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2021 Workers' Compensation Part B Fee Schedule

93620-94005

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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
93620 TC 4 0 0 X 734.33 X
93620 TC 3 0 0 X 746.06 X
93620 TC 2 0 0 X 810.84 X
93620 TC 1 0 0 X 826.25 X
93620 26 4 0 0 X 2,365.16 X
93620 26 3 0 0 X 2,376.73 X
93620 26 2 0 0 X 2,429.72 X
93620 26 1 0 0 X 2,442.46 X
93620   4 0 0 X 2,871.35 X
93620   3 0 0 X 2,910.73 X
93620   2 0 0 X 3,101.91 X
93620   1 0 0 X 3,147.59 X
93621 26 4 0 0 X 2,353.44 X
93621 26 3 0 0 X 2,383.77 X
93621 26 2 0 0 X 2,525.36 X
93621 26 1 0 0 X 2,559.32 X
93622 26 4 0 0 X 2,340.09 X
93622 26 3 0 0 X 2,370.22 X
93622 26 2 0 0 X 2,509.42 X
93622 26 1 0 0 X 2,542.84 X
93623 26 4 ZZZ 0 X 478.44 X
93623 26 3 ZZZ 0 X 484.50 X
93623 26 2 ZZZ 0 X 511.59 X
93623 26 1 ZZZ 0 X 518.01 X
93624 TC 4 0 0 X 162.99 X
93624 TC 3 0 0 X 165.55 X
93624 TC 2 0 0 X 180.08 X
93624 TC 1 0 0 X 183.56 X
93624 26 3 0 0 X 668.24 X
93624 26 4 0 0 X 742.60 X
93624 26 2 0 0 X 759.31 X
93624 26 1 0 0 X 762.53 X
93624   4 0 0 X 823.38 X
93624   3 0 0 X 833.75 X
93624   2 0 0 X 880.81 X
93624   1 0 0 X 892.09 X
93631 TC 4 0 0 X 529.00 X
93631 TC 3 0 0 X 537.12 X
93631 TC 2 0 0 X 592.85 X
93631 TC 1 0 0 X 606.21 X
93631 26 3 0 0 X 1,169.62 X
93631 26 2 0 0 X 1,239.37 X
93631   4 0 0 X 1,684.79 X
93631   3 0 0 X 1,706.67 X
93631   2 0 0 X 1,832.22 X
93631   1 0 0 X 1,862.46 X
93631 26 4 0 0 X 2,418.16 X
93631 26 1 0 0 X 2,455.50 X
93640 TC 4 0 0 X 588.91 X
93640 TC 3 0 0 X 598.33 X
93640 TC 2 0 0 X 650.29 X
93640 TC 1 0 0 X 662.61 X
93640 26 4 0 0 X 734.34 X
93640 26 2 0 0 X 771.67 X
93640 26 1 0 0 X 779.19 X
93640 26 3 0 0 X 917.35 X
93640   1 0 0 X 1,238.64 X
93640   4 0 0 X 1,493.96 X
93640   3 0 0 X 1,515.66 X
93640   2 0 0 X 1,632.52 X
93641 TC 4 0 0 X 588.91 X
93641 TC 3 0 0 X 598.33 X
93641 TC 2 0 0 X 650.29 X
93641 TC 1 0 0 X 662.61 X
93641 26 4 0 0 X 801.43 X
93641 26 2 0 0 X 841.59 X
93641 26 1 0 0 X 849.62 X
93641 26 3 0 0 X 1,122.81 X
93641   1 0 0 X 1,309.03 X
93641   4 0 0 X 1,697.19 X
93641   3 0 0 X 1,721.11 X
93641   2 0 0 X 1,844.36 X
93642 TC 4 0 0 X 588.91 X
93642 TC 3 0 0 X 598.33 X
93642 TC 2 0 0 X 650.29 X
93642 TC 1 0 0 X 662.61 X
93642 26 4 0 0 X 781.05 X
93642 26 2 0 0 X 820.38 X
93642 26 1 0 0 X 828.26 X
93642 26 3 0 0 X 1,060.46 X
93642   1 0 0 X 1,287.69 X
93642   4 0 0 X 1,635.47 X
93642   3 0 0 X 1,658.76 X
93642   2 0 0 X 1,780.04 X
93644 TC 2 0 2 X 131.92 X
93644 TC 3 0 2 X 131.92 X
93644 TC 4 0 2 X 131.92 X
93644 TC 1 0 2 X 154.52 X
93644 26 2 0 2 X 271.79 X
93644 26 3 0 2 X 271.79 X
93644 26 4 0 2 X 271.79 X
93644 26 1 0 2 X 299.46 X
93644   2 0 2 X 403.74 X
93644   3 0 2 X 403.74 X
93644   4 0 2 X 403.74 X
93644   1 0 2 X 453.98 X
93650   4 0 0 X 2,277.11 X
93650   3 0 0 X 2,307.28 X
93650   2 0 0 X 2,458.42 X
93650   1 0 0 X 2,494.73 X
93653   2 0 2 X 1,140.32 X
93653   3 0 2 X 1,140.32 X
93653   4 0 2 X 1,140.32 X
93653   1 0 2 X 1,268.76 X
93654   2 0 2 X 1,521.71 X
93654   3 0 2 X 1,521.71 X
93654   4 0 2 X 1,521.71 X
93654   1 0 2 X 1,693.19 X
93655   2 ZZZ 0 X 570.11 X
93655   3 ZZZ 0 X 570.11 X
93655   4 ZZZ 0 X 570.11 X
93655   1 ZZZ 0 X 634.24 X
93656   2 0 2 X 1,522.23 X
93656   3 0 2 X 1,522.23 X
93656   4 0 2 X 1,522.23 X
93656   1 0 2 X 1,693.64 X
93657   2 ZZZ 0 X 570.65 X
93657   3 ZZZ 0 X 570.65 X
93657   4 ZZZ 0 X 570.65 X
93657   1 ZZZ 0 X 635.01 X
93660     0 0 X * X
93662 TC 2 ZZZ 0 X 281.66 X
93662 TC 3 ZZZ 0 X 281.66 X
93662 TC 4 ZZZ 0 X 281.66 X
93662 26 2 ZZZ 0 X 302.37 X
93662 26 3 ZZZ 0 X 302.37 X
93662 26 4 ZZZ 0 X 302.37 X
93662 26 1 ZZZ 0 X 329.52 X
93662 TC 1 ZZZ 0 X 341.15 X
93662   2 ZZZ 0 X 584.02 X
93662   3 ZZZ 0 X 584.02 X
93662   4 ZZZ 0 X 584.02 X
93662   1 ZZZ 0 X 670.68 X
93668     XXX 9 X * X
93701 26 2 XXX 0 X 16.84 X
93701 26 3 XXX 0 X 16.84 X
93701 26 4 XXX 0 X 16.84 X
93701 26 1 XXX 0 X 18.47 X
93701 TC 2 XXX 0 X 46.66 X
93701 TC 3 XXX 0 X 46.66 X
93701 TC 4 XXX 0 X 46.66 X
93701 TC 1 XXX 0 X 55.22 X
93701   2 XXX 0 X 63.47 X
93701   3 XXX 0 X 63.47 X
93701   4 XXX 0 X 63.47 X
93701   1 XXX 0 X 73.70 X
93702   2 XXX 6 X 143.48 X
93702   3 XXX 6 X 143.48 X
93702   4 XXX 6 X 143.48 X
93702   1 XXX 6 X 167.95 X
93724 TC 4 0 0 X 325.89 X
93724 TC 3 0 0 X 331.04 X
93724 TC 2 0 0 X 360.16 X
93724 TC 1 0 0 X 367.08 X
93724 26 4 0 0 X 659.20 X
93724 26 3 0 0 X 666.91 X
93724 26 2 0 0 X 699.46 X
93724 26 1 0 0 X 707.27 X
93724   4 0 0 X 985.08 X
93724   3 0 0 X 998.03 X
93724   2 0 0 X 1,059.58 X
93724   1 0 0 X 1,074.32 X
93740   1 XXX 9 X * X
93740   2 XXX 9 X * X
93740   3 XXX 9 X * X
93740   4 XXX 9 X * X
93740 TC 4 XXX 9 X 12.74 X
93740 TC 3 XXX 9 X 12.94 X
93740 TC 2 XXX 9 X 13.96 X
93740 26 4 XXX 9 X 39.52 X
93740 TC 1 XXX 9 X 39.55 X
93740 26 3 XXX 9 X 40.07 X
93740 26 2 XXX 9 X 42.98 X
93740 26 1 XXX 9 X 43.68 X
93745     XXX 0 X * X
93750   2 XXX 0 X 76.39 67.29
93750   3 XXX 0 X 76.39 67.29
93750   4 XXX 0 X 76.39 67.29
93750   1 XXX 0 X 83.20 72.44
93770 TC 4 XXX 9 X 2.40 X
93770 TC 3 XXX 9 X 2.41 X
93770 TC 2 XXX 9 X 2.55 X
93770 TC 1 XXX 9 X 2.56 X
93770 26 4 XXX 9 X 28.45 X
93770   4 XXX 9 X 30.79 X
93770 26 1 XXX 9 X 31.12 X
93770   1 XXX 9 X 33.72 X
93770   3 XXX 9 X 45.86 X
93770   2 XXX 9 X 49.55 X
93770 26 3 XXX 9 X 77.55 X
93770 26 2 XXX 9 X 78.31 X
93784     XXX 0 X * X
93786     XXX 0 X * X
93788     XXX 0 X * X
93790     XXX 0 X * X
93792   2 XXX 0 X 64.35 X
93792   3 XXX 0 X 64.35 X
93792   4 XXX 0 X 64.35 X
93792   1 XXX 0 X 74.01 X
93793   2 XXX 0 X 14.85 X
93793   3 XXX 0 X 14.85 X
93793   4 XXX 0 X 14.85 X
93793   1 XXX 0 X 16.11 X
93797   4 0 0 X 40.38 28.48
93797   3 0 0 X 44.07 31.10
93797   2 0 0 X 50.54 35.76
93797   1 0 0 X 51.18 36.11
93798   4 0 0 X 64.62 45.62
93798   3 0 0 X 67.34 47.50
93798   2 0 0 X 71.03 50.07
93798   1 0 0 X 72.01 50.85
93799     XXX 0 X # X
93880 26 4 XXX 0 X 227.78 X
93880 26 2 XXX 0 X 240.74 X
93880 26 3 XXX 0 X 243.46 X
93880 26 1 XXX 0 X 245.42 X
93880 TC 4 XXX 0 X 298.70 X
93880 TC 3 XXX 0 X 303.29 X
93880 TC 2 XXX 0 X 334.03 X
93880 TC 1 XXX 0 X 341.40 X
93880   4 XXX 0 X 535.95 X
93880   3 XXX 0 X 548.48 X
93880   2 XXX 0 X 561.44 X
93880   1 XXX 0 X 563.71 X
93882 26 4 XXX 0 X 208.54 X
93882 26 2 XXX 0 X 220.16 X
93882 26 3 XXX 0 X 223.96 X
93882 26 1 XXX 0 X 224.63 X
93882 TC 4 XXX 0 X 298.70 X
93882 TC 3 XXX 0 X 303.29 X
93882 TC 2 XXX 0 X 334.03 X
93882 TC 1 XXX 0 X 341.40 X
93882   4 XXX 0 X 516.68 X
93882   3 XXX 0 X 528.99 X
93882   2 XXX 0 X 540.88 X
93882   1 XXX 0 X 542.89 X
93886 26 4 XXX 0 X 137.75 X
93886 26 3 XXX 0 X 139.39 X
93886 26 2 XXX 0 X 147.70 X
93886 26 1 XXX 0 X 149.67 X
93886 TC 4 XXX 0 X 298.70 X
93886 TC 3 XXX 0 X 303.29 X
93886 TC 2 XXX 0 X 334.03 X
93886 TC 1 XXX 0 X 341.40 X
93886   4 XXX 0 X 436.44 X
93886   3 XXX 0 X 442.63 X
93886   2 XXX 0 X 481.75 X
93886   1 XXX 0 X 491.08 X
93888 26 4 XXX 0 X 93.36 X
93888 26 3 XXX 0 X 94.40 X
93888 26 2 XXX 0 X 99.14 X
93888 26 1 XXX 0 X 100.33 X
93888 TC 4 XXX 0 X 298.70 X
93888 TC 3 XXX 0 X 303.29 X
93888 TC 2 XXX 0 X 334.03 X
93888 TC 1 XXX 0 X 341.40 X
93888   4 XXX 0 X 392.02 X
93888   3 XXX 0 X 397.68 X
93888   2 XXX 0 X 433.19 X
93888   1 XXX 0 X 441.73 X
93890 26 2 XXX 0 X 95.68 X
93890 26 3 XXX 0 X 95.68 X
93890 26 4 XXX 0 X 95.68 X
93890 26 1 XXX 0 X 104.30 X
93890 TC 2 XXX 0 X 300.07 X
93890 TC 3 XXX 0 X 300.07 X
93890 TC 4 XXX 0 X 300.07 X
93890 TC 1 XXX 0 X 370.77 X
93890   2 XXX 0 X 395.75 X
93890   3 XXX 0 X 395.75 X
93890   4 XXX 0 X 395.75 X
93890   1 XXX 0 X 475.08 X
93892 26 2 XXX 0 X 109.55 X
93892 26 3 XXX 0 X 109.55 X
93892 26 4 XXX 0 X 109.55 X
93892 26 1 XXX 0 X 119.13 X
93892 TC 2 XXX 0 X 312.44 X
93892 TC 3 XXX 0 X 312.44 X
93892 TC 4 XXX 0 X 312.44 X
93892 TC 1 XXX 0 X 385.62 X
93892   2 XXX 0 X 422.00 X
93892   3 XXX 0 X 422.00 X
93892   4 XXX 0 X 422.00 X
93892   1 XXX 0 X 504.73 X
93893 26 2 XXX 0 X 109.55 X
93893 26 3 XXX 0 X 109.55 X
93893 26 4 XXX 0 X 109.55 X
93893 26 1 XXX 0 X 119.13 X
93893 TC 2 XXX 0 X 304.40 X
93893 TC 3 XXX 0 X 304.40 X
93893 TC 4 XXX 0 X 304.40 X
93893 TC 1 XXX 0 X 375.96 X
93893   2 XXX 0 X 413.93 X
93893   3 XXX 0 X 413.93 X
93893   4 XXX 0 X 413.93 X
93893   1 XXX 0 X 495.05 X
93895     XXX 6 X * X
93922 TC 4 XXX 0 X 99.61 X
93922 TC 3 XXX 0 X 101.13 X
93922 26 2 XXX 0 X 150.60 X
93922 26 4 XXX 0 X 156.12 X
93922 26 3 XXX 0 X 165.69 X
93922 26 1 XXX 0 X 167.32 X
93922 TC 2 XXX 0 X 199.61 X
93922 TC 1 XXX 0 X 205.10 X
93922   4 XXX 0 X 285.01 X
93922   1 XXX 0 X 310.51 X
93922   2 XXX 0 X 325.40 X
93922   3 XXX 0 X 332.97 X
93923 26 2 XXX 0 X 166.05 X
93923 26 4 XXX 0 X 170.25 X
93923 26 3 XXX 0 X 180.06 X
93923 26 1 XXX 0 X 183.02 X
93923 TC 4 XXX 0 X 188.08 X
93923 TC 3 XXX 0 X 190.96 X
93923 TC 2 XXX 0 X 232.31 X
93923 TC 1 XXX 0 X 238.55 X
93923   4 XXX 0 X 328.37 X
93923   1 XXX 0 X 359.63 X
93923   2 XXX 0 X 373.58 X
93923   3 XXX 0 X 376.92 X
93924 26 4 XXX 0 X 161.25 X
93924 26 2 XXX 0 X 173.58 X
93924 26 1 XXX 0 X 178.32 X
93924 26 3 XXX 0 X 180.78 X
93924 TC 4 XXX 0 X 205.59 X
93924 TC 3 XXX 0 X 208.75 X
93924 TC 2 XXX 0 X 230.87 X
93924 TC 1 XXX 0 X 236.16 X
93924   4 XXX 0 X 342.50 X
93924   1 XXX 0 X 360.20 X
93924   2 XXX 0 X 380.67 X
93924   3 XXX 0 X 381.84 X
93925 26 4 XXX 0 X 91.24 X
93925 26 3 XXX 0 X 92.38 X
93925 26 2 XXX 0 X 97.77 X
93925 26 1 XXX 0 X 99.08 X
93925 TC 4 XXX 0 X 298.70 X
93925 TC 3 XXX 0 X 303.29 X
93925 TC 2 XXX 0 X 334.03 X
93925 TC 1 XXX 0 X 341.40 X
93925   4 XXX 0 X 389.96 X
93925   3 XXX 0 X 395.69 X
93925   2 XXX 0 X 431.79 X
93925   1 XXX 0 X 440.44 X
93926 26 4 XXX 0 X 45.63 X
93926 26 3 XXX 0 X 46.21 X
93926 26 2 XXX 0 X 49.07 X
93926 26 1 XXX 0 X 49.74 X
93926 TC 4 XXX 0 X 298.70 X
93926 TC 3 XXX 0 X 303.29 X
93926 TC 2 XXX 0 X 334.03 X
93926 TC 1 XXX 0 X 341.40 X
93926   4 XXX 0 X 344.31 X
93926   3 XXX 0 X 349.46 X
93926   2 XXX 0 X 383.06 X
93926   1 XXX 0 X 391.14 X
93930 26 4 XXX 0 X 75.88 X
93930 26 3 XXX 0 X 76.76 X
93930 26 2 XXX 0 X 81.10 X
93930 26 1 XXX 0 X 82.22 X
93930 TC 4 XXX 0 X 298.70 X
93930 TC 3 XXX 0 X 303.29 X
93930 TC 2 XXX 0 X 334.03 X
93930 TC 1 XXX 0 X 341.40 X
93930   4 XXX 0 X 374.47 X
93930   3 XXX 0 X 380.00 X
93930   2 XXX 0 X 415.14 X
93930   1 XXX 0 X 423.60 X
93931 26 4 XXX 0 X 37.48 X
93931 26 3 XXX 0 X 37.94 X
93931 26 2 XXX 0 X 40.15 X
93931 26 1 XXX 0 X 40.65 X
93931 TC 4 XXX 0 X 298.70 X
93931 TC 3 XXX 0 X 303.29 X
93931 TC 2 XXX 0 X 334.03 X
93931   4 XXX 0 X 336.12 X
93931   3 XXX 0 X 341.17 X
93931 TC 1 XXX 0 X 341.40 X
93931   2 XXX 0 X 374.16 X
93931   1 XXX 0 X 382.09 X
93970 26 4 XXX 0 X 107.57 X
93970 26 3 XXX 0 X 108.88 X
93970 26 2 XXX 0 X 115.58 X
93970 26 1 XXX 0 X 117.26 X
93970 TC 4 XXX 0 X 298.70 X
93970 TC 3 XXX 0 X 303.29 X
93970 TC 2 XXX 0 X 334.03 X
93970 TC 1 XXX 0 X 341.40 X
93970   4 XXX 0 X 406.26 X
93970   3 XXX 0 X 412.12 X
93970   2 XXX 0 X 449.64 X
93970   1 XXX 0 X 458.65 X
93971 26 4 XXX 0 X 53.80 X
93971 26 3 XXX 0 X 54.48 X
93971 26 2 XXX 0 X 57.65 X
93971 26 1 XXX 0 X 58.37 X
93971 TC 4 XXX 0 X 298.70 X
93971 TC 3 XXX 0 X 303.29 X
93971 TC 2 XXX 0 X 334.03 X
93971 TC 1 XXX 0 X 341.40 X
93971   4 XXX 0 X 352.49 X
93971   3 XXX 0 X 357.70 X
93971   2 XXX 0 X 391.62 X
93971   1 XXX 0 X 399.75 X
93975 26 4 XXX 0 X 225.45 X
93975 26 3 XXX 0 X 227.98 X
93975 26 2 XXX 0 X 239.02 X
93975 26 1 XXX 0 X 241.75 X
93975 TC 4 XXX 0 X 298.70 X
93975 TC 3 XXX 0 X 303.29 X
93975 TC 2 XXX 0 X 334.03 X
93975 TC 1 XXX 0 X 341.40 X
93975   4 XXX 0 X 524.11 X
93975   3 XXX 0 X 531.24 X
93975   2 XXX 0 X 573.03 X
93975   1 XXX 0 X 583.10 X
93976 26 4 XXX 0 X 113.16 X
93976 26 3 XXX 0 X 114.43 X
93976 26 2 XXX 0 X 119.73 X
93976 26 1 XXX 0 X 121.06 X
93976 TC 4 XXX 0 X 298.70 X
93976 TC 3 XXX 0 X 303.29 X
93976 TC 2 XXX 0 X 334.03 X
93976 TC 1 XXX 0 X 341.40 X
93976   4 XXX 0 X 411.86 X
93976   3 XXX 0 X 417.69 X
93976   2 XXX 0 X 453.77 X
93976   1 XXX 0 X 462.48 X
93978 26 4 XXX 0 X 101.90 X
93978 26 3 XXX 0 X 103.10 X
93978 26 2 XXX 0 X 109.25 X
93978 26 1 XXX 0 X 110.77 X
93978 TC 4 XXX 0 X 298.70 X
93978 TC 3 XXX 0 X 303.29 X
93978 TC 2 XXX 0 X 334.03 X
93978 TC 1 XXX 0 X 341.40 X
93978   4 XXX 0 X 400.53 X
93978   3 XXX 0 X 406.38 X
93978   2 XXX 0 X 443.33 X
93978   1 XXX 0 X 452.14 X
93979 26 4 XXX 0 X 52.14 X
93979 26 3 XXX 0 X 52.80 X
93979 26 2 XXX 0 X 55.90 X
93979 26 1 XXX 0 X 56.67 X
93979 TC 4 XXX 0 X 298.70 X
93979 TC 3 XXX 0 X 303.29 X
93979 TC 2 XXX 0 X 334.03 X
93979 TC 1 XXX 0 X 341.40 X
93979   4 XXX 0 X 350.85 X
93979   3 XXX 0 X 356.04 X
93979   2 XXX 0 X 389.96 X
93979   1 XXX 0 X 398.07 X
93980 26 4 XXX 0 X 224.44 X
93980 26 3 XXX 0 X 226.98 X
93980 26 2 XXX 0 X 237.38 X
93980 26 1 XXX 0 X 239.90 X
93980 TC 4 XXX 0 X 298.70 X
93980 TC 3 XXX 0 X 303.29 X
93980 TC 2 XXX 0 X 334.03 X
93980 TC 1 XXX 0 X 341.40 X
93980   4 XXX 0 X 523.13 X
93980   3 XXX 0 X 530.20 X
93980   2 XXX 0 X 571.45 X
93980   1 XXX 0 X 581.36 X
93981 26 4 XXX 0 X 88.18 X
93981 26 3 XXX 0 X 89.22 X
93981 26 2 XXX 0 X 93.64 X
93981 26 1 XXX 0 X 94.65 X
93981 TC 4 XXX 0 X 275.60 X
93981 TC 3 XXX 0 X 279.83 X
93981 TC 2 XXX 0 X 308.59 X
93981 TC 1 XXX 0 X 315.47 X
93981   4 XXX 0 X 363.77 X
93981   3 XXX 0 X 369.03 X
93981   2 XXX 0 X 402.18 X
93981   1 XXX 0 X 410.09 X
93985 26 2 XXX 6 X 45.97 X
93985 26 3 XXX 6 X 45.97 X
93985 26 4 XXX 6 X 45.97 X
93985 26 1 XXX 6 X 49.49 X
93985 TC 2 XXX 6 X 257.03 X
93985 TC 3 XXX 6 X 257.03 X
93985 TC 4 XXX 6 X 257.03 X
93985 TC 1 XXX 6 X 296.23 X
93985   2 XXX 6 X 303.01 X
93985   3 XXX 6 X 303.01 X
93985   4 XXX 6 X 303.01 X
93985   1 XXX 6 X 345.71 X
93986 26 2 XXX 6 X 29.65 X
93986 26 3 XXX 6 X 29.65 X
93986 26 4 XXX 6 X 29.65 X
93986 26 1 XXX 6 X 32.19 X
93986 TC 2 XXX 6 X 124.32 X
93986 TC 3 XXX 6 X 124.32 X
93986 TC 4 XXX 6 X 124.32 X
93986 TC 1 XXX 6 X 143.32 X
93986   2 XXX 6 X 153.98 X
93986   3 XXX 6 X 153.98 X
93986   4 XXX 6 X 153.98 X
93986   1 XXX 6 X 175.50 X
93990 26 4 XXX 0 X 37.48 X
93990 26 3 XXX 0 X 37.94 X
93990 26 2 XXX 0 X 40.15 X
93990 26 1 XXX 0 X 40.65 X
93990 TC 4 XXX 0 X 298.70 X
93990 TC 3 XXX 0 X 303.29 X
93990 TC 2 XXX 0 X 334.03 X
93990   4 XXX 0 X 336.12 X
93990   3 XXX 0 X 341.17 X
93990 TC 1 XXX 0 X 341.40 X
93990   2 XXX 0 X 374.16 X
93990   1 XXX 0 X 382.09 X
93998     XXX 0 X # X
94002   2 XXX 0 X 127.14 X
94002   3 XXX 0 X 127.14 X
94002   4 XXX 0 X 127.14 X
94002   1 XXX 0 X 136.71 X
94003   2 XXX 0 X 92.40 X
94003   3 XXX 0 X 92.40 X
94003   4 XXX 0 X 92.40 X
94003   1 XXX 0 X 100.09 X
94004   2 XXX 0 X 67.36 X
94004   3 XXX 0 X 67.36 X
94004   4 XXX 0 X 67.36 X
94004   1 XXX 0 X 72.83 X
94005     XXX 9 X * X