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2024 Workers' Compensation Part B Fee Schedule

47135-49423

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CPT/HCPC Code Modifier Medicare Location Global Surgery Indicator Multiple Surgery Indicator Prevailing Charge Amount Fee Schedule Amount Site of Service Amount
47135   001 90 2 X 24,631.78 X
47135   004 90 2 X 24,631.78 X
47135   002 90 2 X 24,631.78 X
47135   003 90 2 X 24,631.78 X
47140   001 90 2 X 7,111.22 X
47140   003 90 2 X 6,471.08 X
47140   002 90 2 X 6,471.08 X
47140   004 90 2 X 6,471.08 X
47141   004 90 2 X 7,832.75 X
47141   002 90 2 X 7,832.75 X
47141   003 90 2 X 7,832.75 X
47141   001 90 2 X 8,557.60 X
47142   004 90 2 X 8,634.13 X
47142   003 90 2 X 8,634.13 X
47142   002 90 2 X 8,634.13 X
47142   001 90 2 X 9,407.03 X
47143     XXX 2 X * X
47144     90 2 X * X
47145     XXX 2 X * X
47146   002 XXX 2 X 677.38 X
47146   003 XXX 2 X 677.38 X
47146   001 XXX 2 X 754.62 X
47146   004 XXX 2 X 677.38 X
47147   004 XXX 2 X 790.28 X
47147   001 XXX 2 X 880.45 X
47147   002 XXX 2 X 790.28 X
47147   003 XXX 2 X 790.28 X
47300   003 90 2 X 2,297.78 X
47300   001 90 2 X 2,063.25 X
47300   002 90 2 X 2,424.31 X
47300   004 90 2 X 1,858.85 X
47350   004 90 2 X 2,093.86 X
47350   002 90 2 X 2,265.15 X
47350   003 90 2 X 2,117.71 X
47350   001 90 2 X 2,300.84 X
47360   003 90 2 X 2,973.51 X
47360   002 90 2 X 3,185.76 X
47360   004 90 2 X 2,939.66 X
47360   001 90 2 X 3,237.25 X
47361   001 90 2 X 5,576.69 X
47361   003 90 2 X 5,036.74 X
47361   002 90 2 X 5,334.67 X
47361   004 90 2 X 4,967.04 X
47362   003 90 2 X 1,799.17 X
47362   002 90 2 X 1,905.58 X
47362   001 90 2 X 1,992.18 X
47362   004 90 2 X 1,774.24 X
47370   002 90 2 X 2,059.41 X
47370   003 90 2 X 2,059.41 X
47370   004 90 2 X 2,059.41 X
47370   001 90 2 X 2,250.03 X
47371   002 90 2 X 1,940.75 X
47371   003 90 2 X 1,940.75 X
47371   004 90 2 X 1,940.75 X
47371   001 90 2 X 2,122.74 X
47379     YYY 2 X # X
47380   004 90 2 X 2,420.86 X
47380   002 90 2 X 2,420.86 X
47380   003 90 2 X 2,420.86 X
47380   001 90 2 X 2,637.72 X
47381   004 90 2 X 2,392.90 X
47381   003 90 2 X 2,392.90 X
47381   002 90 2 X 2,392.90 X
47381   001 90 2 X 2,607.83 X
47382   001 10 2 X 1,584.34 X
47382   004 10 2 X 1,434.76 X
47382   002 10 2 X 1,434.76 X
47382   003 10 2 X 1,434.76 X
47383   001 10 2 X 13,229.02 864.74
47383   004 10 2 X 11,364.10 797.02
47383   003 10 2 X 11,364.10 797.02
47383   002 10 2 X 11,364.10 797.02
47399     YYY 2 X # X
47400   001 90 2 X 2,616.18 X
47400   002 90 2 X 2,533.94 X
47400   003 90 2 X 3,020.14 X
47400   004 90 2 X 2,987.08 X
47420   004 90 2 X 2,771.84 X
47420   002 90 2 X 2,997.40 X
47420   003 90 2 X 2,803.13 X
47420   001 90 2 X 3,044.65 X
47425   001 90 2 X 3,308.46 X
47425   003 90 2 X 3,023.78 X
47425   002 90 2 X 3,252.86 X
47425   004 90 2 X 2,989.13 X
47460   004 90 2 X 3,215.14 X
47460   001 90 2 X 3,350.61 X
47460   003 90 2 X 3,231.17 X
47460   002 90 2 X 3,300.96 X
47480   002 90 2 X 2,061.06 X
47480   003 90 2 X 1,991.55 X
47480   001 90 2 X 2,160.56 X
47480   004 90 2 X 1,950.32 X
47490   003 10 2 X 947.88 X
47490   002 10 2 X 954.29 X
47490   004 10 2 X 967.01 X
47490   001 10 2 X 1,028.92 X
47531   004 0 2 X 546.56 149.04
47531   002 0 2 X 546.56 149.04
47531   001 0 2 X 625.85 160.70
47531   003 0 2 X 546.56 149.04
47532   001 0 2 X 1,377.16 362.34
47532   004 0 2 X 1,204.43 337.07
47532   003 0 2 X 1,204.43 337.07
47532   002 0 2 X 1,204.43 337.07
47533   002 0 2 X 1,961.34 477.60
47533   003 0 2 X 1,961.34 477.60
47533   004 0 2 X 1,961.34 477.60
47533   001 0 2 X 2,250.12 514.04
47534   001 0 2 X 2,771.53 681.67
47534   003 0 2 X 2,419.91 633.84
47534   002 0 2 X 2,419.91 633.84
47534   004 0 2 X 2,419.91 633.84
47535   004 0 2 X 1,619.63 364.46
47535   002 0 2 X 1,619.63 364.46
47535   003 0 2 X 1,619.63 364.46
47535   001 0 2 X 1,861.82 393.13
47536   003 0 2 X 1,192.90 229.89
47536   002 0 2 X 1,192.90 229.89
47536   004 0 2 X 1,192.90 229.89
47536   001 0 2 X 1,373.84 247.01
47537   002 0 2 X 591.73 155.00
47537   003 0 2 X 591.73 155.00
47537   001 0 2 X 678.83 167.84
47537   004 0 2 X 591.73 155.00
47538   002 0 2 X 6,544.26 513.62
47538   003 0 2 X 6,544.26 513.62
47538   004 0 2 X 6,544.26 513.62
47538   001 0 2 X 7,606.83 550.52
47539   003 0 2 X 7,158.95 694.64
47539   002 0 2 X 7,158.95 694.64
47539   004 0 2 X 7,158.95 694.64
47539   001 0 2 X 8,307.73 744.00
47540   001 0 2 X 8,633.41 888.04
47540   004 0 2 X 7,448.75 829.17
47540   003 0 2 X 7,448.75 829.17
47540   002 0 2 X 7,448.75 829.17
47541   001 0 2 X 1,985.26 474.29
47541   004 0 2 X 1,732.88 441.56
47541   003 0 2 X 1,732.88 441.56
47541   002 0 2 X 1,732.88 441.56
47542   004 ZZZ 0 X 759.84 209.09
47542   002 ZZZ 0 X 759.84 209.09
47542   003 ZZZ 0 X 759.84 209.09
47542   001 ZZZ 0 X 872.15 227.77
47543   001 ZZZ 0 X 2,241.28 286.62
47543   004 ZZZ 0 X 1,933.18 262.65
47543   002 ZZZ 0 X 1,933.18 262.65
47543   003 ZZZ 0 X 1,933.18 262.65
47544   002 ZZZ 0 X 1,199.83 336.58
47544   003 ZZZ 0 X 1,199.83 336.58
47544   001 ZZZ 0 X 1,372.12 362.04
47544   004 ZZZ 0 X 1,199.83 336.58
47550   001 ZZZ 0 X 558.77 X
47550   004 ZZZ 0 X 510.69 X
47550   002 ZZZ 0 X 550.46 X
47550   003 ZZZ 0 X 516.20 X
47552   003 0 2 X 802.59 X
47552   002 0 2 X 836.62 X
47552   001 0 2 X 844.96 X
47552   004 0 2 X 824.95 X
47553   003 0 3 X 1,055.04 X
47553   001 0 3 X 1,112.58 X
47553   002 0 3 X 1,120.44 X
47553   004 0 3 X 1,043.14 X
47554   004 0 3 X 1,417.69 X
47554   003 0 3 X 1,433.26 X
47554   002 0 3 X 1,513.46 X
47554   001 0 3 X 1,532.85 X
47555   004 0 3 X 1,019.99 X
47555   001 0 3 X 1,085.32 X
47555   003 0 3 X 1,031.07 X
47555   002 0 3 X 1,078.83 X
47556   001 0 3 X 1,180.80 X
47556   004 0 3 X 1,119.27 X
47556   002 0 3 X 1,173.08 X
47556   003 0 3 X 1,141.55 X
47562   004 90 2 X 1,617.15 X
47562   001 90 2 X 1,804.60 X
47562   003 90 2 X 1,617.15 X
47562   002 90 2 X 1,617.15 X
47563   003 90 2 X 1,739.64 X
47563   002 90 2 X 1,739.64 X
47563   001 90 2 X 1,941.16 X
47563   004 90 2 X 1,739.64 X
47564   002 90 2 X 2,066.12 X
47564   003 90 2 X 2,066.12 X
47564   004 90 2 X 2,066.12 X
47564   001 90 2 X 2,304.02 X
47570   001 90 2 X 2,074.21 X
47570   003 90 2 X 1,856.43 X
47570   002 90 2 X 1,856.43 X
47570   004 90 2 X 1,856.43 X
47579     YYY 2 X # X
47600   001 90 2 X 2,296.90 X
47600   002 90 2 X 2,263.85 X
47600   003 90 2 X 2,109.86 X
47600   004 90 2 X 2,080.34 X
47605   002 90 2 X 2,422.63 X
47605   003 90 2 X 2,251.34 X
47605   001 90 2 X 2,456.56 X
47605   004 90 2 X 2,208.56 X
47610   001 90 2 X 2,857.77 X
47610   004 90 2 X 2,583.61 X
47610   002 90 2 X 2,818.10 X
47610   003 90 2 X 2,642.65 X
47612   004 90 2 X 3,769.55 X
47612   002 90 2 X 3,974.15 X
47612   003 90 2 X 3,823.13 X
47612   001 90 2 X 3,966.63 X
47620   001 90 2 X 3,350.94 X
47620   002 90 2 X 3,296.40 X
47620   003 90 2 X 3,129.90 X
47620   004 90 2 X 3,104.87 X
47700   001 90 2 X 2,916.56 X
47700   004 90 2 X 2,940.56 X
47700   003 90 2 X 2,884.51 X
47700   002 90 2 X 2,959.18 X
47701   004 90 2 X 3,819.32 X
47701   001 90 2 X 4,122.26 X
47701   002 90 2 X 4,070.59 X
47701   003 90 2 X 3,859.19 X
47711   002 90 2 X 3,688.59 X
47711   003 90 2 X 3,447.39 X
47711   004 90 2 X 3,408.74 X
47711   001 90 2 X 3,747.17 X
47712   001 90 2 X 3,747.17 X
47712   004 90 2 X 3,408.74 X
47712   003 90 2 X 3,447.39 X
47712   002 90 2 X 3,688.59 X
47715   001 90 2 X 2,771.08 X
47715   004 90 2 X 2,530.27 X
47715   003 90 2 X 2,558.58 X
47715   002 90 2 X 2,729.57 X
47720   001 90 2 X 2,869.20 X
47720   003 90 2 X 2,497.30 X
47720   002 90 2 X 2,850.74 X
47720   004 90 2 X 2,374.02 X
47721   004 90 2 X 2,922.99 X
47721   001 90 2 X 3,239.34 X
47721   002 90 2 X 3,184.16 X
47721   003 90 2 X 2,956.72 X
47740   004 90 2 X 3,187.49 X
47740   001 90 2 X 3,306.12 X
47740   003 90 2 X 3,200.54 X
47740   002 90 2 X 3,285.53 X
47741   001 90 2 X 4,586.43 X
47741   004 90 2 X 4,261.78 X
47741   003 90 2 X 4,292.69 X
47741   002 90 2 X 4,503.68 X
47760   001 90 2 X 3,873.31 X
47760   002 90 2 X 3,813.65 X
47760   003 90 2 X 3,567.92 X
47760   004 90 2 X 3,528.53 X
47765   004 90 2 X 3,781.49 X
47765   003 90 2 X 4,126.19 X
47765   002 90 2 X 4,360.45 X
47765   001 90 2 X 4,306.90 X
47780   002 90 2 X 4,053.98 X
47780   003 90 2 X 3,788.60 X
47780   004 90 2 X 3,746.15 X
47780   001 90 2 X 4,118.51 X
47785   004 90 2 X 3,746.15 X
47785   001 90 2 X 4,118.51 X
47785   003 90 2 X 3,788.60 X
47785   002 90 2 X 4,053.98 X
47800   004 90 2 X 3,446.57 X
47800   002 90 2 X 3,731.47 X
47800   003 90 2 X 3,544.95 X
47800   001 90 2 X 3,790.86 X
47801   002 90 2 X 1,944.50 X
47801   003 90 2 X 1,842.48 X
47801   001 90 2 X 1,969.24 X
47801   004 90 2 X 1,822.07 X
47802   002 90 2 X 3,158.76 X
47802   003 90 2 X 2,932.05 X
47802   001 90 2 X 3,167.15 X
47802   004 90 2 X 2,898.83 X
47900   002 90 2 X 3,731.47 X
47900   003 90 2 X 3,544.95 X
47900   004 90 2 X 3,446.57 X
47900   001 90 2 X 3,790.86 X
47999     YYY 2 X # X
48000   001 90 2 X 2,439.59 X
48000   003 90 2 X 2,258.94 X
48000   002 90 2 X 2,404.27 X
48000   004 90 2 X 2,234.08 X
48001   004 90 2 X 2,649.55 X
48001   001 90 2 X 2,904.73 X
48001   002 90 2 X 2,860.51 X
48001   003 90 2 X 2,678.64 X
48020   001 90 2 X 2,424.51 X
48020   003 90 2 X 2,236.00 X
48020   002 90 2 X 2,387.58 X
48020   004 90 2 X 2,211.70 X
48100   004 90 2 X 1,594.21 X
48100   002 90 2 X 1,648.35 X
48100   003 90 2 X 1,555.28 X
48100   001 90 2 X 1,686.35 X
48102   002 10 2 X 730.67 X
48102   003 10 2 X 721.81 X
48102   001 10 2 X 739.35 X
48102   004 10 2 X 687.01 X
48105   003 90 2 X 4,356.99 X
48105   002 90 2 X 4,356.99 X
48105   004 90 2 X 4,356.99 X
48105   001 90 2 X 4,878.96 X
48120   004 90 2 X 3,015.04 X
48120   001 90 2 X 3,182.46 X
48120   003 90 2 X 2,568.10 X
48120   002 90 2 X 3,086.89 X
48140   004 90 2 X 3,801.30 X
48140   003 90 2 X 3,741.75 X
48140   002 90 2 X 3,913.45 X
48140   001 90 2 X 4,022.83 X
48145   001 90 2 X 4,335.23 X
48145   003 90 2 X 4,001.70 X
48145   002 90 2 X 4,262.67 X
48145   004 90 2 X 3,917.75 X
48146   003 90 2 X 4,190.75 X
48146   002 90 2 X 4,440.51 X
48146   004 90 2 X 4,141.20 X
48146   001 90 2 X 4,178.41 X
48148   001 90 2 X 2,757.46 X
48148   003 90 2 X 2,546.93 X
48148   002 90 2 X 2,716.30 X
48148   004 90 2 X 2,518.78 X
48150   002 90 2 X 6,825.34 X
48150   003 90 2 X 6,529.18 X
48150   004 90 2 X 6,621.68 X
48150   001 90 2 X 7,024.61 X
48152   001 90 2 X 6,909.65 X
48152   004 90 2 X 6,511.20 X
48152   002 90 2 X 6,711.12 X
48152   003 90 2 X 6,417.66 X
48153   001 90 2 X 7,024.61 X
48153   004 90 2 X 6,621.68 X
48153   003 90 2 X 6,529.18 X
48153   002 90 2 X 6,825.34 X
48154   001 90 2 X 6,909.65 X
48154   004 90 2 X 6,511.20 X
48154   002 90 2 X 6,711.12 X
48154   003 90 2 X 6,417.66 X
48155   001 90 2 X 5,748.75 X
48155   004 90 2 X 4,541.66 X
48155   003 90 2 X 5,589.51 X
48155   002 90 2 X 5,826.51 X
48400   003 ZZZ 0 X 336.84 X
48400   002 ZZZ 0 X 359.79 X
48400   004 ZZZ 0 X 333.20 X
48400   001 ZZZ 0 X 365.30 X
48500   001 90 2 X 2,527.05 X
48500   004 90 2 X 2,296.77 X
48500   003 90 2 X 2,323.19 X
48500   002 90 2 X 2,633.52 X
48510   001 90 2 X 2,176.11 X
48510   003 90 2 X 1,934.71 X
48510   002 90 2 X 1,934.71 X
48510   004 90 2 X 1,934.71 X
48520   002 90 2 X 3,076.96 X
48520   003 90 2 X 2,948.90 X
48520   001 90 2 X 3,172.23 X
48520   004 90 2 X 2,755.08 X
48540   003 90 2 X 3,340.47 X
48540   002 90 2 X 3,493.61 X
48540   001 90 2 X 3,607.69 X
48540   004 90 2 X 3,209.37 X
48545   003 90 2 X 2,526.25 X
48545   002 90 2 X 2,698.14 X
48545   004 90 2 X 2,498.82 X
48545   001 90 2 X 2,739.97 X
48547   004 90 2 X 3,612.39 X
48547   001 90 2 X 3,960.64 X
48547   003 90 2 X 3,652.08 X
48547   002 90 2 X 3,900.19 X
48548   003 90 2 X 2,535.68 X
48548   002 90 2 X 2,535.68 X
48548   004 90 2 X 2,535.68 X
48548   001 90 2 X 2,847.88 X
48551     XXX 2 X * X
48552   003 XXX 2 X 466.61 X
48552   001 XXX 2 X 508.73 X
48552   004 XXX 2 X 466.61 X
48552   002 XXX 2 X 466.61 X
48556     90 2 X * X
48999     YYY 2 X # X
49000   001 90 2 X 1,961.53 X
49000   004 90 2 X 1,775.64 X
49000   002 90 2 X 1,929.20 X
49000   003 90 2 X 1,796.09 X
49002   003 90 2 X 1,742.51 X
49002   002 90 2 X 1,862.49 X
49002   004 90 2 X 1,722.93 X
49002   001 90 2 X 1,891.66 X
49010   001 90 2 X 2,202.41 X
49010   004 90 2 X 2,011.92 X
49010   002 90 2 X 2,169.66 X
49010   003 90 2 X 2,034.76 X
49013   001 0 2 X 676.76 X
49013   004 0 2 X 620.33 X
49013   003 0 2 X 620.33 X
49013   002 0 2 X 620.33 X
49014   002 0 2 X 512.44 X
49014   003 0 2 X 512.44 X
49014   004 0 2 X 512.44 X
49014   001 0 2 X 559.86 X
49020   002 90 2 X 2,066.66 X
49020   003 90 2 X 2,010.90 X
49020   001 90 2 X 2,211.46 X
49020   004 90 2 X 2,010.90 X
49040   002 90 2 X 1,563.82 X
49040   004 90 2 X 1,563.82 X
49040   001 90 2 X 1,770.28 X
49040   003 90 2 X 1,563.82 X
49060   002 90 2 X 1,608.40 X
49060   003 90 2 X 1,608.40 X
49060   004 90 2 X 1,608.40 X
49060   001 90 2 X 1,789.69 X
49062   004 90 2 X 1,796.86 X
49062   001 90 2 X 2,005.06 X
49062   003 90 2 X 1,796.86 X
49062   002 90 2 X 1,796.86 X
49082   003 0 2 X 260.01 114.89
49082   002 0 2 X 260.01 114.89
49082   001 0 2 X 293.26 124.90
49082   004 0 2 X 260.01 114.89
49083   001 0 2 X 553.00 192.67
49083   003 0 2 X 488.32 177.68
49083   002 0 2 X 488.32 177.68
49083   004 0 2 X 488.32 177.68
49084   003 0 2 X 163.53 X
49084   002 0 2 X 163.53 X
49084   001 0 2 X 176.26 X
49084   004 0 2 X 163.53 X
49180   004 0 2 X 744.24 X
49180   001 0 2 X 567.78 X
49180   003 0 2 X 728.43 X
49180   002 0 2 X 688.77 X
49185   002 0 0 X 1,448.84 191.63
49185   003 0 0 X 1,448.84 191.63
49185   001 0 0 X 1,677.50 206.44
49185   004 0 0 X 1,448.84 191.63
49203   002 90 2 X 1,889.04 X
49203   003 90 2 X 1,889.04 X
49203   001 90 2 X 2,099.50 X
49203   004 90 2 X 1,889.04 X
49204   004 90 2 X 2,411.13 X
49204   001 90 2 X 2,675.13 X
49204   003 90 2 X 2,411.13 X
49204   002 90 2 X 2,411.13 X
49205   003 90 2 X 2,759.96 X
49205   001 90 2 X 3,060.38 X
49205   004 90 2 X 2,759.96 X
49205   002 90 2 X 2,759.96 X
49215   004 90 2 X 3,233.96 X
49215   002 90 2 X 2,845.59 X
49215   003 90 2 X 2,739.21 X
49215   001 90 2 X 3,497.61 X
49250   004 90 2 X 1,623.68 X
49250   001 90 2 X 1,678.77 X
49250   003 90 2 X 1,629.99 X
49250   002 90 2 X 1,669.20 X
49255   002 90 2 X 1,546.43 X
49255   003 90 2 X 1,330.82 X
49255   001 90 2 X 1,680.33 X
49255   004 90 2 X 1,431.22 X
49320   002 10 2 X 802.39 X
49320   003 10 2 X 802.39 X
49320   001 10 2 X 897.24 X
49320   004 10 2 X 802.39 X
49321   004 10 3 X 855.20 X
49321   001 10 3 X 956.31 X
49321   003 10 3 X 855.20 X
49321   002 10 3 X 855.20 X
49322   003 10 3 X 889.31 X
49322   002 10 3 X 889.31 X
49322   004 10 3 X 889.31 X
49322   001 10 3 X 992.62 X
49323   004 90 3 X 1,376.65 X
49323   001 90 3 X 1,534.59 X
49323   002 90 3 X 1,376.65 X
49323   003 90 3 X 1,376.65 X
49324   003 10 3 X 601.93 X
49324   002 10 3 X 601.93 X
49324   004 10 3 X 601.93 X
49324   001 10 3 X 679.24 X
49325   002 10 3 X 648.06 X
49325   003 10 3 X 648.06 X
49325   001 10 3 X 733.05 X
49325   004 10 3 X 648.06 X
49326   001 ZZZ 0 X 333.14 X
49326   004 ZZZ 0 X 297.73 X
49326   002 ZZZ 0 X 297.73 X
49326   003 ZZZ 0 X 297.73 X
49327   002 ZZZ 0 X 230.92 X
49327   003 ZZZ 0 X 230.92 X
49327   004 ZZZ 0 X 230.92 X
49327   001 ZZZ 0 X 255.47 X
49329     YYY 2 X # X
49400   001 0 2 X 355.89 X
49400   004 0 2 X 327.46 X
49400   002 0 2 X 351.05 X
49400   003 0 2 X 331.27 X
49402   004 90 2 X 1,297.52 X
49402   002 90 2 X 1,297.52 X
49402   003 90 2 X 1,297.52 X
49402   001 90 2 X 1,459.36 X
49405   004 0 2 X 1,333.19 348.06
49405   001 0 2 X 1,521.81 374.14
49405   003 0 2 X 1,333.19 348.06
49405   002 0 2 X 1,333.19 348.06
49406   001 0 2 X 1,521.20 374.73
49406   003 0 2 X 1,332.64 348.60
49406   002 0 2 X 1,332.64 348.60
49406   004 0 2 X 1,332.64 348.60
49407   001 0 2 X 1,284.59 399.28
49407   004 0 2 X 1,131.06 371.13
49407   003 0 2 X 1,131.06 371.13
49407   002 0 2 X 1,131.06 371.13
49411   001 0 2 X 968.54 373.37
49411   003 0 2 X 845.43 343.58
49411   002 0 2 X 845.43 343.58
49411   004 0 2 X 845.43 343.58
49412   001 ZZZ 0 X 159.52 X
49412   004 ZZZ 0 X 144.27 X
49412   002 ZZZ 0 X 144.27 X
49412   003 ZZZ 0 X 144.27 X
49418   004 0 2 X 2,554.84 408.21
49418   001 0 2 X 2,875.72 446.79
49418   002 0 2 X 2,554.84 408.21
49418   003 0 2 X 2,554.84 408.21
49419   004 90 2 X 860.34 X
49419   001 90 2 X 958.22 X
49419   003 90 2 X 860.34 X
49419   002 90 2 X 860.34 X
49421   002 0 2 X 1,114.89 X
49421   003 0 2 X 1,027.18 X
49421   001 0 2 X 1,123.37 X
49421   004 0 2 X 1,015.34 X
49422   004 0 2 X 1,015.34 X
49422   002 0 2 X 1,114.89 X
49422   003 0 2 X 1,027.18 X
49422   001 0 2 X 1,123.37 X
49423   001 0 2 X 267.91 X
49423   004 0 2 X 238.52 X
49423   002 0 2 X 238.52 X
49423   003 0 2 X 238.52 X