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DLI
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Health Care Services Review
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Medical Fee Review
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Fee Schedule
>
Fee Schedule 95807-95933
Begin Main Content Area
Page Content
Content Editor
2024 Workers' Compensation Part B Fee Schedule
95807-95933
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
95807
001
XXX
0
X
1,103.59
X
95807
26
001
XXX
0
X
371.66
X
95807
TC
001
XXX
0
X
731.92
X
95807
004
XXX
0
X
931.76
X
95807
26
004
XXX
0
X
326.75
X
95807
TC
004
XXX
0
X
604.96
X
95807
003
XXX
0
X
931.76
X
95807
26
003
XXX
0
X
326.75
X
95807
TC
003
XXX
0
X
604.96
X
95807
002
XXX
0
X
931.76
X
95807
26
002
XXX
0
X
326.75
X
95807
TC
002
XXX
0
X
604.96
X
95808
004
XXX
0
X
953.30
X
95808
26
004
XXX
0
X
462.66
X
95808
TC
004
XXX
0
X
501.16
X
95808
002
XXX
0
X
1,222.32
X
95808
26
002
XXX
0
X
535.86
X
95808
TC
002
XXX
0
X
1,029.18
X
95808
003
XXX
0
X
1,106.81
X
95808
26
003
XXX
0
X
526.33
X
95808
TC
003
XXX
0
X
509.10
X
95808
001
XXX
0
X
1,145.00
X
95808
26
001
XXX
0
X
548.88
X
95808
TC
001
XXX
0
X
565.04
X
95810
004
XXX
0
X
953.30
X
95810
26
004
XXX
0
X
462.66
X
95810
TC
004
XXX
0
X
501.16
X
95810
003
XXX
0
X
1,106.81
X
95810
26
003
XXX
0
X
526.33
X
95810
TC
003
XXX
0
X
509.10
X
95810
002
XXX
0
X
1,222.32
X
95810
26
002
XXX
0
X
535.86
X
95810
TC
002
XXX
0
X
1,029.18
X
95810
001
XXX
0
X
1,145.00
X
95810
26
001
XXX
0
X
548.88
X
95810
TC
001
XXX
0
X
565.04
X
95811
004
XXX
0
X
1,220.38
X
95811
26
004
XXX
0
X
584.96
X
95811
TC
004
XXX
0
X
635.41
X
95811
002
XXX
0
X
1,220.38
X
95811
26
002
XXX
0
X
584.96
X
95811
TC
002
XXX
0
X
635.41
X
95811
003
XXX
0
X
1,220.38
X
95811
26
003
XXX
0
X
584.96
X
95811
TC
003
XXX
0
X
635.41
X
95811
001
XXX
0
X
1,417.52
X
95811
26
001
XXX
0
X
648.96
X
95811
TC
001
XXX
0
X
768.56
X
95812
002
XXX
0
X
310.68
X
95812
26
002
XXX
0
X
175.04
X
95812
TC
002
XXX
0
X
150.98
X
95812
001
XXX
0
X
335.17
X
95812
26
001
XXX
0
X
180.49
X
95812
TC
001
XXX
0
X
156.58
X
95812
004
XXX
0
X
292.15
X
95812
26
004
XXX
0
X
159.06
X
95812
TC
004
XXX
0
X
135.11
X
95812
003
XXX
0
X
287.35
X
95812
26
003
XXX
0
X
172.36
X
95812
TC
003
XXX
0
X
120.52
X
95813
004
XXX
0
X
356.57
X
95813
26
004
XXX
0
X
221.48
X
95813
TC
004
XXX
0
X
135.11
X
95813
003
XXX
0
X
361.67
X
95813
26
003
XXX
0
X
224.12
X
95813
TC
003
XXX
0
X
137.54
X
95813
001
XXX
0
X
394.06
X
95813
26
001
XXX
0
X
237.43
X
95813
TC
001
XXX
0
X
156.58
X
95813
002
XXX
0
X
384.06
X
95813
26
002
XXX
0
X
233.16
X
95813
TC
002
XXX
0
X
150.98
X
95816
001
XXX
0
X
323.24
X
95816
26
001
XXX
0
X
176.14
X
95816
TC
001
XXX
0
X
144.09
X
95816
004
XXX
0
X
238.19
X
95816
26
004
XXX
0
X
149.55
X
95816
TC
004
XXX
0
X
127.63
X
95816
003
XXX
0
X
257.73
X
95816
26
003
XXX
0
X
172.08
X
95816
TC
003
XXX
0
X
87.07
X
95816
002
XXX
0
X
282.16
X
95816
26
002
XXX
0
X
169.25
X
95816
TC
002
XXX
0
X
141.21
X
95819
003
XXX
0
X
267.34
X
95819
26
003
XXX
0
X
181.70
X
95819
TC
003
XXX
0
X
87.07
X
95819
002
XXX
0
X
292.55
X
95819
26
002
XXX
0
X
179.63
X
95819
TC
002
XXX
0
X
141.21
X
95819
004
XXX
0
X
285.00
X
95819
26
004
XXX
0
X
159.04
X
95819
TC
004
XXX
0
X
127.63
X
95819
001
XXX
0
X
333.79
X
95819
26
001
XXX
0
X
186.63
X
95819
TC
001
XXX
0
X
144.09
X
95822
004
XXX
0
X
338.14
X
95822
26
004
XXX
0
X
162.87
X
95822
TC
004
XXX
0
X
175.17
X
95822
003
XXX
0
X
342.72
X
95822
26
003
XXX
0
X
202.73
X
95822
TC
003
XXX
0
X
177.92
X
95822
002
XXX
0
X
331.27
X
95822
26
002
XXX
0
X
157.14
X
95822
TC
002
XXX
0
X
186.44
X
95822
001
XXX
0
X
372.08
X
95822
26
001
XXX
0
X
205.15
X
95822
TC
001
XXX
0
X
197.86
X
95824
XXX
0
X
*
X
95829
003
XXX
0
X
468.24
X
95829
26
003
XXX
0
X
662.36
X
95829
TC
003
XXX
0
X
15.17
X
95829
004
XXX
0
X
670.96
X
95829
26
004
XXX
0
X
656.04
X
95829
TC
004
XXX
0
X
14.99
X
95829
002
XXX
0
X
477.81
X
95829
26
002
XXX
0
X
470.69
X
95829
TC
002
XXX
0
X
16.86
X
95829
001
XXX
0
X
480.23
X
95829
26
001
XXX
0
X
472.90
X
95829
TC
001
XXX
0
X
17.27
X
95830
002
XXX
0
X
297.72
X
95830
001
XXX
0
X
274.39
X
95830
004
XXX
0
X
247.56
X
95830
003
XXX
0
X
250.39
X
95836
003
XXX
0
X
154.60
X
95836
002
XXX
0
X
154.60
X
95836
004
XXX
0
X
154.60
X
95836
001
XXX
0
X
168.06
X
95851
004
XXX
0
X
51.49
40.34
95851
002
XXX
0
X
55.10
43.05
95851
003
XXX
0
X
52.07
40.78
95851
001
XXX
0
X
55.72
43.62
95852
004
XXX
0
X
34.36
27.44
95852
003
XXX
0
X
34.80
27.75
95852
002
XXX
0
X
36.97
29.43
95852
001
XXX
0
X
37.58
29.90
95857
001
XXX
0
X
109.50
84.46
95857
002
XXX
0
X
108.41
83.81
95857
003
XXX
0
X
105.26
81.09
95857
004
XXX
0
X
104.53
80.59
95860
001
XXX
0
X
229.58
X
95860
26
001
XXX
0
X
184.96
X
95860
TC
001
XXX
0
X
41.11
X
95860
003
XXX
0
X
223.78
X
95860
26
003
XXX
0
X
180.82
X
95860
TC
003
XXX
0
X
36.94
X
95860
002
XXX
0
X
227.61
X
95860
26
002
XXX
0
X
183.96
X
95860
TC
002
XXX
0
X
44.02
X
95860
004
XXX
0
X
223.86
X
95860
26
004
XXX
0
X
175.29
X
95860
TC
004
XXX
0
X
36.37
X
95861
002
XXX
0
X
378.93
X
95861
26
002
XXX
0
X
299.29
X
95861
TC
002
XXX
0
X
79.58
X
95861
004
XXX
0
X
352.24
X
95861
26
004
XXX
0
X
281.11
X
95861
TC
004
XXX
0
X
71.77
X
95861
003
XXX
0
X
356.81
X
95861
26
003
XXX
0
X
283.91
X
95861
TC
003
XXX
0
X
72.19
X
95861
001
XXX
0
X
384.25
X
95861
26
001
XXX
0
X
303.04
X
95861
TC
001
XXX
0
X
81.18
X
95863
002
XXX
0
X
448.96
X
95863
26
002
XXX
0
X
348.94
X
95863
TC
002
XXX
0
X
100.02
X
95863
003
XXX
0
X
423.25
X
95863
26
003
XXX
0
X
331.44
X
95863
TC
003
XXX
0
X
91.81
X
95863
004
XXX
0
X
417.84
X
95863
26
004
XXX
0
X
327.45
X
95863
TC
004
XXX
0
X
90.37
X
95863
001
XXX
0
X
455.14
X
95863
26
001
XXX
0
X
353.16
X
95863
TC
001
XXX
0
X
101.98
X
95864
001
XXX
0
X
598.68
X
95864
26
001
XXX
0
X
358.73
X
95864
TC
001
XXX
0
X
194.27
X
95864
004
XXX
0
X
545.97
X
95864
26
004
XXX
0
X
373.64
X
95864
TC
004
XXX
0
X
172.37
X
95864
002
XXX
0
X
589.95
X
95864
26
002
XXX
0
X
399.32
X
95864
TC
002
XXX
0
X
190.56
X
95864
003
XXX
0
X
553.36
X
95864
26
003
XXX
0
X
378.28
X
95864
TC
003
XXX
0
X
175.07
X
95865
002
XXX
0
X
215.73
X
95865
26
002
XXX
0
X
169.36
X
95865
TC
002
XXX
0
X
46.33
X
95865
001
XXX
0
X
243.50
X
95865
26
001
XXX
0
X
185.88
X
95865
TC
001
XXX
0
X
57.60
X
95865
004
XXX
0
X
215.73
X
95865
26
004
XXX
0
X
169.36
X
95865
TC
004
XXX
0
X
46.33
X
95865
003
XXX
0
X
215.73
X
95865
26
003
XXX
0
X
169.36
X
95865
TC
003
XXX
0
X
46.33
X
95866
001
XXX
0
X
163.39
X
95866
26
001
XXX
0
X
144.34
X
95866
TC
001
XXX
0
X
19.06
X
95866
003
XXX
0
X
146.59
X
95866
26
003
XXX
0
X
131.72
X
95866
TC
003
XXX
0
X
14.85
X
95866
002
XXX
0
X
146.59
X
95866
26
002
XXX
0
X
131.72
X
95866
TC
002
XXX
0
X
14.85
X
95866
004
XXX
0
X
146.59
X
95866
26
004
XXX
0
X
131.72
X
95866
TC
004
XXX
0
X
14.85
X
95867
002
XXX
0
X
191.29
X
95867
26
002
XXX
0
X
134.10
X
95867
TC
002
XXX
0
X
61.71
X
95867
001
XXX
0
X
158.27
X
95867
26
001
XXX
0
X
134.86
X
95867
TC
001
XXX
0
X
62.93
X
95867
003
XXX
0
X
179.30
X
95867
26
003
XXX
0
X
131.18
X
95867
TC
003
XXX
0
X
56.75
X
95867
004
XXX
0
X
176.86
X
95867
26
004
XXX
0
X
121.00
X
95867
TC
004
XXX
0
X
55.92
X
95868
004
XXX
0
X
340.18
X
95868
26
004
XXX
0
X
275.59
X
95868
TC
004
XXX
0
X
67.05
X
95868
002
XXX
0
X
354.59
X
95868
26
002
XXX
0
X
294.28
X
95868
TC
002
XXX
0
X
74.17
X
95868
003
XXX
0
X
342.76
X
95868
26
003
XXX
0
X
278.98
X
95868
TC
003
XXX
0
X
68.14
X
95868
001
XXX
0
X
357.92
X
95868
26
001
XXX
0
X
297.95
X
95868
TC
001
XXX
0
X
75.61
X
95869
004
XXX
0
X
192.43
X
95869
26
004
XXX
0
X
183.58
X
95869
TC
004
XXX
0
X
20.53
X
95869
003
XXX
0
X
201.16
X
95869
26
003
XXX
0
X
162.49
X
95869
TC
003
XXX
0
X
20.82
X
95869
002
XXX
0
X
188.60
X
95869
26
002
XXX
0
X
166.31
X
95869
TC
002
XXX
0
X
22.89
X
95869
001
XXX
0
X
208.36
X
95869
26
001
XXX
0
X
170.88
X
95869
TC
001
XXX
0
X
23.31
X
95870
004
XXX
0
X
84.46
X
95870
26
004
XXX
0
X
64.91
X
95870
TC
004
XXX
0
X
19.55
X
95870
003
XXX
0
X
84.46
X
95870
26
003
XXX
0
X
64.91
X
95870
TC
003
XXX
0
X
19.55
X
95870
002
XXX
0
X
84.46
X
95870
26
002
XXX
0
X
64.91
X
95870
TC
002
XXX
0
X
19.55
X
95870
001
XXX
0
X
96.83
X
95870
26
001
XXX
0
X
73.05
X
95870
TC
001
XXX
0
X
23.83
X
95872
003
XXX
0
X
280.05
X
95872
26
003
XXX
0
X
220.32
X
95872
TC
003
XXX
0
X
59.63
X
95872
004
XXX
0
X
276.59
X
95872
26
004
XXX
0
X
220.57
X
95872
TC
004
XXX
0
X
58.72
X
95872
001
XXX
0
X
299.51
X
95872
26
001
XXX
0
X
233.04
X
95872
TC
001
XXX
0
X
66.45
X
95872
002
XXX
0
X
446.84
X
95872
26
002
XXX
0
X
230.57
X
95872
TC
002
XXX
0
X
65.19
X
95873
004
ZZZ
0
X
52.87
X
95873
26
004
ZZZ
0
X
38.57
X
95873
TC
004
ZZZ
0
X
14.28
X
95873
002
ZZZ
0
X
52.87
X
95873
26
002
ZZZ
0
X
38.57
X
95873
TC
002
ZZZ
0
X
14.28
X
95873
003
ZZZ
0
X
52.87
X
95873
26
003
ZZZ
0
X
38.57
X
95873
TC
003
ZZZ
0
X
14.28
X
95873
001
ZZZ
0
X
60.29
X
95873
26
001
ZZZ
0
X
42.18
X
95873
TC
001
ZZZ
0
X
18.09
X
95874
001
ZZZ
0
X
61.07
X
95874
26
001
ZZZ
0
X
42.96
X
95874
TC
001
ZZZ
0
X
18.09
X
95874
004
ZZZ
0
X
53.47
X
95874
26
004
ZZZ
0
X
39.22
X
95874
TC
004
ZZZ
0
X
14.28
X
95874
003
ZZZ
0
X
53.47
X
95874
26
003
ZZZ
0
X
39.22
X
95874
TC
003
ZZZ
0
X
14.28
X
95874
002
ZZZ
0
X
53.47
X
95874
26
002
ZZZ
0
X
39.22
X
95874
TC
002
ZZZ
0
X
14.28
X
95875
001
XXX
0
X
212.95
X
95875
26
001
XXX
0
X
165.15
X
95875
TC
001
XXX
0
X
47.79
X
95875
003
XXX
0
X
199.08
X
95875
26
003
XXX
0
X
157.30
X
95875
TC
003
XXX
0
X
41.77
X
95875
002
XXX
0
X
210.26
X
95875
26
002
XXX
0
X
163.57
X
95875
TC
002
XXX
0
X
46.65
X
95875
004
XXX
0
X
196.93
X
95875
26
004
XXX
0
X
155.78
X
95875
TC
004
XXX
0
X
41.14
X
95885
004
ZZZ
0
X
87.89
X
95885
26
004
ZZZ
0
X
29.12
X
95885
TC
004
ZZZ
0
X
58.79
X
95885
003
ZZZ
0
X
87.89
X
95885
26
003
ZZZ
0
X
29.12
X
95885
TC
003
ZZZ
0
X
58.79
X
95885
002
ZZZ
0
X
87.89
X
95885
26
002
ZZZ
0
X
29.12
X
95885
TC
002
ZZZ
0
X
58.79
X
95885
001
ZZZ
0
X
99.39
X
95885
26
001
ZZZ
0
X
31.02
X
95885
TC
001
ZZZ
0
X
68.38
X
95886
001
ZZZ
0
X
155.07
X
95886
26
001
ZZZ
0
X
83.08
X
95886
TC
001
ZZZ
0
X
72.01
X
95886
003
ZZZ
0
X
139.71
X
95886
26
003
ZZZ
0
X
77.76
X
95886
TC
003
ZZZ
0
X
61.94
X
95886
002
ZZZ
0
X
139.71
X
95886
26
002
ZZZ
0
X
77.76
X
95886
TC
002
ZZZ
0
X
61.94
X
95886
004
ZZZ
0
X
139.71
X
95886
26
004
ZZZ
0
X
77.76
X
95886
TC
004
ZZZ
0
X
61.94
X
95887
002
ZZZ
0
X
123.96
X
95887
26
002
ZZZ
0
X
61.01
X
95887
TC
002
ZZZ
0
X
62.99
X
95887
003
ZZZ
0
X
123.96
X
95887
26
003
ZZZ
0
X
61.01
X
95887
TC
003
ZZZ
0
X
62.99
X
95887
004
ZZZ
0
X
123.96
X
95887
26
004
ZZZ
0
X
61.01
X
95887
TC
004
ZZZ
0
X
62.99
X
95887
001
ZZZ
0
X
138.25
X
95887
26
001
ZZZ
0
X
64.99
X
95887
TC
001
ZZZ
0
X
73.25
X
95905
001
XXX
0
X
148.31
X
95905
26
001
XXX
0
X
5.68
X
95905
TC
001
XXX
0
X
142.64
X
95905
002
XXX
0
X
125.15
X
95905
26
002
XXX
0
X
5.02
X
95905
TC
002
XXX
0
X
120.12
X
95905
003
XXX
0
X
125.15
X
95905
26
003
XXX
0
X
5.02
X
95905
TC
003
XXX
0
X
120.12
X
95905
004
XXX
0
X
125.15
X
95905
26
004
XXX
0
X
5.02
X
95905
TC
004
XXX
0
X
120.12
X
95907
001
XXX
0
X
162.82
X
95907
26
001
XXX
0
X
87.82
X
95907
TC
001
XXX
0
X
75.03
X
95907
002
XXX
0
X
146.45
X
95907
26
002
XXX
0
X
82.22
X
95907
TC
002
XXX
0
X
64.23
X
95907
004
XXX
0
X
146.45
X
95907
26
004
XXX
0
X
82.22
X
95907
TC
004
XXX
0
X
64.23
X
95907
003
XXX
0
X
146.45
X
95907
26
003
XXX
0
X
82.22
X
95907
TC
003
XXX
0
X
64.23
X
95908
002
XXX
0
X
180.72
X
95908
26
002
XXX
0
X
103.32
X
95908
TC
002
XXX
0
X
77.40
X
95908
001
XXX
0
X
200.73
X
95908
26
001
XXX
0
X
110.43
X
95908
TC
001
XXX
0
X
90.29
X
95908
004
XXX
0
X
180.72
X
95908
26
004
XXX
0
X
103.32
X
95908
TC
004
XXX
0
X
77.40
X
95908
003
XXX
0
X
180.72
X
95908
26
003
XXX
0
X
103.32
X
95908
TC
003
XXX
0
X
77.40
X
95909
003
XXX
0
X
216.62
X
95909
26
003
XXX
0
X
123.28
X
95909
TC
003
XXX
0
X
93.33
X
95909
002
XXX
0
X
216.62
X
95909
26
002
XXX
0
X
123.28
X
95909
TC
002
XXX
0
X
93.33
X
95909
001
XXX
0
X
240.73
X
95909
26
001
XXX
0
X
131.56
X
95909
TC
001
XXX
0
X
109.18
X
95909
004
XXX
0
X
216.62
X
95909
26
004
XXX
0
X
123.28
X
95909
TC
004
XXX
0
X
93.33
X
95910
001
XXX
0
X
316.86
X
95910
26
001
XXX
0
X
176.20
X
95910
TC
001
XXX
0
X
140.65
X
95910
004
XXX
0
X
285.30
X
95910
26
004
XXX
0
X
164.95
X
95910
TC
004
XXX
0
X
120.33
X
95910
003
XXX
0
X
285.30
X
95910
26
003
XXX
0
X
164.95
X
95910
TC
003
XXX
0
X
120.33
X
95910
002
XXX
0
X
285.30
X
95910
26
002
XXX
0
X
164.95
X
95910
TC
002
XXX
0
X
120.33
X
95911
004
XXX
0
X
345.83
X
95911
26
004
XXX
0
X
206.01
X
95911
TC
004
XXX
0
X
139.84
X
95911
003
XXX
0
X
345.83
X
95911
26
003
XXX
0
X
206.01
X
95911
TC
003
XXX
0
X
139.84
X
95911
002
XXX
0
X
345.83
X
95911
26
002
XXX
0
X
206.01
X
95911
TC
002
XXX
0
X
139.84
X
95911
001
XXX
0
X
383.56
X
95911
26
001
XXX
0
X
219.98
X
95911
TC
001
XXX
0
X
163.58
X
95912
002
XXX
0
X
405.36
X
95912
26
002
XXX
0
X
247.19
X
95912
TC
002
XXX
0
X
158.18
X
95912
003
XXX
0
X
405.36
X
95912
26
003
XXX
0
X
247.19
X
95912
TC
003
XXX
0
X
158.18
X
95912
004
XXX
0
X
405.36
X
95912
26
004
XXX
0
X
247.19
X
95912
TC
004
XXX
0
X
158.18
X
95912
001
XXX
0
X
449.14
X
95912
26
001
XXX
0
X
264.04
X
95912
TC
001
XXX
0
X
185.07
X
95913
001
XXX
0
X
520.40
X
95913
26
001
XXX
0
X
312.93
X
95913
TC
001
XXX
0
X
207.48
X
95913
002
XXX
0
X
470.30
X
95913
26
002
XXX
0
X
293.09
X
95913
TC
002
XXX
0
X
177.16
X
95913
003
XXX
0
X
470.30
X
95913
26
003
XXX
0
X
293.09
X
95913
TC
003
XXX
0
X
177.16
X
95913
004
XXX
0
X
470.30
X
95913
26
004
XXX
0
X
293.09
X
95913
TC
004
XXX
0
X
177.16
X
95919
002
XXX
0
X
17.54
X
95919
26
002
XXX
0
X
11.24
X
95919
TC
002
XXX
0
X
6.31
X
95919
003
XXX
0
X
17.54
X
95919
26
003
XXX
0
X
11.24
X
95919
TC
003
XXX
0
X
6.31
X
95919
004
XXX
0
X
17.54
X
95919
26
004
XXX
0
X
11.24
X
95919
TC
004
XXX
0
X
6.31
X
95919
001
XXX
0
X
19.33
X
95919
26
001
XXX
0
X
12.05
X
95919
TC
001
XXX
0
X
7.27
X
95921
001
XXX
0
X
113.29
X
95921
26
001
XXX
0
X
73.49
X
95921
TC
001
XXX
0
X
39.80
X
95921
003
XXX
0
X
98.81
X
95921
26
003
XXX
0
X
66.14
X
95921
TC
003
XXX
0
X
32.66
X
95921
002
XXX
0
X
101.46
X
95921
26
002
XXX
0
X
67.95
X
95921
TC
002
XXX
0
X
33.53
X
95921
004
XXX
0
X
98.81
X
95921
26
004
XXX
0
X
66.14
X
95921
TC
004
XXX
0
X
32.66
X
95922
003
XXX
0
X
103.65
X
95922
26
003
XXX
0
X
71.03
X
95922
TC
003
XXX
0
X
32.66
X
95922
004
XXX
0
X
103.65
X
95922
26
004
XXX
0
X
71.03
X
95922
TC
004
XXX
0
X
32.66
X
95922
002
XXX
0
X
106.50
X
95922
26
002
XXX
0
X
72.96
X
95922
TC
002
XXX
0
X
33.53
X
95922
001
XXX
0
X
119.08
X
95922
26
001
XXX
0
X
79.34
X
95922
TC
001
XXX
0
X
39.80
X
95923
004
XXX
0
X
98.81
X
95923
26
004
XXX
0
X
66.14
X
95923
TC
004
XXX
0
X
32.66
X
95923
001
XXX
0
X
113.29
X
95923
26
001
XXX
0
X
73.49
X
95923
TC
001
XXX
0
X
39.80
X
95923
002
XXX
0
X
101.46
X
95923
26
002
XXX
0
X
67.95
X
95923
TC
002
XXX
0
X
33.53
X
95923
003
XXX
0
X
98.81
X
95923
26
003
XXX
0
X
66.14
X
95923
TC
003
XXX
0
X
32.66
X
95924
001
XXX
0
X
253.67
X
95924
26
001
XXX
0
X
148.12
X
95924
TC
001
XXX
0
X
105.58
X
95924
002
XXX
0
X
229.41
X
95924
26
002
XXX
0
X
138.54
X
95924
TC
002
XXX
0
X
90.86
X
95924
003
XXX
0
X
229.41
X
95924
26
003
XXX
0
X
138.54
X
95924
TC
003
XXX
0
X
90.86
X
95924
004
XXX
0
X
229.41
X
95924
26
004
XXX
0
X
138.54
X
95924
TC
004
XXX
0
X
90.86
X
95925
001
XXX
0
X
307.98
X
95925
26
001
XXX
0
X
195.73
X
95925
TC
001
XXX
0
X
151.66
X
95925
003
XXX
0
X
296.47
X
95925
26
003
XXX
0
X
176.83
X
95925
TC
003
XXX
0
X
136.32
X
95925
004
XXX
0
X
289.22
X
95925
26
004
XXX
0
X
174.75
X
95925
TC
004
XXX
0
X
134.19
X
95925
002
XXX
0
X
301.59
X
95925
26
002
XXX
0
X
189.34
X
95925
TC
002
XXX
0
X
148.74
X
95926
004
XXX
0
X
193.69
X
95926
26
004
XXX
0
X
111.81
X
95926
TC
004
XXX
0
X
81.88
X
95926
003
XXX
0
X
197.11
X
95926
26
003
XXX
0
X
113.63
X
95926
TC
003
XXX
0
X
83.56
X
95926
002
XXX
0
X
213.35
X
95926
26
002
XXX
0
X
121.12
X
95926
TC
002
XXX
0
X
92.19
X
95926
001
XXX
0
X
223.35
X
95926
26
001
XXX
0
X
126.00
X
95926
TC
001
XXX
0
X
97.35
X
95927
004
XXX
0
X
193.69
X
95927
26
004
XXX
0
X
111.81
X
95927
TC
004
XXX
0
X
81.88
X
95927
003
XXX
0
X
197.11
X
95927
26
003
XXX
0
X
113.63
X
95927
TC
003
XXX
0
X
83.56
X
95927
001
XXX
0
X
223.35
X
95927
26
001
XXX
0
X
126.00
X
95927
TC
001
XXX
0
X
97.35
X
95927
002
XXX
0
X
213.35
X
95927
26
002
XXX
0
X
121.12
X
95927
TC
002
XXX
0
X
92.19
X
95928
002
XXX
0
X
343.92
X
95928
26
002
XXX
0
X
169.92
X
95928
TC
002
XXX
0
X
173.99
X
95928
004
XXX
0
X
343.92
X
95928
26
004
XXX
0
X
169.92
X
95928
TC
004
XXX
0
X
173.99
X
95928
003
XXX
0
X
343.92
X
95928
26
003
XXX
0
X
169.92
X
95928
TC
003
XXX
0
X
173.99
X
95928
001
XXX
0
X
393.99
X
95928
26
001
XXX
0
X
184.39
X
95928
TC
001
XXX
0
X
209.55
X
95929
004
XXX
0
X
357.64
X
95929
26
004
XXX
0
X
169.92
X
95929
TC
004
XXX
0
X
187.79
X
95929
003
XXX
0
X
357.64
X
95929
26
003
XXX
0
X
169.92
X
95929
TC
003
XXX
0
X
187.79
X
95929
002
XXX
0
X
357.64
X
95929
26
002
XXX
0
X
169.92
X
95929
TC
002
XXX
0
X
187.79
X
95929
001
XXX
0
X
410.51
X
95929
26
001
XXX
0
X
184.39
X
95929
TC
001
XXX
0
X
226.06
X
95930
003
XXX
0
X
112.37
X
95930
26
003
XXX
0
X
89.06
X
95930
TC
003
XXX
0
X
23.22
X
95930
004
XXX
0
X
110.43
X
95930
26
004
XXX
0
X
87.63
X
95930
TC
004
XXX
0
X
22.82
X
95930
001
XXX
0
X
126.25
X
95930
26
001
XXX
0
X
99.44
X
95930
TC
001
XXX
0
X
26.77
X
95930
002
XXX
0
X
121.06
X
95930
26
002
XXX
0
X
95.45
X
95930
TC
002
XXX
0
X
25.57
X
95933
003
XXX
0
X
188.64
X
95933
26
003
XXX
0
X
130.21
X
95933
TC
003
XXX
0
X
77.64
X
95933
004
XXX
0
X
186.05
X
95933
26
004
XXX
0
X
127.93
X
95933
TC
004
XXX
0
X
76.41
X
95933
001
XXX
0
X
203.81
X
95933
26
001
XXX
0
X
133.75
X
95933
TC
001
XXX
0
X
86.26
X
95933
002
XXX
0
X
203.33
X
95933
26
002
XXX
0
X
136.69
X
95933
TC
002
XXX
0
X
84.62
X
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