A $0.00 $0.00 $0.0092617 E $0.00 $0.00 $0.0092618 A $0.00 $0.00 $0.0092620 Q1 0365 1.5902 $172.41 $210.75 $129.32 92621 N $0.00 $0.00 $0.00 92625 Q1 0365 1.5902 $172.41 $210.75 $129.32 92626 Q1 0365 1.5902 $172.41 $210.75 $129.32 92627 N $0.00 $0.00 $0.00 92630 E $0.00 $0.00 $0.0092633 E $0.00 $0.00 $0.0092640 Q1 0365 1.5902 $172.41 $210.75 $129.32 92700 Q1 0364 0.5841 $63.33 $77.41 $47.50 92920 J1 0083 61.1978 $6,635.07 $8,110.54 $4,976.61 92921 N $0.00 $0.00 $0.00 92924 J1 0229 129.8028 $14,073.22 $17,202.77 $10,555.56 92925 N $0.00 $0.00 $0.00 92928 J1 0229 129.8028 $14,073.22 $17,202.77 $10,555.56 92929 N $0.00 $0.00 $0.00 92933 J1 0319 200.1597 $21,701.31 $26,527.17 $16,276.99 92934 N $0.00 $0.00 $0.00 92937 J1 0229 129.8028 $14,073.22 $17,202.77 $10,555.56 92938 N $0.00 $0.00 $0.00 92941 J1 0229 129.8028 $14,073.22 $17,202.77 $10,555.56 92943 J1 0229 129.8028 $14,073.22 $17,202.77 $10,555.56 92944 N $0.00 $0.00 $0.00 92950 S 0100 3.2093 $347.95 $425.33 $260.98 92953 Q3 0094 6.3433 $687.74 $840.68 $515.84 92960 S 0094 6.3433 $687.74 $840.68 $515.84 92961 S 0094 6.3433 $687.74 $840.68 $515.84 92970 C $0.00 $0.00 $0.0092971 C $0.00 $0.00 $0.0092973 N $0.00 $0.00 $0.00 92974 N $0.00 $0.00 $0.00


182


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee92975 C $0.00 $0.00 $0.0092977 T 0676 2.6317 $285.33 $348.78 $214.01 92978 N $0.00 $0.00 $0.00 92979 N $0.00 $0.00 $0.00 92986 J1 0083 61.1978 $6,635.07 $8,110.54 $4,976.61 92987 J1 0229 129.8028 $14,073.22 $17,202.77 $10,555.56 92990 J1 0229 129.8028 $14,073.22 $17,202.77 $10,555.56 92992 C $0.00 $0.00 $0.0092993 C $0.00 $0.00 $0.0092997 J1 0229 129.8028 $14,073.22 $17,202.77 $10,555.56 92998 N $0.00 $0.00 $0.00 93000 M $0.00 $0.00 $0.0093005 Q1 0099 1.0579 $114.70 $140.20 $86.03 93010 B $0.00 $0.00 $0.0093015 B $0.00 $0.00 $0.0093016 B $0.00 $0.00 $0.0093017 Q1 0100 3.2093 $347.95 $425.33 $260.98 93018 B $0.00 $0.00 $0.0093024 S 0100 3.2093 $347.95 $425.33 $260.98 93025 S 0100 3.2093 $347.95 $425.33 $260.98 93040 B $0.00 $0.00 $0.0093041 Q1 0340 0.7061 $76.56 $93.58 $57.42 93042 B $0.00 $0.00 $0.0093224 M $0.00 $0.00 $0.0093225 Q1 0099 1.0579 $114.70 $140.20 $86.03 93226 Q1 0099 1.0579 $114.70 $140.20 $86.03 93227 M $0.00 $0.00 $0.0093228 M $0.00 $0.00 $0.0093229 S 0213 2.3813 $258.18 $315.59 $193.65 93260 Q1 0690 0.4739 $51.38 $62.81 $38.54 93261 Q1 0690 0.4739 $51.38 $62.81 $38.54 93268 M $0.00 $0.00 $0.0093270 Q1 0690 0.4739 $51.38 $62.81 $38.54 93271 S 0692 1.7288 $187.44 $229.12 $140.59 93272 M $0.00 $0.00 $0.0093278 Q1 0340 0.7061 $76.56 $93.58 $57.42 93279 Q1 0690 0.4739 $51.38 $62.81 $38.54 93280 Q1 0690 0.4739 $51.38 $62.81 $38.54 93281 Q1 0690 0.4739 $51.38 $62.81 $38.54 93282 Q1 0690 0.4739 $51.38 $62.81 $38.54 93283 Q1 0690 0.4739 $51.38 $62.81 $38.54 93284 Q1 0690 0.4739 $51.38 $62.81 $38.54 93285 Q1 0690 0.4739 $51.38 $62.81 $38.54 93286 N $0.00 $0.00 $0.00 93287 N $0.00 $0.00 $0.00 93288 Q1 0690 0.4739 $51.38 $62.81 $38.54 93289 Q1 0690 0.4739 $51.38 $62.81 $38.54 93290 Q1 0690 0.4739 $51.38 $62.81 $38.54 93291 Q1 0450 0.3942 $42.74 $52.24 $32.06 93292 Q1 0690 0.4739 $51.38 $62.81 $38.54 93293 Q1 0690 0.4739 $51.38 $62.81 $38.54


183


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee93294 M $0.00 $0.00 $0.0093295 M $0.00 $0.00 $0.0093296 Q1 0690 0.4739 $51.38 $62.81 $38.54 93297 M $0.00 $0.00 $0.0093298 M $0.00 $0.00 $0.0093299 Q1 0690 0.4739 $51.38 $62.81 $38.54 93303 S 0270 8.0142 $868.90 $1,062.12 $651.71 93304 S 0269 5.6995 $617.94 $755.35 $463.48 93306 S 0269 5.6995 $617.94 $755.35 $463.48 93307 S 0269 5.6995 $617.94 $755.35 $463.48 93308 S 0267 2.5565 $277.18 $338.81 $207.89 93312 S 0270 8.0142 $868.90 $1,062.12 $651.71 93313 S 0269 5.6995 $617.94 $755.35 $463.48 93314 N $0.00 $0.00 $0.00 93315 S 0269 5.6995 $617.94 $755.35 $463.48 93316 S 0270 8.0142 $868.90 $1,062.12 $651.71 93317 N $0.00 $0.00 $0.00 93318 S 0270 8.0142 $868.90 $1,062.12 $651.71 93320 N $0.00 $0.00 $0.00 93321 N $0.00 $0.00 $0.00 93325 N $0.00 $0.00 $0.00 93350 S 0269 5.6995 $617.94 $755.35 $463.48 93351 S 0270 8.0142 $868.90 $1,062.12 $651.71 93352 M $0.00 $0.00 $0.0093355 N $0.00 $0.00 $0.00 93451 T 0080 34.7342 $3,765.88 $4,603.32 $2,824.59 93452 T 0080 34.7342 $3,765.88 $4,603.32 $2,824.59 93453 T 0080 34.7342 $3,765.88 $4,603.32 $2,824.59 93454 T 0080 34.7342 $3,765.88 $4,603.32 $2,824.59 93455 T 0080 34.7342 $3,765.88 $4,603.32 $2,824.59 93456 T 0080 34.7342 $3,765.88 $4,603.32 $2,824.59 93457 T 0080 34.7342 $3,765.88 $4,603.32 $2,824.59 93458 T 0080 34.7342 $3,765.88 $4,603.32 $2,824.59 93459 T 0080 34.7342 $3,765.88 $4,603.32 $2,824.59 93460 T 0080 34.7342 $3,765.88 $4,603.32 $2,824.59 93461 T 0080 34.7342 $3,765.88 $4,603.32 $2,824.59 93462 N $0.00 $0.00 $0.00 93463 N $0.00 $0.00 $0.00 93464 N $0.00 $0.00 $0.00 93503 T 0103 21.2483 $2,303.74 $2,816.04 $1,727.91 93505 T 0103 21.2483 $2,303.74 $2,816.04 $1,727.91 93530 T 0080 34.7342 $3,765.88 $4,603.32 $2,824.59 93531 T 0080 34.7342 $3,765.88 $4,603.32 $2,824.59 93532 T 0080 34.7342 $3,765.88 $4,603.32 $2,824.59 93533 T 0080 34.7342 $3,765.88 $4,603.32 $2,824.59 93561 N $0.00 $0.00 $0.00 93562 N $0.00 $0.00 $0.00 93563 N $0.00 $0.00 $0.00 93564 N $0.00 $0.00 $0.00 93565 N $0.00 $0.00 $0.00 93566 N $0.00 $0.00 $0.00


184


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee93567 N $0.00 $0.00 $0.00 93568 N $0.00 $0.00 $0.00 93571 N $0.00 $0.00 $0.00 93572 N $0.00 $0.00 $0.00 93580 J1 0319 200.1597 $21,701.31 $26,527.17 $16,276.99 93581 J1 0319 200.1597 $21,701.31 $26,527.17 $16,276.99 93582 J1 0319 200.1597 $21,701.31 $26,527.17 $16,276.99 93583 C $0.00 $0.00 $0.0093600 J1 0085 62.491 $6,775.27 $8,281.93 $5,081.77 93602 J1 0085 62.491 $6,775.27 $8,281.93 $5,081.77 93603 J1 0084 11.7733 $1,276.46 $1,560.32 $957.40 93609 N $0.00 $0.00 $0.00 93610 J1 0085 62.491 $6,775.27 $8,281.93 $5,081.77 93612 J1 0085 62.491 $6,775.27 $8,281.93 $5,081.77 93613 N $0.00 $0.00 $0.00 93615 J1 0084 11.7733 $1,276.46 $1,560.32 $957.40 93616 J1 0084 11.7733 $1,276.46 $1,560.32 $957.40 93618 J1 0084 11.7733 $1,276.46 $1,560.32 $957.40 93619 J1 0085 62.491 $6,775.27 $8,281.93 $5,081.77 93620 J1 0085 62.491 $6,775.27 $8,281.93 $5,081.77 93621 N $0.00 $0.00 $0.00 93622 N $0.00 $0.00 $0.00 93623 N $0.00 $0.00 $0.00 93624 J1 0085 62.491 $6,775.27 $8,281.93 $5,081.77 93631 N $0.00 $0.00 $0.00 93640 N $0.00 $0.00 $0.00 93641 N $0.00 $0.00 $0.00 93642 J1 0084 11.7733 $1,276.46 $1,560.32 $957.40 93644 N $0.00 $0.00 $0.00 93650 J1 0085 62.491 $6,775.27 $8,281.93 $5,081.77 93653 J1 0086 193.6316 $20,993.54 $25,662.00 $15,746.12 93654 J1 0086 193.6316 $20,993.54 $25,662.00 $15,746.12 93655 N $0.00 $0.00 $0.00 93656 J1 0086 193.6316 $20,993.54 $25,662.00 $15,746.12 93657 N $0.00 $0.00 $0.00 93660 S 0096 4.4459 $482.02 $589.22 $361.54 93662 N $0.00 $0.00 $0.00 93668 E $0.00 $0.00 $0.0093701 Q1 0099 1.0579 $114.70 $140.20 $86.03 93702 S 0097 1.5196 $164.76 $201.39 $123.57 93724 S 0691 3.3374 $361.84 $442.31 $271.40 93740 Q1 0367 2.1744 $235.75 $288.17 $176.82 93745 S 0691 3.3374 $361.84 $442.31 $271.40 93750 S 0692 1.7288 $187.44 $229.12 $140.59 93770 N $0.00 $0.00 $0.00 93784 B $0.00 $0.00 $0.0093786 Q1 0099 1.0579 $114.70 $140.20 $86.03 93788 Q1 0099 1.0579 $114.70 $140.20 $86.03 93790 M $0.00 $0.00 $0.0093797 S 0095 1.3927 $151.00 $184.57 $113.25 93798 S 0095 1.3927 $151.00 $184.57 $113.25


185


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee93799 S 0097 1.5196 $164.76 $201.39 $123.57 93880 S 0267 2.5565 $277.18 $338.81 $207.89 93882 S 0267 2.5565 $277.18 $338.81 $207.89 93886 S 0267 2.5565 $277.18 $338.81 $207.89 93888 S 0266 1.8181 $197.12 $240.95 $147.85 93890 S 0266 1.8181 $197.12 $240.95 $147.85 93892 S 0266 1.8181 $197.12 $240.95 $147.85 93893 S 0266 1.8181 $197.12 $240.95 $147.85 93895 Q1 0340 0.7061 $76.56 $93.58 $57.42 93922 S 0097 1.5196 $164.76 $201.39 $123.57 93923 S 0097 1.5196 $164.76 $201.39 $123.57 93924 S 0097 1.5196 $164.76 $201.39 $123.57 93925 S 0267 2.5565 $277.18 $338.81 $207.89 93926 S 0266 1.8181 $197.12 $240.95 $147.85 93930 S 0267 2.5565 $277.18 $338.81 $207.89 93931 S 0266 1.8181 $197.12 $240.95 $147.85 93965 S 0097 1.5196 $164.76 $201.39 $123.57 93970 S 0267 2.5565 $277.18 $338.81 $207.89 93971 S 0266 1.8181 $197.12 $240.95 $147.85 93975 S 0267 2.5565 $277.18 $338.81 $207.89 93976 S 0267 2.5565 $277.18 $338.81 $207.89 93978 S 0267 2.5565 $277.18 $338.81 $207.89 93979 S 0266 1.8181 $197.12 $240.95 $147.85 93980 S 0267 2.5565 $277.18 $338.81 $207.89 93981 S 0267 2.5565 $277.18 $338.81 $207.89 93982 S 0097 1.5196 $164.76 $201.39 $123.57 93990 S 0266 1.8181 $197.12 $240.95 $147.85 93998 Q1 0340 0.7061 $76.56 $93.58 $57.42 94002 Q3 0079 5.0449 $546.97 $668.60 $410.25 94003 Q3 0079 5.0449 $546.97 $668.60 $410.25 94004 B $0.00 $0.00 $0.0094005 M $0.00 $0.00 $0.0094010 Q1 0367 2.1744 $235.75 $288.17 $176.82 94011 Q1 0367 2.1744 $235.75 $288.17 $176.82 94012 Q1 0367 2.1744 $235.75 $288.17 $176.82 94013 S 0369 3.1934 $346.23 $423.22 $259.69 94014 Q1 0367 2.1744 $235.75 $288.17 $176.82 94015 Q1 0367 2.1744 $235.75 $288.17 $176.82 94016 A $0.00 $0.00 $0.0094060 S 0369 3.1934 $346.23 $423.22 $259.69 94070 S 0369 3.1934 $346.23 $423.22 $259.69 94150 Q1 0367 2.1744 $235.75 $288.17 $176.82 94200 Q1 0420 1.7762 $192.58 $235.40 $144.44 94250 Q1 0340 0.7061 $76.56 $93.58 $57.42 94375 Q1 0367 2.1744 $235.75 $288.17 $176.82 94400 Q1 0367 2.1744 $235.75 $288.17 $176.82 94450 Q1 0367 2.1744 $235.75 $288.17 $176.82 94452 Q1 0367 2.1744 $235.75 $288.17 $176.82 94453 Q1 0367 2.1744 $235.75 $288.17 $176.82 94610 Q1 0077 2.2195 $240.64 $294.15 $180.49 94620 Q1 0420 1.7762 $192.58 $235.40 $144.44


186


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee94621 S 0369 3.1934 $346.23 $423.22 $259.69 94640 Q1 0077 2.2195 $240.64 $294.15 $180.49 94642 Q1 0077 2.2195 $240.64 $294.15 $180.49 94644 Q1 0420 1.7762 $192.58 $235.40 $144.44 94645 N $0.00 $0.00 $0.00 94660 Q3 0077 2.2195 $240.64 $294.15 $180.49 94662 Q3 0079 5.0449 $546.97 $668.60 $410.25 94664 Q1 0077 2.2195 $240.64 $294.15 $180.49 94667 Q1 0077 2.2195 $240.64 $294.15 $180.49 94668 Q1 0340 0.7061 $76.56 $93.58 $57.42 94669 Q1 0077 2.2195 $240.64 $294.15 $180.49 94680 Q1 0367 2.1744 $235.75 $288.17 $176.82 94681 Q1 0367 2.1744 $235.75 $288.17 $176.82 94690 Q1 0340 0.7061 $76.56 $93.58 $57.42 94726 Q1 0367 2.1744 $235.75 $288.17 $176.82 94727 Q1 0367 2.1744 $235.75 $288.17 $176.82 94728 Q1 0367 2.1744 $235.75 $288.17 $176.82 94729 N $0.00 $0.00 $0.00 94750 Q1 0367 2.1744 $235.75 $288.17 $176.82 94760 N $0.00 $0.00 $0.00 94761 N $0.00 $0.00 $0.00 94762 Q3 0097 1.5196 $164.76 $201.39 $123.57 94770 S 0369 3.1934 $346.23 $423.22 $259.69 94772 S 0369 3.1934 $346.23 $423.22 $259.69 94774 B $0.00 $0.00 $0.0094775 S 0097 1.5196 $164.76 $201.39 $123.57 94776 S 0097 1.5196 $164.76 $201.39 $123.57 94777 B $0.00 $0.00 $0.0094780 Q1 0340 0.7061 $76.56 $93.58 $57.42 94781 N $0.00 $0.00 $0.00 94799 Q1 0367 2.1744 $235.75 $288.17 $176.82 95004 Q1 0420 1.7762 $192.58 $235.40 $144.44 95012 Q1 0340 0.7061 $76.56 $93.58 $57.42 95017 Q1 0450 0.3942 $42.74 $52.24 $32.06 95018 Q1 0340 0.7061 $76.56 $93.58 $57.42 95024 Q1 0340 0.7061 $76.56 $93.58 $57.42 95027 Q1 0450 0.3942 $42.74 $52.24 $32.06 95028 Q1 0340 0.7061 $76.56 $93.58 $57.42 95044 Q1 0420 1.7762 $192.58 $235.40 $144.44 95052 Q1 0340 0.7061 $76.56 $93.58 $57.42 95056 Q1 0340 0.7061 $76.56 $93.58 $57.42 95060 Q1 0420 1.7762 $192.58 $235.40 $144.44 95065 Q1 0340 0.7061 $76.56 $93.58 $57.42 95070 S 0369 3.1934 $346.23 $423.22 $259.69 95071 Q1 0367 2.1744 $235.75 $288.17 $176.82 95076 S 0361 4.432 $480.52 $587.37 $360.41 95079 N $0.00 $0.00 $0.00 95115 S 0436 0.4393 $47.63 $58.22 $35.72 95117 S 0436 0.4393 $47.63 $58.22 $35.72 95120 E $0.00 $0.00 $0.0095125 E $0.00 $0.00 $0.00


187


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee95130 E $0.00 $0.00 $0.0095131 E $0.00 $0.00 $0.0095132 E $0.00 $0.00 $0.0095133 E $0.00 $0.00 $0.0095134 E $0.00 $0.00 $0.0095144 S 0437 0.7218 $78.26 $95.66 $58.70 95145 S 0436 0.4393 $47.63 $58.22 $35.72 95146 S 0438 1.4593 $158.22 $193.40 $118.67 95147 S 0438 1.4593 $158.22 $193.40 $118.67 95148 S 0437 0.7218 $78.26 $95.66 $58.70 95149 S 0437 0.7218 $78.26 $95.66 $58.70 95165 S 0436 0.4393 $47.63 $58.22 $35.72 95170 S 0437 0.7218 $78.26 $95.66 $58.70 95180 Q1 0420 1.7762 $192.58 $235.40 $144.44 95199 Q1 0450 0.3942 $42.74 $52.24 $32.06 95250 V 0632 1.4327 $155.33 $189.88 $116.51 95251 B $0.00 $0.00 $0.0095782 S 0435 11.5176 $1,248.74 $1,526.43 $936.61 95783 S 0435 11.5176 $1,248.74 $1,526.43 $936.61 95800 S 0213 2.3813 $258.18 $315.59 $193.65 95801 S 0213 2.3813 $258.18 $315.59 $193.65 95803 Q1 0340 0.7061 $76.56 $93.58 $57.42 95805 S 0435 11.5176 $1,248.74 $1,526.43 $936.61 95806 S 0213 2.3813 $258.18 $315.59 $193.65 95807 S 0209 3.1121 $337.41 $412.45 $253.08 95808 S 0435 11.5176 $1,248.74 $1,526.43 $936.61 95810 S 0435 11.5176 $1,248.74 $1,526.43 $936.61 95811 S 0435 11.5176 $1,248.74 $1,526.43 $936.61 95812 S 0209 3.1121 $337.41 $412.45 $253.08 95813 S 0209 3.1121 $337.41 $412.45 $253.08 95816 S 0213 2.3813 $258.18 $315.59 $193.65 95819 S 0213 2.3813 $258.18 $315.59 $193.65 95822 S 0209 3.1121 $337.41 $412.45 $253.08 95824 S 0216 3.6766 $398.62 $487.26 $298.98 95827 S 0209 3.1121 $337.41 $412.45 $253.08 95829 N $0.00 $0.00 $0.00 95830 B $0.00 $0.00 $0.0095831 A $0.00 $0.00 $0.0095832 A $0.00 $0.00 $0.0095833 A $0.00 $0.00 $0.0095834 A $0.00 $0.00 $0.0095851 A $0.00 $0.00 $0.0095852 A $0.00 $0.00 $0.0095857 S 0218 2.1417 $232.20 $283.84 $174.16 95860 Q1 0215 1.2804 $138.82 $169.69 $104.12 95861 S 0218 2.1417 $232.20 $283.84 $174.16 95863 S 0218 2.1417 $232.20 $283.84 $174.16 95864 S 0218 2.1417 $232.20 $283.84 $174.16 95865 Q1 0215 1.2804 $138.82 $169.69 $104.12 95866 Q1 0215 1.2804 $138.82 $169.69 $104.12 95867 S 0218 2.1417 $232.20 $283.84 $174.16


188


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee95868 S 0218 2.1417 $232.20 $283.84 $174.16 95869 Q1 0215 1.2804 $138.82 $169.69 $104.12 95870 Q1 0340 0.7061 $76.56 $93.58 $57.42 95872 S 0218 2.1417 $232.20 $283.84 $174.16 95873 N $0.00 $0.00 $0.00 95874 N $0.00 $0.00 $0.00 95875 S 0218 2.1417 $232.20 $283.84 $174.16 95885 N $0.00 $0.00 $0.00 95886 N $0.00 $0.00 $0.00 95887 N $0.00 $0.00 $0.00 95905 Q1 0215 1.2804 $138.82 $169.69 $104.12 95907 S 0218 2.1417 $232.20 $283.84 $174.16 95908 S 0218 2.1417 $232.20 $283.84 $174.16 95909 S 0216 3.6766 $398.62 $487.26 $298.98 95910 S 0216 3.6766 $398.62 $487.26 $298.98 95911 S 0216 3.6766 $398.62 $487.26 $298.98 95912 S 0216 3.6766 $398.62 $487.26 $298.98 95913 S 0216 3.6766 $398.62 $487.26 $298.98 95921 S 0218 2.1417 $232.20 $283.84 $174.16 95922 Q1 0215 1.2804 $138.82 $169.69 $104.12 95923 Q1 0215 1.2804 $138.82 $169.69 $104.12 95924 S 0218 2.1417 $232.20 $283.84 $174.16 95925 S 0218 2.1417 $232.20 $283.84 $174.16 95926 S 0216 3.6766 $398.62 $487.26 $298.98 95927 S 0218 2.1417 $232.20 $283.84 $174.16 95928 S 0216 3.6766 $398.62 $487.26 $298.98 95929 Q1 0215 1.2804 $138.82 $169.69 $104.12 95930 S 0218 2.1417 $232.20 $283.84 $174.16 95933 Q1 0215 1.2804 $138.82 $169.69 $104.12 95937 S 0218 2.1417 $232.20 $283.84 $174.16 95938 S 0216 3.6766 $398.62 $487.26 $298.98 95939 S 0218 2.1417 $232.20 $283.84 $174.16 95940 N $0.00 $0.00 $0.00 95941 N $0.00 $0.00 $0.00 95943 S 0218 2.1417 $232.20 $283.84 $174.16 95950 S 0435 11.5176 $1,248.74 $1,526.43 $936.61 95951 S 0435 11.5176 $1,248.74 $1,526.43 $936.61 95953 S 0435 11.5176 $1,248.74 $1,526.43 $936.61 95954 S 0218 2.1417 $232.20 $283.84 $174.16 95955 N $0.00 $0.00 $0.00 95956 S 0435 11.5176 $1,248.74 $1,526.43 $936.61 95957 N $0.00 $0.00 $0.00 95958 S 0435 11.5176 $1,248.74 $1,526.43 $936.61 95961 S 0216 3.6766 $398.62 $487.26 $298.98 95962 N $0.00 $0.00 $0.00 95965 S 0446 17.5395 $1,901.63 $2,324.51 $1,426.31 95966 S 0446 17.5395 $1,901.63 $2,324.51 $1,426.31 95967 N $0.00 $0.00 $0.00 95970 Q1 0215 1.2804 $138.82 $169.69 $104.12 95971 S 0692 1.7288 $187.44 $229.12 $140.59 95972 S 0692 1.7288 $187.44 $229.12 $140.59


189


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee95973 N $0.00 $0.00 $0.00 95974 S 0692 1.7288 $187.44 $229.12 $140.59 95975 N $0.00 $0.00 $0.00 95978 S 0692 1.7288 $187.44 $229.12 $140.59 95979 N $0.00 $0.00 $0.00 95980 N $0.00 $0.00 $0.00 95981 Q1 0215 1.2804 $138.82 $169.69 $104.12 95982 Q1 0690 0.4739 $51.38 $62.81 $38.54 95990 S 0439 2.3404 $253.75 $310.17 $190.32 95991 S 0439 2.3404 $253.75 $310.17 $190.32 95992 A $0.00 $0.00 $0.0095999 Q1 0215 1.2804 $138.82 $169.69 $104.12 96000 S 0216 3.6766 $398.62 $487.26 $298.98 96001 S 0216 3.6766 $398.62 $487.26 $298.98 96002 S 0218 2.1417 $232.20 $283.84 $174.16 96003 Q1 0215 1.2804 $138.82 $169.69 $104.12 96004 B $0.00 $0.00 $0.0096020 N $0.00 $0.00 $0.00 96040 B $0.00 $0.00 $0.0096101 Q3 0373 2.6874 $291.37 $356.16 $218.54 96102 Q3 0373 2.6874 $291.37 $356.16 $218.54 96103 Q3 0373 2.6874 $291.37 $356.16 $218.54 96105 A $0.00 $0.00 $0.0096110 E $0.00 $0.00 $0.0096111 Q3 0631 0.7242 $78.52 $95.98 $58.89 96116 Q3 0373 2.6874 $291.37 $356.16 $218.54 96118 Q3 0373 2.6874 $291.37 $356.16 $218.54 96119 Q3 0373 2.6874 $291.37 $356.16 $218.54 96120 Q3 0373 2.6874 $291.37 $356.16 $218.54 96125 A $0.00 $0.00 $0.0096127 Q1 0450 0.3942 $42.74 $52.24 $32.06 96150 Q3 0432 0.6773 $73.43 $89.76 $55.08 96151 Q3 0432 0.6773 $73.43 $89.76 $55.08 96152 Q3 0432 0.6773 $73.43 $89.76 $55.08 96153 Q3 0031 0.3508 $38.03 $46.49 $28.53 96154 Q3 0432 0.6773 $73.43 $89.76 $55.08 96155 E $0.00 $0.00 $0.0096360 S 0438 1.4593 $158.22 $193.40 $118.67 96361 S 0436 0.4393 $47.63 $58.22 $35.72 96365 S 0439 2.3404 $253.75 $310.17 $190.32 96366 S 0436 0.4393 $47.63 $58.22 $35.72 96367 S 0437 0.7218 $78.26 $95.66 $58.70 96368 N $0.00 $0.00 $0.00 96369 S 0439 2.3404 $253.75 $310.17 $190.32 96370 S 0437 0.7218 $78.26 $95.66 $58.70 96371 N $0.00 $0.00 $0.00 96372 S 0437 0.7218 $78.26 $95.66 $58.70 96373 S 0438 1.4593 $158.22 $193.40 $118.67 96374 S 0438 1.4593 $158.22 $193.40 $118.67 96375 S 0436 0.4393 $47.63 $58.22 $35.72 96376 N $0.00 $0.00 $0.00


190


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee96379 S 0436 0.4393 $47.63 $58.22 $35.72 96401 S 0438 1.4593 $158.22 $193.40 $118.67 96402 S 0437 0.7218 $78.26 $95.66 $58.70 96405 S 0437 0.7218 $78.26 $95.66 $58.70 96406 S 0439 2.3404 $253.75 $310.17 $190.32 96409 S 0439 2.3404 $253.75 $310.17 $190.32 96411 S 0437 0.7218 $78.26 $95.66 $58.70 96413 S 0440 3.8439 $416.76 $509.43 $312.59 96415 S 0437 0.7218 $78.26 $95.66 $58.70 96416 S 0440 3.8439 $416.76 $509.43 $312.59 96417 S 0437 0.7218 $78.26 $95.66 $58.70 96420 S 0438 1.4593 $158.22 $193.40 $118.67 96422 S 0440 3.8439 $416.76 $509.43 $312.59 96423 S 0438 1.4593 $158.22 $193.40 $118.67 96425 S 0440 3.8439 $416.76 $509.43 $312.59 96440 S 0439 2.3404 $253.75 $310.17 $190.32 96446 S 0439 2.3404 $253.75 $310.17 $190.32 96450 S 0440 3.8439 $416.76 $509.43 $312.59 96521 S 0439 2.3404 $253.75 $310.17 $190.32 96522 S 0439 2.3404 $253.75 $310.17 $190.32 96523 Q1 0624 1.0626 $115.21 $140.83 $86.41 96542 S 0438 1.4593 $158.22 $193.40 $118.67 96549 S 0436 0.4393 $47.63 $58.22 $35.72 96567 T 0015 1.9702 $213.61 $261.11 $160.22 96570 N $0.00 $0.00 $0.00 96571 N $0.00 $0.00 $0.00 96900 Q1 0450 0.3942 $42.74 $52.24 $32.06 96902 N $0.00 $0.00 $0.00 96904 N $0.00 $0.00 $0.00 96910 Q1 0340 0.7061 $76.56 $93.58 $57.42 96912 Q1 0340 0.7061 $76.56 $93.58 $57.42 96913 T 0326 2.9651 $321.48 $392.96 $241.12 96920 Q1 0012 1.3279 $143.97 $175.99 $107.98 96921 Q1 0012 1.3279 $143.97 $175.99 $107.98 96922 Q1 0012 1.3279 $143.97 $175.99 $107.98 96999 Q1 0012 1.3279 $143.97 $175.99 $107.98 97001 A $0.00 $0.00 $0.0097002 A $0.00 $0.00 $0.0097003 A $0.00 $0.00 $0.0097004 A $0.00 $0.00 $0.0097005 E $0.00 $0.00 $0.0097006 E $0.00 $0.00 $0.0097010 A $0.00 $0.00 $0.0097012 A $0.00 $0.00 $0.0097014 E $0.00 $0.00 $0.0097016 A $0.00 $0.00 $0.0097018 A $0.00 $0.00 $0.0097022 A $0.00 $0.00 $0.0097024 A $0.00 $0.00 $0.0097026 A $0.00 $0.00 $0.0097028 A $0.00 $0.00 $0.00


191


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee97032 A $0.00 $0.00 $0.0097033 A $0.00 $0.00 $0.0097034 A $0.00 $0.00 $0.0097035 A $0.00 $0.00 $0.0097036 A $0.00 $0.00 $0.0097039 A $0.00 $0.00 $0.0097110 A $0.00 $0.00 $0.0097112 A $0.00 $0.00 $0.0097113 A $0.00 $0.00 $0.0097116 A $0.00 $0.00 $0.0097124 A $0.00 $0.00 $0.0097139 A $0.00 $0.00 $0.0097140 A $0.00 $0.00 $0.0097150 A $0.00 $0.00 $0.0097530 A $0.00 $0.00 $0.0097532 A $0.00 $0.00 $0.0097533 A $0.00 $0.00 $0.0097535 A $0.00 $0.00 $0.0097537 A $0.00 $0.00 $0.0097542 A $0.00 $0.00 $0.0097545 A $0.00 $0.00 $0.0097546 A $0.00 $0.00 $0.0097597 T 0015 1.9702 $213.61 $261.11 $160.22 97598 N $0.00 $0.00 $0.00 97602 T 0015 1.9702 $213.61 $261.11 $160.22 97605 Q1 0012 1.3279 $143.97 $175.99 $107.98 97606 T 0015 1.9702 $213.61 $261.11 $160.22 97607 T 0015 1.9702 $213.61 $261.11 $160.22 97608 T 0015 1.9702 $213.61 $261.11 $160.22 97610 T 0015 1.9702 $213.61 $261.11 $160.22 97750 A $0.00 $0.00 $0.0097755 A $0.00 $0.00 $0.0097760 A $0.00 $0.00 $0.0097761 A $0.00 $0.00 $0.0097762 A $0.00 $0.00 $0.0097799 A $0.00 $0.00 $0.0097802 A $0.00 $0.00 $0.0097803 A $0.00 $0.00 $0.0097804 A $0.00 $0.00 $0.0097810 E $0.00 $0.00 $0.0097811 E $0.00 $0.00 $0.0097813 E $0.00 $0.00 $0.0097814 E $0.00 $0.00 $0.0098925 Q1 0060 0.2673 $28.98 $35.43 $21.74 98926 Q1 0060 0.2673 $28.98 $35.43 $21.74 98927 Q1 0060 0.2673 $28.98 $35.43 $21.74 98928 Q1 0060 0.2673 $28.98 $35.43 $21.74 98929 Q1 0060 0.2673 $28.98 $35.43 $21.74 98940 Q1 0060 0.2673 $28.98 $35.43 $21.74 98941 Q1 0060 0.2673 $28.98 $35.43 $21.74 98942 Q1 0060 0.2673 $28.98 $35.43 $21.74


192


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee98943 E $0.00 $0.00 $0.0098960 E $0.00 $0.00 $0.0098961 E $0.00 $0.00 $0.0098962 E $0.00 $0.00 $0.0098966 E $0.00 $0.00 $0.0098967 E $0.00 $0.00 $0.0098968 E $0.00 $0.00 $0.0098969 E $0.00 $0.00 $0.0099000 E $0.00 $0.00 $0.0099001 E $0.00 $0.00 $0.0099002 B $0.00 $0.00 $0.0099024 B $0.00 $0.00 $0.0099026 E $0.00 $0.00 $0.0099027 E $0.00 $0.00 $0.0099050 B $0.00 $0.00 $0.0099051 B $0.00 $0.00 $0.0099053 B $0.00 $0.00 $0.0099056 B $0.00 $0.00 $0.0099058 B $0.00 $0.00 $0.0099060 B $0.00 $0.00 $0.0099070 B $0.00 $0.00 $0.0099071 B $0.00 $0.00 $0.0099075 E $0.00 $0.00 $0.0099078 N $0.00 $0.00 $0.00 99080 B $0.00 $0.00 $0.0099082 B $0.00 $0.00 $0.0099090 B $0.00 $0.00 $0.0099091 N $0.00 $0.00 $0.00 99100 B $0.00 $0.00 $0.0099116 B $0.00 $0.00 $0.0099135 B $0.00 $0.00 $0.0099140 B $0.00 $0.00 $0.0099143 N $0.00 $0.00 $0.00 99144 N $0.00 $0.00 $0.00 99145 N $0.00 $0.00 $0.00 99148 N $0.00 $0.00 $0.00 99149 N $0.00 $0.00 $0.00 99150 N $0.00 $0.00 $0.00 99170 T 0188 1.7659 $191.46 $234.03 $143.60 99172 E $0.00 $0.00 $0.0099173 E $0.00 $0.00 $0.0099174 E $0.00 $0.00 $0.0099175 N $0.00 $0.00 $0.00 99183 B $0.00 $0.00 $0.0099184 C $0.00 $0.00 $0.0099188 E $0.00 $0.00 $0.0099190 C $0.00 $0.00 $0.0099191 C $0.00 $0.00 $0.0099192 C $0.00 $0.00 $0.0099195 Q1 0624 1.0626 $115.21 $140.83 $86.41 99199 B $0.00 $0.00 $0.00


193


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee99201 B $0.00 $0.00 $0.0099202 B $0.00 $0.00 $0.0099203 B $0.00 $0.00 $0.0099204 B $0.00 $0.00 $0.0099205 B $0.00 $0.00 $0.0099211 B $0.00 $0.00 $0.0099212 B $0.00 $0.00 $0.0099213 B $0.00 $0.00 $0.0099214 B $0.00 $0.00 $0.0099215 B $0.00 $0.00 $0.0099217 B $0.00 $0.00 $0.0099218 B $0.00 $0.00 $0.0099219 B $0.00 $0.00 $0.0099220 B $0.00 $0.00 $0.0099221 B $0.00 $0.00 $0.0099222 B $0.00 $0.00 $0.0099223 B $0.00 $0.00 $0.0099224 B $0.00 $0.00 $0.0099225 B $0.00 $0.00 $0.0099226 B $0.00 $0.00 $0.0099231 B $0.00 $0.00 $0.0099232 B $0.00 $0.00 $0.0099233 B $0.00 $0.00 $0.0099234 B $0.00 $0.00 $0.0099235 B $0.00 $0.00 $0.0099236 B $0.00 $0.00 $0.0099238 B $0.00 $0.00 $0.0099239 B $0.00 $0.00 $0.0099241 E $0.00 $0.00 $0.0099242 E $0.00 $0.00 $0.0099243 E $0.00 $0.00 $0.0099244 E $0.00 $0.00 $0.0099245 E $0.00 $0.00 $0.0099251 E $0.00 $0.00 $0.0099252 E $0.00 $0.00 $0.0099253 E $0.00 $0.00 $0.0099254 E $0.00 $0.00 $0.0099255 E $0.00 $0.00 $0.0099281 V 0609 0.8155 $88.42 $108.08 $66.32 99282 V 0613 1.5206 $164.86 $201.53 $123.66 99283 V 0614 2.6747 $289.99 $354.48 $217.51 99284 Q3 0615 4.5003 $487.92 $596.42 $365.96 99285 Q3 0616 6.6424 $720.17 $880.32 $540.16 99288 B $0.00 $0.00 $0.0099291 Q3 0617 8.8569 $960.27 $1,173.81 $720.24 99292 N $0.00 $0.00 $0.00 99304 B $0.00 $0.00 $0.0099305 B $0.00 $0.00 $0.0099306 B $0.00 $0.00 $0.0099307 B $0.00 $0.00 $0.0099308 B $0.00 $0.00 $0.00


194


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee99309 B $0.00 $0.00 $0.0099310 B $0.00 $0.00 $0.0099315 B $0.00 $0.00 $0.0099316 B $0.00 $0.00 $0.0099318 B $0.00 $0.00 $0.0099324 B $0.00 $0.00 $0.0099325 B $0.00 $0.00 $0.0099326 B $0.00 $0.00 $0.0099327 B $0.00 $0.00 $0.0099328 B $0.00 $0.00 $0.0099334 B $0.00 $0.00 $0.0099335 B $0.00 $0.00 $0.0099336 B $0.00 $0.00 $0.0099337 B $0.00 $0.00 $0.0099339 B $0.00 $0.00 $0.0099340 B $0.00 $0.00 $0.0099341 B $0.00 $0.00 $0.0099342 B $0.00 $0.00 $0.0099343 B $0.00 $0.00 $0.0099344 B $0.00 $0.00 $0.0099345 B $0.00 $0.00 $0.0099347 B $0.00 $0.00 $0.0099348 B $0.00 $0.00 $0.0099349 B $0.00 $0.00 $0.0099350 B $0.00 $0.00 $0.0099354 N $0.00 $0.00 $0.00 99355 N $0.00 $0.00 $0.00 99356 C $0.00 $0.00 $0.0099357 C $0.00 $0.00 $0.0099358 N $0.00 $0.00 $0.00 99359 N $0.00 $0.00 $0.00 99360 B $0.00 $0.00 $0.0099363 B $0.00 $0.00 $0.0099364 B $0.00 $0.00 $0.0099366 N $0.00 $0.00 $0.00 99367 N $0.00 $0.00 $0.00 99368 N $0.00 $0.00 $0.00 99374 B $0.00 $0.00 $0.0099375 E $0.00 $0.00 $0.0099377 B $0.00 $0.00 $0.0099378 E $0.00 $0.00 $0.0099379 B $0.00 $0.00 $0.0099380 B $0.00 $0.00 $0.0099381 E $0.00 $0.00 $0.0099382 E $0.00 $0.00 $0.0099383 E $0.00 $0.00 $0.0099384 E $0.00 $0.00 $0.0099385 E $0.00 $0.00 $0.0099386 E $0.00 $0.00 $0.0099387 E $0.00 $0.00 $0.0099391 E $0.00 $0.00 $0.00


195


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee99392 E $0.00 $0.00 $0.0099393 E $0.00 $0.00 $0.0099394 E $0.00 $0.00 $0.0099395 E $0.00 $0.00 $0.0099396 E $0.00 $0.00 $0.0099397 E $0.00 $0.00 $0.0099401 E $0.00 $0.00 $0.0099402 E $0.00 $0.00 $0.0099403 E $0.00 $0.00 $0.0099404 E $0.00 $0.00 $0.0099406 S 0031 0.3508 $38.03 $46.49 $28.53 99407 S 0031 0.3508 $38.03 $46.49 $28.53 99408 E $0.00 $0.00 $0.0099409 E $0.00 $0.00 $0.0099411 E $0.00 $0.00 $0.0099412 E $0.00 $0.00 $0.0099420 E $0.00 $0.00 $0.0099429 E $0.00 $0.00 $0.0099441 E $0.00 $0.00 $0.0099442 E $0.00 $0.00 $0.0099443 E $0.00 $0.00 $0.0099444 E $0.00 $0.00 $0.0099446 E $0.00 $0.00 $0.0099447 E $0.00 $0.00 $0.0099448 E $0.00 $0.00 $0.0099449 E $0.00 $0.00 $0.0099450 E $0.00 $0.00 $0.0099455 B $0.00 $0.00 $0.0099456 B $0.00 $0.00 $0.0099460 V 0632 1.4327 $155.33 $189.88 $116.51 99461 M $0.00 $0.00 $0.0099462 C $0.00 $0.00 $0.0099463 V 0632 1.4327 $155.33 $189.88 $116.51 99464 N $0.00 $0.00 $0.00 99465 S 0094 6.3433 $687.74 $840.68 $515.84 99466 N $0.00 $0.00 $0.00 99467 N $0.00 $0.00 $0.00 99468 C $0.00 $0.00 $0.0099469 C $0.00 $0.00 $0.0099471 C $0.00 $0.00 $0.0099472 C $0.00 $0.00 $0.0099475 C $0.00 $0.00 $0.0099476 C $0.00 $0.00 $0.0099477 C $0.00 $0.00 $0.0099478 C $0.00 $0.00 $0.0099479 C $0.00 $0.00 $0.0099480 C $0.00 $0.00 $0.0099485 B $0.00 $0.00 $0.0099486 B $0.00 $0.00 $0.0099487 N $0.00 $0.00 $0.00 99489 N $0.00 $0.00 $0.00


196


Code Status APC Relative Weight ACH Fee CAH Fee ASC Fee99490 V 0631 0.7242 $78.52 $95.98 $58.89 99495 V 0632 1.4327 $155.33 $189.88 $116.51 99496 V 0632 1.4327 $155.33 $189.88 $116.51 99497 N $0.00 $0.00 $0.00 99498 N $0.00 $0.00 $0.00 99499 B $0.00 $0.00 $0.0099500 E $0.00 $0.00 $0.0099501 E $0.00 $0.00 $0.0099502 E $0.00 $0.00 $0.0099503 E $0.00 $0.00 $0.0099504 E $0.00 $0.00 $0.0099505 E $0.00 $0.00 $0.0099506 E $0.00 $0.00 $0.0099507 E $0.00 $0.00 $0.0099509 E $0.00 $0.00 $0.0099510 E $0.00 $0.00 $0.0099511 E $0.00 $0.00 $0.0099512 E $0.00 $0.00 $0.0099600 E $0.00 $0.00 $0.0099601 E $0.00 $0.00 $0.0099602 E $0.00 $0.00 $0.0099605 E $0.00 $0.00 $0.0099606 E $0.00 $0.00 $0.0099607 E $0.00 $0.00 $0.00A0021 E $0.00 $0.00 $0.00A0080 E $0.00 $0.00 $0.00A0090 E $0.00 $0.00 $0.00A0100 E $0.00 $0.00 $0.00A0110 E $0.00 $0.00 $0.00A0120 E $0.00 $0.00 $0.00A0130 E $0.00 $0.00 $0.00A0140 E $0.00 $0.00 $0.00A0160 E $0.00 $0.00 $0.00A0170 E $0.00 $0.00 $0.00A0180 E $0.00 $0.00 $0.00A0190 E $0.00 $0.00 $0.00A0200 E $0.00 $0.00 $0.00A0210 E $0.00 $0.00 $0.00A0225 E $0.00 $0.00 $0.00A0380 E $0.00 $0.00 $0.00A0382 E $0.00 $0.00 $0.00A0384 E $0.00 $0.00 $0.00A0390 E $0.00 $0.00 $0.00A0392 E $0.00 $0.00 $0.00A0394 E $0.00 $0.00 $0.00A0396 E $0.00 $0.00 $0.00A0398 E $0.00 $0.00 $0.00A0420 E $0.00 $0.00 $0.00A0422 E $0.00 $0.00 $0.00A0424 E $0.00 $0.00 $0.00A0425 A $0.00 $0.00 $0.00


197


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeA0426 A $0.00 $0.00 $0.00A0427 A $0.00 $0.00 $0.00A0428 A $0.00 $0.00 $0.00A0429 A $0.00 $0.00 $0.00A0430 A $0.00 $0.00 $0.00A0431 A $0.00 $0.00 $0.00A0432 A $0.00 $0.00 $0.00A0433 A $0.00 $0.00 $0.00A0434 A $0.00 $0.00 $0.00A0435 A $0.00 $0.00 $0.00A0436 A $0.00 $0.00 $0.00A0888 E $0.00 $0.00 $0.00A0998 E $0.00 $0.00 $0.00A0999 A $0.00 $0.00 $0.00A4206 N $0.00 $0.00 $0.00 A4207 N $0.00 $0.00 $0.00 A4208 N $0.00 $0.00 $0.00 A4209 N $0.00 $0.00 $0.00 A4210 E $0.00 $0.00 $0.00A4211 N $0.00 $0.00 $0.00 A4212 N $0.00 $0.00 $0.00 A4213 N $0.00 $0.00 $0.00 A4215 N $0.00 $0.00 $0.00 A4216 N $0.00 $0.00 $0.00 A4217 N $0.00 $0.00 $0.00 A4218 N $0.00 $0.00 $0.00 A4220 N $0.00 $0.00 $0.00 A4221 N $0.00 $0.00 $0.00 A4222 N $0.00 $0.00 $0.00 A4223 N $0.00 $0.00 $0.00 A4230 N $0.00 $0.00 $0.00 A4231 N $0.00 $0.00 $0.00 A4232 E $0.00 $0.00 $0.00A4233 E $0.00 $0.00 $0.00A4234 E $0.00 $0.00 $0.00A4235 E $0.00 $0.00 $0.00A4236 E $0.00 $0.00 $0.00A4244 N $0.00 $0.00 $0.00 A4245 N $0.00 $0.00 $0.00 A4246 N $0.00 $0.00 $0.00 A4247 N $0.00 $0.00 $0.00 A4248 N $0.00 $0.00 $0.00 A4250 E $0.00 $0.00 $0.00A4252 E $0.00 $0.00 $0.00A4253 N $0.00 $0.00 $0.00 A4255 N $0.00 $0.00 $0.00 A4256 N $0.00 $0.00 $0.00 A4257 E $0.00 $0.00 $0.00A4258 N $0.00 $0.00 $0.00 A4259 N $0.00 $0.00 $0.00 A4261 E $0.00 $0.00 $0.00


198


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeA4262 N $0.00 $0.00 $0.00 A4263 N $0.00 $0.00 $0.00 A4264 E $0.00 $0.00 $0.00A4265 N $0.00 $0.00 $0.00 A4266 E $0.00 $0.00 $0.00A4267 E $0.00 $0.00 $0.00A4268 E $0.00 $0.00 $0.00A4269 E $0.00 $0.00 $0.00A4270 N $0.00 $0.00 $0.00 A4280 N $0.00 $0.00 $0.00 A4281 E $0.00 $0.00 $0.00A4282 E $0.00 $0.00 $0.00A4283 E $0.00 $0.00 $0.00A4284 E $0.00 $0.00 $0.00A4285 E $0.00 $0.00 $0.00A4286 E $0.00 $0.00 $0.00A4290 N $0.00 $0.00 $0.00 A4300 N $0.00 $0.00 $0.00 A4301 N $0.00 $0.00 $0.00 A4305 N $0.00 $0.00 $0.00 A4306 N $0.00 $0.00 $0.00 A4310 N $0.00 $0.00 $0.00 A4311 N $0.00 $0.00 $0.00 A4312 N $0.00 $0.00 $0.00 A4313 N $0.00 $0.00 $0.00 A4314 N $0.00 $0.00 $0.00 A4315 N $0.00 $0.00 $0.00 A4316 N $0.00 $0.00 $0.00 A4320 N $0.00 $0.00 $0.00 A4321 N $0.00 $0.00 $0.00 A4322 N $0.00 $0.00 $0.00 A4326 N $0.00 $0.00 $0.00 A4327 N $0.00 $0.00 $0.00 A4328 N $0.00 $0.00 $0.00 A4330 N $0.00 $0.00 $0.00 A4331 N $0.00 $0.00 $0.00 A4332 N $0.00 $0.00 $0.00 A4333 N $0.00 $0.00 $0.00 A4334 N $0.00 $0.00 $0.00 A4335 N $0.00 $0.00 $0.00 A4336 N $0.00 $0.00 $0.00 A4338 N $0.00 $0.00 $0.00 A4340 N $0.00 $0.00 $0.00 A4344 N $0.00 $0.00 $0.00 A4346 N $0.00 $0.00 $0.00 A4349 N $0.00 $0.00 $0.00 A4351 N $0.00 $0.00 $0.00 A4352 N $0.00 $0.00 $0.00 A4353 N $0.00 $0.00 $0.00 A4354 N $0.00 $0.00 $0.00 A4355 N $0.00 $0.00 $0.00


199


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeA4356 N $0.00 $0.00 $0.00 A4357 N $0.00 $0.00 $0.00 A4358 N $0.00 $0.00 $0.00 A4360 N $0.00 $0.00 $0.00 A4361 N $0.00 $0.00 $0.00 A4362 N $0.00 $0.00 $0.00 A4363 E $0.00 $0.00 $0.00A4364 N $0.00 $0.00 $0.00 A4366 N $0.00 $0.00 $0.00 A4367 N $0.00 $0.00 $0.00 A4368 N $0.00 $0.00 $0.00 A4369 N $0.00 $0.00 $0.00 A4371 N $0.00 $0.00 $0.00 A4372 N $0.00 $0.00 $0.00 A4373 N $0.00 $0.00 $0.00 A4375 N $0.00 $0.00 $0.00 A4376 N $0.00 $0.00 $0.00 A4377 N $0.00 $0.00 $0.00 A4378 N $0.00 $0.00 $0.00 A4379 N $0.00 $0.00 $0.00 A4380 N $0.00 $0.00 $0.00 A4381 N $0.00 $0.00 $0.00 A4382 N $0.00 $0.00 $0.00 A4383 N $0.00 $0.00 $0.00 A4384 N $0.00 $0.00 $0.00 A4385 N $0.00 $0.00 $0.00 A4387 N $0.00 $0.00 $0.00 A4388 N $0.00 $0.00 $0.00 A4389 N $0.00 $0.00 $0.00 A4390 N $0.00 $0.00 $0.00 A4391 N $0.00 $0.00 $0.00 A4392 N $0.00 $0.00 $0.00 A4393 N $0.00 $0.00 $0.00 A4394 N $0.00 $0.00 $0.00 A4395 N $0.00 $0.00 $0.00 A4396 N $0.00 $0.00 $0.00 A4397 N $0.00 $0.00 $0.00 A4398 N $0.00 $0.00 $0.00 A4399 N $0.00 $0.00 $0.00 A4400 N $0.00 $0.00 $0.00 A4402 N $0.00 $0.00 $0.00 A4404 N $0.00 $0.00 $0.00 A4405 N $0.00 $0.00 $0.00 A4406 N $0.00 $0.00 $0.00 A4407 N $0.00 $0.00 $0.00 A4408 N $0.00 $0.00 $0.00 A4409 N $0.00 $0.00 $0.00 A4410 N $0.00 $0.00 $0.00 A4411 N $0.00 $0.00 $0.00 A4412 N $0.00 $0.00 $0.00 A4413 N $0.00 $0.00 $0.00


200


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeA4414 N $0.00 $0.00 $0.00 A4415 N $0.00 $0.00 $0.00 A4416 N $0.00 $0.00 $0.00 A4417 N $0.00 $0.00 $0.00 A4418 N $0.00 $0.00 $0.00 A4419 N $0.00 $0.00 $0.00 A4420 N $0.00 $0.00 $0.00 A4421 N $0.00 $0.00 $0.00 A4422 N $0.00 $0.00 $0.00 A4423 N $0.00 $0.00 $0.00 A4424 N $0.00 $0.00 $0.00 A4425 N $0.00 $0.00 $0.00 A4426 N $0.00 $0.00 $0.00 A4427 N $0.00 $0.00 $0.00 A4428 N $0.00 $0.00 $0.00 A4429 N $0.00 $0.00 $0.00 A4430 N $0.00 $0.00 $0.00 A4431 N $0.00 $0.00 $0.00 A4432 N $0.00 $0.00 $0.00 A4433 N $0.00 $0.00 $0.00 A4434 N $0.00 $0.00 $0.00 A4435 N $0.00 $0.00 $0.00 A4450 N $0.00 $0.00 $0.00 A4452 N $0.00 $0.00 $0.00 A4455 N $0.00 $0.00 $0.00 A4456 N $0.00 $0.00 $0.00 A4458 N $0.00 $0.00 $0.00 A4459 N $0.00 $0.00 $0.00 A4461 N $0.00 $0.00 $0.00 A4463 N $0.00 $0.00 $0.00 A4465 N $0.00 $0.00 $0.00 A4466 E $0.00 $0.00 $0.00A4470 N $0.00 $0.00 $0.00 A4480 N $0.00 $0.00 $0.00 A4481 N $0.00 $0.00 $0.00 A4483 N $0.00 $0.00 $0.00 A4490 E $0.00 $0.00 $0.00A4495 E $0.00 $0.00 $0.00A4500 E $0.00 $0.00 $0.00A4510 E $0.00 $0.00 $0.00A4520 E $0.00 $0.00 $0.00A4550 B $0.00 $0.00 $0.00A4554 E $0.00 $0.00 $0.00A4555 E $0.00 $0.00 $0.00A4556 N $0.00 $0.00 $0.00 A4557 N $0.00 $0.00 $0.00 A4558 N $0.00 $0.00 $0.00 A4559 N $0.00 $0.00 $0.00 A4561 N $0.00 $0.00 $0.00 A4562 N $0.00 $0.00 $0.00 A4565 N $0.00 $0.00 $0.00


201


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeA4566 E $0.00 $0.00 $0.00A4570 E $0.00 $0.00 $0.00A4575 E $0.00 $0.00 $0.00A4580 E $0.00 $0.00 $0.00A4590 E $0.00 $0.00 $0.00A4595 N $0.00 $0.00 $0.00 A4600 E $0.00 $0.00 $0.00A4601 E $0.00 $0.00 $0.00A4602 N $0.00 $0.00 $0.00 A4604 N $0.00 $0.00 $0.00 A4605 N $0.00 $0.00 $0.00 A4606 N $0.00 $0.00 $0.00 A4608 N $0.00 $0.00 $0.00 A4611 E $0.00 $0.00 $0.00A4612 E $0.00 $0.00 $0.00A4613 E $0.00 $0.00 $0.00A4614 N $0.00 $0.00 $0.00 A4615 N $0.00 $0.00 $0.00 A4616 N $0.00 $0.00 $0.00 A4617 N $0.00 $0.00 $0.00 A4618 N $0.00 $0.00 $0.00 A4619 N $0.00 $0.00 $0.00 A4620 N $0.00 $0.00 $0.00 A4623 N $0.00 $0.00 $0.00 A4624 N $0.00 $0.00 $0.00 A4625 N $0.00 $0.00 $0.00 A4626 N $0.00 $0.00 $0.00 A4627 E $0.00 $0.00 $0.00A4628 N $0.00 $0.00 $0.00 A4629 N $0.00 $0.00 $0.00 A4630 E $0.00 $0.00 $0.00A4633 E $0.00 $0.00 $0.00A4634 N $0.00 $0.00 $0.00 A4635 E $0.00 $0.00 $0.00A4636 E $0.00 $0.00 $0.00A4637 E $0.00 $0.00 $0.00A4638 E $0.00 $0.00 $0.00A4639 E $0.00 $0.00 $0.00A4640 E $0.00 $0.00 $0.00A4641 N $0.00 $0.00 $0.00 A4642 N $0.00 $0.00 $0.00 A4648 N $0.00 $0.00 $0.00 A4649 N $0.00 $0.00 $0.00 A4650 N $0.00 $0.00 $0.00 A4651 N $0.00 $0.00 $0.00 A4652 N $0.00 $0.00 $0.00 A4653 N $0.00 $0.00 $0.00 A4657 N $0.00 $0.00 $0.00 A4660 N $0.00 $0.00 $0.00 A4663 N $0.00 $0.00 $0.00 A4670 E $0.00 $0.00 $0.00


202


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeA4671 B $0.00 $0.00 $0.00A4672 B $0.00 $0.00 $0.00A4673 B $0.00 $0.00 $0.00A4674 B $0.00 $0.00 $0.00A4680 N $0.00 $0.00 $0.00 A4690 N $0.00 $0.00 $0.00 A4706 N $0.00 $0.00 $0.00 A4707 N $0.00 $0.00 $0.00 A4708 N $0.00 $0.00 $0.00 A4709 N $0.00 $0.00 $0.00 A4714 N $0.00 $0.00 $0.00 A4719 N $0.00 $0.00 $0.00 A4720 N $0.00 $0.00 $0.00 A4721 N $0.00 $0.00 $0.00 A4722 N $0.00 $0.00 $0.00 A4723 N $0.00 $0.00 $0.00 A4724 N $0.00 $0.00 $0.00 A4725 N $0.00 $0.00 $0.00 A4726 N $0.00 $0.00 $0.00 A4728 B $0.00 $0.00 $0.00A4730 N $0.00 $0.00 $0.00 A4736 N $0.00 $0.00 $0.00 A4737 N $0.00 $0.00 $0.00 A4740 N $0.00 $0.00 $0.00 A4750 N $0.00 $0.00 $0.00 A4755 N $0.00 $0.00 $0.00 A4760 N $0.00 $0.00 $0.00 A4765 N $0.00 $0.00 $0.00 A4766 N $0.00 $0.00 $0.00 A4770 N $0.00 $0.00 $0.00 A4771 N $0.00 $0.00 $0.00 A4772 N $0.00 $0.00 $0.00 A4773 N $0.00 $0.00 $0.00 A4774 N $0.00 $0.00 $0.00 A4802 N $0.00 $0.00 $0.00 A4860 N $0.00 $0.00 $0.00 A4870 N $0.00 $0.00 $0.00 A4890 N $0.00 $0.00 $0.00 A4911 N $0.00 $0.00 $0.00 A4913 N $0.00 $0.00 $0.00 A4918 N $0.00 $0.00 $0.00 A4927 N $0.00 $0.00 $0.00 A4928 N $0.00 $0.00 $0.00 A4929 N $0.00 $0.00 $0.00 A4930 N $0.00 $0.00 $0.00 A4931 N $0.00 $0.00 $0.00 A4932 N $0.00 $0.00 $0.00 A5051 N $0.00 $0.00 $0.00 A5052 N $0.00 $0.00 $0.00 A5053 N $0.00 $0.00 $0.00 A5054 N $0.00 $0.00 $0.00


203


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeA5055 N $0.00 $0.00 $0.00 A5056 N $0.00 $0.00 $0.00 A5057 N $0.00 $0.00 $0.00 A5061 N $0.00 $0.00 $0.00 A5062 N $0.00 $0.00 $0.00 A5063 N $0.00 $0.00 $0.00 A5071 N $0.00 $0.00 $0.00 A5072 N $0.00 $0.00 $0.00 A5073 N $0.00 $0.00 $0.00 A5081 N $0.00 $0.00 $0.00 A5082 N $0.00 $0.00 $0.00 A5083 N $0.00 $0.00 $0.00 A5093 N $0.00 $0.00 $0.00 A5102 N $0.00 $0.00 $0.00 A5105 N $0.00 $0.00 $0.00 A5112 N $0.00 $0.00 $0.00 A5113 E $0.00 $0.00 $0.00A5114 E $0.00 $0.00 $0.00A5120 N $0.00 $0.00 $0.00 A5121 N $0.00 $0.00 $0.00 A5122 N $0.00 $0.00 $0.00 A5126 N $0.00 $0.00 $0.00 A5131 N $0.00 $0.00 $0.00 A5200 N $0.00 $0.00 $0.00 A5500 Y $0.00 $0.00 $0.00A5501 Y $0.00 $0.00 $0.00A5503 Y $0.00 $0.00 $0.00A5504 Y $0.00 $0.00 $0.00A5505 Y $0.00 $0.00 $0.00A5506 Y $0.00 $0.00 $0.00A5507 Y $0.00 $0.00 $0.00A5508 Y $0.00 $0.00 $0.00A5510 N $0.00 $0.00 $0.00 A5512 Y $0.00 $0.00 $0.00A5513 Y $0.00 $0.00 $0.00A6000 E $0.00 $0.00 $0.00A6010 N $0.00 $0.00 $0.00 A6011 N $0.00 $0.00 $0.00 A6021 N $0.00 $0.00 $0.00 A6022 N $0.00 $0.00 $0.00 A6023 N $0.00 $0.00 $0.00 A6024 N $0.00 $0.00 $0.00 A6025 N $0.00 $0.00 $0.00 A6154 N $0.00 $0.00 $0.00 A6196 N $0.00 $0.00 $0.00 A6197 N $0.00 $0.00 $0.00 A6198 N $0.00 $0.00 $0.00 A6199 N $0.00 $0.00 $0.00 A6203 N $0.00 $0.00 $0.00 A6204 N $0.00 $0.00 $0.00 A6205 N $0.00 $0.00 $0.00


204


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeA6206 N $0.00 $0.00 $0.00 A6207 N $0.00 $0.00 $0.00 A6208 N $0.00 $0.00 $0.00 A6209 N $0.00 $0.00 $0.00 A6210 N $0.00 $0.00 $0.00 A6211 N $0.00 $0.00 $0.00 A6212 N $0.00 $0.00 $0.00 A6213 N $0.00 $0.00 $0.00 A6214 N $0.00 $0.00 $0.00 A6215 N $0.00 $0.00 $0.00 A6216 N $0.00 $0.00 $0.00 A6217 N $0.00 $0.00 $0.00 A6218 N $0.00 $0.00 $0.00 A6219 N $0.00 $0.00 $0.00 A6220 N $0.00 $0.00 $0.00 A6221 N $0.00 $0.00 $0.00 A6222 N $0.00 $0.00 $0.00 A6223 N $0.00 $0.00 $0.00 A6224 N $0.00 $0.00 $0.00 A6228 N $0.00 $0.00 $0.00 A6229 N $0.00 $0.00 $0.00 A6230 N $0.00 $0.00 $0.00 A6231 N $0.00 $0.00 $0.00 A6232 N $0.00 $0.00 $0.00 A6233 N $0.00 $0.00 $0.00 A6234 N $0.00 $0.00 $0.00 A6235 N $0.00 $0.00 $0.00 A6236 N $0.00 $0.00 $0.00 A6237 N $0.00 $0.00 $0.00 A6238 N $0.00 $0.00 $0.00 A6239 N $0.00 $0.00 $0.00 A6240 N $0.00 $0.00 $0.00 A6241 N $0.00 $0.00 $0.00 A6242 N $0.00 $0.00 $0.00 A6243 N $0.00 $0.00 $0.00 A6244 N $0.00 $0.00 $0.00 A6245 N $0.00 $0.00 $0.00 A6246 N $0.00 $0.00 $0.00 A6247 N $0.00 $0.00 $0.00 A6248 N $0.00 $0.00 $0.00 A6250 N $0.00 $0.00 $0.00 A6251 N $0.00 $0.00 $0.00 A6252 N $0.00 $0.00 $0.00 A6253 N $0.00 $0.00 $0.00 A6254 N $0.00 $0.00 $0.00 A6255 N $0.00 $0.00 $0.00 A6256 N $0.00 $0.00 $0.00 A6257 N $0.00 $0.00 $0.00 A6258 N $0.00 $0.00 $0.00 A6259 N $0.00 $0.00 $0.00 A6260 N $0.00 $0.00 $0.00


205


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeA6261 N $0.00 $0.00 $0.00 A6262 N $0.00 $0.00 $0.00 A6266 N $0.00 $0.00 $0.00 A6402 N $0.00 $0.00 $0.00 A6403 N $0.00 $0.00 $0.00 A6404 N $0.00 $0.00 $0.00 A6407 N $0.00 $0.00 $0.00 A6410 N $0.00 $0.00 $0.00 A6411 N $0.00 $0.00 $0.00 A6412 N $0.00 $0.00 $0.00 A6413 E $0.00 $0.00 $0.00A6441 N $0.00 $0.00 $0.00 A6442 N $0.00 $0.00 $0.00 A6443 N $0.00 $0.00 $0.00 A6444 N $0.00 $0.00 $0.00 A6445 N $0.00 $0.00 $0.00 A6446 N $0.00 $0.00 $0.00 A6447 N $0.00 $0.00 $0.00 A6448 N $0.00 $0.00 $0.00 A6449 N $0.00 $0.00 $0.00 A6450 N $0.00 $0.00 $0.00 A6451 N $0.00 $0.00 $0.00 A6452 N $0.00 $0.00 $0.00 A6453 N $0.00 $0.00 $0.00 A6454 N $0.00 $0.00 $0.00 A6455 N $0.00 $0.00 $0.00 A6456 N $0.00 $0.00 $0.00 A6457 N $0.00 $0.00 $0.00 A6501 N $0.00 $0.00 $0.00 A6502 N $0.00 $0.00 $0.00 A6503 N $0.00 $0.00 $0.00 A6504 N $0.00 $0.00 $0.00 A6505 N $0.00 $0.00 $0.00 A6506 N $0.00 $0.00 $0.00 A6507 N $0.00 $0.00 $0.00 A6508 N $0.00 $0.00 $0.00 A6509 N $0.00 $0.00 $0.00 A6510 N $0.00 $0.00 $0.00 A6511 N $0.00 $0.00 $0.00 A6512 N $0.00 $0.00 $0.00 A6513 B $0.00 $0.00 $0.00A6530 E $0.00 $0.00 $0.00A6531 N $0.00 $0.00 $0.00 A6532 N $0.00 $0.00 $0.00 A6533 E $0.00 $0.00 $0.00A6534 E $0.00 $0.00 $0.00A6535 E $0.00 $0.00 $0.00A6536 E $0.00 $0.00 $0.00A6537 E $0.00 $0.00 $0.00A6538 E $0.00 $0.00 $0.00A6539 E $0.00 $0.00 $0.00


206


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeA6540 E $0.00 $0.00 $0.00A6541 E $0.00 $0.00 $0.00A6544 E $0.00 $0.00 $0.00A6545 N $0.00 $0.00 $0.00 A6549 E $0.00 $0.00 $0.00A6550 N $0.00 $0.00 $0.00 A7000 Y $0.00 $0.00 $0.00A7001 Y $0.00 $0.00 $0.00A7002 Y $0.00 $0.00 $0.00A7003 Y $0.00 $0.00 $0.00A7004 Y $0.00 $0.00 $0.00A7005 Y $0.00 $0.00 $0.00A7006 Y $0.00 $0.00 $0.00A7007 Y $0.00 $0.00 $0.00A7008 Y $0.00 $0.00 $0.00A7009 Y $0.00 $0.00 $0.00A7010 Y $0.00 $0.00 $0.00A7011 Y $0.00 $0.00 $0.00A7012 Y $0.00 $0.00 $0.00A7013 Y $0.00 $0.00 $0.00A7014 Y $0.00 $0.00 $0.00A7015 Y $0.00 $0.00 $0.00A7016 Y $0.00 $0.00 $0.00A7017 Y $0.00 $0.00 $0.00A7018 Y $0.00 $0.00 $0.00A7020 Y $0.00 $0.00 $0.00A7025 N $0.00 $0.00 $0.00 A7026 Y $0.00 $0.00 $0.00A7027 Y $0.00 $0.00 $0.00A7028 Y $0.00 $0.00 $0.00A7029 Y $0.00 $0.00 $0.00A7030 Y $0.00 $0.00 $0.00A7031 Y $0.00 $0.00 $0.00A7032 Y $0.00 $0.00 $0.00A7033 Y $0.00 $0.00 $0.00A7034 Y $0.00 $0.00 $0.00A7035 Y $0.00 $0.00 $0.00A7036 Y $0.00 $0.00 $0.00A7037 Y $0.00 $0.00 $0.00A7038 Y $0.00 $0.00 $0.00A7039 Y $0.00 $0.00 $0.00A7040 N $0.00 $0.00 $0.00 A7041 N $0.00 $0.00 $0.00 A7044 Y $0.00 $0.00 $0.00A7045 Y $0.00 $0.00 $0.00A7046 Y $0.00 $0.00 $0.00A7047 N $0.00 $0.00 $0.00 A7048 N $0.00 $0.00 $0.00 A7501 N $0.00 $0.00 $0.00 A7502 N $0.00 $0.00 $0.00 A7503 N $0.00 $0.00 $0.00


207


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeA7504 N $0.00 $0.00 $0.00 A7505 N $0.00 $0.00 $0.00 A7506 N $0.00 $0.00 $0.00 A7507 N $0.00 $0.00 $0.00 A7508 N $0.00 $0.00 $0.00 A7509 N $0.00 $0.00 $0.00 A7520 N $0.00 $0.00 $0.00 A7521 N $0.00 $0.00 $0.00 A7522 N $0.00 $0.00 $0.00 A7523 N $0.00 $0.00 $0.00 A7524 N $0.00 $0.00 $0.00 A7525 N $0.00 $0.00 $0.00 A7526 N $0.00 $0.00 $0.00 A7527 N $0.00 $0.00 $0.00 A8000 Y $0.00 $0.00 $0.00A8001 Y $0.00 $0.00 $0.00A8002 Y $0.00 $0.00 $0.00A8003 Y $0.00 $0.00 $0.00A8004 Y $0.00 $0.00 $0.00A9150 B $0.00 $0.00 $0.00A9152 E $0.00 $0.00 $0.00A9153 E $0.00 $0.00 $0.00A9155 B $0.00 $0.00 $0.00A9180 E $0.00 $0.00 $0.00A9270 E $0.00 $0.00 $0.00A9272 E $0.00 $0.00 $0.00A9273 E $0.00 $0.00 $0.00A9274 E $0.00 $0.00 $0.00A9275 E $0.00 $0.00 $0.00A9276 E $0.00 $0.00 $0.00A9277 E $0.00 $0.00 $0.00A9278 E $0.00 $0.00 $0.00A9279 E $0.00 $0.00 $0.00A9280 E $0.00 $0.00 $0.00A9281 E $0.00 $0.00 $0.00A9282 E $0.00 $0.00 $0.00A9283 E $0.00 $0.00 $0.00A9284 N $0.00 $0.00 $0.00 A9300 E $0.00 $0.00 $0.00A9500 N $0.00 $0.00 $0.00 A9501 N $0.00 $0.00 $0.00 A9502 N $0.00 $0.00 $0.00 A9503 N $0.00 $0.00 $0.00 A9504 N $0.00 $0.00 $0.00 A9505 N $0.00 $0.00 $0.00 A9507 N $0.00 $0.00 $0.00 A9508 N $0.00 $0.00 $0.00 A9509 N $0.00 $0.00 $0.00 A9510 N $0.00 $0.00 $0.00 A9512 N $0.00 $0.00 $0.00 A9516 N $0.00 $0.00 $0.00


208


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeA9517 K 1064 $0.00 $0.00 $0.00A9520 G 1463 $0.00 $0.00 $0.00A9521 N $0.00 $0.00 $0.00 A9524 N $0.00 $0.00 $0.00 A9526 N $0.00 $0.00 $0.00 A9527 U 2632 0.1787 $19.37 $23.68 $14.53 A9528 N $0.00 $0.00 $0.00 A9529 N $0.00 $0.00 $0.00 A9530 K 1150 $0.00 $0.00 $0.00A9531 N $0.00 $0.00 $0.00 A9532 N $0.00 $0.00 $0.00 A9536 N $0.00 $0.00 $0.00 A9537 N $0.00 $0.00 $0.00 A9538 N $0.00 $0.00 $0.00 A9539 N $0.00 $0.00 $0.00 A9540 N $0.00 $0.00 $0.00 A9541 N $0.00 $0.00 $0.00 A9542 N $0.00 $0.00 $0.00 A9543 K 1643 $0.00 $0.00 $0.00A9544 N $0.00 $0.00 $0.00 A9545 E $0.00 $0.00 $0.00A9546 N $0.00 $0.00 $0.00 A9547 N $0.00 $0.00 $0.00 A9548 N $0.00 $0.00 $0.00 A9550 N $0.00 $0.00 $0.00 A9551 N $0.00 $0.00 $0.00 A9552 N $0.00 $0.00 $0.00 A9553 N $0.00 $0.00 $0.00 A9554 N $0.00 $0.00 $0.00 A9555 N $0.00 $0.00 $0.00 A9556 N $0.00 $0.00 $0.00 A9557 N $0.00 $0.00 $0.00 A9558 N $0.00 $0.00 $0.00 A9559 N $0.00 $0.00 $0.00 A9560 N $0.00 $0.00 $0.00 A9561 N $0.00 $0.00 $0.00 A9562 N $0.00 $0.00 $0.00 A9563 K 1675 $0.00 $0.00 $0.00A9564 K 1676 $0.00 $0.00 $0.00A9566 N $0.00 $0.00 $0.00 A9567 N $0.00 $0.00 $0.00 A9568 N $0.00 $0.00 $0.00 A9569 N $0.00 $0.00 $0.00 A9570 N $0.00 $0.00 $0.00 A9571 N $0.00 $0.00 $0.00 A9572 N $0.00 $0.00 $0.00 A9575 N $0.00 $0.00 $0.00 A9576 N $0.00 $0.00 $0.00 A9577 N $0.00 $0.00 $0.00 A9578 N $0.00 $0.00 $0.00 A9579 N $0.00 $0.00 $0.00


209


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeA9580 N $0.00 $0.00 $0.00 A9581 N $0.00 $0.00 $0.00 A9582 N $0.00 $0.00 $0.00 A9583 N $0.00 $0.00 $0.00 A9584 N $0.00 $0.00 $0.00 A9585 N $0.00 $0.00 $0.00 A9586 G 1664 $0.00 $0.00 $0.00A9599 N $0.00 $0.00 $0.00 A9600 K 0701 $0.00 $0.00 $0.00A9604 K 1295 $0.00 $0.00 $0.00A9606 K 1745 $0.00 $0.00 $0.00A9698 N $0.00 $0.00 $0.00 A9699 N $0.00 $0.00 $0.00 A9700 N $0.00 $0.00 $0.00 A9900 Y $0.00 $0.00 $0.00A9901 A $0.00 $0.00 $0.00A9999 Y $0.00 $0.00 $0.00B4034 Y $0.00 $0.00 $0.00B4035 Y $0.00 $0.00 $0.00B4036 Y $0.00 $0.00 $0.00B4081 Y $0.00 $0.00 $0.00B4082 Y $0.00 $0.00 $0.00B4083 Y $0.00 $0.00 $0.00B4087 A $0.00 $0.00 $0.00B4088 A $0.00 $0.00 $0.00B4100 E $0.00 $0.00 $0.00B4102 Y $0.00 $0.00 $0.00B4103 Y $0.00 $0.00 $0.00B4104 E $0.00 $0.00 $0.00B4149 Y $0.00 $0.00 $0.00B4150 Y $0.00 $0.00 $0.00B4152 Y $0.00 $0.00 $0.00B4153 Y $0.00 $0.00 $0.00B4154 Y $0.00 $0.00 $0.00B4155 Y $0.00 $0.00 $0.00B4157 Y $0.00 $0.00 $0.00B4158 Y $0.00 $0.00 $0.00B4159 Y $0.00 $0.00 $0.00B4160 Y $0.00 $0.00 $0.00B4161 Y $0.00 $0.00 $0.00B4162 Y $0.00 $0.00 $0.00B4164 Y $0.00 $0.00 $0.00B4168 Y $0.00 $0.00 $0.00B4172 Y $0.00 $0.00 $0.00B4176 Y $0.00 $0.00 $0.00B4178 Y $0.00 $0.00 $0.00B4180 Y $0.00 $0.00 $0.00B4185 B $0.00 $0.00 $0.00B4189 Y $0.00 $0.00 $0.00B4193 Y $0.00 $0.00 $0.00B4197 Y $0.00 $0.00 $0.00


210


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeB4199 Y $0.00 $0.00 $0.00B4216 Y $0.00 $0.00 $0.00B4220 Y $0.00 $0.00 $0.00B4222 Y $0.00 $0.00 $0.00B4224 Y $0.00 $0.00 $0.00B5000 Y $0.00 $0.00 $0.00B5100 Y $0.00 $0.00 $0.00B5200 Y $0.00 $0.00 $0.00B9000 Y $0.00 $0.00 $0.00B9002 Y $0.00 $0.00 $0.00B9004 Y $0.00 $0.00 $0.00B9006 Y $0.00 $0.00 $0.00B9998 Y $0.00 $0.00 $0.00B9999 Y $0.00 $0.00 $0.00C1713 N $0.00 $0.00 $0.00 C1714 N $0.00 $0.00 $0.00 C1715 N $0.00 $0.00 $0.00 C1716 U 1716 0.503 $54.54 $66.66 $40.90 C1717 U 1717 3.6722 $398.14 $486.68 $298.62 C1719 U 1719 0.7244 $78.54 $96.00 $58.91 C1721 N $0.00 $0.00 $0.00 C1722 N $0.00 $0.00 $0.00 C1724 N $0.00 $0.00 $0.00 C1725 N $0.00 $0.00 $0.00 C1726 N $0.00 $0.00 $0.00 C1727 N $0.00 $0.00 $0.00 C1728 N $0.00 $0.00 $0.00 C1729 N $0.00 $0.00 $0.00 C1730 N $0.00 $0.00 $0.00 C1731 N $0.00 $0.00 $0.00 C1732 N $0.00 $0.00 $0.00 C1733 N $0.00 $0.00 $0.00 C1749 N $0.00 $0.00 $0.00 C1750 N $0.00 $0.00 $0.00 C1751 N $0.00 $0.00 $0.00 C1752 N $0.00 $0.00 $0.00 C1753 N $0.00 $0.00 $0.00 C1754 N $0.00 $0.00 $0.00 C1755 N $0.00 $0.00 $0.00 C1756 N $0.00 $0.00 $0.00 C1757 N $0.00 $0.00 $0.00 C1758 N $0.00 $0.00 $0.00 C1759 N $0.00 $0.00 $0.00 C1760 N $0.00 $0.00 $0.00 C1762 N $0.00 $0.00 $0.00 C1763 N $0.00 $0.00 $0.00 C1764 N $0.00 $0.00 $0.00 C1765 N $0.00 $0.00 $0.00 C1766 N $0.00 $0.00 $0.00 C1767 N $0.00 $0.00 $0.00 C1768 N $0.00 $0.00 $0.00


211


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeC1769 N $0.00 $0.00 $0.00 C1770 N $0.00 $0.00 $0.00 C1771 N $0.00 $0.00 $0.00 C1772 N $0.00 $0.00 $0.00 C1773 N $0.00 $0.00 $0.00 C1776 N $0.00 $0.00 $0.00 C1777 N $0.00 $0.00 $0.00 C1778 N $0.00 $0.00 $0.00 C1779 N $0.00 $0.00 $0.00 C1780 N $0.00 $0.00 $0.00 C1781 N $0.00 $0.00 $0.00 C1782 N $0.00 $0.00 $0.00 C1783 N $0.00 $0.00 $0.00 C1784 N $0.00 $0.00 $0.00 C1785 N $0.00 $0.00 $0.00 C1786 N $0.00 $0.00 $0.00 C1787 N $0.00 $0.00 $0.00 C1788 N $0.00 $0.00 $0.00 C1789 N $0.00 $0.00 $0.00 C1813 N $0.00 $0.00 $0.00 C1814 N $0.00 $0.00 $0.00 C1815 N $0.00 $0.00 $0.00 C1816 N $0.00 $0.00 $0.00 C1817 N $0.00 $0.00 $0.00 C1818 N $0.00 $0.00 $0.00 C1819 N $0.00 $0.00 $0.00 C1820 N $0.00 $0.00 $0.00 C1821 N $0.00 $0.00 $0.00 C1830 N $0.00 $0.00 $0.00 C1840 N $0.00 $0.00 $0.00 C1841 H 1841 $0.00 $0.00 $0.00C1874 N $0.00 $0.00 $0.00 C1875 N $0.00 $0.00 $0.00 C1876 N $0.00 $0.00 $0.00 C1877 N $0.00 $0.00 $0.00 C1878 N $0.00 $0.00 $0.00 C1880 N $0.00 $0.00 $0.00 C1881 N $0.00 $0.00 $0.00 C1882 N $0.00 $0.00 $0.00 C1883 N $0.00 $0.00 $0.00 C1884 N $0.00 $0.00 $0.00 C1885 N $0.00 $0.00 $0.00 C1886 N $0.00 $0.00 $0.00 C1887 N $0.00 $0.00 $0.00 C1888 N $0.00 $0.00 $0.00 C1891 N $0.00 $0.00 $0.00 C1892 N $0.00 $0.00 $0.00 C1893 N $0.00 $0.00 $0.00 C1894 N $0.00 $0.00 $0.00 C1895 N $0.00 $0.00 $0.00 C1896 N $0.00 $0.00 $0.00


212


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeC1897 N $0.00 $0.00 $0.00 C1898 N $0.00 $0.00 $0.00 C1899 N $0.00 $0.00 $0.00 C1900 N $0.00 $0.00 $0.00 C2614 N $0.00 $0.00 $0.00 C2615 N $0.00 $0.00 $0.00 C2616 U 2616 210.0856 $22,777.48 $27,842.64 $17,084.16 C2617 N $0.00 $0.00 $0.00 C2618 N $0.00 $0.00 $0.00 C2619 N $0.00 $0.00 $0.00 C2620 N $0.00 $0.00 $0.00 C2621 N $0.00 $0.00 $0.00 C2622 N $0.00 $0.00 $0.00 C2624 H 2624 $0.00 $0.00 $0.00C2625 N $0.00 $0.00 $0.00 C2626 N $0.00 $0.00 $0.00 C2627 N $0.00 $0.00 $0.00 C2628 N $0.00 $0.00 $0.00 C2629 N $0.00 $0.00 $0.00 C2630 N $0.00 $0.00 $0.00 C2631 N $0.00 $0.00 $0.00 C2634 U 2634 1.1569 $125.43 $153.32 $94.08 C2635 U 2635 0.348 $37.73 $46.12 $28.30 C2636 U 2636 0.2621 $28.42 $34.74 $21.31 C2637 B $0.00 $0.00 $0.00C2638 U 2638 0.5719 $62.01 $75.79 $46.51 C2639 U 2639 0.4995 $54.16 $66.20 $40.62 C2640 U 2640 0.8831 $95.75 $117.04 $71.81 C2641 U 2641 0.9158 $99.29 $121.37 $74.47 C2642 U 2642 1.4209 $154.05 $188.31 $115.55 C2643 U 2643 0.7376 $79.97 $97.75 $59.98 C2644 U 2644 0.1787 $19.37 $23.68 $14.53 C2698 U 2698 0.5719 $62.01 $75.79 $46.51 C2699 U 2699 0.2621 $28.42 $34.74 $21.31 C5271 T 0327 5.7989 $628.72 $768.53 $471.57 C5272 N $0.00 $0.00 $0.00 C5273 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 C5274 N $0.00 $0.00 $0.00 C5275 T 0327 5.7989 $628.72 $768.53 $471.57 C5276 N $0.00 $0.00 $0.00 C5277 T 0327 5.7989 $628.72 $768.53 $471.57 C5278 N $0.00 $0.00 $0.00 C8900 Q3 0284 5.7574 $624.22 $763.03 $468.19 C8901 Q3 0336 3.8614 $418.65 $511.75 $314.01 C8902 Q3 0337 6.5129 $706.13 $863.15 $529.63 C8903 Q3 0284 5.7574 $624.22 $763.03 $468.19 C8904 Q3 0336 3.8614 $418.65 $511.75 $314.01 C8905 Q3 0337 6.5129 $706.13 $863.15 $529.63 C8906 Q3 0284 5.7574 $624.22 $763.03 $468.19 C8907 Q3 0336 3.8614 $418.65 $511.75 $314.01 C8908 Q3 0337 6.5129 $706.13 $863.15 $529.63


213


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeC8909 Q3 0284 5.7574 $624.22 $763.03 $468.19 C8910 Q3 0336 3.8614 $418.65 $511.75 $314.01 C8911 Q3 0337 6.5129 $706.13 $863.15 $529.63 C8912 Q3 0284 5.7574 $624.22 $763.03 $468.19 C8913 Q3 0336 3.8614 $418.65 $511.75 $314.01 C8914 Q3 0337 6.5129 $706.13 $863.15 $529.63 C8918 Q3 0284 5.7574 $624.22 $763.03 $468.19 C8919 Q3 0336 3.8614 $418.65 $511.75 $314.01 C8920 Q3 0337 6.5129 $706.13 $863.15 $529.63 C8921 S 0178 9.284 $1,006.57 $1,230.41 $754.97 C8922 S 0177 6.6127 $716.95 $876.38 $537.74 C8923 S 0177 6.6127 $716.95 $876.38 $537.74 C8924 S 0177 6.6127 $716.95 $876.38 $537.74 C8925 S 0178 9.284 $1,006.57 $1,230.41 $754.97 C8926 S 0178 9.284 $1,006.57 $1,230.41 $754.97 C8927 S 0178 9.284 $1,006.57 $1,230.41 $754.97 C8928 S 0178 9.284 $1,006.57 $1,230.41 $754.97 C8929 S 0178 9.284 $1,006.57 $1,230.41 $754.97 C8930 S 0178 9.284 $1,006.57 $1,230.41 $754.97 C8931 Q3 0284 5.7574 $624.22 $763.03 $468.19 C8932 Q3 0336 3.8614 $418.65 $511.75 $314.01 C8933 Q3 0337 6.5129 $706.13 $863.15 $529.63 C8934 Q3 0284 5.7574 $624.22 $763.03 $468.19 C8935 Q3 0336 3.8614 $418.65 $511.75 $314.01 C8936 Q3 0337 6.5129 $706.13 $863.15 $529.63 C8957 S 0440 3.8439 $416.76 $509.43 $312.59 C9025 G 1488 $0.00 $0.00 $0.00C9026 G 1489 $0.00 $0.00 $0.00C9027 G 1490 $0.00 $0.00 $0.00C9113 N $0.00 $0.00 $0.00 C9121 K 9121 $0.00 $0.00 $0.00C9132 G 9132 $0.00 $0.00 $0.00C9136 G 1656 $0.00 $0.00 $0.00C9248 K 9248 $0.00 $0.00 $0.00C9250 N $0.00 $0.00 $0.00 C9254 N $0.00 $0.00 $0.00 C9257 K 1281 $0.00 $0.00 $0.00C9275 N $0.00 $0.00 $0.00 C9285 N $0.00 $0.00 $0.00 C9290 N $0.00 $0.00 $0.00 C9293 K 9293 $0.00 $0.00 $0.00C9349 G 1657 $0.00 $0.00 $0.00C9352 N $0.00 $0.00 $0.00 C9353 N $0.00 $0.00 $0.00 C9354 N $0.00 $0.00 $0.00 C9355 N $0.00 $0.00 $0.00 C9356 N $0.00 $0.00 $0.00 C9358 N $0.00 $0.00 $0.00 C9359 N $0.00 $0.00 $0.00 C9360 N $0.00 $0.00 $0.00 C9361 N $0.00 $0.00 $0.00


214


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeC9362 N $0.00 $0.00 $0.00 C9363 N $0.00 $0.00 $0.00 C9364 N $0.00 $0.00 $0.00 C9399 A $0.00 $0.00 $0.00C9442 G 1658 $0.00 $0.00 $0.00C9443 G 1659 $0.00 $0.00 $0.00C9444 G 1660 $0.00 $0.00 $0.00C9446 G 1662 $0.00 $0.00 $0.00C9447 G 1663 $0.00 $0.00 $0.00C9497 G 9497 $0.00 $0.00 $0.00C9600 J1 0229 129.8028 $14,073.22 $17,202.77 $10,555.56 C9601 N $0.00 $0.00 $0.00 C9602 J1 0319 200.1597 $21,701.31 $26,527.17 $16,276.99 C9603 N $0.00 $0.00 $0.00 C9604 J1 0229 129.8028 $14,073.22 $17,202.77 $10,555.56 C9605 N $0.00 $0.00 $0.00 C9606 J1 0319 200.1597 $21,701.31 $26,527.17 $16,276.99 C9607 J1 0319 200.1597 $21,701.31 $26,527.17 $16,276.99 C9608 N $0.00 $0.00 $0.00 C9724 T 0422 25.8201 $2,799.42 $3,421.94 $2,099.69 C9725 T 0148 5.9659 $646.82 $790.66 $485.15 C9726 N $0.00 $0.00 $0.00 C9727 T 0252 8.7183 $945.24 $1,155.44 $708.97 C9728 S 0310 14.0014 $1,518.03 $1,855.61 $1,138.59 C9733 Q2 0263 4.5438 $492.64 $602.19 $369.50 C9734 S 0066 25.6592 $2,781.97 $3,400.61 $2,086.61 C9737 T 0174 108.7985 $11,795.93 $14,419.07 $8,847.49 C9739 T 0162 28.1079 $3,047.46 $3,725.14 $2,285.73 C9740 T 1564 $0.00 $0.00 $0.00C9741 T 0080 34.7342 $3,765.88 $4,603.32 $2,824.59 C9742 T 0073 16.9813 $1,841.11 $2,250.53 $1,380.92 C9800 T 0328 18.9748 $2,057.25 $2,514.73 $1,543.03 C9898 N $0.00 $0.00 $0.00 C9899 A $0.00 $0.00 $0.00D0120 E $0.00 $0.00 $0.00D0140 E $0.00 $0.00 $0.00D0145 E $0.00 $0.00 $0.00D0150 S 0330 3.4106 $369.78 $452.01 $277.35 D0160 E $0.00 $0.00 $0.00D0170 E $0.00 $0.00 $0.00D0171 E $0.00 $0.00 $0.00D0180 E $0.00 $0.00 $0.00D0190 E $0.00 $0.00 $0.00D0191 E $0.00 $0.00 $0.00D0210 E $0.00 $0.00 $0.00D0220 E $0.00 $0.00 $0.00D0230 E $0.00 $0.00 $0.00D0240 S 0330 3.4106 $369.78 $452.01 $277.35 D0250 S 0330 3.4106 $369.78 $452.01 $277.35 D0260 S 0330 3.4106 $369.78 $452.01 $277.35 D0270 S 0330 3.4106 $369.78 $452.01 $277.35


215


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeD0272 S 0330 3.4106 $369.78 $452.01 $277.35 D0273 E $0.00 $0.00 $0.00D0274 S 0330 3.4106 $369.78 $452.01 $277.35 D0277 S 0330 3.4106 $369.78 $452.01 $277.35 D0290 E $0.00 $0.00 $0.00D0310 E $0.00 $0.00 $0.00D0320 E $0.00 $0.00 $0.00D0321 E $0.00 $0.00 $0.00D0322 E $0.00 $0.00 $0.00D0330 E $0.00 $0.00 $0.00D0340 E $0.00 $0.00 $0.00D0350 E $0.00 $0.00 $0.00D0351 E $0.00 $0.00 $0.00D0364 E $0.00 $0.00 $0.00D0365 E $0.00 $0.00 $0.00D0366 E $0.00 $0.00 $0.00D0367 E $0.00 $0.00 $0.00D0368 E $0.00 $0.00 $0.00D0369 E $0.00 $0.00 $0.00D0370 E $0.00 $0.00 $0.00D0371 E $0.00 $0.00 $0.00D0380 E $0.00 $0.00 $0.00D0381 E $0.00 $0.00 $0.00D0382 E $0.00 $0.00 $0.00D0383 E $0.00 $0.00 $0.00D0384 E $0.00 $0.00 $0.00D0385 E $0.00 $0.00 $0.00D0386 E $0.00 $0.00 $0.00D0391 E $0.00 $0.00 $0.00D0393 E $0.00 $0.00 $0.00D0394 E $0.00 $0.00 $0.00D0395 E $0.00 $0.00 $0.00D0415 E $0.00 $0.00 $0.00D0416 B $0.00 $0.00 $0.00D0417 E $0.00 $0.00 $0.00D0418 E $0.00 $0.00 $0.00D0421 B $0.00 $0.00 $0.00D0425 E $0.00 $0.00 $0.00D0431 B $0.00 $0.00 $0.00D0460 S 0330 3.4106 $369.78 $452.01 $277.35 D0470 E $0.00 $0.00 $0.00D0472 B $0.00 $0.00 $0.00D0473 B $0.00 $0.00 $0.00D0474 B $0.00 $0.00 $0.00D0475 B $0.00 $0.00 $0.00D0476 B $0.00 $0.00 $0.00D0477 B $0.00 $0.00 $0.00D0478 B $0.00 $0.00 $0.00D0479 B $0.00 $0.00 $0.00D0480 B $0.00 $0.00 $0.00D0481 B $0.00 $0.00 $0.00


216


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeD0482 B $0.00 $0.00 $0.00D0483 B $0.00 $0.00 $0.00D0484 B $0.00 $0.00 $0.00D0485 B $0.00 $0.00 $0.00D0486 E $0.00 $0.00 $0.00D0502 B $0.00 $0.00 $0.00D0601 E $0.00 $0.00 $0.00D0602 E $0.00 $0.00 $0.00D0603 E $0.00 $0.00 $0.00D0999 B $0.00 $0.00 $0.00D1110 E $0.00 $0.00 $0.00D1120 E $0.00 $0.00 $0.00D1206 E $0.00 $0.00 $0.00D1208 E $0.00 $0.00 $0.00D1310 E $0.00 $0.00 $0.00D1320 E $0.00 $0.00 $0.00D1330 E $0.00 $0.00 $0.00D1351 E $0.00 $0.00 $0.00D1352 E $0.00 $0.00 $0.00D1353 E $0.00 $0.00 $0.00D1510 S 0330 3.4106 $369.78 $452.01 $277.35 D1515 S 0330 3.4106 $369.78 $452.01 $277.35 D1520 S 0330 3.4106 $369.78 $452.01 $277.35 D1525 S 0330 3.4106 $369.78 $452.01 $277.35 D1550 S 0330 3.4106 $369.78 $452.01 $277.35 D1555 E $0.00 $0.00 $0.00D1999 E $0.00 $0.00 $0.00D2140 E $0.00 $0.00 $0.00D2150 E $0.00 $0.00 $0.00D2160 E $0.00 $0.00 $0.00D2161 E $0.00 $0.00 $0.00D2330 E $0.00 $0.00 $0.00D2331 E $0.00 $0.00 $0.00D2332 E $0.00 $0.00 $0.00D2335 E $0.00 $0.00 $0.00D2390 E $0.00 $0.00 $0.00D2391 E $0.00 $0.00 $0.00D2392 E $0.00 $0.00 $0.00D2393 E $0.00 $0.00 $0.00D2394 E $0.00 $0.00 $0.00D2410 E $0.00 $0.00 $0.00D2420 E $0.00 $0.00 $0.00D2430 E $0.00 $0.00 $0.00D2510 E $0.00 $0.00 $0.00D2520 E $0.00 $0.00 $0.00D2530 E $0.00 $0.00 $0.00D2542 E $0.00 $0.00 $0.00D2543 E $0.00 $0.00 $0.00D2544 E $0.00 $0.00 $0.00D2610 E $0.00 $0.00 $0.00D2620 E $0.00 $0.00 $0.00


217


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeD2630 E $0.00 $0.00 $0.00D2642 E $0.00 $0.00 $0.00D2643 E $0.00 $0.00 $0.00D2644 E $0.00 $0.00 $0.00D2650 E $0.00 $0.00 $0.00D2651 E $0.00 $0.00 $0.00D2652 E $0.00 $0.00 $0.00D2662 E $0.00 $0.00 $0.00D2663 E $0.00 $0.00 $0.00D2664 E $0.00 $0.00 $0.00D2710 E $0.00 $0.00 $0.00D2712 E $0.00 $0.00 $0.00D2720 E $0.00 $0.00 $0.00D2721 E $0.00 $0.00 $0.00D2722 E $0.00 $0.00 $0.00D2740 E $0.00 $0.00 $0.00D2750 E $0.00 $0.00 $0.00D2751 E $0.00 $0.00 $0.00D2752 E $0.00 $0.00 $0.00D2780 E $0.00 $0.00 $0.00D2781 E $0.00 $0.00 $0.00D2782 E $0.00 $0.00 $0.00D2783 E $0.00 $0.00 $0.00D2790 E $0.00 $0.00 $0.00D2791 E $0.00 $0.00 $0.00D2792 E $0.00 $0.00 $0.00D2794 E $0.00 $0.00 $0.00D2799 E $0.00 $0.00 $0.00D2910 E $0.00 $0.00 $0.00D2915 E $0.00 $0.00 $0.00D2920 E $0.00 $0.00 $0.00D2921 E $0.00 $0.00 $0.00D2929 E $0.00 $0.00 $0.00D2930 E $0.00 $0.00 $0.00D2931 E $0.00 $0.00 $0.00D2932 E $0.00 $0.00 $0.00D2933 E $0.00 $0.00 $0.00D2934 E $0.00 $0.00 $0.00D2940 E $0.00 $0.00 $0.00D2941 E $0.00 $0.00 $0.00D2949 E $0.00 $0.00 $0.00D2950 E $0.00 $0.00 $0.00D2951 E $0.00 $0.00 $0.00D2952 E $0.00 $0.00 $0.00D2953 E $0.00 $0.00 $0.00D2954 E $0.00 $0.00 $0.00D2955 E $0.00 $0.00 $0.00D2957 E $0.00 $0.00 $0.00D2960 E $0.00 $0.00 $0.00D2961 E $0.00 $0.00 $0.00D2962 E $0.00 $0.00 $0.00


218


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeD2970 E $0.00 $0.00 $0.00D2971 E $0.00 $0.00 $0.00D2975 E $0.00 $0.00 $0.00D2980 E $0.00 $0.00 $0.00D2981 E $0.00 $0.00 $0.00D2982 E $0.00 $0.00 $0.00D2983 E $0.00 $0.00 $0.00D2990 E $0.00 $0.00 $0.00D2999 S 0330 3.4106 $369.78 $452.01 $277.35 D3110 E $0.00 $0.00 $0.00D3120 E $0.00 $0.00 $0.00D3220 E $0.00 $0.00 $0.00D3221 E $0.00 $0.00 $0.00D3222 E $0.00 $0.00 $0.00D3230 E $0.00 $0.00 $0.00D3240 E $0.00 $0.00 $0.00D3310 E $0.00 $0.00 $0.00D3320 E $0.00 $0.00 $0.00D3330 E $0.00 $0.00 $0.00D3331 E $0.00 $0.00 $0.00D3332 E $0.00 $0.00 $0.00D3333 E $0.00 $0.00 $0.00D3346 E $0.00 $0.00 $0.00D3347 E $0.00 $0.00 $0.00D3348 E $0.00 $0.00 $0.00D3351 E $0.00 $0.00 $0.00D3352 E $0.00 $0.00 $0.00D3353 E $0.00 $0.00 $0.00D3355 E $0.00 $0.00 $0.00D3356 E $0.00 $0.00 $0.00D3357 E $0.00 $0.00 $0.00D3410 E $0.00 $0.00 $0.00D3421 E $0.00 $0.00 $0.00D3425 E $0.00 $0.00 $0.00D3426 E $0.00 $0.00 $0.00D3427 E $0.00 $0.00 $0.00D3428 E $0.00 $0.00 $0.00D3429 E $0.00 $0.00 $0.00D3430 E $0.00 $0.00 $0.00D3431 E $0.00 $0.00 $0.00D3432 E $0.00 $0.00 $0.00D3450 E $0.00 $0.00 $0.00D3460 S 0330 3.4106 $369.78 $452.01 $277.35 D3470 E $0.00 $0.00 $0.00D3910 E $0.00 $0.00 $0.00D3920 E $0.00 $0.00 $0.00D3950 E $0.00 $0.00 $0.00D3999 S 0330 3.4106 $369.78 $452.01 $277.35 D4210 E $0.00 $0.00 $0.00D4211 E $0.00 $0.00 $0.00D4212 E $0.00 $0.00 $0.00


219


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeD4230 E $0.00 $0.00 $0.00D4231 E $0.00 $0.00 $0.00D4240 E $0.00 $0.00 $0.00D4241 E $0.00 $0.00 $0.00D4245 E $0.00 $0.00 $0.00D4249 E $0.00 $0.00 $0.00D4260 S 0330 3.4106 $369.78 $452.01 $277.35 D4261 E $0.00 $0.00 $0.00D4263 S 0330 3.4106 $369.78 $452.01 $277.35 D4264 S 0330 3.4106 $369.78 $452.01 $277.35 D4265 E $0.00 $0.00 $0.00D4266 E $0.00 $0.00 $0.00D4267 E $0.00 $0.00 $0.00D4268 S 0330 3.4106 $369.78 $452.01 $277.35 D4270 S 0330 3.4106 $369.78 $452.01 $277.35 D4273 S 0330 3.4106 $369.78 $452.01 $277.35 D4274 E $0.00 $0.00 $0.00D4275 E $0.00 $0.00 $0.00D4276 E $0.00 $0.00 $0.00D4277 E $0.00 $0.00 $0.00D4278 E $0.00 $0.00 $0.00D4320 E $0.00 $0.00 $0.00D4321 E $0.00 $0.00 $0.00D4341 E $0.00 $0.00 $0.00D4342 E $0.00 $0.00 $0.00D4355 S 0330 3.4106 $369.78 $452.01 $277.35 D4381 S 0330 3.4106 $369.78 $452.01 $277.35 D4910 E $0.00 $0.00 $0.00D4920 E $0.00 $0.00 $0.00D4921 E $0.00 $0.00 $0.00D4999 E $0.00 $0.00 $0.00D5110 E $0.00 $0.00 $0.00D5120 E $0.00 $0.00 $0.00D5130 E $0.00 $0.00 $0.00D5140 E $0.00 $0.00 $0.00D5211 E $0.00 $0.00 $0.00D5212 E $0.00 $0.00 $0.00D5213 E $0.00 $0.00 $0.00D5214 E $0.00 $0.00 $0.00D5225 E $0.00 $0.00 $0.00D5226 E $0.00 $0.00 $0.00D5281 E $0.00 $0.00 $0.00D5410 E $0.00 $0.00 $0.00D5411 E $0.00 $0.00 $0.00D5421 E $0.00 $0.00 $0.00D5422 E $0.00 $0.00 $0.00D5510 E $0.00 $0.00 $0.00D5520 E $0.00 $0.00 $0.00D5610 E $0.00 $0.00 $0.00D5620 E $0.00 $0.00 $0.00D5630 E $0.00 $0.00 $0.00


220


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeD5640 E $0.00 $0.00 $0.00D5650 E $0.00 $0.00 $0.00D5660 E $0.00 $0.00 $0.00D5670 E $0.00 $0.00 $0.00D5671 E $0.00 $0.00 $0.00D5710 E $0.00 $0.00 $0.00D5711 E $0.00 $0.00 $0.00D5720 E $0.00 $0.00 $0.00D5721 E $0.00 $0.00 $0.00D5730 E $0.00 $0.00 $0.00D5731 E $0.00 $0.00 $0.00D5740 E $0.00 $0.00 $0.00D5741 E $0.00 $0.00 $0.00D5750 E $0.00 $0.00 $0.00D5751 E $0.00 $0.00 $0.00D5760 E $0.00 $0.00 $0.00D5761 E $0.00 $0.00 $0.00D5810 E $0.00 $0.00 $0.00D5811 E $0.00 $0.00 $0.00D5820 E $0.00 $0.00 $0.00D5821 E $0.00 $0.00 $0.00D5850 E $0.00 $0.00 $0.00D5851 E $0.00 $0.00 $0.00D5862 E $0.00 $0.00 $0.00D5863 E $0.00 $0.00 $0.00D5864 E $0.00 $0.00 $0.00D5865 E $0.00 $0.00 $0.00D5866 E $0.00 $0.00 $0.00D5867 E $0.00 $0.00 $0.00D5875 E $0.00 $0.00 $0.00D5899 E $0.00 $0.00 $0.00D5911 S 0330 3.4106 $369.78 $452.01 $277.35 D5912 S 0330 3.4106 $369.78 $452.01 $277.35 D5913 E $0.00 $0.00 $0.00D5914 E $0.00 $0.00 $0.00D5915 E $0.00 $0.00 $0.00D5916 E $0.00 $0.00 $0.00D5919 E $0.00 $0.00 $0.00D5922 E $0.00 $0.00 $0.00D5923 E $0.00 $0.00 $0.00D5924 E $0.00 $0.00 $0.00D5925 E $0.00 $0.00 $0.00D5926 E $0.00 $0.00 $0.00D5927 E $0.00 $0.00 $0.00D5928 E $0.00 $0.00 $0.00D5929 E $0.00 $0.00 $0.00D5931 E $0.00 $0.00 $0.00D5932 E $0.00 $0.00 $0.00D5933 E $0.00 $0.00 $0.00D5934 E $0.00 $0.00 $0.00D5935 E $0.00 $0.00 $0.00


221


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeD5936 E $0.00 $0.00 $0.00D5937 E $0.00 $0.00 $0.00D5951 E $0.00 $0.00 $0.00D5952 E $0.00 $0.00 $0.00D5953 E $0.00 $0.00 $0.00D5954 E $0.00 $0.00 $0.00D5955 E $0.00 $0.00 $0.00D5958 E $0.00 $0.00 $0.00D5959 E $0.00 $0.00 $0.00D5960 E $0.00 $0.00 $0.00D5982 E $0.00 $0.00 $0.00D5983 S 0330 3.4106 $369.78 $452.01 $277.35 D5984 S 0330 3.4106 $369.78 $452.01 $277.35 D5985 S 0330 3.4106 $369.78 $452.01 $277.35 D5986 E $0.00 $0.00 $0.00D5987 S 0330 3.4106 $369.78 $452.01 $277.35 D5988 E $0.00 $0.00 $0.00D5991 E $0.00 $0.00 $0.00D5992 E $0.00 $0.00 $0.00D5993 E $0.00 $0.00 $0.00D5994 E $0.00 $0.00 $0.00D5999 E $0.00 $0.00 $0.00D6010 E $0.00 $0.00 $0.00D6011 E $0.00 $0.00 $0.00D6012 E $0.00 $0.00 $0.00D6013 E $0.00 $0.00 $0.00D6040 E $0.00 $0.00 $0.00D6050 E $0.00 $0.00 $0.00D6051 E $0.00 $0.00 $0.00D6052 E $0.00 $0.00 $0.00D6055 E $0.00 $0.00 $0.00D6056 E $0.00 $0.00 $0.00D6057 E $0.00 $0.00 $0.00D6058 E $0.00 $0.00 $0.00D6059 E $0.00 $0.00 $0.00D6060 E $0.00 $0.00 $0.00D6061 E $0.00 $0.00 $0.00D6062 E $0.00 $0.00 $0.00D6063 E $0.00 $0.00 $0.00D6064 E $0.00 $0.00 $0.00D6065 E $0.00 $0.00 $0.00D6066 E $0.00 $0.00 $0.00D6067 E $0.00 $0.00 $0.00D6068 E $0.00 $0.00 $0.00D6069 E $0.00 $0.00 $0.00D6070 E $0.00 $0.00 $0.00D6071 E $0.00 $0.00 $0.00D6072 E $0.00 $0.00 $0.00D6073 E $0.00 $0.00 $0.00D6074 E $0.00 $0.00 $0.00D6075 E $0.00 $0.00 $0.00


222


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeD6076 E $0.00 $0.00 $0.00D6077 E $0.00 $0.00 $0.00D6080 E $0.00 $0.00 $0.00D6090 E $0.00 $0.00 $0.00D6091 E $0.00 $0.00 $0.00D6092 E $0.00 $0.00 $0.00D6093 E $0.00 $0.00 $0.00D6094 E $0.00 $0.00 $0.00D6095 E $0.00 $0.00 $0.00D6100 E $0.00 $0.00 $0.00D6101 E $0.00 $0.00 $0.00D6102 E $0.00 $0.00 $0.00D6103 E $0.00 $0.00 $0.00D6104 E $0.00 $0.00 $0.00D6110 E $0.00 $0.00 $0.00D6111 E $0.00 $0.00 $0.00D6112 E $0.00 $0.00 $0.00D6113 E $0.00 $0.00 $0.00D6114 E $0.00 $0.00 $0.00D6115 E $0.00 $0.00 $0.00D6116 E $0.00 $0.00 $0.00D6117 E $0.00 $0.00 $0.00D6190 E $0.00 $0.00 $0.00D6194 E $0.00 $0.00 $0.00D6199 E $0.00 $0.00 $0.00D6205 E $0.00 $0.00 $0.00D6210 E $0.00 $0.00 $0.00D6211 E $0.00 $0.00 $0.00D6212 E $0.00 $0.00 $0.00D6214 E $0.00 $0.00 $0.00D6240 E $0.00 $0.00 $0.00D6241 E $0.00 $0.00 $0.00D6242 E $0.00 $0.00 $0.00D6245 E $0.00 $0.00 $0.00D6250 E $0.00 $0.00 $0.00D6251 E $0.00 $0.00 $0.00D6252 E $0.00 $0.00 $0.00D6253 E $0.00 $0.00 $0.00D6545 E $0.00 $0.00 $0.00D6548 E $0.00 $0.00 $0.00D6549 E $0.00 $0.00 $0.00D6600 E $0.00 $0.00 $0.00D6601 E $0.00 $0.00 $0.00D6602 E $0.00 $0.00 $0.00D6603 E $0.00 $0.00 $0.00D6604 E $0.00 $0.00 $0.00D6605 E $0.00 $0.00 $0.00D6606 E $0.00 $0.00 $0.00D6607 E $0.00 $0.00 $0.00D6608 E $0.00 $0.00 $0.00D6609 E $0.00 $0.00 $0.00


223


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeD6610 E $0.00 $0.00 $0.00D6611 E $0.00 $0.00 $0.00D6612 E $0.00 $0.00 $0.00D6613 E $0.00 $0.00 $0.00D6614 E $0.00 $0.00 $0.00D6615 E $0.00 $0.00 $0.00D6624 E $0.00 $0.00 $0.00D6634 E $0.00 $0.00 $0.00D6710 E $0.00 $0.00 $0.00D6720 E $0.00 $0.00 $0.00D6721 E $0.00 $0.00 $0.00D6722 E $0.00 $0.00 $0.00D6740 E $0.00 $0.00 $0.00D6750 E $0.00 $0.00 $0.00D6751 E $0.00 $0.00 $0.00D6752 E $0.00 $0.00 $0.00D6780 E $0.00 $0.00 $0.00D6781 E $0.00 $0.00 $0.00D6782 E $0.00 $0.00 $0.00D6783 E $0.00 $0.00 $0.00D6790 E $0.00 $0.00 $0.00D6791 E $0.00 $0.00 $0.00D6792 E $0.00 $0.00 $0.00D6793 E $0.00 $0.00 $0.00D6794 E $0.00 $0.00 $0.00D6920 S 0330 3.4106 $369.78 $452.01 $277.35 D6930 E $0.00 $0.00 $0.00D6940 E $0.00 $0.00 $0.00D6950 E $0.00 $0.00 $0.00D6980 E $0.00 $0.00 $0.00D6985 E $0.00 $0.00 $0.00D6999 E $0.00 $0.00 $0.00D7111 S 0330 3.4106 $369.78 $452.01 $277.35 D7140 S 0330 3.4106 $369.78 $452.01 $277.35 D7210 S 0330 3.4106 $369.78 $452.01 $277.35 D7220 S 0330 3.4106 $369.78 $452.01 $277.35 D7230 S 0330 3.4106 $369.78 $452.01 $277.35 D7240 S 0330 3.4106 $369.78 $452.01 $277.35 D7241 S 0330 3.4106 $369.78 $452.01 $277.35 D7250 S 0330 3.4106 $369.78 $452.01 $277.35 D7251 E $0.00 $0.00 $0.00D7260 S 0330 3.4106 $369.78 $452.01 $277.35 D7261 S 0330 3.4106 $369.78 $452.01 $277.35 D7270 E $0.00 $0.00 $0.00D7272 E $0.00 $0.00 $0.00D7280 E $0.00 $0.00 $0.00D7282 E $0.00 $0.00 $0.00D7283 B $0.00 $0.00 $0.00D7285 E $0.00 $0.00 $0.00D7286 E $0.00 $0.00 $0.00D7287 E $0.00 $0.00 $0.00


224


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeD7288 B $0.00 $0.00 $0.00D7290 E $0.00 $0.00 $0.00D7291 S 0330 3.4106 $369.78 $452.01 $277.35 D7292 E $0.00 $0.00 $0.00D7293 E $0.00 $0.00 $0.00D7294 E $0.00 $0.00 $0.00D7295 E $0.00 $0.00 $0.00D7310 E $0.00 $0.00 $0.00D7311 E $0.00 $0.00 $0.00D7320 E $0.00 $0.00 $0.00D7321 B $0.00 $0.00 $0.00D7340 E $0.00 $0.00 $0.00D7350 E $0.00 $0.00 $0.00D7410 E $0.00 $0.00 $0.00D7411 E $0.00 $0.00 $0.00D7412 E $0.00 $0.00 $0.00D7413 E $0.00 $0.00 $0.00D7414 E $0.00 $0.00 $0.00D7415 E $0.00 $0.00 $0.00D7440 E $0.00 $0.00 $0.00D7441 E $0.00 $0.00 $0.00D7450 E $0.00 $0.00 $0.00D7451 E $0.00 $0.00 $0.00D7460 E $0.00 $0.00 $0.00D7461 E $0.00 $0.00 $0.00D7465 E $0.00 $0.00 $0.00D7471 E $0.00 $0.00 $0.00D7472 E $0.00 $0.00 $0.00D7473 E $0.00 $0.00 $0.00D7485 E $0.00 $0.00 $0.00D7490 E $0.00 $0.00 $0.00D7510 E $0.00 $0.00 $0.00D7511 B $0.00 $0.00 $0.00D7520 E $0.00 $0.00 $0.00D7521 B $0.00 $0.00 $0.00D7530 E $0.00 $0.00 $0.00D7540 E $0.00 $0.00 $0.00D7550 E $0.00 $0.00 $0.00D7560 E $0.00 $0.00 $0.00D7610 E $0.00 $0.00 $0.00D7620 E $0.00 $0.00 $0.00D7630 E $0.00 $0.00 $0.00D7640 E $0.00 $0.00 $0.00D7650 E $0.00 $0.00 $0.00D7660 E $0.00 $0.00 $0.00D7670 E $0.00 $0.00 $0.00D7671 E $0.00 $0.00 $0.00D7680 E $0.00 $0.00 $0.00D7710 E $0.00 $0.00 $0.00D7720 E $0.00 $0.00 $0.00D7730 E $0.00 $0.00 $0.00


225


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeD7740 E $0.00 $0.00 $0.00D7750 E $0.00 $0.00 $0.00D7760 E $0.00 $0.00 $0.00D7770 E $0.00 $0.00 $0.00D7771 E $0.00 $0.00 $0.00D7780 E $0.00 $0.00 $0.00D7810 E $0.00 $0.00 $0.00D7820 E $0.00 $0.00 $0.00D7830 E $0.00 $0.00 $0.00D7840 E $0.00 $0.00 $0.00D7850 E $0.00 $0.00 $0.00D7852 E $0.00 $0.00 $0.00D7854 E $0.00 $0.00 $0.00D7856 E $0.00 $0.00 $0.00D7858 E $0.00 $0.00 $0.00D7860 E $0.00 $0.00 $0.00D7865 E $0.00 $0.00 $0.00D7870 E $0.00 $0.00 $0.00D7871 E $0.00 $0.00 $0.00D7872 E $0.00 $0.00 $0.00D7873 E $0.00 $0.00 $0.00D7874 E $0.00 $0.00 $0.00D7875 E $0.00 $0.00 $0.00D7876 E $0.00 $0.00 $0.00D7877 E $0.00 $0.00 $0.00D7880 E $0.00 $0.00 $0.00D7899 E $0.00 $0.00 $0.00D7910 E $0.00 $0.00 $0.00D7911 E $0.00 $0.00 $0.00D7912 E $0.00 $0.00 $0.00D7920 E $0.00 $0.00 $0.00D7921 E $0.00 $0.00 $0.00D7940 S 0330 3.4106 $369.78 $452.01 $277.35 D7941 E $0.00 $0.00 $0.00D7943 E $0.00 $0.00 $0.00D7944 E $0.00 $0.00 $0.00D7945 E $0.00 $0.00 $0.00D7946 E $0.00 $0.00 $0.00D7947 E $0.00 $0.00 $0.00D7948 E $0.00 $0.00 $0.00D7949 E $0.00 $0.00 $0.00D7950 E $0.00 $0.00 $0.00D7951 E $0.00 $0.00 $0.00D7952 E $0.00 $0.00 $0.00D7953 E $0.00 $0.00 $0.00D7955 E $0.00 $0.00 $0.00D7960 E $0.00 $0.00 $0.00D7963 E $0.00 $0.00 $0.00D7970 E $0.00 $0.00 $0.00D7971 E $0.00 $0.00 $0.00D7972 E $0.00 $0.00 $0.00


226


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeD7980 E $0.00 $0.00 $0.00D7981 E $0.00 $0.00 $0.00D7982 E $0.00 $0.00 $0.00D7983 E $0.00 $0.00 $0.00D7990 E $0.00 $0.00 $0.00D7991 E $0.00 $0.00 $0.00D7995 E $0.00 $0.00 $0.00D7996 E $0.00 $0.00 $0.00D7997 E $0.00 $0.00 $0.00D7998 E $0.00 $0.00 $0.00D7999 E $0.00 $0.00 $0.00D8010 E $0.00 $0.00 $0.00D8020 E $0.00 $0.00 $0.00D8030 E $0.00 $0.00 $0.00D8040 E $0.00 $0.00 $0.00D8050 E $0.00 $0.00 $0.00D8060 E $0.00 $0.00 $0.00D8070 E $0.00 $0.00 $0.00D8080 E $0.00 $0.00 $0.00D8090 E $0.00 $0.00 $0.00D8210 E $0.00 $0.00 $0.00D8220 E $0.00 $0.00 $0.00D8660 E $0.00 $0.00 $0.00D8670 E $0.00 $0.00 $0.00D8680 E $0.00 $0.00 $0.00D8690 E $0.00 $0.00 $0.00D8691 E $0.00 $0.00 $0.00D8692 E $0.00 $0.00 $0.00D8693 E $0.00 $0.00 $0.00D8694 E $0.00 $0.00 $0.00D8999 E $0.00 $0.00 $0.00D9110 N $0.00 $0.00 $0.00 D9120 E $0.00 $0.00 $0.00D9210 E $0.00 $0.00 $0.00D9211 E $0.00 $0.00 $0.00D9212 E $0.00 $0.00 $0.00D9215 E $0.00 $0.00 $0.00D9219 E $0.00 $0.00 $0.00D9220 E $0.00 $0.00 $0.00D9221 E $0.00 $0.00 $0.00D9230 N $0.00 $0.00 $0.00 D9241 E $0.00 $0.00 $0.00D9242 E $0.00 $0.00 $0.00D9248 N $0.00 $0.00 $0.00 D9310 E $0.00 $0.00 $0.00D9410 E $0.00 $0.00 $0.00D9420 E $0.00 $0.00 $0.00D9430 E $0.00 $0.00 $0.00D9440 E $0.00 $0.00 $0.00D9450 E $0.00 $0.00 $0.00D9610 E $0.00 $0.00 $0.00


227


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeD9612 E $0.00 $0.00 $0.00D9630 S 0330 3.4106 $369.78 $452.01 $277.35 D9910 E $0.00 $0.00 $0.00D9911 E $0.00 $0.00 $0.00D9920 E $0.00 $0.00 $0.00D9930 S 0330 3.4106 $369.78 $452.01 $277.35 D9931 E $0.00 $0.00 $0.00D9940 S 0330 3.4106 $369.78 $452.01 $277.35 D9941 E $0.00 $0.00 $0.00D9942 E $0.00 $0.00 $0.00D9950 S 0330 3.4106 $369.78 $452.01 $277.35 D9951 S 0330 3.4106 $369.78 $452.01 $277.35 D9952 S 0330 3.4106 $369.78 $452.01 $277.35 D9970 E $0.00 $0.00 $0.00D9971 E $0.00 $0.00 $0.00D9972 E $0.00 $0.00 $0.00D9973 E $0.00 $0.00 $0.00D9974 E $0.00 $0.00 $0.00D9975 E $0.00 $0.00 $0.00D9985 E $0.00 $0.00 $0.00D9986 E $0.00 $0.00 $0.00D9987 E $0.00 $0.00 $0.00D9999 E $0.00 $0.00 $0.00E0100 Y $0.00 $0.00 $0.00E0105 Y $0.00 $0.00 $0.00E0110 Y $0.00 $0.00 $0.00E0111 Y $0.00 $0.00 $0.00E0112 Y $0.00 $0.00 $0.00E0113 Y $0.00 $0.00 $0.00E0114 Y $0.00 $0.00 $0.00E0116 Y $0.00 $0.00 $0.00E0117 Y $0.00 $0.00 $0.00E0118 E $0.00 $0.00 $0.00E0130 Y $0.00 $0.00 $0.00E0135 Y $0.00 $0.00 $0.00E0140 Y $0.00 $0.00 $0.00E0141 Y $0.00 $0.00 $0.00E0143 Y $0.00 $0.00 $0.00E0144 Y $0.00 $0.00 $0.00E0147 Y $0.00 $0.00 $0.00E0148 Y $0.00 $0.00 $0.00E0149 Y $0.00 $0.00 $0.00E0153 Y $0.00 $0.00 $0.00E0154 Y $0.00 $0.00 $0.00E0155 Y $0.00 $0.00 $0.00E0156 Y $0.00 $0.00 $0.00E0157 Y $0.00 $0.00 $0.00E0158 Y $0.00 $0.00 $0.00E0159 Y $0.00 $0.00 $0.00E0160 Y $0.00 $0.00 $0.00E0161 Y $0.00 $0.00 $0.00


228


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeE0162 Y $0.00 $0.00 $0.00E0163 Y $0.00 $0.00 $0.00E0165 Y $0.00 $0.00 $0.00E0167 Y $0.00 $0.00 $0.00E0168 Y $0.00 $0.00 $0.00E0170 Y $0.00 $0.00 $0.00E0171 Y $0.00 $0.00 $0.00E0172 E $0.00 $0.00 $0.00E0175 Y $0.00 $0.00 $0.00E0181 Y $0.00 $0.00 $0.00E0182 Y $0.00 $0.00 $0.00E0184 Y $0.00 $0.00 $0.00E0185 Y $0.00 $0.00 $0.00E0186 Y $0.00 $0.00 $0.00E0187 Y $0.00 $0.00 $0.00E0188 Y $0.00 $0.00 $0.00E0189 Y $0.00 $0.00 $0.00E0190 E $0.00 $0.00 $0.00E0191 Y $0.00 $0.00 $0.00E0193 Y $0.00 $0.00 $0.00E0194 Y $0.00 $0.00 $0.00E0196 Y $0.00 $0.00 $0.00E0197 Y $0.00 $0.00 $0.00E0198 Y $0.00 $0.00 $0.00E0199 Y $0.00 $0.00 $0.00E0200 Y $0.00 $0.00 $0.00E0202 Y $0.00 $0.00 $0.00E0203 E $0.00 $0.00 $0.00E0205 Y $0.00 $0.00 $0.00E0210 Y $0.00 $0.00 $0.00E0215 Y $0.00 $0.00 $0.00E0217 Y $0.00 $0.00 $0.00E0218 Y $0.00 $0.00 $0.00E0221 Y $0.00 $0.00 $0.00E0225 Y $0.00 $0.00 $0.00E0231 E $0.00 $0.00 $0.00E0232 E $0.00 $0.00 $0.00E0235 Y $0.00 $0.00 $0.00E0236 Y $0.00 $0.00 $0.00E0239 Y $0.00 $0.00 $0.00E0240 E $0.00 $0.00 $0.00E0241 E $0.00 $0.00 $0.00E0242 E $0.00 $0.00 $0.00E0243 E $0.00 $0.00 $0.00E0244 E $0.00 $0.00 $0.00E0245 E $0.00 $0.00 $0.00E0246 E $0.00 $0.00 $0.00E0247 E $0.00 $0.00 $0.00E0248 E $0.00 $0.00 $0.00E0249 Y $0.00 $0.00 $0.00E0250 Y $0.00 $0.00 $0.00


229


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeE0251 Y $0.00 $0.00 $0.00E0255 Y $0.00 $0.00 $0.00E0256 Y $0.00 $0.00 $0.00E0260 Y $0.00 $0.00 $0.00E0261 Y $0.00 $0.00 $0.00E0265 Y $0.00 $0.00 $0.00E0266 Y $0.00 $0.00 $0.00E0270 E $0.00 $0.00 $0.00E0271 Y $0.00 $0.00 $0.00E0272 Y $0.00 $0.00 $0.00E0273 E $0.00 $0.00 $0.00E0274 E $0.00 $0.00 $0.00E0275 Y $0.00 $0.00 $0.00E0276 Y $0.00 $0.00 $0.00E0277 Y $0.00 $0.00 $0.00E0280 Y $0.00 $0.00 $0.00E0290 Y $0.00 $0.00 $0.00E0291 Y $0.00 $0.00 $0.00E0292 Y $0.00 $0.00 $0.00E0293 Y $0.00 $0.00 $0.00E0294 Y $0.00 $0.00 $0.00E0295 Y $0.00 $0.00 $0.00E0296 Y $0.00 $0.00 $0.00E0297 Y $0.00 $0.00 $0.00E0300 Y $0.00 $0.00 $0.00E0301 Y $0.00 $0.00 $0.00E0302 Y $0.00 $0.00 $0.00E0303 Y $0.00 $0.00 $0.00E0304 Y $0.00 $0.00 $0.00E0305 Y $0.00 $0.00 $0.00E0310 Y $0.00 $0.00 $0.00E0315 E $0.00 $0.00 $0.00E0316 Y $0.00 $0.00 $0.00E0325 Y $0.00 $0.00 $0.00E0326 Y $0.00 $0.00 $0.00E0328 Y $0.00 $0.00 $0.00E0329 Y $0.00 $0.00 $0.00E0350 E $0.00 $0.00 $0.00E0352 E $0.00 $0.00 $0.00E0370 E $0.00 $0.00 $0.00E0371 Y $0.00 $0.00 $0.00E0372 Y $0.00 $0.00 $0.00E0373 Y $0.00 $0.00 $0.00E0424 Y $0.00 $0.00 $0.00E0425 E $0.00 $0.00 $0.00E0430 E $0.00 $0.00 $0.00E0431 Y $0.00 $0.00 $0.00E0433 Y $0.00 $0.00 $0.00E0434 Y $0.00 $0.00 $0.00E0435 E $0.00 $0.00 $0.00E0439 Y $0.00 $0.00 $0.00


230


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeE0440 E $0.00 $0.00 $0.00E0441 Y $0.00 $0.00 $0.00E0442 Y $0.00 $0.00 $0.00E0443 Y $0.00 $0.00 $0.00E0444 Y $0.00 $0.00 $0.00E0445 N $0.00 $0.00 $0.00 E0446 E $0.00 $0.00 $0.00E0450 Y $0.00 $0.00 $0.00E0455 Y $0.00 $0.00 $0.00E0457 E $0.00 $0.00 $0.00E0459 E $0.00 $0.00 $0.00E0460 Y $0.00 $0.00 $0.00E0461 Y $0.00 $0.00 $0.00E0462 Y $0.00 $0.00 $0.00E0463 Y $0.00 $0.00 $0.00E0464 Y $0.00 $0.00 $0.00E0470 Y $0.00 $0.00 $0.00E0471 Y $0.00 $0.00 $0.00E0472 Y $0.00 $0.00 $0.00E0480 Y $0.00 $0.00 $0.00E0481 E $0.00 $0.00 $0.00E0482 Y $0.00 $0.00 $0.00E0483 Y $0.00 $0.00 $0.00E0484 Y $0.00 $0.00 $0.00E0485 Y $0.00 $0.00 $0.00E0486 Y $0.00 $0.00 $0.00E0487 N $0.00 $0.00 $0.00 E0500 Y $0.00 $0.00 $0.00E0550 Y $0.00 $0.00 $0.00E0555 Y $0.00 $0.00 $0.00E0560 Y $0.00 $0.00 $0.00E0561 Y $0.00 $0.00 $0.00E0562 Y $0.00 $0.00 $0.00E0565 Y $0.00 $0.00 $0.00E0570 Y $0.00 $0.00 $0.00E0572 Y $0.00 $0.00 $0.00E0574 Y $0.00 $0.00 $0.00E0575 Y $0.00 $0.00 $0.00E0580 Y $0.00 $0.00 $0.00E0585 Y $0.00 $0.00 $0.00E0600 Y $0.00 $0.00 $0.00E0601 Y $0.00 $0.00 $0.00E0602 Y $0.00 $0.00 $0.00E0603 N $0.00 $0.00 $0.00 E0604 A $0.00 $0.00 $0.00E0605 Y $0.00 $0.00 $0.00E0606 Y $0.00 $0.00 $0.00E0607 Y $0.00 $0.00 $0.00E0610 Y $0.00 $0.00 $0.00E0615 Y $0.00 $0.00 $0.00E0616 N $0.00 $0.00 $0.00


231


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeE0617 Y $0.00 $0.00 $0.00E0618 Y $0.00 $0.00 $0.00E0619 Y $0.00 $0.00 $0.00E0620 Y $0.00 $0.00 $0.00E0621 Y $0.00 $0.00 $0.00E0625 E $0.00 $0.00 $0.00E0627 Y $0.00 $0.00 $0.00E0628 Y $0.00 $0.00 $0.00E0629 Y $0.00 $0.00 $0.00E0630 Y $0.00 $0.00 $0.00E0635 Y $0.00 $0.00 $0.00E0636 Y $0.00 $0.00 $0.00E0637 E $0.00 $0.00 $0.00E0638 E $0.00 $0.00 $0.00E0639 E $0.00 $0.00 $0.00E0640 E $0.00 $0.00 $0.00E0641 E $0.00 $0.00 $0.00E0642 E $0.00 $0.00 $0.00E0650 Y $0.00 $0.00 $0.00E0651 Y $0.00 $0.00 $0.00E0652 Y $0.00 $0.00 $0.00E0655 Y $0.00 $0.00 $0.00E0656 Y $0.00 $0.00 $0.00E0657 Y $0.00 $0.00 $0.00E0660 Y $0.00 $0.00 $0.00E0665 Y $0.00 $0.00 $0.00E0666 Y $0.00 $0.00 $0.00E0667 Y $0.00 $0.00 $0.00E0668 Y $0.00 $0.00 $0.00E0669 Y $0.00 $0.00 $0.00E0670 Y $0.00 $0.00 $0.00E0671 Y $0.00 $0.00 $0.00E0672 Y $0.00 $0.00 $0.00E0673 Y $0.00 $0.00 $0.00E0675 Y $0.00 $0.00 $0.00E0676 Y $0.00 $0.00 $0.00E0691 Y $0.00 $0.00 $0.00E0692 Y $0.00 $0.00 $0.00E0693 Y $0.00 $0.00 $0.00E0694 Y $0.00 $0.00 $0.00E0700 E $0.00 $0.00 $0.00E0705 B $0.00 $0.00 $0.00E0710 E $0.00 $0.00 $0.00E0720 Y $0.00 $0.00 $0.00E0730 Y $0.00 $0.00 $0.00E0731 Y $0.00 $0.00 $0.00E0740 Y $0.00 $0.00 $0.00E0744 Y $0.00 $0.00 $0.00E0745 Y $0.00 $0.00 $0.00E0746 N $0.00 $0.00 $0.00 E0747 Y $0.00 $0.00 $0.00


232


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeE0748 Y $0.00 $0.00 $0.00E0749 N $0.00 $0.00 $0.00 E0755 E $0.00 $0.00 $0.00E0760 Y $0.00 $0.00 $0.00E0761 E $0.00 $0.00 $0.00E0762 B $0.00 $0.00 $0.00E0764 Y $0.00 $0.00 $0.00E0765 Y $0.00 $0.00 $0.00E0766 Y $0.00 $0.00 $0.00E0769 B $0.00 $0.00 $0.00E0770 Y $0.00 $0.00 $0.00E0776 Y $0.00 $0.00 $0.00E0779 Y $0.00 $0.00 $0.00E0780 Y $0.00 $0.00 $0.00E0781 Y $0.00 $0.00 $0.00E0782 N $0.00 $0.00 $0.00 E0783 N $0.00 $0.00 $0.00 E0784 Y $0.00 $0.00 $0.00E0785 N $0.00 $0.00 $0.00 E0786 N $0.00 $0.00 $0.00 E0791 Y $0.00 $0.00 $0.00E0830 N $0.00 $0.00 $0.00 E0840 Y $0.00 $0.00 $0.00E0849 Y $0.00 $0.00 $0.00E0850 Y $0.00 $0.00 $0.00E0855 Y $0.00 $0.00 $0.00E0856 Y $0.00 $0.00 $0.00E0860 Y $0.00 $0.00 $0.00E0870 Y $0.00 $0.00 $0.00E0880 Y $0.00 $0.00 $0.00E0890 Y $0.00 $0.00 $0.00E0900 Y $0.00 $0.00 $0.00E0910 Y $0.00 $0.00 $0.00E0911 Y $0.00 $0.00 $0.00E0912 Y $0.00 $0.00 $0.00E0920 Y $0.00 $0.00 $0.00E0930 Y $0.00 $0.00 $0.00E0935 Y $0.00 $0.00 $0.00E0936 E $0.00 $0.00 $0.00E0940 Y $0.00 $0.00 $0.00E0941 Y $0.00 $0.00 $0.00E0942 Y $0.00 $0.00 $0.00E0944 Y $0.00 $0.00 $0.00E0945 Y $0.00 $0.00 $0.00E0946 Y $0.00 $0.00 $0.00E0947 Y $0.00 $0.00 $0.00E0948 Y $0.00 $0.00 $0.00E0950 Y $0.00 $0.00 $0.00E0951 Y $0.00 $0.00 $0.00E0952 Y $0.00 $0.00 $0.00E0955 Y $0.00 $0.00 $0.00


233


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeE0956 Y $0.00 $0.00 $0.00E0957 Y $0.00 $0.00 $0.00E0958 Y $0.00 $0.00 $0.00E0959 B $0.00 $0.00 $0.00E0960 Y $0.00 $0.00 $0.00E0961 B $0.00 $0.00 $0.00E0966 B $0.00 $0.00 $0.00E0967 Y $0.00 $0.00 $0.00E0968 Y $0.00 $0.00 $0.00E0969 Y $0.00 $0.00 $0.00E0970 E $0.00 $0.00 $0.00E0971 B $0.00 $0.00 $0.00E0973 B $0.00 $0.00 $0.00E0974 B $0.00 $0.00 $0.00E0978 B $0.00 $0.00 $0.00E0980 Y $0.00 $0.00 $0.00E0981 Y $0.00 $0.00 $0.00E0982 Y $0.00 $0.00 $0.00E0983 Y $0.00 $0.00 $0.00E0984 Y $0.00 $0.00 $0.00E0985 Y $0.00 $0.00 $0.00E0986 Y $0.00 $0.00 $0.00E0988 Y $0.00 $0.00 $0.00E0990 B $0.00 $0.00 $0.00E0992 B $0.00 $0.00 $0.00E0994 Y $0.00 $0.00 $0.00E0995 B $0.00 $0.00 $0.00E1002 Y $0.00 $0.00 $0.00E1003 Y $0.00 $0.00 $0.00E1004 Y $0.00 $0.00 $0.00E1005 Y $0.00 $0.00 $0.00E1006 Y $0.00 $0.00 $0.00E1007 Y $0.00 $0.00 $0.00E1008 Y $0.00 $0.00 $0.00E1009 Y $0.00 $0.00 $0.00E1010 Y $0.00 $0.00 $0.00E1011 Y $0.00 $0.00 $0.00E1014 Y $0.00 $0.00 $0.00E1015 Y $0.00 $0.00 $0.00E1016 Y $0.00 $0.00 $0.00E1017 Y $0.00 $0.00 $0.00E1018 Y $0.00 $0.00 $0.00E1020 Y $0.00 $0.00 $0.00E1028 Y $0.00 $0.00 $0.00E1029 Y $0.00 $0.00 $0.00E1030 Y $0.00 $0.00 $0.00E1031 Y $0.00 $0.00 $0.00E1035 Y $0.00 $0.00 $0.00E1036 Y $0.00 $0.00 $0.00E1037 Y $0.00 $0.00 $0.00E1038 Y $0.00 $0.00 $0.00


234


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeE1039 Y $0.00 $0.00 $0.00E1050 Y $0.00 $0.00 $0.00E1060 Y $0.00 $0.00 $0.00E1070 Y $0.00 $0.00 $0.00E1083 Y $0.00 $0.00 $0.00E1084 Y $0.00 $0.00 $0.00E1085 E $0.00 $0.00 $0.00E1086 E $0.00 $0.00 $0.00E1087 Y $0.00 $0.00 $0.00E1088 Y $0.00 $0.00 $0.00E1089 E $0.00 $0.00 $0.00E1090 E $0.00 $0.00 $0.00E1092 Y $0.00 $0.00 $0.00E1093 Y $0.00 $0.00 $0.00E1100 Y $0.00 $0.00 $0.00E1110 Y $0.00 $0.00 $0.00E1130 E $0.00 $0.00 $0.00E1140 E $0.00 $0.00 $0.00E1150 Y $0.00 $0.00 $0.00E1160 Y $0.00 $0.00 $0.00E1161 Y $0.00 $0.00 $0.00E1170 Y $0.00 $0.00 $0.00E1171 Y $0.00 $0.00 $0.00E1172 Y $0.00 $0.00 $0.00E1180 Y $0.00 $0.00 $0.00E1190 Y $0.00 $0.00 $0.00E1195 Y $0.00 $0.00 $0.00E1200 Y $0.00 $0.00 $0.00E1220 Y $0.00 $0.00 $0.00E1221 Y $0.00 $0.00 $0.00E1222 Y $0.00 $0.00 $0.00E1223 Y $0.00 $0.00 $0.00E1224 Y $0.00 $0.00 $0.00E1225 Y $0.00 $0.00 $0.00E1226 B $0.00 $0.00 $0.00E1227 Y $0.00 $0.00 $0.00E1228 Y $0.00 $0.00 $0.00E1229 Y $0.00 $0.00 $0.00E1230 Y $0.00 $0.00 $0.00E1231 Y $0.00 $0.00 $0.00E1232 Y $0.00 $0.00 $0.00E1233 Y $0.00 $0.00 $0.00E1234 Y $0.00 $0.00 $0.00E1235 Y $0.00 $0.00 $0.00E1236 Y $0.00 $0.00 $0.00E1237 Y $0.00 $0.00 $0.00E1238 Y $0.00 $0.00 $0.00E1239 Y $0.00 $0.00 $0.00E1240 Y $0.00 $0.00 $0.00E1250 E $0.00 $0.00 $0.00E1260 E $0.00 $0.00 $0.00


235


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeE1270 Y $0.00 $0.00 $0.00E1280 Y $0.00 $0.00 $0.00E1285 E $0.00 $0.00 $0.00E1290 E $0.00 $0.00 $0.00E1295 Y $0.00 $0.00 $0.00E1296 Y $0.00 $0.00 $0.00E1297 Y $0.00 $0.00 $0.00E1298 Y $0.00 $0.00 $0.00E1300 E $0.00 $0.00 $0.00E1310 Y $0.00 $0.00 $0.00E1352 Y $0.00 $0.00 $0.00E1353 Y $0.00 $0.00 $0.00E1354 Y $0.00 $0.00 $0.00E1355 Y $0.00 $0.00 $0.00E1356 Y $0.00 $0.00 $0.00E1357 Y $0.00 $0.00 $0.00E1358 Y $0.00 $0.00 $0.00E1372 Y $0.00 $0.00 $0.00E1390 Y $0.00 $0.00 $0.00E1391 Y $0.00 $0.00 $0.00E1392 Y $0.00 $0.00 $0.00E1399 Y $0.00 $0.00 $0.00E1405 Y $0.00 $0.00 $0.00E1406 Y $0.00 $0.00 $0.00E1500 A $0.00 $0.00 $0.00E1510 A $0.00 $0.00 $0.00E1520 A $0.00 $0.00 $0.00E1530 A $0.00 $0.00 $0.00E1540 A $0.00 $0.00 $0.00E1550 A $0.00 $0.00 $0.00E1560 A $0.00 $0.00 $0.00E1570 A $0.00 $0.00 $0.00E1575 A $0.00 $0.00 $0.00E1580 A $0.00 $0.00 $0.00E1590 A $0.00 $0.00 $0.00E1592 A $0.00 $0.00 $0.00E1594 A $0.00 $0.00 $0.00E1600 A $0.00 $0.00 $0.00E1610 A $0.00 $0.00 $0.00E1615 A $0.00 $0.00 $0.00E1620 A $0.00 $0.00 $0.00E1625 A $0.00 $0.00 $0.00E1630 A $0.00 $0.00 $0.00E1632 A $0.00 $0.00 $0.00E1634 B $0.00 $0.00 $0.00E1635 A $0.00 $0.00 $0.00E1636 A $0.00 $0.00 $0.00E1637 A $0.00 $0.00 $0.00E1639 A $0.00 $0.00 $0.00E1699 A $0.00 $0.00 $0.00E1700 Y $0.00 $0.00 $0.00


236


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeE1701 Y $0.00 $0.00 $0.00E1702 Y $0.00 $0.00 $0.00E1800 Y $0.00 $0.00 $0.00E1801 Y $0.00 $0.00 $0.00E1802 Y $0.00 $0.00 $0.00E1805 Y $0.00 $0.00 $0.00E1806 Y $0.00 $0.00 $0.00E1810 Y $0.00 $0.00 $0.00E1811 Y $0.00 $0.00 $0.00E1812 Y $0.00 $0.00 $0.00E1815 Y $0.00 $0.00 $0.00E1816 Y $0.00 $0.00 $0.00E1818 Y $0.00 $0.00 $0.00E1820 Y $0.00 $0.00 $0.00E1821 Y $0.00 $0.00 $0.00E1825 Y $0.00 $0.00 $0.00E1830 Y $0.00 $0.00 $0.00E1831 Y $0.00 $0.00 $0.00E1840 Y $0.00 $0.00 $0.00E1841 Y $0.00 $0.00 $0.00E1902 Y $0.00 $0.00 $0.00E2000 Y $0.00 $0.00 $0.00E2100 Y $0.00 $0.00 $0.00E2101 Y $0.00 $0.00 $0.00E2120 Y $0.00 $0.00 $0.00E2201 Y $0.00 $0.00 $0.00E2202 Y $0.00 $0.00 $0.00E2203 Y $0.00 $0.00 $0.00E2204 Y $0.00 $0.00 $0.00E2205 Y $0.00 $0.00 $0.00E2206 Y $0.00 $0.00 $0.00E2207 Y $0.00 $0.00 $0.00E2208 Y $0.00 $0.00 $0.00E2209 Y $0.00 $0.00 $0.00E2210 Y $0.00 $0.00 $0.00E2211 Y $0.00 $0.00 $0.00E2212 Y $0.00 $0.00 $0.00E2213 Y $0.00 $0.00 $0.00E2214 Y $0.00 $0.00 $0.00E2215 Y $0.00 $0.00 $0.00E2216 Y $0.00 $0.00 $0.00E2217 Y $0.00 $0.00 $0.00E2218 Y $0.00 $0.00 $0.00E2219 Y $0.00 $0.00 $0.00E2220 Y $0.00 $0.00 $0.00E2221 Y $0.00 $0.00 $0.00E2222 Y $0.00 $0.00 $0.00E2224 Y $0.00 $0.00 $0.00E2225 Y $0.00 $0.00 $0.00E2226 Y $0.00 $0.00 $0.00E2227 Y $0.00 $0.00 $0.00


237


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeE2228 Y $0.00 $0.00 $0.00E2230 Y $0.00 $0.00 $0.00E2231 Y $0.00 $0.00 $0.00E2291 Y $0.00 $0.00 $0.00E2292 Y $0.00 $0.00 $0.00E2293 Y $0.00 $0.00 $0.00E2294 Y $0.00 $0.00 $0.00E2295 Y $0.00 $0.00 $0.00E2300 Y $0.00 $0.00 $0.00E2301 Y $0.00 $0.00 $0.00E2310 Y $0.00 $0.00 $0.00E2311 Y $0.00 $0.00 $0.00E2312 Y $0.00 $0.00 $0.00E2313 Y $0.00 $0.00 $0.00E2321 Y $0.00 $0.00 $0.00E2322 Y $0.00 $0.00 $0.00E2323 Y $0.00 $0.00 $0.00E2324 Y $0.00 $0.00 $0.00E2325 Y $0.00 $0.00 $0.00E2326 Y $0.00 $0.00 $0.00E2327 Y $0.00 $0.00 $0.00E2328 Y $0.00 $0.00 $0.00E2329 Y $0.00 $0.00 $0.00E2330 Y $0.00 $0.00 $0.00E2331 Y $0.00 $0.00 $0.00E2340 Y $0.00 $0.00 $0.00E2341 Y $0.00 $0.00 $0.00E2342 Y $0.00 $0.00 $0.00E2343 Y $0.00 $0.00 $0.00E2351 Y $0.00 $0.00 $0.00E2358 Y $0.00 $0.00 $0.00E2359 Y $0.00 $0.00 $0.00E2360 Y $0.00 $0.00 $0.00E2361 Y $0.00 $0.00 $0.00E2362 Y $0.00 $0.00 $0.00E2363 Y $0.00 $0.00 $0.00E2364 Y $0.00 $0.00 $0.00E2365 Y $0.00 $0.00 $0.00E2366 Y $0.00 $0.00 $0.00E2367 Y $0.00 $0.00 $0.00E2368 Y $0.00 $0.00 $0.00E2369 Y $0.00 $0.00 $0.00E2370 Y $0.00 $0.00 $0.00E2371 Y $0.00 $0.00 $0.00E2372 Y $0.00 $0.00 $0.00E2373 Y $0.00 $0.00 $0.00E2374 Y $0.00 $0.00 $0.00E2375 Y $0.00 $0.00 $0.00E2376 Y $0.00 $0.00 $0.00E2377 Y $0.00 $0.00 $0.00E2378 Y $0.00 $0.00 $0.00


238


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeE2381 Y $0.00 $0.00 $0.00E2382 Y $0.00 $0.00 $0.00E2383 Y $0.00 $0.00 $0.00E2384 Y $0.00 $0.00 $0.00E2385 Y $0.00 $0.00 $0.00E2386 Y $0.00 $0.00 $0.00E2387 Y $0.00 $0.00 $0.00E2388 Y $0.00 $0.00 $0.00E2389 Y $0.00 $0.00 $0.00E2390 Y $0.00 $0.00 $0.00E2391 Y $0.00 $0.00 $0.00E2392 Y $0.00 $0.00 $0.00E2394 Y $0.00 $0.00 $0.00E2395 Y $0.00 $0.00 $0.00E2396 Y $0.00 $0.00 $0.00E2397 Y $0.00 $0.00 $0.00E2402 Y $0.00 $0.00 $0.00E2500 Y $0.00 $0.00 $0.00E2502 Y $0.00 $0.00 $0.00E2504 Y $0.00 $0.00 $0.00E2506 Y $0.00 $0.00 $0.00E2508 Y $0.00 $0.00 $0.00E2510 Y $0.00 $0.00 $0.00E2511 Y $0.00 $0.00 $0.00E2512 Y $0.00 $0.00 $0.00E2599 Y $0.00 $0.00 $0.00E2601 Y $0.00 $0.00 $0.00E2602 Y $0.00 $0.00 $0.00E2603 Y $0.00 $0.00 $0.00E2604 Y $0.00 $0.00 $0.00E2605 Y $0.00 $0.00 $0.00E2606 Y $0.00 $0.00 $0.00E2607 Y $0.00 $0.00 $0.00E2608 Y $0.00 $0.00 $0.00E2609 Y $0.00 $0.00 $0.00E2610 B $0.00 $0.00 $0.00E2611 Y $0.00 $0.00 $0.00E2612 Y $0.00 $0.00 $0.00E2613 Y $0.00 $0.00 $0.00E2614 Y $0.00 $0.00 $0.00E2615 Y $0.00 $0.00 $0.00E2616 Y $0.00 $0.00 $0.00E2617 Y $0.00 $0.00 $0.00E2619 Y $0.00 $0.00 $0.00E2620 Y $0.00 $0.00 $0.00E2621 Y $0.00 $0.00 $0.00E2622 Y $0.00 $0.00 $0.00E2623 Y $0.00 $0.00 $0.00E2624 Y $0.00 $0.00 $0.00E2625 Y $0.00 $0.00 $0.00E2626 Y $0.00 $0.00 $0.00


239


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeE2627 Y $0.00 $0.00 $0.00E2628 Y $0.00 $0.00 $0.00E2629 Y $0.00 $0.00 $0.00E2630 Y $0.00 $0.00 $0.00E2631 Y $0.00 $0.00 $0.00E2632 Y $0.00 $0.00 $0.00E2633 Y $0.00 $0.00 $0.00E8000 E $0.00 $0.00 $0.00E8001 E $0.00 $0.00 $0.00E8002 E $0.00 $0.00 $0.00G0008 S 0436 0.4393 $47.63 $58.22 $35.72 G0009 S 0437 0.7218 $78.26 $95.66 $58.70 G0010 S 0437 0.7218 $78.26 $95.66 $58.70 G0027 N $0.00 $0.00 $0.00 G0101 V 0631 0.7242 $78.52 $95.98 $58.89 G0102 N $0.00 $0.00 $0.00 G0103 N $0.00 $0.00 $0.00 G0104 S 0159 6.3219 $685.42 $837.84 $514.10 G0105 T 0158 8.8312 $957.48 $1,170.40 $718.15 G0106 S 0157 4.6315 $502.15 $613.81 $376.63 G0108 A $0.00 $0.00 $0.00G0109 A $0.00 $0.00 $0.00G0117 S 0230 0.7019 $76.10 $93.02 $57.08 G0118 S 0230 0.7019 $76.10 $93.02 $57.08 G0120 S 0157 4.6315 $502.15 $613.81 $376.63 G0121 T 0158 8.8312 $957.48 $1,170.40 $718.15 G0122 E $0.00 $0.00 $0.00G0123 N $0.00 $0.00 $0.00 G0124 B $0.00 $0.00 $0.00G0127 Q1 0340 0.7061 $76.56 $93.58 $57.42 G0128 B $0.00 $0.00 $0.00G0129 P $0.00 $0.00 $0.00G0130 S 0260 0.8004 $86.78 $106.08 $65.09 G0141 B $0.00 $0.00 $0.00G0143 N $0.00 $0.00 $0.00 G0144 N $0.00 $0.00 $0.00 G0145 N $0.00 $0.00 $0.00 G0147 N $0.00 $0.00 $0.00 G0148 N $0.00 $0.00 $0.00 G0151 B $0.00 $0.00 $0.00G0152 B $0.00 $0.00 $0.00G0153 B $0.00 $0.00 $0.00G0154 B $0.00 $0.00 $0.00G0155 B $0.00 $0.00 $0.00G0156 B $0.00 $0.00 $0.00G0157 B $0.00 $0.00 $0.00G0158 B $0.00 $0.00 $0.00G0159 B $0.00 $0.00 $0.00G0160 B $0.00 $0.00 $0.00G0161 B $0.00 $0.00 $0.00G0162 B $0.00 $0.00 $0.00


240


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeG0163 B $0.00 $0.00 $0.00G0164 B $0.00 $0.00 $0.00G0166 Q1 0420 1.7762 $192.58 $235.40 $144.44 G0168 B $0.00 $0.00 $0.00G0175 V 0633 5.2168 $565.61 $691.38 $424.23 G0176 P $0.00 $0.00 $0.00G0177 N $0.00 $0.00 $0.00 G0179 M $0.00 $0.00 $0.00G0180 M $0.00 $0.00 $0.00G0181 M $0.00 $0.00 $0.00G0182 M $0.00 $0.00 $0.00G0186 T 0247 5.981 $648.46 $792.66 $486.37 G0202 A $0.00 $0.00 $0.00G0204 A $0.00 $0.00 $0.00G0206 A $0.00 $0.00 $0.00G0219 E $0.00 $0.00 $0.00G0235 E $0.00 $0.00 $0.00G0237 Q1 0340 0.7061 $76.56 $93.58 $57.42 G0238 Q1 0340 0.7061 $76.56 $93.58 $57.42 G0239 Q1 0450 0.3942 $42.74 $52.24 $32.06 G0245 V 0632 1.4327 $155.33 $189.88 $116.51 G0246 V 0632 1.4327 $155.33 $189.88 $116.51 G0247 Q1 0012 1.3279 $143.97 $175.99 $107.98 G0248 V 0632 1.4327 $155.33 $189.88 $116.51 G0249 V 0632 1.4327 $155.33 $189.88 $116.51 G0250 M $0.00 $0.00 $0.00G0252 E $0.00 $0.00 $0.00G0255 E $0.00 $0.00 $0.00G0257 S 0170 8.2721 $896.86 $1,096.30 $672.69 G0259 N $0.00 $0.00 $0.00 G0260 T 0207 9.0607 $982.36 $1,200.81 $736.82 G0268 N $0.00 $0.00 $0.00 G0269 N $0.00 $0.00 $0.00 G0270 A $0.00 $0.00 $0.00G0271 A $0.00 $0.00 $0.00G0276 T 0208 55.4537 $6,012.29 $7,349.28 $4,509.49 G0277 S 0659 1.4734 $159.75 $195.27 $119.82 G0278 N $0.00 $0.00 $0.00 G0279 A $0.00 $0.00 $0.00G0281 A $0.00 $0.00 $0.00G0282 E $0.00 $0.00 $0.00G0283 A $0.00 $0.00 $0.00G0288 N $0.00 $0.00 $0.00 G0289 N $0.00 $0.00 $0.00 G0293 Q1 0340 0.7061 $76.56 $93.58 $57.42 G0294 Q1 0340 0.7061 $76.56 $93.58 $57.42 G0295 E $0.00 $0.00 $0.00G0302 S 0209 3.1121 $337.41 $412.45 $253.08 G0303 S 0209 3.1121 $337.41 $412.45 $253.08 G0304 S 0213 2.3813 $258.18 $315.59 $193.65 G0305 S 0213 2.3813 $258.18 $315.59 $193.65


241


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeG0306 N $0.00 $0.00 $0.00 G0307 N $0.00 $0.00 $0.00 G0328 N $0.00 $0.00 $0.00 G0329 A $0.00 $0.00 $0.00G0333 M $0.00 $0.00 $0.00G0337 B $0.00 $0.00 $0.00G0339 B $0.00 $0.00 $0.00G0340 B $0.00 $0.00 $0.00G0341 C $0.00 $0.00 $0.00G0342 C $0.00 $0.00 $0.00G0343 C $0.00 $0.00 $0.00G0364 N $0.00 $0.00 $0.00 G0365 S 0267 2.5565 $277.18 $338.81 $207.89 G0372 M $0.00 $0.00 $0.00G0378 N $0.00 $0.00 $0.00 G0379 Q3 0633 5.2168 $565.61 $691.38 $424.23 G0380 V 0626 0.8456 $91.68 $112.07 $68.76 G0381 V 0627 0.9372 $101.61 $124.21 $76.21 G0382 V 0628 1.5231 $165.13 $201.86 $123.86 G0383 V 0629 2.6827 $290.86 $355.54 $218.16 G0384 Q3 0630 4.1037 $444.92 $543.86 $333.71 G0389 S 0265 1.2362 $134.03 $163.83 $100.53 G0390 S 0618 11.9898 $1,299.93 $1,589.01 $975.01 G0396 S 0432 0.6773 $73.43 $89.76 $55.08 G0397 S 0322 1.2065 $130.81 $159.90 $98.11 G0398 S 0213 2.3813 $258.18 $315.59 $193.65 G0399 S 0213 2.3813 $258.18 $315.59 $193.65 G0400 S 0213 2.3813 $258.18 $315.59 $193.65 G0402 V 0632 1.4327 $155.33 $189.88 $116.51 G0403 M $0.00 $0.00 $0.00G0404 S 0450 0.3942 $42.74 $52.24 $32.06 G0405 B $0.00 $0.00 $0.00G0406 B $0.00 $0.00 $0.00G0407 B $0.00 $0.00 $0.00G0408 B $0.00 $0.00 $0.00G0409 B $0.00 $0.00 $0.00G0410 P $0.00 $0.00 $0.00G0411 P $0.00 $0.00 $0.00G0412 C $0.00 $0.00 $0.00G0413 T 0050 35.0819 $3,803.58 $4,649.40 $2,852.86 G0414 C $0.00 $0.00 $0.00G0415 C $0.00 $0.00 $0.00G0416 S 0661 3.9671 $430.11 $525.76 $322.60 G0420 A $0.00 $0.00 $0.00G0421 A $0.00 $0.00 $0.00G0422 S 0095 1.3927 $151.00 $184.57 $113.25 G0423 S 0095 1.3927 $151.00 $184.57 $113.25 G0424 Q1 0340 0.7061 $76.56 $93.58 $57.42 G0425 B $0.00 $0.00 $0.00G0426 B $0.00 $0.00 $0.00G0427 B $0.00 $0.00 $0.00


242


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeG0428 E $0.00 $0.00 $0.00G0429 B $0.00 $0.00 $0.00G0431 N $0.00 $0.00 $0.00 G0432 N $0.00 $0.00 $0.00 G0433 N $0.00 $0.00 $0.00 G0434 N $0.00 $0.00 $0.00 G0435 N $0.00 $0.00 $0.00 G0436 S 0031 0.3508 $38.03 $46.49 $28.53 G0437 S 0432 0.6773 $73.43 $89.76 $55.08 G0438 A $0.00 $0.00 $0.00G0439 A $0.00 $0.00 $0.00G0442 S 0432 0.6773 $73.43 $89.76 $55.08 G0443 S 0432 0.6773 $73.43 $89.76 $55.08 G0444 S 0031 0.3508 $38.03 $46.49 $28.53 G0445 S 0031 0.3508 $38.03 $46.49 $28.53 G0446 S 0031 0.3508 $38.03 $46.49 $28.53 G0447 S 0432 0.6773 $73.43 $89.76 $55.08 G0448 B $0.00 $0.00 $0.00G0451 Q3 0432 0.6773 $73.43 $89.76 $55.08 G0452 B $0.00 $0.00 $0.00G0453 N $0.00 $0.00 $0.00 G0454 B $0.00 $0.00 $0.00G0455 Q1 0420 1.7762 $192.58 $235.40 $144.44 G0458 B $0.00 $0.00 $0.00G0459 B $0.00 $0.00 $0.00G0460 T 0327 5.7989 $628.72 $768.53 $471.57 G0461 N $0.00 $0.00 $0.00 G0462 N $0.00 $0.00 $0.00 G0463 Q3 0634 1.2977 $140.70 $171.98 $105.53 G0464 N $0.00 $0.00 $0.00 G0466 A $0.00 $0.00 $0.00G0467 A $0.00 $0.00 $0.00G0468 A $0.00 $0.00 $0.00G0469 A $0.00 $0.00 $0.00G0470 A $0.00 $0.00 $0.00G0471 A $0.00 $0.00 $0.00G0472 N $0.00 $0.00 $0.00 G0473 S 0432 0.6773 $73.43 $89.76 $55.08 G0913 M $0.00 $0.00 $0.00G0914 M $0.00 $0.00 $0.00G0915 M $0.00 $0.00 $0.00G0916 M $0.00 $0.00 $0.00G0917 M $0.00 $0.00 $0.00G0918 M $0.00 $0.00 $0.00G3001 S 0442 15.5257 $1,683.30 $2,057.62 $1,262.55 G6001 B $0.00 $0.00 $0.00G6002 B $0.00 $0.00 $0.00G6003 B $0.00 $0.00 $0.00G6004 B $0.00 $0.00 $0.00G6005 B $0.00 $0.00 $0.00G6006 B $0.00 $0.00 $0.00


243


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeG6007 B $0.00 $0.00 $0.00G6008 B $0.00 $0.00 $0.00G6009 B $0.00 $0.00 $0.00G6010 B $0.00 $0.00 $0.00G6011 B $0.00 $0.00 $0.00G6012 B $0.00 $0.00 $0.00G6013 B $0.00 $0.00 $0.00G6014 B $0.00 $0.00 $0.00G6015 B $0.00 $0.00 $0.00G6016 B $0.00 $0.00 $0.00G6017 B $0.00 $0.00 $0.00G6018 B $0.00 $0.00 $0.00G6019 B $0.00 $0.00 $0.00G6020 B $0.00 $0.00 $0.00G6021 B $0.00 $0.00 $0.00G6022 B $0.00 $0.00 $0.00G6023 B $0.00 $0.00 $0.00G6024 B $0.00 $0.00 $0.00G6025 B $0.00 $0.00 $0.00G6027 B $0.00 $0.00 $0.00G6028 B $0.00 $0.00 $0.00G6030 N $0.00 $0.00 $0.00 G6031 N $0.00 $0.00 $0.00 G6032 N $0.00 $0.00 $0.00 G6034 N $0.00 $0.00 $0.00 G6035 N $0.00 $0.00 $0.00 G6036 N $0.00 $0.00 $0.00 G6037 N $0.00 $0.00 $0.00 G6038 N $0.00 $0.00 $0.00 G6039 N $0.00 $0.00 $0.00 G6040 N $0.00 $0.00 $0.00 G6041 N $0.00 $0.00 $0.00 G6042 N $0.00 $0.00 $0.00 G6043 N $0.00 $0.00 $0.00 G6044 N $0.00 $0.00 $0.00 G6045 N $0.00 $0.00 $0.00 G6046 N $0.00 $0.00 $0.00 G6047 N $0.00 $0.00 $0.00 G6048 N $0.00 $0.00 $0.00 G6049 N $0.00 $0.00 $0.00 G6050 N $0.00 $0.00 $0.00 G6051 N $0.00 $0.00 $0.00 G6052 N $0.00 $0.00 $0.00 G6053 N $0.00 $0.00 $0.00 G6054 N $0.00 $0.00 $0.00 G6055 N $0.00 $0.00 $0.00 G6056 N $0.00 $0.00 $0.00 G6057 N $0.00 $0.00 $0.00 G6058 N $0.00 $0.00 $0.00 G8395 M $0.00 $0.00 $0.00G8396 M $0.00 $0.00 $0.00


244


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeG8397 M $0.00 $0.00 $0.00G8398 M $0.00 $0.00 $0.00G8399 M $0.00 $0.00 $0.00G8400 M $0.00 $0.00 $0.00G8401 M $0.00 $0.00 $0.00G8404 M $0.00 $0.00 $0.00G8405 M $0.00 $0.00 $0.00G8410 M $0.00 $0.00 $0.00G8415 M $0.00 $0.00 $0.00G8416 M $0.00 $0.00 $0.00G8417 M $0.00 $0.00 $0.00G8418 M $0.00 $0.00 $0.00G8419 M $0.00 $0.00 $0.00G8420 M $0.00 $0.00 $0.00G8421 M $0.00 $0.00 $0.00G8422 M $0.00 $0.00 $0.00G8427 M $0.00 $0.00 $0.00G8428 M $0.00 $0.00 $0.00G8430 M $0.00 $0.00 $0.00G8431 M $0.00 $0.00 $0.00G8432 M $0.00 $0.00 $0.00G8433 M $0.00 $0.00 $0.00G8442 M $0.00 $0.00 $0.00G8450 M $0.00 $0.00 $0.00G8451 M $0.00 $0.00 $0.00G8452 M $0.00 $0.00 $0.00G8458 M $0.00 $0.00 $0.00G8460 M $0.00 $0.00 $0.00G8461 M $0.00 $0.00 $0.00G8465 M $0.00 $0.00 $0.00G8473 M $0.00 $0.00 $0.00G8474 M $0.00 $0.00 $0.00G8475 M $0.00 $0.00 $0.00G8476 M $0.00 $0.00 $0.00G8477 M $0.00 $0.00 $0.00G8478 M $0.00 $0.00 $0.00G8482 M $0.00 $0.00 $0.00G8483 M $0.00 $0.00 $0.00G8484 M $0.00 $0.00 $0.00G8485 M $0.00 $0.00 $0.00G8486 M $0.00 $0.00 $0.00G8487 M $0.00 $0.00 $0.00G8489 M $0.00 $0.00 $0.00G8490 M $0.00 $0.00 $0.00G8491 M $0.00 $0.00 $0.00G8494 M $0.00 $0.00 $0.00G8495 M $0.00 $0.00 $0.00G8496 M $0.00 $0.00 $0.00G8497 M $0.00 $0.00 $0.00G8498 M $0.00 $0.00 $0.00G8499 M $0.00 $0.00 $0.00


245




246




247




248




249


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeG8927 M $0.00 $0.00 $0.00G8928 M $0.00 $0.00 $0.00G8929 M $0.00 $0.00 $0.00G8934 M $0.00 $0.00 $0.00G8935 M $0.00 $0.00 $0.00G8936 M $0.00 $0.00 $0.00G8937 M $0.00 $0.00 $0.00G8938 M $0.00 $0.00 $0.00G8939 M $0.00 $0.00 $0.00G8940 M $0.00 $0.00 $0.00G8941 M $0.00 $0.00 $0.00G8942 M $0.00 $0.00 $0.00G8944 M $0.00 $0.00 $0.00G8946 M $0.00 $0.00 $0.00G8947 M $0.00 $0.00 $0.00G8948 M $0.00 $0.00 $0.00G8950 M $0.00 $0.00 $0.00G8951 M $0.00 $0.00 $0.00G8952 M $0.00 $0.00 $0.00G8953 M $0.00 $0.00 $0.00G8955 M $0.00 $0.00 $0.00G8956 M $0.00 $0.00 $0.00G8958 M $0.00 $0.00 $0.00G8959 M $0.00 $0.00 $0.00G8960 M $0.00 $0.00 $0.00G8961 M $0.00 $0.00 $0.00G8962 M $0.00 $0.00 $0.00G8963 M $0.00 $0.00 $0.00G8964 M $0.00 $0.00 $0.00G8965 M $0.00 $0.00 $0.00G8966 M $0.00 $0.00 $0.00G8967 M $0.00 $0.00 $0.00G8968 M $0.00 $0.00 $0.00G8969 M $0.00 $0.00 $0.00G8970 M $0.00 $0.00 $0.00G8971 M $0.00 $0.00 $0.00G8972 M $0.00 $0.00 $0.00G8973 M $0.00 $0.00 $0.00G8974 M $0.00 $0.00 $0.00G8975 M $0.00 $0.00 $0.00G8976 M $0.00 $0.00 $0.00G8977 M $0.00 $0.00 $0.00G8978 E $0.00 $0.00 $0.00G8979 E $0.00 $0.00 $0.00G8980 E $0.00 $0.00 $0.00G8981 E $0.00 $0.00 $0.00G8982 E $0.00 $0.00 $0.00G8983 E $0.00 $0.00 $0.00G8984 E $0.00 $0.00 $0.00G8985 E $0.00 $0.00 $0.00G8986 E $0.00 $0.00 $0.00


250


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeG8987 E $0.00 $0.00 $0.00G8988 E $0.00 $0.00 $0.00G8989 E $0.00 $0.00 $0.00G8990 E $0.00 $0.00 $0.00G8991 E $0.00 $0.00 $0.00G8992 E $0.00 $0.00 $0.00G8993 E $0.00 $0.00 $0.00G8994 E $0.00 $0.00 $0.00G8995 E $0.00 $0.00 $0.00G8996 E $0.00 $0.00 $0.00G8997 E $0.00 $0.00 $0.00G8998 E $0.00 $0.00 $0.00G8999 E $0.00 $0.00 $0.00G9001 B $0.00 $0.00 $0.00G9002 B $0.00 $0.00 $0.00G9003 B $0.00 $0.00 $0.00G9004 B $0.00 $0.00 $0.00G9005 B $0.00 $0.00 $0.00G9006 B $0.00 $0.00 $0.00G9007 B $0.00 $0.00 $0.00G9008 B $0.00 $0.00 $0.00G9009 B $0.00 $0.00 $0.00G9010 B $0.00 $0.00 $0.00G9011 B $0.00 $0.00 $0.00G9012 B $0.00 $0.00 $0.00G9013 E $0.00 $0.00 $0.00G9014 E $0.00 $0.00 $0.00G9016 E $0.00 $0.00 $0.00G9017 A $0.00 $0.00 $0.00G9018 A $0.00 $0.00 $0.00G9019 A $0.00 $0.00 $0.00G9020 A $0.00 $0.00 $0.00G9033 A $0.00 $0.00 $0.00G9034 A $0.00 $0.00 $0.00G9035 A $0.00 $0.00 $0.00G9036 A $0.00 $0.00 $0.00G9050 E $0.00 $0.00 $0.00G9051 E $0.00 $0.00 $0.00G9052 E $0.00 $0.00 $0.00G9053 E $0.00 $0.00 $0.00G9054 E $0.00 $0.00 $0.00G9055 E $0.00 $0.00 $0.00G9056 E $0.00 $0.00 $0.00G9057 E $0.00 $0.00 $0.00G9058 E $0.00 $0.00 $0.00G9059 E $0.00 $0.00 $0.00G9060 E $0.00 $0.00 $0.00G9061 E $0.00 $0.00 $0.00G9062 E $0.00 $0.00 $0.00G9063 M $0.00 $0.00 $0.00G9064 M $0.00 $0.00 $0.00


251




252


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeG9124 M $0.00 $0.00 $0.00G9125 M $0.00 $0.00 $0.00G9126 M $0.00 $0.00 $0.00G9128 M $0.00 $0.00 $0.00G9129 M $0.00 $0.00 $0.00G9130 M $0.00 $0.00 $0.00G9131 M $0.00 $0.00 $0.00G9132 M $0.00 $0.00 $0.00G9133 M $0.00 $0.00 $0.00G9134 M $0.00 $0.00 $0.00G9135 M $0.00 $0.00 $0.00G9136 M $0.00 $0.00 $0.00G9137 M $0.00 $0.00 $0.00G9138 M $0.00 $0.00 $0.00G9139 M $0.00 $0.00 $0.00G9140 A $0.00 $0.00 $0.00G9143 N $0.00 $0.00 $0.00 G9147 E $0.00 $0.00 $0.00G9148 M $0.00 $0.00 $0.00G9149 M $0.00 $0.00 $0.00G9150 M $0.00 $0.00 $0.00G9151 M $0.00 $0.00 $0.00G9152 M $0.00 $0.00 $0.00G9153 M $0.00 $0.00 $0.00G9156 M $0.00 $0.00 $0.00G9157 B $0.00 $0.00 $0.00G9158 E $0.00 $0.00 $0.00G9159 E $0.00 $0.00 $0.00G9160 E $0.00 $0.00 $0.00G9161 E $0.00 $0.00 $0.00G9162 E $0.00 $0.00 $0.00G9163 E $0.00 $0.00 $0.00G9164 E $0.00 $0.00 $0.00G9165 E $0.00 $0.00 $0.00G9166 E $0.00 $0.00 $0.00G9167 E $0.00 $0.00 $0.00G9168 E $0.00 $0.00 $0.00G9169 E $0.00 $0.00 $0.00G9170 E $0.00 $0.00 $0.00G9171 E $0.00 $0.00 $0.00G9172 E $0.00 $0.00 $0.00G9173 E $0.00 $0.00 $0.00G9174 E $0.00 $0.00 $0.00G9175 E $0.00 $0.00 $0.00G9176 E $0.00 $0.00 $0.00G9186 E $0.00 $0.00 $0.00G9187 E $0.00 $0.00 $0.00G9188 M $0.00 $0.00 $0.00G9189 M $0.00 $0.00 $0.00G9190 M $0.00 $0.00 $0.00G9191 M $0.00 $0.00 $0.00


253




254




255




256




257


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeG9435 M $0.00 $0.00 $0.00G9436 M $0.00 $0.00 $0.00G9437 M $0.00 $0.00 $0.00G9438 M $0.00 $0.00 $0.00G9439 M $0.00 $0.00 $0.00G9440 M $0.00 $0.00 $0.00G9441 M $0.00 $0.00 $0.00G9442 M $0.00 $0.00 $0.00G9443 M $0.00 $0.00 $0.00G9448 M $0.00 $0.00 $0.00G9449 M $0.00 $0.00 $0.00G9450 M $0.00 $0.00 $0.00G9451 M $0.00 $0.00 $0.00G9452 M $0.00 $0.00 $0.00G9453 M $0.00 $0.00 $0.00G9454 M $0.00 $0.00 $0.00G9455 M $0.00 $0.00 $0.00G9456 M $0.00 $0.00 $0.00G9457 M $0.00 $0.00 $0.00G9458 M $0.00 $0.00 $0.00G9459 M $0.00 $0.00 $0.00G9460 M $0.00 $0.00 $0.00G9463 M $0.00 $0.00 $0.00G9464 M $0.00 $0.00 $0.00G9465 M $0.00 $0.00 $0.00G9466 M $0.00 $0.00 $0.00G9467 M $0.00 $0.00 $0.00G9468 M $0.00 $0.00 $0.00G9469 M $0.00 $0.00 $0.00G9470 M $0.00 $0.00 $0.00G9471 M $0.00 $0.00 $0.00G9472 M $0.00 $0.00 $0.00J0120 K 1666 $0.00 $0.00 $0.00J0129 K 9230 $0.00 $0.00 $0.00J0130 K 1605 $0.00 $0.00 $0.00J0131 N $0.00 $0.00 $0.00 J0132 K 1272 $0.00 $0.00 $0.00J0133 N $0.00 $0.00 $0.00 J0135 K 1083 $0.00 $0.00 $0.00J0153 N $0.00 $0.00 $0.00 J0171 N $0.00 $0.00 $0.00 J0178 K 1420 $0.00 $0.00 $0.00J0180 K 9208 $0.00 $0.00 $0.00J0190 E $0.00 $0.00 $0.00J0200 K 1667 $0.00 $0.00 $0.00J0205 E $0.00 $0.00 $0.00J0207 K 7000 $0.00 $0.00 $0.00J0210 N $0.00 $0.00 $0.00 J0215 K 1633 $0.00 $0.00 $0.00J0220 K 9234 $0.00 $0.00 $0.00J0221 K 1413 $0.00 $0.00 $0.00


258


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeJ0256 K 0901 $0.00 $0.00 $0.00J0257 K 1415 $0.00 $0.00 $0.00J0270 B $0.00 $0.00 $0.00J0275 B $0.00 $0.00 $0.00J0278 N $0.00 $0.00 $0.00 J0280 N $0.00 $0.00 $0.00 J0282 N $0.00 $0.00 $0.00 J0285 N $0.00 $0.00 $0.00 J0287 K 9024 $0.00 $0.00 $0.00J0288 N $0.00 $0.00 $0.00 J0289 K 0736 $0.00 $0.00 $0.00J0290 N $0.00 $0.00 $0.00 J0295 N $0.00 $0.00 $0.00 J0300 K 1341 $0.00 $0.00 $0.00J0330 N $0.00 $0.00 $0.00 J0348 N $0.00 $0.00 $0.00 J0350 E $0.00 $0.00 $0.00J0360 N $0.00 $0.00 $0.00 J0364 E $0.00 $0.00 $0.00J0365 K 1439 $0.00 $0.00 $0.00J0380 N $0.00 $0.00 $0.00 J0390 N $0.00 $0.00 $0.00 J0395 E $0.00 $0.00 $0.00J0400 N $0.00 $0.00 $0.00 J0401 K 1468 $0.00 $0.00 $0.00J0456 N $0.00 $0.00 $0.00 J0461 N $0.00 $0.00 $0.00 J0470 N $0.00 $0.00 $0.00 J0475 K 9032 $0.00 $0.00 $0.00J0476 K 1631 $0.00 $0.00 $0.00J0480 K 1683 $0.00 $0.00 $0.00J0485 K 9286 $0.00 $0.00 $0.00J0490 K 1353 $0.00 $0.00 $0.00J0500 N $0.00 $0.00 $0.00 J0515 N $0.00 $0.00 $0.00 J0520 N $0.00 $0.00 $0.00 J0558 N $0.00 $0.00 $0.00 J0561 N $0.00 $0.00 $0.00 J0571 E $0.00 $0.00 $0.00J0572 E $0.00 $0.00 $0.00J0573 E $0.00 $0.00 $0.00J0574 E $0.00 $0.00 $0.00J0575 E $0.00 $0.00 $0.00J0583 K 3041 $0.00 $0.00 $0.00J0585 K 0902 $0.00 $0.00 $0.00J0586 K 1289 $0.00 $0.00 $0.00J0587 K 9018 $0.00 $0.00 $0.00J0588 K 9278 $0.00 $0.00 $0.00J0592 N $0.00 $0.00 $0.00 J0594 K 1178 $0.00 $0.00 $0.00J0595 N $0.00 $0.00 $0.00


259


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeJ0597 K 9269 $0.00 $0.00 $0.00J0598 K 9251 $0.00 $0.00 $0.00J0600 K 1274 $0.00 $0.00 $0.00J0610 N $0.00 $0.00 $0.00 J0620 N $0.00 $0.00 $0.00 J0630 K 1433 $0.00 $0.00 $0.00J0636 N $0.00 $0.00 $0.00 J0637 K 9019 $0.00 $0.00 $0.00J0638 K 1311 $0.00 $0.00 $0.00J0640 N $0.00 $0.00 $0.00 J0641 K 1236 $0.00 $0.00 $0.00J0670 N $0.00 $0.00 $0.00 J0690 N $0.00 $0.00 $0.00 J0692 N $0.00 $0.00 $0.00 J0694 N $0.00 $0.00 $0.00 J0696 N $0.00 $0.00 $0.00 J0697 N $0.00 $0.00 $0.00 J0698 N $0.00 $0.00 $0.00 J0702 N $0.00 $0.00 $0.00 J0706 N $0.00 $0.00 $0.00 J0710 E $0.00 $0.00 $0.00J0712 N $0.00 $0.00 $0.00 J0713 N $0.00 $0.00 $0.00 J0715 N $0.00 $0.00 $0.00 J0716 K 1431 $0.00 $0.00 $0.00J0717 K 1474 $0.00 $0.00 $0.00J0720 N $0.00 $0.00 $0.00 J0725 K 1668 $0.00 $0.00 $0.00J0735 N $0.00 $0.00 $0.00 J0740 K 9033 $0.00 $0.00 $0.00J0743 N $0.00 $0.00 $0.00 J0744 N $0.00 $0.00 $0.00 J0745 N $0.00 $0.00 $0.00 J0760 N $0.00 $0.00 $0.00 J0770 N $0.00 $0.00 $0.00 J0775 K 1340 $0.00 $0.00 $0.00J0780 N $0.00 $0.00 $0.00 J0795 K 1684 $0.00 $0.00 $0.00J0800 K 1280 $0.00 $0.00 $0.00J0833 K 0835 $0.00 $0.00 $0.00J0834 N $0.00 $0.00 $0.00 J0840 K 9274 $0.00 $0.00 $0.00J0850 K 0903 $0.00 $0.00 $0.00J0878 K 9124 $0.00 $0.00 $0.00J0881 K 1685 $0.00 $0.00 $0.00J0882 K 1482 $0.00 $0.00 $0.00J0885 K 1686 $0.00 $0.00 $0.00J0886 N $0.00 $0.00 $0.00 J0887 N $0.00 $0.00 $0.00 J0888 N $0.00 $0.00 $0.00 J0890 E $0.00 $0.00 $0.00


260


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeJ0894 K 9231 $0.00 $0.00 $0.00J0895 N $0.00 $0.00 $0.00 J0897 K 9272 $0.00 $0.00 $0.00J0945 N $0.00 $0.00 $0.00 J1000 N $0.00 $0.00 $0.00 J1020 N $0.00 $0.00 $0.00 J1030 N $0.00 $0.00 $0.00 J1040 N $0.00 $0.00 $0.00 J1050 N $0.00 $0.00 $0.00 J1071 N $0.00 $0.00 $0.00 J1094 N $0.00 $0.00 $0.00 J1100 N $0.00 $0.00 $0.00 J1110 N $0.00 $0.00 $0.00 J1120 N $0.00 $0.00 $0.00 J1160 N $0.00 $0.00 $0.00 J1162 K 1687 $0.00 $0.00 $0.00J1165 N $0.00 $0.00 $0.00 J1170 N $0.00 $0.00 $0.00 J1180 E $0.00 $0.00 $0.00J1190 K 0726 $0.00 $0.00 $0.00J1200 N $0.00 $0.00 $0.00 J1205 K 0747 $0.00 $0.00 $0.00J1212 N $0.00 $0.00 $0.00 J1230 N $0.00 $0.00 $0.00 J1240 N $0.00 $0.00 $0.00 J1245 N $0.00 $0.00 $0.00 J1250 N $0.00 $0.00 $0.00 J1260 N $0.00 $0.00 $0.00 J1265 N $0.00 $0.00 $0.00 J1267 N $0.00 $0.00 $0.00 J1270 N $0.00 $0.00 $0.00 J1290 K 9263 $0.00 $0.00 $0.00J1300 K 9236 $0.00 $0.00 $0.00J1320 N $0.00 $0.00 $0.00 J1322 G 1480 $0.00 $0.00 $0.00J1324 K 1361 $0.00 $0.00 $0.00J1325 N $0.00 $0.00 $0.00 J1327 K 1607 $0.00 $0.00 $0.00J1330 N $0.00 $0.00 $0.00 J1335 N $0.00 $0.00 $0.00 J1364 K 1669 $0.00 $0.00 $0.00J1380 N $0.00 $0.00 $0.00 J1410 K 9038 $0.00 $0.00 $0.00J1430 K 1688 $0.00 $0.00 $0.00J1435 E $0.00 $0.00 $0.00J1436 N $0.00 $0.00 $0.00 J1438 K 1608 $0.00 $0.00 $0.00J1439 G 9441 $0.00 $0.00 $0.00J1442 K 1469 $0.00 $0.00 $0.00J1446 G 1477 $0.00 $0.00 $0.00J1450 N $0.00 $0.00 $0.00


261


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeJ1451 K 1689 $0.00 $0.00 $0.00J1452 N $0.00 $0.00 $0.00 J1453 K 9242 $0.00 $0.00 $0.00J1455 N $0.00 $0.00 $0.00 J1457 N $0.00 $0.00 $0.00 J1458 K 9224 $0.00 $0.00 $0.00J1459 K 1214 $0.00 $0.00 $0.00J1460 N $0.00 $0.00 $0.00 J1556 G 9130 $0.00 $0.00 $0.00J1557 K 9270 $0.00 $0.00 $0.00J1559 K 1312 $0.00 $0.00 $0.00J1560 N $0.00 $0.00 $0.00 J1561 K 0948 $0.00 $0.00 $0.00J1562 E $0.00 $0.00 $0.00J1566 K 2731 $0.00 $0.00 $0.00J1568 K 0943 $0.00 $0.00 $0.00J1569 K 0944 $0.00 $0.00 $0.00J1570 N $0.00 $0.00 $0.00 J1571 K 0946 $0.00 $0.00 $0.00J1572 K 0947 $0.00 $0.00 $0.00J1573 K 1138 $0.00 $0.00 $0.00J1580 N $0.00 $0.00 $0.00 J1590 N $0.00 $0.00 $0.00 J1595 K 1015 $0.00 $0.00 $0.00J1599 N $0.00 $0.00 $0.00 J1600 K 1742 $0.00 $0.00 $0.00J1602 K 1475 $0.00 $0.00 $0.00J1610 K 9042 $0.00 $0.00 $0.00J1620 E $0.00 $0.00 $0.00J1626 N $0.00 $0.00 $0.00 J1630 N $0.00 $0.00 $0.00 J1631 N $0.00 $0.00 $0.00 J1640 K 1690 $0.00 $0.00 $0.00J1642 N $0.00 $0.00 $0.00 J1644 N $0.00 $0.00 $0.00 J1645 N $0.00 $0.00 $0.00 J1650 N $0.00 $0.00 $0.00 J1652 N $0.00 $0.00 $0.00 J1655 E $0.00 $0.00 $0.00J1670 K 1670 $0.00 $0.00 $0.00J1675 B $0.00 $0.00 $0.00J1700 N $0.00 $0.00 $0.00 J1710 N $0.00 $0.00 $0.00 J1720 N $0.00 $0.00 $0.00 J1725 K 1354 $0.00 $0.00 $0.00J1730 E $0.00 $0.00 $0.00J1740 K 9229 $0.00 $0.00 $0.00J1741 N $0.00 $0.00 $0.00 J1742 K 9044 $0.00 $0.00 $0.00J1743 K 9232 $0.00 $0.00 $0.00J1744 K 1443 $0.00 $0.00 $0.00


262


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeJ1745 K 7043 $0.00 $0.00 $0.00J1750 K 1237 $0.00 $0.00 $0.00J1756 N $0.00 $0.00 $0.00 J1786 K 1327 $0.00 $0.00 $0.00J1790 N $0.00 $0.00 $0.00 J1800 N $0.00 $0.00 $0.00 J1810 E $0.00 $0.00 $0.00J1815 N $0.00 $0.00 $0.00 J1817 N $0.00 $0.00 $0.00 J1826 E $0.00 $0.00 $0.00J1830 K 0910 $0.00 $0.00 $0.00J1835 E $0.00 $0.00 $0.00J1840 N $0.00 $0.00 $0.00 J1850 N $0.00 $0.00 $0.00 J1885 N $0.00 $0.00 $0.00 J1890 N $0.00 $0.00 $0.00 J1930 K 9237 $0.00 $0.00 $0.00J1931 K 9209 $0.00 $0.00 $0.00J1940 N $0.00 $0.00 $0.00 J1945 K 1693 $0.00 $0.00 $0.00J1950 K 0800 $0.00 $0.00 $0.00J1953 N $0.00 $0.00 $0.00 J1955 B $0.00 $0.00 $0.00J1956 N $0.00 $0.00 $0.00 J1960 N $0.00 $0.00 $0.00 J1980 N $0.00 $0.00 $0.00 J1990 N $0.00 $0.00 $0.00 J2001 N $0.00 $0.00 $0.00 J2010 N $0.00 $0.00 $0.00 J2020 K 9001 $0.00 $0.00 $0.00J2060 N $0.00 $0.00 $0.00 J2150 N $0.00 $0.00 $0.00 J2170 N $0.00 $0.00 $0.00 J2175 N $0.00 $0.00 $0.00 J2180 N $0.00 $0.00 $0.00 J2185 N $0.00 $0.00 $0.00 J2210 N $0.00 $0.00 $0.00 J2212 N $0.00 $0.00 $0.00 J2248 K 9227 $0.00 $0.00 $0.00J2250 N $0.00 $0.00 $0.00 J2260 N $0.00 $0.00 $0.00 J2265 N $0.00 $0.00 $0.00 J2270 N $0.00 $0.00 $0.00 J2274 N $0.00 $0.00 $0.00 J2278 K 1694 $0.00 $0.00 $0.00J2280 N $0.00 $0.00 $0.00 J2300 N $0.00 $0.00 $0.00 J2310 N $0.00 $0.00 $0.00 J2315 K 0759 $0.00 $0.00 $0.00J2320 K 1743 $0.00 $0.00 $0.00J2323 K 9126 $0.00 $0.00 $0.00


263


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeJ2325 K 1695 $0.00 $0.00 $0.00J2353 K 1207 $0.00 $0.00 $0.00J2354 N $0.00 $0.00 $0.00 J2355 K 7011 $0.00 $0.00 $0.00J2357 K 9300 $0.00 $0.00 $0.00J2358 K 1331 $0.00 $0.00 $0.00J2360 N $0.00 $0.00 $0.00 J2370 N $0.00 $0.00 $0.00 J2400 N $0.00 $0.00 $0.00 J2405 N $0.00 $0.00 $0.00 J2410 N $0.00 $0.00 $0.00 J2425 K 1696 $0.00 $0.00 $0.00J2426 K 9255 $0.00 $0.00 $0.00J2430 N $0.00 $0.00 $0.00 J2440 N $0.00 $0.00 $0.00 J2460 E $0.00 $0.00 $0.00J2469 K 9210 $0.00 $0.00 $0.00J2501 N $0.00 $0.00 $0.00 J2503 K 1697 $0.00 $0.00 $0.00J2504 K 1739 $0.00 $0.00 $0.00J2505 K 9119 $0.00 $0.00 $0.00J2507 K 9281 $0.00 $0.00 $0.00J2510 N $0.00 $0.00 $0.00 J2513 E $0.00 $0.00 $0.00J2515 K 1456 $0.00 $0.00 $0.00J2540 N $0.00 $0.00 $0.00 J2543 N $0.00 $0.00 $0.00 J2545 B $0.00 $0.00 $0.00J2550 N $0.00 $0.00 $0.00 J2560 N $0.00 $0.00 $0.00 J2562 K 9252 $0.00 $0.00 $0.00J2590 N $0.00 $0.00 $0.00 J2597 K 1440 $0.00 $0.00 $0.00J2650 N $0.00 $0.00 $0.00 J2670 K 1457 $0.00 $0.00 $0.00J2675 N $0.00 $0.00 $0.00 J2680 N $0.00 $0.00 $0.00 J2690 N $0.00 $0.00 $0.00 J2700 N $0.00 $0.00 $0.00 J2704 N $0.00 $0.00 $0.00 J2710 N $0.00 $0.00 $0.00 J2720 N $0.00 $0.00 $0.00 J2724 K 1139 $0.00 $0.00 $0.00J2725 E $0.00 $0.00 $0.00J2730 K 1023 $0.00 $0.00 $0.00J2760 K 1458 $0.00 $0.00 $0.00J2765 N $0.00 $0.00 $0.00 J2770 K 2770 $0.00 $0.00 $0.00J2778 K 9233 $0.00 $0.00 $0.00J2780 N $0.00 $0.00 $0.00 J2783 K 0738 $0.00 $0.00 $0.00


264


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeJ2785 N $0.00 $0.00 $0.00 J2788 N $0.00 $0.00 $0.00 J2790 N $0.00 $0.00 $0.00 J2791 K 0945 $0.00 $0.00 $0.00J2792 K 1609 $0.00 $0.00 $0.00J2793 K 1291 $0.00 $0.00 $0.00J2794 K 9125 $0.00 $0.00 $0.00J2795 N $0.00 $0.00 $0.00 J2796 K 9245 $0.00 $0.00 $0.00J2800 N $0.00 $0.00 $0.00 J2805 N $0.00 $0.00 $0.00 J2810 N $0.00 $0.00 $0.00 J2820 K 0731 $0.00 $0.00 $0.00J2850 K 1700 $0.00 $0.00 $0.00J2910 N $0.00 $0.00 $0.00 J2916 N $0.00 $0.00 $0.00 J2920 N $0.00 $0.00 $0.00 J2930 N $0.00 $0.00 $0.00 J2940 E $0.00 $0.00 $0.00J2941 K 7034 $0.00 $0.00 $0.00J2950 N $0.00 $0.00 $0.00 J2993 K 9005 $0.00 $0.00 $0.00J2995 N $0.00 $0.00 $0.00 J2997 K 7048 $0.00 $0.00 $0.00J3000 N $0.00 $0.00 $0.00 J3010 N $0.00 $0.00 $0.00 J3030 N $0.00 $0.00 $0.00 J3060 G 9294 $0.00 $0.00 $0.00J3070 K 1484 $0.00 $0.00 $0.00J3095 K 9258 $0.00 $0.00 $0.00J3101 K 9002 $0.00 $0.00 $0.00J3105 N $0.00 $0.00 $0.00 J3110 B $0.00 $0.00 $0.00J3121 N $0.00 $0.00 $0.00 J3145 G 1487 $0.00 $0.00 $0.00J3230 N $0.00 $0.00 $0.00 J3240 K 9108 $0.00 $0.00 $0.00J3243 K 9228 $0.00 $0.00 $0.00J3246 K 7041 $0.00 $0.00 $0.00J3250 N $0.00 $0.00 $0.00 J3260 N $0.00 $0.00 $0.00 J3262 K 9264 $0.00 $0.00 $0.00J3265 N $0.00 $0.00 $0.00 J3280 N $0.00 $0.00 $0.00 J3285 K 1701 $0.00 $0.00 $0.00J3300 K 1253 $0.00 $0.00 $0.00J3301 N $0.00 $0.00 $0.00 J3302 N $0.00 $0.00 $0.00 J3303 N $0.00 $0.00 $0.00 J3305 E $0.00 $0.00 $0.00J3310 N $0.00 $0.00 $0.00


265


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeJ3315 K 9122 $0.00 $0.00 $0.00J3320 N $0.00 $0.00 $0.00 J3350 K 1459 $0.00 $0.00 $0.00J3355 K 1741 $0.00 $0.00 $0.00J3357 K 9261 $0.00 $0.00 $0.00J3360 N $0.00 $0.00 $0.00 J3364 N $0.00 $0.00 $0.00 J3365 E $0.00 $0.00 $0.00J3370 N $0.00 $0.00 $0.00 J3385 K 9271 $0.00 $0.00 $0.00J3396 K 1203 $0.00 $0.00 $0.00J3400 E $0.00 $0.00 $0.00J3410 N $0.00 $0.00 $0.00 J3411 N $0.00 $0.00 $0.00 J3415 N $0.00 $0.00 $0.00 J3420 N $0.00 $0.00 $0.00 J3430 N $0.00 $0.00 $0.00 J3465 K 1052 $0.00 $0.00 $0.00J3470 N $0.00 $0.00 $0.00 J3471 N $0.00 $0.00 $0.00 J3472 N $0.00 $0.00 $0.00 J3473 N $0.00 $0.00 $0.00 J3475 N $0.00 $0.00 $0.00 J3480 N $0.00 $0.00 $0.00 J3485 K 1744 $0.00 $0.00 $0.00J3486 N $0.00 $0.00 $0.00 J3489 K 1356 $0.00 $0.00 $0.00J3490 N $0.00 $0.00 $0.00 J3520 E $0.00 $0.00 $0.00J3530 N $0.00 $0.00 $0.00 J3535 E $0.00 $0.00 $0.00J3570 E $0.00 $0.00 $0.00J3590 N $0.00 $0.00 $0.00 J7030 N $0.00 $0.00 $0.00 J7040 N $0.00 $0.00 $0.00 J7042 N $0.00 $0.00 $0.00 J7050 N $0.00 $0.00 $0.00 J7060 N $0.00 $0.00 $0.00 J7070 N $0.00 $0.00 $0.00 J7100 N $0.00 $0.00 $0.00 J7110 N $0.00 $0.00 $0.00 J7120 N $0.00 $0.00 $0.00 J7131 N $0.00 $0.00 $0.00 J7178 K 1478 $0.00 $0.00 $0.00J7180 N $0.00 $0.00 $0.00 J7181 G 1746 $0.00 $0.00 $0.00J7182 E $0.00 $0.00 $0.00J7183 K 1352 $0.00 $0.00 $0.00J7185 K 1268 $0.00 $0.00 $0.00J7186 K 1213 $0.00 $0.00 $0.00J7187 K 1704 $0.00 $0.00 $0.00


266


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeJ7189 K 1705 $0.00 $0.00 $0.00J7190 K 0925 $0.00 $0.00 $0.00J7191 K 1464 $0.00 $0.00 $0.00J7192 K 0927 $0.00 $0.00 $0.00J7193 K 0931 $0.00 $0.00 $0.00J7194 K 0928 $0.00 $0.00 $0.00J7195 K 0932 $0.00 $0.00 $0.00J7196 K 1332 $0.00 $0.00 $0.00J7197 K 1263 $0.00 $0.00 $0.00J7198 K 0929 $0.00 $0.00 $0.00J7199 B $0.00 $0.00 $0.00J7200 G 1467 $0.00 $0.00 $0.00J7201 G 1486 $0.00 $0.00 $0.00J7300 E $0.00 $0.00 $0.00J7301 E $0.00 $0.00 $0.00J7302 E $0.00 $0.00 $0.00J7303 E $0.00 $0.00 $0.00J7304 E $0.00 $0.00 $0.00J7306 E $0.00 $0.00 $0.00J7307 E $0.00 $0.00 $0.00J7308 K 7308 $0.00 $0.00 $0.00J7309 K 1338 $0.00 $0.00 $0.00J7310 K 0913 $0.00 $0.00 $0.00J7311 K 9225 $0.00 $0.00 $0.00J7312 K 9256 $0.00 $0.00 $0.00J7315 G 1448 $0.00 $0.00 $0.00J7316 G 9298 $0.00 $0.00 $0.00J7321 K 0873 $0.00 $0.00 $0.00J7323 K 0875 $0.00 $0.00 $0.00J7324 K 0877 $0.00 $0.00 $0.00J7325 K 0874 $0.00 $0.00 $0.00J7326 K 1417 $0.00 $0.00 $0.00J7327 K 1747 $0.00 $0.00 $0.00J7330 B $0.00 $0.00 $0.00J7336 K 1665 $0.00 $0.00 $0.00J7500 N $0.00 $0.00 $0.00 J7501 K 0887 $0.00 $0.00 $0.00J7502 N $0.00 $0.00 $0.00 J7504 K 0890 $0.00 $0.00 $0.00J7505 N $0.00 $0.00 $0.00 J7506 N $0.00 $0.00 $0.00 J7507 N $0.00 $0.00 $0.00 J7508 G 1465 $0.00 $0.00 $0.00J7509 N $0.00 $0.00 $0.00 J7510 N $0.00 $0.00 $0.00 J7511 K 9104 $0.00 $0.00 $0.00J7513 K 1612 $0.00 $0.00 $0.00J7515 N $0.00 $0.00 $0.00 J7516 N $0.00 $0.00 $0.00 J7517 N $0.00 $0.00 $0.00 J7518 N $0.00 $0.00 $0.00


267


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeJ7520 N $0.00 $0.00 $0.00 J7525 K 9006 $0.00 $0.00 $0.00J7527 N $0.00 $0.00 $0.00 J7599 N $0.00 $0.00 $0.00 J7604 M $0.00 $0.00 $0.00J7605 M $0.00 $0.00 $0.00J7606 M $0.00 $0.00 $0.00J7607 M $0.00 $0.00 $0.00J7608 M $0.00 $0.00 $0.00J7609 M $0.00 $0.00 $0.00J7610 M $0.00 $0.00 $0.00J7611 M $0.00 $0.00 $0.00J7612 M $0.00 $0.00 $0.00J7613 M $0.00 $0.00 $0.00J7614 M $0.00 $0.00 $0.00J7615 M $0.00 $0.00 $0.00J7620 M $0.00 $0.00 $0.00J7622 M $0.00 $0.00 $0.00J7624 M $0.00 $0.00 $0.00J7626 M $0.00 $0.00 $0.00J7627 M $0.00 $0.00 $0.00J7628 M $0.00 $0.00 $0.00J7629 M $0.00 $0.00 $0.00J7631 M $0.00 $0.00 $0.00J7632 M $0.00 $0.00 $0.00J7633 M $0.00 $0.00 $0.00J7634 M $0.00 $0.00 $0.00J7635 M $0.00 $0.00 $0.00J7636 M $0.00 $0.00 $0.00J7637 M $0.00 $0.00 $0.00J7638 M $0.00 $0.00 $0.00J7639 M $0.00 $0.00 $0.00J7640 E $0.00 $0.00 $0.00J7641 M $0.00 $0.00 $0.00J7642 M $0.00 $0.00 $0.00J7643 M $0.00 $0.00 $0.00J7644 M $0.00 $0.00 $0.00J7645 M $0.00 $0.00 $0.00J7647 M $0.00 $0.00 $0.00J7648 M $0.00 $0.00 $0.00J7649 M $0.00 $0.00 $0.00J7650 M $0.00 $0.00 $0.00J7657 M $0.00 $0.00 $0.00J7658 M $0.00 $0.00 $0.00J7659 M $0.00 $0.00 $0.00J7660 M $0.00 $0.00 $0.00J7665 N $0.00 $0.00 $0.00 J7667 M $0.00 $0.00 $0.00J7668 M $0.00 $0.00 $0.00J7669 M $0.00 $0.00 $0.00J7670 M $0.00 $0.00 $0.00


268


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeJ7674 N $0.00 $0.00 $0.00 J7676 M $0.00 $0.00 $0.00J7680 M $0.00 $0.00 $0.00J7681 M $0.00 $0.00 $0.00J7682 M $0.00 $0.00 $0.00J7683 M $0.00 $0.00 $0.00J7684 M $0.00 $0.00 $0.00J7685 M $0.00 $0.00 $0.00J7686 M $0.00 $0.00 $0.00J7699 M $0.00 $0.00 $0.00J7799 N $0.00 $0.00 $0.00 J8498 B $0.00 $0.00 $0.00J8499 E $0.00 $0.00 $0.00J8501 K 0868 $0.00 $0.00 $0.00J8510 N $0.00 $0.00 $0.00 J8515 E $0.00 $0.00 $0.00J8520 K 7042 $0.00 $0.00 $0.00J8521 K 0934 $0.00 $0.00 $0.00J8530 N $0.00 $0.00 $0.00 J8540 N $0.00 $0.00 $0.00 J8560 K 0802 $0.00 $0.00 $0.00J8562 E $0.00 $0.00 $0.00J8565 E $0.00 $0.00 $0.00J8597 N $0.00 $0.00 $0.00 J8600 N $0.00 $0.00 $0.00 J8610 N $0.00 $0.00 $0.00 J8650 K 1424 $0.00 $0.00 $0.00J8700 K 1086 $0.00 $0.00 $0.00J8705 K 1238 $0.00 $0.00 $0.00J8999 B $0.00 $0.00 $0.00J9000 N $0.00 $0.00 $0.00 J9010 E $0.00 $0.00 $0.00J9015 K 0807 $0.00 $0.00 $0.00J9017 K 9012 $0.00 $0.00 $0.00J9019 K 9289 $0.00 $0.00 $0.00J9020 K 0814 $0.00 $0.00 $0.00J9025 K 1709 $0.00 $0.00 $0.00J9027 K 1710 $0.00 $0.00 $0.00J9031 K 0809 $0.00 $0.00 $0.00J9033 K 9243 $0.00 $0.00 $0.00J9035 K 9214 $0.00 $0.00 $0.00J9040 N $0.00 $0.00 $0.00 J9041 K 9207 $0.00 $0.00 $0.00J9042 K 9287 $0.00 $0.00 $0.00J9043 K 9276 $0.00 $0.00 $0.00J9045 N $0.00 $0.00 $0.00 J9047 G 9295 $0.00 $0.00 $0.00J9050 K 0812 $0.00 $0.00 $0.00J9055 K 9215 $0.00 $0.00 $0.00J9060 N $0.00 $0.00 $0.00 J9065 K 0858 $0.00 $0.00 $0.00


269


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeJ9070 K 1408 $0.00 $0.00 $0.00J9098 K 1166 $0.00 $0.00 $0.00J9100 N $0.00 $0.00 $0.00 J9120 K 0752 $0.00 $0.00 $0.00J9130 N $0.00 $0.00 $0.00 J9150 K 0820 $0.00 $0.00 $0.00J9151 K 0821 $0.00 $0.00 $0.00J9155 K 1296 $0.00 $0.00 $0.00J9160 E $0.00 $0.00 $0.00J9165 E $0.00 $0.00 $0.00J9171 K 0823 $0.00 $0.00 $0.00J9175 N $0.00 $0.00 $0.00 J9178 N $0.00 $0.00 $0.00 J9179 K 1426 $0.00 $0.00 $0.00J9181 N $0.00 $0.00 $0.00 J9185 K 0842 $0.00 $0.00 $0.00J9190 N $0.00 $0.00 $0.00 J9200 K 0827 $0.00 $0.00 $0.00J9201 N $0.00 $0.00 $0.00 J9202 K 0810 $0.00 $0.00 $0.00J9206 N $0.00 $0.00 $0.00 J9207 K 9240 $0.00 $0.00 $0.00J9208 K 0831 $0.00 $0.00 $0.00J9209 N $0.00 $0.00 $0.00 J9211 K 0832 $0.00 $0.00 $0.00J9212 E $0.00 $0.00 $0.00J9213 K 1460 $0.00 $0.00 $0.00J9214 K 0836 $0.00 $0.00 $0.00J9215 N $0.00 $0.00 $0.00 J9216 K 0838 $0.00 $0.00 $0.00J9217 K 9217 $0.00 $0.00 $0.00J9218 N $0.00 $0.00 $0.00 J9219 E $0.00 $0.00 $0.00J9225 K 1711 $0.00 $0.00 $0.00J9226 K 1142 $0.00 $0.00 $0.00J9228 K 9284 $0.00 $0.00 $0.00J9230 K 0751 $0.00 $0.00 $0.00J9245 K 0840 $0.00 $0.00 $0.00J9250 N $0.00 $0.00 $0.00 J9260 N $0.00 $0.00 $0.00 J9261 K 0825 $0.00 $0.00 $0.00J9262 G 9297 $0.00 $0.00 $0.00J9263 K 1738 $0.00 $0.00 $0.00J9264 K 1712 $0.00 $0.00 $0.00J9266 K 0843 $0.00 $0.00 $0.00J9267 N $0.00 $0.00 $0.00 J9268 K 0844 $0.00 $0.00 $0.00J9270 N $0.00 $0.00 $0.00 J9280 K 1232 $0.00 $0.00 $0.00J9293 K 0864 $0.00 $0.00 $0.00J9300 E $0.00 $0.00 $0.00


270


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeJ9301 G 1476 $0.00 $0.00 $0.00J9302 K 9260 $0.00 $0.00 $0.00J9303 K 9235 $0.00 $0.00 $0.00J9305 K 9213 $0.00 $0.00 $0.00J9306 K 1471 $0.00 $0.00 $0.00J9307 K 9259 $0.00 $0.00 $0.00J9310 K 0849 $0.00 $0.00 $0.00J9315 K 9265 $0.00 $0.00 $0.00J9320 K 0850 $0.00 $0.00 $0.00J9328 K 9253 $0.00 $0.00 $0.00J9330 K 1168 $0.00 $0.00 $0.00J9340 K 0851 $0.00 $0.00 $0.00J9351 K 1350 $0.00 $0.00 $0.00J9354 G 9131 $0.00 $0.00 $0.00J9355 K 1613 $0.00 $0.00 $0.00J9357 K 1235 $0.00 $0.00 $0.00J9360 N $0.00 $0.00 $0.00 J9370 N $0.00 $0.00 $0.00 J9371 G 1466 $0.00 $0.00 $0.00J9390 N $0.00 $0.00 $0.00 J9395 K 9120 $0.00 $0.00 $0.00J9400 G 9296 $0.00 $0.00 $0.00J9600 K 0856 $0.00 $0.00 $0.00J9999 N $0.00 $0.00 $0.00 K0001 Y $0.00 $0.00 $0.00K0002 Y $0.00 $0.00 $0.00K0003 Y $0.00 $0.00 $0.00K0004 Y $0.00 $0.00 $0.00K0005 Y $0.00 $0.00 $0.00K0006 Y $0.00 $0.00 $0.00K0007 Y $0.00 $0.00 $0.00K0008 Y $0.00 $0.00 $0.00K0009 Y $0.00 $0.00 $0.00K0010 Y $0.00 $0.00 $0.00K0011 Y $0.00 $0.00 $0.00K0012 Y $0.00 $0.00 $0.00K0013 Y $0.00 $0.00 $0.00K0014 Y $0.00 $0.00 $0.00K0015 Y $0.00 $0.00 $0.00K0017 Y $0.00 $0.00 $0.00K0018 Y $0.00 $0.00 $0.00K0019 Y $0.00 $0.00 $0.00K0020 Y $0.00 $0.00 $0.00K0037 Y $0.00 $0.00 $0.00K0038 Y $0.00 $0.00 $0.00K0039 Y $0.00 $0.00 $0.00K0040 Y $0.00 $0.00 $0.00K0041 Y $0.00 $0.00 $0.00K0042 Y $0.00 $0.00 $0.00K0043 Y $0.00 $0.00 $0.00K0044 Y $0.00 $0.00 $0.00


271


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeK0045 Y $0.00 $0.00 $0.00K0046 Y $0.00 $0.00 $0.00K0047 Y $0.00 $0.00 $0.00K0050 Y $0.00 $0.00 $0.00K0051 Y $0.00 $0.00 $0.00K0052 Y $0.00 $0.00 $0.00K0053 Y $0.00 $0.00 $0.00K0056 Y $0.00 $0.00 $0.00K0065 Y $0.00 $0.00 $0.00K0069 Y $0.00 $0.00 $0.00K0070 Y $0.00 $0.00 $0.00K0071 Y $0.00 $0.00 $0.00K0072 Y $0.00 $0.00 $0.00K0073 Y $0.00 $0.00 $0.00K0077 Y $0.00 $0.00 $0.00K0098 Y $0.00 $0.00 $0.00K0105 Y $0.00 $0.00 $0.00K0108 Y $0.00 $0.00 $0.00K0195 Y $0.00 $0.00 $0.00K0455 Y $0.00 $0.00 $0.00K0462 Y $0.00 $0.00 $0.00K0552 Y $0.00 $0.00 $0.00K0601 Y $0.00 $0.00 $0.00K0602 Y $0.00 $0.00 $0.00K0603 Y $0.00 $0.00 $0.00K0604 Y $0.00 $0.00 $0.00K0605 Y $0.00 $0.00 $0.00K0606 Y $0.00 $0.00 $0.00K0607 Y $0.00 $0.00 $0.00K0608 Y $0.00 $0.00 $0.00K0609 Y $0.00 $0.00 $0.00K0669 Y $0.00 $0.00 $0.00K0672 A $0.00 $0.00 $0.00K0730 Y $0.00 $0.00 $0.00K0733 Y $0.00 $0.00 $0.00K0738 Y $0.00 $0.00 $0.00K0739 Y $0.00 $0.00 $0.00K0740 E $0.00 $0.00 $0.00K0743 Y $0.00 $0.00 $0.00K0744 A $0.00 $0.00 $0.00K0745 A $0.00 $0.00 $0.00K0746 A $0.00 $0.00 $0.00K0800 Y $0.00 $0.00 $0.00K0801 Y $0.00 $0.00 $0.00K0802 Y $0.00 $0.00 $0.00K0806 Y $0.00 $0.00 $0.00K0807 Y $0.00 $0.00 $0.00K0808 Y $0.00 $0.00 $0.00K0812 Y $0.00 $0.00 $0.00K0813 Y $0.00 $0.00 $0.00K0814 Y $0.00 $0.00 $0.00


272


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeK0815 Y $0.00 $0.00 $0.00K0816 Y $0.00 $0.00 $0.00K0820 Y $0.00 $0.00 $0.00K0821 Y $0.00 $0.00 $0.00K0822 Y $0.00 $0.00 $0.00K0823 Y $0.00 $0.00 $0.00K0824 Y $0.00 $0.00 $0.00K0825 Y $0.00 $0.00 $0.00K0826 Y $0.00 $0.00 $0.00K0827 Y $0.00 $0.00 $0.00K0828 Y $0.00 $0.00 $0.00K0829 Y $0.00 $0.00 $0.00K0830 Y $0.00 $0.00 $0.00K0831 Y $0.00 $0.00 $0.00K0835 Y $0.00 $0.00 $0.00K0836 Y $0.00 $0.00 $0.00K0837 Y $0.00 $0.00 $0.00K0838 Y $0.00 $0.00 $0.00K0839 Y $0.00 $0.00 $0.00K0840 Y $0.00 $0.00 $0.00K0841 Y $0.00 $0.00 $0.00K0842 Y $0.00 $0.00 $0.00K0843 Y $0.00 $0.00 $0.00K0848 Y $0.00 $0.00 $0.00K0849 Y $0.00 $0.00 $0.00K0850 Y $0.00 $0.00 $0.00K0851 Y $0.00 $0.00 $0.00K0852 Y $0.00 $0.00 $0.00K0853 Y $0.00 $0.00 $0.00K0854 Y $0.00 $0.00 $0.00K0855 Y $0.00 $0.00 $0.00K0856 Y $0.00 $0.00 $0.00K0857 Y $0.00 $0.00 $0.00K0858 Y $0.00 $0.00 $0.00K0859 Y $0.00 $0.00 $0.00K0860 Y $0.00 $0.00 $0.00K0861 Y $0.00 $0.00 $0.00K0862 Y $0.00 $0.00 $0.00K0863 Y $0.00 $0.00 $0.00K0864 Y $0.00 $0.00 $0.00K0868 Y $0.00 $0.00 $0.00K0869 Y $0.00 $0.00 $0.00K0870 Y $0.00 $0.00 $0.00K0871 Y $0.00 $0.00 $0.00K0877 Y $0.00 $0.00 $0.00K0878 Y $0.00 $0.00 $0.00K0879 Y $0.00 $0.00 $0.00K0880 Y $0.00 $0.00 $0.00K0884 Y $0.00 $0.00 $0.00K0885 Y $0.00 $0.00 $0.00K0886 Y $0.00 $0.00 $0.00


273


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeK0890 Y $0.00 $0.00 $0.00K0891 Y $0.00 $0.00 $0.00K0898 Y $0.00 $0.00 $0.00K0899 Y $0.00 $0.00 $0.00K0900 Y $0.00 $0.00 $0.00K0901 A $0.00 $0.00 $0.00K0902 A $0.00 $0.00 $0.00L0112 A $0.00 $0.00 $0.00L0113 A $0.00 $0.00 $0.00L0120 A $0.00 $0.00 $0.00L0130 A $0.00 $0.00 $0.00L0140 A $0.00 $0.00 $0.00L0150 A $0.00 $0.00 $0.00L0160 A $0.00 $0.00 $0.00L0170 A $0.00 $0.00 $0.00L0172 A $0.00 $0.00 $0.00L0174 A $0.00 $0.00 $0.00L0180 A $0.00 $0.00 $0.00L0190 A $0.00 $0.00 $0.00L0200 A $0.00 $0.00 $0.00L0220 A $0.00 $0.00 $0.00L0450 A $0.00 $0.00 $0.00L0452 A $0.00 $0.00 $0.00L0454 A $0.00 $0.00 $0.00L0455 A $0.00 $0.00 $0.00L0456 A $0.00 $0.00 $0.00L0457 A $0.00 $0.00 $0.00L0458 A $0.00 $0.00 $0.00L0460 A $0.00 $0.00 $0.00L0462 A $0.00 $0.00 $0.00L0464 A $0.00 $0.00 $0.00L0466 A $0.00 $0.00 $0.00L0467 A $0.00 $0.00 $0.00L0468 A $0.00 $0.00 $0.00L0469 A $0.00 $0.00 $0.00L0470 A $0.00 $0.00 $0.00L0472 A $0.00 $0.00 $0.00L0480 A $0.00 $0.00 $0.00L0482 A $0.00 $0.00 $0.00L0484 A $0.00 $0.00 $0.00L0486 A $0.00 $0.00 $0.00L0488 A $0.00 $0.00 $0.00L0490 A $0.00 $0.00 $0.00L0491 A $0.00 $0.00 $0.00L0492 A $0.00 $0.00 $0.00L0621 A $0.00 $0.00 $0.00L0622 A $0.00 $0.00 $0.00L0623 A $0.00 $0.00 $0.00L0624 A $0.00 $0.00 $0.00L0625 A $0.00 $0.00 $0.00L0626 A $0.00 $0.00 $0.00


274


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeL0627 A $0.00 $0.00 $0.00L0628 A $0.00 $0.00 $0.00L0629 A $0.00 $0.00 $0.00L0630 A $0.00 $0.00 $0.00L0631 A $0.00 $0.00 $0.00L0632 A $0.00 $0.00 $0.00L0633 A $0.00 $0.00 $0.00L0634 A $0.00 $0.00 $0.00L0635 A $0.00 $0.00 $0.00L0636 A $0.00 $0.00 $0.00L0637 A $0.00 $0.00 $0.00L0638 A $0.00 $0.00 $0.00L0639 A $0.00 $0.00 $0.00L0640 A $0.00 $0.00 $0.00L0641 A $0.00 $0.00 $0.00L0642 A $0.00 $0.00 $0.00L0643 A $0.00 $0.00 $0.00L0648 A $0.00 $0.00 $0.00L0649 A $0.00 $0.00 $0.00L0650 A $0.00 $0.00 $0.00L0651 A $0.00 $0.00 $0.00L0700 A $0.00 $0.00 $0.00L0710 A $0.00 $0.00 $0.00L0810 A $0.00 $0.00 $0.00L0820 A $0.00 $0.00 $0.00L0830 A $0.00 $0.00 $0.00L0859 A $0.00 $0.00 $0.00L0861 A $0.00 $0.00 $0.00L0970 A $0.00 $0.00 $0.00L0972 A $0.00 $0.00 $0.00L0974 A $0.00 $0.00 $0.00L0976 A $0.00 $0.00 $0.00L0978 A $0.00 $0.00 $0.00L0980 A $0.00 $0.00 $0.00L0982 A $0.00 $0.00 $0.00L0984 A $0.00 $0.00 $0.00L0999 A $0.00 $0.00 $0.00L1000 A $0.00 $0.00 $0.00L1001 A $0.00 $0.00 $0.00L1005 A $0.00 $0.00 $0.00L1010 A $0.00 $0.00 $0.00L1020 A $0.00 $0.00 $0.00L1025 A $0.00 $0.00 $0.00L1030 A $0.00 $0.00 $0.00L1040 A $0.00 $0.00 $0.00L1050 A $0.00 $0.00 $0.00L1060 A $0.00 $0.00 $0.00L1070 A $0.00 $0.00 $0.00L1080 A $0.00 $0.00 $0.00L1085 A $0.00 $0.00 $0.00L1090 A $0.00 $0.00 $0.00


275




276




277




278


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeL2640 A $0.00 $0.00 $0.00L2650 A $0.00 $0.00 $0.00L2660 A $0.00 $0.00 $0.00L2670 A $0.00 $0.00 $0.00L2680 A $0.00 $0.00 $0.00L2750 A $0.00 $0.00 $0.00L2755 A $0.00 $0.00 $0.00L2760 A $0.00 $0.00 $0.00L2768 A $0.00 $0.00 $0.00L2780 A $0.00 $0.00 $0.00L2785 A $0.00 $0.00 $0.00L2795 A $0.00 $0.00 $0.00L2800 A $0.00 $0.00 $0.00L2810 A $0.00 $0.00 $0.00L2820 A $0.00 $0.00 $0.00L2830 A $0.00 $0.00 $0.00L2840 A $0.00 $0.00 $0.00L2850 A $0.00 $0.00 $0.00L2861 E $0.00 $0.00 $0.00L2999 A $0.00 $0.00 $0.00L3000 A $0.00 $0.00 $0.00L3001 A $0.00 $0.00 $0.00L3002 A $0.00 $0.00 $0.00L3003 A $0.00 $0.00 $0.00L3010 A $0.00 $0.00 $0.00L3020 A $0.00 $0.00 $0.00L3030 A $0.00 $0.00 $0.00L3031 A $0.00 $0.00 $0.00L3040 A $0.00 $0.00 $0.00L3050 A $0.00 $0.00 $0.00L3060 A $0.00 $0.00 $0.00L3070 A $0.00 $0.00 $0.00L3080 A $0.00 $0.00 $0.00L3090 A $0.00 $0.00 $0.00L3100 A $0.00 $0.00 $0.00L3140 A $0.00 $0.00 $0.00L3150 A $0.00 $0.00 $0.00L3160 A $0.00 $0.00 $0.00L3170 A $0.00 $0.00 $0.00L3201 A $0.00 $0.00 $0.00L3202 A $0.00 $0.00 $0.00L3203 A $0.00 $0.00 $0.00L3204 A $0.00 $0.00 $0.00L3206 A $0.00 $0.00 $0.00L3207 A $0.00 $0.00 $0.00L3208 A $0.00 $0.00 $0.00L3209 A $0.00 $0.00 $0.00L3211 A $0.00 $0.00 $0.00L3212 A $0.00 $0.00 $0.00L3213 A $0.00 $0.00 $0.00L3214 A $0.00 $0.00 $0.00


279


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeL3215 E $0.00 $0.00 $0.00L3216 E $0.00 $0.00 $0.00L3217 E $0.00 $0.00 $0.00L3219 E $0.00 $0.00 $0.00L3221 E $0.00 $0.00 $0.00L3222 E $0.00 $0.00 $0.00L3224 A $0.00 $0.00 $0.00L3225 A $0.00 $0.00 $0.00L3230 A $0.00 $0.00 $0.00L3250 A $0.00 $0.00 $0.00L3251 A $0.00 $0.00 $0.00L3252 A $0.00 $0.00 $0.00L3253 A $0.00 $0.00 $0.00L3254 A $0.00 $0.00 $0.00L3255 A $0.00 $0.00 $0.00L3257 A $0.00 $0.00 $0.00L3260 E $0.00 $0.00 $0.00L3265 A $0.00 $0.00 $0.00L3300 A $0.00 $0.00 $0.00L3310 A $0.00 $0.00 $0.00L3320 A $0.00 $0.00 $0.00L3330 A $0.00 $0.00 $0.00L3332 A $0.00 $0.00 $0.00L3334 A $0.00 $0.00 $0.00L3340 A $0.00 $0.00 $0.00L3350 A $0.00 $0.00 $0.00L3360 A $0.00 $0.00 $0.00L3370 A $0.00 $0.00 $0.00L3380 A $0.00 $0.00 $0.00L3390 A $0.00 $0.00 $0.00L3400 A $0.00 $0.00 $0.00L3410 A $0.00 $0.00 $0.00L3420 A $0.00 $0.00 $0.00L3430 A $0.00 $0.00 $0.00L3440 A $0.00 $0.00 $0.00L3450 A $0.00 $0.00 $0.00L3455 A $0.00 $0.00 $0.00L3460 A $0.00 $0.00 $0.00L3465 A $0.00 $0.00 $0.00L3470 A $0.00 $0.00 $0.00L3480 A $0.00 $0.00 $0.00L3485 A $0.00 $0.00 $0.00L3500 A $0.00 $0.00 $0.00L3510 A $0.00 $0.00 $0.00L3520 A $0.00 $0.00 $0.00L3530 A $0.00 $0.00 $0.00L3540 A $0.00 $0.00 $0.00L3550 A $0.00 $0.00 $0.00L3560 A $0.00 $0.00 $0.00L3570 A $0.00 $0.00 $0.00L3580 A $0.00 $0.00 $0.00


280


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeL3590 A $0.00 $0.00 $0.00L3595 A $0.00 $0.00 $0.00L3600 A $0.00 $0.00 $0.00L3610 A $0.00 $0.00 $0.00L3620 A $0.00 $0.00 $0.00L3630 A $0.00 $0.00 $0.00L3640 A $0.00 $0.00 $0.00L3649 A $0.00 $0.00 $0.00L3650 A $0.00 $0.00 $0.00L3660 A $0.00 $0.00 $0.00L3670 A $0.00 $0.00 $0.00L3671 A $0.00 $0.00 $0.00L3674 A $0.00 $0.00 $0.00L3675 A $0.00 $0.00 $0.00L3677 A $0.00 $0.00 $0.00L3678 A $0.00 $0.00 $0.00L3702 A $0.00 $0.00 $0.00L3710 A $0.00 $0.00 $0.00L3720 A $0.00 $0.00 $0.00L3730 A $0.00 $0.00 $0.00L3740 A $0.00 $0.00 $0.00L3760 A $0.00 $0.00 $0.00L3762 A $0.00 $0.00 $0.00L3763 A $0.00 $0.00 $0.00L3764 A $0.00 $0.00 $0.00L3765 A $0.00 $0.00 $0.00L3766 A $0.00 $0.00 $0.00L3806 A $0.00 $0.00 $0.00L3807 A $0.00 $0.00 $0.00L3808 A $0.00 $0.00 $0.00L3809 A $0.00 $0.00 $0.00L3891 E $0.00 $0.00 $0.00L3900 A $0.00 $0.00 $0.00L3901 A $0.00 $0.00 $0.00L3904 A $0.00 $0.00 $0.00L3905 A $0.00 $0.00 $0.00L3906 A $0.00 $0.00 $0.00L3908 A $0.00 $0.00 $0.00L3912 A $0.00 $0.00 $0.00L3913 A $0.00 $0.00 $0.00L3915 A $0.00 $0.00 $0.00L3916 A $0.00 $0.00 $0.00L3917 A $0.00 $0.00 $0.00L3918 A $0.00 $0.00 $0.00L3919 A $0.00 $0.00 $0.00L3921 A $0.00 $0.00 $0.00L3923 A $0.00 $0.00 $0.00L3924 A $0.00 $0.00 $0.00L3925 A $0.00 $0.00 $0.00L3927 A $0.00 $0.00 $0.00L3929 A $0.00 $0.00 $0.00


281




282




283




284




285




286




287




288


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeL6975 A $0.00 $0.00 $0.00L7007 A $0.00 $0.00 $0.00L7008 A $0.00 $0.00 $0.00L7009 A $0.00 $0.00 $0.00L7040 A $0.00 $0.00 $0.00L7045 A $0.00 $0.00 $0.00L7170 A $0.00 $0.00 $0.00L7180 A $0.00 $0.00 $0.00L7181 A $0.00 $0.00 $0.00L7185 A $0.00 $0.00 $0.00L7186 A $0.00 $0.00 $0.00L7190 A $0.00 $0.00 $0.00L7191 A $0.00 $0.00 $0.00L7259 A $0.00 $0.00 $0.00L7360 A $0.00 $0.00 $0.00L7362 A $0.00 $0.00 $0.00L7364 A $0.00 $0.00 $0.00L7366 A $0.00 $0.00 $0.00L7367 A $0.00 $0.00 $0.00L7368 A $0.00 $0.00 $0.00L7400 A $0.00 $0.00 $0.00L7401 A $0.00 $0.00 $0.00L7402 A $0.00 $0.00 $0.00L7403 A $0.00 $0.00 $0.00L7404 A $0.00 $0.00 $0.00L7405 A $0.00 $0.00 $0.00L7499 A $0.00 $0.00 $0.00L7510 A $0.00 $0.00 $0.00L7520 A $0.00 $0.00 $0.00L7600 E $0.00 $0.00 $0.00L7900 A $0.00 $0.00 $0.00L7902 A $0.00 $0.00 $0.00L8000 A $0.00 $0.00 $0.00L8001 A $0.00 $0.00 $0.00L8002 A $0.00 $0.00 $0.00L8010 A $0.00 $0.00 $0.00L8015 A $0.00 $0.00 $0.00L8020 A $0.00 $0.00 $0.00L8030 A $0.00 $0.00 $0.00L8031 A $0.00 $0.00 $0.00L8032 A $0.00 $0.00 $0.00L8035 A $0.00 $0.00 $0.00L8039 A $0.00 $0.00 $0.00L8040 A $0.00 $0.00 $0.00L8041 A $0.00 $0.00 $0.00L8042 A $0.00 $0.00 $0.00L8043 A $0.00 $0.00 $0.00L8044 A $0.00 $0.00 $0.00L8045 A $0.00 $0.00 $0.00L8046 A $0.00 $0.00 $0.00L8047 A $0.00 $0.00 $0.00


289


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeL8048 A $0.00 $0.00 $0.00L8049 A $0.00 $0.00 $0.00L8300 A $0.00 $0.00 $0.00L8310 A $0.00 $0.00 $0.00L8320 A $0.00 $0.00 $0.00L8330 A $0.00 $0.00 $0.00L8400 A $0.00 $0.00 $0.00L8410 A $0.00 $0.00 $0.00L8415 A $0.00 $0.00 $0.00L8417 A $0.00 $0.00 $0.00L8420 A $0.00 $0.00 $0.00L8430 A $0.00 $0.00 $0.00L8435 A $0.00 $0.00 $0.00L8440 A $0.00 $0.00 $0.00L8460 A $0.00 $0.00 $0.00L8465 A $0.00 $0.00 $0.00L8470 A $0.00 $0.00 $0.00L8480 A $0.00 $0.00 $0.00L8485 A $0.00 $0.00 $0.00L8499 A $0.00 $0.00 $0.00L8500 A $0.00 $0.00 $0.00L8501 A $0.00 $0.00 $0.00L8505 A $0.00 $0.00 $0.00L8507 A $0.00 $0.00 $0.00L8509 A $0.00 $0.00 $0.00L8510 A $0.00 $0.00 $0.00L8511 A $0.00 $0.00 $0.00L8512 A $0.00 $0.00 $0.00L8513 A $0.00 $0.00 $0.00L8514 A $0.00 $0.00 $0.00L8515 A $0.00 $0.00 $0.00L8600 N $0.00 $0.00 $0.00 L8603 N $0.00 $0.00 $0.00 L8604 N $0.00 $0.00 $0.00 L8605 N $0.00 $0.00 $0.00 L8606 N $0.00 $0.00 $0.00 L8609 N $0.00 $0.00 $0.00 L8610 N $0.00 $0.00 $0.00 L8612 N $0.00 $0.00 $0.00 L8613 N $0.00 $0.00 $0.00 L8614 N $0.00 $0.00 $0.00 L8615 A $0.00 $0.00 $0.00L8616 A $0.00 $0.00 $0.00L8617 A $0.00 $0.00 $0.00L8618 A $0.00 $0.00 $0.00L8619 A $0.00 $0.00 $0.00L8621 A $0.00 $0.00 $0.00L8622 A $0.00 $0.00 $0.00L8623 A $0.00 $0.00 $0.00L8624 A $0.00 $0.00 $0.00L8627 A $0.00 $0.00 $0.00


290


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeL8628 A $0.00 $0.00 $0.00L8629 A $0.00 $0.00 $0.00L8630 N $0.00 $0.00 $0.00 L8631 N $0.00 $0.00 $0.00 L8641 N $0.00 $0.00 $0.00 L8642 N $0.00 $0.00 $0.00 L8658 N $0.00 $0.00 $0.00 L8659 N $0.00 $0.00 $0.00 L8670 N $0.00 $0.00 $0.00 L8679 N $0.00 $0.00 $0.00 L8680 E $0.00 $0.00 $0.00L8681 A $0.00 $0.00 $0.00L8682 N $0.00 $0.00 $0.00 L8683 A $0.00 $0.00 $0.00L8684 A $0.00 $0.00 $0.00L8685 E $0.00 $0.00 $0.00L8686 E $0.00 $0.00 $0.00L8687 E $0.00 $0.00 $0.00L8688 E $0.00 $0.00 $0.00L8689 A $0.00 $0.00 $0.00L8690 N $0.00 $0.00 $0.00 L8691 A $0.00 $0.00 $0.00L8692 E $0.00 $0.00 $0.00L8693 A $0.00 $0.00 $0.00L8695 A $0.00 $0.00 $0.00L8696 A $0.00 $0.00 $0.00L8699 N $0.00 $0.00 $0.00 L9900 N $0.00 $0.00 $0.00 M0075 E $0.00 $0.00 $0.00M0076 E $0.00 $0.00 $0.00M0100 E $0.00 $0.00 $0.00M0300 E $0.00 $0.00 $0.00M0301 E $0.00 $0.00 $0.00P2028 A $0.00 $0.00 $0.00P2029 A $0.00 $0.00 $0.00P2031 E $0.00 $0.00 $0.00P2033 A $0.00 $0.00 $0.00P2038 A $0.00 $0.00 $0.00P3000 A $0.00 $0.00 $0.00P3001 B $0.00 $0.00 $0.00P7001 E $0.00 $0.00 $0.00P9010 R 0950 2.9289 $317.55 $388.17 $238.18 P9011 R 0967 1.7588 $190.69 $233.09 $143.03 P9012 R 0952 0.9548 $103.52 $126.54 $77.64 P9016 R 0954 2.5541 $276.92 $338.49 $207.70 P9017 R 9508 1.0091 $109.41 $133.74 $82.06 P9019 R 0957 1.5552 $168.61 $206.11 $126.47 P9020 R 0958 1.8326 $198.69 $242.87 $149.03 P9021 R 0959 2.03 $220.09 $269.04 $165.08 P9022 R 0960 4.3185 $468.21 $572.33 $351.18 P9023 R 0949 0.9341 $101.28 $123.80 $75.96


291


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeP9031 R 1013 1.5117 $163.90 $200.35 $122.93 P9032 R 9500 2.2736 $246.50 $301.32 $184.89 P9033 R 0968 2.1875 $237.17 $289.91 $177.89 P9034 R 9507 5.6564 $613.27 $749.64 $459.98 P9035 R 9501 6.7108 $727.58 $889.38 $545.72 P9036 R 9502 7.6782 $832.47 $1,017.59 $624.39 P9037 R 1019 9.0926 $985.82 $1,205.04 $739.41 P9038 R 9505 2.8023 $303.83 $371.39 $227.88 P9039 R 9504 6.2553 $678.20 $829.01 $508.68 P9040 R 0969 3.7139 $402.66 $492.20 $302.01 P9041 K 0961 $0.00 $0.00 $0.00P9043 R 0956 0.3108 $33.70 $41.19 $25.27 P9044 R 1009 1.0592 $114.84 $140.38 $86.13 P9045 K 0963 $0.00 $0.00 $0.00P9046 K 0964 $0.00 $0.00 $0.00P9047 K 0965 $0.00 $0.00 $0.00P9048 R 0966 0.4535 $49.17 $60.10 $36.88 P9050 R 9506 24.7756 $2,686.17 $3,283.51 $2,014.75 P9051 R 1010 2.2109 $239.71 $293.01 $179.79 P9052 R 1011 9.4963 $1,029.59 $1,258.54 $772.24 P9053 R 1020 8.8777 $962.52 $1,176.56 $721.93 P9054 R 1016 3.292 $356.92 $436.29 $267.71 P9055 R 1017 5.3132 $576.06 $704.16 $432.07 P9056 R 1018 1.8137 $196.64 $240.37 $147.49 P9057 R 1021 6.0513 $656.08 $801.98 $492.09 P9058 R 1022 3.7045 $401.64 $490.96 $301.25 P9059 R 0955 0.9624 $104.34 $127.55 $78.26 P9060 R 9503 0.793 $85.98 $105.10 $64.49 P9603 A $0.00 $0.00 $0.00P9604 A $0.00 $0.00 $0.00P9612 A $0.00 $0.00 $0.00P9615 N $0.00 $0.00 $0.00 Q0035 S 0100 3.2093 $347.95 $425.33 $260.98 Q0081 B $0.00 $0.00 $0.00Q0083 B $0.00 $0.00 $0.00Q0084 B $0.00 $0.00 $0.00Q0085 B $0.00 $0.00 $0.00Q0091 S 0450 0.3942 $42.74 $52.24 $32.06 Q0092 N $0.00 $0.00 $0.00 Q0111 A $0.00 $0.00 $0.00Q0112 A $0.00 $0.00 $0.00Q0113 A $0.00 $0.00 $0.00Q0114 A $0.00 $0.00 $0.00Q0115 A $0.00 $0.00 $0.00Q0138 K 1297 $0.00 $0.00 $0.00Q0139 K 1485 $0.00 $0.00 $0.00Q0144 E $0.00 $0.00 $0.00Q0161 N $0.00 $0.00 $0.00 Q0162 N $0.00 $0.00 $0.00 Q0163 N $0.00 $0.00 $0.00 Q0164 N $0.00 $0.00 $0.00


292


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeQ0166 N $0.00 $0.00 $0.00 Q0167 N $0.00 $0.00 $0.00 Q0169 N $0.00 $0.00 $0.00 Q0173 N $0.00 $0.00 $0.00 Q0174 E $0.00 $0.00 $0.00Q0175 N $0.00 $0.00 $0.00 Q0177 N $0.00 $0.00 $0.00 Q0180 N $0.00 $0.00 $0.00 Q0181 N $0.00 $0.00 $0.00 Q0478 A $0.00 $0.00 $0.00Q0479 A $0.00 $0.00 $0.00Q0480 A $0.00 $0.00 $0.00Q0481 A $0.00 $0.00 $0.00Q0482 A $0.00 $0.00 $0.00Q0483 A $0.00 $0.00 $0.00Q0484 A $0.00 $0.00 $0.00Q0485 A $0.00 $0.00 $0.00Q0486 A $0.00 $0.00 $0.00Q0487 A $0.00 $0.00 $0.00Q0488 A $0.00 $0.00 $0.00Q0489 A $0.00 $0.00 $0.00Q0490 A $0.00 $0.00 $0.00Q0491 A $0.00 $0.00 $0.00Q0492 A $0.00 $0.00 $0.00Q0493 A $0.00 $0.00 $0.00Q0494 A $0.00 $0.00 $0.00Q0495 A $0.00 $0.00 $0.00Q0496 A $0.00 $0.00 $0.00Q0497 A $0.00 $0.00 $0.00Q0498 A $0.00 $0.00 $0.00Q0499 A $0.00 $0.00 $0.00Q0500 A $0.00 $0.00 $0.00Q0501 A $0.00 $0.00 $0.00Q0502 A $0.00 $0.00 $0.00Q0503 A $0.00 $0.00 $0.00Q0504 A $0.00 $0.00 $0.00Q0506 A $0.00 $0.00 $0.00Q0507 N $0.00 $0.00 $0.00 Q0508 N $0.00 $0.00 $0.00 Q0509 N $0.00 $0.00 $0.00 Q0510 B $0.00 $0.00 $0.00Q0511 B $0.00 $0.00 $0.00Q0512 B $0.00 $0.00 $0.00Q0513 B $0.00 $0.00 $0.00Q0514 B $0.00 $0.00 $0.00Q0515 E $0.00 $0.00 $0.00Q1004 E $0.00 $0.00 $0.00Q1005 E $0.00 $0.00 $0.00Q2004 N $0.00 $0.00 $0.00 Q2009 N $0.00 $0.00 $0.00 Q2017 K 7035 $0.00 $0.00 $0.00


293


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeQ2026 B $0.00 $0.00 $0.00Q2028 B $0.00 $0.00 $0.00Q2034 L $0.00 $0.00 $0.00Q2035 L $0.00 $0.00 $0.00Q2036 L $0.00 $0.00 $0.00Q2037 L $0.00 $0.00 $0.00Q2038 L $0.00 $0.00 $0.00Q2039 L $0.00 $0.00 $0.00Q2043 K 9273 $0.00 $0.00 $0.00Q2049 K 1421 $0.00 $0.00 $0.00Q2050 K 7046 $0.00 $0.00 $0.00Q2052 E $0.00 $0.00 $0.00Q3001 B $0.00 $0.00 $0.00Q3014 A $0.00 $0.00 $0.00Q3027 K 1472 $0.00 $0.00 $0.00Q3028 E $0.00 $0.00 $0.00Q3031 N $0.00 $0.00 $0.00 Q4001 B $0.00 $0.00 $0.00Q4002 B $0.00 $0.00 $0.00Q4003 B $0.00 $0.00 $0.00Q4004 B $0.00 $0.00 $0.00Q4005 B $0.00 $0.00 $0.00Q4006 B $0.00 $0.00 $0.00Q4007 B $0.00 $0.00 $0.00Q4008 B $0.00 $0.00 $0.00Q4009 B $0.00 $0.00 $0.00Q4010 B $0.00 $0.00 $0.00Q4011 B $0.00 $0.00 $0.00Q4012 B $0.00 $0.00 $0.00Q4013 B $0.00 $0.00 $0.00Q4014 B $0.00 $0.00 $0.00Q4015 B $0.00 $0.00 $0.00Q4016 B $0.00 $0.00 $0.00Q4017 B $0.00 $0.00 $0.00Q4018 B $0.00 $0.00 $0.00Q4019 B $0.00 $0.00 $0.00Q4020 B $0.00 $0.00 $0.00Q4021 B $0.00 $0.00 $0.00Q4022 B $0.00 $0.00 $0.00Q4023 B $0.00 $0.00 $0.00Q4024 B $0.00 $0.00 $0.00Q4025 B $0.00 $0.00 $0.00Q4026 B $0.00 $0.00 $0.00Q4027 B $0.00 $0.00 $0.00Q4028 B $0.00 $0.00 $0.00Q4029 B $0.00 $0.00 $0.00Q4030 B $0.00 $0.00 $0.00Q4031 B $0.00 $0.00 $0.00Q4032 B $0.00 $0.00 $0.00Q4033 B $0.00 $0.00 $0.00Q4034 B $0.00 $0.00 $0.00


294


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeQ4035 B $0.00 $0.00 $0.00Q4036 B $0.00 $0.00 $0.00Q4037 B $0.00 $0.00 $0.00Q4038 B $0.00 $0.00 $0.00Q4039 B $0.00 $0.00 $0.00Q4040 B $0.00 $0.00 $0.00Q4041 B $0.00 $0.00 $0.00Q4042 B $0.00 $0.00 $0.00Q4043 B $0.00 $0.00 $0.00Q4044 B $0.00 $0.00 $0.00Q4045 B $0.00 $0.00 $0.00Q4046 B $0.00 $0.00 $0.00Q4047 B $0.00 $0.00 $0.00Q4048 B $0.00 $0.00 $0.00Q4049 B $0.00 $0.00 $0.00Q4050 B $0.00 $0.00 $0.00Q4051 B $0.00 $0.00 $0.00Q4074 Y $0.00 $0.00 $0.00Q4081 N $0.00 $0.00 $0.00 Q4082 B $0.00 $0.00 $0.00Q4100 N $0.00 $0.00 $0.00 Q4101 N $0.00 $0.00 $0.00 Q4102 N $0.00 $0.00 $0.00 Q4103 N $0.00 $0.00 $0.00 Q4104 N $0.00 $0.00 $0.00 Q4105 N $0.00 $0.00 $0.00 Q4106 N $0.00 $0.00 $0.00 Q4107 N $0.00 $0.00 $0.00 Q4108 N $0.00 $0.00 $0.00 Q4110 N $0.00 $0.00 $0.00 Q4111 N $0.00 $0.00 $0.00 Q4112 N $0.00 $0.00 $0.00 Q4113 N $0.00 $0.00 $0.00 Q4114 N $0.00 $0.00 $0.00 Q4115 N $0.00 $0.00 $0.00 Q4116 N $0.00 $0.00 $0.00 Q4117 N $0.00 $0.00 $0.00 Q4118 N $0.00 $0.00 $0.00 Q4119 N $0.00 $0.00 $0.00 Q4120 N $0.00 $0.00 $0.00 Q4121 G 1479 $0.00 $0.00 $0.00Q4122 G 1419 $0.00 $0.00 $0.00Q4123 N $0.00 $0.00 $0.00 Q4124 N $0.00 $0.00 $0.00 Q4125 N $0.00 $0.00 $0.00 Q4126 N $0.00 $0.00 $0.00 Q4127 G 1449 $0.00 $0.00 $0.00Q4128 N $0.00 $0.00 $0.00 Q4129 N $0.00 $0.00 $0.00 Q4130 N $0.00 $0.00 $0.00 Q4131 N $0.00 $0.00 $0.00


295


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeQ4132 N $0.00 $0.00 $0.00 Q4133 N $0.00 $0.00 $0.00 Q4134 N $0.00 $0.00 $0.00 Q4135 N $0.00 $0.00 $0.00 Q4136 N $0.00 $0.00 $0.00 Q4137 N $0.00 $0.00 $0.00 Q4138 N $0.00 $0.00 $0.00 Q4139 N $0.00 $0.00 $0.00 Q4140 N $0.00 $0.00 $0.00 Q4141 N $0.00 $0.00 $0.00 Q4142 N $0.00 $0.00 $0.00 Q4143 N $0.00 $0.00 $0.00 Q4145 N $0.00 $0.00 $0.00 Q4146 N $0.00 $0.00 $0.00 Q4147 N $0.00 $0.00 $0.00 Q4148 N $0.00 $0.00 $0.00 Q4149 N $0.00 $0.00 $0.00 Q4150 N $0.00 $0.00 $0.00 Q4151 N $0.00 $0.00 $0.00 Q4152 N $0.00 $0.00 $0.00 Q4153 N $0.00 $0.00 $0.00 Q4154 N $0.00 $0.00 $0.00 Q4155 N $0.00 $0.00 $0.00 Q4156 N $0.00 $0.00 $0.00 Q4157 N $0.00 $0.00 $0.00 Q4158 N $0.00 $0.00 $0.00 Q4159 N $0.00 $0.00 $0.00 Q4160 N $0.00 $0.00 $0.00 Q5001 B $0.00 $0.00 $0.00Q5002 B $0.00 $0.00 $0.00Q5003 B $0.00 $0.00 $0.00Q5004 B $0.00 $0.00 $0.00Q5005 B $0.00 $0.00 $0.00Q5006 B $0.00 $0.00 $0.00Q5007 B $0.00 $0.00 $0.00Q5008 B $0.00 $0.00 $0.00Q5009 B $0.00 $0.00 $0.00Q5010 B $0.00 $0.00 $0.00Q9951 N $0.00 $0.00 $0.00 Q9953 N $0.00 $0.00 $0.00 Q9954 N $0.00 $0.00 $0.00 Q9955 N $0.00 $0.00 $0.00 Q9956 N $0.00 $0.00 $0.00 Q9957 N $0.00 $0.00 $0.00 Q9958 N $0.00 $0.00 $0.00 Q9959 N $0.00 $0.00 $0.00 Q9960 N $0.00 $0.00 $0.00 Q9961 N $0.00 $0.00 $0.00 Q9962 N $0.00 $0.00 $0.00 Q9963 N $0.00 $0.00 $0.00 Q9964 N $0.00 $0.00 $0.00


296


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeQ9965 N $0.00 $0.00 $0.00 Q9966 N $0.00 $0.00 $0.00 Q9967 N $0.00 $0.00 $0.00 Q9968 K 1446 $0.00 $0.00 $0.00Q9969 K 1442 $0.00 $0.00 $0.00R0070 B $0.00 $0.00 $0.00R0075 B $0.00 $0.00 $0.00R0076 B $0.00 $0.00 $0.00V2020 A $0.00 $0.00 $0.00V2025 E $0.00 $0.00 $0.00V2100 A $0.00 $0.00 $0.00V2101 A $0.00 $0.00 $0.00V2102 A $0.00 $0.00 $0.00V2103 A $0.00 $0.00 $0.00V2104 A $0.00 $0.00 $0.00V2105 A $0.00 $0.00 $0.00V2106 A $0.00 $0.00 $0.00V2107 A $0.00 $0.00 $0.00V2108 A $0.00 $0.00 $0.00V2109 A $0.00 $0.00 $0.00V2110 A $0.00 $0.00 $0.00V2111 A $0.00 $0.00 $0.00V2112 A $0.00 $0.00 $0.00V2113 A $0.00 $0.00 $0.00V2114 A $0.00 $0.00 $0.00V2115 A $0.00 $0.00 $0.00V2118 A $0.00 $0.00 $0.00V2121 A $0.00 $0.00 $0.00V2199 A $0.00 $0.00 $0.00V2200 A $0.00 $0.00 $0.00V2201 A $0.00 $0.00 $0.00V2202 A $0.00 $0.00 $0.00V2203 A $0.00 $0.00 $0.00V2204 A $0.00 $0.00 $0.00V2205 A $0.00 $0.00 $0.00V2206 A $0.00 $0.00 $0.00V2207 A $0.00 $0.00 $0.00V2208 A $0.00 $0.00 $0.00V2209 A $0.00 $0.00 $0.00V2210 A $0.00 $0.00 $0.00V2211 A $0.00 $0.00 $0.00V2212 A $0.00 $0.00 $0.00V2213 A $0.00 $0.00 $0.00V2214 A $0.00 $0.00 $0.00V2215 A $0.00 $0.00 $0.00V2218 A $0.00 $0.00 $0.00V2219 A $0.00 $0.00 $0.00V2220 A $0.00 $0.00 $0.00V2221 A $0.00 $0.00 $0.00V2299 A $0.00 $0.00 $0.00V2300 A $0.00 $0.00 $0.00


297


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeV2301 A $0.00 $0.00 $0.00V2302 A $0.00 $0.00 $0.00V2303 A $0.00 $0.00 $0.00V2304 A $0.00 $0.00 $0.00V2305 A $0.00 $0.00 $0.00V2306 A $0.00 $0.00 $0.00V2307 A $0.00 $0.00 $0.00V2308 A $0.00 $0.00 $0.00V2309 A $0.00 $0.00 $0.00V2310 A $0.00 $0.00 $0.00V2311 A $0.00 $0.00 $0.00V2312 A $0.00 $0.00 $0.00V2313 A $0.00 $0.00 $0.00V2314 A $0.00 $0.00 $0.00V2315 A $0.00 $0.00 $0.00V2318 A $0.00 $0.00 $0.00V2319 A $0.00 $0.00 $0.00V2320 A $0.00 $0.00 $0.00V2321 A $0.00 $0.00 $0.00V2399 A $0.00 $0.00 $0.00V2410 A $0.00 $0.00 $0.00V2430 A $0.00 $0.00 $0.00V2499 A $0.00 $0.00 $0.00V2500 A $0.00 $0.00 $0.00V2501 A $0.00 $0.00 $0.00V2502 A $0.00 $0.00 $0.00V2503 A $0.00 $0.00 $0.00V2510 A $0.00 $0.00 $0.00V2511 A $0.00 $0.00 $0.00V2512 A $0.00 $0.00 $0.00V2513 A $0.00 $0.00 $0.00V2520 A $0.00 $0.00 $0.00V2521 A $0.00 $0.00 $0.00V2522 A $0.00 $0.00 $0.00V2523 A $0.00 $0.00 $0.00V2530 A $0.00 $0.00 $0.00V2531 A $0.00 $0.00 $0.00V2599 A $0.00 $0.00 $0.00V2600 A $0.00 $0.00 $0.00V2610 A $0.00 $0.00 $0.00V2615 A $0.00 $0.00 $0.00V2623 A $0.00 $0.00 $0.00V2624 A $0.00 $0.00 $0.00V2625 A $0.00 $0.00 $0.00V2626 A $0.00 $0.00 $0.00V2627 A $0.00 $0.00 $0.00V2628 A $0.00 $0.00 $0.00V2629 A $0.00 $0.00 $0.00V2630 N $0.00 $0.00 $0.00 V2631 N $0.00 $0.00 $0.00 V2632 N $0.00 $0.00 $0.00


298


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeV2700 A $0.00 $0.00 $0.00V2702 E $0.00 $0.00 $0.00V2710 A $0.00 $0.00 $0.00V2715 A $0.00 $0.00 $0.00V2718 A $0.00 $0.00 $0.00V2730 A $0.00 $0.00 $0.00V2744 A $0.00 $0.00 $0.00V2745 A $0.00 $0.00 $0.00V2750 A $0.00 $0.00 $0.00V2755 A $0.00 $0.00 $0.00V2756 E $0.00 $0.00 $0.00V2760 A $0.00 $0.00 $0.00V2761 B $0.00 $0.00 $0.00V2762 A $0.00 $0.00 $0.00V2770 A $0.00 $0.00 $0.00V2780 A $0.00 $0.00 $0.00V2781 B $0.00 $0.00 $0.00V2782 A $0.00 $0.00 $0.00V2783 A $0.00 $0.00 $0.00V2784 A $0.00 $0.00 $0.00V2785 F $0.00 $0.00 $0.00V2786 A $0.00 $0.00 $0.00V2787 E $0.00 $0.00 $0.00V2788 E $0.00 $0.00 $0.00V2790 N $0.00 $0.00 $0.00 V2797 A $0.00 $0.00 $0.00V2799 A $0.00 $0.00 $0.00V5008 E $0.00 $0.00 $0.00V5010 E $0.00 $0.00 $0.00V5011 E $0.00 $0.00 $0.00V5014 E $0.00 $0.00 $0.00V5020 E $0.00 $0.00 $0.00V5030 E $0.00 $0.00 $0.00V5040 E $0.00 $0.00 $0.00V5050 E $0.00 $0.00 $0.00V5060 E $0.00 $0.00 $0.00V5070 E $0.00 $0.00 $0.00V5080 E $0.00 $0.00 $0.00V5090 E $0.00 $0.00 $0.00V5095 E $0.00 $0.00 $0.00V5100 E $0.00 $0.00 $0.00V5110 E $0.00 $0.00 $0.00V5120 E $0.00 $0.00 $0.00V5130 E $0.00 $0.00 $0.00V5140 E $0.00 $0.00 $0.00V5150 E $0.00 $0.00 $0.00V5160 E $0.00 $0.00 $0.00V5170 E $0.00 $0.00 $0.00V5180 E $0.00 $0.00 $0.00V5190 E $0.00 $0.00 $0.00V5200 E $0.00 $0.00 $0.00


299


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeV5210 E $0.00 $0.00 $0.00V5220 E $0.00 $0.00 $0.00V5230 E $0.00 $0.00 $0.00V5240 E $0.00 $0.00 $0.00V5241 E $0.00 $0.00 $0.00V5242 E $0.00 $0.00 $0.00V5243 E $0.00 $0.00 $0.00V5244 E $0.00 $0.00 $0.00V5245 E $0.00 $0.00 $0.00V5246 E $0.00 $0.00 $0.00V5247 E $0.00 $0.00 $0.00V5248 E $0.00 $0.00 $0.00V5249 E $0.00 $0.00 $0.00V5250 E $0.00 $0.00 $0.00V5251 E $0.00 $0.00 $0.00V5252 E $0.00 $0.00 $0.00V5253 E $0.00 $0.00 $0.00V5254 E $0.00 $0.00 $0.00V5255 E $0.00 $0.00 $0.00V5256 E $0.00 $0.00 $0.00V5257 E $0.00 $0.00 $0.00V5258 E $0.00 $0.00 $0.00V5259 E $0.00 $0.00 $0.00V5260 E $0.00 $0.00 $0.00V5261 E $0.00 $0.00 $0.00V5262 E $0.00 $0.00 $0.00V5263 E $0.00 $0.00 $0.00V5264 E $0.00 $0.00 $0.00V5265 E $0.00 $0.00 $0.00V5266 E $0.00 $0.00 $0.00V5267 E $0.00 $0.00 $0.00V5268 E $0.00 $0.00 $0.00V5269 E $0.00 $0.00 $0.00V5270 E $0.00 $0.00 $0.00V5271 E $0.00 $0.00 $0.00V5272 E $0.00 $0.00 $0.00V5273 E $0.00 $0.00 $0.00V5274 E $0.00 $0.00 $0.00V5275 E $0.00 $0.00 $0.00V5281 E $0.00 $0.00 $0.00V5282 E $0.00 $0.00 $0.00V5283 E $0.00 $0.00 $0.00V5284 E $0.00 $0.00 $0.00V5285 E $0.00 $0.00 $0.00V5286 E $0.00 $0.00 $0.00V5287 E $0.00 $0.00 $0.00V5288 E $0.00 $0.00 $0.00V5289 E $0.00 $0.00 $0.00V5290 E $0.00 $0.00 $0.00V5298 E $0.00 $0.00 $0.00V5299 B $0.00 $0.00 $0.00


300


Code Status APC Relative Weight ACH Fee CAH Fee ASC FeeV5336 E $0.00 $0.00 $0.00V5362 E $0.00 $0.00 $0.00V5363 E $0.00 $0.00 $0.00V5364 E $0.00 $0.00 $0.00

Documents

MEDICAL FEE SCHEDULE MAINE WORKERS ......90-351 Chapter 5 page 5 treatment of conditions that are unrelated to the compensable injury or disease. See 39-A M.R.S. 206 (13). NOTE: Health