PART B FEE SCHEDULES

Fee Schedule 95807-95933

CPT/HCPC Code	Modifier	Medicare Location	Global Surgery Indicator	Prevailing Charge Amount	Fee Schedule Amount	Site of Service Amount
95807		001	XXX	X	1,103.59	X
95807	26	001	XXX	X	371.66	X
95807	TC	001	XXX	X	731.92	X
95807		004	XXX	X	931.76	X
95807	26	004	XXX	X	326.75	X
95807	TC	004	XXX	X	604.96	X
95807		003	XXX	X	931.76	X
95807	26	003	XXX	X	326.75	X
95807	TC	003	XXX	X	604.96	X
95807		002	XXX	X	931.76	X
95807	26	002	XXX	X	326.75	X
95807	TC	002	XXX	X	604.96	X
95808		004	XXX	X	953.30	X
95808	26	004	XXX	X	462.66	X
95808	TC	004	XXX	X	501.16	X
95808		002	XXX	X	1,222.32	X
95808	26	002	XXX	X	535.86	X
95808	TC	002	XXX	X	1,029.18	X
95808		003	XXX	X	1,106.81	X
95808	26	003	XXX	X	526.33	X
95808	TC	003	XXX	X	509.10	X
95808		001	XXX	X	1,145.00	X
95808	26	001	XXX	X	548.88	X
95808	TC	001	XXX	X	565.04	X
95810		004	XXX	X	953.30	X
95810	26	004	XXX	X	462.66	X
95810	TC	004	XXX	X	501.16	X
95810		003	XXX	X	1,106.81	X
95810	26	003	XXX	X	526.33	X
95810	TC	003	XXX	X	509.10	X
95810		002	XXX	X	1,222.32	X
95810	26	002	XXX	X	535.86	X
95810	TC	002	XXX	X	1,029.18	X
95810		001	XXX	X	1,145.00	X
95810	26	001	XXX	X	548.88	X
95810	TC	001	XXX	X	565.04	X
95811		004	XXX	X	1,220.38	X
95811	26	004	XXX	X	584.96	X
95811	TC	004	XXX	X	635.41	X
95811		002	XXX	X	1,220.38	X
95811	26	002	XXX	X	584.96	X
95811	TC	002	XXX	X	635.41	X
95811		003	XXX	X	1,220.38	X
95811	26	003	XXX	X	584.96	X
95811	TC	003	XXX	X	635.41	X
95811		001	XXX	X	1,417.52	X
95811	26	001	XXX	X	648.96	X
95811	TC	001	XXX	X	768.56	X
95812		002	XXX	X	310.68	X
95812	26	002	XXX	X	175.04	X
95812	TC	002	XXX	X	150.98	X
95812		001	XXX	X	335.17	X
95812	26	001	XXX	X	180.49	X
95812	TC	001	XXX	X	156.58	X
95812		004	XXX	X	292.15	X
95812	26	004	XXX	X	159.06	X
95812	TC	004	XXX	X	135.11	X
95812		003	XXX	X	287.35	X
95812	26	003	XXX	X	172.36	X
95812	TC	003	XXX	X	120.52	X
95813		004	XXX	X	356.57	X
95813	26	004	XXX	X	221.48	X
95813	TC	004	XXX	X	135.11	X
95813		003	XXX	X	361.67	X
95813	26	003	XXX	X	224.12	X
95813	TC	003	XXX	X	137.54	X
95813		001	XXX	X	394.06	X
95813	26	001	XXX	X	237.43	X
95813	TC	001	XXX	X	156.58	X
95813		002	XXX	X	384.06	X
95813	26	002	XXX	X	233.16	X
95813	TC	002	XXX	X	150.98	X
95816		001	XXX	X	323.24	X
95816	26	001	XXX	X	176.14	X
95816	TC	001	XXX	X	144.09	X
95816		004	XXX	X	238.19	X
95816	26	004	XXX	X	149.55	X
95816	TC	004	XXX	X	127.63	X
95816		003	XXX	X	257.73	X
95816	26	003	XXX	X	172.08	X
95816	TC	003	XXX	X	87.07	X
95816		002	XXX	X	282.16	X
95816	26	002	XXX	X	169.25	X
95816	TC	002	XXX	X	141.21	X
95819		003	XXX	X	267.34	X
95819	26	003	XXX	X	181.70	X
95819	TC	003	XXX	X	87.07	X
95819		002	XXX	X	292.55	X
95819	26	002	XXX	X	179.63	X
95819	TC	002	XXX	X	141.21	X
95819		004	XXX	X	285.00	X
95819	26	004	XXX	X	159.04	X
95819	TC	004	XXX	X	127.63	X
95819		001	XXX	X	333.79	X
95819	26	001	XXX	X	186.63	X
95819	TC	001	XXX	X	144.09	X
95822		004	XXX	X	338.14	X
95822	26	004	XXX	X	162.87	X
95822	TC	004	XXX	X	175.17	X
95822		003	XXX	X	342.72	X
95822	26	003	XXX	X	202.73	X
95822	TC	003	XXX	X	177.92	X
95822		002	XXX	X	331.27	X
95822	26	002	XXX	X	157.14	X
95822	TC	002	XXX	X	186.44	X
95822		001	XXX	X	372.08	X
95822	26	001	XXX	X	205.15	X
95822	TC	001	XXX	X	197.86	X
95824			XXX	X	*	X
95829		003	XXX	X	468.24	X
95829	26	003	XXX	X	662.36	X
95829	TC	003	XXX	X	15.17	X
95829		004	XXX	X	670.96	X
95829	26	004	XXX	X	656.04	X
95829	TC	004	XXX	X	14.99	X
95829		002	XXX	X	477.81	X
95829	26	002	XXX	X	470.69	X
95829	TC	002	XXX	X	16.86	X
95829		001	XXX	X	480.23	X
95829	26	001	XXX	X	472.90	X
95829	TC	001	XXX	X	17.27	X
95830		002	XXX	X	297.72	X
95830		001	XXX	X	274.39	X
95830		004	XXX	X	247.56	X
95830		003	XXX	X	250.39	X
95836		003	XXX	X	154.60	X
95836		002	XXX	X	154.60	X
95836		004	XXX	X	154.60	X
95836		001	XXX	X	168.06	X
95851		004	XXX	X	51.49	40.34
95851		002	XXX	X	55.10	43.05
95851		003	XXX	X	52.07	40.78
95851		001	XXX	X	55.72	43.62
95852		004	XXX	X	34.36	27.44
95852		003	XXX	X	34.80	27.75
95852		002	XXX	X	36.97	29.43
95852		001	XXX	X	37.58	29.90
95857		001	XXX	X	109.50	84.46
95857		002	XXX	X	108.41	83.81
95857		003	XXX	X	105.26	81.09
95857		004	XXX	X	104.53	80.59
95860		001	XXX	X	229.58	X
95860	26	001	XXX	X	184.96	X
95860	TC	001	XXX	X	41.11	X
95860		003	XXX	X	223.78	X
95860	26	003	XXX	X	180.82	X
95860	TC	003	XXX	X	36.94	X
95860		002	XXX	X	227.61	X
95860	26	002	XXX	X	183.96	X
95860	TC	002	XXX	X	44.02	X
95860		004	XXX	X	223.86	X
95860	26	004	XXX	X	175.29	X
95860	TC	004	XXX	X	36.37	X
95861		002	XXX	X	378.93	X
95861	26	002	XXX	X	299.29	X
95861	TC	002	XXX	X	79.58	X
95861		004	XXX	X	352.24	X
95861	26	004	XXX	X	281.11	X
95861	TC	004	XXX	X	71.77	X
95861		003	XXX	X	356.81	X
95861	26	003	XXX	X	283.91	X
95861	TC	003	XXX	X	72.19	X
95861		001	XXX	X	384.25	X
95861	26	001	XXX	X	303.04	X
95861	TC	001	XXX	X	81.18	X
95863		002	XXX	X	448.96	X
95863	26	002	XXX	X	348.94	X
95863	TC	002	XXX	X	100.02	X
95863		003	XXX	X	423.25	X
95863	26	003	XXX	X	331.44	X
95863	TC	003	XXX	X	91.81	X
95863		004	XXX	X	417.84	X
95863	26	004	XXX	X	327.45	X
95863	TC	004	XXX	X	90.37	X
95863		001	XXX	X	455.14	X
95863	26	001	XXX	X	353.16	X
95863	TC	001	XXX	X	101.98	X
95864		001	XXX	X	598.68	X
95864	26	001	XXX	X	358.73	X
95864	TC	001	XXX	X	194.27	X
95864		004	XXX	X	545.97	X
95864	26	004	XXX	X	373.64	X
95864	TC	004	XXX	X	172.37	X
95864		002	XXX	X	589.95	X
95864	26	002	XXX	X	399.32	X
95864	TC	002	XXX	X	190.56	X
95864		003	XXX	X	553.36	X
95864	26	003	XXX	X	378.28	X
95864	TC	003	XXX	X	175.07	X
95865		002	XXX	X	215.73	X
95865	26	002	XXX	X	169.36	X
95865	TC	002	XXX	X	46.33	X
95865		001	XXX	X	243.50	X
95865	26	001	XXX	X	185.88	X
95865	TC	001	XXX	X	57.60	X
95865		004	XXX	X	215.73	X
95865	26	004	XXX	X	169.36	X
95865	TC	004	XXX	X	46.33	X
95865		003	XXX	X	215.73	X
95865	26	003	XXX	X	169.36	X
95865	TC	003	XXX	X	46.33	X
95866		001	XXX	X	163.39	X
95866	26	001	XXX	X	144.34	X
95866	TC	001	XXX	X	19.06	X
95866		003	XXX	X	146.59	X
95866	26	003	XXX	X	131.72	X
95866	TC	003	XXX	X	14.85	X
95866		002	XXX	X	146.59	X
95866	26	002	XXX	X	131.72	X
95866	TC	002	XXX	X	14.85	X
95866		004	XXX	X	146.59	X
95866	26	004	XXX	X	131.72	X
95866	TC	004	XXX	X	14.85	X
95867		002	XXX	X	191.29	X
95867	26	002	XXX	X	134.10	X
95867	TC	002	XXX	X	61.71	X
95867		001	XXX	X	158.27	X
95867	26	001	XXX	X	134.86	X
95867	TC	001	XXX	X	62.93	X
95867		003	XXX	X	179.30	X
95867	26	003	XXX	X	131.18	X
95867	TC	003	XXX	X	56.75	X
95867		004	XXX	X	176.86	X
95867	26	004	XXX	X	121.00	X
95867	TC	004	XXX	X	55.92	X
95868		004	XXX	X	340.18	X
95868	26	004	XXX	X	275.59	X
95868	TC	004	XXX	X	67.05	X
95868		002	XXX	X	354.59	X
95868	26	002	XXX	X	294.28	X
95868	TC	002	XXX	X	74.17	X
95868		003	XXX	X	342.76	X
95868	26	003	XXX	X	278.98	X
95868	TC	003	XXX	X	68.14	X
95868		001	XXX	X	357.92	X
95868	26	001	XXX	X	297.95	X
95868	TC	001	XXX	X	75.61	X
95869		004	XXX	X	192.43	X
95869	26	004	XXX	X	183.58	X
95869	TC	004	XXX	X	20.53	X
95869		003	XXX	X	201.16	X
95869	26	003	XXX	X	162.49	X
95869	TC	003	XXX	X	20.82	X
95869		002	XXX	X	188.60	X
95869	26	002	XXX	X	166.31	X
95869	TC	002	XXX	X	22.89	X
95869		001	XXX	X	208.36	X
95869	26	001	XXX	X	170.88	X
95869	TC	001	XXX	X	23.31	X
95870		004	XXX	X	84.46	X
95870	26	004	XXX	X	64.91	X
95870	TC	004	XXX	X	19.55	X
95870		003	XXX	X	84.46	X
95870	26	003	XXX	X	64.91	X
95870	TC	003	XXX	X	19.55	X
95870		002	XXX	X	84.46	X
95870	26	002	XXX	X	64.91	X
95870	TC	002	XXX	X	19.55	X
95870		001	XXX	X	96.83	X
95870	26	001	XXX	X	73.05	X
95870	TC	001	XXX	X	23.83	X
95872		003	XXX	X	280.05	X
95872	26	003	XXX	X	220.32	X
95872	TC	003	XXX	X	59.63	X
95872		004	XXX	X	276.59	X
95872	26	004	XXX	X	220.57	X
95872	TC	004	XXX	X	58.72	X
95872		001	XXX	X	299.51	X
95872	26	001	XXX	X	233.04	X
95872	TC	001	XXX	X	66.45	X
95872		002	XXX	X	446.84	X
95872	26	002	XXX	X	230.57	X
95872	TC	002	XXX	X	65.19	X
95873		004	ZZZ	X	52.87	X
95873	26	004	ZZZ	X	38.57	X
95873	TC	004	ZZZ	X	14.28	X
95873		002	ZZZ	X	52.87	X
95873	26	002	ZZZ	X	38.57	X
95873	TC	002	ZZZ	X	14.28	X
95873		003	ZZZ	X	52.87	X
95873	26	003	ZZZ	X	38.57	X
95873	TC	003	ZZZ	X	14.28	X
95873		001	ZZZ	X	60.29	X
95873	26	001	ZZZ	X	42.18	X
95873	TC	001	ZZZ	X	18.09	X
95874		001	ZZZ	X	61.07	X
95874	26	001	ZZZ	X	42.96	X
95874	TC	001	ZZZ	X	18.09	X
95874		004	ZZZ	X	53.47	X
95874	26	004	ZZZ	X	39.22	X
95874	TC	004	ZZZ	X	14.28	X
95874		003	ZZZ	X	53.47	X
95874	26	003	ZZZ	X	39.22	X
95874	TC	003	ZZZ	X	14.28	X
95874		002	ZZZ	X	53.47	X
95874	26	002	ZZZ	X	39.22	X
95874	TC	002	ZZZ	X	14.28	X
95875		001	XXX	X	212.95	X
95875	26	001	XXX	X	165.15	X
95875	TC	001	XXX	X	47.79	X
95875		003	XXX	X	199.08	X
95875	26	003	XXX	X	157.30	X
95875	TC	003	XXX	X	41.77	X
95875		002	XXX	X	210.26	X
95875	26	002	XXX	X	163.57	X
95875	TC	002	XXX	X	46.65	X
95875		004	XXX	X	196.93	X
95875	26	004	XXX	X	155.78	X
95875	TC	004	XXX	X	41.14	X
95885		004	ZZZ	X	87.89	X
95885	26	004	ZZZ	X	29.12	X
95885	TC	004	ZZZ	X	58.79	X
95885		003	ZZZ	X	87.89	X
95885	26	003	ZZZ	X	29.12	X
95885	TC	003	ZZZ	X	58.79	X
95885		002	ZZZ	X	87.89	X
95885	26	002	ZZZ	X	29.12	X
95885	TC	002	ZZZ	X	58.79	X
95885		001	ZZZ	X	99.39	X
95885	26	001	ZZZ	X	31.02	X
95885	TC	001	ZZZ	X	68.38	X
95886		001	ZZZ	X	155.07	X
95886	26	001	ZZZ	X	83.08	X
95886	TC	001	ZZZ	X	72.01	X
95886		003	ZZZ	X	139.71	X
95886	26	003	ZZZ	X	77.76	X
95886	TC	003	ZZZ	X	61.94	X
95886		002	ZZZ	X	139.71	X
95886	26	002	ZZZ	X	77.76	X
95886	TC	002	ZZZ	X	61.94	X
95886		004	ZZZ	X	139.71	X
95886	26	004	ZZZ	X	77.76	X
95886	TC	004	ZZZ	X	61.94	X
95887		002	ZZZ	X	123.96	X
95887	26	002	ZZZ	X	61.01	X
95887	TC	002	ZZZ	X	62.99	X
95887		003	ZZZ	X	123.96	X
95887	26	003	ZZZ	X	61.01	X
95887	TC	003	ZZZ	X	62.99	X
95887		004	ZZZ	X	123.96	X
95887	26	004	ZZZ	X	61.01	X
95887	TC	004	ZZZ	X	62.99	X
95887		001	ZZZ	X	138.25	X
95887	26	001	ZZZ	X	64.99	X
95887	TC	001	ZZZ	X	73.25	X
95905		001	XXX	X	148.31	X
95905	26	001	XXX	X	5.68	X
95905	TC	001	XXX	X	142.64	X
95905		002	XXX	X	125.15	X
95905	26	002	XXX	X	5.02	X
95905	TC	002	XXX	X	120.12	X
95905		003	XXX	X	125.15	X
95905	26	003	XXX	X	5.02	X
95905	TC	003	XXX	X	120.12	X
95905		004	XXX	X	125.15	X
95905	26	004	XXX	X	5.02	X
95905	TC	004	XXX	X	120.12	X
95907		001	XXX	X	162.82	X
95907	26	001	XXX	X	87.82	X
95907	TC	001	XXX	X	75.03	X
95907		002	XXX	X	146.45	X
95907	26	002	XXX	X	82.22	X
95907	TC	002	XXX	X	64.23	X
95907		004	XXX	X	146.45	X
95907	26	004	XXX	X	82.22	X
95907	TC	004	XXX	X	64.23	X
95907		003	XXX	X	146.45	X
95907	26	003	XXX	X	82.22	X
95907	TC	003	XXX	X	64.23	X
95908		002	XXX	X	180.72	X
95908	26	002	XXX	X	103.32	X
95908	TC	002	XXX	X	77.40	X
95908		001	XXX	X	200.73	X
95908	26	001	XXX	X	110.43	X
95908	TC	001	XXX	X	90.29	X
95908		004	XXX	X	180.72	X
95908	26	004	XXX	X	103.32	X
95908	TC	004	XXX	X	77.40	X
95908		003	XXX	X	180.72	X
95908	26	003	XXX	X	103.32	X
95908	TC	003	XXX	X	77.40	X
95909		003	XXX	X	216.62	X
95909	26	003	XXX	X	123.28	X
95909	TC	003	XXX	X	93.33	X
95909		002	XXX	X	216.62	X
95909	26	002	XXX	X	123.28	X
95909	TC	002	XXX	X	93.33	X
95909		001	XXX	X	240.73	X
95909	26	001	XXX	X	131.56	X
95909	TC	001	XXX	X	109.18	X
95909		004	XXX	X	216.62	X
95909	26	004	XXX	X	123.28	X
95909	TC	004	XXX	X	93.33	X
95910		001	XXX	X	316.86	X
95910	26	001	XXX	X	176.20	X
95910	TC	001	XXX	X	140.65	X
95910		004	XXX	X	285.30	X
95910	26	004	XXX	X	164.95	X
95910	TC	004	XXX	X	120.33	X
95910		003	XXX	X	285.30	X
95910	26	003	XXX	X	164.95	X
95910	TC	003	XXX	X	120.33	X
95910		002	XXX	X	285.30	X
95910	26	002	XXX	X	164.95	X
95910	TC	002	XXX	X	120.33	X
95911		004	XXX	X	345.83	X
95911	26	004	XXX	X	206.01	X
95911	TC	004	XXX	X	139.84	X
95911		003	XXX	X	345.83	X
95911	26	003	XXX	X	206.01	X
95911	TC	003	XXX	X	139.84	X
95911		002	XXX	X	345.83	X
95911	26	002	XXX	X	206.01	X
95911	TC	002	XXX	X	139.84	X
95911		001	XXX	X	383.56	X
95911	26	001	XXX	X	219.98	X
95911	TC	001	XXX	X	163.58	X
95912		002	XXX	X	405.36	X
95912	26	002	XXX	X	247.19	X
95912	TC	002	XXX	X	158.18	X
95912		003	XXX	X	405.36	X
95912	26	003	XXX	X	247.19	X
95912	TC	003	XXX	X	158.18	X
95912		004	XXX	X	405.36	X
95912	26	004	XXX	X	247.19	X
95912	TC	004	XXX	X	158.18	X
95912		001	XXX	X	449.14	X
95912	26	001	XXX	X	264.04	X
95912	TC	001	XXX	X	185.07	X
95913		001	XXX	X	520.40	X
95913	26	001	XXX	X	312.93	X
95913	TC	001	XXX	X	207.48	X
95913		002	XXX	X	470.30	X
95913	26	002	XXX	X	293.09	X
95913	TC	002	XXX	X	177.16	X
95913		003	XXX	X	470.30	X
95913	26	003	XXX	X	293.09	X
95913	TC	003	XXX	X	177.16	X
95913		004	XXX	X	470.30	X
95913	26	004	XXX	X	293.09	X
95913	TC	004	XXX	X	177.16	X
95919		002	XXX	X	17.54	X
95919	26	002	XXX	X	11.24	X
95919	TC	002	XXX	X	6.31	X
95919		003	XXX	X	17.54	X
95919	26	003	XXX	X	11.24	X
95919	TC	003	XXX	X	6.31	X
95919		004	XXX	X	17.54	X
95919	26	004	XXX	X	11.24	X
95919	TC	004	XXX	X	6.31	X
95919		001	XXX	X	19.33	X
95919	26	001	XXX	X	12.05	X
95919	TC	001	XXX	X	7.27	X
95921		001	XXX	X	113.29	X
95921	26	001	XXX	X	73.49	X
95921	TC	001	XXX	X	39.80	X
95921		003	XXX	X	98.81	X
95921	26	003	XXX	X	66.14	X
95921	TC	003	XXX	X	32.66	X
95921		002	XXX	X	101.46	X
95921	26	002	XXX	X	67.95	X
95921	TC	002	XXX	X	33.53	X
95921		004	XXX	X	98.81	X
95921	26	004	XXX	X	66.14	X
95921	TC	004	XXX	X	32.66	X
95922		003	XXX	X	103.65	X
95922	26	003	XXX	X	71.03	X
95922	TC	003	XXX	X	32.66	X
95922		004	XXX	X	103.65	X
95922	26	004	XXX	X	71.03	X
95922	TC	004	XXX	X	32.66	X
95922		002	XXX	X	106.50	X
95922	26	002	XXX	X	72.96	X
95922	TC	002	XXX	X	33.53	X
95922		001	XXX	X	119.08	X
95922	26	001	XXX	X	79.34	X
95922	TC	001	XXX	X	39.80	X
95923		004	XXX	X	98.81	X
95923	26	004	XXX	X	66.14	X
95923	TC	004	XXX	X	32.66	X
95923		001	XXX	X	113.29	X
95923	26	001	XXX	X	73.49	X
95923	TC	001	XXX	X	39.80	X
95923		002	XXX	X	101.46	X
95923	26	002	XXX	X	67.95	X
95923	TC	002	XXX	X	33.53	X
95923		003	XXX	X	98.81	X
95923	26	003	XXX	X	66.14	X
95923	TC	003	XXX	X	32.66	X
95924		001	XXX	X	253.67	X
95924	26	001	XXX	X	148.12	X
95924	TC	001	XXX	X	105.58	X
95924		002	XXX	X	229.41	X
95924	26	002	XXX	X	138.54	X
95924	TC	002	XXX	X	90.86	X
95924		003	XXX	X	229.41	X
95924	26	003	XXX	X	138.54	X
95924	TC	003	XXX	X	90.86	X
95924		004	XXX	X	229.41	X
95924	26	004	XXX	X	138.54	X
95924	TC	004	XXX	X	90.86	X
95925		001	XXX	X	307.98	X
95925	26	001	XXX	X	195.73	X
95925	TC	001	XXX	X	151.66	X
95925		003	XXX	X	296.47	X
95925	26	003	XXX	X	176.83	X
95925	TC	003	XXX	X	136.32	X
95925		004	XXX	X	289.22	X
95925	26	004	XXX	X	174.75	X
95925	TC	004	XXX	X	134.19	X
95925		002	XXX	X	301.59	X
95925	26	002	XXX	X	189.34	X
95925	TC	002	XXX	X	148.74	X
95926		004	XXX	X	193.69	X
95926	26	004	XXX	X	111.81	X
95926	TC	004	XXX	X	81.88	X
95926		003	XXX	X	197.11	X
95926	26	003	XXX	X	113.63	X
95926	TC	003	XXX	X	83.56	X
95926		002	XXX	X	213.35	X
95926	26	002	XXX	X	121.12	X
95926	TC	002	XXX	X	92.19	X
95926		001	XXX	X	223.35	X
95926	26	001	XXX	X	126.00	X
95926	TC	001	XXX	X	97.35	X
95927		004	XXX	X	193.69	X
95927	26	004	XXX	X	111.81	X
95927	TC	004	XXX	X	81.88	X
95927		003	XXX	X	197.11	X
95927	26	003	XXX	X	113.63	X
95927	TC	003	XXX	X	83.56	X
95927		001	XXX	X	223.35	X
95927	26	001	XXX	X	126.00	X
95927	TC	001	XXX	X	97.35	X
95927		002	XXX	X	213.35	X
95927	26	002	XXX	X	121.12	X
95927	TC	002	XXX	X	92.19	X
95928		002	XXX	X	343.92	X
95928	26	002	XXX	X	169.92	X
95928	TC	002	XXX	X	173.99	X
95928		004	XXX	X	343.92	X
95928	26	004	XXX	X	169.92	X
95928	TC	004	XXX	X	173.99	X
95928		003	XXX	X	343.92	X
95928	26	003	XXX	X	169.92	X
95928	TC	003	XXX	X	173.99	X
95928		001	XXX	X	393.99	X
95928	26	001	XXX	X	184.39	X
95928	TC	001	XXX	X	209.55	X
95929		004	XXX	X	357.64	X
95929	26	004	XXX	X	169.92	X
95929	TC	004	XXX	X	187.79	X
95929		003	XXX	X	357.64	X
95929	26	003	XXX	X	169.92	X
95929	TC	003	XXX	X	187.79	X
95929		002	XXX	X	357.64	X
95929	26	002	XXX	X	169.92	X
95929	TC	002	XXX	X	187.79	X
95929		001	XXX	X	410.51	X
95929	26	001	XXX	X	184.39	X
95929	TC	001	XXX	X	226.06	X
95930		003	XXX	X	112.37	X
95930	26	003	XXX	X	89.06	X
95930	TC	003	XXX	X	23.22	X
95930		004	XXX	X	110.43	X
95930	26	004	XXX	X	87.63	X
95930	TC	004	XXX	X	22.82	X
95930		001	XXX	X	126.25	X
95930	26	001	XXX	X	99.44	X
95930	TC	001	XXX	X	26.77	X
95930		002	XXX	X	121.06	X
95930	26	002	XXX	X	95.45	X
95930	TC	002	XXX	X	25.57	X
95933		003	XXX	X	188.64	X
95933	26	003	XXX	X	130.21	X
95933	TC	003	XXX	X	77.64	X
95933		004	XXX	X	186.05	X
95933	26	004	XXX	X	127.93	X
95933	TC	004	XXX	X	76.41	X
95933		001	XXX	X	203.81	X
95933	26	001	XXX	X	133.75	X
95933	TC	001	XXX	X	86.26	X
95933		002	XXX	X	203.33	X
95933	26	002	XXX	X	136.69	X
95933	TC	002	XXX	X	84.62	X

Fee Schedule 95807-95933

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