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DLI
>
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>
Workers' Compensation
>
Health Care Services Review
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Medical Fee Review
>
Fee Schedule
>
Fee Schedule 19105-21014
Begin Main Content Area
Page Content
Content Editor
2024 Workers' Compensation Part B Fee Schedule
19105-21014
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
19105
002
0
2
X
3,115.22
306.69
19105
003
0
2
X
3,115.22
306.69
19105
004
0
2
X
3,115.22
306.69
19105
001
0
2
X
3,774.12
338.05
19110
002
90
2
X
797.35
X
19110
003
90
2
X
746.66
X
19110
001
90
2
X
870.06
X
19110
004
90
2
X
738.29
X
19112
004
90
2
X
641.93
X
19112
003
90
2
X
697.86
X
19112
002
90
2
X
750.30
X
19112
001
90
2
X
699.45
X
19120
004
90
2
X
798.41
X
19120
002
90
2
X
798.41
X
19120
003
90
2
X
798.41
X
19120
001
90
2
X
895.60
X
19125
001
90
2
X
1,058.31
X
19125
004
90
2
X
884.59
X
19125
002
90
2
X
1,043.16
X
19125
003
90
2
X
890.98
X
19126
003
ZZZ
0
X
729.39
X
19126
002
ZZZ
0
X
522.84
X
19126
004
ZZZ
0
X
724.78
X
19126
001
ZZZ
0
X
530.54
X
19281
002
0
2
X
374.09
165.82
19281
003
0
2
X
374.09
165.82
19281
004
0
2
X
374.09
165.82
19281
001
0
2
X
421.25
178.61
19282
001
ZZZ
0
X
291.34
83.91
19282
004
ZZZ
0
X
257.03
78.95
19282
002
ZZZ
0
X
257.03
78.95
19282
003
ZZZ
0
X
257.03
78.95
19283
004
0
2
X
423.37
167.41
19283
002
0
2
X
423.37
167.41
19283
003
0
2
X
423.37
167.41
19283
001
0
2
X
478.66
180.49
19284
004
ZZZ
0
X
307.35
79.48
19284
001
ZZZ
0
X
349.98
84.51
19284
003
ZZZ
0
X
307.35
79.48
19284
002
ZZZ
0
X
307.35
79.48
19285
002
0
2
X
707.37
141.97
19285
003
0
2
X
707.37
141.97
19285
004
0
2
X
707.37
141.97
19285
001
0
2
X
811.72
152.98
19286
002
ZZZ
0
X
589.64
68.21
19286
003
ZZZ
0
X
589.64
68.21
19286
004
ZZZ
0
X
589.64
68.21
19286
001
ZZZ
0
X
680.13
72.64
19287
004
0
2
X
1,309.86
232.04
19287
003
0
2
X
1,309.86
232.04
19287
002
0
2
X
1,309.86
232.04
19287
001
0
2
X
1,511.29
255.56
19288
001
ZZZ
0
X
1,196.98
108.54
19288
004
ZZZ
0
X
1,036.28
102.04
19288
003
ZZZ
0
X
1,036.28
102.04
19288
002
ZZZ
0
X
1,036.28
102.04
19294
001
ZZZ
0
X
267.36
X
19294
002
ZZZ
0
X
245.30
X
19294
003
ZZZ
0
X
245.30
X
19294
004
ZZZ
0
X
245.30
X
19296
001
0
2
X
11,245.01
466.13
19296
004
0
2
X
9,413.97
421.79
19296
003
0
2
X
9,413.97
421.79
19296
002
0
2
X
9,413.97
421.79
19297
004
ZZZ
0
X
193.64
X
19297
002
ZZZ
0
X
193.64
X
19297
001
ZZZ
0
X
213.43
X
19297
003
ZZZ
0
X
193.64
X
19298
002
0
2
X
3,563.84
677.96
19298
003
0
2
X
3,563.84
677.96
19298
004
0
2
X
3,563.84
677.96
19298
001
0
2
X
4,201.25
741.99
19300
001
90
2
X
955.19
661.54
19300
004
90
2
X
817.69
577.64
19300
003
90
2
X
817.69
577.64
19300
002
90
2
X
817.69
577.64
19301
003
90
2
X
632.00
X
19301
002
90
2
X
632.00
X
19301
004
90
2
X
632.00
X
19301
001
90
2
X
720.69
X
19302
001
90
2
X
1,527.57
X
19302
003
90
2
X
1,347.94
X
19302
002
90
2
X
1,347.94
X
19302
004
90
2
X
1,347.94
X
19303
003
90
2
X
1,376.25
X
19303
002
90
2
X
1,376.25
X
19303
004
90
2
X
1,376.25
X
19303
001
90
2
X
1,523.33
X
19305
004
90
2
X
1,669.72
X
19305
001
90
2
X
1,883.56
X
19305
003
90
2
X
1,669.72
X
19305
002
90
2
X
1,669.72
X
19306
001
90
2
X
1,960.80
X
19306
002
90
2
X
1,735.71
X
19306
003
90
2
X
1,735.71
X
19306
004
90
2
X
1,735.71
X
19307
003
90
2
X
1,745.24
X
19307
002
90
2
X
1,745.24
X
19307
004
90
2
X
1,745.24
X
19307
001
90
2
X
1,972.60
X
19316
90
2
X
*
X
19318
001
90
2
X
4,108.80
X
19318
004
90
2
X
3,945.84
X
19318
002
90
2
X
4,080.12
X
19318
003
90
2
X
3,926.23
X
19325
002
90
2
X
1,684.76
X
19325
003
90
2
X
2,204.70
X
19325
004
90
2
X
1,555.16
X
19325
001
90
2
X
1,711.79
X
19328
002
90
2
X
953.28
X
19328
003
90
2
X
891.83
X
19328
001
90
2
X
1,115.52
X
19328
004
90
2
X
1,013.98
X
19330
003
90
2
X
1,237.19
X
19330
002
90
2
X
1,315.98
X
19330
004
90
2
X
1,223.53
X
19330
001
90
2
X
1,335.17
X
19340
001
90
2
X
3,316.93
X
19340
003
90
2
X
3,224.38
X
19340
002
90
2
X
3,298.89
X
19340
004
90
2
X
1,861.59
X
19342
001
90
2
X
2,944.44
X
19342
003
90
2
X
2,446.93
X
19342
002
90
2
X
2,924.86
X
19342
004
90
2
X
2,417.98
X
19350
004
90
2
X
1,720.17
X
19350
002
90
2
X
1,934.75
X
19350
003
90
2
X
1,879.39
X
19350
001
90
2
X
1,904.09
X
19355
001
90
2
X
1,500.99
X
19355
004
90
2
X
1,364.32
X
19355
002
90
2
X
1,477.25
X
19355
003
90
2
X
1,379.80
X
19357
004
90
2
X
3,229.19
X
19357
001
90
2
X
3,555.93
X
19357
003
90
2
X
3,266.41
X
19357
002
90
2
X
3,499.39
X
19361
001
90
2
X
4,799.49
X
19361
003
90
2
X
3,563.84
X
19361
002
90
2
X
3,792.33
X
19361
004
90
2
X
4,303.33
X
19364
003
90
2
X
5,011.15
X
19364
002
90
2
X
5,358.66
X
19364
004
90
2
X
4,955.57
X
19364
001
90
2
X
5,443.17
X
19367
002
90
2
X
4,911.55
X
19367
003
90
2
X
4,628.86
X
19367
001
90
2
X
4,964.34
X
19367
004
90
2
X
5,225.93
X
19368
001
90
2
X
4,964.34
X
19368
004
90
2
X
5,225.93
X
19368
003
90
2
X
4,628.86
X
19368
002
90
2
X
4,911.55
X
19369
003
90
2
X
4,628.86
X
19369
002
90
2
X
4,911.55
X
19369
001
90
2
X
4,964.34
X
19369
004
90
2
X
5,225.93
X
19370
002
90
2
X
2,082.01
X
19370
003
90
2
X
2,033.70
X
19370
004
90
2
X
1,542.38
X
19370
001
90
2
X
2,093.70
X
19371
001
90
2
X
2,256.28
X
19371
004
90
2
X
1,886.78
X
19371
003
90
2
X
2,180.09
X
19371
002
90
2
X
2,241.45
X
19380
004
90
2
X
1,887.90
X
19380
002
90
2
X
2,058.60
X
19380
003
90
2
X
1,910.30
X
19380
001
90
2
X
2,094.58
X
19396
0
2
X
*
X
19499
YYY
2
X
#
X
20100
004
10
2
X
1,685.82
X
20100
001
10
2
X
1,892.80
X
20100
002
10
2
X
1,810.58
X
20100
003
10
2
X
1,709.44
X
20101
004
10
2
X
532.72
X
20101
003
10
2
X
540.17
X
20101
002
10
2
X
572.21
X
20101
001
10
2
X
598.32
X
20102
002
10
2
X
700.81
X
20102
003
10
2
X
661.68
X
20102
004
10
2
X
652.57
X
20102
001
10
2
X
732.72
X
20103
004
10
2
X
878.05
X
20103
002
10
2
X
943.04
X
20103
003
10
2
X
890.38
X
20103
001
10
2
X
985.72
X
20150
001
90
2
X
3,165.92
X
20150
002
90
2
X
2,832.26
X
20150
003
90
2
X
2,756.16
X
20150
004
90
2
X
2,756.16
X
20200
001
0
2
X
401.41
X
20200
003
0
2
X
381.52
X
20200
002
0
2
X
394.06
X
20200
004
0
2
X
377.05
X
20205
003
0
2
X
637.34
X
20205
002
0
2
X
648.29
X
20205
004
0
2
X
599.71
X
20205
001
0
2
X
660.28
X
20206
004
0
2
X
353.96
X
20206
001
0
2
X
375.07
X
20206
002
0
2
X
362.42
X
20206
003
0
2
X
359.04
X
20220
001
0
2
X
310.37
X
20220
003
0
2
X
276.38
X
20220
002
0
2
X
308.33
X
20220
004
0
2
X
312.71
X
20225
004
0
2
X
499.08
X
20225
002
0
2
X
472.33
X
20225
003
0
2
X
554.59
X
20225
001
0
2
X
479.75
X
20240
002
0
2
X
564.12
X
20240
003
0
2
X
535.89
X
20240
004
0
2
X
529.64
X
20240
001
0
2
X
561.70
X
20245
003
0
2
X
1,120.07
X
20245
002
0
2
X
1,211.18
X
20245
001
0
2
X
1,106.02
X
20245
004
0
2
X
1,190.58
X
20250
001
10
2
X
1,325.74
X
20250
004
10
2
X
1,076.17
X
20250
003
10
2
X
1,340.66
X
20250
002
10
2
X
1,218.21
X
20251
001
10
2
X
1,452.93
X
20251
004
10
2
X
1,327.10
X
20251
003
10
2
X
1,242.73
X
20251
002
10
2
X
1,374.94
X
20500
003
10
2
X
154.77
137.86
20500
002
10
2
X
157.10
139.88
20500
004
10
2
X
153.18
136.50
20500
001
10
2
X
163.12
144.90
20501
001
0
2
X
111.39
X
20501
004
0
2
X
104.74
X
20501
002
0
2
X
110.38
X
20501
003
0
2
X
105.91
X
20520
004
10
2
X
213.05
185.38
20520
002
10
2
X
241.59
208.28
20520
003
10
2
X
238.13
206.60
20520
001
10
2
X
210.03
181.13
20525
004
10
2
X
564.80
X
20525
002
10
2
X
642.56
X
20525
003
10
2
X
566.92
X
20525
001
10
2
X
603.84
X
20526
004
0
2
X
132.84
103.18
20526
002
0
2
X
132.84
103.18
20526
003
0
2
X
132.84
103.18
20526
001
0
2
X
148.78
113.89
20527
004
0
2
X
123.59
98.50
20527
002
0
2
X
123.59
98.50
20527
003
0
2
X
123.59
98.50
20527
001
0
2
X
137.79
108.61
20550
003
0
2
X
114.19
99.22
20550
001
0
2
X
112.82
97.98
20550
002
0
2
X
118.24
102.82
20550
004
0
2
X
111.73
96.88
20551
004
0
2
X
132.84
103.18
20551
002
0
2
X
132.84
103.18
20551
003
0
2
X
132.84
103.18
20551
001
0
2
X
148.78
113.89
20552
004
0
2
X
132.84
103.18
20552
003
0
2
X
132.84
103.18
20552
002
0
2
X
132.84
103.18
20552
001
0
2
X
148.78
113.89
20553
003
0
2
X
132.84
103.18
20553
002
0
2
X
132.84
103.18
20553
001
0
2
X
148.78
113.89
20553
004
0
2
X
132.84
103.18
20555
001
0
2
X
594.01
X
20555
004
0
2
X
542.26
X
20555
002
0
2
X
542.26
X
20555
003
0
2
X
542.26
X
20560
XXX
0
X
*
X
20561
XXX
0
X
*
X
20600
003
0
2
X
115.09
92.84
20600
002
0
2
X
120.52
96.90
20600
001
0
2
X
119.50
95.89
20600
004
0
2
X
114.04
91.86
20604
001
0
2
X
121.16
76.42
20604
003
0
2
X
109.58
71.35
20604
002
0
2
X
109.58
71.35
20604
004
0
2
X
109.58
71.35
20605
001
0
2
X
132.65
107.78
20605
004
0
2
X
122.62
99.83
20605
002
0
2
X
130.96
106.41
20605
003
0
2
X
124.08
100.91
20606
004
0
2
X
120.49
80.70
20606
003
0
2
X
120.49
80.70
20606
002
0
2
X
120.49
80.70
20606
001
0
2
X
133.02
86.46
20610
002
0
2
X
133.70
110.69
20610
003
0
2
X
126.92
105.25
20610
004
0
2
X
125.54
104.17
20610
001
0
2
X
134.89
111.34
20611
001
0
2
X
153.25
102.40
20611
004
0
2
X
138.32
94.85
20611
003
0
2
X
138.32
94.85
20611
002
0
2
X
138.32
94.85
20612
001
0
2
X
133.98
90.32
20612
004
0
2
X
118.65
81.53
20612
002
0
2
X
118.65
81.53
20612
003
0
2
X
118.65
81.53
20615
002
10
2
X
242.04
220.47
20615
003
10
2
X
236.29
216.27
20615
001
10
2
X
244.10
222.40
20615
004
10
2
X
234.72
214.21
20650
004
10
2
X
383.82
X
20650
003
10
2
X
371.95
X
20650
002
10
2
X
395.41
X
20650
001
10
2
X
603.57
X
20660
001
0
2
X
580.65
X
20660
003
0
2
X
573.90
X
20660
002
0
2
X
579.21
X
20660
004
0
2
X
541.65
X
20661
002
90
2
X
1,042.61
X
20661
003
90
2
X
1,020.53
X
20661
004
90
2
X
1,016.05
X
20661
001
90
2
X
1,054.96
X
20662
001
90
2
X
1,490.78
X
20662
002
90
2
X
1,465.58
X
20662
003
90
2
X
1,361.47
X
20662
004
90
2
X
1,344.84
X
20663
001
90
2
X
1,168.11
X
20663
003
90
2
X
1,071.27
X
20663
002
90
2
X
1,149.25
X
20663
004
90
2
X
1,058.57
X
20664
003
90
2
X
1,107.65
X
20664
002
90
2
X
1,107.65
X
20664
004
90
2
X
1,107.65
X
20664
001
90
2
X
1,230.17
X
20665
001
10
2
X
284.58
X
20665
004
10
2
X
190.01
X
20665
003
10
2
X
192.09
X
20665
002
10
2
X
305.25
X
20670
001
10
2
X
499.34
X
20670
004
10
2
X
495.83
X
20670
003
10
2
X
446.92
X
20670
002
10
2
X
452.80
X
20680
001
90
2
X
806.48
X
20680
003
90
2
X
739.82
X
20680
002
90
2
X
793.52
X
20680
004
90
2
X
730.86
X
20690
003
90
2
X
808.77
X
20690
002
90
2
X
857.72
X
20690
004
90
2
X
798.96
X
20690
001
90
2
X
865.97
X
20692
004
90
2
X
1,122.85
X
20692
002
90
2
X
1,186.35
X
20692
003
90
2
X
1,132.03
X
20692
001
90
2
X
1,199.53
X
20693
003
90
2
X
873.44
X
20693
002
90
2
X
922.88
X
20693
001
90
2
X
934.94
X
20693
004
90
2
X
863.89
X
20694
001
90
2
X
768.83
X
20694
003
90
2
X
712.36
X
20694
002
90
2
X
757.81
X
20694
004
90
2
X
704.17
X
20696
004
90
2
X
1,793.46
X
20696
001
90
2
X
1,998.74
X
20696
002
90
2
X
1,793.46
X
20696
003
90
2
X
1,793.46
X
20697
001
0
0
X
2,344.31
X
20697
004
0
0
X
1,976.51
X
20697
002
0
0
X
1,976.51
X
20697
003
0
0
X
1,976.51
X
20700
002
ZZZ
0
X
118.80
X
20700
003
ZZZ
0
X
118.80
X
20700
004
ZZZ
0
X
118.80
X
20700
001
ZZZ
0
X
130.18
X
20701
004
ZZZ
0
X
88.64
X
20701
002
ZZZ
0
X
88.64
X
20701
003
ZZZ
0
X
88.64
X
20701
001
ZZZ
0
X
96.95
X
20702
003
ZZZ
0
X
197.68
X
20702
002
ZZZ
0
X
197.68
X
20702
004
ZZZ
0
X
197.68
X
20702
001
ZZZ
0
X
216.68
X
20703
001
ZZZ
0
X
155.06
X
20703
004
ZZZ
0
X
141.70
X
20703
003
ZZZ
0
X
141.70
X
20703
002
ZZZ
0
X
141.70
X
20704
004
ZZZ
0
X
205.95
X
20704
002
ZZZ
0
X
205.95
X
20704
003
ZZZ
0
X
205.95
X
20704
001
ZZZ
0
X
225.78
X
20705
001
ZZZ
0
X
185.56
X
20705
004
ZZZ
0
X
169.45
X
20705
003
ZZZ
0
X
169.45
X
20705
002
ZZZ
0
X
169.45
X
20802
004
90
2
X
9,077.03
X
20802
002
90
2
X
9,853.86
X
20802
003
90
2
X
9,203.73
X
20802
001
90
2
X
10,161.72
X
20805
001
90
2
X
12,437.93
X
20805
003
90
2
X
11,264.91
X
20805
002
90
2
X
12,060.99
X
20805
004
90
2
X
11,109.88
X
20808
003
90
2
X
14,005.64
X
20808
002
90
2
X
14,995.36
X
20808
004
90
2
X
13,812.92
X
20808
001
90
2
X
15,464.05
X
20816
001
90
2
X
7,622.87
X
20816
003
90
2
X
6,904.09
X
20816
002
90
2
X
7,391.92
X
20816
004
90
2
X
6,809.07
X
20822
002
90
2
X
6,110.75
X
20822
003
90
2
X
5,707.52
X
20822
004
90
2
X
5,628.92
X
20822
001
90
2
X
6,301.74
X
20824
001
90
2
X
7,622.87
X
20824
002
90
2
X
7,391.92
X
20824
003
90
2
X
6,904.09
X
20824
004
90
2
X
6,809.07
X
20827
002
90
2
X
6,283.27
X
20827
003
90
2
X
5,868.50
X
20827
001
90
2
X
6,479.65
X
20827
004
90
2
X
5,787.76
X
20838
004
90
2
X
9,077.03
X
20838
001
90
2
X
10,161.72
X
20838
003
90
2
X
9,203.73
X
20838
002
90
2
X
9,853.86
X
20900
001
0
2
X
931.23
X
20900
003
0
2
X
1,138.57
X
20900
002
0
2
X
1,184.51
X
20900
004
0
2
X
1,293.23
X
20902
002
0
2
X
1,392.77
X
20902
003
0
2
X
1,306.14
X
20902
004
0
2
X
1,291.11
X
20902
001
0
2
X
1,413.76
X
20910
001
90
2
X
453.99
X
20910
003
90
2
X
436.44
X
20910
002
90
2
X
450.76
X
20910
004
90
2
X
618.23
X
20912
004
90
2
X
1,166.70
X
20912
002
90
2
X
1,255.58
X
20912
003
90
2
X
1,180.54
X
20912
001
90
2
X
1,273.68
X
20920
002
90
2
X
1,031.34
X
20920
003
90
2
X
970.28
X
20920
001
90
2
X
1,554.92
X
20920
004
90
2
X
958.83
X
20922
002
90
2
X
1,545.27
X
20922
003
90
2
X
1,164.68
X
20922
004
90
2
X
1,839.04
X
20922
001
90
2
X
1,260.38
X
20924
004
90
2
X
1,272.03
X
20924
001
90
2
X
1,966.00
X
20924
002
90
2
X
1,956.83
X
20924
003
90
2
X
1,287.27
X
20930
XXX
9
X
*
X
20931
004
ZZZ
0
X
407.69
X
20931
002
ZZZ
0
X
442.29
X
20931
003
ZZZ
0
X
413.90
X
20931
001
ZZZ
0
X
463.29
X
20932
002
ZZZ
0
X
1,011.17
X
20932
003
ZZZ
0
X
1,011.17
X
20932
004
ZZZ
0
X
1,011.17
X
20932
001
ZZZ
0
X
1,098.61
X
20933
004
ZZZ
0
X
927.46
X
20933
002
ZZZ
0
X
927.46
X
20933
001
ZZZ
0
X
1,007.50
X
20933
003
ZZZ
0
X
927.46
X
20934
001
ZZZ
0
X
1,098.12
X
20934
002
ZZZ
0
X
1,010.67
X
20934
003
ZZZ
0
X
1,010.67
X
20934
004
ZZZ
0
X
1,010.67
X
20936
XXX
9
X
*
X
20937
002
ZZZ
0
X
681.94
X
20937
003
ZZZ
0
X
638.07
X
20937
001
ZZZ
0
X
714.59
X
20937
004
ZZZ
0
X
628.43
X
20938
003
ZZZ
0
X
690.22
X
20938
002
ZZZ
0
X
737.54
X
20938
001
ZZZ
0
X
772.70
X
20938
004
ZZZ
0
X
679.82
X
20939
004
ZZZ
0
X
100.37
X
20939
002
ZZZ
0
X
100.37
X
20939
003
ZZZ
0
X
100.37
X
20939
001
ZZZ
0
X
109.44
X
20950
001
0
2
X
284.51
X
20950
004
0
2
X
259.00
X
20950
002
0
2
X
327.50
X
20950
003
0
2
X
278.69
X
20955
001
90
2
X
9,826.43
X
20955
003
90
2
X
9,826.43
X
20955
002
90
2
X
9,826.43
X
20955
004
90
2
X
9,826.43
X
20956
004
90
2
X
6,938.59
X
20956
001
90
2
X
7,914.78
X
20956
003
90
2
X
6,938.59
X
20956
002
90
2
X
7,130.27
X
20957
002
90
2
X
7,386.98
X
20957
003
90
2
X
7,188.37
X
20957
001
90
2
X
8,199.69
X
20957
004
90
2
X
7,188.37
X
20962
002
90
2
X
7,130.27
X
20962
003
90
2
X
6,938.59
X
20962
004
90
2
X
6,938.59
X
20962
001
90
2
X
7,914.78
X
20969
002
90
2
X
9,166.91
X
20969
003
90
2
X
8,920.55
X
20969
004
90
2
X
8,920.55
X
20969
001
90
2
X
10,246.76
X
20970
002
90
2
X
9,826.43
X
20970
003
90
2
X
9,826.43
X
20970
004
90
2
X
9,826.43
X
20970
001
90
2
X
9,826.43
X
20972
004
90
2
X
9,826.43
X
20972
002
90
2
X
9,826.43
X
20972
003
90
2
X
9,826.43
X
20972
001
90
2
X
9,826.43
X
20973
001
90
2
X
9,826.43
X
20973
004
90
2
X
9,826.43
X
20973
002
90
2
X
9,826.43
X
20973
003
90
2
X
9,826.43
X
20974
004
0
0
X
465.20
X
20974
001
0
0
X
531.79
X
20974
002
0
0
X
520.15
X
20974
003
0
0
X
471.74
X
20975
004
0
0
X
667.46
X
20975
002
0
0
X
730.16
X
20975
003
0
0
X
675.76
X
20975
001
0
0
X
743.35
X
20979
001
0
0
X
41.11
23.57
20979
003
0
0
X
36.50
21.54
20979
002
0
0
X
36.50
21.54
20979
004
0
0
X
36.50
21.54
20982
001
0
2
X
10,005.65
945.77
20982
004
0
2
X
8,566.11
858.57
20982
003
0
2
X
8,566.11
858.57
20982
002
0
2
X
8,566.11
858.57
20983
004
0
2
X
10,315.99
628.21
20983
003
0
2
X
10,315.99
628.21
20983
002
0
2
X
10,315.99
628.21
20983
001
0
2
X
12,015.54
680.13
20985
001
ZZZ
0
X
285.53
X
20985
003
ZZZ
0
X
251.12
X
20985
002
ZZZ
0
X
251.12
X
20985
004
ZZZ
0
X
251.12
X
20999
YYY
2
X
#
X
21010
004
90
2
X
2,077.33
X
21010
001
90
2
X
2,266.05
X
21010
002
90
2
X
2,234.60
X
21010
003
90
2
X
2,103.80
X
21011
004
90
2
X
518.02
408.66
21011
001
90
2
X
590.29
460.61
21011
002
90
2
X
518.02
408.66
21011
003
90
2
X
518.02
408.66
21012
004
90
2
X
561.81
X
21012
002
90
2
X
561.81
X
21012
003
90
2
X
561.81
X
21012
001
90
2
X
631.47
X
21013
001
90
2
X
915.12
740.59
21013
004
90
2
X
808.37
661.20
21013
002
90
2
X
808.37
661.20
21013
003
90
2
X
808.37
661.20
21014
004
90
2
X
868.35
X
21014
002
90
2
X
868.35
X
21014
003
90
2
X
868.35
X
21014
001
90
2
X
973.50
X
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