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2021 Workers' Compensation Part B Fee Schedule

94010-95806

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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
94010 TC 4 XXX 0 X 34.17 X
94010 TC 3 XXX 0 X 34.70 X
94010 TC 2 XXX 0 X 37.81 X
94010 26 4 XXX 0 X 38.37 X
94010 TC 1 XXX 0 X 38.53 X
94010 26 3 XXX 0 X 40.15 X
94010 26 2 XXX 0 X 41.06 X
94010 26 1 XXX 0 X 41.90 X
94010   2 XXX 0 X 88.18 X
94010   4 XXX 0 X 89.99 X
94010   3 XXX 0 X 90.26 X
94010   1 XXX 0 X 93.98 X
94011   2 XXX 0 X 143.11 X
94011   3 XXX 0 X 143.11 X
94011   4 XXX 0 X 143.11 X
94011   1 XXX 0 X 153.19 X
94012   2 XXX 0 X 220.10 X
94012   3 XXX 0 X 220.10 X
94012   4 XXX 0 X 220.10 X
94012   1 XXX 0 X 235.32 X
94013   2 XXX 0 X 46.60 X
94013   3 XXX 0 X 46.60 X
94013   4 XXX 0 X 46.60 X
94013   1 XXX 0 X 49.99 X
94014 TC 2 XXX 0 X 31.20 X
94014 TC 3 XXX 0 X 31.20 X
94014 TC 4 XXX 0 X 31.20 X
94014 TC 1 XXX 0 X 37.14 X
94014 26 2 XXX 0 X 53.85 X
94014 26 3 XXX 0 X 53.85 X
94014 26 4 XXX 0 X 53.85 X
94014 26 1 XXX 0 X 58.49 X
94014   2 XXX 0 X 85.07 X
94014   3 XXX 0 X 85.07 X
94014   4 XXX 0 X 85.07 X
94014   1 XXX 0 X 95.66 X
94015   2 XXX 0 X 36.74 X
94015   3 XXX 0 X 36.74 X
94015   4 XXX 0 X 36.74 X
94015   1 XXX 0 X 39.86 X
94016   2 XXX 0 X 54.82 X
94016   3 XXX 0 X 54.82 X
94016   4 XXX 0 X 54.82 X
94016   1 XXX 0 X 60.31 X
94060 26 4 XXX 0 X 58.34 X
94060 26 3 XXX 0 X 61.38 X
94060 26 2 XXX 0 X 62.71 X
94060 26 1 XXX 0 X 65.88 X
94060 TC 3 XXX 0 X 75.11 X
94060 TC 4 XXX 0 X 76.31 X
94060 TC 2 XXX 0 X 84.10 X
94060 TC 1 XXX 0 X 85.28 X
94060   3 XXX 0 X 139.56 X
94060   4 XXX 0 X 148.42 X
94060   2 XXX 0 X 158.24 X
94060   1 XXX 0 X 160.41 X
94070 26 2 XXX 0 X 76.77 X
94070 26 3 XXX 0 X 76.77 X
94070 26 4 XXX 0 X 76.77 X
94070 26 1 XXX 0 X 84.90 X
94070 TC 2 XXX 0 X 113.53 X
94070 TC 3 XXX 0 X 113.53 X
94070 TC 4 XXX 0 X 113.53 X
94070 TC 1 XXX 0 X 137.20 X
94070   2 XXX 0 X 190.30 X
94070   3 XXX 0 X 190.30 X
94070   4 XXX 0 X 190.30 X
94070   1 XXX 0 X 222.11 X
94150 TC 4 XXX 9 X 7.17 X
94150 TC 3 XXX 9 X 7.28 X
94150 26 3 XXX 9 X 17.18 X
94150 26 1 XXX 9 X 18.41 X
94150 26 2 XXX 9 X 18.77 X
94150 26 4 XXX 9 X 19.47 X
94150 TC 2 XXX 9 X 33.26 X
94150   4 XXX 9 X 33.78 X
94150 TC 1 XXX 9 X 34.93 X
94150   3 XXX 9 X 35.10 X
94150   1 XXX 9 X 37.21 X
94150   2 XXX 9 X 37.67 X
94200 26 4 XXX 0 X 18.13 X
94200 TC 4 XXX 0 X 20.68 X
94200 TC 3 XXX 0 X 20.99 X
94200 26 3 XXX 0 X 22.98 X
94200 26 2 XXX 0 X 24.32 X
94200 26 1 XXX 0 X 24.63 X
94200   3 XXX 0 X 65.82 X
94200   2 XXX 0 X 66.08 X
94200   1 XXX 0 X 69.27 X
94200   4 XXX 0 X 74.64 X
94200 TC 2 XXX 0 X 75.14 X
94200 TC 1 XXX 0 X 76.51 X
94375 26 4 XXX 0 X 37.81 X
94375 TC 4 XXX 0 X 39.75 X
94375 26 3 XXX 0 X 40.65 X
94375 26 2 XXX 0 X 41.66 X
94375 26 1 XXX 0 X 41.94 X
94375 TC 3 XXX 0 X 95.53 X
94375 TC 2 XXX 0 X 96.37 X
94375   4 XXX 0 X 96.60 X
94375 TC 1 XXX 0 X 97.26 X
94375   3 XXX 0 X 99.99 X
94375   2 XXX 0 X 102.54 X
94375   1 XXX 0 X 103.38 X
94450 TC 4 XXX 0 X 31.79 X
94450 TC 3 XXX 0 X 32.30 X
94450 TC 2 XXX 0 X 35.24 X
94450 TC 1 XXX 0 X 35.92 X
94450 26 4 XXX 0 X 53.87 X
94450 26 3 XXX 0 X 54.52 X
94450 26 2 XXX 0 X 57.26 X
94450 26 1 XXX 0 X 57.95 X
94450   4 XXX 0 X 85.72 X
94450   3 XXX 0 X 86.85 X
94450   2 XXX 0 X 92.48 X
94450   1 XXX 0 X 192.39 X
94452 26 2 XXX 0 X 27.64 X
94452 26 3 XXX 0 X 27.64 X
94452 26 4 XXX 0 X 27.64 X
94452 26 1 XXX 0 X 29.95 X
94452 TC 2 XXX 0 X 58.72 X
94452 TC 3 XXX 0 X 58.72 X
94452 TC 4 XXX 0 X 58.72 X
94452 TC 1 XXX 0 X 70.94 X
94452   2 XXX 0 X 86.34 X
94452   3 XXX 0 X 86.34 X
94452   4 XXX 0 X 86.34 X
94452   1 XXX 0 X 100.88 X
94453 26 2 XXX 0 X 35.56 X
94453 26 3 XXX 0 X 35.56 X
94453 26 4 XXX 0 X 35.56 X
94453 26 1 XXX 0 X 38.37 X
94453 TC 2 XXX 0 X 87.21 X
94453 TC 3 XXX 0 X 87.21 X
94453 TC 4 XXX 0 X 87.21 X
94453 TC 1 XXX 0 X 105.12 X
94453   2 XXX 0 X 122.78 X
94453   3 XXX 0 X 122.78 X
94453   4 XXX 0 X 122.78 X
94453   1 XXX 0 X 143.49 X
94610   2 XXX 0 X 91.73 X
94610   3 XXX 0 X 91.73 X
94610   4 XXX 0 X 91.73 X
94610   1 XXX 0 X 106.11 X
94617 26 2 XXX 0 X 42.05 X
94617 26 3 XXX 0 X 42.05 X
94617 26 4 XXX 0 X 42.05 X
94617 26 1 XXX 0 X 44.57 X
94617 TC 2 XXX 0 X 73.61 X
94617 TC 3 XXX 0 X 73.61 X
94617 TC 4 XXX 0 X 73.61 X
94617 TC 1 XXX 0 X 84.61 X
94617   2 XXX 0 X 115.65 X
94617   3 XXX 0 X 115.65 X
94617   4 XXX 0 X 115.65 X
94617   1 XXX 0 X 129.18 X
94618 TC 2 XXX 0 X 13.49 X
94618 TC 3 XXX 0 X 13.49 X
94618 TC 4 XXX 0 X 13.49 X
94618 TC 1 XXX 0 X 15.55 X
94618 26 2 XXX 0 X 28.78 X
94618 26 3 XXX 0 X 28.78 X
94618 26 4 XXX 0 X 28.78 X
94618 26 1 XXX 0 X 30.49 X
94618   2 XXX 0 X 42.26 X
94618   3 XXX 0 X 42.26 X
94618   4 XXX 0 X 42.26 X
94618   1 XXX 0 X 46.03 X
94619 26 2 XXX 0 X 26.32 X
94619 26 3 XXX 0 X 26.32 X
94619 26 4 XXX 0 X 26.32 X
94619 26 1 XXX 0 X 27.94 X
94619 TC 2 XXX 0 X 53.64 X
94619 TC 3 XXX 0 X 53.64 X
94619 TC 4 XXX 0 X 53.64 X
94619 TC 1 XXX 0 X 62.01 X
94619   2 XXX 0 X 79.96 X
94619   3 XXX 0 X 79.96 X
94619   4 XXX 0 X 79.96 X
94619   1 XXX 0 X 89.96 X
94621 26 2 XXX 0 X 86.60 X
94621 26 3 XXX 0 X 86.60 X
94621 26 4 XXX 0 X 86.60 X
94621 26 1 XXX 0 X 93.89 X
94621 TC 2 XXX 0 X 107.17 X
94621 TC 3 XXX 0 X 107.17 X
94621 TC 4 XXX 0 X 107.17 X
94621 TC 1 XXX 0 X 128.10 X
94621   2 XXX 0 X 193.81 X
94621   3 XXX 0 X 193.81 X
94621   4 XXX 0 X 193.81 X
94621   1 XXX 0 X 222.08 X
94640   3 XXX 0 X 33.93 X
94640   2 XXX 0 X 36.97 X
94640   1 XXX 0 X 37.64 X
94640   4 XXX 0 X 44.67 X
94642     XXX 0 X 72.70 X
94644   2 XXX 0 X 50.02 X
94644   3 XXX 0 X 50.02 X
94644   4 XXX 0 X 50.02 X
94644   1 XXX 0 X 61.66 X
94645   2 XXX 0 X 19.06 X
94645   3 XXX 0 X 19.06 X
94645   4 XXX 0 X 19.06 X
94645   1 XXX 0 X 23.80 X
94660   2 XXX 0 X 134.88 X
94660   1 XXX 0 X 136.62 X
94660   3 XXX 0 X 158.02 X
94660   4 XXX 0 X 164.36 X
94662   4 XXX 0 X 89.38 X
94662   1 XXX 0 X 95.06 X
94662   3 XXX 0 X 160.33 X
94662   2 XXX 0 X 161.81 X
94664   4 XXX 0 X 37.44 X
94664   3 XXX 0 X 41.05 X
94664   1 XXX 0 X 43.26 X
94664   2 XXX 0 X 45.44 X
94667   4 XXX 0 X 48.51 X
94667   3 XXX 0 X 54.99 X
94667   2 XXX 0 X 56.90 X
94667   1 XXX 0 X 57.34 X
94668   4 XXX 0 X 29.40 X
94668   3 XXX 0 X 29.91 X
94668   2 XXX 0 X 32.71 X
94668   1 XXX 0 X 33.36 X
94669   2 XXX 0 X 44.82 X
94669   3 XXX 0 X 44.82 X
94669   4 XXX 0 X 44.82 X
94669   1 XXX 0 X 52.33 X
94680 TC 4 XXX 0 X 45.45 X
94680 TC 3 XXX 0 X 46.17 X
94680 26 3 XXX 0 X 50.05 X
94680 26 4 XXX 0 X 50.22 X
94680 TC 2 XXX 0 X 51.25 X
94680 TC 1 XXX 0 X 52.47 X
94680 26 2 XXX 0 X 62.51 X
94680 26 1 XXX 0 X 66.61 X
94680   4 XXX 0 X 95.71 X
94680   3 XXX 0 X 97.05 X
94680   1 XXX 0 X 107.36 X
94680   2 XXX 0 X 144.47 X
94681 26 4 XXX 0 X 110.49 X
94681 TC 4 XXX 0 X 116.20 X
94681 26 2 XXX 0 X 116.27 X
94681 26 3 XXX 0 X 116.39 X
94681 TC 3 XXX 0 X 118.00 X
94681 26 1 XXX 0 X 118.27 X
94681 TC 1 XXX 0 X 132.07 X
94681   3 XXX 0 X 169.53 X
94681 TC 2 XXX 0 X 186.46 X
94681   1 XXX 0 X 206.55 X
94681   4 XXX 0 X 229.38 X
94681   2 XXX 0 X 238.13 X
94690 26 4 XXX 0 X 14.35 X
94690 26 3 XXX 0 X 14.38 X
94690 26 2 XXX 0 X 14.52 X
94690 26 1 XXX 0 X 14.54 X
94690 TC 4 XXX 0 X 44.48 X
94690 TC 3 XXX 0 X 45.23 X
94690 TC 2 XXX 0 X 49.25 X
94690 TC 1 XXX 0 X 50.21 X
94690   4 XXX 0 X 54.34 X
94690   3 XXX 0 X 55.15 X
94690   2 XXX 0 X 56.44 X
94690   1 XXX 0 X 60.62 X
94726 26 2 XXX 0 X 17.30 X
94726 26 3 XXX 0 X 17.30 X
94726 26 4 XXX 0 X 17.30 X
94726 26 1 XXX 0 X 18.38 X
94726 TC 2 XXX 0 X 54.76 X
94726 TC 3 XXX 0 X 54.76 X
94726 TC 4 XXX 0 X 54.76 X
94726 TC 1 XXX 0 X 63.81 X
94726   2 XXX 0 X 72.05 X
94726   3 XXX 0 X 72.05 X
94726   4 XXX 0 X 72.05 X
94726   1 XXX 0 X 82.18 X
94727 26 2 XXX 0 X 17.30 X
94727 26 3 XXX 0 X 17.30 X
94727 26 4 XXX 0 X 17.30 X
94727 26 1 XXX 0 X 18.38 X
94727 TC 2 XXX 0 X 39.42 X
94727 TC 3 XXX 0 X 39.42 X
94727 TC 4 XXX 0 X 39.42 X
94727 TC 1 XXX 0 X 45.92 X
94727   2 XXX 0 X 56.75 X
94727   3 XXX 0 X 56.75 X
94727   4 XXX 0 X 56.75 X
94727   1 XXX 0 X 64.29 X
94728 26 2 XXX 0 X 17.30 X
94728 26 3 XXX 0 X 17.30 X
94728 26 4 XXX 0 X 17.30 X
94728 26 1 XXX 0 X 18.38 X
94728 TC 2 XXX 0 X 39.42 X
94728 TC 3 XXX 0 X 39.42 X
94728 TC 4 XXX 0 X 39.42 X
94728 TC 1 XXX 0 X 45.92 X
94728   2 XXX 0 X 56.75 X
94728   3 XXX 0 X 56.75 X
94728   4 XXX 0 X 56.75 X
94728   1 XXX 0 X 64.29 X
94729 26 2 ZZZ 0 X 11.54 X
94729 26 3 ZZZ 0 X 11.54 X
94729 26 4 ZZZ 0 X 11.54 X
94729 26 1 ZZZ 0 X 12.34 X
94729 TC 2 ZZZ 0 X 59.54 X
94729 TC 3 ZZZ 0 X 59.54 X
94729 TC 4 ZZZ 0 X 59.54 X
94729 TC 1 ZZZ 0 X 69.23 X
94729   2 ZZZ 0 X 71.11 X
94729   3 ZZZ 0 X 71.11 X
94729   4 ZZZ 0 X 71.11 X
94729   1 ZZZ 0 X 81.59 X
94760   4 XXX 0 X 18.67 X
94760   3 XXX 0 X 18.89 X
94760   2 XXX 0 X 19.99 X
94760   1 XXX 0 X 20.24 X
94761   4 XXX 0 X 38.85 X
94761   3 XXX 0 X 39.38 X
94761   2 XXX 0 X 42.48 X
94761   1 XXX 0 X 43.20 X
94762   4 XXX 0 X 85.78 X
94762   3 XXX 0 X 86.63 X
94762   2 XXX 0 X 91.80 X
94762   1 XXX 0 X 93.05 X
94772 26 1 XXX 0 X 238.26 X
94772 26 2 XXX 0 X 238.26 X
94772 26 3 XXX 0 X 238.26 X
94772 26 4 XXX 0 X 238.26 X
94772 TC 1 XXX 0 X 388.89 X
94772 TC 2 XXX 0 X 388.89 X
94772 TC 3 XXX 0 X 388.89 X
94772 TC 4 XXX 0 X 388.89 X
94772   1 XXX 0 X 627.18 X
94772   2 XXX 0 X 627.18 X
94772   3 XXX 0 X 627.18 X
94772   4 XXX 0 X 627.18 X
94774     YYY 0 X * X
94775     YYY 0 X * X
94776     YYY 0 X * X
94777     YYY 0 X * X
94780   2 XXX 0 X 68.96 33.20
94780   3 XXX 0 X 68.96 33.20
94780   4 XXX 0 X 68.96 33.20
94780   1 XXX 0 X 77.03 35.54
94781   2 ZZZ 0 X 26.76 11.54
94781   3 ZZZ 0 X 26.76 11.54
94781   4 ZZZ 0 X 26.76 11.54
94781   1 ZZZ 0 X 29.97 12.34
94799     XXX 0 X # X
95004   3 XXX 0 X 7.41 X
95004   4 XXX 0 X 7.61 X
95004   1 XXX 0 X 8.17 X
95004   2 XXX 0 X 8.44 X
95012   2 XXX 0 X 26.08 X
95012   3 XXX 0 X 26.08 X
95012   4 XXX 0 X 26.08 X
95012   1 XXX 0 X 32.12 X
95017   2 XXX 0 X 11.63 5.18
95017   3 XXX 0 X 11.63 5.18
95017   4 XXX 0 X 11.63 5.18
95017   1 XXX 0 X 13.16 5.64
95018   2 XXX 0 X 28.38 9.76
95018   3 XXX 0 X 28.38 9.76
95018   4 XXX 0 X 28.38 9.76
95018   1 XXX 0 X 32.09 10.50
95024   1 XXX 0 X 11.53 X
95024   3 XXX 0 X 11.58 X
95024   4 XXX 0 X 11.67 X
95024   2 XXX 0 X 12.33 X
95027   2 XXX 0 X 15.43 X
95027   4 XXX 0 X 16.35 X
95027   3 XXX 0 X 16.45 X
95027   1 XXX 0 X 17.06 X
95028   3 XXX 0 X 17.48 X
95028   4 XXX 0 X 18.27 X
95028   1 XXX 0 X 19.29 X
95028   2 XXX 0 X 19.99 X
95044   3 XXX 0 X 12.94 X
95044   4 XXX 0 X 15.19 X
95044   2 XXX 0 X 16.62 X
95044   1 XXX 0 X 16.89 X
95052   3 XXX 0 X 15.88 X
95052   2 XXX 0 X 17.19 X
95052   1 XXX 0 X 17.30 X
95052   4 XXX 0 X 19.82 X
95056   1 XXX 0 X 13.55 X
95056   2 XXX 0 X 13.87 X
95056   4 XXX 0 X 14.34 X
95056   3 XXX 0 X 14.52 X
95060   4 XXX 0 X 21.10 X
95060   3 XXX 0 X 21.36 X
95060   2 XXX 0 X 22.68 X
95060   1 XXX 0 X 23.03 X
95065   4 XXX 0 X 15.90 X
95065   2 XXX 0 X 17.41 X
95065   1 XXX 0 X 17.73 X
95065   3 XXX 0 X 17.97 X
95070   4 XXX 0 X 175.02 X
95070   3 XXX 0 X 178.07 X
95070   2 XXX 0 X 189.17 X
95070   1 XXX 0 X 191.84 X
95076   2 XXX 0 X 155.47 97.96
95076   3 XXX 0 X 155.47 97.96
95076   4 XXX 0 X 155.47 97.96
95076   1 XXX 0 X 170.75 104.02
95079   2 ZZZ 0 X 110.87 90.11
95079   3 ZZZ 0 X 110.87 90.11
95079   4 ZZZ 0 X 110.87 90.11
95079   1 ZZZ 0 X 119.82 95.74
95115   4 0 0 X 27.92 X
95115   3 0 0 X 29.64 X
95115   2 0 0 X 30.34 X
95115   1 0 0 X 32.23 X
95117   3 0 0 X 39.70 X
95117   4 0 0 X 41.83 X
95117   2 0 0 X 41.94 X
95117   1 0 0 X 42.67 X
95120     XXX 9 X 224.60 X
95125     XXX 9 X 277.11 X
95130     XXX 9 X 112.26 X
95131     XXX 9 X 174.66 X
95132     XXX 9 X 236.79 X
95133     XXX 9 X 299.24 X
95134     XXX 9 X 361.64 X
95144     0 0 X 19.45 X
95145     0 0 X 93.35 X
95146     0 0 X 159.99 X
95147     0 0 X 212.08 X
95148     0 0 X 274.41 X
95149     0 0 X 336.60 X
95165     0 0 X 96.80 X
95170     0 0 X * X
95180   1 0 0 X 128.07 X
95180   3 0 0 X 129.21 X
95180   2 0 0 X 132.26 X
95180   4 0 0 X 180.54 X
95199     0 0 X # X
95249   2 XXX 0 X 65.67 X
95249   3 XXX 0 X 65.67 X
95249   4 XXX 0 X 65.67 X
95249   1 XXX 0 X 75.59 X
95250   2 XXX 0 X 94.06 X
95250   3 XXX 0 X 94.06 X
95250   4 XXX 0 X 94.06 X
95250   1 XXX 0 X 110.90 X
95251   2 XXX 0 X 43.92 X
95251   3 XXX 0 X 43.92 X
95251   4 XXX 0 X 43.92 X
95251   1 XXX 0 X 47.51 X
95700         X * X
95705         X * X
95706         X * X
95707         X * X
95708         X * X
95709         X * X
95710         X * X
95711         X * X
95712         X * X
95713         X * X
95714         X * X
95715         X * X
95716         X * X
95717   2 XXX 0 X 122.40 120.81
95717   3 XXX 0 X 122.40 120.81
95717   4 XXX 0 X 122.40 120.81
95717   1 XXX 0 X 131.53 129.68
95718   2 XXX 0 X 160.83 158.44
95718   3 XXX 0 X 160.83 158.44
95718   4 XXX 0 X 160.83 158.44
95718   1 XXX 0 X 173.66 170.91
95719   2 XXX 0 X 189.23 187.23
95719   3 XXX 0 X 189.23 187.23
95719   4 XXX 0 X 189.23 187.23
95719   1 XXX 0 X 204.01 201.70
95720   2 XXX 0 X 248.92 245.32
95720   3 XXX 0 X 248.92 245.32
95720   4 XXX 0 X 248.92 245.32
95720   1 XXX 0 X 268.83 264.68
95721   2 XXX 0 X 250.91 246.11
95721   3 XXX 0 X 250.91 246.11
95721   4 XXX 0 X 250.91 246.11
95721   1 XXX 0 X 271.12 265.60
95722   2 XXX 0 X 304.55 299.34
95722   3 XXX 0 X 304.55 299.34
95722   4 XXX 0 X 304.55 299.34
95722   1 XXX 0 X 329.08 323.11
95723   2 XXX 0 X 311.08 304.69
95723   3 XXX 0 X 311.08 304.69
95723   4 XXX 0 X 311.08 304.69
95723   1 XXX 0 X 336.51 329.14
95724   2 XXX 0 X 388.88 381.69
95724   3 XXX 0 X 388.88 381.69
95724   4 XXX 0 X 388.88 381.69
95724   1 XXX 0 X 420.17 411.88
95725   2 XXX 0 X 355.05 346.67
95725   3 XXX 0 X 355.05 346.67
95725   4 XXX 0 X 355.05 346.67
95725   1 XXX 0 X 384.16 374.50
95726   2 XXX 0 X 491.50 482.31
95726   3 XXX 0 X 491.50 482.31
95726   4 XXX 0 X 491.50 482.31
95726   1 XXX 0 X 531.09 520.50
95782 26 2 XXX 0 X 173.94 X
95782 26 3 XXX 0 X 173.94 X
95782 26 4 XXX 0 X 173.94 X
95782 26 1 XXX 0 X 185.31 X
95782 TC 2 XXX 0 X 1,168.54 X
95782 TC 3 XXX 0 X 1,168.54 X
95782 TC 4 XXX 0 X 1,168.54 X
95782   2 XXX 0 X 1,342.46 X
95782   3 XXX 0 X 1,342.46 X
95782   4 XXX 0 X 1,342.46 X
95782 TC 1 XXX 0 X 1,358.28 X
95782   1 XXX 0 X 1,543.57 X
95783 26 2 XXX 0 X 190.23 X
95783 26 3 XXX 0 X 190.23 X
95783 26 4 XXX 0 X 190.23 X
95783 26 1 XXX 0 X 202.89 X
95783 TC 2 XXX 0 X 1,243.14 X
95783 TC 3 XXX 0 X 1,243.14 X
95783 TC 4 XXX 0 X 1,243.14 X
95783   2 XXX 0 X 1,433.32 X
95783   3 XXX 0 X 1,433.32 X
95783   4 XXX 0 X 1,433.32 X
95783 TC 1 XXX 0 X 1,445.12 X
95783   1 XXX 0 X 1,648.01 X
95800 26 2 XXX 0 X 85.38 X
95800 26 3 XXX 0 X 85.38 X
95800 26 4 XXX 0 X 85.38 X
95800 26 1 XXX 0 X 91.17 X
95800 TC 2 XXX 0 X 210.38 X
95800 TC 3 XXX 0 X 210.38 X
95800 TC 4 XXX 0 X 210.38 X
95800 TC 1 XXX 0 X 238.26 X
95800   2 XXX 0 X 295.80 X
95800   3 XXX 0 X 295.80 X
95800   4 XXX 0 X 295.80 X
95800   1 XXX 0 X 329.45 X
95801 TC 2 XXX 0 X 65.03 X
95801 TC 3 XXX 0 X 65.03 X
95801 TC 4 XXX 0 X 65.03 X
95801 TC 1 XXX 0 X 73.75 X
95801 26 2 XXX 0 X 75.59 X
95801 26 3 XXX 0 X 75.59 X
95801 26 4 XXX 0 X 75.59 X
95801 26 1 XXX 0 X 80.40 X
95801   2 XXX 0 X 140.62 X
95801   3 XXX 0 X 140.62 X
95801   4 XXX 0 X 140.62 X
95801   1 XXX 0 X 154.14 X
95803     XXX 0 X * X
95805 26 2 XXX 0 X 190.16 X
95805 26 3 XXX 0 X 190.16 X
95805 26 4 XXX 0 X 190.16 X
95805 26 1 XXX 0 X 206.16 X
95805 TC 2 XXX 0 X 405.82 X
95805 TC 3 XXX 0 X 405.82 X
95805 TC 4 XXX 0 X 405.82 X
95805 TC 1 XXX 0 X 491.08 X
95805   2 XXX 0 X 595.91 X
95805   3 XXX 0 X 595.91 X
95805   4 XXX 0 X 595.91 X
95805   1 XXX 0 X 697.17 X
95806 26 2 XXX 0 X 326.92 X
95806 26 3 XXX 0 X 326.92 X
95806 26 4 XXX 0 X 326.92 X
95806 26 1 XXX 0 X 373.67 X
95806 TC 2 XXX 0 X 387.56 X
95806 TC 3 XXX 0 X 387.56 X
95806 TC 4 XXX 0 X 387.56 X
95806 TC 1 XXX 0 X 468.89 X
95806   2 XXX 0 X 714.47 X
95806   3 XXX 0 X 714.47 X
95806   4 XXX 0 X 714.47 X
95806   1 XXX 0 X 842.54 X