Appendix E

Durable Medical Equipment,

Prosthetics, Orthotics, and Supplies

(DMEPOS)

Note: Listing of a payment amount does not guarantee payment

Effective October 20, 2012

HCPCS

Maximum

Payment

A4216 $0.44

A4217 $3.62

A4221 $25.68

A4222 $50.95

A4233 $0.92

A4234 $4.19

A4235 $2.71

A4236 $1.93

A4253 $42.62

A4255 $4.75

A4256 $13.20

A4257 $14.71

A4258 $20.48

A4259 $13.91

A4265 $3.92

A4280 $5.98

A4310 $7.57

A4311 $14.54

A4312 $17.68

A4313 $18.17

A4314 $24.80

A4315 $25.87

A4316 $27.85

A4320 $6.14

A4322 $3.17

A4326 $11.96

A4327 $51.47

A4328 $11.40

A4330 $7.99

A4331 $3.67

A4332 $0.14

A4333 $2.55

A4334 $5.68

A4336 $1.66

A4338 $14.14

A4340 $36.63

A4344 $18.47

A4346 $22.60

A4349 $2.33

A4351 $2.09

A4352 $7.40

A4353 $8.08

A4354 $11.58

A4355 $10.28

A4356 $48.94

A4357 $11.19

A4358 $6.74

A4360 $0.52

A4361 $21.19

A4362 $3.39

A4363 $2.73

A4364 $3.38

A4366 $1.50

A4367 $8.48

A4368 $0.30

A4369 $2.37

A4371 $4.16

A4372 $4.83

A4373 $7.24

A4375 $19.82

A4376 $54.89

A4377 $4.95

A4378 $35.47

A4379 $17.32

A4380 $43.07

A4381 $5.33

A4382 $28.40

A4383 $32.52

A4384 $11.09

A4385 $5.89

A4388 $5.04

A4389 $7.17

A4390 $11.08

A4391 $8.15

A4392 $9.44

A4393 $10.43

A4394 $2.99

A4395 $0.05

A4396 $46.70

A4397 $4.69

A4398 $15.94

A4399 $14.14

A4400 $47.92

A4402 $1.85

A4404 $1.65

A4405 $3.93

A4406 $6.62

A4407 $10.11

A4408 $11.38

A4409 $7.17

A4410 $10.43

A4411 $5.89

A4412 $3.13

A4413 $6.35

A4414 $5.68

A4415 $6.92

A4416 $3.18

A4417 $4.30

A4418 $2.09

A4419 $2.01

A4422 $0.14

A4423 $2.15

A4424 $5.49

A4425 $4.13

A4426 $3.16

A4427 $3.21

A4428 $7.51

A4429 $9.52

A4430 $9.83

A4431 $7.17

A4432 $4.15

A4433 $3.86

A4434 $4.34

A4450 $0.13

A4452 $0.46

A4455 $1.65

A4456 $0.29

A4461 $3.79

A4463 $15.37

A4481 $0.44

A4556 $13.67

A4557 $24.35

A4558 $5.79

A4559 $0.12

A4561 $23.02

A4562 $57.31

A4595 $32.70

A4604 $66.43

A4605 $18.91

A4608 $57.82

A4611 $192.63

A4612 $92.21

A4613 $166.36

A4614 $27.44

A4615 $0.83

A4616 $0.08

A4617 $3.58

A4618 $8.83

A4619 $2.14

A4620 $0.68

A4623 $6.42

A4624 $3.04

A4625 $6.79

A4626 $3.14

A4628 $4.21

A4629 $5.33

A4630 $7.21

A4633 $47.34

A4635 $5.91

A4636 $4.87

A4637 $2.46

A4639 $331.33

A4640 $62.09

A5051 $2.38

A5052 $1.72

A5053 $2.01

A5054 $2.07

A5055 $1.66

A5056 $5.38

A5057 $11.08

A5061 $4.07

A5062 $2.41

A5063 $3.13

A5071 $6.93

A5072 $4.05

A5073 $3.67

A5081 $3.24

A5082 $11.72

A5083 $0.73

A5093 $1.92

A5102 $26.06

A5105 $39.97

A5112 $39.93

A5113 $4.62

A5114 $8.77

A5120 $0.25

A5121 $8.60

A5122 $12.60

A5126 $1.30

A5131 $15.55

A5200 $13.02

A5500 $73.34

A5501 $220.01

A5503 $36.01

A5504 $36.01

A5505 $36.01

A5506 $36.01

A5507 $36.01

A5512 $29.92

A5513 $44.66

A6010 $35.72

A6011 $2.63

A6021 $24.25

A6022 $24.25

A6023 $219.54

A6024 $7.14

A6154 $16.56

A6196 $8.48

A6197 $18.96

A6199 $6.09

A6203 $3.87

A6204 $7.19

A6207 $8.46

A6209 $8.62

A6210 $22.98

A6211 $33.88

A6212 $11.19

A6214 $11.87

A6216 $0.05

A6219 $1.10

A6220 $2.99

A6222 $2.46

A6223 $2.79

A6224 $4.17

A6229 $4.17

A6231 $5.40

A6232 $7.93

A6233 $22.14

A6234 $7.54

A6235 $19.40

A6236 $31.44

A6237 $9.13

A6238 $26.29

A6240 $14.12

A6241 $2.96

A6242 $6.99

A6243 $14.21

A6244 $45.31

A6245 $8.38

A6246 $11.45

A6247 $27.44

A6248 $18.73

A6251 $2.30

A6252 $3.75

A6253 $7.31

A6254 $1.40

A6255 $3.50

A6257 $1.77

A6258 $4.97

A6259 $12.63

A6266 $2.22

A6402 $0.14

A6403 $0.49

A6407 $2.17

A6410 $0.45

A6441 $0.77

A6442 $0.19

A6443 $0.33

A6444 $0.64

A6445 $0.38

A6446 $0.47

A6447 $0.77

A6448 $1.34

A6449 $2.02

A6452 $6.82

A6453 $0.71

A6454 $0.89

A6455 $1.61

A6456 $1.47

A6457 $1.32

A6531 $49.91

A6532 $70.33

A6545 $98.27

A6550 $27.28

A7000 $11.01

A7001 $38.16

A7002 $4.42

A7003 $3.17

A7004 $2.08

A7005 $35.57

A7006 $11.01

A7007 $5.33

A7008 $12.69

A7009 $48.50

A7010 $27.22

A7012 $4.37

A7013 $0.96

A7014 $5.18

A7015 $2.17

A7016 $8.36

A7017 $154.62

A7018 $0.44

A7020 $16.09

A7025 $501.75

A7026 $33.17

A7027 $206.91

A7028 $57.16

A7029 $23.35

A7030 $187.56

A7031 $69.37

A7032 $40.30

A7033 $28.25

A7034 $116.96

A7035 $39.51

A7036 $18.09

A7037 $40.78

A7038 $5.37

A7039 $15.24

A7040 $45.54

A7041 $85.59

A7042 $206.80

A7043 $32.43

A7044 $120.21

A7045 $19.35

A7046 $19.40

A7501 $121.16

A7502 $57.59

A7503 $13.08

A7504 $0.77

A7505 $5.40

A7506 $0.39

A7507 $2.87

A7508 $3.31

A7509 $1.63

A7520 $54.77

A7521 $54.27

A7522 $52.10

A7524 $89.29

A7525 $2.38

A7526 $3.89

A7527 $4.13

A8000 $176.91

A8001 $176.91

E0100 $22.82

E0105 $53.65

E0110 $85.42

E0111 $58.63

E0112 $40.73

E0113 $23.27

E0114 $51.96

E0116 $30.54

E0117 $212.18

E0130 $66.65

E0135 $79.07

E0140 $342.29

E0141 $109.41

E0143 $114.09

E0144 $302.19

E0147 $545.45

E0148 $120.57

E0149 $211.81

E0153 $76.39

E0154 $66.91

E0155 $28.11

E0156 $25.08

E0157 $77.75

E0158 $29.55

E0159 $16.95

E0160 $36.40

E0161 $28.87

E0162 $160.42

E0163 $117.28

E0165 $204.59

E0167 $13.09

E0168 $166.16

E0170 $1,769.56

E0171 $318.47

E0175 $65.50

E0181 $286.90

E0182 $288.23

E0184 $196.43

E0185 $352.15

E0186 $223.55

E0187 $255.53

E0188 $29.10

E0189 $48.64

E0191 $9.35

E0193 $8,573.20

E0194 $30,455.11

E0196 $357.73

E0197 $243.96

E0198 $243.96

E0199 $30.00

E0200 $87.29

E0202 $585.89

E0205 $181.61

E0210 $33.71

E0215 $66.30

E0217 $546.60

E0225 $427.89

E0235 $189.93

E0236 $414.00

E0239 $495.25

E0249 $93.21

E0250 $851.77

E0251 $597.47

E0255 $1,114.79

E0256 $790.89

E0260 $1,332.91

E0261 $1,299.49

E0265 $1,896.76

E0266 $1,614.17

E0271 $210.70

E0272 $163.23

E0275 $16.86

E0276 $14.55

E0277 $6,675.42

E0280 $36.25

E0290 $602.80

E0291 $515.27

E0292 $797.45

E0293 $678.65

E0294 $1,239.74

E0295 $1,208.37

E0296 $1,558.10

E0297 $1,334.86

E0300 $2,693.67

E0301 $2,568.96

E0302 $6,788.99

E0303 $2,884.56

E0304 $7,313.17

E0305 $143.50

E0310 $184.22

E0316 $1,914.29

E0325 $11.13

E0326 $9.83

E0371 $4,217.77

E0372 $5,117.93

E0373 $5,830.92

E0424 $1,804.61

E0431 $301.66

E0433 $529.21

E0434 $301.66

E0439 $1,804.61

E0441 $79.39

E0442 $79.39

E0443 $79.39

E0444 $79.39

E0450 $10,299.10

E0457 $676.56

E0459 $560.26

E0460 $8,076.49

E0461 $10,299.10

E0462 $3,208.25

E0463 $15,483.96

E0464 $15,483.96

E0470 $2,384.77

E0471 $6,093.73

E0472 $6,093.73

E0480 $461.66

E0482 $4,734.47

E0483 $11,704.78

E0484 $40.65

E0500 $1,124.73

E0550 $469.14

E0560 $138.34

E0561 $101.54

E0562 $285.84

E0565 $671.79

E0570 $177.43

E0572 $419.33

E0574 $443.21

E0575 $1,100.85

E0580 $127.20

E0585 $386.01

E0600 $439.62

E0601 $1,060.05

E0602 $32.50

E0605 $29.10

E0606 $244.57

E0607 $73.56

E0610 $222.60

E0615 $448.09

E0617 $3,716.65

E0618 $3,086.69

E0620 $962.68

E0621 $105.69

E0627 $371.39

E0628 $371.39

E0629 $364.11

E0630 $1,121.66

E0635 $1,219.65

E0636 $11,610.48

E0650 $792.94

E0651 $1,011.16

E0652 $5,836.77

E0655 $118.83

E0656 $636.04

E0657 $597.54

E0660 $175.88

E0665 $150.83

E0666 $152.03

E0667 $356.46

E0668 $486.50

E0669 $201.82

E0671 $457.29

E0672 $355.32

E0673 $295.25

E0675 $4,233.86

E0691 $989.33

E0692 $1,242.32

E0693 $1,531.44

E0694 $4,874.41

E0705 $60.69

E0720 $343.99

E0730 $375.78

E0731 $392.71

E0740 $575.66

E0744 $1,008.19

E0745 $985.54

E0747 $4,311.51

E0748 $4,283.58

E0749 $3,130.86

E0760 $3,559.58

E0762 $1,029.01

E0764 $12,184.32

E0765 $92.63

E0776 $157.61

E0779 $184.19

E0780 $11.42

E0781 $2,916.13

E0782 $4,726.95

E0783 $9,013.60

E0784 $4,596.41

E0785 $520.22

E0786 $8,474.90

E0791 $3,481.31

E0840 $80.67

E0849 $567.35

E0850 $115.66

E0855 $544.12

E0856 $169.59

E0860 $36.06

E0870 $128.06

E0880 $138.22

E0890 $130.85

E0900 $141.07

E0910 $189.73

E0911 $472.93

E0912 $1,086.30

E0920 $479.09

E0930 $427.53

E0935 $250.31

E0940 $329.95

E0941 $477.85

E0942 $21.85

E0944 $50.50

E0945 $48.80

E0946 $651.39

E0947 $667.70

E0948 $626.76

E0950 $114.45

E0951 $20.90

E0952 $20.73

E0955 $222.60

E0956 $108.54

E0957 $151.86

E0958 $480.32

E0959 $48.67

E0960 $100.16

E0961 $28.66

E0966 $78.59

E0967 $71.11

E0968 $167.79

E0969 $172.45

E0971 $47.76

E0973 $126.58

E0974 $86.33

E0978 $39.98

E0980 $33.95

E0981 $51.92

E0982 $56.74

E0983 $2,751.71

E0984 $1,840.70

E0985 $223.34

E0986 $5,355.42

E0988 $3,168.99

E0990 $110.44

E0992 $104.77

E0994 $17.89

E0995 $33.48

E1002 $4,462.49

E1003 $4,834.73

E1004 $5,360.72

E1005 $5,802.56

E1006 $7,107.59

E1007 $9,623.94

E1008 $9,624.80

E1010 $1,259.28

E1014 $402.02

E1015 $126.29

E1016 $144.58

E1020 $267.99

E1028 $227.40

E1029 $406.85

E1030 $1,282.94

E1031 $556.16

E1035 $6,751.26

E1036 $9,464.54

E1037 $1,194.43

E1038 $198.44

E1039 $376.48

E1050 $1,121.14

E1060 $1,387.95

E1070 $1,025.00

E1083 $736.87

E1084 $1,059.54

E1087 $1,392.97

E1088 $1,411.02

E1092 $1,415.01

E1093 $1,169.11

E1100 $1,142.88

E1110 $1,119.20

E1150 $898.11

E1160 $688.08

E1161 $2,605.02

E1170 $983.39

E1171 $882.52

E1172 $1,078.51

E1180 $948.33

E1190 $1,095.62

E1195 $1,187.46

E1200 $957.96

E1221 $523.16

E1222 $746.40

E1223 $760.14

E1224 $759.42

E1225 $497.64

E1226 $600.75

E1227 $305.53

E1228 $308.53

E1230 $2,490.19

E1232 $2,354.33

E1233 $2,439.47

E1234 $2,123.73

E1235 $2,044.99

E1236 $1,804.20

E1237 $1,819.97

E1238 $1,804.20

E1240 $1,099.52

E1270 $832.51

E1280 $1,228.26

E1295 $1,166.35

E1296 $541.31

E1297 $115.17

E1298 $452.49

E1310 $2,009.60

E1353 $31.19

E1355 $23.49

E1372 $179.49

E1390 $1,804.61

E1391 $1,804.61

E1392 $529.21

E1405 $2,190.63

E1406 $1,982.04

E1700 $379.66

E1701 $11.68

E1702 $24.86

E1800 $1,348.70

E1801 $1,420.24

E1802 $3,598.06

E1805 $1,391.03

E1806 $1,166.14

E1810 $1,371.66

E1811 $1,476.72

E1812 $946.69

E1815 $1,391.03

E1816 $1,499.98

E1818 $1,531.25

E1820 $84.90

E1821 $115.88

E1825 $1,391.03

E1830 $1,391.03

E1831 $699.56

E1840 $4,213.57

E1841 $4,987.34

E2000 $570.62

E2100 $601.91

E2101 $207.60

E2120 $3,121.54

E2201 $410.78

E2202 $521.84

E2203 $527.42

E2204 $895.54

E2205 $35.35

E2206 $44.05

E2207 $46.92

E2208 $128.60

E2209 $116.03

E2210 $7.21

E2211 $43.03

E2212 $6.37

E2213 $32.93

E2214 $33.69

E2215 $10.40

E2219 $46.07

E2220 $26.69

E2221 $27.65

E2222 $23.19

E2224 $107.96

E2225 $19.16

E2226 $41.78

E2227 $1,980.34

E2228 $1,030.80

E2231 $169.20

E2310 $1,288.40

E2311 $2,608.43

E2312 $2,722.91

E2313 $339.03

E2321 $2,456.29

E2322 $2,601.16

E2323 $76.15

E2324 $48.24

E2325 $1,482.84

E2326 $382.20

E2327 $3,766.20

E2328 $5,455.71

E2329 $1,944.48

E2330 $3,767.64

E2340 $394.54

E2341 $591.87

E2342 $493.22

E2343 $789.16

E2351 $769.18

E2359 $184.33

E2360 $105.13

E2361 $151.00

E2362 $99.58

E2363 $201.35

E2364 $105.13

E2365 $121.45

E2366 $290.24

E2367 $461.39

E2368 $568.73

E2369 $495.38

E2370 $883.91

E2371 $165.96

E2373 $1,148.15

E2374 $587.94

E2375 $943.05

E2376 $1,477.80

E2377 $534.76

E2381 $82.47

E2382 $22.47

E2383 $164.42

E2384 $87.61

E2385 $53.59

E2386 $162.92

E2387 $70.28

E2388 $55.48

E2389 $30.12

E2390 $47.12

E2391 $22.58

E2392 $59.32

E2394 $84.50

E2395 $60.05

E2396 $73.23

E2397 $455.96

E2402 $16,288.17

E2500 $430.54

E2502 $1,316.54

E2504 $1,736.70

E2506 $2,546.52

E2508 $3,937.76

E2510 $7,451.69

E2601 $67.34

E2602 $131.46

E2603 $166.90

E2604 $207.43

E2605 $296.36

E2606 $462.34

E2607 $319.12

E2608 $383.23

E2611 $343.89

E2612 $465.22

E2613 $432.72

E2614 $598.86

E2615 $498.01

E2616 $670.03

E2619 $56.51

E2620 $603.01

E2621 $632.80

E2622 $364.93

E2623 $464.38

E2624 $367.93

E2625 $465.78

E2626 $683.84

E2627 $1,091.19

E2628 $822.04

E2629 $1,040.27

E2630 $727.46

E2631 $247.35

E2632 $157.28

E2633 $156.95

K0001 $614.44

K0002 $933.84

K0003 $998.50

K0004 $1,310.39

K0005 $2,097.07

K0006 $1,446.79

K0007 $2,059.18

K0010 $4,914.19

K0011 $6,561.17

K0012 $3,748.37

K0015 $206.11

K0017 $57.97

K0018 $32.40

K0019 $19.88

K0020 $52.68

K0037 $55.56

K0038 $27.49

K0039 $61.12

K0040 $84.68

K0041 $60.05

K0042 $35.72

K0043 $22.15

K0044 $18.88

K0045 $65.32

K0046 $22.15

K0047 $86.73

K0050 $36.87

K0051 $59.67

K0052 $104.87

K0053 $115.72

K0056 $107.87

K0065 $50.42

K0069 $113.32

K0070 $207.78

K0071 $123.91

K0072 $70.10

K0073 $37.97

K0077 $66.73

K0098 $29.94

K0105 $112.78

K0195 $243.05

K0455 $3,055.53

K0552 $3.02

K0601 $1.28

K0602 $7.34

K0603 $0.66

K0604 $7.01

K0605 $16.84

K0606 $29,051.05

K0607 $248.76

K0608 $155.26

K0609 $1,032.44

K0672 $85.53

K0730 $1,988.84

K0733 $34.85

K0738 $554.51

K0800 $1,285.41

K0801 $2,072.34

K0802 $2,345.23

K0806 $1,554.99

K0807 $2,359.52

K0808 $3,650.69

K0813 $3,597.90

K0814 $4,605.74

K0815 $5,244.13

K0816 $5,022.45

K0820 $3,843.09

K0821 $4,933.31

K0822 $5,962.10

K0823 $6,001.40

K0824 $7,222.54

K0825 $6,612.19

K0826 $9,350.57

K0827 $7,950.71

K0828 $10,303.31

K0829 $9,461.51

K0835 $6,051.45

K0836 $6,275.70

K0837 $7,222.54

K0838 $6,461.29

K0839 $9,350.57

K0840 $14,165.95

K0841 $6,441.10

K0842 $6,441.10

K0843 $7,754.92

K0848 $7,881.33

K0849 $7,577.71

K0850 $9,142.21

K0851 $8,790.15

K0852 $10,563.22

K0853 $10,851.16

K0854 $14,375.27

K0855 $13,579.55

K0856 $8,459.90

K0857 $8,629.37

K0858 $10,496.31

K0859 $10,010.11

K0860 $14,995.19

K0861 $10,914.95

K0862 $10,496.31

K0863 $14,995.19

K0864 $17,844.40

L0112 $1,420.99

L0113 $300.80

L0120 $34.41

L0130 $191.46

L0140 $83.02

L0150 $110.56

L0160 $152.33

L0170 $738.91

L0172 $133.36

L0174 $280.77

L0180 $409.37

L0190 $575.95

L0200 $643.12

L0220 $128.13

L0430 $1,303.24

L0450 $223.24

L0454 $352.12

L0456 $1,009.77

L0458 $905.44

L0460 $1,019.12

L0462 $1,267.65

L0464 $1,509.11

L0466 $458.88

L0468 $550.80

L0470 $661.10

L0472 $469.47

L0480 $1,618.78

L0482 $1,649.80

L0484 $1,728.48

L0486 $1,833.81

L0488 $1,019.12

L0490 $287.21

L0491 $779.72

L0492 $512.86

L0621 $117.53

L0622 $311.95

L0625 $55.91

L0626 $79.13

L0627 $417.33

L0628 $85.18

L0630 $164.43

L0631 $1,042.25

L0633 $291.14

L0635 $1,072.82

L0636 $1,398.80

L0637 $1,141.13

L0638 $1,339.03

L0639 $1,141.13

L0640 $1,062.37

L0700 $1,966.35

L0710 $2,220.96

L0810 $2,674.20

L0820 $2,626.27

L0830 $3,683.71

L0859 $1,184.88

L0861 $218.83

L0970 $111.17

L0972 $100.09

L0974 $180.17

L0976 $190.39

L0978 $199.58

L0980 $18.06

L0982 $16.86

L0984 $66.49

L1000 $2,365.03

L1005 $3,249.48

L1010 $67.71

L1020 $99.25

L1025 $121.28

L1030 $63.57

L1040 $93.86

L1050 $99.68

L1060 $109.60

L1070 $99.06

L1080 $61.24

L1085 $159.85

L1090 $96.68

L1100 $175.68

L1110 $290.71

L1120 $47.81

L1200 $2,031.90

L1210 $254.49

L1220 $263.60

L1230 $552.89

L1240 $80.72

L1250 $73.84

L1260 $77.94

L1270 $75.36

L1280 $87.29

L1290 $78.09

L1300 $1,643.04

L1310 $1,840.33

L1600 $125.34

L1610 $42.70

L1620 $137.30

L1630 $178.02

L1640 $469.49

L1650 $225.18

L1652 $361.90

L1660 $180.38

L1680 $1,580.08

L1685 $1,156.91

L1686 $899.67

L1690 $1,963.25

L1700 $1,597.43

L1710 $1,932.73

L1720 $1,348.26

L1730 $1,150.35

L1755 $1,539.89

L1810 $110.89

L1820 $140.31

L1830 $108.75

L1831 $298.81

L1832 $591.33

L1834 $755.00

L1836 $135.47

L1840 $1,034.50

L1843 $910.96

L1844 $2,046.32

L1845 $825.61

L1846 $1,243.52

L1847 $583.95

L1850 $312.62

L1860 $1,276.04

L1900 $289.27

L1902 $95.21

L1904 $457.38

L1906 $116.97

L1907 $571.27

L1910 $329.01

L1920 $435.83

L1930 $268.72

L1932 $905.98

L1940 $516.71

L1945 $1,015.97

L1950 $965.94

L1951 $852.66

L1960 $539.11

L1970 $719.45

L1971 $475.88

L1980 $456.52

L1990 $551.64

L2000 $1,315.36

L2005 $4,160.27

L2010 $1,187.39

L2020 $1,514.24

L2030 $1,304.08

L2034 $2,058.80

L2035 $182.69

L2036 $2,327.95

L2037 $1,920.52

L2038 $1,617.85

L2040 $222.23

L2050 $469.90

L2060 $665.29

L2070 $130.81

L2080 $403.29

L2090 $568.64

L2106 $681.64

L2108 $1,165.55

L2112 $470.48

L2114 $577.33

L2116 $692.41

L2126 $1,164.67

L2128 $2,223.71

L2132 $784.60

L2134 $983.73

L2136 $1,150.22

L2180 $113.91

L2182 $104.81

L2184 $120.49

L2186 $168.58

L2188 $315.63

L2190 $84.94

L2192 $346.79

L2200 $61.65

L2210 $68.53

L2220 $94.13

L2230 $91.63

L2232 $101.04

L2240 $82.10

L2250 $460.81

L2260 $194.98

L2265 $114.55

L2270 $69.65

L2275 $152.12

L2280 $441.08

L2300 $326.50

L2310 $159.53

L2320 $255.65

L2330 $451.83

L2335 $241.91

L2340 $536.78

L2350 $977.74

L2360 $67.10

L2370 $266.80

L2375 $109.90

L2380 $121.90

L2385 $130.28

L2387 $197.51

L2390 $106.47

L2395 $152.18

L2397 $128.54

L2405 $88.51

L2415 $123.29

L2425 $145.53

L2430 $145.53

L2492 $102.84

L2500 $329.44

L2510 $803.65

L2520 $473.47

L2525 $1,262.09

L2526 $888.26

L2530 $238.62

L2540 $518.67

L2550 $304.78

L2570 $477.24

L2580 $533.48

L2600 $231.37

L2610 $278.85

L2620 $305.89

L2622 $298.27

L2624 $322.08

L2627 $1,667.36

L2628 $2,172.69

L2630 $254.42

L2640 $396.51

L2650 $155.63

L2660 $181.27

L2670 $171.53

L2680 $152.20

L2750 $95.51

L2755 $132.67

L2760 $60.35

L2768 $132.27

L2780 $87.76

L2785 $34.03

L2795 $102.45

L2800 $118.93

L2810 $75.97

L2820 $84.46

L2830 $91.38

L2840 $42.49

L2850 $60.23

L3000 $318.92

L3001 $134.28

L3002 $163.97

L3003 $176.92

L3010 $176.92

L3020 $201.43

L3030 $77.49

L3040 $47.77

L3050 $47.77

L3060 $74.88

L3070 $32.24

L3080 $32.24

L3090 $41.33

L3100 $43.90

L3140 $90.40

L3150 $82.64

L3170 $51.68

L3224 $57.19

L3225 $65.80

L3300 $52.92

L3310 $82.64

L3330 $574.58

L3332 $74.88

L3334 $38.74

L3340 $86.53

L3350 $23.26

L3360 $36.15

L3370 $50.33

L3380 $50.33

L3390 $50.33

L3400 $41.33

L3410 $94.25

L3420 $55.52

L3430 $162.70

L3440 $77.49

L3450 $107.18

L3455 $41.33

L3460 $34.85

L3465 $59.41

L3470 $63.26

L3480 $63.26

L3500 $29.69

L3510 $29.69

L3520 $32.24

L3530 $32.24

L3540 $51.68

L3550 $9.02

L3560 $23.26

L3570 $86.53

L3580 $65.84

L3590 $54.22

L3595 $42.61

L3600 $77.49

L3610 $101.99

L3620 $77.49

L3630 $101.99

L3640 $43.90

L3650 $60.16

L3660 $97.82

L3670 $111.86

L3671 $832.59

L3674 $1,092.18

L3675 $162.14

L3702 $266.80

L3710 $117.66

L3720 $743.57

L3730 $1,000.38

L3740 $1,021.21

L3760 $462.07

L3762 $99.35

L3763 $683.11

L3764 $767.01

L3765 $1,184.77

L3766 $1,254.57

L3806 $419.71

L3807 $231.05

L3808 $332.95

L3900 $1,386.06

L3901 $1,713.60

L3904 $2,787.17

L3905 $916.32

L3906 $394.43

L3908 $76.04

L3912 $120.35

L3913 $250.25

L3915 $491.14

L3917 $97.62

L3919 $250.25

L3921 $296.80

L3923 $90.99

L3925 $59.07

L3927 $32.30

L3929 $90.14

L3931 $178.02

L3933 $197.14

L3935 $204.12

L3960 $786.50

L3961 $1,552.39

L3962 $849.94

L3967 $1,832.85

L3971 $1,739.81

L3973 $1,832.85

L3975 $1,552.39

L3976 $1,552.39

L3977 $1,739.81

L3978 $1,832.85

L3980 $294.23

L3982 $355.31

L3984 $341.91

L3995 $34.54

L4000 $1,408.87

L4010 $778.45

L4020 $932.00

L4030 $642.66

L4040 $529.36

L4045 $321.84

L4050 $483.79

L4055 $263.76

L4060 $393.01

L4070 $323.99

L4080 $116.51

L4090 $117.01

L4100 $135.27

L4110 $109.98

L4130 $643.40

L4350 $95.76

L4360 $359.08

L4370 $244.83

L4386 $160.97

L4392 $23.49

L4394 $17.13

L4396 $167.53

L4398 $77.13

L4631 $1,553.12

L5000 $546.40

L5010 $1,316.57

L5020 $2,441.59

L5050 $2,915.10

L5060 $3,868.26

L5100 $3,021.52

L5105 $4,264.38

L5150 $4,409.33

L5160 $5,379.51

L5200 $4,405.11

L5210 $3,498.87

L5220 $3,977.10

L5230 $5,319.12

L5250 $6,921.77

L5270 $7,415.80

L5280 $7,341.64

L5301 $3,029.68

L5312 $4,756.08

L5321 $4,680.35

L5331 $6,640.86

L5341 $6,931.25

L5400 $1,446.18

L5410 $555.91

L5420 $1,746.77

L5430 $545.24

L5450 $477.13

L5460 $631.75

L5500 $1,388.90

L5505 $1,880.93

L5510 $1,706.00

L5520 $1,555.14

L5530 $2,170.22

L5535 $2,241.66

L5540 $2,392.68

L5560 $2,337.54

L5570 $2,458.63

L5580 $2,816.53

L5585 $3,121.67

L5590 $2,732.89

L5595 $4,881.75

L5600 $6,153.12

L5610 $2,872.42

L5611 $1,907.92

L5613 $2,650.23

L5614 $1,791.45

L5616 $1,468.74

L5617 $593.98

L5618 $337.82

L5620 $320.78

L5622 $452.42

L5624 $407.32

L5626 $591.34

L5628 $653.84

L5629 $343.67

L5630 $547.68

L5631 $475.15

L5632 $320.16

L5634 $381.42

L5636 $339.94

L5637 $321.96

L5638 $596.59

L5639 $1,366.55

L5640 $905.07

L5642 $893.35

L5643 $1,932.23

L5644 $713.16

L5645 $862.86

L5646 $634.27

L5647 $860.22

L5648 $711.98

L5649 $2,176.40

L5650 $620.61

L5651 $1,298.69

L5652 $471.47

L5653 $773.53

L5654 $418.97

L5655 $375.42

L5656 $534.87

L5658 $524.27

L5661 $658.09

L5665 $553.71

L5666 $76.82

L5668 $121.34

L5670 $320.30

L5671 $717.21

L5672 $348.96

L5673 $774.63

L5676 $456.51

L5677 $581.14

L5678 $51.17

L5679 $645.53

L5680 $383.42

L5681 $1,396.45

L5682 $683.74

L5683 $1,396.45

L5684 $69.39

L5685 $135.98

L5686 $68.94

L5688 $75.48

L5690 $114.77

L5692 $168.64

L5694 $260.56

L5695 $176.36

L5696 $266.78

L5697 $115.75

L5698 $135.23

L5699 $265.83

L5700 $3,948.69

L5701 $4,798.50

L5702 $5,745.76

L5703 $2,649.81

L5704 $659.46

L5705 $1,082.62

L5706 $1,073.02

L5707 $1,525.35

L5710 $492.05

L5711 $666.12

L5712 $598.00

L5714 $452.33

L5716 $788.18

L5718 $985.15

L5722 $1,147.05

L5724 $1,736.88

L5726 $2,102.03

L5728 $2,797.51

L5780 $1,238.12

L5781 $4,247.75

L5782 $4,478.08

L5785 $671.19

L5790 $808.15

L5795 $1,161.11

L5810 $601.25

L5811 $788.70

L5812 $682.57

L5814 $3,942.77

L5816 $919.69

L5818 $1,038.51

L5822 $1,841.55

L5824 $1,658.43

L5826 $3,444.00

L5828 $3,053.86

L5830 $2,662.73

L5840 $4,364.81

L5845 $1,902.82

L5848 $1,141.60

L5850 $138.34

L5855 $445.30

L5856 $25,485.30

L5857 $9,043.16

L5858 $19,730.57

L5910 $391.67

L5920 $573.79

L5925 $471.64

L5930 $3,573.36

L5940 $674.44

L5950 $969.42

L5960 $1,108.01

L5961 $5,246.47

L5962 $847.53

L5964 $1,220.09

L5966 $1,581.79

L5968 $3,857.88

L5970 $265.27

L5971 $265.27

L5972 $423.95

L5973 $18,662.81

L5974 $336.00

L5975 $492.16

L5976 $677.02

L5978 $382.62

L5979 $3,259.67

L5980 $4,384.08

L5981 $3,542.32

L5982 $826.38

L5984 $781.24

L5985 $299.80

L5986 $826.88

L5987 $7,637.08

L5988 $2,120.83

L5990 $1,926.02

L6000 $1,915.82

L6010 $2,132.00

L6020 $1,987.76

L6025 $8,495.56

L6050 $2,347.86

L6055 $3,505.72

L6100 $2,528.95

L6110 $2,579.36

L6120 $3,243.46

L6130 $3,732.66

L6200 $3,830.71

L6205 $4,799.32

L6250 $3,572.40

L6300 $5,025.03

L6310 $4,171.18

L6320 $1,848.08

L6350 $5,647.79

L6360 $4,592.68

L6370 $2,196.45

L6380 $1,478.81

L6382 $1,740.90

L6384 $2,203.97

L6386 $499.20

L6388 $548.67

L6400 $2,799.77

L6450 $3,800.64

L6500 $3,844.08

L6550 $5,142.29

L6570 $5,732.17

L6580 $1,948.02

L6582 $1,548.02

L6584 $2,630.20

L6586 $2,247.90

L6588 $3,806.14

L6590 $3,507.05

L6600 $219.80

L6605 $207.36

L6610 $189.11

L6611 $437.11

L6615 $231.12

L6616 $84.23

L6620 $362.00

L6621 $2,428.27

L6623 $778.72

L6624 $3,998.21

L6625 $665.99

L6628 $625.44

L6629 $158.51

L6630 $233.06

L6632 $70.26

L6635 $204.34

L6637 $469.88

L6638 $2,654.86

L6640 $372.57

L6641 $185.70

L6642 $251.17

L6645 $428.71

L6646 $3,348.37

L6647 $551.23

L6648 $3,453.37

L6650 $369.74

L6655 $108.32

L6660 $114.66

L6665 $53.33

L6670 $55.13

L6672 $209.34

L6675 $129.87

L6676 $159.66

L6677 $314.93

L6680 $257.27

L6682 $327.32

L6684 $501.52

L6686 $719.00

L6687 $623.77

L6688 $763.84

L6689 $934.88

L6690 $991.47

L6691 $428.93

L6692 $604.76

L6693 $3,013.97

L6694 $774.63

L6695 $645.53

L6696 $1,396.45

L6697 $1,396.45

L6698 $717.21

L6703 $357.04

L6704 $677.69

L6706 $431.07

L6707 $1,520.81

L6708 $1,061.21

L6709 $1,521.78

L6711 $713.75

L6712 $1,314.14

L6713 $1,658.60

L6714 $1,404.83

L6721 $2,496.91

L6722 $2,152.53

L6805 $457.40

L6810 $216.43

L6881 $4,340.20

L6882 $3,292.23

L6883 $2,216.08

L6884 $3,028.26

L6885 $4,592.68

L6890 $200.81

L6895 $670.43

L6900 $2,099.83

L6905 $2,117.01

L6910 $1,737.51

L6915 $785.24

L6920 $8,414.90

L6925 $9,202.91

L6930 $9,130.07

L6935 $9,649.19

L6940 $10,931.28

L6945 $12,111.80

L6950 $11,417.39

L6955 $12,915.97

L6960 $14,066.95

L6965 $15,885.56

L6970 $15,772.44

L6975 $17,281.59

L7007 $3,772.90

L7008 $6,534.56

L7009 $4,080.40

L7040 $3,257.28

L7045 $1,747.93

L7170 $6,603.26

L7180 $39,620.70

L7181 $42,537.43

L7185 $6,935.90

L7186 $9,565.76

L7190 $8,616.51

L7191 $9,995.65

L7260 $2,454.57

L7261 $5,144.45

L7360 $287.01

L7362 $297.50

L7364 $563.52

L7366 $728.39

L7367 $413.33

L7368 $535.79

L7400 $325.38

L7401 $364.26

L7402 $393.37

L7403 $390.96

L7404 $590.07

L7405 $771.73

L7900 $574.85

L8000 $44.65

L8001 $133.15

L8002 $175.13

L8015 $66.09

L8020 $260.55

L8030 $341.17

L8031 $341.17

L8032 $43.19

L8035 $3,889.43

L8040 $2,654.24

L8041 $3,199.43

L8042 $3,594.84

L8043 $4,026.23

L8044 $4,457.61

L8045 $2,798.22

L8046 $2,875.87

L8047 $1,473.87

L8300 $113.34

L8310 $158.75

L8320 $60.44

L8330 $53.40

L8400 $20.06

L8410 $28.60

L8415 $29.37

L8417 $79.84

L8420 $21.69

L8430 $24.79

L8435 $30.32

L8440 $45.23

L8460 $94.38

L8465 $52.75

L8470 $7.22

L8480 $13.27

L8485 $15.55

L8500 $844.27

L8501 $130.63

L8507 $44.48

L8509 $115.95

L8510 $268.25

L8511 $77.21

L8512 $2.30

L8513 $5.52

L8514 $100.11

L8515 $67.00

L8600 $788.66

L8603 $476.36

L8606 $241.55

L8609 $6,916.98

L8610 $717.39

L8612 $783.19

L8613 $325.51

L8614 $20,315.39

L8615 $478.81

L8616 $111.53

L8617 $97.40

L8618 $27.85

L8619 $8,721.25

L8621 $0.66

L8622 $0.35

L8623 $68.67

L8624 $171.21

L8627 $7,356.95

L8628 $1,364.30

L8629 $190.09

L8630 $364.33

L8631 $2,304.70

L8641 $504.73

L8642 $332.14

L8658 $440.07

L8659 $2,048.62

L8670 $601.97

L8680 $506.60

L8681 $1,166.63

L8682 $6,574.73

L8683 $5,787.27

L8684 $856.54

L8685 $14,421.52

L8686 $9,202.10

L8687 $18,768.14

L8688 $11,975.59

L8689 $1,831.25

L8690 $5,050.36

L8691 $2,830.88

L8693 $1,609.77

L8695 $17.67

Q0478 $178.78

Q0479 $11,749.89

Q0480 $87,619.99

Q0481 $14,136.45

Q0482 $4,427.81

Q0483 $18,240.58

Q0484 $3,542.27

Q0485 $341.99

Q0486 $284.65

Q0487 $332.09

Q0489 $15,813.60

Q0490 $684.02

Q0491 $1,075.36

Q0492 $86.62

Q0493 $246.69

Q0494 $208.75

Q0495 $4,063.68

Q0496 $1,458.52

Q0497 $455.44

Q0498 $499.72

Q0499 $162.36

Q0500 $29.71

Q0501 $496.83

Q0502 $632.53

Q0503 $1,265.09

Q0504 $667.56

Q0506 $830.95