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2024 Workers' Compensation Part B Fee Schedule

22850-24073

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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
22850   004 90 2 X 2,022.96 X
22850   003 90 2 X 2,047.57 X
22850   002 90 2 X 2,052.32 X
22850   001 90 2 X 2,236.59 X
22852   001 90 2 X 2,083.28 X
22852   004 90 2 X 2,032.43 X
22852   003 90 2 X 2,057.45 X
22852   002 90 2 X 2,061.42 X
22853   003 ZZZ 0 X 405.97 X
22853   002 ZZZ 0 X 405.97 X
22853   001 ZZZ 0 X 450.13 X
22853   004 ZZZ 0 X 405.97 X
22854   003 ZZZ 0 X 525.51 X
22854   002 ZZZ 0 X 525.51 X
22854   004 ZZZ 0 X 525.51 X
22854   001 ZZZ 0 X 582.73 X
22855   001 90 2 X 2,019.39 X
22855   003 90 2 X 1,858.38 X
22855   002 90 2 X 1,987.98 X
22855   004 90 2 X 1,836.65 X
22856   002 90 2 X 2,749.66 X
22856   003 90 2 X 2,749.66 X
22856   004 90 2 X 2,749.66 X
22856   001 90 2 X 3,120.22 X
22857   001 90 2 X 2,710.31 X
22857   004 90 2 X 2,406.64 X
22857   002 90 2 X 2,406.64 X
22857   003 90 2 X 2,406.64 X
22858   001 ZZZ 0 X 1,187.50 X
22858   004 ZZZ 0 X 1,039.13 X
22858   003 ZZZ 0 X 1,039.13 X
22858   002 ZZZ 0 X 1,039.13 X
22859   001 ZZZ 0 X 582.73 X
22859   004 ZZZ 0 X 525.51 X
22859   003 ZZZ 0 X 525.51 X
22859   002 ZZZ 0 X 525.51 X
22860         X # X
22861   001 90 2 X 3,711.06 X
22861   004 90 2 X 3,336.34 X
22861   002 90 2 X 3,336.34 X
22861   003 90 2 X 3,336.34 X
22862   001 90 2 X 3,324.95 X
22862   003 90 2 X 2,924.27 X
22862   002 90 2 X 2,924.27 X
22862   004 90 2 X 2,924.27 X
22864   002 90 2 X 3,110.00 X
22864   003 90 2 X 3,110.00 X
22864   004 90 2 X 3,110.00 X
22864   001 90 2 X 3,519.59 X
22865   002 90 2 X 2,847.72 X
22865   003 90 2 X 2,847.72 X
22865   004 90 2 X 2,847.72 X
22865   001 90 2 X 3,237.21 X
22867   001 90 2 X 1,679.16 X
22867   004 90 2 X 1,505.05 X
22867   003 90 2 X 1,505.05 X
22867   002 90 2 X 1,505.05 X
22868   004 ZZZ 0 X 379.29 X
22868   001 ZZZ 0 X 419.92 X
22868   003 ZZZ 0 X 379.29 X
22868   002 ZZZ 0 X 379.29 X
22869   002 90 2 X 824.61 X
22869   003 90 2 X 824.61 X
22869   001 90 2 X 919.60 X
22869   004 90 2 X 824.61 X
22870   003 ZZZ 0 X 220.94 X
22870   002 ZZZ 0 X 220.94 X
22870   004 ZZZ 0 X 220.94 X
22870   001 ZZZ 0 X 244.36 X
22899     YYY 2 X # X
22900   001 90 2 X 1,144.61 X
22900   003 90 2 X 1,073.66 X
22900   002 90 2 X 1,123.44 X
22900   004 90 2 X 926.34 X
22901   003 90 2 X 1,120.34 X
22901   002 90 2 X 1,120.34 X
22901   004 90 2 X 1,120.34 X
22901   001 90 2 X 1,256.17 X
22902   002 90 2 X 693.88 559.74
22902   003 90 2 X 693.88 559.74
22902   004 90 2 X 693.88 559.74
22902   001 90 2 X 787.96 628.85
22903   001 90 2 X 828.29 X
22903   002 90 2 X 738.56 X
22903   003 90 2 X 738.56 X
22903   004 90 2 X 738.56 X
22904   001 90 2 X 1,968.53 X
22904   004 90 2 X 1,759.77 X
22904   003 90 2 X 1,759.77 X
22904   002 90 2 X 1,759.77 X
22905   001 90 2 X 2,553.47 X
22905   004 90 2 X 2,282.03 X
22905   003 90 2 X 2,282.03 X
22905   002 90 2 X 2,282.03 X
22999     YYY 2 X # X
23000   003 90 2 X 818.91 X
23000   002 90 2 X 908.08 X
23000   004 90 2 X 878.70 X
23000   001 90 2 X 885.37 X
23020   003 90 2 X 1,732.10 X
23020   002 90 2 X 1,850.62 X
23020   004 90 2 X 1,711.54 X
23020   001 90 2 X 1,879.31 X
23030   001 10 2 X 639.95 X
23030   003 10 2 X 582.99 X
23030   002 10 2 X 630.69 X
23030   004 10 2 X 585.73 X
23031   003 10 2 X 299.84 X
23031   002 10 2 X 313.60 X
23031   004 10 2 X 300.66 X
23031   001 10 2 X 357.61 X
23035   001 90 2 X 1,707.70 X
23035   002 90 2 X 1,681.39 X
23035   003 90 2 X 1,572.73 X
23035   004 90 2 X 1,554.42 X
23040   004 90 2 X 1,967.33 X
23040   001 90 2 X 2,177.55 X
23040   003 90 2 X 1,991.43 X
23040   002 90 2 X 2,141.29 X
23044   004 90 2 X 1,490.85 X
23044   001 90 2 X 1,652.98 X
23044   002 90 2 X 1,844.82 X
23044   003 90 2 X 1,731.08 X
23065   004 10 2 X 310.93 X
23065   003 10 2 X 278.79 X
23065   002 10 2 X 276.44 X
23065   001 10 2 X 331.83 X
23066   002 90 2 X 418.36 X
23066   003 90 2 X 405.19 X
23066   001 90 2 X 425.07 X
23066   004 90 2 X 387.41 X
23071   004 90 2 X 701.57 X
23071   001 90 2 X 789.43 X
23071   003 90 2 X 701.57 X
23071   002 90 2 X 701.57 X
23073   002 90 2 X 1,163.90 X
23073   003 90 2 X 1,163.90 X
23073   001 90 2 X 1,306.94 X
23073   004 90 2 X 1,163.90 X
23075   001 90 2 X 488.30 X
23075   004 90 2 X 422.25 X
23075   003 90 2 X 450.67 X
23075   002 90 2 X 483.10 X
23076   002 90 2 X 1,153.98 X
23076   003 90 2 X 1,121.01 X
23076   004 90 2 X 1,108.59 X
23076   001 90 2 X 1,223.98 X
23077   004 90 2 X 2,426.96 X
23077   002 90 2 X 1,872.08 X
23077   003 90 2 X 1,784.28 X
23077   001 90 2 X 1,883.76 X
23078   004 90 2 X 2,375.24 X
23078   001 90 2 X 2,657.20 X
23078   002 90 2 X 2,375.24 X
23078   003 90 2 X 2,375.24 X
23100   004 90 2 X 1,447.73 X
23100   003 90 2 X 1,608.20 X
23100   002 90 2 X 1,729.37 X
23100   001 90 2 X 1,613.18 X
23101   003 90 2 X 1,570.24 X
23101   002 90 2 X 1,689.37 X
23101   001 90 2 X 1,703.32 X
23101   004 90 2 X 1,358.31 X
23105   001 90 2 X 2,389.43 X
23105   004 90 2 X 1,991.45 X
23105   002 90 2 X 2,332.83 X
23105   003 90 2 X 2,168.60 X
23106   001 90 2 X 2,340.24 X
23106   004 90 2 X 1,145.44 X
23106   002 90 2 X 1,241.28 X
23106   003 90 2 X 2,196.20 X
23107   002 90 2 X 2,168.54 X
23107   003 90 2 X 2,011.11 X
23107   004 90 2 X 1,986.65 X
23107   001 90 2 X 2,206.64 X
23120   004 90 2 X 1,470.58 X
23120   002 90 2 X 1,510.78 X
23120   003 90 2 X 1,476.61 X
23120   001 90 2 X 1,519.00 X
23125   003 90 2 X 1,944.33 X
23125   002 90 2 X 2,368.50 X
23125   004 90 2 X 1,921.06 X
23125   001 90 2 X 2,113.54 X
23130   001 90 2 X 1,738.27 X
23130   003 90 2 X 1,593.40 X
23130   002 90 2 X 1,710.11 X
23130   004 90 2 X 1,594.68 X
23140   004 90 2 X 1,171.15 X
23140   002 90 2 X 1,262.16 X
23140   003 90 2 X 1,184.51 X
23140   001 90 2 X 1,280.98 X
23145   001 90 2 X 2,044.52 X
23145   003 90 2 X 1,875.45 X
23145   002 90 2 X 2,011.62 X
23145   004 90 2 X 1,853.23 X
23146   002 90 2 X 1,519.46 X
23146   003 90 2 X 1,419.48 X
23146   004 90 2 X 1,403.29 X
23146   001 90 2 X 1,543.73 X
23150   001 90 2 X 1,748.19 X
23150   004 90 2 X 2,028.45 X
23150   003 90 2 X 2,036.42 X
23150   002 90 2 X 2,082.48 X
23155   004 90 2 X 2,036.01 X
23155   001 90 2 X 2,241.01 X
23155   002 90 2 X 2,205.86 X
23155   003 90 2 X 2,060.56 X
23156   001 90 2 X 1,918.78 X
23156   003 90 2 X 1,760.01 X
23156   002 90 2 X 1,887.84 X
23156   004 90 2 X 1,739.06 X
23170   001 90 2 X 1,342.33 X
23170   002 90 2 X 1,322.07 X
23170   003 90 2 X 1,238.49 X
23170   004 90 2 X 1,224.19 X
23172   001 90 2 X 1,369.73 X
23172   004 90 2 X 1,251.41 X
23172   003 90 2 X 1,266.45 X
23172   002 90 2 X 1,216.27 X
23174   001 90 2 X 2,090.60 X
23174   003 90 2 X 1,925.14 X
23174   002 90 2 X 2,058.48 X
23174   004 90 2 X 1,901.87 X
23180   001 90 2 X 1,438.79 X
23180   004 90 2 X 1,325.33 X
23180   002 90 2 X 1,419.56 X
23180   003 90 2 X 1,198.43 X
23182   004 90 2 X 1,560.12 X
23182   002 90 2 X 1,692.81 X
23182   003 90 2 X 1,578.70 X
23182   001 90 2 X 1,720.40 X
23184   002 90 2 X 2,120.60 X
23184   003 90 2 X 1,972.29 X
23184   004 90 2 X 1,471.32 X
23184   001 90 2 X 2,156.45 X
23190   003 90 2 X 1,443.15 X
23190   002 90 2 X 1,526.40 X
23190   004 90 2 X 1,426.12 X
23190   001 90 2 X 1,570.12 X
23195   004 90 2 X 1,993.96 X
23195   002 90 2 X 2,166.51 X
23195   003 90 2 X 2,018.15 X
23195   001 90 2 X 2,202.30 X
23200   003 90 2 X 2,240.64 X
23200   002 90 2 X 2,385.14 X
23200   001 90 2 X 2,421.30 X
23200   004 90 2 X 2,214.05 X
23210   003 90 2 X 2,278.03 X
23210   002 90 2 X 2,431.21 X
23210   001 90 2 X 4,006.58 X
23210   004 90 2 X 2,251.52 X
23220   003 90 2 X 3,037.32 X
23220   002 90 2 X 3,124.02 X
23220   001 90 2 X 3,112.88 X
23220   004 90 2 X 2,822.67 X
23330   004 10 2 X 252.18 X
23330   001 10 2 X 269.10 X
23330   003 10 2 X 254.90 X
23330   002 10 2 X 266.28 X
23333   004 90 2 X 725.32 X
23333   001 90 2 X 808.11 X
23333   003 90 2 X 725.32 X
23333   002 90 2 X 725.32 X
23334   001 90 2 X 1,908.77 X
23334   003 90 2 X 1,720.14 X
23334   002 90 2 X 1,720.14 X
23334   004 90 2 X 1,720.14 X
23335   002 90 2 X 2,054.27 X
23335   003 90 2 X 2,054.27 X
23335   004 90 2 X 2,054.27 X
23335   001 90 2 X 2,276.44 X
23350   002 0 2 X 161.84 X
23350   003 0 2 X 154.14 X
23350   004 0 2 X 152.40 X
23350   001 0 2 X 163.62 X
23395   001 90 2 X 2,883.48 X
23395   004 90 2 X 2,616.88 X
23395   003 90 2 X 2,648.14 X
23395   002 90 2 X 2,837.65 X
23397   004 90 2 X 3,251.31 X
23397   002 90 2 X 3,528.91 X
23397   003 90 2 X 3,290.26 X
23397   001 90 2 X 3,586.65 X
23400   004 90 2 X 2,527.41 X
23400   001 90 2 X 2,774.78 X
23400   002 90 2 X 2,732.30 X
23400   003 90 2 X 2,556.96 X
23405   003 90 2 X 1,714.35 X
23405   002 90 2 X 1,828.65 X
23405   001 90 2 X 1,856.28 X
23405   004 90 2 X 1,693.69 X
23406   001 90 2 X 2,422.91 X
23406   003 90 2 X 2,222.90 X
23406   002 90 2 X 2,383.91 X
23406   004 90 2 X 2,196.65 X
23410   001 90 2 X 2,790.69 X
23410   004 90 2 X 2,533.48 X
23410   003 90 2 X 2,564.00 X
23410   002 90 2 X 2,746.55 X
23412   002 90 2 X 3,142.08 X
23412   003 90 2 X 2,971.54 X
23412   004 90 2 X 2,903.64 X
23412   001 90 2 X 3,299.63 X
23415   002 90 2 X 2,224.65 X
23415   003 90 2 X 2,196.96 X
23415   004 90 2 X 2,207.09 X
23415   001 90 2 X 2,202.56 X
23420   002 90 2 X 3,238.37 X
23420   003 90 2 X 3,055.67 X
23420   004 90 2 X 3,049.21 X
23420   001 90 2 X 3,258.44 X
23430   004 90 2 X 1,867.35 X
23430   001 90 2 X 2,047.29 X
23430   002 90 2 X 2,016.54 X
23430   003 90 2 X 1,889.27 X
23440   002 90 2 X 2,051.20 X
23440   003 90 2 X 1,924.66 X
23440   004 90 2 X 1,902.49 X
23440   001 90 2 X 2,081.86 X
23450   001 90 2 X 2,991.38 X
23450   002 90 2 X 3,102.52 X
23450   003 90 2 X 2,879.69 X
23450   004 90 2 X 2,845.17 X
23455   004 90 2 X 3,278.06 X
23455   001 90 2 X 3,631.57 X
23455   002 90 2 X 3,570.56 X
23455   003 90 2 X 3,318.29 X
23460   004 90 2 X 3,189.39 X
23460   003 90 2 X 3,227.92 X
23460   002 90 2 X 3,460.31 X
23460   001 90 2 X 3,516.52 X
23462   001 90 2 X 3,669.33 X
23462   003 90 2 X 3,357.89 X
23462   002 90 2 X 3,608.66 X
23462   004 90 2 X 3,317.53 X
23465   001 90 2 X 3,491.99 X
23465   004 90 2 X 3,252.53 X
23465   002 90 2 X 3,444.62 X
23465   003 90 2 X 3,025.17 X
23466   001 90 2 X 3,747.34 X
23466   003 90 2 X 3,417.11 X
23466   002 90 2 X 3,682.98 X
23466   004 90 2 X 3,375.39 X
23470   001 90 2 X 4,079.67 X
23470   004 90 2 X 3,657.05 X
23470   002 90 2 X 3,974.36 X
23470   003 90 2 X 3,701.55 X
23472   004 90 2 X 4,913.40 X
23472   002 90 2 X 6,269.32 X
23472   003 90 2 X 6,097.50 X
23472   001 90 2 X 5,526.54 X
23473   004 90 2 X 2,624.47 X
23473   002 90 2 X 2,624.47 X
23473   003 90 2 X 2,624.47 X
23473   001 90 2 X 2,928.68 X
23474   003 90 2 X 2,837.41 X
23474   002 90 2 X 2,837.41 X
23474   004 90 2 X 2,837.41 X
23474   001 90 2 X 3,166.35 X
23480   003 90 2 X 1,900.82 X
23480   002 90 2 X 2,017.77 X
23480   001 90 2 X 2,046.28 X
23480   004 90 2 X 1,879.19 X
23485   001 90 2 X 2,941.47 X
23485   002 90 2 X 2,839.25 X
23485   003 90 2 X 2,701.84 X
23485   004 90 2 X 2,669.89 X
23490   002 90 2 X 2,432.05 X
23490   003 90 2 X 2,092.66 X
23490   004 90 2 X 2,274.98 X
23490   001 90 2 X 2,463.03 X
23491   003 90 2 X 2,833.74 X
23491   002 90 2 X 3,180.07 X
23491   001 90 2 X 3,232.15 X
23491   004 90 2 X 2,929.76 X
23500   004 90 2 X 414.60 X
23500   002 90 2 X 479.87 X
23500   003 90 2 X 409.22 X
23500   001 90 2 X 428.51 X
23505   004 90 2 X 669.95 X
23505   001 90 2 X 685.30 X
23505   003 90 2 X 665.56 X
23505   002 90 2 X 721.00 X
23515   004 90 2 X 1,550.97 X
23515   002 90 2 X 1,684.53 X
23515   003 90 2 X 1,569.83 X
23515   001 90 2 X 1,712.29 X
23520   001 90 2 X 404.59 X
23520   004 90 2 X 371.95 X
23520   002 90 2 X 399.14 X
23520   003 90 2 X 372.20 X
23525   004 90 2 X 584.40 X
23525   001 90 2 X 633.12 X
23525   002 90 2 X 624.98 X
23525   003 90 2 X 591.09 X
23530   002 90 2 X 1,614.87 X
23530   003 90 2 X 1,512.48 X
23530   001 90 2 X 1,639.63 X
23530   004 90 2 X 1,494.23 X
23532   001 90 2 X 1,819.07 X
23532   002 90 2 X 1,789.64 X
23532   003 90 2 X 1,668.26 X
23532   004 90 2 X 1,648.43 X
23540   002 90 2 X 424.82 X
23540   003 90 2 X 400.76 X
23540   001 90 2 X 430.62 X
23540   004 90 2 X 396.12 X
23545   004 90 2 X 568.63 X
23545   001 90 2 X 661.25 X
23545   002 90 2 X 657.83 X
23545   003 90 2 X 582.12 X
23550   001 90 2 X 1,902.26 X
23550   004 90 2 X 1,706.92 X
23550   003 90 2 X 1,728.04 X
23550   002 90 2 X 1,953.56 X
23552   003 90 2 X 1,698.44 X
23552   002 90 2 X 1,819.88 X
23552   004 90 2 X 1,678.26 X
23552   001 90 2 X 1,849.31 X
23570   001 90 2 X 456.73 X
23570   003 90 2 X 422.20 X
23570   002 90 2 X 449.99 X
23570   004 90 2 X 417.26 X
23575   003 90 2 X 745.88 X
23575   002 90 2 X 784.48 X
23575   004 90 2 X 728.45 X
23575   001 90 2 X 795.95 X
23585   003 90 2 X 1,814.35 X
23585   002 90 2 X 1,945.56 X
23585   001 90 2 X 1,977.33 X
23585   004 90 2 X 1,792.80 X
23600   003 90 2 X 749.08 X
23600   002 90 2 X 743.19 X
23600   004 90 2 X 729.94 X
23600   001 90 2 X 718.22 X
23605   004 90 2 X 1,037.15 X
23605   001 90 2 X 1,222.92 X
23605   003 90 2 X 1,129.95 X
23605   002 90 2 X 1,240.43 X
23615   001 90 2 X 2,637.09 X
23615   003 90 2 X 2,171.17 X
23615   002 90 2 X 2,344.79 X
23615   004 90 2 X 2,257.88 X
23616   001 90 2 X 4,033.71 X
23616   002 90 2 X 5,121.40 X
23616   003 90 2 X 4,761.79 X
23616   004 90 2 X 3,524.59 X
23620   004 90 2 X 741.51 X
23620   001 90 2 X 733.16 X
23620   002 90 2 X 768.12 X
23620   003 90 2 X 747.74 X
23625   001 90 2 X 916.59 X
23625   003 90 2 X 839.59 X
23625   002 90 2 X 901.58 X
23625   004 90 2 X 856.09 X
23630   003 90 2 X 2,139.95 X
23630   002 90 2 X 2,198.64 X
23630   004 90 2 X 2,130.72 X
23630   001 90 2 X 2,212.86 X
23650   004 90 2 X 612.26 X
23650   003 90 2 X 590.95 X
23650   002 90 2 X 637.36 X
23650   001 90 2 X 668.72 X
23655   004 90 2 X 787.95 X
23655   001 90 2 X 859.30 X
23655   002 90 2 X 847.13 X
23655   003 90 2 X 797.07 X
23660   002 90 2 X 2,356.73 X
23660   003 90 2 X 2,234.89 X
23660   001 90 2 X 2,438.05 X
23660   004 90 2 X 2,265.33 X
23665   003 90 2 X 858.18 X
23665   002 90 2 X 894.51 X
23665   004 90 2 X 854.68 X
23665   001 90 2 X 908.19 X
23670   001 90 2 X 2,254.52 X
23670   004 90 2 X 2,015.49 X
23670   002 90 2 X 2,212.86 X
23670   003 90 2 X 2,128.83 X
23675   004 90 2 X 1,047.38 X
23675   002 90 2 X 1,127.82 X
23675   003 90 2 X 1,059.55 X
23675   001 90 2 X 1,144.30 X
23680   004 90 2 X 2,446.27 X
23680   001 90 2 X 2,728.14 X
23680   003 90 2 X 2,476.69 X
23680   002 90 2 X 2,679.19 X
23700   001 10 2 X 724.45 X
23700   004 10 2 X 703.42 X
23700   003 10 2 X 705.94 X
23700   002 10 2 X 718.96 X
23800   004 90 2 X 3,318.99 X
23800   001 90 2 X 3,685.53 X
23800   003 90 2 X 3,360.13 X
23800   002 90 2 X 3,622.16 X
23802   001 90 2 X 3,517.61 X
23802   004 90 2 X 3,190.41 X
23802   002 90 2 X 3,461.40 X
23802   003 90 2 X 3,228.97 X
23900   004 90 2 X 3,449.74 X
23900   003 90 2 X 3,489.36 X
23900   002 90 2 X 3,730.58 X
23900   001 90 2 X 3,789.16 X
23920   002 90 2 X 3,368.35 X
23920   003 90 2 X 3,125.01 X
23920   001 90 2 X 3,427.21 X
23920   004 90 2 X 3,087.94 X
23921   003 90 2 X 1,048.68 X
23921   002 90 2 X 1,123.83 X
23921   004 90 2 X 1,036.40 X
23921   001 90 2 X 1,142.06 X
23929     YYY 2 X # X
23930   003 10 2 X 484.53 X
23930   002 10 2 X 513.04 X
23930   004 10 2 X 486.35 X
23930   001 10 2 X 520.03 X
23931   001 10 2 X 278.90 X
23931   004 10 2 X 257.77 X
23931   002 10 2 X 278.29 X
23931   003 10 2 X 261.39 X
23935   003 90 2 X 1,150.88 X
23935   002 90 2 X 1,231.85 X
23935   004 90 2 X 1,137.38 X
23935   001 90 2 X 1,251.39 X
24000   002 90 2 X 1,821.07 X
24000   003 90 2 X 1,888.42 X
24000   004 90 2 X 1,513.88 X
24000   001 90 2 X 1,697.74 X
24006   004 90 2 X 1,754.92 X
24006   001 90 2 X 1,928.28 X
24006   003 90 2 X 1,775.68 X
24006   002 90 2 X 1,898.50 X
24065   001 10 2 X 324.85 X
24065   004 10 2 X 303.05 X
24065   003 10 2 X 274.29 X
24065   002 10 2 X 321.26 X
24066   002 90 2 X 586.86 X
24066   003 90 2 X 569.51 X
24066   001 90 2 X 602.71 X
24066   004 90 2 X 835.73 X
24071   004 90 2 X 680.08 X
24071   002 90 2 X 680.08 X
24071   003 90 2 X 680.08 X
24071   001 90 2 X 764.99 X
24073   004 90 2 X 1,169.58 X
24073   001 90 2 X 1,313.30 X
24073   003 90 2 X 1,169.58 X
24073   002 90 2 X 1,169.58 X