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Health Care Services Review
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Medical Fee Review
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Fee Schedule
>
Fee Schedule 22850-24073
Begin Main Content Area
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Content Editor
2024 Workers' Compensation Part B Fee Schedule
22850-24073
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
22850
004
90
2
X
2,022.96
X
22850
003
90
2
X
2,047.57
X
22850
002
90
2
X
2,052.32
X
22850
001
90
2
X
2,236.59
X
22852
001
90
2
X
2,083.28
X
22852
004
90
2
X
2,032.43
X
22852
003
90
2
X
2,057.45
X
22852
002
90
2
X
2,061.42
X
22853
003
ZZZ
0
X
405.97
X
22853
002
ZZZ
0
X
405.97
X
22853
001
ZZZ
0
X
450.13
X
22853
004
ZZZ
0
X
405.97
X
22854
003
ZZZ
0
X
525.51
X
22854
002
ZZZ
0
X
525.51
X
22854
004
ZZZ
0
X
525.51
X
22854
001
ZZZ
0
X
582.73
X
22855
001
90
2
X
2,019.39
X
22855
003
90
2
X
1,858.38
X
22855
002
90
2
X
1,987.98
X
22855
004
90
2
X
1,836.65
X
22856
002
90
2
X
2,749.66
X
22856
003
90
2
X
2,749.66
X
22856
004
90
2
X
2,749.66
X
22856
001
90
2
X
3,120.22
X
22857
001
90
2
X
2,710.31
X
22857
004
90
2
X
2,406.64
X
22857
002
90
2
X
2,406.64
X
22857
003
90
2
X
2,406.64
X
22858
001
ZZZ
0
X
1,187.50
X
22858
004
ZZZ
0
X
1,039.13
X
22858
003
ZZZ
0
X
1,039.13
X
22858
002
ZZZ
0
X
1,039.13
X
22859
001
ZZZ
0
X
582.73
X
22859
004
ZZZ
0
X
525.51
X
22859
003
ZZZ
0
X
525.51
X
22859
002
ZZZ
0
X
525.51
X
22860
X
#
X
22861
001
90
2
X
3,711.06
X
22861
004
90
2
X
3,336.34
X
22861
002
90
2
X
3,336.34
X
22861
003
90
2
X
3,336.34
X
22862
001
90
2
X
3,324.95
X
22862
003
90
2
X
2,924.27
X
22862
002
90
2
X
2,924.27
X
22862
004
90
2
X
2,924.27
X
22864
002
90
2
X
3,110.00
X
22864
003
90
2
X
3,110.00
X
22864
004
90
2
X
3,110.00
X
22864
001
90
2
X
3,519.59
X
22865
002
90
2
X
2,847.72
X
22865
003
90
2
X
2,847.72
X
22865
004
90
2
X
2,847.72
X
22865
001
90
2
X
3,237.21
X
22867
001
90
2
X
1,679.16
X
22867
004
90
2
X
1,505.05
X
22867
003
90
2
X
1,505.05
X
22867
002
90
2
X
1,505.05
X
22868
004
ZZZ
0
X
379.29
X
22868
001
ZZZ
0
X
419.92
X
22868
003
ZZZ
0
X
379.29
X
22868
002
ZZZ
0
X
379.29
X
22869
002
90
2
X
824.61
X
22869
003
90
2
X
824.61
X
22869
001
90
2
X
919.60
X
22869
004
90
2
X
824.61
X
22870
003
ZZZ
0
X
220.94
X
22870
002
ZZZ
0
X
220.94
X
22870
004
ZZZ
0
X
220.94
X
22870
001
ZZZ
0
X
244.36
X
22899
YYY
2
X
#
X
22900
001
90
2
X
1,144.61
X
22900
003
90
2
X
1,073.66
X
22900
002
90
2
X
1,123.44
X
22900
004
90
2
X
926.34
X
22901
003
90
2
X
1,120.34
X
22901
002
90
2
X
1,120.34
X
22901
004
90
2
X
1,120.34
X
22901
001
90
2
X
1,256.17
X
22902
002
90
2
X
693.88
559.74
22902
003
90
2
X
693.88
559.74
22902
004
90
2
X
693.88
559.74
22902
001
90
2
X
787.96
628.85
22903
001
90
2
X
828.29
X
22903
002
90
2
X
738.56
X
22903
003
90
2
X
738.56
X
22903
004
90
2
X
738.56
X
22904
001
90
2
X
1,968.53
X
22904
004
90
2
X
1,759.77
X
22904
003
90
2
X
1,759.77
X
22904
002
90
2
X
1,759.77
X
22905
001
90
2
X
2,553.47
X
22905
004
90
2
X
2,282.03
X
22905
003
90
2
X
2,282.03
X
22905
002
90
2
X
2,282.03
X
22999
YYY
2
X
#
X
23000
003
90
2
X
818.91
X
23000
002
90
2
X
908.08
X
23000
004
90
2
X
878.70
X
23000
001
90
2
X
885.37
X
23020
003
90
2
X
1,732.10
X
23020
002
90
2
X
1,850.62
X
23020
004
90
2
X
1,711.54
X
23020
001
90
2
X
1,879.31
X
23030
001
10
2
X
639.95
X
23030
003
10
2
X
582.99
X
23030
002
10
2
X
630.69
X
23030
004
10
2
X
585.73
X
23031
003
10
2
X
299.84
X
23031
002
10
2
X
313.60
X
23031
004
10
2
X
300.66
X
23031
001
10
2
X
357.61
X
23035
001
90
2
X
1,707.70
X
23035
002
90
2
X
1,681.39
X
23035
003
90
2
X
1,572.73
X
23035
004
90
2
X
1,554.42
X
23040
004
90
2
X
1,967.33
X
23040
001
90
2
X
2,177.55
X
23040
003
90
2
X
1,991.43
X
23040
002
90
2
X
2,141.29
X
23044
004
90
2
X
1,490.85
X
23044
001
90
2
X
1,652.98
X
23044
002
90
2
X
1,844.82
X
23044
003
90
2
X
1,731.08
X
23065
004
10
2
X
310.93
X
23065
003
10
2
X
278.79
X
23065
002
10
2
X
276.44
X
23065
001
10
2
X
331.83
X
23066
002
90
2
X
418.36
X
23066
003
90
2
X
405.19
X
23066
001
90
2
X
425.07
X
23066
004
90
2
X
387.41
X
23071
004
90
2
X
701.57
X
23071
001
90
2
X
789.43
X
23071
003
90
2
X
701.57
X
23071
002
90
2
X
701.57
X
23073
002
90
2
X
1,163.90
X
23073
003
90
2
X
1,163.90
X
23073
001
90
2
X
1,306.94
X
23073
004
90
2
X
1,163.90
X
23075
001
90
2
X
488.30
X
23075
004
90
2
X
422.25
X
23075
003
90
2
X
450.67
X
23075
002
90
2
X
483.10
X
23076
002
90
2
X
1,153.98
X
23076
003
90
2
X
1,121.01
X
23076
004
90
2
X
1,108.59
X
23076
001
90
2
X
1,223.98
X
23077
004
90
2
X
2,426.96
X
23077
002
90
2
X
1,872.08
X
23077
003
90
2
X
1,784.28
X
23077
001
90
2
X
1,883.76
X
23078
004
90
2
X
2,375.24
X
23078
001
90
2
X
2,657.20
X
23078
002
90
2
X
2,375.24
X
23078
003
90
2
X
2,375.24
X
23100
004
90
2
X
1,447.73
X
23100
003
90
2
X
1,608.20
X
23100
002
90
2
X
1,729.37
X
23100
001
90
2
X
1,613.18
X
23101
003
90
2
X
1,570.24
X
23101
002
90
2
X
1,689.37
X
23101
001
90
2
X
1,703.32
X
23101
004
90
2
X
1,358.31
X
23105
001
90
2
X
2,389.43
X
23105
004
90
2
X
1,991.45
X
23105
002
90
2
X
2,332.83
X
23105
003
90
2
X
2,168.60
X
23106
001
90
2
X
2,340.24
X
23106
004
90
2
X
1,145.44
X
23106
002
90
2
X
1,241.28
X
23106
003
90
2
X
2,196.20
X
23107
002
90
2
X
2,168.54
X
23107
003
90
2
X
2,011.11
X
23107
004
90
2
X
1,986.65
X
23107
001
90
2
X
2,206.64
X
23120
004
90
2
X
1,470.58
X
23120
002
90
2
X
1,510.78
X
23120
003
90
2
X
1,476.61
X
23120
001
90
2
X
1,519.00
X
23125
003
90
2
X
1,944.33
X
23125
002
90
2
X
2,368.50
X
23125
004
90
2
X
1,921.06
X
23125
001
90
2
X
2,113.54
X
23130
001
90
2
X
1,738.27
X
23130
003
90
2
X
1,593.40
X
23130
002
90
2
X
1,710.11
X
23130
004
90
2
X
1,594.68
X
23140
004
90
2
X
1,171.15
X
23140
002
90
2
X
1,262.16
X
23140
003
90
2
X
1,184.51
X
23140
001
90
2
X
1,280.98
X
23145
001
90
2
X
2,044.52
X
23145
003
90
2
X
1,875.45
X
23145
002
90
2
X
2,011.62
X
23145
004
90
2
X
1,853.23
X
23146
002
90
2
X
1,519.46
X
23146
003
90
2
X
1,419.48
X
23146
004
90
2
X
1,403.29
X
23146
001
90
2
X
1,543.73
X
23150
001
90
2
X
1,748.19
X
23150
004
90
2
X
2,028.45
X
23150
003
90
2
X
2,036.42
X
23150
002
90
2
X
2,082.48
X
23155
004
90
2
X
2,036.01
X
23155
001
90
2
X
2,241.01
X
23155
002
90
2
X
2,205.86
X
23155
003
90
2
X
2,060.56
X
23156
001
90
2
X
1,918.78
X
23156
003
90
2
X
1,760.01
X
23156
002
90
2
X
1,887.84
X
23156
004
90
2
X
1,739.06
X
23170
001
90
2
X
1,342.33
X
23170
002
90
2
X
1,322.07
X
23170
003
90
2
X
1,238.49
X
23170
004
90
2
X
1,224.19
X
23172
001
90
2
X
1,369.73
X
23172
004
90
2
X
1,251.41
X
23172
003
90
2
X
1,266.45
X
23172
002
90
2
X
1,216.27
X
23174
001
90
2
X
2,090.60
X
23174
003
90
2
X
1,925.14
X
23174
002
90
2
X
2,058.48
X
23174
004
90
2
X
1,901.87
X
23180
001
90
2
X
1,438.79
X
23180
004
90
2
X
1,325.33
X
23180
002
90
2
X
1,419.56
X
23180
003
90
2
X
1,198.43
X
23182
004
90
2
X
1,560.12
X
23182
002
90
2
X
1,692.81
X
23182
003
90
2
X
1,578.70
X
23182
001
90
2
X
1,720.40
X
23184
002
90
2
X
2,120.60
X
23184
003
90
2
X
1,972.29
X
23184
004
90
2
X
1,471.32
X
23184
001
90
2
X
2,156.45
X
23190
003
90
2
X
1,443.15
X
23190
002
90
2
X
1,526.40
X
23190
004
90
2
X
1,426.12
X
23190
001
90
2
X
1,570.12
X
23195
004
90
2
X
1,993.96
X
23195
002
90
2
X
2,166.51
X
23195
003
90
2
X
2,018.15
X
23195
001
90
2
X
2,202.30
X
23200
003
90
2
X
2,240.64
X
23200
002
90
2
X
2,385.14
X
23200
001
90
2
X
2,421.30
X
23200
004
90
2
X
2,214.05
X
23210
003
90
2
X
2,278.03
X
23210
002
90
2
X
2,431.21
X
23210
001
90
2
X
4,006.58
X
23210
004
90
2
X
2,251.52
X
23220
003
90
2
X
3,037.32
X
23220
002
90
2
X
3,124.02
X
23220
001
90
2
X
3,112.88
X
23220
004
90
2
X
2,822.67
X
23330
004
10
2
X
252.18
X
23330
001
10
2
X
269.10
X
23330
003
10
2
X
254.90
X
23330
002
10
2
X
266.28
X
23333
004
90
2
X
725.32
X
23333
001
90
2
X
808.11
X
23333
003
90
2
X
725.32
X
23333
002
90
2
X
725.32
X
23334
001
90
2
X
1,908.77
X
23334
003
90
2
X
1,720.14
X
23334
002
90
2
X
1,720.14
X
23334
004
90
2
X
1,720.14
X
23335
002
90
2
X
2,054.27
X
23335
003
90
2
X
2,054.27
X
23335
004
90
2
X
2,054.27
X
23335
001
90
2
X
2,276.44
X
23350
002
0
2
X
161.84
X
23350
003
0
2
X
154.14
X
23350
004
0
2
X
152.40
X
23350
001
0
2
X
163.62
X
23395
001
90
2
X
2,883.48
X
23395
004
90
2
X
2,616.88
X
23395
003
90
2
X
2,648.14
X
23395
002
90
2
X
2,837.65
X
23397
004
90
2
X
3,251.31
X
23397
002
90
2
X
3,528.91
X
23397
003
90
2
X
3,290.26
X
23397
001
90
2
X
3,586.65
X
23400
004
90
2
X
2,527.41
X
23400
001
90
2
X
2,774.78
X
23400
002
90
2
X
2,732.30
X
23400
003
90
2
X
2,556.96
X
23405
003
90
2
X
1,714.35
X
23405
002
90
2
X
1,828.65
X
23405
001
90
2
X
1,856.28
X
23405
004
90
2
X
1,693.69
X
23406
001
90
2
X
2,422.91
X
23406
003
90
2
X
2,222.90
X
23406
002
90
2
X
2,383.91
X
23406
004
90
2
X
2,196.65
X
23410
001
90
2
X
2,790.69
X
23410
004
90
2
X
2,533.48
X
23410
003
90
2
X
2,564.00
X
23410
002
90
2
X
2,746.55
X
23412
002
90
2
X
3,142.08
X
23412
003
90
2
X
2,971.54
X
23412
004
90
2
X
2,903.64
X
23412
001
90
2
X
3,299.63
X
23415
002
90
2
X
2,224.65
X
23415
003
90
2
X
2,196.96
X
23415
004
90
2
X
2,207.09
X
23415
001
90
2
X
2,202.56
X
23420
002
90
2
X
3,238.37
X
23420
003
90
2
X
3,055.67
X
23420
004
90
2
X
3,049.21
X
23420
001
90
2
X
3,258.44
X
23430
004
90
2
X
1,867.35
X
23430
001
90
2
X
2,047.29
X
23430
002
90
2
X
2,016.54
X
23430
003
90
2
X
1,889.27
X
23440
002
90
2
X
2,051.20
X
23440
003
90
2
X
1,924.66
X
23440
004
90
2
X
1,902.49
X
23440
001
90
2
X
2,081.86
X
23450
001
90
2
X
2,991.38
X
23450
002
90
2
X
3,102.52
X
23450
003
90
2
X
2,879.69
X
23450
004
90
2
X
2,845.17
X
23455
004
90
2
X
3,278.06
X
23455
001
90
2
X
3,631.57
X
23455
002
90
2
X
3,570.56
X
23455
003
90
2
X
3,318.29
X
23460
004
90
2
X
3,189.39
X
23460
003
90
2
X
3,227.92
X
23460
002
90
2
X
3,460.31
X
23460
001
90
2
X
3,516.52
X
23462
001
90
2
X
3,669.33
X
23462
003
90
2
X
3,357.89
X
23462
002
90
2
X
3,608.66
X
23462
004
90
2
X
3,317.53
X
23465
001
90
2
X
3,491.99
X
23465
004
90
2
X
3,252.53
X
23465
002
90
2
X
3,444.62
X
23465
003
90
2
X
3,025.17
X
23466
001
90
2
X
3,747.34
X
23466
003
90
2
X
3,417.11
X
23466
002
90
2
X
3,682.98
X
23466
004
90
2
X
3,375.39
X
23470
001
90
2
X
4,079.67
X
23470
004
90
2
X
3,657.05
X
23470
002
90
2
X
3,974.36
X
23470
003
90
2
X
3,701.55
X
23472
004
90
2
X
4,913.40
X
23472
002
90
2
X
6,269.32
X
23472
003
90
2
X
6,097.50
X
23472
001
90
2
X
5,526.54
X
23473
004
90
2
X
2,624.47
X
23473
002
90
2
X
2,624.47
X
23473
003
90
2
X
2,624.47
X
23473
001
90
2
X
2,928.68
X
23474
003
90
2
X
2,837.41
X
23474
002
90
2
X
2,837.41
X
23474
004
90
2
X
2,837.41
X
23474
001
90
2
X
3,166.35
X
23480
003
90
2
X
1,900.82
X
23480
002
90
2
X
2,017.77
X
23480
001
90
2
X
2,046.28
X
23480
004
90
2
X
1,879.19
X
23485
001
90
2
X
2,941.47
X
23485
002
90
2
X
2,839.25
X
23485
003
90
2
X
2,701.84
X
23485
004
90
2
X
2,669.89
X
23490
002
90
2
X
2,432.05
X
23490
003
90
2
X
2,092.66
X
23490
004
90
2
X
2,274.98
X
23490
001
90
2
X
2,463.03
X
23491
003
90
2
X
2,833.74
X
23491
002
90
2
X
3,180.07
X
23491
001
90
2
X
3,232.15
X
23491
004
90
2
X
2,929.76
X
23500
004
90
2
X
414.60
X
23500
002
90
2
X
479.87
X
23500
003
90
2
X
409.22
X
23500
001
90
2
X
428.51
X
23505
004
90
2
X
669.95
X
23505
001
90
2
X
685.30
X
23505
003
90
2
X
665.56
X
23505
002
90
2
X
721.00
X
23515
004
90
2
X
1,550.97
X
23515
002
90
2
X
1,684.53
X
23515
003
90
2
X
1,569.83
X
23515
001
90
2
X
1,712.29
X
23520
001
90
2
X
404.59
X
23520
004
90
2
X
371.95
X
23520
002
90
2
X
399.14
X
23520
003
90
2
X
372.20
X
23525
004
90
2
X
584.40
X
23525
001
90
2
X
633.12
X
23525
002
90
2
X
624.98
X
23525
003
90
2
X
591.09
X
23530
002
90
2
X
1,614.87
X
23530
003
90
2
X
1,512.48
X
23530
001
90
2
X
1,639.63
X
23530
004
90
2
X
1,494.23
X
23532
001
90
2
X
1,819.07
X
23532
002
90
2
X
1,789.64
X
23532
003
90
2
X
1,668.26
X
23532
004
90
2
X
1,648.43
X
23540
002
90
2
X
424.82
X
23540
003
90
2
X
400.76
X
23540
001
90
2
X
430.62
X
23540
004
90
2
X
396.12
X
23545
004
90
2
X
568.63
X
23545
001
90
2
X
661.25
X
23545
002
90
2
X
657.83
X
23545
003
90
2
X
582.12
X
23550
001
90
2
X
1,902.26
X
23550
004
90
2
X
1,706.92
X
23550
003
90
2
X
1,728.04
X
23550
002
90
2
X
1,953.56
X
23552
003
90
2
X
1,698.44
X
23552
002
90
2
X
1,819.88
X
23552
004
90
2
X
1,678.26
X
23552
001
90
2
X
1,849.31
X
23570
001
90
2
X
456.73
X
23570
003
90
2
X
422.20
X
23570
002
90
2
X
449.99
X
23570
004
90
2
X
417.26
X
23575
003
90
2
X
745.88
X
23575
002
90
2
X
784.48
X
23575
004
90
2
X
728.45
X
23575
001
90
2
X
795.95
X
23585
003
90
2
X
1,814.35
X
23585
002
90
2
X
1,945.56
X
23585
001
90
2
X
1,977.33
X
23585
004
90
2
X
1,792.80
X
23600
003
90
2
X
749.08
X
23600
002
90
2
X
743.19
X
23600
004
90
2
X
729.94
X
23600
001
90
2
X
718.22
X
23605
004
90
2
X
1,037.15
X
23605
001
90
2
X
1,222.92
X
23605
003
90
2
X
1,129.95
X
23605
002
90
2
X
1,240.43
X
23615
001
90
2
X
2,637.09
X
23615
003
90
2
X
2,171.17
X
23615
002
90
2
X
2,344.79
X
23615
004
90
2
X
2,257.88
X
23616
001
90
2
X
4,033.71
X
23616
002
90
2
X
5,121.40
X
23616
003
90
2
X
4,761.79
X
23616
004
90
2
X
3,524.59
X
23620
004
90
2
X
741.51
X
23620
001
90
2
X
733.16
X
23620
002
90
2
X
768.12
X
23620
003
90
2
X
747.74
X
23625
001
90
2
X
916.59
X
23625
003
90
2
X
839.59
X
23625
002
90
2
X
901.58
X
23625
004
90
2
X
856.09
X
23630
003
90
2
X
2,139.95
X
23630
002
90
2
X
2,198.64
X
23630
004
90
2
X
2,130.72
X
23630
001
90
2
X
2,212.86
X
23650
004
90
2
X
612.26
X
23650
003
90
2
X
590.95
X
23650
002
90
2
X
637.36
X
23650
001
90
2
X
668.72
X
23655
004
90
2
X
787.95
X
23655
001
90
2
X
859.30
X
23655
002
90
2
X
847.13
X
23655
003
90
2
X
797.07
X
23660
002
90
2
X
2,356.73
X
23660
003
90
2
X
2,234.89
X
23660
001
90
2
X
2,438.05
X
23660
004
90
2
X
2,265.33
X
23665
003
90
2
X
858.18
X
23665
002
90
2
X
894.51
X
23665
004
90
2
X
854.68
X
23665
001
90
2
X
908.19
X
23670
001
90
2
X
2,254.52
X
23670
004
90
2
X
2,015.49
X
23670
002
90
2
X
2,212.86
X
23670
003
90
2
X
2,128.83
X
23675
004
90
2
X
1,047.38
X
23675
002
90
2
X
1,127.82
X
23675
003
90
2
X
1,059.55
X
23675
001
90
2
X
1,144.30
X
23680
004
90
2
X
2,446.27
X
23680
001
90
2
X
2,728.14
X
23680
003
90
2
X
2,476.69
X
23680
002
90
2
X
2,679.19
X
23700
001
10
2
X
724.45
X
23700
004
10
2
X
703.42
X
23700
003
10
2
X
705.94
X
23700
002
10
2
X
718.96
X
23800
004
90
2
X
3,318.99
X
23800
001
90
2
X
3,685.53
X
23800
003
90
2
X
3,360.13
X
23800
002
90
2
X
3,622.16
X
23802
001
90
2
X
3,517.61
X
23802
004
90
2
X
3,190.41
X
23802
002
90
2
X
3,461.40
X
23802
003
90
2
X
3,228.97
X
23900
004
90
2
X
3,449.74
X
23900
003
90
2
X
3,489.36
X
23900
002
90
2
X
3,730.58
X
23900
001
90
2
X
3,789.16
X
23920
002
90
2
X
3,368.35
X
23920
003
90
2
X
3,125.01
X
23920
001
90
2
X
3,427.21
X
23920
004
90
2
X
3,087.94
X
23921
003
90
2
X
1,048.68
X
23921
002
90
2
X
1,123.83
X
23921
004
90
2
X
1,036.40
X
23921
001
90
2
X
1,142.06
X
23929
YYY
2
X
#
X
23930
003
10
2
X
484.53
X
23930
002
10
2
X
513.04
X
23930
004
10
2
X
486.35
X
23930
001
10
2
X
520.03
X
23931
001
10
2
X
278.90
X
23931
004
10
2
X
257.77
X
23931
002
10
2
X
278.29
X
23931
003
10
2
X
261.39
X
23935
003
90
2
X
1,150.88
X
23935
002
90
2
X
1,231.85
X
23935
004
90
2
X
1,137.38
X
23935
001
90
2
X
1,251.39
X
24000
002
90
2
X
1,821.07
X
24000
003
90
2
X
1,888.42
X
24000
004
90
2
X
1,513.88
X
24000
001
90
2
X
1,697.74
X
24006
004
90
2
X
1,754.92
X
24006
001
90
2
X
1,928.28
X
24006
003
90
2
X
1,775.68
X
24006
002
90
2
X
1,898.50
X
24065
001
10
2
X
324.85
X
24065
004
10
2
X
303.05
X
24065
003
10
2
X
274.29
X
24065
002
10
2
X
321.26
X
24066
002
90
2
X
586.86
X
24066
003
90
2
X
569.51
X
24066
001
90
2
X
602.71
X
24066
004
90
2
X
835.73
X
24071
004
90
2
X
680.08
X
24071
002
90
2
X
680.08
X
24071
003
90
2
X
680.08
X
24071
001
90
2
X
764.99
X
24073
004
90
2
X
1,169.58
X
24073
001
90
2
X
1,313.30
X
24073
003
90
2
X
1,169.58
X
24073
002
90
2
X
1,169.58
X
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