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2021 Workers' Compensation Part B Fee Schedule

62162-63286

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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
62162   2 90 2 X 2,819.51 X
62162   3 90 2 X 2,819.51 X
62162   4 90 2 X 2,819.51 X
62162   1 90 2 X 3,271.04 X
62164   2 90 2 X 3,054.08 X
62164   3 90 2 X 3,054.08 X
62164   4 90 2 X 3,054.08 X
62164   1 90 2 X 3,524.92 X
62165   2 90 2 X 2,402.00 X
62165   3 90 2 X 2,402.00 X
62165   4 90 2 X 2,402.00 X
62165   1 90 2 X 2,736.89 X
62180   3 90 2 X 2,633.26 X
62180   2 90 2 X 3,433.62 X
62180   4 90 2 X 3,478.26 X
62180   1 90 2 X 3,480.67 X
62190   4 90 2 X 2,468.35 X
62190   3 90 2 X 2,498.50 X
62190   2 90 2 X 2,731.65 X
62190   1 90 2 X 2,788.12 X
62192   3 90 2 X 2,532.89 X
62192   4 90 2 X 2,560.24 X
62192   2 90 2 X 2,746.94 X
62192   1 90 2 X 2,798.77 X
62194   4 10 2 X 410.71 X
62194   3 10 2 X 415.43 X
62194   2 10 2 X 862.93 X
62194   1 10 2 X 906.07 X
62200   1 90 2 X 2,886.55 X
62200   4 90 2 X 2,918.10 X
62200   2 90 2 X 2,923.11 X
62200   3 90 2 X 2,953.98 X
62201   4 90 2 X 1,992.71 X
62201   3 90 2 X 2,015.70 X
62201   2 90 2 X 2,159.56 X
62201   1 90 2 X 2,194.48 X
62220   4 90 2 X 2,721.21 X
62220   3 90 2 X 2,754.60 X
62220   2 90 2 X 2,993.15 X
62220   1 90 2 X 3,050.96 X
62223   4 90 2 X 2,825.38 X
62223   3 90 2 X 2,860.12 X
62223   2 90 2 X 3,099.03 X
62223   1 90 2 X 3,156.75 X
62225   4 90 2 X 885.60 X
62225   2 90 2 X 898.11 X
62225   1 90 2 X 934.29 X
62225   3 90 2 X 1,422.13 X
62230   4 90 2 X 1,877.37 X
62230   3 90 2 X 1,899.92 X
62230   2 90 2 X 2,073.97 X
62230   1 90 2 X 2,083.99 X
62252 26 2 XXX 0 X 77.82 X
62252 26 3 XXX 0 X 77.82 X
62252 26 4 XXX 0 X 77.82 X
62252 TC 2 XXX 0 X 78.75 X
62252 TC 3 XXX 0 X 78.75 X
62252 TC 4 XXX 0 X 78.75 X
62252 26 1 XXX 0 X 84.32 X
62252 TC 1 XXX 0 X 93.04 X
62252   2 XXX 0 X 156.64 X
62252   3 XXX 0 X 156.64 X
62252   4 XXX 0 X 156.64 X
62252   1 XXX 0 X 177.40 X
62256   4 90 2 X 1,181.30 X
62256   3 90 2 X 1,427.88 X
62256   2 90 2 X 1,469.40 X
62256   1 90 2 X 1,521.71 X
62258   4 90 2 X 2,715.50 X
62258   3 90 2 X 2,904.55 X
62258   2 90 2 X 2,961.38 X
62258   1 90 2 X 3,012.84 X
62263   2 10 2 X 827.12 653.92
62263   3 10 2 X 827.12 653.92
62263   4 10 2 X 827.12 653.92
62263   1 10 2 X 937.38 734.83
62264   2 10 2 X 1,057.59 406.72
62264   3 10 2 X 1,057.59 406.72
62264   4 10 2 X 1,057.59 406.72
62264   1 10 2 X 1,210.61 445.54
62267   2 0 2 X 351.29 237.63
62267   3 0 2 X 351.29 237.63
62267   4 0 2 X 351.29 237.63
62267   1 0 2 X 392.77 257.94
62268     0 2 X * X
62269     0 2 X * X
62270   4 0 2 X 156.75 X
62270   3 0 2 X 158.62 X
62270   2 0 2 X 167.04 X
62270   1 0 2 X 168.59 X
62272   4 0 2 X 187.99 X
62272   2 0 2 X 203.53 X
62272   3 0 2 X 207.05 X
62272   1 0 2 X 222.29 X
62273   4 0 2 X 291.58 X
62273   3 0 2 X 294.78 X
62273   2 0 2 X 311.09 X
62273   1 0 2 X 321.89 X
62280   4 10 2 X 244.25 X
62280   3 10 2 X 308.85 X
62280   2 10 2 X 312.71 X
62280   1 10 2 X 455.62 X
62281   4 10 2 X 312.46 X
62281   3 10 2 X 315.78 X
62281   1 10 2 X 341.15 X
62281   2 10 2 X 347.86 X
62282   4 10 2 X 361.64 X
62282   3 10 2 X 372.48 X
62282   2 10 2 X 394.15 X
62282   1 10 2 X 401.06 X
62284   3 0 0 X 349.20 X
62284   1 0 0 X 384.01 X
62284   4 0 0 X 389.26 X
62284   2 0 0 X 437.34 X
62287   4 90 2 X 1,690.72 X
62287   3 90 2 X 1,712.72 X
62287   2 90 2 X 1,897.65 X
62287   1 90 2 X 1,942.36 X
62290   4 0 2 X 469.67 X
62290   3 0 2 X 475.02 X
62290   2 0 2 X 500.66 X
62290   1 0 2 X 506.92 X
62291   3 0 2 X 392.76 X
62291   4 0 2 X 419.49 X
62291   2 0 2 X 447.09 X
62291   1 0 2 X 461.07 X
62292   1 90 2 X 2,017.04 X
62292   3 90 2 X 2,020.58 X
62292   4 90 2 X 2,267.01 X
62292   2 90 2 X 2,401.66 X
62294   4 90 2 X 1,283.38 X
62294   3 90 2 X 1,298.68 X
62294   2 90 2 X 1,375.07 X
62294   1 90 2 X 1,393.49 X
62302   2 0 2 X 315.37 165.64
62302   3 0 2 X 315.37 165.64
62302   4 0 2 X 315.37 165.64
62302   1 0 2 X 353.51 178.33
62303   2 0 2 X 327.44 167.87
62303   3 0 2 X 327.44 167.87
62303   4 0 2 X 327.44 167.87
62303   1 0 2 X 367.65 180.95
62304   2 0 2 X 310.75 162.82
62304   3 0 2 X 310.75 162.82
62304   4 0 2 X 310.75 162.82
62304   1 0 2 X 348.43 175.33
62305   2 0 2 X 338.79 169.85
62305   3 0 2 X 338.79 169.85
62305   4 0 2 X 338.79 169.85
62305   1 0 2 X 380.52 182.85
62320   2 0 2 X 210.57 132.75
62320   3 0 2 X 210.57 132.75
62320   4 0 2 X 210.57 132.75
62320   1 0 2 X 234.17 144.00
62321   2 0 2 X 310.42 143.17
62321   3 0 2 X 310.42 143.17
62321   4 0 2 X 310.42 143.17
62321   1 0 2 X 349.06 155.28
62322   2 0 2 X 195.88 114.20
62322   3 0 2 X 195.88 114.20
62322   4 0 2 X 195.88 114.20
62322   1 0 2 X 218.47 123.83
62323   2 0 2 X 304.23 130.52
62323   3 0 2 X 304.23 130.52
62323   4 0 2 X 304.23 130.52
62323   1 0 2 X 342.54 141.30
62324   2 0 2 X 185.12 121.91
62324   3 0 2 X 185.12 121.91
62324   4 0 2 X 185.12 121.91
62324   1 0 2 X 204.26 131.04
62325   2 0 2 X 276.93 140.20
62325   3 0 2 X 276.93 140.20
62325   4 0 2 X 276.93 140.20
62325   1 0 2 X 308.97 150.55
62326   2 0 2 X 193.70 119.32
62326   3 0 2 X 193.70 119.32
62326   4 0 2 X 193.70 119.32
62326   1 0 2 X 214.70 128.50
62327   2 0 2 X 281.00 127.06
62327   3 0 2 X 281.00 127.06
62327   4 0 2 X 281.00 127.06
62327   1 0 2 X 315.20 136.86
62328   2 0 2 X 300.14 107.89
62328   3 0 2 X 300.14 107.89
62328   4 0 2 X 300.14 107.89
62328   1 0 2 X 338.54 117.16
62329   2 0 2 X 372.60 135.57
62329   3 0 2 X 372.60 135.57
62329   4 0 2 X 372.60 135.57
62329   1 0 2 X 421.90 148.96
62350   4 90 2 X 984.29 X
62350   3 90 2 X 998.38 X
62350   2 90 2 X 1,062.10 X
62350   1 90 2 X 1,116.19 X
62351   4 90 2 X 1,455.59 X
62351   3 90 2 X 1,476.46 X
62351   2 90 2 X 1,570.52 X
62351   1 90 2 X 1,650.27 X
62355   4 90 2 X 820.58 X
62355   3 90 2 X 832.66 X
62355   2 90 2 X 886.40 X
62355   1 90 2 X 928.08 X
62360   4 90 2 X 315.50 X
62360   3 90 2 X 320.07 X
62360   2 90 2 X 340.54 X
62360   1 90 2 X 357.92 X
62361   4 90 2 X 755.64 X
62361   3 90 2 X 766.52 X
62361   2 90 2 X 815.42 X
62361   1 90 2 X 856.81 X
62362   4 90 2 X 989.91 X
62362   3 90 2 X 1,004.11 X
62362   2 90 2 X 1,068.09 X
62362   1 90 2 X 1,122.26 X
62365   4 90 2 X 815.85 X
62365   3 90 2 X 827.95 X
62365   2 90 2 X 881.41 X
62365   1 90 2 X 922.99 X
62367 TC 4 XXX 0 X 37.88 X
62367 TC 3 XXX 0 X 38.64 X
62367 TC 2 XXX 0 X 42.67 X
62367 TC 1 XXX 0 X 45.12 X
62367 26 4 XXX 0 X 69.84 X
62367 26 3 XXX 0 X 70.90 X
62367 26 2 XXX 0 X 75.50 X
62367 26 1 XXX 0 X 79.08 X
62367   4 XXX 0 X 107.72 X
62367   3 XXX 0 X 109.54 X
62367   2 XXX 0 X 118.16 X
62367   1 XXX 0 X 124.18 X
62368 TC 4 XXX 0 X 39.38 X
62368 TC 3 XXX 0 X 40.20 X
62368 TC 2 XXX 0 X 44.36 X
62368 TC 1 XXX 0 X 46.86 X
62368 26 4 XXX 0 X 109.43 X
62368 26 3 XXX 0 X 111.01 X
62368 26 2 XXX 0 X 118.25 X
62368 26 1 XXX 0 X 123.86 X
62368   4 XXX 0 X 148.79 X
62368   3 XXX 0 X 151.23 X
62368   2 XXX 0 X 162.61 X
62368   1 XXX 0 X 170.76 X
62369   2 XXX 0 X 166.89 49.32
62369   3 XXX 0 X 166.89 49.32
62369   4 XXX 0 X 166.89 49.32
62369   1 XXX 0 X 189.41 53.02
62370   2 XXX 0 X 175.67 66.14
62370   3 XXX 0 X 175.67 66.14
62370   4 XXX 0 X 175.67 66.14
62370   1 XXX 0 X 198.27 71.24
62380         X * X
63001   4 90 2 X 3,198.35 X
63001   2 90 2 X 3,508.28 X
63001   3 90 2 X 3,564.23 X
63001   1 90 2 X 3,573.82 X
63003   4 90 2 X 3,139.52 X
63003   3 90 2 X 3,330.84 X
63003   2 90 2 X 3,437.93 X
63003   1 90 2 X 3,500.77 X
63005   4 90 2 X 2,976.01 X
63005   3 90 2 X 3,012.73 X
63005   2 90 2 X 3,261.23 X
63005   1 90 2 X 3,321.28 X
63011   4 90 2 X 2,020.56 X
63011   3 90 2 X 2,044.49 X
63011   2 90 2 X 2,198.62 X
63011   1 90 2 X 2,236.00 X
63012   3 90 2 X 3,108.49 X
63012   4 90 2 X 3,147.72 X
63012   2 90 2 X 3,256.06 X
63012   1 90 2 X 3,312.09 X
63015   4 90 2 X 3,709.25 X
63015   3 90 2 X 3,754.72 X
63015   2 90 2 X 4,077.20 X
63015   1 90 2 X 4,155.20 X
63016   4 90 2 X 3,844.37 X
63016   3 90 2 X 3,891.71 X
63016   2 90 2 X 4,217.05 X
63016   1 90 2 X 4,295.78 X
63017   4 90 2 X 3,591.03 X
63017   3 90 2 X 3,635.25 X
63017   2 90 2 X 3,946.05 X
63017   1 90 2 X 4,021.33 X
63020   4 90 2 X 2,895.16 X
63020   3 90 2 X 2,921.56 X
63020   2 90 2 X 3,178.32 X
63020   1 90 2 X 3,240.42 X
63030   4 90 2 X 2,666.54 X
63030   3 90 2 X 2,706.38 X
63030   2 90 2 X 2,923.43 X
63030   1 90 2 X 2,977.62 X
63035   3 ZZZ 0 X 1,373.37 X
63035   4 ZZZ 0 X 1,401.44 X
63035   1 ZZZ 0 X 1,436.27 X
63035   2 ZZZ 0 X 1,480.53 X
63040   4 90 2 X 5,732.64 X
63040   3 90 2 X 5,752.92 X
63040   2 90 2 X 5,894.05 X
63040   1 90 2 X 5,928.26 X
63042   3 90 2 X 5,585.24 X
63042   4 90 2 X 5,737.24 X
63042   2 90 2 X 5,898.89 X
63042   1 90 2 X 5,935.36 X
63043     ZZZ 0 X * X
63044     ZZZ 0 X * X
63045   4 90 2 X 4,949.64 X
63045   3 90 2 X 4,968.85 X
63045   2 90 2 X 5,088.64 X
63045   1 90 2 X 5,142.20 X
63046   4 90 2 X 3,636.17 X
63046   3 90 2 X 4,932.27 X
63046   2 90 2 X 5,075.61 X
63046   1 90 2 X 5,110.30 X
63047   3 90 2 X 4,875.90 X
63047   4 90 2 X 4,887.84 X
63047   2 90 2 X 5,035.36 X
63047   1 90 2 X 5,071.00 X
63048   2 ZZZ 0 X 3,679.95 X
63048   4 ZZZ 0 X 3,719.65 X
63048   3 ZZZ 0 X 3,724.12 X
63048   1 ZZZ 0 X 3,747.93 X
63050   2 90 2 X 2,389.94 X
63050   3 90 2 X 2,389.94 X
63050   4 90 2 X 2,389.94 X
63050   1 90 2 X 2,745.76 X
63051   2 90 2 X 2,727.60 X
63051   3 90 2 X 2,727.60 X
63051   4 90 2 X 2,727.60 X
63051   1 90 2 X 3,108.26 X
63055   4 90 2 X 4,263.59 X
63055   3 90 2 X 4,315.67 X
63055   2 90 2 X 4,658.47 X
63055   1 90 2 X 4,741.37 X
63056   2 90 2 X 4,283.04 X
63056   4 90 2 X 5,437.93 X
63056   3 90 2 X 5,458.08 X
63056   1 90 2 X 5,620.62 X
63057   4 ZZZ 0 X 745.34 X
63057   3 ZZZ 0 X 754.66 X
63057   2 ZZZ 0 X 820.90 X
63057   1 ZZZ 0 X 836.92 X
63064   4 90 2 X 4,494.66 X
63064   3 90 2 X 6,008.28 X
63064   2 90 2 X 6,153.61 X
63064   1 90 2 X 6,188.81 X
63066   4 ZZZ 0 X 546.51 X
63066   3 ZZZ 0 X 552.80 X
63066   2 ZZZ 0 X 591.83 X
63066   1 ZZZ 0 X 601.37 X
63075   4 90 2 X 3,213.58 X
63075   3 90 2 X 3,611.04 X
63075   2 90 2 X 3,879.66 X
63075   1 90 2 X 3,944.80 X
63076   3 ZZZ 0 X 1,872.65 X
63076   1 ZZZ 0 X 1,950.72 X
63076   2 ZZZ 0 X 1,952.45 X
63076   4 ZZZ 0 X 1,963.45 X
63077   4 90 2 X 3,680.58 X
63077   3 90 2 X 3,724.53 X
63077   2 90 2 X 3,788.14 X
63077   1 90 2 X 3,825.63 X
63078   4 ZZZ 0 X 559.23 X
63078   3 ZZZ 0 X 565.84 X
63078   2 ZZZ 0 X 605.57 X
63078   1 ZZZ 0 X 615.20 X
63081   1 90 2 X 5,670.89 X
63081   4 90 2 X 5,994.90 X
63081   3 90 2 X 6,018.91 X
63081   2 90 2 X 6,175.28 X
63082   4 ZZZ 0 X 1,058.34 X
63082   3 ZZZ 0 X 1,071.53 X
63082   2 ZZZ 0 X 1,165.52 X
63082   1 ZZZ 0 X 1,188.25 X
63085   4 90 2 X 5,017.27 X
63085   3 90 2 X 5,789.41 X
63085   2 90 2 X 5,891.47 X
63085   1 90 2 X 6,214.55 X
63086   4 ZZZ 0 X 836.08 X
63086   3 ZZZ 0 X 846.51 X
63086   1 ZZZ 0 X 944.62 X
63086   2 ZZZ 0 X 1,047.85 X
63087   4 90 2 X 5,328.88 X
63087   3 90 2 X 5,393.30 X
63087   2 90 2 X 5,802.24 X
63087   1 90 2 X 5,901.27 X
63088   4 ZZZ 0 X 1,036.81 X
63088   3 ZZZ 0 X 1,049.74 X
63088   2 ZZZ 0 X 1,141.13 X
63088   1 ZZZ 0 X 1,163.20 X
63090   4 90 2 X 5,295.52 X
63090   3 90 2 X 5,360.23 X
63090   2 90 2 X 5,774.14 X
63090   1 90 2 X 5,874.26 X
63091   4 ZZZ 0 X 547.18 X
63091   3 ZZZ 0 X 553.71 X
63091   2 ZZZ 0 X 593.91 X
63091   1 ZZZ 0 X 603.62 X
63101   2 90 2 X 3,763.57 X
63101   3 90 2 X 3,763.57 X
63101   4 90 2 X 3,763.57 X
63101   1 90 2 X 4,272.49 X
63102   2 90 2 X 3,763.57 X
63102   3 90 2 X 3,763.57 X
63102   4 90 2 X 3,763.57 X
63102   1 90 2 X 4,272.49 X
63103   2 ZZZ 0 X 439.75 X
63103   3 ZZZ 0 X 439.75 X
63103   4 ZZZ 0 X 439.75 X
63103   1 ZZZ 0 X 500.66 X
63170   4 90 2 X 3,543.81 X
63170   3 90 2 X 4,691.69 X
63170   2 90 2 X 4,708.53 X
63170   1 90 2 X 4,947.26 X
63172   4 90 2 X 3,771.41 X
63172   3 90 2 X 3,818.12 X
63172   2 90 2 X 4,228.43 X
63172   1 90 2 X 4,351.51 X
63173   4 90 2 X 3,318.06 X
63173   3 90 2 X 3,357.69 X
63173   2 90 2 X 3,558.17 X
63173   1 90 2 X 3,606.59 X
63185   4 90 2 X 2,837.74 X
63185   3 90 2 X 3,015.00 X
63185   2 90 2 X 3,105.19 X
63185   1 90 2 X 3,161.62 X
63190   4 90 2 X 3,593.14 X
63190   3 90 2 X 3,637.20 X
63190   2 90 2 X 3,943.59 X
63190   1 90 2 X 4,017.79 X
63191   3 90 2 X 2,821.90 X
63191   2 90 2 X 3,017.54 X
63191   4 90 2 X 3,033.65 X
63191   1 90 2 X 3,064.91 X
63194   4 90 2 X 2,897.59 X
63194   3 90 2 X 2,931.27 X
63194   2 90 2 X 3,134.61 X
63194   1 90 2 X 3,183.95 X
63195   4 90 2 X 2,915.99 X
63195   3 90 2 X 2,950.60 X
63195   2 90 2 X 3,147.97 X
63195   1 90 2 X 3,195.72 X
63196   4 90 2 X 3,345.08 X
63196   3 90 2 X 3,385.07 X
63196   2 90 2 X 3,587.31 X
63196   1 90 2 X 3,636.18 X
63197   4 90 2 X 3,205.48 X
63197   3 90 2 X 3,242.70 X
63197   2 90 2 X 3,469.08 X
63197   1 90 2 X 3,523.95 X
63198   4 90 2 X 3,700.14 X
63198   3 90 2 X 3,742.79 X
63198   2 90 2 X 4,009.99 X
63198   1 90 2 X 4,074.81 X
63199   4 90 2 X 4,211.49 X
63199   3 90 2 X 4,262.81 X
63199   2 90 2 X 4,535.03 X
63199   1 90 2 X 4,600.73 X
63200   3 90 2 X 1,833.98 X
63200   2 90 2 X 1,882.72 X
63200   1 90 2 X 2,027.83 X
63200   4 90 2 X 2,819.41 X
63250   2 90 2 X 5,353.90 X
63250   1 90 2 X 5,607.50 X
63250   4 90 2 X 6,337.78 X
63250   3 90 2 X 6,411.03 X
63251   4 90 2 X 5,823.82 X
63251   3 90 2 X 5,889.56 X
63251   2 90 2 X 6,273.23 X
63251   1 90 2 X 6,366.49 X
63252   4 90 2 X 6,402.62 X
63252   2 90 2 X 6,412.86 X
63252   3 90 2 X 6,476.42 X
63252   1 90 2 X 7,050.58 X
63265   4 90 2 X 4,033.61 X
63265   3 90 2 X 4,082.60 X
63265   2 90 2 X 4,403.17 X
63265   1 90 2 X 4,480.70 X
63266   4 90 2 X 4,373.10 X
63266   3 90 2 X 4,426.63 X
63266   2 90 2 X 4,785.02 X
63266   1 90 2 X 4,871.84 X
63267   4 90 2 X 3,741.15 X
63267   3 90 2 X 3,787.08 X
63267   2 90 2 X 4,111.77 X
63267   1 90 2 X 4,190.32 X
63268   4 90 2 X 2,847.25 X
63268   3 90 2 X 2,880.07 X
63268   2 90 2 X 3,085.85 X
63268   1 90 2 X 3,135.82 X
63270   4 90 2 X 4,091.21 X
63270   3 90 2 X 4,138.52 X
63270   2 90 2 X 4,429.90 X
63270   1 90 2 X 5,262.66 X
63271   4 90 2 X 4,949.64 X
63271   3 90 2 X 5,009.53 X
63271   2 90 2 X 5,905.76 X
63271   1 90 2 X 6,100.54 X
63272   4 90 2 X 4,492.50 X
63272   3 90 2 X 4,546.17 X
63272   2 90 2 X 4,895.97 X
63272   1 90 2 X 4,980.68 X
63273   4 90 2 X 3,818.17 X
63273   3 90 2 X 3,862.80 X
63273   2 90 2 X 4,133.62 X
63273   1 90 2 X 4,199.26 X
63275   3 90 2 X 5,503.60 X
63275   2 90 2 X 5,617.24 X
63275   4 90 2 X 5,760.13 X
63275   1 90 2 X 5,861.00 X
63276   4 90 2 X 5,401.40 X
63276   3 90 2 X 5,434.96 X
63276   2 90 2 X 5,514.38 X
63276   1 90 2 X 5,769.01 X
63277   4 90 2 X 4,308.05 X
63277   3 90 2 X 4,317.39 X
63277   2 90 2 X 4,562.08 X
63277   1 90 2 X 4,645.09 X
63278   4 90 2 X 4,114.50 X
63278   3 90 2 X 5,259.93 X
63278   2 90 2 X 5,291.48 X
63278   1 90 2 X 6,361.95 X
63280   3 90 2 X 5,630.45 X
63280   2 90 2 X 5,803.63 X
63280   4 90 2 X 5,941.52 X
63280   1 90 2 X 6,048.12 X
63281   4 90 2 X 5,187.64 X
63281   3 90 2 X 5,462.20 X
63281   2 90 2 X 5,658.76 X
63281   1 90 2 X 5,757.68 X
63282   4 90 2 X 4,705.10 X
63282   2 90 2 X 4,721.74 X
63282   3 90 2 X 4,761.30 X
63282   1 90 2 X 4,807.86 X
63283   4 90 2 X 4,032.60 X
63283   3 90 2 X 4,079.83 X
63283   2 90 2 X 4,372.46 X
63283   1 90 2 X 4,443.40 X
63285   4 90 2 X 5,574.30 X
63285   3 90 2 X 5,638.75 X
63285   2 90 2 X 6,028.24 X
63285   1 90 2 X 6,122.73 X
63286   4 90 2 X 5,951.65 X
63286   3 90 2 X 6,022.09 X
63286   2 90 2 X 6,450.69 X
63286   1 90 2 X 6,554.60 X