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2024 Workers' Compensation Part B Fee Schedule

62162-63286

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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
62162		001	90	2	X	3,833.12	X
62162		004	90	2	X	3,304.00	X
62162		003	90	2	X	3,304.00	X
62162		002	90	2	X	3,304.00	X
62164		002	90	2	X	3,578.87	X
62164		003	90	2	X	3,578.87	X
62164		001	90	2	X	4,130.61	X
62164		004	90	2	X	3,578.87	X
62165		001	90	2	X	3,207.17	X
62165		004	90	2	X	2,814.74	X
62165		002	90	2	X	2,814.74	X
62165		003	90	2	X	2,814.74	X
62180		004	90	2	X	4,075.95	X
62180		001	90	2	X	4,078.76	X
62180		003	90	2	X	3,085.74	X
62180		002	90	2	X	4,023.62	X
62190		003	90	2	X	2,927.82	X
62190		002	90	2	X	3,201.04	X
62190		004	90	2	X	2,892.49	X
62190		001	90	2	X	3,267.21	X
62192		004	90	2	X	3,000.18	X
62192		001	90	2	X	3,279.69	X
62192		002	90	2	X	3,218.96	X
62192		003	90	2	X	2,968.12	X
62194		001	10	2	X	1,061.76	X
62194		004	10	2	X	481.29	X
62194		003	10	2	X	486.81	X
62194		002	10	2	X	1,011.20	X
62200		004	90	2	X	3,419.52	X
62200		001	90	2	X	3,382.55	X
62200		003	90	2	X	3,461.57	X
62200		002	90	2	X	3,425.40	X
62201		002	90	2	X	2,530.64	X
62201		003	90	2	X	2,362.07	X
62201		004	90	2	X	2,335.12	X
62201		001	90	2	X	2,571.57	X
62220		001	90	2	X	3,575.21	X
62220		004	90	2	X	3,188.81	X
62220		003	90	2	X	3,227.92	X
62220		002	90	2	X	3,507.47	X
62223		002	90	2	X	3,631.54	X
62223		003	90	2	X	3,351.59	X
62223		001	90	2	X	3,699.19	X
62223		004	90	2	X	3,310.88	X
62225		003	90	2	X	1,666.50	X
62225		002	90	2	X	1,052.44	X
62225		001	90	2	X	1,094.83	X
62225		004	90	2	X	1,037.77	X
62230		004	90	2	X	2,199.96	X
62230		001	90	2	X	2,442.09	X
62230		003	90	2	X	2,226.38	X
62230		002	90	2	X	2,430.34	X
62252		002	XXX	0	X	183.56	X
62252	26	002	XXX	0	X	91.20	X
62252	TC	002	XXX	0	X	92.29	X
62252		003	XXX	0	X	183.56	X
62252	26	003	XXX	0	X	91.20	X
62252	TC	003	XXX	0	X	92.29	X
62252		004	XXX	0	X	183.56	X
62252	26	004	XXX	0	X	91.20	X
62252	TC	004	XXX	0	X	92.29	X
62252		001	XXX	0	X	207.89	X
62252	26	001	XXX	0	X	98.81	X
62252	TC	001	XXX	0	X	109.02	X
62256		002	90	2	X	1,721.89	X
62256		003	90	2	X	1,673.24	X
62256		004	90	2	X	1,384.29	X
62256		001	90	2	X	1,783.18	X
62258		004	90	2	X	3,182.11	X
62258		002	90	2	X	3,470.24	X
62258		003	90	2	X	3,403.65	X
62258		001	90	2	X	3,530.55	X
62263		001	10	2	X	1,098.46	861.10
62263		003	10	2	X	969.25	766.28
62263		002	10	2	X	969.25	766.28
62263		004	10	2	X	969.25	766.28
62264		004	10	2	X	1,239.32	476.60
62264		001	10	2	X	1,418.63	522.10
62264		002	10	2	X	1,239.32	476.60
62264		003	10	2	X	1,239.32	476.60
62267		001	0	2	X	460.26	302.26
62267		004	0	2	X	411.66	278.46
62267		002	0	2	X	411.66	278.46
62267		003	0	2	X	411.66	278.46
62268			0	2	X	*	X
62269			0	2	X	*	X
62270		002	0	2	X	195.74	X
62270		003	0	2	X	185.88	X
62270		001	0	2	X	197.56	X
62270		004	0	2	X	183.68	X
62272		002	0	2	X	238.50	X
62272		003	0	2	X	242.63	X
62272		004	0	2	X	220.29	X
62272		001	0	2	X	260.49	X
62273		001	0	2	X	377.20	X
62273		003	0	2	X	345.44	X
62273		002	0	2	X	364.54	X
62273		004	0	2	X	341.68	X
62280		001	10	2	X	533.90	X
62280		004	10	2	X	286.22	X
62280		002	10	2	X	366.44	X
62280		003	10	2	X	361.92	X
62281		001	10	2	X	399.78	X
62281		002	10	2	X	407.64	X
62281		003	10	2	X	370.04	X
62281		004	10	2	X	366.15	X
62282		004	10	2	X	423.78	X
62282		001	10	2	X	469.98	X
62282		003	10	2	X	436.48	X
62282		002	10	2	X	461.87	X
62284		002	0	2	X	512.48	X
62284		003	0	2	X	409.21	X
62284		004	0	2	X	456.14	X
62284		001	0	2	X	449.99	X
62287		004	90	2	X	1,981.24	X
62287		001	90	2	X	2,276.12	X
62287		003	90	2	X	2,007.02	X
62287		002	90	2	X	2,223.72	X
62290		004	0	2	X	550.38	X
62290		001	0	2	X	594.03	X
62290		003	0	2	X	556.64	X
62290		002	0	2	X	586.68	X
62291		001	0	2	X	540.30	X
62291		004	0	2	X	491.58	X
62291		003	0	2	X	460.24	X
62291		002	0	2	X	523.92	X
62292		002	90	2	X	2,814.34	X
62292		003	90	2	X	2,367.78	X
62292		001	90	2	X	2,363.63	X
62292		004	90	2	X	2,656.56	X
62294		001	90	2	X	1,632.94	X
62294		004	90	2	X	1,503.90	X
62294		003	90	2	X	1,521.83	X
62294		002	90	2	X	1,611.34	X
62302		004	0	2	X	369.55	194.10
62302		002	0	2	X	369.55	194.10
62302		003	0	2	X	369.55	194.10
62302		001	0	2	X	414.25	208.98
62303		002	0	2	X	383.71	196.72
62303		003	0	2	X	383.71	196.72
62303		001	0	2	X	430.82	212.04
62303		004	0	2	X	383.71	196.72
62304		001	0	2	X	408.30	205.45
62304		004	0	2	X	364.15	190.80
62304		003	0	2	X	364.15	190.80
62304		002	0	2	X	364.15	190.80
62305		004	0	2	X	397.01	199.04
62305		001	0	2	X	445.90	214.27
62305		002	0	2	X	397.01	199.04
62305		003	0	2	X	397.01	199.04
62320		002	0	2	X	246.75	155.56
62320		003	0	2	X	246.75	155.56
62320		001	0	2	X	274.41	168.74
62320		004	0	2	X	246.75	155.56
62321		004	0	2	X	363.76	167.77
62321		002	0	2	X	363.76	167.77
62321		003	0	2	X	363.76	167.77
62321		001	0	2	X	409.04	181.97
62322		001	0	2	X	256.01	145.10
62322		003	0	2	X	229.54	133.83
62322		002	0	2	X	229.54	133.83
62322		004	0	2	X	229.54	133.83
62323		004	0	2	X	356.51	152.94
62323		001	0	2	X	401.40	165.59
62323		003	0	2	X	356.51	152.94
62323		002	0	2	X	356.51	152.94
62324		001	0	2	X	239.36	153.56
62324		004	0	2	X	216.93	142.86
62324		003	0	2	X	216.93	142.86
62324		002	0	2	X	216.93	142.86
62325		004	0	2	X	324.52	164.29
62325		001	0	2	X	362.06	176.43
62325		002	0	2	X	324.52	164.29
62325		003	0	2	X	324.52	164.29
62326		002	0	2	X	226.98	139.83
62326		003	0	2	X	226.98	139.83
62326		004	0	2	X	226.98	139.83
62326		001	0	2	X	251.60	150.58
62327		003	0	2	X	329.28	148.90
62327		002	0	2	X	329.28	148.90
62327		001	0	2	X	369.36	160.38
62327		004	0	2	X	329.28	148.90
62328		001	0	2	X	396.71	137.29
62328		003	0	2	X	351.72	126.43
62328		002	0	2	X	351.72	126.43
62328		004	0	2	X	351.72	126.43
62329		001	0	2	X	494.41	174.55
62329		002	0	2	X	436.62	158.87
62329		003	0	2	X	436.62	158.87
62329		004	0	2	X	436.62	158.87
62350		004	10	2	X	1,153.42	X
62350		002	10	2	X	1,244.61	X
62350		003	10	2	X	1,169.93	X
62350		001	10	2	X	1,307.99	X
62351		003	90	2	X	1,730.16	X
62351		002	90	2	X	1,840.38	X
62351		004	90	2	X	1,705.70	X
62351		001	90	2	X	1,933.84	X
62355		004	10	2	X	961.58	X
62355		003	10	2	X	975.74	X
62355		002	10	2	X	1,038.71	X
62355		001	10	2	X	1,087.55	X
62360		001	10	2	X	419.42	X
62360		004	10	2	X	369.71	X
62360		003	10	2	X	375.07	X
62360		002	10	2	X	399.06	X
62361		004	10	2	X	885.48	X
62361		003	10	2	X	898.24	X
62361		002	10	2	X	955.54	X
62361		001	10	2	X	1,004.04	X
62362		001	10	2	X	1,315.10	X
62362		004	10	2	X	1,160.01	X
62362		002	10	2	X	1,251.62	X
62362		003	10	2	X	1,176.65	X
62365		004	10	2	X	956.04	X
62365		001	10	2	X	1,081.59	X
62365		003	10	2	X	970.22	X
62365		002	10	2	X	1,032.87	X
62367		001	XXX	0	X	145.53	X
62367	26	001	XXX	0	X	92.67	X
62367	TC	001	XXX	0	X	52.87	X
62367		003	XXX	0	X	128.37	X
62367	26	003	XXX	0	X	83.09	X
62367	TC	003	XXX	0	X	45.28	X
62367		002	XXX	0	X	138.47	X
62367	26	002	XXX	0	X	88.47	X
62367	TC	002	XXX	0	X	50.00	X
62367		004	XXX	0	X	126.24	X
62367	26	004	XXX	0	X	81.84	X
62367	TC	004	XXX	0	X	44.39	X
62368		003	XXX	0	X	177.22	X
62368	26	003	XXX	0	X	130.09	X
62368	TC	003	XXX	0	X	47.10	X
62368		002	XXX	0	X	190.55	X
62368	26	002	XXX	0	X	138.56	X
62368	TC	002	XXX	0	X	51.99	X
62368		004	XXX	0	X	174.36	X
62368	26	004	XXX	0	X	128.23	X
62368	TC	004	XXX	0	X	46.14	X
62368		001	XXX	0	X	200.11	X
62368	26	001	XXX	0	X	145.14	X
62368	TC	001	XXX	0	X	54.91	X
62369		003	XXX	0	X	195.56	57.80
62369		002	XXX	0	X	195.56	57.80
62369		004	XXX	0	X	195.56	57.80
62369		001	XXX	0	X	221.96	62.13
62370		003	XXX	0	X	205.85	77.51
62370		002	XXX	0	X	205.85	77.51
62370		001	XXX	0	X	232.35	83.48
62370		004	XXX	0	X	205.85	77.51
62380			90	2	X	*	X
63001		003	90	2	X	4,176.68	X
63001		002	90	2	X	4,111.12	X
63001		004	90	2	X	3,747.93	X
63001		001	90	2	X	4,187.91	X
63003		002	90	2	X	4,028.68	X
63003		003	90	2	X	3,903.19	X
63003		001	90	2	X	4,102.31	X
63003		004	90	2	X	3,678.99	X
63005		002	90	2	X	3,821.62	X
63005		003	90	2	X	3,530.42	X
63005		004	90	2	X	3,487.39	X
63005		001	90	2	X	3,891.98	X
63011		004	90	2	X	2,367.76	X
63011		001	90	2	X	2,620.22	X
63011		003	90	2	X	2,395.81	X
63011		002	90	2	X	2,576.41	X
63012		002	90	2	X	3,815.55	X
63012		003	90	2	X	3,642.63	X
63012		004	90	2	X	3,688.60	X
63012		001	90	2	X	3,881.22	X
63015		001	90	2	X	4,869.20	X
63015		002	90	2	X	4,777.80	X
63015		003	90	2	X	4,399.90	X
63015		004	90	2	X	4,346.62	X
63016		003	90	2	X	4,560.43	X
63016		002	90	2	X	4,941.68	X
63016		001	90	2	X	5,033.93	X
63016		004	90	2	X	4,504.96	X
63017		003	90	2	X	4,259.91	X
63017		002	90	2	X	4,624.11	X
63017		001	90	2	X	4,712.32	X
63017		004	90	2	X	4,208.09	X
63020		003	90	2	X	3,423.58	X
63020		002	90	2	X	3,724.46	X
63020		004	90	2	X	3,392.65	X
63020		001	90	2	X	3,797.23	X
63030		004	90	2	X	3,124.73	X
63030		002	90	2	X	3,425.77	X
63030		003	90	2	X	3,171.43	X
63030		001	90	2	X	3,489.27	X
63035		001	ZZZ	0	X	1,683.06	X
63035		004	ZZZ	0	X	1,642.25	X
63035		002	ZZZ	0	X	1,734.93	X
63035		003	ZZZ	0	X	1,609.36	X
63040		004	90	2	X	6,717.69	X
63040		001	90	2	X	6,946.93	X
63040		003	90	2	X	6,741.46	X
63040		002	90	2	X	6,906.84	X
63042		002	90	2	X	6,912.52	X
63042		003	90	2	X	6,544.97	X
63042		004	90	2	X	6,723.09	X
63042		001	90	2	X	6,955.24	X
63043			ZZZ	0	X	*	X
63044			ZZZ	0	X	*	X
63045		003	90	2	X	5,822.66	X
63045		001	90	2	X	6,025.80	X
63045		002	90	2	X	5,963.04	X
63045		004	90	2	X	5,800.15	X
63046		002	90	2	X	5,947.76	X
63046		003	90	2	X	5,779.79	X
63046		001	90	2	X	5,988.41	X
63046		004	90	2	X	4,260.98	X
63047		004	90	2	X	5,727.74	X
63047		003	90	2	X	5,713.74	X
63047		002	90	2	X	5,900.60	X
63047		001	90	2	X	5,942.36	X
63048		001	ZZZ	0	X	4,391.94	X
63048		003	ZZZ	0	X	4,364.04	X
63048		002	ZZZ	0	X	4,312.29	X
63048		004	ZZZ	0	X	4,358.81	X
63050		004	90	2	X	2,800.62	X
63050		001	90	2	X	3,217.57	X
63050		002	90	2	X	2,800.62	X
63050		003	90	2	X	2,800.62	X
63051		004	90	2	X	3,196.28	X
63051		001	90	2	X	3,642.36	X
63051		002	90	2	X	3,196.28	X
63051		003	90	2	X	3,196.28	X
63052		002	ZZZ	0	X	306.70	X
63052		003	ZZZ	0	X	306.70	X
63052		001	ZZZ	0	X	339.85	X
63052		004	ZZZ	0	X	306.70	X
63053		001	ZZZ	0	X	254.11	X
63053		003	ZZZ	0	X	229.49	X
63053		002	ZZZ	0	X	229.49	X
63053		004	ZZZ	0	X	229.49	X
63055		001	90	2	X	5,556.10	X
63055		004	90	2	X	4,996.21	X
63055		003	90	2	X	5,057.24	X
63055		002	90	2	X	5,458.95	X
63056		001	90	2	X	6,586.42	X
63056		004	90	2	X	6,372.34	X
63056		002	90	2	X	5,019.01	X
63056		003	90	2	X	6,395.95	X
63057		002	ZZZ	0	X	961.96	X
63057		003	ZZZ	0	X	884.33	X
63057		001	ZZZ	0	X	980.73	X
63057		004	ZZZ	0	X	873.41	X
63064		002	90	2	X	7,211.01	X
63064		003	90	2	X	7,040.71	X
63064		001	90	2	X	7,252.24	X
63064		004	90	2	X	5,266.99	X
63066		001	ZZZ	0	X	704.70	X
63066		004	ZZZ	0	X	640.42	X
63066		002	ZZZ	0	X	693.52	X
63066		003	ZZZ	0	X	647.78	X
63075		002	90	2	X	4,546.32	X
63075		004	90	2	X	3,765.78	X
63075		001	90	2	X	4,622.64	X
63075		003	90	2	X	4,231.53	X
63076		002	ZZZ	0	X	2,287.94	X
63076		003	ZZZ	0	X	2,194.43	X
63076		004	ZZZ	0	X	2,300.83	X
63076		001	ZZZ	0	X	2,285.92	X
63077		004	90	2	X	4,313.03	X
63077		001	90	2	X	4,482.99	X
63077		003	90	2	X	4,364.53	X
63077		002	90	2	X	4,439.07	X
63078		003	ZZZ	0	X	663.07	X
63078		002	ZZZ	0	X	709.63	X
63078		004	ZZZ	0	X	655.32	X
63078		001	ZZZ	0	X	720.91	X
63081		004	90	2	X	7,025.01	X
63081		002	90	2	X	7,236.39	X
63081		003	90	2	X	7,053.16	X
63081		001	90	2	X	6,645.33	X
63082		003	ZZZ	0	X	1,255.65	X
63082		002	ZZZ	0	X	1,365.79	X
63082		001	ZZZ	0	X	1,392.42	X
63082		004	ZZZ	0	X	1,240.20	X
63085		001	90	2	X	7,282.41	X
63085		004	90	2	X	5,879.40	X
63085		003	90	2	X	6,784.22	X
63085		002	90	2	X	6,903.82	X
63086		004	ZZZ	0	X	979.74	X
63086		002	ZZZ	0	X	1,227.91	X
63086		003	ZZZ	0	X	991.97	X
63086		001	ZZZ	0	X	1,106.93	X
63087		001	90	2	X	6,915.29	X
63087		002	90	2	X	6,799.26	X
63087		003	90	2	X	6,320.05	X
63087		004	90	2	X	6,244.56	X
63088		004	ZZZ	0	X	1,214.97	X
63088		001	ZZZ	0	X	1,363.08	X
63088		003	ZZZ	0	X	1,230.11	X
63088		002	ZZZ	0	X	1,337.21	X
63090		002	90	2	X	6,766.32	X
63090		003	90	2	X	6,281.30	X
63090		001	90	2	X	6,883.65	X
63090		004	90	2	X	6,205.46	X
63091		004	ZZZ	0	X	641.20	X
63091		003	ZZZ	0	X	648.85	X
63091		002	ZZZ	0	X	695.97	X
63091		001	ZZZ	0	X	707.35	X
63101		001	90	2	X	5,006.63	X
63101		004	90	2	X	4,410.28	X
63101		003	90	2	X	4,410.28	X
63101		002	90	2	X	4,410.28	X
63102		001	90	2	X	5,006.63	X
63102		004	90	2	X	4,410.28	X
63102		002	90	2	X	4,410.28	X
63102		003	90	2	X	4,410.28	X
63103		001	ZZZ	0	X	586.68	X
63103		004	ZZZ	0	X	515.31	X
63103		003	ZZZ	0	X	515.31	X
63103		002	ZZZ	0	X	515.31	X
63170		001	90	2	X	5,797.37	X
63170		002	90	2	X	5,517.61	X
63170		003	90	2	X	5,497.88	X
63170		004	90	2	X	4,152.75	X
63172		004	90	2	X	4,419.46	X
63172		001	90	2	X	5,099.24	X
63172		002	90	2	X	4,955.02	X
63172		003	90	2	X	4,474.20	X
63173		004	90	2	X	3,888.21	X
63173		002	90	2	X	4,169.58	X
63173		003	90	2	X	3,934.65	X
63173		001	90	2	X	4,226.31	X
63185		004	90	2	X	3,325.36	X
63185		001	90	2	X	3,704.90	X
63185		002	90	2	X	3,638.76	X
63185		003	90	2	X	3,533.08	X
63190		003	90	2	X	4,262.19	X
63190		002	90	2	X	4,621.23	X
63190		004	90	2	X	4,210.56	X
63190		001	90	2	X	4,708.17	X
63191		004	90	2	X	3,554.93	X
63191		001	90	2	X	3,591.56	X
63191		002	90	2	X	3,536.05	X
63191		003	90	2	X	3,306.79	X
63197		003	90	2	X	3,799.90	X
63197		001	90	2	X	4,129.48	X
63197		004	90	2	X	3,756.28	X
63197		002	90	2	X	4,065.18	X
63200		001	90	2	X	2,376.29	X
63200		004	90	2	X	3,303.87	X
63200		003	90	2	X	2,149.12	X
63200		002	90	2	X	2,206.24	X
63250		004	90	2	X	7,426.82	X
63250		001	90	2	X	6,571.05	X
63250		003	90	2	X	7,512.66	X
63250		002	90	2	X	6,273.87	X
63251		003	90	2	X	6,901.58	X
63251		002	90	2	X	7,351.17	X
63251		001	90	2	X	7,460.46	X
63251		004	90	2	X	6,824.54	X
63252		004	90	2	X	7,502.80	X
63252		002	90	2	X	7,514.80	X
63252		001	90	2	X	8,262.10	X
63252		003	90	2	X	7,589.28	X
63265		004	90	2	X	4,726.72	X
63265		002	90	2	X	5,159.78	X
63265		003	90	2	X	4,784.12	X
63265		001	90	2	X	5,250.64	X
63266		004	90	2	X	5,124.54	X
63266		001	90	2	X	5,708.98	X
63266		002	90	2	X	5,607.24	X
63266		003	90	2	X	5,187.27	X
63267		001	90	2	X	4,910.35	X
63267		004	90	2	X	4,384.01	X
63267		003	90	2	X	4,437.83	X
63267		002	90	2	X	4,818.31	X
63268		002	90	2	X	3,616.10	X
63268		003	90	2	X	3,374.96	X
63268		004	90	2	X	3,336.50	X
63268		001	90	2	X	3,674.65	X
63270		001	90	2	X	6,166.96	X
63270		004	90	2	X	4,794.21	X
63270		002	90	2	X	5,191.10	X
63270		003	90	2	X	4,849.64	X
63271		004	90	2	X	5,800.15	X
63271		003	90	2	X	5,870.33	X
63271		002	90	2	X	6,920.57	X
63271		001	90	2	X	7,148.81	X
63272		001	90	2	X	5,836.52	X
63272		004	90	2	X	5,264.46	X
63272		002	90	2	X	5,737.25	X
63272		003	90	2	X	5,327.35	X
63273		002	90	2	X	4,843.91	X
63273		003	90	2	X	4,526.55	X
63273		004	90	2	X	4,474.26	X
63273		001	90	2	X	4,920.83	X
63275		002	90	2	X	6,582.46	X
63275		003	90	2	X	6,449.30	X
63275		001	90	2	X	6,868.12	X
63275		004	90	2	X	6,749.91	X
63276		001	90	2	X	6,760.31	X
63276		004	90	2	X	6,329.53	X
63276		003	90	2	X	6,368.87	X
63276		002	90	2	X	6,461.93	X
63277		004	90	2	X	5,048.32	X
63277		002	90	2	X	5,346.00	X
63277		003	90	2	X	5,059.26	X
63277		001	90	2	X	5,443.28	X
63278		003	90	2	X	6,163.76	X
63278		002	90	2	X	6,200.73	X
63278		004	90	2	X	4,821.51	X
63278		001	90	2	X	7,455.14	X
63280		002	90	2	X	6,800.88	X
63280		003	90	2	X	6,597.95	X
63280		001	90	2	X	7,087.39	X
63280		004	90	2	X	6,962.47	X
63281		001	90	2	X	6,747.04	X
63281		003	90	2	X	6,400.78	X
63281		002	90	2	X	6,631.12	X
63281		004	90	2	X	6,079.04	X
63282		004	90	2	X	5,513.59	X
63282		002	90	2	X	5,533.08	X
63282		003	90	2	X	5,579.45	X
63282		001	90	2	X	5,634.01	X
63283		004	90	2	X	4,725.53	X
63283		002	90	2	X	5,123.79	X
63283		003	90	2	X	4,780.88	X
63283		001	90	2	X	5,206.92	X
63285		002	90	2	X	7,064.09	X
63285		004	90	2	X	6,532.15	X
63285		001	90	2	X	7,174.81	X
63285		003	90	2	X	6,607.67	X
63286		001	90	2	X	7,680.89	X
63286		003	90	2	X	7,056.88	X
63286		002	90	2	X	7,559.14	X
63286		004	90	2	X	6,974.33	X

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