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Fee Schedule
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Fee Schedule 50553-51784
Begin Main Content Area
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Content Editor
2024 Workers' Compensation Part B Fee Schedule
50553-51784
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
50553
002
0
2
X
895.88
X
50553
003
0
2
X
823.41
X
50553
001
0
2
X
865.40
X
50553
004
0
2
X
878.10
X
50555
003
0
3
X
1,220.07
X
50555
002
0
3
X
1,287.61
X
50555
001
0
3
X
1,303.87
X
50555
004
0
3
X
1,205.59
X
50557
001
0
3
X
1,224.34
X
50557
004
0
3
X
1,220.17
X
50557
002
0
3
X
1,195.63
X
50557
003
0
3
X
1,129.68
X
50561
004
0
3
X
1,363.69
X
50561
001
0
3
X
1,574.74
X
50561
003
0
3
X
1,535.65
X
50561
002
0
3
X
1,567.07
X
50562
004
90
2
X
1,239.27
X
50562
001
90
2
X
1,366.84
X
50562
003
90
2
X
1,239.27
X
50562
002
90
2
X
1,239.27
X
50570
002
0
2
X
1,216.17
X
50570
003
0
2
X
1,259.60
X
50570
004
0
2
X
1,254.70
X
50570
001
0
2
X
1,280.64
X
50572
002
0
3
X
2,025.33
X
50572
003
0
3
X
1,867.58
X
50572
004
0
3
X
1,895.41
X
50572
001
0
3
X
2,051.28
X
50574
001
0
3
X
2,087.14
X
50574
003
0
3
X
1,959.57
X
50574
002
0
3
X
1,950.34
X
50574
004
0
3
X
1,936.62
X
50575
001
0
3
X
2,777.84
X
50575
004
0
3
X
2,568.74
X
50575
002
0
3
X
2,743.16
X
50575
003
0
3
X
2,599.45
X
50576
004
0
3
X
2,108.72
X
50576
001
0
3
X
2,281.68
X
50576
003
0
3
X
2,134.40
X
50576
002
0
3
X
2,253.14
X
50580
004
0
3
X
1,642.68
X
50580
002
0
3
X
1,729.66
X
50580
003
0
3
X
1,660.31
X
50580
001
0
3
X
1,746.50
X
50590
001
90
2
X
2,320.30
X
50590
002
90
2
X
2,288.12
X
50590
003
90
2
X
2,154.70
X
50590
004
90
2
X
2,127.90
X
50592
004
10
2
X
10,318.16
712.14
50592
001
10
2
X
12,539.34
782.03
50592
003
10
2
X
10,318.16
712.14
50592
002
10
2
X
10,318.16
712.14
50593
003
10
2
X
8,004.35
826.35
50593
002
10
2
X
8,004.35
826.35
50593
001
10
2
X
9,558.40
903.88
50593
004
10
2
X
8,004.35
826.35
50600
001
90
2
X
2,783.42
X
50600
004
90
2
X
2,647.42
X
50600
003
90
2
X
2,624.94
X
50600
002
90
2
X
2,811.34
X
50605
001
90
2
X
2,344.44
X
50605
003
90
2
X
2,215.52
X
50605
002
90
2
X
2,319.26
X
50605
004
90
2
X
2,190.99
X
50606
004
ZZZ
0
X
777.93
245.51
50606
001
ZZZ
0
X
886.52
263.56
50606
003
ZZZ
0
X
777.93
245.51
50606
002
ZZZ
0
X
777.93
245.51
50610
002
90
2
X
3,068.11
X
50610
003
90
2
X
2,901.45
X
50610
004
90
2
X
2,866.69
X
50610
001
90
2
X
3,108.40
X
50620
004
90
2
X
2,765.15
X
50620
002
90
2
X
2,961.44
X
50620
003
90
2
X
2,798.70
X
50620
001
90
2
X
3,000.65
X
50630
001
90
2
X
3,124.87
X
50630
004
90
2
X
2,873.62
X
50630
002
90
2
X
3,082.98
X
50630
003
90
2
X
2,909.04
X
50650
001
90
2
X
3,311.85
X
50650
004
90
2
X
3,058.71
X
50650
003
90
2
X
3,095.47
X
50650
002
90
2
X
3,269.79
X
50660
001
90
2
X
3,640.16
X
50660
004
90
2
X
3,354.50
X
50660
002
90
2
X
5,046.77
X
50660
003
90
2
X
4,963.54
X
50684
002
0
2
X
188.67
X
50684
003
0
2
X
136.50
X
50684
001
0
2
X
193.61
X
50684
004
0
2
X
189.11
X
50686
003
0
2
X
202.10
X
50686
002
0
2
X
210.23
X
50686
004
0
2
X
200.00
X
50686
001
0
2
X
212.15
X
50688
004
10
2
X
162.49
X
50688
002
10
2
X
177.26
X
50688
003
10
2
X
164.24
X
50688
001
10
2
X
173.19
X
50690
002
0
2
X
174.32
X
50690
003
0
2
X
171.64
X
50690
001
0
2
X
169.44
X
50690
004
0
2
X
170.96
X
50693
002
0
2
X
1,549.64
339.73
50693
003
0
2
X
1,549.64
339.73
50693
001
0
2
X
1,781.04
365.37
50693
004
0
2
X
1,549.64
339.73
50694
003
0
2
X
1,710.28
439.32
50694
002
0
2
X
1,710.28
439.32
50694
004
0
2
X
1,710.28
439.32
50694
001
0
2
X
1,959.19
472.07
50695
003
0
2
X
2,086.78
557.73
50695
002
0
2
X
2,086.78
557.73
50695
004
0
2
X
2,086.78
557.73
50695
001
0
2
X
2,387.82
598.73
50700
004
90
2
X
2,879.52
X
50700
002
90
2
X
3,090.28
X
50700
003
90
2
X
2,914.94
X
50700
001
90
2
X
3,132.55
X
50705
002
ZZZ
0
X
2,483.79
314.41
50705
003
ZZZ
0
X
2,483.79
314.41
50705
001
ZZZ
0
X
2,876.11
337.81
50705
004
ZZZ
0
X
2,483.79
314.41
50706
004
ZZZ
0
X
1,122.50
292.31
50706
001
ZZZ
0
X
1,284.54
313.13
50706
003
ZZZ
0
X
1,122.50
292.31
50706
002
ZZZ
0
X
1,122.50
292.31
50715
004
90
2
X
3,137.02
X
50715
001
90
2
X
3,405.38
X
50715
003
90
2
X
3,173.51
X
50715
002
90
2
X
3,360.13
X
50722
001
90
2
X
3,110.53
X
50722
004
90
2
X
2,832.26
X
50722
003
90
2
X
2,864.74
X
50722
002
90
2
X
3,062.56
X
50725
002
90
2
X
3,433.84
X
50725
003
90
2
X
3,231.11
X
50725
004
90
2
X
3,193.64
X
50725
001
90
2
X
3,753.71
X
50727
004
90
2
X
1,388.56
X
50727
001
90
2
X
1,500.99
X
50727
003
90
2
X
1,405.12
X
50727
002
90
2
X
1,482.33
X
50728
003
90
2
X
2,068.44
X
50728
002
90
2
X
2,182.69
X
50728
004
90
2
X
2,043.96
X
50728
001
90
2
X
2,210.34
X
50740
003
90
2
X
3,344.59
X
50740
002
90
2
X
3,530.01
X
50740
004
90
2
X
3,342.88
X
50740
001
90
2
X
3,599.35
X
50750
001
90
2
X
3,730.18
X
50750
002
90
2
X
3,683.56
X
50750
003
90
2
X
3,490.23
X
50750
004
90
2
X
3,448.40
X
50760
002
90
2
X
3,546.18
X
50760
003
90
2
X
3,347.81
X
50760
001
90
2
X
3,594.07
X
50760
004
90
2
X
3,307.96
X
50770
004
90
2
X
3,596.76
X
50770
002
90
2
X
3,854.67
X
50770
003
90
2
X
3,640.68
X
50770
001
90
2
X
3,906.29
X
50780
004
90
2
X
3,336.58
X
50780
001
90
2
X
3,624.29
X
50780
002
90
2
X
3,576.18
X
50780
003
90
2
X
3,377.02
X
50782
004
90
2
X
3,453.07
X
50782
002
90
2
X
3,696.67
X
50782
003
90
2
X
3,494.52
X
50782
001
90
2
X
3,745.44
X
50783
004
90
2
X
3,551.91
X
50783
001
90
2
X
3,848.24
X
50783
003
90
2
X
3,594.28
X
50783
002
90
2
X
3,798.77
X
50785
001
90
2
X
4,081.91
X
50785
004
90
2
X
3,750.06
X
50785
003
90
2
X
3,795.27
X
50785
002
90
2
X
4,053.65
X
50800
004
90
2
X
3,008.76
X
50800
003
90
2
X
3,046.83
X
50800
002
90
2
X
3,351.80
X
50800
001
90
2
X
3,454.94
X
50810
001
90
2
X
3,651.73
X
50810
003
90
2
X
3,392.64
X
50810
002
90
2
X
3,601.16
X
50810
004
90
2
X
3,353.30
X
50815
004
90
2
X
4,180.04
X
50815
001
90
2
X
4,701.24
X
50815
003
90
2
X
4,231.74
X
50815
002
90
2
X
4,532.70
X
50820
004
90
2
X
4,285.57
X
50820
001
90
2
X
4,697.04
X
50820
003
90
2
X
4,337.95
X
50820
002
90
2
X
4,627.18
X
50825
001
90
2
X
6,762.64
X
50825
002
90
2
X
6,662.61
X
50825
003
90
2
X
6,247.03
X
50825
004
90
2
X
6,168.95
X
50830
004
90
2
X
5,419.78
X
50830
001
90
2
X
5,873.68
X
50830
002
90
2
X
5,797.92
X
50830
003
90
2
X
5,484.24
X
50840
003
90
2
X
3,747.56
X
50840
002
90
2
X
4,176.82
X
50840
004
90
2
X
3,386.60
X
50840
001
90
2
X
3,667.71
X
50845
003
90
2
X
3,629.61
X
50845
002
90
2
X
3,830.18
X
50845
001
90
2
X
3,878.66
X
50845
004
90
2
X
3,586.68
X
50860
002
90
2
X
2,880.16
X
50860
003
90
2
X
2,721.28
X
50860
001
90
2
X
2,918.52
X
50860
004
90
2
X
2,688.87
X
50900
004
90
2
X
2,751.30
X
50900
001
90
2
X
2,659.37
X
50900
002
90
2
X
2,872.58
X
50900
003
90
2
X
2,474.45
X
50920
001
90
2
X
2,959.13
X
50920
002
90
2
X
2,852.13
X
50920
003
90
2
X
2,479.43
X
50920
004
90
2
X
2,450.17
X
50930
001
90
2
X
3,497.43
X
50930
004
90
2
X
3,234.44
X
50930
002
90
2
X
3,453.84
X
50930
003
90
2
X
3,273.18
X
50940
001
90
2
X
2,715.00
X
50940
004
90
2
X
2,509.60
X
50940
003
90
2
X
2,539.73
X
50940
002
90
2
X
2,896.62
X
50945
001
90
2
X
2,345.22
X
50945
004
90
2
X
2,140.25
X
50945
002
90
2
X
2,140.25
X
50945
003
90
2
X
2,140.25
X
50947
004
90
2
X
3,233.79
X
50947
002
90
2
X
3,233.79
X
50947
003
90
2
X
3,233.79
X
50947
001
90
2
X
3,572.48
X
50948
002
90
2
X
2,957.06
X
50948
003
90
2
X
2,957.06
X
50948
004
90
2
X
2,957.06
X
50948
001
90
2
X
3,266.37
X
50949
YYY
2
X
#
X
50951
003
0
2
X
1,135.95
X
50951
001
0
2
X
849.17
X
50951
004
0
2
X
1,115.25
X
50951
002
0
2
X
1,149.96
X
50953
002
0
3
X
1,136.43
X
50953
003
0
3
X
1,122.12
X
50953
004
0
3
X
839.64
X
50953
001
0
3
X
890.80
X
50955
001
0
3
X
1,210.50
X
50955
004
0
3
X
992.39
X
50955
003
0
3
X
1,003.39
X
50955
002
0
3
X
1,205.92
X
50957
002
0
3
X
1,047.26
X
50957
003
0
3
X
1,186.69
X
50957
001
0
3
X
1,058.20
X
50957
004
0
3
X
991.54
X
50961
001
0
3
X
991.73
X
50961
004
0
3
X
1,297.38
X
50961
003
0
3
X
1,349.43
X
50961
002
0
3
X
1,368.00
X
50970
003
0
2
X
1,340.87
X
50970
002
0
2
X
1,416.25
X
50970
004
0
2
X
1,324.96
X
50970
001
0
2
X
1,434.46
X
50972
003
0
2
X
905.73
X
50972
002
0
2
X
940.62
X
50972
004
0
2
X
896.32
X
50972
001
0
2
X
949.25
X
50974
004
0
3
X
1,736.25
X
50974
001
0
3
X
1,878.94
X
50974
002
0
3
X
1,855.32
X
50974
003
0
3
X
1,757.24
X
50976
002
0
3
X
1,771.55
X
50976
003
0
3
X
1,678.96
X
50976
004
0
3
X
1,659.15
X
50976
001
0
3
X
1,793.94
X
50980
004
0
2
X
1,065.53
X
50980
001
0
2
X
1,141.11
X
50980
003
0
2
X
872.66
X
50980
002
0
2
X
1,657.42
X
51020
001
90
2
X
1,669.78
X
51020
004
90
2
X
1,659.18
X
51020
003
90
2
X
1,666.55
X
51020
002
90
2
X
1,692.40
X
51030
003
90
2
X
1,637.95
X
51030
002
90
2
X
1,818.90
X
51030
004
90
2
X
1,134.58
X
51030
001
90
2
X
1,636.42
X
51040
001
90
2
X
1,598.76
X
51040
004
90
2
X
1,571.85
X
51040
002
90
2
X
1,613.06
X
51040
003
90
2
X
1,607.38
X
51045
002
90
2
X
1,430.33
X
51045
003
90
2
X
1,610.08
X
51045
001
90
2
X
1,634.42
X
51045
004
90
2
X
1,604.05
X
51050
002
90
2
X
1,701.89
X
51050
003
90
2
X
1,665.38
X
51050
001
90
2
X
1,713.84
X
51050
004
90
2
X
1,657.79
X
51060
002
90
2
X
2,263.09
X
51060
003
90
2
X
2,116.80
X
51060
004
90
2
X
2,089.72
X
51060
001
90
2
X
2,298.29
X
51065
001
90
2
X
1,774.19
X
51065
004
90
2
X
1,631.93
X
51065
002
90
2
X
2,064.71
X
51065
003
90
2
X
1,849.27
X
51080
001
90
2
X
1,254.54
X
51080
003
90
2
X
1,163.47
X
51080
002
90
2
X
1,321.94
X
51080
004
90
2
X
1,271.50
X
51100
002
0
2
X
111.45
69.53
51100
003
0
2
X
111.45
69.53
51100
004
0
2
X
111.45
69.53
51100
001
0
2
X
126.43
75.83
51101
002
0
2
X
225.84
92.18
51101
003
0
2
X
225.84
92.18
51101
004
0
2
X
225.84
92.18
51101
001
0
2
X
262.75
101.61
51102
003
0
2
X
590.87
437.18
51102
002
0
2
X
590.87
437.18
51102
004
0
2
X
590.87
437.18
51102
001
0
2
X
669.20
483.86
51500
002
90
2
X
1,966.14
X
51500
003
90
2
X
1,840.89
X
51500
004
90
2
X
1,819.79
X
51500
001
90
2
X
1,996.53
X
51520
002
90
2
X
2,076.64
X
51520
003
90
2
X
2,027.80
X
51520
001
90
2
X
2,028.94
X
51520
004
90
2
X
1,861.07
X
51525
003
90
2
X
2,556.48
X
51525
002
90
2
X
2,705.88
X
51525
004
90
2
X
2,525.65
X
51525
001
90
2
X
2,741.85
X
51530
001
90
2
X
2,420.45
X
51530
004
90
2
X
2,665.92
X
51530
002
90
2
X
2,649.55
X
51530
003
90
2
X
2,682.32
X
51535
001
90
2
X
2,290.00
X
51535
004
90
2
X
2,101.66
X
51535
003
90
2
X
2,126.08
X
51535
002
90
2
X
2,257.99
X
51550
003
90
2
X
2,737.99
X
51550
002
90
2
X
2,896.93
X
51550
004
90
2
X
2,705.52
X
51550
001
90
2
X
2,935.29
X
51555
001
90
2
X
3,540.79
X
51555
004
90
2
X
3,383.05
X
51555
003
90
2
X
3,406.11
X
51555
002
90
2
X
3,691.16
X
51565
001
90
2
X
4,200.99
X
51565
004
90
2
X
3,869.52
X
51565
003
90
2
X
3,916.26
X
51565
002
90
2
X
4,145.60
X
51570
004
90
2
X
4,072.17
X
51570
001
90
2
X
4,407.94
X
51570
003
90
2
X
4,120.73
X
51570
002
90
2
X
4,352.07
X
51575
004
90
2
X
5,467.24
X
51575
002
90
2
X
5,854.21
X
51575
001
90
2
X
5,931.47
X
51575
003
90
2
X
5,533.88
X
51580
004
90
2
X
5,180.92
X
51580
001
90
2
X
5,606.83
X
51580
002
90
2
X
5,535.97
X
51580
003
90
2
X
5,242.74
X
51585
002
90
2
X
6,592.04
X
51585
003
90
2
X
6,238.15
X
51585
004
90
2
X
6,163.62
X
51585
001
90
2
X
6,677.33
X
51590
001
90
2
X
6,673.79
X
51590
004
90
2
X
6,366.78
X
51590
002
90
2
X
6,330.04
X
51590
003
90
2
X
6,466.10
X
51595
004
90
2
X
7,542.59
X
51595
002
90
2
X
7,892.86
X
51595
003
90
2
X
7,543.96
X
51595
001
90
2
X
8,002.79
X
51596
002
90
2
X
7,414.62
X
51596
003
90
2
X
7,276.91
X
51596
004
90
2
X
7,677.48
X
51596
001
90
2
X
7,454.32
X
51597
002
90
2
X
7,811.38
X
51597
003
90
2
X
7,323.90
X
51597
004
90
2
X
7,236.82
X
51597
001
90
2
X
7,929.30
X
51600
002
0
2
X
109.08
X
51600
003
0
2
X
106.37
X
51600
001
0
2
X
110.85
X
51600
004
0
2
X
105.82
X
51605
004
0
2
X
151.51
X
51605
003
0
2
X
153.10
X
51605
002
0
2
X
159.19
X
51605
001
0
2
X
160.76
X
51610
003
0
2
X
163.39
X
51610
002
0
2
X
174.03
X
51610
004
0
2
X
162.62
X
51610
001
0
2
X
171.81
X
51700
003
0
2
X
110.80
100.28
51700
002
0
2
X
118.18
106.77
51700
001
0
2
X
122.19
110.58
51700
004
0
2
X
103.41
93.82
51701
003
0
2
X
122.63
57.43
51701
002
0
2
X
122.63
57.43
51701
001
0
2
X
139.70
63.03
51701
004
0
2
X
122.63
57.43
51702
004
0
2
X
191.63
62.73
51702
001
0
2
X
220.75
69.26
51702
003
0
2
X
191.63
62.73
51702
002
0
2
X
191.63
62.73
51703
001
0
2
X
303.32
185.67
51703
004
0
2
X
269.14
169.06
51703
002
0
2
X
269.14
169.06
51703
003
0
2
X
269.14
169.06
51705
001
0
2
X
144.53
125.36
51705
004
0
2
X
138.89
121.02
51705
002
0
2
X
142.36
123.44
51705
003
0
2
X
137.53
119.53
51710
004
0
2
X
180.37
X
51710
001
0
2
X
189.02
X
51710
003
0
2
X
181.76
X
51710
002
0
2
X
187.56
X
51715
002
0
2
X
734.17
X
51715
003
0
2
X
695.32
X
51715
001
0
2
X
743.46
X
51715
004
0
2
X
687.15
X
51720
004
0
2
X
202.14
184.07
51720
001
0
2
X
213.21
193.23
51720
003
0
2
X
204.56
185.84
51720
002
0
2
X
210.80
191.56
51725
001
0
2
X
288.05
X
51725
26
001
0
2
X
246.29
X
51725
TC
001
0
2
X
47.70
X
51725
004
0
2
X
236.40
X
51725
26
004
0
2
X
202.84
X
51725
TC
004
0
2
X
41.87
X
51725
003
0
2
X
241.76
X
51725
26
003
0
2
X
206.90
X
51725
TC
003
0
2
X
42.48
X
51725
002
0
2
X
290.36
X
51725
26
002
0
2
X
243.61
X
51725
TC
002
0
2
X
46.72
X
51726
003
0
2
X
271.58
X
51726
26
003
0
2
X
229.93
X
51726
TC
003
0
2
X
54.66
X
51726
002
0
2
X
336.29
X
51726
26
002
0
2
X
266.73
X
51726
TC
002
0
2
X
60.04
X
51726
004
0
2
X
273.89
X
51726
26
004
0
2
X
225.46
X
51726
TC
004
0
2
X
53.81
X
51726
001
0
2
X
319.24
X
51726
26
001
0
2
X
285.29
X
51726
TC
001
0
2
X
61.31
X
51727
002
0
2
X
488.33
X
51727
26
002
0
2
X
188.56
X
51727
TC
002
0
2
X
299.76
X
51727
003
0
2
X
488.33
X
51727
26
003
0
2
X
188.56
X
51727
TC
003
0
2
X
299.76
X
51727
001
0
2
X
560.81
X
51727
26
001
0
2
X
205.07
X
51727
TC
001
0
2
X
355.71
X
51727
004
0
2
X
488.33
X
51727
26
004
0
2
X
188.56
X
51727
TC
004
0
2
X
299.76
X
51728
001
0
2
X
559.42
X
51728
26
001
0
2
X
201.61
X
51728
TC
001
0
2
X
357.86
X
51728
004
0
2
X
487.56
X
51728
26
004
0
2
X
186.04
X
51728
TC
004
0
2
X
301.59
X
51728
002
0
2
X
487.56
X
51728
26
002
0
2
X
186.04
X
51728
TC
002
0
2
X
301.59
X
51728
003
0
2
X
487.56
X
51728
26
003
0
2
X
186.04
X
51728
TC
003
0
2
X
301.59
X
51729
004
0
2
X
525.37
X
51729
26
004
0
2
X
220.24
X
51729
TC
004
0
2
X
305.09
X
51729
001
0
2
X
600.12
X
51729
26
001
0
2
X
238.10
X
51729
TC
001
0
2
X
362.04
X
51729
002
0
2
X
525.37
X
51729
26
002
0
2
X
220.24
X
51729
TC
002
0
2
X
305.09
X
51729
003
0
2
X
525.37
X
51729
26
003
0
2
X
220.24
X
51729
TC
003
0
2
X
305.09
X
51736
004
XXX
2
X
119.91
X
51736
26
004
XXX
2
X
96.70
X
51736
TC
004
XXX
2
X
15.93
X
51736
001
XXX
2
X
130.79
X
51736
26
001
XXX
2
X
110.92
X
51736
TC
001
XXX
2
X
17.87
X
51736
002
XXX
2
X
125.98
X
51736
26
002
XXX
2
X
110.24
X
51736
TC
002
XXX
2
X
17.62
X
51736
003
XXX
2
X
123.22
X
51736
26
003
XXX
2
X
118.55
X
51736
TC
003
XXX
2
X
16.17
X
51741
002
XXX
2
X
192.78
X
51741
26
002
XXX
2
X
162.36
X
51741
TC
002
XXX
2
X
125.30
X
51741
003
XXX
2
X
176.79
X
51741
26
003
XXX
2
X
157.46
X
51741
TC
003
XXX
2
X
23.23
X
51741
001
XXX
2
X
184.70
X
51741
26
001
XXX
2
X
163.47
X
51741
TC
001
XXX
2
X
26.04
X
51741
004
XXX
2
X
175.93
X
51741
26
004
XXX
2
X
156.57
X
51741
TC
004
XXX
2
X
22.93
X
51784
003
XXX
2
X
297.90
X
51784
26
003
XXX
2
X
251.76
X
51784
TC
003
XXX
2
X
46.12
X
51784
002
XXX
2
X
314.68
X
51784
26
002
XXX
2
X
263.87
X
51784
TC
002
XXX
2
X
50.84
X
51784
001
XXX
2
X
322.49
X
51784
26
001
XXX
2
X
269.59
X
51784
TC
001
XXX
2
X
52.88
X
51784
004
XXX
2
X
293.95
X
51784
26
004
XXX
2
X
248.61
X
51784
TC
004
XXX
2
X
45.29
X
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