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2021 Workers' Compensation Part B Fee Schedule

01829-11643

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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
01829   1 XXX 9 65.58 X X
01829   2 XXX 9 65.14 X X
01829   3 XXX 9 62.70 X X
01829   4 XXX 9 58.42 X X
01830   1 XXX 9 65.58 X X
01830   2 XXX 9 65.14 X X
01830   3 XXX 9 62.70 X X
01830   4 XXX 9 58.42 X X
01832   1 XXX 9 65.58 X X
01832   2 XXX 9 65.14 X X
01832   3 XXX 9 62.70 X X
01832   4 XXX 9 58.42 X X
01840   1 XXX 9 65.58 X X
01840   2 XXX 9 65.14 X X
01840   3 XXX 9 62.70 X X
01840   4 XXX 9 58.42 X X
01842   1 XXX 9 65.58 X X
01842   2 XXX 9 65.14 X X
01842   3 XXX 9 62.70 X X
01842   4 XXX 9 58.42 X X
01844   1 XXX 9 65.58 X X
01844   2 XXX 9 65.14 X X
01844   3 XXX 9 62.70 X X
01844   4 XXX 9 58.42 X X
01850   1 XXX 9 65.58 X X
01850   2 XXX 9 65.14 X X
01850   3 XXX 9 62.70 X X
01850   4 XXX 9 58.42 X X
01852   1 XXX 9 65.58 X X
01852   2 XXX 9 65.14 X X
01852   3 XXX 9 62.70 X X
01852   4 XXX 9 58.42 X X
01860   1 XXX 9 65.58 X X
01860   2 XXX 9 65.14 X X
01860   3 XXX 9 62.70 X X
01860   4 XXX 9 58.42 X X
01916   1 XXX 9 65.58 X X
01916   2 XXX 9 65.14 X X
01916   3 XXX 9 62.70 X X
01916   4 XXX 9 58.42 X X
01920   1 XXX 9 65.58 X X
01920   2 XXX 9 65.14 X X
01920   3 XXX 9 62.70 X X
01920   4 XXX 9 58.42 X X
01922   1 XXX 9 65.58 X X
01922   2 XXX 9 65.14 X X
01922   3 XXX 9 62.70 X X
01922   4 XXX 9 58.42 X X
01924   1 XXX 9 65.58 X X
01924   2 XXX 9 65.14 X X
01924   3 XXX 9 62.70 X X
01924   4 XXX 9 58.42 X X
01925   1 XXX 9 65.58 X X
01925   2 XXX 9 65.14 X X
01925   3 XXX 9 62.70 X X
01925   4 XXX 9 58.42 X X
01926   1 XXX 9 65.58 X X
01926   2 XXX 9 65.14 X X
01926   3 XXX 9 62.70 X X
01926   4 XXX 9 58.42 X X
01930   1 XXX 9 65.58 X X
01930   2 XXX 9 65.14 X X
01930   3 XXX 9 62.70 X X
01930   4 XXX 9 58.42 X X
01931   1 XXX 9 65.58 X X
01931   2 XXX 9 65.14 X X
01931   3 XXX 9 62.70 X X
01931   4 XXX 9 58.42 X X
01932   1 XXX 9 65.58 X X
01932   2 XXX 9 65.14 X X
01932   3 XXX 9 62.70 X X
01932   4 XXX 9 58.42 X X
01933   1 XXX 9 65.58 X X
01933   2 XXX 9 65.14 X X
01933   3 XXX 9 62.70 X X
01933   4 XXX 9 58.42 X X
01935   1 XXX 9 65.58 X X
01935   2 XXX 9 65.14 X X
01935   3 XXX 9 62.70 X X
01935   4 XXX 9 58.42 X X
01936   1 XXX 9 65.58 X X
01936   2 XXX 9 65.14 X X
01936   3 XXX 9 62.70 X X
01936   4 XXX 9 58.42 X X
01951   1 XXX 9 65.58 X X
01951   2 XXX 9 65.14 X X
01951   3 XXX 9 62.70 X X
01951   4 XXX 9 58.42 X X
01952   1 XXX 9 65.58 X X
01952   2 XXX 9 65.14 X X
01952   3 XXX 9 62.70 X X
01952   4 XXX 9 58.42 X X
01953   1 XXX 9 65.58 X X
01953   2 XXX 9 65.14 X X
01953   3 XXX 9 62.70 X X
01953   4 XXX 9 58.42 X X
01958   1 XXX 9 65.58 X X
01958   2 XXX 9 65.14 X X
01958   3 XXX 9 62.70 X X
01958   4 XXX 9 58.42 X X
01960   1 XXX 9 65.58 X X
01960   2 XXX 9 65.14 X X
01960   3 XXX 9 62.70 X X
01960   4 XXX 9 58.42 X X
01961   1 XXX 9 65.58 X X
01961   2 XXX 9 65.14 X X
01961   3 XXX 9 62.70 X X
01961   4 XXX 9 58.42 X X
01962   1 XXX 9 65.58 X X
01962   2 XXX 9 65.14 X X
01962   3 XXX 9 62.70 X X
01962   4 XXX 9 58.42 X X
01963   1 XXX 9 65.58 X X
01963   2 XXX 9 65.14 X X
01963   3 XXX 9 62.70 X X
01963   4 XXX 9 58.42 X X
01965   1 XXX 9 65.58 X X
01965   2 XXX 9 65.14 X X
01965   3 XXX 9 62.71 X X
01965   4 XXX 9 58.42 X X
01966   1 XXX 9 65.58 X X
01966   2 XXX 9 65.14 X X
01966   3 XXX 9 62.71 X X
01966   4 XXX 9 58.42 X X
01967   1 XXX 9 65.58 X X
01967   2 XXX 9 65.14 X X
01967   3 XXX 9 62.70 X X
01967   4 XXX 9 58.42 X X
01968   1 XXX 9 65.58 X X
01968   2 XXX 9 65.14 X X
01968   3 XXX 9 62.70 X X
01968   4 XXX 9 58.42 X X
01969   1 XXX 9 65.58 X X
01969   2 XXX 9 65.14 X X
01969   3 XXX 9 62.70 X X
01969   4 XXX 9 58.42 X X
01990   1 XXX 9 65.58 X X
01990   2 XXX 9 65.14 X X
01990   3 XXX 9 62.70 X X
01990   4 XXX 9 58.42 X X
01991   1 XXX 9 65.58 X X
01991   2 XXX 9 65.14 X X
01991   3 XXX 9 62.70 X X
01991   4 XXX 9 58.42 X X
01992   1 XXX 9 65.58 X X
01992   2 XXX 9 65.14 X X
01992   3 XXX 9 62.70 X X
01992   4 XXX 9 58.42 X X
01996   1 XXX 9 65.58 X X
01996   2 XXX 9 65.14 X X
01996   3 XXX 9 62.70 X X
01996   4 XXX 9 58.42 X X
01999   1 XXX 9 65.58 X X
01999   2 XXX 9 65.14 X X
01999   3 XXX 9 62.70 X X
01999   4 XXX 9 58.42 X X
10004   2 ZZZ 0 X 62.04 52.48
10004   3 ZZZ 0 X 62.04 52.48
10004   4 ZZZ 0 X 62.04 52.48
10004   1 ZZZ 0 X 67.82 56.84
10005   2 XXX 2 X 147.74 88.32
10005   3 XXX 2 X 147.74 88.32
10005   4 XXX 2 X 147.74 88.32
10005   1 XXX 2 X 162.96 94.80
10006   2 ZZZ 0 X 71.32 60.16
10006   3 ZZZ 0 X 71.32 60.16
10006   4 ZZZ 0 X 71.32 60.16
10006   1 ZZZ 0 X 77.31 64.50
10007   2 XXX 2 X 328.29 113.38
10007   3 XXX 2 X 328.29 113.38
10007   4 XXX 2 X 328.29 113.38
10007   1 XXX 2 X 368.58 121.98
10008   2 ZZZ 0 X 185.52 73.89
10008   3 ZZZ 0 X 185.52 73.89
10008   4 ZZZ 0 X 185.52 73.89
10008   1 ZZZ 0 X 207.57 79.46
10009   2 XXX 2 X 534.97 137.45
10009   3 XXX 2 X 534.97 137.45
10009   4 XXX 2 X 534.97 137.45
10009   1 XXX 2 X 603.57 147.45
10010   2 ZZZ 0 X 323.33 100.46
10010   3 ZZZ 0 X 323.33 100.46
10010   4 ZZZ 0 X 323.33 100.46
10010   1 ZZZ 0 X 363.51 107.76
10011         X * X
10012         X * X
10021 TC 2 XXX 0 X 32.13 X
10021 TC 3 XXX 0 X 32.13 X
10021 TC 4 XXX 0 X 32.13 X
10021 TC 1 XXX 0 X 38.85 X
10021 26 2 XXX 0 X 127.29 X
10021 26 3 XXX 0 X 127.29 X
10021 26 4 XXX 0 X 127.29 X
10021 26 1 XXX 0 X 139.72 X
10021   2 XXX 0 X 159.46 X
10021   3 XXX 0 X 159.46 X
10021   4 XXX 0 X 159.46 X
10021   1 XXX 0 X 178.54 X
10030   2 XXX 2 X 1,011.44 214.64
10030   3 XXX 2 X 1,011.44 214.64
10030   4 XXX 2 X 1,011.44 214.64
10030   1 XXX 2 X 1,159.54 231.26
10035   2 0 2 X 665.47 114.70
10035   3 0 2 X 665.47 114.70
10035   4 0 2 X 665.47 114.70
10035   1 0 2 X 767.66 123.22
10036   2 ZZZ 2 X 576.43 57.79
10036   3 ZZZ 2 X 576.43 57.79
10036   4 ZZZ 2 X 576.43 57.79
10036   1 ZZZ 2 X 669.00 62.16
10040     10 2 X * X
10060   4 10 2 X 135.67 117.93
10060   3 10 2 X 138.17 119.73
10060   2 10 2 X 141.17 122.16
10060   1 10 2 X 144.00 124.70
10061   4 10 2 X 215.09 194.03
10061   3 10 2 X 252.43 227.84
10061   2 10 2 X 295.61 266.57
10061   1 10 2 X 300.17 270.16
10080   4 10 2 X 153.25 136.19
10080   3 10 2 X 170.00 150.93
10080   1 10 2 X 171.88 152.35
10080   2 10 2 X 179.28 158.71
10081   4 10 2 X 338.32 X
10081   3 10 2 X 339.89 X
10081   2 10 2 X 345.94 X
10081   1 10 2 X 350.31 X
10120   3 10 2 X 148.76 128.72
10120   4 10 2 X 150.76 130.89
10120   2 10 2 X 159.54 138.11
10120   1 10 2 X 161.20 139.54
10121   4 10 2 X 333.19 290.45
10121   3 10 2 X 336.82 293.39
10121   2 10 2 X 352.76 306.76
10121   1 10 2 X 356.68 310.07
10140   4 10 2 X 150.01 131.92
10140   3 10 2 X 156.98 137.92
10140   2 10 2 X 168.06 147.62
10140   1 10 2 X 169.51 149.09
10160   4 10 2 X 134.77 119.19
10160   1 10 2 X 137.95 121.63
10160   3 10 2 X 141.11 124.73
10160   2 10 2 X 148.18 131.05
10180   3 10 2 X 382.73 X
10180   4 10 2 X 383.22 X
10180   2 10 2 X 395.84 X
10180   1 10 2 X 396.02 X
11000   4 0 2 X 119.06 102.17
11000   3 0 2 X 120.42 103.25
11000   2 0 2 X 126.14 107.92
11000   1 0 2 X 127.49 109.05
11001   4 ZZZ 0 X 64.62 53.68
11001   3 ZZZ 0 X 65.38 54.17
11001   2 ZZZ 0 X 68.52 56.67
11001   1 ZZZ 0 X 69.28 57.26
11004   2 0 2 X 975.45 X
11004   3 0 2 X 975.45 X
11004   4 0 2 X 975.45 X
11004   1 0 2 X 1,063.71 X
11005   2 0 0 X 1,326.77 X
11005   3 0 0 X 1,326.77 X
11005   4 0 0 X 1,326.77 X
11005   1 0 0 X 1,451.50 X
11006   2 0 2 X 1,223.15 X
11006   3 0 2 X 1,223.15 X
11006   4 0 2 X 1,223.15 X
11006   1 0 2 X 1,350.07 X
11008   2 ZZZ 0 X 496.56 X
11008   3 ZZZ 0 X 496.56 X
11008   4 ZZZ 0 X 496.56 X
11008   1 ZZZ 0 X 552.12 X
11010   3 10 2 X 751.09 X
11010   4 10 2 X 751.09 X
11010   2 10 2 X 771.83 X
11010   1 10 2 X 862.87 X
11011   3 0 2 X 895.20 X
11011   4 0 2 X 895.20 X
11011   2 0 2 X 919.95 X
11011   1 0 2 X 1,028.21 X
11012   3 0 2 X 1,244.24 X
11012   4 0 2 X 1,244.24 X
11012   2 0 2 X 1,278.58 X
11012   1 0 2 X 1,429.00 X
11042   4 0 2 X 178.44 X
11042   3 0 2 X 188.61 X
11042   2 0 2 X 210.67 X
11042   1 0 2 X 238.60 X
11043   4 10 2 X 382.17 X
11043   1 10 2 X 423.42 X
11043   2 10 2 X 425.27 X
11043   3 10 2 X 437.42 X
11044   4 10 2 X 490.96 X
11044   3 10 2 X 496.97 X
11044   2 10 2 X 537.23 X
11044   1 10 2 X 546.96 X
11045   2 ZZZ 0 X 45.30 26.89
11045   3 ZZZ 0 X 45.30 26.89
11045   4 ZZZ 0 X 45.30 26.89
11045   1 ZZZ 0 X 50.67 29.81
11046   2 ZZZ 0 X 78.92 56.64
11046   3 ZZZ 0 X 78.92 56.64
11046   4 ZZZ 0 X 78.92 56.64
11046   1 ZZZ 0 X 87.44 62.23
11047   2 ZZZ 0 X 130.13 98.65
11047   3 ZZZ 0 X 130.13 98.65
11047   4 ZZZ 0 X 130.13 98.65
11047   1 ZZZ 0 X 144.32 108.70
11055   2 0 2 X 41.26 31.13
11055   3 0 2 X 41.26 31.13
11055   4 0 2 X 41.26 31.13
11055   1 0 2 X 45.96 34.10
11056   2 0 2 X 57.88 44.32
11056   3 0 2 X 57.88 44.32
11056   4 0 2 X 57.88 44.32
11056   1 0 2 X 64.67 48.71
11057   2 0 2 X 60.78 49.95
11057   3 0 2 X 60.78 49.95
11057   4 0 2 X 60.78 49.95
11057   1 0 2 X 66.89 54.15
11102   2 0 2 X 113.82 47.62
11102   3 0 2 X 113.82 47.62
11102   4 0 2 X 113.82 47.62
11102   1 0 2 X 127.81 51.86
11103   2 ZZZ 0 X 61.45 27.55
11103   3 ZZZ 0 X 61.45 27.55
11103   4 ZZZ 0 X 61.45 27.55
11103   1 ZZZ 0 X 68.89 30.00
11104   2 0 2 X 143.07 59.74
11104   3 0 2 X 143.07 59.74
11104   4 0 2 X 143.07 59.74
11104   1 0 2 X 160.63 65.01
11105   2 ZZZ 0 X 70.46 32.57
11105   3 ZZZ 0 X 70.46 32.57
11105   4 ZZZ 0 X 70.46 32.57
11105   1 ZZZ 0 X 78.93 35.47
11106   2 0 2 X 173.19 72.71
11106   3 0 2 X 173.19 72.71
11106   4 0 2 X 173.19 72.71
11106   1 0 2 X 194.47 79.18
11107   2 ZZZ 0 X 83.09 38.84
11107   3 ZZZ 0 X 83.09 38.84
11107   4 ZZZ 0 X 83.09 38.84
11107   1 ZZZ 0 X 93.04 42.26
11200   3 10 2 X 114.41 93.67
11200   2 10 2 X 120.51 98.86
11200   4 10 2 X 121.15 99.64
11200   1 10 2 X 129.40 106.02
11201   4 ZZZ 0 X 39.28 32.07
11201   3 ZZZ 0 X 39.75 32.36
11201   2 ZZZ 0 X 41.96 34.21
11201   1 ZZZ 0 X 42.50 34.67
11300   4 0 2 X 118.41 94.46
11300   3 0 2 X 131.72 105.33
11300   2 0 2 X 131.95 105.21
11300   1 0 2 X 133.65 106.57
11301   4 0 2 X 139.22 110.43
11301   2 0 2 X 148.76 117.78
11301   1 0 2 X 150.66 119.29
11301   3 0 2 X 162.50 132.59
11302   4 0 2 X 178.27 140.20
11302   2 0 2 X 191.05 150.08
11302   1 0 2 X 193.66 152.11
11302   3 0 2 X 207.83 168.40
11303   4 0 2 X 323.73 X
11303   2 0 2 X 335.14 X
11303   1 0 2 X 340.66 X
11303   3 0 2 X 343.98 X
11305   2 0 2 X 117.26 93.11
11305   1 0 2 X 118.77 94.29
11305   4 0 2 X 131.11 107.48
11305   3 0 2 X 135.37 111.05
11306   4 0 2 X 155.97 125.48
11306   3 0 2 X 157.80 126.84
11306   2 0 2 X 166.53 133.75
11306   1 0 2 X 168.67 135.39
11307   4 0 2 X 191.42 151.20
11307   2 0 2 X 205.18 161.91
11307   1 0 2 X 223.01 181.04
11307   3 0 2 X 242.17 198.09
11308   1 0 2 X 287.13 X
11308   2 0 2 X 350.85 X
11308   3 0 2 X 358.76 X
11308   4 0 2 X 358.86 X
11310   4 0 2 X 161.73 129.40
11310   2 0 2 X 174.87 139.77
11310   3 0 2 X 177.89 142.52
11310   1 0 2 X 179.03 142.97
11311   4 0 2 X 205.52 167.84
11311   2 0 2 X 228.95 186.32
11311   1 0 2 X 234.11 190.55
11311   3 0 2 X 236.05 192.63
11312   4 0 2 X 212.86 165.02
11312   1 0 2 X 279.08 224.05
11312   3 0 2 X 279.61 224.77
11312   2 0 2 X 282.51 226.10
11313   2 0 2 X 364.67 X
11313   1 0 2 X 377.11 X
11313   4 0 2 X 378.77 X
11313   3 0 2 X 406.56 X
11400   4 10 2 X 133.73 109.78
11400   3 10 2 X 147.20 120.84
11400   2 10 2 X 147.93 121.13
11400   1 10 2 X 149.62 122.54
11401   4 10 2 X 176.51 147.75
11401   3 10 2 X 181.28 151.40
11401   2 10 2 X 187.24 156.30
11401   1 10 2 X 189.44 158.02
11402   4 10 2 X 224.45 186.40
11402   3 10 2 X 231.01 191.60
11402   2 10 2 X 238.75 197.78
11402   1 10 2 X 241.59 200.07
11403   4 10 2 X 302.16 247.89
11403   1 10 2 X 313.74 257.05
11403   2 10 2 X 317.33 260.14
11403   3 10 2 X 325.02 267.10
11404   2 10 2 X 348.97 X
11404   1 10 2 X 365.65 X
11404   4 10 2 X 371.92 X
11404   3 10 2 X 389.97 X
11406   4 10 2 X 510.45 X
11406   3 10 2 X 527.68 X
11406   2 10 2 X 549.08 X
11406   1 10 2 X 571.43 X
11420   4 10 2 X 146.09 122.41
11420   2 10 2 X 148.47 124.26
11420   1 10 2 X 150.16 125.67
11420   3 10 2 X 150.44 126.14
11421   4 10 2 X 200.31 169.88
11421   3 10 2 X 202.57 171.67
11421   2 10 2 X 212.46 179.60
11421   1 10 2 X 214.80 181.61
11422   4 10 2 X 242.84 202.69
11422   1 10 2 X 249.49 207.54
11422   2 10 2 X 258.39 215.13
11422   3 10 2 X 267.90 223.81
11423   1 10 2 X 340.59 279.67
11423   4 10 2 X 365.65 300.89
11423   2 10 2 X 370.12 303.37
11423   3 10 2 X 383.85 314.85
11424   2 10 2 X 372.99 X
11424   3 10 2 X 378.40 X
11424   1 10 2 X 392.78 X
11424   4 10 2 X 436.62 X
11426   4 10 2 X 517.09 X
11426   3 10 2 X 538.97 X
11426   2 10 2 X 552.58 X
11426   1 10 2 X 559.77 X
11440   4 10 2 X 178.06 145.59
11440   2 10 2 X 191.65 156.62
11440   3 10 2 X 194.30 158.92
11440   1 10 2 X 195.92 159.89
11441   4 10 2 X 228.44 190.82
11441   2 10 2 X 252.72 210.10
11441   1 10 2 X 258.00 214.43
11441   3 10 2 X 259.25 215.80
11442   4 10 2 X 268.76 220.97
11442   3 10 2 X 307.50 252.71
11442   1 10 2 X 307.89 252.85
11442   2 10 2 X 311.13 254.71
11443   4 10 2 X 395.42 326.71
11443   1 10 2 X 399.50 328.34
11443   2 10 2 X 405.91 334.18
11443   3 10 2 X 418.42 345.40
11444   2 10 2 X 360.37 X
11444   1 10 2 X 401.61 X
11444   4 10 2 X 425.89 X
11444   3 10 2 X 492.33 X
11446   2 10 2 X 633.28 X
11446   3 10 2 X 681.80 X
11446   4 10 2 X 691.53 X
11446   1 10 2 X 717.17 X
11450   4 90 2 X 769.26 X
11450   1 90 2 X 809.45 X
11450   2 90 2 X 830.70 X
11450   3 90 2 X 852.45 X
11451   4 90 2 X 630.76 X
11451   3 90 2 X 638.18 X
11451   2 90 2 X 1,431.53 X
11451   1 90 2 X 1,435.83 X
11462   4 90 2 X 450.81 X
11462   1 90 2 X 767.68 X
11462   3 90 2 X 945.64 X
11462   2 90 2 X 959.29 X
11463   3 90 2 X 548.31 X
11463   2 90 2 X 581.00 X
11463   1 90 2 X 588.94 X
11463   4 90 2 X 1,054.80 X
11470   3 90 2 X 900.33 X
11470   4 90 2 X 977.69 X
11470   2 90 2 X 985.79 X
11470   1 90 2 X 1,001.27 X
11471   4 90 2 X 637.17 X
11471   3 90 2 X 644.30 X
11471   2 90 2 X 1,434.72 X
11471   1 90 2 X 1,439.03 X
11600   3 10 2 X 272.80 211.79
11600   4 10 2 X 273.07 211.99
11600   2 10 2 X 278.69 215.87
11600   1 10 2 X 280.36 217.75
11601   4 10 2 X 325.63 260.13
11601   3 10 2 X 326.91 261.70
11601   1 10 2 X 337.31 269.39
11601   2 10 2 X 337.97 270.14
11602   4 10 2 X 359.48 280.90
11602   3 10 2 X 393.52 306.88
11602   2 10 2 X 397.86 309.06
11602   1 10 2 X 404.97 314.55
11603   4 10 2 X 433.66 334.48
11603   1 10 2 X 467.62 359.91
11603   3 10 2 X 478.26 368.46
11603   2 10 2 X 480.66 369.24
11604   3 10 2 X 582.43 X
11604   1 10 2 X 594.17 X
11604   4 10 2 X 594.69 X
11604   2 10 2 X 610.94 X
11606   3 10 2 X 761.13 X
11606   2 10 2 X 860.15 X
11606   4 10 2 X 860.59 X
11606   1 10 2 X 866.95 X
11620   3 10 2 X 300.67 228.81
11620   4 10 2 X 302.88 230.98
11620   2 10 2 X 313.13 238.46
11620   1 10 2 X 319.52 243.77
11621   4 10 2 X 352.49 274.05
11621   3 10 2 X 405.29 315.16
11621   2 10 2 X 412.78 320.36
11621   1 10 2 X 421.49 327.47
11622   4 10 2 X 410.73 316.81
11622   3 10 2 X 440.98 339.24
11622   2 10 2 X 447.41 344.97
11622   1 10 2 X 454.18 349.51
11623   4 10 2 X 501.47 391.07
11623   3 10 2 X 511.47 396.47
11623   2 10 2 X 537.63 418.76
11623   1 10 2 X 544.83 424.39
11624   4 10 2 X 616.77 X
11624   3 10 2 X 636.88 X
11624   2 10 2 X 651.92 X
11624   1 10 2 X 660.92 X
11626   3 10 2 X 724.20 X
11626   4 10 2 X 758.04 X
11626   2 10 2 X 772.53 X
11626   1 10 2 X 784.26 X
11640   3 10 2 X 338.69 255.74
11640   4 10 2 X 344.21 259.58
11640   2 10 2 X 365.01 275.19
11640   1 10 2 X 371.33 280.23
11641   4 10 2 X 411.34 319.77
11641   3 10 2 X 442.26 344.02
11641   1 10 2 X 454.99 352.97
11641   2 10 2 X 455.95 353.47
11642   4 10 2 X 498.86 388.89
11642   2 10 2 X 537.12 416.26
11642   3 10 2 X 539.93 418.42
11642   1 10 2 X 544.98 421.89
11643   4 10 2 X 592.03 463.46
11643   3 10 2 X 619.66 484.03
11643   2 10 2 X 633.94 495.51
11643   1 10 2 X 642.31 502.01