| Jurisdiction A DME MAC | ||||||||||||||
| 2006 DMEPOS Fee Schedule Amounts for Power Mobility Devices | ||||||||||||||
| Effective November 15, 2006 (Revised 4/1/2007) | ||||||||||||||
| Inclusion of a fee schedule amount for an item does not necessarily indicate coverage | ||||||||||||||
| HCPCS | MOD1 | MOD2 | CT | DC | DE | MA | MD | ME | NH | NJ | NY | PA | RI | VT |
| K0813 | NU | $2,412.40 | $2,412.40 | $2,412.40 | $2,412.40 | $2,412.40 | $2,412.40 | $2,412.40 | $2,412.40 | $2,412.40 | $2,412.40 | $2,412.40 | $2,412.40 | |
| K0813 | RR | $241.24 | $241.24 | $241.24 | $241.24 | $241.24 | $241.24 | $241.24 | $241.24 | $241.24 | $241.24 | $241.24 | $241.24 | |
| K0813 | UE | $1,809.30 | $1,809.30 | $1,809.30 | $1,809.30 | $1,809.30 | $1,809.30 | $1,809.30 | $1,809.30 | $1,809.30 | $1,809.30 | $1,809.30 | $1,809.30 | |
| K0814 | NU | $3,087.80 | $3,087.80 | $3,087.80 | $3,087.80 | $3,087.80 | $3,087.80 | $3,087.80 | $3,087.80 | $3,087.80 | $3,087.80 | $3,087.80 | $3,087.80 | |
| K0814 | RR | $308.78 | $308.78 | $308.78 | $308.78 | $308.78 | $308.78 | $308.78 | $308.78 | $308.78 | $308.78 | $308.78 | $308.78 | |
| K0814 | UE | $2,315.85 | $2,315.85 | $2,315.85 | $2,315.85 | $2,315.85 | $2,315.85 | $2,315.85 | $2,315.85 | $2,315.85 | $2,315.85 | $2,315.85 | $2,315.85 | |
| K0815 | NU | $3,516.30 | $3,516.30 | $3,516.30 | $3,516.30 | $3,516.30 | $3,516.30 | $3,516.30 | $3,516.30 | $3,516.30 | $3,516.30 | $3,516.30 | $3,516.30 | |
| K0815 | RR | $351.63 | $351.63 | $351.63 | $351.63 | $351.63 | $351.63 | $351.63 | $351.63 | $351.63 | $351.63 | $351.63 | $351.63 | |
| K0815 | UE | $2,637.23 | $2,637.23 | $2,637.23 | $2,637.23 | $2,637.23 | $2,637.23 | $2,637.23 | $2,637.23 | $2,637.23 | $2,637.23 | $2,637.23 | $2,637.23 | |
| K0816 | NU | $3,367.40 | $3,367.40 | $3,367.40 | $3,367.40 | $3,367.40 | $3,367.40 | $3,367.40 | $3,367.40 | $3,367.40 | $3,367.40 | $3,367.40 | $3,367.40 | |
| K0816 | RR | $336.74 | $336.74 | $336.74 | $336.74 | $336.74 | $336.74 | $336.74 | $336.74 | $336.74 | $336.74 | $336.74 | $336.74 | |
| K0816 | UE | $2,525.55 | $2,525.55 | $2,525.55 | $2,525.55 | $2,525.55 | $2,525.55 | $2,525.55 | $2,525.55 | $2,525.55 | $2,525.55 | $2,525.55 | $2,525.55 | |
| K0820 | NU | $2,576.60 | $2,576.60 | $2,576.60 | $2,576.60 | $2,576.60 | $2,576.60 | $2,576.60 | $2,576.60 | $2,576.60 | $2,576.60 | $2,576.60 | $2,576.60 | |
| K0820 | RR | $257.66 | $257.66 | $257.66 | $257.66 | $257.66 | $257.66 | $257.66 | $257.66 | $257.66 | $257.66 | $257.66 | $257.66 | |
| K0820 | UE | $1,932.45 | $1,932.45 | $1,932.45 | $1,932.45 | $1,932.45 | $1,932.45 | $1,932.45 | $1,932.45 | $1,932.45 | $1,932.45 | $1,932.45 | $1,932.45 | |
| K0821 | NU | $3,307.70 | $3,307.70 | $3,307.70 | $3,307.70 | $3,307.70 | $3,307.70 | $3,307.70 | $3,307.70 | $3,307.70 | $3,307.70 | $3,307.70 | $3,307.70 | |
| K0821 | RR | $330.77 | $330.77 | $330.77 | $330.77 | $330.77 | $330.77 | $330.77 | $330.77 | $330.77 | $330.77 | $330.77 | $330.77 | |
| K0821 | UE | $2,480.78 | $2,480.78 | $2,480.78 | $2,480.78 | $2,480.78 | $2,480.78 | $2,480.78 | $2,480.78 | $2,480.78 | $2,480.78 | $2,480.78 | $2,480.78 | |
| K0822 | NU | $4,008.10 | $4,008.10 | $4,008.10 | $4,008.10 | $4,008.10 | $4,008.10 | $4,008.10 | $4,008.10 | $4,008.10 | $4,008.10 | $4,008.10 | $4,008.10 | |
| K0822 | RR | $400.81 | $400.81 | $400.81 | $400.81 | $400.81 | $400.81 | $400.81 | $400.81 | $400.81 | $400.81 | $400.81 | $400.81 | |
| K0822 | UE | $3,006.08 | $3,006.08 | $3,006.08 | $3,006.08 | $3,006.08 | $3,006.08 | $3,006.08 | $3,006.08 | $3,006.08 | $3,006.08 | $3,006.08 | $3,006.08 | |
| K0823 | NU | $4,023.70 | $4,023.70 | $4,023.70 | $4,023.70 | $4,023.70 | $4,023.70 | $4,023.70 | $4,023.70 | $4,023.70 | $4,023.70 | $4,023.70 | $4,023.70 | |
| K0823 | RR | $402.37 | $402.37 | $402.37 | $402.37 | $402.37 | $402.37 | $402.37 | $402.37 | $402.37 | $402.37 | $402.37 | $402.37 | |
| K0823 | UE | $3,017.78 | $3,017.78 | $3,017.78 | $3,017.78 | $3,017.78 | $3,017.78 | $3,017.78 | $3,017.78 | $3,017.78 | $3,017.78 | $3,017.78 | $3,017.78 | |
| K0824 | NU | $4,842.70 | $4,842.70 | $4,842.70 | $4,842.70 | $4,842.70 | $4,842.70 | $4,842.70 | $4,842.70 | $4,842.70 | $4,842.70 | $4,842.70 | $4,842.70 | |
| K0824 | RR | $484.27 | $484.27 | $484.27 | $484.27 | $484.27 | $484.27 | $484.27 | $484.27 | $484.27 | $484.27 | $484.27 | $484.27 | |
| K0824 | UE | $3,632.03 | $3,632.03 | $3,632.03 | $3,632.03 | $3,632.03 | $3,632.03 | $3,632.03 | $3,632.03 | $3,632.03 | $3,632.03 | $3,632.03 | $3,632.03 | |
| K0825 | NU | $4,433.20 | $4,433.20 | $4,433.20 | $4,433.20 | $4,433.20 | $4,433.20 | $4,433.20 | $4,433.20 | $4,433.20 | $4,433.20 | $4,433.20 | $4,433.20 | |
| K0825 | RR | $443.32 | $443.32 | $443.32 | $443.32 | $443.32 | $443.32 | $443.32 | $443.32 | $443.32 | $443.32 | $443.32 | $443.32 | |
| K0825 | UE | $3,324.90 | $3,324.90 | $3,324.90 | $3,324.90 | $3,324.90 | $3,324.90 | $3,324.90 | $3,324.90 | $3,324.90 | $3,324.90 | $3,324.90 | $3,324.90 | |
| K0826 | NU | $6,269.30 | $6,269.30 | $6,269.30 | $6,269.30 | $6,269.30 | $6,269.30 | $6,269.30 | $6,269.30 | $6,269.30 | $6,269.30 | $6,269.30 | $6,269.30 | |
| K0826 | RR | $626.93 | $626.93 | $626.93 | $626.93 | $626.93 | $626.93 | $626.93 | $626.93 | $626.93 | $626.93 | $626.93 | $626.93 | |
| K0826 | UE | $4,701.98 | $4,701.98 | $4,701.98 | $4,701.98 | $4,701.98 | $4,701.98 | $4,701.98 | $4,701.98 | $4,701.98 | $4,701.98 | $4,701.98 | $4,701.98 | |
| K0827 | NU | $4,809.30 | $4,809.30 | $4,809.30 | $4,809.30 | $4,809.30 | $4,809.30 | $4,809.30 | $4,809.30 | $4,809.30 | $4,809.30 | $4,809.30 | $4,809.30 | |
| K0827 | RR | $480.93 | $480.93 | $480.93 | $480.93 | $480.93 | $480.93 | $480.93 | $480.93 | $480.93 | $480.93 | $480.93 | $480.93 | |
| K0827 | UE | $3,606.98 | $3,606.98 | $3,606.98 | $3,606.98 | $3,606.98 | $3,606.98 | $3,606.98 | $3,606.98 | $3,606.98 | $3,606.98 | $3,606.98 | $3,606.98 | |
| K0828 | NU | $6,908.20 | $6,908.20 | $6,908.20 | $6,908.20 | $6,908.20 | $6,908.20 | $6,908.20 | $6,908.20 | $6,908.20 | $6,908.20 | $6,908.20 | $6,908.20 | |
| K0828 | RR | $690.82 | $690.82 | $690.82 | $690.82 | $690.82 | $690.82 | $690.82 | $690.82 | $690.82 | $690.82 | $690.82 | $690.82 | |
| K0828 | UE | $5,181.15 | $5,181.15 | $5,181.15 | $5,181.15 | $5,181.15 | $5,181.15 | $5,181.15 | $5,181.15 | $5,181.15 | $5,181.15 | $5,181.15 | $5,181.15 | |
| K0829 | NU | $6,011.80 | $6,011.80 | $6,011.80 | $6,011.80 | $6,011.80 | $6,011.80 | $6,011.80 | $6,011.80 | $6,011.80 | $6,011.80 | $6,011.80 | $6,011.80 | |
| K0829 | RR | $601.18 | $601.18 | $601.18 | $601.18 | $601.18 | $601.18 | $601.18 | $601.18 | $601.18 | $601.18 | $601.18 | $601.18 | |
| K0829 | UE | $4,508.85 | $4,508.85 | $4,508.85 | $4,508.85 | $4,508.85 | $4,508.85 | $4,508.85 | $4,508.85 | $4,508.85 | $4,508.85 | $4,508.85 | $4,508.85 | |
| K0830 | NU | $3,914.10 | $3,914.10 | $3,914.10 | $3,914.10 | $3,914.10 | $3,914.10 | $3,914.10 | $3,914.10 | $3,914.10 | $3,914.10 | $3,914.10 | $3,914.10 | |
| K0830 | RR | $391.41 | $391.41 | $391.41 | $391.41 | $391.41 | $391.41 | $391.41 | $391.41 | $391.41 | $391.41 | $391.41 | $391.41 | |
| K0830 | UE | $2,935.58 | $2,935.58 | $2,935.58 | $2,935.58 | $2,935.58 | $2,935.58 | $2,935.58 | $2,935.58 | $2,935.58 | $2,935.58 | $2,935.58 | $2,935.58 | |
| K0831 | NU | $3,914.10 | $3,914.10 | $3,914.10 | $3,914.10 | $3,914.10 | $3,914.10 | $3,914.10 | $3,914.10 | $3,914.10 | $3,914.10 | $3,914.10 | $3,914.10 | |
| K0831 | RR | $391.41 | $391.41 | $391.41 | $391.41 | $391.41 | $391.41 | $391.41 | $391.41 | $391.41 | $391.41 | $391.41 | $391.41 | |
| K0831 | UE | $2,935.58 | $2,935.58 | $2,935.58 | $2,935.58 | $2,935.58 | $2,935.58 | $2,935.58 | $2,935.58 | $2,935.58 | $2,935.58 | $2,935.58 | $2,935.58 | |
| K0835 | NU | $4,132.30 | $4,132.30 | $4,132.30 | $4,132.30 | $4,132.30 | $4,132.30 | $4,132.30 | $4,132.30 | $4,132.30 | $4,132.30 | $4,132.30 | $4,132.30 | |
| K0835 | RR | $413.23 | $413.23 | $413.23 | $413.23 | $413.23 | $413.23 | $413.23 | $413.23 | $413.23 | $413.23 | $413.23 | $413.23 | |
| K0835 | UE | $3,099.23 | $3,099.23 | $3,099.23 | $3,099.23 | $3,099.23 | $3,099.23 | $3,099.23 | $3,099.23 | $3,099.23 | $3,099.23 | $3,099.23 | $3,099.23 | |
| K0836 | NU | $4,207.50 | $4,207.50 | $4,207.50 | $4,207.50 | $4,207.50 | $4,207.50 | $4,207.50 | $4,207.50 | $4,207.50 | $4,207.50 | $4,207.50 | $4,207.50 | |
| K0836 | RR | $420.75 | $420.75 | $420.75 | $420.75 | $420.75 | $420.75 | $420.75 | $420.75 | $420.75 | $420.75 | $420.75 | $420.75 | |
| K0836 | UE | $3,155.63 | $3,155.63 | $3,155.63 | $3,155.63 | $3,155.63 | $3,155.63 | $3,155.63 | $3,155.63 | $3,155.63 | $3,155.63 | $3,155.63 | $3,155.63 | |
| K0837 | NU | $4,842.70 | $4,842.70 | $4,842.70 | $4,842.70 | $4,842.70 | $4,842.70 | $4,842.70 | $4,842.70 | $4,842.70 | $4,842.70 | $4,842.70 | $4,842.70 | |
| K0837 | RR | $484.27 | $484.27 | $484.27 | $484.27 | $484.27 | $484.27 | $484.27 | $484.27 | $484.27 | $484.27 | $484.27 | $484.27 | |
| K0837 | UE | $3,632.03 | $3,632.03 | $3,632.03 | $3,632.03 | $3,632.03 | $3,632.03 | $3,632.03 | $3,632.03 | $3,632.03 | $3,632.03 | $3,632.03 | $3,632.03 | |
| K0838 | NU | $4,372.20 | $4,372.20 | $4,372.20 | $4,372.20 | $4,372.20 | $4,372.20 | $4,372.20 | $4,372.20 | $4,372.20 | $4,372.20 | $4,372.20 | $4,372.20 | |
| K0838 | RR | $437.22 | $437.22 | $437.22 | $437.22 | $437.22 | $437.22 | $437.22 | $437.22 | $437.22 | $437.22 | $437.22 | $437.22 | |
| K0838 | UE | $3,279.15 | $3,279.15 | $3,279.15 | $3,279.15 | $3,279.15 | $3,279.15 | $3,279.15 | $3,279.15 | $3,279.15 | $3,279.15 | $3,279.15 | $3,279.15 | |
| K0839 | NU | $6,269.30 | $6,269.30 | $6,269.30 | $6,269.30 | $6,269.30 | $6,269.30 | $6,269.30 | $6,269.30 | $6,269.30 | $6,269.30 | $6,269.30 | $6,269.30 | |
| K0839 | RR | $626.93 | $626.93 | $626.93 | $626.93 | $626.93 | $626.93 | $626.93 | $626.93 | $626.93 | $626.93 | $626.93 | $626.93 | |
| K0839 | UE | $4,701.98 | $4,701.98 | $4,701.98 | $4,701.98 | $4,701.98 | $4,701.98 | $4,701.98 | $4,701.98 | $4,701.98 | $4,701.98 | $4,701.98 | $4,701.98 | |
| K0840 | NU | $9,498.30 | $9,498.30 | $9,498.30 | $9,498.30 | $9,498.30 | $9,498.30 | $9,498.30 | $9,498.30 | $9,498.30 | $9,498.30 | $9,498.30 | $9,498.30 | |
| K0840 | RR | $949.83 | $949.83 | $949.83 | $949.83 | $949.83 | $949.83 | $949.83 | $949.83 | $949.83 | $949.83 | $949.83 | $949.83 | |
| K0840 | UE | $7,123.73 | $7,123.73 | $7,123.73 | $7,123.73 | $7,123.73 | $7,123.73 | $7,123.73 | $7,123.73 | $7,123.73 | $7,123.73 | $7,123.73 | $7,123.73 | |
| K0841 | NU | $4,318.60 | $4,318.60 | $4,318.60 | $4,318.60 | $4,318.60 | $4,318.60 | $4,318.60 | $4,318.60 | $4,318.60 | $4,318.60 | $4,318.60 | $4,318.60 | |
| K0841 | RR | $431.86 | $431.86 | $431.86 | $431.86 | $431.86 | $431.86 | $431.86 | $431.86 | $431.86 | $431.86 | $431.86 | $431.86 | |
| K0841 | UE | $3,238.95 | $3,238.95 | $3,238.95 | $3,238.95 | $3,238.95 | $3,238.95 | $3,238.95 | $3,238.95 | $3,238.95 | $3,238.95 | $3,238.95 | $3,238.95 | |
| K0842 | NU | $4,318.60 | $4,318.60 | $4,318.60 | $4,318.60 | $4,318.60 | $4,318.60 | $4,318.60 | $4,318.60 | $4,318.60 | $4,318.60 | $4,318.60 | $4,318.60 | |
| K0842 | RR | $431.86 | $431.86 | $431.86 | $431.86 | $431.86 | $431.86 | $431.86 | $431.86 | $431.86 | $431.86 | $431.86 | $431.86 | |
| K0842 | UE | $3,238.95 | $3,238.95 | $3,238.95 | $3,238.95 | $3,238.95 | $3,238.95 | $3,238.95 | $3,238.95 | $3,238.95 | $3,238.95 | $3,238.95 | $3,238.95 | |
| K0843 | NU | $5,199.60 | $5,199.60 | $5,199.60 | $5,199.60 | $5,199.60 | $5,199.60 | $5,199.60 | $5,199.60 | $5,199.60 | $5,199.60 | $5,199.60 | $5,199.60 | |
| K0843 | RR | $519.96 | $519.96 | $519.96 | $519.96 | $519.96 | $519.96 | $519.96 | $519.96 | $519.96 | $519.96 | $519.96 | $519.96 | |
| K0843 | UE | $3,899.70 | $3,899.70 | $3,899.70 | $3,899.70 | $3,899.70 | $3,899.70 | $3,899.70 | $3,899.70 | $3,899.70 | $3,899.70 | $3,899.70 | $3,899.70 | |
| K0848 | NU | $5,433.60 | $5,433.60 | $5,433.60 | $5,433.60 | $5,433.60 | $5,433.60 | $5,433.60 | $5,433.60 | $5,433.60 | $5,433.60 | $5,433.60 | $5,433.60 | |
| K0848 | RR | $543.36 | $543.36 | $543.36 | $543.36 | $543.36 | $543.36 | $543.36 | $543.36 | $543.36 | $543.36 | $543.36 | $543.36 | |
| K0848 | UE | $4,075.20 | $4,075.20 | $4,075.20 | $4,075.20 | $4,075.20 | $4,075.20 | $4,075.20 | $4,075.20 | $4,075.20 | $4,075.20 | $4,075.20 | $4,075.20 | |
| K0849 | NU | $5,080.70 | $5,080.70 | $5,080.70 | $5,080.70 | $5,080.70 | $5,080.70 | $5,080.70 | $5,080.70 | $5,080.70 | $5,080.70 | $5,080.70 | $5,080.70 | |
| K0849 | RR | $508.07 | $508.07 | $508.07 | $508.07 | $508.07 | $508.07 | $508.07 | $508.07 | $508.07 | $508.07 | $508.07 | $508.07 | |
| K0849 | UE | $3,810.53 | $3,810.53 | $3,810.53 | $3,810.53 | $3,810.53 | $3,810.53 | $3,810.53 | $3,810.53 | $3,810.53 | $3,810.53 | $3,810.53 | $3,810.53 | |
| K0850 | NU | $6,302.80 | $6,302.80 | $6,302.80 | $6,302.80 | $6,302.80 | $6,302.80 | $6,302.80 | $6,302.80 | $6,302.80 | $6,302.80 | $6,302.80 | $6,302.80 | |
| K0850 | RR | $630.28 | $630.28 | $630.28 | $630.28 | $630.28 | $630.28 | $630.28 | $630.28 | $630.28 | $630.28 | $630.28 | $630.28 | |
| K0850 | UE | $4,727.10 | $4,727.10 | $4,727.10 | $4,727.10 | $4,727.10 | $4,727.10 | $4,727.10 | $4,727.10 | $4,727.10 | $4,727.10 | $4,727.10 | $4,727.10 | |
| K0851 | NU | $5,893.70 | $5,893.70 | $5,893.70 | $5,893.70 | $5,893.70 | $5,893.70 | $5,893.70 | $5,893.70 | $5,893.70 | $5,893.70 | $5,893.70 | $5,893.70 | |
| K0851 | RR | $589.37 | $589.37 | $589.37 | $589.37 | $589.37 | $589.37 | $589.37 | $589.37 | $589.37 | $589.37 | $589.37 | $589.37 | |
| K0851 | UE | $4,420.28 | $4,420.28 | $4,420.28 | $4,420.28 | $4,420.28 | $4,420.28 | $4,420.28 | $4,420.28 | $4,420.28 | $4,420.28 | $4,420.28 | $4,420.28 | |
| K0852 | NU | $7,082.60 | $7,082.60 | $7,082.60 | $7,082.60 | $7,082.60 | $7,082.60 | $7,082.60 | $7,082.60 | $7,082.60 | $7,082.60 | $7,082.60 | $7,082.60 | |
| K0852 | RR | $708.26 | $708.26 | $708.26 | $708.26 | $708.26 | $708.26 | $708.26 | $708.26 | $708.26 | $708.26 | $708.26 | $708.26 | |
| K0852 | UE | $5,311.95 | $5,311.95 | $5,311.95 | $5,311.95 | $5,311.95 | $5,311.95 | $5,311.95 | $5,311.95 | $5,311.95 | $5,311.95 | $5,311.95 | $5,311.95 | |
| K0853 | NU | $7,275.60 | $7,275.60 | $7,275.60 | $7,275.60 | $7,275.60 | $7,275.60 | $7,275.60 | $7,275.60 | $7,275.60 | $7,275.60 | $7,275.60 | $7,275.60 | |
| K0853 | RR | $727.56 | $727.56 | $727.56 | $727.56 | $727.56 | $727.56 | $727.56 | $727.56 | $727.56 | $727.56 | $727.56 | $727.56 | |
| K0853 | UE | $5,456.70 | $5,456.70 | $5,456.70 | $5,456.70 | $5,456.70 | $5,456.70 | $5,456.70 | $5,456.70 | $5,456.70 | $5,456.70 | $5,456.70 | $5,456.70 | |
| K0854 | NU | $9,638.60 | $9,638.60 | $9,638.60 | $9,638.60 | $9,638.60 | $9,638.60 | $9,638.60 | $9,638.60 | $9,638.60 | $9,638.60 | $9,638.60 | $9,638.60 | |
| K0854 | RR | $963.86 | $963.86 | $963.86 | $963.86 | $963.86 | $963.86 | $963.86 | $963.86 | $963.86 | $963.86 | $963.86 | $963.86 | |
| K0854 | UE | $7,228.95 | $7,228.95 | $7,228.95 | $7,228.95 | $7,228.95 | $7,228.95 | $7,228.95 | $7,228.95 | $7,228.95 | $7,228.95 | $7,228.95 | $7,228.95 | |
| K0855 | NU | $9,105.10 | $9,105.10 | $9,105.10 | $9,105.10 | $9,105.10 | $9,105.10 | $9,105.10 | $9,105.10 | $9,105.10 | $9,105.10 | $9,105.10 | $9,105.10 | |
| K0855 | RR | $910.51 | $910.51 | $910.51 | $910.51 | $910.51 | $910.51 | $910.51 | $910.51 | $910.51 | $910.51 | $910.51 | $910.51 | |
| K0855 | UE | $6,828.83 | $6,828.83 | $6,828.83 | $6,828.83 | $6,828.83 | $6,828.83 | $6,828.83 | $6,828.83 | $6,828.83 | $6,828.83 | $6,828.83 | $6,828.83 | |
| K0856 | NU | $5,672.30 | $5,672.30 | $5,672.30 | $5,672.30 | $5,672.30 | $5,672.30 | $5,672.30 | $5,672.30 | $5,672.30 | $5,672.30 | $5,672.30 | $5,672.30 | |
| K0856 | RR | $567.23 | $567.23 | $567.23 | $567.23 | $567.23 | $567.23 | $567.23 | $567.23 | $567.23 | $567.23 | $567.23 | $567.23 | |
| K0856 | UE | $4,254.23 | $4,254.23 | $4,254.23 | $4,254.23 | $4,254.23 | $4,254.23 | $4,254.23 | $4,254.23 | $4,254.23 | $4,254.23 | $4,254.23 | $4,254.23 | |
| K0857 | NU | $5,786.00 | $5,786.00 | $5,786.00 | $5,786.00 | $5,786.00 | $5,786.00 | $5,786.00 | $5,786.00 | $5,786.00 | $5,786.00 | $5,786.00 | $5,786.00 | |
| K0857 | RR | $578.60 | $578.60 | |||||||||||