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2024 Workers' Compensation Part B Fee Schedule

66155-67880

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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
66155   004 90 2 X 2,395.41 X
66155   002 90 2 X 2,448.32 X
66155   003 90 2 X 2,405.45 X
66155   001 90 2 X 2,458.53 X
66160   003 90 2 X 2,321.22 X
66160   002 90 2 X 2,370.20 X
66160   004 90 2 X 2,134.55 X
66160   001 90 2 X 2,381.92 X
66170   001 90 2 X 2,829.55 X
66170   003 90 2 X 2,476.84 X
66170   002 90 2 X 2,569.14 X
66170   004 90 2 X 2,488.29 X
66172   003 90 2 X 2,559.28 X
66172   002 90 2 X 2,653.58 X
66172   004 90 2 X 2,569.99 X
66172   001 90 2 X 2,914.46 X
66174   003 90 2 X 1,693.00 X
66174   002 90 2 X 1,693.00 X
66174   001 90 2 X 1,877.10 X
66174   004 90 2 X 1,693.00 X
66175   002 90 2 X 1,936.67 X
66175   003 90 2 X 1,936.67 X
66175   001 90 2 X 2,205.16 X
66175   004 90 2 X 1,936.67 X
66179   002 90 2 X 1,393.37 1,660.48
66179   003 90 2 X 1,393.37 1,660.48
66179   004 90 2 X 1,393.37 1,660.48
66179   001 90 2 X 1,519.17 1,831.69
66180   001 90 2 X 3,406.47 X
66180   003 90 2 X 3,176.78 X
66180   002 90 2 X 3,362.16 X
66180   004 90 2 X 3,135.24 X
66183   004 90 2 X 1,689.03 X
66183   001 90 2 X 1,883.42 X
66183   002 90 2 X 1,689.03 X
66183   003 90 2 X 1,689.03 X
66184   004 90 2 X 970.92 1,208.17
66184   001 90 2 X 1,060.14 1,337.73
66184   002 90 2 X 970.92 1,208.17
66184   003 90 2 X 970.92 1,208.17
66185   003 90 2 X 1,891.86 X
66185   002 90 2 X 2,000.43 X
66185   004 90 2 X 1,867.22 X
66185   001 90 2 X 2,026.38 X
66225   003 90 2 X 3,201.30 X
66225   002 90 2 X 2,921.19 X
66225   004 90 2 X 2,723.52 X
66225   001 90 2 X 3,407.05 X
66250   004 90 2 X 1,353.29 X
66250   001 90 2 X 1,465.92 X
66250   003 90 2 X 1,371.06 X
66250   002 90 2 X 1,447.60 X
66500   002 90 2 X 1,163.50 X
66500   004 90 2 X 868.74 X
66500   003 90 2 X 880.15 X
66500   001 90 2 X 942.46 X
66505   001 90 2 X 815.63 X
66505   004 90 2 X 758.83 X
66505   003 90 2 X 768.31 X
66505   002 90 2 X 806.47 X
66600   004 90 2 X 1,857.63 X
66600   003 90 2 X 2,245.16 X
66600   002 90 2 X 2,225.76 X
66600   001 90 2 X 2,226.44 X
66605   004 90 2 X 2,558.75 X
66605   002 90 2 X 2,727.84 X
66605   003 90 2 X 2,591.24 X
66605   001 90 2 X 3,078.24 X
66625   004 90 2 X 1,831.12 X
66625   002 90 2 X 1,746.86 X
66625   003 90 2 X 1,835.11 X
66625   001 90 2 X 2,031.34 X
66630   004 90 2 X 1,455.70 X
66630   001 90 2 X 2,084.40 X
66630   002 90 2 X 1,766.48 X
66630   003 90 2 X 1,803.85 X
66635   001 90 2 X 2,124.88 X
66635   002 90 2 X 1,762.18 X
66635   003 90 2 X 1,899.84 X
66635   004 90 2 X 1,891.08 X
66680   001 90 2 X 1,446.15 X
66680   004 90 2 X 1,393.41 X
66680   003 90 2 X 1,378.07 X
66680   002 90 2 X 1,427.89 X
66682   002 90 2 X 2,378.56 X
66682   003 90 2 X 2,313.75 X
66682   001 90 2 X 2,401.84 X
66682   004 90 2 X 2,353.59 X
66700   001 90 2 X 1,282.93 X
66700   004 90 2 X 1,200.67 X
66700   002 90 2 X 1,195.54 X
66700   003 90 2 X 1,192.99 X
66710   001 90 2 X 1,314.02 X
66710   004 90 2 X 1,207.39 X
66710   002 90 2 X 1,296.57 X
66710   003 90 2 X 1,223.55 X
66711   001 90 3 X 1,129.55 X
66711   004 90 3 X 1,011.99 X
66711   003 90 3 X 1,011.99 X
66711   002 90 3 X 1,011.99 X
66720   004 90 2 X 1,165.57 X
66720   003 90 2 X 1,181.25 X
66720   002 90 2 X 1,250.32 X
66720   001 90 2 X 1,266.89 X
66740   004 90 2 X 1,196.35 X
66740   003 90 2 X 1,212.38 X
66740   002 90 2 X 1,283.88 X
66740   001 90 2 X 1,300.90 X
66761   001 10 2 X 1,493.98 1,001.22
66761   004 10 2 X 1,408.10 941.54
66761   003 10 2 X 1,391.95 929.84
66761   002 10 2 X 1,450.47 971.31
66762   001 90 2 X 1,564.97 X
66762   002 90 2 X 1,542.59 X
66762   003 90 2 X 1,449.14 X
66762   004 90 2 X 1,429.13 X
66770   001 90 2 X 1,577.59 X
66770   002 90 2 X 1,569.22 X
66770   003 90 2 X 1,356.24 X
66770   004 90 2 X 1,526.70 X
66820   002 90 2 X 1,250.78 X
66820   003 90 2 X 941.53 X
66820   004 90 2 X 929.18 X
66820   001 90 2 X 1,008.53 X
66821   002 90 2 X 1,250.67 X
66821   003 90 2 X 929.65 X
66821   004 90 2 X 916.87 X
66821   001 90 2 X 1,004.50 X
66825   002 90 2 X 2,479.47 X
66825   003 90 2 X 2,412.27 X
66825   004 90 2 X 2,451.21 X
66825   001 90 2 X 2,503.35 X
66830   001 90 2 X 1,759.10 X
66830   004 90 2 X 1,631.74 X
66830   002 90 2 X 1,738.52 X
66830   003 90 2 X 1,652.57 X
66840   003 90 2 X 2,175.73 X
66840   002 90 2 X 2,258.99 X
66840   004 90 2 X 1,902.31 X
66840   001 90 2 X 2,295.53 X
66850   002 90 2 X 2,436.16 X
66850   003 90 2 X 2,371.66 X
66850   004 90 2 X 2,363.69 X
66850   001 90 2 X 2,566.36 X
66852   004 90 2 X 2,609.66 X
66852   001 90 2 X 2,843.02 X
66852   003 90 2 X 2,644.94 X
66852   002 90 2 X 2,804.83 X
66920   001 90 2 X 2,457.36 X
66920   004 90 2 X 2,247.42 X
66920   003 90 2 X 2,286.32 X
66920   002 90 2 X 2,406.53 X
66930   001 90 2 X 2,534.58 X
66930   004 90 2 X 2,339.29 X
66930   002 90 2 X 2,399.85 X
66930   003 90 2 X 2,296.75 X
66940   002 90 2 X 2,419.44 X
66940   003 90 2 X 2,347.10 X
66940   004 90 2 X 2,338.53 X
66940   001 90 2 X 2,531.68 X
66982   004 90 2 X 1,975.20 X
66982   001 90 2 X 2,175.10 X
66982   003 90 2 X 1,975.20 X
66982   002 90 2 X 1,975.20 X
66983   002 90 2 X 3,494.67 X
66983   003 90 2 X 3,300.35 X
66983   001 90 2 X 3,571.05 X
66983   004 90 2 X 3,223.46 X
66984   001 90 2 X 3,624.96 X
66984   002 90 2 X 3,571.13 X
66984   003 90 2 X 3,359.90 X
66984   004 90 2 X 3,350.25 X
66985   004 90 2 X 2,405.61 X
66985   001 90 2 X 2,615.02 X
66985   002 90 2 X 2,576.17 X
66985   003 90 2 X 2,429.27 X
66986   001 90 2 X 2,854.07 X
66986   004 90 2 X 2,632.30 X
66986   003 90 2 X 2,658.48 X
66986   002 90 2 X 2,813.37 X
66987     90 2 X * X
66988     90 2 X * X
66989   003 90 2 X 998.84 X
66989   002 90 2 X 998.84 X
66989   004 90 2 X 998.84 X
66989   001 90 2 X 1,092.30 X
66990   003 ZZZ 0 X 178.72 X
66990   002 ZZZ 0 X 178.72 X
66990   004 ZZZ 0 X 178.72 X
66990   001 ZZZ 0 X 195.37 X
66991   001 90 2 X 872.49 X
66991   004 90 2 X 796.05 X
66991   003 90 2 X 796.05 X
66991   002 90 2 X 796.05 X
66999     YYY 2 X # X
67005   002 90 2 X 3,027.07 X
67005   003 90 2 X 2,885.81 X
67005   001 90 2 X 3,099.15 X
67005   004 90 2 X 2,577.88 X
67010   002 90 2 X 2,943.53 X
67010   003 90 2 X 2,508.53 X
67010   001 90 2 X 2,716.93 X
67010   004 90 2 X 2,473.41 X
67015   001 90 2 X 1,398.96 X
67015   003 90 2 X 1,321.88 X
67015   002 90 2 X 1,371.85 X
67015   004 90 2 X 1,386.09 X
67025   004 90 2 X 1,391.84 X
67025   002 90 2 X 1,492.52 X
67025   003 90 2 X 1,409.78 X
67025   001 90 2 X 1,404.22 X
67027   001 90 2 X 2,022.14 X
67027   003 90 2 X 1,818.16 X
67027   002 90 2 X 1,818.16 X
67027   004 90 2 X 1,818.16 X
67028   001 0 2 X 658.21 X
67028   002 0 2 X 649.94 X
67028   003 0 2 X 615.23 X
67028   004 0 2 X 607.25 X
67030   003 90 2 X 1,303.74 X
67030   002 90 2 X 1,299.53 X
67030   001 90 2 X 1,337.12 X
67030   004 90 2 X 1,360.05 X
67031   003 90 2 X 1,799.15 X
67031   002 90 2 X 1,869.68 X
67031   001 90 2 X 1,886.46 X
67031   004 90 2 X 1,784.59 X
67036   001 90 2 X 5,476.30 X
67036   004 90 2 X 4,762.06 X
67036   003 90 2 X 5,007.04 X
67036   002 90 2 X 5,328.61 X
67039   002 90 2 X 4,704.03 X
67039   003 90 2 X 4,420.63 X
67039   004 90 2 X 4,360.05 X
67039   001 90 2 X 4,771.64 X
67040   001 90 2 X 6,985.24 X
67040   004 90 2 X 6,532.97 X
67040   002 90 2 X 6,954.22 X
67040   003 90 2 X 6,251.18 X
67041   001 90 2 X 2,098.72 X
67041   004 90 2 X 1,908.43 X
67041   003 90 2 X 1,908.43 X
67041   002 90 2 X 1,908.43 X
67042   001 90 2 X 2,398.75 X
67042   004 90 2 X 2,185.00 X
67042   002 90 2 X 2,185.00 X
67042   003 90 2 X 2,185.00 X
67043   001 90 2 X 2,520.90 X
67043   003 90 2 X 2,293.36 X
67043   004 90 2 X 2,293.36 X
67043   002 90 2 X 2,293.36 X
67101   004 10 2 X 2,451.11 X
67101   001 10 2 X 2,557.20 X
67101   003 10 2 X 2,472.56 X
67101   002 10 2 X 2,080.53 X
67105   004 10 2 X 2,656.86 X
67105   003 10 2 X 3,069.14 X
67105   002 10 2 X 2,754.38 X
67105   001 10 2 X 3,308.94 X
67107   001 90 2 X 3,809.63 X
67107   002 90 2 X 4,137.43 X
67107   003 90 2 X 4,066.37 X
67107   004 90 2 X 4,053.90 X
67108   001 90 2 X 6,415.50 X
67108   004 90 2 X 6,216.55 X
67108   002 90 2 X 6,350.39 X
67108   003 90 2 X 5,817.15 X
67110   002 90 2 X 2,712.10 X
67110   003 90 2 X 2,549.68 X
67110   001 90 2 X 2,750.75 X
67110   004 90 2 X 2,514.98 X
67113   001 90 2 X 2,769.98 X
67113   004 90 2 X 2,518.24 X
67113   003 90 2 X 2,518.24 X
67113   002 90 2 X 2,518.24 X
67115   001 90 2 X 1,369.83 X
67115   004 90 2 X 1,257.57 X
67115   003 90 2 X 1,274.46 X
67115   002 90 2 X 1,351.47 X
67120   001 90 2 X 1,460.49 X
67120   004 90 2 X 1,348.36 X
67120   002 90 2 X 1,442.20 X
67120   003 90 2 X 1,366.10 X
67121   002 90 2 X 2,000.44 X
67121   003 90 2 X 2,091.40 X
67121   004 90 2 X 2,065.27 X
67121   001 90 2 X 2,224.57 X
67141   002 10 2 X 1,491.74 X
67141   003 10 2 X 1,405.84 X
67141   004 10 2 X 1,386.98 X
67141   001 10 2 X 1,705.94 X
67145   004 10 2 X 1,419.64 1,002.88
67145   001 10 2 X 1,716.77 1,194.67
67145   003 10 2 X 1,438.89 1,015.04
67145   002 10 2 X 1,526.45 1,077.41
67208   001 90 2 X 2,483.95 X
67208   003 90 2 X 2,432.36 X
67208   002 90 2 X 2,362.43 X
67208   004 90 2 X 2,422.97 X
67210   004 90 2 X 2,008.69 1,496.86
67210   002 90 2 X 2,248.88 1,665.63
67210   003 90 2 X 2,211.18 1,643.05
67210   001 90 2 X 2,116.61 1,574.42
67218   001 90 2 X 3,119.88 X
67218   002 90 2 X 2,930.26 X
67218   003 90 2 X 2,782.57 X
67218   004 90 2 X 2,747.22 X
67220   002 90 2 X 1,714.35 1,708.58
67220   003 90 2 X 1,714.35 1,708.58
67220   004 90 2 X 1,714.35 1,708.58
67220   001 90 2 X 1,866.11 1,859.34
67221   001 0 2 X 850.25 617.45
67221   004 0 2 X 748.58 549.86
67221   003 0 2 X 748.58 549.86
67221   002 0 2 X 748.58 549.86
67225   001 ZZZ 0 X 118.75 114.23
67225   004 ZZZ 0 X 88.08 84.24
67225   002 ZZZ 0 X 88.08 84.24
67225   003 ZZZ 0 X 88.08 84.24
67227   004 10 2 X 2,045.26 X
67227   003 10 2 X 1,906.83 X
67227   002 10 2 X 1,901.56 X
67227   001 10 2 X 2,465.08 X
67228   004 10 2 X 2,136.53 1,622.76
67228   001 10 2 X 2,826.75 2,121.43
67228   002 10 2 X 2,784.76 2,089.97
67228   003 10 2 X 2,715.17 2,038.16
67229   004 90 2 X 1,657.08 X
67229   001 90 2 X 1,827.27 X
67229   002 90 2 X 1,657.08 X
67229   003 90 2 X 1,657.08 X
67250   004 90 2 X 1,621.67 X
67250   001 90 2 X 1,745.07 X
67250   003 90 2 X 1,641.85 X
67250   002 90 2 X 1,725.08 X
67255   004 90 2 X 2,449.23 X
67255   001 90 2 X 2,672.59 X
67255   003 90 2 X 2,482.75 X
67255   002 90 2 X 3,155.54 X
67299     YYY 2 X # X
67311   004 90 2 X 1,548.44 X
67311   003 90 2 X 1,793.06 X
67311   002 90 2 X 1,937.29 X
67311   001 90 2 X 1,949.08 X
67312   004 90 2 X 1,818.64 X
67312   001 90 2 X 2,070.14 X
67312   002 90 2 X 2,039.68 X
67312   003 90 2 X 1,842.61 X
67314   001 90 2 X 2,141.45 X
67314   003 90 2 X 1,970.57 X
67314   002 90 2 X 2,126.85 X
67314   004 90 2 X 1,626.49 X
67316   004 90 2 X 2,067.58 X
67316   002 90 2 X 2,212.18 X
67316   003 90 2 X 2,095.28 X
67316   001 90 2 X 2,245.54 X
67318   001 90 2 X 1,886.78 X
67318   003 90 2 X 1,740.14 X
67318   002 90 2 X 1,876.79 X
67318   004 90 2 X 1,440.26 X
67320   004 ZZZ 0 X 2,088.74 X
67320   001 ZZZ 0 X 2,270.63 X
67320   002 ZZZ 0 X 2,240.92 X
67320   003 ZZZ 0 X 2,116.46 X
67331   002 ZZZ 0 X 2,075.47 X
67331   003 ZZZ 0 X 1,885.76 X
67331   004 ZZZ 0 X 1,861.18 X
67331   001 ZZZ 0 X 2,086.10 X
67332   004 ZZZ 0 X 2,067.95 X
67332   002 ZZZ 0 X 2,462.12 X
67332   003 ZZZ 0 X 2,095.28 X
67332   001 ZZZ 0 X 2,473.91 X
67334   001 ZZZ 0 X 1,570.12 X
67334   004 ZZZ 0 X 1,460.67 X
67334   002 ZZZ 0 X 1,552.38 X
67334   003 ZZZ 0 X 1,478.82 X
67335   004 ZZZ 0 X 976.29 X
67335   002 ZZZ 0 X 1,057.79 X
67335   003 ZZZ 0 X 990.26 X
67335   001 ZZZ 0 X 1,073.95 X
67340   004 ZZZ 0 X 1,827.35 X
67340   002 ZZZ 0 X 1,942.03 X
67340   003 ZZZ 0 X 1,850.15 X
67340   001 ZZZ 0 X 1,964.11 X
67343   001 90 2 X 1,454.29 X
67343   002 90 2 X 1,437.90 X
67343   003 90 2 X 1,369.58 X
67343   004 90 2 X 1,352.73 X
67345   003 10 2 X 561.81 X
67345   002 10 2 X 595.26 X
67345   004 10 2 X 555.14 X
67345   001 10 2 X 603.45 X
67346   004 0 2 X 299.59 X
67346   003 0 2 X 299.59 X
67346   002 0 2 X 299.59 X
67346   001 0 2 X 335.39 X
67399     YYY 2 X # X
67400   003 90 2 X 2,398.02 X
67400   002 90 2 X 2,511.38 X
67400   001 90 2 X 2,523.36 X
67400   004 90 2 X 2,410.84 X
67405   004 90 2 X 1,802.99 X
67405   003 90 2 X 1,920.18 X
67405   002 90 2 X 1,936.04 X
67405   001 90 2 X 1,962.32 X
67412   004 90 2 X 2,566.02 X
67412   001 90 2 X 2,644.58 X
67412   003 90 2 X 2,233.97 X
67412   002 90 2 X 2,631.75 X
67413   001 90 2 X 2,047.39 X
67413   003 90 2 X 1,920.63 X
67413   002 90 2 X 2,312.49 X
67413   004 90 2 X 2,231.29 X
67414   004 90 2 X 1,945.49 X
67414   002 90 2 X 2,067.78 X
67414   003 90 2 X 1,969.73 X
67414   001 90 2 X 2,091.29 X
67415   001 0 2 X 509.52 X
67415   002 0 2 X 507.21 X
67415   003 0 2 X 497.74 X
67415   004 0 2 X 495.56 X
67420   002 90 2 X 4,208.97 X
67420   003 90 2 X 3,246.68 X
67420   001 90 2 X 4,312.53 X
67420   004 90 2 X 3,204.76 X
67430   001 90 2 X 2,654.70 X
67430   003 90 2 X 2,500.80 X
67430   002 90 2 X 2,624.92 X
67430   004 90 2 X 2,470.04 X
67440   001 90 2 X 3,960.34 X
67440   002 90 2 X 3,942.63 X
67440   003 90 2 X 3,044.58 X
67440   004 90 2 X 3,005.02 X
67445   001 90 2 X 2,774.36 X
67445   004 90 2 X 2,581.12 X
67445   003 90 2 X 2,613.18 X
67445   002 90 2 X 2,743.16 X
67450   004 90 2 X 2,565.87 X
67450   001 90 2 X 3,217.72 X
67450   003 90 2 X 2,809.91 X
67450   002 90 2 X 2,839.10 X
67500   001 0 2 X 312.36 X
67500   004 0 2 X 297.12 X
67500   003 0 2 X 264.49 X
67500   002 0 2 X 272.17 X
67505   001 0 2 X 351.47 257.84
67505   003 0 2 X 306.18 224.76
67505   002 0 2 X 345.13 253.07
67505   004 0 2 X 344.18 253.24
67515   002 0 2 X 173.11 133.31
67515   003 0 2 X 174.25 134.15
67515   001 0 2 X 140.28 107.65
67515   004 0 2 X 184.12 142.07
67516   004 0 0 X 126.24 101.88
67516   003 0 0 X 126.24 101.88
67516   002 0 0 X 126.24 101.88
67516   001 0 0 X 138.39 110.73
67550   001 90 2 X 2,230.11 X
67550   004 90 2 X 2,058.26 X
67550   002 90 2 X 2,201.84 X
67550   003 90 2 X 2,084.26 X
67560   004 90 2 X 2,654.78 X
67560   001 90 2 X 2,093.08 X
67560   003 90 2 X 1,969.09 X
67560   002 90 2 X 2,706.82 X
67570   004 90 2 X 2,114.88 X
67570   002 90 2 X 2,237.08 X
67570   003 90 2 X 2,140.12 X
67570   001 90 2 X 2,260.46 X
67599     YYY 2 X # X
67700   002 10 2 X 198.88 172.18
67700   003 10 2 X 191.09 165.89
67700   004 10 2 X 188.96 164.18
67700   001 10 2 X 205.33 177.83
67710   003 10 2 X 211.99 X
67710   002 10 2 X 223.54 X
67710   004 10 2 X 209.32 X
67710   001 10 2 X 226.27 X
67715   001 10 2 X 377.81 X
67715   004 10 2 X 281.85 X
67715   003 10 2 X 386.45 X
67715   002 10 2 X 368.16 X
67800   003 10 2 X 226.61 182.11
67800   002 10 2 X 256.43 205.67
67800   004 10 2 X 211.78 171.19
67800   001 10 2 X 259.30 207.90
67801   002 10 2 X 363.92 288.59
67801   004 10 2 X 342.67 272.74
67801   001 10 2 X 368.06 291.76
67801   003 10 2 X 346.82 275.76
67805   001 10 2 X 401.59 X
67805   004 10 2 X 374.94 X
67805   003 10 2 X 379.41 X
67805   002 10 2 X 397.24 X
67808   002 90 2 X 610.79 X
67808   003 90 2 X 591.77 X
67808   001 90 2 X 614.71 X
67808   004 90 2 X 600.08 X
67810   001 0 2 X 259.30 214.86
67810   004 0 2 X 242.50 201.91
67810   002 0 2 X 256.51 212.78
67810   003 0 2 X 245.34 204.02
67820   003 0 2 X 115.01 98.54
67820   002 0 2 X 124.75 106.63
67820   004 0 2 X 117.48 101.06
67820   001 0 2 X 125.77 107.55
67825   003 10 2 X 237.64 191.84
67825   002 10 2 X 248.99 200.30
67825   004 10 2 X 265.04 213.70
67825   001 10 2 X 317.43 255.12
67830   004 10 2 X 465.13 X
67830   002 10 2 X 1,093.29 X
67830   003 10 2 X 1,060.12 X
67830   001 10 2 X 1,132.28 X
67835   004 90 2 X 1,605.29 X
67835   001 90 2 X 1,717.37 X
67835   003 90 2 X 1,409.91 X
67835   002 90 2 X 1,492.85 X
67840   004 10 2 X 338.30 277.34
67840   001 10 2 X 511.15 417.00
67840   002 10 2 X 484.96 396.18
67840   003 10 2 X 387.69 317.48
67850   001 10 2 X 227.38 191.04
67850   002 10 2 X 216.80 182.06
67850   003 10 2 X 203.90 171.40
67850   004 10 2 X 204.67 171.88
67875   003 0 2 X 343.97 X
67875   002 0 2 X 364.80 X
67875   004 0 2 X 339.50 X
67875   001 0 2 X 369.82 X
67880   001 90 2 X 1,143.89 X
67880   004 90 2 X 851.40 X
67880   003 90 2 X 860.77 X
67880   002 90 2 X 903.51 X