You may be trying to access this site from a secured browser on the server. Please enable scripts and reload this page.
Skip Ribbon Commands
Skip to main content
Turn off Animations
Turn on Animations
An Official
Pennsylvania
Government Website
Translate
DLI
Department of Labor & Industry
I am ...
I am ...
Claimant
Worker
Employer
Researcher
Provider
Services
Services
Unemployment Benefits
Unemployment Tax Services
Workers' Compensation
Disability Determination
Job Search & Career Training
Disability Services
Labor Law Compliance
Occ. & Industrial Safety
Document Downloads
Labor Market & Jobs Data
Divisions
Divisions
Unemployment Compensation
Unemployment Tax Services
Workers' Compensation
PA CareerLink®
PennSERVE
Vocational Rehabilitation
Work Statistics
Labor Law Compliance
Occ. & Industrial Safety
Disability Determinitation
About
About
Contact the Pennsylvania Depar
Equal Opportunity
Guide to Services
Boards
Councils and Committees
Right to Know
Search
Search
Menu
Department of Labor & Industry
Menu
I am ...
I am ...
Claimant
Worker
Employer
Researcher
Provider
Services
Services
Unemployment Benefits
Unemployment Tax Services
Workers' Compensation
Disability Determination
Job Search & Career Training
Disability Services
Labor Law Compliance
Occ. & Industrial Safety
Document Downloads
Labor Market & Jobs Data
Divisions
Divisions
Unemployment Compensation
Unemployment Tax Services
Workers' Compensation
PA CareerLink®
PennSERVE
Vocational Rehabilitation
Work Statistics
Labor Law Compliance
Occ. & Industrial Safety
Disability Determinitation
About
About
Contact the Pennsylvania Depar
Equal Opportunity
Guide to Services
Boards
Councils and Committees
Right to Know
I am a(n)...
Find Services
Bureaus & Offices
Make a Payment
Contact Us
Publications
DLI
>
Businesses
>
Workers' Compensation Services
>
Workers' Compensation
>
Health Care Services Review
>
Medical Fee Review
>
Fee Schedule
>
Fee Schedule 15570-19101
Begin Main Content Area
Page Content
Content Editor
2024 Workers' Compensation Part B Fee Schedule
15570-19101
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
15570
004
90
2
X
1,518.93
X
15570
001
90
2
X
3,518.08
X
15570
002
90
2
X
4,215.91
X
15570
003
90
2
X
2,891.21
X
15572
001
90
2
X
3,810.20
X
15572
003
90
2
X
3,607.44
X
15572
002
90
2
X
3,880.07
X
15572
004
90
2
X
4,244.40
X
15574
001
90
2
X
3,260.61
X
15574
003
90
2
X
2,866.61
X
15574
002
90
2
X
3,355.47
X
15574
004
90
2
X
3,368.38
X
15576
001
90
2
X
3,473.29
X
15576
004
90
2
X
3,453.16
X
15576
002
90
2
X
4,054.92
X
15576
003
90
2
X
3,498.79
X
15600
003
90
2
X
693.52
X
15600
002
90
2
X
1,092.25
X
15600
004
90
2
X
1,298.23
X
15600
001
90
2
X
783.41
X
15610
001
90
2
X
1,142.33
X
15610
003
90
2
X
1,144.44
X
15610
002
90
2
X
763.65
X
15610
004
90
2
X
687.77
X
15620
002
90
2
X
1,531.69
X
15620
003
90
2
X
844.79
X
15620
004
90
2
X
834.25
X
15620
001
90
2
X
1,465.89
X
15630
001
90
2
X
1,644.53
X
15630
004
90
2
X
902.54
X
15630
002
90
2
X
1,636.14
X
15630
003
90
2
X
1,601.70
X
15650
004
90
2
X
988.85
X
15650
003
90
2
X
1,224.34
X
15650
002
90
2
X
1,238.27
X
15650
001
90
2
X
1,107.53
X
15730
004
90
2
X
2,232.42
1,355.23
15730
002
90
2
X
2,232.42
1,355.23
15730
003
90
2
X
2,232.42
1,355.23
15730
001
90
2
X
2,491.06
1,484.54
15731
001
90
2
X
1,940.59
1,744.05
15731
004
90
2
X
1,699.58
1,538.91
15731
003
90
2
X
1,699.58
1,538.91
15731
002
90
2
X
1,699.58
1,538.91
15733
003
90
2
X
1,548.80
X
15733
002
90
2
X
1,548.80
X
15733
004
90
2
X
1,548.80
X
15733
001
90
2
X
1,695.50
X
15734
004
90
2
X
5,838.32
X
15734
001
90
2
X
5,900.24
X
15734
003
90
2
X
5,858.95
X
15734
002
90
2
X
5,922.19
X
15736
002
90
2
X
4,877.56
X
15736
003
90
2
X
3,592.77
X
15736
001
90
2
X
4,909.23
X
15736
004
90
2
X
3,549.95
X
15738
001
90
2
X
5,542.56
X
15738
003
90
2
X
5,468.89
X
15738
002
90
2
X
5,585.70
X
15738
004
90
2
X
2,949.12
X
15740
003
90
2
X
3,838.44
X
15740
002
90
2
X
3,763.32
X
15740
004
90
2
X
2,208.41
X
15740
001
90
2
X
3,925.25
X
15750
003
90
2
X
2,560.74
X
15750
002
90
2
X
2,759.69
X
15750
004
90
2
X
2,529.84
X
15750
001
90
2
X
2,807.81
X
15756
001
90
2
X
7,917.98
X
15756
002
90
2
X
7,081.76
X
15756
003
90
2
X
6,891.37
X
15756
004
90
2
X
6,891.37
X
15757
002
90
2
X
7,081.76
X
15757
003
90
2
X
6,891.37
X
15757
001
90
2
X
7,917.98
X
15757
004
90
2
X
6,891.37
X
15758
004
90
2
X
6,891.37
X
15758
002
90
2
X
7,081.76
X
15758
001
90
2
X
7,917.98
X
15758
003
90
2
X
6,891.37
X
15760
001
90
2
X
2,480.15
X
15760
004
90
2
X
1,718.75
X
15760
003
90
2
X
2,417.75
X
15760
002
90
2
X
2,467.98
X
15769
003
90
2
X
669.19
X
15769
002
90
2
X
669.19
X
15769
004
90
2
X
669.19
X
15769
001
90
2
X
740.50
X
15770
004
90
2
X
1,569.04
X
15770
001
90
2
X
1,724.11
X
15770
003
90
2
X
1,588.52
X
15770
002
90
2
X
1,697.78
X
15771
002
90
2
X
795.33
664.63
15771
003
90
2
X
795.33
664.63
15771
001
90
2
X
885.53
735.06
15771
004
90
2
X
795.33
664.63
15772
001
ZZZ
0
X
278.94
216.91
15772
004
ZZZ
0
X
251.99
198.13
15772
002
ZZZ
0
X
251.99
198.13
15772
003
ZZZ
0
X
251.99
198.13
15773
001
90
2
X
893.35
742.86
15773
004
90
2
X
802.63
671.96
15773
003
90
2
X
802.63
671.96
15773
002
90
2
X
802.63
671.96
15774
004
ZZZ
0
X
244.19
190.33
15774
002
ZZZ
0
X
244.19
190.33
15774
003
ZZZ
0
X
244.19
190.33
15774
001
ZZZ
0
X
270.23
208.22
15775
0
2
X
*
X
15776
0
2
X
*
X
15777
001
ZZZ
0
X
397.75
X
15777
004
ZZZ
0
X
357.00
X
15777
002
ZZZ
0
X
357.00
X
15777
003
ZZZ
0
X
357.00
X
15778
001
0
2
X
481.38
X
15778
002
0
2
X
442.20
X
15778
003
0
2
X
442.20
X
15778
004
0
2
X
442.20
X
15780
004
90
2
X
874.55
X
15780
001
90
2
X
924.80
X
15780
003
90
2
X
1,958.68
X
15780
002
90
2
X
916.68
X
15781
004
90
2
X
909.53
X
15781
003
90
2
X
1,021.43
X
15781
002
90
2
X
974.28
X
15781
001
90
2
X
1,041.94
X
15782
001
90
2
X
609.94
X
15782
004
90
2
X
943.22
X
15782
003
90
2
X
579.77
X
15782
002
90
2
X
604.06
X
15783
001
90
2
X
863.68
X
15783
004
90
2
X
643.23
X
15783
002
90
2
X
681.57
X
15783
003
90
2
X
650.45
X
15786
004
10
2
X
276.72
X
15786
001
10
2
X
294.37
X
15786
003
10
2
X
279.70
X
15786
002
10
2
X
291.54
X
15787
003
ZZZ
0
X
60.98
X
15787
002
ZZZ
0
X
64.69
X
15787
001
ZZZ
0
X
65.53
X
15787
004
ZZZ
0
X
60.25
X
15788
90
2
X
*
X
15789
90
2
X
*
X
15792
90
2
X
*
X
15793
90
2
X
*
X
15819
003
90
2
X
1,850.70
X
15819
002
90
2
X
1,964.63
X
15819
001
90
2
X
1,992.18
X
15819
004
90
2
X
1,828.28
X
15820
004
90
2
X
1,202.18
X
15820
002
90
2
X
1,299.45
X
15820
003
90
2
X
1,217.64
X
15820
001
90
2
X
1,319.10
X
15821
002
90
2
X
1,488.65
X
15821
003
90
2
X
1,396.66
X
15821
004
90
2
X
1,378.69
X
15821
001
90
2
X
1,510.72
X
15822
002
90
2
X
2,110.06
X
15822
003
90
2
X
1,778.49
X
15822
001
90
2
X
1,266.94
X
15822
004
90
2
X
1,881.91
X
15823
004
90
2
X
2,032.89
X
15823
002
90
2
X
2,183.26
X
15823
003
90
2
X
2,085.31
X
15823
001
90
2
X
2,218.30
X
15824
0
2
X
*
X
15825
0
2
X
*
X
15826
0
2
X
*
X
15828
0
2
X
*
X
15829
0
2
X
*
X
15830
001
90
2
X
2,120.47
X
15830
003
90
2
X
1,837.77
X
15830
002
90
2
X
1,837.77
X
15830
004
90
2
X
1,837.77
X
15832
90
2
X
*
X
15833
90
2
X
*
X
15834
90
2
X
*
X
15835
90
2
X
*
X
15836
90
2
X
*
X
15837
90
2
X
*
X
15838
90
2
X
*
X
15839
90
2
X
*
X
15840
002
90
2
X
3,365.84
X
15840
003
90
2
X
3,128.28
X
15840
001
90
2
X
3,423.13
X
15840
004
90
2
X
3,089.60
X
15841
001
90
2
X
4,662.13
X
15841
004
90
2
X
4,248.46
X
15841
003
90
2
X
4,298.49
X
15841
002
90
2
X
4,591.30
X
15842
004
90
2
X
6,974.58
X
15842
002
90
2
X
7,459.13
X
15842
003
90
2
X
7,059.56
X
15842
001
90
2
X
7,555.46
X
15845
002
90
2
X
3,376.57
X
15845
003
90
2
X
3,126.46
X
15845
004
90
2
X
3,087.94
X
15845
001
90
2
X
3,436.91
X
15847
YYY
0
X
*
X
15851
0
2
X
*
X
15852
004
0
2
X
126.25
X
15852
002
0
2
X
131.46
X
15852
003
0
2
X
127.08
X
15852
001
0
2
X
132.60
X
15853
001
ZZZ
2
X
14.52
X
15853
003
ZZZ
2
X
12.63
X
15853
002
ZZZ
2
X
12.63
X
15853
004
ZZZ
2
X
12.63
X
15854
004
ZZZ
2
X
17.82
X
15854
001
ZZZ
2
X
20.51
X
15854
002
ZZZ
2
X
17.82
X
15854
003
ZZZ
2
X
17.82
X
15860
0
2
X
*
X
15876
0
2
X
*
X
15877
0
2
X
*
X
15878
0
2
X
#
X
15879
0
2
X
*
X
15920
004
90
2
X
1,137.53
X
15920
002
90
2
X
1,217.64
X
15920
003
90
2
X
1,149.76
X
15920
001
90
2
X
1,234.20
X
15922
001
90
2
X
1,855.81
X
15922
003
90
2
X
1,709.22
X
15922
002
90
2
X
1,827.14
X
15922
004
90
2
X
1,689.95
X
15931
001
90
2
X
1,085.41
X
15931
004
90
2
X
1,167.25
X
15931
002
90
2
X
1,296.60
X
15931
003
90
2
X
1,198.29
X
15933
004
90
2
X
1,860.36
X
15933
002
90
2
X
2,011.27
X
15933
003
90
2
X
1,881.62
X
15933
001
90
2
X
2,030.36
X
15934
001
90
2
X
2,314.45
X
15934
003
90
2
X
2,130.30
X
15934
002
90
2
X
2,278.45
X
15934
004
90
2
X
2,159.35
X
15935
004
90
2
X
2,740.69
X
15935
003
90
2
X
2,772.74
X
15935
002
90
2
X
2,985.80
X
15935
001
90
2
X
3,037.43
X
15936
001
90
2
X
2,703.00
X
15936
004
90
2
X
2,436.23
X
15936
002
90
2
X
3,506.13
X
15936
003
90
2
X
3,425.77
X
15937
003
90
2
X
3,983.53
X
15937
002
90
2
X
4,086.65
X
15937
004
90
2
X
2,998.35
X
15937
001
90
2
X
4,111.58
X
15940
004
90
2
X
1,294.81
X
15940
001
90
2
X
1,406.50
X
15940
002
90
2
X
1,387.36
X
15940
003
90
2
X
1,308.90
X
15941
002
90
2
X
2,047.33
X
15941
003
90
2
X
1,944.07
X
15941
004
90
2
X
1,922.11
X
15941
001
90
2
X
1,981.32
X
15944
004
90
2
X
2,513.89
X
15944
001
90
2
X
2,430.21
X
15944
003
90
2
X
2,524.70
X
15944
002
90
2
X
2,596.62
X
15945
001
90
2
X
3,071.65
X
15945
004
90
2
X
2,528.75
X
15945
002
90
2
X
3,051.42
X
15945
003
90
2
X
2,968.00
X
15946
004
90
2
X
4,092.28
X
15946
001
90
2
X
4,525.88
X
15946
003
90
2
X
4,140.16
X
15946
002
90
2
X
4,450.56
X
15950
003
90
2
X
1,164.96
X
15950
002
90
2
X
1,221.59
X
15950
004
90
2
X
1,189.71
X
15950
001
90
2
X
1,169.66
X
15951
001
90
2
X
2,149.20
X
15951
003
90
2
X
1,964.63
X
15951
002
90
2
X
2,113.18
X
15951
004
90
2
X
1,942.21
X
15952
003
90
2
X
2,094.96
X
15952
002
90
2
X
2,089.93
X
15952
001
90
2
X
2,166.27
X
15952
004
90
2
X
1,931.01
X
15953
003
90
2
X
2,573.45
X
15953
002
90
2
X
2,509.31
X
15953
004
90
2
X
2,306.79
X
15953
001
90
2
X
2,552.08
X
15956
004
90
2
X
3,545.69
X
15956
001
90
2
X
3,968.73
X
15956
003
90
2
X
3,716.02
X
15956
002
90
2
X
3,894.70
X
15958
001
90
2
X
4,091.62
X
15958
004
90
2
X
3,640.89
X
15958
003
90
2
X
3,888.59
X
15958
002
90
2
X
4,012.38
X
15999
YYY
2
X
#
X
16000
003
0
2
X
123.47
107.40
16000
002
0
2
X
130.04
112.42
16000
004
0
2
X
123.02
106.81
16000
001
0
2
X
131.18
113.43
16020
004
0
2
X
113.32
97.57
16020
003
0
2
X
114.62
98.55
16020
002
0
2
X
119.82
102.82
16020
001
0
2
X
121.09
103.86
16025
002
0
2
X
256.81
232.75
16025
003
0
2
X
246.93
224.28
16025
004
0
2
X
244.37
222.04
16025
001
0
2
X
259.30
234.88
16030
001
0
2
X
297.78
X
16030
004
0
2
X
279.36
X
16030
003
0
2
X
282.24
X
16030
002
0
2
X
294.72
X
16035
004
0
2
X
700.42
X
16035
001
0
2
X
757.21
X
16035
003
0
2
X
708.03
X
16035
002
0
2
X
747.65
X
16036
002
ZZZ
0
X
196.32
X
16036
003
ZZZ
0
X
196.32
X
16036
004
ZZZ
0
X
196.32
X
16036
001
ZZZ
0
X
219.64
X
17000
001
10
2
X
103.77
81.32
17000
004
10
2
X
93.57
74.44
17000
003
10
2
X
93.57
74.44
17000
002
10
2
X
93.57
74.44
17003
001
ZZZ
0
X
28.90
22.00
17003
004
ZZZ
0
X
25.82
19.90
17003
003
ZZZ
0
X
25.82
19.90
17003
002
ZZZ
0
X
25.82
19.90
17004
002
10
0
X
466.08
363.84
17004
003
10
0
X
466.08
363.84
17004
004
10
0
X
466.08
363.84
17004
001
10
0
X
521.79
401.68
17106
002
90
2
X
729.38
X
17106
003
90
2
X
697.31
X
17106
004
90
2
X
689.63
X
17106
001
90
2
X
737.24
X
17107
004
90
2
X
1,364.46
X
17107
002
90
2
X
1,444.24
X
17107
003
90
2
X
1,379.61
X
17107
001
90
2
X
1,459.97
X
17108
001
90
2
X
2,568.18
X
17108
004
90
2
X
2,385.33
X
17108
002
90
2
X
2,538.16
X
17108
003
90
2
X
2,414.10
X
17110
004
10
2
X
96.19
77.99
17110
002
10
2
X
96.19
77.99
17110
003
10
2
X
96.19
77.99
17110
001
10
2
X
106.29
84.90
17111
003
10
2
X
139.74
112.46
17111
001
10
2
X
154.99
122.91
17111
002
10
2
X
139.74
112.46
17111
004
10
2
X
139.74
112.46
17250
002
0
2
X
97.28
79.10
17250
003
0
2
X
92.07
74.90
17250
001
0
2
X
98.55
80.20
17250
004
0
2
X
90.91
74.10
17260
004
10
2
X
300.40
X
17260
002
10
2
X
306.59
X
17260
003
10
2
X
299.81
X
17260
001
10
2
X
308.51
X
17261
004
10
2
X
353.15
X
17261
001
10
2
X
366.22
X
17261
003
10
2
X
354.46
X
17261
002
10
2
X
367.04
X
17262
004
10
2
X
405.17
X
17262
001
10
2
X
458.36
X
17262
002
10
2
X
450.01
X
17262
003
10
2
X
444.93
X
17263
002
10
2
X
547.49
X
17263
003
10
2
X
544.36
X
17263
001
10
2
X
532.30
X
17263
004
10
2
X
492.18
X
17264
001
10
2
X
679.27
X
17264
003
10
2
X
664.93
X
17264
002
10
2
X
698.79
X
17264
004
10
2
X
679.42
X
17266
004
10
2
X
972.14
X
17266
001
10
2
X
980.32
X
17266
002
10
2
X
972.16
X
17266
003
10
2
X
855.38
X
17270
004
10
2
X
362.17
X
17270
003
10
2
X
359.65
X
17270
002
10
2
X
374.74
X
17270
001
10
2
X
382.55
X
17271
003
10
2
X
460.10
X
17271
002
10
2
X
468.98
X
17271
004
10
2
X
398.30
X
17271
001
10
2
X
479.25
X
17272
001
10
2
X
515.31
X
17272
004
10
2
X
456.40
X
17272
003
10
2
X
499.61
X
17272
002
10
2
X
507.38
X
17273
002
10
2
X
576.92
X
17273
003
10
2
X
568.65
X
17273
004
10
2
X
536.10
X
17273
001
10
2
X
538.95
X
17274
001
10
2
X
745.27
X
17274
004
10
2
X
697.98
X
17274
003
10
2
X
721.35
X
17274
002
10
2
X
732.36
X
17276
001
10
2
X
888.30
X
17276
004
10
2
X
853.96
X
17276
003
10
2
X
807.28
X
17276
002
10
2
X
877.04
X
17280
004
10
2
X
394.53
X
17280
002
10
2
X
419.21
X
17280
003
10
2
X
388.04
X
17280
001
10
2
X
426.65
X
17281
001
10
2
X
507.54
X
17281
002
10
2
X
508.57
X
17281
003
10
2
X
492.63
X
17281
004
10
2
X
456.65
X
17282
004
10
2
X
507.47
X
17282
001
10
2
X
607.26
X
17282
002
10
2
X
598.04
X
17282
003
10
2
X
601.36
X
17283
001
10
2
X
654.21
X
17283
003
10
2
X
698.07
X
17283
002
10
2
X
707.15
X
17283
004
10
2
X
630.49
X
17284
001
10
2
X
850.92
X
17284
004
10
2
X
838.55
X
17284
003
10
2
X
737.29
X
17284
002
10
2
X
817.88
X
17286
001
10
2
X
1,054.03
X
17286
003
10
2
X
970.69
X
17286
002
10
2
X
1,037.77
X
17286
004
10
2
X
959.08
X
17311
001
0
2
X
1,239.85
656.30
17311
004
0
2
X
1,070.41
593.44
17311
002
0
2
X
1,070.41
593.44
17311
003
0
2
X
1,070.41
593.44
17312
004
ZZZ
0
X
643.43
315.87
17312
001
ZZZ
0
X
750.14
349.41
17312
003
ZZZ
0
X
643.43
315.87
17312
002
ZZZ
0
X
643.43
315.87
17313
004
0
2
X
976.99
531.92
17313
001
0
2
X
1,132.96
588.46
17313
003
0
2
X
976.99
531.92
17313
002
0
2
X
976.99
531.92
17314
004
ZZZ
0
X
595.89
292.12
17314
002
ZZZ
0
X
595.89
292.12
17314
003
ZZZ
0
X
595.89
292.12
17314
001
ZZZ
0
X
694.73
323.08
17315
002
ZZZ
0
X
127.05
82.63
17315
003
ZZZ
0
X
127.05
82.63
17315
004
ZZZ
0
X
127.05
82.63
17315
001
ZZZ
0
X
145.57
91.27
17340
001
10
2
X
113.68
98.51
17340
004
10
2
X
106.82
92.96
17340
003
10
2
X
99.37
86.69
17340
002
10
2
X
112.52
97.57
17360
004
10
2
X
176.55
163.17
17360
001
10
2
X
167.39
154.11
17360
002
10
2
X
184.60
170.26
17360
003
10
2
X
178.38
164.79
17380
0
2
X
*
X
17999
YYY
2
X
#
X
19000
001
0
2
X
149.98
128.52
19000
004
0
2
X
139.85
119.97
19000
003
0
2
X
143.25
122.99
19000
002
0
2
X
144.71
124.38
19001
002
ZZZ
0
X
78.45
X
19001
003
ZZZ
0
X
73.51
X
19001
004
ZZZ
0
X
72.76
X
19001
001
ZZZ
0
X
79.66
X
19020
002
90
2
X
580.38
X
19020
003
90
2
X
570.15
X
19020
004
90
2
X
484.76
X
19020
001
90
2
X
568.82
X
19030
001
0
2
X
213.77
X
19030
003
0
2
X
203.37
X
19030
002
0
2
X
211.74
X
19030
004
0
2
X
201.21
X
19081
001
0
2
X
1,180.64
328.07
19081
004
0
2
X
1,029.57
297.74
19081
002
0
2
X
1,029.57
297.74
19081
003
0
2
X
1,029.57
297.74
19082
004
ZZZ
0
X
824.36
141.29
19082
003
ZZZ
0
X
824.36
141.29
19082
002
ZZZ
0
X
824.36
141.29
19082
001
ZZZ
0
X
949.41
153.63
19083
003
0
2
X
1,021.24
278.82
19083
002
0
2
X
1,021.24
278.82
19083
004
0
2
X
1,021.24
278.82
19083
001
0
2
X
1,171.72
306.79
19084
001
ZZZ
0
X
936.35
144.25
19084
004
ZZZ
0
X
812.61
132.75
19084
003
ZZZ
0
X
812.61
132.75
19084
002
ZZZ
0
X
812.61
132.75
19085
003
0
2
X
1,538.94
325.43
19085
002
0
2
X
1,538.94
325.43
19085
001
0
2
X
1,771.40
357.61
19085
004
0
2
X
1,538.94
325.43
19086
001
ZZZ
0
X
1,403.73
152.94
19086
004
ZZZ
0
X
1,217.46
143.85
19086
002
ZZZ
0
X
1,217.46
143.85
19086
003
ZZZ
0
X
1,217.46
143.85
19100
003
0
2
X
307.86
X
19100
002
0
2
X
297.25
X
19100
001
0
2
X
270.71
X
19100
004
0
2
X
271.49
X
19101
001
10
2
X
691.59
X
19101
002
10
2
X
707.38
X
19101
003
10
2
X
617.90
X
19101
004
10
2
X
610.84
X
Return to CPT/HCPC List