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DLI
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Workers' Compensation
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Health Care Services Review
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Medical Fee Review
>
Fee Schedule
>
Fee Schedule 69644-70450
Begin Main Content Area
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Content Editor
2024 Workers' Compensation Part B Fee Schedule
69644-70450
View the PDF
CPT/HCPC Code
Modifier
Medicare Location
Global Surgery Indicator
Multiple Surgery Indicator
Prevailing Charge Amount
Fee Schedule Amount
Site of Service Amount
69644
002
90
2
X
4,503.58
X
69644
003
90
2
X
4,355.53
X
69644
004
90
2
X
4,300.29
X
69644
001
90
2
X
4,743.10
X
69645
004
90
2
X
4,093.64
X
69645
002
90
2
X
4,440.63
X
69645
003
90
2
X
4,068.90
X
69645
001
90
2
X
4,511.52
X
69646
001
90
2
X
4,702.15
X
69646
003
90
2
X
4,415.75
X
69646
002
90
2
X
4,631.02
X
69646
004
90
2
X
4,280.97
X
69650
003
90
2
X
2,364.03
X
69650
002
90
2
X
2,477.57
X
69650
004
90
2
X
2,334.19
X
69650
001
90
2
X
2,560.67
X
69660
004
90
2
X
3,382.12
X
69660
003
90
2
X
3,015.74
X
69660
002
90
2
X
3,656.24
X
69660
001
90
2
X
3,470.91
X
69661
001
90
2
X
4,015.81
X
69661
004
90
2
X
3,664.48
X
69661
002
90
2
X
3,956.68
X
69661
003
90
2
X
3,711.29
X
69662
001
90
2
X
3,940.65
X
69662
004
90
2
X
3,593.82
X
69662
003
90
2
X
3,639.49
X
69662
002
90
2
X
3,882.20
X
69666
001
90
2
X
3,190.86
X
69666
004
90
2
X
3,072.26
X
69666
002
90
2
X
3,170.71
X
69666
003
90
2
X
3,086.78
X
69667
001
90
2
X
2,851.49
X
69667
004
90
2
X
2,580.97
X
69667
002
90
2
X
3,152.48
X
69667
003
90
2
X
2,614.48
X
69670
001
90
2
X
2,652.37
X
69670
004
90
2
X
2,296.21
X
69670
003
90
2
X
2,537.52
X
69670
002
90
2
X
2,547.17
X
69676
003
90
2
X
1,939.87
X
69676
002
90
2
X
2,057.41
X
69676
004
90
2
X
1,916.22
X
69676
001
90
2
X
2,085.69
X
69700
003
90
2
X
1,736.92
X
69700
002
90
2
X
1,846.22
X
69700
004
90
2
X
1,715.56
X
69700
001
90
2
X
1,872.55
X
69705
002
0
3
X
3,877.46
226.97
69705
003
0
3
X
3,877.46
226.97
69705
001
0
3
X
4,457.36
247.04
69705
004
0
3
X
3,877.46
226.97
69706
001
0
3
X
4,589.25
343.41
69706
004
0
3
X
3,997.38
316.08
69706
002
0
3
X
3,997.38
316.08
69706
003
0
3
X
3,997.38
316.08
69711
90
2
X
*
X
69714
002
90
2
X
2,014.11
X
69714
004
90
2
X
2,014.11
X
69714
001
90
2
X
2,232.73
X
69714
003
90
2
X
2,014.11
X
69716
001
90
2
X
791.64
X
69716
004
90
2
X
727.82
X
69716
003
90
2
X
727.82
X
69716
002
90
2
X
727.82
X
69717
002
90
2
X
2,076.64
X
69717
003
90
2
X
2,076.64
X
69717
004
90
2
X
2,076.64
X
69717
001
90
2
X
2,297.14
X
69719
001
90
2
X
791.64
X
69719
003
90
2
X
727.82
X
69719
004
90
2
X
727.82
X
69719
002
90
2
X
727.82
X
69720
001
90
2
X
4,565.93
X
69720
002
90
2
X
4,445.80
X
69720
003
90
2
X
4,271.80
X
69720
004
90
2
X
3,549.05
X
69725
002
90
2
X
3,880.04
X
69725
003
90
2
X
3,668.33
X
69725
001
90
2
X
3,931.11
X
69725
004
90
2
X
3,624.65
X
69726
004
90
2
X
493.71
X
69726
001
90
2
X
540.56
X
69726
003
90
2
X
493.71
X
69726
002
90
2
X
493.71
X
69727
001
90
2
X
617.54
X
69727
004
90
2
X
565.53
X
69727
003
90
2
X
565.53
X
69727
002
90
2
X
565.53
X
69728
004
90
2
X
683.09
X
69728
002
90
2
X
683.09
X
69728
003
90
2
X
683.09
X
69728
001
90
2
X
748.19
X
69729
004
90
2
X
774.49
X
69729
002
90
2
X
774.49
X
69729
003
90
2
X
774.49
X
69729
001
90
2
X
846.89
X
69730
004
90
2
X
792.64
X
69730
003
90
2
X
792.64
X
69730
002
90
2
X
792.64
X
69730
001
90
2
X
866.66
X
69740
004
90
2
X
2,983.54
X
69740
001
90
2
X
3,259.97
X
69740
002
90
2
X
3,213.00
X
69740
003
90
2
X
3,836.64
X
69745
003
90
2
X
3,497.98
X
69745
001
90
2
X
3,762.44
X
69745
004
90
2
X
3,454.87
X
69745
002
90
2
X
3,711.06
X
69799
YYY
2
X
#
X
69801
004
0
2
X
2,508.71
X
69801
002
0
2
X
2,740.40
X
69801
003
0
2
X
2,763.23
X
69801
001
0
2
X
2,788.30
X
69805
001
90
2
X
3,278.85
X
69805
003
90
2
X
2,999.70
X
69805
002
90
2
X
3,224.72
X
69805
004
90
2
X
2,960.95
X
69806
001
90
2
X
4,348.79
X
69806
002
90
2
X
4,169.29
X
69806
003
90
2
X
3,589.33
X
69806
004
90
2
X
3,542.85
X
69905
003
90
2
X
3,034.05
X
69905
002
90
2
X
3,262.49
X
69905
001
90
2
X
3,317.49
X
69905
004
90
2
X
2,995.28
X
69910
001
90
2
X
4,061.51
X
69910
004
90
2
X
3,675.88
X
69910
003
90
2
X
3,723.89
X
69910
002
90
2
X
3,996.04
X
69915
001
90
2
X
4,538.25
X
69915
004
90
2
X
4,081.18
X
69915
003
90
2
X
4,130.98
X
69915
002
90
2
X
4,388.36
X
69930
001
90
2
X
5,599.04
X
69930
004
90
2
X
4,602.21
X
69930
002
90
2
X
5,030.72
X
69930
003
90
2
X
4,663.58
X
69949
YYY
2
X
#
X
69950
002
90
2
X
4,601.92
X
69950
003
90
2
X
4,325.16
X
69950
004
90
2
X
4,273.58
X
69950
001
90
2
X
5,023.49
X
69955
004
90
2
X
4,598.05
X
69955
001
90
2
X
5,014.18
X
69955
002
90
2
X
4,944.31
X
69955
003
90
2
X
4,654.58
X
69960
004
90
2
X
4,071.04
X
69960
002
90
2
X
5,666.03
X
69960
003
90
2
X
4,120.95
X
69960
001
90
2
X
4,435.50
X
69970
001
90
2
X
4,972.04
X
69970
004
90
2
X
4,559.45
X
69970
002
90
2
X
4,902.65
X
69970
003
90
2
X
4,615.04
X
69979
YYY
2
X
#
X
69990
004
ZZZ
0
X
494.61
X
69990
003
ZZZ
0
X
494.61
X
69990
002
ZZZ
0
X
494.61
X
69990
001
ZZZ
0
X
567.76
X
70010
003
XXX
0
X
595.73
X
70010
26
003
XXX
0
X
196.56
X
70010
TC
003
XXX
0
X
419.95
X
70010
002
XXX
0
X
640.42
X
70010
26
002
XXX
0
X
205.40
X
70010
TC
002
XXX
0
X
455.11
X
70010
001
XXX
0
X
651.02
X
70010
26
001
XXX
0
X
206.11
X
70010
TC
001
XXX
0
X
463.44
X
70010
004
XXX
0
X
587.19
X
70010
26
004
XXX
0
X
191.57
X
70010
TC
004
XXX
0
X
413.31
X
70015
004
XXX
0
X
303.27
X
70015
26
004
XXX
0
X
191.57
X
70015
TC
004
XXX
0
X
129.41
X
70015
002
XXX
0
X
328.13
X
70015
26
002
XXX
0
X
205.40
X
70015
TC
002
XXX
0
X
142.78
X
70015
003
XXX
0
X
307.24
X
70015
26
003
XXX
0
X
196.56
X
70015
TC
003
XXX
0
X
131.46
X
70015
001
XXX
0
X
333.09
X
70015
26
001
XXX
0
X
206.11
X
70015
TC
001
XXX
0
X
145.54
X
70030
004
XXX
0
X
66.41
X
70030
26
004
XXX
0
X
27.76
X
70030
TC
004
XXX
0
X
40.05
X
70030
001
XXX
0
X
71.98
X
70030
26
001
XXX
0
X
29.75
X
70030
TC
001
XXX
0
X
45.15
X
70030
003
XXX
0
X
68.22
X
70030
26
003
XXX
0
X
28.49
X
70030
TC
003
XXX
0
X
40.66
X
70030
002
XXX
0
X
71.94
X
70030
26
002
XXX
0
X
29.72
X
70030
TC
002
XXX
0
X
44.31
X
70100
002
XXX
0
X
95.89
X
70100
26
002
XXX
0
X
31.55
X
70100
TC
002
XXX
0
X
61.22
X
70100
003
XXX
0
X
80.17
X
70100
26
003
XXX
0
X
30.26
X
70100
TC
003
XXX
0
X
51.90
X
70100
004
XXX
0
X
78.03
X
70100
26
004
XXX
0
X
29.40
X
70100
TC
004
XXX
0
X
50.23
X
70100
001
XXX
0
X
87.29
X
70100
26
001
XXX
0
X
31.65
X
70100
TC
001
XXX
0
X
56.30
X
70110
004
XXX
0
X
98.21
X
70110
26
004
XXX
0
X
40.45
X
70110
TC
004
XXX
0
X
59.59
X
70110
001
XXX
0
X
107.54
X
70110
26
001
XXX
0
X
43.43
X
70110
TC
001
XXX
0
X
66.94
X
70110
003
XXX
0
X
100.84
X
70110
26
003
XXX
0
X
41.40
X
70110
TC
003
XXX
0
X
60.50
X
70110
002
XXX
0
X
109.74
X
70110
26
002
XXX
0
X
43.33
X
70110
TC
002
XXX
0
X
65.73
X
70120
004
XXX
0
X
86.46
X
70120
26
004
XXX
0
X
29.40
X
70120
TC
004
XXX
0
X
59.59
X
70120
001
XXX
0
X
95.84
X
70120
26
001
XXX
0
X
31.65
X
70120
TC
001
XXX
0
X
66.94
X
70120
003
XXX
0
X
89.66
X
70120
26
003
XXX
0
X
30.21
X
70120
TC
003
XXX
0
X
60.50
X
70120
002
XXX
0
X
94.27
X
70120
26
002
XXX
0
X
31.55
X
70120
TC
002
XXX
0
X
65.73
X
70130
001
XXX
0
X
138.41
X
70130
26
001
XXX
0
X
58.01
X
70130
TC
001
XXX
0
X
84.69
X
70130
004
XXX
0
X
126.74
X
70130
26
004
XXX
0
X
54.09
X
70130
TC
004
XXX
0
X
75.40
X
70130
002
XXX
0
X
137.12
X
70130
26
002
XXX
0
X
57.82
X
70130
TC
002
XXX
0
X
83.13
X
70130
003
XXX
0
X
130.18
X
70130
26
003
XXX
0
X
55.36
X
70130
TC
003
XXX
0
X
76.62
X
70134
002
XXX
0
X
132.11
X
70134
26
002
XXX
0
X
57.82
X
70134
TC
002
XXX
0
X
78.16
X
70134
003
XXX
0
X
125.36
X
70134
26
003
XXX
0
X
55.47
X
70134
TC
003
XXX
0
X
71.93
X
70134
004
XXX
0
X
122.14
X
70134
26
004
XXX
0
X
53.96
X
70134
TC
004
XXX
0
X
70.78
X
70134
001
XXX
0
X
133.34
X
70134
26
001
XXX
0
X
58.01
X
70134
TC
001
XXX
0
X
79.64
X
70140
003
XXX
0
X
90.65
X
70140
26
003
XXX
0
X
31.20
X
70140
TC
003
XXX
0
X
67.76
X
70140
002
XXX
0
X
95.30
X
70140
26
002
XXX
0
X
32.55
X
70140
TC
002
XXX
0
X
70.20
X
70140
004
XXX
0
X
87.42
X
70140
26
004
XXX
0
X
30.40
X
70140
TC
004
XXX
0
X
59.59
X
70140
001
XXX
0
X
132.17
X
70140
26
001
XXX
0
X
32.66
X
70140
TC
001
XXX
0
X
90.83
X
70150
004
XXX
0
X
114.82
X
70150
26
004
XXX
0
X
42.05
X
70150
TC
004
XXX
0
X
75.40
X
70150
003
XXX
0
X
119.53
X
70150
26
003
XXX
0
X
43.09
X
70150
TC
003
XXX
0
X
76.62
X
70150
002
XXX
0
X
137.06
X
70150
26
002
XXX
0
X
45.09
X
70150
TC
002
XXX
0
X
92.67
X
70150
001
XXX
0
X
127.20
X
70150
26
001
XXX
0
X
45.20
X
70150
TC
001
XXX
0
X
94.22
X
70160
001
XXX
0
X
92.53
X
70160
26
001
XXX
0
X
29.40
X
70160
TC
001
XXX
0
X
66.87
X
70160
002
XXX
0
X
90.72
X
70160
26
002
XXX
0
X
29.36
X
70160
TC
002
XXX
0
X
62.28
X
70160
004
XXX
0
X
75.98
X
70160
26
004
XXX
0
X
27.44
X
70160
TC
004
XXX
0
X
50.23
X
70160
003
XXX
0
X
78.03
X
70160
26
003
XXX
0
X
28.19
X
70160
TC
003
XXX
0
X
53.81
X
70170
003
XXX
0
X
138.41
X
70170
26
003
XXX
0
X
48.85
X
70170
TC
003
XXX
0
X
91.74
X
70170
002
XXX
0
X
146.59
X
70170
26
002
XXX
0
X
51.08
X
70170
TC
002
XXX
0
X
99.58
X
70170
004
XXX
0
X
134.47
X
70170
26
004
XXX
0
X
47.61
X
70170
TC
004
XXX
0
X
90.31
X
70170
001
XXX
0
X
149.13
X
70170
26
001
XXX
0
X
51.21
X
70170
TC
001
XXX
0
X
101.41
X
70190
001
XXX
0
X
99.89
X
70190
26
001
XXX
0
X
36.57
X
70190
TC
001
XXX
0
X
66.94
X
70190
002
XXX
0
X
99.48
X
70190
26
002
XXX
0
X
36.44
X
70190
TC
002
XXX
0
X
65.73
X
70190
003
XXX
0
X
94.47
X
70190
26
003
XXX
0
X
35.00
X
70190
TC
003
XXX
0
X
60.50
X
70190
004
XXX
0
X
91.96
X
70190
26
004
XXX
0
X
35.32
X
70190
TC
004
XXX
0
X
59.59
X
70200
003
XXX
0
X
120.79
X
70200
26
003
XXX
0
X
46.16
X
70200
TC
003
XXX
0
X
76.62
X
70200
002
XXX
0
X
129.68
X
70200
26
002
XXX
0
X
48.27
X
70200
TC
002
XXX
0
X
85.37
X
70200
001
XXX
0
X
134.98
X
70200
26
001
XXX
0
X
48.40
X
70200
TC
001
XXX
0
X
86.80
X
70200
004
XXX
0
X
117.66
X
70200
26
004
XXX
0
X
44.92
X
70200
TC
004
XXX
0
X
75.40
X
70210
001
XXX
0
X
93.81
X
70210
26
001
XXX
0
X
29.40
X
70210
TC
001
XXX
0
X
66.94
X
70210
004
XXX
0
X
84.54
X
70210
26
004
XXX
0
X
26.84
X
70210
TC
004
XXX
0
X
59.59
X
70210
002
XXX
0
X
92.23
X
70210
26
002
XXX
0
X
29.36
X
70210
TC
002
XXX
0
X
65.73
X
70210
003
XXX
0
X
87.55
X
70210
26
003
XXX
0
X
27.47
X
70210
TC
003
XXX
0
X
60.50
X
70220
004
XXX
0
X
112.82
X
70220
26
004
XXX
0
X
40.39
X
70220
TC
004
XXX
0
X
75.40
X
70220
001
XXX
0
X
125.22
X
70220
26
001
XXX
0
X
43.43
X
70220
TC
001
XXX
0
X
84.69
X
70220
003
XXX
0
X
116.26
X
70220
26
003
XXX
0
X
41.40
X
70220
TC
003
XXX
0
X
76.62
X
70220
002
XXX
0
X
123.21
X
70220
26
002
XXX
0
X
43.33
X
70220
TC
002
XXX
0
X
83.13
X
70240
003
XXX
0
X
71.46
X
70240
26
003
XXX
0
X
31.78
X
70240
TC
003
XXX
0
X
40.66
X
70240
002
XXX
0
X
83.95
X
70240
26
002
XXX
0
X
33.12
X
70240
TC
002
XXX
0
X
45.92
X
70240
004
XXX
0
X
69.65
X
70240
26
004
XXX
0
X
30.92
X
70240
TC
004
XXX
0
X
40.05
X
70240
001
XXX
0
X
74.98
X
70240
26
001
XXX
0
X
33.19
X
70240
TC
001
XXX
0
X
45.15
X
70250
003
XXX
0
X
100.03
X
70250
26
003
XXX
0
X
40.01
X
70250
TC
003
XXX
0
X
65.19
X
70250
002
XXX
0
X
127.44
X
70250
26
002
XXX
0
X
41.90
X
70250
TC
002
XXX
0
X
81.96
X
70250
004
XXX
0
X
97.05
X
70250
26
004
XXX
0
X
38.94
X
70250
TC
004
XXX
0
X
59.59
X
70250
001
XXX
0
X
127.63
X
70250
26
001
XXX
0
X
42.05
X
70250
TC
001
XXX
0
X
83.04
X
70260
002
XXX
0
X
153.18
X
70260
26
002
XXX
0
X
57.82
X
70260
TC
002
XXX
0
X
101.03
X
70260
003
XXX
0
X
141.39
X
70260
26
003
XXX
0
X
55.28
X
70260
TC
003
XXX
0
X
87.03
X
70260
004
XXX
0
X
136.53
X
70260
26
004
XXX
0
X
54.13
X
70260
TC
004
XXX
0
X
85.64
X
70260
001
XXX
0
X
150.05
X
70260
26
001
XXX
0
X
58.01
X
70260
TC
001
XXX
0
X
96.38
X
70300
XXX
0
X
*
X
70310
XXX
0
X
*
X
70320
XXX
0
X
*
X
70328
001
XXX
0
X
82.15
X
70328
26
001
XXX
0
X
31.65
X
70328
TC
001
XXX
0
X
60.87
X
70328
002
XXX
0
X
80.82
X
70328
26
002
XXX
0
X
31.55
X
70328
003
XXX
0
X
77.39
X
70328
26
003
XXX
0
X
30.21
X
70328
004
XXX
0
X
75.40
X
70328
26
004
XXX
0
X
29.40
X
70328
TC
002
XXX
0
X
52.27
X
70328
TC
003
XXX
0
X
48.27
X
70328
TC
004
XXX
0
X
47.51
X
70330
001
XXX
0
X
128.37
X
70330
26
001
XXX
0
X
42.04
X
70330
TC
001
XXX
0
X
89.74
X
70330
004
XXX
0
X
116.51
X
70330
26
004
XXX
0
X
38.94
X
70330
TC
004
XXX
0
X
80.08
X
70330
003
XXX
0
X
119.53
X
70330
26
003
XXX
0
X
40.05
X
70330
TC
003
XXX
0
X
81.31
X
70330
002
XXX
0
X
126.21
X
70330
26
002
XXX
0
X
41.87
X
70330
TC
002
XXX
0
X
88.14
X
70332
004
XXX
0
X
280.86
X
70332
26
004
XXX
0
X
89.17
X
70332
TC
004
XXX
0
X
200.20
X
70332
001
XXX
0
X
311.77
X
70332
26
001
XXX
0
X
95.91
X
70332
TC
001
XXX
0
X
224.67
X
70332
002
XXX
0
X
306.69
X
70332
26
002
XXX
0
X
95.70
X
70332
TC
002
XXX
0
X
220.55
X
70332
003
XXX
0
X
290.40
X
70332
26
003
XXX
0
X
91.49
X
70332
TC
003
XXX
0
X
203.37
X
70336
001
XXX
4
X
1,348.71
X
70336
26
001
XXX
4
X
219.29
X
70336
TC
001
XXX
4
X
1,198.77
X
70336
004
XXX
4
X
1,238.45
X
70336
26
004
XXX
4
X
204.01
X
70336
TC
004
XXX
4
X
1,068.72
X
70336
002
XXX
4
X
1,345.09
X
70336
26
002
XXX
4
X
218.98
X
70336
TC
002
XXX
4
X
1,177.10
X
70336
003
XXX
4
X
1,272.53
X
70336
26
003
XXX
4
X
210.75
X
70336
TC
003
XXX
4
X
1,085.94
X
70350
XXX
0
X
*
X
70355
XXX
0
X
*
X
70360
003
XXX
0
X
67.71
X
70360
26
003
XXX
0
X
27.94
X
70360
TC
003
XXX
0
X
40.66
X
70360
002
XXX
0
X
73.07
X
70360
26
002
XXX
0
X
29.18
X
70360
TC
002
XXX
0
X
44.31
X
70360
001
XXX
0
X
71.98
X
70360
26
001
XXX
0
X
29.26
X
70360
TC
001
XXX
0
X
45.15
X
70360
004
XXX
0
X
66.01
X
70360
26
004
XXX
0
X
27.21
X
70360
TC
004
XXX
0
X
40.05
X
70370
004
XXX
0
X
170.87
X
70370
26
004
XXX
0
X
51.25
X
70370
TC
004
XXX
0
X
123.86
X
70370
003
XXX
0
X
176.30
X
70370
26
003
XXX
0
X
52.66
X
70370
TC
003
XXX
0
X
125.78
X
70370
002
XXX
0
X
186.52
X
70370
26
002
XXX
0
X
55.07
X
70370
TC
002
XXX
0
X
136.46
X
70370
001
XXX
0
X
189.60
X
70370
26
001
XXX
0
X
55.17
X
70370
TC
001
XXX
0
X
138.94
X
70371
002
XXX
0
X
356.74
X
70371
26
002
XXX
0
X
145.91
X
70371
TC
002
XXX
0
X
220.55
X
70371
003
XXX
0
X
338.40
X
70371
26
003
XXX
0
X
139.52
X
70371
TC
003
XXX
0
X
203.37
X
70371
004
XXX
0
X
329.60
X
70371
26
004
XXX
0
X
135.97
X
70371
TC
004
XXX
0
X
200.20
X
70371
001
XXX
0
X
358.46
X
70371
26
001
XXX
0
X
146.35
X
70371
TC
001
XXX
0
X
224.67
X
70380
003
XXX
0
X
92.49
X
70380
26
003
XXX
0
X
28.17
X
70380
TC
003
XXX
0
X
65.27
X
70380
002
XXX
0
X
97.27
X
70380
26
002
XXX
0
X
29.36
X
70380
TC
002
XXX
0
X
70.69
X
70380
004
XXX
0
X
89.17
X
70380
26
004
XXX
0
X
27.71
X
70380
TC
004
XXX
0
X
64.25
X
70380
001
XXX
0
X
98.90
X
70380
26
001
XXX
0
X
29.40
X
70380
TC
001
XXX
0
X
71.98
X
70390
004
XXX
0
X
226.06
X
70390
26
004
XXX
0
X
63.04
X
70390
TC
004
XXX
0
X
170.40
X
70390
003
XXX
0
X
229.43
X
70390
26
003
XXX
0
X
61.89
X
70390
TC
003
XXX
0
X
173.12
X
70390
002
XXX
0
X
247.26
X
70390
26
002
XXX
0
X
64.76
X
70390
TC
002
XXX
0
X
187.69
X
70390
001
XXX
0
X
251.49
X
70390
26
001
XXX
0
X
65.04
X
70390
TC
001
XXX
0
X
191.16
X
70450
001
XXX
4
X
653.71
X
70450
26
001
XXX
4
X
148.23
X
70450
TC
001
XXX
4
X
505.53
X
70450
004
XXX
4
X
599.36
X
70450
26
004
XXX
4
X
138.17
X
70450
TC
004
XXX
4
X
461.59
X
70450
003
XXX
4
X
615.85
X
70450
26
003
XXX
4
X
141.45
X
70450
TC
003
XXX
4
X
474.42
X
70450
002
XXX
4
X
649.99
X
70450
26
002
XXX
4
X
147.82
X
70450
TC
002
XXX
4
X
502.32
X
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