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Health Care Services Review
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Medical Fee Review
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Fee Schedule
>
Fee Schedule 66155-67880
Begin Main Content Area
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Content Editor
2024 Workers' Compensation Part B Fee Schedule
66155-67880
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
66155
004
90
2
X
2,395.41
X
66155
002
90
2
X
2,448.32
X
66155
003
90
2
X
2,405.45
X
66155
001
90
2
X
2,458.53
X
66160
003
90
2
X
2,321.22
X
66160
002
90
2
X
2,370.20
X
66160
004
90
2
X
2,134.55
X
66160
001
90
2
X
2,381.92
X
66170
001
90
2
X
2,829.55
X
66170
003
90
2
X
2,476.84
X
66170
002
90
2
X
2,569.14
X
66170
004
90
2
X
2,488.29
X
66172
003
90
2
X
2,559.28
X
66172
002
90
2
X
2,653.58
X
66172
004
90
2
X
2,569.99
X
66172
001
90
2
X
2,914.46
X
66174
003
90
2
X
1,693.00
X
66174
002
90
2
X
1,693.00
X
66174
001
90
2
X
1,877.10
X
66174
004
90
2
X
1,693.00
X
66175
002
90
2
X
1,936.67
X
66175
003
90
2
X
1,936.67
X
66175
001
90
2
X
2,205.16
X
66175
004
90
2
X
1,936.67
X
66179
002
90
2
X
1,393.37
1,660.48
66179
003
90
2
X
1,393.37
1,660.48
66179
004
90
2
X
1,393.37
1,660.48
66179
001
90
2
X
1,519.17
1,831.69
66180
001
90
2
X
3,406.47
X
66180
003
90
2
X
3,176.78
X
66180
002
90
2
X
3,362.16
X
66180
004
90
2
X
3,135.24
X
66183
004
90
2
X
1,689.03
X
66183
001
90
2
X
1,883.42
X
66183
002
90
2
X
1,689.03
X
66183
003
90
2
X
1,689.03
X
66184
004
90
2
X
970.92
1,208.17
66184
001
90
2
X
1,060.14
1,337.73
66184
002
90
2
X
970.92
1,208.17
66184
003
90
2
X
970.92
1,208.17
66185
003
90
2
X
1,891.86
X
66185
002
90
2
X
2,000.43
X
66185
004
90
2
X
1,867.22
X
66185
001
90
2
X
2,026.38
X
66225
003
90
2
X
3,201.30
X
66225
002
90
2
X
2,921.19
X
66225
004
90
2
X
2,723.52
X
66225
001
90
2
X
3,407.05
X
66250
004
90
2
X
1,353.29
X
66250
001
90
2
X
1,465.92
X
66250
003
90
2
X
1,371.06
X
66250
002
90
2
X
1,447.60
X
66500
002
90
2
X
1,163.50
X
66500
004
90
2
X
868.74
X
66500
003
90
2
X
880.15
X
66500
001
90
2
X
942.46
X
66505
001
90
2
X
815.63
X
66505
004
90
2
X
758.83
X
66505
003
90
2
X
768.31
X
66505
002
90
2
X
806.47
X
66600
004
90
2
X
1,857.63
X
66600
003
90
2
X
2,245.16
X
66600
002
90
2
X
2,225.76
X
66600
001
90
2
X
2,226.44
X
66605
004
90
2
X
2,558.75
X
66605
002
90
2
X
2,727.84
X
66605
003
90
2
X
2,591.24
X
66605
001
90
2
X
3,078.24
X
66625
004
90
2
X
1,831.12
X
66625
002
90
2
X
1,746.86
X
66625
003
90
2
X
1,835.11
X
66625
001
90
2
X
2,031.34
X
66630
004
90
2
X
1,455.70
X
66630
001
90
2
X
2,084.40
X
66630
002
90
2
X
1,766.48
X
66630
003
90
2
X
1,803.85
X
66635
001
90
2
X
2,124.88
X
66635
002
90
2
X
1,762.18
X
66635
003
90
2
X
1,899.84
X
66635
004
90
2
X
1,891.08
X
66680
001
90
2
X
1,446.15
X
66680
004
90
2
X
1,393.41
X
66680
003
90
2
X
1,378.07
X
66680
002
90
2
X
1,427.89
X
66682
002
90
2
X
2,378.56
X
66682
003
90
2
X
2,313.75
X
66682
001
90
2
X
2,401.84
X
66682
004
90
2
X
2,353.59
X
66700
001
90
2
X
1,282.93
X
66700
004
90
2
X
1,200.67
X
66700
002
90
2
X
1,195.54
X
66700
003
90
2
X
1,192.99
X
66710
001
90
2
X
1,314.02
X
66710
004
90
2
X
1,207.39
X
66710
002
90
2
X
1,296.57
X
66710
003
90
2
X
1,223.55
X
66711
001
90
3
X
1,129.55
X
66711
004
90
3
X
1,011.99
X
66711
003
90
3
X
1,011.99
X
66711
002
90
3
X
1,011.99
X
66720
004
90
2
X
1,165.57
X
66720
003
90
2
X
1,181.25
X
66720
002
90
2
X
1,250.32
X
66720
001
90
2
X
1,266.89
X
66740
004
90
2
X
1,196.35
X
66740
003
90
2
X
1,212.38
X
66740
002
90
2
X
1,283.88
X
66740
001
90
2
X
1,300.90
X
66761
001
10
2
X
1,493.98
1,001.22
66761
004
10
2
X
1,408.10
941.54
66761
003
10
2
X
1,391.95
929.84
66761
002
10
2
X
1,450.47
971.31
66762
001
90
2
X
1,564.97
X
66762
002
90
2
X
1,542.59
X
66762
003
90
2
X
1,449.14
X
66762
004
90
2
X
1,429.13
X
66770
001
90
2
X
1,577.59
X
66770
002
90
2
X
1,569.22
X
66770
003
90
2
X
1,356.24
X
66770
004
90
2
X
1,526.70
X
66820
002
90
2
X
1,250.78
X
66820
003
90
2
X
941.53
X
66820
004
90
2
X
929.18
X
66820
001
90
2
X
1,008.53
X
66821
002
90
2
X
1,250.67
X
66821
003
90
2
X
929.65
X
66821
004
90
2
X
916.87
X
66821
001
90
2
X
1,004.50
X
66825
002
90
2
X
2,479.47
X
66825
003
90
2
X
2,412.27
X
66825
004
90
2
X
2,451.21
X
66825
001
90
2
X
2,503.35
X
66830
001
90
2
X
1,759.10
X
66830
004
90
2
X
1,631.74
X
66830
002
90
2
X
1,738.52
X
66830
003
90
2
X
1,652.57
X
66840
003
90
2
X
2,175.73
X
66840
002
90
2
X
2,258.99
X
66840
004
90
2
X
1,902.31
X
66840
001
90
2
X
2,295.53
X
66850
002
90
2
X
2,436.16
X
66850
003
90
2
X
2,371.66
X
66850
004
90
2
X
2,363.69
X
66850
001
90
2
X
2,566.36
X
66852
004
90
2
X
2,609.66
X
66852
001
90
2
X
2,843.02
X
66852
003
90
2
X
2,644.94
X
66852
002
90
2
X
2,804.83
X
66920
001
90
2
X
2,457.36
X
66920
004
90
2
X
2,247.42
X
66920
003
90
2
X
2,286.32
X
66920
002
90
2
X
2,406.53
X
66930
001
90
2
X
2,534.58
X
66930
004
90
2
X
2,339.29
X
66930
002
90
2
X
2,399.85
X
66930
003
90
2
X
2,296.75
X
66940
002
90
2
X
2,419.44
X
66940
003
90
2
X
2,347.10
X
66940
004
90
2
X
2,338.53
X
66940
001
90
2
X
2,531.68
X
66982
004
90
2
X
1,975.20
X
66982
001
90
2
X
2,175.10
X
66982
003
90
2
X
1,975.20
X
66982
002
90
2
X
1,975.20
X
66983
002
90
2
X
3,494.67
X
66983
003
90
2
X
3,300.35
X
66983
001
90
2
X
3,571.05
X
66983
004
90
2
X
3,223.46
X
66984
001
90
2
X
3,624.96
X
66984
002
90
2
X
3,571.13
X
66984
003
90
2
X
3,359.90
X
66984
004
90
2
X
3,350.25
X
66985
004
90
2
X
2,405.61
X
66985
001
90
2
X
2,615.02
X
66985
002
90
2
X
2,576.17
X
66985
003
90
2
X
2,429.27
X
66986
001
90
2
X
2,854.07
X
66986
004
90
2
X
2,632.30
X
66986
003
90
2
X
2,658.48
X
66986
002
90
2
X
2,813.37
X
66987
90
2
X
*
X
66988
90
2
X
*
X
66989
003
90
2
X
998.84
X
66989
002
90
2
X
998.84
X
66989
004
90
2
X
998.84
X
66989
001
90
2
X
1,092.30
X
66990
003
ZZZ
0
X
178.72
X
66990
002
ZZZ
0
X
178.72
X
66990
004
ZZZ
0
X
178.72
X
66990
001
ZZZ
0
X
195.37
X
66991
001
90
2
X
872.49
X
66991
004
90
2
X
796.05
X
66991
003
90
2
X
796.05
X
66991
002
90
2
X
796.05
X
66999
YYY
2
X
#
X
67005
002
90
2
X
3,027.07
X
67005
003
90
2
X
2,885.81
X
67005
001
90
2
X
3,099.15
X
67005
004
90
2
X
2,577.88
X
67010
002
90
2
X
2,943.53
X
67010
003
90
2
X
2,508.53
X
67010
001
90
2
X
2,716.93
X
67010
004
90
2
X
2,473.41
X
67015
001
90
2
X
1,398.96
X
67015
003
90
2
X
1,321.88
X
67015
002
90
2
X
1,371.85
X
67015
004
90
2
X
1,386.09
X
67025
004
90
2
X
1,391.84
X
67025
002
90
2
X
1,492.52
X
67025
003
90
2
X
1,409.78
X
67025
001
90
2
X
1,404.22
X
67027
001
90
2
X
2,022.14
X
67027
003
90
2
X
1,818.16
X
67027
002
90
2
X
1,818.16
X
67027
004
90
2
X
1,818.16
X
67028
001
0
2
X
658.21
X
67028
002
0
2
X
649.94
X
67028
003
0
2
X
615.23
X
67028
004
0
2
X
607.25
X
67030
003
90
2
X
1,303.74
X
67030
002
90
2
X
1,299.53
X
67030
001
90
2
X
1,337.12
X
67030
004
90
2
X
1,360.05
X
67031
003
90
2
X
1,799.15
X
67031
002
90
2
X
1,869.68
X
67031
001
90
2
X
1,886.46
X
67031
004
90
2
X
1,784.59
X
67036
001
90
2
X
5,476.30
X
67036
004
90
2
X
4,762.06
X
67036
003
90
2
X
5,007.04
X
67036
002
90
2
X
5,328.61
X
67039
002
90
2
X
4,704.03
X
67039
003
90
2
X
4,420.63
X
67039
004
90
2
X
4,360.05
X
67039
001
90
2
X
4,771.64
X
67040
001
90
2
X
6,985.24
X
67040
004
90
2
X
6,532.97
X
67040
002
90
2
X
6,954.22
X
67040
003
90
2
X
6,251.18
X
67041
001
90
2
X
2,098.72
X
67041
004
90
2
X
1,908.43
X
67041
003
90
2
X
1,908.43
X
67041
002
90
2
X
1,908.43
X
67042
001
90
2
X
2,398.75
X
67042
004
90
2
X
2,185.00
X
67042
002
90
2
X
2,185.00
X
67042
003
90
2
X
2,185.00
X
67043
001
90
2
X
2,520.90
X
67043
003
90
2
X
2,293.36
X
67043
004
90
2
X
2,293.36
X
67043
002
90
2
X
2,293.36
X
67101
004
10
2
X
2,451.11
X
67101
001
10
2
X
2,557.20
X
67101
003
10
2
X
2,472.56
X
67101
002
10
2
X
2,080.53
X
67105
004
10
2
X
2,656.86
X
67105
003
10
2
X
3,069.14
X
67105
002
10
2
X
2,754.38
X
67105
001
10
2
X
3,308.94
X
67107
001
90
2
X
3,809.63
X
67107
002
90
2
X
4,137.43
X
67107
003
90
2
X
4,066.37
X
67107
004
90
2
X
4,053.90
X
67108
001
90
2
X
6,415.50
X
67108
004
90
2
X
6,216.55
X
67108
002
90
2
X
6,350.39
X
67108
003
90
2
X
5,817.15
X
67110
002
90
2
X
2,712.10
X
67110
003
90
2
X
2,549.68
X
67110
001
90
2
X
2,750.75
X
67110
004
90
2
X
2,514.98
X
67113
001
90
2
X
2,769.98
X
67113
004
90
2
X
2,518.24
X
67113
003
90
2
X
2,518.24
X
67113
002
90
2
X
2,518.24
X
67115
001
90
2
X
1,369.83
X
67115
004
90
2
X
1,257.57
X
67115
003
90
2
X
1,274.46
X
67115
002
90
2
X
1,351.47
X
67120
001
90
2
X
1,460.49
X
67120
004
90
2
X
1,348.36
X
67120
002
90
2
X
1,442.20
X
67120
003
90
2
X
1,366.10
X
67121
002
90
2
X
2,000.44
X
67121
003
90
2
X
2,091.40
X
67121
004
90
2
X
2,065.27
X
67121
001
90
2
X
2,224.57
X
67141
002
10
2
X
1,491.74
X
67141
003
10
2
X
1,405.84
X
67141
004
10
2
X
1,386.98
X
67141
001
10
2
X
1,705.94
X
67145
004
10
2
X
1,419.64
1,002.88
67145
001
10
2
X
1,716.77
1,194.67
67145
003
10
2
X
1,438.89
1,015.04
67145
002
10
2
X
1,526.45
1,077.41
67208
001
90
2
X
2,483.95
X
67208
003
90
2
X
2,432.36
X
67208
002
90
2
X
2,362.43
X
67208
004
90
2
X
2,422.97
X
67210
004
90
2
X
2,008.69
1,496.86
67210
002
90
2
X
2,248.88
1,665.63
67210
003
90
2
X
2,211.18
1,643.05
67210
001
90
2
X
2,116.61
1,574.42
67218
001
90
2
X
3,119.88
X
67218
002
90
2
X
2,930.26
X
67218
003
90
2
X
2,782.57
X
67218
004
90
2
X
2,747.22
X
67220
002
90
2
X
1,714.35
1,708.58
67220
003
90
2
X
1,714.35
1,708.58
67220
004
90
2
X
1,714.35
1,708.58
67220
001
90
2
X
1,866.11
1,859.34
67221
001
0
2
X
850.25
617.45
67221
004
0
2
X
748.58
549.86
67221
003
0
2
X
748.58
549.86
67221
002
0
2
X
748.58
549.86
67225
001
ZZZ
0
X
118.75
114.23
67225
004
ZZZ
0
X
88.08
84.24
67225
002
ZZZ
0
X
88.08
84.24
67225
003
ZZZ
0
X
88.08
84.24
67227
004
10
2
X
2,045.26
X
67227
003
10
2
X
1,906.83
X
67227
002
10
2
X
1,901.56
X
67227
001
10
2
X
2,465.08
X
67228
004
10
2
X
2,136.53
1,622.76
67228
001
10
2
X
2,826.75
2,121.43
67228
002
10
2
X
2,784.76
2,089.97
67228
003
10
2
X
2,715.17
2,038.16
67229
004
90
2
X
1,657.08
X
67229
001
90
2
X
1,827.27
X
67229
002
90
2
X
1,657.08
X
67229
003
90
2
X
1,657.08
X
67250
004
90
2
X
1,621.67
X
67250
001
90
2
X
1,745.07
X
67250
003
90
2
X
1,641.85
X
67250
002
90
2
X
1,725.08
X
67255
004
90
2
X
2,449.23
X
67255
001
90
2
X
2,672.59
X
67255
003
90
2
X
2,482.75
X
67255
002
90
2
X
3,155.54
X
67299
YYY
2
X
#
X
67311
004
90
2
X
1,548.44
X
67311
003
90
2
X
1,793.06
X
67311
002
90
2
X
1,937.29
X
67311
001
90
2
X
1,949.08
X
67312
004
90
2
X
1,818.64
X
67312
001
90
2
X
2,070.14
X
67312
002
90
2
X
2,039.68
X
67312
003
90
2
X
1,842.61
X
67314
001
90
2
X
2,141.45
X
67314
003
90
2
X
1,970.57
X
67314
002
90
2
X
2,126.85
X
67314
004
90
2
X
1,626.49
X
67316
004
90
2
X
2,067.58
X
67316
002
90
2
X
2,212.18
X
67316
003
90
2
X
2,095.28
X
67316
001
90
2
X
2,245.54
X
67318
001
90
2
X
1,886.78
X
67318
003
90
2
X
1,740.14
X
67318
002
90
2
X
1,876.79
X
67318
004
90
2
X
1,440.26
X
67320
004
ZZZ
0
X
2,088.74
X
67320
001
ZZZ
0
X
2,270.63
X
67320
002
ZZZ
0
X
2,240.92
X
67320
003
ZZZ
0
X
2,116.46
X
67331
002
ZZZ
0
X
2,075.47
X
67331
003
ZZZ
0
X
1,885.76
X
67331
004
ZZZ
0
X
1,861.18
X
67331
001
ZZZ
0
X
2,086.10
X
67332
004
ZZZ
0
X
2,067.95
X
67332
002
ZZZ
0
X
2,462.12
X
67332
003
ZZZ
0
X
2,095.28
X
67332
001
ZZZ
0
X
2,473.91
X
67334
001
ZZZ
0
X
1,570.12
X
67334
004
ZZZ
0
X
1,460.67
X
67334
002
ZZZ
0
X
1,552.38
X
67334
003
ZZZ
0
X
1,478.82
X
67335
004
ZZZ
0
X
976.29
X
67335
002
ZZZ
0
X
1,057.79
X
67335
003
ZZZ
0
X
990.26
X
67335
001
ZZZ
0
X
1,073.95
X
67340
004
ZZZ
0
X
1,827.35
X
67340
002
ZZZ
0
X
1,942.03
X
67340
003
ZZZ
0
X
1,850.15
X
67340
001
ZZZ
0
X
1,964.11
X
67343
001
90
2
X
1,454.29
X
67343
002
90
2
X
1,437.90
X
67343
003
90
2
X
1,369.58
X
67343
004
90
2
X
1,352.73
X
67345
003
10
2
X
561.81
X
67345
002
10
2
X
595.26
X
67345
004
10
2
X
555.14
X
67345
001
10
2
X
603.45
X
67346
004
0
2
X
299.59
X
67346
003
0
2
X
299.59
X
67346
002
0
2
X
299.59
X
67346
001
0
2
X
335.39
X
67399
YYY
2
X
#
X
67400
003
90
2
X
2,398.02
X
67400
002
90
2
X
2,511.38
X
67400
001
90
2
X
2,523.36
X
67400
004
90
2
X
2,410.84
X
67405
004
90
2
X
1,802.99
X
67405
003
90
2
X
1,920.18
X
67405
002
90
2
X
1,936.04
X
67405
001
90
2
X
1,962.32
X
67412
004
90
2
X
2,566.02
X
67412
001
90
2
X
2,644.58
X
67412
003
90
2
X
2,233.97
X
67412
002
90
2
X
2,631.75
X
67413
001
90
2
X
2,047.39
X
67413
003
90
2
X
1,920.63
X
67413
002
90
2
X
2,312.49
X
67413
004
90
2
X
2,231.29
X
67414
004
90
2
X
1,945.49
X
67414
002
90
2
X
2,067.78
X
67414
003
90
2
X
1,969.73
X
67414
001
90
2
X
2,091.29
X
67415
001
0
2
X
509.52
X
67415
002
0
2
X
507.21
X
67415
003
0
2
X
497.74
X
67415
004
0
2
X
495.56
X
67420
002
90
2
X
4,208.97
X
67420
003
90
2
X
3,246.68
X
67420
001
90
2
X
4,312.53
X
67420
004
90
2
X
3,204.76
X
67430
001
90
2
X
2,654.70
X
67430
003
90
2
X
2,500.80
X
67430
002
90
2
X
2,624.92
X
67430
004
90
2
X
2,470.04
X
67440
001
90
2
X
3,960.34
X
67440
002
90
2
X
3,942.63
X
67440
003
90
2
X
3,044.58
X
67440
004
90
2
X
3,005.02
X
67445
001
90
2
X
2,774.36
X
67445
004
90
2
X
2,581.12
X
67445
003
90
2
X
2,613.18
X
67445
002
90
2
X
2,743.16
X
67450
004
90
2
X
2,565.87
X
67450
001
90
2
X
3,217.72
X
67450
003
90
2
X
2,809.91
X
67450
002
90
2
X
2,839.10
X
67500
001
0
2
X
312.36
X
67500
004
0
2
X
297.12
X
67500
003
0
2
X
264.49
X
67500
002
0
2
X
272.17
X
67505
001
0
2
X
351.47
257.84
67505
003
0
2
X
306.18
224.76
67505
002
0
2
X
345.13
253.07
67505
004
0
2
X
344.18
253.24
67515
002
0
2
X
173.11
133.31
67515
003
0
2
X
174.25
134.15
67515
001
0
2
X
140.28
107.65
67515
004
0
2
X
184.12
142.07
67516
004
0
0
X
126.24
101.88
67516
003
0
0
X
126.24
101.88
67516
002
0
0
X
126.24
101.88
67516
001
0
0
X
138.39
110.73
67550
001
90
2
X
2,230.11
X
67550
004
90
2
X
2,058.26
X
67550
002
90
2
X
2,201.84
X
67550
003
90
2
X
2,084.26
X
67560
004
90
2
X
2,654.78
X
67560
001
90
2
X
2,093.08
X
67560
003
90
2
X
1,969.09
X
67560
002
90
2
X
2,706.82
X
67570
004
90
2
X
2,114.88
X
67570
002
90
2
X
2,237.08
X
67570
003
90
2
X
2,140.12
X
67570
001
90
2
X
2,260.46
X
67599
YYY
2
X
#
X
67700
002
10
2
X
198.88
172.18
67700
003
10
2
X
191.09
165.89
67700
004
10
2
X
188.96
164.18
67700
001
10
2
X
205.33
177.83
67710
003
10
2
X
211.99
X
67710
002
10
2
X
223.54
X
67710
004
10
2
X
209.32
X
67710
001
10
2
X
226.27
X
67715
001
10
2
X
377.81
X
67715
004
10
2
X
281.85
X
67715
003
10
2
X
386.45
X
67715
002
10
2
X
368.16
X
67800
003
10
2
X
226.61
182.11
67800
002
10
2
X
256.43
205.67
67800
004
10
2
X
211.78
171.19
67800
001
10
2
X
259.30
207.90
67801
002
10
2
X
363.92
288.59
67801
004
10
2
X
342.67
272.74
67801
001
10
2
X
368.06
291.76
67801
003
10
2
X
346.82
275.76
67805
001
10
2
X
401.59
X
67805
004
10
2
X
374.94
X
67805
003
10
2
X
379.41
X
67805
002
10
2
X
397.24
X
67808
002
90
2
X
610.79
X
67808
003
90
2
X
591.77
X
67808
001
90
2
X
614.71
X
67808
004
90
2
X
600.08
X
67810
001
0
2
X
259.30
214.86
67810
004
0
2
X
242.50
201.91
67810
002
0
2
X
256.51
212.78
67810
003
0
2
X
245.34
204.02
67820
003
0
2
X
115.01
98.54
67820
002
0
2
X
124.75
106.63
67820
004
0
2
X
117.48
101.06
67820
001
0
2
X
125.77
107.55
67825
003
10
2
X
237.64
191.84
67825
002
10
2
X
248.99
200.30
67825
004
10
2
X
265.04
213.70
67825
001
10
2
X
317.43
255.12
67830
004
10
2
X
465.13
X
67830
002
10
2
X
1,093.29
X
67830
003
10
2
X
1,060.12
X
67830
001
10
2
X
1,132.28
X
67835
004
90
2
X
1,605.29
X
67835
001
90
2
X
1,717.37
X
67835
003
90
2
X
1,409.91
X
67835
002
90
2
X
1,492.85
X
67840
004
10
2
X
338.30
277.34
67840
001
10
2
X
511.15
417.00
67840
002
10
2
X
484.96
396.18
67840
003
10
2
X
387.69
317.48
67850
001
10
2
X
227.38
191.04
67850
002
10
2
X
216.80
182.06
67850
003
10
2
X
203.90
171.40
67850
004
10
2
X
204.67
171.88
67875
003
0
2
X
343.97
X
67875
002
0
2
X
364.80
X
67875
004
0
2
X
339.50
X
67875
001
0
2
X
369.82
X
67880
001
90
2
X
1,143.89
X
67880
004
90
2
X
851.40
X
67880
003
90
2
X
860.77
X
67880
002
90
2
X
903.51
X
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