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2021 Workers' Compensation Part B Fee Schedule

63287-64766

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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
63287   2 90 2 X 5,318.05 X
63287   4 90 2 X 5,700.48 X
63287   3 90 2 X 5,766.86 X
63287   1 90 2 X 6,261.28 X
63290   4 90 2 X 5,888.91 X
63290   3 90 2 X 5,957.96 X
63290   2 90 2 X 6,369.62 X
63290   1 90 2 X 6,469.35 X
63295   2 ZZZ 0 X 543.82 X
63295   3 ZZZ 0 X 543.82 X
63295   4 ZZZ 0 X 543.82 X
63295   1 ZZZ 0 X 617.67 X
63300   4 90 2 X 3,703.78 X
63300   3 90 2 X 5,526.29 X
63300   2 90 2 X 5,619.69 X
63300   1 90 2 X 5,642.28 X
63301   4 90 2 X 4,153.96 X
63301   3 90 2 X 4,201.86 X
63301   2 90 2 X 4,502.07 X
63301   1 90 2 X 4,574.88 X
63302   4 90 2 X 4,397.59 X
63302   1 90 2 X 4,813.72 X
63302   3 90 2 X 5,789.87 X
63302   2 90 2 X 5,912.66 X
63303   4 90 2 X 4,445.54 X
63303   3 90 2 X 4,496.36 X
63303   2 90 2 X 4,796.38 X
63303   1 90 2 X 6,650.30 X
63304   4 90 2 X 4,570.32 X
63304   3 90 2 X 4,625.05 X
63304   2 90 2 X 4,901.07 X
63304   1 90 2 X 4,967.84 X
63305   4 90 2 X 4,903.92 X
63305   3 90 2 X 4,961.40 X
63305   1 90 2 X 5,380.74 X
63305   2 90 2 X 6,817.56 X
63306   4 90 2 X 4,879.47 X
63306   3 90 2 X 4,937.84 X
63306   2 90 2 X 5,232.18 X
63306   1 90 2 X 5,303.30 X
63307   4 90 2 X 4,998.77 X
63307   3 90 2 X 5,059.14 X
63307   2 90 2 X 5,374.45 X
63307   1 90 2 X 5,450.59 X
63308   4 ZZZ 0 X 884.45 X
63308   3 ZZZ 0 X 894.78 X
63308   2 ZZZ 0 X 957.87 X
63308   1 ZZZ 0 X 973.20 X
63600   4 90 2 X 2,178.92 X
63600   3 90 2 X 2,364.00 X
63600   1 90 2 X 2,429.52 X
63600   2 90 2 X 2,518.06 X
63610     0 2 X * X
63620   2 90 0 X 1,100.97 X
63620   3 90 0 X 1,100.97 X
63620   4 90 0 X 1,100.97 X
63620   1 90 0 X 1,253.38 X
63621   2 ZZZ 0 X 348.32 X
63621   3 ZZZ 0 X 348.32 X
63621   4 ZZZ 0 X 348.32 X
63621   1 ZZZ 0 X 391.01 X
63650   4 90 2 X 1,508.01 X
63650   3 90 2 X 1,526.42 X
63650   2 90 2 X 1,816.32 X
63650   1 90 2 X 1,831.59 X
63655   4 90 2 X 2,662.59 X
63655   3 90 2 X 2,696.37 X
63655   2 90 2 X 2,960.44 X
63655   1 90 2 X 3,024.25 X
63661   2 10 2 X 766.46 436.59
63661   3 10 2 X 766.46 436.59
63661   4 10 2 X 766.46 436.59
63661   1 10 2 X 864.39 473.15
63662   2 90 2 X 1,009.95 X
63662   3 90 2 X 1,009.95 X
63662   4 90 2 X 1,009.95 X
63662   1 90 2 X 1,120.71 X
63663   2 10 2 X 1,142.46 680.41
63663   3 10 2 X 1,142.46 680.41
63663   4 10 2 X 1,142.46 680.41
63663   1 10 2 X 1,300.67 752.69
63664   2 90 2 X 1,052.24 X
63664   3 90 2 X 1,052.24 X
63664   4 90 2 X 1,052.24 X
63664   1 90 2 X 1,167.37 X
63685   4 90 2 X 1,329.93 X
63685   3 90 2 X 1,394.35 X
63685   2 90 2 X 1,459.25 X
63685   1 90 2 X 1,486.61 X
63688   2 90 2 X 1,032.85 X
63688   1 90 2 X 1,046.30 X
63688   4 90 2 X 1,077.96 X
63688   3 90 2 X 1,091.19 X
63700   4 90 2 X 2,719.70 X
63700   3 90 2 X 2,756.27 X
63700   2 90 2 X 2,943.42 X
63700   1 90 2 X 3,034.16 X
63702   4 90 2 X 3,059.81 X
63702   3 90 2 X 3,100.92 X
63702   2 90 2 X 3,311.31 X
63702   1 90 2 X 3,413.36 X
63704   4 90 2 X 3,398.98 X
63704   3 90 2 X 3,444.59 X
63704   2 90 2 X 3,678.41 X
63704   1 90 2 X 3,791.82 X
63706   4 90 2 X 3,909.56 X
63706   3 90 2 X 3,962.05 X
63706   2 90 2 X 4,230.84 X
63706   1 90 2 X 4,361.22 X
63707   2 90 2 X 3,515.94 X
63707   3 90 2 X 3,768.86 X
63707   1 90 2 X 3,802.65 X
63707   4 90 2 X 3,812.39 X
63709   3 90 2 X 2,978.14 X
63709   4 90 2 X 3,785.93 X
63709   1 90 2 X 3,842.94 X
63709   2 90 2 X 3,948.59 X
63710   4 90 2 X 2,144.66 X
63710   3 90 2 X 2,169.77 X
63710   2 90 2 X 2,314.86 X
63710   1 90 2 X 2,350.08 X
63740   4 90 2 X 2,468.43 X
63740   3 90 2 X 2,850.64 X
63740   2 90 2 X 2,945.43 X
63740   1 90 2 X 2,968.36 X
63741   4 90 2 X 1,824.67 X
63741   3 90 2 X 1,847.26 X
63741   2 90 2 X 2,021.29 X
63741   1 90 2 X 2,063.43 X
63744   4 90 2 X 1,462.78 X
63744   2 90 2 X 2,551.81 X
63744   3 90 2 X 2,560.42 X
63744   1 90 2 X 2,676.56 X
63746   4 90 2 X 1,072.13 X
63746   3 90 2 X 1,084.92 X
63746   1 90 2 X 1,191.52 X
63746   2 90 2 X 2,306.64 X
64400   2 0 2 X 123.52 106.90
64400   3 0 2 X 129.03 112.28
64400   4 0 2 X 131.64 114.67
64400   1 0 2 X 141.17 122.07
64405   2 0 2 X 154.43 131.54
64405   4 0 2 X 170.89 145.54
64405   1 0 2 X 172.33 146.44
64405   3 0 2 X 175.50 149.46
64408   2 0 2 X 195.01 X
64408   1 0 2 X 197.62 X
64408   4 0 2 X 211.15 X
64408   3 0 2 X 213.67 X
64415   4 0 2 X 143.23 X
64415   3 0 2 X 144.18 X
64415   2 0 2 X 145.54 X
64415   1 0 2 X 147.61 X
64416   2 0 2 X 293.93 X
64416   3 0 2 X 293.93 X
64416   4 0 2 X 293.93 X
64416   1 0 2 X 314.28 X
64417   3 0 2 X 171.85 X
64417   4 0 2 X 176.01 X
64417   1 0 2 X 178.67 X
64417   2 0 2 X 183.10 X
64418   4 0 2 X 163.70 135.21
64418   3 0 2 X 164.94 136.61
64418   2 0 2 X 170.73 141.19
64418   1 0 2 X 172.66 142.97
64420   3 0 2 X 157.97 X
64420   2 0 2 X 166.24 X
64420   4 0 2 X 173.12 X
64420   1 0 2 X 180.24 X
64421   3 0 2 X 224.45 X
64421   2 0 2 X 238.52 X
64421   1 0 2 X 241.93 X
64421   4 0 2 X 245.86 X
64425   4 0 2 X 157.99 139.98
64425   2 0 2 X 194.66 172.50
64425   1 0 2 X 201.08 177.44
64425   3 0 2 X 203.50 180.17
64430   4 0 2 X 202.15 X
64430   3 0 2 X 204.40 X
64430   2 0 2 X 232.61 X
64430   1 0 2 X 238.20 X
64435   3 0 2 X 164.64 X
64435   2 0 2 X 170.12 X
64435   4 0 2 X 179.10 X
64435   1 0 2 X 184.84 X
64445   2 0 2 X 152.40 136.18
64445   3 0 2 X 159.92 142.71
64445   4 0 2 X 162.04 144.99
64445   1 0 2 X 166.24 148.13
64446   2 0 2 X 302.59 X
64446   3 0 2 X 302.59 X
64446   4 0 2 X 302.59 X
64446   1 0 2 X 326.89 X
64447   2 10 2 X 141.24 X
64447   3 10 2 X 141.24 X
64447   4 10 2 X 141.24 X
64447   1 10 2 X 154.31 X
64448   2 0 2 X 278.19 X
64448   3 0 2 X 278.19 X
64448   4 0 2 X 278.19 X
64448   1 0 2 X 300.70 X
64449   2 10 2 X 275.30 X
64449   3 10 2 X 275.30 X
64449   4 10 2 X 275.30 X
64449   1 10 2 X 295.20 X
64450   4 0 2 X 145.89 127.16
64450   3 0 2 X 154.53 134.71
64450   1 0 2 X 157.56 136.97
64450   2 0 2 X 163.91 143.11
64451   2 0 2 X 243.20 95.30
64451   3 0 2 X 243.20 95.30
64451   4 0 2 X 243.20 95.30
64451   1 0 2 X 273.34 103.04
64454   2 0 2 X 245.59 98.10
64454   3 0 2 X 245.59 98.10
64454   4 0 2 X 245.59 98.10
64454   1 0 2 X 276.11 106.27
64455   2 0 2 X 73.21 58.94
64455   3 0 2 X 73.21 58.94
64455   4 0 2 X 73.21 58.94
64455   1 0 2 X 81.44 64.49
64461   2 0 2 X 189.55 114.39
64461   3 0 2 X 189.55 114.39
64461   4 0 2 X 189.55 114.39
64461   1 0 2 X 210.42 122.47
64462   2 ZZZ 0 X 107.74 72.11
64462   3 ZZZ 0 X 107.74 72.11
64462   4 ZZZ 0 X 107.74 72.11
64462   1 ZZZ 0 X 118.91 77.24
64463   2 0 2 X 205.76 111.06
64463   3 0 2 X 205.76 111.06
64463   4 0 2 X 205.76 111.06
64463   1 0 2 X 228.85 118.06
64479   2 0 2 X 437.49 213.04
64479   3 0 2 X 437.49 213.04
64479   4 0 2 X 437.49 213.04
64479   1 0 2 X 494.66 232.13
64480   2 ZZZ 0 X 392.71 147.59
64480   3 ZZZ 0 X 392.71 147.59
64480   4 ZZZ 0 X 392.71 147.59
64480   1 ZZZ 0 X 447.54 160.82
64483   2 0 2 X 403.84 182.15
64483   3 0 2 X 403.84 182.15
64483   4 0 2 X 403.84 182.15
64483   1 0 2 X 456.54 197.28
64484   2 ZZZ 0 X 370.65 127.64
64484   3 ZZZ 0 X 370.65 127.64
64484   4 ZZZ 0 X 370.65 127.64
64484   1 ZZZ 0 X 423.56 139.30
64486   2 0 2 X 160.62 85.98
64486   3 0 2 X 160.62 85.98
64486   4 0 2 X 160.62 85.98
64486   1 0 2 X 179.42 92.08
64487   2 0 2 X 196.23 98.79
64487   3 0 2 X 196.23 98.79
64487   4 0 2 X 196.23 98.79
64487   1 0 2 X 219.62 105.63
64488   2 0 2 X 197.52 106.78
64488   3 0 2 X 197.52 106.78
64488   4 0 2 X 197.52 106.78
64488   1 0 2 X 220.19 114.05
64489   2 0 2 X 273.30 119.09
64489   3 0 2 X 273.30 119.09
64489   4 0 2 X 273.30 119.09
64489   1 0 2 X 307.50 127.10
64490   2 0 2 X 262.16 158.24
64490   3 0 2 X 262.16 158.24
64490   4 0 2 X 262.16 158.24
64490   1 0 2 X 297.42 174.20
64491   2 ZZZ 0 X 133.20 91.34
64491   3 ZZZ 0 X 133.20 91.34
64491   4 ZZZ 0 X 133.20 91.34
64491   1 ZZZ 0 X 149.36 99.73
64492   2 ZZZ 0 X 134.71 92.85
64492   3 ZZZ 0 X 134.71 92.85
64492   4 ZZZ 0 X 134.71 92.85
64492   1 ZZZ 0 X 151.17 101.52
64493   2 0 2 X 234.06 134.18
64493   3 0 2 X 234.06 134.18
64493   4 0 2 X 234.06 134.18
64493   1 0 2 X 266.21 147.75
64494   2 ZZZ 0 X 120.82 77.96
64494   3 ZZZ 0 X 120.82 77.96
64494   4 ZZZ 0 X 120.82 77.96
64494   1 ZZZ 0 X 135.75 84.89
64495   2 ZZZ 0 X 122.33 79.46
64495   3 ZZZ 0 X 122.33 79.46
64495   4 ZZZ 0 X 122.33 79.46
64495   1 ZZZ 0 X 137.54 86.70
64505   2 0 2 X 156.28 134.36
64505   3 0 2 X 162.04 140.26
64505   4 0 2 X 170.69 147.59
64505   1 0 2 X 173.79 149.67
64510   3 0 2 X 226.53 X
64510   4 0 2 X 228.83 X
64510   2 0 2 X 230.80 X
64510   1 0 2 X 239.03 X
64517   2 0 2 X 332.73 215.19
64517   3 0 2 X 332.73 215.19
64517   4 0 2 X 332.73 215.19
64517   1 0 2 X 372.21 233.96
64520   2 0 2 X 200.75 X
64520   1 0 2 X 207.47 X
64520   4 0 2 X 233.84 X
64520   3 0 2 X 233.93 X
64530   4 0 2 X 249.84 X
64530   3 0 2 X 252.69 X
64530   1 0 2 X 266.31 X
64530   2 0 2 X 290.86 X
64553     10 2 X * X
64555   4 10 2 X 227.69 X
64555   2 10 2 X 645.99 X
64555   1 10 2 X 675.75 X
64555   3 10 2 X 698.90 X
64561   2 10 2 X 1,464.25 720.62
64561   3 10 2 X 1,464.25 720.62
64561   4 10 2 X 1,464.25 720.62
64561   1 10 2 X 1,659.28 785.25
64566   2 0 2 X 185.79 44.29
64566   3 0 2 X 185.79 44.29
64566   4 0 2 X 185.79 44.29
64566   1 0 2 X 207.63 47.51
64568   2 90 2 X 943.59 X
64568   3 90 2 X 943.59 X
64568   4 90 2 X 943.59 X
64568   1 90 2 X 1,038.26 X
64569   2 90 2 X 950.05 X
64569   3 90 2 X 950.05 X
64569   4 90 2 X 950.05 X
64569   1 90 2 X 1,069.80 X
64570   2 90 2 X 838.71 X
64570   3 90 2 X 838.71 X
64570   4 90 2 X 838.71 X
64570   1 90 2 X 957.12 X
64575   4 90 2 X 681.53 X
64575   3 90 2 X 689.58 X
64575   2 90 2 X 731.36 X
64575   1 90 2 X 741.49 X
64580     90 2 X * X
64581   2 90 2 X 1,389.78 X
64581   3 90 2 X 1,389.78 X
64581   4 90 2 X 1,389.78 X
64581   1 90 2 X 1,514.96 X
64585   4 10 2 X 271.12 X
64585   3 10 2 X 274.23 X
64585   2 10 2 X 287.37 X
64585   1 10 2 X 290.57 X
64590   4 10 2 X 399.95 X
64590   3 10 2 X 404.63 X
64590   2 10 2 X 433.80 X
64590   1 10 2 X 440.82 X
64595   4 10 2 X 265.29 X
64595   3 10 2 X 268.33 X
64595   2 10 2 X 286.50 X
64595   1 10 2 X 290.97 X
64600   2 10 2 X 554.23 X
64600   3 10 2 X 642.42 X
64600   4 10 2 X 653.83 X
64600   1 10 2 X 667.23 X
64605   4 10 2 X 619.64 X
64605   3 10 2 X 626.06 X
64605   2 10 2 X 657.90 X
64605   1 10 2 X 1,011.02 X
64610   4 10 2 X 1,812.55 X
64610   3 10 2 X 1,819.03 X
64610   2 10 2 X 1,833.42 X
64610   1 10 2 X 1,872.52 X
64611   2 10 2 X 147.26 133.69
64611   3 10 2 X 147.26 133.69
64611   4 10 2 X 147.26 133.69
64611   1 10 2 X 166.02 150.66
64612   4 10 2 X 310.88 X
64612   3 10 2 X 314.61 X
64612   2 10 2 X 333.36 X
64612   1 10 2 X 337.85 X
64615   2 10 2 X 196.56 178.40
64615   3 10 2 X 196.56 178.40
64615   4 10 2 X 196.56 178.40
64615   1 10 2 X 224.35 203.29
64616   2 10 2 X 166.14 147.59
64616   3 10 2 X 166.14 147.59
64616   4 10 2 X 166.14 147.59
64616   1 10 2 X 187.04 165.44
64617   2 10 2 X 253.06 156.31
64617   3 10 2 X 253.06 156.31
64617   4 10 2 X 253.06 156.31
64617   1 10 2 X 283.56 170.81
64620   2 10 2 X 281.94 X
64620   3 10 2 X 286.55 X
64620   1 10 2 X 309.61 X
64620   4 10 2 X 330.17 X
64624   2 10 2 X 468.65 175.28
64624   3 10 2 X 468.65 175.28
64624   4 10 2 X 468.65 175.28
64624   1 10 2 X 528.61 190.77
64625   2 10 2 X 573.58 231.85
64625   3 10 2 X 573.58 231.85
64625   4 10 2 X 573.58 231.85
64625   1 10 2 X 645.44 251.92
64630   4 10 2 X 418.82 X
64630   3 10 2 X 423.44 X
64630   2 10 2 X 452.66 X
64630   1 10 2 X 459.77 X
64632   2 10 2 X 117.54 101.21
64632   3 10 2 X 117.54 101.21
64632   4 10 2 X 117.54 101.21
64632   1 10 2 X 129.09 109.70
64633   2 10 2 X 613.86 329.10
64633   3 10 2 X 613.86 329.10
64633   4 10 2 X 613.86 329.10
64633   1 10 2 X 689.78 359.49
64634   2 ZZZ 0 X 278.99 99.28
64634   3 ZZZ 0 X 278.99 99.28
64634   4 ZZZ 0 X 278.99 99.28
64634   1 ZZZ 0 X 315.91 107.48
64635   2 10 2 X 603.23 322.47
64635   3 10 2 X 603.23 322.47
64635   4 10 2 X 603.23 322.47
64635   1 10 2 X 677.71 352.09
64636   2 ZZZ 0 X 250.85 86.34
64636   3 ZZZ 0 X 250.85 86.34
64636   4 ZZZ 0 X 250.85 86.34
64636   1 ZZZ 0 X 284.08 93.26
64640   4 10 2 X 246.94 218.83
64640   3 10 2 X 247.11 219.38
64640   2 10 2 X 254.76 224.68
64640   1 10 2 X 258.59 228.49
64642   2 0 2 X 187.06 146.83
64642   3 0 2 X 187.06 146.83
64642   4 0 2 X 187.06 146.83
64642   1 0 2 X 209.29 162.41
64643   2 ZZZ 0 X 123.76 98.87
64643   3 ZZZ 0 X 123.76 98.87
64643   4 ZZZ 0 X 123.76 98.87
64643   1 ZZZ 0 X 137.71 108.72
64644   2 0 2 X 213.19 160.27
64644   3 0 2 X 213.19 160.27
64644   4 0 2 X 213.19 160.27
64644   1 0 2 X 238.70 177.05
64645   2 ZZZ 0 X 150.91 113.36
64645   3 ZZZ 0 X 150.91 113.36
64645   4 ZZZ 0 X 150.91 113.36
64645   1 ZZZ 0 X 168.51 124.80
64646   2 0 2 X 201.36 158.82
64646   3 0 2 X 201.36 158.82
64646   4 0 2 X 201.36 158.82
64646   1 0 2 X 225.06 175.53
64647   2 0 2 X 233.17 183.42
64647   3 0 2 X 233.17 183.42
64647   4 0 2 X 233.17 183.42
64647   1 0 2 X 260.43 202.48
64650   2 0 2 X 95.12 63.23
64650   3 0 2 X 95.12 63.23
64650   4 0 2 X 95.12 63.23
64650   1 0 2 X 108.88 69.84
64653   2 0 2 X 110.09 79.89
64653   3 0 2 X 110.09 79.89
64653   4 0 2 X 110.09 79.89
64653   1 0 2 X 125.37 88.39
64680   4 10 2 X 374.65 X
64680   1 10 2 X 538.42 X
64680   3 10 2 X 544.41 X
64680   2 10 2 X 550.13 X
64681   2 10 2 X 814.36 389.62
64681   3 10 2 X 814.36 389.62
64681   4 10 2 X 814.36 389.62
64681   1 10 2 X 925.79 426.53
64702   3 90 2 X 890.89 X
64702   4 90 2 X 897.97 X
64702   2 90 2 X 925.43 X
64702   1 90 2 X 984.64 X
64704   3 90 2 X 937.49 X
64704   4 90 2 X 995.95 X
64704   2 90 2 X 1,046.35 X
64704   1 90 2 X 1,128.31 X
64708   4 90 2 X 1,251.06 X
64708   3 90 2 X 1,266.58 X
64708   2 90 2 X 1,369.35 X
64708   1 90 2 X 1,394.22 X
64712   4 90 2 X 1,582.62 X
64712   3 90 2 X 1,602.12 X
64712   2 90 2 X 1,741.75 X
64712   1 90 2 X 1,767.90 X
64713   4 90 2 X 1,887.15 X
64713   3 90 2 X 1,992.51 X
64713   2 90 2 X 2,052.72 X
64713   1 90 2 X 2,087.38 X
64714   4 90 2 X 1,538.52 X
64714   3 90 2 X 1,555.76 X
64714   2 90 2 X 1,668.21 X
64714   1 90 2 X 2,223.37 X
64716   4 90 2 X 993.88 X
64716   3 90 2 X 1,005.78 X
64716   2 90 2 X 1,071.54 X
64716   1 90 2 X 1,087.51 X
64718   4 90 2 X 1,200.16 X
64718   3 90 2 X 1,204.22 X
64718   2 90 2 X 1,276.55 X
64718   1 90 2 X 1,299.22 X
64719   4 90 2 X 964.33 X
64719   3 90 2 X 966.24 X
64719   2 90 2 X 1,036.81 X
64719   1 90 2 X 1,056.89 X
64721   4 90 2 X 898.77 X
64721   3 90 2 X 901.77 X
64721   2 90 2 X 973.75 X
64721   1 90 2 X 983.23 X
64722   4 90 2 X 1,278.10 X
64722   3 90 2 X 1,355.03 X
64722   1 90 2 X 1,495.45 X
64722   2 90 2 X 1,497.17 X
64726   4 90 2 X 423.94 X
64726   3 90 2 X 428.26 X
64726   2 90 2 X 443.68 X
64726   1 90 2 X 447.41 X
64727   4 ZZZ 0 X 1,200.71 X
64727   3 ZZZ 0 X 1,203.81 X
64727   2 ZZZ 0 X 1,223.34 X
64727   1 ZZZ 0 X 1,228.10 X
64732   4 90 2 X 807.03 X
64732   3 90 2 X 864.15 X
64732   2 90 2 X 878.40 X
64732   1 90 2 X 909.70 X
64734   4 90 2 X 869.62 X
64734   1 90 2 X 957.32 X
64734   3 90 2 X 1,138.47 X
64734   2 90 2 X 1,164.49 X
64736   4 90 2 X 814.08 X
64736   3 90 2 X 824.34 X
64736   2 90 2 X 874.36 X
64736   1 90 2 X 886.42 X
64738   4 90 2 X 975.89 X
64738   3 90 2 X 987.88 X
64738   2 90 2 X 1,146.34 X
64738   1 90 2 X 1,416.65 X
64740   4 90 2 X 973.73 X
64740   3 90 2 X 985.69 X
64740   2 90 2 X 1,050.06 X
64740   1 90 2 X 1,065.64 X
64742   4 90 2 X 998.19 X
64742   3 90 2 X 1,010.48 X
64742   2 90 2 X 1,067.45 X
64742   1 90 2 X 1,081.26 X
64744   4 90 2 X 1,058.18 X
64744   3 90 2 X 1,071.12 X
64744   2 90 2 X 1,170.02 X
64744   1 90 2 X 1,180.55 X
64746   4 90 2 X 896.41 X
64746   3 90 2 X 900.68 X
64746   2 90 2 X 970.69 X
64746   1 90 2 X 986.21 X
64755   4 90 2 X 2,278.07 X
64755   3 90 2 X 2,304.41 X
64755   2 90 2 X 2,482.39 X
64755   1 90 2 X 2,759.80 X
64760   4 90 2 X 1,291.45 X
64760   2 90 2 X 1,418.20 X
64760   1 90 2 X 1,445.21 X
64760   3 90 2 X 1,794.15 X
64763   4 90 2 X 1,096.31 X
64763   3 90 2 X 1,108.96 X
64763   2 90 2 X 1,186.98 X
64763   1 90 2 X 1,205.85 X
64766   4 90 2 X 1,424.17 X
64766   3 90 2 X 1,440.90 X
64766   2 90 2 X 1,543.57 X
64766   1 90 2 X 1,568.50 X