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Unemployment Benefits
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Individual Services
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Misclassified Workers
Businesses
Businesses
Employer UC Info
Finding Skilled Workers
Disability Services
Workforce Development
Workers' Compensation Services
Labor-Management Relations
Pennsylvania Business One-Stop
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Health Care Services Review
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Fee Schedule
>
Fee Schedule 92627-93312
Begin Main Content Area
Page Content
2021 Workers' Compensation Part B Fee Schedule
92627-93312
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
92627
2
XXX
0
X
33.79
X
92627
3
XXX
0
X
33.79
X
92627
4
XXX
0
X
33.79
X
92627
1
XXX
0
X
42.85
X
92630
XXX
9
X
*
X
92633
XXX
9
X
*
X
92640
2
XXX
0
X
75.16
X
92640
3
XXX
0
X
75.16
X
92640
4
XXX
0
X
75.16
X
92640
1
XXX
0
X
92.18
X
92650
X
*
X
92651
2
XXX
0
X
99.30
X
92651
3
XXX
0
X
99.30
X
92651
4
XXX
0
X
99.30
X
92651
1
XXX
0
X
109.70
X
92652
2
XXX
0
X
130.42
X
92652
3
XXX
0
X
130.42
X
92652
4
XXX
0
X
130.42
X
92652
1
XXX
0
X
143.27
X
92653
2
XXX
0
X
95.36
X
92653
3
XXX
0
X
95.36
X
92653
4
XXX
0
X
95.36
X
92653
1
XXX
0
X
104.89
X
92700
XXX
9
X
#
X
92920
2
0
2
X
755.10
X
92920
3
0
2
X
755.10
X
92920
4
0
2
X
755.10
X
92920
1
0
2
X
839.38
X
92921
ZZZ
9
X
*
X
92924
2
0
2
X
897.72
X
92924
3
0
2
X
897.72
X
92924
4
0
2
X
897.72
X
92924
1
0
2
X
998.11
X
92925
ZZZ
9
X
*
X
92928
2
0
2
X
838.84
X
92928
3
0
2
X
838.84
X
92928
4
0
2
X
838.84
X
92928
1
0
2
X
932.78
X
92929
ZZZ
9
X
*
X
92933
2
0
2
X
938.06
X
92933
3
0
2
X
938.06
X
92933
4
0
2
X
938.06
X
92933
1
0
2
X
1,043.06
X
92934
ZZZ
9
X
*
X
92937
2
0
2
X
837.92
X
92937
3
0
2
X
837.92
X
92937
4
0
2
X
837.92
X
92937
1
0
2
X
931.81
X
92938
ZZZ
9
X
*
X
92941
2
0
2
X
939.96
X
92941
3
0
2
X
939.96
X
92941
4
0
2
X
939.96
X
92941
1
0
2
X
1,045.31
X
92943
2
0
2
X
939.96
X
92943
3
0
2
X
939.96
X
92943
4
0
2
X
939.96
X
92943
1
0
2
X
1,045.31
X
92944
ZZZ
9
X
*
X
92950
0
0
X
*
X
92953
4
0
0
X
121.41
X
92953
3
0
0
X
124.10
X
92953
2
0
0
X
130.93
X
92953
1
0
0
X
134.63
X
92960
4
0
0
X
353.19
X
92960
3
0
0
X
357.58
X
92960
2
0
0
X
410.23
X
92960
1
0
0
X
427.90
X
92961
2
0
9
X
473.08
X
92961
3
0
9
X
473.08
X
92961
4
0
9
X
473.08
X
92961
1
0
9
X
517.53
X
92970
0
0
X
*
X
92971
0
0
X
*
X
92973
2
ZZZ
0
X
324.91
X
92973
3
ZZZ
0
X
324.91
X
92973
4
ZZZ
0
X
324.91
X
92973
1
ZZZ
0
X
355.96
X
92974
2
ZZZ
0
X
353.06
X
92974
3
ZZZ
0
X
353.06
X
92974
4
ZZZ
0
X
353.06
X
92974
1
ZZZ
0
X
427.29
X
92975
3
0
2
X
1,180.67
X
92975
2
0
2
X
1,411.72
X
92975
1
0
2
X
1,509.80
X
92975
4
0
2
X
1,998.31
X
92977
4
XXX
0
X
398.97
X
92977
3
XXX
0
X
400.49
X
92977
2
XXX
0
X
435.05
X
92977
1
XXX
0
X
445.40
X
92978
26
3
ZZZ
0
X
209.83
X
92978
26
4
ZZZ
0
X
209.83
X
92978
26
2
ZZZ
0
X
215.63
X
92978
26
1
ZZZ
0
X
232.03
X
92978
TC
3
ZZZ
0
X
331.76
X
92978
TC
4
ZZZ
0
X
331.76
X
92978
TC
2
ZZZ
0
X
340.87
X
92978
TC
1
ZZZ
0
X
401.80
X
92978
3
ZZZ
0
X
541.59
X
92978
4
ZZZ
0
X
541.59
X
92978
2
ZZZ
0
X
556.50
X
92978
1
ZZZ
0
X
633.81
X
92979
TC
3
ZZZ
0
X
166.23
X
92979
TC
4
ZZZ
0
X
166.23
X
92979
26
3
ZZZ
0
X
167.76
X
92979
26
4
ZZZ
0
X
167.76
X
92979
TC
2
ZZZ
0
X
170.82
X
92979
26
2
ZZZ
0
X
172.41
X
92979
26
1
ZZZ
0
X
185.37
X
92979
TC
1
ZZZ
0
X
201.33
X
92979
3
ZZZ
0
X
334.00
X
92979
4
ZZZ
0
X
334.00
X
92979
2
ZZZ
0
X
343.26
X
92979
1
ZZZ
0
X
386.74
X
92986
90
2
X
*
X
92987
4
90
2
X
2,665.61
X
92987
3
90
2
X
2,702.74
X
92987
2
90
2
X
2,845.03
X
92987
1
90
2
X
2,941.49
X
92990
4
90
2
X
2,190.58
X
92990
3
90
2
X
2,216.37
X
92990
2
90
2
X
2,324.09
X
92990
1
90
2
X
2,821.78
X
92997
2
0
2
X
2,004.56
X
92997
3
0
2
X
2,004.56
X
92997
4
0
2
X
2,004.56
X
92997
1
0
2
X
2,274.04
X
92998
2
ZZZ
0
X
775.35
X
92998
3
ZZZ
0
X
775.35
X
92998
4
ZZZ
0
X
775.35
X
92998
1
ZZZ
0
X
864.00
X
93000
4
XXX
0
X
64.19
X
93000
3
XXX
0
X
65.13
X
93000
2
XXX
0
X
69.84
X
93000
1
XXX
0
X
70.94
X
93005
4
XXX
0
X
53.18
X
93005
2
XXX
0
X
61.26
X
93005
1
XXX
0
X
63.67
X
93005
3
XXX
0
X
67.62
X
93010
4
XXX
0
X
27.64
X
93010
3
XXX
0
X
27.96
X
93010
2
XXX
0
X
29.42
X
93010
1
XXX
0
X
29.83
X
93015
3
XXX
0
X
304.03
X
93015
4
XXX
0
X
305.17
X
93015
1
XXX
0
X
319.39
X
93015
2
XXX
0
X
320.06
X
93016
4
XXX
0
X
70.77
X
93016
3
XXX
0
X
71.64
X
93016
2
XXX
0
X
75.57
X
93016
1
XXX
0
X
76.53
X
93017
4
XXX
0
X
138.23
X
93017
2
XXX
0
X
152.88
X
93017
1
XXX
0
X
155.81
X
93017
3
XXX
0
X
174.85
X
93018
4
XXX
0
X
139.37
X
93018
3
XXX
0
X
141.64
X
93018
2
XXX
0
X
141.94
X
93018
1
XXX
0
X
144.44
X
93024
TC
4
XXX
0
X
93.02
X
93024
TC
3
XXX
0
X
94.55
X
93024
TC
2
XXX
0
X
103.19
X
93024
TC
1
XXX
0
X
105.20
X
93024
26
3
XXX
0
X
194.14
X
93024
26
2
XXX
0
X
203.07
X
93024
26
4
XXX
0
X
234.85
X
93024
3
XXX
0
X
248.21
X
93024
26
1
XXX
0
X
256.97
X
93024
2
XXX
0
X
262.12
X
93024
4
XXX
0
X
327.93
X
93024
1
XXX
0
X
362.17
X
93025
2
XXX
0
X
474.73
X
93025
3
XXX
0
X
474.73
X
93025
4
XXX
0
X
474.73
X
93025
1
XXX
0
X
554.56
X
93040
4
XXX
0
X
35.55
X
93040
3
XXX
0
X
35.97
X
93040
1
XXX
0
X
37.88
X
93040
2
XXX
0
X
38.36
X
93041
4
XXX
0
X
42.58
X
93041
1
XXX
0
X
44.89
X
93041
3
XXX
0
X
46.85
X
93041
2
XXX
0
X
50.98
X
93042
3
XXX
0
X
27.07
X
93042
4
XXX
0
X
27.38
X
93042
1
XXX
0
X
28.05
X
93042
2
XXX
0
X
28.46
X
93050
TC
2
XXX
6
X
10.89
X
93050
TC
3
XXX
6
X
10.89
X
93050
TC
4
XXX
6
X
10.89
X
93050
26
2
XXX
6
X
11.02
X
93050
26
3
XXX
6
X
11.02
X
93050
26
4
XXX
6
X
11.02
X
93050
26
1
XXX
6
X
11.75
X
93050
TC
1
XXX
6
X
12.79
X
93050
2
XXX
6
X
21.90
X
93050
3
XXX
6
X
21.90
X
93050
4
XXX
6
X
21.90
X
93050
1
XXX
6
X
24.55
X
93224
4
XXX
0
X
452.12
X
93224
3
XXX
0
X
460.30
X
93224
2
XXX
0
X
473.02
X
93224
1
XXX
0
X
478.13
X
93225
4
XXX
0
X
104.15
X
93225
3
XXX
0
X
106.47
X
93225
2
XXX
0
X
112.55
X
93225
1
XXX
0
X
114.73
X
93226
3
XXX
0
X
182.51
X
93226
4
XXX
0
X
188.18
X
93226
2
XXX
0
X
198.74
X
93226
1
XXX
0
X
202.57
X
93227
1
XXX
0
X
121.95
X
93227
4
XXX
0
X
134.09
X
93227
2
XXX
0
X
136.06
X
93227
3
XXX
0
X
140.35
X
93228
2
XXX
0
X
38.52
X
93228
3
XXX
0
X
38.52
X
93228
4
XXX
0
X
38.52
X
93228
1
XXX
0
X
41.16
X
93229
XXX
6
X
*
X
93241
X
#
X
93242
2
XXX
6
X
16.27
X
93242
3
XXX
6
X
16.27
X
93242
4
XXX
6
X
16.27
X
93242
1
XXX
6
X
18.84
X
93243
X
#
X
93244
2
XXX
0
X
27.45
X
93244
3
XXX
0
X
27.45
X
93244
4
XXX
0
X
27.45
X
93244
1
XXX
0
X
29.21
X
93245
X
#
X
93246
2
XXX
6
X
16.27
X
93246
3
XXX
6
X
16.27
X
93246
4
XXX
6
X
16.27
X
93246
1
XXX
6
X
18.84
X
93247
X
#
X
93248
2
XXX
0
X
30.16
X
93248
3
XXX
0
X
30.16
X
93248
4
XXX
0
X
30.16
X
93248
1
XXX
0
X
32.08
X
93260
TC
2
XXX
6
X
26.39
X
93260
TC
3
XXX
6
X
26.39
X
93260
TC
4
XXX
6
X
26.39
X
93260
TC
1
XXX
6
X
30.92
X
93260
26
2
XXX
6
X
59.32
X
93260
26
3
XXX
6
X
59.32
X
93260
26
4
XXX
6
X
59.32
X
93260
26
1
XXX
6
X
63.45
X
93260
2
XXX
6
X
85.69
X
93260
3
XXX
6
X
85.69
X
93260
4
XXX
6
X
85.69
X
93260
1
XXX
6
X
94.38
X
93261
TC
2
XXX
6
X
26.39
X
93261
TC
3
XXX
6
X
26.39
X
93261
TC
4
XXX
6
X
26.39
X
93261
TC
1
XXX
6
X
30.92
X
93261
26
2
XXX
6
X
51.78
X
93261
26
3
XXX
6
X
51.78
X
93261
26
4
XXX
6
X
51.78
X
93261
26
1
XXX
6
X
55.43
X
93261
2
XXX
6
X
78.17
X
93261
3
XXX
6
X
78.17
X
93261
4
XXX
6
X
78.17
X
93261
1
XXX
6
X
86.37
X
93264
2
XXX
0
X
59.53
42.79
93264
3
XXX
0
X
59.53
42.79
93264
4
XXX
0
X
59.53
42.79
93264
1
XXX
0
X
64.98
45.76
93268
4
XXX
0
X
380.58
X
93268
3
XXX
0
X
386.27
X
93268
2
XXX
0
X
419.74
X
93268
1
XXX
0
X
427.69
X
93270
4
XXX
0
X
100.34
X
93270
3
XXX
0
X
102.15
X
93270
2
XXX
0
X
112.02
X
93270
1
XXX
0
X
116.04
X
93271
4
XXX
0
X
194.91
X
93271
3
XXX
0
X
198.37
X
93271
2
XXX
0
X
218.46
X
93271
1
XXX
0
X
227.10
X
93272
4
XXX
0
X
79.45
X
93272
3
XXX
0
X
80.52
X
93272
2
XXX
0
X
85.48
X
93272
1
XXX
0
X
87.74
X
93278
XXX
0
X
*
X
93279
TC
2
XXX
0
X
28.38
X
93279
TC
3
XXX
0
X
28.38
X
93279
TC
4
XXX
0
X
28.38
X
93279
TC
1
XXX
0
X
34.41
X
93279
26
2
XXX
0
X
53.83
X
93279
26
3
XXX
0
X
53.83
X
93279
26
4
XXX
0
X
53.83
X
93279
26
1
XXX
0
X
58.11
X
93279
2
XXX
0
X
82.22
X
93279
3
XXX
0
X
82.22
X
93279
4
XXX
0
X
82.22
X
93279
1
XXX
0
X
92.52
X
93280
TC
2
XXX
0
X
32.35
X
93280
TC
3
XXX
0
X
32.35
X
93280
TC
4
XXX
0
X
32.35
X
93280
TC
1
XXX
0
X
38.94
X
93280
26
2
XXX
0
X
64.49
X
93280
26
3
XXX
0
X
64.49
X
93280
26
4
XXX
0
X
64.49
X
93280
26
1
XXX
0
X
69.66
X
93280
2
XXX
0
X
96.90
X
93280
3
XXX
0
X
96.90
X
93280
4
XXX
0
X
96.90
X
93280
1
XXX
0
X
108.62
X
93281
TC
2
XXX
0
X
38.06
X
93281
TC
3
XXX
0
X
38.06
X
93281
TC
4
XXX
0
X
38.06
X
93281
TC
1
XXX
0
X
45.88
X
93281
26
2
XXX
0
X
75.24
X
93281
26
3
XXX
0
X
75.24
X
93281
26
4
XXX
0
X
75.24
X
93281
26
1
XXX
0
X
81.17
X
93281
2
XXX
0
X
113.31
X
93281
3
XXX
0
X
113.31
X
93281
4
XXX
0
X
113.31
X
93281
1
XXX
0
X
127.07
X
93282
TC
2
XXX
0
X
34.51
X
93282
TC
3
XXX
0
X
34.51
X
93282
TC
4
XXX
0
X
34.51
X
93282
TC
1
XXX
0
X
41.66
X
93282
26
2
XXX
0
X
70.53
X
93282
26
3
XXX
0
X
70.53
X
93282
26
4
XXX
0
X
70.53
X
93282
26
1
XXX
0
X
76.26
X
93282
2
XXX
0
X
105.02
X
93282
3
XXX
0
X
105.02
X
93282
4
XXX
0
X
105.02
X
93282
1
XXX
0
X
117.89
X
93283
TC
2
XXX
0
X
39.07
X
93283
TC
3
XXX
0
X
39.07
X
93283
TC
4
XXX
0
X
39.07
X
93283
TC
1
XXX
0
X
47.08
X
93283
26
2
XXX
0
X
88.76
X
93283
26
3
XXX
0
X
88.76
X
93283
26
4
XXX
0
X
88.76
X
93283
26
1
XXX
0
X
96.23
X
93283
2
XXX
0
X
127.87
X
93283
3
XXX
0
X
127.87
X
93283
4
XXX
0
X
127.87
X
93283
1
XXX
0
X
143.28
X
93284
TC
2
XXX
0
X
44.19
X
93284
TC
3
XXX
0
X
44.19
X
93284
TC
4
XXX
0
X
44.19
X
93284
TC
1
XXX
0
X
53.15
X
93284
26
2
XXX
0
X
105.42
X
93284
26
3
XXX
0
X
105.42
X
93284
26
4
XXX
0
X
105.42
X
93284
26
1
XXX
0
X
114.06
X
93284
2
XXX
0
X
149.60
X
93284
3
XXX
0
X
149.60
X
93284
4
XXX
0
X
149.60
X
93284
1
XXX
0
X
167.15
X
93285
TC
2
XXX
0
X
26.83
X
93285
TC
3
XXX
0
X
26.83
X
93285
TC
4
XXX
0
X
26.83
X
93285
TC
1
XXX
0
X
32.57
X
93285
26
2
XXX
0
X
44.11
X
93285
26
3
XXX
0
X
44.11
X
93285
26
4
XXX
0
X
44.11
X
93285
26
1
XXX
0
X
47.82
X
93285
2
XXX
0
X
70.97
X
93285
3
XXX
0
X
70.97
X
93285
4
XXX
0
X
70.97
X
93285
1
XXX
0
X
80.39
X
93286
TC
2
XXX
0
X
17.52
X
93286
TC
3
XXX
0
X
17.52
X
93286
TC
4
XXX
0
X
17.52
X
93286
TC
1
XXX
0
X
21.14
X
93286
26
2
XXX
0
X
22.86
X
93286
26
3
XXX
0
X
22.86
X
93286
26
4
XXX
0
X
22.86
X
93286
26
1
XXX
0
X
24.63
X
93286
2
XXX
0
X
40.30
X
93286
3
XXX
0
X
40.30
X
93286
4
XXX
0
X
40.30
X
93286
1
XXX
0
X
45.72
X
93287
TC
2
XXX
0
X
20.21
X
93287
TC
3
XXX
0
X
20.21
X
93287
TC
4
XXX
0
X
20.21
X
93287
TC
1
XXX
0
X
24.72
X
93287
26
2
XXX
0
X
33.04
X
93287
26
3
XXX
0
X
33.04
X
93287
26
4
XXX
0
X
33.04
X
93287
26
1
XXX
0
X
35.16
X
93287
2
XXX
0
X
53.25
X
93287
3
XXX
0
X
53.25
X
93287
4
XXX
0
X
53.25
X
93287
1
XXX
0
X
59.87
X
93288
TC
2
XXX
0
X
27.37
X
93288
TC
3
XXX
0
X
27.37
X
93288
TC
4
XXX
0
X
27.37
X
93288
TC
1
XXX
0
X
33.18
X
93288
26
2
XXX
0
X
35.99
X
93288
26
3
XXX
0
X
35.99
X
93288
26
4
XXX
0
X
35.99
X
93288
26
1
XXX
0
X
38.88
X
93288
2
XXX
0
X
63.36
X
93288
3
XXX
0
X
63.36
X
93288
4
XXX
0
X
63.36
X
93288
1
XXX
0
X
72.06
X
93289
TC
2
XXX
0
X
32.35
X
93289
TC
3
XXX
0
X
32.35
X
93289
TC
4
XXX
0
X
32.35
X
93289
TC
1
XXX
0
X
38.94
X
93289
26
2
XXX
0
X
65.08
X
93289
26
3
XXX
0
X
65.08
X
93289
26
4
XXX
0
X
65.08
X
93289
26
1
XXX
0
X
70.23
X
93289
2
XXX
0
X
97.45
X
93289
3
XXX
0
X
97.45
X
93289
4
XXX
0
X
97.45
X
93289
1
XXX
0
X
109.18
X
93290
TC
2
XXX
0
X
15.65
X
93290
TC
3
XXX
0
X
15.65
X
93290
TC
4
XXX
0
X
15.65
X
93290
TC
1
XXX
0
X
19.28
X
93290
26
2
XXX
0
X
32.03
X
93290
26
3
XXX
0
X
32.03
X
93290
26
4
XXX
0
X
32.03
X
93290
26
1
XXX
0
X
34.33
X
93290
2
XXX
0
X
47.66
X
93290
3
XXX
0
X
47.66
X
93290
4
XXX
0
X
47.66
X
93290
1
XXX
0
X
53.61
X
93291
TC
2
XXX
0
X
24.21
X
93291
TC
3
XXX
0
X
24.21
X
93291
TC
4
XXX
0
X
24.21
X
93291
TC
1
XXX
0
X
29.27
X
93291
26
2
XXX
0
X
36.60
X
93291
26
3
XXX
0
X
36.60
X
93291
26
4
XXX
0
X
36.60
X
93291
26
1
XXX
0
X
39.76
X
93291
2
XXX
0
X
60.82
X
93291
3
XXX
0
X
60.82
X
93291
4
XXX
0
X
60.82
X
93291
1
XXX
0
X
69.02
X
93292
TC
2
XXX
0
X
19.22
X
93292
TC
3
XXX
0
X
19.22
X
93292
TC
4
XXX
0
X
19.22
X
93292
TC
1
XXX
0
X
23.51
X
93292
26
2
XXX
0
X
35.99
X
93292
26
3
XXX
0
X
35.99
X
93292
26
4
XXX
0
X
35.99
X
93292
26
1
XXX
0
X
38.88
X
93292
2
XXX
0
X
55.23
X
93292
3
XXX
0
X
55.23
X
93292
4
XXX
0
X
55.23
X
93292
1
XXX
0
X
62.39
X
93293
26
2
XXX
0
X
25.46
X
93293
26
3
XXX
0
X
25.46
X
93293
26
4
XXX
0
X
25.46
X
93293
26
1
XXX
0
X
27.55
X
93293
TC
2
XXX
0
X
61.61
X
93293
TC
3
XXX
0
X
61.61
X
93293
TC
4
XXX
0
X
61.61
X
93293
TC
1
XXX
0
X
75.08
X
93293
2
XXX
0
X
87.07
X
93293
3
XXX
0
X
87.07
X
93293
4
XXX
0
X
87.07
X
93293
1
XXX
0
X
102.63
X
93294
2
XXX
0
X
54.95
X
93294
3
XXX
0
X
54.95
X
93294
4
XXX
0
X
54.95
X
93294
1
XXX
0
X
59.59
X
93295
2
XXX
0
X
98.98
X
93295
3
XXX
0
X
98.98
X
93295
4
XXX
0
X
98.98
X
93295
1
XXX
0
X
107.15
X
93296
2
XXX
0
X
51.58
X
93296
3
XXX
0
X
51.58
X
93296
4
XXX
0
X
51.58
X
93296
1
XXX
0
X
61.35
X
93297
2
XXX
0
X
38.52
X
93297
3
XXX
0
X
38.52
X
93297
4
XXX
0
X
38.52
X
93297
1
XXX
0
X
41.16
X
93298
2
XXX
0
X
44.11
X
93298
3
XXX
0
X
44.11
X
93298
4
XXX
0
X
44.11
X
93298
1
XXX
0
X
47.82
X
93303
26
3
XXX
0
X
170.44
X
93303
26
4
XXX
0
X
170.44
X
93303
26
2
XXX
0
X
175.10
X
93303
26
1
XXX
0
X
191.00
X
93303
TC
3
XXX
0
X
282.58
X
93303
TC
4
XXX
0
X
282.58
X
93303
TC
2
XXX
0
X
290.36
X
93303
TC
1
XXX
0
X
343.31
X
93303
3
XXX
0
X
452.98
X
93303
4
XXX
0
X
452.98
X
93303
2
XXX
0
X
465.49
X
93303
1
XXX
0
X
534.33
X
93304
26
3
XXX
0
X
105.70
X
93304
26
4
XXX
0
X
105.70
X
93304
26
2
XXX
0
X
108.62
X
93304
26
1
XXX
0
X
118.83
X
93304
TC
3
XXX
0
X
142.33
X
93304
TC
4
XXX
0
X
142.33
X
93304
TC
2
XXX
0
X
146.21
X
93304
TC
1
XXX
0
X
173.05
X
93304
3
XXX
0
X
248.00
X
93304
4
XXX
0
X
248.00
X
93304
2
XXX
0
X
254.82
X
93304
1
XXX
0
X
291.87
X
93306
26
2
XXX
0
X
107.15
X
93306
26
3
XXX
0
X
107.15
X
93306
26
4
XXX
0
X
107.15
X
93306
26
1
XXX
0
X
115.64
X
93306
TC
2
XXX
0
X
279.61
X
93306
TC
3
XXX
0
X
279.61
X
93306
TC
4
XXX
0
X
279.61
X
93306
TC
1
XXX
0
X
337.70
X
93306
2
XXX
0
X
386.76
X
93306
3
XXX
0
X
386.76
X
93306
4
XXX
0
X
386.76
X
93306
1
XXX
0
X
453.31
X
93307
TC
4
XXX
0
X
317.12
X
93307
TC
3
XXX
0
X
322.19
X
93307
26
4
XXX
0
X
332.28
X
93307
26
3
XXX
0
X
333.25
X
93307
26
2
XXX
0
X
337.66
X
93307
26
1
XXX
0
X
338.73
X
93307
TC
2
XXX
0
X
350.34
X
93307
TC
1
XXX
0
X
355.61
X
93307
4
XXX
0
X
606.48
X
93307
3
XXX
0
X
619.23
X
93307
2
XXX
0
X
639.69
X
93307
1
XXX
0
X
643.61
X
93308
26
1
XXX
0
X
119.37
X
93308
26
2
XXX
0
X
122.27
X
93308
26
3
XXX
0
X
122.78
X
93308
26
4
XXX
0
X
132.28
X
93308
TC
4
XXX
0
X
159.77
X
93308
TC
3
XXX
0
X
162.33
X
93308
TC
1
XXX
0
X
180.06
X
93308
TC
2
XXX
0
X
242.26
X
93308
4
XXX
0
X
263.46
X
93308
3
XXX
0
X
269.36
X
93308
2
XXX
0
X
296.59
X
93308
1
XXX
0
X
303.63
X
93312
26
2
XXX
0
X
298.75
X
93312
26
1
XXX
0
X
299.21
X
93312
26
3
XXX
0
X
311.04
X
93312
TC
4
XXX
0
X
315.87
X
93312
TC
3
XXX
0
X
320.82
X
93312
26
4
XXX
0
X
334.45
X
93312
TC
2
XXX
0
X
350.95
X
93312
TC
1
XXX
0
X
358.05
X
93312
4
XXX
0
X
566.43
X
93312
3
XXX
0
X
967.85
X
93312
2
XXX
0
X
986.72
X
93312
1
XXX
0
X
991.23
X
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