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Health Care Services Review
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Fee Schedule
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Fee Schedule 42235-43261
Begin Main Content Area
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Content Editor
2024 Workers' Compensation Part B Fee Schedule
42235-43261
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
42235
003
90
2
X
1,413.80
X
42235
002
90
2
X
1,490.96
X
42235
004
90
2
X
1,396.93
X
42235
001
90
2
X
1,509.59
X
42260
004
90
2
X
883.63
X
42260
002
90
2
X
1,203.64
X
42260
003
90
2
X
894.49
X
42260
001
90
2
X
1,269.49
X
42280
004
10
2
X
374.16
X
42280
003
10
2
X
379.00
X
42280
002
10
2
X
403.10
X
42280
001
10
2
X
408.86
X
42281
003
10
2
X
353.86
X
42281
002
10
2
X
410.12
X
42281
004
10
2
X
349.63
X
42281
001
10
2
X
379.65
X
42299
YYY
2
X
#
X
42300
004
10
2
X
306.37
X
42300
001
10
2
X
330.30
X
42300
003
10
2
X
309.84
X
42300
002
10
2
X
326.36
X
42305
003
90
2
X
746.24
X
42305
002
90
2
X
769.53
X
42305
004
90
2
X
834.08
X
42305
001
90
2
X
893.86
X
42310
004
10
2
X
274.88
X
42310
003
10
2
X
278.04
X
42310
002
10
2
X
286.60
X
42310
001
10
2
X
295.89
X
42320
003
10
2
X
454.23
X
42320
002
10
2
X
481.87
X
42320
004
10
2
X
448.80
X
42320
001
10
2
X
488.49
X
42330
002
10
2
X
401.67
337.66
42330
003
10
2
X
389.53
327.92
42330
001
10
2
X
403.54
339.94
42330
004
10
2
X
392.45
330.68
42335
002
90
2
X
815.07
X
42335
003
90
2
X
794.23
X
42335
001
90
2
X
820.45
X
42335
004
90
2
X
798.43
X
42340
002
90
2
X
1,015.84
X
42340
003
90
2
X
982.76
X
42340
001
90
2
X
1,030.18
X
42340
004
90
2
X
944.66
X
42400
004
0
2
X
175.43
X
42400
003
0
2
X
176.34
X
42400
002
0
2
X
185.72
X
42400
001
0
2
X
188.56
X
42405
004
10
2
X
515.74
X
42405
001
10
2
X
554.98
X
42405
003
10
2
X
521.56
X
42405
002
10
2
X
548.48
X
42408
002
90
2
X
1,273.99
X
42408
003
90
2
X
1,253.25
X
42408
004
90
2
X
828.93
X
42408
001
90
2
X
900.19
X
42409
004
90
2
X
597.99
X
42409
001
90
2
X
653.31
X
42409
003
90
2
X
605.46
X
42409
002
90
2
X
643.96
X
42410
001
90
2
X
2,165.04
X
42410
004
90
2
X
2,037.85
X
42410
003
90
2
X
1,739.56
X
42410
002
90
2
X
2,008.79
X
42415
001
90
2
X
3,431.38
X
42415
004
90
2
X
3,144.67
X
42415
002
90
2
X
3,382.86
X
42415
003
90
2
X
3,182.21
X
42420
002
90
2
X
3,915.90
X
42420
003
90
2
X
3,686.56
X
42420
004
90
2
X
3,642.88
X
42420
001
90
2
X
3,971.24
X
42425
002
90
2
X
2,765.02
X
42425
003
90
2
X
2,646.04
X
42425
001
90
2
X
2,805.85
X
42425
004
90
2
X
2,632.96
X
42426
004
90
2
X
4,849.57
X
42426
001
90
2
X
5,350.54
X
42426
002
90
2
X
5,265.03
X
42426
003
90
2
X
4,910.47
X
42440
001
90
2
X
1,793.58
X
42440
003
90
2
X
1,619.84
X
42440
002
90
2
X
1,733.64
X
42440
004
90
2
X
1,599.74
X
42450
001
90
2
X
1,283.73
X
42450
004
90
2
X
840.49
X
42450
003
90
2
X
1,094.40
X
42450
002
90
2
X
1,114.88
X
42500
002
90
2
X
1,017.94
X
42500
003
90
2
X
954.82
X
42500
001
90
2
X
1,056.35
X
42500
004
90
2
X
942.96
X
42505
004
90
2
X
1,449.86
X
42505
001
90
2
X
1,594.59
X
42505
003
90
2
X
1,468.24
X
42505
002
90
2
X
1,749.19
X
42507
001
90
2
X
1,884.05
X
42507
004
90
2
X
1,164.51
X
42507
003
90
2
X
1,178.28
X
42507
002
90
2
X
1,876.27
X
42509
003
90
2
X
2,051.03
X
42509
002
90
2
X
2,183.97
X
42509
004
90
2
X
2,027.76
X
42509
001
90
2
X
2,216.17
X
42510
002
90
2
X
1,795.79
X
42510
003
90
2
X
1,688.48
X
42510
001
90
2
X
1,821.67
X
42510
004
90
2
X
1,667.71
X
42550
004
0
2
X
167.36
X
42550
002
0
2
X
176.54
X
42550
003
0
2
X
169.25
X
42550
001
0
2
X
178.28
X
42600
001
90
2
X
1,232.50
X
42600
004
90
2
X
920.46
X
42600
002
90
2
X
989.71
X
42600
003
90
2
X
931.63
X
42650
003
0
2
X
125.36
105.76
42650
002
0
2
X
153.25
131.73
42650
004
0
2
X
123.97
104.70
42650
001
0
2
X
135.34
115.92
42660
002
0
2
X
185.47
X
42660
003
0
2
X
137.91
X
42660
004
0
2
X
175.43
X
42660
001
0
2
X
153.05
X
42665
002
90
2
X
640.67
X
42665
003
90
2
X
492.18
X
42665
001
90
2
X
530.32
X
42665
004
90
2
X
486.37
X
42699
YYY
2
X
#
X
42700
001
10
2
X
281.59
X
42700
004
10
2
X
261.10
X
42700
003
10
2
X
264.16
X
42700
002
10
2
X
270.70
X
42720
001
10
2
X
528.61
X
42720
004
10
2
X
486.98
X
42720
002
10
2
X
521.68
X
42720
003
10
2
X
492.76
X
42725
004
90
2
X
1,301.56
X
42725
001
90
2
X
1,406.95
X
42725
002
90
2
X
1,389.29
X
42725
003
90
2
X
1,316.61
X
42800
001
10
2
X
249.43
207.32
42800
004
10
2
X
234.06
194.97
42800
003
10
2
X
236.40
196.98
42800
002
10
2
X
237.58
197.49
42804
003
10
2
X
319.01
X
42804
001
10
2
X
339.24
X
42804
002
10
2
X
331.16
X
42804
004
10
2
X
322.09
X
42806
004
10
2
X
318.77
X
42806
001
10
2
X
371.85
X
42806
003
10
2
X
322.73
X
42806
002
10
2
X
362.30
X
42808
002
10
2
X
461.74
X
42808
003
10
2
X
438.95
X
42808
004
10
2
X
450.64
X
42808
001
10
2
X
475.64
X
42809
002
10
2
X
292.34
X
42809
003
10
2
X
278.94
X
42809
004
10
2
X
275.80
X
42809
001
10
2
X
295.56
X
42810
004
90
2
X
701.58
X
42810
001
90
2
X
772.86
X
42810
003
90
2
X
710.15
X
42810
002
90
2
X
760.66
X
42815
002
90
2
X
1,980.42
X
42815
003
90
2
X
1,879.26
X
42815
001
90
2
X
2,014.02
X
42815
004
90
2
X
1,764.32
X
42820
004
90
2
X
726.41
X
42820
001
90
2
X
789.61
X
42820
003
90
2
X
735.30
X
42820
002
90
2
X
779.07
X
42821
004
90
2
X
874.54
X
42821
003
90
2
X
885.25
X
42821
002
90
2
X
904.90
X
42821
001
90
2
X
956.18
X
42825
004
90
2
X
637.36
X
42825
001
90
2
X
694.98
X
42825
003
90
2
X
645.02
X
42825
002
90
2
X
685.27
X
42826
001
90
2
X
842.44
X
42826
003
90
2
X
777.39
X
42826
002
90
2
X
829.84
X
42826
004
90
2
X
767.72
X
42830
002
90
2
X
542.64
X
42830
003
90
2
X
482.45
X
42830
004
90
2
X
476.79
X
42830
001
90
2
X
552.50
X
42831
001
90
2
X
585.45
X
42831
004
90
2
X
537.75
X
42831
003
90
2
X
544.33
X
42831
002
90
2
X
577.52
X
42835
001
90
2
X
462.24
X
42835
004
90
2
X
429.84
X
42835
003
90
2
X
435.15
X
42835
002
90
2
X
456.99
X
42836
001
90
2
X
694.92
X
42836
004
90
2
X
637.58
X
42836
002
90
2
X
685.30
X
42836
003
90
2
X
645.41
X
42842
001
90
2
X
1,600.22
X
42842
004
90
2
X
1,549.92
X
42842
002
90
2
X
1,545.34
X
42842
003
90
2
X
1,515.82
X
42844
001
90
2
X
2,790.69
X
42844
004
90
2
X
2,560.44
X
42844
002
90
2
X
2,752.01
X
42844
003
90
2
X
2,591.46
X
42845
004
90
2
X
4,402.48
X
42845
001
90
2
X
4,800.41
X
42845
003
90
2
X
4,455.83
X
42845
002
90
2
X
4,733.41
X
42860
003
90
2
X
512.95
X
42860
002
90
2
X
524.28
X
42860
004
90
2
X
436.10
X
42860
001
90
2
X
475.01
X
42870
002
90
2
X
853.12
X
42870
003
90
2
X
812.19
X
42870
004
90
2
X
803.20
X
42870
001
90
2
X
861.90
X
42890
004
90
2
X
2,237.60
X
42890
001
90
2
X
2,431.90
X
42890
003
90
2
X
2,264.40
X
42890
002
90
2
X
2,088.11
X
42892
003
90
2
X
3,442.91
X
42892
002
90
2
X
2,891.73
X
42892
004
90
2
X
2,695.27
X
42892
001
90
2
X
2,931.34
X
42894
003
90
2
X
4,026.71
X
42894
002
90
2
X
4,266.79
X
42894
004
90
2
X
3,978.85
X
42894
001
90
2
X
4,324.85
X
42900
001
10
2
X
1,092.54
X
42900
004
10
2
X
1,002.87
X
42900
002
10
2
X
1,077.41
X
42900
003
10
2
X
1,015.08
X
42950
001
90
2
X
2,104.84
X
42950
004
90
2
X
1,915.07
X
42950
002
90
2
X
2,072.83
X
42950
003
90
2
X
1,997.69
X
42953
004
90
2
X
1,597.40
X
42953
001
90
2
X
1,746.86
X
42953
002
90
2
X
1,721.37
X
42953
003
90
2
X
1,616.32
X
42955
003
90
2
X
1,073.62
X
42955
002
90
2
X
1,131.32
X
42955
004
90
2
X
1,061.53
X
42955
001
90
2
X
1,145.35
X
42960
004
10
2
X
360.86
X
42960
001
10
2
X
387.69
X
42960
002
10
2
X
390.58
X
42960
003
10
2
X
365.00
X
42961
004
90
2
X
740.40
X
42961
002
90
2
X
781.70
X
42961
003
90
2
X
748.52
X
42961
001
90
2
X
789.71
X
42962
001
90
2
X
1,494.53
X
42962
004
90
2
X
1,370.05
X
42962
003
90
2
X
1,386.86
X
42962
002
90
2
X
1,473.59
X
42970
003
90
2
X
517.70
X
42970
002
90
2
X
495.88
X
42970
004
90
2
X
576.46
X
42970
001
90
2
X
462.17
X
42971
004
90
2
X
910.62
X
42971
003
90
2
X
921.09
X
42971
002
90
2
X
969.45
X
42971
001
90
2
X
981.14
X
42972
004
90
2
X
1,222.29
X
42972
001
90
2
X
1,336.13
X
42972
003
90
2
X
1,236.51
X
42972
002
90
2
X
1,316.74
X
42975
003
0
3
X
134.42
X
42975
002
0
3
X
134.42
X
42975
001
0
3
X
146.44
X
42975
004
0
3
X
134.42
X
42999
YYY
2
X
#
X
43020
001
90
2
X
2,107.41
X
43020
004
90
2
X
1,547.05
X
43020
002
90
2
X
1,660.61
X
43020
003
90
2
X
1,565.92
X
43030
001
90
2
X
1,985.71
X
43030
004
90
2
X
1,911.97
X
43030
003
90
2
X
1,820.71
X
43030
002
90
2
X
1,953.63
X
43045
002
90
2
X
3,758.93
X
43045
003
90
2
X
3,519.20
X
43045
001
90
2
X
3,817.14
X
43045
004
90
2
X
3,479.47
X
43100
002
90
2
X
2,791.67
X
43100
003
90
2
X
2,407.05
X
43100
004
90
2
X
1,611.69
X
43100
001
90
2
X
1,762.04
X
43101
003
90
2
X
2,770.53
X
43101
002
90
2
X
2,958.98
X
43101
001
90
2
X
3,004.76
X
43101
004
90
2
X
2,739.51
X
43107
004
90
2
X
5,585.08
X
43107
003
90
2
X
5,650.23
X
43107
002
90
2
X
6,073.10
X
43107
001
90
2
X
6,175.61
X
43108
004
90
2
X
6,216.58
X
43108
001
90
2
X
7,331.34
X
43108
003
90
2
X
6,289.43
X
43108
002
90
2
X
7,266.25
X
43112
004
90
2
X
5,905.83
X
43112
002
90
2
X
6,065.63
X
43112
003
90
2
X
5,885.61
X
43112
001
90
2
X
6,212.69
X
43113
004
90
2
X
6,216.58
X
43113
001
90
2
X
7,331.34
X
43113
003
90
2
X
6,289.43
X
43113
002
90
2
X
7,266.25
X
43116
003
90
2
X
6,289.43
X
43116
002
90
2
X
7,266.25
X
43116
004
90
2
X
6,216.58
X
43116
001
90
2
X
7,331.34
X
43117
001
90
2
X
7,331.34
X
43117
004
90
2
X
6,216.58
X
43117
002
90
2
X
7,266.25
X
43117
003
90
2
X
6,289.43
X
43118
004
90
2
X
6,216.58
X
43118
003
90
2
X
6,289.43
X
43118
002
90
2
X
7,266.25
X
43118
001
90
2
X
7,331.34
X
43121
002
90
2
X
5,791.27
X
43121
003
90
2
X
5,581.51
X
43121
004
90
2
X
5,604.53
X
43121
001
90
2
X
6,587.99
X
43122
002
90
2
X
5,791.27
X
43122
003
90
2
X
5,581.51
X
43122
001
90
2
X
6,587.99
X
43122
004
90
2
X
5,604.53
X
43123
001
90
2
X
7,331.34
X
43123
002
90
2
X
7,266.25
X
43123
003
90
2
X
6,289.43
X
43123
004
90
2
X
6,216.58
X
43124
004
90
2
X
5,585.08
X
43124
002
90
2
X
6,073.10
X
43124
003
90
2
X
5,650.23
X
43124
001
90
2
X
6,175.61
X
43130
004
90
2
X
2,456.18
X
43130
003
90
2
X
2,427.16
X
43130
002
90
2
X
2,545.26
X
43130
001
90
2
X
2,586.33
X
43135
002
90
2
X
3,244.91
X
43135
003
90
2
X
3,028.86
X
43135
001
90
2
X
3,297.18
X
43135
004
90
2
X
2,993.98
X
43180
001
90
2
X
917.98
1,011.74
43180
004
90
2
X
838.48
918.60
43180
003
90
2
X
838.48
918.60
43180
002
90
2
X
838.48
918.60
43191
004
0
2
X
203.60
X
43191
002
0
2
X
203.60
X
43191
003
0
2
X
203.60
X
43191
001
0
2
X
222.88
X
43192
001
0
3
X
265.75
X
43192
002
0
3
X
243.12
X
43192
003
0
3
X
243.12
X
43192
004
0
3
X
243.12
X
43193
004
0
3
X
290.09
X
43193
001
0
3
X
316.51
X
43193
003
0
3
X
290.09
X
43193
002
0
3
X
290.09
X
43194
002
0
3
X
264.62
X
43194
003
0
3
X
264.62
X
43194
004
0
3
X
264.62
X
43194
001
0
3
X
286.89
X
43195
001
0
3
X
317.12
X
43195
004
0
3
X
290.62
X
43195
003
0
3
X
290.62
X
43195
002
0
3
X
290.62
X
43196
003
0
3
X
319.22
X
43196
002
0
3
X
319.22
X
43196
004
0
3
X
319.22
X
43196
001
0
3
X
349.19
X
43197
002
0
2
X
285.54
130.31
43197
003
0
2
X
285.54
130.31
43197
001
0
2
X
322.00
141.14
43197
004
0
2
X
285.54
130.31
43198
004
0
3
X
319.49
155.20
43198
001
0
3
X
359.39
167.98
43198
002
0
3
X
319.49
155.20
43198
003
0
3
X
319.49
155.20
43200
002
0
2
X
553.00
X
43200
003
0
2
X
563.68
X
43200
001
0
2
X
703.13
X
43200
004
0
2
X
552.92
X
43201
001
0
3
X
584.00
301.48
43201
003
0
3
X
512.92
272.55
43201
002
0
3
X
512.92
272.55
43201
004
0
3
X
512.92
272.55
43202
001
0
3
X
703.02
X
43202
004
0
3
X
621.45
X
43202
002
0
3
X
635.32
X
43202
003
0
3
X
622.92
X
43204
001
0
3
X
1,128.33
X
43204
004
0
3
X
1,060.83
X
43204
002
0
3
X
1,152.56
X
43204
003
0
3
X
1,137.38
X
43205
004
0
3
X
640.01
X
43205
001
0
3
X
688.03
X
43205
002
0
3
X
680.15
X
43205
003
0
3
X
647.70
X
43206
0
3
X
*
X
43210
004
0
3
X
664.46
X
43210
001
0
3
X
720.08
X
43210
002
0
3
X
664.46
X
43210
003
0
3
X
664.46
X
43211
001
0
3
X
434.69
X
43211
003
0
3
X
397.65
X
43211
002
0
3
X
397.65
X
43211
004
0
3
X
397.65
X
43212
001
0
3
X
344.92
X
43212
003
0
3
X
314.77
X
43212
002
0
3
X
314.77
X
43212
004
0
3
X
314.77
X
43213
002
0
3
X
1,879.76
442.66
43213
003
0
3
X
1,879.76
442.66
43213
001
0
3
X
2,158.27
483.95
43213
004
0
3
X
1,879.76
442.66
43214
001
0
3
X
350.23
X
43214
004
0
3
X
320.06
X
43214
003
0
3
X
320.06
X
43214
002
0
3
X
320.06
X
43215
003
0
3
X
799.73
X
43215
002
0
3
X
817.79
X
43215
004
0
3
X
781.73
X
43215
001
0
3
X
965.16
X
43216
004
0
3
X
1,033.52
X
43216
001
0
3
X
1,095.31
X
43216
003
0
3
X
990.23
X
43216
002
0
3
X
1,132.79
X
43217
001
0
3
X
1,095.31
X
43217
004
0
3
X
1,033.52
X
43217
002
0
3
X
1,132.79
X
43217
003
0
3
X
990.23
X
43220
002
0
3
X
621.02
X
43220
003
0
3
X
559.23
X
43220
004
0
3
X
581.78
X
43220
001
0
3
X
677.97
X
43226
003
0
3
X
586.76
X
43226
002
0
3
X
623.72
X
43226
001
0
3
X
632.52
X
43226
004
0
3
X
579.09
X
43227
003
0
3
X
899.40
X
43227
002
0
3
X
1,095.07
X
43227
001
0
3
X
1,132.79
X
43227
004
0
3
X
1,101.93
X
43229
001
0
3
X
1,273.34
370.74
43229
002
0
3
X
1,112.92
338.22
43229
003
0
3
X
1,112.92
338.22
43229
004
0
3
X
1,112.92
338.22
43231
002
0
3
X
527.34
X
43231
003
0
3
X
527.34
X
43231
004
0
3
X
527.34
X
43231
001
0
3
X
578.87
X
43232
001
0
3
X
672.98
X
43232
004
0
3
X
612.59
X
43232
003
0
3
X
612.59
X
43232
002
0
3
X
612.59
X
43233
002
0
3
X
379.96
X
43233
003
0
3
X
379.96
X
43233
004
0
3
X
379.96
X
43233
001
0
3
X
415.47
X
43235
001
0
2
X
758.84
X
43235
004
0
2
X
717.69
X
43235
002
0
2
X
726.55
X
43235
003
0
2
X
704.12
X
43236
002
0
3
X
600.89
340.06
43236
003
0
3
X
600.89
340.06
43236
004
0
3
X
600.89
340.06
43236
001
0
3
X
678.80
372.22
43237
003
0
3
X
461.08
X
43237
002
0
3
X
461.08
X
43237
004
0
3
X
461.08
X
43237
001
0
3
X
503.15
X
43238
003
0
3
X
572.51
X
43238
002
0
3
X
572.51
X
43238
004
0
3
X
572.51
X
43238
001
0
3
X
621.23
X
43239
003
0
3
X
786.12
X
43239
002
0
3
X
865.84
X
43239
004
0
3
X
834.94
X
43239
001
0
3
X
917.19
X
43240
003
0
3
X
931.14
X
43240
002
0
3
X
931.14
X
43240
004
0
3
X
931.14
X
43240
001
0
3
X
1,021.20
X
43241
001
0
3
X
1,102.81
X
43241
002
0
3
X
963.91
X
43241
003
0
3
X
1,014.94
X
43241
004
0
3
X
1,032.87
X
43242
001
0
3
X
733.41
X
43242
004
0
3
X
670.22
X
43242
002
0
3
X
670.22
X
43242
003
0
3
X
670.22
X
43243
002
0
3
X
1,196.70
X
43243
003
0
3
X
1,200.39
X
43243
001
0
3
X
1,185.14
X
43243
004
0
3
X
1,148.26
X
43244
002
0
3
X
823.94
X
43244
003
0
3
X
784.99
X
43244
001
0
3
X
833.32
X
43244
004
0
3
X
775.58
X
43245
004
0
3
X
1,122.83
X
43245
002
0
3
X
1,163.74
X
43245
003
0
3
X
1,151.30
X
43245
001
0
3
X
1,179.24
X
43246
004
0
3
X
1,166.53
X
43246
001
0
3
X
1,204.20
X
43246
003
0
3
X
1,163.65
X
43246
002
0
3
X
1,190.76
X
43247
004
0
3
X
964.44
X
43247
001
0
3
X
1,075.47
X
43247
003
0
3
X
932.90
X
43247
002
0
3
X
980.75
X
43248
001
0
3
X
796.32
X
43248
004
0
3
X
728.96
X
43248
003
0
3
X
738.40
X
43248
002
0
3
X
785.13
X
43249
003
0
3
X
693.94
X
43249
002
0
3
X
761.89
X
43249
004
0
3
X
710.73
X
43249
001
0
3
X
753.34
X
43250
004
0
3
X
1,225.83
X
43250
001
0
3
X
1,288.99
X
43250
003
0
3
X
1,259.15
X
43250
002
0
3
X
1,296.93
X
43251
004
0
3
X
1,225.83
X
43251
002
0
3
X
1,296.93
X
43251
001
0
3
X
1,288.99
X
43251
003
0
3
X
1,259.15
X
43252
0
3
X
*
X
43253
004
0
3
X
440.73
X
43253
003
0
3
X
440.73
X
43253
002
0
3
X
440.73
X
43253
001
0
3
X
482.05
X
43254
004
0
3
X
457.95
X
43254
002
0
3
X
457.95
X
43254
003
0
3
X
457.95
X
43254
001
0
3
X
501.02
X
43255
003
0
3
X
1,252.57
X
43255
002
0
3
X
1,303.83
X
43255
004
0
3
X
1,202.52
X
43255
001
0
3
X
1,306.73
X
43257
004
0
3
X
618.64
X
43257
003
0
3
X
618.64
X
43257
002
0
3
X
618.64
X
43257
001
0
3
X
675.64
X
43259
0
3
X
*
X
43260
003
0
2
X
1,219.26
X
43260
002
0
2
X
1,267.54
X
43260
004
0
2
X
1,186.59
X
43260
001
0
2
X
1,311.36
X
43261
001
0
3
X
1,321.70
X
43261
002
0
3
X
1,298.78
X
43261
003
0
3
X
1,229.37
X
43261
004
0
3
X
1,216.75
X
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