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DLI
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Health Care Services Review
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Medical Fee Review
>
Fee Schedule
>
Fee Schedule 73218-74022
Begin Main Content Area
Page Content
Content Editor
2024 Workers' Compensation Part B Fee Schedule
73218-74022
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
73218
002
XXX
4
X
1,059.05
X
73218
26
002
XXX
4
X
117.77
X
73218
TC
002
XXX
4
X
941.35
X
73218
003
XXX
4
X
1,059.05
X
73218
26
003
XXX
4
X
117.77
X
73218
TC
003
XXX
4
X
941.35
X
73218
004
XXX
4
X
1,059.05
X
73218
26
004
XXX
4
X
117.77
X
73218
TC
004
XXX
4
X
941.35
X
73218
001
XXX
4
X
1,244.88
X
73218
26
001
XXX
4
X
127.87
X
73218
TC
001
XXX
4
X
1,117.04
X
73219
001
XXX
4
X
1,491.56
X
73219
26
001
XXX
4
X
151.94
X
73219
TC
001
XXX
4
X
1,339.58
X
73219
004
XXX
4
X
1,268.91
X
73219
26
004
XXX
4
X
140.24
X
73219
TC
004
XXX
4
X
1,128.65
X
73219
003
XXX
4
X
1,268.91
X
73219
26
003
XXX
4
X
140.24
X
73219
TC
003
XXX
4
X
1,128.65
X
73219
002
XXX
4
X
1,268.91
X
73219
26
002
XXX
4
X
140.24
X
73219
TC
002
XXX
4
X
1,128.65
X
73220
002
XXX
4
X
1,409.43
X
73220
26
002
XXX
4
X
256.88
X
73220
TC
002
XXX
4
X
1,177.10
X
73220
003
XXX
4
X
1,306.38
X
73220
26
003
XXX
4
X
245.84
X
73220
TC
003
XXX
4
X
1,085.94
X
73220
004
XXX
4
X
1,286.71
X
73220
26
004
XXX
4
X
239.51
X
73220
TC
004
XXX
4
X
1,068.72
X
73220
001
XXX
4
X
1,433.95
X
73220
26
001
XXX
4
X
257.64
X
73220
TC
001
XXX
4
X
1,198.77
X
73221
003
XXX
4
X
1,272.53
X
73221
26
003
XXX
4
X
210.34
X
73221
TC
003
XXX
4
X
1,085.94
X
73221
002
XXX
4
X
1,345.09
X
73221
26
002
XXX
4
X
218.98
X
73221
TC
002
XXX
4
X
1,177.10
X
73221
004
XXX
4
X
1,238.45
X
73221
26
004
XXX
4
X
206.93
X
73221
TC
004
XXX
4
X
1,068.72
X
73221
001
XXX
4
X
1,348.71
X
73221
26
001
XXX
4
X
219.29
X
73221
TC
001
XXX
4
X
1,198.77
X
73222
004
XXX
4
X
1,268.91
X
73222
26
004
XXX
4
X
140.24
X
73222
TC
004
XXX
4
X
1,128.65
X
73222
003
XXX
4
X
1,268.91
X
73222
26
003
XXX
4
X
140.24
X
73222
TC
003
XXX
4
X
1,128.65
X
73222
002
XXX
4
X
1,268.91
X
73222
26
002
XXX
4
X
140.24
X
73222
TC
002
XXX
4
X
1,128.65
X
73222
001
XXX
4
X
1,491.56
X
73222
26
001
XXX
4
X
151.94
X
73222
TC
001
XXX
4
X
1,339.58
X
73223
003
XXX
4
X
2,277.84
X
73223
26
003
XXX
4
X
188.68
X
73223
TC
003
XXX
4
X
2,089.19
X
73223
004
XXX
4
X
2,277.84
X
73223
26
004
XXX
4
X
188.68
X
73223
TC
004
XXX
4
X
2,089.19
X
73223
002
XXX
4
X
2,277.84
X
73223
26
002
XXX
4
X
188.68
X
73223
TC
002
XXX
4
X
2,089.19
X
73223
001
XXX
4
X
2,684.42
X
73223
26
001
XXX
4
X
205.65
X
73223
TC
001
XXX
4
X
2,478.78
X
73225
XXX
4
X
*
X
73501
004
XXX
0
X
43.01
X
73501
26
004
XXX
0
X
14.49
X
73501
TC
004
XXX
0
X
28.54
X
73501
001
XXX
0
X
48.96
X
73501
26
001
XXX
0
X
15.52
X
73501
TC
001
XXX
0
X
33.45
X
73501
003
XXX
0
X
43.01
X
73501
26
003
XXX
0
X
14.49
X
73501
TC
003
XXX
0
X
28.54
X
73501
002
XXX
0
X
43.01
X
73501
26
002
XXX
0
X
14.49
X
73501
TC
002
XXX
0
X
28.54
X
73502
001
XXX
0
X
68.48
X
73502
26
001
XXX
0
X
18.36
X
73502
TC
001
XXX
0
X
50.13
X
73502
002
XXX
0
X
59.96
X
73502
26
002
XXX
0
X
17.18
X
73502
TC
002
XXX
0
X
42.79
X
73502
003
XXX
0
X
59.96
X
73502
26
003
XXX
0
X
17.18
X
73502
TC
003
XXX
0
X
42.79
X
73502
004
XXX
0
X
59.96
X
73502
26
004
XXX
0
X
17.18
X
73502
TC
004
XXX
0
X
42.79
X
73503
003
XXX
0
X
74.95
X
73503
26
003
XXX
0
X
22.01
X
73503
TC
003
XXX
0
X
52.96
X
73503
002
XXX
0
X
74.95
X
73503
26
002
XXX
0
X
22.01
X
73503
TC
002
XXX
0
X
52.96
X
73503
004
XXX
0
X
74.95
X
73503
26
004
XXX
0
X
22.01
X
73503
TC
004
XXX
0
X
52.96
X
73503
001
XXX
0
X
85.69
X
73503
26
001
XXX
0
X
23.65
X
73503
TC
001
XXX
0
X
62.04
X
73521
004
XXX
0
X
57.41
X
73521
26
004
XXX
0
X
17.68
X
73521
TC
004
XXX
0
X
39.76
X
73521
001
XXX
0
X
65.53
X
73521
26
001
XXX
0
X
18.97
X
73521
TC
001
XXX
0
X
46.54
X
73521
003
XXX
0
X
57.41
X
73521
26
003
XXX
0
X
17.68
X
73521
TC
003
XXX
0
X
39.76
X
73521
002
XXX
0
X
57.41
X
73521
26
002
XXX
0
X
17.68
X
73521
TC
002
XXX
0
X
39.76
X
73522
001
XXX
0
X
80.82
X
73522
26
001
XXX
0
X
24.75
X
73522
TC
001
XXX
0
X
56.08
X
73522
004
XXX
0
X
70.96
X
73522
26
004
XXX
0
X
23.09
X
73522
TC
004
XXX
0
X
47.88
X
73522
003
XXX
0
X
70.96
X
73522
26
003
XXX
0
X
23.09
X
73522
TC
003
XXX
0
X
47.88
X
73522
002
XXX
0
X
70.96
X
73522
26
002
XXX
0
X
23.09
X
73522
TC
002
XXX
0
X
47.88
X
73523
001
XXX
0
X
93.86
X
73523
26
001
XXX
0
X
26.47
X
73523
TC
001
XXX
0
X
67.41
X
73523
002
XXX
0
X
82.23
X
73523
26
002
XXX
0
X
24.70
X
73523
TC
002
XXX
0
X
57.54
X
73523
003
XXX
0
X
82.23
X
73523
26
003
XXX
0
X
24.70
X
73523
TC
003
XXX
0
X
57.54
X
73523
004
XXX
0
X
82.23
X
73523
26
004
XXX
0
X
24.70
X
73523
TC
004
XXX
0
X
57.54
X
73525
004
XXX
0
X
280.86
X
73525
26
004
XXX
0
X
90.51
X
73525
TC
004
XXX
0
X
200.20
X
73525
003
XXX
0
X
290.40
X
73525
26
003
XXX
0
X
91.49
X
73525
TC
003
XXX
0
X
203.37
X
73525
002
XXX
0
X
306.69
X
73525
26
002
XXX
0
X
95.70
X
73525
TC
002
XXX
0
X
220.55
X
73525
001
XXX
0
X
311.77
X
73525
26
001
XXX
0
X
95.91
X
73525
TC
001
XXX
0
X
224.67
X
73551
002
XXX
0
X
40.39
X
73551
26
002
XXX
0
X
12.86
X
73551
TC
002
XXX
0
X
27.53
X
73551
003
XXX
0
X
40.39
X
73551
26
003
XXX
0
X
12.86
X
73551
TC
003
XXX
0
X
27.53
X
73551
001
XXX
0
X
46.08
X
73551
26
001
XXX
0
X
13.82
X
73551
TC
001
XXX
0
X
32.25
X
73551
004
XXX
0
X
40.39
X
73551
26
004
XXX
0
X
12.86
X
73551
TC
004
XXX
0
X
27.53
X
73552
001
XXX
0
X
53.76
X
73552
26
001
XXX
0
X
15.52
X
73552
TC
001
XXX
0
X
38.21
X
73552
002
XXX
0
X
47.09
X
73552
26
002
XXX
0
X
14.49
X
73552
TC
002
XXX
0
X
32.60
X
73552
003
XXX
0
X
47.09
X
73552
26
003
XXX
0
X
14.49
X
73552
TC
003
XXX
0
X
32.60
X
73552
004
XXX
0
X
47.09
X
73552
26
004
XXX
0
X
14.49
X
73552
TC
004
XXX
0
X
32.60
X
73560
004
XXX
0
X
74.28
X
73560
26
004
XXX
0
X
26.11
X
73560
TC
004
XXX
0
X
50.23
X
73560
002
XXX
0
X
80.82
X
73560
26
002
XXX
0
X
27.73
X
73560
TC
002
XXX
0
X
55.23
X
73560
003
XXX
0
X
76.48
X
73560
26
003
XXX
0
X
26.48
X
73560
TC
003
XXX
0
X
51.08
X
73560
001
XXX
0
X
82.15
X
73560
26
001
XXX
0
X
27.76
X
73560
TC
001
XXX
0
X
56.30
X
73562
004
XXX
0
X
81.79
X
73562
26
004
XXX
0
X
29.40
X
73562
TC
004
XXX
0
X
54.94
X
73562
003
XXX
0
X
84.97
X
73562
26
003
XXX
0
X
30.31
X
73562
TC
003
XXX
0
X
55.79
X
73562
002
XXX
0
X
89.23
X
73562
26
002
XXX
0
X
31.55
X
73562
TC
002
XXX
0
X
60.72
X
73562
001
XXX
0
X
90.80
X
73562
26
001
XXX
0
X
31.65
X
73562
TC
001
XXX
0
X
61.87
X
73564
004
XXX
0
X
93.87
X
73564
26
004
XXX
0
X
35.85
X
73564
TC
004
XXX
0
X
59.59
X
73564
002
XXX
0
X
100.73
X
73564
26
002
XXX
0
X
38.43
X
73564
TC
002
XXX
0
X
65.73
X
73564
003
XXX
0
X
96.38
X
73564
26
003
XXX
0
X
36.80
X
73564
TC
003
XXX
0
X
60.50
X
73564
001
XXX
0
X
102.44
X
73564
26
001
XXX
0
X
38.57
X
73564
TC
001
XXX
0
X
66.94
X
73565
001
XXX
0
X
79.02
X
73565
26
001
XXX
0
X
25.90
X
73565
TC
001
XXX
0
X
50.72
X
73565
004
XXX
0
X
71.46
X
73565
26
004
XXX
0
X
24.08
X
73565
TC
004
XXX
0
X
46.09
X
73565
002
XXX
0
X
77.79
X
73565
26
002
XXX
0
X
25.50
X
73565
TC
002
XXX
0
X
50.23
X
73565
003
XXX
0
X
72.50
X
73565
26
003
XXX
0
X
24.28
X
73565
TC
003
XXX
0
X
47.16
X
73580
001
XXX
0
X
369.69
X
73580
26
001
XXX
0
X
95.91
X
73580
TC
001
XXX
0
X
312.07
X
73580
002
XXX
0
X
363.38
X
73580
26
002
XXX
0
X
95.70
X
73580
TC
002
XXX
0
X
277.28
X
73580
003
XXX
0
X
337.04
X
73580
26
003
XXX
0
X
91.68
X
73580
TC
003
XXX
0
X
255.47
X
73580
004
XXX
0
X
332.11
X
73580
26
004
XXX
0
X
89.86
X
73580
TC
004
XXX
0
X
251.42
X
73590
001
XXX
0
X
84.21
X
73590
26
001
XXX
0
X
27.76
X
73590
TC
001
XXX
0
X
58.83
X
73590
003
XXX
0
X
76.46
X
73590
26
003
XXX
0
X
26.54
X
73590
TC
003
XXX
0
X
51.08
X
73590
002
XXX
0
X
80.82
X
73590
26
002
XXX
0
X
27.73
X
73590
TC
002
XXX
0
X
56.56
X
73590
004
XXX
0
X
74.28
X
73590
26
004
XXX
0
X
25.92
X
73590
TC
004
XXX
0
X
50.23
X
73592
001
XXX
0
X
78.06
X
73592
26
001
XXX
0
X
26.31
X
73592
TC
001
XXX
0
X
53.25
X
73592
003
XXX
0
X
72.37
X
73592
26
003
XXX
0
X
25.18
X
73592
TC
003
XXX
0
X
48.27
X
73592
002
XXX
0
X
76.82
X
73592
26
002
XXX
0
X
26.27
X
73592
TC
002
XXX
0
X
52.27
X
73592
004
XXX
0
X
70.48
X
73592
26
004
XXX
0
X
24.56
X
73592
TC
004
XXX
0
X
47.51
X
73600
002
XXX
0
X
76.82
X
73600
26
002
XXX
0
X
26.27
X
73600
TC
002
XXX
0
X
52.27
X
73600
004
XXX
0
X
70.48
X
73600
26
004
XXX
0
X
24.96
X
73600
TC
004
XXX
0
X
47.51
X
73600
001
XXX
0
X
79.24
X
73600
26
001
XXX
0
X
26.31
X
73600
TC
001
XXX
0
X
54.45
X
73600
003
XXX
0
X
72.38
X
73600
26
003
XXX
0
X
25.22
X
73600
TC
003
XXX
0
X
48.27
X
73610
001
XXX
0
X
84.08
X
73610
26
001
XXX
0
X
29.75
X
73610
TC
001
XXX
0
X
57.27
X
73610
004
XXX
0
X
77.91
X
73610
26
004
XXX
0
X
27.76
X
73610
TC
004
XXX
0
X
51.15
X
73610
003
XXX
0
X
80.14
X
73610
26
003
XXX
0
X
28.54
X
73610
TC
003
XXX
0
X
52.02
X
73610
002
XXX
0
X
84.51
X
73610
26
002
XXX
0
X
29.72
X
73610
TC
002
XXX
0
X
56.30
X
73615
004
XXX
0
X
280.86
X
73615
26
004
XXX
0
X
89.17
X
73615
TC
004
XXX
0
X
200.20
X
73615
001
XXX
0
X
311.77
X
73615
26
001
XXX
0
X
95.91
X
73615
TC
001
XXX
0
X
224.67
X
73615
003
XXX
0
X
290.40
X
73615
26
003
XXX
0
X
91.49
X
73615
TC
003
XXX
0
X
203.37
X
73615
002
XXX
0
X
306.69
X
73615
26
002
XXX
0
X
95.70
X
73615
TC
002
XXX
0
X
220.55
X
73620
004
XXX
0
X
70.48
X
73620
26
004
XXX
0
X
24.56
X
73620
TC
004
XXX
0
X
47.51
X
73620
003
XXX
0
X
72.38
X
73620
26
003
XXX
0
X
25.22
X
73620
TC
003
XXX
0
X
48.27
X
73620
002
XXX
0
X
76.82
X
73620
26
002
XXX
0
X
26.27
X
73620
TC
002
XXX
0
X
52.27
X
73620
001
XXX
0
X
78.06
X
73620
26
001
XXX
0
X
26.31
X
73620
TC
001
XXX
0
X
53.25
X
73630
004
XXX
0
X
77.91
X
73630
26
004
XXX
0
X
27.85
X
73630
TC
004
XXX
0
X
51.15
X
73630
003
XXX
0
X
80.14
X
73630
26
003
XXX
0
X
28.54
X
73630
TC
003
XXX
0
X
52.02
X
73630
002
XXX
0
X
84.46
X
73630
26
002
XXX
0
X
29.72
X
73630
TC
002
XXX
0
X
56.30
X
73630
001
XXX
0
X
84.08
X
73630
26
001
XXX
0
X
29.75
X
73630
TC
001
XXX
0
X
57.27
X
73650
004
XXX
0
X
68.67
X
73650
26
004
XXX
0
X
24.61
X
73650
TC
004
XXX
0
X
45.60
X
73650
002
XXX
0
X
74.87
X
73650
26
002
XXX
0
X
26.30
X
73650
TC
002
XXX
0
X
50.25
X
73650
003
XXX
0
X
70.34
X
73650
26
003
XXX
0
X
25.20
X
73650
TC
003
XXX
0
X
46.31
X
73650
001
XXX
0
X
77.45
X
73650
26
001
XXX
0
X
26.31
X
73650
TC
001
XXX
0
X
51.18
X
73660
004
XXX
0
X
59.23
X
73660
26
004
XXX
0
X
20.48
X
73660
TC
004
XXX
0
X
40.05
X
73660
003
XXX
0
X
60.96
X
73660
26
003
XXX
0
X
20.99
X
73660
TC
003
XXX
0
X
40.66
X
73660
002
XXX
0
X
64.80
X
73660
26
002
XXX
0
X
21.87
X
73660
TC
002
XXX
0
X
44.31
X
73660
001
XXX
0
X
67.31
X
73660
26
001
XXX
0
X
22.04
X
73660
TC
001
XXX
0
X
46.66
X
73700
001
XXX
4
X
702.23
X
73700
26
001
XXX
4
X
188.18
X
73700
TC
001
XXX
4
X
530.42
X
73700
004
XXX
4
X
632.36
X
73700
26
004
XXX
4
X
174.87
X
73700
TC
004
XXX
4
X
472.88
X
73700
003
XXX
4
X
649.53
X
73700
26
003
XXX
4
X
179.63
X
73700
TC
003
XXX
4
X
480.55
X
73700
002
XXX
4
X
690.59
X
73700
26
002
XXX
4
X
187.54
X
73700
TC
002
XXX
4
X
520.89
X
73701
004
XXX
4
X
733.16
X
73701
26
004
XXX
4
X
187.44
X
73701
TC
004
XXX
4
X
563.16
X
73701
003
XXX
4
X
744.12
X
73701
26
003
XXX
4
X
193.07
X
73701
TC
003
XXX
4
X
572.26
X
73701
002
XXX
4
X
801.60
X
73701
26
002
XXX
4
X
201.16
X
73701
TC
002
XXX
4
X
620.40
X
73701
001
XXX
4
X
815.34
X
73701
26
001
XXX
4
X
201.68
X
73701
TC
001
XXX
4
X
631.86
X
73702
004
XXX
4
X
886.10
X
73702
26
004
XXX
4
X
196.48
X
73702
TC
004
XXX
4
X
708.39
X
73702
001
XXX
4
X
986.19
X
73702
26
001
XXX
4
X
211.27
X
73702
TC
001
XXX
4
X
794.61
X
73702
002
XXX
4
X
969.52
X
73702
26
002
XXX
4
X
210.75
X
73702
TC
002
XXX
4
X
780.26
X
73702
003
XXX
4
X
899.46
X
73702
26
003
XXX
4
X
201.67
X
73702
TC
003
XXX
4
X
719.87
X
73706
001
XXX
4
X
913.95
X
73706
26
001
XXX
4
X
161.65
X
73706
004
XXX
4
X
778.60
X
73706
26
004
XXX
4
X
148.48
X
73706
002
XXX
4
X
778.60
X
73706
26
002
XXX
4
X
148.48
X
73706
003
XXX
4
X
778.60
X
73706
26
003
XXX
4
X
148.48
X
73706
TC
001
XXX
4
X
752.26
X
73706
TC
002
XXX
4
X
630.10
X
73706
TC
003
XXX
4
X
630.10
X
73706
TC
004
XXX
4
X
630.10
X
73718
003
XXX
4
X
1,059.05
X
73718
26
003
XXX
4
X
117.77
X
73718
TC
003
XXX
4
X
941.35
X
73718
001
XXX
4
X
1,244.88
X
73718
26
001
XXX
4
X
127.87
X
73718
TC
001
XXX
4
X
1,117.04
X
73718
002
XXX
4
X
1,059.05
X
73718
26
002
XXX
4
X
117.77
X
73718
TC
002
XXX
4
X
941.35
X
73718
004
XXX
4
X
1,059.05
X
73718
26
004
XXX
4
X
117.77
X
73718
TC
004
XXX
4
X
941.35
X
73719
004
XXX
4
X
1,268.91
X
73719
26
004
XXX
4
X
140.24
X
73719
TC
004
XXX
4
X
1,128.65
X
73719
002
XXX
4
X
1,268.91
X
73719
26
002
XXX
4
X
140.24
X
73719
TC
002
XXX
4
X
1,128.65
X
73719
001
XXX
4
X
1,491.56
X
73719
26
001
XXX
4
X
151.94
X
73719
TC
001
XXX
4
X
1,339.58
X
73719
003
XXX
4
X
1,268.91
X
73719
26
003
XXX
4
X
140.24
X
73719
TC
003
XXX
4
X
1,128.65
X
73720
004
XXX
4
X
1,286.71
X
73720
26
004
XXX
4
X
241.31
X
73720
TC
004
XXX
4
X
1,068.72
X
73720
003
XXX
4
X
1,306.38
X
73720
26
003
XXX
4
X
246.01
X
73720
TC
003
XXX
4
X
1,085.94
X
73720
002
XXX
4
X
1,409.43
X
73720
26
002
XXX
4
X
256.88
X
73720
TC
002
XXX
4
X
1,177.10
X
73720
001
XXX
4
X
1,433.95
X
73720
26
001
XXX
4
X
257.64
X
73720
TC
001
XXX
4
X
1,198.77
X
73721
001
XXX
4
X
1,348.71
X
73721
26
001
XXX
4
X
219.29
X
73721
TC
001
XXX
4
X
1,198.77
X
73721
002
XXX
4
X
1,345.09
X
73721
26
002
XXX
4
X
218.98
X
73721
TC
002
XXX
4
X
1,177.10
X
73721
003
XXX
4
X
1,272.53
X
73721
26
003
XXX
4
X
210.36
X
73721
TC
003
XXX
4
X
1,085.94
X
73721
004
XXX
4
X
1,238.45
X
73721
26
004
XXX
4
X
204.01
X
73721
TC
004
XXX
4
X
1,068.72
X
73722
001
XXX
4
X
1,491.56
X
73722
26
001
XXX
4
X
151.94
X
73722
TC
001
XXX
4
X
1,339.58
X
73722
004
XXX
4
X
1,268.91
X
73722
26
004
XXX
4
X
140.24
X
73722
TC
004
XXX
4
X
1,128.65
X
73722
003
XXX
4
X
1,268.91
X
73722
26
003
XXX
4
X
140.24
X
73722
TC
003
XXX
4
X
1,128.65
X
73722
002
XXX
4
X
1,268.91
X
73722
26
002
XXX
4
X
140.24
X
73722
TC
002
XXX
4
X
1,128.65
X
73723
002
XXX
4
X
2,277.84
X
73723
26
002
XXX
4
X
188.68
X
73723
TC
002
XXX
4
X
2,089.19
X
73723
003
XXX
4
X
2,277.84
X
73723
26
003
XXX
4
X
188.68
X
73723
TC
003
XXX
4
X
2,089.19
X
73723
001
XXX
4
X
2,684.42
X
73723
26
001
XXX
4
X
205.65
X
73723
TC
001
XXX
4
X
2,478.78
X
73723
004
XXX
4
X
2,277.84
X
73723
26
004
XXX
4
X
188.68
X
73723
TC
004
XXX
4
X
2,089.19
X
73725
004
XXX
4
X
1,319.85
X
73725
26
004
XXX
4
X
251.12
X
73725
TC
004
XXX
4
X
1,068.72
X
73725
003
XXX
4
X
1,339.82
X
73725
26
003
XXX
4
X
253.85
X
73725
TC
003
XXX
4
X
1,085.98
X
73725
002
XXX
4
X
1,443.74
X
73725
26
002
XXX
4
X
266.54
X
73725
TC
002
XXX
4
X
1,177.20
X
73725
001
XXX
4
X
1,468.42
X
73725
26
001
XXX
4
X
269.60
X
73725
TC
001
XXX
4
X
1,198.83
X
74018
004
XXX
0
X
38.63
X
74018
26
004
XXX
0
X
13.47
X
74018
TC
004
XXX
0
X
25.16
X
74018
002
XXX
0
X
38.63
X
74018
26
002
XXX
0
X
13.47
X
74018
TC
002
XXX
0
X
25.16
X
74018
003
XXX
0
X
38.63
X
74018
26
003
XXX
0
X
13.47
X
74018
TC
003
XXX
0
X
25.16
X
74018
001
XXX
0
X
43.32
X
74018
26
001
XXX
0
X
14.36
X
74018
TC
001
XXX
0
X
28.97
X
74019
001
XXX
0
X
52.78
X
74019
26
001
XXX
0
X
18.17
X
74019
TC
001
XXX
0
X
34.61
X
74019
004
XXX
0
X
47.16
X
74019
26
004
XXX
0
X
17.06
X
74019
TC
004
XXX
0
X
30.09
X
74019
003
XXX
0
X
47.16
X
74019
26
003
XXX
0
X
17.06
X
74019
TC
003
XXX
0
X
30.09
X
74019
002
XXX
0
X
47.16
X
74019
26
002
XXX
0
X
17.06
X
74019
TC
002
XXX
0
X
30.09
X
74021
004
XXX
0
X
55.19
X
74021
26
004
XXX
0
X
20.22
X
74021
TC
004
XXX
0
X
34.99
X
74021
003
XXX
0
X
55.19
X
74021
26
003
XXX
0
X
20.22
X
74021
TC
003
XXX
0
X
34.99
X
74021
002
XXX
0
X
55.19
X
74021
26
002
XXX
0
X
20.22
X
74021
TC
002
XXX
0
X
34.99
X
74021
001
XXX
0
X
61.87
X
74021
26
001
XXX
0
X
21.60
X
74021
TC
001
XXX
0
X
40.27
X
74022
004
XXX
0
X
119.00
X
74022
26
004
XXX
0
X
50.90
X
74022
TC
004
XXX
0
X
70.78
X
74022
003
XXX
0
X
122.15
X
74022
26
003
XXX
0
X
52.06
X
74022
TC
003
XXX
0
X
71.93
X
74022
002
XXX
0
X
128.22
X
74022
26
002
XXX
0
X
54.44
X
74022
TC
002
XXX
0
X
78.16
X
74022
001
XXX
0
X
130.30
X
74022
26
001
XXX
0
X
54.66
X
74022
TC
001
XXX
0
X
79.64
X
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